key: cord- -k ad qgu authors: kabir, k. m. ariful; tanimoto, jun title: modelling and analysing the coexistence of dual dilemmas in the proactive vaccination game and retroactive treatment game in epidemic viral dynamics date: - - journal: proc math phys eng sci doi: . /rspa. . sha: doc_id: cord_uid: k ad qgu the dynamics of a spreadable disease are largely governed by four factors: proactive vaccination, retroactive treatment, individual decisions, and the prescribing behaviour of physicians. under the imposed vaccination policy and antiviral treatment in society, complex factors (costs and expected effects of the vaccines and treatments, and fear of being infected) trigger an emulous situation in which individuals avoid infection by the pre-emptive or ex post provision. aside from the established voluntary vaccination game, we propose a treatment game model associated with the resistance evolution of antiviral/antibiotic overuse. moreover, the imperfectness of vaccinations has inevitably led to anti-vaccine behaviour, necessitating a proactive treatment policy. however, under the excessively heavy implementation of treatments such as antiviral medicine, resistant strains emerge. the model explicitly exhibits a dual social dilemma situation, in which the treatment behaviour changes on a local time scale, and the vaccination uptake later evolves on a global time scale. the impact of resistance evolution and the coexistence of dual dilemmas are investigated by the control reproduction number and the social efficiency deficit, respectively. our investigation might elucidate the substantial impacts of both vaccination and treatment in the framework of epidemic dynamics, and hence suggest the appropriate use of antiviral treatment. the dynamics of a spreadable disease are largely governed by four factors: proactive vaccination, retroactive treatment, individual decisions, and the prescribing behaviour of physicians. under the imposed vaccination policy and antiviral treatment in society, complex factors (costs and expected effects of the vaccines and treatments, and fear of being infected) trigger an emulous situation in which individuals avoid infection by the pre-emptive or ex post provision. aside from the established voluntary vaccination game, we propose a treatment game model associated with the resistance evolution of antiviral/antibiotic overuse. moreover, the imperfectness of vaccinations has inevitably led to anti-vaccine behaviour, necessitating a proactive treatment policy. however, under the excessively heavy implementation of treatments such as antiviral medicine, resistant strains emerge. the model explicitly exhibits a dual social dilemma situation, in which the treatment behaviour changes on a local time scale, and the vaccination uptake later evolves on a global time scale. the impact of resistance evolution and the coexistence of dual dilemmas are investigated by the control reproduction number and the social efficiency deficit, respectively. the appearance of epidemiological dynamics in the mechanism of pre-emptive voluntary vaccination has been studied in various contexts [ ] , such as perfect and imperfect vaccination [ , ] , dynamical behaviour of vaccination [ ] , vaccination with information spreading [ ] , metapopulation migration modelling [ ] and heterogeneous networks [ ] . furthermore, chen & fu [ ] studied an effective antiviral treatment with prescribing behaviour and resistance evolution. remarkably, influenza-like illnesses, oseltamivir (tamiflu) [ ] is a widely used ex post treatment originally administered against influenza a and b viruses. however, over the years, the societal benefits of antiviral treatment have lessened with overuse, leading to treatment resistance. these trends are evidenced by the interplay between prescription behaviour and resistance evolution. here, the theoretical studies of vaccination and treatment strategies have considered different effectiveness, associated costs, payoff structures and time scales. previously, compartment models with the mean-field approximation, such as the si [ ] , sis [ ] , sir [ ] , seir [ ] and seiqr [ ] models, are exhibited by dividing the population into several distinct groups. in these designations, s, i, r, e and q represent the proportions of susceptible, infected, recovered, exposed and quarantined individuals, respectively. recently, kabir et al. extended the simple sir model by introducing an awareness effect on epidemic spreading and implemented a two-layer sir-ua model on well-mixed [ ] and heterogeneous networks [ ] . additionally, treatment is an important compartmented state that reduces the disease after infection. treatments such as antibiotics, quarantine and isolation have been theoretically investigated by many researchers [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] . the consequences of vaccination and treatment on an epidemic model were investigated in an influenza model with age structure by qiu & feng [ , ] and feng et al. [ ] , an sivs model with vaccination age by li et al. [ ] , an sir epidemic model with optimal control theory by zaman et al. [ ] and a pandemic influenza model by towers et al. [ ] . all these works presumed that vaccination, quarantine or treatment would reduce epidemic infection in a simple dynamical situation on local time scales and with no game aspect. by contrast, the present study aims to establish a theoretical epidemic model encompassing both vaccination and treatment as an evolutionary game approach. the human decision-making process is affected by the cost and risk of the vaccine, selfopinion, networks and neighbours' decisions; therefore, how vaccine acquiescence is influenced by various factors must be investigated [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] . according to prior studies, a game approach to epidemiological vaccination can fairly predict the infection risk in both vaccinated and nonvaccinated individuals [ ] [ ] [ ] [ ] . such voluntary vaccination game approaches have been studied theoretically and in multi-agent simulations (mas). to elucidate the mechanism of infectiousdisease control, these approaches incorporate a two-layer time scale: a local time scale (epidemic season) of epidemic diffusion and a global time scale on which the strategy updates at the end of the season (at local equilibrium), followed by repeated seasons. kuga & tanimoto [ ] developed a theoretical model of imperfect vaccination on local and global time scales and validated it by mas. however, kabir & tanimoto [ ] claimed that an individual's decision to take a vaccination after social learning (dynamical behaviour) also occurs on local time scales, so this strategy should be updated instantly. accordingly, it seems that the voluntary vaccination game approach can be implemented into the local time scale while maintaining the framework on the global time scale (strategy update at the end of each season). in the same context, antiviral treatment depends on the local time scale, antiviral resistance and prescribing behaviour. to shed light on this complex phenomenon, we newly propose the dual-dilemma game structure that considers the roles of both the proactive vaccination and retroactive treatment games. this approach admits different strategy update rules and different time scales of the two provisions. in most of the previous studies [ , , [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] , the proactive vaccination permits an individual to accept or decline a vaccination at the end of every epidemic season. this repeated choice is made on global time scales. on the other hand, the retroactive treatment prescribes the behaviour and the antiviral resistance of a certain individual only when s/he is actually infected at a certain time in an epidemic season, which occurs on local time scales. an excessive antiviral treatment may also trigger another viral resistant strain; this behaviour is an expected social problem concerning seasonal influenza in japan [ ] . in this case, the so-called vaccination dilemma modelled by the vaccination game is joined by another dilemma, whereby an individual seeking to use public goods (i.e. accepting the antiviral) induces another viral strain with devastating consequences for others. using our novel idea backed by the theoretical game approach, we quantify the impact of the pre-emptive vaccination game (before the disease spreading) and the treatment game (after the infection), which includes the prescribing behaviour as an ex post provision. both games are influenced by vaccine effectiveness, treatment efficacy, treatment cost and vaccination cost. such a double social dilemma situation, perhaps quite ubiquitous in the real world, has not been considered in related previous studies. the vaccination game in the double-dilemma scenario occurs on a larger time scale (over repeated seasons) than the treatment game, which occurs on a day-by-day basis. therefore, a coevolutionary process can be plausibly modelled in the present study. we employ a pre-emptive control measure that prevents the breakout of infection at an early stage based on an individual's decision. meanwhile, the ex post treatment can be regarded as a fail-safe provision implemented after infection. owing to the imperfections of vaccines and the unwillingness to take vaccines as a pre-emptive provision, people probably consider a retroactive treatment as the 'ultimate weapon' against disease dispersion. however, overuse of antiviral treatment and prescribing behaviour can trigger the emergence of resistant strains, encouraging more ex post provision activity by individuals. to handle these two provisions working on different time scales, our model implants the second social dilemma incurred by the antiviral treatment rather than the so-called vaccination dilemma acquired by the proactive provision. to our knowledge, no previous theoretical analysis has considered two provisions in the same context of the evolutionary game process. we also develop another new concept called the social efficiency deficit (sed). such a framework can explicitly elucidate the social dual-dilemma on both global (vaccination) and local (treatment) time scales. in our model, the retroactive antiviral treatment targets the individuals harbouring a sensitive or resistant strain that is controlled by the treatment (antiviral/antibiotic) potency (efficacy). the resistant strain incurs a high medical cost, mortality and the risk of antiviral/antibiotic use, which increases when the demand for antiviral use is driven by the individual's self-interest and overprescribing. here, we emphasize the social learning behaviour for prescription of antiviral treatment under the evolutionary dynamics of resistance that can uphold the optimal use of the treatment. to explore this evolutionary process of vaccination and treatment, we impose three strategy update rules: individual-based risk assessment (ib-ra), society-based risk assessment (sb-ra) and direct commitment (dc). these rules govern the individual's connection with society. moreover, we derive the control reproduction numbers of the sensitive and resistant strains, and hence analyse the disease-free equilibria situations in an epidemic. the remainder of this paper is organized as follows. the 'methods and model' section introduces the new model of epidemic vaccination with the antiviral treatment model and demonstrates it schematically. the 'results and discussion' section validates the proposed model in numerical simulations. finally, the 'conclusion' section summarizes and further discusses our findings. to model the social dual-dilemma as a two-stage game, the pre-emptive vaccination and ex post treatment are developed in the framework of sir epidemic dynamics in a well-mixed population (figure ). in stage , the individuals make their vaccination decisions (yes or no) that will control their infection risk during the pandemic season. in stage , the infected people with either the sensitive strain or resistant strain decide their treatment provision (treated or untreated) on the local time scale. the antiviral (antibiotic) treatment case incorporates a feedback loop between the prescription behaviour and resistance evolution. to model the disease diffusion in a single season, the initially susceptible people are compartmentalized into vaccinated and nonvaccinated groups. the individuals in the susceptible state can be infected with either sensitive or resistant strains, then seek treatment at an overall treatment rate (treatment probability) denoted as ωp , where p is the prescribing rate and ω determines the probability at which infected people accept treatment from the prescribing individuals. consequently, the individuals can recover in two ways: natural recovery with no antibiotic/antiviral treatment or recovery after treatment. the epidemiological dynamics are described by the following system of ordinary differential equationsṠ here, the fractions of vaccinated plus non-vaccinated individuals infected with the sensitive and resistant strains are denoted by i u sen and i u res , respectively. t denotes the fraction of infected individuals receiving treatment and r represents the fraction of individuals who have recovered from infection by a sensitive or resistant strain. in addition, β s and β r (γ s and γ r ) are the disease transmission rates (infection recovery rates) for the sensitive and resistant strains, respectively and γ t is the recovery rate of infected individuals receiving treatment. finally, μ s and μ r are the mutation rates of the sensitive and resistant strains, respectively. without mutation, the coexistence of sensitive and resistant strains is forbidden by the competitive exclusion principle. the portion of vaccinated individuals is separated into perfectly immune and nonimmune individuals, distinguished by the vaccine's effectiveness e( ≤ e ≤ ). the treatment efficacy ε controls the treatment efficiency of the sensitive and resistant strains. when ε = , the treatment is far less beneficial against the resistant strain than against the sensitive strain. on the other hand, when ε = , the higher number of people in the resistant state is now taking the highest benefit of treatment and is ineffective against the sensitive strain. the basic reproduction number (ratio) r is the estimated number of infected individuals instigated by a susceptible individual (r = β/γ ). in particular, if r < , the disease will eventually die out, whereas if r > , the disease will spread through the population. in this case, we presume separate control reproduction numbers r s and r r for the sensitive and resistant strains, respectively. to evaluate the control reproduction numbers, we initially set let us express the model dynamics as we can write similarly, we have as mentioned above, the control reproduction number must reflect the stability of the diseasefree equilibrium state. according to equations ( . ) and ( . ), the control reproduction numbers of both sensitive (r s ) and resistant (r r ) strains act like a decreasing function of p and x; both ranging from to displayed in figure in panels (a-ii) and (a-iii), we can find the critical treatment probability p c at which the treatment probabilities of the sensitive and resistant strains are equal. when < p < p c , the sensitive strain is more prevalent than the resistant strain (i.e. r s > r r ). however, when p > p c , the resistant strain will outperform against the sensitive strain. at the social optimum, the critical treatment probability p c specifies the maximum treatment control under which resistant strains will not emerge. assuming r s = r r in equations ( . ) and ( . ), p c is calculated as . we incorporate two-game aspects (treatment and vaccination) in a single epidemiological game model. this model reproduces the coevolutions of accepting a vaccination at the beginning of every season and receiving treatment after becoming infected in a season. in the treatment game, the individual decision to receive or decline treatment against the infectious sensitive and resistant strains occurs on the local time scale. in the vaccination game, the individuals can consent to alter their strategy (accept or decline vaccination) based on the progress of the last pandemic season, which occurs on the global time scale. based on a feedback loop between the resistance evolution and prescription norm, the game approach establishes a social learning dynamical process that somehow controls the optimum use of the antiviral treatment. to quantify the evolutionary decision dynamics of treatment versus non-treatment (prescribing versus non-prescribing), we specify the relative treatment cost c t visà-vis the infection cost c i = . we also introduce the benefit b t of treating the sensitive strain (the resistant strain is excluded, because it is much more difficult to treat than the sensitive strain, so b t is always positive). this idea is formulated as a two-strategy game in table . the fractions of individuals infected with the sensitive and resistant strains are, respectively, given by the expected payoffs of the treated and untreated individuals are, respectively, given by and to model the two-strategy game, we presume the dc strategy update rule presented in iwamura & tanimoto [ ] . this rule is designed by comparing the expected payoffs of the treated π t and untreated π u individuals. in the present study, the strategy updates (in both the treatment and vaccination games (see later)) apply the mean-field approximation. the modified fermi function of dc is given by where π i and π j are the mean payoffs of the focal portion of individuals and the opponent strategy (fraction), respectively. here, we consider pairwise comparison between two groups; which depends on the payoff difference π j − π i . because, the pairwise fermi has been wellaccepted strategy-updating procedure that stochastically comparable to the real-world human decision-making process. the probabilities of the population transiting from untreated to treated and from treated to untreated are, respectively, calculated as and consequently, the treatment game is expressed by the following dc dynamics: considering the defined payoff structure and the portion of individuals presented in table , the social average payoff π , expected value of vaccinators π c and expected value of nonvaccinators π d are, respectively, given by to formulate the evolutionary process, we consider two types of strategy adaptation procedures [ ] ; ib-ra and sb-ra. in the case of ib-ra, an individual can update strategy by observing a neighbour's strategy. the update is governed by the transition probability prob(s i ← s j ) taken from the pairwise fermi function [ ] . alternatively, in an sb-ra, an individual relies on the mean payoff of all opposite neighbours [ ] . we apply the mean-field approximation to formulate the adaptation dynamics in both the ib-ra and sb-ra rules. here, we replace the first row by the actual transition probabilities in the second row of table . to establish the dynamical system at the end of each epidemic season, we formulate ib-ra and sb-ra as mathematical models that modify the fraction of vaccinators x. the evolutionary dynamics of the ib-ra and sb-ra are, respectively, given by individual-based risk assessment (ib-ra) society-based risk assessment (sb-ra) we have now established all mathematical frameworks in both the vaccination and treatment cases. the above set of equations is numerically solved by the explicit finite difference method. the calculation results affected by the two-stage process (the sitr/v dynamical model and treatment update) are together obtained in a single season (local update) at equilibrium, and the vaccination strategy is adopted at the end of every season (global update). the initial values were set as v( the results are presented in two-dimensional ( d) phase diagrams. the strategy update rules of the vaccination game (ib-ra or sb-ra) and the dc were applied on the global and local time scales, respectively (where the dc depicts the prescribing behaviour of the treatment policy). the coalescing impact of proactive vaccination and the retroactive treatment policy based on human behaviour was formulated by the conventional mean-field approximation. the simultaneous changes of two coevolutionary decision-making processes were globally demonstrated in two cases. we first explored the phase diagram of the final epidemic size (fes), vaccination coverage (vc), fraction of treated people (ftr) and the average social payoff (asp) while varying two parameters: the vaccination effectiveness e and the treatment efficacy ε, maintaining sensible fixed values of the other parameters. in the second case, we introduce sed that explicitly reveals the as shown in figure , the fes increased (higher infection region) with increasing vaccination cost c r and treatment cost c t . reducing the cost of both vaccination (c r = . ) and treatment (c t = . ) improved the fes (lowered the infection region) ( figure (a-i) , both panels). furthermore, reducing the costs (c r , c t < . ) more effectively benefitted the fes (in terms of the critical borderline between infection breakout and diminution) in ib-ra than in sb-ra (cf. panel sets a and b); the reverse tendency was found at higher costs (c r , c t ) as analogously reported by fukuda et al. [ ] . when the costs are relatively low, vaccination is more encouraged in sb-ra than in ib-ra, which hampers the reduction in the infected number of individuals in the early stage of each season. thus, based on the human decision-making of whether to accept or decline both vaccination and treatment, the changing propensity of the fes can be significantly enhanced by the vaccination effectiveness, treatment efficacy and their corresponding costs. as indicated in figure , lowering the vaccination cost and increasing the reliability (effectiveness) of the vaccine enticed the individuals to accept more vaccines. this tendency was more marked in the sb-ra than in the ib-ra, and enhanced the vaccination acceptance when the post-infection treatment cost was high (c t = . ) on the local time scale. however, the portion of individuals making treatment provision (ftr) diminished at higher treatment costs (c t = . ) in both schemes (panels (*-iii) in figure ). a small treatment cost attracts individuals to the treatment provision, whereas a higher cost hampers the treatment-seeking behaviour (lowers the ftr). therefore, either lowering the vaccination cost or improving the vaccination effectiveness to explore the dual-dilemma structure on an epidemiological model, we considered the joint impact of vaccination and treatment games in the same context. a typical scenario is demonstrated in figure . our idea was motivated by the endorsement of social dilemma situations in the strategies of evolutionary game theory, in which the players are all individuals in a well-mixed population. in a coevolutionary adaptation process, it is important to know whether the social dual-dilemma exists under certain combinations of the model parameters, such as the vaccination effectiveness, treatment efficiency and their associated costs. unlike simple by games in which the so-called dilemma strength (ds) can be explicitly defined [ ] , a real social dilemma typically observed in the vaccination game [ , [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] , traffic flow [ ] [ ] [ ] [ ] [ ] [ ] [ ] and others may have a time-variable game structure. in the vaccination and traffic games, this structure is mainly influenced by the disease-spreading and traffic flow dynamics, respectively. the timevariable game structure is too complex to represent by the payoff matrix in a × game or the time-constant payoff structure function in the -strategy and n-player game. thus, the ds is difficult to determine in advance even when the mathematical model is well defined. our new sed concept (defined above and mathematically formulated blow) was inspired by the seminal idea of traffic flow analysis (e.g. [ ] [ ] [ ] [ ] [ ] [ ] [ ] ). the ds indicates the existence or absence of a social dilemma (behaving as a prognostic index), whereas the sed provides an 'ex post' or diagnostic index. here, let us define sed as the gap between the result of the evolutionary trail (which can be evaluated by the nash equilibrium (ne)) and the optimum solution (ideal result from a social-welfare standpoint [ ] ). the payoff at the ne can always be observed by taking an evolutionary game approach, whereas the optimal social payoff is observable in a model of any complexity. therefore, one can evaluate the sed in any context, and hence predict the occurrence of a social dilemma (if the sed is positive, the gap exists; if it is zero, the evolutionary trail matches the optimum). thus, the sed indicates that the payoff can be improved from that at the ne. mathematically, the sed is given by sed = (social optimal payoff) − (payoff at nash equilibrium) ( again, let us reiterate that sed = implies no social dilemma, while any social dilemma causes a positive sed. according to the abovementioned conceptual definition, sed in the current model (which deals with both vaccination and treatment games) is given by meanwhile, the asp is the quantity of payoff. the superscript 'opt' and subscript 'social' together indicate the social optimal. the c i was taken as the standardizing denominator as previously defined as . the seds in the vaccination and treatment game of the present model are, respectively, defined as follows: social reflect the fact that the maximum asp is obtained for varying x ranging from to (for fixed p k ) and varying p from to (for fixed x l ), respectively. figure presents the stepwise procedure of finding sed and quantifying the dual dilemma in the proposed method. step . construct the asp phase diagram based on the evolutionary game approach (figure (i)). to this end, implement both the vaccination and treatment games and obtain the appropriate asp at the ne, along with a certain vaccine effectiveness (e) and treatment efficacy (ε). the asp associated with the fraction of vaccinators and probability of treatment (x l , p k ) at the ne can also be observed for a precise (e i , ε j ). step . for this fixed (e i , ε j ), evaluate asp to address whether a dual dilemma exists in the vaccination and treatment games, we plot the sed diagrams in the vaccination effectiveness (e) versus treatment efficacy (ε) planes at different costs. panels a and b of figure are plotted under the strategy update rules ib-ra and sb-ra, respectively, and plots (a-*) and (b-*) present the seds in the vaccination game sed v and the treatment game sed t , respectively. moreover, the combined vaccination and treatment costs (c r , c t ) were varied as ( . , . ), ( . , . ), ( . , . ) ( . , . ), and ( . , . ) in plots (*-i), (*-ii), (*-iii) and (*-iv), respectively. as demonstrated in the above sed formulation, the dilemma situation (non-white areas in the plots) appeared in all cases, but interestingly depended on e and ε. nodilemma regions, in which either the vaccination or treatment game became trivial, were also observed. now, comparing panels (a-i) and (a-ii) for c r = . with panels (a-iii) and (a-iv) for c r = . , one finds that the non-dilemma region (whiteout region) expanded with increasing vaccination cost. at the smaller vaccination cost (c r = . ), the region of larger sed appeared at a relatively low vaccination effectiveness (around e = . ; dotted red box in panel (a-i)). the huge gap between ne and the social optimal results from the lower ne due to a lower efficiency which makes fewer people commit vaccination when compared with a situation allowing a relatively higher efficiency which makes much more people commit. by contrast, a relatively high vaccination efficiency entices people to vaccinate, thus increasing the ne. meanwhile, increasing the vaccination cost (c r = . ) shifted the region of reasonably high sed to the maximally high vaccination effectiveness (dotted blue box in panel (a-iv)). this occurred because despite the high vaccination effectiveness, low vaccination efficiency hampers the commitment to vaccination. reliable vaccination provides a high commitment incentive, but high cost encourages free-riding on the herd immunity of the devoted others. in summary, we have numerically demonstrated that the sed precisely and easily detects the social dilemma in our dual-dilemma coevolutionary model. this paper developed an sitr/v epidemic model that combines the effects of proactive vaccination and retroactive treatment on the control and prevention of infectious viral diseases. the model building and its investigation were presented in this work. the most important contribution is that our new model gives a brand-new framework in which both pre-emptive vaccination and treatment as an ex post provision having different evolutionary time scales, which dovetails the ideological dynamics with the dynamics of the human decision-making process. this concept has been never studied. also, our model gives a clear procedure to quantify the social dilemmas, respectively, entailed by 'vaccination game' and 'treatment game'. the most novel aspect of our model is the simultaneous implementation of two social dilemma games: the antiviral treatment game and the vaccination game, which none of the previous work has tried to implement. the vaccination game implements on the global time scale under two strategy adaptation rules: ib-ra and sb-ra, assuming an infinite and well-mixed population. meanwhile, the treatment game describes the behaviour of antiviral administration with resistant-strain emergence. the treatment game is updated on the local time scale by presuming the dc rule, and precisely integrating a feedback loop between the sensitive and resistant strains. the outcome of antiviral and vaccination use depends on the effectiveness of the vaccine, the efficiency of treatment and their corresponding costs. increasing the effectiveness of the vaccine and lowering its administration cost reduced the final epidemic size (increased vaccination coverage). lowering the treatment cost and enhancing the treatment efficacy exerted a similar effect. thus, by applying retroactive antiviral use with pre-emptive vaccination, we can deeply understand and investigate individual decisions regarding vaccination and implement proper strategies that lessen the diffusion of infection or recommend appropriate and careful administration of both antivirals and vaccination. we also introduced the social optimum point p c that distinguishes the conditions under which treatment resistance emerges under antibiotic overuse and its associated factors. besides evolving the voluntary vaccination game, our model introduces a new game aspect with two provisions: vaccination as a proactive measure and treatment as a retroactive measure. presuming seasonal influenza-like diseases, the (pre-emptive) vaccination works over repeated seasons on global time scales, whereas the ex post treatment works seasonally on local time scales and depends on the antiviral cost, prescription behaviour and resistant-strain emergence. in the present model, we successfully established a 'double-layer' game structure of pre-emptive vaccination and ex post treatment. unlike the vaccination game model, which only considers whether the vaccine is accepted or declined, and whether an ex post provision is taken in a single season, the treatment game includes an aspect that depends on the antiviral resistance evolution and prescribing behaviour. to explicitly prove the dual-dilemma situation in the 'double-layer' game, we proposed the sed indicator, which quantifies whether the dynamics develop a social dilemma structure. this indicator is measured by the gap between the ne and the social optimal state. the dilemma strength [ ] [ ] [ ] , which explains the dilemma structure in simple two-player and two-strategy ( × ) games, is too simplistic for realistic dilemma games with substantially complex and time-dependent structures, such as vaccination games and traffic flow analysis. however, sed can quantify whether a game intrinsically has a social dilemma or not. we applied the 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our gratitude to the funders. key: cord- -cpl zf f authors: provoost, judith; valour, florent; gamondes, delphine; roux, sandrine; freymond, nathalie; perrot, emilie; souquet, pierre-jean; kiakouama-maleka, lize; chidiac, christian; lina, gérard; dumitrescu, oana; sénéchal, agathe; ader, florence title: a retrospective study of factors associated with treatment decision for nontuberculous mycobacterial lung disease in adults without altered systemic immunity date: - - journal: bmc infect dis doi: . /s - - -x sha: doc_id: cord_uid: cpl zf f background: nontuberculous mycobacteria (ntm) lung diseases are increasingly recognized as chronic opportunistic infections, occurring in individuals with a wide variety of underlying conditions. in the absence of systemic immunodeficiency, decision of ntm lung disease treatment must relies on a careful risk/benefit assessment, given the requirement of long-term administration of multidrug therapies supported by limited evidence. the primary objective was to identify the factors associated with anti-ntm treatment initiation. clinical and radiological outcome upon treatment were studied. methods: this retrospective, single center study ( – , months) addressed the criteria supporting treatment decision among adults with ntm lung disease without systemic immunodeficiency at our institution, with the assigned goal to harmonize the practice. all patients matched the current international definitions of ntm lung disease according to the american thoracic society criteria. factors associated with anti-ntm treatment were investigated by conditional logistic regression. clinical and radiological outcomes of treated and untreated ntm-disease cases were examined. mortality rate was assessed. an expert radiologist conducted a blinded computed tomography (ct)-scan review of the treated and untreated patients. results: among cases of ntm lung diseases, ( %) received anti-ntm treatment. in univariate analysis, a body mass index (bmi) < kg/m( ) (odds ratio (or), . [ % confidence interval (ci) . – . ]; p = . ), hemoptysis (or, . [ % ci . – . ]; p = . ), excavation(s) (or, . [ % ci . – . ], p = . ), prior anti-ntm treatment (or, . [ % ci . – . ]; p = . ), aspergillus spp. co-infection (or, . [ % ci . – . ]; p = . ) were associated with treatment initiation. in multivariate analysis, aspergillus spp. co-infection was the only independent determinant of treatment initiation (or, . [ % ci . – . ]; p = . ). twenty-one ( %) patients received ≥ anti-ntm drugs. median treatment duration and follow-up were . (interquartile range [iqr], . – . ) weeks and . (iqr, . – . ) months, respectively. regarding radiological outcome, ct-scans were reviewed, showing similar rates of regression or stabilization in treated and untreated patients. overall mortality rate was not different in treated and untreated patients. conclusion: the most relevant variable associated with anti-ntm treatment initiation was aspergillus spp. co-infection. radiological regression or stabilization of pulmonary lesions was not different between the treated and untreated patients. nontuberculous mycobacteria (ntm) are ubiquitous bacteria of environmental origin including a widely diverse number of species (> ), some of which cause disease in humans [ ] [ ] [ ] . prevalence of ntm lung diseases is unexpectedly increasing in industrialized countries, as consistently uncovered by recent studies [ , ] . the key issue remains to determine whether ntm are the true and single promoter of an evolving lung disease or chronic airway colonizers, among others. to standardize the diagnosis of ntm lung disease, the guidelines for ntm diagnosis of the american thoracic society (ats)/infectious disease society of america (idsa) and the british thoracic society (bts) require isolation and growth of the same ntm strain on at least two separate samples from the patient [ , ] . human host and pathogenic ntm relationship is still poorly understood, as ntm virulence is highly variable from one species to another. ntm lung disease is strongly associated with pre-existing pulmonary conditions such as chronic obstructive pulmonary disease (copd), cystic fibrosis, idiopathic bronchiectasis, prior active tuberculosis or pneumoconiosis [ ] . it is also frequently associated with genetic or acquired systemic immune deficiency such as defects in the pathways of inflammatory cytokines interleukin (il)- , tumor necrosis factor (tnf)-α or interferon (ifn)-γ, immunosuppressive treatments (including anti-tnf-α therapy or corticosteroids), solid-organ transplantation, or acquired immune deficiency syndrome (aids)/human immunodeficiency virus (hiv) infection [ ] [ ] [ ] [ ] [ ] [ ] [ ] . however, it may also occur in individuals without recognized severe immune local or systemic deficiency. in the absence of patent predisposition, ntm diseases are overrepresented among the specific morphotype of slender women with a low body fat [ ] . treatment decision for ntm lung disease is challenging. there is debate as to which patients should benefit the most from treatment according to medical background, comorbidities, clinical status, radiologic features and causal ntm strain. assessment of clinical, microbiologic, and radiologic response to treatment is not standardized as well. we focused on ntm lung diseases in adults without systemic immunodeficiency that met the ats criteria guidelines. based on the comparison of a group of treated and untreated patients, the primary objective was to identify the factors associated with physician decision of initiating anti-ntm treatment. secondary objectives were to study the outcome upon treatment and to propose a standardized evaluation for the diagnosis and decision making to treatment of ntm lung diseases in adults without systemic immunodeficiency. we conducted a retrospective, observational, single-center study between january and february ( months) among adults (≥ year-old) without systemic immunosuppression presenting ntm lung disease. exclusion criteria were hiv infection, cystic fibrosis, primary ciliary dyskinesia, active malignant disease, solid-organ transplantation or ongoing immunosuppressant treatments such as tnf inhibitor or high-dose corticosteroid (≥ mg/kg more than days). case identification was based on cross-referencing the databases of the mycobacteria laboratory and the departments of infectious and pulmonary diseases. patients eligible for inclusion in the ntm lung disease cohort were those who matched the criteria previously defined by the ats/idsa and the bts guidelines with the minimum requirement of clinical and microbiologic following criteria: (i) pulmonary symptoms associated with multifocal bronchiectasis with multiple small nodules on computed tomography (ct)-scan; (ii) proper exclusion of other diagnoses; (iii) ntm-positive culture results from at least two separate expectorated sputum samples or a ntm-positive culture result from at least one bronchial wash or lavage [ , ] . patients' characteristics at diagnosis were collected in order to perform analysis on selected variables: demographics; history of predisposing factors; underlying pulmonary diseases; comorbidities; pulmonary function testing; respiratory bacterial or mycological co-infection(s), which definition was similar to ntm criteria, namely positive culture isolation of the same species from at least two separate expectorated sputum samples or a positive culture result from at least one bronchial wash or lavage; immunologic status; nutritional status; clinical features; microbiologic assessment through identification of ntm species on positive ntm cultures and sample culture conversions; radiologic features on high-resolution ct-scans (fibrocavitary disease or nodular/bronchiectasis disease); prior treatment for ntm lung disease, treatment combination and duration; outcome. because of the retrospective observational nature of the study and the lack of any modification in patients' management, the need for informed consent was waived with the authorization of the ethics committee of lyon university hospital (comité d'ethique, hospices civils de lyon), which approved the study under the number - . an independent expert chest radiologist, blinded to the patient information, retrospectively reviewed the ct-scans performed without injection of intravenous contrast media, assigned in random order at diagnosis and six to months after treatment or during the follow up of the untreated patients. the number and size of cavity(ies) and their wall thickness were evaluated in the lung window setting. nodular opacity(ies) (≥ mm), cluster(s) of small nodules (≤ mm), the tree-in-bud pattern, the presence of bronchiectasis in any of the lobes or multifocal bronchiectasis were evaluated. based on the number and size of the lesions, the expert classified the lesions as improved, stable or worsening. the primary endpoint was to identify the factors significantly involved in the decision of initiating anti-ntm treatment by patient referent physician. secondary endpoints were the assessment of clinical and radiological outcomes upon anti-ntm treatment in comparison with no treatment. based on these findings, a standardized appraisal was proposed to assist diagnosis management and treatment decision for ntm lung diseases in adults without altered systemic immunity. descriptive data were used to estimate the frequencies of the study variables. there were expressed as count (percentage, %) for dichotomous variables and as medians (interquartile range [iqr]) for continuous values. the number of missing values was excluded from the denominator. non-parametric statistical methods fisher exact test, χ test and mann-whitney u test were used to compare groups, where appropriate. the probability of treatment initiation over time was evaluated by kaplan-meier survival curve analysis, with group comparison using the log-rank (mantel-cox) test. stepwise binary logistic regression analysis was used to assess the determinants for treatment initiation, expressed as odd ratios (or) with % confidence intervals ( % ci). after checking the variables for interactions, variables with medical meaning and with p-values obtained in the univariate analysis of < . were included in the final multivariate model. a value of p < . was considered significant. all analyses were performed using spss software version . (spss. chicago. il). out of patients eligible to ats/idsa ntm lung disease criteria, patients were included in the study, of who ( %) received and ( %) did not receive anti-ntm treatment (fig. ). the median age was (interquartile range [iqr], - ) year-old with a male/ female ratio of . . etiologic ntm agents were mycobacterium avium (n = , . %), m. chimaerae (n = , . %), m. xenopii (n = , . %), m. intracellulare (n = , . %), m. simiae (n = , . %), m. kansasii (n = , %), and m. abscessus (n = , %), with three patients having ≥ concomitant ntm lung diseases. importantly, the evidence of ntm lung disease has led to diagnose six underlying chronic lung diseases, of which a genetically documented cystic fibrosis in a year-old women. on descriptive analysis, patient's characteristics did not significantly differ, to the exception of a lower bmi (p = . ) and a higher number of previously known ntm lung disease (p = . ) in treated versus untreated patients (table ) . notable percentages of missing data at diagnosis have to be acknowledged for active tobacco smoking ( . %, n = ), respiratory functional testing ( . %, n = ) with a very few patients having a -min walk test, baseline arterial blood oxygenation levels ( . %, n = ), ct-scan follow up within months after diagnosis in untreated patients ( %, n = ). factors leading the patient referent physician to initiate anti-ntm treatment were assessed using bivariate analysis. table ). the probability of treatment initiation over time according to the presence or not of targeted variables was investigated. the probability was significantly higher in case of bmi < vs. > kg/m (p = . ), of hemoptysis vs. no hemoptysis (p = . ), of aspergillus spp. co-infection vs. no co-infection (p = . ), of pulmonary excavation(s) vs. no excavation (p = . ) (fig. a, b, c and d, respectively) . (table ) . finally, all-cause mortality was not different between treated and untreated groups, although lost to follow-up was high in the untreated group (n = , . %). regarding the four patients that deceased (n = in the treated group and n = in the untreated group), the cause of mortality was linked to the underlying diseases rather than ntm-related mortality. in the present study, treated patients were characterized by bmi < kg/m , presence of hemoptysis and excavation(s), aspergillus spp. co-infection, and prior anti-ntm treatment. aspergillus spp. co-infection was the only independent factor associated with treatment initiation. a single study from five english centers has recently addressed the factors that influence anti-ntm treatment initiation using similar retrospective design of treated and untreated cohort comparison inclusion criteria which allowed non-aids/hiv immunosuppressed patients ( and % in the treated and untreated subsets, respectively) to be evaluated. in the multivariate analysis, patients had increased odds of anti-ntm treatment in case of cavitation on ct imaging, night sweats and weight loss [ ] . here, three out of four criteria are part of guideline criteria leading to decision of anti-ntm treatment. they all reflect a degree of severity of ntm lung disease linked with progression of an impaired respiratory condition. the current problematic of ntm lung diseases shifts from distinguishing colonization from infection toward differentiating stable, poorly active vs. progressive active ntm disease, the latter being responsible for further structural lung damage(s). the risk/benefit analysis includes prescribing recommended long-term multidrug regimens with concerns over suboptimal cure rates and frequently reported drug-related side effects. to support these arguments, others have already shown that physician ats/idsa guideline [ ] . another study conducted in france has shown that among a cohort of ntm lung diseases, only ( . %) received appropriate treatment matching ats/idsa guidelines [ ] . inappropriate prescriptions were mostly related to shorter treatment duration ( months or less) and/or off-recommendation regimen, particularly those excluding macrolide from the combination or those using a single-drug macrolide regimen [ , ] . it has to be acknowledged that guidelines specify that treatment for mac-associated lung disease in hiv-negative individuals can be a three-times-weekly drug regimen upon culture conversion while on therapy for year, which may favor treatment compliance [ , , ] . patients with bronchiectasis and ntm lung disease have a higher prevalence of being sensitized to aspergillus than patients with ntm-free bronchiectasis [ ] . allergic airway manifestations in response to aspergillus are termed aspergillus-related lung diseases with a spectrum going from aspergillus-induced hypersensitivity to the severe allergic bronchopulmonary aspergillosis (abpa) [ ] . by itself, the coexistence of ntm and aspergillus in lung airway justifies the need for testing aspergillus serology, total serum immunoglobulin (ig)e and aspergillus-specific ige levels as well as mycological direct examination and culture of sputum or bronchial aspirates for presence of filamentous fungi in the diagnosis algorithm of patients with ntm lung diseases. active co-infections with ntm and aspergillus spp. have also been described, in which patients with ntm lung disease develop chronic forms of pulmonary aspergillosis which definitions and management have been revisited in recent updated guidelines [ ] [ ] [ ] [ ] . radiographic improvement may be hampered by concomitant lung disease and the limited potential for resolution of consolidated radiologic abnormalities. a previous study has investigated radiologic response to treatment showing consistent results with those found in the present study. although anti-ntm treatment led to an improvement or stabilization of lesions for a majority of patients, these modifications were not significantly different from the untreated group who went through ct-scan follow up indicating that anti-ntm treatment did not lead to radiological abnormalities reversion [ ] . the present study has strengths and limitations. the strength is the study of the largest cohort so far of ntm lung diseases in patients without systemic immunodeficiency with exhaustive data collection and blinded radiological assessment. we acknowledge the biases that contribute to mitigate conclusions from the study such as being conducted in a single center, the important differences in physician's management resulting in lack of consistency in treatment decision making, the number of missing data. in addition, the ct-scans were not performed at fixed intervals, particularly in the untreated subset of patients. finally, treatment duration and outcome criteria were not standardized, which prevent to properly assess treatment efficacy. useful consensus definitions for key outcome parameters to be used in the treatment of ntm lung diseases have been released very recently, which should harmonize data collection regarding ntm treatment [ ] . future researches are necessary to better define criteria associated with progressive active ntm disease in the immunocompetent setting. concretely, this preliminary study has led to implement in our institution a standardized appraisal for the diagnosis of ntm lung diseases in this particular setting ( table ). the aim is to provide a future basis for the development of a diagnosis scoring system supporting anti-ntm treatment decision. future studies should focus as well on the most relevant ct imaging variables associated with response to treatment over time that may be applied in future clinical trials to assess treatment outcome. in summary, the main factors supporting anti-ntm treatment decision in immunocompetent were low bmi, hemoptysis, lung excavation(s), prior anti-ntm treatment and aspergillus pp. co-infection, the latter being the only independent factor. anti-ntm treatment did not achieve radiological abnormalities reversion, as pulmonary lesions assessment showed no difference between the treated and the untreated patients. a diagnosis of ntm lung disease in an immunocompetent patient requires investigating the presence of a chronic pulmonary underlying disease. pulmonary disease caused by non-tuberculous mycobacteria nontuberculous mycobacterial lung disease: the top ten essentials leveraging advances in tuberculosis diagnosis and treatment to address nontuberculous mycobacterial disease pulmonary nontuberculous mycobacterial disease prevalence and clinical features: an emerging public health disease an official ats/idsa statement: diagnosis, treatment, and prevention of nontuberculous mycobacterial diseases british thoracic society guidelines for the management of non-tuberculous mycobacterial pulmonary disease (ntm-pd) pulmonary disease by nontuberculous mycobacteria-clinical management, unmet needs and future perspectives patients with nontuberculous mycobacterial lung disease exhibit unique body and immune phenotypes factors which influence treatment initiation for pulmonary non-tuberculous mycobacterium infection in hiv negative patients; a multicentre observational study lack of adherence to evidence-based treatment guidelines for nontuberculous mycobacterial lung disease are guidelines on the management of non-tuberculous mycobacteria lung infections respected and what are the consequences for patients? a french retrospective study from early results (at months) with intermittent clarithromycin including regimens for lung disease due to mycobacterium avium complex intermittent antibiotic therapy for nodular bronchiectatic mycobacterium avium complex lung disease nontuberculous mycobacterial disease and aspergillus-related lung disease in bronchiectasis nontuberculous mycobacterial lung infection complicated by chronic necrotising pulmonary aspergillosis chronic necrotizing pulmonary aspergillosis as a complication of pulmonary mycobacterium avium complex disease chronic pulmonary aspergillosisrationale and clinical guidelines for diagnosis and management treatment outcome definitions in nontuberculous mycobacterial pulmonary disease: an ntm-net consensus statement the authors gratefully acknowledge pr gilles devouassoux for helpful insights. no external funding was received for this study. the datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. authors' contributions jp contributed to conception and design of the study, acquisition of the data, interpretation of the data, drafted the manuscript and approved the final version; fv carried out the statistical analysis, participated in revision of the paper for important intellectual content, and approved the final version; dg carried out the blinded review of ct-scans with the examination of each imagery, she participated in revision of the paper for important intellectual content, and approved the final version; gl and od are in charge of the mycobacteria laboratory and have provided ntm strain identification and drug susceptibility tests. they participated in revision of the paper for important intellectual content, and approved the final version; sr, nf, ep, pjs, lkm, and cc contributed to acquisition of the data, revision of the paper for important intellectual content, and approved the final version; fa and as are the project initiators, contributed to conception and design of the study, drafted the manuscript and approved the final version. fa coordinated the project until the submission of the article. all authors read and approved the final manuscript. the ethics committee of lyon university hospital (comité d'ethique, hospices civils de lyon) approved the study under the number - . because of the retrospective observational nature of the study and the lack of any modification in patients' management, the need for informed consent was waived with the authorization of the ethics committee of lyon university hospital (comité d'ethique, hospices civils de lyon), which approved the study under the number - . not applicable. the authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. no writing assistance was utilized in the production of this manuscript. springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.author details département de pneumologie, hospices civils de lyon, lyon, france. key: cord- -vboa xn authors: richards, j. a.; beaumont, i.; beech, a. n. title: coronamolars? date: - - journal: br dent j doi: . /s - - - sha: doc_id: cord_uid: vboa xn nan acceptance of the virtual clinic concept in maxillofacial surgery: a departmental survey. br j oral maxillofac surg ; : - . https://doi.org/ . /s - - - dental education sir, the last months of dct in oral and maxillofacial surgery have highlighted challenges and complications presented by facial aesthetic treatments. a mysterious alteration in the soft tissue profile of a pre-operative orthognathic case was explained when the patient revealed a recent use of filler injections. a similarly difficult clinical assessment involved a mucocele of the lip, in which the patient admitted to lip enhancement injections a few weeks prior to the swelling appearing. an infected facial sebaceous cyst in a history of 'silhouette face lifts' , which reportedly involved insertion of needles into the face, raised questions as to appropriate follow-up and with whom responsibility should lie to identify adverse outcomes. reality tv, notably love island and years younger in days, may reflect increasing demand for aesthetic treatments. dentists advertising themselves as an 'aesthetic doctor' seem commonplace on social media platforms, widening accessibility to these services. this may be prompting a culture of self-identifying perceived unappealing physical traits and fuelling a vulnerability towards a desire to alter facial appearance. the british association of aesthetic plastic surgeons warn that 'people who struggle with their psychological health can feel pressured to turn to "quick fix" procedures to improve their appearance' and recommend pre-treatment psychological assessments. with mental health becoming increasingly topical, i question how equipped dentists are in assessing psychological wellbeing in this context. conditions such as body dysmorphia could be implicated and missed with damaging repercussions. i am unaware of any dental schools teaching facial aesthetic treatments including dermal fillers as part of the undergraduate course. it is therefore somewhat unsettling that dentists can attend a one-day course before providing treatments such as 'nonsurgical rhinoplasty' when they have likely had no training on this in their professional degree. increasingly concerning is the practice of non-dentists providing facial aesthetic treatments, such as pharmacists, nurses and midwives, who will have limited, if any, knowledge or consideration for oro-facial anatomy and pathology. these practitioners may underestimate the scope for serious complications alongside varied experience in obtaining informed consent. the gdc state that you must 'undertake appropriate additional training to attain the necessary competence' and you 'must not mislead patents into believing that you are trained and competent to provide other services purely by the virtue of your primary qualification'. what constitutes appropriate additional training and how practitioners can evidence competence is open to interpretation. it seems obvious that change is required in the regulations surrounding facial aesthetic procedures, particularly training of practitioners and steps to protect psychological health. it may be sensible to include such training within the bds degree given the large proportion of dentists going on to provide these services. j. virdee, harrow, uk cosmetic surgery trends: reduction in overall numbers as industry associations campaign for education and tighter regulation gdc guidance on advertising we have all been taught in our undergraduate training about 'mulberry molars' from maternal syphilis and hypoplastic first molar teeth in which maternal viral infection has been implicated. we wonder, due to the current covid- global health crisis, will we see 'coronamolars' in six or so years' time and what will their form take? https://doi.org/ . /s - - - sir, it was interesting to see how undergraduate orthodontic teaching has progressed since the early computer assisted learning (cal) pioneers professor chris stephens and penny grigg in the s. , chris pioneered the use of computers not only in orthodontic teaching, but also early ai in treatment planning and teledentistry for orthodontic advice. but, way back then it was not known as blended learning, key: cord- -pp m xk authors: venkatesan, sudhir; myles, puja r.; leonardi-bee, jo; muthuri, stella g.; al masri, malak; andrews, nick; bantar, carlos; dubnov-raz, gal; gérardin, patrick; koay, evelyn s. c.; loh, tze ping; memish, ziad; miller, elizabeth; oliva, maria e.; rath, barbara a.; schweiger, brunhilde; tang, julian w.; tran, dat; vidmar, tjasa; waight, pauline a.; nguyen-van-tam, jonathan s. title: impact of outpatient neuraminidase inhibitor treatment in patients infected with influenza a(h n )pdm at high risk of hospitalization: an individual participant data metaanalysis date: - - journal: clin infect dis doi: . /cid/cix sha: doc_id: cord_uid: pp m xk background. while evidence exists to support the effectiveness of neuraminidase inhibitors (nais) in reducing mortality when given to hospitalized patients with a(h n )pdm virus infection, the impact of outpatient treatment on hospitalization has not been clearly established. we investigated the impact of outpatient nai treatment on subsequent hospitalization in patients with a(h n )pdm virus infection. methods. we assembled general community and outpatient data from clinical centers in different countries collected between january and december . we standardized data from each study center to create a pooled dataset and then used mixed-effects logistic regression modeling to determine the effect of nai treatment on hospitalization. we adjusted for nai treatment propensity and preadmission antibiotic use, including “study center” as a random intercept to account for differences in baseline hospitalization rate between centers. results. we included patients with influenza a(h n )pdm , of whom ( . %) had laboratory-confirmed infection. eight hundred seventy-three patients ( . %) received outpatient or community-based nai treatment, of ( . %) with available data had dyspnea or respiratory distress, and hospitalizations occurred in ( . %). after adjustment for preadmission antibiotics and nai treatment propensity, preadmission nai treatment was associated with decreased odds of hospital admission compared to no nai treatment (adjusted odds ratio, . ; % confidence interval, . – . ). conclusions. in a population with confirmed or suspected a(h n )pdm and at high risk of hospitalization, outpatient or community-based nai treatment significantly reduced the likelihood of requiring hospital admission. these data suggest that community patients with severe influenza should receive nai treatment. to also suggests that nais given to high-risk community patients with influenza may reduce subsequent hospitalization [ ] . to the best of our knowledge, similar data on hospitalization during the - pandemic period are absent. we therefore performed a global individual participant data (ipd) metaanalysis to address this question. research centers participating in the post-pandemic review of anti-influenza drug effectiveness (pride) study were identified while conducting a metaanalysis of published studies on the effectiveness of nai treatment in hospitalized patients [ ] . a detailed description of the pride study has been published previously [ ] . in total, the pride consortium obtained data on potentially eligible patients from research centers in countries across world health organization regions. a subset of these centers provided community or outpatient data, which were then used for the current analysis. no data were provided or funded for collection by pharmaceutical companies. the protocol for this study was registered with the prospero register of systematic reviews (crd ) [ ] . data were available on community patients or those attending outpatient clinics with laboratory-confirmed or clinically diagnosed influenza a(h n )pdm from centers (argentina, canada, france, germany, israel, saudi arabia, singapore, slovenia, and the united kingdom). these were standardized using a data dictionary (supplementary table ) before pooling for analysis. the primary outcome variable was influenza-related hospital admission as determined by case records linking admission to the influenza illness episode. the primary exposure variable was treatment with an nai initiated in any community or outpatient setting as compared to no nai treatment in the community or outpatient setting. if data were available, we further distinguished early treatment (nai started ≤ days after symptom onset) vs later treatment (> days after symptom onset). we excluded from all our analyses those patients who received nai treatment in the community on the day of hospital admission, on the grounds that treatment would not have had sufficient opportunity to work in these patients. this exclusion also accounts for any physician decisions to prescribe nais taken after a decision to admit the patient to the hospital, amounting to confounding by indication. covariates adjusted for in the final multivariable model were outpatient or community-based antibiotic treatment (yes/no) and propensity score (by quintile) for receiving nai treatment in the community. we computed propensity scores for the likelihood of community-based nai treatment for individual patients within each contributing dataset using the method described by hirano and imbens [ ] . multivariable logistic regression models developed to calculate propensity scores included the following covariates: age, sex, presence of a comorbid condition (yes/no), and an indicator of disease severity (in order of preference: documented severe respiratory distress or shortness of breath). the resulting propensity scores were then categorized into quintiles for use in subsequent analyses. in the primary analysis, we used a mixed-effects logistic regression model to investigate the association between community-based nai treatment and subsequent hospital admission using the xtmelogit command in stata (version ). to account for differences in baseline outcome between individual datasets, we included individual study centers as a random intercept. we ran both unadjusted and adjusted models, the latter containing covariates for community-based antibiotic treatment and propensity scores. to allow for comparisons between the unadjusted and adjusted models, we included missing data as a dummy variable category. the c-statistic (area under the receiver operating characteristic curve) was used to assess model fit. where data were available, we explored the potential impact of timing of nai administration (early nai treatment vs later nai treatment) on hospitalization. we also performed stratified analysis in patients with laboratory-confirmed a(h n )pdm influenza and adults (aged ≥ years) and children. furthermore, we carried out an additional analysis restricted to patients with high-risk conditions. patients were classified as having a high-risk condition if they had at least chronic illness recorded that would trigger seasonal influenza vaccination [ ] or were aged ≥ years. results from our mixed-effects logistic regression models are presented as odds ratios (ors) with % confidence intervals ( % cis). we received outpatient data on patients with clinically or laboratory-confirmed influenza from centers. however, centers (n = patients) offered surveillance data that did not contain clinical data on either nai use or subsequent hospitalization status. therefore, the final study population comprised patients from study centers ( figure ). data from of the included study centers (n = patients) came from outpatient (ambulatory care) clinics attached to hospitals. of the remaining study centers, provided community surveillance data collected by a local ministry of health (n = ) and the other provided data from primary care (n = ). three of the included centers (canada, germany, and israel; total n = ) were from pediatric outpatient clinics and comprised entirely of patients aged < years. patients from the german study center were particularly young with a median age of . years (supplementary table ). of patients in our pooled dataset, ( . %) had laboratory-confirmed a(h n )pdm infection; ( . %) were children (< years) and ( . %) were aged > years. overall, ( . %) were admitted to the hospital and ( / ; . %) had clinically observed shortness of breath or respiratory distress as a marker of severity. where data were available (n = ), the median interval between date of symptom onset and date of nai treatment initiation was day (interquartile range [iqr], - ) for the whole study population, day (iqr, - ) for nonhospitalized patients, and day (iqr, - ) for hospitalized patients. of the hospitalized patients, where calculable (n = ), the median interval between date of symptom onset and date of hospital admission was days (iqr, - ). general characteristics of the study population are presented in table . about one half ( . %) of the cohort was eventually admitted to the hospital, and . % had or more indications of severe respiratory illness as denoted by observed shortness of breath or respiratory distress. in addition, fewer than % of the cohort were elderly and about % had no recorded comorbid conditions, suggesting that most patients were young and previously healthy. indeed, . % were children and . % of women aged - years were pregnant, reflecting the inclusion of obstetric clinic (n = ) within the data. of the patients who were hospitalized, we had data on the subsequent course in patients. of these hospitalized patients, ( . %) were treated with nais in-hospital, patients ( of subsequent hospital stay in a smaller subgroup of patients where the median length of stay was days (iqr, - ; median, days [iqr, [ ] [ ] [ ] [ ] in treated and median, days [iqr, . - ] untreated). of the patients who were excluded from the analyses because they were hospitalized on the same day as nai treatment initiation, ( %) were admitted to critical care facilities and ( . %) died. in of these patients on whom we had pneumonia data, ( . %) were found to have had clinical signs of pneumonia; in ( . %) of these patients the pneumonia was radiologically confirmed. the median length of hospital stay in an even smaller subgroup (n = where data were available) was found to be days (iqr, - ). in patients with laboratory-confirmed or clinically diagnosed a(h n )pdm influenza, after adjustment for community-based antibiotic treatment and propensity score, the likelihood of hospital admission in patients with outpatient or community-based nai treatment was . ( % ci, . - . ) when compared to no nai treatment in the community (table ) . a c-statistic of . ( % ci, . - . ) suggested that the predictive performance of our model was acceptable. when restricted to laboratory-confirmed a(h n )pdm patients, the estimate was very similar to the estimate for the overall study population ( table ) . nai treatment, when in the pooled dataset, patients ( . %) were recorded to have at least high-risk condition. in this subpopulation of higher-risk patients, we also observed a reduction in the odds of hospital admission (or, . ; % ci, . - . ) in those treated with nais in the community compared with no nai treatment. full results of the sensitivity and stratified analyses are summarized in table . the hospital admission rate varied widely among each of the included study centers, ranging from . % to . %. to separate any effects that hospital admission rates among centers may have had on the association between nais and hospitalization, we did a post hoc stratified analysis by median hospitalization rate ( . %). after adjusting for community-based antibiotic treatment and propensity score, the pooled or for the association between nai treatment and subsequent hospitalization in study centers with a hospital admission rate < . % (n = ) was . ( % ci, . - . ), whereas in centers where the admission rate was > . % (n = ), the or was . ( % ci, . - . ). in this study, we assembled data from a large cohort of community-based patients who had pandemic influenza in - , of whom % had laboratory confirmation of influenza a(h n )pdm infection. the demographic and clinical findings (table ) reveal that most patients were young and previously healthy, yet with relatively severe influenza (indicated by the presence of either documented severe respiratory distress or shortness of breath at presentation). as such, we recognize that our results are not generalizable to a wider range of community-based patients with mild pandemic influenza and may not be generalizable to the elderly. our main findings ( table ) suggest that nai treatment in the community for patients with severe pandemic influenza substantially reduced the likelihood of hospital admission due to influenza a(h n )pdm . in a pandemic context, individuals generally have little or no preexisting cross-reactive immunity to the infecting virus; therefore, effect size might be lower for seasonal (interpandemic) influenza, and our findings should be interpreted with more caution in that context. in a sensitivity analysis restricted to patients with laboratory-confirmed a(h n )pdm , this finding was unaltered; and in patients with underlying at-risk conditions, the risk reduction was greater. a limitation of our analysis is that we did not have data on body mass index and therefore could not include obesity as a high-risk condition. we also explored potential differences in effect size between adults and children and found that the effect of nais in reducing the likelihood of hospital admission was maintained and broadly consistent in both age groups. these findings contrast with our previous analysis of mortality data, in which we failed to demonstrate significantly reduced mortality in hospitalized children treated with nais [ ] . this discrepancy is potentially explained by the relatively high attack [ ] and hospitalization rates in children with a(h n )pdm [ ] compared with a relatively low case fatality rate [ ] but could also relate to statistical underpowering in the mortality study [ ] . a question of considerable clinical relevance relates to the timing of antiviral treatment in relation to the magnitude of benefit obtained, especially since data already exist to suggest that symptom alleviation and mortality reduction are both diminished by delayed treatment [ , ] . we were able to perform a sensitivity analysis on nai-treated patients in whom we had specific data on the timing of symptom onset and antiviral treatment. this revealed that earlier treatment (within hours of symptom onset) was significantly more beneficial than later treatment. because the dataset contained so few elderly patients, perhaps reflecting the low incidence of a(h n )pdm infection in the elderly [ , ] , we were unable to cast any further light on the effectiveness of nais in this particular subgroup of patients. although smaller than our previous ipd analysis that focused on mortality reduction in hospitalized patients [ ] , one strength of this study is the relatively large number of patients included from geographically diverse clinical centers. although we were unable to adjust specifically for disease severity in our multilevel models because of the heterogeneity of severity measures used across individual datasets, we nevertheless included physician-recorded breathlessness and severe respiratory distress when deriving propensity scores. however, we acknowledge that confounding by indication [ ] may still be present. if it is, we surmise that physicians may have been more likely to treat severe cases than milder ones or to treat putative at-risk groups such as pregnant women with nais. therefore, the treated group would have a higher underlying likelihood of being admitted to the hospital; this in turn would produce a bias in the analysis, tending toward underestimation of any treatment effect. likewise, we recognize that some nai treatment may have been given immediately prior to hospital admission when there was no practical window in which an antiviral drug could have had time to work or perhaps even when the physician had already decided that the patient needed to be admitted. therefore, we think there is sound clinical rationale for excluding patients in whom nai treatment was initiated on the day of hospital admission. another potential limitation of our propensity scoring approach is that we lacked data on vaccination, albeit knowledge of vaccination status might be associated with physicians' decisions to prescribe nais and to hospitalize patients. to explore this further, we determined that patients whose illness onset was on or before october could not have been vaccinated due to nonavailability prior to this date. even if they had been vaccinated, they would not have had time to seroconvert. we subsequently performed a stratified analysis around this date by dividing the overall pooled dataset into "early pandemic" and "later pandemic. " we had onset dates in patients of whom were on or before october . the adjusted ors ( % cis) in both groups were very similar (early pandemic group, . ( . - . ) and late pandemic group, . ( . - . )]. on this basis, we believe that vaccination is unlikely to have been a major confounder in our study. other residual confounding is nevertheless possible as these are observational data. two obvious drawbacks in our data are the overall high rate of hospitalization in the cohort studied, which limits generalizability to patients at high risk of hospitalization, and the substantial variability between hospitalization rates across individual centers, ranging from % to %. the dataset with the lowest hospitalization rate was from a surveillance system in the united kingdom where a national policy was in place for - to offer nai treatment to all patients with clinically apparent influenza, irrespective of severity. stratifying the analysis around median hospitalization rate revealed no effect of nais in centers below the median but revealed a strong positive effect in centers above the median. we surmise that these data confirm the beneficial effect of nais (beyond symptom relief) in patients who are severely unwell and at high risk of hospitalization vs those with milder illness. to our knowledge, this is the first individual participant data metaanalysis to investigate the association between preadmission nai antiviral use and hospitalization relating to the - influenza pandemic. as such, these data have potential importance for future pandemic stockpiling and treatment policies and may be of relevance to seasonal epidemics, especially for community patients with relatively severe influenza and those with underlying comorbidities. we note that our point estimates of treatment effectiveness are somewhat higher than the % reduction in hospitalization for the treatment of seasonal influenza previously reported by hsu and colleagues [ ] . however, the disparity in effect size might be explained by the fact that the studies [ ] metaanalyzed by hsu et al included patients with generally milder influenza than in the present study. in addition, of these studies were based on diagnoses of influenza-like illness (ili) without laboratory confirmation and therefore were highly vulnerable to misclassification bias. an earlier pooled analysis of clinical trial data from patients with laboratory-confirmed seasonal influenza also showed a % reduction in hospitalization [ ] . this was confirmed in recent ipd analysis of seasonal influenza patients that reported a risk reduction of % in treated patients (intention-to-treat infected population) [ ] , which is somewhat similar to our own data. another study not included in hsu's metaanalysis also suggested a % reduction in hospitalization associated with oseltamivir but was again based on diagnoses of ili without laboratory confirmation [ ] . a recent study from british columbia, based on clinically diagnosed cases of pandemic influenza a(h n )pdm , also noted % effectiveness of nais in reducing hospitalization [ ] ; however, the hospitalization rate in this cohort was . %, suggesting cases were comparatively very mild. we therefore recognize that our findings reflect the experience of nai use in a cohort of community patients at high risk of hospitalization. in addition, we noted higher effectiveness in patients with or more comorbidities that would have placed them in a target group for annual seasonal influenza vaccination. placed in the context of the limited previous work on this subject, our findings suggest that the greatest benefit from community use of nais is likely to be achieved by targeting individuals for treatment who have clinically suspected or proven influenza and who are also in a recognized at-risk group or clinically assessed to have severe influenza (irrespective of comorbid status). in these groups of patients, substantial reductions in the likelihood of hospitalization can be achieved, especially if treatment is commenced within hours of symptom onset. our data support current advice on nai treatment given by major public health agencies [ , ] and the findings of a recent independent report from the uk academy of medical sciences and the wellcome trust, which recommend against use of nais in the community for the treatment of mild influenza, but advise that patients with severe influenza should be treated as soon as possible [ ] . supplementary materials are available at clinical infectious diseases online. consisting of data provided by the authors to benefit the reader, the posted materials are not copyedited and are the sole responsibility of the authors, so questions or comments should be addressed to the corresponding author. financial support. the pride study is funded via an unrestricted educational grant from f. hoffmann-la roche, switzerland (the manufacturers of oseltamivir [tamiflu]). the funder had no role in protocol design, no opportunity to comment on it, and no opportunity to see it other than via the prospero website; no access to any data (and no rights to future access); no role in analysis or interpretation; no opportunity to preview results/findings before entry into the public domain; and no opportunity to contribute to, preview, or comment on manuscripts and presentations arising from this work. the research contract between the university of nottingham and the funder is freely available for inspection (commercial details redacted) at: http://www.nottingham.ac.uk/research/groups/healthprotection/projects/pride.aspx potential conflicts of interest. b. a. r. reports grants from f. hoffmann-la roche to her institution (charité universitätsmedizin berlin) outside the submitted work. d. t. reports grants from the canadian institutes of health research/sickkids foundation new investigator (xg - r), the canadian institutes of health research catalyst (cat ), and the university of toronto dean's fund pilot study grant during the conduct of the study. j. s. n.-v.-t. reports that a grant to the university of nottingham from f. hoffmann-la roche funded the current study; he also reports grants to the university of nottingham from glaxosmithkline for research in the area of influenza; and nonfinancial support from the european scientific working group on influenza to lecture on influenza outside the submitted work. all other authors: no potential conflicts of interest. all authors have submitted the icmje form for disclosure of potential conflicts of interest. conflicts that the editors consider relevant to the content of the manuscript have been disclosed. antivirals for influenza: where now for clinical practice and pandemic preparedness? evidence and policy for influenza control neuraminidase inhibitors for preventing and treating influenza in adults and children impact of neuraminidase inhibitor treatment on outcomes of public health importance during the - influenza a(h n ) pandemic: a systematic review and meta-analysis in hospitalized patients effectiveness of neuraminidase inhibitors in reducing mortality in patients admitted to hospital with influenza a h n pdm virus 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agents for the treatment and prophylaxis of seasonal influenza ( − ) version . use of neuraminidase inhibitors in influenza key: cord- - zuij i authors: frank, johannes; barker, john h.; marzi, ingo title: necrotizing fasciitis of the extremities date: - - journal: eur j trauma emerg surg doi: . /s - - - sha: doc_id: cord_uid: zuij i necrotizing fasciitis (nf) describes a life threatening soft tissue infection characterized by a rapid spreading infection of the subcutaneous tissue and in particular the fascia. various synonyms for this type of infection are used, often due to the difficult diagnosis. necrotizing fasciits of the extremities is found after simple skin lacerations and often in rural, farming or garden setting environments. many of the infections are found in immunologically healthy people, but persons revealing a compromised wound healing are endangered additionally, e.g., diabetes. in the majority of the microbiological analyses, streptococci alone or a mixture with mainly anaerobic bacteria may be detected. the management of infected extremities requires a rapid diagnosis, dedicated aggressive surgical management as soon as possible, and a wide debridement extending the border of the infected fascia. timely surgical revisions within the first day or days together with antibiotic treatment are the only measures to stop the infection. depending on the status of the patient a hyperbaric oxygenation treatment seems to be useful in order to limit the infection. in fulminated cases early amputations, maximal intensive care treatment of the septic patient are required, where all means are warranted to save the patients life. as a consequence, early clinical diagnoses with thorough surgical debridement of the infected liquid necrotic fascia as well as correct antibiotic treatment are needed. secondary plastic reconstruction of the soft tissue defects will generally be required. necrotizing fasciitis (nf) is an infection accompanied by spreading crepitating edema and blister formation. it was first described by hippocrates in the fifth century as erysipelas [ ] . in the eighteenth century a detailed description of nf was provided by british naval physicians and in the early nineteenth century, it was named as gangrenous ulcer, putrid ulcer, malignant ulcer, phagedenic ulcer, phagedena, and phagedena gangrenosa and hospital gangrene [ ] . in , during the civil war, j. jones, an american surgeon, mentioned more than , cases very possible nf. afterwards pfanner described in in the german medical literature the clinical picture of necrotizing erysipelas and found streptococci related to the disease [ , ] . in , meleney used the name hemolytic streptococcal gangrene [ ] . since then, various names have been given to nf (table ) . finally, in , wilson used the term necrotizing fasciitis (nf). the anogenital manifestation of nf was first described by fournier in and is since then called fournier's gangrene [ , ] . the early onset of this type of soft tissue infection is a discrepancy between pronounced pain and clinical appearance. the aggressive progression induces finally skin and fascia necrosis, coagulopathia and cellulites. five diagnostic criteria can be defined ( table , [ ] ). the missing isolation of clostridium perfringens does not necessarily exclude gas gangrene nor prove nf. in patients suffering from nf, more often diabetes, hypertonic blood pressure, arterial occlusive disease, and obesity are found as well as higher percentage of alcohol and drug abuse, immunosuppressant therapy and hivinfections. even a varicella zoster virus infection in combination with the use of nsaids is discussed as risk factor [ ] . it is more likely to appear in elderly people, but children also can be affected. in the literature various reasons have been related to the primary focus and include minor skin lesions, bites of insects and wounds after surgical procedures [ ] . initial microbiological tests discover in a high amount streptococci (app. %), a mixture of different bacteria and less common pseudomonas aeruginosa (app. %, table ). due to an increased amount of invasive streptococcal infections in the us during the s, a ''streptococcal septic shock syndrome (stss)'' was defined. this is characterized by a systemic sepsis with multiple organ failure, especially the kidney. today, nf caused by streptococci group a is classified as a subgroup of this infection. also myositis caused by streptococcimostly due to direct inoculation/contaminationshould be differentiated. in such cases rapid lyses of the involved muscle, with edema formation, focal development of a compartment syndrome with consecutive necrosis is observed [ ] [ ] [ ] [ ] [ ] [ ] . therefore necrotizing soft tissue infections (nsti's) characterize various diseases. clinically they can be separated in superficial infections involving cutis/subcutis and deep infections affecting fascia and muscle (nf, myositis). these deep infections are further classified as type i (polymicrobial) and type ii (monomicrobial). bacterial factors play an important role in nsti. in the cases of invasive streptococcal infections, surface proteins (m , m ) increase adhesion and prevent phagocytosis and exotoxines (a, b, c, streptococci super-antigen) induce the release of cytokines and could bind to t-cell receptors causing further release of tnf-a, il- and il- ending in a stss [ , ] . although m-types and are common other types have been isolated in invasive infections; however, a stable genetic change was observed in m-type group a streptococci in the s, resulting in its ability to produce nicotinamide adenine dinucleotide glycohydrolase (nadase) and might be one factor in severe invasive infections [ ] . the rapid tissue destruction is a result of toxin-induced vascular occlusion. as the infection progresses more toxins are produced and tissue destroyed. this microvascular occlusion contributes to shock and organ dysfunction. in the case of nf early diagnosis is critical with respect to the survival of the patient. this is primarily a clinical diagnosis with no typical changes in lab diagnostics. serum creatinine phosphokinase (cpk) might be useful in detecting deeper soft-tissue infections. even a mild leukocytosis could be combined with an increasing percentage of immature neutrophils and should be a reason to be suspicious. renal impairment precedes hypotension, as well as hypoalbuminemia and hypocalcemia are early signs. especially in the extremities the bacteria are inoculated mostly through a minor skin lesion. the infection is in the early stage characterized by un-proportional local pain due to fascia necrosis. after this, skin changes are visible with edema and erythema ( figure ). the typical pattern of skin necrosis with or without blisters is found later; however, the necrosis generally spreads rapidly in the proximal direction. the necrosis of the fascia has already much further spread, compared to the changes of the skin ( figure ). crepitating skin can be recognized in about % of the patients and is suspicious of a poly-bacterial infection. the typical clinical signs are listed in table . since the time to surgery needs to be diminished no demanding diagnostics like histology or bacterial isolation is possible. to support the diagnosis of nf ultrasound can be used demonstrating fluid between the muscle and subcutaneous tissue because of fascia necrosis. sometimes x-rays can reveal gas formation which could be easily palpated. ct or mri could be of some use, but with little impact on the final decision to proceed to the operative treatment. mri has some impact due to soft tissue and multiplanar imaging and might be helpful in case the source of infection lies deep inside the body. during surgery an excision biopsy could be done, but the typical discoloration of the fascia (yellow to green) and the possibility to manually dissect the fascia (like chewing gum) will assure the diagnosis. in contrast to myositis caused by streptococci the muscles appear normal and not as necrotic with a discoloration, brown to grey, comparable to loam. stss is more often found in association with pharyngitis, or small lesions of the skin or mucosa (scratches, insect bites). this syndrome appears in normally healthy people of all ages, in children more often seen following chickenpox infection [ ] . isolation of streptococci group a is typical -also in normally sterile body compartments -and of course the signs of a systemic shock. however, % of the stss cases are accompanied by nf. the typical serious soft tissue infections are listed in table . the relevance of a surgical management could be proved by kaiser and cerra. a reduced surgical treatment was followed by a significant increase of death rate [ ] . there is no space for incision and drainage or limited evacuation of the abscess. the only surgical option is the radical surgical excision of the infected subcutaneous tissue in particular including the grey pale fascia. in these cases, the fascia is grey, has lost all its strength and can more or less be pealed off. it is essential to resect the infected fascia and to debride into healthy tissue. furthermore, it is essential to follow up by surgical re-interventions after a short time -even again on the same day in fulminant cases or at least the subsequent day. in general this regime is followed a few days until the spreading in the proximal direction has been stopped. an amputation in the extremities is not the primary treatment, but in cases where the whole tissue is necrotic and most muscles involved, this might be the only option to stop further spreading and systemic sepsis with multiple organ failure. these amputations have to be performed as open amputations, again requiring second look operation and secondary closure. after primary intensive care and control of the infection and sepsis (mostly after week) reconstructive procedures are initialized reaching from secondary wound closure and skin grafting to flap coverage saving viable tissue and restore function. histology histology of the excised tissue reveals infiltration of fascia by polymorphic nuclear cells, with peri-vascular focus. sometimes bacteria are detectable. later, a co-liquation necrosis of the fascia is visible, involving subcutaneous tissue and skin. the tissues cannot be differentiated anymore and muscle tissue is involved as well. demanding a radical debridement, therefore the resulting wound areas are extensive in most cases and therefore the increased fluid turnover already justifies an intense care treatment. an adjusted antibiotic regime is mandatory. in undefined cases gram-negative, gram positive and anaerobic bacteria must be addressed. mono-therapy includes imipenem-cilastatin, meropenem, ertapenem, piperacillin/tazobactam and tigecycline. a combination-therapy adds vancomycin, linezolid or daptomycin to a carbapenem or b-lactam/ b-lactamase inhibitor combination, if methicilin-resistant staphylococci are possible. another combination therapy includes penicillin, clindamycin and fluoroquinolone or aminogycoside to cover gram-negative bacteria. in a case of streptococcal infection clindamycin should be included into the medication, since it has been shown to inhibit the toxin production (m-protein and exotoxin) in severe cases [ ] . especially streptolycin o (slo) induces changes to the leukocytes. it is specific to phenoloxidase important in the mechanism of host defense and much reduced in nf-cases due to streptococci infection. this significant immunosuppressive effect is accompanied by the effect that phenoloxidase catalyses the transformation of tyrosine to dehydroxy-phenylalanine necessary to produce catecholamine, one reason a patient with nf might need catecholamine substitution. additionally, some immunotherapies (e.g., immunoglobulins) are also suggested by some authors [ ] . the mechanism is believed to be related to the neutralization of superantigen activity and reduction of tnf-a and il- . intensive care therapy various efforts have been made to categorize patients with respect to the risk of mortality. negative parameters are age above years, wbc > , cells/ mm , hematocrit > %, hr > , temperature < °c and creatinine > mg/dl [ ] . if the patient develops a septic shock or stss an acute respiratory distress syndrome (ards) is also very likely (app. %) and needs mostly intubation and mechanical ventilation to achieve adequate oxygen supply. every patient with signs of sepsis or impaired immune response should have intensive care treatment, since organ failure is very common in the time course of nf. the patients are at an extremely high risk to run into systemic sepsis with a poor prognosis. good oxygenation, cardiac output and control of homeostasis are the primary goals in treating a systemic sepsis and septic shock according to the current guidelines [ ] . these guidelines have to be included stepwise in the treatment of sepsis due to necrotizing fasciitis. additional treatment options to enhance systemic toxin and mediator reduction have been discussed, such as continuous hemofiltration [ ] . due to the variation and limited number of patients in single centers, this approach has been only applied in isolated cases [ ] . besides the basic treatment including intensive care medicine and surgical debridement numerous adjuvant therapies have been recommended with respect to the systemic management of these infections as well as possibilities for local wound treatment. hyperbaric oxygenation (hbo) necrotizing infections are considered to be one of the primary indications for hbo as well as decompression disease, gas embolism, co-and smoke intoxication, anaerobic infections (clostridia infections) and radionecrosis [ ] . hbo-therapy is able to increase blood oxygen content by % and thereby tissue oxygenation tenfold [ ] . other effects related to this treatment are vasoconstriction, reduced leukocyte sequestration, lipid peroxidation, free radical scavenging and reduction of tissue edema resulting in an increased tissue perfusion/microcirculation [ ] [ ] [ ] . another important effect, thought to be helpful in treating nf by improving host defense, is the activation of leukocytes. also reparative processes might be stimulated due to fibroblast migration, proliferation and collagen synthesis [ , , ] . these effects might be very helpful to support healing/granulation tissue formation of these mostly difficult wounds [ ] . various treatment regimes are recommended to be followed-up; however the most intense is that in accordance with crush injury with three treatments within the first hours ( - . ata, - h o breathing), followed by two treatments the next h and finally h once a day. since the use of hbotreatment is connected with high medical and technical expenditure, especially if the patient is critically ill due to sepsis and needs breathing support, estimation is necessary, also the literature is controversial about the effects on morbidity and mortality rates [ , , ] . however, this therapy needs to be considered focusing an increasing network and therapeutic standard in hbo-treatment. another possibility to increase oxygen in the body is an intravenous application (regelsberger's intravenous oxygen therapy). however the effect needs to be proved for nf, also with respect to an increase of granulocytes [ ] . therefore the major focus in nf should be related to intensive care management and the vital surgical therapy with no delay. after primary surgical treatment in most cases a topical wound treatment is used. various substances according to the isolated bacteria can be chosen. mostly the following antiseptic substances are recommended: polyhexamid, povidon-iodine, silver sulfadiazine, actate mafenid. also wine vinegar and citric acid have been applied, especially to modify the wound environment and lower the ph in cases of pseudomonas infections. vacuum sealing is a widely used approach to condition destroyed soft tissue in order to allow granulation and a safe secondary reconstruction [ ] . it is extremely useful in cleaned wounds of the extremities and the abdomen and reduces surgical interventions to intervals between and days. in acute stages of necrotizing fasciitis, however, vacuum sealing is not indicated during the early states of purulent infections and infected tissue necrosis. but subsequently, when infected and destroyed soft tissues have been removed, vacuum sealing seems to be very useful for conditioning the defects and occasionally allowing limited tissue closure using skin graft; if not, a complex reconstruction is required [ ] . the clinical cases with nf and primary focus on the extremities are listed in tables and . most of these have had minor injuries with rapid spreading of the infection. one exemplary case is described to illustrate the significance of early operative treatment and excision of the devastated tissue. a -year-old gentleman was visiting a garden market. by lifting various flowers, he experienced a minor scratch, while handling various flowers, on the ulna side at the middle phalanx of the left ring finger. this happened on a thursday afternoon and since there was no obvious skin lesion he did not care about it. during the next night and day he experienced increasing swelling and pain of the whole hand -not only the finger. on saturday morning he consulted a local surgeon, who admitted him immediately to the hospital. the patient had already clear signs of local infection (figure ), systemic sepsis with reduced blood pressure, tachycardia and fever up to °c. immediately, he was brought to the surgery room where a primary excision of the possibly involved tissue was done, up to the elbow. however, the patient did not recover very well afterwards in the intensive care unit. finally he was brought back to surgery -on the same day -and a radical debridement was performed, including the amputation of the ring finger and excision of all obvious involved fascias (figure ). after this, four more wound care procedures were done in the operating theatre. finally after days the wounds could be closed with a pedicle groin flap and skin graft. three more reconstructive procedures were followed including flap division, and two more correction with a final skin graft ( figures and ). during the treatment period at the intensive care unit also hbo-therapy was followed daily starting at day for days. conclusion necrotizing fasciitis (nf) is a life threatening soft tissue infection, characterized by foudroyant spreading necrosis of the involved fascias. since a high variety of bacteria can be isolated the two different types of nf can be differentiated: type characterized by a poly-bacterial infection of aerobic and anaerobic bacteria and type with streptococci group a as source of infection [ ] . the type infections are less common, but are more often found in the case of the involvement of extremities. every fascia in the body can be destroyed by this disease. early diagnosis is critical to the survival of the patient and must rely on the clinical picture. when there is doubt, there should be no delay in performing surgery with radical debridement. the suggested treatment strategy with adequate early surgical and intensive care medicine could help reduce the up to % lethality rate, as stated in some publications, to less than % [ ] [ ] [ ] . infections of the extremities are less likely lethal, whereas an intra-abdominal occurrence leads mostly to the death of the patient. higher age, diabetes, arterial occlusive disease, immunosuppressant status and the onset of nf due to iatrogenic infections is linked to a much worse prognosis. nf is an infection still observed very seldom; however, some data indicate an increase of this type of infection in the last decade, therefore clinicians should be aware and alert in cases of a significant soft tissue infection to rule out nf. hippokrates: zweites buch der volkskrankheiten necrotising fasciitis, hospital gangrene, and phagedena investigations upon the nature, causes and treatment of hospital gangrene as it prevailed in the confederate armies - zur kenntnis und behandlung des nekrotisierenden erysipels hemolytic streptococcal gangrene gangrene foudroyante de la verge necrotizing fasciitis necrotizing fasciitis necrotizing cellulitis complicating varicella in two children given nonsteroidal antiinflammatory drugs chirurgisches konzept und ergebnisse bei nekrotisierender fasziitis streptococcal infections of the skin and the soft tissues a multicenter review of the treatment of major truncal necrotizing infections with and without hyperbaric oxygen therapy infections by streptococcus pyogenes: new aspects of diagnosis, epidemiology, clinical practice, and therapy changing epidemiology of group a streptococcal infections in the usa outbreak of 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oxygen therapy: committee report. kensington: undersea and hyperbaric medical society life without blood. a study of the influence of high atmospheric pressure and hypothermia on dilution of the blood reduction of postischemic edema with hyperbaric oxygen hyperbaric oxygen reduces edema, necrosis of skeletal muscle in compartment syndromes associated with hemorrhagic hypotension studies on inflammation and wound healing: angiogenesis and collagen synthesis stimulated in vivo by resident and activated wound macrophages role of oxygen in repair processes hyperbaric oxygen therapy in the management of crush injuries: a randomized double-blind placebo-controlled clinical trial hyperbaric oxygen therapy for necrotizing fasciitis reduces mortality and the need for debridements necrotizing fasciitis: an indication for hyperbaric oxygenation therapy? regelsberger's intravenous oxygen therapy -an interpretation of results in practice from a biochemical and physiological point of view literature on the subject of vacuum therapy review and update reconstruction of lower extremity fractures with soft tissue defects bacteriology of necrotizing fasciitis improved results from a standardized approach in treating patients with necrotizing fasciitis necrotising fasciitis due to group a streptococci in western norway: incidence and clinical features necrotizing fasciitis -a preventable disaster key: cord- - t zix authors: wallhult, elisabeth; quinn, barry title: early and acute complications and the principles of hsct nursing care date: - - journal: the european blood and marrow transplantation textbook for nurses doi: . / - - - - _ sha: doc_id: cord_uid: t zix haematopoietic stem cell transplantation (hsct) generally includes preparative or conditioning regimes containing chemotherapy and/or radiotherapy in high doses. these regimens, as well as other treatments before and after hsct such as immunosuppressive drugs to prevent graft versus host disease (gvhd) (see chap. ), may affect the patient’s organs and tissues and may cause both acute and long-term complications. in the evolving field of stem cell therapies, some complications that traditionally have been regarded as early complications are now, due to changes in preparative regimens and choice of stem cell source, sometimes seen later in the post-transplant out-patient setting. the complications covered in this chapter generally occur within days post hsct and are thus classified as early complications. two of the most common early complications are oral complications/mucositis and sepsis. some other relatively rare complications are also covered here: haemorrhagic cystitis (hc), endothelial damage (ed) syndromes including engraftment syndrome (es), idiopathic pneumonia syndrome (ips), diffuse alveolar haemorrhage (dah), transplant-associated microangiopathy (tam) and sinusoidal obstruction syndrome/veno-occlusive disease (sos/vod). for all complications, recommendations for prevention and principles for nursing care are presented since careful nursing monitoring, prompt intervention and care may have an influence on patients’ morbidity and mortality. oral care in transplantation mindful of the many developments in the field of hsct aimed at improving survival and quality of life, the correct and consistent approach to managing oral care problems still remains a challenge in many transplant settings across europe. there is much evidence to show that rather than taking a proactive approach to this aspect of care, many clinicians simply react to oral complications once they occur with a sometimes inconsistent and anecdotal approach. oral problems and damage may be temporary or permanent resulting in a significant health burden for the individual while making substantial demands on limited healthcare resources. however, oral complications are not always inevitable, and much can be done to reduce or minimise the severity of symptoms by taking a more proactive approach to this aspect of care. working as a multidisciplinary team with the patient at the centre of care and treatment plan, the early detection of potential and actual problems and treatment can help to reduce oral problems and prevent interruptions to treatment while maximising patient safety and comfort (national cancer institute ). oral mucositis (om) has been defined by rubenstein et al. ( ) , al-dasoogi et al. ( ) and others as the inflammation of the mucosal membrane, characterised by ulceration, which may result in pain, swallowing difficulties and impairment of the ability to talk. the mucosal injury caused by om provides an opportunity for infection to flourish, and in particular putting the severely immunocompromised patient in the hsct setting at risk of sepsis and septicaemia. om and oral problems in the hsct setting (table . ) can be expected to occur in as many as % of patients undergoing autologous hsct and % of patients undergoing allogeneic hsct (filicko et al. ; bhatt et al. ). with the increasing use of targeted drug therapies and approaches in the cancer and haematology setting, problems in the oral cavity will increase and become even more of a challenge . all treatment strategies aimed at improving mouth care are dependent on four key principles: accurate assessment of the oral cavity, individualised plan of care, initiating timely preventative measures and correct treatment (quinn et al. ). the assessment process should begin prior to hsct by identifying all the patient risks most likely to increase oral damage. each patient needs to be assessed in relation to the following risk factors that may put them at higher risk of oral complications during treatment: patients about to commence hsct should undergo dental assessment by a specialist (elad et al. ) . this is to establish general oral health status and identify and manage existing and/or potential source of infection, trauma or injury. any identified dental problems should be corrected before starting treatment regimen. some patients will need regular dental follow-up following treatment. a further baseline assessment of the oral mucosa should be taken as close to the administration of the first treatment dose as possible. the oral cavity should be assessed by trained healthcare professionals using a recognised grading system to ensure accurate monitoring and record keeping. the tool chosen should contain both objective and subjective elements. the assessment should include changes to the oral mucosa, the presence or absence of pain and the patient's nutritional status (quinn et al. ) . assessments should be completed daily during hsct and at regular intervals posttreatment to monitor for complications. patients can be encouraged to assess their own mouth using a patient-reported tool and to report any changes they notice or experience to the transplant team. • clinical tools: good light source, gloves, tongue depressor and dry gauze • patient in convenient and comfortable position • use valid and reliable assessment instrument which is easy to interpret • oral sites to be evaluated (cheeks, lips, soft palate, floor of mouth, tongue) care of the oral cavity is central to helping to prevent and/or reduce oral complications during and after treatment. the oral care team in the hsct setting includes dental professionals, dietician, nurse, doctor and pharmacist. the support provided by the team along with good communication and the patient at the centre of all care plans is central to maintaining patient's oral health. all patients should be provided with clear instructions and encouraged to maintain good oral hygiene. education should also include potential oral complications to enable patients to identify and report these early (clarkson et al. ; quinn et al. ) . all patients should receive written information, as well as verbal instruction, about oral care as part of the prevention and treatment of oral changes. good nutrition is vital in helping to fight infection, maintain mucosal integrity, enhance mucosal tissue repair and reduce exacerbation of existing mucositis. issues that may affect nutrition such as loss of appetite, taste changes and dysphagia should be addressed. there are certain foods that can damage the oral mucosa; this may include rough, sharp and hard foods and should be avoided. spicy, very salty and acidic foods may cause mucosal irritation but may be preferred or tolerated by some patients. brushing of teeth, gums and tongue should be performed two to four times a day preferably after meals and before going to bed (peterson et al. ) . soft-bristled toothbrush (manual or electric) is recommended to prevent injury to the oral mucosa and must be rinsed thoroughly with water after each use. if the mouth is painful or patients cannot open their mouths fully, soft oral sponges may be used. to prevent infections, the toothbrush should be stored with the brush head upwards and not soaked in disinfectant solution. these should also be monitored for evidence of fungal/bacterial colonisation. in order to protect the enamel, nonabrasive toothpaste containing mild fluoride ( - ppm) should be used. daily interdental cleaning with brushes may reduce plaque formation between the teeth (sambunjak et al. ). however, the use of interdental cleaners should be used with caution for patients with thrombocytopenia or clotting disorders. after each meal, dentures must be rinsed. thorough cleaning by brushing with soap and water should be performed at least twice a day. dentures should be cleaned, dried and stored in a closed container overnight (duyck et al. ) . the goal of using mouthwashes may include oral hygiene, preventing/treating infection, moistening the oral cavity or providing pain relief. as a minimum to keep the mouth clean, bland gargles and rinses with water, normal saline ( . % nacl) and saltwater are recommended at least four times a day (lalla et al. ; quinn et al. ) . some patients will require assistance; it may be necessary for healthcare professionals to perform/support oral care through rinsing with normal saline ( . % nacl) (elad et al. ) , with or without suction. lubricants, lip balm or lip cream may be used to moisten the lips. patients should maintain adequate hydration and drink water frequently to keep the mouth moist. several factors could contribute to dryness such as oxygen therapy and supportive care medications (e.g. antidepressants, antihistamines, sedatives and opioids). to keep the oral mucosa moist, regular sipping or spraying water may help. use of saline sprays and mouthwashes as well as use of saliva substitutes may be used. there is anecdotal evidence that fresh pineapple chunks may also help stimulate saliva but should be used with caution as their acidity could irritate the oral mucosa and affect the teeth (lalla et al. ). the choice of prevention regimens should be guided by evidence-based or expert opinion interventions, working with the individual patient and the potential risk of oral mucositis which may include the following (adapted quinn et al. while good oral hygiene is fundamental, antifungal and antiviral treatments will be prescribed to reduce infections in patients in the transplant setting. patients should receive an antifungal agent given orally or intravenously. antiviral prophylaxis should also be given. the choice of drug will be dependent on local policies/ guidance. all treatment plans should be based upon the grading of oral damage and patient reports; these may include the following. • once oral damage develops, patients should be supported to continue oral care. • frequency of oral rinsing may be increased. the aim is to keep the oral surfaces clean and moist (elad et al. ). • check for oral infections, swab and treat appropriately. review of antifungal treatment, local or systemic, should be administered if required (watson et al. ). • dexamethasone containing gels may be used for aphthous lesions. • consider mucosal protectants ). • dietary requirements should be assessed and foods causing discomfort avoided. • swallowing problems, malnutrition and weight loss should be monitored and patients given support/advice. adjustments to food consistency, methods of intake, food fortification and methods of intake should be assessed, support and education offered to patients. use of supplement drinks, peg, rig or nasogastric feeding should be considered ). • fluid intake should be assessed and route of administration of pain relief continually monitored. general health problems should also be assessed (swallowing of tablets, decreased blood sugar levels and decreased blood pressure, decreased renal function leading to overdosing of substances). • patients will need adequate pain medication including topical and systemic analgesia such as paracetamol, codeine, morphine rinses, benzydamine mouthwash, trimecaine and lidocaine. patients should be offered education on use and possible side effects including numbness of the oral mucosa. • increase pain medication following patient needs • increase nutritional support • increase oral rinses and care when oral damage progresses, closer monitoring and support for patients is required. an important aspect of care is to control the pain thereby helping the patient to continue food and fluid intake, communication and sleep. for topical treatment the use of topical analgesics can be intensified. there is insufficient evidence that many products reduce the severity of mucositis but comfort can be provided for the patient by some of these oral care products. institutions can offer a range of mouthwashes selecting the most appropriate for the clinical situation and the patients trying out which one works best for them. generally spoken, topical antibacterial substances are not recommended. the use of oral rinses, topical gels or films can be individually considered. any with sufficient safety and positive experiences can be used: caphosol ® , mugard ® , oralife ® , gelclair ® and episil ® are just a few of them. for systemic pain medication, it is useful to follow a step-by-step increase, with the aim of the patient becoming pain-free within h. it can be helpful to monitor the efficacy of pain medication with pain assessment tools. institutions should follow a standardised pattern of pain medication following the who recommendations where applicable. in severe mucositis, the use of opiates with the optimal application route should be considered. the best route of application depends on many individual and setting factors and may be oral, subcutaneous, intravenous or transdermal with patches. patients may require a combination of slow-release and fast-acting drugs. patient controlled analgesia should be considered. careful monitoring should include pain relief and any potential side effects, and including family members may prove helpful to obtain a wider view of how well the patient copes outside the treatment unit. bleeding from om continue mouth gargling. tranexamic acid has been widely used in oral surgery, and gargling/ swishing with tranexamic acid ( mg) as a mouthwash may be worth considering (watson et al. ) . as this may be due to or increased by concurrent mediation, a review of the patient's medications is needed and if possible adjustments made. patients should be encouraged to increase sip-ping of fluids. artificial saliva, viscous solutions and gels to protect and moisten the mucosa should be considered; patients should be counselled on correct application. in chronic radiotherapy-related xerostomia, pilocarpine should be used. this is a common side effect during and post high-dose radiotherapy. patients should be given helpful exercises, and the team may consider mechanical devices to help alleviate the problem. oral damage may be a hallmark of graft versus host disease (gvhd) in patients following allogeneic stem cell transplantation, and the presence of lichenoid hyperkeratotic plaques (diagnostic sign), gingivitis, mucositis, erythema, pain, xerostomia and ulcers may indicate gvhd. kuten-shorrer et al. ( ) suggest that solutions of dexamethasone or other steroids are used as firstline treatment; second-line may include solutions of steroids in combination with other immunosuppressant drugs. oral damage in the hsct will require several weeks/months to heal, and patients need continuing support and care during this period. advice and support by suitably qualified health professional should continue during this period. support to manage side effects including pain and the gradual reduction of analgesia is extremely important. chronic side effects may include dental decay, trismus, fibrosis, lymphedema, chronic xerostomia and chronic pain and will require careful management. all patients should be individually assessed and appropriate care and treatment given. follow-up care should be planned and supervised to address longer-term and late complications. the principles presented here are intended as a support and in no way should replace clinical decision-making related to the particular patient and clinical situation. depending on the severity of oral complications and the impact on the patient, the team will need to review the plan of care. sepsis and principles of care the increased risk of infections in patients undergoing haematopoietic stem cell transplantation (hsct) is well known, and infection is a leading cause of morbidity and mortality. hsct patients are particularly at risk, especially during the neutropenic period following the conditioning treatment. in hsct patients, signs and symptoms of sepsis may be subtle and difficult to recognise due to neutropenia or other complications of the transplant procedure. preventive measures should be applied, but vigilance and close monitoring of the patient, strong team collaboration and immediate action will allow for prompt and appropriate management of septic patients. (singer et al. ) , sepsis can be defined as: a life-threatening condition caused by aberrant and dysregulated host response to infection. the pathobiology is still not completely known but the divergent infection response injures the body's own tissues and organs and causes organ dysfunction. that is also what differentiates sepsis from infection in general. septic shock is a subset of sepsis in which particularly profound circulatory, cellular and metabolic abnormalities are associated with a greater risk of mortality than with sepsis alone. the table below has limited clinical diagnostic relevance but is a schematic description of the evolution from systemic inflammatory response system (sirs) to septic shock (table . ). it is worth noting that the symptoms of sirs will not delineate between sirs and sepsis itself, and since many of the signs and symptoms may be present in hsct patients, an individual assessment, including other examinations as well, needs to be performed for the diagnosis of sepsis. the consequence of the inflammatory response and evolution of sepsis is called the sepsis cascade and is illustrated in fig. . . in the early phase of hsct, i.e. day to day + , the main risk factors for infections are (rovira et al. ): a longer period of neutropenia can be expected in allogeneic than in autologous transplant. the stem cell source also affects the length of the neutropenic period where peripheral blood (pbsc) has an expected neutropenic phase of about weeks, bone marrow (bm) weeks and cord blood (cb) weeks. myeloablative conditioning (mac) treatment will cause a longer neutropenic phase than reduced intensity conditioning (ric). all kinds of barrier breakdown will increase the infection risk and mucositis occur in almost all transplant patients.skin breakdown can be caused by, e.g. drugs and acute graft versus host disease (agvhd). indwelling catheters such as peripheral cannulas, central lines, urinary catheters and pyelostomy catheters are a potential port of entry for microorganisms into the blood stream. allogeneic transplant is always followed by long-lasting immunodeficiency. conditioning treatment may include t-cell depleting agents and even non-myeloablative regimens cause lymphodepletion with prolonged periods of immune incompetence. donor type and degree of histocompatibility (human leukocyte antigen (hla) match) are other factors that influence the time to immune reconstitution. immunosuppression for gvhd prophylaxis is necessary in allogeneic hsct and will delay immune reconstitution (toubert ) . need for immunosuppressive treatment will increase the risk for infections. the sepsis cascade starts with an inflammatory response that will cause microvascular injury, vasodilation and tissue hypoxia. the microvascular injury will lead to capillary leak resulting in oedema, decreased urinary output, tachycardia, with an initially bounding pulse which will then become weaker, and an increased respiratory rate. hypotension is another symptom caused by both microvascular injury and vasodilation. the vasodilation will also cause decreased renal blood flow. the hypovolemia will cause poor tissue perfusion causing tissue hypoxia with anaerobic metabolism. in this process oxygen and lactate are released for metabolism and thus causing metabolic acidosis (e-learning package sepsis and sepsis six http://sonet.nottingham.ac.uk/, ) mucosal or skin barrier breakdown further increases the risk. if the patient is not in remission at hsct, there is a greater risk for infection and sepsis. comorbidity, such as diabetes, is another risk factor. the most important action to prevent infections acquired by exogenous organisms is good hand hygiene performed correctly. all clinical staff should also wear a uniform that is clean and short sleeved. protective isolation during the neutropenic phase is recommended, and the patient should not be in contact with any staff or visitors with symptoms of infection. for prevention of endogenous infections, oral hygiene and skin care to maintain the mucosal and skin barrier and use of prophylactic antibiotics are the most important actions. correct handling of any indwelling catheters is also a key nursing responsibility in infection control. other areas where infections can be prevented are air and water quality, food hygiene and the environmental cleaning. environmental cleaning includes medical equipment as well. for more detailed guidance on infection control, see chap. . routine surveillance screening for infection by bacterial and/or fungal cultures, i.e. blood, urine, faeces, swabs from nasopharynx and central line insertion site and serum galactomannan blood test, may allow for earlier identification and implementation of therapy, although the benefit of such routines can be discussed (nesher et al. ) . regular monitoring of blood tests such as full blood count, electrolytes, urea and/or creatinine and c-reactive protein (crp) may assist in detecting any changes that could indicate infection. prophylactic antibiotics, e.g. fluoroquinolones, antifungal and antiviral medication, will be used in most hsct patients, at least during the neutropenic phase. early recognition and treatment is vital for a successful outcome of sepsis. temperature, pulse, blood pressure, respirations and saturation (vital signs) should be frequently monitored. signs of infection are not always obvious, but if the patient has a temperature ≥ . °c, cultures should be taken, i.v. antibiotics and i.v. fluids started or increased and oxygen therapy initiated. the goal is always to start antibiotic treatment within h from detection of fever (swedish "pro sepsis" programme group sepsis ) . this is sometimes referred to as "the golden hour" (or "door to needle time" for patients admitted from outside the hospital) and is the most critical period in the patient's survival from sepsis. recognising sepsis can be a challenge in hsct patients during the immediate posttransplant period where often a plethora of symptoms are present but also after discharge, in the outpatient setting, since some symptoms are rather unspecific. other than fever, chills or rigouring, feeling unwell or different (without clear explanation), changes in behaviour or mental changes, feeling faint or changes in skin tone can indicate sepsis. an increased respiratory rate can be seen even if saturation is normal. an increased pulse and lowered blood pressure may be noted. some patients may not develop fever, and hypothermia, i.e. < °c, can also be a sign of sepsis. if an outpatient with symptoms that could be sepsisrelated reports a normal body temperature, it should be checked again in the clinic with a reliable thermometer and correct method. diarrhoea and vomiting are frequently seen in sepsis but can easily be mistaken for gastroenteritis, mucositis or acute graft versus host disease (agvhd). diffuse or local pain, e.g. in the abdomen, is common. falls are often secondary to sepsis particularly in elderly patients. any of these indices need prompt and thorough assessment. the concept of the sepsis six has been developed as a guide to prioritise interventions in patients where sepsis is suspected (daniels et al. when sepsis is suspected, all cultures should be taken prior to commencing antimicrobials, if possible (rhodes et al. ) . cultures should be taken from central lines, wounds, nasopharynx, urine and faeces. it is also sensible to consider peripheral i.v. cannulae as a possible source of infection. despite conventional practice to collect blood cultures at a fever spike in order to increase the chances of detecting bacteraemia, there is so far no data to support this principle (kee et al. ) . testing could include polymerase chain reaction (pcr) virology (e.g. for cytomegalovirus (cmv) or epstein-barr virus (ebv)) and screening for fungus (e.g. oral swab), depending on symptoms and suspected microbial agent. for the procedures for diagnosis of central line-associated bloodstream infections (clabsi), please see chap. . laboratory tests should be taken to monitor electrolyte status, organ function, blood count and signs of infection. a site of infection may not always be identified. if a source of infection is confirmed, or strongly suspected, applicable actions should be taken, e.g. wound care or removal of peripheral i.v. needle with signs of thrombophlebitis (schorr et al. ) . upon initiation of antimicrobial treatment, a broad-spectrum antibiotic is usually used. depending on the results of the cultures performed, the chosen drug may need to be changed later. fever and infection will affect the blood count and frequently cause platelet consumption why transfusions may be necessary. early recognition and intervention are achieved by frequent monitoring of the patient's vital signs and general condition and paying attention to subtle changes that should be promptly reported. as described above, immediate action is required at the first indication of sepsis. when treatment has been initiated, the patient must be continually monitored to determine the effect of treatment or worsening of the condition. this includes vital signs, fluid balance including weight and assessment of identified and/or potential infection sites (mouth, skin, any indwelling or tunnelled catheter, urine, stools, etc.), mental status, signs of bleeding, pain and general appearance and well-being. antibiotics should be delivered with strict adherence to the prescribed time schedule. antipyretics should be avoided since they may mask fever but may under certain circumstances be used to alleviate patient discomfort and pain. laboratory tests results will guide the need for electrolyte replacement and blood product transfusion that may be ordered prophylactically or in case of bleeding. cultures may need to be repeated to confirm infection and/or response to treatment. oxygen should be administered as needed to ensure adequate saturation (i.e. ≥ %, or - % for patients with chronic obstructive pulmonary disease (copd) (royal college of physicians )). if the patient's condition worsens and organ support such as assisted ventilation or haemodialysis is required, the patient may need to be prepared for transfer to the intensive care unit (icu). extra psychological support is important for both the patient and family. educating the patient and the carer about the condition and actions taken or planned will prevent unnecessary worrying and enable them to alert the staff about symptoms or changes. information and education may also facilitate mental preparedness if the condition worsens and a higher level of care, icu, is needed. patients with sepsis are likely to need additional nursing care such as assistance with oral care and personal hygiene. it is important to ensure that the patient's and caregivers' information, education and support needs are met. on discharge from the hospital, we need to ensure that the patient and their caregiver are aware of when, why and how to contact the clinic or hospital that they have a fever thermometer at home, know when to take their temperature and are aware of the level that constitutes a fever. haemorrhagic cystitis haemorrhagic cystitis (hc) is sometimes seen in haematopoietic stem cell transplantation (hsct) patients and can on its own or by subsequent complications cause significant morbidity and even death. according to nci dictionary of cancer terms, it is defined as "a condition in which the lining of the bladder becomes inflamed and starts to bleed. the blood can be seen in the urine. symptoms include pain and a burning feeling while urinating, feeling a need to urinate often, and being unable to control the flow of urine. haemorrhagic cystitis may be caused by anticancer drugs, radiation therapy, infection, or being exposed to chemicals, such as dyes or insecticides" (nci dictionary of cancer terms https://www.cancer.gov/publications/ dictionaries/cancer-terms?cdrid= ). haematuria can be symptomatic or asymptomatic. it can be described as microscopic (not visible to the eye but detected on a dipstick and in the microscope) or macroscopic (red urine or visible blood or clots) (table . ). normally about million erythrocytes are excreted daily in the urine. this is equal to one to three erythrocytes per highpower field (magnification × ) under the microscope. haematuria is defined as abnormal presence of blood in the urine, i.e. more than three erythrocytes per high-power field in the micro-scope. to be confirmed as microscopic haematuria, two positive samples on consecutive days are needed. the haematuria can be visually detected (macroscopic) as red urine at levels as low as ml blood per litre urine. the visible blood does however not necessarily correspond to the degree of blood loss through the urine. red urine may also have other causes which will not be described here. cystitis is the term used to describe inflammation of the bladder. the inflammation can be caused by an infection or as a reaction to certain drugs or radiation therapy. the following symptoms may be seen in all types of cystitis: • urinary urgency and frequency • burning or stinging with urination or right after • pain, dysuria (painful urination), lower abdominal or supra-pubic pain • nocturia, when sleep is disturbed twice or more at night due to a need to urinate • urinary incontinence • general feeling of illness reported incidences of hc after hsct range between % and % depending on risk factors and use of preventive measures or not, but most materials describe an incidence between % and %. the pathogenesis leading to hc is not completely known but is likely to be multifactorial. the onset is seen either early, within the two first weeks after start of conditioning treatment, or late, more than weeks after hsct. conditioning treatment with chemotherapy, irradiation, cytopenia, viral infections due to immunosuppression and alloimmune reactions (immunisation by development of antibodies in response to an antigen, i.e. a protein from a donor, e.g. by receiving hsct or transfusion) may all contribute to hc in the posttransplant period. higher incidence of late-onset hc in hsct with unrelated donors, older patients, and in patients with graft versus host disease (gvhd) and thrombocytopenia does support the conclusion that the pathogenesis is multifactorial (de padua silva ). early-onset hc is usually a direct and immediate effect of the conditioning treatment. conditioning therapy for hsct often contains one or more alkylating agent. cyclophosphamide, ifosfamide, busulfan, melphalan and thiotepa are among the most commonly used drugs in conditioning regimens and the major drug-related cause of hc. use of other alkylating agents and etoposide may also increase the risk of hc. when cyclophosphamide or ifosfamide is metabolised in the body, it produces a metabolite called acrolein. acrolein will cause direct toxicity to the inner lining of the urinary tract, the urothelium. the degree of damage is dose dependent, and the toxicity may increase with previous or concomitant radiation therapy and if busulfan is included in the conditioning regimen together with cyclophosphamide. the time of duration that acrolein is exposed to the bladder also contributes to the degree of damage. for cyclophosphamide, the maximal concentration of active metabolites is reached after - h of oral or intravenous administration. most of the cyclophosphamide, - % of the dose, is excreted in the urine as metabolites, and up to % is excreted as intact drug (hassan and ljungman ) . in patients with decreased renal function, particularly in severe cases, decreased renal excretion may result in increased plasma levels of cyclophosphamide and its metabolites. this can cause increased toxicity. the following substances may also increase the concentration of toxic metabolites, possibly through inhibited breakdown or decreased renal excretion: allopurinol, cimetidine, hydrochlorothiazide and hiv protease inhibitors. when hc occurs more than weeks after hsct, a common cause in the immunocompromised host can be viral infection. viral particles are frequently identified from the urine of hsct recipients. of these, reactivation of the polyoma bk virus (bkv) is the commonest and most consistent risk factor for hc following hsct, as the virus is almost invariably present in the urine of patients with hc (leung et al. ) . the damaged urothelial cells provide a milieu for viral replication. immunosuppression leads to viral reactivation and causes viruria. however, the exact pathogenetic link between bkv and hc remains enigmatic. other viral agents such as adenovirus, cytomegalovirus (cmv) and other polyomaviruses similar to bkv may also but less often cause hc. alloimmunity after engraftment by attack from donor lymphoid cells against infected urothelial cells has not been confirmed as causing hc but may be an additional potential factor for development of this complication. the diagnosis of hc is confirmed by the presence of haematuria and symptoms of cystitis taking into account risk factors such as: in most cases of chemotherapy-induced hc with pre-engraftment onset and in polyomaviruria, the condition is self-limiting and the prognosis is good. if the viruria is caused by adenovirus, the prognosis is worse with the risk of progression to systemic adenovirus infection. in these cases early pharmacological intervention with antiviral drugs, e.g. cidofovir, is recommended. hyperhydration with forced diuresis, i.e. l/ m / h with the goal of a diuresis of > ml/h, during and until the day after administration of an alkylating agent is the most important preventive action. if the diuresis is insufficient, diuretics should be administered. the forced diuresis will not just dilute the urine but shorten the time of duration for acrolein exposure to the bladder and thus prevent the toxic effects. during the days of hyperhydration, the patient shall be closely monitored for fluid balance, including weight, at regular intervals. an electrocardiogram (ecg) should be taken, and approved, prior to start of treatment, and vital signs (blood pressure, pulse, oxygen saturation and respiratory rate) should be checked throughout the day in order to ascertain circulatory stability. electrolytes and renal function should be monitored by blood samples and electrolyte substitution given where required. a need for potassium substitution is not uncommon. the patient should also be assessed for any urinary or low abdominal pain or discom-fort. all assessments mentioned above should be performed at least every h. informing the patient about the treatment and treatment goals as well as the importance of reporting any symptoms of hc will help ensure that appropriate actions and early intervention can be applied without delay. for patients receiving cyclophosphamideor ifosfamide-based regimens, the drug mesna (sodium -mercaptoethanesulfonate) can be used as pharmacological prophylaxis, although the additional benefit in the hsct setting has not been scientifically proven in comparison with hyperhydration and forced diuresis. mesna binds to the toxic metabolite acrolein and forms a non-toxic compound. by additional actions mesna also reduces the forming of acrolein in the urine. the drug itself has low toxicity (mesna summary of product characteristics (spc) [in swedish]). in hsct conditioning with cyclophosphamide, the recommended dose of mesna according to the summary of product characteristics (spc) is % of the cyclophosphamide dose and the first mesna dose should be administered immediately prior to the cyclophosphamide. subsequent doses will then be given at , , and h after administration of cyclophosphamide (totalling % of the cyclophosphamide dose). it is important to adhere to the timing of mesna doses in order to ensure efficacy of the treatment. mesna treatment should be continued during the cyclophosphamide treatment period plus the time predicted for the metabolites to reach non-toxic levels. this will usually occur between and h after completed cyclophosphamide administration. this treatment schedule for mesna may however vary according to conditioning regimen and doses as well as to patient individual factors. an example of a checklist to be used during high-dose cyclophosphamide treatment is enclosed. bk virus-induced hc may be prevented by the administration of quinolones (e.g. ciprofloxacin) (dropulic and jones ) . although quinolones are not strictly antiviral, fluoroqui nolones are capable of inhibiting the helicase activity of bkv large t antigen (tag) protein, which seems to be crucial for separation of the double-stranded dna genome during replication of the virus (umbro et al. ) . there is currently no consensus regarding this prophylaxis because many patients with bkv do not develop hc. the fact that there is a general increase of multidrug-resistant microorganisms makes the use of this prophylaxis a matter for careful consideration. the first intervention will be hyperhydration with forced diuresis to prevent clot formation. hc is usually painful and analgesia should be administered. if the patient is thrombocytopenic, a higher threshold level for platelet transfusion and intensive platelet support should be applied, in particular in haematuria grades iii-iv. catheterisation and bladder irrigation with . % sodium chloride (normal saline) may be necessary to prevent clot obstruction. catheter insertion should be performed so that the risk of additional injury to the urothelium is minimised. treatment with bladder instillation of various compounds such as formalin, alum, silver nitrate, sodium hyalonurate, prostaglandins, gm-csf, fibrin glue, cidofovir, ciprofloxacin or ribavirin has been reported as effective, but experiences are still limited (carreras ) . if obstruction occurs, cystoscopy can be performed. selective embolisation of bladder arteries and catheterisation of both ureters to rest the bladder are actions that can be taken in severe cases. cystectomy remains the last resort if all other treatment attempts fail. in addition to actions mentioned above, treatment with systemic administration of palifermin, oral oestrogens and recombinant fviia may be used (carreras ) . systemic antimicrobial drugs, e.g. cidofovir, ciprofloxacin and ribavirin, can be started, if the hc is confirmed or likely attributable to adeno-or bk virus. decreased immunosuppression could be considered in particular in cases of relapsing viral cystitis. note that anticoagulants such as tranexamic acid and aminocaproic acid are contraindicated in hc due to risk of clot formation and retention! another type of treatment that has proven effective is hyperbaric oxygen (savva-bordalo et al. ) . the patient then receives % oxygen in a hyperbaric chamber but limited access to hyperbaric chambers, and the likely need and inability for the patient to move to another treatment unit often makes this intervention less of an option. during treatment with hyperhydration, the same need for close monitoring and assessments as in the prophylactic setting applies (see above). assess the need for platelet transfusion prior to catheterisation as well as after. blood transfusions may also be necessary with significant blood loss. standard monitoring for signs of infection, injury, pain, clot formation and other potential complications from the urinary catheter is important. in cases of bladder irrigation keeping the fluids for irrigation at ambient temperature may alleviate discomfort. complications of the irrigation can be prevented or minimised by close monitoring and recording of fluid balance. it is also important to maintain patient comfort by adequate pain management and general nursing interventions such as comfortable positioning and assistance with personal hygiene. the need for information and psychological support should be observed for both patient and family. since in particular viral hc may occur after discharge from the hospital, careful assessment of any signs and symptoms related to the urinary tract and that may indicate viral infection is just as important in the outpatient setting. assessments for treatment with high dose g/m or g/m cyclophosphamide (cy) sinusoidal obstruction syndrome/veno-occlusive disease sinusoidal obstruction syndrome (sos) is also known as veno-occlusive disease (vod) and is referred to as sos/vod hereafter. of the early complications that are considered to be of vascular endothelial origin, this is the most described. there are diagnosis and severity criteria (mcdonald et al. (mcdonald et al. , jones et al. ; deleve et al. ; mohty et al. ) , although the ebmt criteria proposed in (mohty et al. ) is expected to be further validated, and there is approved treatment available. careful monitoring of hsct patients allows early detection of sos/vod. treatment can then be started without delay, ultimately improving patient outcomes. from pre-transplant assessment to medical management and overall care of the patient, nurses thus have an essential role to play as part of a multidisciplinary team (wallhult et al. ). there are specific differences between the clinical presentation of sos/vod in adults versus in children which has not been reflected in the older diagnosis and severity criteria. for this reason, ebmt has also developed a classification for diagnosis and severity criteria for sos/vod in paediatric patients (corbacioglu et al. ). the information presented below is related to adults. for the paediatric population, please see original article and/or the vod learning programme on the ebmt website. when drugs used in haematopoietic stem cell transplant (hsct) conditioning regimens are metabolised in the liver, it results in toxic metabolites being produced by the hepatocytes. the metabolites trigger the activation, damage and inflammation of the endothelial cells lining the sinusoids (sinusoids being small capillary-like blood vessels in the liver). this trigger mechanism can start as soon as the conditioning treatment is administered. the activated sinusoidal endothelial cells release inflammatory cytokines, chemokines and the enzyme heparanase which break down the extracellular matrix that supports the structure of the sinusoids. the endothelial cells are then forced to round up, and gaps form between the cells. the gaps allow for red blood cells, white blood cells and other cellular debris to exit through these gaps in the sinusoid walls into the space of disse. (the space of disse is the perisinusoidal space that is located between the endothelium and the hepatocytes.) when cells and debris accumulate in this space, the sinusoids become narrower. due to the sinusoidal damage, endothelial cells can dissect off and embolise further downstream thus contribute to the narrowing. the damage also leads to an increase in the expression of tissue factor (tf) and plasminogen activator inhibitor- (pai- ). this coagulopathy causes an increase in clot formation and a decrease in the breakdown of clots. the deposition of fibrin and the clot formation will contribute to the narrowing of the sinusoids and may ultimately lead to hepatic sinusoidal obstruction. the result is sos/vod which is characterised by obstruction of the sinusoids, portal vein hypotension and reduced hepatic venous outflow. severe cases can progress to multi-organ dysfunction (mod)/multiorgan failure (mof) and death. sos/vod usually develops before day + after hsct with a peak incidence around day , but about - % of the sos/vod cases have a late onset, after day + . although relatively rare, sos/vod is one of the main causes of non-relapse, transplant-related mortality. a mean incidence of % (coppell et al. ) has been reported, but it varies with the diagnostic criteria, depending whether the seattle (mcdonald et al. (mcdonald et al. , or the slightly stricter baltimore criteria (jones et al. ) have been used. it will also depend on risk factors including intensity of conditioning regimen and type of transplant. after allo-hsct with myeloablative conditioning (mac), the incidence is approximately - %, but if reduced intensity conditioning (ric) is used, the incidence is < %. this is the same incidence as for auto-hsct. early-stage sos/vod, mild sos/vod, may not be particularly well-recognised since the symptoms are subtle, may not require treatment and spontaneously resolve within a few weeks. unrecognised sos/vod may however progress, sometimes very rapidly, into moderate or severe. severe sos/vod is associated with mod/mof and a mortality rate of %. the risk factors for sos/vod can be divided into patient-and disease-related and transplantrelated risk factors (mohty et al. ) . as mentioned above, the risk factors, as well as the clinical presentation of sos/vod, differ between the adult and the paediatric population, and the risk factors presented here are related to adults. the patient-and disease-related risk factors are: despite the fact that diagnostic criteria were developed in the s and have been used in clinical practice and research studies, it is often hard to identify early or mild cases of sos/vod before it progresses to a more severe form. some reasons are lack of sensitivity and specificity of the criteria, the dynamic manifestations that makes definition of the condition hard and that early signs and symptoms often are subtle and makes differentiation from other transplant complications difficult. given the poor prognosis of severe sos/vod, it is however vital to identify mild cases before they progress to moderate, with signs of hepatic injury and requiring more aggressive intervention, or further progress to severe sos/vod with mod/ mof. the most recent diagnostic criteria proposed by ebmt (mohty et al. ) are the same as the baltimore criteria (jones et al. ) for classical sos/vod with onset within the first weeks after hsct, but if sos/vod develops after day + , elevated serum bilirubin level is not always seen, why a modified version of the criteria can be used for diagnosis of late sos/vod (mohty et al. ) (table . ). the ebmt criteria will also better capture the dynamic manifestations of the disease and thus facilitate an early diagnosis as well as a more accurate assessment of severity. treatment can then be started at a stage with greater chance for treatment response. differential diagnoses will need to be excluded by assessing risk factors, symptoms and lab tests since liver dysfunction can also be seen in sepsis, viral infection, graft versus host disease (gvhd) and iron overload and as a side effect from many of the drugs used in the hsct setting. in addition to the signs and symptoms required for diagnosis haemorrhagic complications, thrombocytopenia with platelet refractoriness, pulmonary dysfunction, renal dysfunction and encephalopathy are "late" signs that can be seen in more severe cases of sos/vod. further it is worth noting that all symptoms are also observed in other conditions and that many other complications may coexist with sos/vod. examples of differential diagnosis for classical symptoms of sos/vod are listed in table . . when sos/vod is diagnosed, it is important to classify the severity grade in order to intensify the monitoring and identify patients that will need therapeutic intervention. the ebmt severity grading criteria (mohty et al. ) stress the importance of taking the time since the appearance of the symptoms into account. a rapid progression of symptoms, and in particular bilirubin kinetics (the rate of increase) with a doubling time of h, should be classified as a more severe grade than if symptoms develop more slowly over several days (table . ). the first strategy for prevention is to be aware of pre-existing risk factors and try and eliminate them as far as possible and potentially establish supportive or treatment measures prior to transplant. the patient-and disease-related risk factors, including hepatic, are often difficult or impossible to change, but the transplant-related risk factors should be carefully considered in the pre-transplant setting. no proven medical prophylaxis exists but sodium heparin, prostaglandin e , ursodeoxycholic acid and low molecular weight heparin have jones et al. ( ) been tried, although data about effectiveness remains inconclusive (carreras (carreras , . defibrotide, approved for treatment of severe sos/vod, has also been used as prophylaxis (dignan et al. ) , and one randomised study in children has shown a reduction in sos/vod incidence (corbacioglu et al. ). as soon as sos/vod is suspected, supportive therapy should be initiated. in mild cases of sos/ vod, close monitoring to detect progression and supportive management is often sufficient. the monitoring should include: for more details about nursing interventions see below. the only curative treatment for sos/vod is the drug defibrotide. defibrotide protects the endothelial cells, reduces inflammation and restores thrombo-fibrinolytic balance (richardson et al. ) . the recommended dose is . mg/kg body weight administered as a -h, i.v. infusion every h (to a total dose of mg/kg/day). recommendation for treatment duration is at least days but should continue until the symptoms and signs of severe vod resolve. defibrotide is generally well tolerated (keating ) but should not be used with products that affect platelet aggregation, e.g. nonsteroid anti-inflammatory drugs (nsaids), anticoagulant therapy or other products that increase the risk of bleeding. it is important to perform a risk assessment considering the risk factors mentioned above and to take baseline measurements including defining a threshold of > % for weight gain or what level and pattern of weight gain that represents a clinical concern. most baseline measurements will be standard for hsct patients, but in patients at high risk for sos/vod, assessments of abdominal girth, right upper quadrant (ruq) pain and inspection of sclera should be added. standard daily monitoring should include temperature, pulse, blood pressure, respiration rate and saturation. one of the most important daily monitoring aspects is an accurate fluid balance including intake, output and weight since fluid imbalance is one of the earliest signs of sos/vod. a fluid retention which does not respond to diuretics represents an early sign of endothelial damage. when performing abdominal girth measurement, it is advised to use a marked line for placement of the measuring tape and to choose one position (i.e. sitting/standing/lying) for the patient, to be used consequently. abdominal discomfort, tenderness, pain (in particular ruq pain) and inspection for collateral circulation and/or spiders should always be included in abdominal assessment. for nurses trained in palpation and percussion for ascites, bulkiness, liver margins and size these assessments should also be performed. sclera and skin should be assessed for bleeding/bruising and discoloration (jaundice). knowledge of the relevant reference ranges of daily laboratory values, particularly liver enzymes, serum bilirubin, blood count, electrolytes, urea and serum creatinine will enable early detection of significant change or trend in values since nurses are likely to take blood samples and see the results first and can alert medical colleagues. all findings should be precisely documented and any changes promptly reported. this is especially important in patients identified as high risk as early detection of sos/vod may affect the overall outcome. if sos/vod is suspected, the monitoring should be intensified and adequate vascular access established. in addition to standard lab tests, coagulation parameters should be performed daily. if possible, hepatotoxic drugs should be avoided and diuretics and pain medication administered as needed. electrolyte replacement may be necessary, and in case of thrombocytopenia or bleeding, blood products will be administered. if fluid restriction is enforced, it is important to know the smallest volumes that can be safely delivered. the patient may also need assistance to be comfortably positioned. when sos/vod has been diagnosed, the supportive care and monitoring will be further intensified including assessing for failure in respiratory, cardiac and renal function. defibrotide treatment will most likely be started, and patients in need for ventilatory support should be prepared for transfer to the intensive care unit (icu). patients should be informed and educated to notify the staff of any signs and symptoms that may need closer monitoring or intervention. in case sos/vod is diagnosed, both patient and family will need reassurance and support. other early complications of endothelial origin a number of early complications to haematopoietic stem cell transplantation (hsct) seem to be initiated by damage to the vascular endothelium. the most well defined and well described of these complications is sinusoidal obstruction syndrome (sos)/veno-occlusive disease (vod) described in a separate section of this chapter. other syndromes in this group have been named engraftment syndrome (es), diffuse alveolar haemorrhage (dah), idiopathic pneumonia syndrome (ips) and transplant-associated microangiopathy (tma). the similarities in their clinical manifestations and the lack of established diagnostic criteria often make determination of incidence and differential diagnosis difficult (soubani and pandya ; afessa et al. ) . although many times mild and with spontaneous recovery, these complications also share the risk for progression to multi-organ failure (mof)/multi-organ damage (mod) resulting in a poor outcome. ongoing research and efforts for better characterisation and treatment indicate that there will be future changes in terminology and diagnostic criteria, as well as interventions, for the early hsct complications mentioned here. several factors in the hsct setting activate the endothelial cells that line the blood vessels. contributing factors are the conditioning treatment and use of other drugs such as granulocyte colony-stimulating factor (g-csf) and calcineurin inhibitors (cni), e.g. cyclosporine-a, and microbial products translocated through mucosal barriers. the result is that fluid and proteins leak out of tiny blood vessels and flow into surrounding tissues. if unrecognised, this may lead to dangerously low blood pressure and subsequently mof and shock. the symptoms often appear around the time of neutrophil recovery, i.e. when the absolute neutrophil count (anc) increases to ≥ . × /l, which is why the complex process of engraftment may also play a role in activation of endothelial cell damage. the activation of the endothelial cells leads to further damage and inflammation by the release of pro-inflammatory cytokines. since the incidence of vascular endothelial syndromes is higher after allogeneic transplantation, alloreactivity (the immune response to non-self cells) is considered to play a role in activation and damage of endothelial cells. engraftment syndrome (es) es usually occurs after auto-hsct although described in allo-hsct as well, in particular when reduced intensity conditioning (ric) and cord blood (cb) have been used. due to lack of diagnostic criteria, the term es has been used as synonymous with capillary leak syndrome (cls), auto-aggression syndrome, peri-engraftment respiratory distress syndrome (perds), aseptic shock syndrome and autologous graft versus host disease (agvhd). although there are differences, their common denominator is that they share some or all symptoms that have been attributed to es. engraftment is defined as when the number of neutrophils in the patient's blood rises to an absolute neutrophil count (anc) of ≥ . × /l. peri-engraftment can be defined as the period within days of neutrophil engraftment. due to the diagnosis difficulties, there is no reliable incidence figure and numbers between % and % have been reported. there is also a lack of survival data. most cases are mild and respond well to corticosteroid therapy, but es may progress and lead to transplant-related mortality and decrease in overall survival. patients who require mechanical ventilation has a poor prognosis. a number of potential risk factors related to patient characteristics, disease, previous treatment, conditioning treatment, stem cell source and supportive drug treatment have been reported, but there is a lack of consensus which can in part be contributed to the lack of diagnostic criteria. changes in hsct practices with new drugs and alternate stem cell sources may impact the risk factors in the future. among the risk factors described are: • female gender • advanced age • no or little prior chemotherapy • previous use of bortezomib and lenalidomide in multiple myeloma patients • cord blood transplantation • cd + cell number and engraftment rate • g-csf treatment • amphotericin treatment • cyclosporine (cya) treatment • auto-hsct for amyloidosis, multiple myeloma, poems (polyneuropathy organomegaly endocrinopathy monoclonal protein and skin abnormalities) syndrome and autoimmune diseases there are two tools to aid diagnosis of es; the spitzer ( ) and the maiolino et al. ( ) diagnostic criteria. the clinical manifestations are divided into major or minor clinical criteria (table . ), but maiolino only has one major criteria, non-infectious fever. the timing of symptoms relative engraftment also differs between the two, where maiolino has a stricter timeframe from h before to any time after neutrophil recovery compared to spitzer's h after (table . ). however, in some patients others have described onset of symptoms from days before (for patients with poems) to days after engraftment, and in cases with more severe symptoms, the early symptoms may have been overlooked, why the clinical criteria sometimes could be used regardless of appearance of symptoms in relation to time for engraftment (chang et al. ). c-reactive protein (crp) is not used for diagnosis in either criteria, but a sudden and significant increase in the crp level has been found to support the diagnosis. early recognition of signs and symptoms is the most important aspect since there is no standard prophylaxis for es, although there is evidence that corticosteroids may prevent this complication. before treatment is initiated, other diagnoses such as infection, drug rash, diarrhoea associated with infection or medication and intravenous (i.v.)-related fluid overload should be excluded. broad-spectrum antibiotics should be used until infection is ruled out (cornell et al. ) . if cultures are negative, symptoms remain after - h of antibiotic treatment and other etiologies can be excluded, corticosteroid treatment can be initiated. methylprednisolone in doses of - mg/kg/ day i.v. are recommended until symptoms begin to subside. response to treatment is usually seen within - days. corticosteroids could then be switched to oral administration and should be slowly tapered. early intervention with steroids prevents progression to more severe manifestations, and in the vast majority ( %) of patients, there is then complete resolution in less than days. in cases with no response to steroid treatment after h, biopsies of affected organs may be necessary. if biopsies are performed for evaluation of diarrhoea, the findings may not be able to distinguish from gvhd. this does however not exclude es since overlap and coexistence with gvhd is possible. if a biopsy supports the es diagnosis treatment with additional immune suppressants should be started and continued until response. if the result of the biopsy is an alternative diagnosis, the patient should be treated accordingly. in addition to pharmacological treatment supportive care with i.v. fluids, with electrolyte supplement as needed, and oxygen therapy may be necessary depending on the symptoms. in cases of encephalopathy or severe es with mof, plasma exchange may be considered (yeoung-hau and syed ). daily nursing assessments are critical in early detection and diagnosis of all complications to hsct. the patient's general well-being should be assessed, and listed below are the nursing assessments that should be carried out frequently, the findings that could indicate es and actions that can be taken in order to detect or rule out the es diagnosis (table . ). all findings should be monitor frequently, and if symptoms of pulmonary dysfunction, e.g. dyspnoea, tachypnoea, change in breathing pattern, chest pain or cough, are present, a chest x-ray or pulmonary ct scan may be performed. in order to ensure adequate oxygenation, administration of oxygen therapy may be necessary weight and fluid balance assess the patient's weight daily and perform calculation of fluid balance at least once daily to note any trends. if oedema, ascites or other symptoms of fluid retention occurs diuretics should be administered as ordered skin perform assessment at least daily and note any rashes. if a rash is detected, review the patient's medication chart for medication that may cause drug rash jaundice and yellow sclera are signs of liver dysfunction and bilirubin levels should be checked stools monitor frequency and consistency and obtain cultures and test for clostridium difficile in cases of diarrhoea in order to rule out infection. pale stools are a sign of liver dysfunction and bilirubin levels should be checked (continued) documented and any abnormalities promptly reported to the treating physician. if steroid treatment is started, the patient should be assessed for possible side effects such as hyperglycaemia and insomnia. blood glucose should be monitored daily. idiopathic pneumonia syndrome pulmonary complications (pcs) are the leading cause of patients' admission to intensive care unit (icu) after hsct. pc can be divided into infectious or non-infectious. one of the non-infectious pcs is idiopathic pneumonia syndrome (ips). for the purpose of this chapter, ips will be defined and described according to the definition by the american thoracic society (panotskaltsis-mortari et al. ) as "an idiopathic syndrome of pneumopathy after hsct, with evidence of widespread alveolar injury and in which an infectious etiology and cardiac dysfunction, acute renal failure or iatrogenic fluid overload have been excluded". the alveolar injury is a result from the release of proinflammatory cytokines during engraftment increasing alveolar permeability and causing diffuse alveolar or interstitial infiltrates. ips also includes a subset of diagnoses of primary lung injuries classified according to the anatomical sites of inflammation. they can either be related to the pulmonary parenchyma (e.g. acute interstitial pneumonitis and acute respiratory distress syndrome (ards)), the airway endothelium (e.g. bronchiolitis obliterans syndrome (bo)), the vascular endothelium (e.g. different forms of es (perds, cls)) or be unclassifiable. other less frequent non-infectious pcs have also been identified. none of these entities will be described here. pcs are common in hsct recipients and a major cause of morbidity and mortality. ips is more often seen in patients undergoing allogeneic hsct with a mean estimated incidence of - % ( % in auto-hsct) (chi et al. ). the overall outcome is different between auto-and allo-hsct recipients, and where ips in patients that have undergone auto-hsct usually has a favourable prognosis, the mortality is - % in the allo-setting (carreras ) . ips has a progressive nature, and patients with progression to respiratory failure and need for mechanical ventilation have a very poor prognosis with % mortality. for ips the following risk factors have been identified (diab et al. ): • older age • low performance status (karnofsky score) • high-intensity conditioning regimen • total body irradiation (tbi) • allo-hsct • acute graft versus host disease (agvhd) • malignant disease pre-transplant pulmonary function abnormalities have also been associated with early respiratory failure and mortality (chien et al. ) . educate the patient about signs and symptoms of es and explain why it is important to report any symptoms without delay. explain actions taken in diagnosis and management of es and provide emotional support to both patient and family thoele ( ) the most common signs and symptoms are fever, non-productive cough, rales, dyspnoea, tachypnoea and low saturation with an increasing need for oxygen support. the diagnosis will be based on alveolar injury confirmed clinically, radiologically and/or functionally. x-ray will reveal diffuse pulmonary infiltrates. infection must have been ruled out by negative cultures and tests in bronchoalveolar lavage (bal) or lung biopsies (zhu et al. ) , and there should be no evidence of cardiac dysfunction, acute renal failure or treatment-related fluid overload. it is however considered possible that some cases of ips may be caused by an unidentified underlying infection since infections may lack typical signs and symptoms in the neutropenic patient. the ips diagnosis can thus be supported by lack of improvement despite broad-spectrum antibiotics and other antimicrobial drugs. the typical onset will be around day + , but ips may also present later after hsct, why it is important to be alert for this complication also after discharge from the hospital, in the outpatient setting. there are no standard guidelines for diagnosis and evaluation of pc after hsct, but the course of illness should be considered when differential diagnoses are to be excluded. when symptoms occur, ips may rapidly progress to pulmonary dysfunction requiring mechanical ventilation. for patients at risk for ips, careful consideration of treatment options pre-and posttransplant such as avoiding conditioning with tbi or highintensity regimens and choice of gvhd prophylaxis may be beneficial. monitoring of pulmonary function and symptoms after transplantation will enable prompt intervention. in patients with decreased lung function prior to hsct and suspected lung injury in the posttransplant setting, close collaboration with pulmonary specialist or the intensive care team may prevent progression of pulmonary dysfunction (elbahlawan et al. ). beyond supportive care, there is no proven treatment for ips. in auto-hsct patients, corticosteroids can be effective, but this is usually not the case for allo-transplanted patients, irrespective of steroid dose. studies with etanercept, a tnf-αbinding protein, given in combination with corticosteroids have reported improved pulmonary function in patients with ips following allogeneic hsct and may be considered (carreras ) although a small but later study (yanik et al. ) could not confirm the benefit of this treatment. the close monitoring and daily nursing assessments that apply for all hsct patients should be employed. depending on risk factors, extra attention may be needed to early and subtle symptoms of pulmonary dysfunction, such as decrease in saturation, shortness of breath and cough. monitoring of daily weight and fluid balance, with administration of diuretics if necessary, will prevent and rule out fluid overload. several different tests and examinations may be performed to establish or rule out the diagnosis of ips. sputum cultures and laboratory tests, such as polymerase chain reaction (pcr) for mycoplasma, and serum galactomannan for aspergillus may need to be obtained, and chest x-ray or computed tomography (ct) scan performed to rule out infection. in case a bal, with or without transbronchial biopsy, will be performed, information to the patient and preparation prior to the procedure as well as support both before and after and post procedure monitoring is important. the bal may add substantial discomfort, in particular to an already seriously ill patient. other lung function tests may also be repeated, for comparison with pretransplant results. when corticosteroids are administered, the blood glucose levels should be followed daily and the patient should be informed of and assessed for other side effects, e.g. insomnia. oxygen therapy may need to be administered and noninvasive positive pressure ventilation necessary. respiratory difficulties generate anxiety, and the patient should be offered psychological support as well as assistance with positioning and breathing techniques and exercises. medication for anxiety may be necessary. referral to a physiotherapist, respiratory therapist or other staff with expertise in pulmonary diseases should be made for advice on tools and exercises that may help the patient to maintain pulmonary function and prevent worsening of the condition. if the condition shows no signs of improving, the patient should be prepared for transfer to the icu. identification of patients at risk, prompt intervention to signs and symptoms of pulmonary dysfunction and close collaboration within the team will increase the chances of a positive outcome. diffuse alveolar haemorrhage diffuse alveolar haemorrhage (dah) is a noninfectious pulmonary complication associated with haematopoietic stem cell transplant (hsct) and other causes (park ) . it is differentiated from idiopathic pneumonia syndrome (ips) through confirmation of pulmonary haemorrhage by bronchoscopy and bronchoalveolar lavage (bal). the bleeding can be either insidious, causing a gradual pulmonary dysfunction, or a more acute bleeding into the alveolar space. damage to the alveolar-capillary barrier from conditioning treatment and the engraftment process with recovery of neutrophils leads to entry of blood into the alveolar space. an approximate incidence of around % up to %, with a mortality rate ranging between % and %, has been reported for dah in hsct recipients (afessa et al. ; majhail et al. ; carreras ) . the incidence is similar between auto-and allo-hsct. the implication of prognostic factors has not been well studied, but early-onset dah (within the first days after transplant) in patients undergoing auto-hsct has a favourable prognosis. risk factors for the development of dah in hsct recipients include: • older age • total body irradiation (tbi) • myeloablative conditioning (mac) regimens • acute graft versus host (agvhd) disease dyspnoea, dry cough and fever are the most common complaints. haemoptysis is rarely observed in hsct recipients. hypoxemia may be present and diffuse or focal interstitial or alveolar infiltrates can be found on chest x-ray or computed tomography (ct) scan. with such findings, bronchoscopy with bal and transbronchial biopsy is indicated although performing these invasive tests in patients with severe illness, and unstable respiratory status is a challenge. the diagnosis is based on bal findings which become progressively more blood stained, indicating blood in the alveoli. other causes, such as heart failure and fluid overload, should be excluded. infection needs to be ruled out by obtaining relevant cultures. presence of hemosiderin-laden macrophages in bal fluid is not diagnostic for dah but may support the diagnosis. it is often very difficult to differentiate dah from ips and the es form of respiratory distress (perds). ips is more common in allo-hsct, after engraftment, and does not respond to corticosteroids and has a more progressive nature. in perds the majority of patients do not have bal findings becoming progressively bloodier. the mean onset of dah has been reported on day after transplant and days after absolute neutrophil count (anc) recovery. reversal of some risk factors, e.g. choice of conditioning treatment, may be possible, but otherwise no prophylaxis exists. high-dose corticosteroids, using methyl prednisolone in doses of - mg every h for - days followed by slow tapering, is considered first-line treatment even if efficacy can be questioned. with early diagnosis and treatment with steroid therapy, respiratory failure can often be prevented. noninvasive ventilation may decrease mortality although the majority of patients with dah require mechanical ventilation, and sepsis and mof/mod will cause death in a large proportion of patients (rabe et al. ) . other pharmacological therapies, as well as plasma exchange, have been tried for treatment of dah. recombinant factor viia (rfviia) has been administered and achieved temporary control of bleeding. tranexamic acid or the tnfα-inhibitor etanercept have been used in addition to corticosteroids but have not proved to be effective. transfusion of platelets and red blood cells (rbc) may be necessary. patients need frequent monitoring for early detection of any pulmonary symptoms. respiration rate and saturation should be assessed together with temperature and other standard assessments. if cough is noted, this should be reported to the team and the treating physician. cultures and blood tests may be necessary to rule out infection. cultures should be performed according to signs and symptoms, but screening cultures can be collected to possibly enable detection of occult infection. the patient's circulatory status and fluid balance should be controlled by monitoring pulse, blood pressure, weight and input and output. the patient should be instructed to report all symptoms, and if bal and lung biopsy will be performed, patient information and support throughout the whole procedure is vital. administration of transfusions, oxygen therapy and non-invasive ventilation should be performed as ordered and since dyspnoea and other breathing difficulties are associated with a great deal of anxiety patient support, sometimes with pharmacological treatment, is crucial. proper positioning together with breathing exercises using appropriate breathing technique may alleviate some discomfort. during high-dose corticosteroid treatment, blood glucose should be monitored, and it is important to be alert to steroid-related changes in the patient's mental status. transplant-associated microangiopathy (tam) transplant-associated microangiopathy (tam) is also known as haematopoietic stem cell transplantation (hsct)-associated thrombotic microangiopathy (ta-tma). in this text, the term tam is being used. tam is characterised by microangiopathic haemolytic anaemia with schistocytes (fragmented red blood cells) and thrombocytopenia from platelet consumption. these symptoms are due to endothelial dysfunction causing small vessels thrombosis in the microcirculation. tam is a multi-visceral disease most often affecting the kidneys, but pulmonary, gastrointestinal and central nervous system (cns) involvement can also be seen. complement system dysregulation plays an important role in the severity of tam. defects in the complement system lead to formation of the lytic complex c b- . this complex can be detected in blood, and an increased level will support the tam diagnosis. the incidence will vary with the criteria used to diagnose tam. in retrospective data, the incidence is approximately % in auto-hsct, % has been reported in allo-hsct (carreras ) , whereas one prospective study has shown an incidence close to % (jodele et al. ) . conditioning intensity, myeloablative (mac) versus reduced (ric), has not shown any difference in incidence in allo-hsct. as with many early complications in hsct prompt recognition of early signs and symptoms with early diagnosis and intervention will increase the chances of a positive outcome. cases of mild tam where calcineurin inhibitor (cni), e.g. cyclosporine, tacrolimus and sirolimus, is the cause generally have a good prognosis if cni can be discontinued. if tam is not related to cni treatment, the prognosis is worse due to lack of effective treatment options. exact figures for mortality rate are difficult to establish, but in patients with tam and multi-organ involvement, the mortality is as high as > %. patients surviving tam are as a consequence at greater risk for chronic kidney disease (ckd) and hypertension later on. use of total body irradiation (tbi) in conditioning treatment, cni, graft versus host disease (gvhd), infections (e.g. cytomegalovirus (cmv) and fungal infections) and unrelated donor transplant (in particular if mismatched) are all considered risk factors or triggers for tam, although reported data is conflicting (nadir and brenner ; rosenthal ). tam usually has an onset between and months after hsct but can be seen both earlier and later. several slightly different criteria for diagnosis of tam are being used (sahin et al. ) . see adapted table . . the diagnosis is difficult but can be confirmed with a biopsy tissue sample although this invasive test may not always be an option for the seriously ill hsct recipient. tam has clinical similarities with idiopathic thrombotic thrombocytopenic purpura (ttp), and laboratory testing for the von willebrand factor regulator adamts can be performed to support the diagnosis. in classical ttp, there is a severe deficiency, while no significant decrease of adamts is seen in tam (graf and stern ) . renal tam should be suspected if the patient requires higher doses of antihypertensives than would be expected considering the situation and concomitant and/or nephrotoxic medication. example of a differential diagnosis is virusrelated nephropathy. symptoms such as tachycardia, chest pain and hypoxemia should lead to suspicion of lung involvement and pulmonary hypertension. the diagnosis can be supported by findings of cardiomegaly on chest x-ray, pericardial effusion on transthoracic echocardiography and blood tests. intestinal tam presents with the same symptoms as acute gvhd (agvhd), abdominal pain, diarrhoea, vomiting and gastrointestinal bleeding. the symptoms can also be mistaken for infectious colitis, but in tam the cause of the bleeding is ischemia in the bowels due to the microangiopathy. in addition to the general diagnostic criteria, specific criteria for gastrointestinal tam have been proposed. besides the clinical symptoms, x-ray findings with signs of ileus and thick mucosal wall and endoscopy with mucosal erosions and haemorrhages are included in the gastrointestinal tam diagnostic criteria, but the only definite diagnostic test is a biopsy tissue sample. as a result of generalised vascular injury in tam, polyserositis with pericardial and pleural effusion and ascites can occur. it can easily be mistaken for gvhd, but where gvhd more seldom is associated with microangiopathic anaemia, proteinuria and hypertension, these symptoms are common in tam. no specific prophylaxis exists, so vigilant monitoring of clinical signs and symptoms is neces-sary. cni concentration in blood, lactate dehydrogenase (ld or ldh) and serum creatinine should be closely followed, i.e. two to three times/week, with laboratory testing. additional blood tests with peripheral blood smear, haptoglobin and direct and indirect antiglobulin tests (dat and iat) should be performed if an increase is seen in cni, ld and creatinine levels. there is currently no established treatment for tma but supportive measures should always be taken. traditionally the first step is to discontinue cni, despite paucity of evidence for this action. it is also important to treat infections, gvhd and jodele et al. ( ) hypertension. changing to other gvhd prophylaxis and use of antimicrobial drugs should be based on a risk-benefit assessment where, for example, nephrotoxicity is considered. administration of diuretics may be necessary to treat fluid and sodium retention due to steroid treatment. vasodilators and renin-angiotensin antagonists may also be used to treat hypertension. it is recommended to restrict platelet transfusion in microangiopathic disease, but this is often impossible due to the need to prevent bleeding complications. a potential treatment for tma is eculizumab. eculizumab stops the complement-activating cascade preventing formation of c b- . this leads to hampering of the intravascular haemolysis. eculizumab has shown effect when started early after diagnosis (jodele et al. ) . monitoring for effect by following serum concentration levels is important, and dose adjustments may be necessary to reach and maintain the desired therapeutic levels and effect. in a small number of cases, successful treatment with rituximab and other monoclonal antibodies has been reported. treatment attempts have also been made with defibrotide at the same dosing as approved for treatment of severe sinusoidal obstruction syndrome/veno-occlusive disease (sos/vod) but with variable results. total plasma exchange (tpe) has been tried due to the clinical similarities between tam and ttp, but where ttp can be successfully treated with tpe, it is not recommended for tam due to poor response rates. careful assessments will facilitate early diagnosis of, or ruling out, tma and thus improves the outcome. close monitoring of vital signs and being alert to any changes or trends is standard. keeping track of fluid balance and weight is equally important. blood pressure should be kept below / in adult patients (jodele et al. ) . the patient's urine should be monitored for proteinuria and the patient instructed about what abnormal findings and symptoms to look for and to notify staff of any discomfort including signs of gastrointestinal bleeding. if invasive tests such as biopsies are to be performed, proper preparation and support is vital. if pharmacological treatment with eculizumab is started, serum level concentration needs to be followed. treatment with rituximab and defibrotide should be administered as ordered, and the patient should be monitored accordingly for effect and side effects. since the onset of tam can occur after discharge from the transplant unit, it is important to be observant to symptoms and consider this diagnosis even in the outpatient setting. open access this chapter is licensed under the terms of the creative commons attribution . international license (http://creativecommons.org/licenses/by/ . /), which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license and indicate if changes were made. the images or other third party material in this chapter are included in the chapter's creative commons license, unless indicated otherwise in a credit line to the material. if material is not included in the chapter's creative commons license and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. outcome of diffuse alveolar hemorrhage in hematopoietic stem cell transplant recipients risk factors and outcome of pulmonary complications after autologous hematopoietic stem cell transplant emerging evidence of the pathobiology of mucositis implementation of a standardised protocol for prevention and management on oral mucositis in patients undergoing haematopoitiec stem cell transplant ebmt-esh handbook on haematopoietic stem cell transplantation how i manage sinusoidal obstruction syndrome after haematopoietic cell transplantation et al ngraftment syndrome after 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network guidelines double-blind placebocontrolled trial of soluble tumor necrosis factor receptor: enbrel (etanercept) for the treatment of idiopathic pneumonia syndrome after allogeneic stem cell transplantation: blood and marrow transplant clinical trials network protocol brain teaser: encephalopathy after stem cell transplantation incidence, risks, and outcome of idiopathic pneumonia syndrome early after allogeneic hematopoietic stem cell transplantation acknowledgement european oral care in cancer group (eocc). key: cord- - o uu d authors: kivity, shaye; katz, uriel; daniel, natalie; nussinovitch, udi; papageorgiou, neophytos; shoenfeld, yehuda title: evidence for the use of intravenous immunoglobulins—a review of the literature date: - - journal: clin rev allergy immunol doi: . /s - - - sha: doc_id: cord_uid: o uu d intravenous immunoglobulins (ivig) were first introduced in the middle of the twentieth century for the treatment of primary immunodeficiencies. in , paul imbach noticed an improvement of immune-mediated thrombocytopenia, in patients receiving ivig for immunodeficiencies. this opened a new era for the treatment of autoimmune conditions with ivig. since then, ivig has become an important treatment option in a wide spectrum of diseases, including autoimmune and acute inflammatory conditions, most of them off-label (not included in the us food and drug administration recommendation). a panel of immunologists and internists with experience in ivig therapy reviewed the medical literature for published data concerning treatment with ivig. the quality of evidence was assessed, and a summary of the available relevant literature in each disease was given. to our knowledge, this is the first all-inclusive comprehensive review, developed to assist the clinician when considering the use of ivig in autoimmune diseases, immune deficiencies, and other conditions. abstract intravenous immunoglobulins (ivig) were first introduced in the middle of the twentieth century for the treatment of primary immunodeficiencies. in , paul imbach noticed an improvement of immune-mediated thrombocytopenia, in patients receiving ivig for immunodeficiencies. this opened a new era for the treatment of autoimmune conditions with ivig. since then, ivig has become an important treatment option in a wide spectrum of diseases, including autoimmune and acute inflammatory conditions, most of them off-label (not included in the us food and drug administration recommendation). a panel of immunologists and internists with experience in ivig therapy reviewed the medical literature for published data concerning treatment with ivig. the quality of evidence was assessed, and a summary of the available relevant literature in each disease was given. to our knowledge, this is the first all-inclusive comprehensive review, developed to assist the clinician when considering the use of ivig in autoimmune diseases, immune deficiencies, and other conditions. intravenous immunoglobulins (ivig) are gamma globulins purified from the pooled plasma of thousands of donors, typically containing more than % of unmodified immunoglobulin g (igg) and only trace amounts of iga or igm. immune globulin products from human plasma were first used in to treat immune deficiencies. about years later, paul imbach observed that patients with immune thrombocytopenia and agammaglobulinemia receiving immunoglobulins as immune replacement therapy recovered from their thrombocytopenia [ ] . this was the first observation to suggest treatment of autoimmune diseases with ivig. later on, the ability to administer large quantities of immunoglobulin intravenously was gained owing to technological advances, among them the improvement in plasma fractionation. as a result, ivig slowly became an important treatment option in a number of diseases beyond primary immune deficiencies, including autoimmune and acute inflammatory conditions, most of them off-label indications. these indications have crossed over into almost every medical specialty. the us food and drug administration (fda) has approved the use of ivig for the following six conditions: primary immunodeficiencies, immune thrombocytopenic purpura (itp), kawasaki disease, hematopoietic stem cell transplantation, chronic b cell lymphocytic leukemia, and pediatric hiv. many offlabel indications have emerged; some of these new indications for ivig are based on solid clinical evidence; others are based on relatively few data or anecdotal reports (case series, case reports). this lack of firm evidence is due to the difficulty in performing appropriate clinical trials in diseases with low prevalence. there is a need for an evidence-based guidance for the use of ivig to help improve patient care consistency. another issue is the efficacy of different preparations of ivig. the fda has recommended the use of particular preparations of ivig for each labeled indication in accordance to the specific preparation used to demonstrate a beneficial effect. of course, there is selection bias since generally only a few preparations have been tested for a given disease. this is in recognition of the difficulty to reproduce the properties of an ivig preparation, which may vary from one manufacturer to the other due to differences in the donor population, number of donors, period of donation, production methods, virus/bacteria inactivation methods, etc. ivig properties may also vary from batch to batch made by the same manufacturer, complicating homogeneity even more. possible mechanisms of action of ivig in autoimmune and inflammatory diseases are: intact fc-dependent blockage of igg (as in itp), inhibition of membrane attack complexes (c b-c ) and activated components c b and c b (as in kawasaki's disease), and anti-idiotypes against autoantibodies (as in acquired hemophilia due to autoantibodies against factor viii). ivig also contains various cytokines and natural antibodies that may act against pathogens, altered molecules, cells, autoreactive b cell clones, and tumors. ivig therapy reviewed the medical literature indexed in pubmed using specific terms for each specific disease/ condition and ("ivig" or "igiv" or "intravenous immunoglobuli*" or "gamma globuli*"). there was no limitation on language, year of publication, or publication status. we used all clinical data ranging from multicentered randomized controlled trials (rct) and meta-analysis to case reports. from each article, we extracted details of the study design, number of patients, type of intervention including the dose and ivig preparation used (if mentioned), and response to treatment. the relevant data were summarized in a hierarchical manner according to the study design and number of participants. when evidence was based on higher level of evidence studies, such as rcts, lower levels of evidence studies (such as case control studies) were disregarded. specific diseases were classified in tables according to the specialty they belong to and are followed by a short summary of recommendations, including the level of evidence and the strength of recommendation, as assessed by known guidelines (table ) [ ] . to our knowledge, this is the first comprehensive review which summarizes all up-to-date published data regarding the usage of ivig in autoimmune diseases, immune deficiencies, and other indications. the tables below summarize the clinical data gathered from studies dealing with ivig treatment for different conditions. each table is followed by our evidence-based recommendations for the usage of ivig. the following conditions refer to ( table ) . level of evidence b systemic lupus erythematosus (sle) is a multisystemic disease with various manifestations. there is some evidence that ivig, given in patients without an increased risk for thromboembolic events or renal failure, is a safe and beneficial adjunct therapy for sle patients with systemic flare-ups who are resistant to or refuse conventional treatment (strength of recommendation iia). level of evidence c lupus myocarditis is an uncommon but severe complication of sle. there is no consensus on the specific treatment of sle myocarditis. most reports describe treatment with high-dose corticosteroids (cs), followed by either cyclophosphamide or azathioprine, in addition to conventional treatment for heart failure. there is little evidence that ivig is effective when immunosuppressive therapy fails (strength of recommendation iia). level of evidence b as with the treatment of itp, ivig seems to be useful in managing the bleeding complications of patients with lupus-associated thrombocytopenia (strength of recommendation i). level of evidence c standard therapy for subacute cutaneous lupus erythematosus (scle) includes cs (topical, intralesional, systemic), antimalarials, and other immunosuppressive agents. ivig may be considered in refractory cases, but more study should be done (strength of recommendation iia). level of evidence c kikuchi, also called histiocytic necrotizing lymphadenitis, is a rare benign disease. there is little evidence that treatment with ivig is superior to other antiinflammatory treatments (strength of recommendation iia). level of recommendation c giving the fact that adult still disease responds to cs and biological and anti-tumor necrosis factor (tnf) treatment, there is low-level evidence that ivig has an additional benefit for treatment of this disease (strength of recommendation iia). level of recommendation b immunosuppression with css and cytotoxic agents should be used in systemic vasculitis before considering ivig. there is however some evidence that ivig might be useful and therefore in refractory cases it may be worth to try (strength of recommendation iia). level of evidence b css is a rare disease. the initial management of css consists of high doses of cs. for patients with severe disease or those who are unresponsive to cs, treatment with ivig was warranted (strength of recommendation iia). level of evidence b infection with hepatitis c virus (hcv) may be associated with a variety of autoimmune phenomena causing a therapeutic dilemma for treatment with interferon alpha (ifn alpha), which stimulates autoimmune symptoms, or with cs, which may lead to an increase of viral load. treatment with ivig may act synergistically with table recommendation guidelines [ ] level of evidence a: more than one randomized controlled trial (rct)/meta-analysis b: a single rct or well-designed nonrandomized trial like prospective observational registries (case-controls, cohorts). c: expert consensus: this includes case reports and retrospective series; here, the expert decides based on his experience strength of recommendation class i: conditions for which there is evidence and/or general agreement that a given procedure/therapy is useful and effective class ii: conditions for which there is conflicting evidence and/or divergence of opinion about the usefulness/efficacy of performing the procedure/therapy class iia: weight of evidence/opinion is in favor of usefulness/efficacy class iib: usefulness/efficacy is less well established by evidence/opinion class iii: conditions for which there is evidence and/or general agreement that a procedure/therapy is not useful/effective and in some cases may be harmful ( ) , acquired factor viii inhibitors ( ) , acquired von willebrand disease ( ) , pure red cell aplasia( ), pancytopenia ( ), myelofibrosis ( ), pneumonitis ( ) , pleural effusion ( ), pericarditis ( ) , myocarditis ( ) , cns improvement of sle-related condition level of evidence c mixed connective tissue disease (mctd) is an autoimmune condition which combines features of polymyositis, systemic lupus erythematosus, scleroderma, and dermatomyositis and is thus considered an overlap syndrome. there is scarce evidence that treatment with ivig helps to improve skin manifestations in mctd (strength of recommendation iia). level of evidence b systemic sclerosis is characterized by hardening and scarring of the skin and inner organs. there is some evidence that treatment with ivig helps to improve skin and systemic symptoms (strength of recommendation i). level of evidence a there is evidence that ivig is useful for the treatment of patients with severe chronic jra; its treatment may help also reduce the need for cs and other immunosuppressive therapy (strength of recommendation i). level of evidence b there is hardly any convincing evidence that ivig benefits patients with ra (strength of recommendation iib). level of evidence c there is some evidence that patients with ataxic sensory neuropathy refractory to immunosuppressive therapy will benefit from ivig (strength of recommendation iia). level of evidence b in patients with dm and pm that are resistant or partially responsive to conventional therapies, ivig was effective (strength of recommendation i). level of evidence a in ibm, ivig showed marginal improvements in muscle strength which were nonsignificant and thus were not recommended (strength of recommendation iii). level of evidence c behcet's disease is a multisystemic disorder presenting with recurrent oral and genital ulcers as well as ocular and central nervous system involvement. the severe cases may respond to systemic css, interferon, or anti-tnf therapy. there is some evidence to support ivig treatment for refractory eye and skin involvement (strength of recommendation i). the following conditions refer to (table ) . level of evidence b there is weak evidence that ivig is useful in the treatment of acquired hemophilia. ivig may be tried in the case in which cs and cytotoxic agents fail or when facing an emergency situation as an additional therapy ivig (strength of recommendation iia). level of evidence a there is strong evidence that ivig is of benefit in reducing the number and severity of infections in patients with acquired hypogammaglobulinemia in the context of hematological malignancy (strength of recom-mendation i). while this is true, both cost and the potential of adverse effects, most prominently acute renal failure and thromboembolic phenomena [ ] [ ] [ ] , prevent a clear-cut recommendation for the use of ivig in acquired hypogammaglobulinemia. with this in mind, ivig may be recommended at the replacement dose of mg/kg each to weeks in cases in which severe or recurrent infections have occurred. level of evidence c pure red cell aplasia may be immunemediated due to a background neoplasia, most frequently hematologic, or due to an immune disease or as an immune response triggered by drugs. it may also occur secondary to parvovirus b infection which may also lead to aplastic anemia. treatment of the causative disease is the most important issue. weak evidence supports the use of ivig in pure red cell aplasia. ivig may however be used in the case in which first-line therapy (i.e., cs and immunosuppressive drugs) fails to achieve a remission (strength of recommendation iia). ivig is first-line therapy in immunosuppressed hosts in which infection with parvovirus b results in pure red cell aplasia. level of evidence b and c according to federici and colleagues [ ] , % of the cases of acquired von willebrand syndrome are associated with lymphoproliferative diseases, % with myeloproliferative disorders, and % with cardiovascular diseases. in another paper, federici and colleagues [ ] claim that % of the reported cases are associated with a monoclonal gammopathy of uncertain significance. then, the detection and specific treatment of the underlying disease is as important as the immediate therapy of the coagulation disorder. in accordance to the scant existing evidence of ivig therapy in this disorder, ivig should be used in cases of standard therapy (desmopressin and factor viii/von willebrand factor concentrate) failure and in urgent situations as an addition to such therapy (strength of recommendation iib). ivig may also be used in the preparation for surgery. level of evidence c while idiopathic aplastic anemia can be transient as in the case of parvovirus-b -induced bone marrow depression, idiopathic aplastic anemia should first be treated with immunosuppressive drugs like cs or cyclosporine or with antithymocyte or antilymphocyte immunoglobulins as well as supportive blood components transfusions. stem cell poems syndrome polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy, and skin changes transplantation is always the alternative in the case of failure of the aforementioned treatments. due to the low level of evidence of ivig for the treatment of idiopathic aplastic anemia, we cannot recommend its liberal use but it may be tried in the case of treatment failure, before stem cell transplantation is performed (strength of recommendation iib). level of evidence b immunosuppression with cs and then cytotoxic agents should be used in autoimmune hemolytic anemia before considering ivig. there is however some evidence that ivig might be useful and therefore in refractory cases before considering splenectomy it may be worth a try (strength of recommendation iib). level of evidence c although immune neutropenia may also be an adverse effect resulting from ivig treatment as have been published elsewhere [ ] , ivig has been used to treat immune neutropenia. the evidence is weak and responses are not as good as those with cs and granulocyte colony-stimulating factor (strength of recommendation iib). level of evidence c evans' syndrome is usually a therapyresistant condition that has been treated combining cs, ivig, and immunosuppressive therapy. although convincing evidence is lacking for the use of ivig in view of the severity and the refractory nature of several cases of evans' syndrome, ivig may be considered among the treatment options generally together with cs with or without immunosuppressive therapy (strength of recommendation iib). level of evidence b the only study comparing ivig against other treatment (cs), although nonrandomized, suggests that ivig raises the platelet number and prevents intracranial bleeding in a significant percentage of treated patients. the level of evidence is low, but the alternatives for prenatal treatment of fetuses at risk are not better and the risks involved are huge (strength of recommendation iib). level of evidence a strong evidence denies any benefit from the use of ivig around stem cell/bone marrow transplantation, both from the infectious or from the graftversus-host disease point of views (strength of recommendation iii). level of evidence a there is clear evidence for the use of ivig when facing newborn hemolysis as it reduces the need of plasmapheresis (pp) therapy (strength of recommendation i). level of evidence c there is no reliable evidence to recommend the use of ivig to prevent or to treat hemolytic transfusion reactions (strength of evidence iib). level of evidence c apart from two papers reporting two cases and another case, there is no evidence to recommend the use of ivig either to prevent or to treat hemolytic transfusion reactions in sickle cell patients, specially taking into consideration the additional risk of thrombosis due to a change in the rheologic properties of the blood after ivig infusion (strength of recommendation iib). level of evidence b there is conflicting evidence that ivig benefits patients with hemolytic uremic syndrome (strength of recommendation iib). level of evidence b there is no evidence that ivig benefits patients with thrombotic thrombocytopenic purpura (strength of recommendation iii). level of evidence c there is low-level evidence that ivig is useful for this disease. on the other hand, thromboembolic phenomena, which are part of the heparin-induced thrombocytopenia clinical picture, might be enhanced by the rheologic blood changes after ivig infusion. therefore, ivig should not be generally recommended for this disease (strength of recommendation iib). level of evidence b evidence comes only from one crossover randomized placebo-controlled trial which supports the use of ivig in hiv-associated thrombocytopenia, especially when platelet count is very low or the risk of bleeding is high (strength of recommendation iia). level of evidence a since imbach's observation [ ] , acute itp has been the prototype of ivig-responsive immune disease. there is consistent evidence that ivig is beneficial in children with itp (strength of recommendation i). notwithstanding this, cs therapy is still the first-line treatment for itp, and single-dose anti-d immunoglobulin [ , ] is a [ ] good alternative for rh-positive patients. ivig should be considered when there is bleeding or when the bleeding risk is high or upon failure of other treatments. in adult acute itp patients, there is no placebo-controlled rct, but when compared with cs ivig induces a faster response. again, cs is the first-line treatment for adults but ivig may be given in severe or refractory cases. there is weak evidence that ivig can improve mother and fetal prognosis in pregnancy. ivig may be used when a fast correction in platelet number is needed. level of evidence b by the merits of its own research, ivig may be considered to treat itp in the context of hiv. although no hard evidence exists due to the fact that this particular group of patients has not been investigated as well as has non-hiv-related itp, it will be hard to argue that the recommendation of the latter may not be extended to hiv-related itp (strength of recommendation i). in chronic itp, ivig has so far not demonstrated a plausible benefit. only prospective noncontrolled trials are available and we found only one evaluating maintenance ivig for chronic itp, in which the overwhelming majority of patients had a recrudescence of thrombocytopenia in spite of a good initial response to ivig (level of evidence and strength of recommendation b-iib). a small number of patients benefited and therefore ivig might be tried in drug refractory cases of chronic itp in which there is a contraindication for splenectomy. level of evidence c series of patients treated with fast response to ivig suggest a benefit of ivig treatment in posttransfusional purpura, although with low-level of evidence. in the context of a patient with severe risk to bleeding or actual bleeding, ivig can be used if the diagnosis of posttransfusional purpura is made (strength of recommendation iib). level of evidence c hemophagocytic syndrome is a severe reaction leading to high mortality. inconsistent and low-level evidence do not warrant a clear-cut recommendation of ivig for this syndrome. however, due to the lack of effective and standardized treatment in an otherwise highly lethal disease, ivig may be used along with other therapies like monoclonal antibodies, cs, cytotoxic drugs, and support measures (strength of recommendation iib). level of evidence c there are only anecdotal reports, both showing benefit and lack of benefit. there is no evidence that ivig has a beneficial effect on polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy, and skin changes (strength of recommendation iib). level of evidence c there is no convincing evidence that ivig has any beneficial effect in this disease (strength of recommendation iib). the following conditions refer to (table ). level of evidence b ivig is not used for the treatment of cmv infection but may be helpful in treatment of hemophagocytic syndrome related to cmv and other viruses (see hematology section); there is some evidence for its effectiveness in preventing seroconversion in transplant patients who are immunosuppressed (strength of recommendation iia). level of evidence b ivig can reduce infections in children with perinatal hiv but has not been proven to reduce mortality (strength of recommendation iia). level of evidence b no evidence for the effectiveness of ivig in the treatment in malaria exists (strength recommendation iii). level of evidence a postpolio syndrome (pps) typically affects survivors of poliovirus infection, - years after the original infection, with fatigue, muscular weakness, and pain. there are two rcts demonstrating some inconsistent evidence for the effectiveness of ivig treatment on quality of life, pain, and muscle strength in patients with pps (strength of recommendation iia). level of evidence a sepsis is a life-threatening condition, resulting mainly from the patient's immune response to a severe infection. significant but heterogenic reduction in mortality with ivig treatment in septic patients was demonstrated in a meta-analysis of rcts. these results were not confirmed when only high-quality studies were analyzed (strength of recommendation iia). level of evidence c infection with west nile virus can cause fatal encephalitis in immunosuppressed and elderly patients, in which case effective treatment is lacking. the effectiveness of ivig in these situations is supported by a few case reports and may be considered (strength of recommendation iia) level of evidence a treatment with ivig has not proven to reduce infectious-related mortality in postsurgical patients, but there is inconsistent evidence that ivig reduces icurelated infections and hospital stay in these patients (strength of recommendation iia). level of evidence a there is conflicting evidence regarding the usefulness of ivig treatment for these patients. it should be taken into consideration that patients treated with ivig after bone marrow transplantation (bmt) may have a higher incidence of fatal hepatic veno-occlusive disease (strength of recommendation iia). level of evidence b necrotizing fasciitis is caused by deep-skin infection with bacteria, mainly group a streptococcus. the mainstay of nuclear factor treatment is prompt surgical exploration and antibiotic therapy. ivig might have additional benefit to antibiotic therapy for treatment of patients who refuse surgery or are not surgical candidates. (strength of recommendation iia). level of evidence b there is weak evidence that ivig is useful in the treatment of recurrent otitis media (strength of recommendation iib). level of evidence b some evidence that ivig is effective in preventing perinatal transmission of varicella. ivig may also be used for treatment adults with severe respiratory failure due to varicella pneumonia (level of recommendation iia). the following conditions refer to (table ) . level of evidence b although the best level of evidence is not strong, the improvement shown for treated pregnancies is beyond the natural possibility of a subsequent spared pregnancy which has been estimated to be approximately % ( [ ] # ). in view of this data and the difficulty for large rcts, ivig may be considered to prevent recurrent perinatal hemochromatosis (strength of recommendation iia). level of evidence a there is evidence that ivig improves the outcome of pregnancy in secondary recurrent miscarriage (in women that had a previous pregnancy that reached at least the second trimester (strength of recommendation iib)). this has so far not been shown for primary recurrent miscarriage (strength of recommendation iii). level of evidence a the evidence is against the use of ivig in pregnancy of women affected by antiphospholipid syndrome (strength of recommendation iii). level of evidence b evidence from a small rct indicates that ivig may reduce the rate of fetal infection after premature rupture of membranes (strength of recommendation iia). level of evidence a the evidence is scarce but the only meta-analysis based on data from three rcts found a benefit in the number of live births in women treated with ivig. after in vitro fertilization (ivf) failure, ivig along with ivf techniques may be weighted (strength of recommendation iib). the following conditions refer to (table ) . level of evidence b a randomized double-blind study has demonstrated significant increase of ejection fraction (ef) and improved quality of life following ivig administration, regardless of the congestive heart failure (chf) cause. chf is a proinflammatory state due to an increase of cytokines such as tnf-α and interleukin (il)- . some of the cytokines have been shown to induce myocardial dysfunction due to negative inotropic effect [ ] . another possible mechanism in chf pathogenesis is mediated by anti-β adrenergic receptor (strength of recommendation iia). level of evidence b dilated cardiomyopathy (dcm) is caused by various triggers or may be idiopathic. immune abnormalities and autoantibodies may play a role in the pathogenesis. nevertheless, no significant effect was noted following ivig administration in recent-onset dcm compared to placebo [ ] . a trial on patients with idiopathic dcm showed significant improvement of ef and quality of life compared with placebo [ ] . therefore, ivig treatment in dcm remains controversial, and it is possible that ivig treatment is beneficial in specific subpopulation and when treatment is initiated at a certain time window (strength of recommendation iib). level of evidence c peripartum cardiomyopathy (ppcm) is a rare disorder. it is believed that autoimmune mechanisms play a role in the pathogenesis. in a small nonrandomized retrospective trial, there was a significant improvement of ef following ivig administration compared with conventional treatment. although there is partial evidence of ivig effectiveness in ppcm, its use should be considered due to the generally poor prognosis of ppcm patients who show no clinical improvement (strength of recommendation iia). level of evidence b treatment with cs or cytotoxic agents was found ineffective [ , ] . in an rct trial of patients with new-onset dcm of which some had myocarditis [ ] , there was no significant difference in ef improvement between ivig and placebo group. nevertheless, in a prospective nonrandomized trial, there was a significant improvement of fractional shortening compared to control. we conclude that further research is warranted regarding ivig use in myocarditis due to inconclusive results (strength of recommendation iib). chronic idiopathic pericarditis (cip) appears in up to % of acute pericarditis cases. it may be associated with viral infections and autoantibodies [ ] . there is limited evidence on the role of ivig as an alternative therapy for prolonged steroid or colchicine treatment in cip (strength of recommendation iia). atherosclerosis is believed to be mediated also by humeral and cellular immune mechanisms. there are accumulating data that support a role of ivig in prevention of atherosclerosis. possible mechanisms include decrease of matrix metalloproteinase secretion from mononuclear cells [ ], increase of il- [ ] , and decrease of oxidized lowdensity lipoprotein uptake by macrophages [ ] . nevertheless, clinical trials are required in order to establish the relationship between ivig use and atherosclerosis therapy. level of evidence a it is the leading cause of acquired heart disease in the usa. kawasaki disease is an fda-approved absolute indication for ivig therapy. the frequency of ca aneurysm development and associated morbidity and mortality have been dramatically decreased as a result of ivig therapy when given within days following the onset of fever. a single dose of g/kg of ivig over h is usually level of evidence b because there is no efficient treatment for established rheumatic carditis, several agents has been proposed in an attempt to change the natural history. ivig has failed to change clinical outcome and disease progression and therefore is not recommended for treatment of acute rheumatic fever (strength of recommendation iii). level of evidence c neonatal lupus erythematosus is a rare disease that is associated with anti-ro and anti-la autoantibodies [ ] . a single case series of eight subjects had level of evidence c ivig has anti-idiotypic properties, as well as human leukocyte antigen molecules that may neutralize high panel reactive antibodies in sensitized patients awaiting cardiac transplantation. there is some evidence for ivig benefit in patients with left ventricular assist device who are awaiting cardiac transplantation (strength of recommendation iia). nevertheless, ivig did not reduce sensitization in previously unsensitized patients who underwent norwood procedure (strength of recommendation iii). the following conditions refer to (table ) . level of evidence c linear iga bullous disease may affect the eye (in % of patients) and may present as chronic cicatrizing conjunctivitis. systemic disease may be treated with systemic cs and dapsone. in poorly responsive patients, ivig treatment may be used, although its use should be further investigated (strength of recommendation iia). level of evidence c mucous membrane pemphigoid (mmp) may involve the eye. there is some evidence for the beneficial effect of ivig in mmp that involves the eye. ivig may provide more rapid control of symptoms and prevents remissions during long-term follow-up [ , ] . this notion should be supported by larger randomized trials (strength of recommendation iia). level of evidence c there are some but limited data regarding the potential benefit of ivig use in behcet's disease. further study is required. nevertheless, ivig should be carefully considered in patients resistant to conventional immunosuppressive therapy (strength of recommendation iia). level of evidence a the natural history of optic neuritis in multiple sclerosis patients is not altered by ivig transfusion, neither clinically nor radiologically. therefore, ivig is not recommended in that setting (strength of recommendation iii). level of evidence c there is anecdotal evidence for the possible beneficial role of ivig in the treatment of inflammatory pseudotumor of orbit (strength of recommendation iib). level of evidence c birdshot retinochoroiditis is a rare inflammatory disease (bilateral autoimmune posterior uveitis of idiopathic origin). without immunosuppressive treatment, a progressive visual deterioration will occurs in % of patients [ ] . there is supporting evidence for the use of ivig, especially in patients unresponsive to other therapies (strength of recommendation iia). level of evidence c it is caused by inflammatory process of unknown etiology, which is confined to the orbit. there are very limited data on the effect of ivig in patients with orbital myositis. such treatment might be considered in symptomatic patients, resistant to other therapies (strength of recommendation iia). level of evidence c most cases of refractory uveitis (ru) are associated with autoimmune mechanisms. there are some data supporting the use of ivig in resistant ru, although more research is required in order to establish clinical guidelines (strength of recommendation iia). level of evidence b it seems that ivig is as efficient as cs in the treatment of graves' ophthalmopathy. nevertheless, despite similar clinical response to treatment, ivig was associated with fewer side effects and the study group showed more tolerance towards it. therefore, we conclude that ivig should be considered in cs intolerance (strength of recommendation i). level of evidence c there is limited evidence for the benefit of ivig in cancer-associated retinopathy. nevertheless, since spontaneous recovery usually does not occur, ivig may be used in progressive visual compromise in addition to cs or plasmapheresis (strength of recommendation iib). the following conditions refer to (table ). level of evidence b a few case reports and a single rct clearly indicate the efficacy of ivig in the treatment of lupus nephritis. in all cases, patients had a beneficial response to ivig and a significant improvement of renal function was noted. therefore, ivig is recommended as an alternative treatment in lupus nephritis or in cases that conventional immunosuppressive treatment fails (strength of recommendation i). level of evidence c although evidence for the use of ivig in renal transplant rejection is limited to case reports and case series results showed that ivig may be effective for treating acute or chronic renal transplant rejection. ivig may improve renal function and reverse ab-mediated rejection. ivig may be considered among the treatment options generally together with immunosuppressive therapy (strength of recommendation i). level of evidence c there is weak evidence indicating significant benefit from the use of ivig in antineutrophil cytoplasmic antibody (anca)-associated rpgn. several case series and case reports showed that ivig may improve renal function and therefore is recommended as a potential therapy for anca-associated rpgn (strength of recommendation i). level of evidence c the use of ivig in bk-virus-associated nephropathy in renal allograft recipient is limited only in a few case reports. nevertheless, in these cases, ivig showed significant efficacy and with concomitant reduction of immunosuppression it may be considered as one of the treatment options in this disease (strength of recommendation i). level of evidence b results coming from a single-arm nonrandomized study and a prospective cohort study showed that ivig may be effective in treating severe iga nephropathy and therefore it may be considered as a possible treatment option. however, rcts are needed to confirm this efficacy (strength of recommendation i). the efficacy of ivig in membranous nephropathy was studied in few retrospective trials and a case series. results from these studies indicate that ivig may be effective in induction of remission. although there is no strong evidence, ivig may be considered as an additional option in treatment of membranous nephropathy (strength of level of evidence c; recommendation i). the following conditions refer to (table ). level of evidence b there is some evidence that ivig have steroid-sparing effect and may be effective as monotherapy and/or adjunctive therapy in patients with previously severe unresponsive pemphigus vulgaris (strength of recommendation iia). level of evidence c adjunctive to standard immunotherapy treatment with ivig may cause improvement in clinical course and may have steroid-sparing effect in previously steroid-dependent patients with refractory pemphigus foliaceus (strength of recommendation iia). level of evidence c in some severe cases of bullous pemphigoid, ivig was found to be effective as monotherapy and adjunctive therapy as well; it had steroid-sparing effect and led to improvement of quality of life (strength of recommendation iia). level of evidence c there is some evidence that ivig monotherapy may be at least as effective as standard immunosuppressive treatment and lead to quick therapy response and better quality of life (strength of recommendation iia). level of evidence c the sparse data of positive effect of ivig on severe cases of epidermolysis bullosa acquisita, linear iga disease, and pemphigoid gestationis were published (strength of recommendation iia). summary in autoimmune blistering diseases, the treatment with ivig may be effective and has to be implicated in cases with severe disease, resistant to conventional therapy or those who experienced severe complications of such therapy. level of evidence c the randomized studies have not been performed and the current knowledge about effectiveness of ivig in sjs and ten is based on results of multiple prospective noncontrolled studies, retrospective case series, and case reports. the data are limited and inconclusive (strength of recommendation iib). level of evidence b the current data based on single, randomized, controlled, and evaluator-blinded trial and number of prospective noncontrolled studies suggest that ivig may be effective as monotherapy in pediatric patients and as adjunctive therapy in adults. however, in view of the low-cost effectiveness of ivig, this treatment should be used in cases of severe disabling atopic dermatitis (strength of recommendation iia). level of evidence c a number of case reports and case series describe the beneficial effect of ivig in chronic idiopathic and autoimmune urticaria, but randomized controlled studies are still lacking. the use of ivig has to be limited to severe unresponsive cases of chronic urticaria or in case of severe complications of conventional treatment (strength of recommendation iia). level of evidence c only three cases of severe resistant psoriasis with psoriatic arthritis responsive to treatment with high-dose immunoglobulin were reported. we conclude that there is now evidence of effectiveness of ivig in psoriasis (strength of recommendation iib). level of evidence c ivig was successfully used in few cases of previously unresponsive pyoderma gangrenosum, but its systematic use cannot be recommended (strength of recommendation iia). level of evidence c several case reports and case series showed ivig to be effective for nephrogenic fibrosing dermopathy, pretibial myxedema, and arndt-gottron scleromyxedema, but still well-controlled studies are lacking. we suppose that ivig can be used in severe cases of these rare conditions, unresponsive to conventional treatment (strength of recommendation iia). the following conditions refer to (table ). retrospective series report [ ] no difference in length of stay, mechanical ventilation, severity of inflammatory response or incidence of sepsis, wound progression, time to healing, and mortality ten patients with initial rash involving ± %, treated with ivig vs. patients with ten initial rash involving ± % not treated with ivig ivig (gamimune® n, bayer inc., toronto, ca) . to . g/kg per day according to discretion of attending physician on duty, as % or % solution according to availability, for ± day retrospective [ ] no difference of scorad index and in global evaluation of disease severity by patients at day adult patients (mean age ) with sever atopic dermatitis ivig g/kg per day (sandoglobulin®, sandoz, france) immediate or delayed by month (meanwhile intensive therapy with emollients and topical cs (limited to class ii g/month)), for days in -h infusion, as monotherapy rc evaluatorblinded trial [ ] atopic dermatitis improvement in skin score (measi) was apparent in responders ( / patients) from to months and continued to improve over a -month period; after months, there was a significant reduction of the overall measi; cd -expressing t cells decreased to % from baseline; no change of tnf-a and ifn-g adult patients with severe stable atopic dermatitis flebogamma® % g/kg per month given in - days for months as adjunctive treatment, followed for months open, single center, prospective [ ] / patients improved skin scores, allowing reduction of steroid dose adult patients with severe atopic dermatitis and steroid-related side effects alphaglobin® (grifols, uk) or sandoglobulin ® (novartis, uk) g/kg per month in - days adjunctive to cs case report [ ] clinic rev allerg immunol ( ) : - case report [ ] first patient had significant reduction in skin scores ( / to / ) for year only; second had a dramatic sustained response with continued tx (interval subsequently increased to weeks) patients with scleromyxedema and severe skin disease ivig . g/kg per day for days, monthly case report [ ] improvement after the first treatment, continuous skin softening and reduction of induration, sustained response to treatment after courses a -year-old female with long-standing scleromyxedema unresponsive to highdose cs and immunosuppressive (cp, melphalan) treatment ivig g/kg in days (intratect®; biotest, dreieich, germany) every weeks, adjunctive to pd mg/day case report [ ] progressive clinical improvement over several months allowing discontinuation of pd but rapid deterioration afterwards with lethal cva despite reinstating pd and cp an -year-old female with scleromyxedema and iddm ivig (gamimune n, %, bayer) . g/ kg (dose reduced due to chf) every weeks and oral pd mg/day case report [ ] a positive response after cycles an -year-old female with a -year history of scleromyxedema unresponsive to various preceding therapies venimmun® n (zlb behring, germany) . g/kg for days at -week intervals as monotherapy case report [ ] marked clinical improvement, maintained with repeated ivig infusions a -year-old woman with scleromyxedema ivig (sandoglobulin®) g/kg over days as monotherapy case report [ ] complete clearance of skin lesions, sustained effect after year without treatment case report [ ] clinic rev allerg immunol ( ) : kaposi's sarcoma level of evidence c a patient with polymyositis and kaposi sarcoma had remission of both conditions on ivig therapy (strength of recommendation iib). level of evidence c stabilization of metastatic melanoma was shown in the small group of patients after addition of ivig to standard therapy (strength of recommendation iib). level of evidence civig was shown to be effective in preventing severe recurrent chemotherapy-induced oral mucositis in two patients treated with methotrexate (strength of recommendation iia). level of evidence c anecdotal case report describes complete remission of metastatic malignant thymoma after four cycles of ivig given to myasthenic patient (strength of recommendation iib). level of evidence c after thymectomy, two patients with good syndrome were maintained with ivig for developed immunodeficiency; one of them developed kaposi sarcoma after years (strength of recommendation iib). the following conditions refer to (table ) . summary there are still no randomized controlled trials evaluating efficacy of ivig and it cannot be recommended for treatment of epithelial or other solid malignancies. level of evidence c there is some evidence that ivig therapy can improve the neuropathy impairment score in patients with diabetic demyelinating polyneuropathy (strength of recommendation iia). a few case reports describe regression of symptoms of proximal diabetic neuropathy, diabetic amyotrophy, and cranial nerve neuropathy in different diabetic patients treated with ivig (strength of recommendation iia). we conclude that evidence for the use of ivig in diabetic neuropathies is poor and its systematic use cannot be recommended. disease improvement in all but relapse in patient, weeks to months for full response, most needing - weekly cycles patients, - years old with scleromyxedema ivig g/kg per month given over days; octagam® ( patients), sandoglobulin® ( patients), gammagard ®sd ( patient), unknown ( patients); adjunctive to pd ( patients) and thalidomide ( patient) or as monotherapy ( patients) review of published case reports [ ] regrowth of eyelashes, eyebrows, and body and scalp hair after second dose, significant hair regrowth with - cm of scalp hair level of evidence b therapeutic efforts including dietary therapy and immunomodulation with ivig fail to improve prognosis in patients with x-linked adrenoleukodystrophy and bmt remains the only treatment that can reverse early neurological manifestations and adrenal impairment of ald (strength of recommendation iii). level of evidence c no evidence supports the use of ivig in waterhouse-friderichsen syndrome due to meningococcal sepsis (strength of recommendation iii). level of evidence c no evidence supports the use of ivig in autoimmune polyendocrine syndrome type (strength of recommendation iib). the following conditions refer to (table ) . level of evidence c there is weak evidence coming out from several case reports that ivig may be a useful treatment option either as a combination therapy with cs or in cases that steroid treatment fails (strength of recommendation i). level of evidence b taking into consideration the limited evidence (one rct) and the unfavorable effect of ivig treatment, at this point, ivig should not be used as treatment of adrenoleukodystrophy (strength of recommendation iii). level of evidence c no benefit was observed from the use of ivig in two case series. considering the weak evidence and the negative outcome, ivig is not recommended for the treatment of amyotrophic lateral sclerosis (strength of recommendation iii). level of evidence c the use of ivig in autism is only limited to case series and the effect is questionable. ivig is not recommended at the moment for the treatment of autism (strength of recommendation iii). level of evidence a several rcts evaluated the effectiveness of ivig. the results of these studies are strongly pointing to the useful effect of ivig in patients with chronic inflammatory demyelinating polyneuropathy. ivig should be considered as an additional option in combination with other immunosuppressive agents (strength of recommendation i). level of evidence c in this rare syndrome, ivig was reported in several case reports and a retrospective study proved that it induced significant response. although there is no strong evidence, ivig may be considered as an additional option in treatment of opsoclonus myoclonus (strength of recommendation i). level of evidence b results coming from one small rct testing the effect of ivig showed significant improvement in symptoms; therefore, ivig is recommended as an additional option for treatment of pandas (strength of recommendation i). level of evidence a data from several rcts and a metaanalysis showed significant differences between ivig and placebo favoring the use of ivig in relapsing-remitting multiple sclerosis (ms). on the other hand, a recent rct including patients with relapsing-remitting ms treated with ivig or placebo showed no significant difference in the proportion of relapse-free patients among treated groups. another recent rct including patients showed that ivig can delay progression of disease in primary chronic progressive ms but no significant difference in progression was noted for secondary chronic progressive ms. to conclude, ivig may be used as an alternative therapy in relapsingremitting ms and in primary chronic progressive ms when standard immunosuppression therapy fails (strength of recommendation iib). level of evidence a there is strong evidence, several randomized controlled trials, and a meta-analysis that prove that ivig is of benefit in improving the disability grade in patients with guillain-barré syndrome. no significant difference between ivig and pp was found. ivig should be considered as a treatment option in guillain-barré syndrome (strength of recommendation i). level of evidence a there is no reliable evidence to recommend the use of ivig in paraproteinemic neuropathy. a restricted number of rct's and a systematic review showed only modest benefit with ivig in the short term (strength of recommendation iib). level of evidence b a single small rct showed significant improvement in patients suffering from lambert-eaton myasthenic syndrome with the use of ivig compared to placebo. therefore, it is acceptable to consider the use of ivig in this rare and severe neurological syndrome (strength of recommendation i). level of evidence b data from a small randomize control trial and several case reports showed that the use of ivig led to significant improvement in patients with stiff-person syndrome and was superior to placebo. ivig should be considered as a treatment option in this syndrome especially if the first-line treatment fails (strength of recommendation i). level of evidence a two rcts investigated the efficacy of ivig in patients with intractable childhood epilepsy compared with placebo. results from these studies do not support benefit from the use of ivig. therefore, ivig is not recommended for the treatment of intractable childhood epilepsy (strength of recommendation iii). level of evidence c there is no reliable evidence (level of evidence c-iii) to recommend the use of ivig in the treatment of critical illness polyneuropathy (strength of recommendation iii). level of evidence a several rcts and a meta-analysis examined the efficacy of ivig in patient with myasthenia gravis. results are conflicting. a recent metaanalysis concluded that there is insufficient evidence to determine the efficacy of ivig in myasthenia gravis. ivig may be used as treatment for myasthenia gravis severe acute exacerbations (strength of recommendation iia). the following conditions refer to (table ). level of evidence b retrospective analyses revealed that ivig is beneficial in terms of reduction of acute and chronic infections and days of stay in the hospital. intravenous route is preferred over intramuscular administration of immunoglobulin and the number and severity of complications are inversely correlated with the dose of ivig (strength of recommendation i). level of evidence c despite relatively low evidence of effectiveness of ivig, the majority of was patients are treated with ivig, which appears to be effective in reduction of acute and chronic infections in these immunodeficient patients (strength of recommendation iia). level of evidence c there is weak evidence that ivig is useful in the treatment of hyper-ige syndrome. ivig may be tried in cases in which recurrent live-threatening diseases cannot be controlled by antibiotic prophylaxis (strength of recommendation iib). level of evidence c there is scarce evidence that ivig is useful in the treatment of igg subclass deficiencies. most of the experience reported is patients with igg deficiency. in our opinion, when antibiotic treatment is not effective, ivig would be a reasonable alternative (strength of recommendation iib). level of evidence b this is a heterogeneous group. specific deficiency of antibodies after vaccination has been found to correlate with infection susceptibility. most of the published experience regarding ivig is in patients with deficiency of antibodies to capsular polysaccharide. ivig has been reported to be beneficial in some cases. this is not surprising as antibodies to bacterial capsular polysaccharide are contained in ivig [ ] . the evidence for the use of ivig in specific antibody deficiency is not strong but might be warranted when recurrent infection is present and it is possible to demonstrate low antibody responses to a relevant vaccine (strength of recommendation iia). level of evidence b the hyper-igm syndrome (higm) is a rare hereditary immune deficiency, characterized by a low or nil level of igg and iga and a normal or increased level of igm, predominately affecting boys. its clinical manifestations are dominated by recurrent infection, notably of the digestive tube, the ears, nose, and throat and the lungs. ivig may be considered to treat patients with higm and recurrent infections (strength of recommendation i). level of evidence c transient hypogammaglobulinemia of infancy is characterized by a prolongation and accentuation of the physiologic hypogammaglobulinemia normally occurring during the first to months of life and recovers spontaneously between and months of age. infants with transient hyogammaglobulinemia of infancy (thi) may remain asymptomatic or develop recurrent sinopulmonary infections, but severe or lifethreatening infections are rare. in general, supportive and antimicrobial therapies are sufficient management for the treatment of specific infections in patients with thi. in cases in which infections are severe or refractory to conventional therapy, ivig is sometimes considered although literature reports are lacking (strength of recommendation i). level of evidence b scid is a severe form of heritable immunodeficiency in which both "arms" of the adaptive immune system are defected. these babies, if untreated, usually die within year due to severe recurrent infections. treatment with bmt is successful, and ivig is used as an adjuvant for this therapy (strength of recommendation i). many different genetic diseases will ultimately result in primary phagocytic defect: cyclic neutropenia, severe congenital neutropenia, shwachman-diamond syndrome, leu-kocyte adhesion deficiency, rac deficiency, interferon-γ and il- defects, chronic granulomatous disease, myeloperoxidase deficiency, chediak-higashi syndrome, and neutrophil-specific granule deficiency [ ] . an extensive pubmed-based search revealed little if any information regarding the efficacy of ivig in the above entities. iga deficiency may be associated with preventable anaphylaxis or anaphylactoid reaction following ivig transfusion [ ] . this adverse reaction is encountered in patients with selective iga deficiency and high titer of anti-iga antibodies. in those patients, anaphylaxis can be avoided by the use of iga-depleted ivig preparation [ ] . this article summarizes most of the studies dealing with ivig administration that were publicized until recently. we have included an array of clinical conditions, some in which the use of ivig is expected according to their pathogenesis, such as primary immunodeficiencies and rheumatic diseases, and others somewhat less obvious indications including cardiac and oncologic diseases. in some diseases, the usage of ivig was found to be highly recommended (with a level of evidence a and strength of recommendation i): kawasaki disease, acquired hypogammaglobulinemia, juvenile rheumatoid arthritis, hemolytic disease of the newborn, acute immune thrombocytopenic purpura, chronic inflammatory demyelinating polyneuropathy, and guillain-barré syndrome. for many other diseases, treatment with ivig was found effective as well, but this was less well established, either due to a lack of well-designed studies or due to conflicting evidence among them. in some diseases, there is a strong recommendation against using ivig (with a level of evidence a and strength of recommendation iii): stem cell/bone marrow transplantation, inclusion body myositis, recurrent pregnancy loss due to antiphospholipid syndrome, optic neuritis, and intractable childhood epilepsy. nevertheless, the effectiveness of ivig in such a large span of diseases fortifies the accumulating evidence that many pathological conditions are autoimmune mediated. high-dose intravenous gamma globulin therapy of refractory, in particular idiopathic thrombocytopenia in childhood acc/ aha guidelines for the evaluation and management of chronic heart failure in the adult: executive summary. a report of the american college of cardiology/american heart association task force on practice guidelines (committee to revise the guidelines for the evaluation and management of heart failure): developed in collaboration with the international society for heart and lung transplantation review: intravenous immunoglobulin therapy and thromboembolic complications intravenous immunoglobulin: adverse effects and safe administration intravenous immunoglobulin and the kidney-a two-edged sword acquired von willebrand syndrome: data from an international registry treatment of acquired von willebrand syndrome in patients with monoclonal 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sclerosis: a pilot study skin score decrease in systemic sclerosis patients treated with intravenous immunoglobulin-a preliminary report intravenous immunoglobulin in the treatment of polyarticular juvenile rheumatoid arthritis: a phase i/ii study. pediatric rheumatology collaborative study group therapeutical and immunological effects of methylprednisolone pulse therapy in comparison with intravenous immunoglobulin. treatment in patients with juvenile chronic arthritis intravenous immunoglobulin therapy in systemic onset juvenile rheumatoid arthritis: a follow-up study high dose immunoglobulin therapy in severe juvenile chronic arthritis: long-term follow-up in patients failure of low-dose intravenous immunoglobulin therapy to suppress disease activity in patients with treatment-refractory rheumatoid arthritis immunomodulating therapy of rheumatoid arthritis by high-dose intravenous immunoglobulin high dose intravenous immunoglobulin (ivig) in severe refractory rheumatoid arthritis: no evidence for efficacy successful treatment of 'malignant rheumatoid arthritis' in japan with pooled intravenous immunoglobulin benefit of ivig for long-standing ataxic sensory neuronopathy with sjögren's syndrome. iv immunoglobulin intravenous immunoglobulin treatment in painful sensory neuropathy without sensory ataxia associated with sjögren's syndrome intravenous immunoglobulin therapy in sensory neuropathy associated with sjögren's syndrome a controlled trial of high-dose intravenous immune globulin infusions as treatment for dermatomyositis intravenous immunoglobulin treatment in autoimmune diseases efficacy of high-dose intravenous immunoglobulin therapy in japanese patients with steroid-resistant polymyositis and dermatomyositis a controlled study of intravenous immunoglobulin combined with prednisone in the treatment of ibm high-dose immunoglobulin therapy in sporadic inclusion body myositis: a double-blind, placebo-controlled study treatment of inclusion-body myositis with ivig: a double-blind, placebo-controlled study intravenous immunoglobulin therapy for resistant ocular behcet's disease behcet's syndrome treated with highdose intravenous igg and low-dose aspirin a prospective study of treatment of acquired (autoimmune) factor viii inhibitors with high-dose intravenous gamma globulin low response to high-dose intravenous immunoglobulin in the treatment of acquired factor viii inhibitor intravenous immunoglobulin therapy for acquired coagulation inhibitors: a critical review combined prednisolone and intravenous immunoglobulin treatment for acquired factor viii inhibitors: a -year review prophylaxis against infections with low-dose intravenous immunoglobulins (ivig) in chronic lymphocytic leukemia. results of a crossover study crossover study of immunoglobulin replacement therapy in patients with low-grade b-cell tumors randomized trial of intravenous immunoglobulin prophylaxis for patients with chronic lymphocytic leukaemia and secondary hypogammaglobulinaemia randomised trial of intravenous immunoglobulin as prophylaxis against infection in plateau-phase multiple myeloma. the uk group for immunoglobulin replacement therapy in multiple myeloma immunoglobulin prophylaxis during intensive treatment of acute lymphoblastic leukemia in children treatment of fever and neutropenia with antibiotics versus antibiotics plus intravenous gamma globulin in childhood leukemia immunoglobulin replacement in chronic lymphocytic leukaemia prophylaxis against infections with intravenous immunoglobulins in multiple myeloma hypogammaglobulinaemia in low grade b cell tumours; significance and therapy pure red cell aplasia: treatment with intravenous immunoglobulin concentrate treatment of pure red cell aplasia by high dose intravenous immunoglobulins dose-by-dose virological and hematological responses to intravenous immunoglobulin in an immunocompromised patient with persistent parvovirus b infection pure red cell aplasia due to parvovirus b infection after liver transplantation: a case report and review of the literature acute renal failure in a pediatric kidney allograft recipient treated with intravenous immunoglobulin for parvovirus b induced pure red cell aplasia pure red cell aplasia due to parvovirus following treatment with chop and rituximab for b-cell lymphoma relapsing pure red cell aplasia associated with b-cell chronic lymphocytic leukemia successfully treated by intravenous immunoglobulin concentrate a case of persistent anemia in a renal transplant recipient: association with parvovirus b infection fulminant parvovirus infection following erythropoietin treatment in a patient with acquired immunodeficiency syndrome chronic pure red cell aplasia caused by parvovirus b in aids: use of intravenous immunoglobulin-a report of eight patients successful treatment of persistent erythroid aplasia caused by parvovirus b infection in a patient with common variable immunodeficiency with lowdose immunoglobulin red cell 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aplastic anemia transient aplastic anemia caused by parvovirus b infection in a heart transplant recipient treatment of hematologic disorders other than immune thrombocytopenic purpura with intravenous immunoglobulin (ivig)-report of seven cases and review of the literature efficacy of intravenous immunoglobulin in the treatment of autoimmune hemolytic anemia: results in patients diagnosis and clinical course of autoimmune neutropenia in infancy: analysis of cases use of intravenous gamma globulin for the treatment of autoimmune neutropenia of childhood and autoimmune hemolytic anemia evans syndrome: results of a national survey evans syndrome. results of a pilot study utilizing a multiagent treatment protocol intravenous gamma globulin for thrombocytopenia in children with evans syndrome induction of remission with intravenous immunoglobulin and cyclophosphamide in steroid-resistant evans' syndrome associated with dermatomyositis fetomaternal alloimmune thrombocytopenia: antenatal therapy with ivigg and steroids-more questions than answers. european working group on fmait should immunoglobulin therapy be used in allogeneic stem-cell transplantation? a randomized, double-blind, dose effect, placebocontrolled, multicenter trial a randomized trial of high dose polyvalent intravenous immunoglobulin (hdigg) vs. cytomegalovirus (cmv) hyperimmune igg in allogeneic hemopoietic stem cell transplants (hsct) a controlled trial of long-term administration of intravenous immunoglobulin to prevent late infection and chronic graft-vs.-host disease after marrow transplantation: clinical outcome and effect on subsequent immune recovery intravenous immunoglobulin and cmv-seronegative blood products for prevention of cmv infection and disease in bone marrow transplant recipients a multicenter, randomized, double-blind comparison of different doses of intravenous immunoglobulin for prevention of graft-versus-host disease and infection after allogeneic bone marrow transplantation high-dose weekly intravenous immunoglobulin to prevent infections in patients undergoing autologous bone marrow transplantation or severe myelosuppressive therapy. a study of the american bone marrow transplant group immunomodulatory and antimicrobial efficacy of intravenous immunoglobulin in bone marrow transplantation immunoglobulin infusion for isoimmune haemolytic jaundice in neonates systematic review of intravenous immunoglobulin in haemolytic disease of the newborn high-dose intravenous immunoglobulin in non-abo transfusion incompatibility haemolytic transfusion reaction-successful attenuation with methylprednisolone and high dose immunoglobulin hyperhemolytic transfusion reaction in sickle cell disease use of intravenous immunoglobulin and intravenous methylprednisolone in hyperhaemolysis syndrome in sickle cell disease post-transfusion hyperhaemolysis in a patient with sickle cell disease: use of steroids and intravenous immunoglobulin to prevent further red cell destruction the use of intravenous gamma globulin in the treatment of typical hemolytic uremic syndrome high-dose intravenous gamma globulin infusions in hemolytic-uremic syndrome: a preliminary report treatment of thrombotic thrombocytopenic purpura with high-dose immunoglobulins. results in patients. italian cooperative group for ttp efficacy of intravenous immunoglobulin in the treatment of thrombotic thrombocytopaenic purpura. a study of cases high-dose intravenous gamma-globulins for heparininduced thrombocytopenia: a prompt response the therapy of the heparin-induced thrombosis-thrombocytopenia syndrome with immunoglobulins an evaluation of intravenous immunoglobulin in the treatment of human immunodeficiency virus-associated thrombocytopenia intravenous immunoglobulin or high-dose methylprednisolone, with or without oral prednisone, for adults with untreated severe autoimmune thrombocytopenic purpura: a randomised, multicentre trial the comparison of gamma globulin to steroids in treating adult immune thrombocytopenia. an interim analysis a prospective, randomized trial of high-dose intravenous immune globulin g therapy, oral prednisone therapy, and no therapy in childhood acute immune thrombocytopenic purpura clinical course of children with immune thrombocytopenic purpura treated with intravenous immunoglobulin g or megadose methylprednisolone or observed without therapy intravenous immunoglobulin in the treatment of human immunodeficiency virus-related thrombocytopenia usefulness of a low-dose intravenous immunoglobulin regimen for the treatment of thrombocytopenia associated with aids clinical efficacy and safety of a novel intravenous immunoglobulin preparation in adult chronic itp treatment of adult chronic autoimmune thrombocytopenic purpura with repeated high-dose intravenous immunoglobulin high-dose intravenous immunoglobulin for posttransfusion purpura high-dose intravenous immunoglobulin for post-transfusion purpura post-transfusion purpura following open heart surgery: management by high dose intravenous immunoglobulin infusion high-dose immunoglobulin therapy in renal transplant recipients with hemophagocytic histiocytic syndrome hemophagocytic syndrome: a review of pediatric cases immunomodulation treatment for childhood virus-associated haemophagocytic lymphohistiocytosis infection associated hemophagocytic syndrome: a report of children intravenously administered immune globulin for the treatment of infection-associated hemophagocytic syndrome successful treatment of cytomegalovirus-associated hemophagocytic syndrome by intravenous immunoglobulins rapidly deteriorating polyneuropathy associated with osteosclerotic myeloma responsive to intravenous immunoglobulin and radiotherapy poor response to intravenous immunoglobulin therapy in patients with castleman's disease and the poems syndrome intravenous immunoglobulin therapy in poems syndrome: a case report successful treatment of post-transplant lymphoproliferative disorder with interferon-alpha and intravenous immunoglobulin cytomegalovirus prophylaxis with intravenous polyvalent immunoglobulin in high-risk renal transplant recipients the national institute of child health and human developments intravenous immunoglobulin study group ( ) intravenous immune globulin for the prevention of bacterial infections in children with symptomatic human immunodeficiency virus infection intravenous immunoglobulin in symptomatic and asymptomatic children with perinatal hiv infection plasmodium falciparum: diversity of isolates from malawi in their cytoadherence to melanoma cells and monocytes in vitro parasitologic and clinical human response to immunoglobulin administration in falciparum malaria intravenous immunoglobulin for post-polio syndrome: a randomised controlled trial post-polio syndrome patients treated with intravenous immunoglobulin: a double-blinded randomized controlled pilot study effect of intravenous immunoglobulin in patients with post-polio syndrome-an uncontrolled pilot study polyclonal intravenous immunoglobulin for the treatment of severe sepsis and septic shock in critically ill adults: a systematic review and meta-analysis possible benefit of intravenous immunoglobulin therapy in a lung transplant recipient with west nile virus encephalitis treatment of west nile virus encephalitis with intravenous immunoglobulin prophylactic intravenous administration of standard immune globulin as compared with core-lipopolysaccharide immune globulin in patients at high risk of postsurgical infection polyvalent immunoglobulins for prophylaxis of bacterial infections in patients following multiple trauma. a randomized, placebo-controlled study prophylactic intravenous immunoglobulin replacement in high-risk burn patients safety and efficacy of intravenous immunoglobulin prophylaxis in pediatric head trauma patients: a double-blind controlled trial prevention of infection in multiple trauma patients by high-dose intravenous immunoglobulins reduced incidence of postoperative infection after intravenous administration of an immunoglobulin a-and immunoglobulin menriched preparation in anergic patients undergoing cardiac surgery immunoglobulin replacement in patients with chronic lymphocytic leukaemia: a comparison of two dose regimes clinical experience with cases of group a streptococcus necrotizing fasciitis and myonecrosis: to successful management of severe group a streptococcal soft tissue infections using an aggressive medical regimen including intravenous polyspecific immunoglobulin together with a conservative surgical approach high-dose immunoglobulin-life-saving in invasive group a streptococcal infection group a streptococcal bacteraemia and necrotizing fasciitis in a renal transplant patient: a case for intravenous immunoglobulin therapy the effect of intravenous immunoglobulin treatment in recurrent acute otitis media effect of intravenous gamma globulin therapy in igg deficient and igg sufficient children with recurrent infections and poor response to immunization with haemophilus influenzae type b capsular polysaccharide antigen prophylaxis of intravenous immunoglobulin and acyclovir in perinatal varicella experience of intravenous immunoglobulin and acyclovir in neonates at risk for severe varicella infection-report of five cases two cases of severe adult varicella pneumonia varicella pneumonia in a healthy adult presenting with severe respiratory failure intravenous immunoglobulin in adult varicella pneumonia complicated by acute respiratory distress syndrome varicella pneumonia complicated by acute respiratory distress syndrome in an adult intravenous gamma globulin therapy for thrombocytopenic purpura associated with active varicella infection an adult patient with varicella preceded by acute thrombocytopenia high-dose immunoglobulin during pregnancy for recurrent neonatal haemochromatosis use of intravenous immunoglobulin for treatment of recurrent miscarriage: a systematic review immunotherapy for recurrent miscarriage intravenous immunoglobulin (ivig) and recurrent spontaneous pregnancy loss a randomized, double-blind, placebo-controlled trial of intravenous immunoglobulin in the prevention of recurrent miscarriage: evidence for a therapeutic effect in women with secondary recurrent miscarriage critical analysis of intravenous immunoglobulin therapy for recurrent miscarriage short-term therapy for recurrent abortion using intravenous immunoglobulins: results of a double-blind placebo-controlled italian study intravenous immunoglobulin for treatment of recurrent pregnancy loss placebocontrolled trial of treatment of unexplained secondary recurrent spontaneous abortions and recurrent late spontaneous abortions with i intravenous immunoglobulin in the prevention of recurrent miscarriage prevention of recurrent miscarriage for women with antiphospholipid antibody or lupus anticoagulant randomized study of subcutaneous low molecular weight heparin plus aspirin versus intravenous immunoglobulin in the treatment of recurrent fetal loss associated with antiphospholipid antibodies a multicenter, placebo-controlled pilot study of intravenous immune globulin treatment of antiphospholipid syndrome during pregnancy. the pregnancy loss study group pregnancy outcome in recurrent spontaneous abortion associated with antiphospholipid antibodies: a comparative study of intravenous immunoglobulin versus prednisone plus low-dose aspirin pregnancy complicated by the antiphospholipid syndrome: outcomes with intravenous immunoglobulin therapy the selective use of heparin/aspirin therapy, alone or in combination with intravenous immunoglobulin g, in the management of antiphospholipid antibody-positive women undergoing in vitro fertilization recurrent first trimester spontaneous abortion associated with antiphospholipid antibodies: a pilot study of treatment with intravenous immunoglobulin normal fetal growth in women with antiphospholipid syndrome treated with high-dose intravenous immunoglobulin (ivig) the effect of antenatal intravenous immunoglobulin on ascending intrauterine infection after preterm premature rupture of the membranes: a pilot study is intravenous immunoglobulins (ivig) efficacious in early pregnancy failure? a critical review and meta-analysis for patients who fail in vitro fertilization and embryo transfer (ivf) treatment of repeated unexplained in vitro fertilization failure with intravenous immunoglobulin: a randomized, placebo-controlled canadian trial intravenous immune globulin in the therapy of peripartum cardiomyopathy treatment of acute inflammatory cardiomyopathy with intravenous immunoglobulin ameliorates left ventricular function associated with suppression of inflammatory cytokines and decreased oxidative stress gamma-globulin treatment of acute myocarditis in the pediatric population the prevention of coronary artery aneurysm in kawasaki disease: a meta-analysis on the efficacy of aspirin and immunoglobulin treatment the treatment of kawasaki syndrome with intravenous gamma globulin treatment of kawasaki disease with a moderate dose ( g/kg) of intravenous immunoglobulin clinical responses of patients with kawasaki disease to different brands of intravenous immunoglobulin therapeutic effectiveness of intravenous immunoglobulin at g/kg and g/kg on kawasaki disease: a comparative and follow-up study a randomized prospective study on the use of g-ivig or g-ivig as therapy for kawasaki disease a single intravenous infusion of gamma globulin as compared with four infusions in the treatment of acute kawasaki syndrome intravenous immunoglobulin in acute rheumatic fever: a randomized controlled trial intravenous immunoglobulin reduces anti-hla alloreactivity and shortens waiting time to cardiac transplantation in highly sensitized left ventricular assist device recipients low-dose prophylactic intravenous immunoglobulin does not prevent hla sensitization in left ventricular assist device recipients failure of prophylactic intravenous immunoglobulin to prevent sensitization to cryopreserved allograft tissue used in congenital cardiac surgery linear iga bullous disease limited to the eye: a diagnostic dilemma: response to intravenous immunoglobulin therapy a randomized trial of intravenous immunoglobulin in inflammatory demyelinating optic neuritis a double-blind, randomized trial of iv immunoglobulin treatment in acute optic neuritis successful intravenous immunoglobulin therapy for resistant inflammatory pseudotumor of the orbit efficacy of intravenous immunoglobulin in the treatment of birdshot retinochoroiditis successful treatment of orbital myositis with intravenous immunoglobulins the treatment of refractory uveitis with intravenous immunoglobulin efficacy of intravenous immunoglobulin treatment in refractory uveitis intravenous immunoglobulin versus corticosteroid in treatment of graves' ophthalmopathy randomized trial of intravenous immunoglobulins versus prednisolone in graves' ophthalmopathy treatment of paraneoplastic visual loss with intravenous immunoglobulin: report of cases improvement in visual fields in a patient with melanoma-associated retinopathy treated with intravenous immunoglobulin a case-bycase protocol of membranous nephropathy treatment with endovenous infusion of high doses of human immunoglobulins intravenous immunoglobulin therapy of membranous nephropathy: efficacy and safety the short-and long-term outcomes of membranous nephropathy treated with intravenous immune globulin therapy. kanazawa study group for renal diseases and hypertension high-dose intravenous immunoglobulin pulse therapy in patients with progressive immunoglobulin a nephropathy: a long-term follow-up intravenous immunoglobulin as a treatment for bk virus associated nephropathy: one-year follow-up of renal allograft recipients intravenous immunoglobulin as rescue therapy for bk virus nephropathy clinical efficacy of intravenous immunoglobulin for patients with mpo-ancaassociated rapidly progressive glomerulonephritis successful use of high dose intravenous immunoglobulin in rapidly progressive crescentic glomerulonephritis with vasculitis treatment of antineutrophil cytoplasmic autoantibodypositive systemic vasculitis and glomerulonephritis with pooled intravenous gamma globulin successful treatment of chronic antibody-mediated rejection with ivig and rituximab in pediatric renal transplant recipients early diagnosis and successful treatment of acute antibodymediated rejection of a renal transplant plasmapheresis, intravenous cytomegalovirus-specific immunoglobulin and reversal of antibody-mediated rejection in a pediatric renal transplant recipient: a case report posttransplant therapy using high-dose human immunoglobulin (intravenous gamma globulin) to control acute humoral rejection in renal and cardiac allograft recipients and potential mechanism of action intravenous immunoglobulin compared with cyclophosphamide for proliferative lupus nephritis intravenous immunoglobulin treatment of lupus nephritis intravenous immunoglobulin therapy in a patient with lupus serositis and nephritis successful treatment of rapidly progressive lupus nephritis associated with anti-mpo antibodies by intravenous immunoglobulins intravenous immunoglobulin therapy in the treatment of patients with pemphigus vulgaris unresponsive to conventional immunosuppressive treatment the role of ivig treatment in severe pemphigus vulgaris treatment of pemphigus with intravenous immunoglobulin corticosteroid-sparing effect of intravenous immunoglobulin therapy in patients with pemphigus vulgaris effectiveness of intravenous immunoglobulin therapy for skin disease other than toxic epidermal necrolysis: a retrospective review of mayo clinic experience intravenous immunoglobulin therapy for patients with pemphigus foliaceus unresponsive to conventional treatment influence of ivig therapy on autoantibody titers to desmoglein in patients with pemphigus foliaceus steroid sparing effect of intravenous immunoglobulin therapy in patients with pemphigus foliaceus intravenous immunoglobulin therapy for patients with bullous pemphigoid unresponsive to conventional immunosuppressive treatment role of intravenous immunoglobulin in the treatment of bullous pemphigoid: analysis of current data treatment of oral pemphigoid with intravenous immunoglobulin as monotherapy. long-term follow-up: influence of treatment on antibody titers to human alpha integrin a severe persistent case of pemphigoid gestationis treated with intravenous immunoglobulin and cyclosporin effect of high-dose intravenous immunoglobulin therapy in stevens-johnson syndrome: a retrospective, multicenter study intravenous immunoglobulin therapy for children with stevens-johnson syndrome prospective, noncomparative open study from kuwait of the role of intravenous immunoglobulin in the treatment of toxic epidermal necrolysis high-dose intravenous immunoglobulin for severe drug reactions: efficacy in toxic epidermal necrolysis intravenous immunoglobulin treatment for stevens-johnson syndrome and toxic epidermal necrolysis: a prospective noncomparative study showing no benefit on mortality or progression treatment of toxic epidermal necrolysis. experience with patients with consideration of intravenous immunoglobulin intravenous immunoglobulin for treatment of toxic epidermal necrolysis use of intravenous immunoglobulin in children with stevens-johnson syndrome and toxic epidermal necrolysis: seven cases and review of the literature treatment of toxic epidermal necrolysis with high dose intravenous immunoglobulins: multicenter retrospective analysis of consecutive cases analysis of intravenous immunoglobulin for the treatment of toxic epidermal necrolysis using scorten: the university of miami experience treatment of toxic epidermal necrolysis with intravenous immunoglobulin in children intravenous immunoglobulin does not improve outcome in toxic epidermal necrolysis a randomized controlled evaluator-blinded trial of intravenous immunoglobulin in adults with severe atopic dermatitis adjunctive high-dose intravenous immunoglobulin treatment for resistant atopic dermatitis: efficacy and effects on intracellular cytokine levels and cd counts the treatment of atopic dermatitis with adjunctive high dose intravenous immunoglobulin: a report of three patients and review of the literature high dose immunoglobulin in atopic dermatitis and hyper-ige syndrome a review of high-dose intravenous immunoglobulin treatment for atopic dermatitis intravenous immunoglobulin un autoimmune chronic urticaria the effectiveness of low dose intravenous immunoglobulin in chronic urticaria effect of highdose intravenous immunoglobulin delayed pressure urticaria solar urticaria: one case treated by intravenous immunoglobulin treatment of solar urticaria by intravenous immunoglobulins and puva therapy intravenous immunoglobulin therapy suppresses manifestations of the angioedema with hypereosinophilia syndrome psoriasis: response to high-dose intravenous immunoglobulin in three patients treatment of pyoderma gangrenosum with intravenous immunoglobulin pyoderma gangrenosum treated with high-dose intravenous immunoglobulins: two cases and review of literature nephrogenic fibrosing dermopathy: response to high-dose intravenous immunoglobulin pretibial myxedema and high-dose intravenous immunoglobulin treatment scleromyxedema. a case series highlighting long-term outcomes of treatment with intravenous immunoglobulin (ivig) scleromyxoedema: treatment of cutaneous and systemic manifestations with high-dose intravenous immunoglobulin scleromyxedema: response to highdose intravenous immunoglobulin (hdivig) arndt-gottron scleromyxedema: successful therapy with intravenous immunoglobulins combination oral prednisone and intravenous immunoglobulin in the treatment of scleromyxedema successful therapy of scleromyxedema arndt-gottron with low-dose intravenous immunoglobulin marked improvement in scleromyxedema with high-dose immunoglobulin tumorous variant of scleromyxedema. successful therapy with intravenous immunoglobulins use of igiv in the treatment of atopic dermatitis, urticaria, scleromyxedema, pyoderma gangrenosum, psoriasis, and pretibial myxedema effect of ivig on the hair regrowth in a common variable immune deficiency patient with alopecia universalis regression of kaposi's sarcoma after intravenous immunoglobulin treatment for polymyositis efficacy and safety of intravenous immunoglobulin in patients with metastatic melanoma intravenous immunoglobulin as prophylaxis of chemotherapy-induced oral mucositis total remission of thymus carcinoma after treatment with intravenous immunoglobulin thymoma and immunodeficiency (good syndrome): a report of unusual cases and review of the literature diabetic demyelinating polyneuropathy responsive to intravenous immunoglobulin therapy intravenous immunoglobulin therapy markedly ameliorates muscle weakness and severe pain in proximal diabetic neuropathy simultaneous multiple cranial nerve neuropathies and intravenous immunoglobulin treatment in diabetes mellitus a case of diabetic amyotrophy with severe atrophy and weakness of shoulder girdle muscles showing good response to intravenous immune globulin antibodymediated rejection of a pancreas allograft multifocal motor neuropath, type diabetes and asymptomatic hashimoto's thyroiditis: an unusual association multifocal motor neuropathy and asymptomatic hashimoto's thyroiditis: first report of association thyrotoxic autoimmune encephalopathy in a female patient: only partial response to typical immunosuppressant treatment and remission after thyroidectomy high dose immunoglobulin iv treatment in adrenoleukodystrophy discussion on: high dose immunoglobulin iv treatment in adrenoleukodystrophy waterhouse-friderichsen syndrome and bilateral renal cortical necrosis in meningococcal sepsis autoimmune polyendocrine syndrome. treatment with intravenous immunoglobulins rituximab and intravenous immunoglobulins for relapsing postinfectious opsoclonus-myoclonus syndrome treatment of idiopathic opsoclonus-myoclonus syndrome with intravenous immunoglobulin parainfectious opsoclonus-myoclonus syndrome: high dose intravenous immunoglobulins are effective forty-one year follow-up of childhood-onset opsoclonus-myoclonus-ataxia: cerebellar atrophy, multiphasic relapses, and response to ivig treatment with intravenously administered immunoglobulins of the neuroblastoma-associated opsoclonus-myoclonus treatment of opsoclonus-myoclonus with high-dose intravenous immunoglobulin neuroblastoma-associated opsoclonus-myoclonus treated with intravenously administered immune globulin g high-dose i.v. human immunoglobulin in a case with infantile opsoclonus polymyoclonia syndrome clinical outcome in adult onset idiopathic or paraneoplastic opsoclonusmyoclonus therapeutic plasma exchange and intravenous immunoglobulin for obsessive-compulsive disorder and tic disorders in childhood intravenous immunoglobulin in relapsingremitting multiple sclerosis: a dose-finding trial intravenous immunoglobulin in primary and secondary chronic progressive multiple sclerosis: a randomized placebo controlled multicentre study no effect of intravenous immunoglobulins on cytokine-producing lymphocytes in secondary progressive multiple sclerosis intravenous immunoglobulins in the treatment of relapsing remitting multiple sclerosis-results of a retrospective multicenter observational study over five years intravenous immunoglobulin in secondary progressive multiple sclerosis: randomised placebo-controlled trial intravenous immunoglobulin g for the treatment of relapsing-remitting multiple sclerosis: a meta-analysis intravenous immunoglobulins in therapy of intermittent multiple sclerosis. an update sarova-pinhas i ( ) intravenous immunoglobulin treatment in multiple sclerosis. effect on relapses a double-blind, cross-over trial of intravenous immunoglobulin g in multiple sclerosis: preliminary results immunotherapy for guillain-barré syndrome: a systematic review high-dose immunoglobulin therapy for guillain-barré syndrome in japanese children intravenous immune globulins in patients with guillain-barré syndrome and contraindications to plasma exchange: days versus days intravenous immunoglobulin therapy for guillain-barré syndrome with igg anti-gm antibody randomised trial of plasma exchange, intravenous immunoglobulin, and combined treatments in guillain-barré syndrome intravenous immune globulin in the guillain-barré syndrome immunotherapy for igm antimyelin-associated glycoprotein paraprotein-associated peripheral neuropathies a randomised controlled trial of intravenous immunoglobulin in igm paraprotein associated demyelinating neuropathy a controlled study of intravenous immunoglobulin in demyelinating neuropathy with igm gammopathy intravenous immunoglobulin therapy in amyotrophic lateral sclerosis effect of high-dose intravenous immunoglobulin on amyotrophic lateral sclerosis and multifocal motor neuropathy effects of intravenous immunoglobulin on muscle weakness and calcium-channel autoantibodies in the lambert-eaton myasthenic syndrome treatment of stiff-man syndrome with intravenous immune globulin treatment of stiffman syndrome with intravenous immunoglobulin long-term remission of refractory stiff-man syndrome after treatment with intravenous immunoglobulin high-dose intravenous immune globulin for stiff-person syndrome high dose immunoglobulin iv treatment in adrenoleukodystrophy treatment of refractory epilepsy with intravenous immunoglobulins. results of the first double-blind/ dose finding clinical study intravenous immunoglobulin: a single-blind trial in children with lennox-gastaut syndrome effects of early treatment with immunoglobulin on critical illness polyneuropathy following multiple organ failure and gramnegative sepsis failure of high dose intravenous immunoglobulins to alter the clinical course of critical illness polyneuropathy experience with immunomodulatory treatments in rasmussen's encephalitis positive response to immunomodulatory therapy in an adult patient with rasmussen's encephalitis improvement in adult-onset rasmussen's encephalitis with long-term immunomodulatory therapy medical treatment of rasmussen's syndrome (chronic encephalitis and epilepsy): effect of high-dose steroids or immunoglobulins in patients intravenous immune globulin ( % caprylate-chromatography purified) for the treatment of chronic inflammatory demyelinating polyradiculoneuropathy (ice study): a randomised placebocontrolled trial randomized controlled trial of intravenous immunoglobulin versus oral prednisolone in chronic inflammatory demyelinating polyradiculoneuropathy randomized controlled trial of ivig in untreated chronic inflammatory demyelinating polyradiculoneuropathy intravenous immunoglobulin treatment in chronic inflammatory demyelinating polyneuropathy. a double-blind, placebo-controlled, cross-over study intravenous immunoglobulin for myasthenia gravis iv immunoglobulin in patients with myasthenia gravis: a randomized controlled trial randomized, controlled trial of intravenous immunoglobulin in myasthenia gravis immunoglobulin treatment versus plasma exchange in patients with chronic moderate to severe myasthenia gravis immunoglobulin treatment in refractory myasthenia gravis high-dose, rapid-infusion ivig in postvaccination acute disseminated encephalomyelitis outcome of severe encephalomyelitis in children: effect of highdose methylprednisolone and immunoglobulins effectiveness of intravenous immunoglobulin treatment in adult patients with steroid-resistant monophasic or recurrent acute disseminated encephalomyelitis improvement of atypical acute disseminated encephalomyelitis with steroids and intravenous immunoglobulins dramatic improvement of severe acute disseminated encephalomyelitis after treatment with intravenous immunoglobulin in a three-year-old boy treatment of acute disseminated encephalomyelitis with intravenous immunoglobulin brief report: a pilot open clinical trial of intravenous immunoglobulin in childhood autism early and prolonged intravenous immunoglobulin replacement therapy in childhood agammaglobulinemia: a retrospective survey of patients highvs. low-dose immunoglobulin therapy in the long-term treatment of xlinked agammaglobulinemia efficacy of intravenous immunoglobulin on the prevention of pneumonia in patients with agammaglobulinemia intravenous immunoglobulin therapy for antibody deficiency the effect of two different dosages of intravenous immunoglobulin on the incidence of recurrent infections in patients with primary hypogammaglobulinemia intravenous immunoglobulin, splenectomy and antibiotic prophylaxis in wiscott-aldrich syndrome new diagnostic and therapeutic aspects of hyper-ige syndrome hyperimmunoglobulin e syndrome: two cases and a review of the literature high dose intravenous immunoglobulin in atopic dermatitis and hyper-ige syndrome immunodeficiency presenting as hypergammaglobulinaemia with igg subclass deficiency deficiency in immunoglobulin subclasses as cause of increased infection susceptibility-a family study chronic rhinosinusitis and recurrent nasal polyps in two children with igg subclass deficiency and review of the literature a case of igg subclass deficiency with the initial presentation of transient hypogamma immunoglobulinemia of infancy and a review of igg subclass deficiencies antibody response in patients with osteomyelitis of the mandible. oral surg oral med oral pathol oral radiol endod clinical and laboratory characteristics of patients with specific polysaccharide antibody deficiency syndrome selective antibody immune deficiency in a patient with smith-lemli-opitz syndrome clinical, immunologic and genetic analysis of patients with autosomal recessive hyper-igm syndrome due to activation-induced cytidine deaminase deficiency the hyper-igm syndrome: observations effects of intravenous immunoglobulin on clinical and immunological findings of patients with humoral immunodeficiency diseases non-x-linked hyperimmunoglobulin m syndrome with chronic interstitial pneumonitis successful management of neutropenia in a patient with cd ligand deficiency by immunoglobulin replacement therapy hyper-igm syndrome: report of one case transient hypogammaglobulinemia of infancy presenting as staphylococcus aureus sepsis with deep neck infection transient hypogammaglobulinemia of infancy with severe bacterial infections and persistent iga deficiency hematopoietic stem-cell transplantation for the treatment of severe combined immunodeficiency efficacy of intravenous immunoglobulin in the prevention of pneumonia in patients with common variable immunodeficiency key: cord- -ytv dwr authors: casadevall, arturo; scharff, matthew d. title: return to the past: the case for antibody-based therapies in infectious diseases date: - - journal: clin infect dis doi: . /clinids/ . . sha: doc_id: cord_uid: ytv dwr in the preantibiotic era, passive antibody administration (serum therapy) was useful for the treatment of many infectious diseases. the introduction of antimicrobial chemotherapy in the s led to the rapid abandonment of many forms of passive antibody therapy. chemotherapy was more effective and less toxic than antibody therapy. in this last decade of the th century the efficacy of antimicrobial chemotherapy is diminishing because of the rapidly escalating number of immunocompromised individuals, the emergence of new pathogens, the reemergence of old pathogens, and widespread development of resistance to antimicrobial drugs. this diminishment in the effectiveness of chemotherapy has been paralleled by advances in monoclonal antibody technology that have made feasible the generation of human antibodies. this combination of factors makes passive antibody therapy an option worthy of serious consideration. we propose that for every pathogen there exists an antibody that will modify the infection to the benefit of the host. such antibodies are potential antimicrobial agents. antibody-based therapies have significant advantages and disadvantages relative to standard chemotherapy. the reintroduction of antibody-based therapy would require major changes in the practices of infectious disease specialists. the antibiotic era is about years old. as we approach the st century, the progress made in controlling infections is threatened by the growing numbers of immunosuppressed individuals; the emergence of new pathogens; the reemergence of old pathogens; and the widespread resistance of organisms to antimicrobial drugs. each development poses its own set of challenges; in combination, these developments are already undermining the efficacy of antimicrobial chemotherapy. there is a worldwide epidemic of immunosuppression due to malnutrition, aids, medical therapies for cancer and autoimmune diseases, and organ transplantation. immunosuppressed hosts provide ecological niches for low-virulence microorganisms [ ] . in addition, antimicrobial drugs are less effective and sometimes are unable to eradicate infection in individuals with impaired immunity. classical pathogens such as mycobacterium tuberculosis and treponema pallidum have reemerged and are difficult to treat in immunosuppressed individuals [ , ] . the increasing frequency of drug-resistant organisms is an equally alarming development, and resistance may be developing faster than new antibiotics can be introduced [ ] . for example, in one new york city hospital, the percentage of vancomycinsusceptible enterococcus faecium decreased from % to % in years [ ] . the problem of resistance is not limited to bacteria; there are numerous reports of fluconazole-resistant candida albicans [ ] . we briefly review the use of antibody-based therapy in the early th century and make the case for reintroducing passive antibody administration for the treatment ofinfectious diseases. advances in monoclonal antibody (mab) technology provide new opportunities for developing antibody-based therapies. in the case of pathogens for which antimicrobial chemotherapy already exists, antibody-based therapies could be used with existing chemotherapy to improve outcome and possibly reduce the development of resistance. in the case of pathogens for which no effective chemotherapy exists, antibody-based therapies could be used for primary therapy. given the diminishing efficacy of existing antimicrobials because of widespread resistance and the difficulties of treating infections in immunosuppressed individuals, the reintroduction of antibody-based therapies is an option that should be given serious consideration. this reintroduction would require major changes in the practice of infectious disease medicine. the administration of immune serum (usually animal) for the treatment of infections was called serum therapy and was introduced in the s for the treatment of diphtheria. by the s, serum therapy was widely used for the treatment of table . infectious diseases that were treated with antibody-based therapies in the preantibiotic era. bacterial and viral infections (table ) . for example, in the late s, % of patients with type i pneumococcal pneumonia admitted to boston city hospital were treated with type-specific serum [ ] . from to at bellevue hospital (new york), > , patients with erysipelas were treated with serum [ ] (figure ). the efficacy of serum therapy varied with the type or severity of infection. several large controlled studies revealed that type-specific serum reduced the mortality ofpneumococcal pneumonia [ ] . serum therapy also appears to have significantly reduced mortality due to meningococcal meningitis in some epidemics [ , ] . serum therapy reduced mortality due to haemophilus irif/uenzae meningitis, but the effect was small [ ] [ ] [ ] . serum therapy for erysipelas reduced mortality in comparison to historical controls [ , ] . serum therapy reduced mortality in diphtheria, and antibody therapy continues to be used today to treat this disease [ ] . the efficacy of serum therapy for whooping cough, anthrax, dysentery (shigella dysenteriae), and gas gangrene was uncertain. human convalescent serum was effective for prophylaxis ofmeasles, which had a mortality rate of %- % in some populations [ ] [ ] [ ] . the effectiveness of serum in the pre-paralytic stage of poliomyelitis was uncertain [ , ] . no consistently effective sera were developed against many pathogens, including staphylococcus [ ] , mycobacterium, and salmonella species [ ] . the historical use of serum therapy provides lessons for the effective use and development of antibody-based therapies. accurate microbiological diagnosis was essential for successful treatment, and serum therapy was most effective when used for prophylaxis or for therapy early in the course of infection. note. this is not a complete list. [ ] [ ] [ ] [ ] [ ] nevertheless, it was possible to treat established bacterial infections such as meningococcal meningitis and pneumococcal pneumonia if antibody was administered shortly after symptoms began [ ] . antibodies functioned as direct antibacterial agents (e.g., pneumococcal antisera) or antitoxins (e.g., diphtherial antisera). nonphysiological and nontherapeutic animal models of infection allowed investigators to successfully identify clinically useful antibody reagents [ ] . a considerable amount of basic immunologic and microbiological research was required to develop each serum, and many fundamental discoveries were made in the search for better sera. (the contributions of pneumococcal research to basic science are discussed in [ ] .) sulfonamides were introduced in and rapidly became the standard therapy for many infections [ ] . because antimicrobial chemotherapy had significant advantages over serum therapy, the latter was largely abandoned. systemic administration of animal sera caused fevers, chills, and allergic reactions [ , ] ; "serum sickness," a self-limited syndrome characterized by rash, proteinuria, and arthralgias, occurred in %- % of patients because of immune complex disease. in addition, strain typing was necessary for choosing pneumococcal antisera; there was significant lot-to-lot variation in serum efficacy [ ] ; and dosing was based on clinical experience. inadequate dosage, delays in treatment, errors in typing, mixed infections, and complicated infections (e.g., empyema) could result in failure of serum therapy [ ] . serum was expensive because of the costs of animal husbandry, antibody purification, refrigeration, and reliance on mouse protection tests for standardization. chemotherapy was less toxic and more effective than serum therapy. treatment with type-specific serum reduced the mortality of pneumococcal pneumonia from %- % to %- % [ ] , whereas the mortality rate among patients treated with sulfonamide was % [ ] . serum therapy reduced the mortality rate of erysipelas from % to % [ ] , whereas the mortality rate for patients treated with sulfonamides was %- % [ ] . for meningococcal meningitis, the efficacy of serum depended on the epidemic. in the mid- s, waghelstein [ ] reported that the mortality rate for patients with meningococcal meningitis who were treated at sydenham hospital (baltimore, md) with sulfonamide was . % and for those treated with serum it was %. in controlled trials, the superiority of chemotherapy over serum therapy was lessevident. for example, the mortality among patients with meningococcal meningitis who were treated early with adequate serum therapy was . % vs. . % for sulfanilamide therapy [ ] . the mortality among patients with pneumococcal pneumonia treated with antimicrobial drugs or serum was % and . %, respectively, but there was no difference in the mortality rates among younger .. literature sent on request. is used at bellevue hospital. it is supplied in packages of one therapeutic dose of approximately ten cubic centimeters. the data cited were published in [ ] . patients, and younger patients who received serum recovered faster than those who received antimicrobials [ ] . in the early days of the antibiotic era there was interest in using combination therapies with antibiotics and serum. sulfonamides and serum had a synergistic or additive effect against streptococcus pneumoniae [ ] [ ] [ ] [ ] , streptococci [ ] , and meningococci [ ] . the finding that sulfonamides made pneumococci more susceptible to antibody-mediated phagocytosis supported the idea of combination therapy [ ] . it was similarly recognized that sulfonamides, unlike antibody, did not neutralize bacterial toxins or modify the course of disease caused by diphtheria or tetanus toxins [ ] . combination therapy was recommended for scarlet fever [ ] , pneumococcal pneumonia [ , , ] , whooping cough [ ] and meningitis due to pneumococcus [ , ] , meningococcus [ , , , ] , or h. influenzae [ ] . however, the side effects of serum made the potential benefits of combination therapy marginal [ ] . in summary, serum therapy was abandoned because of toxicity, difficulty in administration, narrow specificity, lot-to-lot variation, and expense. chemotherapy was less toxic and easier to use, lots were more consistent, and it was more effective in eradicating infection. in addition, there was no need for strain typing with chemotherapy. however, it is ironic that the broad antimicrobial activity of these drugs used for chemotherapy might have contributed to widespread resistance, and today susceptibility testing is essential to the selection of appropriate antimicrobial drugs. although antibodies are no longer used directly as antibacterial drugs, they continue to be used in infectious diseases (for recent reviews see [ ] [ ] [ ] ). the majority of antibody preparations are now human. antibody administration reduces infection in individuals with immunodeficiencies [ ] [ ] [ ] [ ] and is effective for postexposure prophylaxis against measles, hepatitis a and b, rabies, and varicella viruses. specific antibody is used for the treatment of botulism [ ] , diphtheria [ ] , tetanus [ ] , snake bites [ ] , and spider stings [ ] . passive antibody administration has been used for prophylaxis and/or therapy of several viral infections, including cytomegalovirus (cmv) [ , ] , rotavirus [ ] , lassa virus [ ] , varicella [ ] , enterovirus [ , ] , and parvovirus b infections [ ] . in recent years, there has been renewed interest in the use of antibody preparations to prevent infection in high-risk groups. intravenous administration of polyclonal antibody has been reported to reduce the number of infections in patients with aids [ ] [ ] [ ] , patients in surgical intensive care units [ ] , organ transplant recipients [ ] , and neonates [ , ] (for critical reviews and commentary on this practice see [ ] [ ] [ ] [ ] ). antibody therapy is used for a variety of illnesses that may or may not be infectious, including autoimmune thrombocytopenia, kawasaki disease, and autoimmune neuromuscular diseases [ , ] . passive antibody administration is used for prevention of rh-hemolytic disease [ ] . equine lymphocyte antiserum [ ] and murine mabs to lymphocytes are used to prevent organ rejection [ ] . digitalis-binding antibodies are useful for the treatment of digoxin toxicity [ ] . thus, antibody therapy is still widely used in medicine, but its role in the treatment of infections is limited largely to viral and toxin neutralization and replacement therapy in patients with immunoglobulin deficiencies. in reconsidering the antibody option it is clear that heterologous antibody (i.e., serum therapy) is a poor choice because of toxicity. human immune sera have fewer side effects, but there are concerns about availability, potency, and consistency. a major disadvantage of all immune sera is that specific antibodies make up a small minority of the antibody present. there is significant variation in pathogen-specific opsonic activity of commercially available immunoglobulin preparations [ ] . there is also concern about the potential of human sera to transmit infectious agents [ ] . the discovery of hybridoma technology in [ ] and recent advances in mab technology, including the generation of humanized antibodies [ ] , make mab-based therapies a more attractive therapeutic option. in contrast to polyclonal sera, mabs are homogeneous and reproducible reagents that can be generated in large amounts. generation of mabs from mice and rats is still easier and more efficient than production of human mabs. however, several technologies are available for the humanization of murine mabs and generation of human mabs [ ] . mouse-human chimeric antibodies can be constructed by linking the genes expressing the mouse variable region to human constant region genes [ ] . the result is a molecule that is mostly human and has a longer half-life than the murine precursor [ ] . as an alternative, the antigen binding regions of murine mabs can be grafted into human antibody frameworks by molecular techniques [ ] , resulting in molecules that are almost completely human in origin. other strategies to generate human antibodies are the transformation of human b cells, the generation ofrecombinant antibody libraries from human b cells, and the use of transgenic mice that have the human immunoglobulin locus. recent setbacks for mab-based therapies: historical perspective clinical trials of antiendotoxin mabs for gram-negative sepsis have produced inconclusive results [ , ] . when the difficulties encountered in developing antiendotoxin mab strategies are considered in the context of the development of serum therapy, they do not seem unusual or unexpected. for example, passive protection with pneumococcal antisera was demonstrated in by the klemperers [ ] , but - years elapsed before serum therapy for pneumococcal pneumonia was widely accepted. for pneumococcal antiserum therapy to be consistently successful, several developments were necessary. these included the appreciation of antigenic variation in pneumococci [ ] , the need for type-specific sera [ ] , the development of rapid in vitro assays to establish antigenic type (i.e., capsular swelling and agglutination reactions) [ ] , the development of methods to standardize potency (mouse protection test) [ ] , and improved purification techniques that would reduce the toxicity of serum. for meningococcal antisera the situation was reversed; flexner's serum significantly reduced mortality in early epidemics of meningitis [ ] but was subsequently less effective, possibly as a result of antigenic changes in neisseria meningitidis [ ] . research into better meningococcal antisera was then hampered by the lack of useful animal models, loss of strain virulence in vitro, and poor understanding of the antigenic diversity of n meningitidis [ , ] . a lesson from the preantibiotic era is that a considerable amount of basic research on the immunology and pathogenesis of each infection is usually necessary before antibody therapy can be developed that will be successful in clinical practice. spectrum ofactivity. antibodies can modify bacterial, fungal, parasitic, and viral infections and are a class of biological agents with broad antimicrobial activity against diverse pathogens. antibody-based therapies are usually pathogen-specific and have the theoretical advantage that they should not affect the normal flora of the patient or select for resistance in nontargeted microbes. nevertheless, narrow specificity is a disadvantage because mixed infections may not be treated by a single antibody preparation. pneumonia due to s. pneumoniae with more than one serotype was recognized as a reason for the failure of type-specific serum therapy [ ] . one solution is to use cocktails of mabs active against common antigenic types. cocktails may be designed to include mabs to multiple serotypes and mabs with multiple isotypes to enhance antibody effector function. pathogen-specific drugs (such as mabs) are less attractive to the pharmaceutical industry because the narrow specificity reduces the potential market for the drug. however, the increasing incidence of resistant organisms resulting from the use of broad-spectrum antibiotic regimens could make pathogen-specific drugs attractive to drug companies. precedents for the development of pathogen-specific drugs already exist in the area of antiviral drug research. mechanisms ofaction. antibodies mediate protection by a variety of mechanisms. direct antibody mechanisms of action include inhibition of attachment, agglutination (and immobili-cm ; (july) zation), viral neutralization, toxin neutralization, antibodydirected cellular cytotoxicity, complement activation, and opsonization [ ] . antibody therapy has the potential to enhance immune function in immunosuppressed hosts. however, since the mechanism of action of many antibodies involves promoting microbial clearance through nonspecific cellular immunity, antibody-based therapies may be less effective in individuals with defective macrophage, neutrophil, and natural killer cell function. in this regard, it is encouraging that antibodies are effective against pseudomonas aeruginosa in neutropenic mice [ ] and that they can reduce the number of infections in pediatric patients with aids [ ] . antibodies are usually considered to be "protective" effector molecules of the immune system. however, not all antibody responses to pathogens are protective and some may be deleterious to the host. for example, some viral-specific antibodies are capable of enhancing infection [ ] . thus, antibody molecules being considered for clinical development will require extensive testing in vitro and in vivo. studies of the mechanisms of antibody action are important for understanding the mode of protection and for designing clinical trials. pharmacokinetics. the pharmacokinetics of human igg suggests several useful characteristics for its role as an antiinfective agent. these include a long half-life (~ days [ ]), good tissue penetration [ ] , and, depending on the isotype, the ability to either cross the placenta to provide antibody protection to fetuses and newborns [ ] or to be excluded from the placenta if fetal toxicity is a concern. heterologous mabs (i.e., murine mabs) have shorter half-lives in humans, but chimeric and humanized mabs have longer half-lives than their murine precursors. mabs with a longer half-life can, in principle, be engineered by altering the regions of the constant domain that regulate clearance. a disadvantage of antibody-based therapies is the need for systemic administration. oral administration is unlikely to be effective, with the possible exception of therapy for enteric pathogens [ , ] . the blood-brain barrier is a potential obstacle for antibody therapy for infections of the brain. however, in infections of the brain in which there is inflammation, there is increased antibody penetration, and intravenous administration of antibodies appears to have been successfully used for therapy of meningococcal meningitis [ ] . antibodybased therapies can also be administered directly into the subarachnoid space, as has been done for the treatment ofmeningococcal and h. influenzae meningitis [ , ] . enhanced penetration of the brain can be achieved by modifying the charge of the molecule [ ] or by linking it to carrier proteins that cross the blood-brain barrier [ ] . antibody therapy for brain infections may be feasible if the blood-brain barrier is leaky, if antibody is administered directly into the subarachnoid space, or if antibodies with greater brain penetration are used. additional research into the pharmacokinetics of antibodies in infection is likely to be required for optimal use of antibody-based therapies. studies of antibody binding to tumors have revealed complex pharmacokinetics [ ] . there may be problems with antibody penetration into abscesses as have been found with tumors. toxicity. immunoglobulins are generally safe drugs [ ] . nevertheless, serious side effects have been reported with highdose ( . - g/kg) antibody therapy, including rare cases of renal failure [ ] , aseptic meningitis [ ] , and thromboembolic events [ , ] . high-dose immunoglobulin therapy is unlikely to be required in antiinfective mab therapy. in the past, serum therapy was effective against various pathogens despite the fact that immune sera contained only small amounts of specific antibody. mabs have significantly higher specific activity than polyclonal preparations. for example, . mg of two anti-tetanus toxin human mabs provides the same activity as - mg of immune globulin [ ] . thus, the toxicities described for high-dose immunoglobulin therapy may not be relevant in antiinfective therapies with mabs. until fully human mabs are available, rodent, mousehuman chimeric, or humanized mabs are therapeutic options. for over a decade, murine mabs directed against t cells have been used to prevent organ graft rejection in humans [ ] . a murine igm to endotoxin (e ) was tested in patients with sepsis and appeared to be a safe treatment [ ] . although administration of murine mabs is generally well tolerated in humans, allergic reactions occur in %- % of patients [ ] and most patients develop antibody responses to the murine mabs that may interfere with their therapeutic function [ , ] . experience with human-mouse chimeric antibodies and humanized mabs is accumulating rapidly as clinical trials with several compounds progress. a chimeric anti-cd mab for the treatment of rheumatoid arthritis has been well tolerated [ ] , but approximately half the patients had infusion-related side effects (headaches, nausea, fever, and chills), which were diminished by slowing the infusion rate [ ] . mouse-human chimeric and humanized mabs are less immunogenic than their murine precursors [ , ] , but antiidiotypic responses occur after repeated treatments [ ] . overall, the experience with chimeric and humanized mabs suggests that they are relatively safe compounds [ , [ ] [ ] [ ] [ ] . antigenic variation and antibody resistance. the efficacy of antibody-based therapies may be diminished by antigenic changes in the pathogen. this could be minimized by antigenic surveillance systems, as is presently done for influenza virus. antibody-resistant mutants can be generated in the laboratory [ ] , and it is likely that the same can occur in patients. mechanisms of antibody resistance include mutations that change the antigenic site and protease production. antibody use may select for antigenically distinct variants. evidence for the horizontal transfer of iga protease genes exists in neisseria gonorrhoeae and it is conceivable that widespread antibody use would result in selection of protease-producing strains for many pathogens [ ] . thus, large-scale use of antibody-based therapies may result in rapid emergence of antibody resistance in a manner analogous to that of antibiotic resistance. however, one advantage of antibody-based therapies is the versatility of antibody compounds. for example, emergence of an antibodyresistant strain could be countered by a new antibody directed toward the mutated epitope or another antigenic target. emergence of protease-producing strains could be countered by designing antibodies without protease cleavage sites (although these may then be recognized as foreign and be immunogenic) or by addition of antiprotease mabs. selection of antibodyresistant organisms could be minimized by using cocktails of mabs directed at multiple antigenic targets or by using a combination of antibodies and antimicrobials. cost. cost effectiveness is a significant concern that is likely to be a major obstacle for the development of passive antibody therapies. antibody prophylaxis for cmv infections can cost $ , to $ , per patient [ ] . the cost effectiveness of antibody therapy for prevention of infection in leukemic patients has been questioned [ , ] . however, in selected populations such as premature infants, antibody therapy may be cost effective [ ] . furthermore, the cost of a drug when first introduced may not reflect its long-term costs given the potential for improvements in technology and production. mabs are presently made in tissue culture, so the cost of production is high. mabs can be made in bacteria or yeast, and less costly means of production might be developed [ ] . in the past, serum therapy was used despite its high cost because it was believed to be effective. new antibody-based therapies are likely to be used if they prove to be effective. for pathogens such as s. pneumoniae, n. meningitidis, and h infiuenzae, there is a large body of experimental and clinical evidence to support the development of passive antibody therapy. however, for many pathogens, antibody immunity has not been proven to be important. for example, cryptococcus neoformans is a fungus for which the importance of antibody immunity is uncertain. however, administration of preformed antibodies can modify the course of cryptococcal infection in various animal models [ ] [ ] [ ] [ ] [ ] , and the combination of antibody and amphotericin b is a more effective treatment than the use of either agent alone [ ] [ ] [ ] . studies with mabs have shown that there are protective, nonprotective, and deleterious antibodies to the c. neoformans capsule polysaccharide [ ] . heavy chain isotype [ , ] and epitope specificity [ ] are important determinants of protective efficacy. the existence of protective and nonprotective antibodies against c. neoformans, a fungus for which antibody immunity mayor may not be important, provides a paradigm that may be applicable to other pathogens. we propose the hypothesis that for every pathogen there exists an antibody that will modify the course of infection to the benefit of the host; such antibodies are candidates for development as antimicrobial drugs. our proposal includes the use of antibodies for intracellular pathogens; for example, anti-bodies may exist that could prevent cell entry of intracellular bacteria and/or shift the intracellular location of such bacteria by promoting internalization through fe receptors. an mab that inhibits intracellular toxoplasma gondii infection has recently been described [ ] . in addition, antibodies have been described that can neutralize viruses intracellularly [ ] or penetrate the nuclear membrane [ ] . our proposal is not limited to those pathogens for which antibody immunity has been demonstrated to be protective. conclusions on the importance of antibody immunity are usually based on observations made with polyclonal sera (i.e., passive protection or correlation of immunity with the presence of antibody). since polyclonal sera might contain protective antibodies, nonprotective antibodies, and disease-enhancing antibodies, the existence of protective antibodies cannot be ruled out on the basis of absence of protection in experiments involving passive transfer of polyclonal sera or immunizations. conversely, experiments that demonstrate that polyclonal sera can mediate protection indicate the existence of protective antibodies. for pathogens for which polyclonal antibody has shown no protection, the question of whether useful antibodies exist must be reevaluated with mabs since the presence of nonprotective or deleterious antibodies in polyclonal sera could create confounding variables. a corollary of our proposal is that antibody-based therapies may be developed against pathogens for which antibody immunity is not considered to be important. infections that are difficult to treat and that can be modified by antibody immunity provide a logical starting point for the development of antibody-based therapies. antibodies have historically been more effective in prophylaxis than in therapy. antibody-based therapies have traditionally been most effective in infections where viral and toxin neutralization modifies the course of the disease. however, most of the historical experience was gained with polyclonal preparations of uncertain composition and mayor may not be applicable to mab preparations with high activity. opportunistic infections. infections with low-virulence organisms in immunosuppressed individuals are often difficult to treat and are sometimes incurable. since the problem is deficient immunity, antibody therapy is an attractive option because antibodies can enhance immune function. table lists examples of opportunistic pathogens for which antibody can modify the course of infection. antibiotic resistance. drug-resistant organisms are targets for development of antibody-based therapies. the spread of penicillin-resistant s.pneumoniae, methicillin-resistant staphylococcus aureus, and multiply-drug-resistant e. faecium has limited the useful antibiotic arsenal against these pathogens [ , , ] . for pneumococcus, antibody therapy has been shown to be useful [ ] . antibody may be useful against staphylococcal infection [ , ] . for e.faecium, the role of antibody immu-ern ; (july) table . opportunistic pathogens for which experimental data suggest a potential role for antibody-based therapies. nity is uncertain, but some patients make opsonic antibodies, which might be protective [ ] . significant work has already been done in the development of pseudomonal antibodies for resistant gram-negative organisms (table ). the addition of antibody-based therapies to chemotherapy may slow the development of resistance and improve outcome. toxin neutralization. the ability to neutralize toxins is a unique characteristic ofantibody-based therapies. antitoxin antibodies are useful for the treatment of diphtheria, tetanus, botulism, snake bites, and black widow bites (see above). recent attempts to develop antibody therapy for gram-negative sepsis have focused on mabs to neutralize endotoxin [ , , ] and cytokines [ ] . pseudomonas aeruginosa sepsis, combination therapy with mabs to endotoxin and tumor necrosis factor was superior to therapy with a single mab [ ] . examples ofpotential targets for antibody-based therapy include the toxins and proteases associated with toxic shock syndromes [ , ] . combination therapy with antibodies to exotoxins could improve outcome, but cocktails of mabs may be necessary because of toxin heterogeneity [ ] . intravenous immunoglobulin administration has been associated with dramatic clinical improvement in a patient with streptococcus pyogenes toxic shock syndrome [ ] . antivirals. virus neutralization is an established property of antibodies. in the preantibiotic era, serum was used for prophylaxis ofmeasles, chickenpox, mumps, and poliomyelitis. recently, the potential of antibody therapy against many viruses, including hepatitis b [ ] , hiv [ ] , respiratory syncytial virus [ ] , cmv [ ] , and parvovirus [ ] , has received considerable attention. newly identified viral illnesses are targets for antibody drug research. combination ofantibody therapy and chemotherapy. antibody-based therapies are unlikely to be used alone unless they are the only available therapy or are being used for prophylaxis of infection. combinations of antibody therapy and chemotherapy offer theoretical advantages. antibodies promote microbial killing directly by a complement-mediated lytic process or indirectly by enhancing nonspecific immune mechanisms. table lists examples of bacterial, fungal, and viral pathogens for which combination therapy has shown promise. combination therapy could reduce the amount of either agent required to table . pathogens for which the combination of chemotherapy and antibody based therapy has shown some promise. pathogen chemotherapy antibody [ , ] neisseria meningitidis sulfanilamide horse immune sera [ ] streptococcus pneumoniae rabbit immune sera [ , ] haemophilus infiuenzae sulfonamide rabbit, horse immune sera [ ] staphylococcus aureus sparftoxacin human igg mab [ ] p. aeruginosa human igm mab [ ] p. aeruginosa murine e lps antibodies [ ] p. aeruginosa human gamma globulin [ ] escherichia coli murine e lps antibodies [ ] shistosoma mansoni praziquantel rabbit immune sera [ ] candida albicans amphotericin b human gamma globulin [ ] cryptococcus neoformans amphotericin b rabbit immune sera [ , ] c. neoformans murine igg mab [ ] c. neoformans murine igg mab [ ] lassa virus ribavirin monkey immune sera [ , ] cytomegalovirus ganciclovir murine immune sera [ ] herpes simplex virus adenine arabinoside rabbit and human sera [ ] herpes simplex virus acycloguanosine human immune globulin note. this is not a complete list. achieve a therapeutic effect. for example, some antibiotics are quite toxic, and the ability to reduce doses could lessen side effects. in a similar vein, the addition of chemotherapy to antibody therapy could reduce the amount of antibody necessary to achieve a therapeutic effect, which would lessen the cost of therapy. the availability of broad-spectrum antibiotics has diminished the need for making exact microbiological diagnoses. for example, gram-negative sepsis or presumed fungal infections can be treated with empirical therapy without identifying the pathogen. this situation is in contrast to the practice of infectious diseases in the s when identification of the pathogen (and its serotype) was necessary for choosing the correct antiserum. for antigenically diverse pathogens such as s. pneumoniae, rapid protocols were developed for typing strains. the present practice of infectious diseases is not unlike a gambling strategy where the probability of infection by a given microbe is matched to the likelihood of activity by the available antibiotics. this has resulted in great emphasis on broad-spectrum antibiotic "coverage" and less emphasis on making an exact microbiological diagnosis. although the relative merits of this practice are beyond the scope of this article, widespread antimicrobial resistance is decreasing the effectiveness of existing antibiotics, and increased caution is warranted when designing broad-spectrum combinations. a return to antibody therapy would force greater emphasis on precise microbiological diagnosis and would foster the development of more accurate and more rapid diagnostic strategies. the use of antibody-based therapies may also require antigenic screening in the clinical laboratory, a practice not unlike the present one of antimicrobial susceptibility testing. in cost-conscious 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characteristics of invasive streptococcus pyogenes isolates with clinical components of streptococcal toxic shock syndrome intravenous immunoglobulin therapy for toxic shock syndrome human combinatorial antibody libraries to hepatitis b surface antigen passive immunization for the prevention and treatment ofhiv infection human monoclonal fab fragments derived from a combinatorial library bind to respiratory syncytial virus f glycoprotein and neutralize infectivity efficacy of human immunoglobulin and penicillin g in treatment of experimental group b streptococcal infection protection of mice against meningococcus infection by polyvalent antimeningococcic serum combined protective action of human gamma globulin and antibiotics when administered simultaneously in experimental staphylococcal infections synergism between human gamma globulin and chioroamphenicol in the treatment of experimental bacterial infections combined serum and sulphanilamide in the treatment of streptococcal infections in mice monoclonal antibodies for treatment of gram-negative infections efficacy of anti-endotoxin monoclonal antibody e alone or in combination with ciprofloxacin in neutropenic rats with pseudomonas sepsis praziquantelinduced exposure of schistosoma mansoni alkaline phosphatase: drugantibody synergy which acts preferentially against female worms. parasite immuno effects of immunoglobulin g and low-dose amphotericin b on candida albicans infections in burned mice combination of -flucytosine and capsule-binding monoclonal antibody in therapy of cryptococcus neoformans infection enhanced treatment of lassa fever by immune plasma combined with ribavirin in cynomolgus monkeys - -dihydroxy- -propoxymethyl) guanine prevents death but not immunity in murine cytomegalovirus-infected normal and immunosuppressed balb/c mice combined effects of acycloguanosine and humoral antibodies in experimental encephalitis due to herpesvirus hominis synergistic antiviral effects of adenine arabinoside and humoral antibodies in experimental encephalitis due to herpesvirus hominis unequalled but unobtainable key: cord- -qfvceu authors: ang, juan lyn; ah-moye, sarah; kim, leah n.; nguyen, vuong; hunt, adrian; barthelmes, daniel; gillies, mark c.; mehta, hemal title: a systematic review of real-world evidence of the management of macular oedema secondary to branch retinal vein occlusion date: - - journal: eye (lond) doi: . /s - - - sha: doc_id: cord_uid: qfvceu this review assessed the real-world evidence of the management of macular oedema secondary to branch retinal vein occlusion (brvo). a meta-analysis of eyes from real-world studies of therapies for macular oedema secondary to brvo was conducted. baseline characteristics, visual, anatomical and safety outcomes were recorded. the weighted mean and weighted estimates from random-effects models were calculated for visual acuity (va) and central subfield thickness (cst) changes at , and months. primary outcome was change in va (logmar letters) at months. study quality was assessed using the quality appraisal checklist for case series developed by institute of health economics. the mean baseline va for the pooled data was . ( . , . ) letters and the mean baseline cst was . ( . , . ) µm. the random-effects estimate for mean ( % ci) change in va was . ( . , . ) letters at months (n = ). the random-effects estimate for mean ( % ci) change in cst was − . (− . , − . ) µm at months (n = ). the quality of studies varied considerably. ocular and systemic adverse events were discussed in % and % of treatment arms respectively, with possible under-reporting. visual and anatomical gains achieved in the real-world for anti-vegf therapy were not as impressive as seminal rcts, possibly due to reduced injection frequency in the real world and differences in baseline characteristics. there is an urgent need for consensus on the minimum efficacy, treatment burden and safety data to collect to strengthen the real-world evidence base. the leading cause of vision impairment in branch retinal vein occlusion (brvo) is persistent macular oedema, which if left untreated can permanently disrupt the macular architecture [ ] . there are a range of treatments currently available for managing macular oedema secondary to brvo that have been investigated in randomised controlled trials (rcts). the question is whether these rct results can be replicated in the real world. the branch vein occlusion study (bvos) was a landmark trial published in assessing macular grid laser for brvo. it established grid laser as the first-line therapy of macular oedema secondary to brvo for subsequent decades. more participants in the grid laser group ( %) had ten or more letter vision gain at months compared with the placebo group ( %) at months [ ] . intravitreal corticosteroid therapies, which inhibit numerous local inflammatory modulators and vascular endothelial growth factor (vegf), then emerged [ ] . the standard care versus corticosteroids for retinal vein occlusion (score) study found no difference in visual acuity (va) and macular centre point thickness at months between patients treated with and mg triamcinolone and grid photocoagulation, but there were higher rates of adverse events particularly elevated intraocular pressure (iop) and cataract in the group treated with mg of triamcinolone [ ] . intravitreal dexamethasone implants for brvo were evaluated as part of the global evaluation of implantable dexamethasone in retinal vein occlusion with macular edema (geneva) trial which reported a letter va gain at days in % of the dexamethasone implant . mg group, % in the . mg group and % in the sham group [ ] . a -month extension of the geneva study examined safety outcomes at months [ ] . only combined brvo and crvo data were reported; there was greater cataract progression in the % of eyes re-treated with dexamethasone implants compared with % of eyes that received a single implant [ ] . iop-lowering medications were started in % of eyes in the initial dexamethasone treatment groups and in additional % of those who had a second implant [ ] . more recently intravitreal anti-vegf therapies have become available and are often first-line treatment for macular oedema secondary to brvo [ ] . ranibizumab has been the anti-vegf agent most widely investigated in rcts, first in the branch retinal vein occlusion: evaluation of efficacy and safety (bravo) study [ , ] , then in horizon [ ] , an open-label, single-arm extension trial for bravo and other phase iii ranibizumab studies and subsequently the extended follow-up of patients with macular oedema due to branch retinal vein occlusion or central retinal vein occlusion previously treated with intravitreal ranibizumab (retain) study [ ] . overall, patients who received ranibizumab had greater visual gains and greater central foveal thickness (cft) reductions compared with patients who received sham treatment at months [ ] and after crossover to ranibizumab, the sham group experienced visual gains but not to the same level of improvement as other groups which were treated with ranibizumab early on [ ] . this reinforced the importance of initiating treatment early. ranibizumab was compared against macular laser in the brighter study, where ranibizumab groups had superior outcomes compared with the laser monotherapy group at months and months [ , ] . overall, the brighter study results suggested that addition of laser did not lead to better visual outcomes and did not reduce the number of ranibizumab injections ( . vs. . ; p = . ) [ ] . the vibrant study was a randomised, doublemasked phase iii trial that evaluated whether aflibercept was superior to grid laser for macular oedema secondary to brvo [ , ] . monthly aflibercept led to greater vision gains and central retinal thickness (crt) reduction at months compared with the macular laser arm [ ] . at weeks the laser arm was allowed rescue therapy with aflibercept. the crt and bcva improved at weeks when aflibercept was added, however the improvement was not as great as those eyes treated initially with aflibercept [ ] . the marvel study was a small trial involving participants compared intravitreal injections of bevacizumab and ranibizumab. the -month findings suggested no significant difference in visual outcomes between the drugs using the ʻas required regimeʼ, with an average of three to four injections needed in the first months [ ] . the comparison of anti-vegf agents in the treatment of macular edema from retinal vein occlusion trial (crave) randomised patients to ranibizumab or bevacizumab every month for months and reported no difference in functional and anatomical outcomes between treatment arms in the short term [ ] . the brvo study, an rct comparing . mg bevacizumab against . mg ranibizumab delivered monthly to patients reported no difference in visual outcomes at months [ ] . ranibizumab was compared against dexamethasone implants in the comrade-b [ ] trial and a study by bandello and colleagues [ ] but the trials employed different treatment regimens (see table ). comrade-b reported greater visual acuity gains in patients treated with ranibizumab compared with dexamethasone over a -month study period [ ] whereas bandello and colleagues [ ] reported no significant difference in visual outcomes between the arms, though acknowledged their study was under-powered [ ] . other treatment options that have been explored for treatment of macular oedema secondary to brvo include vitrectomy with internal limiting membrane peeling [ ] or arteriovenous sheathotomy [ , ] , and systemic haemodilution [ ] . these treatment options are not discussed further here as there is not enough evidence from rcts to consider them current mainstream therapy. there are multiple reviews assessing the rct evidence for these treatment options, including cochrane reviews [ , ] and american academy of ophthalmology guidelines [ ] . a summary of findings from seminal rcts is presented in table . although rcts are generally considered the 'gold standard' for providing evidence for efficacy and safety of therapies, results from these selected populations may not always be generalisable to the real world [ ] . real-world studies can also inform us as to the long-term safety and efficacy of drugs beyond the timeframe of the rcts. they can also highlight different outcomes that reflect limitations on drug availability and reimbursement in different healthcare systems [ ] . although there may be a lower level of certainty on the evidence hierarchy compared with rcts, real-world data may have better external validity and can complement findings from rcts [ , ] . here, we present a systematic review of real-world evidence of the management of macular oedema secondary to brvo to inform clinicians and identify gaps in the evidence base that could be addressed in future real-world studies. real-world studies of therapies for macular oedema secondary to brvo published between january and september were included. assessment of eligibility was performed independently by two authors (ja and sa-m) and any disagreements were discussed with a senior author (hm). real-world studies have inherent noise, and therefore we have chosen to include only studies with at least a treatment arm reporting eyes at months (± weeks) follow-up from commencement of intervention. studies were included if they reported visual outcomes for patients regardless of whether they were treatment-naïve or not. the main interventions for macular oedema secondary to brvo comprised macular lasers, intravitreal corticosteroids and intravitreal anti-vegf agents. rcts and their post hoc analyses were excluded as the focus of this review was real-world evidence. studies were excluded for the following reasons: (a) if the brvo results could not be differentiated from central retinal vein occlusion (crvo) results, (b) if it was not possible to identify which treatment was delivered to achieve the visual acuity outcome, (c) non-interventional studies, (d) studies investigating switching therapies, (e) studies that did not report on baseline and post-intervention visual acuity which we consider core data, (f) studies that only presented subgroups and not the full dataset of interventions, (g) follow-up data at no clear time-point and (h) conflicting data reported. a list of excluded studies along with corresponding reasons for exclusion is provided (available as online supplement, supplementary table a) . articles were reviewed and data were extracted by two authors independently (jla and sa-m). any discrepancies were discussed with a third senior author (hm) to reach consensus. the following data were extracted from each report: ( ) study design ( ) country or region ( ) number of eyes ( ) mean age of patients ( ) percentage of female patients ( ) treatment-naïve status ( ) treatment regimen and dosage ( ) time to commencement of treatment ( ) reporting of ischaemic or non-ischaemic status at the macula and in the periphery at baseline ( ) reporting of presence of subretinal fluid (srf) at baseline ( ) reporting of hypertension, diabetes mellitus and smoking status of patients at baseline ( ) inclusion or reporting of high-risk group at baseline e.g., patients with history of cardiovascular disease or cerebrovascular disease ( ) reporting of percentage of eyes that were pseudophakic at baseline ( ) visual acuity at baseline, months, months and months after commencing treatment ( ) central subfield thickness at baseline, months, months, months after commencing treatment ( ) mean number of intravitreal injections administered over the follow-up period ( ) macular laser treatment administered over the followup period ( ) need for retinal laser therapy for neovascularisation ( ) need for rescue therapy ( ) total number of ocular adverse events ( ) mean number of visits over follow-up period ( ) ocular adverse events: number of cases of endophthalmitis, neovascularisation of disc (nvd), neovascularisation elsewhere (nve), neovascularisation of iris/angle (nvi/a), iop increase requiring iop-lowering therapy, rubeotic glaucoma, traumatic cataract, cataract progression, retinal detachment, macular changes affecting vision (e.g. epiretinal membrane, whole pigment clumping, atrophy) and vitreous haemorrhage study quality was assessed using the quality appraisal checklist for case series developed by institute of health economics (ihe) [ ] , as this was the preferred tool by national institute for health and care excellence (nice) [ ] . this was conducted independently by two authors (jla and sa-m) and any discrepancies were discussed with a senior author (hm) to reach consensus. the assessment was based on aspects of study objective, study design, study population, intervention and co-intervention, outcome measure, statistical analysis and results and conclusion [ ] , and criteria for aspects of the checklist were customised for the ophthalmology studies included in this review (available as online supplement, supplementary table b ). scores were assigned to studies based on this assessment for ease of comparison. eyes were said to have entered the study at a similar point of the disease if standard deviations (sd), inter-quartile ranges or equivalent measures were reported to be ≤ months or if studies specified that eyes entered at a similar point e.g., newly diagnosed or acute or chronic stages of macular oedema [ ] . the rationale for using months as a cut-off comes from the finding of bravo, in which patients in the control arm who experienced a delay in ranibizumab treatment by months did not achieve the same visual gains as the patients who received ranibizumab from the start [ ] . if a study was not specified as single or multi-centre in nature, or if only one location was specified, it was assumed to be a single-centre study. if a study only reported the number of patients, it was assumed that one eye per patient was included. visual acuity scores were converted to log-mar letters for consistency. the change and absolute visual acuities and cst were calculated where they were not supplied. the term cst was used as a blanket term to include cft, central macular thickness, central subfield thickness and foveal centre point thickness. all numbers were rounded to a single decimal point where applicable. if a proportion of patients were reported to have received any prior treatment, the cohort was assumed to be non-naïve. as there is wide variation in how studies reported the duration before starting treatment, we directly quoted them in the real-world studies summary table. duration was converted to days if reported in a different unit. when it was uncertain as to whether the location of ischaemia was peripheral or at the macula, this was reported in the summary table. if studies excluded patients with ischaemic brvo or ischaemic maculae, it was assumed that % of patients had ischaemia at baseline. only results from time points at which there were or more patients were included in the va, cst and injection number meta-analyses. when outcomes were reported for different numbers of patients at different time points, the outcomes for , or month time points were preferentially extracted, even if there were a smaller number of patients due to loss to follow up at these time points. we avoided extracting outcomes for subgroups in included studies, unless it was the only data available. reported presence of srf and serous retinal detachment were considered to be equivalent. when dosage was not specified it was assumed that the standard doses were used. there was a high level of heterogeneity in treatment and patient population between studies. we described the characteristics and quality of each study and their outcomes as specified in our protocol, stratified by treatment arms defined by treatment drug and dose. parameters described qualitatively were not considered for quantitative metaanalysis. for the purposes of the meta-analyses, the primary outcome was change in va (logmar letters) at months. secondary outcomes included change in va at and months, change in cst at , and months and number of treatments over , and months. metaanalyses could only be performed if there was more than one included real-world study of an intervention. primary and secondary outcomes were pooled by calculating the mean across all studies weighted according to their total sample size. we also calculated weighted estimates from random-effects models to account for heterogeneity both within and between studies. the inverse-variance method was used to weight studies in the random-effects estimates. heterogeneity between studies was measured using the i statistic, with values of %, % and % denoting low, moderate and substantial heterogeneity, respectively [ ] . mixed-effects meta-regression models were used to estimate and compare outcomes by treatment groups with additional adjustments for age, va and cst at baseline for estimates of changes in va and cst. the mean and standard deviation were estimated when studies only reported the median and first and third quartiles (q and q ). the mean was estimated as the sum of the median, q and q , divided by three [ ] . the standard deviation was estimated as q minus q , divided by . [ ] . if the standard deviation was not available and could not be derived or estimated from other summary statistics, these values were imputed using multiple imputations and the model results pooled [ , ] . analyses were conducted using r version . . . the mice package (version . . ) was used for multiple imputations and the metafor package (version . - ) was used to conduct meta-analyses and random-effects models [ ] . the literature search returned a total of articles on medline, articles on pubmed and articles on embase. based on our inclusion and exclusion criteria, articles published between january and september were included. of these, studies were included in the meta-analyses. there was a total of eyes with macular oedema across all the studies included. a summary of the review and study selection process is presented in fig. . visual and anatomical outcomes along with treatment burden findings of included real-world studies are presented as an online supplement (supplementary table c ). the baseline characteristics of all included studies are listed in table . the systemic risk factors and details of additional therapy including lasers reported in studies are presented as online supplements (supplementary tables d and e, respectively) . there was no quality of life data to report in included studies. the quality of studies as assessed using the adapted ihe critical appraisal checklist is presented as an online supplement (supplementary table f ). scores for quality of studies ranged from . to . with a maximum of points available. in particular, of the studies had clear reporting of consecutive recruitment while in other studies this was unclear. eligibility criteria was clearly stated in all but three studies. of the studies included in this review, only explicitly reported partial masking during cst or bcva assessment. it was unclear whether the further studies employed masking. moreover, the feasibility and importance of partial or complete masking in real-world studies have not yet been established. loss to follow-up was not consistently reported, with of the studies not reporting on loss to follow-up. visual and anatomical outcomes were measured appropriately in the majority of studies, but it was noted that a variety of oct technologies were used in the included studies, with time-domain octs used more frequently in older studies [ ] [ ] [ ] [ ] and spectral-domain octs used frequently in more recent studies [ ] [ ] [ ] [ ] . in some studies, different oct technologies were used in different centres or over time [ , ] . of the studies, only studies fully reported on competing interests and sources of support. treatment arms with or more eyes were included in meta-analyses. ineligible treatment arms have been included in the summary tables if they belonged to a study with an eligible treatment arm. using the criteria above, the meta-analyses were only applied to the following interventions: there were only single included real-world studies of the following interventions: bevacizumab mg, aflibercept, grid laser, subthreshold laser, sub-tenon triamcinolone, conbercept, ziv-aflibercept and a variety of combination therapies. weighted means and mean estimates as estimated by random-effects models or mixed-effects models for baseline characteristics of studies included in the meta-analysis are presented in table . the mean ( % ci) percentage of females across all studies estimated from the random-effects model was . ( . , . )%; the mean age was . ( . , . ) years. the mean baseline va for the pooled data was . ( . , . ) letters and the mean baseline cst was . ( . , . ) µm. the mixed-effects model estimates for mean ( % ci) baseline va for real-world studies in america, asia and europe, were . ( weighted outcome means, outcome measures as estimated by random-effects models (for overall outcomes) or mixedeffects models (for treatment-group outcomes) and heterogeneity (i ) across studies are presented in table . the random-effects estimate for mean ( % ci) change in va was . ( . , . ), . ( . , . ) and . ( . , . ) letters at months (n = ), months (n = ) and months (n = ), respectively. at months, mean ( % ci) va change for bevacizumab . mg, bevacizumab . mg, dexamethasone, ranibizumab and triamcinolone was . ( . , . ), . ( . , ), . ( . , . ), . ( . , . ) and . ( . , . ) letters, respectively. except for dexamethasone which achieved a mean va change of . ( . , . ) letters, mean va change continued to improve further at months table weighted means and mean estimates as estimated by randomeffects models (for overall) or mixed-effects models (for by continent) for baseline characteristics of studies included in the meta-analysis. the random-effects estimate for mean ( % ci) change in cst was − . the presence of srf at baseline was only reported in of the studies ( %), with its presence in eyes ranging between . and % within treatment arms. visual outcomes were reported according to the presence of srf at baseline in two studies. in one study, they identified final visual acuity was not significantly different in the % of eyes with srf at baseline compared with the whole cohort, however baseline va for both groups was not specified [ ] . in the other study, similarly, it was reported that there was no statistically significant difference in the change of visual acuity at months between the groups with and without srf [ ] . patients received a mean ( % ci) estimate of . ( . , . ), . ( . , . ) and . ( . , . ) injections at months (n = ), months (n = ) and months (n = ), respectively, across all treatment groups. for patients who received steroid therapies, there were generally a lower number of injections or implants compared with anti-vegf therapies. patients on steroid therapies received a mean ( %) estimate of . ( . , . ) dexamethasone implants and . ( . , . ) intravitreal triamcinolone injections over months. in contrast, patients in the intravitreal bevacizumab . mg and intravitreal ranibizumab treatment groups received a mean estimate of . ( . , . ) and . ( . , . ) injections over months, respectively. mean number of laser applications was reported by two of the three treatment arms investigating subthreshold micropulse laser photocoagulation and two of the three treatment arms investigating combination therapies that involved macular laser. mean number of visits were reported in only ( %) of the treatment arms reported [ , ] . the amount of heterogeneity (i ) for change in va ranged from . to . %, indicating moderate heterogeneity across studies. heterogeneity for change in cst and injection frequency was consistently > %, indicating substantial heterogeneity across studies for these outcome measures. of the studies, were single-arm studies and assessed multiple treatment arms. the study was conducted prospectively in treatment arms, retrospectively in treatment arms and study design was not clear in treatment arms. there were treatment arms, of which were monotherapies, was a control arm and were combination arms. intravitreal anti-vegf therapies were the most widely investigated, being studied in % of treatment arms. anti-vegf treatment arms were dominated by bevacizumab ( arms) and ranibizumab ( arms). initiation of therapy varied, however the vast majority of studies adopted subsequent pro re nata (prn) treatment regimes. the dose of bevacizumab was typically . mg ( arms), but in some studies a dose of . mg was used ( arms), one study used mg and arms did not specify the dose [ ] . when reported, the dose of ranibizumab was consistently . mg. for intravitreal bevacizumab, arms ( %) used a single injection followed by a prn regimen, arms ( %) used loading injections followed by a prn regimen, arms ( %) used single or loading injections followed by a prn regimen, arms ( %) used single injection only, while another arms ( %) utilised had different and unique treatment regimens [ , , , ] . there were six intravitreal ranibizumab arms ( %) that used a single injection followed by a prn regimen and seven arms ( %) used three loading injections followed by a prn regimen. only one treatment arm was included in our review using intravitreal aflibercept administered as a single . mg injection followed by monthly prn treatment [ ] . another treatment arm used conbercept with a loading phase of three injections at one month intervals followed by a prn regimen. ziv-aflibercept was used in a treatment arm with injections given monthly until the macula was free of all intraretinal and srf and/or the cmt ≤ µm [ ] . the next most reported intervention was corticosteroid therapy representing % of treatment arms (intravitreal dexamethasone %, intravitreal triamcinolone %, subtenon triamcinolone %). for intravitreal dexamethasone and triamcinolone, single therapies were administered at baseline and decisions for re-treatment were on a prn basis. subthreshold laser photocoagulation was investigated in two treatment arms with clearly defined energy parameters delivered at baseline then on a prn basis [ , ] . one study used a nm diode laser photocoagulation device and avoided the foveal centre, while the other used a nm yellow laser system to treat the entire area of leakage demonstrated on fluorescein angiography including the foveal centre [ ] . combination therapy was investigated in three treatment arms that utilised macular grid laser in combination with intravitreal bevacizumab [ ] or intravitreal triamcinolone [ ] . another study used the combination of intravitreal triamcinolone and bevacizumab given at baseline then on a prn basis [ ] . the safety outcomes of each study are available as an online supplement (supplementary table g) . in some studies, the adverse events for brvo eyes could not be differentiated from crvo eyes and therefore we have not included them in the following description. of the treatment arms, ocular adverse events were discussed in ( %) treatment arms. however, few studies specified commented on the specific breakdown of complications. of these studies, studies reported zero ocular adverse events. only ( %), ( %) and ( %) of treatment arms specifically reported zero rates of endophthalmitis (excluding treatment arms investigating subthreshold laser photocoagulation), retinal detachment or rubeotic glaucoma, respectively. the occurrence of neovascularisation was not well reported. less than % of treatment arms commented on this complication. there were no reported cases of nvd and there were nve events and nvi/a event. increased iop requiring iop-lowering medications was reported in ( %) of the included treatment arms. it was reported in of steroid treatment arms and of the non-steroid treatment arms. of the steroid treatment arms where this was reported, required iop-lowering medications compared with of the non-steroid treatment arms. macular changes affecting vision was rarely reported as a category of ocular complication, with only two ( %) of the included treatment arms commenting on this. these studies focused on epiretinal membrane formation. one of these treatment arms utilised intravitreal bevacizumab and the other utilised intravitreal triamcinolone, both in combination with macular grid laser. of the treatment arms, ( %) arms specifically reported rates of vitreous haemorrhage, with treatment arms (all assessing intravitreal bevacizumab . mg) reporting event each. there were variations as to how cataract outcomes were reported. overall, ( %) of the treatment arms reported on any of the following cataract outcomes: cataract progression, traumatic cataract and/or patients requiring cataract surgery. another five ( %) treatment arms excluded patients who required cataract surgery from the study and did not report on other cataract outcomes, however two ( %) treatment arms excluded those who required cataract surgery from the study but did reported on other cataract outcomes [ ] . only treatment arms reported baseline lens status but did not analyse outcomes according to this characteristic. in treatment arms, sectoral laser photocoagulation was administered for non-perfused or ischaemic areas, or if there was ocular neovascularisation. the type and settings used were only described by one study [ ] while another only specified the type of laser [ ] . only in ( %) of the treatment arms, it was specified whether patients received rescue macular laser therapy in addition to the main therapy being investigated. in of these treatment arms, grid laser photocoagulation was administered during the study if there was suboptimal response to the main therapy investigated; however, the settings of the laser photocoagulation treatment were only described by two studies [ , ] . the criteria for judging suboptimal response were not always defined [ ] . in a study which identified no significant difference in visual outcomes between ziv-aflibercept and bevacizumab for macular oedema secondary to brvo, it should be noted that % of bevacizumab treated eyes had additional macular laser whereas no eyes in the ziv-aflibercept group were reported to have received additional macular laser treatment [ ] . the absence or presence of macular ischaemia was reported in of treatment arms ( %) and of these arms, macular ischaemia was present in treatment arms ( %), as shown in online supplement (supplementary table h ). there were three treatment arms that reported no macular ischaemia at baseline, confirmed with fluorescein angiography. in treatment arms ( %), presence of macular ischaemia was specified as an exclusion criterion. in two treatment arms, it was uncertain as to whether the ischaemic areas were at the macula or in the periphery [ , , ] . peripheral ischaemia was reported in of treatment arms ( %). in five ( %) of the studies eyes were excluded if the ischaemic areas were larger than a set area. there was different terminology and a wide range of approaches in describing time to commencement of treatment, as shown in the online supplement (supplementary table h) . a number of studies specified this duration to be from time of ʻsymptom onsetʼ or ʻfrom diagnosisʼ, while some reported ʻduration of macular oedemaʼ or ʻduration of diseaseʼ. at baseline, there were treatment-naïve arms, nonnaïve treatment arms and treatment arms where this information was not clearly provided. the proportion of patients who were hypertensive was reported in treatment arms ( %), and in of these treatment arms, ʻuncontrolled hypertensionʼ was excluded. a further eight ( %) treatment arms excluded patients with ʻuncontrolled hypertensionʼ but did not report the proportion of patients who had hypertension. there was a significant variation in rates of hypertension in the population studied ranging from . to % in the treatment arms. two treatment arms from a single study reported ʻpatients with a history of uncontrolled hypertension…were not usually injected with bevacizumab, but this decision was left at the discretion of the treating physicianʼ [ ] . the proportion of patients who had diabetes mellitus was reported in treatment arms ( %). there was a significant variation in rates of diabetes mellitus in the population studied ranging from to . % in treatment arms. two studies excluded patients with diabetes mellitus and two studies excluded patients with ʻuncontrolled diabetesʼ [ , ] . only one study [ ] reported percentage of smokers ( %) but did not report how this impacted on visual outcomes. there was a range of terminology used when describing strokes and myocardial infarction, ranging from ʻthromboembolic eventsʼ, ʻcardiovascular diseaseʼ and ʻsystemic thrombosisʼ. it was not always clear whether this related to a previous stroke or myocardial infarction. there were treatment arms that reported on the proportion of patients with a history of these diseases, treatment arms reported zero patients with such risk factors and treatment arms excluded patients with such diseases. two treatment arms from a single study reported ʻpatients with a history of…recent thrombo-embolic events were not usually injected with bevacizumab, but this decision was left at the discretion of the treating physicianʼ [ ] . systemic adverse events were only reported by ( %) of the treatment arms, of which arms reported no systemic adverse events. the remaining three treatment arms reported a total of four systemic adverse events [ , , ] . there was an episode of palpitations, an episode of chest pain, a non-ocular serious adverse event and a death [ , , ]. real-world studies confirm that treatment can lead to visual gains and anatomical resolution of macular oedema secondary to brvo. where meta-analysis of anti-vegf agents was possible, the va gains and cst improvements were less impressive in the real-world than in rcts. this might relate to reduced injection numbers (on average < intravitreal anti-vegf injections over months) and different baseline characteristics in the real world compared with rcts. these results may reflect the challenge of delivering frequent anti-vegf therapy in the real-world setting where patients have other co-morbidities and healthcare resources are stretched. an unmet need appears to be longer-acting therapies, which would increase the chances of rct results being replicated in normal clinical practice. it would also be helpful to report the number of visits patients attend in real-world settings to more accurately determine treatment burden. where meta-analyses were possible for intravitreal steroid therapy, va gains were more comparable between the real-world and rct populations. this could be due to the small number of included studies or the more manageable number of treatments required. in study populations receiving ranibizumab . mg in the bravo and the brighter study, the mean age at baseline was . (sd . ) and . (sd . ) years, respectively, similar to the included real-world studies [ , ] . mean ( % ci) baseline va was better in the study populations of included real-world studies at . ( . , . ) letters compared with rcts, with baseline va (sd . ) letters in groups receiving ranibizumab . mg in bravo and . (sd . ) letters in brighter [ , ] . mean ( % ci) baseline cst in our included real-world studies was thinner at . ( . , . ) µm compared with the baseline central subfield foveal thickness in brighter at . (sd ) µm [ ] and the baseline cft in bravo at . (sd . ) µm [ ] . as for the studies assessing bevacizumab . mg, the included real-world studies had a mean ( % ci) age of ( . , . ) years. this is older compared with the study population of marvel receiving . mg bevacizumab, with a mean of . (sd . ) years [ ] . mean ( % ci) baseline va was . ( . , . ) letters in the included real-world studies, better than that of marvel's at . (sd ) letters [ ] . mean ( % ci) baseline cst in our included studies was . ( . , . ) µm, which was similar to the mean crt of . (sd . ) µm in the marvel study [ ] . for the triamcinolone studies, our real-world study sample's mean ( % ci) age was . ( . , ) years. this population is younger compared with that of score, where mean age was . (sd . ) and . (sd . ) years for the groups, which received intravitreal triamcinolone and mg, respectively [ ] . mean ( % ci) va at baseline in included real-world studies was worse than that of score at . ( . , . ) letters compared with . (sd . ) and . (sd . ) letters for the treatment arms that received triamcinolone and mg, respectively [ ] . centre point thickness at baseline however, was thicker in the score study at (sd ) µm and (sd ) µm for patients receiving triamcinolone and mg, respectively [ ] . however, note that the oct outcomes measured in real-world studies and rcts vary, which include cst, cft and csft, therefore these oct measures may not be directly comparable. as the outcome data reported in the geneva study could not be differentiated into brvo and crvo eyes, it could not be compared with the dexamethasone implant data from our included real-world studies. in rcts such as vibrant [ ] and bravo, increasing time to commencement of treatment was a negative predictor of outcome. in this review it has been observed that real-world studies lacked consistency in the use of terminology and approaches in describing time to commencement of treatment. baseline age on average appeared to be slightly lower in asian populations ( . years) compared with the american ( . years) and european populations ( . years) studied. baseline va and cst were lower in the american studies compared with other real-world studies. the presence of srf and its association with visual outcomes was only reported in two included studies [ , ] . however, some studies have suggested that serous retinal detachment was a negative predictor of visual prognosis in brvo patients [ , ] , while subgroup analysis of bravo data reported that presence of central srf did not influence visual outcomes [ ] . therefore, capturing such anatomical features and exploring their associations with outcomes in realworld studies may help us understand possible prognostic factors for macular oedema secondary to brvo. included studies utilised a variety of time-domain and spectral-domain octs. there may be limitations to the comparability of outcomes of these studies because of the potential differences between oct technologies in fluid detection and thickness measurements [ , ] . the recording of treatment-naïve status at baseline is an important parameter that was not consistently recorded. in rcts, study populations were mostly treatment-naïve or have a period without treatment prior to commencing intervention. switching studies were excluded from this analysis. another baseline characteristic that was poorly reported in the included real-world studies was the presence of ischaemia. many studies did not report on this characteristic and of those studies that did, some did not clearly specify that whether the location of ischaemia was macular or peripheral. gains in vision were comparable in subgroups with and without macular ischaemia at baseline in the brighter rct [ ] . one included real-world study [ ] reported that no significant difference in visual and anatomical outcomes was found between those with and without macular ischaemia [ ] , whilst another study suggested macular ischaemia was a negative predictor for visual outcomes [ ] . there are many monotherapy and combination therapy options for the management of macular oedema secondary to brvo. this is reflected in the wide range of treatment interventions and dosing regimens reported in real-world studies. there were limited real-world studies on some of the more recently available intravitreal anti-vegf therapies. there was zero occurrence of endophthalmitis, retinal detachment, rubeotic glaucoma or nvd reported in included treatment arms. an explanation is that these adverse events are very uncommon, but it is also possible that there is under-reporting of safety outcomes in realworld studies compared with rcts. endophthalmitis is a potentially devastating complication that can occur after intravitreal injections, and a meta-analysis of clinical trials and real-world data on infectious endophthalmitis after intravitreal anti-vegf injections for any indication identified cases of endophthalmitis among a total of , intravitreal anti-vegf injections, . % ( % ci, . − . %) [ ] . the use of sectoral laser photocoagulation was described in some of the included studies, but the indication for which it was used in the real world was variable. in some studies, it was applied when significant peripheral ischaemia is detected while in others, this is only done when there is development of active neovascularisation or vitreous haemorrhage. rcts have either specified that patients can receive scatter photocoagulation if there is ocular neovascularisation [ ] or have excluded those anticipated to require scatter laser photocoagulation within months of starting treatment [ ] . the royal college of ophthalmologists (rcophth) guidelines state ʻit is recommended that sector laser photocoagulation is applied once retinal or optic disc neovascularisation occurʼ [ ] . reporting of use of sectoral laser photocoagulation and when it is specifically used in patients in real-world studies may help answer questions as to the optimum timing. notably, less than half of the included treatment arms reported systemic safety outcomes. understandably, ophthalmologists may not always have this data and systemic adverse events may not have been recorded for therapies such as local laser but it would be useful to know the background rate of systemic adverse events in these populations. there is a controversy whether intravitreal anti-vegf treatment causes similar problems to systemically delivered anti-vegf of increased blood pressure and risk of thrombo-embolic events. results of meta-analyses of systemic cardiovascular complications in patients receiving intravitreal anti-vegf therapies are conflicting [ ] [ ] [ ] . rcts excluded patients with recent myocardial infarction, cerebrovascular events and uncontrolled hypertension [ , , , ] . real-world studies therefore, offer an opportunity to observe outcomes of therapies for these potentially high-risk groups. there is also the potential to link registries of rvo therapy and thrombo-embolic events to identify any association. risk factors for brvo have been documented in epidemiological studies, and these include cardiovascular risk factors such as hypertension, diabetes mellitus and smoking [ ] . a case-control study identified that brvo was associated with an increased risk of subsequently developing hypertension, diabetes, congestive heart failure and cerebrovascular disease [ ] and the rcophth guidelines recommend careful cardiovascular assessment and treatment of cardiovascular risk factors in patients with rvo [ ] . although these risk factors were recorded in some of the included treatment arms, at times the terminology used to describe them was unclear as to what they constituted e.g., ʻcardiovascular diseaseʼ. in view of the importance of these risk factors in brvo, we suggest that they should be reported in a standardised manner. rescue therapies with macular laser and anti-vegf were not consistently described in the included real-world studies. it has been observed that only a small number of studies reported the type of laser and settings used in laser photocoagulation therapy. macular laser photocoagulation can potentially affect outcomes as shown in the bvos study [ ] and there can be a widely varying settings and laser type used in real-world studies [ , ] . as use of any rescue therapy can potentially impact outcomes, it is important that it is fully described in real-world studies. it has also been observed that a number of studies included hemi-retinal vein occlusions (hrvo) together with brvo eyes in treatment arms [ , , ] . there does not appear to be a consensus whether hrvo is a variant of brvo or crvo or is a separate condition, with some reports of differences in risk factors, clinical features and systemic associations between the three groups [ ] . however, in the score study there was no significant difference in the three disease entities in frequency of treatments and adverse events [ ] . reporting outcomes for the hrvo subgroups in future real-world studies may provide more information to differentiate it from the other disease entities. notably, none of the included studies in this review reported on quality of life outcomes, despite the known detrimental impact of rvos in vision-related quality of life [ ] . results from the bravo trial indicated that patients with macular oedema secondary to brvo treated with monthly ranibizumab had greater improvements in visionrelated function compared with sham-treated patients through months [ ] . we propose that it would be beneficial for prospective real-world studies to record quality of life outcomes to allow payers of healthcare services to understand the broader benefits of treatment. the included real-world studies in this systematic review were generally of lower quality. because of the lack of a control group, a case series is prone to bias, occupies a low position in the hierarchy of evidence and is considered the weakest study design from which to obtain evidence on effectiveness [ ] . although some included studies in this review had a comparator group, characteristics and outcomes were analysed by treatment arms and therefore we treated every treatment arm as a case series. the quality appraisal of case series studies checklist published by ihe [ , ] was chosen mainly because it is one of the preferred tool recommended in the manual for developing nice guidelines [ ] . the strengths of this meta-analysis are its thorough literature search, large sample size with over eyes and extraction of data and quality assessment of the original studies independently by two authors. however, there are several limitations to this review. first, varied follow-up periods, treatment regimens and study populations led to considerable heterogeneity, which limits the interpretability of the pooled results. the meta-analyses were analysed by treatment and dose. we could not perform sub-analyses by treatment regimen as there was too much variability between included studies. although the average visual and anatomical outcomes were recorded in the majority of the included studies, the spread of data was not consistently reported. there was non-standardised and incomplete capture and reporting of baseline characteristics, risk factors, treatment burden, use of rescue therapies, quality of life data and ocular and systemic adverse events. a consensus statement on the minimum dataset for collection of real-world outcomes related to rvos is required so future real-world studies can more easily be compared. a minimum set of standardised patient-centred outcome measures for macular degeneration was facilitated by the international consortium for health outcomes measurement to allow easy comparison between different units nationally and internationally [ ] . the fight retinal blindness! registry has been tracking outcomes of therapy for neovascular age-related macular degeneration and diabetic macular oedema with a mandatory minimum dataset [ ] . a standardised web-based tool has been developed to prospectively collect a minimum mandatory dataset for outcomes of therapy for macular oedema secondary to retinal vein occlusions [ , ] . the american academy of ophthalmology intelligent research in sight (iris) registry launched in has already become the largest american clinical specialty data registry [ ] . the iris registry is designed to extract data from the practice's server, which contains the electronic medical record (emr) database using systems integrator software. a limitation of the iris registry approach is that a minimum dataset is not mandated [ ] . in conclusion, although visual and anatomical gains can be seen in the real-world management of macular oedema secondary to brvo, these gains particularly for anti-vegf therapy were not as impressive as the seminal rcts. this might be explained by differences in baseline characteristics and reduced injection frequency in the real world. to 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oedema requiring repeat intravitreal ranibizumab injection in eyes with branch retinal vein occlusion key: cord- -p mb r v authors: luo, yan; chalkou, konstantina; yamada, ryo; funada, satoshi; salanti, georgia; furukawa, toshi a. title: predicting the treatment response of certolizumab for individual adult patients with rheumatoid arthritis: protocol for an individual participant data meta-analysis date: - - journal: syst rev doi: . /s - - -x sha: doc_id: cord_uid: p mb r v background: a model that can predict treatment response for a patient with specific baseline characteristics would help decision-making in personalized medicine. the aim of the study is to develop such a model in the treatment of rheumatoid arthritis (ra) patients who receive certolizumab (ctz) plus methotrexate (mtx) therapy, using individual participant data meta-analysis (ipd-ma). methods: we will search cochrane central, pubmed, and scopus as well as clinical trial registries, drug regulatory agency reports, and the pharmaceutical company websites from their inception onwards to obtain randomized controlled trials (rcts) investigating ctz plus mtx compared with mtx alone in treating ra. we will request the individual-level data of these trials from an independent platform (http://vivli.org). the primary outcome is efficacy defined as achieving either remission (based on acr-eular boolean or index-based remission definition) or low disease activity (based on either of the validated composite disease activity measures). the secondary outcomes include acr ( % improvement based on acr core set variables) and adverse events. we will use a two-stage approach to develop the prediction model. first, we will construct a risk model for the outcomes via logistic regression to estimate the baseline risk scores. we will include baseline demographic, clinical, and biochemical features as covariates for this model. next, we will develop a meta-regression model for treatment effects, in which the stage risk score will be used both as a prognostic factor and as an effect modifier. we will calculate the probability of having the outcome for a new patient based on the model, which will allow estimation of the absolute and relative treatment effect. we will use r for our analyses, except for the second stage which will be performed in a bayesian setting using r jags. discussion: this is a study protocol for developing a model to predict treatment response for ra patients receiving ctz plus mtx in comparison with mtx alone, using a two-stage approach based on ipd-ma. the study will use a new modeling approach, which aims at retaining the statistical power. the model may help clinicians individualize treatment for particular patients. systematic review registration: prospero registration number pending (id# ). (continued from previous page) systematic review registration: prospero registration number pending (id# ). keywords: rheumatoid arthritis, certolizumab, individual participant data meta-analysis, prediction model, treatment response background rheumatoid arthritis (ra) is a chronic inflammatory disease, for which we cannot currently expect complete cure. the drugs that can delay disease progression are known as disease-modifying anti-rheumatic drugs (dmards). there are categories: conventional synthetic dmards (csdmards), biologic dmards (bdmards), and targeted synthetic dmards (tsdmards). bdmards can be further divided into several subtypes according to the target, among which the tumor necrosis factor (tnf) α inhibitors are the most classic and widely used. most ra patients undergo long-term treatment. according to the treat-to-target strategy proposed by the eular (european league against rheumatism) practice guideline [ ] , repeated assessment of disease activity should be performed every to months after a treatment is given, to evaluate the response and decide the next-step strategy: switching drugs, maintenance, tapering, or discontinuation. hence, the disease course of ra is composed of many short-term ( to months) intervention-response loops. for the purpose of improving long-term prognosis, such as delaying the progression of bone fusion or functional deficiency, short-term intervention-response loops need to have beneficial outcomes [ ] . to find the optimal treatment for a particular patient, it is necessary to personalize the treatment. it would be helpful if we could predict the probability of treatment response based on the patient's genetic, biologic, and clinical features. however, common evidence in the form of randomized controlled trials (rcts) or their meta-analyses (mas) at the aggregate level only reports average results. the drug that works for the average patients might not work or even be harmful for a particular patient. consequently, it is desirable to identify subgroups of patients associated with different treatment effects. individual participant data meta-analysis (ipd-ma) has been previously employed to develop prediction models for treatment effects [ ] [ ] [ ] [ ] . previous treatment response prediction models for ra were mainly based on observational studies [ ] [ ] [ ] [ ] [ ] . observational studies seem suited for predicting the absolute risk of an outcome, but it may be less satisfactory in estimating the relative risk between different drugs, because unknown confounders may persist even when we try to adjust for known confounders. on the other hand, though the population in rcts is highly restricted hence may be less representative, data from rcts are more rigorously collected and more likely to provide an unbiased estimate of the relative treatment effects [ ] . the synthesis of rct data via ipd-ma can increase the statistical power [ ] and have been used to predict treatment response [ , [ ] [ ] [ ] [ ] . to the best of the authors' knowledge, such an approach has not been taken to predict treatment response in ra to date. our aim is to develop a prediction model of treatment effects based on individual characteristics of ra patients through ipd-ma. since tnfα inhibitors are the most classic and widely used bdmards for ra, we will build a model for certolizumab (ctz), a tnfα inhibitor with sufficient ipd data, in this study. we will first estimate the pooled average effect sizes for the primary and secondary outcomes using one-stage bayesian hierarchical ipd-ma. the main objective of the study is to use a two-stage risk modeling approach to predict the individualized treatment effects interest [ ] . the first stage is to build a multivariable model aiming to predict the baseline risk for a particular patient blinded to treatment. in the second stage, this baseline risk score will be used as a prognostic factor and an effect modifier in an ipd meta-regression model to estimate the individualized treatment effects of ctz. we consider to validate and optimize the modeling approach in the present study, and plan eventually to expand it to an ipd network meta-analysis to compare several drug types (e.g., interleukin- inhibitors, anti-cd antibodies) as our future research perspective. the present protocol has been registered within the prospero database (provisional registration number id# ) and is being reported in accordance with the reporting guidance provided in the preferred reporting items for systematic reviews and meta-analyses protocols (prisma-p) statement [ ] (see the checklist in additional file ). the proposed ipd-ma will be reported in accordance with the reporting guidance provided in the preferred reporting items for systematic reviews and meta-analyses of individual participant data (prisma-ipd) statement [ ] . any amendments made to this protocol when conducting the study will be outlined and reported in the final manuscript. studies will be selected according to the following criteria: patients, interventions, outcomes, and study design. we will include adults ( years or older) who are diagnosed with either early ra ( american college of rheumatology (acr)/european league against rheumatism (eular) classification criteria) [ , ] or established ra ( classification criteria) [ ] . patients with inner organ involvement (such as interstitial lung diseases), vasculitis, or concomitant other systemic autoimmune diseases will be excluded. we will include both treatment-naïve patients and patients who have insufficient response to previous treatments. we will include patients with moderate to severe disease activity based on any validated composite disease activity measures. patients who have already achieved remission or at low disease activity at baseline will be excluded. patients who have used certolizumab (ctz) within months before randomization will be excluded. we will include rcts which compare certolizumab (ctz) plus methotrexate (mtx) with mtx monotherapy, regardless of doses. if a study compares ctz + any csdmards with any csdmards, we will only include patients on ctz + mtx or mtx from that study. trials investigating the tapering or discontinuation strategy of ctz will be excluded. our primary outcome is efficacy defined by disease states, which is achieving either remission (based on acr-eular boolean or index-based remission definition [ ] ) or low disease activity (based on either of the validated composite disease activity measures [ ] : das (disease activity score based on the evaluation of joints) ≤ . [ ] , cdai (clinical disease activity index) ≤ [ ] , sdai (simplified disease activity index) ≤ [ ] ) at months (allowance - months) after treatment, as a binary outcome. we choose it as our primary outcome because it is suggested as the indicator of the treatment target in both the practice guideline [ ] and the guideline for conducting clinical trials in ra [ ] , and it has been shown to provide more information for future joint damage and functional outcomes compared to relative response (change from baseline) [ ] . we have two secondary outcomes. one is efficacy defined by response (improvement from baseline), for which we will use the acr response criteria acr ( % improvement based on acr core set variables) [ ] . another is adverse events (aes). we will perform an ipd-ma separately for patients with all kinds of infectious aes within months since it is one of the most important aes for biologic agents. we will also describe other noticeable aes within months reported in the trials. we will not make predictions models for the secondary outcomes. we will include double-blind rcts only. if there are crossover rcts, only the data of the first phase will be used for analysis. cluster rcts, quasi-randomized trials, and observational studies will be excluded. we will conduct an electronic search of cochrane cen-tral, pubmed, and scopus from inception onwards, with the keywords: "rheumatoid arthritis," "certolizumab" or "cdp " "cimzia", "methotrexate" or "mtx," without language restrictions. a draft search strategy is provided in additional file . we will search who international clinical trials registry platform to find the registered studies. we will search the us food and drug administration (fda) reports to see if there are any unpublished reports from the pharmaceutical companies. for ipd, we will contact the company which markets certolizumab and request ipd through http://vivli.org. we will assess the representativeness of the ipd among all the eligible studies by investigating the potential differences between trials with ipd and those without ipd. two independent reviewers will screen the titles and abstracts retrieved from the electronic searches to assess for inclusion. if both reviewers agree that a trial does not meet eligibility criteria, it will be excluded. the full text of all the remaining articles will be obtained for further reading, and the same eligibility criteria will be applied to determine which to exclude. any disagreements will be resolved through discussion with a third member of the review team. two reviewers will independently extract the information for all the included studies at aggregate level. a detailed data extraction template will be developed and piloted on articles; after finalizing the items on the data extraction form, the articles will be re-extracted. the main information includes intervention/control details, trial implementation features (e.g., completion year, randomized numbers, dropouts, follow-up length), baseline demographic and disease-specific characteristics, and outcomes of interested. the above information will be used for: ( ) exploring the representativeness of the trials with ipd among all the eligible trials and ( ) confirming if the ipd is consistent with the reported results. when the ipd is ready to be used, we will identify the variables of interest before the analysis. the variables regarding intervention, control, and outcomes are defined as the above in the "eligibility criteria" section. with regard to patient or trial characteristics to be used as potential covariates in the prognostic model, based on the literature [ ] [ ] [ ] and our clinical practice, we propose the following factors as candidates of potential prognostic factors (pfs, baseline factors that may affect the response regardless of the treatment) (table ) , which will be used for baseline risk model development (see the "predicting treatment effect for patients with particular characteristics: a two-stage model" section below). we will try to collect all the information listed in table from the data, but only available factors that have been recorded in the trials will be added into the model. we will decide in which type (e.g., continuous, categorical, binary, etc.) a covariate will be put into the model according to the distribution of that covariate after we obtain the data. two independent reviewers will assess the risk of bias (rob) for each included rct according to "rob tool" proposed by the cochrane group [ ] . for the efficacy primary outcome, rcts will be graded as "low risk of bias," "high risk of bias," or "some concerns" in the following five domains: risk of bias arising from the randomization process, risk of bias due to deviations from the intended interventions, missing outcome data, risk of bias in measurement of the outcome, and risk of bias in selection of the reported result. the assessment will be adapted for ipd-ma, i.e., as per the obtained data and not the conducted and reported analyses in the original publications. finally, they will be summarized as an overall risk of bias according to the rob algorithm. since our primary aim is to develop a prediction model and not to get a precise estimation of the treatment effects, all the analyses will be based on ipd only. therefore, we will neither analyze aggregate data together nor investigate the robustness of the ipd-ma including aggregate data, for they are beyond the perspectives of the present study. we first synthesize the data using one-stage bayesian hierarchical ipd-ma [ ] . we will estimate the average relative treatment effect in terms of odds ratio (or) for efficacy. let y ij denote the dichotomous outcome of interest (y ij = for remission or low disease activity), for patient i where i = , , …, n j in trial j out of n trials, t ij be / for patient in control/intervention group, and p ij is the probability of having the outcome. where α j is the log odds of the outcome for the control group, in trial j, which is independent across trials; δ j is table potential candidates to be involved as prognostic factors in the prognostic model *factors that have been proved to be a prognostic factor for any treatments in previous studies # since genetic tests for ra are not routinely implemented in clinical practice, we anticipate that most studies will not report them. although genetics are often considered critical in precision medicine, we will consider it justifiable if no genetic information is included in our model, because there is no single one that has been proven to be strongly associated with the prognosis or treatment responses, and two studies have indicated that genetic information barely contribute in predicting treatment effects [ ] the treatment effect (log or), which we assume to be exchangeable across trials; δ is the summary estimate of the log-odds ratios for the intervention versus the control arm; and τ is the heterogeneity of δ across trials and normally distributed across trials. predicting treatment effect for patients with particular characteristics: a two-stage model data pre-processing within each study, the outcomes and the covariates will be evaluated for missing data, and we will further look at their distributional characteristics and correlations between the covariates (listed in the "at ipd level: for studies with ipd available" section). we will use multiple imputation methods for handling missing data [ ] . we will consider data transformation for continuous variables to resolve skewness and re-categorization for categorical variables if necessary. if two or more variables are highly correlated, we will only retain the variable that is most commonly reported across studies and in the literature or the variable that has the least missing values. stage : developing a baseline risk model in this step, we will build a multivariable model to predict the probability that a patient, given her or his baseline characteristics, is likely to achieve remission or low disease activity irrespective of treatment; we will refer to this model as the baseline risk model. the risk model can be built using the patients from the control group only, or from both intervention and control group. the former is more intuitive; however, a simulation study indicated that models based on the whole participants produced estimates with narrower distribution of bias and were less prone to overfitting [ ] . we will fit a multivariable logistic regression model: r ij is the probability of the outcome for patient i from trial j at the baseline. b j is the intercept, which is exchangeable across studies. pf ijk denotes the k prognostic factor (in total, there are p prognostic factors) in study j for patient i, and b kj is the regression coefficient for k prognostic factor in study j and is exchangeable across studies. in order to select the most appropriate model, we propose two approaches: ( ) use previously identified prognostic factors and through discussions with rheumatologists to decide the subset of the most clinically relevant factors and estimate the coefficients using penalized maximum likelihood estimation shrinkage method and ( ) use lasso penalization methods for variable selection and coefficient shrinkage [ ] . for each possible model, we will examine the sample size first, in order to assess the reliability of the model. we will calculate the events per variable (epv) for our model, using all the categories of categorical variables and the degrees of freedom of continuous outcomes [ ] . we will calculate efficient sample size for developing a logistic regression model [ ] . validation is essential in prediction model development. since no external data is available, we can only use internal validation. via resampling methods like bootstrap or cross-validation, we can estimate the calibration slope and c-statistic for each model, to indicate the ability of calibration and discrimination. stage : developing a meta-regression model for treatment effects we use the same notation system as that in the "average relative treatment effect: ipd-ma" section. the logit(r ij ) from stage will be used as a covariate in the meta-regression model, both as a prognostic factor and as an effect modifier. let logitðr ij Þ j denote the average of logit-risk for all the individuals in study j. the regression equation will be: γ a j is the log odds in the control group when a patient has a risk equal to the mean risk, which is assumed to be independent across trials. g j is the coefficient of the risk score, while g j is the treatment effect modification of the risk score for the intervention group versus the control group; both are assumed to be exchangeable cross trials and normally distributed about a summary estimate γ and γ respectively. predicting the probability of having the outcome for a new patient assume a new patient i who is not from any trial j has a baseline risk score g logitðr i Þ calculated from stage-one. in order to predict the absolute logitprobability to achieve the outcome, we use: we would have estimated δ, γ , and γ in the metaregression stage. we will estimate logitðrÞ as the mean of logit(r ij ) across all the individuals and studies. for a, we will estimate it by synthesizing all the control arms. then, we can calculate the individual probability of the outcome both for the control and the intervention and estimate the predicted absolute and relative treatment effect. to evaluate the performance of the two-stage prediction model, we will use internally validation methods via both the traditional measures, like c-statistic, and measures relevant to clinical usefulness. publication bias considering that we will probably not be able to include all the relevant research works, as some studies or their results were likely not published owing to non-significant results (study publication bias and outcome reporting bias) [ , ] , we will evaluate this issue by comparing the search and screening results (as we will try to retrieve possibly unpublished reports) with the ipd we can get. if necessary, we will address it by adding the study's variance as an extra covariate in the final ipd meta-regression model (see the section "predicting treatment effect for patients with particular characteristics: a two-stage model"-"stage : developing a meta-regression model for treatment effects"). statistical software we will use r for our analyses. stage will be performed in a bayesian setting using r jags. for the development of the baseline risk model, we will use the pmsampsize command to estimate if the available sample size is enough. we will examine the linear relationship between each one of the prognostic factors and the outcome via rcs and anova commands. the lasso model will be developed using the cv.glmnet command. we will use the lrm command for the predefined model based on prior knowledge, and then for the penalized maximum likelihood estimation, we will use the pentrace command. for the bootstrap internal validation (both for the baseline risk score and for the two-stage prediction model), we will use self-programmed r-routines. we have presented the study protocol for a prediction model of treatment effects for ra patients receiving ctz plus mtx, using a two-stage approach based on ipd-ma. though there are many optional drugs in treating ra, as treatment failure is relatively high, individualizing the treatment is imperative. many prognostic models for ra have been proposed, but no one is sufficiently satisfactory [ ] . we have discovered several problems. most previous models focused on long-term radiographic or functional prognosis. although they are certainly the critical outcomes that both clinicians and patients care about, the complex therapeutic changes during the long treatment process are extremely difficult to handle in developing prediction models. thus, it usually ends up with a simplified strategy, such as taking only the initial treatment into account, which compromises the clinical interpretation and relevancy of the model. on the other hand, a good short-term treatment response is always positively associated with good longterm prognosis [ , ] . predicting short-term treatment effect is instructive in clinical practice; however, research is lacking. a few established "short-term" diseaseactivity-oriented prediction models used an outcome measured at months or months. the problem is, unless in active-controlled studies, there would be considerable dropouts after - months; furthermore, due to ethnical issues, many trials would offer the nonresponders other active treatments after - months. under the itt principle, patients were commonly analyzed as originally allocated; when dropouts were not negligible, imputation methods were usually used, but mostly single imputation such as non-responder imputation or last observation carried forward (locf) [ ] . one may argue that these estimates were conservative to the intervention group though not precise. but in fact it is not always conservative for a relative effect estimate, while unbiased relative estimates are of critical interest in building personalized prediction models. as a result, in order to be methodologically rigorous, we choose the outcome measured at months, when the randomization is likely kept, and which is consistent with the assessment time recommended by the guideline [ ] . additionally, thanks to the ipd, we will be able to use multiple imputation to handle missing data, rather than the single imputations used in primary rcts. we will use a two-stage approach to construct the prediction model using ipd-ma. unlike the usual approach, which includes baseline features as prognostic factors and effect modifiers (through interaction terms) simultaneously, we first build a risk model for baseline factors, then treating the risk score as both a prognostic factor and an effect modifier. by doing so, overfitting problem caused by too many covariates and interaction terms can be alleviated. moreover, since penalization will only be used in common regression during risk modeling stage but not in meta-regression, the compromised penalization in meta-regression can be avoided. for stage , generally there are two types of risk models. one is an externally developed model, which is derived based on data independent from the data used at stage , such as established models from previous studies, or using some other studies. the other is an internally developed risk model, for which the same data will be used to build both the risk model and the treatment effects model [ ] . because there is no well-established risk model to predict the short-term disease activity for ra patients and also because we will very probably not have sufficient sample size to divide the entire data into two parts, we will use the internal risk model for our study. we acknowledge several limitations in our study. first, we handle effect modification at the level of risk scores, instead of particular covariates. that is, we will not try to identify specific effect modifiers. this may cause some problems in interpretation, as the concept of distinguishing prognostic factors and effect modifiers is well recognized. however, our approach assures the statistical power. second, due to the restricted sample size, only internal validation is planned while external validation is lacking. it needs to be validated on an external dataset in the future. third, we only focus on short-term treatment response for ra patients receiving two kinds of treatment, ctz and mtx. future studies may extend the scope to compare several kinds of therapies and treatment strategies and finally model for the long-term prognosis taking into consideration all the treatment processes. supplementary information accompanies this paper at https://doi.org/ . /s - - -x. additional file . prisma-p checklist. eular recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: update committee for medicinal products for human use (chmp): guideline on clinical investigation of medicinal products for the treatment of rheumatoid arthritis a framework for developing, implementing, and evaluating clinical prediction models in an individual participant data meta-analysis developing and validating risk prediction models in an individual participant data meta-analysis cochrane ipdm-amg: individual participant data (ipd) meta-analyses of diagnostic and prognostic modeling studies: guidance on their use statistical approaches to identify subgroups in meta-analysis of individual participant data: a simulation study arthritis: which subgroup of patients with rheumatoid arthritis benefits from switching to rituximab versus alternative anti-tumour necrosis factor (tnf) agents after previous failure of an anti-tnf agent? prediction of response to methotrexate in rheumatoid arthritis prediction of response to targeted treatment in rheumatoid arthritis association of response to tnf inhibitors in rheumatoid arthritis with quantitative trait loci for cd and cd assessment of a deep learning model based on electronic health record data to forecast clinical outcomes in patients with rheumatoid arthritis personalized evidence based medicine: predictive approaches to heterogeneous treatment effects meta-analysis of individual participant data: rationale, conduct, and reporting getreal methods review g: get real in individual participant data (ipd) meta-analysis: a review of the methodology quantifying heterogeneity in individual participant data meta-analysis with binary outcomes a critical review of methods for the assessment of patient-level interactions in individual participant data meta-analysis of randomized trials, and guidance for practitioners cognitive-behavioral analysis system of psychotherapy, drug, or their combination for persistent depressive disorder: personalizing the treatment choice using individual participant data network metaregression preferred reporting items for systematic review and meta-analysis protocols (prisma-p) preferred reporting items for systematic review and meta-analyses of individual participant data: the prisma-ipd statement rheumatoid arthritis classification criteria: an american college of rheumatology/ european league against rheumatism collaborative initiative rheumatoid arthritis classification criteria: an american college of rheumatology/ european league against rheumatism collaborative initiative the american rheumatism association revised criteria for the classification of rheumatoid arthritis american college of rheumatology/european league against rheumatism provisional definition of remission in rheumatoid arthritis for clinical trials the definition and measurement of disease modification in inflammatory rheumatic diseases the disease activity score and the eular response criteria acute phase reactants add little to composite disease activity indices for rheumatoid arthritis: validation of a clinical activity score remission and active disease in rheumatoid arthritis: defining criteria for disease activity states the importance of reporting disease activity states in rheumatoid arthritis clinical trials american college of rheumatology. preliminary definition of improvement in rheumatoid arthritis remission-induction therapies for early rheumatoid arthritis: evidence to date and clinical implications assessing prognosis and prediction of treatment response in early rheumatoid arthritis: systematic reviews poor prognostic factors guiding treatment decisions in rheumatoid arthritis patients: a review of data from randomized clinical trials and cohort studies crowdsourced assessment of common genetic contribution to predicting anti-tnf treatment response in rheumatoid arthritis rob : a revised tool for assessing risk of bias in randomised trials meta-analysis using individual participant data: one-stage and two-stage approaches, and why they may differ missing data in randomised controlled trials: a practical guide using internally developed risk models to assess heterogeneity in treatment effects in clinical trials regression shrinkage and selection via the lasso risk prediction models: i. development, internal validation, and assessing the incremental value of a new (bio)marker minimum sample size for developing a multivariable prediction model: part ii -binary and time-to-event outcomes randomized controlled trials of rheumatoid arthritis registered at clinicaltrials.gov: what gets published and when dissemination and publication of research findings: an updated review of related biases rheumatoid arthritis treatment: the earlier the better to prevent joint damage evaluation of different methods used to assess disease activity in rheumatoid arthritis: analyses of abatacept clinical trial data a systematic review of randomised controlled trials in rheumatoid arthritis: the reporting and handling of missing data in composite outcomes publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations authors' contributions yl and taf conceived the study. kc and gs designed the modeling strategy. ry and sf provided substantial contribution to the design of the study during its development. yl drafted the manuscript, and all the authors critically revised it. all authors gave final approval of the version to be published. this study was supported by the intramural support to the department of health promotion and human behavior, kyoto university graduate school of medicine/school of public health. the funder has no role in the study design, data collection, data analysis, data interpretation, writing of the report, or in the decision to submit for publication. the data that support the findings of this study are available from http://vivli. org but restrictions apply to the availability of these data, which were used under license for the current study, and so are not publicly available. data are however available from http://vivli.org upon reasonable request and application, after their permission. this study does not require institutional review board approval and participant consent.competing interests taf reports personal fees from mitsubishi-tanabe, msd, and shionogi and a grant from mitsubishi-tanabe, outside the submitted work; taf has a patent - . gs was invited to participate in two methodological meetings about the use of real-world data, organized by biogen and by merck. all the other authors report no competing interests to declare. key: cord- - lkkez n authors: nan title: invited speakers date: - - journal: respirology doi: . /j. - . . .x sha: doc_id: cord_uid: lkkez n nan the physiology of respiration reaches its extreme limits when man is exposed to the effects of high altitude, which is basically a decrease in ambient pressure and temperature. the process of acclimatization of humans to high altitude occurs within minutes of ascent, starting with increases in cardiac output, and ventilation. these result in acute changes in pao and paco . slower changes of acclimatization include increase in hemoglobin concentration (polycythemia), and muscle capillarity, but decrease in mitochondrial volume density and cellular aerobic capacity. through acclimatization, animals and human inhabitants of high altitude areas have developed adaptations that allow them to function as near normal as those living at sea level. humans who undergo acute ascent to high altitude could acclimatize, but some fail to do so. if there is failure to acclimatize, oxygen diffusion impairment results, due to decreased partial pressure, and lower affi nity of hb for oxygen. in addition, there is signifi cant increase in ventilation/perfusion heterogeneity. the resulting hypoxia leads to hypoxic pulmonary vasoconstiction (hpv) which results from multiple components: changes in epithelial cell wall that lead to intracellular calcium increase and/or calcium sensitization. subsequently, pulmonary hypertension develops, with actual breaks in the capillary endothelium leading to an infl ammatory process (seen more during exercise), and decrease in alveolar fl uid clearance. these mechanisms contribute to the development of alveolar edema, high altitude pulnary edema (hape), which is one of the two major diseases due to acute mountain sickness (ams). both hape and the other ams, high altitude cerebral edema (hace) could be potentially fatal, and must be recognized and treated early. knowledge of the pathophysiology of the ams would allow more rational approaches to their prevention and treatment. high altitude illnesses can develop among healthy individuals who sojourn for recreation and work: cerebral form called acute mountain sickness (ams) and potentially fatal pulmonary form called high altitude pulmonary edema (hape). ams is generally self-limited. high-altitude cerebral edema (hace) is likely a continuum of ams and the end-stage of ams. ams is not a precondition for the development of hape. hape develops in non-acclimatized mountaineers after rapid ascent to altitudes above m. hape may develop even in the absence of ams. severe ams may be a risk factor for hape. the altitude, the rate of ascent to new altitude, (> m/day to an altitude above m), and individual susceptibility are major determinants of ams and hape. on ascent to high altitudes all people have swelling of the brain. patient with ams often experience "hangover headache." other symptoms occur within the fi rst to h. these include malaise, anorexia, nausea and vomiting, and insomnia. ams patient must be evaluated for signs of global encephalopathy rather than focal fi ndings, although retinal hemorrhage is commonly seen. when these are present, the subject has hace until proven otherwise. patient may die if not treated promptly. brain herniation is the usual cause of death. the hallmark of hape is an excessively elevated pap which precedes the development of pulmonary edema. symptoms are incapacitating fatigue, chest tightness, dyspnea with effort, orthopnea, cough, and pink frothy sputum in advanced stage of disease. prevention of all altitude complications requires ascending at an increment rate to allow acclimatization. at > m, one should not spend subsequent nights m higher than the previous night. trekker must take a rest day every to days. anyone with ams should not ascend until symptoms are resolved. acetazolamide and dexamethazone are effective in prevention and treatment of ams from proceeding to hape or hace. at the fi rst sign of hace, patients should descend to a lower altitude while supplementary oxygen is given. increasing oxygenation is the highest priority in the treatment of and prevention of hape. if supplemental oxygen is unavailable, then descent, use portable hyperbaric chamber, or both become lifesaving. nifedipine is necessary only when supplemental oxygen is unavailable or descent is impossible. because of its pulmonary vasodilatory effects, phosphodiesterase inhibitors can be used for prevention and treatment of hape. rudolf virchow in described that the determinant risk factors for venous blood clot formation are stasis, endothelial injury and hypercoagulable state. dr simpson et al , a british surgeon observed that during the london blitz, the world war ii, britons who were forced to remain on sitting in cramped position and deck chairs for hours during the air raids developed fatal pulmonary embolism. it was suggested in by homans that "prolonged dependency stasis" or immobilization is one factor that predisposes patients to develop thrombosis in the deep veins of the legs. several risk factors have been identifi ed for developing venous thromboembolism (vte). travel is one of the transient risk factors. it is not confi ned to one mode of travel such as air travel. it is also incriminated to other modes of land travel such as car, bus and train. the term "economy class syndrome" was proposed by symington and stock ( ) and by the group of cruickshank ( ) for venous thromboembolism occurring in patients during air fl ight travel. it is usually seen in patients sitting in limited or cramped circumstances in the economy coach or tourist class seats, however it is also found out that patients who were also seated in the business class also develop this syndrome. factors implicated were the long duration of travel, immobilization or inactivity in sitting position, and the low cabin pressure, low humidity and dehydration during air fl ights. in several studies performed on large airports in europe, the presence of genetic factors such as factor v leiden and environmental factors such as the use of oral contraceptives predispose patients several fold to develop venous thromboembolism. signs and symptoms pertaining to vte develop not only during and after the fl ight but also several weeks after the travel. nowadays, airlines as well as bus companies have advisories and measures impose to prevent development of vte and deaths due to vte during the travel period. with the steadily increasing use of air travel, more and more patients with pulmonary disease are fl ying long distances, at high altitude in partially pressurised aircraft. this is associated with long periods of reduced mobility and exposure to reduced inspired pressures of oxygen and reduced barometric pressure. some individuals therefore may be at risk of barotrauma, hypoxia or venous thrombo-embolism (vte). therefore it is important to identify these individuals and adequately assess the real risk entailed by fl ying. the effect of reduced atmospheric pressure is a potential risk for patients with recent or pre-existing pneumothorax but otherwise is unlikely to be associated with risk other than that due to the associated reduced inspired oxygen fraction (fio ), typically . ( %) in a commercial aircraft at cruising altitude. the reduced (fio ) may be problematic for patients with hypoxic lung disease or in patients with other co-morbidities that may exacerbated by hypoxia. medical history, lung function and resting oxygen saturation will help identify patients at risk although it is diffi cult to predict the clinical effects of altitude from tests (even hypoxic challenge tests) conducted at sea level. there is currently a lack of good data defi ning the clinical outcomes due to hypoxia during fl ight in patients with lung or other diseases. the risk of vte increases with duration of fl ight above four hours, presumably related to the duration of immobility, although the role of prolonged hypoxia remains to be determined. preventive measures are now currently invoked on most airlines and guidelines for the use of antithrombotic agents are available, stratifi ed by risk. it is anticipated that guidelines will continue to be updated as new data are made available. cardio-pulmonary exercise testing is now well accepted as an appropriate test for the investigation of shortness of breath on exertion. in addition the test has been found to be useful for the assessment of pulmonary vascular dysfunction and the assessment of fi tness for major thoracic surgery. even though there are well described and internationally accepted protocols to perform the test, the interpretation of a cardio-pulmonary exercise test often leaves the interpreting physician confused. importantly with the multiple facets of the test (respiratory, cardiac, peripheral vascular) that need to be interpreted it is easy for the interpreting physician to look at a certain aspect of the test relating to their specialty and to give the other facets relatively little attention. in this presentation we review the process of interpreting cardio-pulmonary exercise tests. in addition we will interpret a number of tests based on our previous discussion on how to interpret these tests. finally we will review the literature regarding new interpretive strategies for exercise induced pulmonary vascular disease. bronchoscopy as an image-guided intervention has benefi tted from advances in optical and non-optical imaging technologies. some current bronchoscopy advances incorporate higher resolution ccd (charged-couple device) digital-"chip" technology and magnifi cation lenses to enhance the image resolution. the hope is that improved visualization combined with analysis of concomitant tissue biopsies may realize so-called "in-vivo endoscopic diagnosis" without the need for tissue biopsies, however studies of highmagnifi cation endo-cytoscopy, co-focal micro-endoscopy and optical coherence tomography (oct) remain investigational. further limiting these near-histologic resolution imaging modalities is the need for an initial screening of "highly suspicious" mucosa to focus attention upon. to facilitate identifi cation of abnormal airway mucosa, there are advances in the bronchoscopic detection of dysplastic and malignant mucosa. newer generations of autofl uorescent (af) bronchoscopes combine video ccd technology with af signaling to enhance the visual resolution of the images. non-af technologies being evaluated for the same purpose include fi ltered-light narrow band imaging (nbi) and post image-capture processing by a number of other spectral estimation technologies (set). bronchoscopic image guided interventions (bigi) also benefi tted from advances in non-traditional bronchoscopy technologies. foremost has been endobronchial ultrasound (ebus), initially designed as radial probes modeled after intravascular us and modifi ed for the airways. while useful in advancing our understanding of endobronchial mucosal structure, predicting tumor invasion depth and responsiveness to endobronchial interventions, radial ebus did not permit real-time guidance. dedicated linear-array ebus bronchoscope has changed this dramatically as the . mhz needle-puncture ebus bronchoscope has increased diagnostic accuracy of peri-bronchial lymph nodes/masses from a previous average of < % to > % for even small targets (< cm) in experienced hands. simultaneously miniaturization of radial ebus probes (thin . mm) and incorporation of guide-sheaths have increased the utility of ebus in evaluating parenchymal lung pathology. concomitant work in image processing of radiology imaging data (dicom data of chest ct images) has made available a number of "virtual bronchoscopic navigation" programs to assist the bronchoscopists in navigating towards smaller peripheral focal targets, and to improve the historic diagnostic yield of smaller (< cm) peripheral nodules from - % up to - %. these systems include passive endobronchial "road-maps" view (similar to "mapquest"/"google earth") and more technology enhanced electromagnetic navigation bronchoscopy (enb) (similar to gps guidance). all these ancillary technologies have spurred improvements in the basic bronchoscope, as thinner bronchoscopes capable of reaching peripheral segments ( . mm and . mm with . mm working channel; . mm with . mm working channel) are coupled with new biopsy instruments. the eventual development of steerable single fi ber scanning endoscopes with multi-wavelength imaging may change our current concepts of the bronchoscopes and how we can use them. journal compilation © asian pacifi c society of respirology pg - diagnostic tests pleural effusions are common and often present diagnostic challenges. the new british thoracic society guidelines on investigation of pleural effusions detailed some of the new approaches to undiagnosed pleural effusions. traditional teaching recommends measurement of blood and pleural fl uid protein and ldh levels as the fi rst step of investigation to categorize the effusion into a 'transudate' and 'exudate' using light's criteria. the need to apply this to all effusions is questionable in . current efforts focus on the development of disease-specifi c diagnostic tools incorporating clinical, radiologic and biochemical parameters. • elevated ntpro-bnp levels in pleural fl uids are useful in confi rming cardiac failure as the etiology of a pleural effusion, especially in patients whose fl uid may be falsely elevated into the 'exudative' range by concurrent diuretic therapy. • pleural ntpro-bnp levels are elevated in cardiac failure effusions, but not in other transudative effusions (eg hepatic hydrothorax). • pleural fl uid ntpro-bnp appears a better marker than pleural fl uid bnp. variations in accuracy may also in part depend on the commercial kits used. adenosine deaminase: • ada measurements in pleural fl uids are useful in the diagnosis of tb pleural effusions with a sensitivity and specifi city of and % respectively. limiting the test to lymphocytic pleural effusions will further improve the diagnostic accuracy. • ada is cheap and fast to perform and is now widely used in endemic countries. false positives can occur with bacterial infections, rheumatologic effusions, and occasionally malignant effusions. false negatives are uncommon, and therefore present a valuable 'rule-out' test in regions of low tb rates. • ada is at least as diagnostically useful as pleural fl uid total interferon-gamma levels. • igras have been tested in pleural fl uid and blood of patients with tb pleural effusions in several studies. the diagnostic sensitivity and specifi city are poor and igras are not recommended for the investigation of tb pleuritis. • serum mesothelin is a fda-approved test for the diagnosis and monitoring of mesothelioma. • pleural fl uid mesothelin adds information to pleural fl uid cytology in the diagnosis of mesothelioma, providing a diagnostic sensitivity of % (specifi city %). elevated pleural fl uid mesothelin levels suggest epithelioid or biphasic mesothelioma or occasionally metastatic carcinomas. procalcitonin: • early evidence suggest that serum level of procalcitonin may aid differentiation of pleural infection from pleural effusions of non-infective etiologies. the value of pleural fl uid procalcitonin level is limited. management strategies imaging guidance for pleural procedures: • pleural procedural complications are often under-estimated and underreported. studies have now shown that mandatory imaging guidance (especially bedside pleural ultrasound), and restricting procedural privilege to certifi ed trained clinicians can signifi cantly reduce complication rates from pleural procedures. this practice is now incorporated into many national and professional society guidelines. intrapleural therapy for pleural infection/empyema: • recent clinical trials on intrapleural delivery of fi brinolytics alone have failed to improve important clinical outcomes of pleural infection. however, the combination of tissue plasminogen activator and dnase has shown promising results. • recent studies have revealed increasing concerns of complications of talc pleurodesis, and randomized studies have shown a much lower success rate than previous non-randomized literature, even in selected patients. the concept of drainage without needing to create pleurodesis has growing appeal and the use of indwelling pleural catheters is now regarded as fi rst-line therapy in increasing number of centers. chronic respiratory disease (crd) is non-communicable respiratory disease including asthma, chronic obstructive pulmonary disease (copd), allergic rhinitis, idiopathic pulmonary hypertension, hypersensitivity pneumonitis, occupational respiratory disease. among these crd asthma and copd are important for regional health. facts of asthma million people suffer from asthma. , people died of asthma in . prevalence of asthma has increased or is increasing. asthma is the most common disease among children over % of asthma death occurs in low and lower-middle income countries. asthma is underdiagnosed and under-treated (who, ). facts of copd copd is a life-threatening lung disease that interferes with normal breathing. it is more than a "smoker's cough". an estimated million people have copd worldwide. more than million people died of copd in , which is equal to % of all deaths globally that year. almost % of copd deaths occur in low-and middle-income countries. the primary cause of copd is tobacco smoke (through tobacco use or second-hand smoke). the disease now affects men and women almost equally, due in part to increased tobacco use among women in high-income countries. copd is not curable, but treatment can slow the progress of the disease. total deaths from copd are projected to increase by more than % in the next years without interventions to cut risks, particularly tobacco smoking (who, ). prevention and control of crd in asia pacifi c were held by dokkyo medical university group, later designated as who collaborating centre for prevention and control of crd (du-wcc). seven countries and a district in asia pacifi c joined the meeting. prevalence of asthma in adults was reported from . to . % with a median of . % based on reports. prevalence of childhood asthma ( - y/o) was from . to . % with median of . % based on reports. prevalence of copd was . to . % with a median of . % based on nation-wide surveys. in spirometry-based survey reported, prevalence of copd was . % in adults years and over in japan, % in adults years and over, and . % in adults years and over in china. management in most of the countries gina and gold were adopted for their national guidelines. major risk factors for crd, especially for copd were smoking and indoor air pollution for cooking/heating. pharmacological early interventions have been reported to improve the prognosis of asthma and copd. occupational respiratory diseases are disorders which are induced by occupational and industrial conditions. providing information of the risks of industrial activities would reduce this disorder. strategic direction for the prevention and control of crd most of crd are treatable and at least partially preventable. development of user-friendly guides for prevention and control of crd for offi cials in health care, fi rst-line health-care givers and patients and their family and its implementation would decrease the burden of these crd. the scientifi c foundation of asthma diagnosis and management has grown in leaps and bounds. evidence-based strategies to control asthma and treat its exacerbation are published yearly in the gina guidelines. the -year finland study showed that these strategies work. while cases treated did increase (through better detection), the hospital days and cost per case markedly decreased. the study also showed that widespread adaption and effective implementation of these strategies is best done through a national program. cmes for medical practitioners are important but are of limited reach. all stakeholders must be enlisted to buy-in. for asthma, the target stakeholders are the health care personnel, nurses and village health volunteers included; the patients and their families; the government and its public health offi cials; the asthma advocacy groups; the community-at-large; and the pharmaceutical industry. the idea is to present the problem to them, include their inputs in the formulation of the plan, collegially decide on target indicators of success and engage them to work for the implementation of the program in the context of what each one can do best. duplicating the finnish experience is a big challenge in the asia pacifi c region. while most countries have their own adaptation of the gina guidelines, few have working national asthma programs. in developing economies, the health infrastructure is not that well developed yet to absorb all guideline recommendations. spirometry may not be widely available nor affordable. government spending for health is commonly below the % of gdp level that who recommends. in the philippines, signifi cant out-of-pocket health expense is borne by the patient. furthermore, programs like tb control, dengue treatment and malaria eradication, which are no longer concerns in developed countries, compete for the meager public health funds. for low income countries, the international recommendations may have to be rewritten to emphasize on simple algorithm for separating non-infectious from infectious respiratory illnesses; practical objective measurements for diagnosis and management such as peak fl ow; available, affordable, and low-risk medications recommended for asthma control; and a simple regimen for recognizing severe asthma (gina). to be viable, the national asthma program will have to piggy back to the existing national health delivery infrastructure which must ensure, among others, access to free or cheap medication. lung cancer and copd commonly coexist in smokers, and the presence of copd increases the risk of developing lung cancer. in addition to smoking cessation and preventing smoking initiation, understanding shared mechanisms in these smoking-related lung diseases is critical, to develop new methods of prevention, diagnosis and treatment of lung cancer and copd. common mechanisms may involve infl ammation, abnormal repair, oxidative stress, epithelial-mesenchymal transition, altered nicotine receptor biology and epigenetic alterations. strategies to study genomics and epigenomics, in addition to gene-environment interaction, will yield greater insight into the shared pathogenesis of lung cancer and copd. copd clinical guidelines are important to guide diagnosis and management of people with copd. the australian 'copdx' guidelines are evidence-based guidelines that are prepared by the australian lung foundation and thoracic society of australia and new zealand. relevant literature is searched regularly and evaluated by a clinical committee. updates are then produced regularly during the year. challenges regarding critical appraisal, resources and dissemination to clinicians will be discussed. national copd guidelines in this region are different from country to country, but basically are adapted from gold. copd prevalence in asia pacifi c countries and region estimated by regional copd working group was . %. vietnam has the highest prevalence: . %. the copd management and guideline implementation problems in the asia pacifi c region are: smoking, biomass using are common; continuous medical education (cme) for health workers are not compulsory; lack of device and personnel for performing proper spirometric tests; over burden for health workers; low access to medical care and low affordability for copd medications. all of these problems result in that copd diagnosis are mostly in late stage, high rate of emergency room visit, icu admission and hospitalization. the consensus is expected to cover following resolutions: reducing the smoking and biomass smoke exposure, screening for copd in large scale using questionnaires and confi rming by spirometry, advocacy for compulsory cme on copd, establishing asthma and copd outpatient care unit (acocu) in different levels of health care settles and introducing copd medications into insurance medication list. infections caused by environmental mycobacteria are more common than tuberculosis in many parts of the world. the more than species of mycobacteria have similarities, but generally the diseases and hosts fi t in specifi c patterns. disease due to environmental mycobacteria can be diffi cult to diagnose and treat and can confuse workup for tuberculosis. mycobacteria have low virulence and even lower invasiveness. they form biofi lms that protect them and allow long term persistence. the treatment is often frustrating for the patients and physicians. learning their metabolic mechanisms and attacking them should be the strategy for combating the disease caused by these organisms. lung cancer and copd commonly coexist in smokers, and the presence of copd increases the risk of developing lung cancer. in addition to smoking cessation and preventing smoking initiation, understanding shared mechanisms in these smoking-related lung diseases is critical, to develop new methods of prevention, diagnosis and treatment of lung cancer and copd. common mechanisms may involve infl ammation, abnormal repair, oxidative stress, epithelial-mesenchymal transition, altered nicotine receptor biology and epigenetic alterations. strategies to study genomics and epigenomics, in addition to gene-environment interaction, will yield greater insight into the shared pathogenesis of lung cancer and copd. airway epithelial cells, which are the fi rst line of cells to contact with inhaled substances such as microorganisms, play an important role in the host defense by two major mechanisms. first, they actively contribute to the innate immune system by recognition of the pathogen and production of antimicrobial substances and cytokines. second, they provide a passive barrier function that prevents invading microorganisms, air pollutants and airborne allergens into the internal milieu. on the other hands, airway epithelial cells are involved in the production of airway infl ammation in asthma and copd by excessively and un-regulatory expressing pro-infl ammatory and pro-allergic cytokines, executing apoptosis and losing barrier function. there is very close relationship between epithelial barrier function and innate immune response of epithelial cells. for instance, losing barrier function results in not only allowing foreign substance and pathogens to invade into the internal milieu but also enhancing innate immune responses. asthma and copd are different diseases, but they may have the same mechanism in the pathogenesis of exacerbation of these diseases in term of losing epithelial barrier functions. in this symposium, we will present the latest information on and the regulatory mechanism of airway barrier function and discuss in the context with asthma and copd pathogenesis and exacerbations. key words; airway epithelial cells, barrier function, asthma, copd patients with severe and diffi cult-to-treat asthma ("refractory asthma", approximately % of total asthma) have impaired health status refl ected by persistent symptoms, severe airfl ow limitation and frequent asthma exacerbations despite taking maximally recommended doses of inhaled corticosteroids and long-acting β -agonists. a better understanding is thus needed regarding factors associated with such troublesome condition and, in our cross-sectional observational study, clinical and demographic characteristics of patients fulfi lling the american thoracic society workshop criteria for refractory asthma (ajrccm, , group a) were compared with those of patients with severe persistent asthma defi ned on the basis of the gina guideline (group b). there were no signifi cant differences between the two groups with respect to age, gender, smoking status, disease duration, pulmonary function (fev , pef, dlco), or markers of airway infl ammation in the induced sputum (eosinophils, neutrophils, ecp, tryptase). however, in contrast to group b, all patients in group a were adult-onset, and % of the patients already had severe symptoms at the time of disease onset. prevalence of atopy, postbronchodilator fev /fvc ratio and fev reversibility were signifi cantly less in group a than in group b. patients in group a complained of copious amounts of phlegm associated with chronic sinusitis and/or chronic bronchitis, and showed high concentrations of mucin (muc ac + muc b) in the sputum. in addition, nasal clearance time assessed by saccharine test was signifi cantly longer in the group a than in the group b patients, indicating impairment of airway mucociliary clearance. these fi ndings and other pathophysiological and clinical data suggest that "refractory asthma" may be a different form of asthma (phenotype) rather than a progression of asthma severity during follow-up of natural history of the disease. furthermore, it is likely that irreversible airway narrowing possibly due to airway remodeling and airway mucus hypersecretion are important factors contributing to the pathogenesis of severe and diffi cult-to-treat (refractory) asthma. the results prompt for further longitudinal studies and interventions to defi ne the mechanisms of this unique phenotype of asthma. journal compilation © asian pacifi c society of respirology drug development is a long and expensive process. on average it takes at least years and more than a billion dollars to develop a compound from basic science discovery through clinical trials and fi nal approval by regulatory authorities of a new therapeutic. one of the main obstacles to development of new compounds is the diffi culty in obtaining good pre-clinical proof of effi cacy for a new drug. most of this is currently obtained from experiments using animal models of disease or cell lines, neither of which refl ect well human disease nor predict whether responsiveness in these models predicts responsiveness in human disease. recent studies have focused on developing methods that employ human cells or tissues taken from the relevant organ and from relevant patient populations. of these models, the explant model, which uses whole tissue samples, is the closest to the in vivo situation because it maintains the complex cell-to-cell interactions. in asthma, studies have shown that this model can sometime be even better than in vivo study. thus, for example, the explant model vivo offers several advantages over in vivo allergen challenge of asthmatic volunteers. first, repeat bronchoscopy to sample the airways after initial allergen challenge is not required. second, tissue responses of more severe asthmatics, who for safety reasons cannot be challenged with allergen in vivo, can be studied. third, problems of dilution of secreted mediators during bal are avoided and released mediators are not consumed by in-coming infl ammatory cells, thus increasing the sensitivity of the model. finally, and most importantly when seeking pre-clinical proof of concept of drug effi cacy, the model allows testing of novel compounds at an early stage before its full safety profi le is established, a process that is both expensive and time-consuming. we have previously shown that the asthmatic airways generate increased t cell chemotactic activity compared to healthy controls. using a highly selective ccr antagonist we have recently shown that the ccr -chemokine axis plays a key role at least in the traffi cking of t cells into the asthmatic airways. having established this, we then showed that predominantly the ccr + t cells are recruited in response to allergen stimulation. we have further shown that the selective removal of these ccr + t cell from blood signifi cantly reduced allergic infl ammation as shown by a marked reduction in the production of the th cytokines il- , il- and il- but with no consequences for th responses. taken together, our studies have strongly suggested that inhibiting the migration of t cell to the asthmatic airway by targeting ccr is likely to abrogate the allergic infl ammation in the airways without affecting immune responses that serve to protect against infection. these studies have also shown the value of using such ex vivo models of asthma to provide proof of concept for new drugs, giving the pharmaceutical industry the necessary pre-clinical proof to proceed with confi dence into further clinical development. sleep-disordered breathing (sdb) or obstructive sleep apnea (osa) is a prevalent but largely undiagnosed sleep disorder. apnea-hypopnea index (ahi: the number of apneas and hypopneas per hour of sleep) is used to classify sdb severity. in icsd- (international classifi cation of sleep disorders ver. ), "osa syndrome" was defi ned as ahi ≥ with hypersomnolence/ daytime symptoms or as ahi ≥ regardless of the symptoms. epidemiological studies clarifi ed that sdb is associated with increased likelihood of hypertension, cardiovascular disease, stroke, motor vehicle accidents, depression, diminished quality of life, and even mortality. clinical guidelines for hypertension put weights on sdb as a cause of hypertension. international diabetes federation (idf) made a consensus statement on sleep apnea and type diabetes. "overlap syndrome" (coexist of copd and sdb) was reported to have much higher mortality than sdb alone. sleepiness was thought to be a major symptom for osa syndrome. it is true that there is a signifi cant trend that the severe the sdb is the more the subjects had sleepiness. however, the majority of sdb subjects (even the majority of subjects with ahi ≥ ) do not have sleepiness (ess: epworth sleepiness scale > ). the berlin sleep questionnaire was used to screen high or low risk subjects for sdb. four-item screening tool was also developed (gender, bmi, blood pressure, snoring frequency). these tools may be useful, when certifi ed with sleep monitoring in each population. prevalence of ahi ≥ , estimated from two-stage sampling, was - % in male and - % in female. two-stage sampling is oversampling the subjects with sleepiness or snoring to perform sleep monitoring, and weighting of results to the survey sample. when all the participants underwent sleep monitoring, the prevalence of ahi ≥ was - % in male and - % in female. there is a strong need for better recognition, screening and treatment of sdb. more studies are needed, especially for long-term outcomes of asymptomatic sdb. genome-wide association studies may be useful to elucidate causes or underlying mechanisms of sdb. continuous positive airway pressure (cpap) is a standard treatment for patients with obstructive sleep apnea (osa), especially for moderate to severe osa. the mechanism of action is to provide a pneumatic splint to preserve upper airway. the pressure level required to maintain airway patency is determined by manual pressure titration by a sleep technologist during attended laboratory polysomnography (psg) to eliminate obstructive respiratory-related events (e.g., apneas, hypopneas, respiratory effort-related arousals [rera], and snoring). despite wide acceptance as a standard therapy for treatment of osa patients, very few pap titration protocols have been published so far, and there are inconsistency and variations in cpap titration protocol among clinical sleep laboratories. for this reason, the pap titration task force developed evidence-and consensus-based standardized pap titration protocol and published its guideline entitled "clinical guidelines for the manual titration of positive airway pressure in patients with obstructive sleep apnea" in journal of clinical sleep medicine . in this lecture, i will explain about manual cpap titration guidelines as below based on publications which are recommended by positive airway pressure titration task force of the american academy of sleep medicine (aasm): ( ) important considerations prior to cpap titrations. ( ) criteria for cpap pressure to be increased. ( ) minimum and maximum starting cpap pressure. ( ) an interval and minimum pressure to eliminate obstructive respiratory events. ( ) different algorithms for cpap pressure to be increased to eliminate obstructive respiratory events observed for patients ≥ years and < years. interventional bronchoscopy has typically been associated with obstructive tumor removal to regain central airways patency; such interventions, whether with rigid or fl exible instruments were also limited to the navigable fourth or fi fth generation airways. tissue destructive techniques included ablative heat techniques (laser, electrocautery and argon plasma coagulation), cold techniques (cryotherapy) and mechanical coring with the rigid bronchoscope. a current new crop of tissue debridement devices include modifi cations of established technologies: fl exible co laser fi ber usable beyond the trachea, cryotherapy using non-contact surface cryospray, rotational microdebrider devices adopted from otolaryngology, pulsating balloon resectors. the latter three devices do not involve heat that may cause post-treatment infl ammation and cartilage destruction and subsequent airway fi brosis or malacia. previous direct intra-lesional injection, with mitomycin or steroid was directed towards non-malignant fi brotic lesions, conversely on-going studies with cytotoxic agents ( fu) and compounds thought to have immune adjuvant effects (pts) are demonstrating potential utility in endobronchial tumors. photo-dynamic therapy (pdt) compounds with shorter half-lives require fewer bronchoscopies and have shortened photo-toxicity side effects. therapeutic bronchoscopic image guided interventions (bigi) have benefi tted from advances in "virtual bronchoscopic navigation" software available to improve reaching small peripheral lesions. for radiation therapy for focal lung lesions not resectable because of patient co-morbidities or preference, the accurate placement of fi ducial markers (gold) are used to direct high-dose rate external-beam intentiy modulated radiation therapy (imrt) including cyberknife machine. trials also demonstrate feasibility and effi cacy of treating peripheral lesions by high-dose rate (hdr) brachytherapy through catheters placed with image guidance. one area of new focus is bronchoscopy in the management of chronic obstructive lung diseases (old) including emphysema and severe asthma. based on lung volume reduction surgery for severe emphysema with heterogeneous distribution and air-trapping, non-surgical bronchoscopic lung volume reduction (blvr) has taken on a number of innovative approaches including exclusion by spigots (watanabe), valves (emphysys, spiration), metallic coil retraction (pneumrx), airway bypass to relieve trapped gas (broncus), atelectasis by bio-glue (aeris) or by heat steaming (uptake). although none of the clinical devices in trials have shown unqualifi ed success, some devices are now being marketed (europe), or are available on a compassionate basis for management of broncho-pleural fistulas (bpf). airway radio-frequency ablation (rfa) of airway smooth muscle is usa-fda approved for management of severe asthma. future innovations in interventional bronchoscopy will likely incorporate advances in diagnostic bronchoscopy such as video-autofl uorescence and "in-vivo biopsy" techniques to guide local endobronchial therapies for in-situ cancers; image processing software to design custom stents for compromised airways; and drug-eluting stents to maintain airway integrity in a variety of malignant and benign airway diseases. pleuroscopy describes a minimally invasive procedure that provides the physician a window into the pleural space. it refers to a procedure that is performed in an endoscopy suite or operating room with the patient under conscious sedation and local anesthesia. increasingly these procedures are being performed by nonsurgeon pulmonologists to diagnose pleural pathology such as pleural effusions or pleural carcinomatosis; talc pleurodesis and chest tube placement under direct visual guidance. pleuroscopy was fi rst conceived in a report dated , which documented the fi rst endoscopic examination of the pleural space by richard cruise in a year old girl with empyema. it did not gain widespread application until when hans christian jacobaeus published his technique also known as the jacobaeus operation. in this procedure he created a pneumothorax by severing adhesions using galvanocautery that collapsed the underlying lung, and allowed safe entry as well as unobstructed examination of the pleural space. since then, pleuroscopy has been applied both as a diagnostic and therapeutic tool. for a hundred years, rigid endoscopic instruments such as stainless steel trocars and telescopes have been pivotal in the technique. smaller telescopes and instruments have been applied with excellent views of the pleural space and comparable diagnostic yield. a signifi cant advance is the creation of fl exrigid pleuroscope that is fashioned like the fl exible bronchoscope. the fl ex-rigid pleuroscope consists of a handle, and a shaft that measures mm in outer diameter, -cm proximal rigid portion and -cm fl exible distal end. the fl exible tip is movable by a lever on the handle, which allows -way angulation degrees up and degrees down. it has a . mm-working channel that accommodates biopsy forceps, needles and other accessories, and is compatible with various electrosurgical and laser procedures. the fl ex-rigid pleuroscope allows autoclaving. a notable advantage is its easy interface with existing processors and light sources made by the manufacturer for fl exible bronchoscopy or gi endoscopy at no additional costs. although certain endoscopic characteristics such as nodules, polypoid masses and "candle wax drops" are suggestive of malignancy, early stage mesothelioma can resemble pleural infl ammation. autofl uorescence and narrow band imaging have been incorporated to white light pleuroscopy to enhance diagnostic accuracy. both modes of imaging discriminate early malignant lesions from non-specifi c infl ammation, aid in selecting appropriate sites for biopsy and better delineate tumor margins for more precise staging, but are of little value at present in clinical practice since most patients with malignant pleural effusions have extensive pleural involvement that is easy to diagnose with white light pleuroscopy for pleuroscopic guided pleural biopsies, specimens obtained with the rigid forceps are larger than those with the fl ex-rigid pleuroscope since they are limited by size of the fl exible forceps, which in turn depends on the diameter of the working channel. the fl exible forceps also lacks mechanical strength in obtaining pleural specimens of suffi cient depth, which can be overcome by the use of insulated tip (it) diathermic knife. full thickness parietal pleural biopsies are obtained with it knife, and the electrocautery knife is particularly useful when smooth thickened lesions are encountered, of which nearly half are due to mesothelioma. to improve analgesia before talc poudrage, lidocaine can be administered to the parietal pleura via spray catheter inserted through the working channel of the pleuroscope. similarly talc poudrage can be administered under visualization using the spray catheter. with the introduction of the fl ex-rigid pleuroscope, similar in design and handling to the fl exible bronchoscope, and compatible with standard light source and video processor available in most bronchoscopy suites, pleuroscopy will enjoy an expanded interest as more practitioners acquire the skill. the fl exrigid pleuroscope is a signifi cant invention in the history of minimally invasive pleural procedures and will revolutionize the practice of pulmonary medicine by replacing conventional biopsy methods in future. the common known causes of interstitial lung disease (ild) are drug toxicities, environmental exposures and collagen vascular disease (cvd). among these causes, drug or environmental exposures can be excluded by medical history. however, cvd-related ild may often be confused with idiopathic interstitial pneumonia (iip) because the radiological and histological characteristics of cvd-related ild are often indistinguishable from those of their idiopathic counterparts and occasionally, systemic manifestations of the underlying cvd develop several months or years after the diagnosis of ild. early diagnosis of occult cvd is very important in patients presenting with ild, because there are signifi cant differences in prognosis between the iip and cvd-ild groups. patients with cvd-ild survive longer than those with iip. additionally, different treatment regimens and evaluation for additional systemic involvement or malignancy may be needed in patients with cvd-ild. although, cvd-ild and iip is often considered indistinguishable, there are some clues that can help clinicians detect occult cvd in patients presenting with ild. first, a thorough medical history and physical examination can detect occult cvd. its importance cannot be overemphasized. the cvds frequently associated with ild are scleroderma, rheumatoid arthritis (ra), polymyositis/dermatomyositis (pm/dm), sjögren's syndrome, mixed connective tissue disease (mctd), undifferentiated connective tissue disease (uctd) and systemic lupus erythematosus (sle). therefore, symptoms and signs that occur frequently in these cvds should be searched for. these symptoms and signs include raynaud's phenomenon, gastro-esophageal refl ux disease, telangiectasis, dry eyes, dry mouth, arthritis, the characteristic skin lesions of dm (heliotrope rash, gottron's papule, mechanic's hand) and various serositis etc. second, certain fi ndings on hrct can help in the diagnosis of cvd. although the parenchymal abnormalities are similar to their idiopathic counterparts, the presence of airway-related abnormalities -mosaic attenuation, bronchial wall thickening, and nodules -are more common in cvd-ild. the presence of extrapulmonary abnormalities may also provide important clues to the underlying diagnosis. patients with cvd more frequently have pleural and pericardial effusions, pericardial thickening, enlarged pulmonary artery and esophageal dilatation. hrct can also show joint abnormalities or soft tissue calcifi cations. third, there are some serologic tests that can help in the diagnosis of cvd even in patients with obscure symptoms. high titers of antinuclear antibody and rheumatoid factor are often found in patients with cvd. other more disease specifi c tests currently available are anti-ssa/ssb antibody for primary sjögren's syndrome, anti-scl- antibody for systemic sclerosis, anti-jo- antibody for pm/dm, anti-u ribonucleoprotein (rnp) antibody for mctd, antibody to cyclic citrullinated peptides (ccp) for rheumatoid arthritis and so on. fourth, the frequent pathologic patterns of ild associated with cvd are nsip, uip, op, lip and dad. among them, nsip is the most frequent pathologic pattern in cvd-ild. therefore, pathologic pattern consistent with nsip should raise suspicions about the possibility of cvd. other pathologic fi ndings that may be suggestive of an underlying cvd include follicular bronchiolitis and lymphoid follicles. however, it is still impossible to diagnosis all occult cvds at the outset of ild because the initial clinical presentations can be essentially indistinguishable from those of iip. therefore, close follow up for a developing cvd is very important especially in patients with nsip. the role of pathological diagnosis for non-neoplastic lung disease is important and critical. however, agreement of pathological diagnosis in iips may not be that high. despite the expectations after publication of ats/ers classifi cation of idiopathic interstitial pneumonias (iips), interobserver variability in the pathological diagnosis of iips is still problematic. there are several major reasons for the poor agreement in pathological diagnosis of iips in which the biggest reason is a lack of specifi c and diagnostic fi nding to any type of iips. in the session, i would fi rst share the virtual steps of making diagnosis on surgical lung biopsy with audience, indicate recent data of inter-observer agreement in iips cases, and then, introduce factors behind the poor agreements followed by several possible solutions to this important issue. children's interstitial lung disease (child) differs from adult interstitial lung disease in that certain classic idiopathic pneumonias described in adults are not seen in children and unique forms of interstitial lung disease are found in infants and young children but not in adults. the most common form of idiopathic interstitial pneumonia in adults is idiopathic pulmonary fi brosis (ipf), also known as cryptogenic fi brosing alveolitis (cfa), a progressive and fatal disorder, defi ned pathologically as usual interstitial pneumonia (uip). uip is characterized by a heterogeneous mixture of normal lung, mild infl ammation, and fi brosis and the presence of fi broblastic foci, felt to be the leading edge of fi brosis. previously, although many infants and children were given the diagnosis of ipf, cfa, or uip, they did not have the characteristic fi broblastic foci. thus although the uip pattern is occasionally seen in the context of another primary disorder, such as abca mutations, true ipf/uip does not exist in children. the tendency to use the term ipf in children merely serves to obscure the real diagnosis and creates anxiety in families whose affected children may not actually have a fatal disorder. unique conditions have been described mainly in infants and young children that do not occur in adults. these include growth abnormalities, inborn errors of surfactant metabolism, neuroendocrine cell hyperplasia of infancy (nehi), and pulmonary interstitial glycogenosis (pig). growth abnormalities occur as a consequence of an early insult to the lung that results in retarded or arrested lung development and alveolar simplifi cation. risk factors associated with growth abnormalities include prematurity, congenital heart disease, and chromosomal defects, most commonly down syndrome. the major advance in child has been the discovery of genetic mutations that lead to surfactant dysfunction. these include mutations in the sp-b, sp-c, abca , ttf- , and gm-csfra genes. clinical presentation can vary from severe respiratory failure at birth leading to death (sp-b, abca mutations) to more insidious onset with chronic lung disease (sp-c, abca , ttf- , gm-csfra mutations). nehi is a chronic benign form of child presenting in the fi rst year of life with tachypnea, crackles, hypoxemia, characteristic features of symmetric ground glass densities in the right middle lobe and lingula and central lung regions on hrct, and a mixed restrictive/obstructive pattern on infant lung function testing. lung biopsy shows increased numbers of neuroendocrine cells and neuroepithelial bodies in the distal airways with otherwise normal lung architecture. pig is another benign form of child seen in infants and characterized by interstitial widening with glycogen-rich interstitial cells. pig is seen as a primary disorder ("pure" pig) and as a patchy disorder seen in the background of some other primary disorder, such as a growth abnormality ("patchy" pig). in conclusion, it is important to recognize the differences between pediatric and adult interstitial lung disease so that the proper diagnosis and prognosis can be given and the appropriate treatment applied. journal compilation © asian pacifi c society of respirology not to treat acute bronchitis with initial antibiotics, with the following exceptions. those at high risk of serious complications because of preexisting co-morbidity, patients over years of age with acute cough and two or more of the following, or patients over years of age with one or more of the following; ( ) admission to hospital in the previous year ( ) type or type diabetes ( ) history of congestive heart failure ( ) current use of oral glucocorticoids. clinicians need to address patients' concerns, perspectives, and expectations about the treatment and explain to patients that antibiotics are not necessary for a self-limiting respiratory tract infection. physicians should tell patients that antibiotic use increases the risk of an antibiotic resistant infection. and physicians also need to spend time answering questions and offer a contingency plan if symptoms worsen, and advise patients to return for a consultation if symptoms are not starting to settle in accordance with the expected course of the illness or if symptoms worsen signifi cantly. some physicians are certain that patients will benefi t from antibiotics and prescribe for expectation of fast relief. they are mostly comfortable with their prescribing decisions by their clinical experiences. taiwan's study demonstrates substantial variations among physician groups in the practice of prescribing antibiotics for viral respiratory infections. older physicians and those practicing in clinics rather than medical centers were signifi cantly more likely to prescribe antibiotics, and dispensing doctors in contrast to those without dispensing privileges or on-site pharmacists were signifi cantly highly prescribing antibiotics. statistical data from nhic in korea showed that general physicians in clinics prescribe antibiotics in % of acute bronchitis patients, while doctors at tertiary hospitals showed less but still fairly high rate of %. efforts and interventions to reduce the potentially inappropriate prescription of antibiotics should target modifi able factors. quality improvement (qi) strategies like using active clinician education, delayed prescriptions and targeting management, may yield reductions in antibiotic use. anti-tussives are occasionally useful and can be offered for short-term symptomatic relief of coughing. a meta-analysis and systematic review found that beta- -agonists were not effective for the treatment of acute bronchitis or cough of < weeks duration in children or in adults unless airfl ow obstruction was present. summary acute bronchitis is one of most commonly diagnosed and treated diseases in daily clinical practice. however, since it is mostly a self limiting disease, the standardization of diagnosis and treatment has long been neglected leaving various controversies in the management, particularly the use of antibiotics. the inappropriate prescription of antibiotics for acute bronchitis will surely lead to the emergence of resistant organisms in the community let alone the increase of socio-economic burden. further attention and research is needed for the reasonable approach to the treatment of acute bronchitis in order to prevent overuse of antibiotics and improve health-economy. prevalence acute bronchitis is one of the most common conditions encountered in clinical practice, accounted for approximately million visits to korean physicians in , and consistently ranks among the top reasons for ambulatory visits in the united states. defi nition acute bronchitis refers to a clinical syndrome distinguished by a relatively brief, self-limited infl ammatory process of large and midsized airways that is manifested predominantly by cough with or without phlegm production which lasts for up to weeks and absence of fi ndings suggestive of pneumonia. acute bronchitis should be distinguished from acute exacerbations of chronic bronchitis and acute infl ammation of the small airways -asthma or bronchiolitis. those with underlying lung disease, congestive heart failure, or a compromised immune system are considered to be at high risk for complications of acute bronchitis. etiology acute bronchitis is one of the most common causes of antibiotic abuse. in healthy communities, there is little evidence of bacterial infection in people with bronchitis, but there are few practical studies to distinguish between bacterial and viral bronchitis. within this context, the use of antibiotics to treat acute bronchitis is controversial but common in real practice. viruses are usually considered the most common cause of acute bronchitis but have been isolated in a minority of patients. those isolated in acute bronchitis include, in order of frequency of occurrence, are infl uenza, parainfl uenza, respiratory syncitial virus (rsv), coronavirus, adenovirus, and rhinovirus. the yield of specifi c pathogens varies according to several factors, including the presence or absence of an epidemic, the season of the year, and the infl uenza vaccination status of the population. bacterial pathogens are thought to play a very minimal role in acute bronchitis. the bacteria that have been causally linked to acute bronchitis in otherwise healthy individuals include only mycoplasma pneumoniae, chlamydophila pneumoniae and bordetella pertussis. antibiotic treatment of patients with pertussis is indicated to limit transmission, but there are no compelling data to support the prospect that cough will be less severe or less prolonged with antibiotic therapy. clinical manifestations acute bronchitis cannot be distinguished from upper respiratory infections in the fi rst few days. acute bronchitis is suggested by the persistence of cough for more than fi ve days, and most often lasts from to days. approximately % of patients with acute bronchitis report the production of purulent sputum. it usually represents sloughing of cells from the tracheobronchial epithelium, along with infl ammatory cells, and does not signify bacterial infection. pulmonary function test fi ndings consistent with bronchial hyperresponsiveness are common. fev less than % at the initial visit was present in % of adults from the mid western united states with no history of underlying lung disease. pft abnormalities are usually transient, typically resolving after to weeks, although they may last as long as months. fever is a relatively unusual sign in acute bronchitis and, when accompanying cough, suggests either infl uenza or pneumonia. diagnosis acute bronchitis is established in a patient who has the sudden onset of cough, with or without sputum expectoration, and without evidence of pneumonia, the common cold, acute asthma, or an acute exacerbation of chronic bronchitis. the absence of the following fi ndings reduces the likelihood of pneumonia suffi ciently to eliminate the need for a chest radiograph: ( ) heart rate > beats/min; ( ) respiratory rate > breaths/min; ( ) oral body temperature of > °c; and ( ) chest examination fi ndings of focal consolidation, egophony, or fremitus. chest radiography should be reserved for use in patients with any of these fi ndings or cough lasting > weeks. an exception, however, is a cough in elderly patients; pneumonia in elderly patients is often characterized by an absence of distinctive signs and symptoms. rapid diagnostic tests exist for several pathogens currently linked to acute bronchitis. patients with severe paroxysmal cough, with or without post-tussive vomiting should be evaluated for pertussis regardless of the immunization history. rapid tests should be used primarily when the suspected organism is treatable, the infection is known to be circulating in the community, and the patient has suggestive symptoms or signs. treatment statistical data from korea national health insurance corporation (nhic) shows that approximately - % of patients with acute bronchitis receive antibiotics despite the evidence that, with few exceptions, they are ineffective. meta-analyses of randomized, controlled trials all concluded that routine antibiotic treatment is not justifi ed. the decision not to use an antibiotic should be addressed individually and explanations should be offered because many patients expect to receive an antibiotic based on previous experiences and public expectations. main challenges for appropriate antibiotic use in acute bronchitis are the diagnosis is based on clinical fi ndings, without standardized diagnostic methods and sensitive or specifi c confi rmatory laboratory tests. how to identify accurately the few patients who are seriously ill or whose symptoms could be meaningfully ameliorated by prompt antibiotic treatment is not standardized. recent studies have suggested that the annual decline in fev is greater in gold stage ii than in later stages of the disease. ( ) if the decline in pulmonary function predominantly occurs early in the course of the disease, then it is logical that diagnosis and intervention aimed at reducing the progression of the disease should mainly occur in the early stages of the disease. severity of copd at diagnosis differs enormously on where it is done: population based studies, screening or hospital patients. epidemiologic studies: prevalence, underdiagnosis and severity there are increasingly more data on the prevalence and distribution of copd from around the world. the prevalence of chronic obstructive pulmonary disease (copd) varies from country to country, mainly due to the effects of cumulative exposure to smoking and the increased life span of the population. ( ) ( ) ( ) ( ) systematic review of epidemiological studies concluded that the prevalence of copd, in adults aged years and more, worldwide ranges around - %. ( ) these differences may be related, at least in part, to differences in genetic background, smoking habits and exposure to other environmental risk factors, and are accompanied by differences in diagnostic rates and in management of the disease around the world. there is a large underdiagnosis of copd with about only one out of three or four of all subjects fulfi lling diagnostic criteria of copd identifi ed by the health care system. ( ) ( ) ( ) copd in general population is diagnosed at earlier stages. data from latinamerica (platino), similar from those from spain, showed severity was distributed as follows: stage i, % and stage ii, . %. screening for copd screening, combined with smoking cessation advice, help motivated smokers to attempt quitting smoking. ( ) in general practice, when individuals were preselected on the basis of smoking age and respiratory symptoms chronic cough was a better predictor of airfl ow obstruction than other symptoms, such as wheeze and dyspnoea. age was also a good predictor of obstruction; smokers over with cough had a % chance of having an obstruction. ( ) diagnosis at the hospital the decrease in lung function is gradual. the disease is usually diagnosed late because patients may adapt to the condition or doctors may not notice the symptoms. by then, the patient is diagnosed at the hospital, when lung function is often poor, sometimes less than % of normal. the relationship between lung disease and increased body weight can take two forms: the effects of increased body weight on the normal respiratory system and the association of increased body weight with diseases of the respiratory system. obesity (body mass index, bmi, greater than kg/m ) can reduce normal static lung volumes (principally functional residual capacity, but also total lung capacity and residual volume at very high bmi), ventilation (particularly during sleep and exercise) and gas exchange (increased gas transfer). the epidemic of overweight and obesity has been associated with the increased prevalence of asthma through proposed mechanisms such as dietary effects, reduced lung volumes and lung recoil affecting airway responses to breathing, a general infl ammatory effect and through associated sedentary lifestyle. however more recent epidemiological data suggests the association between asthma and obesity is not as close as once thought. overweight and obesity clearly are associated with the high prevalence of obstructive sleep apnoea with increased body weight increasing the likelihood of upper airway collapse on a background of reduced upper airway dimensions and snoring and reducing minute ventilation in patients with obstructive sleep apnoea, predisposing to hypoventilation and chronic hypercapnoeic respiratory failure. the increased load to breathing also affects breathing, especially during sleep, in patients with respiratory muscle weakness or abnormal chest wall mechanics due to kyphoscoliosis or previous chest wall surgery such as thoracoplasty. increased body weight will also exacerbate the effects on symptoms of existing chronic respiratory diseases including asthma, chronic obstructive pulmonary disease and interstitial lung diseases. avoidance of weight gain and continued efforts at weight loss remain an important goal in patients with respiratory disease. this presentation will be a review of recent fi ndings and implications from imaging studies in asthma. the use of -dimensional imaging in asthma has provided useful insights into the understanding of pathophysiology of disease, which may have implications on how asthma is treated. small airways disease plays a major role in asthma and has traditionally been diffi cult to probe. however, the combined use of new imaging methods combined with complex lung function has provided useful insights into pathophysiology. findings and implications from hrct, pet, spect and mri will be discussed. the assessment of pulmonary function has changed very little over the past to years. all techniques performed in the laboratory still view the lung as a very simple single compartment unit. measures of volume and fl ow only assess disease in the medium to large airways whilst the small airways receive relatively little attention. however there are a number of emerging techniques on the horizon that have the potential to give great insight in to the periphery of the lung where most respiratory disease emanates. the measurement of mechanics using the forced oscillation technique and gas mixing using the multiple breath nitrogen washout test are now emerging as very powerful tools for assessment of peripheral lung function. in this presentation we will be discussing the state of the art in terms of assessing pulmonary function and what may we expect to see in the future. copd is a major public health problem in asia. copd prevalence was . % ( . % in males and . % in females) in china (> yrs), . % in japan (> yrs). in most of the developing countries in asia, copd is always underdiagnosed by physicians owning to lack of routine spirometry test and only based on symptomatic diagnosis. smoking is the most important risk factor contributing to development of copd. however, copd prevalence was . % in chinese non-smokers (> yrs) and . % in korea (> yrs), similar to those in mexico city ( . %) and caracas ( . %). in china, non-smokers accounted for . % of copd patients compared with . % in usa and . % in the uk. exposure to environmental tobacco smoke (passive smoking) and indoor air pollution (particularly the coal and biomass combination) may contribute to the higher prevalence of copd in developing countries. to reduce the risk factors (smoking, coal or biomass fuel for cooking, indoor and outdoor air pollution) are the priority for reducing the prevalence in the asian developing countries. government in some countries had made some effect in tobacco control and reducing air pollution. unlike hypertension or diabetes, the management of copd is only based on symptomatic treatment, owing to lack of specifi c biomarkers. annual lung function test with spirometer is the only parameter in detecting early stage of copd. data showed that more reversibility of fev was demonstrated in stages i-ii copd patients with ics/laba or tiotropine administration, as compared with those in stages iii-iv. an intervention study at the community level has shown that early intervention (improvement of indoor ventilation, bronchodilators) was able to reverse rapid annual fev, decline in copd patients. more affordable medication should be developed in the low income countries. data showed that oral administration of carbocysteine (thio compounds) reduced exacerbation rate by . %, which was consistent with inhaled administration of fluticasone/formoterol (seretide) or tiotropine. in addition, orally administered low dose teophylline ( mg, bid) improved pre-bronchodilator fev, and reduced exacerbation rate. there was a synergistic effi cacy in fev , with the combination of teophylline and inhaled corticosteroids. chronic obstructive pulmonary disease (copd) is characterized by the presence of airfl ow limitation due to loss of lung elasticity and/or airway narrowing. the pathological hallmark of loss of lung elasticity is emphysema and airway wall remodeling contributes to the airway narrowing. using computed tomography (ct) these lesions can be assessed by measuring low attenuation areas (laa) and airway wall thickness/luminal area, respectively. recently, copd has been widely recognized as a systemic infl ammatory disease, and body weight loss is one of its clinical features. traditionally, the patients who had copd with predominant emphysema and a low body mass index (bmi) were called "pink-puffers". however, the relationship between body weight loss and emphysema had not been assessed. based on these back ground, we have evaluated the body composition, emphysema and airway dimensions in copd patients using ct images. bmi was signifi cantly lower in the emphysema dominant phenotype compared to the airway dominant phenotype. furthermore, bmi correlated with laa% (ρ = − . , p < . ) but not with wa%. chest subcutaneous fat mass was also correlated with laa% (ρ = − . , p < . ). these data indicated that the "pink-puffer hypothesis" is correct in some aspects. next, we postulated that reduced leptin and leptin receptor signaling could contribute the development of emphysema. serum leptin was correlated with bmi which was correlated with dl co /v a . the expression of leptin and leptin receptor was evaluated pcr in human lung tissues. both genes were detected in the lung tissues, but the expression of leptin gene was low. the leptin receptor gene expression was signifi cantly lower in copd patients and it was signifi cantly correlated with dl co /v a . the leptin receptor gene expression in the lung did not correlated with body weight. these data suggested that the patients' physique can be associated with the relative contribution of emphysematous lesions in copd and leptin and leptin receptor system might affect the mechanism of developing emphysema. nutritional support has been one of possible clinical approaches as a copd therapy these days. however, its effect is still controversial. to clarify the relationship between low bmi and emphysema and to classify the phenotypes of copd based on the patients' physique may help to fi ne the defi nite targets for nutritional support even in the early stage of copd. journal compilation © asian pacifi c society of respirology sy - at present copd is often only treated in gold stage iii or iv . it is without question possible to diagnose copd earlier. if spirometry would be more readily performed in general practice, copd could be diagnosed in gold stage i and ii, as is evident from the practice of "spirometry days" organized by the belgian thoracic society in which the majority of the patients were diagnosed in gold stage ii . whether gold stage i and ii truly represent the "early" stages of the disease may be debated , but this defi nition of early copd could certainly be used as an operational defi nition. it is clear now that spirometry is required for early diagnosis of copd . although at present there is no irrefutable evidence that early treatment of copd is warranted, there is accumulating suggestive evidence that early treatment of copd may result in better outcomes. this evidence is primarily related to secondary analyses of the torch and uplift , studies. first, it was demonstrated in a secondary analysis of the torch study, that inhaled corticosteroids, long-acting betaagonists and their fi xed combination reduced the rate of decline of fev by , and ml, respectively . if treatment indeed reduces the progression of the disease, then an easy case for early treatment is made. in addition, a subgroup analysis demonstrated that except for the effect on the sgrq (st. george's respiratory questionnaire) all other treatment effects were numerically larger in gold stage ii than in gold stage iii and iv . a subgroup analysis of the uplift study demonstrated numerically greater treatment effects in gold stage ii as well. in addition, tiotropium reduced the rate of decline of fev in these patients (albeit only by ml/year), which was not the case in the later gold stages . finally, in patients not taking any medication at the onset of the study (maintenance naïve patients) tiotropium substantially reduced the rate of decline of fev and the rate of deterioration of the sgrqscore . taken together these data demonstrated that: ) large treatment effects were obtained in early disease; ) indications of disease modifi cation were present in early disease. hence, they support early treatment of copd. pulmonary rehabilitation is now the standard of care for patients with chronic obstructive pulmonary disease (copd) who remain symptomatic despite bronchodilator therapies. combining the best of interprofessional, personalized and evidence-informed care, pulmonary rehabilitation allows clinicians and their patients to realize signifi cant benefi ts in a variety of important patientcentered copd outcomes. the fundamental elements required for an effective pulmonary rehabilitation program will be discussed, and the scientifi c evidence supporting their effectiveness will be summarized. issues relating to optimal site of delivery, components of effective rehabilitation programming, duration of rehabilitation, timing of rehabilitation and target populations will be reviewed. recent developments in this rapidly expanding area will also be highlighted. lastly, methods to establish or enhance an existing pulmonary rehabilitation program will be discussed, with the goal of fully realizing the many substantive benefi ts of pulmonary rehabilitation in copd. however, only very low gene transfer seen after a second dose with either day and day spacing. we attribute this to rapid upregulation of neutralizing antibodies against adenovirus. anti-tumor humoral immune responses were seen almost all patients with reactions seen against known meso tumor antigens (sv large t antigen and mesothelin) and against unknown proteins in cell lysates. given the caveats of phase trials (small numbers, different doses, heavily pretreated patients), we still saw clinical responses (defi ned as prolonged stable disease, prolonged survival, partial or complete responses by modifi ed resist criteria, decreased metabolic tumor activity by pet scanning, or "mixed" responses) in about / of the patients. we are currently administering two doses spaced only three days apart. this appears to be well tolerated. based on strong preclinical data supporting the combination of gene therapy and chemotherapy, we have started a trial using ad.inf instillation into the fi rst treatment cycle of fi rst line (cisplatin/pemetrexed) or second line chemotherapy (gemcitabine). our groups is also generating "designer chimeric t cells" in which a single chain antibody fragment is linked to the transmembrane and cytoplasmic regions of the t-cell receptor. this artifi cial t-cell receptor is then transduced into t-cells that are then reinfused. the t-cells are then activated by cells expressing mesothelin. preclinical data show striking activity against mesothelin-expressing tumors in mice. mesotheliomas make large amounts of the immunoinhibitory cytokine, transforming growth factor-beta (tgf-β). preclinical studies using tgf-β blockers have shown activity in mouse models of mesothelioma and a clinical trial using an anti-tgf-β antibody is now underway at the university of pennsylvania. in summary, gene-based and immunotherapies are being actively studied in mesothelioma and have shown some promising results. future trials are focusing on combining these approaches with chemotherapy and surgery. given the relatively mild and non-overlapping toxicities, we believe these, or other gene therapy and/or immunologic approaches will soon become part of the standard therapeutic armamentarium. the burden of asbestos-related diseases (ards), in particular mesothelioma, has been shouldered mostly by the developed countries of the west. this is a consequence of the heavy dependence on asbestos use up to around the s by those countries. in contrast, the majority of asian countries started to depend on asbestos since then and has not yet reached the suffi cient latency time for the related diseases to manifest. japan is an exception, because it heavily used asbestos during the period to catch-up with the west. japan has now become one of the global epicenters of ards. it is a tragic consequence of experiencing the burden of ards that many developed countries decided to move towards banning asbestos or a de facto non-dependence. in the asia-pacifi c, this group comprises australia, new zealand, japan, korea and singapore (the "forerunner" group in terms of ards). in contrast, the many other countries in asia still use asbestos at substantial levels, turning asia into the world's center of asbestos consumption today. however, as these countries start to use up the latency time, and manage to improve medical recognition, reporting and recording, ards will soon emerge as a major public health issue in the region. early indications of this forecast do exist. not only should lessons be learnt from the experiences incurred by the "forerunner" group of countries, but more importantly, they should crystallize in international collaboration involving national administrators, academia, ngos and international organizations, for the effective recognition and countermeasures of ards. i will also refer to the progress made and hurdles encountered by the asian asbestos initiative and the who global plan of action on the elimination of asbestos-related diseases. at the international level, ards present a domino-effect that needs to be coped with. sy - interstitial pneumonia (ip) can be classifi ed into two groups in terms of known causes. pneumoconiosis, drug-induced pneumonitis, radiation-induced pneumonitis, and hypersensitivity pneunonitis (hp) are categorized as ip with known causes. on the other hand, idiopathic interstitial pneumonias (iips), which include idiopathic pulmonary fi brosis (ipf), nonspecifi c interstitial pneumonia (nsip), cryptogenic organizing pneumonia (cop), and desquamative interstitial pneumonia (dip), have no known causes. most physicians tend to diagnose of ip patients as iips without intensive examinations. however, some environmental and occupational lung diseases, especially asbestosis and chronic hp, should carefully be differentiated from iips. asbestosis is one type of pneumoconiosis, which is induced by asbestos exposure with a latent period of usually more than years. bilateral fi ne crackles can be frequently auscultated and pulmonary function test shows restrictive and diffusing impairments. chest hrct shows subpleural dot, subpleural curvilinear shadow, ground glass opacity, interlobular septal thickening, traction bronchiectasis, and honeycombing. in our case series of asbestosis (n = ) in yokosuka, a town of shipyard for more than years, honeycombing was seen in cases ( %). chronic hp is an allergic disease induced by long-term exposure to antigens. major causative antigens are avian dropping and feather, mold, and bacteria. chest hrct tends to show traction bronchiectasis and honeycombing in advanced stages, which are similar to ipf. in surgical lung biopsy, most cases are classifi ed as nsip-like and uip-like patterns. to clarify the importance of unrecognized exposure to avian antigen, we precisely reviewed patients with bird-related chronic hp. in the patients, patients were bird-breeders with direct exposure to avian antigen by contacting their own birds, whereas patients seemed to be exposed to wild birds, neighbor's birds, feather duvets, stuffed bird, and fertilizer with chicken droppings without recognition of avian contact. number of patients is very limited both in asbestosis and chronic hp, which suggests that there is a small group of subjects who are susceptible to develop pulmonary fi brosis after exposure to asbestos or antigens. however, genetic background of susceptibility to pulmonary fi brosis has not elucidated. in our case series of chronic hp (n = ), cases ( %) had the fi rst-degree family members with ip, who might have common environmental and/or genetic factors. further studies are needed to determine host susceptibility to pulmonary fi brosis, which might contribute to clarify the pathogenesis of ip. long acting beta- agonists has been in the doctors' armory of asthma medications for about years (available in in uk and in usa). there is little doubt that laba when combined with inhaled corticosteroids can improve asthma symptoms for a subsection of people with asthma, and is generally superior to add-on leukotriene receptor antagonist. indeed addition of laba to inhaled corticosteroids is in all major asthma guidelines as a step-up therapy. however, after the salmeterol multicentre asthma research trial was prematurely halted, a focus on effi cacy and safety of the wide use of laba severe pulmonary arterial hypertension (pah) is a fatal condition associated with complex pathobiology. vasoconstriction, thrombosis, and remodeling of the pulmonary vessel wall contribute to increased pulmonary vascular resistance in pah. the pathology of pulmonary hypertension can be classifi ed into endothelial, smooth muscle, and/or adventitial lesions, although not all compartments of the pulmonary artery wall are involved in each case of severe pah. the classic lesion of severe pah is the plexiform lesion, an abnormal proliferation of predominantly endothelial cells. smooth muscle thickening can be seen in all forms of the disease but is not a constant feature in the idiopathic pulmonary arterial hypertension. the adventitia is often markedly remodeled in patients with certain forms of collagen vascular diseases associated with severe pah, most notably scleroderma. the obligatory lining of pulmonary arteries with a monolayer of endothelial cells is disrupted in severe pah. the three-dimensional vascular pattern is rather suggestive of an intravascular tumor-like proliferation (tumorlet), instead of a retracted scar if this lesion would represent an abnormal healing to an injury to the vascular wall. the evidence of a tumorlike endothelial cell proliferation was provided by the demonstration that plexiform lesions in patients with idiopathic pah were preferentially monoclonal, whereas similar lesions in lung of patients with secondary pah due to congenital heart malformations were polyclonal. monoclonality was also observed in plexiform lesions of patients from anorexigen-induded pah. vasoconstriction has been related to abnormal potassium channels and to endothelial dysfunction. endothelial dysfunction leads to impaired production of vasodilators such as nitric oxide and prostacyclin along with overexpression of vasoconstrictors such as endothelin (et)- . many of these abnormalities not only elevate vascular tone and promote vascular remodeling but also represent logical pharmacological targets. recent genetic and pathophysiologic studies have emphasized the relevance of several mediators in this condition, including nitric oxide, prostacyclin, et- , serotonin, angiopoietin- , and members of the transforming-growth-factor-beta superfamily. disordered proteolysis of the extracellular matrix is also evident in pah. the unraveling of the pathobiology of severe pah may lead us to novel therapies and approaches to better treat the disease. unfractionated heparin (ufh) and low-molecular-weight-heparin (lmwh), acted by enhancing the ability of antithrombin (at) to inhibit coagulation proteases, have been used as initial anticoagulant therapy for vte. they are delivered intravenously or by subcutaneous injection. subcutaneous fondaparinux, a synthetic pentasaccharide with specifi c anti-factor xa activity, is also recommended as the initial treatment for vte according to recent guideline. oral vitamin k antagonists, acting by reducing the activity of several coagulation proteases, are used for long-term anticoagulation. the major disadvantage of vitamin k antagonists is the need for frequent coagulation monitoring to maintain a therapeutic level. new anticoagulants, including oral direct thrombin inhibitors, such as dabigatran, and oral anti-factor xa inhibitors, such as rivaroxaban and apixaban, are emerging in recent clinical trials. these new drugs may replace heparins and vitamin k antagonists, which are expected to have a huge impact on the treatment of vte in the near future. thrombolytic therapy should immediately be used in patients with massive (high risk) pte. the effect of thrombolysis in patients with submissive (intermediate risk) pte remains controversial. further stratifi cation of these patients is necessary. patients with multiple poor prognostic indicators such as right heart dysfunction, thrombolytic therapy should be considered. several countries have started to support activities raising public awareness of vte, with the goal to decrease mortality and morbidity. in us, national institutes of health (nih) and centres for disease control (cdc) have fostered thrombosis activities to improve the prevention of vte and its long-term complications. in the united kingdom, a thrombosis group has been formed to promote awareness among parliamentarians about the risk and management of vte; to increase knowledge of its causes, effects, and treatments; and to monitor the implementation of government initiatives and other researches being and this program has corrected the wrong perception that pte is a rare disease in china pulmonary hypertension (ph) is a common complication of chronic respiratory diseases, such as chronic obstructive pulmonary disease (copd) or interstitial lung diseases (ild). ph associated with respiratory diseases is classifi ed as diagnostic group iii according to the current clinical classifi cation of dana point . it is suggested that the pulmonary vascular abnormalities originate at an early stage of the diseases. the functional (hypoxic vasoconstriction) and morphological factors (vascular remodeling, destruction of the pulmonary parenchyma) explain the elevation of pulmonary vascular resistance that leads to ph. the ph is mild to moderate in copd with mean pulmonary artery pressure (mpap) usually ranging between and mmhg, however, worsening during exercise and exacerbations. a small proportion of copd patients may exhibit severe ph defi ned by a resting mpap > to mmhg, whose prognosis is particularly poor. ph is relatively frequent in advanced ild, particularly in idiopathic pulmonary fi brosis, which predicts a poor prognosis. the diagnosis of ph is suggested by doppler echocardiography, but the confi rmation still requires right heart catheterization. the potential treatments of ph associated with respiratory diseases are as follows: ) treat underlying lung disease; ) provide supplemental oxygen therapy when appropriate; ) rehabilitation; ) treat right heart failure; ) consider vasomodulator therapy; and ) consider lung transplantation when indicated. journal compilation © asian pacifi c society of respirology sy - tobacco use is the most common preventable cause of death. about half of the people who don't quit smoking will die of smoking-related problems. the epidemic varies among countries and is increasingly affecting developing countries, where most of the world's smokers ( %) live. close to half of all men in low income countries smoke daily and this has been increasing. legislation the framework convention on tobacco control (fctc) was adopted by who member countries in may to commit all countries to protect nonsmokers from tobacco smoke in public places, to eliminate all tobacco advertising, promotion and sponsorship, to require warning labels of cigarette packs and to prohibit misleading tobacco product descriptors such as "light" and "mild". even though many countries have passed legislation mandating smoke-free environments and the total global population covered by comprehensive smoke-free laws increased from . % to . % in one year, the overwhelming majority of countries still have no smoke-free laws, very limited laws, or ineffective enforcement. compliance with smoke-free laws is low. treatment to aid smoking cessation support for smoking cessation or "treatment of tobacco dependence" refers to a range of techniques including motivation, advice and guidance, counselling and appropriate pharmaceutical aids, all of which aim to encourage and help tobacco users to stop using tobacco and to avoid subsequent relapse. the success of these interventions depends on their synergistic use in the context of a comprehensive country tobacco-control strategy. in many countries, provision for treatment, training of health-care providers, education and information on the wide use of cessation is scarce. therapies, as well as fi nancial resources are limited and rarely incorporated into standard health care. also, smoking cessation is not seen as a public health priority and is not necessarily approached as a key tobacco-control strategy. smoking cessation services are most effective when they are part of a coordinated tobacco control programme. brief cessation counselling is relatively inexpensive when integrated into existing primary health-care services, is usually well received by patients, and is most effective when it includes clear, strong and personalized advice to quit. communication technologies -such as telephone quitlines, text messaging, interactive telephony, and online counselling -as well as psychological and behavioural modifi cation therapies, offer important support. cessation prescription medicines, available in many countries like nicotine replacement therapies, bupropion and varenicline can double the likelihood that someone will successfully quit. bronchiectasis is an old disease that we all treat, but surprisingly little about this disease has been well studied. the defi nition, diagnosis, natural history, pathogenesis and treatment are all uncertain. this talk examines these points in the light of new information about biofi lms and "normal" bacteria. it asks more questions than it answers, but the questions raise thoughts on whether our usual approaches are the best. the mediastinum is generally split into three compartments strictly for the purpose of classifi cation of the most likely abnormality in the individual compartment. there are no anatomical boundaries or fascial planes that divide one compartment from the other. classically, the compartments have been classifi ed as anterior, middle, and posterior. a recent change in classifi cation has used the categories of anterior, middle-posterior, and paravertebral compartments. approximately % of mediastinal tumors are located in the anterior compartment, % in the middle compartment, and % in the posterior compartment. asymptomatic masses are more likely to be benign than malignant, and symptomatic masses are more likely to be malignant than benign; however, there is a large variation the most common tumors in the anterior mediastinum consist of thymoma, lymphoma, germ cell tumors, and thyroid tumors. thymoma is by far the most common anterior mediastinal tumor and approximately / are encapsulated and non-invasive while / are invasive. the most common paraneoplastic syndromes associated with thymoma include myasthenia gravis, hypogammaglobulinemia, and pure red blood cell aplasia. benign teratomas occur in both male and females, while malignant germ cell tumors of the mediastinum are almost exclusively in males. lymphoma can occur most commonly in the anterior or middle mediastinum and may be associated with systemic symptoms and occasionally superior vena cava syndrome. the most common abnormalities in the middle mediastinum include lymphoma, granulomatous disease, and developmental cysts. bronchogenic cysts are almost always benign, although they can cause symptoms such as obstructive pneumonia and are generally treated with surgical resection. recent mediastinal compartment classifi cation has switched from posterior mediastinum to naming this the paravertebral compartment. it is located posterior to an imaginary line drawn to connect the anterior aspects of the vertebral bodies on the lateral chest radiograph. the most common tumors in this location are neurogenic tumors, meningoceles, or thoracic spine lesions. the most common neurogenic tumors in adults are neurilemomas, and they are almost always benign. neurofi bromas also occur in this compartment. they are frequently benign, but may be malignant, especially in patients with neurofi bromatosis. in these individuals, malignant tumors of the nerve sheath origin are more common. ganglioneuroma, ganglioneuroblastoma, and neuroblastoma are more common neurogenic tumors in children or adolescents.. cough is an important lung defense. in a refl ex manner, noxious agents are expelled from the airways as these are sensed by the receptors in the airway epithelium. in addition to appreciating its cleansing function, understanding cough refl ex is important in the diagnosis and treatment of common clinical conditions. most diseases associated with cough are transient. a problem arises when cough persists and becomes chronic. an in-depth search for the underlying pathology is warranted since treatment directed to the cause of the cough is curative in over % of cases. an anatomic-diagnostic protocol ensures a systematic search for cough etiology but unfortunately, this approach can be lengthy and in many settings, impractical. thus an empiric syndromic approach is now recommended. this paradigm shift is borne by the following premises: ( ) the current awareness of the relative frequency of the disorders (alone or in combination) that can cause cough; ( ) the sensitivity and specifi city of many (but not all) diagnostic tests in predicting the cause of cough has been established; ( ) a sequential evaluation and treatment for the common causes of cough using a combination of selected diagnostic tests and empiric therapy has been proven effective; and ( ) a sequential and additive therapy is often crucial because more than one cause of cough is frequently present. a recent study by dr. aileen wang on "the management of chronic cough in a tertiary center: an asian perspective" showed that even in a filipino immunocompetent population, the most common causes of chronic cough is asthma, post-nasal drip syndrome (pnds) and gastroesophageal refl ux disease (gerd). the study concluded that: ( ) the accp recommendations are generally applicable to an asian setting. research of viruses, their structure, pathogenicity and host-interactions has burgeoned. we now understand how viruses infect cells, how they replicate, how they interfere with host defences and how they interact with other tissue events and pathologies. rhinovirus infection causing the common cold is the most frequent and 'common' infection in humans. it is also implicated in most exacerbations of asthma and copd. the patho-biology of rhinovirus will be used to illustrate virus pathogenicity, virus-host-interactions and to highlight potential future therapeutic options. sy - much hope has been placed in the discovery of biomarkers to help understand the mechanisms of diseases such as copd, help stratify the disease better and guide treatment. it is also hoped that some of these could speed up drug discovery by serving as surrogate markers that respond to novel drugs within a shorter timescale than is the case with current drug trials in which the main outcome is the spirometric measurement of forced expiratory volume in one second (fev ). although studies in patients with copd have identifi ed several biomarkers, most of these need to be validated and their prognostic value is unclear. many of the markers have been identifi ed in blood and although it is recognised that there are non-pulmonary consequences of copd, some of which can be viewed as systemic biomarkers measured and/or generated in the lungs are likely to be most informative. there are several methods to identify and quantify biomarkers of copd and different biological samples (blood, bal, sputum and lung tissue) can be used to provide material for such analyses. whilst most studies to date used commercial immunoassays (elisa), there has been a keen interest in applying unbiased approaches such as proteomics. we have recently completed a large programme of work which applied -dimenshional electrophoresis and mass spectrometric analysis to identify biomarkers of copd. induced sputum was obtained from copd patients with a spectrum of disease severity and control subjects. two-dimensional gel electrophoresis and mass spectrometric identifi cation of differentially expressed proteins was fi rst applied to induced sputum from gold stage copd patients and healthy smoker control subjects. initial results thus obtained were validated by a combination of immunoassays (western blotting and elisa) applied to a large subject cohort. the biomarkers were localised to bronchial mucosa by immunohistochemistry. of individual protein spots identifi ed, were quantitatively and qualitatively different between the two groups. protein spots were subjected to tandem mass spectrometry, which identifi ed separate protein species. seven of these were further quantifi ed in induced sputum from individuals. using this sequential approach, two of these potential biomarkers (apolipoprotein a and lipocalin- ) were found to be signifi cantly reduced in copd patients when compared to healthy smokers. their levels correlated with fev /fvc, indicating their relationship to disease severity. in summary, a potential role for apolipoprotein a and lipocalin- in innate defence has been postulated previously; our discovery of their reduction in copd indicates a defi cient innate defence system in airways disease that could explain increased susceptibility to infectious exacerbations. persistent chronic infl ammation, repetitive tissue injury, and dysregulated epithelial repair leading to tissue remodeling and fi brosis are the hallmarks of chronic lung diseases, such as chronic obstructive pulmonary disease (copd), chronic asthma, pneumoconiosis, pulmonary fi brosis and sarcoidosis. the innate immunity system with its pattern recognition receptors are recently identifi ed to involve in the pathogenesis of these chronic lung diseases. the neutrophilic infi ltration of the airway mediated through t h and il- family may play an important role in steroid-resistant asthma and status asthmaticus. in addition, the epigenetic modifi cation of gene expressions and cellular senescence may modulate the progression of chronic asthma and copd. histone deacetylase (hdac ), which can be inactivated by oxidative stress or pi k-akt pathway, may regulate corticosteroid-related anti-infl ammatory response. manipulation of hdac activity is a new treatment direction in steroid-resistant asthma and copd. sirt , a nad + -dependent deacetylase, is an important signaling pathway related to cell survival, dna repair, and apoptosis. the sirt is decreased in alveolar macrophages of smokers and copd patients, and associated with pro-infl ammatory response through the activation of nf-κb. understanding the complexity of infl ammatory and epigenetic regulations in chronic lung diseases may potentiate the development of novel therapies. fibrosis is a common fi nding in chronic lung diseases, with tgf-β-related pathways play important roles. myofi broblasts are the principal effective cells in the fi brogenic process. they can be evolved from the activation of resident pulmonary fi broblasts, marrow-derived fi brocytes, or the trans-differentiation of pulmonary epithelial cells through epithelial mesenchymal transition (emt). further understandings on the emt process in lung tissue repair may help to elucidate the mechanism of lung remodeling and fi brosis. in addition, lung stem/progenitor cell study appears to be a new and potential fi eld in lung injury and repair. it is anticipated that more clear mechanisms behind lung remodeling and fi brosis can be identifi ed and new treatment modalities be developed accordingly. sy - cancers are genetic diseases with constitutional genomic variations that are present in normal cells contributing to an individual's risk of developing cancer such as lung cancer. furthermore, cancer cells acquire genetic mutations and genome wide changes in their dna as well as their epigenome compared to their normal cellular counterparts. some of these mutations have turned out to be important driver mutations and are associated with exquisite sensitivity to targetted cancer therapies. some of these genetic changes include egfr and eml -alk fusion gene mutations. epigenetic changes include methylation abnormalities as well as histone modifi cations, and possess the characteristic of potential reversibility which is attractive for the development of new therapies. the human genome project and rapid technological advances including deep dna sequencing have contributed signifi cantly to the ability to detect cancer specifi c genetic, genomic and epigenomic aberrations. these genetic and genomic abnormalities have promise across the translational spectrum from identifying individual susceptibility to cancers, early diagnosis markers, molecular pathology and tailoring of treatment (predictive biomarkers) as well as informing on outcome (prognostic biomarkers). much work remains to be done to validate clinical utility and translate these potential useful biomarkers into useful clinical tools. this session will review some of the developments in the genomics and epigenomics of lung cancer and mesothelioma. asthma is a disease that is diagnosed largely on a history of variable symptoms and the demonstration of variable airway narrowing. it is associated with airway infl ammation (cd t-lymphocytes, b-cell lymphoid aggregates, macrophages, eosinophils and, in adults, neutrophils) and airway wall remodelling (airway wall thickening, principally increased airway smooth muscle and deposition of collagen below the basement membrane, with minor encroachment on the airway lumen). it is not associated with a prominent effect on the lung parenchyma. the cause(s) of asthma remains unknown and the severity of disease remains largely constant. copd is diagnosed with a spirometer and is defi ned as a fi xed reduction in fev , relative to fvc. when caused by cigarette smoke it is associated with airway infl ammation (cd t-lymphocytes, b-cell lymphoid aggregates, macrophages and neutrophils) and airway remodelling (mild increase in airway wall thickness including airway smooth muscle with encroachment on the airway lumen) and tissue destruction (emphysema and loss of small conducting airways). the severity of copd increases with age and continued exposure to irritants. copd has many causes including smoking cigarettes, burning of biomass fuels, asthma and early life respiratory illness and exposures (viral infections, bronchopulmonary dysplasia). as a group, patients with asthma have reduced lung function, in relation to disease severity, and may have a slightly increased rate of decline in lung function. patients with asthma who smoke have reduced lung function and an accelerated decline in lung function. apart from stopping smoking there is no current treatment that can improve the rate of decline in lung function in patients with asthma or copd. therefore prevention, early intervention and uncovering the unknown environmental and genetic contributions to airway diseases remain critical. sy - situation the isaac and ariap studies have showed the different prevalence but heavy burden caused by asthma in asia pacifi c countries is common. goals with inhaled corticosteroids and other medications, the goals in managing asthma in developing countries should attain those stated in gina: control of symptoms, maintaining normal activity levels, normal pulmonary functions, preventing asthma exacerbations, avoiding adverse affects and preventing asthma mortality. in developing countries, avoiding the abuse of short-acting beta agonists, systemic corticosteroids and antibiotics is also a major problem. accessing medical care and medications is crucial. steps a core group, preferably at an university medical center, is the basic step. the asthma and copd outpatient care unit (acocu) run by this core group will help in getting experience and capacity building. the following steps are gina dissemination and implementation, patient club formation, increasing awareness, training doctors and nurses, advocacy, researches, efforts for the availability of affordable asthma drugs, and multiplying acocu in the whole country. the sustainability of acocu is assured by successful implementation of gina. a network of acocu will encourage and improve the activities of acocus. successful provincial acocu will encourage the building of district and even commune acocus. diffi culties the continuous medical education for all doctors on gina, the medication affordability, spirometers and mechanism to maintain an acocu. despite the advances in asthma diagnosis and treatment, slta cases continue to present in the er, sometimes leading to unnecessary mortalities. these are highly preventable situations with inhaled steroid based chronic therapy. with expert care, most patients get through er/icu urgent phase with good outcomes. these strategies are published and updated regularly in the international asthma guidelines. the finnish experience confi rms that a national program that pushes for implementation of guideline recommendations is able to reduce asthma hospitalizations and cost of care. not all countries have such a program but in most developed economies, the cost of asthma care including medications is covered provided the guidelines are followed. unfortunately, even in these affl uent countries, a subset on patients still lands in the er with sltas. while there may have been a failure of health care delivery, the cross-country existence of this problem raises the prospect that some patients are prone to life-threatening exacerbation. sltas may have its own specifi c risk factors that are distinct from the risk factors for simple hospital admission for acute severe asthma. by defi ning risk factors for slta within the population of those admitted to hospital with acute asthma, we may be able to develop specifi c interventional strategies to reduce its occurrence. reported slta risk factors include advancing age, chronic severe asthma, increased infl ammation markers, asthma exacerbated by pneumonia and low nutritional status. other risk factors include recent hospital admission, prior intubation, steroid dependence, non-adherence to inhaled corticosteroids, psychological or psychosocial problems, lack of access to medical care, lower fev , and current cigarette-smoking. a specifi c phenotype of severe brittle asthma has been reported. the backbone of er management for slta includes quick assessment of severity, oxygen therapy, early use of systemic steroids and repetitive saba bronchodilator administrations. enhancements include the use of saba with high intrinsic effi cacy, the addition of ipratropium in refractory cases and the concurrent administration of inhaled corticosteroid for its non-genomic, airway edema-reducing effect. mgso can also be considered for refractory cases. when ventilator support is needed, niv may be attempted in some patient. for intubated cases, the ventilatory strategy includes low tv and rr, high i : e ratio, and monitoring for the development of dynamic hyperinfl ation. the burden of the slta problem can be mitigated by identifying its phenotype a priori, providing preventive therapy before actual exacerbation occurs and putting in the er/icu the appropriate treatment protocols. journal compilation © asian pacifi c society of respirology available treatment of asthma using inhaled corticosteroids and long-acting inhaled β -agonists (labas) is highly effective and safe. importantly, it is also relatively inexpensive. however, many patients remain poorly controlled despite the use of optimal treatment. most advances in asthma therapy have been achieved by improving these drugs and more recently several promising once-a-day labas have been developed. new corticosteroids are also being developed with differential effect on trans-activation and trans-repression of pro-infl ammatory transcription factors, thus giving them a better therapeutic index. the big challenge in asthma is posed by corticosteroid unresponsiveness which is relative and therefore requires high doses to achieve symptom control which inevitably leads to side-effects. one option being pursued is to develop activators of the nuclear enzyme histone-deactylase (hdac) which is recruited to the gene initiation site of pro-infl ammatory mediators. there is an increasing appreciation that asthma is not a single disease and is increasingly seen as a syndrome consisting of several phenotypes. so far, two relatively clear subsets have been identifi ed: eosinophilic and neutrophilic forms of asthma. with this notion in mind, attempts are being made to develop more-specifi c inhibitors for a range of mediators with the hope that sub-phenotypes of asthma will be identifi ed that respond well to either single mediator inhibitors or a combination of these. a number of cytokine modulators have been tested in clinical trials, the most notable example being anti-tnf inhibitors which is felt to be more relevant to neutrophilic asthma. unfortunately, large clinical trials with tnf inhibitors have not found them to be very effective. treatment with blocking antibody for the eosinophils growth factor, il- , has been slightly more effective, with early clinical trials showing that the treatment reduces the frequency of exacerbations in patients who have eosinophilia. whilst the exact mechanisms leading to the development of these two subphenotypes is not fully understood, it is thought that eosinophilia represents a risk factor for exacerbations which has led to eosinophils counts in sputum being used as a guide to treatment; this has been benefi cial in reducing exacerbations. neutrophilic forms of asthma represent a special challenge because patients with neutrophilia tend not to respond well to corticosteroids, making them reliant on bronchodilators. such patients' asthma may be driven by mechanisms that involve il- which induces the production of neutrophil chemoattractants by the epithelium, which makes il- and its chemo-attractant axis a target for novel therapies. the major unmet need in asthma is the treatment of infections. there are early indicators of antibiotic treatment (macrolides) being effective in the treatment of severe asthma. but the real hope comes from novel strategies aimed at the effects of viruses which are the cause of most acute exacerbations, both in milder and more severe forms of disease. recent studies have identifi ed a defi ciency in type i interferons (ifn), the production of which by the bronchial epithelium -the prime target of virus infection -has been shown to be reduced when epithelial cells from asthmatic are grown in culture and infected ex vivo. in the acute care setting, niv must usually start without delay to avoid further deterioration and an increased likelihood of failure. thus, the decision to start must be made quickly based on a bedside assessment. i recommend a simple two step process, the fi rst of which is to assess the patient's need for ventilatory assistance. if the patient has increased dyspnea (moderate to severe) and evidence of increased work of breathing including tachypnea (> /min in obstructive diseases and > /min in hypoxemic respiratory failure), increased accessory muscle use or abdominal paradox, the patient needs ventilatory assistance. arterial blood gases are helpful in making this assessment, but i discourage awaiting blood gas results before starting if the need is obvious, because the window of opportunity may close if initiation is too delayed. i do recommend obtaining baseline blood gases, however, and using them for comparison with later measurements to make certain that the patient is responding. the second simple step is to make sure patients have no contraindications to niv. these include patients with a need for immediate intubation by virtue of a respiratory arrest, hypotensive shock, or uncontrolled arrhythmias or upper gastrointestinal bleeding. the inability to fi t a mask because of a facial deformity, recent facial surgery or burns is also a contraindication. relative contraindications include agitation that prevents the patient from tolerating the mask, increased secretions or diminished ability to protect the airway. patients with these contraindications are at increased risk of failure if placed on niv and should be promptly intubated. patients with multiple risk factors for niv failure should be started only by experienced personnel under very close monitoring. in patients with hypercapneic respiratory failure, these include higher acute physiology scores, marked tachypnea, greater acidemia at baseline and a worse neurological score. in hypoxemic respiratory failure, risk factors for niv failure include the diagnosis of ards or pneumonia, greater age, hypotension and the failure to improve oxygenation substantially within the fi rst hour. although patients at high risk of niv failure can still be given a trial if the clinicians judge it to be indicated, but they must be watched very closely in an icu, with plans to intubate if there is no improvement within the fi rst hour or two. just as the decision to endotracheally intubate a patient in respiratory failure is a clinical judgment that requires the consideration of multiple factors, so is the decision to implement noninvasive ventilation. in the largest rct to date, cpap and nppv performed similarly, both improving dyspnea scores and ph more rapidly than with oxygen alone, but neither lowered intubation nor mortality rate (the major outcome variable) compared to oxygen-treated controls. however, this study enrolled patients whose intubation rate was slightly below % in all of groups, including controls, suggesting that they were too mildly ill to manifest a signifi cant mortality benefi t. meta-analyses of the rcts on cpap or nppv compared with o therapy alone have confi rmed the benefi ts described above, even showing a signifi cant mortality benefi t with cpap. meta-analyses comparing the modalities show equivalency of nppv and cpap with regard to reduction of intubation, lengths of stay and mortality, and with similar myocardial infarction rates. therefore, by virtue of its greater simplicity and potentially lower cost, cpap alone is generally regarded as the initial noninvasive modality of choice for cardiogenic edema patients. but because some studies have found that nppv reduces dyspnea and improves gas exchange more rapidly than cpap alone, nppv is preferred by some initially and can be substituted for cpap if patients treated initially with cpap remain dyspneic or hypercapnic. the success of noninvasive positive pressure to treat cardiogenic pulmonary edema has encouraged its extension into the pre-hospital setting. an emerging trend is to provide cpap devices on ambulances for initial therapy of cardiogenic pulmonary edema, a practice that has been associated with decreased need for intubations in the fi eld. patients with advanced chronic obstructive pulmonary disease (copd) experience poor quality of life and very high levels of symptom burden, including intractable shortness of breath, activity limitation, fatigue, social isolation, anxiety and depression. many of the these burdens are shared with caregivers, and resources in the community to support individuals and their families with chronic illness in the community are often lacking. with the recognition that patients with advanced copd and their caregivers have so many unmet needs, there is a growing acceptance for the need to improve the care and quality of life for patients with advanced copd. while signifi cant gaps in our knowledge and understanding of this area remain, factors contributing to these adverse experiences will be discussed. the importance of prevention, relief, reduction, and soothing of symptoms, without affecting a cure, will be emphasized as an integral component of the care provided for these patients. techniques and tools to optimize the care of patients with advanced copd, including optimizing pharmacologic therapies, inter-professional team care, anticipating and appropriately initiating end-of-life planning, patient and caregiver advocacy, as well as timely and effective communication will be reviewed. withdrawal or withholding life support in medically futile cases has been recognized as an ethical and a legal procedure. it is based on the inherent right of a person to autonomy in making health care decisions. the western model however may not apply to the asian setting being widely varied in terms of cultures, religions and economic progress. more than an individual decision, it may actually be a communal decision with a heavy reliance on input of relations, especially the elders. life support withdrawal often entails complete discontinuation of all measures. efforts to avoid feelings of guilt or abandonment may make families opt for partial withdrawals even when they are not shown to be any more benefi cial. studies have shown that distrust with the medical system does play a major role. active discussions may be diffi cult with reticent cultures or when there are gender differences between patients or their families and the physicians. in this era of globalization and migrations, an understanding of these differences may minimize potential confl icts that arise out of these discussions. awareness that the western approach may not fi t the asian medical model allows the health care providers to be sensitive to the needs and wants of their patients and their families. it is hoped that the data reviewed spurs the development of asia pacifi c guidelines that try to fi nd some uniformity in the diversity of the region. screening for lung cancer is not currently recommended by any major medical organization. multiple phase ii non-randomized trials of computed tomography (ct) screening have yielded enticing results. they have demonstrated that ct screening detects smaller size lung cancer of - mm in diameter. it has been documented that the chest radiographs miss - % of the cancers detected by screening ct. in prevalence studies, - % of detected cancers are stage i. when ct screening results were compared to a validated control group, ct has been shown to detect times more lung cancer than would be expected and results in ten times more thoracic operation than would be expected. additionally, no decrease in advanced stage cancers or decrease in lung cancer deaths were observed. to date, multiple small randomized controlled screening trials (rct) have been reported, but they have been too small to assess if ct screening reduces mortality. a meta-analysis of baseline fi ndings from six small randomized controlled trials observed more stage i and more total lung cancers in the ct screened group. for every individuals screened with low dose ct, stage i nsclc and false positive nodules were detected and thoracic operations were performed for benign nodules. the two large rct of ct screening that may defi natively answer the question of ct screening and its ability to decrease lung cancer mortality are the national cancer screening trial (nlst) and the nederlands-leuvens longkanker screenings onderzoek (nelson) trial. mortality results from those two trials are anticipated in and respectively. a recent report from the nelson trial validated the use of ct volumetric assessment of nodules to assess malignancy and determine which nodules should be treated surgically. currently, there is considerable effort to identify susceptibility genes for lung cancer with particular interest in q - which is strongly associated. this region contains several genes of interest, including three genes that encode nicotinic acetylcholine receptor subunits. however, these genes may just be associated with nicotine dependence. a recent report utilizing gwas (genome wide association scan) methodology identifi ed snps at q . associated with lung cancer susceptibility in never smokers. an enormous research effort is underway related to biomarkers in airway epithelial cells, blood, sputum, breath, and urine for early diagnosis or prediction of high risk. intense efforts are devoted to develop models of risk for determining which individuals should be offered screening. journal compilation © asian pacifi c society of respirology sy - lung cancer is the leading death-related cancer worldwide. molecular targeted therapy appears to be an alternative approach for patients with non-small cell lung cancer (nsclc). the epidermal growth factor receptor (egfr) is one of these targets, responsible for the cell growth, proliferation, apoptosis and metastasis of the tumors. egfr-tyrocine kinase inhibitor (tki) has been applied to target egfr and suppress the development of tumors. some egfr-tkis, including gefi tinib and erlotinib, have been approved, while the others are still under development or in clinical trials. several studies demonstrated that egfr somatic mutations might predict the high response rate and greater survival benefi t of egfr-tki. in addition, egfr amplication, k-ras mutation, met amplication or the egfr t m mutation might predict the clinical effect of these drugs. both erlotinib and gefi tinib have been undergoing several clinical trials for nsclc treatment as a single drug or in combination with chemotherapy. br. trial showed that erlotinib improved survival with previously treated nsclc patients in a randomized multicenter during phase iii study. thus, erlotinib was approved to be the second or third-line treatment of advanced nsclc patients. however, isel failed to demonstrate a statistically important benefi t of gefi tinib in overall survival as compared with placebo. different study population, dosing and drugs of br. and isel might explain the different results. in ipass trial, clinical selected nsclc patients with asian origin and characterised by adenocarcinoma histotype were treated with gefi tinib or paclitaxel/carboplatin doublets as the fi rst line therapy. the results showed that gefi tinib had the superiority in terms of progression free survival (pfs) in patients with egfr mutation. in eortc and perol trials, gefi tinib and erlotinib maintenance therapy showed the trend of improved pfs, but not overall survival in advanced nsclc patients. the toxicity of gefi tinib and erlotinib includes diarrhea, rash, etc., which can be well-tolerated. novel egfr-tkis include vandetanib, sorafenib, sunitinib, and cediranib, of which some are under evaluation in phase iii trials as monotherapy or in combination with standard chemotherapy. vandetanib targets both egfr and vegfr and was tested in the second phase trial, suggesting the addition of vandetanib to the single chemotherapy might improve response rates and survival. sorafenib has been applied to different carcinoma histology and in combination with different chemotherapy. when combined with paclitaxel and carboplatin to treat patients with squamous cell cancer, no survival benefi t was seen. however, another clinical trial was launched to investigate the effect of sorafenib, in which squamous cell cancer were not eligible. novel egfr-tkis are under development with hope of overcoming resistance to egfr-tki gefi tinib and erlotinib. there is a great need of further clinical trials. egfr-tki is one of the important alternatives in treatment of nsclc and has shown promising potential in the future. more promising results may come out if the combination and sequence of egfr-tki with traditional therapies, like chemotherapy, radiotherapy and surgery, can be optimized. there is also a need of disease-specifi c biomarkers to predict the effect of the drugs and identify the patients most likely to benefi t from the drugs. lung cancer is the number one cause of cancer death. most cases are found after distant metastasis, and outcome of drug therapy for these patients used to be disappointing. however, we have faced a new paradigm shift, i.e., the molecular targeted therapy and the individualized therapy. many promising data has reported from not only western countries but also asian countries such as the effi cacy of egfr tki to tumors with mutated egfr, that of alk inhibitor to tumor with eml -alk fusion protein, and that of pemetrexed to non-small non-squamous cell lung cancers. new questions have emerged from these new evidences derived from some important clinical trials. among them, questions regarding with ethnic difference would be one of the most important issues. is survival data same between asian and caucasian? (data from japan lung cancer registry study as well as some global trials have shown survival of asian patients with lung cancer appears to be obviously better than that of caucasian.) why egfr mutation is frequent in asian patients? is only egfr gene status related with prognosis of lung cancer? what would be the cause of alk abnormality? is the criteria of pathological diagnosis for lung cancer same between asian countries and western countries? here, newest evidences for treatment of lung cancer will be presented, and importance of ethnic difference and asian trials will be discussed. the burden of chronic obstructive pulmonary disease (copd) is growing. despite these growing numbers, many patients with patients with copd remain undiagnosed, the greatest number being those with milder disease. delays in the diagnosis of copd are common. evidence suggests that patients with mild copd experience increased symptoms, reduced activity levels and exercise capacity, and impaired health-related quality of life. this growing body of evidence has made it clear that mild copd is not 'normal'. with recognition of this reality and efforts to appropriately recognize copd at an earlier stage, clinicians must be aware of the various therapeutic options for their patients. the defi nition of mild copd will be discussed, as well as effective strategies for the targeted early diagnosis of copd. the numerous and varied disease manifestations and consequences for patients with milder copd will be reviewed. in addition, practical and effective management options available to clinicians caring for patients with mild copd will also be examined. clinicians have been long aware that neither the traditional distinctions of "emphysema" versus "chronic bronchitis" nor the traditional clinical phenotypes of "blue bloater" and "pink puffer" are suffi cient to categorize patents that suffer from chronic obstructive pulmonary disease (copd). recently, the global initiative for chronic obstructive lung disease (gold) workshop has used quantitative measures (fev and fev /fvc ratio) to defi ne copd, but this defi nition fails to take into account the full heterogeneity of copd. with an increased understanding of pathophysiologic variation, copd now clearly represents a spectrum of overlapping diseases with important extrapulmonary consequences. a "phenotype" describes the outward physical manifestations of a particular disease, and comprises anything that is part of the observable structure, function or behavior of an individual. such phenotypic distinctions in copd include: frequent exacerbator, pulmonary cachectic, rapid decliner, airways hyperresponsiveness, impaired exercise tolerance, and emphysema versus airways disease. these variable manifestations, each with unique prognostic, clinical and physiologic implications, represent distinct phenotypes within copd. while all of these phenotypes have smoking as a common risk factor, the other risk factors that determine these phenotypes remain poorly understood. an individual smoker has variable expression of each phenotype and there is mounting evidence that copd phenotypes have different clinical outcomes. these phenotypes can be broadly classifi ed into one of three groups: clinical, physiologic and radiographic. thus, the paradigm that copd is one disease may be incorrect, and suggests that copd should be considered as a spectrum of smoking-related diseases. failure to consider copd phenotypes is likely to limit the power of therapeutic trials since not all copd patients are likely to benefi t from each therapy. the challenge to future copd researchers is to better characterize these phenotypes and identify their risk factors. measurement of fractional exhaled nitric oxide (feno) is an attractive biomarker of diseases where airway eosinophilia dominates. indeed even before any randomized controlled trials were published some were advocating treatment tailored in accordance to feno data. commercially available bench-top and portable feno analyzers are now readily available and in some countries, feno measurements attract a payment. however, despite the ease of measuring feno, it has its drawbacks in biological and measurement issues. biologically feno is signifi cantly infl uenced by atopy, intake of caffeine, exercise, ethnicity, etc on the measurement front, variabilites include: feno measured by different analyzers may provide different values and on-line vs off-line measurements. the cut-off for determining 'abnormally high results' is yet unknown. not surprisingly, there is discordance on the effi cacy of tailoring asthma medications in accordance to sputum eosinophils [ ] and feno [ ] in people with asthma, although both are eosinophilia infl ammatory markers. tailoring of medications in accordance to sputum eosinophilia (compared to standard practice) significantly reduced exacerbations in adults with asthma (odds ratio . , %ci . , . ). in contrast, the benefi t of tailoring of medications in accordance to feno was, at best, modest. the utility and limitations of using feno levels in the clinical setting will be discussed in this talk. shortness of breath and activity limitation are cardinal symptoms experienced by patients suffering from respiratory illness or disease. cardiopulmonary exercise testing (cpet) allows for the objective evaluation of these symptoms, recognizing that exercise involves the effective integration of respiratory, cardiovascular, neuromuscular and metabolic functions. the organs involved in these varied and important roles have a sizeable reserve, with the consequence that clinical manifestations of a disease state or abnormality may not become readily apparent until the functional capacity of the organ(s) is markedly impaired. objective assessment of various parameters during exercise, which places an increased physiologic demand on the functional reserve capacity of these organs, can provide a sensitive method for the early detection of abnormal function and responses(s). the results from exercise testing also parallel functional capacity and quality of life more closely than measurements obtained only at rest, and have been shown to accurately predict important outcomes, such as mortality, in a variety of patients and clinical circumstances. a brief overview of normal exercise physiology and characteristic responses demonstrated by patients with various disorders frequently assessed by the pulmonologist will be offered. in addition, a summary of the indications, conduct, and practical interpretation of cpet will be presented in this session. effect of tiotropium on outcomes in patients with moderate chronic obstructive pulmonary disease (uplift): a prespecifi ed subgroup analysis of a randomised controlled trial obstructive lung disease and low lung function in adults in the united states: data from the national health and nutrition examination survey international variation in the prevalence of copd (the bold study): a population-based prevalence study chronic obstructive pulmonary disease in fi ve latin american cities (the platino study): a prevalence study prevalence of copd in spain: impact of undiagnosed copd on quality of life and daily life activities global burden of copd: systematic review and metaanalysis prevalence of chronic obstructive pulmonary disease in china. a large, population-based survey diagnostic labeling of chronic obstructive pulmonary disease in fi ve latin american cities copd prevalence in a random population survey: a matter of defi nition treatment of copd: the sooner the better clinical copd phenotypes: a novel approach using principal component and cluster analyses offi ce spirometry signifi cantly improves early detection of copd in general practice: the didasco study salmeterol and fl uticasone propionate and survival in chronic obstructive pulmonary disease clinical trial design considerations in assessing long-term functional impacts of tiotropium in copd: the uplift trial a -year trial of tiotropium in chronic obstructive pulmonary disease mortality in the -year trial of tiotropium (uplift) in patients with chronic obstructive pulmonary disease effi cacy of salmeterol/fl uticasone propionate by gold stage of chronic obstructive pulmonary disease: analysis from the randomised, placebo-controlled torch study effects of tiotropium on outcomes in patients with moderate chronic obstructive pulmonary disease (uplift): a prespecifi ed subgroup analysis of a randomised controlled trial tiotropium as a first maintenance drug in copd: secondary analysis of the uplift trial treating tobacco use and dependence: update. clinical practice guideline tobacco atlas the mpower package. geneva, world health organization implementing smoke-free environments. geneva, world health organization curbing the epidemic: governments and the economics of tobacco control clinical and public health signifi cance of treatments to aid smoking cessation we report that pulmonary emphysematous lesions appear to be a dynamic phenomenon that involves not only the gradual loss of alveolar structure, but apoptosis, cellular proliferation, and cellular senescence as well. cellular proliferation compensates for increased alveolar cell apoptosis in chronic obstructive pulmonary disease (copd) patients. however, smoking, age, and the increased cell cycle turnover that compensates for apoptosis accelerate alveolar cell senescence, thereby halting cellular proliferation and tipping the balance toward apoptosis, which, in turn, promotes the formation of emphysematous lesions. as a result, alveolar cells disappear and the emphysematous lesions progress. at the same time, cellular senescence is thought to induce infl ammation. more specifi cally, senescent alveolar cells induce infl ammation by producing various infl ammatory cytokines in tissue. lymphocytes and clara cells may also age more rapidly in the lungs of copd patients. lymphocyte senescence may induce an autoimmune reaction and increase susceptibility to infection, and clara cell senescence may impair airway regeneration as well as sustain airway infl ammation. thus, cellular senescence may be involved in arrested tissue repair, chronic infl ammation, and increased susceptibility to infection, which are the typical features of copd. there is increasing recognition that copd is an increasing global burden. new drug treatments continue to emerge suggesting that copd is more responsive to treatments than previously thought. however, there is still much that is unknown about copd that will contribute to further advances in treatment and management. pulmonary imaging can contribute by providing information on how structure and function relate to relevant clinical parameters, such as disease progression, treatment responses and exacerbations. in other words, imaging can help characterise copd in terms of clinical outcomes or phenotypes. there have been many advances in imaging methodology, including ct, mri, spect and pet. recent fi ndings from research studies using innovative methods of studying structure and particularly function, in copd will be reviewed. their clinical implications will be discussed. the spectrum of children's interstitial lung disease (child) encompasses a large, heterogeneous group of pediatric diffuse lung disorders that are diffi cult to diagnose and treat. as the differential diagnosis is large, a systematic approach is needed for accurate diagnosis. the classic fi rst step of obtaining a detailed history and performing a careful physical examination remains essential for providing diagnostic clues as well as assessing severity of illness. as examples, a history of hemoptysis and fatigue would suggest an alveolar hemorrhage syndrome; exposure to avian antigens, hypersensitivity pneumonitis; and a history of adenovirus pneumonia, bronchiolitis obliterans. the presence of growth failure, crackles, loud p , and clubbing on physical examination would point to a severe and progressive lung process with cor pulmonale. recent advances in diagnostic modalities have greatly improved the ability of clinicians to identify these disorders. in infants and children with diffuse lung disease, genetic testing can be diagnostic for surfactant dysfunction mutations (sp-b, sp-c, abca , ttf- , gm-csfra receptor). infant lung function testing has proven useful for assisting in the diagnosis of certain disorders, such as neuroendocrine cell hyperplasia of infancy (nehi) and distinguishing nehi from surfactant mutations. hrct may detect extent and severity of disease, but can also be useful in diagnosing specifi c disorders, such as nehi (symmetric ground glass densities in the right middle lobe and lingula and the central lung regions), bronchiolitis obliterans (mosaic perfusion, vascular attenuation, and central bronchiectasis), hypersensitivity pneumonitis (ill-defi ned centrolobular micronodules), and pulmonary alveolar proteinosis (crazy-paving). bronchoalveolar lavage can aid in the diagnosis of specifi c conditions, such as alveolar hemorrhage syndromes (hemosiderin-laden macrophages), aspiration (lipid-laden macrophages), hypersensitivity pneumonitis and sarcoidosis (lymphocytosis), eosinophilic pneumonias (eosinophilia), and histiocytosis (cd a + cells). lung biopsy performed by video-assisted thoracoscopic surgery (vats) has largely supplanted conventional open lung biopsy as the procedure of choice as it is equally accurate, but associated with less morbidity. although lung biopsy remains the gold standard for diagnosis of child, it must be interpreted in the context of the clinical and radiologic fi ndings. it should be emphasized that although lung biopsy can be diagnostic in some disorders, such as bronchiolitis obliterans, it may not be necessary because less invasive studies such as hrct may be suffi cient for diagnosis. finally, some pulmonary vascular disorders, such as pulmonary vein stenosis or atresia, may mimic child. for these disorders, echocardiography, mra, or cardiac catheterization may be required for diagnosis. with a systematic approach and improved diagnostic capabilities, it is reasonable to expect that a specifi c diagnosis can now be made in the vast majority of child cases. key: cord- -l k authors: finke, jürgen; bertz, hartmut; kaskel, anna-katharina; heinz, jürgen; thomas, a.k.; berger, dietmar p.; engelhardt, rupert; schmah, oliver title: hematology and hemostasis date: journal: concise manual of hematology and oncology doi: . / - - - - _ sha: doc_id: cord_uid: l k nan destruction / suppression of hematopoietic stem cells or progenitor cells caused by various factors is of central importance: • activation of the immune system with primary or secondary (immunologically induced) bone marrow aplasia with activated cytotoxic t-cells, which cause destruction of cd -positive progenitor cells via: -direct t-cell-mediated cytotoxicity -production of ifnγ and tnfβ -induction of fas receptor and antigen → apoptosis induction • direct dna damage (e.g., irradiation) • cellular membrane damage and interference with the cellular metabolism (e.g., viral infection) • drug-induced: direct toxicity or hapten-mediated autoimmune reaction • secondary clonal expansion of hematopoiesis • nk cells ↓ (as with other autoimmune diseases) • fanconi's anemia: chromosomal instability based on multiple genetic defects (fanconi anemia genes fanc a-l). characteristics are: progressive bone marrow aplasia, increased incidence of malignancy, and abnormalities in skin, musculature, skeletal system, and urogenital system. in > % of cases, manifestation is during infancy. • increased incidence of aplastic anemia in the presence of hla a , dr , dr , and dpw . • pnh association ( chap. . • antibiotics (particularly sulfonamides, chloramphenicol), antimalarial drugs • thyreostatics, antidiabetics • antirheumatics, nsaids (e.g., phenylbutazone, gold) • diuretics (furosemide), ticlopidine, nifedipine • antiepileptics (e.g., carbamazepine, phenytoin) • cytotoxic compounds (e.g., busulfan) • aromatic solvents (e.g., benzene) • insecticides (lindane, ddt, etc.) • parvovirus b (isolated erythropoietic aplasia, "pure red cell anemia") • hepatitis (non-a-b-c-g hepatitis, poor prognosis, mostly young men) • ebv (infectious mononucleosis, rare) • hiv • complete blood count: bi-or trilineage cytopenia, generally without pathological morphology, increased granulation, neutropenia, monocytopenia, and eosinopenia; reticulocytes ↓; in cases of thrombocytopenia: small platelets • ferritin, haptoglobin, coombs' test, blood group, coagulation parameters • esr, total protein, electrophoresis, immunoglobulins, immunofixation, cold agglutinins, rheumatoid factor, ana • pnh exclusion (ham's test, sugar water test, gpi-linked proteins, cd , cd ) • vitamin b , folic acid (exclusion of megaloblastic anemia) • liver function (exclude past history of hepatitis) • serology (ebv, cmv, hav, hbv, hcv, hiv, hsv, parvovirus b ) • hypocellular (cellularity < %) with predominance of fat cells • lymphocytes, macrophages, and plasma cells present • cd -positive progenitor cells ↓; in bone marrow cultures, reduced colony formation (cfu-gm, colony-forming units -granulocytes / macrophages) and ltcic (long-term culture-initiating cells). improved growth pattern in t-cell-depleted cultures (→ t-cell-mediated reaction?) • chest x-ray, abdominal sonography • hla typing (in cases of potential transplantation) • cytogenetics, chromosome analysis (exclusion of mds, fanconi's anemia) • increased serum levels of hematopoietic growth factors: g-csf (granulocyte colony-stimulating factor), tpo (thrombopoietin), m-csf, and erythropoietin; scf (stem cell factor) not increased • myelodysplasia with hypoplastic bone marrow ( chap. . ) • primary myelofibrosis (pm) ( chap. . . ) • vitamin b deficiency, folic acid deficiency ( chap. . . ) • paroxysmal nocturnal hemoglobinuria (pnh) ( chap. . . ) • leukemias, lymphomas, solid tumors with bone marrow infiltration • development of pnh in % of cases ( chap. . . ) • transformation into mds or acute leukemia in - % of cases ( chaps. . . , . . , . ) indications for treatment hematology and hemostasis • infection prophylaxis, antibiotics, amphotericin b prophylaxis • oral hygiene • prophylaxis / therapy of hemosiderosis (desferrioxamine mesylate) • granulocyte transfusions ( chap. . ) • suppress menses, avoid platelet aggregation inhibitors • blood products (cmv negative, irradiated); erythrocyte transfusions according to symptoms, platelet transfusions for counts below , - , /µl • growth factors: granulocyte colony-stimulating factor (g-csf), erythropoietic factors attention: use blood products as sparingly as possible until decision on bmt / pbsct is made (danger of alloimmunization). do not use blood products from relatives. transplantation types ( chaps. . , . ) • in patients under years of age, allogeneic hematopoietic stem cell transplantation (hsct) from hla-identical related (family) donors in conjunction with fludarabine / cyclophosphamide-containing protocols • matched unrelated donor (mud) transplantation recommended only in patients under years of age • most common form: drug-induced toxic suppression of granulopoiesis or direct neutrophilic damage ("delayed onset neutropenia, " e.g., after radio-or chemotherapy), usually with simultaneous thrombocytopenia ( chap. . ) • drug-induced allergic reactions with destruction of neutrophils, often caused by metabolites • usually, rapid granulocyte decrease within week after exposure; in case of re-exposure, within hours. destruction of mature granulocytes ("abrupt onset neutropenia"), acute onset with fever and chills (dd: infection). causative agent: e.g. phenylbutazone • in rare cases, slow decrease, between and months after the beginning of treatment, due to destruction of hematopoietic progenitor cells. causative agent: e.g., clozapine, in patients with hla phenotype b and alleles dr and dqw • autoimmune diseases: t-cell-mediated inhibition of granulopoiesis (felty's syndrome, rheumatoid arthritis) or as a result of clonal t-cell expansion in patients with t-γ-lymphoproliferative disease ("t-γ-disease") • complement activation (e.g., with hemodialysis, sepsis): expression of adhesion molecules on the surface of neutrophils → neutrophilic aggregation, capillary occlusion (esp. pulmonary capillaries) • pseudoneutropenia ("shift neutropenia"): neutrophilic redistribution (shift) from the peripheral blood into the tissues, e.g., with infections • congenital dysgenesis with familial pancytopenia • reticular dysgenesis with congenital aleukocytosis: agranulocytosis + lymphoid hypoplasia + thymic aplasia; unknown etiology • periodic neutropenia: stem cell regulation defect; neutropenic phases in -to -day intervals, compensatory monocytosis; autosomal dominant inheritance • kostmann's syndrome: severe agranulocytosis in children (abnormal differentiation in the promyelocytic stage), reversible by administration of g-csf (attention: possibly higher risk of mds / aml development); autosomal dominant or recessive inheritance • x-linked agammaglobulinemia • schwachman-diamond-oski syndrome: neutropenia + pancreatic insufficiency + metaphyseal dysplasia; unknown etiology; autosomal recessive inheritance • neutropenia with bi-/ tetraploid leukocytes: abnormal phagocytosis and chemotaxis as well as bi-and tetraploid granulocytes • chédiak-higashi syndrome: albinism + neurological disorders + leukocytic granulation abnormalities; unknown etiology • dyskeratosis congenita: neutropenia, skin abnormalities; x-linked inheritance • lazy leukocyte syndrome: chemotaxis defect (actin defect); unknown etiology • cytostatic treatment, immunosuppressives, azidothymidine (azt), benzenes, ionizing radiation • idiosyncratic drug reactions (individual sensitivity) in % of cases: antibiotics (penicillin, chloramphenicol, cephalosporins, sulfonamides) , sulfasalazine, nonsteroidal antirheumatics (ibuprofen, indomethacin, phenylbutazone), phenothiazine, thyreostatics, quinidine, procainamide, propafenone, ticlopidine, antihistamines, anticonvulsives, nifedipine, levamisole, tamoxifen, allopurinol, tranquilizers, neuroleptics (clozapine), gold, captopril + interferon • bone marrow aspiration, biopsy and culture (cfu) • abdominal sonography (spleen), chest x-ray (exclusion of infection) • leukemia ( chaps. . . , . . ) • myelodysplasia ( chap. . ) • primary myelofibrosis ( chap. . . ) • aplastic anemia ( chap. . ) • susceptibility to infections, fever ( chap. . ) • mucositis, gastroenteritis ("neutropenic enterocolitis") • hygiene, anti-infectious environment, isolation • mucositis prophylaxis • selective intestinal decontamination • oral antimycosis (e.g., fluconazole mg/day p.o.) • signs of infection: blood cultures, urine and stool cultures, swabs, immediate start of empirical antibiotic treatment ( chap. . ) • with severe infections: granulocyte transfusion ( chap. . ) • discontinue all drugs administered within weeks of onset of symptoms • g-csf (filgrastim, lenograstim) - µg/kg daily s.c. treatment according to the assumed pathogenic causes, e.g.: • in patients with clinically relevant recurrent infections, g-csf may be used as long-term treatment • use of other hematopoietic growth factors in clinical studies: gm-csf, il- , stem cell factor (scf) • in cases of autoimmune neutropenia: -prednisolone mg/kg daily p.o. (maximum weeks) -cyclosporin a (serum level target: - ng/ml): initial treatment over at least weeks; if successful, continue for at least months -azathioprine - mg/kg daily • with hypersplenism: consider splenectomy (only after pneumococcus vaccination) • in cases of congenital neutropenia: consider allogeneic transplantation ( chap. web: web: . neutropenia and agranulocytosis decreased platelet count (< , /µl), most common cause of hemorrhagic diatheses. • thrombopoiesis: megakaryoblasts → megakaryocytes → platelets; regulated by thrombopoietin and other cytokines (e.g., il- , il- , il- ) • directly after being released by the bone marrow, approximately one third of platelets are reversibly stored in the spleen ("pool") • two thirds of platelets circulate in the blood, life span - days, biological half-life - days; % of these platelets are spent daily to maintain hemostasis splenomegaly (portal hypertension, splenic infiltration with hematological neoplasia). • heart valve and vascular prostheses • extracorporeal circulation (surface activation) • immune thrombocytopenia (itp) ( chap. . . ) • microangiopathic disorders: hemolytic-uremic syndrome (hus) , thrombotic-thrombocytopenic purpura (ttp) ( chap. . . ) • disseminated intravascular coagulation (dic) ( chap. . . ) • disturbances in platelet and coagulation factor interaction: von willebrand's disease type iib, heparin-induced thrombocytopenia (hit) ( chap. . bone marrow aspiration and biopsy: megakaryocytes ↓ in case of dysfunctional thrombopoiesis, megakaryocytes normal or ↑ in cases of peripheral platelet loss. attention: if platelet count < , /µl: risk of hemorrhage → iliac crest biopsy (no sternal puncture), apply careful pressure imaging chest x-ray (lymphomas, infections), abdominal sonography (lymphomas, spleen) note: if plasmatic coagulation and blood vessels are normal, there is only a low risk of hemorrhage with a platelet count of > , - , /µl. "pseudothrombocytopenia": formation of platelet aggregates in edta blood: . - % of blood samples; cause: autoagglutinating igg antibodies → in vitro platelet aggregation in the presence of the anticoagulant agent edta → false low count by automatic platelet counter → repeat platelet count with citrated or heparinized blood • therapeutic: at signs of bleeding or acute hemorrhage (e.g., petechiae, hemorrhage of mucous membranes or epistaxis) with proven thrombocytopenia or thrombocyte dysfunction. • prophylactic: platelet count < , - , /µl. with concomitant diseases (especially acute leukemia, fever, sepsis, splenomegaly) risk of hemorrhage with higher platelet counts ( , - , /µl). with invasive interventions (e.g., catheter installation, punctures) the platelet count target is > , - , /µl. to avoid alloimmunization, transfusions should be avoided in patients scheduled for allogeneic hematopoietic stem cell transplantation. acquired thrombocytopenia, platelet count < , /µl. classic definition: itp = idiopathic thrombocytopenic purpura. diagnosis by exclusion; acquired thrombocytopenia of unknown etiology with normal to increased megakaryocyte count in the bone marrow. alternative definition: itp = immune thrombocytopenic purpura. acquired thrombocytopenia caused by antithrombocytic antibodies. incidence: - cases / , population / year. distribution male:female = : . igg-mediated immune reaction (rarely igm) against platelet membrane antigens, e.g., gpiib / gpiiia (fibrinogen receptor), gpib / ix (von willebrand receptor), and gpia / iia (collagen receptor). • specific platelet antibodies detectable in approximately - % of cases • macrophage binding via fcγ i, ii, and iii receptors (in itp patients: receptor polymorphism with altered binding affinity for igg) • complement activation • complement-mediated lysis and enhancement of phagocytosis → res phagocytosis of igg-coated platelets, esp. in spleen → biological half-life of platelets ↓↓ to a few hours • decreased thrombocytopoiesis (antibodies against megakaryocytes and thrombopoietic progenitor cells) • possibly t-cell-mediated process (in vitro, cd + t-cells can be activated by platelets) • without known causative disease ("primary itp") • in conjunction with an underlying disease ("secondary itp"): lymphoproliferative diseases, autoimmune diseases (systemic lupus erythematosus, etc.), viral diseases (e.g., hcv, hiv), bacterial infections (esp. in children), after bone marrow transplantation • children: in > % of cases, "acute" course: severe thrombocytopenia, usually spontaneous remission within months • adults: in > % of cases, "chronic" course (thrombocytopenia > months): < % risk of fatal hemorrhages (esp. intracranial), rarely spontaneous remission ( %), persists for more than months despite adequate treatment in % of patients thrombocytopenia with normal differential and morphology. normal or reactively increased megakaryocyte count, increased number of immature megakaryocytes. otherwise, normal bone marrow, no abnormal cells. • rare with platelet count > , /µl . itp • petechial type of hemorrhage (skin, mucous membranes), with hematomas / bruising / epistaxis • complication: intracerebral hemorrhage (rare), organ bleeding, retinal bleeding, gastrointestinal bleeds the diagnosis of itp is a diagnosis of exclusion. therefore, the diagnostic strategies are aimed at identifying potential underlying causes of secondary thrombocytopenia. • medical history, family history, drug exposure, occupational hazards • physical examination (petechiae, bruising, mucosal bleeds) • full blood count with differential • virology: hcv / hiv serology in patients at risk • screening for platelet antibodies ( % positive) bone marrow biopsy and smear in accordance with recommendations of ash (american society of hematology) and bcsh (british committee for standards in hematology): • patients over years of age • laboratory abnormalities (neutropenia, anemia) • prior to splenectomy • poor response to primary treatment. differential diagnosis of thrombocytopenia chap. . only a small number of randomized studies have been conducted in itp. the life expectancy of itp patients with a platelet count > , /µl is equal to that of the normal population. with higher platelet counts ( , /µl), treatment is therefore only indicated if blood loss is expected (perioperatively, before delivery) or in the case of active hemorrhage. • initial response rate > %, long-term effect in % of patients, low-dose maintenance treatment is required in most cases • prednisolone - mg/kg daily, duration of treatment depending on response, or dexamethasone mg/d for days • with durable platelet response: dose reduction of prednisolone over - weeks, monitoring of platelet counts • if no increment to > , /µl within - weeks or required steroid dose markedly above the threshold dose for cushing's disease → change treatment to immunoglobulins or alternative immunosuppressive drugs • initial response rate %, normalization of the platelet count in % of patients; however, only transient (up to weeks) • standard dose: . g/kg daily i.v. days - or g/kg daily i.v. day + • alternative: anti-d igg in rh-positive patients, µg/kg body weight over - days. disadvantage: i.v. product not available in all countries, high costs in cases of severe or life-threatening hemorrhage: combined administration of methylprednisolone g daily i.v. over days and immunoglobulins . - g/kg daily over - days, platelet transfusion. due to the short platelet half-life in itp, the expected platelet need is approximately - times higher than in other forms of thrombocytopenia. in patients with uncomplicated itp, platelet transfusions are, generally not indicated. thrombopoietic agent, binds to tpo receptor and stimulates platelet production of the bone marrow. in phase iii studies in itp, platelet responses in - % of cases. starting dose µg/kg once weekly s.c., dose adjustment according to platelet counts. • immunoapheresis • rituximab (cd antibody) . itp acquired heparin-induced thrombocytopenia d . incidence of hit type ii (see below) with intravenous use of unfractioned heparin (ufh): - %, with use of low-molecular-weight heparin (lmwh): < . %. • dose-dependent mild early-onset thrombocytopenia (platelet count , - , /µl) in the initial - days of heparin treatment (ufh / lmwh) • caused by minor heparin-induced platelet aggregation, no immunological genesis • usually self-limiting (after - days) while heparin administration is ongoing • frequency of up to % • dose-independent late-onset thrombocytopenia, - days after start of heparin treatment (ufh / lmwh). in patients previously exposed to heparin (< days), reoccurrence within hours • severe thrombocytopenia (platelets < , /µl), median platelet count approximately , /µl, rarely < , /µl or decreased to < % of the initial count; worsening of thrombocytopenia if heparin treatment is continued • thromboembolic complications up to days after heparin administration • igg antibodies mostly against the platelet factor (pf )-heparin complex → immune complex formation → platelet activation due to binding of the immune complex to the fc receptor (fcγ riia), pf release → platelet aggregation, endothelial cell damage, thrombin activation → thromboembolic complications ("white clot syndrome") clinical relevance: hit type ii: • main symptom: thrombophilia, not hemorrhage • warning signs: exanthema or necrosis at injection site • high incidence (up to %) of venous and arterial thrombosis, renal dysfunction, pulmonary embolism, infarction (complications may occur weeks after discontinuation of heparin) • exclusion of other causes of thrombocytopenia ( chap. . ). • combination of a functional test (e.g., heparin-induced platelet activation, hipa) with elisa (detection of pf -heparin complexes). • attention: if hit ii is clinically suspected, discontinue heparin immediately and use alternatives, even without positive test. the diagnosis of hit is based on clinical findings. tests serve as confirmatory tools only. exclude other causes of thrombocytopenia ( chap. . ) therapeutic intervention (with hit type ii): • discontinue heparin treatment (ufh / lmwh). attention: exclude exposure to "hidden" heparin, e.g., coagulation factor products, "heparin lock" of central catheters • anticoagulation must be continued for at least weeks, using: − danaparoid sodium: heparin-free heparinoid, atiii-mediated inhibition of factor xa, half-life h, renal elimination, monitoring via factor xa levels, no antidote available − hirudin derivatives, e.g., lepirudin: bivalent direct thrombin inhibitor, half-life . h, renal elimination, monitoring via ptt, no antidote available . hit thrombocytopenic thrombotic microangiopathies with hemolytic anemia (microangiopathic hemolytic anemia, maha). subtypes: • thrombotic-thrombocytopenic purpura (ttp, moschcowitz disease): main symptoms are microangiopathic hemolytic anemia, thrombocytopenia, and neurological symptoms; renal dysfunction in % of cases • hemolytic-uremic syndrome (hus, gasser's disease): main symptoms are acute renal failure (renal microangiopathy, glomeruli are particularly affected) and hemolytic anemia; thrombocytopenia and neurological symptoms are less pronounced than in ttp • toxic microangiopathic hemolytic anemia (toxic maha): after treatment with mitomycin c or high-dose chemotherapy it is not yet clear whether ttp and hus are separate diseases or whether they are different manifestations of one syndrome. due to the frequently overlapping symptoms, the more commonly used term is ttp-hus (in adult patients). exception: hus in children after e. coli infection. ttp: age peak - years, distribution male:female = : hus: incidence - cases/ , children/year, age peak - years, distribution male:female = : • acquired or congenital (total) dysfunction of the vwf-cleaving protease (= adamts ; a disintegrin and metalloprotease with thrombospondin type- motifs; cleaves vwf between the amino acids and ), with unusually large von willebrand factor multimers (ul-vwf-m), particularly in chronically recurrent ttp • acquired ttp: autoimmune disease with anti-vwf protease autoantibodies • associated with infections (hiv), pregnancy, postpartum, after allogeneic bone marrow transplantation, drugs (mitomycin c, cyclosporine, ticlopidine, clopidogrel, quinine), autoimmune diseases (sle) • normal vwf protease activity. • commonly associated with gastrointestinal infections caused by shiga toxin or verotoxin-producing escherichia coli (serotypes oh, particularly o :h , o :hu, o :h ), rarely shigella (shigella dysenteriae serotype i). • in the absence of gastrointestinal infections, hus is probably complement-mediated and occurs in connection with autosomal recessively inherited factor h mutations. in sporadic forms, factor h autoantibodies are thought to be involved. in this case, association with glomerulonephritis type ii and involvement of autoantibodies against c convertase. under physiological conditions, vwf multimers are excreted by endothelial cells and deposited subendothelially. in the case of endothelial damage → complex formation of vwf multimers with thrombocytes → thrombocyte aggregation due to binding to platelet glycoproteins ib, ix, and v as well as activated gp iib/iiia. in cases of thrombotic microangiopathies, platelet aggregates or microthrombi are formed in capillaries and small vessels causing infarction, particularly in cns and kidney. • thrombocytopenia due to peripheral destruction • anemia due to mechanical destruction of erythrocytes in partially thrombosed small vessels (fragmentocytes, ldh ↑, haptoglobin ↓↓). . ttp-hus thrombotic microangiopathies constitute a hematological emergency → immediate specific treatment is of vital importance. without adequate treatment, the mortality rate is %. • plasma exchange via pheresis with fresh frozen plasma (ffp) initially ml/kg daily • aim: depletion of vwf multimers and autoantibodies, substitution of vwf protease (t½ > h) through ffp or as cryoprecipitate • success parameters: normalization of ldh and platelets, regression of neurological symptoms; once laboratory parameters have normalized, lengthening of pheresis intervals • if symptoms persist: increase pheresis frequency to twice daily or raise volume to ml/kg (in individual cases, as much as ml/kg/day may be indicated → however, twice daily pheresis seems to be more effective); in addition, prednisone ( mg/kg/day) or methylprednisolone ( mg i.v. twice daily) and possibly vincristine or immunoglobulins • pheresis is often accompanied by moderate citrate toxicity (muscle cramps, tetany) → calcium replacement • even with adequate treatment, full reconstitution of renal function may be delayed • with suspected acquired ttp: prednisolone × mg/day i.v. or p.o. over week, withdraw gradually over a period of at least weeks • patients with acquired antibody-mediated ttp who respond insufficiently to plasmapheresis or have relapsed: additional immunosuppressive treatment, e.g., splenectomy, immunoadsorption via protein a column, possibly azathioprine or other immunosuppressives (e.g., anti-cd antibody rituximab ± cyclophosphamide, cyclosporine). • congenital vwf protease deficiency: treatment according to symptoms: replacement of vwf protease ± plasmapheresis, prophylactic platelet aggregation inhibitors may be required with platelet recovery. platelet transfusion only after careful benefit-risk assessment (e.g., life-threatening hemorrhage) → possible deterioration of symptoms (increased intravascular thrombus formation). . ttp-hus reduced hemoglobin concentration and hematocrit. red blood cell (rbc) number below normal level. substitution of packed red blood cells: restrictive indication ( chap. . . ). • individual assessment of transfusion indication for each patient. • in acute blood loss, consider indication when hemoglobin < . g/dl. • with chronic anemia lower levels of hemoglobin ( - g/dl) are generally tolerated. • patients with coronary heart disease or risk of cerebral ischemia: transfusion indication at hemoglobin < g/dl. • specific conditions (surgery, thalassemia major, etc.) may require rbc transfusion support. the indication for transfusion is based on clinical symptoms. asymptomatic blood loss does not constitute an indication for transfusion. anemias with decreased corpuscular hemoglobin (mch < pg) and decreased corpuscular hemoglobin concentration (mchc < %): • iron deficiency anemia (> % of hypochromic anemias) • anemia of chronic disease (inflammation-/ infection-/ tumor anemia) • thalassemia ( chap. . . ) • rare causes: vitamin b deficiency, lead intoxication iron deficiency anemia most frequent form of anemia. proportion male:female = : . about - % of women in childbearing age demonstrate latent iron deficiency. daily iron resorption required: men mg, women and adolescents - mg, pregnant women - mg. about - % of body iron store bound in hemoglobin, additional % in myoglobin. g hemoglobin contains . mg of iron. in iron deficiency the iron need is greater than the available iron supply, resulting in hemoglobin synthesis disorders → microcytic, hypochromic erythrocytes. • ferritin serum : correlates with total iron (↓ in iron deficiency) • transferrin serum : correlates with circulating iron and need (↑ in iron deficiency) most important cause: loss of iron due to chronic bleeding → in manifest iron deficiency evaluation of underlying cause is of central importance. microcytic, hypochromic erythrocytes, poikilocytosis, anisocytosis, anulocytes. iron stain (prussian blue stain): storage iron not detectable (ferritin, hemosiderin). • skin and nail changes: skin atrophy, spoon-shaped nails (koilonychia) • oral rhagades, impairment of mucous membranes, in extreme cases painful mucous membrane atrophy of tongue, pharynx, and esophagus with dysphagia (plummer-vinson syndrome) • history, esp. infections, drugs, bleeding, nutritional habits • physical examination: including skin, mucous membranes, lymph node status, spleen / liver, heart (tachycardia, particularly systolic murmur), rectal examination with fecal blood test, urine dipstick • gynecological examination • endoscopy: esophago-gastro-duodenoscopy, colonoscopy, rectoscopy • hematology: blood count, mcv ↓, mch ↓, reticulocytes, differential blood count • clinical chemistry: routine tests with bilirubin, renal function parameters, iron status (iron ↓, ferritin ↓, transferrin-binding capacity ↑) • blood group (if red cell substitution necessary) • iron resorption test (if resorption deficiency is suspected) in inconclusive cases eventually bone marrow aspiration / biopsy, including iron staining, to exclude other causes of anemia. • anemia of chronic disease (iron ↓, ferritin normal or elevated, transferrin-binding capacity ↓) • thalassemia (mcv ↓↓, iron, ferritin, and transferrin-binding capacity normal) • hemolytic anemia (bilirubin, ldh, haptoglobin, coombs' test) treatment of anemia with iron deficiency always requires a combined approach: . treatment of the underlying cause of iron deficiency (e.g., chronic blood loss) . iron substitution • application of ferrous ii preparation, e.g., fe(ii) sulfate, fumarate, gluconate, or succinate, - mg/day p.o., for - months. • pkin: oral bioavailability, depending on preparation, - %, better bioavailability when taken prior to food. • se: gastrointestinal tract symptoms (nausea, vomiting,), dark discoloration of stool (atten-tion misdiagnosis: upper gastrointestinal bleeding). • treatment monitoring: after - days reticulocytes ↑, hemoglobin ↑. most frequent cause of a treatment failure is lack of compliance, followed by combined anemia (e.g., coexisting iron deficiency and lack of vitamin b ). • parenteral application of iron should be limited to individual cases (e.g., in malabsorption syndrome), due to severity of side effects. • strictly intravenous application of ferrous(iii) preparations, consider premedication with steroids and antihistaminics. • se: thrombophlebitis, headache, flush, nausea, vomiting, fever, allergic reactions up to anaphylaxis. with paravenous injection local pain and visible iron deposits in tissue. application of packed red blood cells is generally not indicated in iron deficiency anemia. exceptions exist in patients with additional blood loss and clinical symptoms. second most common form of anemia (after iron deficiency anemia). multifactorial anemia with chronic underlying disease (malignancy, inflammation, infection, collagen diseases). pathogenetic factors: • cytokine-mediated (tnfα, interleukin- , interferon γ) → erythrocyte-survival time ↓, interference with iron mobilization from reticuloendothelial iron stores (macrophages), iron uptake / utilization in normoblasts ↓, erythropoietin secretion and effect ↓, inhibition of erythroid progenitor cells, etc. • treatment-associated (drugs, radiation therapy, etc.) • consequence of underlying disease normochromic, normocytic or hypochromic, microcytic red blood cells, poikilocytosis, anisocytosis. • pallor of skin and mucous membranes, nail beds, conjunctivae • weakness, tiredness, reduced performance, exertional dyspnea • lack of concentration, headache depending on disease, generally with • tiredness, weakness, reduced performance • fever, weight loss, night sweats (b symptoms) • loss of appetite, myalgia, arthralgia, etc. in inconclusive cases consider bone marrow aspiration / biopsy, including iron staining, to exclude other causes of anemia. anemia with increased erythrocyte volume (mcv > fl), usually caused by lack of vitamin b (cobalamin) and/or folic acid. incidence - cases/ , population/year, distribution male:female = : , age peak years the reference nutrient intake (rni) for vitamin b is µg, with maximum daily absorption in the terminal ileum of - µg. "intrinsic factor" (glycoprotein) is a prerequisite for vitamin b resorption. • cofactor in the synthesis of succinyl coa, methionine, and tetrahydrofolic acid • in case of vitamin b deficiency: → dna synthesis and fatty acid metabolism impaired → delayed nuclear maturation, normal cytoplasmic development → ineffective myelopoiesis, large cells with altered nucleus: plasma ratio • most frequent cause: pernicious anemia ( % of cases): autoimmune atrophic gastritis with antibodies against gastric parietal cells ( % of cases) and/or antibodies against intrinsic factor ( % of cases) → achlorhydria, intrinsic factor deficiency → decreased vitamin b resorption in the terminal ileum • insufficient vitamin b uptake (strict vegetarians, alcoholics) • postoperatively (gastrectomy, resection of the terminal ileum, blind loop syndrome) • vitamin b malabsorption, rare (crohn's disease, scleroderma, amyloidosis) • infections / parasites (fish tapeworm, bacterial gastrointestinal infections) macrocytic hyperchromic erythrocytes, poikilocytosis, anisocytosis, hypersegmented granulocytes (right shift); in severe cases, granulocytopenia and thrombocytopenia. megaloblastic changes: ineffective left-shifted erythro-, thrombo-, and granulopoiesis, pronounced erythropoiesis with increased numbers of immature erythroid precursors (erythropoietic hyperplasia with megaloblastic erythroblasts), giant band forms, immature megakaryocytes. • pale skin and mucous membranes, icterus (due to intramedullary hemolysis) • weakness, fatigue, reduced performance, dyspnea on exertion • difficulty concentrating, headache in advanced cases: funicular myelosis: neuropathy caused by symmetrical damage of the posterior columns of the spinal cord, the corticospinal tract and peripheral nerves; motor abnormalities mainly affecting the lower extremities; staggering gait, ataxia, spastic paresis, impaired vision, psychological disorders. • type a gastritis • trophic disorders of the skin and mucous membranes: hunter's glossitis, etc. • sterility (gonad dysfunction), reversible • medical history: infections, drugs, hemorrhage, nutritional habits • physical examination: skin, mucous membranes, lymph node status, spleen / liver, heart (tachycardia, in some cases: systolic cardiac murmur), rectal examination and test for fecal blood, neurological examination • hematology: blood count with mcv (↑), mch (↑), reticulocytes (↓), differential blood count • clinical chemistry: liver and renal function tests, total protein, hemolysis parameters (bilirubin ↑, ldh ↑↑, haptoglobin ↓ due to intramedullary hemolysis) • antibodies against gastric parietal cells and/or against intrinsic factor • vitamin b serum level (normal: - pg/ml), folic acid serum level • vitamin b absorption test (schilling's test): oral administration of radioactive b ± intrinsic factor, determination of urinary vitamin b , comparison of vitamin b absorption / excretion with and without intrinsic factor • blood group (if red cell transfusion is necessary) • gastroscopy: detection of chronic atrophic gastritis, exclusion of gastric carcinoma (incidence times higher with chronic atrophic gastritis) • bone marrow aspiration / biopsy to confirm megaloblastic abnormalities • alcoholism (most common cause of a macrocytic blood count) • hepatic disorders, severe hypothyroidism • reticulocytosis, myelodysplasia ( chap. hydroxycobalamin mg i.m. → initially: injections within - weeks (to replenish vitamin b stores), then: one injection every months. additionally: application of ferrous ii preparation and folic acid to cover increased erythropoesis during substitution phase. attention: close monitoring during the first days of treatment: critical increase in reticulocytes and platelets possible → increased risk of thrombosis, potassium and iron deficiency. gastroscopy at regular intervals due to increased risk of gastric cancer. reference nutrient intake (rni) for folic acid: - µg, during pregnancy µg. • folic acid is a cofactor of thymidylate synthesis (c transfer), i.e., dna synthesis • in case of folic acid deficiency: → disorder of dna synthesis → delayed nuclear maturation with normal cytoplasmic development → ineffective myelopoiesis, giant cells with an abnormal nucleus: plasma ratio • insufficient folic acid intake: nutritional deficiency, alcoholism, anorexia nervosa • malabsorption: gluten-induced enteropathy, tropical sprue, crohn's disease, scleroderma, amyloidosis, postoperatively (small bowel resection, gastrectomy) • increased demand: pregnancy, chronic hemolytic anemia, chronic inflammatory disease, or malignancies • loss of folic acid: hemodialysis • drug-induced (with folic acid antagonists): methotrexate, trimethoprim, pyrimethamine, phenytoin, triamterene see vitamin b deficiency anemia • pale skin and mucous membranes, icterus (due to intramedullary hemolysis) • weakness, fatigue, reduced performance, dyspnea on exertion • difficulty concentrating, headache • folic acid deficiency during pregnancy: increased incidence of neural tube defects (spina bifida, anencephaly) • sterility (gonadal dysfunction), reversible • hematology: blood count with mcv (↑), mch (↑), reticulocytes (↓), differential blood count • clinical chemistry: liver and renal function tests, total protein, hemolysis parameters (bilirubin ↑, ldh ↑, haptoglobin ↓ due to intramedullary hemolysis) • vitamin b level, folic acid level (normal: - ng/ml) • blood group (if red cell transfusion is necessary) • esophago-gastro-duodenoscopy: exclusion of gluten-sensitive enteropathy (sprue) • bone marrow aspiration / biopsy to confirm megaloblastic abnormalities see vitamin b deficiency anemia anemia caused by erythrocyte destruction characterized by decreased erythrocyte survival (< days) in the bone marrow, × erythrocytes are produced per day; median erythrocyte survival: days; erythrocyte destruction in spleen and liver (reticuloendothelial system, res). generally, normochromic normocytic anemia with normal leukocytes and platelets; characteristic changes in cases of hereditary membrane defects (spherocytes, elliptocytes, etc.); anisocytosis, poikilocytosis, and, in some cases, fragmentocytes. . hemolytic anemia erythropoietic hyperplasia, increase in erythroblasts. consider bone marrow aspiration / biopsy, including iron stain, to exclude other causes of anemia. therapeutic options depend on the anemia subtype. treatment components are: • supportive treatment: red cell transfusion (only in individual cases with symptomatic anemia, controversial in cases of autoimmune hemolytic anemia) • treatment of underlying disease • immunosuppression (in cases of autoimmune hemolytic anemia) • splenectomy → removal of the sequestration filter for damaged erythrocytes attention splenectomy • splenectomy can correct the decrease in erythrocyte survival, but it is not a causal therapy in the sense of a correction of the triggering hemolytic defect. • prior to splenectomy, mandatory vaccination against streptococcus pneumoniae, neisseria meningitidis, and haemophilus influenzae because of the sepsis risk. • after splenectomy, prevention of thromboembolic events (platelets ↑) → low-dose heparin. most common hereditary hemolytic disease; prevalence . %; in most cases hereditary disease (autosomal dominant), spontaneous mutation is rare. rare, higher incidence in mediterranean countries / africa (increased malaria resistance of elliptocytes) heterogenic disease group with > % of elliptic erythrocytes; protein defects of the erythrocytic cytoskeleton (spectrin, protein . r) usually asymptomatic; only - % of patients have varying degrees of anemia, icterus or hemolytic crises • positive family history • blood smear with > % elliptocytes in symptomatic patients: splenectomy acquired clonal disorder of myeloid stem cells (i.e., of the erythrocytic, granulocytic, and thrombocytic line) with somatic mutations of phosphatidylinositol-glycan a (pig a) → defect of the "phosphatidylinositol-glycan anchor" (pig anchor) the pig anchor fixes various proteins to the cell membrane, including three complement-regulating proteins: cd (membrane inhibitor of reactive lysis; mirl), cd (decay accelerating factor; daf), and "c binding protein" (cbp). → changes in the pig anchor lead to a decrease in the respective proteins in the cell membrane → reduced resistance against activated complement factors → complement-mediated lysis ↑, incidence of thromboembolic events ↑ • chronic hemolytic anemia • different severity levels of nocturnal hemolysis (even nocturnal hemolytic crises), with morning hemoglobinuria • recurrent thrombosis, particularly portal vein, liver veins (budd-chiari syndrome), cerebral vessels, splenic vein, skin veins (skin necrosis) • iron deficiency anemia due to chronic loss of iron (renal) • medical history: circadian occurrence of symptoms • physical examination: anemia signs and symptoms, urinary discoloration • normochromic normocytic anemia, in some cases with granulocytopenia and thrombocytopenia • hemolysis parameters (ldh ↑, haptoglobin ↓, indirect bilirubin ↑, hemoglobinuria) • acid hemolysis test (ham's test) and sugar water test (sucrose test), pathological: complementmediated lysis after addition of sugar water or acid to the blood sample • molecular genetic proof of the pig defect in rare cases development of aplastic anemia, myelodysplasia, or aml • prophylactic anticoagulant therapy: phenprocoumon. attention: avoid heparin → possible complement activation • iron and folic acid supplementation • in cases of hemolytic crisis: corticosteroids (prednisolone - mg i.v.), supportive treatment • blood transfusion: only washed erythrocytes to avoid administration of additional complement • eculizumab, antibody against complement c , inhibits complement-mediated lysis of pnh erythrocytes allogeneic stem cell transplantation ( chap. . ): only in severe cases with repeated hemolytic crises or complications (thromboembolic events, etc.) hereditary disease, genetic modification of the glucose- -phosphate dehydrogenase (> mutants worldwide) one of the most common hereditary diseases worldwide, regional differences in incidence and prevalence. in africa, asia, and the mediterranean region, as much as - % of the population may be affected (patients are more resistant to malaria plasmodia). x-chromosomal recessive inheritance → mainly males affected. heterozygotics have two different populations of erythrocytes and usually have less pronounced symptoms. hereditary defect of the enzyme pyruvate kinase, i.e., the erythrocytic glycolysis. most common hereditary glycolytic defect (embden-meyerhof pathway), autosomal recessive inheritance. heterozygotic individuals are usually asymptomatic. homozygosis (rare) leads to hemolytic anemia. pyruvate kinase deficiency results in abnormal glycolysis: → atp deficiency → abnormal na + / k + -atpase activity in the erythrocyte membrane → membrane instability, hemolysis usually asymptomatic. in homozygotic individuals, hemolytic crises may occur. • blood smear with acanthocytes, anisocytosis, poikilocytosis • hemolysis parameters, reduced erythrocytic pyruvate kinase activity symptomatic patients: splenectomy; in cases of iron overload: venesection therapy and administration of desferrioxamine. hemoglobin s (hbs): point mutation in the β-globin locus (chromosome ) of the hemoglobin molecule in position : replacement of glutamic acid by valine (β glu → val). hbs precipitates when deoxygenated (risk factors: lack of oxygen, dehydration, fever, increased serum osmolality, stasis): → sickle-shaped erythrocytes with reduced elasticity → hemolysis, disturbed microcirculation, capillary occlusion heterozygotic individuals (hbas) are usually asymptomatic. in homozygotic cases (hbss): • hemolytic anemia and hemolytic crisis • vaso-occlusive crises: organ infarction (particularly spleen, kidney, cns), bone infarction, pulmonary hypertension • abdominal pain, bone pain, cerebral disorders, in some cases with fever, tachycardia, leucocytosis • hepatosplenomegaly, recurrent splenic infarction → "autosplenectomy, " functional asplenia • osteoporosis, growth defects due to recurrent bone infarction • pure red cell aplasia / aplastic crisis with parvovirus b infections • proliferative retinopathy → impaired vision • bilirubin gall stones • immunodeficiency (due to recurrent splenic infarction) • medical history (family history), clinical examination • hemoglobin electrophoresis • sickle cell test: erythrocytes show sickle shape after addition of sodium sulfide • molecular genetic screening (pcr) other hemoglobinopathies: more than hemoglobinopathies have been described. hb c, e, and d are the most common. sickle cell anemia is treated supportively: • fluid replacement, at least , ml/day • oxygen (via nasal tube, - l/min) • treatment of infections, analgesia • red cell transfusion, in case of severe complications: exchange transfusion • in cases of splenic infarction / hemorrhage / rupture: splenectomy • prophylactic pneumococcus vaccination • hydroxyurea prevention of lack of oxygen, dehydration, and infections. quantitative disturbance of hemoglobin synthesis due to a genetic defect in globin chain formation. subtypes: • β-thalassemia: abnormal β-chain synthesis • α-thalassemia: abnormal α-chain synthesis (rare) regional differences in incidence: β-thalassemia in mediterranean regions, africa, and asia; αthalassemia in south east asia and africa. abnormal synthesis of the hemoglobin β-chain, i.e., no formation of normal adult hba (αα/ββ). → compensatory formation of γ-or δ-chains (hbf = αα/γγ and hba = αα/δδ) → ineffective erythropoiesis (free α-globin is toxic for erythroblasts) with intramedullary hemolysis → hypochromic microcytic anemia, signs of hemolysis . hemolytic anemia hematology and hemostasis usually, no clinical symptoms; in some cases minor chronic hemolysis, anemia, and splenomegaly. • chronic hemolysis, icterus • hepatosplenomegaly • cardiac insufficiency • infections • microcytic hypochromic anemia (hb ↓, hct ↓, mcv ↓, mch ↓) • iron serum ↑, ferritin ↑, transferrin iron-binding capacity ↓ • blood smear: microcytic hypochromic erythrocytes, target cells, polychromasia, isolated normoblasts • chronic erythropoietic bone marrow hyperplasia → expanded marrow, detectable in bone marrow scan or skull x-ray ("hair-on-end" sign) • hemoglobin electrophoresis: increase in hbf (αα/γγ) and hba (αα/δδ) • molecular genetic detection of the defective globin gene (via pcr) iron deficiency anemia ( chap. . . ) . • rbc transfusion • hemosiderosis treatment: desferrioxamine , iu/day s.c. in homozygotic cases / severe hemolysis: allogeneic stem cell transplantation during infancy. autoimmune hemolytic anemia caused by igg incomplete "warm" autoantibodies (incomplete antibodies: antigen-antibody binding, but no lysis or agglutination). seventy-five percent of all autoimmune hemolytic anemias. • in non-hodgkin's lymphoma, particularly in low-malignant nhl (cll) • with autoimmune diseases, e.g., systemic lupus erythematosus (sle) • following infections (viral infections, rarely bacterial infections) • drug-induced hemolysis (various mechanisms): antibiotics, α-methyldopa, l-dopa, quinine, quinidine, x-ray contrast agents, procainamide, diclofenac • idiopathic ( % of cases) • binding of incomplete antibodies to erythrocytes • destruction of antibody-coated erythrocytes in spleen and liver (extravascular non-complement-mediated lysis by cells of the reticuloendothelial system) • hemolysis and hemolytic crises, with icterus, hemoglobinuria, fever, etc. • anemia symptoms (fatigue, weakness, reduced performance, pallor, headache, etc.) • case history including medication • physical examination including signs and symptoms of anemia treatment of underlying disease or discontinuation of causative drugs. • corticosteroids (prednisolone - mg/day i.v.), slowly taper dose after hemolysis parameters have normalized • in cases of chronic hemolysis and poor response to corticosteroids: use alternative immunosuppressive agents, e.g., azathioprine mg/m /day, cyclophosphamide mg/m /day p.o. • splenectomy: in cases of treatment-refractory chronic hemolysis or refractory acute hemolytic crisis • transfusion of packed red cells only in cases of symptomatic anemia (e.g., cardiovascular symptoms, dyspnea, cerebral ischemia) autoimmune hemolytic anemia caused by igm complete "cold" autoantibodies, usually targeting the i-antigen of the erythrocyte membrane (complete antibodies: capable of agglutination and lysis induction after antigen-antibody binding). fifteen percent of all autoimmune hemolytic anemias. • in low-malignant non-hodgkin's lymphoma or hodgkin's disease • after infection (viral infections, mononucleosis / ebv infection, mycoplasma pneumoniae) → cold agglutinin titer up to : , rare congenital disease → cold agglutinin titer up to : , when the intravascular temperature drops to < - °c: antigen-antibody binding, agglutination and complement-mediated intravascular hemolysis. • exposure to cold leads to hemolysis and hemolytic crisis (with icterus, hemoglobinuria, fever, etc.) • anemia symptoms (fatigue, weakness, reduced performance, pallor, headache, etc.) • acrocyanosis: painful / malperfused extremities (fingers / toes / nose) • splenomegaly . hemolytic anemia hematology and hemostasis • medical history, physical examination • diagnostic clues: erythrocyte agglutination when blood is drawn and during laboratory analysis • anemia (hb ↓, hct ↓), signs of hemolysis (ldh ↑, indirect bilirubin ↑, haptoglobin ↓), detection of cold autoantibodies • exclusion of potential underlying diseases • blood group treatment of the underlying disease. • protection against cold • with severe acute hemolysis: plasmapheresis (objective: removal of autoantibodies), often technically difficult (due to agglutination within the plasmapheresis system) • with chronic hemolysis: immunosuppressive drugs, e.g., azathioprine, cyclophosphamide, or chlorambucil • with symptomatic anemia (cardiovascular symptoms, dyspnea, cerebral malperfusion, etc.): transfusion of washed packed red cells (avoid complement administration in cases of complement-mediated hemolysis) • corticosteroids and splenectomy are usually ineffective anemia with normal corpuscular hemoglobin (mch - pg) and normal corpuscular hemoglobin concentration (mchc - g/dl). • hemolytic anemia ( chap. . . ) • aplastic anemia ( chap. . ) • acute posthemorrhagic anemia • renal anemia normochromic normocytic hyporegenerative anemia as a result of chronic renal failure. incidence: - cases/ , per year. • complex pathogenesis based on renal insufficiency • renal erythropoietin synthesis ↓, the degree of anemia correlates with the severity of the underlying disease • myelosuppresion and intramedullary hemolysis due to accumulation of uremic toxins • concurrent chronic blood loss due to hemodialysis • pale skin and mucous membranes • weakness, fatigue, reduced performance, dyspnea on exertion • difficulty concentrating, headache • uremic fetor • "café au lait" complexion due to urochrome deposits and concurrent anemia, pruritus • weakness, headache • medical history: signs of chronic renal insufficiency • physical examination: skin, mucous membranes, lymph node status, spleen / liver, heart (tachycardia, systolic heart murmur), rectal examination and testing for fecal occult blood • hematology: blood count including mcv (normal), mch (normal), reticulocytes (↓), differential blood count • clinical chemistry: hepatic and renal function tests, total protein, hemolysis parameters (bilirubin, ldh, normal haptoglobin, low-grade hemolysis due to uremic toxins) • vitamin b level, folic acid level • serum iron, ferritin, transferrin; in cases of chronic blood loss due to hemodialysis, iron deficiency may occur • erythropoietin ↓ / normal (i.e., inadequate increase given the degree of anemia) • blood group (if red cell transfusion is required) • erythropoiesis stimulation with darbepoetin . µg/kg body weight once weekly s.c. or i.v., adjust dose according to hemoglobin response • alternatively, recombinant erythropoietin, iu/kg body weight three times weekly s.c. or i.v., adjust dose according to hemoglobin response . normochromic anemia • target hemoglobin - g/dl • attention: blood pressure may rise as hematocrit increases, especially in cases of pre-existing hypertension • hemodialysis • additional iron supplementation with signs of iron deficiency ( chap . . ) causal treatment • vasoconstriction • platelet adhesion to endothelial lesion, aggregation, clot formation (primary hemostasis) • coagulation cascade, fibrinogenesis (secondary hemostasis) • fibrinolysis coagulation and fibrinolysis are physiologically balanced and are regulated by activators and inhibitors. the distinction of an extrinsic and intrinsic system is artificial and not relevant for the physiological situation (in vivo). however, it helps to understand in vitro phenomena and clotting laboratory tests (quick's value, ptt). . coagulation disorders • antithrombin (at): prevention of excessive thrombin activation by formation of thrombin-at complex, inhibition of iia, ixa, xa, xia, xiia; important physiological coagulation inhibitor; at deficiency constitutes an increased risk of thrombosis (thrombophilia, chap. . ) • protein c: thrombin-induced conversion into active protein c (apc); apc inhibits fva and fviiia and induces the release of tpa (plasminogenic activator); protein c deficiency constitutes an increased risk of thrombosis ( chap. . ) • protein s: cofactor of protein c • heparin: activation of physiological at → inhibition of thrombin generation; ineffective in cases of at deficiency. unfractionated (ufh) and low molecular weight (lmwh) heparins • hirudin: direct thrombin inactivation, effective in cases of at deficiency • coumarin: vitamin k antagonists; inhibition of the hepatic synthesis of the factors ii, vii, ix, and x as well as the proteins c and s • acetylsalicylic acid: irreversible cyclooxygenase inhibition • ticlopidine: inhibition of fibrinogen binding by interaction with gpiib/iiia • tirofiban hydrochloride: gpiib/iiia receptor antagonist • dipyridamole: increases the level of cellular cyclic amp (camp) • clopidogrel: selective inhibition of adp binding, inhibition of adp-mediated activation of the gpiib/iiia receptor complex vitamin k deficiency or abnormal synthesis of vitamin k-dependent clotting factors ( chap. . . ) • severe liver damage • antibiotic treatment, malabsorption syndrome, abnormal fat absorption, alcoholism coagulopathies which may occur spontaneously or as a result of an underlying disease which is not primarily related to the hemostatic system. in contrast to primary disorders, several components of the hemostatic system are usually affected. impaired synthesis and metabolic defects can be distinguished. the liver is the primary site of formation and elimination of coagulation factors and their inhibitors as well as filtration → hepatic dysfunction can lead to complex hemostatic disorders: • impaired synthesis of clotting factors → factor deficiency (esp. factor ii, v, vii, ix, x, xiii, fibrinogen, plasminogen, α -antiplasmin, antithrombin, protein c, protein s) • impaired elimination of clotting factors → factor excess (e.g., viii, von willebrand-factor) • impaired thrombopoiesis / platelet function (hypersplenism, bone marrow defect due to toxic effects of alcohol, vitamin b / folic acid deficiency, thrombopoietin deficiency) • hyperfibrinolysis • ascites → loss of coagulation factors (loss of coagulation factors via ascites) • signs of hepatic failure • bleeding signs and symptoms: hematomas, mucous membrane hemorrhage, epistaxis • esophageal variceal bleeding (life-threatening) • quick's test ↓ (earliest indication of hepatic coagulation defects: includes factor vii which is the first to decrease due to its short half life of h); suitable parameter for monitoring hepatic disorders • aptt: may be normal or increased in advanced hepatic disorders • platelets ↓, fibrinogen ↓, factor v ↓, protein c ↓, protein s ↓, antithrombin ↓ (may be increased in case of cholestasis), d-dimers ↑ • determination of separate factors usually not required • initial treatment with fresh frozen plasma (ffp) ml/kg. • if insufficient: antithrombin supplementation, fibrinogen supplementation (for levels below . g/l), administration of cryoprecipitate. • administration of platelet concentrates, desmopressin (ddavp; . µg/kg) and antifibrinolytics (e.g., aprotinin , iu in min, million iu/day i.v.) may be considered. atten-tion: dic ( chap. . . ) . • if factor xiii concentration < % and ffp is without effect: administration of factor xiii concentrate. • if initial values are unknown / emergency situations: empirical treatment with antithrombin iu/kg, fibrinogen g, and ppsb iu/kg. in cases of severe hemorrhage, treatment with activated factor viia may be considered. administration of antifibrinolytics (e.g., tranexamic acid g three times daily), vitamin k antibodies to clotting factors, occurring as primary (spontaneous) or secondary (due to underlying disease) antibodies: • autoantibodies − inhibitors to individual clotting factors (most commonly to factor viii, antigen-induced hemophilia) − antiphospholipid antibodies ( chap. . ) − monoclonal immunoglobulins, heparin-like antibodies • alloantibodies (inhibitors in hemophilia a / b replacement therapy) incidence of factor viii inhibitors : , , acquired factor viii inhibitors: % of cases occur spontaneously, secondary inhibitors in conjunction with: asparaginase therapy of acute leukemias • impaired synthesis of clotting factors (esp. fibrinogen, antithrombin, protein c and s, factors ii, ix, and xiii) • potential complication: dic ( chap. . . ) hemorrhages of all degrees and in all locations (hematomas, mucous membrane hemorrhage, postoperative bleeding) levels of fibrinogen, antithrombin, d-dimers . acquired coagulation disorders hereditary bleeding disorder caused by deficiency ( % of cases) or inactivity ( %) of coagulation factor viii (fviii, ahg-a, antihemophilic globulin a). most common hereditary coagulopathy, incidence case/ , men/year. women are heterozygotic carriers of the gene. clinically apparent hemophilia in women is rare. ratio between hemophilia a and b approximately : . • factor viii coding gene located on the x chromosome → mainly men are affected, x-linked recessive inheritance ( % of cases) or spontaneous mutations ( %) • synthesis in liver, kda protein, no vitamin k dependence; half-life: - h • factor viii circulates in the plasma bound to von willebrand factor (vwf) → protection from proteolytic degradation attention: treatment must be provided as early as possible and must be sufficient with respect to dosage and treatment period. ddavp, nasal spray, or intravenous administration ( . - . µg/kg in ml saline over min, every - h); effect occurs within - min: transient fviii increase by factor - for up to days; may also be given prior to minor surgery (e.g., tooth extraction), possibly with antifibrinolytics. administration of recombinant factor viii or plasma factor viii. administration of recombinant factor products excludes the risk of viral contamination (hbv, hcv, hiv, hsv, ebv, cmv, etc. (feiba) - iu/kg body weight every - h. in emergency situations: plasmapheresis or immunoadsorption normal life expectancy • early detection of signs of bleeding • controlled exercise and sports program to prevent bleeding into joints and to maintain mobility • avoid platelet aggregation inhibitors (ass, etc.), no intramuscular injections • caries prophylaxis, meticulous local hemostasis during surgical procedures; no surgery without prophylactic administration of fviii • hepatitis a/b vaccination is recommended • x-linked inheritance → examine coagulation status of patient's relatives bleeding-related arthropathy often goes unnoticed → close monitoring, permanent fviii treatment in cases of severe hemophilia: - iu/kg - times weekly → rate of complications / arthroplasty significantly decreased. • severe bleeding / planned operation: increase factor ix for days to > % , then keep at > % for days • in cases of emergency, fresh frozen plasma (ffp) may be used, if recombinant fix concentrate is not available • aptt monitoring is not sufficient, plasma factor ix should be determined (shortly after replacement and before administration of the next dose) • - % of patients develop antibodies against infused factor, with treatment resistance → monitoring via fvii inhibitor assay normal life expectancy patient information and instruction ( chap. . . ) bleeding-related arthropathy often goes unnoticed → close monitoring, prophylactic factor ix treatment in cases of severe hemophilia in children: - iu/kg times weekly → significant decrease of complication / arthropathy rate. hereditary coagulopathy due to qualitative or quantitative deficiencies of the von willebrand factor (vwf). d . most common hereditary coagulopathy, heterozygotic gene carriers : to : , ; incidence of symptomatic cases: cases/ , , population. von willebrand factor is a heterogenic multimeric plasma glycoprotein (normal serum level: mg/l). the vwf precursor is synthesized as a monomer in the endothelium and megakaryocytes. active forms (vwf multimers) are found in the endothelium, platelets, and plasma. functions: • mediation of platelet adhesion to vascular wall (collagen) via high-molecular vwf multimers and binding to platelet glycoprotein ib (gpib) • factor viii carrier in plasma hereditary defect caused by mutation in the vwf gene (chromosome ); autosomal-dominant (subtype and ) or autosomal-recessive (subtype and ) inheritance. consequences: • impaired platelet adhesion • reduced fviii activity rare: acquired cases due to vwf antibodies in connection with autoimmune diseases, lymphoproliferative diseases, or after multiple transfusions ("von willebrand syndrome, " vws). defects in the vwf-binding glycoprotein gpib can mimic von willebrand's disease ("pseudo-vwd"). frequency definition • type : mild form, bleeding time ↑, discrete tendency to bleed, epistaxis, gum bleeding, increased menstruation, bleeding after minor surgery • type : different characteristics depending on subtype; increased soft tissue bleeding, mucous membrane bleeding, gastrointestinal bleeding, hematuria; bleeding into joints less common than with hemophilia; rarely intracerebral bleeding • type : most severe form with pronounced bleeding (soft tissue bleeding, bleeding into joints, and petechial type bleeding) • attention: in all types life-threatening bleeding may occur up to days after surgery. • medical history (including family history) • physical examination including type of bleeding systemic consumption coagulopathy due to release of coagulation activators, with intracapillary coagulation, microthrombus formation, subsequent ischemic organ damage (kidney, liver, lung) and organ failure. diffuse tendency to bleed due to collapsed hemostasis with secondary hyperfibrinolysis. acute dic is a severe life-threatening disease. chronic dic with continuous coagulation may occur in patients with malignant diseases. • infections: sepsis (gram-negative / gram-positive), malaria, rickettsia, chlamydia, mycobacteria, meningococcus (waterhouse-friderichsen syndrome: consumption coagulopathy with adrenocortical bleeding), viral infections • solid tumors: carcinomas of the lung, pancreas, stomach, colon, prostate, kasabach-merritt syndrome (hemangiomas) • hematological neoplasia: acute promyelocytic leukemia (fab m ) • obstetric complications: placenta abruptio, amniotic fluid embolism, septic abortion, eclampsia, postpartal hemolytic-uremic syndrome • hypoxia and shock: traumatic, hemorrhagic, cardiac, septic • hemolysis: transfusion errors, toxins, paroxysmal nocturnal hemoglobinuria • operations on organs with a high thrombokinase content (prostate, pancreas, lung), extracorporeal circulation (contact activation of the endogenous coagulation system) • trauma: head injury, soft tissue damage, fat embolism • others: snake bites, heat stroke (endothelial damage), abdominal aortic aneurysms excessive thrombin synthesis leads to fibrin formation and subsequent intravascular coagulation with consumption of platelets and clotting factors. inhibitory mechanisms (e.g., inhibition of fva and fviiia via thrombomodulin-activated protein c) cannot compensate the thrombin formation. . dic initially (phase i and ii), pathological laboratory parameters only. only with severe consumption coagulopathy (phase iii) clinically detectable symptoms: • hemorrhagic diathesis with ubiquitous bleeding, % of cases: skin / mucous membrane bleeding, hematomas, secondary bleeding after venipuncture / from puncture sites, pulmonary hemorrhage, gastrointestinal bleeding, renal bleeding, hematuria, adrenal bleeding / insufficiency, intracerebral bleeding • multiple microthromboses with impaired organ function, %: acute renal failure, impaired liver function, acute respiratory insufficiency (ards, "acute respiratory distress syndrome"), intradermal microvascular thrombosis → "purpura fulminans" (skin bleeding with central necrosis), cerebral small vessel ischemia (coma, epileptic seizures) • shock: tachycardia, decrease in blood pressure, edemas, organ failure • chronic course: coagulation factor synthesis ↑, thrombosis ↑ → malperfusion of larger blood vessels (embolisms, cerebral ischemia, etc.) • case history including risk factors • physical examination i activation rapid decrease of platelets, platelet count n / ↓, antithrombin n / ↓, fv n / ↓, fviii n / ↓, coagulation products ↑ (soluble fibrin, prothrombin fragment f + , thrombin-antithrombin complex tat) ii early consumption platelets ↓, antithrombin ↓, quick ↓, coagulation factors (fibrinogen, fv) ↓, ptt ↑, tat ↑, protein c ↓ iii late consumption platelets ↓↓ (< , /µl), antithrombin ↓↓, quick ↓↓, coagulation factors ↓↓ (fibrinogen, fv, and fviii), ptt ↑↑, thrombin time ↑↑, fibrinogen degrading products / fibrin monomers +, d-dimers +++, detectable fragmentocytes iv recovery decrease in coagulation products (soluble fibrin, prothrombin fragment f + , tat), increase of clotting factors (fibrinogen, fv, fviii), normalization of global clotting tests n normal, f factor, tat thrombin-antithrombin complex, ptt partial thromboplastin time • basic diagnosis: platelets (platelet decrease often first symptom), antithrombin, d-dimers, fibrinogen, quick's test, ptt • advanced diagnosis: fibrin monomers (soluble fibrin), prothrombin fragments f + , thrombin-antithrombin complex (tat), plasmin-plasmin inhibitor complex, factor v, protein c, possibly protein s (in cases of purpura fulminans) basic screening test score a score ≥ indicates ongoing dic; with scores < diagnostics should be repeated every - h depending on the individual clinical condition. • with tumors / infections / pregnancy, the platelet count is often increased ("reactive thrombocytosis") → normal platelet counts may already indicate dic. • fibrinogen is an acute-phase protein → "normal" fibrinogen levels may already be pathologically decreased (e.g., with infections). • with dic, frequent monitoring is required to determine the dynamics and course of disease. • primary hyperfibrinolysis: normal platelet count, normal atiii, no fibrin monomers basic therapy • antithrombin (at) replacement if at level < % (initially , iu, then iu every h), check level (target: - %) • heparin: - iu/kg/day (not with aml type m or patients with high bleeding risk), depending on platelet count organ dysfunction, bleeding • fresh frozen plasma (ffp, ml/kg) • antithrombin (at), - iu every h • fibrinogen replacement with fibrinogen levels of < mg/dl • platelet transfusion (target: > , /μl) • red cell transfusion according to hemoglobin level, compensation of acidosis • heparin is contraindicated, no intramuscular injections • patients should be treated in intensive care unit • severe uncontrollable bleeding: administration of activated fviia. attention: potential risk of thromboembolic complications attention: administration of coagulation factors can increase dic and should be avoided. for replacement therapy, use fresh frozen plasma (ffp). • severe sepsis: activated protein c (drotrecogin) µg/kg/h over h → decreases mortality from % to %. attention: with thrombocytopenia higher risk of hemorrhagic complications. contraindicated after brain hemorrhage, epidural catheter, etc. • in dic, avoid fibrinolysis inhibitiors: → in cases of uncontrollable bleeding: use aprotinin (e.g., , units in the first half hour, followed by million units/day), platelets, fibrinogen, and ppsb. in cases of life-threatening bleeding or lack of success: administer recombinant fviia. • fibrinolysis inhibitors (antifibrinolytics, e.g., tranexamic acid) may be indicated with hyperfibrinolytic conditions (prostate carcinoma, aml m ) in phase i of a dic only. • low-dose heparinization is indicated in cases of: purpura fulminans, acral ischemia, venous thrombosis. for phase i, some studies favor low-molecular weight heparin ( - units/kg/ day). • clinical monitoring: close monitoring of neurological, cardiovascular, respiratory and renal parameters • monitoring of bleeding: tachycardia, hemoglobin decrease, retroperitoneal bleeding (→ sonography), neurology • laboratory tests: coagulation parameters, blood count, hepatic and renal function parameters, electrolytes dd: dd: th: th: . dic platelet aggregation inhibitors (acetyl salicylic acid, ticlopidine, clopidogrel) new therapies for itp guidelines for the investigation and management of idiopathic thrombocytopenic purpura in adults, children and pregnancy amg , a thrombopoiesis stimulating protein, for chronic itp management of adult idiopathic thrombocytopenic purpura idiopathic thrombocytopenic purpura: a guideline for diagnosis and management of children and adults long-term outcomes in adults with chronic itp after splenectomy failure morbidity and mortality in adults with idiopathic thrombocytopenic purpura long-term observation of adults with chronic idiopathic thrombocyto--argatroban: direct thrombin inhibitor, interacts with the active site of thrombin. half-live min., monitored by ptt. no dose adjustment in renal failure • in cases of existing thrombosis: coumarin overlapping with danaparoid or hirudin. • avoid using lmwh how i treat heparin-induced thrombopenia and thrombosis heparin-induced thrombocytopenia british committee for standards in haematology. the management of heparin-induced thrombocytopenia heparin-induced thrombocytopenia: new evidence for the dynamic binding of purified anti-pf -heparin antibodies to platelets and the resultant platelet activation delayed-onset heparin-induced thrombocytopenia cancer-related anemia: pathogenesis, prevalence and treatment eortc guidelines for the use of erythropoietic proteins in anaemic patients with cancer guidelines for the clinical use of red cell transfusion the impact of hemoglobin levels on treatment outcomes in patients with cancer red cells i: inherited anaemias red cells ii: acquired anemias and polycythaemia ash/asco clinical practice guideline update on the use of epoetin and darbepoetin modern treatment of thalassaemia intermedia british committee for standards in haematology. guidelines for the diagnosis and management of hereditary spherocytosis hereditary elliptocytosis: spectrin and protein . r management of cold haemolytic syndrome the complement inhibitor eculizumab in pnh treatment of autoimmune hemolytic anemia glucose- -phosphate dehydrogenase deficiency sickle-cell disease recessively inherited coagulation disorders mechanisms of disease: the impact of antithrombotic therapy in cancer patients coagulation disorders • ffp ml/kg (coagulation factor increase by • antithrombin concentrate: iu/kg → increase by approximately blood coagulation and its regulation by anticoagulant pathways: genetic pathogenesis of bleeding and thrombotic diseases acquired haemophilia: review and meta-analysis focused on therapy and prognostic factors the antiphospholipid syndrome identification of the gene for vitamin k epoxide reductase rituximab in the treatment of acquired factor viii inhibitors treatment of acquired hemophilia by the bonn-malmö protocol immune tolerance induction: recombinant vs. human-derived product haemophilia : emerging risks of treatment haemophilia a: from mutation analysis to new therapies recombinant activated factor vii in patients at high risk of bleeding dose and response in haemophilia: optimization of factor replacement therapy comparing outcomes of different treatment regimens for severe haemophilia consensus perspectives on prophylactic therapy for haemophilia: summary statement inhibitor development in haemophilia b recombinant activated factor vii in patients at high risk of bleeding dose and response in haemophilia: optimization of factor replacement therapy clotting factor concentrates given to prevent bleeding and bleeding-related complications in people with hemophilia a or b prg: prg: px: px: ref: ref: web: web ref: web: web: in cases of manifest severe dic: - % mortality administration of heparin efficacy and safety of recombinant human activated protein c for severe sepsis the prothrombotic state in cancer: pathogenetic mechanisms update on the treatment of disseminated intravascular coagulation disseminated intravascular coagulation: what's new? dic : a review of disseminated intravascular coagulation high dose antithrombin iii in severe sepsis dic in acute leukemia: clinical and laboratory features at presentation thrombosis: localized intravascular aggregation of blood components → thrombus (clot) formation with consecutive vascular occlusion embolism: migration of detached thrombus (clot) elements in the blood stream with consecutive vascular occlusion. triggers: thrombotic material, tumor particles or leukemic cell thrombi, sclerotic material, fat droplets, amniotic fluid, air. thrombophilia: increased risk of occurrence of thromboembolic events thrombosis incidence: cases/ , population/year; location: > % in inferior vena cava or leg / pelvic veins; male:female = : ; particularly in patients > years of age idiopathic" deep vein thrombosis or pulmonary embolism in clinically "healthy" adults is due to an underlying malignancy in - % of cases pulmonary embolisms or venous thromboses are found in up to % of cancer patients at autopsy virchow triad: major pathomechanisms of thrombogenesis • • • endothelial alterations: vascular sclerosis, inflammation, trauma, etc. circulation disorders: intravascular stasis, vortex formation endothelial alterations (esp. with arterial thrombosis) phlebitis circulation disorders • immobilization, bed rest • intravascular stasis due to vascular constriction or compression: e.g., after extended periods of travel ("economy class syndrome"), varicosis, obesity, pregnancy, solid tumors, or lymphomas • altered blood flow due to cardiac disorders hypercoagulability thrombocytosis e.g., myeloproliferative syndromes ( chap. . ) def: def: icd- : icd- : ep: ep: pg: pg: . thromboembolism and thrombophilia apc (activated protein c) resistance: most common cause of thrombophilia; in % of cases due to factor v mutations → abnormal apc binding site (mainly point mutations in the factor v gene, g a, "factor v leiden") → insufficient inactivation of factor v by mutated apc. prevalence: heterozygotic carriers - % of normal population, - % among patients with thrombosis. relative thrombosis risk in heterozygotic cases approximately -to -fold, in homozygotic cases -to -fold increased. other causes (< %) for apc resistance: antiphospholipid antibodies, oral contraceptives, pregnancy. factor ii mutation: prothrombin mutation g a, often associated with increased prothrombin levels. prevalence: heterozygotic carriers - % of normal population; among patients with thrombosis - %. relative risk of thromboembolisms: -to -fold increased. factor viii increase: % of thrombosis patients show persistent fviii increase of unknown etiology antithrombin / protein c / protein s defects: rare hereditary disorders; at deficiency especially is associated with a high risk of thrombosis. dd: hepatic diseases. hyperhomocysteinemia: hereditary defect of cystathionine β synthetase; or acquired due to vitamin b , b , or folic acid deficiency. antiphospholipid syndrome: most common acquired form of thrombophilia; occurs as primary or secondary (as a result of systemic lupus erythematosus sle, collagenosis, malignancy, medication, infections) subtype − rapid onset of the anticoagulation effect; minimal laboratory monitoring required (platelet count during first weeks, antifactor xa levels in patients with renal failure, cachectic, or overweight patients) hemorrhagic complications, osteoporosis, and heparin iu bolus > kg; then continuous intravenous treatment: , iu/ h, maximum , iu/ h; dosage according to ptt: target ptt > - s, first ptt test after h, then every h; once stable, it is sufficient to check ptt once daily • alternatively, subcutaneous administration: , - , iu s.c. times daily; studies have shown that with identical ptts, intravenous and subcutaneous administration are equally effective • side effects: hemorrhage (in up to % of patients), hypersensitivity (urticaria, bronchospasm, fever, even shock), alopecia (rare), vasospasm (rare), osteoporosis (with long-term use), heparin-induced thrombocytopenia • arterial occlusion (extremity arteries, acute myocardial infarction discontinuation of heparin treatment • adoption of coumarin: discontinuation of heparin treatment once target inr is reached (usually after days); exception: in cases of extensive thrombosis (calf to pelvis), continue heparin treatment for - days • absence of contraindications and patient compliance provided, lmwh treatment may be possible in an outpatient setting effect vitamin k antagonism → inhibition of the hepatic synthesis of coagulation factors f ii, vii, ix, x of age, hemorrhagic diathesis, sepsis • uncompensated hypertension, liver or renal insufficiency • surgery within last - days, arterial puncture, intramuscular injections • cns surgery within the last months, cerebral bleeding, cerebral sclerosis, csf puncture within the last days • pancreatitis, endocarditis lenta, diabetic retinopathy, nephrolithiasis • pulmonary / gastrointestinal diseases with high risk of bleeding recommendations from the british committee for standards in haematology and national patient safety agency british committee for standards in haematology (bcsh). guideline. investigation and management of heritable thrombophilia prophylaxis for thromboembolism in hospitalized medical patients the effect of low molecular weight heparin on survival in patients with advanced malignancy deep vein thrombosis randomized comparison of low molecular weight heparin and coumarin derivatives on the survival of patients with cancer and venous thromboembolism deep venous thrombosis asco guideline: recommendations for venous thromboembolism prophylaxis and treatment in patients with cancer hereditary coagulopathy due to deficiency or inactivity of coagulation factor ix (fix, christmas factor, antihemophilic globulin b, ahg-b). rare hereditary coagulopathy, incidence case/ - , men/year. women are heterozygotic carriers of the gene.• factor ix coding gene is located on the x chromosome → mainly men are affected, x-linked recessive inheritance; hereditary forms ( % of cases) and spontaneous mutations ( %) • hepatic synthesis, kda protein, vitamin k-dependent, half-life h • mild bleeding: vasopressin analog desmopressin (ddavp), nasal spray or intravenously, e.g., every - h . µg/kg body weight i.v. in ml saline . % over min → release of vwf in endothelium, increase of the vwf level by factor - . response within - min in > % of patients; duration of effect - h. since not all patients respond, conduct provocation test prior to treatment; treatment must be interrupted after - days due to depletion of endogenous vwf stores. • with menstruation, single doses of ddavp prior to menstruation are usually sufficient; supportive estrogen therapy with subtype . • severe bleeding: similar strategy to type b, n, and . • administration of high-vwf plasma products (e.g., - u/kg - times daily or - u/kg/ h per infusor) until ristocetin cofactor activity > % for at least h. attention: recombinant fviii products contain no vwf and are ineffective in von willebrand's disease → use special high-vwf plasma or fviii products. • platelet concentrates • if surgery is planned: vwf antigen as well as ristocetin cofactor activity should be %, pre-as well as postoperatively. • attention: with subtype b, ddavp did not demonstrate a clear benefit (risk of thrombocytopenia). with subtype iii, it is ineffective. • monitoring of vwf antigen, fviii function (fviii:c), ristocetin cofactor (ricof) according to disease subtype.th: th:. von willebrand's disease• development of vwf alloantibodies in - % of cases, risk of anaphylactic reactions with repeated exposure. with neutralizing antibodies and bleeding complications factor viia may be given. • if ddavp has proven to be effective, give min prior to surgery • high risk of hemorrhage (e.g., tonsillectomy): raise vwf antigen and ristocetin cofactor activity up to %; administer high-vwf fviii concentrate • intraoperative use of fibrin glue and fibrinolysis inhibitors (e.g., tranexamic acid mouthwash with dental surgery) • during pregnancy, hormone-induced increase in vwf and fviii:c → with subtype and no further treatment required • peripartum: keep vwf antigen and ristocetin cofactor activity above %; with cesarean section, aim for % pre-and postoperatively • vessel wall defects: endothelial alterations due to intravascular catheters / lines, antineoplastic treatment, direct invasion of tumor tissue; cytokine-mediated activation of the endothelium → enhanced expression of tissue factor / adhesion molecules / pai and decreased endothelial thrombomodulin expression → thrombophilic surface • changes in blood flow: immobilization, tumor-related vascular compression, stasis, hyperviscosity • changes in coagulation system: fibrinogen ↑, factor v ↑, fviii ↑, von willebrand factor ↑, fxii ↑, at ↓ • release of procoagulating substances ("cancer coagulants, " e.g.,tissue factor = tf, fx activators) with activation of the extrinsic system via factor vii or direct fx activation; high levels of tf in promyelocytes of acute leukemia type fab m • decrease in coagulation inhibitors (antithrombin, protein c and s) due to chemotherapy (asparaginase) • swelling of the arm, hyperthermia, livid discoloration, tightness • pain in forearm, upper arm and/or shoulder, fever veins, mesenteric veins); thromboembolic event despite effective anticoagulation; thrombosis during pregnancy and tendency to miscarriage and stillbirth − analysis of: fibrinogen, antithrombin, protein c, protein s, prothrombin (fii), fviii, apc resistance, factor ii mutation, antiphospholipid antibodies (lupus anticoagulants, anticardiolipin antibodies), plasminogen deficiency − extended diagnostics: homocysteine, methyltetrahydrofolate reductase (mthfr) mutation g t, fix, and fxii − in most cases, repeated tests are required. with suspected thrombophilia, patients should be referred to specialized hematology centers. • venous thrombi → pulmonary embolism (in > % of cases due to phlebothrombosis, approximately % of patients with phlebothrombosis develop pulmonary embolism) • arterial / cardiac thrombi → cerebral malperfusion, renal infarction, extremities • post-thrombotic syndrome (after - years, in - % of conventionally treated patients) • chronic leg ulcer (in % of patients) • effect: factor xa inhibition, half-life: - min • dosage: enoxaparin mg/kg twice daily s.c., dalteparin iu/kg twice daily, or tinzaparin iu/kg once daily • advantages of treatment with lmwh compared to ufh: according to inr ("international normalized ratio"). in normal weight patients (≈ kg), the following rule of thumb applies: current quick value divided by is the number of coumarin tablets to be given in the first days. on day , give tablets, on days and give (or ) tablets (slow initiation to reduce the risk of coumarin necrosis). the inr should be checked on day . the result determines the dosage of subsequent treatment. heparin treatment may be discontinued once the target inr has been reached (usually after - days). the duration of anticoagulation treatment has to be determined individually for each patient, based on thrombosis type, location, risk factors and comorbidities. guideline: patients with contraindications against coumarin may receive low molecular weight heparin as secondary prophylaxis on a long-term basis. half the therapeutic lmwh dose is usually recommended (comparable to an inr of - ); start after - days of "full dose" therapeutic lmwh treatment. cancer patients in particular benefit from treatment with low molecular weight heparin. due to frequent occurrence of hemorrhagic complications ( - %), increased mortality ( - %) and limited long-term benefit (no reduction in occurrence of post-thrombotic syndrome), fibrinolysis now only plays a secondary role. an indication for treatment with fibronolytics (e.g., streptokinase, urokinase) may exist in young patients with extensive fresh thrombosis. surgical thrombectomy allows immediate perfusion of the blood vessel. however, endothelial injury and incomplete thrombus removal often lead to rapid reformation of thrombi. indications: • phlegmasia cerulea dolens • fresh isolated descending pelvic vein thrombosis (not older than - days) • acute arterial occlusion placement of a filter in the v. cava reduces the risk of severe pulmonary embolism in patients with recurrent thromboses. indications are:• recurrent pulmonary embolism despite effective anticoagulation • contraindication against anticoagulants • immobilization: studies did not confirm a role for immobilization in the prevention of pulmonary embolisms. • in patients with severe pain or edema: elevation and immobilization of the leg for a limited number of days. • compression therapy: compression dressings with bandages or compression stockings; contraindicated with peripheral arterial occlusive disease and phlegmasia cerulea dolens. compression stockings should be worn for at least years as secondary prophylaxis after dvt of the lower extremity. in most cases, calf compression stockings on the affected leg are sufficient.• anticoagulants • platelet aggregation inhibitors, acetylsalicylic acid mg daily p.o. (protective effect in particular with arterial occlusion and coronary heart disease) • elimination of risk factors (see above), early postoperative mobilization, physiotherapy, compression stockings key: cord- -vx rgs r authors: nair, ranjit; patel, krina title: what the intensivists need to know about critically ill myeloma patients date: - - journal: oncologic critical care doi: . / - - - - _ sha: doc_id: cord_uid: vx rgs r multiple myeloma (mm) is a hematological malignancy characterized by an increase in aberrant plasma cells in the bone marrow leading to rising monoclonal protein in serum and urine. with the introduction of novel therapies with manageable side effects, this incurable disease has evolved into a chronic disease with an acceptable quality of life for the majority of patients. accordingly, management of acute complications is fundamental in reducing the morbidity and mortality in mm. mm emergencies include symptoms and signs related directly to the disease and/or to the treatment; many organs may be involved including, but not limited to, renal, cardiovascular, neurologic, hematologic, and infectious complications. this review will focus on the numerous approaches that are aimed at managing these complications. mm is a hematological malignancy characterized by an increase in aberrant plasma cells in the bone marrow leading to rising monoclonal proteins in the serum and urine. in general, it is a disease of older adults; however, mm may effect younger patients as well: % are < years, % are < years, and . % are < years in age [ ] . it accounts for about % of hematological malignancies in the united states, with an estimated , new cases in . patients often present with osteolytic bone lesions, fractures, bone pain, progressive anemia, hypercalcemia, renal insufficiency, recurrent infections, and/or bleeding. if not treated appropriately and urgently, any of these may lead to death. the introduction of novel agents to the traditional arsenal of drugs comprising of steroids, chemotherapy, and autologous stem cell transplantation has shifted the treatment platform from one which often required repeated acute interventions to that of a more chronic manageable disease. as the acute complications can be potentially fatal, early recognition and intensive care management is the key to successful outcomes. these patients who present with complications are often excluded from mm trials, and their prognosis in the modern era is uncertain. reports suggest that in-hospital mortality from acute complications of mm has decreased significantly over the past decade. continued risk factors for death in this group of patients are organ failure, poor chronic health status, and delayed intensive care management [ ] . despite having increased life expectancy now, the majority of mm patients ultimately develop resistant subclones, leading to disease progression and disease-related complications. with increasing complexity of mm treatments, patients are at risk for more challenging drug toxicities. recognizing and managing the potential side effects of present-day novel regimens is therefore a cornerstone in mm care. in this chapter, we will provide a systematic review of the key critical clinical events which cause medical emergencies in mm. this crucial, fundamental knowledge for all clinicians who routinely care for mm including intensivists will allow for optimal treatment outcomes and survival in mm. complications resulting from stem cell transplant or newer therapies including chimeric antigen receptor t cell therapy are beyond the scope of this review and will not be discussed here. renal insufficiency in mm is a medical emergency that needs immediate work-up and management. there is a wide variation in data reporting on the incidence and the degree of renal failure due to differences in the definitions of renal dysfunction, sample sizes of studies, and populations assessed. renal dysfunction occurs in more than a third to half of newly diagnosed patients (serum creatinine (scr) above the upper normal limit or mg/dl or egfr < ml/min/ . m ). table details the list of common causes of renal dysfunction encountered in clinical practice. as per the rifle risk category, approximately - % of patients develop renal failure, and half become dialysis dependent [ , ] . even after an initial renal recovery with appropriate myeloma-directed therapy, more than half of patients can still develop renal failure during the disease course. in the absence of renal recovery, mortality risk is reported to be higher in this population with shortened overall survival. with novel therapies in myeloma, reversibility of renal insufficiency (ri) is associated with improved survival with some studies demonstrating similar survival in patients who recover from acute kidney injury (aki) and those without renal impairment. therefore, achieving renal recovery is of priority and the main goal in these patients [ , , , , ] . mm kidney: in many cases (approximately - % of cases), renal damage is caused by the disproportionate free light chain (flc) excretion through kidney glomeruli, buildup of light chains in distal tubules, and cast formation which further leads to renal tubular obstruction, an entity referred to as mm kidney. the tubules eventually rupture and flc extravasates, causing interstitial inflammation and damage. this is usually compounded by renal injury from hypercalcemia, dehydration, poor intake, use of nephrotoxic analgesics, iv contrast, use of ace/arb blockade, underlying chronic kidney disorder, and/or underlying infection. early diagnosis and timely therapeutic intervention at the time of presentation to the emergency center are critical. therapy should include aggressive resuscitation with iv fluids in efforts to maintain normal urine output, treating concomitant hypercalcemia and other electrolyte imbalances, initiating treatment of underlying infection, and avoiding nephrotoxins. a multidisciplinary approach with hematology and nephrology consults is paramount to optimize care in these patients. suspicion of cast nephropathy in newly diagnosed myeloma patients with serum flc above mg/l should be high, especially if associated selective proteinuria composed of flc/bjp exists, as the degree of renal injury is usually related to tumor load [ ] . a percutaneous kidney biopsy with histology is not required to initiate treatment if myeloma has been confirmed but can be helpful to confirm the diagnosis, assess concomitant light chain or amyloid deposition disease, and predict prognosis. the need for a renal biopsy should be discussed for patients with lower levels of toxic flc, as these patients are more likely to have alternate etiologies for their ri. in patients with significant light chain burden, it is critical to begin treatment immediately with renal recovery as the major immediate goal. the only proven modality with the best chance of renal recovery is rapid cytoreduction to decrease light chain production. newer chemotherapy agents lower flcs quickly, especially with a combinatorial approach. many clinical trials have shown that a bortezomib-dexamethasone combination regimen achieves this goal [ ] . attaining a pre-dialysis serum-free light chain level below mg/l and a % reduction after the first cycle of chemotherapy are independent predictive factors of renal recovery and hemodialysis independence at year [ , ] . hemodialysis or tpe for the sole purpose of offloading tumor burden is currently investigational, as none of the randomized trials have shown a significant benefit. though it takes a few days to weeks to observe the impact of chemotherapy on light chain production, current evidence suggests using hemodialysis only for clinical indications of renal replacement therapy which may exist and not solely for reduction of tumor load. based on two randomized clinical trials, the use of high cutoff hemodialysis to rapidly reduce the load of nephrotoxic light chains may be an option in patients requiring dialysis when treated with bortezomib-based therapies, but the results may be stochastic at best [ , , ] . tpe can rapidly reduce flc loads; however its role in cast nephropathy comes from small retrospective trials which provide no data on the renal histology or sflc levels. in studies that demonstrated benefit, obtaining a biopsy and using a proteasome inhibitor (pi)-based treatment were not uniformly applied, making interpretation of the data difficult. especially in the era of novel drugs, the evidence in favor of tpe is limited [ , , ] unless there is evidence of igm or iga paraproteinemia-associated hyperviscosity syndrome. the utility of urinary alkalization is debated as this theoretically decreases tubular cast formation and, however, can cause risk of renal calcium precipitation, especially if the patient presents with concurrent hypercalcemia. acute tubular necrosis: atn is a consequence of an already compromised renal function in patients with cast nephropathy. hypercalcemiarelated vasoconstriction with subsequent reduced renovascular flow, dehydration, and use of loop diuretics can speed up cast formation. there are some reports of carfilzomib causing direct proximal tubular injury; however, the risk appears to be very small [ ] . monoclonal deposition disease: in contrast to myeloma kidney, midd (heavy chain, light chain, or heavy chain-light chain) and al amyloidosis result from gradual non-fibrillar (congo red negative) and fibrillar (congo red positive) protein deposition, respectively, in the glomeruli. midd is most commonly kappa subtype, while al amyloidosis tends to be lambda; both tend to be associated with predominant albuminuria unlike cast nephropathy. though the most characteristic presentation is nephrotic syndrome due to glomerular involvement, patients with midd can have rapid deterioration of renal function which could be fatal if diagnosis is not reached in a patient presenting with new-onset renal failure. life-threatening complications which need to be closely monitored include arrhythmias, congestive heart failure, and bleeding diathesis. to confirm the diagnosis, subcutaneous fat pad biopsy can be pursued initially, as it is less invasive and can potentially diagnose an al amyloid deposition disease. if negative, proceed with kidney biopsy to look for al amyloid, midd, or other potential renal glomerulopathy. fanconi syndrome: the presence of hypophosphatemia, hypokalemia, hypouricemia, renal tubular acidosis, and glycosuria should raise the suspicion of fanconi syndrome in mm. it is a rare wasting syndrome due to proximal renal tubule dysfunction more commonly seen in patients with mgus leading to loss of glucose, phosphate, amino acids, and uric acid. though it runs a benign course, it can complicate the concomitant electrolyte imbalance and renal failure. ironically, despite the glycosuria, the serum glucose is usually normal, which goes along with the defect in the proximal tubular transport defect [ ] . mm patients are at high risk for cardiac complications secondary multiple factors including an older age group of patients with underlying comorbidities, concurrent kidney involvement, mm-associated deposition disease, and/or anti-mm drug-related side effects. cardiac amyloid: approximately % of patients with mm can have concomitant light chain (al) amyloidosis, the most common type of systemic amyloidosis associated with plasma cell dyscrasias; often this association is missed at the time of mm diagnosis. in amyloidosis, heart involvement is seen in approximately half of the cases [ ] . cardiac amyloidosis can be clinically silent initially, and a mm patient presenting with progressive dyspnea, worsening edema with evidence of heart failure, or dysrhythmia presenting as syncope or hypotensive event requires a thorough work-up to rule out coexisting amyloid disease. detection of amyloid in any organ requires ruling out cardiac involvement. other symptoms which warrant amyloid work-up include easy bruising, periorbital purpura, macroglossia (which is better appreciated when associated with tooth indentation), and carpal tunnel syndrome. once significant symptoms of cardiac amyloid appear, most commonly related to heart failure, median survival shortens, especially in the event of a late diagnosis. amyloid deposition takes place extracellularly throughout the ventricles, atria, valves, conduction system, and in the perivascular regions of small vessels. this eventually leads to thickened, non-dilated ventricles as well as atrial thickening that eventually progresses to thinned dilated atria. the serum concentration of free light chains and cardiac enzymes (n-terminal pro-brain natriuretic peptide and cardiac troponins) are sensitive markers for systemic and cardiac involvement, respectively, in al amyloidosis [ ] . n-terminal pro-b-type natriuretic peptide levels are elevated in cardiac amyloidosis, even in the absence of heart failure, due to regional myocardial stress due to fibrillar extracellular deposition [ ] . cardiac troponins can be elevated, even with an unremarkable coronary angiography, due to predominant deposition in the small intramural vessels sparing the epicardial arteries, but associated with nonischemic destruction of cardiomyocytes. ecg findings suggestive of cardiac involvement include a pattern of low voltage (cardiac changes from amyloid infiltration rather than myocyte hypertrophy) defined as a qrs voltage amplitude of . mv in all limb leads or mv in all precordial leads (sensitivity - %). this may be described as a pseudo-infarct pattern ( - %). atrioventricular right-or left-bundle branch blocks may also suggest cardiac amyloid. echocardiography in advanced stages usually demonstrates a restrictive pattern due to the structural changes and increased echogenicity of the myocardium with a "granular speckling" (low sensitivity of - % but with a high specificity ( - %)). cardiac mri in advanced cardiac amyloidosis shows diffuse subendocardial heterogeneous enhancement in a nonvascular distribution on delayed contrast-enhanced mr images using inversion recovery technique. this, along with diffuse multichambered wall thickening, posterior right atrial wall thickening, or interatrial septal thickening > mm, is specific to amyloidosis [ , , ] . cardiac catheterization is not always required but used to obtain endomyocardial biopsy. it may help to provide important information for cardiac hemodynamics, which generally shows impaired ventricular filling with an elevated left ventricular end-diastolic pressure. demonstration of left ventricular diastolic pressure greater than right remains to distinguish restrictive cardiomyopathy from its differential diagnosis of constrictive pericarditis. fine-needle aspiration of abdominal fat is relatively sensitive for amyloid deposits (> % of patients with al amyloidosis); other sites of amyloid deposition include minor salivary glands, gingiva, and rectum [ , ] . in a patient with clinical suspicion of cardiac involvement, the presence of physical exam findings, blood markers, imaging, and a cardiac biopsy consistent with amyloid are adequate for diagnosis. patients presenting with acute heart failure in al amyloidosis require intensive care monitoring and aggressive supportive care. diuresis is the key and is probably the only treatment modality that can improve hemodynamics. optimal therapy usually requires using higher doses of diuretics or in combinations (furosemide, torsemide, spironolactone, and metolazone) to maintain adequate diuresis, especially in the setting of nephrotic syndrome. an intravenous route is likely preferred in the acute stage, due to the often-present gut edema and better bioavailability. aggressive supportive care includes maintaining strict intake output measurements, dietary salt restriction, measuring daily weights, and monitoring for arrhythmias. the uses of cardiac protective drugs such as beta-blockers should be reserved for cases of atrial fibrillation to maintain adequate filling pressure. in patients without af, its use should be discussed on a case-by-case basis, considering the significant risks including labile blood pressure due to autonomic neuropathy and risk of bradycardia due to coexistent conduction defects. caution should be maintained with the use of angiotensin-converting enzyme inhibitors and angiotensin ii inhibitors, due to similar risk of exacerbating hypotension. both digoxin and calcium blockers, especially nifedipine, have the tendency to bind to amyloid fibrils. this can precipitate congestive heart failure due to increased susceptibility to digoxin toxicity and enhance the negative ionotropic effect with calcium channel blockers [ , , ] . syncope can result from af with rapid heart rate, embolic phenomenon, conduction defects, bradycardia, and ventricular arrhythmias. the most common atrial arrhythmia ( - % of patients) is af and is associated with a very high incidence of thromboembolism. in a mayo clinic study, cardiac amyloidosis patients undergoing transesophageal echocardiography had a higher frequency of intracardiac thrombus ( %) irrespective of the presence of atrial fibrillation. factors associated with increased risk of intracardiac thrombosis include atrial fibrillation, poor left ventricular diastolic function (grade or ), lower left atrial appendage emptying velocity ( cm/s), increased rv wall thickness, low systolic blood pressure, and increased heart rate. this group of patients should be considered high risk for thromboembolic events and merits screening with tee. anticoagulation should be strongly considered in the presence of any of these risk factors due to the heightened risk for mural thrombus development and embolic events. this should be weighed against the risk of bleeding in these patients due to the potential for concomitant coagulopathy and fragile vasculature [ ] . pacemakers are a consideration in the presence of heart block or symptomatic bradycardia. the role of intracardiac defibrillators is controversial due to limited evidence showing a survival benefit both for primary and secondary prevention. several studies report ventricular arrhythmias in about a third of patients; however, this does not appear to be the leading cause of mortality in this patient group. once congestive heart failure occurs, the clinical course for patients rapidly deteriorates, with a median survival of - months from diagnosis. death in severe cardiac amyloid is often heralded by agonal bradycardia, followed by electromechanical dissociation or pea. nonetheless consensus guidelines do not support icd placement for primary prevention of scd in patients if life expectancy is < year. hence these devices have rarely been used in patients with cardiac al amyloidosis. with improvement in the therapeutic platform of cardiac amyloidosis and improved survival, it becomes a priority to be able to select the patients that benefit from antiarrhythmic prophylaxis and primary prevention icds. with the available data, icds should be considered in cardiac amyloid patients with recurrent episodes of non-sustained vt, unexplained syncope, young age at diagnosis, early stages of disease at diagnosis with low levels of cardiac biomarkers, and prognosis > year [ , , , ] . anti-myeloma drug-related cardiotoxicity: proteasome inhibitors are currently the main class of drugs used in front line and in the relapsed setting of mm. fda-approved therapies in this class include bortezomib, carfilzomib, and ixazomib [ ] . among them, carfilzomib has shown the highest rates of cardiotoxicity. in a meta-analysis looking at the cardiotoxicity of carfilzomib, all-grade and high-grade cardiotoxicity were seen in % and % of patients, respectively, higher than the control arm. the most significant events included heart failure ( %), arrhythmias ( . %), and ischemic events ( %). rare reports of carfilzomibassociated cardiac arrests also exist. risk can be higher in patients with comorbidities such as older age, obesity, anemia, kidney dysfunction, previous mediastinal radiation, high-dose corticosteroids, prior or concurrent anthracycline exposure, use of higher carfilzomib doses, short infusion times, and undiagnosed amyloidosis [ , , , , ] . anecdotal reports suggest bortezomib may lead to cardiotoxicity as well, although a recent meta-analysis did not find a significantly increased risk compared to the control arm [ , ] . the first intervention in suspected cardiotoxicity is to hold further therapy and follow expectant management. in cases of congestive heart failure, once the heart failure symptoms improve, it is reasonable to restart the chemotherapy at a lower dose, with a longer infusion time and limiting peri-treatment iv fluids. arrhythmic events would require careful consideration regarding rechallenging patients after considering the risk-benefit ratio. hyperviscosity syndrome: in a patient undergoing work-up for mm or with an established diagnosis, symptoms of headache, nose bleeds, mental status or visual changes, auditory symptoms, focal weakness, excessive lethargy, seizures, or coma should raise suspicion for hyperviscosity syndrome. though extremely uncommon in mm ( %) in comparison to waldenström's macroglobulinemia ( - %), a low threshold should be kept to work up a patient for hyperviscosity as this can be fatal if not recognized early. the viscosity tends to increase with increase in molecular size, shape, and weight of the involved paraprotein and abnormal polymerization. patients tend to develop symptoms when the serum viscosity reaches centi-poise (cp) (normal serum viscosity, . - . cp). this usually corresponds to an m spike of g/dl if igm, g/dl for igg, and - g/dl for iga paraproteinemia. however, these levels are arbitrary, and the relationship is nonlinear as patients can have symptoms even with a level lower or could be asymptomatic with a higher level [ , ] . in mm, igg (mostly igg ) or iga paraprotein tends to be reported more commonly with hyperviscosity than igm most likely due to the inherent rarity of igm mm [ , ] . due to increased serum viscosity, there is impaired blood flow and sludging throughout the microvasculature, leading to tissue ischemia, placing the patient at risk for thrombosis to major organs leading to myocardial, cerebrovascular, and retinal ischemia. with passive venous congestion, patients can often present with bleeding symptoms. thorough physical exam is paramount including a fundoscopic exam, which may reveal dilated, tortuous, engorged, "sausage" veins with associated hemorrhages. bleeding at sites involving mucosa is common which can include oral and nasal cavity, the uterus, and the gastrointestinal tract. purpura and skin bruising are also common. consensus mm guidelines do not recommend plasmapheresis in the absence of signs or symptoms for hyperviscosity. however, a low threshold should be maintained to initiate treatment at the earliest suspicion of symptoms or signs; it follows a two-prong strategy consisting of immediate plasmapheresis to lower the excess paraproteins and chemotherapy directed at the primary process of mm. unlike the response of igm-related paraproteinemia (> % intravascular), where a - % reduction of viscosity is expected with one treatment, iga or igg (< % intravascular) hyperviscosity can take several sessions to achieve the same result [ ] . if plasmapheresis is not readily available and the patient is having lifethreatening symptoms, phlebotomy may reduce hyperviscosity-related acute symptoms. in mm patients, who are often anemic at presentation, blood transfusions should be done only in emergent situations and with caution until after the initiation of plasmapheresis to prevent rise in serum viscosity [ , ] . venous thromboembolism: patients with mm are at an increased risk of venous thrombosis due to patient-related, disease-related, and treatment-related factors. patient-related factors include older age, recent surgery or immobilization, and decreased functional status; the major disease-related factor is increased pro-thrombotic status from heightened inflammatory markers, especially at diagnosis. there is a high level of factor viii and von willebrand factor as well as acquired resistance to activated protein c [ ] . in addition, mm patients treated with immunomodulators especially thalidomide or lenalidomide used in combination with steroids or other chemotherapeutic agents increase the risk further [ , ] . management of acute dvt or pe involves withholding the offending drug if any and starting immediate systemic anticoagulation with low-molecular-weight heparin or unfractionated heparin. lmwh is the preferred anticoagulation at the time of transition to outpatient therapy as evidence suggests better safety and a superior efficacy in stabilizing the clot in comparison to other anticoagulants [ ] . factors that make oral anticoagulation less ideal is drugdrug interaction and unreliable therapeutic levels resulting from patient-related malnutrition, infection, and drug holds from cytopenias. once full anticoagulation is attained, the immunomodulator can be reintroduced. in the presence of thrombocytopenia, which is commonly encountered in mm patients, the dose of lmwh needs adjustment and in general a recommendation of % dose reduction if platelet counts below , /μl, and discontinuation if platelet count < , /μl is followed. duration of anticoagulation should be a minimum of months; however in the presence of the offending drug, systemic anticoagulation should be continued for the total duration of therapy [ ] . arterial thromboembolic events, though rare, have also been reported with thalidomide, lenalidomide, and pomalidomide; rarely, this may present as myocardial infarction or stroke. the role of newer oral anticoagulants including factor xa inhibitors and direct thrombin inhibitors is currently investigational in the treatment of malignancy-associated thromboembolic events; however, they are a good alternative for patients with renal failure [ ] . sepsis/invasive infections: - % of newly diagnosed mm patients succumb to the disease in the first few months with infection contributing to more than half the cases [ , , ] . high incidence of early infection in mm is due to the suppressed humoral and t cell-mediated immunity by the disease itself. immunosuppression is mediated by disease-and treatment-related factors including decreased ratio of functional to dysfunctional immunoglobulins, defects in antibody opsonization, steroid-related t cell defects, secondary immunodeficiency related to chemotherapy, restricted pulmonary reserve from thoracic rib fractures and opiate use, mucosal damage, indwelling catheters, and presence of renal failure [ , , ] . bacterial infections, especially streptococcus pneumoniae, haemophilus influenzae, and escherichia coli, tend to be the predominant organisms causing infection at diagnosis, while staphylococcus aureus and other gram-negative infections are more common in the relapsed refractory setting [ , ] . the use of novel drugs combined with steroids has increased the rate of viral and fungal infections which can occur any time during the disease course [ , , ] . viral infections, especially herpes simplex virus (hsv) and varicella-zoster virus (vzv), have increased in incidence with the introduction of proteasome inhibitors such as bortezomib. viral prophylaxis with acyclovir or valacyclovir is recommended in all patients undergoing therapy with proteasome inhibitors or monoclonal antibodies. although invasive fungal infection (approximately - %) incidence is low, the mortality rate is high with approximately % of patients requiring icu management. the introduction of novel agents tends to be associated with later-onset invasive fungal infections compared to studies from the conventional chemotherapy era where an earlier onset was noted [ ] . furthermore the use of long-term and high-dose dexamethasone can cause persistent defect in t cell-mediated immunity which predisposes patients to mucosal candidiasis, p. jirovecii, hsv, and vzv infections. following sepsis guidelines with aggressive fluid resuscitation and broad-spectrum antibiotic coverage as well as growth factor support if neutropenic is warranted in a patient presenting with suspected sepsis/infection. in case of clinical deterioration with unclear source of infection, persistent febrile neutropenia, or hemodynamic compromise, consider computer tomography (ct) scan including sinus imaging. other investigative modalities for diagnosis should include bronchoscopy/bal with microscopy and bacteria, viral, and fungal culture. in suspected cases of fungal infection, aspergillus pcr and galactomannan testing on serum and bal should be performed. due to concomitant immunodeficiency, treatment with intravenous immunoglobulins is considered in patients with recurrent bacterial or viral infections; however its role in treating an acute infection is limited. direct involvement of pulmonary parenchyma in mm is extremely rare. pulmonary complications can arise from a broad range of different mechanisms both infectious and noninfectious. in majority of the cases presenting with respiratory failure, the etiology is infectious. patients with myeloma can present with lung infiltrates, ground glass opacities, nodules, masses, effusion, and lymphadenopathy. noninfectious causes that need to be ruled out include congestive heart failure, pulmonary embolism, pulmonary hemorrhage, and drug-induced pneumonitis. myeloma lung: case reports and case series describe the various ways mm can involve the lung. presentation of lung disease is variable and includes consolidative or interstitial pattern infiltrates on imaging, intraparenchymal plasmacytomas, intrapulmonary calcifications, or pleural effusions [ , , ] . presentations similar to ards have also been reported [ , , , , ] . a high index of suspicion is required as there is a broad differential of diagnoses with similar radiographic findings. patients with extramedullary mm tend to have more aggressive disease and can deteriorate rapidly due to disease progression if not recognized and treated early. if there is evidence of mm progression on blood tests or bone marrow, a biopsy (surgical, transbronchial) or bronchoscopy with aspiration and/or bronchoalveolar lavage (bal) should be strongly considered with microbiologic and flow cytometric analysis. once infection is excluded and evidence of progression is confirmed, prompt initiation of mm directed therapy is warranted [ ] . diffuse alveolar hemorrhage: in patients presenting with acute onset hypoxia, pulmonary opacities, and fevers, especially in the setting of thrombocytopenia and anemia, pulmonary hemorrhage is a possibility. diffuse alveolar hemorrhage (dah) has been rarely reported in mm patients, but there have been cases associated with bortezomib and in the posttransplant setting [ , , , ] . though rare, this is potentially a fatal event. a thorough microbiology screen, echocardiogram, ct imaging, autoimmune work-up, and coagulopathy work-up are warranted [ ] . bal showing presence of gross blood and the percentage of hemosiderin-laden macrophages (siderophages) > % at bal are suggestive of a diagnosis of dah [ , , ] . aggressive supportive care and empiric broad-spectrum antimicrobial therapy should be considered. the role of early initiation of steroids is currently based on retrospective series and case reports. an md anderson prospective study examined critically ill adult hematopoietic transplant patients treated for dah, and on multivariate analysis, an initial medium ( - mg/day) and high-dose ( mg/day) steroids were associated with a higher icu mortality (p = . ) as compared with the low dose (< mg/day). adjunctive treatment with aminocaproic acid in this study, which is commonly used in dah, did not produce differences in outcomes [ , ] . drug-induced interstitial pneumonitis (dip): dip manifesting as interstitial lung disease has been reported with lenalidomide, thalidomide, and bortezomib [ , , , ] . though mechanisms are not fully elucidated, oxidative stress, prostaglandin e (pge ) inhibition, fibroblast proliferation, and impairment of cell repair by epidermal growth factor receptor blocking may play a role. bal with culture and microscopy should be able to help rule out infectious causes. the lymphocytic preponderance typically seen in bronchoalveolar lavage (bal) is supportive of a hypersensitivity mechanism; however, this finding is nondiagnostic and requires meticulous exclusion of other causes. invasive procedures like biopsy usually do not provide any specific findings diagnostic for dip and, therefore, should be obtained only on a case-by-case basis. once dip is suspected, stopping the offending agent is the main therapeutic approach; steroids may be used in severe cases [ , ] . although no guidelines exist on the duration of steroids, in general, a slow taper is recommended [ ] . caution should be maintained on rechallenging the patients with the offending medication as the risk of recurrent reaction is extremely high. hypercalcemia: being one of the four diagnostic criteria for mm (crab criteriacalcium, renal insufficiency, anemia, and bone disease), hypercalcemia is defined as calcium level corrected for albumin mg/dl. almost a third of mm patients are diagnosed with hypercalcemia at diagnosis or during the disease course [ , ] . the mechanism is due to local osteolysis; at the cellular level, it is mediated by interleukin , interleukin , and tumor necrosis factor α with rankl being the final common mediator. most patients presenting with hypercalcemia have associated anemia, thrombocytopenia, kidney dysfunction, lytic lesions, and advancedstage disease. hypercalcemia is associated with aggressive disease biology and heavy disease burden and remains a poor prognostic feature even in the era of novel agents [ ] . clinically, hypercalcemia can be asymptomatic; however, patients often have symptoms which range from subtle signs of malaise or fatigue to severe consequences including renal failure, altered mentation, seizures, shortened qt, and risk of arrhythmias. gastrointestinal manifestations such as nausea, vomiting, ileus, anorexia, and episodes of pancreatitis have been reported [ ] . if not treated promptly, hypercalcemia is lethal. increased calcium promotes natriuresis which can further worsen an already compromised kidney function. this dehydration then leads to worsening hypercalcemia and renal function. though the threshold levels are arbitrary, patients with serum calcium level < mg/dl or minimal symptoms can be managed with fluid resuscitation which reverses the hypovolemia, repletes the intravascular volume deficit, and improves urinary calcium excretion. though the definitive approach is prompt mm treatment initiation, often due to patient frailty and concomitant organ damage, chemotherapy cannot be initiated until the patient is more stable. if the patient is on calcium, vitamin d supplements, thiazide diuretics, or any other drugs which promote hypercalcemia, they should be stopped immediately. in patients with levels > mg/dl or with significant symptoms, other adjunct therapies should be used as a temporizing measure. loop diuretics, which were previously commonly used for hypercalcemia, should not be routinely used. the utility of forced saline diuresis is not consistent; with lower doses, calciuresis is an indirect effect of the accompanying natriuresis. to cause a direct calciuretic effect, doses as high as mg/h is required, which can cause unwanted metabolic derangements and worsening renal cast formation with risk of worsening renal dysfunction [ ] . the use of calcitonin to treat patients with hypercalcemia is limited owing to its inability to dramatically lower serum calcium levels. however, it can work synergistically with other therapies without significant adverse side effects until chemotherapy can be initiated. calcitonin, by inhibition of bone resorption and increased renal calcium excretion, has rapid onset of action and can lower calcium levels by - mg/dl ( . mmol/l). the dose is iu/kg given subcutaneously or intramuscularly every - h. the efficacy in general wears off after - days due to the escape phenomenon (tachyphylaxis) of the calcitonin sensing receptors [ ] . preclinical studies suggest tachyphylaxis can be prevented with the addition of corticosteroids [ , , ] . with its anti-mm effect, adding corticosteroids can add to the synergy to this combination in the treatment of hypercalcemia. the role of steroids in hypercalcemia of malignancy comes from case reports and case series. corticosteroids decrease calcium absorption from the gut, decrease renal tubular reabsorption, and promote excretion [ , ] . prednisone (dose of - mg/day) or iv hydrocortisone (dose of - mg/day) for - days is usually used in this setting. this dose, which is effective in patients with chronic granulomatous diseases (e.g., sarcoidosis) and malignancies such as lymphoma, may be suboptimal for patients with mm due to the direct osteolytic action of mm cells. if clinical status permits, dexamethasone should be considered at mm treatment doses ranging from to mg weekly or to mg daily on a days on, days off schedule. intravenous bisphosphonates (pamidronate, zoledronic acid, ibandronate) work by blocking osteoclast-mediated bone resorption. intravenous zoledronic acid is more routinely used than other drugs in this category due to its higher potency, efficacy, and shorter infusion time ( min) , when compared to ibandronate and pamidronate [ , , , ] . bisphosphonates have an established role in severe or symptomatic hypercalcemia, but often it is challenging to administer them upfront for mm patients due to the renal function-based dose limitation [ ] . it also has slow onset of action and reaches peak in about - days; therefore it needs to be used in a combinatorial approach. denosumab, on the other hand, has a renally independent clearance mechanism and hence does not require kidney functionbased dosing adjustments. it is currently fda approved to treat hypercalcemia of malignancy refractory to bisphosphonate therapy and is dosed at mg subcutaneous injection every weeks with additional doses of mg on days and of the first month of therapy [ , ] . mithramycin and gallium nitrate are drugs of historical interest and are not currently used in the standard setting. in refractory cases of hypercalcemia seen in advanced mm and kidney involvement, with impending cardiovascular or cerebrovascular deterioration, hemodialysis ca + -free dialysate should be strongly considered. tumor lysis syndrome: due to the low proliferative activity of plasma cells which is < % in majority of patients, tls is extremely uncommon in mm [ , ] . mm patients who are likely to be at risk are patients with high tumor burden (as noted by an increased serum lactate dehydrogenase and beta- microglobulin), diffuse bone marrow disease (plasma cells > % of all nucleated cells as per a case series), extensive skeletal involvement, high-risk cytogenetics, and plasmablastic morphology [ , ] . there are reports of bortezomib, thalidomide, and steroid associated tls [ , ] . tumor lysis syndrome manifests due to lysis of massive numbers of tumor cells releasing intracellular potassium and phosphorous causing hyperkalemia and hyperphosphatemia. this causes calcium to precipitate as calcium phosphate in tissues causing secondary hypocalcemia. hyperuricemia results from the breakdown of nucleic acids in the tumor cells. the resultant metabolic derangement, if left untreated, can progress to kidney failure, mental status changes, seizures, arrhythmias, and even death. diagnosing tls can be challenging in patients with mm due to its uncommon association and often seen associated renal insufficiency [ ] . it is imperative for clinicians to be aware of this complication in mm patients undergoing treatment with novel combinations. tls is managed with aggressive intravenous hydration, rasburicase, allopurinol, and at times sodium bicarbonate. timely initiation of renal replacement therapy is paramount in patients with lifethreatening electrolyte disturbances. epidural spinal cord compression (escc): acute emergencies related to the nervous system in mm are mostly related to escc. vertebral involvement is prevalent in - % of mm patients, and escc is encountered in approximately - % of patients either at presentation or during the course of disease [ , ] . the compression usually results from vertebral fractures caused by osteolytic tumors or malignant osteoporosis. very rarely, it has been reported due to extraosseous epidural mm or from extradural extension of plasmacytoma [ ] . in majority of the cases, thoracic or lumbar spinal cord is involved (> %) [ , ] . it is vital to recognize the symptoms early, with prompt imaging since the strongest predictor of neurologic outcome with treatment is the neurologic status when treatment is initiated [ ] . clinical features depend on the site and degree of involvement. a new-onset back pain or a worsening of an existing pain in a mm patient should prompt a work-up to rule this out. pain can be localized or radiating which usually worsens with lying down. associated bowel and bladder dysfunction is present in about half of the cases [ ] . if treatment is delayed, myelopathy progresses to loss of sensory and motor function leading to paraplegia. spinal cord injury at the cervical level is uncommon; however, if affected above c -c , it results in respiratory, cardiac, and autonomic decompensation [ ] . gadolinium-enhanced mri is the initial gold standard imaging modality as it can aid in the thorough evaluation of spine, degree of tumor or fracture involvement, and for radiation planning [ ] . the safety of mri should be discussed in the presence of pacemakers and defibrillators in a multidisciplinary fashion, and if contraindicated, ct myelography should be performed. there is a lack of consensus guidelines for treatment and hence warrants an emergent multidisciplinary team consult involving the oncologist, neurosurgeon, and radiation oncologist. the optimal management depends on the extent of disease, performance status of the patient, and presence of spine instability. immediate therapeutic strategies involve achieving minimal mobility until stability of the spine is achieved. steroids should be initiated even while awaiting diagnostic study results (dexamethasone at doses mg iv followed by mg daily in divided doses with a taper over weeks) [ ] . doses as high as mg initial bolus were used in the past, but are not used any more due to risk of significant side effects and limited evidence to suggest benefit [ ] . spine stabilization by reducing the mechanical load can be achieved with the use of a neck collar (e.g., philadelphia collar) in case of cervical spine or braces at other sites and is not generally recommended for longer than months [ ] . a thorough baseline neurological exam followed by serial neurological exams should be done to assess clinical status. radiotherapy should be started as soon as possible as mm is extremely radiosensitive, unless in very late in the disease. in a retrospective study which included patients with mm/lymphoma treated with rt alone, % of the patients experienced an improvement in motor function, % had no change, while % deteriorated. in this group, patients who experienced slowly progressive motor deficit defined as time of onset > days had better response rates than patients who had fast onset deficit defined as time of onset < days. the improvements in motor function in these groups were % and %, respectively. no patients who received radiotherapy progressed in the slow onset motor weakness group [ , ] . current evidence does not support resorting to surgery in patients with escc, as most mm cases respond to radiation. the need for surgical stabilization with fixation or by percutaneous repair is in general reserved for cases with spine instability or spine compression from a vertebral body. treatment of the underlying malignancy with systemic chemotherapy or novel agents, bone-modifying agents, and neurorehabilitation can help in recovery of the vertebral and spinal damage [ , ] . cns myelomatosis: neurological symptoms in mm are most commonly due to hypercalcemia, cord compression, anti-mm drug related, hyperviscosity, or amyloid-related neuropathy. direct involvement by malignant cells of the central nervous system (cns) or peripheral nervous system, unlike lymphoma, is uncommon in mm. direct cns involvement in mm often presents as leptomeningeal myelomatosis (lmm), intraparenchymal metastasis, cranial nerve involvement, or radiculopathy [ , , ] . though conventional wisdom would suggest cns involvement is seen later during the disease, most patients present relatively early with median time of diagnosis of lmd around months from mm diagnosis. hence the risk is unlikely only related to improved survival in mm patients but also due to an aggressive early biology. supporting this contention, cns involvement is reported mostly in patients with high-risk mm with heavy tumor burden, plasmablastic morphology, or plasma cell leukemia [ ] . patients often present with focal weakness, cranial nerve palsies, mental status changes, speech and gait disturbances, symptoms of increased intracranial pressure, and/or seizures. csf examination reveals pleocytosis, increased protein levels higher than g/dl, presence of monoclonal plasma cells, and in some cases an increased opening pressure. the diagnosis is usually reached with the first analysis of csf [ ] . mri imaging with and without contrast would aid in identifying the presence and extent of the disease. in the presence of symptoms, steroids can help in alleviating the symptoms and reducing intracranial pressure. therapy involves strategies similar to that used for other hematological malignancies with cns involvement, including intrathecal chemotherapy and cranial irradiation with systemic chemotherapy. despite majority of patients achieving csf clearance with cns-directed therapy showing significant potential for symptom improvement, the overall prognosis is grim with the currently approved therapies in mm. the median survival ranges from to months, with a small fraction surviving past years [ ] . hence it is paramount to have a thorough discussion on the goals of therapy once cns involvement is diagnosed [ , ] . anemia: hematological emergencies in mm most commonly arise due to disease-or treatment-related myelosuppression. anemia (hb > g/dl below the lower limit of normal or a hemoglobin value < g/ dl) is a common complication seen in - % mm patients at presentation and in nearly all patients at some point in the disease course [ ] . several factors drive anemia in mm patients which include bone marrow involvement, low serum erythropoietin level due to kidney dysfunction, hemolysis, impaired availability of storage iron, and anti-mm treatment-related bone marrow suppression. an aggressive anti-mm treatment approach despite the severity of anemia is warranted in patients with anemia suspected to be from mm. this is likely encountered in most cases of newly diagnosed mm. myeloma therapy often worsens the anemia, before it improves once myeloma responds. these patients should be closely monitored for transfusion requirement. no universal guidelines exist for transfusion goals. in general, leukoreduced and irradiated blood is used for transfusion for hemoglobin level < - g/dl or symptomatic anemia. the transfusion goal can vary in the presence of other comorbidities such as cardiac ischemia, active bleeding, or if symptoms due to hypoperfusion are present. a major proportion of patients with mm who have chronic anemia are those with long-standing disease in partial remission or stable response. erythropoiesis-stimulating agents are not routinely used, except in this population after careful selection, to improve the ongoing anemia despite chemotherapy. anti-mm drug-induced tma: in patients who present with new-onset anemia and thrombocytopenia, more than often, it is ascribed to myelosuppressive treatment or for mm progression. in the setting of worsening aki, it is imperative to check for evidence of hemolysis with a haptoglobin level, ldh level, and peripheral blood smear looking for schistocytes. one should strongly consider ruling out tma as it has been reported with novel drugs and with older chemotherapeutic agents; two notable novel drugs are bortezomib and carfilzomib, and a chemotherapeutic agent is cisplatin. prompt discontinuation of these medications is warranted if the medication is suspected to be the likely culprit. plasmapheresis is initiated in most of patients, and eculizumab has been tried in a small number of patients. the role of these two therapies in malignancy-associated tma is controversial and should be discussed on a case-by-case basis [ , , , ] . the novel drug combinations with manageable adverse profile hold great promise in mm, which has turned mm into a chronic disease with an acceptable quality of life for patients. it is also crucial to recognize the complications of mm or its treatment and understand the management strategies, which could help prevent excess morbidity or mortality associated with this incurable disease. multiple myeloma and light chain-associated nephropathy at end-stage renal disease in the united states: patient characteristics and survival diffuse alveolar hemorrhage in hematopoietic stem cell transplant recipients fine-needle aspiration of abdominal 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malignancies, prothrombotic mutations, and the risk of venous thrombosis treatment of myeloma cast nephropathy (mcn): a randomized trial comparing intensive haemodialysis (hd) with high cut-off (hco) or standard high-flux dialyzer in patients receiving a bortezomib-based regimen (the myre study, by the intergroupe francophone du myélome (ifm) and the french society of fanconi's syndrome induced by a monoclonal vκ light chain in waldenström's macroglobulinemia thalidomide-induced reversible interstitial pneumonitis in a patient with recurrent ovarian cancer intracranial involvement in plasmacytomas and multiple myeloma: a pictorial essay tumor lysis syndrome in patients with light chain multiple myeloma: report of two cases renal failure with the use of zoledronic acid lenalidomide-induced interstitial lung disease plasma exchange when myeloma presents as acute renal failure: a randomized, controlled trial high cut-off haemodialysis (hco-hd) does not improve outcomes in myeloma cast nephropathy: results of european trial of free light chain removal by extended haemodialysis in cast nephropathy rapid complete remission in multiple myeloma with bortezomib/thalidomide/dexamethasone combination therapy following development of tumor lysis syndrome effect of steroid therapy on hypercalcemia and renal insufficiency in sarcoidosis alveolar hemorrhage. diagnostic criteria and results in immunocompromised hosts new anticoagulants in the treatment of patients with cancer-associated venous thromboembolism metabolic disorders in hematologic malignancies-a review guidelines for standard investigative workup: report of the international myeloma workshop consensus panel renal impairment in patients with multiple myeloma: a consensus statement on behalf of the international myeloma working group vmp (bortezomib, melphalan, and prednisone) is active and well tolerated in newly diagnosed patients with multiple myeloma with moderately impaired renal function, and results in reversal of renal impairment: cohort analysis of the phase iii vista study neurologic complications of plasma cell disorders the clinical features of immunoglobulin light-chain (al) amyloidosis with heart involvement acquired resistance to activated protein c (aapcr) in multiple myeloma is a transitory abnormality associated with an increased risk of venous thromboembolism myeloma of the central nervous system: strong association with unfavorable chromosomal abnormalities and other high-risk disease features tumour lysis syndrome complicating high-dose treatment in patients with multiple myeloma intracardiac thrombosis and anticoagulation therapy in cardiac amyloidosis denosumab versus zoledronic acid for treatment of bone metastases in men with castration-resistant prostate cancer: a randomised, double-blind study tumor lysis syndrome in a multiple myeloma treated with thalidomide mechanisms and treatment of hypercalcemia of malignancy aggressive phase of multiple myeloma with pulmonary plasma cell infiltrates selective binding of nifedipine to amyloid fibrils occult pulmonary haemorrhage in leukaemia improvement in renal function and its impact on survival in patients with newly diagnosed multiple myeloma spinal cord compression. in: decision making in medicine a pilot randomised comparison of dexamethasone mg vs mg per day for malignant spinal-cord compression treated by radiotherapy: trog . superdex study plasmablastic morphologyan independent prognostic factor with clinical and laboratory correlates: eastern cooperative oncology group (ecog) myeloma trial e report by the ecog myeloma laboratory group light-chain cardiac amyloidosis: strategies to promote early diagnosis and cardiac response outcome and incidence of appropriate implantable cardioverterdefibrillator therapy in patients with cardiac amyloidosis hyperviscosity in plasma cell dyscrasias randomized, double-blind study of denosumab versus zoledronic acid in the treatment of bone metastases in patients with advanced cancer (excluding breast and prostate cancer) or multiple myeloma renal thrombotic microangiopathy and podocytopathy associated with the use of carfilzomib in a patient with multiple myeloma bortezomib and heart failure: case-report and review of the french pharmacovigilance database risk of early mortality in patients with newly diagnosed multiple myeloma multiple intraparenchymal brain plasmacytomas with spontaneous intratumoral hemorrhage treatment of acute renal failure secondary to multiple myeloma with chemotherapy and extended high cut-off hemodialysis the pathogenesis and diagnosis of acute kidney injury in multiple myeloma early reduction of serum-free light chains associates with renal recovery in myeloma kidney immunosuppression and infection in multiple myeloma discrimination of metastatic from acute osteoporotic compression spinal fractures with mr imaging diffuse pulmonary parenchymal involvement in multiple myeloma: antemortem diagnosis nonspecific interstitial 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extradural spinal cord compression multiple myeloma causing interstitial pulmonary infiltrates and softtissue plasmacytoma myeloma in patients younger than age years presents with more favorable features and shows better survival: an analysis of patients from the international myeloma working group central nervous system involvement in multiple myeloma patients in the era of novel therapies (p . ) zoledronic acid is superior to pamidronate in the treatment of hypercalcemia of malignancy: a pooled analysis of two randomized, controlled clinical trials effectiveness of radiation therapy without surgery in metastatic spinal cord compression: final results from a prospective trial multiple myeloma invasion of the central nervous system proliferative activity of myeloma cells determined by ki- antibody: biological and clinical significance acute respiratory distress syndrome due to pulmonary involvement by neoplastic plasma cells in multiple myeloma hyperviscosity syndrome in plasma cell dyscrasias acute pancreatitis secondary to hypercalcemia of multiple myeloma effect of plasmapheresis on hyperviscosity-related retinopathy and retinal hemodynamics in patients with waldenstrom's macroglobulinemia cardiac amyloidosis and its new clinical phenotype: heart failure with preserved ejection fraction corticosteroids as adjunctive therapy for diffuse alveolar hemorrhage associated with bone marrow transplantation acute tachypnea during mechanical ventilation in a -year-old man with multiple myeloma involving the spinal cord optimizing the management of patients with spinal myeloma disease risk factors for early death in patients undergoing treatment for multiple myeloma prophylactic low-dose aspirin is effective antithrombotic therapy for combination treatments of thalidomide or lenalidomide in myeloma is elevated plasma b-natriuretic peptide in amyloidosis simply a function of the presence of heart failure? infections in patients with multiple myeloma in the era of high-dose therapy and novel agents unexpected cardiotoxicity in haematological bortezomib treated patients phase i trial of the proteasome inhibitor bortezomib in patients with advanced solid tumors with observations in androgenindependent prostate cancer cerebral infarction in igg multiple myeloma with hyperviscosity meningeal and cerebral involvement in multiple myeloma patients randomized phase ii trial comparing different doses of the bisphosphonate ibandronate in the treatment of hypercalcemia of malignancy efficacy and safety of ibandronate in the treatment of hypercalcemia of malignancy: a randomized multicentric comparison to pamidronate continued survival gains in recent years among critically ill myeloma patients acute respiratory distress syndrome with pulmonary calcification in two patients with b cell malignancies immunodeficiency and immunotherapy in multiple myeloma is surgery required in the management of spinal cord compression in myeloma patients? carfilzomib: a cause of drug induced thrombotic microangiopathy final results of a prospective study of the prognostic value of the time to develop motor deficits before irradiation in metastatic spinal cord compression outcome after radiotherapy alone for metastatic spinal cord compression in patients with oligometastases low-, medium-and highdose steroids with or without aminocaproic acid in adult hematopoietic sct patients with diffuse alveolar hemorrhage lung postmortem autopsy revealing extramedullary involvement in multiple myeloma causing acute respiratory distress syndrome digoxin sensitivity in amyloid cardiomyopathy o dialysis with hco membrane in combination with potent chemotherapy increases the probability for renal recovery and better survival in patients with acute renal failure due to myeloma kidney-data from biphasic pattern of bacterial infection in multiple myeloma guidelines on the use of therapeutic apheresis in clinical practiceevidence-based approach from the writing committee of the american society for apheresis: the seventh special issue combination of calcitonin and pamidronate for emergency treatment of malignant hypercalcemia evaluation and management of the cardiac amyloidosis lenalidomide induced interstitial lung disease. drug induced lung disease: case reports changing patterns of infections in patients with multiple myeloma autoimmune manifestations in patients with multiple myeloma and monoclonal gammopathy of undetermined significance serum free light chain analysis for diagnosis, monitoring, and prognosis of monoclonal gammopathies leptomeningeal myeloma pulmonary complications of bone marrow transplantation evidence-based focused review of management of hyperviscosity syndrome early-onset severe diffuse alveolar hemorrhage after bortezomib administration suggestive of pulmonary involvement of myeloma cells carfilzomib associated thrombotic microangiopathy initially treated with therapeutic plasma exchange invasive fungal infections in patients with multiple myeloma: a multi-center study in the era of novel myeloma therapies hypersensitivity pneumonitis-like syndrome associated with the use of lenalidomide spinal cord compression from epidural metastases incidence and outcome of patients starting renal replacement therapy for end-stage renal disease due to multiple myeloma or light-chain deposit disease: an era-edta registry study mr findings in cardiac amyloidosis implantable cardioverterdefibrillator placement in patients with cardiac amyloidosis severe reversible cardiac failure after bortezomib treatment combined with chemotherapy in a non-small cell lung cancer patient: a case report regulation of calcitonin receptor by glucocorticoid in human osteoclast-like cells prepared in vitro using receptor activator of nuclear factor-κb ligand and macrophage colonystimulating factor local control and survival in spinal cord compression from lymphoma and myeloma management of tumor lysis syndrome in patients with multiple myeloma during bortezomib treatment thalidomidedexamethasone as primary therapy for advanced multiple myeloma carfilzomib-associated cardiovascular adverse events: a systematic review and meta-analysis multiple myeloma presenting as interstitial lung disease into the heart: the emerging role of the ubiquitin-proteasome system incidence and risk of cardiotoxicity associated with bortezomib in the treatment of cancer: a systematic review and metaanalysis acute spinal cord dysfunction. in: the washington manual of medical therapeutics retracted: overview of recent trends in diagnosis and management of leptomeningeal multiple myeloma multiple myeloma involving skin and pulmonary parenchyma after autologous stem cell transplantation proteasome inhibitor associated thrombotic microangiopathy hypercalcemia remains an adverse prognostic factor for newly diagnosed multiple myeloma patients in the era of novel antimyeloma therapies conflicts of interest kp = research funds from poseida, intrexon/ziopharm, takeda. advisory board/consultancy in takeda, dava oncology, celgene, janssen, amgen, bms, and oncopeptides. key: cord- -e bn ui authors: nan title: ecr book of abstracts - a - postgraduate educational programme date: - - journal: insights imaging doi: . /s - - - sha: doc_id: cord_uid: e bn ui nan for pet-ct, the ct exam is generally performed as standard whole-body exam from the base of the skull to the upper thighs. standard parameters are non-ionic iodinated intravenous contrast material at . g/kg bodyweight with a venous delay of seconds after injection and - mm thick continuous axial reconstructions with medium soft convolution kernels. ct images frequently contain important diagnostic information beyond mere 'anatomic landmarking', so generally a diagnostic, contrast enhanced normal-dose ct should be performed except if a recent diagnostic ct scan is available for fusion. then, a low-dose ct is sufficient for attenuation correction. a difference from routine ct protocols is the expiratory position to match the respiratory position of pet acquisition. also, negative oral contrast material should be applied and the whole body should be included in the field of view to allow effective attenuation correction of pet images. diagnostic reading has to include lung, soft tissue and bone windows. optimally, the assessment should be performed by one reader evaluating ct and pet images simultaneously on multiplanar reformats. learning objectives: . to get acquainted with standard ct examination parameters for oncological imaging including the requirements for an effective attenuation correction. . to see the diagnostic value of ct beyond 'anatomical landmarking'. . to learn effective ways to interpret pet-ct examinations. nuclear medicine perspective t. beyer; zurich/ch combined pet/ct images were first proposed as early . since pet/ ct became available for broader clinical testing. since its commercial introduction in more than ' pet/ct systems were installed worldwide. pet/ct is a logical and technical consequence of early, manual or semi-automatic efforts to align functional and anatomical images for easier and improved diagnosis. pet, or positron emission tomography, is an emission tomographic imaging method based on the application of radioactively labelled biomolecules in order to measure and quantitate signalling or metabolic pathways. ct, computed tomography, on the other hand, uses an external ionising radiation transmission source to generate projection data of the transmitted radiation, thus helping to generate high spatial resolution images of the anatomy of the subject. both sets of information can be combined easily in a pet/ct, whereby both the pet and ct components can be operated in close spatial proximity within a single gantry without cross-talk effects. through the combination of ct and pet overall examination times of oncology pet studies are reduced by %. in addition, pet instrumentation has been advanced to include time-of-flight measurements for improved signal-to-noise ratio, extended axial field-of-view-coverage for higher sensitivity and novel image reconstruction for improved contrast. today, high-quality one-stop shop staging with pet/ct is possible in min, or less. learning objectives: . to illustrate the origin of combined pet/ct imaging. . to motivate the strength of pet: high spatial sensitivity, quantification and functional information. . to appreciate the difference between "contrast" and "tracer" imaging. . to highlight novel developments in pet imaging: time of flight (tof), extended axial field-of-view. computed tomography is the main contribution to diagnostic medial radiation exposure to the public. in the year , ct accounted for only % of all radiationassociated examinations; however, at the same time it accounted for % of the total radiation exposure. since the beginning of this century numerous international surveys had been performed with the aim to define diagnostic reference levels in european countries. radiation exposure by ct has increased particularly by cardiac ct examination, what has caused awareness to utilise all strategies for radiation protection in ct. modern ct scanners are equipped with automated anatomical or organ sparing exposure control. it is the ct investigators responsibility to check the clinical indication, limit the scan range and decide for the appropriate scan protocol with the least radiation exposure. newer technical developments in ct scanner hard and software will enable to further reduce the dose from ct. all these strategies are essentially necessary since the number of ct investigations and the scope of clinical indications are expanding with advancing medical progress. learning objectives: . to understand the meaning of diagnostic reference values. . to become aware of dose intense ct protocols. . to learn about strategies for radiation protection in ct. nuclear medicine perspective s.p. mueller; essen/de different radiopharmaceuticals labelled with positron emitting radioisotopes are used to study a multitude of molecular processes using a positron-emissiontomography (pet) scanner which nowadays is typically integrated with a ct scanner (pet/ct). this lecture will enable the attendee to comprehend that the radiation exposure from pet depends on the biodistribution and kinetics of the radiopharmaceutical, the physical half-life of the positron emitting radioisotope used for labelling, and the injected activity, leading to an understanding that there is no generic "radiation exposure from pet or pet/ct". learning objectives: . to learn that the comparison of doses for different radiopharmaceuticals is based on the concept of the effective dose which expresses the total stochastic risk from the non-uniform radiation exposure to individual radiosensitive organs in terms of a uniform whole body radiation dose. . to understand that the effective dose from certain radiopharmaceuticals may be reduced by simple means, e.g. if it is renally eliminated by frequently voiding the bladder, and that the effective doses for the most prevalent radiopharmaceuticals lie within the typical range of other diagnostic nuclear medicine tests and compare favourably to the radiation exposure from the ct portion of a whole-body pet/ct scan. pet and pet/ct are non-invasive, -dimensional imaging modalities which have become standard of care in patients with malignant lymphomas. these modalities have been extensively studied for staging, restaging, monitoring response to therapy, surveillance after definite treatment, and assessment of transformation. more recently, pet tracers have been suggested as surrogate markers for cancer drug development. learning objectives: . to understand in which clinical scenarios pet and pet/ct imaging are superior to standard imaging modalities or other diagnostic tests. . to learn the diagnostic accuracy and predictive potential of pet and pet/ct for staging/restaging hodgkin's disease and non-hodgkin's lymphoma. of the examination. therefore, for oncologic applications, pet-ct has already gained widespread acceptance for the initial staging of cancer, the management of recurrent cancer, and for monitoring the response to therapy. the development of a large variety of radiotracers is an evolving procedure. the most frequent used radiotracer in clinical practice, f fdg, is based on the identification of the fundamental aspects of tumour glucose metabolism. new radiotracers, with promising potential for pet-ct, are also currently available to visualise specific cellular and molecular tumour pathway and more being developed. learning objectives: . to appreciate the advantage of a combined pet-ct technique. . to consolidate our knowledge of optimal examination protocols and to be aware of the pitfalls that may be encountered using this technique. . to understand the indications for pet-ct in the diagnosis, staging, and therapy monitoring of a large variety of gi tumours. . to become familiar with the different radiotracers to obtain a tailored and personalized diagnosis for the large variety of gi tumours. a- integrated positron emission tomography (pet)/ct provides combined metabolic and anatomic information of malignancies. the addition of ct to pet for urogenital purposes is very useful. ct should be performed with oral and intravenous contrast agent administration as a full diagnostic technique. if performed under these conditions, this technique can help to avoid pet pitfalls including focal retained activity in ureters and urinary bladder, and increased uptake in physiologic and benign pelvic processes such as endometrial uptake in the menstrual phase, leiomyomatosis, endometriosis or infection. we will describe the use of pet/ct in the characterisation, staging and surveillance of urogenital malignancies including kidney, prostate, bladder, uterine cervix, endometrium and ovaries. pet/ct is internationally accepted as the most useful surveillance imaging tool in patients with ovarian cancer, and its use as a problem-solving modality has also rapidly grown in the rest of urogenital malignancies. learning objectives: . to learn the appropriate protocols and settings of a diagnostic ct in pet/ct for urogenital purposes. computed tomography remains the workhorse of clinical cross sectional imaging due to its good availability, enormous speed, high spatial resolution and sufficient tissue contrast to evaluate most diseases based on morphology. compared to pet and spect, room for improvement remains in sensitivity and specificity for certain diseases and, compared to ultrasound and mri, in dynamic imaging. however, already today there are new ct techniques which can provide diagnostically equivalent information as spect or pet but with higher spatial resolution, in shorter acquisition time and without radioactive tracers. one of these techniques is ct perfusion imaging with repeated low-dose acquisitions of the same organ. with this method, a detailed evaluation of brain perfusion is feasible e.g, for stroke assessment, or of tumour perfusion, e.g. to assess early therapy response. another option is dual energy ct which does not require additional dose but can provide additional important diagnostic information similar to pet or spect. examples are the evaluation of lung ventilation und perfusion with xenon gas and iodine contrast. for oncological imaging, the evaluation of tumour perfusion based on spectral identification of iodine is an attractive option to increase specificity without additional dose or radioactivity. similarly, it is feasible to assess myocardial perfusion along with coronary ct angiography. for some diseases, even the molecular substrate can be identified with this technique, e.g. uric acid in gout patients. these new techniques provide significant advantages in oncological imaging and may further add to disease characterisation if combined in pet-ct. learning objectives: . to understand the strengths of current ct technology in oncological imaging based on morphology. . to learn about the diagnostic value of ct beyond anatomical referencing. energy ct as options to improve disease characterisation. tracers beyond fdg in daily routine m. beheshti; linz/at the ability of positron emission tomography (pet) to study different biological processes opens up new windows for both researches and daily clinical use. addition of computed tomography (ct) to pet improves detection efficiency and results in better localization of the lesions. the aim of this review is to consolidate knowledge of oncological applications of pet tracers other than [( )f]fluoro- -deoxy-d -glucose] (fdg) in the daily clinical practice. fdg, as a non -specific tracer, has limited value in the assessment of different cancers such as prostate cancer, neuroendocrine tumours (net), brain tumours, hepatocellular carcinoma (hcc), and some types of breast cancers. hence, due to high sensitivity of pet in performing non-invasive functional studies, further investigations and developments are warranted for defining specific pet radiotracers and theirs clinical applications regarding different tumour entities. oncological non-fdg pet tracers can be generally categorized into groups: those labeled with f- , c- and other non-fdg tracers. fluorine- and c- are labeled with different amino acids, substrates involved in fatty acid synthesis, protein synthesis, amino acid transport substrate and tracers linked to nucleic acid synthesis. these tracers are also labeled with specific ligands for receptor imaging. the other non-fdg a- with the increasing use of abdominal cross-sectional imaging, incidental adrenal masses are being detected more often. the important clinical question is whether these lesions are benign adenomas or malignant primary or secondary masses. benign adrenal masses such as lipid-rich adenomas, phaeochromocytomas, myelolipomas, adrenal cysts and adrenal haemorrhage have pathognomonic cross-sectional imaging appearances. however, there remains a significant overlap between imaging features of some lipid-poor adenomas and malignant lesions. the nature of incidentally detected adrenal masses can be determined with a high degree of accuracy using computed tomography and magnetic resonance imaging alone. positron emission tomography is also increasingly used in clinical practice in characterising incidentally detected lesions in patients with cancer. the performance of the established and new techniques in ct, mri and to a lesser extent pet, that can be used to distinguish benign adenomas and malignant lesions of the adrenal gland will be reviewed. with the increasing use of imaging, incidentally detected renal masses are very common. while masses detected by ct or mr usually can be properly classified, renal masses detected by ultrasound frequently require further workup. the following considerations determine the diagnostic workup: simple cysts are very common but may present atypically. renal cell carcinomas may be cystic but usually display at least a small solid component. renal cell carcinomas have a bad prognosis when metastasized but metastases hardly every develop before the tumour has reached cm in diameter. differentiation between solid tumours by imaging alone is exceedingly difficult, save for the identification of angiomyolipomas in adults. this course will discuss suitable diagnostic algorithms based on the initial presentation of the mass. typical imaging findings of various benign and malignant renal masses will be presented. the role of the bosniak classification will be illustrated. newer developments such as a waitand-see approach or primary biopsy for small solid renal masses will be discussed. learning objectives: . to learn how to detect and characterise a renal mass. . to understand how to apply adequate protocols according to the clinical situation. the wrist and hand are characterised by variability of bones, fibrocartilage, ligaments, muscles and neurovascular structures. coalitions (most commonly lunotriquetral, prevalence of . %), ulnar impaction positive variance of the ulna, carpe bossu and an accessory medial lunate facet associated with osteoarthritis are typical variants of bone. the triangular fibrocartilage complex (tfcc) and the interosseous ligaments often present with small defects. radial tfcc defects are present in % of symptomatic but also in % asymptomatic wrists. in addition, their prevalence increases with age, apparently without increasing symptoms. accessory muscles are common and may clinically mimick a neoplasm. disease may also be mimicked by imaging artifacts. magic angle effects cause increased tendon signal and may thus lead to the incorrect diagnosis of tendinopathy. the lunate appears to be more dorsally tilted on sagittal mr images than on standard radiographs (radiolunate angle ~ ° larger on mr images). this value increases to ~ ° if the wrist is positioned in ulnar deviated as is commonly the case when the wrist is examined in the "superman position", with the arm above the head. magic angle artefacts are commonly encountered in the wrist. the extensor and flexor pollicis longus are especially prone to such artefacts, due to their oblique course approaching the critical ° with regard to the b field. in conclusion, variability is rather the rule than the exception in the hand and wrist. only part of the findings have clinical meaning. technical aspects add another dimension of variability. learning objectives: . to become familiar with the normal anatomy. . to be able to identify normal variants. . to appreciate the range of pitfalls that may simulate pathology. the imaging of the trauma stratifies the severity and the treatment strategy. the leading modalities in low-energy trauma are x-ray and ultrasound. the different approach has to be used in high-energy trauma -the silent life-threatening injury must be actively searched. although the first examination on the site of the accident could estimate whether the severe trauma is present, the imaging must confirm or exclude it. besides fast transport to the trauma centre has the extraordinary impact on survival the diagnostic algorithm. the installation of ct, ultrasound and x-ray directly within the emergency department is extremely important for the trauma management. if the focused assessment sonography for trauma (fast) is replaced by whole body ct, the life-threatening injury is detected at fastest. protocol includes imaging of non-enhanced ct head and cervical spine followed by the contrast-enhanced ct of the entire thorax, abdomen and pelvis, in cases of lower extremities trauma covering whole body. ct could be performed also under resuscitation, because whole imaging takes about three to five minutes. following findings listed recently according to their impact on survival must be confirmed or excluded: intracranial injury, cervical spine trauma, aortic injury, overpressure pneumothorax, severe bleeding in the abdominal cavity, organs injury, peripheral vascular trauma, bone trauma; the trauma team including anaesthesiologist, surgeon and radiologist discusses the findings and plans of the treatment. over the last two decades, spiral-ct has become a highly reliable imaging modality to diagnose haemorrhage in trauma, while the role of catheter angiography has changed from a diagnostic to a therapeutic modality. traumatic injuries of the heart and aorta lead to sudden death occurring at the accident site, whereas uncontrollable haemorrhage from larger arteries and parenchymal organs is the most frequent cause of mortality during the first h following severe trauma. in patients with ruptured aorta or major arteries, stenting and temporary balloon occlusion may contribute to saving lives, while transcatheter embolisation may prevent exsanguination in haemorrhage from visceral organs, arteriovenous fistulas, and secondary onset haemorrhage. however, a haemodynamically stable patient is a prerequisite for all angiographic interventions. definite haemostasis using the above-mentioned techniques can be obtained in - % (major and periphery arteries) and - % (visceral organs), respectively. possible complications following angiographic haemostatic interventions depend very much on the treated vessel bed but are, in general, as low as %. learning objectives: . to understand potential treatment options and when to treat and when not to treat. a s c b d e f g h to current best practice, restriction of opinions to one's own expertise, expression of opinions that take into consideration all of the material facts, and the readiness to change that opinion if additional information becomes available. any unusual, contradictory or inconsistent features of the case should be highlighted. the expert should highlight whether a proposition is a hypothesis (in particular a controversial hypothesis) or an opinion deduced in accordance with peer-reviewed technique, research and experience accepted as a consensus in the scientific community. he/she should indicate whether the opinion is provisional (or qualified), stating the qualification and the reason for it, and identify what further information is required to give an opinion without qualification. when there is a range of opinion on any question to be answered by the expert, (a) the range of opinion should be summarised, (b) highlight whether that range of opinion includes an 'unknown cause' (because of limited facts of the case or limited research/peer-reviewed publications), and (c) give reasons for the opinion expressed. reprints of scientific publications will assist the court, but will also enable the attorneys to undertake a more robust cross examination! learning objectives: . to learn about imaging findings in relation to whether or not abuse has occurred. . to understand in which cases the diagnosis of child abuse should be raised in the radiology report. . to become familiar with the terms that should be used when highly specific imaging indicators are identified in an otherwise normal infant. the radiologist at the eye of the storm : imaging plays a central role in the diagnosis of child abuse. is there any risk of the radiologist having a detrimental impact on either the welfare of the patient or the judicial process by either under-diagnosing or over-diagnosing child abuse? ovarian cancer continues to be a challenge to radiologists and clinicians, as it is one of the most lethal female tumours. this is mainly due to its diagnosis in an advanced stage in the majority of patients. however, new developments can be observed: new insights in tumour biology, advances in imaging and new concepts of ovarian cancer treatment and surveillance. furthermore, a multidisciplinary expert team approach has also substantially changed the management of patients with suspected ovarian cancer. the findings of radiology are becoming pivotal in a more individualised patient care. the role of radiology includes (a) characterisation of sonographically indeterminate adnexal masses, (b) staging as guidance for surgery and treatment planning (including identification of sites of non optimal resectabilty) in suspected ovarian cancer, (c) assessment of recurrent disease, and (d) in selected cases image-guided biopsy. in this session we provide an update on the aetiology and current concepts of treatment of ovarian cancer and on the contribution of radiology in characterisation and staging in patients with the working diagnosis of ovarian cancer. the panel discussion will focus on the role of radiology in multidisciplinary conferences in suspected ovarian cancer. session objectives: . to learn about new concepts in etiology and treatment of ovarian cancer. . to become familiar with optimised imaging protocols to diagnose ovarian cancer. . to learn about the value of ct and pet/ct as a basis for treatment planning in ovarian cancer. . to appreciate the role of the radiologist in multidisciplinary consensus conferences. session objectives: . to learn about current imaging practices in the evaluation of suspected child abuse. . to learn about imaging changes which permit a firm diagnosis of child abuse. . to become familiar how to construct a comprehensive report providing evidence of child abuse. how to image and detect patterns of skeletal injury indicating child abuse p.k. kleinman; boston, ma/us (paul. kleinman@childrens.harvard.edu) in infants, skeletal injury may form the basis for the diagnosis of abuse. the first step is the acquisition of a skeletal survey utilising meticulous technique adhering to a rigorous imaging protocol. a proper interpretation is ensured when the radiologist is familiar with the various patterns of skeletal injury, their specificity for abuse and those entities which may simulate inflicted injury. appreciation of the lesion morphology, the fundamental pathologic alterations and mechanism of injury are essential in assessing the significance of the findings and placing them in the clinical context. dating fractures poses a significant challenge, but in most cases, injuries can be placed in a certain time frame, especially if a follow-up skeletal survey is obtained. although radiography forms the basis of skeletal imaging, ultrasound, ct, scintigraphy and mri may clarify findings and optimise diagnosis and management. the radiology report must be constructed with care and the language should be crafted with the expectation that the radiologist may be called to testify in court, a daunting challenge in an often highly adversarial environment. learning objectives: . to learn about the appropriate imaging protocols and quality for skeletal survey in suspected child abuse. . to learn about patterns of skeletal injury typical of child abuse. . to become familiar with findings that point to alternative diagnoses. imaging strategies to fully determine intracranial injury resulting from child abuse c. adamsbaum, c. rey-salmon; paris/fr (c.adamsbaum@svp.ap-hop-paris.fr) radiologists play a key role in the early diagnosis of abusive head trauma (aht). symptoms are various and may range from coma to asymptomatic children. changing elements of the history provided previous injuries, bruising in non-ambulatory children and delay in seeking care raise a high index of suspicion. the most common finding in aht is of multifocal subdural haematomas over the cerebral hemispheres, the convexity, the posterior interhemispheric fissure and the posterior fossa. the haematomas are often associated with hypoxic-ischaemic injury and retinal haemorrhages. ct is the first diagnostic examination to be used for patients with acute injury. it can reveal intracranial haemorrhage, fracture and soft tissue swelling with a high degree of sensitivity. ct should be repeated after a time interval if the findings are doubtful or if there is a discrepancy with the neurological picture. mri (including t , t , t *, diffusion sequences and cervical spine examination) is required to fully determine intracranial injury as it can exquisitely demonstrate hypoxic-ischaemic injuries by showing areas of cytotoxic oedema. it is impossible to date precisely a haematoma whose pattern is influenced by numerous factors. however, the main point is to determine the presence of 'age-different' lesions. this not only provides a strong argument for the diagnosis but also suggest repetitive violence and thereby, a high risk for further injury unless protective action is undertaken. brain imaging must be performed in all siblings younger than years, living in the same conditions as the index case. learning objectives: . to learn about imaging protocols designed to: a) detect acute treatable conditions b) depict fully and determine the timing of all injuries. . to become familiar with imaging findings that are highly suggestive of child abuse. . to learn about head trauma that may simulate child abuse. what is the information required by any court and how the radiological reports should be phrased s. chapman; birmingham/uk (stevechapman@doctors.org.uk) this presentation will describe the role of a paediatric radiologist as an expert witness (as opposed to a witness to fact). the expert has an overriding duty to the court that takes precedence over any obligation from whom the expert has received instructions or by whom the expert is paid. particular duties include advice that conforms a- : ovarian cancer: update and role of radiology j.a. spencer; leeds/uk (johnaspencer @hotmail.com) ovarian cancer is known as the 'silent killer'. it is usually diagnosed late and most women have disease disseminated to the peritoneum (and/or pleura) at presentation. standard treatment comprises cytoreductive surgery followed by platinumbased chemotherapy. an alternative is neoadjuvant chemotherapy followed by interval debulking surgery (ids) then completion chemotherapy. data from the eortc trial show this to be as effective as the standard of care. there are strong genetic predispositions to ovarian, fallopian tube and primary peritoneal cancers. there is linkage with breast cancer in women with brca gene mutations and with colon cancer with the hnpcc gene. ongoing trials are screening women in the general population and at high risk of the disease. these use the serum tumour marker ca followed by us as screening tools. mr imaging is an effective tool to assess sonographically indeterminate adnexal masses and offers an earlier diagnosis of cancer than interval reassessment with us. ct is the most commonly used modality for assessment of disease extent prior to surgery. image-guided biopsy is necessary prior to starting neoadjuvant chemotherapy. the eortc and mrc (uk) ov trials of women with treated ovarian cancer have shown no outcome advantage for women treated early at 'ca relapse' of disease versus later with clinical or ct evidence of relapse. this questions the role of ca in follow-up and argues against investigation of the 'ca +ve, ct -ve' woman with more expensive and scarce imaging resources such as ct-pet and dcemr. learning objectives: . to become familiar with clinical features of ovarian cancer. . to learn about the etiology of ovarian cancer, including genetic predisposition and the current research into screening. . to become familiar with new concepts of treatment ovarian cancer and surveillance of the treated patient and their impact for the use and choice of imaging modalities. imaging of adnexal masses: is it feasible to diagnose ovarian cancer? i. thomassin-naggara; paris/fr (isabelle.thomassin@tnn.aphp.fr) adnexal masses can be depicted by many imaging modalities (us, ct, mr and pet-fdg). however, the characterisation of adnexal tumours is mainly based on two techniques: us and mri. for complex adnexal masses, mr imaging add to conventional criteria of malignancy common to all imaging modalities (bilaterality, tumour diameter larger than cm, predominantly solid mass, cystic tumour with vegetations, and secondary malignant features, such as ascites, peritoneal involvement, and enlarged lymph nodes) specific features based on the characterisation of the solid tissue (including vegetation, thickened irregular septa, and solid portion) of the adnexal tumour. signal intensity of solid tissue on t sequence (fibrous tissue), perfusion (neoangiogenesis), and diffusion (cellularity) are combined to make a decision tree analysis. low t signal, absence of high b signal, and time intensity curve type are predictive of benignity whereas high t signal and time intensity curve type are predictive of malignancy. combining common classical features and specific mr features for predicting malignancy, mr imaging has a high degree of accuracy ( %) for characterising complex adnexal tumours. this high diagnostic confidence rate may help young women wishing to preserve childbearing potential to opt for conservative surgery and avoid the systematic removal of benign complex adnexal masses in menopausal women. learning objectives: . to understand the role of ultrasonography in assessing and managing complex adnexal lesions. . to learn how to optimise the mri protocol and how to improve the characterisation of indeterminate complex adnexal masses. . to understand the added value of functional sequences (dce mri and dwi) in diagnosing adnexal masses. the european and american guidelines include breast ultrasound in a restricted diagnostic scenario for breast cancer diagnosis. the fourth edition of the european guidelines ( ) reviewed in refers to us in only twice. acr in its acr practice guideline reduces breast ultrasound examination to seven situations. evaluation of the axilla and ultrasound as a screening tool on high risk women is considered an area of research. the progression of us makes guidelines become obsolete very fast. its application still remains pending on the results of clinical trials. image smoothing on sono-ct or multiple frequency transducers will produce images, eventually with more diagnostic information. second tissue harmonics will produce sharper and more clear images. cad systems, doppler and contrast doppler will help in diagnosis. d with the new software and automatic probes constitute a very promising work in progress. they will make a dramatic change in our workload. the radiologist will be released of performing the exam, to review the images in the workstation. sonoelastography has evolved from the manual to the actual automatic shearwave. this system measures the transversal transmission of sound in biologic tissues. it is a new and promising technology, probably more objective and non-operator dependant, that is able to differentiate benign from malignant conditions. all of these systems will be reviewed and evaluated for its actual situation. the problem now is how to introduce new terms, new descriptors, and new technologies in the bi-rads system, once clinical evidence is demonstrated. diffusion-weighted mri (dwi) is a promising technique in oncology. it can be used for in vivo quantification of the combined effects of capillary perfusion and diffusion. using echoplanar imaging (epi), dwi is possible with fast imaging times minimising the effect of gross physiologic motion from respiration and cardiac movement. in this lecture, we will discuss the acquisition, post-processing and quantification methods and results of dwi in abdominal and pelvis tumours. we will also review the mechanisms associated with diffusion changes in tumours. mri-pathologic correlation will be shown. finally, limitations and future directions of the technique will be reviewed. diagnostic potentials -as well as limitations -associated with morphological cross-sectional imaging on the one hand and functional imaging on the other are increasingly well understood. it has become obvious that in many cases both kinds of imaging complement one another. hence, hybrid pet/ct imaging must be considered one of the most promising new developments in medical imaging. however, some questions have to be raised and challenges have to be met to avoid overrating pet/ct in oncology. pet/ct with [ f]- -fluoro- -deoxy-d-glucose (fdg) as a radioactive tracer has been reported to be more accurate than either imaging modality alone and sometimes even more accurate than ct and pet read side by side. however, the clinically important question should rather be the following: does this higher accuracy have an impact on patient management? furthermore, some tumours do not have an increased glucose metabolism making them fdg-pet negative. the most recently launched line of pet/ct scanners combines high-definition pet with high-end multislice ct. these imaging systems not only provide a higher diagnostic accuracy based on detection of smaller lesions with ct and pet, but also offer integration of complex ct protocols into the pet/ct scan. these protocols include ct perfusion, three-dimensional ct image reconstruction or virtual fly-through. the aim of this talk is to give an overview concerning pet/ct in oncology. the mechanism of radionuclide uptake, different tracers, the indications of pet/ct in oncology and its accuracy will be addressed. learning objectives: . to understand why uptake of the tracer provides information on the viability of solid tumours. . to learn whether pet/ct is able to give reliable quantitative information. . to know whether pet/ct is a valuable tool for tumour response to treatment. to gain additional functional information. functional imaging techniques such as diffusion tensor imaging and tractography as well as fmri are increasingly used and relied on in clinical practice. with diffusion tensor imaging and tractography the location, course and integrity of the major white matter tracts can be depicted, while with fmri the brain's cortical function is visualised. despite major technical advances, these techniques are still time consuming, labour intensive and have several limitations. they therefore need to be used and interpreted with care. the purpose of this lecture is to review the functional anatomy of the brain in a clinically relevant context and to illustrate when additional functional imaging techniques may be indicated. the most important eloquent brain areas are addressed and include the motor, visual and language systems. routine clinical cardiac mri requires speed and efficiency as a result of physical motion. consequently, the challenges and benefits of rapid mri are nowhere more apparent than in the field of cardiovascular mr imaging. to meet these challenges, one must balance the competing constraints of signal-to-noise ratio (snr), contrastto-noise ratio (cnr), spatial resolution, temporal resolution, scan time, and image quality. one of the main determinants of snr is the static magnetic field strength. hence, cardiovascular mri at . t or more holds the promise to overcome some of the snr limitations and to extend the capabilities of cardiac mri. all studies in cardiac mri at higher field strength have proven the feasibility of cardiac mri for the comprehensive assessment of cardiac morphology and function. the studies demonstrated a significant snr increase, but also outlined image-quality problems associated with b -field inhomogeneities and specific absorption rate (sar) constraints. with regard to acquisition speed, parallel imaging mri capabilities form an important enabling factor, especially if enough snr is available. therefore, the combination of higher field strength and parallel imaging strategies may help to overcome several of the present limitations in cardiac mri like cardiac perfusion and coronary artery imaging. the present indications, advantages and limitations of cardiac mri at . t will be discussed. the risks associated with the exposure of ionising radiation has raised increasing concerns in the radiological community. the recent years have shown an overall increase in the use of ct for the imaging of the heart and the coronary arteries. the downside of this increased use of cardiac ct is the increase in the collective radiation dose with cardiac ct which have been reported to be associated with an effective radiation dose of msv or more. increased awareness of the radiation dose with cardiac ct led to the development of several effective radiation dose reduction strategies including prospective ecg gating technique, anatomy and ecg-based tube current modulation, high pitch acquisition, and adaptation of the ct scanning parameters to the body habitus. however, the dose reduction strategies should be selected carefully on an individual patient basis in order to avoid serious image quality impairment by noise and artefacts. the lecture outlines the different radiation dose saving techniques currently used in clinical practice, the anatomy of the brain is often perceived as being complicated. especially the cortex is seen as an irregular arrangement of variable structures, which are difficult to differentiate and to identify. we will review the overall subdivision of the brain into lobes and describe their boundaries and their major gyri and sulci. we will then describe the location of specific functions. . primary sensorimotor cortex: motor is located in the precentral gyrus, sensory in the postcentral gyrus around the central sulcus (cs), hence the importance of always correctly identifying the cs. we will present interlocked methods to identify the cs in the axial plane (a) knob, (b) lateral axial, (c) medial axial, (d) gyral/cortical thickness and to identify it in the sagittal plane (a) lateral sagittal, (b) hook, (c) medial sagittal. . primary auditory cortex (a ): centred at the postero-medial part of heschl's gyrus (hg), we will present simple landmarks in each of the planes: (a) axial: adhaesio interthalamica, (b) sagittal: omega/heart shape of hg, (c) coronal: omega shape of hg. . primary visual cortex (v ): centred on the calcarine sulcus, we will discuss the characteristic shape that allows the identification of this structure in all planes. at the end of this lecture, you will know the subdivision of the cortex; the methods and landmarks necessary to identify the primary sensorimotor, speech, auditory, and visual areas. magnetic resonance imaging (mri) has undergone a rapid development in the last decade with numerous new techniques. nevertheless, pattern recognition of brain lesions based on signal intensities on conventional mr sequences (t -and t -weighted, flair) is the first step in diagnostic "work up". good examples for pattern recognition are lesions with t -shortening ("bright" on t wi) such as: fat containing lesions (lipoma), melanoma, lesions with colloid content, calcifications, and haemorrhagic metastatic lesions. t -shortening ("dark" on t wi) in enhancing lesions is suggestive of lymphoma and certain infections (tuberculosis, fungal abscesses). flow void (absence of signal) reflects high velocity flowing blood or csf, and will help in diagnosing vessel abnormalities and related pathologies. the purpose of this lecture is to refresh knowledge on patterns and normal variants useful for clinical practice. a simplified "pipeline" consisting of easy consecutive steps will be introduced. learning objectives: . to learn important normal variants of different structures and lesions in the brain. . to learn about recognition patterns that might be helpful in suggesting the most likely etiology of common brain lesions. . to consolidate the key imaging findings in different types of lesions and normal variants. a- : c. clinical symptoms correlated to brain anatomy m. smits; rotterdam/nl (marion.smits@erasmusmc.nl) diagnostic neuro-imaging heavily depends on a thorough understanding of brain anatomy in relation to the brain's function. clinical neurological symptoms and deficits not only give us an indication of the brain area(s) involved but may also direct us towards the use of specific imaging techniques, such as diffusion tensor imaging and tractography, as well as functional magnetic resonance imaging (fmri). specific imaging findings, on the other hand, may direct clinical management in a neurologically intact patient, such as the decision to resect a brain tumour in or near an eloquent brain area. again, specific imaging techniques may be used evaluation of response to treatment allows an early assessment of tumour response typically after - cycles of chemotherapy. this evaluation is most commonly performed with pet/ct during therapy for high grade non-hodgkin's lymphoma. this review presentation looks at the potential roles that ct, regional mri and whole body mri do and could play in response evaluation from a radiology perspective. the presenter is a radiologist who is clinical director of a medium volume pet/ ct centre. the talk focuses on discrepancies between ct and pet findings in tumour response and on tumours or situations where ct is the primary modality to determine tumour response. potential roles for whole body mri in response evaluation and assessment of solid tumours by mri are examined. at a general level, the role of the radiologist as part of the multidisciplinary oncology meeting (mdm), including when and where to use image-guided biopsy in response evaluation and the use of recist versus precist criteria is discussed. the aim of the presentation is to outline the role of ct in tumour response evaluation in the era of pet/ct and to explore potential roles particularly for whole body mri in tumour assessment. the presenter hopes to encourage radiologists to get fully involved in mdm discussions regarding ct, mri and pet/ct evaluation. learning objectives: . to learn the standard method (tumour measurements) for the evaluation of tumour response to treatment. . to understand the limits of international standard. . to become familiar with methods that provide functional or structural information, like perfusion ctmr or dw-mri. evaluation of tumour response to therapy: the role of nuclear medicine a. chiti; milan/it (arturo.chiti@humanitas.it) the high costs and possible side effects of chemotherapy and radiation therapy treatments favour the use of effective ways to monitor the treatment efficacy in oncology. molecular imaging demonstrated to be effective in evaluating the response after and during the course of therapy, in order to assess chemo-sensitivity and chemo-resistance of a particular neoplasm. the use of pet-ct in this setting can vary from very sophisticated and complex quantitative evaluation to simple qualitative analyses. in malignant lymphoma, international criteria for monitoring response to therapy have recently been revised, and fdg now plays a central role in defining tumour response. in a variety of solid tumours, studies have indicated that fdg pet-ct may provide early and accurate assessment of tumour response, suggesting that it could play a significant role in personalising the treatment of malignant tumours. performed during and after therapy for hl and aggressive nhl, fdg pet results have a high prognostic value and correlate with survival. fdg pet has been incorporated into revised response criteria for aggressive lymphomas, and several ongoing trials are under way to investigate the value of treatment adaptation based on early fdg pet results for hl and aggressive nhl. many technical aspects must be taken in consideration to avoid critical errors in evaluating response. from patient preparation to image acquisition a series of possible pitfalls must be avoided. in the clinical practice, the most widely used parameter is the suv, which can improve the accuracy of qualitative image assessment in many clinical settings. learning objectives: . to understand why pet-ct can be used to assess tumour viability. . to become familiar with the principles of signal quantification and to discuss its advantages and limits. . to learn about the incoming tracers that might enhance the role of pet-ct in the evaluation of tumour response. alzheimer's disease: the role of radiology j. alvarez-linera; madrid/es (jalinera@ruberinternacional.es) neurobiological changes in alzheimer's disease (ad) occur in an stereotypical pattern that begins in the medial temporal lobe (mtl) years before the clinical manifestation (brain reserve). brain atrophy is a marker of neurodegeneration that reflects the neurobiological disorder and is correlated with the neuropsychological changes at all stages of the disease. other imaging markers may reflect changes in microstructural (diffusion), functional (perfusion) or metabolic (mrs) domains that would provide additional information but are awaiting wider validation. in the early stages of ad, the most effective mri markers are those that reveal atrophy in mtl, particularly the measures of the hippocampus. the mtl atrophy mea-the required conditions in whom they may be successfully used, and how these techniques could be implemented in the daily clinical practice. proper linking of the data acquisition to the patients ecg is among the crucial prerequisites for successful cardiac imaging. while cardiac ct data acquisition itself does not impose any effect on the patients' ecg, inherent physical effects in the mr environment does show impact on the ecg trace and may hamper proper r-peak delineation. in addition, patient-related factors such as arrhythmia might affect image quality (iq). dose saving strategies in cardiac ct limit the possibilities of retrospective iq optimisation and as such more emphasis is recommended prior to data acquisition which is mainly related to patient selection/heart rate control. in cardiac mr a high amplitude ecg without influence of magnetic or scanning effects is of outmost importance. arrhythmia also remains a challenge that might be overcome by arrhythmia-rejection algorithms or real-time imaging. suboptimal contrast enhancement ought to be avoided by proper planning and timing as the majority of post-processing algorithms is based on signal behaviour. in the unfortunate situation of suboptimal contrast enhancement often only the use of standard post-processing tools is possible while semi-automated tools for cardiac post-processing may fail or necessitate substantial user interaction. the use of straight forward visualisation techniques is recommended for diagnosis while complex visualisation tools may add on confidentiality but are mainly suited for case presentations. coronary evaluation is typically performed using centerline tools allowing for the easy assessment of cad. while these tools potentially allow for estimation of the degree of diameter and area stenosis, accuracy though may still be limited. this is the second session between esr and eanm at each society's annual congress. few would argue but that patient's interests are best served by crossfertilisation and open communication between specialties. this is particularly true for radiology and nuclear medicine. this session elaborates on clinical scenarios where cross-fertilisation between both specialties is particularly important. the session will elaborate the radiologist and nuclear medicine perspectives on two common clinical scenarios, i.e. tumour response to therapy and evaluation of alzheimers disease. session objectives: . to appreciate how nuclear medicine and radiology provide complementary information. . to learn how each method can enhance the mutual performance of the radiologist and nuclear medicine physician. . to learn about recent advances in the field of tumour evaluation and early detection of alzheimer's disease. shown on mdct-images in the axial, coronal, and sagittal plane. variants of the normal anatomy, which are important to describe and to know are also shown. some of these variants are also delineated on mr images. in the second part of the lecture, the different expressions of congenital malformations of the external and middle ear will be explained. the different findings of the severity of the malformations will be shown and their importance for further clinical-therapeutical procedures will be explained. imaging investigation of cholesteatoma is required before surgery. if no surgery has been performed previously, ct will provide information about the location of the lesion (epi, pro, meso, retro, hypotympanum), the partial or total destruction of the ossicles, and possible extension to the inner ear. if there is no doubt about any of these factors ct is sufficient. in doubtful cases an mri examination is performed to confirm or refute the presence of cholesteatoma using t sequences without iv contrast medium, and diffusion weighted imaging with or without high resolution t , depending on the age of the patient. in postoperative recurrent cholesteatoma, mri is becoming the modality of first choice for detecting cholesteatomas, appearing : low in signal on t sequences, high in signal on diffusion weighted imaging. however, care is required since performing diffusion weighted imaging without t may lead to false positives. a granuloma with a slightly or markedly increased t signal is often associated with a high signal on diffusion. measurement of adc is useful for detecting cholesteatomas, infected cholesteatomas or abscess. finally whilst mri is the first examination in the follow-up of postoperative patients, the use of contrast medium is not necessary in most of the cases. a- : c. implants and postoperative findings in the middle ear b. verbist; leiden and nijmegen/nl many conditions which affect the function of the middle ear may require surgical intervention. postoperative imaging will be requested either to evaluate complete removal of diseases (eg in cholesteatoma) or because of new, persisting or recurrent complaints of the patient (e.g. vertigo after stapes replacement). in this presentation, different surgical procedures will be reviewed including the indications for a certain surgical approach as well as the different types of prosthesis. the normal postoperative imaging appearance of the most common surgical techniques will be shown. it will be discussed whether ct or mri should be performed to answer the clinical questions. an overview of possible failures and complications will be given. the management of patients with vascular malformations is often suboptimal. the reasons for this are many but include confusion regarding classification, uncertainty about the most appropriate imaging of the various forms of malformation and a sures are helping to propose new diagnostic criteria for ad, allowing a diagnosis of probable ad in predementia stages, when memory loss criteria are attached to imaging criteria (mri or pet) or measures of amyloid/tau in csf. the use of atrophy markers (global or mtl) increases the effectiveness in clinical trials (both by reducing the size of the sample and increasing the statistical power) and is therefore contributing significantly to the development of new treatments. the association of multiple markers of structural and functional imaging (mri and pet) and the use of advanced computational analysis techniques will allow better management of ad but it needs a broader validation and know the most efficient combination of biomarkers at each stage of the disease, including the preclinical period. scientists, researchers and clinicians all benefit from molecular imaging in dementia providing exciting new insights into their basic biology and pathophysiology. targeting specific aspects of neurotransmission, metabolism, inflammation or plaque formation -just to mention some of the current molecular approaches -increasingly gains impact on establishing the correct diagnosis, following the course of dementia or developing cns drugs. this talk will highlight the molecular targets and major pet and spect tracers for application in dementia, and will update on the results of the clinical imaging studies published in recent years. typical imaging patterns of alzheimer's disease (ad) will be discussed, including also the diagnostic discrimination from other types of neurodegenerative dementias such as frontotemporal dementias, lewy body dementia, and others. assessment of mci patients and the probability of transition in manifest dementia (predominantly ad) will be addressed together with its prognostic relevance. furthermore, recent advances in analysing tools which further improved the high diagnostic accuracy already reached by visual assessments will be presented. even though in competition with other modalities, ‚standard fdg' pet has shown to be a robust and both, sensitive and specific marker in the diagnostic work-up of dementia. fdg information will be markedly extended in clinical practice by specific amyloid imaging in the near future when these tracers are approved and thus generally available. learning objectives: . to become familiar with the nuclear medicine method that enables detection and evaluation of alzheimer's disease. . to learn about the potential development of functional studies using nuclear medicine. . to understand how nuclear medicine and radiology can provide complementary information. symptoms may require explanation and reassurance only. lesions with a mainly cutaneous element may be treated with laser. deeper lesions are usually treated with several episodes of sclerotherapy. agents such as alcohol, polidocanol and std will be discussed and the relative advantages and issues explained. informed consent is vital, and the approach to this will be outlined. high flow lesions are frequently associated with severe cosmetic changes, invasion of surrounding tissues, haemorrhage, and high output cardiac failure. lesions may be life threatening. in the extremities peripheral ischaemia and ulceration due to steal of blood by the arteriovenous malformation is common. informed consent will again be discussed, as potential for major complications is high. key to endovascular management of these lesions is an understanding of the nidus, arterial inflow and venous outflow. the role of liquid and solid embolic agents and specifics of transarterial, venous and direct approaches will be discussed. avms pose a major problem regarding classification and treatment. a case report discussed by the panellists demonstrates how these patients should be approached. the importance of establishing an interdisciplinary outpatient clinic is also presented. the most important organisational steps for providing an efficient clinical service are given. in addition, the most common pitfalls and complications of treatment are illustrated. computer-aided detection/diagnosis (cad) is recognised as a workstation or a system developed in order to assist the radiologists (clinicians) in performing their daily diagnostic tasks. clinically implemented cads are available at workstations and (if dicom compliant) may serve as a plug-in to pacs. the three-layer cad system includes: ( ) image analysis procedures whose development requires a medical and technical knowledge, ( ) a database module that is managed by experienced radiologists and it professionals, and ( ) graphical user interface (gui) that enables a user-friendly access to the data, the processing tools, and the results. a modern cad development involves a multidisciplinary team whose members are experts in medical and technical fields. a close collaboration of all experts is required at all stages of system life-cycle. at each stage the physicians knowledge and experience are indispensable. it includes medical analysis of the diagnostic problem, data collection, image analysis evaluation, and clinical verification. design, testing, and evaluation have to be successful in order to ensure cad implementation in a daily clinical routine. in this session three experts will share their experiences in the area of the overall cad architecture, its evaluation, validation and acceptance by clinicians, advantages and restrictions of solutions and clinical implementation in lung, breast and colon cancer. reading paradigm (primary, concurrent, second) in oncology as well as results of cad clinical implementation will be presented. perspectives in clinical cad implementation in diagnosis and treatment will be discussed. patients presenting with vascular malformations mostly are nomadic and hopeless individuals looking for help. finally having reached a "multidisciplinary specialistgroup" after a sometimes long and misleading trip throughout the ocean of "singleplayers" of different specialities these patients do not ask for any more diagnostics -they strongly claim for therapy. vascular malformations are congenital lesions, although merely seen at birth they become evident throughout the individuals growth. these developmental errors can affect all components of the vascular tree in any area of the body. the therapeutic goal must be defined rather as "control" than "cure" of this disease. to make this point understandable for both patients and collegues a fundamental understanding of the pathogenesis and natural course must be created. in special cases of complex vascular malformations the precise diagnosis and the information about all potential side-effects as well as risk-factors of progression enables these patients to manage their daily life. therefore, indications for treatment vary depending on the specific type of slow flow or high flow lesion, location, pain, functional and cosmetic impairments and general side-effects of each particular lesion, since no single specialist has enough knowledge to diagnose or treat vascular anomalies beyond the border of his distinct speciality multidisciplinary working-groups emerged at these interdisciplinary interfaces. their common language in classifying and their overall understanding of pathogenesis, prognosis offer these mostly hopeless patients a custom-fit treatment addressing their symptoms. imaging of vascular malformations should be directed by clinical assessment of the type of malformation to be expected, clinical symptoms and need for treatment. in order to make the proper decision of the required imaging modality or treatment, it is essential that the (interventional) radiologist is a member of a dedicated vascular malformation team. imaging needs to be tailored to the individual patient although general rules can be applied. duplex ultrasound together with a clinical assessment is often sufficient to make a proper diagnosis. this is especially true for the paediatric population. if more information about the extent of the lesion is needed, mr is often used in case of low flow lesions (venous/lymphatic), and mra or cta in case of high flow lesions. angiography is mandatory if an avm is diagnosed and treatment is planned. high frame rate imaging and selective injections are the only options for a proper evaluation of the nidus architecture of the avm. there are exceptions that warrant deviating from the above general rules. in this lecture, both the general rules and the exceptions will be discussed. at the onset of the st century humankind is focusing its attention on a very small molecule, as controlling co in the atmosphere is becoming a major goal, economically, socially and politically. yet, there is another small molecule which is going to play a more prominent role in the near future. h o, especially in its liquid form, the 'blue gold', is just indispensable to our lives. water makes to % of the human body weight and is crucial to the working of the biological machinery. still, how such a tiny molecule with its ° 'magic' angle could have been at the origin of life remains largely a mystery. different organisms have adopted different strategies in the way they get the most out of water, depending on their environment, and water contributes to the biodiversity. faulty mechanisms in the use of water by tissues may lead to severe diseases or death. clearly, water deserves to be seen as the prime 'biological molecule', and radiologists have long recognised its importance from the days of 'dry' (bone and air) radiology to the advent of ct which allowed contrast from 'wet' tissues to be explored. with mri one went one step further, as magnetisation of water is the sole source of contrast. life has led to intelligence, and recent mri studies have suggested that water may also actively contribute to the mechanisms underlying brain function. could the 'molecule of life' also be the 'molecule of the mind'? clearly, water must be radiologists' best friend. learning objectives: . to comprehend how the structure of the water molecule makes it important to life. . to understand the importance of water in biological and cellular processes. . to become familiar with the different ways water is responsible for image contrast in radiology. a. the role of cad in modern-day imaging a. todd-pokropek; london/uk (a.todd@ucl.ac.uk) the use of cad in medicine is an important and growing area of research. firstly good data must be acquired including not just images but associated information. the first step in that of preprocessing, notably (but not only) noise reduction. the data are then passed onto the segmentation step. often this step is semi-automatic requiring some manual intervention. conventional edge detection methods are not often of value, but active shape and appearance models, the use of markov random fields etc are commonly used. the next step is that of feature extraction both of shape and texture. these data are then submitted to one of several classifiers such as artificial neural networks (including mtanns) support vector machines (svm) and data reduction using principle and independent component analysis, and multiple voting techniques such as adaboost are also of value. the output may simply be returned to the observer (clinician) or as further input for a decision support system. examples considered will be in breast imaging (mammography), lung nodule detection, virtual colonoscopy and lumber spine. the use of the cad system as a simultaneous assistant or as a second reader is important. the use of cad in therapy is of increasing important. the assessment of such cad system (evaluation and validation) is still controversial. the difficulty of bringing systems both instrumentation and software for use in clinical practice in often underestimated and there have been some notable failures. some example of 'failures' will be given. ct colonography has evolved rapidly and disseminated widely over the last decade. the ability to provide an accurate whole colon examination with near perfect completion rates, use of reduced laxative bowel preparations and extra-colonic organ review has attracted very considerable interest amongst the wider radiological and gastroenterological community. inclusion of ct colonography in several core radiological training programmes confirms its evolution from super-specialist technique (performed in only a few centres) to mainstream. however, evidence supports highly variable performance, which is perhaps unsurprising given the complexity of both technique and interpretation methods -both which require specific training. notably, attendance at a training workshop generally represents the beginning of a radiologist's experience of ct colonography. indeed, most delegates rapidly progress from unconscious to conscious incompetence, acknowledging the need for a planned implementation strategy prior to offering ct colonography in their routine clinical practice. thankfully a decade of intensive research and large volume clinical experience has equipped the radiological community with knowledge and experience to inform successful ct colonography implementation strategies. by combining this experience with training and accreditation practices developed for colonoscopy, the prospect of a robust quality assurance framework is realistic and necessary to reassure both service commissioners and the general public alike. step one: the publication of international ct colonography standards, co-authored by eminent radiologists from across europe and beyond has been achieved. this talk will review the likely next steps. computer-assisted detection (cad) for ct colonography is now widely available in europe from a number of different vendors. this presentation will detail factors that potential users will need to know in order to properly evaluate cad systems, use them in clinical practice, and evaluate their likely impact. the different ways in which the performance of cad systems can be assessed will be discussed and the difference between weak methodologies (e.g. internal validation) and more valid assessments (e.g. external validation) will be explained. now that the diagnostic performance of ct colonography has been well-established, this state-of-the-art symposium will deal with issues related to the implementation ct colonography in day to day clinical practice. the lecturers will deal with the diagnostic performance of ct colonography, the technical requirements necessary to obtain high quality diagnostic data, the factors that underpin a high-quality service (including reader training), how implementation differs across different countries, and the possible impact of new developments, including computer-assisted detection (cad). two decades ago spiral ct technology initiated a new era in diagnostic imaging with virtual colonoscopy or ct colonography (ctc) as a major innovation. introduced by david vining in , ctc was rapidly endorsed as a potential tool for colorectal cancer screening. after an initial pioneering period defining the basic ctc principles, the advent of multi-slice ct significantly improved spatial and temporal resolution, allowing for isotropic image reconstruction with detailed d rendering of the colonic wall and very short acquisition times, reducing motion artefacts. furthermore, application and refinement of (ultra-) low dose technique almost completely tackled the issue of radiation dose. these improvements have resulted in the perfect optical colonoscopy imitator with reliable fly through of the colon in a timely manner. consecutively, the primary d reading paradigm with d problem-solving is getting more and more adepts, although in experienced hands primary d-read with d-problem solving is a solid contender. to improve depiction of the colonic wall new d visualisation methods were developed. these technical improvements with the application of state-of-the-art ctc technique have resulted in a very good performance of polyp detection. in three multi-centre studies, totalising patients, sensitivity ranged between - % and - % and specificity between - % and - % for lesions > mm and > mm, respectively. finally, it may be expected that further refinements of cad, laxative-free ctc with electronic cleansing and dual energy ct will bring ctc to the next level and will enhance it as the reliable and cost-effective tool for colorectal cancer screening. learning objectives: . to review the evolution of ct colonography since its introduction, with a focus on data acquisition and methods of data visualisation and interpretation. . to review the currently achievable test characteristics of ctc (sensitivity, specificity, accuracy) via reference to current trial data. . to become familiar with imminent developments that may further enhance ctc test characteristics. astinitis and extension of infection from adjacent spaces (neck, pharynx, pleura or retroperitoneum). typical cases including the role of radiologic findings with respect to sensitivity and specificity, and important differential diagnosis will be discussed. the distinction between a parapneumonic pleural effusion and an empyema based on radiologic findings is often impossible. features suggesting a "complicated" course requiring interventional or even surgical treatment at some point will be discussed. features of empyema and lung abscess at ct will be illustrated as well as ct indices of severity of empyema and its effect on the underlying lung that allow some prediction of functional outcome after surgical decortication. an empyema necessitatis describes a chronic empyema that attempts to decompress through the chest wall. infectious agents include tuberculosis, actinomyces, staphylococcus and various types of fungi. it has to be differentiated from other mostly neoplastic diseases that cross fascial planes such as lymphoma or pancoast tumour. most lymphomas arise in lymph nodes or other lymphatic tissues. extranodal lymphomas arise in tissues normally devoid of lymphoid tissue. involvement of so-called extranodal organs is a common finding after staging investigation, however, and a substantial part of nhl even arises in these sites. the latter form is often referred to as primary extranodal nhl. splenic lymphoma is common in both hodgkin disease and non-hodgkin lymphomas but it may be difficult to detect by imaging techniques because lymphoma nodules in the spleen are often smaller than cm. splenic enlargement alone is not a good indicator of lymphomatous involvement. primary hepatic lymphoma is rare compared with disseminated diseases at both nodal and extranodal sites. several forms of hepatic involvement can be seen including mass lesions/nodules, diffuse infiltrative form and extrahepatic involvement of the hepatic ligament. lymphomatous involvement of liver hilum nodes often infiltrates along the hepatic artery and portal vein toward the head of the pancreas and produces an infiltrative bulky mass that involves the liver, pancreas and duodenum. primary pancreatic lymphoma is very rare and can be difficult to differentiate from pancreatic adenocarcinoma. definitive pathological diagnosis of lymphomas is often obtained using image-guided biopsy. this noninvasive procedure is important as the prognosis and management of lymphomas differ greatly from that of adenocarcinoma or metastatic diseases. staging (ann arbor classification or modifications) and response to therapy is primarily by ct. community acquired pneumonia (cap) is a major health care problem because of their high morbidity and mortality rates. patients exposed to non-hospital risks who develop pneumonia have been traditionally categorised as having communityacquired pneumonia (cap). healthcare-associated pneumonia (hcap) is a new designation for pneumonias affecting individuals residing in non-hospital health care facilities, patients undergoing outpatient procedures or therapies, and patients who have been recently discharged from the hospital setting. when the diagnosis of cap or hcap is suspected, imaging studies are mandatory for the evaluation of affected patients. a nosocomial pneumonia is defined as one not acquired in a hospital or a long-term care facility. it occurs most commonly among icu patients, predominately in individuals requiring mechanical ventilation. pulmonary infection is a major cause of morbidity and mortality in patients with impaired immune function. increasing numbers of patients are becoming immunosuppressed, because of solid organ and hematopoietic stem cell transplantation, the use of immunosuppressive agents for treating a host of inflammatory diseases, or congenital and acquired diseases such as acquired immune deficiency syndrome (aids). mildy impaired host immunity as it occurs in chronic debilitating illness, diabetes mellitus, malnutrition, alcoholism, advanced age, prolonged corticosteroid administration and chronic obstructive lung disease have also been regarded as predisposing factors of pulmonary infections. the rapid diagnosis and treatment of pulmonary infections are essential. combination of pattern recognition with knowledge of the clinical setting is the best approach to pulmonary infectious processes. acute mediastinitis is a potentially life threatening but fortunately rare condition that requires prompt diagnosis and treatment. spontaneous or iatrogenic oesophageal rupture is the by far most common cause. other causes include post-surgical medi-ask the patient for those information. at the time of mr imaging plain films and/ or results of an ultrasound exam of the shoulder, if possible, should be available. however, only such prerequisites allow to run a tailored examination protocol and to support the orthopaedic colleague with the needed answers for further adequate therapy. the patient has to be placed in the magnet in a pleasant situation to avoid artefacts due to patients movement, which usually cause motion artefacts. it is very important to explain to patients to keep quiet during the whole examination, because artefacts may need repetitions of sequences, and lead so to prolongation of total examination time. furthermore, they make diagnosis more difficult and eventually more or less inaccurate. lastly, sequence repetitions decrease patient throughput and therefore cost effectiveness. imaging in three orientations (axial, paracoronalparallel to the supraspinatus tendon, and parasagittal -parallel to the glenoid cavity) using t w (pdw) and/or t w sequences have to be performed. in case of specific questions regarding lesions of the labrum intraarticular administration of contrast agent (mr arthrography) should be considered, which is sometimes (different from country to country) possible after discussion with referring orthopaedic surgeon only. mr imaging (mri) and mr arthrography are the primary diagnostic imaging modalities applied to patients with degenerative, traumatic and sports-related shoulder lesions. in this categorical course the characteristic mr imaging and mr arthrographic features of articular pathologies of the shoulder, in particular, instability-associated injuries, rotator cuff tears and biceps tendon lesions are discussed. beside lesion detection the radiological analysis comprises the understanding of the underlying pathomechanism and recognition of possible interrelations between different type of lesions (for example, secondary impingement and associated lesions of the posterosuperior labrum). the use of classification systems for specific lesions is introduced in order to improve the radiological report. a reasonable structure for written reports is discussed comprising a brief and clear description of pathological findings with subsequent interpretation and categorisation of findings with a view of therapeutic decision making. tissue changes in the treated neck by surgery and/or radiotherapy (rt) make the detection of residual or recurrent tumour more difficult. clinical evaluation of the neck is also hampered by these changes. therefore, any (non-invasive) method helping in the detection of recurrence is welcome. in order to evaluate the treated neck, radiologists should be familiar with expected post-rt findings. histological changes post-rt will be discussed in combination with imaging examples. this knowledge will enable radiologists to recognise non-expected findings post-rt. non-expected post-rt findings can be caused either by tumour recurrence, or by complications of treatment (e.g. chondro-radionecrosis). imaging examples will be shown. especially after surgery, including various types of neck dissection, lymphatic drainage patterns of the head and neck are altered. it is important that radiologists are aware of these changes. imaging examples will be shown. ct and/or mr-findings in the treated neck may be inconclusive. in these cases, there may be an additional role for metabolic (pet) imaging. at present, the position of metabolic imaging in the imaging protocol for the treated neck is unclear. information from the recent literature will be discussed. also, examples from daily practice will be shown, with emphasis on the importance of base-line imaging after treatment and the timing of such base-line scans. this knowledge will help in understanding the current indications and limitations of post-treatment metabolic (pet) imaging of the head and neck. an increasing number of functional and metabolic imaging options reflecting relevant aspects of tumour biology have rapidly been incorporated into clinical trials and, progressively, into clinical practice. while tumour staging according to the tnm system still rules most decisions regarding treatment choice in head and neck cancer, biological information from the tumour and its microenvironment has proven to have important predictive and prognostic value heading for a tailored and individualised patient's management. ct, mr and pet are the mainstay imaging modalities to access tumour extent, both of the primary tumour, lymphatic and distant metastases and for early depiction of recurrence during patient's follow-up. hypoxia and angiogenesis, the major driving forces for tumour aggressiveness, long linked to chemo and irradiation treatment failure, can now be imaged both by pet ( f-miso or cu atsm) or mri (bold and pwi, respectively). this information is being used to define biological tumour volumes, to tailor conformational and intensity modulated radiation treatments and to select patients for specific treatments such as radiosensitizers, hypoxia selective cytotoxic and antiangiogenic drugs. overexpression/amplification of egfr (epidermal growth factor receptor) are common genetic abnormalities in scc linked to increased cell proliferation and worse prognosis. imaging techniques reflecting cell proliferation/ density ( f-flt -desoxyfluorothymidine-and diffusion-weighted mri) can be used to select patients for treatment with egfr inhibitors. this special focus session will review the use of these imaging modalities both prior, during and after treatment of head and neck cancer focusing on their specific advantages and accuracies in these different settings. contrast-enhanced ct and mri are routinely used in order to determine the precise localisation, size and anatomic extent of the primary lesion. on the other hand, positron emission tomography (pet) is the most sensitive and specific technique for in vivo imaging of metabolic pathways and receptor-ligand interactions in the tissues. a common question is which of these techniques should be used in a particular patient. the most widely used technique is ct, as it has a number of important advantages over mri, like wide availability, relative low cost and short examination time. however, ct also has a number of disadvantages compared to mri: relative low soft tissue contrast resolution, severe image quality degradation by dental fillings or other metallic foreign objects, and radiation exposure. pet in combination with ct and/or mri has a good sensitivity and specificity for the detection of primary tumour and for nodal staging as well as for detection in a single examination distant metastases, occult tumours, second synchronous tumours, and for radiotherapy planning. by combining pet with ct and mri studies, either sequentially or synchronous performed, the diagnostic accuracy is significantly higher. in those situations, it has been proven that magnetic resonance (mr) imaging is a valuable adjunct to delineate the pathology. in non-pregnant woman the radiological evaluation is less difficult. still, a multimodality approach may be needed in certain cases. in this lecture, radiological features of non-gynaecologic emergencies such as acute appendicitis, diverticulitis, renal calculi and pyelonephritis will be discussed. the purpose is to discuss the role of imaging and the potential of different methods applicable in childhood uti -with a focus on us. the imaging task in uti has changed, and new questions arouse for radiology. in addition, growing economical demands pressurise radiology to restrict imaging to those conditions where an evident benefit has been demonstrated. this efficacy-oriented approach is difficult in children due to the lack of evidence-based data. thus, controversies exist on if, when and how to investigate childhood uti, trying to minimise procedures and reduce burden on children and health budgets without missing important conditions that may pose a threat to the kidney. furthermore, modern imaging with new methods, applications and potential (e.g. contrast-enhanced voiding urosonography = ce-vus) may influence the imaging algorithm. the in utero and post-natal follow-up of foetuses with urinary tract dilatation has provided lots of information about the proper management of urinary tract malformations. nowadays, affected neonates are evaluated following standardised charts panel discussion: the three musketeers were actually four : ct, mr and pet: how to choose between modalities in head and neck cancer patients. an increasing number of imaging modalities reflecting functional and metabolic aspects of tumours have rapidly been incorporated into clinical practice. these modalities provide additional information on tumour vascularisation/ angiogenesis (ct and mr perfusion); on tumour metabolism, hypoxia and proliferation (pet using different radioactively labelled substances) and on tumour architecture and cellular density (dwi). hybrid imaging, pet-ct and, in the near future pet-mr, can provide morphologic, metabolic and functional information in a one-stop-shop examination. the choice of the best modality (ies) to answer specific questions in the diagnosis, follow-up and in the prediction of response to treatment and prognosis will be addressed. acute abdominal and pelvic pain in pregnant women may be the manifestation of various gynaecological and non-gynaecological conditions. the correct diagnosis of the causes of acute pain during pregnancy is critical to minimise maternal-foetal morbidity and mortality. although ultrasound (us) is the primary imaging investigation in the diagnostic evaluation of the pregnant patient, the role of magnetic resonance (mr) imaging in the evaluation of foetal and maternal diseases in pregnant patients continues to expand. mr imaging offers different potential advantages in comparison to us for evaluating acute abdominal and pelvic pain; these include multiplanar imaging capabilities, a higher soft tissue contrast and the ability to detect and distinguish blood from other fluid collections. when us is equivocal or nondiagnostic, mr imaging is a valuable complement to determine the exact aetiology of acute abdominal pain. the intrinsic safety and the accuracy of mri in diagnosing abdominal and pelvic disease make it an excellent choice for triage of pregnant patients with acute abdominal and pelvic pain. mr imaging provides important information that influences patient management, and it is important for the radiologist to recognise the mr imaging appearance of the common causes of acute abdominal and pelvic pain during pregnancy. this lecture will discuss the use of mr imaging for maternal diseases that cause acute abdominal and pelvic pain during pregnancy. moreover, this lecture will discuss the different mr imaging techniques to use, and will show how to detect and to differentiate the gynaecologic and non-gynaecologic causes of pain during pregnancy. in this lecture, the role of imaging in the evaluation of gynaecologic emergencies will be presented. a combined approach using both clinical findings and imaging features is necessary. accurate evaluation is important as failure to make a diagnosis may lead to serious consequences. presenting symptoms, such as pelvic pain or vaginal bleeding or discharge, may overlap with pregnancy-related emergencies and with non-gynaecologic abdominal emergencies. the range of conditions to be considered include ovarian cyst emergencies (cyst rupture, haemorrhage or torsion), infective conditions (bartholins' or vulval abscess, pelvic inflammatory disease or tubo-ovarian abcess) and acute bleeding (from inflammation, neoplasm, or trauma). pain may be related to the menstrual cycle, as in endometriosis or ruptured corpus luteum, or may be unrelated, such as in fibroid or ovarian torsion or pelvic inflammatory disease. the imaging features of these acute abnormalities will be reviewed and discussed in the context of the differential diagnoses. the major functional imaging tools for tumour management are obtained with dynamic contrast-enhanced imaging, diffusion-weighted mr imaging, and mr elastography. these acquisitions allow understanding of tumour angiogenesis and perfusion, and tumour architecture. dynamic contrast material-enhanced imaging allows assessment of perfusion parameters. diffusion-weighted mr imaging provides information that reflects tissue cellularity and the integrity of cellular membranes. mr elastography evaluates the mechanical properties of tissue such as stiffness and viscosity. to date, tumour detection is mainly based on morphologic features. however, changes in perfusion parameters have been shown as early parameters of liver metastases detection in patient with colorectal carcinoma or breast carcinoma. tumour characterisation is usually based on morphologic features. yet, perfusion parameters have been shown to correlate with microvascular density and tumour differentiation helping tumour characterisation. furthermore, apparent coefficient diffusion (diffusion-weighted mr imaging) and stiffness and viscosity (mr elastography) are significantly different in benign and malignant tumours. despite these differences, these last parameters usually do not allow definitive subtyping. functional imaging starts playing a major role in non-surgical treatment follow-up especially with targeted cancer therapy. changes in perfusion parameters, apparent coefficient diffusion, and stiffness and viscosity are observed in responders. interestingly, these changes appear promptly after treatment initiation. these functional variables are not included in recist . but might be part of response criteria in the next future. many examples of functional imaging for tumour management will be provided. learning objectives: . to understand the potential of functional imaging in tumour detection. . to understand the potential of functional imaging in tumour characterisation. . to learn about the future use of functional imaging in treatment planning and follow-up. (among others, thanks to the esur-espr working group). at birth, a confirmatory ultrasound is performed in order to evaluate the type and degree of the malformation. urinary tract dilatation are separated into mild, moderate and marked. mild and moderate dilatation will be followed by us. voiding cystogram and functional studies will be performed only if the dilatation is significant or persists. the prognosis is usually good. patients with marked dilatation would be managed more "aggressively". their work-up would be initiated as soon as diagnosed in order to diagnose cases that need therapeutic manoeuvre. for them voiding cystogram, anatomical and functional studies cannot be skipped and are important for the prognosis. long-term follow-up are needed to prevent further damage. learning objectives: . to learn which infants with antenatal diagnosis of urinary tract dilatation require imaging and when. . to become familiar with the most important differential diagnosis. . to learn about the imaging strategies in these infants. c. renal and pararenal masses: basic rules p. tomà; rome/it (paolo.toma@opbg.net) the differential diagnosis of renal and pararenal masses firstly depends on the age of the child. wilms tumour (nephroblastoma) is the most common abdominal tumour in - years old ( % of cases in children less than years old -peak age . years). renal non-wilms tumours represent a significant proportion of renal tumours in children, especially in children aged less than months or greater than years. neuroblastoma most commonly arises from the adrenal gland but can arise anywhere along sympathetic chain; it is the most common tumour in children under years of age ( % of cases in children less than years -mean age < years). adrenal adenomas and carcinomas also occur in childhood. us is the initial imaging modality to investigate an abdominal mass in children. ct or mri is used to confirm the us findings and not uncommonly add new, valuable information. concerning wilms tumour there is a very diverse approach to treatment according to geographical location. this variation in therapeutic attitude has consequences for the choice of imaging modality at diagnosis. neuroblastoma staging includes also i-mibg, and laboratory investigations (bilateral bone marrow aspirates with histochemical tests and urine catecholamine level measurements). we focus on the points under discussion: revision to the staging of neuroblastoma, the problems inherent in distinguishing nephrogenic rests from wilms tumour and the approach regarding small lung nodules in children with wilms tumour. the principle of bi-rads imaging finding should be that of "quasi-benign" type, i.e. with a very low associated risk of malignancy (< %), opening the possibility of a short-term imaging follow-up as an alternative to imaging-guided needle biopsy. however, a number of issues should be regarded as relevant to radiologists and patients. ) radiologists' differences in classification. . when needle biopsy is optioned, vacuum-assisted biopsy under stereotactical guidance for mammographic only findings (typically, microcalcifications) and core-biopsy for sonographic findings should be used; fine needle aspiration cytology should be avoided due to the high probability of benign lesions which need larger tissue samples. . when short-term follow-up (typically, months) is optioned, the same technique on which the bi-rads lesions was initially detected should be used. . in the screening setting, short-term follow-up option is commonly not considered and the reader is forced to give a dichotomic reading (recall/not recall). . the choice between the two options should be clearly discussed with the patient, including the psychological cost of waiting six months to get a conclusive report, and a really informed consent should be obtained. . till now, there is insufficient evidence for using tomosynthesis or mri for evaluating mammographic or sonographic bi-rads findings. the premise behind the bi-rads classification is to identify a group of low risk lesions that can be safely placed on follow-up rather than biopsy. in practice this can be very difficult and is anachronistic to the principles of the european population screening programmes where the radiology objective is to diagnose or discharge. the panel will discuss these dilemmas. starting in the late s an american college of radiologists task force developed the concept of guidelines to standardise mammography reporting: breast imaging reporting and data system (bi-rads). there is evidence that over time there have been improvements in consistency of use, sensitivity, specificity and positive predictive value. however, bi-rads 'probably benign; short interval follow-up recommended; less than % risk of malignancy' has always been the most difficult and controversial, with the highest levels of discordance between classification and recommendation, wide variation in both intra-and inter-observer agreement and a literature review demonstrating ppv for malignancy of between and %. management of breast disease has moved on a great deal since the s. in the main driven by increasing specialisation associated with population screening programmes. nowadays a specialist breast radiologist works with a wide variety of needle options at his hip to such an extent that the breast multi-disciplinary team increasingly feels that failure to obtain a non-operative diagnosis of discrete lesions is unacceptable. in this setting, and mindful of the medico legal consequences of 'delayed diagnosis', is there still room to allow a patient to leave the one stop clinic without a definitive diagnosis? as the leaders of the diagnostic team we also have to take account of the emotional and psycho-social consequences for our patients as well as the financial costs to patient and the healthcare economy. breast imaging reporting and data system (bi-rads) was developed for standardising reporting and include mammography, ultrasound, and mri. bi-rads category "probably benign finding -short-interval follow-up suggested" should have less than % risk of malignancy. category has been subgrouped into a, b, and c, and this influence the classification of bi-rads . mammographic bi-rads : three nonpalpable findings in this category include clusters of punctate microcalcifications, well-circumscribed and noncalcified solitary masses, and benign-appearing asymmetric density. digital mammography will increase detection of amorphous microcalcifications and the number of bi-rads (or a) lesions. intramammary lymph nodes and calcified fibroadenomas are bi-rads lesions. ultrasonographic bi-rads : a most important bi-rads lesion is a solid oval mass ("tumour") with gently lobulations, circumscribed margins, and parallel orientation. using strict criteria, the negative predictive value is approaching %. two other lesions are nonpalpable "complicated cyst" and clustered microcysts. the "complex" cyst, i.e., a mass with cystic and solid components, should be classified as bi-rads . mri bi-rads : there is lack of evidence which mri findings should be categorised bi-rads . nonmass-like enhancement (nmle) and enhancement kinetics are unique to mri. lesions less than mm ("foci") need no assessment. a challenge is mri-detected tumours < mm as morphologic analysis is of limited value. benign kinetic curves may justify short-term follow-up. in high-risk women, mri-guided vacuum-assisted biopsy should be considered. in conclusion, bi-rads is justified in diagnostic settings but should be avoided or kept at a minimum in screening. what will be the standard machine and field of the future? l. darrasse; orsay/fr (luc.darrasse@u-psud.fr) improving the sensitivity has still been an essential issue in mri, because the signal from nuclear spins relies on extremely weak magnetic interactions dominated by thermal fluctuation. to push the signal-to-noise ratio upward, the basic routes have been (i) to increase the field strength, (ii) to improve the signal detection with radiofrequency coils and (iii) to enhance the signal dynamically with contrast agents or alternative preparation techniques. the first route is the most obvious one, driven by the trends in analytical mr spectroscopy and small-animal mri. going up to or even above t represents a considerable challenge, both technically and in view to renew the mr equipment market. however, this way is limited by safety issues, radiofrequency penetration concerns and susceptibility artefacts. alternatively, improving the radiofrequency system relies on a complex electrodynamics background, where tissue conductivity and different sources of noise have to be considered. during the last half-period of mri development, radiofrequency coil arrays have appeared as a powerful mean to improve the signalto-noise and to accelerate the spatial encoding process, even able to overcome some pitfalls with high-field mri. finally, the topics of an optimal field strength has always been highly controversial because the contrast mechanisms, on which the diagnostic information is mainly founded, are essentially field-dependent. basically, the contrast mechanisms tend to be dominated, respectively, by macromolecular cross-relaxation at low field, and by susceptibility-weighted diffusion at high field. an emerging question is then to address different pathologies or organs with either general-purpose or dedicated mri systems. learning objectives: . to learn about the possibilities of gaining a jump in signal. . to understand the respective strategies of field increase and coil improvements. . to consider the probable system in . will new technologies allow a jump in sensitivity? j. hennig; freiburg/de (juergen.hennig@uniklinik-freiburg.de) imaging technologies have made breathtaking progress for several decades and in all aspects of medical imaging -mr, ct, us and pet. amongst the current developments in mri there are several areas which hold promise to redefine the boundaries of sensitivity. ultrahighfield mri with field strengths of t and more starts to reveal insights into tissue microstructure so far inaccessible to mr (or any other technique). this is still under intense technological development with some key issues to resolve notably safety issues related to the high radiofrequency power. the unique contrast and resolution does hold promise for highly relevant applications such as neurodegenerative disease, small vessel disease, ms and others -although definite clinical studies for a ‚killer application' are still lacking. c-hyperpolarisation of metabolites such as pyruvate, succinate, bicarbonate, etc. lead to an increase in detection sensitivity by factors of - , . finally, the development of targeted probes is progressing extremely rapidly and for all imaging modalities. most of this work is aimed at preclinical research, but the tremendous impact of the new insight in translational research promises to be of high impact for clinical application. will these technologies allow a jump in sensitivity? yes and no. image quality, contrast and sensitivity will grow significantly. the biggest impact will, however, lie in the combination of the new possibilities with other data -imaging as well as non-imaging. a true change in paradigm will only be achieved if the current parcellated knowledge about various aspects of the disease is unified into a comprehensive picture. learning objectives: . to review the recent developments in rf-coils and gradients. . to learn about the new measurements technologies. . to envision how these new tools will allow a huge gain in sensitivity. will new mr contrast probes compete with pet? s. aime; turin/it (silvio.aime@unito.it) purpose: molecular imaging is a new science that will have a tremendous impact in the development of innovative diagnostic tools. in the first stage of its enrolment, it has relied massively on pet/spect and optical imaging technologies because of the superior sensitivity of their probes. in the long-term, mri/mrs approaches may recover a central role, provided that further sensitivity improvements will be attained. high sensitivity mri probes have been designed and tested for molecular imaging applications. in the case of paramagnetic based systems they rely on improved design of the coordination cage as well as on the encapsulation/incorporation in proper nanocarriers. for multiple detection studies, cest as well hyperpolarized c- containing molecules have been considered. results: as molecular imaging is the evolution of biologists' in vitro work that has revolutionized the way living cells and intact tissues were investigated, mri multiplex-visualization of biological processes appears to be a key task for the forthcoming years for an efficient translation of such outstanding achievements. the search for frequency-encoding mri contrast agents represented by cestand hyperpolarized c- containing molecules have opened the interesting perspective of detecting more than one agent in the same anatomical region. this task is largely precluded to nuclear probes. moreover merging mri and nanotechnology allows the attainment of high sensitivity systems also with the classical relaxation agents. conclusion: recent achievements in amplification procedures allow to tackle the intrinsic insensitivity of mri probes to make them more competitive in the arena of molecular imaging applications. the use of imaging to monitor response to treatment has become central in the care of patients with cancer. it is crucial therefore that radiologists involved in the management of patients with cancer understand the place of imaging within the clinical context of the management of patients with cancer; that they are aware of the criteria of the accepted current criteria for assessing response and are familiar not only with new developments in imaging that act as a surrogate end-point for evaluating the success of treatment but are also aware of how imaging is used to predict the likely response early in the patient's pathway. this session will concentrate on all these aspects on the use of cancer imaging in monitoring response to treatment in patients with cancer. we are in the era of targeted cancer therapy, whether by small molecules derived from knowledge of the molecular pathogenesis of tumours, or from biological therapies emerging from our understanding of immunology and cell biology. these approaches convey new challenges for the monitoring of response. small molecule therapeutics often stabilise tumours for significant periods without producing clear reduction of masses, and for these the assessment of surrogate endpoints takes on increasing importance. the measurement of pharmacodynamics is central to early phase trials in which confirmation of on-target effects is required to determine the biologically effective dose, and in many cases this is best done by functional imaging. biological therapeutics such as monoclonal antibodies and cellular immunotherapy also need novel approaches for the determination of their actions in vivo, particularly as they are frequently tested in the setting of low level disease. randomised trials are underway to assess the contribution of functional imaging, in particular ct-pet as a means to guide therapy. the emerging data suggest that there are broad variations in accuracy, both according to the disease in question and the context in which studies are performed, even before factors such as imaging quality control and standardised reporting are included. for the future, standardisation of techniques and common quality control will play a vital part in advancing our understanding in this rapidly evolving field. tas. there is regression of portions of these arches, but several remnants normally persist. any failure in this process can result in congenital anomalies of the aorta or pulmonary vessels. these anomalies can be categorised into aortopulmonary anomalies, systemic arterial anomalies, and pulmonary artery anomalies. the aortopulmonary anomalies comprise truncus arteriosus, hemitruncus arteriosus, aorticopulmonary window, patent ductus arteriosus, and transposition of the great arteries. the systemic arterial anomalies include the anomalies of the aortic arch, of which the most common is a left aortic arch with aberrant right subclavian artery. double aortic arch is the most common cause of a vascular ring and is characterised by left and right aortic arches arising from the ascending aorta and encircling the trachea and oesophagus. a right aortic arch can have three "subtypes": aberrant left subclavian artery, mirror image branching, or isolated subclavian artery. the first type is the most common one and is the second most common cause of vascular ring. aortic coarctation, pseudocoarctation and interruption of the aortic arch are other systemic arterial anomalies. the most important pulmonary artery anomalies are idiopathic dilatation of the pulmonary trunk, absence or proximal interruption of a pulmonary artery, pulmonary arterial stenosis, and pulmonary sling. cardiovascular magnetic resonance (cmr) imaging has become integrated into the assessment pathways for congenital heart disease in both paediatric and adult patients. cmr provides a powerful tool, giving anatomical and haemodynamic information that echocardiography and catheterisation alone do not provide. extracardiac anatomy, including the great arteries, systemic and pulmonary veins, can be delineated with high spatial resolution. vascular and valvular flow can be assessed, shunts can be quantified, and myocardial function can be measured accurately and with high reproducibility, regardless of ventricular morphology. finally, cmr surpasses both catheterisation and echocardiography in providing high resolution, isotropic, three-dimensional ( d) datasets. this allows for reconstruction of data in any anatomical imaging plane, giving complete visualisation of complex congenital cardiac anomalies, without the use of ionising radiation. in the congenital heart disease, cmr can be justified for any patient in whom clinical or echocardiographic data are insufficient for monitoring, decision-making or surgical planning. due to the complexity of both the anatomy and physiology of congenital heart disease, it is essential to have a systematic approach for cmr when assessing these patients. with the development of novel ct scanners, especially the dual source ct, novel strategies of examining congenital heart disease became possible. especially newborns and infants younger years of age are difficult to examine, since compliance cannot be expected. also young children are especially susceptible to ionizing radiation and should be exposed as little as possible. in a first step the course will illustrate the underlying technical principle how to examine children in < sec with sub msv exposure. also the course will teach how to avoid sedation in children of any age. in a second step the course will show how to apply contrast media in children of all ages and what strategy to use. in a third step the course will show how to appropriately choose scanning parameters for the ct scan since the size and weight varies considerable in children as there are small to date newborns with < kg body weight up to adolescents with a body weight > kg. since little comprehensive data is available how to examine with an optimal compromise between sufficient image quality and unnecessary radiation overexposure the data of the erlangen study will be presented and discussed. in a forth part typical indications for the exam are shown and how to interpret the exam. also limits for the exams are shown. in a final step a comparison with mri is shown which method is used for which pathology. in this session contrast-induced nephropathy and nephrogenic systemic fibrosis will be discussed. measures to reduce the incidence these adverse effects will also be presented. the pathophysiology of cin is complex and not well understood. basically, a misbalance between vasodilatation and vasoconstriction takes place inside the kidney after intra-arterial or intravenous cm administration. furthermore, increased oxygen demand of tubular cells due to increased reabsorbtion of sodium and water is a second mechanism, leading to transient medullar ischaemia. identifying the patient at risk is the first step in prevention. knowledge of the patient's medical record and a recent basic kidney function are mandatory. high-risk patients should receive prevention. two major topics in cin prevention are the questions whether iso-osmolar cm cause significantly less cin than low-osmolar cm and whether hydration schedules with nahco give significantly less cin than hydration schedules with nacl . %. currently up to % of all mri examinations worldwide are performed using contrast agents, either an extracellular agent or an organ-specific agent. the extracellular mri contrast agents are chelates that contain the paramagnetic ion gadolinium which strongly affects the relaxation properties of water protons, leading to changes in tissue contrast. gd-dtpa was the first extracellular agent to be introduced in clinical practice. since the introduction of gd-dtpa in , various gadolinium chelates with different chemical properties became available for clinical use. for many years, it was believed that gadolinium-based contrast agents (gbca) a s c b d e f g principles in the use of conventional/anatomic imaging for response assessment l. schwartz; new york, ny/us (lschwartz@columbia.edu) the standard way to assess a patient's response to chemotherapy is to use computed tomography (ct) to measure tumour size using uni-dimensional (recist) or bi-dimensional (who) criteria. this methodology has changed little in the past years despite the emergence of new therapies and advances in imaging technology. measuring the changes in the size of tumours in one or two dimensions does not always capture the effects of novel therapies on primary tumours and metastases. radiographic changes in the size of tumours treated, for instance, with epidermal growth factor receptor tyrosine kinase inhibitors such as gefitinib or erlotinib or inhibitors of angiogenesis such as bevacizumab do not necessarily occur at the same magnitude or speed as observed in those individuals treated with standard cytotoxic therapies. with these newer agents, tumours respond by undergoing cystic change, central necrosis, and density changes that may not be captured by conventional measurements of the largest lesion diameter. learning objectives: . to understand and appreciate the use of conventional/anatomic imaging for response assessment in clinical practice as well as in clinical trials. . to understand general and disease-specific challenges associated with response assessment at imaging. . to recognise potential improvement in imaging and image post-processing for response assessment. pet in monitoring response w. weber; freiburg/de pet imaging and specifically pet/ct with the glucose analogue fluorodeoxyglucose (fdg) has been evaluated in a significant number of studies to monitor tumour response in patients undergoing chemotherapy, radiotherapy or targeted therapies. the clinical value of for differentiation of residual or recurrent viable tumour and therapy-induced fibrosis or scar tissue has been established for malignant lymphomas and various solid tumours. furthermore, there are now several reports suggesting that quantitative assessment of therapy-induced changes in tumour fdg-uptake may allow prediction of tumour response to chemotherapy and targeted drugs very early in the course of therapy. in non-responding patients treatment may be adjusted according to the individual phenotype of the tumour tissue. current studies investigate whether fdg-pet can be used to "personalise" treatment and to reduce the side effects and costs of ineffective therapy. in addition to fdg, several other imaging probes are in clinical studies to monitor tumour response to therapy. these include among others [ f]fluorothymidine (flt) for imaging of cellular proliferation, [ f]fluoromisonidazole for assessment of tumour hypoxia and radio-labelled rgd-peptides for angiogenesis imaging. preclinical and early clinical trials with these imaging probes are encouraging, but need to be confirmed in larger clinical trials. learning objectives: . to understand how image acquisition and reconstruction influence visual and quantitative analysis of pet studies. . to describe current criteria for assessing tumour response in lymphoma and solid tumours and recognise the limitations of these criteria. . to understand how differences between scanner models can influence response assessment by pet. panel discussion: why does the radiologist need to understand the importance of monitoring response and how it is done? : monitoring the response to treatment has become a critical part of the management of patients with cancer. the markedly improved diagnostic performance of crosssectional imaging in delineating the extent of malignancy has meant that imaging has become increasingly important as a surrogate end-point. these two factors have resulted in an increasing need for a standardisation of the criteria of response both in therapeutic trials and in clinical practice. it is vital that all radiologists imaging patients with cancer are familiar with the limitations, pitfalls and strengths of these changing criteria and also are aware of the possibility of using imaging to evaluate the changing molecular make-up of the cancer. stent-grafts is steadily increasing. therefore, knowledge of this treatment option is fundamental to provide basis for procedure planning and a meaningful radiological reporting. imaging plays a crucial role in the assessment of patients with aortic aneurysms. eligibility for endovascular treatment depends very much on detailed anatomical knowledge of the aorta, its branches and vascular access through the iliac arteries. we will review the role of imaging modalities: us, ct, mr for detection and evaluation of anatomy of thoracic and abdominal aneurysms. the strength and weakness of each modality will be reviewed and inclusion criteria for endovascular aortic aneurysm repair will be presented. the precise sizing of the stentgraft obtained from the images is certainly one of the most critical points of the endovascular procedure and a condition of its success. although it is a minimally invasive treatment it is associated with complications. there is a strong need for general radiologists to know about the most prevalent normal and abnormal findings of the post-treatment aorta. the session will end with discussion addressing the central role of imaging in pre-and post-treatment evaluation of the patients with aortic aneurysms. indications for and experience with placement of endovascular stent grafts in the thoracic aorta are still evolving. recent advances in imaging technologies have drastically boosted the role of pre-procedural imaging. the accepted diagnostic gold standard, digital subtraction angiography, is now being challenged by the state-ofthe-art computed tomography angiography (cta), magnetic resonance angiography (mra) and trans-oesophageal echocardiography (tee). among these, technological advancements of multidetector computed tomography (mdct) have propelled it to being the default modality used, optimising the balance between spatial and temporal resolutions and invasiveness. mdct angiography allows the comprehensive evaluation of thoracic lesions in terms of morphological features and extent, presence of thrombus, relationship with adjacent structures and branches as well as signs of impending or acute rupture, and is routinely used in these settings. in this presentation, we review the current state-of-the-art radiological imaging for thoracic endovascular aneurysm repair (tevar), especially focusing on the role of mdct angiography. after analysing the technical aspects for optimised imaging protocols for thoracic aortic diseases, we will discuss pre-procedural determinants of candidacy, and how to formulate interventional plans based on cross-sectional imaging. the purpose is to present the essential principles of endovascular repair of abdominal aortic aneurysms (evar). abdominal aortic aneurysms (aaa) larger than . cm should be treated. inclusion criteria for evar include satisfactory aneurysm neck morphology and suitable access vessels. preprocedural imaging involves cta from the diaphragm to the femoral arteries. several devices may be used to cover a wide range of anatomy. evar procedures are generally performed as combined procedures by teams of vasculr surgeons and interventional radiologists. patients are followed up indefinitely by cta (or ultrasound) and plain radiography. the periprocedural mortality is three times lower compared with surgery. late mortality rates are similar between surgery and evar. quality of life issues favour evar in the short and medium term. early published series reported high complication and reintervention rates for evar, although these have reduced with increased experience and improved device technology. gene-reporter imaging has been used to monitor cell-based therapies in neurology. one of the most promising applications of molecular imaging principles is the targeting of amyloid deposition in the patients with alzheimer's disease. it is hoped that early diagnosis of the neurodegeneration may lead to better therapies. the advent of hybrid-imaging will be associated with the need for multimodal contrast agents exploiting the imaging characteristics of the involved instrumentation for more differentiated visualisation of structure, physiology, and biology. learning objectives: . to understand the working mechanism and radiation of current clinical tracers. . to become familiar with the potential clinical indications and applications. . to learn about potential new tracers. panel discussion: what specific precautions are mandatory in order to guarantee contrast media safety to patients and healthcare professionals? : current contrast agents are safer than previous products. however there are still safety aspects to consider, including patient's kidney function, thyroid metabolism, allergy, radiation exposure, or specific medical history, and there is no such thing as total or complete safety. while these simple precautions may appear obsolete in the era of sophisticated technical approaches, these issues are still quite complex and crucial in maintaining a high safety level. the discussion will give guidelines and tips for achieving a high level of safety when using contrast agents. room q the abc of evar magnetic resonance imaging (mri) is the best tool to explore white matter disorders (wmd), including the most common demyelinating disease: multiple sclerosis (ms). the formation of demyelinating lesions is related to an "inflammatory attack". new techniques as diffusion tensor imaging (dti), perfusion weighted imaging and uspio enhancing can explore earlier and more specifically lesions formation. acute demyelinating lesions may resolve (remyelination) or persist as "chronic black holes". chronic demyelinating lesions lead to axonal injury and wallerian degeneration. a diffuse neurodegenerative process leading to cerebral atrophy is actually a major landmark in ms. conventional mri sequences allows visualisation of white matter lesions (seen as hyper t /flair lesions, low signal t lesions and possible gadolinium contrast enhancement), presently the basis of ms diagnosis. ms follow-up is usually clinic but imaging could provide prognosis and therapeutic parameters ("surrogate markers") even if disease progression and axonal loss are independent from "lesion load". mr spectroscopy, dti or magnetization transfer imaging (mti) provide measurement of diffuse tissue damage in clinical research, and may correlate to disease progression, as well as brain volume measurement. after exclusion of alternative diagnosis (mri "red flags" as other wmd), mri lesions dissemination in space and time criteria are the main points in ms diagnosis. the widely used revised mcdonald criteria may be replaced by more simple and efficient magnims criteria. such criteria could allow starting "modifying disease treatments" as soon as the first "clinical isolated syndrome". since blood oxygenation level-dependent (bold) signal changes have been observed using mri and modulated using neuronal stimuli, functional mri (fmri) has quickly become the most popular non-invasive functional neuroimaging technique in clinical practice and cognitive neuroscience. indeed, high-field mr scanners and bold-sensitive sequences are now widely accessible in both clinical and research settings. bold signal that relies on deoxyhaemoglin concentration is detectable without injection of external contrast media. the colourful activation maps combined with three-dimensional brain anatomy may have also made this imaging method as much attractive as controversial. numerous applications of fmri have been suggested in medicine. after a -year long history in clinical practice and thousands of scientific papers even in prestigious journals, the role of fmri remains mostly dedicated to map eloquent cortex before a neurosurgical procedure. in fact, bold fmri is challenging because the relationship between the neuronal response to a stimulus and the activation blobs relies on neurovascular coupling, haemodynamic response, mr signal detection, and complex time-series analyses. besides an obvious and partially elucidated complexity, and several concerns on the interpretation of experimental paradigms in cognitive neuroscience, fmri is based on a robust physiological and physical framework. bold signal is reproducible across subjects and mr scanners. fmri requires a rigorous methodology to acquire and analyse data, an advanced knowledge in sulcogyral and functional neuroanatomy to estimate spatial displacement and reorganisation in patient with focal lesion, and a solid experience in bold imaging to distinguish artefacts and potential confounds from appropriate results. learning objectives: . to know the key points of quality in fmri. . to know the main pitfalls in fmri interpretation. . to learn more about advances in fmri of brain perfusion. a- : the role of imaging in follow-up k.a. hausegger; klagenfurt/at (klaus.hausegger@lkh-klu.at) the goal of surveillance after evar is to prevent late rupture eurysm. high pressure els (type i and type iii el) are risk factors for late rupture therefore have to be treated. type-ii, iv and type v (endotension) els are low pressure els with a low rupture risk. thus, it is essential not only to detect els but also to classify els correctly. until recently stent graft surveillance has been performed with contrast enhanced multislice ct (msct), typically , , and months after evar and thereafter in yearly intervals. however, although msct proved to be a very effective in fu cumulative radiation exposure, repetitive contrast medium load and increasing work load have to be seen critically. therefore, alternative surveillance protocols especially including ultrasound have been evaluated. several studies have shown that a risk-adjusted follow-up regime might be most efficient. patients with low risk of aneurysm-related mortality after evar have a normal -and -month msct scan and sack shrinkage at months. in these patients regular contrast enhanced us in yearly intervals have been proven to be safe for further fu. a one yearly non-enhanced low-dose ct or a plain film may be recommended to detect distortion or migration of the stent-graft. patients with a persistent type ii el after one year need to be followed more closely and imaging modality is chosen depending on the character of the el. in most cases el classification can be made correctly by msct or us; however, sometimes dsa may be needed. panel discussion: the key role of imaging in endovascular aortic aneurysm repair : many patients with aortic aneurysms are currently treated endovascularly. therefore the number of patients imaged pre and post-procedurally is increasing. radiologists evaluating aortic aneurysms with different modalities should know the key imaging features to look for in pre-treatment as well as follow-up examinations. j.-p. pruvo; lille/fr (jppruvo@chru-lille.fr) neuroimaging is one of the fields of radiology with the most exciting recent advances. moreover, these advances show dramatically important clinical applications. some are useful for the specialised neuroradiologist, but most are critical for the general radiologist as well. in this session, we will try to address some of the most relevant issues: white matter disorders are common diseases. expertise of the radiologist is important in detecting the disease, and in the evaluation of the activity after treatment. with this respect, standardisation of criteria is desirable for appropriate medical decisions. functional imaging is a fascinating insight into the human brain. it opens new horizons and has found many applications in the evaluation of psychiatric diseases, and in the planning before treatment of brain lesions, among other potential applications. although it is obvious that we ignore much more than we know, this field is already one of the most exciting topics in neuroradiology. although these methods are still in the field of specialists, everybody should be aware of the possibilities of functional imaging of the brain and its recent developments. stroke is by excellence a clinically relevant problem. because it is an emergency situation, time really matters, and we have more than one imaging tool to explore these patients, it is mandatory to provide strong recommendations and guidelines for the radiologist, in accordance with the clinical situation and with the treatment options. at the end of this session, the attendees will be aware of important advances in the domain of neuroradiology, and will take home very important landmarks for their own clinical practice. jaundice is rare in children but imaging has a major role to establish the cause which differs according to age. in the neonatal period the leading cause is biliary atresia (ba) which consists of the obliteration of the extrahaepatic bile duct (bd) without dilatation of intrahaepatic bd and requires urgent surgical treatment to reduce the need for liver transplantation. ba must be considered when there are persistent white acholic stools and firm hepatomegaly. us shows the absence of dilated bd and in a few cases a cyst at the porta hepatis or findings of the splenic malformation syndrome, but often it is not conclusive. mrcp has not yet proved to be reliable for the diagnosis of ba. other neonatal cholestases include medical intrahepatic causes which can be identified by biological tests or histological findings and rare causes of extrahepatic obstruction with dilated bd such as lithiasis, choledochal cyst or spontaneous perforation of bd. in childhood, us easily identifies all causes of extrahepatic obstruction by showing dilated bd; the main causes include choledochal cyst (the most frequent congenital malformation, defined by an abnormally long common bilio-pancreatic channel), cholelithiasis, tumoural compression, sclerosing cholangitis, portal vein obstruction, postsurgical or posttraumatic stenosis… in all these cases, in our experience, mrcp has become the modality of choice and has replaced invasive procedures which are nowadays reserved for treatment. mdct may be useful in rare instances, for example, to differentiate calculi and aerobilia after surgery. imaging protocols and illustrative cases will be presented. neonatal bowel obstruction generally presents within hours of birth. the diagnosis of bowel obstruction is clinical but imaging is vital to determine the cause. the plain radiograph will distinguish upper from lower intestinal obstruction. the radiograph alone is diagnostic in duodenal atresia and jejunal atresia and the baby may be taken directly to surgery. if the radiograph shows multiple dilated loops of bowel, more than loops, then the obstruction is distal ileal or colonic. the radiograph may give some clues as to the possible cause, such as a large fluid level in the dilated loop proximal to an atresia. contrast enema, usually with low osmolar water soluble contrast, is used in most cases, however, to determine the cause of lower intestinal obstruction because the management of this is different for different causes of obstruction. meconium ileus and ileal atresia are the commonest ileal causes of obstruction and hirschprung's disease and meconium plug syndrome are the commonest colonic causes of obstruction. colonic atresia is rare and imperforate anus is a clinical diagnosis. radiologically guided reduction is used to treat meconium ileus. intestinal obstruction in the older neonate may be due to volvulous, pyloric stenosis, duodenal stenosis or omphalomesenteric band. in the baby born prematurely, obstruction may be caused by stricture secondary to necrotising enterocolitis. radiographs and contrast studies are also used to evaluate these conditions. learning objectives: . to learn about the most common causes of neonatal obstruction. . to understand the role of plain radiography in establishing the diagnosis. . to know when upper and lower gi contrast studies are indicated and the contrast medium used. stroke around the clock: will the challenger (ct perfusion) beat the champion (diffusion mri)? in patients admitted for a suspected stroke, time management is the most important criterion for therapeutic decisions. less than four hours and a half, all patients admitted in emergency for an acute neurological deficit without impairment of consciousness (nih < ) and presented with a brain ischaemia of less than one third of the territory of the middle cerebral artery should receive iv thrombolysis. brain imaging must exclude bleeding and quantify the extent of ischaemic damages. between . and hours after onset of symptoms, intravenous thrombolysis and/ or intraarterial mechanical or chemical thrombolysis may be indicated in selected cases. the assessment of ischaemic penumbra and vessel permeability is particularly important for the therapeutic decision. this may be evaluated either by mri or ct. mri is the technique of choice that should be used whenever possible because of the absence of irradiation and iodine-related side effects, the optimal anatomical coverage, the detection of lacunar infarct and its sensitivity for evaluating ischaemic brain damages of the posterior fossa. imaging protocol should include flair (fluid attenuated inversion recovery), t *, diffusion/perfusion and mr angiographic sequences. in case of unstable patient or if mri is not available, a non-contrast ct scan must be performed and completed by perfusion ct and ct angiography. the main advantages of this technique are the short time of data acquisition and the absolute quantification of perfusion due to the linear relation between attenuation and concentration. pneumonia is a common cause of attendance to hospital. chest infections in children are usually viral and self limiting, but sometimes chest infections can be prolonged or repeated. there are many underlying causes for this, for example, congenital anatomical causes, underlying patient susceptibility, inhaled foreign bodies and unusual organisms. one of the more common causes seen in hospital is when pneumonia has become complicated by empyema. very rarely other conditions such as kawasaki's disease or tumours can masquerade as pneumonia. this session will review these conditions together with the benefits and limitations of plain radiography. it will also consider times when other imaging modalities such as ct and ultrasound can help to guide diagnosis and treatment. in children, congenital heart disease (chd) is more frequent than acquired heart disease. diagnosis and subsequent management of patients with chd relies heavily on different and often multiple complementary imaging modalities. serial assessment of the morphology and function of the heart and thoracic vessels is needed at various stages of care. although chest radiography is frequently used for monitoring the cardiorespiratory status and complications that may arise during clinical care or intervention, it rarely provides a complete diagnosis. echocardiography, as first line imaging modality, often provides all information required for diagnosis and follow-up, especially in small children with good acoustic windows. contrastenhanced computed tomography (ct) and magnetic resonance (mr) imaging are valuable for detailed three-dimensional evaluation of the extracardiac vasculature and cardiac anatomy. in addition to being radiation free, mr has the advantage to provide both morphologic and functional information with the use of different techniques including ecg gated gradient-echo cine imaging, gadolinium-enhanced angiography and velocity-encoded phase-contrast imaging. a comprehensive mr evaluation including quantitative measurements of ventricular volumes and function as well as blood flow in vessels and across valves can give important information on long-term sequelae of the underlying cardiac defect, the significance of residual lesions, and potential complications of surgery. it is also valuable for planning and timing of future interventions. today, ct and mr have become the next line of investigation when echocardiography does not provide sufficient information, while catheter angiography is reserved for the assessment of coronary arteries, measurements of pulmonary vascular resistance and interventional procedures. over the past years, diagnostic imaging has witnessed a veritable explosion in the modalities available for studying patients. when applied to the study of the thorax, they contribute to earlier detection of abnormalities and greater diagnostic accuracy. yet, the conventional radiographic examination of the chest continues to be the most commonly performed imaging study and, when properly interpreted, continues to demonstrate a wealth of information. for a correct interpretation of the chest radiograph, several premises should be met by the radiologist: a proper knowledge of the anatomy and semiology of the thorax, stressing the need for a lateral projection, understand the importance of reviewing previous studies and try to avoid unnecessary cross-sectional studies. this lecture will address the radiological approach to imaging children of all age groups presenting with cough. this is a common symptom with very diverse causes, from acute viral infection to complex vascular and intrinsic congenital tracheal anomalies and can be the presenting symptom of acute (rapidly fatal if not managed adequately) and chronic effects of foreign body aspiration. the various causes of cough vary with age and whether cough is acute, sub-acute or chronic. this has effects on radiological investigations deployed, and thence on subsequent clinical management. we will present a pragmatic approach to radiological investigations in this diverse set of patients, using simple algorithms and illustrate the more important (and often rarer) causes of cough with discussion around deployment of examinations that are fit for purpose using alara principles. guidance on imaging algorithms and ct technique will be given to children with this important presenting symptom of myriad diverse pathological processes. the attendee will learn the value and optimal use of imaging with tips on optimising ct technique as fit for purpose. learning objectives: . to learn about the differential diagnoses in the very young child and in older children. . to learn which imaging modalities best help to determine the final diagnosis in the various age groups. . to understand radiation protection requirements in chest ct examinations. clinical examples of dual energy ct l.s. guimarães; viseu/pt (luis.s.guimaraes@gmail.com) dual energy (de) computed tomography (ct) allows the discrimination of different materials, which has several clinical applications. the ability to differentiate calcium from uric acid renal stones allows the identification of patients that will benefit from drugs that alkalinise urine. a musculoskeletal application of the same technique is in tophaceous gout, where the crystals can be differentiated from bone. postprocessing of ct angiography images can be facilitated using de techniques to identify and remove the calcium signal. such an approach removes both bones and calcified plaques. "virtual non-contrast" images can be obtained by identifying and removing the iodine-containing voxels of contrast-enhanced ct images, simulating non-contrast images and potentially eliminating the need for some non-contrast acquisitions, but it should be realised that small misclassifications could result in missing tiny caliceal tip stones, for example. dect also allows the utilisation of low energies without the prejudice of unacceptable noise. since iodine signal is significantly higher at low energies, disease conspicuity can be improved. this is particularly beneficial in the liver (for hepatocellular carcinoma identification), in the pancreas (for visualisation of hypo-and hypervascular lesions), and in enterography (to increase the identification of hyperenhancement). the approach for displaying the enhanced iodine signal may be one of blending information from the two energies (into a single grey-scale image), or via an iodine-only view. further validation of dual energy techniques and their limitations is needed to understand the patient populations in which such techniques can be utilised and where conclusions based on dual energy data can be trusted. ct perfusion imaging is a quantitative technique that employs rapid sequences of ct images after bolus administration of intravenous contrast material to measure a range of physiological processes related to the microvasculature of tissues. ct perfusion parameters can provide surrogates for tissue hypoxia as well as the physiological processes such as vasodilatation that represent vascular responses to hypoxia. although the basic techniques for dce-ct have been available for decades, more recently a range of technological advances have contributed to the greater applicability of perfusion ct in the clinical environment including wider ct detectors, shorter gantry rotation times, 'table-toggling', radiation dose reduction and software corrections for image mis-registration due to respiratory or other patient motion. consensus guidelines are now available for the acquisition and processing of ct perfusion studies for the brain and body. to date, the main applications of ct perfusion imaging in stroke have been the confirmation of stroke diagnosis and extent, identification of penumbra and selection of patients for thrombolysis. the main applications in oncology have been in lesion characterisation, risk-stratification and assessment of treatment response. computed tomography (ct) systems have provided three-dimensional (x, y, z) data since their clinical introduction in the s. this session will address the extension of ct imaging into the fourth and fifth dimensions. the rapid acquisition capabilities of modern ct scanners open the door to the fourth dimension -time -where a time-course ct scan can provide clinical information about blood flow, perfusion and other physiological measures regarding organ function. the door to the fifth dimension -energy -is opened by dual energy image acquisition techniques, which are made possible by dual source ct scanners or rapidly switching x-ray source ct scanners. dual energy ct images can be manipulated to provide quantitative information with regard to the elemental composition of tissues, which, in turn, can be used to differentiate between bone and iodine contrast, with many other applications possible as well. modern ct scanners now provide multidimensional data sets characterised as i (x, y, z, t, e), and the additional information provided by these five-dimensional data sets provide genuinely useful clinical information which add to the diagnostic potential of computed tomography. x-ray computed tomography (ct) usually measures the attenuation of the patient or object cross-section in question at a fixed chosen voltage value; the result is presented as the linear attenuation coefficient µ expressed in hounsfield units (hu). dual energy ct (dect) acquires data at two different mean energies and evaluates the differences in attenuation. dual energy ct imaging has been a topic since the s. the acquisition modes have changed over the years from two separate scans at different voltages to single scans with rapid kv-switching, and dual source ct operating with different voltages and pre-filtrations. these concepts will be explained in detail including future options of energy-discriminating detectors. the basic physics principles remain the same for all acquisition schemes. the two independent measurements allow separating two tissue characteristics contributing to attenuation. for example, low and high effective atomic number material densities can be determined in the so-called basis material decomposition. arbitrary combinations such as monoenergetic or electron density and effective atomic number images can then be provided. these will be illustrated and explained by examples such as differentiation between plaque and contrast agent or virtual unenhanced abdominal organ imaging. dect meanwhile offers quite a number of accepted clinical applications which will be covered in a separate talk. ous lesions (adenomas) and curable early-stage cancer, screening for crc has high potential for reducing incidence and mortality of the disease. nevertheless, the benefit of population-based crc screening needs to be weighed against potential risks, psychological distress and required resources since only a minority of the population develops the disease and may thus benefit from screening. several industrialised countries offer faecal occult blood testing as a primary screening tool, with positive test results being followed up by colonoscopy. some countries, such as the united states and germany, also offer colonoscopy as a primary screening tool. while the results of randomised controlled trials regarding screening colonoscopy are still outstanding, there is evidence from observational studies that support its effectiveness in population-based crc screening. recent evidence suggests that colonoscopy, when performed in the community setting, is more effective in protecting from neoplasms in the left colon and rectum than in the right colon. decision-analytic models support the (cost)-effectiveness of screening colonoscopy but results vary, among others, according to compliance, (country-specific) cost estimates and screening schedules. learning objectives: . to learn about the incidence and prevalence of colorectal cancer and its precursors in the target population of screening. . to understand the rationale for colorectal cancer screening. . to become familiar with estimated (cost) effectiveness of colorectal cancer screening when using optical colonoscopy as a primary screening tool. facts from the statistician (true for once?): how accurate is ct colonography the issue of diagnostic accuracy of ctc for crc and polyps has been debated for a long time, because of the conflicting results published in the literature. those results led researchers to design three important studies: two large, multicenter trials testing the performance of ctc in comparison with cc in asymptomatic individuals (acrin and impact) and one randomised, double-arm trial (siggar) conducted on symptomatic patients with the aim to detect crc. both the acrin and impact reported per-patient sensitivity of % for polyps > mm and - % for polyps larger than mm; per-patient specificity was extremely high, over %, independent of lesion size. the major drawback of the acrin was represented by the poor positive predictive value (ppv) ( % for polyps ≥ mm); a definitely better ppv was documented in the impact trial ( % for lesions larger than mm) as well as in studies obtained in high-experienced centers. however, the negative predictive value in both the acrin and the impact was rather high, approaching %; this is extremely important in order to reassure negative patients about the significance of the examination. excellent results were also obtained in the munich colorectal cancer prevention trial, a single-center study where around asymptomatic subjects underwent low-dose ctc in comparison with other screening tests (cc, sigmoidoscopy and fobt). despite the good results there are still some open issues: the significance of diminutive (< mm) polyps, the management of intermediate ( - mm) lesions and the detection rate for non-polypoid, flat lesions. colonoscopy is a very useful and important method to examine the colon. in recent years virtual colonoscopy has become a popular alternative to optical colonoscopy. disorder of the colon includes colorectal cancer, which is one of the most common cancers worldwide and presents a threat to life since the mortality is almost %. colorectal cancer screening has been shown to be an efficient method to find early forms of colorectal cancer and also to reduce mortality in this disease. in this session we will discuss the various methods used to examine the colon, how useful they are and the economy behind using them. facts from the epidemiologist: incidence, prevalence, rationale for screening, standard results of optical colonoscopy. colorectal cancer (crc) is the third most common cancer in the world, with about million new cases and more than . deaths per year. incidence of crc strongly increases by age and is higher in men than in women. the lifetime risk differs between countries and is about % in the united states. because most cases of crc develop from removable precancer-stabilisation complex system a dual echo t /dp sequence could be performed in a sagittal-oblique plane drawing an imaginary line which on an axial image used as reference plane, is done perpendicular to popliteous tendon. gradient echo (ge) sequences are useful in cartilage and traumatic pathology. t -weighted sequences understimate cartilage thickness since cortex and cartilage have the same signal. pd sequences may have the similar signal for cartilage and adjacent joint fluid, obscuring defects; fat suppression solves this. if available, acquisitions performed in orthostatism could give further information in the assessment of meniscal and patello-femural pathology. learning objectives: . to understand the influences of patient positioning, scan parameters and magnet/coil technology on image quality. . to learn how to optimise scan protocols to maximise patient throughput without compromising diagnostic quality. . to recognise how and when to modify scan protocols to answer specific clinical questions. this talk will review appearances of normal anatomic variants identified at mri of the knee including discoid meniscus, transverse meniscal ligaments meniscal flounce, ossicles, and pseudotears. subsequently the talk will focus on diagnostic pitfalls reflecting both imaging technique and variations in anatomy such as the effect of motion, imaging plane and anatomic variations in patella shape. mri of the knee is one of the most frequent performed investigations, thus indicating that common abnormalities need to be familiar to the general radiologist. a simple and straightforward method of enabling assessment of clinically relevant anatomical entities is based upon a (pre)structured radiology report. use of speech recognition facilitates implementation of pre-structured reporting in a kiss manner. since one now is enabled to structure the report, using digital tools, terminology used should be discussed between the reporting radiology department and the clinical partners. it is mandatory that the important message, the clinical relevance of the information that radiologists put in their report, is understood by the referring clinician in the same manner as it was meant to be. we should consider the background of our referring physician, and tailor our report, both in chosen terminology as well as detailed information. when working in a centre in which both specialised orthopaedic surgeons as well as general practitioners (gps) or sports physicians are referring for mri, each of the three needs a tailored report, especially considering advise for secondary referral: gps and sports physicians will need different approach, compared to medical specialists. also, the knowledge of terminology used should be considered. the presentation focuses on common encountered pathologies, considering common abnormalities. emphasis is given to common abnormalities, and pitfalls that should be dealt with. some sports specific entities are discussed. implication of clinical correlation is stressed. the presentation will include casebased clinical illustrations. learning objectives: . to review the imaging appearances of common abnormalities. . to understand the use of terminology to describe pathological findings. . to learn how to structure a radiological report to ensure clarity and brevity. of view and the "third eye" colonoscope are under investigation. at the moment, however, the combination of both, exact diagnostic and sufficient therapeutic action at the same time, is the reason why optical beats virtual in this particular indication. since its evolution ct colonography has been advocated as a safe well tolerated alternative to colonoscopy, particularly in the context of colorectal cancer screening. notably perforation rates are lower than those of colonoscopy and cardiovascular effects are less. however, patient preference studies have produced mixed results and it is not clear if standard ctc will increase compliance with screening. furthermore, issues over apparent inferior sensitivity for polyp detection compared to colonoscopy, need for prolonged radiologist education and radiation dose exposure have been cited as barriers to widespread implementation in a screening context. technical developments in recent years are beginning to address these issues. use of reduced laxative regimes supplemented with faecal tagging have shown good results with superior patient acceptability. software developments have also speeded up dataset analysis -notably panoramic or "virtual pathology" d views reducing or eliminating hidden areas within the colon. furthermore, computer-aided detection software is increasingly fit for purpose and good data show a positive effect on radiologist performance both in the research setting and day to day clinical practice. this presentation will review the data on patient preference and safety and highlight developments in those areas in which ctc holds advantages over conventional endoscopic techniques. discussion will focus not only on colon cancer screening but also the on data supporting ctc in older symptomatic patients who are at higher risk of adverse events during colonoscopy. learning objectives: . to review the patient safety of ct colonography and conventional colonoscopy. . to review advanced computer techniques for maximising visualisation of the colon during ct colongraphy including d visualisation methods and computer aided detection. . to review the data on ct performance with particular emphasis on patientfriendly reduced laxative regimens. . to consider patient preference data. osteoporosis, osteomalacia, hyperparathyroidism and paget's disease have conventionally been considered the disease entities that comprise metabolic bone disease. the lecture will follow this convention and discuss the imaging characteristics that suggest osteoporosis in the elderly or anorexia nervosa in younger patients by the distribution of fractures and marrow changes as well as the role of bone mineral density evaluations in osteoporosis. oncogenic osteomalacia will be discussed in the context of appropriate imaging for detecting the tumour and emphasise the basic biochemical abnormality that most radiologists should be familiar with that leads to the diagnosis. radiologists most frequently encounter hyperparathyroidism in renal osteodystrophy with over a million patients worldwide kept alive by dialysis. dialysis-induced imaging changes such as amyloid and the spectrum of findings from long-term dialysis will be shown and demonstrated. paget's disease is on the decline. its distinctive mri signal characteristics in uncomplicated cases, in contrary to most bone lesions encountered in clinical practice, will be explained. learning objectives: . to get an overview of the entities that are considered in the realm of metabolic bone disease. . to understand common, less common and rare findings. . to learn about some imaging findings that occur as a consequence of treatment. osteoporosis is of great socioeconomic impact, as approximately % of all postmenopausal women have osteoporosis in developed countries. ageing of populations worldwide will be responsible for a major increase of the incidence of osteoporosis in postmenopausal women. in , the who working group defined osteoporosis according to measurements of bone mineral density (bmd) using dual energy x-ray absorptiometry (dxa) as a bone density t score at or below . standard deviations (t score) below normal peak values for young adults. the relative risk of a fracture is between . and . for each unit decline in spine or total hip t score. due to limitations of the t-score concept a -year risk calculating tool has been developed by the who to determine intervention thresholds. fragility fractures are, however, not only related to bone mineral density (bmd). trabecular bone microarchitecture is a significant determinant of the bone's mechanical properties and is thus of major clinical relevance in predicting fracture risk. trabecular bone structure analysis can be based on images from multidetector computed tomography, high-resolution peripheral computed tomography, highresolution mri and projection radiography. advantages and disadvantages of the different methods depend on radiation, costs, availability and a reasonable time for in vivo scanning. the purpose of this refresher course is to demonstrate bone ablation. the main aim of thermal tumour ablation is to destroy the tumour using ionic movement to kill the malignant cells without damaging adjacent vital structures. multiple sources of energy have been used to induce cell death. rf energy is an electromagnetic one. radio waves emanate from the non-insulated distal portion of the electrode. heat is produced by resistive forces (i.e., ionic agitation) surrounding the electrode as the radio waves attempt to find their ground. other type of ablations (using different wave lengths) include microwave, electoporosis, laser and radiofrequency ablation is still seeking its place among bone interventional techniques. this presentation is an overview, in an area of non-vascular interventions in the spine and the appendicular skeleton. it will explain the patient selection, indication and possible approaches to a bone lesion. available material will be discussed, as well as possible combinations of them in order to yield maximum results, while reducing possible drawbacks. over the last two decades, open nephron sparing surgery has become the preferred surgical alternative to nephrectomy for treatment of patients with a single, small (< cm) localised renal mass and a normal contralateral kidney. because - % of newly diagnosed small renal masses are identified incidentally on crosssectional imaging, often in elderly patients, less invasive surgical nephron sparing alternatives have been advocated, including laproscopic partial nephrectomy and laproscopic cryoablation, for select tumours in an effort to reduce surgical mortality and morbidity while preserving renal function. percutaneous image-guided ablation offers potential advantages over surgical methods including the minimally invasive nature of the procedure, less mortality and morbidity than surgery, shorter hospital stay, and quicker recovery. local tumour control rates of up to % have been reported for small tumours. central tumours and tumours greater than cm in diameter are more difficult to successfully treat with local tumour progression occurring % of central tumours. tumours larger than cm in diameter typically require overlapping ablations and incomplete treatment can result from residual tumour at the ablation interfaces. while in some reports, local tumour progression occurred in up to % of tumours larger than cm, in contrast, others have shown that all exophytic tumours, despite their size, can successfully be treated using multiple overlapping ablations and complete treatment may require more than one ablation session. the most clinically relevant and potentially avoidable complication is ureteral injury with resultant obstruction of the intrarenal collecting system. percutaneous image-guided radiofrequency ablation (rfa) represents as a safe and effective minimally invasive procedure in selected patients with unresectable or medically inoperable lung malignancies. when adequately performed, in selected patients, the procedure is associated with over % immediate technical success rate and relatively low incidence of major ( - %) and minor complications ( - %). pneumothorax represents the most frequent complication (up to %) but presentation, the worse the outcome in adulthood. avn is a significant complication. ct/mr assists orthopaedic planning. imaging strategy: plain radiographs. small children localise pain poorly. whole limb radiographs may be needed. us detects hip effusions but cannot differentiate pus from effusion. nuclear medicine may need sedation for scanning phase. a full bladder may obscure the pelvis. mr is sensitive for soft tissue pathology and marrow disease included in the area imaged. radiographs are needed before mr, which is insensitive for bone detail. other causes: spinal problems -discitis, avulsions of muscle origins, trauma -toddler's fracture, diffuse bone disease, localised bone disease; blind areas: spine, pelvis/sacroiliac joints. learning objectives: . to learn about the imaging approach to the child with suspected developmental hip dysplasia. . to become familiar with the differential diagnosis in the older child with a limp. . to learn which imaging modalities best help to arrive at a diagnosis. skeletal injuries are the most common findings noted on imaging studies in cases of child abuse. in infants, certain lesions, such as the classic metaphyseal lesion and posteromedial rib fractures are sufficiently characteristic to point strongly to the diagnosis of inflicted trauma. other fractures are less specific for abuse, but when correlated with other imaging findings and clinical information, their presence may add strong support for the diagnosis. many of the most specific injuries produce subtle radiographic alterations, and meticulous technique, adhering to a strict imaging protocol, is vital in providing optimal detection of the fractures. in recent years, increasing attention has been given to those conditions that may simulate inflicted injury. a variety of normal variants, naturally occurring diseases and accidental injuries may be confused with the findings of child abuse. other conditions, real or hypothetical, may be suggested by consultants in medico-legal proceedings. to be credible, a witness must be prepared to counter reckless and irresponsible testimony given by uninformed or biased medical "experts". to ensure that investigators and finders of fact are provided with testimony that is clear, concise and accurate, the radiologist must be fully informed and prepared to address the radiologic alterations and their significance to a reasonable medical certainty. learning objectives: . to learn in detail the investigation of a child with suspected non-accidental injury. . to learn about the typical skeletal injuries seen on plain radiography and the differential diagnosis. . to understand when further imaging is required and which imaging modality is best. acute osteomyelitis and septic arthritis are diagnostic and therapeutic emergency in children. diagnosis remains challenging because of their variable expression (acute, subacute, chronic stages, causative agents and hosts). imaging strategy relies on a multimodality approach including radiographs and ultrasonography as first line examinations with a complementary role for bone scintigraphy and mri. mri is especially useful for misleading challenging presentations (such as axial skeleton, pelvis and calcaneus osteomyelitis) and for detection of reversible osteocartilaginous ischaemia requiring urgent surgical drainage. juvenile idiopathic arthritis (jia) is an heterogeneous group of chronic inflammatory disorders that are classified on their mode of onset (systematic, pauci and polyarticular diseases). it is a diagnosis of exclusion and imaging plays a major role in the differential diagnosis. radiographic scoring systems of jia are different from adult scoring systems with less emphasis on joint space narrowing. doppler-ultrasonography and mri play an increasing role in a the assessment of disease activity and response to treatment. learning objectives: . to learn about the imaging approach to a child with suspected osteomyelitis and septic arthritis and to outline the classical features. . to learn how best to investigate a child with suspected arthropathy and the specific findings. . to understand the differential diagnoses of bone and joint infections. semiquantitative scoring method. vertebral morphometry is based on radiographs or scans from dxa-machines calculating ratios of vertebral heights with normal values to identify vertebral fractures. great need for early, accurate and reliable imaging indicators of tumour response to anti-angiogenic drugs which is ultimately defined by overall survival rate, but is mostly based on changes in number and size of measurable tumour "targets", i.e. blood vessels. thanks to its characteristics of high temporal and spatial resolution in limited fields and lack of ionising radiation and side effects (i.e. easy repeatability), contrast-enhanced us (ceus) is currently the simplest and also most reliable imaging modality for detection, analysis and quantification of intratumoural macro-and microvascularity (up to μm in diameter). even minimal changes can be easily detected and quantified with ceus during anti-angiogenic treatments: early disappearance (or severe reduction) of tumoural vascularisation is highly predictive of complete (or significant) response even before tumour volume decreases. initial clinical studies were conducted on hypervascular hepatic metastases (e.g. metastases from gists), but recently also hypovascular hepatic metastases and primary cancers of different organs are being assessed. for the quantitative analysis of tumour vascularity changes several parameters (peak intensity, time-to-peak intensity, area under the curve, etc). are currently being investigated and specific perfusion software connected to working stations are being developed and clinically tested. the clinical application of mr-mammography (mrm) in the last years has shown that this imaging tool has had significant diagnostic advantages in the field of breast diagnosis, e.g. the proof of small breast cancers, the differentiation between scar and recurrent tumours, the detection of multifocality/multicentricity, the search for primary tumours, the delineation of implants, etc. the clinical use of mr-mammography is steadily increasing. however, many still describe a "high sensitivity but a low specificity", which is wrong. achieving a high quality is not an easy task; a lot of teachers have to be learned and considered. this refresher course is focussing on high quality concerning technical and diagnostic aspects, especially focussing the question of improving specificity. dynamic contrast enhanced computed tomography (dce-ct) is a noninvasive method showing haemodynamic changes in living tissue in various oncologic and non-oncologic applications. recently, it has gained an increased popularity for studying malignant tumour blood supply and formation of new vessels, also known as angiogenesis, that plays a critical role in the growth of cancer. technical remarks: repeated rapid ct scans are acquired at the same location to allow determination of time-attenuation curves (tac). several quantitative parameters are assessed: tumour blood flow (tbf) (ml/min/ g), tumour blood volume (tbv) (ml/ g), permeability surface product (psp) (ml/min/ g) and mean transit time (mtt) (s) are calculated using dedicated perfusion software. indication: perfusion ct may be used by the distinction of benign from malignant lesions when conventional methods are unreliable, may improve staging by demonstrating occult hepatic metastases, may guide biopsy to the tumour region most likely to be of highest grade. several tumours with higher perfusion are more sensitive to the chemoradiation than that with lower perfusion. findings at dce-ct images after chemoradiotherapy are a significant predictor of early tumour response and overall survival. its applications have been stimulated by the development of anti-angiogenesis therapy for monitoring the effects of therapy and additionally may be used as a noninvasive tool in detection of hepatic toxicity of chemotherapy. in the future, new prognostic information could impact clinical management. studying the response of cancers by measuring changes in their blood flow may provide useful information on oncologic patients for managing cancers in the future. advanced imaging is now widely utilised in the research and clinical settings. in the clinical setting, qualitative, semi-quantitative and quantitative approaches such as review of colour-coded maps to roi analysis and analysis of signal intensity curves are being applied in practice. we will also compare the relative advantages for t dce mri with t * dsc mri in the estimation of perfusion and permeability metrics in the clinic as well as some more automated histogram analysis methods. the role of advanced imaging in the characterisation of tumour biology and different pathologies will be reviewed. differentiating between recurrent tumour and therapeutic necrosis is often a challenge. we will review the role of advanced imaging and also the effects of anti-angiogenic therapies on tumour microvasculature/microenvironment resulting in changes in diffusion, perfusion and mrs. pseudophenomenon has made conventional imaging with gadolinium contrast agent almost obsolete necessitating mechanistic techniques to differentiate entities such as pseudoprogression which is seen more commonly as a result of therapy with temozolomide and radiation for high grade gliomas as well as pseudo-response and pseudo-pseudoprogression. lastly to combine and apply these different imaging techniques in a multi-parametric algorithmic fashion in the clinical setting can be shown to increase our diagnostic specificity and confidence. learning objectives: . to become familiar with different advanced mr techniques used in brain tumour imaging. . to learn the role of permeability, perfusion, diffusion imaging and mr spectroscopy in characterising brain tumour biology and differential diagnostics. . to become familiar with a complete imaging protocol, which can be implemented in a multi-parametric algorithm fashion in brain tumour diagnosis. monitoring and prediction of treatment response p.c. maly sundgren; lund/se (pia.sundgren@med.lu.se) high-grade gliomas have a poor survival rate despite improvements in surgery, radiation and chemotherapy. a contributing factor to the poor survival is the inability of currently available imaging techniques to accurately delineate the tumour which results that targeted focal treatment my not be effective. conventional imaging is not able to give an early assessment of the effectiveness of radiation and/or chemotherapy. early identification of patients with a poor treatment response or who suffer from tumour recurrence can be of great advantage: it provides the opportunity to adjust individual more rapidly, and sparing patients unnecessary morbidity, and breast mri has shown diagnostic sensitivities of - % for invasive breast cancer; however, specificities have been reported significantly lower with values between % and %. the specificity of breast mri is in a routine clinical setting based on the evaluation of morphologic features and relative "slow" dynamic characteristics of enhancing lesions. the only moderate specificity that is achieved using these characteristics can result in a significant number of false positive findings during, for instance, screening or pre-operative imaging. these findings will often require short-term follow-up, target ultrasound with biopsy or even mri-guided biopsy. fast dynamic imaging, spectroscopy and diffusion weighted imaging (dwi) have been described to have potential for improving the specificity of breast mri. the use of fast dynamic imaging sequences result in a more accurate evaluation of the initial enhancement of the lesion. in combination with pharmacokinetic modelling this can result in a more quantitative evaluation of enhancement. in proton-mr spectroscopy (mrs) the presence of a choline signal, a cell-membrane precursor, in breast lesions can be used to differentiate benign from malignant lesions. the specificity of mrs varies between and % in literature (average %). dwi has also shown potential in differentiating between benign an malignant lesions, but, like with other techniques, varying specificity values are reported ranging between % and %. in this presentation the value of these techniques for improving the performance of breast mri will be discussed. although bedside chest radiograph is one of the less elaborate imaging examinations in our diagnostic armamentarium, it remains the most frequent radiologic procedure performed in intensive care patients. despite its limitations chest imaging is an important tool in the management of the critically ill patient. though the advent of digital radiography has vastly contributed to improved image quality of the bedside radiographs, optimal positioning and technique remain a real challenge for the performing technologist. in addition, the interpretation of chest radiography in the critically ill patient poses a challenge for the radiologist, because findings are frequently unspecific and lung opacifications have similar appearances in a variety of different cardiopulmonary pathologies. clinical information and an interdisciplinary approach are therefore crucial for optimal interpretation of these chest radiographs. the american college of radiology has established expert recommendations for the use of bedside chest radiography. current recommendations suggest that routine daily chest radiographs should be reserved for patients with acute cardiopulmonary problems and in patients receiving mechanical ventilation. acquisition of a portable chest radiograph is recommended after insertion of endotracheal tubes, central venous catheters, pulmonary artery catheters, chest tubes, and nasogastric tubes. therefore, knowledge of correct positioning of catheters, tubes, and monitoring devices and of various malpositions and associated complications is essential for the interpreting radiologist. chest ultrasonography (chus) is a useful imaging tool in patients at intensive care units, because of its simplicity and reproducibility. however, there are some limitations such as low specificity of some crucial sonographic signs and limited searching area (soft tissues, pleural cavity and lung consolidations). the icu patient can be examined in supine or sometimes in lateral or partly lateral position using intercostal spaces as an acoustic window. supine analysis of the anterior chest wall rules out pneumothorax, while lateral approach detects clinically relevant pleural effusion and parenchymal consolidations. chus is a method of choice in detection as well as in characterisation and volume estimation of free and/or loculated pleural fluid. with chus we can explore and characterise lung consolidations from the moment they reach the visceral pleura. they can be in contact with pleural line or can be observed through an effusion. however, in case of subcutaneous emphysema and/or diffuse oedema of soft tissues the lung parenchyma can not be reliably assessed. also, in the question of pulmonary embolisms in critically ill patient, chus could be contributive. sometimes small pleural effusion can be visible with some peripheral lung tissue consolidations indicating minute pulmonary infarction. typical pulmonary infarction is triangular tissue consolidation with air bronchogram and absence of doppler blood flow signals within consolidated lungs but cect for confirmation is mandatory. chus exploration of the diaphragm can reliably evaluate respiratory movements since pleural effusion even substantial does not affect the amplitude of diaphragmatic excursion. learning objectives: . to understand the advantages and limitations of bedside thoracic ultrasonography. . to learn about the us findings of pleural and parenchymal diseases suitable for bedside ultrasonography. . to review current guidelines for estimation of pleural effusion volume. delay in initiation of other maybe more effective treatment. in recent years, different functional imaging approaches such as dynamic contrast-enhanced (dce) and dynamic susceptibility-weighted contrast (dsc) mri, diffusion-weighted imaging and spectroscopy have been complementary used for diagnosis and treatment response. in this lecture different advance mr and ct imaging methods as well as the traditional way of monitoring to assess treatment response will be discussed. in addition, a novel recently published promising technique will be described -the parametric response mapping (prm), a novel voxel-wise analytical method of monitoring physiological and environmental changes in a tumour volume during treatment will be presented and compared to the traditional methods used. finally, the aim of the lecture is to consolidate the present knowledge and novel ideas in brain tumour imaging for future monitoring of treatment response and the possibility and limitations for future individualisation of cancer therapy. learning objectives: . to gain an understanding of the present traditional model for the treatment cycle for brain tumours and how they are monitored. . to learn about different imaging biomarkers for early assessment of brain tumour treatment response that might result in individualisation of cancer therapy. . to consolidate present knowledge and ideas in brain tumour imaging for future brain tumour therapy and monitoring of response. radiation necrosis and pseudo-progression vs recurrent tumour pseudophenomenon has made conventional imaging with gadolinium contrast agent almost obsolete necessitating mechanistic techniques to differentiate entities such as pseudoprogression which is seen more commonly as a result of advanced multimodal therapeutic concepts. advanced, non-enhanced and contrast enhanced mr imaging techniques include mr-spectroscopy, perfusion mr imaging, dynamic contrast enhanced mri and diffusion tensor mr. in the presentation we will analyse the application of those techniques in brain tumour assessment with focus on the post-therapeutic brain to differentiate therapy induced from tumourinduced changes. the results of the available studies in literature, all with relatively limited patient numbers, indicate that the combination of functional mri proved to be useful in the post-therapeutic workup of gliomas, lymphomas and metastatic disesease. the typical patterns of tumour recurrence and the different therapyinduced effects will be presented. in perfusion (dsc-mri) and dynamic contrast enhanced magnetic resonance imaging (dce-mri) the signal intensity measurements of the tumour reflect a composite of tumour perfusion, vessel permeability, and the extravascular-extracellular space. in contrast to conventional enhanced mri, which simply presents a snapshot of enhancement at one time point, both techniques permits a fuller depiction of the wash-in and wash-out contrast kinetics within tumours, and this provides insight into the nature of the bulk tissue properties on its microvascular level. with the strong demand in drug development the identification of biomarkers that can assess tumour microvascular properties noninvasive dynamic mri is the method of choice to assess tumour response and to identify atypical tumour response findings. indications and spectrum of pathological findings functional abnormalities of the pelvic floor represent a significant health-care problem, as they affect approximately % of older multiparous women. moreover, nearly . surgeries in united states are annually performed to correct those disorders. the success of medical and surgical therapies relies on the correct classification of dysfunction and identification of the pelvic compartments involved. clinical classifications of pelvic floor abnormalities are primarily topographic, rather than functional. however, as the pelvic floor muscles tend to act as a unique functional entity, their dysfunction usually leads to dysfunction of more than one organ system (genitourinary or gastrointestinal), resulting in a wide spectrum of symptoms variably associated, including dysuria, urinary incontinence, uterine prolapse, anal or pelvic pain, obstructed defaecation, rectal prolapse or faecal incontinence. because of the variability of symptoms and complexity of physio-pathological mechanisms, diagnosis of pelvic floor disorders is usually achieved by combining different diagnostic tools. dynamic mri of the pelvic floor has emerged as an alternative and effective modality for assessing and understanding of these disorders. it currently offers a complete morphological and functional evaluation of all three compartments at the same time. constipation and pelvic organ prolapse are the most common indications for a dynamic mri. the physio-pathological features of the main pelvic floor disorders and their mri findings will be shown in detail. mr images and movies, with particular regard to posterior pelvic floor abnormalities, such as rectocele, rectal invagination and prolapse, enterocele, descending perineal syndrome and spastic pelvic floor syndrome, will be illustrated and discussed. the ability to perform and interpret dynamic pelvic floor imaging is essential for the modern gastrointestinal (and indeed urogynaecological) radiologist. the other speakers in this session will be reviewing indications, pathologic findings, clinical relevance, and mr technique. although i will detail the mr and fluoroscopic techniques used at my institution, i will focus on the specific technical and diagnostic advantages and disadvantages of both dynamic pelvic mr and conventional fluoroscopic evacuation proctography (defecography). many practitioners wising to initiate this type of imaging will wish to know what modality to chose and existing practitioners using fluoroscopy will possibly be interested in migrating their practice to mr. i will illustrate what imaging findings are best imaged by each technique, continually referencing this to whether the finding is ultimately important to the referring clinician or not. using examples from our own research programme and clinical practice, i will illustrate why we have migrated our practice exclusively to dynamic mr. although dynamic pelvic mr imaging is increasingly used for imaging pelvic floor disorders, the crucial question is whether the technique can completely replace conventional techniques. although mr imaging provides excellent soft-tissue contrast which is a particular advantage when imaging the pelvis, it has to be acknowledged, that the examination is performed in supine position and not in physiological sitting position. this presentation will review the ultrasound appearances of pleural disease in ward and itu-based patients, and will discuss the indications for pleural procedures and the complications associated with them. the use of colour doppler to aid the diagnosis of effusions will be discussed, as will the identification of septations and the need for intrapleural fibrinolytic therapy. the advantages of guided versus blind drain insertion will be presented, and the benefits of large versus small bore drains will also be discussed. pelvic floor function and structure is complex. imaging has a key role in guiding the clinician in managing patients with incontinence, constipation, difficult rectal evacuation and pelvic organ prolapse. dynamic imaging is of particular interest for assessment of the pelvic floor since this kind of imaging gives a near physiological data set of what is happening and gives us a better understanding of the multifactorial causes of pelvic floor dysfunction. whereas conventional evacuation proctography was over years standard of reference for dynamic imaging of the pelvic floor, dynamic mr imaging of the pelvic floor is gaining increasing acceptance among radiologists and clinicians. however, dynamic mr imaging of the pelvic floor is (due to the architecture of most the clinically mr magnets) usually performed in supine position which does exclude the axial load on the pelvic floor. the lack of a physiological patient positioning during dynamic pelvic floor mr imaging is still brought into discussion if dynamic mr imaging of the pelvic floor can replace conventional techniques or not. the pelvic floor is a complex anatomic and functional unit. in clinical routine a simple anatomic concept of the female pelvic floor has gained acceptance. especially for treatment planning, the female pelvic floor may be separated into three functional compartments: the anterior compartment (bladder and urethra), the middle compartment (vagina, cervix, uterus, and adnexa), and the posterior compartment (anus and rectum). intact structure of the pelvic floor is a basic prerequisite for a normal mechanism of defecation and continence. over the last years, mr imaging has gained increasing acceptance as imaging modality for evaluation of the pelvic floor, which enables a global and integrated approach to the pelvic floor. using static t weighted sequences the morphology of the pelvic floor can be visualised in great detail. a rapid half-fourier t -weighted, balanced steady state free precession (bssfp), or gradient-recalled echo (gre) sequence are used to obtain sagittal images while the patient is at rest, during pelvic squeeze, during pelvic strain and to document the evacuation process. on these images the radiologist identifies the pubococcygeal line (pcl) (which represents the level of the pelvic floor). in normal findings, the base of the anterior and the middle compartment are above the pcl at rest, and the pelvic floor elevates during contraction. during straining, although most clinical diagnostic imaging studies employ anatomic techniques such as computed tomography (ct) and magnetic resonance (mr) imaging, much of radiology research currently focuses on adapting these conventional methods to physiologic imaging as well as on introducing new techniques and agents for studying processes at the cellular and molecular levels in vivo, i.e. molecular imaging. molecular imaging promises to provide new methods for the detection of minimal changes in diseased tissue and support for personalised therapy. although molecular imaging has been practiced for over years in the context of nuclear medicine, other imaging modalities have only recently been applied to the noninvasive assessment of physiology and molecular events. nevertheless, there has been sufficient experience with specifically targeted contrast agents and high-resolution techniques for mr imaging and other modalities that we must begin moving these new technologies from the laboratory to the clinic. several projects relevant to oncology will be discussed with emphasis on how they were/will be moved from the bench to the clinic. aortic dissection is increasingly managed by endovascular means. it is important for all radiologists to understand the benefits and disadvantages of varying imaging modalities in the differential diagnosis and the fundamental anatomical requirements for assessing suitability for endovascular repair. the causes, detection, classification and complications of aortic dissection will be discussed followed by a panel discussion of imaging strategies which give the best information for diagnostic work-up, endograft planning and monitoring of patients during and after treatment. with the introduction of targeted therapeutics and personalised therapy regimen there is increasing need to improve diagnosis of diseases in a way that insight into pathophysiological and molecular regulation is provided. in this context, molecular imaging can be of tremendous help in basic research, drug development and the clinics. many interesting approaches of molecular imaging have been tried in small animal models. new methods and tools have been identified, which are easy enough to handle, aceptable in its costs and, most importantly, reliable enough to be translated to clinical practice. unfortunatenly, as soon as they have entered the clinics they are often not classified as molecular imaging anymore. among those are mr-spectroscopy, spio/uspio enhanced liver and res imaging but also contrast agents like gd-eob-dtpa and most applications for pet/spect. other interesting applications such as targeted ultrasound imaging are already established tools in preclinical research and very close to first clinical use. near infrared optical imaging is another example of a rapidly developing technology and first clinical devices and dyes (e.g. to detect arthritic lesions) are availibe now. it can be expected that with the availability of targeted and activatable probes the acceptance and the use of optical imaging methods will further rise. most proably, this will initially happen in context with intraoperative diagnosis and endoscopy. in summary, it is the aim of this talk to give a realistic overview on the available molecular imaging tools and on their potential for preclinical research and patient use. cardiovascular diseases remain the number one cause of morbidity and mortality, both in the developed and developing countries, and in men and women alike. it is expected that these numbers will continue to increase in the coming decades due to escalating proportions of obesity and the aging population. atherosclerosis is the major cause for cardiovascular disease. since in about % of cases a stroke or acute myocardial infarction is the first symptom of atherosclerosis, it is of paramount importance to identify patient at high risk. a first step in the identification is the use of clinical risk profiling, such as the framingham risk score, which has an area under the curve (auc) of about . using roc analysis. however, clinical risk profiling alone is not sufficient to identify individual patients at imminent risk to develop a cardiovascular event in the near future. a next step in a more precise identification of the patient at risk is the development of serum biomarkers for atherosclerotic disease. however, so far serum biomarkers have failed to contribute substantially to improve the auc in the prediction of cardiovascular events using roc analysis. a major step forward in risk stratification is provided by the rapid development of cardiac computed tomography, which offers a rapid visual access to the coronary tree, at low radiation dose and in a patient friendly manner. however, for the identification of the vulnerable plaque we need to go beyond anatomical imaging, and use molecular imaging tools. in the lecture i will discuss the different targets for molecular imaging within the vulnerable plaque, such as inflammation, apoptosis and angionenesis. imaging of these substrates of plaque vulnerability may offer opportunities for a precise identification of the patient at risk, at the individual level. the aim of the lecture is to familiarise the audience with the specific paediatric conditions in trauma radiology. it will be described the major pathophysiologic differences in childhood and the consecutive altered injury pattern. the standard radiological imaging protocol for various involved body regions and different trauma settings/varying queries will be described, with suggestion for standardised diagnostic algorithams in some typical settings. special regard will be given to radiation protection and the potential of imaging modalities such as ultrasound, multi-detector ct as well as mri in paediatric trauma patients. the roll of the lecture is to provide some basic guidelines for young radiologists and general radiologists who less often have to deal with paediatric patients. learning objectives: . to become familiar with the major pathophysiologic differences in childhood trauma . to standardised diagnostic algorithm in some typical settings in field of pediatric trauma. basic principles in the interpretation of signal intensities on t -and t weighted images g. wilms; leuven/be (guido.wilms@uz.kuleuven.ac.be) the signal intensities of normal structures and pathological findings on conventional t -and t -weighted mr images depend on many factors. the amount of water, proton density, chemical structure and/or binding, presence or absence of flow (of blood or csf), calcification, fat, blood degradation products, melanin, mucine and even air are all factors that influence the signal characteristics. t -and t -lenghtening is the rule in most tumoural, vascular and infectious lesions and therefore is rather unspecific. t -and t -shortening can be due to the presence of fat (lipoma), melanin (melanoma and metastasis of melanoma), mucine (metastasis of sigmoid carcinoma), colloid material (colloid cyst, rathke cleft cyst) and even calcification (falx!). t -shortening with t -lengthening can be due to cholesterine (cholesterol granuloma, craniopharyngioma), high protein content (tumoural cysts), and methaemoglobin (late haemorrhage, thrombus). t -lengthening and t -shortening is almost exclusively due to deoxyhaemoglobin. acute haemorrhage and meningioma can be iso-intense on t -weighted images, while some meningiomas and micrometastases can be iso-intense on t -weighted images. absence of signal can be due to high-velocity flowing blood (aneurysm, avm, hypervascular tumours), high velocity flowing csf (normal pressure hydrocephalus, cortical bone or extensive calcification, air and a large amount of iron (coils, clips). it is concluded that the simple use of a combination of t -and t -signal intensities on conventional mr images can be used to arrive at the diagnosis and differential diagnosis of brain lesions. complications occurring after acute aortic dissections should be separated into those related to the disease per se and those related to post-treatment conditions. life-threatening complications related to the disease should be familiar as immediate consequences for treatment may ensue. most of these are either located in the aortic root or related to mal-perfusion syndromes. the aortic root with very thin walled structures of the sinus of valsalva is located within the pericardial sac. the structure is prone to rupture and may produce life-threatening pericardial tamponade or present clinically as sudden onset of severe aortic regurgitation. all imaging modalities suitable for diagnostic workup in such conditions have to be rapidly accessible and performable. this precludes lengthy mr imaging procedures and renders ultrasound and ct as the mostly used modalities. the condition that has to be recognised as the most important inductor of malperfusion syndromes in the descending aorta is the progression of dissection into aortic branches and the true lumen collapse. both conditions are easily discernible with ct imaging. complications related to treatment should be sub-classified into those after pure surgical treatment and those related to endograft repair. the acute surgical complication with most deleterious effects is related to spinal cord ischaemia. the condition also applies to endograft repair. it is therefore beneficial for the radiologist involved either in pre-surgical imaging or interventional treatment to acquire thorough knowledge of the spinal cord blood supply. endograft complications of interest encompass endoleak formations, stent migrations and endoluminal stent collapse. learning objectives: . to learn the most common complications. . to learn the most appropriate imaging strategy for diagnosis. . to understand the clinical significance of the most common complications. which imaging modality is best for endovascular management? : the various imaging modalities for establishing the diagnosis of acute non-traumatic dissections will be discussed. the panellists will present recommendations for diagnostic work-up with special respect to differential diagnosis such as acute myocardial infarction and acute pulmonary embolism. also, the problem of sizing the endograft and planning the procedure will be addressed. the panellists will discuss strategies for detection of complications and for monitoring patients following treatment. the quality of radiographs is determined by many parameters from both technical and clinical origin. during the presentation, we will make an overview of the particular features of x-ray tubes and plain films that affect the quality of the radiological image. the training session will start from very simple x-ray tubes and film, and gradually introduce more sophisticated, state-of-the-art technology. we will briefly explain concepts such as focal spot, heel effect, beam quality, filters, grid, film sensitivity, automatic exposure control, etc. from a practical point of view. the european commission and selected research groups have developed criteria to judge the quality of the images and we will show how they can be used to improve the daily practice. a more technical evaluation of quality is possible with images of test objects, some of which are very straightforward and interesting if problems have to be retrieved. x-ray quality should be at a high level every day. therefore quality control procedures have a role. one example evaluates the stability of the imaging chain by means of acquisitions of homogeneous blocks of pmma. we will illustrate typical findings with repercussions on the radiological practice, and show that the fight against artefacts is a never ending process. both with film and digital detectors, radiologists should be aware that quality management and quality control procedures are needed. quality has to be organized, and quality control procedures have to be automated and included in the routine practice. there are diverse underlying causes for "diagnostic mistakes". missed lesions due to inadequate technique, "satisfaction of search" or lack of perception have to be differentiated from interpretative mistakes of lesions that have well been seen but erroneously interpreted due to the lack of experience, misconception or overlap of findings that complicates the differential diagnosis. each of these underlying reasons require a different approach to avoid them or reduce their risk of occurrence. the first type of mistake arises more often when interpreting chest radiographs and refers to the detection of mostly small focal parenchymal densities but also to the interpretation of mediastinal and hilar contours. by analysing typical cases, visual "tricks", helpful display techniques and strategies for systematic review and analysis will be outlined that are thought to be helpful in reducing the risk of "missing" a lesion. the second type of mistake mostly represents a problem of interpreting parenchymal abnormalities seen on ct. since the lung has limited means to "react" against an injury, many radiologic findings are aspecific. interpretation of pathology of parenchymal changes is based on pattern analysis, the knowledge of disease distribution and additional findings of pleura and mediastinum. in many cases, an interdisciplinary approach of radiologists and clinicians is essential for correct interpretation. cases will be analysed to illustrate difficult differential diagnosis occuring in daily routine (e.g., infectious pneumonia versus organising pneumonia) and key features helping in going into the right interpretative direction will be outlined. emphasis will lie on focal lung disease rather on the interpretation of diffuse interstitial lung diseases. learning objectives: . to learn about visual tricks and strategies to overcome typical perception errors in chest radiography. . to become familiar with overlaps of morphologic findings of focal parenchymal lesions frequently occuring in daily routine when interpreting thoracic ct. . to recognise those additional findings that represent the "helpful clue" for correctly narrowing the differential diagnosis. panel discussion: what have we learned from our mistakes? : interpreting the results of imaging studies is more and more challenging and time consuming due to the large volume of data to evaluate, compare and post-process. moreover, errors in the interpretation of imaging studies can have significant effects on patient care, particularly in acute medicine and oncology. so the question is how to be aware of the potential pitfalls that may be encountered in the realisation and the interpretation of imaging studies and how to avoid them or to learn from them. acute pancreatitis remains a potentially life threatening condition with an overall mortality rate of %. its outcome is strongly related to a precise and timely diagnosis, a correct estimate of severity and subsequent appropriate treatment. radiologic imaging, particularly ct, plays a key role in staging the severity and therefore helps guiding therapeutic decisions. management of interstitial or edematous pancreatitis is supportive while severe or necrotising pancreatitis requires intense monitoring and specific therapies. the latter has a higher mortality and guarded prognosis, since it may lead to organ failure, infection, pseudocyst formation and extrapancreatic parenchymal and vascular complications. a number of severity indices have been established to determine the prognosis of acute pancreatitis, based both on clinical and imaging criteria. a ct-based severity index has become the main prognostic method to predict outcomes. this course reviews relevant imaging findings of various stages of acute pancreatitis and its complications by ct, including special conditions such as groove pancreatitis and autoimmune pancreatitis. currently established and modified severity indices are reviewed to learn how to estimate prognosis and guide therapy. interpreting the results of imaging studies is more and more challenging and time consuming due to the large volume of data to evaluate, compare and post-process. radiology errors are inevitable, affect all radiologists and may be defined as a mistake that has management implications for the patient. errors can be broadly classified into technical errors, active errors (errors in perception, judgment or knowledge) and errors of communication. the majority of errors are false-negative interpretations and occur during interpretation of ct examinations. good communication between the referring physician and the radiologist is essential. unfortunately, only a small minority of radiologists keep a personal record of their errors. patient safety should benefit from the repeat organisation of "error meetings" through the act of collective learning. radiologists and radiology departments must continue to improve the process of recording and addressing errors. a- : radiologists do make mistakes, diagnostic errors can be the cause of severe consequences to patients or, luckily, in many cases, they can be corrected. learning from mistakes is quite important since understanding why a mistake has been made help to avoid it in the future. during this lecture a series of mistakes made in the field of gu will be presented and causes which have lead to each of them will be analysed. dyspnoea is a common symptom in patients presenting to the emergency room. in almost two-thirds of all cases, dyspnoea is caused by either a pulmonary or a cardiovascular disorder. imaging in patients with dyspnoea depends mainly on the clinical presentation and the medical history of the patient. chest radiographs are a cost-effective and rapid test for the evaluation of patients with dyspnoea, with a fair sensitivity and specificity. for this reason, chest radiographs are usually performed early in the diagnostic evaluation of patients with acute and chronic dyspnoea. chest radiographs enable the diagnosis of frequent causes of dyspnoea of pulmonary origin, such as pneumonia, pneumothorax, pleural effusions, interstitial lung diseases, and emphysema. the diagnosis of cardiovascular disorders, such as pulmonary venous hypertension, cardiomyopathy, as well as valvular diseases, is also facilitated by chest radiographs. if chest radiographs, clinical studies, and laboratory tests, however, are non-diagnostic or equivocal, ct is indicated. ct offers high sensitivity and specificity for the evaluation of pulmonary embolism and for diseases of the pulmonary parenchyma and the airways. high-resolution ct represents the method of choice for the evaluation of suspected diffuse lung disease. additional expiratory scans are useful for the evaluation of mosaic perfusion and air-trapping. chronic pancreatitis (cp) is an inflammatory disease of the pancreas, with irreversible morphologic changes and fibrotic replacement of the gland, which progressively result in loss of exocrine and endocrine function. cp is morphologically characterised by irregular sclerosis associated with destruction and permanent loss of the exocrine parenchyma which may be either focal, segmental or diffuse. the primary symptoms of cp are abdominal pain and maldigestion, which may be physically and socially debilitating, although it is acknowledged that chronic pancreatitis can occasionally be painless. a classification based on the causes of cp is useful in order to better define the therapeutic interventions. however, morphological changes of the pancreatic ducts are the main rule of thumb for the classification in order to better compare the results of the treatment. imaging techniques have a role both on the diagnosis -especially in the early phases of the disease -and on the classification of cp, either for the grading of the disease, to explain the aetiology -even for rare forms -and to differentiate the focal mass from ductal adenocarcinoma. ct, mri and ercp have a specific role in the assessment of cp, due to the different capacity of the techniques to explore the pancreatic gland. however, thanks to heavily t w sequences, mri has a competitive role with ercp, which actually has more an interventional role in case of obstructive cp. finally, mri thanks to secretin test and dwi sequences is able to give a non-invasive assessment of pancreatic exocrine function. complications of pancreatitis may include fluid collections and pseudocysts, vascular complications such as arterial pseudoaneurysm or thrombosis of the portal venous system, and stenosis of common bile duct and pancreatic duct. inflammatory fluid collections in the context of acute pancreatitis often resolve spontaneously. drainage may become necessary in the presence of clinical complications such as abdominal pain, compression of adjacent organs by large pseudocysts, or if superinfection of a pseudocyst occurs. depending on clinical, morphologic, or technical factors, drainage may be accomplished with image-guided external catheter placement, by endoscopic internal (transgastric) drainage or by internal surgical drainage. arterial pseudoaneurysm carries the risk of acute intra-or extraperitoneal bleeding, and transarterial embolisation is usually indicated when pseudoaneurym is detected. strictures of the common bile duct secondary to chronic pancreatitis may require percutaneous or endoscopic retrograde intervention. learning objectives: . to review interventional techniques that are used to manage fluid collections in the setting of pancreatitis. . to compare the results with those obtained by surgical and/or endoscopic approach. . to learn about algorithms used for clinical decision making, and for treatment evaluation and follow-up. . to understand major shortcomings and complications and how to avoid them. discussion : ants include the presence of accessory muscles, a low-lying peroneus brevis muscle belly, pseudosubluxation of the peroneus brevis tendon, and a bifurcated or mildly crescentic peroneus brevis tendon. accessory muscles in the ankle area include in the lateral aspect the peroneal tertius and peroneal quartus, in the medial aspect the flexor digitorum accessorius longus, and posteriorly the peroneocalcaneus internus, tibiocalcaneus internus and accessory soleus. as variations are commonly seen in asymptomatic ankles, matching with clinical symptoms is important. pitfalls include pseudoloose bodies in the ankle joint, pseudolipomas, and artefacts such as the "magic angle" effect, chemical shift, susceptibility, motion, "ghost" and partial volume averaging. knowledge of normal anatomy, pitfalls and variants, aids radiologists in making the precise diagnosis of various disorders. the aetiology of dyspnoea is varied. it may be due to pulmonary or pleural disease, cardiac pathology or extrathoracic causes. imaging is an useful adjunct in the diagnosis of majority of cases of dyspnoea. in this lecture we will present selected cases which will demonstrate the usefulness of different imaging modalities, emphasising when cross-sectional imaging is indicated. learning objectives: . to review typical cases illustrating the role of imaging modalities in the differential diagnosis of dyspnea cases. . to motivate the audience by the use of voting pads to be involved in the diagnostic process. . to highlight the conclusion that may be drawn on the basis of the discussed cases. the term bone marrow oedema was introduced to describe ill-defined bone marrow hypointensity on t wi and hyperintensity on t wi and water sensitive sequences. bone marrow edema can be found in many similar unrelated disorders, such as bone contusions, osteonecrosis, inflammatory or degenerative disease, being a non-specific mri abnormality representing a diagnostic challenge for radiologist. recently has been demonstrated that bone marrow oedema might be a prognosis marker for oa (osteoarthritis) and inflammatory disease, and could be used as a powerful predictive tool for treatment options. therefore our role as radiologist is to try to increase specificity to help patient management and decrease progression. subchondral bone marrow lesions (bmls) are a hallmark of osteoarthritis (oa) on mri. radiologically, bmls in oa are understood as non-cystic subchondral areas of ill-defined hyperintensity on t w images and of hypointensity on t w images, but only water-sensitive fat-suppressed sequences depict the lesions to their maximum extent. bmls are observed regularly in conjunction with adjacent cartilage alterations. higher grades of cartilage loss are associated with higher prevalence and greater volume of concomitant bmls. as the disease progresses, an increase in bml volume is seen in the same region subchondrally in many patients, which is positively correlated with an increase in cartilage loss and radiographic joint space narrowing. cysts are strongly associated with bmls in the same subregion and develop within non-cystic bmls. the published data on the natural history of bmls are ambiguous but recent reports showed that the majority of subchondral bmls may regress or resolve completely. note that progression and regression of bmls may be observed within the same knee simultaneously. histologic correlation studies showed that the lesions consisted of a mixture of different tissue patterns with only little oedema. specific changes in bone mineralisation and remodelling in areas of bmls have been shown, and they appear sclerotic compared to unaffected regions from the same individual. differential diagnoses of oa-related bmls include traumatic bone contusions and fractures with or without disruption of the articular surface. osteonecrosis, inflammation, idiopathic bmls, red marrow and post-surgical alterations should also be considered. learning objectives: . to learn about the basic physiopathology of oa and its relation with bme. . to analyse the distribution and natural history of bme in oa. . to understand the differential diagnosis and relevance of bme in staging oa and as a marker of prognosis. b. bme and early inflammatory disease a.j. grainger; leeds/uk (andrew.grainger@leedsth.nhs.uk) marrow oedema is identified as a feature of many forms of inflammatory and mechanical arthritis, but has been most studied in the inflammatory arthritides and particular in rheumatoid arthritis. it was first reported as a feature of ra as far back as . work has been undertaken both using human specimens and specimens from animal models which suggest that marrow oedema seen on mri in ra corresponds to areas of inflammation been associated with invading pannus, lymphocytic aggregates and hypervascularity. there is also evidence that the marrow lesions seen on mri in ankylosing spondylitis correspond to histopathological inflammatory change. marrow oedema has been shown to be an important predictor the recent technological advances of ctu and mru have had an exceptional impact on the assessment of chronic/intermittent obstruction. imaging studies should help answer the clinical questions raised concerning the presence, level, and cause of obstruction. in this session, the recommended techniques of ctu and mru will be described and their relative merits and limitations reviewed. d ct images should be used as an adjunct to the transverse images, instead of a replacement, because volume-rendered images best depict the lumen and not the wall of the urinary tract. thin-section reformatted ct images likely are as sensitive as transverse images in the detection of urinary tract abnormalities. mru is being increasingly used because it provides excellent anatomic and functional imaging in a single setting. it has proved particularly valuable in pregnant women and children. the relative advantages of static-fluid mru and excretory mru will be discussed. the main aetiologies of chronic/intermittent obstruction will be illustrated, including intraluminal diseases (stones, clots, etc.), wall abnormalities (transitional cell carcinomas, tuberculosis, etc.) and extraluminal diseases (pelvic and retroperitoneal tumours, retroperitoneal fibrosis, gi tract diseases, etc.) upj syndrome is the most common site of urinary tract obstruction in children. vessels crossing a ureteropelvic junction obstruction contribute to the degree of hydronephrosis in up to % of these patients. demonstration of these vessels and their location anterior or posterior to the obstruction facilitates surgical planning. at the end of the lecture, attendees will become familiar with moderate or severe urinary obstruction and their various features and causes. . technological advances in both computed tomography (ct) and magnetic resonance (mr) imaging have improved the diagnostic imaging of the urinary tract, surpassing ultrasound and the intravenous urogram. multidetector computed tomography urography (ctu) is defined as ct examination of the kidneys, ureters and bladder with at least one imaging series acquired during the excretory phase of contrast enhancement. mr urography (mru) can be performed using heavily t -weighted sequences without contrast material or t spoiled gradient -recalled echo sequences during the excretory phase after administration of gadoliniumbased contrast material. in adults, ctu or mru is now the preferred examination. technical aspects of image acquisition and processing will be explored and technical tips relating to protocol design given. . the typical and atypical appearances of upper urinary tract urothelial tumours and bladder cancers will be demonstrated. a method of fluoroscopic biopsy of upper tract tumours is described for validation of the imaging diagnosis. . early and accurate diagnosis of urinary tract tumours helps optimise prognosis but conventional investigative pathways are complicated and lengthy, utilising multiple imaging tests and many diagnostic algorithms exist without rigorous evaluation. ctu offers a single imaging test of high diagnostic accuracy with the potential to replace multiple alternative imaging tests in the diagnostic pathway, improve patient experience, improve diagnostic performance and accelerate diagnosis. mru is a promising technique that may be used for the initial evaluation of patients at high risk for developing upper-tract urothelial carcinoma when ctu or intravenous urography is contraindicated. rhage and periventricular echodensities. the posterior fontanelle approach improves the detection of grade ii haemorrhage in % more cases than the anterior fontanelle, and the mastoid fontanelle approach is essential for diagnosing cerebellar haemorrhage. ventricular dilatation is the main complication of intraventricular haemorrhage and resolves spontaneously in approximately % of cases. the main challenge with periventricular echodensities is to differentiate them from classical periventricular leukomalacia. when cysts appear during follow-up, the diagnosis is straightforward. mri is considered to be more sensitive than us for evaluating white-matter damage. congenital brain malformations including ventricular dilatation of diverse aetiologies, corpus callosus agenesis and posterior fossa malformations are usually diagnosed prenatally. mri complements us for this purpose. acquired abnormalities arise mainly from infections and hypoxic-ischaemic injury. although mr is considered the gold standard, us still plays an important role in the study of hypoxic-ischaemic lesions when used to its full capacity. depending on the duration and severity of the hypoxic insult, patterns different from those seen in premature infants may be observed. brain malformations are conditions where the brain has not formed properly during pregnancy. these problems in brain structure are almost often (with some exceptions) associated with neurological and developmental problems. often, brain malformations are part of syndromic complexes that require a multidisciplinary approach. malformations may be caused by inherited genetic defects, spontaneous mutations within the genes of the embryo, or effects on the embryo due to the mother's infection, trauma, or drug use. classification schemes are currently shifting from a morphological to a genetic approach. the most frequent congenital brain abnormalities may be categorised into anomalies of the corpus callosum and telencephalic commissures, holoprosencephalies and related entities, malformations of the cerebral cortex, and malformations of the cerebellum. these congenital brain defects are diagnosed either from direct physical examination or from imaging studies including ct and mri. prenatal mri offers a viable method to improve detection and characterisation of these entities in utero. learning objectives: . to learn about the common supra-and infratentorial congenital abnormalities. . to learn when mri is required and the appropriate imaging protocol. . to learn if and when ct is still useful in the investigation of congenital anomalies. in addition to predicting bone destruction for erosion, marrow oedema is independently predictive of joint space loss and therefore cartilage destruction. it also correlates well with other measures of disease activity. we have applied dynamic contrast enhancement techniques to show that treatment with anti-tnf therapy brings about a reduction in contrast uptake in areas of marrow oedema in patients with ra. in the seronegative arthritides marrow oedema in the spine in ankylosing spondylitis has been shown to be predictive of future changes and of response to treatment. diffusion weighted imaging of marrow lesions in ankylosing spondylitis can also be used to show a treatment response, seen as a change in the apparent diffusion coefficient. bone marrow oedema, also referred as bone contusion or bone bruise, is frequently identified at magnetic resonance imaging after an injury to the musculoskeletal system. it may result from a direct blow to the bone, compressive forces from adjacent bones impacting one another, or from traction forces that occur during an avulsion injury. its location reflects the mechanism of injury, which allows for a focused search for predictable patterns of associated internal derangements. it is seen in any joint but are particularly common in the knee reflecting mechanisms such as pivot shift, hyperextension, contrecoup or dashboard injuries, as well as lateral patellar dislocation. in a context of trauma, bone marrow oedema, identified at mr imaging as areas of poorly marginated signal intensity alteration (best seen on fat-suppressed sequences) in the cancellous bone and marrow, represents areas of oedema and haemorrhage secondary to trabecular injury. it can be seen as soon as one hour after trauma and usually resolves in the following six to eight months, except in case of subsequent chondral lesion. learning objectives: . to learn about bhe physiopathology in trauma scenario, direct and indirect mechanism. . to recognise bme as a footprint that allows other soft tissue injuries to be ruled out. . to analyse whether bme can be a value tool for follow-up. can we still use the term bme or should we be more specific? : the term bone marrow oedema was introduced to describe ill-defined bone marrow hyperintensity on t weighted images. since then many studies have demonstrated that it can be found in many similar unrelated disorders, such as bone contusions, osteonecrosis, inflammatory or degenerative disease, and that it is a non-specific mri abnormality. it has been demonstrated that bone marrow oedema might be a prognosis marker for oa (osteoarthritis) and inflammatory disease, and could be used as a powerful predictive tool for treatment options. therefore our role is to increase specificity to help patient management and decrease progression. room e sonography is an essential tool for studying the neonatal brain. brain scans are usually performed via the anterior fontanelle; however, a more complete assessment of the brain can be achieved using the posterior and mastoid fontanelles, high-resolution linear array transducers and colour or power doppler. the most common lesions in premature infants are intraventricular/periventricular haemor- at initiation, tumours in a pre-vascular phase are supplied by oxygen and nutrients that diffuse from pre-existing normal vessels. when the tumour reaches a critical size of approximately - mm diameter, the resultant ischaemia leads to secretion of angiogenic factors. these factors, such as vascular endothelial growth factor (vegf), recruit and maintain tumour vessels. "new" vessels (neovasculature) exhibit increased blood volume and permeability compared with normal vessels. various new specific therapies in oncology target tumour vasculature or tumour neoangiogenesis. it is not uncommon that these targeted therapies have pronounced cytostatic and not predominantly cytotoxic effects. this limits the usefulness of size-based morphological tumour response assessments. of newer magnetic resonance imaging (mri) modalities, perfusion mri has emerged as a valid marker of tumour-induced blood vessels and their function. mri perfusion measures the vascularity within a tumour, as well as its component heterogeneous parts. of parameters which can be measured to date, blood volume and permeability are commonly applied in patient studies. blood volume measures the aggregate size of the vascular space, while the permeability function informs about the integrity of vessels and their ‚leakiness' to contrast agents. we will describe the use of mr perfusion to monitor such new therapies and discuss its specific advantages and limitations in comparison to ct perfusion protocols. pet-based strategies for targeted treatment-monitoring in oncology will be briefly mentioned, with prospect on the significance of combined vascular and metabolic imaging for further optimising non-invasive response assessment in specific anticancer therapies. after a brief review of physical and technical principles of diffusion-weighted mr imaging and pet-ct, the lecture describes the ability of these techniques in evaluating functional parameters in tumour tissue. diffusion-weighted sequences have been used in an attempt to further increase the diagnostic capability of baseline and dynamic mr study by providing functional information. diffusion-weighted mr imaging is based on the random microscopic movement of molecules that can be quantified by means of apparent diffusion coefficient (adc). in the early post-treatment period after loco-regional therapies, tumours may not change in size. recent studies demonstrated that water diffusion can be used to differentiate viable and cellular regions from necrotic area in the tumour, regardless morphologic or dimensional changes. moreover, new classes of antitumour therapy have been developed that have an antiproliferative effect, inducing a delay in tumour shrinkage. diffusion mr imaging can be promising in this clinical setting as a biomarker to predict early response to systemic chemotherapy. on the other hand, pet/ct, combining the functional and the structural imaging approach, was shown to be superior regarding conventional imaging modalities in the identification of intrahepatic and extrahepatic metastases. less experience and less publications are available for pet-ct in monitoring tumour response after interventional therapies, but the ability of pet-ct to measure early metabolic changes could make this technique useful in the development of novel anticancer drugs. until now, in oncology, only the recist criteria based on anatomical measurement of the tumour size are used for drug trials or in clinical practice because this is a standardised way to assess the tumour response that allows the calculation of the progression-free survival (pfs) or the time to progression (ttp) that are usually accepted as surrogate end point for overall survival. however, tumour follow-up evaluation using only morphology is usually delayed and with the emergence of new numerous and very expensive targeted therapies there is now a need to move beyond morphology to find new ways to assess tumour responses or progression not only for clinical trials but also in clinical practice to maintain or to change quickly a treatment. this is the aim of the functional imaging using ultrasound, ct, mri or pet. the ultimate goal of these technique is to find biomarkers able to predict the likely course of disease, irrespective of treatment (prognostic biomarkers) or able to forecast the likely response to treatment (predictive biomarkers); before (baseline values of a parameter) or during the treatment (dynamic variation of the parameter during the follow-up). during this session the presenters will discuss the technical issues and the results obtained today using ultrasound with share-waves or microbubbles, functional ct, dynamic contrast enhanced mri, diffusion weighted mri and pet-ct. the candidate biomarkers will be presented as well as the limits and the problems that are still to be overcome. a. us and ceus m. claudon; vandoeuvre-les-nancy/fr (m.claudon@chu-nancy.fr) for tumour evaluation, the main advantages of ultrasound (us) associate a high frame rate and a large range of data and parameters potentially extracted from the signal backscattered from tissues. beyond morphology, elastography is a first modality, based on in vivo estimation of the mechanical properties of tissues. data on displacement or strain of tissues and lesions can be obtained by manual external compression, but shear wave generation techniques allow for a quantitative and more precise estimation of their visco-elastic properties. in oncology, clinical evaluation included first breast. contrast-enhanced us (ceus) is obtained after intravenous administration of microbubbles which are pure blood pool contrast agents. ceus is capable for detection, characterisation and follow-up of tumour lesions, based on enhancement profiles during bolus, destruction-replenishment, or contrast burst depletion imaging. quantification of perfusion in normal tissues and lesions may be obtained by extracting various blood flow and blood volumerelated parameters from time-intensity curves. protocols have entered validation processes to improve reproducibility. as a predictive technique, ceus is a promising tool for monitoring changes of haemodynamic parameters and evaluating the early response during chemotherapy or antiangiogenic treatment. it is helpful in the guidance and follow-up of lesions treated by radiofrequency or cryoablation. recent advances of us and ceus include d/ d real-time imaging with matrix technology, and the evaluation of targeted agents, to be released on site after bubble destruction by the us beam. interventional radiology (ir) is the part of clinical radiology based on the percutaneous or endoluminal treatment of widespread conditions. the procedures performed by the interventional radiologists require a deep level of knowledge of clinical imaging and specific training in patient management and care. technical skills are also needed because complex devices and materials are used in some procedures. therefore, specific training programmes are required to address the training needs for the interventional radiologist. a multidisciplinary approach is required (based on team work) with defined levels in patient care. ir procedures have become the treatment of choice for many conditions as an alternative for some surgical procedures. even for some conditions without a defined treatment are now being treated by ir. thus, it is a discipline with a great deal of interaction with other clinical specialities that requires a clear definition. ir specialists have to receive recognition in the patient care process and their activity has to be known by the medical community. the recognition of ir as a subspecialty of clinical radiology by the uems will contribute to the development of specific training programmes in the european community and will promote training centres with certified specialists. interventional radiology (ir) procedures are complex and require specific training to ensure good results. in the uk, a curriculum for subspecialty training was established in specifying the required knowledge, training and core procedures expected of trainees. this curriculum has undergone several reforms since that time. however, training is not uniform throughout europe and this stimulated the development of a europe wide ir training document to ensure similar training in all countries as a way of ensuring good medical practice. radiology training is based on years of common radiology training and years of subspecialty training with an option for further specialist training in the th year. regular appraisals and assessments of trainees' performance should guide progress at local training institutions with the aim that competence is assessed formally at the end of training by a european board examination. this qualification will be recognised thoughout europe and ensures that the required proficiency in ir procedures has been attained. competence in the core skills for ir occurs during the first years of training. in the next years, trainees undertake modular training depending on their areas of interest and ultimate goals. the majority of this training is practical, supervised training in interventional suites and theatres, with clinical exposure. simulators play a role alongside the more traditional training methods and allow early training in a more forgiving environment away from the patient. development and validation of such simulation models is progressing. discrimination of individual x-ray quanta, i.e. the detectors can 'see' the colour of the x-rays. different materials attenuate the energy spectrum in their own characteristic way. by comparing the measured spectra with the spectrum emitted from the x-ray tube the penetrated material can be characterised. colour x-ray imaging can be used in breast imaging to detect, for example the uptake of an iodinated contrast agent to show the vasculature of a tumour while reducing the impact of the structures from the surrounding tissue. it can also be used to estimate the breast density and as a material decomposition technique to separate the digital mammogram into compositional images, showing different material types separately. colour x-ray imaging can, for example be realised with pulse height discrimination in a photon counting detector, multiple exposures with different x-ray tube settings or filtering the x-ray beam before or after the object. the most simple form of colour x-ray is dual energy where two images are acquired at different x-ray energies. lung cancer staging is based on imaging techniques in combination with tissue diagnosis and surgical exploration. the tnm staging system describes the local tumour extent (t -t ), presence or absence of lymph node metastases (n -n ) and distant metastases (m /m ). different combinations of t-, n-and m-factors translate into tumour stages (stages ia-iv). therapeutic decisions and assessment of prognosis are based on these tumour stages. recently, the tnm system has been modified: tumour size is now used more precisely for t staging: tumours <= cm: t a, > - cm: t b, > - cm: t a, > - cm: t b, > cm: t . satellite tumour nodules in the same lobe are now classified as t (previously t ) and in a different lobe of the ipsilateral lung as t (previously m ). satellite nodules in the contralateral lung (previously m ) and pleural or pericardial metastases (previously t ) are now classified as m a, whereas distant metastases outside the chest are classified as m b (previously m ). also, the tnm staging system should now be applied not only to non-small cell lung cancer (nsclc) but also to small cell lung cancer (sclc). during this refresher course the different t-, n-and m-stages will be presented including the recent changes and examples will be presented and discussed with the audience. therapeutic strategies in different tumour stages will be described and key decisions highlighted. the accuracy of different imaging procedures and findings will be presented and the role of biopsy in specific clinical scenarios will be discussed. x-ray computed tomography (ct) has been proposed and evaluated recently as a potential alternative method for breast imaging. efforts so far showed success with respect to contrast-enhanced dynamic imaging, but suffered from limited spatial resolution. respective efforts and clinical results will be reviewed. the new concept presented here builds upon micro-ct scanning approaches and aims at providing both high spatial resolution at around µm for micro-calcification imaging and advanced dynamic scan capabilities with continuous acquisition and scan times of about seconds for differential diagnosis of lesions. to achieve this, spiral scan modes, slipring technology, high-resolution detectors and high-power micro-focus x-ray tubes are demanded. the concept has been evaluated and confirmed by simulations and basic experiments; feasibility studies are expected by the end of . colour x-ray imaging can best be described as the x-ray analogy to optical colour imaging. in optical imaging the wavelength -the energy -of the light gives the different colours that we see. emerging x-ray detector technologies enable energy maintenance of confidentiality of patient information. in contrast, more hierarchical cultures often defer to elders for decision-making whereas communal cultures may involve community leaders in a shared decision-making process. gender and religious issues can also affect the provision of high-quality procedures with same gender care being a requirement within some cultural groups and gowning procedures that maintain cultural values frequently being an expectation. in addition, in many countries in the developing world, radiation still has mystique and fear associated with it, affecting participation in screening programs and recruitment to medical radiation technology educational programs. this presentation will present findings from a variety of countries and cultures that will help to contextualise these issues through a cross-cultural imaging lens. first line image interpretation is now commonly used in the united kingdom. for many years radiographers have used a system commonly known as "red dot" in order to identify to the referring clinician that an abnormality has been recognised on a radiographic image. this has more recently evolved into radiographer comment where the radiographers' experience in recognising abnormalities can help referring clinicians. junior doctors are often inexperienced at image interpretation, thus this system can assist in ensuring that a higher percentage of fractures and injuries are observed and the appropriate treatment obtained. this presentation will demonstrate the fundamentals of basic image interpretation of the cervical, thoracic and lumbar spine in a trauma situation. it will include basic anatomy, mechanism of injury, common fractures and soft tissue signs. using these principles this will encourage radiographers to use the comment system, both developing the radiographer's role and helping to improve patient care. two fasciae cross the suprahyoid neck: the superficial cervical fascia (scf) and the deep cervical fascia (dcf). the latter can be divided into three parts and these layers define different fascial spaces or compartments. the descriptions of these compartiments in the literature vary almost as much as those of the fasciae themselves. in addition, the names of the formed compartiments vary within the literature. despite these controversies, the knowledge of these compartiments is inestimable for correct differential diagnosis of pathologies that arise in the suprahyoid neck. with the utilisation of cross-sectional imaging, it has been noticed that growth of some tumours appears restricted by fasciae and knowledge of the anatomy of these fasciae allows not only prediction of growth patterns. by allocation of a tumour to a certain compartiment the number of differential diagnosis drop dramatically due to the fact that in different compartiments different types of tissue occur. in addition, the exact localisation of infectious disease of the suprahyoid neck may predict further intracranial or mediastinal spread. even though the number management of cancer patients, imaging pitfalls must be recognised to avoid both false-positive and false-negative interpretation. the principles and good practices of pet/ct will be explained. normal distribution of fdg, pitfalls and normal variants will be presented. specific examples will be discussed to demonstrate how the combined information of images of human anatomy upon which biological information within body structures is added improves delineation of disease, can guide surgical and radiation planning and biopsy. advances in technology result in new training requirements for radiologists who should promote close collaboration with nuclear medicine specialists. the metabolic syndrome refers to the clustering of cardiovascular risk factors including diabetes, obesity, dyslipidaemia and hypertension. the association between metabolic syndrome and cardiovascular diseases raises important questions about the underlying pathological processes. insulin resistance and visceral obesity have been recognised as the most important pathogenic factors. metabolic syndrome generally precedes and is often associated with type diabetes. cardiovascular risk reduction in individuals with metabolic syndrome should include ( ) control of obesity, diet and physical activity and ( ) control of the individual components of metabolic syndrome, especially atherogenic dyslipidaemia, hypertension, hyperglycaemia and prothrombotic state. appropriate management of metabolic syndrome should be able to prevent the progression from impaired glucose tolerance to frank diabetes and thus to prevent the increasing prevalence of type diabetes and vascular diseases. each % increase in hba c is associated with a % increase in risk of incident pad. diabetes is also highly associated with progression of pad and especially with the development of critical limb ischemia. rigorous control of blood glucose prevents the microvascular complications of diabetes, although similar benefits on the macrocirculation have not been ascertained. patients with diabetes and pad should have an aggressive control of blood glucose levels with a hba c goal of < . % or as close to % as possible. in the new tasc paper this recommendation is graded as c, meaning that it is based on evidence obtained from expert committee reports or opinions and/or clinical experiences of respected authorities, while there are no applicable studies of good quality. peripheral arterial disease (pad) is a common cardiovascular complication in patients with diabetes. in contrast to non-diabetic pad, it is more prevalent and, because of the distal territory of vessel involvement and its association with peripheral neuropathy, it is more commonly asymptomatic. diabetic pad thus may present later with more severe disease and have a greater risk of amputation. the pervasive influence of diabetes on the atherothrombotic milieu of the peripheral vasculature is unique. the abnormal metabolic state accompanying diabetes results in changes in the arterial structure and function. the proatherogenic changes include increases in vascular inflammation and derangements in the vascular cellular components, alterations in blood cells and haemostatic factors. these changes are associated with an increased risk for accelerated atherogenesis as well as poor outcomes. in contrast to the focal and proximal atherosclerotic lesions of non-diabetic pad, in diabetic patients the lesions are more likely to be more heavily calcified, diffuse, and distal, sparing the proximal vessels and mainly affecting the more distal arteries in the calf and, in a later stage, the foot. by identifying a patient with subclinical disease and instituting preventative measures, it may be possible to avoid acute, limb-threatening ischaemia. the primary imaging modality to be used should be duplex ultrasound, due to its non-invasive nature, lower risks and costs. ct-angiography and mr-angiography are now replacing dsa as standard imaging methods, providing a non-invasive assessment of the localisation and extension of a vascular lesion and allowing an accurate planning of endovascular and/or surgical treatment. of spaces in the literature varies from seven to fourteen, the use of seven spaces or compartiments seems to be helpful for a sufficient diagnostic approach using cross-sectional imaging. anatomic landmarks and the radiologic appearance in a non-pathologic suprahyoid neck and a pathologic involvement of the suprahyoid compartiments will be reviewed extensively in a coherent manner. the anatomy of the suprahyoid neck is complex and the spectrum of diseases is wide. to improve studies of the neck, radiologists should become increasingly more familiar with the anatomy and expected pathology in the various spaces. this familiarity provides crucial information required for the selection of treatment options and therapeutic planning. in addition, radiologists should be aware of situations when diagnostic inaccuracies may lead to serious consequences and complications. for example, surgical approach to a deep lobe parotid tumour as though it is a parapharyngeal lesion will in all likelihood result in facial nerve injury. mri artefacts such as complex flow-induced increase in signals may be mistaken as a lesion prompting an unnecessary operation. an awareness of such pitfalls helps to improve the quality of imaging studies. this presentation highlights some pertinent anatomical knowledge that may help to improve the diagnostic accuracy of neck studies and at the same time explain the existence of pitfalls that may ruin imaging studies. three layers of the deep cervical fascia define the suprahyoid neck compartments, which include: prevertebral, retropharyngeal, carotid, masticator, parapharyngeal and pharyngeal mucosal space. knowledge of the structures inherent to these spaces will provide the radiologist with an accurate basis for differential diagnosis. also, expanding lesions will distort or displace adjacent structures and fascia in predictable fashion, which is crucial in defining the site of origin. both mri and ct are frequently used in the imaging of suprahyoid neck lesions. the introduction of functional imaging has also given some benefits. primary and secondary, benign and malignant processes occupying major suprahyoid neck spaces will be discussed, with regard to crucial findings necessary for appropriate treatment selection and treatment planning. since correct diagnosis requires close collaboration with ent surgeons, clinical findings will also be discussed, together with practical information needed for surgery. in vivo proton mr spectroscopy is a non-invasive mr technique that is routinely used to assess a number of paediatric neurologic conditions. it is based on the fact that protons belonging to different metabolites resonate at slightly different frequencies (chemical shift). using water suppression and volume localisation techniques we can obtain a spectrum (single voxel) or spectra (si) containing metabolite peaks corresponding to predetermined anatomical site(s). in paediatrics the majority of spectroscopy is performed in the brain and the metabolites detected usually are: n-acetyl aspartate, n-acetyl aspartyl glutamate, creatine and phosphocreatine, choline containing compounds (free choline, acetylcholine, phosphocholine, cytidine diphosphate choline and glycerophosphocholine), myoinositol, myoinositol monophosphate and glycine, aminoacids (glutamine, glutamate and gaba), lactate, lipids and macromolecules. these metabolites participate in fundamental metabolic pathways and their levels are being disturbed by various pathologies. thus, mr spectroscopy has a vast field of application including paediatric tumours, infarction, hypoxia, ischaemia, infection, inflammation, metabolic disorders neurological disorders and trauma. in many cases, it can redirect or narrow differential diagnoses; in selected instances, it may provide the key finding that points to a final diagnosis. however, mr spectroscopy alone is usually not specific, but can be very helpful especially in combination with other clinical, diagnostic and other mr methods. finally, particular caution is needed in data evaluation because spectral appearance and concentrations of the most prominent metabolites are affected by (a) experimental and preprocessing factors and (b) brain development. stroke in children is most often of ischaemic origin and thrombophlebitis is the second cause of stroke in children. stroke is considered as rare compared to the adult population. however, numerous aetiologies impose to look for a cause through series biological investigations. the goal of brain imaging is to confirm the diagnosis of stroke, to evaluate the extension of ischaemia and mostly to participate in the search of a cause for the stroke. prognostic is mostly related to the aetiology. a lot of cases are performed under general anaesthesia leading to limited indications of mra in the acute phase compared to adult. the role of cta at the acute phase is mostly to confirm thrombophlebitis and is the primary method to assess intracranial vessels at the acute phase of haemorrhage of arterial or venous origin. it is also the primary method to assess arterial vessels at the neck level (especially when dissection is suspected). cta permits to confirm or rule out arterial lesion that was suspected on mr: indeed, cases with pitfalls are numerous with mr angiography. the role of mra, also always performed in the acute phase or follow-up of vascular diseases, is not as clear as cta role because of artefacts especially in young children. the role of angiography (dsa) is finally limited to prove vasculitis when the other methods are not contributive and in cases of arterial or arterio-venous malformation to plan the treatment (endovascular procedure versus surgery or radiosurgery). diffusion tensor imaging (dti) studies demonstrate progressive apparent diffusion coefficient (adc) decrease within grey and white matter areas starting from foetal life as sign of brain maturation; meanwhile, fractional anisotropy (fa) increases in some white matter structures. changes in fa and adc, together with radial and axial diffusivity values, during cell proliferation-migration and during myelination, well correlate with modifications known from developmental histologic studies. acute adc decrease (i.e. ischaemia) can be detected already in foetal stroke and its measure is pivotal in monitoring neonatal hypoxic-ischaemic encephalopathy. adc calculation allows also to assess acute osmotic and metabolic anomalies in neonate (i.e. hypernatremia, hypoglycaemia, etc.). early fa decrease, with radial and axial diffusivity changes, is observed in white matter areas as sign or early wallerian degeneration after acute brain damage. chronic regional white matter fa reduction is detectable in sequelae of periventricular leukomalacia or adjacent to malformative cortex. also, in children with neurodevelopmental delay (autism, adhd, dyslexia, etc.). fa reduction and radial or axial diffusivity changes have been demonstrated, but in these conditions not on a single case basis rather in cohort quantitative studies. finally, building fiber tracking and colour coded (rgb) maps from dti data may help in better characterising suspected structural anomalies on a single case basis (i.e. corpus callosum, hippocampal fornix, optic radiation, cerebellar peduncles malformations, etc.). however, the potentials of fiber tracking applications still need to be fully exploited, especially in view of future higher spatial resolution image acquisitions. learning objectives: . to understand the relationship of adc-fa values with the structural characteristics of the normal developing brain. . to understand adc-fa value changes in paediatric cns diseases. . to learn about the potential impact of fibre tracking in clinical paediatric neuroradiological practice. congenital pulmonary malformations may involve the lung parenchyma, bronchi, arterial supply, and venous drainage. the pulmonary developmental abnormalities that most commonly result in clinically significant complications in neonates and children are hypogenetic lung syndrome, bronchopulmonary sequestration (bps), congenital lobar emphysema (cle), bronchial atresia, congenital cystic adenomatoid malformation (ccam), and bronchopulmonary foregut cysts. it should be noted that there is often considerable overlap between these conditions and that multiple lesions may be identified in the same patient either separately or as hybrid lesions. the aim of this presentation is to illustrate the characteristic imaging manifestations of the most important congenital lung diseases and their main differential diagnosis. emphasis will be given to pre-natal diagnosis using ultrasound or magnetic resonance imaging (mri) and post-natal diagnosis using mri or low dose ct in multidetector scanners. ultrasonography (us) is the primary screening modality in prenatal imaging. its diagnostic accuracy is usually very high so that the indications for foetal mri should be very rare. in some countries, because us is considered of secondary importance and is not exploited as much as it could be, there is a progressive shift from us to mri as a prenatal imaging modality. consequently, there are many discrepancies regarding the relative contributions of foetal us and mri in the prenatal literature. the main indications for foetal mri will be discussed, with emphasis on the central nervous system, which remains the main field of application. in daily practice, the technique of foetal mri has not changed during the last decade and most diagnoses can be assessed using t , t and t * sequences. the basic technique and patient preparation will be described. new techniques, based on a functional or a metabolic approach, have been developing during the past few years but their impact on daily practice is still very limited. many studies have underlined the high diagnostic contribution of foetal mri compared with us. however, the diagnostic accuracy of mri has not been studied in large series. comparison between pre-and postnatal data or between foetal mri and pathological findings make it possible to define the main limits of foetal mri. regarding the brain, migration or cortical development disorders are often overlooked or underdiagnosed. a tight collaboration between colleagues practicing prenatal us and mri should increase diagnostic accuracy, both modalities being complementary. founded on september , , the brazilian college of radiology comprises regional societies and ten thousand associates. the college is a branch of the brazilian medical association (amb) acting as its scientific department of radiology, imaging diagnosis and radiotherapy. it collects, under the same umbrella medical professionals and legal entities in the field of diagnosis and treatment using imaging methods and/or ionising radiation. session objectives: . to get an introduction to the practice of radiology in brazil. . to understand the importance of radiology as a method for diagnosing diseases in brazil. granulomatous interstitial lung disease: hrct path correlation c.i.s. silva; salvador/br (c.isabela.silva@gmail.com) granulomatous interstitial lung diseases are a group of lung diseases in which granulomas are an important component of the histologic findings. the most common conditions are hypersensitivity pneumonitis and sarcoidosis. hypersensitivity pneumonitis is very common in brazil because of the warm and humid climate in most regions and a large number of birds. the prevalence of sarcoidosis in brazil seems to be lower than that in north america and europe. other ubiquitous causes of granulomatous interstitial lung disease include intravenous talcosis, drug reactions, and some forms of vasculitis (e.g. churg-strauss syndrome). the aim of this presentation is to illustrate the characteristic high-resolution ct and histologic manifestations of the most common granulomatous interstitial lung diseases and to summarise the main differential diagnosis based on the pattern and distribution of abnormalities seen on high-resolution ct. learning objectives: . to become familiar with the characteristic high-resolution ct and histologic findings of the most common granulomatous interstitial lung diseases (hypersensitivity pneumonitis and sarcoidosis). . to learn about the most helpful features in distinguishing the granulomatous interstitial diseases from other parenchymal lung diseases. a- : the most common granulomatous lung diseases are fungal infections and tuberculosis. these infections are particularly prevalent in brazil, the most common fungal infection being paracoccidioidomycosis (south american blastomycosis). histoplasmosis and coccidioidomycosis may occur but they are uncommon. paracoccidioidomycosis is the most frequent endemic systemic mycosis in latin america, being seen particularly in brazil, argentina, colombia, and venezuela. the lungs are the main target organ of p. brasiliensis organisms, and infection of the lungs is the leading cause of morbidity and mortality in these patients. fungal infections need to be considered not only in patients living in endemic regions but also in patients who have travelled to these areas. although the prevalence of pulmonary tuberculosis has decreased in brazil in recent years it remains one of the most important causes of pulmonary morbidity and mortality. the aim of this presentation is to discuss the radiologic manifestations of the granulomatous pulmonary infections with emphasis in paracoccidioidomycosis and tuberculosis and to summarise the main differential diagnosis. magnetic resonance imaging (mri) is a highly sensitive technique that provides complementary information to conventional breast imaging (i.e. mammography and ultrasonography) for the detection of multinodular disease and for the assessment of primary tumour extent. the use of mr breast imaging has increased considerably in the past decade. although its use is well established for some indications, e.g. detection of unknown primary and assessment of uncertain disease extent, breast mri is still under investigation for other applications such as preoperative assessment in patients eligible for breast conserving therapy on the basis of conventional imaging and clinical examination. despite its superior ability to visualise disease spread, recent studies have shown increased rates of mastectomy without reduction in positive surgical margins or local recurrence rates. nonetheless, a shift in paradigm is occurring, focusing on the use of breast mri to reduce involvement of healthy tissue in breast-conserving therapy. this paradigm involves new methodology to optimise the transfer of information to the surgeons and radiation oncologists. new technological developments, such as diffusion-weighted imaging (dwi) and magnetic resonance spectroscopy (mrs) provide new insights to establish a link with underlying biology of the tumour. contrast-enhanced mri, dwi and mrs are examined for their ability to extract prognostically relevant information to individualise therapy to individual patients and tumours. this overview aims to summarise the current status of breast mr imaging and new developments geared towards providing therapists with patient-tailored information for treatment decision, treatment guidance and therapy response. this talk will review the current literature and clinical use of foetal mri in cases with ventriculomegaly. the initial part will discuss antenatal ultrasound in the detection, categorisation and diagnosis at the -week anomaly scan. the role of foetal mri will be discussed including which cases may benefit most from foetal mri when the resource is limited. the timing of the foetal mr with relation to gestational age and the value of further foetal mr scans at a later gestational age will also be discussed. this is still a controversial and debated area especially when the resource is limited or there are financial constraints. the current literature will be discussed on the issues around foetal mri in cases with ventriculomegaly both isolated ventriculomegaly and ventriculomegaly associated with other abnormalities. finally, this section will conclude by looking at the common associated abnormalities seen in cases referred with ventriculomegaly. the final section will discuss the role of foetal mr in imaging the posterior fossa, an area often difficult with ultrasound especially in the later stages of pregnancy. again the current literature will be discussed and the use of foetal mr in clinical practice. the concluding time will be used to summarise the referral pathway used by local centre in the uk. this will differ with other uk centres and centres worldwide. hopefully, time will allow an open discussion on this at the end of the session. learning objectives: . to learn about the differential diagnoses of ventriculomegaly identified on foetal ultrasonography. . to learn when mr should be performed and its value when compared to ultrasonography. . to understand the value of mri in assessing posterior fossa abnormalities. prenatal diagnosis involves obtaining genetic, anatomic, biochemical and physiological information about the foetus and analysing whether there are any alterations that might have repercussions during the foetal period or after birth. magnetic resonance imaging (mri) has been useful in the diagnosis of foetal anomalies for many years. thoracic abnormalities play an important role in infant morbidity and mortality. survival after birth depends largely on adequate lung development during gestation, and various pulmonary problems can affect foetuses. heart defects are present in of live births, and up to % of these are associated with other malformations. other thoracic anomalies (tracheoesophageal malformations, chest wall defects, and tumours, amongst others) can also cause morbimortality. congenital abdominal anomalies can affect many organs. it is essential to determine the location and morphological characteristics of the lesion to ensure an accurate diagnosis. mri's excellent contrast resolution between tissues is very useful in the diagnosis of these conditions. prenatal diagnosis also makes it possible to detect anomalies that can be difficult to recognise clinically in newborns but require early treatment to minimise possible complications.this presentation stresses the importance of diagnosing chest and abdominal problems before birth and analyses the usefulness of mri in this context. learning objectives: . to learn about the mr protocol when investigating the foetal chest. . to recognise the situations in which mri is helpful in assessing chest abnormalities. . to understand the value of mri when compared to ultrasonography in assessing congenital renal and gastrointestinal abnormalities. a s c b d e f g h structured reporting: improving the quality of radiology reports c.e. kahn; milwaukee, wi/us (kahn@mcw.edu) the radiology report communicates the results of an imaging procedure and provides the enduring legal record of the procedure. structured reporting uses standardised language and predefined formats to create reports. structured reports can integrate information collected during the imaging procedure, such as clinical data, technical parameters, measurements, annotations, and key images. in this presentation, well defined structured reporting describes its advantages and disadvantages, and identifies the motivations for its adoption. this session will discuss how structured reporting can make it easier to retrieve reported information, evaluate the appropriateness of exams, and aggregate data across health care enterprises. structured reporting can support radiology quality improvement, research, and education, and has the potential to improve the quality of communication between radiologists and their referring colleagues. beyond air-space disease is secondary to occupation of the acini and alveoli by oedema, exudates or malignant cells. it presents in the chest radiograph as ill-defined densities which tend to coalesce. the presence of an air bronchogram is pathognomonic. when the disease is widespread it shows the typical "butterfly" appearance. air- the pixel data set of modern imaging is transformed into a life altering insight for the individual patient through the radiologic report. a good report is patient and service centred, and forms the basis of the reciprocal relationship between radiologist and referring clinician. it is a creative process with serious scientific purpose and becomes part of the permanent record in a person's life. its primary role is communication of diagnostic and procedure-related imaging information but it has many vital adjunct roles in quality service delivery. in current practice of multidisciplinary care the report content must be of value to all the stakeholders beyond radiology. structured reports must have uniformity where possible to permit data-mining and audit whilst preserving the individual radiologist practice and style and the individual nature of each patient's health. report design has a particular role in modern alerting and safety-net systems when unexpected or critical imaging findings are discovered. the properly written report can be vital in medico-legal defence to reflect good practice. ultimately guidelines and standards on reporting must be meaningful to the users and appropriate to local resources, systems and needs. learning objectives: . to comprehend the role of the modern radiological report. . to understand the role of the report in communication and patient safety. . to become familiar with structured report formulations. structured reporting: european perspective r. silverio; grosseto/it (rsilverio@sirm.org) in the last decade, we observe an increasing interest in structured report (sr). this is a part of the dicom standard, where the technical and clinical information are organised in a standard format so that it can be retrieved and reused for clinical, statistical and research scopes. structured reports have three important features: a "structured" format, with fixed paragraphs, heading and subheading in which to describe technical data and clinical findings, impressions and conclusions; a consistent, "itemised" organisation, leading to a better way of reporting, even with automated speech recognition systems; and the possibility, or rather the need, of a common, shared language. when defined terms from a standard lexicon are associated with imaging reports, the information in the report becomes more accessible and reusable. moreover, sr allows the interoperability between the dicom world and the complex sphere of the e-health (electronic patient record, patient care, etc). it is possible to convert a radiological report created as sr in a cda (clinical document architecture) document. this clinical document will be used in every computerised healthcare application, as well in the several regional e-health projects (epsos, elga, calliope, renewing health, etc). promoted by european community. integrating the healthcare enterprise (ihe) initiative is as a key partner in fostering the adoption of structured report. in short, question of whether sr will be adopted by radiologists is now a question of "when", not "if." learning objectives: . to become familiar with structured report. . to keep up to date on the developments of e-health projects in europe. acute mesenteric insufficiency (ami) is due to arterial or venous occlusion. arterial ami is an emergency. the typical patient is elderly, may have atrial fibrillation and has recent onset intense visceral pain disproportionate to clinical signs. ct is the mainstay of diagnosis and may be supplemented by ct angiography (cta). waste no time if arterial ami is suspected. average mortality rates of % ( - %) have been reported and symptom duration before therapy is an independent predictor of mortality. age > years, metabolic acidosis and renal failure are other danger signs. interrupt routine ct lists; ensure that these patients are scanned as soon as possible -neutral oral contrast and high-dose iv contrast are essential. ct appearances should be correlated with serum lactate as acute arterial occlusion without reperfusion may produce falsely 'normal' bowel wall thickness. early diagnosis and aggressive surgical intervention combining bowel resection with revascularisation offer the best prognosis. venous ami may present with a more chronic, intermittent course of pain, fever, abdominal tenderness and ascites. therapy is bowel resection and anticoagulation. ischaemic colitis occurs in elderly patients with atherosclerosis spontaneously or after aortic aneurysm repair. this invited lecture explores the groundbreaking use of ct for studying antiquities and artworks from a wide range of cultures, irrespective of their age or material. dr. marc ghysels, a former interventional radiologist, comes from a family of artists and collectors. about ten years ago he set up a private radiology practice in brussels where he analyses antiquities and artworks. over the years he has built an international reputation among collectors and art dealers as well as museum curators and experts working in auction rooms. art specialists call on his radiological skills and knowledge to authenticate antiquities, and more specifically to show: what methods were used to make the works, what damage they have suffered over the years, how much restoration has been done, and to expose the many tricks used by forgers to deceive not only the discerning eye of the collector but also the methods of scientific analysis more commonly used than ct scans. his presentation will highlight the prominent role of ct as a nondestructive test to explore selected artworks made in wood, terracotta, stone, and ivory. acute abdominal organ ischaemia may be caused by hypovolaemic shock, spasm (ergotism), embolisation and aortic dissection. embolisation is the most common cause. it occurs typically in elderly patients with atrial fibrillation, after myocardial infarction or due to a thoracic aortic aneurysm (taa). the primary diagnosis is made by ct with contrast enhancement which can also demonstrate cardiac thrombi or a taa. interventional treatment can be performed with a thrombectomy device or fibrinolysis with recombinant tissue plasminogen activator (rt-pa; mg loading dose, mg/hr infusion dose). acute aortic dissection may cause dynamic compression of the true lumen with occlusion of the ostium of the visceral arteries (floating visceral sign). the primary diagnosis is made by ct. occlusion of the primary entry tear with a thoracic aortic stentgraft may decompress the false lumen followed by reexpansion of the true aortic lumen followed by reperfusion of the visceral arteries. chronic abdominal ischaemia in younger patients may be due to fibromuscular dysplasia, takayasu arteritis or neurofibromatosis. in the elderly it is usually caused by arteriosclerosis. the patient may have post-prandial abdominal pain (angina abdominalis), diarrhoea and/or weight loss. due to the collateral circulation, symptoms usually occur only if more than one of the major arteries (celiac trunk, superior and inferior mesenteric artery) is narrowed. the diagnosis can be made by color doppler ultrasound (cdus), ct and mr with contrast enhancement. endovascular treatment is done by pta and stent placement. to learn what to include in the report of cns infections for the treatment planning. . to learn how to report follow-ups and treatment monitoring of cns infections. finding of a palpable mass in the abdomen always raises the possibility of an important clinical problem. a potentially life-threatening process, especially malignancy is the major concern. the list of differential diagnosis of "abdominal mass" is a very long one. in the process of differential diagnosis the most common approach is to evaluate the patient according to the gender, age, patient history and co-existing clinical and laboratory findings. the accompanying symptoms and signs and the location of the abdominal mass are the key indicators in the clinician's way of thinking in the process of differential diagnosis. for instance, a palpable mass with acute abdomen or intestinal obstruction will be assessed differently than a mass found incidentally. imaging is commonly required to confirm or ascertain the diagnosis. cross-sectional imaging is required to accurately evaluate a palpable abdominal mass in most situations. ultrasound and computed tomography have each been used successfully in evaluating patients with palpable abdominal mass. although each modality is appropriate in most situations, the advantages and disadvantages of each modality in certain situations will be addressed and the appropriateness criteria will be reviewed in this lecture. knowledge of a detailed clinical history is as important to the radiologist as to the clinician. its impact on the diagnostic accuracy in the interpretation of the images will also be addressed. a palpable abdominal mass has a long list of benign and malignant differential diagnoses. these diagnoses may be as different as a hydatid cyst of the liver, a volvolus, an aneurysm, or a giant renal cell carcinoma. the diagnostic approach is based on two major steps: first, the affected organ must be indentified. second, the differential diagnosis must be established based on imaging characteristics. the choice of ultrasound, ct or mri should be based on location and size of the mass. despite the fact that ultrasound is frequently used as a first step, the overview and anatomic orientation in large masses may be hampered, making ultrasound a better technique for image-guided biopsy than for primary diagnosis. in the vast majority of cases, multidetector ct is the first technique of choice. a thin-section protocol should be used to allow for high-quality multiplanar imaging. a pre-contrast scan is usually not required but can be helpful in suspected hemorrhage. for most upper and middle abdominal masses, biphasic imaging in the arterial and portal phase is recommended in order to establish the relation of the mass to the vasculature and to assess vascularity. in the small pelvis, mr is the superior imaging technique. otherwise, mri is mainly used for problem-solving. this course will discuss how to use the various imaging tool efficiently to narrow the differential diagnosis, decide about the need for biopsy and establish a suitable therapy. the most common viral infection of the brain is herpes encephalitis (hsv ). it is a necrotising encephalitis with a a mortality of more than %. on imaging studies lesions will be seen in the "limbic system", i.e. the temporal lobes, hippocampi, insular cortex and cingulate gyrus. they appear as hypodensity on ct, t -and flair hyperintensity on mri, possibly with haemorrhagic transformation. diffusion is restricted in the early phase. enhancement occurs at a later stage. human immunodeficiency virus (hiv) infection is a multifocal giant-cell encephalitis eventually leading to a progressive leuco-encephalopathy. on mr atypical focal or diffuse symmetrical signal abnormalities are seen neither with mass-effect nor with enhancement and typically sparing the u-fibers. spectroscopy can show an increase of myo-inositol. progressive multifocal leuco-encephalopathy (pml) is due to reactivation of the jc polyomavirus in immunocompromised patients, % of which are hiv positive. on mri "scalloped" multifocal asymmetrical lesions are seen with minimal mass-effect and without enhancement. new treatments of hiv, especially highly active antiretroviral therapy (haart) can lead to a paradoxical worsening of patients due to the immune reconstitution inflammatory syndrome (iris). on mri mass lesions are seen with diffuse patchy enhancement. cerebral toxoplamosis appears as multiple enhancing lesions with marked perilesional oedema. calcification is possible. prion diseases are caused by a proteinaceous infectious particle leading to creutzfeld-jacob disease in humans. diffusion weighted mr-images show high signal intensities in the cortex and the basal ganglia. abnormalities on t -weighted images and flair occur at a later stage where atrophy is mostly prominent. to learn how to assist clinicians for the diagnosis and differential diagnosis of bacterial and parasitic cns infections. susceptibility effects, increased radiofrequency (rf) field inhomogeneity and more pronounced magnetic shielding effects. in the mean time, many investigators have proposed strategies to optimise imaging protocols and to decrease sar levels and to reduce artefacts including optimised coil and hardware design, in combination with parallel imaging and modulation of refocusing flip angles. many clinical applications in neurology and angiography for high field mri that were recently being investigated showed benefits over . t. however, as of to date, virtually no prospective comparative studies have been performed and published that could help to estimate whether or not there would be any clinical benefit of . t msk over . t. although many authors described the improved snr of msk imaging at . t allowing for higher spatial resolution this has not been prospectively investigated with comparison to . t. further studies have to show whether the improvement in speed and resolution will also translate into increased patient throughput and earlier depiction of disease in msk applications at . t. ultrasound is the best imaging modality for evaluation of acute scrotal conditions. mri is used only rarely, when us findings are equivocal and in cases of suspected infarction. ct is used exceptionally, for example, to detect air in the scrotal wall. high-frequency transducers with modern software like compound imaging and native harmonic, and very good colour sensitivity for low flow in small vessels provide excellent insight into testicular morphology and vascularisation. it is very important to distinguish testicular torsion from the acute inflammation, as it has important therapeutic and even medicolegal consequences. in testicular torsion rapid diagnosis is vital, and salvage rate is directly related to timely operation. torsion is more common in younger patients and orchiepididymitis is more common in adults. infection usually starts at the epididymis and then spreads to testis the patient presenting with an abdominal mass represents a common clinical problem. clearly, the differential diagnosis is large and obviously will depend on the age and sex of the patient as well as location of the mass. of course history and clinical examination are mandatory, but formal diagnosis will usually rest on radiological interpretation. contrast examinations have now been replaced by cross-sectional imaging and endoscopy and it behoves the clinical radiologist to be aware of the advantages and limitations of these methods in order to reach a diagnosis. particular difficulty may be encountered when the mass is so large that it is difficult to determine the organ of origin. the purpose of this interactive case discussion is to explore the relative merits of ultrasound, ct, mr and endoscopy in establishing a diagnosis in two different cases. the cases concerned are: . a -year-old man who presents with a right iliac fossa mass, but is otherwise asymptomatic. . a -year-old woman who presents with anaemia and a large upper abdominal mass. active audience participation will be encouraged by means of key pads in order to respond to issues raised during the debate. the most straightforward expectation from t mri scanners is a gain in snr that could be translated in improving spatial resolution and/or reducing imaging time at an at least constant cnr. together with field strength, susceptibility effects, chemical shift and t increase and t and t * decrease. also, relaxation properties of contrast agents are modulated. rf power deposition is higher at t and is often a limiting factor in sequence parameter optimisation. hence, the need to optimise mri sequence protocol parameters at t. for cartilage, muscle, synovial fluid and fat, t increases by between % and %, t decreases by between % and % and r of gd chelates decrease by % to % when b increases from . t to t. in most applications reduced t and increased t work synergistically towards a reduced snr. since the change in relaxation times is not linear for the different tissues, cnr varies with field strength, too. a relatively straight forward approach is to lengthen tr in order to compensate for longer t and to shorten te to compensate for shorter t (*). in non-fat-sat images bandwidth needs to be increased to control chemical shift effects. because of the better fat and water peak separation, t often helps improve frequency-based fat saturation but may also be greatly impaired by field inhomogeneities in the presence of metallic materials. field strength (b ) and appropriate dedicated multi-element coils are the hardware prerequisites to bring high resolution (hr) isotropic imaging into clinical routine. depending on the age of the child, hip symptoms may predict a variety of diseases. in the infant, developmental dysplasia and infection should be considered. after the age of , irritable hip most commonly due to transient synovitis is the commonest disease but infection is the more worrying condition. perthes disease affects some and this condition overlaps into those over who may have a slipped upper femoral epiphysis. fractures and rare cases of osteonecrosis and chondrolysis are a concern in the adolescent. in the young and indeed in most cases, ultrasound provides a useful first line test. aspiration of effusion may be both diagnostic and therapeutic. in the older child and, especially when sufe is a risk, conventional radiographs with an external rotated "frog leg" view is very important. despite the logistics problems in children, there is an important role for mri especially in cases where the initial imaging does not explain the symptoms. i will review the imaging pathways and provide examples of common diseases. i will also discuss how to manage the difficult case and show recent audit data on detection rates and clinical management. fai refers to a conflict between the proximal femur and the acetabulum. both an abnormal shape of the proximal femur (fai of the "cam-type": aspheric femoral head with a laterally increasing radius and/or a waist deficiency of the femoral neck) and the acetabulum (fai of the "pincer-type": acetabular retroversion or a deep acetabulum) or a combination of the two may be present. for a long period the fai may be asymptomatic and the only clinical finding will be an impaired internal rotation of the hip joint. later as the disease progresses, cartilage damage (outside-in abrasion of the acetabular cartilage/cartilage delamination) and labral tears occur. labral tears are most common in the anterosuperior aspect of the acetabulum. a typical labral tear is an incomplete detachment with a tear located at the base of the labrum. anatomic variants such as a sulcus may be present and should be distinguished from tears. a sulcus is common at the junction of the labrum with the transverse ligament and is generally located beyond the equator of the hip joint. insufficiency fractures about the hip commonly occur in the region of the femoral neck. another site vulnerable to overuse is the symphysis pubis. often, a bone marrow oedema pattern around the symphysis pubis is observed. a characteristic finding is the "secondary cleft sign", which reflects a partial tear of the adductor tendon aponeurosis at the symphysis pubis. understanding age-related changes is essential for interpretation of imaging studies. age is a risk factor strongly correlated with osteoarthritis (oa) which is the most common hip joint disease seen in adults. the diagnosis of oa is based on a combination of radiographic findings and characteristic subjective symptoms. the lack of a radiographic consensus definition has resulted in a variation of the that is painful and hypervascularised on colour doppler imaging. in cases of torsion b-mode findings are non-specific, while on colour doppler flow is absent in complete torsion, but may be present and diminished in incomplete torsion, or increased in intermittent torsion. in cases of trauma ultrasound is important to diagnose haematoma, haematocele to evaluate integrity of testis and assess whether the testicular fracture is present or if the surgery is needed in cases of testicular rupture. imaging is helpful in cases of rare causes of the acute scrotum, such as fournier gangrene, testicular appendage torsion, vasculitis, and also in evaluation non-scrotal causes of symptoms, like in cases of renal colic, abdominal inflammatory and traumatic conditions, etc. a scrotal mass is an important clinical problem and a source of anxiety to the patient. radiologists play an important role in the management of these cases, since imaging is required to provide information about precise anatomical location of the lesion, its size and extension and, possibly, to elucidate the nature of the disease. the us and mri findings of the many different scrotal tumours will be presented in this lecture. special attention will be given to two topics. the first are the possibilities offered by imaging to differentiate among the different pathologies, especially to differentiate between benign and malignant lesions. the second will be the problem of the small, non-palpable, indeterminate testicular mass. such lesions have been shown to be relatively frequent. prevalence of malignancy varies widely in the literature, and orchidectomy seems not justified in all cases. the use of contrast-enhanced mri and of advanced us techniques (contrast-enhanced us and elastography) may help to narrow the differential. furthermore, the use of intraoperative us to guide removal of non-palpable testicular nodules can help to perform conservative surgery in lesions with no malignant potential. learning objectives: . to understand the typical imaging appearance of benign and malignant scrotal tumours. . to review differential diagnosis of intra and extratesticular scrotal tumours and the impact of imaging. c. imaging of the penis m. bertolotto; trieste/it (bertolot@univ.trieste.it) ultrasonography (us) is the first-line imaging modality in patients with penile disease. using high-end equipment after pharmacologically induced erection penile anatomy is well defined and virtually all clinically significant penile vessels can be evaluated in normal and in impotent men. the superior soft-tissue contrast resolution afforded by mr imaging provides an opportunity to advance imaging evaluation of the penis in selected cases. in the clinical practice, erectile dysfunction is the most frequent penile abnormality which is investigated with doppler us. the clinical role of this evaluation, however, reduced after the introduction of oral medications for impotence. differentiation among different forms of erectile dysfunction is mainly based on evaluation of doppler waveform changes in the cavernosal arteries. peyronie's disease is the most frequent cause of penile induration. imaging is often required to evaluate the extension of the plaques, involvement of the penile septum, and relationship between the plaques and penile vasculature. in patients with penile traumas, imaging allows accurate evaluation of albugineal tears, extra-albugineal and cavernosal haematomas, vascular lesions producing high flow priapism and other pathological changes. compared with us, mr imaging has some advantages in identification of small albugineal tears, and is more accurate in identification of urethral or spongiosal involvement. other situations in which penile imaging can be required are circumscribed or diffuse cavernosal fibrosis, tumours, priapism, severe inflammation, and evaluation of postsurgical complications. most of these conditions are first investigated with us; mr imaging is optimal for tumour staging. endocrine tumours of the pancreas are derived form the apud cell system. they often show early clinical sign related to the hormones produced by these tumours. the usually very specific symptoms raise the suspicion of an endocrine tumour of the gastro-entero-pancreactic tract and initiate imaging studies for tumour detection. in this setting usually the pancreas is among the most frequent tumour sites. since endocrine active tumours of the pancreas usually show a strong vascularisation, they can be differentiated from other solid tumours of the pancreas -including adenocarcinoma of the pancreas. metastases in the pancreas are very rare -however, they represent a potential differential diagnosis either for non-functioning neuroendocrine tumours or for adenocarcinoma of the pancreas. since the evaluation of the whole pancreas is crucial, transabdominal ultrasound plays an only limited role for the detection of endocrine pancreatic tumours. usually mri and ct -alone or in combination with specific nuclear medicine tracers in pet -are needed for accurate diagnosis and staging of these tumours. published incidences and prevalence of oa. the progression of oa traditionally has been measured using radiographic joint space width (jsw). weight-bearing radiographs centered on the hip are the most reproducible and reliable ones. the sequence of degeneration includes the following radiographic findings: joint space narrowing, osteophyte formation, subchondral sclerosis, and cyst formation. current definitions of radiological oa based on reduced jsw and osteophytes display predictive validity for clinical hip oa. radiographs are also useful for assessing developmental dysplasia and other congenital disorders which may lead to early oa. there are cases though, that radiographs show minor changes and the clinical suspicion of early disease can be confirmed with more sophisticated imaging methods, such as ct and mri. ct is helpful for additional measurements such as femoral and acetabular abnormal version which might lead to oa. femoroacetabular impingement has been shown to cause labral and chondral lesions and leads to oa. prompt recognition of abnormal head-neck junction on radiographs enables proper conservative or surgical treatment planning. mr arthrography is the method of choice for assessing the labra whereas ct arthrography might be used as an alternative for articular cartilage assessment. cystic tumours of the pancreas include a variety of masses which can be classified into cystic tumours of the exocrine pancreas, cystic tumours of the endocrine pancreas, cystic tumour-like lesions of the exocrine pancreas. in order to simplify the approach only the relatively common cystic tumours -the intrapapillary mucinous tumours (ipmt), the serous cystoadenoma (sc) and the mucinous cystoadenoma (mc) -will be considered. ipmt are characterised by ductal dilatation. imaging characteristics of ipmt are best displayed at mr-cholangiopancreatography. on the basis of the extent, these tumours can be divided into ipmt of the main duct (or central), ipmt of the secondary ducts (or peripheral) and mixed ipmt. central and mixed ipmt have a malignant behaviour and therefore need to be treated surgically, while peripheral ipmt have a benign behaviour and, in general, need only follow-up. sc are characterised by a microcystic architecture in most cases. imaging features are typical in cases of microcystic appearance and consist of small amounts of fluids interspersed within multiple septae of a "sponge like" mass. the differential diagnosis with a mucinous cystoadenoma is difficult in cases with a oligo-macrocystic appearance. mc appears as a uni-oligolocular cystic mass, with a simil-ovaric stroma in the tail of the pancreas. imaging features include a cystic mass with a definite wall and inner septae. when calcifications and enhancing nodules are present, a mucinous cystoadenocarcinoma has to be suspected. therefore, a careful evaluation of imaging features of pancreatic cystic tumours is needed to differentiate benign form malignant masses. learning objectives: . to understand the classification and management of cystic pancreatic tumours using rad/path correlation. . to learn how to provide a differential diagnosis and how, when and why imaging techniques should be used. . to review pathological and imaging findings of intra-ductal cystic tumours. . to learn how to deal with the incidental pancreatic cyst. a s c b d e f g the evolving role of the radiologist p. brader; vienna/at (peter@brader.md) in the past two decades, enormous strides have been made in medical imaging and many new technologies and agents are now available for breast cancer research, clinical trials and patient care. advances in experimental and clinical breast imaging are likely to improve our knowledge of how breast cancer arises at the cellular level, which will help not only to identify and locate tumours but also to assess the activity of biological processes within these tumours. this recent and concomitant progress, in imaging in general, and in breast imaging in particular, has been facilitated by the convergence of molecular cell biology, pathology, chemistry, physics and engineering in a multimodality and multidisciplinary way. the challenge for radiology is to begin thinking at the molecular level. it is, therefore, important that the next generation of radiologists become more involved in multidisciplinary research and clinical work, and that younger radiologists receive special training in diagnostic imaging and nuclear medicine, as well as a solid understanding of physics, radiochemistry, pathology and biology. applying this approach to breast cancer patients should allow earlier detection, stratification of patients for treatment, and objective evaluation of new therapies. the outcome will be considerably better management and care of those with breast cancer. breast cancer is the leading cause of cancer death among women worldwide. imaging plays a key role in the early detection of breast cancer. mammography is an accepted screening modality with some limitations such as over-treatment. to overcome these limitations research is going on to characterise breast cancer more accurately. currently researchers are working on different strategies spanning the spectrum from tomography-based systems to mri and even molecular imaging. this panel discussion will focus on these different strategies. the auditorium will learn if in imaging still plays a major role in breast cancer detection or whether a simple blood test will eventually solve the problem. breast cancer is the leading cause of cancer death among women world wide. imaging plays a key role in the early detection of breast cancer. mammography is an accepted screening modality with some limitations such as over treatment. to overcome this limitations, research is going on to characterise breast cancer more accurately. currently researchers are working on different strategies spanning the spectrum from tomography-based systems to mri and even more molecular imaging. this panel discussion will focus on these different strategies. the auditorium will learn if in imaging still plays a major role in breast cancer detection or a simple blood test will eventually solve the problem. is mammography still an accepted modality for breast cancer imaging in ? m.j. yaffe; toronto, on/ca (martin.yaffe@sunnybrook.ca) x-ray mammography is currently the only imaging modality that when used in routine screening has been demonstrated to contribute to reduced mortality in women in the age range - . but, the accuracy of mammography is limited with respect to both sensitivity and specificity. digital mammography has provided increased sensitivity in women with dense breasts and three-dimensional methods such as digital breast tomosynthesis or dedicated breast ct promise to yield further improvement. however, these techniques are dependent on detecting rather gross physical changes as masses, microcalcifications or architectural distortions develop and, therefore, their ultimate potential is limited. it is likely that before , detection tools that are more specifically targeted to molecular characteristics or early functional changes associated with cancer will be clinically available. these may be either in the form of an imaging test, based on a specific biomarker for the cancer or possibly an innocuous test designed to sense a circulating biomarker in the blood or urine. in the latter case, a positive test would be followed by an imaging study to provide localisation for therapy. such tests could not only detect the presence of disease but would also provide prognostic information to guide the type and aggressiveness of therapy so that overtreatment could be avoided. promising imaging techniques based on targeted imaging with ultrasound, x-ray contrast agents, mr and radio-labelled agents are already under investigation. by exploiting new molecular or functional signals one of these is almost certain to replace mammography before . can we assess cell density of tumours with imaging techniques? d.-m. koh; sutton/uk imaging is increasingly used to define endpoints of clinical trials in oncology. tumour cellular density may be inferred by diffusion-weighted mr imaging (dw-mri) and measurement of the t relaxation time. dw-mri is unique as the mechanism of contrast is based on differences in the mobility of water between tissues, which can be quantified by the apparent diffusion co-efficient (adc). tumours are frequently more cellular compared with their tissue of origin which impedes water diffusion, resulting in increased conspicuity on dw-mri and lower adc values. studies have shown negative correlations between histopathologically determined cell density and adc in several tumour types, including prostate cancer, soft tissue sarcomas and cerebral tumours. dw-mri is sensitive for tumour detection, especially for disseminated peritoneal disease, liver and bone metastases. whole body dw-mri with background suppression (dwibs) is an emerging technique that has shown substantial promising for staging of lung cancer, prostate cancer, lymphoma and multiple myeloma. effective treatment results in reduction in cell density due to cell lysis, apoptosis and necrosis, leading to a rise in adc value. adc increase has been observed within days of anti-tumour treatment (including chemotherapy and radiotherapy); and as early as one to two weeks after treatment. quantitative adc measurements may also be prognostic as tumours with higher pre-treatment adc have been shown to respond poorer to chemotherapy and radiotherapy. nevertheless, a number of challenges still have to be overcome to qualify adc as a response and prognostic biomarkers in a multi-centre setting across different imaging platforms. angiogenesis is an essential process whereby tumours derive vascular supply from adjacent tissue, to sustain tumour growth and metastatic spread. newer targeted antiangiogenic therapies differ significantly from current cytotoxic therapies for cancer. the methods of dose selection are either invasive, such as biopsy and histology, or time consuming, such as tumour shrinkage and time to disease progression, both of which take months to assess and fraught with other limitations. moreover, cancer is a very variable disease, which means that some patients will respond to a particular therapy while others will not. there is, therefore, a great need to establish surrogate markers for drug response that are both rapid and reliable, not only for clinical trials of new drugs but also to aid in the selection of optimal treatment for individual patients. multiparametric imaging techniques provide a non-invasive insight into tumour cell density, vascularisation, and biochemistry. imaging data have the potential to provide information on disease profiling pertaining to diagnosis, prognosis, selection of therapy, monitoring of response to therapy, and pharmacokinetic information of drugs. undoubtedly, these methods hold great promise, but how can we standardise these techniques, in terms of acquisition parameters and image analysis (post-processing), and validate imaging parameters as biomarkers in multicenter international cancer trials. beginning with a review of the frequently used response evaluation criteria in solid tumours (recist), the development and optimisation of new imaging parameters as biomarkers of treatment response and optimised monitoring of tumour therapy in multicenter eortc clinical trials will be presented. dw-mri is sensitive for tumour detection; adc is affected by the different cellular density of a tumour. still, a number of challenges need to be overcome to qualify adc as a response and prognostic biomarker in a multicenter setting. the large variety in primary tumours and imaging methods, as well as the large variety and continual evolution of imaging equipment, point towards the need for a concerted design of imaging protocols in order to assure that these protocols are applicable to multicenter trials. furthermore, reliable evaluation of imaging data requires imagers experienced in the area of the definite cancer targeted in this trial and in the use of imaging tools for lesion quantification. from this session, a roadmap for future collaboration between eortc and esr combining different imaging modalities will emerge. session objectives: . to prove that advanced multiparametric imaging techniques play a crucial role in the diagnosis, staging, treatment monitoring and follow-up of oncological patients. . to explore avenues for future collaboration between eortc and ecr. . to suggest input of radiologists in the design and implementation of multicenter trials. the eortc imaging group: vision and strategy on cancer imaging s. stroobants; antwerp/be (sigrid.stroobants@ua.ac.be) response to cancer treatment is evaluated by subsequent assessments of target lesions and is defined as a significant decrease in measurable tumour dimensions (who, recist). the new targeted therapeutics which cause cytostasis rather than cytotoxicity have challenged volume-based response criteria and tumour regression is increasingly recognised as an unreliable end point. new imaging modalities looking at tumour biology, like positron emission tomography (pet) or diffusion weighted (dw) and dynamic contrast enhanced (dce) magnetic resonance imaging (mri) or increasingly used to identify subpopulation of patients most likely to respond. recently, new response criteria were introduced that incorporate fdg-pet (recist . for solid tumours and new cheson criteria for lymphomas). since imaging is becoming increasingly important in novel trial design, the eortc decided to invest in an imaging platform. eortc has established a medical imaging exchange infrastructure allowing to store imaging data linked to the clinical databases. a functional imaging expert group is set up to review protocols, organise central review and develop specific initiatives for imaging biomarker validation. eortc is part of the quicconcept consortium that within the eu innovative medicine initiative (imi) will try to validate the use of novel pet probes and dw-mri as biomarkers for apoptosis and proliferation. functional imaging techniques can only evolve successfully into biomarkers that are clinically valuable and important for drug development, when there is agreement on the standards for measurement and analysis and working groups are set up in collaboration with the different professional organisations (esr, eibir, eanm) to set up imaging guidelines. conditions such as ttts in twin pregnancies and foetal demise. the living foetus can also suffer from abnormal blood supply to the cns, and thus showing small or even large hemispheric infarcts. other diffusion technique, dti is also used to demonstrate the white matter formation of the foetal brain. mrs is also used in the evaluation of the foetal brain. the values of the naa, choline and the existence of lactate are different than the values in the paediatric and adult brain. learning objectives: . to explore the new imaging techniques for the study of the foetal brain. . to understand the use of diffusion-weighted imaging in the foetal brain. . to become familiar with the accurate use of t -weighted sequences in the foetal brain. . to understand the possibilities of tractography in the fetal brain. the paediatric central nervous system is a complex structure undergoing rapid development. as such, there is a rapid, continuous modification of what is "normal" in relation with age and the stage of development. knowledge of the normal patterns of brain development in the clinically relevant ages from to years is necessary to interpret neuroimaging findings correctly. knowledge of embryology and normal variants is also greatly helpful. mr imaging equipment and parameters need to be adjusted and optimisation for paediatric studies. pitfalls often occur from the misunderstanding of normal conditions that are perceived as abnormal based on a comparison with the appearance of the normal brain in adults. this includes, for instance, the evaluation of the brain in the first - years of life during the course of the process of myelination. a summary of the most frequent conditions that may lead to misinterpretation of findings will be provided here. learning objectives: . to understand a different approach to neuroimaging in the developing paediatric brain and spine. . to appreciate that, despite the wide and potentially complex spectrum of diseases seen in neuropaediatrics, most interpretations can be made through the thoughtful application of basic neuroradiological analytical techniques. . to be aware of certain areas where common pitfalls, myths and misunderstandings occur. the ability to develop more aggressive treatments of acute neurological disorders in children is nowadays improving; however, infants and children are often uncooperative, clinical signs are not always easily localised, and diagnosis and therapy may be both delayed. effective imaging of the central nervous system assumes an increasingly important role in the evaluation of these critically ill children. this lecture will review the main indications to perform a neuroimaging procedure in children with a neurological emergency. with didactic purposes, acute conditions will be classified in traumatic and non-traumatic (ischaemic and haemorrhagic stroke, infection and acute metabolic disorders). differential diagnosis will be discussed based on representative cases selected from the daily routine in a paediatric tertiary hospital. the varied neurological complications that can occur in the child admitted at the intensive care unit will also be presented in a didactic manner, including pres (posterior reversible encephalopathy syndrome), acute liver failure, osmotic demyelination syndrome, hypoglycaemic encephalopathy or induced neurotoxicity. eventually, some peculiarities in oncologic and immunosupressed children, particularly opportunistic infections, will be highlighted. practical algorithms with the preferential use of either ct or mri will be developed for each section. ct continues being the primary modality for trauma, although it should be better used in cases of non-available mri in the other acute conditions to save radiation in children. mr imaging is nowadays better for imaging these children owing to the new techniques that can be used, such as diffusion imaging (di), spectroscopy, arterial spin labelling (asl) or susceptibility-weighted imaging (swi). learning objectives: . to learn the characteristic neuroimaging findings that may be useful in establishing differential diagnoses. . to understand the various neurological complications that can occur in the intensive care unit and to become familiar with their most typical imaging patterns. . to consolidate knowledge of the best neuroimaging protocols for the acutely ill child and establish the main indications for the use of mr imaging, particularly diffusion and spectroscopy. challenges for morphologic imaging in oncology trials: reproducibility and reading f.e. lecouvet; brussels/be (frederic.lecouvet@uclouvain.be) beside clinical endpoints and biological or molecular parameters, beside emerging perfusion or diffusion imaging techniques, morphologic imaging remains the cornerstone of the evaluation of treatment response in the majority of primary or metastatic tumours. the large variety in cancers and imaging methods, as well as the large variety and permanent evolution in imaging equipments, raises the need for a concerted design of imaging protocols to guarantee transposability of these protocols to multiple centers. the reliable evaluation of imaging studies obtained in trials requires readers experienced in the area of the definite cancer targeted in this trial, and in the use of imaging tools for lesion quantification. the imaging group of the eortc targets this optimisation of imaging protocols. first, the different "organ groups" of the eortc will benefit from the availability of expert radiologists in the different fields of oncology, involved in the choice and tuning of adequate and generalisable imaging tools from the beginning of trials design. the design of ct or mri studies should target acquisition parameters transposable in a large number of centers; there is no need for "cutting edge" protocols for a reliable assessment of response in a majority of cancer patients. second, the central review of imaging studies will be possible based on the involvement of expert radiologists, and on a robust imaging platform that guarantees availability, quality control, and "side by side" evaluation of baseline and follow-up examinations. principles and limits of response evaluation by morphologic imaging in oncology will be illustrated. a practical approach to hrct of the chest for diagnosis of diffuse lung diseases includes: recognition of the abnormalities, definition of their distribution within the secondary lobule or the lung, identification of associated findings. when combined with the patient clinical history, these steps allow to shorten the list of differential diagnoses and may sometimes lead to a specific diagnosis. a reticular pattern consists of multiple lines as the result of interlobular septal thickening, intralobular lines or cystic walls of honeycombing. when present as a predominant abnormality, thickening of interlobular septa has a limited differential diagnosis which includes pulmonary oedema/haemorrhage, lymphangitic spread of cancer, sarcoidosis and alveolar proteinosis. honeycombing represents destroyed and fibrotic lung tissue containing numerous cystic airspaces with fibrous walls and is considered a ct feature of established pulmonary fibrosis. when honeycombing is present, uip is likely the histologic pattern and ipf is the most likely diagnosis, in the absence of a known disease. a nodular pattern consists of multiple rounded opacities - mm in size. the distribution of nodules is the most important factor in making an accurate diagnosis. a centrilobular predominance of nodules that typically spare pleural surfaces is a frequent sign of bronchiolitis and airway disease. a perilymphatic distribution is most frequently seen in patients with sarcoidosis, silicosis and lymphangitic spread of cancer. a random distribution with nodules diffusely and uniformly distributed can be the result of infection, haematogenous metastases and other rare diseases such as langerhans cell histiocytosis. the diffuse interstitial lung diseases (dilds) are a heterogeneous group of disorders which principally affect the lung parenchyma. basic hrct patterns are common to many disease processes and are usually non-specific. however, their distribution and their temporal evolution are often characteristic enough for diagnostic purposes. increased lung opacity: air-space consolidation, by definition, occurs when alveolar air is replaced by fluid, cells, or other material. on hrct, consolidation results in an increase in lung opacity associated with obscuration of underlying vessels. conversely, ground-glass opacity is defined as: "... hazy increased attenuation of lung with preservation of bronchial and vascular margins". the significance of ground-glass opacity depends on the clinical scenario. cysts and decreased lung opacity: a cyst appears as a round parenchymal lucency or low-attenuating area with a well-defined interface with normal lung. lung diseases characterised by cysts include langerhan´s cell histiocytosis, lymphangioleiomyomatosis, lip, postinfectious pneumatoceles, and amyloidosis. recently, lung cysts have been reported in association with extrinsic allergic alveolitis. honeycombing is a process characterised by the presence of cystic spaces.the determination of the presence or absence of honeycombing on hrct in patients with idiopathic interstitial pneumonia is of great importance. honeycombing may have an atypical distribution particularly in asbestosis, sarcoidosis, non-specific interstitial pneumonia (nsip), drug-related fibrosis and hypersensitivity pneumonitis. hrct is now an integral component of the clinical investigation of patients with suspected and established interstitial lung disease. a knowledge of the close relationship between histopathological changes and ct appearances. learning objectives: . to understand the different patterns on hrct scans of the chest. . to learn about a systematic approach to differential diagnosis of diffuse lung diseases. . to review key imaging findings. how do we report ct of the chest? : the radiology report is often the primary method of communicating imaging findings to the referring physician. practical guidelines on how to report ct scans of the chest for diffuse infiltrative lung diseases will be provided by the panel. emphasis will be placed on both report content and style in order to provide the clinician a tool for good patient care. with the advent of volumetric data acquisition and with increasing knowledge of patho-radiological correlations, hrct has further matured over the last decade and provides the radiologist with an excellent tool for accurately demonstrating gross lung anatomy and precisely analysing abnormal findings. the radiologic diagnosis of many pulmonary abnormalities is based on an assessment of their pattern and distribution. while the pathologist has the advantage of being able to evaluate specimens microscopically, the radiologist is confined to the assessment of more gross disease. however, the radiologist is able to examine the entire lung providing him with information about the distribution of disease and about additional diagnostic clues in mediastinum and pleura. both together, characterisation of the gross findings and knowledge of their distribution represent the key features for arriving at a confident diagnosis. session objectives: . to become familiar with the standardized and internationally accepted terminology for describing and analysing hrct findings. . to learn how a structured analysis of the predominant pattern and its distribution represent the key for making a specific diagnosis in the best case scenario or to understand how it helps to narrow the differential diagnosis. . to promote the understanding how the variability of manifestations of some diseases can cause an overlap of findings being responsible for difficulties the radiologist encounters when categorizing diffuse diseases of the lung parenchyma. a. most radiological reports consist of a ‚descriptive part' in which the radiologist describes the findings and a short ‚conclusion part' containing the interpretation of what is seen. both parts are filled with ‚jargon'. some terms are typical radiological ‚language' while others refer to terminology also used by clinicians and pathologists. some terms are purely descriptive but others may contain already some interpretation of what is seen and hence narrow the differential diagnosis. the meaning of a term may also change over time. it is very important that both radiologists and the readers of their reports speak the same language and know and understand the meaning and full content of each term. this is especially important when radiological findings in patients with diffuse lung diseases are described and interpreted. diagnosis of diffuse lung disease is indeed largely based on the recognition and description of the appearance pattern of the disease because this often allows developing an appropriate list of differential diagnosis. members of the fleischner society have introduced a glossary of terms for thoracic imaging. this presentation will emphasise on the importance of such a glossary for both describing and interpreting chest images. special attention will be given to the terms used to describe the different patterns in diffuse lung diseases: ( ) reticular and short linear opacities, ( ) nodular opacities, ( ) increased lung opacity and ( ) cysts and decreased lung opacity. a s c b d e f g h the purpose is to describe ethical dilemmas related to the use of radiation in finnish radiographer's work in diagnostic imaging. the data were collected during the spring and summer of , and it consisted of thematic interviews of diagnostic radiographers (n= ) whose working experience varied from to years. the data were analysed by the method of data-oriented qualitative inductive content analysis. ethical dilemmas related to the use of radiation were found to concern justification and optimisation principles, which were found to be inadequately implemented by radiographers. the background factors of these dilemmas were found to be both dependent on and independent of the employee, resulting in worsened well-being at work and in seeking for change. the current processing methods of dilemmas were found to be insufficient, and suggestions for better processing methods were made. the results suggest that there may be shortcomings in radiographers' knowledge of radiation usage. attitudinal problems within the work community seem to maintain ethical shortcomings. instead of ethically inadequate routines and passing the baton to other professionals, radiographers should be encouraged in committing themselves into responsibility and safety culture. respondents repeatedly described powerlessness and inability to intervene in ethical problems. the common cold is one of the most frequent illnesses in europe and the united states. although most cold are mild and resolve within a short time period, colds cost billions of dollars per year, mostly due to lost time at work and school. the common cold is a group of symptoms caused by one of a large number of viruses. rhinoviruses cause the greatest number of colds; there are more than different varieties of rhinovirus. the average adult experiences two to three colds per year, while children average - colds per year. in most cases, colds do not cause serious illness. most colds last for - days, although many people continue to have symptoms (coughing, sneezing and congestion) for up to weeks. some viruses that cause the common cold can also depress the immune system or cause swelling in the lining of the nose or airways; this can lead to bacterial infection. one of the more common complications is sinusitis, which is usually caused by viruses and rarely (about % of the time) by bacteria. however, it can be difficult to distinguish bacterial sinusitis from sinusitis caused by a cold because the signs and symptoms can be similar. however, due to the fact that a runny nose can also result from inflammation, trauma, foreign body and other abnormal processes, including tumours, an excellent diagnostic workup is necessary. the purpose is to examine the relationship between man and technology within radiography without considering man and technology as separate entities. the study is designed as an observational study which took place in a danish radiological department. it involved examinations followed up by three semi-structured interviews. through emergent narratives radiographers construct a practice in which the relationship between man and technology is marked by a struggle of domination of one over the other. the struggle expresses itself through two competing plots: a diagnostic plot with a prevailing, but not merely chronological structure mostly composed of events tied to pathology. the life story, in opposition, plots the examination as a significant experience in the patient's life, transforming it into events stretching towards a future yet unknown. most often the radiographers contributed to the domination of man over technology through active engagement of their narrative alertness. errors and failure to keep the time schedule can, however, lead the radiographers to a change of perspective that makes them displace man from the scene of radiography by playing on the premises of technology. in several stories technology can be labelled ‚setting' while the patient plays the main role. the radiographers act with the patient as point of origin, but they reason with technological arguments. hence, the human aspects of radiography constitutes an underground practice, which is not explicitly articulated valuable. this creates a field of tension between man and technology, with risk of technological dominance. the private life of everyone of us as well as the everyday practice of our profession is deeply embedded in ethical/deontological aspects which play a critical role into: our profession, the relationship with our patients, with our colleagues, with the health care team we work with, and with ourselves. the radiographer's everyday practice has to take this aspects into account. ethics finds its origins in the fusion of three different sources, as if it were a compromise between: the species we belong to, the society we live in, and ourselves. yet, we are not obliged to abide to these three elements. it is through our actions that we decide how to behave in certain situations. and this is the reason why every single action towards the others gathers importance, the simple rites when individuals meet play a pivotal role in the creation of a relationship with the others. shaking hands, greeting and using polite forms of speech, all these actions are ethically important, they allow us to catch the benevolence of our interlocutor and to discourage any possible hostility. what would happen if our professional identity were perceived and acknowledged through the way we can interact and relate to others? in this case, the work no longer ennobles the man, but it is the man, through his actions, who ennobles his profession. behaving ethically towards one's own profession, towards the others and towards ourselves, is it, or could this be the common ground of european professional ethics? whenever a diagnostic x-ray examination of a pregnant patient is considered to be necessary, conceptus dose estimation is an important step in assessing the risks to the unborn child. accurate estimation of conceptus dose is also needed after inadvertent irradiation of a pregnant patient from a diagnostic x-ray procedure. several methods have been developed to estimate conceptus dose from radiologic examinations. when the uterus is remote from the directly exposed tissues, the conceptus is exposed to scattered radiation and its dose is negligible (< mgy). examinations involving the abdomen-pelvis may deliver higher dose to the child. variations in maternal body size and uterus position should be taken into account to obtain accurate conceptus dose estimation. multidetector ct (mdct) scanners have replaced conventional ct technology. conceptus doses from abdominal mdct range from about to about mgy during the first post-conception weeks for a scan acquired at kvp, mas with a pitch of . , depending on maternal body size and uterine position. multi-phase abdominal ct examinations may deliver relatively high doses to the unborn child. doses to the conceptus below mgy should not be considered a reason for termination of pregnancy. the risk to the embryo/foetus for stochastic effects is assessed on the basis of dose using appropriate risk factors. although these risks from a single diagnostic procedure are low for the majority of diagnostic x-ray examinations, it is important to ensure that doses are kept as low as reasonably achievable. learning objectives: . to learn how to manage and counsel pregnant patients in case of (a) intentional and (b) accidental exposure. . to learn how to estimate conceptus radiation dose from diagnostic x-ray examinations. . to learn how to assess the radiogenic risks to the embryo/foetus from diagnostic x-ray examinations. epithelial cells. the mucociliary transport drains each sinus in a specific pattern through its ostium to the nasal cavity and ensures a constant flow of mucus containing bacteria and particulate matter. functional endoscopic sinus surgery (fess) aims to enlarge the preformed ostia to allow physiologic drainage. preoperatively, anatomic variants have to be ruled out or shown by ct to avoid injury. special emphasis lies on the ostiomeatal unit, a complex anatomic region at crossroads of mucociliary drainage from frontal, anterior ethmoid and maxillary sinuses (uncinate process, haller, agger and frontoethmoidal cells, inverse turbinate). description of the level of the cribriforme plate in relation to the roof of the ethmoid is another key element in a report to avoid skull base injury (keros i-iii). preoperative identification of variations in the location of the optic nerve and the cavernous portion of the internal carotid artery is also mandatory. furthermore, the close proximity of the sinuses to neighbouring structures and their thin bony walls predispose to certain pathways of spread. runny and stuffy noses may be due to a long list of pathologic conditions, which require distinct imaging strategies and treatment options. acute rhinosinusitis, for example, is normally managed by gps without any imaging study. occasionally, signs and symptoms suggest orbital or intracranial complications: in such cases msct allows a prompt diagnosis and is preferred to mri for wider availability and faster acquisition. persistence of signs/symptoms for longer than weeks classifies rhinosinusitis as chronic (crs); the condition may or may not be associated with the presence of nasal polyps. in patients affected by crs cross-sectional imaging aims at precisely depicting bone structures and air conduits. in detail, imaging shows the anatomic arrangement of sinus drainage pathways and their patency, maps anatomic variants that may facilitate crs or increase surgical risk, depicts bone changes induced by crs or by the mechanical pressure exerted by polyps. these tasks are better accomplished by ct, even more so after the advent of multislice technology allowed multiplanar reconstructions along oblique planes. after surgery, imaging is required when signs/symptoms recur -to asses presence and extension of crs or nasal polyps -or when late complications are suspected -such as mucosal synechiae impairing mucus drainage or mucocele. mri plays a limited role in sinusitis because it fails to demonstrate thin bone structures; nonetheless, its use is advocated in aggressive inflammatory diseases (such as invasive mycoses and wegener's granulomatosis) to demonstrate the involvement of deep spaces of the face and of the skull base. sinonasal tumours are rare and comprise only % of all malignancies. the clinical and radiological challenge is to differentiate malignancy from benign or inflammatory changes. most malignant tumours present at advanced stages. malignant tumours are most common in the th - th decades and have a male preponderance. squamous cell carcinomas are the most prevalent ( %) followed by adenocarcinomas. squamous cell carcinomas are most common in the maxillary sinus, next the nasal cavity and ethmoid sinuses, while adenocarcinomas are most often seen in the ethmoid sinuses, and commonly caused by occupational exposures, e.g. nickel and hardwood workers. inverting papilloma is one of the most common benign tumours and have been associated with human papillomavirus. ct should be the first modality in paranasal sinus imaging, while complementary mri before and after gadolinium i.v. is mandatory to differentiate tumour from inflammatory disease. a general rule is that tumours more often have unilateral extension and that malignant tumours usually erode the bone. however, malignancy may mimic benign tumours with thickening or remodelling of the adjacent bone. while ct is superior to demonstrate changes in the bone, mri can differentiate tumour from inflammatory changes and demonstrate tumour invasion and perineural spread. malignant tumours are: squamous cell carcinoma, adenocarcinoma, adenoid a s c b d e f g h b. x-ray imaging and pregnancy: justification and optimisation of exposure p. vock; berne/ch (peter.vock@insel.ch) as outside pregnancy, justification and optimisation are the main steps to be done when an imaging examination using ionising radiation is considered during pregnancy. however, the risk concerns the embryo/foetus in addition to the mother which means that justification has to be more critical whenever the uterine dose is not neglectable. the practical approach to an examination in any woman of child-bearing age starts by ruling out pregnancy, whether by taking history or by a laboratory test. when pregnancy cannot be ruled out, further steps will depend on the type of examination needed and the urgency of diagnostic clarification. ultrasound is the alternative to be preferred when it can answer the clinical question. but even among x-ray examinations, the uterine dose is varying widely which asks for a careful selection, optimisation and, maybe, for postponing the test. once pregnancy is confirmed, the major question is whether the specific type of diagnostic examination will include the uterus in the primary radiation field. examinations not involving the uterus by direct radiation -despite a potentially significant exposure by scattered radiation -can usually be performed without a relevant risk to the embryo/ foetus. the situation is more critical when the uterus is within the examination field and when therapeutic interventions are considered. the presentation will discuss the practical approach to these different situations, the influence of the stage of pregnancy, optimisation methods and the choice between alternative methods in some frequent clinical situations. this paper explores the risks to the foetus when magnetic resonance imaging (mri) is used. mri uses three main components to produce images from inside the body: a static magnetic field; a pulsed radio-frequency (rf) fields and time-varying gradient electromagnetic fields. the exact frequencies of these fields depend on the mri system purchased, for example; a . t scanner uses mhz rf, a . t system uses mhz and a t system uses mhz rf. there is also a wide range of options for gradient strengths and slew rates to be considered as well. the overall exposure for the foetus depends ultimately on the imaging sequence used and the area being scanned. this paper will discuss particular hazards that need to be addressed for pregnant women including biological effects of the static and time-varying magnetic fields, heating effects of the rf pulses and acoustic noise generated by the spatial encoding gradients. the circumstances for foetal exposure in mri will also be discussed including the following situations: the patient may not be aware that she is pregnant, likely to be in the first trimester; the mother is referred for direct foetal imaging after ultrasound (normally second or third trimester); the expectant mother may need diagnosis; research on pregnant volunteers. the exposure for pregnant staff working in mri is also an essential consideration. finally, how to minimise the exposure for the foetus during mr imaging will be discussed. a b c d e f g h in terms of cerebral perfusion (rcbf, rcbv, mtt and ttp) and cell metabolism (cytotoxic versus vasogenic oedema, diffusion restriction). the fundamental goals of stroke imaging in the acute phase are: . to rule out intracranial haemorrhage, and other non-stroke causes of the patient's symptoms; . to show occlusion of a major blood vessel, e.g. by ct or mr angiography; . to demonstrate ischaemic brain tissue (cytotoxic oedema), e.g. by diffusion-weighted mri; . to reveal tissue blood flow and to identify areas of salvageable brain tissue ("penumbra"), e.g. by perfusion ct or mri; . to select candidates for thrombolytic therapy within the critical to hour time window. the purpose of this presentation is to review how new developments in neuroimaging improve our understanding of the pathophysiology of acute stroke and to demonstrate that multiparametric techniques now play a crucial role in the rapid diagnosis, clinical management, therapy and outcome prediction of patients with an acute stroke. organisation is crucial to the practice of dethrombosis. the first step is to grasp the fact that ischaemic stroke is an emergency. stroke victims require an organisation similar to that provided for heart attack patients. patients must be taken to hospital in an ambulance manned by a specifically trained crew. ideally equipped with a mini ct scanner recently made available. this device provides an immediate morphological scan and ct angiogram to be sent by satellite to the reference hospital so that the problem will be clear and the medical team ready on the patient's arrival. clinical and neurological assessment of the patient must be undertaken immediately along the lines of uk practice implementing a simple, clear and rapid procedure. if the clinical, ct and ct angiography findings indicate intra-arterial treatment, responsibility shifts to the neuroradiology team, organised to work a hour shift, at the hospital or at least on call. dedicated imaging systems must be available: a multi-layer ct device (ct angiography and perfusion studies). dedicated angiography suite is essential. a flat panel system would be ideal. there is growing evidence supporting the availability of an mr system. this device would certainly enhance the possibilities of a stroke unit but it is not essential in the initial stages. a stroke unit should be based on a dedicated facility, with emergency access separate from the general emergency room, dedicated equipment, dedicated ambulances and appropriate links including a dedicated ward and a rehabilitation unit essential to the success of the project. learning objectives: . to learn about the benefits and risks in stroke intervention. . to consolidate knowledge of different methods of intervention in stroke therapy. . to learn about the different imaging methods used to decide on and perform stroke intervention. where do we stand in stroke therapy today? : stroke is a common health problem with high socio-economic costs. in recent years much effort has been focused on finding ways to ensure early intervention as well as new methods not only for early detection but for early treatment. the discussion will focus on where we stand today and whether we think stroke imaging and treatment will advance further. during the last decade imaging of stroke has developed from a minor field dealing with a barely treatable disease to one of the most dynamic parts of neuroradiology. the routinely treatment with intra-venous thrombolysis within the . hour time window and the continuously expanding treatment of severe strokes with intra-arterial thrombectomy have lead to increasing requests from clinicians and interventional neuroradiologists to provide imaging information for treatment guidance. all radiologists involved in the management of stroke are facing mainly three demands: first, to have good knowledge of the causes and the pathophysiology of ischaemic stroke and a proper understanding of the current models for infarct development, as a prerequisite for rational decision making and efficient communication with the clinicians. second, to be able to choose and to use appropriate imaging modalities for the acute work up of patients with stroke and to be aware of the benefits and drawbacks of ct and mri. finally, is good knowledge about the therapy options mandatory in order to be able to support the clinicians in the time critical treatment decision. this session will try to cover these three demands in order to give an overview on the current status and the opportunity to discus future perspectives. a. aetiology and pathophysiology of stroke r. von kummer; dresden/de (ruediger.vonkummer@uniklinikum-dresden.de) "stroke" is the commonly used diagnosis for disturbances of brain blood supply due to ischaemia, haemorrhage, or venous obstruction. it is evident that "disturbances of blood supply" in stroke patients do not represent a useful concept in order to develop effective treatment. it is the radiologist's task to describe the acute brain pathology, its conditions (pathophysiology), and its aetiology to give directions for specific treatment and prophylaxis. the approach is vascular and brain tissue imaging. brain ischaemia is the cause of stroke in about % of patients, intracranial haemorrhage in % of patients. arterial obstruction causing brain ischaemia is thrombotic or embolic. it can as well be caused by arterial wall dissection or inflammation. arterial wall diseases and heart diseases including a patent foramen ovale are sources for brain embolism. the obstruction of a brain supplying artery causes brain tissue ischaemia of various degrees depending on the capacity of collaterals supplying the same arterial territory. the chances for collateral compensation depend on the site of obstruction and the development of collateral vessels. neurons cannot tolerate low cerebral blood flow (cbf) below ml/ g x min for more than minutes and develop first cellular then irreversible ionic oedema. they survive, but do not function with low cbf between and ml/ g x min. enhancement of cbf in such regions, e.g. by arterial recanalisation can mean functional recovery. the imaging diagnosis of damaged brain is therefore the first aim in acute ischaemic stroke patients. focal liver lesions are part of our everyday practice because radiologists performing various types of examinations may encounter them without being aware of any clinical condition rising the suspicion of these changes. in a situation like this several important decisions are to be made by the radiologists, like: is the lesion clinically significant, is the lesion benign or malignant, are additional imaging examinations necessary, does it require medical, surgical or interventional radiological action, should it be, and if yes, how frequently followed up, etc. for providing a well-established answer to these questions the reporting radiologist has to be familiar with medical history and results of former examinations (physical, laboratory, imaging, etc.); consider the age, gender, physical condition, eating and drinking habits, potential drug abuse of the patient; bearing in mind the prevalence and statistical probabilities of different pathologic conditions. with all this information at hand the thorough analysis of images obtained by different modalities will allow a rather reliable differential diagnosis and a well-established planning of therapy of the incidentally detected lesions. learning objectives: to learn more about the clinical conditions that may result in the appearance of focal liver lesions. . to be informed about the clinician's way of thinking in the process of differential diagnosis. the spectrum of differential diagnoses is broad in the liver. therefore, incidentally discovered liver lesions represent a challenging clinical situation. fortunately, there are specific imaging features for the most common benign and malignant liver lesions (such as, e.g. hemangioma, fnh, cysts, vascular pseudolesions, hcc and metastases) so that a minimal-invasive diagnosis with a biopsy is not needed in a lot of cases. in ultrasound, the echogenity and recently also the contrast agent behaviour are used for liver lesions characterisation. in ct, attenuation and also contrast agent behaviour are used for characterisation. mr imaging offers several options including t -and t -weighted images, use of chemical shift imaging, gre sequences with long echos and diffusion weighted images, so that tissue components such as fat, water, glycogen, iron, etc. can be evaluated already in the pre-contrast examination. beside the evaluation of dynamic signal characteristics in the early dynamic phase after contrast agent application, mr can utilize also tissue-specific contrast agents dedicated to the res or to the hepatocytes. other modalities such as angiography, pet or other nuclear medicine methods usually only play a minor role nowadays in the evaluation of incidental liver lesions in nononcological patients. in oncological patients the clinical consequences and also the range of diagnoses and pre-test probabilities are different from the non-oncological group; therefore, the demands to imaging are even higher. in case of atypical presentation of otherwise benign liver lesions such as sclerosed hemangioma close follow-up or even biopsy can be necessary in such a setting. thyroid nodules are common. in - % of adults nodules can be palpated and at ultrasonographic examination nodules are seen in - %. most nodules are benign, the eventual diagnosis in patients with a palpable nodule is carcinoma in only % of cases. the incidence of thyroid carcinoma is low. papillary carcinoma is the most common type and is found in - % of thyroid cancer. lymph node metastases in thyroid carcinoma are primary to the paratracheal and prelaryngeal nodes (level vi), and the upper (level iii) and lower (level iv) jugular nodes. malignancy should be suspected when there is rapid growth, a firm or fixated mass, when enlarged lymph nodes are present or in case of vocal cord paralysis. in patients with multiple thyroid nodules the cancer risk per patient is not altered. ultrasound is the primary imaging technique in patients with a palpable thyroid nodule. it is best performed with the patient supine, the neck slightly extended and using a high frequency linear-array transducer. several ultrasonographic features are more often associated with benign or malignant nodules. however, while some ultrasonographic features may strongly suggest malignancy it may be very difficult to rule out malignancy by means of these features alone. ultrasound-guided fine needle biopsy can be performed in an attempt to differentiate between benign and malignant nodules. unfortunately, even with ultrasound guidance, an important number of cytological examinations will be non-diagnostic. in addition, in follicular lesions it is usually impossible to differentiate cytologically between benign and malignant follicular nodules. learning objectives: . to learn about the optimal settings for us examination of the thyroid. the neck is host to a large variety of benign and malignant diseases ranging from simple cysts to acute inflammation with complications to highly malignant sarcomas and imaging plays an important role to assess the nature and the extention of disease. patient history and clinical findings will decide which imaging technique is best suited to resolve the diagnostic dilemma. ultrasound is recommended to differentiate between a cystic or solid lesion, to guide fna, being quick and accurate. pathologic flow within or around a lesion can be assessed adding doppler technique. in acute illnesses with anticipated complications, such as a deep neck abscess, contrast-enhanced ct is required to evaluate local extention and demonstrate spread from the neck deep to the mediastinum. mri is indicated to assess non-inflammatory, subacute or chronic diseases, such as vascular malformations, branchial cleft cysts, benign and malignant soft tissue tumours, brachial plexus pathology and neurologic diseases. vascular malformations are easily depicted with mri using t sequences in different image planes. persistent fistulas of the branchial system can also be depicted by mri running from the anterior border of the sternocleidomastoid muscle to the lateral pharyngeal wall. assessing the origin of a soft tissue tumour has major implications for surgery. staging a malignant soft tissue tumour must comprise the skull base and upper mediastinum including local extention, pathologic neck nodes and perineural spread. follow-up during chemotherapy and postoperative monitoring of malignant disease are important indications for (mr) imaging, the more so in young patients, diminishing ionising radiation. learning objectives: . to identify different compartments in the neck. . to be able to choose the optimal imaging technique relating to request. . to become familiar with the most common pathology in adults and children. . to be able to address a short list of differential diagnoses. patients ( %) and by ultrasound in patients ( %). the activity of the disease was assessed correctly in % patients by ultrasound, compared to % patients by enteroclysis. there was no statistically significant difference. bowel us is a useful investigation for the diagnosis and follow-up of patients with crohn´s disease. learning objectives: . to learn about us techniques used in the assessment of patients with inflammatory bowel disease. . to learn tips for interpretation of us in the diagnosis and follow-up of patients with inflammatory bowel disease. . to understand the pros and cons of using us, including ceus, in the diagnosis and follow-up of patients with inflammatory bowel disease, including assessment of disease activity. . to appreciate the accuracy, reproducibility and usefulness of us compared with other imaging techniques in assessing patients with inflammatory bowel disease. a- : the use of computed tomography (ct) in the diagnostic imaging of patients affected by inflammatory bowel disease (ibd) has a long standing history. ct techniques such as ct-enteroclysis and ct-enterography have been reported as efficient tools for a radiological assessment of disease. the state-of-the art methods will be reported and their potentialities in diagnostic accuracy discussed in different clinical type of ibd. the acute setting of unknown ibd could be demanded as well to ct examination performed in emergency without endoluminal contrast medium administration. the ct appearance of the intestinal wall of the segments involved by an active disease could be not correctly interpreted if the knowledge of basic and classic typical findings of ibd is not combined to consider different pathologic entities that could affect the intestine, offering similar but not even equal signs. the entire abdominal background needs to be evaluated according to the clinical symptoms, signs, laboratory parameters and history of the patient. ct examination could be an efficient tool to determine the degree of disease activity in patient with known ibd as well as to assess the presence of an acute inflammatory disease of the intestine in patients with unknown ibd affection. the actual role of ct in the early diagnosis of ibd, in disease staging and detection of complications as well as monitoring therapy in follow-up will also be considered and discussed. learning objectives: . to learn about state-of-the-art ct techniques for the assessment of patients with inflammatory bowel disease. . to learn tips for interpretation in terms of diagnosis and differential diagnosis of inflammatory bowel disease. . to discuss the value of ct in determining disease activity and monitoring therapy. the aim of this lecture is to give an overview of the techniques and typical findings for imaging crohn's disease (cd) with either multidetector row computed tomography (mdct) or with magnetic resonance imaging (mri) and compare the two different modalities. optimal imaging of cd begins with the preparation phase. the small bowel has to be distended for a concise examination. this can be done either invasively, i.e. enteroclysis or orally, which is named enterography. there is much debate on which of these two preparation methods is better. for the administered intraluminal contrast, best is water with some additives, which are neutral in ct and biphasic in mr. imaging in mdct is done sec and sec after iv administration of iodinated contrast with a thin collimation. all image data are reconstructed in axial, coronal and sagittal planes. the aim of imaging in cd should be to establish the following: ( ) presence, severity, and extent of the disease; ( ) its activity; and ) extra-intestinal complications. both modalities have proven to be a good tool to evaluate the extent, the activity of the disease and the presence of extraluminal complications. both are also able to identify the type of the disease, being either the active/inflammatory, the fistulising/perforating, the fibrostenosing or the reparative/regenerative type. the challenge for mri is mostly the in-plane resolution of the image data whereas radiation dose is for ct. incidental lesions are frequently discovered during routine radiographic evaluations. correlation with clinical history and additional confirmatory imaging is essential to the development of an accurate, focused differential diagnosis and for appropriate management. the objective of this presentation is to describe the imaging findings associated with incidentally found liver lesions and to review those clinical and radiologic features, which should be considered in development of an ordered and accurate differential diagnosis. learning objectives: . to introduce typical cases illustrating the role of imaging modalities in the differential diagnosis of unexpected liver lesion cases. . to motivate the audience by the use of voting pads to be involved in the diagnostic process. . to highlight the conclusion that may be drawn on the basis of the discussed cases. the diagnosis of ibd is based on complex evaluation of clinical signs, endoscopic appearance, radiological imaging, laboratory tests and histology. besides crohn's disease (cd) and ulcerative colitis (uc) the modern classification advises to use the term ibdu (ibd unclassified) colitis to those % of cases, where the distinction between cd and uc is impossible based on the results of multiple exams. these cases are usually clinically more severe, with humbler therapeutic results. the new classification of cd types includes besides the phenotype (b : inflammatory non stenosing non penetrating, b : stenosing, b : penetrating) the age (a : ≤ y, a : - y, a : > y) the location (l : ileum, l : colon, l : ileocolic, l : upper gi tract) and p perianal involvement. in uc the most important clinical factors are extent, type and severity. the classification includes length and clinical types as acute, relapse-remission and chronic continuum. the radiological imaging in cd is needed for lesions not reachable by the endoscope, for categorising, for follow-up and detecting complications. different modalities fit best for these different tasks. the goal of imaging in uc is rather to help differential diagnosis and detection of complications. while in uc there are good correlation between laboratory and endoscopic signs of activity and severity so there is not much need for radiological activity indices, in cd the clinical activity does not correlate with the histological changes. although cdai is widely used for clinical studies, it includes several subjective factors, thus radiological activity indices may be of help. crohn's disease is more likely a systemic disease governed by a shift in the immune response, thus affecting the whole malt system. bowel ultrasound is a quick, simple and effective investigation. the method is simple and requires no bowel preparation. we use both -convex (c - -overview, anatomical orientation) as well as linear transducer (l - -preferred, incl. ceus, l - -children and very slim patients, l - -tdps, deep structures). we examine patients in supine position, first small bowel, than mesentery and large bowel. finally, we examine the terminal ileum and cecum or the areas of anastomoses. we assess folds, hastrum, wall thickness, vascularity, echogenity of the surrounding fat, the presence of nodes and peristalsis. in some cases we use intravenous contrast (ceus). at least four studies have prospectively compared the diagnostic accuracy of us with radiological studies, endoscopy or surgery in those with suspected crohn's disease. in these studies, the sensitivity of us ranged between % and % and its specificity reached % and %. in our prospective study we investigated patients by ultrasound and enteroclysis. we established the diagnosis by enteroclysis in the central venous vasculature and particularly the upper venous system may be obstructed by either benign or malignant lesions. malignant central venous obstructions are mainly due to bronchial carcinoma, mediastinal metastasis, mesothelioma or lymphoma. the most common cause for benign central venous obstruction is haemodialysis related; other benign reasons are rather uncommon but increasing due to the omnipresent use of permanent central venous access catheters as well as implantable cardiac rhythm management devices. the incidence of haemodialysis-related central venous obstruction resulting in angioplasty is described to be more than times higher compared to, for example, pace-makerinduced stenosis. in any case, early detection and treatment of complications are essential to provide adequate care. contrast venography for many years has been the standard of reference; yet this procedure has its shortcomings. sonography is not consistently reliable for detection of central pathologies, owing to difficult access to these vessels. today contrast enhanced ct is employed to define the site of the obstruction and the presence of possible thrombosis and reveal surrounding soft tissue alterations. mri is of comparative or even higher sensitivity and specificity in evaluating the patency of the central veins. the efficacy and safety of stent placement in central venous occlusion of benign and malignant origin lead to rapid relief. stenting provides fast symptomatic help. repetitive percutaneous intervention can prolong the cumulative patency. thrombolysis may be required to improve the final result, should, however, not be employed as a sole means for revascularisation. us and mr are excellent imaging techniques for studying tendons and muscles. during this integrated session we will review the advantages and disadvantages of us and mr for the diagnosis and follow-up of sports injuries. tricks of both techniques will be addressed, together with some useful guidelines for specific sports injuries. ultrasound is being used at the pitch side and in sports medicine practice as an adjunct to clinical practice. with this in mind there are a number of questions that will be answered in these talks. . when us and mri are the primary imaging and when they are complimentary. . what advances have there been in us and mri imaging to help advance our use of these techniques in tendon and muscle injury. . should we be aspirating haematomas and using autologous blood injections or prp to treat tendon or muscle disease. . can we predict the athletes return to sport? a- : muscle imaging is inherently complex and presents unique morphologic challenges and continuing integration of dynamic, physiologic and functional capabilities. in sports medicine, ultrasound (us) has proved to be an excellent tool to evaluate muscle strain and contusion injuries in athletes providing good correlation with clinical findings. in the acute phase, us has nearly equal sensitivity to mr imaging to diagnose muscle strains, except in the first few hours after the injury, when fresh haemorrhage and oedema have similar echogenicity to normal muscle and strains may go unnoticed. later in the process, us has been shown to be a useful tool in assessing the sequential stages of muscle repair, showing progressive resolution of blood fluid products, decrease in oedema and formation of scar tissue, thus aiding rehabilitation planning. dynamic us during muscle contraction can be valu- . to compare the diagnostic accuracy of ct versus mri in crohn's disease. . to learn about a strategy for the use of ct and mri in the radiological workup of patients with inflammatory bowel disease. five good reasons for the radiologist to be at the forefront : the chairman and speakers will debate the optimum imaging paradigms according to ( ) the clinical indication, ( ) assessment of those with suspected but as-yetundiagnosed disease, ( ) staging of the small bowel in those with newly diagnosed crohn disease, ( ) evaluation of response to therapy and ( ) assessment of those with long standing disease. the optimum approach to assessing and monitoring disease activity will be discussed. deep vein thrombosis (dvt) is a common condition which can lead to possible lifethreatening pulmonary embolism (pe). the primary imaging modality nowadays is duplex ultrasound. in cases where the pelvic veins and/or the vena cava is involved, a venous-phase ct is helpful to determine the exact extend of the clot burden. standard therapy for dvt is anticoagulation. however, if there is a contraindication or a complication (bleeding) to anticoagulation a vena cava filter is a good option to prevent pe. a filter should also be considered if a catheter directed thrombolysis is performed. with the new optional filters the filtration can be terminated either by removing the filter or by converting the filter into a stent. one problem which was observed with these optional filters is that (too) many of them are left in place. despite a low complication rate of filters, a filter may cause an increased risk of further dvt, or a caval occlusion and in rare cases even a migration or penetration is possible. therefore, patients with optional filters should be followed and filters should be retrieved when clinically no longer needed. varicose veins are an early manifestation of venous insufficiency of the lower limbs which can also lead to skin changes including extensive ulceration. it is a very common problem affecting up to % of adults in europe. patients presenting with venous insufficiency must first be assessed by a history and clinical examination to determine the presence and extent of the disease. a duplex ultrasound examination is essential to determine the cause from which an appropriate treatment plan can be decided. depending on the patients wishes and their funding options it is perfectly reasonable to treat all stages of the disease even if just cosmetic. treatment aims to eliminate the reflux in all contributing veins starting proximally and moving distally. surgery used to be the commonest treatment offered to patients but this has been largely superceded by endovenous methods which have significant advantages including: no general anaesthesia, outpatient based, no cuts, no scars, low recurrence, rapid convalesence. there are several endovenous methods using laser, rf, foam sclerotherapy and most recently steam heating and a combined mechanical/sclerosant system (clarivein (r)). laser and rf give almost identical results and % permanent truncal vein closure is to be expected. foam sclerotherapy is cheaper and quicker but long-term results are poorer and patients often have to return for repeat procedures. having ablated the main truncal veins using laser or rf at least % of patients require additional treatments for residual varicosities, e.g. microavulsions or foam sclerotherapy. adenocarcinoma is the most common pancreatic malignancy, affecting the head in - %. mdct is very effective in detection and staging of adenocarcinoma, with a sensitivity of up to % for detection and accuracy of - % for staging, but it has limitations (detection of small cancers, characterisation). mri is a problem-solving tool in equivocal ct to depict small cancers. mri with mrcp helps to differentiate between adenocarcinoma and focal pancreatitis. the "duct penetrating sign" at mrcp is indicative of an inflammatory mass. examination protocols for mdct include oral administration of - . l of water ("hydro-ct"), iv contrast administration of ml/kg b.w. (app. - ml), a flow rate of - ml/s, and a biphasic scan in parenchyma and venous phases. mri protocol should include non-fatsat and fat-sat t w gre, t w tse, dwi, mrcp, and contrast-enhanced sequences. gadoliniumenhanced t w d-gre are helpful for assessment of vessel infiltration and cystic tumours, whereas mangafodipir-enhanced sequences improve delineation of small tumours. in patients with locally advanced tumours, neoadjuvant chemoradiation may be used for tumour downsizing to make it amenable to radical surgery. however, pancreatic cancer often does not shrink after tumour response, which renders mdct or mri unreliable for tumour assessment in this setting. pet/ct may play a role in this indication. in conclusion, ce hydro-mdct is an excellent and robust tool for pancreatic cancer detection and staging. mdct in combination with mri or eus provides high accuracy for characterisation of tumours. further improvement is needed to assess tumour response after neoadjuvant chemoradiation. ct is the established imaging technique for evaluation of pancreatic adenocarcinoma. mri, however, can play a major role in this disease. technical advances of mri including parallel imaging techniques, multichannel receive coils of the abdomen, dynamic gadolinium-enhanced t -weighted fat sat d gre sequences, d mrcp sequences, mangafodipir-enhanced mri and diffusion weighted imaging (dwi) have greatly improved the results of mri in the assessment of pancreatic tumours. standard imaging sequences include t -weighted gre with fat saturation, in-phase and opposed phased t -weighted, axial single-shot turbo spin-echo (tse) and coronal/oblique d and/or d mr cholangio-pancreatography (mrcp) pulse sequences, post-gadolinium-enhanced d t -weighted fat sat sequence and dwi with multiple b values. mr imaging may be useful as subsequent examination for: ( ) detection of small non-contour-deforming tumours with isoattenuated appearance at ct, ( ) evaluation of local extension and vascular encasement, ( ) detection of the presence of lymph node and peritoneal metastases, and ( ) detection and characterisation of associated liver lesions and liver metastases. diffusion-weighted imaging may be helpful as a complementary imaging method in the differentiation between mass-forming focal pancreatitis and pancreatic adenocarcinoma. due to its superior soft-tissue contrast compared with ct, mri ap-able to monitor the healing process. local complications, such as vein thrombosis, irritation of adjacent neurovascular bundles, chronic haematoma and myositic ossificans can be demonstrated with this technique as well. however, us tends to underestimate the extent of injury and the abnormalities seen disappear more quickly when compared with mr imaging. at least in elite athletes, mr imaging seems, therefore, to play a more significant role in management of muscle injury, particularly when decisions regarding the time at which the patient can return to play are needed. by contrast, us is more accessible, and cheaper than mr imaging. in most clinical settings, us should be regarded as the first-line imaging choice for assessing skeletal muscle injury. learning objectives: . to understand the mechanism of injury of muscles in athletes. sports activity can affect tendons due to chronic overuse or acute injury. both can result in complete tendon rupture. us is helpful in precise assessment of rupture severity and extend, but enables alsofor assessment of tendon degeneration, where rupture of individual collagen fibres stimulates a chronic cycle of reparative response caused due to repetitive microtrauma. in chronic tendinopathy histopathological changes, such as hypoxic, mucoid, calcifying, or lipoid degenerations are present. us enables for differentiation of partial tears, tendinosis, tenosynovitis or paratendinosis, because of active and passive dynamic examination possibilities, and high-resolution capability when using high frequency probes. us developments as power doppler us, sonoelastography and contrast enhanced us allow further for new insights into tendinopathy. with the use of us, tendon changes can be diagnosed before they become symptomatic and a reduction of tendon load and initiation of treatment before the condition becomes chronic seem to gain important place in therapeutic regimes. furthermore, us-guided therapies are advisable over blinded-guided injections to minimise side effects and to allow an accurate targeted therapeutic approach. although diagnosis of acute muscle injuries in athletes is usually clinical, magnetic resonance imaging (mri) is a very helpful adjunct tool in this setting, showing the location, extent and severity of the injury and thereby streamlining the management of the patient. portability of ultrasonography (us) on the playfield in the acute setting is not matched by mri, which nevertheless has distinct patterns of grade - muscle strains; however, it is usually with nonacute and deeper injuries of the muscles that mri is especially helpful. presence of bone contusion, stress reaction, or stress fracture is readily displayed by mri and this is practically beyond the limits of us. evolving haematomas, fibrosis, scarring, and myositis ossificans are sequelae of direct or indirect muscle injury which are usually outlined in a single field of view by mri. delayed onset muscle soreness and chronic exertional compartment syndrome, as well as acute and chronic stages of muscle denervation changes, are readily diagnosed with mri. by providing an understanding of distinct muscular denervation changes, mri may actually noninvasively point to the entrapped or involved nerve and guide medical or surgical intervention. foci of mucoid degeneration within the muscle, myotendinous junction, or tendon itself are readily shown by mri, which thereby displays potential sites of failure during sport activities. diffusion tensor imaging may have a role in displaying the subtle architectural disruptions of directly or indirectly injured muscles. learning objectives: . to understand the specific role of mri in the evaluation of muscle and tendon injuries in athletes. . to recognise imaging patterns of tendon abnormalities in athletes: acute and over-use injuries. . to review different mechanisms of muscle injuries: direct and indirect. . to understand how mri might be used in the management of athletes. when a defect occurs in the bowel wall, air will appear within the peritoneal cavity, most frequently due to perforated peptic ulcer and perforated sigmoid diverticulitis. in most perforating gastrointestinal conditions however, the -imminent-perforation is walled-off by neighbouring bowel loops, mesentery and especially by the omentum, nick-named "policeman of the belly". if this walling-off process occurs timely and effectively, no or only minimal free air will appear. the most important causes of walled-off gastrointestinal perforation are appendicitis, peptic ulcer disease, sigmoid diverticulitis, bowel malignancy, crohn disease and -often underdiagnosed-accidently ingested sharp foreign bodies, as toothpicks, fish bones, chicken bones, etc. the extent to which the perforation is walled-off, determines the eventual course of the disease. the us hallmark of -imminent-perforation is inflamed fat around the involved bowel structure. inflamed fat on us corresponds to what is often called "dirty fat" on ct scan: hypodense fat is interspersed with hyperdense streaks. this represents oedema or cellular infiltration of the fatty mesentery and omentum, which have migrated towards the site of the imminent perforation in an attempt to seal it off. on us inflamed fat is recognised as hyperechoic, non-compressible fatty tissue often interspersed with hypoechoic streaks. if fluid collections occur within the inflamed fat, this implies abscess formation. inflamed fat is an important and valuable sign in perforating gastrointestinal conditions. if found in the absence of bowel pathology, the diagnosis is usually epiploic appendagitis or omental infarction. mdct is an extremely powerful tool when the search for a gi perforation is required. the high spatial and contrast resolutions make mdct the most accurate imaging method to identify even small amount of free intraperitoneal air. there is general consensus about the acquisition of a contrast-enhanced scan acquired during the portal venous phase of enhancement (delay of around - sec). controversies are still present in the literature about the utility of a pre-contrast scan as well as the need for a preliminary administration of an oral soluble iodinated cm or for an enema or gaseous distention of the distal gi tract. image reviewing needs the use of a workstation because multiplanar reformations have been demonstrated to improve the detection of small amount of free air. an appropriate window setting is mandatory and it makes mdct % accurate for identification of free air and almost % accurate in the identification of the precise site of perforation. the aim of the examination is not only to assess the presence of free air but also to detect the site of perforation: this is an extremely useful clinical information especially if surgeons decide to perform a laparoscopic repair. several ct signs have been described, able to guide the diagnosis and to differentiate between a perforation originating in the upper gi tract (stomach and duodenum), in the small bowel or in the colon. evidence-based radiology' (ebr) is based on best current evidence, traditionally acquired radiological expertise, the alara principle and the values of referring doctors and patients. any appropriately trained radiologist can formulate an answerable question, search the literature, appraise the retrieved evidence, apply their findings to local practice and evaluate the results. this presentation will describe and illustrate the 'ebr' process. patients with chronic pancreatitis (cp) may present with features resembling pancreatic carcinoma, for which cp is a risk factor with an incidence of . % after yrs. ebr methods were applied to the problem of differentiating mass-forming cp from pancreatic adenocarcinoma. a focused question and literature search found no secondary literature or imaging guidelines. primary literature searching found relevant papers, comprised current best evidence. for ct, time-attenuation curve characteristics had a sensitivity of % and a specificity of % for carcinoma. for mr, dynamic time intensity curve characteristics were only reported in a descriptive study but the duct penetrating sign (mrcp) had a sensitivity of % and a specificity of %. for pet/ct, f-fdg had a sensitivity for carcinoma between % and % with specificity of %- %. for eus/fna, the sensitivity for carcinoma in pre-existing cp was consistently low ( - %), but the specificity was %. simple bayesian analysis was used to establish the best order in which to apply these studies in practice. an algorithmic approach will be presented. the presentation will also consider other 'grey areas' in the field of pancreatic adenocarcinoma imaging using ebr methods. learning objectives: . to learn about evidence-based methods of literature searching and appraisal. . to understand how these methods can be used to produce diagnostic algorithms using the differentiation of pancreatic adenocarcinoma from mass-forming chronic pancreatitis as an example. . to learn about diagnostic algorithms based on different clinical scenarios (local and distant staging, advance versus early disease) involving multiple imaging techniques. : - : room f the hole in the guts in recent years, continuing trends in radiology have diminished the importance of plain films of the abdomen significantly. ultrasonography and mdct are applied with enormous success to the investigation of many abdominal conditions in the emergency setting. in the eyes of the radiologist, plain films, therefore, seem irrelevant in the presence of such powerful imaging procedures. surprisingly, referring physicians, mostly surgeons, gastroenterologists and urologists, still request plain films although the potential of mdct is obvious to them as well. in their perception, the plain film is either a definitive examination before initiation of treatment (e.g. stone at the ureteropelvic junction in us proven hydronephrosis) or a preliminary study prior to mdct or surgery (exclusion of pneumoperitoneum or ileus). in the present climate of cost and radiation consciousness this trend may continue. moreover, many surgeons, gastroenterologists, urologists, etc. have greater skills in reading plain films than in understanding mdct. therefore, the radiologist should poration. all these techniques remain investigational at this time for the treatment of breast cancer. the limitations of and challenges associated with each ablation technique and the issues raised by early pilot studies, which have so far prevented these techniques from replacing standard surgical techniques, will be discussed. in the elderly the co-existence of several diseases, the prevalence of involutional and degenerative aspects, together with physical and cognitive problems represent 'the norm'. it is therefore important to know how to distinguish the healthy elderly from those in need of treatment to avoid overdiagnosis and overtreatment. so the question is how to be aware of the potential and limits of diagnostic imaging and its applications in geriatric patients. brain development occurs rapidly during the last trimester of pregnancy and continues at a rapid pace in the first two years of life. more subtle maturation, for example in the white mater, occurs well into the third decade of life, as evidenced by diffusion tensor imaging (dti). evidence of brain degeneration is occurring soon afterwards and includes mild brain volume los, reductions in white mater integrity on dti, widening of virchow-robin spaces and accumulation of incidental white matter lesions (wml). severe wml and incidental cerebral microbleeds (mbs) are associated with know cardiovascular risk factors and while the concurrent impact may be subtle in terms of cognition, they carry a poor prognosis in the long run. the same is true for silent cerebral infarcts, which increase the risk of dementia. neurodegenerative (general brain volume loss, ventricular dilatation and hippocampal atrophy) changes also occur well before the onset of clinical signs of dementia. in genetically predisposed subjects (e.g. apoe carriers) abnormal (compensatory) brain activity on functional mri and increased (compensatory) cerebral metabolism on fdg-pet have been observed that predict subsequent cognitive decline. more recently, pet studies employing amyloid tracers have shown abnormal binding in a significant proportion of cognitively elderly, suggesting that these subjects are at risk to develop alzheimer's disease -the pace of which is currently undetermined. the objective of percutaneous needle biopsy of the breast is to obtain an accurate preoperative diagnosis with a low upgrade rate post-surgery. indications arise in both symptomatic and screen-detected lesions. a range of biopsy needle designs are available and their selection depends on being aware of the range of needle design types, their advantages and limitations. cutting needles, guns, vacuum systems and mr compatible devices will be discussed. guidance technique for ultrasound, x-ray stereotaxis and mr-guided procedures is extremely important, beginning with patient positioning and anaesthesia prior to commencing the procedure. accurate needle placement under direct vision using high frequency ultrasound probes, x-ray stereotaxis with digital systems and mr guided -with the option of using a cad system for distance calculation -will be presented. typical imaging signs and potential pitfalls of each technique, both anatomical and technical, will be highlighted. methods to increase accuracy including the use of meticulous technique, adequate sampling and correlation of specimen pathology with imaging findings at multidisciplinary meetings are essential. there is always the possibility of a false negative biopsy results in any type of percutaneous image-guided needle biopsy (fnac, core biopsy, vacuum-assisted biopsy). the risk depends upon the quality of the harvested cytologic or histologic material. the quality is closely related to the amount of material collected and the accurate targeting of a lesion. some lesions are at a higher risk of underestimation (sizes < mm, architectural distortions, microcalcifications, stellate lesions) than others (i.e. focal lesions). the false-negative rates for microcalfications using vacuum-assisted biopsy were reported to be . %, for mass lesions . %. using ultrasound-guided g-core needle biopsy the false-negative rates were reported to be in the range of . %. radiologic-histologic correlation plays a key role in the definite and correct judgement of the diagnostic result. in case of imaging-histologic discordance re-biopsy, possibly using larger needle diameters, or even open biopsy should be considered. the european guidelines for quality assurance of breast cancer screening and diagnosis define outcome parameter for breast biopsies. guidelines from the european society of breast imaging published in define the standards and skills necessary to perform these procedures. documentation standards should be used (b -b ) to allow continuous yearly evaluation of the individual institution results and quality improvement. the aim of any needle biopsy is to get as much, i.e. representative material as possible. nevertheless, a certain amount of underestimation, caused by lesion type (adh, dcis, lin, papilloma, for example) will remain and has to be reflected. the presentation will discuss the role of large vessel arteritis within the spectrum of thoracic vascular diseases. it will detail the pathological entities and their morphological, functional, and clinical characteristics. it will present typical ct and mri findings and discuss key elements to the differential diagnosis. it will finally discuss the clinical relevance of this diseases, with a special emphasis on overall evolving importance of thoracic vascular disorders. severe haemoptysis can occur in about % of patients. it is associated with high mortality due to asphyxiation, if not treated, and needs urgent and comprehensive evaluation of the lung parenchyma, airways, and thoracic vasculature. multidetector row ct angiography is a very useful noninvasive imaging modality for initial assessment of haemoptysis in stable patients. it can accurately identify the source and the most common predisposing causes of haemoptysis (bronchiectasis, chronic bronchitis, lung malignancy, tuberculosis and fungal infection) and the effects of haemorrhage on the lungs and airways. moreover, the combined use of thin-section axial and complex reformatted images allows clear depiction of the origins and trajectories of abnormally dilated systemic arteries that may be responsible for the bleeding in over % of cases requiring intervention with arterial embolisation or surgery. nonbronchial arteries may also represent an important cause of haemoptysis. the road maps of dilated bronchial and nonbronchial arteries provided by ct angiography represent a useful guide for endovascular treatment. ct angiography is a quick and noninvasive tool that is helpful in the diagnosis and management of haemoptysis. disorders that affect the elderly population. some misleading radiological presentations typically occurring in this population will be also presented. in the elderly the coexistence of several diseases, the prevalence of involutional and degenerative aspects, together with physical and cognitive problems represent 'the norm'. it is therefore important to know how to distinguish the healthy elderly from those in need of treatment to avoid overdiagnosis and overtreatment. so the question is how to be aware of the potential and limits of diagnostic imaging and its applications in geriatric patients. fast development in the area of imagining modalities demands a lot of work in dose and image quality optimisation and management. deterministic harms have been reported both in interventional and diagnostic radiology. there are also some special groups (e.g. children) which need a lot of attention and especially tight indications for x-ray examinations. radiation dose and image quality optimisation can be applied with small steps in everyday clinical work as a part of self assessment, if the safety culture is agreed by all professionals. the vendors put the settings high in order to reach the best image quality. after installation the settings must be re-evaluated before starting clinical use of the equipment. also, the sensitivity of aec (automatic exposure control) must be turned according the detector. using the air gap ( cm) instead of grid, e.g. in hip axio-lateral project or scoliosis, dose decrease can be even two thirds. the role of radiographer is expanding to new areas. quality assurance and dose and image optimisation could be parts of the expanded role. the new technical solutions in imaging offer a lot of possibilities for dose reduction, if we want, but there is also danger of dose creeping if the doses are not followed up frequently. the management and legislation offer the basics but the work must be done among those who are working in radiological departments. commitment to the safety culture on all levels in medical radiation offers better care and procedures with lower doses to the patients. radiological procedures are performed because of medical benefits to patients, but they also cause some harm because of the dose. if medical benefit overweighs detriment the procedure is justified. the purpose of the optimisation is then to adjust the procedure in a way to maximise the ratio of benefit over harm. question is who is responsible to do it and how it can be done. who should participate: we believe there is a major role of radiographer as she/he is present at each and every radiological procedure performed. but it is absolutely mandatory for them to understand benefits of the procedure and understand harm (dose). radiographer's position is the connection between radiologist, medical physicist and vendor's engineers. radiologists usually do not have in depth knowledge of technology and dose and physicists and engineers on the other hand do not understand in depth the medical aspects of procedure. radiographers must also understand operational possibilities of every x-ray machine. to get to know them they should be there at the acceptance of the x-ray machine and talk to service engineers and applicators. they should also talk to physicist when he/she is doing tests. and finally simulation of procedure(s) using different phantoms is the best way to understand how machine parameters are affecting image quality and dose. in presentation, some examples for different modalities will be given. learning objectives: to gain knowledge about how to start with optimisation of radiological procedures. . to understand the basics of quality control (qa) for radiographic modalities and how to use experience acquired from qa in daily work. . to become familiar with guidelines and applications for good radiological practice and how to implement them in the optimisation process. . to consolidate knowledge of technology of radiographic modalities and the use of materials in daily practice according to guidelines, and to be familiar with the radiographers responsibility in the field of radiation protection. the availability of magnetic resonance (mr) scanners operating at t and above has already proved beneficial for mr imaging and spectroscopy of the human brain and promises similar benefits in the human body. these advantages result from the increases with the magnetic field of the intrinsic signal-to-noise ratio, blood oxygenation level dependent (bold) contrast, which forms the basis of the vast majority of functional mr imaging (mri) experiments, and chemical shift dispersion. these gains can be exploited in improving the spatial and/or temporal resolution of anatomical and functional mri experiments and in increasing the spectral resolution in volume selective spectroscopy or chemical shift imaging. operation at the increased magnetic field also offers easier access to t * -contrast and improved implementation of susceptibility-weighted imaging (swi) in which the phase of gradient echo images provides information about local variation of magnetic susceptibility. in the brain, such variation appears to be dominated by differences in iron concentration and myelin content, so that high-field swi may provide useful information about the progression of neurodegenerative disease. the elevated t relaxation times at t also offer benefits for arterial spin labelling and time of flight angiography. current and potential future applications of high-field mri in clinical and pre-clinical studies in a number of areas and will be discussed in this presentation, along with the barriers to wider usage of t systems for clinical studies. the purpose is to present and discuss the role of imaging in non-traumatic acute abdomen, with particular focus on ultrasound (us). the neonatal gi tract emergencies, associated with specific disorders and imaging strategies, are excluded. acute abdomen in children refers to a wide variety of conditions ranging from benign disorders, such as gastroenteritis, to threatening disease, such as midgut volvulus or intussusception. the recognition of a surgical emergency requires usually, after a competent clinical evaluation, an imaging investigation in order to avoid negative or unnecessary surgery. abdominal plain film is known as poorly sensitive in most situations, except bowel occlusion. ultrasound requires experience and a thorough examination but has demonstrated a high sensitivity and specificity for diagnosing bowel obstruction, midgut volvulus, intussusception, acute appendicitis, over the recent years the clinical mri field strengths have gradually been increased to tesla; however, whole body mri systems with higher fields of up to . tesla have become available in experimental settings. compared to clinical field strengths, mri at very high magnetic fields has several advantages but also some unique challenges. with increasing field strength the signal-to-noise ratio increases, which can be used to either increase the spatial resolution in the images, or to acquire the images more rapidly. unfortunately, the energy deposited in the human body via the rf excitation scales quadratically with the field strength. thus, the specific absorption rate (sar) is a critical factor in all rapid imaging protocols, and requires the design of rf pulses with low sar, (e.g. verse pulses). inhomogeneities of the rf field which are induced by standing wave phenomena have to be compensated, and make the design of efficient spin echo pulse sequences very difficult. at higher field also the field inhomogeneities become larger and stronger imaging gradients are required to overcome the susceptibility-induced image distortion. stronger gradient systems are difficult to manufacture, and the usable gradient slew rate is limited by peripheral nerve stimulation thresholds. furthermore, stronger and faster gradients become very loud at high fields, and special measures for sound protection are required. despite these limitations, high-field mri offers image with very high resolution, it provides unique contrasts, a better spectral separation of the resonance lines and high signal for non-proton applications. clinical mri usually aims to depict anatomic regions of interest with uniform coverage and contrast behaviour. to this end it is essential to use suitably homogeneous radiofrequency (rf) magnetic fields for spin excitation, refocusing, and saturation. traditionally, such uniform transmit fields are generated by volume resonators based on quasi-stationary electrodynamics, which, however, gradually cease to apply as clinical mri explores high field strengths of t and beyond. the concomitant increase in operating frequency entails shorter rf wavelength and increasing tissue interactions, which render the tailoring of rf fields substantially more complex and patient-dependent. one promising response to this challenge is to depart from volume resonators and perform rf transmission by multiple, individually fed transmitter elements. with such transmit arrays the effective rf field can be tailored on a per-patient and per-scan basis by adjusting the relative magnitude and phase of driving the elements (rf shimming). in advanced imple- : - : room z neural stem cells are in the process of finding their translation into the clinic. however, it is well-known that the cells by themselves do not regrow lost tissue. to this end, neural stem cells need further support and guidance. tissue engineering is using biomaterials to provide a structural support for cells, but can also incorporate the release of factors that guide the fate of transplanted cells. ideally, an in vivo imaging approach would encompass all these processes. we here demonstratethe use of a f mri contrast agent to detect clinical-grade human neural stem cells non-invasively over days within a tissue cavity formed by stroke. to provide structural support for these transplanted cells within the tissue cavity, cells were mixed with an engineered de-cellularisedextracellular matrix (ecm). using diffusion mri, we were able to detect the presence of the ecm within the stroke cavity. this approach hence provides a novel approach as to how we can study transplanted cells and tissue regeneration in vivo by mri. our lab has been among the first to exploit dendritic cell (dc) therapy to treat melanoma patients. over the past years, immunological responses are increasingly reported and clinical responses have consistently been observed. moreover, dc therapy often has much milder side effects than standard chemotherapy. a key hurdle in the development of the dc therapy is accurate delivery of the cells to lymph nodes (lns), or their successful migration from the site of injection to lns. in particular, tools for measuring cell migration in vivo are necessary. ideally, we would be able to quantify the number of dcs at the relevant site, with high resolution anatomical context to allow differentiation of lns and the possibility of longitudinal data acquisition. furthermore, functional data on the ensuing immune response is also required. towards these ends, we have been working on developing imaging techniques to study dcs in vivo, for example with scintigraphy on in-labeled dcs, and magnetic resonance imaging (mri) on iron-labelled dcs. scintigraphy is quantitative, but it is restricted to the relatively short half-life of the radioisotope and is unable to resolve individual lns. mri allows high resolution anatomic localisation, but the use of contrast agents such as iron oxide is not quantitative. our recent work has focused on imaging the functionality of these dcs using positron emission tomography (pet) to study ln activation. finally, we have also developed in vitro assays that closely mimic in vivo dc migration in d scaffolds imaged using quantitative f mri, as a substitute for in vivo optimization. we plan on applying f mri to the tracking of dcs in vivo, as the technique allows both quantification and high-resolution anatomic detail. hypertrophic pyloric stenosis, etc. it enables some differential diagnosis such as infectious ileocolitis, ischaemic colitis, henoch schonlein purpura, complicated meckel diverticulum or duplication, etc. or even pyelonephritis. it can provide some findings suggesting mesenteric adenolymphitis, viral gastroenteritis, etc. the us findings will be described as well as the potentialities and limitations of us in each of these conditions. the accurate knowledge of the clinical findings together with the results of us will guide the need for another imaging modality: enhanced ct in case of suspected appendicitis with inconclusive us, upper gi series in an infant with bilious vomiting and impossibility to display the mesenteric vessels, etc. at last, some aspects of pancreatic and biliary tract emergencies will be shown. the purpose is to discuss the role of emergency imaging in acute paediatric gu conditions, with particular focus on the potential of ultrasound (us). besides gu tract trauma conditions such as urosepsis, renal failure, renal colics, ovarian or testicular torsion with all the respective relevant differential diagnoses have to be considered and urgently addressed adequately. particularly with respect to radiation protection (alara-principle) and due to the superb us potential in childhood, us is often used as the primary imaging tool. in many conditions us will reveal all treatment relevant information and no additional imaging is necessary in the acute setting. however, in other conditions such as severe (multiple) trauma ct remains the best primary imaging tool, however, only by using age-adapted ct protocols. the work-up and follow-up may also require imaging, usually achievable by us and partially by mri, scintigraphy and/or cystography. all these lead to imaging algorithms that differ from adults. the most important conditions, their imaging appearance, the potential pitfalls and some important methodical details will be presented, also discussing the recommended dedicated paediatric imaging algorithms. in most paediatric acute gu conditions us is adequate as the first and often sufficient imaging modality. rarely other imaging is necessary particularly in the acute setting -except for ct in severe (multiple) trauma. all imaging should be indicated with respect to therapeutic consequences and the alara principle, and proper paediatric protocols as well as methododical skills (e.g., dedicated paediatric us) should be provided hours throughout the year. learning objectives: . to learn about the diagnostic imaging approach in acute urinary tract disease. computed tomography (ct) is the imaging method of choice in the evaluation of abdominal injury after blunt trauma in haemodynamically stable children. an unstable patient needs to be stabilised prior to ct or to proceed directly to surgery. evaluation with ct allows for accurate detection and quantification of injury to solid and hollow viscera, and can also identifies an active haemorrhage. ct can help prioritise optimal management by diagnosing the major or most life-threatening site of haemorrhage or injury. ct can also demonstrate associated bony injury to ribs, spine, and pelvis. a normal ct examination may prevent other unnecessary explorations. the decision for operative intervention in the small percentage of children who require surgical haemostasis is primary made based on clinical criteria and not on ct findings. interventional techniques deeply changed approach to treatment of diseases. in each country, interventional radiology practice establishment varies according to local factors, but following a standard strategy seems better to set up this facility. according to above-mentioned points, i decided to establish this specialty in our hospital since as the pioneer center in interventional radiology iran. at first the procedures included percutaneous laser disc decompensation (pldd), and vertebroplasty followed by vascular procedures such as uae in later years. now, we are performing all interventional procedures in our country including aortic stent and all neurointervention procedures. the following items will be discussed: . prepare step by step strategies for establishing intervention. . solving issues regarding interventions procedures. . modified techniques for lowering costs to cover interventions in poor people. . setting of fellowship courses. . co-operation with dedicated and pioneer international centers such as using neocrylate for treatment of brain aneurysms in conjunction with ucsd for the first time on human. when presenting our experience we want to review how we should start interventional radiology in developing countries. fibroids are the most common benign tumours of the uterus during female reproductive age. uterine artery embolisation (uae) is a procedure in which using embolic particles (pva, gelfoam, etc.) we block blood supply to uterine fibroids. it has been reported as a relatively safe, effective, and durable nonsurgical alternative method diminishing fibroid-related symptoms. uae is typically performed in both uterine arteries by an experienced interventional radiologist. after uae, reduction in menorrhagia has been reported as - % and the mean decrease in fibroid size varies from % to % in the literature. complications including amenorrhoea are frequency ranging from % to % in the literature. uae may be followed by menopause in % of the cases. nevertheless, it is usually encountered in women in their late s. it seems that the future of uae depends on optimal selection of patients based on the prediction of volume-shrinkage, the outcome of fertility, and the long-term efficacy. although pregnancy is possible after embolisation, neither fertility preservation nor its improvement can be definitely guaranteed. women who desire to become pregnant should definitely be cautioned about potential complications during pregnancy. in this presentation we are going to review the position of uae in iran and to present our experience about the efficacy, and safety of uae. besides, we will discuss some methods of dose reduction during uae and the effects of uae on fertility and pregnancy outcome. purpose: labelling pancreatic islets (pi) with superparamagnetic markers enables their detection as hypointense spots on magnetic resonance (mr) images. we tracked pi transplanted into the liver and quantified their signal loss in liver tissue using mr imaging over a six-month period. methods and materials: pi were labelled with ferucarbotran μl/ml for - hours and transplanted into the portal vein in c-peptide negative recipients ( infusions). the liver was examined prior to transplantation and subsequently day and , , and weeks after transplantation using a t mr scanner. results: in all recipients significant c-peptide levels and near-normal hba c values were achieved with - % insulin dose reduction. no side-effects related to the labelling procedure were documented. a significant decrease in the number of islet spots was detected at week post-transplantation (on average %) with a subsequent only slight decrease for up to weeks. in two subjects with a labelling period of less than and hours respectively only a few islet spots were detected corresponding to poor islet visualization in phantoms labelled for the same period of time. conclusion: pi visualization was successful in all recipients but was less efficient if the labelling period was less than hours. a significant decrease in islet spots occurred at week post-transplantation suggesting early islet destruction or impaired engraftment. then, the decrease in islet spot numbers slowed and islets were still detected at weeks post-transplantation. data shows that mr detection of ferucarbotran-labelled islets correlates with sustained c-peptide production. areolar complex), the presence of other imaging findings (extension to the skin, inflammatory cancers) and the status of regional lymph nodes. this information influences the type of treatment given to the patient and it is very important to gather as much information as possible in order to obtain a one-step surgical excision with free margins at pathology. on the basis of this information and on discussions held in multidisciplinary meetings, markers will be placed wherever needed in order to locate the exact distribution of the tumour(s). the different parts of a structured report (clinical data relevant to the report, technical description of the diagnostic or the interventional modality, pitfalls during the exam, description of breast composition, description of lesions, categories and overall assessment) should always be included in order to guarantee that all the important information is there. breast imaging, like other subspecialties in radiology, is a multimodality area of knowledge where it is vital to integrate the information obtained through diagnostic and interventional procedures in order to supply the clinician with a body of data that is useful and straightforward. liver metastases are of the most difficult therapeutic challenges in oncologic managements. surgery is frequently impossible due to disease extent and systemic chemotherapy usually fails. in other body parts, the combination of radiotherapy and systemic chemotherapy is used for several types of malignancies. we successfully adopted a novel image-guided form of this combination for such masses referred to as radiochemoembolisation, which substantially intensifies the treatment locally. patients underwent transarterial radiochemoembolisation with chemotherapy protocol of mitomycin, doxorubicin, and cisplatin and embolisation with radioisotope particles of p. the effectiveness of method was determined by comparing contrast-enhanced ct images, pre-and post-intervention. treatment response was evaluated using recist criteria. we also used some arbitrary criteria such as tumoural mean density and enhancement pattern. for stable and partial-response cases, the procedure was repeated. we did not repeat the treatment for progressive diseases. complete-response cases were only followed. after completing treatment sessions, regardless of the tumour source, considerable amount of patients showed substantial response. in terms of recist criteria, a significant portion of patients gained at least a "partial response". but the decrease in tumour density and the appearance of non-enhancing tissues were more promising. radiochemoembolisation is an effective method for the treatment of patients with unresectable hepatic metastases. although this study lacks a control group, it shows the effectiveness of the treatment. literature review showed the response to treatment with regard to recist criteria had been better in our study comparing with studies only used chemoembolisation or radioembolisation. , which showed the superiority of digital mammography for younger and perimenopausal women, as well as those with dense breasts; the national ct colonography trial (nctct), demonstrating the equivalence of ctc with colonoscopy; and the national lung screening trial (nlst) which has preliminarily reported a % decrease in lung cancer-specific mortality associated with annual ct screening. acrin's current focuses include the assessment of emerging imaging biomarkers for the prediction of and monitoring of response to treatment and the extension of its activities to disease processes beyond cancer. according to the second approach, termed as ‚dark lumen mrc', dense barium or tapped water is used to distend the colon in conjunction with post-gadolinium d gradient echo with fat-saturation sequences. the colonic wall and the corresponding polyps exhibit high signal intensity as a result of gadolinium uptake while the colonic lumen presents with low signal intensity. mr imaging of the pancreas and bile ducts relies upon a combination of t -w and t -w strategies in order to safely acquire anatomic, cross-sectional and functional information. tissue-imaging strategies include free breathing t -w imaging (obtained with echo-train spin-echo sequences with or without fat saturation) and breath-hold d-gradient echo t -w imaging (obtained with fat saturation) without gadolinium and in the capillary phase and in the interstitial phase post-gadolinium. this combination is valuable in the assessment of the full spectrum of pancreatic diseases and malignant bile duct obstruction. hardware improvements (gradients) and the advent of more sophisticated phased-array coils and parallel imaging capabilities in modern mr scanners allowed to increase the spatial and temporal resolution of "conventional" t -w and t -w sequences. furthermore, it provided the possibility of adding high-b-value diffusion weighted imaging (dwi) to our routine protocol in order to increase the sensitivity of mri in detecting malignant and inflammatory diseases. to obtain conventional mrcp imaging thick-slab heavily t -w tse sequences or d heavily t -w tse sequences may be used. advantages and limitations of both sequences will be underlined. functional bile duct imaging is obtained imaging modality or technique for this problem. increasing technological capabilities and knowledge of how to optimise ct/mr contrast utilisation provides better ways to characterise tumours than ever before such that key clinical specialties outside of radiology now recommend nonbiopsy imaging diagnosis of hcc to triage patient treatment. radiologists must work extra diligently to learn the clinical issues, triage points and implications that are associated with specific clinical presentations and imaging findings. the perfect test that does not require cognitive interpretation of the constellation of imaging findings with integration of the patient clinical presentation to optimise patient care is not in our near future. this lecture emphasises historical advances in liver imaging and how data in the literature impacted patient care decisions in ways that may be different than expected from radiologists. an emphasis on pathologic-imaging correlation will be used to put apparent disparate published results in proper perspective to allow radiologists to meaningfully interact with clinical colleagues in determining optimal patient treatment. liver mri is undertaken to assess the liver parenchyma, vasculature, and biliary system. it is necessary to use a variety of unenhanced and contrast-enhanced mr pulse sequences to achieve lesion detection and characterisation. a set of t -, t -w and dwi sequences is now standard for lesion delineation and assessment of liver fat and iron content. in-phase and opposed-phase t -w gre images show focal or diffuse fatty infiltration and focal sparing. a fat-suppressed t -w tse sequence is robust and provides high tumour contrast, with . t units now allowing acquisition of isotropic d-tse sequences. the quite popular t -w half-fourier single-shot tse (e.g., haste) pulse sequences show anatomic detail (including bile ducts), but lack lesion contrast. in case of suspected iron overload (i.e., haemosiderosis and haemochromatosis) an additional t *-w gre is recommended. acquisition of dwi patient transport into the radiology department, contact to other potentially infectious persons, and things such as breath-holding are reasonable burdens and dangers to immunocompromised patients. when searching the focus of fever, imaging should help to identify an affected organ system in order to eventually guide invasive procedures to identify underlying micro-organism or non-infectious disease. equally relevant is the exclusion of its involvement with a reasonable specificity. depending on local epidemiology, organ system, and the clinical signs and symptoms, suspected differential diagnosis can be derived from image patterns. some of these diagnoses might be exclusion diagnosis, others might require invasive procedures including time consuming and costly analysis to be verified. invasive procedures, however, require adequate hemostasis, which is usually not available for a substantial duration due to pancytopenia in patients who underwent chemotherapy. if imaging fails to derive the underlying disease confident and conclusively in a fast way, clinicians might need to treat on an empirical basis. empirical treatment plays a major role in immunocompromised or severely ill patients at risk, because mortality rises within hours of untreated disease. on the other hand, empiric treatment causes relevant toxicity and substantial costs, while imaging might become cost-effective. using contrast agents that are taken up by hepatocytes and excreted through the biliary system in combination with volumetric t -w sequences. we use this technique in postoperative complications and to elucidate complex biliary anatomy. functional imaging of the pancreas is obtained by combining mrcp along with hormonal stimulation with secretin. in addition, secretin improves anatomic delineation and allows mri quantification of fluid production by the exocrine pancreas. despite the advance of cross-sectional techniques, the chest radiograph remains a basic tool for the initial approach to heart diseases. in this lecture we will present our current approach to evaluate cardiac pathology in conventional radiography illustrating it with selected cases. the basic approach consists of seven steps, evaluating the size and shape of the cardiac silhouette, cardiac calcifications, pulmonary circulation and lung changes, great vessels and implanted devices, all of them correlated with the clinical findings. looking at the heart on a chest film may be considered at a first glance as wasting time since, today, many other techniques are available today to offer an impressive luxury details of the morphological and functional evaluation of heart. nevertheless, the chest film remains often the first modality performed in many situations in which symptoms can be both from pulmonary or cardiac origin and then, careful analysis of heart may avoid rough mistakes in patient management. acquired and congenital pericardial or cardiac abnormalities may be responsible for a deformity of the cardiac silhouette and lead to explore the patient by a chest ct. ct with fast scanning capabilities can acquire images of the thorax with reduced cardiac motion artefacts, improving the evaluation of the heart in the course of a thoracic ct. unexpected findings of cardiac structures on both unenhanced and enhanced acquisition can dramatically influence the patient's clinical management. in many situations, a chest ct is performed without cardiac gating and it may be necessary to complement the initial examination by a gated acquisition to provide a more dedicated analysis. the normal appearance of cardiac structures and the most common cardiac abnormalities should be known by all the radiologists. various conditions such as idiopathic and acquired cardiomyopathy, ischaemic heart disease, valvular dysfunction can be identified even on non-gated scans. pulmonary diseases may also involve pericardium and cardiac structures and this should be clearly identified. learning objectives: . to learn how to detect and characterise cardiac abnormalities in the chest radiograph. . to learn how to detect and characterise cardiac abnormalities on chest ct. . to learn the limitations of the interpretation of cardiac abnormalities on ungated chest ct. . to learn when further evaluation is required. nal in discs and vertebrae to the adult shape and signal pattern will be reviewed. the normal pattern of unfused bony segments and apophyses in the child and fusion to the mature adult form will be reviewed. normal variants such as persistent segmentation/non-union leading to limbus vertebrae and dysraphism will be reviewed. intervertebral discs, vertebral body endplates, posterior elements and bone marrow show a wide degree of variation and the borderland of normal variant versus pathological abnormality is often difficult to navigate. common borderland findings such as schmorl's nodes versus scheuermann's disease will be discussed. transitional vertebrae as such are normal but incomplete transitional changes are associated with clinical symptoms. even without associated pathological changes the terminology of transitional vertebrae is a common pitfall. simple coping strategies will be reviewed. various imaging artefacts can have an influence on image interpretation though lumbar spine mr imaging is more resistant to these than imaging of the cervical and thoracic spine. this talk will review an approach to imaging complications of total hip replacements. the talk will briefly review surgical techniques and types of prostheses. the talk will subsequently review early and late complications of prostheses and focus on the integrated use of all modalities including radiographs, aspiration arthrography, scintigraphy and mri in achieving a diagnosis. there are many surgical techniques to repair meniscal tear, focal cartilage defect, cruciate ligament tear, malalignment, fracture, osteoarthrosis, etc. conventional radiography, ct-scan, ct-arthrography and mri play an important role in evaluation of the knee after surgery or arthroscopy. indications for postoperative imaging are infection, persistent pain and dysfunction. every radiologist should be familiar with "normal" imaging findings after arthroscopy, osteosynthesis, ligament reconstruction, osteotomy, knee prosthesis and meniscal or (osteo)chondral repair, but also recognise the main complications after knee surgery or arthroscopy. orthopaedic hardware is usually evaluated on plain radiography or ct, and only a relative contraindication for mri. microscopic metal artefacts and fibrotic scarring are frequently seen along the course of the instrumentation tract. after partial meniscectomy, an obtuse angle at the apex of the meniscus and increased signal intensity of the remnant part of the meniscus are normal findings, whereas fibrillation and recurrent tear may explain the complaints of the patient. various intra-and extra-articular reconstructive procedures exist for anterior and posterior cruciate ligament reconstruction. besides the neoligament, an osseous tunnel, screws and metal artefacts are also visible. postoperative findings of the extensor apparatus include a thickened patellar tendon, focal myxoid degeneration, fibrosis and focal defects, e.g. after harvesting tendon tissue for acl reconstruction or after release of the lateral patellar retinaculum for 'unstable' patella. accelerated osteoarthritis may be a late postoperative finding. mri very well depicts incorporation and alignment of osteochondral auto-or allografts, and the position, morphology and integrity of the meniscus after repair or transplantation. to evaluate postsurgical patients it is important to know the primary clinical diagnosis, the surgical treatment, the interval since surgery, and patients' current clinical symptoms. radiography is the most common imaging modality to evaluate the postoperative ankle, particularly in traumatic cases; after reduction and fixation of a fracture or dislocation it is generally carried out as routine. ultrasonography is highly sensitive and specific in postoperative tendon assessment, thanks to the superb resolution, and the opportunity for dynamic evaluation of tendon integrity. chest drains ( - fr) with underwater seals achieved decompression of pleural fluid collections. recent literature suggests small bore drains may be adequate, with image guidance playing an important role. pleural space anatomy, including fissural locations will be revised. aetiology of transudates, exudates and empyemas, along with typical clinical presenting features are outlined. various examples of plain film, ultrasound, multi-detector computed tomography and mri appearances of pleural collections and their aetiologies are presented. selection of patients, image guidance methods, catheter size, insertion technique, pitfalls and procedure complications are discussed. importance of physician-radiologist liaison with respect to catheter management and catheter dwell times is emphasised. pleural space fluid collections are common clinical entities that radiologists can accurately diagnose as well as successfully treat. overview of aetiology, radiological appearances and method of image-guided drainage of infected pleural fluid collections is provided. pelvic abscess drainage may employ more difficult access routes due to anatomic restrictions. the procedure may carry a higher risk of complications compared to simple abdominal drainage. to optimise patient preparation, correction of coagulation deficits, optimisation of antibiotic treatment, and sedation or anesthesia may be needed. the usual access routes for deep pelvic abscesses are the anterolateral and the posterior transgluteal approach. in selected cases, a transvaginal or transrectal approach may be the safer and more efficient option. depending on the viscosity of the drained fluid, the presence of necrotic solid tissue and gas, different sizes of drainage material may be needed. do not hesitate to employ large drainage catheters if indicated. an overview of the available material will be given. intestinal laceration is a major complication which can be managed percutaneously in selected circumstances. often, the weakest part of percutaneous drainage is the postinterventional management. it is advocated that the management is actively guided by the interventionalist who ensures that the drainage is properly handled, rinsed, and cleaned, that follow-up imaging is performed at the right intervals, and who is also responsible for indicating drain removal. chest ct and mri are commonly performed to evaluate patients with acute chest pain. a number of imaging techniques are available that may cover the entire chest, including the cardiovascular system. the radiologist will encounter more and more cardiovascular disease that was not visible with ungated ct and mri techniques. the differential diagnosis of acute chest pain may include over possible diagnoses, a substantial number related to cardiovascular disease. it is important to recognise chronic and acute coronary disease, myocardial infarction and its complications, left ventricular function, pericardial disease, atrial disease and large vessel disease. case material will be presented and discussed using both ct and mri techniques to illustrate the spectrum of usual and more unusual cardiovascular pathology that should be considered in the differential diagnosis of unexplained chest pain. pulmonary hypertension (pht) remains a disease difficult to diagnose because the clinical findings are nonspecific, often leading to a delayed diagnosis. once recognised, it is necessary to determine the underlying cause and to estimate the severity of pulmonary hypertension. among the noninvasive methods of assessment of pht, ct angiography (cta) now plays an important role in the diagnosis and post-therapeutic management of pht. numerous recent technological advances of multidetector-row ct technology (mdct) have reinforced the clinical impact of this technology by introducing new tools for the morphological evaluation of small-sized pulmonary arteries and pulmonary capillaries, the latter being accessible with dual energy ct and often referred to as pulmonary "perfusion". the role of ct now also includes the possibility to investigate the presence of pht on the basis of functional parameters, such as the distensibility of the pulmonary arterial wall, and to integrate cardiac functional information, with great interest towards right ventricular function. the major clinical impact of these new scanning modes is that morphology and function can be obtained from the same data set, with no restriction on the diagnostic performance of high-resolution ct angiographic images. the purpose of this lecture is to review these new trends in imaging of pht and estimating right ventricular function through practical clinical situations, including the most common causes of pht. ct scans of the chest are usually performed and reported as if the lungs were the only organs in the thoracic cage. however, the heart and pulmonary arteries can show significant abnormalities either as associated findings of the parenchymal disease or as incidental findings. so the recommendation is: do not forget the heart and pulmonary vessels when reporting a ct scan of the chest. mri has rapidly become important in post-operative assessment of the ankle, because it provides high soft-tissue contrast, multiplanar capability and osseous structures visualisation. it shows signal changes of ligaments and tendons, hypointense subchondral sclerosis, subchondral bone marrow oedema, joint effusion, capsular thickening, fibrosis, and synovitis. mri has also an important role in the evaluation of post-surgery ankle pain due to impingement syndrome and in the hindfoot chronic instability related to postoperated sinus tarsi syndrome; it demonstrates the anatomy of sinus tarsi, chronic synovitis and nonspecific inflammatory changes, synovial cysts, fibrosis and subtalar joint effusion. it is important also in the follow-up of tumours and tumour-like conditions of bone and soft tissues after surgery. computed tomography is the most valuable method to define the osseous anatomy of the postoperative ankle, so it is important in the follow-up of the operated osteochondral lesions of the talus. ct allows the evaluation of irregularities or degenerative changes, and progressive degenerative arthritis; however, ct usually fails to evaluate soft tissue's ankle lesion. the development of subsecond mdct scanners with high temporal and spatial resolution has significantly reduced scanning times and now it is possible to have very good quality images of the heart during routine chest ct examinations. therefore, the importance of looking at the heart and pulmonary vessels on a ct scan performed for non-cardiac reasons will be emphasised. anatomic cardiac details that every radiologist should know will be discussed in the first talk; the presentation is aimed mainly at the non-cardiac radiologist. it will review normal cardiac anatomic details, as routinely encountered on modern multi-detector ct studies. it is now possible to delineate much of the intracardiac anatomy on a contrast enhanced study and significant pathology may also be evident on non-enhanced ct examinations. important incidental findings and their clinical relevance will be discussed in the second talk. unexpectedly, cardiac abnormalities may be diagnosed when lung disease is clinically suspected and vice versa; the focus of this presentation will be the comprehensive evaluation of lung and heart/large vessels diseases.the strong correlation existing between pressure in the pulmonary artery system and dilatation of the pulmonary trunk and central branches will be discussed in the last talk. ct is considered more useful than echocardiography because it can depict the cardiac structures in all patients including those with extensive parenchymal abnormalities. at the end of the presentations we should try to answer the question about the routine reporting of cardiovascular findings on ct scan of the chest. a. anatomic cardiac details that every radiologist should know s.p.g. padley; london/uk (s.padley@ic.ac.uk) this presentation is aimed at the non-cardiac radiologist. it will review normal cardiac anatomic detail, as routinely encountered on modern multi-detector ct studies. it is now possible to delineate much of the intracardiac anatomy on a contrast enhanced study, and significant pathology may also be evident on non-enhanced ct examinations. this study will primarily review normal cardiac anatomy, including cardiac chambers, valves and coronary vessels. the typical radiological appearances of innocent incidental intra-pericardial abnormalities will then be reviewed. important incidental pathology will be discussed in the next talk. liver fat, inflammation, and fibrosis are important pathological features in patients with diffuse liver disease. the clinical gold standard for assessing these features is liver biopsy. due to its invasiveness and sampling variability, however, liver biopsy is suboptimal for screening, monitoring, and clinical research. there is, therefore, a need to develop biomarkers to assess liver fat, inflammation, and fibrosis non-invasively. in recent years, many quantitative imaging techniques have been developed, refined, tested, and made available. the question becomes: are these techniques ready for routine clinical use or are they most appropriate for research? in this special focus question, we will begin with a brief overview of diffuse liver disease and discuss basic concepts of biomarker validation and qualification. dr. reeder then will discuss conventional and state-of-the-art imaging-based biomarkers of liver fat. dr. cobbold will discuss the current status of non-invasive biomarkers for liver inflammation. dr. van beers will discuss ultrasound-and mr-based biomarkers of liver fibrosis, with emphasis on techniques such as transient elastography and mr elastography that measure visco-elastic properties of liver tissue. we will conclude with a panel discussion asking the question: are the repeatability, reproducibility, and robustness of the non-invasive biomarkers presented in this session adequate for routine clinical implementation? session objectives: . to review the clinical importance of diffuse liver disease. . to understand that key features of diffuse liver disease include fat accumulation, inflammation, and fibrosis. . to understand the need for non-invasive biomarkers to assess fat, inflammation, and fibrosis. . to review basic concepts in biomarker validation and qualification. quantification of liver fat s.b. reeder; madison, wi/us (sreeder@wisc.edu) intracellular deposition of fat within hepatocytes (steatosis) is a common condition of the liver. fat is the histological hallmark of non-alcoholic fatty liver disease (nafld) but also may occur with alcohol abuse, viral hepatitis, hiv and genetic lipodystrophies, and chemotherapy. nafld alone afflicts an estimated - million in the us and is a rapidly growing condition in other western societies, paralleling the expanding epidemics of obesity and diabetes type ii. this talk will review the clinical, pathogenic and histological features of liver fat, including an overview of fatty liver disease and diseases where fat is an important disease feature. next, it will review the current use and limitations of non-targeted biopsy in diffuse liver disease, and why quantitative non-invasive biomarkers of liver fat and iron would be beneficial. currently available conventional magnetic resonance imaging techniques that attempt to detect and quantify liver fat will then be discussed, as well as known confounding factors that corrupt the ability of conventional methods to quantify fat. this lecture will then describe emerging quantitative imaging methods for accurate and precise quantification of liver fat, and the advantages offered by these methods address in comparison with conventional methods. finally, remaining challenges and unsolved problems for quantifying liver fat will be discussed. conventional mri techniques, such as t w and gadolinium-enhanced t w sequences, which are highly sensitive for detecting demyelinating plaques, are recognised as the most important paraclinical tool for diagnosing multiple sclerosis (ms). however, the changes seen on mri in patients with ms are not diseasespecific, as focal white matter t hyperintense lesions (thl) are also commonly observed not only in the elderly but also in middle age and young patients, and in a large list of different disorders such as hypoxic-ischaemic vasculopathies (atherosclerotic and hypertensive small vessel disease, cadasil, fabry's disease and susac's syndrome), cns vasculitis, sarcoidosis, adult forms of leucoencephalopathies, trauma and radio chemotherapy, and acquired metabolic conditions (hepatic encephalopathy, alcoholism), among others. while it is recognised that a combination of findings from clinical history, physical examination and laboratory tests is commonly required to correctly establish a firm and clear aetiological diagnosis of thls, a detailed analysis of different mri features should also be considered essential, e.g. lesions shape, size, and distribution; contrast-uptake; and associated structural lesions (microbleeds, infarcts, spinal cord, brainstem and cerebellar involvement, …). in addition to these conventional mri-based features, non-conventional mr techniques (diffusion, mrs and perfusion) may also provide in some cases useful diagnostic information. knowledge of these features will assist the diagnostic work-up of patients presenting with thls, and should be considered a first step to take full advantage of the potential of mri, and in doing so should result in a reduced chance of misdiagnoses and facilitate the correct diagnosis of sometimes treatable disorders. learning objectives: . to be aware of the limited specificity of brain multifocal t abnormalities. . to learn about recognition patterns that might be helpful in suggesting the most likely etiology of brain multifocal t lesions. . to learn about the role of spinal cord imaging and advanced neuroimaging techniques for the differential diagnosis of brain t hyperintense lesions. . to be able to establish a neuroimaging diagnostic strategy in patients with multiple brain t lesions of unknown origin. breast imaging reporting and data system (bi-rads) was developed by american college of radiology in order to set standards for mammography reporting, common terminology and data collection. bi-rads is being used widely for over a decade and many studies have assessed the validity of the system. an important component of bi-rads is the lexicon which gives descriptors of specific imaging features that facilitate image interpretation and unify the reports. two main titles for these descriptors are about masses and calcifications. an asymmetry is called a mass when it is seen in two projections. a mass is defined with its shape, margin and density. definition of a mass with these three modifiers would help the radiologist to determine the type of the mass and probability of its malignancy. calcifications are divided into three categories by their shapes and another descriptor is defined for their distribution. the first category is for typically benign calcifications. the other two are for probably malign calcifications where biopsy should be suggested. the distribution modifiers for calcifications can also play an important role in assessing the probability of malignancy. bi-rads defines assessment categories from to for the final report that facilitate data management for yearly audits. category is the transition zone between malignant and benign lesions where the suspicion for malignancy should be less than % and requires short-term follow-up. bi-rads morphology and distribution descriptors are effective in assessing the risk of malignancy with a reasonable positive predictive value. the breast imaging reporting and data system (bi-rads ® ) for ultrasound (us) was developed by the american college of radiology (acr) and published in . although this lexicon was created to achieve a consensus among radiologists when describing breast abnormalities, clinical practice shows substantial intraobserver agreement but only moderate interobserver agreement. most problems are reported for descriptors related to shape (when trying to classify abnormalities containing lobulations and/or elliptical with not-parallel orientation), echo pattern and margin. especially mass margin is a critical feature for determining whether a lesion should be biopsied or not. other problems are related to the final assessment, including difficulties in applying the subcategories and the relatively high percentage of false negative cases for lesions interpreted as category . many computer-aided diagnosis software have shown the potential to improve performance amongst less experienced readers and decrease interobserver variability; still they do not solve all the problems. the bi-rads ® lexicon is actually under advanced revision by an international panel and ellen b. mendelson chairs the us subcommittee. revision is reviewing both descriptors and categories; it will include also new parameters linked to the evolution of us technology as colour flow mapping and elastography. troubles. characterisation of aml is possible, based on identification of its fatty content mainly using ct. when microscopic, this component may be missed and biopsy is required with immunostaining. mr imaging may be helpful using chemicalshift sequences but thresholds, to rule-out clear cell carcinoma, have to be better defined. presence of necrosis or calcifications rules-out diagnosis of aml. amls must be treated if haemorrhagic, painful or if diameter exceeds cm. embolisation is the main nonsurgical method, using microparticles, alcohol and/or coils but postembolisation syndrome must be prevented. volume regression may require all agents whereas aneurysm occlusion requires coiling. the effect on volume and on haemorrhagic risk is substantial making surgery as an alternative method for nephron sparing purposes. secondary surgery is required in less than % of embolisation. rf ablation is also possible but its efficacy is still under evaluation. the number of small renal tumours is increasing due to the large amount of imaging examinations of the kidneys performed with various modalities and the true increasing incidence of renal cancer. conservative therapy of small renal tumours is now widely recognised as the reference technique for the treatment of these small lesions. the increasing rate of chronic renal failure in the elderly and the efficacy of conservative therapy to treat cancer as demonstrated by the urologists performing partial nephrectomy and tumourectomy emphasise the role of percutanaeous minimally invasive ablative procedures, particularly in patients with surgical contraindications. radiofrequency ablation and cryotherapy are the two most developed techniques, but new technical approaches are under development such as microwave ablation, electroporation, etc. the evaluation of the success of the procedure relies on imaging techniques showing the lack of enhancement within the lesion and the size and shape of the necrotic covering the entire tumour area. the techniques, indications, results, and complications of both radiofrequency ablation and cryotherapy will be discussed. a variety of diseases including neoplasms, but also infectious, inflammatory, vascular and traumatic processes, may present as focal intracranial mass lesions. modern neuroimaging, primarily with mri, enables differentiation of these entities allowing for accurate diagnosis in almost all cases. the requirements are appropriate image acquisition and detailed analysis of imaging findings, while pertinent clinical information may be very helpful in certain cases. the distinction is frequently broad, between different disease processes, such as with tumefactive demyelination versus neoplasm, which is often sufficient for clinical decision making and patient management; at times this may be more specific, approaching histological diagnosis, such as with pilocytic astrocytoma versus medulloblastoma. this presentation will go briefly over the imaging techniques and various disease processes, while heavily concentrating on the differentiating features of intraaxial primarily non-haemorrhagic mass lesions. the emphasis will be on the key distinguishing imaging features, such as presence or absence of mass effect or vasogenic oedema, signal intensity characteristics, presence and pattern of contrast enhancement, as well as diffusion and perfusion features. decision making process will be discussed. a number of cases with intracranial masses will then be reviewed and analysed, using a step by step approach, accentuating the most reliable distinguishing findings. the role of mr imaging in adult gliomas consists of many steps. ( ) is there a lesion in the brain? ( ) is the lesion a tumour? ( ) is the tumour a glioma? ( ) is it a high-or low-grade glioma? ( ) if there is a suspicion and a biopsy is planned, which part of the tumour should be targeted at biopsy. ( ) how the surgery should be performed to avoid injury to functional areas of the brain (e.g. motor cortex). ( ) if there is need for adjunctive radiotherapy, how the extent of the tumour should be defined? ( ) after radiotherapy, if a new enhancing lesion occurs, is it a recurrent neoplasm or radiation necrosis? conventional anatomical mr imaging is not always powerful enough to answer these questions. however, with advanced mr imaging techniques such as diffusion mr (including tractography), perfusion mr, mr spectroscopy and functional mri (fmri) we can answer the above questions reliably in most cases. the purpose is to gain numerical information of accuracy in the treatment of localised prostate cancer and calculate the necessary size of the safety margin around the clinical target volume (ctv-ptv). in addition, the purpose was to evaluate the accuracy in treatment set up with patients with high bmi to find out whether patients with high bmi need a larger safety margin. portal imaging was used to measure off-line random set-up error from bony structure. the sample size was , i.e. all the patients who received radiation treatment for localised prostate cancer in landspítali -university hospital (lsh) . a total of portal images were acquired. in , the task was repeated for patients having gold fiducial markers in the prostate. the calculated -d imrt safety margins in lsh was to be . mm. correlation is with high bmi and set-up errors in medio lateralis (m-l) direction (r= . ). this indicates that a patient with an increased pelvic circumference has a tendency to have more set-up errors. reformed procedural workflow resulted in more acceptable calculated margins in . when corrected on line times per week the margin is to be . mm and . mm if corrected times per week. in conclusion, for delivery of - gy to the prostate with imrt and spare surrounding healthy tissue effort is needed to secure the accuracy in the overall procedure of treatment planning and delivery. learning objectives: . to gain knowledge on how to improve the target accuracy in treating prostate cancer with radiation therapy using electronic portal imaging. . to understand the importance of gaining numerical information of accuracy in the treatment of clinically localised prostate cancer and how to use the information to calculate the necessary size of the safety margin around the clinical target volume. . to become familiar with the preparation needed before starting treatment with imrt and be aware that there is a need to look at all the treatment elements including the technical side, quality, education, staff and patients. . to consolidate knowledge of radiation therapy for prostate cancer and the meaning of giving high dose to the target while minimising radiation dose to healthy tissue. b. image-guided radiation therapy: when imaging meets therapy a. sarchosoglou; athens/gr (anastasia @hotmail.com) the aim of this presentation is: to understand the necessity of imaging in the delivery of external radiotherapy; to be familiar with the technology of image-guided radiation therapy and to to gain knowledge about the implementation of d igrt. the aim of radiotherapy is to deliver high dose to target volume while minimising the dose to surrounding healthy tissues. however, during treatment delivery many uncertainties may arise that can result in higher toxicity and poor local control. thus, it is crucial to monitor and adjust if necessary, the actual treatment. image-guided radiation therapy is the process where images are taken immediately prior or during a course of radiation treatment, to assess and improve the accuracy of therapy. manufactures have developed a number of systems to perform igrt providing the options of ionising radiation images/non-ionising imaging technology and gantry mounted/room mounted equipment. d igrt can be performed by acquiring computed tomography images on the treatment unit. these images are matched with reference images from planning ct and potential discrepancies are recognised, calculated and corrected by couch shifts giving optimal results. such advanced technologies require quality assurance systems to be in place and high trained personnel. when properly implemented, igrt meets the aim of radiation therapy. imaging provides confidence to radiation therapy to be aggressive, to fight cancer. imaging promises radiation therapy a great future with improvements in clinical outcomes and patient survival! multicentre trials have shown that ct colonography is ready for widespread clinical use. however, these studies have also highlighted the inconsistent performances of ct colonography, with divergent results being recorded in different centres and between readers. inter-observer and inter-centre variability may be related to reader experience but it is also affected by how ct colonography is performed. while faecal tagging has been accepted universally as the proper way to prepare patients for ct colonography, there is no consensus on which tagging agent is better, on the timing of contrast agent administration and on whether laxatives should be administered and in what dosage. in a similar way it is not yet clear which is the best way to obtain colon distension, whether by administering spasmolytic agents routinely or by changing patient's decubitus. standardising bowel preparation and technique is one of the most important goals that need to be achieved for ct colonography to be universally accepted and this presentation will attempt to deal with the issue using an evidence-based approach. the evaluation of ct colonography (ctc) studies is based on detection, interpretation and reporting of colonic findings. it is performed on a computer workstation equipped with dedicated ctc software by a primary d or a primary d approach. in either case, the alternative viewing technique must be available for rapid correlation and characterisation of suspicious findings. primary d evaluation is based on "lumen tracking" by interactively scrolling through the axial slices and multiplanar reformatted images, focusing only on the air-distended colonic lumen from one end to the other one. primary d evaluation provides information about the attenuation of findings during the search process and is time-efficient. primary d evaluation is based on d virtual endoscopy in an antegrade and retrograde fashion and increases both, the conspicuity, especially of small and medium-sized polyps, and the duration of visualisation. the use of advanced d displays like virtual dissection or unfolding techniques may reduce the interpretation time for primary d evaluation. computer-aided detection (cad) algorithms used as a nd reader were shown to reduce the number of perceptual errors by pointing out possible abnormalities that might otherwise be missed. colonic findings are characterised by their morphology, their attenuation characteristics, and by their mobility. knowledge of ctc imaging features of common colonic lesions and artefacts is necessary for characterisation of findings and differentiation between definite colonic lesions and pseudo-lesions. standardisation of ctc reporting facilitates classification and communication of findings and the comparison with previous studies, thereby better assisting physicians in making appropriate management decisions. the revolutionary development in multidetector ct (mdct) technology during the past decade has contributed to a substantial increase in its diagnostic applications and accuracy in children. a major drawback of mdct is the use of ionising radiation with the risks of radiation-induced side effects, of which the induction of secondary cancer is the most important. therefore, justification and optimisation of paediatric mdct is of great importance in order to reduce these risks as much as possible (‚as low as reasonably achievable' principle). optimisation of paediatric mdct starts with a solid understanding of all technical aspects of ct, including the most relevant scan parameters, dose reduction techniques and technique of iv contrast material administration. furthermore, due to the smaller size and lack of visceral fat in young children the interaction and absorption of radiation will be different which will influence the choice of the various technique and scan parameters. although all these issues are pivotal for a successful ct examination, it may become worthless if the importance of pre-scan issues such as justification and patient preparation are ignored. after a short overview concerning the current knowledge on radiationrelated risks in children, this lecture will focus on several aspects relevant for mdct optimisation in children. issues such as justification, patient preparation, technique and scan parameters will be addressed. finally, some guidelines for radiation dose level-based ct protocols will be given. the purpose is to present an overview of the safety hazards and safety protocols related to infants undergoing mri examinations. mri infrastructure-dependent safety hazards originating from: (a) static and fringe magnetic fields, (b) gradient subsystems, (c) radiofrequency subsystems and (d) acoustic noise sound pressure will be reviewed and discussed. safety hazards related to upcoming technological issues and future trends concerning mri will be presented. the current status of the organisations responsible to the problems of mr safety will be reviewed. which authority is responsible and where the responsibility is addressed to (directives, legislation policies, etc). an optimised protocol related to a variety of clinical mr sequences in reference to temperature measurements, emf measurements, sar and acoustic noise figures using basic commercially available infrastructure will be presented. d/ d tse sequences with different etl's, d/ d gre, d/ d ssfp and se/gre epi sequences with multi-(b) diffusion gradients and d tof mr angiography sequences will be examined. in vitro measurements of snr, spatial resolution and scan times will be performed for each clinical mr sequence. a comprehensive mri equipment operational policy (optima: (etl, tr, te, b-value, epi factor etc).) for a safety protocol for infants undergoing mri is proposed. recommendations for safe infant mri examinations will be summarised and presented. conclusion: mri equipment can operate safely for infant imaging but require policies and procedures beyond those required for standard diagnostic mri examinations. learning objectives: . to get an overview of the three basic safety hazards related to infants undergoing mri examinations. . to become familiar with safety hazards related to upcoming technological issues and future trends. . to learn about a safety protocol that could be applied in mri examinations for infants. a s c b d e f g h perfusion imaging. new possibilities arise in mri almost every day. imaging algorithms are to provide the correct diagnosis in the shortest time with the lowest expenses and harm to the patient. mri is the first method of choice in neurological diseases with two exceptions: acute stroke and acute trauma, ct providing the necessary information, more available and with easier patient care. adequate imaging protocols optimally visualise the anatomical region of interest and pathological processes, optimise the comparison between serial examinations and provide the information in reasonable examination time. appropriate and well understood clinical information is indispensable (neuroradiology means good clinical knowledge combined with expertise in imaging methods and their evaluation). complicated protocols are superfluous without competent clinical background but adequate information must be provided to experienced clinicians. basic protocols help to gather important information but do not exclude additional necessary methods. examples to be demonstrated are mri protocol for the pituitary, epilepsy, multiple sclerosis and spine. the up-to-date concepts of image evaluation and interpretation will be demonstrated for brain ct, brain mri and spinal mri, including the importance of follow-up. the body and conclusion part of the structured neuroradiological report will be discussed. consultation with other neuroradiologists and with clinicians is the final tool to reach the goal: to help in recovering the patients' health. ten authentic and original typical clinical cases illustrating the importance of imaging modalities in the differential diagnosis of focal neurological symptoms from headache to epilepsy will be presented while respecting the privacy of the patient. the spectrum of pathologies includes vascular, inflammation, metabolic, degenerative diseases, congenital malformations and neoplasms of the central nervous system. each case story will be described shortly in a standard form followed by demonstration of typical ct and/or mri images. in some cases, conventional mri will be supplemented by multi-voxel mr spectroscopy, dti, mr tractography images, and morphological pictures. follow-up images will be presented where appropriate. several diagnostic options will be offered for attendants. the audience will be asked to participate in the diagnostic process by the use of voting pads. after highlighting of final diagnosis the basic differential diagnostic considerations will be briefly summarised and emphasised from the clinical and imaging point of view for each presented case. learning objectives: . to introduce typical cases illustrating the role of imaging modalities in the differential diagnosis of focal neurological symptoms. . to motivate the audience by the use of voting pads to be involved in the diagnostic process. . to highlight the conclusion that may be drawn on the basis of the discussed cases. diagnostic quality mri of soft tissue masses can be performed using a variety of magnetic equipments and a variety of field strengths. regardless of system design, efforts should be made to maximise signal-to-noise ratios (snr) using the most appropriate coil to include the lesion and associated oedema. fov should be tailored to the size of the patient and the size of the mass. it is important to obtain images in at least two planes through the lesion. slice thickness vary depending on the size of the lesion and interslice should be not more than one-half of the slice width. imaging matrix should be balanced to in-plane spatial resolution. parallel while ctc has achieved excellent results in average risk individuals with regard to detection of clinically relevant polyps, it has not yet been implemented on a large scale in colorectal cancer (crc) screening programmes. this is mainly due to the fact that it uses ionising radiation. there is uncertainty about adequate screening strategies and the risk of radiation-induced malignancy. this presentation will summarise recent results of ctc in a screening setting, will look at the dose associated with ctc, and summarise calculations of radiation-associated risk of malignancy. the key question is whether low doses from ctc will cause relevant negative effects in the screening population. the lecture will also feature a comparison between ct and mr colonography, an imaging test that might be able to provide high sensitivity crc screening without ionising radiation. from headache to epilepsy… or from "normal", physiological "headache" to life threatening pathological conditions. when do we need "neuroimaging" and what is the optimal diagnostic work-up? the radiologist must and should remain first of all a medical doctor: he/she should keep close contact with the clinical world and always keep an active dialogue with the referring clinician. indeed, medical imaging has become more and more sophisticated but also more expensive. imaging is not a "screening procedure" in brain pathology but should be performed in order to confirm a clinical, suspected diagnosis keeping still in mind that differential diagnosis must be considered as well. imaging plays also a unique role in lesion evaluation and treatment monitoring. the radiologist must answer precise questions about the patient's suspected pathological condition and if necessary, discuss the imaging findings with the clinician in order to narrow the differential diagnosis. each mri or ct must be performed with a clear knowledge of the clinical question and the suspected pathology. therefore, the radiologist will make the proper choices of imaging techniques especially with mri where imaging sequences have become numerous. headaches and seizures are symptoms only and may be present in multiple and very diverse pathological conditions as infectious, neoplastic, haemorrhagic, vascular diseases: by knowing the clinical history a good "clinically conscious" radiologist will undoubtedly be of greater "added value"! learning objectives: . to learn more about the clinical conditions causing focal neurological symptoms. . to be informed about the clinician's way of thinking in the process of differential diagnosis. neuroradiology has a continuously changing and developing array of modalities. conventional radiography has lost its importance. angiographic practice has shifted from diagnostics to therapy. ms-md ct scanners provide high-quality ct angiography and a s c b d e f g h t w-mri to localise pz-zone pca. in the t-zone, stromal nodules commonly have a low adc value simulating pca. significant differences in tumour adc values existed between patients with low-risk, and those with higher risk localised p-zone pca. with s-mri, the best accuracy for diagnosing pca is obtained by combining a positive t w-mri and a choline+creatine/citrate ratio > . . in the t-zone, s-mri has the same limitations than dce and dw-mri. multiparametric functional mri accuracy of mri to detect pca can be improved by combining different functional sequences. at the moment, it seems that the most widespread used protocol is a combination of dw and dce-mri for detection of p-zone tumours. performance of functional mri to detect t-zone pca is less well established. multiparametric mri can now be used to perform stereotaxic trus-guided biopsies after trus-mri image fusion. the role of imaging in patients with increased psa level after radical prostatectomy or radiation therapy is to aid in differentiating locally recurrent disease which can be managed with local therapy from distant metastatic disease requiring systemic therapy. although the majority of local recurrences in post-surgical patients can be detected by mri in the perianastomotic region which can also be evaluated with trus and trus-guided biopsy, some recurrences can occur at pelvic sites that are beyond the range of trus; mri has a role of labelling these sites for trusguided biopsy. the combination of an external phased-array coil and endorectal coil is recommended for detecting local recurrent cancer. current protocols involve t -weighted mri combined with functional techniques such as dynamic contrastenhanced mri (dce-mri), magnetic resonance spectroscopy and diffusionweighted mri. in the post-prostatectomy bed, recurrences present as lobulated masses having low to intermediate signal intensity on t -weighted images and showing early, nodular enhancement with early washout of gadolinium on dce-mri. the predominant finding after radiotherapy is a diffusely low signal intensity with an indistinct zonal anatomy where the contrast between a hypointense recurrence and benign irradiated tissue decreases. on dce-mri, peripheral zone enhancement is lower after radiotherapy and any focal enhancement should be regarded as suspicious. the overall diagnostic efficacy of dce-mri for detecting recurrent prostate cancer is better than t -weighted mri alone. on mri, bone metastases have low and high signal intensity on t -and t -weighted images, respectively, and enhance after intravenous gadolinium administration. learning objectives: . to understand the role of mri in the follow-up of the patients with prostate cancer after radical prostatectomy or radiotherapy. in this presentation new techniques with potential clinical value will be described with a focus on prostate cancer multi-modality mr imaging. techniques such as t w, dwi, dce and mrsi will be addressed, and their role in screening, determination of tumour aggression and localisation, mr-guided biopsy, mr-guided minimal invasive focal therapy (laser, cryo, hifu), and mr-guided radiotherapy will be discussed. examples will be shown. the major area of debate is how to approach patients with increased psa levels. the discussion has two parts: one is the patient who has not had a prior cancer diagnosis and the other one is the patient who has already been treated for prostate cancer. what is the role of mr (as well as mrs, dw mr and dynamic mr) in precluding the need for multiple biopsies? when should we stop in cases with high or increasing levels of psa despite consecutive negative biopsy outcomes? a s c b d e f g h and that radiation therapy and systemic treatments play a major role for curing minimal residual disease. for evaluating and predicting response to neo-adjuvant treatments, the major question is the debate between morphology (size and volume) and function (perfusion, spectroscopy and diffusion). for follow-up after treatment, considering the number of women concerned, cost benefit analyses are mandatory to offer the most efficient imaging strategies based not only on defined subgroups (risk factors of local relapse) but also over time. one of the first take home messages of this course is the multidisciplinary approach of this disease or in another way: we do not treat images but patients! a. evaluation of residual disease after excisional biopsy c. boetes; maastricht/nl (c.boetes@mumc.nl) mammography can have an additional value in evaluating if microcalcifications are left behind in the case of dcis and irradical operation. ultrasonography has proven to have no additional value in evaluating the postoperative breast, because of haematoma and scar tissue. mr imaging of the breast can of all imaging techniques predict residual disease in the most accurate way. however, false positive results can exist because of enhancing scar tissue. also, false-negative results exist, especially owing to residual low and intermediate grade dcis. it is recommended to perform postoperative breast mri in premenopausal women in the right time of the menstrual cycle, that means between the th and th day after the start of the menstrual cycle. unclear is how soon after the operation one should perform breast mri. if a large mass of residual disease is suspected, mri is an excellent tool to confirm this fact. but, if a mastectomy is considered, pathological confirmation before the re-operation is recommended. another imaging technique is tc- m-mibi scintimammography. this seems a promising technique with a high sensitivity and specificity. neoadjuvant chemotherapy is regularly used for downstaging of locally advanced breast cancer. while it is equivalent to adjuvant therapy regarding overall survival and occurrence of distant metastasis, more patients are eligible for surgical treatment by less aggressive breast conservative therapy. neoplastic growth depends on blood supply with nutrients and oxygen. hypoxia-induced angiogenesis is an early step in tumour progression. mri is the imaging modality providing highest sensitivity for detection of breast cancer, highlighting tumour vascularisation by injection of t -shortening contrast agents. characteristic differences between benign and malignant lesions are cause. ultrasound (us) and computed tomography (ct) are readily available and widely used imaging techniques for this work up. us comprises an examination of the abdomen with the graded compression technique. a transducer should be used optimised for the visualisation of the bowel. the ct protocol includes the use of intravenous contrast medium, while oral contrast medium will not be routine in many institutions. findings are bowel wall thickening (or enlarged appendiceal diameter), fat infiltration, free air and fluid collections. the present evidence on the role of imaging in appendicitis and diverticulitis is substantial and has been summarised in systematic reviews. although us is accurate in diagnosing appendicitis and diverticulitis, ct is more accurate than us. further advantages of ct are better identification of alternative diagnoses and better comparison between consecutive examinations. thereby, ct is more helpful in communicating the diagnosis to the referring physician. cost effectiveness of ct in acute appendicitis has been demonstrated as well as the positive impact on management. for colitis, the evidence is more limited and imaging has more limitations here. drawback of ct is ionising radiation exposure. an imaging strategy with initial us and ct only in inconclusive of negative us cases results in the highest sensitivity, reduces ionising radiation exposure and is cost effective. accurate and rapid diagnostic imaging is essential for the appropriate management of acute biliary tract disorders. ultrasonography (us) continues to be the first and often the only test needed to confirm suspected diagnoses affecting the ducts and gallbladder. however, there has been an increase in the overall use of computed tomography (ct) in the emergency room setting, mostly because for its widespread availability and the relative speed, ease and uniformity with which evaluations can be performed. thus, ct may be the first imaging examination performed on patients presenting with signs and symptoms that are less specific for biliary diseases. magnetic resonance (mr) imaging has similarly robust potential as ct, although its integration into the acute care setting requires greater technical and logistical effort. improved mr imaging sequences, advances in coil technology, streamlined imaging protocols, and increased technical and professional familiarity with the modality make it an increasingly attractive option when there is concern about patient radiation exposure or allergy to iodinated contrast material, as in pregnant patients with acute abdominal symptoms. mr can also be used as a problem-solving modality. in this presentation, the common and uncommon imaging appearances on us, ct and mr of acute diseases of the biliary tract and gallbladder will be reviewed. potential pitfalls to be avoided with the three modalities are also illustrated. learning objectives: . to learn the etiology and clinical presentation of acute inflammatory liver diseases. . to understand imaging strategies using us, ct and mri. . to know typical findings and the spectrum of differential diagnoses. pancreatitis is an abdominal condition potentially life threatening. imaging plays a key role not only in the diagnosis but also in the staging and patient management of acute and chronic pancreatitis. pancreatic inflammation and necrosis can be easily identified by imaging methods and has prognostic implications. the clinical prognostic criteria in acute pancreatitis are currently coupled with imaging criteria. ct plays a central role in the evaluation of patients with known or suspected pancreatitis. a ct-based severity index is the main prognostic method to predict outcomes. in addition, mri and mrcp play increasingly important roles in pancreatitis evaluation. integrity of the pancreatic duct can be easily evaluated by this last method, particularly if enhanced with the use of secretin. imaging appropriateness criteria determine the value of distinct imaging modalities with regard to the stage of disease. we review the modern imaging criteria for the diagnoses, staging and patient management in acute and chronic pancreatitis. we also discuss current severity indices and imaging appropriateness criteria. advancements in ct and mri technology have lead to an increasing use of these modalities in the non-invasive assessment of coronary arteries, myocardial perfusion, and cardiac function. while their role in detecting coronary artery disease and functional disorders has been widely accepted, it is still unclear whether they could be adopted in triaging patients for the best therapeutic approach. large studies have already suggested that indication for surgery and percutaneous interventions cannot be solely based on the demonstration of morphologic alterations and that such "cosmetic" interventions are not always leading to the expected outcomes. therefore, non-invasive imaging techniques have to offer more then just the detection of grades of coronary artery stenosis, of areas of infarcted myocardium, or of valvular alterations. adjustment of imaging protocols for additional evaluation of coronary flow reserve, of myocardial perfusion and contractility and of valve size, position and damage with subsequent quantification of degree of stenosis and/ or regurgitation are necessary in order to allow to choose the most appropriate therapeutic approach and thus become the "gold standard" for prognosis and pretherapeutic diagnosis of cardiac diseases. a. can ct predict the outcome of percutaneous intervention? c. loewe; vienna/at (christian.loewe@meduniwien.ac.at) the outcome of coronary revascularisation is not only defined by primary technical success but also by improvement of symptoms and quality of life. thus, despite the individual comorbidities, the outcome and thus the potential benefit of coronary revascularisation depends on many different factors, including morphology, distribution and severity of coronary lesions, myocardial viability, and ventricular function. consequently, the detection of coronary stenosis is not sufficient for planning an optimised treatment. it should be evaluated if the myocardial territory supported by the diseased artery is still vital. in addition, lesions at risk for plaque rupture (culprit lesions) should be identified and treated to avoid major coronary events. cardiac ct allows for the exact assessment of coronary morphology including length, calcification and severity of lesions. based on this morphological information, success of a percutaneous revascularisation procedure can be anticipated with high prognostic accuracy. in addition, the possibility of identification of culprit lesion by means of coronary ct has been described recently. by this, dedicated treatment of only the relevant stenosis should become possible avoiding multiple, potentially unneeded, stents. finally, even the assessment of myocardial viability by means of ct becomes possible. using all the possibilities of cardiac ct optimised treatment plan can be established, and outcome can be estimated. radiological interpretation always incurs some degree of error due to the nature of disease presentation coupled with the difficulty in diagnosis, especially where early signs of disease need to be identified such as in medical screening. early research studies of radiologists' performance concentrated upon the chest radiograph but more recent work has studied breast screening extensively, as well as mri and ct. as radiology is now almost fully digital then research has also examined observer behaviour with a range of digital images, viewing conditions, and image display presentations. it is possible that radiological interpretation will never be accomplished without some errors occurring; however, it is important that steps are taken to minimise any causes of errors as far as possible. the reported error rates found in numerous investigations across different radiological domains will be reviewed and the reasons for these will be elucidated. appropriate reporting conditions will be highlighted for different image viewing scenarios. a theoretical framework for understanding error causation, especially where abnormalities are missed will be detailed. furthermore, the underlying visual, perceptual and cognitive processes which lead to errors will be detailed and approaches to minimise error occurrence will then be proposed. the relationship between human perceptual and cognitive skills and computer imaging processing will be discussed and the usefulness of cad systems outlined as how they can best aid the radiologist from the human performance viewpoint. learning objectives: . to review the basic principles of perception, detection and detectability. . to learn about specifics of perception in medical imaging. . to learn how image processing can help us with the perception process. ing using graf's method led to higher treatment and follow-up rates than that based on nhi alone, i.e. - % vs. . - . % and - % vs. - %, respectively. however, improved examination techniques and a better understanding of the findings have led to a more tailored approach, and an extensive meta-analysis performed in , including papers, could not find any differences in treatment rates due to different ultrasound techniques. in this lecture i will present a crude status for us techniques used and also give recommendations for a worth while screening strategy based on present knowledge, and on work performed within the espr's ddh task force group. with technological advances in recent years, paediatric whole body imaging is now a clinically feasible and increasingly accessible technique. the two principle modalities available are pet, with or without co-registered ct images, and whole body mri (wb-mri), both of which can be utilised to evaluate widespread disease states efficiently. the main application of these techniques has hitherto been oncological; however, as these techniques become more accepted, their use is becoming more varied. pet provides functional assessment, utilising a radiotracer, most commonly fdg- , to assess metabolic activity within tissues, with areas of greater metabolic activity depicted as increased tracer uptake. the use of combined ct-pet enables accurate specific uptake values (suv) to be determined, via attenuation correction, and anatomical co-registration which reduces perceptual errors. wb-mri primarily provides an anatomical assessment, using tissue contrast to identify pathology. this typically uses water sensitive sequences to provide high sensitivity. "physiologic" mri sequences, such as diffusion weighted imaging (dwi) can also be employed to obtain functional mri data, either qualitatively or quantitatively. there are advantages and disadvantages to both techniques, including ionising radiation exposure, acquisition times, movement and other artefacts, and reproducibility, which all need to be considered when choosing a particular technique for whole body assessment in any given paediatric patient, with the disease process being investigated also influencing the technique used. the relative merits, clinical applications and evidence base for the use of pet/ct and wb-mri in paediatrics will be discussed. near future developments, such as pet-mri will be touched upon. the practice of medical image diagnosis is currently undergoing a fast transformation. vast amounts of data can be generated in standard examinations and focus is shifting from improving the collection of relevant data for diagnosis to development of effective methods to analyse, visualise, navigate and interact with medical information. it is now becoming generally accepted in the medical community that one of the most important keys to manage the increasing information work load is the use of d and d applications. this talk will take its starting point in state-ofthe-art medical visualisation and then discuss the need for a research agenda that focuses on the development of the next generation of medical visualisation tools, emphasising the fact that these tools must be based on medical user requirement and work flow studies as well as on new technical developments. childhood osteomyelitis is a relatively rare finding in childhood with an estimated annual incidence of per and is predominantly seen in young children (< years). it can be caused by via haematogenous spread, contiguously from local areas of infection or from penetrating trauma or surgery. usually it is caused by bacterial infections, but occasionally fungi, viruses or parasites are causative agents. clinical findings can range from mild to severe and depends on many factors such as age, site of infection, acute versus chronic osteomyelitis, and causative agent. the crp and sedimentation rate are usually elevated; however, this is not always the case. given the variability in clinical presentation radiology plays a crucial role in the detection of osteomyelitis. although conventional radiography (cr) has a limited sensitivity and specificity for the diagnosis of osteomyelitis, its wide availability makes it the first diagnostic technique of choice in children. for further analysis both mri and radionuclide bone scintigraphy (rbs) have shown to have a high sensitivity for the detection of osteomyelitis. the advantages and disadvantages of both the techniques will be addressed. ct mostly plays a role in the diagnosis of chronic osteomyelitis or in the pre-surgical work-up. the use of radiology also allows for a differential diagnosis of osteomyelitis, based on clinical cases, an overview of this differential diagnosis will be given. the aim of this lecture is to present an evidence-based diagnostic strategy for childhood osteomyelitis. developmental dysplasia of the hip (ddh) is the most common musculoskeletal disorder in childhood, with a reported prevalence of - % according to method of ascertainment and definitions used. ultrasound has enabled a detailed view of both neonatal hip stability (nhi) and morphology, and two different schools have developed; one arguing that nhi alone is the major pathology warranting splinting, the other including acetabular dysplasia as an important feature. both static (graf, morin) and dynamic (harcke) ultrasound techniques, as well as a combination of the two (modified graf (rosendahl)), have been described and are currently used. in europe, graf's ultrasound technique or a modification of this is commonly used within the german speaking countries and areas, in parts of scandinavia, the uk, italy, france, hungary and the netherlands. others use a modified morin's method while harcke's method is used only occasionally. initially, universal ultrasound screen-(helium or xenon), oxygen-enhancement or other technologies. all of these might also provide quantitative read-outs for disease and/or therapy monitoring. learning objectives: . to learn how ct and other imaging methods can be used to examine the structure-function relationship in sad. . to review the state-of-the-art imaging methods that can provide information about disease extent, disease activity and global and regional lung function in patients with sad. . to become familiar with the current use and the future developments of these techniques. panel discussion: signs of small airways disease can be seen on ct but when and why do they really matter? : signs of small airways disease are a frequent finding on ct especially when expiratory scans are performed in addition to inspiratory scans. when should we report these changes? are they always important, do they perhaps predict the development of more severe disease, or are there cases where they have little influence on diagnosis and therapy? when should an expiratory scan be performed? careful preoperative staging and preoperative using high-resolution mri together with preoperative multidisciplinary team discussion has been shown to reduce margin involvement by tumour from % to < % by identification of patients that require more radical preoperative therapy and surgery. the detailed demonstration of preoperative prognostic factors also recognises patients on imaging that are not at risk of local recurrence and therefore the avoidance of unnecessary preoperative therapy in a proportion of patients. the use of eus can help in the assessment of early stage flat lesions suitable for local excision and is a powerful complementary tool. pet-ct is crucial for the preoperative work up of patients undergoing radical procedures such as metastatectomy. follow-up for colorectal cancer patients at high risk for developing recurrent disease is now well established, and the emergence of specialised multidisciplinary teams, combined with a range of treatment options for recurrent disease has improved curative resection rates following metastatectomy and pelvic recurrence surgery. radiologists with a solid understanding of not only the pathological manifestations of primary and recurrent rectal cancer but also the treatment options available play a key role in enabling the appropriate selection of patients -increasing overall cure rates and reducing treatment-related morbidity. this refresher course aims to provide radiologists with an understanding of local staging of rectal cancer, the assessment of recurrent disease, and assessing response to treatment. the course will highlight how imaging underpins the key preoperative decisions for surgical and oncological treatment planning in rectal cancer. a. staging with us and ct a. maier; vienna/at (andrea.maier@meduniwien.ac.at) for rectal cancer surgery a variety of alternative operations are currently possible. furthermore, there is an increasing trend towards treating patients with radiotherapy before surgery. the choice of operation and the decision whether to employ radiotherapy is based on preoperative staging. in patients with primary rectal cancer accurate assessment of tumour extent and the presence or absence of lymph node invasion are factors for determining prognosis and risk of tumour recurrence. endorectal ultrasound (eus) is effective for t-staging. it has been recommended as the investigation of choice in the selection of potentially curative local excision. lymph node staging by this method is less precise than tumour staging. initial reports of the use of ct for tumour staging were encouraging. studies which compare ct with eus staging consistently show the latter to be more accurate for both tumour stage and lymph node stage. thus, the usefulness by the speakers at the end of the session. at the other end of the clinical and imaging spectrum to obliterative bronchiolitis is exudative small airways disease, typified by (japanese) diffuse panbronchiolitis. the exudative bronchiolitides are characterised by direct signs on hrct, notably a tree-in-bud pattern. while this is a readily appreciated and specific sign, other diseases that mimic this hrct finding will be discussed. bronchiectasis of variable severity is a usual accompaniment to both obliterative and exudative bronchiolitis and the relationship between large and small airways disease will be explored. the instances in which hrct findings of obliterative and exudative bronchiolitis co-exist are relatively few, and the differential diagnosis for this situation will be considered. in practice, hrct will often show signs of bronchiolitis (whether obliterative or exudative) limited to a segment or even subsegment, and the interpretation of the clinical significance of such a chance finding is sometimes a difficult judgement. learning objectives: . to become familiar with the direct and indirect signs of small airway involvement on ct. . to know how to correlate these signs with the pathological changes. . to understand the differential diagnosis with other diseases that can show similar ct findings. from pattern to diagnosis c. beigelman; paris/fr various schemes of classification of sad have been proposed according to clinical, pathologic or imaging criteria that are confusing. an optimal approach, mainly based on ct analysis of direct and indirect features, usually allows the recognition of the two main types of sad, namely inflammatory/exudative and fibrotic/constrictive/ obliterative bronchiolitis. a miscellaneous group that corresponds to bronchiolar involvement in diverse diffuse lung diseases may also be individualised. direct signs of sad that refer to direct visualisation of diseased bronchioles strongly suggest inflammatory bronchiolitis. they mainly consist in centrilobular nodules with tree in bud appearance. conversely, indirect signs mainly represented by mosaic attenuation, air trapping, bronchial wall thickening and dilation characterise fibrotic bronchiolitis. volumetric acquisition, performed a dose reaching that obtained with classical hrct protocols, may be of interest in several ways. particularly, maximum intensity projection tool may facilitate the recognition of the tree in bud pattern. the minimum intensity projection mode may optimise the recognition of the mosaic attenuation pattern requiring an appropriate contrast resolution, as well as the analysis of proximal airways. expiratory ct, optimally performed on a dynamic mode, may be useful in some conditions at a dose equivalent to around chest x-rays. a combination of post-processing tools from a volumetric acquisition performed with carefully chosen parameters might therefore appear useful in the evaluation of sad. furthermore, additional co-existing findings such as ground glass opacity or other features of interstitial pneumonias may be detected. their analysis may help to recognise the cause of sad in addition to clinical data. structural changes associated with sad are difficult to depict directly on ct. indirect signs of sad, such as mosaic attenuation on an inspiratory scan and/or air trapping on an expiratory scan, are common findings. they nicely illustrate the structure-function relationship between obstruction or expiratory collapse of the small airways and the subsequent effects on ventilation (local hyperinflation) and perfusion (hypoxic vasoconstriction). these "functional" signs are thought to be more sensitive than the direct visualisation of the underlying structural changes. careful interpretation and software tools help to generate data about disease extent as well as global and regional lung function. beyond paired inspiratory-expiratory ct scanning, dynamic expiratory cine as well as perfusion and ventilation imaging on the basis of both, ct and mri, can be applied to increase sensitivity, specificity and accuracy of the diagnosis of sad. some of them are ready for routine clinical use, such as dynamic expiratory cine ct, cine mri during continuous breathing as well as gadolinium-enhanced perfusion mri. future developments in the fields of ct and mri will provide novel technical approaches for functional imaging of sad. these will include novel applications of dual energy/spectral ct using iodine-enhancement for perfusion and xenon-enhancement for ventilation enhancement as well as ventilation mri using hyperpolarised gases to understand the advantages and limitations of bi-rads in clinical practice to appreciate the potential of an automated analysis of the descriptors to trace continuous modifications required by technological advancements. . to review bi-rads categorisation with case illustrations a. how i do it p. richards; stoke-on-trent/uk (paula.richards@uhns.nhs.uk) . always report in the same logical manner for each examination, which imprints normal pathology 'jumps out at one'. . evaluate all images before looking at the clinical information to prevent bias and satisfaction of search. . review every scout image. scoliosis transitional vertebrae and pseudoarthrosis become more obvious on coronals. single kidneys, hydronephrosis and renal tumours may explain 'back pain', especially if there are mets. . review any x-rays or old ivus, remembering that abdominal x-rays show the spine. . indications; summarise the reason for the scan. think of the differential diagnosis to exclude. . technique; allows one to check the levels scanned. be sure there has been no area missed between studies. . report vertebral alignment and disc height. . mri just like an x-ray, i.e. there is normal alignment from d to s . . start at the far sagittals and look at the nerve roots in the 'key hole', the pars and facets. . determine the worst abnormality on the axials and report the most significant findings first. check the facets at each level. . have a checklist of normals at the end; 'the bone marrow, cord and csf return normal signal. the conus ends normally with no pars or metastasis'. .opinion: explain what you think is causing the patient's symptoms. assume this is the only part read, so if there is only one kidney reiterate here. the lecture will illustrate additional information on scout images and benefits of coronal images. learning objectives: . to understand the influences of patient positioning, scan parameters and magnet/coil technology on image quality. . to learn how to optimise scan protocols to maximise patient throughput without compromising diagnostic quality. . to recognise how and when to modify scan protocols to answer specific clinical questions.a- the lumbar spine undergoes morphological changes with age. normal appearances and relevant normal variants will be discussed. in particular, the morphological change from an almost round intervertebral disc in newborns with high water sig-postgraduate.educational.programme s a b c d e f g h radiotherapy is an area with a rapidly improving development of new techniques and improved possibilities for accuracy. this lecture aims to illustrate and discuss points of contact and the need for collaboration between radiotherapy and radiography. european educational programmes and working fields for radiotherapy nurses and radiotherapy technicians are compared. radiotherapy nurses and radiotherapy technicians are responsible for the administration of radiotherapy to cancer patients and for the clinical care related to the treatment. apart from prevention and treatment of side effects and psychosocial support during the treatment, it encompasses preparations, delivery and verification of the radiation dose. educational programmes differ in terms of academical level and target groups, whether it is nurses or technicians in radiology or radiotherapy exclusively. areas in the radiotherapy process where competences from radiography are needed are discussed, considering both technical development and research progresses. learning objectives: . to gain knowledge about the differences and similarities between the areas of education and profession in radiography and radiotherapy from a historical perspective. the demand from the public for greater accountability and standards has increased the importance of audit and accreditation in modern healthcare delivery. specifically radiology departments participate in audit and accreditation by a number of entities. these include: . national bodies concerned with improving radiation safety particularly originating from eu / directives. . hospital wide accreditation surveys from state and private accrediting organisations. . auditing of standards from within professional bodies. . following from investigation of specific incidents such as misdiagnosis or radiation concerns. . modality-specific standards.although the specific requirements of the accrediting or auditing body may differ, the processes and practical aspects in demonstrating compliance with standards and quality improvement are generally similar. mechanisms such as outcomes, quality cycles, and performance indicators are critical in the success of any accreditation or audit program. in addition to fulfilling basic regulatory requirements, the medical physicist is playing an increasing role in developing performance indices particularly in radiation safety, clinical image quality and equipment management. the increasing role of the medical physicist in audit underpins the requirement for inclusion of audit and accreditation as part of their education. recent experience of setting up and participating in eu / directive-based clinical audit in ireland highlighted the critical need for clarity of roles and ownerships of processes to be communicated to those who are carrying out audit and those who are being audited in hospitals and dental practices. performing imaging studies in a child requires basic knowledge. the first point is to reassure and to avoid stressful/painful procedure. training of radiographer and radiologist is fundamental. explanations, presence of a parent (if not pregnant…), are preferable. specific devices may be useful for immobilisation and to avoid repeated exposures. antalgic drugs (traumatic circumstances) or sedative nitrous oxide inhalation (mcug) may be useful. x-rays exposition in relation with conventional radiology is lower than the one encountered with ct. but dose depends on type of examination and also on imaging equipment. new devices, such digital fluoroscopy with x-rays pulsed emission, flat-panel detector, slot-scanning x-ray imager need less ionising radiation than conventional screen-films devices or even photostimulable phosphor imaging plates. the scale between the higher and the lower dose for the same examination can be from ten to one. common principles of protection that apply to all x-ray imaging procedures, known as alara concept (as low as reasonably achievable), have to be used daily. act in accordance of the medical justification of the examination, without any non-ionising alternative method, remains the first step. the second one is the optimisation of each procedure, the limitation of expositions, with control of the x-ray beam adjusted to optimise the critical balance between image quality and exposure to the child. measure of the dose is mandatory to demonstrate appropriate levels on child exposure and to be sure in the future that very low radiation doses received during conventional imaging procedures will not produce adverse effects. the council directive / /euratom introduced the concept of clinical audit to medical radiological (diagnostic radiology, nuclear medicine and radiotherapy) procedures. clinical audit is a systematic review of the procedures in order to improve the quality and the outcome of patient care. according to the directive, clinical audits shall be implemented in accordance with national procedures. the review of its implementation in europe has revealed a high variation of approaches and many practical problems. therefore, the european commission has published further guidelines on clinical audits in its report radiation protection no. ( ). the purpose is to improve the implementation of clinical audits and to enable the member states to adopt the model of clinical audit with respect to their national legislation and administrative provisions. the guideline points out the importance of both internal and external assessments for clinical audit. it deals with all types and levels of clinical audit and gives practical guidance for application. it defines the list of topics which should be covered, while the actual criteria of good practice are discussed on generic levels only. the borderline between clinical audit and other quality assessments (accreditations, certifications, peer reviews) and regulatory inspections is also discussed. the guideline is addressed to all professional groups, hospital management, auditing organisations and regulatory bodies. it is important to recognise that the guideline is not a legal requirement. this refresher course lecture will give a summary of the ec guidelines and discuss briefly the implementation of clinical audits in europe.learning objectives: . to understand the purpose and essential contents of the european commission guideline on clinical audit. b. national perspective: clinical audit inspections s. ebdon-jackson; didcot/uk (steve.ebdon-jackson@hpa.org.uk) european council directive / /euratom requires under article ( ) that "clinical audits are carried out in accordance with national procedures". implementation of this requirement across europe has been varied. this paper will reflect on the experience in the uk and will consider examples of the various initiatives undertaken in the uk by professional bodies and organisations. this will be contrasted with the role of the regulator and the aims of the inspection process with regard to compliance with the specific regulation addressing clinical audit and the remaining regulations addressing justification, optimisation, etc. examples will be provided of the type of audits undertaken within uk hospitals. a uk perspective of ec and iaea initiatives in clinical audit will be provided. percutaneous radiofrequency ablation (rfa) is a safe and effective treatment for well selected patient with hepatic tumours such as hepatocellular carcinoma (hcc) and liver colorectal metastases (lcm). an appropriate selection is crucial. it is based on clinical and technical arguments. clinically, surgical resection of the haepatic tumours remains the gold standard. indeed, survival data following rfa are not as good as surgical resection. the only exception seems to be the rfa of the very early hcc (≤ . cm) in cirrhosis that is not candidate for liver transplantation. most often, the rfa offers an alternative for patients with medical comorbidities, poor liver function or prior hepatectomy. technically, there are three decisive points for complete ablation. the first point is the good visualisation of the tumour either under ultrasound or un-enhanced computed-tomography (ct) examination. metallic coil placement, lipiodol tattoo and virtual ct sonography with magnetic navigation are technical tricks that allow the rf ablation of "invisible" tumour. the second point is the tumour size: in most series, a diameter less than - mm is commonly admitted as a prognostic factor. this is probably because the maximal ablation diameter is slightly larger than mm with the electrode needles available now. micro-waves ablation might improve the local control by increasing the ablation diameter. the last point is the "heat-sink effect" that requires a temporary occlusion of a large vessel close to the tumour. the quality of follow-up imaging is a key factor for evaluation of tumour destruction. partial hepatectomy for liver metastases or primary liver tumours can only be performed when the future remnant liver volume (frlv) is considered large enough to avoid the risk of post-operative liver failure. in normal livers a frlv of - % is considered safe whereas in compromised livers a frlv of at least % is required. in patients whom the flrv is considered to small, pve may be performed pre-operatively to increase the frlv. pve involves percutaneous selective embolisation of the portal venous (pv) system, usually of the right liver lobe, which leads to atrophy of the embolised lobe. this, in turn, leads to hypertrophy of the frlv. because of the dual vascular supply to the liver (arterial and portal venous), necrosis of the embolised lobe does not occur. this compensatory hypertrophy of the left lobe facilitates resection in patients in whom the frlv would otherwise have been to small to allow resection. pve is most often performed percutaneously under conscious sedation and local anaesthesia through an ipsilateral approach, using a combination of particles, such as polyvinyl-alcohol (pva) and embolisation coils. potential complications of pve include thrombosis of the contralateral pv, liver abscess formation or cholangitis and are rare. most of the hypertrophy occurs in the first - weeks after pve and increase in volume of the frlv averages % after this time period. ct-volumetry should be performed both before pve and after - weeks to measure increase in frlv. accurate identification and reporting on soft tissue extremity masses is essential for correct diagnosis and optimal treatment planning. this lecture focuses on the mri signs to stage and grade-characterise soft tissue mass lesions. these two objectives are the major structural components of the mri report and fit the request of the referring clinician. this implies an accurate description of these signs with appropriate terminology in the report. local staging is essential for the preoperative work up. important staging parameters are size, compartmental location, skip lesions and relationship to neurovascular structures and joints, as well as distance to the nearest joint space. grading and characterisation is complex and multifactorial and classifies the lesions as "certainly benign" (no biopsy needed) and "possibly " or "certainly malignant" (biopsy needed). grading parameters are homogeneity, (changing) signal intensities in multiple acquisition techniques and static and dynamic gadolinium enhancement pattern. these are used to define the composition of the lesion, i.e. fat, met-hb, hemosiderin, myxoid tissue, collagen, viable, cystic or necrotic components. other important grading and parameters are lesion margin, shape, perilesional invasion or destruction, multiplicity, specific location and associated findings but also age and gender of the patient. image guidance and imaging fusion techniques represent an integral element in oncologic interventions and liver surgery. in addition, several liver planning techniques such as the virtual liver surgery planer enhance simulation of a proposed liver resection. using roboter-assistance or navigational guidance combined with thermal ablation techniques such as radiofrequency ablation, significantly enhances accuracy of ablation probe placement and efficacy of ablation necrosis. furthermore, the local recurrence rate can be considerably reduced, and the amount of complete tumour ablation is significantly more likely. integrating magnetic resonance imaging, and focused ultrasound to deliver and activate nano-capsules carrying anti-cancer drugs to effectively target tumours will be another task. this will involve drugs being injected into the body in the form of tiny capsules, which are harmless until they are activated by a concentrated focused ultrasound `blast'.the mri scanner will then be used to track the passage of the drugs, visualise the target and monitor the delivery of the drug treatment. the risks associated with radiation exposure in ct is of concern to radiologists, medical physicists, government regulators, and the media. thoracic ct is a technically robust, non-invasive imaging technique for the evaluation of several traumatic and non-traumatic thoracic emergencies. technical advances in the past years have resulted in improvements in image acquisition speed, spatial resolution, and the temporal resolution. consequently, thoracic ct can now be performed rapidly in emergency conditions without substantial delay in treatment. state-of-the-art ct systems are now capable of imaging the entire thorax within a few seconds. however, radiation exposure associated with thoracic ct have been increased with the advantages of modern ct systems particularly in the evaluation of chest pain syndrome. thoracic aortic ct angiography with cardiac gating may now be considered the preferred technique for the evaluation of chest pain syndrome in selected patients but is associated with a substantial higher radiation dose than routine non-gated thoracic ct. several effective strategies have been developed to limit the radiation exposure in cardiac gated thoracic ct including prospective ecg gating techniques, anatomy and ecg-based tube current modulation, high pitch acquisition, and adaptation of the ct scanning parameters to the body habitus. in addition, several techniques are available to reduce the radiation exposure in nongated thoracic ct depending on the patient's body habitus and the clinical indication. because of advancing technical developments and increasing diagnostic utility of mdct in emergency care, its use has expanded significantly and has changed patient care, especially in chest emergencies. however, mdct has important drawbacks in cost and radiation exposure. the first presentation will discuss mdct in acute chest pain (acp). scan techniques in different scanners will be addressed. the reasons why cta/ctca can be a viable application for acp and the current evidence for cta in acp will be discussed followed by an update on indications. the next presentation will address mdct in chest trauma. its significance, the utility of this imaging method and its advantage compared to other modalities will be discussed. the examination protocol and the role of post-processing methods will be addressed. the interpretation of mdct, findings, benefits, limitations and pitfalls will be shown. the utility of chest x-ray and ultrasound as primary examinations and the indication for mdct, routine or selective, will be discussed. our last speaker will familiarise us with procedures to measure radiation dose in thoracic mdct, followed by an update of radiation exposure associated with the protocols for the different clinical indications. finally, available techniques for radiation dose reduction in ecg-gated and non-gated mdct and their effectiveness in radiation dose reduction will be demonstrated. however, the best way to reduce radiation is to perform mdct only when there is an appropriate indication and this will be the focus of the concluding panel discussion of this session. chest trauma is, particularly in younger population, a significant cause of morbidity and mortality. it is directly responsible for - % of trauma-related deaths and in other % of deaths it is an important contributing factor. imaging methods play the key role in management of this group of patients. introduction of mdct in the last decade of the th century markedly changed the diagnostic approach to the thoracic trauma. fast data acquisition and increased resolution in the z-axis enabled reliable assessment of all chest anatomical components (often together with other parts of the body) in one examination. compared to x-ray mdct defines more accurately the extent and severity of traumatic changes and may detect serious in % of nontraumatic cases, subarachnoid haemorrhage (sah) is the result of aneurysmal rupture. other causes of sah include perimesencephalic sah ( %) and other disorders ( %) such as arteriovenous malformation (avm), vertebrobasilar artery dissection, dural av-fistula, cortical vein thrombosis, amyloid angiopathy, … sah represents an emergency situation and diagnosis should be established asap.plane computed tomography (ct) is the initial diagnostic test of choice (wide availability, easy accessibility, high sensitivity and specificity). if ct is negative, lumbar puncture and/or mri of the brain (including flair images) and spine should be performed. d tof mr angiography (mra) sequences have high sensitivity and specificity in detecting cerebral aneurysms; but because of their lower spatial resolution are insufficient to analyse in detail aneurysm morphology. this in contrast with cta. both cta and mra may be proposed as a first-choice, noninvasive examination, but the negative predictive value is poor, and therefore digital subtraction angiography (dsa) is mandatory for all sah cases with negative cta or mra. catheter angiography remains the golden standard in the detection and evaluation of cerebral aneurysms (size, relationship between neck and adjacent vessels, etc). increased attenuation (ct) and hyperintense signal (flair) within the basal cisterns and sulci are a characteristic finding of sah; however, it is aspecific. pattern and location of the blood may help to locate the ruptured aneurysm; sometimes helpful when multiple aneurysms are found. pseudo-sah may be a potential imaging pitfall because it may be observed in other acute neurological conditions (cerebral edema, bacterial meningitis, etc). recurrent disease following treatment for primary breast cancer can occur in the same breast following conservation surgery, ipsilateral breast tumour recurrence (ibtr) or in the contralateral breast, metachronous contralateral breast cancer (mcbc). estimations for the rate of recurrence are between and . % each year. the rate of recurrence is higher than breast cancer incidence in the general population. risk factors for recurrence are young age (< ), high grade disease, incomplete tumour excision and no radiotherapy. due to the large numbers of women who develop and survive breast cancer the cost and resource required to follow-up these women is considerable. there are variable guidelines in europe for the surveillance of women but most regimes include clinical follow-up and mammography. variations concern the frequency of mammography, the length of follow-up required, and whether clinical examination is required. the clinical effectiveness and cost-effectiveness of different surveillance mammography regimens after the treatment of primary breast cancer will be reviewed together with the results of systematic reviews. modelling of two data registries was undertaken to ascertain the survival benefit. alternative methods of surveillance will be considered such as mri with the diagnostic accuracy of the various imaging techniques considered. a summary of the economic evaluation will be presented to demonstrate the assumptions that require to be made in this complex area where there is a paucity of evidence.learning objectives: . to understand the risk of recurrent disease and second primary following the treatment of breast cancer. . to review literature on surveillance mammography and other imaging methods for detection. . to appreciate the range of recommendations for surveillance mammography and clinical follow-up with cost benefit analysis. the new challenge in breast cancer: evaluation of response : evaluation of the treated breast is one of the major challenges in breast imaging.there is especially much debate on the evaluation of response to therapy. the best imaging modality, the best imaging criteria, timing, accuracy and limitations of imaging are currently being investigated. whether it is time to reach conclusions regarding these aspects is the issue of this panel discussion. intracranial aneurysms are abnormal dilatations of the arteries, and will be found in % to % in general population. in % cerebral aneurysms are saccular and develop from the arteries of the circle of willis or its major branches. aneurysms typically become symptomatic between the age of and years, with subarachnoid haemorrhage (sah) or intracerebral haematomas. less common are giant aneurysms usually found in middle-aged women presenting with signs more indicative of a mass lesion. ct angiography (cta) has been proven to be an excellent tool to visualise intracranial arteries. the average sensitivity of cta for the detection of intracranial aneurysms reaches %. post-processing allows assessment of the aneurysm with maximum intensity projections (mip) and surface-rendered d projections in multiple plains. mr angiography (mra) is a practical and noninvasive tool for screening of high-risk individuals for aneurysms. dsa is diagnostic method of choice for assessment of intracranial aneurysms and was considered to be a 'gold standard' for evaluation of cerebral vessels. a clear shift from invasive to noninvasive imaging of cerebral vessels has been noticed in the last decade. this lecture will discuss advantages and disadvantages of cta, mra and dsa in detection, assessment, and post-treatment evaluation of intracranial aneurysms. intracranial aneurysms have a multifactorial origin. a heterogeneous and complex group of pathogenic mechanisms including luminal, mural and extramural factors interact for the development and growth of aneurysms. there are several types of intracranial aneurysms, being the saccular the most common type. the aneurismal treatment is dependent on its type and needs a multidisciplinary approach including endovascular and microsurgical teams. endovascular treatment is recognised as the first-line treatment for most of the ruptured saccular intracranial aneurysms. there has been an enormous improvement in the endovascular technology and techniques offering a wide spectrum of treatment possibilities that broadened the variety of aneurysms that can be treated. the treatment options include the use of coils with/without the help of balloon-remodelling and/or stenting. other options include the use of covered stents, of "flow-diverter" stents, of liquid embolics, or the parent vessel occlusion. the multislice computer tomography angiography (mscta) is a reliable method for pretreatment evaluation of intracranial aneurysms. for the posttreatment evaluation, magnetic resonance angiography (mra) can be used for the follow-up of embolised aneurysms; and mscta may be used for the follow-up of surgically treated aneurysms. there are several challenges remaining in aneurysm management. in the diagnostic field, improvement of the non-invasive techniques for the diagnosis, for the morphological and haemodynamic characterisation and for the posttreatment follow-up of aneurysms is expected. in the endovascular field, technological breakthroughs to improve the occlusion rate, to increase the treatment durability, and to promote the vessel wall healing are desired. learning objectives: . to learn about present treatment of brain aneurysms. . to understand the strategies for multimodal ct and mr aneurysm imaging pre and post-treatment. . to present the challenges for neuroimaging in the field in the near future. where do we stand in brain aneurysm treatment today? : there is a significant difference in the management of patients with ruptured versus un-ruptured brain aneurysms. this panel discussion will focus on the management of patients with brain aneurysms and will with simple case presentations show the management in ruptured and un-ruptured aneurysms and discuss the involvement of the neurosurgeon in more complex cases.cone beam ct (cbct) is a method for obtaining ct-like images using a c-arm system. our aim was to investigate the accuracy of these images compared with multi-detector ct (mdct) as a gold standard in radiological imaging of abdominal aortic aneurysms (aaa). patients with aaa referred for elective evar were included in a pre-therapy protocol ( patients) and in a post-therapy protocol ( patients). all were exposed to standard mdct and one additional cbct. image data were evaluated by two radiologists and statistically compared using a linear mixed model. first, predefined arterial measurements were performed, then predefined anatomical areas were assessed and scored for visibility on a scale from to . all measurements were chosen to be relevant for evaluating of aaa before and after evar. for the arterial measurements no significant differences were found between mdct and cbct. visibility for the anatomical areas was significantly better for mdct; however, most of the cbct readings were above lowest acceptable level. visualisation of the iliac arteries was suboptimal. we think that our results support the start of clinical trials that scientifically can test the outcome without the use of mdct immediately before and after evar. the problem with poor visualisation of the distal iliac arteries might be solved with newer technology. in conclusion, the result indicates that cbct in the operation room gives sufficient image-based information to support evar in a pre-and post-therapy setting. undertaking theatre radiography can appear a daunting task for the radiographers lacking in confidence in their ability but others (like all expert practitioners) make it look easy and uncomplicated. theatre radiography requires all the knowledge, skills and abilities of a competent radiographer together with assertiveness, reflection and the ability to modify your technique at a moment's notice. there are a multitude of 'traits' which distinguish the expert from the novice. these include production of optimum images, effective use of the equipment, radiation protection, infection control, effective communication and teamworking. there is also a clear depth of knowledge together with a multitude of skills and abilities. the key to a stress-free experience is preparation. it is essential that there is a mechanism for theatre staff and the radiology department to communicate effectively and give the radiographer prior notice of all cases requiring their attendance. it is also desirable to be in the theatre when the patient arrives for their examination to enable you to check the patient's identity, pregnancy status and ensure the patient is positioned correctly to facilitate screening. there are few excuses to give the surgeon if you cannot screen the area of interest because of poor positioning of the patient and equipment. this paper will discuss the knowledge, skills and abilities required to undertake theatre radiography in a safe and proficient manner without feeling threatened by the experience. learning objectives: . to understand the key skills required to undertake radiographic procedures in the operating theatre. . to gain an insight into the interpersonal skill required for effective radiographic practice in the operating theatre. prediction of coronary revascularisation outcome represents a major clinical question because a large number of medical and surgical options have become available for ischaemic cardiomyopathy with need to identify more rigorous criteria for patient's selection. the combination in a single examination of function, stress-perfusion and tissue characterisation with t -weighted 'oedema-sensitive' and late-gadolinium enhancement (lge) techniques supported the role of cardiac mr (cmr) as an important technique for the evaluation of patients candidates to revascularisation. besides more "traditional" indicators such as ejection fraction, end-diastolic wall thickness or endsystolic volumes, extent and distribution of myocardial scar depicted with lge has been identified as one of the most important predictors of post-revascularisation outcome with direct influence on functional recovery and on major adverse cardiovascular events (mace) due to the potential induction of arrhythmias from the scar.lge technique has been shown to be superior to nuclear medicine for the assessment of myocardial viability due to the higher spatial resolution (up to -fold greater than spect) and an intrinsic high contrast resolution. a further technique that could be adopted before revascularisation is stress imaging. myocardial ischaemia detected by either cmr adenosine first-pass perfusion or dobutamine-induced wall motion abnormalities has been shown to predict subsequent cardiac death whereas normal stress perfusion showed a high negative predictive value for mace. in conclusions, although as a relatively new diagnostic modality prognostic evidence is predominantly derived from singlecenter studies, cmr is increasingly becoming an important tool for risk stratification of patients before revascularisation, offering indications about outcome and mortality. cardiac valve diseases are an important public health problem, strongly linked to the general increasing age of the western population. the most frequent valve disease is aortic stenosis, for which percutaneous aortic valve replacement (pavr) is currently evolving to a feasible alternative therapy for the classical surgical approach in high-risk patients. nevertheless, careful evaluation of all aspects of this new approach is still required to avoid uncontrolled diffusion. imaging plays a key role in selecting patients who may be eligible for pavr, focusing on the evaluation of leaflet anatomy, severity of valve dysfunction, haemodynamic consequences and potential problems in the access route. while echocardiography is commonly used for both the anatomical and functional evaluation, multidetector ct (mdct) has important intrinsic advantages providing state-of-the-art d imaging with a high spatial resolution over a large anatomic coverage. during this course, we will discuss the advantages and disadvantages of mdct compared to other imaging modalities. the relevant anatomy of the aortic valve and annulus will be reviewed, with emphasis on correct alignment of the imaging planes, and its implications for correct reporting of the necessary measurements targeted at the clinicians need. furthermore, mdct scan protocol design will be reviewed, focusing not only on optimal implementation of common scan parameters but also on the need of ecg-triggering and its consequences. finally, we will present the current status of evidence on using mdct in pavr procedures, and discuss future challenges and perspectives. learning objectives: . to understand how to optimise the imaging protocol for aortic valve imaging. . to learn how to report the findings and what to include in the report. . to understand the impact of this approach on patient management. the need for quantitative image analysis in radiology is universal: computer-aided detection, segmentation for d volume visualisation, image enhancement, pattern recognition, etc. all need effective, robust and preferably generic (not 'ad hoc') algorithms for the computer. how to design such algorithms? a good inspiration source is the functionality of the visual system, the best investigated brain structure today. in this talk we will explain how we think the brain calculates features in images, why the retina measures at a wide range of resolutions and how we can exploit this. the visual system is strongly adaptive and self-learning. new optical recording techniques have given new insight in how the cells in the visual cortex are functioning. we will go through these functionalities step-by-step. what we discover is quite amazing. we recognise huge amounts of filter banks in the first stages of vision: many filters analyse each pixel of the incoming image at a range of scales, orientations, derivative order, for each colour, and also as a function of time. extensive feedback loops take care of optimal settings locally. we programmed these filters into the computer, and were able to build many interesting applications for computer-aided diagnosis: detection of catheters at seriously reduced levels of x-ray radiation dose, automatic polyp detection, quantitative analysis of ischaemic heart ventricle deformation, breast cancer cad, pulmonary emboli cad and analysis of in vivo microscopy images now so abundant in modern life-sciences research. postgraduate.educational.programmethe gi tract are leading causes but any tumour involving the abdominal cavity or haematological malignancy may be implicated. during treatment with chemotherapy or radiotherapy acute abdominal symptoms are common as a consequence of direct toxicity. imaging must be used as an adjunct to clinical assessment. patterns of abdominal involvement are often modified in the later phases of disease. gi tract obstruction may be due to progression or the mechanical consequences of prior surgery and is more commonly at multiple levels. perforation or fistulation may occur with either progressive disease or tumour lysis in response to therapy. cancer does not protect against the common inflammatory conditions but poor host response and the use of steroids may mask signs leading to extensive abnormality at diagnosis. bone marrow suppression increases susceptibility to infection including neutropenic enterocolitis and haemorrhage. bone marrow transplantation and consequent graft versus host disease is a potent cause of acute abdominal symptoms. ct is the major imaging technique although mr has an increasing role particularly in the assessment of the female pelvis. major determinants when considering the differential diagnosis include; the nature and initial stage of the primary, any prior anatomical modification (surgery), the nature and relationship to current treatment and the bone marrow status. this workshop will begin by describing the current limitations of mri in evaluating prostate cancer patients and will show how to overcome these with advanced imaging techniques including diffusion weighted mri (dw-mri), mr spectroscopic imaging ( h-mrsi) and dynamic contrast enhanced mri (dce-mri). the emphasis will be on the use of processing tools that are readily available for clinical practice. we will describe how to analyse images and provide a scheme for reporting findings back to surgeons/oncologists. we will show that using more than one mri tool improves imaging performance and that the relative importance of each technique remains unresolved. we will demonstrate new indications for advanced mri in prostate cancer patients. abdominal hernias are common in daily practice and can be divided into: external or abdominal wall hernias, internal hernias and diaphragmatic hernias. external hernias typically involve protrusion of abdominal contents through a defect in the abdominal wall. internal hernias involve protrusion of viscera through congenital or acquired defects in the mesentery or the peritoneum. diaphragmatic hernias involve protrusion of abdominal contents into the chest. among these conditions, the diagnosis of internal hernia is the most challenging. bariatric surgery and liver transplantation with biliary-enteric anastomosis, with the roux-en-y loop placed in a retrocolic position, are recognised predisposing factors for internal hernia development. symptoms of hernia are nonspecific and vague, and clinical and radiologic diagnosis can sometimes be challenging. immediate diagnosis is mandatory because misdiagnosis can be complicated by bowel obstruction, volvulus, strangulation, incarceration, or trauma. mdct with its multiplanar capabilities is widely believed to facilitate this diagnosis, because it is able to delineate hernia type, location, size, and shape and is particularly useful to diagnose unsuspected hernias. it also allows distinguishing hernias from masses of the abdominal wall, such as tumours, haematomas and abscesses. as a result, knowledge of the ct findings of abdominal hernias may allow early and more accurate diagnosis, with a resultant decrease in the mortality rate. the title of this talk limits the discussion of torsion to the mesentery and omentum. it has to be mentioned, however, that an abnormal twist (torsion) can involve any peritoneal reflection of those suspending and fixating hollow viscera, (e.g. stomach, small bowel, cecum, sigmoid and gallbladder), solid organs, (e.g. spleen, ovaries), or even extraperitonel (extraabdominal) organs such as the testicles, leading to the pathologic entity of volvulus or torsion of the corresponding viscous with its associated (different) imaging findings, prognosis and treatment. moreover, twisting of the mesentery and volvulus can occur secondary to a variety of conditions including congenital anomalies of intestinal rotation with variable prognosis. finally, torsion of the omentum can be either primary or secondary, also associated with different pathology, imaging findings and treatment. consequently, a broad spectrum of abnormalities ensues related to the pathophysiology of torsion which requires a detailed classification, an accurate description and the use of correct terminology making it impossible to be covered within the time limits of a presentation. therefore, focusing the discussion on to abnormal twist of small bowel mesentery and omentum will simplify the approach to avoid overlaps and confusion. this case-based lecture will present typical clinical cases of pelvic pain as well as some unusual but important causes. cases of acute and of chronic pelvic pain, and benign as well as malignant disease will be included. the audience will have the opportunity to participate in case discussion by the use of interactive voting pads. the selection of imaging modality for each clinical presentation and the importance of knowing the clinical findings at the time of the radiological interpretation will be discussed. for each case, the key radiological features will be illustrated. the essential elements of the radiology report and the key information required by the clinician will be discussed. in each case, the differential diagnosis and the need for follow-up imaging will be considered. the key teaching points for each diagnosis will be reviewed. this lecture provides a practical approach to the fundamentals of normal cross-sectional anatomy of the hip. basic knowledge necessary to identify the different portions and contents of the joint anatomy is provided. a special emphasis is on cartilaginous structures, the acetabular fossa, and capsular fibers and ligaments. functional anatomy of muscles and tendons about the hip is reviewed. the location of bursae and their association with adjacent structures is discussed. in the second part of the lecture attendees will learn how to avoid commonly seen pitfalls about the hip. a special focus on anatomic variants of the acetabular labrum simulating disease is given. osseous variants including acetabular ossicles and the superior acetabular notch will be explained and explored. debates about the role of herniation pits referred to as a normal variant are reviewed. the lecture offers an overview of muscular and tendinous variations around the hip joint. pelvic pain is an important part of clinical practice for any clinician who provides health care for women. pelvic pain may be acute, recurrent or chronic. acute pelvic pain (app) rarely lasts more than one month without crisis, resolution, or cure. pain of more than or or months of duration is considered as chronic pelvic pain (cpp) and in many settings may be considered and treated as an illness itself. women who present with app frequently exhibit nonspecific signs and symptoms. diagnostic considerations encompass multiple organ systems, including obstetric, gynaecologic, urologic, gastrointestinal, and vascular aetiologies. as the first priority, urgent life-threatening conditions (e.g. ectopic pregnancy, appendicitis and ruptured ovarian cyst) and fertility-threatening conditions (e.g. pelvic inflammatory disease and ovarian torsion) must be considered. adolescents and pregnant and postpartum women require unique considerations. ccp is a common and significant disorder of women, with a prevalence of . - %. many disorders of the reproductive tract, gastrointestinal system, urological organs, musculoskeletal system, and psychoneurological system may be associated with ccp, the most common being endometriosis, adhesions, irritable bowel syndrome and interstitial cystitis. ultrasonography should be the initial imaging test because of its sensitivities across most aetiologies and its lack of radiation exposure. computed tomography (ct) serves an important role in patients with nonlocalizing symptoms, an indeterminate us evaluation, or in patients who require a wider search beyond the field of view available with us. magnetic resonance imaging is an extremely useful second-line modality for problem solving after us or ct. fat-suppression sequences help to establish fat-containing lesions and increase the conspicuity of inflammatory lesions. different sequences will be discussed. mr is rated below us and ct for evaluation of acute pelvic conditions, but is excellent alternative when administration of iodinated contrast media or radiation exposure is undesirable, especially in young or pregnant patients. long imaging times, limited access and cost are major drawbacks of mri. imaging findings of various gynaecologic and nongynaecologic conditions causing female pelvic pain will be presented. an overview of the interventional radiology management of painful osseus metastases will be presented. consideration will be given to patient, lesion and treatment modality selection (including radiofrequency ablation, cryoablation, microwave ablation, laser ablation, ethanol ablation, mr focused ultrasound ablation, cement osteoplasty, transarterial embolisation and combinations therein, e.g. combined radiofrequency ablation and cement osteoplasty). the evidence supporting these techniques and patient outcomes will be reviewed. molecular imaging -defined as the non-invasive assessment of biological mechanisms at molecular and cellular level -will play a major role in future disease diagnosis and treatment planning. in this context, the aim of this session is to introduce in simple terms several major research areas in molecular imaging and to discuss their future potential for clinical radiology. the differential diagnosis of hip pain is broad and includes intra-articular pathology, extra-articular pathology including referred pain from the spine, and mimickers including groin pain and pain from the joints of the pelvic ring. the diagnosis of all causes of hip pain/pathology has improved with greater use of magnetic resonance imaging (mri) to complement traditional investigations. in this session pathology involving the hip and groin will be reviewed in a systematic way which will outline an approach to the hip that will allow the reader to maximise their diagnostic ability. the review will include evaluation of bone marrow disorders such as avascular necrosis and transient osteoporosis and intra-articular pathology including labral tears and femoroacetabular impingement (arthritis and traumatic fractures will not be reviewed). extra-articular diagnoses such as bursitis, groin pain (osteitis pubis and adductor/ gracilis dysfunction) and common muscle and tendon injuries will then be reviewed. today, many procedures of bone and joint are performed under imaging control. minimally invasive procedures require less resources, time, recovery, and cost, and often offer reduced morbidity and mortality, compared to other modalities. many percutaneous techniques are available. some aim to treat pain and consolidate bone (cementoplasty). others ablate or reduce the tumour (chemical and thermal ablation techniques). the interventional radiologist with an efficient imaging-guided technique (flat panel fluoroscopy, ct, and mri) can increase the precision of the above-described procedures allowing an improvement of the results and reduction of the complications. furthermore, the presented interventions are carried out either on an outpatient basis or with hours hospitalisation which contributes to the reduction of overall costs and presents a major advantage for patients of working age. some of these minimally invasive procedures can be considered as alternatives to surgery without excluding further surgical options if necessary. back pain is one of the most common complaints, it is estimated that almost % of working adults will experience it in any given year. diseases of peripheral skeleton may produce painful symptomatology as well. some of the algogenic structures of the spine and peripheral skeleton are lumbar intervertebral discs, facet joints and atlanto-axial/occipital joints, sacroiliac joints, nerve root dura, periosteum, ligaments, fascia. among several aetiologies which can involve these structures, spine degenerative pathology plays the leading role. nowadays, several different interventional techniques are available, each one with its specific target of action. with the right indication each of them has been proved to be effective as painkilling modality. herein, we present an up to date comprehensive overview on the interventional techniques available with their own indications. small airways and small airways diseases (sad) have attracted a lot of interest that has resulted in a large number of publications since the early s. despite the several histopathological and clinical subtypes that have been described diagnosis is not always obvious. the introduction of thin section ct and the fact that this ct technique is able to depict signs of sad has not only renewed interest but has also improved insights in these disorders. in this session the direct and indirect ct signs of sad will be presented and the ct techniques that can improve their detection will be explained. correlations between pathological findings and the presence of these ct signs will be made and diseases that can mimic these ct findings will be discussed. schemes of classification of sad based on clinical and pathological findings will be discussed briefly, but most attention will be given to the radiological classification, which is based on the recognition of the direct and indirect signs of sad. algorithms that help to identify the cause of sad will be presented. finally, the use of ct and also of mr as a tool to examine the structure-function relationship in sad will be discussed. it will be shown how careful interpretation and software tools can help to generate data about disease extent and global and regional lung function. the ability to recognise direct and indirect signs of small airways disease on hrct has led to renewed interest in these elusive disorders. the "purest" of these diseases is constrictive obliterative bronchiolitis which is manifested on hrct by the indirect sign of a mosaic attenuation pattern; the differential diagnosis for mosaicism and an algorithm that helps to identify the correct cause of small airways disease will be presented. the necessity for routine expiratory hrct to make the diagnosis of obliterative bronchiolitis is controversial and will be discussed jointly whole body fluorescent imaging and bioluminescent imaging are now widely applied in small animals to study all kinds of biological and molecular processes like i.e. gene expression, tumour progression and metastasis, apoptosis, inflammation, angiogenesis, proteolysis and to follow trafficking, differentiation and fate of cells (i.e. stem-, immune-and tumour cells). this has been done mainly by using gene reporters expressing fluorescent proteins or luciferases. recently new mutated red shifted fluorescent proteins (with better light penetration and less absorption and autofluorescence) and codon optimized and mutated luciferases have been developed making optical imaging more sensitive and offering the possibility to use dual gene reporters. apart from new "smart gene reporters" there has also been a great development in injectable near infrared fluorescent (nirf) probes, especially for tumour detection. these nirf probes can either be targeted or enzyme-cleavable. these new developments has opened up the possibility to apply nirf imaging in the clinic especially to image tumour tissue and to identify sentinel lymph nodes during operation. the assessment of the tumour-free margin during cancer surgery is critical to completely remove the tumour and improve the prognosis of the patient. by injecting a tumour specific nirf probe, tumour tissue and local metastases can be visualised in real-time during operation using a dedicated nirf camera system. we now already use nirf imaging in the clinic to detect the sentinel lymph node (sln) in several types of cancers. in the current presentation preclinical and clinical applications of nirf imaging in image-guided surgery will be discussed. targeted ultrasound contrast agents have opened up the door for molecular imaging with sonography. these contrast agents, which consist of encapsulated gas microbubbles, are coated with antibodies or specific ligands. injected into the circulation, microbubbles are retained in diseased tissue where they can be detected and quantified by different approaches such as "semiquantitative -d" or "quantitative -d" imaging techniques. due to their size, microbubbles behave similar to red blood cells and remain within the intravascular space. therefore, the disease process must be characterised by specific molecular changes on the surface of the endothelial cells to be assessable by ultrasound. several angiogenic markers such as vegfr , α v β -integrins, icam- and vcam are known to be overexpressed by the endothelium in neoplastic, inflammatory and vascular diseases. thus, molecular ultrasound imaging seems perfectly suited to detect these markers and monitor changes which might occur during treatment response or disease progression. today, targeted ultrasound contrast agents are becoming a routinely used preclinical tool and the first application of specific microbubbles in a clinical scenario is expected for the near future. this talk will introduce into the principles of molecular imaging with ultrasound. based on recent studies, basics of tumour biology, potential endovascular targets, synthesis of molecular probes and different imaging approaches for a preclinical and clinical application of molecular ultrasound will be discussed. in this rc, a general insight of imaging in epilepsy, including indications, protocols, and the most common neuroradiological conditions to be identified, will be covered. particular interest will be given to tumours as a cause of epilepsy, and to their more relevant neuroradiological aspects. finally, the contributions of different imaging techniques in the specific context of epilepsy surgery will be reviewed. brain tumours are a common cause of epilepsy more often in adults, less in children.tumours detected in patients with chronic epilepsy are predominantly located in the brain cortex area, affecting the temporal lobe most often. any benign or malignant brain tumour can be responsible for seizures, but some are more frequently associated with epileptic symptoms. low-grade astrocytomas, oligodendrogliomas, gangliomas, dysembryoplastic neuroepithelial tumours (dnets) and glioblastomas multiforme are the tumours significantly often presenting with seizures in adult population. brain tumour-related epileptogenesis in not fully understood yet, but one can list a number of factors playing an important role in this process, including: disruption of physiological neuronal structure, tumour affection on the release of neurotransmitters and abnormal electrical activity of the brain. different imaging techniques are widely used for evaluation for neoplasms in epileptic patients. ct is reserved for acute conditions, one must remember to exclude other possible aetiologies of seizures like haemorrhage, trauma or inherited malformations. mri remains the gold standard in imaging investigation of patients with epilepsy. conventional pre-and post-contrast se sequences are mandatory to perform in every subject. newer and more sophisticated techniques such as diffusion-weighted imaging (dwi), functional studies (fmri), spectroscopy (mrs) and pet are helpful in qualification for surgery and preoperative functional mapping. mri has become established as the modality of choice for preoperative local staging of rectal cancer. the most important general advantages of mri compared to other crosssectional imaging modalities are the soft tissue contrast resolution between the propria muscle layer of the rectum and the perirectal fat, the ability to visualise the different pelvic compartments including the visceral pelvic (mesorectal) fascia and the surrounding tissues in the pelvis. high resolution t -weighted sequences sagittal, transaxial and perpendicular to the tumour is the basic standard for morphological evaluation of the tumour, the distance of the tumour to the anal verge and for evaluation of extramural extension and the distance to the circumferential resection margin. presence of other adverse features such as extramural venous invasion and local lymph node metastases is also noted. the mr-images are ideally demonstrated by the radiologist in a local multidisciplinary conference to make sure that the information is used to select the best possible treatment for the patient. when neo-adjuvant treatment is administered, mri is usually performed both before and after treatment to assess treatment response. when planning surgery, both the pre-as well as the post-treatment images should be available for surgical planning. finally in this lecture, the potential benefits of t compared to . t for pre-operative imaging of rectal cancer as well as the present role of additional techniques, such as diffusion-weighted imaging (dwi) and specific contrast agents that have been evaluated for assessment of rectal cancer will be addressed. locally recurrent rectal cancer is the main concern after rectal cancer surgery and has long been regarded as a rarely curable disease. patients were treated palliatively, and subsequent median survival was months and the -year survival rate was %. however, during the past - years, more patients were considered candidates for curative treatment due to better treatment options. patients with distant recurrences from colorectal cancer, especially those in the liver or lung, have improved chances for cure with better imaging, better surgery and alternative minimal invasive treatment. in the follow-up after colorectal cancer surgery it is thus important to detect recurrences at an early stage. besides cea, imaging is often used as a surveillance tool. it is still unclear which is the most cost-efficient (imaging) tool for monitoring distant and local recurrences. this lecture aims at providing the evidence for surveillance by imaging and reviewing the guidelines for the detection of recurrences after colorectal cancer surgery. it will also discuss the role of mri for establishing resectability of locally recurrent rectal cancer and the imaging patterns and features of recurrent disease. its strength comprises a high sensitivity in detecting coronary stenosis > % and an excellent negative predictive value. the stringent limitation of cta lies in its confinement to anatomic grading of coronary stenosis and a lack of information regarding whether a stenosis causes reversible myocardial ischaemia indicating the need for coronary revascularisation. recently published data in animals and humans indicate that myocardial computed tomography perfusion (ctp) imaging is feasible, promising and accurate. the advantage of cta is the comprehensive evaluation of coronary arteries and myocardial perfusion defects from the same datasets, which permits both visualisation of coronary anatomy and physiology.further, ct provides information about regional and global myocardial function. the aim of this course is to understand basic principles of ct perfusion and functional imaging, to learn "how-to" perform ctp and comprehensive cta/ctp scans, to review current scientific evidence and to discuss potential clinical applications. nuclear medicine tests (spect and pet), mri and more recently mdct have been involved in myocardial perfusion imaging. in clinical practice, perfusion analysis is routinely performed with qualitative or semiquantitative assessment, both based on relative evaluation of uptake or enhancement of myocardium, considering a remote region as normal. however, the assumption of part of myocardium as normal can be wrong and cause false negatives. absolute quantification has been introduced mostly with pet perfusion imaging (water, ammonia and rubidium), but its incremental value for the clinical decision making has not been widely investigated. more recently, mr perfusion imaging has been used for quantitative analysis with different technical approach. there are some clinical scenarios where quantification can change the clinical interpretation: . multivessel coronary artery disease (cad), . balanced multivessel cad, . exclusion of cad in symptomatic patients, . microvascular disease, . revascularised patients. however, there are still some limitations in the use of absolute quantification: first, the setting of cutoff value for normal or abnormal perfusion; second, some clinical situations, such as heart failure patients, where perfusion is reduced and heterogeneous. finally, studies concerning the prognostic value and the cost-effectiveness are needed. epilepsy is a common disorder with a prevalence of up to % in the general population. epilepsies are broadly classified into generalized and focal. though most generalised seizures are controlled pharmaceutically, % of focal seizures are medically intractable. in this subset of patients, the overall sensitivity of mri in identifying responsible substrates is approximately %. the purpose of neuroimaging in epilepsy patients is to identify underlying structural abnormalities that require specific treatment (usually surgical) and to aid in formulating a syndromic or aetiologic diagnosis. in this presentation imaging findings of the most common non-neoplastic lesions responsible for focal epilepsy, namely: a. hippocampal sclerosis, b. malformations of cortical development, c. vascular abnormalities and e. gliosis, will be discussed along with their differential diagnosis and pertinent imaging pitfalls. since routine mr imaging is suboptimal in identifying epileptogenic substrates, imaging should be tailored accordingly. hippocampal sclerosis, the most common cause of mesial temporal lobe epilepsy, is best demonstrated when the temporal lobes are imaged with thin sections in coronal plane perpendicular to the longitudinal axis of the hippocampus. inversion recovery sequences best demonstrate morphology and volume loss in the hippocampus, mammilary body and fornix. t and flair images best demonstrate the increased signal due to gliosis. for malformations of cortical development flair is useful in assessing hyperintense signal. t gradient volume sequences can demonstrate subtle developmental malformations. finally, because many epileptogenic lesions are subtle and easily overlooked, a systematic diagnostic approach to mri interpretation in the clinical setting of epilepsy is helpful and will be discussed. epilepsy surgery is an effective and safe therapy for selected patients with intractable localisation-related epilepsy. when morphological mri fails to reveal focal, structural pathology (e.g. tumour, dysplasia, etc). as the putative aetiology for the seizures, other modalities may be taken into account. in the absence of structural pathology it is essential to identify the epileptogenic zone as exactly as possible in order to (a) increase the chance of a good outcome (reduction or termination of seizures) and (b) limit post-surgical sequelae. this lecture will cover some modalities that may add valuable information in this process. the need to individualise the pre-surgical evaluation and the concept of a multimodality epilepsy protocol will be discussed. the main focus will be on spect (single-photon-emission computed tomography), functional mri, pet (positron-emission tomography) and the added value of co-registration on morphological mri (e.g. siscom). briefly, ictal spect may help to identify focal areas of hyperperfusion (ictal zones). functional mri is used for several reasons. one is to determine language laterality (dominant hemisphere); another is to localise eloquent cortical structures to aid the planning of the surgical approach. pet may detect hypometabolic areas corresponding to areas involved in epilepsy. mrs (magnetic resonance spectroscopy), meg (magnetoencephalography) and intradural eeg-registration and stimulation will be mentioned. the term epilepsy covers a wide spectrum of symptoms and underlying etiologies. an essential part of the work-up of patients with epilepsy includes the radiological examination. in recent years more sophisticated methods radiological methods have emerged and the discussion will focus on how these new advanced techniques may help finding underlying causes and be of help in the pre-surgical work-up. excellence in teleradiology: key issues in workflow management j. schillebeeckx; bonheiden/be (jan.schillebeeckx@imelda.be)the healthcare market is undergoing significant change. the market is evolving from a provider centric to a patient centric model, requiring relevant data to converge at patient level in a timely and structured fashion. the push towards setting up collaborative networks for radiology is strong in most european countries. the most important challenge for teleradiology is to ensure that it develops in a manner that benefits patient care and ensures overall patient safety, and does not in any way reduce the quality of radiology services provided to the citizen. therefore, these collaborative networks require more than just it infrastructure with it support. but as important is case management, workflow management and the administrative and management support that provides all the stakeholders with operational, analytical and statistical qa reports. through a centrally operated hub, the radiology workflow is optimised to ensure throughput of cases, involving radiologists in the network, with the difference that only the services are provided by the hub to the network, not the medical acts, which remain in the hands of the radiologists. learning objectives: . to learn about the technical needs of a teleradiology infrastructure adapted to a distributed environment. . to understand that teleradiology involves much more than just technology.optimising the workflow and time management are also important. . to appreciate how creating collaborative networks can improve the efficiency of radiology procedures and bring improved work/life balance to radiologists. to make teleradiology an integrated part of clinical radiology, it must change from being a provider of radiology reports into a close collaboration with the client radiology department. there are many different aspects on workflow in a clinical setting and the teleradiology service should adapt to these specific needs in order to make a seamless collaboration. however, there are advantages with the global aspects of teleradiology that could improve diagnostic accuracy and efficiency in the clinical setting that should be woven into the collaboration. teleradiology services have developed substantially over the last few years from limited use between hospitals and tertiary care centres for second opinions and patient transfer to the international provision of reporting services. there is no doubt that teleradiology provides a valuable service in some circumstances, but it also has a number of inherent limitations regarding the proper provision of imaging services to the patient and therefore may increase risks for the patient. we will highlight the problems that have arisen and reiterate key parts of the guidelines which were developed for the benefit of patient care. this lecture will demonstrate a multimodality approach to the imaging of salivary colic. the relevant us and mri salivary anatomy will be highlighted and the ultrasound, computed tomography and magnetic resonance appearances of salivary grafts. respectively. graft sclerosis develops in % of nonoccluded venous bypass vessels after years and in % after years. this sclerosis causes more than % luminal narrowing in approximately half of the affected vessels. non-invasive imaging of coronary bypass grafts by md-ct require information about the operative procedure. with the increasing implementation of slice ct scanners and beyond, it is possible to scan the heart and the full anatomic extent of grafts with sub-millimeter slice-thickness within a single breath-hold. when analysing the grafts, three graft segments should be assessed: the origin or proximal anastomosis, the body of the graft and the cardiac anastomosis, either single or sequential. recent studies have shown that graft patency and the presence of significant graft stenosis can be assessed with an accuracy of % using most recent md-ct technology ( / slice ct or dual source ct). the assessment of native coronaries with respect to the progression of cad may still be problematic in cases with severe calcifications of the native coronary arteries. in these cases, mr perfusion imaging in combination with cine and late gadolinium enhancement (lge) imaging may be helpful in detecting newly developed, stress-induced myocardial ischaemia. teleradiology services have developed substantially over the last few years from limited use between hospitals and tertiary care centres for second opinions and patient transfer to the international provision of reporting services there is no doubt that teleradiology provides a valuable service in some circumstances, but it also has a number of inherent limitations regarding the proper provision of imaging services to the patient and therefore may increase risks for the patient. we will highlight the problems that have arisen and to reiterate key parts of the guidelines which were developed for the benefit of patient care. it is now well understood that teleradiology cannot be considered just as 'telereporting', i.e. the simple interpretations of images remotely acquired and sent as a message in the bottle. teleradiology procedures, being medical acts, must ensure the full involvement of the interpreting radiologist in all phases of the well established practice of diagnostic imaging: appropriateness check, personalised acquisition protocols, access to clinical history and prior imaging examinations, communication with referring physician and patient. any obstacle that teleradiology causes to these activities may put our patients at risk (and therefore may expose us at liability suits). the presentation will describe the organisational as well as technological remedies for reducing such risk. for several decades, monte carlo simulation has been recognised as a powerful technique to simulate the transport of radiation in media, as well as to provide solutions for calculations too complex for classical approaches. several general purpose codes and databases providing particle interaction cross-sections have been developed, and with the increase in computing power, simulation has become more and more popular within the field of medical imaging. using monte carlo simulation methods, the different steps involved in the formation of a medical image can be analysed in detail, and the whole system optimised. a topic that has deserved particular attention in the past is the simulation of x-ray tubes and x-ray spectra, which is the first step in the simulation of a medical imaging system. when simulating an x-ray tube, various complex phenomena need to be taken into account, such as the electron multiple scattering, bremsstrahlung interactions, characteristic x-rays emitted from the k-shell and auger electrons emitted during a photon interaction. together with the simulation of the target material and the filtration of the x-ray beam through permanent (e.g. a be window) and added filtration (e.g. al, mo, rh, ag, etc)., this technique can lead to a good estimation of the emitted x-ray spectrum, a task which is hard to achieve with experimental methods. this review will provide an overview of the basic knowledge necessary to start the simulation of an x-ray tube as well as of how to accelerate the calculations. emphasis will be given to mammographic x-ray tubes. breast cancer screening and diagnostic imaging, as all clinical imaging, are increasingly multimodality. a number of new imaging modalities have been developed, including digital breast tomosynthesis and dedicated breast ct. they have shown promise in early studies; however, their technological complexity present obstacle for optimisation. the ultimate technology tests are clinical trials, which are, however, challenging, particularly for breast cancer screening, as large studies are needed due to the small number of detected lesions. clinical trials are costly, long, and they involve repeated exposure of women to radiation. as an alternative, we have been developing virtual clinical trials, based upon our virtual breast phantoms and simulation of phantom images. this talk will describe the development of anthropomorphic computer breast phantoms, and illustrate their use in the analysis of phantom digital mammography and digital breast tomosynthesis images. different currently used phantom designs will be compared in terms of their flexibility and realism. specific phantom requirements related to different imaging modalities will be emphasised. the role of phantoms in tissue-specific analysis of the radiation dose during mammography will be discussed. in addition to the anthropomorphic phantoms for breast imaging, the use of virtual patients in various clinical imaging disciplines will also be illustrated. learning objectives: . to learn about requirements for anthropomorphic phantoms (virtual patients). . to understand the value of anthropomorphic phantoms for breast imaging. . to compare advantages and disadvantages of several types of anthropomorphic phantoms. . to learn how to estimate typical patient doses from simulations with virtual phantoms.colic will be shown and techniques for optimising the imaging of salivary colic given. the use of us, ct, mri, and both mri and conventional sialography in the imaging of salivary colic will be discussed. the role of interventional sialography and minimally invasive techniques in benign salivary gland obstruction will be demonstrated. trigeminal neuralgia is defined as recurrent episodes of lancinating pain most common in the second (v ) or third division (v ) of the trigeminal nerve. the pathogenesis is a neurovascular conflict by an artery or vein associated with focal demyelination of sensory fibers at the glia-schwann cell junction. apposition of demyelinated fibers induces abnormal generation and transmission of impulses. mr imaging is based on high-resolution d sequences: ciss/fiesta/ d t space with coronal and sagittal oblique mpr and a d tof intracranial sequence with axial and coronal thin mip reconstruction to delineate the course of vessels along the trigeminal nerve form the pons, and glia schwann cell junction to the gasserian ganglion. the brainstem and brain are assessed by t , flair and d isotropic gd-enhanced t sequences; the viscerocranium is examined by a noncontrast and coronal t gd fat suppressed sequence. analysis of images is focussed on recognition of displacement and distortion of the proximal trigeminal nerve by the sca, rarely by the aica, ba or petrosal, pontomesencephalic or peduncular vein. correlation of the circumferential site of distortion at the root entry zone with the somatopic representation of fibres increases the, in general, low specificity of the neurovascular contact. ruling our compressive tumours, neoplastic infiltration, inflammation or demyelination and delineating a neurovascular conflict stratifies patients for potential microvascular decompression in case of failure of medication. the purpose of this lecture is to provide an overview of the key imaging features of painful swallowing with or without associated mucosal pathology. in the presence of a mucosal lesion, painful swallowing is most often caused by infectious, neoplastic or traumatic lesions of the pharynx itself, whereas in the absence of mucosal alterations, painful swallowing is the result of functional disorders (dysfunction of the cricopharyngeus muscle), infectious, inflammatory or neoplastic diseases affecting adjacent neck spaces (retropharyngeal and paraphyrngeal space), neurologic impairment (glossopharyngeal neuralgia), carotidodynia and eagle's syndrome. the indications for ct, mri, us and videofluoroscopy will be reviewed and their respective role in the detection and precise description of the underlying cause. major emphasis will be put on how to report the findings in a comprehensive way. learning objectives: . to recognise the most common causes of painful swallowing in patients with a normal pharynx at clinical examination. . to review the role of different imaging techniques in the diagnosis and treatment of painful swallowing. . to review the key imaging techniques in the diagnosis and treatment of painful swallowing. . to review the key imaging features of the most common causes of painful swallowing as seen with the respective imaging techniques.the typical hrct features of interstitial lung disease are ground-glass opacity, consolidation, pulmonary nodules, tree-in but sign, bronchiolar wall thickening, mucoid impaction, air trapping, septal thickening, mosaic perfusion and honey combing. most frequent diseases in children to be dealt with are bronchiectasis, cystic fibrosis, asthma, constrictive bronchiolitis, bronchiolitis obliterans and extrinsic allergic alveolitis and they will be demonstrated with use of a systematic approach. during the lecture we will present and validate methods to simulate radiographic images with the monte carlo software mcnp/mcnpx in a time efficient way. we will start the lecture by introducing three image detector models that can be used in mcnp/mcnpx. the first detector model that will be presented is the standard semideterministic radiography tally, which has been used in previous image simulation studies. furthermore, we will present two alternative stochastic detector models: a perfect energy integrating detector and a detector based on the energy absorbed in the detector material. the image detector models will be validated by comparing calculated scatter-to-primary ratios (sprs) with published and experimentally acquired spr values. subsequently, we will introduce a method to modify the images, generated with the mcnp/mcnpx image detector models, for the physical characteristics of a computed radiography (cr) imaging systems. the method presented in this lecture takes into account the signal intensity variations due to the heel effect along the anode-cathode axis, the spatial resolution characteristics of the imaging system and the various sources of image noise. to demonstrate the accuracy of our model we will compare the threshold-contrast detectability in simulated and experimentally acquired images of a contrast-detail phantom. thoracic trauma in children is most commonly seen in a polytrauma context, and is associated with significant morbidity and mortality. blunt trauma accounts for the majority of cases, often resultant from motor vehicle accident and pedestrian crash. common thoracic injuries include pulmonary contusion, rib fractures, pneumothorax and haemothorax. diaphragmatic and mediastinal injuries, such as aortic rupture and tracheobrocheal tear, are rare but potentially life threatening. different patterns of injury are seen in children due to anatomical and physiological differences, and these should be recognised. chest radiography is the first and most important imaging modality. mdct allows accurate diagnosis for most traumatic injuries, and is usually performed for severe chest and/or polytrauma. adapted paediatric protocols are essential. foreign body inhalation is a common paediatric domestic accident, with potential serious or even fatal consequences. clinical history is the key for the diagnosis. with a definite history, bronchoscopy is the modality of choice for both diagnosis and treatment. however, in many cases the aspiration event is not witnessed and the diagnosis is often delayed or overlooked. the majority of aspirated foreign bodies are non-opaque and imaging findings largely result from complete or incomplete airway obstruction. chest radiography is the first imaging modality. expiratory films (or lateral decubitus or fluoroscopy) are very useful to demonstrate air-trapping. chest mdct offer excellent details of the tracheobronchial tree and pulmonary parenchyma, and is usually reserved for more complex cases and/or long-standing foreign bodies. high-resolution ct of the chest is the imaging technique of choice for the evaluation of most infiltrative diseases of the chest. in children dose-adapted protocols should be used and recommendations for suitable protocols will be given in the course. the mediastinum is a region of the thorax that separates both lungs and communicates with the neck and the abdomen. these two anatomic features are very important to understand the behaviour of some diseases and their radiological manifestations. most asymptomatic mediastinal masses are benign, while clinical symptoms might raise the possibility of a malignant lesion. imaging plays a very important role, especially ct and mri. in the presence of a mediastinal mass we must ask ourselves two questions: . where is the mass located? the classic divisions of the mediastinum in compartments remains very useful, because it narrows the differential diagnosis. . is the lesion cystic or solid? pure mediastinal cysts are benign and their characterisation depends on their location. thymic cyst (anterior mediastinum), bronchogenic and duplication cysts (middle mediastinum) and menyngoceles (posterior mediastinum). solid lesions may be benign or malignant while some lesions may have a cystic component. solid lesions of the anterior mediastinum are usually thymomas, germ cell tumours or lymphomas. in the middle mediastinum most masses are of lymphatic origin but we should also include aortic or oesophageal pathology. intrathoracic thyroid usually follows the trachea and thus is situated in the upper-middle mediastinum although posterior and anterior extensions may occur. in the posterior mediastinum most masses are of neural origin. there are some locations that will typically indicate specific diagnosis or a narrow differential. such is the case of the cardiophrenic angle masses, juxtadiaphragmatic lesions and thoracic inlet pathology. colorectal cancer is common. approximately , new cases occur each year in the million population of the states which comprise the eu. after lung, it is the second commonest cause of cancer death resulting in approximately , deaths per annum. these relatively high mortality figures are a reflection of the fact that the disease is often advanced at the time of presentation. efforts to reduce mortality, therefore centre on early detection as well as accurate staging. the latter is particularly important in rectal cancer-the commonest site for colonic cancer. detection depends on presentation, which is often protean or non-existent; hence, the introduction of screening programs. typical diagnostic tools include the barium oenema, optical colonoscopy and ct colonography. the limitations of the barium enema have been exposed by optical colonoscopy and it can no longer be advocated in this role. ct colonography, however, rivals optical colonoscopy in the detection of polyps and tumours, although of course has no therapeutic potential. major advances in the treatment of rectal cancer include total mesorectal excision (tme) of the rectum as well as neo-adjuvant therapies such as chemo-radiation. their use depends on highly accurate staging of the primary disease, which can only be achieved by mr examination, although of course ct or pet/ct is required for the assessment of more distant metastatic disease. finally, once treated, it is essential that these patients are followed-up; usually by a regime of colonoscopy and ct. these issues will be discussed in an interactive lecture. decreased opacity of the lung may be a bilateral or unilateral process. if unilateral, it may involve an entire lung, a lobe or a segment. faulty radiological technique must always be excluded. the most common cause of unilateral decreased opacity is a previous mastectomy. bilateral decreased opacity occurs in copd and asthma. it is also caused by decreased blood flow in the lung/s. expiratory films separate the true lung causes from all the others, by demonstrating air trapping. pulmonary nodules are spherical radiographic opacities (solid and subsolid) that measure up to mm in diameter. extremely common in clinical practice, pulmonary nodules, especially small ones under cm in diameter, are a challenge to manage. it is important to identify malignant nodules because they are potentially curable. the first step in assessing a pulmonary nodule on a chest radiograph is to determine that it is indeed a lung nodule rather than a pleural or chest wall abnormality. it is essential to review images from previous examinations, because a solid nodule that remains stable for at least years is probably benign. topics discussed in this talk include the importance of nodule size, growth rate, margin morphology, density (solid, ground-glass and part solid), calcifications or fatty components within the nodules, the significance of cavitations or bubble-like densities, enhancement patterns at dynamic contrast-enhanced ct, and findings on positron emission tomography (pet). the talk also covers the current guidelines for the management of incidentally detected nodules (solid and subsolid). this presentation has the purpose to familiarise radiologists with the spectrum of mesenteric and omental cystic masses, demonstrating the additional correlation with the underlying pathology. cystic masses of the mesentery or omentum are not common lesions; however, radiologists should be aware of these entities as well as with other cystic lesion of the abdomen. important tool for the diagnosis is to determine the organ from which the mass originates. common types of mesenteric and cystic masses include lymphangioma, enteric duplication cyst, enteric cyst, mesothelial cyst and non-pancreatic pseudocyst. other entities such as cystic mesothelioma, cystic spindle cell tumour and cystic teratoma could be located in the mesentery also. due to the overlap in the imaging features, not always the final diagnosis could be reached by imaging only and therefore histologic examination is necessary to establish the diagnosis. however, it is important for the radiologist to define the cystic nature of the mass and demonstrate the potential mesenteric or omental origin, targeting to the correct differential diagnosis of the cystic lesion. cancer cells from intraabdominal neoplasms, carried by peritoneal fluid throughout the abdominal cavity, result in widespread metastases in the form of implants, the socalled peritoneal carcinomatosis. the location of implants development is governed mostly by peritoneal fluid circulation and by specific anatomic pathways formed by peritoneal reflections. the most common sites where the peritoneal fluid may temporarily arrested facilitating implantation of cancer cells include cul-de-sac, distal small bowel mesentery, right paracolic gutter, posterior sub-hepatic space, greater omentum and sub-phrenic spaces. the role of imaging is to disclose the presence and extent of the disease -i.e. fundamental in candidates for cytoreductive surgery -to monitor response to treatment and to reveal recurrences. mdct with thin collimation and i.v. contrast material supplemented by multiplanar reconstructions is the primary imaging modality for the investigation of peritoneal carcinomatosis. ascitis, contrast enhanced smooth, nodular, or plaque-like peritoneal thickening, peritoneal nodules, plaques or masses, rounded, ill-defined soft-tissue or cystic mesenteric masses, mesenteric fixation with increased attenuation values and thickening, irregular soft-tissue permeation of omental fat or confluent solid omental masses are the most frequent ct findings of peritoneal carcinomatosis. ct has a sensitivity and specificity between and %, depending on the size/location of implants and examination protocol used. mr imaging employing a post-gadolinium-enhanced d flash sequence with fat saturation may alternatively be used and it is advantageous in cases of diffused layered type of peritoneal/mesenteric involvement. diffusion mri may be of value in post-treatment imaging evaluation. primary solid tumours of the peritoneum and mesentery occur much less frequently than metastatic disease in the same location. however, these rare primary neoplasms (peritoneal mesothelioma, primary peritoneal serous carcinoma, desmoplastic small round cell tumour, mesenchymal tumours, mesenteric fibromatosis or mesenteric desmoid tumour, mesenteric sarcoma, etc.) are often first detected at ct and should be considered in the absence of a known primary organ-based malignancy. ct appearance combined with patient's relevant clinical and demographic data can help narrow the differential diagnosis for a primary peritoneal or mesenteric tumour in many cases; diffuse sheetlike thickening of the peritoneum and stellate appearance of the mesentery at ct or mri are suggestive of primary malignant mesothelioma in older men with high level of asbestos exposure. absence of an ovarian mass is mandatory in suggesting the diagnosis of primary peritoneal serous carcinoma in a post-menopausal woman. desmoplastic small round cell tumour occurs in young men and often presents with a large primary peritoneal mass with calcification. a solid mesenteric mass at ct or mri, regardless of its pre-and post-contrast appearance, occurring in a patient with familial postgraduate.educational.programme embolisation of hcc with drug eluting beads k. malagari; athens/gr (kmalag@otenet.gr)drug eluting beads have proved predictable pharmacokinetics and achievement of higher doses of the chemotherapeutic, prolonged contact time with cancer cells.in addition, research data today have shown response, and tolerance benefit of drug eluting beads compared to conventional chemoembolisation for the more advanced subgroup of bclc -class b patients. for diameters larger than μm dc bead loaded with doxorubicin have proven to be more effective with respect to local response, recurrence rates and time to progression (ttp) compared to bland embolisation with similar diameters. in this session results of studies on dc bead loaded with doxorubicin for the treatment of hcc will be discussed, and guidelines for optimal clinical use will be presented. selective internal radiotherapy j.i. bilbao; pamplona/es (jibilbao@unav.es)selective internal radiotherapy, also called radioembolisation (re), consists in the delivery of beta-radiation to liver tumours using microspheres loaded with yttrium- (y ) that are injected into the hepatic artery or its branches. y is a pure beta-emitting radioisotope, with a limited tissue penetration (average: . mm and maximal: mm) and a half life of hours. y can be either incorporated or labelled into glass or resin microspheres ( µm). once the particles are infused into the hepatic artery, they travel to the distal tumoural arterioles, from where the beta-emissions from the isotope irradiate the tumour. with traditional external beam radiation, doses are limited to - gray (gy) due to the risk of radiation-induced liver disease that may occur with higher doses. with re, tumours can receive a higher dose of radiation due to their preferentially arterial vascularisation and a higher tolerance of the non-tumoural liver parenchyma to this form of radiation. re has shown an encouraging antitumoural activity with a good safety profile in patients with hepatocellular carcinoma, even in the presence of portal vein thrombosis or invasion. local tumour growth control is achieved in the majority of patients although response rates using volumetric criteria are achieved in only - % of patients. in liver-predominant unresectable metastases, there is promising evidence that re combined with systemic chemotherapy significantly extends the time to progression of liver metastases and increases objective response rates as well as enabling patients to receive systemic chemotherapy for a longer period of time. learning objectives: . to learn about the technique, legal and safety requirements in the cathlab. . to understand the diagnostic and interventional procedures before radioembolisation. combined therapies before and after ablation r. lencioni; pisa/it (lencioni@med.unipi.it) image-guided rfa is currently established as the standard of care for patients with early-stage hcc when transplantation or resection is precluded. however, histologic data from liver specimens of patients who underwent rfa as bridge treatment for transplantation showed that the rate of complete tumour eradication is highly dependent on the size and the presence of large abutting vessels. combined percutaneous-transcatheter approaches that aim at increasing the ablation volume by minimising heat loss due to perfusion-mediated tissue cooling have been developed, using either a balloon catheter occlusion of the tumour arterial supply at the time of the rfa or by performing a prior tace. experimental studies in animal tumour models have shown that lowering the temperature threshold at which cell death occurs by combining sublethal heating with cell exposure to trans-arterial chemoembolisation takes advantage of the largely portal vascularisation of liver tissue, while metastatic tissue is supplied almost exclusively by hepatic arteries. the benefit of intra-arterial application of chemotherapeutic drugs is proportional to the first pass extraction of the drug by the target tissue and inversely proportional to the body clearance of the drug. these figures vary greatly with different chemical properties of the drug. intratumoural drug concentration after transarterial application (compared to intravenous application) is approximately x for thp-adriamycine, x - x for fu, x - x for mitomycine, x for cisplatin or oxaliplatin, and x for doxorubicin. several trials support superiority of intraarterial fu over i.v. application in response rate, and partly with a moderate survival benefit. however, with the advent of novel chemotherapeutics (mainly oxalyplatin, irinotecan), response rates of i.v. chemotherapy approached the results after i.a. fu. more recently, i.a. oxaliplatin has shown a % response rate in a multicenter trial on non-responders to i.v. oxalyplatin. also, combinations of i.a. oxalyplatin and i.v. fu and cetuximab have achieved promising response rates as first line therapy. even though intraarterial chemoembolisation alone can achieve promising response rates, the actual survival benefits are limited to date. also, the beneficial effect of additional embolization (over conventional arterial injection) remains largely unproven for a large number of different embolisation agents in hepatic metastases. in an attempt to further increase tumour uptake, chemotherapeutic agents (anthracyclines and irinotecan) have been electrostatically coupled to microspheres. irinotecan-eluting microspheres have been untilized in the treatment of crc metastases in smaller case series. due to the high parenchymal drug uptake, appropriate medications to mitigate postembolization side effects need to be emphasised. while the initial response rates were over % (according to easl), tumour progression was observed within months in the majority of responders, suggesting potential stimulation of angiogenesis at the tumour boarders. potentially, adjuvant antiangiogenic treatment can provide an overadditive effect in these patients.primary bone tumours require both local staging and the identification of distant metastases to guide management. mr imaging is the modality of choice to determine local disease extent and allows excellent depiction of intra-and extraosseous disease. chest ct enables pulmonary metastases to be identified and bone scintigraphy allows evaluation of the presence of bone metastases. the roles of whole body mri and pet/ct in the staging of bone tumours will also be discussed. whilst imaging may allow a narrow differential diagnosis to be reached, histological confirmation of the nature of the lesion is required pre-operatively to plan appropriate treatment. image-guided biopsy may be performed using fluoroscopy, ct, mri and occasionally ultrasound guidance. the relative values of each of these techniques will be covered. percutaneous therapies are increasingly being utilised in the treatment of a number of primary bone tumours. radiofrequency ablation is the method of choice for osteoid osteoma and is now used in the treatment of chondroblastoma. alternatives include microwave therapy, cryotherapy and sclerotherapy. these percutaneous techniques may also be used for local disease control where disease recurrence is encountered. magnetic resonance imaging (mri) has evolved to become the most important diagnostic method for local staging of primary bone tumours and for detecting postoperative tumour relapse. it allows accurate preoperative staging of local tumour extent and helps to obtain adequate safety margins. mri is a noninvasive technique that can be used to obtain information regarding tumour vascularisation, metabolism, and pathophysiology, and allows early assessment of therapeutic effects of cancer drugs. one approach is dynamic contrast-enhanced (dce) mri, which measures tumour vascular characteristics after administration of a contrast medium. mri enhanced with small-molecular-weight contrast agents is extensively used in the clinic to differentiate benign from malignant lesions, as well as to monitor tumour microvascular characteristics during treatment. diffusion-weighted mri (dwi) is a more recent technique and it allows noninvasive characterisation of biologic tissues based on the random microscopic motion of water proton measurement. several studies have shown that dwi allows early detection of tumour response to chemotherapy. the use of water diffusion is a surrogate marker used to distinguish highly cellular regions of tumour from acellular and necrotic regions. whole body diffusion-weighted sequence (wb dwi) is a new promising technique feasible to evaluate multifocal disease. dwi has revealed great potential in the evaluation of patients with cancer or benign disease, as it supplies both quantitative and qualitative information of the whole body. this presentation will focus on the potential role of dwi in combination of dce mri in bone tumours as well as on the possibilities of wb dwi. in this integrated refresher course, the impact of basic and advanced imaging on the entire process, from diagnosis to treatment of bone tumours, will be addressed. diagnosis is based on understanding the imaging features from a histopathologic chemotherapeutic agents is an attractive alternate strategy to increase tumour necrosis. the efficacy of a combination therapy, including rfa plus the intraarterial administration of drug-eluting beads has been recently demonstrated, while the use of intravenously administered, thermally sensitive drug carriers is currently being explored. despite the advances in local treatment, the long-term outcome of treated patients remains unsatisfactory because new tumours emerge in about % of the cases within years. clinical trials evaluating the usefulness of adjuvant molecular targeted therapies with anti-angiogenic and anti-proliferative activity in preventing early recurrence after successful ablation are ongoing. in this integrated refresher course, the impact of basic and advanced imaging on the entire process from diagnosis to treatment of bone tumours will be addressed. diagnosis is based on understanding the imaging features from a histopathologic perspective. staging, biopsy and image-guided treatment require an integration of imaging findings with basic knowledge of surgical-oncological principles, as well as skills. can technically driven development of advanced mr techniques change how we diagnose, monitor therapy and determine prognosis. techniques and procedures that improve patient outcome in a cost-effective way will be identified based on presentations and a panel discussion. a. diagnosis: from radiographs to mri k. wörtler; munich/de (woertler@roe.med.tum.de)the diagnosis of a bone tumour is based on clinical findings, the age of the patient, the location of the lesion, its radiologic appearance, and, if imaging does not allow for a specific diagnosis, its histopathologic features. radiography remains the initial imaging modality for evaluation of the localisation of the lesion with respect to the longitudinal and axial planes of the involved bone, for the depiction of matrix mineralisations, and for estimation of biologic activity by analysing the patterns of bone destruction and periosteal response. ct can add "radiographic" information particularly in regions of complex skeletal anatomy such as the spine, pelvis and shoulder girdle. mr imaging has classically been used to determine the local extent of a bone tumour (local staging). in addition to radiography and/or ct, it can at times also be valuable in establishing the differential diagnosis, especially in cystic bone lesions and cartilaginous tumours. whole-body applications have recently gained importance in demonstrating the presence and extent of bone (marrow) involvement in benign and malignant systemic/polyostotic tumourous diseases. this course reviews the basic principles of diagnosing bone tumours in a multimodality approach (with an emphasis on conventional radiography). the different steps of morphologic analysis as well as the advantages and disadvantages of the individual imaging techniques are illustrated on the basis of pathologically confirmed cases. s a b c d e f g h review: ( ) the biological rationale for using perfusion imaging in brain tumours, ( ) methods available for the imaging of microvascular structure and function in brain tumours. we will discuss the relevant advantages and disadvantages of t versus t weighted acquisition strategies. early diagnosis and treatment of acute stroke is crucial for a favourable prognosis. while non-contrast mri is much more sensitive to ischaemia in comparison with non-contrast ct, perfusion studies make both techniques comparable. ultrafast ct scanners cover most of the brain with perfusion imaging; the scanning is faster and quality imaging results depend less on patient co-operation than in mri. however, mri enables diffusion imaging adding more specific information to the diagnostic process. because of the short time window to eventual vascular intervention, in many institutions ct is the technique of choice. besides depiction of hyperacute stroke by means of diffusion weighted imaging, mri has the advantage of performing a contrast agent-free perfusion study using a promising new technique called arterial spin labelling (asl). thus, an mri perfusion study can be performed even in patients with impaired renal functions where iodine and gadolinium-based contrast agents may be dangerous. perfusion imaging is an emerging non-invasive tool that enables evaluation of brain function via assessment of various hemodynamic measurements such as cerebral blood volume, cerebral blood flow, and mean transit time. these techniques have become important clinical tools in the diagnosis and treatment of patients with cns disorders via evaluation of brain tissue during cerebrovascular diseases, noninvasive histopathologic assessment of tumours, evaluation of neurodegenerative conditions and assessment of the effects of drugs. perfusion imaging is helpful to analyse and assist in judging the biological behaviour (especially haemodynamic features) of central nervous system diseases. qualitative and quantitative information can be obtained to evaluate pathoanatomical structures and pathophysiological changes of the lesions. cerebral blood flow (cbf), cerebral blood volume (cbv), mean transient time (mtt), permeability surface (ps), regional blood volume, microvascular permeability measurements and more information can be obtained for the diagnosis and differential diagnosis of the diseases. advantages and disadvantages of the ct perfusion imaging (ctp) and magnetic resonance perfusion imaging (mrp) in the different diseases will be evaluated in detail. hints and tips for the better applications and postprocessing will also be discussed. techniques for ct and mr, post-processing, radiation r.a. meuli; lausanne/ch (reto.meuli@chuv.ch)brain perfusion can be assessed by ct and mr. for ct, two major techniques are used. first, xenon ct is an equilibrium technique based on a freely diffusible tracer. first pass of iodinated contrast injected intravenously is a second method, more widely available. both methods are proven to be robust and quantitative, thanks to the linear relationship between contrast concentration and x-ray attenuation. for the ct methods, concern regarding x-ray doses delivered to the patients need to be addressed. mr is also able to assess brain perfusion using the first pass of gadolinium based contrast agent injected intravenously. this method has to be considered as a semi-quantitative because of the non linear relationship between contrast concentration and mr signal changes. arterial spin labeling is another mr method assessing brain perfusion without injection of contrast. in such case, the blood flow in the carotids is magnetically labelled by an external radiofrequency pulse and observed during its first pass through the brain. each of this various ct and mr techniques have advantages and limits that will be illustrated and summarised. learning objectives: . to understand and compare the different techniques for brain perfusion imaging. . to learn about the methods of acquisition and post-processing of brain perfusion by first pass of contrast agent for ct and mr. . to learn about non contrast mr methods (arterial spin labelling). brain tumours a. jackson; manchester/uk (alan.jackson@manchester.ac.uk) this presentation will discuss the current 'state of the art' in the use of perfusion imaging techniques in neuro-oncology. the term "perfusion imaging" is commonly used but is in fact a misnomer since perfusion and blood flow are not the only imaging biomarkers of microvascular structure and function in common use. indeed, in oncological applications measurements of proportional blood volume, endothelial capillary permeability or vessel size can be of equal or greater importance. we will reproduction is by spore formation which is prolific and therefore human respiratory tract exposure is almost constant. the spectrum of aspergillus infection includes aspergilloma (mycetoma), chronic pulmonary aspergillosis, chronic necrotising pulmonary aspergillosis (subacute invasive, chronic airway invasive), invasive pulmonary aspergillosis (angioinvasive, non-angioinvasive including acute tracheobronchitis, exudative bronchiolitis and bronchopneumonia), and allergic disease (allergic bronchopulmonary aspergillosis (abpa) and bronchocentric granulomatosis). immunocompromised individuals are particularly susceptible to invasive aspergillosis. the risk factors for invasive aspergillosis include: profound neutropenia, haematopoietic stem cell transplant recipients, solid organ transplantation, potent immunosupressive therapy, prolonged corticosteroid use and aids. invasive aspergillosis can be further subdivided into angioinvasive and non-angioinvasive forms. the imaging features of angioinvasive aspergillosis are characterised on ct by nodules with a 'halo' of surrounding ground glass opacity due to alveolar haemorrhage. in the context of neutrophil recovery, nodules may demonstrate cavitation. airway invasive aspergillosis may manifest as areas of consolidation (bronchopneumonia), nodular 'tree-in-bud' densities on ct (exudative bronchiolitis), or an acute tracheobronchitis with large airway thickening. falling rates are stabilising in europe. tuberculosis is developing new faces due to changes in host cellular immunity, such as hiv infection, immunosuppressive therapy, malignancy and due to multi-drug resistance. chest radiography plays a major role in screening, diagnosis, and response to treatment of patients with tb; however, radiographs may be normal or show only mild or nonspecific findings in active disease. ct and high-resolution ct (hrct) are more sensitive than chest radiography in the detection and characterisation of parenchymal disease, small foci of cavitation, mediastinal lymphadenopathy, and pleural complications. based on these findings, hrct is useful in determining disease activity and plays also an important role in the management of tb. radiological manifestations of primary tuberculosis are lymph node enlargement, airspace consolidation and pleural effusion. the most common findings of post-primary tuberculosis are centrilobular nodules, branching linear and nodular opacities, patchy or lobular areas of consolidation, and cavitation. miliary tuberculosis results from acute haematogenous dissemination of tb bacilli in lungs and other organs and ct-findings consist of innumerable small nodules randomly distributed throughout both lungs. airway tuberculosis is characterised by circumferential wall thickening and luminal narrowing, with involvement of a long segment of the bronchi.sensitive diagnostic tool. radiological semiotics are always useful and often very specific in addressing the diagnosis: some fundamental concepts include the peculiar pattern of vasogenic oedema, which, in opposition to what happens in the brain, tends to involve the central grey more than the peripheral white matter. distribution pattern of the lesion can also often address to aetiological diagnosis. in fact, lesions selectively involving posterior or lateral columns, asymmetrically, and sparing the central grey matter, are more typical expression of demyelinatinginflammatory diseases (multiple sclerosis, adem, devic's disease, les, behcet's disease), while selective and symmetrical involvement of both posterior columns, extended for more than myelomers, and possibly associated with involvement of lateral columns, is typical expression of combined sclerosis (b vitamin deficit). ischaemic lesions are also usually symmetrical, but they involve both grey and white matter, extending to the anterior two-third of the cord, or, sometimes, remain limited to the central grey matter. on the other hand, selective involvement of the anterior horns is typical of poliomyelitis. early stage head and neck cancer can be cured by surgery or radiotherapy. the choice depends on the functional and cosmetic result to be expected, tumour histology, patient's condition and preference, and institutional policy. in advanced lesions, nowadays concomitant chemoradiotherapy is offered, with surgery reserved for salvage. a relatively high locoregional control rate can be obtained, at the expense of acute and late toxic side effects, and a higher incidence of treatment complications. on post-therapeutic imaging studies, treatment-induced tissue changes are often visible; these changes should not be misinterpreted as evidence of persistent or recurrent tumour, or treatment complication. after radiotherapy, the visible changes depend on the radiation dose and rate, the irradiated tissue volume, and the time elapsed since the end of treatment. basically, thickening of the laryngeal and pharyngeal walls, increased attenuation of fat planes, postirradiation sialadenitis, lymphatic tissue atrophy, and retropharyngeal oedema will be seen. these irradiation-induced tissue changes usually appear symmetrical. the acute effects of radiotherapy occur during or immediately after treatment, and usually settle spontaneously. complications of radiotherapy are usually seen months to years after the end of treatment. there is no clear consensus regarding optimal time points for surveillance, but clinical assessments are more frequent in year and are performed over at least - years, during which time most locoregional failures and second primary tumours are detected. ideally for imaging surveillance at least one post-treatment baseline head and neck scan (mri/ct) should be performed at - months, and often closer surveillance is desirable. candidates for salvage surgery after (chemo) radiotherapy undergo a post-treatment scan at - weeks, followed by regular scans ( - months in year ; - months thereafter, the exact time period being tailored to the patient the most recent advances of radiotherapy techniques are characterised by the increased precision with which the radiation energy is released to the target, the reduced collateral damage to adjacent non-neoplastic tissues, and the synergic viral agents are part of the spectrum of organisms which cause community acquired pneumonias. furthermore, they are thought to function as a trigger for bacterial infections in the hospital or health care setting. in addition, viruses play a significant role as causative agents for infections in the immunocompromized host. within the last years, outbreaks of viral infections have challenged regional, national and even global health care systems, have effected thousands of individuals and have resulted in significant morbidity and mortality. most of the involved viral agents represented emerging organisms with an unpredictable impact on individual and society health. the radiologic community has learned several lessons from the documented outbreaks, and radiologists around the world have contributed to the early diagnosis of the disease, the monitoring of its course, and the documentation of complications as well as of response to therapy. thus, imaging plays an important role in the diagnosis and management of these patients. in this course, epidemiologic aspects, patho-physiology and clinical features of emerging viral infections will be presented. in addition, their radiologic features and the role of radiology in diagnosis and management will be discussed. attendees will learn how to understand, recognize, report and follow patients with emerging viral infections. major changes in the treatment of head and neck neoplasms encompass the advances of endoscopic-based surgical techniques, mainly for nasosinusal and laryngeal tumours, and the application of sophisticated radiation therapy techniques, combined with chemotherapy. as most tumours arise from the mucosa of the upper aero-digestive tract, clinical surveillance is necessary to detect superficial recurrences, while morphological and 'functional' imaging techniques are indispensable to detect subclinical extra-mucosal and nodal recurrences. how can imaging techniques discriminate recurrence, inflammation, necrosis or scar? key points include the knowledge of the normal appearance of tissues (morphology and signals) on ct, mri, and pet-ct after surgery and chemo-radiotherapy. specifically, when non-surgical treatment has been used, that means to become familiar with the expected changes both of tumour and adjacent tissues. morphology-based imaging techniques are often inadequate to discriminate small recurrences from vascularised scar tissue (enhancing). ct or mri do require to be integrated by information provided by functional-based imaging techniques, fdg-pet-ct being the most established. recently, a great interest among radiologists is focused on the application of dce-ct or dce-mri and dwi-mri in the follow-up of head and neck neoplasms. in fact, several studies have credited these techniques for providing functional information about tissues (perfusion, water exchange) that help to discriminate scar from recurrences. obviously, the horizon pursued is to combine morphology and functional data in a single examination. though clearly promising, these new techniques share significant limitations, like the reproducibility of ct and mr-based functional results, their introduction and feasibility in the day practice. today, ct angiography (cta) is considered as a safe, non-invasive and wellestablished procedure for vascular imaging. modern multi-slice ct technology allows for coverage of larger vascular territories -even the whole body -in just several seconds. further technical improvements such as wide detectors of up to cm width or moving table techniques are making new applications possible, such as perfusion imaging, or time-resolved ct angiography. especially with the moving table technique (the so-called "shuttle-mode"), vascular territories of up to cm can be covered in a dynamic fashion, which can be helpful in the diagnosis of aortic dissections or peripheral vascular occlusive disease. on the other side, radiation exposure has to be maintained within a reasonable range applying these repeated acquisition modes. another interesting field opening new options in cta is dual energy ct (dect). a number of technical setups may allow for spectral ct imaging, such as systems with two tubes (dual source ct), ct systems with switching kv modes or with special detectors. in vascular applications, dect is especially helpful for automated bone removal, plaque removal, and potentially for "perfusion" imaging (iodine mapping). in this course, the basics of modern ct angiography will be highlighted, with a special focus on new applications such as time-resolved cta and dual energy cta. angio- d with digital flat-panel detector has recently been adapted for use with c-arm systems and provides a higher detector quantum efficiency (dqe) than conventional detectors based on ii camera. this configuration represents the next generation of imaging technology available in the interventional radiology suite and is predicted to be the platform for many of the three-dimensional ( d) roadmapping and navigational tools that will emerge in parallel with its integration. it provides projection radiography, fluoroscopy, digital subtraction angiography, and volumetric computed tomography (ct) capabilities with the ability for immediate multiplanar post-treatment assessment in a single patient setup, within the interventional suite. such capabilities allow the interventionalist to perform intraprocedural volumetric imaging without the need for patient transportation. the clinical benefits of d angiography with these new systems have been assessed in the fields of cardiology and interventional radiology. these key features alone may translate to a reduction in the use of iodinated contrast media, a decrease in the radiation dose to the patient and operator, and an increase in the safety and performance of interventional procedures. proper use of this new technology requires an understanding of both its capabilities and limitations. this article provides an overview of the potential of this new technology. learning objectives: . to learn the basic principles of flat panel ct. . to review imaging protocols, results and radiation exposure aspects. . to become familiar with the most common applications.effect of chemo-radiotherapy. as the treatment planning becomes progressively 'tailored', strong predictive factors for the individual tumour arising in a specific patient have to be identified. these factors would ideally provide a quantitative assessment of the risks of both relapsing (in the primary, nodal or distant sites) and developing treatment-related (early or late) complications. predictors are related to tumour's characteristics (biology, metabolism, site, volume and spread) and to patient's overall clinical conditions. imaging-based predictive factors have been founded upon morphological findings ( d, volume) until the development of new techniques, which analyse 'functional' parameters like fdg-pet-ct, the most established, and perfusion-ct or dwi-mri. evidence of level a has been provided on the impact of negative predictive value of fdg-pet-ct in ruling out residual disease, whilst there is no clear data regarding the role of pre-treatment intensity of glucose metabolism (suv) in predicting the outcome after radiotherapy. this limitation can be addressed to the enrolment of tumours arising in various sites in the head and neck. a major disadvantage common not only in pet studies but also in most dce and dwi-mri studies. perfusion-ct and dwi-mr are promising techniques, as they provide information about neo-angiogenesis and water-flow in submicroscopic tissue compartments. however, these techniques still require randomised trials and confirmation studies about the reproducibility of their interesting results. in the follow-up after minimal invasive surgical techniques or chemo-radiation, a major limitation of standard morphological imaging is the differentiation of the highly vascularised scar tissue (enhancing, with mass effect) from persistent or recurrent neoplasm. is it time for integrating standard imaging with the functional information provided by dwi and/or ct or mr perfusion techniques? which evidence level are we at presently? is it now feasible in daily practice? three-tesla mri scanners offer an increased signal and contrast for mr-angiography (mra) compared to . -tesla machines. mra can be performed within a shorter time enabling the acquisition of temporally resolved three-dimensional datasets with high spatial resolution. due to high signal and contrast the dose of gadolinium may be reduced. furthermore, novel imaging protocols for mra at . -tesla with intravasal contrast agents and prolonged enhancement during high-spatial-resolution steady-state enable new possibilities for angiography of the upper and lower extremities including veins and vessels below the knee, spinal arteries, vascular malformations, and double-gated angiography of coronary arteries and bypass vessels to compensate for the complex cardiac motion pattern. a . -tesla mri system equipped with a matrix coil system allows for whole body mra with continuous table movement, which is an applicable technique for imaging peripheral vessels without the need for planning different steps and field of view positioning, thereby considerably reducing the examination time. phase contrast magnetic resonance angiography may develop into an important, noninvasive method for obtaining quantitative information on blood flow. in addition, non-enhanced three-dimensional mr angiography using turbo spin echo (tse) imaging with non-selective refocusing pulses may be a promising imaging technique for vascular imaging in patients with renal insufficiency. the advent of minimally invasive surgery has made even more important the place of preoperative imaging assessment of patients selected for this type of surgery. in fact, the loss of tactile feed-back and the bi-dimensional intraoperative vision have limited the capability of surgeons to assess extent and anatomic relationship of a given disease, particularly cancer. preoperative planning can be further enhanced by the use of d models of the target anatomy, derived from ct scan dataset. in addition, dedicated technology can be implemented to introduce mixed reality environments in the operative room. using d helmets with built-in microcameras, the surgeons' view of the operative field can be fused with the preoperative d anatomy of the patient. localiser should be used, either infrared based or electromagnetic. the last step would be intraoperative navigation. this offers special problems to be addressed, due to organ shifting and soft tissue in the setting of abdominal surgery. the appropriate use of information and communication technology (ict) and associated systems is considered by many experts as a significant contribution to improve workflow and quality of care in clinical settings. a conceptual design and prototypical implementation of such an infrastructure, i.e. a therapy imaging and model management system (timms) will be introduced as a solution to a patientspecific medicine. a timms is an information technology concept and framework for the collection, organisation, and utilisation of medical information from sources such as the electronic medical record, pacs, etc. timms was originally designed as a surgical assist system, but has many general medical uses as well, including all forms of model-guided medicine and may therefore be generalised to a medical information and model management system. the architectural framework and a number of individual ict components of a timms have been realised. these include standardised interfaces for communication of patient-specific and workflow models, thereby creating a unified environment for the input and output of data, including the representation and display of information and images, as well as the electromechanical control of interventional and navigational devices. in conclusion, the patient-specific model (psm) is the central construct for a patient within a personalised medicine environment in order to provide a clinician with a real-time representation of critical information about the patient. the required information concerning the patient for model-guided therapy is extracted by timms agents and assembled within the framework of an active psm and workflow management system. the introduction of picture archiving and communication systems (pacs), through a much more effective image sharing, has dramatically changed the role of radiology both within the hospital and on a geographic perspective. historically, the latter has become apparent first with the early implementation of teleradiology applications. physicians and the general public have understood that digital images can be read, processed, and stored independently on the site of production. therefore, teleconsultation and telereporting activities have been carried out among medical users, and generic users have learnt to include radiological images in their own on-line personal health records. only later the full potentialities of multidisciplinary image sharing within the hospital have been discovered, and now it is increasingly common to see advanced integration between radiologists and surgeons for planning and guiding surgical interventions. during this session, the lecturers -exceptionally expert in their respective fields -will give insights into image sharing: from the geographical applications (teleradiology) to the hospital-based applications, with specific reference to the support to surgeons (intraoperative guidance and model-guided surgery). medical imaging is part of a changing medical environment, a changing patient environment and consequently a new medical world. in the recent decennium one of the most important changes in radiology is the conversion from analogue to digital. in no time medical images have become interchangeable through the digital highway and could be post-processed in a different location. teleradiology has become a reality since then. we have seen the maturation of commercial international teleradiology companies offering a wide portfolio of services. another aspect is the availability of image data for all medical specialties beyond radiology and beyond the regular medical disciplines. an increasing number of surgical or oncological specialties and even pharmaceutical companies increasingly use image data to prepare a strategy for operative procedures, to choose the right therapy, to decide which prosthesis to the best to use, for follow-up or for post-processing purposes. they are supported by many new techniques and software. an increasing number of medical computer applications such as complex navigation and visualisation tools based upon digital images is already in clinical use or under development. another trend is the increasing interest in e-health and telemedicine in europe, also among european policy makers. now we see mobile health that brings care directly into the patient environment. the purpose of this presentation is to give a comprehensive overview of and insight into these new developments and to create awareness among radiologists of the increasing importance of integration of medical imaging in a multidisciplinary environment. key: cord- -tqd m i authors: zheng, yi; zhang, xuewen; guo, jiaoli title: application in medicine systems date: - - journal: dan shen (salvia miltiorrhiza) in medicine doi: . / - - - - _ sha: doc_id: cord_uid: tqd m i modern pharmacological studies on danshen have shown that the pharmacologic actions of danshen mainly include dilating vessels, promoting blood flow, improving microcirculation, changing blood viscosity, increasing myocardial blood and oxygen supplies, reducing myocardial consumption of oxygen, etc. the drug is used to treat diseases of the cardio-cerebrovascular system. in addition, danshen also has antitumor, antibacterial, and anti-inflammatory functions. therefore, danshen has wide clinical application. in recent years, there has been an increase in the number of reports on the clinical application of danshen extract and danshen compound preparations. danshen is seldom used alone; rather, it is usually combined with other drugs to form compound preparations. various danshen preparations have been developed, such as compound danshen tablets, compound danshen dropping pill ( dantonic™), compound danshen granules, compound danshen capsule, compound danshen oral liquid, compound danshen aerosol, and compound danshen injection (cdi), etc. the successful development of these preparations has improved product quality, enhanced efficacy, and opened up broader prospects for danshen’s clinical application. modern pharmacological studies on danshen have shown that the pharmacologic actions of danshen mainly include dilating vessels, promoting blood flow, improving microcirculation, changing blood viscosity, increasing myocardial blood and oxygen supplies, reducing myocardial consumption of oxygen, etc. the drug is used to treat diseases of the cardio-cerebrovascular system. in addition, danshen also has antitumor, antibacterial, and anti-inflammatory functions. therefore, danshen has wide clinical application. in recent years, there has been an increase in the number of reports on the clinical application of danshen extract and danshen compound preparations. danshen is seldom used alone; rather, it is usually combined with other drugs to form compound preparations. various danshen preparations have been developed, such as compound danshen tablets, compound danshen dropping pill (dantonic™), compound danshen granules, compound danshen capsule, compound danshen oral liquid, compound danshen aerosol, and compound danshen injection (cdi), etc. the successful development of these preparations has improved product quality, enhanced efficacy, and opened up broader prospects for danshen's clinical application. danshen has the function of effectively dilating the coronary artery, increasing coronary blood flow, reducing heart rate, inhibiting platelet aggregation and thrombopoiesis induced by platelet activation factors, promoting the recovery of injured cardiac muscle, increasing cardiac contractility, and protecting cardiac muscle cells; thus it can be widely applied in treating the diseases of the circulation system. the preparations of danshen used in the clinical treatment of coronary heart disease are mainly decoctions and compound injections. compound danshen decoctions are usually combined with other drugs such as the qi-boosting drugs ginseng and astragalus root, qi-moving drugs common aucklandia root, sichuan lovage root, and sandalwood, and the blood-invigorating drug safflower. compound injections are usually combined with drugs for supplementing qi, nourishing yin, and activating blood circulation. the application of danshen preparations can also be adjusted in timing and dosage. liu [ ] observed the effect of modified danshen beverage on the treatment of patients with coronary heart disease and angina pectoris. patients in the treatment group were administered modified danshen beverage; the prescription included g danshen, g ginseng, g american ginseng, g villous amomum fruit, g leech, g sanchi, and g sandalwood, with a course of treatment lasting weeks. patients in the control group were orally administered compound danshen tablet. the results showed that the total effective rates in the treatment group and control group were . and . %, respectively, and there was a significant difference between the two groups (p \ . ). ecg efficacies in the treatment and control groups were . and . %, respectively, and the difference was statistically insignificant (p [ . ). the blood lipids and hemorheology indices in the two groups changed after treatment. the rate of reduced or ceased use of nitroglycerin in the treatment group was . %, and in the control group was . %; the difference was significant (p \ . ). the authors concluded that the modified danshen beverage has the functions of improving coronary artery blood supply, reducing blood lipids, reducing blood viscosity, and inhibiting myocardial ischemia. li et al. [ ] observed the clinical therapeutic effects of combined chinese and western medicines on the treatment of unstable angina pectoris (uap). patients with uap were randomly divided into treatment and control groups, patients in each group. the patients in the control group were administered with -isosorbide dinitrate ( -ismn ) by intravenous drip; the patients in the treatment group were administered with, in addition to -ismn , compound danshen aerosoleach, four sprays per time, three times a day. the results showed that in the treatment group, some therapeutic effects on improving angina pectoris symptoms, physical signs, and ischemic electrocardiogram, etc. were observed; the drug also has the function of reducing total cholesterol, ldl level, and platelet adhesion rate, and stabilizing plaques. they found that combined treatment with danshen for uap was better than that of -ismn used alone. meng and zou [ ] reported the effect of modified pulse-engendering powder combined with danshen beverage on the treatment of patients with coronary heart disease and angina pectoris. the patients in the treatment group were administered with g of heterophylly false satarwort root, g of radix ophiopogonis, g of chinese magnolia vine fruit, g of danshen, g of villous amomum fruit, and g of liquorice root. the above drugs were decocted with water and taken one dose twice a day for weeks as one course of treatment. the patients in the control group were administered with mg of isosorbide dinitrate three times a day. the results showed that angina pectoris in the two groups after treatment was significantly relieved and the average number of days in the treatment group and control group was . ± . days and . ± days, respectively. the average number of days when angina pectoris disappeared in the treatment group and control group was . ± . and . ± days (p \ . ), respectively. hu and yang [ ] reported the effect of modified muxiang danshen beverage (木香丹 参饮) on the treatment of coronary heart disease and angina pectoris. the basic prescription contained g of common aucklandia root (木香), g of clove flower (丁香), g of round cardamon kernel (白蔻仁), g of villous amomum fruit (砂仁), g of agastache (藿香), g of sandalwood (檀香), g of danshen, and g of liquorice root (甘草). the above drugs were decocted and administered with water and divided into two parts, to be taken as one part twice per day. the results showed a therapeutic effect on the symptoms of angina pectoris: of the patients, there were patients with a marked effect, patients with an effect, and patients without effect. the effective rate was . %. regarding therapeutic effects on the electrocardiogram st-t segment, of the patients, patients had a marked effect, patients had an improving effect, and patients had no effect; the effective rate was . %. chen and gao [ ] reported the effect of modified harmonious yang decoction and danshen beverage on the treatment of patients with coronary heart disease and angina pectoris. patients in the control group were treated with western medicines; mg of isosorbide mononitrate was orally administered twice a day, along with mg of enteric-coated aspirin once a day. the patients in the treatment group were administered with the above western medicines plus tcm decoctions, i.e., modified harmonious yang decoction and danshen beverage, which contained g of prepared rhizome of rehmannia (熟地), g of danshen, g of antler glue (鹿角胶), g of mongolian snakegourd fruit (全瓜蒌), g of cassia bark tree twig (桂枝), g of villous amomum fruit (砂仁), g of sandalwood (檀香), g of raw liquorice root (生甘草), g of szechwan lovage rhizome (川芎), and g of white mustard seed (白芥子). the above drugs were decocted and taken with water, one dose twice a day, for days as one course of treatment, and the two groups were treated in two consecutive courses. the therapeutic effects were evaluated at the end of the treatment. the result showed that effective rate in the treatment group was . %, which was significantly higher (p \ . ) than that of the control group, which was . %. in the clinical application of danshen's modern preparations, compound danshen injection (cdi) occupies a very important position. cdi can significantly improve blood viscosity, so that blood flow is accelerated and intravascular pressure is reduced. cdi can antagonize calcium, dilate blood vessels, increase blood flow, and improve microcirculation of the heart. it also has the function of inhibiting platelet adhesion, aggregation and release, and improving prostacyclin metabolism, etc. these functions have been documented in large amounts of clinical literature, and cdi has been proven to have reliable therapeutic effects. on the basis of using cdi alone, various injections with the function of activating blood circulation, such as daidzein, and with the function of supplementing qi and nourishing yin, such as shenmai injection, etc., have been developed. lu and xu ( ) observed patients with average ages of ± years in a control group, and patients with average ages of ± years in the danshen treatment group. the patients in the control group were administered with ml of low molecular dextran combined with ml of % magnesium sulfate, ml of % potassium chloride, and iu human insulin by intravenous drip at - drops/min, once a day, for - weeks as one course of treatment. the patients in the danshen treatment group received the same treatment as those in the control group, but received an additional - ml of danshen injection. the therapeutic effects were evaluated according to clinical symptoms and electrocardiograms. the results showed that the marked effective rate and improvement rate in the danshen treatment group were higher than those in the control group, the total effective rates of the two groups were . and . %, respectively, with a significant difference (p \ . ). judging by ischemic electrocardiograms, the marked effect rate and improvement rate in the danshen treatment group were significantly higher than those in the control group, and the total effective rates were and %, respectively (p \ . ). the effective rates of reducing arrhythmia recurrence in the two groups were . and %, respectively (p \ . ), which demonstrated that the recurrence rate of arrhythmia in the danshen treatment group was significantly reduced compared to that in the control group. during the treatment period, neither abnormal changes nor any adverse reactions were shown in blood and urine routine assays, and the blood sugar and liver and kidney functions were normal. yang [ ] reported the application of shenmai and danshen injections in the treatment of patients with coronary heart disease and angina pectoris. the patients were administered with ml of shenmai injection and ml of danshen injection by intravenous drip, once per day for weeks, and the results showed the treatment had significant anti-angina pectoris effects. fu et al. [ ] reported the application of . / ml of puerarin and glucose injection combined with ml of cdi in the treatment of patients with coronary heart disease and angina pectoris, and the results showed that in the treatment group there were patients with a marked effect, patients with an effect, patients without effect, and the total effective rate was . %. there is a report showing that the effectiveness of danshen drugs might vary with the timing of drug administration. xing [ ] reported the application of cdi in the treatment of patients (treatment group: patients, control group: patients) with coronary heart disease and angina pectoris and blood stasis based on temporal rhythm. the patients were divided into a morning group and afternoon group, with the same drug and dosage ( ml of cdi) administered by intravenous drip. the results showed that the total effective rates of the treatment group in the morning and control group in the afternoon were . and . %, respectively, and the difference between the two groups was significant (p \ . ). the results demonstrated that better therapeutic effects of danshen could be obtained when the heart of the patient was in a vigorous condition. mao et al. [ ] reported the application of cdi and danshen injection in the treatment of patients with coronary heart disease, based on the theory that danshen has the effects of activating blood circulation, dissipating blood stasis, nourishing the heart to promote blood circulation, and benefiting vital energy and strengthening yang. ml of cdi and ml of danshen injection were mixed together, then the acupoints of inner pass (pc ), heart shu (bl ), and jueyinshu (bl ) were selected and the liquid was injected after needle sensation. heart shu and jueyinshu received ml of the injection each time, and inner pass received ml. the acupunctural injection was performed once every other day for days as one course of treatment, and usually two courses of treatment were necessary. the synergistic effects were obtained by the combination of acupuncture and medication. the effects were judged according to clinical symptoms, electrocardiogram and hemorheology. the total effective rate of clinical symptoms was . %, the total effective rate of improvement of electrocardiogram st-t was . %, and both whole blood viscosity and serum viscosity were significantly reduced. zhang [ ] reported the application of compound danshen aerosol on the treatment of patients with coronary heart disease and angina pectoris. the patients were sublingually administered with - sprays of the aerosol three times a day, for days as one course of treatment. patients in the control group were administered with isosorbide dinitrate tablet. the results showed that the total short-term effective rates for angina pectoris in the treatment group and control group were . and %, respectively; judging by electrocardiograms, the total short-term effective rates were and %, respectively, and the differences were significant (p \ . ). the immediate effective rates in the two groups were and %, respectively; the onset times were . ± . and . ± . min, respectively. the therapeutic effects on angina pectoris in short term, immediate effects, and the effects on severe angina pectoris and unstable angina in the treatment group were significantly better than those in the control group (p \ . ). the mechanisms for the treatment of coronary heart disease by danshen injection were clinically investigated. kong et al. ( ) found that after treatment with danshen preparations, the platelet aggregation test (pagt), β-tg (β-thromboglobulin) txb (thromboxane b ), and pgf α (prostaglandin f α) in patients with coronary heart disease were significantly reduced, and there were downward trends in pagt ( μmadp) and pf (platelet iv factor) after treatment, though the differences were not statistically significant. there were no significant changes in the ratios of β-tg/pf and txb /pgf α. the results demonstrated that danshen had wide cardiovascular pharmacologic actions (e.g., inhibiting platelet aggregation, dilating coronary artery blood vessels, cleaning oxygen radicals, anticoagulation, etc.) and reducing oxygen consumption by the myocardium so as to antagonize angina pectoris. zhang et al. [ ] reported the application of danshen in the treatment of patients with coronary heart disease and angina pectoris by injectio ad acumen at heart shu (bl ). the results showed that the blood plasma et- and mda were significantly reduced to a normal level after treatment. the authors concluded that danshen injection at heart shu point could remit the impairment of blood vessel endothelial cells in the patients with coronary heart disease and angina pectoris and alleviate angina pectoris. xing [ ] used danshen injection to treat patients with coronary heart disease, and observed the changes in the contents of lipid peroxides (lpo) and superoxide dismutase (sod) before and after the treatment. healthy individuals were used as the control. the results showed that lpo of patients with coronary heart disease was significantly higher than that of healthy individuals (p \ . ), but blood sod was lower significantly than that of healthy individuals (p \ . ); after treatment with danshen, lpo was significantly reduced (p \ . ), and sod was significantly increased (p \ . ). the results demonstrated that danshen had the function of reducing lpo and enhancing the activity of sod in serum. lin [ ] used danshen powder injection combined with nitroglycerin to treat high myocardial infarction patients with st segment elevation, and obtained satisfactory therapeutic results. danshen (lyophilized) powder has the function of dilating the coronary artery, inhibiting platelet aggregation, inhibiting thrombopoiesis, and improving hemorheology and microcirculation. danshen powder injection can be used to substitute longterm use of aspirin in the treatment of coronary heart disease. drug resistance can be induced by long-term use of nitroglycerin, and thus the therapeutic effect can be reduced to some extent. when danshen powder injection was added to the comprehensive treatment scheme (nitroglycerin, low molecular heparin, etc.), the total effective rate was . %, the blood rheology was significantly improved, and no apparent toxicity or sideeffects on liver and kidney function was observed. qi et al. [ ] observed the therapeutic effects of sodium tanshinone ii a sulfonate (sts) injection on the treatment of acute myocardial infarction (ami). patients with ami were randomly divided into an observation group ( cases) and control group ( cases). conventional therapy methods were performed in the control group, but sts injection in addition to conventional therapy was performed in the observation group. the results showed that the incidence of angina pectoris after infarct in the treatment group was significantly reduced weeks after treatment, and there was a significant difference between the treatment group and control group but no significant difference in arrhythmia and hospital mortality rate between the two groups. the results demonstrated that ventriculus sinister function and myocardial ischemia in patients with ami can be improved by sts injection, and it was safe and effective in clinical application. how to reverse left ventricular remodeling and slow down congestive heart failure after myocardial infarction (ami) is an important issue for physicians. clinically, β receptor blockers, angiotensin converting enzyme inhibitors, angiotonin ii receptor antagonists, and aldosterone receptor antagonists have been used for left ventricular remodeling treatment after ami. chao et al. [ ] observed the therapeutic effect of tanshinone ii a (tsn) on left ventricular remodeling after ami, and they found that tsn had significant inhibitory effects on remodeling compared with the control group. the results showed that tsn could significantly reduce the levels of ledvi and lesvi and increase the levels of lvef and e/a - weeks after treatment, thus inhibiting the post-ami enlargement of left ventricular internal diameter at the end of diastasis and left ventricular remodeling. the results demonstrated that tsn had a marked effect on the disease. it was revealed that the main pharmacologic actions of tsn on the cardiovascular system included anticoagulation and antiplatelet aggregation, improving coronary artery collateral circulation, reducing infarcted cardiac muscle area, reducing left ventricular end-diastolic pressure, reducing myocardial consumption of oxygen, and increasing left ventricular work. cheng et al. [ ] reported the application of san shen decoction (三参汤) in the treatment of patients with old myocardial infarction (omi) and premature ventricular contractions (vpc). - days later after taking antiarrhythmia drugs, the patients began to take san shen decoction which contains g of danshen, g of lightyellow sophora root (苦参), g of pilose asiabell root (党参), pieces of common jujube (大枣), one dose taken twice a day (morning and evening), continuing for - days. the dilatation drugs and cardiac diuretic were not discontinued while taking san shen decoction. the results showed that the total effective rate was %. there were three patients who suffered from accidental nausea and vomiting, but no significant side effects were observed in the other patients. danshen has the function of dilating vessels, enhancing the cardiac muscle's resistance to hypoxia, and improving heart function; combining the three drugs for the treatment of omi accompanied by vpc is an effective method. danshen has the function of dilating the coronary artery, enhancing resistance of the cardiac muscle to hypoxia, dilating peripheral vessels, and improving microcirculation. it especially has the function of improving cardiac contractility in the situation of can't affecting oxygen consumption when the patient is suffering from cardiac insufficiency, reducing the heart rate, significantly improving heart function, accelerating blood flow, and opening more capillary beds. these improvements are very important for patients with chronic congestive heart failure. in the treatment of chronic congestive heart failure, the dosage of cdi is usually ml or more; the therapeutic effect will be lessened if the dosage used is less than ml. the drug has poor efficacy on edema, which might have something to do with the amount of activity, salt intake, age, and other complications. huang and chen [ ] reported the application of true warrior decoction combined with danshen beverage in the treatment of patients with deficiency in heart-yang and kidney-yang types of heart failure; the prescription includes - g of red ginseng, - g of prepared common monkshood daughter root (熟附子), - g large head atractylodes rhizome (白术), - g of indian buead (茯苓), g of danshen, g of villous amomum fruit (砂仁), g of sandalwood (檀香), - g of oriental waterplantain tuber (泽泻), and - g of asiatic plantain seed (车前子) (decocting in wrapped condition), with days for one course of treatment. after the treatment, cases were clinically cured, cases showed a marked effect, cases showed an effect, and cases showed no effect; the effective rate was . %. liu [ ] observed the effect of cdi combined with shenmai injection on the treatment of patients with chronic congestive heart failure, of which there were males and females; cases of pulmonary heart disease, cases of coronary heart disease, cases of hypertensive cardiopathy, case of rheumatic heart disease, case of coronary heart disease, case of lung cancer; cases of class ii cardiac function, cases class iii, cases class iv; cases of left congestive heart failure, cases of right congestive heart failure, and cases of whole congestive heart failure. ml of % glucose was mixed with ml of shenmai injection and administered by intravenous drip; ml of % glucose was mixed with ml of cdi and administered by intravenous drip. the drugs were given once daily for - days as one course of treatment. the patients were usually treated for - courses, with an average period of . courses and an interval of - days between the courses. after various symptoms and physical signs were improved, the patients took compound danshen tablet and shengmai beverage orally to consolidate the therapeutic effect. the results showed that there were patients with marked effect, patients with effect, patients with no effect, and the total effective rate was %. hong et al. [ ] reported that patients with congestive heart failure were randomly divided into two groups; cases were treated with conventional therapy, and cases were treated with conventional therapy plus mongolian milkvetch root (黄芪) and cdi by intravenous drip. the changes of clinical therapeutic effect, heart function, and lpo and sod in the two groups were observed. the results showed the total effective rate in tcm group was . %, which was higher than that in the conventional group ( . %) (p \ . ). the heart functions of the two groups were improved after the treatments (p \ . ). the therapeutic effect in the tcm group was significantly better than that in the conventional group (p \ . ). the lpo levels in the two groups were reduced after the treatments, sod levels were increased (p \ . ), lpo in the tcm group was reduced, and sod was significantly increased compared to the conventional group. the authors concluded that the treatment of congestive heart failure with mongolian milkvetch root and cdi has the effects of strengthening the heart, relieving cardiac load, and improving blood circulation. the combination of the two drugs has the effects of benefiting vital energy and activating blood circulation, and promoting diuresis, which is consistent with tcm principles of treating heart failure. transluminal coronary angioplasty (ptca) with thorough understanding of the etiological factors of coronary heart disease and the increasing maturation, improvement, and advancement of cardiac cathetenization, percutaneous transluminal coronary angioplasty (ptca) is becoming an important method for physicians to treat coronary heart disease with. however, clinical studies have shown that about one-third of patients with a successful ptca operation suffer from coronary artery restenosis within months, which seriously affects the long-term therapeutic effects of ptca. the occurrence of restenosis is a complex biological process involving various factors. so far, there are no marked effective drugs for the prevention and treatment of restenosis, therefore the research and development of such drugs which can effectively prevent coronary artery restenosis is of great significance. danshen injection can inhibit the propagation of rabbit aorta smooth muscle cells cultured in vitro, and also has the function of inhibiting in vivo hyperplasia after the operational removal of endothelium in rabbit artery, which suggests that the development of danshen into an effective drug for restenosis is hopeful. xu [ ] observed the application of cdi in the treatment of patients with dilated cardiomyopathy. ml of % glucose solution or ml of . % physiological saline were added into - ml of cdi and administered by intravenous drip, once daily for days as one course of treatment. the dosage of cdi in the treatment of dilated cardiomyopathy was usually greater than ml/time; a lesser amount will give a poor therapeutic effect. glucose solution should be substituted by . % physiological saline for patients with diabetes. a small amount of patients after using cdi suffered from side effects such as active bowel sounds, loose stool, or increased number of dejection, etc., but the majority of patients suffered no adverse reactions. zhu et al. [ ] observed the therapeutic effects of mongolian milkvetch root injection combined with cdi on the treatment of patients with dilated cardiomyopathy. the patients were divided into two groups; both groups were treated with conventional therapy (low salt diet, using cardiotonic and diuretic drugs and converting enzyme inhibitors, etc.), then the patients in the control group were administered by intravenous drip with mg of atp, units of coenzyme a, g of vitamin c, . g of vitamin b , and ml of trommcardin, in ml of % glucose, once daily for days as one course of treatment, and the patients were treated for - courses. ml of mongolian milkvetch root injection ( ml injections contains g of mongolian milkvetch root) and ml of cdi were mixed with ml of % glucose injection and administered by intravenous drip to the patients in the treatment group, once daily for days as one course of treatment, and the patients were treated for - courses. the results showed that cases in the treatment group showed marked effect, cases effect, cases no effect ( cases died), and the total effective rate was . %; in the control group, cases showed marked effect, cases effect, cases no effect, cases died, and the total effective rate was %. the differences in effective rates and fatality rates between the two groups were statistically significant (p\ . ). it was concluded that cdi has the function of activating blood circulation and dissipating blood stasis, regulating vital energy and inducing resuscitation, inhibiting platelet aggregation, dilating the coronary artery, increasing blood flow, reducing heart rate, and promoting the repair of damaged myocardial cells. in the combination of the two drugs, the ml of mongolian milkvetch root injection is the principal drug which has the major function of nourishing qi and the adjutant function of diuresis; the ml of cdi is the adjutant drug which has the function of activating blood circulation. the combination of the two can complement each other. in this study, the total effective rate of the treatment group was . %, and the difference was significant compared with the control group. no toxicity or side effects were observed and no tolerance was induced. yan wanying and he jianping reported the application of a self-made decoction in the treatment of patients with elderly sick sinus syndrome; the prescription included g of pilose asiabell root (党参), g of mongolian milkvetch root (黄芪), g of chinese angelica (当归), g of red peony root (赤芍), g of danshen, g of szechwan lovage rhizome (川 芎), g of rehmannia dride rhizome (生地), g of spine date seed (酸枣仁), g of cassiabarktree twig (桂枝), g of common motherwort herb (益母草), g of lobed kudzuvine root (葛根), g of fried submature bitter orange (炒枳壳), and g of prepared liquorice root (炙甘草). among the patients treated, cases showed marked effect, which was defined as the disappearance of clinical symptoms and an increase in heart rate by beats/min in month of treatment; cases showed effect, which was defined as improvement of the clinical symptoms and an increase in heart rate by - beats/min in months of treatment. cases were classified as no effect, which means there were some improvements in clinical symptoms, but no changes in heart rate after months of treatment. fu [ ] reported the application of salbutamol and danshen in the treatment of patients with idiopathic sick sinus syndrome. the patients were administered with . mg of salbutamol by intravenous drip, three times a day, and ml of danshen injection, one time a day. a half month after treatment, the patients were administered orally with compound danshen tablet, three times a day, three tablets each time, for months as one course of treatment. the results showed that months after salbutamol and danshen treatment, all patients showed some degree of alleviation of clinical symptoms. the sinoauricular node recovery time (snrt) and sinoatrial conduction time (sact) were significantly shortened in patients; the maximal shortened snrt was , ms, the minimal was ms, and average was , ms; the maximal shortened sact was ms, the minimal was ms, and average was ms. there was no significant change in snrt and sact in three patients. there are many causes of sick sinus syndrome, but after examining the electrocardiograms, echocardiograms, sternum x-rays, blood fat, and blood sugar of the patients, no definite etiological causes were confirmed and thus they were classified as having idiopathic sick sinus syndrome. salbutamol is a β receptor stimulant which has the function of dilating vessels, improving sinoauricular node blood supply and enhancing pacing. danshen preparation has the function of activating blood circulation, promoting qi, dilating vessels and increasing coronary artery blood supply, increasing sinoauricular node blood supply, and reducing blood viscosity, thus preventing fibrosclerosis of the sinoauricular node. the therapeutic effects were enhanced by the combination of the two drugs, and satisfactory clinical therapeutic effects were obtained. shi et al. [ ] reported that patients having intracardiac operations under direct vision were randomly divided into a treatment group and control group, with patients each. the patients in the treatment group were administered with mg/kg cdi by intravenous injection before operation and after heart resuscitation after rewarming, and the patients in the control group were administered with physiological saline. the results showed that cdi has the function of increasing the pgi /txa ratio in the reperfusion phase, effectively inhibiting the production of endothelin and promoting the recovery of cardiac function after ischemia-reperfusion. base upon the above reviewed data, we can see clearly that danshen has significant therapeutic effects on the treatment of heart and circulation system diseases such as coronary heart disease, myocardial infarction, heart failure, cardiomyopathy, myocardial ischemia, sick sinus syndrome, and so on. the therapeutic effects are especially better when danshen is combined with other traditional chinese drugs. besides the functions of antiplatelet aggregation, reducing thromboxane a and promoting prostacyclin production, danshen also has the function of blocking ca + channels, improving the tolerance of brain cells to ischemic and hypoxic conditions, reducing free radical content, stabilizing cell membranes, and improving microcirculation. danshen has the function of increasing brain blood flow, and improving brain circulation. it is widely applied in the treatment of stroke (such as nervous system diseases, cerebral thrombosis, cerebral hemorrhage, subarachnoid hemorrhage (sah), etc.) in tcm, and satisfactory therapeutic effects can be obtained. li et al. [ ] demonstrated that the function of danshen was mild and comprehensive. large doses of mannitol could induce pachyemia, aggravate the high viscosity and hypercoagulability of the blood, and aggravate ischemic damage after cerebral hemorrhage. however, danshen can reduce blood viscosity, inhibit platelet aggregation, and improve microcirculation, and has the function of regulating the fibrinolysis system and promoting fibrin degradation, has anti-free radical activity, and relieves ischemic damage after cerebral hemorrhage and promotes hematoma absorption. when combined with dehydrating agents, danshen can relieve cerebral edema, promote the absorption of hematoma, promote the repair and regeneration of brain tissue, and alleviate sequelae. patients with cerebral hemorrhage were treated with cdi, and the rates of recovery and significant improvement in the treatment group were significantly better than those in the control group, and no side effects were observed. especially for patients with a small amount of hemorrhage, danshen can improve neurologic impairment and enhance the recovery rate. it is believed that senile patients usually suffer from blood system abnormalities, and the majority of research has reported that fibrinolysis activity in the elderly is low, thus they can easily suffer from thromboembolic disease. however, special attention needs to be paid to the possibility of hyperfibrinolysis or rehaemorrhagia or hematoma enlargement, which can be induced by various causes, in patients with cerebral hemorrhage. pang et al. [ ] observed the therapeutic effect of danshen injection on the treatment of cerebral hemorrhage. patients with cerebral hemorrhage were randomly divided into two groups; patients in the treatment group, and patients in the control group. the basic prescription in two groups was the same, namely, ml of % mannitol by intravenous drip, each for - h, continued for - days. days after the onset, the patients in the treatment group received ml of danshen injection by intravenous drip, once a day for weeks. ct examination was performed before and and weeks after treatment to measure hematoma volume. nerve function was also evaluated for the patients in the two groups. there was no significant difference in hematoma volume between two groups before the treatment (p [ . ), and hematomas in the treatment group were smaller than in the control group after treatment (p \ . ). there was no significant difference in neurological deficit between the two groups before treatment (p [ . ), but it was significantly reduced after treatment in the treatment group compared to the control group (p \ . ). the difference was especially obvious months later (p \ . ). these results demonstrate that danshen injection can promote hematoma absorption and nerve function recovery. pang et al. [ ] investigated the preventive nerve protective effect of dantonic™ on hypertensive patients. a large-sample epidemiological survey was conducted, and patients with hypertension who met the diagnostic criteria were selected. the patients were divided into groups. cases in the treatment group were administered with dantonic™ and nifedipine or captopril. cases in the control group were administered with nifedipine or captopril alone. they were followed up for months, and the changes in blood pressure, blood lipids, microcirculation, blood flow, thrombin, and other indices and the incidence of cerebral ischemic stroke were monitored. after treatment, there were significant differences in the clinical marked effective rate; effective rate and average pressure decrease between the two groups (p \ . ). the improvements in blood lipids, microcirculation, blood flow, and thrombin etc. in the treatment group were significantly better than those in the control group (p \ . ). the incidences of cerebral ischemic stroke in the treatment group and control group were . % ( / ) and . % ( / ), respectively, and the difference was significant (p \ . ). the results demonstrated that dantonic™ has a good prophylactic neuroprotective effect on patients with hypertension. zhang ( ) reported the application of a prescription with the function of unblocking the orifices, invigorating blood, and promoting urination in the treatment of patients with apoplexy. the ct examination showed patients with cerebral hemorrhage, patients with cerebral infarction, and patients with brain atrophy. the prescription included danshen, szechwan lovage rhizome (川芎), red peony root (赤芍), peach seed (桃仁), safflower (红花), common motherwort herb (益母草), medicinal cyathula officinalis root (川牛膝), indian buead (茯苓), forest musk (麝香) [or taiwan angelica root (白芷), synthetic borneol (冰片)], mongolian milkvetch root (黄芪), suberect spatholobus stem (鸡血藤), and earthworm (地龙). the above drugs were decocted and taken with water, one dose a day. after treatment, patients almost completely recovered, patients showed marked effect, cases showed no effect, and the total effective rate was . %. the prescription was especially effective on slurred speech. qi [ ] reported the application of sanqi panax notoginseng and cdi in the treatment of patients with cerebral infarction. the patients were - years old and all hospitalized h to days after onset; among them there were mild cases, moderate cases, and severe cases. the patients were divided into two groups, with cases in each group. the patients in the treatment group were administered with sanqi panax notoginseng and cdi by intravenous drip, and the patients in the control group were administered with cdi by intravenous drip. the two groups were comparable in gender, age, number of cases, and clinical classification. the patients in both two groups were treated according to the conventional procedure for cerebral infarction: those without significant anticoagulation contraindication or ulcer or hemorrhagic diseases were administered with anticoagulation drugs, such as mg heparin by intravenous drip for - h; mg antiplatelet aggregation drug aspirin, one time a day. % mannitol and dexamethasone were administered according to individual situations to reduce intracranial pressure, relieve cerebral edema and clean free radicals, and maintain water and electrolyte equilibria. the patients in the treatment group received ml of sandi panax notoginseng in ml of % glucose solution and ml of cdi in ml of % glucose solution, both administered by intravenous drip once a day. the patients in the control group received ml of cdi in ml of % glucose solution, with days as one course of treatment, and the patients were treated for courses. the interval between courses was days. for cured patients, the treatment was stopped immediately, and these patients were treated for - days. the results showed that there were patients with near complete recovery in the treatment group, patients with significant improvement, patients with improvement, patients without improvement, and the total effective rate was . %. in the control group, there were cases of recovery, cases of significant improvement, cases of improvement, cases of no improvement, and the total effective rate was %. the difference in effective rates of the two groups was significant (p \ . ). huang et al. [ ] observed the therapeutic effect of intravascular irradiation by a low energy he-ne laser and danshen treatment on acute cerebral infarction. in addition to traditional neurological treatment, cases of cerebral infarction (research group) were treated with intravascular irradiation by a low energy he-ne laser and danshen, and there was a corresponding control group. the hemorheology and blood fat indexes were determined before and after the treatment. the results showed that the effective rate in the research group was . % compared to . % in the control group, and the difference between the two groups was significant (p \ . ). the results demonstrate that intravascular irradiation by low energy he-ne laser combined with intravenous drip of danshen is a good method for the treatment of acute cerebral infarction. zhai et al. [ ] observed therapeutic effect of high-dosage danshen on the treatment of patients with acute cerebral infarction; ml of danshen injection was added into ml of low molecular dextran and administered by intravenous drip to patients in the treatment group, and mannitol and antibiotics etc. were administered according to pathogenetic conditions. anticoagulation, thrombolysis, and dilating vessel drugs were not used in the treatment. the patients in the control group were administered with the same drugs as in the treatment group, except for cdi. the drugs were administered by intravenous drip once a day, for weeks as one course of treatment. the results showed that there were cases with a clinical cure, cases with marked effect, cases with improvement, cases without effect, and the total effective rate was % in treatment group. in the control group, there were cases with marked effect, cases with improvement, cases without effect, and the total effective rate was . %. there was a significant difference in therapeutic effects between the two groups (p \ . ). it was revealed that compound danshen can significantly improve the majority of cerebral hemodynamic indexes, especially those of brain blood flow speed, vessel wall elastic wave speed, and critical pressure, which demonstrated that it had important functions in promoting cerebral blood flow, improving the elasticity of cerebral vessels, and reducing blood viscosity. therefore, application of danshen in the early stage can enhance the therapeutic effect and reduce disability rate. sun [ ] investigated the cerebral hemodynamic change of patients with sah, and the protective effect of danshen on brain ischemic damage. patients with sah were divided into two groups, with patients in both groups on absolute bed rest. the patients were administered conventional drugs with the function of reducing intracranial pressure and antifibrinolysis. ml of cdi was added into ml of % glucose injection and administered by intravenous drip to the patients in the danshen treatment group once a day, and the maximal length of the treatment was weeks. the cerebral hemodynamic changes and fatality rate in the two groups, ecg abnormal incidence, and cerebral vessel spasm incidence were observed. the results showed that the cerebral hemodynamic parameters of patients with sah were significantly changed, especially the minimum blood flow speed and cerebral vessels peripheral resistance; the cerebral hemodynamic changes between the danshen group and control group were very significant (p \ . ). it was revealed that sah can induce cerebral hemodynamic abnormality, and danshen preparation has a protective effect on brain ischemic change due to sah. with further pharmacology and clinical research on danshen, an increasing number of clinical documents have demonstrated that there are satisfactory therapeutic effects of danshen and its preparations on the treatment of cerebral vessel diseases, including cerebral hemorrhage and cerebral infarction. numerous facts have demonstrated that danshen can be actively used in the prevention and treatment of cerebral vessel diseases. zhang [ ] reported the application of integrated medicine to the treatment of trigeminal neuralgia. tcm preparations were anointed on the surface of the trigeminal neuralgia site. after locating the "trigger points" in the trigeminal neuralgia site, about ml of % lidocaine was injected at each point. min later, μg of vitamin b combined with mg dexamethasone were injected in the same site, once every days. during the blocking period, the patients took compound danshen tablet orally, tablets each time, times a day, plus . g of spiramycin each time, times a day. the results showed that patients were cured by times of blocking treatment, patients were cured by times of blocking treatment. the patients were followed up for - months, and there were no recurrences during the months to years period; the curative rate was %. the results demonstrate that integrated medicine can be used to treat trigeminal neuralgia, which can rapidly control the onset of the pain. the method is simple and practical, and can be further extended. wu [ ] reported the treatment of trigeminal neuralgia cases with cdi and "wu bai decoction" (五白汤). the patients were administered with ml of cdi by intramuscular injection, twice a day. traditional chinese drug "wu bai decoction" contains g of white peony root (白芍), g of giant typhonium tuber (白附子), g of taiwan angelica root (白芷), g of white stiff silkworm (白僵蚕), g of troubles territories (白蒺藜). the above drugs were decocted twice with water and administered one dose a day. the recovery rate was . %, the total effective rate was . %, and therapeutic effects were significantly better than those in the control group. it was revealed that compound danshen by intramuscular injection has the function of dilating microcirculation and improving local blood supply; a high dosage of white peony root has the function of nourishing blood and retaining yin with astringent, nourishing liver, and relieving pain. there was no toxicity or side-effects in clinical application, and the courses of treatment were short. gao et al. [ ] reported the application of dantonic™ in the treatment of patients with middle-aged and elderly facial neuritis. the patients in the control group received treatment with hormones, vitamins, antiviral drugs, physical therapy, and anti-inflammatory drugs, etc., and the patients in the treatment group received the same treatment as the control group plus - pills of dantonic™, times a day for days as one course of treatment, and courses of treatment were performed. the results showed that the total effective rates in the treatment group and control group were . and . %, respectively, and there was a significant difference in the total effective rate between the two groups. the study demonstrated that dantonic™ has the function of relieving vasospasm, improving local blood circulation around the facial nerves, and relieving inflammatory edema, thus it can be used to treat the disease. zhang [ ] reported the treatment for cases of migraine. - ml of cdi was added into % glucose salt water, and administered by intravenous drip for days as one course of treatment. patients without improvement after the first course received another course of treatment after - days. the results showed that five cases significantly improved after one course, and cases improved after the second course of treatment. it was believed that danshen's effects might be related to its function of stabilizing vasoconstriction and improving microcirculation. ge et al. [ ] reported the treatment of serious migraine with danshen, diclofenac sodium, and β-sodium aescinate. cases of serious migraine were treated with ml of danshen, . g of diclofenac sodium, and mg of β-sodium aescinate, and the effects were compared with those in cases of serious migraine treated by diclofenac sodium alone. the results showed that the total effective rates of the combined drug treatment group and single diclofenac sodium group were and %, respectively, and the differences in total effective rate and control rate between the two groups were significant (p \ . ). wang [ ] reported the treatment of migraine with compound danshen and - in cases. mg of - injection and cdi was added into ml liquid and administered by intravenous drip to the patients in the treatment group once per day, and days later they were orally administered with three tablets of compound danshen tablet and mg of - tablets, three times a day for month as a course of treatment. the patients in the control group were administered orally with not more than six tablets of ergotamine and caffeine tablets each day, then mg of nimodipine tablets twice a day after pain remission. the results showed that in the treatment group, cases showed marked effect, cases showed effect, cases showed no effect, and the total effective rate was . %. in the control group, cases showed marked effect, cases showed effect, cases showed no effect, and the total effective rate was . %, with a significant difference (p \ . ). it was believed that the effect of compound danshen and - on migraine treatment was related to their functions of vessel dilation and vasospasm relief; the study demonstrated that there was both blood vessel constriction and vasospasm during the migraine attack phase, compound danshen and - has the function of regulating vasoconstriction to stabilize blood vessels, thus controlling the migraine attack. there was a synergistic effect when the two drugs were used together, and with gentle adverse reactions; a few patients suffered from dry mouth, pharyngalgia, and other symptoms which might be related to the side effects of - . zhou et al. [ ] administered a mixture of ml of danshen injection and ml of cerebrolysin by intravenous drip to elderly patients with functional insomnia. the results showed that the clinical recovery rate and effective rate were . and . %, respectively, which were significantly better than those of the control group (p \ . ). it was believed that danshen has the functions of cleaning oxygen radicals and antilipid peroxidation, so it can delay the degeneration of brain cells and improve sleep. tong [ ] reported on patients with insomnia randomly divided into two groups; the patients were, respectively, treated with danshen zaoren decoction (丹参枣仁汤) and diazepam tablets, and the therapeutic effects in the two groups were observed. the patients in the treatment group were treated with self-made danshen zaoren decoction, which contains g each of danshen, raw dragon's bones (生龙骨), raw common oyster shell (生牡蛎), tuber fleeceflower stem and leaf (夜交藤), silktree albizia bark (合欢皮), and g each of stir-baked semen ziziphi spinosae (炒枣仁), and chinese arborvilae seed (柏子仁). the patients in the control group were administered with . mg of diazepam tablets orally before sleep, once a day. the therapeutic effects were evaluated days after the treatment. the results showed that the effective rate in the treatment group ( . %) was significantly higher than that in the control group ( . %), and the difference was significant (p \ . ). li [ ] reported the treatment of meniere's disease with a combination of cdi and qingkailing injection (清开灵注射液) for cases. - ml of cdi was added to - ml of % glucose injection and administered by intravenous drip, and - ml of qingkailing injection was added to physiological saline or - ml of % glucose injection and administered by intravenous drip in the treatment group. for the control group, mg of anisodamine injection was added to physiological saline or ml of % glucose injection and administered by intravenous drip, ml of low molecular dextran was administered by intravenous drip, and mg of atp, u of coenzyme a, mg of inosine, mg of vitamin b , and g of vitamin c were added to ml of % glucose injection and administered by intravenous drip. the symptoms of acid-base imbalance and electrolyte disturbances were treated at the same time. the therapeutic effects in the two groups were compared days after the drug administrations. the results showed that the recovery rate ( . %) in the treatment group was significantly higher than that in the control group ( . %). it was revealed that cdi has the function of activating blood circulation and dissipating blood stasis, regulating vital energy, and inducing resuscitation. qingkailing injection has the function of clearing heat and resolving toxins, cooling the blood and dissipating blood stasis, calming the liver and extinguishing wind, awakening the brain and opening the orifices, and eliminating sputum and dredging collaterals. the treatment using the combination of the two drugs targets both the causes and symptoms of meniere's disease, so satisfactory therapeutic effects were obtained. liu et al. [ ] reported that ml of danshen injection and mg of - injection were administered by intramuscular injection every h; or ml of % glucose combined with ml of danshen and ml of % glucose combined with mg of - injection were administered by intravenous drip each day. days after administration, the dosage of - was gradually reduced to mg, mg or complete withdrawal, depending on the patients' conditions and whether a toxic effect was induced by - . the dosage of danshen was not changed. patients with polyneuritis were treated and all of them were cured. the course of treatment was - days. xiao [ ] observed the therapeutic effect of cdi combined with banxia baizhu tianma decoction (半夏白术天麻汤) on acute dizziness. patients with acute dizziness were randomly divided into a treatment group and control group. in the treatment group, ml of cdi was added to ml of % gs and administered by intravenous drip for days, once a day; modified banxia baizhu tianma decoction was administered for days, one dose per day. in the control group, . - . g of venoruton injection was added into ml of % gs and administered by intravenous drip for days, once a day. the results showed that among the cases in the treatment group, cases were cured, cases showed an effect, and only cases showed no effect; the total effective rate was . %. in the control group, cases were cured, cases showed effect, cases showed no effect, and the total effective rate was . %, there was a significant difference between the treatment group and control group (p \ . ). liu et al. ( ) reported that cases of pulmonarye encephalopathy were randomly divided into a treatment group ( cases) and control group ( cases). the patients in the two groups were treated with the conventional therapy. ml of cdi was added to ml of % glucose solution and administered by intravenous drip to the patients in the treatment group, and ml of niuhuang xingnao injection (牛黄醒脑注射液) i and ii were administered by intramuscular injection, - times a day. the results showed that in the treatment group, the remission rate was % and mortality was %, and in the control group, the remission rate was . % and mortality was . %. the difference in fatality rate between the two groups was significant ( . \ p\ . ). it is believed that danshen has the functions of reducing blood vessel fragility and permeability, relieving the stagnation and aggregation of erythrocytes, reducing blood hypercoagulability, improving microcirculation in important organs such as the brain, heart, lung, and kidney, regulating tissue repair and regeneration, enhancing the body's compensatory ability, and promoting blood circulation. niuhuang xingnao injection was developed from the prescription of angong niuhuang wan, which has the function of clearing heat and resolving toxins, and calming the nerves and relieving spasms. it promotes consciousness recovery, and has significant anti-inflammatory effects. it can improve the body's tolerance to hypoxia. some therapeutic effects have been obtained by the combination of the two drugs in the treatment of pulmonary encephalopathy. lin [ ] investigated the effect of compound danshen preparations on the treatment of craniocerebral injury. patients with craniocerebral injury confirmed by head ct were selected in the study and randomly divided into two groups. the patients in the treatment group were administered with compound danshen preparations in addition to conventional therapy. the total effective rates in the treatment group and control group were . and . %, respectively. the results showed that better therapeutic effect was obtained in the treatment of craniocerebral injury by application of compound danshen preparations, and no significant side effects were observed. danshen has extensive applications to the treatment of nervous system diseases. besides on the pathological changes of cerebral vessels, it also has satisfactory therapeutic effects on trigeminal neuritis, facial neuritis, migraine, insomnia, dizziness, etc., so it is worthy of physicians' consideration when they face these diseases. respiratory system disease there was no significant difference (p [ . ) in common condition (gender, ages, pathogenesis), levels of infection (body temperature, symptoms, physical signs, x-ray, blood routine assays, bacteriology examination, etc.), and baseline disease and so on between the two groups. the patients in the two groups were treated according to their disease conditions. besides the above treatments, ml of cdi was added into ml of % glucose and administered by intravenous drip for the patients in treatment group, once a day. all patients were treated for days. the results showed that in the treatment group, cases recovered, cases showed marked effect, cases showed effect, cases showed no effect, and the effective rate was . % ( / ); in the control group, there were cases of recovery, cases of marked effect, cases of effect, cases with no effect, and the effective rate was . % ( / ). the effective rate in the treatment group was significantly higher than that in the control group (p \ . ). no toxicity or side-effects were observed. it was believed that cdi has the function of activating blood circulation and dissipating blood stasis, dilating vessel and restoring blood capillary relaxation ability, relieving blood vessel obstructions and blood stasis, relieving lung arteriola spasm, improving and promoting lung microcirculation, recovering pulmonary ventilation function, enhancing pulmonary oxygen function, promoting absorption of rales, and improving dyspnea conditions. in recent years, it has been demonstrated by research that danshen has inhibitory effects on gram-positive bacteria and some gram-negative bacteria, enhancing the body's immunity and thus enhancing the body's ability to fight infection. in addition, cdi also has the function of changing the blood rheology, improving pulmonary hypertension, shortening the course of lower respiratory infection in senile patients, and reducing mortality. shi ( ) reported the treatment of patients with persistent pneumonia who had been treated with various antibiotics, gamma globulins, plasma or fresh blood transfusions, physical therapy, and cortical hormones for more than month, but had obtained no significant therapeutic effects. the patients in the study were administered by intravenous drip with - mg of tanshinol, twice a day. - days after the treatment, patients were cured and patients had improved. it was revealed that in the pathogenesis of pneumonia, viruses and anoxia act upon the lung tissues to produce vasoactive substances and thus induce lung arteriola spasm and microcirculatory disturbance. compound danshen has the function of vascular dilation and improving microcirculation, thus promoting the patients' recovery from pneumonia. xu et al. ( ) used the ultrasonic atomizing inhalation of cdi to treat bronchial asthma. ml of cdi was diluted with ml of distilled water, and ultrasonic atomizing inhalation was performed once a day for days as one course of treatment. among the patients treated, there were cases of acute bronchitis, cases of chronic bronchitis, cases of asthma, and the average number of treatments was - times. the results showed that cases showed marked effect, cases showed effect, and the total effective rate was . %. the effect of the treatment on asthma patients began slowly, but the therapeutic effect was strengthened after the asthma was relieved. cases were followed up, and the disease did not recur one year after treatment. li et al. [ ] reported the application of cdi in the treatment of cases of bronchial asthma during the attack phase. the patients in the control group were treated with regular treatments such as oxygen inhalation, spasmolysis, β agonists, glucocorticoids, antibiotics, and so on. the patients in the treatment group were treated in the same way as those in the control group, but received an additional ml of cdi which was added into ml of % glucose and administered by intravenous drip, once a day for days as a course of treatment. the results showed that the total effective rates in the treatment group and control group were . and %, respectively. statistical analysis showed that there was a significant difference in therapeutic effect between the two groups. the mechanism of cdi in the treatment of bronchial asthma might be: ① inhibiting the release of bioactive compounds, reducing the high reactivity of airway, improving lung ventilation; ② improving microcirculation, enhancing the body's tolerance to anoxia; ③ dilating the coronary artery, increasing coronary blood flow, improving myocardial blood supply, enhancing cardiac contractility, and promoting remission of asthma; and ④ the obvious of antibacterial and anti-inflammatory functions have adjuvant therapeutic effects on lung infections. zhang [ ] reported that patients with acute aggravating stage pulmonary heart disease were randomly divided into a treatment group ( cases) and control group ( cases). comprehensive treatments (relieving cough and eliminating sputum, cardiotonics, anti-inflammation, low flow oxygen inhalation, etc.) were performed on the patients in the two groups, and ml of cdi in ml of % glucose was administered by intravenous drip to the patients in the treatment group, once a day for weeks as one course of treatment. the results showed that in the treatment group there were cases with marked effect, cases with improvement, cases without effect, and the total effective rate was . %. in the control group, there were cases with marked effect, cases with improvement, cases of no effect, case of death, and the total effective rate was %. the effective rate in the treatment group was significantly higher than that in the control group (p \ . ). patients with chronic pulmonary heart disease have some changes in their hemorheology, which include three characteristics: "dense" (increased erythrocytes), "sticky" (increased whole blood viscosity), and "accumulation" (enhanced erythrocyte aggregation). compound danshen has the function of improving the blood rheology, reducing blood viscosity, inhibiting erythrocytes and platelet aggregation, promoting the activity of fibrinolysis system, dilating vessels, promoting blood flow, improving microcirculation, increasing heart renal blood supply and anti-infection, enhancing body immunologic function, and so on, so it has significant clinical therapeutic effects. to calculate the effect of danshen on the pulmonary artery pressure (pap) of patients with chronic lung disease, the cardiac output (co), lung circulation resistance (rvr), and lung blood vessel compliance (pvc) were compared for some patients before and after treatment. the results showed that after injection of danshen, the extents of pap reduction in the high pressure group and normal pressure group were . - . and . - . kpa, respectively, and the differences before and after the treatment were significant. the results demonstrated that danshen has the function of reducing pap, and the reduction period was usually about - min with no cases taking longer than min, suggesting that danshen has circulation dynamic effects similar to those of dihydropyridines. zhang and chen [ ] reported the use of cdi to treat patients with chronic pulmonary heart disease. the patients were administered by intravenous drip with ml of cdi in ml of % glucose, once a day for days as one course of treatment, and four indexes (lpo, erythrocytes sod, whole blood gsh-px, and catalase activity) were observed. the results showed that danshen could significantly reduce enhanced lipid peroxidation and correct the imbalance of antioxidant enzymes in patients with chronic pulmonary heart disease. the studies demonstrated that the drug has the function of cleaning and inhibiting free radicals, thus inhibiting the occurrence and development of pulmonary hypertension in patients with chronic obstructive pulmonary emphysema. it is believed in traditional chinese medicine that the heart controls blood circulation and the lung controls respiration; the normal circulation of blood depends on the pushing power of qi, and the movement of qi depends on the normal circulation of blood. for this reason, danshen and its preparations, which are good drugs for activating blood circulation and dissipating blood stasis, can exert satisfactory therapeutic effects on pulmonary system diseases, which has been shown in the above examples. experimental research has already demonstrated that danshen can improve disturbances in liver microcirculation, has the functions of anti-lipid peroxidation, protecting hepatocytes, promoting the repair of liver damage, increasing fibrin levels in plasma, enhancing the phagocytic function of the reticuloendothelial system, inhibiting hepatic fibrosis, and promoting the resorption of fiber. in addition, danshen also has the function of promoting the secretion of mucus by the stomach mucous membrane, relieving intracellular calcium overload, increasing blood flow in mucous membranes, improving microcirculation, inducing the synthesis and release of endogenous prostaglandin, and inhibiting gastrointestinal motility. therefore, it can be extensively used in the treatment of digestive system diseases such as chronic hepatitis b, hyper-bilirubinemia, cirrhosis, peptic ulcers, chronic gastritis, etc. viral hepatitis is a complex and high incidence disease, and there are no effective drugs available for its treatment. in recent years, it has been found by pharmacological research and validated by clinical practice that danshen has the function of improving liver as well as systemic blood circulation, promoting the regeneration of liver cells, preventing and curing hepatic fibrosis, detoxication, regulating immunity, recovering liver function, etc. lu et al. [ ] reported the treatment of patients with hav igm positive and hyper-bilirubinemia. after one course of treatment, the degrees of bilirubin reduction were compared. the results showed that danshen injection's effective rate of jaundice elimination was %, which was better than those of yinzhihuang (茵 栀黄), ( . %), aspartate potassium magnesium ( %), and potenlin ( %). zhao [ ] reported that significant therapeutic effects were obtained by the application of danshen injection to the treatment of patients with chronic hepatitis b. ml of danshen injection ( ml of injection was equivalent to g of raw danshen) was added to ml of % glucose injection in the treatment group, and the drug was administered by intravenous drip once a day. a traditional chinese drug decoction (no danshen) was used in the control group. the results showed that the total effective rates in the treatment group and control group were . and . % (p \ . ), respectively. there were cases ( . %) in the treatment group with marked effect, cases ( . %) with effect, cases ( . %) without effect, and the total effective rate was . %. danshen injection can improve blood circulation in the liver and has the function of relieving ischemia anoxia and stagnant blood in the liver and relieving toxic injury from oxygen radicals; therefore, it has significant therapeutic effects on chronic hepatitis b. sun [ ] clinically observed the protection effect of danshen on hepatocyte ischemia in patients with hepato-vascular disease and liver cancer. the porta hepatis was blocked by operation and danshen injection by preoperative and intraoperative intravenous drip was administered, and the protecting function of danshen on ischemia in hepatocytes was observed. ml of cdi was added to ml of % glucose and administered by intravenous drip to the patients within days before the operation in the treatment group, and ml of cdi was added to ml of % glucose and administered by intravenous drip before blocking the porta hepatis. during the partial hepatectomy, blood was collected from the hepatic vein before blocking the porta hepatis for min and recovering blood flow for min; at the same time, the residual hepatic tissue was observed under a light microscope and electron microscope. the results showed that the content of oxygen radicals in the hepatic tissue and hepatic vein during the ischemia and reperfusion phase in the treatment group was significantly reduced, and pathological changes were significantly relieved. zhang and sun [ ] observed the therapeutic effects of tiopronin combined with cdi on the treatment of patients with chronic hepatitis b. the patients were divided into two groups; in the treatment group were orally administered with mg of tiopronin times a day, and ml of cdi was added to ml of % glucose injection and administered by intravenous drip once a day. cases in the control group were administered orally with mg of tiopronin, times a day. patients in both groups received g of vitamin c injection and mg of vitamin k injection by intravenous drip once a day. the course of treatment was months. the results showed that in the treatment group, there were cases ( . %) with marked effect, cases ( . %) with effect, and cases ( . %) without effect; the total effective rate was . %. in the control group, there were cases with marked effect ( . %), cases with effect ( . %), and cases with no effect ( %); the total effective rate was . %. the total effective rate in the treatment group was significantly higher than that in the control group (p \ . ). it was believed that the combination of tiopronin and cdi has a synergistic effect on the treatment of chronic hepatitis b and can promote the recovery of liver function. there are some important factors acting on the formation of cirrhosis, such as disturbance of liver microcirculation, overactivation of lipid peroxidation, deposition of collagen fibers, and specific binding of plasma fibronectin (pfn) and the corresponding pfn decrease and phagocytic function weakening in the reticuloendothelial system. danshen has the function of improving liver microcirculation, enhancing pfn levels, and enhancing the phagocytic function of the reticuloendothelial system. in addition, danshen has the function of inhibiting the growth and propagation of fibroblasts, promoting reabsorption of the formed fibrous tissue of the liver, and delaying and blocking the process from chronic hepatitis to cirrhosis. danshen has the function of promoting degradation of the formed collagen fiber and enhancing reabsorption of the fibrous tissue of the liver. experimental research has shown that salvianolic acid is an important component of danshen with the function of inhibiting hepatic fibrosis, and its strength is equivalent to that of raw danshen and colchicine. li et al. [ ] reported changes in the hemodynamics of the portal vein of patients with cirrhosis - weeks after orally taking danshen decoction. the hemodynamics were monitored by doppler ultrasound, and it was revealed that both the internal diameter and blood flow of the portal vein and the internal diameter and blood flow of the splenic vein in the patients were significantly reduced, and there were improvements on acratia, anorexia, and abdominal distension, as well as on liver function. there were no side effects. the study demonstrated that danshen is a safe and effective drug for the treatment of portal hypertension. in addition, danshen has the function of preventing hepatic fibrosis, reducing blood viscosity, inhibiting txa production, etc., and can reduce resistance from the portal vein. zhou [ ] observed the therapeutic effect of danshen injection on cirrhosis in cases. cases with cirrhosis were randomly divided into two groups. . g/kg danshen injection was added to ml of % gs and administered by intravenous drip to patients in the treatment group, and common hepato-protection treatment was performed for the patients in the control group. the course of treatment was month, and the patients were treated for a total of three courses. the changes in five indices of liver function and hepatic fibrosis were observed. the results showed that the liver function of the patients in the treatment group was significantly improved at the end of treatment, five indices of hepatic fibrosis were significantly reduced, and there was a significant difference between two groups (p \ . ). it was revealed that danshen injection has the function of inhibiting liver damage and hepatic fibrosis in patients with cirrhosis. wang [ , ] combined diammonium glycyrrihizinate with danshen injection to treat hepatic fibrosis. cases of patients with chronic viral hepatitis were randomly divided into three groups: cases in the treatment group (diammonium glycyrrihizinate + danshen); cases in control group (diammonium glycyrrihizinate); cases in control group (danshen), and hepatic fibrosis indices were detected at the end of the treatment. the results showed that the symptoms and physical signs of the patients from the three groups improved to different extents after treatment, liver function improved as time elapsed, hepatic fibrosis indices were significantly reduced in the treatment group after treatment (p \ . ), and hepatic fibrosis indices in the control group were also reduced after treatment, but the extent of reduction was less than that in the treatment group. it was revealed that diammonium glycyrrihizinate combined with danshen injection can improve the symptoms and physical signs of chronic viral hepatitis, recover liver function, significantly reduce hepatic fibrosis indices, and has good anti-hepatic fibrosis function. it was demonstrated that there was an additive effect in the combination. ma et al. ( ) observed the therapeutic effect of compound danshen combined with mongolian milkvetch root (黄芪) and aspartate potassium magnesium on the treatment of old cirrhosis ascites. the patients were allowed to rest, on a low-salt diet, and treated for hepatoprotection and diuresis. however, after weeks' treatment, no effects were observed and ascites volume was not significantly changed. ml of cdi, ml of mongolian milkvetch root injection, and ml of aspartate potassium magnesium injection were added to ml of % glucose and administered by intravenous drip to the patients in the treatment group once a day. ml of cdi was added to ml of % glucose and administered by intravenous drip to the patients in the control group once a day. the ascites volume was determined by b-ultrasound each week. the liver function and magnesium and potassium ion levels were determined before and after treatment, with days as one course of treatment, and the patients were treated for two courses. there was a significant difference in liver function, magnesium ion, and potassium ion levels between the two groups, and before and after treatment (p \ . ). the total effective rates of the treatment group and control group were . and . %, respectively, and the difference was statistically significant (χ = . , p \ . ). ye [ ] observed the effect of compound danshen on the -year mortality of decompensated liver cirrhosis. based on comprehensive treatment, cases in the treatment group were treated with a high dosage of cdi (or tablets) for a long term, and the changes in -year mortality and alimentary tract hemorrhage rate were observed. the results showed that the -year mortality in the treatment group was . % ( / cases), and in control group was . % ( / cases), and there was a significant difference between the two groups (p ); the incidence of upper gastrointestinal hemorrhage within years in the treatment group was . % ( / people), and in the control group was . % ( / people), and the difference between the two groups was significant (p \ . ). it was concluded that an early and continued high dosage of compound danshen preparations benefits the stabilization of the disease condition, reduces complication, and thus enhances the long-term survival rate. it has been discovered that danshen has a strong inhibitory function against helicobacter pylori. the tanshinol in danshen can rapidly eliminate necrotic tissue in ulcer sites and has the function of activating macrophages and promoting cell regeneration, thus promoting ulcer healing. liu and yi [ ] reported the application of cdi in the treatment of patients with peptic ulcer disease, and the effects were compared with those in patients in the ranitidine treatment group. ml of cdi was added to ml of % glucose and administered by intravenous drip to the patients in the treatment group once a day; . g of ranitidine was administered orally twice to the patients in the control group. the two groups were treated for weeks, and then the therapeutic effects were recorded. the results showed that in the treatment group, there were recovery cases, effective cases, and case without effect; the recovery rate was . %. in the control group, there were recovery cases, effective cases, and case without effect; the recovery rate was . %. there was no significant difference in recovery rate between the two groups (p [ . ). peptic ulcers usually belong to the category of chronic disease, and according to tcm theory, chronic illness is usually associated with stasis, and prolonged disease and pathogens usually intrude into the collaterals. danshen has the function of activating blood circulation and dissipating blood stasis. it is believed in modern medical research that danshen has an inhibitory function against helicobacter pylori, and that tanshinol in danshen can effectively clean necrotic tissue in ulcer sites, activate macrophage function, and promote cell regeneration, thus promoting healing. there was no significant difference in the therapeutic effects of compound danshen and ranitidine for the treatment of peptic ulcers. however, compound danshen had scanty side effects and was welcomed by the patients. liu et al. [ ] observed the treatment of peptic ulcers with danshen and ranitidine; ① the treatment group: danshen and ranitidine were administered at the same time. g of raw danshen each day was soaked in ml of water for min, then ml of water was added and decocted by slow fire for three times. the physic liquor was concentrated to ml and taken orally in two times. mg of ranitidine was administered in two times a day. ② the control group: mg of ranitidine was administered in two times in a day. the course of treatment for the two groups was weeks. the therapeutic effects were evaluated by endoscopy. the results showed that after weeks of treatment, the peptic ulcer recovery rates of the control group and treatment group were and . %, respectively, and there was a significant difference (p \ . ). the lpo and et plasma contents in the control group were . ± . µg/ml and . ± . pg/ml, respectively, which were lower than . ± . µg/ml and . ± . pg/ml before treatment (p \ . ). in the treatment group, the numbers were . ± . µg/ml and . ± . pg/ml, respectively, which were significantly lower than . ± . µg/ml, . ± . pg/ml before treatment (p \ . ). the results demonstrated that danshen's mechanism of action in the treatment of peptic ulcers might include ① cleaning oxygen radicals and inhibiting lipid peroxidation, which could protect the mucous membrane of the stomach and duodenum from injury, thus promoting ulcer healing. ② reducing blood plasma et levels, improving microcirculation, and increasing blood flow in the mucous membranes of the stomach and duodenum. it has been demonstrated in recent years that et can be produced by the intestinal mucosa epithelial cells of the stomach, and the mechanism through which et causes ulcers is related to its ability to cause vasoconstriction in the stomach and duodenum, which leads to mucous membrane ischemia, anoxia and acidosis. on the other hand, ischemia, anoxia and endothelium cell damage can stimulate the release of et, creating a vicious cycle. danshen can be used as an et antagonist, and it has the function of reducing et content in the blood plasma and improving the blood supply of the gastroduodenal hemorragemucous membrane, thus preventing ulcer formation. in tcm, chronic gastritis belongs to the category of blood stasis. research has shown that there is a close relationship between blood stasis and microcirculatory disturbance. danshen is one of the traditional drugs with the function of activating blood circulation and dissipating blood stasis; it can improve microcirculation, eliminate metabolism disturbances of the stomach mucous membrane, and antagonize inflammation, thus promoting the regeneration of tissue, softening the proliferative pathological changes, and enhancing absorption function. li [ ] reported the application of modified danshen beverage in the treatment of patients with chronic gastritis. the patients in the treatment group were treated with modified danshen beverages according to their symptoms. the basic prescription contains g of danshen, g of sandalwood (檀香), and g of villous amomum fruit (砂仁). the patients in the control group were orally administered mg of omeprazole twice a day, . g of amoxicillin three times a day, and . g of metronidazole three times a day. the above three drugs were administered together for weeks, and then omeprazole was administered for another weeks. during the treatment period, the patients should correct their poor eating habits, have a regular diet, avoid eating various stimulatory foods or drugs, and avoid smoking and drinking alcohol or strong tea. there was a significant difference (p \ . ) between the two groups in therapeutic effects; the effective rate of the treatment group was %, which was significantly higher than the % of the control group. the research in recent years has shown that hemorheology abnormality is one of the important etiological factors of severe pancreatitis. it is the main cause of blood circulation disturbance in the pancreas. compound danshen has the function of inhibiting platelet adhesion, aggregation and release, and it can significantly reduce erythrocyte aggregation, improve the blood rheology, regulate blood viscosity, improve microcirculation, enhance the tolerance of pancreatic tissue to anoxia, reduce the production of oxygen radicals, and relieve pathological changes in pancreatic tissue. in addition, tanshinol in danshen has the function of rapidly cleaning necrotic tissue in the pancreas, promoting the regeneration of pancreatic cells, dilating pancreatic blood vessels, and promoting recovery from pancreatitis. xie [ ] reported the treatment of severe pancreatitis cases with cdi. ml of cdi was diluted with ml of glucose solution and administered by intravenous drip once a day, for - days as one course of treatment. the patients were treated after operation, and cases in the control group were treated with normal western medicine. the results showed that the fatality rate in the treatment group was only . %, while the fatality rate in the control group was higher ( . %), and the difference was significant (p \ . ). the hematocrit levels in the treatment group were reduced from ± . % before operation to . % ± . % after operation, and the difference was significant (p \ . ). it was concluded that hematocrit can be reduced to the normal lower limit by cdi after severe pancreatitis surgery, reducing blood viscosity, improving circulatory disorders of the body organs, promoting pancreatic tissue recovery, and contributing to the correction of serious complications such as adult respiratory distress syndrome (ards), so that mortality in the treatment group was significantly lower than in the control group. zhang and liu [ ] reported the treatment of ulcerative colitis cases. cases in the treatment group were treated with the general treatment plus danshen injection. ml of danshen injection was added into glucose solution and administered by intravenous drip for weeks, once a day. the results showed that no significant differences were found in the levels of platelet α granule membrane protein (gmp- ), thromboxane (txb ), -ketone-prostaglandin f α ( -keto-pgf α ) and von wilebrand factor related antigen (vwf:ag) before and after the general treatment. in the danshen treatment group, however, the levels of gmp- , txb , and vwf:ag were significantly reduced compared with those before the treatment (p \ . ), and there was no significant changes in -ke-to-pgf α. it was believed that the combined treatment of active phase patients with danshen injection and conventional methods could correct hypercoagulability, relieve inflammation responses, and improve disease conditions. blood stagnation is one of the most common types of syndromes in tcm. it exists in many systemic diseases, including diseases of the digestive system. based on clinical practice and observation, different degrees of stagnation could be induced by the prolonged pathogenesis of both lung and stomach intestinal diseases. therefore, the application of danshen and its preparations in the treatment of chronic diseases of the digestive system has its theoretical and practical foundations. urinary system diseases wang and wen [ ] observed the effect of - and cdi by intravenous drip on the treatment of patients with acute nephritis. the patients in the treatment group were treated with conventional therapy (mainly benzylpenicillin, low salt diet, symptom relief, etc.), and at the same time, mg of - and - ml of cdi were, respectively, added into ml of % glucose and administered by intravenous drip, once a day, for - days as one course of treatment. if necessary, the drugs were discontinued for days, then the second course of treatment was performed, and the treatment could be stopped if no effect was obtained. urine-routine was measured before and after treatment. the patients in the control group were administered with the traditional treatment. the results showed that in the treatment group cases were cured, and among them cases had their symptoms of nephritis all disappear after one course of treatment (spirit and appetite were recovered, edema was dissipated, and urine protein turned negative) and cases had their urine protein turn negative after courses of treatment. five cases showed improvement, and two cases showed no effect. the average time for edema to subside was . ± . days, the average time for blood pressure to return to normal was . ± . days, the average time for urine protein to turn negative was . ± . days, and the average time of hospitalization was . days. in the control group, cases were cured, cases improved, and cases showed no effect. the average time for edema to subside was . ± . days, the average time for blood pressure to return to normal was . ± . days, the average time for urine protein to turn negative was . ± . days, and the average time of hospitalization was . days. cdi has the function of reducing platelet aggregation and adhesion, inhibiting platelet generation, inhibiting blood coagulation, promoting fibrinolysis, improving hemorheology, and so on. the combination of - with danshen has the function of dilating the renal arteries, reducing blood viscosity, increasing renal blood flow, improving kidney microcirculation, increasing the flow rate of urine in renal tubules, and preventing and relieving the occlusion of cast and cast-off cells on the distal convoluted tubules, thus realizing the effects of diuresis, subsiding edema, and eliminating proteinuria in a short time. months of follow-up was performed, with affirmative therapeutic effects. patients with chronic glomerulonephritis (cgn) usually suffer from a disequilibrium of thromboxane-prostacyclin (txa-pgi), which can result in kidney vessel and mesangial constriction, reducing the filtration area of the renal glomerulus, promoting the adhesion and aggregation of platelets and leucocytes, and participating in thrombopoiesis, inflammation response, and nephridial tissue and cell damage; thus, it is one of the causes of the sustained development of chronic glomerular lesions and renal dysfunction. experiments have demonstrated that danshen has the function of improving microcirculation, increasing the content of cyclic adenosine monophosphate in blood capillaries, and increasing pgi synthetase. it also has the function of inhibiting txa synthetase, which can improve the balance of txa-pgi. with the improvement of txa-pgi balance, renal blood flow and glomerular filtration rate increased and urine protein was reduced. in addition, danshen can enhance fibrinolysis activity, thus promoting fibrinolysis, relieving fibrin deposition in the renal glomerulus, and relieving renal glomerulus damage. shen [ ] reported the treatment of cgn with danshen. ml of cdi was added to ml of % glucose injection and administered by intravenous drip to patients with cgn, once a day, for days as one course of treatment. the results showed that there were cases of complete remission ( . %), cases of general remission ( . %), cases of partial remission ( . %), and cases of no effect. the total effective rate was %. patients with chronic renal failure (crf) usually suffer from reduced plasma-albumin and increased fibrin. fibrin is related to the increase in cholesterol. high levels of fibrinogen will increase blood viscosity, thus leading to blood hypercoagulability and fibrinolysis disturbance in patients with crf. danshen is a traditional drug with the function of activating blood circulation and removing blood stasis. it has functions of anticoagulation, thrombolysis, reducing blood lipids, etc., and improving crf-induced disorders in renin and blood plasma volume and the chain reactions induced by the increase of renin, such as increased renal tubule resistance, deposition of erythrocytes, blood vessel occlusion, reduced renal blood flow, local disturbance of circulation, reduced oxygen supply and renin release, etc. jiang [ ] reported the use of cdi for the intervention of peritoneal dialysis; cases with acute or crf were treated, and the drug was added together with anisodamine ( - ) into peritoneal dialysis solution for cases in the control group. the results showed that the serum creatinine (scr) of cases in the treatment group was reduced by more than %, cases by more than %, and cases by more than %; cases in control group reduced by more than %, cases by more than %, and cases by more than %. the blood urea nitrogen (bun) of cases in the treatment group was reduced by more than %, cases by more than %, and cases by more than %; cases in control group reduced by more than %, cases by more than %, and cases by more than %. the total effective rate in the treatment group was . %, and in the control group was . %; the total effective rate in the treatment group was significantly better than that in the control group. zhang [ ] reported the treatment of crf with cdi combined with energy mixture. patients with crf were randomly divided into groups; cases in the treatment group were treated according to their symptoms and administered with cdi and energy mixture by intravenous drip. cases in the control group were treated according to their symptoms and administered with glucose and insulin by intravenous drip. the therapeutic effects in the two groups were observed after one course of treatment. the results showed that the total effective rate in the treatment group was . %, while the total effective rate in the control group was . %, and the treatment group was significantly better than the control group (p \ . ). bun and scr were reduced after cdi treatment, and there was a significant difference before and after the treatment (p \ . ). there was no significant difference in bun and scr in the control group before and after the treatment (p [ . ). it showed that cdi combined with energy mixture can protect residual renal function, delay the development of crf, and there was a promising perspective. acute renal failure (arf) belongs to the category of "difficulty in urination-defecation" and "disuria and urine retention" in traditional chinese medicine. its pathological feature is that the root is deficient and the branches are excessive, namely, the cause is kidney deficiency and blood stasis is the symptom, which may also include water-dampness and heat bind. danshen has the function of activating blood circulation and removing blood stasis, cooling the blood and clearing heat. rosewood heart wood (绛香) has the function of activating blood circulation and relieving pain. the combination of the two drugs has the function of breaking the constraint of qi and dispersing the stasis of blood, so as to recover renal function. modern medical research has shown that tanshinone and tanshinol in danshen can dilate small blood vessels, increase microcirculatory flow rate, increase capillary networks, etc., and that rosewood heart wood has anticoagulation function. when the drugs are combined with western medicine, the functions of dilating kidney vessels, correcting hypercoagulability, improving microcirculation, increasing renal blood flow, enhancing glomerular filtration rate, and improving renal function can be obtained. in addition, microcirculation can be directly improved by intraperitoneally administered danshen, thus increasing the peritoneal dialysis rate, and it also has antibacterial and anti-inflammatory effects and prevents the occurrence of peritonitis. huang et al. ( ) reported the effect of danshen on the treatment of afr. patients with arf were treated with ml of cdi in ml of % glucose by intravenous drip, once a day, for - days as one course of treatment. the results showed that all patients were cured, and that bun was reduced by . mmol/l within days and the diuresis stage began within - days (average of days) of treatment. jiang [ ] used cdi in peritoneal dialysis solutions to obtain a concentration of ml. cases were treated with a total effective rate of . %, and the total effective rate in the - injection control group (concentration was mg) was . %. there was no significant difference (p [ . ) between the two groups, but the effects in the treatment group were significantly better than those in the control group, and no patient was complicated by peritonitis in the treatment group during hospitalization. patients with nephrotic syndrome (ns) usually experience hypercoagulability; the blood viscosity is increased, microcirculation is dysfunctional, and even vascular microthrombosis is complicated, which aggravates ns treatment. modern pharmacological studies have shown that danshen has the function of dilating peripheral arteries, improving local blood circulation, reducing inflammation effusion, promoting absorption, etc., thus localizing the nonspecific inflammation in nephridial tissue, which is conducive to renal tissue repair. danshen also activates blood circulation, removes blood stasis, and acts as an anticoagulant. in addition, danshen can cool the blood and eliminate carbuncles, relieve restlessness and calm the nerves. thus, it can be used to alleviate the blood-heat and stasis induced by taking hormones, and to treat hormone-induced sore swelling and sore toxin, as well as sleeplessness. huang and wu [ ] reported that good effects on the treatment of nephrotic syndrome were obtained by using cdi and hormones. ml of cdi was added to ml of % glucose and administered by intravenous drip to cases in the treatment group, once a day, and mg of prednisone was administered orally, three times a day, for days as one course of treatment. the patients in the control group were administered prednisone only. the results showed that the remission rate in the treatment group was %, and in the control group was . %, and the difference between the two groups was significant (p \ . ). when people suffer from nephrotic syndrome, their blood capillary filter membrane in the renal glomerulus experiences immunoinflammatory reactions, their glomerular basement membrane proliferates, their blood is in a state of hypercoagulability, and their kidneys have different degrees of fibrosis. compound danshen has the function of reducing cholesterol, inhibiting fibroplasia, relieving fibrin deposition, improving hypercoagulability induced by renal insufficiency, and recovering renal function, thus it can effectively treat nephrotic syndrome. liu et al. [ ] reported therapeutic effects of compound danshen and mongolian milkvetch root (huangqi, 黄芪) in the treatment of nephrotic syndrome. patients with nephrotic syndrome were randomly divided into two groups, and patients in the control group were administered orally with prednisone and dipyridamole. the patients in the treatment group were administered orally with prednisone and by intravenous drip with dipyridamole plus ml of cdi and ml of huangqi injection, once a day, for weeks as one course of treatment. before and after treatment, plasma-albumin, urine protein, cholesterol, and triglyceride levels in each group were determined. the results showed that plasma-albumin levels in the two groups increased after treatment compared to before treatment, and the levels in the treatment group were significantly higher than in the control group (p \ . ). urine protein, cholesterol, and triglycerides in the two groups were reduced after treatment, and the reductions in the treatment group were significantly larger than those in the control group (p \ . , p \ . ). it was concluded that the therapeutic effects in the treatment of nephrotic syndrome can be increased when the conventional prednisone and dipyridamole treatments are combined with compound danshen and mongolian milkvetch root. purpura nephritis, or henoch-schönlein nephritis (hsn), belongs to the category of bruising and urine hemorrhage in tcm, which is usually caused by the heat injury of blood collaterals. the main clinical manifestations include hemorrhage and stagnant blood symptoms. danshen is bitter in taste and slightly cold in nature, and has the function of activating blood circulation, cooling blood, eliminating congestion, and stopping bleeding. pharmacological studies have demonstrated that compound danshen has the function of promoting microcirculation, regulating the metabolism and immunologic function, and increasing renal blood flow and filterability, thus increasing urinary production, eliminating edema, reducing blood pressure, eliminating haematuria and proteinuria, and promoting hsn recovery. meng et al. ( ) reported that cdi . - ml/(kg·d) was added to % glucose injection and administered by intravenous drip to patients with hsn. the results showed that cases were cured, cases improved, case showed no effect, and the total effective rate was . %. zhang et al. ( ) reported that a high dosage of cdi, - ml, was added to ml of % glucose solution and administered by intravenous drip to patients with hsn, once a day. the results showed that cases were cured, cases improved, cases showed no effect, and the total effective rate was %. research has shown that diabetic nephropathy (dn) is related to factors such as microangiopathy of the renal glomerulus, increased plasma viscosity, abnormal platelet function, abnormal coagulation and anticoagulant mechanisms, etc. in addition, patients with dn also suffer from sod activity reduction, glomerular basement membrane thickening, and glomerulosclerosis, which are typical pathological changes of dn. danshen has the function of activating blood circulation, removing blood stasis, improving microcirculation, inhibiting platelet aggregation, and reducing blood lipids and blood viscosity, etc. it can also increase sod activity, eliminate oxygen radicals, relieve small vasospasms, and improve renal anoxia conditions, thus it could eventually reverse the pathological changes of the glomerular basement membrane, so as to cure dn and delay the process of renal dysfunction. yang [ ] mixed ml of cdi in ml of physiological saline and administered by intravenous drip to patients with dn, once a day, for week as one course of treatment. patients in the control group were administered with western medicine only. the results showed that the total effective rate in the treatment group was . %, while in control group was %, and the difference was significant (p \ . ). li et al. [ ] divided patients with dn randomly into a treatment group ( cases) and control group ( cases). the patients in the treatment group were treated with normal therapy plus ml of danshen injection, administered for weeks by intravenous drip, once a day. the results showed that blood plasma endothelin (et- ), type iv collagen (civ), and -h urinary protein excretion rates in the treatment group were significantly reduced (p \ . ). the results demonstrated that danshen has some preventative and treatment effects on dn at the early stage, and the mechanism the drug's inhibition of the production of et- and synthesis of civ. zhang [ ] showed that danshen had inhibitory effects on renal desmocytes and inducing cell apoptosis by promoting the high level expression of c-myc protein. taking high dosages of danshen for a long period of time could have some therapeutic effects on interstitial fibrosis, thus preventing or reducing the production of lesions and delaying the occurrence of uremia, demonstrating that danshen could promote the absorption of excessive connective tissue. huang and wu [ ] reported the effect of danshen on the treatment of chronic allograft nephropathy. besides the routine anti-rejection therapy, ml of danshen was added to physiological saline and administered by intravenous drip to patients with chronic allograft nephropathy for weeks. the results showed that the improvement in renal function indexes in patients in the treatment group was better than that in the control group (p. ), and danshen has the function of reducing urine nagase activity (p \ . ). it was concluded that danshen has protective effects against acute or chronic renal damage, and the mechanism is danshen's inhibition of the overproduction of nitric oxide and peroxide. danshen has the function of preventing chronic rejection and thrombopoiesis induced by the ciclosporin damage to the renal tubule, thus improving transplanted kidney function. zhang et al. [ ] reported the treatment of hypertension accompanied by renal injury with cdi combined with benazepril hydrochloride in cases, and the changes in urinary albumin were observed. blood pressure was measured twice each day for all patients with hypertension over the days before treatment, and the average of the six blood pressure values was used as the baseline blood pressure before treatment. urinary albumin was measured within h before drug administration. the patients in the control group were administered with mg of benazepril once a day, and the patients in the treatment group were administered orally with mg of benazepril once a day, and ml of cdi in ml of % glucose injection was administered by intravenous drip once a day. blood pressure was measured once each day for the patients in the two groups. two weeks after treatment, if the blood pressure was not reduced to / mmhg or lower, benazepril would be increased to mg, once a day, treated for weeks. the average blood pressure over days at the end of treatment was used as the blood pressure after treatment, and urinary albumin was measured within h after treatment. urinary albumin was examined by radiation immunity. the results showed that there was no statistical difference in blood pressure reduction between the two groups after treatment (p[ . ). there was, however, a statistical difference in the reduction of urine protein between the two groups after treatment (p \ . ). the results demonstrated that the effect of danshen and benazepril treatment on urinary albumin was significantly better than that of benazepril alone, and significant therapeutic effects could be obtained by the combination of the two drugs. the method is convenient and the side effects are few, making it an effective method for the treatment of hypertensive renal injury. he et al. [ ] reported the use of cdi in the treatment of patients with benign prostatic hyperplasia by local injection to the perineal prostate capsule, ml each time, once every days, for injections as one course of treatment. the results showed that the international prostate symptom score (ipss) was reduced compared to the conditions of patients before treatment (p \ . ), the maximal urinary flow rate increased (p \ . ), and the residual urine volume was significantly reduced (p \ . ). danshen activates blood circulation and dissipates blood stasis, promotes blood circulation and nourishes blood, promotes the excretion of prostatic fluid, shrinks the gland, and improves urination function. huang ( ) reported the administration of danshen and metronidazole mixture by prostate injection. one course of treatment later, symptom disappearance occurred in cases, improvement in cases, and the total effective rate was . %. reexamination showed that in cases, the swollen gland was significantly shrunken and tubercles were softened. tian [ ] reported the use of cdi to treat impotency. cdi was administered by injection to acupoint qugu (rn ) in patients with impotency; the patients were - years old, the average age was . , and the course of disease was - years. before treatment, the patients were asked to empty their bladder, then normal skin disinfection was performed. . - ml of cdi was injected at qugu, once every days, times as one course of treatment, and sexual intercourse was prohibited during the treatment period. the results showed that cases were cured, cases showed effect, cases showed marked effect, cases showed no effect, and the total effective rate was . %. although the application of danshen in the urinary system is not as popular as in the cardiocerebrovascular and digestive systems, what is affirmed is that danshen and its components have relatively good therapeutic effects on acute or chronic nephrosis due to the retention of stagnant blood, interior harmful retention of toxin and heat, such as acute nephritis, acute and crf, nephrotic syndrome, dn, chronic prostatic hyperplasia, and so on. jiang [ ] reported the treatment of cases of type diabetes mellitus (the majority were complicated with angioneuropathy) with cdi. the patients were randomly divided into the treatment group and control group, cases each. the patients in both groups had reasonable dietary control, and one or more hypoglycemic agents were used for blood sugar control according to their conditions. some patients were treated with vitamin b , b and other treatments according to their symptoms. - ml of cdi in - ml of physiological saline was administered by intravenous drip to the patients in the treatment group, once a day for - weeks. the results showed that in the treatment group there were cases showing marked effect, cases showing improvement, cases showing no effect, and the total effective rate was %. in the control group, cases showed marked effect, cases showed improvement, cases showed no effect, and the total effective rate was %. the therapeutic effects in the treatment group were significantly higher than those in the control group (p \ . ). the mechanism of the effects might be that the activity of sod, which has the function of cleaning oxygen radicals, was reduced in patients with type diabetes mellitus, and there was lipid peroxidation damage. cdi has the function of enhancing the tolerance of pancreatic tissue to anoxia, reducing the production of oxygen radicals, increasing sod activity, and effectively relieving lipid peroxidation damage. danshen also reduces blood sugar and protects pancreatic islet β cells in experimental diabetes. therefore, cdi will have important clinical significance in the prevention and treatment of diabetic complications. lü [ ] observed the therapeutic effects of huangqi injection combined with danshen powder injection on the treatment of type dn at the early stage. cases in the control group received conventional hypoglycemic antihypertensive therapy. the patients in the treatment group received conventional therapy plus ml of huangqi injection and . g of danshen powder injection in ml of physiological saline, administered by intravenous drip, once a day, for month as one course of treatment. the changes in urinary albumin excretion (uae) within h were observed. the results showed that there was no significant change in uae in the control group before and after the treatment (p [ . ), but in the treatment group, the uae was significantly reduced after treatment compared to before (p \ . ). it was concluded that huangqi injection combined with danshen powder injection has therapeutic effects on dn at the early stage. chen [ ] observed the therapeutic effect of cdi combined with domperidone on diabetic gastropathy. inpatients and outpatients suffered from type diabetes mellitus, male, female; cases were complicated with coronary heart disease; fasting plasma glucose was . - . mmol/l; average fasting plasma glucose was . ± . mmol/l. all patients received the conventional diabetes treatment, and those who had complications of peptic ulcers, stomach and duodenum operation, and ketosis acidosis were excluded. cases in the control group had no dyspepsia symptoms or peptic ulcer history, and liver and kidney functions were normal. cases with dg were divided into groups based on gastric emptying function and medication condition. cases in the domperidone group were administered orally with mg of domperidone, three times a day; cases in the danshen group were administered by intravenous injection with ml of cdi, once a day; cases in the domperidone + danshen group were administered with domperidone and danshen, and the dosage and administration were the same as the above therapies. the course of treatment was weeks, and fasting plasma glucose, liver and kidney functions, and gastric emptying function were reviewed within days after treatment. there were no significant differences in gender, age, or disease condition and fasting plasma glucose among the groups. the results showed that the gastric emptying half-times in the diabetes group and control group were . ± . min and . ± . min, respectively, and the difference between the two groups was significant (p \ . ). the gastric emptying function of patients with diabetic gastropathy was significantly improved, and that of the drug combination group was the most significant. there were different extents of improvement in the pathological changes of the peripheral nerves and cardiovascular system after treatment with danshen, but there was no significant difference in fasting plasma glucose before and after treatment. li et al. [ ] observed the treatment of diabetic peripheral neuropathy (dpn) with danshen combined with mecobalamin (methycobal). cases of dpn were randomly divided into two groups. cases in the treatment group received ml of danshen injection in ml of physiological saline, administered by intravenous drip each day, and μg of methycobal, administered by intramuscular injection, once a day for weeks. cases in the control group received the conventional diabetes treatment. the results showed that the marked effect rate and the total effective rate in the treatment group were . and %, respectively, which were significantly higher than those in the control group, . % (p \ . ) and . % (p \ . ), respectively. therefore, it was concluded that better therapeutic effects were obtained by danshen combined with methycobal in the treatment of dpn. gong [ ] observed the therapeutic effect of yinxing (ginkgo) damo injection combined with danshen injection on the treatment of dpn. patients with type diabetes mellitus complicated with dpn were randomly divided into three groups according to the chronological order of hospitalization. there were patients in group administered with yinxing damo injection combined with danshen injection, patients in group administered with yinxing damo injection, and patients in group administered with danshen injection. the treatment period in the above three groups lasted for weeks. all three treatments showed some degree of therapeutic effects on dpn; they could improve symptoms such as numbness, pain, chill, fever and others, and neural conduction function was significantly enhanced. the clinical therapeutic effects in group were better than those in treatment group (p \ . ), but those in group were better than in group and group (p \ . ). there were significant therapeutic effects of yinxing damo injection combined with danshen injection in dpn treatment. diabetes is a common clinical disease and is one of the three diseases which threaten human health. the patients' quality of life is usually directly reduced due to related complications which appear during the later stages of the disease. from the related documents we have found, danshen and its preparations are mainly used in the treatment of dn, stomach diseases, and peripheral nerve pathological changes etc., and satisfactory therapeutic effects have been obtained, so it is worthy of consideration. lin [ ] reported the application of danshen injection in the treatment of cases of high blood viscosity syndrome, and observed the effect of danshen on the hemorheology hemorheology. ml of danshen injection in or % glucose was administered by intravenous drip, one time a day, times as one course of treatment. after - courses of treatment, the rate of total plasma viscosity reduction was . %; among them, improvement in - indexes was . %, and in - indexes or more was . %. it was revealed that the drug can effectively improve hematocrit, erythrocyte electrophoretic time, fibrinogen and blood plasma viscosity, and thus can be used as one of the adjuvant therapies for polycythemia, pulmonary heart disease, heart failure, burn, frostbite, ischemic stroke induced by fibrinogen and blood plasma viscosity increase, myocardial infarction, diabetes, hyperlipidemia, globulin increase, and other diseases. yan et al. [ ] investigated the effect of salvianolate on platelet function and its clinical therapeutic effect on stable angina pectoris. patients with stable angina pectoris were randomly divided into the salvianolate low dosage group (group a), high dosage group (group b) and danshen injection control group (group c). the patients were treated for days, observing symptom remission, treadmill tests, platelet aggregation rate, and changes in p-selectin level. platelet aggregation reduction rate and p-selectin in group a and group b were better than in group c, but symptom remission and treadmill tests were similar to those in group c. salvianolate significantly inhibits platelet aggregation and activation, and improves angina pectoris and st-t changes in electrocardiograms. secondary increases in erythrocytes and blood viscosity can be induced by anoxia during an attack of pulmonary heart disease. qian [ ] reported the application of normal therapy combined with cdi in the treatment of pulmonary heart disease in cases. the results showed that there were significant changes in whole blood viscosity in hemorheology, viscosity, and plasma viscosity in the treatment group before and after treatment (p \ . ). the treatment period for primary nephrotic syndrome is lengthy and the recurrence rate is high. blood hypercoagulability plays an important role in the occurrence, development and turnover of the disease. to search for a safe anticoagulation drug, cases with primary nephrotic syndrome were treated with compound danshen by li et al. ( ) . the patients were treated with prednisone and compound danshen tablet (danshen, sanchi, synthetic borneol), one tablet a day, two times a day for patients younger than years old and three times a day for patients older than years old, for month as one course of treatment, - courses of treatment were observed. indexes (platelets, blood clotting time, plasma viscosity, packed red cell volume, blood sedimentation) were observed. the results showed that there was a significant difference between the observation group and control group before and after treatment (p \ . ). hui [ ] observed platelet recovery in cases with epidemic hemorrhagic fever treated with danshen injection. the patients in the treatment group were treated with conventional therapy plus danshen injection, ml each time, times a day. administration was discontinued until platelet levels were × /l or more, which was used as the standard for marked effect. the results showed that there were cases ( . %) with marked effect and cases ( . %) without effect. the effective rate in the control group, who were treated with conventional therapy only, was . %, the ineffective rate was . %, and there was a significant difference between the two groups. it was revealed that danshen can directly or indirectly reduce damage to platelets and promote platelet production, so the platelet number was rapidly recovered. in theories of traditional chinese medicine and western medicine, there are common and different aspects of stagnant blood in tcm and hyperviscosity in western medicine. however, danshen's functions in activating blood circulation and dissipating blood stasis are confirmed by both tcm theory and modern pharmacological experiments. from this point of view, the effect of danshen and its preparations on hemorheology is self-evident, and the data presented above are corroborative evidence. china's naturopathy integr tradit chine west med pract crit care med mod recovery key: cord- -v ye authors: ganguly, nirmal kumar; saha, gautam kumar title: pharmacogenomics and personalized medicine for infectious diseases date: - - journal: omics for personalized medicine doi: . / - - - - _ sha: doc_id: cord_uid: v ye humans have been plagued by the scourge of invasion by pathogens leading to infectious diseases from the time in memoriam and are still the cause of morbidity and mortality among millions of individuals. trying to understand the disease mechanisms and finding the remedial measures have been the quest of humankind. the susceptibility to disease of an individual in a given population is determined by ones genetic buildup. response to treatment and the disease prognosis also depends upon individual’s genetic predisposition. the environmental stress induces mutations and is leading to the emergence of ever-increasing more dreaded infectious pathogens, and now we are in the era of increasing antibiotic resistance that has thrown up a challenge to find new treatment regimes. discoveries in the science of high-throughput sequencing and array technologies have shown new hope and are bringing a revolution in human health. the information gained from sequencing of both human and pathogen genomes is a way forward in deciphering host-pathogen interactions. deciphering the pathogen virulence factors, host susceptibility genes, and the molecular programs involved in the pathogenesis of disease has paved the way for discovery of new molecular targets for drugs, diagnostic markers, and vaccines. the genomic diversity in the human population leads to differences in host responses to drugs and vaccines and is the cause of poor response to treatment as well as adverse reactions. the study of pharmacogenomics of infectious diseases is still at an early stage of development, and many intricacies of the host-pathogen interaction are yet to be understood in full measure. however, progress has been made over the decades of research in some of the important infectious diseases revealing how the host genetic polymorphisms of drug-metabolizing enzymes and transporters affect the bioavailability of the drugs which further determine the efficacy and toxicology of the drugs used for treatment. further, the field of structural biology and chemistry has intertwined to give rise to medical structural genomics leading the way to the discovery of new drug targets against infectious diseases. this chapter explores how the advent of “omics” technologies is making a beginning in bringing about a change in the prevention, diagnosis, and treatments of the infectious diseases and hence paving way for personalized medicine. over the millennia with the progression of human civilization, the condition of human health has changed considerably. the lifespan of the human has increased considerably with the advent of vaccines against several diseases which has eradicated small pox, and now we are embarking on the global campaign to eradicate poliomyelitis and have controlled the disease in most parts of the world. the treatment of infectious diseases got a boost with the discovery of penicillin by alexander fleming in the earlier part of the twentieth century. as a range of antibiotics were later discovered, infectious diseases such as meningitis, bacterial pneumonia, sepsis, and other lifethreatening bacterial infection were treatable. also the survivability of patients undergoing operative procedures and aggressive chemotherapy was feasible and their recovery high. the last years of the twentieth century have been eventful with the discovery of antimicrobials that had given us the hope that we shall eradicate all infectious diseases. despite all the efforts and progress we have made in medical science, infectious disease remained a major health problem. but the golden era of the antibiotics will not be long if we go on unregulated administering and promoting rampant use of antibiotics, as is evident from the rise of antibiotic resistance (caramia and ruffi ni ) , and the new emerging diseases have posed major challenge (table . ). in the last few decades with the advent of fi eld of genomics, there is a new hope in prevention, diagnostics, and treatment of infectious diseases. we will explore in this chapter the table highlights the organisms that are of public health importance and their year of discovery source : world health organization: newly discovered organisms of public health importance: page . from who regional offi ce east-asia: combating emerging infectious diseases in south east asia region ( ) how the host genetic polymorphisms of drug-metabolizing enzymes and transporters affect the bioavailability of the drugs which further determine the effi cacy and toxicology of the drugs used for treatment. further, the fi eld of structural biology and chemistry has intertwined to give rise to medical structural genomics leading the way to the discovery of new drug targets against infectious diseases. this chapter explores how the advent of "omics" technologies is making a beginning in bringing about a change in the prevention, diagnosis, and treatments of the infectious diseases and hence paving way for personalized medicine. how the advent of new technologies is bringing about a change in medical treatment of the infectious diseases. for the use of "omics" technology to be successful requires considerable information of pathogen genome as well as genome information of the host. the pathogen genomic and proteomic information helps to identify antigens that can give us information necessary for making a diagnostic tool and vaccine design. the pathogen genome on one hand gives us the information about the important genes conferring disease pathogenesis as well as drug resistance, while the genome of the host on the other hand will reveal the susceptibility genes, and the further knowledge of polymorphisms in genes of the host metabolic and immune system will lead to the new vaccine strategies, drugs targets, and also their treatment outcomes. rapid advances of biotechnological and informatics tools in the past few decades mainly in fi elds of genetics, genomics, and proteomics are leading the way in identifying treating and thus improving the health of human beings. the effective treatment in a patient can only be achieved by fi rst rapid diagnosis of the disease and also identifying its causative agent that is particularly important in the cases of infectious diseases. new insights gained by the analysis of genome and structural feature of pathogen macromolecules have brought about new hope in the treatment of the dreaded diseases. the knowledge of system biology in respect to the microbial infections is still in development, and data available is mostly for few human infections. the rapid development of new generation sequencing technologies have led to generation of new knowledge base and with more advancement of such technologies in the coming years has brought in a hope that all diseases will conquered. in the near future, we will have complete sequences of the total transcriptomes, like genome sequences a decade earlier, and proteomic technologies will attain the throughput and sensitivity of microarrays. other technologies like metabolomics, glycomics, lipidomics, and phosphoproteomics when referred to in the context of infectious diseases are still in various stages of development, but we are taking the right steps in the direction of development of such technologies (antony et al. ). the technologies of transcriptomics and functional genomics are transforming our understanding of microbial infections and helping us decipher the reason of infections susceptibility in the humans. transcriptomics have been developed and used by scientists to broaden our understanding of infectious diseases. to elucidate the hostpathogen interaction, cdna microarrays have been widely used. the studies have focused on how the pathogens effect the host cell gene expression. the wild-type virulent strains and isogenic mutants have been used to gauge the responses of the host cell. the major fi ndings of these studies have shown how the pathogen virulence factors modify host cell factor expression (roy and mocarski ) . the role of pathogen recognition receptors (prr) affecting hostpathogen interaction has been studied. these studies have shown that the host cell responses have an alarm signal (jenner and young ) . studies have also shown that gene cluster signals are responsible for generating the alarm signals that are the target of attack by the invading pathogens (hamon and cossart ) . array technologies are being used with molecular probes of host human (also animals/plants) and microbial genes to monitor and at the same time point the expression of genes from host cells and those of the pathogens to better understand the full complexity of host-pathogen interaction. functional genomics have also led to the development of tools to decipher infectious diseases by manipulating the cellular mechanisms. the technology of the rna interference (rnai) has undergone tremendous development in the last decade which has led to the large-scale reverse genetic screens in human cells and model organisms (boutros and ahringer ) . rnai technology uses double-stranded ribonucleic acid (dsrna) with having complementary sequence to the target mrna sequence and is used to silence or downregulate the gene expression of its target. long dsrna induces interferons or other unspecifi c responses in mammalian cells which is avoided by the use of small interfering dsrna (sirna) directly or small hairpin rna (shrna). rnai screening using rna probes, which induces loss of function of host genes, leads to discovery of host resistance factors (hrf). it is made possible when silencing this restrictive factors leads to invading pathogen replication enhancement and may also identify host susceptibility factors (hsf) and also identify permissive factors, that when silenced will decrease the pathogen replication. the rnai screens still have some limitations due to offtarget sirna effect (echeverri et al. ) . thus, the primary screening validation is made by using additional sirna screens. from the several rnai screenings in human and in fruit fl y cells, only host factors were validated from about , and , targets identifi ed in the initial screen (agaisse et al. ; brass et al. ; konig et al. ; krishnan et al. ; zhou et al. ) . to make the system biological tools like rnai more effective in fi nding mechanisms in host-pathogen interaction and thus fi nding cure for the microbial infections, there is a need for integrations of all data obtained from the omics technologies. in addition several rounds of biological experimentations are required by using mutant pathogens, cellular rnai knockdowns, or humanized animal models using mice or primate infection model. the resulting inferences from the validated data would help us build predictive models which could lead us to the better understanding of pathogen interactions with the host. it is evident from human history of infectious diseases that not everybody in a given population is affected by an infective disease. for an infective organism to cause an infection, both the virulence of the pathogen and the host susceptibility are important. the identifi cation of genetic factors of host innate and adaptive immunity that determine the protection from pathogen is an important endeavor of scientists. animal models of infectious diseases especially mouse models have been used to fi nd the genetic factors and biochemical mechanism of disease susceptibility (marquet and schurr ) . the identifi cation of candidate genes responsible for disease susceptibility or resistance and the occurrence of genetic polymorphism in them give us the best possible biological scenario of the disease. researchers have found that in bacterial diseases, tuberculosis and leprosy seem to have similar genetic susceptibility determinants in the host as exemplifi ed from the fi nding that higher incidence of these diseases was found in the monozygotic twins than in dizygotic twins and siblings (abel et al. ; vidal et al. ) . mouse model of infections has revealed that gene encoding the natural resistance-associated macrophage protein ( nramp ) confers natural resistance to infections caused by mycobacterium , salmonella , and leishmania . nramp is found in the membrane of the phagosome of the macrophages where it seems to be probably affecting the replication of the infecting intracellular bacterium (gruenheid et al. ) . the genomic analysis in humans has found a similar gene to that of mice which is also having similar pattern of expression. hence, it has been inferred that humans too carry similar susceptibility gene. there have been further studies which have shown that polymorphisms found in the nramp gene are related to the infectivity of leprosy and tuberculosis (abel et al. ). in one of the studies, it was found that persons who carry an nramp heterozygous variant will be four times more likely to be infected by tuberculosis than persons who are carrying more common variants of the nramp (bellamy et al. ). cell-mediated immunity plays an important role in the context of tuberculosis and is well studied. research has further gone ahead to fi nd links between tuberculosis susceptibility and polymorphism in the gene coding for receptors of interferon-γ and interleukin- , which are cytokines belonging to t-helper cell type (th ). the absence of functional copies of either of these genes in families and of isolated patients leads to high susceptibility to m. tuberculosis infection (jouanguy et al. (jouanguy et al. , newport et al. ; altare et al. ) . the highly polymorphic human leukocyte antigen (hla) system is the name of the major histocompatibility complex (mhc) in humans. the hla class i glycoproteins are highly expressed on the surface of every nucleated human cell, and they present endogenous peptides derived from the cell to the cytotoxic t cells. hla class i glycoprotein plays a major role during the viral infection as it presents intracellular viral peptides on the surface which leads to cellmediated immune response, which further leads to the destruction of virus-infected cells. hla class ii glycoproteins which are present on the surface of antigen-presenting cells (apcs) on the other hand present - amino acids long peptides that are derived from the engulfed pathogen and displayed on the surface which then are recognized by t cell as foreign antigens, and it will elicit an immune response to the antigen. the length of antigen as well as composition are important in deciding if the antigenic peptide will bind to the antigenic peptide-binding cleft. polymorphisms occur almost solely in the peptide-binding cleft of hla class i and ii in the glycoproteins. the diversity of hla-binding region ensures that some pathogenic peptides will be preferentially presented compared to the others. thus, in a given population, the hla diversity ensures the advantage that some of the hla glycoprotein peptide-binding clefts will be able to bind and present the pathogenic antigen peptide which will lead to an immune response to any invading pathogen. this ensures the survivability of the species against an infection. thus, genomic studies have focused on the identifi cation of susceptibility genes which would lead to the better management of infectious diseases in the population. the tuberculosis susceptibility has been associated with hla class ii genetics. the association is evident from the studies that have been found between pulmonary tuberculosis and class ii hla antigens in several populations (marquet and schurr ) . as is now clear, the knowledge of the mechanism of action of the pathogen and the identifi cation of the susceptibility genes goes a long way in the management of the disease in context of a public health perspective to prevent, diagnose, identify, and target the vulnerable populations against a given infectious disease. the requirement of the genomic information of both the host and pathogen is important to fully carry out infectious disease management. the fi rst sequence map of human genome being completed in june (lander et al. ; venter et al. ) , followed by discovery of genome-wide single-nucleotide polymorphisms (sachidanandam et al. ) and further genomic sequencing of several pathogens by institutes like the j. craig venter institute ( www.jcvi.org ) gradually opened the pathway to create new treatment and disease management methods. the ultimate aim of genomic technologies to bring personalized medicine for every infectious disease scenario is still decades away, but here we will focus only on important breakthrough which has shown us the way forward in respect to infectious disease identifi cation and treatment. neisseria meningitidis is a bacterium that can cause meningitis and other forms of meningococcal disease such as meningococcemia, a lifethreaten-ing sepsis ( www.cdc.gov/meningococcal/ ). n. meningitidis is a major cause of morbidity and mortality during childhood in industrialized countries and has been responsible for epidemics in africa and in asia . neisseria meningitidis serogroup b is responsible for causing about one third of infection. the genome sequence of n. meningitidis has opened a new way for disease management (pizza et al. ; tettelin et al. ) . the vaccine that was used only contained capsular polysaccharides from the serogroups a, c, y, and w only. serogroup b polysaccharide contained elements that resemble human polysialic acid and hence is poorly immunogenic and might generate autoantibodies (hayrinen et al. ) . in this scenario the n. meningitidis serogroup b was sequenced, and potential antigens from the serogroup b were expressed in escherichia coli to fi nd the potential vaccine candidate. the expressed proteins are injected into mice to fi nd immunogenic antigens that can developed into a vaccine. similar strategies are being used to fi nd vaccine candidates for other serotypes of neisseria species and for other pathogenic organisms. pathogen genomic information is also being used to fi nd the immunologically important peptides for cytotoxic t lymphocytes (ctls) epitopes. the response of ctls is to seek out virally infected cells by recognizing the peptides presented by human leukocyte antigen (hla) glycoproteins on the cell surface and killing the infected cells. ctl epitopes are the viral peptide that is presented by the hla and recognized by ctls. the peptides are of the length of amino acids, and genome sequence is used to fi nd out and synthesize these peptides for immunogenic evaluation. amino acids are divided into segments of peptide, measuring amino acids in length and overlapping the previous peptides amino acids, for example, west nile virus genome translates into , amino acids which can be segmented into , peptides that are amino acids in length. immunoinformatics, a fi eld of bioinformatics, is speeding up the fi nding of ctl epitopes for the scientist working in the fi eld. algorithms on computer softwares are being used to match the viral peptides with the hla glycoproteins in silico for binding based on previously known results and are being tested (de groot et al. ). informatics based algorithms help eliminate % of the peptides that would not be used in the experimental screens. thus, the time and effort to screen for the ctl epitopes have been reduced drastically. ctl epitopes may be used for making subunit-based vaccines and diagnostic tests. virusspecifi c antibody found using ctl epitopes can be used in enzyme-linked immunosorbent assay. it may be even possible to use ctl epitopes to test for the antigen itself. basically as of now only four types of molecular diagnostic tests are carried out to detect infection in laboratory setup. first is by direct detection where the pathogens can be detected directly by imaging technologies of microscopy and cell culture. second method of diagnosis is by the detection of proteins produced by pathogens by the use of specifi c antibodies, like that used in enzymelinked immunosorbent assay (elisa). third method is by detection of the specifi c antibodies iga, igm, and igg against the pathogens and the changes in their titers using antibody capture assay. fourth method uses detection of nucleic acid of the pathogens and amplifying their signal using techniques like polymerase chain reaction. latest diagnostic technologies have been developed on these basic four biotechnological technologies (speers ) . pathogen genome can also be used to identify the infecting organism itself. microbial dna in the clinical specimen can be used to identify the disease-causing pathogens. human immunodeficiency virus (hiv), hepatitis virus, borrelia burgdorferi (causative agent of lyme disease), and mycobacteria are few examples of pathogens that can be identifi ed by their genomic sequences. mycobacterium tuberculosis antimicrobial resistance strain-caused infections are becoming quite common, and genomic information has deciphered few potential candidates like katg gene mutations in resistant strains (siqueira et al. a , b ; marahatta et al. ) . the traditional culture test for mycobacterium which is time-consuming and less sensitive is giving way to restriction fragment length polymorphism (rflp), a specifi c technique used in dna fi ngerprinting (van soolingen ). the technology uses restriction enzymes that cut dna at the places having certain particular nucleotide sequences. the nucleotide pattern that is obtained is then compared to the previously identifi ed specifi c nucleotide pattern of the genome of the pathogen dna. dna patterns can be separated on the basis of length, and the pattern of dna fragments in the dna fi ngerprint is characteristic of particular isolate, and each particular pathogen has a unique pattern. dna fi ngerprint technology is faster and reliable than culturing of the mycobacteria, ideal for discovering new drug-resistant strains from unique genomic sequences of each mycobacterium. the technology is very useful for identification of strains during the time of outbreaks and further epidemiological studies. the knowledge of viral load in patients is also important for dosage determination in drug therapy; hence, detection of the viral pathogenic dna and rna in clinical specimens is of paramount importance. treatment of viral diseases like hiv, chronic hepatitis b, and hepatitis c often depends on the knowledge of viral load (revets et al. ) . for example, hiv viral loads are detected by enzymatic amplifi cation of the viral nucleic acid and detection of the signal from the labeled probes that hybridizes with them. the signal usually is either a color signal conjugated to the probe or a chemiluminescent probe, and the intensity of the signal corresponds to the number of copies of the nucleic acid rna. capillary electrophoresis detects hybridized probes at a very high sensitivity with detecting as low as , copies of hiv rna in milliliters of plasma (kolesar et al. ). the rampant uncontrolled use of antimicrobials has led to increased number of antibiotic bacterial strains. genomic mutations allow the certain bacterial strains to overcome the effects of antimicrobials and are able to propagate in spite of the presence of antibiotics. fluoroquinolones are drugs that act on the bacterial dna replication by binding to bacterial enzymes involved in bacterial dna replication, that is, dna gyrase and topoisomerase. the bacterial resistance to quinolone occurs due to mutation in the quinolone-binding site in the enzymes mentioned above. the mutation leads to change in the amino acid at the site of binding of fl uoroquinolones to the enzymes. if both the bacterial enzymes are mutated, then high-level resistance occurs to the quinolone drug affecting the treatment of infection as compared to when either of the enzymes is mutated (hooper ) . now genetic test is available to detect antimicrobial resistance in the infecting pathogens. the information is important because it would lead to a better treatment management of the infection. the methicillin-resistant staphylococcus aureus phenotype is detected when cultured in the presence of oxacillin after a period of h. before the era of omics technology, the only means of resistance detection was by culture test which is a very time-consuming test. methicillin resistance in s . aureus is controlled by alternations of penicillin-binding protein pbp a. gene meca controls the production of pbp a. polymerase chain reaction test is used to detect the presence of meca in reference laboratories, while commercially developed kit can detect the same using a fl uorescein-labeled meca probe. both dna probe and pcr technology when used for analysis can detect meca -resistant gene in a given sample in less than h. the rapid detection of antimicrobial resistance in pathogens helps patients in providing adequate treatment opportunities (louie et al. ) . the study of the host genome becomes important to fully understand the drug effects and as such design more effective methods of treatments. although the ultimate goal is to decipher the system biological effect, the trend of single gene effects is also very important. cytokines play a very important role in human immunity (paul and seder ) . in hepatitis c infection, interferon alpha is used to stimulate cell-mediated immunity against the viral infection and is the primary treatment. however, studies have shown that response to interferon-alpha treatment is only % in some cases even when combined with other antiviral treatment (manns et al. ) . further studies have shown that if chronic hepatitis c patients have il- polymorphism variant, it leads to the reduction in expression of il- itself, and they will have fi ve times more chance of effective treatment with interferon alpha than those who do not carry the polymorphism (edwards-smith et al. ) . interleukin- (il- ) is a polymorphic cytokine and is a t-helper cell type ii (th ) cytokine that is associated with the induction of the production of large amount of antibodies in body's immune response. th cytokines which promote cell-mediated immunity inhibit th response and vice versa. thus, people with high-expressing il- genotype if infected and suffering with chronic hepatitis c infection are less likely to respond to interferon-alpha treatment. new treatment regimes have to be developed for patients suffering from chronic hepatitis c infection and carrying il- polymorphism associated with high cytokine expression. vaccine responses can be used as a system of gauging the state of immune system ( poland a , b ) . vaccines are administered to large number of population as an integral part of public health system. vaccines are used to mimic the infective disease conditions that induce immunological memory to protect the individual against subsequent exposure to the pathogen and lead to prevention of disease. the phenomenon to gain protective immunity against a pathogen upon being vaccinated for the particular pathogen depends on individual genetic build. as studies have shown, not all healthy individuals are able to generate a protective immune response upon vaccination. it has been observed in the case of measles vaccination that only % of the population was seronegative and clustered in family (poland a , b ; poland et al. c ). both hla i and hla ii class alleles have been responsible for the measles vaccine response, while hla-b , hla-b , hla-drb * , and hla-dqa * are associated with positive measles vaccine response, and hla-b, hla-dr, and hla-dqa have been responsible for the vaccine being noneffective (hayney et al. (hayney et al. , poland et al. ). drugs used for targeting any pathogenic infection can only be successful if we are aware how it is affecting the host and pathogen at genomic level and hence are able to explain the host effi cacy and toxicity. we look at few important infectious diseases where pharmacogenomic research has been bringing a landscape change in the disease treatment. leishmaniasis is a very complex major tropical infection transmitted by the vector sand fl y is all right. the infection is caused by intracellular protozoan parasites of leishmania genus. there are more than species of leishmania . the type of infective species, virulence factors, and host immune responses and depending on the clinical symptoms, the disease is categorized into cutaneous leishmaniasis (cl) and visceral leishmaniasis (vl). vl is also known as kala-azar; the origin of the name is from the eastern and northeastern part of the indian subcontinent where the disease is endemic. depending upon the place where one has acquired the infection, cl is further categorized into "new world" from central america and south america and "old world" if from asia, middle east, africa, or southern europe. more than - . million cases of leishmaniasis occur worldwide (about countries are affected) with major countries being the developing nations of asia, africa, and latin america ( www.who.int/topics/leishmaniasis/en/ ) . species of leishmania are several causing different clinical manifestations of the infectious disease. l . donovani produces primary cutaneous disease as well as gives rise to visceral leishmaniasis (vl) and also post-kala-azar dermal leishmaniasis (pkdl) that is manifest after the treatment of the initial visceral disease. visceral leishmaniasis main causative pathogen is the l. donovani complex with old world vl disease being caused by the species l. donovani and l. infantum, and new world disease is mainly caused by different species of l. chagasi in the cases of infection caused by l. braziliensis complex, there is always a chance that the infection dissemination to mucosal region can occur to give rise to mucocutaneous leishmaniasis (mcl) (herwaldt ) . the complex disease is manifested due to multiple factors ranging from environmental factors such as time and number of exposure with infected vector sand fl ies, species of the infecting leishmania pathogen, to host genetic factors that include immune status of both innate and adoptive immune systems that determine the clinical outcome of the disease. other reasons for leishmania disease susceptibility are malnutrition, immunodefi ciency with hiv coinfection, and young age. the protection against invading pathogenic leishmania protozoa and even the curative resolution of the disease is provided by th cytokine response involving cytokine interferon gamma (ifn-γ), interleukin (il)- , and tumor necrosis factor alpha (tnf-α), whereas th response cytokines il- , transforming (tgf)-β, and il- have been implicated in increasing susceptibility to the disease in the experimental animals (reed and scott ; sacks and noben-trauth ) . nonhealing lesions and diffused lesions in cl have been implicated to th response, while self-healing lesion has been associated with th response (melby et al. ) . however, in some situation il- (a th cytokine) has been implicated to induce il- production and lead to th cytokine response, and it has also been found in some cases that th response occurs independent of il- (alexander and bryson ; mansueto et al. ). leishmania infection is a complex infection depending on host factors as well as strain polymorphism. leishmania mexicana cysteine proteases which target il- that prevents th protective response (buxbaum et al. ) , while the leishmania analogue of activated c kinase (lack) from the leishmania major induces th response that leads to host parasitization (kelly et al. ) . polymorphism of l. braziliensis also affects disease outcomes (cupolillo et al. ; schriefer et al. ). pkdl is a complication arising after treatment of vl, affecting % of vl patients in sudan (study carried out in united sudan) and also - % patients in india. pkdl has been found to be associated with increased levels of il- (zijlstra et al. ; ganguly et al. ). the major treatment regime of cl which has propensity of dissemination towards vl and mcl is with parenteral antimonials like sodium stibogluconate or meglumine antimoniate, pentamidine, and oral miltefosine (olliaro et al. ; ameen ; amato et al. ) , whereas cl with low risk of spread is treated with local and physical therapies such as intralesional antimonials, topical paromomycin, cryotherapy, and thermotherapy or by oral azoles. however, when the disease progresses to mcl, treatment is prolonged, and toxicity from such long-duration drug use is a common occurrence (marsden ; amato et al. ) . vaccine is still elusive in the case of leishmania. some trials with dna vaccines do have shown a way forward. these vaccines have shown the promise to be effective as they have been able to induce l- production, which was in response from the persistent antigen exposure from the dna vaccine (requena et al. ). in venezuela killed leishmania promastigotes along with bacillus calmette-guerin (bcg) used as immunotherapy have shown results with a high cure rate in clinical trials by inducing th response (convit et al. ) . l. major vaccine trial with bcg and parenteral antimony combined have been successfully used for treatment of pkdl (mansueto et al. ). the search for effective vaccine for leishmania had got a boost with knowledge from genome sequence data of several leishmania strains. more vaccine candidate genes will be evaluated in the future (stober et al. ). in the absence of an effective vaccine with recurring infection such as pkdl, dissemination infection to mucosa leads to aggravating of the disease. prolonged treatment with parenteral antimonials that give rise to high-level risk of toxicity with high morbidity and mortality from the disease is a problem of concern (convit et al. ; muse et al. (samaranayake et al. ) . l. donovani though normally associated with causing vl is shown in few places, kenya, yemen, cyprus, and the himalayan region of north india, and is the main causative pathogen of cl (mebrahtu et al. ; pratlong et al. ; sharma et al. ; antoniou et al. ) . to deduce the genetic susceptibility of the leishmania disease, experimental murine animal models along with clonal parasite line (to control environmental variable) have been used to fi nd the genes responsible for disease progression along with their human homologues of disease susceptibility (handman et al. ) . first genes that were used to deduce from such analysis in murine model were nramp and the h- locus had been implicated in l. donovani infection (blackwell et al. ) . hla class ii antigen hla-pq is found to be associated with cl in venezuela (lara et al. ) and mcl in brazil caused by l. braziliensis (petzl-erler et al. ) . pcr genotyping studies in mexico on leishmania patients has found an association with hla class ii genes with cutaneous leishmaniasis (cl) (olivo-diaz et al. ) . high blood tnf has been found to be associated with mcl (castes et al. ) and acute vl (barral-netto et al. a , b ) . a venezuelan study has implicated that allele of tnf-β polymorphism with high risk of developing mcl caused l. braziliensis and higher frequency of allele of tnf-α polymorphism was also associated with mcl (cabrera et al. ) . in brazil by using family-based disequilibrium test analysis (tdt), investigation has shown that tnf polymorphism has been linked to l. chagasi infection (karplus et al. ) . in asymptomatic patients having positive skin test, l. chagasi has been associated with tnf- allele of tnf-α gene, while in case of symptomatic l. chagasi vl patients, tnf- allele is implicated. due to parasite heterogeneity, this tnf polymorphism association has not been correlated to infection by other leishmania species such as in l. infantum vl (meddeb-garnaoui et al. ) and l. major cl (kamali-sarvestani et al. ) . variation in promoter of il- and ifn-γ gene polymorphism has been found to be linked to l. major cl disease susceptibility and progression respectively in an iranian study, while in a sudanese vl patient study, il- polymorphism has been shown to increase disease susceptibility (mohamed et al. ) . polymorphism in promoter region of il- gene leads to higher il- production which has been shown to increase the risk of having skin lesions during an infection of l. braziliensis (salhi et al. ). il- can diminish the high th proinfl ammatory response that occurs when l. braziliensis cl progresses to mcl (hatzigeorgiou et al. ; bacellar et al. ) . il- polymorphism plays an important role in the progression of l. braziliensis cl to mcl, and this fi nding is important since their genetic markers have high prognostic value (castellucci et al. ) . genome-wide linkage have been performed for l. donovani-infected vl patients in artinga ethnic group in sudan to help identify loci on chromosome q and is associated with disease susceptibility genes (bucheton et al. a , b ) . il- receptor β chain (il rb) gene is present in the highly susceptible loci on chromosome q that was identifi ed from this study. il- receptor has been detected in high levels during vl infection and plays a critical role in t cell genetic responses (barral-netto b ) . further studies have shown il rb polymorphism in association with l. donovani vl (bucheton et al. ) . another candidate gene found is slc a (formerly nrampi) on chromosome q , an innate resistance gene that regulates macrophage activation and contributes to increased vl risk in sudanese population (bucheton et al. a , b ; mohamed et al. ) as well as increased susceptibility to several intracellular pathogens (blackwell et al. ) . other studies have shown that genotypes having signifi cantly high level of mannan binding lecithin occur more prominently in patients with clinical vl. an opsonin, mannanbinding protein, is known to enhance pathogen infection. polymorphism in mannan-binding gene has been shown to increase risk of developing l. chagasi vl in brazilian study population (alonso et al. ) . in pkdl there is elevated level of ifn-γ. polymorphism of ifn-γ receptor from study in sudan has been implicated in pkdl (salih et al. ). the ifn receptor expression is important for the activation of macrophages via ifn-γ. drug treatments are not very effi cient in the treatment of leishmaniasis disease; more effective treatment regimes can be developed by thoroughly knowing the genetic factors that lead to disease progression. thus, unnecessary drug use and adverse reaction can be avoided. as various genetic susceptibility studies have shown, cytokine response determines the disease progression in leishmaniasis. role of il- in pathogenesis of leishmaniasis is known and is well established, and il- polymorphisms have shown to increase risk of lesions in l. braziliensis infection. in a study with l. guyanensis infected cl patients from french guiana, high level of mrna il- within lesions leads to poor chemotherapy response and treatment failure (bourreau et al. ) . it is hypothesized that il- might be regulating the response to chemotherapy by blocking the th response. the increased level of il- has been linked to the active vl (nylen and sacks ) and pkdl (saha et al. ) and also associated with persistent cl infection occurring from l. major (melby et al. ) and l. mexicana (louzir et al. ). success of vl treatment with amphotericin b and the complete elimination of il- are associated with one another (saha et al. ). on the other hand, mcl is associated with low il- receptor expression and low il- secretion that decrease the ability for modulation of proinfl ammatory response (faria et al. ) . progress has been made to fi nd the susceptibility genes and will provide further insight into disease pathogenesis and will lead to progress in the fi eld of diagnostic markers, drug targets, and vaccine development to control, treat, and eradicate leishmaniasis. improving the treatment of malaria by pharmacogenomics malaria is vector-borne (mosquito) disease that has been one of the top causes of mortality in the world for generations especially in tropical countries of asia and africa. even after renewed global efforts, still there is high infectivity and mortality. three billion people are at risk with - million deaths attributed to malaria each year ( www.who.int/topics/malaria/en/ ). four species of protozoan parasite are involved from genus plasmodium, i.e., p. falciparum , p. vivax , p. malariae, and p. ovale . these malaria-causing combination parasitic species occur in human population and occur in infected individuals (gurarie et al. ) . in respect to prevalence, virulence, and multidrug resistance, p. falciparum has been a major cause of mortality and morbidity. p. falciparum accounts for about % cases of malaria in africa (roca-feltrer et al. ). next to it is p. vivax which causes - million cases annually (price et al. ). the most commonly used drugs are chloroquine (cq) and sulfadoxine-pyrimethamine (s-p fansidar ® ) that are becoming less effective due to the development of resistance in malaria parasite by p. falciparum, and the species has become predominant and become a threat to travelers and people alike (schlagenhauf and petersen ) . in the absence of vaccine and in addition, development of resistance even in the mosquito vector control against chemical methods using insecticides has thrown new challenges for the researchers (greenwood et al. ) (fig. . a ). some of the recent developments in malarial treatment using pharmacogenomics are bringing about improvements in the effi cacy of treatment regime of malaria. current treatment regimes have recommended artemisinin combination treatments (acts) in cases of uncomplicated falciparum malaria in nonpregnant adults (lin et al. ) . the drug regime is highly effi cacious and has reduced development to resistance. in cases of uncomplicated malaria, the act is being used in countries by . in the coming years, a number of patients including women and children will be brought under act therapy regime as per world health organization. like the treatment of hiv and tuberculosis, combination therapy is now being used for malaria treatment too, which reduces resistance among the highly effi cacious drug the artemisinins which rapidly eliminate the parasite from blood and thus limit the number of parasites so that the other more bioavailable drugs given in combination act on the parasite. unrelated mode of action of two or more combination drugs also reduces the chances of resistance (yeung et al. ). among many other factors which contribute to drug effectiveness, malarial drug bioavailability and tolerability are depended upon the host metabolic mechanisms. the severe drug reaction to primaquine in the s used in antimalarial treatment was instrumental in the discovery of glucose- -phosphate dehydrogenase (g pd) defi ciency in ; thus, importance of the use of pharmacogenetics in malarial treatment was realized (alving et al. ). the polymorphism leading to variation g pd or even its defi ciency is a grave problem in designing the effective drugs. even now during malarial terminal prophylaxis to decrease transmission, primaquines are administered. thus, the g pd status of patient becomes quite important (luzzatto ) . knowledge of both the host and parasitic genetics is necessary to designing drugs and dosage for effective treatment regimes. parasitic genetics helps us in deciphering the modes of resistance, and host genetics help us in giving the information about host drug bioavailability and explain adverse reaction to the drugs. g pd polymorphisms and genetic variation in cyp c can play pivotal role in point of care diagnostics, but these genetic testings will have to be incorporated into the laboratories and national health programs. the knowledge of this important genetic variations in population would ultimately reduce cost and make the treatment regime more effective and with lesser adverse reaction and ultimately reduce the suffering of the patients. the pharmacogenetic drug policy in context of malaria is slowly becoming a reality as per efforts of the who and other agencies. genetics is becoming a guide to new drug policy. amodiaquine was generally known to be tolerated in malarial treatment, but later when it was found in the caucasian population during the decades of and to be responsible to cause agranulocytosis with fatalities and also cause hepatotoxicity (hatton et al. ; raymond et al. ; phillips-howard and west ) , the drug was fi rst removed from the list of essential drugs against malaria but then had to be added back to the list as alternate drugs started showing resistance. amodiaquine induced adverse reaction in individuals was attributed to genetic make up of the individual. the genotypes of individuals harboring cyp c , cypia , and cyp b have been reported in studies to show immunogenic adverse reaction to amodiaquine (li et al. ; kerb et al. ). some population in africa has shown hepatotoxicity and leucopenia with only two doses given weeks apart (orrell et al. ) . amodiaquine when administered to an individual with reduced cyp c activity impairs the metabolism of the drug and hence leads to the cause of hepatotoxicity and agranulocytosis. other common variants of the enzymes cyp c * and cyp c * have been associated with decrease in the metabolizing activity of cyp c enzyme as is evident from studies with anticancer drugs (dai et al. ) . individuals with cyp c * genotype have no cyp c enzymatic activity in vitro (parikh et al. ). in a study from burkina faso, patients carrying cyp c * genotype showed common adverse effects to amodiaquine and in addition patients have also reported to experience more abdominal pain when compared to healthy individuals. the study from burkina faso and ghana could not clearly establish the relation between drug efficacy and cyp c genotype (adjei et al. ) . though the inactivated gene of cyp c is not very high in population, estimates have shown that cyp c * and cyp c * occur in about . % of the population in zanzibar, united republic of tanzania, which was about , patients of the total malarial patients ~ , (cavaco et al. ) . in ghana it was found that . % of the population has been estimated to have metabolic variants of cyp c . hence, due to high disease burden, the study of pharmacogenomics for drug metabolism was carried out in large patient samples from the population to get a clear correlation between genotype and effi cacy of drug treatment as well as adverse reaction. major active antimalaria metabolite of artemisinin is dihydroartemisinin (dha) (ilett et al. ) . artesunate is rapidly converted to its active metabolite catalyzed via cyp a which is a major enzyme; conversion to dha also includes minor enzymes cyp b , cyp a , and cyp a (li et al. ) . cyp a has about variant forms of which at least have been implicated as slow metabolizing enzymes, and have been reported to show no activity in vitro (di et al. ) . hence, lower level of cypba enzymes in patients will have reduced bioavailability of dha the major antimalarial metabolite and hence have lower antimalarial activity. major endemic areas of malaria like sub-saharan africa, ghana, sabah region of malaysia have been evaluated for the presence of cyp a genotype. among these population of ghana has high wild-type cyp a along with % alleles being cyp a * a (gyamfi et al. ) , whereas malaysian population has an allele cyp a * a frequency of % with only % wild-type enzyme (yusof and gan ). other asian populations have been reported to carry several other alleles of cyp a with even alleles that do not show any cyp a enzyme activity at all. no activity variant of cyp a is found about . - . % in japanese, chinese, and thai populations (gyamfi et al. ) . hence, artesunate is expected to be more effective in population of ghana. in some parts of thailand, about % of patients have shown resistance to artemisinins (white ) . though it has been found by study that about % frequency of cypz alleles have no activity in the thai population and the antibiotic resistance is indicative to be related to cyp a activity and ability to convert artesunate to dha (noedl et al. ), more studies require to be done to clearly establish the relation between the genotype and resistance to artemisinin-based therapy. several mutations in gene targeted by antimalarial drug have been identifi ed which led to the resistance in vivo of act drug partners such as mefl oquine, lumefantrine, amodiaquine, and chlorproguanil (kerb et al. ; mehlotra et al. ). identifi cation of genes and mechanism is important for controlling the infection. research has yielded the information regarding the gene responsible and underlying mechanism of action resistance of some drugs against p. falciparum and p. vivax . chloroquine resistance (cqr) in p. falciparum has been linked to point mutation cq resistance transporter gene (pfcrt chromosome ). the mutation pfcrt -k t is a reliable marker for cqr. while cq-sensitive strain carries wild-type allele cvmnk , the variant cqr alleles are s agt vmnt (asia, south america, africa), s tct vmnt (south america), cvmnt (south america, philippines), cviet (southeast asia, africa), and cvmet (colombia). another multidrug resistance gene ( pfmdr chromosome ) is a parasite transporter gene. polymorphism, point mutation, and copy number variation have been implicated in multi drug resistance. in different geographic regions, the pfmdr two mutant alleles have been reported, namely, y_ y_ s_ n_ d found mostly in asia and africa and n_ f_ c_ d_ y predominantly from south america (valderramos and fidock ) . the pfcrt- and pfmdr - y mutations have been related jointly to contribute in giving rise to cqr phenotype in addition to other likely parasite genes (hayton and su ) . p . falciparum dhps enzyme ( pf-dhps , chromosome ) has been linked to resistance to the sulfa class of antimalarial drugs, while mutations in dhfr ( pf-dhfr , chromosome ) domain have been linked to high level of pyrimethamine resistance. combination of sulfadoxine-pyrimethamine (s-p) treatment failure has been found to be associated with pf-dhps double mutant ( g with either e or g), combined with the pf-dhfr triple mutant ( n_ _ r) (hayton and su ; hyde ) . point mutations in p. vivax ortholog of pfcrt (pcvg ) are associated with clinical cqr. pfmdr p. vivax ortholog that is pvmdr has been proven and has also been identifi ed. y cf point mutation of pvmdr has been linked to cqr. pv-dhs and pv-dhr gene point mutations have been identifi ed and are suspected to link to clinical resistance in antimalarial s-p treatment (hayton and su ) . more data is required for new mutations in the parasite genes, and in addition more data is needed for therapy of other act drug partners like sulfadoxine-pyrimethamine and lumefantrine. a new rejuvenation is taking place in pharmacology and pharmacokinetics development of databases of antimalarial pharmacogenetics. worldwide antimalarial resistance network ( http://www.wwarn.org/ ) has set up a module together with high-quality pharmacological research data for optimum drug dosage in light drug resistance information and adverse event reporting. the aim to achieve global cooperation will go a long way to personalized malarial treatment as per population needs. during the last half a century (for about years), the most effective treatment regimes have been the combination therapies of drugs that was because a single drug treatment was found to be in invariantly leading to resistance for the drug, leading to much more severity and complications (crofton ) . due to rampant and unregulated use of tuberculosis drugs, however, this has led to emergence of multidrug resistant tuberculosis (mdr) (fig. . b ) . now the treatment course is usually for months with the combination of isoniazid, rifampicin, pyrazinamide, and ethambutol for the fi rst months. this has to be followed up by the next months with isoniazid and rifampicin treatment. if the treatment is taken up with diligence and patient completes the whole drug course, then it has been reported that effi ciency of the treatment is very high with more than > % patients getting cured and relapse is in less than % of patients (menzies et al. ). another advantage of multidrug treatment is that the treatment regime helps in treating different population of tubercle bacilli. for the last years, knowledge from the fi eld of genetic molecular basis of drug treatment outcomes has helped us in the better management of and understanding of treatment effi ciency and of drug. the difference in drug response is found among different individuals of the population. the individual person tends to show similar type of response to tuberculosis drugs that do not change over time. thus, in light of above observations, we say that there is a huge variation in drug response among individuals due to variation in genes involved in drug metabolism, drug transporters, and drug targets compared to minimal within-subject variation as found from studies. further studies on drug response revealed that - % of variation in drug pharmacokinetics is due to genetic factors (kalow et al. ). the sequence variation in drug-metabolizing enzymes, drug transporters, or drug targets leads to the variation in drug response among individuals (evans and relling ; evans and johnson ) . some nongenetic factors such as nutrition organ function, age and other concomitant therapies, nature of disease, and drug interaction can also effect in drug response, but genetic determinant remains constant throughout the lifetime of the individual. pharmacogenomics have played an important role in deciphering therapeutic effi cacy of drug metabolism and occurrence of adverse events. though research is still being pursued to decipher the intricacies of how genetic differences play an important role in regard to clinical application of the drug however, through research we have gained information on the role of genetic polymorphism with respect to drug effi cacy for the treatment of tuberculosis. in this section we will discuss the knowledge we have gained through newer technologies in regard to different drugs being used for tuberculosis. since isoniazid has been in use for antituberculosis treatment since , it is the most well studied of the lot (ellard and gammon ) . this drug has been found to be tuberculosis specifi c in its action against tubercle bacilli and has relatively minimal toxicity. now pharmacogenomics is playing a very important role in making isoniazid the fi rst-line treatment drug. acetylation of isoniazid takes place mainly in the liver and gut mucosa. for any drug ingested in the body, it is absorbed and metabolized and then its soluble by-products are released or excreted out of the body. the drugs have specifi c retention and metabolizing rates depending upon their chemical composition and the genetic polymorphisms of the metabolizing enzymes. the activation of isoniazid is catalyzed by highly polymorphic enzyme n-acetyltransferase (nat ) and leads to formation of acetyl isoniazid. this is formed by the transfer of acetyl group from the acetyl coenzyme a to acceptor amine leading to formation of an amide. acetyl isoniazid combines with several other cellular compounds to give a variety of metabolites which do not have any antituberculosis activity. the level of acetylating isoniazid that will be subjected to during metabolism in the body determines the disease outcome. the level of bioavailability of the drugs determines whether the drug would be effective for elimination of the invading pathogen or toxic to the human body. acetylation of isoniazid varies from individual to individual depending as per his or her genetic predisposition. genetics determines the amount of active nat enzyme that an individual expresses. the metabolism of isoniazid is catalyzed by nat enzyme which takes place in liver or gut mucosa. thus, the level of nat gene expression is controlled by the type of polymorphism in nat that particular individual carries. thus, for the pharmacogenomic and personal medicine in effect to succeed, the dosage for the drugs that are metabolized by nat should be tailor made as per the enzymatic activity depending upon the polymorphic variant (roy et al. ) . the enzymatic activity being highly variable cascorbi and roots ( ) has been studied over the years in human subjects who have been categorized as slow or rapid inactivators ( http://www. brti.co.zw ). the categorization has been based on the measure of capacity of nat enzyme to acetylate isoniazid to acetyl isoniazid thus inactivating it. here the rapid inactivators are those who have more concentration of active nat enzymes than slow inactivators. based on the new technologies, genotypic studies have led to further classifi cation depending upon enzymatic activity nat variant as rapid acetylators, that is, the wild type gene which codes for the completely active enzyme. rapid acetylators are highly active forms of the enzyme denoted by nat * allele. patients harboring these alleles can tolerate conventional dosage of drug that is rapidly metabolized by nat enzyme. individuals who carry nat heterozygous alleles where only one of the allele is active/functional should be administered lower than average drug (those are nat metabolized) dosage to get an optimum effective drug response without adverse drug response. mutations in nat enzyme in human individuals designated as nat * a , nat * b , nat * a, and several others which lead to rendering the nat gene activity are termed as slow acetylators which can lead to diminished drug clearance and toxicity. the variation of frequency of slow acetylator gene is depended on the race, population type, and the ethnicity from one country to the next. it is found in a study that % of middle eastern, % in south indian population, caucasian and negroid, and % of the us population harbor slow acetylator gene. in mongoloid populations like the eskimos, japanese, and the chinese, slow acetylators are found in only % of study subjects. in another study carried out in a population of healthy caucasian, there is variability in isoniazid clearance. while isoniazid preparation is responsible for only % variation and body weight accounted for only % variation in isoniazid clearance, the majority variation of % in isoniazid clearance was due to nat genotypes (kinzig-schippers et al. ) . highactivity nat allele-carrying individuals have higher isoniazid clearance. other studies have shown that - times more isoniazid concentration in individual is carrying slow acetylator nat genotype (parkin et al. ) . a study estimating the comparison of urinary isoniazid excretion in japanese patients to normal, healthy individuals showed that persons with higher number of active nat alleles had higher level of isoniazid acetylation (kita et al. ) . the relation between isoniazid concentration in blood with drug effi cacy and toxicity knowledge is important. peak isoniazid concentration to minimum inhibitory concentration ratio has been proposed to serve as a means to outcome tuberculosis treatment (mitchison ) . mean early bactericidal activity of isoniazid depends on its level in the plasma which in turn depends upon the variant nat genotype carried by an individual. comparatively the mean bacterial activity is lower in rapid acetylators than in the slow acetylators (donald et al. ) . therapeutic failure or relapse of infection is thus attributed to the lower plasma level due to rapid metabolism of isoniazid in rapid acetylator genotypes, while on other hand high level of isoniazid in slow acetylators may lead to the high level of toxicity (weiner et al. ) . nat allele genotyping of tuberculosis patients prior to the treatment with isoniazid is the way forward. dosage adjustment of isoniazid could be carried out depending upon if the patient is harboring none, one, or two alleles nat rapid acetylators. thus, isoniazid would be more pharmaceutically viable for treatment of tuberculosis. in pulmonary tuberculosis patients with known acetylator state, the response to isoniazid treatment analysis was carried out when it is administered alone or in combination with p-aminosalicylic acid. the study compared isoniazid response between nat slow and fast acetylators, and the study revealed that there is association with treatment response and bacteriological negativity (selkon et al. ) . tuberculosis treatment trials used dosage regimes of daily, twice weekly (tuberculosis research centre madras, study , , or three times weekly drug regimes (ellard and gammon ) . by means of controlled clinical trials, it was observed that using once a week uptake of isoniazid showed better clinical response to treatment compared to rapid acetylators, with cure rate of - %. it was postulated that metabolic status of isoniazid may have lesser clinical signifi cance for daily isoniazid treatment regime as compared to thrice weekly or twice weekly treatments. in slow acetylator individuals, the peak concentration of isoniazid was higher than rapid acetylators, and the level of isoniazid decreased more gradually. the effectiveness of a drug in tuberculosis treatment is determined in terms of coverage and the exposure. coverage has been defi ned as the number of hours for which bacteriostatic concentration of isoniazid is ( . µg/ml) maintained in the blood, while exposure is defi ned as area under concentration time curve. both parameters have been found to be signifi cantly greater in slow acetylators. hence, in rapid acetylator individuals, there is a suboptimal concentration of isoniazid which leads to failure of once-weekly regime of isoniazid (sarma et al. ) . other studies using onceweekly isoniazid-rifapentine were compared with twice-weekly isoniazid-rifampicin; treatment also showed that in case of once-weekly treatment regimes, treatment outcome was poor and was associated with isoniazid acetylator status of the patients (weiner et al. ) . the clinical studies have shown that rapid acetylators having infected from combined tuberculosis and hiv infection are at a further disadvantage since it has been found that antituberculosis drug bioavailability becomes suboptimal in those individuals (gurumurthy et al. ) . tuberculosis patients having chronic renal failure are also at a risk from adverse drug reactions if they also happen to harbor slow acetylator genotypes of nat . studies have shown that slow acetylators have higher peak isoniazid concentration, exposure, and half-life compared to rapid acetylators and healthy subjects ( gurumurthy et al. ) . hence, in the case of pulmonary tuberculosis patient also suffering from chronic renal failure, the isoniazid dosage should be administered based on their nat genotypes status. in adult pulmonary patients, studies were carried out to determine correlation between isoniazid dosage and nat genotypic and phenotypic status. determination of isoniazid therapeutic dosage has shown that the fast acetylators need higher drug dosage to have an optimum positive treatment response. fast acetylators tuberculosis patients when administered with mg/kg isoniazid had similar exposure level as mg/kg isoniazid administered to slow acetylators does (donald et al. ). in a further study in a population of south african tuberculosis patients, it was found that current treatment regimes were causing suboptimal exposure of isoniazid in patients having rapid acetylator status (wilkins et al. ) . several fi eld studies have further suggested that there is a need for calibration of isoniazid dosage as per the individual tuberculosis patient's age, acetylator status, and disease process for an effective antimicrobial outcome of drug treatment (jeena et al. ) . in children affected with tuberculosis, it was shown through several studies that the exposure of isoniazid was reduced in the rapid acetylators when compared to the slow acetylators and thus likely to affect the outcome of the treatment of tuberculosis (cranswick and mulholland ; schaaf et al. ; mcilleron et al. ). though isoniazid has been found to be nontoxic during conventional regimes, two types of adverse reactions to isoniazid have been reported. the most common isoniazid toxicity reported is hepatotoxicity which affects - % of the patients (tostmann et al. ) . another isoniazid-associated adverse event is peripheral neuropathy. neuropathy usually occurs in slow acetylators due to administration of high doses of isoniazid (devadatta et al. ) . hepatotoxicity is the major adverse reaction of isoniazid, and the factors that are responsible are nat acetylation, oxidation by cytochrome p s oxidation (cyp) ei, and detoxifi cation by glutathione s-transferase (gst) enzyme activity (roy et al. ) . accumulation of acetyl hydrazine, a toxic metabolite of isoniazid, has been implicated in peripheral neuropathy, and the condition in humans is reversible by concomitant administration of pyridoxine (zilber et al. ) . further, it has also been deduced that hepatotoxicity occurs due to hydrazine metabolites of isoniazid. rifampicin also causes induction of isoniazid metabolism and inducing isoniazid hydrolase to produce isonicotinic acid and hydrazine. the rifampicin induction is more pronounced in slow acetylators compared to rapid acetylators (sarma et al. ) . in some populations studies have established association with nat acetylator status and isoniazid-induced hepatotoxicity, while in other studies it has not. studies in japanese and taiwanese populations have shown that the acetylator status of nat increased the risk factor for hepatotoxicity by -fold isoniazidinduced hepatotoxicity (ohno et al. ; huang et al. ) . in another study on the korean population, the nat slow acetylator status has been implicated to increase isoniazidinduced hepatotoxicity by two-to eightfold, and hence the nat acetylator genotype could serve as predictor of hepatotoxicity (cho et al. ) . nat * / b , nat * a/ a , it/t, and a/a diplotypes have been indicated and could be used as biomarkers for prediction of antituberculosis drug-induced toxicity (ben mahmoud et al. ) . slow acetylator nat alleles have been attributed to increase - -fold to -fold higher risk in isoniazid-induced hepatotoxicity. but other studies in tuberculosis patients have not been able to fi nd any association of nat acetylator status and the drug-induced hepatotoxicity. case studies of caucasian origin patients with tuberculosis (leiro-fernandez et al. ) , genotyping in an indian population (roy et al. ) , and study on heterogeneous population of hispanics, africans, caucasian, south american, and asian have not reported any linkage between nat acetylator status and isoniazid-induced hepatotoxicity polymorphisms (vuilleumier et al. ) . cytochrome p e is one of the enzymes of the hepatic microsomal enzyme system. cyp e gene encodes a member of the cytochrome p superfamily of enzymes. the cytochrome p proteins are monooxygenases which catalyze many reactions involved in drug metabolism and synthesis of cholesterol, steroids, and other lipids. cyp e is an enzyme which brings about conversion of acetyl hydrazine to hepatotoxins, such as acetyl diazone and ketene, and brings about conversion of acetylonium ion (nelson et al. ) . polymorphism in cyp e has been linked with increasing the risk factor associated with isoniazid-induced liver injury (lee et al. ) . the enzyme relocates to the endoplasmic reticulum and can be induced by isoniazid or its metabolite hydrazine. in animal model studies using rat, it has been found that cy pe activity is linked to blood isoniazid levels (yue et al. ). in the presence of variant genotype of cyp e , isoniazid could on the other hand inhibit the activity of the cytochrome p e enzyme. enhanced cytochrome p e activity leads to the increased production of hepatotoxins and hence causing hepatotoxicity. both nat and cyp e polymorphisms have been shown to be associated with susceptibility of fi rst-line druginduced hepatitis. cyp e polymorphisms have been related to increase in risk of antituberculosis drug-induced liver toxicity. the common * a/* a genotype of cyp e , in tuberculosis patients from taiwan, has been linked to increase in the liver damage risk by . times. presence of both slow nat acetylator status and the * a/* a genotype further increases risk of hepatotoxicity when compared to presence of either of the single polymorphism (huang et al. ) . the cyple * and * a* * d haplotypes in indian pediatric patients have been shown in sep-arate study and have shown to increase the liver toxicity. further, the common * a allele at cyp e has been implicated to hepatotoxicity in various heterogeneous population comprising of asians, africans, caucasians, hispanics, and south americans (leiro-fernandez et al. ), but study done on a korean population on the other hand could not fi nd any association between cyp e polymorphism and liver toxicity (huang et al. ) . the glutathione s-transferases are class of two distinct supergene families of proteins located in cytosolic and membrane-bound forms. glutathione s-transferases are a class of enzymes that are responsible for detoxifi cation of therapeutic medication, carcinogens, therapeutic medication, and toxic chemicals that are mostly electrophilic in nature. gsts are present both in eukaryotes and prokaryotes. at present, eight distinct classes of the soluble and cytoplasmic mammalian glutathione s-transferases have been identifi ed: alpha, kappa, mu, omega, pi, sigma, theta, and zeta. the cytosolic gst enzymes are encoded by at least fi ve different loci coding for gst enzymes, distantly related gene families (designated class alpha, mu, pi, sigma, and theta gst), whereas the membrane-bound enzymes, microsomal gst, and leukotriene c synthetase are encoded by single genes and both have arisen separately from the soluble gst (simon et al. ; strange et al. ) . glutathione s-transferase catalyzed elimination of toxic chemicals from the human body is carried out by making the toxic chemical soluble by conjugation with glutathione. in context of isoniazid-related hepatotoxicity, studies have indicated that deletions of gst mu ( gstm ) and gst theta ( gstt ) are associated with liver damage (cho et al. ; huang et al. ) . gst enzymes play an important role in removing the harmful metabolites of isoniazid from the body. the toxic metabolites generated by isoniazid metabolisms are from intracellular free radicals that are scavenged by conjugation with glutathione in reactions catalyzed by gst enzymes. now, studies in indian patients suffering from tuberculosis show that those harboring homozygous gstm mutations have higher risk of hepatotoxicity. it was also found in a study on taiwanese tuberculosis that patients have twice the risk of isoniazid-induced hepatotoxicity if they have homozygous gstm deletion. thus, it can be inferred from similar studies that identifi cation of gstm deletion in patients will lead to the better management of isoniazidinduced hepatotoxicity. reactive oxygen species as we have been aware is a causative agent for damage to hepatic tissue. it has been deduced that level of mitochondrial oxygen species is reduced by the action of manganese superoxide dismutase (msd). as the name suggests, msd catalyzes the dismutation of superoxide into oxygen and hydrogen peroxide and is the fi rst line of defense against reactive oxygen species. polymorphism in the msd enzyme has been found in a study in the population in taiwan, where genotypes having t > c polymorphism in codon lead to variant amino acid valine in place of alanine which increases in risk associated with antituberculosis druginduced hepatotoxicity (huang et al. ) . the presence of valine at codon causes the increased activity in the enzyme manganese superoxide dismutase which leads to the accumulation of the toxic byproduct hydrogen peroxide which can cause hepatotoxicity. rifampicin has been proven to show concentration-dependent activity against m. tuberculosis and is a very important fi rst-line drug against tuberculosis (ji et al. ; jayaram et al. ) . drug transporters p-glycoprotein and oatp b transporters uptake rifampicin as a substrate and hence play an important role in distributing the drug throughout the body. the drug transporters are transcriptionally regulated by the nuclear receptors, i.e., pregnane x receptor and constitutive androstane receptor. the phenomenon variation in bioavailability of rifampicin among individuals in a population on administration of standard dosage has been subjected to investigation by the scientists. the pharmacokinetics of rifampicin depends upon the uptake of machinery of the cells in the body. it has been found that there is a relation between pharmacokinetics and polymorphisms of genes that is responsible for drug effl ux and infl ux. a study group of individuals suffering from tuberculosis who were categorize as per place of origin africans versus non-africans, it was observed that in drug transporter gene, slco b c > a polymorphism leads to reduced rifampicin exposure and bioavailability (weiner et al. ) . the people of african origin (black subjects) that carry slco b c > a gene polymorphisms have been associated with more pronounced reduced rifampicin exposure compared to people from other races. the study thus showed for the very fi rst time that marked interindividual variation in rifampicin exposure can be attributed to slco b polymorphism. another study in south africa has also highlighted that the variant allele of slco b rs polymorphism reduced the bioavailability of rifampicin in the body of the patients when present both in the homozygous and heterozygous states (chigutsa et al. ). this fi nding has been attributed to the observation that there is about % variability in drug clearance among the patients. polymorphisms in the abcb , pxr, and car genes have not been found to affect the pharmacokinetics of rifampicin in the patients in any signifi cant manner. researchers have further predicted by means of stimulation that increasing the dosage of rifampicin in patients carrying slco b rs would increase the plasma availability of the drug and thus would have a positive impact on the treatment outcome. however, more studies needed to be carried out to know the exact association of slco b gene polymorphisms between rifampicin bioavailability to provide an effective treatment regime. as has been already mentioned, the variation in human leukocyte antigens also is known cause of disease susceptibility and the response to treatment has also in indian patients the lack of human allele hla dqai* , while the presence of dqb * has been reported to be associated with antituberculosis-induced hepatotoxicity (sharma et al. ) . aminoglycosides are antibiotics which are molecules that consist of amino-modifi ed sugars, and some of the drugs of this class have been used for treatment of tuberculosis. aminoglycosides such as kanamycin, streptomycin, and amikacin have been used to treat tuberculosis. aminoglycosides have known to cause ototoxicity. ototoxicity is term used when there is damage to the ear (oto-), specifi cally the cochlea or auditory nerve and sometimes the vestibular system due to toxins. the association between aminoglycosideinduced ototoxicity and mitochondrial mutations has been found in a study in chinese family. the deafness phenotype was found to be associated with c > t s rrna gene polymorphisms which could be induced with the administration of aminoglycosides or even get more aggravated (zhao et al. ). there is still no clear relationship of ethnicity and genetic background and response to antituberculosis treatment, and no single variant of nat and cyp e genes is associated with signifi cant liver damage (yamada et al. ). more extensive pharmacogenomic research is still needed for realization of robust personalized medicine for tuberculosis. the antifungal medicine amphotericin b has been found to be effective and well quite toxic. further investigations revealed that the immunomodulatory role of amphotericin b also involves the induction of production of proinfl ammatory cytokine. in human cell the amphotericin-induced higher mrna expression and cytokine production have been detected in studies (rogers et al. ) . the discovery of induction of proinfl ammatory cytokine production was able to explain the infusion-related toxicity effect like nausea, fever, chills, and hypotension that are characteristics of this cytokine release. it was also able to explain the mechanism of action of amphotericin b since the proinfl ammatory cytokines are responsible for the activation of monocytes, macrophages, and promote chemotaxis that led to enhanced immune response to the infection. since the advent of the era of omics technology, the number of drugs that have been discovered have not delivered as was fi rst predicted especially in the case of infectious disease. some of the shortcoming and the remedial measures have already been discovered in the previous sections. it has been found that even with high-throughput screening of number of drug, candidates have not been successful always (payne et al. ). the fi eld of scientifi c research which has become all encompassing and interdisciplinary has added strength along the way and opened new avenues. the fi eld of biology is intertwined with structural biology and chemistry has given rise to the fi eld of medical structural genomics. the exact causes of failure of high-throughput screens have not been well defi ned. the fi eld of structure-based drug discovery has tried to overcome these limitations in the availability of chemical libraries and absence of structural information of many of the targets. the fi eld of structure-based drug discovery has its origin from the fi eld of x-ray crystallography and nuclear magnetic resonance (nmr) technology. with the availability of human genome sequences and pathogen genome sequence databases, the fi eld of structural genomics has gained importance, and hence over the past decade, more than such projects have been taken up. the fi eld of structural biology has got a boost with the coming together of robotics and informatics in the biological research sphere (haquin et al. ) . for the synthesis of an effective drug, by means of medical structural genomics, the protein which drug will affect should be well defi ned experimentally in both structure and functional aspects as the potential target. the protein should not only be well characterized structurally but also should be well defi ned as essential for the survival of the pathogen. once drug and its protein target in a microorganism is identifi ed, the fi eld of medical structural genomics provides rapid mechanisms using high-throughput x-ray crystallography and nmr assay system to fi nd the ligand-bound structures. to identify such drug targets, it is very essential to know the complex host and pathogen interaction. the mode the pathogen uses to cause the infections is very diffi cult to elucidate and is a long process. the technologies of rna interference and other gene knockout techniques should be complimented with experimental chemical biology approaches as microorganisms adopt multiple mechanisms for survival. this has been emphasized for the fact examples of efforts of scientist for targeting the fatty acid biosynthesis pathways of bacteria. at fi rst drugs were found to have high bioavailability and are potent against the bacterial replication in vitro. these compounds were subjected to be tested in animals and have been found to be not effective, the reason being that the bacterium utilizes the fatty acids present in their host vertebrates (brinster et al. ). hence, this study proves that there is need for more effective screening using the services of scientist from several spectra of biology like microbiologist, biochemists along with structural biologist, and chemical biologists to fi nd effective molecules and compounds which can eliminate the pathogen under proper infective conditions (hoon et al. ) . in pharmaceutical research scenario, it might also be possible that the drug target for a cell active compound is not known and then medical structural genomics provides a number of purifi ed protein targets which can be assayed for binding interaction with bioactive compound by means of number of biophysical techniques like thermal stability (ericsson et al. ). such efforts have already been carried out in the fi eld of protozoan pathogens. the program of medical structural genomics of protozoan pathogens ( http://msgpp.org/description.shtml ) has been initiated to screen for drugs for ten protozoan diseases. the initiative has screening of thousands of potential antimalarial drugs against about putative plasmodium falciparum protein targets by expressing them in bacterial expression system in the laboratory and deciphering their d structures. further, the com-pounds are assayed for their effectiveness in live organisms and further validated in appropriate disease model. the terms chemical validation and drugability are often used in conjunction in such cases. drugability is meant to be used how tractable a given drug target is for the development of a drug candidate, while chemical validation means that drugs have been found to be active in live organism. drugs which fulfi ll the abovementioned criteria are worth the effort, time, and resources. in the future more collaborative efforts between medical structural genomic centers and the chemical biology institutes would be possible with the availability of collection of phenotypically defi ned compound that would have proven anti-pathogen activity resulting in the synergistic target validation and hit to lead development using structure-based drug design. pharmaceutical industry has now taken fragment-based drug discovery methodology as an alternatively less expensive and at times more effective than high throughput screening. variety of methods like x-ray crystallography, nmr, surface fl uorescence polarization, plasmon resonance yield, and differential thermal denaturation have been used to obtain macromolecular structure to screen libraries of small fragment that are obtained from compounds that are building blocks of drugs and hence can be more drug like. the fragment-based drug discovery is based on the screening libraries of small molecules on the rule of three which has the molecular weight < da, the calculated log of octanol/water coeffi cient (clog p) < , and ≤ rotatable bonds and hydrogen bonds (rees et al. ; congreve et al. ) . protein-protein interactions are important for all biological processes. metabolic activities in the biological system are catalyzed by proteinbased enzyme where in certain cases their activities are regulated by modulation of an equilibrium of an alternate, nonadditive, functionally distinct oligomeric assemblies (morpheeins) that have now been described as mode allostery. the oligomerization from the protein-protein interaction need not lead to gain in free energy, and it has been found that small molecules can block or disrupt any protein-protein interaction that is necessary for biological systems, for example, being in the development of potent peptidomimetic inhibitor of hsv ribonucleotide reductase with antiviral activity (liuzzi et al. ). the discoveries have opened avenues where structure-based information can be used to develop small novel antimicrobial molecules that can be made which can target protein-protein interfaces (wells and mcclendon ) . an example of this technology has been used to fi nd small-molecule species-specifi c allosteric drugs for porphobilinogen synthase (pbgs). the oligomeric equilibrium for porphobilinogen synthase (pbgs) consists of high-activity octamers, low-activity hexamers, and two dimer conformations. in silico docking analysis from a small molecule library helped in selecting suitable compounds and molecules that had more affi nity for docking pbgs allosteric site and thus were subjected to testing in vitro . in one compound whose inhibition mechanism is species specifi c, conversion of pbgs octamers to hexamers was thus identifi ed (lawrence et al. ) . the above fi ndings have led the way of targeting of oligomeric enzymes in pathogenic organism bacteria. prime example is bacterial inorganic pyrophosphatases, which function as hexamer (kankare et al. ) . on the other hand, the eukaryotic, cytosolic, and mitochondrial pyrophosphatases function as homodimers (oksanen et al. ) and hence have different interfaces than its bacterial counterparts as evident from the study of evolutionary aspects of inorganic phosphatases. in this context the strategy has been to target the oligomeric state of the bacterial inorganic pyrophosphatase enzymes to inhibit their activity rather than their conserved active site (sivula et al. ) . the technology has opened a novel pathway where more antibiotics can be developed. the amount of knowledge of protein structures being generated is enormous; the need of the hour is dissemination of the knowledge databases among scientists and academic researchers on a worldwide scale. the protein structural know-how should be in the public domain without any constrains and copyright restrictions; also in addition the databases should be available free of any monetary charge. structural genomic projects the world over have solved the structures of many proteins and have made the knowledge available for world community by submitting the structures to protein data bank {pdb; http://www.wwpdb.org/ }. worldwide protein data bank is the site whose mission is to maintain a single protein structural public database which can be accessed by the global community (berman et al. ) . there is lot of structural data of protein-ligand complexes that is in private pharmaceutical industries not in the public domain. the economic incentives of drug discovery are driving force for this secrecy, but in this process there are a lot of valuable data that are duplicated and lots of valuable resources and energy efforts. the learning process from failures and successes in pharmaceutical corporate sectors is never known to the scientifi c community, and a major loss is of most valuable time. hence, as we can see, the drug discovery resources are not being adequately utilized across the academia and industry, so there is suggestion to have open-access industry-academia partnerships as possible mechanisms to overcome the problem. a frame work is need where both fi nancial and intellectual properties of the innovators are safeguarded when there structural data are deposited in the databases like pdb. a simple proposition would delay the release date of such structural data so that protection of intellectual property is feasible. policies which can bring into the public domain structural data from the corporate world could only be possible by the concerted efforts of all stakeholders from industry, national, and international research funding agencies from all nations (edwards et al. ). apart from easier dissemination of structural information related to infectious diseases and collaboration of structural biologist with medical chemist and molecular biologist, there is need for development of automation in several technologies to bring about unprecedented growth in the new drug discovery. fragment-based drug design needs the support of high throughput technologies such that along with structural genomics, there will be more success in the determining protein-ligand structure determination. decades of experience have shown that the infectious diseases would emerge with more vigor and virulence. when the diseases are not controlled, then it would take a considerable toll of human health both in terms of mortality and morbidity. the life would be affected by emerging microbial disease-causing pathogen whatever the region, ethnicity, lifestyle, socioeconomic status, and ethnic background. hence, the threat from infectious diseases is real and the situation is overtly challenging. the great advances in the genetics, genomics, and proteomics have the potential to take up the challenge in the coming decades. it is evident that these technologies have the potential to change the fi eld of diagnostics, treatment, and discovery of drugs and vaccines. the need of the hour is to strengthen the public health 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cord- -psqmqpff authors: erdem, guliz; buckingham, don; drewes, kevin; kenney, brian; gibson, annika; gallup, nathaniel; barson, william title: decreasing the duration of discharge antibiotic treatment following inpatient skin and soft tissue abscess drainage date: - - journal: pediatr qual saf doi: . /pq . sha: doc_id: cord_uid: psqmqpff introduction: skin and soft tissue abscesses do not require prolonged systemic antimicrobial treatment following drainage. we aimed to decrease the duration of discharge antibiotic treatment to less than days following inpatient incision and drainage of uncomplicated abscesses. methods: a new treatment protocol that defined uncomplicated abscesses, as well as inclusion and exclusion criteria, was created to monitor the accurate duration of prescribed therapy at discharge. we implemented a treatment algorithm that takes into account the epidemiologic changes in microbial etiologies and the presence of systemic findings for patients after surgical incision and drainage. we used control charts to assess the impact of the interventions. results: four hundred and eighteen patients were discharged following abscess drainage from our inpatient infectious diseases unit in . the patients were months to years of age. only ( %) patients had prescribed discharge antibiotic treatment courses that were less than days [range – days, median days (iqr , )], and the average prescribed course at discharge was . days. during the study period, we significantly decreased the average duration of discharge antibiotics to . days in all patients (p = . , % ci: − . to − . , difference of means − . ). the discharge treatment duration of patients with uncomplicated abscess was shorter at . days [range – days, median days, (iqr , )]. prescription compliance to less than days treatment course at discharge increased from the baseline of % to % overall. conclusions: standardizing definitions of uncomplicated skin and soft tissue abscesses was critical to the success of this project. in addition to possible improved treatment adherence and decreased side effects, our protocol led to decreased patient care costs with no documented changes in readmission rates. skin and soft tissue infection (ssti) is one of the most frequent indications for antibiotic use in infectious diseases and results in more than million emergency department visits annually. sstis have been on the rise, paralleling the observed increase in infections due to methicillin-resistant staphylococcus aureus. , sstis generally present with cellulitis and/or abscesses. skin and soft tissue abscesses are distinct as they require incision and drainage (i&d) for optimal management. the appropriate strategy for the antimicrobial treatment following i&d of abscesses has not been well established. studies have demonstrated that antibiotics may not be required for the care of an abscess after an appropriate i&d but indicated for other non-abscess sstis. , [ ] [ ] [ ] the infectious disease society of america (idsa) guidelines also recommend a shorter course or no antibiotic treatment following drainage of abscesses. however, recently, cure rates for simple abscesses due to s. aureus treated with i&d plus clindamycin or trimethoprim-sulfamethoxazole (tmp-smx) were found to be significantly higher than in patients who were treated with i&d plus placebo. , published ssti treatment studies also demonstrated that shorter durations of or days were as effective as days of treatment. , the treatment of abscesses presents an additional complexity as there is usually a residual area of cellulitis following abscess drainage that may require further antibiotic treatment. we defined a short course of therapy as days or less, which is in line with the idsa recommendations. additional rationales for shorter courses of therapy include limiting the development of bacterial resistance, decreasing the total cost burden of care, and reducing adverse effects associated with antibiotic therapy. we observed that prolonged antibiotic use following drainage of skin and soft tissue abscesses was frequent in our institution. our primary aim was to decrease the duration of prescribed antibiotics for patients discharged from our inpatient infectious diseases unit following i&d of simple skin and soft tissue abscesses to days or less. our balancing measure was to monitor the readmission rates due to skin and soft tissue abscess within month of discharge for patients receiving a shorter course of treatment and compare it to the readmission rates. the section of pediatric infectious disease at nationwide children's hospital (nch) launched this quality improvement project. the nch institutional review board determined that this project was quality improvement work and not human subjects research. therefore, the irb did not require review and approval or written informed consent. nch is one of the largest free-standing children's hospitals in the nation, serving a population of over million people in central ohio. the pediatric infectious diseases section is unique, with a dedicated inpatient infectious disease unit. the inpatient infectious disease unit has ~ , discharges annually. a significant number of these inpatients have admission diagnoses of sstis. patients evaluated at local urgent care clinics or emergency rooms with skin and soft tissue abscesses are frequently referred to nch for admission to the inpatient infectious disease unit for antibiotic therapy and i&d of the abscess. these patients are then discharged shortly after the procedure on an oral antibiotic treatment course. the emergency room physicians and/or the consulting pediatric surgeons consider admission to the inpatient unit for patients who failed to respond to initial outpatient antibiotic treatment, and/or had an abscess that required drainage requiring appropriate in-patient-administered sedation. we assembled a multidisciplinary team, which included infectious disease physicians, pediatric surgeons, nurses, clinical pharmacists, and quality improvement specialists. the team brainstormed rationales for prolonged course of antibiotic treatment and organized these into an affinity diagram revealing key drivers: accurate baseline duration of prescribed outpatient therapy, physician prescribing culture, physician and staff awareness and understanding, and effective monitoring of compliance with the suggested standard treatment protocol by all faculty members (fig. ) . we considered individual physician management and treatment styles and identified concerns for a shorter course of treatment, such as the risk of infection progression and recrudescence of infection. we discussed the study protocol with aims during multiple infectious disease section meetings that initiated a positive change even before the implementation of the official protocol. during this period, we identified the need for a treatment algorithm addressing individual and group concerns. these concerns included the possibility of a more severe infection in young patients, patients with systemic signs including persistent fevers, and those with severe cellulitis. we discussed the definition of an uncomplicated abscess and the approach to treatment in patients with cellulitis despite a drained abscess. additional concerns included the possibility of inadequate treatment, access to care for families living in remote areas, and the possibility of readmissions. we then developed inclusion and exclusion criteria for our treatment protocol to which all infectious disease physicians agreed (table ). our project included patients between months to years of age who were admitted with skin and soft tissue abscesses and discharged from the infectious diseases inpatient unit following i&d performed during the hospitalization with no or minimal residual cellulitis at the time of discharge (uncomplicated abscess). we defined minimal residual cellulitis as cm or less at the time of discharge. we decided that these patients could be discharged with days or less of antibiotic therapy. beginning january , we serially introduced interventions including plan, do, study, act cycles. we finalized the education of faculty, fellows, and staff for shortened antibiotic treatment by february . the treatment algorithm following abscess i&d that takes into account the epidemiologic changes in microbial etiologies and the presence of systemic findings was implemented in march (fig. ) . during the study period, any inpatient antibiotic administered after i&d but before discharge was included in calculating the total discharge antibiotic duration. the primary goal was to decrease the duration of discharge antibiotic treatment following inpatient i&d of skin and soft tissue abscesses by discharging patients with uncomplicated abscesses after or fewer days of antibiotics. we reviewed patient discharge orders and, when available, reviewed nch pharmacy prescription dosing to assess the duration of treatment. the nch information services department queried the electronic medical record (emr) for defined inclusion and exclusion criteria, and one of the physician team members reviewed charts monthly to ascertain the number of patients identified. we generated control charts to track the performance of individual physicians, to analyze shifts, to measure the impact of the interventions on the prescribed duration of antibiotic treatment following i&d, and the readmission rate to nch due to the persistence or recurrence of ssti within month of discharge. we used a -sample t test for analysis of baseline data (see supplemental digital content at http://links.lww.com/pq /a for tables). minitab . software was used to compare data before and after project implementation (supplemental digital content at http://links.lww.com/pq /a for table ). during monthly qi meetings, we discussed the process, and addressed unforeseen barriers such as the inaccurate identification of patients with uncomplicated skin and soft tissue abscess. individual providers received specific feedback. during the pre-intervention period, patients were admitted and discharged following abscess drainage from our inpatient infectious disease unit. the patients were between months to years of age. only ( %) patients had a discharge antibiotic treatment course that was less than days (range - days, median days), and the average prescribed treatment course at discharge was . days. during the study period, may , , through december , , patients were admitted with the diagnosis of ssti and abscess. the average duration of prescribed discharge antibiotics in these patients was . days (range - days, median days, iqr , ). physician prescription compliance to less than days prescribed treatment course at discharge increased to %. of these patients, patients fulfilled the protocol inclusion and exclusion criteria. the discharge treatment duration of these patients (uncomplicated abscess) was shorter at . days [range - days, median days, (iqr , ), and the prescription compliance of or fewer days of antibiotic at discharge increased to % (fig. ] . we excluded patients as they had more serious infections with diagnoses such as tenosynovitis and osteomyelitis or residual cellulitis following i&d larger than cm. we did not observe any prolongation of the length of stay after we started our project in comparison to baseline. patients with prolonged hospital stays had either complicated infections that required exclusion from the study or had oral intolerance or social problems requiring an extension of their stay for continued parenteral therapy. decreasing the duration of antibiotic treatment led to no significant change in readmission rates. during fig. . treatment algorithm developed by infectious disease faculty. *fever > °f with tachycardia > sd for age over hours of hospitalization, diaphoresis, fatigue, anorexia, and vomiting that is not due to medication taste. r, resistant. and the first months of , the readmission rate due to ssti with abscess following i&d within month of discharge was . %. during the first months of the study, the readmission rate was . % (p = . , % ci − . to . for before and after intervention periods, the difference between means, . ); however, the overall readmission rate to our unit was higher. a shorter treatment duration possibly increased treatment adherence and tolerance to oral medications preventing potential readmissions. during the study, a -day treatment course of oral clindamycin based on a bodyweight of kg would cost $ . (the oral suspension would cost $ .) the decrease in treatment duration from baseline of . days to days saved an estimated - usd per patient. based on the decreased treatment duration and patient numbers since may , the protocol saved families and payors , - , usd estimated annually. outpatient treatment duration after hospitalization for sstis among pediatric patients is not well studied. available evidence suggests that shorter courses of treatment could be used after appropriate abscess drainage. , , in a few studies, tmp-smx or clindamycin, compared with no antibiotics, reduced the absolute risk of treatment failure by % at month. in patients who were cured, these antibiotics reduced the absolute risk of recurrence at months by ~ %. however, in another recent study performed in adults, no significant reduction was found in treatment failure with the addition of antibiotics following drainage of abscesses in the emergency room. most studies and the idsa guidelines do not adequately address the outpatient treatment of abscesses in children in whom there is an area of cellulitis surrounding the abscess site. , - a recent meta-analysis including both children and adults found moderate-to-high quality evidence that in patients with "uncomplicated" skin abscesses treated with i&d, adjuvant antibiotic therapy lowers the risks of treatment failure, abscess recurrence, hospitalization, additional surgical procedures, and pain during treatment; but increases the risk of overall antibiotic (tmp-smx and clindamycin) gastrointestinal side effects. however, the authors did not define "uncomplicated" infection. standardizing the treatment of ssti and the uncomplicated abscess was the most challenging intervention but was critical in achieving physician consensus and the success of our project. after we reached a consensus on the definition, we created the treatment algorithm. following these crucial steps, the implementation was smooth, and we achieved our goal even before our official start date. in addition to possibly increasing treatment adherence and decreasing side effects, decreasing the duration of antibiotic treatment will lead to decreased patient care costs. ssti and abscesses are an important application of inpatient and outpatient antibiotic stewardship. the definitions of simple ssti and abscess in children, fig. . average days of prescribed antibiotic therapy at discharge following i&d. continuous/variable data (average days) measured using shewhart xbar chart calculating upper and lower control limits to signal special cause variation. however, are quite variable between physicians. highly variable provider prescription habits, as seen in our baseline data and concern for risk avoidance, especially with the public scares associated with methicillin-resistant staphylococcus aureus, continue to drive unnecessary use of antibiotics. , , our study was unique with the creation of stringent definitions and exclusion criteria. although our results may be limited as a single-center study, the specific definition of uncomplicated abscesses in children after application of exclusion criteria and ease of its adaptability will potentially guide other institutions to implement similar measures. we are implementing a similar process in other areas of our healthcare system (inpatient units, emergency and urgent care, outpatient clinics). presentation of this qi project at local meetings brought further involvement from community physicians, emergency room physicians, and pediatric surgeons. the study team started collaborations with community physicians to create a diagnosis and management framework that will utilize preventive efforts to decrease recurrent sstis such as patient and family education regarding appropriate hygiene, use of chlorhexidine baths, and treatment of uncomplicated ssti. revised staffing and scheduling permitted our emergency room to have additional i&ds done in the emergency room, preventing the need for inpatient admission. collaboration is in place toward the establishment of an outpatient multidisciplinary clinic that will be equipped to perform i&ds of uncomplicated skin and soft tissue abscesses within our hospital system. we did not review the emr in all of the patients identified during the pre-intervention period. the emr queries were done with the defined exclusion and inclusion criteria, but we did not know the actual number of patients during the baseline period with the diagnosis of uncomplicated abscess who were treated with days or less of antibiotics at discharge. we also did not know the patient's severity of illness. the median treatment duration of days during the pre-study period was consistent with clinical observations of prolonged antibiotic treatment courses. also, during this baseline period, documentation of drainage procedures may not have been accurate as some patients might have had surgical drainage at an outside facility, although this is very unlikely. there were no changes in hospital admission practices before and during our study period. although we did not observe significant changes in the study population in terms of payors and demographics during the study period, these factors were not fully analyzed during the baseline period. nch follows all readmissions to our facilities within month of discharge, and patients routinely seek follow-up care within our system if any concerns arise following their discharge. although this passive collection of data may not capture out-of-network admissions, these are very rare, considering that the majority of our patient population reside in regions served by nch. we strongly believe that this work can be expanded to other healthcare organizations, although it is difficult to determine how well our conclusions will generalize to other settings. the authors have no financial interest to declare in relation to the content of this article. national hospital ambulatory medical care survey: emergency department summary methicillin-resistant s. aureus infections among patients in the emergency department dmid - team. a placebo-controlled trial of antibiotics for smaller skin abscesses incidence of skin and soft tissue infections in ambulatory and inpatient settings trends in emergency department management of skin abscesses high prevalence of methicillin-resistant staphylococcus aureus in emergency department skin and soft tissue infections treatment of cutaneous abscess: a double-blind clinical study infectious diseases society of america. practice guidelines for the diagnosis and management of skin and soft tissue infections: update by the infectious diseases society of america trimethoprimsulfamethoxazole versus placebo for uncomplicated skin abscess comparison of shortcourse ( days) and standard ( days) treatment for uncomplicated cellulitis tedizolid phosphate vs linezolid for treatment of acute bacterial skin and skin structure infections: the establish- randomized trial appropriateness of antibiotic management of uncomplicated skin and soft tissue infections in hospitalized adult patients decreasing duration of antibiotic prescribing for uncomplicated skin and soft tissue infections antibiotics after incision and drainage for uncomplicated skin abscesses: a clinical practice guideline effectiveness of outpatient antibiotics after surgical drainage of abscesses in reducing treatment failure impact of systemic antibiotics on staphylococcus aureus colonization and recurrent skin infection randomized, controlled trial of antibiotics in the management of community-acquired skin abscesses in the pediatric patient trimethoprim-sulfamethoxazole therapy reduces failure and recurrence in methicillin-resistant staphylococcus aureus skin abscesses after surgical drainage are antibiotics necessary after incision and drainage of a cutaneous abscess antibiotics for uncomplicated skin abscesses: systematic review and network meta-analysis identifying targets for antimicrobial stewardship in children's hospitals skin and soft-tissue infections requiring hospitalization at an academic medical center: opportunities for antimicrobial stewardship we appreciate the assistance of nationwide children's hospital infectious disease physicians, nurses, pediatric surgeons, and lindsay landgrave, pharmd. key: cord- -b yywn f authors: hasan, ashfaq; praveen, sai haranath; tarke, chandrakant; abdullah, fahad title: clinical aspects and principles of management of tuberculosis date: - - journal: mycobacterium tuberculosis: molecular infection biology, pathogenesis, diagnostics and new interventions doi: . / - - - - _ sha: doc_id: cord_uid: b yywn f tuberculosis over the ages, has killed more people than any other infection has. notwithstanding the advances in modern science, clinical diagnosis sometimes remains elusive, owing principally to the frequent paucibacillary occurrence of the disease and the slow doubling time of the organism; empiric treatment is often fraught with risks in the era of increasing drug resistance. this chapter attempts to provide an overview of the disease, beginning with the pathogenesis and its protean clinical presentations. it also discusses the recent evolution of molecular methods that have lately provided an impetus to early diagnosis with a clear opportunity to unmask drug resistance before initiating “blind”, potentially ineffective, and sometimes harmful treatment with standard therapy. the chapter also provides insight into tuberculosis in special situations, and discusses briefly the treatments in uncomplicated cases as well as in special situations, and in instances of drug resistance. preventive methods including current and upcoming vaccines are mentioned. finally, a short discussion of the sequelae of tuberculosis—which have the potential to be confused with active disease—is presented. tb can involve all organs except the nails, hair and teeth [ekaterina kulchavenya. ther adv infect dis. apr; ( ): - ]. pulmonary tb is the most common form of tb. the symptomatology of tb has to do with its pathogenesis, the specific organ system involved and the duration of the disease. primary tb, which occurs in the mycobacterium-naive individual, usually presents with a frequently occult primary focus in the peripheral lung parenchyma (stead's focus) accompanied by a pleural effusion; or by a primary focus-frequently inapparent-in the lower part of the upper lobe or the upper part of the lower lobe (ghon's focus) accompanied by lymphadenopathy. other manifestations of primary tb such as erythema nodosum or phlyctenular conjunctivitis may be present. in young children with immature cellular immunity, or in immunocompromised individuals, the process may evolve to progressive primary disease. symptoms and signs relate to the compressive effect of enlarged lymph nodes on adjacent structures (collapse or hyperinflation of a lobe or segment), or rupture of caseating lymph nodes into a bronchus, with bronchiectasis later supervening in such a lobe. post-primary disease, the typical adult form of tb, usually occurs by reactivation of a dormant focus-or less frequently, by reinfection; the better aerated lung apices are preferentially involved. the classical triad of the constitutional symptoms of tb (fever, night sweats, weight loss)-most usually of several weeks' duration-is present in a high proportion of patients (heemskerk et al. ) . the extent of disease at the time of first diagnosis may be variable, from patchy consolidation to a large cavity. this not only reflects the protean pulmonary forms of the process but also has to do with host immunity, the virulence of the strain and, most of all, with the time elapsed between disease onset and diagnosis. cavitation is an important milestone in the timeline of the post-primary pulmonary tuberculosis. with ingress of o -rich air into a fresh cavity (caused by the coughing out of a caseous collection), the aerobic mycobacterium is presented with an opportunity to multiply manifold in an aerobic environment: the infectiousness of the subject (and the possibility of a positive diagnosis on sputum testing) commensurately increases (golub et al. ) . cavitation also increases the propensity to haemoptysis (which may sometimes be massive) and that of cavitary colonization with a fungal ball (mycetoma) later on in healed disease. one third of all individuals affected with post-primary tb die within a few months ("galloping consumption") (reported tuberculosis in the united states, ). the remainder either go on to develop a chronic pattern with a more gradual progressive decline or undergo spontaneous remission of the process and restoration to health. with chronicity, fibrosis is common. disseminated tb, which often casts "miliary" shadows in the lungs, occurs due to haematogenous dissemination following either primary or post-primary tb. the name derives from the resemblance of the widespread granulomatous lesions to millet seeds (seen in pathological specimens as - mm yellow granules). symptoms may be nonspecific and depend on the site and degree of organ involvement. hepatosplenomegaly, lymphadenopathy and pleural effusions may be present. fundus examination, often neglected, will frequently show choroid tubercles, which are virtually diagnostic of the condition in a likely setting. diagnosis often hinges on microbiology from broncho-alveolar lavage (bal) or on biopsy of involved organs (lewinsohn et al. ) though it may occasionally be made on sputum (sponaneously expectorated or induced). disseminated tb disseminated tb should always raise suspicion for an accompanying immune deficiency such as hiv disease. sometimes an occult disseminated form of tb ("cryptic miliary tb") presents as a "fever of unknown origin", usually in the elderly or immunocompromised patients. in difficult cases (as with the classic miliary form), bone marrow or liver biopsy with mycobacterial cultures may be diagnostic. unlike the post-primary form of disease, untreated miliary tb is predictably fatal. extra-pulmonary tuberculosis has been increasingly seen since the advent of the hiv epidemic. tb can involve any organ of the body (other than nails, hair and teeth). organ systems typically involved include pleura (pleural effusions), lymph nodes (generally cervical or mediastinal), airway (endobronchial tuberculosis), skeletal (joint or vertebral involvement, sometimes with a psoas abscess), gastrointestinal, genitourinary, meningeal and pericardial involvement. symptoms pertain to the system involved, but diagnosis may be difficult unless a high degree of suspicion is maintained. tissue or fluid samples from the involved organs with staining, mycobacterial cultures or molecular probe assays are often diagnostic although radiological patterns in specific cases may be very suggestive of the process (e.g. vertebral involvement with a paraspinal abscess) (lewinsohn et al. ) . the diagnosis of tuberculosis, especially in the developed nations, rests on the keystone of suspicion. physical examination is generally unrewarding. auscultation of the lung typically underestimates the lung problem relative to that seen on imaging. with a pleural effusion, breath entry is typically decreased, with a flat note over the effusion. cavernous bronchial breathing may be detected over a cavity, and tubular bronchial breathing over an area of consolidation or dense fibrosis. the radiologic features in the various forms of pulmonary tb have already been discussed above under the relevant heads. microbiological isolation of the mycobacterium tuberculosis on culture has been the only definitive test for tb thus far, though it could be argued that molecular probes for specific mycobacterial genes and other technologies (discussed below and also elsewhere in this book) offer viable and more attractive options for diagnosis. presumptive diagnosis is typically achieved by microscopy (usually of sputum, but also of fluid obtained by bal and other means) (pai et al. ). mycobacteria, not being stainable by "conventional" stains, require a modified acid stain (the ziehl-neelsen method) in order to be visualized; led microscopy though relatively expensive, by making the bacilli easy to see under low power, enables more fields to be scanned in a shorter period of time, and thus increases the sensitivity of microscopy several-fold (bhalla et al. ) . conventional culture methods are slow ( - weeks, less by radiometric assays), and frequently there is a compelling need to start appropriate anti-tubercular therapy as early as possible. rapid culture techniques are now in universal use. they use liquid rather than solid media. the mycobacteria growth indicator tube (mgit) method takes days rather than weeks and facilitates drug sensitivity testing. since relapses (see below) occur in approximately % of patients after months of standard therapy, it is a moot point whether establishment of minimum inhibitory concentrations (mics) in the presence of a "critical concentration" of drug is relevant in selected cases (colangeli et al. ) . automated nucleic acid amplification technology (naat) has the potential of amplifying even a fragment of mycobacterial dna rapidly (in h) and has revolutionized tb diagnosis. in its currently available form, the genexpert test is intended specifically to diagnose mycobacterium tuberculosis (and thereby differentiate it from other mycobacteria such as environmental mycobacteria), and also presumptively diagnose rifampicin resistance. though not invariable, rifampicin resistance also implies inh resistance. together, rifampicin and inh resistance fulfil the diagnosis of multiple drugresistant tb (mdr-tb). thus a positive genexpert test makes a presumptive diagnosis of mdr-tb (steingart et al. ). the test is more sensitive than direct microscopy and extremely specific (steingart et al. ). the test is not infallible, however, and any result that is discordant with the clinical picture should either be repeated or further information sought using another modality. false-positive naat results can occur due to laboratory contamination. importantly, naat can detect nucleic acid from dead non-viable bacilli, and so a positive test after completion of the course of treatment has no relevance in that situation (boyles et al. ) nor is it of relevance in monitoring response to treatment (friedrich et al. ) . it is important to realize that naat is not a substitute for afb smear and culture testing; culture is essential for species identification and for drug susceptibility testing (cheng et al. ) . a more sensitive version of xpert has been developed. the line probe assays (lpa) can permit rapid identification of specific gene markers associated with rifampicin resistance alone or in combination with isoniazid, and provide clinically relevant information about the level of inh resistance (low level associated with the inh-a gene; versus high level associated with the kat-g gene) (who treatment guidance for drug resistant tuberculosis ). definitive diagnosis has traditionally hinged on the culture characteristics of mtb: species discrimination can be achieved on the basis of colony morphology as well as on the basis of biochemical tests performed on the culture. conventional culture (lowenstein-jensen medium and its variants) is capable of detecting as few as ten bacteria per millilitre with the sensitivity and specificity of sputum culture approximating and %, respectively (morgan et al. ) . following initial culture, species identification is done by any of the following techniques: biochemical methods (testing, nucleic acid hybridization probes, high-pressure liquid chromatography or mass spectrophotometry). drug sensitivity testing is subsequently carried out, usually at a reference laboratory (shinnick and good ) to first-line anti-tubercular agents, but sometimes to second-line agents as well when resistance to components of first-line anti-tubercular agents has been documented. in individuals living with hiv who have cd counts < cells/mm , or those who are immunocompromised, mycobacterial cultures of blood and urine should complement conventional testing. point-of-care urinary detection of lipoarabinomannan, a component of the mycobacterial cell wall (urine lam test) may be useful for hiv-infected individuals, and its use may possibly confer a mortality benefit (reported tuberculosis in the united states, ). the future of point-of-care devices is next-generation sequencing, and, perhaps, innovations like detection of volatile organic compounds in exhaled breath (garcia-basteiro et al. ) serological tests (tests for antibodies against tb) have poor sensitivity and specificity; false-positive tests are ubiquitous, and serologic testing for the diagnosis of tb is discouraged by the who. a pleural fluid adenosine deaminase (ada) > u/l has been reported to be % sensitive and % specific for the diagnosis of pleural tb in lymphocytic exudates (garcia-zamalloa and taboada-gomez ). tb infection can rapidly progress to disease in infants and young children (progressive primary tb). mortality is high in early childhood because of the severe forms of tb (such as miliary tb and meningeal tb) that occur more frequently in young children. progressive primary tb is a serious consequence of primary tuberculosis. consolidation or bronchopneumonia is more common than cavitary disease in children. haematogenous dissemination leading to miliary tb is also more common in infants and young children. tubercular pleural effusion, however, is less common in children below years of age. central nervous tb is the most serious form of childhood tb (prevention ). the presentation is usually with nonspecific symptoms such as fever, headache, drowsiness and irritability, but in advanced cases, vomiting, neck rigidity, seizures, focal neurologic deficit and coma may supervene. since sputum samples for diagnosis are difficult to obtain in young children (children tend to swallow sputum rather than expectorate), gastric washings can rather be sent for microbiological examination. a ppd test that is greater than mm in bcg-unvaccinated children and > mm in bcg-vaccinated children is considered positive. (targeted tuberculin testing and treatment of latent tuberculosis infection. this official statement of the american thoracic society was adopted by the ats board of directors, july . this is a joint statement of the american thoracic society (ats) and the centers for disease control and prevention (cdc). this statement was endorsed by the council of the infectious diseases society of america. (idsa), september , and the sections of this statement .) the principles of treatment of tuberculosis in children are similar to that of adults. paediatric tb patients should be monitored carefully for ethambutol-induced ocular toxicity, owing to the fact that children are less likely to report visual impairment than adults. in a prospective study of children on multidrug-resistant tuberculosis, children had lower serum concentrations in spite of higher dosing of moxifloxacin, a fact that was ascribed to increased drug elimination in children. quinolones have also been known to rarely cause arthropathy and tendon rupture. more recent studies have shown that most quinolones are quite well tolerated but very specific and narrow indications are present for quinolone use in children (patel and goldman ) . tuberculosis in pregnancy has important implications for the mother and child (loto and awowole ) . the diagnosis of tuberculosis in pregnancy can be challenging, since many of the symptoms of early tb may be confounded by pregnancy; for instance, the normal weight gain in pregnancy may temporarily mask the associated weight loss. chest radiograph is not an absolute contraindication and when necessary may be carried out with "abdominal shielding" of the fetus. the complications of tb in pregnancy include early spontaneous abortion, intrauterine growth retardation, preterm delivery, low birth weight and increased neonatal mortality. congenital tb is rare, but can be associated with high perinatal mortality. first-line oral drugs, i.e. isoniazid, rifampicin, ethambutol and pyrazinamide, can all be used during pregnancy safely. streptomycin and other aminoglycosides have been proven to be potentially teratogenic in pregnancy. they are also capable of causing eighth nerve paralysis, with deficits ranging from mild hearing loss to bilateral deafness (loto and awowole ) . concerns have been raised about the use of fluoroquinolones in pregnancy even though the weight of the evidence seems to point toward safety (acar et al. ) tb is considered an aids-defining disease [centers for disease control and prevention. appendix a: aids-defining conditions. mmwr. ; (rr ): ]. the risk of developing tb is estimated to be between and times greater in people living with hiv than among those without hiv infection. hiv and tb have a salutary impact upon each other and expedite each other's progression. the risk of progressing from latent to active tb is estimated to be between and times greater in people living with hiv than among those without hiv infection (global tb report ). against the backdrop of hiv infection, the rate of progression of tb from the acquisition of infection to full-blown disease may take weeks, rather than years-as is the case in hiv-negative individuals (mayer and dukes hamilton ) . it is important to realize that tb can occur at all "stages" of hiv disease. the clinical presentation of hiv patients who have relatively high cd counts is no different to that which occurs in individuals without hiv. such individuals manifest with the classical manifestations of post-primary tuberculosis such as upper lobe infiltrates. on the other hand, lower lobe involvement, pleural effusions and intrathoracic lymphadenopathy are common in individuals with low cd counts (typically < /μl). indeed the chest x-ray may sometimes only show vague interstitial infiltrates or even be normal (mayer and dukes hamilton ) . taken together, the fact that in advanced hiv disease (a) the sputum is less likely to be positive for afb (b) the ppd is usually non-reactive (c) the x-ray abnormalities are likely to represent other opportunistic infections or even non-infective conditions associated with hiv disease and (d) histopathology of involved tissues is characterized by lack of typical granulomata; these considerations make the diagnosis extremely challenging in this setting. in addition, there is increased frequency of extra-pulmonary tb among hiv-positive individuals. frequently, a positive naat (genexpert) test is the justification for starting treatment. however it must be cautioned that even a negative naat test cannot convincingly rule out disease, and, given that delays in treatment may be fatal, the decision to initiate treatment is sometimes taken on clinical grounds. the treatment of tuberculosis differs from the treatment of most other infections in certain respects. multiple drugs are required in a regimen since spontaneous mutations can lead to resistance to the action of one or more drugs. also, because the bacterium is relatively slow growing, it takes longer to achieve bacteriologic sterility. multidrug therapy, the norm for tb, has been very effective, with a modest rate of relapse (colangeli et al. ) . the standard four-drug regime ("short course") comprises a -month intensive phase with the four front-line drugs (rifampicin, isoniazid, ethambutol and pyrazinamide), followed by a continuation phase with the drugs (minus pyrazinamide and possibly ethambutol) for a further months. the four front-line drugs have been chosen based on their efficacy in rapidly reducing the number of organisms initially (during the initial phase), thus reducing infectivity; and on their sterilizing potential (the ability to eradicate viable bacteria completely and so prevent relapses); and their relative lack of side effects (see table . ). these drugs are combined into regimens. the six classes of second-line agents (fluoroquinolones, the aminoglycosides, capreomycin, ethionamide and prothionamide, para-amino salicylic acid (pas), cycloserine and terizidone) have a rather lower efficacy and a higher propensity for side effect and drug intolerance. several other antibiotics of uncertain efficacy have also been categorized as anti-tubercular agents and have a role in treating multidrug-resistant tb (mdr-tb) (see table . ). two new agents, bedaquiline (a diaryl-quinolone) and delamanid (a nitroimidazole), are now approved for the treatment of mdr-tb. the who recommends using a daily regimen and fixed-dose combinations (guidelines for treatment of drug-susceptible tuberculosis and patient care ). administration of the drugs on a daily basis both during the intensive and during the continuation phase is preferable although daily administration during the initial phase and intermittent (thrice weekly) administration during the continuation phase is also acceptable (guidelines for treatment of drug-susceptible tuberculosis and patient care ). intermittent administration of drugs (especially in the initial phase) is not offered in the presence of hiv disease. if at the end of the intensive phase the bacteria are sensitive to the three most important agents (isoniazid, rifampicin and pyrazinamide), ethambutol may be discontinued (nahid et al. ). however, drug testing for three of the four frontline drugs for each patient at the end of the intensive phase is impractical, and limited testing (genexpert) is usually performed initially in those patients whose sputum remains positive. there is evidence to show that extending the continuation phase by months (making up a total duration of treatment of months) helps in preventing relapse in those patients who have cavitation on initial chest x-rays; and also in those who show positive cultures at the end of the initial phase of treatment (benator et al. ) ; as well as in those whose medication given during the initial phase did not include pyrazinamide. anti-tubercular drugs require to be supplemented with carefully monitored steroid therapy in two circumstances: tubercular meningitis (a short course of dexamethasone or prednisolone is typically given, tapered over to weeks) and tuberculous pericarditis (guidelines for treatment of drug-susceptible tuberculosis and patient care ). since many patients cannot be relied upon to regularly take their drugs, and irregular intake of drugs has the potential to result in drug resistance (see treatment failure and relapse; and drug resistant tb, below), it is imperative to ensure adherence to the regimen. directly observed therapy, short-course (dots) is the direct observation by another person, of the patient taking the medication (chaudhuri ) . the use of dots has improved adherence in subgroups of patients such as tb with hiv or if dots was at the site of dots centre or provider location. self-administered therapy (sat) modified with some form of monitoring incorporated into the process shows some promise. although dots could be administered by a family member, the preferred person is a trained lay provider or healthcare worker (guidelines for treatment of drug-susceptible tuberculosis and patient care ). the treatment of tb in hiv disease merits special consideration. antiretroviral therapy (art) should be started irrespective of the clinical stage of hiv disease and cd count. anti-tubercular therapy (att) should precede the commencement of art. art should then be commenced as soon as it is evident that att is being tolerated (typically between weeks and months). the immune reconstitution inflammatory syndrome (iris) is sometimes seen with the returning immune competence that follows art; an increased immune response to tubercle bacilli or antigens occurs. iris usually occurs between and months of the commencement of art and is associated with a decrease in viral load and an increase in cd + t cell count. there is a worsening in the clinical picture weeks or months into treatment, with an increase in the size of lymph nodes, development of pleural effusions and features of noncommunicating hydrocephalus in a patient with tb meningitis. although most patients with iris have mild to moderate symptoms, iris, especially when related to tb meningitis, can be life-threatening. an "unmasking iris" may occur in patients with unsuspected tb (raviglione ) . treatment of iris includes addition of steroids (which probably work by decreasing the levels of pro-inflammatory cytokines) and the continuation of att and art. with both att and art on board, drug-drug interactions especially involving rifampicin (by induction of the cytochrome p system) may occur. rifamycins induce the metabolism of non-nucleoside reverse transcriptase inhibitors and protease inhibitors. rifampicin is a more potent inducer of the cytochrome p system than rifapentine, which in turn is more potent than rifabutin. despite potential drug interactions, rifamycins should nevertheless be included in tb regimens, with dosage adjustment if necessary. rifabutin is the preferred rifamycin in hiv-positive individuals. host-directed therapy to modulate the immune response to tb is an active area of research (kaufmann et al. ) . the use of an anti-diabetic drug-metformin, for example-is being investigated. also, studies of autologous mesenchymal stromal cell infusions is being investigated in mdr and xdr-tb (skrahin et al. ). an approach using high-altitude sanatoria was also explored (murray ) in a throwback to the pre-anti-tubercular chemotherapy era. study using atypical mycobacterial injection in tuberculous did not show any major outcome differences from placebo although steroids did decrease the subsequent development of constrictive pericarditis (mayosi et al. ) . given the role that vitamin d plays at the level of the antigen-presenting cell, the role of vitamin d deficiency as a possible player in tb predisposition has recently come into focus; indeed a recent meta-analysis has revealed that vitamin d supplementation in fact did not affect time to sputum culture conversion overall, though it did accelerate sputum culture conversion in patients with multidrug-resistant pulmonary tuberculosis (jolliffe et al. ). patients with tb may be admitted to an icu for a variety of reasons, including respiratory failure, multiorgan failure, decreased consciousness associated with tubercular meningitis, pneumothorax, cardiogenic shock (due to massive pericardial effusion) and liver or kidney failure due to a drug reaction induced by att. confluent tuberculous bronchopneumonia and tb ards are less common causes of respiratory failure (hagan and nathani ) . tuberculosis treatment is especially challenging in critically ill patients due to potential for poor gastric absorption and the high rates of organ dysfunction and drug toxicity in this subset of patients. deciding the optimal regimen and dosing becomes challenging in the presence of concomitant hepatic and renal failure. in a recent study done on tb patients requiring icu admission, mortality was . % (tatar et al. ). treatment failure is suspected when the sputum remains positive for afb at the end of the first months of treatment. it occurs due to factors that may involve incorrect regimens or dosing or indeed due to malabsorption or poor-quality drugs (lambregts-van weezenbeek and veen ) . patients are regarded as treatment failures when a microbiologic indicator like sputum smear/culture for tb remains positive after - months of starting treatment or comes back positive after a period of remaining negative (fall and rise phenomenon) (prasad et al. ) . patients may respond for a short time after starting treatment or do not respond to treatment from the inception. in any case the implication of treatment failure is drug-resistant tb (see below), and strenuous efforts must be made to look for microbiological resistance to first-and, in the proper context, to second-line agents-by the available tools. relapse, on the other hand, is the recurrence of tb after completion of treatment that has been successful, with documented culture negativity. relapse may be due either to a reinfection or reactivation of the dormant bacillus. drugresistant tb is to be considered in these settings. the implications of relapse are not as grave, the isolates generally being drug sensitive. in either case, the exact regimen chosen should be based upon the drug sensitivity pattern. specific recommendations upon the construction of such a regimen are available at who treatment guidelines for drug-resistant tuberculosis update (http://www.who.int). drug-resistant tb is a major global problem and is a threat to the success of the end tb strategy. mdr-tb or multidrug-resistant tb (mdr-tb) is defined by resistance of m. tuberculosis against to at least rifampicin and isoniazid. since these two drugs are the most effective drugs available against tb, resistance to both considerably shortens the odds of complete cure. xdr-tb or extensively drug-resistant tb is defined as resistance to rifampicin and inh plus resistance to at least one fluoroquinolone and one second-line injectable agent (amikacin, kanamycin or capreomycin). some of the reasons that lead to drug resistance have been mentioned in the section above. however the most important of these are failure to comply with the treatment regimen on the part of the patient and the addition of a single drug ("monotherapy") to a failing regimen; or a situation of unrecognized primary (that which is present at the start of therapy) or secondary (that which develops during treatment) drug resistance. inh mono-resistance of itself probably does not impact the outcome of therapy provided that ethambutol and possibly pyrazinamide are used for the entire duration of therapy. consideration should be given in this case to extending the duration of treatment to months from the standard (sadanand ). for reasons already discussed, rifampicin-resistant individuals should be managed as mdr-tb patients. in such patients it is not unusual to encounter resistance to additional drugs (e.g. ethambutol). it has been shown that clinical cure is possible in patients with mdr and even xdr-tb (who drug resistant tb ). however, owing to a variety of reasons not the least of which is drug intolerance, only about half of mdr-tb and a third of xdr-tb patients ever complete therapy. the who estimates there are over , mdr-tb or rifampicin-resistant cases annually (global tb report, who update ; wwww.who.int). the treatment of mdr-tb and xdr-tb is complex and requires specialized knowledge and close monitoring to ensure rational and safe therapy (lange et al. ) . the choice of drugs for treatment of mdr-tb is frequently difficult. formulation of drugs into regimens is facilitated by the organization of drugs into groups: group a ¼ levofloxacin/moxifloxacin, bedaquiline, linezolid. group b ¼ clofazimine, cycloserine/terizidone. group c ¼ ethambutol, delamanid, pyrazinamide, imipenem-cilastatin, meropenem, amikacin (streptomycin) , ethionamide/prothionamide, p-aminosalicylic acid. the who makes specific recommendations for short and long mdr-tb regimens. in the who's update (who treatment guidelines for multidrug-and rifampicin-resistant tuberculosis ), for those mdr-tb patients "who have not been previously treated for more than one month with second-line medicines used in the shorter mdr regimen or in whom resistance to fluoroquinolones and second-line injectable agents has been excluded," the who permits a shorter mdr-tb regimen of - months. for mdr/rr (rr¼ rifampicin resistant) tb patients on longer regimens, the who recommends that "all three group-a agents and at least one group-b agent (should) be included to ensure that treatment starts with at least tb agents likely to be effective, and that at least three agents (are) included for the rest of treatment after bedaquiline is stopped. if only one or two group a agents are used, both group b agents are to be included. if the regimen cannot be composed with agents from groups a and b alone, group c agents are added to complete it. kanamycin and capreomycin are not to be included in the treatment of mdr/rr-tb patients on longer regimens" (who treatment guidelines for multidrug-and rifampicin-resistant tuberculosis ). a detailed discussion about the treatment of mdr-tb is available at the foregoing resource. novel anti-tubercular agents (e.g. bedaquiline and delamanid) have been discussed elsewhere in this text. the remodelling of the lung that follows tb can significantly contribute to morbidity and mortality. haemoptysis is frequently one of the remote sequelae and can on occasion be life-threatening. an unresolved cavity is frequently the cause, and bleeding from an unsupported blood vessel in the cavity wall or in a post tubercular bronchiectatic segment can be a source of troublesome bleed. cavities colonized by fungi (aspergillomas), broncholiths eroding into the bronchial wall and rarely expansion and subsequent rupture of an unsupported blood vessel in the cavity wall (rasmussen's aneurysm) can cause massive haemoptysis (van den heuvel and van rensburg ) . a scar carcinoma sometimes develops in an area of fibrosis and may sometimes be difficult to distinguish from a dense fibrotic infiltrate (gao et al. ) . post-tubercular bronchiectasis is predisposed to when caseation necrosis and inflammation with retention of secretions leads to destruction of bronchial walls with ensuing permanent dilatation. sometimes compression of bronchial lumen by enlarged lymph node can produce bronchiectasis by a different mechanism. postprimary tb involves the upper lobes of the lung, and so the gravitationally advantaged upper lobes do not usually undergo a process of chronic and recurrent infection unlike the lower lobes that are involved by bronchiectasis of other aetiologies. mycetoma (fungal ball) is a mass of fungal hyphal material that grows within a cavity. aspergillus fumigatus is the most common aetiological agent, but other fungi such as mucor or fusarium can also cause a fungal ball to develop (rippon ) . such a mycetoma is usually asymptomatic but can sometimes lead to haemoptysis. no treatment required in asymptomatic cases, but surgical treatment needs to be considered in patients with massive or recurrent haemoptysis. a list of adverse effects associated with anti-tubercular agents appears in table . . side effects are possible with any of the anti-tubercular agents, and on rare occasions, they may be serious and even fatal. the risk of liver injury with anti-tb therapy is always a concern. among the four first-line agents inh, rifampicin and pyrazinamide are all capable of causing hepatotoxicity. isoniazid is capable of causing asymptomatic mild elevation in transaminases in - % as well as fatal severe acute hepatitis in . - %. jaundice with liver injury can occur in . - %. peripheral neuropathy due to pyridoxine deficiency can occur with inh therapy in up to . % of elderly individuals (ruan et al. ); pyridoxine supplementation is required for all patients taking inh (john ). factors increasing the chances of inh hepatotoxicity include age, female gender, alcohol use, prior hepatitis, concurrent use of cytochrome-inducing agents and slow acetylator status (sharma et al. ) . acute inh toxicity can present as seizures due to decreased gaba levels. inh is metabolized to several metabolites including the hepatotoxic metabolite hydrazine, toxic-free radicals and mono-methylhydrazine. degradation by acetylation occurs via n-acetyltransferase- gene (nat ); a deficiency of the nat enzyme can lead to accumulation of hepatotoxic metabolite. ten percent of patients with anti-tubercular drug-induced hepatotoxicity show progression to acute liver failure; the rest are self-limited (badrinath and john ) . if the serum bilirubin rises to ! mg/dl or serum transaminases exceed more than five times the upper limit of normal (or exceed three times the upper limit of normal in a symptomatic patient), all drugs should be stopped (nahid et al. ). the decision on what regimen to use on restarting should be individualized. the regimen, even if retailed, might then still include one or more potentially hepatotoxic drugs, and these should be restarted one at a time, only when liver function tests return to their baseline (e.g. the transaminases fall to less than twice normal). in general, a cholestatic type of derangement would prompt addition of inh first; with a non-cholestatic picture, rifampicin could first be added (sterling) . needless to say, careful monitoring with frequent testing of serum liver function is required. most physicians would omit pyrazinamide when restarting att except in the mildest of cases or with other compelling reasons (sterling) . patients receiving ethambutol (emb) should be questioned regarding their vision at each monthly visit. monthly visual acuity and colour vision discrimination testing is recommended in those patients in whom emb doses of greater than - mg/kg are being used, those who have been taking ethambutol for longer than months and those with renal insufficiency in whom the levels of drug may be expected to rise (blumberg et al. ) . for patients who require a regimen with no hepatotoxic agents, potential agents include ethambutol, levofloxacin or moxifloxacin, an injectable agent and other second-line oral drugs. the optimal choice of agents and duration of treatment (at least - months) is uncertain. (see "antituberculous drugs: an overview", section on "second-line agents".) in the end, efforts to finally eradicate tb will need to hinge upon preventative aspects as much as upon its treatment. these strategies would include currently established practices, as well as novel strategies. the former include the following. tuberculosis is now the primary cause of death from infectious diseases exceeding hiv, aids and malaria. the who estimates . million new cases and . million deaths every year (who global tb report ). of these, . million are hiv patients who die mostly in lmic (low-and middle-income countries) (who global tb report ; www.who.int). within the next years, the goal is to reduce tb incidence by % but the progress has been painfully slow. the most effective way to reduce the burden of tb in the community, to date, has been to identify patients affected with tb as early as possible and to treat them effectively with antitubercular therapy. the role of vaccines in this regard, though potentially vital, has been disappointing. of all vaccine tested to date, the bacillus calmette-guerin (bcg)-a live attenuated vaccine that was made in after an incredible years and sub-cultures (hasan )-is still the most effective vaccine we have today. yet its effect has been inconsistent, ranging from % to zero protection; several factors including geographical differences appear to play a role (british adolescents had better responses than south indian participants perhaps due to background exposure to mtb or atypical mycobacteria). the efficacy of bcg has been most manifested in its protection of infants and young children from the dangerous forms of tb (such as disseminated "miliary" tb and tb meningitis). also, its effects appear to wane with time (hasan ) . the bcg is not a single vaccine. several strains-all derived from the original bgc strain-are in use, which also partly explains its variable efficacy. in , the sanger centre in cambridge, britain and paris's pasteur institute in france cracked the genetic code for the old h rv strain of tubercle bacillus, and then, the genome of highly virulent cdc (the "oshkosh" strain) was mapped at the tigr (fine ). these developments have led to the possibility of exciting new candidate vaccines, several of which are in fact in the pipeline. it has been estimated that one-third of the world has been infected with tb bacteria. a relatively small number of immunocompetent individuals affected with ltbi will ever progress to active disease. reactivation of tb occurs when the immune system is compromised by external factors such as steroids or other immunosuppressants or by immune deficiency syndromes, which enables the latent (dormant) bacteria to "awaken" causing active disease. there is unfortunately no test that can currently predict which of these individuals will progress to active disease immunocompromised individuals have a high possibility of doing so. given that perspective, treatment for latent tb infection is most relevant for children under years, the elderly and individuals with hiv infection. to eliminate tb from the planet, a multipronged strategy incorporating early and effective treatment, vaccination and elimination of dormant reservoir of latent tb will be essential. ltbi treatment with inh ("chemoprophylaxis") is still the mainstay for treating latent tb infection but given that treatment extends to months, and that there is one death from hepatotoxicity for every , - , cases with such treatment, alternate strategies including rifamycin-based regimens are being explored (rangaka et al. ) . pregnancy outcomes following quinolone and fluoroquinolone exposure during pregnancy: a systematic review and meta-analysis rifapentine and isoniazid once a week versus rifampicin and isoniazid twice a week for treatment of drug-susceptible pulmonary tuberculosis in hiv-negative patients: a randomised clinical trial performance of light-emitting diode fluorescence microscope for diagnosis of tuberculosis infectious diseases society of america: treatment of tuberculosis false-positive xpert (r) mtb/rif assays in previously treated patients: need for caution in interpreting results recent changes in technical and operational guidelines for tuberculosis control programme in india - : a paradigm shift in tuberculosis control molecular diagnostics in tuberculosis bacterial factors that predict relapse after tuberculosis therapy the bcg story: lessons from the past and implications for the future five-year follow-up of a controlled trial of five -month regimens of chemotherapy for pulmonary tuberculosis assessment of the sensitivity and specificity of xpert mtb/rif assay as an early sputum biomarker of response to tuberculosis treatment ct features of lung scar cancer point of care diagnostics for tuberculosis diagnostic accuracy of adenosine deaminase and lymphocyte proportion in pleural fluid for tuberculous pleurisy in different prevalence scenarios delayed tuberculosis diagnosis and tuberculosis transmission guidelines for treatment of drug-susceptible tuberculosis and patient care ( ) world health organization clinical review: tuberculosis on the intensive care unit adjunctive vitamin d in tuberculosis treatment: meta-analysis of individual participant data progress in tuberculosis vaccine development and host-directed therapies -a state of the art review control of drug-resistant tuberculosis drug-resistant tuberculosis: an update on disease burden, diagnosis and treatment infectious diseases society of america/centers for disease control and prevention clinical practice guidelines: diagnosis of tuberculosis in adults and children tuberculosis in pregnancy: a review synergistic pandemics: confronting the global hiv and tuberculosis epidemics prednisolone and mycobacterium indicus pranii in tuberculous pericarditis comparison of a radiometric method (bactec) and conventional culture media for recovery of mycobacteria from smearnegative specimens worth a try in extensively drug-resistant tuberculosis? official american thoracic society/ centers for disease control and prevention/infectious diseases society of america clinical practice guidelines: treatment of drug-susceptible tuberculosis tuberculosis diagnostics: state of the art and future directions safety concerns surrounding quinolone use in children multidrug-resistant tuberculosis/rifampicin-resistant tuberculosis: principles of management reported tuberculosis in the united states controlling the seedbeds of tuberculosis: diagnosis and treatment of tuberculosis infection (ed) harrison's infectious diseases, th edn. mcgraw-hill education medical mycology: the pathogenic fungi and the pathogenic actinomycetes isoniazid-induced hepatotoxicity and neurotoxicity in rats investigated by ( )h nmr based metabolomics approach harrison's infectious diseases miliary tuberculosis: a new look at an old foe diagnostic mycobacteriology laboratory practices autologous mesenchymal stromal cell infusion as adjunct treatment in patients with multidrug and extensively drug-resistant tuberculosis: an open-label phase safety trial xpert(r) mtb/rif assay for pulmonary tuberculosis and rifampicin resistance in adults treatment of drug-susceptible pulmonary tuberculosis in hiv-uninfected adults this official statement of the american thoracic society was adopted by the ats board of directors contributing factors to mortality rates of pulmonary tuberculosis in intensive care units who treatment guidance for drug resistant tuberculosis ( ) who treatment guidelines for multidrug-and rifampicin-resistant tuberculosis fluoroquinolones for treating tuberculosis key: cord- -xhzvp g authors: berencsi, györgy; szomor, katalin n. title: fetal and neonatal illnesses caused or influenced by maternal transplacental igg and/or therapeutic antibodies applied during pregnancy date: - - journal: maternal fetal transmission of human viruses and their influence on tumorigenesis doi: . / - - - - _ sha: doc_id: cord_uid: xhzvp g the human fetus is protected by the mother’s antibodies. at the end of the pregnancy, the concentration of maternal antibodies is higher in the cord blood, than in the maternal circulation. simultaneously, the immune system of the fetus begins to work and from the second trimester, fetal igm is produced by the fetal immune system specific to microorganisms and antigens passing the maternal-fetal barrier. the same time the fetal immune system has to cope and develop tolerance and t(reg) cells to the maternal microchimeric cells, latent virus-carrier maternal cells and microorganisms transported through the maternal-fetal barrier. the maternal phenotypic inheritance may hide risks for the newborn, too. antibody mediated enhancement results in dengue shock syndrome in the first month of age of the baby. a series of pathologic maternal antibodies may elicit neonatal illnesses upon birth usually recovering during the first months of the life of the offspring. certain antibodies, however, may impair the fetal or neonatal tissues or organs resulting prolonged recovery or initiating prolonged pathological processes of the children. the importance of maternal anti-idiotypic antibodies are believed to prime the fetal immune system with epitopes of etiologic agents infected the mother during her whole life before pregnancy and delivery. the chemotherapeutical and biological substances used for the therapy of the mother will be transcytosed into the fetal body during the last two trimesters of pregnancy. the long series of the therapeutic monoclonal antibodies and conjugates has not been tested systematically yet. the available data are summarised in this chapter. the innate immunity plays an important role in fetal defence. the concentration of interferon is relative high in the placenta. this is probably one reason, why the therapeutic interferon treatment of the mother does not impair the fetal development. at term, the amount of maternal igg antibody is higher in the neonate than in the mother. this pattern holds when the igg antibody is an anti-tnfa medication. a specific fc receptor neonate (fcrn) facilitates transfer of the igg antibodies across the syncytiotrophoblast into the fetal circulation (kane and acquah ). due to the high rate of igg transfer near term, babies have been found to have similar blood levels of infliximab to the mother. by discontinuing this drug - weeks prior to delivery, the baby will likely be born with no or minimal serum levels, thus avoiding immunosuppression in a young infant. though there are some suggestive data that certolizumab does not cross the placenta as easily as the igg derived drugs due to the pegylation of the molecules (clowse ) . in early human placenta the exchange tissue area (villi) is formed around the entire surface of the conceptus. this placental shape is called diffuse placenta. by the third month of pregnancy, only the villi near the initial site of implantation have persisted, leading to the formation of the disc-shaped placenta. although chorioallantoic placenta in humans begins functioning already by the end of the fourth week of pregnancy, this process is completed with the formation of diskshaped placenta (sadler ) . during the first trimester, the human fetus is surrounded by two fluid cavities, i.e., the inner amniotic cavity and the outer extra-embryonic coelomic cavity. the chorioallantoic placenta is only formed of fetal vessels' endothelium and trophoblastic layer, bathed directly in the maternal blood (van der aa et al. ). for out of monoclonal therapeutic compounds, for which toxicity studies (in a broad sense) were performed, no significant maternal, fetal, or neonatal toxicity was observed. for the remaining seven products, the most common adverse effects on reproduction and development were reduced fetal weight, increased abortion rates, and reduction in fertility, indicating the general toxicity of these compounds (pentsuk and van der laan ). twenty-four ( %) of the children had one or more congenital anomalies that are part of vacterl association, but only one child (with maternal etanercept administration) was diagnosed with vacterl association i.e. v: vertebral defects, a: anal atresia or imperforate anus, c: cardiac abnormalities [atrial septal defect, ventricular septal defect, and tetralogy of fallot], t: tracheoesophageal fistula or tracheal atresia/stenosis, e: esophageal atresia, r: radial and or renal abnormalities, and pre-axial l: limb abnormalities (carter et al. (carter et al. , ). fc-fcgr interactions play a critical role in the biological function of antibody and are likely to be instrumental in preventing or modulating lentiviral infections. antibody responses that depend on fc-fcgr interactions may help widen the spectrum and increase the potency of vaccine-induced antibodies (forthal and moog ) . maternofetal transmission of non-neutralising dengue virus specific antibodies result in the development of hemorrhagic fever of the newborns even in the case of the first infection with a heterotypic virus. the mechanism is the formation of non-neutralised neonatal virus and heterotypic maternal igg complexes, which will be taken up by endothelial and hematopoetic cells by (virus-abfc)-fcgr pinocytosis. the risk disappears after the th month of age of the children, when the maternal igg disappeared from the circulation of the children (libraty et al. ). this phenomenon has been observed in the case of other flaviviruses and enteroviruses, too (ferenczi et al. ; wang et al. b ). dengue serotype cross-reactive cytotoxic lymphocytes (ctl) clones showing high avidity for antigen produce higher levels of inflammatory cytokines than serotype-specific clones. high avidity cross-reactive memory ctl may produce inflammatory cytokines during the course of secondary infection, contributing to the pathogenesis of vascular leak. these cells appear to be subsequently deleted leaving a more serotype-specific memory ctl pool. antibody-dependent enhancement ade is neither a sufficient nor an absolutely necessary precondition for the development of severe shock syndrome or hemorrhagic disease. ctl response to a viral infection can be modulated by the infection history of an individual in a manner likely to contribute to disease severity l€ uhn et al. ). respiratory syncytial virus (rsv) enhancer activity of transplacental maternal antibodies have been observed first by osiowy et al. ( ) . rsv infection is also enhanced by non-neutralising antibodies (johnson and graham ) . vaccination using inactivated virus particles were caused immune enhancement in the case of rsv in contrast to other, for example influenza viruses (openshaw et al. ; ye et al. ) . cytotoxic t-cells, cytokines and interferon induction by toll-like receptors may potentiate this enhancement (mobbs et al. ; boukhvalova et al. ; tregoning et al. ; lee et al. a, b; nguyen et al. ; ubol and halstead ) . tumour necrosis factor b block of cell-replication enhances rsv-replication (gibbs et al. ). the evidence of the enhancer effect of non-neutralizing antibodies to rsv can be prevented by the treatment of children at increased risk with neutralizing monoclonal antibodies directed against the fusion (f) protein of rsv (motavizumab and/or palivizumab). this monoclonal antibodies were not found to cause harmful effects in connection with the preventive treatment of neonates and infants at risk (martin-mateos ; nieri et al. ; weisman ; groothuis et al. ). anti-rsv-f protein specific antibodies can prevent also the rsv-s. pneumoniae enhancement of respiratory infections (hament et al. ) . the blocking of influenza specific anti-neuraminidase antibodies using antiidiotypes indirectly enhanced the hemagglutination-inhibition titers of antisera (dowdle et al. ) . influenza h specific antisera were found to enhance virus replication in a macrophage-like cell line p d , when p d cells, previously had been treated with neuraminidase to remove the viral receptors (ochiai et al. ). maternal antibodies systemic lupus erythemadosus (sle), is characterised by antibodies towards dsdna and ro (e ligase regulating tlr signalling) which, are present several years before the onset of disease and the neonatal disease is caused by some of these transplacental antibodies (watson et al. ) . systemic lupus erythematosus (sle) is the most common autoimmune disease affecting women of reproductive age and is associated with poor maternal and fetal outcomes. cd (+)cd (+) t reg cells are a subset of t lymphocytes with potent immunosuppressive activity that play crucial roles in controlling immunological self tolerance. evidence suggests that they are augmented in pregnancy, especially in the first trimester, suggesting an important role in early placental development. the literature describing t reg cells in sle is conflicting, but sle is associated with reduced numbers and functionally defective t reg cells, which may predispose pregnant women with the disease to pregnancy complications. this article discusses the role of t reg cells in sle and pregnancy, and how these cells may contribute to poor pregnancy outcome in sleaffected women (blois et al. ; clark et al. ) . sle was induced by interferon a administration, and by a specific stimuli i.e. sunshine exposure and smoking. the hla-dr haplotype was also found to be a risk factor (klareskog et al. ) . alcohol consumption was shown to be protective in these illnesses. vaccinations in adult age was found to be innocuous concerning the risk of ra according to the results of a case-control study when common vaccinations years before onset of ra had been followed up. the effects of environment, however, are unknown for the neonatal heart block in p and ro positive women, but the active immunisation does not increase the risk of it (bengtsson et al. a, b) . in sle and sj€ ogren's disease pregnants with high antibody titers against the p epitope of ro are those who almost exclusively carry the risk that their fetuses will develop neonatal heart block between gestational weeks - . monitoring during these period the anti-ro antibodies, steroid treatment or preventive in utero pacemaker treatment may reduce the risk (wahren-herlenius ). foetal genes, maternal age and infectious agents may contribute to the risk of congenital heart block. especially inherited high level interferon production was also shown to be a risk factor for sle (niewold et al. ) . heparin treatment and intravenous gamma globulin (ivig) treatment and specific anti-idiotypes reduce the risk of the disease (clark et al. ) . ivig enhanced the anti-id antibody response in pregnant women with anti-la/ssb antibodies. the id:anti-id ratio was significantly higher in mothers whose offspring developed neonatal lupus compared to mothers who gave birth to a healthy child (p < . ). removal of anti-id antibodies substantially increased the reactivity against la( - ) in sera from five of seven mothers tested. ivig from batches administered to mothers who gave birth to a healthy child had an id:anti-id activity ratio of < , in contrast to that given to mothers who gave birth to a child with neonatal lupus (brucato et al. (brucato et al. , routsias et al. ) . the main pathomechanism of the development of neonatal lupus erythematosus is the transcytosis of maternal antibodies, and probably microchimeric cells. the pathogenesis of the maternal disease is extremely complex as summarised recently by perl ( ) and perl et al. ( ) . mitochondrial hyperpolarization underlies mitochondrial dysfunction, depletion of atp, oxidative stress, abnormal activation, and death signal processing in lupus t cells. nitric oxide production, expression of endogenous retroviral and repetitive elements such as hres- , (the long interspersed nuclear elements ), trex , interferon alpha (ifn-alpha), toll-like receptors and (tlr- / ), high-mobility group b protein, extracellular signal-regulated kinase, dna methyl transferase , histone deacetylase, spleen tyrosine kinase, proteasome function, lysosome function, endosome recycling, actin cytoskeleton formation, the nuclear factor kappa b pathway, and activation of cytotoxic t cells were shown to be components of the pathogenesis (varghese et al. ) . the hres- human endogenous retrovirus (erv) encodes a k nuclear autoantigen and a -kd small gtpase, termed hres- /rab . hres- /p is a target of cross-reactive antiviral antibodies, whereas hres- /rab regulates the surface expression of cd via endosome recycling. hres- /rab is overexpressed in lupus t cells where it correlates with increased recycling of cd and cd and contributes to downregulation of cd /tcrs via lysosomal degradation. erv proteins may trigger lupus through structural and functional molecular mimicry, whereas the accumulation of erv-derived nucleic acids stimulates interferon and anti-dna antibody production. erv proteins may trigger lupus through structural and functional molecular mimicry, whereas the accumulation of erv-derived nucleic acids stimulate interferon and anti-dna antibody production in sle (perl ; perl et al. ) . these complex of pathogenetic factors many of them influenced by pregnancy results the clinical disease of the newborns (ruiz-irastorza and khamashta ). neonatal lupus erythematosus (nle) is an inflammatory disorder of neonates characterized by transient cutaneous lesions and/or congenital heart block. the cutaneous lesions usually heal with minimal scarring within - months, but may be delayed for many months in occasional cases. the maternal antibodies disappear from the circulation of the newborns within - months, the long-lasting clinical symptoms indicate, that irreversible events, or impairment of fetal cells occur during the fetal life. photosensitivity is recognized as a component of this syndrome. u ribonucleoprotein (u -rnp) specific antibodies can be detected in the circulation of the newborns. skin and cardiac manifestations coexist in only % of patients. hepatic, hematological and, less commonly, pulmonary, neurological and gastrointestinal abnormalities may also be present (watson et al. ; perez et al. ) . neonatal lupus is a model of passively acquired autoimmunity in which a mother-, who may have systemic lupus erythematosus (sle) or sj€ ogren's syndrome (ss) or may be entirely asymptomatic-synthesizes antibodies to ssa/ro and/or ssb/ la ribonucleoproteins that enter the fetal circulation via trophoblast fcrn receptors and presumably cause tissue injury (lee ) as mentioned above. congenital heart block is a passively transferred autoimmune condition, which affects the children of mothers with ro/ssa autoantibodies. during pregnancy, the antibodies are transported across the placenta and affect the fetus. it has been previously demonstrated that antibodies directed to the - amino acid (aa) stretch of the ro component of the ro/ssa antigen correlate with the development of congenital heart block. the antibody recognition is dependent on a partly alpha-helical fold within the putative leucine zipper of the - aa stretch (ottosson et al. ). smith (sm) antigen, which is highly specific for sle is composed of at least nine different polypeptides with molecular weights ranging from to . kda, b (b , kda), b (b , kda), n (b , . kda), d ( kda), d ( . kda), d ( kda), e ( kda), f ( kda), and g ( kda). sle patients develop antibodies against the sm complexes of the small nuclear rnas u to u in the mother and recently these were also detected in neonatal le patient (ortiz-santamaria et al. ) . in neonatal lupus, mothers with high anti-idiotypic antibody activity against anti-la autoantibodies are at lower risk of giving birth to an unhealthy child, as compared with mothers without anti-idiotypic antibodies. usually anti-idiotypic antibodies may confer protection from the harmful effect of autoantibodies in certain autoimmune diseases (tzioufas and routsias ) . ivig enhanced the anti-id antibody response in pregnant women with anti-la/ssb antibodies. a high id:anti-id ratio in both the ivig preparation and the maternal serum may explain the absence of an effect of ivig in preventing recurrent neonatal lupus in some cases (routsias et al. ) . the children of the mothers suffering from sle and sj€ ogren's syndromes are at risk also for other rheumatic/autoimmune diseases without carrying antibodies reactive with ssa/ro or ssb/la antigens. among the siblings without neonatal lupus developed later juvenile rheumatoid arthritis, hashimoto thyroiditis, psoriasis and iritis, diabetes mellitus, congenital hypothyroidism and nephrotic syndrome (martin et al. ; winter and schatz ) . experimental systemic lupus erythemetosus could be induced in mice using immunisation with anti-idiotype antibodies (ab ) specific to the anti-dna-specific monoclonal antibodies (mendlovic et al. ) . identical twins of mothers suffering from sle had also transient neonatal bullous skin disease (nakajima et al. ). autoimmunity has been defined as a normal physiological state with control mechanisms that prevent autoimmunity from progressing to overt pathology. the onset of a subset of rheumatoid arthritis (ra) begins with appearance of citrullinated protein antigen (cpa) positivity when tolerance to certain citrullinated proteins/peptides is broken supported by certain hla-dr haplotypes (hla-dr and hla-drb in smokers). local expression of peptidylarginine deiminases and occasional elevation of inflammatory cytokines can be measured (klareskog et al. ) . methotrexate was significantly more effective than placebo in preventing progression to this disease state in anti-cpa-positive patients with undifferentiated arthritis (ua) whereas no difference between methotrexate and placebo was seen in the acpa-negative group of patients with undifferentiated arthritis (ua; arthritis without arthralgia). the risk of ra was lower in this group without treatment (ehrenstein et al. ; van dongen et al. ). the treatments using therapiesinfliximab (a tumour necrosis factor (tnf-a) blocker) and abatacept (t cell costimulation inhibitor; anti-cd and anti-cd ) did not result in significant improvement of the acpa patients with ua (saleem et al. ; emery et al. ) . the analysis of myeloid-related proteins in serum is an excellent tool for the diagnosis of systemic onset of juvenile idiopathic arthritis (jia), allowing early differentiation between patients with systemic-onset of jia and those with other inflammatory diseases. mrp- /mrp- and il- b represent a novel positive feedback mechanism activating phagocytes via two major signaling pathways of innate immunity (tlr ) during the pathogenesis of systemic-onset of jia (frosch et al. ). the rheumatoid arthritis was found to be improved during pregnancy probably due to galactosylation of igg molecules (f€ orger and Østensen ). women with ra can acquire the susceptibility allele through microchimeric cells. very high amounts ( . % of total pbmcs) of drb * microchimerism in patients with ra were observed. similarly, drb * microchimeric dna was observed in significantly higher quantities in women with ra compared with healthy control subjects. in contrast, there was no difference between women with ra and control subjects when microchimerism for non-ra-associated alleles (hla-dqb * and drb * / ) was analyzed (rak et al. ). by analogy to graft-versus-host disease (gvhd), pioneer studies on microchimerism in women with scleroderma proposed direct and indirect recognition mechanisms as underlying reactions of microchimeric cells (nelson ) . in gvhd, donor cells invade the recipient, which is not what is observed with microchimerism in patients with ra. however, the presence of drb * microchimerism ( . %) and drb * microchimerism ( . %) is not negligible, with frequencies among total host pbmcs similar to the frequencies of antigen-specific cd + t cells, which thus are sufficient to impact the host immune reactions. the haplotypes of the patients influence the progression of the rheumatoid arthritis, too (liu et al. ). autoimmune neonatal bullous skin disease caused by placental transfer of maternal igg autoantibodies is rare. it has been reported in neonates born to mothers with pemphigus vulgaris, pemphigus foliaceus, and gestational pemphigoid. vertically acquired congenital autoimmune blistering disorders appear to be self-limited and resolve with supportive therapy, concomitant with the presumed clearance of maternal autoantibodies from the neonate's circulation (abrams et al. ). antiphospholipid antibody syndrome (apas) is regarded as the most frequently acquired risk factor for thrombophilia. thrombophilia is the tendency to thrombosis. the antiphospholipid antibody syndrome (apas) is a disorder of recurrent vascular thrombosis, pregnancy loss and thrombocytopenia, associated with persistently raised levels of anti-phospholipid antibodies (apa). the apa are phospholipids (part of a cell's membrane) recognized by the body as foreign and antibodies are produced against them. maternal autoimmune diseases significantly reduce the pregnancy outcome of the women. the most frequent illnesses were antiphospholipid syndrome, antiphospholipid syndrome associated with a rheumatic disease (aps/rd), other rd patients, isolated autoantibodies (autoabs) in the absence of a definite autoimmune disease (aabs) and reactive arthritis or spondyloarthropathies. of these patients, . % had previous pregnancy complications with an anamnestic livebirth rate of . %. in these patients, . % of pregnancies resulted in preterm delivery and . % newborns had low weight at delivery. aps/rd patients had the worse outcome: . % resulted in miscarriage, . % resulted in growth restriction and % resulted in preterm delivery. this result was mainly due to patients with aps/systemic lupus erythematosus (sle) that had the lowest gestational age at delivery ( . ae . weeks) and the lowest newborn weight (canti et al. ) . antiphospholipid syndrome was suggested to be the result of antibodies, directed against cardiolipin as a result of antigenic mimicry. the suspected antigen is beta- -glycoprotein-i (b gpi) (sherer et al. ) . clinically significant are lupus anticoagulant, anticardiolipin antibodies and anti-b glycoprotein-i (anti-b gp-i) antibody. neonates born to mothers with primary aps are at risk of prematurity, being small for gestational age, and having thrombocytopenia (chou et al. ). antiphospholipid antibodies (apl) can impair the physiologic development of a fetus during pregnancy not only by causing thrombosis of the placental vessels, but also by directly binding throphoblast cells and modifying their functions (tincani et al. ). transplacentally transferred antiphospholipid antibodies act as a risk factor, but are not usually a sufficient condition for thrombosis and other thrombophilic risk factors should be systematically evaluated. long-term studies of children born to antiphospholipid-antibody-positive mothers provided the evidence of possible neurodevelopmental changes in these children and regular neuropsychological assessments are recommended. antiphospholipid-antibody-related thromboses in children are frequently associated with multiple antiphospholipid antibody positivity and concomitant presence of inherited prothrombotic disorders can be also detected in addition to nonthrombotic manifestations, particularly hematological, skin and neurological manifestations (avcin ) . treatment of pregnant women with apas results in marked improvement in the live birth rate ( . - . %). however, complications like preeclampsia and intrauterine growth restriction (iugr) occur even after treatment, requiring strict monitoring and timely delivery. aberrant concentrations of fetuin a and heat shock protein might have also role in the preeclamptic inflammation (molvarec et al. a, b; dadhwal et al. ). foetal/neonatal disease is due to transplacental thyrotrophin receptor stimulating antibodies (trab). it's extremely important recognising and treating graves' disease in mothers as soon as possible, because a thyrotoxic state may have adverse effects on the outcome of pregnancy and both on the foetus and newborn. neonatal grave's disease tends to resolve spontaneously within - weeks as maternal thyroid stimulating immunoglobulins are cleared from the circulation but subsequent development may be impaired by perceptual motor difficulties. hashimoto's thyroiditis is a very common autoimmune thyroid disease. in presence of maternal hashimoto's thyroiditis, there are usually no consequences on foetal thyroid, even if antitpo and antitg antibodies can be found in the newborn due to transplacental passage. however there are some reports describing foetal and neonatal hyperthyroidism in the affected mothers' offspring (radetti et al. ; hemminki et al. ) . a number of autoimmune diseases; especially autoimmune thyroid diseases, erythema nodosum and sarcoidosis parity might somehow be involved in maternal disease development (jørgensen et al. ) . maternal thyroid status assessment and treatment improves fetal outcomes and neuropsychological developmental of the newborn (staii et al. ). juvenile myasthenia gravis is associated with antibodies to the acetylcholine receptor (achr) in most patients. thymoma is rare, but often malignant in children. the frequency of juvenile myasthenia gravis with antibodies to the musclespecific kinase (musk) varies markedly in different countries. neonatal myasthenia gravis associated with musk antibodies is often a severe and protracted albeit transient disease (béhin et al. ; evoli ) . transient neonatal myasthenia gravis (mg) is a human model of passively transferring the disease. although all newborn babies of myasthenic mothers have anti-achr antibodies at birth (morel et al. ; tzartos et al. ) , only a small percentage of them ( - %) express the myasthenic syndrome (namba et al. ) . the myasthenic symptoms usually appear a few hours after birth and their average duration is about weeks. neonatal myasthenia gravis is transiently transferred from the mothers to the newborn. nicotinic acetylcholine receptor (achr) antibodies result in loss of achrs and also directly block the function of the remaining achr molecules, thereby causing a defect in neuromuscular transmission. the majority, though not all, of both myasthenic and non-myasthenic infants were found to have a repertoire of anti-achr specificities very similar to their mothers. no significant differences were observed between sera from the two groups of mothers. adequate treatment in mothers can reduce both frequency and severity of neonatal disease. neonatal disease will recover following ivig treatment (béhin et al. ; o'carroll et al. ). the absence of neonatal myasthenia gravis might be caused by the antigenic differences between the fetal and adult enzymes similar to those detected in rats (hall et al. ; hesselmans et al. ). the human fetal acetylcholine receptor (achr) is present until weeks gestation, when the fetal (g) subunit is replaced by the adult (e) subunit. the term "fetal acetylcholine receptor inactivation syndrome" has been proposed for the illness, when other developmental disorders were also caused by the maternal antibodies (oskoui et al. ). neonatal guillain-barré syndrome (gbs) was observed to occur - days postpartum in children born to mothers with gbs. serum from mother and infant depressed quantal content by approximately % and reduced the amplitude of postsynaptic currents by - % in mouse, newborn and juvenile rats. the antibody nature of the blockade could be confirmed by showing that monovalent fab fragments were similarly effective as purified immunoglobulin (ig) g. both cellular and humoral immune mechanisms are operative in guillain-barré syndrome (gbs). transplacentally transferred blocking antibodies may be specifically directed at epitopes of the mature but not the fetal neuromuscular junction (luijckx et al. ; buchwald et al. buchwald et al. , . guillain-barré syndrome and sydenheim's chorea are diseases, which were shown to be associated with the immune response after microbial infections. the occurrence of guillain-barré syndrome noted in infants whose mother had harmless autoimmune antibodies during pregnancy (buchwald et al. ; sladky ) . the syndrome's occurrence within families is also of interest. the mmp c(- )t and tnfa c(- )a snp were associated with severe weakness and poor outcome, indicating that these snps may be one of the factors predisposing to a severe form of gbs (geleijns et al. ). the associated features of er / ek carriers consist of favorable metabolic and body compositional conditions. in contrast, the n s polymorphism was reported to be associated with an enhanced sensitivity to glycocorticoids. haplotypes carrying the minor allele of the bcli polymorphism of the glycocorticoid receptor gene was related to the phenotype and outcome of gbs explaining the family dependence of the syndrome and other neonatal disorders (dekker et al. ). mutations in about a dozen of genes have been linked to the development of permanent neonatal diabetes mellitus (pndm). the most frequent causes of pndm are heterozygous mutations in the kcnj , ins and abcc genes. although pndm is a rare phenomenon (one case in about , live births), this discovery has had a large impact on clinical practice as most carriers of kcnj and abcc gene mutations have been switched from insulin to oral sulphonylureas with an improvement in glycemic control (aguilar-bryan and bryan ; rubio-cabezas et al. ). the majority of transient neonatal diabetes mellitus (tndm) cases have an abnormality in chromosome q . half of the ndm cases are transient (tndm) and the other most frequent causes of ndm are missense mutations in the pancreatic b-cell k atp channel genes kcnj , ins and abcc (chr ), and in the preproinsulin gene, ndm has been linked to numerous other genetic causes including point mutations in gck (chr ), glis (chr ), eif ak (chr ), pdx (chr ), ptf a (chr ), slc a (chr ), hnf b(chr ) or foxp (chrx) (aguilar-bryan and bryan ; bonnefond et al. ) . genetic mutations were identified in~ % of non-consanguinous probands with pndm/mdi, using sequential screening of kcnj , ins and abcc genes in infants diagnosed within the first months of age. this percentage decreased to % in those with diabetes diagnosed between and months. patients belonging to the latter group may either carry mutations in genes different from those commonly found in pndm/mdi or have developed an early-onset form of autoimmune diabetes. islet-cell antibodies (ica), glutamic acid decarboxylase autoantibodies (gada), tyrosine phosphatase-related proteins-islet antigen autoantibodies (ia- a), insulin autoantibodies (iaa), zinc transporter autoantibodies (znt a) were found in the sera of the children, suggesting autoimmune origin of their disease (russo et al. ). biliary atresia (ba) is a devastating disease of infants, invariably leading to cirrhosis, end-stage liver disease, and death if untreated. it has been shown using microarray technique, that the t-cell regulatory gene rras seems to be a key factor in the development of the disease (zhao et al. ) . a recent review reported that ba may involve a primary perinatal hepatobiliary reoviral or rotaviral infection and a secondary autoimmune-mediated bile duct injury (mack ). the maternal virus infections followed by maternofoetal microchimerism seems to be a very impressive explanation of the etiology (muraji et al. ) . in a mouse model, oral vaccination before mating with rotateq and rotarix prevented most rhesus rotavirus-induced ba (turowski et al. ). biliary atresia is probably the endresult of different aetiological factors, among which viruses and other agents may cross the placenta. otherwise it cannot be understand, why only one of the twins obtain the disease (morris et al. ) . the anti-idiotypes transcytosed by different efficiency into the circulation of the twins, might be an additional explanation for the asymmetric disease. maternal symptomless paraproteinemia was also found to be transmitted to the fetus. the paraprotein was detected after birth for months in the serum of the child and caused prolonged immunosuppression without later consequences (littlewood et al. ; littlewood and payne ) . transient neonatal acquired von willebrand syndrome (avws) has been observed peripartum. its clinical management is analogous to monoclonal gammopathy of undetermined significance (mgus) of the mother since it is the consequence of transplacental transfer of maternal igg antibodies (simone et al. ; nageswara rao et al. ). immune trombocytopenic purpura associated with pregnancy. fetal and neonatal alloimmune thromocytopenia (fmait) results from transplacental transfer of maternal antibodies that develop in response to alloimmunization against paternal human platelet antigens (hpas) expressed on fetal platelets. this thrombocyte loss could be prevented using modified igg molecules (ghevaert et al. ) . at present seven biallelic human platelet antigen (hpa) systems have been determined and can be typed using genomic dna. platelet genotyping is a valuable tool in confirming platelet antigen specificities of alloantibodies detected in patients' sera to complement the clinical history in the diagnosis of alloimmune platelet disorders such as fetal and neonatal alloimmune thrombocytopenia (fnait). prenatal platelet typing of the fetus in suspected cases of fnait became also available (curtis ) . half of the infants were borne with low platelet counts and of required replacement therapy upon birth (ozkan et al. ; gasim ) . the maternal, transplacental igg binding to the fetal platelets was suggested to prevent their recirculation by fcgr binding to and phagocytosis by macrophages. the pathogenesis of immune trompcytopenic purpura and that associated to myelodysplasia and leukemia were shown to be different (psaila and bussel ; psaila et al. ). neonatal endarteritis has been diagnosed in the newborns of mothers suffering from endarteritis nodosa. fatal myocardial infarction in a neonate due to coronary arteries is compared with two lethal cases of mucocutaneous lymph node syndrome and/or infantile periarteritis nodosa (mlns/ipn). cutaneous polyarteritis was transmitted to the newborn, too (kitzmiller ; krapf et al. ; stone et al. ) . during the last decade no publication could be found on neonatal endarteritis. probably the pathogenesis of this disease has been reevaluated in the light of the molecular diagnostic findings. hereditary autoinflammatory syndromes are caused by monogenic defects of innate immunity and are classified as primary immunodeficiencies. these syndromes are characterized by recurrent or persistent systemic inflammatory symptoms and must be distinguished from infectious diseases, autoimmune diseases, and other primary immunodeficiencies. the sited review describes the epidemiological, clinical and laboratory features, prognosis, and treatment of the main autoinflammatory syndromes, namely: familial mediterranean fever; tnf receptor associated periodic syndrome; the cryopyrinopathies; mevalonate kinase deficiency; pediatric granulomatous arthritis; pyogenic arthritis, pyoderma gangrenosum and acne syndrome; majeed syndrome; and deficiency of interleukin receptor antagonist. the cryopyrinopathies discussed include neonatal-onset multisystem inflammatory disease (also known as chronic infantile neurologic, cutaneous and articular syndrome), muckle-wells syndrome, and familial cold autoinflammatory syndrome (jesus et al. ) . primary immunodeficiencies (pids) were analyzed to gain insight into the physiopathology of sle. some pids have been consistently associated with sle or lupus-like manifestations: (a) homozygous deficiencies of the early components of the classical complement pathway in the following decreasing order: in c q, % of affected patients developed sle; in c , %; inc r/s, %; and in c , up to %; (b) female carriers of x-linked chronic granulomatous disease allele; and (c) iga deficiency, present in around % of juvenile sle. mutations of the complement system (c -inhibitor; c q, c r, c s, c , c , c , c , c , c , c and c deficiencies were shown to facilitate the development of sle in addition to the facilitation of bacterial infections (c and c , encapsulated bacteria; c to c neisseria). other autoimmune diseases, i.e. polyendocrinopathy candidiasis ectodermal dystrophy (apeced), immune dysregulation polyendocrinopathy enteropathy x-linked (ipex), and autoimmune lymphoproliferative syndrome (alps), suggesting that mechanisms considered as critical players for induction and maintenance of tolerance to autoantigens, such as ( ) aire-mediated thymic negative selection of lymphocytes, ( ) foxp + regulatory t cell mediated peripheral tolerance, and ( ) deletion of auto-reactive lymphocytes by fas-mediated apoptosis, were not found to be associated with sle physiopathology (blois et al. ; carneiro-sampaio et al. ). behçet syndrome (bs) is a multisystem chronic inflammatory disorder, which is characterized by relapsing oral and genital ulceration and iridocyclitis. while being of unknown etiology, vasculitic changes of possible autoimmune origin are common to all involved organs, and thrombotic complications, which may adversely affect gestation, are frequently seen was shown to possess genetic etiology on the basis of the comparison of its incidence among monozygotic and dizygotic twins (masatlioglu et al. ). pregnancy does not have a deleterious effect on the course of bd and may possibly ameliorate its course. however, it seems that bd may adversely affect pregnancy. the miscarriage rate was higher, and the pregnancy complications and cesarean section rates were significantly elevated (jadaon et al. ) . overall, parity was associated with an % increased risk of female predominant autoimmune diseases. pregnancies resulting in liveborn children therefore seem to contribute only little to the general female predominance in autoimmune diseases. crohn's disease and ulcerative colitis; in idiopathic inflammatory bowel diseases (ibd), including crohn's disease and ulcerative colitis, there is pathogenic build-up of cd + t cells at sites of inflammation, mediated in part by il- , which provides (as described earlier) an anti-apoptotic signal to t cells through the induction of bcl- and bclxl and promotes th lineage differentiation. il- is upregulated in patients with both types of ibd. il- levels are elevated markedly in the serum of patients with ibd, decrease with treatment of inflammation and are predictive of ibd relapse. microbial pattern-recognition receptors, such as the tlrs and nod (nucleotide oligomerization domain ), which activate nf-kb, have been implicated in these conditions. neutralisation with an anti-il- r antibody largely prevented the colitis in mice (arad et al. ) . most women and men with ulcerative colitis (uc) and crohn's disease (cd) can expect a healthy child with neither preterm birth nor low birthweight. no neonatal forms have been described (ludvigsson and ludvigsson ; van assche et al. ) . later crohn's disease was shown to impair the fetal outcome in the case of the affected mothers (naganuma et al. ). colitis-associated-cancer (cac); tgf-b suppresses the formation of cancer by inhibiting il- trans-signaling and human samples of colon cancer have low-levels of il- r, as do samples of inflamed colon. adenomatous polyposis coli (apc) gene of mice with apc mutation develop cancer, genetic deletion of the tlr-adaptor protein myd decreased the number of cancers markedly. because myd activation in turn activates nf-kb, it is not surprising that il- production was decreased greatly in mice deficient in myd and supports prior data showing that il- is one of the effector signals in the tlr-nf-kb activation pathway (becker et al. ) . tgf-b was found to suppresses tumor progression in colon cancer by inhibition of il- trans-signaling. huntington disease was found to be of congenital origin, and the diagnosis can be obtained before implantation (hdcrg ; peciña et al. ) . the causal mutation is the expansion of a cag trinucleotide repeat tract in exon of a large gene on chromosome that results in the extension of a polyglutamine tract at the n-terminus of the encoded, ubiquitously expressed protein called huntingtin. from the maternal blood the dna from the fetal-maternal transport can be also applied for the prenatal diagnosis (bustamante-aragones et al. ). hypoparathyroidism with autoimmunity due to the q . deletion syndrome. the majority of patients acquired autoimmune antibodies, but without antiparathyroid antibodies (lima et al. ). wegener granulomatosis (wg) is systemic disease of unknown etiology characterized by necrotizing granulomatous inflammation, tissue necrosis, and variable degrees of vasculitis in small and medium-sized blood vessels. the classic clinical pattern is a triad involving the upper airways, lungs and kidneys. ninety percent of patients present with symptoms involving the upper and/or lower airways, and % will eventually develop renal disease (mubashir et al. ) . pregnancy in patients with wg requires preconceptional planning, careful clinical management, and vigorous treatment of active disease. the management is individualized and the pregnancy outcome is variable. antenatal management and therapeutic options are important (koukoura et al. ) . no neonatal disease have been described, and ivig treatment could be successfully applied in the steroid resistant patients (bellisai et al. ). kawasaki disease (kd) is an illness mostly of infants and young children, the majority being less than years old. the peak age of onset of illness is - months. it is unusual in very young infants. from to , only six instances of kd occurred in infants days of age or younger in japan, and infants days of age or younger accounted for only . % of all patients. the youngest infant of kd to date (a neonate week old) was reported by stanley and grimwood. the youngest reported from india is a -day-old infant (thapa et al. ). therapeutic monoclonal antibodies (mabs) are most commonly of the igg subclass, which is transported most efficiently to the fetus. in all animal species used for testing developmental toxicity, fetal exposure to igg is very low during organogenesis, but this increases during the latter half of gestation such that the neonate is born with an igg concentration similar to the mother. the therapeutic monoclonal antibodies might cause developmental and reproductive toxicity (dart) requiring testing of antibody-based therapeutics (pentsuk and van der laan ). guillain-barré syndrome during pregnancy can be also treated with ivig and plasmapheresis. (niklasson et al. ; goyal et al. ; bahadur et al. ; modi et al. ; ohlsson and lacy ) . polyclonal antisera, administered for passive immunization, are mixtures of different proteins, sharing binding activity against the antigen (ag) determinants of the same immunogen preparation. immunoadhesins (or immunoglobulin fusion proteins) are antibody-like molecules resulting from the fusion of a constant region (e.g., fc portion) of an immunoglobulin and the ligand-binding region of a receptor or an adhesive molecule. antibody fragments such as fab, scfv, diabodies, and minibodies are molecules devoid of part or whole of the fc portion. therefore, they have faster clearance and better tissue/tumor penetration than whole immunoglobulins and they will perform better than whole iggs in conditions where a short half-life is desirable, such as in radio-imaging and/or radio-therapy. they have no adcc and cdc triggering activity. the smallest proteins retaining antigen binding are a single variable domain antibody (nieri et al. ). ivig prevention improves the risk of heart block of sle patients (friedman et al. ) . several members of the idiotype-anti-idiotype network and antibody dimers including antigen-antibody complexes were found in the ivig preparations (luijten et al. ; osterhaus et al. ; clark et al. ). ad anti-idiotype monoclonal antibody can mimic the cd antigen. the molecular basis of ad mimicry has been identified with three cdr regions of ad showing similarity to three regions of cd . these regions have been analysed for potential t-cell epitopes, and sequences that are predicted to bind to hla/a , , and to hla/dr , , have been identified within the cdrh region of ad . ad can stimulate cd and cd responses in colorectal cancer patients with the appropriate haplotype. only a few patients produce a sustained memory response (durrant et al. ; reinartz et al. ) . most of these vaccines for the lymphoma therapy use the tumor b cell idiotype (the unique variable region of the surface immunoglobulin) as a tumor-specific antigen. in spite of several problems anti-idiotype vaccines prospect towards integration of this strategy in the therapeutic armamentarium for lymphoma (houot and levy ) . clinical studies have been published using different preparations and summarised at the end of table . . abagovomab (aca ) acts as an antigen mimic of the carbohydrate ovarian cancer antigen (wagner et al. ) . the frequency of peripheral t reg s was increased during abagovomab therapy in a high percentage of patients. despite higher t reg counts compared with baseline levels, the suppressive capacity of t reg s was reduced in a subset of patients. the data further indicate that the ability of t cells to proliferate in response to ca- in vitro could be associated with diminished t reg activity. importantly, ca- -specific immunity could not be enhanced by in vitro t reg depletion, as ca- induced cd + foxp + t reg s with suppressive capacity. abatacept (orencia) human igg fc domain ctla- ; anti-cd and anti-cd . abatacept (abt, orencia, bristol-myers squibb ltd) rheumatoid arthritis tumor necrosis factor inhibitor in phase clinical trial, but it was found effective only in very early phase of the disease (malottki et al. ; emery et al. ) . prophylactic withdrawal of drugs before pregnancy is mandatory (Østensen et al. ) . at present reports on abatacept, tocilizumab or anakinra are inconclusive therefore throughout pregnancy cannot be recommended (Østensen and f€ orger ) . abciximab (reopro) igg k-fab, chimera -integrina b (platelet-gp)haemostasis/trombosis (nieri et al. ). using immunohistochemistry, reopro was only detected attached to maternal and fetal platelets, and to the trophoblastic surface of the placental villi (miller et al. a, b) . the effect of abciximab to icam- was excluded, but an effect to monocytes could not be excluded (voisard et al. ) . adalimumab (ada, humira; abbott) human recombinant, igg k, anti-tnfa, as, psa, cd, pp, jia (van schouwenburg et al. ) tnf-alpha blocker therapy (adalimumab). the therapy of pregnants showed no increase in miscarriage, prematurity or structural malformations in neonates compared with non-exposed pregnancies (Østensen et al. ) . expression of hla-g on pmbcs is up-regulated in ankylosing spondylitis (as), correlates with acute phase reactants and decreases after tnf-alpha blocker therapy (chen et al. ) . anti-tnfa is used for the treatment of infectious bowel diseases even during pregnancy, which might influence the development of the fetal immune system (arsenescu et al. ) . anti adalimumab anti-idiotype antibodies (bartelds et al. malottki et al. ; nieri et al. ). ( ) ? teplizumab anti-cd t. diabetes herold et al. ( herold et al. ( , ? integrin a b direct exposure to anti-tnf treatment during pregnancy was not related to a higher incidence of adverse pregnancy outcomes than infectious bowell diseases overall (schnitzler et al. ). the anti-tnf agent was started prior to conception and continued until there was evidence of fetal cardiac activity. in women treated with a combination of anti-tnf therapy, anticoagulation therapy, and ivig, the live birth rates ( %) were greater than those in women treated with anticoagulation therapy alone ( %) or in those receiving a combination of anticoagulation therapy and ivig ( %). fetal outcomes, including gestational age and birth weight, were similar across the groups, and no congenital anomalies were reported after anti-tnf agent exposure (winger and reed ; vinet et al. ). rheumatoid arthritis, juvenile idiopathic arthritis, ankylosing spondylitis, psoriasis, psoriatic arthritis, crohn's disease (Østensen and f€ orger ) . all users requested at least one time repeatedly the treatment in norway (mahic et al. ) . long term treatment did not resulted in reactivation of chronic hepatitis b virus infection (mori ) . the treatment caused the improvement in two bone formation markers -b-alkaline phosphatase and osteocalcin (veerappan et al. ) . alemtuzumab (mabcampath, genzyme) humanized, igg k, anti-cd anti-ca immunoglobulin directed against cd antigen expressed on t-and b lymphocytes, monocytes, macrophages, nk cells, and a subpopulation of granulocytes, but not on hematologic precursors. induction of cdc or adcc on an fcreceptor g-binding mechanism. pancreas transplant recipients on alemtuzumab maintenance therapy suffered frequently from red cell aplasia, and autoimmune hemolytic anaemia. (elimelakh et al. ) cord-blood-hematopoetic-stem-cell expansion and increase the availability of cord-blood units for transplantation (lim et al. ) . in contrast to ivig and rituximab the compound may be an effective therapy for complex immunohematologic disorders complicating hematopoietic stem cell transplantation. the paper emphasizes the importance of t-cells in transplant associated immune cytopenias (chao et al. ). b-ccl (nieri et al. ). alicaforsen is a human monoclonal antibody a b -integrin, also known as leukocyte function antigen (lfa)- , and its ligand, intercellular adhesion molecule- (icam- ), is important for the recruitment of leukocytes to inflammatory sites (bosani et al. ). anti-cd and anti cd intratumoral microvessel density (imvd) monoclonal antibodies. anti-cd was more effective against non-small cell lung cancer than anti-cd (tanaka et al. ) . anti-cd mab (bms- , bristol-myers squibb) - bb (cdw ), a member of tumor necrosis factor receptor (tnfr) superfamily stimulating t-cells, nk-cells and dcs . anti-cd mab enhances rituximabdependent cytotoxicity against the lymphoma cells (lee et al. ; kohrt et al. ) . anti-leu- b or anti-leu- c, igg a, marker of t-cell subpopulation (clement et al. ; champlin et al. ) . apomab (genentech) igg , against extracellular domain dr /tumor necrosis factor related (trail) receptor apoptosis inducing ligand (nieri et al. ). basiliximab (simulect) chimeric, igg k, anti-cd , il r antagonist (aktas et al. ) % reduced fetal body weight (pentsuk and van der laan ) . bavituximab (peregrine pharmaceuticals, inc., tustin, ca), anti-phosphatidylserine bavituximab combined with radiotherapy holds promise as a vascular targeting and immune enhancement strategy for the treatment of human glioblastoma (he et al. ). hcv therapy (immunostimulant) (dammacco et al. ; quer et al. ) . belatacept (ctla -ig) is a new recombinant molecule that interferes with the signal of t lymphocyte activation and prevents acute rejection after renal transplantation. hla-g acts as a naturally tolerogenic molecule in humans. patients treated with ctla -ig displayed significantly higher soluble hla-g (shla-g) plasma concentrations than patients treated with calcineurin inhibitors or healthy donors (bahri et al. ). ctla -ig-treated dc acted as tolerogenic apc through shla-g secretion as they suppressed t cell alloproliferation, which could be restored by using a neutralizing anti-hla-g ab (bahri et al. ). the use of anti tumour necrosis factor mabs are not recommended (partlett and roussou ) . cytotoxic t-lymphocyte-associated protein (ctla- ) is a negative regulator of t cell activation and may modulate peripheral self-tolerance (kaufman et al. ) . bevacizumab (avastin) humanized, igg k, anti-vascular endothelial growth factor-a (vegf-a) used for the treatment of non-small cell lung cancer, (nsclc) colorectal cancer (cc); (nieri et al. ). efd rabbit: dose-dependant decrease in maternal bodyweight, increase in fetal malformations and late resorptions; (pentsuk and van der laan ). intravitreal bevacizumab therapy during pregnancy for off-label ocular indications can result in significant visual improvement without adverse fetal events related to treatment (tarantola et al. ) . intravitreal . mg bevacizumab may reach the systemic circulation in plasma concentrations of ng/ml (csáky and do ) . two pregnants have lost their babies within days following intravitreal injections of bevacizumab (petrou et al. ). placenta gf levels are elevated in the plasma of colorectal and rectal carcinoma patients receiving bevacizumab (xu and jain ) . prevention of angiogenesis by msc in pancreatic cancer (beckermann et al. ) . blinatumomab (epcam, antigen -epithelial cell-adhesion molecule, -present on % of cancer cells) and mt- and mt present on all non-hodgin lymphoma cells (armstrong and eck ; nieri et al. ). cd /cd bispecific, single chain recombinant antibody topp et al. ) . catomaxomab (removab) bifunctional recombinant anti epidermal cell adhesion molecule epcam and anti-cd . it is inducing adcc in ovarian and stomach cancer. epcam is the ligand for human leukocyte immune-globulin like receptor (lair- ) (armstrong and eck ; nieri et al. ; bokemeyer ; r€ ussel et al. ) . ceavac (mimicking carcinoembryonic antigen) colon cc (foon et al. ). certolizumab (cimzia®; ucb) pegylated humanized antibody fab' fragment of tnf-a monoclonal antibody; ra, cd; (Østensen and f€ orger ) . certolizumab does not cross the placenta as easily as the igg derived drugs due to the pegylation of the molecules, thus reducing the harmful consequences to the fetus (clowse ) . cetuximab (erbitux) chimeric, igg k, anti-epidermal growth factor receptor- (her- ), apoptosis, cdcc colorectal cancer (cc); squamous cell cancer of head and neck (scchn) weight loss and reduced food consumption in high-dose group dose-dependent increase in abortion rates (not known, if could be associated with treatment) weight loss and reduced food consumption in high-dose group (powell et al. ; pentsuk and van der laan ; rech and vonderheide ) . chaglycd (cd -specific) a humanized antibody, an aglycosylated human igg antibody directed against cd was shown to reduce the insulin-requirement of the patients. residual beta-cell function was better maintained with chaglycd than with placebo (keymeulen et al. ) . cixutumumab (img- or cix) targeting insulin-like growth factor receptor (igf-ir) treatment for multiple cancers. human igg , blocks interaction between igf-ir and its ligands, igf-i and -ii, and induces internalization and degradation of igf-ir. its combination of cetuximab (mab against egfr) inhibited the growth of pancreatic cancer and promoted its regression. an antiangiogenic mechanism was associated with cix treatment. reviewed recently (quatrale et al. ) . hyperglycemia is a regular side effect, but the fetal consequences during pregnancy have not been evaluated yet (mckian and haluska ) . eyelash trichomegaly in adults (bouché et al. ; garrido et al. ) . cnto chimeric monoclonal antibody with high affinity for human il- myeloma multiplex sensitivity to glycocorticoid (voorhees et al. ). ct- (curetech) humanized anti-pd- igg mab that binds to mouse and human pd- , programmed death receptor . pd- but not ctla- blockage abrogates the protective effect of regulatory t cells in a pregnancy murine model. mkrtichyan et al. ; stagg et al. ; wafula et al. ). dacetuzumab (sgn- ; seattle genetics) humanized; and hcd fully human (novartis/xoma); cd , tumour necrosis factor receptor; b-cells, dcs, macrophages lymphomas . daclizumab (zenapax) humanized, igg k, anti-a-chain of cd , il- r antagonists (elimelakh et al. ; aktas et al. ) transplant rejection. eculizumab (soliris) humanized, igg / j, anti-human complement c ; paroxismal nocturnal haemoglobinuria (pnh); (thomas et al. ; nieri et al. ; danilov et al. ). there was no evidence of complement blockade from cord blood samples taken at delivery. eculizumab appears safe to use in this setting and is likely to prevent many of the complications usually observed (kelly et al. ) . edrecolomab (panorex) igg a, epcam antigen cdc-adcc cancer (nieri et al. ). efalizumab (raptiva) humanized, igg k, anti-integrin-cd a -psoriasis (nieri et al. ). progressive multifocal leukoencephalopthy was found to be a rare, but lethal disease associated with long term efalizumab therapy (kothary et al. ). epratuzumab, a humanized igg unconjugated anti-cd antibody effective against non-hodgkin lymphoma and follicular lymphoma (leonard et al. ; watanabe ) . consequences of the application during pregnancy has not been reported. etanercept (etn, enbrel, wyeth pharmaceuticals) human igg fc domain tnfr /p ; anti-tnfa as, psa, pp, jia; ng/ml cord blood. ng/ml week postpartum ng/ml; weeks postpartum; undetectable weeks postpartum (clowse ) . reduction of post-partum microchimerism (rak et al. ). complications of the therapy may be acute anterior uveitis (etanercept), psoriasis (infliximab > etanercept) and infectious bowel disease (ibd) (etanercept > infliximab) which were observed in association with the treatment using tnfantagonists. the paradoxical consequences, however, affected less than % of the treated patients (fouache et al. ). eternacept, which is a recombinant human p soluble receptor to tnf, failed in a phase ii trial with crohn's disease and the trial was discontinued. the recombinant receptor proved to be useful for the treatment of rheumatoid arthritis (malottki et al. ), but its use in pregnants has not been approved (Østensen et al. ) . etanercept treatment ( mg  /week) has been stopped weeks before pregnancy. the treatment had to be reinitiated from the th week of pregnancy and no fetal complication was observed (umeda et al. ). the etanercept treatment was initiated weeks before pregnancy ( mg/sq-m  weekly). the cord blood contained ng/ml etanercept in contrast to the maternal serum ( , - , ng/ml). no detectable etanercept was found in the newborn's blood th week after delivery, although the breast milk contained . ng/ml etanercept (murashima et al. ). all patients requested at least one times the repetition of the treatment according to a publication from norway (mahic et al. ) . fontolizumab used for the preventive treatment of newborns at risk for respiratory syncytial virus infection (rsv) resulted a significant decrease in c-reactive protein levels suggested a beneficial biological effect. (nieri et al. ; reinisch et al. ) . galiximab, a human-primate chimeric anti-cd antibody: galiximab is a human-primate chimeric anti-cd antibody with excellent tolerability and singleagent effectiveness for recurrent follicular lymphoma (fl), resistant to other therapeutical means (watanabe ) . gemtuzumab (mylotarg k ) igg k; humanised; cd -monocyte, myeloid cell drug targeting (nieri et al. ). golimumab (simponi®; centocor ortho biotech) human monoclonal igg antibody ra, as, psa (Østensen and f€ orger ) . hcd (novartis/xoma) cd -specific fully human igg mab with antagonistic activity that mediates adcc and blocks cd l-induced survival and proliferation of normal and malignant b cells (chatenoud and bluestone ) . ibritumomab tiuxetan (zevalin) murine, igg k, anti-cd ; radiol (yttrium ) imc-c (nieri et al. ). infliximab (ifx, remicade, schering-plough ltd) chimeric, igg k, anti-tumor necrosis factor alpha (tnfa) rheumatoid arthritis (ra) and crohn's disease (cd) (saleem et al. ; van schouwenburg et al. ) . fatal case of disseminated mycobacterial infection has been reported in an infant who received bcg vaccine at months of age. the mother had been treated with infliximab throughout her pregnancy. vaccination with live bacteria and viruses should be postponed in infants exposed to infliximab in utero, until serum levels are undetectable which may require more than months (djokanovic et al. ) . the fetal concentration of infliximab was found to be higher than that of the mother. this might be a risk for the postnatal development of the immune system (zelinkova et al. ). due to the high rate of igg transfer near term, babies have been found to have similar blood levels of infliximab to their mothers (clowse ) . all reported pregnancy outcomes under treatment with infliximab showed no increase in miscarriage, prematurity or structural malformations in neonates compared with non-exposed pregnancies (Østensen et al. ) . only the chimeric monoclonal anti-tnf antibody infliximab is currently available worldwide. the potency of this agent in moderate-to-severe ulcerative colitis (uc) and cd has been one of the most important advances in the care of inflammatory bowel disease (ibd) in the past decade (d'haens and daperno ) . anti-infliximab anti-idiotypes. no association was found between the patients' allotypes and the presence or concentration of anti-infliximab antibodies ) reduction in fertility (not known, whether related with male or female animals) (pentsuk and van der laan ). vacterl association? acute graft versus host disease (couriel et al. ) were described, but it proved to be useful for the treatment of rheumatoid arthritis (malottki et al. ) . inotuzumab ozogamicin (cmc- ), the calicheamicin-conjugated anti-cd monoclonal antibody and rituximab combination were used for the treatment of ankylosing spondilitis, psoriatic arthritis and ulcerative colitis; (nieri et al. ; smith et al. ) the concentration in the blood of the newborn was . mg/ml week post-partum and slowly declined over months (clowse ) . ipilimumab (fcgriib binding) overcoming tcla- -mediated immunosuppression, increasing anticancer immune-response (melanoma malignum; mdx- ; bristol-myers squibb/medarex); ctla- (cd ) t cells; t reg cells; colon and prostatic cancer; (nieri et al. ; houot et al. ) . iratumumab (sgn- and mdx- ) cd -specific igg used for the treatment of hodgkin's lymphoma. myelosuppression, fatigue, elevated liver enzymes were documented during therapy (klimm et al. ) . lfb-r , a fully human anti-rhesus d (rhd) antibody, for the prevention of feto-maternal allo-immunization in rhd-women, as a substitute for human polyclonal anti-rhd immunoglobulins (urbain et al. ). lfb-r , a monoclonal antibody directed against cd , for the treatment of b cell malignancies. antibody-dependent cellular cytotoxicity (adcc) activity and enhanced affinity to fcgriii (cd ), both correlated to a glycosylation pattern characterized by a low fucose content (urbain et al. ). mapatumumab; trail receptor activation (death receptor ) mediator of apoptosis in cancer cells (nieri et al. ). matuzumab (humanised anti-egfr monoclonal antibody; reviewed by seiden et al. ; and recently by quatrale et al. ) . melimmune: anti-idiotype antibody that mimic the high molecular weight chondroitin sulfate proteoglycan antigen of melanoma cells (pride et al. ; murray et al. ; ward et al. ) . mitumomab (bec , imclone systems) bec- anti-idiotype (giaccone et al. ; bottomley et al. ) bec is an anti-idiotypic antibody that mimics gd , a ganglioside that is expressed on the surface of tumor cells and is of neuroectodermal origin. ganglioside gd can be used as a vaccine against small cell lung cancer (sclc) (nieri et al. ). mln- anti-a b integrin antibody of igg type, humanised (reviewed by bosani et al. ) approved for the treatment of crohn's disease. motavizumab (humanised mouse monoclonal antibody). motavizumab targets a highly conserved epitope in the a antigenic site of the rsv fusion (f) protein, which is important in the invasion of rsv from cell to cell. motavizumab, which differs from palivizumab by just amino acids, has exhibited a -fold enhancement in binding to the rsv f protein compared with the first-generation mab, with an -fold faster association rate and sixfold slower disassociation rate (nieri et al. ; weisman ). muromonab, igg a, murine, t-cell cd blocade. cd -specific monoclonal antibodies can re-establish immune homeostasis in treated individuals. this occurs through modulation of the t-cell receptor (tcr)-cd complex (also termed antigenic modulation) and/or induction of apoptosis of activated autoreactive t cells, which leaves behind 'space' for homeostatic reconstitution that favours selective induction, survival and expansion of adaptive regulatory t cells establishing long-term tolerance. it is used for early treatment of diabetes type (chatenoud and bluestone ; nieri et al. ). natalizumab (tysabri) humanized, igg k, anti-a -integrin (vla- ), in the treatment of sclerosis multiplex (van schouwenburg et al. ) . natalizumab blocks both alpha- b integrin (vcam ) and alpha- b integrin (madcam ) interactions (rutgeerts et al. ). therapy of sclerosis multiplex will be more efficient in combination with interferon (miller et al. a, b; nieri et al. ). in animal experiments efd g. pig: reduced pregnancy rates in high-dose group; ppnd cyn: increased abortion and stillbirth rates (pentsuk and van der laan ). in cynomolgus monkeys, however, the abortion rate had not been increased, but hematopoetic changes were observed. natalizumab had no adverse effects on the general health, survival, development, or immunological structure and function of infants born to dams treated with natalizumab during pregnancy (wehner et al. a, b) . % of natalizumab therapy has been stopped because of pregnancy. three of patients treated at least for months developed progressive multifocal encephalopathy (pml; piehl et al. necitumumab (imc- f ) anti-egfr human monoclonal antibody (kuenen et al. ) . nimotuzumab (theracim) humanised, anti-egfr- /her- ; apoptosis, adcc; head and neck cancers (hncc), (spicer ; nieri et al. ; reviewed recently by quatrale et al. ) . omalizumab (xolair) humanized, igg k, anti-ige -asthma. causing marked reduction in serum levels of free ige and down-regulation of ige receptors on circulating basophils. effective in monozygotic twins (holgate et al. ; just et al. ; nieri et al. ) tolerability (corren et al. ). onercept, is a recombinant human p soluble receptor to tnf, failed in a phase ii trial with crohn's disease and the trial was discontinued (bosani et al. ). palivizumab (synagis) humanized, igg k, anti-respiratory syncytial virus "a" epitope of fusion protein. it is used for the prevention of respiratory syncytial virus infection of newborns with different risks for respiratory infections (martin-mateos ; nieri et al. ; weisman ) . panitumumab (vectibix) human, igg k, anti-human epidermal growth factor receptor binding the catalytic kinase domain of the receptor of colorectal cancer (cc; nieri et al. ). increased frequency of abortion/fetal death rates were observed in high-dose group (reviewed by pentsuk and van der laan ; nieri et al. ). eyelash trichomegaly in adults were seen (zhang et al. ; morris et al. ) . racotumomab( e ), an anti-idiotypic vaccine mimicking the n-glycolyl-gm ganglioside (guthmann et al. ; hernández et al. ) effective against breast and lung cancers. ngcgm is practically undetectable in healthy human tissues as a result of an alu-mediated inactivation of the gene, the ganglioside is highly expressed in several human cancer cells presumably due to incorporation of dietary ngc . ramucirumab (dc- ) (an antibody to the vegf receptor- ) (tonra et al. ; krupitskaya and wakelee ) . ranibizumab (lucentis, genentech) humanized, igg -fab, anti-human vasc. endothel. growth factor-a (vegf-a); for the treatment of choroidal neovascular (wet) age-related macular degeneration (armd) reviewed recently (ferrara et al. (ferrara et al. , ; neovascular acute myeloid leukemia (neovascular-aml); (csáky and do ; nieri et al. ). retuximab (epstein-barr virus) anti-cd- (sodani et al. ) . rituximab (rtx, mabthera k , roche) chimeric, igg k, anti-cd (sulesomab, leukoscan). murine fab, binds to surface granulocyte non-specific crossreacting antigen present on neutrophils. rhinitis, fever, chills and toxic laboratory findings occurred during the treatment (klimm et al. ) . hcv cryoglobulinaemia could be also treated (dammacco et al. ) . the treatment of pregnants because of bukitt's lymphoma resulted high rituximab concentrations and a transient complete b-cell depletion in the cord blood. b-cell recovery was fast, showing a regular immunophenotype without loss of cd antigen, no functional deficits and adequate vaccination igg titers (friedrichs et al. ) . administration in third trimester of pregnancy suppresses neonatal b-cell development, but without later neonatal consequences (klink et al. ) , in spite of these the prophylactic withdrawal has been recommended before pregnancy (Østensen et al. ) . human fetal b-cell depletion and lymphocytopenia in cynomolgus, were observed, too (vaidyanathan et al. ) . reduction of post-partum microchimerism was documented (rak et al. ). useful in rheumatoid arthritis therapy (malottki et al. ) in combination with chemotherapy depending on human concentrative nucleotide transporter (hcnt ) gene expression rate (rabascio et al. ) . non-hodgkin lymphoma, rheumatoid arthritis were the indications (nieri et al. ). cd is a costimulatory molecule expressed on a variety of immune cells after activation, including nk cells. cd stimulation by specific igg enhances the antilymphoma activity of anti-cd antibodies by enhancing adcc . of pregnancies with known outcomes, resulted in live births. twenty-two infants were born prematurely; with one neonatal death at weeks. eleven neonates had hematologic abnormalities; none had corresponding infections. four neonatal infections were reported (fever, bronchiolitis, cytomegalovirus hepatitis, and chorioamnionitis). two congenital malformations were identified: clubfoot in one twin, and cardiac malformation in a singleton birth. one maternal death from pre-existing autoimmune thrombocytopenia occurred. women should continue to be counseled to avoid pregnancy for months after rituximab exposure; however, inadvertent pregnancy does occasionally occur. practitioners are encouraged to report complete information to regulatory authorities for all pregnancies with suspected or known exposure to rituximab (chakravarty et al. ) . due to ongoing bleeding, rituximab was given in the th week of pregnancy. the platelet count rose to over  ( )/l after weeks. the neonatal b-lymphocyte count normalized at months after delivery. there were no neonatal complications of rituximab therapy (gall et al. ) . passenger lymphocyte syndrome has been described by lee et al. ( a, b) . siplizumab (cd or medi- ) is a humanised igglk monoclonal antibody that binds to human cd antigen. preclinical studies demonstrated that siplizumab kills target cells by adcc (fanale and younes ; watanabe ) . teplizumab (cd -specific, hokt g -ala-ala), a humanized fc mutated anti-cd monoclonal antibody induced tolerance, on the progression of type diabetes in patients with recent-onset disease even years after the first diagnosis (herold et al. (herold et al. , . tocilizumab (toc, roactemra, roche) against receptor of il- (mouse anti-human il- r antibody into human igg -k chain to create a human antibody with a human il- r binding site il- r a-chain or cd ; b-chain or cd ) at a low concentration of microg/ml, tocilizumab (anti-human il- receptor monoclonal antibody) inhibited the il- -induced matrix-metallo-proteinase (mmp) secretion which was shown to be stimulated in preterm premature rupture of membranes (pprm) (sato et al. ; mano et al. ; malottki et al. ; pham et al. ) . clinical phase trial for the treatment of rheumatoid arthritis has been approved. inherited autoinflammatory syndrome can be sometimes treated with anakinra and tocilizumab (goldfinger ). at present reports on abatacept, tocilizumab or anakinra are inconclusive therefore throughout pregnancy cannot be recommended (Østensen and f€ orger ) . normal pregnancy is characterised by elevated th activity and anti-inflammatory cytokines during the first trimester, followed by increased th activity and proinflammatory factors near term (challis et al. ). in contrast, preeclampsia (pe) is marked by an increase in proinflammatory tumor necrosis factor-a (tnf-a) and interleukin (il- ) cytokines as well as a decrease in the anti-inflammatory cytokines il- and il- . in cases of restricted fetal growth, tnf-a is also elevated when compared with normal pregnancy (dávila et al. ) . women living at , versus , m in colorado had higher proinflammatory (il- , tnf-a) relative to anti-inflammatory (il- ) cytokines during the second and third trimesters (coussons-read et al. ) . multigenerational andean versus shorter duration european high-altitude residents were found to be protected from altitudeassociated fetal growth restriction. higher il- b might play a role in protection from altitude-associated reductions in fetal growth (coussons-read et al. ; dávila et al. ) . tocilizumab treatment increased serum levels of il- and soluble il- r (sil- r; nishimoto et al. ). in combination with other drugs adult onset of still's disease can be improved using monoclonal antibodies (efthimiou and georgy ) . tositumomab anti-cd igg, b-cell lymphoma (armstrong and eck ; nieri et al. ). trastuzumab (herceptin) humanized, igg k, erbb , anti-her . induction of cdc or adcc on an fcreceptor g-binding mechanism. human anhydramnion and oligohydramnion will develop because of the caused fetal kidney insufficiency (watson ; robinson et al. ; katsumi et al. ; matsumoto et al. ). this decrease in amniotic fluid seems to be reversible with the discontinuation of trastuzumab (sukumvanich ) . transfer using aav-recombinant in mice does not induce anti-idiotypes (wang et al. a, b) . the mechanism of toxicity to the fetal kidneys is proposed to be associated with the different structure of egfr in the fetal renal-tubule epithelial cells (heterodimer of egfr and erbb in fetus vs. homodimer of egfr in adults). thus, trastuzumab will have a damaging effect on the fetal renal function, but it does not affect the kidneys of the adult (robinson et al. ) . anti-trastuzumab (ladjemi et al. ): anti-trastuzumab anti-id scfv , used as a therapeutic or prophylactic vaccine, protects mice from developing her -positive mammary tumors by inducing both anti-her ab antibody production and an anti-her th -dependent immune response. these results suggest that scfv could be used as an anti-id-based vaccine for adjuvant therapy of patients with her -positive tumors to reverse immunological tolerance to her . calmodulin inhibitors rescue trastuzumab sensitivity of breast tumours (kulkarni et al. ). the majority of these patients were able to tolerate therapy; however, oligohydramnios or anhydramnios occurred in out of the patients. this decrease in amniotic fluid seems to be reversible with the discontinuation of trastuzumab (sukumvanich ) . tremelimumab (cp- , ; pfizer); ctla- (cd ) t cells; t reg cells; colon and prostatic cancer; . triab d (triab) breast cancer (reece et al. (reece et al. , (reece et al. , . trigerm (disialoganglioside gd ) melanoma . tositumomab (iodine labelled), murine cd , cdc, adcc, radio-cytotoxicity non-hodgkin-lymphoma (nieri et al. ) veltuzumab is a humanized anti-cd antibody with structure-function differences from chimeric rituximab (watanabe ) . visilizumab (cd -specific) for the management of both crohn's disease (cd) and ulcerative colitis (uc). biologics under evaluation or approved for uc that are discussed include monoclonal antibodies to tumor necrosis factor ([tnf] infliximab), inhibitors of adhesion molecules (mln and alicaforsen), anti-cd antibodies (visilizumab), and anti-interleukin (il)- receptor antibodies (daclizumab). biologics under evaluation or approved for cd that are reviewed include three monoclonal antibodies to tnf (infliximab, adalimumab, and certolizumab pegol), monoclonal antibodies against il- , interferon-g, and il- receptors, inhibitors of adhesion molecules (natalizumab, alicaforsen), and growth factors. only the chimeric monoclonal anti-tnf antibody infliximab is currently available worldwide (d'haens and daperno ) . yttrium-ibritumomab tiuxetan and iodine-rituximab are anti-cd monoclonal antibodies combined with radioactive materials for diagnostic and/or therapeutic applications (watanabe ) . zalutumumab anti-egfr mab able to facilitate complement lysis of cancer cells (klausz et al. ) . reviewed recently (quatrale et al. ). expressed by antigen presenting myeloid cells (apc) (magnani et al. ). cd t-cell receptor (tcr)-cd complex resulting in the cells becoming 'blind' to antigen, a process that is also known as antigenic modulation (chatenoud and bluestone ) . cd over % (sato et al. ). cd ctla- negative regulator of t cell activation (kaufman et al. ). trail dr /tnf related receptor (nieri et al. interleukin (naugler et al. ; naugler and karin ; voorhees et al. ; reinartz et al. ). pd- programmed death protein ). complement factor thomas et al. ( ) breast cancer protein reece et al. ( reece et al. ( , reece et al. ( , ige immunoglobulin e, hypersensitivity (corren et al. ). anti-idiotypes carrier of the mimicry of epitopes (ab ) of antigens (k€ ohler ) . respiratory syncytial virus (nieri et al. ). cytotoxic t lymphocyte antigen- (ctla- ) and programmed cell death (pd- ) are members of the known t reg -associated molecules. blocking pd- abrogate the protective effect of t reg , resulting in a higher median abortion rate in comparison with the t reg / isotype-treated control while ctla- blockage did not interfere with the protective effect of t reg . pd- as an important mediator in t reg -induced fetal protection in the cba/ j · dba/ j murine model (wafula et al. ). ctla- was shown to interact with cd and cd resulting in termination of immune response (alegre et al. ) . mice genetically deficient in ctla- expression develop a lymphoproliferative disease which terminates in death by - weeks of age (tivol et al. ; waterhouse et al. ) . the cd possesses also role in the regulation of t-cells (sansom and walker ) . blockade of the interactions between cd and their ligands, cd and cd , has been shown to induce antigen-specific peripheral tolerance in organ transplantation. this knowledge has been successfully used in animal models to prevent allograft rejection by blocking cd and/or cd , thereby leading to long-term graft survival. cytokines favoring the maintenance of fetal survival mainly belong to the th -type (e.g. il- , il- , tgf-b), whereas pregnancy failure is associated with the th -type cytokines (e.g. ifn-g, tnf-a) at the materno-fetal interface and/or the absence of th -type cytokines. the combined use of anti-cd and anti-cd mabs in mice was effective in inducing maternal tolerance to the allogeneic fetus. blockade in vivo of cd and cd costimulation could prevent abortions by shifting cytokines from th predominance to th bias and expanding peripheral cd + cd + regulatory t cells (jin et al. ) . breakdown of immunologic self tolerance maintained by activated t cells expressing il- receptors (cd- ) results in the development of autoimmune diseases (sakaguchi et al. ; sakaguchi ) , which can be mitigated using anti-cd monoclonals. suppressive cd + cd t reg cells are elevated also during pregnancy (somerset et al. ) . intergins: progressive multifocal leukoencephalopathy was observed (pml) probably of polyomavirus etiology after natalizumab (anti-integrin-a ) therapy of crohn's disease (edula and picco ). tnfalpha blockers were shown to induce autoimmunity on ana and anti-dsdna antibodies in ra and spa patients. autoimmunity was induced more frequently with infliximab than etanercept and to a lesser degree to adalimumab therapy but, more importantly, this emergent autoimmunity was exceptionally associated to clinical manifestations of lupus (bacquet-deschryver et al. ) . the effect of infliximab, etanercept or adalimumab on spermatogenesis has been studied in patients with spondylarthritis (villiger et al. ) . sperm abnormalities were found in healthy controls. patients on anti-tnf therapy showed significantly better sperm motility and vitality than untreated patients (Østensen and f€ orger ). antibody products licensed for prevention or treatment of viral diseases include non-immune human immunoglobulin for use against hepatitis a and measles, virusspecific polyclonal human immunoglobulin against cytomegalovirus, hepatitis b, rabies, respiratory syncytial virus (rsv), vaccinia, and varicella-zoster, and the humanized monoclonal antibody palivizumab, fonolizumab and motavizumab (groothuis et al. ) . polyclonal immunoglobulin has also been used with various success for diseases caused by other human viruses including parvovirus b (pv b ), lassa virus, west nile virus, some enteroviruses, herpes simplex virus, crimean-congo haemorrhagic fever virus (cchfv), junin virus, severe acute respiratory syndrome-associated coronavirus (sars cov) and human immunodeficiency virus (hiv). serum polyclonal antibody preparations have been clinically effective in many cases, problems related to toxicity including a risk for allergic reactions, lot to lot variation and uncertain dosing have limited their use (casadevall (casadevall , . the use of rabies and tick-borne encephalitis virus-specific hyperimmune gamma globulins are used in several countries immediately following virus exposure (animal injuries or tick bites). cytomegalovirus-specific hyperimmune gamma globulin is used in the transplantation surgery (schmitz and essuman ) before the era of gancyclovir preventive therapy. sars cov surface glycoprotein, also called spike glycoprotein, (s protein or s glycoprotein) mediates viral entry into the host cell and has two functional domains s and s . the s domain is involved in the binding of the cellular receptor ace whereas the s domain facilitates the fusion between viral and host cell membranes. infections by many viruses, including coronaviruses, elicit potent neutralizing antibodies (nabs) that can affect the course of infection and help clear the virus; they can also protect an uninfected host exposed to the virus. an improved method for epstein-barr virus (ebv) transformation of human b cells has been developed based on cpg oligonucleotides that increases the b cell immortalization efficiency from - % to - %, and this method was used for selection of human abs specific for sars cov proteins. one of the selected antibodies, which was specific for the s glycoprotein on the viral spikes, was about -fold more efficient in neutralization than convalescent serum. nipah virus (niv) and hendra virus (hev) are closely related emerging paramyxoviruses that comprise the henipavirus genus. they are biological safety level- (bsl- ) pathogens, and are on the niaid biodefense research agenda as zoonotic emerging category c priority pathogens that could be used as bioterror agents (zhu et al. ). monoclonal antibodies of enzyme activity have been developed. these can be used in cancer therapy, but the application for the treatment of pregnant women is at present not yet approved (kulkarni et al. ; quatrale et al. ). immunotherapy offers a range of potential treatment options: drug treatment, as well as the treatment of overdose, prevention of brain or cardiac toxicity and fetal protection in pregnant drug abusers. clinical trials, cocaine and nicotine vaccines have been shown to induce antibody titers while producing few side effects (haney and kosten ) . plasmin may serve as a major driving autoantigen for some anticardiolipin (acl) in anti-phospholipid syndrome (aps) patients who are positive for igg anti-plasmin ab. one mab displayed the anti-cardiolipin (acl) and the lupus anti-coagulant (lac) activities and induced fetal loss when injected into pregnant mice ). molecular mimicry has been suggested to play a role in the pathogenesis of many autoimmune diseases, such as allergic encephalomyelitis, experimental myocarditis, and experimental autoimmune keratitis and uveitis antigenic molecular mimicry is characterising anti-dna antibodies. these are reacting with different proteins i.e. enzymes (blank and shoenfeld ) . in case of schizophrenia, the overall finding has been that, when a monozygotic twin has this serious neuromental disorder (nmd), the other identical twin has a % risk; whereas among dizygotic twins, the risk -when one is afflicted -is only %. neuromental disorders (nmd) might be caused indirectly by maternal transplacentally-acquired antibodies, to agents with epitope molecular mimicry with the developing nervous system, and cause alterations which will clinically manifest years later (nahmias et al. ) . serological evidence of previous exposure to ebv in children with ms supports a role for ebv infection early in ms pathogenesis, as already indicated by prospective studies in adults. higher antibody titers and t-cell responses to ebv in patients compared to healthy ebv carriers indicate possible continuous viral reactivation. ms patients have increased cd + and cd + t-cell responses to ebv antigens, particularly ebna . there is some evidence that ebv could break immune tolerance to myelin antigens through molecular mimicry. detection of ebv-infected b-cells in patients' brain raises the possibility that intrathecal b-cell abnormalities and t-cell-mediated immunopathology in ms are the consequence of a persistently dysregulated ebv infection. accordingly, targeting t-cells and/or b-cells with monoclonal antibody therapies ameliorates ms. whether ebv has a causative or pathogenic role in ms can now be addressed in relation to genetic, hormonal and other environmental influences that may affect ebv-host interactions (salvetti et al. ). functional suppression by cd + cd + regulatory t cells was also found to be impaired in ms patients (viglietta et al. ). newborns of pregnants suffering from multiple sclerosis (ms) were impaired by the disease. in case the father of the newborn was suffering from ms, no negative consequences could be documentet i.e. safe paternity characterises ms-patients. the results of mothers does not seem to have an impact on birth weight, however, ms may contribute to a reduced birth weight (hellwig et al. ) . the mothers suffering from ms are usually treated with long-term interferon (ifn) beta-therapy in spite of the pregnancy. the foetal exposure to subcutaneous interferon beta- a therapy before treatment discontinuation was at least days; most pregnancies ( / ; . %) were exposed for days. the rates of spontaneous abortion and major congenital anomalies in live births were in line with those observed in the general population (amato et al. ; sandberg-wollheim et al. ) . the in vitro susceptibility of bewo cells was increased for toxoplasma gondii following treatment with interferon gamma, interleukin and transforming growth factor -beta (barbosa et al. ), but similar consequences were not observed during pregnancy in vivo. congenital epidermolysis bullosa acquisita: vertical transfer of maternal autoantibody from mother to infant neonatal diabetes mellitus comparison of basiliximab and daclizumab with triple immunosuppression in renal transplantation t-cell regulation by cd and ctla- ms study group of the italian neurological society ( ) pregnancy and fetal outcomes after interferon-b exposure in multiple sclerosis phase i/ii study of an anti-cd monoclonal antibody (mdx- ) in hodgkin's lymphoma and anaplastic large-cell lymphoma interleukin- and n-terminal pro-brain natriuretic peptide cord blood levels in premature infants: correlations with perinatal variables epcam: a new therapeutic target for an old cancer antigen tnf-a and the development of the neonatal immune system: implications for inhibitor use in pregnancy impact of three anti-tnfalpha biologics on existing and emergent autoimmunity in rheumatoid arthritis and spondylarthropathy patients successful maternal and fetal outcome of guillain-barré syndrome complicating pregnancy dendritic cells secrete the immunosuppressive hla-g molecule upon ctla -ig treatment: implication in human renal transplant acceptance bewo trophoblast cell susceptibility to toxoplasma gondii is increased by interferon-gamma, interleukin- and transforming growth factor-beta anti-infliximab and antiadalimumab antibodies in relation to response to adalimumab in infliximab switchers and anti-tnf naive patients: a cohort study constitutive p promoter activation and il- production in the terminal ileum mediated by dendritic cells vegf expression by mesenchymal stem cells contributes to angiogenesis in pancreatic carcinoma severe neonatal myasthenia due to maternal anti-musk antibodies pregnancy in wegener's granulomatosis: successful treatment with intravenous immunoglobulin effect of medication on microvascular vasodilatation in patients with systemic lupus erythematosus common vaccinations among adults do not increase the risk of developing rheumatoid arthritis: results from the swedish eira study 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a multicenter, prospective, open-label clinical trial the effects of rituximab treatment during pregnancy on a neonate the myeloid-related proteins and complex, a novel ligand of toll-like receptor , and interleukin- beta form a positive feedback mechanism in systemic-onset juvenile idiopathic arthritis rituximab for management of refractory pregnancy-associated immune thrombocytopenic purpura t cells are crucial for the anti-metastatic effect of anti-epidermal growth factor receptor antibodies immune thrombocytopenic purpura in pregnancy: a reappraisal of obstetric management and outcome genetic polymorphisms of macrophage-mediators in guillain-barré syndrome developing recombinant hpa- a-specific antibodies with abrogated fcg receptor binding for the treatment of fetomaternal alloimmune thrombocytopenia phase iii study of adjuvant vaccination with bec /bacille calmette-guerin in responding patients with limited-disease small-cell lung cancer (european organisation for research and 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patients with multiple sclerosis the epidemiology of graves' disease: evidence of a genetic and an environmental contribution characterization of the antibody response against neugcgm ganglioside elicited in non-small cell lung cancer patients immunized with an anti-idiotype antibody anti-cd monoclonal antibody in newonset type diabetes mellitus a single course of anti-cd monoclonal antibody hokt g (ala-ala) results in improvement in c-peptide responses and clinical parameters for at least years after onset of type diabetes development of innervation of skeletal muscle fibers in man: relation to acetylcholine receptors anti-immunoglobulin e treatment with omalizumab in allergic diseases: an update on anti-inflammatory activity and clinical efficacy immunomodulating antibodies and drugs for the treatment of hematological malignancies behçet's disease and pregnancy pediatric hereditary autoinflammatory syndromes blockade of cd and cd at the time of implantation inhibits maternal rejection to the allogeneic fetus in abortion-prone matings contribution of respiratory syncytial virus g antigenicity to vaccine-enhanced illness and the implications for severe disease during primary respiratory syncytial virus infection childbirths and risk of female predominant and other autoimmune diseases in a population-based danish cohort effectiveness of omalizumab in monozygotic twin sisters with severe allergic asthma placental transport of immunoglobulins: a clinical review for gastroenterologists who prescribe therapeutic monoclonal antibodies to women during conception and pregnancy trastuzumab activates allogeneic or autologous antibody-dependent cellular cytotoxicity against malignant rhabdoid tumor cells and interleukin- augments the cytotoxicity the ctla- gene is expressed in placental fibroblasts the management of pregnancy in paroxysmal nocturnal haemoglobinuria on long term eculizumab insulin needs after cd -antibody therapy in new-onset type diabetes autoimmune disorders: maternal, fetal, and neonatal risks prevention of autoimmune rheumatic disease: state of the art and future perspectives complement-mediated tumor-specific cell lysis by antibody combinations targeting epidermal growth factor receptor (egfr) and its variant iii (egfrviii) progressive multifocal leukoencephalopathy complicating treatment with natalizumab and interferon beta- a for multiple sclerosis current treatment and immunotherapy of hodgkin's lymphoma rituximab administration in third trimester of pregnancy suppresses neonatal b-cell development regulation of immune response by anti-receptor antibody d stimulation enhances the antilymphoma activity of anti-cd antibodies progressive multifocal leukoencephalopathy associated with efalizumab use in psoriasis patients successful term pregnancy in a patient with wegener's granulomatosis: case report and literature review lethal vasculitis of coronary arteries in a neonate and two infants: possible neonatal variant of the mlns/ipn complex? ramucirumab, a fully human mab to the transmembrane signaling tyrosine kinase vegfr- for the potential treatment of cancer a phase i pharmacologic study of necitumumab (imc- f ), a fully human igg monoclonal antibody directed against egfr in patients with advanced solid malignancies calpain regulates sensitivity to trastuzumab and survival in her -positive breast cancer vaccination with human anti-trastuzumab anti-idiotype scfv reverses her immunological tolerance and induces tumor immunity in mmtv.f.huher (fo ) mice maternal autoantibodies and pregnancy. ii. the neonatal lupus syndrome administration of agonistic anti- - bb monoclonal antibody leads to the amelioration of inflammatory bowel disease rituximab for passenger lymphocyte syndrome associated with allogeneic sct ifn-gamma production during initial infection determines the outcome of reinfection with respiratory syncytial virus durable complete responses from therapy with combined epratuzumab and rituximab: final results from an international multicenter, phase study in recurrent, indolent, non-hodgkin lymphoma a prospective nested case-control study of dengue in infants: rethinking and refining the antibody-dependent enhancement dengue hemorrhagic fever model effect of anti-cd antibody alemtuzumab on ex-vivo culture of umbilical cord blood stem cells hypoparathyroidism and autoimmunity in the q . deletion syndrome placental transfer of igg paraprotein with prolonged immunosuppression placental transfer of an igg paraprotein associated with prolonged immunosuppression influence of hla-drb genes and the shared epitope on genetic susceptibility to rheumatoid arthritis in taiwanese increased frequencies of cd + cd (high) regulatory t cells in acute dengue infection guillain-barré syndrome in mother and newborn child monoclonal antibodies to p basic protein and their use in the investigation of some aspects of the guillain-barré syndrome the pathogenesis of biliary atresia: evidence for a virus-induced autoimmune disease killing of myeloid apcs via hla class i, cd and cd defines a novel mechanism of suppression by human tr cells prevalence, incidence and persistence of etanercept and adalimumab in norway adalimumab, etanercept, infliximab, rituximab and abatacept for the treatment of rheumatoid arthritis after the failure of a tumour necrosis factor inhibitor: a systematic review and economic evaluation tocilizumab inhibits interleukin- -mediated matrix metalloproteinase- and - secretions from human amnion cells in preterm premature rupture of membranes long-term followup of children with neonatal lupus and their unaffected siblings monoclonal antibodies in pediatrics: use in prevention and treatment a twin study in behçet's syndrome identification of predictive biomarkers for response to trastuzumab using plasma fuca activity and n-glycan identified by maldi-tof-ms the role of anti-idiotypic antibodies in the induction of experimental systemic lupus erythematosus in mice international natalizumab multiple sclerosis trial group ( a) a controlled trial of natalizumab for relapsing multiple sclerosis marginal transfer of reopro (abciximab) compared with immunoglobulin g (f ), inulin and water in the perfused human placenta in vitro clinicopathological features of malignant lymphoma in japan: the miyagi study anti-pd- synergizes with cyclophosphamide to induce potent anti-tumor vaccine effects through novel mechanisms cytokines in severe respiratory syncytial virus bronchiolitis guillain-barré syndrome in pregnancy: a rare complication of varicella preeclampsia is associated with decreased serum alpha( )-hs glycoprotein (fetuin-a) concentration circulating anti-heat-shock-protein antibodies in normal pregnancy and preeclampsia neonatal myasthenia gravis-a new clinical and immunologic appraisal on cases past hepatitis b virus infection in rheumatoid arthritis patients receiving biological and/or nonbiological disease-modifying antirheumatic drugs biliary atresia in a twin eyelash trichomegaly secondary to panitumumab therapy wegener granulomatosis: a case report and update maternal microchimerism in underlying pathogenesis of biliary atresia: quantification and phenotypes of maternal cells in the liver etanercept during pregnancy and lactation in a patient with rheumatoid arthritis: drug levels in maternal serum, cord blood, breast milk and the infant's serum fine specificity of high molecular weight-melanoma-associated antigen-specific cytotoxic t lymphocytes elicited by anti-idiotypic monoclonal antibodies in patients with melanoma conception and pregnancy outcome in women with inflammatory bowel disease: a multicentre study from japan transient neonatal acquired von willebrand syndrome due to transplacental transfer of maternal monoclonal antibodies the possible role of transplacentally-acquired antibodies to infectious agents, with molecular mimicry to nervous system sialic acid epitopes, as causes of neuromental disorders: prevention and vaccine implications neonatal lupus erythematosus in identical twins, showing transient bullous lesions neonatal myasthenia gravis: report of two cases and review of literature the wolf in sheep's clothing: the role of interleukin- in immunity, inflammation and cancer gender disparity in liver cancer due to sex differences in myd -dependent il- production microchimerism: incidental byproduct of pregnancy or active participant in human health? the synthetic bacterial lipopeptide pam csk modulates respiratory syncytial virus infection independent of tlr activation high serum ifn-alpha activity is a heritable risk factor for systemic lupus erythematosus could myocarditis, insulin dependent diabetes mellitus, and guillain-barré syndrome be caused by one or more infections agents carried by rodents mechanisms and pathologic significances in increase in serum interleukin- (il- ) and soluble il- receptor after administration of an anti-il- receptor antibody, tocilizumab, in patients with rheumatoid arthritis and castleman disease transient neonatal myasthenia gravis in a baby born to a mother with new-onset anti-musk-mediated myasthenia gravis infection enhancement of influenza a h subtype viruses in macrophage-like p d cells by cross-reactive antibodies intravenous immunoglobulin for suspected or subsequently proven infection in neonates immunopathogenesis of vaccine-enhanced rsv disease neonatal lupus erythematosus: a possible role for anti-sm antibodies antibody-dependent enhancement of respiratory syncytial virus infection by sera from young infants fetal acetylcholine receptor inactivation syndrome and maternal myasthenia gravis treatment with biologics of pregnant patients with rheumatic diseases update on safety during pregnancy of biological agents and some immunosuppressive antirheumatic drugs induction of anti-viral immune response by immunization with monoclonal anti-idiotype antibodies directed to private idiotopes structurally derived mutations define congenital heart blockrelated epitopes within the - amino acid stretch of the ro protein neonatal outcomes of pregnancy complicated by idiopathic thrombocytopenic purpura the treatment of rheumatoid arthritis during pregnancy one-step multiplex polymerase chain reaction for preimplantation genetic diagnosis of huntington disease an interspecies comparison of placental antibody transfer: new insights into developmental toxicity testing of monoclonal antibodies pathogenic mechanisms in systemic lupus erythematosus endogenous retroviral pathogenesis in lupus early loss of pregnancy after intravitreal bevacizumab injection club rhumatismes et inflammation (cri) ( ) tocilizumab: therapy and safety management swedish natalizumab (tysabri) multiple sclerosis surveillance study partial reduction of human foxp cd t cells in vivo after cd -directed recombinant immunotoxin administration enhancement of cell-mediated immunity in melanoma patients immunized with murine anti-idiotypic monoclonal antibodies (melimmune) that mimic the high molecular weight proteoglycan antigen fc receptors in immune thrombocytopenias: a target for immunomodulation? differences in platelet function in patients with acute myeloid leukaemia and myelodysplasia compared to equally thrombocytopenic patients with immune thrombocytopenia nti-egfr monoclonal antibody in cancer treatment: in vitro and in vivo evidence new strategies for the treatment of hepatitis c virus infection and implications of resistance to new direct-acting antiviral agents expression of the human concentrative nucleotide transporter (hcnt ) gene correlates with clinical response in patients affected by waldenstr€ om's macroglobulinemia (wm) and small lymphocytic lymphoma (sll) undergoing a combination treatment with -chloro- -deoxyadenosine ( -cda) and rituximab foetal and neonatal thyroid disorders transfer of the shared epitope through microchimerism in women with rheumatoid arthritis clinical use of anti-cd antibody daclizumab to enhance immune responses to tumor antigen vaccination by targeting regulatory t cells use of the anti-idiotype antibody vaccine triab after autologous stem cell transplantation in patients with metastatic breast cancer interim analysis of the use of the anti-idiotype breast cancer vaccine d (triab) in conjunction with autologous stem cell transplantation in patients with metastatic breast cancer use of the anti-idiotype breast cancer vaccine d in conjunction with autologous stem cell transplantation in patients with metastatic breast cancer interleukin- fused to an anti-idiotype antibody in a vaccine increases the specific humoral immune response against ca + (muc- ) ovarian cancer fontolizumab in moderate to severe crohn's disease: a phase , randomized, doubleblind, placebo-controlled, multiple-dose study targeted treatment using monoclonal antibodies and tyrosine-kinase inhibitors in pregnancy association of the idiotype:anti-idiotype antibody ratio with the efficacy of intravenous immunoglobulin treatment for the prevention of recurrent autoimmuneassociated congenital heart block permanent neonatal diabetes mellitus -the importance of diabetes differential diagnosis in neonates and infants inflammatory lesions of the peritoneum mimic carcinomatosis after treatment with intravenous chemotherapy and intraperitoneal catumaxomab permanent diabetes during the first year of life: multiple gene screening in patients biological therapies for inflammatory bowel diseases langman's medical embryology, th edn cd as a molecular target for immunotherapy to treat acute myeloid leukemia with high evi expression naturally arising cd + regulatory t cells for immunologic self-tolerance and negative control of immune responses immunologic self-tolerance maintained by activated t cells expressing il- receptor alpha-chains (cd ) does the use of tumour necrosis factor antagonist therapy in poor prognosis, undifferentiated arthritis prevent progression to rheumatoid arthritis? preferential use of b . and not b . in priming of vaccinia virus-specific cd t cells epstein-barr virus and multiple sclerosis pregnancy outcomes in multiple sclerosis following subcutaneous interferon beta- a therapy natalizumab induction and maintenance therapy for crohn's disease the role of cd and cytotoxic t-lymphocyte antigen- (ctla- ) in regulatory t-cell biology reshaping a human antibody to inhibit the interleukin -dependent tumor cell growth comparison of the neutralizing and elisa antibody titres to human cytomegalovirus (hcmv) in human sera and in gamma globulin preparations outcome of pregnancy in women with inflammatory bowel disease treated with antitumor necrosis factor therapy a phase ii trial of emd (matuzumab), a humanized anti-egfr monoclonal antibody, in patients with platinum-resistant ovarian and primary peritoneal malignancies antiphospholipid syndrome (aps): where does it come from? acquired von willebrand's syndrome in systemic lupus erythematosus guillain-barré syndrome in children b-cell homeostasis requires complementary cd and blys/br survival signals purified t-depleted, cd + peripheral blood and bone marrow cell transplantation from haploidentical mother to child with thalassemia normal human pregnancy is associated with an elevation in the immune suppressive cd +cd + regulatory t-cell subset technology evaluation: nimotuzumab, the center of molecular immunology/ym biosciences/oncoscience anti-erbb- mab therapy requires type i and ii interferons and synergizes with anti-pd- or anti-cd mab therapy hashimoto thyroiditis is more frequent than expected when diagnosed by cytology which uncovers a pre-clinical state cutaneous vasculitis in the newborn of a mother with cutaneous polyarteritis nodosa review of current treatment options for pregnancy-associated breast cancer evaluation of angiogenesis in non-small cell lung cancer: comparison between anti-cd antibody and anti-cd antibody intravitreal bevacizumab during pregnancy the huntington's disease collaborative research group (hdcrg) ( ) a novel gene containing a trinucleotide repeat that is expanded and unstable on huntington's disease chromosomes inhibition of complement activity by humanized anti-c antibody and single-chain fv loss of ctla- leads to massive lymphoproliferation and fatal multiorgan tissue destruction, revealing a critical negative regulatory role of ctla- combined antibody mediated inhibition of igf- r, egfr, vegfr for more consistent and greater anti-tumor effects targeted therapy with the t-cell-engaging antibody blinatumomab of chemotherapy-refractory minimal residual disease in b-lineage acute lymphoblastic leukemia patients results in high response rate and prolonged leukemia-free survival the role of t cells in the enhancement of respiratory syncytial virus infection severity during adult reinfection of neonatally sensitized mice preconceptional oral vaccination prevents experimental biliary atresia in newborn mice neonatal myasthenia gravis: antigenic specificities of antibodies in sera from mothers and their infants idiotype, anti-idiotype network of autoantibodies: pathogenetic considerations and clinical application a patient with rheumatoid arthritis who had a normal delivery under etanercept treatment emabling antibodies: from feto-maternal alloimmunisation prophylaxis to chronic lymphocytic leukaemia therapy developmental immunotoxicology assessment of rituximab in cynomolgus monkeys progressive multifocal leukoencephalopathy after natalizumab therapy for crohn's disease mechanisms of drug transfer across the human placenta efficacy of methotrexate treatment in patients with probable rheumatoid arthritis: a double-blind, randomized, placebo-controlled trial a novel method for the detection of antibodies to adalimumab in the presence of drug reveals "hidden" immunogenicity in rheumatoid arthritis patients systemic lupus erythematosus, regulatory t cells and pregnancy review article: the effects of antitumour necrosis factor-a on bone metabolism in inflammatory bowel disease loss of functional suppression by cd +cd + regulatory t cells in patients with multiple sclerosis effects of tnf antagonists on sperm characteristics in patients with spondyloarthritis biologic therapy and pregnancy outcomes in women with rheumatic diseases effects of abciximab on key pattern of human coronary restenosis in vitro: impact of the si/mpl-ratio targeted inhibition of interleukin- with cnto sensitizes pre-clinical models of multiple myeloma to dexamethasone-mediated cell death pd- but not ctla- blockage abrogates the protective effect of regulatory t cells in a pregnancy murine model immunological responses to the tumor-associated antigen ca in patients with advanced ovarian cancer induced by the murine monoclonal anti-idiotype vaccine aca immunological contribution to the pathogenesis of congenital heart block persistent expression of biologically active anti-her antibody by aavrh. -mediated gene transfer enterovirus infection of monocytes with antibody-dependent enhancement a glycoengineered anti-cd antibody with potent antibodydependent cellular cytotoxicity activity in vitro and lymphoma growth inhibition in vivo treatment strategies for nodal and gastrointestinal follicular lymphoma: current status and future development lymphoproliferative disorders with early lethality in mice deficient in ctla- herceptin (trastuzumab) therapy during pregnancy: association with reversible anhydramnios neonatal lupus erythematosus. a clinical, serological and immunogenetic study with review of the literature postnatal development in cynomolgus monkeys following prenatal exposure to natalizumab, an alpha integrin inhibitor embryo/fetal development in cynomolgus monkeys exposed to natalizumab, an alpha integrin inhibitor motavizumab, a second-generation humanized mab for the prevention of respiratory syncytial virus infection in high-risk populations treatment with tumor necrosis factor inhibitors and intravenous immunoglobulin improves live birth rates in women with recurrent spontaneous abortion prevention strategies for type diabetes mellitus: current status and future directions down-regulation of placenta growth factor by promoter hypermethylation in human lung and colon carcinoma mhc class ii tetramers containing influenza hemagglutinin and ebv ebna epitopes detect reliably specific cd + t cells in healthy volunteers high intra-uterine exposure to infliximab following maternal anti-tnf treatment during pregnancy acquired trichomegaly and symptomatic external ocular changes in patients receiving epidermal growth factor receptor inhibitors rras: a key regulator and an important prognostic biomarker in biliary atresia exceptionally potent cross-reactive neutralization of nipah and hendra viruses by a human monoclonal antibody key: cord- -fyqc bat authors: gleckman, richard; gantz, nelson m. title: cost‐effective antibiotic prescribing date: - - journal: pharmacotherapy doi: . /j. - . .tb .x sha: doc_id: cord_uid: fyqc bat antibiotics are often misused, resulting in a high frequency of adverse effects, emergence of drug‐resistant organisms, and excessive costs. the high cost of antibiotics is currently receiving the greatest attention. considerable cost savings can be achieved by appropriate prescribing of antibiotics for patients receiving these drugs prophylactically as well as for those with established infections. this article cites specific examples of how cost‐effective antibiotic prescribing practices can realize substantial cost savings without any diminished quality in patient care. therapy of established disease appropriate indications use of "therapeutic equivalents" single agent therapy oral versus parenteral route treatment duration hidden costs self or family administration no class of drugs in the hospital formulary is currently receiving closer scrutiny than the antibiotics. these agents are being subjected to intensive examination because of increased pharmaceutical lobbying efforts, concern over the emergence of drugresistant organisms, and the continuous introduction of new compounds. undoubtedly, however, the keen interest in antibiotics primarily stems from the fact that, as a class of drugs, they account for the single largest component of the pharmacy budget. in this age of cost-containment antibiotics will continue to remain in the limelight, particularly for those pharmacists and hospital administrators dedicated to holding the fiscal line. we shall identify antibiotic prescribing practices, both prophylactic and therapeutic, that can be changed to permit cost reductions. we will also describe innovative approaches that are being implemented to counteract the spiraling costs of health delivery. it is often unappreciated that between one-fourth and one-half of all antibiotics prescribed within a hospital are dispensed for prophylaxis. most of these agents are administered to surgical patients to prevent postoperative infections. it thus becomes apparent that if guidelines for perioperative antibiotic use are complied with, significant cost savings can be realized. postoperative wound infections are not only unsightly, but they contribute to morbidity and, most importantly, constitute a threat to the patient's life. these postoperative infections can cause extensive focal infection, bacteremia, hematogenous dissemination, septic shock and multiple organ failure. in addition, postoperative wound infections significantly increase the expense of hospitalization. ' prophylactic antibiotics are indicated exclusively for selective clean and clean-contaminated surgical procedures. clean procedures are those in which neither the respiratory, alimentary, genitourinary, or oropharyngeal cavities are entered and there is no break in technique. clean-contaminated procedures are those in which these cavities are entered without unusual contamination. antibiotic prophylaxis is indicated for a "clean" procedure when a prosthesis is being implanted, or the risk exists for a catastrophic infection. antibiotic prophylaxis is indicated for a "clean-contaminated" procedure when the incidence and consequences of infection are great, and the responsible organisms are predictable and susceptible to antibiotics. infections that are associated with frankly contaminated and dirty procedures merit antibiotics, but here the indication is not prophylaxis but definitive therapy of an established infection. a number of factors have been identified that contribute to postoperative wound infections. surgical factors have included the duration of the operation, the extent of local contamination, and the presence of hematomas, debris and foreign bodies.* host factors that predispose to wound infections include age greater than years, malnutrition, obesity, diabetes mellitus, malignant diseases and the presence of remote infe~tion.~ concerns about prophylactic antibiotics have focused on four issues: drug expense, adverse drug reactions, alterations in the patient's indigenous microflora with the risk for superinfection, and the emergence of drug-resistant organisms that pose a threat to other patients exposed to the hospital flora. these concerns can only be allayed by the intelligent use of perioperative antibiotics in well defined indications. preferred prophylactic antibiotics should be nontoxic, inexpensive, and possess activity against the major pathogens likely to be encountered in the operative area. however, the antibiotics need not be active against every bacterial species present in the operative area. a very limited role exists for the second generation agent cefoxitin, and no indication exists for the third generation cephalosporins cefotaxime, moxalactam, and cefoperazone for perioperative pro phyla xi^.^ these more expensive agents have not been found to be more effective than less expensive agents, and their unrestrained use could encourage the emergence of drug-resistant organisms. effective antibiotic prophylaxis requires attainment of significant tissue concentrations during the "critical period", the period of the early inflammatory response to bacterial contamination. as a general rule adequate tissue concentrations of an antibiotic during the critical period can be obtained by a single dose of the drug administered shortly before the operation, and additional doses dispensed either earlier or later are usually unnecessary. the most common error in surgical prophylaxis appears to be excessive duration of admini~tration.~ no study indicates value to extending prophylaxis beyond hours. limiting perioperative antibiotic prescribing to the first hours would reduce drug-related adverse reactions, the rate of emergence of resistance microorganisms, and the cost of medications. table , , and outline those clean and cleancontaminated surgical procedures that merit perioperative prophylactic antibiotics. the tables describe the indication for prophylaxis and also provide a recommended antibiotic program. among the first generation cephalosporins cefazolin is probably the preferred agent for prophylaxis. this drug produces the highest and most sustained serum concentrations, can be given as infrequently as every hours, and when administered according to a three times daily schedule, is the least expensive cephalosporin. when cefaxolin is prescribed for prophylaxis gram of the drug should be administered i.m. on call to the operating room or i.v. at anesthesia induction. prophylactic antibiotics are also indicated for patients with congenital valvular disease, acquired valvular heart disease or prosthetic valves who are to be subjected to dental, urinary tract, biliary tract or lower intestinal tract instrumentation or surgery. the prophylaxis is designed to prevent bacterial endocarditis. detailed recommendations have been previously published to assist the physician in managing these patients the suggestion has also been made that patients with orthopedic implants be considered candidates for prophylactic antibiotics when they are exposed to procedures that could result in bacteremia. the implant could serve as a locus minoris resistentiae, and a deep wound infection would ensue. this suggestion has, however, neither been confirmed nor refuted by properly executed prospective controlled studies. table lists those operative procedures where prophylactic antibiotic administration has been a common practice despite the lack of controlled studies and scientific justification. we feel that perioperative antibiotics should not be routinely prescribed for these procedures until properly performed clinical studies document their value. major cost savings and a reduction of adverse effects can be attained by appropriate antibiotic usage. a number of investigations have confirmed that at least to % of prescribed antibiotics are not indicated. approximately one quarter to one half billion dollars could be saved annually in the united gleckman and gantz one day is clamped ahigh risk patients for cesarean section prophylaxis include women from the lower socioeconomic status, obese women and patients who have internal fetal monitoring. some experts also recommend prophylaxis for those women with prolonged labor, membranes ruptured more than hours or women subjected to multiple vaginal examinations. states, without compromising patient care by more appropriate antibiotic pre~cribing.'-~ one example of the problem of antibiotic misuse is the practice of prescribing antibiotics for those disorders in which studies have failed to demonstrate any benefit from drug therapy. no justification exists to treat nonpregnant women or elderly chronically catheterized patients with asymptomatic bacteriuria.'o similarly, antibiotics appear to be of no proven value when administered to patients with acute symptomatic bronchitis or acute symptomatic exacerbations of chronic bronchitis. acute bronchitis, an inflammatory disorder of the trachea and bronchi, occurs predominantly in the winter and is often preceded by an upper respiratory infection. invariably a self-limited disease, acute bronchitis is caused most frequently by viruses. antibiotic treatment is not indicated for this inflammatory process. acute exacerbations of chronic bronchitis, consisting of a change in the color, consistency and amount of sputum as well as increasing cough and dyspnea, have been ascribed to viruses (rhinovirus, coronavi rus, influenza) , mycoplasma pneumoniae and bacteria, including haemophilis influenzae, streptococcus pneumoniae, gram-negative bacilli and "normal respiratory flora." antibiotics have been prescribed to shorten the duration of the exacerbation, prevent respiratory failure or forestall progressive pulmonary deterioration that often occurs in patients with chronic bronchitis. no evidence has emerged that antibiotics can accomplish any of these desired goals. in fact, nicotra and associates could not document any beneficial effect by the addition of antibiotics to the conventional modes of therapy in patients with acute exacerbations of chronic bronchitis requiring hospitalization.'* it has become ritual to prescribe antibiotics to noncompromised patients with localized cutaneous abscesses. for patients with normal host defenses drainage is adequate therapy, and antibiotics are not indicated. i in addition to the problem of prescribing antibiotics for disorders in which no benefit has been established, physicians often equate "best" treatment with the newest, invariably more expensive, antibiotic. penicillin g remains the drug of choice for pneumococcal pneumonia, community-acquired aspiration pneumonia, dental infections, streptococcal pharyngitis and syphilis. although the more expensive cephalosporins possess an expanded spectrum of activity, cure rates are not improved by prescribing these antibiotics instead of penicillin. only when controlled studies show enhanced efficacy or reduced toxicity should the newer, more expensive agent be prescribed. similarly, the inexpensive sulfonamides remain highly effective agents to treat communityacquired symptomatic bacterial cystitis in women. in the absence of a history of an allergic reaction to sulfonamide, there is no reason to prescribe the more expensive compounds, such as cefaclor, cephalexin, cefadroxil, nitrofuratoin or trimethoprimsulfame-thoxazole, when treating a woman with symptomatic, community-associated bacterial cystitis. generic gentamicin is available at a cost that is approximately one-third that of the other aminoglycosides tobramycin, netilmicin, or amikacin. for hospitals, particularly community hospitals, where gentamicin-resistant gram negative bacilli are uncommon pathogens, generic gentamicin can be selected as the preferred aminoglycoside. in other hospitals, generic gentamicin can be substituted for the other aminoglycosides as soon as results of antibiotic susceptibility tests permit. for patients with suspected or established infections caused by pseudornonas aeruginosa, tobramycin should be selected while awaiting the results of antibiotic susceptibility tests. tobramycin is also preferred by some experts for treating patients with renal insufficiency who have infections requiring an aminoglycoside; the rationale is based on a lower frequency of nephrotoxicity, as measured by serum creatinine values. amikacin should be selected to treat infections caused by proteus vulgaris or providencia stuarfii while awaiting susceptibility reports. for patients with nosocomial gram negative infections requiring an aminoglycoside, tobramycin or amikacin should be selected initially if gentamicin resistant strains are prevalent in the hospital. as soon as the results of antibiotic susceptibility tests are available, gentamicin can be substituted for tobramycin or amikacin. with the above exceptions, gentamicin can be selected initially or after the results of susceptibility tests are known; this strategy will result in considerable cost savings to patients. cephalosporins account for up to one third of total pharmacy drug expenditures. the first generation cephalosporins cephalothin, cephapirin and cefazolin have essentially the same spectrum of activity. pharmacokinetically, cephalothin and cephapirin are interchangeable, but use of cephapirin can result in substantial savings. because of its more favorable pharmacokinetic profile, cefazolin can be given in doses that are one third those of cephalothin or cephapirin, with comparable effectiveness. cefazotin also requires less frequent dosing per day than cephalothin (four versus six times). since cefazolin can be given intramuscularly, intravenous administration costs are saved. cefazolin also is subject to competitive pricing since it is sold by two drug companies. with desirable pharmacokinetic properties as well as the ability to purchase the drug on bid, cefazolin is probably the first generation cephalosporin of choice. a common error in antibiotic prescribing is the failure to modify therapy when the results of antimicrobial susceptibility tests are available. an example of this error is the severely ill patient presenting with high fever, sweats, chills, hypotension and no obvious source of infection. broad spectrum therapy with two antibiotics is usually prescribed pending the results of cultures and antimicrobial susceptibility tests. initial therapy should not dictate later therapy, however. when the infecting organism is known and the susceptibility report is available, it is often possible to discontinue the initial broad spectrum combination drugs and prescribe a single, less expensive and potentially less toxic agent. while multiple drugs may be preferred therapy to treat selected infections such as fneumocysfis carinii pneumonia, malaria, toxoplasmosis, tuberculosis, enterococcal endocarditis, infection caused by psuedomonas aeruginosa or gram negative bacteremia in an immunosuppressed host, a single pathogen usually requires therapy with only one antibiotic. prescribing more than one drug to the patient is not only more expensive, but this practice often entails greater risk for untoward events. the use of a combination of antibiotics has been the conventional initial therapy for patients with intraabdominal and pelvic sepsis. until the results of cultures and susceptibility tests are available, usually an aminoglycoside with clindamycin, metronidazole, chloramphenicol or one of the extended spectrum pencillins (carbenicillin or ticarcillin) is prescribed to assure activity for the anaerobic components, particularly bacferoides fragilis, as well as the facultative gram-negative rods contributing to these infections. recently, cefoxitin therapy has been compared with the combination of clindamycin plus amikacin for the treatment of mixed aerobicianaerobic infections." a prospective randomized trial of patients given these therapies revealed no difference in therapeutic efficacy or incidence of toxicity. however, the cost of cefoxitin therapy was significantly less than the cost of the drug omb bin at ion.'^ these results were confirmed in a subsequent study of patients given either cefoxitin or a combination of clindamycin and an aminoglycoside for the treatment of polymicrobial pelvic and abdominal infections. therefore, it appears that cefoxitin alone may well be as safe and therapeutically effective as the standard combination treatments when it is administered to selected patients with community-acquired mixed anaerobidaerobic infections that result from appendicitis, diverticulitis, bowel trauma, pelvic inflammatory disease or endometritis. however, it would be preferable to add an aminoglycoside to cefoxitin for those patients with intraabdominal or pelvic infections who have received antibiotics within the preceding weeks or who have experienced a nosocomial abdominal or pelvic infection. considerable cost savings can be achieved by changing from parenteral to oral antibiotic administration and by replacing hospitalization with carefully supervised home treatments. oral therapy eliminates the cost of intravenous solutions and sets and the personnel time involved in preparation and infusion. recent studies have confirmed the efficacy and reduced expense of oral antibiotics prescribed for selected children with osteomyelitis and septic arthritis. " in , it was reported that favorable results ensued when oral antibiotic therapy was prescribed for hospitalized patients with serious infectionsz fourteen patients with osteomyelitis were treated successfully with oral cephalexin after they had received a short course of parenteral cephaloridine. however, it was not until when tetzlaff and associates reported on children with osteomyelitis and septic arthritis, who had been treated with a brief initial course of intravenous therapy followed by oral antibiotics, that major attention was directed to this novel cost saving approach. the children with acute osteomyelitis and septic arthritis were hospitalized for the entire course of therapy. parenteral therapy was given initially for about one week, and volume , number , july~august then oral antibiotics were administered for a mean of approximately weeks. drug absorption was monitored by measuring serum antibiotic concentrations and by determining serum bacterial activity. the oral antibiotics were well tolerated and all infections except one responded in , prober and associates reported on their experience treating children with serious staphylococcal infections (predominantly osteomyelitis). the children were treated with a short course of parenteral therapy followed by oral administration of antibiotic~.~~ once the children became asymptomatic they were discharged from the hospital for supervised oral therapy at home. the children were seen once or twice weekly in an outpatient setting; serum bactericidal levels of the antibiotics were monitored. this report and subsequent studies appear to indicate that with careful monitoring oral antibiotic therapy can be as effective as the standard prolonged intravenous therapy for specific skeletal infections in oral therapy is cost effective, particularly when given at home, and this form of treatment is not associated with the inherent risks of intravenous infusion, namely, chemical phlebitis and bacteremia. home oral therapy permits increased patient comfort for the child. however, oral therapy necessitates careful sequential clinical monitoring; demonstration of therapeutic serum bactericidal antibiotic concentrations is since follow-up evaluations beyond years on children who have received oral therapy have not been reported, prolonged vigilance will be required to detect recrudescent disease; relapses have been detected more than years after the first attack of osteomyelitis. hospitalization and parenteral antibiotic therapy has been considered the conventional treatment program for women with acute symptomatic community-acquired bacterial pyelonephritis. however, this infection can be treated in an outpatient setting when diagnosis is secure, the patient does not appear "toxic", the patient can tolerate oral medication, clinical and laboratory "follow-up" can be obtained, and the patient has not recently received antibiotics or been subjected to instrumentation. trimethoprimsulfamethoxazole possesses a spectrum of activity that encompasses most organisms that cause community-oriented bacterial pyelonephritis in women, and this drug has been successfully used for the outpatient treatment of symptomatic pyelonephri-ti^.^^ metronidazole administered orally is well absorbed even in the presence of food. consequently, the serum concentrations of metronidazole that are achieved are similar after either oral or intravenous administration of the drug. patients who are responding to parenteral metronidazole therapy can be successfully switched to oral metronidazole when the clinical situation dictates, and this results in substantial savings. if a patient is unable to swallow tablets, the drug can be given as a liquid preparation that can be formulated by the hospital pharmacist. duration of drug therapy contributes to antibiotic costs. virtually all recommendations as to how long drug therapy should continue are empiric, even for common disorders such as pneumococcal pneumonia and streptococcal c e l l~l i t i s .~~~ since limited information is available on the precise duration of drug therapy, patients are probably treated for unnecessarily long periods. as new data emerge, however, we learn that antibiotic therapy can often be shortened, thereby resulting in cost savings and diminished toxicity. single dose therapy has emerged as the preferred treatment tactic for acute, symptomatic bacterial cystitis in young women.i when compared to the conventional - day course of treatment single dose therapy is less expensive, safer, equally effective, and associated with better compliance. single dose treatment of women with bacterial cystitis has not resulted in bacteremias, hospitalization or death. ' single dose treatment should be limited to women who are not pregnant, have neither renal insufficiency nor structural abnormalities of the urinary tract, and are able to provide post-treatment cultures. the following antimicrobial agents are safe and effective single dose therapy: sulfisoxazole g; trimethoprim mg; trimethoprim-sulfamethoxazole regularstrength tablets and amoxicillin g." no explanation exists for why cephalosporins have consistently failed as single dose therapy.i a single oral dose of grams of metronidazole (eight mg or four mg tablets) is less expensive, as effective, and as well tolerated as the conventional - day course of therapy to treat vaginitis caused by trichomonas ~a g i n a l i s .~~ studies have also documented the efficacy of shorter treatment courses employing regimens of ampicillin, tetracycline or erythromycin to treat disseminated gonococcal i n f e~t i o n .~~ formerly, disseminated gonococcal infections were treated for a minimum of weeks by the intravenous route exclusively. adults with disseminated gonococcal infection can be effectively treated with a one week program consisting initially of million units of penicillin g administered every hours followed by oral ampicillin or amoxicillin prescribed as mg four times daily. , hospitalization is usually recommended to establish the diagnosis of disseminated gonococcal disease since misdiagnosis occurs not infrequently with this disorder. selected patients can complete the oral regimens in an outpatient setting or, alternatively, they can be treated entirely without ho~pitalization.~~ acceptable oral regimens consist of giving amoxicillin ( mg four times daily), tetracycline ( mg four times daily), or erythromycin ( mg four times daily) for at least days. the following requirements should be met before home treatment is recommended: the diagnosis should be well established; the patient should be considered compliant; complications, such as purulent joint effusions, must be cost-effective anti b iotlc prescribing gleckman and ganfz absent; and the patient must be able to return for follow-up observations. the standard treatment for pulmonary tuberculosis consists of the combination of isoniazid (inh)ethambutol, inh-rifampin, or rifampin-ethambutol prescribed for - months. prolonged chemotherapy is expensive and is associated with compliance and toxicity problems. studies have confirmed that specific regimens given for to months to adults with uncomplicated pulmonary tuberculosis are as effective as more prolonged therapy and have the advantage of being less expensive and well tolerated. s short course treatment regimens for adults consist of administering inh ( mg) and rifampin ( mg) daily for to months. if the patient has had previous antituberculosis therapy or has emigrated from an area such as asia or africa, where high levels of initial drug resistance exist, then the inh-rifampin should be supplemented with streptomycin ( - mg/kg), pyrazinamide ( mg/kg), or ethambutol ( mg/kg) daily for the first months, pending the results of susceptibility tests. if resistance to inh or rifampin is found by susceptibility tests, then short course chemotherapy is not indicated. a regimen should be selected using two or three drugs to which the organisms are susceptible, and it should be given for a period of to months. for the abbreviated treatment to be successful, patient compliance is critical. patients should be seen monthly, pill counts should be performed, urines should be tested for the presence of inh and rifampin, and bacteriologic examinations of sputum must be done. treatment should be continued until at least months have elapsed from the time of conversion of the sputum culture from positive to negative. for most patients, the total duration of therapy will be months. patients should be followed closely for year after completing the short course regimen in order to detect relapse. for noncompliant patients, after an initial phase of daily inhrifampin treatment administered for to months, therapy can be continued twice-weekly with inh ( mg/kg) and rifampin ( mg) for to months. the medications must be administered under supervision, and patients who receive intermittent rifampin should be monitored for the development of thrombocytopenia and a "flu syndrome." these abbreviated treatments cannot be recommended for children, for patients harboring drug-resistant organisms, for patients with extra-pulmonary tuberculosis, for patients with unique predisposing concomitant disease, such as silicosis or diabetes, or patients who have experienced previous drug failure or microbiological relapse. conventional therapy for endocarditis caused by penicillin-susceptible streptococci, defined as those strains with a minimum inhibitory concentration of d . pg/ml, consist of either million units of penicillin per day administered intravenously alone for four weeks or million units of parenteral penicillin for four weeks and concomitant streptomycin ( g/day) during the initial two weeks. a regimen consisting of penicillin and streptomycin prescribed for only two weeks appears to be as safe and as effective as these four week regimen^.^^.^^ no data are available showing that the relapse rate after the two week treatment course exceeds that of the conventional - week treatment program. the patients are treated in the hospital and receive procaine penicillin ( . million units every six hours) and streptomycin ( mg every hours) intramuscularly for weeks. short term therapy is not, however, recommended for patients who have had symptoms that exceed three months or have infection involving a prosthetic valve. preexisting vestibular disease, the presence of complications, (mycotic aneurysm, shock, cerebritis), abnormal renal function, or the identification of streptococcal endocarditis caused by resistant (mic > . pg/ml) or nutritionally dependent strains precludes short course therapy. the principal disadvantages of the two week regimen are the frequent intramuscular injections required and the risk of streptomycin-induced otoxicity. the total cost of antibiotic therapy consists of a number of components, only one of which is the drug price. "hidden" costsadministration sets and supplies, tests for laboratory monitoring, pharmacy preparation time and nursing timeare usually omitted in cost analyses. these ancillary costs can account for approximately one-half of the total expense of antibiotic the rap^.^' potentially less toxic antibiotics that require minimal laboratory monitoring for evidence of adverse reactions can decrease drug costs. for example, laboratory monitoring of renal function and aminoglycoside serum concentrations can contribute as much as one-third of the total antibiotic costs when aminoglycoside antibiotics are pre-s~ribed.~' an antibiotic such as cefazolin that possesses desirable pharmacokinetic properties (i.e., infrequent dosing, reduced dosage and diminished nephrotoxicity when compared with other first generation cephalosporins) and can be prescribed by the intramuscular route can decrease these "hidden" costs considerably. for example, by substituting intramuscular cefazolin for an intravenous betalactam resistant penicillin, a savings of $ per day could occur. when studies demonstrate that different antibiotics provide equivalent therapeutic eff icacy and safety, these "hidden" costs should be considered when antibiotic recommendations are being offered. prolonged administration of intravenous antibiotics, i.e., therapy that exceeds weeks in duration, has emerged as the preferred treatment course for patients with osteomyelitis, infective endocarditis and systemic fungal infections. traditionally, these patients have remained in the hospital for the dura- pharmacotherapy volume , number , july/august tion of treatment even though one to two weeks after the onset of therapy many patients feel well and are anxious to return home to complete their treatment. one innovative approach to the treatment of these serious infections has focused on the use of selfadministration of intravenous antibiotics in the the cost of home parenteral antibiotic therapy is about one-fourth to one-third of the inhospital the concept of home intravenous therapy is not new. successful home intravenous programs have included patients with hemophilia who receive clotting factors, patients with parenteral alimentation, and patients sustained by chronic hemodialysis. in , rucker and harrison were the first investigators to report on the use of intravenously administered antibiotics given in the home. sixty-two children with cystic fibrosis were treated at home with either intravenous gentamicin or colistimethate for the management of pseudomonas-related pulmonary infections. in that study, infectious episodes were treated at home, resulting in a % reduction in the need for hospitalization. the patients were seen once weekly, and no major complications were noted. subsequent reports on parenteral administration of antibiotics at home appeared in , (table ) and to date patients have been treated at five centers in the united states and almost half of the patients ( ) were treated at home in a program developed at the fairfax hospital, a large community-teaching hospital in the washington, d.c. area. patients selected for home treatment are considered to have responded satisfactorily to the intravenous program initiated in the hospital and require only a more extended course of intravenous antibiotics. home intravenous programs are coordinated by a team consisting of infectious disease specialists, pharmacists and nurses skilled in performing intravenous infusion. one to two days prior to discharge the patients and a family member are taught the techniques necessary to care for an i.v. cannula. the cannula is changed twice a week at home by a visiting nurse or in the hospital's outpatient department. the duration of home i.v. therapy averaged two to three weeks. in each of the published series, patients with osteomyelitis and septic arthritis have predominated, but patients with other infections have also been successfully managed (table ) . a vast array of antibiotics have been used, and the solutions, which have been prepared in the hospital pharmacy, are kept refrigerated at home. antibiotics with long half-lives, such as cefazolin, are preferred since they permit dosing every six or eight hours. patients may be given a four or five day supply of antibiotic, depending on the stability of the drug, and they are instructed to return to the outpatient department once or twice weekly to have their progress evaluated. all studies have monitored patients for cornplications of the initial infection, compliance, adverse effects, including antibiotic toxicities and i.v. compli-cations, and superinfection. to date, all programs have confirmed the safety and efficacy of this form of therapy. long-term follow-up is not available in all of the studies, but short term efficacy data parallel the experience of in-hospital care. patients have been able to return to work and to school. home antibiotic programs require compliant patients, appropriate close monitoring, and the houra-day availability of a hospital team consisting of a pharmacist, i.v. nurse and physician. successful programs also require that insurance carriers reimburse patients for these out-of-hospital extended charges. to date, medicare has not paid for outpatient antibiotic therapy, and some insurance carriers will reimburse policy holders for only % of the charges. it appears that for selected patients substantial cost savings can be realized with this novel approach to prolonged antibiotic the rap^.^' success of home intravenous antibiotic programs mandates careful selection of patients. those selected must be well enough to go home (except for the need for intravenous therapy), be compliant, and be proficient or have a family member trained in the administration and aseptic care of an i.v. cannula. various strategies have been advocated to reduce antibiotic misuse. approaches have included physician education, omission from formulary, restriction of selected antibiotics by pharmacists or infectious disease specialists, peer audits of prescribing practices, and surveillance of drug use by clinical pharm a c i s t~.~~ an additional strategy for improving antibiotic prescribing practices consists of providing more readily accessible information on antibiotics to clinic i a n~.~~ unfortunately, these efforts have often had limited success. in a study by jones et al, hospital staff did not improve their usage of antibiotics after an intensive educational program. a greater impact on unjustified antibiotic usage has been reported in studies employing direct control measures. substantial savings resulted when usage of selected antibiotics required either an infectious disease consultation or written justification by the mcgowan and finland demonstrated that by removing an antibiotic from the restricted list, there was a marked increase in usage of that agent ' in a study by durbin and associates, physicians were required to indicate the rationale for antibiotic usage. depending on the category selected, drugs were discontinued after days for prophylaxis, after days for empirical therapy, and after days for a therapeutic indication. a new prescription form had to be completed for the drug to be reordered. this program resulted in a % reduction in the mean duration of antibiotic prophylaxis. there was, however, little impact on antimicrobial use on the medical service with the prescription system. another approach that could reduce indiscriminate antibiotic usage is for hospitals to develop their own antibiotic guidelines similar to those developed the guidelines should be developed by a multidisciplinary committee composed of physicians who prescribe antibiotics as well as representatives from infectious diseases, pharmacy, and hospital administration. there should be agreements as to what constitutes appropriate and unacceptable antibiotic usage. once antimicrobial surveillance data to monitor compliance are accumulated, corrective action will require peer pressure from chiefs of services and strong administrative support. postoperative wound infection: a controlled study of the increased duration of hospital stay and direct costs of hospitalization postoperative wound infections: the influence of ultraviolet irradiation on the operating room and of various other factors surgical wound infection occurrence in clean operations the third-generation cephalosporins: a plea for restraint use of antimicrobial drugs in general hospitals: patterns of prophylaxis prevention of bacterial endocarditis use of antibiotics: a brief exposition of the problem and some tentative solutions this is medical progress? trends and consequences of antibiotic use in the united states a study of antimicrobial misuse in a university hospital the controversy of treatment of asymptomatic bacteriuria in nonpregnant women-resolved role of infection in chronic bronchitis antibiotic therapy of acute exacerbations of chronic bronchitis. a controlled study using tetracycline cutaneous abscesses clinical management of urinary tract infection antibiotic combinations: the clinical relevance of synergy and antagonism prospective, randomized, comparative study of clindamycin, chloramphenicol, and ticarcillin, each in combination with gentamicin, in therapy for intraabdominal and female genital tract sepsis cost comparison of two antimicrobial regimens for treating mixed aerobic-anaerobic infections a prospective randomized controlled trial of cefoxitin versus clindamycin-aminoglycoside in mixed anaerobic-aerobic infections clindamycin treatment of osteomyelitis and septic arthritis in children oral antibiotic therapy for skeletal infections of children. ii. therapy of osteomyelitis and suppurative arthritis high-dose dicloxacillin treatment of acute staphylococcal osteomyelitis in children long-term follow-up of ambulatory management of osteomyelitis success with cephalordine-cephalexin therapy use of the serum bactericidal titer to assess the adequacy of oral antibiotic therapy in the treatment of acute hematogenous osteomyelitis marks mi et at. oral antibiotic therapy of skeletal infections in children oral antibiotic therapy for bone and joint infections oral versus parenteral therapy of pyelonephritis metronidazole: an update on its expanding role in clinical medicine for how long should antimicrobial therapy continue (editorial) current practices in antimicrobial dosing efficacy of single-dose and conventional amoxicillin in urinary-tract infections localized by the antibody coated bacteria technique treatment of trichomonas vaginalis infections treatment of disseminated gonococcal infections gonococcal tenosynovitis-dermatitis and septic arthritis sexually transmitted diseases treatment guidelines short-course chemotherapy for tuberculosis with largely twice-weekly isoniazid-rifampin british thoracic association. a controlled trial of six months chemotherapy in pulmonary tuberculosis. second report: results during the months after the end of chemotherapy guidelines for short-course tuberculosis chemotherapy antimicrobial therapy for penicillin-sensitive streptococcal infective endocarditis: two-week regimens outpatient intravenous medications in the management of cystic fibrosis intravenous antibiotic therapy in an outpatient setting intravenous antibiotic therapy at home feasibility of outpatient self-administration of parenteral antibiotics outpatient intravenous antibiotics experience with patients intravenous antibiotic therapy at home training patients to administer intravenous antibiotics at home self-administration of intravenous antibiotics: an efficient, cost-effective home care program. cma j . frame pt. outpatient intravenous antibiotic therapy (editorial) evaluation of antibiotic usage: a comprehensive look at alternative approaches antimicrobial misuse, antibiotic policies and information resources the effect of an educational program upon hospital antibiotic use the antibiotic utilization committee: an effective tool in the implementation of drug utilization review that monitors the medical justification and cost of antibiotic use infection and antibiotic usage at boston city hospital: changes in prevalence during the decade - usage of antibiotics in a general hospital: effect of requiring justification improved antibiotic usage following introduction of a novel prescription system successful two-week treatment schedule for penicillin-susceptible streptococcus viridans endocarditis guidelines for peer review, veterans administration ad hoc interdisciplinary advisory committee on antimicrobial use, audits of antimicrobial usage the influence of dose frequency - key: cord- -oswgjaxz authors: nan title: abstracts: (th) european congress of trauma and emergency surgery may – , brussels, belgium date: journal: eur j trauma emerg surg doi: . /s - - -z sha: doc_id: cord_uid: oswgjaxz nan introduction: frequently fractures of modern sport disciplines are fractures of the clavicle. most of them are uncomplicated and still treated without operation. therefore there is a lack of bigger studies about the treatment of clavicle fractures by elastic stable intramedullary nailing (esin). nevertheless this method becomes more and more popular, especially for young and active people. intention of this investigation was to analyze risks and results of this method to check the indication for operative treatment of simple fractures in this group of patients. material and methods: this study is a retrospective analysis of patients whose fractures of the clavicle were treated by intramedullary nailing. crucial for the decision for operation was the individual request of the patient after information of the relative indication. included were patients with fractures of the middle third, fractures of the lateral third and fractures with concomitant shoulder injuries from to . the duration of operation, intraoperative radioactive loading and complications were analyzed from the medical file. the functional outcome was measured by the constant-score. the anatomical reduction was proved by measuring the difference of the length of both clavicles ( - month after operation). results: the average duration for the middle third was min ( - ), for the lateral third ( - ) minutes and for fractures with concomitant injuries min . the mean radioactive surface dose was , cgy/cm . four complications ( %) cause revision operations: one secondary dislocation which leads to pseudarthrosis and two imminent penetrations of the medial end of the nail. one patient had developed a painful pseudobursa due to lateral penetration of the nail. additional there were two prematurely nail extractions because of medial irritation of the soft tissue. altogether we documented complications in % of the operations. overall an open reduction was necessary in %. after healing there has been no significant shortening of the fractured clavicle in comparison of both sides. the constant-score showed good postoperative results (average: , median: , lowest / ). conclusion: esin with titan nails is an alternative method of treatment with good results. nevertheless we documented complications in %. in the literature complication rates from - % has been described. the complication rate of esin seems to be comparable to the conservative treatment. in our opinion the relevant intraoperative radioactive dose is an often underestimated factor. the operation time is often longer than thought before starting and often an open reduction is necessary. because of these reasons the conservative therapy should still be the standard. esin can be an alternative especially for young athletic ambitious patients after a detailed information about the risks. disclosure: no significant relationships. introduction: the optimal management of clavicle fractures is still controversial, although the nonoperative treatment remains the standard in most fractures. recent studies have reported a higher nonunion rate and unsatisfactory functional results after nonoperative treatment. therefore, there is an increasing interest in the primary operative management of displaced midshaft fractures. however, no treatment-consensus exists at this moment. the goal of the present study was to compare plate fixation with nonoperative treatment of displaced midshaft clavicle fractures in adults with a minimum of weeks follow-up. material and methods: in a multi-center prospective clinical trial patients with a fully displaced midshaft clavicle fracture were included within one week after the injury. after a standard information procedure, patients were asked if they wanted to have a operative or a nonoperative treatment. outcome analysis included standard clinical follow-up, the constant shoulder score, the disability of the arm, shoulder and hand (dash) score and complication rate at and weeks after the injury. results: between january and october a total of patients were included: patients were treated operatively ( . % men, mean age . years) and patients were treated nonoperatively ( . % men, mean age . years). constant and dash scores were significantly higher in the operative group compared with the nonoperative group at weeks ( vs and . vs . ). there was no significant difference at weeks ( vs and . vs . ). in both groups two patients developed pseudartrosis, all four required surgery. in the nonoperative group symptomatic malunion was more frequent: twelve patients at weeks ( . %) versus none in the operative group. other complications in the operative group were mostly hardware related: pain and irritation requiring plate removal after consolidation in four patients ( . %), two broken plates due to the earlier mentioned pseudartrosis ( . %), one early outbreak of the plate ( . %) and one woundinfection ( . %). furthermore, patients with heavy professional work activities returned to their jobs at an average of three weeks after injury in the operative group compared with seven weeks in the conservative group. at weeks after the injury, the patients in the operative group were more satisfied compared to those in the nonoperative group ( % vs %). conclusion: operative fixation of a displaced midshaft clavicle fracture results in improved functional outcome at weeks after injury and in a higher satisfaction rate at weeks. this study shows that patients with heavy jobs restarted their professional activities sooner if they were treated operatively. furthermore, higher satisfaction with the appearance of the shoulder may be a reason for surgery. introduction: the unstable shoulder girdle with a fracture of the clavicle (floating shoulder, ipsilateral serial rib fractures) is a classical indication for a plate osteosynthesis of the clavicle. despite a relatively high complication rate ( - %), such as implant failure, non-union and refracture after implant removal, open reduction and internal plate fixation (orif) has been the gold standard for many years. this open procedure with direct reduction maneuvres might be blamed for at least some of the complications due to iatrogenic damage of the blood supply of the fracture fragments. our hypothesis is that a closed method with indirect reduction might reduce some of the complications. the goal of our study was to test the practicability of the mipotechnique in clavicle fractures in unstable shoulder girdles. material and methods: between and we included, out of internally fixed shaft fractures in total ( x plate, x elastic nail), patients with either a floating shoulder (n = ) or a clavicle fracture in combination with ipsilateral serial rib fractures (n = ), in this study. operative technique: a locking compression plate (lcp) . with - holes was anatomically shaped to the anterior (-caudal) contour of the contralateral clavicle and then inserted percutaneously from lateral to medial using a short incision at the anterior border of the lateral end of the clavicle. using mainly indirect maneuvres, the fracture was reduced and then fixed in a pure bridging technique never using interfragmentary lag screws. free unloaded rom was allowed immediately after the operation with full loading - weeks later. follow-up examination was performed to years later with clinical (dash-score, shoulder function, length measurement) and radiological (fracture healing, length measurement) examination. results: / fractures healed without complications. clinical and radiological length measurement showed no significant differences to the contralateral side (range: + mm to - mm). in all patients a very good functional result was achieved with an average dash score of . ( - ). one implant failure occured two years after the initial trauma in a road workman. at reoperation only a partial consolidation of the original fracture was observed. restabilization and bone grafting led to an uneventful healing. conclusion: the mipo technique is feasible even in clavicle fractures and can lead to good functional and cosmetic results. the advantage might be its low invasiveness which better preserves the vascular supply of the fracture fragments. however it is technically demanding mainly due to the small size of the fractured bone. therefore in our opinion it requires a surgeon experienced in the mipo technique of treating fractures of larger bones as tibia and femur. introduction: there are some reports on the difficulties of removing the locking compression plate in clavicle fractures, due to problems of removing the self tapping locking screws. we retrospectively investigated if this was also the case in our institution in removal of lcp plate of the clavicle and if this was incidential or becoming a trend. material and methods: from october till october , we have removed locking compression plates after claviclefracture stabilization. all of the locking screws were inserted by trauma surgeons with the use of the torque limiting srewdriver according to the manufacturer's recommendations. a total of screws where removed. they consisted of fifty-one . mm self tapping cortical screws and hundred and twenty . mm self tapping locking screws. results: from the locking compression plates that where removed after claviclefracture stabilization, in eleven patients ( %) a problem with removal of the plate arised. this was caused by a total of self tapping locking screws. in all cases jamming of the screwheads in the plate was found to be the reason. there was ''cold welding'' between the threaded head of the locking screw and the locking plate. for removal four different strategies were used. in two screws the head was drilled off and the plate removed and subsequent the rest off the screw removed with forceps. five times the plate was bend around the screw and by rotating the plate (helicopter) both were taken out. in eight screws the recess of the head of the screws were enlarged and a conical extraction screwbit . was used to remove the screws. two times a combination of cutting the plate and helicopter tecnique was used succesfull. in comparison the fifty-one . mm selftapping cortical screws were removed without any problem. conclusion: the locking compression plate is a usefull attribute in fracture treatment of the clavicle. however in one-third of the patients removal of locking compression plates and especially the . mm self tapping locking screws from the clavicle, becomes an increasingly challenging procedure. we find this an unacceptably high percentage. number of mri studies it was possible to describe the intraarticular disc. until now there was no in vivo verifying of one of these mri protocols. the introduction of a high resolution mri protocol using a superficial coil ( d wats and t ffe) that has been developped in an ex-vivo model allows the visualisation of the intra-articular structures. the aim of this study is to ascertain the significance of the mentioned mri protocol and the applicability in the clinical practice in a limited patients cohort with instability of the ac-joint. the mri findings are compared to the arthroscopic findings. material and methods: in a one year period patients with chronic acromioclavicular-joint dislocation rockwood type ii and iii were seen in the outpatient clinic the major symptom was pain followed by loss of power. inclusion criteria where a history of more than three month the exclusion of subacromial pathologies, age over and the indication for arthroscopic revision of the ac-joint. the radiological examiner was blinded to the clinical findings. the mri-scan was performed on both sides. at the time of the operation the surgeon was blinded to the mri reading. the surgical procedure was performed by arthroscopy in beach chair position. the surgical findings have been documented by video and also in a descriptive manner. the examination was performed on a . t mri-system . results: throughout the radiological examination, in / patients a rupture of the intra-articular disc was suspected. in / cases degenerative alterations were described. in one case the reading was negative (e.g. ,,no rupture of the intra-articular disc''). during the surgical examination / patients showed ruptures of the intraarticular disc. in one patient no signs of macroscopical disintegration of the disc could be detected. in the case with negative radiologiocal reading, the disc was verified as intact during surgery. in all other cases the disc was disintegrated, including those with the radiological reading ''alterations without clear signs of rupture''. the significance of the described mri protocol was %. introduction: cancer of the colon is a common disease. the choice of treatment after diagnosis is surgery, in an elective setting, to remove the tumor. however, a large number of patients present with colonic obstruction requiring acute surgery before the diagnosis is known, or before the set date for elective surgery. previous studies have shown a worse outcome for patients who undergo surgery in the acute setting compared to patients in scheduled care. the aim was to establish characteristics and prognosis in patients with acute obstructing colon cancer compared to patients who underwent elective colon cancer surgery. material and methods: all patients diagnosed with colon cancer during - in the linkoping area were identified through the swedish colorectal cancer register (n = ). a retrospective analysis of patients with colonic obstruction (n = ) was done using various criteria from the medical records. exclusion criteria were acute surgery due to reason other than obstruction (n = ), non-surgical treatment (n = ), other diagnosis (n = ), or missing medical records (n = conclusion: acute surgery due to colonic obstruction of colon cancer is common. tumor stage seems to be more advanced in patients with obstructing disease than in patients scheduled for elective surgery and consequently the rate of complications is higher and the outcome is worse. however, when stratified for different tnm-stages, the worse outcome in -year survival for patients with acute obstructing colonic cancer still remains. the explanation for this difference is to be elucidated in further studies. disclosure: no significant relationships. introduction: acute colonic obstruction due to malignancies is often a surgical emergency. hartmann's procedures or one stageresection with primarary anastomosis (with or without ileostomy) have been the treatment of choice. however these procedures are associated with a significant morbidity and mortality rate. self expanding metallic stents (sems) have shown their efficiency as palliative treatment in colonic cancer. colonic stenting has been advocated as a''bridge'' towards surgical procedures in potentially resectable diseases. the aim of this study is to evaluate the efficacy of colonic stenting in the emergency treatment of large bowel occlusion either for palliation or to enable to planned surgical procedure. s. tamulis, e. v. gaidamonis surgical, vilnius unuversity emergency care hospital, vilnius, lithuania introduction: to evaluate the results of the treatment of patients with the small bowel obstruction due to intestinal adhesions. material and methods: medical records for the patients treated with small bowel obstruction due to adhesions from to were reviewed. the patient's age, gender, previous abdominal operations, method of the treatment and outcomes were analyzed. results: there were patients admitted to the vilnius university emergency hospital during years period. appendectomy as a previous operation was recorded in % of cases. surgery was required in of the cases ( . %). strangulated small bowel was found in patients ( , %). in cases ( , %) the surgical procedure was limited to adhesiolysis, whereas in cases ( , %) an intestinal resection was performed. enterodecompresion tube was used in cases ( , %). the operative mortality was , % ( cases). mortality after the treatment due to strangulation was , % ( cases). conclusion: there were % of surgicaly treated patients. main reasons of adhesions formation was previous performed apendectomy and midline lower laparotomy. the criteria of uneffective conservative treatment were absent of the positive results of the physical, laboratory, rentgenological and ultrasound examination. mortality after the strangulated small bowel resection was higher. operative enterodekompresios reduces the risc of the postoperative complications and mortality. disclosure: no significant relationships. introduction: hartmann's procedure (hp) still remains the most frequent performed procedure in diffuse peritonitis due to perforated diverticulitis. [ ] [ ] [ ] nevertheless it is associated with high morbidityand mortality . the aim of this study was to assess feasibility, morbidity and mortality of resection with primary anastomosis (pa) with or without diverting loop ileostomy versus hp in case of diverticular peritonitis. , . material and methods: we retrospectively reviewed our prospectively collected database from / to / of patients who were operated in the emergency department of bellvitge university hospital. only patients operated on generalized diverticular peritonitis (hinchey iii-iv) were included. data on patients' demographics, asa classification, hinchey score, peritonitis severity score (pss), surgical procedure, post-operative morbidity, mortality and post-operative hospital stay were studied. results: a total of patients [median age ( - ) years], female . % were included. sixty ( %) had undergone hp and ( %) pa. only in patients ( . %) a diverting ileostomy was performed. overall post-operative morbidity was . %, most frequent complications were wound infection . %, respiratory complications . % and sepsis . %. overall mortality was . % ( pt). these patients had a mean pss of . while the survival group . . there was an overall reintervention rate of . %, after pa . % and after hp . %. significant differences were found in the hp versus pa group in asa score (asa i-ii: % v %, asa iii-iv: % v %) and the median pss ( versus ) . % ( / pt) with pss £ underwent pa, but none ( / ) with pss ‡ . the post-operative morbidity was significantly higher for hp ( . %) compared to pa ( . %). focusing on hospital stay there was a significant difference between pa (mean . days) versus hp (mean . days). in the stratified analysis considering patients with hinchey iii peritonitis we found a mortality of . % ( / pt) in the hp group versus . % ( / pt) of the pa group. the mortality rate stratified for asa and surgical procedure shows no difference in asa i-ii, but in asa iii-iv a lower postoperative mortality for hp ( . %) versus pa ( . %). including only patients with pss less than ( patients) there is a significantly lower morbidity in pa ( . %) versus hp ( . %). conclusion: our data show that pa can be performed safely with lower morbidity and mortality for diverticular peritonitis in patients with asa i-ii, hinchey iii peritonitis grade or pss less than respectively to hp. these findings are supported by a shorter hospital stay in favor to pa. y. arlettaz orthopaedics and trauma, chcvs hô pital du valais, sion, switzerland introduction: one of the most demanding steps of intramedullary nailing is the distal locking. most of young surgeon are ''affraid'' to treat a long bone fracture by a nail because of the distal locking. the aim of this study is to evaluate a new frendly radiation free targeting device on cadavers. material and methods: the study was conducted on fixed cadavers. femurs were available. the method consists of the following steps: determining the zero position of the device; opening the tip of the great trochanter; introducing the nail (sirus nailÒ x (zimmer inc.)); introducing an emitter inside the nail to be positioned in the distal holes; adaptation of the guide on the standard handle with a receptor; moving the receptor to be aligned to the emitter; changing the receptor for the sleeve and performing the drilling and the locking. for the second or even third screw, the targeting device needs a little adjustment. results: on the distal locking procedures ( screws), we observed only one failure due to the breakage of the prototype. this translates as a % success rate for two screws with a mean time of . min. two surgeons conduct this study. not only the inventor but also a inexperimented surgeon tested the new device with the same succes. conclusion: this new device has the advantage to be fully mechanical, to be solidly linked to the patient and to be totally radiation free. it can be used in any hospital, by any surgeon. the procedure is easy to learn and reproducible. it could be adapted to any nail system and does not need external power supply. introduction: anterior knee pain is one of the most frequent complication of tibial nailing. its aetiology remains unclear, potentially being a multifactorial event. the aim of this prospective study was to evaluate if anterior knee pain has any negative influence on: bone healing(the hypothesis is if the patient has anterior knee pain he or she will not put weight on the affected leg and this will not stimulate the bone healing), ability to return to work and quality of live. material and methods: european level trauma center was involved in this study. methods: between januari and december , patients with a tibia fracture was admitted to the trauma departments we used a standard t tibia nail(stryker) with the possibility of proximal and distal fixation with screws the approach was trans or parapatellar. results: at - weeks, months, months follow-up we had , , patients with anterior knee painthe vas decreased from , to , , bone healing was % and for % of patients it was possible to do their previous full time job after months. the quality of life (walking up and down stairs normally without any help, putting on shoes and socks, sitting/standing from a chair, total weight bearing,) was improving. conclusion: we conclude that anterior knee pain in this study is mild, that the two different method of patellar tendon approach(trans or paratendinous approach) have no relevance and it does not have a negative influence on bone healing, ability to return to work and the quality of live. introduction: the aim of this study was to see if there is any difference between manual traction and fracture was applied in one step. twenty-seven femurs and thirthy-three tibias were treated. the mean distraction rate was . mm (range . - . mm) for the femur and . mm (range . - . mm) for the tibia. the necessary pressure to advance the distraction in the tibia was average of bar (range - bar), to distract the femur, bar (range - bar). results: bone healing index for tibia . and femur . months/cm distraction. implant failure five cases; infections three cases. nonunion of the distraction site or docking site four cases. we did not encounter major stiffness of the adjacent joints. conclusion: although the presented technique is a semi-closed distraction procedure, we find this system appealing because of it simplicity in use, low cost and the ability to immediate weight bearing. introduction: bone transport for treatment of segmental bone defects as a salvage procedure is related to a high complication rate. posttraumatic soft tissue problems and callus insufficiency are to be dealed with especially in posttraumatic conditions. the ilizarov ringfixator allows a stable external bone fixation enabling full weight bearing. in bone defect reconstruction bone transport is commonly used. a major problem is the skin cutting wires for bone fixation. a new method of the cable transport with intramedullary cable passing avoids skin cutting thus reducing skin problems. material and methods: patients with a metaphyseal and diaphyseal bone defect of the tibia after open trauma and posttraumatic infection were treated with debridement, bone resection and soft tissue coverage by local and free flaps. after soft tissue healing the monolateral external fixation was replaced in each patient by a four ring ilizarov fixator with a proximal percutaneous tibia osteotomy. for bone transport a flexible cable was placed around the distal part of the segment and passed intramedullarly through the distal segment out of the tibia and onto the ilizarov fixator and the transport clickers. the bone segment was transported after a delay of days anterograd by the intramedullar placed cable one mm per day. results: in all patients the bone defect was closed by the bone transport. in one patient early consolidation of the regenerate occurred and a rupture of the cable. two patients had an insufficiency of the callus. the distal docking site was augmented in all patients after the segment transport with iliac bone graft for consolidation. the one patient with early consolidation was treated by a second osteotomy; the two patients with insufficiency were augmented during the docking operation with iliac bone graft. conclusion: the intramedullar cable transport is a new modification of the bone transport with the ilizarov ringfixator. the main advantage is the soft tissue spearing and protecting transport mechanism enabling bone transports after free flap soft tissue coverage with micro vascular anastomosis. therapeutical course before and after amputation (number of operations before and after amputation) in relationship to co-morbidities and bacteria which caused the infection. results: hospital data from ( female, male) patients were available for septic amputations in the lower extremities on account of non-manageable infections. the average age was . years ( to years). the first age peak lies with , the second with years. in cases infected endoprostheses were found ( total hip arthroplasties, total knee arthroplasties) in cases osteomyelitis was diagnosed. before amputation the patients underwent an average of . interventions (between and ) in oder to control the infection. the average treatment period before the amputation was . days (from to days). post amputationem an average . interventions were necessary (from to ). the average period of treatment was about . days (from to days). the analysis of the co-morbidities showed that hypertension was the most frequent, cases ( . %), followed by diabetes in cases ( . %), coronary desease in cases ( . %), obesity in cases ( . %) and copd in cases ( . %). conclusion: a statistical relevant risk-assesment based on these data (correlation of microbiological findings co-morbidities and risk of amputation) cannot be carried out due to the relatively small number of patients. however, a trend may be estemated: combination of mrsa, diabetes and cardial disease in combination with a great number of operations leads to an increased amputation-risk independent to the individuals age. introduction: maggot debridement therapy (mdt) as an ancient method is succesfully used for the treatment of acute and chronic wound infections in trauma surgery . the underlying mechanisms of action of mdt are unknown, but could provide information for a novel treatment modality against infection, which is important in these times of increasing antibiotic resistance. therefore, in this research the effect of living maggots on planktonic cells was investigated. furthermore, the influence of maggot excretions on planktonic cells and on bacterial biofilms was tested. material and methods: sterile tubes were filled with living maggots in a bacterial suspension and every two hours samples were cultured and compared with controls. a turbidimetric assay was performed to test the susceptibility of six bacterial species to maggot excretions. bacterial biofilms were formed in vitro on polyethylene, stainless steel and titanium and maggot excretions were added to test their influence. results: the results show that living maggots as well as their excretions stimulate the bacterial growth of s. aureus, e. faecalis, cns, s. pyogenes and k. oxytoca (all p-values £ . ). only p. aeruginosa had a decrease of bacterial growth (p = . ). the strongest biofilms in vitro were formed by s. aureus, s. epidermidis and p. aeruginosa in contrast to the weak and inconsistent formed biofilms by e. faecalis, e. cloacae and k. oxytoca. for p. aeruginosa, stainless steel was the best biomaterial with respect to biofilm formation and for s. aureus and s. epidermidis, the best biomaterial was titanium. maggot excretions were added to the strongest biofilms, named above, and reduced these on all biomaterials. the maximal biofilm inhibition by maggot excretions was seen on polyethylene: % for p. aeruginosa (p < . ), % for s. aureus (p < . ) and % for s. epidermidis (p < . ). conclusion: this study shows that nor living maggots, neither maggot excretions have direct antibacterial properties. however, maggot excretions do reduce biofilms formed by different bacterial species on commonly used biomaterials. future research will focuss on the exact mechanism and the substance(s) that cause biofilm reduction. furthermore, possible indirect antibacterial activity will be investigated and the potential role herein of the immune system. introduction: tetanus is an acute disease caused by a neurotoxin produced by the bacterium clostridium tetani, characterised by generalised rigidity, muscle spasm and fatality. open orthopaedic injuries are at particular risk of developing infection from tetanus spores found in the environment. the uk department of health has established guidelines for the prevention of tetanus infection. we assessed the adherence of these guidelines on the initial pre-operative management of tetanus prone open orthopaedic injuries in trauma patients admitted for surgery. material and methods: a retrospective case note review was conducted on patients admitted to the orthopaedic department for intervention with a tetanus prone wound between february and june . tetanus prone injuries included open fractures, soft tissue injury requiring surgical intervention that is delayed for > h, wounds with significant devitalised tissue, wounds in contact with soil and open injuries containing foreign bodies. we assessed to what extent these patients had their immunisation status ascertained, application of wound irrigation and appropriate dressing, correct tetanus prophylactic cover (tetanus toxoid booster versus human tetanus immunoglobulin) and appropriate administration of antibiotics. results: of the patients included in the study, ( %) of patients were considered to have a 'high risk' tetanus prone injury and ( %) patients were deemed as having a 'low risk' clean wound based on the nature and extent of injury. performance within the high risk category showed that % of patients had their tetanus immunisation status ascertained, % correctly received wound irrigation and betadine dressing, % of patients were appropriately given prophylactic antibiotics. only % of patients with a high risk tetanus prone wound received tetanus immunoglobulin and % of patients were given a tetanus toxoid booster as a method for prophylaxis. conclusion: our study showed that a large proportion of patients correctly received supportive wound care and antibiotics. we also demonstrated that patients with open tetanus prone orthopaedic injuries are not adequately receiving correct tetanus immunoglobulin as the indicated prophylaxis. a large number of patients were given tetanus toxoid instead, which does not protect immunity early enough to cover the acute injury period, thus posing a major risk of developing a devastating and largely preventable infection. the orthopaedic and trauma doctor attending these patients must adhere closely to the correct initiation of simple measures in the management of tetanus prone orthopaedic wounds. all patients were irrigated and debrided, before the application of vac system. required debridements were maintained during vac therapy. time elapse between the injury time and vac application time was days on the average (min , max ). when the granulation tissue became sufficient to cover the bone, these wounds have been closed secondarily with several methods. time elapse between the start of vac and wound closure or formation of sufficient granulation tissue for grafting was days on the average (min , max ). results: distribution mean postinjury time for the osteosynthesis was , hours. three of these wounds were closed spontaneously without any need for other wound closure procedures. split thickness grafting is applied in patients, free flap to patients, full thickness grafting to patients, secondary suturing was applied in wound to close it. there was no infection in any extremities that we had osteosynthesed by internal or external methods. conclusion: wound care is as much important as osteosynthesis in open fractures. even if osteosynthesis is successful, failures in wound care may result in loss of extremity. vac alone does not suffice for wound closure. expectation in this therapy is to obtain ideal granulation tissue and to prevent infection development via appropriate wound care. the greatest disadvantage of vac therapy at the time being is its high economic cost. introduction: surgical haemostasis in trauma patients can be difficult and hazardous. commercial products are promoted to accomplish this task at a reasonable cost. in this study we compared the effectiveness of two topical gelatin-based haemostatic agents, flosealÒ and surgifloÒ in a porcine liver trauma model. material and methods: we compared the activity of flosealÒ (with human or bovine thrombin), surgifloÒ and surgifloÒ with added bovine thrombin in two porcine models. one anesthetised piglet mimicked ''normal'' conditions, while the other was kept in a status of hypotension, hypothermia and haemodilution, necessitating inotropic support (''critically ill''). laparotomy was performed, after which we inflicted five identical stab wounds on each liver lobe. each wound was treated with one of the four agents, while one wound was kept as a control. haemostasis was evaluated clinically. after euthanizing the piglets, the pathologist performed a macroscopic, microscopic and electron microscopic evaluation, blinded for which agent was used in which wound. results: clinically, surgifloÒ was able to produce a clot in some of its applications in the healthy piglet (''normal'' conditions), which was not the case in the critically ill animal, not even with the added thrombin. flosealÒ induced clotting in every wound. both microscopic (hematoxylin and eosin and mallory stain) and electron microscopic examination of the stab wounds confirmed that flosealÒ created a stable and dense agglomerate of gelatin and fibrin, firmly attached to the adjacent liver tissue, whereas with surgifloÒ, the gelatin contained more air bubbles, there was a lot less fibrin included in the clot and the clot was not strongly adherent to liver tissue. conclusion: it would seem that flosealÒ is a superior haemostatic agent, creating a dense and stable blood clot, even in a critically ill animal, hence ensuring haemostasis. disclosure: no significant relationships. introduction: bleedings stemming from splenic traumas are still among important causes of morbidity and mortality. aim of this study is comparison of fibrin glue with hemostasis effectiveness of ankaferd blood stopper lower lob resections on spleen of rats. material and methods: the study was performed at the animal laboratory of istanbul university after obtaining an approval from the ethics committee. twenty-four rats were randomly divided into three groups, namely, fibrin glue group (n = ), abs group (n = ) and control group (n = ). a wedge resection was performed on the lower lobe of the spleen. in fibrin glue group, spleen was hemostasis with fibrin glue (tisseel), while abs was administrated on the lower lobe surface in abs group. chronometric measurements were made to determine bleeding times. blood samples from the tail and vena cava were used for whole blood count and blood chemistry. histopathological scores were measured postoperatively on day th. results: in abs group, chronometric bleeding period is , s. whereas in fibrin glue group it takes , secods (p > , ). it was noted that the hemogramme test results, hemoglobin and hematocrit levels on the th days of abs and fibrin glue groups did not show sensible differences from one another ( . vs . ) p = . ( , vs , ) p = , . conclusion: there are no differences between the hemostasis speed and effectiveness of ankaferd blood stopper and fibrin glue as an applied material in bleeding stemming from experimental partial lower lob resections on spleen of rats. of the hemoperitoneum in right iliac fossa was performed and days after trauma, resulting in drainage of and cc of blood. patients were discharged month later and follow up was successful. conclusion: in selected hemodynamically unstable patients and upon availability of appropriate facilities, nom can be safely challenged over the usual limits. the indicators of tissue perfusion such as ph and be seems to be more reliable and sensitive prognostic parameter than hemodynamic instability evaluated by blood pressure and heart rate, in selecting the patients needing surgical control of hemorrhage. a moderate iah in young patients able to tolerate an increased intra-abdominal pressure, can allow a mechanical compression of the injured parenchyma achieving the arrest of hemorrhage, and extend the indications for nom in selected hemodynamically unstable patients, without signs of severe tissue hypoperfusion. material and methods: our case describes a year old male who fell m and landed on the right side of his torso dislocating a rib through the diaphragm, causing a transecting grade liver injury to liver lobes iv and vii, the right hepatic artery and a lesion of the retrohepatic vena cava (vc). the patient presented alert, hemodynamically stable with normal breath sounds. ct scan showed right sided hemothorax and a grade liver injury. a right sided chest tube drained ml of blood. the patient became unstable and was transferred to the or. profuse haemorrhage from the liver was encountered and massive blood transfusion protocol was initiated. the right hepatic artery showed to be injured and was ligated. pringles manoeuvre and packing of the liver were not enough to control the bleeding. an injury to the retrohepatic vc was suspected and manual compression was not sufficient to gain control. endovascular assistance was called for and using a bilateral femoral vein approach two occlusive balloons were placed and inflated under x-ray and open view in the vc to gain proximal and distal control. the patient stabilized and the injury to the vc could be sutured and covered with a topical haemostatic agent. the balloons were deflated but were left in place as a security measure. the liver was then again packed. the pringle manoeuvre had intermittently been used for approximately h in total. two vessel loops were left tension free around the hepatodoudenal ligament and brought out through the midline incision as a security measure. units of rbcs, units of ffps and units of platelets were given. angioembolization of the right hepatic artery was performed after the first surgery. during the second operation, the haemostats, vessel loops and occlusion balloons could safely be removed. days after the injury the patient showed increasing signs of liver failure. the patient was accepted for liver transplantation days after the injury; this procedure was carried out successfully. the combined open and endovascular approach in this case was crucial. the nature of the injury, the pringle manoeuvre, packing of the liver and arterial embolization caused permanent damage to the liver which had to be managed with liver transplantation which was successful. the use of endovascular occlusive balloons might also have had a role in the permanent damage of the liver, but had great benefit in saving the patients life. introduction: the incidence of pulmonary failure in multiple trauma patients is postulated to be influenced by several factors such as thoracic trauma and liver injury. the incidence of pulmonary failure increases in patients with an abbreviated injury scale thorax ‡ (ais) and they are more likely to face poor outcome. thus, the aim of the present study was to test the hypothesis that patients sustaining significant thoracic trauma (ais thorax ‡ ) in combination with a relevant liver injury (ais liver ‡ ) are more likely to develop pulmonary failure when compared to patients which sustained thoracic trauma without additional liver injury. material and methods: records of multiple trauma patients documented in the trauma registry of the german society for trauma surgery were analyzed using uni-and multivariate analyses. patients were subdivided into four groups according to their liver and thoracic injury: group (ais thorax < ; ais liver < ); group (ais thorax ‡ ; ais liver < ), group (ais thorax < ; ais liver ‡ ) and group (ais thorax ‡ ; ais liver ‡ ). potential relevant variables were subjected to univariate analysis between groups using the chi square test to predict the probability for pulmonary failure rate. subsequently, multivariate logistic regression analysis was performed, employing pulmonary failure as the dependent variable. differences at the level of p < . were considered statistically significant. results: , patients with a mean age of . ± . years and a mean iss of . ± . points fulfilled the inclusion criteria and were enrolled in this study. the overall rate of pulmonary failure was ± %. % of the patients in group , % in group and % in group developed pulmonary failure. the largest proportion of patients ( %) who developed pulmonary failure was found in group . those factors which proved to show a significant correlation with the incidence of pulmonary failure were included in a subsequent multivariate analysis. however, the presence of relevant lung injury, male gender, pre-existing medical conditions (pmcs), transfusion of more than packed red blood cells (prbcs) as well as iss and age played a significant role. in contrast to our hypothesis, liver injury did not proof to be associated with the incidence of pulmonary failure. conclusion: pulmonary contusion and significant liver injury seem to have a synergistic effect on the incidence of pulmonary failure. however, multivariate analysis with adjustment of further relevant factors reveal, that liver injury is not a predictive factor for the incidence of pulmonary failure. rather male gender and reported pmcs together with relevant lung injuries are more likely to develop pulmonary failure following multiple trauma. nethertheless, patients with combined pulmonary and liver injury are at higher risk for pulmonary failure with critical outcome. disclosure: no significant relationships. introduction: thoracic trauma is the leading death cause in % of politraumatised patients and contributes to the death of another % of these fatalities. identifying the determining causes, assessing their severity, early and qualified intervention in a multidisciplinary team may improve outcome of these patients. the goal of this paperwork is to assess the effects of thoracic trauma on clinical management, morbidity, mortality and outcome. material and methods: retrospective study of politraumatised patients admitted in the emergency department of st. pantelimon hospital between jan and jun . the followed parameters were most common injuries, severity, mortality, survival rate correlated with iss and rts, using data from emergency charts, hospital charts and anatomopathologic exams. results: out of patients, associated thoracic trauma, with a survival rate of , %. patients had blunt trauma. injuries that claimed early surgical intervention and had the highest death rate were: massive haemothorax patients ( % mortality rate), aortic and great vessels injuries patients ( % mortality rate), open pneumothorax patient ( % mortality rate), tension pneumothorax patients ( % mortality rate), flail chest patients ( % mortality rate). conclusion: thoracic trauma is often associated to politrauma and may increase significantly the mortality rate of these patients. lifesaving surgical procedures must be immediately performed, on patient arrival. it is important to adopt intervention protocols for multiple trauma, with a leading role of the emergency department medical staff. disclosure: no significant relationships. introduction: to evaluate treatment modalities of penetrating and/or contusive hemothorax, we reviewed our experience with patients admitted for traumatic hemothorax to our center for thoracic surgery. material and methods: from january to we treated consecutive patients (mean age, + sd years; m/f, / ) presenting traumatic hemothorax: patients had contusive hemothorax (cont) following car accident ( %), fall ( %), motorbike accident ( %), crushing trauma ( %), bike accident ( %); patients had penetrating trauma (pen) following stab wound ( . %), gunshot ( %) and impalement ( . %). we recorded demographic data, injury severity score (iss) at admission, endo-and extrathoracic injuries, method of treatment and outcome. results: there were no statistically significative differences between cont group and pen group regarding mean age ( vs years), gender (m/f = / vs / ), mean iss ( vs ) and icu admission rate ( % vs %). the cont group however presented a higher rate of extrathoracic lesions (bone, visceral, cns) than the pen group ( . % vs %: p < . ). in all patients a chest tube was immediately inserted, as the definitive treatment in % of cont pts and in % of pen pts (p < . ). surgical introduction: evaluation of penetrating injuries to the chest presented at a level traumacenter. the main study question was to see whether there was an increase in incidence in time. material and methods: in this retrospective study fifty-nine consecutive patients were included with penetrating injuries of the chest during the period of june until june . the penetrating injury had to be caused by gunshot or stab incident. statistical analyses of the data was performed using spss . . results: the study group consisted of fifty-nine patients. ninety percent were male with a mean age of years (range - ). the mechanism of injury were stab ( , %) and gunshot wounds ( , %). sixteen patients required a thoracotomy. in four other cases a laparotomy was performed. twenty-two ( , %) patients were admitted to the icu. the number of patients treated in the first year of the study period ( of the patients with a shotwound % died of their injuries and mortality rate of the patients with a stabwound was . %. in the last year of the study period the mortality of gunschot wounds was . %. conclusion: there is an increase in incidence of penetrating injury of the thorax for both stabwounds and gunshot wounds. the increase of gunshot wounds was especially large in the period july -june . the risk of suffering a gunshot or stabwound to the chest in our traumaregion is gender related. with the increase in the number of gunshot wounds, and thus experience, the mortality seems to decrease. introduction: rib fractures and more specific the flail chest are currently treated conservative. in our level one trauma centre we have on average patients with rib fractures and flail chests/yr. until recently we mainly treated the patients conservative. according to the literature the morbidity and mortality increases twofold with or more ipsilateral rib fractures and an age > yrs old. , some studies have also shown that operative fixation of rib fractures may reduce the morbididity significantly with this data and the recent development of specific dedicated osteosynthesis material for rib fractures we devised a pilot study in order to analyse the efficacy of this new matrixÒ rib fixation system (synthesÒ) and the effect on the morbidity/mortality of the patient. material and methods: during a month period we included all patients with the before mentioned criteria( rib fractures, > yr) or with a flail chest. we analysed operation details, lenght of icu stay, hospital stay and recorded complications. the results were compaired with a matched control group from . results: patients were included with an average age of yrs and a m:f distribution of : . patients had a flail chest and patients had or more rib fractures. on average all patients were operated within days ( - ). on average ( - ) rib were stabilized with an operating time of min ( - ). no implant failures were seen. patients had an average icu stay of days ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . total hospital stay for the whole group was days ( - ), specific for flail chest it was days and for the ipsilateral rib fractures it was days. one patient sustained an extra rib fracture due to the procedure and one patient sustained an iatrogenic pneumothorax. one patient died due to neurologic complications. one patient had a superficial wound infection. no deep infections, pneumonia or chest related mortality occurred. compared to a matched control group of , the overall length of stay was not significant different. vs days. the length of stay for the ipsilateral fractures was not significantly shorter, vs . however the length of stay for the flail chest was significantly shorter in the study group vs (p < . ) the control group had significant more pneumonia, vs (p < , ). conclusion: the new matrixÒ system is easy and safe to work with. the system has good stabilizing capabilities. operative treatment reduces pneumonia and length of stay with flail chest. these results warrant a randomised study, comparing operative treatment vs conservative treatment. introduction: severe thoracic wall injuries can result in long time icu stay with ventilatory support substantial morbidity and even death. if the patient recovers persistent thoracic wall pain, restricted respiratory capacity and/or non union of the rib fractures can be the consequence. in a systematic review of literature we demonstrated that there is some evidence that early internal fixation can shorten the on-ventilator time, the icu stay and lower the short time morbidity. long term pulmonary function is not altered by internam fixation, however the rate of rib nonunion and chest wall pain is decreased. however high quality evidence is lacking. in order to evaluate the feasability of rib osteosynthesis with a new plating system: the synthes matrix system a preliminary study is performed and its results presented. this study preceeds a randomised controled trial comparing plate ad screw osteosynthesis and conservative treatment. material and methods: consecutive patients with flail chest and or serial rib fractures involving at least five ribs necessitating measures other than analgetics to maintain pulmonary function are included and prospectively documented. exlusion criteria: *hemodynamic instability necessitating a damage controle approach *intrathoracic injuries necessitating surgery *normal pulmonary function *patient refusing surgical treatment *patient not available for follow-up all patients are operated upon with use of the matrixrib system. postoperative icu stay, on-respirator time, pain at defined moments of follow-up, healing of the rib fractures and complications are recorded prospectively. patients grade their rate of satisfaction (functional and esthetical) on a scae of to . the results in these patients concerning on-ventilator time, icu stay and morbidity are compared to a historical series of patients with comparable iss. prospective case series with historical control group.(level iii) results: preliminary data indicate: *a shorter time on ventilator than anticipated (based on comparisson to historical data) * a shorter time on icu * less pneumoniae * no intra-operative complications * good healing results of the rib fractures * no implant failures * acceptable pain scores * good overal satisfaction * acceptable cosmetic results conclusion: internal fixation of rib fractures (flair chest or multiple sequential fractures with pulmonary function compromise) results in a earlier recuperation of pulmonary function with shortened icu stay. the overal satisfaction of the patient after operative treatment is good, with acceptable cosmetic results. there were no implant related complications. these results form the basis for a randomised control trial comparing operative fixation with the matrix rib system to conservative treatment. disclosure: no significant relationships. a. e. elsherif , m. fawzy , n. badr , m. marashda surgery, tawam hospital/johns hopkins international, abu dhabi, uae, surgery, tawam hospital, abu dhabi, uae, surgery, tawam hospital/johns hopkins international, abu dhabi, uae introduction: acute airway emergencies result from a wide variety of malignant and benign diseases. for both the patient and the clinician, the presentation can be frightening, and advanced interventional pulmonary/endobronchial techniques are required to achieve prompt relief of symptoms. general anesthesia is sometimes prohibited in these situations with complete loss of airway. we report our initial experience with these patients in a tertiary referral center. material and methods: three patients (two males) with acute proximal airway emergencies were included. two patients presented with acute stridor. the third presented with massive bronchial air leak and purulent drainage after an acute traumatic event. all patients were treated emergently with bronchoscopy and placement of an ultraflex bronchial stent under local anesthesia. all patients were followed up after discharge. results: there was no perioperative mortality or morbidity. the median age was . one patient had anaplastic thyroid cancer obstructing the trachea and was denied treatment elsewhere. the second patient had a malignant tracheoesophageal fistula. the third patient had an acute bronchopleural fistula following pneumonectomy for a gunshot wound. complete symptom relief was obtained after stenting under local anesthesia in all patients. median length of stay was days for the patients with malignancy. on a median follow up of months; two patients were symptom free, one patient died from malignant disease progression. conclusion: stenting under local anesthesia is feasible with acute airway emergency. obstruction of the central airways by malignant tumor is associated with poor prognosis.the alleviation of central airway obstruction by tumor is most often palliative, with improvement of quality of life the primary goal rather than cure. introduction: on april th an earthquake measuring . on the richter scale stuck a large area of the abruzzo region in central italy. the first notice suggested a lot of injured people and destroyed structures, incuded the main hospital of the area, the san salvatore hospital. material and methods: the national civil protection immediately send the field hospital (fh) of the marche regional government, the neighbouring region, together with a large amount of medical staff and personnel by the non governmental organization ares (regional association sanitary emergencies). this association, already involved during other national and international disaster situations and relief efforts, sent professionals volunteers (md and nurses) whit disaster knowledge and specific medical specializations. the international literature demonstrated that a fh is a complex structure and often the time required to be completely functionally is very long, indeed longer than the affected people needs. results: from april th , june th when the mission ended, the fh provided medical treated to almost patients, and the ares personnel ( ) where backed by the sanitary personnel of the san salvatore hospital. conclusion: a well planned medical response is very important to provide health assistance during a disaster, yet it is very hard to substitute a damaged hospital in the hearth of the disaster area. a modular sanitary structure, very light at the beginning, with specific and restricted medical supplies, with a little number of specialists in disaster medicine and disaster logistics, could improve the already good results obtained in the l'aquila abruzzo mission. disclosure: no significant relationships. around , people died, twice as many were injured, and almost million people were made homeless. in any situation of disaster, both natural and complex, may be produced a large number of victims that defeat the ability of local health resources to provide adequate health care. on one hand, the system may be overwhelmed with a high number of casualties. on the other hand, hospitals and other health care facilities generally may be compromised heavily: buildings may be destroyed or damaged and the supply of water, electricity, medical gasses, etc. may be limited. the transportation infrastructures may be severely damaged, creating problems for both people and equipment arriving at the hospital. damage to the health care infrastructure will further compromise the delivery of health services. material and methods: italian government responded immediately to this emergency after the official request for international relief efforts from the president of pakistan. two days after the impact, the first italian evaluation emergency team was already arrived in pakistan and the initial field structure was already fully operative, offering medical care, especially advanced trauma care and life support intervention, provided by specialists. later, when the structure had been completed and became larger provided also hospitalization, and surgical abilities, appropriate treatments and essential drugs. all the medical activities of the responding italian mission team field hospital in manshera were recorded and evaluated. results: a total of , patient contacts occurred at the field hospital during the days it operated, patients were admitted in the field hospital with a total number of nursing days with a average length of stay per admission of , days and with the occupancy rate of , %. a total number of major operations were performed. introduction: mass casualty incident's (mci) management is a present problem which is now more frequent because of iraki, afghan wars and terrorists actions. numerous new plans are evolved in each emergency association or military organization. nato as built a ''masscal'' plan to help teams in role ii in afghanistan to take care mci. through two experiences of mci in french role ii in afghanistan (kaboul) and through the litterature, we discuss the different ways of taking in charge mci. material and methods: the french role ii is located in kaboul near helicopter area. there are surgical teams ( pax, nationalities), emergencies boxes, icu beds and operating theatres. we have a pool of blood units, an echograph, a first generation ct-scan and all materials for traumatologic surgery. for mci, we use nato triage classification. each trauma undergoes ressucitation room, has needing x-ray exams, fast echography and intensive care if necessary. patient who needs urgent surgery runs immediately to operating theatre. iss score is calculated. the first mci concerns patients involved in a suicid bomber's explosion near the role ii. all were taken in charge min later. the second concerns an attack against a french coy occured km in the east of kaboul. there were casualties and soldiers died. they were taken in charge belatedly between to h later. results: fisrt mci : surgical interventions, one %burned, and a blast injury. second mci : surgical interventions, injuries with no surgery, blast injuries. we organize for these second mci a stratevac in france for casualties in less than h. mean iss score is for alive injuries and for the died soldiers. through these mci, we analyse the litterature and discuss about presents concepts in mci management. conclusion: the contemporary history of war, especially in iraqi and afghanistan constrains military surgical teams to improve their way of management of mci. training is necessary. first of all we have to define clearly each place of each actor, the conditions of triage, wich priority for which surgery and the possibility of modern communications and fast and efficient transports. the lower extremity ( %). % suffered multiple severe injuries, % upper extremity injury, % upper extremity and head/neck injury, % back injury, % head/neck injury, % upper and lower extremity injury, % abdominal injury and % miscellaneous. patients ( %) underwent an primary amputation of one or more extremities. ( %) patients underwent secondary amputation. all primary amputated limbs were shortened later. patient ( %)died one day after arrival in the cmh because of multiple severe injuries. conclusion: this single-center, and therefore complete dataset of the repatriated military personnel demonstrates the impact of participating in a nato mission for a small european country. it puts a high and challenging burden on the shoulders of the medical personnel in our hospital. further it shows, in contrast to studies from owens and dougherty, a higher prevalence of lower extremity injuries than upper extremity injuries. data regarding admission time, infection rate, disposition and quality of life will be presented. a lot of medical-ethical decisions had to be made about continuation of medical threatment or to decide whith patient will be treated and with patient will not be treated. as war surgeon you have to do operation for which you were not educated. because there is no other surgeon you have to the operation or the patient will die. it gives the opportunity to learn and gives a lot of surgical experience. this can be useful in civilian circumstances also. conclusion: the period as war surgeon in afghanistan has been of a forse impact. i had to take a lot of medical-ethical decisions and to do operations in which i was not trained. but i have learned a lot about war surgery and on human aspects also. introduction: there are a lot of unique challenges for the medical personnel which are assigned to the combat environment in afghanistan. especially the medical groups are in contact with patients from different nationalities and with different characteristics under special and difficult war circumstances. this article evaluates the effectiveness of the co-operation between a german and a greek surgical team during a -month period in a role ii hospital in north afghanistan. material and methods: from st july through th september , patients were admitted. there were male ( %) and female ( %). we reviewed the type of diseases, mechanism and location of injuries, management, type of surgical procedures performed, blood supply and outcome. results: . % of the patients were international security assistance force (isaf) personnel. most of the patients were men in a percentage of %. four children were included among the local patients. . % of the patients had surgical diseases while the rest . % were of orthopaedic interest patients. ( . %) patients underwent a surgical operation; ( . %) of them were operated immediately. gunshots were the main mechanism of injury for local patients whereas isaf personnel were usually presented with burns after improvised explosive devices (ieds) and rocket attacks. conclusion: the co-operation between medical teams from different countries, when appropriately trained, staffed, and equipped, can be highly effective in order to manage war casualties. introduction: in the emergency caused by natural and social disasters there are evident deficits between the health needs of affected population and the local health system capacity. the causes of disasters are various and not predictable, usually the health structures can not face up to the population needs. knowing that disaster medicine has different protocols and materials from ordinary medicine structures and that improvisation during the disaster's acute phases is not a good practice, it has been created an emergency operating health group, the non-profit ares association. (regional association sanitary emergencies) material and methods: the ares, whose members are about , all over the nation, is configured as an extraordinary health resource, activated by the national civil defence operations centre, in according with the regional centre of marche, in disater situations results: the main objectives of ares are training and organization of medical staff and structures and its growth crosses several missions including: ae earthquake in molise, introduction: cephalomedullary nails rely on a large lag screw that provides fixation into the femoral head. there is an option to statically lock the lag screw (static mode) or to allow the lag screw to move within the nail to compress the intertrochanteric fracture (dynamic mode). the purpose of this study was to compare the biomechanical stiffness of static and dynamic modes for a cephalomedullary nail used to fix an unstable peritrochanteric fracture. material and methods: thirty intact synthetic femur specimens (model # , pacific research laboratories, vashon, wa) were potted into cement blocks distally for testing on an instron (instron, canton, ma). a long cephalomedullary nail (long gamma nail, stryker, mahwah, nj) was then inserted into each of the femurs. an unstable four-part fracture was created, anatomically reduced, and the cephalomedullary nail was reinserted. mechanical tests were conducted for axial, lateral, and torsional stiffness with the lag screws in: ) static and ) dynamic modes. a paired student's t-test was used to compare the two modes. results: the axial stiffness of the cephalomedullary nail was significantly greater (p < . ) in the static mode ( . ± . n/mm) than in the dynamic mode ( . ± . n/mm) (fig a) . similarly, the lateral bending stiffness of the nail was significantly greater (p < . ) in the static mode ( . ± . n/mm) than the dynamic mode ( . ± . n/mm). the torsional stiffness of the nail was significantly greater (p = . ) in the dynamic mode ( . ± . n/mm) than in the static mode ( . ± . n/mm). a post hoc power analysis with a = . and ß = . revealed that the paired t-test on samples was sufficiently powered to determine a difference in mean axial stiffness of . n/mm ( . % of static stiffness), a difference in mean lateral bending stiffness of . n/mm ( . % of static stiffness) and a difference in mean torsional stiffness of . n/mm ( . % of static stiffness). conclusion: our results show that there is a n/mm reduction in axial stiffness of the cephalomedullary nail when the lag screw is changed from static to dynamic mode. this represents a . % reduction in axial stiffness with a change from axial to dynamic modes which may be clinically significant. the differences in lateral ( . n/mm, . %) and torsional ( . n/mm, . %) are small enough that they are likely not clinically significant. we felt that a difference of greater than % in axial stiffness and a difference of greater than % in lateral or torsional stiffness would be clinically significant. our study was adequately powered to detect these differences. given the significant reduction in axial stiffness with dynamization of the cephalomedullary nail construct, we recommend use of the static mode when treating unstable peritrochanteric fractures with a cephalomedullary nail. disclosure: no significant relationships. introduction: minimizing tip-apex distance has been shown to reduce clinical failure of sliding hip screws used to fix peritrochanteric fractures. the purpose of this study was to determine if such a relationship exists for the position of the lag screw in the femoral head using a cephalomedullary device. material and methods: thirty intact synthetic femur specimens (model # , pacific research laboratories, vashon, wa) were potted into cement blocks distally for testing on an instron (instron, canton, ma). a long cephalomedullary nail (long gamma nail, stryker, mahwah, nj) was inserted into each of the femurs. an unstable four-part fracture was created, anatomically reduced, and repaired using one of lag screw placements in the femoral head: ) superior (n = ), ) inferior (n = ), ) anterior (n = ), ) posterior (n = ), ) central (n = ). mechanical tests were repeated for axial, lateral and torsional stiffness. all specimens were radiographed in the anterioposterior and lateral planes and tip-apex (tad) distance was calculated. a calcar referenced tip-apex distance (caltad) was also calculated. anova was used to compare means of the five treatment groups. linear regression analysis was used to compare axial, lateral and torsional stiffness (dependent variables) to both tad and caltad (independent variables). results: anova testing proved that the mean axial (p < . ) and torsional stiffness (p < . ) between the five groups was significantly different, but lateral stiffness was not statistically different (p = . ). post hoc analysis showed that the inferior lag screw position provided significantly higher mean axial stiffness ( . ± . n/mm) than superior ( . ± . n/mm; p < . ), anterior ( . ± . n/mm; p = . ) and posterior ( . ± . n/mm; p = . ) lag screw positions. there as no significant difference in mean axial stiffness between inferior ( . ± . n/mm) and central ( . ± . n/ mm) lag screw positions (p = . ). post hoc analysis revealed significantly less mean torsional stiffness for the superior lag screw position compared to other lag screw positions (p < . all pairings). there were no significant correlations between tad and axial (r = - . , p = . ), lateral (r = - . ,p = . ) or torsional (r = . , p = . ) stiffness. there were significant correlations between caltad and axial (r = - . , p < . ), lateral (r = - . , p = . ) and torsional (r = - . , p = . ) stiffness. conclusion: our results suggest that placement of the lag screw inferiorly in the femoral head when using a cephalomedullary nail to treat an unstable peritrochanteric fracture results in the stiffnest construct in axial and torsional biomechanical testing. a simple radiographic measurement, caltad, provides an intraoperative method of determining optimal cephalomedullary nail lag screw position to achieve greatest construct stiffness. introduction: a potential of polymethylmethacrylate (pmma) augmentation to increase the purchase of cephalic implants in the treatment of intertrochanteric hip fractures has been proven in sev-eral biomechanical studies [ ] [ ] [ ] [ ] . the aim of this study is to compare the cut-out ratio of pmma augmented helical blades to not augmented ones in human cadaveric femoral heads. material and methods: six pairs of osteoporotic cadaveric femoral heads were instrumented with a proximal femoral nail antirotational (pfna) blade in a standardized manner. within each pair, one blade was augmented using ml of pmma cement. cyclic loading was performed at hz. starting at n, the load was monotonically increasing by . n/cycle until failure of the construct. x-rays were taken at cycle increments to monitor the movement of the blade with respect to the head. paired nonparametric test statistics were used to identify differences between groups. results: a significant higher number of cycles to cut-out was found for the augmented group (p = . ). a significant correlation was observed between bone mineral density and cycles to cut-out for the non-augmented specimens (p < . , r = . ), whereas no correlation was found for the augmented group (p = . introduction: when treating distal tibial deformities or fractures with the ilizarov external fixator the ankle joint and foot is often transfixed within the ring construction. for some patients full weight bearing can only be achieved in assembling a walking device on the distal ring. the biomechanical effect of the indirect loading on the fixator stiffness, the osteotomy and the wire tension is still unkown. material and methods: on the basis of a standarized ilizarov external fixator ( rings, mm diameter) with two , mm wires per ring applied in anatomical position on composite tibiae ( rd generation sawbones) direct and indirect loading was analyzed using a universal testing machine (model , uts germany). a middiaphyseal osteotomy of , mm was performed. the following parameters were recorded: micromotion at the osteotomy, relative movement between bone and rings, compressive forces at the osteotomy and strain of the wires. each experimental setup was tested ten times with kg maximal axial loading. results: the osteotomy gap closure occurred at n at direct loading and at an average of n at indirect loading. the compressive forces at the osteotomy were almost double as high at direct loading. regarding the relative motions between rings and bone the amplitude of motion was higher at indirect loading. the stress on the wires was up to four times higher when the walking device was applied on the distal ring for indirect loading. conclusion: the indirect loading using a walking device has a substantial influence on the mechanical characteristics of the ilizarov fixator which determine the biomechanical environment of the osteotomy/fracture. the results showed a higher mechanical load while achieving less compressive forces at the osteotomy. in the need of the walking device we suggest to apply additional half-pins at least in the distal fragment. ) . three randomized groups of pairs were formed. after the osteosynthesis with the implants was done the fracture (a . ) was made with a jigsaw. for further destabilsation the troch. minor was removed. the femura were fixed in the testing machine and tested under dynamic condition with a physiologic load for normal walking ( . x bodyweight) under cycles. we measured the load on the implant, the migration and rotation of the bone around the implant. the data was dokumented with lab view, results: the intramedulare implants showed significant lower migration rates (mean . mm) of the head compared to the extramedular implants (mean . mm). the rotation of the head around the lag screw startet earlier within the dhs an showed higher rates (mean °) followed by the gamma (mean °) until the end of the cycle. the best stabilisation against rotation was documented for the pfn a (mean °). the post x-rays showed a significant migration and sintering process of the femoral head with lateralisation and fracture of the lateral wall. this was even higher in probes with a low bmd. introduction: excising part of an implant through the femoral head is a rare but severe complication of osteosynthesis of proximal femoral fractures. there is little evidence in the literature about incidence and management of this complication. according to opinion leaders in an recent international user meeting most cases end up in total hip arthroplasty (tha). the value of re-osteosynthesis remains unclear. most patients that suffer an excision are geriatric and multimorbid patients, rather suitable to less invasive revision surgery. to assess the incidence and management of cutting out of the pfna blade (proximal femoral nail antirotation by synthes gmbh international) was the aim of this multicenter study. material and methods: the incidence and management of excision of the pfna blade in trochanteric femoral fractures was assessed retrospectively in cases in participating hospitals all over europe in a time period between and . all implantations were screened for this complication. the preoperative, follow up x-rays and patients' medical records including the surgical reports were collected and analysed with a special focus on revision surgery until union or tha. results: the incidence of excision of the implant was . % ( / ). the mean age of patients was years. % of mostly female ( %) patients sustained an unstable a fracture according to the ao classification. final revision surgery was performed with tha in cases ( %). in cases re-osteosynthesis led to union ( %). reosteosynthesis was either exchange of blade with or without cement augmentation alone or re-nailing. in % of tha revisions additional revision was necessary. in % of revisions with exchange of blade additional revision was required (all tha). % ( / )of revision cases with cement augmented blades healed. in % of revision with re-nailing, additional surgery was inevitable. on average . operative procedures were performed after excision of the pfna blade. conclusion: cutting out of the blade of the pfna is a rare complication. nevertheless the management after removal is challenging as indicated by the high number of surgical revisions. revision with total hip arthroplasty showed a lower rate of reoperations compared to re-osteosynthesis. nevertheless % of all revision cases were managed successfully with a minimally invasive osteosynthesis. this gives a rationale for osteosynthesis in managing this complication in geriatric multimorbid patients with a high risk for operation. references: . simmermacher, r. k., j. ljungqvist, et al. ( ) . ''the new proximal femoral nail antirotation (pfna) in daily practice: results of a multicentre clinical study.'' injury ( ) in a prospective series of subtrochanteric fractures with or without involvement of the pertrochanteric region and in revision procedures of this area the pf lcp was applied. in out of patients a fixation failure was observed. this paper reports on these fixation failures. material and methods: all patients with a multifragmented subtrochanteric fracture with or without involving the trochanteric or the femoral neck region which where judged to present a compromised nail entry point from may until may were stabilized using the pf lcp. the plates were applied in a minimally invasive manner through soft tissue windows (mipo). intrinsic stability of the fixation was increased by excentric drilling or applying the tensioning device. all patients were followed up to fracture healing. intraoperative and postoperative complications were noticed. intraoperative and postoperative x-rays were analysed using the ccd angle and the gardens alignment index. results: we report out of patients who sustained a fixation failure with secondary varus collapse requiring revision surgeries until healing. revision consisted in a reosteosynthesis in one, a plate exchange to a o blade plate in the second and a dhs in the third patient. in all our reported cases of implant failure the posteromedial buttress was missing [two ao a and two seinsheimer type v], and all patients were not able to restrict wheight bearing due to different reasons like, noncompliance (alcohol abuse, limited force, advanced age) leading to increased axial bending forces and finally to breakage of the femoral neck screws with varus collapse of the fracture. conclusion: in conclusion the pf lcp proximal femoral plate . / . due to its guide wire technique allows for straightforward plate application and reduction also in very complex fractures of the trochanteric region, including fractures with extension into the greater trochanter or reverse oblique intertrochanteric fractures. however in fracture patterns with missing posteromedial support and limited ability to restricted weight bearing (e.g.: advanced age, additional handicap or mal-compliance) an alternative fixation device should be considered, e.g. the hook plate extension of the lcp proximal femoral plate to apply higher intrinsic stability of the fixation when using the tensioning device. further clinical and biomechanical studies are needed to evaluate the potentiality and limitation of this device for the treatment of these challenging fractures of the trochanteric region. the majority of the the former fixation was replaced by a blade plate. in % we performed a total hip prosthesis. in these cases we saw an overproportional tend to prosthesis-luxations. conclusion: we conclude that mechanical complications like cut out are a little more frequent after dhs-implantation and should be treated by change to a blade-plate-osteosynthesis. this allows a fracture consolidation in that the minor trochanter becomes that stable, that a regular total hip replacement becomes possible. this seems to be the best prevention of mechanical complications after posttraumatic hip replacement like luxations. disclosure: no significant relationships. introduction: hip fractures often concern elderly patients with a high degree of co-morbidity and therefore susceptible for the associated postoperative morbidity and mortality. according to the literature, several factors have an influence on the amount and severity of postoperative complications after hip fractures. low preoperative haemoglobin levels (hb) in elderly patients seem to be associated with increased short-term morbidity and even mortality after surgery. the aim of this study was therefore to establish the impact of anaemia and blood transfusion on postoperative recovery of hip fracture patients. results: there were women and men with medium age of , years ( - years) and with medium follow-up of years ( - years). the lesions occur in sports, % of the fractures occur while practicing soccer. the fractures were bimalleolar (n = ), medial malleolus (n = ), lateral malleolus (n = ), with sindesmotic lesion (n = ) and trimalleolar (n = ). months after surgery % of the patients returned to sports activity ant at months %. at months the younger patients (p = , ) and men (p = , ) returned earlier to sports activity. at one year % of the amateur and % of the professional athletes, had returned to sports practice. fractures of the lateral malleolus returned earlier in , weeks than medial malleolus fracture in , weeks. the smfa and aofas scores were high in all types of fracture. conclusion: correct treatment of instable ankle fractures in athletes, with anatomic reduction and preservation of the integrity of the articular surface, is crucial to the return to sports practice. the fractures that influence an earlier return were younger age, male sex and less severe fracture, and negative predictors were older age and female sex. athletes submitted to open reduction and internal fixation with adequate and precocious programme of physical rehabilitation, can return to the same level of sports practice, despite the seriousness of the fracture without pain and functional limitation( ). results: in all cases anatomic reduction could be achieved. no secondary dislocation was observed and all fractures healed uneventfully. conclusion: indirect reduction of the volkmann triangle from anterior makes an image intensifier mandatory and has potential of not achieving anatomic reduction due intercalated tissue. in larger fragments the fixation with a lag crew from anterior, the buttressing effect might not be sufficient to avoid secondary displacement. with the use a postero-lateral approach and dorsal plate for fixation of the volkmann triangle, it is possible to reliably obtain an anatomical reduction of the dorsal articular surface of the tibia, thus potentially minimizing the risk of posttraumatic osteoarthtitis. introduction: after ankle-and hindfoot fractures, edema often delays surgery and postoperative mobilisation. therefore effective treatment of edema is of great importance. the aim of this study was to evaluate the efficacy of the continuous lymphological multi-layer compression therapy and of the av-intermittent impulse compression (avi) in reducing ankle-and hindfoot edema. material and methods: randomized, controlled, single-blinded, clinical trial. patients ( ± years, m, f) with unilateral fractures of the ankle or hindfoot pre-or postoperatively were randomized into a) the control group (elevation and cold packs), b) the continuous multi-layer compression therapy group (cct) or c) the av-impulse compression group (avi). primary outcome was the pre-respectively postoperative reduction of edema as measured with the figure-of-eight methode . results: pre-and postoperatively the continuous lymphological multi-layer compression therapy (cct) showed a significant better edema reduction when compared to the control group. after three days of intervention the mean preoperative edema reduction in the control group was - . ± . mm ( . %) figure-of-eight methode vs. - . ± . mm ( . %) in the cct group (p < . ) and vs. - . ± . mm ( . %) in the avi group. three days postoperatively the mean edema reduction was - . ± . mm ( . %) in the control group vs. - . ± . mm ( . %) in the cct group (p < . ) and - . mm ± . ( . %) in the avi group. pre-and postoperatively the cct group shows moderate effect sizes after two days of intervention and large effect sizes after three days. avi is more effective when combined with elevation during off-session periods. conclusion: continuous lymphological multi-layer compression therapy leads to a clinical relevant and significant better reduction of ankle-and hindfoot edema as compared to the standard treatment with elevation and cold packs. av-intermittent impulse compression shows a tendency towards a better edema reduction compared to the standard treatment. continuous lymphological multi-layer compression therapy reasonably can be applied when edema delays operation or postoperative mobilisation. considering the avi application we strongly recommend to elevate the leg during off-session periods. introduction: the objective of the study is to define the global hospital costs of a group of patients that suffered from severe trauma. additionally we identify the distribution of the expenses between the different services and the different procedures fulfilled to the patient. ( ), season ( ), moon phases ( ), times on duty ( ) and weather condition ( ) . the observed mortality was adjusted with the risc based prognosis and the smr calculated. results: the selected collective had an average age of . years and % of the patients were males. the mean iss was . and the mean hospital mortality was of . %. for the time of day the highest rate of admission was between : and : p.m., with the highest numbers on saturdays. in the times of on-call duty (weekend, public holiday, weekday between : p.m. and : a.m.) twice as much trauma patients were delivered to trauma centers as within the regularly working hours. in summer, the admission rate was highest ( . %) and lowest in winter ( . %), with more victims of car accidents in autumn and winter as in the warm season and more victims of motor-and bicycle accidents in spring and summer as in the cold season. but none of the mentioned factors showed an effect on survival (smr between . and . ). the moon phases had no influence either on frequency of accidents nor on outcome. the effects of temperature was similar to this of the seasons: with warm temperatures/month less car accidents and more bike accidents occurred (and the opposite for cold temperatures). in the subgroup with temperatures under zero degree the mortality was % higher ( . %) than in the subgroups with temperatures above zero ( , to , , even though a similar iss ( , vs. , to , ) . in a second step a multivariat analysis was done in order to improve the predictive power, but none of the external factors could improve the prognosis. conclusion: there are large variations in the incidence of severe accidents due to time of day, day of week and time of year. but there is no effect of patient's outcome in regard to medical care in german trauma centers. the quality of medical trauma care is consistent around the day, the week and throughout the year. additionally, we observed an increasing difference between mortality rate and risc prediction rate from - , % to - , %, means less deceased polytraumatized patients than predicted. within the late secondary transferring patients with spinal cord injuries were leading ( %), followed by patients with pelvic injuries ( %), infections ( %) and complex extremity injuries ( %). conclusion: with this investigation, we tried to characterize the influence of the new mapping of germany on patient data using the example of the regional trauma network ''saar-(lor)-lux-west-rhineland-palatinate''. although, knowing a lot of interferences, we noticed an abrupt rise of primary admittances of trauma patients in our level- hospital since starting networking. among the load rejection for smaller hospitals this fact leads to a distinct concentration of the treatment of polytraumatized patients in specialized trauma centers. the improved routine by increased quantity could be responsible for the improvement of process and outcome quality in the treatment of severely injured patients. but, the enormous quantity of emergency patients also reflects a future challenge in dealing with emergency operations besides routine operations as well as seldom icu-beds in these trauma hospitals. the role of the nlfc is to work in parallel to doctor led clinics, assessing and treating uncomplicated musculoskeletal injuries with a favourable natural history. since its inception, throughput in this clinic has increased and with greater clinical exposure and training, the spectrum of referred injuries has also broadened. the aim of the present study was to determine patient satisfaction with the nlfc using a validated questionnaire with a specific emphasis on how patients viewed being seen by a nurse rather than a doctor material and methods: consecutive patients were prospectively recruited in the nlfc in january . patients were referred by their resepective consultants after reviewing the presenting history, examination findings and radiographs. after their consultation with the nurse, each patient was asked to fill in a item questionnaire consisting of different domains related to patient satisfaction based on a validated patient satisafction questionnaire adapted for use in the fracture clinic setting. results: there were respondents, men and women, with a mean age of years (range - years). questionnaires were completed by parents, by carers and the remainder by the patients themselves. the most common treated injuries were distal radial, metatarsal and metacarpal fractures. % of patients felt they received the best care from the staff working in the clinic with greater than eighty percent of patients registering satisfaction with the nurse's assessment of their injury, their bedside manner and the treatment and information given. only % of patients felt that they would rather be seen by a doctor for their injury. the highest rates of dissatisfaction related to the building and seating comfort. conclusion: generally, over % of patients were satisfied with their clinic visit with the vast majority of patients not having any objection to seeing a nurse rather than a doctor. patient satisfaction with treatment remains the ultimate outcome measure by which healthcare interventions should be assessed. the results of this study demonstrate the nlfc to be an effective method of managing selected patients in a clinic setting thus reducing the workload of patients which would traditionally be reviewed by the doctor. this has significant implications for improving opportunities for doctors training as well as reducing clinic waiting times. [ ] [ ] [ ] [ ] . the aim of this study is to evaluate the anatomical correlation between the lateral end of the clavicle and the attachment area of the supraspinatus tendon. material and methods: using a mathematical model based upon ct-scan data performed on healthy individuals, the dimensional correlation between the lateral and of the clavicle and the rotator cuff is analyzed. each individual is examined in supine position, using different positions of the arm (maximum external rotation, maximum internal rotation and maximum abduction and external rotation (''aber position''), respectively). for every position the contact area of the lateral end of the clavicle and the spupraspinatus tendon is calculated. results: six healthy individuals ( shoulders) could be included into the study. the average contact area between the lateral end of the clavicle and the supraspinatus tendon (%) is . % for maximum external rotation, . % for maximum internal rotation, respectively. in the aber position only / shoulders showed a contact area > % (av. . %). conclusion: according to these morphological findings the contact area between the lateral clavicle and the supraspinatus tendon is less than %. this contact zone is located in the dorsal aspect of the clavicle. therefore the additional resection of an osteophyte, especially at the anterior part of the lateral clavicle should not have a significant influence on the outcome after subacromial decompression. and good to moderate outcome in the cs (mean ), one patient had a moderate dash score of with a poor cs of . irrespective of treatment strategy the majority of the patients regained normal range of motion and grip strength in the affected shoulder. the most common complication was impingement of the shoulder, which occurred three times in the conservatively and four times in operatively treated patients. all but one conservatively treated patient with a non-union healed without complications. conclusion: minor ( £ mm) and moderate ( - mm) displaced greater tuberosity fractures can successfully be treated conservatively with good to excellent long-term rehabilitation of function with a low risk of complications. whereas there is no doubt that major displaced fractures (> mm) should be treated operatively, special attention must be paid to moderate ( - mm) displaced fractures, as the degree of displacement may be misinterpreted on plain standard radiographs. disclosure: no significant relationships. introduction: a recent study found that after median term follow-up disability correlated with pain rather than the limited residual impairments in motion and strength. we studied impairment and disability an average of twenty-one years after injury in a cohort of dutch patient, with the hypotheses that ) objective measurements of impairment correlate with disability, ) depression and misinterpretation of nociception correlate with disability; and ) patients injured when skeletally mature and immature have comparable impairment and disability. material and methods: seventy-one patients were evaluated an average of years after injury. the majority of the skeletally immature patients were treated conservatively with closed reduction and cast immobilization and the majority of the skeletally mature patients were treated with plate and screw fixation. objective evaluation included radiographs and measurements of range of motion and grip strength. questionnaires were used to measure arm-specific disability (disabilities of the arm, shoulder and hand: dash), misinterpretation or over interpretation of pain (pain catastrophizing scale-pcs-), and depression (ces-d). multivariable analysis of variance and multiple linear regression were used to analyse the ability of the independent variables to account for variation in the dash-score. (spss . , spss inc., chicago). results: there were men and women with a an average age of forty-one at time of follow-up (range, to ). fractures were classified as ao/ota-type a in patients (simple), b in (including wedge fragment) and c fractures in patients (comminuted). the average dash score was points ( to ) and % reported no pain. both rotation and wrist flexion/extension were % of the uninjured side; grip strength was %. there were small, but significant differences in rotation ( versus degrees, p = . ) and wrist flexion/extension ( versus degrees, p = . ), but not disability between skeletally mature and immature patients. the best predictors of dash score were pain catastrophizing, pain, ipsilateral injury and grip strength, explaining % of the variation in dash scores. pain alone accounted for % of variation in dash scores. conclusion: twenty-one years after initial fracture, both skeletally immature and mature patients have limited impairment (averaging over % motion and grip strength) and disability after non operative and operative treatment respectively. patients that were skeletally immature at the time of injury had better motion, but comparable disability. disability correlated with pain and pain catastrophizing rather than motion. results: the mesenteric injuries vizualized on initial ct-scan were mesenteric vascular beading or extravasation in cases, and mesenteric infiltration or hematoma in cases. associated abnormalities of the gastrointestinal tract (thickening, abnormal enhancement, perforation) were present in / cases ( %). nine patients underwent surgery ( %), patients in the early hours, and others after a delay of more than h. indication for surgery was hemodynamic instability in cases and suspicion of bowel perforation in cases. in total, intestinal perforations were found in patients. three patients ( . %) died of associated injuries. no false positive scan has led to unnecessary surgery. however, the negative predictive value of initial ct was % for intestinal associated lesions. conclusion: the mesenteric injuries in blunt polytrauma patients are uncommon but serious. the whole body scanner is a powerful tool for the diagnosis of these mesenteric lesions. conservative treatment is feasible but a clinical and paraclinical reassessment is essential for early detection of intestinal lesions initially undiagnosed, or aggravation of initial lesions. disclosure: no significant relationships. introduction: drug smuggling by gastrointestinal concealment, body-packers, is an increasing problem in developed countries. although conservative treatment is usually successful in most cases, some of these patients suffer complications such as obstruction, gastrointestinal perforation or massive drug intoxication due to a leaking package. despite an urgent surgery and a careful management in the icu, morbidity and mortality remain high. our aim was to assess the outcomes of conservative and surgical management of these patients in our hospital, the referral centre for this entity in madrid. ( ) ( ) pre-hospital fatalities were more frequent (although not statistically significant), which may reflect improvement of trauma organization in recent years ( ) ( ) ( ) ( ) . domestic (may related to delay due to victim's solitude) and urban environment (inexperienced personnel, delay due to referral to another hospital) incidents lead more frequently in pre-hospital death. age and iss as indicators of physiologic reserve and severity of injury were independent predictors of fatality before the victim reaches hospital. introduction: the triad of the elbow is a complex traumatic injury. these injuries have traditionally been considered a poor prognosis for the consequences that arise as a secondary instability, stiffness and loss of functional ability. the objective of this free paper is to review from a clinical and radiological perspective our experience with cases. material and methods: we retrospectively reviewed patients with this type of injury. in patients was not carried out a comprehensive treatment of all existing lesions. the coronoid process was not addressed specifically and fractured radial head was removed or and an osteosynthesis was performed. in the remaining were treated by a treatment protocol trying to repair all the damaged structures (coronoid synthesis, radial head arthroplasty/orif and ligament repair, at least in the external lateral ligament complex). the median followup was months ( - ).the results were evaluated by the scale of may elbow performance score (meps), range of mobility, radiographic parameters and complications during follow up. results: patients treated according to protocol in a systematic manner trying to repair all damaged structures had better outcomes in both the radiological point of view as functional, as well as a lower rate of complications. meps in these patients the average was points (vs. the other group), the arc of º flexoextensió n (vs. º) and the arc pronosupinació n º (vs º). conclusion: despite being an injury traditionally associated with poor results, which have been established treatment protocols that try to treat all manner of injured structures involved in the injury outcomes have improved significantly. we think it must be performed a radial head artroplasty/orif (not resection), anchorage/ osteosynthesis coronoid process and a ligament repair at least of the external lateral ligament complex. if residual instabilty results it may be repaired the medial colateral ligament complex and a temporal external fixator may be used. disclosure: no significant relationships. tion. patients received a secondary implantation including chronic luxations, nonunions, failed osteosynthesis and reimplantation after deep prosthetic infection. the mean follow up was ± months. the functional outcome was measured by using the mayo elbow performance score. results: we had female and male patients with a mean age of ± years. all patients achieved very good results based on the ,,mayo elbow performance score'' with a postoperative mean of points (range between and points) with a maximum performance of points. the mean range of motion concerning extension and flexion was degrees ( to degrees), concerning pronation and supination degrees ( to degrees). the mean flexion deformity was degrees ( to degrees), the mean maximum flexion was degrees ( to degrees). we had two partial ruptures of the triceps tendon, one treated by operative refixation and one conservative, one temporary lesion of the ulnar nerve with complete recovery and one postoperative hematoma which needed surgical treatment. one patient needed revision surgery and resection arthroplasty due to a deep infection, but received a new prosthesis after two months. we recorded no radiographic loosening or other mechanical problems so far. conclusion: according to the used ''mayo elbow performace score'' all patients achieved a very good functional outcome. eventhough they all had severe injuries of the elbow. with modern types of elbow prosthesis the rate of complications and revision surgery is quite low. Ô ur findings indicate that total elbow arthroplasty should be considered as an additional treatment alternative. patients with a lower functional demand and of higher age benefit most from a prosthesis. for younger patients preservation of the joint should be achieved as far as possible. introduction: it is not always possible to reconstruct complex radial head fractures. as non-anatomical reconstruction and healing disturbances result is loss of motion and severe post-traumatic arthritis of the elbow joint, radial head resection as been proposed for these cases. however secondary overload of the lateral facet of the humero-ulnar joint (with consequent arthritis), instability (especially in the presence of medial collateral ligament injury), painfull anteroposterior instability of the radial stump, and radial shortening (in essex-lopresti lesions) with wrist pain can be the result. radial head arthroplasty widely is proposed as prevention of these complication. however as we demonstrated in a systematic review of the litterature, radial head arthroplasty has equally high secondary arthritis rates as radial head resection. the complex anatomy of the radial head, articulating both with the capitellum and the proximal ulna is not reproduced by most contemporary radial head prostheses. material and methods: we describe the complex radial head anatomy based upon an analysis of mriâ e tm s of the elbow performed in healthy volunteers under standardised situations. we describe the next variables: â e¢radial head shape and diameter at the most proximal part of the pruj (proximal radio-ulnar joint) â e¢radial head shape and diameter at the midpoint of the pruj â e¢radial head height medial and lateral â e¢depth of the radial head through â e¢offset of the radial headâ e tm s through relative to the center of the radial head â e¢offset of the radial headâ e tm s through relative to the axis of the radius â e¢offset of the radial head relative to the axis of the radius â e¢angulation of the radial neck to the axis of the radius we compare these parameters to the available radial head prostheses. results: there is a high variability of the different parameters and no relation between all of the parameters could be determined. the existing radial head prostheses do only reproduce the anatomy to a limited extend. conclusion: the high rates of post arthroplasty arthritis can be related to the non-anatomical shape of the existing designs. as the proximal radius articulates both with the capitellum and the proximal ulna, a precise reconstruction of both joints is a necessity to avoid maltracking and/or edge contact in both joints. given the high variability this only can be realised using a theoretic modular prosthesis that allows for reconstruction of the synchronisation between both joints. we found no significant differences (p > . ) in the deficit of the range of motion. flexion: screws ± °, prosthesis ± °, plate ± °e xtension: screws ± °, prosthesis ± °, plates ± °p ronation: screws ± °, prosthesis ± °, plates ± °s uppination: screws ± °, prosthesis ± °, plates ± °a ccording to elbow functional evaluation criteria by broberg and morrey, we found excellent and good results in % of all patients treated with screws, in % of all patients treated with prosthesis and in % of all patients treated with plates (p > . ) the average dash score of patients treated with screws was ± points, of patients treated with prosthesis ± points and of patients treated with plates was ± points (no significant differences, p > . ). the physical and mental component of the sf- score was at the time of follow-up within the normal range at all patients (physical component: screws ± . , prosthesis ± . , plate ± . ; mental component: screws ± . , prosthesis ± . , plate ± . ). in the subcategory of physical functioning, screws performed better than prosthesis (p < . ). no other items of sf- were significantly different (p > . ). conclusion: according to our results osteosynthesis with only screws seem to be the best of the three studied methods. radial head prosthesis replacement yields better functional results than treatment with plates. it must be considered that prosthesis replacement of the radial head has the long-term risk of loosening, especially in young and active patients. plates showed worse clinical results especially in rotation of the forearm even after removing the plate in patients. disclosure: no significant relationships. s is angular stable osteosynthesis of the olecranon more economical than traditional treatment? n. spaepen , k. govaerts , s. nijs , p. broos trauma surgery, uz leuven, leuven, belgium, department of traumatology, university hospitals leuven, leuven, belgium, traumatology, university hospitals leuven, leuven, belgium introduction: although tension band wiring is considered as the gold standard in the treatment of simple olecranon fractures and olecranon osteotomies, the complication rate is high (delayed healing in up to % of cases, hardware migration %). in an historical series using anatomical preshaped lcp plates, we could lower the rate of healing disturbances, but the volume of the implant did make hardware removal necessary in the majority of patients. the lcp , mm hook plate is a low volume angular stable compression plate, designed for the treatment of simple fractures and osteotomies of the olecranon. in this study we want to evaluate the early results of using this new device for the treatment of acute fractures and osteotomies at a level trauma centre. material and methods: we prospectively include all patients treated by lcp , mm hook plate between and. months results considering range of motion (as measued by), meps (mayo elbow performance score), complications and radiographic results are presented. we perform a cost analysis of primary operation using the different implants available, length of stay and time off work. we also perform a cost analysis for reoperation because of delay in union results: we included patients. average age is , years (range - ). there were female and male patients. at months average extension deficit was °, the average flexion °. there was no substantial loss of pro-supination. all factures but one united anatomical (early loss of reduction, but patient refused reoperation). there were complications: early loss of reduction (treated conservatively), crps (complex regional pain syndrome) and arthrofibrosis necessitating implant removal). because of symptomatic hardware two additional hardware removals have been performed. according to the mayo elbow performance score all but patient scored good to based upon the cost analysis the predicted average cost per patient is significantly lower in the hook plate group as compared to the tension band and anatomical preshaped plate group. conclusion: although still a limited series, the early results of this implant are very promising. we document ranges of motion witch are comparable to those described previously in tension band wiring or anatomical plating, but at lower complication and reoperation rates. based upon an analysis of the cost of treatment and of reoperation we advocate the routine use of the olecranon hook plate in the treatment of simple olecranon fractures and osteotomies. disclosure: no significant relationships. material and methods: dutch surgeons (n = ) were asked to draw two incisions for an olac on embalmed human specimen (n = ). they also filled out a questionnaire of their experience. all incisions were photographed and digital measurements were taken. each incision was compared to the gold standard on criteria. incisions should not be closer than two-thirds of the distance between: ) distal tip of the lateral malleolus and the achilles tendon. there was no correlation between number of mistakes and number of procedures per year or years of experience (spearman correlation: . and - . respectively) the median of the mistakes for l-shaped incisions was (iqr = ) and (iqr = ) for j-shaped incisions (p = . , mann-whitney). the spearman correlation between the mistakes for the two incisions drawn by each surgeon was . . conclusion: conclusions: inter-surgeon variation of incision lines was high and since the number of mistakes per incision was not correlated to the surgeon's experience, casam can be useful in two ways: ) pre-operative planning using casam, might assist the surgeon in determining a 'tailor made' safe zone in each patient. ) for educational purposes casam is able to compare a student's incision with the gold standard or the computed location of the sural nerve, thus providing personal feedback. introduction: a precise sustentaculum tali screw placement is crucial for the fixation strength of operatively treated calcaneus fractures, as shown in biomechanical studies. due to the complex anatomic shape of the calcaneus and the limited visualization of the sustentaculum tali fragment via the common lateral approach, the exact screw positioning is demanding and a bright knowledge of the surgeon is mandatory. with the introduction of navigation procedures an increased precision of implant positioning could be achieved for different applications, as reported for pedicle-and iliosacral screw placement. the aim of this study was the evaluation of different navigation procedures compared to the conventional technique for the placement of the sustentaculum tali screw. material and methods: sustentaculum tali screws were placed via a standard lateral approach in artificial calcanei with a prefabricated soft tissue envelope. we used different navigation techniques: group i: d-based fluoroscopic navigation group ii: d-based fluoroscopic navigation group iii: fluoro-free navigation compared to the standard procedure without navigation (group iv). for each screw the time of procedure and time of fluoroscopy was measured. the precision was evaluated in postoperative ct scans. results: no x-ray exposure was necessary for the standard procedure and the fluoro free navigation, whereas ± . and . ± . s of fluoroscopy time were needed for the d-and d-based fluoroscopic navigation. significant differences were observed for the mean procedure time: . ± . (group iv), . ± . (group iii), . ± . (group i) and . ± . min (group ii). no significant differences were seen for the precision with one mal-placed screw in each group. whereas for the image based navigation procedures wide experience in computer assisted surgery was necessary, the fluoro free navigation procedure could easly used without that experience, due to a simplified and self-explanatory workflow. conclusion: all three navigation procedures increase the intraoperative orientation for the placement of the sustentaculum-tali screw, but significant differences of precision compared to the standard technique could not be observed in our experimental set up. potential reasons are a visual and tactile memory effect, despite a randomized order of drillings and a better visualization of the osseous structures in the used artificial model. in clinical situations a lack of surgical routine for this rare injuries and a limited display of anatomic landmarks exist, making all of the evaluated navigation procedures to a helpful tool. if the fracture reduction is controlled intraoperatively by an d fluoroscopic scan, we recommend the d navigation, otherwise we use the fluoro free navigation. disclosure: no significant relationships. overall satisfaction of functional status was measured using a visual analogue scale (vas; range zero to ten). results: four-hundred metatarsal fractures were identified in patients. the distribution of fractured metatarsals was: first metatarsal %, second %, third %, fourth %, and fifth %. multiple metatarsal fractures were seen in . %. most fractures were caused by an inversion injury or fall from height ( %). more than eighty percent of fractures were undisplaced or minimally displaced, and most fracture patterns were transverse or oblique/spiral. a total of patients ( . %) returned the questionnaire with a median follow-up of months. responders were female in % and had a median age of years (p -p - ). in . % of cases the left side was affected. the median aofas-score was points (p -p - ), the median vas was points (p -p - ). in the univariate analysis the aofas and vas score were inversely dependent of the body mass index (r s = - . and - . ; p < . ). patients with known diabetes reported lower vas (p = . ) and aofas scores (p = . ). female patients reported a lower aofas (p = . ). an increase in dislocation (> mm) resulted in a decrease in vas (p = . ). no correlations were identified with outcome and which metatarsal was affected, number of fractured metatarsals, fracture type and location, articular involvement, and smoking habits. in the multivariate analysis the bmi correlated with the aofas (p < . ) and vas (p = . ) and the dislocation with the vas (p = . ). conclusion: this is the first investigation using two validated outcome scoring systems to determine functional outcome in metatarsal fractures. overall outcome in metatarsal fractures is high, as almost all fractures healed without complaints at months. outcome is dependent of bmi, diabetes, gender, and dislocation at the fracturesite. disclosure: no significant relationships. introduction: incidence of fracture non-union is increased after severe trauma. the systemic inflammatory response syndrome (sirs) resulting from major trauma appears to play a role in this healing impairment. especially the cellular reaction associated with sirs influences the inflammatory response, which is of vital importance in fracture healing. we hypothesize that systemic inflammation may impair healing through an altered interaction between neutrophils and stem-or osteoprogenitor cells within the fracture hematoma. we therefore investigated the effect of neutrophils on differentiation of mesenchymal stem cells (mscs). material and methods: osteogenic differentiation of mscs was assessed using an alkaline phosphatase colorimetric assay on the adhered cell lysate after culturing mscs for days in the presence of different quantities of neutrophils. chondrogenic differentiation of mscs was assessed within the same samples using a glycosaminoglycan colorimetric assay in the cell medium. proliferation was measured within the same samples using a picogreen(r) dsdna fluorescent assay. to assess whether any effect was mediated through release of soluble factors or through direct cell-cell contact, supernatants of stimulated neutrophils were used. stimulation of neutrophils was achieved during h with tnf-alfa. tnf-alfa in the supernatant was subsequently blocked with humira prior to interaction with mscs. results: low neutrophil concentrations resulted in increased alkaline phosphatase concentrations compared to control levels. high concentrations of neutrophils resulted in increased glycosaminoglycan concentrations and decreased alkaline phosphatase concentrations. introduction: angiogenesis is a cue element in the early wound healing and is considered most important for tissue regeneration. in addition to aiding research in understanding the regulatory mechanisms of angiogenesis and vasculogenesis, the concept of co-cultures has helped to better understand the mechanisms of interactions between osteoblasts and endothelial cells focusing on new therapeutic approaches for critical size bone defects. here, we describe in detail the cellular and molecular interaction between human osteoblasts (hob) and human endothelial progenitor cells (epc) in a complex d-environment. material and methods: we investigated endothelial differentiation and morphological organization of human epc in cocultures with hob using methylcellulose sphaeroids as well as collagen biomatrices. cocultures of human umbilical vein endothelial cells (huvec)/ hob were used as controls. epc were tracked with cell tracker red, whereas hob were transduced using a lentiviral egfp-vector to allow direct cell visualization using confocal laser microscopy and analysis of cell-specific gene expression. we studied the survival of both cell types and formation of vessel-like sprouts as a criterion of endothelial activity of epc. expression of several relevant angiogenic and osteogenic markers, as well as different extracellular matrix proteins was investigated using quantitative rt-pcr. results: using the hybrid coculture technology we could clearly show that hob regulate the survival, proliferation, and spouting of epcs. concordantly, expression of endothelial cell markers cd and vwf was significantly up-regulated by cocultivation with hob. by contrast, epcs did neither proliferate nor did they form any apparent vessel-like structures when cultured in a monoculture. using the lentiviral egfp-reporter transduction method the expression of osteoblast marker genes was also estimated accurately. we could clearly show that epcs inhibit the terminal differentiation of hob by interfering with expression of specific transcription factors runx and sp . in contrast, cell proliferation and expression of the early osteoblastic differentiation marker alp were induced in cocultures. conclusion: in the present study we demonstrate that human endothelial progenitor cells interact with human osteoblasts on the cellular level. we have identified a complex regulatory mechanism which accounts for endothelial cell survival and cell differentiation of both cell types. this study provides new insight into regulatory mechanisms of bone regeneration and may unveil potential applications in bone tissue engineering and fracture healing. introduction: failure of fixation is more common in osteoporotic than in other fractures. early treatment of osteoporosis as well as early stimulation of the fracture healing may improve the later clinical outcome. bisphosphonates are effective in osteoporosis treatment, and bone morphogenetic proteins (bmps) stimulate fracture healing, although several studies show less effect in estrogen deficient models. in order to determine the effect on early fracture healing of bisphosphonates and bmps in osteoporotic fractures, these treatment modalities were applied in estrogen deficient rats. material and methods: fourty rats underwent an ovariectomy (ovx), followed by low calcium diet during six weeks. ten rats underwent a sham operation, followed by normal diet. after six weeks, a closed femoral fracture was induced in all animals. the ovx animals were then assigned to four different groups: ovx alone, injection of bisphophonate, injection of bmp- in the fracture gap, or the combination of these. all animals received a normal diet after the fracture. after sacrifice at two weeks, fracture healing was evaluated using radiographs and four-point bending stiffness andstrength. results: radiographs showed a higher score in the bmp- treated animals, with or without the bisphosphonates (p = . , kruskal-wallis test). no delay in healing was seen in estrogen deficiency as compared to the sham group. bending stiffness was higher in the bmp- treated groups compared to the others (p = . , kruskal-wallis), as was the strength (p = . , kruskal-wallis). no significant improvement was found by the injection of bisphosphonates conclusion: early fracture healing is significantly stimulated by injection of bmp- in the fracture gap in estrogen deficient rats. early treatment with bisphosphonates showed no effect on fracture healing. introduction: traumatic brain injury (tbi) is associated with an increased rate of heterotopic ossification within skeletal muscle, possibly due to humoral factors. however, the pathophysiological mechanism of heterotopic ossification after tbi is still not fully understood. this study investigated whether cells from skeletal muscle adopt an osteoblastic phenotype in response to serum from patients with tbi. material and methods: blood was collected from patients with severe tbi as well as ten control subjects. primary skeletal muscle cell cultures were isolated from orthopedic surgery patients and characterized using immunohistochemical techniques. proliferation and osteoblastic differentiation were assessed using commercial cell assays, western blotting (for osterix protein) and the villanueva bone stain. results: all serum-treated cell populations expressed osterix after one week. cells treated with serum from both study groups in mineralization medium had increased alp activity and mineralized nodules within the mesenchymal cell subpopulation after three weeks. serum from patients with tbi induced a significant increase in the rate of proliferation of these cells compared to the controls (p < . ). introduction: the current gold standard to establish the diagnosis of osteoporosis and to follow the pharmacological treatment is the measurement of the bone mineral density (bmd). with a growing number of predicted fractures due to osteoporosis the expenses for bmd-measurement will increase. it was therefore the objective of this study to determine parameters that possibly allow a laboratory follow-up of these patients. material and methods: since we operated patients (Ø . y, % female) with an osteoporotic fracture (group ). all of them were more than years old and underwent a laboratory screening including the serum levels of vit-d -oh, vit-d . -oh, calcium (s-ca), phosphate (s-pho), p np, b-cross-laps, intact pth, osteocalcin, tsh and sex hormones as far as the urine concentration of calcium (u-ca) and phosphate (u-pho). in vit d -oh insufficient patients without treatment a therapy with alandronat lg once a week and daily calcium and vitamin d substitution was started. patients (Ø . y, % female) of the orthopedic department underwent the same screening and served as a control (group ). these patients did not sustain a fracture or relevant surgery within at least months. in a second part we checked the evolution of group -patients laboratory screening at a , and -months postoperative interval. results: group and displayed significant differences with regard to s-ca, u-ca, u-pho (p < . ), osteocalcin (p < . ) and vit-d -oh level (p < . ). after separating male and female patients significant serum concentration differences of testosteron (p < . ) in the male patients and of fsh (p < . ) and oestradiol (p < . ) in the female patients could be observed. during the follow up at , and months we could demonstrate a significant elevation of s-ca (p < . ), s-pho (p < . ), osteocalcin (p < . ) and vit-d -oh (p < . ) concentration. further we found a significant elevation of fsh-(p < . ), lh-(p < . ) and testosteron (p < . ) concentration as well as a significant decrease of the oestradiol (p < . ) concentration. as former studies showed we confirmed by comparing group and a deficiency of vit-d -oh, s-ca and an elevation of u-ca in patients with osteoporotic fractures. we could also show a significant difference of the concentration of osteocalcin. by following these blood parameters during treatment we found an improvement or normalization of these differences as a result of the treatment. therefore we believe that vit-d -oh, s-ca, u-ca and osteocalcin could serve as follow-up parameters in the treatment of osteoporosis. further our preliminary results suggest that under the treatment there is a decrease of the testosterone level in male patients and a decrease of the fh-and increase of the oestradiol-concentration in female patients which has not been reported in the literature yet. in consecutive cycli an alternating traction of newton was exerted on the subscapularis and infraspinatus, while a continuous force was applied for the supraspinatus. the motion of the tuberosities and the shaft were recorded by high-speed cameras. the following parameters were investigated: failure of osteosynthesis, intertuberosity motion, motion lesser tuberosity-shaft, motion greater tuberosity-shaft, motion metaphysis-shaft. results: group : cable fixation was significantly more stable for intertuberosity motion and tuberosity-shaft motion. furthermore we found failures for the lesser tuberosity in the suture group. we found no significat difference for the metaphysis-shaft motion. group : the greater tuberosity-shaft motion was significantly lower using two cables. all other parameters showed no significant difference. we found no failures. group : since the tuberosity-shaft motion and the intertuberosity motion were significant higher using fibre-wire, this series was abandoned after / pairs. conclusion: cable fixation is significantly more stable than suture fixation for tuberosities in shoulder arthroplasty. double-cable fixation does not improve intertuberosity stability. we found tendencies for an enlarged tuberosity-shaft stability. introduction: the results following prosthetic treatment of primary humeral head fractures present great variability. dissolving of tuberosities leading to dysfunction of the rotator cuff with limited motion, pain and instability are often reported. the short term results on inverse prosthesis on the one hand are promising, whereas scapular notching turns out to be a major problem leading to a high failure rate in the long run. high complication rates are also reported. material and methods: in an ongoing prospective and consecutive multicentre study until today, cases with an inverse shoulder prosthesis system are documented. in this series we analyse the results of the cases treated for primary fracture as indication. in all cases the affinis Ò fracture inverse prosthesis has been used. this implant was specially designed as a reversed treatment option for selected fracture cases. mechanical and biological notching should be reduced due to the special design features of the prosthesis. patients were asked to describe pain and satisfaction for the injured shoulder one week before the trauma and also to fill in the ases score. the constant score for the healthy shoulder was measured whenever possible. postoperatively constant and the ases score were assessed. the x-rays were evaluated for notching and the healing of the tuberosities. results: from february until today a total of n = cases ( females and males) were treated for primary fracture with the fracture prosthesis. mean age at operation was . years (range . - . ). according to the neer classification we treated patients with a -part fracture, with a -part fracture and cases with a head split fracture. after a mean of months (range - ) the cs reached . points. active forward elevation was . °and passive . °. the active lateral elevation (abduction) was . °for the active movement and . °passive. the ases score was . points at the latest follow-up and the value for pain and satisfaction were . and . respectively. we found no notching in this series and the tuberosities were judged as anatomically healed in % of the cases. we found no difference in the clinical outcome between patients with healed tuberosities compared to the group with non visible tuberosities. postoperatively two complications occurred one fracture of the clavicula and one fracture of the acromion. so far we did not have any luxations or implant disconnections. introduction: the purpose of this study is to evaluate the survival and function of splenic autotransplants using spleen imaging with tc m labeled heat-damaged erythrocytes. material and methods: patients with splenic rupture underwent spleen imaging with tc m labeled heat-damaged erythrocytes at to months after splenic autotransplantation (early scans); also, of them underwent the same imaging technique at to months after operation (follow-up scans). results: on early scans, splenic autotransplants were faintly and the intensity of radioactivity in autotransplants was lower than in liver. the increase of intensity of tracer accumulation in autotransplants was significant higher on follow-up scans. one week after operation the levels of cd , cd and cd /cd ratio were significantly lower than those of controls and returned to normal months later. conclusion: the spleen imaging with tc m labeled heat-damaged erythrocytes is a valuable and effective method for evaluation of the survival and function of splenic autotransplants. , respectively / in the group ''skiers''( %) and / in the group ''snowboarders''( %). the aast grade of injury was: aast case; aast cases; aast cases; aast cases; aast case. of the ''skiers''( %) and of the ''snowboarders''( %) showed a high grade (aast > ) splenic injury. patients has an injury severity score > ( / skiers and / snowboarders): cases of severe brain injury, case of associated liver injuries, cases of associated left renal injuries. patient had associated colonic and pancreatic injury. four patients were not stables at admission and had immediate laparotomy with splenectomies. patients were elected for nonoperative management. results: splenectomies was performed with a splenic salvage rate of. %. there was no mortality and morbidity was %. for thr three patients who had immediate splenectomy the recovery was uneventfull. in te group nonoperative management three patients had angioembolization and four had delayed laparotomy ( for delayed splenic rupture at post injury , and resectively; for sirs). in the patients with availables data, mean hospital stay was days ( - ), . days ( - ) for the group skiers and - days ( - ) for the group snowboarders. patients( %) were recovered less than days. patients were admitted initially in icu ward(from h to days). conclusion: ski accidents are in cause for more the one-third of all splenic injuries admitted to grenoble university hospital. the mean age is lower and male incidence is higher than splenic injuries admitted for others causes (road traffic accident, falls, other mountain accidents). an high number of snowboarder's' accidents was observed and pattern of injury is poor in these patients. the incident of polytrauma cases was the same in two groups and this observation confirm that snowboard practice is at higher risk than skiing for severe splenic injuries. in france, if number of raod traffic accidents is decreasing, the number of sport accidents is imcreasing in the last years. a better comprehension of mechanism, epidemiology and hystological findings of splenic injuries resulting from skiing and snowboarding is necessary to improve trauma preventiin programs. introduction: management of splenic injuries has evolved over the past three decades. prior to that time, a diagnostic peritoneal lavage positive for blood was an indication for exploratory laparotomy because of the concern about ongoing hemorrhage and/or missed intraabdominal injuries. in children the nonoperative management (nom) of splenic injuries rapidly gained interest because of the significant incidence of post-splenectomy sepsis as well as the complications associated with non-therapeutic laparotomies. the last decade has witnessed a proliferation of reports of nom in adults with injuries to the spleen. inclusion criteria for nom in adults, which have been a source of controversy, continue to evolve. moreover we noted that most publications focused on isolated splenic injury and not on patients with multiple injuries. this study was conducted to summarize the indications for the nom of blunt splenic injury with special attention to the multiply injured patient. material and methods: we conducted a medline search. the search was designed to identify english language citations between and : using the keywords: blunt splenic injury, conservative management, multiply injured patients and blunt abdominal trauma. the bibliographies of the selected references were examined to identify relevant articles not identified by computerised search. one hundred articles were identified. a cohort of three trauma surgeons selected articles for review and analysis. we used the methodology developed by the agency for health care policy and research of the united states department of health and human services to group the references into three classes. reviewing all data showed that the nom of blunt splenic injury is a save treatment modality in isolated cases but also the multiply injured patient. conclusion: currently the non-operative management of blunt injury to the spleen is the treatment modality of choice. important is a haemodynamically stable patient, with no signs of peritonitis on physical examination. patients who only maintain their blood pressure by the constant infusion of crystalloid or blood products are not haemodynamically stable and need surgical intervention. ct scan findings and grade of injury are not, in themselves, criteria for laparotomy. these criteria are applied to isolated injuries to the spleen but can also be applied to the multiply injured patient. age itself is not a contraindication. the general condition of an individual patient needs to be decisive. and finally hospitals with a low trauma incidence can safely use these guidelines in their management protocol. introduction: the treatment of trauma patients with solid organ injury has changed over the last years towards a less invasive treatment. still our algorithms especially in dealing with trauma patients with ongoing internal abdominal haemorrhages is still based on fast control en stopping of the bleeding by any means. the use of ct-abdomen and subsequent performing angiography and embolization takes time. we analyzed the time path involved in angiographic control of the bleeding spleen. material and methods: a retrospective study. the study group consisted of ten patients presenting at our institution with a traumatic spleen injury in the period november till november . all patients were managed according to the principles of atls. data were analyzed using spssÒ . . results: the study group consisted of seven men and three women. average age was years (range till ). the iss was on average (range - ). all patients in the study group received an angiography after ct-abdomen which showed an active bleeding focus in the spleen. organ injury score were eight grade and two grade spleen injuries. average time from admission to angiography was min. time to control of bleeding by embolization took average min. time loss between ct and angiography was on average min. conclusion: the time paths involved in managing this group of trauma patients with spleen injuries by embolization are much longer than expected. the time involved after diagnoses to actual control of the bleeding spleen injury is much longer than anticipated. logistic changes to limit the time loss in interpretation of data from the ct-a, transfer of the patient, preparation of the angio-suite and less time consuming technique to actual embolization are needed. articles were eligible if they reported the failure rate of nom with or without angio-embolization (ae) in pediatric patients with splenic and/or liver injuries with a contrast blush on ct and included two or more trauma patients. two reviewers independently assessed the eligibility and the quality of the articles and performed the data extraction. interrater differences were resolved by discussion. results: nine studies were included describing pediatric patients. the median sample size was five (range - ). seven studies (including patients) reported a total of patients with failure after nom without ae. failure rates across these studies ranged from . to %; the pooled percentage was . % ( % ci: . %- . %). the failure percentages after nom with or without ae ranged from to %; the pooled percentage was % ( % ci: . %- . %. two studies (including patients) reported a total of patients with failure after nom with primary ae: a percentage of . %. conclusion: despite the current low level of evidence on failure rate of nom when a contrast blush is present on ct we emphasize that there is a significant amount of patients in whom nom fails. we therefore recommend that the management of splenic and hepatic injury in children should not only be based on the physiological response but also when a contrast blush is present on ct. results: primary blast injury: this form of injury results from the deleterious effects of the blast wave passing through the body. these waves have little or no effect on solid organs but have their major destructive potential in air containing organs, especially lungs. secondary blast injury refers to the impact on a patient's body of projectiles usually inert. the addiction of destructive metal fragment, nails and other such objects to bombs increase the severity of injury and lethality. tertiary blast injury refers to the deceleration and impact with the ground, wall or other inanimate object of the patient whose body is displaced by the blast. quaternary blast injury refers to the miscellaneous forms of injury by-products of explosions, burns, inhalation of dust, contamination in case of ''dirty bombs'' or penetration of allogenic body parts shrapnel. this last one asks the question of contamination by hepatitis or hiv and modalities of surveillance and treatment. conclusion: blast injuries are complex and require the expertise of surgeons for their evaluation, treatment and longterm recovery. the victims of this form of terrorism sustain unusually severe and complex multidimensional forms of trauma not typically encountered in routine surgical practice. surgeons must be leaders and active participants in disaster planning and management; they are uniquely qualified to manage the physical trauma that results from most forms of mass casualty events, including blasts. disclosure: no significant relationships. a. s. dogjani general surgery, military university central hospital, tirana, albania introduction: as the risk of terrorist attacks increases in the world, disaster response personnel must understand the unique pathophysiology of injuries associated with explosions and must be prepared to assess and treat the people injured by them. the explosions at the army depot in gerdec village, some km north of tirana, were heard more than km ( miles) away. introduction: during the last decades there is a debate concerning the fact if the facial fracture can cause further damage or somehow to protect the brain parenchyma from a more severe injury. the aim of our study is to analyze the effects of facial trauma exerted upon brain parenchyma. material and methods: a series of patients with craniofacial fractures was studied. the injuries were separated into five grades of severity based on neurological examination including cranial ct. the injuries was also grouped into three categories based of facial regional involvement ct -facial reconstruction results: the control group included patients with head trauma but without any facial fracture or brain injury. in group a included ( , %) patients with both facial fracture and brain damage.among them diagnosed with temporal-mandibular fractures accounting for , %, patients( , %) had lower mandibular fracture, patients ( , %) diagnosed with nasal fractures and patients ( , %) had orbital fractures. in group b were categorized patients with only brain damage accounting for %. conclusion: the data demonstrated that patients with upper facial fractures were at greatest risk for serious closed head injury (chi).injuries to both the mandibular and the midfacial regions with no upper facial involvement more frequently resulted in mild chi with a modest likelihood of no neurological deficits. trauma to only the mandibular region or to only the midfacial region was least likely to involve chi disclosure: no significant relationships. introduction: post-traumatic stress disorder (ptsd) is a psychiatric disorder that results from exposure to a traumatic event. the individual may develop symptoms of three distinctive types: intrusive and unwanted recollections, avoidance followed by emotional withdrawal, and heightened physiological arousal. people who are exposed to traumatic events may also have somatic symptoms and physical illnesses, particularly hypertension, asthma and chronic pain syndromes. hospitalized victims of suicide terror attacks are unique due to the circumstances and severity of their injuries which could have possibly affected the occurrence of ptsd and delayed the recognition of ptsd development. our objectives were to evaluate the prevalence and severity of ptsd among hospitalized victims of suicide bombing attacks and to assess variables of physical injury as risk factors for the development of ptsd. material and methods: forty-six hospitalized victims of suicide bombing attacks were evaluated for ptsd using the pss-sr questionnaire by phone. demographic and medical data considering the severity of injury, type of injury and medical treatment were collected from the medical files. injury severity scale (iss) was used to assess severity of physical injury. results: the prevalence of ptsd among hospitalized victims of suicide bombing attacks was . %. presence of blast lung injury was significantly higher in the ptsd group compared with the non-ptsd group ( . % vs. . % respectively, p < . ). there was no significant difference in iss values between ptsd and non-ptsd groups. blast lung injury and intracranial injury were found to be predictors of ptsd (odds ratio and , respectively). no correlation was found between length of hospital stay, length of icu stay or severity of physical injuries to the severity of ptsd. conclusion: hospitalized victims of suicide bombing attacks are considerably vulnerable to develop ptsd. they should be evaluated with a high level of suspicion in order to identify ptsd symptoms and treated as soon as possible in conjunction with physical treatment. blast lung injury and intra cranial injury are predictors of ptsd. victims suffering from these conditions should be monitored closely and treated in conjunction with their physical treatment. conclusion: from the use of the smart adopted for the evaluation of the code of entrance in emergency department, we have deduced and confirmed the facility and the speed of use of this new model of triage. the triage smart typically holds not only besides in consideration the traumatic pathologies but also internists that, it is an usable advanced triage both on the territory and in the hospital. we can classify the model smart triage as a valid system in case of a disaster as is reliability and sensibility of assessment of patients result to be more appropriates in comparison to the other models of triage taken in examination. conclusion: we showed that alcohol, massive bleeding needed blood transfusion and age were risk factor of trauma and japanese emergency medical technician attendance was effective for trauma care. we suggested the reason of detachment by the injury form was that japanese penetrating wound include many stub wound not gun shot wound. introduction: rapid aging of japanese population is causing numbers of emerging problems in trauma patients care which consists of trauma in elderly people and increased pre-existing co-morbidities such as cardiovascular diseases, neoplasms and organ failures. nevertheless, little is known about the relationship between co-morbidities and trauma. the aim of the study was to clarify the influences of co-morbidities on the trauma mortality, using data from the japan trauma data bank (jtdb), a multicenter, nationwide and prospectively recruited trauma registry in japan. material and methods: we selected the records from jtdb which fulfilled the requirements to estimate trauma injury severity score (triss) system. logistic regression analysis after adjustment for baseline trauma severity based on triss system assessed the risk of in-hospital trauma death for following co-morbidities: hypertension (ht), diabetes (dm), psychotic disorders (pd), dementia (de), stroke (st), chronic obstructive lung diseases (cold), bronchial asthma (ba), coronary diseases (chd), congestive heart failure (chf), liver cirrhosis (lc), chronic hepatitis (ch), chronic renal failure on dialysis (crf) and active cancer (acn). we conducted a couple of analysis which were adjusted or unadjusted by age in consideration for confounding between co-morbidities and elderly in age. introduction: monitoring the quality of trauma care is frequently done by analyzing the preventability of trauma deaths and errors during trauma care. in the academic medical center traumatic deaths are discussed during a monthly morbidity and mortality meeting. in this study an external multidisciplinary panel assessed the trauma deaths and errors in management of a dutch level- trauma center for (potential) preventability. material and methods: all patients who died during or after presentation in the trauma resuscitation room in a two year period were eligible for review. all information on trauma evaluation and management was summarized by an independent physician. an external multidisciplinary panel individually evaluated the cases for preventability of death. disagreements in classification were resolved during two consensus meetings. potential errors or mismanagements during the admission were classified for type, phase and domain. overall agreement on (potential) preventability was compared between the panel and the amc consensus. results: of the evaluated trauma deaths one was judged preventable and were judged as potentially preventable by the review panel. overall agreement on preventability between the review panel and the amc consensus was moderate (kappa . ). the classification of the panel was more favourable than the amc consensus. the interobserver agreement between the review panel members was also moderate (kappa . ). the panel judged errors to have occurred in the (potential) preventable death group and errors in the non-preventable death group. most frequently mentioned errors were related to choice or order of diagnostics, rewarming of hypothermic patients, and correction of coagulopathies. conclusion: the preventable death rate in the present study was comparable to the available literature. external review does not seem necessary to improve our current internal reviewing system. however, multidisciplinary reviewing of our trauma deaths provided us potential insights to optimize trauma care. disclosure: no significant relationships. arab emirates (uae). the aim of this paper is to report on the long term effects of our early analysis of this registry. material and methods: data in the early stages of this trauma registry were collected for patients during a period of months in . data was collected on a paper form and then entered into the trauma registry using a self-developed access database. descriptive analysis was performed. results: most were males ( %), the mean age (sd) was . ( . ). uae citizens formed . %. road traffic collisions caused an overwhelming . % of injuries with . % of those involving uae citizens while work-related injuries were . %. the early analysis of this registry had two major impacts. firstly, the alarmingly high rate of uae nationals in road traffic collisions standardized to the population led to major concerns and to the development of a specialized road traffic collision registry three years later. second, the equally alarming high rate of work-related injuries led to collaboration with a preventive medicine team who helped with refining data elements of the trauma registry to include data important for research in trauma prevention. conclusion: analysis of a trauma registry as early as six months can lead to useful information which has long term effects on the progress of trauma research and prevention. disclosure: no significant relationships. as a result of injuries related to skating on natural ice. we analysed epidemiological aspects, diagnostically examinations, prevalence of injuries per anatomical location as well as the necessary therapeutic interventions and costs for national health services. results: injuries related to skating on natural ice accounted for % of all attendances. the mean age for man and women did not significantly differ ( , and , years resp.; p < . ), but adults aged - years are more prone to injuries. women were affected in %. radiological examinations were requested in % ( % xrays; % ct-scans). the upper extremity was affected in %, with the wrist accounting for % of those injuries. fractures accounted for % of all ice-skating related attendances. an operative therapy was indicated in %. the mean costs for national health services were e per patient. conclusion: fractures, especially those of the upper extremity, were the predominate type of injury as a consequence of collectively performed skating on natural ice. this incidence is > times higher compared to fractures occured during skating on artificial ice-rinks [ ] . wearing wrist guards is an effective tool in protecting skaters against injuries. we recommend wearing wrist guards during skating on natural ice [ , ] . especially (employed) adults aged - years are very prone to injuries resulting in a high loss of work days [ ] . in contrast to children, adults might be more accessible for wearing protectors [ ] . in future it seems reasonable for national health services to provide steps to increase public awareness on the benefits of prophylactic safety measures. this might result in a substantial reduction of costs for health care and society. introduction: liver cirrhosis has been shown to be associated with impaired outcome in patients who underwent elective surgery. we therefore investigated the impact of alcohol abuse and subsequent liver cirrhosis on outcome in multiple trauma patients. material and methods: using the multi-center population-based trauma registry of the german society for trauma surgery, we retrospectively compared outcome in patients (iss > = , > = ) with pre-existing alcohol abuse and liver cirrhosis with healthy trauma victims in univariate and matched-pair analysis means were compared using student's t-test and analysis of variance (anova) and categorical variables using chi (p < . = significant). results: overall , patients met the inclusion criteria and were, thus, analyzed. ( . %) patients had a documented alcohol abuse and ( . %) suffered from liver cirrhosis. patients abusing alcohol and suffering from cirrhosis differed from controls regarding injury pattern, age and outcome. more specific, liver cirrhotic patients showed significantly higher in-hospital mortality than predicted ( % vs. predicted %) and increased single-and multi organ failure rates. while alcohol abuse increased organ failure rates as well this did not affect in-hospital mortality. of note, alcohol abuse significantly decreased -hour mortality. conclusion: patients suffering from liver cirrhosis are at maximised risk for impaired outcome after multiple injuries. pre-existing condition such as cirrhosis should be implemented in trauma scores to assess the individual mortality risk profile. introduction: early in-hospital treatment of severely injured patients has been internationally standardized by the implementation of algorithms such as the atls Ò -concept. however, due to lack of time, the instability of the patients and the complexity of injuries, there is a risk that some lesions will be missed at this stage. the purpose of our study was to evaluate the incidence and significance of these missed injuries. material and methods: retrospective chart analysis (in-hospital and follow-up as outpatient) of data prospectively collected via an accessÒ-based documentation system was performed. missed injuries were determined as injuries not found during primary and secondary survey. introduction: complication registration is important for monitoring the quality of health care. aim of this article was to describe the incidence, type and impact of complications occurring within months after the initial trauma in multitrauma patients. second, we assessed potential risk factors for the occurrence of complications. material and methods: during a -year period all trauma patients presented to the academic medical center and having an injury severity score of ‡ were included. patients who were directly transferred to other hospitals were excluded. we used the prospective dutch national surgical complication registry of the amc, a level- trauma center, to assess complications within months after the initial trauma. for verification we additionally performed a chart review and searched the decubitus specialists-and icu registration. complications were graded (no real health loss) to (lethal). identification of risk factors associated with an increased risk of complications was performed by univariate analysis. we also analyzed an autopsy findings of these patients and found that of ( . %) had a difference between clinical and autopsy iss. the most frequent missed injury were rib fractures. six of these patients were hospitalized in a period when we did not use msct routinely in multiple injured patients. conclusion: triss is not a clinical prognostic tool but is used retrospectively for clinical and epidemiological research, performance evaluation, and resource allocation. it is required as a basis for quality assessment and improvement. in combination with autopsy findings, triss methodology can be an valuable tool for recognition of unexpected trauma deaths and further analyze of possible treatment errors. patients had to be operated , times and were treated days in the icu and stayed days in hospital. mortality rate was % and rate of multi-organ failure %. % demonstrated severe senso-motoric dysfunction as well as residues of severe head injury. % recovered well or at least moderately. out of survivors answered the polochart. a personal interview was performed with patients. the state of health was at least moderate in % of patients. in % interpersonal problems and in % severe pain was observed. in % problems in working ability concerning duration, as well as quantitative and qualitative performance were observed. symptoms of post-traumatic stress disorder were found in %. the more distal the lesions were located (foot/ankle) the more functional disability affected daily life. in only %, working ability was not impaired. out of interviewed patients demonstrated complete work disability. conclusion: even severely injured patients after polytraumatization have a good prognosis. the iss is an established tool to assess severity and prognosis of trauma, whereas prediction of clinical outcome cannot be deducted from this score. introduction: one of the most common cause of preventable deaths in severe trauma is represented by delay in diagnosis and treatment of injuries, therefore a good teamwork aimed to reduce time consumption and errors is essential. there is in fact good evidence that the outcome of trauma care depends on effective trauma team performance (ttp). critical points during trauma management are represented by lack of leadership, information sharing, difficult communication and decision making. to improve ttp, advanced simulators with full scale realistic patients ( ) and trauma crew resource management (crm) educational programmes are increasingly being used. material and methods: we made a survey among health care professionals (hcp) from different level i and level ii trauma centers in the milan area that confirmed that difficulties in communication and conflictual behavior during trauma action is perceived as a barrier to ideal management. after a focus group interview to establish the need to improve performance we tested in our hospital a tailored trauma teamwork course using an advanced human patient simulator. the peculiarity of this course is the recreation of the same location of the trauma bay using same trauma team components and teamwork laboratory conducted by a professional coach as facilitator for the teamwork. this role is particular important since with this facilitation hcp can reach the awareness of wrong attitudes that lead to errors and bad performance. in particular, the tasks of the facilitator were the following: to help people understand their common goals to assists the trauma team to plan to achieve common goals to assist the group in achieving a consensus of any disagreements that preexist or emerge in the meeting so that it has a strong basis for future action a second survey few months after the course was made among hcp of our institute to evaluate the possible improvement of the ttp. results: the second survey confirmed a perceived benefit among hcp who started to work in a proactive manner. in particular % of hcp reported the feeling of a better ttp and % suggested regular practice with advanced simulation. conclusion: integration of a tailored advanced simulation and a facilitator assisted teamwork could be a powerful method to improve quality of treatment in trauma patients. a score index to evaluate the improvement of the ttp during the course and in reality is although needed and is under evaluation. introduction: our university hospital is one of the only two national university hospitals in tokyo and our emergency medial center is one of the busiest emergency center in japan that receives to ambulances per day. japan has a quite unique emergency medical system in the world. in japan, emergency patients are stratified into tiers, minor-primary, moderate-secondary, severe-tertiary. japanese emergency doctor, that is not same as the emergency physician in the usa, take care only for the most severe emergency cases, tertiary level emergency patients. and if they find out the patient who needed an emergency operation, then they do the surgery by themselves. if the patients need to admit to icu, they take care the patient in icu by themselves. this unique system was installed in mid- s. japanese emergency doctors do not only trauma cases, but also nontrauma severe emergency cases. for talking about trauma, they do not only the initial management of trauma patients but also do emergency surgery and trauma critical care. the mou came into effect with the signatures of the appropriate representatives, acknowledging that four courses had been run in portugal prior to its signature and that all future courses would be conducted in accordance with the essential requirements established by iatsic. in practical terms, the first two courses run after signing the mou must be of the form and nature as laid down by iatsic. thereafter, variations as determined by the nsc may be allowed. the slide material will be provided ''locked''. after the two initial courses, the ''unlock'' code will be provided. details of all modifications must be lodged with the iatsic. nsc will be responsible for ensuring the maintenance of high standards in the conduct of all courses and the selection of participants, ensuring that they meet the minimum standards as laid down by iatsic. nsc is entitled to appoint two representatives at international subcommittee meetings. introduction: clinical skills must be to the fore of medical occupation, especially in surgery, where the mastery of basic skills is of great importance for the young learner. the acquisition of basic clinical skills during surgery clerkships has been shown to be inadequate. this work presents an analysis of different teaching methods in a standardized training program for basic clinical skills in surgery. material and methods: the program is part of a four week surgical rotation for th year medical students, consisting of the one-week training program in basic surgical skills and a three-week clerkship on surgical ward. during the skills training, a maximum of students per group rotate through modules. in a randomized study, the effects of different teaching modalities as skills lab, simulation and role play, as well as different teaching methods as four-step-approach, short-lecture, video were tested on their effect on theoretical and practical skills acquisition. results: a total of students participated on a voluntary basis. the theoretical and practical examinations revealed significant differences in the acquired skills comparing the different teaching modalities and methods. the use of video as part of the -step approach was effective for training the basic skills such us suturing and wound care. least effective for all skills were short-lectures. conclusion: the choice of teaching modality and method has a significant impact on students' skills acquisition and its long term retention. disclosure: no significant relationships. training in trauma center: where to pay attention to? l. handolin traumatology, helsinki university hospital, helsinki, finland introduction: systematic trauma team simulation training was started in helsinki university hospital in . in terms of getting the optimal advantage of training and maintaining the justification of resource allocation, an advantageous balance in various team training principles has to be applied. the aim of the present study was to analyze the standardized written feedback given by trainees after training sessions. material and methods: the study period was three years ( ) ( ) ( ) . the collected data consisted of a subjective self-assessment on the level of knowledge, skills, and team work in traumaresuscitation. also a selfassessment on the effect of training on decision making, communication, skills, team work, and leadership, as well as a general rating of training session were collected. self-assessment was done using five step scoring system from one to five. results are presented as means. conclusion: the actual evaluated interspinous devices led to a significant reduction of rom during flexion-extension, but to a significant increase of rom for the whole specimen (l -l ) during lateral bending and rotation, which increases the risk of adjacent level degeneration. therefore the decision for the optimal individual treatment should be made on the knowledge of the biomechanical effect of each device and the underlying disease of the patient's symptoms. introduction: gait analysis is a powerful tool to monitor the degree of convalescence in fracture care after fracture fixation and during bone healing. because of the availability of a large array of monoclonal antibodies and gene-targeted animals, the mouse has become the preferred species for molecular studies on fracture healing. of interest, gait analysis after fracture fixation and during the bone healing process has not been performed in mice yet. we present a novel technique for dynamic gait analysis in mice and report the change of motion pattern after femur fracture and fixation. materials and methods: all animal procedures were performed according to the national institute of health guidelines for the use of experimental animals and were approved by the german legislation on the protection of animals. ten cd- mice were divided into two groups: fracture group (n = ) and control group (n = ). all mice were anesthetized by an i.p. injection of xylazine ( mg/bw) and ketamine ( mg/bw). a standardized closed midshaft fracture according to ao-classification a -a was stabilized by a common pin. the non-fractured tibia was additionally marked with a pin, allowing a measurement of the tibio-femoral angle by a digital videoradiography system recording images/s. for the control group, one pin was inserted into the femur and one into the tibia without producing a femoral fracture. dynamic gait analysis was performed at day fourteen after surgery in a x-ray compatible running wheel and the following gait parameters were determined: the minimum and maximum tibio-femoral angle, the stride frequency, the stride time, the stride length and the stride velocity. eighteen representative strides per mouse were analyzed. all measurements were done using osirix imaging software and the open source program imagej. all data are given as means ± standard error of the mean (sem introduction: single distal locking screw insertion had been accepted as an option in clinical practice of femoral nailing. however, effect of number and location of the screw on rotational stability of the construct was still doubtful. therefore, this experimental study was conducted to compare rotational stability of the femoral nail construct among three different conditions (two distal screws, single distal screw in different locations). materials and methods: eight right femoral sawbones were selected for this study. each of which was implanted with gk femoral interlocking nail ( · mm) and a static proximal locking screw follow by single distal screw insertion in the most distal screw hole. then, transverse osteotomy was performed at the mid-shaft to simulate simple fracture. after the femur was stabilized on the custom holding jig, rotational force was applied to the femoral condyle by using a torque wrench connecting to the distal part of the jig starting from to nm in nm increment. total rotational angle in each situation was measured by modification of navigation system. thereafter, testing protocol was repeated to the same specimen but two distal locking screws and single distal locking screw in the most proximal screw hole, sequentially. different angle in each testing condition was compared among the different constructs by using paired t-test. results: rotational stability was significantly better in the group of two distal locking screws in every testing condition (p < . ). single distal screw in the most proximal screw hole provided more rotational stability than that in the distal screw hole at nm (p = . ). conclusion: this study demonstrated that two distal locking screws provide more rotational stability than single screw in the case of simple mid-shaft femoral fracture stabilized with interlocking nail. if single distal screw was considered, insertion in the most proximal hole would be a better option in term of rotational stability than that in the most distal hole. introduction: the exothermal reaction of pmma leads to an extensive interaction between the bone cement and the plastics of the application system. this chemical reaction changes the structure of the bone cement and especially makes air pockets. it is necessary to develop application systems with a special composition of the plastics so that there is no interaction between the cement and the application system. in this study a new application system is presented for the first time which does not interact with the bone cement. materials and methods: two different application systems for bone cement were tested in this study. one popular and frequently used system made of polyethylene and a new system made of polypropylene. a special testing unit, in which the application systems were mounted, was used. the testing unit worked with a certain pressure so that a defined amount of bone cement was injected. the resistence data and the time were digitally collected and statistically evaluated. in all procedures were carried out. after the injection all application systems and the injected bone cement were microscopically analyzed. results: two groups, old versus new application systems, were divided. both groups showed significant differences. when using the old application systems made of polyethylene the time frame for injection of the cement was min while the time frame with new system made of polypropylene was min. microscopically there is a significant interaction between the plastics and the cement in the old systems with massive air pockets. in contrast there is no interaction, no air pockets and a homogeneous pattern of the cement when using the new systems. conclusion: the new application system made of polypropylene showed a significant longer time frame for application of the cement as well as no interaction with the plastics. it is possible to treat more than one localization with one application system which makes it financially rewarding. additionally there are no air pockets reducing the danger of infection und increasing the structural stability of the bone cement. introduction: femoral neck fractures are common fractures. despite the frequency of this fracture and the consequences associated with it, little is known about the functional changes that can be expected during and after rehabilitation. the aim of this study was to identify prognostic factors for functional outcome, using a modified harris hip score, after a femoral neck fracture treated with an arthroplasty. materials and methods: we included patients who sustained a displaced femoral neck fracture treated with an arthroplasty. functional outcome after surgery was assessed using a modified harris hip score, and was evaluated after (hhs ) and (hhs ) years. we analyzed the following prognostic factors for functional outcome of patients after treatment of femoral neck fractures with an arthroplasty: age, pre-operative co-morbidity, asa-score, type of arthroplasty (hemi-or total hip replacement), surgeon experience (resident or attending surgeon), interval between trauma and operation, blood loss, direct (associated with the arthroplasty) peri-and post operative in-hospital complications related to the arthroplasty and general post operative in-hospital complications. to challenge the outcome of the analyses we used the cronbach's alpha coefficients for testing the internal consistency. results: after one year the existence of co-morbidities ( ‡ ) was a significant predictor for a poor functional outcome. with and without co-morbidities the mean hhs was . and . , respectively. after years all potential prognostic factors did not have significant influence on the functional outcome. to further analyse this outcome, internal consistency of the hhs was assessed. when pain and function of the hhs were analysed together the internal consistency was poor (hhs : . and hhs : . ). the internal consistency of the harris hip score solely in function (without pain) improved to . (hhs ) and . (hhs ). when the potential prognostic factors were analysed with only the functional aspect, age and the existence of co-morbidities could be defined as a predictors for the functional outcome of femoral neck fractures after and years (r and % resp). conclusion: pain has such a dominant position in the harris hip score that even immobile patients without pain can obtain a reasonable hhs score. the hhs, with the omittance of pain, is therefore a more reliable score to estimate the functional outcome. after using the hhs in this modification, age and the existence of preoperative co-morbidities appeared to be predictors of the functional outcome after and years. many studies have shown that delay to theatre beyond h has an associated increased risk of morbidity and mortality in this cohort. our data revealed that there is certainly room for improvement regarding treated more patients within the h guideline however, there will always be a group of patients whom medical input is required prior to surgical management. lack of theatre time appears to be a significant administrative reason for delay. this is an area of potential improvement however it must be noted that any system of this nature will carry an intrinsic delay in processing. . x-rays and post-op data were analyzed on displacement, postoperative reduction, loss of reduction, and avascular necrosis (avn) and revision rates. high volume surgeons were defined as surgeons who performed > fixation procedures for proximal femoral fractures annually. results: mean age ( vs. years) and percentage of fracture displacement ( vs. %) were equal in both groups. re-operations following loss of reduction or infection was seen in ( %) patients. less frequent complications were avn ( %), coxarthrosis ( %) and pain due to screws bulging out ( %) led to a total conversion rate to arthroplasty in %. displaced fractures show a higher rate in loss of reduction ( %, p < . ) and revision ( %, p = . ) than non-displaced fractures ( . %; . %). patients > years showed % loss of reduction, % avn and taking the reoperations due to coxarthrosis and pain into account, a total revision rate of % was seen compaired to , , and % in younger patients. radiological analyses revealed that the lack of medial support lead to revisions in % of the cases, dorsal angulation in %. low volume surgeons did not perform worse than high volume surgeons. the latter group showed % loss of reduction, % avn and total revision rate %, compared to , and % in the low volume group. we found no differences in the outcome of treating displaced fractures. conclusion: the outcome of fixation of femoral neck fractures is poor. especially displaced fractures, inadequate fracture reduction and high age were associated with poor outcome. therefore, arthroplasty should be considered in patients older than years with displaced fractures that cannot be reduced anatomically. we could not demonstrate that high volume surgeons performed better in this group but we are convinced that further specialization of care is mandatory to improve results of this unsolved fracture. ( ) ( ) ( ) ( ) . internal fixation has shown to provide minor results. the majority of these patients are therefore treated by a hemiarthroplasty of the hip. since the primary goal is to regain the pretraumatic level of mobility as soon as possible( ; ), we sought to investigate, if a minimal invasive anterior approach would be beneficial in regard of perioperative blood loss ( ), postoperative pain( ; ) and thus postoperative mobility ( ) . material and methods: in a randomised controlled trial, patients were treated by a hemiarthroplasty of the hip via an anterior or lateral approach in supine position within hours after trauma( ). apart from parameters like age, asa-score or body-mass-index, the main focus was set on perioperative blood loss, pain and postoperative mobilisation. all data collected were compared between groups to detect statistical significant differences. additionally the same parameters were checked for significant differences comparing patients with or without complications within their group. results: a significant difference between groups was found for postoperative pain within the first hours and for operation time, both to the disadvantage of the minimal invasive approach group. within groups, time of operation and patient's age were significantly higher in patients with complications in the minimal invasive group such as pain at hours was rated higher in patients with complications in the lateral approach group. these results though did not seem to influence postoperative mobility since no significant differences were found between groups at follow-up. conclusion: despite some differences in the postoperative course, postoperative mobility does not seem to be greatly influenced by the choice of the approach for hemiarthroplasty of the hip in femoral neck fractures. still, the operation time was significantly linked to postoperative complications. in this respect, it can be concluded, that the approach an individual surgeon is most familiar with is likely to lead to best results. of the patients, ( . %) received a formal assessment for antiresorptive therapy. the outcomes of this assessment is as follows: . % did not require any antiresorptive therapy, . % awaiting bone clinic assessment on discharge, . % awaiting a dexa scan, . % of patients were started on antiresorptive therapy and % were continued on antiresorptive therapy from pre-admission. conclusion: our study highlighted that in our trust only . % received this assessment formally. we can conclude that when this assessment occurs the guidelines and hence subsequent fragility fracture secondary prevention is addressed. we have then presented this data locally and amended our integrated neck of femur documentation pathway to include a section on antiresorptive therapy assessement. to follow this up we plan to re-audit from st january to st january . in the upper thoracic spine / ( %) could be placed with navigation, / ( %) were controlled intraoperatively. occasionally, scan-setup was problematic, in addition, we experienced technical problems. correct placement was seen for each screw, thus correlating well with theintraoperative findings. conclusion: the application of the combination of intraoperative d-imaging and navigation for posterior instrumentation of the cervical and the upper thoracic spine is technically feasible and reliable in clinical use. user-and software-dependant sources of error could be solved during the first course of the series. image-quality at the cervical spine is depending on individual bone density, and possible metal artifacts. with undisturbed visibility of the vertebral body, the reliability of d-based navigation at the cervical spine is comparable to that of ct-based procedures. additionally, it has the advantage of skipping preoperative acquisition of data as well as thematching-process. furthermore, exposure to radiation is reduced due to the possibility of sparing pre-and postoperative ct. disclosure: no significant relationships. the average lka measurements in order were: . °, . °, . °( p < . ), and for aca: . °, . °, . °(p < . ). while a significant difference between the averages of lka, e/f of group and group (p < . ), no statistical difference was found comparing the average aca angle (p = , ). while there was no significant change in e for all groups (p > . ), the increase in f after surgery was considered significant (p < . ), and no difference was observed between the averages of group and group (p > . ). vas was . ( - ). conclusion: at the end of an average year follow up period of posterior tl fractures no difference was found between the early and late period measurements of aca and anterior height although lka showed a statistical loss in height the correction degree achieved in the late period was found to be significantly higher than preop. ( cases), crushing without skeletal injuries ( cases) in all these cases, pulse was present at the first evaluation, and the onset of acute post-traumatic ischaemia was at - hrs after trauma . tha diagnosis, based on clinical suspicion, became definite after doppler evaluation and arteriography. the anatomical base of ischaemia was late thrombosis ( cases) and compressive hematoma ( cases). thrombosis was due to obstruction of the big arteries ( cases) and microcirculation, due to overrun compartment syndrome- cases.vascular restoration and fasciotomy was performed whenever muscles were viable, but amputation was necessary in cases results: the patients were analysed from the point of view of the corelation between the moment of onset of the ischaemia, the type of injury, the status of the muscular structures, the algorithm of diagnosis, the type of the treatment, and the clinical outcome. the study revealed that the clinical outcome was better when the time between trauma and ischamia onset was less, since the muscular ischaemic had less time to develop. in the same time, there were cases in which clinical symptomes were not corresponding to the imagistic evaluation. conclusion: high energy trauma affect all the structures of the limbs. clinical suspicion has particular importance especially when trauma affects one of the regions which is known as establishing a dangerous environment between the arteries and the bones / joints. in all the cases that authors analyse, complete and early diagnosis and treatment of acute post-traumatic ischaemia, based on the close monitoring of the patient and '' clinical alarm signs '' seemd to be the conditions for the favourable outcome of the patients. introduction: the aim of presentation is to demonstrate the surgical treatment and postoperative period of a patient who was caught on a fence-pole and suffered severe injuries of perineal region and lower extremity. material and methods: after a long time of technical rescue the patient arrived to our department with a one meter long portion of fence in his perineal region. after the urgent extraction of metal fence we performed an intraoperative rectoscopy. during the debridement and exploration of deep perineal injuries we realised a heavy swelling around the punctated wound of the left leg. we made a femoral incision and exploration and recognised the several injury of the femoral vein and artery. we provided the cm long injuries with stitches. results: in the postoperative period we made a second-look and debridement because of lymhphatic retention and small skin necrosis around the incision. no real vascular or circular lesions were recognised during the control period of the patient. injuries were totally improved. conclusion: the edification of this case is that it's never sure that the major wound makes the biger trouble to the patient or to the surgeon. in our presentation we plan to demonstrate the intra -and postoperative pictures and the results of controll period. results: the incidence of various types of trauma were blunt in patients ( %), gunshot wounds in patients ( %), and stab wounds in patients ( %). only ( %) patients were hemodynamicaly stable. isolated abdominal vascular trauma was detected in patients ( %). vessels injured included aorta ( , %), inferior vena cava ( , %), named visceral arteries ( %), named visceral veins ( %), iliac arteries ( , %), and iliac veins ( , %), epigastric, hypogastric, intercostal arteries ( , %), epigastric, hypogastric, intercostal veins ( %), gonadal vessels ( %), renal veins ( %), non-named mesenteric vessels with segmental bowels necrosis ( , %). two or more vascular injuries were found in ( , %) patients. according to organ injury scaling, st grade injuries were found in ( %), nd -in ( %), rd -in ( %), th -in ( %), and th -in ( , %) patients. the most frequent associated injuries were small bowel - , liver - , colon - , stomach , duodenum - , diaphragm - , pancreas - , spleen - , with an incidence of %, %, %, , %, , %, %, % and , % respectively. all injuries were managed according to injury score. infrarenal v. cava ligation was performed in all cases of hemodynamic instability. minor named abdominal vessels were ligated in all cases. segmental intestinal resection was performed in all patents with th grade of intestinal injuries due to devascularisation. overall mortality rate was %. the vessels with the highest mortality rates were inferior vena cava ( % - / ). there were no mortalities in isolated abdominal vascular trauma patients and in cases of st grade of injury. mortality rate in accordance to ois was: nd - patients ( %), rd - patients ( , %), th - patients ( %), th - patient ( %). no differences in mortality rate were found according to type of trauma (blunt or penetrating). the associated injuries with the highest mortality rates were pancreas ( / - %), diaphragm ( / - , %), liver ( ( ), a rupture of the heart ( ) or a aneurysma dissecans with a rupture of the aorta ( ). in addidtion to the detailed forensic examination and autopsy, we took the anthropometrical measurement of all corpses in dimensions, so that we were able to create a biomechanical simulation of the accidents with ''finite element models''. there the shear forces affecting the aorta can be calculated. as three forces (frontal impact, side impact and deceleration) are the most important, we will present three comprehensible example accidents. the reason of death is always the ''aortic rupture'', but every time the biomechanical way of application of the force was completely different. in detail they are a car accident (frontal collision of a small car with a wall); a downfall from the height of meters in suicidal purpose and a compression of the thorax of a eight year old boy with a shovel of an excavator. results: although all three accidents have completely different course of crash, we were able to see the same reason for death: a rupture of the aorta at the onset of the ligamentum arteriosum botalli. by using the numerical simulation, it can be shown that three main directions of force are important in an accident: the frontal impact, the side impact and the deceleration. in all these examples, it was able to simulate the reaction of the aorta in relation to the development of the force. the simulation will be presented as well as all clinical treatement made by the medical stuff. conclusion: although the rupture of the thoracic aorta is a frequent cause of death, the injury mechanism has not been comletely known. a database with several victims of aortic ruture was created and special accident types will be presented and simulated. introduction: overlooked compartment syndrome represents a catastrophic complication for patients and orthopedic surgeons. invasive compartment pressure measurement continues to be the gold standard. however, repeated measurements in uncertain cases can be difficult to achieve. we, therefore, developed a model for a noninvasive technique to assess tissue pressure by ultrasound based elastography. material and methods: a perforated plastic tube filled with saline was surrounded by a silicone sealed plastic cover, mimicking the shape of the tibial compartment. a pressure transducer inside the compartment was installed. a second pressure transducer was installed on the ultrasound probe to allow simultaneous monitoring of the pressure inside the compartment and the tissue deformity. for calibration, ultrasound images were generated at and mmhg. the plastic cover to tube distance was measured before and after compression (delta d). subsequently, increments of mmhg pressure increases were used to generate a standard curve ( - mmhg), thus mimicking rising compartment pressures. the intra-observer reliability was tested by using subsequent measurements. a correlation was determined between the skin to bone distance (delta d) and the pressure measurement (p). the pearson correlation coefficient was calculated, and a regression analysis was performed. ( ), better antibiotics and computed tomography-guided percutaneous drainage ( ). however, when everything else has failed, the burder of decision making the choice of a 'last resort' operation will be shifted again to the surgeon. we here described our recent experience with such cases treated by abbreviated laparotomy using the bogota bag technique ( ). results: for the seven first patients, we performed colon resection with colostomy. after extensive debridement, lavage and drainage, the peritoneal cavity was closed with a sterile gastric bag sutured on the rectus aponeurosis according to the so-called bogota-bag procedure ( ). the mean operative time was minutes. a second look laparotomy was planned after hours: one patient required one reexploration, four patients required two and two required three. the decision of re-exploration was based on the visual aspect of the peritoneal content, the clinical evolution and the bacteriologic results. for the last three cases, we elected perform colon resection without colostomy followed by anastomosis in two patients in the second look laparotomy and colostomy in one because of two relaparotomies. none of the ten patients required further percutaneous drainage. two patients died in multiple organs failure (one with perforated diverticulitis and one with ischemic colon after aneurysm repair). conclusion: abbreviated laparotomy with temporary closure of the abdominal wall associated with planned re-exploration of the peritoneal cavity is a simple and effective way to treat patients with severe abdominal sepsis. introduction: pelvic fractures usually are the result of high energy trauma and such patients often have many associated injuries. long term outcome data of pelvic injury patients is sparse, we present our information with special emphasis on poly-trauma patients, with consideration for the combined involvement of associated injuries on functional outcome. material and methods: general functional outcome and clinical outcome were determined with an examination by a physician and patient assessment at a minimum of years after the injury. pelvic fracture patients that had suffered poly-trauma were categorized by fracture location: acetabular, pelvic ring, or a combination. results: the long term outcome in the patients with pelvic ring fractures (exclusive of acetabular fracture) was the worst clinically, as evidenced by evaluation of pain( . %), increased use of special medical aids( . %), a poor merle d'aubigne score( . %), and worse sf- and haspoc scores. patients with acetabular fracture had poorer general functional outcomes than those with combined pelvic acetabular fractures and were noted to have higher incidence of associated injuries such as type iv pipkin fractures. further subcategorization of pelvic ring fractures into anterior, posterior or combination showed specifically those patients with combined anterior posterior pelvic ring fractures had the worst long term outcome. conclusion: a combined anterior posterior pelvic ring injury accounts for the worst long term outcome of pelvic injury poly-trauma patients. we found that bilateral pelvic injury and particular associated injuries greatly influence long term functional outcome. disclosure: no significant relationships. material and methods: canulated screws were placed in human semi-cadaver models and plastic pelvis models in d navigated, d navigated and conventional matta technique. aim of this study was to evaluate intraoperative time, intraoperative radiation dose (fluoroscopy time, area dose product and images per screw) and accuracy (amount of exactly placed screws, mean deviation of tip placement and misplaced screws per group). results: the accuracy of d navigated procedures is significantly higher (p < , ) than in the conventional technique. there is a significant lower radiation dose in the navigated procedures (p < , ) for the operation team. the intraoperative radiation dose is increasing significantly from conventional method to d navigated to d navigated procedures for the patient (p < , ). there is a significant higher time per screw necessary for navigated procedures (p < , ). conclusion: the usage of flatpannel technology seems promising in d navigation. our data shows a benefit from using navigated procedures in transilliosacral screw placement. the higher precision and lower radiation exposure for the operation team show that d navigation is superior to d navigated procedures. the higher accuracy of the d navigated procedures renders a postoperative routine ct scan obsolete thus lessening the total radiation exposition of the patient. introduction: the purpose of this biomechanical study was to determine whether locking screws or smooth locking pegs optimize fixation of ao a distal radius fractures. material and methods: pairs of fresh-frozen human distal radii were used. ao a extra-articular distal radius fractures were created by removal of a -cm-wide dorsal wedge of corticocancellous bone centered cm from the articular margin of the distal radius and were fixed using palmar locking plates. the radii were divided into matched-paired groups for comparison. the side order, the fixation order and the testing order were randomized. the distal fragment in group i was stabilized with angular stable screws. the distal fragment in group ii was fixed with locking pegs. the proximal fragment in both groups was fixed with screws. the probes were tested with . nm for torsion and with n axial load for cycles each. stiffness was measured from the first cycles regarding torsion and axial load. then the differences of the stiffness were recorded during the remaining cycles. the wilcoxon test was performed, a value of p £ . was considered statistically significant. results: there were no statistically significant differences in the first load cycles within the eight matched pairs. after cycles the constructs with locking screws (group i) showed statistically higher stiffness values (p = . ) compared to the constructs with smooth locking pegs (group ii introduction: plate fixation of the odontoid process without c -c arthrodesis appears to a practicable option for the management of odontoid fractures that are not suitable for conventional screw fixation. although previous biomechanical works have evaluated the effectiveness of different odontoid screw fixation techniques, no study has quantified the mechanical stability of odontoid fixation by a plate device. the purpose of this study was to measure the mechanical stability of odontoid plate fixation using a specially designed plate construct, and to compare the results to those after odontoid single-and double screw fixation. material and methods: the second cervical vertebra was removed from fifteen fresh human spinal columns. the specimens were fixed to the experimental apparatus, with the load cell at the articular surface of the odontoid process. in a first test series, stiffness and failure load of the intact odontoid were measured. type ii odontoid fractures were created by °oblique extension loading at the articular surface of the odontoid process. afterwards, the specimens were randomly assigned to one of the following three groups: in group i (n = ) the fractures were stabilized using a specially designed plate construct, in group ii the fractures were fixed using two . mm cortical screws, and in group iii we used one regular . mm cortical screw. in a second test series, stiffness and failure load of the stabilized odontoid fractures were assessed for comparison and statistical analysis. results: group i (plate device) showed a significantly higher mean failure load than group ii and group iii. the mean failure load of group i after fixation of the odontoid fracture was % of the mean failure load that was necessary to create a type ii odontoid fracture, initially. comparing group ii (double screw technique) and group iii (single screw technique), there was no significant difference regarding the mean failure load. in both groups the mean failure load after odontoid fixation was approximately % of the mean failure load of the intact odontoid. statistical analysis also revealed a significantly higher stiffness of the stabilized odontoid after plate fixation, than after single or double screw fixation. conclusion: plate fixation of the odontoid process as an alternative procedure in certain fracture patterns provided a significantly higher biomechanical stability than the technique of odontoid screw fixation. using a specially designed plate construct fixed with two cancellous screws into the body of c and an additional cortical screw inserted in the odontoid process, % of the original stability of the intact odontoid was restored. single or double screw fixation of the odontoid only restored approximately % of the original strength. results: extension and flexion were not influenced of all implants significantly. all dynamic implants and also the rigid implant led to a significant increase of the mobility during side bending and rotation in the area of the adjacent segments. conurrently the cephaled adjacent segment (l /l ) showed a significantly higher mobility than the caudal adjacent segment (l /l ). conclusion: dynamic implants such as the interspinous spacer enlarge the mobility of the adjacent segments during side bending and rotation in a comparable size as the rigid implant. to this extent is to be assumed that reinforced adjacent degeneration cannot be prevented by the use of the interspinous spacer substantially. introduction: osteoporosis is a systemic skeletal disease characterized by reduced bone mineral density and disrupted microarchitecture of bone tissue. the most severe consequence of osteoporosis are osteoporotic fractures. these are mainly low-energy fractures, which anamnestically, clinically and radiologically differ from fractures in healthy bone. we tried to find the answer to a queston, whether it is possible, that osteoporotic compression fractures are single events, or if they represent a gradual, progressive vertebral collapse in patients with osteoporosis. we evaluated the forces, necessary for vertebral fractures, regarding the bone mineral density. material and methods: cadaver vertebrae were isolated with the approval of ethics committee. we mesured their bone mineral density and then subjected them to the stress-test. we used the computer-controlled hydraulic press and stress vertebrae to the fracture point and beyond, monitoring the deformation and the load. a sigma-epsilon diagram was constructed from the data. results: with the loading of vertebrae the pressure grew exponentially as a function of deformation to the breakage point. then we observe a plateau of saw-like shape, which corresponded to the progressive vertebral collapse. further deformation led to gradual compacting of vertebrae and we observed once again an exponential increase in pressure. this bone compaction is therefore the first mechanisms of fracture repair. the saw-like plateau form suggests progressive collapse of vertical trabeculae and their jaming into the horizontal, which then with the increasing deformation and load also fail. a similar phenomenon can be observed in the collapse of buildings during the demolition. (the - phenomenon). conclusion: unlike a high energy vertebral fractures, the osteoporotic fractures are presented as a gradual vertebral collapse. they take place parallel with the processes of bone reparation and remodelation. from this standpoint, osteoporotic fracture is unique. vertebral collapse increases the bone mineral density in the broken vertebrae, what is observed radiologically and densitometrically. repair of medium to large, but reparable, rotator cuff defects, augmented with a restore patch or not. patients have been randomly assigned to receive standard repair augmented with the restore implant or to receive non-augmented standard repair as the repair procedure is exactly the same in both patient groups, and the implantation of the restore implant does not necessitate any additional incision or measures, neither the patient nor the assessors are aware of the fact an implant has been used. the ethical committee of the university hospitals leuven has approved the study. all patients get full information and are enrolled in the screening program after written consent only. clinical evaluation, both pre-operatively and at months post-operative is performed by the same, independent physiotherapist trained in shoulder evaluation using the constant score structural evaluation is performed by ultrasonography, performed by a radiologist specialised in musculoskeletal radiology and sonography. unpaired two-tailed t tests, performed with prism software for mac osx, were used to compare the results of the scores in the control group with those in the xenograft group. fisher exact tests were used to evaluate the significance of differences in the proportions of retears in the patients for whom a sonography was obtained. results are expressed as the mean and standard error and significance was set at p < . . results: we included patients. there were female and male patients. in the non-augmented group there were females and males. in the restore group there were female and male patients. the average age of patients was years of age. in the non-augmented group the average age is , y (+/- , ) years of age, in the restore group , y (+/- , ). the mean pre-operative constant score of the non-augmented group was , +/- , points whereas it was +/- , points for the restore augmented group. post-operative the functional outcome months after surgery again was scored using the constant score. the mean score in the non-augmented group was +/- , points; in the restore group it was , +/- , points in the non-augmented group we documented a retear in / patients, in the restore group we had a retear in / patients ( small tears, massive tear). introduction: it has been estimated that up to % of adults suffer from rotator cuff tears [ ] , which can impair their ability to work or perform household tasks [ ] . management of rotator cuff tears is difficult as a large proportion of technically correct surgical repairs re-rupture, estimated between - % [ ] . it has been estimated that thousands of extracellular matrix repair grafts are used annually [ ] to augment surgical repair of rotator cuff tears and act as temporary scaffolds to support tendon healing. the only mechanical assessment of the suitability of these grafts for rotator cuff repair has been made using tensile testing only, and compared grafts to canine infraspinatus [ ] . as the shoulder is subject to shearing as well as uniaxial loading, we compared the response of repair grafts and human rotator cuff tendons to shearing mechanical stress. we used dynamic shear analysis (dsa), which is a form of rheology and allows the study of flow and material deformation. material and methods: the shear properties of four different commercially available rotator cuff repair grafts were measured (restore, graftjacket, zimmer collagen repair and sportsmesh). mm punch biopsies were taken from the grafts and subjected to oscillatory deformation under compression. the bulk storage modulus (g') was calculated [ ] and used as an indicator of mechanical integrity. to assess how well the repair grafts were matched to torn and normal rotator cuff tendons, the storage modulus was calculated for human rotator cuff specimens obtained from the edge of rotator cuff tears during surgery, from patients aged between and years. age and sex matched normal controls were also obtained during shoulder hemiarthoplasties and stabilisations. results: we report a significant difference in the shear moduli of all four rotator cuff repair grafts (p < . , way anova). of the repair grafts (restore and graftjacket) had a significantly lower storage modulus when compared to human rotator cuff tendons (p < . , dunn's multiple comparison test). only the zimmer collagen repair and sportmesh had a storage modulus which was comparable to that of normal rotator cuff tendons (p > . ), and thus were most closely matched. conclusion: with increasing numbers of repairs of rotator cuff tears, and augmentation of these repairs, there is a need to understand the mechanical and biological properties of the both repair grafts and the tendons they are designed to augment. there is no clear definition of the ideal mechanobiological properties. current rotator cuff repair grafts display a wide variation in their shear mechanical properties, and how closely they are matched to the mechanical properties of human rotator cuff tendons. it is hoped that this study, in conjunction with others, will help to guide surgeons in deciding on the most appropriate repair graft. three-dimensional computed tomography reconstructions also improved the average intraobserver reliability for all fracture characteristics, from j d = . (substantial agreement) to j d = . (substantial agreement). the addition of three-dimensional images had limited influence on the average interobserver reliability for the recognition of specific fracture characteristics (j d = . versus j d = . , both moderate agreement). three-dimensional computed tomography images improved interobserver reliability for the recognition of coronal plane fractures from fair (j d = . ) to moderate (j d = . ) but this difference was not statistically significant. conclusion: three-dimensional computed tomography is helpful for; ) individual orthopaedic surgeons for preoperative planning (improves intraobserver reliability for the recognition of fracture characteristics), and for ) comparison of clinical outcomes in the orthopaedic literature (improves interobserver reliability of classification systems). disclosure: no significant relationships. introduction: in recent years, d fluoroscope has used increasingly in orthopaedic surgery because it offers some advantages such as generation d data without anatomic registration requirement. previous studies have focused on the clinical use of d fluoroscope in surgical procedures such as calcaneus or acetabular fracture reduction, or placement of screws in spinal surgery. there are no reported data on radiation exposure of d flu to orthopaedic theater staff. we want to correlate radiation exposure and distance concerning the patients and members of surgical team during using three-dimensional fluoroscope and study how far is enough until radiation exposure can not be measured. material and methods: an isocentric c-arm fluoroscope (siremobile isoc d) was used for the study. human cadaveric extremity was used for target. digital dosimeters (mydose mini pdm- , aloka) were used to measure radiation exposure at specific distances. dosimeters were systematically exposed by the following protocol. represented positions were direct contact and every -cm. radius from the center of the beam. the distances were increasing until the dosimeters could not detect the radiation. each radius distances were designed to record different positions; top, bottom, left and right side. dosimeters were exposed and removed ( dosimeter positions at a time from each radius). first we used low resolution scan technique to obtain the images. after all radiation exposure records were collected, we changed to use high resolution scan technique and repeated the protocol. each technique was repeated in times to obtain the mode of data. results: radiation dose at ground zero is lsv in high resolution and lsv in low resolution. radiation in high resolution technique can not be measured beyond meter from the center of the beam at the top, bottom, and right direction and . meters at the left direction. in low resolution, radiation cannot be detected farther than cm. in the top, bottom and right direction and . meters at left direction. conclusion: radiation dose measurements in each direction are decreased during increasing distance and dose in left direction is higher and farther than others. beyond . meters is safe from radiation in knee application. high resolution gives higher radiation and farther than low resolution. introduction: tibial plateau fractures with impression are often associated with poor outcomes and a high rate of complications. the current guidelines advocate anatomic reduction, re-establishment of tibial alignment, stable fixation, and filling of the sub-articular defect. we hypothesized that fixed-angle liss-plates provide adequate stabilization with less need for void filling, minimal complications and good radiological outcome. material and methods: retrospective evaluation study. in the period - , we operated patients with an intra-articular tibial plateau fracture. forty were treated with a liss-plate. mean age was years, were male. all fractures were classified as ao type b or c; were schatzer type ii, type iv, type v, and type vi. five patients were initially treated with external fixation. mean time until definitive surgery was days (range, - days). in fractures, the subchondral void was filled with either hydroxy or bone graft, in the other cases no graft was used. demographic data and fracture classification were equal in both groups. articular impression was measured by independent evaluators pre-operatively, post-operatively and months after surgery on plain x-rays. results: mean pre-operative impression was . mm (with void filling . mm, without . mm, ns). thirty-four fractures were additionally stabilized with k-wires or screws. the post-operative impression was on average . mm. evaluation criteria included the lysholm and tegner activity score. all fractures were stabilized post primarily. the surgical main approach was strictly medial. exposure of the entire medial condyle fracture was first performed anteromedial following the fracture line to the articular border. the posterolateral impaction was addressed directly through the main fracture gap. small fragments were removed, larger reduced and preliminarily fixed with separate kwire(s). the posteromedial part of the condyle was then prepared for main reduction and application of a buttress t-plate in a posteromedial position, preserving the pes anserinus and medial collateral ligament. in addition a parapatellar medial mini-arthrotomy through the same main approach was performed for reduction and pds-suture-fixation of the anterior eminence (acl and anterior horn of lateral meniscus). results: we treated patients with fractures. median age was years ( - ). we could evaluate patients ( %), patients were lost to follow-up due to foreign residency. the fractures were treated post primarily at an average of days, of them in a twostaged procedure with initial knee-spanning external fixator. all fractures healed without secondary displacement or infection. patients showed none to moderate osteoarthritis after a median of years. one patient showed a severe osteoarthritis after years. all patients judge the result as good to excellent. the lysholm score reached ( - ) and the tegner activity score ( - ). all patients have achieved a minimum flexion of °. conclusion: in our view it is crucial to recognize this increasingly observed type of knee injury in winter sport areas. with our strategy we achieved good results in nearly all patients. the described larger medial approach allows addressing most of the injured parts of the tibial head (medial condyle with posteromedial buttressing, tibial spine, posterolateral impaction). material and methods: it is presented one new minimally invasive method for closed fracture reduction and one extramedullary selfdynamisable internal fixator (sif). there is no contact between bone and internal fixator in fracture area. it has been widely investigated biomechanicaly. in clinical use it has been applied to metaphyseal fractures of distal femur and proximal and distal tibia. the age of patients was from to years. this internal fixator is applied by two small incisions. reduction is achieved using standard traction table or using special reduction device. for opened fracture it has been used high mobile external fixation system as temporarily ( fractures) or definitive ( fracture) method. results: received clinical results are promising, as it has been shown early callus formation and radiological union within the . - months. it has been allowed to patients early full weight bearing, if fractures not intraarticular. during the treatment it has been confirmed working of self-dynamisation concept, which probably all together with d configuration resulted in unexpectedly quick fracture healing. follow up was months ( - ). when used external fixation system, axial dynamisation has been regularly activated. conclusion: according to results obtained, it can bee concluded that new biological internal fixator is suitable for minimally invasive technique, without opening of fracture site if no intraarticular dislocation. it can be used as primary method or soon after external fixation if damaging control concept used. introduction: disaster, is the disproportion between the need for medical care and the means available in the community. this discrepancy of needs /means is the major problem in every step of the rescue chain, when a disaster situation is present. this is more obvious at the end of the chain, which is the hospital and especially, the bottleneck of the entire disaster's management system, the emergency department. material and methods: in greece, the most common and frequent disaster situation is the earthquake. and so, the most expected pathology of the victims is trauma. because of the lack of . special organization of emergency medicine and . independent modern emergency departments in greek hospitals, their directors did not give the appropriate attention to organize a disaster plan (internal or external introduction: accurate response to major incidents requires accurate decisions on all levels, from command level to the care of the individual patient. development, evaluation and training of the process of decision-making requires standardized models providing complete and accurate information as a base for the decisions; a decision based on incomplete or incorrect data can not be properly evaluated. the aim of the present project was to design a simulation model that could be used both for evaluation of different methods in the response to major incidents and for training and evaluation of skills in making correct decisions. material and methods: a system was created providing the information required for this process in the whole chain of management and performance: scene, transport, hospital response, co-ordination and command. input data were based on real scenarios and real resources. for evaluation of methodology, all parameters except the one studied, in this study triage, were standardized. the results from (a) physiological and (b) anatomical triage, performed by staff on different levels of competence and experience, serving as their own controls, were compared. for training, the system was used in courses in medical response to major incidents with training of the whole chain of management and performance, from prehospital patient management to over all co-ordination and command. results: the methodological evaluation showed differences in priority and outcome between anatomical and physiological triage related to the level of experience and to the position in the chain of response, providing a base for choice of method related to those factors. the results from training with the use of the system, so far only evaluated by the participants own ranking, showed high percepted improvement of relevant skills. conclusion: a methodology for simulation of major incident response designed for scientific evaluation of methodology also provides a very good educational tool, since correct and complete data as a base for decision making also gives an effective and realistic training. disclosure: one of the authors, sl, has the copyright to the mac-sim system, a non-commercial system intended mainly for scientific use. equipment for training can be produced by users, but also purchased for production costs. introduction: interhospital referral of traumapatients for reasons of special (most neuro-)surgical competencies to a specific level traumacenter, is common practice in the netherlands. these traumapatients are sometimes admitted directly through specialized intensive care units and therefore do not enter the emergency department (ed). therewith the standard assessment according to the atls guidelines is bypassed in these cases. this withholds the risk of an incomplete assessment. we therefore consistently coordinate the assessment of all transferred traumapatients. in this study we analysed the number of newly found injuries in referred polytraumatized patients and the clinical consequences in terms of extra treatment, permanent damage or death to the patient. we also analysed possible risk factors for missing injuries. introduction: synchronous admission of large numbers of patients into the hospital requires a perfect coordination of activities of designated teams in the process of reclassification at the entry to the hospital and subsequent continuous provision of medical care for the patient in the course of examination and treatment, up to his hospitalisation at the target department, in accordance with the characteristics of the injury and seriousness of his medical condition. this process cannot be accomplished through improvisation but only with creating a uniform organisational scheme, defining the recommended structure of medical teams and their activities during a multiple admission of casualties into the hospital. in this article, we present a proposal of such consensual organisational scheme, partially verified in practice. the organisational scheme is defined in the following areas: -space arrangements -places of admission and organisation of work -creation of mini trauma teams (anaesthesiologist, traumatologist and surgeon or another traumatologist take over the most serious patients, the teams are accompanied by consulting specialists of relevant specialities (neurologist, neurosurgeon, radiologist), the whole teams or at least parts of them, accompany the patients for the whole period up to the definite treatment at operating theatre, or his placement at a destination department -the continuity of care is secured in this way, without the need to pass on any findings and information -placement of patients into individual hospital departments (follows certain rules, it is necessary to direct all the admitted patients into as few departments as possible (one or two), and thus keep the best possible view over the priorities during their treatment -entry corridors -,,green corridor'' -patients are immediately transported through this area by transport teams into the ''green'' designated area, the ''red'' and ''yellow'' entry area does not have to be extremely large, however it requires an adequate equipment from the material and technical point of view results: multiple admission of patients must be well-organised and managed, most often by a head-physician of the ua department, or another authorised specialist (in hospitals without the ua department). the idea of the traumanetwork d dgu is to built up regional networks of various trauma centers with the objective to standardise and optimise the treatment of severely injured patients -with the additional involvement of rescue services, physicians and competent facilities and centres for the treatment of specific injuries as severe burn or spinal cord injuries etc. to assure that all participating hospitals meet the criteria needed for the treatment of trauma patients, a certification firm (diocert) was assigned to accomplish the audits and to control the process of certification. thus, every hospital has to pay a sum of nearly eur for audit, certification, benchmarking, yearly quality reports and the use of special it-tools which were designed for the traumanetwork d dgu. material and methods: coordination of traumanetwork implementation coordination of audit and certification process results: since the beginning in the year actually hospitals are participating the traumanetwork d dgu. these hospitals are organized in regional traumanetworks. % of the hospitals are preliminary categorized as local trauma centers, % as regional trauma centers and % as over-regional traumacenters (the highest category). % still aren¢t categorized. hospitals have already signed the contract with the german trauma society and paid the participation fee. hospitals meet the criteria for audit and hospitals are already audited by the firm. in october the first regional trauma network (trauma network east bavaria / tno) was certificated with a total of participating hospitals. conclusion: in the past years the number of participating hospitals increased year by year. the nationwide acceptance and the high level of participation in the traumanetwork d dgu in germany show that the treatment of severely injured patients is one of the main topics and exercises for trauma surgeons in germany. if the expected improvement in treatment quality and the decline in trauma mortality is only wish and fiction or reality and fact has to be proven by studies in the next years. therefore a working group with focus on quality improvement, changes in mortality, improvement in rehablitation results etc. was founded. introduction: one of the challenges in trauma care is diagnosing all injuries. any delay in treatment can lead to increased morbidity, prolonged length of hospital stay, costs, and even mortality. despite the use of standardized guidelines for initial evaluation such as atls, the incidence of missed injuries in the literature is considerable. the aim of this study was to assess the rate of missed injuries in trauma patients evaluated in two dutch level- trauma centers and to determine potential factors that contribute to injuries being missed. we assessed all radiological reports during initial admission and operation records of the patients included in the prospective randomized react trial. this study was part of a randomized trial conducted in two dutch level- trauma centers investigating the role of ct scanning in the trauma room. missed injuries were defined as not diagnosed during initial radiological evaluation in the trauma room. we assessed all missed injuries and the phase in which these injuries were diagnosed. second, we assessed potential contributing factors by univariate analysis. results: there were a total of total calls performed with real patients and test calls. of the actual calls, ( %) were performed while moving and ( %) were done from a stationary position. initial video quality in was rated good in cases ( %) and initial audio quality was rated good in ( %) cases with actual patients. of the actual calls ( %) experienced some sort of temporary video drop during the entirety of the call and calls ( %) experience some sort of temporary audio drop. these drops were a result of the setup of mesh wifi and the need to jump from router to router. users in the hospital found the program to be a very useful trauma and emergency medicine tool, but adjustments need to be made to improve the network. conclusion: the use of telemedicine in a pre-hospital setting may play a significant role in the management and treatment of trauma and critically ill patients as hospital medical staff can intervene in real time during transport. patients can be evaluated in real time which allows the necessary staff and resources to be available on arrival. initial user feedback has been encouraging with users acknowledging its usefulness as a pre-hospital tool. ( ) in the elective setting it is logical that a lower egfr reflects poor renal function and low overall physiological reserve. the same is not obviously true for emergency patients who may have an ''artificially'' low egfr merely as a reflection of acutely altered fluid balance. change in egfr from admission to hospital to itu admission was also significantly different between survivors and nonsurvivors. this would suggest that egfr reflects a response to treatment as well as renal function. this study supports the use of egfr in the decision making process when trying to predict outcome in emergency general surgery patients. introduction: the surgical medium care (smc) in our hospital is a bed ward with monitoring facilities, and is used critical ill patients from the trauma and other surgical wards. over the last years there has been an increase in the number and severity of trauma patients admitted to out hospital, as well as there has been an increase in patients undergoing major elective surgery. the aim of this study was to verify if these trends are reflected in an increase in patient-and workload on our smc. in this study we describe the patient-and workload on the smc between and using the tiss- . the modified therapeutic intervention scoring system (tiss- ) is a validated score of therapeutic activities and an alternative approach to evaluate outcome of critically ill patients ( ) ( ) ( ) . material and methods: a prospective cohort study of all consecutive patients admitted to the smc between / / and / / was performed, using the tiss- database. of all admitted patients a daily tiss-score was performed. besides the tiss data, patients demographics, referring ward, discharge destination, length of stay, and hospital mortality were retrieved from the database. results: there were a total of admissions of patients in the study period. % of patients were male, % were female. the median length of stay was days ( - ). the overall hospital mortality rate was , %, with no significant differences over the years. % of the patients admitted to the smc came from the icu, % came from the emergency department, , % came from home, , % came from the recovery ward, and % came from the trauma and surgical ward. these percentages did not change over time. the average tiss score during the study period was and did not significantly differ during the study period. there was, as expected, no significant difference in tiss score between patients who survived and the non survivors. introduction: the demands placed on systems and organisations that protect the general population are constantly growing. the reasons for this include, among other things, circumstances altered by the threat of inter-national terrorism and the increasing frequency and magnitude of mass public events and natural catastrophes. crisis situations such as these present unique, often completely unprecedented chal-lenges to those affected and to all actors with responsibility for crisis management and the protec-tion and rescue of people.with regard to effective interdisciplinary crisis management, both germany's security and rescue forces and its general population suffer from widely acknowledged and scientifically proven deficits. impact on people and the society. in this context, all natural and man-made threats will be considered (''all hazards approach''). elearning and virtual reality modules based on these scenarios will be offered to target groups via the internet on an individualised basis. results: the aim of this project is to develop a platform to prepare security and rescue forces, doctors, caregiv-ers and the general population for terrorist attacks, crises and disasters. an online platform with a modular structure (employing teaching methods such as e learning, blended learning etc) will offer innovative and specialised instruction and advanced training to all users. conclusion: experts agree that the modern teaching methods and computer-based simulations mentioned here (such as virtual reality methods) are excellent tools to help train people efficiently to respond to events that cannot be planned, such as terrorist attacks and other catastrophes. the use of these innovative methods and com-pletely novel, userfriendly, web-based instruction and information modules is designed to address -to a heretofore unprecedented degree -all security and rescue forces concerned as well as the general population in particular. ultimately this will signifi-cantly improve security and rescue operations in the event of terrorist attacks, crises and disasters. conclusion: in a proper setting, laparoscopic emergency is feasible, effective, safe and beneficial for patients to be a part of a common surgical practice, as long as adequate training is obtained and proper preparation observed when more advanced procedures are attempted in critically patients. the diagnostic and therapeutic versatility afforded by the laparoscopic approach avoids extensive preoperative studies, averts delay in operative intervention and minimize morbidity and shorten the postoperative hospitalization. we do think that laparoscopy should be incorporated into general surgeon's armamentarium for the management of patients with acute abdomen as just as another tool to be used selectively when indicated. laparoscopy, however, must not be used as an alternative to good clinical judgment. about our algorithm in patients with acute abdomen: if there aren't any contraindications to laparoscopy, obtained an informed consensus, in presence of a well trained surgical team in minimally-invasive surgery, excluded any major gynaecological diseases (about which we and our gynaecological colleagues haven't a skilled experience with a laparoscopic approach), we always approach laparoscopically. introduction: stable patients with thoracoabdominal penetrating or blunt injuries resulting in diaphragmatic injuries represent a difficult and challenging management dilemma. although laparoscopy and thoracoscopy have now emerged as the most reliable and efficient diagnostic and treatment modality of these injuries, a conversion to laparotomy for mere evidence of peritoneal penetration and or diaphragmatic injuries is common for most trauma surgeons. we hypothesized that laparoscopically-assisted mini-thoracotomy for repair of diaphragmatic injuries will be as effective as open laparotomy or thoracotomy and will prevent the morbidity associated with open technique and should be used in hemodynamically stable trauma patients. we designed a minimally invasive technique that combines laparoscopic exploration of the intraperitoneal cavity and existing injury site as an entrance to the injured site or organ. open hassan technique, using vertical midline incision is used to create the pneumoperitoneum. additional two to three or mm ports are placed to enable thorough examination of the peritoneum, running the small bowel and examining other abdominal viscera. diaphragmatic lacerations are repaired by extending ( - cm) the existing thoracic stab or gunshot wound. the diaphragm is grasped with two graspers and brought to the operative field. continuous or interrupted suture are used for repair. we applied this technique to hemodynamically stable trauma patients (la group) treated over a year period at the university level i trauma center and compared to trauma patients requiring laparotomy (og) for isolated diaphragmatic injury repair . all laparoscopically assisted procedures were performed by the senior author (rl). length of stay, morbidities and complications were studied in both groups. both groups were matched for iss, age, and gender and mechanism of injuries. results: there were patients (five with stab, two with gunshot wound and one with blunt trauma and chronic diaphragmatic injury) in the la group. introduction: acute small bowel obstruction is mostly due to adhesions ( %), while internal hernia can cause acute small bowel obstruction in % of cases. this clinical condition has been considered for many years a relative contraindication for laparoscopic surgical treatment. with the introduction of ct-scan in the diagnosis of this clinical situation and the experience in laparoscopic techniques, more surgeons are now attempting laparoscopic management for this indication. the advantages of laparoscopy in abdominal surgery are now well defined, such as a shorter intestinal function recovery, a shorter hospital stay and less post-operative pain complained by the patients. in our presentation we want to analyse the importance of laparoscopy in the diagnosis and the treatment of acute small bowel obstruction, in order to underline advantages and limits of this technique. material and methods: in san raffaele hospital milan (italy) a total of patients underwent a surgical intervention for small bowel obstruction from january to december . % of the obstructions was due to adhesions, % to internial hernias. all the patiens underwent preoperative abdominal x-ray and ct-scan. results: of the total of patients, have been operated on with a laparoscopic approach, with a conversion rate of . %. postoperative morbidity was % in the laparoscopic group and . % in the traditional surgical approach, with a shorter hospital staying in the first group. conclusion: the analysis of our data suggests us that the selection of patients that can benefit from a laparoscopic approach to acute small bowel obstruction has to be made accurately, better with the use of ct-scan, in order to limit the percentage or useless laparoscopy and to diminish the conversion rate and to give the patient the better curative option. introduction: intestinal obstruction has remained one of the most common surgical emergencies. the aim of our study is to evaluate the feasibility, safety and palliative role of laparoscopic bowel surgery in the management of large bowel obstruction. material and methods: in a period of years, patients were subjected to loop sigmoidostomy. in patients the diagnosis was bowel obstruction due to rectal cancer. in patients the obstruction was attributed to ovarian cancer. from those patients with rectal cancer, patients had contominant liver and lung metastases and had an unresectable liver lession. in that period lapassisted ileo-transverse anastomosis were performed due to obstruction from cecum carcinoma together with mlitple liver and lung metastases. single surgeon-performed pocus in the evaluation of acute appendicitis led to a correct diagnosis in , % ( / ). surgeons trained in us ordered a ct scan in , % of cases and ratio of negative appendectomy was , %. surgeons not trained in us ordered a ct scan in , % and their ratio of negative appendectomy was , % (including pts that underwentent surgery on clinical investigation basis only). conclusion: surgeon-performed pocus has a high sensitivity in the assessment of acute appendicitis and it is a powerful tool that minimize the use of ct scan and ratio of negative appendectomy with reduction of hospital and social costs; furthermore an advantage for the patients in terms of radiation exposure can be achieved. moreover, to reduce additional costs, laparoscopic approach should be indicated only when the appendix cannot be perfectly visualized and localized. introduction: severe bleeding is, besides head injury, the most important predictive factor in severe trauma. therapy of hemorrhagic shock starts already at the scene of accident. however, the best strategy regarding preclinical volume therapy is controversially discussed. the traumaregister of the german society for trauma surgery (tr-dgu) observes the routine management of severely injured patients since many years. this registry will be used to describe the behaviour of preclinical volume administration as well as the consequences in early hospital care and its changes during the last ten years. material and methods: the tr-sdgu is a voluntary anonymous documentation of severely injured patients for the purpose of quality management. data collection started in . about parameters are collected per patient. for the present investigation only adult patients (age >= ) admitted directly from the scene to one of the participating hospitals during the past ten years ( - ) were considered. a minimum injury severity of iss > = and available data for volume administration and blood transfusion were required. means and prevalence rates were analyzed on a yearly basis. results: a total of , patients injured between and were analyzed. mean age was . years, and % of patients were males. in % of cases there was a blunt trauma mechanism, and % of cases were unconscious at the scene (gcs £ years that required presentation in one of the two level- trauma centers (amc or vumc) were eligible. in the amc the ct scanner was located in the trauma room (intervention group) and in the vumc the scanner was located in the radiology department (control group). randomization was performed prehospitally at the time of dispatch from the scene. primary outcome measure was the number of non-institutionalized days within the first year following trauma. secondary outcomes were mortality, length of initial admission and transfusion requirements. preplanned subgroup analyses consisted of multitrauma patients and severe traumatic brain injury (tbi) patients. results: in total, patients were included for analysis of which were multitrauma patients and had severe traumatic brain injury (tbi). demographic data were comparable between both groups except that there were more multitrauma patients evaluated in the amc. introduction: the effective initial treatment in the emergency room of polytraumatized children requires a sound knowledge of common injury patterns, incidence, mortality, and consequences. the needed inital radiological imaging remains controversial and should be adapted to the expected injury pattern. material and methods: in this retrospective study, the injury patterns of polytraumatized paediatric patients (age £ years) in the period from december to may were evaluated. all children were initially diagnosed with a whole body ct scan. the cause of accident, the localization including the detailed diagnose, the lethality and the severity of the injuries were analyzed. the ais (abbreviated injury scale) and iss (injury severity score) were used to classify the severity of injuries in different body regions. moreover the number and the kind of operation as a consequence of the initial made diagnoses were investigated. results: the mean score of the iss was ± in boys and girls with a mean age of ten years. the lethality was % and only % in the first hours. the most severe and most frequent injury was craniocerebral trauma in % with an ais ‡ in %. surgical intervention of the head was done in %. thorax injuries were found in % with % with an ais ‡ and in % a thoracic drainage was needed. abdomial trauma was found in % (surgery %) with an ais ‡ in %. fractures of the spine occured in % (surgery %) with an ais ‡ in % and pelvic injuries were diagnosed in % (surgery %) with an ais ‡ in %. injuries of the upper extremity were found in % (surgery %) with an ais ‡ in % and of the lower extremity in % (surgery %) with an ais ‡ in %. conclusion: especially because of the detected high percentage of head and thorax injuries in polytraumatized children and the needed head surgery the authors recommend a whole body ct scan in children who are potentially polytraumatized. not only in adults but especially in children the authors suggest the initial use the quickest imaging with a high sensitivity-the whole body ct scan. introduction: patients who suffer physical injuries following a traumatic event are at risk for developing posttraumatic distress. care workers in hospitals treating polytrauma patients are in an optimal position to screen and identify patients developing posttraumatic stress disorder (ptsd). to start early intervention procedures and possibly lower the prevalence, a screening instrument to identify patients at a higher risk is needed. aims of this study were to determine if the severity of injury is related to the prevalence of ptsd and to review the personality traits of patients with ptsd. with these results a screening instrument might be developed. to simulate an unstable extraarticular distal radius fracture, an osteotomy with a mm gap was made. axial loads of - to - n and torque loads of - , to , nm were applied by a testing machine to the intact radii and to the radii after each device was fixed as recommended by the manufacturer. after that, cycles of dynamic torque load alterations of , to , nm (or - , to - , nm convenient to side) at , hz with a preload of - n were performed. in the specimens that were still intact after cycles, loading in torque was continued until failure occurred. axial and torque stiffnesses of the osteosynthesis system were calculated. results: with a median of , n/mm axial stiffness of xscrewÒfixed specimens was higher than of dnpÒ-fixed specimens with a median of , n/mm but did not reach statistical significance. with a median of , nm/°torque stiffness of xscrewÒ-fixed specimens was significant higher than of dnpÒ-fixed specimens with a median of , nm/°. the xscrewÒ-group reached % of the axial stiffness and % of the torque stiffness and the dnpÒ-group reached % of the axial stiffness and % of the torque stiffness of the intact radii. conclusion: fixation of unstable extraarticular distal radius fractures with a xscrewÒ provide biomechanically more stability than a fixation with a dnpÒ. disclosure: no significant relationships. after distal radius fractures occur in % to % of fracture cases. the resulting deformity resembles madelungs deformity and is also called pseudo-madelungs deformity. this deformity leads to ulnocarpal impaction and dorsal dislocation of the distal radioulnar joint (druj). several treatment options such as lengthening of the radius and shortening of the ulna or epiphysiodesis of the distal ulna have been described. the taylor spatial frame (tsf) is a hexapod based external ring fixator, which is widely used to perform six-axis deformity corrections of the lower limb. tsf-planning is web based (www.spatialframe.com) but its use is only available for lower extremities. the purpose of this study was to apply the tsf to the upper extremities to correct pseudo-madelung deformities. material and methods: defining the nomenclature to correct bony deformities with the tsf, one must determine the deformity parameters, the frame parameters, and mounting parameters for the web based planning program. the six deformity parameters and the four mounting parameters use the anatomic nomenclature for the lower extremities. to use the tsf on the forearm, one must transfer the nomenclature of the deformity parameters and the mounting parameters to the nomenclature of the forearm with the transferred nomenclature, one can correct forearm deformities with the correction mode long bone of the planning program for the lower limb. patients two boys (patient , years, patient , years old) and two girls (patient , years, patient , years) were seen in our clinic with progressive pseudo-madelung deformities after an epiphysial fracture of the distal radius at age in the boys and in the girls. skeletal maturity (rus, tw method) was equivalent to the patientâ e tm s age. results: in the four patients, the multiplanar deformitiy of the distal radius could be corrected anatomically with the tsf. there were no frame changes or frame modifications necessary for deformity correction. patient was slightly overcorrected because of some growth in the distal ulnar growth plate. during the distraction, each patient had two low-dose ct scans for better visualization of the radiocarpal and radioulnar joint. the web-based planning program was adjusted twice until total deformity correction was achieved. no further immobilization after frame removal was required. the one-year follow-up showed an anatomic aligned forearm/hand relation with increased pronation and supination compared to the preoperative range of motion in all patients. the wrist and especially the druj were stable and reduced at the one-year follow-up examination. the patients did not complain about any pain or functional deficits in the hand. conclusion: in conclusion, the power of the tsf with the ability to move two fragments precisely can be transferred to the forearm. this allows for the correction of multiplanar radial deformities simultaneously without the need for frame modifications of rotational and translational deformities, as is necessary with the standard ilizarov system. material and methods: thirty-four consecutive patients with a suspected scaphoid fracture (post-injury tenderness of the scaphoid and normal radiographs) underwent ct and mri within ten days after trauma. ct-reconstructions were made in planes defined by the long axis of the scaphoid. the reference standard for a true fracture of the scaphoid was -week follow-up radiographs in four views, based on current available evidence in the literature. a panel including surgeons and radiologists came to a consensus diagnosis for each type of imaging considered in a randomized and blinded fashion, independent of the other types of imaging. we calculated sensitivity, specificity and accuracy as well as positive (ppv) and negative predictive values (npv) for both imaging modalities. results: according to the reference standard there were six true fractures of the scaphoid (prevalence % both mri and ct are better at ruling fractures out than in ruling them in and both were subject to false positive and false negative interpretations. the best reference standard for a true fracture is debatable, but for now it is not clear when bone edema on mri and small unicortical lines on ct represent a true fracture. we advice ct because costs are lower and overall availability is higher. introduction: the scaphoid bone is the carpal bone most commonly fractured in wrist trauma. traditionally, non-displaced scaphoid fractures are considered by most as stable with predictable rates of healing with conservative treatment. conversely, displaced fractures are recognised as unstable, with a significant risk of non-union if not treated surgically. there is a current trend in orthopaedic practice, however, to treat non-or minimal displaced fractures also with early open reduction and internal fixation. this trend is not evidence based. in this systematic review and meta-analysis, we pool data from trials comparing surgical and conservative treatment for acute scaphoid fractures, thus aiming to summarise the best available evidence. material and methods: fourty fresh frozen cadaver scaphoid bones have been sampled at our disposal for testing of screws. the bone density measurement of all specimens has been performed using a qct scan. a transverse osteotomy will be performed at the waist of each scaphoid simulating a b fracture according to the herbert classification. a load cell will be interposed, in an already established method, between the proximal and distal pole of the bone to measure compression force while introducing the screw. the screws will be applied as recommended by the manufacturer using original instruments. the intrascaphoid compression will be recorded at the peak during insertion of the screw, and after and seconds, , , and minutes. results: preliminary results determined that a greater compression can be sustained over a time by headless compression screws with significant differences between those screws. the tests will be finished at the end of january and we will present the final results. conclusion: in more than % of our cases a fracture was missed with the initial radiograph. bone scintigraphy is still a good choice to detect an occult fracture around the wrist. introduction: operations in trauma patients represent a second insult and the extent of the surgical procedures influences the extent of the inflammatory response. the aim of this study was to evaluate the operative burden related to femoral intramedullary nailing. our hypothesis was that a reamer-irrigator-aspirator (ria) system would cause lesser inflammatory response than traditional reaming (tr) due to a lesser intramedullary pressure increase and thereby reduced intravasation of bone marrow content. material and methods: coagulation, fibrinolysis and cytokine responses were studied in norwegian landrace pigs during and after intramedullary reaming and nailing with the two different reaming system; the tr (n = ) and the ria (n = ) reaming system, and compared to a control group (n = ). the animals were followed for hours. simultaneously arterial, mixed venous and femoral vein blood were withdrawn peroperatively and until two hours after the nail was inserted for demonstration of pulmonary, systemic and local activation. results: significantly procedure-related increased levels were found for tat, t-pa and il- in the tr group and tat in the ria group. the local and the pulmonary activation of coagulation, fibrinolysis and cytokine response was more pronounced in the tr than in the ria group, but the difference did only reach significance for il- (femoral vein) and pai- (arterial). the arterial levels of il- and tat exceeded the mixed venous levels indicating an additional pulmonary activation. these differences, however, did not reach significance. two animals in the tr group, who died prior to planned study end point, demonstrated higher inflammatory response compared to rest of the tr group. conclusion: the inflammatory response to the reaming and nailing procedure was modest, and the response was lesser in the ria group than in the tr group. introduction: approximately . million joint arthroplastic operations are performed annually worldwide. implant failure due to massive bone loss and aseptic prosthesis loosening, however, is a major complication of joint replacement. it is generally accepted that small particles (''wear debris'') and activated macrophages play a key role in aseptic loosening. but also the prosthesis loosening fibroblast (plf) plays an important role. material and methods: between and abg- -hip arthroplasties were implantated. after a year analysis % had to be removed because of massive wear of polyethylene (pe) and consecutive acetabular osteolysis. we analysed the influence of patient and surgeon, the implantdesign incl. pe-thickness, anchorage coupler, material roughness i.e. and the material i. medtronic) the application of the cements was done according to the specifications of the manufacturer. after extrapedicular kyphoplasty on cadaveric lower thoracic spine vertebrae (th - ), the intervertebral distribution pattern was investigated by microtomography ( lct). besides creating high resolution d and d reconstructions, the mathematic calculation of the porosity of the vertebra, the bone substitute material and the relative part within the different compartments was performed. of special interest were the characterization of the bone substitute material -spongiosa -interface and the penetration of the calcium phosphate cement into the adjacent spongiosa. the following parameters were investigated: . trabecular structure, porosity and hydroxylapatite concentration of the native vertebrae . structure (homogeneity, distribution of pores) of the bony substitute material . characterization of the bone-bone substitute-interface a. central located, filled kyphoplasty defect b. transition zone with spongiosa and bone substitute material c. solitary spongious bone results: the investigation of the native spongiosa yielded a comparable trabecular structure, porosity and hydroxylapatite concentration in the intra-individual comparison of the vertebrae of the lower thoracic spine. between the cements differences in the solitary structure as well as distribution pattern during kyphoplasty were observed. especially the analysis of the ability to penetrate into the spongiosa adjacent to the centrally located kyphoplasty defect yielded significant differences. the main influencing factor of the ability to penetrate into the spongiosa is the different viscosity of the -according to manufacturer specification -used calcium phosphate cements. the cements differ in their native structure as well as in their distribution pattern during kyphoplasty. the differences in micro-morphology of the calcium phophate cements have a high probability to influence the degradation of the sedimentation products and later osseointegration. disclosure: this research was funded by a grant of ao germany. introduction: it is difficult to predict the long-term clinical outcome in the early period following an acetabular fracture. introduction: the tremendous increase of acetabular fractures in the elderly provides new challenges for the surgical treatment of acetabular fractures. surgical reduction of the acetabular joint represents the most reliable possibility to prevent the development of premature arthrosis even in the elderly. biomechanical studies showed, that plates with periarticular long screws result in an increased stability of the osteosynthesis, it has to be considered that the insertion of these screws always bears the risk of penetrating the joint the aim of this study was to evaluate the biomechanical properties of these standard plates and newly developed minimal invasive osteosynthesis techniques for stabilization of an anterior column combined with posterior hemitransverse fracture type (acphtf), which represents a typical acetabular fracture in the elderly. material and methods: using a single-leg stance model we analyzed different implant systems for the stabilization of acphtfs in synthetic pelvises (standard reconstruction plate, new developed prototype and definitive repofix Ò (adi -ao foundation, switzerland). applying an increasing axial load in a biomechanical testing machine, fracture dislocation was analyzed with a multidirectional ultrasonic measuring system (zebris, germany). differences in change of center of gravity are statistical analysed by man-whitney-u -test. results: analog to a long bow, the repofix Ò supports the quadrilateral surface sufficiently and reconstructs the surface of the pelvic brim from the inner side of the pelvis. in synthetic pelvises, the new repofix Ò is associated with a significantly less pronounced dislocation (center of gravity) of the fractured quadrilateral surface when compared to prototype and the standard reconstruction plate. the biomechanical results could be seen at a measuring point at the quadrilateral surface and in the rotation around the x -axis (angle y results: we collected data on acetabular fractures. a conventional image intensifier was used in cases (group a), d-navigation was used in cases (group b). in group a the kocher-langenbeck-approach was used in most of the cases ( %), followed by the maryland-approach ( %). in group b, the kocher-langenbeck-approach and the ilio-inguional-approach were used in an almost equal number of patients ( % / %), but extended approaches were only used twice. in % of the cases in group b fractures were stabilised by navigated placement of percutaneous lag screws. when we excluded the percutaneous operations in group b (n = ), the difference in or-time between navigated (n = , ± min) and conventional treatment (n = , ± minutes) was significant (p < , ). in group a we detected relevant postoperative complications in % of patients. the complication rate was significantly lower in group b ( %, p < , ). the postoperative radiological analysis revealed a better qualitiy of reduction in group b (n = ) with an average post-op fracture gap of , mm vs , mm in group a (p < , ). conclusion: by using a navigation system and a d image intensifier we found a significant increase in the or-time in the navigated group. however, in the postoperative radiological analysis, we detected a better quality of fracture reduction in the navigated group. navigation in combination with the -dimentional pictures of the iso-c d led to a better visualisation of the acetabulum, therefore the need for extended approaches was reduced. to our opinion, this explains the significant reduction of postoperative complications in group b. we conclude that navigation and a d image intensifier should always be used for orif of acetabular fractures. disclosure: no significant relationships. introduction: the traumatism is the first cause of the mortality in patients under . it means a serious incapacity in of trauma patients. the initial management in trauma patients is essential to improve these results material and methods: this is a prospective and multicentric study with the participation of hospitals in catalunya (spain). the objectives are to improve the evaluation and the initial management of trauma patients, and to improve the knowledge of the frequency, the magnitude and the approach of these trauma patients. we defined points to improve which are: to intubate patients with glasgow < ( ); to not remove the cervical collar without clinical or radiologic cervical exploration ( ); to move trauma patients monitorized ( ); to not move haemodinamically instable trauma patients ( ); to use two thick intravenous cannulations ( ); to take thorax and pelvic simple radiographies in the trauma box ( ); to fix pelvis fracture with a grassland before moving the patient ( ) we took more thorax and pelvic radiographies in the trauma box (from . % and % in the first period to . % and . % in the second period, p < . ). and we also fixed more pelvis fracture with a grassland before moving the patient, from % in the first period to . % in the second period. conclusion: the registration of the information about trauma patients allows the identification of the points to improve. we improved the evaluation and the initial management of the trauma patients, especially in the monitorization of trauma patients and in the management of the thoracic and pelvic traumatism introduction: there is wide evidence about the importance of having good protocols for assisting trauma patients and a teaching system for the personnel involved in this assistance is needed. it is also well known that the formation for assisting trauma patients in spain is not very much spread in general. material and methods: we describe how we have arranged the care for this type of patients in a level ii center and a teaching system for our staff and we prospectively analyze the impact of this specific formation by means of a questionnaire and analyzing how correctly the trauma team is activated. results: from november through october ( months), editions of our course have taken place and people have participated ( , % of the staff for whom the course is aimed to). we found a clear improvement on the results of the test (prior and after the course: % of improvement for physicians and % for nurses, p < . ) and the qualification of the final exam was superior. the incidence of rightly activated trauma team improved as the staff was completing the course. conclusion: we conclude by enhancing the importance of having adequate protocols for treating these patients and the correct means for teaching the personnel because they can improve the care of these patients. (tonk) score. this system is specialty specific and tries to eradicate the weaknesses in a previously published scoring system, which was generic. material and methods: a total score of is assigned to each firm from the beginning and marks are deducted for missed documentation. sets of notes are randomly selected from discharged patients for each firm, one from trauma and one from elective surgery, each having at least entries. each case note is given marks and the total deduction for both case notes are then subtracted from the total score of to give the resultant score. the tonk score has four major parts comprising initial clerking, subsequent entries, discharge letter and legibility. an objective system of scoring the legibility of medical notes is part of the tonk score. this scoring system is easily reproducible and it's been validated using the kappa statistic. introduction: despite the increasing mechanization in medicine, clinical skills must be to the fore of medical occupation and consequently must have a main focus in medical training. especially in surgery, the mastery of basic clinical skills is of great importance for the young learner as it besides the knowledge of elementary principles substantially contributes to the understanding of the subject, the development on the wards, the operation theatre and the ambulance. in order to assure a standardized training using reliable, effective modern teaching methods, a ''train-the-teacher''-course was developed. material and methods: in an -hour training, the important teaching modalities and methods for surgical skills as skills lab, simulation, role play, -step approach are presented and trained in small groups with a maximum of participants per group. furthermore, the training focuses on ,,giving adequate feedback'' and examining practical skills. the training is evaluated using a standardised evaluation form. furthermore, the teachers are evaluated by their students after each of their teaching sessions before and after the training. results: a total of surgeons participated in the training program ( chief physicians, senior physicians). overall, the training was rated to be very good ( %) or good ( %). in students' evaluation, there was a significant increase in positive ratings for teachers' didactical compentencies as well as for their overall training after the participation in the training program. introduction: sports injury risk management and prevention is a very complex challenge that must be addressed . one of the basic tasks is to perform epidemiological studies to estimate the risk in different types of sport. up to now many studies were conducted on injury rates in specific organised sports . just a few taking into account any physical activity (pa) . therefore only for specific sports data about the influence of higher sport skills on injury risk can be found . the goal of our study was to investigate the relevance of motor skills and sport education on injury risk, including the total pa and the occurrence of any injury in any type of sport. material and methods: in two austrian secondary schools (gymnasien) fifty-five of classes were asked to fill out a two sided questionnaire regarding pa and sports injuries within the last year. demographic data and information about the types of sport, the intensity and the occurrence of injuries was collected. pupils, from a ''normal'' school (ng) and from a ''sports-school'' (sg) filled out the questionnaire. in the sg every child has to pass an entrance exam containing basic coordinative and motor tasks as well as complex motion sequences in different types of ballgames. in the educational program of this school a strong emphasis is placed on sports. in the ng just the basic sport lectures are held. results: the total physical activity (pa) containing organised, unorganised sports and leisure time activities was significant higher in the sports-school (sg), . hours per week vs. . h/w (p < . ). the most performed types of sport were similar: in the sg soccer (n = , %), riding bike (n = , %) and running (n = , %); in the normal school (ng) riding bike (n = , %), soccer (n = , %), snowboarding (n = , %) and running (n = , %). proportionally there were more boys than girls in both schools: % boys, % girls vs % boys, % girls. boys ( . h/w, . h/w) were more active than girls ( . h/w, . h/w) in both schools. the rate of injury was statistically significant higher in boys ( . ) than in girls ( . ) (p < . ). the mean age was higher in the normal school . vs . years. the proportion on injured children was at the same highest level ( %) in and , and , and in and year-olds. the ratio of injury per pupil is statistically significant higher in the sg ( . ) than in the ng ( . ) (p < . ). but including the extension of activity the injury risk is a little bit lower in the sg: . injuries in hours of pa vs . . conclusion: it seems that better motor skills and intense sport education have no effect on the population risk . the individual risk has to be investigated more extensively in future studies. references: fuller, spinks, spinks, schwebel disclosure: no significant relationships. introduction: pain is one of the main complaints of trauma patients in emergency medical care ( ). in the netherlands, a third of all prehospital emergency medical systems (ems) rides concern trauma patients and yearly . patients are treated in the accident & emergency department (ed) due to an injury. significant deficiencies in pain management in emergency medicine have been identified ( ) . as a consequence, patients unnecessarily suffer from pain, and also recovery and healing are delayed. furthermore, chronic pain is reported one year after trauma ( ). there is no appropriate systematic approach to acute pain management in the chain of care for trauma patients in prehospital ems and the ed. aim: the aim of the research project is the development of a national evidence-based guideline for the management of acute pain in adult trauma patients in prehospital ems and the ed. during the open reduction we applied a incision allowing to remove soft tissues and to set fragments of fractured bone correctly. in patients we performed close reduction of the fracture without the fixation because of a patient's age. results: xr month after surgical procedure was done and in all cases we achieved consolidation of the ulnar fracture and good of radial head reduction. complication after the treatment was the paresis of the median nerve, neurosurgical procedure needed. the nails were remove , month after procedure ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . after obtaining the union of the fracture and rehabilitation of the limb we removed the nails ( - month after procedure). conclusion: featured way of the operative treatment doesn't claim wide opening region of the fracture and reduces possibility of complications. dislocated radial head after close reduction and immobilization period shows full stability. years. data and x-rays were retrospectively gathered and analyzed. all fractures were scored according to the ao-pediatric classification. patients were treated with solely closed reduction and cast immobilisation and patients were additionally treated with k-wire fixation. spss version . was used for all statistical analysis. results: incidence of recurrent dislocation was significantly higher in patients treated solely with closed reduction ( %) compared to patients treated with additional k-wire fixation ( %) (p . ). the proportion of patients requiring a second surgical intervention was also higher in patients treated with closed reduction: % versus % of patients treated with additional k-wire fixation (p . ). additional k-wire fixation results in a relative risk reduction of % and % for recurrent dislocation and secondary surgical interventions respectively. complications of k-wire fixation comprised local infection (n = ) and k-wire migration (n = ). conclusion: additional k-wire fixation might reduce the incidence of recurrent dislocation and secondary surgical interventions after closed reduction of displaced distal forearm fractures in children. larger and randomized studies will have to be obtained to confirm the results from our data. radiographic controls were planned after one and six month and until the removal of the intramedullary nailing. we documented all peri-and postoperative morbidity, further operative procedures, the radiographic findings as classified by capanna and the time till removal of the nails. results: a cohort of children (four girls, six boys) was recruited. mean patient age was , years ( - y). the bone defects included eight juvenile and two aneurysmatic bone cysts. four patient suffered earlier unsuccessful treatment after pathologic fracture. the other six presented with acute pathologic fractures (five humeral, one femoral). no postoperative complications occurred after the treatment combination of elastic intramedullary nailing, curettage, artificial bone substitute and autologous platelet rich plasma (gps Ò-system). the radiographic findings showed at six month a total resolution of the cysts in eight cases (capanna typ i), in two cases a tiny residual cyst remained (capanna typ ii). the removal of the nails was possible after six to nine month. one fourteen year old boy (typ ii capanna) wished a further gps application to reach a total resolution. all patients showed very good functional results and no refracture occurred. conclusion: the gpsÒ-system enhances the treatment of bone cysts in children. it is a save method without additional perioperative complications. by this, total treatment time can be shortened and secondary procedures as difficult changes of the elastic nails will be lessened. technically the decisive factor is the debridement of the . albumin values were significantly lower in patients with two or three complications than those with zero complications (zero and two complications p = . , zero and three complications p = . ). no significant difference in levels was found between one and zero complication (p = . ). admission albumin was not significantly lower in patients with wound infection than those without ( . ± . g/l versus . ± . g/l, p = . ). patients with a dry and intact wound had a higher mean albumin value than those with wound healing complications (mean albumin ± . g/l versus ± . g/l, p = . ). conclusion: our study findings support the hypothesis that lower preoperative albumin levels are associated with a more adverse inpatient post-operative recovery. these patients can be identified and optimised early in preparation for adverse events likely to occur in the post-operative period. material and methods: the targon fn is a new kind of side plate with six locking screw ports. the two distal holes are used to fix the plate to the lateral cortex of the femur with angle stable . mm cortical screws. the proximal holes allow the implementation of up to four ''telescrews'' which cross the fracture site. these . mm screws are dynamic and allow therewith the collapse of the fracture at the femoral neck. we present a prospective study on patients with a comparative patients case control with a total hip cementless arthroplasty for the same indication at the same period. results: this new device show a lower incidence of complications on the first weeks than with the total hip group. wereas the month control show no difference between the two groups. there are an x rays neck collapse one year folow up in osté oporotic patients with singh an stade with no significant consequences on the functional score. conclusion: targon fn is a good alternative for older and multimorbid patients with less surgical burden and reduced early access morbidity in comparison to the prosthesis group. conclusion: the number of re-interventions and the mortality within one year after hip fracture surgery is sizable. nonetheless, our numbers are not unfavourable in comparison with international literature. the percentage of re-interventions in the cannulated hip screw group is significantly higher than in the other subgroups. on the contrary, the mortality in this group is low. this is undoubtedly an expression of our attempts to preserve the femoral head in vital, active patients. possibly, the combination of the two standardsnamely the re-intervention and mortality-is a new accurate performance indicator. informed. the operative treatment with lcp and tension bandages shows small morbidity regardless the comorbidities and the geriatric cohort. it remains standard procedure for periprosthetic fractures of the femur at our institution. we are expecting the number of periprosthetic fractures to be increasing rapidly. introduction: periprosthetic femoral fractures are rare but severe complications following total hip-or knee-arthroplasty. the incidence for of these fractures are increasing, caused by a raising frequency of total arthroplasty for both younger and elderly patients as well as by a higher life expectation. so far there are very little long-term results regarding this issue. material and methods: patients ( female, male) with a mean age of years ( - ) were clinically and radiologically examined on average months after surgery. we investigated the prosthesis (total hip arthroplasty vs. total knee arthroplasty) and compared the treatment (revision arthroplasty vs. osteosynthesis) in this study. for the clinical examination we used the harris-hip-score (hhs), oxford-hip-score (ohs), the oxford-knee-score (oks), the sf- and the funktionsfragebogen hannover (ffh) which measured the functionality of patients in his daily routine in his environment. results: tha + osteosynthesis (n = ) % of the patients had fair or better results with an average hhs of . % of this group had a good or excellent result with an average ohs of and % had a ffh score of ‡ %. % of the patients had a possible hip flexion of ‡ °and ( % ‡ °). the average sf- score for this group was . tha + revision arthroplasty (n = ) % of the patients had fair or better results an average hhs of . % of this group had a good or excellent result with an average ohs of and % a mean ffh score of ‡ %. % had a possible hip flexion of ‡ °( % ‡ ° the results of the scores are mainly caused by the high age, the common multimorbidity and the low overall functionality of the patients and confirm the severity and importance of these kinds of fractures. most authors suggest a treatment of these fractures according to the classification by using osteosynthesis to treat stable fractures and revision for unstable fractures. however we see a slightly better outcome of the revision arthroplasty compared to the patients that were treated with osteosynthesis. we suggest more studies with a higher number of patients regarding this issue. introduction: fracture dislocation of the proximal humerus is a rare but challenging situation for the orthopaedic surgeon. if a closed attempt to reduce the dislocation fails, a demanding surgical procedure is required and the emergency setting is not always the best situation to face difficult cases. as a matter of fact a proper approach to this fractures involve an experienced surgeon, more than one assistant and a variety of instrumentation that often lack in emergency. fracture dislocation of the humeral head is related with a significant increase of the risk of the humeral head necrosis and it is widely accepted that these lesions are best treated in emergency, but there are no reports on the influence of the dislocation time on the results of the surgical procedure. with this study we wanted to determine if a delayed procedure could affect the outcome of these lesions and if there is a rationale in postponing the procedure to allow a better organisation of the surgical time. material and methods: we retrospectively analysed the clinical and radiological records of patients admitted at out institute for fdhh between jan and jan . ten out of them were operated in emergency while with a minimum delay of hours. all the patients underwent open reduction and fracture fixation with locking plates. results: the results of the two groups were similar and influenced mainly by the bone quality and age of the patient. it seems that a delay in the procedure do not alter the result in terms of rate of necrosis of the humeral head or influence a worse clinical outcome conclusion: on the basis of these results we do not consider these fractures as emergencies anymore: our preference is still an immediate operation provided the presence of an experienced surgeon, assistant and nurse and the availability of the proper instrumentation, conversely we believe that the risks of an immediate procedure overwhelm its benefits. introduction: minimal invasive plate osteosynthesis (mipo) should belong nowadays to the armentarium of each trauma surgeon. applied correctly, mipo not only meets the criteria of a ''biological'' osteosynthesis by minimizing invasivity as well as iatrogenic soft tissue damage caused by the operation, but can also provide adequate reduction and stability for fracture healing and early functional aftertreatment. up to date, only few publications report on mipo of humeral shaft fractures mainly using the antero-lateral deltopectoral approach for plate insertion - . material and methods: in this present study, we evaluated patients (mean age years, range - ) with displaced metadiaphyseal fractures of the proximal humerus treated in mipo technique using an angular stable long philos Ò -plate. a lateral deltoid-split approach was used proximally and a brachialis/ brachioradialis intermuscular approach with exposure of the radial nerve was used distally. there were acute fractures including two periprosthetic as well as one pathological fracture. three patients were operated after failed conservative treatment, one for delayed-union and two cases were revision surgeries. results: there were no infections and no iatrogenic injuries to the axillary and radial nerve, respectively. all the patients were immediately allowed active shoulder and elbow movement. one patient had to be reoperated ten weeks postoperatively for redislocation of the distal fragment with screw breakage, which was most likely due to incorrect screw placement. this patient was successfully operated using the same method and implant. whereas one patient refused follow-up, patients showed entirely healed fractures and satisfactory shoulder and elbow function after a mean follow-up of months (range - months). conclusion: minimal invasive long philos Ò -plate osteosynthesis using a combined lateral deltoid-split and brachialis/brachioradialis intermuscular approach proved to be a safe and viable procedure for the treatment of metadiayphyseal fractures of the proximal humerus with low morbidity and good functional outcome. introduction: plating for reduction and stabilization of proximal humerus fractures is a common orthopaedic procedure. however, angular and rotational malalignment is not an infrequent result, and extensive use of fluoroscopy is commonly involved. we checked the accuracy of a computerized navigation system(vector vision trauma navigation system, brain lab) to enhance multiplanar fracture reduction and to decrease the requirement for fluoroscopy. material and methods: men and women aged to (mean, ) years underwent philos plate fixation for proximal humeral fractures. all fractures were closed with no associated injuries and classified as -a (n = ), -b (n = ), and -b (n = ), according to the ao classification. the cases were assessed operation time, radiation time. and accuracy measurements were taken. results: patients were followed up for to (mean, ) months. all the fractures united and occured no avascular necrosis. the mean operation time and radiation time were minutes (range, - ) and . minutes (range, - ). the mean distance between fluoroscopy and navigation of reduction accuracy at the fracture site were . mm (range, - ). conclusion: the fluoroscopic operation using pilos plate was troublesome, but navigated operation was easy to reduce the fracture because of the direction visualization at the same time. and computerized navigation has the potential for increasing precision in fracture reduction while minimizing fluoroscopic requirements at proximal humerus fractures. introduction: the proximal humerus fracture is a frequent fracture in the elderly people. the lower density of the bone with increasing age is one of the main reasons for implant failure after osteosynthesis with a range of - %. the options of therapy are including the screw-, platelet-or nail-osteosynthesis or the endoprosthesis.belonging to failure rates and the demand for early activity there is a tendency to be seen for early and strong stabilisation. material and methods: since august proximal humerus fractures were operated with the retron-humerus-shortnail. the average of age was , +- , ( - ) years. the demographic data, bone quality and fracture classification were documented including procedure of reposition, details of the implants, complications and postoperative course. results: there were , % a fractures, , % c , , % c and , % c fractures (ao-classification). the reposition was done in a closed mannor with a direct percutaneous assistance respectively. intraoperatively secondary dislocations and corticalis brake was to be seen. there have been insufficient nailing procedures. screws had to be exchanged. the gymnastic began immediately after operation or with a delay of - weeks depending on the fracture classification. the evaluation of the constant score is on the way. the results show a good stability of the nail especially in osteoporosis. comparing with platelets or antegrade nailing it is a minimal invasive procedure. the exraarticular access avoids any damage to the shoulder structures, especially to the rotator muscles. therefore early gymnystic of the shoulder is possible. shoulder impingement, screw dislocation and problems with the shoulder are avoided principally. the learning curve is short. shoulder score was used to evaluate functional outcomes. anova was used for statistical analysis, with significance set at p < . . results: files were available on patients. failure rate was . % at mean follow-up of . years and a mean ases-score of . . there was a reoperation rate of . %. mean age at operation was . years. mean operative delay was days (range - ). delay did not influence outcome. young age at operation was associated with better results. when evaluating fracture characteristics significant better outcomes were evaluated with ao type aand b-fractures, valgus or neutral fracture type, the presence of impaction and less displaced fractures. quality of reduction and fixation of the fracture was evaluated with significant better results with anatomic reduction of the medial cortical border, less residual displacement and a ccd-angle that was corrected or in residual valgus. osteosynthesis failed significantly more in c-type fractures, in fractures with an avascular head fragment, in varus displaced fractures and in fractures where an anatomical reposition was not obtained. introduction: fractures of the proximal humerus are responsible for - % of all fractures.the most extensive used operative treatments are the plate osteosynthesis and the intra-medullarry nail fixation with proximal locking nailsscrews. especially the latter technique can give iatrogenic injury of the axillary nerve. in this study, we define a safe-zone by using radiological parameters material and methods: the following procedure was performed in ten shoulders of embalmed specimen. first, the deltoid muscle was dissected from the clavicle. then the axillary nerve was identified together with its branches and was marked with clips and radioopaque wires. the muscle was then re-attached to its anatomical position.standard ap radiographs were made with the forearm in neutral (anatomical) position and exorotation. on these radiographs, the distance between the cranial side of the humeral head and the axillary nerve and its branches was measured. results: the median distance from the head of the humerus to the axillary nerve is mm (sd = . mm, range - mm) measured on the ap radiograph in degrees exorotation. the mean number of branches to the deltoid muscle is three. the distances vary from to mm. the median distance from the first proximal branch measured from to the humeral head is mm (n = , range - mm), to the second branch mm (n = , range - mm), to the third branch mm (n = , range - mm) and to the fourth branch mm (n = , range - mm). conclusion: there is a great variation in the course of the axillary nerve and its branches. with the insertion of an intra-medullar nail from the proximal side or by placing locking-screws nails the surgeon has to reckon with the course of this clinically important nerve. it is unsafe to place the locking-screws nail in the zone between mm and mm from the humeral head with the arm in exorotation. the greatest risk to damage the main branch of the axillary nerve is in the zone between and mm. this study provides distances to avoid damage to the axillary nerve. in contrast to the existing literature these distances are measured from the humeral head. there are several reasons to use the humeral head instead of the acromion are: first, the distance between the humerus and the acromion can vary due to the preceding trauma, relaxation of the deltoid muscle or by manipulation of the arm. second, from an anatomical perspective, the position of the axillary nerve is determined by the position of the humerus due to the connection to the deltoid muscle. results: emg/eng records were without pathologic variances of the axillary nerve. of them pre-operatively showed pathologic variances. of these continued to show variances months after the operation, which indicates a chronic lesion. just one patient showed a pathologic eng after surgery which was not seen before. the constant score was as expected. introduction: patella recurrent dislocation and patellofemoral pain syndrome is a common cause of instability in young patients and especially athletes. in the present study we present the results of the extension mechanism realigment throughout the fulkerson oblique osteotomy of the tibial tubercle and soft tissue balancing. material and methods: during the last two years patients ( men, women, mean age . / range - ) were treated operatively for recurrent dislocation of the patella using the fulkerson procedure. all our patients had as onset a traumatic dislocation of the patella that developed to recurrent. all patients were underwent knee arthroscopy for the treatment of potential chondral trauma or loose bodies removal and lateral retinaculum release. after that, we performed oblique osteotomy of the tibial tubercle, medialization and internal fixation with two cortical screws. this oblique osteotomy provides additionally to the medialization, anteriorization of the tibial tuberosity as we move it medially. moreover we perform medial plication. all patiens used functional brace locked in  º immediately after the operation and gradual rom increase untill the th p.o. week. results: the patients had no initial or long term complication. during their last follow up examination had a painless knee with full rom and marked improvement of the patella tracking. the mean lysholm score was improved from . to . . no patella dislocation was referred. conclusion: our findings show that fulkerson procedure of the tibial tubercle osteotomy and anteriomedialization, with additional intervention on the lateral and medial patella retinaculum is an excellent option for the treatment of recurrent patella instability and relief of patellofemoral pain. disclosure: no significant relationships. introduction: injuries to the knee involving the anterior cruciate ligament (acl) are very common related to sports especially in soccer and skiing. more than % of those with acl injury will develop radiographic osteoarthritis (roa) within years of injury although it is not known if return to sports is a risk factor for longitudinal roa development. in this retrospective study, we evaluated the long term radiographic and clinical results of acl reconstruction by comparing the injured knee with the contralateral knee in athletes returning to pre-injury sports. material and methods: twenty-eight patients ( men and women, mean age years at the time of acl surgery, bmi . ± . kg/ m ) were studied. patients returning to previous sports and without meniscal injury at baseline were selected. acl reconstruction was performed using patella tendon or hamstrings tendon graft. radiological assessments using x-ray and a -t mri of both legs were obtained at a mean follow up of years after acl reconstruction. roa was determined according to the classification of bohndorf. the ikdc score and tegner activity index were used for clinical evaluation and the knee injury and osteoarthritis outcome score (koos) for evaluating self-reported knee function. results: the -t mri revealed positive signs of roa on the operated knee in % and on the non-operated knee in %. these changes were however limited to small localized areas of the knees. the statistical difference of morphological and clinical outcome of acl reconstructed patients weeks after injury vs. replacement after this period showed no significance (p = , - . ). the total ikdc score was . ± . points and the total koos was . ± . . the median pre-injury tegner score was (range - ) corresponding to (range - ) at follow up. in % of the patients the tegner score was unchanged from pre-injury to follow up. according to the ikdc score % had type a symptoms, % type b, % type c, and none type d. conclusion: eight years after acl reconstruction in athletes returning to pre-injury sports, the risk of developing knee roa in the injured knee was not higher than the risk of developing roa in the contra lateral knee. disclosure: no significant relationships. radiographs and a mri of the knee were available for all patients. all patients were followed prospectively and lysholm, tegner and ikdc score were surveyed before treatment and after at least months. after diagnosis, a brace immobilization with tibial supporter with full extension of the knee was applied for weeks followed by another to weeks of pcl brace with tibial supporter and posterior elastic rubber band to prevent posterior sagging of the proximal tibia. all patients received concomitant physiotherapy. after at least weeks, stress radiographs were taken for evaluation of the pcl. the further treatment depended on the harner classification based on the stress radiographs. in cases of grade a or asymptomatic grade b injuries, conservative treatment was continued. in cases of symptomatic grade b, grade c or d injuries, operative treatment with arthroscopic transtibial pcl reconstruction using single bundle hamstring tendons was performed. results: patients were treated conservatively (group i), patients had an arthroscopic pcl reconstruction (group ii). mean patient age was . years (range - years). the mean tegner score in group i raised from . before treatment to at follow up, in the operative group from . to . . the mean lysholm score ascended in the conservative group from to , in group ii from . introduction: the virtual reality (vr) d arthroscopy surgical simulator provides arthroscopy training on knees in a controlled, stressfree, and virtual-reality environment. it is unknown whether better visomotoric three-dimensional ( d) condition will facilitate arthroscopic training. therefore, our objective was to evaluate the visomotoric condition to novice individuals and assess whether visomotoric abilities ameliorates arthroscopic performance within a d surgical environment. material and methods: medical students without any knee arthroscopic experience were investigated. both groups received a fixed protocol of simulator based arthroscopic skills training and a visomotoric skills test. this consisted of an arthroscopy of a longitudinal meniscus tear on a vr knee arthroscopy simulator. . their learning curve was assessed objectively using motion analysis. time taken, path length and roughness for probe and camera were recorded. results: motion analysis demonstrated objective improvement in performance during simulator training, if visomotoric skills performed better. conclusion: better condition of visomotoric skills lead to subsequent improvement at an arthroscopic vr skills training simulator. this may assume that visomotoric skills training before arthroscopic vr skills training is a useful tool. however further studies are necessary to find preliminary practice exercises to get a better performance at an arthroscopic vr skills training simulator. -ii and c-iii after tscherne § open fractures o-ii and o-iii after gustilo o urgent operative treatment § first stabilisation with miniosteosynthesis and external fixation § soft tissue debridement and their temporary closure o second look after - hours, next looks after the soft tissue condition o delate treatmentdefinitive stabilisation -osteosynthesis conversion in - days after injury. o type of osteosynthesis § orif with lcp distal tibia platesmedial or anterolateral § imterlocked intrtamedullary nail § external fixation -in cases of serious soft tissue defects we prefer fracture stabilisation ae serious soft tissue defects closing with rotation or microsurgery stem lobs. introduction: fractures of the distal tibial metaphysis account for . % of fractures over the distal end of the tibia. many of them are high-energy injuries causing extensive articular damage and compromise the soft tissues. managing these fractures continues to challenge most orthopaedic surgeons, as soft tissue injury could be further compromised by unjudicious surgical technique. aim of the treatment is to restore physiological alignment of the distal tibia and stabilize the fracture with minimal damage to soft tissues. material and methods: we designed an implant for the stabilization of distal tibial metaphyseal fractures, and gave the name ''angle stable''. the features of the implant are: precontoured plate with holes above the distal metaphysis providing positioning of screws with angular stable characteristics. the screws are self tapping and self cutting at the threaded part (far end) and have a cylindrical shape with a rim at the near end, that tightly fits into the holes at a special angle, guided by a targeting device. the distal screws penetrate the opposite cortex, and when they are tightened, compression is achieved. the plate is introduced through a small incision and guided onto the surface of distal tibia. screws can be inserted distally, proximal screws are inserted through stab wounds. biomechanical tests of this system were performed on cadaver bones. since the ''angle stable'' system has been used in patients in cases as a primary stabilization, and in cases as conversion of external fixation. follow-up time was months. outcome was assessed with regard to function, pain and alignment. introduction: the fracture of the distal lower limb with or without participation of the ankle joint remains a challenge to the surgeon. due to the high energy released at the time of fracture, these injuries are usually accompanied by a severe soft-tissue damage. the success of the surgical therapy of tibial pilon fractures depends largely on the extent of the soft tissue damage as well as the quality of reconstruction of the tibial joint surface. a problem of the minute anatomical reconstruction is an increase in soft tissue problems and bone infection. aim of this study was to investigate the results gained by a primary stabilization by external fixator followed by a multidirectional locked plate osteosynthesis after soft tissue consolidation. material and methods: setting is a level trauma centre, the design a consecutive series with a retrospective data evaluation. between and , patients with high-energy fractures of the tibial plafond were treated using a two-staged treatment plan: . the fracture was stabilized with an external fixator immobilizing the ankle joint. . after stabilization of the soft tissue situation (mean . days) internal fixation with a locked-screw plate was performed. the implant used was a multi-directional locking internal plate fixator (tifix, litos, hamburg/germany), made of pure titanium with locking holes for titanium screws which can be fixed in different angles and is available in seven different lengths ( - holes in the diaphyseal area). the mean follow-up time was . months. all follow-up examinations were supervised by a specialized orthopedic trauma surgeon. the examination consisted of a set of standardized questions, clinical evaluation, the aofas score and radiographs. results: superficial wound-necrosis was noted times, conservative treatment led to complete wound healing. dvt of the injured leg occurred in cases. in cases autologous bone graft was necessary after and months. deep wound infection or postoperative osteomyelitis was not observed. the definitive treatment was performed after an average of . days. in cases an autologous bone graft was used. in a further cases a later autologous bone graft was performed for delayed union at and weeks after orif. full weight bearing was reached after an average of . weeks. bony union was achieved in all cases after an average of . months as determined by conventional radiographs. in cases range of motion (rom) of the ankle did not show any restriction compared to the opposite side. in cases the range of motion was reduced by less than / compared to the opposite side, of up to / in patients and restriction of > / was not noted in cases. the mean aofas score was . . conclusion: a twostage treatment plan in fractures of the distal lower limb with external fixation followed by locked-plate osteosynthesis reduces local complications with a good functional result. disclosure: no significant relationships. introduction: the internal fixation for complex distal tibial fractures is sometimes challenging. nowadays, successful outcome were reported about osteosynthesis through medial and anterior approaches including minimally invasive plate osteosynthesis (mipo). however, there are cases in which such methods are not indicated because of their soft tissue problems or their fracture pattern. in this presentation, the new posterior plating procedure using the mipo technique is reported. material and methods: this procedure was indicated only when no other internal fixation methods were present, which includes intramedullary nailing or medial/anterior plating, were found. so the indication for this procedure was extremely rare. from to , cases of ao classification -a and c type fractures were treated operatively in our institution. cases met the criteria. both of them were female and aged and . the follow up period was and months. the procedure was as follows; before the operation, the spanning external fixator was applied and the alignment was reduced as properly as possible. the patient was in the supine position and the knee was flexed at about degrees. the distal window for mipo was positioned between the distal fibula and achilles tendon, which is called a ''posterolateral approach.'' blunt dissection was performed, and exposed the edge of the flexor hallucis longs muscle (fhl). the tunnel over the periosteum at the posterior surface of the distal tibia was made and the plate was inserted. then an incision was made at the posteromedial border of the tibial shaft and exposed the proximal part of the plate (proximal window). the plate was placed properly under the image intensifier and fixed with screws. the wounds were irrigated and sutured in layers. postoperative rehabilitation included a range of motion exercise and non-weight bearing gait and use of crutches immediately begun. full weight bear was permitted around twelve weeks post operatively. time to union, complication and final ambulatory ability were evaluated. results: bony union was uneventfully completed within three months in both cases. there were no complications such as infection, skin problems, or plate irritation/impingement. free gait was achieved within four months in both cases. conclusion: posterior plating using the mipo procedure for complex distal tibial fractures can be a good option, although our experience is very limited. however, this procedure should be indicated only when no other osteosynthetic methods are found because irritation/ impingement of the fhl or the achilles tendon or some other complications may arise, which has already been reported in open reduction and internal fixation through posterolateral approach. references: hayes ag, nadkarni jb. extensile posterior approach to the ankle. j bone joint surg ; b: - . disclosure: no significant relationships. introduction: even the most modern technology has failed to induce satisfactory functional regeneration of traumatically severed peripheral nerves. delayed neural regeneration and in consequence slower neural conduction seriously limit muscle function in the area supplied by the injured nerve. this inferiority study aimed to compare a new nerve coaptation system involving an innovative prosthesis with the classical clinical method of sutured nerve coaptation. besides the time and degree of nerve regeneration, the influence of electrostimulation was also tested. material and methods: the ischiatic nerve was severed in female gö ttinger minipigs with an average weight of approx. - kg. the animals were randomized electronically to four groups: group i: nerve prosthesis without stimulation; group ii: nerve prosthesis with stimulation; group iii: microsurgical coaptation without stimulation; group iv: microsurgical coaptation with stimulation. in groups iii and iv, the nerve was sutured microsurgically, while the animals in groups i and ii received the new nerve prosthesis. postoperative monitoring and the stimulation schedule covered a period of months, during which axonal budding was evaluated monthly. results: preliminary data indicate that results with the nerve prosthesis are comparable to those with conventional coaptation. the results of this pilot study indicate that implantation of the nerve prosthesis allows good and effective neural regeneration. this new and simple treatment option for peripheral nerve injuries can be performed in any hospital with surgical facilities as it does not involve the demanding microsurgical suture technique that can only be performed in specialized centers. disclosure: no significant relationships. in mean there were , previous operations. in cases a change of osteosynthesis was neccessary. in cases bmp was used alone. in cases bmp was expanded by autologeous bone grafting. in cases the bmp was extended by autografts or ceramic scaffolds. results: divided in a healing group and a not healing group we found in the healing group a excellent clinical result by . points (able for sports) for the atrophic non unions and a good result of . points (walking long distances) for the post infected non unions. the radiological score is as high . / . ( cortices healed and bridging callus). in the non healing group the clinical rate was . / . (walking with splint) and the radiological rate was . / . (two cortices healed) the overall healing rate was %. divided in several groups the healing rate increases from % (infected non unions not tibia) to % (atrophic aseptic non union tibia). overal the secondary intervention rate was %. the healing time is . months in the middle. we see only mild side effects in %, like swelling. the most serious complication was the bony reinfection in %. there were amputations. conclusion: compared to the literature the healing rate of non unions could be increased using a strong concept in the treatment. as a part of the treatment the bmp treatened group increases the healing rate from % (friedlä nder) to %. the results are similar to the papers from kanakaris or zimmermann. there were no significant side effects noticed. material and methods: methods: at our level i trauma institute, from july, to september, each patient who presented with a clavicle fracture that was deemed operative received plate fixation alone or supplemented with bioresorbable calcium phosphate cement or autogenous bone grafting. patient records and radiographs were retrospectively reviewed. follow-up included standard radiographs to evaluate union at a minimum of months. all complications were also reviewed. results: results: two different clavicle plating systems, smith and nephew (smith and nephew, memphis, usa) ( clavicles) and implant technology systems (i.t.s., lassnitzhohe, austria) ( clavicles), were used with orif alone ( ), autogenous bone graft ( patients), or bioabsorbable calcium phosphate ( clavicles). of patients treated with open reduction internal fixation, complications have occurred at a minimum of month follow-up. three prominent hardware occurrences necessitated plate removal. one nonunion, one distal screw cut-out and one hardware breakage have been treated successfully with revision plating. using fisherâ e tm s exact test, no statistical significance was seen between the orif alone, autogenous bone grafting ( ) and bioabsorbable calcium phosphate ( ) in regard to overall failure incidence (p = . ). complications necessitating revision orif with bioabsorbable calcium phosphate ( ) and bone graft ( ) were not statistically significant either (p = . ). conclusion: there appears to be no statistically significant difference between union and complication rates between orif alone, or orif augmented with bioresorbable calcium phosphate cement or autogenous bone graft in this retrospective study. introduction: the purpose of the present study was to determine the effect of two anti-osteoporotic treatments on fracture healing in osteoporotic ovx rats, days after fracture occurrence. pth which has been proven to influence fracture healing in ovx rats, was taken as a control treatment. strontium ranelate is acting on both resorption and formation. we combined the rat model of a closed, standardised diaphyseal fracture of the femur with the model of a post-ovariectomy osteopenic rat, mimicking post-menopausal bone loss. material and methods: forty-five animals were ovariectomised at the age of weeks and a further were sham operated. at the age of weeks, osteopenia in the ovx rats was diagnosed. then, in all animals, a standardised mid-diaphyseal fracture was induced. at the time of fracture, the animals were divided into four groups. group was the sham control group, groups , and were the ovx treatment groups. groups and were treated with nacl . % s.c. daily, group was treated with mg/kg/d strontium ranelate p.o. daily and group received lg pth - x/ week s.c. the animals were killed after days and the fractured femur removed. the samples were scanned using microct by scanco medical, zurich, switzerland. the evaluation of the data focused on outer callus contour, cortical contour and marrow contour as well as cortical thickness. torsion testing on the bones was carried out using the axial-torsional system by instron (darmstadt, germany). results: treatment with strontium ranelate significantly improved the mechanical properties of the callus when compared to the ovx control group, while the improvement induced by the treatment with pth - did not reach significance. pth - and strontium ranelate both showed a significant increase in bone volume of the callus when compared to ovx control rats with no significant difference between the two treatments. as for the callus tissue volume, the increase induced by strontium ranelate was significant compared to ovx whereas pth induced no change and the difference between both drugs was significant . in both the pth - -and strontium ranelate-administered animals bv/tv was significantly increased compared to the ovx control rats . the bv/tv of the pth-treated rats was even higher than in the sham rats. conclusion: this is the first report on the enhancement of fracture healing with strontium ranelate. the callus in strontium ranelatetreated animals is even more resistant to torsion in comparison to ovx and sham-untreated animals and even to those treated with pth - . pth did not significantly enhance the resistance of the callus versus ovx, despite a significant increase in bv/tv within the callus. the superior results obtained with strontium ranelate compared to pth could be the consequence of a better quality of the new bone formed within the callus. introduction: recent clinical and animal studies suggest an elevated homocysteine serum concentration to be a risk factor for osteoporosis and fragility fractures ( ) . in vitro studies showed that increasing homocysteine concentrations stimulate the activity of human osteoclasts ( ). however, there is no data demonstrating that circulating homocysteine is related to structural and biomechanical properties of human bones. this study aimed to investigate the relation between morphological as well as biomechanical bone properties and homocysteine serum concentrations in humans. material and methods: fasting blood samples and femoral heads were obtained from males and females who underwent hip arthroplasty. bones were assessed by dual energy x-ray absorptiometry (dxa), biomechanical testing (indentation method), and histomorphometry. blood was sampled to measure homocysteine, folate, vitamin b , and vitamin b . according to their homocysteine serum concentration, subjects were classified as hyperhomocysteinemic (> lmol/l, n = ) and normohomocysteinemic (< lmol/l, n = ). results: folate and vitamin b , but not vitamin b , were significantly lower in hyperhomocysteinemic subjects when compared to controls. however, dxa, biomechanical testing, and histomorphometry did not reveal significant differences in bone quality between hyperhomocysteinemic subjects and controls. the results of the present study do not indicate a significant relation between circulating homocysteine and morphological as wells as biomechanical bone properties. introduction: sometimes fractured bones heal poorly with standard treatment and sometimes a bone defect is a major problem. although the bone grafting technique is considered a standard, there is a need for enhancement of this procedure. healing of the cancellous bone is a complex process in which many inflammatory and signaling molecules take part. to improve the outcome of the healing process, one can influence it by applying platelet rich plasma gel locally, thereby releasing cytokines and growth factors ( ). cancellous bone is rich with mesenchymal stem cells that produce new bone when stimulated. material and methods: we enlisted patients with hard to heal fractures and fractures that demonstrated poor healing in the study. five of the patients had osteomyelitis in the fracture and all fractures resulted in a bony defect as a serious complication after treatment. we designed a protocol for the preparation of allogeneic platelet rich plasma gel with suspended autologous cancellous bone, based on laboratory experiments in vitro ( ) . cancellous bone was harvested from iliac bone crest. we used standard ab and rhd identical, leukocyte depleted and irradiated platelets from a blood bank. activation of the platelet gel was achieved by using a cacl and thrombin mixture. we accepted patients after fulfilling the inclusion criteria and they were operated on in a standardized manner by their elected surgeons under technical supervision. in their follow-up, the ingrowths of bone grafts were measured by using x-ray analysis ( ). results: in patients the transplant was sufficiently incorporated in the fracture to give a limb full function. there were no major complications related to the platelet rich plasma additives. in one patient a nerve paresis was observed, which resolved spontaneously. in patients bone graft was not sufficiently incorporated, once because of poor compliance and the other time because of complex nature of distal tibia fracture. the clinical outcome of the operated patients ( %) is satisfactory and encouraging. conclusion: the preliminary clinical results show that using platelet rich plasma and cancellous bone in the treatment of large bone defects has a promising therapeutic potential. ( ) marx re. platelet-rich plasma: evidence to support its use. time from injury to reduction and to surgical intervention was noted. apoptosis was verified by microscopy with tunel, hematoxilin and eosine stained specimens after decalcification of the samples, a time consuming process. the number of live, apoptotic and necrotic chondrocytes were counted. the patients are followed with harris hip score, merle de aubigne score and radiographs for two years. results: patients were admitted directly to our hospital, the rest transferred from other hospitals. patients had their hip reduced after a mean time of minutes. had femoral traction applied and patients were not reduced. mean time from trauma to operation was ± . days. three patients received total hip arthroplasty. the results of will be presented at the congress. conclusion: the conclusions will be given at the presentation. introduction: distal inter-locking using free-hand technique in intramedullary nailing is always a time consuming procedure. the use of xray amplifier is mandatory and the exposure to radiation is rarely modest. if we use navigation devices we rarely trust the device completely and that is why we check the position with x-ray amplifier more than we need to. that is why we did laboratory testing of the new system using the electromagnetic navigation with the use of micro sensors for free-hand interlocking technique in laboratory without the use of x-ray amplifier to ensure the use of system in the operating theatre. material and methods: three residents with little experience in distal interlocking and no experience with this device were testing the electromagnetic navigation system with the use of micro sensors for free-hand interlocking technique. interlocking holes were drilled by the use of guiding star platform in lidis module, ekliptik, slovenia. the system producer had minutes of introduction time, afterwards drilling was done. distal locking was done on utn synhes nail and instead of bone, cannulated hard wood rods were used. we measured time needed for calibration and time needed for reaming and weather we were successful or not. introduction: percutaneous catheter drainage (pcd) is a useful method to manage pericardial effusion. however, pcd is not always effective in a case of hemopericardium due to clot. to perform subxiphoid pericardiotomy within a minute for emergency cases, we have done this procedure in a blind method following finger dissection by subxiphoid approach, which was preliminary reported in . we present the final data to report the usefulness of blind subxiphoid pericardiotomy (bsp) for emergency cases with acute hemopericardium. material and methods: we designed a study to determine a favorable management for cardiac tamponade due to hemopericardium. emergency patients with acute hemopericardium secondary to trauma (n= ), acute aortic disease (n= ) and cardiac rupture following acute myocardial infarction (n= ), were the subjects. board certified surgeons performed bsp (n= ) and other emergency physicians performed pcd (n= ) for patients with cardiopulmonary arrest (cpa) or near cpa due to cardiac tamponade from to . since , bsp (n= ) or pcd (n= ) has been performed at the physicians' discretion. results: bsp was effective to relieve cardiac tamponade in all cases but pcd was ineffective in cases ( . %, p=. ) because of clot in pericardium (n= ) or right ventricular puncture (n= ). in addition to ineffective drainage, acute occlusion of percutaneous drainage tube (n= ) were observed and resulted in deaths in the pcd group. procedure-related complication rates of bsp and pcd and survival rates of bsp and pcd were % and . % (p=. ), . % and . %, respectively (p=. ). sixteen patients (bsp, ; pcd, ) could discharge following emergency surgery (n= ) or conservative treatment (n= ). conclusion: blind subxiphoid pericardiotomy was safe and could be performed quickly in an emergency situation. percutaneous catheter drainage for hemopericardium could not avoid critical complications because of clot in pericardium in some cases. disclosure: no significant relationships. introduction and objectives: heart trauma, mostly penetrating, is not common in our community, but carries a significant morbidity. its clinical presentation can be variable. our objective was to asses the incidence, clinical presentation, associated injuries and mortality of our patient population with trauma to the heart. material and methods: observational, descriptive, retrospective analysis of patient with heart trauma included in our trauma registry between and . we reviewed demographic characteristics, mechanism of injury, associated injuries, injury severity score (iss) and new injury severity score (niss), mortality, triss probability of survival (ps), and hospital length of stay. results: we found ( . %) patients with cardiac traumatism out of . patients included in our registry, ( %) with associated injuries and ( %) isolated; ( . %) were from penetrating trauma, and only ( . %) were from blunt trauma. mean iss and niss were of (+/- ) and (+/- ), respectively. three patients presented ''in extremis'' (agonal status), nine presented with hemodynamic ''stability'' (sbp> mmhg) ( % of them with a hr> bpm), and five patients presented with hemodynamic instability. only % of the patients presented with cardiac tamponade, without hemothorax. two pericardiocentesis ( %), pericardial windows ( %), and emergency room thoracotomies were done ( . %). the most frequent location was in the left ventricle, followed by right atrium and right ventricle. the most frequent associated injuries were in the lungs ( %), followed by the abdomen and vascular injuries ( . %). fifty-nine percent required icu admission, with a median length of stay of days. ten patients died ( %), and three of them ( . %) were dead on arrival. two patients ( . %) died with a ps > . . conclusion: heart trauma is not frequent in our community, and displays great variability in its clinical presentation, with a high mortality. over half of the patients presented with hemodynamic ''stability''. disclosure: no significant relationships. approach of two cases of secondary aortoesophageal fistula results: the st patient was a -y-old man in which fistula was secondary to a fish-bone ingestion, days before the admission. in the nd cause, a -y-old man, fistula was secondary to rupture in oesophagus of a known thoracic aortic aneurysm. diagnosis was made by a contrast-enhanced ct scan; a gastrografin x-ray in the st and an endoscopy in the nd case completed the examination. in both cases the lesion consisted of a few-mm-diameter defect of the oesophageal wall. in the i case an emergent endovascular repair of thoracic aorta by bolton relay · mm stent graft was per-formed; in the ii case, endovascular repair of thoracic aorta (by bolton relay x mm) was associated to an endoprosthesis placement for primary treatment of a preexisting infrarenal abdominal aortic aneurysm. postoperatively tpn was administered. definitive treatment of fistula was performed in both cases by an explorative right thoracotomy (in v and vii post-operative day respectively): oesopagus was primarily repaired and reinforced by a pedicled intercostal muscle flap and a nutritional jejunostomy was associated. subsequent post-operative course consisted in ne administration, prolonged nasogastric suction, resuscitation with fluids, antibiotics. hemorrhagic complications or infections were excluded by repeated ct scan. oral feeding was in th and th postoperative day, after exclusion of a persistent fistula at a gastrografin x-ray of oesophagus. hospital stay was of days in both cases. no late complications were registered at follow-up. conclusion: when an aortoesophageal fistula occurs (if consists of a small oesophageal lesion), emergent treatment of endovascular aortic repair can be successfully associated to a second-step primary repair using a pedicled intercostal muscle flap via a right thoracotomy. results: case : a -year-old male is taken to our hospital after a car crash. on ct scan there was a periaortic hematoma from isthmus to diaphragm, multiple rib (flail chest) fractures, and a pelvic fracture. the aorta was repaired with an endograft with good immediate results. case : a -year-old male, injured in a frontal car crash. on ct scan a mediastinal periaortic hematoma was seen, with a pseudoaneurysm at the origin of the descendent thoracic aorta, distal to the sublavian artery. the aorta was repaired with an endograft, which was replaced at day th because of a leak. on follow-up he is doing very well. case : a -year-old male, injured in a car crash. ct scan findings were as follows: a left diaphragamatic herniation, bilateral lung contusion, traumatic laceration of the descending aorta, pelvic fracture and spleen laceration. he underwent an emergency laparotomy with splenectomy and diaphragmatic repair. on the nd postop. day an endograft was placed at the descending thoracic aorta, without complications. case : a -year-old male, injured in a frontal car crash. on ct scan there was a thoracic aortic laceration, distal to the isthmus, and an aortic endovascular repair was undertaken at day th , after complete hemodynamic normalization. the patient died at day th from multiple organ failure. conclusion: traumatic thoracic aortic injuries are frequently associated to severe thoracic, abdominal and orthopaedic injuries. traditional early surgical aortic repair through thoracotomy, with single lung ventilation and, occasionally, extracorporeal circulation carries a high morbidity and mortality. that is the reason why aortic repair has classically been delayed, but this carries an additional mortality rate of between % and %. endovascular treatment allows for an early management in severely traumatized patients who otherwise wouldn't stand such a risky surgery. it has also revealed lower rates of paraplegia after years of follow-up. introduction: injuries in zone i of the neck are rare and difficult to manage particularly in environment of war. this area gathers aerodigestive, vascular, lymphatic and nervous elements. all the difficulties lie in diagnosis of the lesions, in the decision of a surgical exploration and in the way of repair if necessary. in that situation, fistula between carotid artery and jugular vein is very uncommon, accounting for % of all arterial injuries. through one case, which has occurred in afghanistan, we discuss the various possible solutions to repair such a lesion. material and methods: we report one case of a french soldier, yo, who was wounded by a rocket splinter on left side of the area i of the neck. he was transported immediately in french role ii in kaboul. respiratory tracks are not injured, there's no neurologic lesions. he had a huge haematoma of the area with a tracheal back pushing (xray exam). during an effort of cough, a haemorrhage through the wound occurred requiring an oro-tracheal intubation and a surgical exploration by a cervicotomy. no obvious vascular lesions were found but just a thrill at the base of the neck. the patient was hemodynamically stable. he was transferred by medevac to france in the night. an angioscanner showed a fistula between carotid and jugular vein ( photos). results: he was re-operated h after. the fistula was just behind the first rib requiring an enlarging by sternotomy to control the origine of left carotid. there was a section of left pneumogastric nerve. after exclusion of the fistula and the vein, we interposed an allograft on carotid artery ( photos). the patient discharged from the hospital one week later without lateral damage except a bitonal voice with no need of re-education. conclusion: arterio-veinous fistula is an uncommon consequence of carotid injury. the taking in charge of this patient and the decision of the kinds of repair are difficult. stenting has also been used to repair distal internal carotid injuries that are not easily approached surgically. the favorable outcome of this case illustrates that surgery is a reasonable alternative when an endovascular approach is not feasible in patients with trauma-acquired arteriovenous fistulae. allograft or vein graft, if possible, is also a good solution for this kind of injuries. introduction: we report cases of subclavian artery injury caused by traffic accidents. in all cases, surgical vascular reconstruction was undertaken. in of the cases, the subclavian artery was obstructed by intimal dissection caused by falling down from a motorcycle. in the remaining case, subclavian artery aneurysm caused by seat belt injury occurred. material and methods: case : -year-old male while driving a large motorcycle, the patient collided with a car and the left side of his body was trapped in the car. this resulted in traumatic pneumothorax and severe ischemia of his left upper limb, and he was transported to our level trauma center for surgical treatment. bypass surgery using a mm diameter ptfe was performed. postoperative arteriography showed good patency of the graft and the patient was discharged. recovery from the motor dysfunction caused by brachial plexus injury took months. case : -year-old male for this case, the patient ran into a wall while driving a cc motorcycle. bypass surgery and clavicular orif were undertaken simultaneously for right clavicular fracture and ischemia of the right upper limb. postoperative arteriography showed good patency of the graft and the ischemia improved. however, rehabilitation was needed for the motor dysfunction caused by brachial plexus injury. case : -yearold female the patient ran into a tree while driving a car resulting in hemorrhagic shock caused by bilateral femoral and humeral fractures. she was transported to our center by helicopter. a scar from seat belt injury was found in the right cervical area. she presented with an expanding mass around the subclavian artery with accompanying pulsating pain. arteriography detected a cm-diameter pseudoaneurysm and aneurysmectomy was undertaken. postoperative computed tomography confirmed the disappearance of aneurysm and she was discharged. results: these cases showed favorable outcomes with surgical vascular reconstruction. conclusion: traumatic subclavian artery stenosis is caused by crushinduced local dissection and is frequently complicated with brachial plexus injury. subclavian artery aneurysm caused by seat belt injury occurred. disclosure: no significant relationships. results: case description: years old male patient who was brought in after receiving a large stab wound below the mid-portion of the left clavicle. severe external bleeding was prevented by manual compression in transit to the hospital. three foley catheters introduced through the wound at the ed failed to temporarily control the bleeding due to its large size, and he was rushed to the or. an emergency left antero-lateral thoracotomy allowed for the blind manual compression of the bleeding vessel from within the thoracic cavity, and was very successful in stopping the external bleeding. a long supra-and infra-clavicular incision was done, and the clavicle was divided. this failed to expose the bleeding vessel, due to the large muscle mass of the patient. a decision was taken to split the sternum in a ''trap-door'' approach, which nicely exposed a large laceration of the subclavian vein. this was suture-ligated, and the incision closed, in a surgical field with profused oozing from coagulopathy. he was taken to the icu, and then back to the or two hours later because of persistent bleeding through the chest drains. the ''trap-door'' incision was reopened and careful haemostasis was performed. the patient had a protracted course in the icu but eventually recovered. as a striking and very uncommon sequel he developed severe blindness from bilateral ischemic optic neuropathy attributed to hypotension and use of vasopressors. he is free of pain at the incision and with good cosmetic results conclusion: ''trap-door'' incisions are very infrequently used nowadays, but should be kept in mind in the armamentarium of trauma surgeons. disclosure: no significant relationships. conclusion: mortality in patients with ivc injuries can be well predicted by hemodynamic parameters on arrival and intra-operative findings .hemodynamic instability and intraoperarive findings of expanding hematomas and active intra-peritoneal bleeding are associated with high mortality. introduction: vascular complications due to intravenous drug abuse pose significant challenges to vascular surgeons and no standardized surgical management of the resultant infected pseudoaneurysm was established. material and methods: we present our successful management of a case of an expanding retroperitoneal haemathoma due to external iliac artery pseudoaneurysm caused by self inflicted trauma (heroin administration). mri showed an external iliac artery pseudoaneurysm surrounding by an infected old haemathoma, venous thrombosis (external illiac and femoural) and multiple muscular abscesses of the left thigh. a self-expandable stent-graft was deployed across the pseudoaneurysm after crossing the lession with an exchange glide wire through the left brachial artery route. post-stenting angiography showed complete exclusion of the pseudoaneurysm with no residual stenosis. we decided local surgical debridement; after haemathoma evacuation we identified external illiac artery presenting a stent graft and reinforced it by double layer of tissue sealing surgical patch. results: postoperative course was favorable under complex general and local therapy. conclusion: endovascular treatment of arterial pseudoaneurysms has become feasible as natural extension of the endovascular techniques. ct, mri, sonography and angiography may all be valuable in the imaging working of pseudoaneurysms. prompt diagnosis and treatment are necessary to avoid the morbidity and mortality secondary to hemorrhage and rupture. although endovascular stent-grafting is not considered a standard therapy for infected aneurysms, our case suggest that stent-graft deployment, secondary surgical debridement and major antimicrobial therapy may be the most favorable treatment option for patients unfit for major surgery. introduction: the incidence of traumatic vascular injuries (tvi) has increased significantly in the last decades, with penetrating trauma as the most frequent mechanism. our aim was to estimate the incidence, management by interventional radiology, and the preventable death rate in our patient population. material and methods: a retrospective observational study based on our trauma registry covering a -year period (july to july ) . we have assessed the demographics, severity, diagnostic and therapeutic approaches, outcome, and triss probability of survival (ps). results: patients ( % males, with a mean age of years) suffered a tvi located at the head ( ), neck ( ), thorax ( ), abdomen ( ), upper extremities ( ) and lower extremities ( ), respectively. ( . %) were caused by a blunt mechanism, and ( . %) by an open one. the average time spent before being taken to hospital was minutes. upon arrival to hospital, were in shock, required orotracheal intubation, and a cardiac massage. the diagnostic methods used were a ct scans in , dpl in , fast in , angiography in , echocardiogram in and duplex-doppler in . ( . %) patients underwent emergency surgery and ( . %) were treated with interventional radiology ( of them associated with surgery). only ( . %) were treated conservatively. overall mortality was of patients ( . %) ( of them died upon their arrival to hospital or in the operating room, all of them with an aortic injury), out of which ( . %) had a triss ps > . . the incidence of tvi increased from cases in the - period to in - , remaining stable in - ( ) . however, the mortality rate has shown a steady decline over the years (from % in - , to % in - ) . conclusion: the incidence of traumatic vascular injuries has increased considerably during the last years in our hospital. these injuries are most commonly located in the lower extremities, followed by the thorax. % of patients could be managed by interventional radiology techniques. introduction: the tip apex distance (tad) is a simple measurement that predicts screw cut out in the femoral head in peritrochanteric fractures treated with a fixed angle sliding hip screw device. we wanted to assess whether the tad measurements in our centre were comparable to previously published results, how reproducible these measurements were between observers and how accurate we were at reducing the fractures. material and methods: a retrospective review was conducted of consecutively treated peritrochanteric fractures over a month period. patients were excluded because they did not sustain a peritrochanteric fracture, had treatment of a pathological fracture or because of incomplete radiographic data. three observers used a standardised method to measure the tad (from orthogonal projections with a correction for magnification). the stability of the fracture patterns and the accuracy of reduction were measured according to criteria from the original baumgaertner paper introduction: distal locking screw insertion of the short gamma nail is normally performed by using a targeting device attached firmly to the proximal part of the nail. generally, the accuracy of targeting device should be promising. however, missing the target in the process of drilling might be a potential risk. we report cases of such condition in term of early radiographic finding, method of solving and the result of treatment. material and methods: the patient records, operative notes and intraoperative c-arm images of the patients underwent short gamma nailing for unstable pertrochanteric fractures during october to october have been reviewed in order to identify an error of distal locking screw insertion via a targeting device. the intraoperative radiographic finding, solving procedure and the outcome has been analyzed. results: there were cases of short gamma nailing over the past one year in our institute. five of which had an error during distal screw insertion even using the targeting device. an error occurred in the drilling process in all cases. intraoperative images showed that the drillbit missed its target posteriorly after perforating the near cortex of the femur. all has been corrected by using a free-hand technique under c-arm guidance. no any serious complication afterword and all fractures healed in an appropriated time. conclusion: distal screw insertion during gamma nailing can be missed even though using the targeting device. therefore, radiographic confirmation on the lateral view after perforation the near cortex is recommend in all cases in order to obtain early detection prior to bicortical perforation. freehand technique can be carried out in order to correct the error. . systemic antibiotics were used in patients ( %). ten different types of antibiotics were used after wound exploration for a period between and weeks. in-hospital mortality was %. sixty-nine percent (n= ) was finally discharged from follow-up. conclusion: we conclude that our infection rate was higher than reported in literature and the infections classified initially as superficial required a prolonged treatment as well. moreover, the treatment of this disastrous complication showed no uniformity whatsoever and should be the topic of further research, resulting in a clear protocol to increase survival and decrease morbidity. introduction: allograft meniscal transplantation is known as a possible procedure to solve pain and loss of function in the knee of patients with a history of subtotal or total meniscectomy. medium-term and long-term results after meniscal allograft transplantation in the knee are scarce. in this study patients who received an arthroscopically assisted meniscal allograft transplantation with a follow-up between and years were evaluated using subjective questionnaires, a clinical and a radiographical evaluation. material and methods: demographic data of all patients were collected and pre-operative results, using the koos (knee injury and osteoarthritis outcome score), the lysholm score, the tegner score, the sf and the vas (visual analogue scale) for pain were compared with actual results of those questionnaires to evaluate the therapeutic effects of allograft meniscal transplantation in the knee during medium-term follow-up. patients were evaluated with a standardized clinical examination of the knee to objectivate knee related symptoms. standard weight bearing radiographs and a full leg standing radiograph were performed to evaluate the evolution of osteoarthritis and malalignment. results: for all questionnaires (vas, koos, lysholm, sf ) there is a significant (p< , ) and clinically relevant increase in postoperative score. this improvement stays consistent during the followup period. the more severe the osteoarthritis, the lower the improvement. despite the meniscal transplantation, there is still a significant (p= , ) increase in osteoarthritis. an increase in osteoarthritis grade was seen in % of the patients, as scored following the kellgren-lawrence classification. when strictly respecting the indications, there is no significant correlation between preoperative cartilage damage, pre-operative osteoarthritis, alignment deviation, gender and body mass index on the one hand and outcome scores or improvement on the other hand. conclusion: meniscal allograft transplantation results in important pain relief and functional improvement in patients with a history of (sub)total meniscectomy and pain localized in the affected compartment. strictly following the indications, meniscal transplantation can give good and predictable results. introduction: intramedullary nailing of the tibia has become the conventional therapy for tibial shaft fractures. one of the most common complaints associated with this procedure is chronic knee pain. incidence rates between % and % have been reported and a significant number of patients have problems in kneeling, affecting professional and recreational activities. surgical damage to the infrapatellar nerve is one possible causative factor for post-nailing knee pain. the infrapatellar nerve is exclusively sensory and runs subcutaneously almost perpendicular to the patellar tendon just below the patella. the purpose of this study was to determine the prevalence of chronic knee pain in our institute and its relation with sensory disturbances in the knee area. material and methods: a chart review was conducted. all patients between and years with healed traumatic tibial shaft fractures treated with an intramedullary nail between and were included. exclusion criteria were: fracture lines extending into the knee or ankle joint, any other fracture in the affected leg, lacerations in the knee area, pre-operatively existing knee pain and loss of follow-up. chronic knee pain was defined as persisting pain in the knee area months after tibial nailing. sensory disturbances were defined as hyperesthesia or anesthesia at the nail entry site. introduction: femoral nailing causes an influx of fat in the circulation. in the multiply injured patient, especially in the patient with concomitant lung or brain contusion, this can lead to ards, fat embolism syndrome and multiple organ failure. the timing and kind of fixation of femoral fractures in patients with multiple injuries is controversially. the advantage of damage control orthopaedics (external fixation) would be less fat embolisation but some authors report more problems of infection and delayed healing. the aim of our study was to investigate the effect of external fixation on healing and infection rates of femoral shaft fractures in the multiply injured patient. material and methods: between january and januari , we treated femoral shaft fractures. in this group there where polytrauma patients with a total of fractures. we compared the rate of infection and delayed union in the group treated by damage control external fixation to the group primarily treated by intramedullary nailing. results: no significant difference in infection or union rates could be demonstrated between the damage control external fixation and the primary nailing group. we also noted that there's a correlation between the complexity of the fracture and the percentage of prolonged healing. and although not statistical significant there seems a tendency of less healing problems with the reamed femoral nail in comparison with the unreamed femoral nail. introduction: the diagnostic information power of a level one emergency room has risen excessively within the last years. the need for quality control, judicial regulations, insurance claims and forensic reasons still lead to a high number of autopsies being performed in patients not surviving the first h after admission to the er. however, the number of autopsy clarification featured in a level one trauma centre after trauma related deaths considerably vary and also the rate of deathly diagnoses missed within er assessment of early stage deceased patients differ in the literature. the aim of this study was to assess the value and necessity of autopsy after modern er assessment with a multi-slice ct-scan as an integrated part of the diagnostic algorithm. material and methods: prospectively reviewing our emergency database, case histories, laboratory values and radiological findings compared to findings in autopsy between jan and sep , we charged for missed deathly diagnoses in early stage deceased trauma patients (< h). patients were classified into two groups: group : patients with limited diagnostic assessment (conventional xray, sonography). group : patients with full er assessment (msct). all patients in group could not be sufficiently stabilised in terms of circulation patterns and therefore did not receive full assessment. non-trauma patients and patients reaching the er under cpr were excluded. results: the autopsy rate of all included patients was %. the overall incidence of missed deathly diagnoses was . %. in terms of missed deathly diagnoses, groups varied significantly (group : . %;group : . %).the iss after autopsy increased significantly in group from to . . in group there was no difference of iss between status emergency room and after autopsy. the most concerned region of missed deathly injuries was thorax with . % of all patients with autopsies followed by pelvic ( %) and spine injuries ( . %). conclusion: in spite of complete and nearly ideal conditions within a modern emergency room assessment nowadays, detecting all diag-noses is still challenging. overall, our findings show that almost every tenth early stage deceased patient showed at least one missed potential deathly diagnose in a level one trauma centre. regarding the insufficient assessment performance in group , the relative high rate of missed diagnoses seem explicable. nevertheless, even having acquired full assessment power (group ), still . % deathly diagnoses were missed. for this reason, autopsy is still the most powerful and indispensable tool in finding the ''whole'' diagnosis. completeness of autopsies after trauma related death therefore is essential referring a continuous gain of quality. introduction: in a physiological environment metallic biomaterials undergo corrosion through a variety of mechanisms. this study investigated whether, beside the well recognized electrochemical aspect of corrosion, human osteoclasts are able to directly corrode titanium alloys, uptake and finally release corresponding metal ions into their environment. the released ions are believed to cause inflammatory reactions and activate osteoclastic differentiation and activity, which most likely play a role in the pathophysiological mechanisms of aseptic loosening [ ] . material and methods: human monocytes and in vitro generated osteoclasts were seeded onto titanium and aluminum (positive control) foils. after days scanning electron microscopy analysis was performed in order to assess whether monocytes were able to grow and differentiate on the metals. in order to visualize uptake and distribution of intracellular metal ions, a novel protocol using confocal microscopy analyses with newport greentm dcf diacetate ester staining was developed [ ] . additionally, the concentrations of metal ions released into the culture supernatant were measured using atomic emission spectrometry. ). nine bre-gfp mice were used. mice were allowed unrestricted activity. a mini-external fixator fixed to the proximal and distal tibia was applied under general anesthesia on day . the animals were permitted full weight baring and unrestricted activity after awakening from anaesthesia. the gfp signal of tibia and fibula in bilateral limbs was measured on days , , , and after application of the external fixator. results: baseline measurements of the gfp-signal ranged from . x e photons to . x e photons between individual mice. after application of the external fixator, the gfp signal of the unloaded tibia and fibula decreased in all mice to on average % of baseline on day (sd ± %, p = . ), % on day (sd ± %, p < . ), % on day (sd ± %, p < . ), % on day (sd ± %, p = . ) and % on day (sd ± %, p < . ). in the contra-lateral non-operated limb, the gpf signal increased to an average % on day (sd ± %, p = . ), % on day (sd ± % p < . ), % on day (sd ± %, p = . ), % on day (sd ± %, p < . ) and % on day (sd ± %, p < . ). introduction: the aim of the present study was to assess the effect of antibiotic loaded fresh-frozen allografts and compare it with antibiotic loaded acrylic bone cement in staphylococcal tibia osteomyelitis and to combine the effects of bone repair and eradication of infection in one stage surgery. material and methods: a unicortical . -mm-diameter defect was created in the proximal tibial metaphysis of thirty-six new zeland albino rabbits. after contamining the wounds with x colony forming units of staphylococcus aureus, we divided the animals into four groups. the negative control group received no treatment, the positive control group received teicoplanin-impregnated polymethylmethacrylate beads, the allograft group received fresh-frozen allografts and the experimental group received teicoplanin-impregnated fresh-frozen allografts. histopathological evaluation with light microscope were made and intraosseous tissue cultures were performed on postoperative day . clinical evaluation in a daily-routine were made. results: the cultures showed no evidence of intramedullary infection in the experimental or the positive control group in eight of the nine rabbits, but they were positive for staphylococcus aureus in one of the nine rabbits in the experimental group, one of the nine rabbits in the positive control group and all of the rabbits in the negative control and allograft groups. the experimental group and the positive control group has similar effects in eradication of the infection. conclusion: teicoplanin-impregnated allografts was effective in preventing intramedullary staphylococcus aureus infection in a staphylococcal tibia osteomyelitis model. this combination therapy could potentially eliminate the need for surgical removal of cement beads. using an antibiotic-graft compound, eradication of pathogens and grafting of bony defects may be carried out in a one stage procedure. introduction: we first report a case of an infection in humans by streptococcus pluranimalium, a new streptococcal species that has been isolated in the genital tract and tonsils of cattle, tonsils of a goat and a cat, and from the crop and the respiratory tract of canaries. according our knowledge there are a few reports in the literature reporting infections by this strain of streptococcus in animals, but never since now in humans. a year old farmer, fit and well, nonimmunocompromised has been treated in our department, for a close tibial plateau fracture (schatzker vi), with a circular external fixator. postoperatively, i.v antibiotics -cefuroxime mg every h was administrated for hours. radiological and clinical healing of the fracture achieved successfully within weeks of the fracture. the frame removed and the patient was followed up as an outpatient. six days after the removal of the frame, the patient turned up to the a&e department, systematically unwell, complaining for a swollen painful knee, and a discharging abscess in one of the proximal pin sites near by the joint line.fluid samples from the abscess and the knee aspiration, obtained and revealed streptococcus pluranimalium in all samples. debridement of the abscess and an arthroscopic wash out was performed twice, followed by i.v antibiotics according to the sensitivity test (levofloxacin ( mgx ) ceftriaxone ( grx )) for six weeks, and p.o antibiotics (clarithromycin mg every h and levofloxacin mg every ) for another two weeks. results: symptoms were settled and the patient is free of infection for the last months. conclusion: we hypothesized that the bacterium was settled on the wires of the circular fixator and was inoculated in the patient during the removal of the frame. according our knowledge, it is the first case of infection in a human individual by this specific strain of streptococcus. disclosure: no significant relationships. introduction: post traumatic knee joint contracture is the most difficult complication of the lower limbs traumas, considerably limits the functional abilities and make the patients invalids. besides, the frequent consequence of knee joint injure is gonarthrosis, and kinesitherapy is one of the element of the complex treatment. the basis of the procedure is the joint relief, leading to adjoining muscles tonus lessening, and paraarticular tissues general tense lessening and infrajoint hydrostatic pressure, joint tissues nourishing improvement. the introduction: ilizarov frames are still removed in the operating theatre in a lot of centers. this is due to a variety of reasons, the main one being that it is a painful procedure. we decided to evaluate patient satisfaction and pain experienced on removal of ilizarov frames in an outpatient setting, using oral analgesia and entonox. material and methods: seventy consecutive patients, who had their frames removed in the out patients department, had their level of pain scored using a visual analogue score (vas) and a simple questionnaire. results: the mean score for frame removal was . on the vas. there was no difference between male and female scores. the age of the patient does make a difference in the pain score, the pain score decreases with the age of the patient. pain increases when there are or more olive wires to be removed conclusion: removal of ilizarov frames in the outpatient department is a moderately painful but well tolerated procedure. introduction: the proximal metaphyseal tibial fractures are difficult to treat due to their frequent association with tibial plateau fracture and due to their aspect, which is often comminuted and has a significant impact on the function of the knee. surgery has to restore local anatomy and to allow early rehabilitation, meaning proper evaluation and stabilization of the fracture. material and methods: cases, operated between . . - . . (mean age - yrs) with proximal metaphyseal tibial fractures, were analysed. pre-operative planning using ct scan was used. the fractures were complicated with compartment syndrome ( cases) which needed additional fasciotomy.the fractures were stabilized with : plates and screws ( cases) or external fixation ( cases) depending on the soft tissue status. bone graft was used in cases. the patients were monitorised at , , , and months postoperative, concerning: bone healing, restoring of the axis of the knee, joint mobility, septic complications. results: the axis of the knee were completely restored in all the cases. bone healing appeared in all the patients (starting from months- cases, at months in the rest of the fracture) depending on the initial aspect of the fracture. flexion of the knee was limited in cases ( % of the pactients) and extension was affected in patients, depending, also, on the initial characteristics of the fracture. the frequency of the complications depended on the initial aspect of the fracture, initial stabilization, time from intial stabilization to final fixation. conclusion: results after surgery for tibial plateau fractures depend on the initial aspect of the fracture, but also on the results of surgery . the method proposed by the authors, which allows the suspension of the articular surphace, is valuable especially when the fracture is cominuted and has small fragments. the double plate fixation (medial and lateral) with single anterior incision is the best, effective and simple procedure in treatment of complex proximal tibial fractures (type v and vi of schautzker classification). introduction: compartment syndrome is one of the most frequent complications after proximal metaphyseal tibial fractures, due to the anatomical characteristics of this area. the importance of the problem is that the compartment syndrome radically changes the local and general and especially the type of fixation of the fracture. the purpose of this study is to evaluate the impact of the compartment syndrome on the outcome of the patients with this type of fracture, when recognized and treated early and complete. material and methods: the authors analyse cases of proximal metaphyseal tibial fractures treated in the emergency hospital, bucharest, between . . - . . . from these, in cases, compartment syndrome was diagnosed. in all these cases, the patients were operated and the fracture stabilized (with plates and screws in cases and external fixation in cases). decompressive fasciotomy was performed in all the cases with installed compartment syndrome and intra-compartimental pressure was monitored post-operative in all the other cases. frome these, in cases secondary compartment syndrome developed and fascitomy was necessary - hours after surgery the patients are analysed concerning: the moment of surgical treatment, and the characteristics of the patient in that moment, post-operative treatment, the postoperative local and general outcome, local and general complications. results: the incidence of the complications was influenced by the time between trauma and complete surgery. there were cases of superficial infection and case of deep infection, without needing implant removal. all the fractures healed, the interval proved to be longer when external fixation was first used. there were no systemic definitive complications after these trauma. conclusion: compartment syndrome is frequent after proximal metaphyseal tibial fractures and the incidence of this complication was significant in the group of patients we studied, and the outcome was good when the treatment was early and complete . the compartment syndrome influenced the local and general prognosis, due to the importance of microcirculation in healing after trauma. results: a ct pulmonary angiogram illustrated a metallic density, which appeared to lie in the lumen of the main pulmonary artery just proximal to the pulmonary valve. conclusion: in this case, the respiratory symptoms and signs were due to a metallic pulmonary embolus rather than fat or thrombus. formal anticoagulation was initiated and the patient's clinical condition consistently improved without the need for cardiothoracic surgery, although this is described in the literature with retained catheter fragments. eight months after the injury, the fracture has consolidated with the patient returning to work. toid is often necessary to obtain adequate exposure. as an alternative to this we promote the minimal invasive transdeltoid approach. material and methods: the operative technique of the minimal invasive transdeltoid approach is explained in a first section. this approach has the advantage of direct access to the fracture site with more opportunities for adequate reduction and good plate placement without extensive distraction of the muscles. an important step in the procedure is the palpation of the axillary nerve. in a second section the results of a prospective cohort of the first patients treated with this technique will be presented. the neer criteria were used as guidelines for operative treatment. fractures were classified according to the ao-classification. the ases shoulder score was used to evaluate functional outcomes. preoperative xrays were used to evaluate displacement, vascularity of the humeral head (according to the hertel criteria) and ao fracture type. postoperative x-rays were analyzed for quality of reduction of the ccd angle, reconstruction of the medial hinge and reposition of the tuberosities. follow-up x-rays were evaluated for healing, avascular necrosis, loss of reduction and implant related failures of osteosynthesis. the -year-old male patient was taken to hospital after a traffic accident. he was a pedestrian hit by a car. he suffered comminuted proximal humeral fracture on the dominant right side. the fracture was closed. the glenoid cavity was damaged and acromion was broken. the fractures of the v-vi th ribs were found without complication. otherwise the patient's condition was good. he had only a controlled hypertension. for preoperative planning ct scan was performed. as pieces of the humeral metaphysis wedged into the glenoid cavity insertion of glenoid component seemed uncertain. an early shoulder replacement was done on the th day. the denudated fragments were removed. the tubercles with the muscle attachments were preserved. as a long bone defect remained in the metaphyseal zone normal stem would have been insufficient. a cm long stem used in tumor cases was implanted. the length of the arm and size of the humeral head were compared to the intact side. the tubercles were attached to the prosthesis by non absorbable sutures. after the operation long bone defect remained which was filled up by heterotopic bone visible on x-ray. the postoperative period was complication free. fever, severe pain, hematoma did not occur. the arm was in rest for weeks, only controlled pendulum exercises were done from the second week. active physiotherapy was started on the th week. after months the patient finished the follow up treatment. he was pain free and self-sufficient. conclusion: for three-or four-part displaced fractures in which replacement is indicated, hemiarthroplasty with tuberosity reattachment remains the reference treatment/ , /. in trauma cases short prosthesis stem is usually sufficient but in comminuted fractures involving the metaphyseal zone long stem has to be used for certain bone-prosthesis contact. introduction: there is a trend to apply plate and screw fixation directly medial and lateral (so-called parallel plating), and many implants designed specifically for the distal humerus extend more laterally to improve fixation. this may risk injury to the origins of the common extensor and flexion musculature and the collateral ligaments either via operative dissection or by damage to the blood supply. internal plate and screw fixation is often accomplished with subperiosteal elevation of muscle attachments and tight apposition of the plate to the bone, but this should not be done over the epicondyles. plates applied to the medial and lateral aspects of the lateral and medial epicondyles should be placed directly over the soft tissues without elevating or disturbing them. damage to the collateral ligaments could cause elbow instability. material and methods: in order to emphasize these important technical aspects, we report three patients in whom detachment of the origins of the lateral collateral ligament and common extensor muscle origins from the lateral epicondyle led to post-operative instability after open reduction and internal fixation of a fracture of the distal humerus. results: while the cases are very complex and the exact cause of elbow instability by necessity somewhat speculative, our concern is that the operative dissection performed to apply implants to the lateral side of the elbow contributed to the ulnohumeral instability. injury to the lcl is the most common cause of recurrent elbow dislocation. attempts to place a direct lateral implant directly on the bone by elevating soft tissues will put the origin of the lcl at risk. it is preferable to place implants directly over the soft tissues, although there is a risk of interfering with blood supply leading to soft tissue insufficiency. it seems safe to assume that the operative treatment contributed in some way to the instability in each patient. patient one in particular had osteoporotic bone noted intraoperatively, so that one would expect failure to occur through bone with any subsequent trauma. the failure through the ligamentous structures seems to implicate the operative technique. conclusion: in any case, these three patients establish that instability of the ulnohumeral joint is an uncommon complication or sequel of the operative treatment of a bicolumnar fracture of the distal humerus. our intention in reporting these cases is to increase awareness of these potential complications and we encourage others to report any similar cases so that we can learn enough to limit the risk of this complication. introduction: orif of comminuted distal humerus fractures carries a high risk of complications such as secondray loss of reduction, pseudarthrosis and heterotopic ossifications. especially elderly patients with osteoporotic bone quality are struck by these complications. therefore total elbow arthroplasty (tea) is gaining more and more in importance as it has proven to achieve good results in elderly patients with poor bone quality. the latitude total elbow system (tornier inc., stafford, usa) is a modular, convertible implant that allows not only linked and unlinked tea with or without radial head replacement but also hemiarthroplasty. the aim of this system is to reproduce the patient's anatomy to reconstitue the elbow's physiologic kinematics. therefore the latitude prosthesis is offered in four different sizes, respecting the flexion-extension axis and three different humeral offsets based on anatomical findings. the purpose of our study was to evaluate the short-term results after elbow arthroplasty with the latitude system. introduction: it is not always possible to reconstruct complex radial head fractures. as non-anatomical reconstruction and healing disturbances result is loss of motion and severe post-traumatic arthritis of the elbow joint, radial head resection as been proposed for these cases. other authors propose radial head arthroplasty as an alternative to radial head resection to avoid the complications of radial head resection. different concepts of radial head prostheses are available: silicon prosthesis, monopolar prosthesis (loose fit and cemented/thight fit) and bipolar prostheses. evidence is lacking on the exact place for arthroplasty as opposed to radial head resection. to answer this question we performed a systematic review of litterature. material and methods: inclusion criteria are clinical studies reporting on radial head resection or radial head arthroplasty, published between and today in english, french, german or dutch language. a search has been performed using the pubmed and embase databank. a secondary search has been performed based upon the reference list of the included publications. exclusion criteria are: â e¢cadaver or animal studies â e¢biomechanic studies â e¢clinical studies with a follow up of less than years â e¢clinical studies with less than patients data extraction â e¢elbow function â e¢complication rate â e¢arthritis rate data are reported according to the moose guidelines. results: only low evidence studies are available. we did not find any randomised controlled trial comparing resection to radial head arthroplasty. there is evidence that radial head resection results in high complication rates (including arthritis) and poor function in case of elbow instability and/or essex-lopresti lesions. the rate of complications in these indications is higher than for radial head arthroplasty. in cases without instability or essex-lopresti lesion there is a trend to better function in radial head resection. complication rate is higher in the prosthesis patients. the rate of post-traumatic arthritis is not significantly differing between the resection and the arthroplasty group, and remains very high (+/_ %). conclusion: complex radial head fractures remain difficult to treat. based upon the findings of this systematic review we suggest: â e¢that adequate level of evidence studies are a necessity â e¢that in case of fracture without evident instability or essex lopresti lesion resection results in better function and less complications than arthroplasty â e¢that in case of fracture with evident instability or essex lopresti lesion resection results in worse function and higher complication rates than arthroplasty â e¢as secondary arthritis rate remains %, further therapeutic optimisation is a must. often, mortality. a new pelvic stabilizer (t-pod Ò ) provides secure and effective simultaneous circumferential compression of the pelvis. material and methods: in this study we have managed fifteen patients with a prehospital untreated unstable pelvic fracture with signs of hypovolaemic shock with the t-pod Ò . before and minutes after applying the t-pod Ò , heart rate and blood pressure were measured. an x-ray before and after applying the t-podÒ was made to measure the effect on reduction in symphyseal diastasis. results: application of the t-pod Ò reduced the symphyseal diastasis with % (n= ; p= . ). the mean arterial pressure (map) increased significant from . to . mmhg (n= ; p= . ) and the heart rate declined from beats per minute to (n= ; p= . ). in ten patients of whom circulatory response before and after the t-pod Ò was recorded, there were seven good responders, one transient and two poor responders. conclusion: in the acute setting, the t-pod Ò device has a clear compressive effect on the pelvic volume in unstable pelvic fractures. the t-pod Ò is therefore an easy to use and effective way of (temporarily) stabilizing the pelvic ring in an acute setting. introduction: thoracolumbar and lumbar fractures treated with surgical methods aim to decompress the spinal cord and correct the deformity. we aimed to compare the effects of anterior, posterior and anterior-posterior surgery on the local kyphosis angle in thoracolumbar and lumbar vertebral fractures. material and methods: thoracolumbar and lumbar, burst or compression fractured and surgically treated patients were evaluated retrospectively. preoperative, postoperative and follow-up local kyphosis angles were measured on the x-rays and changes in these angles were compared according to the applied surgical treatment methods. results: early application of surgical treatment following trauma decreases the correction loss suffered after surgery. the increase in correction loss continues after removal of the hardware. it is observed that laminectomy applied in the course of posterior surgical interventions has no effect on the correction loss. the length of the implantation, fusion and the addition of a hook to the lamina of the vertebra which is located one segment lower than the transpedicular screw applied vertebra do not affect the loss of correction. conclusion: in the surgical treatment of thoracolumbar and lumbar vertebral fractures, different degrees of correction loss are observed after each surgical treatment modality. considering the corrective effect of combined anterior-posterior surgery on the correction of kyphotic derformity due to trauma and the preoperative local kyphosis angle, follow-up correction achievement is higher when compared with anterior and posterior surgical approaches. domain questionnaire (eq- d), the point self-rated back pain (vas) and device and/or procedure related adverse events. the ethic committee of the hospital did not accept a randomized study because of the results in this proof of concept, they accepted the study with a minimum of patients (based on the results of a previous proof of concept). the incidence of missed injuries without the application of the tertiary survey was % and this incidence has been reduced to % with the application of the tertiary survey (it means a reduction of the . % in the incidence of missed injuries). the incidence of clinically significant missed injuries without the application of the tertiary survey was % and it has been reduced to % with the application of the tertiary survey (it means a reduction of the % in the incidence of missed injuries). the tertiary survey is an essential task in the management of the trauma patients to reduce the incidence of missed injuries and clinically significant missed injuries. introduction: knee-arthroscopy is a complex surgical ability. it is a combination of factors like anatomical knowledge, hand-eye coordination, three-dimensional mental activity and operating experience. surgeons as well as students were not able to train knee arthroscopy before. parts of these abilities were trained by playing video games. former studies indicated a correlation between a better performance in virtual reality (vr) laparoscopy simulation and video game experience. the aim of this study is to show that experienced video gamer perform better in a virtual arthroscopy simulation. material and methods: medical students did an arthroscopy of a longitudinal meniscus tear on a vr knee arthroscopy simulator (the insight arthro vr Ò gmv, madrid, spain). the students completed a questionnaire asking for their game experience: none (n = ), monthly (n = ) weekly (n = ) daily (n = ) before they did the arthroscopy. the simulator assessed different parameters: time, distance moved and roughness both for probe and camera and a global score (combination of all metrics). results: students with game experience (n = ) performed significantly (p <= , ) better than not experienced students (n = ). there is a tendency that the performances get better with more game experience. conclusion: gamer performed better in a vr knee arthroscopy than not gamer. these result correlates to the laparoscopic simulator training. there is a tendency of achieving a better performance in vr arthroscopy simulation due to a higher frequency of playing games. extensive training on the simulator improves the abilities of nongamers with respect to their arthroscopy skills. we will evaluate these dates in the future. ) and mostly injuries of tendons (n = ) and/or vessels / nerves (n = ). buzzsaws of different manufacturers and different price ranges were used. the work conditions were well in all cases, the saws were placed firmly on the ground and the lighting was sufficient. most injuries appeared on the week-end (friday n = , saturday n = ). a break or a meal, taken shortly before the accident, had no influence on the injury risk. all patients had a several years lasting experience in dealing with buzzsaws, half of the patients even for at least years. the safety device of the saw was folded back in most cases (n = ), only few patients (n = ) had correctly put on the saw safety device at the accident time, patients provided moreover no information. the accident had entered in cases shortly before working end, mostly with the last cut. in cases a wooden piece had become stuck in the saw and the patient had tried to solve it. conclusion: a many years' routine in dealing with buzzsaws can lead to the fact that necessary safeguarding measures are not followed any more and so cause an increased injury risk. in particular shortly before working end the attention decreases and the injury risk rises. an especially injury-laden situation is becoming stuck of wooden parts in the saw. the attempt to solve these parts without switching off the saw before bears a high injury risk. the patients showed predominantly heavy injuries. this might be the result of our clinic as a university clinic. patients with less severe injuries are concerned to be treated in smaller clinics next to their residence . ethibond was then used to anatomically oppose the ends of the sleeve fracture. the construct was reinforced with a circlage wire with the wire twisted so that it could be retrieved later through a small lateral incision post operatively the legs were immobilised in lightweight casting material for a period of weeks followed by an unlicked hinged knee brace for weeks. the circlage wires were removed at months. the child now has full, pain free range of motion. the knee is stable and he has no functional problems. conclusion: we report a rare case and emphasize the timing of diagnosis as being crucial in outcome. early operative intervention with accurate open reduction will yield good results. this publication serves to educate and refresh those who deal with general and paediatric lower limb trauma. introduction: the purpose of this study was to evaluate the effect of electromagnetic fields in healing progression of delayed union of long bones in the lower extremities. we defined delayed union, as failure of expected healing progression and nonunion when a minimum of nine months has elapsed since injury and failure or halting of healing progression was observed in three successive monthly radiographs (infection ruled out results: an average of . x-rays were performed on each patient from the time of diagnosis to discharge from clinic. none of these fractures displaced on follow up x-rays. conclusion: stable undisplaced ankle fractures treated conservatively with a below knee non weight bearing cast do not displace. hence these patients do not require to be followed up frequently with serial x-rays as they may be exposed to unnecessary harmful radiation and follow up appointments thereby saving time, money and resources. ( ). we aim to describe the rate of postoperative complications after calcaneal plate osteosynthesis in relation to the hospital fracture load as a means to increase insight into the clinical audit data. material and methods: a search was performed using the disease code for intra-articular calcaneal fractures and operative code for orif for the period - . the medical records of all included patients were obtained. as postoperative complications we included superficial and deep wound infection, mobilisation problems with need for orthopaedic shoes or walking aid and secondary arthrodesis. current complication rate of deep infection and arthrodesis rate from the clinical audit were compared with the mean logarithmic correlation coefficient relating complication rates with the institutional fracture load data, reported earlier in the literature ( ) . results: over a period of months a total of intra-articular calcaneal fractures were reconstructed with a calcaneal plate using orif (mean institutional fracture load = . fractures per month). eight patients had a wound infection, six of them were treated with antibiotics and two of them needed surgical debridement. thirteen patients have mobilisation problems, patients suffered from pain when walking, patients used orthopaedic shoes and one patient mobilised using a wheelchair. two patients had an secondary arthrodesis (n = , . %). in seven patients the osteosynthesis was removed due to pain. both deep infection rate and arthrodesis rates related to the institutional fracture load were below the % ci reported in the literature. the outcome of open reduction and internal fixation of intra-articular calcaneal fractures is known to be determined not only by factors related to patient and the fracture, but also to the institutional fracture load ( ) . the complication rate regarding deep wound infection and arthrodesis is below the data reported in the literature, related to the institutional fracture load. clinical audits studying the complication rate should take the institutional fracture load into account. introduction: toe fractures are the most common fracture of the foot. there is little data on demographics and no studies on functional outcome of toe fractures. material and methods: the initial radiographs of all consecutive patients with toe fractures treated between january and september at the reinier de graaf groep in delft, the netherlands were re-evaluated; patient and fracture characteristics were collected. all patients in aged to ( patients) were sent a questionnaire concerning pain, activity and functional limitations, footwear, walking distance, and gait (aofas midfoot score). overall satisfaction was measured using a visual analogue scale (range zero to ten). results: a total of patients with digital and phalangeal fractures of the foot were identified. the distribution of fractured toes was: first %, second %, third %, fourth %, and fifth %. multiple digital fractures were seen in . %. most fractures were caused by stubbing the toe or a crush injury ( . %). more than % of the fractures were undisplaced or minimally displaced and most fracture patterns were transverse or oblique/spiral. a total of patients ( %) returned the questionnaire with a median follow-up of months. responders were female in . % and had a median age of years (p -p - ). in . % of cases the left side was affected. the median aofas-score was points (p -p - ), the median vas was points (p -p - ). no correlations were identified with outcome and which toe or phalangeal bone was affected, number of fractured toes, fracture type and location, articular involvement, gender, age, body mass index, smoking habits, and diabetes. in the univariate analysis a trend was found for dislocation and aofas score (p = . ). in the multivariate analysis the vas was dependent of age (p = . ) and gender (p = . ). the aofas midfoot score was not influenced by any of the parameters. conclusion: this is the first investigation using two validated outcome scoring systems to determine functional outcome. almost all toe fractures were healed without complaints at months. patient satisfaction is slightly less in younger female patients. the appendix has been one of the most common site of carsinoid tumors( ). carsinoid tm is seen incidental in appendectomised cases( , - , ) and frequently in female( , ). mean diagnosis age is between - in literature, whereas in our serise it is ( ). postoperative living prognosis is good in incidental carsinoid tumors of appendix ( ) .in our cases, additional surgical procedure was not applied because tumor is less than cm, mesoappendix is healthy, and vascular invasion was not seen in hystopathologic examination. introduction: for clinical importance, two cases are presented who were operated with diagnosis of acute apppendicitis. intraoperatively,appendixes were normal, for this reason meckel's diverticulas were explored and diverticulitis were seen. material and methods: two cases are explored retrospectively results: case :the case is years old male patient.he admitted to emergency department with abdominal pain for days.there were defans and rebaund on the right inferior quadrant of the abdomen. leucocytosis( , x /mm ), aperistaltic intestinal ans in ultrasonografic examination were seen. in the operation appendix was normal,so meckel's diverticula researched and diverticulitis was seen at th cm from ileocecal valve.wedge resection for diverticulitis and appendectomy for appendix were performed.in microscopic pathologic examination appendix was normal, and meckel's diverticulitis was seen case :the case is years old male. he admitted to emergency departmant with abdominal pain for days because his pain increased last days. he has nausia, vomiting, fever( , °c), leucocytosis( , x /mm ), defans and rebaund on the right inferior abdomen. in the operation appendix was normal,so meckel's diverticula researched and diverticulitis was seen at th cm from ileocecal valve.wedge resection for diverticulitis and appendectomy for appendix were performed.in microscopic pathologic examination appendix was normal, and meckel's diverticulitis was seen. conclusion: meckel's diverticula is the most congenital anomalies of the gastrointestinal anomalies and it was found % in autopsy ser-ies. ( ) .it is asymptomatic generally. risk of complication is - %( ). preoperative diagnosis may not be done frequently, so to delay of operation may be serious complication.( )in our clinic, we explore meckel's diverticula, over(in female) and duodenum, if we do not see pü rü lant material on the appendix. results: patients with abdominal tb were diagnosed by laparoscopy and peritoneal biopsy in cases and by laparotomy in cases. from these patients we observed peritoneal tb in cases, intestinal tb in cases, mesenteric lymph nodes tb in case. at admission patients presented complications: cases with perforations and peritonitis, case with intestinal obstruction and cases presented as ileo-cecal ''tumors'' (solved by right colectomy); other surgical procedure performed was enterectomy with either entero-entero-anastomosis, either ileo-colic anastomosis. in abdominal tuberculosis ascites was present in cases. other common findings were weight loss ( cases), weakness ( cases), abdominal pain ( cases), anorexia ( cases) and night sweat ( cases). only patients had chest radiography suggestive of a new tb lesion. in those patients with peritoneal tuberculosis subjected to operation, the findings were multiple diffuse involvements of the visceral and parietal peritoneum, white ''miliary nodules'' or plaques, enlarged lymph nodes, ascites, ''violin string'' fibrinous strands, and omental thickening. biopsy specimens revealed granulomas, while ascitic fluid showed numerous lymphocytes. postoperative management was applied by the tb medical system. all patients were treated for months by specific drug therapy, with favorable evolution. pcr of ascitic fluid was positive for mycobacterium tuberculosis (m. tuberculosis) in all cases. introduction: abdominal trauma represents an important cause of morbidity and mortality in children. conservative management is preferred in blunt trauma with hemodynamic stability although there is a risk of intestinal damage when free fluid without solid organ injury is found in image studies. early laparotomy may be unnecessary in most cases but a delay in diagnosis of bowel perforation could lead to increased rate of complications. on the other hand the presence of a penetrating abdominal trauma is considered an absolute indication of laparotomy. we present five cases of abdominal trauma treated in our department in which laparoscopy proved to be an optimal diagnostic and therapeutic tool. material and methods: chart review of our cases and literature review results: three cases of blunt abdominal trauma underwent laparoscopy. we found a small bowel perforation in one case that was repaired by externalization of the jejuna loop by one of the ports. in the other two cases we found intestinal and mesenteric contusions that were treated by peritoneal drainage. two cases of penetrating trauma underwent laparoscopy. one of them presented omentum evisceration with no other injuries and the second presented a gastric perforation that needed reconversion to laparotomy. conclusion: in our experience and according to literature, laparoscopy should be taken into account as a diagnostic procedure in blunt abdominal trauma in stable children with abnormal abdominal examination and moderate free fluid and no solid organ injury in image studies, and it could be a first and sometimes definitive approach to minimal penetrating abdominal trauma. %) patients, biliary tract injury in ( . %) patients, multiple stones in the abdomen due to perforation in ( . %) patients, inadequate technical equipment in ( . %) patients, liver injury in ( . %) patient, intraoperatively detected umbilical hernia in ( . %) patient, uncontrollable bleeding in trocar entry site in ( . %) patient, insufficient insufflation in ( . %) patient, and unstoppable bleeding of arteria cystica in ( . %) patient, respectively. conclusion: although laparoscopic cholecystectomy is the golden standard of treatment in cholecystectomy, it involves the risk of conversion to open surgery. the rate of conversion to open surgery has been reported to be between - % in many series and is considered to be % on average. in our study, we found it as . %, a rate which is close to the rate reported in the literature. chief reasons for conversion from laparoscopic to open cholecystectomy include the difficult dissection of callot's triangle due to obscured anatomy and adhesions, gallbladder perforation, bleeding, the failure to produce pneumoperitoneum, gallbladder cancer, and injury in main biliary tracts and neighboring organs. the presence of pericholecystic adhesion and liquid in acute cholecytitis cases and the presence of edema in the tissue affect regional anatomy and complicate dissection, which increases the risk of gallbladder perforation. in our study, changes due to acute cholecytitis and difficulties in the preparation of callot's triangle ranked first among the indications for open cholecystectomy with a rate of . % ( / introduction: the most difficult decision in the management of the patients with severe necrotizing pancreatitis is whether surgery is required and which of the complementary approaches to necrosectomy and drainage is appropriate. recently a great deal of data has emerged suggesting that a pulsating irrigation stream delivered at high pressure and with a high flow effectively decreases bacteria, foreign bodies, and necrotic crushed tissue in wounds and decreases the incidence of resultant wound infection. this study evaluates the effect of inter pulse jet irrigation, used for the first time in open abdominal surgery. material and methods: twelve patients presenting proven infected/ non-infected pancreatic necrosis during course of acute pancreatitis and not responding to radiological or laparoscopic drainage were prospectively offered necrosectomy using itner pulse jet irrigation. open necrosectomy and subsequent jet irrigation were performed using a midline laparotomy. in all patients, to tube drainages were placed during necrosectomy for continuous closed lavage. temporary abdominal closure using modified mesh-foil laparostomy was applied for relief of abdominal compartment syndrome. results: no intraoperative complications were recorded with a median operative time of +/- minutes. in cases two sessions of necrosectomy were sufficient to completely clear the necrotic tissues. another patients with extended retroperitoneal necrosis required irrigation procedures. necrosectomy using inter pulse jet irrigation was successful in all patients, and none required complementary surgical or radiological treatment. introduction: intra-abdominal hypertension (iah) and abdominal compartment syndrome (acs), have been described often in patients with abdominal trauma or after emergency abdominal surgical operations. we present patients with vomiting, meteorism, acute abdomen and acute respiratory insufficiency provoked by phytobezoars. aetiopathogenesis, symptoms and differential diagnosis are analyzed and a brief report of the literature is discussed. material and methods: three patients, were admitted to the emergency department of our hospital during the last year. all patients were presented with acute respiratory failure, abdominal pain, discomfort, meteorism and vomiting. the first patient, a years old man, alcoholic was admitted with meteorism, acute abdominal pain and discomfort. a fr nasogastric tube was introduced and the symptoms were remitted after gastric evacuation. the second patient suffered from bowel obstruction after closure of colostomy as a result of traumatic injury of sigmoid colon. a laparotomy was performed and a phytobezoar was revealed at the level of anastomosis. the last patient was presented with meteorism, vomiting and dyspepsia, as a result of enlarged gastric mass, revealed after endoscopy. results: gastric evacuation in the first patient revealed lt of fluid mixed with a smelly gas under pressure (iap = cmh o after evacuation) followed by washouts. laparotomy was performed in the second patient revealing a large phytobezoar at the level of anastomosis. mini laparotomy and gastrotomy in the third patient (after two unsuccessful gastroscopies) revealed large phytobezoars. introduction: the objective was the substantiation of using dcs tactics in wounded with ctmi. material and methods: in case of cranial injuries dcs tactics implied treating superficial wounds of skin, arrest of exterior bleeding and subsequent evacuation of the wounded within the first hours after getting trauma. in case of extremity injuries, dcs tactics implied first of all the operations on the occasion of gunshot injuries, including the arrest of bleeding, application of the external fixation apparatuses, application of temporary shunts for injured vessels. the burn wounds treating were carried out after helping the patient out of shock. in case of the wounded with chest injury in the presence of hemo-and pneumothorax, drainage of pleural cavity of silicone tubes with active air aspiration was fulfilled. in case of abdomen injuries after laparotomy abdominal cavity was cleaned and inspected including examination of the most probable sources of bleeding: liver, spleen, magistral vessels. on the background of unstable hemodynamics the abdominal cavity tamponage along the right and left side canals, supraliver and underliver space and small pelvis. results: thus, in accordance with dcs principles in case of ctmi, operations regarding gunshot injuries were made in the first turn, and operations connected with burns -in the second turn. the first were urgent operations. then, intensive therapy in the conditions of resuscitation unit. conclusion: the repeated operation of the second stage -final removal of lesions -was carried out after the condition of the wounded had been stabilized. introduction: the aa highlight the importance of the damage control philosophy in difficult emergency surgery situations like the perforation of an oesophagojejunal anastomosis by an oesophagojejunal tube. material and methods: man, age , rd pod after total gastrectomy with precolic reconstruction for gastric cancer (t n mxr ) in another institution. no significant past diseases. mechanically ventilated, in septic shock, with purulent drainage from right hemithorax and blue drainage from right abdominal upper quadrant, after ''methilene blue'' swallow. distended abdomen. relaparotomy with median frenotomy (pinotti) and damage control procedures for oesophagojejunal and cardiophrenic pleural sinus perforation by an esophagojejunal tube, with right pleural empyema, mediastinitis and peritonitis: primary closure of the perforation, washing and drainage of the pleura, mediastinum and peritoneum, delayed abdominal closure (dac, rotondo and schwab) and intensive care unit (icu). on th pod, revision of the mediastinum and peritoneum, no evidence of fistula: internal pleural drain retired, fibrin glue and collagen placed to protect the anastomosis, dac and icu. on th pod, anastomotic leak: a ttube (kehr) has been placed as a minimal drainage procedure; dac and icu. on th pod, descendent feeding jejunostomy and abdominal closure. on th pod, subfrenic abscess on ct scan: surgical drainage through the upper third of the previous closed laparotomy. on nd pod, intestinal suboclusion: drainage jejunostomy above the feeding one. on st pod, right pleural drainage: oesophagoscopy, t-tube removed and expansible silicon covered oesophageal prosthesis inserted, covering the anastomotic fistula. on nd pod, patient left the icu. results: on th pod, patient sent back to the institution where he has been operated first. on th pod, endoscopical removal of the prosthesis with baritated swallow control, with patient sent back home. conclusion: this case highlights the importance of the damage control philosophy in difficult emergency surgery situations like the perforation of an oesophagojejunal anastomosis by an oesophagojejunal tube. disclosure: no significant relationships. y. el-ashaal , a. hefny , y. saadeldinn , f. m. abu-zidan al-ain hospital, department of surgery, al-ain, united arab emirates, al-ain hospital, department of radiology, al-ain, united arab emirates, surgery, department of surgery, uae university, al-ain, united arab emirates introduction: acute gastric dilatation due to superior mesenteric artery syndrome in healthy subjects is extremely rare. herein we report its sonographic findings and highlight the value of point of care bedside ultrasound in such a case. material and methods: a -year old female was admitted to al-ain hospital complaining of epigastric pain of two days duration following excessive eating. she was nauseated but could not vomit. succussion splash was positive. bedside ultrasound has shown a hyperactive duodenum, a distended stomach compressing on the ivc, and a narrowed angle between the superior mesenteric artery and the aorta. these findings were confirmed by abdominal ct scan. the angle between the aorta and superior mesenteric artery was only â -p p . gastrographin follow through has shown complete obstruction of the third part of the duodenum. nasogastric tube immediately drained ml of yellowish fluid. results: five days later gastrographin follow through has shown free passage of the dye to the small intestine with significant reduction in the stomach size. the patient was discharged home in a good condition. conclusion: bedside ultrasound has proven extremely useful for both the diagnosis and management of this rare case. introduction: a rare and potentially lethal complication during right hemicolectomy material and methods: a year-old male, underwent a right hemicolectomy due to malignancy in the cecal region. during the operation the relatively constant venous anastomosis between the middle colic vein and the inferior pancreaticoduodenal vein close to the lower border of the pancreas was injured, resulting in excessive haemorrhage. in the effort to manage the bleeding, the superior mesenteric vein (smv) was torn, and after multiple unsuccessful efforts to repair the vein, we finally had to ligate the smv. the operation was completed by typical right hemicolectomy and the abdomen was closed. five hours later the patient showed acute distention of the abdomen together with respiratory distress. due to increased abdominal pressure (> cm h o), the patient was taken back to the or. the small bowel was edematous, bluish but viable. the abdomen left open and was closed by using the vac. the patient was taken to the icu. six days later the small bowel returned to normal colour and thickness, but the generalized edema made the closure of the abdomen impossible. by day ten the patient was on full enteral feeding, and was taken to the or, where free partial thickness skin grafts were used to close the abdomen. results: the patient was extubated by day sixteen and was taken to the rehabilitation center. conclusion: accidental injury of the venous anastomosis between the middle colic vein and the inferior pancreaticoduodenal vein close to the lower border of the pancreas, may prove a potentially life threatening condition. we present this case in order to point out this rare complication of right hemicolectomy. aimed to explore the influence of different surgical diagnosis groups on long term health status and to make comparisons with general population norms. material and methods: qol was measured in all surviving surgical icu patients admitted to a dutch teaching hospital between and . patient-reported data on qol were collected with the euroqol- d + after a mean follow up of (range - ) years. patient characteristics, surgical diagnosis group, length of icu stay and survival were prospectively registered. eq-utility scores (eq-us), eq visual analoge scales (vas) and prevalences of domain-specific health problems were calculated. the effect of surgical diagnosis group on eq-us/eq-vas was assessed by multivariable generalized linear regression analysis. logistic regression was used to explore the influence of surgical diagnosis group on domain specific health problems. long term quality of life of surgical icu patients was compared to an age-and sex-matched general dutch population using the t-test analysis. results: patients survived the icu and were available for follow up. in ( %) patients the health-related qol was measured. for all surgical groups combined, after - years nearly half of all patients still suffered from problems in the dimensions mobility ( %), usual activity ( %), pain ( %) and cognition ( %). compared to the age-and sex matched general dutch population hrqol was worse with a difference of . on the eq utilities score (range - ). oncological surgery patient had the best (eq-us . ) and vascular patients had the worst (eq-us . ) hrqol. trauma (odds ratio between . - . ) and vascular surgery ( . - . ) showed significantly increased prevalences of problems in mobility, self-care, usual activities and cognition. conclusion: more than years after a surgical icu admission, quality of life of this patient population is largely reduced. many patients still suffer from a variety of health problems, including decreased cognitive functioning. treatment advances should be made to reduce the current health deficit of surgical icu survivors compared to the general population. disclosure: no significant relationships. u. sekmen , g. altaca , s. aktas kalayci , g. moray general surgery, baskent university, ankara, turkey, general surgery, baskent university, ankara, turkey, internal medicine and division of gastroenterology, baskent university, ankara, turkey introduction: predicting the prognosis in severe acute pancreatitis is cruciate in order to constitute effective treatment strategies. material and methods: thirteen consecutive patients admitted with the diagnosis of severe acute pancreatitis according to glasgow or ranson criteria were evaulated. we searched the prognostic values of age, gender, etiology of pancreatitis, comorbidity and labarotory values and their affects on complications and length of hospital stay. results: mean age was , years (range: - yrs). etiology was biliary in patients ( after ercp). acute cholecystitis was also present in patients. patients had diabetes mellitus. two patients had percutaneous cholecystestostomy. five patients had ercp at a mean of , days after admission. cholecystectomy was performed in patients, either at the first admission (n: ) or after - weeks. mean wbc, alt, ast, and ldh values on admission and mean highest hscrp levels and mean lowest serum calcium (ca) levels in the first hours were /mm , u/l, u/l, u/l, and mg/l and mg/dl, respectively. pancreatic necrosis ( , %) was diagnosed by computerised tomography in patients ( / in diabetics, / in nondiabetics); a total of patients ( %) had systemic complications. mean ldh ( u/l vs u/l) and lipase levels ( u/l vs u/l) were higher in patients who developed necrosis, though not statistically significant. other parameters were similar in patients with or without necrosis. two patients who had pancreatitis due to ercp underwent pancreatic necrosectomy. median hospital stay was days (range: - days). all patients survived. mean highest hscrp and lowest ca levels in the first hours correlated significantly with the hospital stay (r: . p: . for hscrp, and r: - . p: . for ca). conclusion: although we have a limited number of patients, we may conclude that high levels of ldh, lipase, hscrp and low levels of ca can be used as predictive factors for severe pancreatitis. pancreatitis seen after ercp and in diabetic patients tend to be more severe. abdomen. abdominal imaging reveals persistent bleeding and multiple bone lesions compatible with bone hemangioma with low blood platelets count -kasabach-meritt syndrome. patient is transferred to a central hospital for arterial embolization of the right hepatic artery that is not effective. the authors describe surgical control of the bleeding without liver resection. second look surgery was undertaken with removal of hepatic packing and pringle's manoeuvre with temporary control of the haemorrhage with haemostasis and ligation of the right hepatic artery. it was needed several surgery's more with additional packing, haemostatic mesh and haemostatic products in order to control the bleeding. the patient was proposed for liver transplant during the process but was not accepted. introduction: management of splenic injury has evolved over the past years. nonoperative management has gained currency, first in children and after in adults. material and methods: we present a case of a years-old man who falled for m, haemodinamically stable, presenting pain on the left part of thorax and upper abdomen. results: the patient fall for m hours before the arrive in our er; he was haemodinamically stable (bp= / mmhg, av= bpm) and presented pain on the left thorax and left hypocondrium. laboratory showed , g/dl haemoglobin. radiologic test: laterally th left rib fracture. ct scan revealed iv grade spleen injury and perisplenic hemoperitoneum. we choosed non-operative managementafter days ct scan showed reduced dimensions of dilacerated spleen injury and no hemoperitoneum. the patient status was stable during the days hospitalisation. imagistic control after month: homogenous spleen structure. conclusion: the haemodinamic status of the patient is the most reliable criteria for non-operative management, not ct aspect of the injury. years old) submitted to upper partial splenectomy for blunt trauma. residual spleen after surgery was / and / respectively. ceus was preceded by standard b-mode us with color flow mapping in all cases; videoclips of each exam were stored for forensic medicine issue too. mean time for ceus exam was - minutes. results: ceus allowed to recognize regular perfusion of the residual spleen in both patients. conspicuity of ceus imaging was high and impressive. homogeneous complete distribution of the contrast medium in the parenchyma was observed on day in both pts. ceus follow-up on day and did not add any supplementary information. pts were discharged on day and day respectively, without indications for vaccinations or antibiotic prophylaxis. conclusion: ceus is an effective method for assessing perfusion of the residual spleen after partial splenectomy. ceus can be performed bedside by the surgeon in the early po period or on an outpatient basis. imaging interpretation is immediate and distribution of the contrast medium assure about viability of the splenic tissue. ceus imaging allowed us to omit prophylactic vaccinations. it is the first description of the use of ceus in this particular setting. introduction: injuries to the abdominal visceral vessels are uncommon but devastating entities that incur extremely high rates of mortality.the rarity of these injuries prevents many trauma centers and trauma surgeons from developing a significant knowledgement learning curve. the authors describe a case with abdominal visceral vascular abdominal blunt trauma, presented with laceration in the confluence of inferior mesenteric vein and splenic vein, laceration of the hepatic artery associated with hepatic hematoma, periduodenal and peripancreatic hematoma. the routine principles of vascular surgery were applied to the management of these visceral blood vessels injuries :adequate exposure, proximal and distal control, dé bridement of the vessel wall,meticulous arteriorraphy and venorraphy with fine monofilament vascular sutures and early instituition of damage control resulting a successfull repair. material and methods: the authors made a review of several large series in the literature wich are also consistent with a low incidence of visceral vessel injuries. vascular trauma is complex and ideally is carried out by experts in a multidisciplinary environment a broad spectrum of surgical specialities are involved in the ressuscitative phase of trauma care including general, trauma, thoracic and vascular surgery . despite a relatively low incidence of vascular trauma in portugal, the results are satisfactory because of active and early management by surgeons on call, weather with vascular training or not, treating all kinds of vascular surgical emergencies. a trauma and emergency surgical speciality is a challenge. results: little information describing the first repair or ligation of any visceral vessel injuries can be found in the literature. visceral vascular injuries carry a significant mortality rate. vascular injury poses a small but significant challenge in portugal trauma care. opportunities such as better practise guidelines and minimum standars will allow surgeons to improve delivery of quality care to the next generation of vascular trauma victims. training in the management of vascular trauma surgery with integration of vascular and general surgeryin trauma care should optimize outcomes. conclusion: from reviews of large series dealing with the management of abdominal vascular injuries, the incidence can be estimated to be between . % to . %of all vascular injuries. few data are available describing the mortality rate for patients with portal veins injuries. te author's vision is that all vascular and general surgery trainees would eventually undertake the definitive surgical trauma care course and improve outcomes and reduce mortality. introduction: high rates of intra-abdominal pressure, has been proved to increased mortality, especially in multi-trauma patients followed laparotomy. multiple organ failure syndrome (mofs), derived by intra-abdominal hypertension, has been called abdominal compartment syndrome (acs), the epidemiology and the characteristics of which, have not been thoroughly determined. introduction: intercostal pulmonary hernias are rare and mostly resulting from complications related to the chest trauma.the authors report a case of traumatic intercostal pulmonary hernia in a -yearold man. he was admitted to the hospital as a traumatic patient after a motor-cycle accident . material and methods: beside multiple polytraumatic injuries the patient had a blunt injury to the left chest.physical examination revealed a bulge on palpation of the left chest wall.computed tomography (ct) scan of the chest revealed the protrusion of lung tissue outside the intercostal space.size of hernia, incarceration and respiratory insufficiency mandate immediate surgical intervention.postoperative course was uneventful, and there has been no sign of recurrence of hernia. results: post -traumatic lung herniation through a defect in chest wall is an uncommon injury .various methods of tratement and repair have been described, including both purely thoracoscopic to full open techniques.the authors repaired a case using a minithoracotomy. conclusion: lung hernia is an uncommon entity defined as the protrusion of pulmonary tissue and pleural membranes through defects of the thoracic wall.chest trauma is the most common cause.timely surgical intervention is critical to favorable patient outcomes.effective management, surgical approaches and repair of thoracic injuries are discussed and the available literature. of the hernia from the outside, dé bridement and closure layer-bylayer with maxon- was performed. the postoperative course was uneventful. conclusion: a tawh after blunt trauma is a rare entity. the reported incidence of acute hernia ranges from ,%- , % . in our case the tawh was already diagnosed in the trauma room. mahajna et al. reported the case of herniation of the right colon with vessel strangulation, which wasn't seen in the primary survey. a right hemicolectomy had to be performed on the nd posttraumatic day. in our case we decided intraoperatively to perform a primary reconstruction of the abdominal wall without mesh repair. the potential advantage of a mesh implantation lies in the augmentation of the abdominal wall, thereby potentially lowering the risk of incisional hernia. however, the benefits of such augmentation should be cautiously weighed against the risk of foreign body contamination when resecting bowel during the same operation. introduction: impalement is an uncommon and spectacular injury, which combines aspects of both blunt and penetrating trauma. impalement injuries from falls are rarely seen, because most of the patients die at the scene of injury. we present an unusual case in which a patient survived a perineal impalement after a fall.with reference to our latest case and discuss the initial management and the operative treatment of this rare injury according to a literature review. material and methods: a young man was working on a construction site when he suddenly lost his footing and fell m off a scaffold. he orientated such that he landed in a sitting position on a vertical aluminium u-tube, which penetrated his perineal region and stucked. upon arrival at the emergency room he was in stable condition, intubated. after the initial treatment and diagnosis according to atls a ct of the abdomen was performed; it showed a penetrating tube perianal left, from caudal into the cavity of the pelvis, the point of the tube stucked in the sacrum -in the hole of neuroforamina s . there was no intraabdominal or laceration. the patient was taken to the operating room in stable condition. the laparotomy was performed. there was no laceration detected, explorating the praesacral cavity brought out a profuse bleeding of the main pelvic vein. after the active bleeding was stopped the tube was removed from the outside. after lavage and positioning of drains, a protective loopileostoma was placed to avoid further contamination. the perineal wound was carefully debrided, drains were inserted and the wound was not completely closed by adapting stitches. a wash-out of the colon was performed, he received antibiotics and the perineal wound was rinsed daily. he was dismissed days post-trauma. results: impalement injuries result when a solid object pierces a body cavity or extremity. the object often remains fixed within the body. this case report showed a positive outcome. impalement injuries are impressive but also rare, so it is important to show an algorithm in management of such injuries. the object should be in situ during transport. in large or immoveable objects, the impaling device should be cut just above the skin. the management of the injuries depend on the particular body region of penetrating. perineal impalement often appear quite complex. these injuries may need the assistance of gynecology and urology surgery praesacral drainage and distal rectal washout is recommended. wound care is essential in the care of impalement injuries. the skin should generally left open. even uncomplicated wounds have to be treated with antibiotics. conclusion: impalement injuries are rare and treating is a challenge for the surgeon. the degree of the injury determines the functional result. strict adherence to the transportation and management principles outlined in this paper are necessary to decrease morbidity and mortility disclosure: no significant relationships. introduction: the insertion of foreign objects into the anus and rectum is a well-known phenomenon. rectal foreign bodies can present a difficult diagnostic and management dilemma. . a foreign body may be inserted by a doctor for diagnosis or treatment like rectal thermometer, enema tubes or anal packs, by the patient for self eroticism or by a third party as a result of assault or sexual activity, but the most common cause for insertion of a foreign body is sexual stimulation. , , . anorectal foreign bodies are more common in men than in women . they can be caused by a wide variety of objects, lead to variable degrees of local trauma to the surrounding tissues, rectal bleeding and can be associated with perforation or delayed injury. material and methods: in this study, in the ten years from to , we used the medical records of patients with foreign bodies in the rectum have been diagnosed and treated,at izmir teaching and research hospital,izmir. results: all patients were men.they ranged in age from to (mean age ).two of these patients had impulse body spray, two patients had bottle, one patient had eggplant,one patient had brush and one patient had wishbone (after oral ingestion) in the rectum. five objects were removal transanally extracted by anal dilatation under general anesthesia.two patients required laparotomy.one patient of these the object was high lying in the rectosigmoid and performed laparotomy.the object was removal transanally extracted by abdominal manuplation.one patient had a intraperitoneal rectosigmoidal perforation.the perforation was treated by primer suture, proximal colostomy and appropriate antibiotic therapy. routine rectosigmoidoscopic examination is performed after removal.one patient had perforation of the rectosigmoid and had lacerations of the mucosa. no patient had a mortality. conclusion: foreign bodies in rectum should be managed in a wellorganized manner. the diagnosis is confirmed by means of plain abdominal radiographs and rectal examination. manual extraction without anaesthesia is usually only possible for very low lying objects. patients with high lying foreign bodies generally require general anaesthesia to achieve complete relaxation of the anal sphincters to facilitate extraction.open surgery should be reserved only for those patients with perforation, peritonitis and impaction of the foreign body. results: definitive pathological examination confirmed the diagnosis of pancreatic pseudocyst. the patient postoperative outcome was unremarkable and was discharged from the hospital at the seventh postoperative day. conclusion: retroperitoneal and ''well protected'' location implies that a high energy traumatism is needed to injury the pancreas. the fact that in this case a non-classical injury mechanism has occurred, makes the diagnosis more difficult to reach. pancreatic pseudocyst is the most frequent complications in this type of traumatisms. effective treatment of fracture-dislocations of the olecranon requires a stable trochlear notch uncomplicated mason type-ii and iii fractures of the radial head and neck in adults. a long-term follow-up study surgical treatment of intra-articular fractures of the distal part of the humerus. functional outcome after twelve to thirty years disclosure: one or more of the authors received funding from the small bone innovations (dr) fractures of the neck of the talus. long-term evaluation of seventy-one cases tuberosity malposition and migration: reasons for poor outcome after hemiarthroplasty for displaced fractures of the proximal humerus tuberosity osteosynthesis and hemiarthroplasty for four part fractures of the proximal humerus abdominal -mdct for suspected appendicitis: the use of oral and iv contrast material versus iv contrast material only socioeconomic factors, medicolegal issues, and trauma patient transfer trends: is there a connection? are patients being transferred to level-i trauma centers for reasons other than medical necessity? the delaware trauma system: impact of level iii trauma centers improving outcomes in a regional trauma system: impact of a level iii trauma center jupiter -metaanalysis: nondisplaced scaphoid fractures. operative vs. nonoperative management(update to nov dodds -minimally invasive management of scaphoid nonunions chess -a biomechanical analysis of intrascaphoid compression using the herbert scaphoid screw system. an vitro cadaveric study is the mortality rate for septic shock really decreasing? systemic inflammation after trauma in vivo effects of a synthetic -kilodalton macrophage-activating lipopeptide of mycoplasma fermentans after pulmonary application alveolar macrophages from septic mice promote polymorphonuclear leukocyte transendothelial migration via an endothelial cell src kinase/nadph oxidase pathway macrophage inflammatory protein- alpha mediates lung leukocyte recruitment, lung capillary leak, and early mortality in murine endotoxemia fracture-dislocation of the hip joint. the nature of the traumatic lesion, treatment, late complications, and end results cervical spine trauma in the pediatric patient spinal injuries in children and adolescents long-term clinical and radiographic outcomes after open reduction for missed monteggia fracture-dislocations in children elastic stable intramedullary nailing as alternative therapy for pediatric monteggia fractures unstable diaphyseal fractures of both bones of the forearm in children: plate fixation versus intramedullary nailing delayed radial paralysis after monteggia fracture-a case report, unfallchirurg a simple modified arthroscopic procedure for fixation of displaced tibial eminence fractures a fracture of the intercondylar eminence of the tibia treated by arthroscopic fixation an analysis of different types of surgical fixation for avulsion fractures of the anterior tibial spine modified arthroscopic suture fixation of a displaced tibial eminence fracture tibial spine fractures in children fractures of the tibial spine in children seventeen-year follow-up of a reattachment of a nonunited anterior tibial spine avulsion fracture arthroscopic fixation of displaced tibial eminence fractures: a new growth plate-sparing method the mechanism of clavicular fracture: a clinical and biomechanical analysis functional outcome following clavicle fractures in polytrauma patients evidence-based orthopaedic trauma working group. treatment of midshaft clavicle farctures: systemic review of fracturese: on behalf of the evidence-based orthopaedic working group harnroongroj t, vanadurongwan v. biomechanical aspects of plating osteosynthesis of transverse clavicular fracture with and without inferior cortical defect autologous bone versus calcium-phosphate ceramics in treatment of experimental bone defects iliac crest autogenous bone grafting: donor site complications clinical results of harvesting autogenous cancellous graft from the ipsilateral proximal tibia for use in foot and ankle surgery healing and graft-site morbidity rates for midshaft clavicle nonunions treated with open reduction and internal fixation augmented with iliac crest aspiration literature review of current techniques for the insertion of distal screws into intramedullary locking nails a new fluoroscopy-free navigation device for distal interlocking screw placement disclosure: we all are surgeons at gregorio marañ ó n hospital, madrid. dr. turegano is the chief of the emergency surgery department. references: -nandapalan and al factors related to mortality in inferior vena cava injuries: a year experience disclosure: we certify that all our affiliations with or financial involvement (employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending) with any organization or entity with a financial interest. references: . blaisdell, f.w. the pathophysiology of skeletal muscle ischemia and the reperfusion syndrome: a review. references: robinson cm evaluation of consecutive patients with the extended data set of the standardised audit for hip fractures in meniscus allograft transplantation: a current concepts review homologous meniscus transplantation: experimental and clinical results cell survival after transplantation of fresch meniscal allografts: dna probe analysis in a goat model freezing causes changes in the meniscus collagen net: a new ultrastructural meniscus disarray scale meniscus replacement with bone anchors: a surgical technique meniscal allograft transplantation: long-term clinical results with radiological and magnetic resonance imaging correlations clinical evaluation of arthroscopic-assisted allograft meniscal transplantation knee joint biomechanics following arthroscopic partial meniscectomy an evaluation of a shockroom located ct scanner: a randomized study of early assessment by ct scanning in trauma patients in the bi-located trauma center north-west netherlands (react trial) overlooked spine injuries associated with lumbar transverse process fractures frequency and importance of transverse process fractures in the lumbar vertebrae at helical abdominal ct in patients with trauma traumatic lumbosacral dislocation: report of two cases references: prevalence of suicide ideation and suicide attempts in nine countries uptake and intracellular distribution of various metal ions in human monocyte-derived dendritic cells detected by newport green dcf diacetate ester biomechanical analysis of bicondylar tibial plateau fixation:how does lateral locking plate fixation compare to dual plate fixation? operative treatment of tibial plateau fractures.:five to years follow-up results treatment of high energy tibial plateau fractures with half ring external fixation combined with minimal internal fixation. nan fang yi ke da xue xue bao disclosure: no significant relationships de smet l, debeer p, degreef i. fixation of a periprosthetic humeral fracture with ccg-cable system results of non-operative and operative treatment of humeral shaft fractures. a series of cases complex distal humeral fractures: internal fixation with a principle-based parallel-plate technique. surgical technique the anteromedial facet of the coronoid process of the ulna ring d, doornberg jn. fracture of the anteromedial facet of the coronoid process. surgical technique broberg ma, morrey bf. results of treatment of fracture-dislocations of the elbow disclosure: one or more of the authors received funding from the small bone innovations (dr perilunate and axial carpal dislocations and fracture dislocations evaluation of the spanish versió n of the dash and carpal tú nel síndrome health-related quality-of-life instruments: cross-cultural adaptation process and reliability philadelphia: w. b. saunders company; . p. - . . meyer pr. complications of treatment of fractures and dislocations of the dorsolumbar spine no significant relationships. references: . general medical council. consent: patients and doctors making decisions together is informed consent effective in trauma patients is informed consent in trauma a lost cause? a prospective evaluation of acutely injured patients' ability to give consent factors affecting the quality of informed consent the impact of objective assessment and constructive feedback on improvement of labrascopic performance in the operating room united arab emirates, medical education at the main trauma hospital. results: patients were studied ( . % males) having a mean age of . years. % of patients were from the indian subcontinent and % were uae nationals. % of patients presented immediately following injury. ambulances brought only % of the patients. % of trauma took place in the street or highway, % in work places and % at home. the mechanisms of injury were road traffic collision in % and falls in %. % of injuries were to extremities, % to head, face and neck, and % to chest. the mean iss was . . the mean (range) hospital stay was . ( - ) days; ( %) patients needed icu admission of whom ( . %) died. the mean icu stay was . days (range - ). overall mortality was ( . %). conclusion: road traffic collisions and falls are the main cause of trauma admissions in al ain city. extremities, head, neck, face and chest are the main body regions sustaining injuries. disclosure: no significant relationships hip fractures in the elderly: a world-wide projection disclosure: no significant relationships. references: d. ring et al.: predictors of acute carpal tunnel syndrome associated with fracture of the distal radius pm non-surgical treatment of the distal radial fracture. is there an advantage in immobilization in degrees dorsiflexion compared to immobilization in a neutral position? janzing , l. horta emergency department, viecuir medical centre the netherlands introduction: according to the literature immobilization of collespoints where radiological (dorsal dislocation, radial inclination), functional, the necessity for surgical intervention a comparison of methods of plastic cast fixation in treatment of loco classico radius fracture. a prospective, randomized study, unfallchirurg pm buzzsaw injuries: mechanisms of damages and predisposing factors r. ziegler , w. knopp woodworking injuries: an epidemiologic survey of injuries sustained using woodworking machinery and hand tools references: beasley ls, vidal af. traumatic patellar dislocation in children and adolescents: treatment update and literature review long-term functional outcome after lateral patellar retinacular release in adolescents: an observational cohort study with minimum -year follow-up mri of traumatic patellar dislocation in children reconstruction of the medial patellofemoral ligament for the treatment of habitual or recurrent dislocation of the patella in children injuries to the inferior pole of the patella in children disclosure: no significant relationships pm results of electromagnetic fields in healing progression of delayed union in the lower extremities the effect of low-frequency electrical fields on osteogenesis references: complex trauma of the limbs with vascular injuries-olivera lupescu, mihail nagea carcinoid tumour of the appendix:an analysis of consecutive emergency appendectomies tuberculous peritonitis of the wet ascitic type: clinical features and diagnostic value of image-guided peritoneal biopsy. dig. liver dis at perforated ulcer treatment, suture of the place of prefotation was used at ( , %) people, billroth ii stomach resection at six ( , %), suture of the place of prefotation with psv at three ( , %), and billroth i stomach resection at one ( , %) patient. postoperative complications were noticed at ( , %) people. we had postoperative mortality at four ( , %) patients. recidive ulcer was registred at ( , %) patients who were surgically treated for perfored ulcer before. conclusion: ulcer perforation is an acute complication of the ulcer disease that appears most frequently after bleeding and which usually requires surgical treatment. references: . behçet disease complicated by a perforated ileal ulcer presenting as an acute abdominal emergency gastro-duodenal ulcers with perforation caused by short-term acetylsalicylic acid ingestion: case report culafiÄ à d, matejiÄ à o perforated gastroduodenal stress ulcer melinte c, dragomir c pubmed -indexed for medline] spontaneous rupture of the spleen as immediate complication in autologous transplantation for primary systemic amyloidosis delayed splenic rupture as a cause of haemoperitoneum in a capd patient with amyloidosis boluda garcà a f, calvo català ¡ j, campos fernà ¡ndez c, parra rà denas jv, gonzà ¡lez cruz mi laparoscopic cholecystectomy for acute cholecystitis disclosure: no significant relationships. references: . pokorný j. et al. urgentní medicína, . st edition: praha, galé n . stetina et al. medicína katastrof a hromadný ch neštÄ >stí pt perforation of oesophagojejunal anastomosis by venous anatomy of the right colon: precise structure of the major veins and gastrocolic trunk in cadavers pt validation of fournier's gangrene severity index score (fgsis) general surgery dobrzanska l, newell r. readmissions: a primary care examination of reasons for readmissions of older people and possible readmission risk factors pt spontaneous rupture of giant cavernous hemangioma of the liver in a patient with systemic hemangiomatosys and kasabach-meritt syndrome. an interactive and multidiscipline case b general surgery general surgery portugal introduction: hemangiomas are frequent benign tumors of the liver nonoperative management of blunt splenic and liver injury is ct grading of splenic injury useful in the nonsurgical management of blunt trauma? management of blunt splenic trauma: ct contrast blush predicts failure of nonoperative management references: . ochsner mg. factors of failure for nonoperative management of splenic injuries associated injuries in blunt solid organ trauma: implications for missed injury in nonoperative management introduction: aim. to establish the diagnostics and management trauma, ( , %) -head trauma, ( . %) -limbs injuries, and ( %) -severe shock. in cases the splenic injury was initially manifested - ( . %), and in ( , %) cases the clinical signs developed later (p < . ) practice management guidelines for the evaluation of blunt abdominal trauma: the east practice management guidelines work group diagnostic accuracy of surgeonperformed focused abdominal sonography (fast) in blunt paediatric trauma surgeon-performed bedside organ assessment with sonography after trauma (boast): a pilot study from the wta multicenter group disclosure: no significant relationships. pt incidence of abdominal compartment syndrome in patients with multiple injuries. a single institution experience koulas , o. mousafiri hatzikosta general hospital, ioannina, greece, intensive care unit, g. hatzikosta general hospital intensive care unit, g hatzikosta general hospital delayed presentation of traumatic parasternal lung hernia management of retained colorectal foreign bodies:predictors of operative intervention disclosure: no significant relationships. treatment. disclosure: no significant relationships. references: .demetriades d, velmahos g. technology-driven triage of abdominal trauma: the emerging era of nonoperative management management of high grade renal trauma: -year experience at a pediatric level i trauma center pt blunt abdominal trauma. year experience in our department greece ( , %), without spinal fractures. resection/anastomosis was permorbidity. in first group, there were deaths ( , %), cases due to intestinal injuries. the second group (without seatbelt sign) had deaths ( , %), none due to intestinal injuries but related with multiple thoracic and cranial lesions. conclusion: in this study we found a consistent evidence that ''seatbelt sign small-bowel and mesentery injuries in blunt trauma mortality reduction with air bag and seat belt use in head-on passenger car collisions disclosure: no significant relationships. references: management strategies in isolated pancreatic trauma disclosure: no significant relationships. references: enterocutaneous fistula complicating trauma laparotomy: a major resource burden the american surgeon staged management of giant abdominal wall defects injured patients -documentation of black spots j. heinzmann , u. culemann , t. pohlemann universitä tsklinik des saarlandes, klinik fü r unfall-, hand-und wiederherstellungschirurgie, homburg, saar, germany, trauma-, hand and reconstructive surgery, university of saarland, homburg, saar, germany, klinik fü r unfall-, hand-und wiederherstellungschirurgie, universitä tsklinikum des saarlandes, homburg, saar, germanyintroduction: nonunions of the tibia represent a complex problem, particularly if they occur at the distal third of the tibia. the aim of the study was to evaluate a standardized treatment concept to manage different types of nonunions of the tibia with regard to their location within the tibia. material and methods: prospective, non randomised study ( / - / ); nonunions of the diaphyseal and metaphyseal tibia (ao type / ); standardized treatment concept: diaphysis: reamed intramedullary nailing; dia-metaphyseal junction and pilon: lcp with a minimal invasive approach or an open approach plus bone grafting from the iliac crest; infected nonunions: external fixator. analysis parameters: demographic data, fracture type (ao classification), primary surgery, healing process, time to union (radiographic), complications. results: forty-eight patients ( m, f; mean age , y) with hypertrophic (primary surgery: x nail, x external fixator) and atrophic nonunions of the tibia (primary surgery: x nail, x plate, x screws and x external fixator) were included in the study. fifteen tibial nonunions had been primary treated in our department, patients had been admitted from other hospitals. seventy-three% of all nonunions were located at the distal third of the tibia ( % at the diaphyseal-metaphyseal junction, ao-classification type ; % at the pilon, ao-classification type ). seventy-five% of the dia-metaphyseal fractures and % of the pilon fractures were primary treated with an intramedullary nail. the mean time between injury and nonunion-surgery was , ( - ) months. follow up: / patients ( %) for an average time period of , months; union-rate: / (hypertrophic nonunions / ; atrophic nonunions / : re-nonunions each). complications: death by lung embolism, re-nonunion (united after second surgery), implant (plate) loosening with the need of reosteosynthesis, x varus malalignment, x valgus malalignment, x peroneal nerve lesion. conclusion: especially the distal third of the tibia still represents a high risk area for nonunions. impaired perfusion, thin soft tissue coverage, as well as the rising number of nailing even of distal tibial fractures are some of the causes. we think that the herein introduced treatment concept is effective to manage tibial nonunions. thus, the union-rate in this study population was % , . an adequate primary osteosynthesis as well as the prevention of extensive soft tissue damage during surgery are mandatory to improve the outcome of tibial fractures. besides, new therapy options as e.g. the application of growth factors and ultrasound have to be considered also for the treatment of tibial nonunions. g. heinrichs , a. p. schulz , e. wilde , r. oheim , c. jü rgens trauma&orthopedics, university lü beck, lü beck, germany, trauma&orthopaedics, university lü beck, lü beck, germany, trauma + orthopaedics, university lü beck, lü beck, germany, trauma&orthopedics, university lü beck, hamburg, germanyintroduction: high energy tibial head fractures with bicondylar involvement have a much poorer outcome compared to the other forms of tibial head fracture. soft tissues are almost allways compromised. bilateral plating carries the risk of soft tissue and bone infections. due to loss of reduction, steps or gaps might remain in the joint surfaces. aim of this study was to evaluate the clinical and radiological outcome of schatzker , and six type fractures treated with locked osteosynthesis plating. material and methods: between january und january we treated patients suffering from a tibial head fracture. in cases osteosynthesis was performed with the use of an angular stable implant, this group forms the study population. indication for locked screw plates were bicondylar fractures treated unilateral to avoid bilateral approach with double-plate osteosynthesis and tibial head fractures with a shaft involvement (schatzker ). follow-up was performed after an average of . months after surgery. we treated male and female patients with an average of . years of age ( to years). there were no patients with open fractures or primary nerve injury included in this study. operative treatment was performed after an average of . days after trauma. we used an angular stable plate fixator made from pure titanium (tifixÒ, litos, hamburg/ germany). the plate is consisting of the softer titanium grade ; the screws are made from harder titanium grade .results: there was one case of a postoperative peroneal nerve lesion with spontaneous regression after two weeks. no postoperative wound necrosis or infection occured. all patients showed bony consolidation after a mean of . weeks as judged by radiographs. additional autologous bone transplantation was not necessary. we did not observe any secondary loss of reduction or loosening of the internal plate fixator when comparing direct postoperative radiographs to those at follow up. rom of the knee did not show any restriction compared to the opposite side in patients. cases showed mild and cases a remarkable restriction of rom compared to the not injured side.applying the rasmussen score, cases achieved a good and very good result. patients had to be judged as moderate and as poor conclusion: unilateral plate fixation for the treatment of bicondylar tibial head fractures seems to offer advantages in particular concerning infection rate and implant failure in the treatment of tibial head fractures. results: the adjacent level th-l fracture was found in . % ( / patients) in kyphoplasty group and in % ( / patients) in vertebroplasty group. we did not found any serious complication but established postoperative bmd loss. we did not found any intradiscal cement leakage in cases with adjacent level fractures. intraoperative correction of kyphosis was better achieved in kyphoplasty group; pain relief was similar in both groups.conclusion: natural process of further bone loss seems to be the most influent factor for future compression fractures in elderly patients. trauma patients represent a challenge in terms of obtaining informed consent as they are often in significant pain and maybe under the influence of strong medication at the time of the consent process. we designed a prospective, randomised un-blinded control study to test the hypothesis that there would be no difference in the ability of trauma patients to recall details of the consent process whether the patients were given verbal compared with verbal and written information.material and methods: a consecutive cohort of trauma patients presenting to a major teaching hospital were recruited and randomised into two groups. group a received structured verbal information only. group b received structured verbal information and written information about the proposed procedure. all patients were interviewed within the first post operative week (mean . days) and scored on their ability to recall key facts given in the original consent interview. results were analysed using the mann-whitney u test.results: patients have been recruited. information recall was significantly improved in the group receiving written information (mean questionnaire score % vs % for verbal information alone, p= . ). patient satisfaction with the consent process was also significantly improved in the group receiving written and verbal information, with . % of patients reporting they understood the risks of surgery when they signed the consent form, compared to . % who received verbal information alone (p= . ).conclusion: written information improves patient recall of the consent process. it is a simple, cost-effective intervention with high patient acceptability. introduction: survivorship of second hip fracture patients is worse than initial hip fracture patients. however, previous studies included in-hospital mortality. the actual survivorship of initial hip fracture patients with subsequent second hip or major long bone of extremity or vertebral body fracture by exclusion of in-hospital mortality patients have not been studied. we aim to compare the actual survival of initial hip fracture patients with and without second hip or subsequent major fracture. in addition, risk factors, mortality causes, and hazards ratio of each fracture groups were studied. material and methods: in - , after exclusion of in-hospital mortality patients, initial hip fracture patients were reviewed and divided into four groups. group i, ii, iii, and iv were initial hip fracture patients with second hip, subsequent major long bone of extremity, vertebral body fracture, and without any subsequent fractures, respectively. we set group i, ii, and iii as study groups comparing the data with group iv (control group). age, gender, mobility-status, co-morbidity, causes of death, and survival years after hospitalization of last fracture treatment of each group were recorded. actual survival rate and risk factors difference between initial hip fracture with and without subsequent fracture were analyzed by chi-square test. hazards ratio differences among the groups were analyzed by cox regression models.results: there were ( . %), ( . %), ( . %), and ( . %) subjects in group i, ii, iii, and iv respectively. at one-year and one-to-five year mortality of group i were . % and . %, group ii were . % and . %, group iii were . % and . %, and group iv were . % and . % respectively. statistical analysis by using chi square test of one-year mortality and one-to-five year mortality rate showed no significant difference among four groups (p > . ). but from cox regression analysis, second hip fracture produced significant hazards ratio as . (p = . ). the actual survivorship of initial hip fracture patients with second hip or other subsequent fracture were not different from patients who have only one hip fracture. however, special care should be focused in patients with second hip fracture which produced significantly highest hazards ratio for mortality.reduction or redislocation after one week of treatment. due to the lack of sufficient patient data a statistical analysis was not carried out. it was obvious that the dorsal dislocation after reduction was worse in the dorsiflexion group. there was no obvious difference in radial inclination or functional outcome between the two groups. conclusion: mainly the dorsal inclination was worse in the degrees dorsiflexion group. a possible explanation for these results is the technique used when modeling the plaster cast. in our hands immobilization in dorsiflexion yielded poorer results then immobilization in a neutral position. due to the poor results the study was terminated prematurely. the traumatic patellar luxation in adult patients is operatively treated with medial reefing and lateral release. the value for the treatment of adolescents is still discussed controversially in literature. the aim of the present study was to evaluate the efficacy of the minimal-invasive treatment of traumatic patellar luxation in adolescents. , that was treated with acute angular shortening using a monolateral ao fixator followed by gradual correction using the taylor spatial frame (tsf). the conversion in the tsf was achieved in exchanging only two half-pins. results: the deformity was anatomically corrected without any soft tissue complications. the fixator was worn for weeks under full weight bearing while the actual correction took only days. we did not see any typical external fixator complications like pin trac infection. conclusion: acute angular shortening can lead to direct soft tissue closure without any additional plastic surgery. the accuracy the the fixator allows the gradual anatomical reduction of the fracture and simplifies the correction of the mostly multiplanar deformities. when the surgeon is familiar with the tsf even a primary treatment of such fractures could be recommended. the image control (plain x-rays, ct) revealed and definitively determined whether a two-part or three part triplane fracture in the distal tibial physis were present, the amount of the displacement, and the co-existed fracture of the fibula. the principal goal must be the anatomical reduction of the fracture initially closed and in failure opened. an open reduction and fixation with steinmann via anterior approach followed. a long-leg cast worn for initial weeks, followed by a short-leg cast for weeks. results: at a minimum of fourteen months of clinical follow -up all patients lacked complaints and had full range of motion in ankle.conclusion: these injuries occur in the adolescent age group generally slightly younger than the child with a tillaux fracture, needed good image control (ct) and must reduced anatomically and fixed. disclosure: no significant relationships. it is necessary in - % of patients. to provide dynamisation using conventional methods, it is necessary to perform one additional surgery. in this presentation it is shown one new method of selfdynamisation. material and methods: it is presented one new minimally invasive method for closed fracture reduction and one extramedullary selfdynamisable internal fixator. there is no contact between bone and internal fixator in fracture area. it has been widely investigated biomechanicaly. in clinical use it has been applied to , patients in treatment of femoral fractures. the age of patients was from to years. this internal fixator is applied by two small incisions. reduction is achieved using standard traction table or using special reduction device. this reduction device provides possibility of reduction with minimal using of fluoroscopy or even, after more experience without using of any imaging technique as fluoroscopy, ultrasound or computer navigation. results: received clinical results are promising, as it has been shown early callus formation and radiological union within the - months. it has been allowed to patients early full weight bearing. during the treatment it has been confirmed working of self-dynamisation concept (in % of patients), which probably all together with d configuration resulted in unexpectedly quick fracture healing. follow up was months ( - the severity of injury was measured by the injury severity score (iss). the outcomes for categorical variables were tested using v test and a significance level at p < . was maintained. delayed complications were defined as any complication directly attributable to the splenic injury that occurred more than hours after injury. the following data was retained: age, sex, mechanism of injury, iss, number of icu days, overall length of stay, number of blood units transfused, day of operation and discharge status. results: our study found , % incidence of delayed complications after nom. these complications include delayed hemorrhage ( cases), splenic artery pseudoaneurysm ( ) and splenic abscess ( case). the need for operation due to ongoing bleeding was retained in following situations: more than u of blood to maintain a hb higher than g/dl, systolic pressure to less than mm hg despite resuscitation and evidence of peritoneal signs. of the patients failing nom, % failed between days and and % in the first week. in all cases a splenectomy is performed with no mortality rate. the results of this study indicate independent risk factors of failure of nom: a high ct grade of splenic injury (grade iii and above) and a transfusion with more than u of blood. results: results : out of the patients suffering of liver injuries patients had grade , and grade liver injuries and were treated conservatively. patients had grade and liver injuries and were operated. patient who was initially managed conservatively was operated due to inability to control the blood loss. out of the patients suffering injuries of the spleen, were grade and grade and were successfully operated and were grade and and were treated conservatively. all patients suffering of injuries of the retroperitoneal space, unilateral kidney injuries and injuries of the hypogastrium were managed conservatively. conclusion: blunt abdominal injuries can be managed successfully and safely by conservative treatment whenever it is allowed by the circumstances. the ct scan is a very sensitive diagnostic scanning, capable of diagnosing intrabdominal haemorrhages retroperitoneal lesions as well as the extent of the organ injury and is a necessary tool for the physician in order to diagnose accurately any abdominal injury. disclosure: no significant relationships. introduction: more and more hepatic injuries are treated non operatively if the hemodinamic's and lesion's stability is confirmed. the count and the scaling of lesions doesn't directly influence surgical indications. we report about cases of blunt trauma with serious hepatic and renal lesions treated successfully with a non operative management material and methods: we treated liver and renal injury associated in a period from to . patients were admitted to tor vergata -roma and hospital universitario clínico san carlos-madrid. data collected were: age, sex, comorbidities, sequence of events, type and number of associated lesions, management, morbidity and mortality. all liver and renal organ's injuries were evaluated by abdominal ct scan with contrast and classified according to ct-based scale results: middle age was ± sd years. patient were male in ( , %) of cases. ct scale of liver lesion was °for ( , %) patient and °for two ( . %) patients. renal lesions were i°category in cases ( , %) and ii°category in patient. no ureteral or major vessels rupture were founded. all patients have been treated non operatively. a ct based follow up of lesions was planned (at admittance, after hours, after a week and after a month). the mean length of hospitalization was ± sd days. during hospitalization, patients were monitored by clinic and labs daily. all patients were dismissed in good conditions and are in in health on a months follow up. at ct follow up, one patient presented an intra-hepatic biloma, that was successfully treated with ct-guided drainage conclusion: this work support the hypothesis that the association of liver and renal lesions in a blunt abdominal trauma, doesn't necessarily influences indications for an explorative laparotomy. if an ureteral rupture is suspected, a more aggressive treatment is necessary, in order to prevent peritonitisintroduction: the aim of this study is to analyze the most frequent mechanisms of injury, the evaluation in the emergency department and the period of increase of the blunt abdominal trauma incidence. material and methods: during the last years ( - ) patients were admitted to our department for blunt abdominal trauma.the most frequent mechanisms of injury were: traffic accidents (automobile crashes and motor vehicle collisions) ( , %) work accidents ( , %) . others (fall from high altitude, beating) ( , %) we analyzed the most frequent injuries observed, the final treatment for these patients and the period of increase of blunt abdominal trauma.results: the peak incidence occurs in persons aged - years. the male/female ratio was : . the most frequent abdominal injuries regarded: spleen ( , %), liver ( , %), large bowel ( , %), small bowel ( %), pancreas ( , %). patients underwent surgical treatment ( , %). the incidence of missed injuries is quite low, one case with pancreatic injury and one with small bowel injury. during summer period a significant increase in blunt abdominal trauma incidence occurs because of the increase of population due to tourism. the initial physical examination, after appropriate primary survey and initial resuscitation with the help of diagnostic studies such as ultrasonography, abdominal ct scan, is essential for the final treatment for these patients, operative or not operative. abdomino-throcal injuries were found in ( %) patients.abdominal organ injuries were found in decreasing frequencies in small bowel( %),liver ( %),large bowel ( %), spleen ( %), major vasculer, stomach and others. thoracal injuries were found in lung and heart in and cases.one organ injury was found in ( %) patients,mostly small bowel,and these group had a good haemodynamic status.thirty-two( %) patients had two organ injuries which of them associated with lung injury.three, and < organ injuries were found in , and patients. haemodynamic unstability at presentation,and shock was found in five patients( , and organ injury in , and cases). the overall mortality was found in ( %) patients.mortality from gun injury was % from major vascular injury ,lung,pancreas and large bowel ,lung and large bowel one.mortality from penetrating trauma was % from lung and multipl abdominal organ injury ,heart ,lung,spleen and stomach injury and major vasculer injury from blunt trauma in one ( %) patient. five patients who remain haemodynamically unstable after resuscitation died intraopreoperative period.these group was not received some resuscitation, and they referred to our hospital later than hours of injury. introduction: retroperitoneal location of the pancreas makes the diagnostic of any traumatism to be difficult, especially when this is not suspected. we report on a case of blunt pancreatic trauma with months delayed diagnosis, after injury due to maneuvers in a difficult birth. material and methods: we report on a case of a twenty-nine year-old female who consulted at the emergency department for constant right upper quadrant pain that didn't ease with any analgesic prescribed by the general practitioner. these symptoms started after a birth six months before and loss of kg of weight was associated. after reviewing the previous history of the patient, the birth had been difficult and forceps, suction pad and repeated abdominal pressure maneuvers were needed. abdominal examination showed a painful non-pulsatile mass located at epigastrium and both right and left upper quadrants. abdominal ultrasonography and enhanced ctscan were performed and demonstrated the presence of multicystic x x cm mass located between the stomach, spleen and left kidney. the high density content seemed to be blood. the mass was pushing the stomach anteriorly and no communication between both of them was shown. the splenic vein was pushed superiorly and thinned and plenty collateral circulation was evidenced. the tail and the body of the pancreas were not identified in any of the studies. the first choice diagnosis was posttraumatic complicated (with bleeding) pancreatic pseudocyst. the patient underwent emergency operation and a big cystic pancreatic mass was encountered, with plenty of collateral circulation. intraoperative biopsy confirmed that it was a pseudocyst and therefore, the majority of the cyst was removed and roux-en-y pancreatojejunostomy was performed. cholecistectomy was also done. introduction: unnoticed traumatic injuries produce avoidable morbidity, mortality and a higher medical cost. we present a special case of the reconstruction of a catastrophic abdomen with several intestinal fistulae and giant abdominal wall defect. material and methods: we present the case of a year old woman with blunt thoraco-abdominal trauma secondary to a road traffic accident. several lower left rib fractures, a fast echo with free fluid without solid organ injury and fractures of l and l were seen in the initial assessment. on the third day surgery was required due to septic shock with diffuse peritonitis due to a jejunal laceration and section of the body-tail of the pancreas. simple suture of the jejunal laceration, distal pancreatectomy, and abdominal packing without closure of the abdomen was performed. she developed several intestinal and colonic fistulae. over surgical procedures were performed on her and she was discharged months later with night parenteral nutrition, a closed abdomen by secondary intention and intestinal fistulae. she was readmitted a year later for reconstruction. we performed monoblock resection of the abdominal wall and the fistulized loops, subtotal colectomy and bowel transit reconstruction with three enteroenteric and an ileosigmoid anastomosis, leaving , m of small bowel. abdominal plastia with permacol mesh was also performed. results: surgical time was of minutes and oral tolerance was initiated on the th postoperative day. she was discharged on the th day postop. the only complication was a fever secondary to infection a central venous catheter on the rd day. key: cord- -a qz tb authors: nan title: th annual meeting of the austrian society of surgery, graz, june – , date: journal: eur surg doi: . /s - - - sha: doc_id: cord_uid: a qz tb nan background. aortic valve replacement (avr) in the elderly with significant co-morbidities is associated with increased operative risk. trans-apical catheter based avr is being evaluated in a phase study. we report the initial results of the first generation equine pericardial cribrier- edwardsvalve. methods. access is through a small antero-lateral thoracotomy with direct puncture of the apex. after initial balloon valvuloplasty the ascendra delivery system is used to position the balloon mounted crimped bioprosthesis under fluoroscopic and transesophageal echo guidance in the native aortic annulus. results. high risk patients (log euroscore . ae , female and male) with a mean age of ae . years were operated. valve positioning was successful in pts (valve size in pts and size in pts) and were converted to full sternotomy and conventional valve replacement performed. deployment time was . ae . min. delivery was achieved without cardiopulmonary bypass in % of patients. however in pts cpb became necessary to treat bleeding complications. there were deaths within days ( valve related, cardiac, abdominal). operative revision was necessary in patients for bleeding and was related to the apical access in , intercostals artery , lung laceration and was diffuse in . hemodynamic evaluation showed satisfactory results in regard to aortic insufficiency (none: , minimal ) and excellent gradients (peak gradient: . ae . mmhg). conclusions. we conclude from our data that trans-apical aortic valve replacement with the cribrier-edwards bioprosthesis can be performed in high risk patients successfully. cardiopulmonary bypass may be avoided. complications may be attributed to the high risk profile of the elderly population treated in the early learning curve. excellent imaging technology in the operating room and excellent collaboration between surgeons and cardiologist as well as anesthetists appears crucial for the successful implementation of this new treatment modality. aortic valve replacement through partial upper sternotomy: a safe alternative to full sternotomy erate to good left ventricular function and without any previous cardiac surgery at our institution. we reviewed retrospectively data on patients ( males, females) who underwent avr through a partial upper sternotomy between and . mean age was . ( - ) years. mean logistic euroscore and mean peak transvalvular gradient were . ( . - . ) and . ( - ) mmhg, respectively. results. mean cross clamp time, mean bypass time and mean operation time were . ( - ) min; . ( - ) min and . ( - ) min, respectively. in patients ( . %) a conversion into full median sternotomy was necessary. patients ( . %) had to be reexplorated due to bleeding. the mean intraoperative and postoperative red blood cell transfusions were . and . , respectively. deep sternum infection occurred in patients ( . %) . mean icu and total hospital stay were . and . days, respectively. there were hospital deaths giving a perioperative mortality of . %. conclusions. avr through a partial upper sternotomy is a safe and effective technique with a similar perioperative morbidity and mortality to conventional aortic valve surgery showing superior cosmetic results. state-of-the-art : mitral valve repairminimally invasive or median sternotomy? background. more than ten years have passed since minimally invasive mitral valve surgery employing different access and different techniques has been introduced. in spite of obvious advantages acceptance by cardiac surgeons is generally low. to define its current position in clinical practice the development of our program, actual indications and results are presented. methods. minimally invasive and conventional mitral valve procedures from to were documented prospectively. indications for the minimally invasive vs. conventional approach through median sternotomy are compared. results. seventy-five patients had minimally invasive mitral valve surgery through a cm minithoracotomy. carpentier type i, ii and iiia lesions involving the posterior, anterior or both mitral leaflets were treted using carpentier repair techniques. combined procedures of the tricuspid valve, asd and modified maze operations were performed in % of cases, patients had prosthetic mitral valve replacement. patient died at home on postoperative day from unknown causes. functional results: residual mi grade : %, grade i: %, grades i-ii: . %, grade ii: . %, grade iii or iv: . reoperations after months: . in in our department % of all mitral valve repairs needing no concomitant cabg or aortic valve operations were performed minimally invasive. conclusions. more than % of mitral valve repairs can be performed minimally invasive with excellent results. as the procedure is superior concerning cosmesis, the procedure is favored by patients and referring cardiologists. at this time disadvantages are neither proven nor suspected, advantages concerning surgical complications and rehabilitation are assumed. insights from cases of remote access perfusion for minimal invasive cardiac surgery n. bonaros , t. schachner , a. Ö hlinger , o. bernecker , g. feuchtner , g. laufer , j. bonatti background. remote access perfusion (rap) is a prerequisite for performance of minimal invasive cardiac surgery on the arrested heart. during implementation several technical challenges may be encountered. in this study we assess the incidence and the influence of these challenges on the perioperative outcome and we describe clinical results in a large patients' series. methods. we retrospectively analyzed patients who underwent minimal invasive cardiac surgery (totally endoscopic coronary artery bypass grafting: , endoscopic atrial septal defect repair: , totally endoscopic mitral valve repair: ) using rap (estech: , heartport: ). intra-and postoperative parameters were analyzed according to the occurrence or not of technical challenges attributed to remote access perfusion. results. we observed no perioperative mortality and no severe complications in this patients' series. technical problems occurred in patients ( %). three patients ( %) underwent conversion to other operative method as severely atherosclerotic peripheral vessels did not allow positioning of the balloon in the ascending aorta. another patients required an additional arterial cannula in the contralateral femoral artery to ensure adequate perfusion. balloon migrations occurred in patients ( %). in cases was a cannula replacement required ( %), in four of which due to balloon rupture. in patients ( %) positioning of the balloon in the ascending aorta required the use of fluoroscopy, as this was not possible under echocardiographical guidance. patients with technical difficulties (group ) had no worse outcome than those in whom no rap-associated problems occured (group ) with the exception of longer total operative time (group : ae min group : ae min, p ¼ . ). ventilation time, intensive care unit stay and hospital stay were all similar in the study groups (p ¼ ns). a comparison between the two cannula types showed only a higher balloon pressure needed for positioning of the estech cannula vs the heartport system ( ae vs. ae , p < . ) although comparable injection volumes were used. conclusions. we conclude that technical difficulties are not rare during rap but in most of the cases can be easily managed at the cost of increased operative time. the postoperative outcome is not compromized provided that major complications are avoided. neoangiogenesis after combined transplantation of skeletal myoblasts and angiopoietic progenitors leads to increased cell engraftment and lower apoptosis rates in ischemic heart failure background. we report on a modified minimally invasive and cosmetic approach of surgical repair of atrial septal defects (asd) i with emphasis on infant patients weighing below kg. methods. from august to july , patients underwent this procedure (mmit-modified minimally invasive technique). the heart was exposed by a limited midline skin incision and partial sternotomy (newly developed sternal spreader, fa. fehling, germany), and the atrial septal defect was closed through a right atriotomy using special new aortic and dual venous cannuals. basic results were matched to those obtained from patients (st-standard technique) . results. atrial morphology was more complex in mmit pts ( overriding svcs, sinus venosus defects), nevertheless op times were accurate and similar to st pts. early extubation was forced and made possible by fast-track methods. totally, asds were directly closed, pts had patch repair. postoperatively we observed mild postpericardectomy syndroms, cholecystitis and pneumothorax requiring drainage in st pts, only pt with mild pericardial effusion was found in mmit group. retention of pericardial effusions was not a risk factor and hospital stay was also not prolonged. conclusions. this approach achieves a cosmetically superior result with newly developed but standard instrumentation and cardiopulmonary bypass techniques, without compromising exposure or using peripheral incisions even in dysmorphic, low weight congenital patients. mmit (pts) . clinical data and follow-up were collected prospectively and analyzed retrospectively. statistical data are shown as mean values and standard deviation. in larger tumors a preoperative interventional embolization was performed. postoperatively pts were seen as outpatients once per year including ultrasound control. results. of the pts with a mean age of . þ . years there were female and male pts. in pts the unilateral tumor was located on the right side, in pts on the left side. at time of diagnosis pts ( = pts ¼ %) presented with bilateral paraganglioma. histological analysis showed benign paraganglioma in pts and malignant paraganglioma in pt. after a follow-up of to months (mean: . þ . months) pts were alive and well whereas pts were lost to follow-up. duplex ultrasound gave no evidence for recurrence of npg in pts. the patient with the malignant tumor is alive and free of recurrence after years and months. the most recent patient with bilateral paraganglioma tested positive for sdh-d mutation. two brothers and sister of this patient were diagnosed with phaeochromocytoma. conclusions. more female patients were affected than male pts. in male patients there was a higher incidence of bilateral paraganglioma of the neck. long-term survival in patients after surgical removal of neck paraganglioma appears not limited. because of the possibility to identify mutations in the sdhgene (sdhd, sdhb, sdhc) further testing of patients with bilateral paraganglioma is mandatory. screening for phaechromocytoma in these pts and evaluation of patients' families is recommended. background. endarterectomy remains the treatment of choice for ica stenosis. one major complication of surgery is cni ( - %) , encouraging transfemoral stent placement for ica stenosis. the aim of this study is to evaluate a possible reduction of this complication by the use of eversion endarterectomy (eea) compared to standard patch endarterectomy. methods. prospective study design in patients treated at a tertiary university based care center. consecutive patients were enrolled into the study. age (median years, range - years), sex (male , female ), medical risk factors (smoking %, hypertension %, diabetes mellitus %) and indication for surgery (asymptomatic stenosis %) were equally distrtributed among both groups ( patients each). all patients were evaluated pre-and postoperatively for cni by an independent neurologist and ent specialist blinded for the operative procedure. results. one patient in the conventional group suffered patch rupture with consecutive stroke days postoperatively. two patients in the conventional group developed cni ( recurrent larygeal and facial nerve deficit, hypoglossal and glossopharygeal nerve deficit). after months of follow up the latter patient showed spontaneous resolution of cranial nerve symptoms. no patient developed cni after eea. conclusions. cni has been detected in % after endarterectomy of the ica in our series. symptoms of cni may be transient, but are disturbing if no clinical improvement is observed. eea requires less operative dissection in the neck compared to standard patch endarterectomy, and therefore seems to be favourable technique with regard to cni development. eea has the potential to curb the current trend toward application of endovascular surgery for ica stenosis. background. total occlusion or stenosis of the common carotid artery is rare and the indications and techniques of surgical treatment are still a matter of controversy. we demonstrate the feasibility of retrograde common carotid endarterectomy. methods. retrospective case report study. participants. in a period of fifteen years thirty-nine patients underwent retrograde endarterectomy of the common carotid artery. twenty-nine patients were males, middle age (min , max ). ten patients were females, middle age (min , max ). symptoms of brain ischemia were present in fifteen patients. retrograde endarterectomy of the common carotid artery and endarterectomy of the internal carotid artery were done together in all patients. indication for retrograde tea was a verified stenosis > % or occlusion of the common carotid artery diagnosed by duplex ultrasound and arteriography. in three patients iatrogenically dissection of the common carotid artery was seen as indication for that procedure. main measurements. postoperative early mortality, stroke rate, medium and long-term endarterectomy patency. results. in all patients who underwent that procedure there was no occurence of major complications or statistically increased mortality. the day mortality was . % ( patients). one of them died in cause of a heart attack and one because of a cerebral bleeding. there was one ipsilateral stroke ( . %) eight month after the procedure. three patients were lost to follow-up. mean follow-up was months ( to ). there were ( . %) late deaths caused by cardiovascular related problems, pneumonia and cancer. in all living patients, controlled by duplex ultrasound, no occlusion or stenosis was found. conclusions. retrograde tea can be done through only one cervical incision for common carotid artery stenosis= occlusion, for tandem lesions of the carotid arteries as well as for iatrogenic dissections of the common carotid artery. compaired to bypass grafting this technique is a faster and easier method. our retrospective study indicates a long-term patency and freedom from neurologic events. stenosis and occlusion of the proximal subclavian artery -surgical or interventional treatment? an analysis of our own patients and international studies m. tomka, a. baumann, p. konstantiniuk, t. ott, t. cohnert division of vascular surgery, department of surgery, medical university of graz, graz, austria background. seventeen percent of all supraaortic occlusions concern subclavian artery, but only % of them fulfil the clinical and angiographic qualification of steal syndrome. methods. since patients with stenosis or occlusion of the proximal subclavian artery were treated on our department. patients underwent end-to-side transposition of the subclavian into the common carotid artery; a carotid-subclavian bypass using synthetic grafts was applied to patients. surgical treatment and evaluation, complications, short and long term patency of our patients were compared to interventional techniques and international literature. results. the primary success rate of both operative techniques achieved %. -days mortality was %, -days morbidity % ( = ) in the transposition group and . % ( = ) in the bypass-group respectively. median follow-up time was months in the transposition-group vs. months in the bypass-group. only in the latter one late occlusion ( . %) was seen. conclusions. our data show a slight (not significant) favour for the transposition, which is consistent with results from other studies. concerning long term patency and infection rates the transposition of the subclavian into the common carotid artery by single incision is to be recommended first choice of treatment. avoiding synthetic grafts leads to optimal compliance. flow in natural direction and less mortality and morbidity rate are ensured. critical, because preoperative ef is predictive for long-term survival. here, we report results from a genomic study in patients with as in compensated and decompensated state and present candidate genes that could be predictive for the progression of heart failure. methods. biopsies from the lv septum of male patients (  a ae yrs) with isolated as undergoing biologic aortic valve replacement (carpentier edwards magna a + ) were harvested either from hearts with normal ef (> %, n ¼ ) or from a group with low ef ( %, n ¼ ) and served as controls. total rna was analyzed on affymetrix hg-u a genechips, which allowed to measure expression levels of more than . human gene transcripts. low level expression analysis was performed using the gc-rma algorithm and statistical significance analysis was done by bayesian t-test. class prediction was performed using the brb arraytools package (nci). results. expression levels clearly distinguished as from cad. annotation of these transcripts revealed a close correlation with the hypertrophic response and progressive fibrosis. these targets completely reflected the current understanding of key processes involved in heart failure. within a list of several ( ) as classifier genes that revealed well-known markers such as the natriuretic peptide precursors a and b and troponin i, we identified: ( ) the connective tissue growth factor ( vs. ; p < . ), known to be triggered by mechanical stress in fibroblasts; ( ) periostin ( vs. , p ¼ . ), an important matricellular component recently shown to be responsible for ventricular dilation. when specifically searching for low ef class predictors, we found potential candidates of unknown function, which were consistently expressed at a higher level only in as with ef < %: ( ) the pom and zp fusion gene ( vs. , p ¼ . ) and ( ) the transcription factor ets variant ( vs. , p ¼ . ). conclusions. in this study we could clearly identify patients with cad from those with as by the help of gene expression profiling. moreover, we were able to identify gene expression signatures that could be predictive for the progression of heart failure. background. despite tremendous advances in immunosuppressive therapy acute rejection still remains a problem following solid organ transplantation. proteome analysis has emerged as a valuable tool for the study of large scale protein expression profiles and biomarker detection. here we applied this novel technology to identify specific biomarkers for acute cardiac allograft rejection. methods. cardiac allografts of c bl= mice were placed into fully mhc-mismatched c h=he recipients. syngeneic transplants served as controls. protein expression analysis was performed using fluorescence two-dimensional difference gel electrophoresis ( d-dige) on day six post transplant. spots of interest were subjected to nanospray ionization tandem mass spectrometry (ms=ms) for protein identification. expression of selected proteins was confirmed by western blot analysis. results. median graft survival of untreated hearts was . ae . days whereas all syngeneic animals showed indefinite graft survival > days. analysis of the d-dige gels revealed a total of protein spots that were significantly regulated by more than . -fold during acute rejection when compared to syngeneic controls. spots with highest altered regulation identified with ms=ms were derived from coronin a, vimentin, protein disulfide isomerase a precursor, skeletal muscle lim-protein , aconitate hydratase, and fumarate hydratase. peroxiredoxin and pyruvate kinase isozyme m were selected for further analyses. western blotting and immunohistochemistry showed significantly higher expression of these proteins during acute rejection compared to syngeneic grafts. conclusions. this study demonstrates that proteomics is a powerful method to detect biomarkers of acute cardiac allograft rejection. identified proteins like peroxiredoxin and pyruvate kinase isozyme m represent novel indicators of acute rejection and may become useful surrogate markers for monitoring the alloimmune response. impact of endothelin-a receptor blockade on myocardial gene expression post mi w. dietl , g. mitterer , m. bauer , k. trescher , w. schmidt , b. k. podesser background. despite promising experimental results of endothelin-a (et-a) receptor blockade in treatment of heart failure (hf), clinical trials failed to confirm these findings. in order to elucidate this discrepancy, we decided to evaluate the impact of et blockade on myocardial gene expression (ge) post myocardial infarction (mi). methods. mi was induced in male sprague-dawley rats using lad ligation. three days post mi, rats were randomized to receive either tbc -na or placebo and to survive either or days. sham-operated rats served as control group. prior scarification, rats underwent echocardiography. following excision, hearts were analyzed morphometrically. rna was extracted from non-infarcted areas of the lv. targets for quantification were identified using affymetrix gene chip + technology and subsequently quantified by real time pcr. results. et-a blockade did not influence morphology or hemodynamics on day , while it significantly improved both parameters on day . in contrast, ge analysis revealed that the majority of mi-induced changes in ge occur early after mi, with the majority of genes returning to baseline after days. five days of et-a blockade resulted in an attenuated expression of mi-induced transcripts (e.g. tnc, spp , sparc, mmp ) involved in post-mi remodeling. conclusions. apparently, endothelin receptor blockade influences early post-mi remodeling. this data adds further evidence that timing is crucial in et therapy post mi: administered to early, myocardial wound healing is disturbed and lv function deteriorates. given in time, excessive ventricular remodeling is attenuated and lv function improves. identification of sex-specific targets in experimental heart failure m. bauer , g. mitterer , w. dietl , k. trescher , w. m. schmidt , b. k. podesser background. sex-specific differences have been reported in ischemic heart failure. the aim of the present study was to screen for diferentially expressed genes in experimental ischemic heart-failure using genechip + technology. methods. mi was induced in male (n ¼ ) and female (n ¼ ) sprague-dawley rats by ligation of the lad. and days post-mi, surviving animals were sacrificed and samples of the non infarcted free wall gained to perform transcription analysis. sham-operated males (n ¼ ) and females (n ¼ ) served as control. extracted rna of animals per group was pooled and affimetrix genechip + technology was used to screen for differentially expressed targets. genechips + were analyzed using the mas . algorithm and the following rules employed comparing mi vs. corresponding sham to identify sex-specific targets: ) increase in expression in one sex and a decrease in the other, ) increase in expression one sex and absent in the other, ) decrease in expression one sex and present in the other. results. our strategy revealed targets differentially expressed. of these targets were expressed differentially on day only, on day , only one target was expressed differentially on both and days post-mi. of this targets were selected for further analysis including: keratins, caspase- , aldehydoxidase- , cdkn- a and triadin and will be evaluated using rt-pcr. conclusions. ) there are sex-specific targets in post-mi gene expression. ) this targets can be identified using gene-chip as screening tool. bilirubin rinse suppresses early mapk activation in cardiac ischemia-reperfusion injury r. Ö llinger , p. kogler , f. bösch , c. koidl , r. sucher , m. thomas , j. troppmair , f. bach , r. margreiter background. heme oxygenase- (ho- ) expression is crucial in preventing ischemia reperfusion injury (iri). bilirubin, a product of heme catabolism by ho- at least in part accounts for the protective effects mediated by ho- , however, the mechanisms by which bilirubin mediates these effects remain to be elucidated and strategies to apply the bile pigment are needed. mitogen activated protein kinases (mapk) are activated upon stress and play an important role in the early phase of iri. we hypothesized that in a mouse model of heart transplantation, a brief rinse with bilirubin of the graft before reperfusion would affect mapk activation. methods. isogenic c bl= hearts (n ¼ =group and time point) were harvested, stored in uw solution at degrees for h and then rinsed with bilirubin at . mm or ringer lactctate as a control before anastomosis. anastomosis time was kept constant at min by using a cuff-technique, subsequently thereafter perfusion was restored. samples were collected at various times. western blot analysis was carried out for total (t) and phosphorylated (p) forms of akt, erk = , jnk = and p mapk. p=t ratio was quantified by imagej and statistically analyzed using anova. results. after anastomosis and before any reperfusion phosphorylation of erk and p mapk was increased when compared to h of ischemia allone. this was not seen when grafts were rinsed with bilirubin. further, at min after reperfusion, phosphorylation of all mapks being investigated was dramatically increased when compared to the non-reperfused isografts. at this time point, bilirubin significantly inhibited phosphorylation of erk and jnk (p < . ) as well as p -mapk and akt (p < . ). conclusions. bilirubin rinse of mouse cardiac isografts causes a dramatic decrease of mapk activation associated with the proinflammatory response to the stress of iri. bilirubin rinse of allografts before implantation might be a potent aproach to avoid early organ dysfunction. improvement of myocardial protection by a selective endothelin-a receptor antagonist added to cardioplegia in failing hearts background. ischemia=reperfusion (i=r) injury due to cardioplegic arrest is a problem in patients with reduced lv function. we investigated the effect of chronic versus acute administration of the selective endothelin-a receptor antagonist tbc- na during i=r in failing hearts. methods. male sprague-dawley rats underwent coronary ligation. three days post infarction group (n ¼ ) was administered tbc- na continuously with their drinking water, groups and received placebo. seven weeks post infarction hearts were evaluated on a blood perfused working heart during ischemia and reperfusion. in group (n ¼ ) tbc- na and in group placebo was added to cardioplegia during ischemia. results. at similar infarct size postischemic recovery of cardiac output (group : ae %, group : ae % vs. placebo: ae %; p < . ) and external heart work (group : ae %, group : ae % vs. placebo: ae %, p < . ) group was significantly enhanced in both tbc- na treated groups while recovery of coronary flow was only improved in group (group : ae % vs. group : ae %, placebo: ae %, p < . ). evaluation of blood gas measurements showed enhanced myocardial oxygen delivery and consumption with acute tbc- na therapy. in addition high energy phos-phates were significantly higher and transmission electron microscopy revealed less ultrastructural damage only under acute tbc- na administration. conclusions. acute endothelin-a receptor blockade is superior to chronic blockade in attenuating i=r injury in failing hearts. ultrastructural and biochemical evaluation indicate an improvement in capillary perfusion by acute tbc- na administration during reperfusion resulting in a better cardiac function post ischemia. therefore acute andothelin-a receptor blockade might be an interesting option for patients with heart failure undergoing cardiac surgery. background. except in inguinal hernia with strong fascia, treatment of these hernias requires a reinforcement of the inguinal wall. different methods have been established based on different approaches and different degree of reinforcement: partially (lichtenstein, rutkow=robbins) or totally (rives, stoppa, wantz, tipp, tep, tapp) . in danish and swedish hernia register a surprisingly high number of female (especially femoral) recurrencies were found emphasizing the problem, as mainly lichtenstein procedure was performed. increasing knowledge of reasons of fascial insufficiency give further hints towards using a total reinforcement of the inguinal region. among these procedures the transinguinal preperitoneal hernioplasty with a memory-ring armed polyprolylene patch (polysoft patch tm ) is new and promising. methods. between . . and . . inguinal hernias in patients have been treated by tipp with polysoft patch tm ( bassum-suhlingen, idstein). operation and patient data were recorded prospective. we operated male and female hernias. after - month patients were interviewed with a standard questionaire. = patients ( . %) answered. results. medial, lateral, combined and femoral hernias were done. = recurrent hernias ( . %), = incarcerated hernias ( . %). intraoperative complications: = ( . %). postoperative complications have been bleedings, infection, wound dissections. haematomas= seromas we have seen preperitoneal in cases, subcutaneous in cases. re-operations and punctions have been performed. a hydrocele has been seen in = cases, an ileoinguinal syndrome we have noted in cases (no resection has been performed). under intention of a preperitoneal repair, patients have got another treatment: lichtenstein, rutkow and shouldice procedures. in = patients ( . %) the positioning of the patch was difficult mainly due to very small or fatty anatomy. longterm results ( year postoperative): . % had some pain or heavy pain, . % had occasional pain and . % had little or some movement problems. there was recurrent femoral hernia ( mm hole with fat; months post op), only one patch has been removed because of strong pain in riding or sitting in low seats. conclusions. tipp is a safe procedure which fulfills the requirement of a total reinforcement of the inguinal wall. the memory-ring armed polypropylene patch covers the inguinal region and makes the procedure easier compared to the predecessors (e.g. wantz). results. there were primary and recurrent hernias. in cases local and in spinal anaesthesia was used. no intraoperative complications occured, all meshes could be placed easily. patient had local pain for weeks. at followup patients were symptom-free, had paresthesia and infra-inguinal swelling. conclusions. parietene mesh is easy and fast to use and gives satisfying early results. since part of the mesh will resorb within year long-term results will have to be awaited. light versus heavy meshes for laparoscopic inguinal hernia repair -a biomechanical study the incidence of recurrence, first of all, has been lowered by a laparoscopic technique. methods. during the last years we have operated on patients for incisional and abdominal wall hernias. results. there were men and women with a mean age of . years. we applied an intraperitoneal onlay meshtechnique (ipom) by a laparoscopic way. twenty-three patients had an abdominal incisional hernia, an umbilical hernia, an epigastric hernia, a trocar-hernia and one patient a spigelian-hernia. the diameter of abdominal wall defects was - cm. in patients a parietex composite-mesh has been used, in a proceed-mesh, in a bard composix-mesh and in one patient two  cm timeshes. mesh-size was  cm to  cm . hernia sacs were left in place, hernia contents, mostly omentum, were replaced into the abdominal cavity. meshes were fixed using endo-clips in patients, tacks in and the salute fixation-system in patients. postoperative follow-up includes a control at week, month and year postoperatively. there were no problems during operation. patients were discharged on the second postoperative day. after a mean follow-up of . months ( - months) two patients have a hernia recurrence, three patients had local pain for one month and one patient had an umbilical infection, which could be managed without the removal of the mesh. conclusions. laparoscopic incisional and abdominal hernia repair has a low incidence of complications and shows a rapid postoperative recovery of patients. long-term follow-up is necessary for evaluation of mesh reactions with regard to infection as well as to adhesion formation with the intestine. background. the fixation of hiatal meshes with perforating devices, such as tacks or sutures, can be associated with potentially life threatening complications [ ] . fibrin sealant (fs, tissucol, baxter biosciences, vienna, austria) is successfully used for atraumatic mesh fixation in inguinal and incisional hernia repair [ , ] . the rationale of this study was to test the potential of fs fixation of hiatal meshes in pigs. methods. in general anaesthesia, domestic pigs were subjected to laparotomy and designated meshes (ti-sure, gfe, nuremberg, germany) were implanted at the hiatus. the titanized polypropylene material was found to be favorable in combination with fs in a previous study [ ] . meshes were sealed with ml of fs, which was applied with a spray system. the observation period was weeks in all animals in order to assess tissue integration after the fs was already degraded. results. all meshes showed excellent integration and no sign of dislocation or perforation into the neighbouring organs. histology was used to confirm. conclusions. fs for hiatal mesh fixation provides a safe and effective alternative to perforating fixation devices in an animal model of repair. background. we aimed to assess the incidence for esophageal, cardiac and gastric cancer. methods. annual incidence data and age adjusted rates for the years to were obtained from statistics austria which operates the nationwide austrian cancer registry. according to icd-o- (international classification of diseases for oncology, third edition), the following categories were considered: esophageal squamous cell carcinoma (c , - ), esophageal adenocarcinoma, (c , - ), cardiac adenocarcinoma (c . , - ) and non cardiac gastric adenocarcinoma (with known and unknown subsite, c . [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] , esophageal and gastric tumors with ill-defined histology and death certificate only (dco)-cases. results. annual incidence of esophageal squamous cell carcinoma increased from cases in to in , peaked in ( cases) towards ( ) , declined towards and cases in and , respectively. from to adenocarcinoma of the esophagus increased fold ( vs. ). the number of unspecified epithelial neoplasms of the esophagus remained stable ( - cases). dco cases, comprising no histological information, were stable from (n ¼ ) to (n ¼ ), decreased until ( cases) and increased in ( cases). from to adenocarcinoma of the cardia increased . fold ( vs. ) and remained rather stable with about cases per year until ; cases were registered. non cardiac gastric adenocarcinomas and gastric adenocarcinomas with ill-defined location decreased . fold ( vs. ) and . fold ( vs. ), respectively. the numbers of histologically unspecified cases of malignant cardia tumors and dco cases remained rather stable (unspecified: in and in ; dco: cases in and cases in ) . gender distribution shows an increase of esophageal squamous cell carcinoma in females (male:female : ¼ . in to : ¼ . in ) and esophageal adenocarcinoma (male: female ratio vs. ; : vs. : ; ratio . vs. . ) and cardiac adenocarcinoma for males ( : vs. : ; ratio . vs. . ) . age adjusted rates per . population of non-cardiac gastric carcinomas decreases for both sexes (data not shown). we observed an increase of esophageal squamous cell carcinoma in females and esophageal and cardiac adenocarcinoma for males and a decrease of non-cardiac gastric carcinomas for both sexes. endoscopic versus open esophageal resection: a prospective case-control study within the learning curve background. esophageal resection for cancer is followed by remarkable morbidity. endoscopic surgery has been established to reduce the physical burden. in our institution endoscopic and open esophageal resection is performed transthoracally (tse) or transmediastinally (lstme) as appropriate. we aimed to compare outcomes of case matched open and minimal access esophageal resection by a case-control analysis. methods. endoscopic minimal access esophageal resection (mae) has been performed since (mae). a retrospective case control study including patients (prospectively collected data) who underwent mae (tse, , lstme, ) has been undertaken with matched (pairs matched for sex, age, tumour type and type of resection) historical open (oe) cases operated between and (transthoracic esophageal resection tte, , transmediastinal esophageal resection tme, ). groups were comparable regarding age, sex distribution, tumour type (as consequence of matching) as well as regarding tumour stage and comorbidities. results. forty patients (males, ; females, ; mean age ae yrs) were included in the study. there were adenocarcinomas and squamous cell cancers. patients had neoadjuvant chemotherapy (fu=cis). duration of surgery, number of resected lymphnodes, duration of intubation, icu stay and hospital stay was vs. min (p ¼ . ), vs. (p ¼ . ), . vs. . days (p ¼ . ), vs. days (p ¼ . ) and . vs. days (p ¼ . ) in the mae and oe group, respectively. due to preexistent anemia = mae patients received erythrocyte substitution preoperatively, = patients of the oe group needed erythrocyte subsitution perioperatively. = and = patients underwent reoperation for a complication in the mae and oe group. overall surgical morbidity was % ( = ) and % ( = ). postoperative pneumonia was observed in = and = among mae and oe patients. conclusions. during the learning curve duration of mae is significantly longer when compared with oe. morbidity was reduced, icu and hospital stay were significantly shorter after mae, regarding duration of postoperative ventilation there was a trend towards mae. oncological quality was comparable between groups with respect to the number of resected lymph nodes. the need for blood substitution and reoperation was higher in open esophageal resection. even during initial establishment mae seems advantageous for the patient in this case-control study. randomised trials are still missing. does the route of gastric pull-up influence the oxygen supply of the anastomosis? background. microcirculation and oxygen supply at the level of oesophagogastric anastomosis following oesophagectomy are among the crucial factors determining anastomotic healing. methods. twenty-nine patients (mean age . yrs) were evaluated during oesophagectomy and on the intensive care unit by inserting a micro-probe (licox) and continuously recording the interstitial po of the tubulated stomach in the anastomotic region. two different surgical procedures were applied: group ( = ) had gastric pull-up via a retrosternal, group ( = ) via an orthotopic route. the interstitial po values were averaged over specific consecutive periods: intraoperatively after ligation of the short gastric vessels, after ligation of the left gastric artery, after forming the conduit and after gastric pull-up. postoperative measurements were recorded during intubation, while breathing oxygen by mask or by nose delivery, respectively and finally while breathing air. results. before ligating the left gastric artery the interstitial po -levels were significantly higher (mean . mmhg) than after ligation (mean . mmhg; p < . ). comparing the retrosternal ( . mmhg) versus the orthotopic pull-up route ( . mmhg) a significant difference (p < . ) in favour of the orthotopic route could be found after gastric pull-up as well as during each postoperative measurement period. no differences could be detected when comparing the various oxygen supply systems. conclusions. these data suggest that the oxygen supply at the anastomosis of the pedicled gastric conduit reaches higher levels after orthotopic than following retrosternal gastric pull-up. p tailored therapy for esophageal cancerpilot study in reported -year survival rates of % in this group. factors identifying this subgroup of responders and selecting optimal drugs for non responders could dramatically enhance treatment efficacy. several studies suggest that mutations in the p gene may induce drug resistance especially for agents whose effect is based on apoptosis induction, like cisplatin. methods. in order to test the hypothesis that the p genotype is predictive for chemotherapy response, a prospective study was conducted. thirty-eight patients with potentially respectable esophageal cancer were evaluated for the relation between p genotype and response to two different neoadjuvant treatments. p gene mutations were assessed by complete direct sequencing of dna extracted from diagnostic biopsies. response to neoadjuvant chemotherapy was assessed pathohistologically in the surgical specimen. results. twenty squamous cell carcinoma and adenocarcinoma were included. overall the p mutation rate was % ( = ), with % for squamous cell and % for adenocarcinomas, respectively. patients received cis= fu (cisplatin mg=m d -fu mg=m d - , q , cycles), received docetaxel ( mg=m , q , cycles). the overall response rate was % ( = ). patients with p mutation did not respond to cis= -fu ( = ), while all mutant patients responded to docetaxel ( = ). the overall response to p adapted neoadjuvant therapy was %. p adapted treatment was associated with a significant survival advantage (p ¼ . ) after a median follow up of . months. conclusions. a prospective randomized trial was initiated to test the interaction between the predictive marker p and response to respectively. a new method of anti-ischemic graft protection in retrosternal colon esophagoplasty a. albokrinov , a. pereyaslov , r. kovalskiy lviv children's regional clinic hospital, lviv, ukraine; lviv d. halytsky national medical university, lviv, ukraine background. retrosternal colon esophagoplasty is the operation of choice in infants with esophageal atresia with great diastasis. although complications are rare, some cases of graft ischemia are registered. epidural block have beneficial effect on splanchnic blood flow because of drug sympathectomy. methods. we retrospectively analyzed rate of graft ischemia in infants with retrosternal colon esophagoplasty and conventional postoperative course with anticoagulants and antiaggregants (group , n ¼ ). group , n ¼ was investigated prospectively with preoperative catheterization of epidural space (th -th level, lost of resistance test, g size) and . % bupivacaine administration in daily dose of . mg=kg every h. the rest of therapy was equal in all patients. graft status was determined visually. gut motility was considered to restore when stool have been obtained. results. rate of graft ischemia was significantly lower in group then in group ( vs , p < . ). besides this, gut motility restoration in group was significantly earlier ( . ae . vs . ae . days, p < . ). conclusions. epidural block with local anesthetic is an effective method of anti-ischemic protection of neo-esophagus and powerful instrument in gut motility restoration. background. atrial fibrillation (af) is often associated with thromboembolic complications, heart failure and stroke; in addition an increase in mortality, even with adequate anticoagulation, is observed. the maze operation is an effective and accepted method to terminate af, nevertheless the risk for intraoperative bleeding is increased compared to left atrial ablation procedures using variable energy sources. left atrial ablation is an alternative method to convert af into sinus rhythm (sr), as with this procedure linear lesions connecting the four pulmonary veins and the posterior mitral annulus are created with microwave or high frequency technique. methods. a consecutive series of patients ( females, males; age a, range - a) underwent ablation during various cardiac surgical procedures between and . endocardial ablation using either microwave or radiofrequency energy was performed times ( . %) and epicardial with microwave energy in five cases ( . %) . preoperative parameters: ejection fraction . % ae . %; diameter left atrium . ae . mm. forty-one patients underwent mitral valve repair (mvp), patients obtained mitral valve replacement (mvr), patients received aortic valve replacement (avr), patients underwent coronary bypass surgery (cabg) and patients had combined valve surgery (others). results. others combined valve replacement: mvr þ tvp, mvr þ avr; af atrial fibrillation; aflut atrial flutter; pm pace maker no intraoperative or postoperative complications related to the concomitant ablation procedure were observed. one patient died because of multiple organ failure. after a mean follow up period of months ae patients remained in sr ( . %), patients into af ( . %), patients changed rhythm into atrial flutter ( . %) and one patient required a pace maker ( . %). conclusions. in approximately two thirds of patients left atrial ablation is effective in restoration and maintenance of sr in patients with structural heart disease and af. this method represents a valid alternative to the maze technique, reducing myocardial ischemic time and risk of bleeding. midterm results are promising; however for determination of a long term benefit especially regarding thromboembolic events, a higher number of patients and a longer follow up period are desired. background. the study aim was to evaluate the efficacy and outcome of endocardial and epicardial atrial fibrillation (af) ablation in patients undergoing heart surgery. methods. between february and december , patients (mean age years, range - ) underwent left atrial ablation combined with other type of cardiac surgery. in patients endocardial left atrial ablation using a unipolar radiofrequency device (cardioblate tm , medtronic, usa) was performed, mainly in combination with mitral valve (mv) surgery ( mv repair, mv replacements) . in patients epicardial pulmonary vein isolation using microwave energy (flex tm , guidant-boston scientific, usa) was done during aortic valve replacement ( ) and bypass grafting ( ) . indication for atrial ablation was permanent af in all patients. endocardial ablation was performed during extracorporal circulation (ecc) with a mean time of min ( - ), epicardial ablation before ecc with a mean ablation time of min ( ) ( ) ( ) ( ) ( ) ( ) . % of the patients ( ) received amiodarone postoperatively, % ( ) betablocker. patients underwent epicardial cardioversion with synchrus tm (guidant, usa) wires postoperatively. results. the overall mortality was . % ( patients during mv replacement due to posterior bleeding) complications were posterior rupture ( ) , lco with the need of intraaortoc pallon pump ( ), resternotomies for bleeding, and and ( %) pacemaker implantations ( . %). there were no ablation procedure related complications. sinus rhythm (sr) was achieved in % after operation, % at discharge and % at the month follow up. a nodal rhythm was found in % after operation, % at discharge and in % after months. patients developed atrial flutter ( in the group of endocardial and in the group of epicardial ablation). af persisted in % of the patients at month. conclusions. af ablation combined with cardiac surgery is safe and effective. recurrent af is frequent during the first three months after ablation also under therapy with antiarryhthmic drugs. background. patient-prosthesis mismatch is a frequent cause of high postoperative mortality and gradients. the objective of this study was to determine whether mismatch can be predicted at the time of operation. methods. indices used to predict mismatch were valve size, indexed internal geometric area and projected indexed effective orifice area (eoa) calculated at the time of operation, and results were compared with the indexed eoa measured by doppler echocardiography after operation in patients. results. the sensitivity and specificity of these indices to detect mismatch, defined as a postoperative indexed eoa of . cṁ =ṁ or less, were % and % for valve size % and % for indexed internal geometric area, and % an % for projected indexed eoa. conclusions. the projected indexed effective orifice area calculated at the time of operation accurately predicts mismatch, where as valve size and indexed internal geometric area cannot be used for this purpose. excellent long-term results after emergency cardiac surgery d. martin, a. yates, h. mächler, l. salaymeh, d. dacar, b. rigler division of cardiac surgery, department of surgery, medical university of graz, graz, austria background. data from all adult patients undergoing emergency heart surgery between and at the division of cardiac surgery, medical university of graz, austria, were reviewed retrospectively. methods. data were stored in a local cardiac surgery database. the registery included all relevant patients data and euro-score. no patient was lost to follow-up. a series of relevant perioperative data were collected. recorded complications were use of the intra-aortic balloon pump (iabp) and low cardiac output syndrome. hospital and late mortality data were collected from the austrian national populations register. multivariante analysis was performed to determinate predictors for cardiac related death. results. between and patients underwent emergency cardiac surgery at our institution. there were men ( . %) and women ( . %) with an average age of . years. coronary artery bypass was performed in . %, . % combined valve and bypass, . % valve, . % aortic dissection and . % had other procedures. eighty-seven patients ( . %) had a postoperative low cardiac output syndrome. the intra-aortic balloon pump was used in patients ( . %). variables identifying as high risk for perioperative cardiac related death were diagnosis other then coronary artery disease, patients with iabp and high catecho-lamine demand. there were no postoperative wound infections. eighteen patients ( . %) had excessive postoperative bleeding and ( . %) required a late re-intervention. hospital mortality was . % and the late mortality after years was . %. conclusions. the hospital mortality was higher in the emergency group but there was no difference in the long-term results for elective and emergency surgery. early mortality was significant higher in patients operated for other reason than coronary artery disease. background. acute renal failure is a serious adverse event after cardiac surgery, which is associated with high perioperative mortality and prolonged hospitalization. the aim of our study was to evaluate pre-and intraoperative risk factors for the development of acute renal failure requiring hemofiltration (arf) after cardiac surgery. the influence of different methods for evaluation of renal function was investigated. methods. from = through = , patients underwent cardiac surgery at our institution. patients developed arf ( . %), patients suffering from chronic end-stage renal insufficiency were excluded from the study. patient characteristics and operative variables were analyzed. a multivariate logistic regression analysis was performed to determine risk factors for arf. results. patients, who developed arf, were older (p < . , or: . ) as compared to patients who did not develop arf. furthermore, diabetes mellitus (p ¼ . , or: . ), peripheral artery disease (p ¼ . , or . ), cardiogenic shock (p ¼ . , or: . ), congestive heart failure (p ¼ . , or: . ) und emergent surgery (p ¼ . , or: . ) were predictive for development of arf. preoperative serum creatinine was not predictive for arf (p ¼ . , or: . ). classification of preoperative serum creatinine into normal ( . mg=dl), slightly elevated ( . to < mg=dl) and severely elevated (! mg=dl), reveals a correlation with the development of for severely elevated creatinine levels (p ¼ . , or: . ), as well as for slightly elevated levels (p ¼ . , or: . ). calculation of creatinine clearance mwith the cockcroft-gault formula demonstrated a strong correlation with the development of arf (p ¼ . , or: . ). calculation of creatinine clearance with the mdrd formula, however, failed to reveal any correlation with (p ¼ . , or: . ). conclusions. our data indicate, that advanced age, diabetes mellitus, peripheral artery disease, cardiogenic shock and congestive heart failure, as well as emergent surgery independently predict arf after cardiac surgery. even slightly elevated creatinine levels are a risk for the development of arf after cardiac surgery. calculation of creatinine clearance with the cockcroft-gault formula is more suitable for preoperative risk stratifica-tion as compared to calculation of creatinine clearance with the mdrd formula. background. the matricellular protein tenascin-c (tn-c) induces production of matrix metalloproteinases (mmps), inhibits cellular adhesion and mediates cellular deadhesion. these effects are crucial in the dynamic process of cardiac remodeling. it has been reported that tn-c expression is up-regulated in ventricular remodeling following myocardial infarction (mi) in the border zone between scar tissue and non-infarcted area. we analysed the expression of tn-c in the post mi infarcted and non-infarcted area after the treatment with the selective endothelin a (et a )-receptor antagonist tbc -na. blockade of the et a -receptor decreases cell proliferation, lv hypertrophy, and secretion of pro-inflammatory mediators. methods. mi was induced in male sprague dawley rats by lad ligation. three days post mi, rats were randomised to receive either the endothelin antagonist tbc -na (n ¼ ) or placebo (n ¼ ), as control rats were sham-operated without lad ligation (n ¼ ). after days hearts were harvested and tissue samples from scar, peri-infarct and free wall were analysed by western blot using a monoclonal antibody specifically recognizing the egf like domain of tn-c. tissue was homogenized in urea buffer and protein samples were subjected to % polyacrylamide gel sds-page, transferred on to a membrane and immunostained with the anti-tn-c monoclonal antibody and antimouse alkaline phosphatase antibody. additionally on day and echocardiography and morphological analysis were performed to assess the effect of tbc -na therapy on cardiac function. results. infarct size was comparable in all groups (et agroup . ae . %, placebo group . ae . %). during early remodelling on day , in the placebo group, tn-c was upregulated in scar tissue. in contrast, in the et a -group, tn-c was down regulated in scar tissue. on day post mi, no differences were seen in the tn-c levels. echocardiography showed significant improvements in hemodynamics in the et a -group in contrast to controls. conclusions. from these results, we can conclude that ( ) endothelin-a receptor blockade attenuates the development of heart failure post mi, ( ) reduction of tn-c expression seems to have a positive effect on postinfarct remodeling, ( ) tn-c regulation is influenced by et a -blockade and ( ) that tn-c is a marker for lv remodeling after myocardial infarction. background. diabetes is a risk factor for neurocognitive and neurological complications after cardiopulmonary bypass. we sought to determine if temperature management during cardiopulmonary bypass (cpb) affects the incidence of neurocognitive and neurological complications in diabetic patients. methods. in this prospective randomized study, we measured the effects of mild hypothermic ( c, n ¼ ) vs. normothermic ( c, n ¼ ) cpb on neurocognitive function. all patients underwent elective coronary artery bypass grafting (mean age . ae . years, mean es . ae . ) . neurocognitive function was objectively measured by objective p auditory-evoked potentials before surgery, week and months after surgery, respectively. clinical data and outcome were monitored. results. p evoked potentials were comparable between patients operated with mild hypothermic ( ae ms) and normothermic cpb ( ae ms) before the operation (p ¼ . ). patients operated with mild hypothermic cpb, showed marked impairment ( ¼ prolongation) of p evoked potentials week ( ae ms; p< . ) and months ( ae ms; p ¼ . ) after surgery. in contrast, patients operated with normothermic cpb did not show impairment of p evoked potentials week ( ae ms; p ¼ . ) and months ( ae ms; p ¼ . ) after surgery. group comparison revealed prolonged p peak latencies in the patient group operated with mild hypothermic cpb (p ¼ . ) week after surgery. four months postoperatively, no difference between the two groups could be shown (p ¼ . ). operative data and adverse events were comparable between the two groups. conclusions. normothermic cardiopulmonary bypass reduces neurocognitive deficit in diabetic patients undergoing elective coronary artery bypass grafting. ergebnisse. die paclitaxelbehandlung führte zu einer dosisabhängigen reduktion der intimalen hyperplasie im vergleich zur kontrollgruppe (p ¼ . bei mmolar, p ¼ . bei mmolar, p ¼ . bei mmolar und p ¼ . bei mmolar). in der elasticafärbung fanden sich sowohl in der media als auch in der intima meist nur vereinzelte elastische fasern, wohingegen sich in der trichromfärbung in der media insbesondere subintimal reichlich kollagene fasern fanden, die intima selbst jedoch hierfür negativ blieb. immunhistochemisch zeigte sich die media und die intima praktisch vollständig positiv für sma. bei der desmin-färbung fand sich die media ebenfalls fast durchgehend spezifisch positiv für desmin, die intima hingegen färbte sich hierfür jedoch in unterschiedlichen ausmaß ( - %) an. in der proliferationsfärbung mit ki zeigten sich vorwiegend die längsverlaufenden muskelfasern der media stark proliferierend, wohingegen der subintimale mediabereich und die intima nur vereinzelt ki positiv war. schlussfolgerungen. paclitaxelbehandlung reduziert die intimale hyperplasie in der vena saphena im organkulturmodell. elastische fasern, kollagenfasern, sma positive und desminpositive zellen sowie ki positive (proliferierende) zellen weisen unterschiedliche bevorzugte lokalisationen innerhalb der gefässwand auf. heat shock proteins = = = = = = = = = a and s proteasome in on-versus off-pump coronary artery bypass graft patients background. heat shock protein (hsp) , hsp , hsp , hsp and s immune-proteasome are known chaperons. they play a prominent role in housekeeping processes, in the intracellular regulation of the immune system and in apoptosis. serum levels of circulating chaperons are not known in patients undergoing the on-versus off-pump coronary artery bypass graft (cabg) procedure. methods. forty patients were prospectively included in the study (on-vs. off-pump cabg, each n ¼ ). elisa technique was utilized to detect levels of soluble hsp , , , and s immune-proteasome in serum samples. results. on-pump cabg procedure is associated with an increased leakage of heat shock proteins into the vascular bed when compared to off-pump cabg technique. these differences were highly significant for hsp , and min after initiation of cardiopulmonary bypass (cpb) (all, p< . ). concentrations of soluble s immune-proteasome were increased h after operation in on-and off-pump cabg patients (p < . ) and correlated significantly with the serum content of hsps , and at min after initiation of cpb (p < . ). conclusions. our data evidence the spillage of chaperons, normally intracellular restricted proteins, into the systemic circulation. as these proteins are related to immunomodulatory and apoptotic processes, we conclude that the innate immune system is more activated in on-pump as compared with off-pump cabg patients. however, the precise immunological consequence and interpretation requires further investigations. background. in the treatment of ruptured abdominal aortic aneurysm (raaa) the results of open graft replacement (ogr) remained constant but discouraging over the last four decades. provided patients have a suitable vascular anatomy, elective endovascular abdominal aortic aneurysm repair (evar) turned out to be less invasive than ogr and led to improved perioperative mortality especially for patients with severe comorbidities. thus, it is reasonable to assume that endovascular treatment should improve the results of patients with risk factors heavily impaired by rupture of their aaa. the purpose of this study was to test whether the use of both endovascular and open repair for raaa was able to improve results. methods. retrospective analysis of a consecutive series of patients presenting with raaa from october, , until july, . observation period was divided in two periods of months, respectively. during the first period patients were treated by ogr exclusively. period two started with the availability of an evar protocol to treat raaa, according to which patients received open repair while patients underwent evar. kaplan-meier survival estimates were calculated and possible differences were analyzed by log-rank and wilcoxon-test. results. kaplan-meier survival estimates revealed a statistically significant reduction in overall postoperative mortality following the introduction of evar in (p < . ). ninety day overall mortality was reduced from . % during period one to . % during the second period (p < . ). especially survival of patients older than . years was improved ( % vs. . %, p < . ). in parallel there was a significant reduction of the day mortality rate after ogr from . % (i.e. overall mortality) to % (p < . ). conclusions. offering both evar and ogr in the treatment of raaa led to significant improvement of postoperative survival. especially older patients seem to benefit from the less invasive endoluminal technique. fast track concept for infrarenal aortic aneurysm repair c. senekowitsch , r. schwarz , a. assadian , w. hartmann , g. hagmü ller background. the aim and main benefit of the fast track concept in surgery are increased patient comfort and reduced perioperative morbidity and mortality. in abdominal surgery, this concept has proven efficient. we present our experience of fast track aortic surgery. methods. retrospective analysis of prospectively collected data. since initiating this method of perioperative patient management in january , patients underwent infrarenal aortic reconstructions for aortic aneurisms applying the fast track concept. this comprises of modified nutrition and fluid management, anaesthesiological management and a special retroperitoneal access allowing aggressive postoperative mobilisation. results. patients were included in the study, their mean age was years (range - years) none of the patients had surgical complications, no mortality was observed. the icu days were reduced to for all patients. the mean hospital stay was days (range - days). conclusions. hospital stay and icu days could be reduced dramatically compared to standard therapy at our institution. this new concept in aortic surgery is a valid alternative to evar for selected patients. aneurysma der a. lienalis: fallbericht über interventionell-chirurgisches management e. gü nen, j. demmer, c. groß department of cardio-thoracic and visceral surgery, general hospital linz, linz, austria aneurysms of splenic arteries are seldom ( . % of all aneurysms). nevertheless they are disastrous when ruptured since they bleed into the free abdominal cavity without any means of self-tamponade. occurrence of splenic aneurysms is related to female gender, esp. after multiple gravidities. these aneurysms are usually symptomless and tend to rupture during labour pains. this fact explains the reports on ruptured splenic aneurysms in young women from developing countries whereas in western countries most findings are incidental in routine imaging scans. we report on a yo female from chechnya with a huge splenic aneurysm and splenomegaly. she complained about chronic fatigue and nausea. splenomegaly and a pulsating growth in the mid epigastrium were palpable in the physical examination. the wbc blood counts showed severe pancytopenia. ct-scan revealed a calcified aneurysm (Ø cm) of a tortous splenic artery and an enlarged spleen ( cm). we decided to occlude the origin of splenic artery interventionally and and to perform a ''lone splenectomy'' leaving the unperfused aneurysm in situ. the intervention achieved total angiographic occlusion. however during surgery the aneurysm was still under pulsatile pressure. the pulsation ceased on surgical ligation of the proximal splenic artery. subsequently the splenectomy was performed. the patient recovered without surgery related complications. a year after surgery she has normal blood counts. the aneurysm has not shrunk but shifted to left to adopt the space left over by the spleen. background. the transilluminated powered phlebectomy (tipp; trivex + , smith and nephew) was introduced in the year in our hospital. trivex + is a procedure for minimal invasive vein surgery including an illuminator device, a powered vein resector, a light source and a controll unit. the use of tumescent solution allows hydrodissection and facilitates ablation (rotating inner blade of vein resector combined with suction). methods. in an retrospective study we report patients ( males and females; mean age . years; limbs) treated with this technology during the years and . we used a combination stripping the saphenus veins ( ligations of the sapheno-femoral junction, ligations of the popliteo-femoral junction) or ligations of perforantes ( ) if necessary according to sonography. twenty-seven patients underwent single trivex + treatment. . % were done in general anaesthesia. a follow up is proposed to all patients after to months ( patients, . %). results. the average time of surgical treatment was . min, with single trivex . min. the trivex + procedure for one single leg took about min. the average stay was . days. regarding to postoperative complications one patient experienced laceration of the femoral vein ( . %), one profound bleeding caused a revision the same day ( . %). patients developed lokal wound infektion within the first weeks ( . %). during the follow up period complications like swelling ( ), seroma ( ), brown scars ( ), nerve injury=numbness ( ), haematoma ( ) occured. there was no skin perforation, no phlebitis, none of our patients died. conclusions. according to these results the trivex + procedure seems to be a quick and safe treatment for minimal invasive removement of superficial varicosities. background. this randomized, patient and observer blinded trial compared early postoperative outcomes in saphenectomy with either a new bipolar coagulating electric vein stripper (evs) or invagination stripping. methods. the primary outcome was pain at rest and following physical stress (climbing stairs), as assessed by a visual analog scale (vas) h after surgery. secondary outcomes included haematoma formation (diagnosed and measured by ultrasound), duration of postoperative compression, and disability. quality of life was assessed by a disease-specific chronic lower limb venous insufficiency questionnaire (civiq), and the generic short form (sf- ). results. two hundred patients were assigned to three vascular centers, with patients randomized to the evs and to the conventional arm. there were no complications or conversions. pain at rest averaged . in the evs and . in the conventional group (mean difference . , per cent confidence interval (c.i.) . to . , p < . ). following physical stress, mean ratings were . and . (mean difference . , per cent c.i. . to . , p < ). no measurable haematoma was found in the stripping canal of the evs group, while in the conventional arm patients had haematomas within this region (risk difference per cent, per cent c.i. to percent). duration of compression therapy was significantly decreased in the evs group (mean difference days, per cent c.i. to days). in the evs group, patients returned to work after week and after weeks, compared to and patients in group . civiq and sf- ratings favored the evs. conclusions. the evs is a safe instrument. it is effective in avoiding painful haematomas following saphenectomy, reduces recovery time and improves patients' ratings of quality of life. elt in combination with pin stripping in the treatment of epifascial truncal veins a. j. flor background. in the treatment of varicose truncal veins, endolaser treatment has widely been accepted as the method of choice. yet laser treatment -in particular in epifascial veins -may result in a painful contraction. we examine the functional and cosmetic results as well as the patients' comfort, combining elt and pin stripping in patients with epifascial truncal veins. methods. preoperative evaluation is carried out by color duplex sonography. emphasis is laid on patients with a partially epifascial course of the greater saphenous vein (gsv). following extensive evaluation and information of the patient, the decision is made to use endolaser treatment (biolitec, nm) in combination with pin-stripping (retriever-pin by oesch, salzmann medico). a guiding wire is inserted, duplex-controlled or through miniphlebectomy, into the gsv at the point of perforation through the fascia. a laser fiber is then positioned at the sapheno-femoral junction, and laser energy is applied to the intrafascial part of the truncal vein ( - j=cm) depending on the vein diameter. the epifascial part of the vein is then retrieved by the pin stripper. results. until now the combination of endolaser plus pin stripping has been applied in patients. following observation periods of to months, endolaser treatment provides an occlusion rate of %. skin incisions need not be wider than mm. crossectomy can be avoided. patients tend to have more hematomas in the pin-stripped region, yet a hardened, sometimes brown coloured and often painful strand -as often seen in patients treated by endolaser only -can be avoided thereby. conclusions. in about - % of the cases, an epifascial position of the gsv might been detected by duplex sonography. in cases of epifascial course of the truncal vein, decision to use elt treatment alone should be considered critically. in such cases, endolaser treatment combined with pin stripping should result in a higher degree of patient comfort, apparently providing an optimal solution for a minimally-invasive approach. endovenous laser treatment with the nm laser system; years of experience, follow-up of over veins k. freudenthaler background. chronic venous insufficiency is a common desease. the aims are to offer a minimal invasive alternative to traditional surgery such as crossectomia and stripping with less pain for the patient and a short reconvalescence. methods. since years over patients with more than veins have been treated by evlt, by grand saphenous veins a valve repair by venocuff ii was possible. only patients have been treated by traditional crossectomia and stripping. usually the grand and the short saphenous vein as well as the acessoria vein, insufficient perforaters and the giacomini anastomosis are treated by evlt. the treatment is done in general or in local anaesthesia and monitored by permanent ultrasound control. in no case a surgical crossektomia was necessary. after treatment the patient has to wear a compression stocking for two weeks dayover and should not lift heavy duties. results. after treatment the results are verified by ultrasound. the patients are controlled after one week, month and yearly thereafter. the total sucess rate is % in all cases (complete resorption of the treated vein). there were no complications like pulmonal embolia, infects or skin burns. conclusions. the evlt is a very safe treatment of chronic venous insufficiency and offers a minimal invasive alternative to traditional surgery such as crossektomia and stripping. Ö sterreichische gesellschaft fü r chirurgische forschung: die zukunft hat schon begonnen -bedeutung der molekularen biologie fü r diagnostik, prognose und therapie in der gastrointestinalen chirurgie proteomic profiling of the secretome of human liver endothelial cells (hlec) background. liver endothelial cells play significant roles in the physiology and pathology of the liver. they are not simply barrier cells regulating the traffic of blood components to the parenchyma and vice versa, but highly specialized cells with complex roles, including scavenger functions and regulation of inflammation, leukocyte recruitment and host immune responses to pathogens and shaping of the microenvironment by secretion of functionally relevant proteins. thus, investigation of the functional and physiological properties of lec is critical in understanding liver biology and pathophysiology. the aim of this study was to establish techniques to isolate and cultivate human liver endothelial cells and to obtain a protein profile of the secretome of quiescent and vegf-activated hlec. methods. hlec from unaffected tissue of resected liver segments from patients undergoing surgery for liver tumours were isolated using magnetic beads coated with anti-cd -antibodies. cells where cultured in medium ebm- (mv) supplemented with vegf, bfgf, igf, egf, heparin, endothelial cell growth supplement and % fetal calf serum. expression of endothelial cell surface markers cd , cd , cd e, cd and podoplanin as well as fibroblast marker cd was investigated by facs. hlec where starved for h in protein free medium and activated with vegf for further h. supernatants were collected and subjected to shotgun proteomics. human umbilical vein endothelial cells (huvec) served as a control. results. isolated cells where morphologically similar to huvec. % of cells where positive for cd , cd , and cd . % expressed cd . % of cd positive cells where positive for podoplanin. expression of cd was low, but consistent. cd e was induced in % of cells and expression of cd was upregulated fold after h activation with tnf-. shotgun proteomics of the secretome revealed a distinct differ-ence in the secretion pattern of several functionally relevant proteins compared to huvec. conclusions. our results point towards a significant and persistent difference in secretion patterns of functionally relevant proteins between hlec and other endothelial cells both in quiescence and after vegf activation. these findings may lead to a better understanding of physiology of the liver. finally, this study demonstrates the suitability of magnetic bead isolation in combination with in vitro cell culture and proteomics for investigation of hlec functions. hypermethylation of sfrp gene in stool dna test: a future technology in colorectal cancer screening w. zhang, w. hohenberger, k. matzel background. stool dna test is considered as a future technology in screening for colorectal cancer (crc). both genetic and epigenetic changes in shed cells from gastrointestinal tumours into stool could be detected. epigenetic hypermethylation can result in transcriptional silencing of tumour suppressor genes and is considered to be a key event of sporadic colorectal carcinogenesis. sfrp is a tumour suppressor protein that contains a domain similar to one of wnt-receptor proteins and inhibits wnt-receptor binding to its signal transduction molecules. detection of hypermethylation of sfrp gene in human dna isolated from stools might provide a novel strategy for the detection of sporadic crc. our study aims to prove the methylation status of sfrp gene in stool samples, and compare the dna methylation status before and after neoadjuvant radiochemotherapy. methods. to explore the feasibility of stool dna test, fecal samples were obtained from crc patients (crc patients post neoadjuvant radiochemotherapy n ¼ ). twenty fecal samples were obtained from patients without evidence of gastrointestinal disease or neoplasia. isolated genomic dna from stool was modified with sodium bisulfite and analyzed by specific pcr for methylation of sfrp promoter. results. with stool dna test we were able to detect the hypermethylation in the promoter region of sfrp gene in the fecal dna from colorectal cancer patients (p ¼ . ). sensitivity was %, specificity was %. methylation status of sfrp gene was significantly changed after neoadjuvant radiochemotherapy (p ¼ . ). conclusions. the hypermethylation of sfrp gene in the stool dna test has a high sensitivity and specificity for crc and may be valuable for screening purposes, especial for the sporadic crc. compared with current colorectal cancer screening methods, stool dna test is more patient-friendly, non-invasive, more sensitive and specific. the cost-effectiveness of screening may also be improved by using single dna stool test with one sensitive dna marker. the methylation status of sfrp seems to be changed after neoadjuvant radiochemotherapy, which may open new fields for crc research. summarized this new diagnostic tool may yield ben-efits in earlier detection and in the design of better antitumour interventions. background. although the function and interaction partners of the glycoprotein dickkopf- (dkk- ) still remain unclear, gene expression of dkk- has been shown to be upregulated in tumor endothelium of colorectal cancer. for the first time, we analyzed expression of dkk- protein and its potential as a marker of neoangiogenesis in colorectal cancer. methods. we utilized tissue microarrays (tmas) to evaluate dkk- protein expression in microvessels of colorectal cancer samples from patients, in microvessels of adjacent tissue samples from the same patients compared to normal colorectal mucosa tma samples. a second microarray section was stained with cd to quantify neoangiogenesis by defining the microvessel count. results. out of cancer samples with cd positive microvessels, . % were dkk- positive in all microvessels. these samples showed a significantly higher mean microvessel count ( . vessels) than dkk- negative samples ( . vessels; p ¼ . ). dkk- protein expression increased with rising numbers of microvessels per sample (p < . ). out of cd positive adjacent tissue samples, % were dkk- positive. these samples also had a higher mean microvessel count ( . vessles) than dkk- negative samples ( . vessels; p < . ). similar to colorectal cancer tissue, dkk- expression in non-cancerous adjacent tissue increased with rising numbers of microvessels (p < . ). in contrast, all microvessels in normal colorectal mucosa samples demonstrated a negative staining reaction for dkk- . univariate analysis of several clinicopathologic variables in correlation to dkk- expression revealed significant differences in tumor site (colon vs. rectum; p ¼ . ) and mean age (p ¼ . ). survival analysis according to kaplan-meier method showed a statistical trend toward a higher diseasefree survival for patients with dkk- negative samples (p ¼ . ). conclusions. our study demonstrates for the first time that microvessels of colorectal cancer and adjacent non-cancerous tissue are identical concerning dkk- protein expression, but distinct from normal colorectal mucosa. therefore, dkk- can be considered as a putative pro-angiogenic protein in the process of neovascularization, may have the potential to serve as a marker for neoangiogenesis, and may represent a target structure for novel therapeutic approaches. nevertheless, it is mandatory to further confirm these findings using normal tissue sections. background. we have developed the first genetically engineered oncolytic influenza a viruses (ns deletion viruses), which replicate and lyse cancer cells but are apathogenic in normal tissue. infection of influenza a viruses are usually highly dependent on the presence of a serine-like protease (i.e. trypsin), which cleaves the viral entry protein, the hemagglutinin. cancer cells are known to endogenously produce proteases. methods. we here investigate, whether colon cancer associated proteases support lytic growth of the oncolytic influenza viruses in those cells. results. ns deletion viruses grew to high titers in the colon cancer cell lines caco or ht- independent of the addition of trypsin. correspondingly, viral infection rate, cleavage of the hemagglutinin and virus-induced cytopathic was not compromised by the lack of trypsin in these cell lines. zymogram analysis indicated that the caco and ht- associated protease is not trypsin itself but trypsin unrelated. conclusions. the specific activation of the influenza a virus in colon cancer cell lines suggests an effective use of this virus for oncolysis in colon cancer in vivo. background. for decades the bile pigment bilirubin has been considered a toxic waste product of heme catabolism. however, serveral clinical studies show an inverse correlation between elevated plasma bilirubin levels in healthy individuals and the incidence=mortality of colorectal cancer. based on these findings, we hypothesized that bilirubin and its precursor biliverdin may suppress tumor cell growth in vitro and inhibit tumor progression in vivo. methods. in vitro hrt- colon cancer cells were treated with bilirubin at various concentrations or pbs as a control. a casy cell counter was used for proliferation assays. cell cycle progression and apoptosis were analyzed by facs. western blot analysis was carried out using antibodies directed against p , rb, p , parp- and caspase as well as total and phosphorylated forms of erk, mek and akt. further, cells were treated with pharmacological inhibitors of mek and pi -kinase in presence or absence of bilirubin. in vivo, nude mice bearing hrt- tumors were treated with bilirubin i.p. at mg=kg=day or pbs as a control. tumor size was measured using a caliper. statistical analysis was performed using anova. results. bilirubin significantly inhibited proliferation of hrt- colon cancer cells in a dose dependent manner. this mainly was mediated by induction of g =g cell cycle arrest and apoptosis through strong activation of akt, mek and erk resulting in overexpression of the cell cycle regulators p , p , hypophosphorylation of rb as well as an increase of parp- and caspase cleavage. the antiproliferative effects were dependent on akt and erk activation, in that inhibition of upstream pi -kinase and mek reversed the effects observed under bilirubin treatment. in vivo, bilirubin dramatically decreased tumor growth by % (sd ae . ) when compared to the control. conclusions. bilirubin is a potent inhibitor of hrt- colon cancer cell growth in vitro and in vivo, presumably by modulating mitogen activated protein kinase signaling pathways resulting in cell cycle arrest and apoptosis. background. tetrahydrobiopterin (bh ) is an essential cofactor for nitric oxide synthases and thus a critical determinant of no production. recently we have shown that bh depletion contributes to ischemia reperfusion injury (iri) after pancreas transplantation. here we analysed the therapeutic potential of bh supplementation during organ procurement and the early post-transplant period. methods. murine cervical heterotopic pancreas transplantation was performed with a modified no-touch technique. pancreatic grafts were subjected to h prolonged cold ischemia time (cit) and different treatment regiments: untreated (i), bh mm to perfusion solution (ii), bh mg=kg i.m. at reperfusion (iii). nontransplanted animals served as controls (iv). intravital fluorescence microscopy was used for analysis of graft microcirculation by means of functional capillary density (fcd) and capillary diameters (cd) after h of reperfusion. quantitative assessment of inflammatory responses (mononuclear infiltration) and endothelial disintegration (edema formation) was done by histology (h&e) and peroxynitrite formation assessed by nitrotyrosineimmunostaining. results. fcd was significantly reduced after prolonged cit, paralleled by an increased peroxynitrite formation, when compared with controls (all p < . ). microcirculatory changes correlated significantly with intragraft peroxynitrite generation (spearman: r ¼ À . ; p < . ). pancreatic grafts treated with bh either during retrieval (ii) or systemically (iii) displayed markedly higher values of fcd (p < . ) and abrogated nitrotyrosine staining (p < . ). cd were not significant different in any of the investigated groups. histologic evaluation showed increased inflammation, interstitial edema, hemorrhage, acinar vacuolization and focal areas of necrosis after h cit in group i, which could be diminished by both bh treatment regiments (p < . ). conclusions. bh treatment significantly reduces postischemic deterioration of microcirculation as well as histologic damage and might be a promising novel strategy in attenuating iri in clinical pancreas transplantation. methods. forty-seven biopsies obtained from the endoscopic esophagogastric junction in patients ( females, males; age ; range - years) with symptoms of gastroesophageal reflux disease were processed for histopathology and immunohistochemistry. biopsies were stained with routine h&e and immunofluoresence staining using an antibody directed against hydrogen=potassium atpase (h þ =k þ atpase beta) (pot) for detection of parietal cells (pot ¼ monoclonal clonal mouse igg antibody, g clone, dilution : ; product numberma affinity bioreagents d- hamburg, germany). pot detects the beta-subunit of hydrogen= potassium atpase in bovine, human, canine, porcine, rabbit, mouse, ferret, and rat tissues. histopathology in h&e stained sections was conducted according to the paull-chandrasoma classification of columnar lined esophagus (cle) including oxyntocardiac (ocm; mucus and parietal cells) and cardiac mucosa (cm; mucus cells only) with or without intestinal metaplasia (im ¼ barrett esophagus). out of biopsies also contained gastric oxyntic mucosa (mucus, parietal and chief cells) and served as controls (these biopsies contained both cle and om). the detection of parietal cells in h&e and pot-staining was compared. results. h&e staining showed that out of patients had cm with im (barrett esophagus), had cm without im. a total of slices was investigated ( h&e pot). pot stained the cytoplasma of parietal cells indicating the presence of biologic active acid pump. in biopsies parietal cells were only detected in pot stained slices, whereas in the other biopsies parietal cells were detected by both h&e and pot-staining. parietal cells were detected in all biopsies containing gastric om. therefore pot did not significantly increase the parietal cell detection rate in cle compared to h&e staining. conclusions. detection of ocm within biopsies from columnar lined esophagus is not significantly increased by the use of an antibody directed against h þ =k þ atpase. h&e staining is adequate for detection of parietal cells within cle. lymphovascular invasion and lymphangiogenesis in adenocarcinoma of the esophagus: impact on patient survival e. rieder , s. schoppmann , s. kandutsch , f. wrba , f. langer , c. neumayer , p. panhofer , g. prager , j. zacherl background. a special feature of esophageal cancer is its early lymphatic spread in comparison with other cancers of the gastrointestinal tract. due to the discovery of specific markers for lymphatic endothelium, selective staining of lymphatic vessels has become possible. in recent studies the prognostic value of peritumoral lymphangiogenesis and lymphovascular invasion in various human malignancies has been shown. tumor-associated macrophages (tam), expressing the lymphoangiogenic growth factor vegf-c, were shown to be related to tumor-associated lymphangiogenesis, lymphovascular invasion and lymph-node metastasis. aim of this study was to assess tumor-associated lymphangiogenesis as well as the role of tams in a cohort of adenocarcinoma of the esophagus. methods. fourty formalin-fixed, paraffin-embedded surgical specimens of patients (age range: - ) presenting with adenocarcinoma of the esophagus at the university hospital of vienna were included into this study. specimens were stained with antibodies against podoplanin, vegf-c and anti-cd . semiquantitative measurements of lymphatic microvessel density (lmvd) and lymphatic vessel invasion (lvi) were carried out. results. it could be demonstrated that lymphangiogenesis occurs in barrett adenocarcinoma and is correlated with lvi. statistical analysis revealed that lvi is associated with disease-free (p ¼ . ) as well as overal survival (p ¼ . ) of patients with barrett carcinoma. furthermore over-expression of vegf-c was seen in barrett carcinomas and vegf-c expressing tams were detected peritumoral and therfore may play a role in lymphogenic metastasis of esophagus carcinoma. conclusions. these preliminary data demonstrate that lymphovascular invasion as well as tumor-induced lymphangiogenesis is associated with patient survival in barrett adenocarcinoma and anti-lymphangiogenic therapies might be a beneficial approach. background. the role of tissue-inhibitor of metalloproteinases- (timp- ) in cancer progression is still unclear. although timp- is an important inhibitor of metastasis-associated proteases, it is often correlated with a bad prognosis. in an animal model, elevated levels of timp- , achieved by adenoviral-gene-transfer, led to induction of hepatocyte growth factor (hgf)-signaling and expression of several metastasispromoting genes in the liver, representing a host-microenvironment with increased susceptibility to a challenge of tumor cells. we examined the expression of candidate metastasis-promoting factors by qrt-pcr. methods. liver-tissues of consecutive metastatic colorectal cancer patients ( males, females; mean age, . ae . y) were obtained. to determine timp- -associated gene expression signatures in the normal liver tissue, specimen were harvested from zones greater than cm away from visible liver metastases and analyzed by quantitative-real-time-pcr (qrt-pcr, taqman + -low-density-arrays) of metastasis-associated genes. results. human liver tissue with elevated timp- levels was associated with an identical pro-metastatic gene expression signatures as previously identified in the animal model, namely increased expression of hgf, pcna, upa, upar, tpa, matriptase, mmp- , mmp- , adam- , cathepsin g, and neutrophil elastase. conclusions. we reveal here for the first time a ubiquitous (human and mouse=different tumor types) timp- -related gene expression profile. this profile, consisting of metastasis-promoting genes, can explain the correlation between tumor aggressiveness in cancer patients and increased levels of timp- and demonstrates the impact of the host microenvironment on its susceptibility to invading tumor cells. this concept is important for future considerations of cancer therapies. Ö gth -herz: varia rv-lv depolarisation-interval as a predictor of longterm-survival of crt-patients: a criteria for intraoperative quality control t. schwierz , s. winter , h. nesser , r. fü gger surgical department, elisabethinen-hospital, linz, austria; cardiological department, elisabethinen-hospital, linz, austria background. for cardial resynchronisation therapy the left-ventricular lead should stimulate the most delayed myocadial area. we introduce a method, established in or dayly routine, for intraoperative verification of the hemodynamically best lead-position. methods. the electrical distance between rv-and lv-lead we verify by measurement of the time between rv-pacing and lv-sensing (depolarisation-intervall). by a cox regressionmodel we analized the data of patients with regard to possible predictors of patients-survival following crt. results. significant predictors of survival were the age of patients (p ¼ . ), lvef (p ¼ . ), biventricularly stimulated qrs-duration (p ¼ . ), reduction of qrs-duration under biventricular stimulation in relation to rv-pacing in % (p ¼ . ), depolarisation-intervall (p ¼ . ), depolarisation-intervall in relation to qrs-duration under rv-pacing in % (p ¼ . ). conclusions. out of the predictors significant for the patients-survival following crt only the depolarisation-intervall can be influenced activly during the implantation procedure. the rv-and lv-lead should be implanted so that the depolarsation-intervall is as long as possible. ideally, the depolarisation-intervall covers the entire qrs-duration under rv-pacing. in that case the lv-lead stimulates exactly the latest depolarisized myocardial area. the fibrin derived peptide b-beta - ameliorates ischemia-reperfusion injury in a rat heart transplant model background. the purpose of this study was to evaluate the protective effect of the fibrin-derived peptide b-beta - on ischemia=reperfusion injury in a rat cardiac transplant model. methods. lew hearts were flushed with chilled ( - c) custodiol preservation solution and either transplanted immediately or stored for or h in the same solution and then transplanted into syngeneic recipients. b-beta - was given i.v. at a dose of . mg immediately after transplantation or added to the preservation solution prior to harvest. at h and d, graft function was assessed and hearts were retrieved for morphological evaluation. at time of harvest, serum samples were collected for troponin level analysis. results. hearts transplanted immediately or after h of cold ischemia did neither show any morphological damage at h nor at days. in contrast, h of ischemia resulted in severe myocardial ischemia associated with an inflammatory response at h. lesions further progressed at days. administration of b-beta - resulted in a significant amelioration of myocardial necrosis together with a diminished inflammatory response. a protective effect towards myocyte damage was further underlined by reduced troponin levels in groups receiving b-beta - . acute cellular rejection after cardiac transplantation -is there a way to reduce the number of biopsies? background. acute cellular rejection significantly contributes to mortality and morbidity after cardiac transplantation (htx). routine endomyocardial biopsies (embs) are performed to early detect and treat cellular rejection. although emb can be performed with little risk, a number of potentially fatal complications are inherent in the procedure. the aim of our investigation was to evaluate the incidence of acute cellular rejection after heart tranplantation and to evaluate possibilities to reduce the number of embs. methods. patients underwent cardiac transplantation from january through december at our institution. the mean age of the patients was . ae . years. . % were female. indication for htx was icmp in . %, dcmp in . % und others in . % of the cases. according to our institutional standard, patients underwent emb weekly during the first month after htx, biweekly during months and , monthly up to month , once in month , and . a total of embs were investigated over a follow-up period of months after htx. results. the majority of embs showed no signs of rejection ( . % ishlt ). mild signs of rejection without therapeutical consequence (ishlt ia) were found in . % of embs. rejection ishlt ib was found in . % of the evaluated embs. the incidence was . % during the first month after htx, in the second month . %, in rd month . %, in th and th month . %, in th and th month . %, and from the th month . %. a moderate rejection (ishlt ii) was detected in . %. during the first month after htx, the incidence was . %, during nd month . %, during rd month . %, in th und th month . %, in th und th month . % and from the th month . %. more severe rejections were rare ( x ishlt iiia ¼ . %, x ishlt iiib ¼ . %) and occurred in month , , and . conclusions. severe cellular rejection after htx is seldom. mild to moderate rejection episodes, however, occur more frequently. in contrast to the traditional emb schedules, rejection hardly ever occurs during the first weeks after htx. most rejection episodes are observed between the second and seventh month after htx. afterwards, the incidence of rejection lowers again. based on these findings, the number of routine embs can safely be reduced, especially during the first weeks after htx. background. renal dysfunction has consistently been one of the greatest risks for mortality with the use of left ventricular assist devices (lvad). we aimed to determine the impact of renal function on survival and time-dependent changes in renal function after lvad implantation. methods. we retrospectively reviewed patients with advanced heart failure (mean age . ae . yrs, % male, % ischemic cardiomyopathy) who received lvad implantation as a bridge to transplant therapy from to . renal function was assessed using the modification of diet in renal disease (mdrd)-derived glomerular filtration rates (gfr). patients were divided into groups based on renal function pre-lvad implantation; group : normal (gfr ! ml=min= . m , n ¼ ), group : impaired (gfr < ml=min= . m , n ¼ ) renal function. results. patient survival was comparable between the groups. the , and -month kaplan-meier estimate of survival was . %, . % and . % for group and . %, . and % for group (p ¼ . ). gfr paired sample analysis in group showed an early increase in gfr from preimplantation ( . ae . ml=min= . m ) to postoperative day (pod) ( . ae . ml=min= . m ; p ¼ . ). there was no increase in gfr from pre-implantation ( . ae . ml= min= . m ) to heart transplantation ( . ae . ml=min= . m ; p ¼ . ). in contrast, gfr paired sample analysis in group showed an early increase in gfr from pre-implantation ( . ae ml=min= . m ) to pod ( . ae . ml= min= . m ; p< . ), and a further increase in gfr from pod ( . ae ml=min= . m ) to pod ( . ae . ml= min= . m ; p ¼ . ). there was a significant increase in gfr from pre-implantation ( . ae . ml=min= . m ) to heart transplantation ( . ae . ml=min= . m ; p< . ). conclusions. renal function improves rapidly after lvad implantation. renal dysfunction does not adversely affect outcome after lvad implantation. methods. bed interdisciplinary paediatric intensive care unit, university hospital. patients. patients after open heart surgery; prospective controlled study. group a received mg tc=kg bodyweight pre-and post operation and h after operation, whereas group b received mg tc=kg bw in the same period. drug levels and routine laboratory parameters were investigated daily in the picu. the aim of both groups was a tc serum concentration of - mg=l by adapting dosage after h. results. in group a tc concentration were . ae . and . ae . mg=l after and h, in group b . ae . and . ae . mg=l (p < . both), respectively. crp values were in group a ae . mg=l and ae . mg=l and in group b ae . mg=l and ae . mg=l (p < . and p < . ), respectively. there were no differences in physiological scoring. conclusions. to achieve drug levels of tc higher than mg=l during the first h after surgery, the higher dosage of mg=kg bw had to be administered initially. the high tc dosage was well tolerated and was associated with significantly lower crp in the first two days. background. the fontan operation eliminates the systemic hypoxemia and ventricular volume overload in congenital patients with single ventricle physiology. retrospectively, we report on our longtern results of surgical palliation and on different concepts concerning tcpc (total cavo-pulmonary connection). methods. between and , a total of patients (mean age . ae . years) underwent surgical fontan palliation at our institution by tcpc technigue. in % of all patients, a staged concept was carried out, patients had a central fenestration ( mm). all of our latest patients in the operation series were palliated -according to the new ''fontan concept'' -with an extracardiac conduit as second step. in , inhalative no (nitric oxyde) therapy was also introduced in the early postoperative phase. results. kaplan-meier overall survival after a mean followup of years was . % (in patients with staged procedure . %, . % in patients with fenestrated fontan). out of patients survived a periopertive fontan take-down. without any exception, we lost patients in the learning curve phase, of them because of neurologic complications, patients died due to low cardiac output (lco). in those patients who were palliated with an extracardiac fontan, mortality was %; furthermore under no-therapy, perioperative mortality also was %. after ae months of follow-up, % of all patients were in nyha i, % in nyha ii, % of all patients were in sinus rhythm. pleuropericardial effusions were found in % of all patients. conclusions. definitive palliation by means of tcpc in patients with congenital single ventricle physiology leads to more than acceptable clinical results. staged palliation, fenestration procedures, extracardiac fontan and inhalative no-therapy were introduced as ''modern'' surgical therapy concepts and resulted in a significant positive influence on perioperative and longterm clinical results. neue erkenntnisse in der mund-, kiefer-und gesichtschirurgie background. as we are living in an aging society, the number of active patients older than is increasing. the impact of age on trauma related injuries, e.g. femur neck fractures, and their outcome has been well documented in the literature. so far, data on a broad cohort suffering from oraland maxillofacial injuries (omfi) are missing. thus it was the aim of the present retrospective analysis to observe the effect of increasing age on trauma related omfi. methods. the records of patients with omfi were collected at the department of cranio-maxillofacial and oral surgery at the medical university of innsbruck in the period from = = to = = . according to the who definition of elderly people the collected values were divided into persons older than years of age and younger. were younger and were older than years. data were registered regarding: diagnosis, age and gender, cause, type and localization of the injury and concomitant injuries. subsequently the data of both groups were compared and statistically analysed. statistical analysis was performed in spss (version . ) using chi-square-test, fisher s exact test and mann-withney u test. this was followed by a logistic regression analysis in order to investigate trends and to demonstrate significant differences between the groups. a value of p< . was considered significant. results. with increasing age the risk for a domestic accident was raising. the accident mechanism in the elderly people was mainly a fall ( . %) or was not reproducible ( . %). there was a significant difference between both groups regarding concomitant injuries. . % of the older and . % of the younger patients suffered from additional neurological symptoms (p < . ). until the age of the risk for concomitant neurological injury is increasing, beyond there is no significant higher risk. the injuries in the older patients were mainly referred to the soft tissue and the mid face. conclusions. thanks to major progress in general health care the percentage of elderly and most notably active old people in our society has been constantly stepping up in the past three decades. the increased number of concomitant injuries in elderly people requires a detailed investigation of the injured patient. furthermore medication and possible cardiovascular disease of the older generation restricts the indication for surgical treatment of these patients. influence of different surface termination on surface energy and subsequently on connective tissue attachment in vivo background. connective tissue attachment is of major significance for the longevity of transdermal=-mucosal implants. a tight soft tissue sealing around the implant prevents from acute and chronic infections. major focus of former investigations has been the influence of different surface roughness on the connective tissue attachment to the implant surface. the aim of the current investigation was to demonstrate the influence of different surface terminations of nano-crystalline diamond (ncd) on surface energy and subsequently its influence on in vivo connective tissue healing. methods. ncd coated titanium membranes were terminated either by hydrogen or oxygen and were compared to pure titanium membranes. these samples were evaluated by contact angle measurement, scanning electron microscopy, atomic force microscopy and electrostatic force microscopy to evaluate the surface potentials. to assess the in vivo integration, the different substrates were randomly distributed and inserted into the sub-dermal layer of wistar rats. animals were sacrificed after , and weeks to investigate the adjacent connective tissue histologically. cell number, connective tissue=implant contact ratio and scar formation were evaluated. statistical analysis was performed using wilcoxon-rank test and kruskal-wallis h-test. p < . was considered significant. results. the ncd coating of the titanium membranes preserved its microstructure. contact angle measurement confirmed h-termination hydrophobic and o-termination hydrophilic. o-termination resulted in a strong polarity, whereas no electrostatic interactions were observed at the hydrophobic surface. the histological evaluation demonstrated a comparable cell number after week in all groups. after four weeks a significantly increased cell number at the o-terminated ncd with a less tight scar formation was observed. furthermore a markedly higher connective tissue=implant contact was observed after weeks at the hydrophobic surface. conclusions. o-termination of ncd renders the surface electrostatically active. the surface polarity promotes connective tissue healing in vivo. furthermore the surface energy is of higher importance compared to the structure of the surface. the o-termination of surfaces thus is a promising technique for a controlled influence of connective tissue adhesion in vivo. the risk of concomitant injuries and complications in cranio-maxillofacial trauma. das risiko von begleitverletzungen und komplikationen in der kiefer-gesichtschirurgie background. the registration of concomitant injuries on patients with cranio-maxillofacial trauma is an important criteria to optimize the healing process and to minimize the incidence of complications due to unlevied diagnostic findings. interdisciplinary, cranio-maxillofacial trauma management includes exact documentation. therefore a large collective of patients was examined against the background of their maxillo-facial trauma to diagnose the additional injuries. methods. between - at the department of oraland maxillofacial surgery among patients with craniomaxillofacial trauma, patients ( . %) with concomitant injuries were registered. data of patients were recorded including age and gender, cause and type of injury, location and frequency of their additional trauma. statistical analyses performed including descriptive analysis, chi square test, fisher's exact test and mann-whitney s u-test. logistic regression analysis determined the impact of different ages on the type of injury. results. within patients (mean age ¼ . ; #:$ ¼ . ) the most common sort of concomitant injury occured during sports, household and play ( . % each). the most frequent type of additional injury was the commotio cerebri in . % ( patients). fracture of the base of the skull occurred in patients ( . %), patients had a fracture of the skull and patients suffered from contusio cerebri. even one patient had a paresis of the facial nerve. in patients injuries of the eye were denoted, among them . % had a contusio bulbi and patients a retrobulbar hematoma. contusio of the lung appeared in . %, blunt abdominal trauma in . % and a fracture of the cervical spine in . % of patients with concomitant injuries. in patients fractures of the facial bone were recorded. soft tissue injuries of the face were found in patients ( . %). in concomitant injuries male persons aged between to are prone to cervical spine fractures (increase of %=year of age) and thoracal injuries (increase of %=year of age), as well as neurological trauma (increase of %=year of age) mainly found in traffic accidents. conclusions. in the catchment area of our department injuries of the neurocranium and the eye were often associated with trauma of the viscerocranium. interdisciplinary and coordinated management is not only important for the initiation of preventive measurements but also for forensic causes. to minimize the complication rate and to optimize the therapy a neurological-, neurosurgical-, as well as eye-consiliary examination should be preferably accomplished at a preoperative stage on the awakened patient. background. orbital injury may lead to incarceration of periorbital tissue and to ocular motility disturbances and diplopia on a long-term basis. however, orbital surgery is not free of risks. the treatment of periorbital lesions demands a precise planning approach in order to secure high success rates without causing iatrogenic damage. we want to demonstrate computer assisted surgery as part of the surgical routine of posttraumatic orbital reconstruction. methods. four cases of posttraumatic orbital deformities are presented. two patients showed protruding bone fragments after unrecognized fractures of the orbital walls. two patients presented with foreign bodies in the orbital cavity after shotgun injuries. in all four patients preoperative acquired ct-data was reformatted on a commercially available d-navigation system. image guided surgery in the orbital cavity was performed using an intraoperatively calibrated high-resolution endoscope. results. the shotgun pellets and the protruding bone fragments were easily detected and removed via a minimal invasive access. diplopia and bulb motility improved significantly. postoperative rehabilitation was restricted to a few days. conclusions. according to our opinion computerized navigation surgery of the orbit can improve the results of surgery in terms of safety and accuracy. these extended techniques should lead to a more direct and less invasive method for approaching orbital lesions or posttraumatic deformities giving the surgeon a high degree of security in sparing vital anatomic structures. background. surgically assisted rapid maxillary expansion (sarme) has become a widely used and acceptable technique to expand the maxilla in adolescents and adult patients. sarme takes the advantage of bone formation at the maxillary edges of the midline, while they are separated by an external force. sarme is indicated in patients with isolated, considerable (more than mm) transverse maxillary deficiency. while surgically assisted palatal expansion is performed in patients after closure of the sagittal palatal suture, conservative rapid maxillary expansion can be used in younger patients. studies concerning such cases show, that just % of the expanded width is located in the area of the palatal suture, while the rest of the extention ( %) are reached by dentoalveolar movements like tipping. the aim of this study was to evaluate the amount of expansion caused by expansion of the maxillary suture and by the dentoalveolar complex. furthermore changes of the nasal cavity should be discussed. methods. all patients included in the study showed a tranverse maxillary deficiency of at least mm. all patients were older than years ( min, max). in all patients a fractional le fort i osteotomie consisting of sagittal osteotomie and osteotomie of the anterior maxilla and the pterygoid bone was performed. ct scans were performed preoperatively and about weeks postoperatively (after the needed expansion). measuring points were defined to evaluate the skeletal and the dental changes after maxillary expansion. conclusions. the results of the current study will be presented. background. the main indication for microvascular reconstruction of the face is the best possible functional and aesthetic outcome. here every special kind of missing tissue is to be substituted. by using the chimera-flap technique a combination of different transplants for individual defect coverage is possible. methods. in seven patients with extended or penetrating defects of the lower face, reconstruction was performed with a double flap technique. a combination of microvascular iliac crest transplants or microvascular femur transplants for mandibula reconstruction and an anterolateral thigh perforator flap (altpf) or saphenus perforator flap for soft tissue reconstruction was performed after ablative tumour surgery. the pedicle of the altpf or saphenus flap was used for elongation of the microvascular bone flap pedicle. all patients had radiotherapy weeks after surgery. results. all patients had good functional and aesthetic results and have been successfully treated with implant retained prostheses. there were no severe postoperative complications. there was no tumour relapse within - months postoperatively. conclusions. the chimera-technique makes good aesthetic and functional outcome possible. the iliac crest transplant is of a good dimension for reconstruction of non-high atrophic mandibles after complete resection. the microvascular femur is well suited for covering partial defects of the mandible. implant placement is possible in both transplant types. the altpf and the saphenus perforator flap have a low incidence of complications and donor site morbidity and can be shaped adequately to a soft tissue defect of the lower face. parry-romberg-syndrom (hemiatrophia faciei progressiva) -interdisziplinäre zusammenarbeit mehrerer ü bergreifender fächer bei der definitiven diagnosestellung und den daraus resultierenden therapiemöglichkeiten zugt gesichts-und schädelskelett. die hemiatrophia faciei progressiva (v. romberg) ist primär durch einen schwund der betroffenen gesichtsseite, an der die haut, das subcutane fettgewebe und bindegewebe und später auch die muskelatur und die gesichtsschädelknochen beteiligt sind. die ausgeprägte gesichtsasymmetrie ist häufiger als ein funktionsausfall ursache der behandlung. nur eine effiziente diagnostik sichert eine gute therapie und gute resultate bei einem romberg-syndrom-patienten. bei der diagnostik wird nicht nur die mund-, kiefer-und gesichtschirurgie herangezogen, sondern interdisziplinär mit der dermatologie, hno, mund-, kiefer-und zahnheilkunde, augenheilkunde, neurologie, psychiatrie, plastischen chirurgie und radiologie zusammengearbeitet. es werden die jeweiligen disziplinen mit ihrem abklärungsgebiet beim romberg-syndrom präsentiert und dargestellt. in jeder disziplin werden die patienten in der dermatologie auf eine sklerodermie, in der neurologie -anhand eines mrtsdie neuralgiformen symptome und in der augenheilkunde die ophthalmologischen symptome, in der radiologie -anhand von bildgebungsverfahren (ct, szintigraphie) die knochenaktivität in bezug auf die fortschreitende knochenatrophie untersucht und abgeklärt. die therapieform wird nach der diagnosestellung und der daraus resultierenden diagnosebestätigung und anhand der symptomatik beim patienten bestimmt. verschiedene therapieoptionen wie eine autologe lipoinjektion, eine fettgewebstransplantation, eine freie mikrochirurgisch-anastomosierende fettgewebslappenplastik oder injektion allogener materialien werden angewendet. die diagnostik und das chirurgische vorgehen werden an zwei fallbeispielen demonstriert. die grundlegenden behandlungsstrategien stammen aus der zeit der beiden weltkriege. Ä nderungen der konzepte ergaben sich im bereich der sekundären rekonstruktion verlorengegangener strukturen sowohl im weichgewebe als auch im hartgewebsbereich durch etablierung neuer operationstechniken, welche die erzielung besserer ästhetischer und funktioneller ergebnisse ermöglichen. neben der beschreibung des traumamechanismuses erfolgt anhand von klinischen fällen die darstellung der versorgungsprinzipien. responsible for preventing fecal incontinence as well as enabling defecation. methods. works on anorectal vascularization are presented and diagnostic tools for clinical practice are discussed. results. filling and drainage of the internal hemorrhoidal plexus can be visualized by transperineal color doppler ultrasound. the terminal branches of the superior rectal artery exclusively contribute to the arterial blood supply of the internal hemorrhoidal plexus. according to anatomical studies an intramural network of anastomoses exists between the superior and inferior rectal arteries. ultrasound studies of the anorectum clearly highlighted a stage-dependent alteration of the morphology and perfusion of these terminal branches in different grades of hemorrhoids. conclusions. hypervascularization of the anorectum is proposed to contribute to the growth of hemorrhoids rather than being a consequence of hemorrhoids. pre-and postoperative assessment of the anorectal vascularization helps to judge the success of a technique for treatment of different grades of hemorrhoids. the doppler-guided haemorrhoidal artery ligation is a new, minimally invasive technique in the treatment of haemorrhoidal disease. since february patients with symptomatic second and third degree haemorrhoids have been treated this way at our department. postoperative complications occurred in , %. one month after treatment % of the patients were symptom-free and satisfied with the results. since there are very little data regarding the efficiency and the patient comfort on the long term, we questioned consecutive patients which had undergone surgery between february until december st . the questionnaire was done via telephone using standardised questions. patients with persisting or recurring symptoms were invited for a control re-examination. the results of this follow-up will be presented. background. guidelines may be helpful to standardize the management of hepatocellular and cholangiocellular carcinoma as the diagnostic and therapeutic spectrum has been considerably enlarged by recent developments. methods. ''state of the art'' guidelines deducted from the literature and from recent consensus conferences are elaborated; issues that remain controversial or not sufficiently documented by data are discussed. results. some standards have been introduced in hepatic surgery such as preoperative evaluation of liver function (and portal branch embolisation if required) or intraoperative ultrasonography. for other essential items such as techniques used for transsection of liver parenchyma or for hemostasis a variety of possibilities is at choice and the decision often depends on the personal attitude of the surgeon. as success of surgery is influenced by so many factors and imponderabilities, exact clinical evaluation is delicate and statements fulfilling the strict criteria of evidence based medicines are rarely found. only in a minority of patients with hepatocellular carcinoma transplantation or resection is possible. for the remaining patients, a variety of therapeutic procedures are warranted with effects difficult to compare given the bias of patient selection and the great inter-patient and inter-institutional variability. in the treatment of patients with bile duct carcinoma, surgery (liver resections for klatskin tumors stage bismuth i-iii, whipple's procedure for more distally localized tumors), if feasible, plays a key role as well. conclusions. excellent interdisciplinary cooperation is the clue to providing ''state of the art'' management of hepatocellular and cholangiocellular carcinoma. treatment not only has to consider tumor type and stage, but also the individuality and the overall condition of every single patient. background. colorectal carcinoma is one of the most common malignant diseases primarily diagnosed in the industrialized world. thanks to standardized surgical procedures and multimodal treatment concepts, the prognosis has improved considerably in recent decades. methods. state-of-the-art treatment of colorectal carcinoma is presented and discussed on the basis of the current literature, including the current status of minimally invasive techniques in the surgical treatment of malignant colorectal disease. results. carcinomas of the colon and rectum are two separate entities as far as biology, probability of local recurrences, metastasis patterns, surgical strategy and multimodal treatment regimes are concerned. operative treatment of colon carcinoma is generally standardized, but the concept of sentinal node biopsy is a new aspect. a metaanalysis of stage ii colon carcinoma showed a survival advantage of up to % for adjuvant therapies including -fu. the mortality rate for stage iii colon cancer could be reduced by - % with adjuvant chemotherapy. the operative standard for rectal carcinoma is heald's technique of total mesorectal excision. for proximal rectal carcinomas, a partial mesorectal excision with a greater distance (at least cm) to the edge of the tumor is adequate. with rectal carcinoma, neoadjuvant radiochemotherapy is more effective at reducing local recurrences and involves fewer complications than does postoperative treatment. accordingly, neoadjuvant radiochemotherapy is indicated at least for t- tumors of the lower and middle thirds of the rectum. in all, total survival and fewer local recurrences are seen with combined radiochemotherapy for rectal carcinoma. a number of randomized prospective studies published since showed comparable long-term results for laparoscopic and open colon surgery. the results of such studies on rectal carcinoma are not yet available. conclusions. the key factors for improving the prognosis of colon and rectal carcinoma are, besides early diagnosis, standardized surgery and multimodal, individualized treatment concepts. prophylactic operations in palliativ surgerya conflict? background. to date approximately % of the eu-citizens decease on malign tumors. here an increased tendency was noticed in the past. this circumstance is present in the surgical day-to-day life. patients with predictable and linited prognosis often require the decision whether a prophylactic surgical procedure would prevent further complications or may declerate progression of malign tumors. methods. the status and progression of patients with oncological focus were analyzed in the department of surgery of the helios-hospital schwerin. two groups were studied. first surgical procedures due to general symptoms of the tumorous disease. second, surgical therapy of specific symptoms as a consequence of the tumor. results. inter-disciplinary diagnosis and discussion were crucial for the decision whether a palliativ-prophylactic operation was necessary or not. futhermore, prophylaxis in palliative medicin and surgery required a multi-disciplinary therapy regime. for the inter-disciplinary decision, guidelines proposed by the established ''tumorboard organization'' were applied. for general symptomatic treatment, palliativ-prophylactic procedures due to pain therapy, gastro-intestinal symptoms, emesis, ileus, ascites, icterus, cachexia, respiratory and urological complications, and wound management were accomplished. conclusions. prophylactic operations are frequent and represent the reality in palliative surgery. the ''tumorboard organization'' was administrable for a structured ultimate therapy decision. here forensic guidelines regarding self-determination, protection of integrity, autonomy of the patient, and euthanasia have to be considered. the perception of the personally responsibility of the attending physician still possess highest priority. background. within the last decade thyroid surgery has been radicalized. two parties have emerged from the discussion. one group, trying to preserve thyroid as central element of the body -the other one, in light of an easy replacement therapy, does not feel the need for that. methods. we compare patients operated from - at our department. one group underwent dunhilloperation (dh) n , the second thyroidectomy (t) n . complication rate and change of therapy were compared, remaining tissue was sonographed. the patient's opinions were sought using questionnaires. results. monitoring period lasted - months. recurrensrate showed no significant difference (dh: . =t: . ) and bleeding results also didn't show any differences. we did notice a higher hypoparathyroidismus rate with the thyroidectomy group (dh: . =t: . ). % of all sonographies in the dunhill group required further investigation because of remaining nodulare tissue. changes with substitution therapy didn't show any differences. the patient's opinions were identical in both groups. conclusions. both techniques require a simple substitution therapy. they are both safe methods, although the hypoparathyroidism is higher with thyroidectomy. on the other had we observed a progress in learning over the years thus we noticed no significance in . when using dunhill procedure, remaining tissue must be checked regularly. in our opinion, it is no benefit for patients with replaced tissue. evaluation of a new needle for thyroid fine needle aspiration biopsy p. wretschitsch , m. glehr , t. kroneis , a. leithner , r. windhager background. to verify the destinction of thyroid tumors, the volume of harvested cells in fine needle aspiration biopsy is one of the significant parameters for histological criteria and diagnosis. in consequence of the new aeration valve, the new needle is deaerated after the aspiration. thereby no blood or other not thyroid-cell elements are aspirated and more thyroidcells are harvested. methods. under blinded setting punctures, for each needle (standard needle, -needle with air valve and multi needle system with air valve), from fresh pig thyroid gland were made and recorded. the measurement was done according the manufacturers recommendations for casy (casy + technology, reutlingen). the aspirated cell material was evacuated into ml casyton (cell-culture liquid, casy + technology, reutlingen) and calculated with the casy (casy + technology, reutlingen) cell counter. total cell amount and amount of vital cell was counted and recorded. statistical analysis was performed using t-test (p < . was considered significant). results. per needle respectively punctures were made and counted. the mean cellular amount of the standard needle was cells=ml. the mean cellular amount of the -needle system with aeration valve was cells=ml. the average of cell amount for the multi needle system (thyrosampler + kurtaran-frass, vienna) was cells=ml. the mean difference between the standard needle and the -needle system with air valve was significant with total cells (p ¼ . ) and with vital cells (p ¼ . ). the difference between -needle and multineedle system was not significant with total cells (p ¼ . ) and with vital cells (p ¼ . ). tag conclusions. the needle systems with the air-valve lead to a significant higher cell amount in needle aspiration biopsy. according to the requirement of cytological diagnosis more cell volume could be harvested, which is a well-defined benefit. does the lunar phase influence the incidence of postoperative haemorrhage after thyroid surgery? a preliminary report background. it is claimed by non-scientific sources that operations carried out at waxing moon or especially at full moon are associated with a higher incidence of postoperative complications. therefore patients referring to lay press confront surgeons with the lunar phase's influence and claim for special dates for surgery. postoperative haemorrhage is a typical complication after thyroid surgery with an incidence of about . %. thus it is a suitable to assess this assumption by evidence-based data. methods. we retrospectively evaluated patients requiring reoperation after thyroid surgery. the exact time of skin incision was evaluated by anaesthesia's reports and its lunar phase was calculated by an online-calculator. results. in a timeframe of days (in all) around full moon patients had to be reoperated, days around new moon patients needed surgical reintervention. patients were operated during waxing moon, the phase that is believed to be a risk for postoperative complications, and patients during waning moon. no differences were seen between the categories st þ th quarter ( operations), the quarters around new moon, and nd þ rd quarter ( operations), the quarters around full moon. conclusions. our study shows no correlation between postoperative haemorrhage after thyroid surgery and lunar phase at initial surgery. these evidence-based data prove, that lunar phase does not influence the risk of bleeding after surgical interventions. these results should serve as information for those patients, who are convinced, not to be operated during full moon phase. the result should also bring the ''superstition'' to a halt. background. recently gender-specific medicine has become the focus of interest. after thyroid surgery we observed more hypocalcaemia-related symptoms in women than in men. our goal was to find out gender-specific differences in the postoperative calcium-and parathyroid hormone (pth)-kinetics. methods. pth-and calcium-levels as well as postoperative hypocalcaemia-related symptoms were monitored according to a prospective protocol. a total of women and men underwent extensive thyroid surgery. postoperative calcium levels revealed a non-significant difference of . mmol between women and men on the st postoperative day. perioperative pth-kinetics showed no significant differences too, neither in symptomatic patients, nor in the whole study population. the rate of postoperative hypocalcaemia-related symptoms was about higher in women than in men ( - %, respectively). conclusions. despite of similar perioperative pth-and calcium-kinetics women suffer more often from postoperative hypocalcaemia-related symptoms. the mechanism remains unclear and needs further research in gender-specific postoperative calcium-metabolism. background. grave's disease (gd) is thought to be associated with a higher incidence of postoperative hypocalcaemiarelated symptoms. methods. parathyroid hormone (pth)-and calcium-levels as well as postoperative hypocalcaemia-related symptoms were monitored according to a prospective protocol. preliminary data were analysed for patients with an observation period of more than months. results. total or near-total thyroidectomy was carried out in patients with gd and patients with benign euthyroid multinodular goitre. differences between patients with gd and patients with benign euthyroid nodular goitre were found for postoperative hypocalcaemia-related symptoms ( . , . %, respectively). these findings were statistically significant (p < . ). furthermore, no significant differences were found in perioperative pth-and calcium-kinetics between the groups. patients with gd were of a significant (p < . ) lower mean age ( ae ) than patients with benign euthyroid multinodular goitre ( ae ). conclusions. there is a significant higher risk of postoperative hypocalcaemia-related symptoms after surgery for gd compared to benign euthyroid multinodular goitre. there is no significance concerning the risk of permanent hypoparathyroidism in our preliminary data set. background. intraoperative parathyroid hormone [pth] monitoring is an important prerequisite for minimally invasive parathyroid surgery. thus, surgical success essentially depends on the correct intraoperative interpretation of the pth-decay. pth-''spikes'' caused by unintentional ''manipulation'' of the hypersecreting glands during dissection may lead to interpretation problems. it is unclear how often these ''spikes'' occur and how they influence the operative strategy. we evaluated manipulated pth-excretion during surgery in a large number of patients and analyzed its influence on the interpretation of the intraoperative pth-curve. methods. intraoperative pth-values (intact pth, nichols, san jose, california) of patients with primary hyperparathyroidism and single gland disease were analyzed. of these patients, ( . %) were successfully treated with open minimally invasive parathyroidectomy (omip), ( . %) with primary bilateral neck exploration (bne) and ( %) patients had to be converted from omip to bne. to evaluate the occurrence of manipulation, patients were divided into groups: ''moderate'' pth-increase (< pg=ml), ''extensive'' increase (> pg=ml), ''no'' increase (ae pg=ml) and ''decrease'' before excision. changes were referred to the ''baseline''-level which was sampled right after induction of anaesthesia and before incision. intraoperatively, pth was measured before, , and min after removal of the enlarged gland. results. overall ( %) had a moderate increase and ( . %) an extensive increase. no increase occurred in ( . %) and a decrease in ( . %) patients. in patients undergoing omip, ( %) glands were manipulated moderately, another ( %) glands were extensively manipulated, ( . %) had no increase and ( . %) had a decline. in patients undergoing primary bne, ( . %) glands were manipulated moderately, ( . %) extensively and ( %) had no increase. a decrease was observed in ( . %) patients. a conversion from omip to bne was performed in patients because of incorrect preoperative localization by sestamibiscintigraphy and=or sonography. five ( %) of them had moderate manipulation and no patient had extensive manipulation. eighteen ( %) showed no pth alterations and ( %) a decrease, retrospectively. in none of the converted patients a misinterpretation of pth-''spikes'' were the underlying cause. conclusions. the data show that intraoperative manipulation is documented in bne and omip. the ''spikes'' caused by unintentional manipulation were identified by a subsequent prolonged pth-decline but did not lead to a change in the surgical strategy. parathyreoideakarzinome zählen zu den seltenen tumoren und sind für weniger als % aller primären hyperparathyreoi- background. at international meetings, delegates from many countries report an increasing lack of young doctors willing to choose operative specialities. the aim of this study was to evaluate the working conditions for surgeons in austria and to define the most crucial items calling for amelioration. methods. an anonymous survey was prepared and by e-mail all the members of the austrian surgical society were asked to complete a questionnaire which could be reached online by a direct link. it comprised twenty questions and was kept deliberately short in order to require a minimum of time for response. results. just some examples of the essential items can be given here: working conditions (such as working hours and payment) have to be improved. notably the young surgeons require career perspectives that are better and defined more clearly. the time spent for non-medical duties such as organization and documentation must be reduced. more priority is needed for surgical training both in the operating room and in practically oriented courses. conclusions. this evaluation provides the basis for further discussion at a session dedicated to this topic during the austrian surgical congress of . background. surgical training and education is neither standardized nor regulated. there is no validation, no obligatory training goal and no implementary rotation system. recently, the training permission for surgeons in education in the surgical department of kaiserin elisabeth spital has been shortened by the austrian medical association from to years without evidence based data i.e.without the consideration of the underlying number of operations performed in the clinic. methods. the surgical department is a center of thyroid and parathyroid surgery, which also covers the extended oncological cases, minimal invasive surgery, hernia operations and has the largest capacity for acute abdominal diseases in vienna. to analyze the quality of surgical education, the whole number of operations as well as the number of trainees in nd and th training year are tallied for analysis. results. in , a total number of operations ( thyroid and non thyroid operations) have been performed in our surgical department. trainee a ( years of education) performed ( thyroid and non thyroid operations), trainee b ( years of education) operations ( thyroid and non thyroid operations). the non thyroid operations of trainee a included cholecystectomies, herniotomies, appendectomies, operations of colon or small bowel, all other will be listened in detail. trainee a had = , trainee b = gastroscopies=colonoscopies performed. conclusions. the number of operations prove that the goal of training for surgeons in education is easily achievable. the reduction of training permission by the vienna medical chamber was not evidenced by data. however, this procedure has once again raised the insufficient structures in surgical education, the lack of valid training program and standardized approaches for a defined rotation and the obligation for both, senior surgeons and trainees to perform a certain number of teaching operations. a structured reform of rules and regulations for training is necessary. background. the purpose of this study was to review our hospital's experience in a retrospective single-center analysis of all patients undergoing surgery for posttraumatic thoracic pathologies between and . methods. from to october a total of aortic procedures were performed at our institution. eighty eight patients ( . %) underwent an intervention ( surgical procedures, stentgraft implantations) due to a posttraumatic injury of their thoracic aorta. in > % the descending aorta was involved, the injuries consisting of % aortic rupture, . % posttraumatic pseudo-aneurysms and . % aortic dissection. in the surgical cohort . % of the patients had to undergo an emergency procedure, . % an urgent and . % an elective procedure. there were . % female patients and . % male patients with a mean age of . years (range - yrs). results. during the three decades total hospital mortality was . % with a decrease over the years, thus resulting in a hospital mortality of . % ( - ) versus . % ( - ) . hospital mortality in the emergency group dropped from . % ( - ) to . % ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . improved outcome is mainly due to preoperative aggressive control of blood pressure and aortic shear forces using -blockade, intraoperative the use of heparin bounded circuits with cardiopulmonary bypass and most of all, a selectively delayed operative procedure (!). conclusions. although endovascular stent graft techniques continue to evolve, emergent=urgent patients will be anatomically not suitable for stent grafts and long term outcomes have yet to be determined. we therefore still consider selectively delayed surgery in patients with posttraumatic aortic pathology as a cornerstone in the choice of treatment for these patients. combined surgical and endovascular repair of complex aortic pathologies with a new designed hybridprosthesis background. in the present study the use of a new combined surgical and endovascular approach in the treatment of aortic dissection or aneurysm is evaluated. the aim of this technique is to treat extensive aortic diseases in a single stage procedure. the operative and follow up data are summarized in this report. methods. between = and = six patients ( ae years; female) with different aortic pathologies ( dissections, aneurysms) underwent replacement of ascending aorta, aortic arch and stentgraft implantation into the descending aorta using the e-vita open endoluminal stentgraft under circulatory arrest in moderate hypothermia with selective antegrade cerebral perfusion. the stentgraft was deployed under direct vision through the open aortic arch into the true lumen. results. intraoperative antegrade stenting of the descending aorta combined with distal ascending aorta and aortic arch repair was performed successfully in all patients. all patients survived the procedure one patient had neurological deficit, which recovered completely. a complete thrombosed perigraft space was observed in patients after one to eleven days. in two patients a partial thrombosis of the false lumen of descending aorta was observed. one patient underwent thoracoabdominal repair five months later. conclusions. this report shows that a combined surgical and endovascular approach of extended aortic lesions is a feasible option and extends aortic repair in a single stage method without increase of risk. background. to evaluate mid-term results of supraaortic transpositions for extended endovascular repair of aortic arch pathologies. methods. from through , patients (mean age yrs) with aortic arch diseases were treated (arch aneurysms n ¼ , type b dissections n ¼ , perforating ulcers n ¼ ). strategy for distal arch disease was autologous sequential transposition of the left carotid artery and of the left subclavian artery in patients. strategy for entire arch disease was total supraaortic rerouting using a reversed bifurcated prosthesis in patients. endovascular stent-graft placement was performed metachronously thereafter. results. two in-hospital deaths occured (myocardial infarction on the day prior to discharge n ¼ , rupture while waiting for stent-graft placement n ¼ ). at completion angiography, all reconstructions were fully patent. four patients had small type ia endoleaks, two of them resolving spontaneously. mean follow-up is months ( - months) . three late deaths occured (myocardial infarction n ¼ , sudden unknown death n ¼ ). one year survival was % and three year survival was %, respectively. redo stent-graft placement was performed in one patient after months (type iii endoleak). the remaining patients had normal ct scans with regular perfusion of the supraaortic branches without any signs of endoleaks. conclusions. mid-term results of alternative treatment approaches in elderly patients with aortic arch pathologies are satisfying. extended applications provide safe and effective treatment in patients at high risk for conventional repair. background. to determine mid-term durability of endovascular stent-graft placement in patients with perforating atherosclerotic ulcers (pau) involving the thoracic aorta and to identify risk factors for death as well as early and late adverse events. methods. from through , patients (mean age yrs) presented with pau, seven patients had rupture. seventy-eight percent were unsuitable for conventional repair. mean numeric euroscore was and mean logistic euroscore was . median follow-up was ( - ) months, being complete in all patients. outcome variables included death and occurrence of early and late adverse events. results. in-hospital mortality was %. primary success rate was %. actuarial survival rates at , and years were , and % and actuarial event-free survival rates were , and %, respectively. hemodynamic instability as well as logistic euroscore was identified as independent predictos of early and late adverse events. conclusions. endovascular stent-graft placement in patients with pau is an effective palliation for a life-threatening sign of a severe systemic process. hemodynamic instability at referral and a high preoperative risk score predict adverse outcome. during mid-term follow-up, patients are mainly limited by sequelae of their underlying disease. background. the performance of endovascular stent-graft placement in patients suffering from aneurysms involving the descending aorta originating from chronic type b dissections is unclear. methods. within a two-year period, we treated six patients with this pathology. four patients required extension of the proximal landing zone (autologous double transposition n ¼ , subclavian-to-carotid artery transposition n ¼ ) prior to stentgraft placement. results. supraaortic rerouting procedures and endovascular stent-graft placement were performed successfully in all patients. closure of the primary entry tear, full expansion of the stent-graft and consecutively, thrombosis of the false lumen was achieved in five patients. in one patient with a short proximal landing zone, a persisting type ia endoleak had to be observed. in all patients with successful primary entry closure, a reduction in aneurysm diameter could be seen. mean follow-up is months ( - months). conclusions. endovascular stent-graft placement of aneurysms involving the descending aorta originating from chronic type b dissections may serve as a valuable treatment option in a complex pathology. the chronic dissection membrane can be successfully approximated to large parts of the native aortic wall. a sufficient proximal landing zone is mandatory for early and late success. background. the aim of the study was to determine late vascular events in patients after endovascular stent-graft placement of thoracic aortic diseases. methods. between and a total of patients (mean age a; % male ¼ ) underwent endovascular stentgraft placement of thoracic aortic diseases at our institution. indications were aneurysms (n ¼ ), acute and chronic type b dissections (n ¼ ), penetrating ulcers (n ¼ ) and traumatic transsections (n ¼ ). results. during a median follow-up of months ( - months), in % of patients, late vascular events were observed. the highest incidence was observed in patients after stent-graft placement for type b dissections ( %), closely followed by patients after stent-graft placement for penetrating ulcers ( %). the incidence after stent-graft placement for aneurysms was %. no events were observed in patients after traumatic transsections. interestingly, patients undergoing stent-graft placement due to dilatative arteriopathy developed further dilatations in other regions and patients undergoing stent-graft placement due to obliterative arteriopathy were more prone to sustain obliterative diseases in other vascular beds. conclusion. this study clearly outlines the necessity of a close follow-up in these patients, not only to assess long-term outcome of endovascular stent-graft placement, but also to monitor these patients for new vascular pathologies. tenascin-c as a key factor in the remodeling of the ascending aorta leading to chronic dilatation and acute type a dissection background. the extracellular matrix molecule tenascin-c (tn-c) plays an important role in embryonic development, wound-healing, cancer invasive fronts and myocardial remodeling by loosening the linkage between connective tissue and cells lying within. as there is clear evidence for an involvement in vascular remodeling as well, we hypothesized tn-c being a mediator in the pathogenesis of chronic dilatation of the ascending aorta and acute aortic dissection. methods. ascending aortic wall specimens were obtained from patients undergoing aortic reconstruction due to chronic dilatation of the ascending aorta (n ¼ ) and acute aortic dissection stanford type a (n ¼ ). specimens of patients (n ¼ ) undergoing aortic valve replacement with a macroscopically normal aorta served as controls. formalin-fixed paraffin-embedded specimens were morphologically evaluated by hematoxylin-eosin staining and immunostaining for tn-c expression. results. there were no differences in clinical characteristics concerning age and gender between patients with acute dissection, chronic dilatation and control. patients with a known connective tissue disorder or bicuspid aortic valve were excluded from the study. histologic examination showed a clear difference between chronic dilatation and acute dissection. in chronic dilatation tn-c staining was homogenously distributed throughout the media parallel to the orientation of vascular smooth muscle cells. in contrast specimens in acute aortic dissection showed a focal strong positive staining especially surrounding vasa vasorum and sites of intramedial hemorrhage and subsequent dissection throughout the whole vessel wall with tn-c negative areas in between. whereas in control aorta tn-c expression was almost absent. conclusions. these data suggest a role for tn-c in the remodeling of the ascending aorta leading to chronic dilatation and type a dissection. keeping in mind the differences in tn-c expression between chronic dilatation and acute dissection one may speculate that changes of the vascular wall leading to aortic dissection are mediated or at least accompanied by a change in tn-c distribution. a complicated type b-dissection: how (not) to do it j. demmer , m. alavian , p. pichler , c. groß chirurgie , akh linz, linz, austria; radiologie, akh linz, linz, austria complex type b-dissection is still accompanied with high mortality. we report on a years old male with a weeks ongoing history of thoracic pain. he was admitted to another hospital where a left renal artery stenosis in ct scan was suspected and a stent was applied into the false lumen of this artery. then the patient was transferred to our institution. angiogram revealed a type b-dissection with a hugh entry distal to the left subclavian artery, the coeliac trunk arising from the false lumen but the hepatic arteries adequately collateralized by the superior mesenteric artery. though guidewire insertion to the true lumen of the common hepatic artery was feasible, stent application was not possible.the entry in the proximal descending aorta was covered with an endostent, thoracic pain disappeared immediately. though a slight pain in the right upper abdomen and a moderate raise of got, gpt and y-gt was to be seen for a few days, the patient could be discharged weeks after stenting in good condition without having pain or signs of cholecystitis. another days later he was readmitted in bad condition with signs of peritonitis in the right upper abdomen, , wbc and a massive increase of liverenzymes. laparatomy was performed immediately. the gallbladder presented necrotic, the whole liver dark blue without any pulsation in the hepatic arteries. after choecystectomy an autologous venous bypass from the common iliac to the propriet hepatic artery was performed. the postop. course presented uneventful, angio-ct at postop. day showed a well contrasted bypass. the patient could be discharged at postop. day without any signs of infection and only slightly elevated liverenzymes. background. endovascular aneurysm repair (evar) evolved as a treatment option for high risk patients, in whom previously open graft replacement (ogr) could only be carried out with a high, nearly prohibitive risk or open repair even had to be denied. by employing evar the mortality rates (mr) were lowered to - % in specialized centers. unsolved is the problem of how to deal with patients unsuitable for evar. the hypothesis of this study was to test whether thoughtful watching combined with management of present risk factors or ogr were second best to evar in asa class iv patients with abdominal aortic aneurysms (aaa). methods. out of a total of aaa-patients two groups of asa class iv patients were selected and compared. group consisted of patients who underwent ogr from - . group included patients unfit or unwilling to undergo evar in the period from - . kaplan-meier survival estimates were calculated and possible differences were analyzed by the log-rank-test. results. the day survival was . % in group versus % after days following the denial of operation in group (p < . ). the days survival was again significant with p < . , group % versus group . %. after one year survival was not significant anymore, i.e. group . % versus group . % (p < . ). conclusions. ogr has a significantly worse survival than conservative treatment in asa class iv patients in the first months after operation. after one year both treatment options show similar results. background. abdominal aortic aneurysm (aaa) size has been recognized as risk factor of rupture. several reports presented evidence that aaa with diameters exceeding . cm are associated with increased risk of rupture compared to smaller aneurysms. regarding these findings a diameter of more than . cm is generally considered as indication for exclusion. this analysis was undertaken to determine the influence of aneurysm diameter on long term outcome after either type of elective aaa repair. methods. eight hundred and sixty four consecutive patients underwent elective repair of an infrarenal aaa either by open graft replacement (ogr, n ¼ ) or endovascular aneurysm repair (evar, n ¼ ) from january, , through june, . median aaa diameter was chosen as threshold to discriminate between small and large aneurysms. patient characteristics, distribution of preoperative risk factors and postoperative outcome after either type of aaa exclusion were assessed. survival was compared using kaplan-meier estimates at years. results. overall median aaa diameter was . cm as well as in both treatment groups. analysis of risk factors only re-vealed that patients with larger aneurysms were significantly older (ogr . years vs. . years, p < . ; evar . vs. . years, p < . ) but comparison of individual health status expressed by the american society of anesthesiologists (asa) score did not reach statistical significance. at years, overall survival was higher in patients with small aneurysms ( . vs. . %, p < . ). similar results were obtained in patients undergoing ogr ( . vs. . %, p < . ) as well as evar ( . vs. . %, p < . ). conclusions. patients with aneurysms smaller than . cm have improved survival at years after either type of elective aaa repair. large aneurysm diameter is accompanied with increased age, which might negatively influence long term outcome. thus, the provoking issue to exclude small aaa before they reach . cm may rise again. background. about microsurgical techniques without sutures many references in literature databases are found. among facilities like rings, clips, stents, laser and adhesives the vessel coupling system (coupler + ) is mentioned. thereby two coupling rings interlock, which anastomose the vessels. methods. over the last two years in our division the coupler + was used in nine cases of free tissue transfer for breast reconstruction. in six of them the arterial and venous anastomosis were performed with the coupler + , in three cases only the venous anastomosis was done mechanically. in all cases the anastomosis was end-to-end. results. because of insufficient arterial adaptation in two cases we switched to a conventional procedure with sutures. all the other anastomosis showed a normal flow. except of one partial necrosis of a flap, which was not due to the coupler + , all flaps survived. the mean duration of doing the anastomosis was less than five minutes. conclusions. the coupling system (coupler + ) is a useful, secure and time saving tool for the venous anastomosis when performing a free tissue transfer. for the arterial anastomosis the conventional method is preferable, especially in cases of arteries with thick walls. background. non-operative management of splenic injuries is beneficial compared to surgery in hemodynamically stable patients. aim of this study was to assess whether conservative treatment would also translate into better quality of life post injury. methods. all consecutive patients with splenic injuries between january to february were included. splenic injuries were graded according to aast recommendations [ ] . patients were identified from our electronic inpatient index and stratified by non-operative treatment (non-operative group, nog) or primary surgery (splenectomy) (surgical group, sg). postdischarge quality of life was evaluated by a standardized telephone questionnaire. data are reported as total numbers (%) and statistical analysis performed using chi -tests. significance was assumed if p < . . results. of a total of patients enrolled, ( . %, nog) were treated non-operatively, and ( . %, sg) underwent splenectomy. splenic injury grading was comparable between both groups. after trauma, most patients were able to leave their bed three days after trauma ( rd postoperative (po) day: nog ( . %) vs. sg ( . %), p ¼ . ; st week po: nog ( . %) vs. sg ( . %), p ¼ . ; nd week po: nog ( . %) vs. sg ( . %), p ¼ . ), and the majority felt seriously ill during hospitalization (critically ill: nog ( . %) vs. sg ( . %), p ¼ . ; seriously ill: nog ( . %) vs. sg ( . %), p ¼ . ; not very ill: nog ( . %) vs. sg ( . %), p ¼ . ). unlike sg patients, about half of the nog patients could be discharged one week after trauma ( week: nog ( . %) vs. sg ( . %); p ¼ . ). sg patients significantly longer felt severe pain compared to nog patients ( weeks: nog ( . %) vs. sg ( . %), p ¼ . ; > months: nog ( . %) vs. sg ( . %), p ¼ . ). after discharge, nog patients were able to resume daily life activities earlier compared to patients after surgery ( weeks: nog ( . %) vs. sg ( . %), p ¼ . ; < month: nog ( . %) vs. sg ( . %), p ¼ . ; ! months: nog ( . %) vs. sg ( . %), p ¼ . ). conclusions. patients with non-operative management reported less pain and were earlier able to resume daily life after splenic trauma compared to patients undergoing splenectomy. plantation in order to prevent cmv disease. we recently evidenced immunomodulatory properties of pooled human immunoglobulines. the aim of this study was to evaluate influence of cytotect + and cytoglobin + a) on proliferative properties of peripheral blood mononuclear cells (pbmcs), b) on cell viability and c) on natural occurring cell mediated cytotoxicity. methods. pbmcs from healthy donors (n ¼ ) were stimulated with anti-cd ( mg=ml) or in an allogeneic mixed lymphocyte reaction (mlr). proliferation was determined by incorporation of [h]-labeled thymidine. apoptosis was measured by flow cytometric analysis (annexinv, -aad, cd , cd , cd , cd ). transmission electron microscopy (tem) was utilized to support facs data. antibody dependent cell mediated cytotoxicity (adcc) was determined utilizing a standard europium release assay. cmvig (cytotect + biotest, cytoglobin + bayer) was used at therapeutic concentrations in all experiments. results. cytotect + and cytoglobin + evidenced anti-proliferative properties in t-cell specific stimulation and in mlr blastogenesis assays. this effect was dose dependent and ceased at concentrations of . mg=ml (p < . ). facs analysis and tem pictures revealed that the reduced proliferation was associated with induction of apoptosis in stimulated as well as in resting pbmcs (p < . ). furthermore, adcc against panc- and jurkat cell lines was significantly reduced after preincubation of effector cells with cmvig (p < . ). conclusions. our results provide evidence that cmvig containing drugs possess, in addition to their known application as passive cmv immunization, immunological features related to tolerance induction. background. multichannel intraluminal impedance (mii) monitoring is a new diagnostic tool for esophageal bolus transport and reflux assessment. methods. review on mii technology for diagnosis of esophageal disorders. results. impedance is a measure of resistance to the flow of an alternating electrical current. a low voltage current is applied to surface ring electrodes on a nonconductive catheter. impedance is determined by the conductivity of the medium bridging these electrodes. entry of liquid into the esophageal lumen produces a drop of impedance. gas entry results in a sudden rise of impedance. monitoring impedance in several channels detects direction, velocity and extent of the movement of liquid or gas through the esophagus. stationary equipment combining manometry and impedance is used for simultaneous esophageal motility and transit studies. transport studies using impedance only can also be done with probes intended for reflux testing. saline and a viscous gel are used to assess transport through the esophagus. in a recent study with combined impedance and manometry a significantly higher proportion of patients with incomplete transport of both liquid and viscous boluses ( = , %) presented with dysphagia than patients with complete transport of both ( = , %) or incomplete transport of only one ( = , %) of the test substances. equipment joining impedance with high-resolution manometry is currently being developed. a higher sensitivity and specificity for regional motility and transport abnormalities is to be expected from this technical advancement. portable recorders are available for -hour mii-and ph-monitoring. refluxes are detected by retrograde impedance changes: liquid refluxes are characterised by retrograde drops, gas refluxes by rapid increases and mixed liquid=gas refluxes by a sequence of both deviations from the baseline. the main advantage of impedance technology over conventional ph-monitoring is the detection of refluxes independent of ph. off antisecretory medication refluxes with ph > are mainly encountered postprandially, at a time when regurgitation is commonly experienced by reflux patients. the diagnostic yield of symptom to reflux association analysis is significantly increased by the inclusion of refluxes with ph > . distribution of impedance channels along the catheter facilitates the calculation of reflux exposure at different levels above the lower esophageal sphincter. conclusions. mii is a valuable new diagnostic tool for esophageal transport assessment without radiation exposure. combined mii-and ph-monitoring significantly increases the diagnostic yield of reflux testing. both applications of impedance technology have implications on surgical decisionmaking. trans-illuminated powered phlebectomy w. mayerhoffer the trans-illuminated powered phlebectomy was introduced in austria in about by smith and nephew as the ''trivex system''. a . mm shaver, as used by orthopaedists for cartilage, was used in order to mill out subcutaneous veins in a transilluminated technique. due to only a few and small incisions needed, the method seemed very attractive, so many surgical departments started using this orthopaedic equipment. most surgeons had a lot of complications, such as disastrous extensive haematomas, which made them stop using this method. mean while the trans-illuminated powered phlebectomy has been further developed. instead of the orthopaedic tools, a special phlebologic equipment is used now which allows the vein to be ''sucked'' out in a very non-traumatic order, instead of being milled out. the procedure is standardized and can be reproduced easily. it shows to be a non-traumatic and minimal invasive method to extract subcutaneous varicose veins, leaving a minimum of scares. large clusters of varicose veins are the best indication to use this procedure. the veins are made visible by transillumination in order to be accurately removed through a minimal number of small incisions. the new equipment and the technique will be described and explained. examples and results will be shown. background. total endoprosthesis in wrist joint is a rather new procedure compared to hip and knee surgery. biomechanics of the wrist joint is very complex and therefore designing the carpal and radial component of the prosthesis should respectfully consider this. indication for joint replacement and total endoprosthesis are posttraumtic and degenerative arthrosis of wrist joints. generally we tend to perform a partial fusion depending on where the arthrosis is located, but we have stopped to perform total arthrodesis of the wrist joint due to unsatisfying long term results, according to literature. we perform total endoprosthesis in all cases when a partial fusion is impossible for any reason or a total arthrodesis would be indicated. methods. nine males [ - a] four females [ - a]. seven of nine men suffered from a posttraumatic arthrosis ( slac snac). all patients sufferd from serious reduction of range of motion and severe pain. in one case a partial fusion was converted into a total prosthesis. two women had degenerative alterations of their wrists based on rheumatoid desease. the follow up covered months to years. results. in = cases range of motion was improved impressively and pain was relieved almost completely. seven men displayed a rom of s = = ; pro-supination totally unaffected and free. in one case we found rds. x-ray examination revealed a slightly false implant position of the radial component to us. rom in women was at least s = = . conclusions. in the beginning of wrist joint endoprosthesis results were less well and it was shown that this was due to misunderstanding biomechanical basics of the wrist joint. the fixation of the carpal element was a severe problem, like passing through the cmc , and joint line distally into the basis of the metacarpal bones and since cmc and joints have a rather high rom the distal element consequently often loosened immediately. recent implants respectfully avoid passing through these joints and loosening of the distal element has never been seen in all our cases. in our opinion the endoprosthesis of wrist joint is a real alternative to common procedures in the treatment of wrist arthrosis. background. volar fixed-angle plate osteosynthesis of distal radius fractures is a new method of treatment that provides the benefits of stable internal fixation without incurring the disadvantages of the dorsal approach. the aptus + plate is a new fixation implant that was introduced specifically for the purpose of managing dorsal displaced fractures (colles fracture) from the volar aspect. the aptus + system provides stepless multidirectional placement of screws. the range of swivel ae in all directions, can be freely selected by the surgeon. methods. between april and september ( months) we have seen patients with a distal radius fracture. eighty five patients ( women, men; mean age . years) were treated with the medartis + aptus + plate. our therapy regimen: closed reposition in the operating room palmar access along the radial side of the flexor carpi radialis (fcr) muscle plating with subchondral screw placement begin of physiotherapy on the first postoperative day and removeable orfit splint for weeks. results. the clinical and radiological follow up after Ø months showed no secondary loss (relative protrusion of the ulna, dorsal or radial tilting) of correction. compared to the contralateral side the range of motion was decreased for % in extension=flexion, % in ulnar=radialduction, % in pronation=supination. the grip strength was decreased for % compared with the contralateral side. the castaing score shows perfect results, good results, adequate result and no moderate, poor or bad results. conclusions. our data clearly show that secondary correction loss can be avoided with the aptus + system. the system provides a reliable subchondral screw placement and solid support for the joint surface. this new plate makes meaningful early mobilization possible. the palmar approach provides exact fracture reposition and with its good soft-tissue coverage not only reduces the risk of infections but also offers the possibility of not having to remove the plate. a cancellous bone graft is not necessary. background. the arthrosis of the first carpometacarpal joint is one of the most common problems in handsurgery. primarily elderly women are affected by rhizarthrosis. under conservative treatment the continuing progress leads to operation indication, for pronounced pain and insufficiency of conservative therapy options. the huge amount of well-know operation methods shows, that no satisfying option could have been described. next to simple resection procedures, today interposition and suspensionarthroplasties play a key role in the care of arthrosis of the thumb saddle joint. the amount of endoprothetic procedures in the first carpometacarpal joint has been rather small, the results often remained unsatisfying. a rather new concept is the prosthesis elektra, developed by fixano in , that reminds of the classic de la caffiniere prosthesis, first described in . methods. in the years = in our department patients (Ø . years - , male:female ¼ : ) with advanced saddle joint arthrosis were treated with different operation methods: patients received an elektra-prosthesis, patients a resection-suspension arthroplasty martini. thirty seven of these were recorded in the follow-up study. the rest of the patients were deceased, removed or not accomplishable. the follow up examination contained following criteria: dash score, subjective pain scale, range of motion and radiology. results. in the follow-up examination of patients no significant differences in average results of the different operation methods could be investigated. thus, the group of patients with very good results contained significantly more patients with elektra prostheses than patients treated with martini operation. in the opposition a higher complication rate could be seen in patients with elektra prostheses. especially the loosening of the implant cup was a frequent complication in average dash score, subjective pain scale and range of motion showed similar results in both methods. conclusions. our results show that the elektra prosthesis is a good and efficient alternative method to other well-known treatment concepts of rhizarthrosis. the amount satisfying results of the elektra group excel the good results in the martini group. the biggest problem concerning the elektra prosthesis is the high frequency of cup loosening, that is unacceptable high. the treasons for that matter could be complex: . biomechanical problem, because of the converting of a saddle joint to a universal joint, . metallurgic problem that could be solved by the use of different surface material, . vitality problem of the os trapezium because of an unfavourable quotient of metal and bone. unsettled remains, if revision or cementing of the cup could be a possibility to salvage of the implant. a conversion of the procedure to resection methods is possible anytime. so the use of the elektra prosthesis still is a good alternative under the condition of a clear indication and information of the patient about the possibilities of loosing. background. posttraumatic arthrosis as well as loss of function in the pip joint due to rheumatoid disease mean for the patient to be afflicted with pain. in many cases this leads to serious diminution of quality of life and in some cases the patient looses his occupation. it is the goal of implantation of total endoprosthesis to sustain movement and improve the range of motion, but most importantly to exterminate the pain. certainly removement of pain can be obtained by a simple arthrodesis but this of course is less satisfying in comparsion with mobility in the pip joint provided by the prosthesis. since pip joint endoprosthesis is a relativley young and new procedure there are only view experiences found in literature. methods. nine pip-endoprostheses have been implanted without cement so far. in cases posttraumtic arthrosis was the indication for this procedure; in cases rheumatoid destruction of the joint. in all cases the collateral ligmantes were intact. four lpm and sr avantas were used. postoperative the finger was placed on a splint for one week in intrinsic plus position. after days we commenced passive ergotherapiy and after one week we started with active motion. results. mobility was improved impressively in cases. all patients were almost completely free of pain. all pipjoints were stable. there was one patient who suffered from a new trauma after the operation and the proximal component had gotten loose, so we had to convert it to an arthrodeses. in cases we found a significant loss of extensor tendon function. conclusions. development and design of pip endoprosthesis has not found its final goal; this can be told by the variety of pip-joints which are found in the free market. passing throgh the extensor tendon is a sensitive point in the procedure and it should be noted in the preoperative information that there might be a decreased extensor tendon function. nevertheless in our eyes the pip prosthesis represents an intersting alternative to pip-arthrodesis and in cases of failure of the prosthesis it can be easily converted into a classical arthrodesis. osteosynthesis of proximal humeral fractures using a dynamic angular stable plate e. aschauer , l. schmid , c. maier unfallchirurgie, bad ischl, austria; fa. hofer, fürstenfeld, austria background. fractures of the proximal humerus are frequent and represent a therapeutic problem. the proximal humerus plate of the dfd system (double-fix-dynamic) fixes the fragments angular and rotational stable and is implanted minimally invasive. a special instrument allows precise closed reduction. due to the dynamic character of the osteosynthesis bone healing is stimulated. methods. two plates are connected with short screws in linear holes so that they can move against each other. the head fragment is fixed to the main plate with long screws coming steeply from distally. the dynamizing plate fixes this situation to the humeral shaft. for implanting the plate is fixed to a guide instrument, which therefore can be used as a joy-stick. so it is possible to reduct the shaft to the head exactly. to implant the dfd only two small incisions are required. one of cm to slip the plate under the delta muscle and to insert the head screws. and a second of cm proximally to fix the guide instrument and insert the shaft screws. in bad ischl the dfd-php is in use since november . up to now patients were operated. fourty three were female, male. the average age was . years ( - ). in cases it was a dislocated subcapital fracture. nineteen had a threepart-, a fourpart fracture. four fracture dislocations and true headsplits also could be done with closed reduction on this technique. four fractures were located at the anatomical neck. results. our first experiences were very well. currently we cannot report any complications due to the implant. there was no loosening or breakage. we watched no loss of reduction. noticeable was lack of pain immediately after the operation. so the patients came back to their former level of activity very fast. our complications were one infection forcing us to remove the implant -the case came to an end in pseudarthrosis which the patient bears well. another lady suffered a repeated fracture caused by a slight injury. one pseudarthrosis happened due to too early removal. conclusions. with the dfd-php now an implant is available that enables us to expand the indications for head preserving therapy of proximal humeral fractures. especially older people benefit from this method because there is hardly soft tissue damage but nevertheless a reliable stable situation that leads to bone healing in correct position and a good shoulder function. background. treatment of unstable distal metaphyseal tibial fractures with intramedullary nailing remains challenging even in fractures without intra-articular involvement. proximity to the ankle and biomechanical aspects makes the surgical treatment more complicated compared to fractures of the midshaft. intramedullary nailing (imn) is the ''golden standard'' for midshaft fractures but can be challenging in distal metaphyseal fractures. therefore, optimal surgical treatment of these fractures remains controversial. the aim of our study was to evaluate different tibial nails of the newest generation in a biomechanical approach. methods. defined osteotomy was performed in sawbone composite tibial fractures to create an unstable distal tibial fracture model. after nail insertion, distal tibial locking was performed with or locking screws. samples were cyclically loaded with , cycles and increasing load from ae n to and n. defined parameters such as alignment, varus, valgus deformation, antecurvation and recurvation were recorded. samples were then statically loaded until failure. acoustic emission technique was used to detect microfractures of bone, screws and nail. data according to failure of screws and nail were obtained. results. in case of physiological loading ( , cycles; ae n) loss of stability and damage of screws, nails and bone could not observed. failures occurred in loading series. stiffness was significantly higher in tibial nails with distal locking screws. stability of nail-bone construction was significantly higher in nails with distal locking options and in nails with diameter of distal locking screws more than mm. conclusions. intramedullary nailing can be recommened in unstable distal metaphyseal tibial fractures without intra articular involvement. four distal locking screws with . mm diameter should be used. our data suggests that immediate full weight bearing is possible postoperatively in young healthy patients without osteopenia even in this fracture type. because of the rising number of implantation rates of hip and knee arthroplasty as well as the increase number of osteosyntheses of the femur in geriatric patients the periprosthetic fractures are becoming more importance in orthopedic and trauma surgery. osteoporosis and the high rate of comorbidity makes a strong preoperative planning of the operation procedure necessary. prosthesis loosening or defects of the periprostetic bone may indicate a revision arthroplasty. in the new literature ostheosynthesis is usually conducted with locked screw plates as well as with intramedullary locking nail systems. a traditional alternative is the application of a condylar plate. usually used in trochanteric and subtrochanteric fractures of the proximal femur as well as in complex distal femur fractures it is also an effective implant system in periprosthetic fractures. several examples are shown and discussed. we respect to the classification of periprostetic fractures of johanson in our report about patients. six of them underwent a revision arthroplasty and in cases an osteosynthesis was done. five of them include the implantation of a condylar plate. the improved trauma room management by installation of a four-phase watch g. fronhöfer, m. kerl background. since the parameters of the severe traumatised patients of the trauma hospital graz have been collected and analysed at the trauma register of the dgu. according to the recommendation of the dgu a special four-phase watch was installed in to improve the effectiveness of the diagnosis and treatment process optimize in the trauma room. methods. the watchface has the typical colour coded phases and a flipchart shows the prepared standard sequence of trauma room management which has been developed interdisciplinary by surgeons, anesthetists, radiologists and carers. the parameters and the time process are further documented according to the guidelines of the trauma register of the dgu. results. the timelapse to x-ray or ct is reduced, the diagnoses are found quicker and patients can therefore be treated earlier at their adequate therapy. the motivation of the medical team is increased. conclusions. the four-phase trauma room watch has a many advantages and as recommended by the dgu should be installed in each trauma room. background. the treatment of an acute abdomen is without a doubt a domain of the surgical department. there are already specific treatment algorithms in place. due to the ever-present pressure to keep costs to a minimum, as well as the ever-changing technical advancements of diagnostics, it is vital to re-think and possibly modify existing treatment algorithms. therefore, patients in our facility were analyzed. methods. in erlangen, patients with an acute abdomen were treated in the timeframe from january , to december , . the average age was years, and the ratio males:females was : . . all data were collected prospectively through patient histories as well as clinical documentation. consequently, they were retrospectively evaluated. following the case history, labarotory tests and physical examination, sonography of the abdomen was used as the baseline diagnostic modality, as well as conventional radiography of the abdomen. results. of the treated patients, only ( %) required surgery. the average length of stay was days. in patients, a clinical diagnosis of appendicitis was made. in % of these patients, the confirmation of their diagnosis could be made, using the baseline diagnostic modalities. for the rest of the patients, further diagnostic modalities were needed (such as ct). in patients, a primary diagnosis of coprostasis was made. in % of these patients, a conservative treatment could be offered, and the patients left our facility without symptoms. in % of the patients, further diagnostic modalities (radiological and=or endoscopic) showed a finding that required surgical attention. conclusions. in the normal=routine clinical picture of appendicitis, baseline diagnostics are sufficient. however, behind apparently harmless diagnoses such as coprostasis, there are serious illnesses that may be masked. therefore a different course of action must be considered (ct). as a possible side-effect of this course, patients without pathological manifestations could be treated on an out-patient basis, thus reducing total costs. background. the aim of the study was to investigate: i) relevant and combined determinants of the development, management and outcome of a representative patient cohort (n ¼ . ) with acute appendicitis enrolled in a prospective unicenter study through a time period of years (middle europe), and ii) the frequency and impact of specific categories (e.g., characteristics of the medical history, clinical and intraoperative findings, complications), correlation and relative risk factors of the disease and its prognosis. methods. by the mean of a prospective unicenter observational study, numerous characteristics as mentioned in the ''aims'' were documented and influencing variables with significant impact on the outcome were statistically determined. results. ) the wound abscess rate was . %. perforation, surgical intervention on time, acute, gangrenous and chronic appendicitis, age, adverse diseases such as obesity, arterial hypertonus, diabetes mellitus, sex and missing pathological finding intraoperatively showed a significant impact on the postoperative development of a wound abscess. ) the longer the specific appendicitis-related medical history lasted, the i) more frequent a perforated appendicitis occurred (interestingly, this rate significantly increased up to . % through the various time periods), ii) greater the false-positive appendectomy rate was (p < . ), and iii) higher the rate of the required second (subsequent) interventions was ( . %; p < . ), which occurred significantly more often in obesity ( . %) and wound abscess ( . %). ) the mean postoperative hospital stay was days. ) there was a significant decrease of the percentage of patients with no pathological finding of the ''appendix vermiformis" intraoperatively, who underwent appendectomy, in particular, to only . % through the last investigation period from to ( - , . %; - , . %). ) the mortality was . % showing no significant difference between male and female patients (p ¼ . ), between the investigation periods (p ¼ . ) and between the patients with false-positive appendectomy ( . %) and that with acute appendicitis ( . %; p ¼ . ). conclusions. in summary, this study demonstrated a substantial progress of the quality of surgical care within the participating clinics with regard to the rates of false-positive appendectomies, of postoperative wound abscesses and, in particular, to mortality, one of the strongest criteria of quality control. despite this, there is an increasing rate of perforated appendicitis in the investigated cohort. in conclusion, quality control remains an indispensable tool for evaluation and assessment of surgical care even in the most frequent diseases of the daily practice, which can be further improved by a multicenter study setting. acute mesenteric ischaemia -looking at the past, learning for the future e. schröpfer, a. thiede, t. meyer background. acute mesenteric ischaemia (ami) is a rare disease with still -despite all progresses in medicine -a high mortality rate ranging from to % according to literature. the aim of this study was to analyse the outcome of our patients after traditional therapy, in order to be able to conduct new strategies of treatment. methods. in this retrospective study all clinical reports (since = ) containing the diagnosis ami (icd : k . ) were analyzed with regard to initial laboratory findings, pre-operative diagnostics, surgical methods, intra-operative results, etc. results. the diagnosis ami was encoded for patients in the aforementioned period of time. twenty patients had to be excluded from the study, due to other collateral diseases. among the remaining patients (with an average age of . years) died initially (initial mortality . %). the main risk factor ( . %) was arrhythmia absoluta. . % of the patients presented the symptoms of an acute abdomen, . % were suffering from progressive abdominal pain. besides anamnesis, physical examination and laboratory only . % of the patients obtained an abdominal ct and . % obtained a dsa. because of the unambigousness of the anamnestic and clinical findings . % of the patients received an immediate explorative laparotomy without any further diagnostic. conclusions. despite the typical triphasic progression of the ami (intense abdominal pain -apparent recovery -acute spreading peritonitis) and all modern possibilities of diagnostics the mortality rate of ami is still appallingly high. looking at the past, diagnostics as well as therapy should be included in modern findings and open up new possibilities. bckground. data are rare about the impact of infection on postoperative mortality in an unselected surgical population. aim of the study was to analyze whether infection is a significant cause of death in these patients. methods. at a department of general, vascular and thoracic surgery in a secondary to tertiary referral centre, all patients operated from = to = (n ¼ ) were included in a prospective database and analyzed retrospectively. overall mortality rate . % (n ¼ ( abdominal, vascular, thoracic surgery)). . % emergency - . % planned operations. cause of death was defined by clinical chart review and post mortem section. stratification criteria (sex, age group, asa, malignancy, infection prior to surgery, abdominal surgery, emergency operation) were analyzed by multivariate regression analysis. results. cause of death: n ¼ ( . %) infection, n ¼ ( . %) cardiovascular, n ¼ ( . %) progression of malignancy, n ¼ ( . %) pulmonary embolism. subgroup analysis of postoperative death due to infection revealed that . % (n ¼ = ) of patients had infection already prior to surgery and . % (n ¼ = ) developed postoperative lethal infection. mortality caused by infection was . % (n ¼ ) in abdominal, . % (n ¼ ) in vascular and % (n ¼ ) in thoracic surgery. regression analysis identified infection prior to surgery (p ¼ . ) and abdominal surgery (p ¼ . ) as statistically significant independent risk factors for postoperative mortality due to infection. conclusions. postoperative mortality is highly associated with infection. in an unselected cohort of surgical patients those presenting with infection prior to surgery and those undergoing abdominal surgery are at highest risk of death from infection. management of complications in laparoscopic colo-rectal surgery m. hufschmidt, u. obwegeser, a. haid, e. wenzl background. laparoscopic colo-rectal surgery is considered to be a standardized procedure for the two main-indications: diverticular disease of the sigmoid colon and complicated crohn's disease of the ileo-cecal region. moreover these procedures seem to have served as a sort of pacemaker to so-called fast-track-protocols. while the extension of laparoscopic procedures to oncological indications is in a wide-spread controversial discussion, only few publications are considering the impact of complications in the outcome of surgical therapy of benign diseases. methods. a retrospective study of laparoscopic colorectal procedures performed between = and = was undertaken. indications and technical approaches as well as rates of conversion, duration of intervention and hospital-stay are detailed. complications leading to relaparotomy, interventional or conservative therapy are reviewed in detail to analyse their reasons. results. with a conversion-rate of . %, a mortality of . % and an overall morbidity of . % the occuring complications may be categorised in different groups, distinguishing intra-operativly, early or late, major or minor and procedurerelated or intercurrent-ones solicitating either conservative, interventional ( . %) or surgical ( . %) treatment. several causes are being isolated such as learning-curve, body-mass-index, comorbidity, sequelae of previous operations and severity of intraoperative findings. conclusion. as for conversion, complications influence parameters as hospital-stay or feasibility of fast-track-protocols somewhat watering the advantageous results of laparoscopic colo-rectal surgery. a careful analysis is therefore advisable not only to avoid reiterating complications but also to permit the access to oncological colo-rectal laparoscopic surgery as well. background. the value of quality control in general surgery is actually soaring. unplanned reoperation is seen as one of the most important quality measures. however, there is a lack of data regarding the impact of infection as an indication to unplanned reoperation. methods. at our department of general (including kidney transplant), vascular and thoracic surgery in a secondary to tertiary referral centre, all patients undergoing unplanned reoperation from = to = were included in a prospective database. unplanned reoperation was defined as unplanned return to the or within days during hospitalization. targets were unplanned reoperation due to infection, type of infection, type of primary surgery, mortality and a comparison to a former data collection from = - = after starting a monthly review of reoperation data in terms of a morbidity-=mortality conference = . results. one hundred and thirty nine ( . %) of patients were undergoing unplanned reoperation. ( . %) due to infection, ( . %) due to postoperative bleeding and ( . %) due to other indication. subgroup analysis of those reoperated due to infection identified leakage of the anastomosis in % ( = ) and abdominal wall rupture in . % ( = ) as predominant causes to reoperation. other indications to unplanned reoperation were small bowel perforation ( = ), abscess ( = ), leakage of ileostoma ( = ), thoracical phlegmon ( = ), ureter-necrosis ( = ), recurrent infection of lung parenchyma ( = ) and superficial surgical site infection ( = ). mortality in the infection subgroup was . % ( = ) compared to . % ( = ) of all reoperated patients. overall mortality was . % ( = ). furthermore we could achieve a decrease of mortality in infection subgroup from to . % comparing to our former data collection of = - = . an additional analysis of infection germs was not striking. conclusions. postoperative infection is the underlying mechanism leading to reoperation in a significant number of patients. data analysis showed a much higher mortality in these patients. the reported decrease of mortality from to . % maybe attributed to the consequent prospective monitoring and monthly review of reoperation data we had introduced = . gallstone-ileus -nowadays still a remaining important differential-diagnosis to consider at presence of acute abdominal pain r. hammer , p. habertheuer , w. brü nner , c. bauer , n. schreibmayer , f. flü ckiger , p. steindorfer department of surgery, lkh graz-west, graz, austria; department of radiology, lkh graz-west, graz, austria background. - % of all mechanical obstructions in small bowel are represented by gallstone-ileus as a complication of cholelithiasis. as it is frequent in the elderly population (it accounts for almost % of non-strangulated intestinal obstruction in patients > years), there is a high mortality-rate of - % depending on age and co-morbidity. in less than % of patients with gallstones cholecystoenteric fistula occurs (most likely cholecystoduodenal in %, cholecystocolic, cholecystogastric-and cholecystodochoduodenal have also been described). methods. between october -december we performed cholecystectomy on patients and laparatomy on patients due to mechanical obstruction of the small bowel. the frequency of gallstone-ileus can be reported on patients, which underwent surgery due to intestinal obstruction because of gallstones. one recurrence of gallstone-ileus due to the lack of exploration on finding massive postinflammatory adhesions and adherence of the major omentum was seen. in all patients clinical evidence of intestinal obstruction detected pneumobilia as well as ectopic gallstones was confirmed by either plain x-ray or ct-scans. results. at our department a frequency of patients (average age . yrs (range - yrs) males, females) presenting with gallstone-ileus (in a total of patients undergoing cholecystectomy and patients undergoing laparotomy due to small-bowel-obstruction) were treated, that means a rate of gallstone-ileus in . % ( = ) compared to the patients with che, and . % ( = ) in laparotomies due to small-bowel obstructions performed at this period. all patients underwent an one-stage operation, in cases consisting of enterolithotomy and stone-extraction as single procedure only (without dismantlement and exploration of the fistula), in further cases cholecystectomy and suturing of the entero-biliary fistula synchronously were additionally performed. the obstruction occurred  duodenal,  jejunal and  ileal, the location of the fistula situated duodenal in times, once jejunal and  non-explored. the diameter of the obstructing stone varied between and cm (average of . cm), patients recovered well, one expired because of the development of ards. conclusions. gallstone-ileus is a rare diagnosis, nevertheless it should still be kept in mind and considered as important differential-diagnosis in acute abdominal pain as shown on the numerous cases at our department. for reducing perioperative mortality the treatment has to be adapted on patients conditions, if necessary performing enterolithotomy as a single procedure only, and considering to correct the fistula in a second procedure on symptomatic patients. in the program of the austrian surgical convention different working groups and specialised societies are listed up, stating that the specialisation in surgery is increasing. however, the question remains, which fields of specialisation are realistic for a general surgical department with a limited staff? in the last years a main focus of interest has been established for the following fields: endoscopy: gastroscopy, sigmoideoscopy, colonoscopy with interventions is performed by all, ercp by two surgeons of the staff. minimal-invasive surgery: choleystectomy, appendectomy, hernia surgery is performed by all surgeons, colon resections, gastro-oesophageal surgery by three of the staff. endocrine surgery: surgery of the thyroid and parathyreoid gland by three surgeons. specialized breast surgery: such as oncoplastic surgery and breast reconstruction by two surgeons. varicositas surgery: crossectomy and stripping, evlt, trivex, venocuff by two surgeons. the development of specialization in a general surgical unit will be presented. methods. review on cle. results. due to reflux esophageal squamous epithelium is damaged and replaced by cle, which is of esophageal origin and interposed between squamous and gastric oxyntic mucosa (om). the paull-chandrasoma histopathology cle classification includes oxyntocardiac (ocm; mucus and parietal cells) and cardiac mucosa (cm; mucus cells only) without or with intestinal metaplasia (im ¼ barrett esophagus). via low (lgd) and high grade dysplasia (hgd), im may progress towards eso-phageal adenocarcinoma (ac; annual incidence . - . %). presence of cle is associated with pathologic esophageal acid exposure and impaired esophageal motility and dysfunction of the lower esophageal sphincter, as assessed by ph monitoring and esophageal manometry, respectively. cle without and with im is assessed in and - % of symptomatic gerd patients, respectively, irrespective of presence or absence of endoscopic visible cle. surveillance endoscopy and biopsy sampling are recommended after - , - and . years for cm, im and lgd, respectively. treatment of hgd and ac stage ia include endoscopic mucosal resection or esophagectomy. esophagectomy is recommended for ac > stage ia. recent studies indicate that antireflux surgery may reverse im and low grade dysplasia (lgd). seven years after ph-monitoringproven effective (n ¼ ), but not ineffective (n ¼ ) nissen fundoplication, im reversed towards cm without progression towards ac. fourty months after nissen fundoplication and bile diversion (n ¼ ), % regressed from im to cm, % remained at im. . years after gastric bypass (n ¼ ), im-patients regressed (n ¼ ) or had im (n ¼ ), none progressed. a recent study compared the effect of proton pump inhibitor (ppi) (n ¼ ) vs. fundoplication (n ¼ ) in patients with cle containing low grade dysplasia (lgd). eighteen months after ppi treatment and fundoplication, out of ( . %) and all out of patients, respectively, reversed from lgd towards intestinal metaplasia. conclusions. cle is defined by histopathology. evidence justifies to investigate impact of effective fundoplication on cle within prospective studies. background. during endoscopy the stomach is considered to commence at the level of the rise of ''gastric'' rugal folds. anatomy studies suggested that rugal folds may contain columnar lined esophagus (cle), the morphologic consequence of gastroesophageal reflux disease (gerd). we investigated the histopathology of endoscopic ''gastric'' rugal folds in gerd patients. methods. seventy-five consecutive gerd patients ( males), age: ( - ) years, prospectively underwent endoscopy, including biopsy sampling from the endoscopic esophagogastric junction (egj): , . , . cm distal and . and . cm proximal to the rise of the rugal folds. cle was cataloged according to the histopathologic paull-chandrasoma classification. results. normal endoscopic esophagogastric junction, visible cle . and > . cm was assessed in ( %) and ( %) and ( %) patients, respectively. histology: all patients had cle at the level of rise of the ''gastric'' folds. in and % of patients cle extended . and . cm, respectively, distal to the rise of the rugal folds. gastric oxyntic mucosa was not assessed above the level of the rise of rugal folds. intestinal metaplasia (¼ barrett esophagus) was assessed histologically in ( %) patients. conclusions. regarding the diagnosis of cle, the esophagogastric junction (egj) cannot be assessed by endoscopy, but by histopathology (i.e. level of transition from cle towards gastric oxyntic mucosa). presence or absence of barrett esophagus can not be excluded by endoscopy. histopathology of multi level biopsy sampling should be considered for definition of egj and exclusion of barrett esophagus in gerd patients. pre-clinical trial of a modified gastroscope that performs a true anterior fundoplication for the endoluminal treatment of gerd background. laparoscopic fundoplication provides good reflux control but side effects due to the surgical procedure are known. different endoluminal techniques have been introduced but all with disappointing results. evaluation of the feasibility and safety of a new device, that enables a totally endoluminal anterior fundoplication for the treatment of gerd. methods. the device is a modified video gastroscope, which incorporates a surgical stapler (using standard . b shaped surgical staples) and an ultrasonic sight. the cartridge is mounted on the shaft and the anvil is at the tip. this enables accurate stapling of the fundus to the esophagus, using the ultrasonic sight to guide distance and alignment of the anvil and the cartridge. sixteen female swine of mixed breed were used in the study, underwent the endoscopic procedure, and were used a controls to monitor weight gain. the study animals were sacrificed at , , and weeks ( pigs each time) and visually inspected for complications, healing and fundoplication. the study was sponsored by medigus ltd. and monitored for compliance with glp regulations by an external company (econ inc.), which is glp certified by the german federal government. it was conducted at the animal testing facility of the charite virchow clinic in berlin. results. the procedure went smoothly in all pigs, median procedure time was min (range - min). at sacrifice the stapled area had healed well, all animals had a satisfactory anterolateral fundoplication, and there were no procedure related complications. conclusions. creating a satisfactory anterior fundoplication with the new device is feasible, easy, and safe. proof of efficacy must await clinical trials, which are underway. design and instrumentation of new devices for performing appendectomy at colonoscopy g. silberhumer , e. unger , w. mayr , t. birsan , g. prager , j. zacherl , c. gasche background. appendectomy is the most common operation in the gastrointestinal tract. there is increasing interest in interval appendectomy as a treatment for refractory ulcerative colitis. a less-invasive flexible endoscopic method for removing the appendix might offer advantages especially for interval appendectomy in patients undergoing colonoscopy. aim: to design, develop and test new devices for removing the appendix via natural orifice transluminal endoscopic surgery (notes). methods. tests were performed on the bench in colons from adult human cadavers. various prototypes were tested, which could be inserted into the appendiceal orifice to its tip and could invert the appendix at its base in a controlled fashion into the lumen of the cecum. the advantage of using a tubular structure as counter force to aid inversion of the appendix was evaluated. after partial inversion the growing strain was relieved by endoluminal incision of the mesenteric side of the appendix. closure methods with endoloops, clips and thread ties were studied. appendiceal resection was completed by snare diathermy leaving an inverted intraluminal stump. results. the position of the appendix was retrocecal in seven cases, pelvic in two, and pre-ileal or post-ileal in one each. the median length and luminal diameter was mm ( - mm) and . mm ( - mm), respectively. partial obstruction of the lumen was present in = cases. it was possible to advance the guide-wires and retraction devices to the tip of the appendiceal lumen in all cases. partial inversion of the appendix was successful in = tests. the median length of the inverted stump was mm ( - mm) . the tension and volume (due to fat deposit) of the mesoappendix was the main reason for incomplete inversion. complete inversion was achieved by endoluminal incision in = tests. the mean volume of the resected tissue (inverted appendix incl. its mesoappendix) was . ae . ccm. conclusions. despite high individual variability, appendectomy at flexible colonoscopy proved to be feasible and relatively easy. new devices to allow appendix inversion were successfully tested. endoscopic necrosectomy -a feasible and safe alternative treatment option for infected pancreatic necroses in severe acute pancreatitis (case series of patients) u. will , r. gerlach , i. wanzar , f. meyer department of gastroenterology, municipal hospital, gera, germany; department of surgery, university hospital, magdeburg, germany background. endoscopic necrosectomy of infected pancreatic necroses in severe acute pancreatitis is considered an alternative but minimally invasive treatment option instead of the more traumatic open surgery. the aim of the study was to investigate feasibility and outcome of endoscopic necrosectomy in infected organized pancreatic necroses (iopn). methods. through a -year time period, all consecutive patients with symptomatic iopn who underwent this novel endoscopic approach were prospectively documented in a computer-based registry and were retrospectively evaluated (systematic case series). the endoscopic approach comprised: . necrosectomy via the transgastric route under eus guidance; and (optionally). . additional a) transpapillary stenting of the pancreatic duct; or b) percutaneous drainage if indicated. feasibility was characterized by success rate (clearence=downsizing of iopn, hospital stay) and outcome by complication rate (frequency of bleeding or perforation), mortality and shortterm follow-up. results. from = = - = = , patients with symptomatic iopn (maximal diameter, - cm) who underwent endoscopic necrosectomy were enrolled in the study. sixteen of them ( . %) were necrosectomized from all nonviable tissue using - (range) necrosectomies (mean, . ). in = cases ( . %), iopn were incompletely removed. the pancreatic duct was drained through the papilla because of duct disruption or dilatation in = cases ( . %). a percutaneous drainage was placed into fresh, non-organized necroses or because of acute septic problems in = patients ( . %). complications occurred in = subjects (rate, . %): bleeding (n ¼ ) managed endoscopically; cardiac arrhythmia (n ¼ ); no perforation. at the time of discharge (mean hospital stay, . d), i) internal drainage was still in situ (range, - double pigtails) in = individuals ( . %), which was extracted in the post-hospital range of - d; ii) = patients ( . %) were asymptomatic indicated by normal inflammatory laboratory parameters; iii) = subjects ( . %) showed no further iopn whereas in = patients ( . %), there was a -fold (mean) down-sizing of iopn. one patient ( . %) died from cardiac infarction on the th day of hospital stay (intervention-related mortality, %). follow-up investigation (range, - d): = subjects ( . %) developed pancreatic pseudocyst, which was endoscopically approached. conclusions. endoscopic necrosectomy combined with endoscopic placement of a internal (transgastric) drainage or transpapillary stent into the pancreatic duct is a feasible and safe treatment option even in the case of extended iopn with large pieces of necrotic tissue. background. leakage and fistulization of the gastrojejunostomy have been the major drawback of gastric bypass surgery since its first description. most authors agree that operative treatment is the mainstay of therapy in all patients with signs of sepsis. however, intestinal contents causing localized infection may impede healing of sutured leaks in some patients and fistulas develop. as the anastomosis cannot be disconnected or exteriorized for anatomical reasons other forms of treatment have to be applied. results. leakage of the gastro-jejunostomy occurred in three patients after gastric bypass and resulted in formation of a fistula; one fistula developed in a patient days after surgery. coated self-extending stents were implanted endoscopically in all patients. enteral nutrition could be started six days later. stents were removed two months after implantation without problems. weight loss and quality of life after stent removal were excellent in all patients. conclusions. in our experience implantation of coated selfexpanding stents represents a very effective and minimally invasive therapy of gastro-jejunal anastomotic fistulas after gastric bypass when surgical repair is not possible. in these cases application of stents allows septic source control without any other intervention. methods. fetal mri studies were performed on a . t (philips) superconducting unit using a five-element surface phased-array coil, usually after th gestational week. no sedation is necessary. in addition to routine t -weighted (w) sequences, t w sequences (mainly to demonstrate meconium-containing bowel loops), t à w-sequences (in case of hemorrhagic lesions), steady state fast precession (ssfp) sequences (to depict vessel-abnormalities), dynamic ssfp sequences to show swallowing and peristalsis, flair and diffusionweighted sequences (for further tissue characterization) were done. results. one hundred and twenty-six fetuses with extra-cns malformations, prenatally examined with fetal mri, had postpartal or postmortal follow up at the medical university clinic of vienna: among these, congenital diaphragmatic hernias (cdh, ) could be selected for primary repair ( ) because of adequate lung maturity, with extreme lung hypoplasia underwent extra corporal membran oxygenation. cystic adenomatoid malformation ( ) and lung sequestration ( ) were diagnosed, requiring immediate postnatal or later repair. abdominal anomalies ( ): stenosis, obstructions or atresias of small bowel ( ) were treated by adequate therapy from the very beginning. anal atresias ( ) were differentiated into high and low forms, cases which needed colostomy or could be corrected in an one stage repair. nine gastroschisis ( ) and omphaloceles ( ) were delivered pretermly dependent on the amount of eventerated bowels. ovarial cysts ( ) were differentiated from abdominal tumors ( ), the latter requiring immediate surgery, the former only depending on size and content. urologic pathologies ( ) could often be treated conservatively. conclusions. the results of fetal mri do not have an impact on the type of surgical procedure. however, early accurate diagnosis of pathology, including information about vital functions (such as the degree of lung maturity) may influence the decision of the time to perform the operation, to achieve a most successful outcome for the patient. background. common bile duct (cbd) stones represent a diagnostic and therapeutic challenge in pediatric age group. the aim of the study was to evaluate our management of children with suspected cbd stones and to develop an algorithm for the rational use of perioperative ercp, mrcp and intraoperative cholangiography (ioc). methods. between and , children that had undergone laparoscopic cholecystectomy (che) were evaluated for preoperative findings suggestive for cbd stones, preoperative use of ercp or mrcp, use of ioc and findings during surgery. a diagnostic and therapeutic algorithm for cbd stones was developed. results. twelve children ( %) had preoperative findings suggestive for cbd stones. of the children with elevated liver enzymes and abnormal ultrasound findings, ( %) were identified to have cbd stones. five had preoperative ercp which detected and successfully cleared stones in patients. ioc identified cbd stones in children, including one patient with a preoperative negative ercp. of the children with either elevated liver enzymes or abnormal ultrasound, only one stone in the cystic duct was identified by a gall bladder edema in the preoperative mrcp followed by ioc. three children received preoperative mrcp and ioc was performed in . no retained stones were detected postoperatively. conclusions. cases with high suspicion for cbd stones should undergo a preoperative ercp followed by intraoperative cholangiography, if no stones could be found. in case preoperative findings are ambiguous, prevalence of cbd stones is low and we suggest mrcp or ioc as the diagnostic methods of choice. pure esophageal atresia with normal outer appearance -a new subtype? -case report m. sanal , b. häussler , w. tabarelli , k. maurer , c. sergi , j. hager background. isolated esophageal atresia (vogt type ii) is characterized by an agenesia of the midportion of the esophagus. this paper presents a case of such a form of esophageal atresia with a cm long fibrous segment between the two esophageal pouches resembling the subtype ii according the kluth's atlas. methods. thirty-seven week gestation boy born by uneventful vaginal delivery with g birth weight was transferred to our department because of inability to pass a nasogastric catheter. resection of the fibrous segment and primary anastomosis of the esophagus was performed succesfully. results. the postoperative course was uneventful and the patient was discharged on the postoperative day. histological examination of the atretic segment showed an haphazard distribution of not functional lumina and blood vessels. conclusions. kluth has described ten types of esopageal atresia in his atlas; pure esophageal atresia is classified as type ii in which the proximal and distal segments are atretic without a tracheo esophageal fistula. matsumoto described a subtype in which the midportion of the esophagus is atretic and there is a cyst located in the atretic strand. loosbroek also described in a new type of isolated esophageal atresia that included double membranes with a cm gap between them. we describe here a similar case of pure esophageal atresia, showed neither a cyst nor a membrane. extensive review of the literature failed to disclose any similar case showed this kind of histological character. we report our experience with the minimal invasive method of surgical reconstruction of pectus excavatum recurrence. since at our department pectus excavatum patients have been operated on by the modified minimally invasive method of reconstruction (modified nuss technique). seven patients aged . ae . showed a severe recurrence ( patients after ravitch-welsh-rehbein method primarily operated elsewhere, one after explantation of the ''nuss bar'' operated in our department). five patients suffered on reduced physical effort and patients aim for a better cosmetic result. preoperative investigations include blood samples, ecg, heart sonography, chest x-ray, chest mri=ct with -d reconstruction and spirometry. the following intraoperative events deserve mention: . severe retrosternal scarred tissue complicate the retrosternal preparatory mobilisation of the pericardial sac and the sternal portion of the diaphragm n ¼ . . intraoperative thoracoscopy showed pleural adhesions which were divided thoracoscopically n ¼ . . non compliant stiff thorax due to sternal kinking and=or ossification of the regenerated ribs after ravitch procedure made the following procedures necessary: a. additionally osteotomies of the ossificated ribs (n ¼ ). b. implantation of a second bar (n ¼ ). c. an oblique wedge shaped partial sternal osteotomy (n ¼ ). due to preparation we had intraoperative bleeding episodes of the internal mammaric vessels, lesion of the pericardial sac (scar tissue) and superficial lesion of the right visceral pleura (adhesions). vertebral index changed from preoperatively to a normal range of postoperatively. postoperative cosmetic results were perfect in %. in summary cases with pectus excavatum recurrence are manageable with extremely satisfactory results using the described extended modified correction technique. osteotomies do not destabilize the chest and can be sufficiently combined with the nuss technique. background. former surgical approaches to laparoscopic repairs of morgagni hernias in children involved pros-thetic as well as nonprosthetic repairs. we simplified a nonprostethic laparoscopic method to an easily feasible procedure. methods. two boys with retrosternal diaphragmatic hernias (morgagni) underwent primary laparoscopic repair. a nonabsorbable suture was inserted directly through the anterior abdominal wall and the hernia was tightened in a lateral to medial fashion by a continous suture and tied in the subcutaneous tissue of the xiphoid region. results. two boys, months and five-year old, with coincidentally diagnosed bilateral retrosternal diaphragmatic hernias (morgagni), underwent laparoscopic repair of their hernias. they had an uneventful postoperative recovery, apart from a port site hernia in one. conclusions. this technique for primary laparoscopic repair of morgagni hernia is safe and easy to perform. laparoscopic closure of the defect by suturing the posterior rim of the hernia to the anterior abdominal wall with a continous nonabsorbable suture provides a safe and effective therapy for this type of diaphragmatic hernias. our experience of post-natal diaphragm paralysis treatment in newborns a. kuzyk , a. pereyaslov , r. kovalsky , o. leniv background. the paralysis of right cupula of diaphragm in newborns in many cases is the result of birth trauma and is indicated as erb-duchene syndrome. the paralysis declares itself by the high standing of diaphragm and its paradoxical movements during respiration, displacement of mediastinum and lung compression which bring to heavy respiratory distress, cardiovascular insufficiency development and requires artificial pulmonary ventilation in first post-natal hours. methods. in the period of - , children with post-natal paralysis of diaphragm right cupula and child with post-natal paralysis of diaphragm left cupula have been treated in our clinic. the body weight at birth was - g. the basic symptoms were: hard respiratory distress and cardiovascular insufficiency, pulmonary hemorrhage, depression of the central nervous system. two children with low body weight had been on artificial pulmonary ventilation during period from the birth to surgical treatment. conservative therapy was done from to . months without positive clinical effect -respiratory insufficiency had not been reduced, the children had retarded in physical growth and development. all children were operated on diaphragm goffering from thoracotomy on the affected side. results. after surgery all patients needed artificial pulmonary ventilation during - days. with good clinical results all children were discharged from the hospital. conclusions. the newborns with post-natal diaphragm paralysis with not effective treatment during - weeks needed surgical correction -diaphragm goffering on the affected side. long term experience with the paulprocedure in a large animal model background. this study was designed to assess the long term efficacy of the paul-procedure for abdominal wall defect repair in a large animal model (lam). methods. we created  cm full-thickness abdominal wall defects in goettinger miniature piglets (n ¼ ; body weight: . - . kg). the defect was repaired by the paul-procedure, using an extracellular matrix of xenogeneic origin as an interpositional graft. a weekly examination of the animals followed, including measuring of bodyweight and observation the possible development of a hernia. additional the abdominal cavity was evaluated laparoscopically at , , and months after paul-procedure. the adhesions to the intestine were measured and the neo-abdominal wall was taken for histological examination. results. ( ) the paul-procedure could be performed technical easily in lam. ( ) background. gastroschisis is a relatively rare congenital anomaly in which eviscerated fetal abdominal organs are exposed to amniotic fluid in utero through an anterior abdominalwall defect. since the first surgical treatment of gastroschisis by fear in the evolution of therapeutical concepts is steadly proceeding. methods. a retrospective study enclosing all children with gastroschisis treated at vienna general hospital from to was carried out using patient charts. statistics was performed using spss . . the results are compared with the literature. results. fifty-five children with gastroschisis were treated. birth was performed between and week of gestation ( % caesarean section). diagnosis was established between and week of gestation. in % of the patients primary surgical closure was performed. oral feeds were started on . day, mechanical ventilation was stopped after . days. twenty children developed infection=sepsis=pneumonia ( . %) children developed ileus=perforation=vovolus=nec=patch infection ( . %). thirty four children had single gastroschisis related surgery ( . %), secondary surgery up to operations. mortality was . % ( deaths). conclusions. since bianchi's publication of minimal intervention management for gastroschisis in traditional surgical concepts have often been questioned. our results are comparable with international data. although very tantalizing there are no large prospective randomized multicenter studies that show clear superiority of one or another strategy. epidemiologic data show an increasing incidence of gastroschisis which shows the importance of standardized successful procedures for the future. background. colorectal cancer is one of the most common cancers in western countries with incidence rates that are quite stable through the last years. while surgical therapy with high central vessel ligation and adequate lymph node dissection seems well standardised -in laparoscopy as well as conventional surgery -great efforts have been made in new adjuvant treatment strategies and in treatment of colorectal liver metastases. methods. we report about a consecutive series of more than patients treated with colorectal cancer since . . . data about epidemiology, localisation of the primary, surgical methods, tumor classification, complication and mortality rates and survival will be presented in detail. results. the median age was years, % of the patients were more than years old, . % were female. fifteen percentage were treated with an acute onset like ileus or perforation. thirty five percentage had right sided primary, hartmann procedure was performed in %. about % of patients were operated as stage (uicc), the year survival rates of all groups including stage was %. pathohistological assessment showed % r resections (stage included) and a median lymph node count of (pn). perioperative mortality was %, complication rate with the necessity for at least surgical reintervention was . %. conclusions. we demonstrate that surgical therapy of colorectal cancer is safe and effective in terms of oncological outcome and perioperative morbidity and mortality, although colon resections in our department are typical teaching operations. modern anaesthesia and intensive care allows radical oncological surgery even in the elderly. interdisciplinary treatment keeps its way, exact pathohistological processing and cooperation with the pathologist still is the most important factor in quality assessment of oncology surgery of the colorectum. background. although adjuvant -fu-based chemotherapy showed to increase -year survival in stage iii colon cancer, the role of adjuvant chemotherapy in stage ii colon cancer is still unclear. p , a frequently mutated tumour suppressor gene needed for correct induction of apoptosis, is a promising marker to define subgroups of patients who benefit from adjuvant chemotherapy in stage ii colon cancer. methods. in order to evaluate the clinical relevance of p mutations, we investigated stage ii colorectal tumor biopsies from a previous randomised study of adjuvant chemotherapy, who were randomly assigned to adjuvant chemotherapy or surgery alone. for detection of p mutations we used singlestranded conformation polymorphism analysis. results. p mutation was detected in ( %) of informative tumor dnas. when receiving -fluorouracil-based adjuvant chemotherapy, patients with p mutation turned out to have a significant better disease-free -year survival ( . vs. . %, p ¼ . ). in contrast, when assigned to the surgery alone group there was no significant difference in -year disease-free survival between patient with p mutation and patients with wildtyp p . the difference between the patients receiving chemotherapy as compared to those which did not in respect to the presence of p mutations was significant (p ¼ . ). conclusions. in our patient cohort patients whose cancer had a mutation of p had a significantly better benefit from -fluorouracil-based therapy, what is contrary to previous observations. this discrepant result emphasise the need for a standardisation and validation of the methodology, patient selection and interpretation of clinical data before any prognostic marker can be routinely used. is tme an adequate treatment for low rectal cancer? p. lechner, g. humpel background. two patients who had had neo-adjuvant chemotherapy followed by surgery for cancer in the lower rectum presented with metastases in pre-aortic lymph-nodes after and months, respectively. this rose our suspicion that distant spread may in some cases follow the lymphatic vessels along the aorto-iliac axis. methods. after having performed very low anterior or even abdomino-perineal resection for cancer in the lower third of the rectum, biopsies are taken from nodes at the pelvic wall, along the iliac arteries, and the aorta. these are all compartments that remain untouched during routine tme. results. in one out of four patients we find at least one of the above mentioned groups of nodes to be involved. this is most often the case in patients, in whom the mid rectal vascular bundle requires ligation on at least one side. so there are obviously metastases that cannot be detected during the pathological work-up of the tme-specimen. twenty five p.c. of the patients considered to be n-o are already in dukes' stage c, thus requiring additional treatment. these findings -confirmed by the recent literature -suggest, that metastases may arise via lymphatic vessels along the mid rectal arteries and -further onalong the aorto-iliac vessels. conclusions. after standard tme for low rectal cancer lymph node biopsies should be taken in order to avoid understaging of the disease and to allow accurate patient stratification in clinical trials. transanal endoscopic microsurgery for rectal carcinoma: own experiences after cases p. patri, r. schmiederer, a. tuchmann background. transanal endoscopic microsurgery (tem) is an one access technique for local excision of rectal tumours using gas dilatation of the bowel and a stereoscope for unrestricted vision on the operation field. the tem-technique was invented by buess, theiss and hutterer and has been performed at our department since . sessile benign adenomas of the rectum inappropriate for colonoscopic resection represent the vast majority of cases indicated for tem-procedure, using the advantages of sphincter preserving resection in all thirds of the rectum without considerable access trauma. furthermore, tem can be applied to a highly selected group of rectal carcinoma patients in curative objective, including t g or g l v lesions, classified as low risk carcinomas after hermanek's criteria for malignant potential, with recurrence and -yearsurvival-rates equal to radical surgery. under palliative purposes tem can be considered in more advanced carcinomas such as high risk carcinomas (t g ) or in t - carcinomas without stenosis in patients with high risk for general anaesthesia, rejection of stomal construction or present distant metastases. methods. from = until = tem procedures were performed in patients, males, females, mean age was . years ( - ), the median hospital stay was days . following diagnoses were included: rectal adenomas (n ¼ ), rectal carcinomas (n ¼ ), carcinoids (n ¼ ), fistulas (n ¼ ), gist (n ¼ ) and melanoma (n ¼ ). all patients underwent tem-procedure as described by buess et al., the median operation time was min ( - ). highlighting the carcinoma patients regarding to postoperative histopathology tem was performed in n ¼ tis-lesions, n ¼ t low risk carcinomas, n ¼ t high risk carcinoma, n ¼ t and n ¼ t carcinomas. results. in carcinoma patients undergoing tem for curative objective recurrence rate was . %. if tem was performed in primarily palliative intention recurrence rate was %. no conversion to open technique had to be performed, no postoperative surgical complications were observed, one patient died weeks postoperative due to liver failure following esophageal varices bleeding. conclusions. transanal endoscopic microsurgery is a technically highly demanding but excellent procedure for curative therapy of rectal adenomas and low grade early carcinomas. furthermore, tem is feasible in more advanced carcinomas for palliative purposes. besides the technical advantages the procedure can prevent patients of rectal resection or stomal construction. background. anastomotic leak is the most feared early complication in the postoperative period after low anterior resection. the incidence varies between and %. use of tme technique lessens the percentage of local recurrences but increases the incidence of an anastomotic leak. a surgeon has to assess the risk factors and decide whether to create a protective stomy that protects the patient from fatal consequences of an anastomotic leak. methods. one hundred and three patients who had a low anterior resection without a protective ileostomy in the period - were included in the analysis. data of those who developed an anastomotic leak and those without were compared and the connection between specific risk factors and the incidence of an anastomotic leak was assessed. results. eleven patients ( . %) developed a clinically confirmed anastomotic leak. death after low anterior resection occurred in cases ( . %), in two cases in patients who developed a leak, resulting in a . % mortality rate for anastomotic leakage. there was no difference between males and females (p ¼ . ) and age groups (< vs. > years), (p ¼ . ). tumor localization in the lower third of the rectum was roughly showing statistical importance (p ¼ . ). the stage iv. of disease showed obvious connection (p ¼ . ). connection between the anastomotic leak and preoperative radiotherapy or high asa score (> ) was not established (p ¼ . and p ¼ . ). conclusions. the incidence of an anastomotic leak was comparable with results of other studies. localization of a tumor in the lower third in advanced disease represents an important indication for protective ileostomy. background. while adverse events occur in up to ten percent of all patients admitted to hospitals sentinel events do not happen often. however, these events represent great risks for medical institutions and persons involved. a thorough analysis of sentinel events is mandatory and can be achieved by root cause analysis (rca). methods. root cause analysis has been designed in order to assess underlying human, technical, and organizational factors contributing to adverse events. rca has to be performed in a standardized way by a team approach. the main goal of this analytic technique is to establish a relationship between causal factors and events under systemic aspects. after identifying incidental findings causal statements are formulated and actions are developed. conclusions. root cause analysis is a standardized investigative technique which allows to identify causes of severe adverse events and to develop preventive actions for the future. background. thyroid surgery can be followed by typical complications i.e. recurrent laryngeal nerve injury, postoperative hypoparathyreoidism and postoperative haemorraghe. refined surgical technique has improved the outcome and lowered the risk of complication to a minimum. methods. we analyzed global outcome and individual performance in more than , thyroid operations. the complication rates were compared in consecutive periods representing different surgical techniques and individual surgical performances. the data were repeatedly presented to the surgeons. the effect of this quality control procedure was reevaluated. results. exposure of the recurrent nerve and the parathyroid glands significantly reduced the global rate of post-operative=permanent rlni and hypoparathyreoidism. some but not all surgeons improved their results by recurrent nerve dissection (e.g., permanent rlni rates ranged from to . %) and refined dissection of the parathyroid glands (e.g., parathyroid insufficiency ranged from to . %). global outcome and individual performance were compared in periods and presented to the surgeons. the effect of this quality control procedure and the selective improvement of outcome will be shown by data. the extent of resection and the individual refinement of surgical technique was the source of variability. conclusions. refined surgical dissection significantly reduces the risk of complications in thyroid surgery. quality control can improve the global outcome and identify the variability in individual performance. this cannot be eliminated by merely confronting surgeons with comparative data; hence, it is important to search for the underlying causes. recent developments in medical litigation and liability in austria d. schaden , j. pritz krankenhaus der barmherzigen brüder, graz, austria; amt der steiermärkischen landesregierung, graz, austria the recent medical judgements of the highest court (e.g.: wrongful birth ogh ob = h) have been debated very controversially in medical profession and have attracted closer attention to the legal aspects of medical documentation and enlightenment. particularly in the surgical disciplines the patient should be made fully aware and get a detailed information about the risk of treatment failure, possible complications, limits to the procedures and long term outcome. exact information by the doctor is the condition necessary for the patient to give valid consent to the treatment and to avoid medical negligence litigation in these risky specialties. unfortunately these often for the doctors existentially important aspects are not part of the medical or surgical training nor are there any compulsory guidelines of medical enlightenment in the austrian legal practice which creates widespread individualism in all disciplines. we want to give an overview of the latest medico-legal lawsuits and judgements and their consequences for the daily working routine focussing on issues that can result in a doctor or facility being sued. background. every patient has the right to be informed about the consequences of surgery enabling him to give his informed consent. until recently the process of giving this information was not well organized. in the context of improving quality control at the hospital, a uniform process for patient information was established and the training of interns for giving informative talks was standardized and intensified. to measure whether these changes are reflected by an improved patient satisfaction, patients were surveyed before and after the changes. methods. two surveys were performed on patients before and after the improvements were introduced, and the results were compared. results. in each survey and questionnaires were returned. with the improved process the number of patients satisfied with the length of the informative talk rose ( - %, p < À ), less patients wanted a more detailed talk ( - %, p ¼ . ) and more patients considered the sketches on the informed consent protocol helpful ( - %, p <  À ). fewer patients thought the surgery was worse than expected ( - %, p ¼ . ). conclusions. using the new information process, a measurably better patient satisfaction could be observed. thus, by relatively simple means a highly efficient information process can be established even at a large hospital. the discontented patient j. pritz , d. schaden the number of claims after surgical procedures (not only bariatric or cosmetic surgery) is still increasing and patients nowadays are getting better informed about medical malpracti-ce=error in the media and the various possibilities to assert their rights. in austria various kinds of out-of-court settlement are installed to facilitate patient's compensation without the risk of litigation. in many cases misconceptions in the patient-doctor relationship can be solved without motion to court. but how can the terms ''malpractice'' or medical error be defined at all? which conditions must be fulfilled for the motion to court or the medical arbitration committee? we want to give a survey of the activity of the arbitration committee, the members, and the possibilities of compensation. moreover, the different consequences between criminal and civil law should be explained. the role of the expert witness, the course of procedure at the arbitration committee and possible consequences for the doctor or the facility will complete the presentation. background. negative resection margins are significant for prevention of recurrence in liver surgery. preoperative d models of imaging data provide significant improvements for visualization and planning, but intra-operative realisation is still a challenge. possibly navigation technology can improve oncological safety in liver resections. methods. fifty-four of liver resections for liver metastases were selected for intra-operative navigation due to complex anatomical situations. exact surgical plan was documented on virtual d models. planned resection margins were assessed and measured preoperatively. intra-operative d ultrasound data were acquired and localized with an optoelectronic tracking system, thus navigation of surgical instruments was provided in a virtual environment of these registered ultrasound data. surgical resection margins were compared with the surgical plan. results. navigated surgery was realized in of resections. r resection was achieved in of patients. mean histological resection margins were ( - ) mm. maximum deviation from the surgical plan was mm. conclusions. d ultrasound-based optoelectronic navigation is a feasible device for liver surgery, provides optimal anatomic orientation and can realize precise resection margins. background. during liver resection, a low central venous pressure plays a crucial role in reducing blood loss and intra-as well as post-operative morbidity. however, excessive volume restriction could lead to microcirulatory impairment and organ hypoperfusion. in the present study, we evaluated a standardized intra-operative protocol for optimal fluid replacement therapy. methods. in a prospective study, patients for elective liver resection were included. intra-operative fluid replacement was restricted to ml=kg=h in patients with thoracic epidural analgesia or ml=kg=h for patients without thoracic epidural analgesia. following target parameters were defined: central venous oxygen saturation > %, intra-operative lactate levels < mmol=l, urine output > ml=h, central venous pressure < mbar, and norepinephrine dosage < . mg=kg=min. in patients where at least one of the parameter values exceeded the predefined limit, fluid replacement therapy was intensified and dobutamine . mg=kg=h was started. patients were monitored for intra-operative blood loss, intra-and post-operative complications, and length of hospital stay. results. patients that remained within the intra-operative target parameters for central venous oxygen saturation, lactate levels, urine output, central venous pressure, and norepinephrine dosage had lower blood loss, fewer complications, and shorter hospital length of stay. conclusions. the standardized protocol is a good approach for optimal intra-operative fluid replacement and to minimize blood loss, post-operative complications and hospital length of stay. background. bile duct injuries (bdi) are still the most feared complication of laparoscopic cholecystectomy. the patient has to face prolonged postoperative treatment, even life threatening complications; the hospital and the surgeon rising costs and pricely and possibly time-consuming malpractice procedures. the repair of bdi requires special hepatobiliary expertise, but the long-term results even in the best centres are still sobering. there are different types of bdis requiring a tailored approach. we analyzed predisposing factors and types of bile duct injuries treated in our institution. methods. we analyzed our operative and endoscopy database from - for patients treated with bile duct injuries after cholecystectomy. bile duct injuries were classified according to a system proposed in by siewert and colleagues. results. between and a total of cholecystectomies were performed at our institution. there were laparoscopic (lc) and open procedures (oc; inculuding procedures with conversion from lc to oc); during the same period, patients ( females= males, mean age years; range: - ) were treated for bile duct injuries; of these patients were initially operated in an other hospital. there were patients with class i lesions (bile leak of the cystic duct or lesion of luschka ducts), patients with class ii leions (stricture of the cbd). two patients with class iii injuries (incomplete trans-section of the common bile duct) and patients with class iv lesions (transsection of the cbd or chd). thirty four of the initial ( % -all open and converted and laparoscopic) operations were considered difficulty by the surgeon performing the cholecystectomy. of operations were laparoscopic ( - %), converted from lc to laparotomy ( %) and laparotomy from the incision ( - . %). of the original operations, had been performed by an experienced surgeon, by a novice. conclusions. cystic duct leakage is still the most common type of biled duct lesions after cholecystectomy. bile duct injuries occur a s commonly in operations performed by by novices as in procedures done by experienced surgeons. in order to present the current concept for treatment of bpl patients suffering from traumatic brachial plexus lesion (bpl) who underwent microsurgical reconstruction were analysed. within one year in our institution male patients, aging from to years were scheduled for surgery. three suffered from complete, from upper bpl. six patients were diagnosed as supraclavicular lesions and as infraclavicular lesions. patients with diagnosed supraclavicular lesions were scheduled for surgery between and months after trauma. surgical exploration revealed root avulsion and or rupture in all cases. classic intraplexual reneurotisation was performed in patiens, whereas all patients received extraplexual reneurotisation procedures, utilising the spinal accesssory, the ulnar and intercostal nerves. three patients received secondary reconstructive procedures. patients with infraclavicular lesions were treated surgically between and months after injury. in all patients nerve grafts were used to reconstruct the injured fascicles, a nerve transfer was used in case only. one patient required secondary reconstructive surgery. the reconstructive strategy in bpl surgery has been changed dramatically during the last years. the strategy changed from a single surgical intervention one year after the trauma to a prozessual concept consisting of early primary nerve reconstruction and secondary reconstructive procedures. nerve grafting with use of autologuous nerve grafts for ''intraplexual'' reconstruction is still state of the art, additionally nerve transfers were introduced to utilize ''extraplexual'' sources for reeinnervation. regarding this concept most of the patients regain not only some motor function but functionality of their impaired upper extremity. teaching means learning -who benefits from academic teaching duties? p. lechner, g. humpel background. in the department of surgery at the danube clinics intulln, a level i hospital, has been named a teaching institution associated with the vienna medical university. this has certainly led to various organisational changes the results and consequences of which we attempt to identify. methods. all teaching institutions are subject to continuous evaluation by the students. in addition to that, we undertook an extra evaluation aiming at potential organisational and medical improvements from which patients, personnel, and students may benefit. results. ) as the students are available only from . through . o'clock, all organisational routines at the department (staff-rounds, meetings, lectures, etc.) now follow a more rigorous daily schedule. ) bed-side teaching means explaining everything that is undertaken in the presence of the patients. so the patients receive more information on their diseases and treatments. ) students tend to question everything, and so we also call in question many routines ''that have always been performed like that''. this allows us to simplify numerous operating procedures and means continuous organisational learning to the institution. ) for the same reason lecturers -and all those who are involved in teaching (physicians, nurses, and others)have to keep their academic knowledge up-to-date any time. ) teaching during meetings and ward rounds is of course not ''limited'' to university students, but also comprises interns and residents. conclusions. the department's current status as an academic teaching institution turned out beneficial for patients, personnel, and students, concerning professional, technical, and organisational aspects. though the additional workloadespecially in the beginning -must not be under-estimated, the advantages clearly exceed the burdens. background. necrotizing enterocolitis (nec) is the most common gastrointestinal complication of prematurity at the neonatal intensive care unit. the first aim of the study was to investigate the correlation between clinical parameters, extent of disease and mortality, and the second purpose was to analyse the surgical procedures and their outcomes. methods. in a retrospective study we reviewed medical charts of patients who were operated within a five years periode. preoperative blood results and demographic data were collected and evaluated. according to the extent of disease, birth weight and operative procedure different groups were analysed. results. a total number of patients underwent surgical procedures for nec from to , and % (n ¼ ) weighted less than g. in patients focal disease, in patients multifocal disease and in children panintestinal disease were found. preoperative blood tests revealed a median crp level of . mg=dl (normal range . ), median wbcc of . g=l and a median platelet count of g=l. primary laparotomy with defunctioning enterostomy was performed in %. overall mortality was %. conclusions. the extent of disease and the condition of the infants still determines the survival. preoperative blood results are of limited prognostic value. primary laparotomy with defunctioning enterostomy was the preferred technique in our unit, and even in the group of vlbw and elbw neonates surgery was well tolerated. discussion regarding the best operative procedure is still going on and no consensus in the management of nec is agreed on. methodik. während der letzten jahre wurden neugeborene (gestationsalter - wochen, geburtsgewicht - g, alter bei der darmperforation - tage) mit einer oder mehreren dünndarmperforationen beobachtet. die symptome waren jeweils etwa ident: abdominelle distension mit verfärbung der flankenhaut bei initial insgesamt stabilem allgemeinzustand. bei ,,nur'' der kinder zeigte sich im abdomen-leer-röntgen freies gas in der bauchhöhle, bei allen aber war sonographisch intraabdominell freie flockige flüssigkeit festzustellen, ohne nec-typische veränderungen am intestinaltrakt. kinder wurden aufgrund ihres schlechten zustandes nur punktiert=drainiert und antibiotisch behandelt. patienten wurden laparotomiert: bei kindern fand sich die perforation im bereich des jejunum, bei weiteren im unteren jejunum=oberen ileum und bei im terminalen ileum, davon hatte eines und eines perforationen. der betroffene darmabschnitt wurde jeweils reseziert; bei kindern wurde eine end-=end-anastomose durchgeführt, bei den verbleibenden patienten wurde wegen der peritonitis eine doppelläufige enterostomie angelegt. eines dieser kinder verstarb aufgrund einer sepsis-bedingten gerinnungsstörung. eines der beiden drainierten kinder wurde wochen nach der intervention wegen eines ,,verwachsungsbauches'' adhäsiolysiert. ergebnisse. die Ü berlebenschance sehr kleiner frühgeborener nahm während der letzten jahre deutlich zu. parallel dazu mußte bei diesen kindern eine zunahme umschriebener, ätiologisch nach wie vor nicht ganz geklärter darmperforationen zur kenntnis genommen werden. zur behandlung stehen grundsätzlich differente vorgehensweisen zur verfügung: im vordergrund steht eine resektion des lädierten darmabschnittes und, abhängig von den lokalen gegebenheiten (peritonitis ja=nein), entweder eine end-zu-end-anastomose und=oder nur eine doppelläufige enterostomie. als zweite prinzipielle therapieform gibt es die möglichkeit, die bauchhöhle zu punktieren= drainieren, wodurch die affektion auch beherrscht werden kann; im einzelfall kann sie letztlich aber doch nur chirurgisch zu sanieren sein. dieses vorgehen gilt für uns als ultima ratio. schlussfolgerungen. auch wenn eine isolierte darmperforation bei einem kleinen frühgeborenen relativ gut behandelbar ist, sollte durch klärung ihrer Ä tiologie eine prävention dafür möglich werden, da diese kinder wegen ihrer kritischen voraussetzung bereits per se außerordentlich gefährdet sind. the endorectal pull-through procedure (erpt) for hirschsprung's disease g. schimpl background. whereas in the past various operative techniques in patients with hirschsprung's disease (hd) were used, erpt was introduced as a single-stage operation. methods. sixteen patients with hd ( females, males) aged months to years were treated using the erpt procedure and the level of bowel resection was determined by intraoperative biopsies. results. the length of hd was in patients up to the sigmoid colon, in patients up to the transverse colon and one patient had a total colonic hd. two patients required a laparoscopic mobilisation of the left colonic flexure. in the patient with total colonic aganglionosis, the resection of the entire colon and sauer's procedure was performed using a periumbilical laparotomy. oral nutrition was started in all but on the first post operative day and they were discharged after - days. complication occurred in two patients: one had to be reoperated due to misinterpretation of intraoperative biopsies and a second patient with years of age developed a retrorectal abcess which was treated coservatively. in a follow-up, - years postoperatively, all patients are continent and have normal bowel movements. conclusions. erpt is an advance in the treatment of hd and can be performed at any age. it avoids the creation of enterostomies, is a single step procedure with excellent functional results and low complication rates. in long segment hd this procedure can be combined with laparoscopic or open surgical procedures. single-port appendectomy in obese children -a useful alternative? t. petnehazy, h. ainoedhofer, s. beyerlein, j. schalamon background. the rapidly increasing prevalence of obesity among children poses challenging problems in abdominal surgery. there is a growing body of evidence that single-port appendectomy (spa) is a feasible and safe alternative to open appendectomy (oa). very little is known about the clinical outcome of spa in overweight children. we present our experience with the treatment of suspected appendicitis in obese children using spa. methods. from january to december we performed spa in obese children with suspected appendicitis ( females, males, median age of . years). obesity was defined as a bmi > th percentile for age and gender (median weight . kg). in the procedures a -mm instrument was introduced through the umbilicus (combination of a -mm wide angle optic with -mm working channel). after exploration of the abdominal cavity and meckel's search, the appendix was exteriorized through the umbilical trocar and removed by open technique. patients' records were evaluated regarding anaesthetic time, complications, time until reintroduction of solid diet and histopathological findings. results. average operating time was . min (range - min). neither intra-nor postoperative complications occurred. reintroduction of solid diet to all patients was possible on the first postoperative day. the histology is presented in the below table. our results indicate that the advantages of spa such as: excellent evaluation of the peritoneal cavity, minimal rate of intraoperative incidents and superior cosmetic results make this technique a valid alternative for the treatment of appendicitis in obese children. background. ovarian torsion is a surgical emergency. because of unspecific clinical findings, diagnosis can be delayed and therefore may result in oophorectomy. recently preservation of ovarian function by means of laparoscopic detorsion has been proposed even in advanced cases. methods. we retrospectively reviewed patients with diagnosis of ovarian torsion who presented at our institution between and . a total of ovarectomies and detorsion were performed. twenty patients underwent minimal-invasive surgery, in cases laparotomy was performed. in cases a conversion was necessary. the accuracy of preoperative imaging modalities, surgical technique, correlation with postoperative histopathologic findings, complications and outcome were assessed. results. all patients were investigated by means of ultrasound. mri was applied in patients whereas ct-scan was done in patients. histopathological and intraoperative findings revealed simple torsions, twisted cysts and twisted teratomas. sensitivities to detect ovarian torsion were % for ultrasound (us), % for mri, and % for ct. entirely oophorectomies and detorsions in patients were performed. one of these patients presented with asynchronous bilateral ovarian torsion caused by a unilateral benign teratoma. in patients a laparoscopic contralateral oophoropexy was done. mean hospital stay was (laparoscopic) versus days (open approach). the complication-rate was marginal in both groups. conclusions. preoperative imaging is essential to improve the diagnostic accuracy. however, sensitivity only approaches %, emphasizing the importance of surgical exploration when symptoms are compatible with torsion. when a neoplasm is suspected, mri or ct imaging is essential. in order to preserve ovarian function and fertility, laparoscopic detorsion without primary resection should be the procedure of choice. it constitutes an easy, quick and equally safe procedure. the need for contralateral oophoropexy has to be discussed. background. differential diagnosis of lower abdominal pain include beneath common causes such as appendicitis and gastrointestinal infections some not so common diseases as ovarian pathologies in female patients. this may be ovarian cysts but can also be pathologies like ovarian torsions or tumours that have to be operated. however, the differential diagnosis between ovarian cysts and ovarian torsions is often radiologically inclonclusive and therefore makes a surgical intervention mandatory. methods. we analysed retrospectively the data from female patients hospitalised for ovarian pathologies in between and . twenty nine patients underwent surgical intervention for different causes. results. most patients presented with acute abdominal pain demonstrated signs of peritonitis and required pain relief. on the other hand we had patients with only mild clinical signs such as newborns with already prenatally diagnosed ovarian cysts. we found in our patients cases of benign ovarial cysts, cases of benigne teratomas, cases of serous cystadenomas, case of serous cystadenofibroma, case of yolk sac tumor and cases of ovarial torsions. conclusions. diseases of the ovaries are a rather rare but important cause of lower abdominal pain in children and adolescents and requires a mediculous diagnostic procedure and often an urgent surgical intervention. background. adrenal tumors, other than neuroblastoma, are rare in children. the aim of the study was to present the outcome of functioning tumors of the adrenal gland in children. methods. we reviewed medical records of children with adrenal tumors treated in our unit from to . demographic datas, clinical features, operative details, histopathological details and follow up were studied. results. there were children with the mean age . ae . years. two patients had virilizing tumors and presented with an acute abdomen, one patient had conn's syndrome, one patient cushing's syndrome and one patient presented with severe haemorrhagic shock syndrome. all patients were treated surgically. histopathological diagnosis were adrenocortical carcinoma (acc) in two patients, adrenocortical adenoma (aca) in two patient and adrenocortical cyst in one patient. ultrasound sonography, computerized tomography and magnet resonance imaging were used for diagnosis and follow up. patients with acc had advanced-stage disease and died despite total surgical resection and agressive chemotherapy. patients with aca and adrenocortical cyst were cured by surgical resection. conclusions. adrenal tumors constitue less than % of paediatric neoplasm. aca and adrenocortical cyst are cureable by surgical treatment, but the outcome is still poor in cases of acc. endoscopic subureteral injection of bulking agents has become an established alternative to long-term antibiotic prophylaxis and ureteral reimplantation. we evaluated the effectiveness of dextranomer=hyaluronic acid copolymer (deflux + ) and predicting factors for success or failure. a total of ureters= patients with a mean age of . years underwent endoscopic treatment with dextranomer= hyaluronic acid (dx=ha) copolymer. vur in duplex ureters was treated in patients. the presence of voiding dysfunction and renal scars, the volume of deflux injected and the endoscopic appearance of the ureter were recorded. dextranomer-hyaluronic-acid was injected submucosally beneath the intramural part of the ureter at o'clock, but if the appearance was not satisfying or the ureter opens during flow an additional injection at and o'clock was performed. all patients received antibiotic treatment till a voiding cystourethrography (vcug) was performed weeks after injection. ultrasound examination was performed after hours, months, months and one year. success was defined as no reflux on postoperative voiding cystourethrography. a total of ureters underwent to treatments. the overall success rate was %. the cure rate according to reflux grade was % for grade i, % for grade ii, % for grade iii. in vur grade iv and v the endoskopic treatment failed in most cases. there was no case of obstruction at up to month postoperatively. haemorrhage occurred in one patient. in five ureters an increase of vur grade developed. new contralateral vur was seen in six patients. in . % vur was found on postoperative vcug at years after endoscopic treatment. there was no statistic significant difference in volume injected when successes were compared with failures. among children with a small kidney the response rate was %. a positive response was observed in % of children with duplex ureters. the presence of voiding dysfunction had no influence on success. patients in whom endoscopic treatment failed underwent open surgery. the subureteral injection of dextranomer=hyaluronic acid is an effective and well tolerated alternative to open surgery or conservative treatment, also in patients with duplex ureters. in patients, who subsequently require reimplantation, the operative repair does not appear to be compromised. background. almost all patients with symptomatic vur were treated with a cohen procedure and a very high success rat. since we offer the endoscopic procedure with deflux. the outcome of the endoscopic treatment is evaluated. methods. between = and = , patients with refluxing units were treated (i ¼ , ii ¼ , iii ¼ , iv ¼ , v ¼ ). the control after treatment was between and months. additional urological diseases are: solitary kidney ( ), double kidney ( ), neurogenic bladder with mmc ( ), bladder trabeculation w=o neurological disease ( ), cloacal malformation ( ), bladder exstrophy ( ), urethral valve ( ) . age at treatment was between mths and yrs. injection was performed under general anesthesia, bolus was between . and . ml. three patients were additionally treated with botox. results. sixty patients need no further treatment after injection ( resolved and patients have reflux). in of patients, who need a second injection ( overactive bladder), reflux resolved as well as in patients after third injection. in patients with neurogenic bladder and mmc we had no success and further treatment (augmentation) was necessary. in patients reflux worsened and cohen operation was performed. in patients a vcug will performed in the near future and three are lost for control. conclusions. in cases of moderate reflux with no neurogenic bladder it is an excellent method to treat reflux. in cases of neurogenic bladder, we cannot recommend it and cases with bladder trabeculation need an additional medical treatment or operation with a higher success rate. all these patients need a long term follow-up. background. bariatric surgery in austria has a long tradition since , but has always been different to the international trends. in order to obtain an overview of growth and time trends of obesity surgery in austria a nationwide review has been done by the austrian national federation for surgery of obesity every two years since . methods. e-mail requests are sent to every department of surgery in public hospitals and clinics to collect the recent number of operations including revisional procedures. results. the last reviews (including ) showed a steady increase of obesity surgery particularly in the years through the number of operations increased %. since a constant number of interventions of about per year ( : ) had been observed. predominant operation techniques were restrictive procedures: - vbg (vertical banded gastroplasty) and since agb (adjustable gastric banding). since the late nineties austria is a gastric-banding country ( % in ) compared to the worldwide review data ( % in ), but since we observe a steep increase of gastric bypass paralleled by a decrease of agb. by the time of the conference data of the review starting in january will be presented a showing the trend of the last two years. conclusions. bariatric surgery as the only effective treatment against the alarmingly increasing disease of severe obesity is already an important part of the surgical work of some austrian surgical departments. in view of this fact quality control by continuous data collection is of major importance. restrictive bariatric procedures -long term results and complication management k. miller background. vertical banded gastroplasty (vbg) has been in clinical use since and the adjustable gastric band (agb) since . as promising results were achieved with the adjustable gastric bands available in the market, some surgeons came to the conclusion that vbg might be entirely abandoned and replaced by the adjustable gastric band. the aim of this study was to compare the long term outcome of the two different restrictive procedures. methods. within a period of years ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) , gastric restrictive procedures were performed in the course of a prospective non-randomized comparative trial. we report the outcomes of vbgs and agbs performed by two surgeons. the mean bmi was . ae . for vbg and . ae . for agb. patient selection was performed by admittance to one of the two surgeons. vbg was performed via laparotomy and agb by the laparoscopic procedure. the bariatric analysis and reporting outcome system (baros) was used to evaluate the postoperative health status and quality of life. results. the mean duration of follow-up was months, with a minimum of years (range, - months). the overall follow-up rate was %. in the short-term follow-up of years, no statistically significant difference was registered between agb and vbg in terms of weight loss, reduction of co-morbidity or improvement of quality of life. the -day mortality rate was . % ( patients) for vbg and . % ( patient) for agb. the overall re-intervention rate in the long term was . % for vbg and . % for agb (p < . , or . , % ci . - . ), the re-operation rate . % for vbg and . % for agb (p < . ), respectively. the excess weight loss (ewl) was significantly higher in the vbg group after months ( % for vbg vs. % for agb; p < . ). in the long-term follow-up with a mean value of months, no significant weight loss was registered between the study groups ( % for vbg and % for agb; p ¼ . ). the baros score in the short term ( years) was good to excellent in and % of the vbg and agb groups, respectively. in longterm follow-up the baros score was significantly in favor of the agb group ( . vs. . %; p < . , or . , % ci . - . ). the overall loss of co morbidities was % in both groups. conclusions. this long-term follow-up study shows that vbg and agb are effective restrictive procedures to achieve weight loss, and loss of comorbidities. a statistically significant lower re-intervention and re-operation rate and an improved health status and quality of life were registered for agb. pilot study on the effects of gastric electrical stimulation (tantalus tm ) on glycemic control in morbidly obese patients with type diabetes (t dm) a. bohdjalian , b. ludvik , s. shakeri-manesch , r. weiner , c. rosak , g. prager background. previous work suggests that non-excitatory electrical stimulation, synchronized to the gastric refractory period and applied during meals, can induce weight loss in morbidly obese subjects. the tantalus tm system (metacure n.v.) is a minimally invasive implantable gastric stimulation modality that does not exhibit malabsorptive or restrictive characteristics. aim: to investigate the potential effect of the tantalus tm system on glycemic control and weight in morbidly obese subjects with t dm. methods. in this european multi-center, open label study, t dm obese ( m, f, bmi: . ae . kg=m ) subjects treated either with insulin ( ) or oral anti-diabetic medications ( ) were implanted laparoscopically with the tantalus tm system. the system includes a pulse generator and three bipolar leads and delivers a non-excitatory signal initiated upon automatic detection of food intake. results. twenty subjects have completed one year and exhibit a decrease in hba c from ae . % at baseline to . ae . % (p ¼ . ) and in fasting blood glucose from ae mg=dl to ae mg=dl (p< . ). sixteen subjects on oral anti-diabetic medications showed a decrease in hba c from . ae . % at baseline to . ae . % (p< . ) and an average weight loss of . ae kg (p< . ), self glucose monitoring available at months post-op from subjects shows a significant (p< . ) decrease in hours post-prandial glucose ( ae mg=dl vs. ae mg=dl). in a subset of patients at months of post-operative follow-up we could find an increase in adiponectin ( . ae . vs. . ae . mg=ml, p < . ) and a decrease in fasting ghrelin ( ae vs. ae pg=ml, p < . ). the areas under the curve (auc) measured during meal tolerance test were significantly higher for adiponectin and lower for ghrelin (p < . ) compared to pre-therapy. four insulin subjects have completed one year and showed no significant changes in hba c and weight. conclusions. interim results with the tantalus tm system suggest that this stimulation regime can potentially improve glucose levels and induce weight loss in obese t dm subjects on oral anti-diabetic therapy. further evaluation is required to determine whether this effect is due to induced weight loss and=or due to direct signal dependent mechanisms. background. gastric sleeve resection was initially devised as the first step of the duodenal switch operation in bariatric surgery. later, it was performed as an isolated restrictive procedure, mostly laparoscopically. we present intermediate to long-term results from a large series of laparoscopic sleeve resections (lsg) in three austrian centers. methods. ninety-eight patients ( males, females) who all met the ifso criteria for bariatric surgery were included in this study. the mean bmi was . kg=m (range, - kg=m ). patients with symptoms of gastro-esophageal reflux or large hiatal hernias as well as ''sweet eaters'' were excluded and allocated for a different procedure (usually roux-en-y gastric bypass). ninety-five of the operations were performed laparoscopically: after establishing a pneumoperitoneum of mmhg, four to five working trocars were introduced. beginning opposite the crow's foot, the greater curvature was dissected from the omentum up to the angle of his. the left crus of the diaphragm was always identified to ensure complete resection of the gastric fundus. the stomach was then reduced to a tube over a f gastric bougie with several magazines of an endostapler, the staple line was finally oversewn with a continuous - pds suture. three patients had sleeve resection via an open access. results. after a median follow-up of months, patients had lost . kg=m of their bmi or % of their excessive weight on the average. there were six failures of lsg: three patients had gained weight despite lsg and three patients had lost less than % of their ew within one year. three of these patients underwent gastric bypass operations that were successfully performed laparoscopically. major complications included leaking of the staple line necessitating reoperation (three patients), severe wound infection (two cases, one of them after conventional sg), minor wound infections (three cases), and postoperative gastro-esophegeal reflux (one case), resulting in an overall complication rate of . % for severe and . % for minor complications. there was no operative mortality. conclusions. laparoscopic gastric sleeve resection is an effective and safe procedure with encouraging intermediate results. there is no implantation of foreign material, the procedure is less invasive than malabsorptive techniques. in the case of failure, it can readily be converted to gastric bypass or duodenal switch (with or without biliopancreatic diversion). on the other hand, this method has yet to stand the test of time within the spectrum of bariatric surgical procedures. background. bariatric surgery is indicated in patients with a bmi exceeding and presenting comorbidities or bmi ! . lgb is accepted as one of most successful surgical procedures to treat obesity. aim of study: a prospective analysis of the first patients who had been treated with lgb in our centre. methods. according to our treatment protocol at least dietetic attempts have to be failed to enrol the patient in the surgical program. lgb is performed in patients with a bmi ! with comorbidities or a bmi ! when gastric banding is unlikely to succeed. thirty patients (f:m ¼ : ) with a mean age of ( - ), mean bmi . (sd . %) underwent an antecolic, laparoscopic gastric bypass, performing the gastro-enteric as well as the entero-enteric anastomosis with linear stapler, closure of the enterotomies with manual continuous suture with pds, closure of the mesenteric defect with a non absorbable running suture. the postoperative controls had been performed on month ., ., ., . and . calculating the corresponding bmi. results. perioperative morbidity: two reoperations due to intestinal obstruction, two intraluminal bleeding of the anastomotic suture line, one case treated endosopically, one conservatively, no mortality was observed. the ewl months after performance of lgb was calculated to be % (sd %). conclusions. this series document that acceptable results may be achieved even during the learning curve of laparoscopic gastric bypass. background. in up to twenty five percent of morbidly obese patients restrictive procedures as vertical banded gastroplasty (vbg) or adjustable gastric banding (lagb) do not lead to adequate weight losses. transformation to a gastric bypass represents a therapeutic option in these patients. methods. from to revisional gastric bypass was performed in patients ( after vbg, after lagb, and after sleeve gastrectomy). the main indication for redo surgery was inadequate weight reduction. results. four ( %) surgical complications (incarcerated trocar hernia, intra-abdominal abscess, subphrenic abscess, leakage gastro-jejunostomy) occurred and had to be treated by a reoperation. one patient died of septic shock caused by a subphrenic abscess resulting in gastro-jejunal leakage and peritonitis (mortality rate: %). on follow-up patients after complications lost equal amounts of excess weight compared to uncomplicated cases. conclusions. revisional gastric bypass is a safe and potentially effective option for patients with inadequate weight loss after restrictive surgery. however, postoperative morbidity and mortality rates are higher compared to primary operations. operational cost accounting reflects in an impressive manner the medically already evident advantages for our patients. a laparoscopically performed colon resection with fast tracking costs e . , including pre-and post-surgical hospitalization. the same procedure without fast tracking results in costs of e . , . open colon resection including fast tracking adds up to e . , . conventional procedure without fast tracking even amounts to e . , . furthermore combining the operational results with the economical calculation results in a cost cutting potential of an extra e , per person, who has undergone laparoscopic surgery and was treated with fast tracking. in conclusion it can be stated, that this strategy of treatment means not only a severe post-surgical improvement of quality of life but in addition also shows significant economical advantages. the best method of treatment from both the medical but also the economical point of view is therefore the combination of laparoscopic colon surgery with fast tracking. is the laparoscopic sigmoid resection with a primary anastomosis in acute sigmoid diverticulitis the optimal surgical therapy? background. the late elective laparoscopic sigmoid resection for diverticulitis has become an acceptable therapy for diverticulitis, but the optimal surgical procedure of the acute diverticulitis has not been established. the optimal waiting period after acute symptoms of diverticular disease is still discussed controversial. the resection and primary anastomosis in acute diverticulitis may advance the challenging process for this surgical approach. methods. from may to january a laparoscopic sigmoid resection was performed in patients (male: , female: ) with a sigmoid diverticulitis. the average age was years for the males and years for the females. = patients were operated early elective within days after acute signs of diverticular disease (according to hansen and stock grade iia and iib) by a single surgeon, and = patients late elective by different surgeons. from all patients the clinical course, the operative time, the length of the sigmoid resection, the post-operative hospitalization and the complication rate were evaluated. results. according to the asa-classification = patients were graded as asa i, = as asa ii and = as asa iii. patients were divided in three groups. group i ( = ): early elective operations, group ii ( = ): late elective operations but with intraoperatively signs of an acute diverticulitis and group iii ( = ): late elective operations without manifestations of an acute process. the average operative time in minutes was in group i: (range - ), group ii: (range - ) and group iii: (range - ). the length of the resection specimen was comparable in group i and iii with an average length of mm, in group ii mm. the average extent of hospitalization was in group i: . days, group ii: . days and group iii: . days. none of the patients had conversion to laparotomy. complications were: group i one wound seroma, group ii one ureteral injury, one incision hernia and group iii three wound infections, one anastomotic leak and one incision hernia. since the localization and operative technique of the wound suturing was varied, an incision hernia was not observed. conclusions. the advantage of the early elective sigmoid resection after acute sigmoid diverticulitis is a short one-stage hospitalization with a low complication rate. in experienced centers the laparoscopic early-elective sigmoid colectomy seems to be a feasible and optimal surgical procedure for the acute sigmoid diverticulitis. laparoscopic resections for colorectal diseases: indications, operations, results s. riss, c. bittermann, p. dubsky, f. herbst background. laparoscopic assisted surgery for colorectal diseases has potential advantages over the traditional open technique. several studies reported that the laparoscopic approach offers multiple benefits such as faster recovery, better cosmesis, a lower incidence of adhesion-related complications and incisional hernias. the current study was designed to assess the role and feasibility of laparoscopic procedure in colorectal surgery. methods. from to patients ( females, males) underwent laparoscopic colorectal resections. mean age was (range - years) with a mean body mass index of . kg=m (range . - . kg=m ). indications included benign (inflammatory bowel diseases, diverticulitis, slow transit constipation, colon adenoma, fap) and malignant conditions with curative and palliative intent. all operations were performed or directly supervised by one single surgeon. intraand postoperative parameters were documented and statistically analysed retrospectively. results. over a year period operations in patients were performed, including bowel resections ( malignant) and anastomoses. average duration of operation was min (range - ). the mean time of hospital stay was days (range - ). the total conversion rate was . %. postoperative complications were observed in patients: surgical complications occurred in cases, with patients requiring reoperation (bowel obstruction n ¼ , anastomotic leak n ¼ , trocar hernia n ¼ , anastomotic bleeding n ¼ ). thirteen patients developed medical complications after operation and were treated conservatively. one patient ( . %) died due to cardiorespiratory failure. conclusions. the present study included a wide range of indication criteria. notable, despite a high number of patients with inflammatory bowel diseases, there was a low rate of surgical complications. thus the minimal invasive approach seems to be safe and effective for a broad spectrum of colorectal diseases. rectal carcinoma in the era of ''minimal invasive''-and ''fast track''-surgery p. razek, c. kienbacher, a. tuchmann background. laparoscopic surgery for colon cancer is feasible and effective with good results in regard of postoperative recovery. fast track protocols are changing perioperative treatments to the same aim. at the time there are no randomized studies available to compare the effect of laparoscopy and fast tract strategies to an open and conventional procedure for rectal carcinoma, which is still surgical standard. methods. from to patients were operated laparoscopically for rectal cancer ( males and females; mean age a, a- a). patients staged t were excluded. excessive preoperative surgery (i.e. right hemicolectomy, sigmoid resection, prostate resection), severe cardiac and pulmonary diseases or a high bmi did not effect the indication for laparoscopy. patients, ( %) staged t preoperatively, received chemotherapy and long time radiation. in the first period (-ii= ) patients were treated according to a conservative perioperative management. thereafter ( ) ( ) ( ) a fast track protocol was applied to the following patients. results. abdominoperineal extirpations (n ¼ ), anterior resections in double stapler technique (n ¼ ) and coloanal anstomosis (n ¼ ) were performed. conversion to open surgery was necessary in two cases ( . %), [bulky disease and a narrow male pelvis (n ¼ ), anatomical reasons (n ¼ )]. operation time was long and varied from to minutes (mean minutes). r was achieved in % ( patients with metastatic disease were staged r , one patient with a colonic wall lesion and potential spillage). postoperative stay for the laparoscopic group was days, for the combined laparoscopic þ fast track group was days (in comparison with days for conventional and open surgery). complications, mortality and side effects were reported. conclusions. exceptional view inside a narrow pelvis by the means of laparoscopy creates good conditions for total mesorectal excision and nerve sparing technique. minimal invasive surgery reduces the surgical trauma as a basis for an early postoperative recovery. the combination with a fast track protocol furthermore helps to establish even better results. the importance of laparoscopy in the management of postoperative complications c. kienbacher, p. razek, p. patri, a. tuchmann background. postoperative complications, especially anastomotic leakage after laparoscopic colon surgery are a hazard for all surgeons. most important is to recognize the early signs of complications such as abdominal pain, fever, chill, persisting nausea and vomiting and increasing abdominal swelling. the erlier a reintervention is done the better is the outcome for the patient. requesting a single and sufficient procedure, most surgeons don't even think about a minimal invasive reintervention. from = until = patients underwent laparoscopic colon surgery, patients had to be reoperated. twenty-five patients had a relaparoscopy, only two times we converted to the open procedure. patients had to underwent primarily open abdominal surgery, patients had abdominal wall problems and did not need an intraabdominal procedure. methods. concerning the intraabdomial complications we performed laparoscopic washouts, patients had a laparoscopic incisional hernia repair, patients bleeded from the trocarincisions, a laparoscopic anastomosis resection was performed, patients got a laparoscopic ileostomie, times it was necessary to perform a laparoscopic bowel diversion and times the hartmann procedure was performed minimal invasive. results. the traditional open reinvention was required in patients, all showed a peritonitis and a colon diversion with stomatherapie was done. eighteen patients had a single reintervention. after laparoscopic redos the median postoperative stay was far shorter than after open procedure. patients died. conclusions. laparoscopic reinterventions are feasable in most cases, the advantages are less postoperative pain, shorter hospital stay, quicker return of bowel fuction and improved cosmetic results. compensatory sweating after endoscopic sympathetic block at t background. endoscopic thoracic sympathectomy is the treatment of choice for patients with primary hyperhidrosis (hh). compensatory sweating (cs) is the most frequent unwanted side-effect of this surgical procedure. recently, clip application (endoscopic sympathetic block, esb) has been introduced as it provides reversibility. furthermore, sympathetic block solely at the level of the th thoracic ganglion (t ) was proposed to reduce cs and still effectively cure palmar hh. the aim of the study was to analyze the outcome of patients treated by esb at the level t with special reference to cs. methods. between and patients (mean age . ae . years) prospectively underwent procedures (one unilateral and bilateral operations). satisfaction rates and quality of life scores have been evaluated. mean follow up was . ae . months obtainable from patients ( . %). results. one hundred and three patients ( . %) had palmar, ( . %) axillary and ( . %) combined hh. at follow-up, all patients with palmar and . % with axillary hh were completely or nearly dry. cs was observed in ( . %) patients. most frequently, the back ( . %), the thighs ( . %), the abdomen ( . %), the feet ( . %) and breasts ( . %) were affected. in . % one single body region was affected, in . % two and in . % three regions became humid. cs significantly diminished quality of life (p < . for both questionnaires). consequently, . % were unsatisfied with the final outcome. however, the vast majority of patients were completely or almost completely satisfied. conclusions. esb at t gives excellent results for palmar and good results for axillary hh. however, cs primarily affecting the back and the thighs diminishes patients' quality of life and satisfaction. right donor nephrectomy, a major challenge is adequate renal vein length, due to vascular anatomy. methods. all patients undergoing laparoscopic donor uretero-nephrectomy between and were included. side of nephrectomy was selected based on selective renal function assessment and vascular anatomy. standard laparoscopic access was gained through trockars, the kidney dissected from its capsule, the vessels isolated, and the ureter transsected. following transsection of the renal artery (proximal closure with clips to maximize retrieved vessel length), and the renal vein (proximal closure with vascular stapler), the organ was procured through a mini-laparotomy connecting two trokars. in laparoscopic assisted right nephrectomy, the vein was retrieved with a vena cava patch using a semi-open approach: following isolation of the vascular structures and ureteral transsection, the confluens of the renal vein with the inferior vena cave was excluded using a curved clamp through a mini-laparotomy in the right upper quadrant. the caval patch was created by cutting the vein closely distal to the clamp, with reconstruction of the vena cava by a running blalock suture. patients undergoing laparoscopic assisted right resection (study group sg) were compared to patients with laparoscopic left nephrectomy (control group cg). data are reported as mean ae standard deviation or total numbers (% . total morbidity was ( . %), including ( . %) infections, and ( . %) postoperative lymphatic leaks. two ( . %) major complications (bleeding ( ) and intraabdominal abscess ( )) resulted in reoperation (sg vs. cg ; p ¼ . ). conclusion. the laparoscopic assisted approach to right kidney procurement is feasible, allows for sufficient length of the right renal vein for transplantation, and donor morbidity is comparable to laparoscopic left nephrectomy. clinical implementation of radius surgical system in mis w. feil, i. pona, t. filipitsch, p. jiru, u. satzinger limited mobility of instruments and absence of depth perception are significant issues in advanced laparoscopy. by that procedures including complex suturing and anastomoses in narrow operating fields in difficult angles of visualisation exceptionally challenge experienced surgeons. the radius surgical system (tübingen scientific medical gmbh, tübingen, germany) consists of manipulators for mis (right and left hand) suitable for mm trocars allowing a freedom of movement comparable to robotic devices. the instrument tip can be deflected by by handle deflection and rotated via handle knob. compressing and releasing of the instrument jaws works conventionally. radius system was implemented in the ekh vienna by = . in advance a -day training course was absolved by the surgical team. radius system was used for a series (n ¼ ; = ) of reflux operations to perform hiatal suturing and fundoplication. in practice handling of radius taking advantage of all features turned out so physically mandatory, that a training course is unanimously recommended even for surgeons with experience in all mis suturing techniques. in pratice the needle could be guided with significantly higher precision if compared to convention needle-holders. even suturing in narrow cavities and in difficult angles became feasible (video). after full accomodation to radius the next step of implementation is the creation of handsewn anastomoses, esp. in bariatric surgery. precision, reliability, safety and tightness of sutures and sewn anastomoses are crucial for the outcome quality of advanced mis procedures. for that the radius surgical system has shown to be extremely beneficial. does lifting of the abdominal wall for the set up of the pneumoperitoneum for laparoscopy increase the safetiness? a. shamiyeh , j. zehetner , h. kratochwill , k. hörmandinger , f. fellner , w. u. wayand background. to evaluate the intraabdominal changes while lifting the fascia with regard to the distance between the fascia and the retroperitoneal vessels and the intestine for access in laparoscopy. fifty percent of all complications during laparoscopic procedures occur during the establishment of the pneumoperitoneum. the blind insertion of the veress needle is the most popular way of access. elevation of the abdominal wall or the fascia is recommended, though the benefit has not been proven yet. methods. for patients scheduled for laparoscopic cholecystectomy the operation started in the ct scan. after orotracheal intubation a ct scan was performed of the umbilical region with cm proximal and distal margin. after a supraumbilical incision the fascia was freed and elevated with stay sutures. during maximal elevation, a second ct scan was performed. the distance between the fascia and the intestinal structures (small bowel) and the retroperitoneal vessels (iliac artery, aorta, vena cava) was measured after both scans and the difference was evaluated. results. lifting of the fascia increased the distance between the fascia and the intestinal structures with a mean of . cm (range . - . cm), the distance between the fascia and the retroperitoneal vessels with a mean of . cm (range - cm). conclusions. elevation of the fascia at the umbilical region prior to the first entering into the abdominal cavity for laparoscopy does increase the safeties due to enlargement of the distance between the fascia and the intraabdominal and retroperitoneal structures. background. despite many years of experience in breast reconstruction even as an immediate one stage procedure, there are still rumours about this technique, even among oncologic surgeons. these are concerning the influence on the oncological outcome, radio-and chemotherapy, severity of the operation, possible complications and patient's satisfaction. the presentation offers answers to most of these rumours from our own experience and the recent literature. methods. one hundred and eighty breast reconstructions were performed between and in our department, as immediate and as delayed procedures. eighty-seven were done with microsurgical autologous flaps and with a latissimus dorsi flap, in the rest various techniques like prostheses and expanders were applied. patient data were collected concerning early and late complications, oncological outcome, influence on radio-and chemotherapy and patient's satisfaction. results. reconstructions with prostheses required shorter operating times, but mostly late revisions were more frequently, especially in combination with radiotherapy. among the group of patients, in whom flaps were applied, only one was lost. with increasing experience, the need for blood transfusions, the postoperative morbidity and the length of the hospital stay decreased. in no case radio-or chemotherapy had to be delayed due to immediate breast reconstruction. secondary axillary lymph node dissection due to a positive sentinel node was possible even after a flap which was pedicled in the axillary vessels. our experience is well reflecting the results of the recent literature. conclusions. despite many existing rumours breast reconstruction, even as an immediate single stage procedure, can be regarded as an operation which does not inflict the oncological therapy. to optimise the results, however, indications must be set very carefully. background. positron emission tomography with the glucose analog [ f]-fluorodeoxyglucose (fdg-pet) has been used for response evaluation in patients with esophageal squamous cell carcinoma (escc) during neoadjuvant radiochemotherapy (rtx=ctx). this prospective study was undertaken to compare fdg-pet assessment of tumor response during rtx=ctx with histopathology in patients with escc, and to correlate the findings with survival. methods. sixty-one patients with histologically proven escc (ct , cn =þ, cm ) underwent preoperative, simultaneous rtx=ctx followed by esophagectomy between and . the patients underwent fdg-pet prior to and weeks after the begin of rtx=ctx ( gray). histopathological response was quantified as the percentage of residual tumor cells. the threshold pre-therapy-to-during-therapy decrease in standardized uptake value by fdg-pet used to define metabolic responders (Ásuv r ) was À %. results. receiving-operator-curve analysis (roc) for determination of metabolic response revealed an area-under-curve (auc) of (p ¼ . ) with a sensitivity of %, specificity ( %), a positive predictive value of % and a negative predictive value of % (p < . ). responder by fdg-pet during the neoadjuvant treatment (p ¼ . ) as well as histopathology (p < . ) showed substantially better survival compared to nonresponders. conclusions. changes in tumor metabolic activity by fdg-pet during neoadjuvant rtx=ctx allows an accurate determination of response due to the multimodal approach in patients with escc. this stratification may lead to a change of the neoadjuvant into a definitive therapy concept in nonresponders (individualized tumor therapy). background. totally endoscopic coronary artery bypass grafting (tecab) requires telemanipulation technologies because attempts using conventional thoracoscopic instrumentation have completely failed. these complex operations take individual and team learning curves and a stepwise approach is necessary. methods. from to cabg procedures were performed using the davinci tm system. a low risk patient population (age ( - ) years, euroscore ( - )) was treated. the following procedures were carried out: endoscopic ima takedown in midcab, opcab, and cabg (n ¼ ), robotic suturing of lima to lad anastomoses through sternotomy (n ¼ ), single vessel tecab (n ¼ ), double vessel tecab (n ¼ ). results. the number of totally endoscopic approaches through ports only increased from % in to % in . there was no hospital mortality and cumulative risk adjusted mortality (cram) plots showed that . predicted events did not occur. given event free procedures clopper pearson estimations revealed a % confidence interval between . % and . % for perioperative mortality. cumulative year survival was %, and year freedom from angina was %. conclusions. introduction of robotic totally endoscopic coronary artery bypass grafting seems to meet current cabg safety standards. initial application in low risk patients and a stepwise approach to completely endoscopic versions of the operation seem worthwhile. using this way single and double vessel tecab can be performed. intermediate term survival and revascularization results appear to be very satisfactory. icu stay was a mean of day in both groups and hospital stay lasted on average . ae . days in the bh group and . ae . days in the ah group (p ¼ . ). the advantages of arrested heart tecab are various -more space through the relaxed heart, -superior anastomosis quality through the arrested heart, -no manipulation of the lad with tapes and a clear operating field through the use of crystalloid cardioplegia, -no occlusion of the lad with the risk of ischemia, and result in shorter anastomosis as well as operating times and do not increase icu and hospital stay. methods. initially an experienced gi-surgeon was trained in an experimental centre in the application in both, open and laparoscopic application of the flexible shaft stapling system. after experimental sessions the system was used in clinical open surgery in cases before the laparoscopic approach was used. for laparoscopic procedures a stepwise learning curve was applied (from laparoscopic appendectomy, colon resection to laparoscopic gastric resection and esophageal resection). for intraabdominal application of the linear stapling device a mm trocar and for the circular stapling device a mm trocar was used. technical problems, operation time and operative complications were prospectively documented. results. the flexible stapling device was used in patients ( conventional, laparoscopic surgery). a mean of stapling procedures (range - ) was performed per patient. during the early phase technical problems were observed in patients ( formation of gastric tube for esophageal reconstruction, three formations of colonic anastomoses). all problems were solved by repetition of the anastomoses. nine leakages ( . %) were observed: two after esophageal surgery ( = ; . %), one after gastric surgery ( = ; . %) and six after colon surgery ( = ; . %). conclusions. the flexible shaft stapling device is safe in open and laparoscopic surgery. technical problems in the early phase were not due to malfunction of the device. the problems and complications are within the limits of conventional stapling. since there is a learning curve for handling, proper training in laparoscopic and open surgery is advised. the new flexible stapling device showed beneficial in special indications in laparoscopic surgery. the handling of the device is possible in any location in the abdomen, which makes procedures like collis-plasty feasible to be performed laparoscopically. circular stapled anastomoses of the colon above the rectosigmoid junction can easily be performed in circular stapling technique. background. intra-und extraplexuale nerventransfers kommen routinemäßig in der rekonstruktion posttraumatischer plexus brachialis läsionen zur anwendung. in den letzten jahren wurden einige neue selektive distale nerventransfers beschrieben, welche ein geringes defizit an spendernerven hervorrufen, möglichst nur motorische fasern beinhalten und ein hohes maß an funktioneller synergie besitzen. in der vorliegenden retrospektiven arbeit werden die operativen details, und langzeitergebnisse von patienten bei welchen diese techniken zur anwendung kamen vorgestellt und analysiert. methodik background. long lasting brachial plexus lesions (bpl) require free functional muscle transplantation to restore some distinct motor function. methods. five patients, receiving a total number of free vascularized muscle transplants are presented. all patients were male, aging , , , and years. patients suffered from obstetrical, from traumatic bpl. unstable shoulder (n ¼ ) and lacking biceps function (n ¼ ) were the indications for surgery. the gracilis muscle was used in cases to replace deltoid (n ¼ ) and biceps (n ¼ ). in one case a rectus femoris muscle was transferred into deltoid position. reinnervation of the muscle transplants at the shoulder was perfomed end-to-side to the spinal accessory nerve. in biceps position the motor nerves of the gracilis were coaptated end-to-end with the ulnar nerve (oberlin procedure, n ¼ ) or intercostal nerves (n ¼ ). results. surgery was successful in all cases primarily. all transplants showed reinnnervation starting months after surgery. stabilisation of the shoulder was achieved in all cases, furthermore of these cases regained active shoulder abduction= flexion up to degree. gracilis in biceps position reached m , are reinnervating. conclusions. free vascularized muscle transplantation seems to represent an useful tool for reconstruction of some distinct, essential motor function in paretic limbs due to bpl. background. since viterbo presented his exquisite results from terminolateral coaptation in small animals a new source for neurotisation seemed to be provided. viterbos results and our own good experience with free functional muscle transplantation encouraged us to use the technique in brachial plexus surgery. in a retrospective analysis we wanted to prove whether or not terminolateral neurorrhaphy produces functional results in brachial plexus surgery. methods. in patients, suffering from minimum c , avulsion and=or rupture a total of terminolateral procedures was carried out: times the suprascapular nerve was connected with the spinal accessory nerve and times the biceps motor nerve with the ulnar nerve, after creation of an epineureal window in all cases. results. patients were investigated . (ae ) month after surgery. the modified oberlin procedures (n ¼ ) showed m . the ss to xi procedures ranged from m (n ¼ ) to m (n ¼ ). multichannel emg evaluation did not reveal isolated function of the reinnervated muscles but action in parallel with the ''source muscles''. in out of procedures the terminolateral neurorrhaphy was sufficient to regain useful muscle function, i.e. to stabilise the shoulder and to add some minimal active function. conclusions. with respect to the severity of the lesions one might consider this an acceptable result. actually we did expect better results from the procedures, as we did achieve m and m function with free functional muscle transplantation and terminolateral neurorrhaphy in children. regarding our experience, the technique represents an useful tool for reinnervation, provided an unimpaired function of the donor nerve. current concept for treatment of obstetrical brachial plexus lesions w. girsch background. for a long time the treatment of obstetrical brachial plexus lesions (obpl) consisted of conservative treatment mainly. surgery was indicated only in severe cases suffering from persistant complete flail arm. gilbert introduced a much more aggressive concept with surgical intervention whenever the biceps is not working at three months of life, a strategy which caused discussions permanently. as a result of this discussion and with respect to clarkes work the concept was modified in the last years again. methods. the diagnosis of an obpl has to be followed by monthly clinical examinations. testing for muscle regeneration is not only focussed on biceps muscle but also on time and topographic course of regeneration. lack of shoulder and biceps activity at three months of life or negative ''handkerchief-test'' at six months represent indications for immediate surgical revision of the brachial plexus (primary early nerve surgery). in cases showing ongoing regeneration the conservative treatment is maintained. relevant deficiencies in motor function (less than % of rom or power in correlation with the unaffected side) at twelfe months of life represent an indication for brachial plexus surgery again (primary late nerve surgery). further nerve procedures, usually isolated nerve transfers (secondary late nerve surgery), can be performed in selected cases up to two years of life. after that time musle transfers and osteotomies (secondary procedures) are perfomed to achieve further increase in function. results. in brachial plexus surgery new concepts of ''extraplexual neurotisation'' and ''end-to-side neurorraphy'' have increased the possibilities of reconstruction by increasing the amount of nerve sources. secondary procedures, including free functional muscle transplantation, have become an integrative part of the overall treatment strategy. conclusions. although obstetrical techniques have improved in the industrialized countries, there still exists an incidience of - obpl per newborns, last but not least with regard to an increasing number of babies weighing more than g. it is known that of obpl recover spontaneously. new investigations have revealed relevant deficiencies in out of of these children at an age of years. actually the number of children requiring surgery is small. but for these children it is important to make the right decisions in time to minimise deficiencies and achieve optimal results. external derotation osteotomy of the humerus in patients with erb's palsy -effects on upper extremity kinematics b. gradl, m. mickel, m. schmidt, g. weigel, a. kranzl, w. girsch orthopädisches spital speising, kinderabteilung, wien, austria background. patients with untreated upper brachial plexus lesions frequently develop an internal rotation contracture of the shoulder, deficient active shoulder abduction and especially external rotation. the humeral derotation osteotomy combined with muscle transfers is one of the most common secondary reconstructive procedures to correct this deformity and improve the upper limbs function. the aim of this study was to investigate the patients' benefit of the surgical intervention. in order to objectively assess the functional outcome an optoelectronic motion analysis system was used to capture and analyze the kinematics of the involved limbs pre-and postoperatively. methods. eight children with secondary deformities following an obstetrical erb palsy were investigated before and after humeral derotation and muscle transfers. the patients' movements were captured by tracking the reflective markers which were applied to the upper limb and the trunk. the motion analysis was finished on the pc, resulting in various kinematic parameters, such as joint angles, motion curves, velocity and acceleration. static data was calculated to measure the amount of the shoulder malposition. results. results of the motion analysis document a dynamic as well as a static improvement of the involved limb in all eight patients. the average effective external derotation of the upper arm was , which means a correction to a nearly physiologic rotational positioning. active abduction increased in of patients with enhancement between and . active shoulder rotation improved in all patients ($ ). the maximum active elbow flexion did not increase, but the motion curves describing the movement changed: the velocity increased ( %), the compensatory shoulder abduction, which was observed during elbow flexion preoperatively in all patients, was reduced to a physiologic extent (compared to healthy probands). conclusions. derotation of the humerus as a secondary procedure allows functional improvement in patients with erb's palsy. this can be assessed by using a d motion analysis system. following global or lower brachial plexus lesions with intact biceps function in combination with missing radial nerve and weak median nerve function a supination contracture of the forearm is resulting. the supinated position of the forearm is functionally useless and often causes neglect of the extremity. five patients underwent surgical correction of this deformity, females (aging , and years) and males (aging and years). the biceps tendon was rerouted to the outside of the radius in cases and to the medial side of the ulna in one case. additionally correction osteotomies of radius and ulna had to be performed in the y old patient. reconstruction of extensor function was done in classical manner by tendon transfers. the tendon transfers did not only reanimate the extensors of carpus and hand but also augmented the light pronation of the forearm. all patients regained normal biceps and some simple hand function. regarding this, all patients started to use the extremity during adl for some, mostly bimanual tasks. correction of the supination contracture was highly beneficial for the patients. the procedure changed a useless extremity into a functioning part of the body. background. reconstruction of the distal weight-bearing area of the foot is surgical challenge, especially in diabetic patients. skin grafts do not provide adequate and permanent coverage of a weight-bearing region. local surgical options to cover these distal skin defects include forefoot amputation, a toe fillet flap and a reverse medial plantar island flap. the reverse medial plantar island flap is based on a very thin and possibly damaged intermetacarpal network. conventional angiography often is not a helpful tool for preoperative assessment, because foot vessels often remain occult. methods. the purpose of this study was to evaluate the viability of the distally based medial plantar flap in cadavers. angiographic imaging was possible in only cadavers reflecting the clinical preoperative assessment. distally based medial plantar flap dissection was done in all cadavers, as well as vascular dissection of the superficial and deep plantar arch. results. we found a well developed deep plantar arch in all cases. the deep plantar artery formed the main feeder of the deep plantar arch in %, while the second proximal perforating artery contributed to the deep plantar arch in %. the superficial plantar arch usually appeared slender and incompletely. conclusions. the distally based medial plantar flap could be dissected in all cadavers, whereas the quality of vessels was varying explicitly. the results of dissection always showed a constant vascular supply, but varying quality of supply. no clinical conclusions can be drawn, considering the slender vas-cular supply of the distally based medial plantar flap. optimized diagnostic angiographic procedures like mra or biplane selective dsa are essential for preoperative assessment planning distally based medial plantar flap. limberflap -salvage procedure for the non healing pilonidalis sinus t. kapp, h. marlovits, j. beck, f. hetzer kantonsspital st. gallen, switzerland background. surgical treatment of pilonidal sinus disease has a significant morbidity and recurrence rate. the rhomboid flap of limberg is a transposition flap that has been advocated for treatment of this condition. we present the technique and our experience. methods. in a prospective study starting in january we analysed consecutive patients ( females), median age years (range - years), with recurrent pilonidal sinus disease. we performed a complete rhomboid excision and closed the lesion by an excentric transposition flap designed to obliterate the middle cleft. morbidity was recorded and patient's satisfaction was analysed by a visual analog scale (vas). results. the median hospital stay was . days ( - days). we found in all patients a primary healing. minor complications were found in two patients. there was one flap oedema and one wound dehiscence, which were conservatively treated. no wound infection was observed. during the median followup of months ( - months) no recurrence occurred and high patient satisfaction was noticed. conclusions. although the limberg flap results in a slight asymmetric gluteal region patient's acceptance is high. fast healing, low complication and recurrence rate are the important advantages for this procedure. treatment of human painful neuromas and complex regional pain syndromes (crps) by co laser welding and regional subcutaneous venous sympathectomy (rsvs) -a new surgical approach w. happak, l. kriechbaumer background. since nearly years the treatment of painful neuromas is an unsolved problem. up to techniques are described with a recurrency rate of the pain between and %. the intramuscular transposition, the implantation into a vein and the end-to-side coaptation of the nerve stump are the state of the art operations. besides for years the treatment of complex regional pain syndromes type ii (crps ii) has been an unsolved problem. therapeutic approaches have included conventional pain medication, physical therapy, sympathetic blocks, transcutaneous or spinal cord stimulation, injections or infusion therapies and sympathectomy. alone or in combination these therapies often yielded unfavorable results. the majority of physicians, dealing with crps patients are convinced that surgical treatment only exacerbates the symptoms, and after the third neuroma pain-operation no improvement can be expected. after unsuccessful anaesthesiologic pain therapy over more than months, patients, with chronic neuroma or phantom pain were operated by co laser welding of the nerve stump in the last years. one third of the patients had or more pain operations. subsequently patients developed a crps type ii at the upper or the lower limb. the exact pain area was determined and the most proximal part where the crps commenced was infiltrated with % xylocain. when the sympathetic, deep, burning pain could be blocked, the subcutaneous veins in the previously determined area were removed surgically in a second step. a visual analogue scale (vas), the nottingham health score (nhs) and physical examinations were used to evaluate outcome of the operation. results. ninety-five percent of surgically treated painful neuromas and crps type ii patients showed significant improvement of limb function, the visual analogous scale (vas) and the nottingham health score (nhs). the medical pain therapy could considerably be reduced. conclusions. the presented data show that the superficial epicritical pain of neuromas can be treated successfully with co laser welding. the sympathetic, deep pain of the complex regional pain syndrome type ii can be treated successfully by a regional subcutaneous venous sympathectomy (rsvs). first clinical study of successful erbium-yag laser vaporisation of cutaneous neurofibromas l. kriechbaumer, w. happak background. with a prevalence of in births neurofibromatosis type i is one of the most common genetic defects. the mode of inheritance is autosomal dominant and affects a gene (nf ), which is responsible for the production of the tumor suppressor protein neurofibromin. the consequence is an uninhibited expansion of neural tissue which leads to cosmetic disfigurement of the patients. in comparison to the plexiform neurofibromas the cutaneous tumors do not undergo malignant transformation. excision and co laser vaporisation were established as standard treatment but cause unattractive scars. methods. in operations on two patients more than neurofibromas were removed with an erbium:yag laser. the tumors were dissected by shooting holes into the skin and vaporising the neurofibromas in-between or underneath. from test areas several biopsies were harvested for er:yag-, co and electrosurgical treatment in vitro to evaluate the difference of thermal necrosis histologically. photographs were taken to assess the cosmetic results. results. the fast healing by second intention as well as the minimal discomfort and scar formation following er:yag laser vaporisation was judged as excellent by patients and surgeons. we did not observe any hypertrophic scarring or lasting dyspigmentation. histologic evaluations revealed minor thermal damage to adjacent tissue resulting from this laser. conclusions. scars and changes in pigmentation resulting from excision or co laser-vaporisation often yield unfavourable results and the treatment is time consuming. er:yag laservaporisation of huge numbers of cutaneous neurofibromas is an uncomplicated and rapid procedure that achieves excellent cosmetic effects. background. lichen sclerosus usually presents a precancerous skin lesion of the genital region. skin grafting of penile defects is difficult because of the flexibility of the underlying recipient bed. this leads to disruption of the vascular ingrowth into the skin graft and compromises the results of the reconstruction. methods. we successfully used a circumferential vacuumassisted closure dressing with an incorporated urethral catheter to secure penile skin grafts in place during the early postoperative period. results. we achieved perfect take-rate of the graft and postulate good functional result concerning the stretched penile position during application of the vac-device. conclusions. a vacuum-assisted closure dressing can be used successfully to secure large and circumferential skin grafts, as well as skin grafts on concealed penises. background. there is a trend in reconstructive surgery towards modern techniques of defect coverage. such techniques are expected to combine high levels of safety, low donor-site morbidity, high aesthetic claims, short patient immobilisation and inpatient periods. the speculative applications for free, microvascular tissue transfers are expanded monthly while traditional reconstructive flap designs are no longer accepted as ''state of the art''. we present a case where modern defect coverage was not successful due to multiple comorbidities, localisation and complexity of the defect, and a step back to traditional flap designs was inevitable. methods. a previously healthy -year-old woman found a tumour on her back four years ago. diagnostic imaging and multiple biopsies revealed a cm-diameter chondrosarcoma with partial osteolysis of th = , tumour reaching into the spinal canal. she underwent radical resection and orthopaedic stabilisation from th -l , followed by chemotherapy and radiation of gy. one year after the operation metastatic lesions were found in both lungs. they were resected by video assisted thoracic surgery. due to resection of the erector trunci, the spine stabilisators loosened, two screws broke and the metal parts penetrated the skin. after local necrectomy, vac-therapy was performed for more than one year. severe headache and massive exsudation of the wound started in , suggesting dural leakage. a reversed latissimus dorsi-flap was performed, additional microanastomosis could not be done due to the very small calibre of the intercostal vessels. after one week, the metal-covering part of the flap showed muscle necrosis and had to be resected. a large fasciocutaneous transposition flap was designed and cautiously raised in steps of delay and could finally cover the defect. results. in this rare case of a chronic vertebral defect including spinal instability and liquorrhea reconstructive aims could not be reached by microsurgical techniques but by returning to traditional local flap designs. the patient is mobile and painfree, and there is no recurrence of liquorrhea since discharge. conclusions. technical advances and refinements in defect coverage are the basis for progress in reconstructive surgery. selected indications for traditional flap techniques still remain in modern reconstructive surgery dominated by microsurgical tissue transfer to cover problem defects. the missing link between tradition and innovation: skin tissue engineering l. kamolz, m. frey background. the need to achieve rapid wound closure in patients with massive burns and limited skin donor sites led to the investigation of in vitro cellular expansion of keratinocytes. the use of cultured epithelial grafts was first reported in the treatment of major burns. since , support for the use of keratinocytes has varied. the factors potentially limiting the use of cultured keratinocytes were cultivation time, reliability of 'take', vulnerability of grafts on the newly healed surface and long-term durability. the aim of this review is to evaluate the real impact of the clinical use of keratinocytes. one of the main aspects is to introduce new methods, which found or will find their way into clinical practice. methods. this study is mainly based on our long lasting experience in cultivating and transplanting cultivated keratinocytes (more than patients and sheets). results. the coverage of burn wounds with viable keratinocytes renders constant and reliable results. understanding keratinocyte-matrix interactions has not only allowed us to influence keratinocyte outgrowth, adhesion, and migration, but also has guided us to modify matrices for enhancing keratinocyte take. due to these improvements we have achieved a proper material in the adequate situation. conclusions. as surgeons, our goal is to help burn patients with the best quality of skin in the shortest time possible. as tissue engineers, we have not achieved the goal of a universal skin product yet, but by continually reviewing new options and using them, the anatomy and physiology of engineered skin substitutes will improve and they will become more similar to native skin autografts. thereby tissue-engineered skin may match the quality of split-skin autografts in future. background. the survival of patients with major burns goes hand in hand with early escharectomy and the survival of skin grafts. methods. the application of topical negative pressure has improved increased graft take especially in difficult anatomic regions. results. securing skin grafts in pediatric burn patients enabled a near % graft take. perfect protection from shear forces, early mobilisation, patient comfort, nursing comfort and abandonment of splinting are major advantages concerning conventional dressings. conclusions. we postulate the application of vac for securing skin grafts as a valuable tool in pediatric burns management. wide meshed grafts and including donor sites protected by silicon layers into the dressing in extensive burns should be evaluated carefully because of possible bleeding. background. versajet is a high -pressure hydrosurgery system, which enables a very precise surgical procedure. this single device technique combining lavage, excision, cleansing and aspiration allows a sharp debridement on any surface, or space. there are lot different indications for the use of versajet in plastic and reconstructive surgery. this system is appropriate for a variety of burn and traumatic wounds. because of the precise handling the use of this device is also in cosmetic surgery possible. methods. in this device a high velocity stream of sterile saline jets across the operating window and into an evacuation collector. because of a physical effect, a localised vacuum is created across the operating window. this holds and cuts targeted tissue while aspirating tissue from the site. therefore it enables to precisely target damaged tissue and spare viable tissue. surgical techniques can be enhanced, for instance the device holds targeted tissue during irrigation and excision. in addition, versajet cleans and cools at the same time as debriding, so additional cleaning techniques are not required. the depth of the skin -debridement is absolute predictable. in about cases the versajet has been used. the range of indications included burns, infected wounds (decubitus ulcers, traumatic wounds, fournier gangrene, necrotizing fasciitis). the advantage of this hydrosurgery system compared to sharp debridement using scalpels, dermatome, etc. is a more rapid and precise debridement, therefore the preservation of viable tissue, the precise and easy treatment of concavities and convexities and a reduction of blood loss could be achieved. histological findings proved the feasibility of an exact abrasion into different layers of the dermis. results. by using the versajet device, a reduction of the debridement procedures, an earlier reconstruction and a shorter time of hospitalisation could be achieved. the most important indication is the treatment of b burn-wounds. in burn cases the necrosectomy with some other devices may be quicker and more useful. although there is a learning curve which is very short, this tool is easy to handle. there has been no adverse effects. conclusions. the versajet-handpiece is a disposable product, but because of the advantages it is at least cost-covering. debridement is highly effective since it enables selective tissue targeting. removal of non-viable tissue is more complete as a result. background. in more than children (age < years) were suffering from burns. the gold standard of surgical care is still under discussion. the aim of the study was to evaluate an optimised treatment regime for scalds in children. methods. between and , children underwent surgical intervention due to salds. thirty-six of them were enrolled into the study. twenty-two children with deep dermal scalds (total-body-surface-area burned (tbsa) . %) were treated by early excision and keratinocyte-coverage (keratinocyte-group). fourteen children (tbsa . %) were treated with autologous skin grafts (skin-graft-group). both groups were comparable according to age, burn depth and tbsa. the complete clinical follow-up was at least months. the scar formations were classified (vancouver-scar-scale (vss) and the need of blood transfusions were administered. results. the use of keratinocytes led to complete epithelialisation. no secondary skin grafting was necessary. skin take rate was % in the skin-graft-group. the mean volume of transfused blood was . ml in the keratinocyte-group and thereby significantly lower than the volume of . ml, which was administered in the skin-graft-group (p ¼ . ). the vss observed in the keratinocyte-group was . and thereby significantly lower than the vss of . in the skin-graft-group (p ¼ . ). conclusions. in children the use of keratinocytes renders constantly reliable results in deep dermal scalds. it minimizes the areas of skin harvesting and reduces the amount of blood transfusions. the fact that also less scarring is observed leads to the conclusion that skin grafting should be restricted to full thickness scalds. background. ventriculo-peritoneal (vp) shunting is the treatment of choice for hydrocephalic children. however, serious complications related to infectious and non-infectious reasons may subsequently appear during lifetime of these patients. as we attend nearly all our patients from birth to adulthood we had to face various kinds of abdominal problems over the years. hydrocephalic children underwent vp shunt placement. outcome and follow-up of these patients were discussed. results. our analysis showed that non infectious complications like: shunt dislocation, kinking and obstruction including some rare phenomenon are well described in literature and can hardly be avoided. but being confronted with various infectious complications we had to change our strategy over the years. severe shunt infection appeared after appendicitis in patients. therefore we consequently performed elective appendectomies since . consecutively we had to face problems with following malone procedure. because of abdominal pseudo cysts after recurrent shunt revisions bacterial culturing methods and antibiotic therapy regimen changed. treatment of post haemorrhagic ventricular dilatation in premature very low birth weight infants had changed over the years from intervention with external drainage, early lumbar punctures, repeated ventricular punctures to implantation of the new ''side-inlet integra reservoir''. conclusions. the lesson we learned out of this retrospective analysis is that treatment of these hydrocephalic patients needs to be designed concerning all problems of the disease during life time period. therefore we think that experience and retrospective analysis is a very important point of view for the future. years' experience with lymphangiomas in children j. burtscher, e. horcher background. the management of lymphangioma in children is still challenging. complete resection is difficult to achieve in some cases and recurrences are common. methods. a retrospective study over a period of years was carried out. fifty-one patients were treated. males and female patients. the involved sites were head and neck, trunk and extremities as well as retroperitoneal, intraabdominal or intrathoracic location. prenatal mri was introduced to plan operative strategy especially for cervical location. results. there were recurrences. recurrence rate was highest in intrathoracal location. there was so significant differences, in terms of outcome, between those who had their surgery immediately at the time of diagnosis and those who had delayed surgery. conclusions. prenatal mri is a helpful tool in planning operative strategies like exit-procedure (ex utero intrapartumprocedure). risk factor for recurrence included location, size or complexity of lesion. background. hemangioma is the most frequent tumor in childhood. in more than % of cases hemangiomas are located in the face and the decision about the need for treatment, and the type of treatment may be difficult. complex hemangiomas need emergent systemic drug therapy, which may be combined with other types of interventional therapy, such as surgery or laser treatment. the aim of this study was to evaluate our experience in the treatment of complex hemangiomas. methods. analysis of complete records of patients who were treated in the period between . . and . . . results. out of patients referred to us, patients ( %) needed hospital treatment ( % girls), mainly because of rapid growth, and complications which were present in patients ( %). the most frequent localization of hemangiomas were the head and neck region ( %) and % of patients had multiple hemangiomas. median age at first referral was months, with % of patients referred to us before months of age. more than half of patients received their first treatment before months of age, and within days after referral. treatment consisted in laser therapy ( %), excision ( %), and additional (or exclusive) drug therapy in % of patients (cortisone, interferon). interdisciplinary treatment was necessary in patients ( %), involving mostly plastic surgeon, dermatologist, pediatric oncologist, pediatric radiologist, ophthalmologist, and psychotherapist. the majority of interdisciplinary treated patients ( %) received initial treatment in other centers, patients ( %) presented with complications, and rapid growth was present in % of patients. parotid hemangiomas (n ¼ ) were treated solely by systemic cortisone treatment (n ¼ ). intra-tracheal hemangiomas (n ¼ ) required often a laser treatment (n ¼ ), in addition to administration of systemic cortisone. massive segmental facial hemangiomas (n ¼ ) needed additional treatment with interferon (n ¼ ). in one case a phaces syndrome was diagnosed and the patient needed a complex therapy. conclusions. the need for treatment of hemangioma must be made on the individual basis. most hemangiomas need only observation. however, patients with complications and=or facial localization of hemangioma with rapid growth require often emergent treatment in medical centers with the possibility for an interdisciplinary management. early therapy may be a precondition for a good cosmetic result. background. treatment of appendicular peritonitis is closely connected with prophylaxis and treatment of surgical complications during postoperative period. the abscess of omentum major is one of such a complications, elsewhere discussed in medical literature. the aim of the study was the reduction in frequency of this complication. methods. during - years we treated patients with the abscess of caul. all of the patients were also treated for the appendicular peritonitis in the past. the time since the discharge from outpatient department to re-admission to the hospital varied within - days. the disease manifested with abdominal pain, increase in body temperature to the febrile grade. all the patients presented with tumour-like abdominal mass of various size. two patients presented with umbilical fistula and purulent effusion. abdominal ultrasound elicited masses with fluid content in patients. laboratory work-out revealed significant increase of tests relevant to endotoxicosis. all patients were operated. five patients underwent dissection of infiltrate, and the total resection of caul. two patients passed drainage of abscess through the anterior abdominal wall. results. all the patients recovered. complications of early and late postoperative period were not observed. patients were on the close follow-up for to years without any sequalae. hospitalisation span was . ae . days. conclusions. . abscess of caul can manifest during early as well as late postoperative period. . management of omental abscess: -complete resection within visually intact tissues; -careful washing of abdominal cavity with antiseptic solutions; -vigorous antibacterial therapy in postoperative period. beneficial effects of mixed hyperalimentation in children with septic form of acute hematogenic osteomyelitis a. albokrinov , a. pereyaslov lviv children's regional clinic hospital, lviv, ukraine; lviv d. halytsky national medical university, lviv, ukraine background. septic form of acute hematogenic osteomyelitis (aho) is severe sepsis with multiple organ dysfunction syndrome (mods) according to accp=sccm consensus conference committee, . mortality and morbidity rates from this remain unacceptably high, in spite of achievements in intensive care medicine. nutritional support is the method of intensive care with proven efficacy, but the ''perfect'' regimen of it is unknown. methods. in - in our clinic children with septic form of aho were treated. they received standard therapy of severe sepsis which included surgical treatment (osteoperforation, suppurative focus drainage, pleural drainage in case of pyopneumothorax), antibacterial therapy, hemodynamic support. all of patients were mechanically ventilated (mv) because of acute hypoxemic respiratory failure on the basis of metastatic pneumonia. regarding to nutritional regimen patients were randomized on two groups: control (enteral alimentation with isocaloric isonitrogenic diet fitting basic energy expenditure (bee) multiplied by coefficient . ), and basic (mixed enteral ( . bee) plus parenteral (protein ¼ g=kgÃday, energy ¼ . bee) hyperalimentation). results. there was strong tendency of patients in basic group to have less pulmonary complications, better gas exchange values, less ventilation days and less intensity of hypermetabolic-hypercatabolic syndrome (see table, à p < . ). conclusions. mixed enteral-parenteral hyperalimentation in children with septic form of aho is an effective method of prevention of pulmonary tissue destruction and respiratory function improvement. background. the aim of this study was to gain information about the mechanisms of injuries and injury pattern at primary and secondary schools in austria. methods. at the department of pediatric surgery in graz and six participating hospitals (klagenfurt, salzburg, steyr, krems, schladming and innsbruck) all children from to years presenting with trauma were included within a two year study period. in total, pediatric trauma cases were filed. data were analyzed regarding personal data, site of the accident, circumstances and mechanisms of accident and the related diagnosis. results. at the department of pediatric surgery, medical university of graz, questionnaires were completed, out of which children had suffered from school accidents ( %). questionnaires from outside hospitals included school accidents ( %) with a mean age of . years in the children from graz and . years in children from participating hospitals. the male=female ratio was : . in general, sport injuries lead to a higher rate of severe trauma ( % severe injuries) compared with other activities in and outside of the school building ( % severe injuries) with ball-sports being the most dangerous activity with a % proportion of severe injuries. over all, the upper extremity was most frequently injured ( %), followed by lower extremity ( %), head and neck area ( %) and injuries to thorax and abdomen ( %). conclusions. half of all school related injuries occur in children between and years of age. there are typical gender related mechanisms of accident: boys get frequently injured during soccer, violence, and collisions in and outside of the school building and during handicrafts. girls have the highest risk of injuries at ball sports other than soccer. background. objects and notably coins are frequently swallowed by children - years old. their precise management on asymptomatically passing the gastro-esophageal junction remains controversial. this study was performed to assess dissolution of specific metals from coins immersed in simulated gastric juice. methods. four types of euro and us coins were immersed in simulated gastric juice for , , and hours. six metals were evaluated by inductively coupled plasma-atomic control group (n ¼ ) basic group (n ¼ ) sofa, mean (sd) . ( . ) . conclusions. coins retained in the stomach will release a number of heavy metals well known to cause dose-dependent poisoning. studies to evaluate their toxicity and absorption are needed to optimize treatment. the surgical tactic on the splenic injury in children a. pereyaslov, s. chooklin, i. korinevska, a. troshkov medical university, lviv, ukraine splenectomy in children often leads to various complications. retrospectively, results of the management of children (range from to years), which underwent surgery due to the liens' injury, were examined. the immunological and hormonal investigations were performed. out of operations in the splenectomy, in cases the splenectomy with the tissue autotransplantation of the lien in the greater omentum and in cases the organ-preservation operations were performed. purulentseptic postoperative complications were noted in ( . %) patients, which connected with the inadequate of the immune answer. the obvious t-cellular immunodeficit, low concentration of igm, decrease of phagocytosis were observed in this category of patients. by that, on the background of activation of the renin-aldosteron system and changes of the eicosanoids synthesis, the danger of the sepsis and septic shock development were arisen. the autotransplantation of the lien tissue did not protect the organism from the purulent-septic complications in the nearest postoperative period. as the answer to the transplanted tissue and necrobiotic processes, which had been occurred in it, the autoimmune processes and reactions of the hypersensitivity of the immediate type (the increase of ige and dna antibodies levels) were intensified. with the goal to prevent complications in the postoperative period the thymic hormones, interferon a, aspirin and dipyridamol were applied. in the remote terms, the postsplenectomy syndrome manifested itself in patients, which underwent the splenectomy in childhood. predisposition to the infections and thrombohemorrhagic processes prevailed. the disturbances of hemostasis are linked with the significant increase of the t-helpers that connected with the intensifying of the il- action, which also evokes the proliferation of the preactivated b-lymphocytes, and, as the result, the obvious synthesis of igg. igg in the composition of the immune complexes can stimulate the function of the neutrophyles. all this promotes to transfering the hageman factor in the active condition, activation of the coagulative and kininogen-kinin blood system, intensification of the fibrinolysis, the deposit of fibrin and the development of the hemorrhages. the autotransplantation of the lien tissue could not enhance defence of the organism in full value. thus, at the traumatic injury of the spleen the prevalence must be given to the organpreserving operations. background. mri of the breasts has been described the most sensitive imaging modality for detection of multicentric or multifocal malignant tumor manifestations. in we began with routine preoperative mri-staging in breast cancer patients. the aim of this study is to analyse the benefit of preoperative mr-imaging regarding surgical treatment and follow up in patients with invasive breast cancer. methods. the retrospectice study (n ¼ ) includes all female patients with histologically verified invasive breast carcinoma, which have been operated at our department between and . exclusion criteria were carcinoma in situ, local recurrence, inflammatory carcinoma and neoadjuvant therapy. demographic, radiological, operative and histological data, standardized follow up (dfs, os) and recurrence rate were analysed. results. surgical treatment consisted in bct ( . %) and mrm ( . %). % of tumors showed an invasive ductal differentiation. lymph nodes were positive in %. tumor size showed the following pattern: pt %, pt % and pt = %. grading was . % (g i), % (g ii) and . % (g iii), respectively. mr-imaging revealed multifocal or multicentric tumor manifestations in % of patients, the mri results changed surgical treatment in % of cases. mean follow up was months. the local recurrence rate was . %, . % of patients developed carcinoma in the contralateral breast, incidence of distant metastases was . %. conclusions. the data confirm the importance of routinely performed mr-imaging in preoperative staging of breast cancer patients. mri-identification of multifocal or multicentric tumor manifestations is essential to choose the optimal surgical treatment and reach a minimal recurrence rate. methods. between july and october patients with operable breast cancer were treated at general hospital feldkirch. of subsequent patients with non-palpable lesions intraoperative sonography was used in (group ), wire localisation in cases (group ). the study was conducted as nonrandomised trial with prospective data collection. results. breast-conserving surgery was performed in % in group and % in group . primary r -resection was significantly higher in group ( %) than in group ( %, p < . ) while median clear margins were . and . mm in these groups (p < . ). both wire localisation and intraoperative sonography proved to be feasible with tumor identification rates of %. conclusions. intraoperative sonography proved to be reliable and feasible in breast cancer patients in the hands of the surgeon. clear advantages next to tumor identification and topographic orientation for excision were organisational acceleration and improvement: discomforting, time and labour intensive wire localisation can be avoided and breast lesions can be excised in a tissue-sparing and breast-conserving technique in a very high percentage. background. extensive intraductal disease represents an important clinical problem in the management of patients with invasive or in situ breast cancer. we present a new method for intraoperative ductoscopy with intraductal biopsy of suspicious lesions. methods. intraoperative ductoscopy was performed in women undergoing operation for breast cancer or nipple discharge. a rigid gradient index microendoscope ( . mm) with a special biopsy device for vacuum assisted biopsy was used for all examinations. ductoscopy findings were documented prospectively and correlated with preoperative mammography and histology of the resection specimen. results. ninety-two percent of the patients were examined successfully. ductoscopy identified intraductal lesions (ie, red patches, ductal obstruction, or microcalcifications) in % of the patients. abnormal ductoscopic appearance was found in more than % of the patients with extensive intraductal disease %. patients with an abnormal ductal appearance on ductoscopy, compared with those with a normal ductal appearance, had a greater incidence of extensive intraductal spread of cancer ( % vs. %) and a greater incidence of positive surgical margins ( % vs. %). ductoscopic biopsy of intraductal lesions was technically successful in all but one case. generally, the quality of the biopsy samples was good. diagnostic biopsy samples were obtained in of patients ( %). two samples contained necrosis and were considered to be non-representative. histological analysis of the biopsy specimens showed papilloma, in situ carcinoma and invasive carcinoma. conclusions. high-resolution ductoscopy is able to detect extensive intraductal disease in a considerable number of women with breast cancer. vaccum assisted biopsy allows intraductal tissue sampling of very small lesions. in selected patients, a combination of both preoperative imaging and intraoperative ductoscopy may help to avoid incomplete resections and re-excisions. background. preoperative chemotherapy (pc) for breast cancer was initially focused on locally advanced tumors. later on it has been established to downstage operable tumors primarily not suitable for breast conserving surgery. now pc is often used as an invivo test for chemotherapy regimens. methods. since the austrian breast and colorectal cancer study group (abcsg) conducted trials with pc. abcsg- analysed the effect of pre-and postoperative versus postoperative chemotherapy alone with cyclophohamide= methotrexate=fluorouracil. abcsg- compared versus cycles of epirubicin=docetaxel þ g-csf regarding the rate of pathologic complete response (pcr). abcsg- analysis the rate of pcr between cycles of epirubicin=docetaxel and cycles of epirubicin=docetaxel=capecitabine ae trastuzumab for her- positive patients. results. from to abcsg- enrolled eligible patients. after a follow up of years recurrence-free survival is worse in the pc arm (hr . , . - . ; p ¼ . ), overall survival doesn't differ significantly (hr . ; . - . ; p ¼ . ). patients were accrued to the abcsg- trial between and . the rate of pcr was significantly higher in patients after cycles than in those after cycles ( . % vs. , %; p ¼ . ). also significantly more patients had a negative axillary status after cycles than after only cycles ( . % vs. . % p ¼ . ). recruitment of abcsg- started in and is still ongoing. conclusions. while pc fails to improve prognosis so far, regimens which improve the rate of pcr have been found and we are still hoping to tranpose this effect in better prognosis. sentinel node biopsy performed before preoperative chemotherapy for axillary lymph node staging in breast cancer p. schrenk , c. tausch background. sentinel node (sn) biopsy following preoperative chemotherapy (pct) in breast cancer patients is associated with a lower identification rate (ir) and an increased false negative rate (fnr) compared to sn biopsy in patients with primary breast cancer. methods. sn biospy was performed in breast cancer patients with a clinical negative axilla prior to pct. following chemotherapy sn mapping was repeated and the current lymph node status was assessed with axillary lymph node dissection (alnd). results. sn mapping prior to chemotherapy successfully identified a mean of . sns in all patients (ir %). patients revealed a negative sn, a positive sn (micrometastasis in = ). following pct re-sn mapping was successful in = patients (ir %). ir for re-mapping was % for patients with a primary negative sn or a micrometastatic sn compared to % for patients with primary macrometastatic sns. none of the patients with a negative sn biopsy and none of the patients with micrometastasis prior to chemotherapy revealed positive lymph nodes following pct. contrary to that = patients with a macrometastasis prior to pct revealed positive nodes following chemotherapy, and this was irrespective of the type of tumor remission due to pct. the fnr of remapping was % and false negative sns were only found in patients with macromatastatic sns in the primary sn mapping. conclusions. patients with a negative sn biopsy or with a micrometastatic sn prior to pct may forego complete alnd following pct, whereas this may not be valid for patients with macrometastatic sns. sn biopsy following pct is associated with a low ir and a high fnr. background. standard pancreatoduodenectomy (pd) for the treatment of resectable tumors of the periampullary region or the pancreatic head involves a radical pancreatoduodenectomy with an extensive gastric resection. the modified whipple operation aims to preserve the stomach, pylorus and proximal duodenum so as to decrease postgastrectomy complications and improve the patient's quality of life. however, there were still many postoperative complications after pylorus-preserving pancreatoduodenectomy (ppd). unfortunately, in some retrospective studies tumors of the periampullary region and the ductal carcinoma of the pancreatic head are still not differentiated. this methodological problem and the improved surgical strategy (lymphadenectomy, etc.) in combination with the excellent histopathological diagnosis by experienced pathologists are decisive factors in determining the ultimate outcome as demonstrated. methods. patients (all treated at smz-süd -kaiser franz josef spital department of surgery) with a exocrine malignant tumor of the pancreatic head or periampullary region were retrospectively analyzed by comparing a year period before and after . results. in the last period of observation the complication rate and lethality was reduced (there was one cases of death because of technical reasons). the number of r resections (incl. mesoduodenum) improved from % to %. also the number of the resected lymphatic nodes increased from to ( - ). the actuarial year survival rate in patients after resection of a pancreatic ductal adenocarcinoma at r , n stage increased from % up to %. an increase in long-term survival could also be observed in the n-positive group. conclusions. at an oncologic center with optimal interdiciplinary collaboration of the different departments (internal medicine, surgery and pathology) a respectable actuarial year survival ( %) of the pancreatic ductal adenocarcinoma can be achieved without interfusing different tumorentities. the lethality caused by technical reasons should be almost %. detailed information will be discussed during the presentation. background. complete surgical resection remains the only potentially curative treatment, improving -year survival, for patients diagnosed with pancreatic cancer. preoperative administration of chemotherapy or combined radiochemotherapy may present a way in increasing the number of patients were radical surgical therapy is reasonable and feasible. lower perioperative mortality and morbidity rates are reported in high volume centres. methods. between jan. and dec. patients, diagnosed with locally advanced non metastatic pancreatic cancer, received preoperative chemotherapy with neoadjuvante intent. patients had curative surgery at time of diagnosis and adjuvant chemotherapy depending on their stage of disease. a subset of patients have been diagnosed at an far advanced stage of disease and were treated in palliative ways. results. the observed perioperative mortality rate was . % ( = ). a total of ( . %) patients required reoperation because of complications after curative resection. minor complications, which have been treated in conservative ways, occurred in . % of patients. sixteen patients ( = , . %) demonstrated sufficient tumor response to undergo surgical curative resection after neoadjuvante chemotherapy. in this group the median survival time was month ( . - . % ci). median survival time for patients who underwent curative tumor resection at the time of diagnosis, was month ( . - . % ci). for patients, unable to undergo curative surgery after neoadjuvant therapy (n ¼ ), median survival ( month, . - . % ci) did not differ from life expectance of primary palliative treated patients ( . - . % ci). conclusions. we suggest that in several patients, suffering from nonresectable cancer of the pancreas, preoperative chemotherapy significantly rises overall survival to a level so far reserved to patients with operable carcinoma. in other malignancies neoadjuvante chemotherapy is an accepted standard of cancer treatment. there are many potential advantages of neoadjuvant chemotherapeutic regimes for both resectable and advanced pancreatic carcinoma. novel targeted molecular therapies and their combination with established chemotherapeutic agents may lead to higher conversion rates after neoadjuvante therapy and improved -year survival rates in the near future. background. haemodynamic impairments after pneumonectomy are rare complications and present in two different forms or a combination of both. changes in the anatomical situation of the left atrium and elevated pulmonary artery pressure can lead to a significant right-left shunt via a previously closed foramen ovale (pfo) and diaphragmatic relaxation can lead to a dislocation of the liver into the right hemithorax, compressing the right atrium with subsequent inflow obstruction. methods. we retrospectively analysed our patient cohort from to for occurrence of haemodynamic complications requiring surgical intervention after pneumonectomy. results. five patients ( female, males, age ae years) were identified. all underwent right pneumonectomy due to nsclc (n ¼ ) or atypical carcinoid (n ¼ ). two patients were readmitted months and years postoperatively due to increasing platypnoea and orthodeoxia. after closure of a pfo which was found as the underlying pathological mechanism respiratory symptoms were resolved. one patient required reintubation already hours postoperatively; after surgical closure of a pfo the respiratory situation significantly improved. one patient was readmitted due to right atrial inflow obstruction months after right pneumonectomy. underlying cause was a severe diaphragmatic relaxation with compression of the atrium by the liver. after diaphragmatic plication all symptoms resolved. one patient was readmitted months after pneumonectomy and partial atrial resection due to cyanosis and dyspnoea. diagnostics revealed a pfo and a massive raise of the right diaphragm with compression of the right atrium. after surgical correction of the contorted foramen ovale and diaphragmatic plication symptoms vanished. conclusions. haemodynamic alterations due to a reopened foramen ovale or right atrial inflow obstruction are rare however severe complications after pneumonectomy. they occur at variable points in time after pneumonectomy. closure of the pfo either surgical or interventional and=or plication of the elevated diaphragm are mandatory. in our experience these complication occur only after right pneumonectomy. chronic sequels after thoracoscopic procedures for benign disease -long-term results j. hutter, s. reich-weinberger, h. j. stein background. video-assisted thoracic surgery (vats) is recognized to be as effective as open surgery for a variety of diagnostic and therapeutic conditions, but with significantly less morbidity. chronic postoperative pain (cpp) is defined as persisting more than months after the procedure. cpp and other neurological sensations like disesthesia or numbness are found frequently, but little is known about the outcome of those patients many years after the primary procedure. methods. in we retrospectively investigated a group ( . %) out of patients who were identified with sequels at a mean of months after a vats procedure. now at months post-operation we reinvestigated those patients for ongoing sequels. results. from patients were still alive and could be reached for an interview. ( %) were now free of symptoms while ( %) still suffered from sequels. from the group of patients operated on, sequels were now present in ( . % at months vs. . % at months, p ¼ . ) patients. pain was present in ( . vs. . %, p ¼ . ), in three ( . vs. . %, p< . ) even at rest, and in ( . vs. . %, p ¼ . ) patients only at exercise. ten ( . vs. . %, p ¼ . ) patients suffered from pain occasionally e.g. due to changing weather. painkillers were only taken by one ( . vs. . %, p< . ) patient occasionally, and the sequels impacted the life of one woman ( . vs. . %, p< . ) badly. numbness was present in . vs. . % (p ¼ . ) of patients. conclusions. early postoperative sequels are frequently found in vats procedures, but patients with pain even after years have a nearly % chance to eliminate their problems. in addition, numbness and disesthesia seem to disappear almost completely several years after the procedure. intrapulmonary injection of fibrin glue as a treatment of persistent parenchymal fistulas after pulmonary surgery: a case series s. b. watzka , h. redl , b. el nashef background. persistent parenchymal fistulas are a major problem after pulmonary operations particularly in lung emphysema patients. conventional surgical remedies, like over-suturing or stapling of injured lung surfaces are rarely efficient. here we present our preliminary experience with a novel application of fibrin glue as a sealant of persistent parenchymal fistulas. methods. patients with postoperative parenchymal fistulas persistent for more than six days, and not responding to conservative measures, underwent re-operation. lung surfaces not anymore suitable to reconstruction by suturing were sealed by peripheral intrapulmonary injection of fibrin glue. after discharge, the patients were regularly followed-up. in addition, the macroscopic distribution of injected fibrin within lung tissue has been investigated in a porcine in vitro lung preparation. a total of six patients underwent the above described procedure. the primary operation was upper lobectomy in four cases, laser resection in the upper lobe in one case, and empyema evacuation by vats in one case. the mean volume of injected fibrin was ae . ml. in five out of six patients the fistula was stopped permanently. in one case, however, the parenchymal fistula re-appeared and had to be treated by combined application of fibrin glue and hemostyptic tissues. after a mean follow-up of . ae . days, all patients are well and symptom-free. in the animal tissue preparation, the fibrin was macroscopically distributed exclusively in peripheral lung parenchyma. conclusions. in selected cases of persistent postoperative parenchymal fistulas, peripheral intrapulmonary injection of fibrin glue offers a low-risk and efficient surgical option. background. recent case-matched studies demonstrate that stage i non-small cell lung cancer (nsclc) in functionally inoperable patients can be treated by limited resection approaches without compromising the oncological result. the recently introduced -nm nd-yag laser enables the highly selective and parenchyma-saving excision of pulmonary lesions, and was thus originally designed for the removal of multiple lung metastases and more central lesions. in this prospective study, we are evaluating for the first time the mid-term results after local resection of stage i primary nsclc by laser knife in functionally inoperable patients as defined by predicted postoperative fev (ppofev ) less than %. methods. between and , functionally inoperable patients underwent local resection of stage i nsclc by -nm nd-yag laser. we assessed their postoperative course, tumor recurrence, and survival by statistical means. results. postoperative mortality was zero. three patients ( %) had minor surgical complications in the postoperative period (persistent air leak, delayed wound healing). the postoperative respiratory function was unchanged as compared to the pre-operative value. the median follow-up was . months (range - months). recurrence rates ( . %) and actuarial -year survival ( %) were comparable to standard lobectomy results, as reported in the literature. none of the three deaths observed during the follow-up period was cancer-related. conclusions. the -nm nd-yag laser enables the resection of stage i nsclc in functionally inoperable patients under complete preservation of respiratory function, but without jeopardizing the oncological outcome. zentrumsbildung breast-cancer centers -between european visions and regional feasibility h. hauser background. there have been major improvements in the western world in recent decades in early diagnosis of breast cancer, breast conservation and survival. nonetheless, there are blank spaces on the map of europa and very likely of austria as well, where diagnosis and treatment of breast cancer are not optimal. collecting and treating patients with diseases of the breast in a few defined ''breast centers'' should give every patient with breast cancer the same highest quality treatment. methods. in , a working group was formed in florence, italy, to define the tasks to be met by such a center. in , the results produced by this group were published (eusoma ) . the aim of this guideline was to improve quality and quality control in the treatment of breast cancer. one of the main demands made of a breast center is to treat at least new primary breast cancer cases per year. further, a multidisciplinary nucleus team specialized in the treatment of breast cancer should be in place and should hold regular interdisciplinary tumor conferences. this team should include a surgeon=gynecologist, radiologist, pathologist, medical oncologist, radiotherapist, breast-care nurse, data manager, etc.). results. as early as , roohan et al. (am j public health , ) showed that the probability of survival of breast-cancer patients was directly proportional to the treatment volume of the hospital. regardless of tumor stage, patients treated in a hospital that saw less than cases per year had a % higher mortality risk than those treated in hospitals with more than operated cases per year. an operation performed by a breast cancer specialist reduces the mortality risk by % in comparison to operations performed by non-specialists (gillis cr, hole dj bmj , ) . the results of dubois et al. ( ) and others also indicate a better outcome for breast cancer when patients are operated in a specialized hospital with a large number of cases and a suitable interdisciplinary environment. the minimum number of cases of primary new breast cancer cases per year and center recommended by eusoma (but with an evidence level of and so not scientifically verified) would reduce the number of breast centers in austria to about . an analysis of the austrian situation nonetheless showed that many small surgical units produced excellent results, with interdisciplinary cooperation, in some cases together with external services. conclusions. certified, highly qualified interdisciplinary breast centers are intended to provide breast-cancer patients with highest quality care. the extent to which the eusoma criteria can be adapted to the austrian situation remains to be seen. breast cancer centres -can quality only be achieved in high-volume-institutions? b. zeh, g. humpel, p. lechner background. discussion is ongoing about institutional caseload and technical equipment that both may be required for up-to-date-treatment of breast cancer. we present the network architecture our department of surgery at the danube clinics in tulln is part of, aiming at multi-disciplinary diagnosis and treatment of approx. cancer patients per year. methods. . diagnosis: mammogram, ultrasound and mri can -and shall -be performed in an outpatient setting, considering that a close partnership with an experienced radiologist has been established. this is true also for the imaging techniques for staging. . interventional diagnosis with core needle biopsy, mammotome + , ecc., should be left to the surgeon! this may facilitate localisation of a non-palpable lesion during the subsequent operation. . surgery for breast cancer is not that demanding per se, on condition that the technical equipments for sentinel biopsy, specimen radiography, and frozen section are at hand. the procedures must be left to permanent team if surgeons with an individual experience of more than cases each. . systemic adjuvant treatment requires the availability of a clinical oncologist, at our institution on a consultant basis. patients are treated in clinical trials whenever feasible, preferably in those launched by abcsg. . radiotherapy is typically performed on an outpatient basis, disregarding at which institution the previous operation was performed. . follow-up needs to be co-ordinated by a qualified physician. we have established an oncological outpatient department, but co-ordination could also be left to an office-based oncologist. the mandatory management tools for close follow-up as well as for the prevention of unnecessary examinations are it-support and a patient log-book. conclusions. being embedded in a multi-disciplinary network, our institution's self perception is that of a part in a ''virtual centre of excellence''. we think that we are not only able to provide high medical quality, but that this quality is also subject to external control by our partners. background. the expectancy of life of patients with intraabdominal malignancies and peritoneal dissemination is usually poor. the surgical approach of a combination therapy of complete resection of the primary cancer, the peritonectomy and a perioperative intraperitoneal chemotherapy was developed to improve the prognosis of these patients. this treatment is cost-intensive and associated with special technical expertises. the aim of this study was to determine the modalities and to discuss the feasibility of this approach. methods. since june , a combination-therapy of visceral resections, cytoreduction of the peritoneal cancer and a heated intraoperative intraperitoneal chemotherapy was performed in patients ( female, male, average age . years) with visceral malignancies and peritoneal carcinomatosis as a curative approach. the same procedure was designated for six more patients but was not performed because of inoperable tumor masses. mitomycin c ( mg=m ) was utilized for the intraperitoneal chemotherapy and applied to the abdomen using a heartlung machine to guarantee a steady circulation and to keep the intraperitoneal fluid at c. the handling with the chemotherapeutic substance required special protective clothing for the staff as well as the competent disposal of all used materials. results. a multi-visceral resection was performed in = patients. a complete cytoreduction (cc- ) was obtained in eight patients, in one a cc- and in another one a cc- situation remained. the average operative time was minutes (range - minutes). a peridural catheter was necessary for a sufficient postoperative pain therapy. the average time at the intensive care unit was . days (range - days) and the average hospitalization was . days (range - days). no complications were observed associated with the surgery. morbidity was determined by gastrointestinal symptoms like prolonged postoperative ileus. in the follow-up three patients had a recurrence of the malignancy, = with a cystadenocardinoma of the pancreas after three and five months, respectively, and = patients after months with a metastatic sigmoid carcinoma. one patient died eight months after surgery because of malignancy progress. the average expense of this treatment was . eur. conclusions. specialized centres may provide the logistics and expenses to establish this treatment innovation to the surgical approach of intraabdominal malignancies to extend the long-term survival of patients with otherwise poor outcome. prospective studies are needed for additional adjuvant and neoadjuvant concepts in diseases with peritoneal malignancies. background. rectal carcinoma needs careful preoperative staging. in our department neoadjuvant treatment with long term radiation and chemotherapy is standard in patients with carcinoma of low and middle part of the rectal wall. main prognostic factors for long term survival are r resection, sharp dissection of the mesorectal fascia without coning, distal resection margin of at least mm and complete lymph node dissection along the mesentery vessels. there is no recommendation about the lymph nodes that should minimally be dissected in this group of patients until now. methods. we consecutively evaluated patients after neoadjuvant radiochemotherapy (rct) and surgery in terms of survival, local recurrence, perioperative mortality and morbidity. tumor regression grading (trg) and number of dissected lymph nodes (ypn) were analysed and correlated with survival. results. in our series local recurrence rate was lower than %, the r resection rate reached % and sphincter preserving surgery was possible more than %. the median number of dissected lymph nodes (ypn) reached > , the perioperative morbidity was lower than %. especially leakage and anastomotic stenosis with the need for reoperation or dilatation are typical complications of radiation therapy. the tumor regression grade clearly correlates with outcome. conclusions. multimodality treatment of rectal carcinoma including preoperative radiochemotherapy (rct) is well standardised with good results in outcome and morbidity. we show that high numbers of lymph nodes even after rct can be collected and suggest a minimum account of at least . tumor regression grading is a marker with prognostic significance and should be taken into clinical-pathohistological classification. we suppose that some patients are overtreated with preoperative rct. to proof this hypothesis, a randomised multicenter trial -together with german cancer centers -based on mri diagnostic is currently planned. background. the incidence of (hpv)-associated disease of the anal canal is rising. efficient anal screening by cytology is hampered because of poor specificity. hpv testing is proposed in addition to pap testing for the detection of cervical neoplasia. the purpose of this study was to determine the usefulness of a hpv-dna detection test (hc ) to detect hpv-associated disease and to compare two different methods of sample collection. methods. in patients anal samples were obtained using a cervix brush and a dacron swab to test for hr-and lr-hpv-dna. qualitative (positive=negative) and quantitative (rlu's, relative light units) were obtained. patients positive for hpv dna underwent anoscopy. biopsies were taken from visible lesions. results. lr-hpv-dna was found in of patients ( . %) and hr-hpv-dna in of patients ( . %). dacron swab sampling yielded more positive results than sampling by cytobrush ( . % vs. . % for lr-hpv, p < . ; . % vs. . % for hr-hpv, p < . ). a positive correlation of rlus was found for both sampling methods in the total cohort (p< . ), and patients with positive results (p< . ). sampling with dacron swabs yielded higher rlu values compared to sampling with cervix brush for lr-hpv-dna and hr-hpv-dna. conclusions. anal screening for hpv-dna by hc is a useful method for detection of hpv-associated disease. sample collection using dacron swabs identifies more hpv-positive patients, and yields higher rlu values, than using the cervix brush. background. persistent human papilloma virus-(hpv-) infection, immunedeficiency (hikv, immunosuppression after organ transplantation) are known risk factors for anal intraepithelial neoplasia (ain) and squamous cell cancer (scc) of the anus. the incidence in high rik groups is rising (hivpositive, men who have sex with men (msm)). screening programms employing anal cytology or anal colposcopy have been implemented in these risk groups. however, sensitivity and specificity are low for both screening methods. since persistent hpv-infection seems to be a prerequisite for ain and scc it seems reasonable to use hpv-typing as an adjunct to screening in risk groups. methods. three hundred and eighty-five consecutive patients with hpv-associated anal disease were included. sexual orientation, hiv-status, smoking habits and psychological strain were documented. all patients underwent clinical examination, rigid sigmoidoscopy and anal hpv-testing. biopsies from macroscopically visible lesions were taken and categorized in condyloma or the three grade-scale of ain according to the bethesda terminology for reporting results in cervical histology. hpv-testing for low-risk (lr) and high-risk (hr)-types was performed using hybrid capture (hc ). qualitative (positive=negative) and semiquantitative results (relative loight units, rlu's) as an indirect measure of ''viral load'' were obtained. results. hiv-status was the only significant risk factor for hr-hpv-infection in univariate and multivariate analysis. in univariate analysis positive hiv-status and patients tested positive for hr-hpv-dna or both types of hpv-dna were significant risk factors for presence of any type of ain. smoking habits, presence of psychological stress and detection of lr-hpv-dna did not significantly influence presence of ain. in multivariate analysis only presence of hr-hpv-dna was a significant risk factor for ain. univariate interclass correlation showed a significant correlation between grade of anal dysplasia and presence of hr-hpv-dna, grade of anal dysplasia and smoking, grade of anal dysplasia and positive hiv-status, presence of lr-hpv-dna and hr-hpv-dna and presence of hr-hpv-dna and positive hiv-status mean number of rlus for hr-hpv-dna was . for hiv negative patients and . for hiv positive patients. there was also a significant difference in the number of rlus for hr-hpv-dna for different grades of anal dysplasia. this difference was only seen in hiv-positive patients, but not in hiv-negative patients. conclusions. our results show the strong relation between persistent hr-hpv-infection and grade of dyplasia. this warrants hpv-typing to be introduced as an adjunct to screening for ain in risk groups. human papillomavirus and anogenital lesions: burden of illness and basis for treatment f. aigner, e. gander, f. conrad background. human papillomavirus (hpv) infections in the anogenital region have become an immanent disease pattern in daily clinical routine. still there is ignorance concerning the etiology and course of hpv associated anogenital lesions, thus demanding an interdisciplinary approach to this disease, which affects more frequently younger individuals. high recurrence rates and the propensity of high-risk hpv associated lesions for malignant transformation (cervical=anal cancer) led to the assessment of diagnostic and treatment options within our association. methods. the results of a consensus meeting in the framework of the rd innsbruck coloproctology winter meeting based on this topic are presented. results. the incidence of anogenital hpv associated lesions (anogenital warts, anal and cervical intraepithelial neoplasia, ain and cin, and anal=cervical carcinoma) has dramatically increased over the last years. in our centre the number of patients presenting with anogenital warts has been doubled from to , closely associated with an increase of diagnosed anal cancers. in the last two years new cases of ain iii (mean age years; males, females), cases of ain ii (mean age years; males, females) and cases of ain i (mean age years; males, one female) were treated in our proctologic unit and introduced to the gynaecologists. treatment algorithm includes excision, electrocauterization or laservaporisation of perianal or anal warts or ain i, ii and anal ain iii on the one hand and radical excision of perianal ain iii on the other hand. immunomodulatory treatment with imiquimod (aldara + ) should be preferentially applied for recurrent anogenital warts. histological examination of suspect lesions has to be performed routinely. conclusions. hpv associated anogenital lesions should be treated by a multidisciplinary approach. histological investigation of the excised material should be performed routinely as well as patients' surveillance including standard anoscopy and colposcopy in a specialized unit. gigip: tissue engineering und implantat induzierte immunologische reaktionen th -immunresponse to xenogeneic matrix grafts t. meyer , k. schwarz , b. höcht pediatric surgery unit, department of surgery, würzburg, germany; department of anatomy, saarland university, homburg=saar, germany background. extracellular matrix (ecm) biomaterials of xenogeneic origin, such as lyoplant + , pelvicol + or surgis + are beginning to be used as acellular, resorbable bioscaffolds for tissue repair in pediatric surgery. although a vigorous immune response to ecm is expected, to date there has been evidence for only normal tissue regeneration without any accompanying rejection. the purpose of this study was to determine the reason for a lack of rejection. methods. full-thickness abdominal wall defects were created in wistar-wu rats and reconstructed with either a lyoplant + -matrix (b=braun aesculap, germany) or prolene +matrix (polypropylene-matrix [ppp], prolene + , ethicon germany). animals were checked daily for local and systemic complications in both treatment and control groups. bodyweight was recorded and the possible development of a hernia was monitored. after weeks the abdomen was reopened and adhesions to the intestine were determined. histopathology and immunohistochemistry were performed to evaluate the immunological reaction to the xenograft. results. compared to the untreated animals, all rats had a physiological growth and body weight curve: no wound infection could be observed throughout the experiment. only in one rat, treated with a ppp-matrix, an abdominal hernia developed at the implant site. all other animals showed excellent clinical recovery and cosmetic results. ppp animals showed a pronounced inflammatory response indicated by an increased number of fibroblasts. the lyoplant + -matrix implantation induced an infiltration of cd and cd positive cells. in addition an active neovascularization was found, observing a remodelling process. this inflammatory response was significantly milder than in ppp implanted rats. interestingly some cd positive cells were detected in the lyoplant + -group. conclusions. xenogeneic extracellular matrix, such as lyoplant + , induces an immune response, which is predominately th -like, comparable with a remodeling reaction rather than rejection. background. mesh graft infections after hernia repair are an awkward complication. in more extensive infections many surgeons recommend removal of the mesh, due to the difficulty to treat microbes in th infected artificial material. the vac system now offers a new possibility in the treatment of complicated wounds, including mesh infections. methods. in this study, records of patients with mesh graft infections after incisional abdominal wall hernia repair were retrospectively analysed who have been operated on between january st and february th at the department of surgery, general hospital vienna. results. of patients ( %, female and male) operated in the period of investigation were suffering from mesh graft infections ( vypro ii mesh, composix mesh and surgipro mesh). mean age of patients was years. mean duration of wound therapy was days. % of the patients had an extensive infection. in those, topical negative pressure therapy (vac) was used. this led to a preservation of % of meshes in this group. in patients with a wound smaller than cm, infection could be successfully treated in of cases ( %). the type of mesh had an influence, whether it could be preserved. all of vypro ii-mesh grafts ( %), of composix mesh ( %) and of surgipro mesh ( %) could be preserved by conservative treatment. conclusions. data suggest that vypro ii mesh grafts are superior to composix and surgipro mesh regarding mesh graft preservation in case of postoperative mesh graft infection. vac therapy should be considered for successful treatment of more extensive infection. finally, small wounds (< cm) seem to have a good prognosis for mesh graft preserving healing. background. revisional procedures after restrictive bariatric operations are necessary in increasing numbers of patients. these procedures may be performed laparoscopically but represent demanding and in some cases risky operations. a meticulous technique is mandatory in order to achieve good postoperative results. methods and results. laparoscopic roux-y gastric bypass is performed as revisional procedure after laparoscopic gastric banding, sleeve gastrectomy and vertical gastric banding. the indication for a transformation to gastric bypass is inadequate weight loss or weight regain and technical failures of procedures. formation of the gastric pouch may be difficult because of adhesions and formation of a capsula in case of banding. gastro-jejunostomy may be performed by different techniques. conclusions. revisional gastric bypass is a more complicated procedure than primary bypass. in order to achieve good results a number of technical details have to be respected. background. laparoscopic sleeve gastrectomy has become a standard bariatic procedure in the last five years. this procedure has been performed with a number of different techniques using laparoscopic staplers and mobilizing the greater curvuture as primary step of the operation. methods. sleeve gastrectomy with a modified technique starting with the formation of the gastric sleeve prior to mobilisation of the greater curvuture is demonstrated. stapling is performed with linear straight staplers. conclusions. the advanages of performing laparascopic sleeve gastrectomy by a modified technique are shorter operating times, and a better overview especially near the his angle. the modified technique may therefore become a surgical standard in bariatric surgery. we present a video showing the technique of laparoscopic approach for reoperation on cases with complications due to ''lost gallstones'' after laparoscopic cholecystectomy. case is a years old female patient, operated for symptomatic cholecystolithiasis in august . in august she presented with right upper quadrant pain, the computertomography revealed a liver abscess in the right lobe and a retroperitoneal abscess. case is a years old male patient, operated for symptomatic cholecystolithiasis in november . in july he presented with right upper quadrant abdominal pain, the computertomography showed a small suspected abscess formation between liver segment and the right kidney. laparoscopic reoperation was performed the day after diagnosis. in case after adhesiolysis the liver was elevated and the abscess opened to perform rinsage and drainage of the cavity. the ''lost gallstones'' were taken out with a suction device. in case multiple stones were found in the upper abdomen under the peritoneum and in the abscess cavity. adhesiolysis and rinsage was performed. if abscess formation around the liver is seen even years after laparoscopic cholecystectomy, the diagnosis of a complication from ''lost gallstones'' should be suspected. reoperations for ''lost gallstones'' after laparoscopic cholecystectomy can be performed by laparoscopy if the abscess formation is accessible; results will be superior to ct-guided drainage due to the stone extraction by laparoscopy. grundlagen. die isr ist eine technik, bei der auch tiefsitzende karzinome des rektum sphinktererhaltend reseziert werden können. wir haben kürzlich eine operationstechnik entwickelt, bei der dieser eingriff laparoskopisch ohne großen zusätzlichen zeitaufwand durchgeführt werden kann. methodik. dieser eingriff wird nach genauer präoperativer abklärung durch ) digitalbefund, ) endoskopie und biopsie, ) mrt des rektums und ) sphinktermanometrie geplant. ausschließungsgründe für die operation sind: undifferenzierter tumor, t -stadium und schlechte sphinkterfunktion. der abdominelle teil wird im trokarttechnik (  mm optikport,  mm arbeitsport) durchgeführt. die präparation erfolgt entweder mit dem mm ultracision oder dem mm ligasure-atlas. der eingriff wird synchron von abdominell und peranal von teams durchgeführt. dafür wurde eine eigene lagerungstechnik entwickelt. die operation verläuft in folgenden phasen: ) totale mesorektale exzision, ) peranale intersphinktäre resektion des rektum ) bildung eines axialen kolonpouches, ) durchzug des kolon und koloanale anastomose, ) protektive transversostomie oder ileostomie. die präparatbergung erfolgt von peranal, sodass keine zusätzliche inzision am abdomen notwendig ist. der stomaverschluß erfolgt nach wochen. ergebnisse. von den insgesamt intersphinktären resektionen wurden laparoskopisch durchgeführt. die mittleren operationszeiten betrugen bei der offenen isr min, bei der laparoskopischen min. schlussfolgerungen. die laparoskopische intersphinktäre resektion ist ein praktikables operationsverfahren, dass mit vertretbarem zeitaufwand durchgeführt werden kann. die vorteile der laparoskopischen vorgangsweise können derzeit bis auf das hervorragende kosmetische ergebnis noch nicht abgeschätzt werden. schlussfolgerungen. der konsequente einsatz eines hochthorakalen pdks mit adäquater füllung zur schmerztherapie und sympathikolyse war von unserer anästhesieabteilung nicht regelhaft umsetzbar, so dass wir in der oralen gabe von oxycodon plus oraler stimulation des gastrointestinaltraktes eine hervorragende alternative zur durchführung der fast-track-rehabilitation gefunden haben. unsere ergebnisse decken sich mit den resultaten die derzeit von den chirurgischen zentren publiziert werden. die wiederaufnahme-( . %) und die gesamtkomplikationsrate ( %) ist bei längerer verweildauer etwas niedriger. unsere ergebnisse zeigen, dass das konzept der fast-track-rehabilitation gut in einem nicht ausgewählten patientengut umsetzbar ist. aufgrund der ausbildungssituation ist die zahl der lap. eingriffe relativ gering.in der oralen opiod-analgesie haben wir eine unerwartet gute alternative zum pdk gefunden. fast track surgery without thoracic peridural anaesthesia? background. thoracic pda is considered to be one of the main pillars of fast track surgery (fts). our anaesthetists being reluctant to perform thoracic pda as a routine, we decided to make an attempt to do surgery without thoracic pda yet following all other criteria of fts. methods. between jan. and dec. we have performed elective colonic procedures following our modified criteria. in these patients we have prospectively examined those parameters which could be expected to be influenced the most by pda: -postoperative intestinal paralysis -postoperative pain control -rate of complications results. the postoperative need of antiemetic drugs and the time of the first clinical signs of bowel activity (passing winds or stool) were examined as criteria for postoperative paralysis: - . % of patients never needed an anitemetic drug - . % of patients were having bowel activity not later than on po day standard postoperative pain control regimen contained two doses of mg paracetamol and two doses of mg diclofenac iv. as long as needed followed by the same combination given orally. mg of piritramid sc. was presribed as reserve treatment. - % of patients needed the standard iv-regimen for longer than three days - % of patients never needed a single dose of piritramid - . % of patients needed more than two doses of piritramid in the last months of the study only patients ( . %) needed piritramid for sufficient pain control (learning curve of nurses and doctors!). overall we have seen complications ( . % of procedures): background. multimodal fast track rehabilitation is based on modified perioperative fluid management, avoidance of preoperative fasting, effective analgesic therapy using epidural anesthesia, early postoperative mobilisation and immediate oral nutrition in order to accelerate recovery, reduce general morbidity and decrease length of hospital stay. young people seem to be the most suitable patients for fast track rehabilitation, but majority of the patients requiring colorectal surgery is older than years and often has several comorbidities. in this analysis we compared ''fast track'' feasibility and efficacy in young and old patients to examine, whether an age dependent management is required. methods. during one year all patients scheduled for colorectal surgery for colorectal cancer or sigmadiverticulitis on one ward were treated according to our multimodal ''fast track'' program. demographic and perioperative data, postoperative follow up (e.g. first bowel movement, vomiting, intravenous infusion therapy, fluid balance), local and general complications were prospectively assessed and evaluated on the basis of two groups (group a: age< a, n ¼ ; group b: age> a, n ¼ ). results. median postoperative hospital stay was days (a) and . days (b) with one readmission in both groups. the incidence of local and general complications was . % and %, respectively. a aged patient with stenotic rectal cancer with liver metastases and parkinsons disease died because of multiorgan failure. conclusions. the multimodal ''fast track'' rehabilitation concept is feasible in young and old patients. although older patients have a higher morbidity, our data show, that especially older patients benefit from enhanced recovery programs. background. the restrictive perioperative intravenous (i.v.) fluid management is an important element of multimodal fast track surgery. recent studies have shown a better outcome for patients with moderate or restrictive intravenous i.v. fluid therapy, but adequate interdisciplinary standards are missing and therefore optimal perioperative fluid management still remains controversial. in october we started ''fast track'' treatment in colorectal surgery on one ward, in this study we present our experience with modified perioperative fluid management. methods. during one year consecutive patients underwent elective surgery for colorectal cancer or sigmadiverticulitis ( laparoscopically, conventionally). demographic, pre-, intra-and postoperative data (e.g. fluid supply, urine excretion, creatinine, electrolytes, first bowel movement, vomiting), local and general complications were prospectively assessed and evaluated, median age of patients was years ( - years). results. intraoperative i.v. fluid administration was . ml=h=kg. on the first postoperative day patients oral intake was ml ( - ml) with an urine excretion of ml ( - ml). no hypovolemia associated complications were observed, creatinine and electrolytes showed no significant pre-and postoperative changes. general morbidity was % (urinary tract infection, pneumonia). median postoperative hospital stay was days (no readmissions). conclusions. reduced intraoperative and restrictive postoperative i.v. fluid therapy is feasible and has no negative impact on water and electrolyte balance. early oral fluid administration guarantees a sufficient hydration with adequate urinary output and contributes significantly to fast (track) rehabilitation and improvement of patients comfort. background. malignant pleural mesothelioma is a mainly asbestos-related neoplasm with increasing frequency associated with a poor prognosis. extrapleural pneumonectomy was initially performed as a stand-alone treatment in patients with respectable disease, however is currently almost uniformely applied as part of a multi-modal approach. its value and advantage over other therapeutic strategies remain point of discussion. we therefore analysed our experience with extrapleural pneumonectomy in the treatment of malignant pleural mesothelioma. methods. we retrospectively reviewed our institutional experience with all consecutive patients undergoing extrapleural pneumonectomy for malignant pleural mesothelioma from to . patients were analysed with regard to hospital data and outcome. results. forty-nine patients ( females= males, mean age ae years) underwent extrapleural pneumonectomy during the observation period. median icu stay was day, median postoperative length of hospital stay was days. after a mean follow-up of days median survival was days (mean ae days, range - ). year survival was . %, years survival . % and years survival . %. conclusions. extrapleural pneumonectomy as part of a multi-modal treatment regimen is a good treatment option for selected patients with malignant pleural mesothelioma. the long term results of this limited series compare favourable to non-surgical treatment regimens. larger randomised prospective multi-center trials are warranted to establish clear guidelines. background. the accelerated progress in genomics and data analysis technologies give a new view to customized treatment for stage iii lung cancer. the histopathological diagnosis will be accompanied by molecular classification. present treatment for advanced lung cancer is unsatisfactory and nearly % of newly diagnosed patients will die within two years. methods. from to patients underwent neoadjuvant treatment with platin-based chemotherapy followed by surgical resection. a panel of genes (p , p , mib- , cyclind , cycline, ercc ) were identified in pre-and posttherapeutic specimens. the expression profile was correlated to the histological regression grade and survival. results. the investigated different pathways allow an explanation of platin-based chemotherapy resistance and short duration of response according to the gene expression levels. conclusions. a prediction of a patient's prognosis could be improved by combining standard clinical staging methods with molecular-pathological evaluation. background. in the last years the video assisted approach (vats) has become the standard of care for persistent or recurrent (after tube drainage) spontaneous pneumothorax (sp) . but what is the standard treatment in recurrent pneumothorax after primary operation in the era of vats? moreover, we only have little information about the rate of contra lateral pneumothorax in those patients. to find answers to these questions we investigated the patients operated for sp in recent years. methods. we retrospectively analysed patients with sp treated by vats between = and = . only patients with years of age or younger without any underlying chronic lung disease were included. the treatment of choice was bullectomy or apical lung resection with apical partial pleurectomy (app) by vats. results. we identified patients at a mean age of years ( - ) with the female: male ratio of : . . the interval of the study and the operation was at mean of months. the primary vats for sp was successful in % (n ¼ patients). in three patients with primary failure persisting pneumothorax was reoperated by vats (postoperative day , , ) . none of these three patients had a recurrence. of patients treated successfully for spontaneous pneumothorax . % (n ¼ patients) suffered from recurrence at a mean of ( - ) months with one case of a second recurrence. only minor or no adhesions were found at the apex of the thoracic cavity, a bulla was found in one woman. moreover, in all patients an intact neopleura was found. major morbidity was postoperative hemothorax treated conservatively in % (n ¼ patients). interestingly, % (n ¼ patients) developed primary pneumothorax on the contra lateral side at a mean . ( - ) months. all these patients underwent vats without recurrence. conclusions. . successful treatment of sp can be achieved by vats with low recurrence rate, low morbidity and a high primary success rate. . in sp with bullae the role of app is not defined as yet and in recurrence or primary failure a thoracoscopic pleurodesis e.g. with talcum, should be considered. . in the light of the high rate of almost % of contra lateral sp a primary intervention on both sides should be considered. . a study to identify patients of risk for contra lateral sp with e.g. low dose ct in the first event should be considered. background. surgical treatment of myasthenia gravis and thymoma necessitates the complete resection of the thymus with the whole fatty tissue adherent to the pericardium. the aim was to investigate the efficacy and safety of robotic approach. methods. from = to = patients with myasthenia gravis (n ¼ ) or thymoma (n ¼ ) (mean age ae years, male to female ratio : ) were operated with the intention to perform a totally endoscopic, complete resection with the davinci telemanipulator system. in all but one patient a left sided approach was chosen. results. in out of patients the operation was carried out totally endoscopic. two patients had to be converted because of bleeding (patient ) and thymus carcinoma (patient ) requiring extensive resection. in the remaining patients, operative time was ae minutes, intubation time ae minutes. icu stay was day, in hospital ae . days. in all patients it was possible to identify both phrenic nerves and the complete fatty tissue above the anonymal vein along the supraaortal vessels was resected. histology revealed normal persisting thymus tissue (n ¼ ) and thymoma (n ¼ ) -who stage b and b (in cases each); masaoka stage i (n ¼ ), ii (n ¼ ) and ivb (n ¼ ), respectively. all resection borders were free of tumor. in all myasthenia gravis patients acethylcholinereceptor antibodies decreased during follow up. conclusions. complete endoscopic thymus surgery with the da vinci surgical system, is feasible and safe to implement into clinical practice. due to the minimal trauma, patients can return to full activity in a short time period. self-expandable covered metal tracheal type stent for sealing cervical anastomotic leak after esophagectomy and gastric pull-up: pitfalls and possibilities background. the rate of anastomotic leakage after cervical esophagogastrostomy following esophagectomy and reconstruction with the tabulated stomach ranges between and %. the treatment options comprise redo-surgery, endoscopical stapling, glueing or insertion of plastic stents, or conservative management with drainage procedures. the aim of this study was to evaluate the efficacy of self-expandable covered metal tracheal type stents for sealing the anastomotic leak. methods. from = to = , patients with leakage of the cervical esopahgogastrostomy following esophagectomy and reconstruction underwent endoscopic stenting using the self-expandable covered tracheal type device. the extent of the dehiscences ranged from to % of the anastomotic circumference. mortality, morbidity, healing rate of the anastomosis and hospitalisation time were evaluated. results. in all cases stenting was done without any complication. stent extraction could be performed after an average period of days, ranging from to days. in all cases, healing of the anastomosis was satisfactory. patients developed stenosis after removal which was successfully managed by bouginage. stent migration was observed in patients, treated by repositioning in one and two attempts of re-stenting followed by eventual suturing of a small residual leak in the other. conclusions. endoscopic insertion of a self-expandable covered metal tracheal stent represents a safe approach resulting in immediate closure and subsequent healing of cervical anastomotic leakage. there was no leakage-related morbidity, oral intake of food was resumed one day after successful stenting. however, stent dislocation and stricture after stent removal may occur. background. squamous-lined cyst of the pancreas is a rare entity with only about one hundred reported cases. three types of cysts are differentiated: lymphoepithelial, dermoid and accessory-splenic epidermoid cysts. the literature on this entity is limited to reports of single or small numbers of cases. the two most common cystic tumors of the pancreas are serous cyst adenoma and mucinous cystic neoplasms. we herein report the case of a lymphoepithelial cyst of the pancreas. case report. a -year-old man presented with a month history of upper abdominal pain and bloating. the disorders were related to food ingestion and were not followed by nausea or vomiting. he experienced low weight loss. he was in good general health with a normal physical examination and no tenderness in the upper abdomen. laboratory investigation including ca - , cea and hcg were within the normal range. imaging studies with ct, mrt and eus showed a  cm mass in the uncinate process of pancreas with contact on to the mesenterial vessels. the mass presented in ct=eus as a solid, expansive tumor, whereas mrt showed a cystic mass. fine-needle biopsy revealed squamous epithelial cells with sebaceous material, but without atypia. because of the progressive symptoms with compression of the duodenum and to rule out malignancy we resected the cystic tumor. no encasement, invasion or other aspects of malignancy were found. the resection defect was drained with a jejunal y-roux-loop. histological findings showed a benign lymphoepithelial cyst and the patient had an uneventful postoperative and four-month follow-up period. conclusions. establishing a preoperative diagnosis of a lymphoepithelial cyst is not possible. squamous-lined cysts of the pancreas have a low malignant potential, however, there are reports of mature dermoid cysts developing into malignant forms. to distinguish squamous-lined cysts from other cystic lesions of the pancreas, particularly malignant processes, is rather difficult. therefore we recommend a complete surgical removal of every cystic lesion suspicious to be a squamouslined cyst to avoid or treat malignancy. ten year experience with duodenum preserving pancreatic head resection in chronic pancreatitis r. j. klug, f. kurz, m. aufschnaiter kh barmherzige schwestern linz, chirurgie, linz, austria background. the chronic head accentuated pancreatitis is on the rise in industrialised countries. alcohol is the predominant aetiological factor.the incidence is per . inhabitants. in up to % of patients with chronic pancreatitis the head of the gland will be grossly enlarged by an inflammatory mass, often associated with bile duct stenosis and duodenal hold-up.in our institution the standard whipple operation has been replaced by the duodenum preserving pancreatic head resection (dpphr). methods. we present our meanwhile year experience with dpphr. our patients are analysed retrospectively. results. between november and november we performed dpphr in males and females patients. the average age was . years ( - years). the follow-up was done by the aid of an inventory referring to postoperative pain control, development of diabetes, postoperative weight gain and subjective success assessment. the complications are described and discussed as well. the results are presented. conclusions. the dpphr developed by beger about years ago has become the standard procedure for the operative treatment of.chronic head accentuated pancreatitis in our institution. the intervention is demanding but offers the advantages of maximal organ preservation, satisfactory endocrinological and functional results, a justifiable low complication rate as well as a high degree of satisfaction on the part of the patients. segmental duodenectomy at periampullary lesions -an adequate therapy? j. karner, b. sobhian, m. klimpfinger, g. udvadi, f. sellner smz-süd kaiser franz josef spital, vienna, austria background. the radical surgical procedure for treatment of the resectable periampullary tumors is the partial pancreatoduodenectomy or the pylorus-preserving pancreatectomy. in rare selected cases a segmental duodenectomy with reinsertion of the pancreatic and choledochus duct might be suitable alternative to improve the patient's quality of life. methods. about to patients were hospitalized annually with the diagnosis of a pancreatic or periampullary tumor at the smz-süd -kaiser franz josef spital department of surgery. to ensure radical resection either a partial pancreatoduodenectomy or a pylorus-preserving pancreatectomy was performed. in two patients with low-and=or high-grade dyspla-sia of the papilla and the peripapillar mucosa a segmental duodenectomy with resection of the papilla vateri was performed. after radical excision (proven by an intraoperative frozensection diagnosis) a duodeno-duodenal anastomosis with reinsertion of the splinted pancreatic and choledochus duct was performed. results. the postoperative course was uneventful. three months after the operation, clinical follow-up including gastroscopy revealed a normal mucosa of the duodenum and an excellent quality of life. conclusions. accurate surgical technique and pre-(gastroscopy), intra-and final histopathological diagnosis by an experienced pathologist are decisive factors in determining the ultimate outcome. if the histological findings as to benignity are uncertain, resection of the head of the pancreas with or without preservation of the pylorus by an experienced surgeon is indicated. the segmental duodenectomy might be an adequate therapy of the periampullary lesions in carefully selected cases. background. five randomized trials and an increasing number of phase studies confirm the opinion that the combination of peritonectomy-procedures and intraperitoneal chemotherapy positively influence the outcome in patients suffering from peritoneal carinomatosis (pc) of appendiceal tumors, colon cancer, ovarian cancer and gastric cancer as well as rare tumors of the peritoneum per se. nevertheless, according to the literature postoperative mortality was observed in - %, postoperative minor and major morbidity in - %. methods. in the last years patients (pts) suffering from pc arising from different primary tumors were treated at our institution in cooperation with surgical, gynecological or oncological departments in austria and germany. at the time of writing complete records from patients (mean age: . ae yrs, others ) are evaluated for analysis. primary objectives to assess were overall survival and time to progression of intraperitoneal or general disease. factors influencing these parameters were determined. secondary objectives to assess were postoperative mortality and morbidity. results. completeness of cytoredutive surgery, favourable histology (ovary, appendix, colon) and n -stage - (n ¼ pts) made a -year survival rate of % and a -year survival rate of % possible. (updated extended analysis of the different groups of patients will be presented) postoperative mortality within days was . %, within days . %. conclusions. cytoreductive surgery in combination with intraperitoneal, hyperthermic chemoperfusion ae systemic chemotherapy has a curative potential in selected patients. background. an increasing amount of patients confronted with an incurable or chronic progressive disease demands a special palliative procedure in physical, psychosocial and spiritual treatment. medical and nursing staff members in the hospital are not always prepared to handle with these patients and their relatives in a proper way. reasons behind may be lack of time, skills and experiences. deficits in management and in multiprofessional communication complicate the situation. a palliative liaison service provides, in this context, support in pain management, control of severe symptoms, treatment of terminal patients, coordination of professionals, discharge management, cooperation with mobile hospiz teams and support in ethical conflicts. methods. in we asked medical and nursing staff members for the importance and the need of palliative support in their daily routine. from may to december we documented consultations of patients, which means an effort of , hours. in we asked members of the medical and nursing staff in leading positions about the amount of satisfication with the provided support and the acceptance of the instution pls year after the implementation. results. in % of the staff members asked, confirmed the importance of palliative care and % agreed to the cooperation with a palliative liaison service. from may to december , , % of the demands for support came from surgical wards. the primary reasons for the first contact were pains and other severe symptoms. about % of the patients had cancer in the diagnosis. in the extent of satisfaction with the performances of the palliative support team was between , and , (satisfaction is defined until , within a range of to ). % to % from the provided performances were already requested. conclusions. the service of a palliative support team in the hospital was highly accepted already after a short time. more than the half of the consultations took place on surgical wards. we conclude that a palliative support service provides benefits for staff and patients in a difficult situation. especially in a time of rapid medical progress, limited resources and increasing ethical demands of autonome patients, the public health institutions may request for the right balance between curative and palliative settings. background. the ileus is often the sign of an advanced stage of malicious illnesses that require palliative treatment. medicine and especially palliative medicine has changed medical treatment in the way that it now aims at an improvement of life quality. methods. in our hospital cases with patients were analysed. these patients suffered from ileus in connection with an advanced malicious illness. results. an ileus was localised with patients in the field of the small intestine and with patients in the field of colon. cases were treated in a conservative way, cases required operative treatment. primary tumors were found predominantly in the colon and also in the feminine genitals as well as in the stomach. on average the remaining life time was two months. % of the patients with ileus in the field of the small intestine were treated without operation. conclusions. the life time of patients with ileus and advanced malicious illness is short. operations with high risk should be avoided. patients with ileus in the field of the small intestine should be given conservative treatment which in case of failing may be converted into interventional or operative treatment. operation can hardly be avoided with patients with ileus in the field of colon. if available, interventional therapy for the removal of stomach and intestine contents should be applied. the patient's wish is to be considered. treatment should aim at improving the patient's life quality. penetrating abdomino-thoracic injuriesreport of four impressive cases z. halloul, f. eder, f. meyer, h. lippert department of surgery, university hospital, magdeburg, germany background. penetrating wounds are distinguished in impalement and gun shot or stab wounds (stab=impalement injuries more frequently in europe), which are often very spectacular. the aim of the representative case reports is to analyze the kind of injury þ the adequate surgical, in particular, the complex wound management. methods. the impressive case series includes patients with abdomino-thoracic penetrating traumas ( stab=impalement wounds each) who were treated in a surgical university hospital centre during months. results. ( ) impalement injury by a steel pipe i) entering the body above the right kidney behind the liver, through the mediastinum via the right thorax, passed heart and aortic arch up to the left clavicle, ii) approached with sternotomy=median laparotomy to remove the rod including suture of the left subclavian vein only (postoperatively, residual lesion of the left brachial plexus=temporary pneumonia). ( ) one leg of a chair drilled into the left ''foramen obturatorium'' leaving the body at the right anterior iliac spine: initial removal=excision of the gluteal penetration canal. developing abdominal signs= symptoms indicated explorative laparotomy revealing peritonitis because of perforated ileum: segmental resection= anastomosis (postoperatively, i) right inguinal wound necrosis requiring excision=vacuum-assisted closure sealing; ii) remaining paresthesia in the left leg due to sacral plexus lesion). ( ) due to a violent conflict, stabs entered the right thorax while one injured the right pulmonary lobe=diaphragm=liver dome between segment viii&v þ a big scalp avulsion at the left= right parietooccipital site þ a transection of the right biceps muscle approached with right subcostal incision=anterior thor-acotomy=liver packing ( towels removed after d)=suture of the diaphragm=pleural drainages. ( ) stab injury at the left thorax (pneumothorax=lesions of the diaphragm & left third of the transversal colon) and neck (lesions of the pharynx=internal jugular vein) approached with left thoracic drainage=suture of the colonic & diaphragmatic lesions (postoperatively, i) right thoracotomy because of a right pleural empyema due to bronchopneumonia as a consequence of the blunt right thoracic trauma; ii) relaparotomy because of an abscess within the douglas' space; iii) billroth-ii gastric resection because of recurrent forrest-ia bleeding). conclusions. important aspects of such trauma care are immediate life-saving measures, transferral to a trauma centre, first care, prompt diagnostic=initiation of an adequate surgical treatment provided by trauma=general=abdominal=vascular and=or cardiac surgeons (e.g., surgical interventions at vessels= organs=soft tissue) as well as the postoperative course and rehabilitation. if these measures are provided with high medical standards and an interdisciplinary setting, optimal outcome can be achieved in order to prevent fatal outcome, to ensure maximal organ function, and to minimize permanent damages. background. today infections with clostridium perfringens are rare, but still most of the cases turn out lethal, although receiving timely medical treatment. this report deals with three different patients, who were transferred to our surgical department since june . the first patient (male ), with the suspected diagnosis ''femoral hematoma'', a second patient (male ) because of an ''acute abdomen'' and the third patient with suspicion of gas gangrene after chronic ulcer of the right food. methods. first patient: already at the physical examination of the femoral an impressive crepitation was palpable. besides this the man was suffering from myelodysplasia and showed a marked ulcer on the left side of the scrotum. on suspicion of gas gangrene we performed an exarticulation of the left femoral after intensive-care stabilization. besides all efforts this patient died the same day because of an acute circulatory failure. second patient: because of an acute abdomen the second patient received a ct and in suspicion of appendicitis an explorative laparotomy was indicated. furthermore a known haematoma at the right shoulder began to extend in sizeand shortly after the typical crepitation was palpable as well. even though the arm was exarticulated during an immediate operation the patient died because of the massive progressing infection. third patient: this patient was sent to our hospital because of the suspicion of gas-gangrene. during physical examination the typical crepitation was palpable at the right femoral and lower leg with associated emphysema. during operation the wound seemed unsuspicious. immediate examination of the tissue (department of hygienic and microbiology) showed a negative result concerning an infection with clostridum perfringens, so it could be refrained from an amputation of the femoral. entirely some incisions of the skin and the fascia were done. postoperative we kept watch on the wound in short intervals -showing consistent results the patient was transferred to our general ward to be treated because of his chronic ulcer on the right leg. conclusions. once pandora's box has been opened, still % of all gas-gangrene-infections pass off lethal. the first two cases demonstrate that (besides the low incidence of . events per mio. persons and year) infections of clostridum perfringens should always be kept in mind, especially in high-riskpatients. in contrast to this the third patient shows, that severe consequences because of a precipitate indication can be avoided by experience and careful evaluation. results. altogether patients were treated for rsh at our institution during the study period. seven patients were on oral anticoagulation, patients were taking acetylsalicylic, was on clopidogrel and patient was on anticoagulation with low dose heparin, whereas patients had no anticoagulation. a previous trauma event was apparent in six of the cases, one of this patient was on oral anticoagulation, one on acetylsalicylic, one was taking clopidogrel and three had no anticoagulation. rsh was correctly identified by means of ultrasound in of cases, in which this investigation was performed. a ct scan investigation demonstrated the haematoma in all ( of cases) cases. thirteen patients were managed conservatively, patients underwent surgical treatment. eight patients needed blood transfusion and four patients received vitamin k medication. all patients could be discharged from hospital in good general condition. clinical re-evaluation (median follow up years, range month- years) showed all patients were free of symptoms at this time. conclusions. our data confirm the multifactorial aetiology of rsh and the strong association with different forms of anticoagulation. ct scan is the diagnostic tool of choice, whereas identification with ultrasound is strongly dependent on the experience of the examiner. conservative as well as surgical management have good results, with good restitution to fine health of all patients. surgery seems to be only indicated when complications appear (homodynamic instability, severe pain, which cannot be managed conservatively). background. intestinal metaplasia (im) in specialized columnar lined epithelium in the distal esophagus is a precancerous lesion with a cancer risk of . % or case in patientyears. there are no prospective multicenter-data available for germany regarding the cancer-risk and also no data regarding different therapeutic treatment options. the purpose of this study was to evaluate the progression of dysplasia in barrett's esophagus (be) in patients under antireflux therapy -laparoscopic fundoplication (lf) or treatment with proton pump inhibitors (ppi) -based on the data of the german barrett esophagus registry. methods. in a consensus process a protocol was established by pathologists (n ¼ ), gastroenterologists (n ¼ ) and surgeons (n ¼ ). patient history, findings on endoscopy, histopathology and functional diagnostics were collected in a multicentric database. patients gave their informed consent for a central data registration. barrett's esophagus was defined as specialized, intestinal metaplasia in the endoscopic visible columnar lined epithelium of the esophagus independent of its length. the natural and posttherapeutic course of patients with im was registered prospectively. participating centres were free to decide for their own treatment approach for each patient regarding im as well as the underlying reflux disease. patients were followed with routine endoscopy and biopsy every - months. results. since january , patients with be were prospectively registered and analysed. of fourteen participating centres three were surgical (n ¼ ) and gastroenterological (n ¼ ). symptoms of reflux were present in % of patients daily or weekly, in % they were absent. the mean age of patients was years (range - ). two hundred and ninety six were male and female. three hundred and fifty patients ( %) had short-segment-be and ( %) long-segment-be. intraepithelial neoplasia was initially diagnosed in patients (low grade intraepithelial neoplasia (lgien) in , high grade intraepithelial neoplasia (hgien) in , indefinite in ). in the second histological confirmation hgien, lgien and indefinite ien were confirmed. in the other patients ien was excluded. from all patients ( insufficient and on competent lf) have shown progression from im to lgien and one from im to cancer (ppi) in a total of patient-years. conclusions. the current analysis shows a low rate of progression of im to ien for ppi treatment as well as antireflux surgery. this confirms recent reports on barrett's esophagus, that progression is a rather infrequent problem, which cannot be prevented by antireflux surgery or ppi. background. impaired esophageal motility plays an important role in the pathogenesis of gastroesophageal reflux disease (gerd) and its evaluation is important for the assessment of a therapeutic effect. the comparison of szintigraphic, manometric and symptomatic evaluation has not been shown yet. methods. sixty patients were evaluated with endoscopy, esophageal manometry, radionuclide scanning of esophageal emptying and assessment of symptoms prior to treatment (operation or medical therapy) and months later. in gerd patients with normal esophageal peristalsis the nissen fundoplication was performed, in further patients with impaired esophageal peristalsis a partial posterior fundoplication was chosen and further patients received continous medical treatment with ppi. all groups were comparable regarding age and gender of the patients. esophagitis was most pronounced in those patients who underwent partial posterior fundoplication. results. on endoscopy acute esophagitis resolved in all patients after fundoplication, whereas after months of medical therapy patients still had an acute esophagitis. on manometry there was a significant improvement of the competence of the lower esophageal sphincter postoperatively regardless of the performed technique. however, les relaxation was complete only after the toupet fundoplication but incomplete after the nissen fundoplication. esophageal peristalsis measured manometrically did not improve after medical therapy, was significantly strengthened after partial posterior fundoplication but was worsened by the nissen fundoplication. on szintigraphic evaluation of esophageal emptying for solid meals, there was no improvement after medical therapy but a significant improvement after partial posterior fundoplication. after the nissen fundoplication there was a significant deterioration of esophageal emptying. there was a strong correlation between szintigraphic and manomteric evaluation of peristalsis, preoperatively (rs ¼ À . p < . ) and postoperatively (rs ¼ À . p < . ). evaluation of symptoms showed no change regarding dysphagia after medical therapy and after the nissen fundoplication but a significant improvement after partial posterior fundoplica-tion. globus sensation was significantly improved after partial posterior fundoplication but did not change after medical therapy or the nissen fundoplication. postprandial bloating and inability to belch were significantly more common after the nissen than after partial posterior fundoplication. conclusions. antireflux surgery controls gerd better than medical therapy with ppis. however, partial posterior fundoplication is the more physiologic approach than the nissen fundoplication. background. combined impedance-and ph-monitoring (mii-ph) is a recently introduced diagnostic tool to assess gastro-esophageal reflux. we report our experience with this technology. methods. three hundred and fifty-seven mii-ph studies were performed in patients with clinical signs of gastroesophageal reflux disease (gerd) between may and december . a catheter was introduced into the esophagus via the nose and connected to a portable data logger. ph was monitored cm and impedance , , , , and cm above the manometrically located lower esophageal sphincter. symptoms were entered by the patients by pushing buttons on the data logger. diagnostic criteria for gerd were: pathologic acid exposure: ph < during > . % of total, > . % of upright, or > . % of recumbent recording time. pathologic impedance monitoring: > liquid or mixed liquid=gas refluxes detected by retrograde impedance drops > % from the baseline. positive symptom to reflux correlation: > % of > symptom events within a -minute time window after a reflux episode detected by mii-ph. results. three hundred and nine mii-ph procedures were performed after discontinuation of antisecretory medications for ! days in patients without prior esophageal or gastric surgery (age . ae . years). recording time was . ae . hours. the diagnostic yield of mii-ph is summarized in table . median total acid exposure was significantly higher in males than females ( . vs. . %; p < . ) as was the median number of reflux episodes detected by impedance ( vs. ; p < . ). the median number of symptoms was almost equal ( vs. ; n.s.). positive symptom correlation was significantly more frequent in females than males (p ¼ . ). the overall diagnostic yield of mii-ph was not significantly different between genders. conclusions. mii-ph is a valuable new tool for the diagnosis of gerd with significantly increased diagnostic yield over conventional ph-monitoring. acid exposure and the number of reflux episodes were significantly higher in male than female patients. sensitivity to reflux was significantly higher in females. diagnosis of gerd based on acid exposure alone lacks diagnostic sensitivity, especially in female patients. background. the surgical treatment is the most effective method for weight reduction in morbid obesity laparoscopic adjustable silicone gastric banding (lsgb) for morbid obesity has been reported to provide long term weight loss with a low risk of operative complications. nevertheless, esophageal dilation leading to achalasia-like and reflux symptoms is a feared complication of lasgb. patients undergoing obesity surgery were prospectively included in an observation study. this study evaluates the clinical benefit of routine preoperative esophageal manometry in predicting outcome after lasgb in morbid obese patients. methods. before surgery, each of the patients underwent pulmonary functional test, esophageal manometry and gastroscopy. drug medication and esophageal symptoms were recorded. a review of prospectively collected datas on patients (male , female ), who underwent esophageal manometry routine prior to lasgb for morbid obesity from january -december were performed. aberrant motility and other non specific esophageal motility disorders noted on preoperative esophageal manometry defined patients of the abnormal manometry group. outcome differences in weight loss, emesis, band complications were compared between patients of the abnormal and normal manometry groups after lsagb. results. of the patients tested had abnormal esophageal manometry results, whereas had normal manometry results before lsagb. there was no significant difference in wheight loss between the groups after gastric banding. severe postoperative emesis and achalasia like esophageal dilation occurred more frequently in patients with abnomal manometry results. band related complication were found in both groups. there was no difference in the prevalence of reflux symptoms or esophagitis before and after gb. the lower esophageal sphincter was unaffected by surgery, but contractions in the lower esophagus weakend after lsagb. conclusions. postoperative esophageal dysmotility and gastresophageal reflux are not uncommon after lsagb. preoperative testing should be done routinely. low amplitude of contraction in the lower esophagus and increased esophageal acid exposure should be regarded as contraindication to lsagb. patients with such findings should be offered an alternative procedure, such as laparoscopic sleeve gastrectomy or gastric bypass. background. laparoscopic implantation of an adjustable gastric band (agb) still represents the most frequently performed bariatric operation in austria. however, in recent years a general tendency to gastric bypass procedures can be observed. a mayor cause for this development may be long term problems such as the development of an esophageal dilatation. methods. from january until november , patients ( female, male) were treated with agb for morbid obesity at the krankenanstalt rudolfstiftung in vienna. adjustments of the band were performed under radiologic control weeks after the operation and on demand thereafter. of these patients, patients ( female, male, median age: years, range: - years), an equivalent of %, developed an esophageal dilatation during follow up. the median time from the operation to the occurrence of esophageal dilatation was months (range: - months). at the time of esophageal dilatation the median excess weight loss was % (range: - %), the median filling volume was ml (range: . - . ml). twelve patients had to be reoperated in a median of months (range: month- months) after the dilatation occurred. eleven patients had a gastric bypass operation after band explantation and one was converted into a sleeve gastrectomy. in the other patients a conservative approach has been persued so far, consisting of a deflation of the band and careful refillings after approximately month. eleven patients were already available for follow up a median of months (range: month- months) after the dilatation. ten patients significantly gained weight again. the median excess weight loss was reduced from % (range: - %) at the time of the dilatation to % (range: À - %) at follow up. only one patient managed to lose further weight without radiologic signs of esophageal dilatation after refilling of the band. conclusions. esophageal dilatation is a serious long term complication after agb which occurs approximately years after the operation and leads to a failure of this bariatric procedure in the majority of cases. further studies are needed to identify potential candidates for esophageal dilatation after agb. oversewing of gastric pull up staple line in reconstruction after esophageal resection: counterproductive or helpful procedure? considerable postoperative morbidity and mortality. recent studies have emphasized a notable improvement in morbidity rates at specialized centers. in our analysis we put special considerations on the need for an invaginatig suture of the mechanical staple line used for gastric tubulization. methods. between and , patients were treated for esophageal cancer by resection. perioperative data were collected prospectively. among those patients ( . %) underwent gastric pull-up reconstruction. the gastric tube has been constructed by gias using mm staple cartridges. these patients were included in the presented study. it was put upon the discretion of the treating surgeon, whether the staple line has been oversewn by an interrupted invaginating suture or not in a non-randomized manner. the main endpoint measure of the study is leak rate at the longitudinal staple line of the gastric tube without signs of major gastric ischemia. results. the mean age of the patients was . ae . years, . % of the patients were male. in = ( . %) patients an adenocarcinoma was diagnosed, whereas = ( . %) patients had a squamous cell carcinoma and = ( . %) were classified as others. in = ( . %) patients the gastric staple line was not oversewn (group a). in = ( . %) patients the gastric staple line has been reinforced by an invaginating interrupted suture (group b) . a leak at the staple line has to be reported in = ( . %) patients in group a, whereas no leak was seen in group b (p ¼ . ). two= patients ( . %, a: , b: ) experienced ischemic gastric tip necrosis. other surgical complications were anastomotic leakage ( = patients; . %; a: = , b: = ), temporary recurrent nerve injury ( = patients; . %; a: = , b: = ), anastomotic stenosis ( = patients; . %; a: = , b: = ) and chylus fistula ( = patients; . %; a: = , b: = ). conclusions. no significant difference was found between group a and b. however, all staple line leaks of the gastric tube developed, when the gastric tube staple line has not been oversewn. background. cardia carcinoma (ca) is characterized by different features compared with the remaining gastric ca; its incidence in western countries is increasing. the aim of the study was to investigate diagnostic, therapeutic and outcome measures of cardia ca in daily surgical practice. methods. all consecutive patients with cardia ca out of a pool of patients with histologically confirmed diagnosis of gastric ca who were treated in surgical departments were enrolled in this prospective observational multicenter study through a period of months. detailed patient, diagnostic and treatment characteristics were recorded in a computerbased format for analysis. short-term outcome was characterized by hospital stay, complication rate, morbidity and hospital mortality. results. from = - = = , . patients with gastric ca from surgical departments of each level of care were registered out of them subjects ( . %) with cardia ca. tumor localization was classified in patients according to siewert: typi, n ¼ ( . %); typii, n ¼ ( . %); typeiii, n ¼ ( . %). one hundred and seventy two patients underwent surgical intervention (operation rate, . %) of whom individuals underwent resection (rate, . %). a potentially curative resection could be offered to patients (r resection rate, . vs. . % in all gastric ca). fresh frozen section was only used in resections (rate, . %). of standard resections (distal esophagectomy with proximal or total gastrectomy), systematic d , d and d lymphadenectomy was performed in . , . and . %, respectively. histologic investigation revealed uicc stage i=ii in . % of all operated patients: iii=iv, %; not classified, . %. distant metastases occurred most frequently at the peritoneal site ( . %), liver ( . %) and non-regional lymph nodes ( . %). postoperative morbidity was . %. anastomotic leakage occured in patients ( . vs. . % in total of all gastrectomies in gastric ca) from whom subjects ( . %) underwent surgical reintervention. hospital mortality was . % (n ¼ ) compared to . % in all patients with gastric ca. conclusions. more than % of patients diagnosed with cardia ca show an advanced tumor stage at the time of surgical intervention. not all resections estimated as potentially curative were accompanied by d lymphadenectomy. in particular, to further improve hospital volume and r resection rate, to consequently use intraoperative fresh frozen section for the detection of an adequate tumor-free resection margin and to lower the rate of anastomotic insufficiency, it is suggested to treat patients with cardia ca at surgical centres for optimal outcome ( -year survival rate is being under investigation). deep brain stimulation therapy for psychiatric diseases g. m. friehs brown university, providence, usa background. obsessive-compulsive disorder (ocd) and major depressive disorder (mdd) causes tremendous suffering in those affected and in their families. neurosurgical lesioning procedures have been in existence for several decades and the overall reported success rate is widely quoted in the - % range. over the past years deep brain stimulation (dbs) has become available for a variety of conditions including ocd and mdd and has largely replaced lesoining procedure. methods. we report on our experience with patients with ocd ( ) and mdd ( ) treated with dbs of the anterior limb of the internal capsule (al-ic). patients who did not have multiple medication trials of adequate length and dose and trials of psychotherapy or behavioral therapy were excluded. also, mdd patients were required to have had a full course of electro-shock therapy (ect). patients were evaluated by a panel of independent psychiatrists before being referred for neurosurgery. all patients underwent a routine dbs surgery with implantation of bilateral electrodes into the al-ic. the stereotactic coordinates were - mm anterior to the anterior commissure (ac) and - mm lateral to anatomical midline, the electrode tip reached into the area of the nucleus accumbens. all patients had pre-and postoperative neuropsychology evaluations with testing batteries including the yale-brown-obsessive-compulsive-disorder scale (ybocs), global assessment of functioning scale (gaf) and hamilton-depression scale (ham-d) or the montgommery depression scale (mds). results. patients were followed for - months (average: . years), follow-up was complete for all patients ( %). = patients ( %) with ocd had improvements in their ybocs scores of more than % which was found to be significant (p < . ). also, these patients showed a significant (p < . ) improvement in their overall gaf. it was furthermore noted that the depression scores had a tendency towards improvement. of the five patients with mdd = patients ( %) had a significant improvement in their ham-d scores and gaf scores (p < . ). complications included one postoperative seizure, slight wound healing problems which did not require surgical intervention ( = , %). of note is the fact that the dbs batteries have to be changed very frequently (on average every - months). conclusions. dbs for ocd and mdd is a viable treatment for patients who have failed all other known therapeutic options. it is currently reserved for research centers who have a team of psychiatrists dedicated to the treatment of such patients. controlled studies will be necessary to develop guidelines for electrode placement and programming parameters. background. the number of patients demanding endoscopic neck surgery is rising. the access trauma of the axillary, breast and chest approaches is bigger than in open or video assisted surgery. we tested the feasibility of he sublingual transoral access which is in our opinion the only real minimally-invasive extracollar endoscopic access to the thyroid gland. methods. we performed an experimental investigation in a porcine model. in pigs we made endoscopic transoral thyroidectomys with a modified axilloscope with the help of ultrasonic scissors and a neuro-monitoring system for identification of the recurrent laryngeal nerve. results. the average operation time from the introduction to the removal of the obturator just above the larynx was seconds. the mean operation time was minutes. with the help of the neuro-monitoring system we proved in all cases the function of the recurrent laryngeal nerve on both sides. the pigs were observed for another two hours after operation. during and after the operation no complications appeared. conclusions. we could show that the endoscopic transoral thyroid resection in pigs is possible and save. our results might be useful for using this access for endoscopic thyroid resection in humans. background. actually, the surgical community receives some new impulses from interventionally orientated and skilled gastroenterologist by the so-called ''n.o.t.e.s.'' -natural orifice transluminal endoscopic surgery. this seems to be challenge enough to cooperate and contribute some surgically constructive ideas and critics. the surgical answer -with the intention to develop the arguments for a surgical engagement -to the presently still extra-clinical concept of ''notes'' may be given through an alternative procedure named ''flexible endoscopic minimally invasive transperitoneal'' (f.e.min.in. tra.p.) cholecystectomy. methods. after presentation of ''notes'', it's principles and aims, it's supporting societies and boards and their self-definition, a summary of already existing ''notes''-procedures and description of instrumental developments will be given. in contrast surgical considerations will be focused on more or less established surgical transluminal or even natural-orifice-transluminal techniques. in this context a special attention will be paid to surgical history and the life and times of e.mÜ he and the fact of a nearly-missed change of paradigms. as testimony for surgical endoscopic competence in interventional procedures the hybrid-model of f.e.min.in. tra.p. cholecystectomy will be opposed as surgical pendant to the conceptual idea of ''notes'' throughout a short clip-sequence. results. arguments for a surgical engagement in the development of ''notes'' are based on the following items: conclusions. only a close interdisciplinary cooperation may show weather the idea of ''notes'' will lead to clinical usefulness. it's invasivity as well as it's apparent strangeness to surgical behaviour and thinking should incline to an at least active interest. background. sacral nerve stimulation (sns) proves to be an effective therapy in patients with faecal incontinence. during the past years there were as well some promising results in the therapy of chronic obstipation. this study describes the experience with sns in patients with outlet obstruction. methods. four patients suffering of outlet-obstruction ( women), median age years (range - ) underwent test stimulation with a permanent electrode (tined lead). all patients had multiple previous conservative and operative unsuccessful therapy attempts. when complaints could be reduced by at least % with external stimulation, a permanent stimulator was implanted (two staged procedure). success of treatment was evaluated by: clinical examination, patient satisfaction (visual analogue score;vsa), cleveland-clinic-obstipation-score, and morbidity. evaluations were performed before start of treatment, before implantation and months after implantation. results. three of four patients completed the test stimulation stage successfully and received a permanent implant; median duration of stimulation stage was days (range - ). all these patients had a clear improvement according to their vas and cleveland-clinic obstipations-score. there was no postoperative morbidity. the median follow-up was months ( - ). conclusions. chronic obstipation can be treated successfully with chronic sacral nerve stimulation even after other therapeutic approaches have failed. however, this observation has to be confirmed in larger, controlled trials. background. the stapled transanal rectum resection (starr) is an accepted technique for the treatment of the obstructed defecation syndrome (ods). however, the technique with a circular stapling device (pph- ) is limited in large prolapse and the resection is performed ''blind''. a new device, the contour trans-starr (str g), has been designed with the aim of overcoming pitfalls of the current starr technique. this study describes the new technique and the initial experience in treating outlet obstruction or rectal prolapse. methods. all patients had multiple previous conservative or operative unsuccessful therapy attempts. the procedure was performed in lithotomy position and under spinal or general anaesthesia. the prolapse was sutured at the apex with the goal to obtain a uniform circumferential traction (parachute technique). then the new device was introduced into the rectum and a circumferential resection was performed step by step. success of treatment was evaluated by: clinical examination, ods-score, and morbidity. evaluations were performed before the treatment and months later. results. the study started in january and we estimate to enrol eight patients until the end of may . indications, patient's inclusion and exclusion criteria, morbidity and short term outcome will be discussed. conclusions. with the new device the starr procedure may become easier and more effective in the treatment of ods. however, safety and effectiveness has to be confirmed in larger, controlled trials. leber-gallengang therapeutic options for pyogenic liver abscesses h. cerwenka background. clinical management of pla (pyogenic liver abscess) has changed in the last decades due to constant improvements, for instance, in inventional radiology and antibiotic therapy. in surgical departments, we usually treat a selected group of patients with particularly severe forms. methods. our clinical study comprised a series of patients with pla. antibiotic treatment was modified according to sensitivity testing. additional therapy consisted of percutaneous puncture=drainage, endoscopic papillotomy=stenting and surgical interventions when indicated. results. fifty-eight patients ( %) had single and patients multiple pla. the disease was confined to the right hepatic lobe in % and to the left lobe in %; both lobes were affected in %. etiology was biliary in %, hematogenous in %, posttraumatic in % and cryptogenic or attributable to rare reasons in the remaining patients. microbiological culture was sterile in %, which was at least partly due to antibiotic pre-treatment. staphylococci, streptococci and e. coli were most often identified. anaerobes were found in %. factors associated with the need for surgery included: empyema of the gallbladder, underlying malignancy, perforation, multicentricity, vascular complications (hepatic artery thrombosis) and foreign bodies (e.g., toothpick, infected ventriculo-peritoneal shunt). in patients with biliary fistulae it was crucial to ensure prompt bile flow (for instance, by papillotomy=stenting). conclusions. assessment of underlying diseases is decisive for timely identification of patients requiring more invasive treatment. microbiological testing provides clinically important information for treatment monitoring and modification. special attention must be paid to diagnosis and treatment of concomitant biliary fistulae. therapy methods of hydatid disease from the tradition to the future m. sanal , h. guvenc , j. hager in europe. however there are some regions: upper bavaria, suedwuerttemberg (swabian alb), bathing (black forest), furthermore tirol, kaernten and steiermark, switzerland and north italy involved with this parasite. also people from turkey and the balkans bring the illnesses again and again. this lead to the necessity for physicians to be aware of its clinical features, diagnosis and management. methods. thirty patients with cyst echinococcus (ce) in liver, lung, kidney and spleen were in three different pediatric surgery departments innsbruck, bursa and kocaeli surgically treated. in the patients were cystotomy capitonage, simple cystotomy, unroofing, splenectomy, cyst excision performed. seven patients underwent minimal invasive surgery. results. postoperative bronchopleural fistula resolved spontaneously under negative pressure in five cases. the long-term postoperative results are considered good, with no recurrences observed. conclusions. surgery has remained the mainstay for the treatment of ce. the basic steps of the surgical procedures are eradication of the parasite by mechanical removal, sterilization of the cyst cavity by injection of a scolicidal agent, and protection of the surrounding tissues. pair technique in ce; performed using either ultrasound or ct guidance, involves aspiration of the contents via a special cannula, followed by injection of a scolicidal agent for at least minutes, and then reaspiration of the cystic contents. in the last years video assisted intervention has also been performed successfully. background. group milleri streptococci (gms), a heterogeneous group of streptococci, are associated with purulent infections. methods. retrospective analysis of all consecutive biliary infections due to gms in a four-years period. results. out of gms positive patients the innsbruck medical university within the study period, the biliary tract was affected in ( . %). the mean patient age was . ae . years, with a female:male ratio of : . . polymicrobial infections were present in . %. thirty percent of all patients were immuno-compromised after liver transplantation ( = ). seventy-nine patients ( . %) had clinical signs of infection, which was confined to the gallbladder in ( . %) (group i), while patients ( . %) presented with cholangitis (group ii). underlying diseases in the cholangitis group were biliary complications following liver transplantation in , other causes for mechanic cholestasis in , malignant intrahepatic disease in , ascending infections in and a ductus choledochus cyst in one patient. twenty patients ( . %) had gms positive bile cultures without clinical signs of infection (group iii) obtained during evaluation of cholestasis ( ), status post liver transplantation ( ), bilioma post liver resection ( ), and psc ( ). antibiotics were administered to patients ( . %) in group i, all patients ( . %) in group ii, and one patient ( . %) in group iii. in group i, all patients also underwent cholecystectomy. interventions were required in patients ( . %) in group ii (ercp ( ), external drainage ( ), surgery ( )), and patients ( . %) in group iii (ercp ( ), external drainage ( ), surgery ( )). gms isolates were susceptible to all penicillins, clindamycin and most cyclosporins, but were resistant to aminoglycosides and showed intermediate susceptability to ciprofloxacin. conclusions. the biliary tract was affected in one out of five patients with group milleri streptococci (gms). gms cause infection in % of all cases, and are often associated with mechanical cholestasis. background. peritonitis ossificans is a rare disorder with only few reported cases in literature. metaplastic bone formation in abdominal scars seems to be an own entity with only several descriptions mostly associated with trauma, gun shot wounds and repeated abdominal surgery. we report about a case with development of metaplastic bone formation and peritonitis ossificans after multiple acute surgical interventions. methods. chronological review of our patients medical history, pathohistological features and comparison of published data of ''peritonitis ossificans'' and ''metaplastic bone formation'' via pub med. results. our patient developed multiple nodular lesions with massive calcifications between the small bowel mesentery (heterotopic mesenteric ossification) after primary adhesive ileus and revision surgery because of colonic leakage. the situation developed within days from a prior abdominal situs without calcification. small bowel fistula occurred and we used abdominal vac therapy. ten weeks later partial secondary closure was performed and no sign of calcification could be observed. histological features showed fatty necrosis and scary tissue with metaplastic cartileage and bone tissue. literature is rare, pathophysiology, therapy and prognosis remains unclear. conclusions. male gender, multiple abdominal surgery or trauma with peritonitis, peritoneal dialysis and pancreatitis seem to be predisposing factors. extensive activation of myofibroblasts appears to be the major cause for hyperproliferation. the prognostic impact depends on secondary complications including postoperative fistula and leakage and intestinal obstructions. actually, literature shows no causative therapy. background. the differential diagnosis of dysphagia predominantly includes gerd, neoplasm, diverticula or achalasia. infrequent causes are diffuse esophageal spasm, scleroderma and other systemic diseases. eosinophilic esophagitis as a cause for dysphagia is found increasingly in recent literature and as a headline topic at congresses. methods. case report of a a old adipose male patient with multiple allergies who was suffering from dysphagia and bolus events for about years. they have been independent from pain, stress, temperature or consistency of food. gastroscopic examination showed a narrow esophagus with fragile, slightly corrugated mucosa. barium radiography and mri did not show any pathology. the patient underwent an esophageal manometry which showed a normal les with normal relaxation, but pressure peaks of mmhg on swallowing and % simultaneous waves. iced water or metoclopramide had no effect. ppi and nitro showed no improvement. sample biopsies of the whole upper gi during a second endoscopy revealed massive eosinophilic infiltration of the whole esophagus. results. the diagnosis eosinophilic esophagitis was herewith confirmed. the patient was treated with orally administered topic steroids (pulmicort spray bid orally for three months). his symptoms improved markedly. conclusions. eosinophilic esophagitis is an uncommon disorder. only publications with all over patients are published. male to female ratio is to . in % of the patients, food allergies can be found. peripheral eosinophilia can be detected in % and high ige in %. most of the patients are in the range of normal weight. the main symptoms are dysphagia in %, food impaction in % and heartburn in % of patients. endoscopically mucosal fragility can be detected in almost all patients, furthermore edema %, rings %, strictures %, corrugated esophagus, papules % and small caliber esophagus in %. eosinophilic infiltration ( =hpf) in the upper and lower esophagus without presence of eosinophils in the stomach or duodenum are detected histologically. the recommended therapy is oral administration of fluticasonpropionate or bethametason spray for two months. the initial response is about %, but relapse is common. systemic steroids are also effective. dilatation should not be performed because of a significantly elevated perforation risk and a high relapse rate. sample biopsies of the upper gi should be taken in every patient with unclear dysphagia since eosinophilic infiltration exclusively in the whole esophagus is pathognomonic for eosinophilic esophagitis and consequently dilatation should not be performed. p cholangiocellular carcinoma of the bile duct after resection of a congenital choledochal cysta rare manifestation background. the risk of malignant degeneration of a bile duct cyst is reduced by an early resection, but the risk of malignant change persists, as we show in our case. only few cases are published in the literature. as the prognose of a malignant degenerated choledochal cyst is very poor, the only useful possibility to minimize the risk of carcinoma is the early cystectomy. based on our case we like to discuss the indication for surgery, incidence of malignant change, risk factors, discovery and diagnosis, detection and prevention, the surgical procedures for the treatment of chledochal cysts and especially whether the typ of surgery have an impact on malignant transformation? methods. we report about a female patient who was examinated by ercp because of recurrent cholangitis. in her medical history we found out that on our patient a cholecystectomy has been carried out at the age of years and in addition to that procedure a congenital choledochal cyst typ i was resected, nevertheless the patient developed a massive cholangiocellular carcinoma which leaded to death at the age of years. after examination using multiphase ct we diagnosed a carcinoma to a great extent, which was inoperable. with the intention to obtain an operable condition, our patient was treated with neoadjuvant chemotherapy which remained unsuccessful. results. there are series of theories in the literature which try to explain the genesis of choledochal cysts, the real reason of their development is not clear, many possibilities for their emergence are discussed: i.e. weakness of the bile duct, distal obstruction, pancreatico-choledochal reflux caused by a long common channel, a wrong estuary of the pancreatic duct in the choledochus or also a pathologic distribution of ganglion cells on the wall of the choledochus. reviewing the worldliterature, the risk of degeneration of choledochal cysts is described differently, but the early resection is always recommended. conclusions. choledochal cysts are associated with an increase in the incidence of bile duct carcinoma. as it is shown, excision of a choledochal cyst is not protection by itself against the development of cancer in the future. after resection patients should have long term follow up. any patient, especially any adult, with recurrent symptoms following cyst related surgery must be evaluated for malignancies in the biliary tract. a surgical treatment after diagnosis of a choledochal cyst is necessary to avoid bile duct carcinoma. background. sporadic lymphangioleiomyomatosis (lam) is a nonmalignant proliferation of immature smooth muscle cells, usually in the lung but occasionally in the retroperitoneal lymph nodes as well. there is perilymphatic, perivascular and, with pulmonary manisfestation, peribrochiolar proliferation and invasion. it is an extremely rare disease (prevalence : ) that exclusively afflicts women of childbearing age. the most common presenting symptoms are dyspnea, cough, recurring pneumothorax or chylous ascites. the definitive diagnosis is obtained by biopsy. lam has a typical histological picture featuring diffuse, sometimes nodular proliferations of immature smooth muscle that stain specifically with the marker hmb- . unlike tuberous sclerosis (ts), sporadic lam is triggered by a mosaic mutation of the tsc- gene in the involved tissue. ts in contrast is caused by a somatic mutation of the tsc- gene. this somatic mutation leads above all to neurological symptoms (a trias of epilepsy, cognitive impairment, dermatological manifestations) but, in some cases, to a pulmonary manifestation of lam. at present, there is no curative treatment for lam, though a trial with gestagens is an option. terminal pulmonary failure is an indication for lung transplant. case report. in the course of a routine sonographic examination, a -year-old woman was found to have an expansive cystic process in the retroperitoneum. abdominal ct showed a pre-aortal lesion measuring .   cm with a partially cystic, partially soft-tissue structure suggestive of a cystic lymphoma or a cystic lymphangioma. the cyst was drained and partially resected laparoscopically. the histological diagnosis was lymphangioleiomyomatosis without indication of malignancy. preoperative chest x-ray and spirometry were within normal limits, but high-resolution thorax ct showed the cystic alterations typical for pulmonary lam. at present, the patient is free of complaints but due to the typical chronic course of the disease, close follow-up is indicated. conclusions. although it is a very rare disease, the diagnosis of a cystic retroperitoneal expansive process should suggest lam as a differential diagnosis. a definitive diagnosis can only be obtained with histology. because pulmonary involvement tends to be the rule, a thorax ct is indicated with primary abdominal manifestation. if there are neurological or dermatological manifestations, tuberous sclerosis should also be considered in the differential diagnosis. fetal mri: what is its worth outside the central-nervous system in extra-central-nervous system regions as it is mandatory in pediatric surgery. since fetal mri is performed at our institution, whenever a congenital malformation is suspected in the prenatal ultrasound. methods. fetal mri studies are performed on . t (philips) superconducting unit using a five-element surface phased-array coil, after th gestational week to avoid the possibility of magnetic fields interfering with organogenesis. no sedation is necessary. in addition to routine t -weighted (w) sequences, t -weighted sequences (mainly to demonstrate meconium-containing bowel loops), t -sequences (in case of hemorrhagic lesions), steady state fast precession (ssfp) sequences (to depict vessel-abnormalities), dynamic ssfp sequences to show swallowing and peristalsis, flair and diffusion-weighted sequences (for further tissue characterization) were performed. results. fetal mri is applied the following pediatric surgery cases: suspected lung anomalies ( cases), abdominal anomalies ( ), anal atresias ( ), esophageal atresias ( suspected), congenital diaphragmatic hernias (cdh) ( ), head-and-neck diseases ( ) and for urologic cases ( ). conclusions. detailed morphological description of congenital malformations is possible with fetal mri which may have a bearing on prognosis. it has become mandatory for antenatal counseling. in some findings such as esophageal atresia, gastroschisis or cdh an antenatal transport can be arranged to a perinatal center. background. in inflammation, activation of coagulation and inhibition of fibrinolysis lead to microvascular thrombosis. thus, clot stability might be a critical issue in the development of multiple organ dysfunction syndrome. activated fxiii (fxiiia) forms stable fibrin clots by covalently cross-linking fibrin monomers. in recent studies, multiple polymorphisms have been described in the fxiii-a subunit gene. the val leu polymorphism affects the function of fxiii by increasing the rate of fxiii activation by thrombin, which results in an increased and faster rate of fibrin stabilization. in the present study, we analysed the influence of the common fxiii val leu polymorphism on inflammatory and coagulation parameters in human experimental endotoxemia. methods. healthy volunteers received ng=kg endotoxin (lps, n ¼ ) as a bolus infusion over min. blood samples were collected by venipunctures into edta anticoagulated vacutainer tubes before lps infusion. for determination of the fibrinogen promoter polymorphism, we developed a new mutagenic separated polymerase chain reaction assay. results. fxiii levels were higher for homozygous carriers of the fxiii v l polymorphism in comparison to wild-typ and heterozygous. homozygous carriers had lower levels of tnf and il- in comparison to wild-type. interestingly, subjects homocygous for the fxiii v l polymorphism had lower monocyte and neutrophil levels throughout the timecourse. the fxiii v l genotype was not associated with clinically relevant differences in plasma d-dimer or f þ levels after lps challenge, which is consistent with the lack of effect on early thrombin generation. conclusions. our findings indicate, that the common fxiii v l polymorphism is associated with differences in the selected inflammation parameters and in monocyte and neutrophil cell counts in response to systemic lps infusion in humans. those findings may have an impact on clinical treatment for patients with inflammatory diseases. p stamm-kader gastrostomy or peg w. h. weissenhofer time-honoured or forgotten? the stamm-kader gastrostomy, introducing a nelaton catheter via a stab incision through the upper abdominal wall, guided by direct vision after laparotomy or using a minilaparotomy or even by laparoscopy can be considered an easy alternative to the widely used peg or similar endoscopic procedures. the ''old'' and simple stamm-kader procedure offers not only direct vision, possibilities of local anaesthesia and a minimum of instruments and therefore costeffectiveness, but is also a welcomed addition to the surgical armamentarium -once learned. the actual procedure includes an abdominal accesswhether minimal or already present in case of operations for bowel obstruction, further a double pursestrig suture between large and small curvature of the stomach, stab incision and introduction of a large lumen balloon catheter, the double pursestring sutures are tied in such a way that a short channel in the stomach wall is formed and then covering sutures between abdominal wall and stomach are tied. the catheter can be used immediately for decompression and early feeding. obviously this is a surgical method and has therefore a much smaller following and tends to be forgotten as there are no ''progressive'' endoscopic devices to be advertised and there is minimal economic interest to be generated for medical companies. nonetheless it is in my opinion and experience an useful route in more ways than the peg or button gastrostomies can ever offer. the blood levels of c-reactive protein (crp), interleukin (il) , , and icam- were measured using the elisa technique in all patient before, immediately after operation, at the first and third day after surgery. the pre-operations levels of crp and all mediators had no differences in both group of patients. significant increase of il- , il- and icam- level was noted in the first group vs. insignificant changes of mediators' levels in patients of the laparoscopic group immediately after operation. the gradually increase of all mediators' plasma levels were noted in first group up to the third day after operation. crp was peaked at the third day in both group, but the increase after open adrenalectomy was more pronounced (p < . ). levels of il- and icam- had strong correlation with the hematological changes that observed in the postoperative period. the cytokines play a pivotal role in the orchestration of the immune response. the increased levels of il- and il- pointed on enhance of th response. activation of th cytokines may provoke the immunosuppression and the catabolic stage and may have adverse consequences for patient recovery. thus, there is a clear correlation between the changes in cytokine levels and the degree of surgical trauma. methods. combined retroperitoneal pancreas-kidney transplantation was performed in a -year-old patient with type-idiabetes and diabetic nephropathy. the patient had a bmi of and had undergone renal transplantation in the right iliac fossa years ago. after mobilization of the colon and mesocolon ascendens, the graft was anastomosed end-to-side to the aorta and to the inferior caval vein. the graft was in a retroperitoneal position. for exocrine drainage a side-to-side duodenojejunostomy was performed after bringing a jejunal loop through a window in the colon mesentery. results. the anastomoses could be performed with ease. duration of the pancreas implantation was minutes, minutes for implantation of the kidney in the left iliac fossa. ischemic time was hours. a revision was necessary due to obstruction of the graft ureter. from day after transplantation the patient required no more insulin, and lipase and amylase levels were within the normal range. conclusions. the first experience with retroperitoneal pancreas transplantation with systemic-enteric drainage showed, that the technique was safe, and had technical advantages as compared with the classic method. it should be especially applied in high risk patients (obesity, severe atherosclerosis). background. recell + is a new medical product for yielding a cell suspension of the skin. in this process cells are removed from the basal layer of a thin split skin graft. the removal of the skin graft, the preparation of the cell suspension and the covering of the defect can be done in one treatment session in the operating theatre. recell + could be used for the coverage of superficial defects in burns, scars, skin resurfacing and vitiligo. the advantages of this new technique are a shorter healing period, better scar quality and the ability of repigmentation. methods. for yielding cell suspension, which is quickly available, a thin split skin graft (thickness . - . mm) is taken. depending on the defect, the size of the split skin biopsie is from  cm for coverage of cm to  cm for coverage of cm treatment area. after separation of the different layers of the skin, the special cell suspension could be prepared. then the cell suspension is immediately sprayed or trickled on the prepared wound area. a special laboratory is not required. the first change of the wound dressing is done week postoperatively. conclusions. the result of this new treatment option is a skin of good quality, colour and function -comparable with the original skin. the first experiences show recell + as an interesting amendment to the previous therapeutical options. however, other studies should be done to fathom the spectrum of the indications and to confirm the first results. p early experience with ductoscopy guided minimal invasive surgery for intraductal breast lesions c. tausch, p. schrenk, e. grafinger-witt, t. gitter, s. wölfl, s. bogner, w. wayand background. intraductal breast lesions which have been diagnosed by radiological ductography are sent to breast surgery. by a cirumareolar incision a poorly defined extent of tissue will be removed. it can be supported by presentation of the main duct by injection of blue dye. taking into consideration that papillomas are benign in - %, it is worthful to minimize the extent of the intervention. this fact and the aim to visualize the origin of most types of breast cancer -the terminal ductolobular unit (tdlu) -induced the development of endoscopes for the milk ducts. methods. after canulating the ductus lactiferous it will be distended by a special dilatator. the endoscope (laduskop + , polydiagnost comp.) is inserted through this dilatator and the inspection of the ductal system is possible til over the fourth bifurcation. endosopes are available with device for flushing and working ducts for biopsies. results. this a first report about the experience with ductoscopy in patients presented with unilateral secretory disease. after successful localisation of an intraductal leason a tissue sparing excision of the affected duct follows guided by the in situ lying ductoscope. conclusions. endoscopy of the mammary duct system is a precious diagnostic tool for onesided secretory disease und is able to minimize the extent of the removed tissue. the role of the method in the perioperative visualisation of intraductal diessemination of breast malignancies needs further evaluation. p ruptured aneurysma of arteria lienalis with massive bleeding because of fibromuscular dysplasia background. fibromuscular dysplasia (fmd), a non-ather-osclerotic=non-inflammatory vascular disease, is a rare cause of visceral artery aneurysmas (vaa). in about % of all cases, vaa presents first with rupture and leads to a overall-mortality of . %. about % of fmd are familial, most likely in female and often as multifocal lesions. patient's history. a years old female patient was admitted to our department with nausea and epigastric pain. former history showed an aneurysma of the iliacal artery treated by iliacofemoral bypass (pathohistological examination of the aneurysma showed fmd), and several episodes of spontaneous subcutaneous haematomas. abdominal ultrasound, x-ray and gastroscopy showed no abnormalities. moderate anaemia without any sign of gastrointestinal bleeding made us perform a ct-scan which showed an intraabdominal and peripancreatic haematoma without any sign of a recurrent aneurysma. under icu-monitoring the patient showed another episode of acute epigastric pain and developed signs of haemorrhagic shock. we performed an acute median laparotomy and found no cause of intraabdominal bleeding. exploration of the peripancreatic haematoma showed the cause of bleeding as a ruptured aneurysma of the central splenic artery. resection of the aneurysma and splenectomy had to be performed. the patient was discharged from the hospital on the th postoperative day. conclusions. ruptured vaa caused by fmd as rare reasons for acute abdominal pain need most aggressive treatment to avoid postoperative mortality. background. today, iatrogenic injuries are the most common cause of hemobilia. the hepatobiliary system is at risk for damage as side effect from procedures such as percutaneous bile drains and liver biopsies. complications of open and laparoscopic surgical procedures can also be responsible for hemobilia. methods. we report of a rare case of iatrogenic hemobilia occurring after laparoscopic cholecystectomy. results. a -year-old patient was readmitted to our department, days after laparoscopic cholecystectomy, complaining about upper abdominal pain and presenting with signs of jaundice (bi ¼ . mg=dl but ap ¼ u=l) and anaemia (hb ¼ . g=dl). the patient, who was a jehovah's witness, refused blood transfusions. on readmission ercp demonstrated fresh active bleeding from the papilla of vater. cholangiography demonstrated obstruction of the common bile duct by intraluminal blood clots. blood clots were retrieved by means of an endoscopic ballon-catheter. ct scan and angiography showed a . cm contrast retaining pseudoaneurysm in the hilus of the liver oroginating from the stump of the cystic duct. interventional radiological selective stenting of the hepatic artery could not be performed for technical reasons. the patient was re-operated, the site of bleeding was identified as the cystic artery stump and surgically controlled with sutures. the patient's further postoperative course was uneventful with quick recovery and without the need for blood transfusion. conclusions. hemobilia is a rare complication after cholecystectomy, which may stem from a pseudoaneurysm of damaged vessels, e.g., the stump of the cystic artery. when management by interventional radiology fails, surgical intervention is mandatory. background. we describe on of the rare cases with a perforated barrett-ulcer resulting in an esophagopleural fistula. the importance of recognizing esophageal disorders and catastrophes in the management of acute abdominal emergencies is emphasized. methods. chronological review of our patients medical history, pathohistological features and comparison of published data of ''esophageal perforation'' via pub med. results. a young, male, alcohol-addict patient presented to the emergency department after a fall over staircase with serial rips-fracture and only little discomfort. chest x-ray and blood sample were inconspicuous. on the following day patients general condition got worse, a pneumothorax occurred. so it was necessary to install a bulau drainage which encouraged food out of the left pleuracave -therefore an ''esophageal perforation'' was supposed. the patient was transferred, now with a mediastinial sepsis and multi organ-failure, to our medical surgery unit, where primarily a esophageal stent and a thoracotomy with cleansing and drainage of the mediastinum and the pleural cavity was set. but within a week the stent became insufficient and an esophagectomy and a gastrostomy were necessary. after weeks therapy on the intensive care unit, the patient underwent again a thoracotomy with decortication of a pleura callositiy because of the persistence of a fluidopneumothorax. the patient is now disposed to a colon interposition. conclusions. possible risk factors for perforation in general and in this patient included alcoholism, severe gastroesophageal reflux, noncompliance with antacid and ppi blocker therapy and the presence of acid-secreting parietal cells in the barrett's epithelium. misdiagnosis is the most important contributing factor in the continuing high morbidity and mortality of esophageal-perforation as shown by all reported cases. background. the use of ergotamine, e.g., suppositories for migraine headaches, may have systemic as well as local side effects. systemic poisoning is known as ergotism, historically mostly due to the ingestion of rye infected with claviceps purpura fungi. local complications, like rectal ulcers and rectovaginal fistula may require surgical management. methods. we report about the case of a year old female patient with deep anal necrosis, insufficiency of the anal sphincter, anovaginal cloaca and rectal prolapse, as long-term sequelae of ergotamin suppository application. results. the patient was hospitalized for treatment of the rectal syndrome mentioned above. the anoderm appeared completely destroyed, with extensive scarring and manifestation of an anaovaginal cloaca. anal manometry showed almost no anal pressure. anal sonography demonstrated an anterior semicircular defect of the internal as well as the external anal muscles. the patient had already been seen in our hospital two years previously, when a perineal necrosis had raised suspicion of a locally advanced anal cancer. that time, she had refused to undergo further diagnostic work-up (including re-biopsy, etc.) and treatment, after endosonography had suggested an infiltrative process affecting the anal sphincter and the histopathologic diagnosis spoke of a ''tumor necrosis . . . but without viable tumor cells''. now, after exclusion of a neoplastic process, the patient underwent a complex surgical procedure for management of her incontinence syndrome: a laparoscopic resection of the rectum and rectopexy was performed. furthermore sphincter and perineum were reconstructed using an anterior levator plasty and ventral sphincter-overlapping repair. a temporary protective loop ileostomy was created in addition. conclusions. this case describes the -to our knowledgemost extensive local complication due to ergotamine suppositories, in the world literature. it suggests that ergotamine suppositories should be used with precaution, and a close followup by the prescribing practitioner is mandatory. furthermore, patients with unclear inflammatory destructive alterations of the perineum and unexplained rectal syndrome should be asked for ergotamine suppository (ab)use. p intrapancreatic accessory spleen: a differential diagnosis of pancreatic tumour background. according to autoptic studies, accessory spleens may be found in to % of the population and most of them are usually located at or near the splenic hilum. only in to % they are located in the pancreatic tail. we report a rare case of intrapancreatic accessory spleen which radiologically mimicked a tumor in the tail of the pancreas. methods. a -year-old man was diagnosed with a tumor at the pancreatic tail. in the preoperative computed tomography (ct), there was a lesion ( . cm in diameter) in the pancreatic tail and two locoregional lesions ( . and . cm in diameter), which had intensive contrast enhancement. it was diagnosed as a nonfunctioning endocrine pancreatic tail carcinoma with lymph node metastasis. results. intraoperative examination showed two accessory spleens nearby the pancreatic tail. as pancreatic cancer could not be excluded because of the local findings, an oncological left pancreatectomy was performed. histological examination excluded cancer and revealed an intrapancreatic accessory spleen and two accessory spleens nearby the pancreatic tail. conclusions. intrapancreatic accessory spleen should be included in the differential diagnosis of pancreatic neoplasm. a useful diagnostic tool is scintigraphy with technetium- marked, heat shock denaturated autologous erythrocytes. background. sacral nerve stimulation (sns) is a widely accepted therapeutic options for patients suffering from faecal incontinence based on a neurogenic dysfunction. more recently case reports have been published showing a positive effect of this treatment in patients suffering from faecal incontinence after low anterior rectal resection. the purpose of this study was to perform a nationwide survey for this selected indication for sns in order to gain more information by recruiting a larger number of patients. methods. in the period to three austrian departments reported data of patients who underwent sns for faecal incontinence following rectal resection. data were available of patients ( females, males) with a median age of years (min -max ). six patients had undergone rectal resection as a treatment for low rectal cancer. one patient had undergone rectal resection for crohn's disease, one patient subtotal colectomy and ileorectostomy for slow colon transit constipation. results. in all patients test stimulation was performed in the foramen s unilaterally over a median period of days ( - d) . seven patients reported a marked reduction of incontinence in the observation period. five patients reported a marked improvement compared to the baseline of their continence situation. three patients had no further incontinence episodes following the permanent implant. two patients reported ''rare events'' ( - incontinence episodes= month). one patient who had previously reported an improvement of his continence function during his test stimulation complained about repeated urgency problems as well as incontinence episodes. conclusions. despite our observations and the promising results of others the role of sns in the treatment of faecal incontinence following rectal resection needs further research as well as more clinical data by a larger number of patients. p lymphatic vessel invasion in upper gi cancer: an indication for an additive or adjuvant therapy? and ac had significant lower lvi-rates compared to nonresponders. these data warrant prospective data and might result in the future into an additive or adjuvant multimodal therapy. [up to now = recurrencies ( . %) were seen.] all patient data were collected prospectively. in the present study we compared all patients with an operations time of minutes or more with those with operation times < minutes and compared patient related factors (asa, bmi, type of hernia, recurrent hernia, scrotal hernia, incarcerated hernia and situs-related problems) and operation related factors (surgeon's experience, intraoperative problems, anaesthesiologic problems). results. mean operation time was . ae . minutes. operation time did not increase with asa and bmi (pearson coefficient . resp . ). direct hernia were faster operated than indirect, combined or recurrent hernias in total (average time . ae . ; . ae . ; . ae . ; . ae . ). the proportion of recurrent ( . %) and scrotal hernia ( . %) in operations longer than minutes was significantly higher (n.s. resp. p < . ), in incarcerated hernia ( . %)and hernias with long anamnesis and difficult scarred situs ( . %) or combined with additional operations ( . %) as well. in operation related factors individual designed ring-armed patches demanded - minutes more operation time and thus clearly prolonged the operation (p < . ), unexpected intraoperative problems (e.g. in positioning the patch) or complication (bladder injury) as well. in rare cases anaesthesiological problems (insufficient spa) caused delay as well. most important seems to be surgeon's experience. with increasing experience the average operation time and the proportion of long lasting operations decrease. conclusions. while patient's asa and bmi do not influence the tipp operation significantly, hernia type, recurrency, incarceration and scrotal hernia resp scared situs influence the operation clearly. in operation related factors surgeon's experience seems to be most important, intraoperative problems or complications result in an unexpected delay as well. in preoperative planning knowledge of recurrency (previous operation method), scrotal hernia or incarceration or scar-inducing anamnestic factors give hints to a prolonged hernioplasty. p biomechanical analysis of the ventral abdominal wall for incisional hernias c. hollinsky, c. yiwei, j. ott, s. sandberg, m. hermann background. for the therapy of ventral abdominal wall hernias, different reinforcement techniques with mesh are available. nevertheless the outcome of treatment for ventral abdominal wall hernias is currently unsatisfactory. biomechanical load flow calculations are introduced in this study. methods. we took peritoneum and abdominal wall muscles of recently deceased cadavers to determine the friction coefficient for mesh protheses. therefore we placed the mesh between peritoneum and muscles and loaded them with tension. furthermore we analyzed the different fixation elements for their load resisting capacity. results. the prostheses demonstrated a frictional coefficient of m ¼ . . the elasticity module e of polypropylene is ¼ n=cm . for laparoscopic techniques, leight meshes showed an unproportional high bending and sheared off at low loads. for the reinforcement elements, large differences between different tensile load capacities were detected. conclusions. the overlap of the protheses over the hernia orifice should be selected proportionally to the hernia size. light meshes are unfit for the laparoscopic techniques and should not be used for the therapy of ventral wall hernias. p the axillary access in unilateral thyroid resection k. witzel ; universitätsklinik für chirurgie, salzburg, austria; the new european surgical academy (nesa), berlin, germany background. with this study, we intended to find out if it is possible to avoid the typical scar after thyroid resection by using a mm axillary access and a . mm incision in the jugulum. methods. we present the results of our proof-of-concept study with patients. for this technique, a modified axilloscope and ultrasonic scissors were used, which permit a total resection of the unilateral thyroid. results. the feasibility of this endoscopic technique was shown by the successful operation of these patients with uni-lateral pathological findings. furthermore, we showed that this technique allows to resect tissue up to a whole lobe while at the same time finding and identifying the recurrent laryngeal nerve and subsequently verifying the findings by using the neuromonitoring system. conclusions. this study shows that endoscopic thyroid surgery approximates the norms of endocrine neck surgery. the presented method is useful in thyroid surgery for patients with single nodules and a small thyroid gland. background. ventral incisional hernias have a high incidence after laparotomy closure. laparoscopic hernia repair is a minimal invasive technique with less operative trauma. the aim was to assess the reccurence rate and morbidity after the laparoscopic repair. methods. data of all patients with laparoscopic incisional hernia repair operated in our department between december and november were recorded in a prospective data base. forty two patients (m:f ¼ : ) with a mean age of years ( - ) and a mean bmi of kg=m ( - ) were operated. results. conversion rate was % due to intraoperative lesions to small bowel during adhesiolysis. mean operation time was min ( - ). in patients the dual-mesh, in patients the bard composite ex mesh and in patients the parietex mesh was implanted. mean hospital stay was days ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . the morbidity-rate was . % ( hematomas) . four patients complained about prolonged pain. in the long term follow up patient had to be reoperated due to mesh related complications. mean follow up time was months, patients presented with a recidive hernia. conclusions. laparoscopic ventral hernia repair can be performed with acceptable recurrence rate ( . %) and low morbidity ( . %) independent of the used mesh. p outcome of clip removal after endoscopic sympathetic block anecdotal reports are available on clinical outcomes after cr. the aim of the study was to investigate whether cr actually resulted in reversal of compensatory sweating (cs), and whether the initially obtained therapeutic effect on hyperhidrosis of the upper limbs (hh) and the face (fh) and facial blushing (fb) diminished with time. methods. between = and = a total of patients ( females, males) with a mean age of ae years underwent cr after esb. three patients underwent unilateral clip removal due to mild ptosis (one patient with esb , patients with esb ). twenty patients had their clips removed due to unbearable cs. levels of hh, fh, fb and cs were graded by a visual analogue scale ranging from (no sweating= blushing) to (most severe sweating=blushing). mean followup after cr was ae months obtainable from patients ( %). results. the patients who suffered from ptosis started to improve weeks after cr, complete relief was observed months thereafter. in each group with esb and esb , . % of patients underwent cr. only one patient after esb had to be reoperated ( . %, p < . compared to esb and esb ). four patients ( %) reported no change in cs after cr, in patients ( %) cs dissolved completely. overall, cs improved from . ae . to . ae . (p < . ). hh, fh and fb recurred to about % of the initial levels, patients ( %) reached preoperative levels. conclusions. clip removal because of unwanted side effects is more common in patients after esb and esb than after esb . cr results in partial reversibility of cs and causes partial recurrence of the initial complaints. although some patients do not benefit from cr, our study provides valid data that esb is a reversible technique. p acute reinterventions following laparoscopic transabdominal preperitoneal inguinal hernia repairs (tapp) b. walzel, p. patri, p. razek, a. tuchmann background. today the tapp method is a frequently used surgical procedure for treating inguinal hernia. although this type of operation has some advantages compared to open procedures, some complications typical for laparascopy might arise. we report about managing such complications as based on our experience. methods. between january and december tapp was applied in our hospital to (n ¼ ) patients. from among those patients (n ¼ ), ( m, aged - ) laparoscopy had to be repeated because of acute complications which occurred between the st and th postoperative day. three patients presented post op a bilateral tapp. reasons for interventions were: obstruction of the small intestine due to incarceration with a dehiscent peritoneal suture (n ¼ ), hematoma in the area of surgery applied (n ¼ ) and one hemorrhage caused by a trocar (n ¼ ). in three patients (n ¼ ) with a mechanical obstruction of the small intestine, repositioning by laparoscopy of the incarcerated ileus was carried out, followed by a peritoneal suture. in two cases with intraabdominal hemorrhage, the bleeding was stopped and the prolene nets were removed via laparoscopy. in only one of the cases replacement of the net was possible, in the other one the procedure was changed to open surgery for inguinal hernia because of an infected net. in one patient (n ¼ ) hemorrhage due to injury by trocar repair was possible by a simple suture. results. in out of cases the complication was successfully repaired by way of laparoscopy. in one case the shouldice repair was applied. in the other a paralysis of the ileus occurred post laparoscopy, requring a smoothing of the ileus by laparotomy. conclusions. among our patients severe complications following tapp needing surgical intervention occurred but rarely ( . %). frequently treatment by way of laparoscopy was successful. p clip displacement does not effect postoperative outcome after endoscopic sympathetic block p. t. panhofer , c. neumayer , s. nemec , r. jakesz , g. bischof , j. zacherl background. endoscopic thoracic sympathectomy is the treatment of choice for patients with severe primary hyperhidrosis (hh). recently, clip application (endoscopic sympathetic block, esb) has been introduced providing potential reversibility. the clips are visible on x-rays allowing postoperative evaluation. at our institution ganglion oriented procedures are performed taking rib levels into account. the aim of the study was to investigate if failures, recurrences and unwanted sideeffects (compensatory sweating, cs) can be explained by clip displacement. methods. between and , patients (mean age . ae . years) prospectively underwent esb procedures. esb was performed in patients ( . %) with facial blushing (fb), esb in patients ( . %) with facial sweating (fs) and esb in patients ( . %) with hh of the upper extremities following the lin-telaranta scheme. a mm titan clip was placed above and below the corresponding ganglion. two quality of life scores have been evaluated. mean follow up was . ae . months obtainable from patients ( . %). results. ninety-eight patients ( . %) had palmar, ( . %) axillary hh, ( . %) fs and patients ( . %) fb. cs was observed in ( . %) patients. a total of clips ( . %) were displaced in patients ( . %). two patients with fs ( . %) and with hh of the upper extremities ( . %) showed up with side differences regarding placement. in each group, one single patient was found with clips one level below the expected destination ( patients, . %). four patients ( . %) were completely and patients ( . %) partly satisfied after esb despite displaced clips. two patients have been lost to follow-up. moderate cs was observed in one patient ( . %) in each of the fb and fs groups. the patient from the latter group suffered from a mild transient ptosis additionally. two recurrences ( . %) were documented. methods. blood samples were collected from patients before major surgery. whole blood was incubated with escherichia coli lipopolysaccharide (lps) and il- production in supernatants was assessed by enzyme-linked immunosorbent assay. the prognostic impact of ability to synthesize il- before surgery was investigated in patient subgroups with respect to sepsis-related mortality using multivariate binary logistic regression analysis. results. il- synthesizing capability in patients who survived sepsis was significantly higher than that in patients who developed fatal sepsis (p ¼ . ). in multivariate analysis only il- was associated with a lethal outcome from postoperative sepsis (p ¼ . ). the prognostic impact of il- was evident in patients with underlying malignancy (p ¼ . ) and in those who had undergone neoadjuvant tumour treatment (p ¼ . ). when patients were analysed according to the type of neoadjuvant therapy, preoperative ability to synthesize il- had a significant prognostic impact in patients who had neoadjuvant radiochemotherapy (p ¼ . ), but not in those who had neoadjuvant chemotherapy. conclusions. il- production after stimulation of whole blood with lps appears to be useful for the preoperative assessment of risk of sepsis-related death after operation in patients who have undergone neoadjuvant radiochemotherapy. p lipocalin- , regulator or byproduct during ischemia and reperfusion? background. the main focus of this work was to analyze the possible implication of lipocalin- (lcn- ) upregulation for the course of ischemia=reperfusion (ir) during heart transplantation and effects on polymorphonuclear cells (pmn) as well as to investigate the nature of the lcn- producing cell. methods. male inbred c bl= and the lcn- À=À mouse were used in our transplantation experiments. pmn from wildtype and lcn- À=À mice as were isolated and promyeloid cell lines ( d) used to demonstrate the effect of lcn- on cell physiology. western blot, rt-pcr, immunohistochemistry and tunel assay were performed to determine lcn- expression and apoptosis in the graft. cell viability and migration assays after various stimuli (e.g. ir) were applied to elucidate cell growth and viability. results. infiltrating pmn were the major contributors to lcn- expression during ir peaking h after reperfusion. the number of infiltrating pmn was significantly reduced in lcn- À=À recipients. no difference was observed in the apoptotic rate between wildtype and lcn- À=À donors and lcn- expression also increased during acute graft rejection. migration of pmn during reperfusion was negatively influenced by the absence of lcn- or lack of lcn- specific cell surface receptors in the lcn- À=À mice. the promyeloid cell lines responded to ir with increased lcn- mrna and protein levels. conclusions. our data suggest a chemoattractant function of increased lcn- expression in the transplanted heart due to infiltrating pmn. lcn- is a novel inflammatory marker upregulated during ir and acute graft rejection. our observations shed light on a possible function of lcn- to the recruitment of pmn to the site of ir and identify possible targets for therapeutic intervention. p preliminary results of a tumour-lysate loaded dendritic cell vaccination therapy in patients with recurrent or metastatic skeletal malignancies p. t. background. vaccination with tumour-lysate loaded dendritic cells (dc) has shown to modulate potent immune response in several animal models and clinical trials. this study presents preliminary data of patients treated with dc-vaccination for recurrent or metastatic skeletal malignancies. methods. in patients suffering recurrent chondrosarcoma ( ), haemangio-endothelioma ( ), ewing's sarcoma ( ), osteosarcoma ( ), or osseous metastatic disease of renal cell carcinoma ( ) dc-vaccination was applied additional to standard therapy such as surgery and=or chemotherapy and=or radiation. dc precursor cells were obtained from peripheral blood mononuclear cells by apheresis and incubated with autologuous tumor cell lysate gained by surgery. in each patient vaccinations of  e cells ( ¼ . ml) were administered intranodally under sonographic guidance in weekly intervals. delayed type hypersensitivity (dth) controls and standard clinical and radiological follow-up was performed before and after treatment. results. no adverse or side effects were observed in any patient throughout treatment. dth reaction was negative in all patients after therapy. six patients died of disease, patients showed progressive state of disease in terms of local recurrence or pulmonary metastasis, revealed stable disease. helper as well as cytotoxic t-lymphocytes of patients showed in vitro reactivity in terms of cd expression against tumour antigens and against the tracer antigen klh by both cd and cd expression. one patient had no increase of cd and cd expression neither against tumour nor tracer antigen, one patient showed positive immunological reaction against klh but not tumour. conclusions. in all patients with recurrent or metastatic skeletal malignancies investigated in this study dc vaccine therapy was primarily administered at very late stage of disease. the best clinical results could be achieved in patients with metastases of renal cell carcinoma, who both revealed stable disease over more than months. all patients with metastatic disease of recurrent sarcoma showed poor clinical response to therapy, though some showed immunological reaction. the absence of adverse reactions and uncomplicated therapeutic regimen, however, together with monitored immunological responses suggest that the effects of dc-vaccination should be investigated in earlier stages of sarcoma to improve clinical outcome in these patients as well as in all stages of metastatic disease of renal cell carcinoma. p analysis of the risk factors helicobacter infection, overweight, sex, and age in gallstone disease and gallbladder carcinoma in germany background. helicobacter infection of the hepatobiliary system has been proposed as a novel risk factor in the pathogenesis of gallstone disease (gsd) and gallbladder carcinoma (gbc). because there seem to be differences in the incidences of helicobacter infection in various populations, we investigated whether helicobacter infection of the biliary tract is present in germany, a region with a high incidence of gsd, but with a low incidence of gbc. methods. gallbladder tissue from patients who had undergone cholecystectomy were investigated: patients with gsd, cases with gbc, and control patients. the presence of helicobacter spp. was investigated by culture, immunohistochemistry, and a group-specific pcr targeting the s rrna and detecting all currently known helicobacteraceae. results. of the cases investigated, only one patient with gsd was pcr-positive for helicobacteraceae. in this subject, sequence analysis of the s rrna showed closest homology to the s rrna sequence of h. ganmani. helicobacteraceae were not detected by culture or immunohistochemistry. there was a higher body mass index in patients with gsd compared to controls (p < . ). mean age of patients with gbc was significant higher than for gsd (p < . ) or control patients (p < . ), whereas there was no difference between gsd and controls. conclusions. these data suggest that helicobacteraceae play no predominant role in the pathogenesis of gsd and gbc in the german population. the low prevalence of helicobacteraceae in the gallbladder mucosa of german patients could be a possible explanation for the relatively low prevalence of gbc although gsd is frequent. background. apoptosis is implemented in colorectal cancer (crc) development and has emerged as a potential target for cancer treatment at various stages of tumor progression. measurement of the apoptosis (m )=necrosis (m ) ratio may have a role in therapy monitoring. to define the value of preoperative assessment of apoptosis and necrosis we measured these parameters in the sera of crc patients and correlated these values with conventional clinical parameters. methods. we used an enzyme linked immunosorbent assay (elisa) to detect an apoptotic product and necrosis (m and m -antigen) in the sera of patients with crc; uicc i: n: ; uicc ii: n: , uicc iii: n: ; uicc iv: n: ; relapse: n: and healthy controls. results. patients with colorectal cancer showed significant higher m antigen levels than healthy controls (p < . ). when stratified to tumor stages the different preoperative m antigen expressions between healthy controls and tumor patients remained throughout all stages. detailed results are depicted in the following table: m results and the clinical applicability of the m =m ratio are under investigation and will be presented at the meeting. conclusions. levels of circulating m -antigen are increased in patients with colorectal cancer. clinical follow up studies will reveal the usefulness of a ratio value of apoptosis and necrosis. methods. expression of fgf in tumor tissue was determined from tissue specimen obtained from patients with colorectal carcinoma by rt-pcr relative to gapdh. furthermore immunostaining in carcinoma, adenoma, normal mucosa and liver metastases was performed. the biological function of the growth factor was analysed using cell lines expressing high (sw ) or low fgf (caco , lt , vaco ) as a model. low expressors received exogenous fgf while expression in sw cells was knocked down by sirna. the effects on tumor cell growth was determined by mtt and colony formation assays. signaling events were investigated by western blotting. in addition paracrine effects on fibroblasts and endothelial (huvec) cells were investigated using scratch assay for migration and tube formation for blood vessel formation. results. addition of the growth factor to the culture medium of slowly growing colorectal tumor cell lines lt , vaco and caco stimulated growth within hours. the stimulatory effect involved increased phosphorylation of erk = - minutes after factor addition and increased phosphorylation of s - minutes after fgf addition. sw cells that produce large amounts of autocrine fgf were not affected within this time frame, but fgf supported tumor cell survival under conditions of serum starvation. in addition down-modulation of fgf production by sirna significantly reduced colony formation after plating at low density in sw cells and restored sensitivity to exogenous fgf . secreted fgf also affected colonic fibroblasts inducing growth and migration and stimulated huvec cells to differentiate. conclusions. fgf is upregulated during tumor progression in the majority of the investigated patients. we showed that fgf can induce both autocrine and paracrine effects on the epithelial as well as the stromal compartment of colorectal tumor cells to further tumor growth, spread and neovascularization. this makes fgf an oncogene. further studies should prove the clinical relevance of fgf as a prognostic marker and as a potential target in antitumor therapy. p immunohistochemical peculiarities of gastric carcinomas in patients younger than years c. w. schildberg , a. dimmler , s. merkel , t. littwin , w. hohenberger , t. horbach background. young patients ( < years) comprise - % of all gastric carcinomas. therefore, immunohistochemical peculiarities were analyzed in our facility. methods. the examined group had patients. the median age of the group was years ( - years), the ratio male= female was . = . tumor tissue, which was embedded in paraffin, was initially marked, so that it could be further examined using the tissue array technique and consequently immunohistochemically stained. following this, the following markers were analyzed: cox , egfr, e-cadherin, p , tff and cdx . after semi-quantitative representation, a link to data of the tumor register was performed. results. in the younger patients, the diffuse type (laurén-classification) was overwhelmingly represented with %. early tumor stages (i and ii) were distributed similarly with % as advanced stage carcinomas with %. the -year survival rate was %. notable was that stage iiia had a distinctly better -year survival rate with % than those patients with stage ii ( %). in our evaluation of the immunohistochemical stains, it showed that younger patients with the diffuse type showed significantly more down-regulation of cox . this is particularly noticeable when one compares tumor stages ii and iiia ( vs. %). with tff , there was a notable over-expression shown (p > . ) in stage ii and iiia ( vs. %). cdx and e-cadherin were significantly more frequently extracted for the diffuse type. conclusions. it is known that younger patients with worse histological results (diffuse vs. intestinal = %) display a better -year survival rate. in particular, there seems to be a difference between stages ii and iiia. this could be contributed to and explained by a down-regulation or an over-expression of cox or tff . p toxic responses and side effects using various antineoplastic drugs in an experimental setting of peritoneal carcinomatosis in rats a. hribaschek , k. ridwelski , f. meyer , d. kuester , w. halangk , h. lippert background. during the last decade, intraperitoneal (i.p.) chemotherapy against peritoneal tumor spread originating from gi-cancers has been increasingly used. the aim of this systematic comparative study was to investigate various toxic responses=side effects of various cytostatic substances, which had been primarily tested for their efficacy to prevent=treat experimentally induced peritoneal carcinomatosis in rats. methods. using a basic experimental trial, established= novel antineoplastic drugs such as mitomycin ( mg=m ), cisplatin ( mg=m ), -fu ( mg=m ), oxaliplatin ( mg=m ) and cpt- ( mg=m ) (limited dosage adapted according to their ld ) were applied i.p. to prevent=treat peritoneal carcinomatosis induced in rats by transfer of , , tumor cells (colon adenocarcinoma cell line cc- ; cell-lines service, heidelberg, germany) via laparotomy (groups of animals per drug; control groups [sham operation ae tumor cells]). animals were sacrificed under general anesthesia on the th postoperative day and autopsied. toxic responses=side effects were characterized by occurrence of i) necrosis assessed as ''þ'' vs. ''À'' (equal to yes=no) at the peritoneal surface, ii) hepatic necrosis, iii) bleeding at the mesenteric tissue, and iv) death. the cytostatic effects were used as control for the therapeutic efficacy of the agents indicated by tumor weight and '' ae '' detectable tumor growth, which were correlated with the nonfavorable adverse phenomenons. results. (table ) : mitomycin and cisplatin were the most toxic substances (e.g., peritoneal necrosis in and animals out of , respectively) comparing the chemotherapeutic drugs but, however, this correlated with the most pronounced cytostatic effect (no detectable tumor growth). though the use of oxaliplatin showed also a high rate of necrosis (n ¼ = ) and death (n ¼ = ), its therapeutic potential was only low (tumor detectable in each animal). it was not surprising that the occurrence of necroses at the peritoneal surface was the most sensitive characteristic of toxic responses=side effects. in addition, the induction of a treatment-related bleeding was associated with earlier death prior to the th day after tumor cell transfer, the end of the experimental observation period, in the majority of cases. interestingly, cpt- provided the best compromise in decreasing i.p. tumor growth on one hand and an acceptable rate of side effects on the other hand. conclusions. the results suggest that, despite some favorable effects of novel=established cytostatic drugs in i.p. chemotherapy, toxic responses=side effects need to be simultaneously tested even in earlier stages of drug development as well as experimental=clinical studies for an appropriate dose escalation=adaptation. further studies should also focus on other parameters=study characteristics, e.g., i) combination of drugs, ii) various application time=mode (e.g., i.p.=i.v.), and iii) effects on wound=anastomosis healing as well as iv) induction of peritonitis. p retrograde reperfusion via inferior vena cava reduces ischemia= = =reperfusion injury after orthotopic liver transplantation in a rat model methods. in a pilotstudy patients with a significant internal carotid stenosis will be investigated prae-and postoperatively for visual field changes. results. at the time of the congress we will present the study design in detail and early results. conclusions. in case of no changes perioperatively, the study will be closed. in case of perioperative changes a larger prospective trial with additional neurological assessment will follow. p occlusion of the common femoral artery after misplacement of an angio-seal tm vascular closure device t. ott, p. konstantiniuk, t. cohnert background. femoral closure systems are becoming increasingly popular. they promise to shorten both the time to hemostasis and to mobilization. the most frequently used systems are angio-seal(tm), perclose + and vasoseal + . case report. a -year-old male patient underwent successful percutaneous transluminal coronary angioplasty, stenting and hemostasis with angio-seal tm , which, however, was followed by acute deterioration of pre-existing stage iib peripheral arterial occlusive disease (paod) with incomplete ischemia of the right lower extremity and development of a dry necrosis of the right great toe. magnetic resonance angiography showed occlusion of both superficial femoral arteries (afs) and of the right common femoral artery (afc). intraoperatively, the right afc was found was found to be completely occluded by a collagen plug from the angio-seal(tm), which was removed without difficulty. the symptoms improved significantly after the operation. due to the patient's critical cardiac situation, no further reconstructive measures were undertaken. conclusions. the literature indicates that femoral closure systems have led to complications in the form of vascular stenoses or occlusions that are unknown with conventional compression. these systems may be contraindicated in patients with known paod. background. ablation of the vein by endovenous laser treatment (evlt) is a new procedure that is less invasive than surgery and has a lower complication rate. evlt works by means of thermal destruction of venous tissues. methods. we retrospectively analysed the results of the endoluminal laser-treatment, which we applied at patients in a time frame of years ( - ) . we compared them with the effect of the traditional surgical approach ligation and division of the saphenous trunk and all proximal tributaries followed by the stripping of the vena saphena magna. results. there was no significant difference in the rezidiverate between endoluminal laser technique and the traditional stripping of the vena saphena magna. the biggest problem of the laser technique appeared to be a lower sensibility in the range of the inner ankle during a year ( %). in % of the cases the vena saphena magna was rechannelled. and also % reported about a still noticeable cord for a year. ninety six percentages demonstrated remarkable improvement. conclusions. the evlt-procedure is simple and effective. it takes less than an hour and get patients back to their everyday activities right away. with a high success rate and minimal side effects evlt is a new standard in varicose vein treatment. although we know that saphenofemoral recurrence occurs even after correct saphenofemoral ligation, it does not imply that this ligation has become obsolete. background. this study presents long-and short-term results after surgery of currently active, chronic venous leg ulcers, focusing on the effects of ulcer healing, recurrence and concomitant risk factors. methods. between january and march , patients ( legs) with a currently active, chronic venous leg ulcer were surgically treated, based on the two main steps of functional phlebologic surgery: the surgical interruption of reflux in the superficial and perforating veins to reduce venous hypertension in the entire leg and=or the affected area and occasionally, the surgical procedure involving the ulcer. a total of patients ( legs) who came to the follow-up were examined. the data collection included a preoperative examination incorporating medical history and clinical diagnoses and various measurements at the follow-up. results. initial ulcer healing occurred in % of the cases ( legs), % ( legs) of the venous ulcers never healed, and recurrent venous ulcers occurred in % ( legs). conclusions. we conclude that surgery is indicated before an ulcer is intractable to treatment. based on the understanding and identification of the causes and symptoms of venous ulceration we recommend standard surgical methods for the therapy of venous leg ulcers at any stage. background. popliteal artery aneurysm (paa) is a rare condition with an incidence of approximately % in men ( - years). it involves the risk of peripheral embolism or progressive thrombosis that may result in acute or chronic ischemia with claudication or loss of the extremity. distal vessels are increas-ingly embolized through a persistent dispersion of mural thrombi, and the possibilities for surgical vascular reconstruction are limited by the absence of open outflow vessels. case report. a -year-old male patient with an acute ischemic left leg was referred for emergency treatment. he presented with a -year history of intermittent claudication in his right leg. no signals were detected by duplex screening above the foot arteries of the left leg, and typical symptoms of acute occlusion were present. imaging tests revealed a paa on each side (diameter left cm; right . cm). the left paa was completely occluded, the right paa was partially open but the distal popliteal artery and the the posterior tibial artery were already completely occluded. a vascular bypass reconstruction to improve circulation was not possible due to occlusion of the outflow vessels. the patient was treated conservatively (systemic heparinization, i.v. prostacyclin administration). circulation in the left leg gradually improved, with remaining claudication, a free walking distance of m, and rest pain. amputation was prevented for the time being. conclusions. elective surgery for asymptomatic paa > cm is recommended to prevent permanent limited mobility or amputation. the procedure of choice is to ligate the aneurysm and to restore blood flow by a concurrent interposition of a vein segment, from the superficial femoral artery to the open infragenual popliteal artery. the male risk population ( þ) should undergo duplex screening of the popliteal artery. while asymptomatic aneurysms > cm should be treated surgically, smaller ones should be observed, since aneurysms < cm in diameter have a distinctly lower occlusion and amputation rate. in symptomatic cases a revascularisation with venous bypass should be attempted, if there are open outflow vessels to connect the venous graft to. if a vascular bypass reconstruction is not promising a conservativ treatment may prevent amputation. background. three dimensional motion analysis is a new evaluation method of upper extremity function. this video based system provides accurate and reproducible d kinematic data by tracking movements. the method is derived from clinical gait analysis which has already reached global acceptance within this field. it should overcome the deficiencies of subjective investigations. in order to demonstrate the use of the system the analysis of patients with brachial plexus lesions before and after surgical treatment is presented. methods. a d optoelectronic camera system with passive markers was used to capture the possible active rom. twenty seven markers coated with retroreflective tape were applied over anatomical landmarks on both upper limbs and recorded simultaneous by cameras. a -dimensional reconstruction of the position of the markers was done by special designed software. joint centres and joint movements were calculated by using the expert vision and orthotrak software (motion analysis corporation). healthy probands and patients suffering from brachial plexus lesions and receiving primary nerve surgery or secondary reconstructive procedures were investigated. results. the motion curves of all, probands and patients with different questions argue for a reproducible motion sequence. we were able to produce and analyse static data, rom and position of segments as well as kinematic data, especially motion curves of distinct movements. moreover compensatory movements could be investigated. obtained pre-and postoperative kinematic data document the enhancement of the involved limbs' function. conclusions. the method enabled objective analysis of patients suffering from brachial plexus lesions. measured angles are reliable and reproducible but generally lower than angles obtained from physical measurements. this is due to several reasons concerning the biomechanical model. because of the more complex nature of upper limb kinematics the transfer of the system from lower to upper extremity still involves unsolved problems. p thoracic outlet syndrome: objective criteria to indicate surgery g. weigel, b. gradl, m. mickel, w. girsch background. reviewing the literature the indication for thoracic outlet syndrome (tos) -surgery is based on clinical findings only in the majority of the cases due to lack of objective findings. in a retrospective study we have analyzed our cases in order to evaluate objective criteria for surgical intervention. methods. seventeen patients ( men, women aging from to ) were diagnosed clinically times for tos (duration of symptoms months, nrs ). additionally objective investigations were performed: x-ray of the cervical spine to detect a cervical rib; a comprehensive electroneurographic investigation to detect signs of nerve compression; mr-angiography of the subclavian artery with elevated and adducted upper extremity to detect a stenosis of the artery as an indirect sign of compression of the brachial plexus. results. concerning the objective assessment a cervical rib was present in % of our cases. the electroneurographic investigation revealed signs of nerve compression in % of our cases. in nearly % of our cases a stenosis of the subclavian artery confirmed the clinical diagnosis. all patients underwent tos-surgery via a small single supraclavicular incision and recovered from their symptoms. conclusions. in our series we did base the indication for tos surgery not only on clinical examination but also on objective findings, either the presence of a cervical rib and=or positive electroneurographic findings and=or a stenosis of the subclavian artery. the mr-angiography was the most significant investigation to objectify the clinical findings. the presented investigation setup seems to be appropriate to objectively diag-nose tos and indicate surgery. the small supraclavicular incision gave adequate access to perform neurolysis of the brachial plexus, scalenotomy and resection of cervical or first rib without major complications in all cases. background. the necessity of antibiotic prophylaxis in the clinic of child surgery is caused by following: -increase invasive method of investigation; -increase cases of postoperative supurative complication; -high economic expenses; -spreading of polyresistent microorganism. methods. the clinic retrospective investigation of the patients, who were treated in the surgical department of lviv regional children's hospital ''ohmatdyt'' from till yr. the antibiotic prophylaxis was performed in surgical operation of ii category (conventional purity) and iii category (contaminational) of purity, which are accompanied by middle or high individual risk of the development of pyo-septic complications. eighty two of the patients took combined medications of clavulane acid with amoxicillin (augmentin, amoxuclav in dose mg per kg, the others patient took cephalosporinus of i-ii generastion (cephazolinum, cephuroximus in dose mg per kg) conclusions. effective abp allows to reduce the amount of the postoperative complications ( group- %, group- %), postoperative fever ( group- . %, group- . %), duration of the hospital treatment in the group- . days, in the group- . days), and treatment expenses. optimal drugs of choice for abp in the clinic of pediatric surgery are combined preparations of clavulane acid with amoxicillin. the goal of this study was to improve the results of management children with bat. one hundred twenty-eight children with the age ranged from weeks to years were enrolled in this study. among these patients the splenic injury was established in ( . %), liver injury -in ( . %), intraperitoneal hematoma -in ( . %), and retroperitoneal hematoma -in ( . %) of patients. according to the moor's classification grade i of the liver damage was established in patients, grade ii -in , grade iii -in , and grade iv -in one patient. according to the classification of american association of trauma surgery the grade i of splenic injury was diagnosed in patients, grade iiin , grade iii -in , grade iv -in , and grade v -in patients. laparoscopic drainage of abdominal cavity was performed in patients with active bleeding, which stopped by the surgicel + (ethicon) and electrocoagulation, from the hematoma of mesocolon and mesojejunum and in patients with grade i liver and splenic injury. the laparoscopic coagulation with applying of surgicel was performed in all patients with grade ii liver and splenic damage and in patients with grade iii. laparotomy was performed in patients with grade iii and in all patients with grade iv-v. resection of the spleen was applied in patients with grade iii and in two patients with grade iv. for the bleeding control, the surgicel nu-knit + (ethicon) was used in one patient with the grade iv of splenic damage. splenectomy was performed in patients with the grade v. parenchymal suture was used in patients with the grade iii of the liver damage and non-anatomical resection -in one patient with grade iv. retroperitoneal endoscopy with coagulation was performed in all patients with retroperitoneal hematoma. one child died with the grade iv of the liver damage. thus, the endoscopic coagulation with applying of surgicel + is effective in the management of patients with bat. the choice of management dependent of the grade of damage. we used malone antegrade continence enemas (mace), administered through a continent cutaneous appendicostomy or a caecal flap to achieve reliable evacuation and faecal continence in seven children with myelomeningocele and after surgery of anorectal malformation. postoperative complications included one subcutaneous pericaeceal abscess requiring exploration and in one case stenosis of the stoma. except well known and already described complications all seven patients are continent of stool at a mean of months follow-up. despite our efforts to develop an effective bowel management program regarding application of the enema regimen this procedure provided some technical problems especially for children who have had prior appendectomy. so we developed a new simple technique to perform a caecal tube stoma. we also want to demonstrate a new device to simplify handling and application of enemas. the basic idea of a simple method of bowel cleansing like mace is followed by significant improvement in quality of life and more social acceptance of patients. but overall success will be achieved by improvement of technical procedure and handling. extended caecum. the appendix could not be detected. a surgical intervention was decided with the intention for an appendectomy. at the operative sight a caecum duplex was revealed. the lumen of the blind caecum was completely filled by a large fecolith. also the appendix vemiformis was inflammated. caecal duplex resection and an appendectomy was performed. the pathology report described ulcerations and segmental ischemia of the resected caecum. an oxyuriasis of the vermiform appendix was also reported. there was no immediate or delayed post-operative complication. conclusions. approximately % of duplications have been reported to be located within the abdominal cavity. small bowel lesions are the most commonly described ( %), while colonic lesions are found in % of cases. a review of the literature has revealed cases of colonic duplications, that occurs mostly in pediatric patients. surgical intervention is indicated in case of complicated colonic duplications such as obstruction of the colon as a result of direct compression, volvulus, hemorrhage, ulcerations, ischemia or perforation. in most instances duplications can be completely excised as described in our case. special care should be taken of the possible abnormal blood supply to the adjacent intestinal segment. background. reports on complications are part of every medical scientific investigation. regarding the definition of a surgical or post-interventional complication there are different views. this is one reason for the variation width in complication reporting concerning the same interventions in the surgical literature. the following work presents the advantages of a prospectively standardised documentation of complications in a surgical department as a part of a hospital quality management. methods. over a period of one year in patients data sheets about post surgical complications were collected and entered in a electronically data base. all abdominal procedures, including the abdominal wall and additionally varices surgeries were enclosed in the following evaluation. patients were excluded from the investigation when treated in the surgical ambulatory or treated as day-surgical patients. the complication system according to clavien was used to classify the complication grades. this system encloses five grades, lower grading indicating lower level of complication whereas grade three is divided in subclasses a and b (dindo et al. ( ) ann surg : - ) . for statistical analysis the mann-whitney u-test and spearman correlation were used (p < . ). results. out of operations there were ( . %) operations according to our inclusion criteria with patient's average age of . ae . years ( . % male patients). the overall complication rate according to clavien averaged . % (differences between different surgical methods and surgeons are given in a table). referring to general used grading the mean complication rate ranged between . and . %. conclusions. using the system of clavien complication rates appear higher than usual. this is caused by the fact that all post surgical events apart from normal stay slip into the system. the system allows a good comparability between single surgeons and between different operations. results from prospectively entered data evaluation can be used to detect weak points in a team, and to find out technical as well as personal problems. as a consequence, for instance education programs could be provided to compensate weaknesses or the team could be restructured. periodical evaluation of a standardized data bank allows fast reactions to occurring problems and guaranties an adequate surgical complication management. lymphatic vessel invasion (lvi) has been rtx=ctx þ esophagectomy). ( -ac): n ¼ : n ¼ (esophagectomy) vs. n ¼ (ctx þ esophagectomy). results. ( -escc): rtx=ctx led to a lvi-reduction detectable lvirate: ( -escc): rtx=ctx led to significant lower lvi-rates compared to primary resected patients tyrolean cancer research institute, innsbruck, austria; department of pathology germany p the role of fgf in colorectal carcinogenesis institut für krebsforschung p , p , p sachsenplatz - , wien, Ö sterreich. -datenkonvertierung und umbruch: manz crossmedia druckerei ferdinand berger & söhne gesellschaft m. b. h., horn, Ö sterreich. -verlagsort: wien. -herstellungsort: horn. printed in austria p. b. b.= = =erscheinungsort: wien= = =verlagspostamt wien background. survival of patients with lung cancer is strongly affected by lymph node metastases. identification of n disease is thus crucial. we compared the diagnostic accuracy of image fusion of positron-emission tomography (pet) and computed tomography (ct) with that of ct only and that of pet only for mediastinal lymph node staging in patients with non-small-cell lung cancer (nsclc).methods. in patients with proven nsclc a preoperative fdg-pet and ct examination of the body trunk were performed. pet, ct and pet-ct image fusion were evaluated separately; nodal stations were identified according to the mapping system of the american thoracic society. a lymph node was considered to be infiltrated by tumor if the minimal diameter was cm or more in ct, or the standard uptake value (suv) was larger than . in pet. all patients underwent mediastinoscopy, biopsies from lymph node regions were taken (ats . %, ats . %, and ats . %). if primary pulmonary resection was achieved, ipsilateral lymph nodes were dissected and the histological findings were considered for statistical analysis. histological findings were compared with results of ct, pet and pet-ct image fusion. sensitivity and specificity were obtained using the confusion matrix.results. histopathological assessment revealed positive mediastinal lymph nodes out of , sensitivity was . % for ct, . % for pet and . % for image fusion, specificity was . % for ct, . % for pet and . % for pet-ct fusion.conclusions. pet-ct image fusion improves sensitivity, specificity and accuracy in mediastinal staging of nsclc patients. the high negative predictive value of pet-ct image fusion ( . ) may abandon mediastinoscopy in nsclc patients with negative mediastinal pet-ct image fusion. however, larger series are mandatory in order to gain statistical significant power. local resection of stage i primary lung cancer by -nm nd-yag laser in functionally inoperable candidates: a prospective study s. b. watzka , w. grossmann , p. n. wurnig , f. lax , m. r. mü ller , p. h. hollaus background. hydatid disease is a parasitic infestation by a tapeworm of the genus echinococcus. it is not endemic background. in a pathway regarding the management of liver trauma was established in our hospital. the aim of the study was to assess the outcome after implementation of the guidelines.methods. data on all patients with liver injuries managed in our institution in the past years was evaluated. liver trauma was classified using moore's trauma score. additionally, coexisting injuries were assessed.results. from to a total of patients with liver trauma (motor vehicle accidents , falls , horse riding accidents ) were admitted to our trauma unit (median age of . years). grade iii traumas ( . %) were the most common injuries, followed by grade iv ( . %), grade i ( . %), grade ii ( . %), grade v ( . %) and grade vi ( . %). the laparotomy rate varied from . % in grade i injuries to % in grade v injuries, resulting in an overall laparotomy rate of . %. two patients required second look laparotomy for removal of liver packing and one patient required puncture of a posttraumatic bilioma. the most common associated concomitant injuries were right or bilateral rib fractures ( ), pelvic fractures ( ), long bone fractures ( ), laceration of the spleen, spine injuries ( ), and head injuries ( ). the mortality rate of patients with liver trauma ranged from % in grade iv injuries to % in grade i injuries with an overall mortality rate of % ( ). all patients with grade v or grade vi traumas survived ( ). if laparotomy was required because of hemodynamic instability or concomitant abdominal injury the mortality rate increased to %.conclusions. the clinical pathway of management of hepatic trauma in our patients showed favourable results. apart from the grade of liver injury the overall laparatomy rates and mortality rates largely depend on concomitant injuries. colitis cystica profunda is a rare benign disorder of the large intestine characterized by submucosal cyst formation. the clinical appearance of the disease can be highly variable; it can be associated with rectal prolapse and chronic inflammatory bowel disorders such as crohn's disease and ulcerative colitis.we describe a case of colitis cystica profunda associated with rectal prolapse. the female patient had a one-year history of constipation and rectal pain. an altemeier procedure was performed to correct the rectal prolapse. histology confirmed the presence of colitis cystica profunda. the operative and postoperative course was uneventful.it should be borne in mind that colitis cystica profunda can be associated with rectal prolapse. conservative management is usually satisfactory, but a mucosal resection (delorme's procedure) or perineal protectomy (altemeier procedure) is recommended when there is rectal prolapse.p peritonitis ossificans -a rare situation after acute major abdominal surgery m. ruzicka , s. thalhammer , s. stättner , m. mostegel , b. sobhian , j. karner background. treatment of the congenital intestinal obstruction of newborns is one of the main problems of the pediatric surgery.methods. patient p. had been hospitalized to the intensive care unit days after birth with symptoms of absence of stool from birth, frequent vomiting, full-blown abdominal distension. the signs of endotoxicosis, the intestinal loops posterized image through the anterior peritoneal wall, dilatation of the venae anterior peritoneal wall, abdomen lower sections and scrotum edema were noted at the time of admission. x-ray of the abdominal cavity reveals the signs of the low intestinal obstruction, bowel perforation -presence of liquid and free air at the abdominal cavity. diagnosed -the intestinal obstruction, peritonitis and after a short-term of the preoperative preparation patient underwent surgery. atresia of the sigmoid colon, necrotic enterocolitis with the affection of the = of the large bowel, perforation of rising section of the large intestine, the meconium peritonitis were established during surgery. the right side hemicolectome, terminal ileostomy and transverse colostomy. the reoperation at the month was done: ileotransversostomy, descendosigmostomy with the preserving of transverse colostomy were performed. the diameter of the descending large bowel exceeded the diameter of the sigmoid colon by - . times, that's why the anastomosis had been raised by the type ''side to side''.results. within the course of weeks after the radical surgery the child started to have stool passage through the rectum. presently the child's condition is satisfactory, the physical development corresponds to the age norms, stool passage takes place only through the rectum. the final stage of the treatment will be the closure of the transverse colostomy with the complete restoring of the passage of the chyme through the bowels.conclusions. the bringing of the intestinal stomas out with the delayed radical surgery in some case of newborns may significantly improve the prognosis of the results of treatment. background. different inguinal hernia operationtechniques must be compared to their recurrency rate, acute and long term complication rate, patients comfort and duration before returning to daily life, return to work and to sports etc. under economical aspects they should be safe, quick, and require limited resources (personal, equipment, implantate). with increasing economical pressure the latter features gain increasing importance. we therefore made a comparative time analysis between tipp and lichtenstein.methods. between . . and . . hernias were operated in tipp technique and hernias in lichtenstein (lich) technique. patients were from an identical district and comparable in epidemiological data, comorbidity, hernia distribution and in-resp outdoor treatment. each series was performed by surgeon in the same operation unit. implantates used were polysoft hernia patch tm (tipp) and ultrapro mesh tm (lich). total operation time was recorded (min). additionally, operation phases were defined:opening phase: from skin split to preparation phase: from opening of the external aponeurosis to introduction of the mesh repair phase: from introduction of the mesh to the end of the suture of the external aponeurosis closing phase: end of repair phase to skin closure.assuming individual differences between the surgeons and management-associated differences as well as intermethodical differences relative phase intervals were deduced from the original recordings and compared. statistical comparison was done by t-test and pearson correlation coefficient.results. average operation time of lich was ae . min (range - min, median min), average operation time of tipp . ae . min (range - min, median min). up to now there was = recurrent hernia in tipp and = in lich (n.s.). the correlation of preparation phase time and operation time was high (pearson coefficient: tipp . ; lich . ) and lower for repair phase (tipp . ; lich . ). there was no difference in the correlation of the preparation phases in tipp and lich (p < . ). on this basis we estimated the expected time of the compared method to each series, i.e. presumable time for lich in tipp series and vice versa. comparison of lich vs. tipp (expected) and lich (expected) vs. tipp revealed that tipp was faster and required . % time of lich (p < . ).conclusions. tipp and lich show a comparable time effort towards preparation, tipp is significant faster in repair phase enabling a quicker total operation time.p transinguinal preperitoneal hernioplasty (tipp) using a memory ring armed polypropylene patch: which factors influence the operation?quality of life improved significantly in all patients with clip displacement.conclusions. esb has a displacement rate of less than % and gives excellent results for quality of life, which are not diminished by inappropriate clip application. grundlagen. post anal repair ist eine methode zur verbesserung der kontinenzfunktion bei diffuser schädigung des schließmuskels. die methode wurde in den letzten jahren kontrovers diskutiert. langzeitergebnisse wurden nur sporadisch publiziert. methodik. die operation wurde in der technik von parks [i] in steinschnittlage und allgemein-, oder spinalanästhesie durchgeführt. eine präoperative darmreinigung und eine perioperative antibiotikaprophylaxe wurden routinemäßig durchgeführt. prä-, und postoperativ wurde eine sphinktermanometrie in der durchzugstechnik mit einem perfundierten dreilumigen katheter vorgenommen. die auswertung erfolgte mit einem programm der firma gastrosoft. bei der klinischen untersuchung wurde der kontinenz-score nach williams verwendet.ergebnisse background. peptic ulcer in the excluded segment of a gastric bypass has been reported in the literature in only cases. we report a -year-old woman with a perforated duodenal ulcer, who underwent laparoscopic roux-en-y gastric bypass surgery for morbid obesity months ago.methods. on physical examination, the patient's abdomen was marginally tender to palpation. laboratory findings were unremarkable except for an elevated leucocyte count of . =ml (normal . - . =ml). abdominal radiography and sonography showed no pathology. because of the persistent abdominal pain we performed an abdominal computed tomography scan, which demonstrated free air.results. she was successfully treated by a laparoscopic repair of the perforated duodenal ulcer. after surgery, a standardized analgesic regimen was administered for pain relief. intravenous piperacillin-tazobactam was continued for at least days, then a helicobacter eradication therapy was performed. feeding was resumed on the first postoperative day and the patient was discharched on day six without any complications.conclusions. peptic ulcer in the excluded segment of a gastric bypass has been reported in the literature in cases. the pathogenesis of ulcer perforations in the excluded sto-mach=duodenum is unclear. of the total cases, free air in the abdominal radiography was only noted in one case. recognizing that free air under the diaphragm will be absent is one of the most important diagnostic considerations when gastric or duodenal ulcer perforation is suspected in the postgastric bypass patient. abdominal ct scan and early surgical exploration remain the treatment of choice.chirurgische forschung p blood interleukin as preoperative predictor of fatal postoperative sepsis after neoadjuvant radiochemotherapy background. a serious impediment in transplantation medicine especially after liver-transplantation is the damage by ischemia and reperfusion. we compared different types of reperfusion within a rat model and investigated the different consecutive ischemia=reperfusion injuries.methods. arterialized orthotopic liver transplantation (olt) was performed in syngenic male lewis rats. the animals were divided into experimental groups: i-and ii-control groups with antegrade reperfusion and group iii with retrograde reperfusion. laboratory parameters as well as histopathological changes of the liver-graft-tissue were evaluated , and hours after olt.results. the got-values showed hours after olt significant differences between group i=ii (antegrade reperfusion) and group iii (retrograde reperfusion) ( . ae . u=l vs. . ae . u=l; p < . ). gpt-as well as got-values were significantly lower in group iii (retrograde reperfusion) hours after olt. evaluation by histopathology revealed significant less areas of necrotic liver tissue within group iii compared to group i=ii (p < . ).conclusions. these results show that the retrograde reperfusion (by order of: infrahepatic inferior vena cava -opening suprahepatic inferior vena cava -hepatic veins -retrograde reperfusion of the liver) has a protective effect on the graft in regard to the ischemia=reperfusion injury. background. clamping of internal carotid artery during carotid endarterectomy (cea) leads to cerebral ischemia in - % of patients. routine carotid shunting has a high morbidity as described in literature. selective carotid shunting under general anaesthesia requires an intraoperative monitoring. the registration of somatosensory evoked potentials (sep) is a well accepted technique.methods. from to we assessed prospectively consecutive cea under general anaesthesia and sep monitoring, without primary shunting. routinely preoperative neurological assessment, duplex sonography and mr-angiography were performed. the onset of a clinical neurological deficit after carotid artery clamping was related to changes in the n =p waveforms in sep-recording. sep was evoked by stimulating median nerve. criteria for shunting was reduction in sep-amplitude > %. routinely postoperative neurological examination and duplex sonography were performed.results. patients underwent cea between and . intraoperativ sep-monitoring was available in patients. in patients ( . %) sep-monitoring was inadequate (primary shunting). in procedures ( . %) sep-monitoring didn't show deviations. significant sep-alterations appeared in of cases ( . %). in cases sep-alterations normalised after shunting without neurological deficits. in cases sep-alterations were reversible after shunting, but were associated with postoperative neurological deficits ( permanent, transient). cases ( . %) had normal sep-findings (false negative), but postoperative neurological deficit occurred ( permanent, transient).conclusions. the selective use of carotid shunting during cea requires an intraoperative monitoring technique. based on our data and literature findings, sep-monitoring is a reliable method to prevent neurological vascular deficits and effectively minimizes shunting frequency.p perioperative changes in internal carotid endarterectomy p. konstantiniuk , t. ott , u. gratzer , i. steinbrugger , a. wedrich , t. cohnert p poland syndrome with partial heart ectopia and dextrocardia r. kovalsky , a. kuzyk , o. leniv , i. avramenko lviv regional children hospital, lviv, ukraine; lviv national medical university, lviv, ukraine; lviv regional children hospital ohmatdyt, lviv, ukrainebackground. poland syndrome is seen in = of the newborns. it can declare itself by its different components and joining of the additional defects in every concrete patient.methods. a girl, born by the cesarean section, with the weight of g and week gestational age was brought to the pediatric surgery clinic on the . . in a couple of hours after birth. when examined the skewness and chest distortion attracted attention, especially on the right side. the oval form defect of the chest wall  cm was seen in the anterior of the chest parasternal on the right in the ii rib level from the costal margin, an also thinning of body of sternum. a part of liver with the size of  . cm covered with peritoneum was projecting form the lower part of the latter. a gastric part of the heart, covered with pericardium and non-epithelized membrane with the upper part directed to the right was projecting over it from the defect. there were no signs of heart and respiratory failure. during the echocardiography the following was discovered: heart rotation in the chest, right ventricular and atrial hypertrophy, good running of the great vessels, not violated valve function and good myocardial contractility. ejection fraction from the left ventricle %. during the intraoperative inspection the diaphragm defect in the right place parasternal triangle with the size of  cm through which the part of liver prolapses. the hepatic lobectomy was done as well as diaphragma defect repair.results. in eight months the plastic operation was done on the defect through the replacement of the front edge of the costal arch and musculocutaneous flap, formed from the greater pectoral muscle. the child was discharged from the hospital in a good shape.plastische, Ä sthetische und rekonstruktive chirurgie background. traditional abdominoplasty aims at elimination of redundant fat tissue and skin as well as tightening of muscular aponeurosis on the abdomen. in the massive weight loss (mwl) patient this procedure often yields only mediocre results. specific areas such as hips, buttocks and the lateral thigh are addressed inadequately.methods. patients after mwl are treated with a central or lower body lifting according to the specific needs at our institu-tion. the central body lift includes a circumvertical dermolipectomy concentrated on the central torso without significant mobilisation of caudal tissues. in the lower body lift, the circumvertical dermolipectomy is located more inferior on the torso with an additional extensive mobilisation of the subcutaneous tissue down to the level of the knee.results. these new innovative techniques led to a much improved contour and results compared to the traditional abdominoplasty procedure. although there is an increase in operative time, postoperative recovery and complications appear comparable according to our initial limited experience. we present in detail representative cases with step-by-step explanation of operative techniques.conclusions. especially after mwl, such as after bariatric surgery, the surgeon has to deal with a tremendous amount of redundant tissue on the lower part of the torso and thighs. traditionally this problem was solved in a staged manner with multiple surgeries, such as abdominoplasty, buttock lift or medial thigh lift. however, in many cases this approach led to unsatisfying results. new innovative techniques allow for an optimal repositioning of the descended tissues und most often to a much improved postoperative result compared to the traditional techniques. a. m. rokitansky, r. j. hahn background. we report our experience using the modified minimal invasive method of pectus excavatum repair in adults. thirty one adults with a mean age of ( - . ) suffering from pectus excavatum have been corrected using by the extended modified minimally invasive repair method. the ravitch= welsh=rehbein technique, performed elsewhere, has corrected patients insufficiently. reduced physical capacity, mild cardiac valve dysfunctions (prolapse, pulmonary valve insufficiency), chest pain in the area of the funnel and reduced ventilatory function were detected. two thirds of the patients emphasized the wish of a better cosmetic result. preoperative investigations include blood samples, ecg, heart sonography, chest x-ray, chest mri=ct with -d reconstruction and spirometry.methods. retrosternal mobilization and intraoperative stretching of the anterior thorax by long lasting sternal elevation modified the original nuss technique. additionally an oblique wedge shaped partial sternal osteotomy and=or osteotomies of the ossificated ribs were performed. in adults usually pectus pars (ps -implant + fa. hofer austria) should be used.results. due to preparation we observed intraoperative bleeding episode from the internal mammaric vessels, superficial lesion of the right visceral pleura (adhesions). postoperatively we saw pleural effusions, subcutaneous hematoma and two prolonged wound-healing episodes (superficial infections with no necessity of bar removal). vertebral index changed from . preoperatively to a normal range of . postoperatively. postoperative cosmetic results were perfect in %. in summary adults with pectus excavatum are manageable with extremely satisfactory results using the described extended modified correction technique. osteotomies do not destabilize the chest and can be sufficiently combined with the nuss technique. background. minimal invasive av-valve surgery is an increasingly popular procedure in cardiac surgery, but -due to the complexity -still reserved to few selected centers. aim of this study was to present learning curve issues for program introduction. methods. a total of minimal invasive av-valve procedures were performed by a single surgeon and were successful in ( . %). seventy one patients ( . %) underwent av-valve repair, ( . %) received mitral valve replacement. in patients ( . %), concomitant asd closure and=or tricuspid valve repair had to be performed. one intraoperative conversion to valve replacement had to be performed due to residual mitral regurgitation. for calculation of learning curves, regression models with logarithmic curve fit for operating time (ot), aortic cross-clamp (axt) and cardio-pulmonary bypass time (cpbt) for all patients and for patients with posterior mitral leaflet prolapse were applied.results. within approximately consecutive minimal invasive procedures, a steady decline of either ot, axt and cpbt could be observed for the overall surgical population even despite the increasing number of concomitant procedures and was similar in patients with posterior mitral leaflet prolapse. after overcoming this steep learning curve, a mean axt of ae min, a cbp time of ae min and a total ot of ae min is required to treat isolated posterior leaflet prolapse.conclusions. minimal invasive av-valve surgery can be safely introduced into a heart surgery program. however, sufficient number of cases per year are required per surgeon to come over this learning curve. case report. a -year-old male patient without clinical symptoms presented an enlarged heart shadow in a routine radiological examination. the following ct revealed a structure in the pericardial sac that was initially classified as a pericardial cyst. in order to confirm the diagnosis, an ecg-triggered multi-slice ct was performed resulting in the diagnosis of a gigantic coronary fistula originating from the left main coronary artery leading to the right atrium. the shunt volume of the coronary fistula was estimated to be %. echocardiography demonstrated dilatation of the right chambers due to volume overload. since operative mortality was deemed extremely low in this patient surgical correction was advised. after median thoracotomy, initiation of heart lung machine and extensive cardioplegia, the coronary fistula was identified to originate from the left main coronary artery meandering around the posterior side of the left heart with a mean diameter of cm and entering the right atrium at the level of the vena cava superior. the fistula was ligated in the right atrium and at its origin at the branching site of the circumflex artery. to secure optimal surgical outcome bypass grafting was performed to lad (left anterior descending) and its diagonal branch as well as the circumflex artery. postoperatively performed ecg-triggered multislice-ct evidenced successful repair of this anatomical malformation. the postoperative course was uneventful. background. to document severity of illness and to evaluate the predictive value of clinical scoring systems in infants and children after cardiac surgery. prospective study with follow up to hospital discharge. a bed multidisciplinary paediatric icu in a university hospital. between = and = infants and children were admitted after open heart surgery.methods. data relevant to the acute physiologic score for children (apsc), pediatric risk of mortality (prism iii), therapeutic intervention scoring system (tiss ) and organ system failure (osf) score were collected in all patients during the first days of postoperative intensive care. eighty one percentages of the patient underwent a total repair, % had a palliative correction.results. the mean age of the patients was . ae . years. there were survivors (s) and non survivors (ns). the mean duration of mechanical ventilation was . ae . days for survivors and . ae . days for non survivors. on the first postoperative day the mean apsc and prism iii scores of survivors and non survivors were . ae . vs. . ae . (p < . ) and . ae . vs. . ae . (p< . ), respectively. the mean tiss and osf scores of survivors and non survivors were . ae . vs. . ae . (p< . ), and . ae . vs. . ae . (p< . ), respectively. the overall hospital mortality rate was . %. patients with an apsc score < and a prism score < had a survival rate of %, whereas patients with an apsc score > and a prism score > had a mortality rate of %. the area under the receiver operating characteristic (roc) curve for apsc, prism, osf and tiss was . , . , . and . , respectively.conclusions. apsc, prism and tiss describe accurately the severity of illness in infants and children after cardiac surgery, and all physiologic scores identify those patients at increased risk for mortality.p non-bacterial pyopericardium leading to lethal sepsis in a patient with severe humoral immunodeficiency k. mészáros , i. knez , b. rigler , g. p. tilz klinische abteilung für herzchirurgie, graz, austria; abteilung für klinische immunologie, graz, austriabackground. pyopericardium is the accumulation of pus in the pericardium mainly caused by bacterial infection. purulent pericarditis most commonly occurs as a direct extension of an infection from an adjacent pneumonia or empyema. alternatively, a distant infection can haematogenously seed the pericardium. primary pericardial infection is rather rare. pyopericardium is an illness requiring acute intervention by the heart surgeon (pericardial drainage) and adequate medication.methods. a -year-old man was admitted with diffuse chest pain, dyspnoea, tachycardia and nausea. laboratory examination revealed massive leukocytosis and elevation of creactive protein. echocardiogram showed circumferential pericardial effusion without valvular vegetations. after a subsequent clinical impairment to a highly septic state, he underwent surgical pericardial drainage. the pericardium was full of pus of creamy aspect. after continuous pericardial lavage and operative revision in several steps, final sternal closure took place ten days later. no infectious agent could be identified to be responsible for the purulent pericarditis.at the term of next surgery, . litres of serous ascites and . litres of serous pericardial effusion were drained. the patient developed a gangrenous cholecystitis, op-site findings revealed a non-purulent ascites, intra-operative cholangiography was without pathological findings.results. detailed immunological analysis showed a severe decompensated immunodeficiency with adentritocytaemia. the therapy with polyvalent immunoglobulin and imutin was ineffective, the patient died one day later from a therapy-refractory septic shock.conclusions. in cases with unclear non infectious purulent pericarditis, it is of high importance to carry out the correct diagnosis as soon as possible to provide an adequate therapy. background. early results of mi treatment of proximal humeral fractures using the ncb + -ph plate showed promising results reaching points ( % of age related normal value) in the constant score months postoperatively and an acceptable complication rate ( . %). the purpose of this study was to analyze the long-term results focusing on functional outcome and complications.methods. so far out of a total number of cases we have gained the data of patients ( women, men; age in the mean) who sustained fractures of the proximal humerus treated mi with the ncb-ph + plate (zimmer company, winterthur, switzerland). in cases ( %) osteoporosis had been diagnosed preoperatively. radiological follow-up in two planes and functional outcome is assessed clinically (rom) and using visual analogue scale (vas) for pain and function, constant score and a modified adl score (activities of daily living).results. average rom (in degree) for anteversion was , glenohumeral abduction , external rotation and internal rotation . average vas for pain was , points ( ¼ worst) and for function , points ( ¼ best). average constant score was points, average adl score was points ( ¼ best). between and months postoperatively one case ( , %) of sintering of the humeral head and one case ( , %) of avascular necrosis was detected. in cases ( %) of reversed impingement we performed total removal of hardware. four younger patients ( %; age in the average) underwent the same procedure demanding it though not suffering of limited rom or pain.conclusions. in the early results ncb-ph + proved to be an effective mi method of treatment of fractures of the humeral head. the year follow up data show further functional improvement (approx. % of constant score). the complication rate remains low ( = ¼ %). especially, no cases of lesions of the axillary nerve or frozen shoulder were seen. the latter we believe is due to the mi procedure and the early functional treatment which is possible since the ncb-ph + plate creates high primary stability. the long-term results prove the ncb-ph + plate to be a safe and effective method of treatment reaching a functional outcome that enables the mostly old patients to regain an acceptable level of activity. removal of hardware is easy to perform and offers especially in the younger patient a possibility to at least improve patients' subjective outcome. background. the gastrointestinal duplication in adults is a rare congenital abnormality and only few cases are described in the literature. although intestinal duplications are considered to be benign lesions, mostly asymptomatic, they may result in significant morbidity and mortality, if left untreated. this study reports of one case of caecal duplication with an overview of the literature.methods. a -year-old female patient was hospitalised with pain in the right lower abdomen. a relocatable and solid tumor ( cm dm) was palpable. blood examination revealed a slight increase of leu and crp. the gynaecologic examination was entirely unremarkable. the sonography showed only an key: cord- -j trahab authors: loo, may title: select populations: children date: - - journal: complementary and alternative medicine doi: . /b - - - - . - sha: doc_id: cord_uid: j trahab nan the majority, usually seeking cam therapy as an adjunctive management for pain and other discomforts related to the oncologic illness or to medications. in the general pediatric population, chiropractic is the most common form of cam treatment used by children. reports indicate that children made up % of chiropractic patients in and % in . a survey of the boston metropolitan area revealed that an estimated , chiropractic visits were made by children in . childhood disorders being treated include pain, respiratory and gastrointestinal tract problems, ear infection, enuresis, and hyperactivity. homeopathy was the second most popular form of cam therapy used by children in spiegelblatt's report. in , however, the university of pittsburgh found that homeopathy was the most common cam therapy used by children who visited an emergency department (ed). also, in a survey of homeopathic practitioners in massachusetts, children constituted one third of patient visits. homeopathic remedies are highly diluted substances that induce self-healing. these remedies are readily available from a variety of sources, including some grocery stores. although homeopathy may be safe and effective in many childhood conditions, many practitioners believe that homeopathic remedies are best used as adjunctive therapy to conventional medicine in chronic conditions and in acute disorders that respond poorly to conventional therapy. , acupuncture is the third most common therapeutic method used in children but has the largest body of scientific data compared with other cam therapies. a harvard survey of patients with a median age of years who received acupuncture treatment, which included needle insertion, moxa/heat, cupping, and magnets, reported that % of patients rated the therapy as pleasant and % thought treatment helped their symptoms. electrical stimulation, laser, heat, magnet methods, and acupressure or acumassage are effective alternatives to needles for treating children with needle phobia. acupuncture and traditional chinese medicine (tcm) have been used in asia and europe to treat a wide spectrum of childhood illnesses. their use in the united states has been recent but is growing rapidly in popularity. naturopathy ranks with acupuncture as the third most common complementary therapy used by children, although scientific data are sparse. currently, evidence-based information is limited about safety and efficacy of herbal remedies, especially in terms of dosage and application in infants and children, who may be more susceptible to some of the adverse effects and toxicities because of differences in physiology and immature metabolic enzyme systems. , other cam treatments used in children include touch therapy (therapeutic touch), osteopathy, oligotherapy, and hypnosis. religious practices such as prayer have also become prevalent in the pediatric population. children have reported the ability to readily feel energy field from touch therapy. the increasing support for therapeutic touch (tt) , has been anecdotal with little scientific data. approximately % of children receiving treatment with cam therapies seek osteopaths, who claim success in treating many common childhood conditions, including colic and otitis. approximately % of pediatric cam visits are to oligotherapists, who administer poorly absorbed trace elements such as copper, manganese, and zinc to improve health. relaxation training and imagery are forms of hypnosis that have also been effective in children. in fact, children seem to be able to learn relaxation training better and faster than adults. table - summarizes the cam therapies most often used to treat various pediatric conditions. box - lists additional and recent surveys and reviews of cam therapies used to treat pediatric conditions. vaccination is an essential component of pediatric well-child care and has both public health and educational ramifications because up-to-date vaccination is required for vaccine safety is monitored closely. adverse events are reported to the vaccine adverse event reporting system (vaers), administered by the centers for disease control and prevention (cdc) and the u.s. food and drug administration (fda). approximately , adverse cases are reported each year. data are shared internationally by independent scientific experts on the joint committee on vaccination and immunization and committees of the medicines control agency. surveillance results in product withdrawal when there is clear evidence of a safety issue. currently, several serious pediatric conditions are controversially attributed to vaccination: immune compromise, neurologic sequelae, autism, and crohn's disease. the medical community has expressed concern about the effects of vaccination on an immature immune system, especially in neonates. controversial debates are ongoing regarding the possible connection between vaccination and autoimmune illnesses, such as the association between measles and anti-hepatitis b virus (hbv) vaccines with multiple sclerosis. tetanus toxoid, influenza vaccines, polio vaccine, and others have been related to autoimmune phenomena ranging from autoantibody production to full-blown illness, such as rheumatoid arthritis and guillain-barré syndrome. recent evidence suggests that autism may be related to the immune system. the mechanism of autoimmune reactions after immunization has not yet been elucidated. one possibility is molecular similarity between some viral antigen (or other component of the vaccine) and a self-antigen. this similarity may be the trigger to the autoimmune reaction. , before , whole-cell pertussis vaccine was used, composed of a suspension of formalin-inactivated bordetella pertussis b cells. convulsions occurred in case to doses administered, and acute encephalopathy occurred rarely, at . cases per million doses administered. sudden infant death syndrome (sids) and infantile spasms have also been suggested to be associated with diphtheria-pertussis-tetanus (dpt) vaccination. in the s, reports linking pertussis vaccine with infant brain damage attracted media attention, which in turn caused great parental and professional anxiety; the immunization rate fell from % to %. between and , three major pertussis epidemics occurred in the united states, resulting in more than , hospitalizations and at least deaths. in countries such as sweden, japan, united kingdom, ireland, italy, and australia, antivaccine movements targeted pertussis whole-cell vaccines. opponents to the pertussis vaccine have argued that the risks of vaccination outweigh the benefits. the largest study to date conducted by the national institute of child health and human development at the national institutes of health (nih) revealed that sids was actually less likely to occur in recently vaccinated infants. another large study showed that the permanent neurologic sequelae due to pertussis vaccine are so rare as to be unquantifiable. nevertheless, concerns about brain damage led to the development of acellular pertussis vaccine (dtap) that contains purified, inactivated components of b. pertussis cells. this form is associated with a lower frequency of adverse events and is more effective in preventing pertussis disease. dtap was first licensed for the fourth and fifth doses of the pertussis series in and for the primary series in . several studies conducted in europe and africa revealed that u.s.-licensed dtap vaccines have efficacy ranging from % to %. currently, only acellular pertussis vaccine is used. no encephalopathy has been reported. hypotonic hyporesponsive episode (hhe) is the sudden onset of hypotonia, hyporesponsiveness, and pallor or cyanosis that occurs within hours of vaccination, usually after pertussis vaccine administered to children under years of age. hhe occurred in approximately of every dta vaccinations. the largest published report of , cases concluded that although hhe does occur after the administration of dtap and other non-pertussis-containing vaccines, it is generally benign, self-limited, and nonrecurrent. the connection of encephalopathy with pertussis vaccine was biologically more plausible than the proposed link between pertussis, measles vaccines, and autism. the incidence of autism has increased from in , in to in in in some u.s. communities. a study of autistic children suggests that autism may be caused by a pertussis toxin found in the dpt vaccine. the toxin separates the g-alpha protein from retinoid receptors, which are critical for vision, sensory perception, language processing, and attention-characteristic problems of autism. those children most at risk have at least one parent with a preexisting g-alpha protein defect, presenting clinically with night blindness, pseudohypoparathyroidism, or adenoma of the thyroid or pituitary gland. natural vitamin a may reconnect the retinoid receptors. in recent years, discussion has increasingly centered on the controversy concerning the possible association of the measles-mumps-rubella (mmr) vaccine with autism and crohn's disease.* the chinese were among the first populations to vaccinate, beginning with smallpox vaccine, which was injected intranasally. tcm considers most childhood illnesses to occur at superficial levels, and vaccination actually introduces pathogens, still considered energetically active, into deeper blood levels of the body. in addition, tcm also posits that the body can usually effectively handle only one process at a given time. when two separate processes occur at the same time, the human system could become overwhelmed, especially the tender system of an infant or a young child. therefore, although multiple vaccines given at the same time are less traumatic for children and save nursing time, they can easily overwhelm an immature immune system and make the child weak and deficient. although the fear of epidemics motivates the chinese to vaccinate all their children, tcm practitioners in the west often advise against immunization. there is discrepancy among the homeopaths regarding recommendation of conventional vaccines. a german questionnaire survey reported that homeopathic physicians generally do not refuse vaccinations but show a preference for the dpt vaccines. a british survey conducted between and reported that preference for homeopathic remedies for illnesses and religion were the most common reasons parents refused immunization; % believed the risk of diseases to be less than the risk of vaccination and would seek homeopathic treatment if any illness developed in their children, and % believed that children "are protected by god and not by vaccines." a u.s. cross-sectional descriptive survey of homeopathic practitioners and naturopathic practitioners in massachusetts revealed that the majority of the practitioners did not actively recommend immunizations. many homeopaths recommend homeopathic vaccines, which are not yet supported by scientific data. a random sample survey by mail of % of american chiropractors revealed that one third believe there is no scientific proof that immunization prevents disease, that vaccinations cause more disease than they prevent, and that contracting an infectious disease is safer than immunization. a reported % believed that immunization should be voluntary and that spinal adjustment is a viable alternative. a crosssectional, descriptive survey of chiropractics in the boston metropolitan area reported that only % actively recommended childhood immunization. the decision of whether or not to immunize a child is difficult for both parents and practitioners. the advantages of vaccination are difficult to refute, but the temporal relationship between immunization and side effects and the controversies surrounding potential risks are disconcerting. although data are insufficient on cam approaches to vaccination today, practitioners should be aware of the slow yet steady trend toward alternatives and should properly address parental concerns and questions regarding immunization. each practitioner needs to inform parents of the most up-to-date pros and cons of vaccination, be as objective as possible, put aside personal belief systems, and be supportive and understanding of whichever decision the parents make. parents need to become as informed as possible, consider all the pros and cons, weigh the risks and benefits, and realize that ultimately they must live with the outcome of their decision. the common cold is the most frequent infection in children in the united states and throughout the industrialized world. a preschool-aged child has an average of to colds per year. the clinical symptoms vary greatly without any correlation with specific viruses. , the majority of the symptoms are mild, consisting of rhinorrhea, sneezing, nasal congestion and obstruction, postnasal drip, and cough. there may often be additional symptoms of low-grade fever, sore throat, clear eye discharge, digestive discomfort, and general malaise. , , some common viruses that cause upper repiratory tract infections (uris) include rhinovirus, coronavirus, adenovirus, respiratory syncytial virus (rsv), influenza virus, and parainfluenza virus. , , transmission varies with different viruses. for example, rsv spreads primarily through contact with symptomatic children and contaminated objects, whereas influenza spreads mainly through airborne droplets. the precise route of transmission for rhinovirus remains controversial. the virulence of rhinovirus is maximum in infants before year of age (median age . months) and in immunocompromised children. wheezing is associated with rsv in children younger than years of age and with rhinovirus in those over age . simultaneous infection by more than one virus, such as rsv and adenovirus together, can also occur frequently in the pediatric population. many children may also have associated bacterial infection, such as haemophilus influenzae conjunctivitis. the viruses gain entry into host cells through specific viral surface proteins, which cause tissue injury and result in clinical disease. recent studies suggest that the host's response to the virus, not the virus itself, determines the pathogenesis and severity of the common cold. proinflammatory mediators, especially the cytokines, appear to be the central component of the response by infected epithelial cells. , specific viral diagnosis is not necessary because of the benign, self-limiting nature of the disease and the prevalence of different viruses overlapping from fall to spring, which makes it difficult to determine precisely which virus or viruses are causing the symptoms. current medical management of uri remains symptomatic, controversial, and in most cases, ineffective. fluid, rest, humidifier, and saline nose drops constitute the mainstay of nonpharmacologic treatment. topical adrenergic agents do not have systemic side effects, but overuse can result in rebound congestion. , antihistamine and combinations of antihistamine with decongestants are the ingredients in at least over-the-counter (otc) cold remedies. the majority of studies have concluded that antihistamines are of marginal or no benefit in treating cold symptoms. , , , , dextromethorphan is an antitussive that is abundant in otc formulations. although this medication is reportedly safe when taken in the recommended dosages, there have been cases of "recreational" use by teenagers, and deaths by overdose have been reported. codeine is ineffective in controlling uri cough. medications are often overprescribed, leading to higher health care costs and dangerous side effects, such as greater antibiotic resistance. more steroids are prescribed, which leads to a myriad of complications. although interferon has been shown to produce good protection against infection, the high doses necessary to produce a prophylactic effect are often associated with serious undesirable side effects, including nasal stuffiness, bloody mucus, and mucosal erosions, and the trauma of daily intramuscular injection makes it an unlikely remedy for children. research for new medical therapies for the common cold is directed toward increasing resistance to or immunity against the viruses. histamine antagonists are not indicated in the common cold. antiinflammatory mediators and specific antiviral agents may be promising. development of an effective vaccine against the common cold is unlikely because of the large number of viral serotypes. rhinovirus, for example, has at least different immunotypes. although viral uri is a benign illness of short duration, it can lead to bacterial complications such as otitis media, sinusitis, lower respiratory tract infections, mastoiditis, and even meningitis. scientific data on cam treatment for the common cold are surprisingly sparse. in , linus pauling carried out a meta-analysis of four placebo-controlled trials and concluded that vitamin c alleviates cold symptoms, but subsequent reviews indicated that the role of vitamin c in uri is still controversial. [ ] [ ] [ ] although breast-feeding has been believed to protect against infection in infants, studies have been inconsistent in demonstrating its efficacy. in a -year prospective study that actively tracked breast-feeding and respiratory illnesses in healthy infants, breast-feeding was found to reduce significantly the duration of respiratory illnesses during the first months of life. a retrospective review from saudi arabia of randomly selected charts revealed that a direct correlation exists between duration of breast-feeding and frequency of uri in the first years of life. a hospital-based descriptive recall study from sri lanka examined the relationship between breastfeeding and morbidity from respiratory illnesses in infants. of the infants, were admitted and were controls. an inverse relationship was found between the length of breast-feeding and incidence of respiratory illnesses. a nutritional study of healthy newborns followed for months demonstrated that breast-feeding lowers frequency and duration of acute respiratory tract infection compared with formula feeding. a more recent japanese study examined the incidence of pathogenic bacteria isolated from the throat of healthy infants fed with different methods. no pathogens were detected in breast-fed and mixed-fed infants, while h. influenzae and moraxella catarrhalis were isolated from the oropharynx of formula-fed infants. the investigators suggest that breast milk may inhibit the colonization by respiratory bacterial pathogens of the throat of infants. the mechanism was thought to be enhancement of mucosal immunity against respiratory tract infection. in addition to the presence of secretory immunoglobulin a (iga), another mechanism may be the presence of complex carbohydrates in human milk. these glycoconjugates may exert various antipathogenic effects, such as inhibiting the binding of pathogens to the receptors and reducing the production of bacterial toxins. however, a u.s. study that examined nasopharyngeal swabs from infants at month of age and swabs from of these infants at months of age (keeping environmental parameters similar, e.g., number of children in household, number of siblings in day care, proportion with recent uri) revealed that the exclusively breast-fed (n = ) and exclusively formula-fed (n = ) infants did not differ significantly in the number of pathogens. a multicenter randomized trial was conducted in hospitals in the republic of belarus. evaluation within the first year revealed that breastfeeding had no significant reduction in respiratory tract infection compared with the control group. a survey from singapore of breast-feeding mothers at months postpartum revealed no significant differences in the rates of uri between breast-fed and non-breast-fed infants. data are sparse on acupuncture, herbal, and homeopathic remedies for treatment of uri, especially in children. most data are uncontrolled, clinical reports. current information on adults supports efficacy of acupuncture for treating the common cold. , , , acupuncture has been shown to increase the velocity of the nasal mucociliary transport in chronic rhinitis patients. one possible use of acupuncture in uri is its potential effect on the immune system. when chinese herbs were pasted onto acupoints for treating rhinitis and bronchitis in infant, serum immunoglobulin m (igm), igg, complement c , and especially iga levels increased. acupuncture has also been shown to increase t lymphocytes. even massaging local acupoints was effective in relieving symptoms and in enhancing immune functions, with increases in immune indices that persisted for at least months. one report of acu massage of only one point for just seconds resulted in clinical relief from nasal congestion, even though there was no change in nasal airway resistance or airflow. these reports are encouraging for parents because acupressure can be easily learned by nonprofessionals, is well tolerated by children of all ages (including infants), has no side effects, and costs nothing. a clinical trial administering a nontoxic chinese herbal mixture to infants demonstrated more than . % effectiveness in treatment of uri. in a single-blind trial using a chinese herb for acute bronchiolitis with serologic evidence of rsv, hospitalized children were randomized into three treatment groups: herbs, herbs with antibiotics, and antibiotics alone. herbal treatment was found to decrease symptoms and duration of illness without adverse effects. in a randomized, controlled trial using an herbal mixture, children in the treatment group demonstrated % efficacy versus % of children in the control group. there was no description in the abstract (original article in chinese) of what constituted control (e.g., placebo herb, no treatment, conventional drugs) or what constituted efficacy (e.g., improvement in symptoms, duration, of illness). further rigorous studies are needed to demonstrate safety and efficacy of herbal treatment. a recent clinical trial that included children over age years and used a fixedcombination homeopathic remedy for a mean . days of treatment reported that . % reported subjective feelings of being symptom free or significantly improved without complaint of any adverse side effects. a randomized, double-blind, placebocontrolled study from great britain of children with a starting median age of . years in the experimental group and . years in the placebo group concluded that individually prescribed homeopathic remedies seem to be ineffective in reducing symptoms or decreasing the use of antibiotics in pediatric patients with uri. otitis media (om) represents a continuum of conditions that include acute om, chronic om with persistent effusion, chronic suppurative om, recurrent om, unresponsive om, and om with complications. acute otitis media (aom) is most prevalent in young children to months of age. approximately two thirds of all children will have had at least one episode of aom before age years, and half of them will have recurrences or chronic serous om with effusion into early elementary school years. by the time the child reaches adolescence, aom occurs infrequently. almost one third of pediatric office visits are for treatment of aom. the most common etiologic factors are allergic rhinitis , and ascending bacterial or viral agents from the nasopharynx attributable to eustachian tube dysfunction. the most common viral culprits are rsv, influenza virus, and adenovirus. two thirds of middle ear infections are caused by bacteria. the predominant organisms are pneumococci, h. influenzae, m. catarrhalis, , , , and group b streptococcus. bacterial pathogens adhere to mucous membranes, and colonization ensues. the severity of infection or the response to the invading bacteria depends on the health of the child's immune system. the humoral system is especially significant in protecting the middle ear cavity from disease, and the nasopharyngeal lymphoid tissues are the first line of defense against bacterial colonization. , the sterility of the eustachian tube and tympanic cavity depends on the mucociliary system and on secretion of antimicrobial molecules, such as lysozyme, lactoferrin, and betadefensins. evidence indicates that a number of children with recurrent episodes of aom have minor immunologic defects. pneumococcus is by far the most virulent of aom bacteria. it causes approximately million cases of om annually in the united states. uncontrolled pneumococcal otitis can lead to meningitis. the incidence of aom is higher in winter and early spring. clinically, the child with aom presents with earache and fever, usually accompanied by upper respiratory symptoms such as rhinorrhea. on otoscopic examination the tympanic membrane varies from hyperemia with preservation of landmarks to a bright-red, tense, bulging, distorted appearance. in advanced stages of suppuration the tympanic membrane ruptures with a gush of purulent or blood-tinged fluid from the ear. because viral or bacterial om usually cannot be distinguished by otoscopic examination, aom is usually treated empirically, using antibiotics such as amoxicillin that have a high concentration in the middle ear fluid. , however, the widespread use of antibiotics has resulted in increasing resistance to the more common medications. , currently, % of children with aom are recalcitrant to antibiotic therapy. the prevalence of resistant organisms tends to increase in the winter months. economically, treatment failure due to drug resistance has been responsible for further escalating the billions of dollars spent treating aom. in addition, antimicrobials suppress normal flora, which is beneficial to the host because the antibiotic can interfere with and therefore prevent pathogenic infections and may enhance recovery from uris. on the other hand, since the advent of antibiotics, complications such as mastoiditis and intracranial infections have significantly decreased. the current focus is on prevention of aom. breast-feeding confers lifesaving protection against infectious illness, including otitis. , pneumococcal conjugate vaccine (pcv), approved in for use in the united states, covers the seven serotypes that account for about % of invasive infections in children younger than age years. pcv was demonstrated to have more than % efficacy and has resulted in a modest reduction of total episodes of aom. the goal of pcv is to prevent symptomatic infections in the middle ear and prevent colonization of the pneumococci that can cause subsequent middle ear infections. pcv may eliminate nasopharyngeal carriage of pneumococci. however, because pcv only prevents disease caused by the most common serotypes, there is concern that the nonvaccine serotypes will become more common, especially in children less than years of age. an effective rsv vaccine for the infant and young child could greatly decrease om disease. intranasal spray of attenuated viruses is currently under investigation, in the hope that early antiviral therapy would reduce the risk of om after uri. , chronic otitis media with effusion (ome) is one of the most common diseases in childhood. ome is associated with infection, eustachian tube obstruction, allergic or immunologic disorders, and enlarged adenoids. the serous fluid still contains bacteria, such as h. influenzae and pneumococci. ome has been implicated to be an immune-mediated disease because immune complexes have been demonstrated in the middle ear effusion, and highly organized lymphatic tissue has been found in the middle ear mucosa. the rationale for treating ome is prevention of recurrence of aom. currently, a once-daily antibiotic regimen is the recommended prophylaxis. the benefit is also weighed against the increasing risk of emergence of resistant bacteria. when antibiotics fail to control recurrent om, a short trial of prednisone may be prescribed. surgery is recommended when medical treatment fails, especially when the child has hearing loss. tympanostomy tubes appear to be beneficial in ome but are of less value in chronic suppurative otitis. increase in hearing loss has been reported with insertion of ventilation tubes. adenoidectomy is sometimes recommended, especially after tympanostomy tube failure. any safe and effective cam therapy for om would be an important contribution to the pediatric population. large-scale, randomized, controlled studies for cam treatment would need medical collaboration, especially for otoscopic examination and tympanometry. in addition, since aom has a high rate of spontaneous resolution, any clinical study must also prove that treatment effect is faster than natural improvement. although breast-feeding has been found to reduce uri, data concerning its association with frequency or duration of om have been conflicting. epidemiologic reports consistently provide evidence of protection of young children from chronic otitis with prolonged breast-feeding. a u.s. study that followed infants at well-baby visits in two suburban pediatric practices reported that the cumulative incidence of first om episodes increased from % to % between and months of age in infants exclusively breast-fed versus % to % in infants formula-fed from birth. there was a two-fold risk of first episodes of aom or ome in formulafed babies in the first months. a danish study that evaluated infants using monthly questionnaires reported no statistical difference in the breast-fed versus formula-fed infants in incidence of om. an earlier jewish study comparing infants visiting a pediatric ed with healthy infants found that breast-feeding significantly reduced infectious diseases, including om in infants under months of age. a study from switzerland evaluated children with aom by administering individualized homeopathic medicine in the pediatric office. if there was insufficient pain reduction after hours, a second (different) homeopathic medicine was given. antibiotics were given if there was lack of response to the second dose. pain control was achieved in % of the patients after hours, with another % after hours. the resolution rate was . times faster than in placebo controls. no complications were observed in the study group. in a u.s. double-blind, placebo-controlled pilot study, children ages months to years with ome and ear pain and/or fever for more than hours were randomized into individualized homeopathic medicine or placebo group. no statistically significant results were noted. a british nonblinded, randomized pilot study was done with children ages months to years who had ome and hearing loss greater than db and an abnormal tympanogram. the results revealed that the homeopathy group had more children with a normal tympanogram, fewer referrals to specialists, lower antibiotic consumption, and a higher proportion with a hearing loss less than db at follow-up. however, the differences were not statistically significant. further research with larger groups is needed for a definitive trial. in a prospective, observational study carried out by one homeopath and four conventional ear-nose-throat (ent) physicians, a single (nonindividualized) homeopathic remedy was compared with nasal drops, antibiotics, and antipyretics. children between months and years of age were included in the study. homeopathic treatment was given to children and conventional treatment to children. homeopathic remedies were found to be significantly more effective in reducing duration of pain and in preventing relapses. because om tends to affect predominantly young children, it would be more appropriate for studies to compare results in children of similar age rather than a wide range of ages, from infancy to preadolescence. a retrospective, nonrandomized study of children under years of age receiving weeks of treatment from a single chiropractor reported a decrease in om symptoms. the limitations to this study included retrospection and a lack of comparison with the natural course of ear infections. an israeli controlled clinical trial examined the efficacy and tolerance of ear drops made with naturopathic extracts in the management of aom pain. ranging in age from to years, children were randomized into the treatment group and control group using a conventional anesthetic ear drop. there was statistically significant improvement in both groups, indicating that the naturopathic ear drops were as effective as the anesthetic ear drops. the university of arizona has initiated a study of the use of echinacea, a dietary supplement, in the prevention of recurrent om. acupuncture data are lacking on treatment of om in children. the theoretical potential benefit of acupuncture would appear to be its effect on the immune system, as discussed in the section on uri. allergic rhinitis affects % to % of children. perennial rhinitis is related to allergens that children are exposed to continuously, such as animal dander, house dust mites, mold, and feathers. seasonal rhinitis is related to seasonal pollenosis and rarely affects children under age or years. allergic diseases are major causes of morbidity in children of all ages, , , and allergic rhinitis is a significant cause of middle ear effusions. , , , conventional therapy usually consists of avoidance of allergens, use of air-clearing devices, desensitization shots, and medication with antihistamines and at times steroids, both of which are frequently abused. , antihistamines may be beneficial when sneezing and itching are present. cam therapy is common among children with allergic diseases in sweden and is becoming more popular in the united states, although scientific data specifically on children are still lacking. physicians have become more aware of the importance of nutrition , and environmental factors in the development of allergic symptomatology in childhood. , , a prospective, longitudinal study of healthy infants followed from birth to years of age concluded that recurrent wheezing is less common in nonatopic children who were breast-fed as infants. hypnosis has been reported anecdotally to be effective in hay fever. homeopathic efficacy has received increasing attention in recent years, but data consist of adult studies. an international multicenter study involving investigators in four countries and patients with three diagnoses, including upper and lower respiratory tract allergies, concluded that homeopathy appeared to be at least as effective as conventional medicine. another multicenter study using a randomized, double-blind, placebo-controlled parallel group design also demonstrated that homeopathic preparations differ from placebo for allergic rhinitis. homeopathic remedies for allergic children are unsupported by scientific studies at this time. an adult study using changes in conductance of specific acupuncture points for diagnosis and treatment demonstrated statistically significant changes that correlated with clinical improvement. in a randomized study of patients that included older teenagers, desensitization was compared with specific acupuncture treatment for allergic asthma, allergic rhinitis, or chronic urticaria. the study was ridden with multiple, tedious variables. the conclusion that acupuncture was significantly more effective than desensitization in improving symptoms and in reducing recurrence in all three conditions did not give a breakdown in age groups. in a clinical report of chronic allergic rhinitis cases that included three cases in children to years of age and cases in -to -year-olds, two different acupuncture treatments were administered according to tcm diagnoses. there was a cumulative % cure rate without age differentiation. asthma is the most common cause of chronic illness in childhood, with approximately % of children in the united states carrying the diagnosis. , , a significant number of school days are lost because of asthma. a wide variation of incidence is found in different countries, with the highest rates in the united kingdom, australia, and new zealand and the lowest rates in eastern europe, china, and india. , in recent years, prevalence of asthma is increasing worldwide, especially in children under years of age. , although asthma can have onset at any age, % to % of asthmatic children have their first symptoms before to years of age. children up to age years have distinct symptoms and require special consideration. they have increased health service utilization, including a higher annual rate of hospitalization, which has almost doubled in the united states from to for children to years of age. the same trend is observed by other nations worldwide. , among american children ages to years, asthma death rates almost doubled from to . new zealand and canada have observed a similar increase in severity and mortality. , asthma is a diffuse, reversible, obstructive lung disease with three major features: bronchial smooth-muscle spasm, edema and inflammation of the mucous membrane lining the airways, and intraluminal mucus plugs. during the last two decades, chronic airway inflammation, rather than smooth muscle contraction alone, has been recognized as playing the key role in the pathogenesis of asthma in adults. , although this association is less well established in children, recent guidelines for managing asthma in the pediatric population still have emphasized that treatment be directed toward the inflammatory aspects of the disease. , , chronic inflammation is caused by the local production of inflammatory mediators and an increase in recruitment of inflammatory cells, predominantly eosinophils and mast cells. studies in young adults suggest that the chronic inflammation may be responsible for longterm pulmonary changes, including bronchial hyperresponsiveness, airway remodeling, and irreversible airflow obstruction. because of difficulties in conducting studies in infants and young children, pediatric information is incomplete. limited studies have detected increases in inflammatory cells and thickening of the lung basement membrane in infants and young children and have found that asthmatic children have significantly lower lung function at years of age compared with nonwheezers when both groups of children began with the same baseline at age months. these data support the possible presence of an asthmalike inflammation at a very early age that is associated with nonreversible impairment of lung function. the excessive inflammatory changes indicate that asthma is caused by a poorly regulated "immunologic runaway response" that, instead of protecting the host, destroys normal structure. increased concentrations of proinflammatory mediators, such as histamine and leukotrienes, are found in the airways as well as the blood and urine of asthmatic patients during an acute attack and after allergen and exercise challenge. strong evidence correlates asthma with rsv infection; children who enter day nursery before age months and who are exposed to viruses early in life have built up immunity, with decreased development of allergies. in most children, whose asthma is triggered mainly by respiratory infections at a younger age, asthma symptoms appear to remit by the adolescent years. in older children and teenagers, emotions play a significant role both as the cause of symptoms and as the result of interplay of a chronic illness affecting the child's self-image and family dynamics. the latest asthma management guidelines classify pediatric asthma into four groups of severity: mild intermittent, mild persistent, moderate persistent, and severe. mild intermittent asthma can be typified by exercise-induced asthma, a common pediatric condition. status asthmaticus, defined as progressive respiratory failure that does not respond to conventional management, is becoming more prevalent in american children. conventional treatments for pediatric asthma vary from allergen avoidance to state-of-the-art biochemical therapy. avoiding allergens has been a successful management of asthma since the sixteenth century. asthma is a much more complex problem today because of the increasing number of pollutants and chemicals in the environment that are potential allergens for children. parental education, especially in regard to smoking, can reduce hospital admissions. because infections that trigger asthma attacks are mostly viral, antibiotics are not routinely indicated. medication consists primarily of bronchodilators and inhaled steroids, which are now justified as first-line therapy, both as long-term management and for acute attacks. because growth suppression due to inhaled corticosteroids has been well documented, it is important to distinguish infants with early-onset asthma from those with transient wheezing. recently, the fda has also approved leukotriene receptor antagonists for use in asthmatic children under years of age. these agents counteract the hyperimmune response, resulting in diminished airway inflammation and decreased eosinophilia in the airway mucosa and peripheral blood. parents turn to cam for their asthmatic children because of drug side effects or fear of taking long-term medication, especially steroids. , a recent survey from texas of multicultural parents of children with asthma reported the usage of a variety of cam therapies, including homeopathy, herbal therapy, vitamins, and massages. hispanic parents were more likely to use herbal and massage therapies, whereas african-american parents often turned to prayers. the relatively abundant studies on cam therapy in asthma are on adults and often have flaws in methodology. significant improvement , , and even complete cure have been demonstrated with hypnosis, although most studies had weak designs. hypnosis was recommended for children because they were found to be more hypnotizable, but it is unclear whether the efficacy of hypnosis in asthmatic children is a reflection of children's greater suggestibility or a result of a more reversible disease process. in a recent preschool program, children ages to years received treatment with seven hypnotherapy sessions. the number of physician visits was reduced, and parental confidence in self-management skills increased. tcm has been used to treat asthma for centuries. asthma epitomizes the chinese medicine concept of "winter disease, summer cure," which means the best treatment for asthma should be given during the summer, when the child is symptom free. in china, many asthmatic children who were treated with herbal patches applied to acupoints during the summer had minimal or no symptoms during asthmatic seasons. , , although several recent adult studies used herbs for asthma, only two involved children. a controlled study comparing herbal treatment of children with penicillin and aminophylline treatment of another children revealed no significant difference in the response from the two groups. a multicenter doubleblind, placebo-controlled clinical herbal study from taiwan evaluated asthmatic children using tcm diagnoses. the children were randomized into three different herbal and placebo groups. although both groups showed improvement, the herbal groups showed greater improvement in symptomatology and in biochemical changes, such as increase in total t cells and decrease in histamine. an animal experiment using a -herb concoction revealed . % efficacy in easing bronchial spasm. another animal study with an herbal preparation demonstrated strong smooth muscle relaxation through inhibition of histamine and acetylcholine. from the pediatric standpoint, it would be worthwhile to follow the development of external tcm approaches and noninvasive acupuncture. one clinical obser-vation of pasting chinese herbs to acupuncture points in infants with acute bronchitis showed high cure and improvement rate, especially in infants. humoral immune substances, especially iga, were found to be increased after treatment. another clinical observation reported % efficacy in children treated with external application of plasters made of herbal mixtures with antitussive and antiasthmatic properties and % efficacy in children treated with antiasthmatic herbal patches. success was also reported with a different herbal patch for acute attacks. the patches were well received by the children. improvement from acupuncture treatment has been reported in asthmatic adults. , , , despite methodologic weaknesses, it still seems that acupuncture may help asthma, especially drug-induced or allergic asthma. in some european countries, almost a fourth of general practitioners believe in the efficacy of acupuncture in the treatment of asthma. its role in the united states is still controversial; some physicians accept acupuncture's effectiveness, whereas others criticize data based on poorly conducted studies. the few current studies and clinical reports on acupuncture treatment of children with asthma are generally favorable. , a german practitioner reported good results treating asthmatic children using a simple acupuncture regimen in uncontrolled clinical experience. one study demonstrated that although acupuncture did not affect the basal bronchomotor tone, when administered minutes before exercise, acupuncture was shown to be effective in attenuating exercise-induced asthma, which is common in children. one possible mechanism of acupuncture is in reducing the reflex component of bronchoconstriction, but not in influencing direct smooth muscle constriction caused by histamine. for children who are fearful of or who cannot tolerate needles, safe and painless treatments such as cupping and auricular press pellets, laser acupuncture, , and massage of acupuncture points have also been found to be effective. the most interesting future role for acupuncture in asthma lies in its potential both in stimulating an immune response and, more importantly, in regulating or modulating a hyperimmune response. at this time, ample biochemical data in the literature support the theory that acupuncture activates both the humoral and the cellular immune systems to protect the host.* studies have also demonstrated that acupuncture can modulate the synthesis and release of proinflammatory mediators. , , current hypotheses suggest that this is most likely mediated through a common pathway connecting the immune system and the opioids, , , which has been well known to be associated with analgesic effects of acupuncture. homeopathic remedies have been reported to be remarkably effective in asthma in adults, , , and homeopathic doses of allergens have been shown to alleviate allergic symptoms and desensitize patients to allergens. however, there is paucity of scientific data on homeopathy in both children and adults, as well as a lack of consensus among homeopaths as to the appropriate treatment, administration regimen, or potency for asthma. homeopathic practitioners believe that in chronic conditions such as asthma, homeopathic remedies can stimulate the child's innate healing ability, thereby leading to improvement. , two recent large reviews on the role of homeopathy in clinical medicine concluded that, except for the occasionally demonstrated benefit, little scientific evidence exists to support the use of homeopathy in most clinical settings. , the availability of homeopathic, nutritional, and herbal remedies without a prescription is appealing to the asthmatic adolescent's desire for independence. in a number of european countries, chiropractic is often used for treatment of asthma. one of the many difficulties in evaluating chiropractic efficacy lies in the varying abilities of the manual therapy practitioners. natural human differences exist in manual applications and techniques. the practitioners have various training backgrounds, including physiotherapy, respiratory therapy, chiropractic, and osteopathy. a danish questionnaire survey of families with children up to age years reported that % of parents who sought chiropractic help considered the treatment beneficial for their children. , an australian survey reported that the most common cam visits were to chiropractors. a u.s. prospective, observer-blinded, clinical pilot evaluated children from to years of age with mild to moderate persistent asthma for chiropractic treatment in addition to optimal medical management. children were randomized into treatment and sham spinal manipulative therapy (smt) for months. the children with combined smt and medical treatment rated their quality of life substantially higher and their asthma severity substantially lower, and their improvements were maintained at -year follow-up. however, there were no significant changes in lung function or hyperresponsiveness. further research is needed to determine which components of the chiropractic encounter are responsible for the improvements. a controlled, patient-blinded trial of chiropractic manipulation for children with mild or moderate asthma randomized the children into an active or a simulated chiropractic manipulation for months. each subject was treated by of participating chiropractors, selected by the family according to location. no significant benefit was observed in the treatment group. a few studies in adults generated statistically insignificant data. one study found subjective but not objective improvements in individuals with asthma who received treatment in a chiropractic clinic. a systematic review revealed that the majority of the studies on smt had poor methodology; the two good studies did not demonstrate significant differences between chiropractic smt and sham maneuver. the reviewers concluded that the evidence is still insufficient at this time to support the use of manual therapies for patients with asthma. a german pilot study of children ages to years with bronchial asthma combined relaxation using various techniques, including progressive muscle relaxation, autogenic training, fantasy travels, mantras, and periodic music, and demonstrated significant improvement in a number of pulmonary function parameters. however, it is difficult to interpret the results because of the variety of techniques used. a u.s. review of anecdotal reports indicated that massage therapy can improve asthmatic symptoms. [ ] [ ] [ ] diarrhea acute diarrhea is a common occurrence in the pediatric population and a significant cause of pediatric morbidity and mortality in both developed and underdeveloped countries. , , each year an estimated , to , u.s. children are hospitalized for diarrhea, and more than million infants and young children worldwide die of acute infectious diarrhea. infants under months of age have the highest risk for hospitalization and mortality. children under age years have an average of approximately . episodes of gastroenteritis per year in the united states. , internationally, the average is approximately . episodes annually. both diagnosis and treatment continue to be problematic in the pediatric population. the infectious pathogens that cause acute diarrheal episodes in children include viruses, bacteria, and parasites. transmission is most likely through the fecal-oral route, from ingesting contaminated food or water, or in infants and toddlers, by mouthing contaminated toys. the nature of food-borne diseases is changing as more mass-produced, minimally processed, and widely distributed foods result in nationwide and international outbreaks of diarrheal disease instead of just a few individuals who shared a meal. a majority of the cases are caused by viral infections. rotavirus is the most prevalent, and human astrovirus (hastv) is a significant cause of diarrheal outbreaks. frequently, children are co-infected by several viruses. viral diarrhea tends to involve the small bowel, producing large, watery, but relatively infrequent stools. these illnesses usually have short, self-limiting courses, typically lasting to days. however, the diarrheal bouts can be devastating to children with compromised immune systems or structural abnormalities of the gastrointestinal tract. the most common bacterial agents are enteropathogenic escherichia coli, shigella/salmonella, and campylobacter. , these are much more virulent pathogens that usually cause mucocal injury in the small and large intestines, producing frequent, often bloody stools containing leukocytes. e. coli has become an important public health problem in recent years, causing more than , cases of infection and up to deaths per year in the united states. , transmission of infection is most often linked to consumption of contaminated meat, water, unpasteurized milk, leafy lettuce, alfalfa sprouts, and goat's milk, , and exposure to contaminated water in recreational swimming sites. the most common parasitic infection is giardia lamblia, which often causes secretory diarrhea without blood and frequently leads to chronic diarrhea. diagnosis and treatment are still inconsistent. because most acute diarrheal conditions are self-limited, physicians often do not obtain stool cultures or examination for ova and parasites because the results are not available sometimes for several days. stool culture can identify different types of bacteria, but detection of specific enteropathogenic strains of e. coli requires specific serotyping that is not performed in routine stool cultures. it is expensive, time-consuming, and often not sufficiently specific or sensitive and therefore is not recommended for routine diagnosis. the primary treatment focus is on correction of dehydration, which is the most important cause of morbidity and mortality in acute diarrhea. oral rehydration treatment (ort) with solutions containing appropriate concentrations of electrolytes and carbohydrates is recommended by the world health organization (who) and has significantly reduced mortality. , , after rehydration, early refeeding with a lactose-free or normal, age-appropriate diet is important for reducing diarrheal duration, severity, and nutritional impact. supplementation with specific dietary ingredients that are lost in diarrhea, such as vitamin a, zinc, and folate, is also recommended. because most of the acute infectious diarrheal conditions are viral, patients do not require antimicrobial therapy. , the rotavirus vaccine was put on the market in the united states in october . this vaccine, as the natural infection, decreases the risk of acute rotavirus diarrhea by % and the risk of severe diarrhea with dehydration by more than %. improving hygiene such as handwashing is also important, especially in day care. breast-feeding is one of the most important preventive measures. continuation of breast-feeding has been found to control acute diarrheal episodes and lower the frequency and duration of acute diarrhea, especially in infants under months of age. a large-scale randomized trial was conducted in hospitals in the republic of belarus. evaluation within the first year revealed that breast-feeding significantly reduced the risk of gastrointestinal tract infection compared with the control group. however, a survey from singapore of breast-feeding mothers at months postpartum revealed no significant differences in the rates of diarrheal diseases between breast-fed and non-breast-fed infants. treatment with antimicrobial therapy must be instituted carefully and only with specific identification of pathogen and drug sensitivity. with the increasing frequency of antibiotic resistance, common antibiotics may be ineffective in patients with acute diarrhea. , , treatment of salmonellosis with antibiotics can prolong the carrier state and lead to a higher clinical relapse rate. injudicious antimicrobial therapy may also lead to susceptibility to other infections, enhance colonization of resistant organisms, , and disrupt the normal intestinal flora, the body's natural defense against infection. homeopathy has the most convincing evidence of efficacy in treating diarrhea in children. a randomized, double-blind clinical trial comparing homeopathic medicine with placebo in the treatment of acute childhood diarrhea was conducted in nicaragua in . eighty-one children months to years of age were given treatment with individualized homeopathic medicine. standard ort was also given. there was a statistically significant decrease in the duration of diarrhea in the treatment group. although criticisms of the study include homeopathic theory being inconsistent with scientific belief and possible toxicity of the dilute homeopathic remedies, the report was also praised for being an impressive, well-designed study that paves the way for future research into the efficacy of homeopathy and other cam therapies. using the predefined measures based on the study, the same group of researchers more recently carried out a similar study and replicated the same findings of decrease in the duration of diar-rhea and number of stools in children in nepal, ranging in age from months to years. a few studies have demonstrated effectiveness of acupuncture in pediatric diarrhea. the treatment protocols in point selections generally depend on tcm diagnoses, with the majority of points chosen on the two major digestive channels. , , , , acupuncture has also been shown to induce favorable anatomic and biochemical changes in improving intestinal peristaltic function and in enhancing both humoral and cellular immunity. a randomized study comparing shallow acupuncture treatment (needles inserted superficially and withdrawn swiftly) with drugs in children ages to months reported significantly higher therapeutic effect in the acupuncture group. the diagnosis and subsequent choice of points were based on tcm principles, not on stool culture results. unlike the homeopathy study, this investigation grouped together patients with acute and chronic diarrhea. in a clinical trial using one chinese herbal formula for treatment of acute diarrhea, there was significant reduction of symptoms and duration of diarrhea. a clinical report of years' application of a seven-herb concoction in children demonstrated . % improvement and % cure rate. this nonrandomized, nonblinded report used tcm diagnoses that encompassed a variety of diarrheal conditions, including acute, chronic, infectious, and noninfectious diarrhea. the mechanisms were hypothesized as eliminating pathogenicity, improving immunity, accelerating intestinal digestion, and inhibiting intestinal peristalsis. in a clinical report comparing chinese herbs to western medicine in children with diarrhea due to rotavirus, the herbs were reported to be superior and had a viral inhibitory rate of . %, but no mention was made of the efficacy of conventional medicine. chronic nonspecific diarrhea of childhood differs from acute diarrhea in that it is not associated with significant morbidity. once potentially serious causes are excluded, appropriate diet can be instituted to minimize complications, and reasonable time is then allowed for spontaneous resolution. in a nonrandomized clinical trial involving children ages months to years with chronic diarrhea of to months' duration that was unresponsive to western medicine and tcm, individualized acupuncture treatment eliminated symptoms and normalized stools. infantile colic is estimated to affect % to % of all infants under months of age and remains a medical enigma of nature versus nurture. colic may represent a heterogeneous expression of developmental variance, unmet biologic needs, psychologic or emotional distress from poor parent-infant interaction, intrinsic temperamental predisposition, colonic hypermotility, or milk allergy.* although colic is selflimiting by to months of age, treatment is mandated because the psychologic consequences may result in a disturbed mother-infant relationship. , evidence suggests that uncontrollable crying is the precipitating factor in many cases of infant abuse. , because the precise etiology is not understood, the therapeutic goal of western medicine is not aimed at "curing" colic but at containment of the crying. removing cow's milk protein from the mother's diet, changing formula, and prescribing antispasmodic medications are the mainstays of conventional treatment and may be helpful. treatment is often directed toward behavioral changes in mothers. parents may be referred for therapy to learn parenting and coping skills. cam treatments yield inconsistent results. herbs have not yet been proven to be efficacious, although a survey of hispanic mothers in an urban neighborhood in texas revealed that herbal teas were commonly used for colic. evidence is controversial for chiropractic treatment of colic. a multicenter prospective, uncontrolled study of colicky infants involving chiropractors in clinics in the united kingdom for months demonstrated efficacy with chiropractic smt in controlling colic, as reported by mothers in % of cases. a retrospective questionnaire study in revealed satisfactory results of chiropractic treatment in % of infants. a randomized, blinded, placebo-controlled clinical trial of infants with typical colic reported that chiropractic manipulation was no more effective than placebo. however, a randomized, controlled, -week trial comparing smt with the drug dimethicone demonstrated significantly better results in the chiropractic treatment group. craniosacral therapists empirically claim success in treatment of colic. massage therapists have also found empirically that touch therapy can decrease severity of colic. in a finnish clinical trial, infants less than weeks of age perceived as colicky by their parents were randomized into an infant massage group (n = ) and a crib vibrator group (n = ). over weeks there was no difference in the reduction of colicky crying between infants receiving massage and those with a crib vibrator, leading the investigators to conclude that the decrease of crying reflects more the natural course of early infant crying and colic than a specific effect of intervention. therefore infant massage is not recommended as treatment for colic. enuresis is defined as inappropriate or involuntary voiding during the night at an age when urinary control should be achieved. enuresis is a complex disorder with poorly understood pathogenicity and pathophysiology. it affects children worldwide, with about to million children affected in the united states and as many as % of school-age children in italy. the condition is classified as primary nocturnal enuresis (pne) when the child has never been dry at night or secondary nocturnal enuresis (sne) when wetting follows a dry period, usually after an identifiable stress. , by age years, % to % of children should have nighttime dryness. in % of pne patients, bedwetting is monosymptomatic, with a spontaneous remission rate of % per year of age. both the etiology and the pathophysiology of enuresis are still not well understood. multiple factors may interplay: genetic and psychologic predispositions, delayed maturation of the central nervous system, sleep disorders, urinary reservoir abnormalities, detrusor-sphincter incoordination, and urine production disorders. although enuresis is benign, treatment is warranted because of adverse personal, family, and psychosocial effects. , nocturnal enuresis delays early autonomy and socialization because of a decrease in self-esteem and self-confidence and a fear of detection by peers. the child may be at increased risk for emotional or even physical abuse from family members. , the conventional treatment modalities are still controversial. because the vast majority of pne cases resolve spontaneously with time, treatment should carry minimal or no risk. the moisture alarm is both safe and inexpensive and should be the treatment of choice in most cases , , but is often the one least prescribed. , the medications imipramine and ddavp were frequently chosen as first-line treatment choices. adjunctive therapy may include bladder-stretching exercises, which have a success rate of %, and behavioral conditioning. numerous cam therapies are available for childhood enuresis; the most common are hypnosis, acupuncture, and biofeedback. less common cam therapies are chiropractic and nutrition management. hypnotherapy has been recognized by conventional practitioners as a potentially effective therapy. , uncontrolled studies have reported high rates of success. , , , , in one comparative study of imipramine and direct hypnotic suggestion with imagery for functional nocturnal enuresis in -to -year-old patients, % of the imipramine group and % of the hypnosis group had positive response. after termination of treatment, the hypnosis group continued practicing self-hypnosis. at -month follow-up, % of the hypnosis group maintained dryness compared with only % of the imipramine group. hypnosis and self-hypnosis were found to be less effective in younger children (ages to years) compared with imipramine treatment. hypnotherapy has the added advantage that nonphysician health care professionals, such as nurse practitioners, can easily learn the technique to help children. a recent review of controlled studies reported promising findings for hypnosis in children with enuresis, but none of the interventions can currently qualify as efficacious. a major limitation is the lack of treatment specification via a manual of its equivalent. the requirement that the child practice the self-hypnosis technique several times a day limits compliance with the program. acupuncture has been used as an effective treatment for enuresis since at least the s. current worldwide literature in general demonstrates its viability as either a primary or an adjunctive therapy for the enuretic child.* a turkish clinical study on subjects treated with electroacupuncture therapy reported a success rate of . %. acupuncture has been found to be successful both in decreasing the occurrence of enuresis during treatment and in exerting a long-term effect after treatment. , , parents also report a decrease in sleep arousal threshold. although the precise mechanism of acupuncture is still unknown, a multidisciplinary approach that included acupuncture demonstrated on electroencephalography (eeg) that treatment normalized activities of the cerebral cortex. data from china usually consist of clinical reports of large sample populations. results in one study of patients treated with acupuncture on only two body points demonstrated cure in patients ( %), improvement in , and no response in patients. number of treatments ranged from one to three in patients and four to six in . another study of enuretic children ages to years ( over years; oldest years) used tcm diagnosis of organ imbalance and different combinations of acupuncture points, with treatments constituting one course. the results showed that patients were cured, showed marked improvement, and were "effectively" treated. treatment using scalp acupuncture has also been reported to be successful. in one clinical study, children ages to years were treated for to sessions, and some needed a second course. cure was obtained in children, marked improvement in , improvement in , and no response in children. in all these clinical reports, subjects of a wide range of ages were included in the same study; the discussions were short and generalized, giving very few or no details about the children (e.g., types of enuresis, duration of enuresis, number of wet nights, types of improvement); the methods of treatment were laden with numerous variables (e.g., number of points, treatment courses). a clinical study from italy of children with bladder instability due to uninhibited contractions of the detrusor muscle reported that acupuncture treatment was successful in gradual elimination of enuresis in and improvement of symptoms in children. the mechanism was not clarified. a russian clinical trial of using acupuncture specifically for enuresis due to neurogenic bladder dysfunction demonstrated that acupuncture was beneficial in of children. in a clinical report of enuretic children, short-term success in reducing wet nights was % with acupuncture versus % with ddavp, whereas long-term success rates were % and %, respectively. a zagreb report of a clinical trial of acupuncture treatment on children with mean age of years who failed psychotherapy demonstrated a statistically significant decrease in enuresis even at months after treatment. a self-controlled regulating device operating on the principles of acupuncture was found to be effective in the treatment of nocturnal enuresis attributable to neurogenic bladder dysfunction. a controlled clinical study of children between and years of age randomly selected into four groups of : treatment with ddavp alone, acupuncture alone, combined ddavp with acupuncture, and placebo. efficacy of treatment, expressed as a percentage of dry nights, was high in both ddavp and acupuncture groups, but the combined-treatment group had the best results. a scandinavian clinical trial used traditional chinese acupuncture for treatment of primary persistent pne in children ranging in age from to years. the response rate was monitored at -week, -week, and -month intervals. within months, ( %) of children were completely dry and ( %) were dry on at least % of nights, leading the clinicians to conclude that acupuncture is effective, with stable results. another scandinavian study investigated the efficacy of electroacupuncture in treating children ranging in age from to years. twenty treatments were administered over weeks. the number of dry nights consistently increased when the children were reevaluated at weeks, months, and months after treatment. five children had more than % reduction of wet nights at months, and % had more dry nights at the -month follow-up. a recent teaching round at the china academy of traditional chinese medicine in beijing discussed successful acupuncture treatment of a complicated case of enuresis in a -year-old student who had previously failed both western and chinese medicines for his physical and emotional sequelae. using tcm diagnosis of organ imbalances, the treatment combined body acupuncture, scalp acupuncture, and auricular acupressure seed. the patient began improving after three treatments in the first week. he received more weeks of treatment, with no recurrence of enuresis at month follow-up. children are often unwilling to undergo needle acupuncture because of fear of pain, prompting researchers to use noninvasive forms of acupuncture. simple acumassage has been previously reported to be beneficial to the enuretic child. an austrian prospective, randomized trial evaluated efficacy of laser acupuncture versus desmopressin in children over age years with pne. at -month follow-up, the desmopressin-treated group had % success rate with complete resolution of symptoms, an additional % had a more than % reduction in wet nights, and % did not respond. the laser acupuncture group had %, %, and % rates, respectively. the results were not statistically significant. therefore laser acupuncture should be considered as an alternative, noninvasive, painless, cost-effective, and short-term therapy in children with normal bladder function and high nighttime urine production. worldwide reports have demonstrated efficacy in treating enuresis with biofeedback, , , , which aims at learning or relearning of influence of involuntary functions. a clinical study from italy treated boys and girls ages to years with detrusor-sphincter dyssynergy. biofeedback was successful in all the children, with sne resolving significantly sooner than pne and girls responding better than boys. two-year follow-up still revealed an . % success rate, with % at years. in a french study, children with three predominant urinary disorders that included nocturnal enuresis were treated with biofeedback. detrusor-sphincter discoordination was diagnosed in children. pelvic floor biofeedback produced excellent results in these children. belgian investigators reported a clinical biofeedback study of children with median age of . years who did not respond to anticholinergics. seventeen subjects had complete resolution of enuresis, six had a decrease in symptoms, and one child did not respond. at -month follow-up, two children in the cured group had recurrence of enuresis. another study from belgium also reported success in using biofeedback in children with pseudo-detrusor-sphincter dyssynergy; were completely cured, and improved considerably. a spanish study used biofeedback to treat unstable detrusor in enuretic children; complete disappearance of symptoms was seen in . %, with improvement in . %. in a u.s. report of boys and girls ages to years who underwent an average of hours of biofeedback for nocturnal and diurnal enuresis, improvement was noted in % of nocturnal enuresis and % of diurnal enuresis. another u.s. clinical study used biofeedback for children with dysfunctional voiding; ( %) had an excellent response, ( %) had a fair response, and ( %) was too inconsistent to rate. the average number of sessions to achieve a consistent urodynamic response was . (range to ). average follow-up was months (range to months). the investigators recommended biofeedback as an effective method that requires only a short period for treating dysfunctional voiding. all these worldwide studies were clinical reports, not randomized, controlled, blinded studies. the efficacy of chiropractic manipulation in enuresis has been inconsistent. one clinical report identified an -year-old boy with functional enuresis who had successful treatment with manipulation. in an uncontrolled study of children ages to years, with responses monitored by parents, chiropractic manipulation resulted in only . % success. however, a randomized, controlled clinical trial of children demonstrated that % of the treatment group had % or more reduction in enuretic symptoms, although the pretreatment to posttreatment change in wet night frequency was not statistically significant, and there was no long-term follow-up. a comprehensive review of the literature revealed that smt was no more effective than the natural regression of enuresis with age. food allergy as a cause of enuresis has been in the literature for several decades. a recent study of children with severe migraine or attention deficit disorder (add) included children with enuresis. oligoantigenic diets were successful in curing children and improving enuresis in other children. relapse of wetting occurred when foods were reintroduced; the substances implicated most often were chocolate, citrus, fruits, and milk from cows. although no studies are available on naturopathic approaches, which focus on natural remedies (e.g., corn silk and tea, tea and honey), physicians should not dismiss parental opinion that these remedies may be safe and effective. the future of treatment for enuresis should combine various methods to increase the probability of treatment success and minimize risk to the child. atopic dermatitis affects almost % of all children and % of children ages to years. , it accounts for more than % of outpatient pediatric visits. most children with atopic dermatitis typically come to medical attention with cradle cap and facial and extremity rashes by age to months. despite considerable research, the etiology of allergic disease remains poorly understood. allergic dermatitis can be thought of as an inherited skin "sensitivity" that reacts to various external allergens and changes in psychologic states. food causes atopic dermatitis in % of infants, % to % of young children, and % to % of children after puberty. topical steroids remain the main therapeutic method. dermatologists tend to prescribe antibiotics and use potent topical steroids, which are more readily absorbed in children and can result in hypothalamic-pituitary-adrenal axis suppression. new immune modulators have shown promise in severe atopic dermatitis. , cam therapies are increasingly used for dermatitis, although most of the information is in clinical reports, and research data are limited. a database review of randomized clinical trials of atopic eczema covering at least different interventions revealed that evidence is still insufficient to make recommendations on maternal allergen avoidance for disease prevention, herbs, dietary restrictions, homeopathy, massage therapy, hypnotherapy, or various topical cam therapies. a multicenter randomized clinical trial conducted in hospitals in the republic of belarus reported that breast-feeding significantly reduced the risk of atopic eczema compared with the control group in the first year of life. psoriasis was found to worsen with cam treatments such as herbs, dietary manipulation, and vitamins. dietary management with evening primrose oil, rich in gamma-linolenic acid, has been found to be inconsistently effective in small studies. fish oil supplements (enriched in n- polyunsaturated fatty acids) have also been used. various herbs offer relief for eczema. a placebo-controlled, double-blind trial used a chinese herbal prescription specifically formulated for widespread nonexudative atopic eczema. thirty-seven children were randomly assigned to -week active treatment and placebo, with an intervening -week "washout" period. the response to active treatment was significantly superior to placebo, without evidence of hematologic, renal, or hepatic toxicity. the same investigators monitored the children over the following months. eighteen children had at least a % reduction in eczema, and five showed lesser degrees of improvement. two randomized, double-blind placebo-controlled trials from singapore revealed that a concoction of chinese herbs was efficacious in the treatment of atopic dermatitis in both children and adults, and that the mechanism may be through the beneficial immunosuppressive effects. toxicity is a concern, however, because exact dosing of the active derivatives is difficult to achieve. acupuncture treatment of acne has been reported to be successful in as many as . % of adolescents given treatment. other tcm techniques have also been reported to be helpful. a clinical trial treated children with severe, resistant atopic dermatitis with hypnosis. nineteen showed immediate improvement, maintained improvement in itching, and maintained improvement in sleep disturbance months after treatment. homeopathy is frequently used to treat dermatitis. in one homeopathic clinic in israel, more than % of the patients expressed satisfaction with treatment. however, the authors of the survey believed that homeopathic medicine complements conventional medicine and is not an alternative. chiropractic treatment has also been sought by children for allergic problems. a small british study tested the hypothesis that massage with essential oils (aromatherapy) used as a complementary therapy in conjunction with normal medical treatment would help to alleviate the symptoms of childhood atopic eczema. eight children were randomized into the treatment group, who were massaged with oil, and the control group, massaged without essential oil. no significant difference was found between the two groups. there was a later deterioration of eczema in the oil massage group, suggesting allergic contact dermatitis provoked by the essential oils themselves. attention deficit-hyperactivity disorder (adhd) is the most common neurodevelopmental disorder of childhood, with a prevalence rate between % and %, averaging about %. , , the road constellation of hyperactive, inattentive, and impulsive symptoms combined with the multiple comorbid conditions makes the definition and adhd controversial and the diagnosis flawed. adhd is a chronic, heterogeneous condition with academic, social, and emotional ramifications for the school-age child. the disabling symptoms persist into adolescence in approximately % of children and into adulthood in approximately %. , there is a developmental pattern in the primary symptoms of the disorder; hyperactivity diminishes while attentional deficits persist or increase with age. the precise etiology of adhd is still unknown, and assessment and management remain diverse. medication continues to be the mainstay of treatment, with methylphenidate (ritalin) the treatment of choice. the tricyclic antidepressants were added as an alternative medication in the s, with clonidine, buspirone (buspar), and other antidepressants and neuroleptics added to the list in the s. , although it is generally agreed that drugs are beneficial on a short-term basis, there is a paucity of data on the long-term efficacy and safety of medications, especially in children younger than years of age. these drugs have not been shown to produce long-term gains academically or socially. besides pharmacotherapy, a multimodal approach using a combination of drugs and other methods, such as cognitive-behavioral therapy (cbt), psychotherapy, social skills training, and school interventions, is frequently prescribed for adhd. cbt represents the most widely used alternative to pharmacotherapy, although previous studies have shown disappointing results. , , , in the national institutes of mental health (nimh) began a -month, multisite clinical trial, the multimodal treatment study of adhd (mta). , the results indicated that high-quality medication management (with careful titration and follow-up) and a combination of medication and intensive behavioral therapy were substantially superior to behavioral therapy and community medication management. there is slight advantage of combination of medication and behavioral therapy over medication alone. psychotherapy can be an effective adjunct to medication , but usually requires a long-term commitment to several years of treatment. concerns about side effects of medication, , treatment acceptability, , and compliance are additional factors that complicate management of the adhd child. clearly, there is room to explore safe, acceptable, and relatively easy alternatives. interest is increasing in more natural, holistic integrative approaches to adhd. studies using cam therapy for treating adhd encompass more than the usual research difficulties because of the complexity and heterogeneity of the disorder, as well as subjective evaluation by parents and teachers of a wide range of characteristics that may qualify for several different diagnoses. a majority of the cam therapies to date continue to have mostly anecdotal and empiric evidence. the few welldesigned studies include biofeedback, herbal medicines, dietary modifications or supplements, and acupuncture. studies have demonstrated that there is a significant difference in baseline eeg measurements in children with attention deficit disorder (add) compared with normal-achieving preadolescent males. these differences occur mainly in the parietal region for on-task conditions and in the cortex and corticothalamic excitatory and inhibitory interactions. , biofeedback or neurofeedback is a technique for modifying neurophysiology for learning. in a critical review of studies in which biofeedback was used as a treatment for hyperactivity indicated that biofeedback alone had not been effectively evaluated, and methodologic problems limit generalizations that it may be applicable to the entire hyperactive population. a review continues to indicate that although anecdotal and case reports cite promising evidence, methodologic problems coupled with a paucity of research preclude any definitive conclusions as to the efficacy of enhanced alpha and hemisphere-specific eeg biofeedback training. some recent studies using more sophisticated technology claim that neurofeedback can improve attention, behavior, and intellectual function in the child with add, , , with measurable eeg improvement in the frontal/central cortex. its stabilizing effect has also been found to last as long as years after treatment. hypnotherapy and biofeedback do not appear to alter the core symptoms of adhd but may be helpful in controlling secondary symptoms. these methods allow children to become active agents of their own coping strategies. a mailed questionnaire survey of children with adhd with a % response rate reported that % were using stimulant medication and that % of the respondents used or were using a nonprescription therapy. diet therapies constitute the most common cam therapy ( %). one review of cam therapy lends support to individualized dietary management and specific trace element supplementation in some children with adhd. nutritional management of add includes elimination diet, megavitamins, , supplements, and trace element replacement. simple sugar restriction seems ineffective. the well-known feingold diet eliminates natural salicylates, food colors, and artificial flavors. studies have demonstrated mixed results. megavitamins were demonstrated to be ineffective in the management of add in a two-stage study with clinical trial and double-blind crossover. potential hepatotoxicity is a major concern with use of megavitamins. in a recent longitudinal, nonrandomized clinical trial, adhd children were given a glyconutritional product containing saccharides known to be important in healthy functioning and a phytonutritional product containing flash-dried fruits and vegetables. five children were not receiving methylphenidate (ritalin), six children were taking prescribed doses of methylphenidate, and the remaining six children had their medications reduced by half after weeks. the glyconutritional supplement was administered for the entire weeks, and the phytonutritional supplement was added after weeks. the teachers and parents rated behavioral items for adhd, oppositional defiant disorder, and conduct disorder. the conclusion was that the glyconutritional supplement decreased the number and severity of adhd, associated odd and cd symptoms, and side effects of medications during the first weeks of the study; there was little further reduction with the addition of the phytonutritional supplement. the three groups did not differ statistically in degree or reduction of symptoms. this -week study had too many variables and too few subjects without control for a definitive conclusion, although the concept of simple nutritional supplement is important to explore. there is increasing interest in abnormality of fatty acid metabolism as the etiology of at least some features of adhd. these abnormalities can range from genetic abnormalities in the enzymes involved in phospholipid metabolism to symptoms that were reportedly improved after dietary supplementation with long-chain fatty acids. in a randomized, double-blind, placebo-controlled trial of docosahexaenoic acid (dha) supplementation, children ages to years receiving stimulant medication were randomly assigned to receive dha supplementation or placebo for months. there was no significant improvement in the treatment group. oligotherapy focuses on deficiency of trace elements in children with add. , in a polish controlled clinical trial, magnesium deficiency was found in blood and in hair of hyperactive children. fifty -to -year-old add children were given a magnesium supplement of mg/day for months while the control group of children continued on their medical regimen. increase in magnesium contents in hair correlated with a significant decrease of hyperactivity in the treatment group, whereas hyperactivity actually intensified in the control group. the same investigators also found deficiencies of copper, zinc, calcium, and iron, with magnesium being the most common deficiency, in children with adhd. a thorough literature review of alternative treatments for adhd identified cam therapies and reported that chinese herbal treatment has promising pilot data. a clinical trial using chinese herbs in the treatment of children with a diagnosis of hyperkinesia based on the american psychiatric association's diagnostic and statistical manual of mental disorders, ed revised (dsm-iiir) criteria demonstrated . % effectiveness in ameliorating hyperactivity and improved attention and school performance. the herbal remedy was prepared according to the tcm diagnosis of common energetic (qi) imbalance found in these children. clinical observations were substantiated by laboratory findings of significant increase in urinary content of norepinephrine, dopamine, dihydroxyphenylacetic acid, cyclic adenosine monophosphate, and creatinine. in a randomized study, chinese herbal treatment was found to be comparable to methylphenidate but had fewer side effects. research is currently being conducted to investigate the efficacy of herbal and homeopathic remedies because current evidence is inconsistent or lacking. in a prospective, randomized, double-blind pilot study funded by nih that integrated dsm-iv diagnostic criteria, conventional theories of frontal lobe dysfunction, and neurotransmitter abnormalities with traditional chinese theories of energetic imbalances, laser acupuncture was used in the treatment of adhd in -to -year-old children. preliminary data on the six children in the treatment group showed promise in reducing signs and symptoms of adhd. using conners scale as a weekly follow-up measure, improvement in classroom behavior was reflected by substantial drops in the teachers' scores before and after treatment in five of six children. the parents' scores dropped in three children but did not change in the other three children (figures - and - ). one child was promoted to the gifted program, and another demonstrated marked improvement in learning disabilities. there are no data at this time on homeopathic or chiropractic treatment of adhd, although many practitioners claim anecdotal success with the use of homeopathic desipramine (norpramin) and manipulation. pediatric use of cam therapies continues to increase. it is therefore advisable for physicians who treat children to take a thorough history of cam use, especially in those with chronic disorders, to become knowledgeable about the various alternative therapies that can complement conventional care. this allows practitioners to consider possible adverse effects or interactions of cam with conventional therapy, to open lines of communication with cam providers, and even to consider integrating effective cam therapy into their medical regimen. although cam therapy is in general considered safe, there have been a few reports of significant side effects. , continuous research is needed to investigate the safety and efficacy of cam therapies for children; to address explicitly the tremendous heterogeneity between and among the practices, beliefs, and providers of professional and lay services; and to study how cam may enhance the quality of mainstream health services. although children are entitled to new therapies, pediatric research in cam is further complicated by children's vulnerability to violation of their personal rights and to risk exposure. in children of the same age, varying cognitive capacity can be required for informed consent. , differences in physiologic maturation can change the kinetics, end-organ responses, and toxicity of therapy, so data from adult studies cannot be extrapolated for children. even in conventional medicine, children are often rendered "therapeutic orphans" because of history of abuses in pediatric research, a heightened sensitivity to risks in children-especially since the thalidomide disaster-and a limited market potential. in the united states, % of drugs have age limits or contain disclaimers for pediatric use. therefore protecting children by giving them only scientifically proven therapies is counterbalanced by denying them access to possible safe and effective treatment that may not be proven for many years to come. a frequently expressed concern is that visits to cam practitioners may cause delay in diagnosis. a more serious concern is the lack of formal pediatric training in many cam therapists so that they may fail to 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observation of cases cases of child bronchial asthma treated by auricular plaster and meridian instrument acupuncture of guanyuan (ren ) and baihui (du ) in the treatment of cases of enuresis effect of acupuncture on bronchial asthma acupuncture treatment of chronic rhinitis in cases immediate antiasthmatic effect of acupuncture in cases of bronchial asthma preliminary study of traditional chinese medicine treatment of minimal brain dysfunction: analysis of cases clinical and experimental study on yifei jianshen mixture in preventing and treating infantile repetitive respiratory infection clinical investigation on massage for prevention and treatment of recurrent respiratory tract infection in children pneumococcal conjugate vaccine for young children prevention of asthma morbidity: recent advances key: cord- -fyrbe tw authors: venkatesan, sudhir; myles, puja r; bolton, kirsty j; muthuri, stella g; al khuwaitir, tarig; anovadiya, ashish p; azziz-baumgartner, eduardo; bajjou, tahar; bassetti, matteo; beovic, bojana; bertisch, barbara; bonmarin, isabelle; booy, robert; borja-aburto, victor h; burgmann, heinz; cao, bin; carratala, jordi; chinbayar, tserendorj; cilloniz, catia; denholm, justin t; dominguez, samuel r; duarte, pericles a d; dubnov-raz, gal; fanella, sergio; gao, zhancheng; gérardin, patrick; giannella, maddalena; gubbels, sophie; herberg, jethro; higuera iglesias, anjarath lorena; hoeger, peter h; hu, xiao yun; islam, quazi t; jiménez, mirela f; keijzers, gerben; khalili, hossein; kusznierz, gabriela; kuzman, ilija; langenegger, eduard; lankarani, kamran b; leo, yee-sin; libster, romina p; linko, rita; madanat, faris; maltezos, efstratios; mamun, abdullah; manabe, toshie; metan, gokhan; mickiene, auksė; mikić, dragan; mohn, kristin g i; oliva, maria e; ozkan, mehpare; parekh, dhruv; paul, mical; rath, barbara a; refaey, samir; rodríguez, alejandro h; sertogullarindan, bunyamin; skręt-magierło, joanna; somer, ayper; talarek, ewa; tang, julian w; to, kelvin; tran, dat; uyeki, timothy m; vaudry, wendy; vidmar, tjasa; zarogoulidis, paul; nguyen-van-tam, jonathan s title: neuraminidase inhibitors and hospital length of stay: a meta-analysis of individual participant data to determine treatment effectiveness among patients hospitalized with nonfatal pandemic influenza a(h n ) virus infection date: - - journal: j infect dis doi: . /infdis/jiz sha: doc_id: cord_uid: fyrbe tw background: the effect of neuraminidase inhibitor (nai) treatment on length of stay (los) in patients hospitalized with influenza is unclear. methods: we conducted a one-stage individual participant data (ipd) meta-analysis exploring the association between nai treatment and los in patients hospitalized with influenza a(h n ) virus (a[h n ]pdm ) infection. using mixed-effects negative binomial regression and adjusting for the propensity to receive nai, antibiotic, and corticosteroid treatment, we calculated incidence rate ratios (irrs) and % confidence intervals (cis). patients with a los of < day and those who died while hospitalized were excluded. results: we analyzed data on patients from clinical centers. after adjustment, nai treatment initiated at hospitalization was associated with a % reduction in the los among patients with clinically suspected or laboratory-confirmed influenza a(h n )pdm infection (irr, . ; % ci, . –. ), compared with later or no initiation of nai treatment. similar statistically significant associations were seen in all clinical subgroups. nai treatment (at any time), compared with no nai treatment, and nai treatment initiated < days after symptom onset, compared with later or no initiation of nai treatment, showed mixed patterns of association with the los. conclusions: when patients hospitalized with influenza are treated with nais, treatment initiated on admission, regardless of time since symptom onset, is associated with a reduced los, compared with later or no initiation of treatment. seasonal influenza epidemics and pandemics increase pressure on hospital bed capacity. early initiation of monotherapy with neuraminidase inhibitors (nais) reduces illness duration in patients with uncomplicated influenza [ ] [ ] [ ] ; associated reductions in complications, hospitalizations, and mortality are supported by systematic reviews of observational data [ ] [ ] [ ] [ ] [ ] . the evidence is less clear that nai treatment reduces length of stay (los) in hospitalized patients with influenza, compared with supportive care without antiviral treatment [ ] [ ] [ ] [ ] [ ] [ ] [ ] . minimizing the los is important in managing hospital surge and limiting healthcare costs due to seasonal influenza epidemics and pandemics. we undertook a one-stage individual participant data (ipd) [ ] meta-analysis to explore the association between nai treatment of patients hospitalized with pandemic influenza a(h n ) virus (a[h n ]pdm ) infection and the los during the - influenza pandemic. details regarding identification of study centers and inclusion of patients have been published previously [ ] . briefly, we requested data from multiple clinical centers worldwide on patients admitted to hospital with laboratory-confirmed or clinically diagnosed a(h n )pdm infection for whom a minimum data set was available. of the ipd that we received, we excluded patients who had laboratory-confirmed absence of a(h n ) pdm infection, retaining only patients who had laboratoryconfirmed a(h n )pdm infection and patients with clinically diagnosed pandemic influenza (ie, those for whom the clinical suspicion and working diagnosis was one of pandemic influenza but laboratory confirmation was not performed) [ ] . the pride study protocol was registered with the prospero register of systematic reviews (crd ) prior to data collection [ ] . this states that the study will investigate the impact of nai treatment on multiple outcomes of public health interest in a(h n )pdm -infected patients, using mixedeffects models. after collection and standardization of the data, sufficient data existed to assess indicators of "severe hospital outcomes"-requirement for ventilatory support (ie, intensive care unit [icu] admission) and los. in this article, we present the findings relating to the los. we standardized data from individual data sets before we pooled the data (supplementary table ). the primary outcome was the los (in whole days). we excluded patients with known receipt of nai treatment before admission, to ensure uniform potential for treatment to influence the los. we excluded patients with continuing postdischarge nai treatment; patients with a los < day, on the grounds that they would have received a maximum of doses of nai inpatient treatment and that their admission may have been precautionary; and patients with nosocomial influenza (defined as influenza with symptom onset after the hospital admission date; figure ). finally, since rapid deterioration and early death during hospitalization would be an adverse outcome associated with a paradoxically short los, those who died in the hospital were excluded from analysis. the primary exposure variable was in-hospital nai treatment received on the day of hospital admission, compared with later or no nai treatment. additionally, where data were available, we defined further exposure variables: nai treatment (at any time) versus no nai treatment, early nai treatment (initiated within ≤ days after symptom onset) versus no nai treatment, and early nai treatment versus later treatment (initiated > days after symptom onset). we derived propensity scores via multivariable logistic regression for each exposure variable, as described by hirano and imbens [ ] , separately for individual study centers, based on patient characteristics recorded on admission. propensity score derivation models included, a priori, the following variables: age, sex, comorbidity (yes/no), and an indicator of disease severity, plus any additional covariates (ie, obesity, smoking, pregnancy, asthma, chronic obstructive pulmonary disease, lung disease, heart disease, immunosuppression, neurological disease, renal disease, and/or diabetes) that remained statistically significant in a regression model. variables for which data from > % of participants were missing were excluded from propensity score derivation. to investigate the impact of nai treatment on the los, we performed a one-stage ipd meta-analysis using a mixed-effects negative binomial regression model, including study center as a random intercept to account for clustering. a negative binomial model was chosen to account for overdispersion in the los data (as represented in supplementary figure ). we tested a zeroinflated negative binomial regression model on a subgroup of the data and found that the model fit was inferior to that of a negative binomial regression model. in our primary analysis, we aimed to quantify the potential benefits of a pragmatic treat-on-admission policy (irrespective of the time elapsed since symptom onset), compared with patients who received no nai treatment and those whose treatment was delayed until after the day of admission. by way of sensitivity analysis, we restricted the comparator group to patients who did not receive nai treatment at any point. for both analyses, we adjusted for propensity score quintile, in-hospital antibiotic treatment, in-hospital corticosteroid treatment, and the delay between symptom onset and hospital admission. in addition, we performed secondary analyses for the following exposures: nai treatment (at any time) versus no nai treatment, early nai treatment (≤ hours after symptom onset) versus later nai treatment (> hours after symptom onset), and early nai treatment versus no nai treatment, adjusting for propensity score, in-hospital antibiotic treatment, and corticosteroid treatment. we performed a priori-specified analyses for the following subgroups: patients with laboratory-confirmed a(h n ) pdm infection, children (age, < years), elderly patients (age, ≥ years), patients with chest radiography-confirmed influenza-related pneumonia (irp), and patients with confirmed absence of irp. we looked at pregnant women and obese patients as post hoc subgroups. furthermore, we investigated, by stratification, the impact of nai treatment on the total los in patients admitted to critical care facilities (ie, icus) at any point and patients treated exclusively by using standard ward-based care. both unadjusted and adjusted models were run, and results are presented as unadjusted incidence rate ratios (irrs) or adjusted irrs (airrs) with % confidence intervals (cis). missing data in the covariates were included in the analysis as dummy variable categories. using airr point estimates, we determined the difference in the los (in days) between a treated patient and an untreated patient with similar characteristics by scaling the model prediction for los without treatment by (airr- ). repeating this for all patients in our data set gave us a distribution of expected changes in the los due to treatment (with timing as defined for each regression analysis). this does not account for error in the estimates of model covariates, which would require a bayesian approach; however, it offers a clinically relevant interpretation of airrs. the statistical analyses were performed using stata (version . ; statacorp, college station, tx). we identified patients admitted to the hospital between january and march with laboratory-confirmed or clinically diagnosed a(h n )pdm infection [ ] . the analysis population included patients ( . %; figure ). the included patients came from clinical centers in countries across all world health organization regions. the americas contributed the most data ( . % of patients), followed by europe (for . %). the country that contributed the most to the pooled data set was mexico ( . % of patients), followed by spain ( . %), the united states ( . %), and the united kingdom ( . %). among patients in the final study population, . % were adults, and . % had laboratoryconfirmed a(h n )pdm infection; general characteristics of the included population are further described in table . among the patients ( . %) for whom data on the timing of nai treatment were available, ( . %) received early nai treatment, and ( . %) initiated treatment on the day of admission. the median delay from illness onset to hospital admission was days (interquartile range [iqr], - days), and among patients with data on the timing of treatment, . % presented ≤ hours after symptom onset; the median los was days (iqr, - days; supplementary figure ). in patients whose nai treatment was initiated on the day of hospital admission, the median interval between symptom onset and admission was days (iqr, - days). in our primary analysis, we observed that nai treatment started on the day of admission was associated with a % overall reduction in the los (airr, . [ % ci, . -. ]; median decrease, . days [iqr, . - . days]), compared with no or later initiation of nai treatment. this association was of similar magnitude and remained significant in all subgroups (table and supplementary table ). in the sensitivity analysis, we observed that nai treatment on the day of hospital admission was associated with an % reduction in the los among patients not admitted to the icu ( after adjustment, nai treatment at any time was associated with an % overall increase in the los (airr, . [ % ci, . - . ]; median increase, . days [iqr, . - . days]), compared with no nai treatment. by exploring subgroups, we identified corresponding statistically significant findings in patients with laboratory-confirmed a(h n )pdm infection, children, patients admitted to the icu, and patients with confirmed irp but not in the elderly, patients requiring non-icu care, or patients with confirmed absence of irp (table ) . we did not find any evidence of effect modification by pandemic influenza vaccination (p = . ) or by in-hospital antibiotic treatment (p = . ); however, a borderline significant effect modification was observed for in-hospital corticosteroid treatment (p = . ), the irr was further adjusted for time from onset to admission. c statistically significant (p < . ). d data are for patients admitted to the icu at any point. the irr was calculated for the total length of hospital stay, not time in the icu. our sensitivity analyses and secondary analyses must be interpreted with caution because they may be affected by various time-dependent biases and patients with confirmed irp ( table ). our study extends the existing literature by offering data on the association between nai treatment and the los in > adult and pediatric patients, of whom > % had a laboratoryconfirmed diagnosis of a(h n )pdm infection. we found a mixed pattern of association between nai treatment and los, depending on the delay to initiation of treatment, age, and case severity. the most pragmatic and important question is whether nai treatment, started on admission, irrespective of delay since symptom onset, reduces the los in hospitalized patients with influenza. clinically, this is important because there can be significant uncertainty in ascertaining symptom onset, even by the attending physician. the uncertainty in ascertaining symptom onset could mean prescribing nai treatment outside the recommended (licensed) window of ≤ hours after symptom onset. however, there is evidence pointing to the effectiveness of nai therapy, albeit reduced, even when given > hours after symptom onset [ ] . statistically, by defining our exposure variable on the basis of treatment decisions made on admission, we avoided introducing correlations between exposure and los that can lead to survivorship bias in linear regression models of time-to-event data [ , ] . additionally, this approach ensures that the propensity scores, modeled on symptom severity at admission, should appropriately correct for treatment bias [ ] . however, this choice of exposure variable also reflects the clinical reality that patients present to the hospital at varying intervals after symptom onset (ranging from - days in our study) and that clinicians and policy makers want to know whether a so-called treat-at-the-door policy applied to patients admitted to the hospital with clinically recognized influenza will be beneficial, compared with no nai treatment or a watch-and-see approach. this was addressed by our primary analysis, which revealed that initiation of nai treatment on the day of admission was associated with a % reduction in the los (median decrease, . days), compared with later or no treatment, with similar statistically significant findings across all patient subgroups including children, pregnant women, and obese patients. these findings emphasize the importance of presumptive nai treatment in patients admitted to the hospital with suspected influenza, coupled with early diagnosis using standard laboratory or rapid diagnostic tests. in our sensitivity analysis, we found a significant reduction of % in the los (median decrease, . days) among patients with confirmed absence of irp and a reduction of % (median decrease, . days) among patients who required supportive ward-based care. in contrast, nai treatment (compared with no treatment) was associated with a % increase in the los (median increase, . days) among patients with irp. these data suggest that nais may be more effective in reducing the los when patients do not have irp and are consistent with the fact that nais have no known antibacterial properties. in secondary analyses, we observed an % overall increase in the los associated with nai treatment, equivalent to a median increase of about . days and irrespective of the time between symptom onset and initiation of therapy. compared with no treatment, nai treatment initiated within hours after symptom onset was associated with a % overall reduction in the los, equivalent to a median decrease of . days; this effect was not observed in children and patients requiring icu care. this finding is clinically important because it suggests that rapid access to antiviral treatment after symptom onset may influence the los in adults and elderly individuals; nevertheless, we did not observe the same result among patients requiring icu care. our results in children may be influenced by a higher a(h n ) pdm viral load in children [ ] than in adults, leading to prolonged hospital stay, suboptimal dosing in very young children [ ] , increased likelihood of antiviral resistance emergence in children [ ] , secondary bacterial infections, confounding by indication related to baseline illness severity [ ] , or a combination of these factors. although we attempted to adjust for influenza severity by using propensity scores, we found icu care to be very strongly associated with a prolonged los (irr, . ; % ci, . - . ) and nai treatment to be associated with a higher likelihood of requiring icu care (adjusted odds ratio, . ; % ci, . - . ). furthermore, we found that patients who presented to the hospital > days after symptom onset were % more likely to eventually require icu care than patients who presented earlier (odds ratio, . ; % ci, . - . ). in addition, patients requiring icu care have frequently developed extrapulmonary manifestations of influenza and multiorgan decompensation; therefore, inhibition of virus replication may not correspond with rapid clinical recovery. we noted no association between nai treatment and los among hospitalized children with influenza when considering early treatment versus no treatment. the study may have been underpowered in children, but other factors might have contributed to our findings. the los is typically shorter among children, compared with adults; mortality and serious outcomes are less common among hospitalized children with influenza, compared with adults; and different discharge policies and thresholds for children could also influence the findings. in addition, vomiting is a recognized side effect of oseltamivir in children [ ] , and this may have prevented discharge in some cases. previous studies examining whether use of nais in patients hospitalized with influenza affects the los have generally been of smaller size (< individuals) as compared to our study and reached variable conclusions. of note, studies [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] (of which one [ ] was a randomized trial) assessed nai treatment of hospitalized children, but only (both with an observational design) concluded that the total number of hospital days in the nai-treated hospital cohort was reduced (by % [ . days]) [ , ] , with the other reporting no differences [ - , , ] . only studies have addressed the same question in adults. in hong kong, a study of adult patients hospitalized with laboratory-confirmed seasonal influenza showed that early oseltamivir treatment was associated with a reduced los in both unadjusted and multivariable analyses [ ] , compared with no or later treatment, with the median los decreasing from to days; this accords with our primary analysis. a canadian study of adult patients with seasonal influenza found that oseltamivir treatment was not associated with the los among surviving patients [ ] . a further study in spanish hospitals involving patients with laboratory-confirmed a(h n )pdm infection noted that the los increased by % (odds ratio, . ), after adjustment for confounders, if nai treatment was instigated < hours after symptom onset; however, this was of borderline statistical significance [ ] . a recent american study analyzed data on adult patients with laboratory-confirmed seasonal influenza, reporting that nai treatment was not associated with the los overall but was associated with a reduced los among vaccinated individuals (hazard ratio of discharge, . ; % ci, . - . ; p = . ) [ ] . finally, studies included patients of all age groups. one of them, performed in hospitalized patients with a(h n )pdm infection in spain, found that early nai treatment reduced the los by . days (p = <. ) [ ] . the other, an american study using insurance claims data from patients with seasonal influenza, reported that patients treated with nais spent fewer days in the hospital (p = <. ) [ ] . this study has a number of strengths and weaknesses. we combined data from geographically diverse centers, offering broad generalizability of our findings. we used propensity scores to adjust for major confounders. by excluding patients who died ( %), we removed the paradoxical possibility that a short los (a positive outcome in our analyses) was associated with an extremely unfavorable clinical outcome. however, a limitation of this approach is that it does not explain the impact of nai treatment on the relationship between los and in-hospital mortality. in our primary analysis, we adjusted for the delay between illness onset and admission, to address length bias [ ] , and chose our exposure variable to avoid time-dependent/survivorship bias [ , ] . however, our secondary analyses, which used time since onset to define the exposure variable, are subject to time-dependent biases and must therefore be interpreted with caution. indeed, the benefit of early versus late treatment ( table ) will be partially driven by this bias [ ] . all of our analyses may be subject to residual competing risk bias, which was not removed through adjustment; for example, we found a significant difference between propensity scores to receive nais in the hospital for surviving and nonsurviving patients in the data set (p < . , by the kruskal-wallis test), signaling that our removal of nonsurviving patients altered the aggregate presenting patient characteristics for which our results hold. our data, generated during the - influenza pandemic, contained relatively few elderly patients and children, consistent with patterns of a(h n )pdm infection [ ] , and differs in profile from seasonal influenza a(h n ) virus infection, for which patients admitted to the hospital tend to be much older and to have a median los higher than the los of days we observed [ , ] . in addition, the prevalence proportions of clinically recorded obesity ( %) and pregnancy ( %) were both comparatively high. optimally, clinicians wish to treat patients with influenza within hours after symptom onset, yet in many cases patients with influenza do not seek medical care during this therapeutic window. our data show that . % of included patients were hospitalized > hours after symptom onset. what then matters is whether initiation of treatment upon hospitalization (on the day of admission), irrespective of the time elapsed since symptom onset, is effective and whether this is preferable to nontreatment or further delays in treatment. we revealed a % reduction in the los (median decrease, . days) among patients who were treated with an nai upon admission, compared with those who received no or later treatment; the trend was observed across all subgroups, including children. this treatment approach would avoid the uncertainties associated with ascertaining the symptom onset date. our data support current recommendations to treat adults hospitalized with clinically suspected influenza with nais as soon as possible upon admission; furthermore, this approach appears to be superior to no treatment or delayed treatment in terms of a reduced los. if used consistently, this strategy would contribute to the management of surge pressures and healthcare costs during seasonal influenza epidemics and pandemics. the pride consortium investigators are as follows (affiliations are listed in supplementary neuraminidase inhibitors for preventing and treating influenza in healthy adults and children. cochrane database syst rev oseltamivir treatment for influenza in adults: a meta-analysis of randomised controlled trials efficacy and safety of oseltamivir in children: systematic review and individual patient data meta-analysis of randomized controlled trials antivirals for treatment of influenza impact of neuraminidase inhibitor treatment on outcomes of public health importance during the - influenza a(h n ) pandemic: a systematic review and meta-analysis in hospitalized patients effectiveness of neuraminidase inhibitors in reducing mortality in patients admitted to hospital with influenza a h n pdm virus infection: a metaanalysis of individual participant data impact of outpatient neuraminidase inhibitor treatment in patients infected with influenza a(h n )pdm at high risk of hospitalization: an individual participant data metaanalysis oseltamivir effect on antibiotictreated lower respiratory tract complications in virologically positive randomized trial participants factors associated with early hospital discharge of adult influenza patients timing of oseltamivir administration and outcomes in hospitalized adults with pandemic influenza a (h n ) virus infection oseltamivir shortens hospital stays of critically ill children hospitalized with seasonal influenza: a retrospective cohort study a randomized, double-blind, placebo-controlled trial evaluating the safety of early oseltamivir treatment among children - years of age hospitalized with influenza in el salvador and panama clinical characteristics of influenza b virus in children and the efficacy of oseltamivir: data from two university hospitals oseltamivir treatment for influenza in hospitalized children without underlying diseases clinical features, oseltamivir treatment and outcome in infants aged< months with laboratory-confirmed influenza a in meta-analysis of individual participant data: rationale, conduct, and reporting a systematic review of the impact of neuraminidase inhibitor antiviral use on outcomes of public health importance during the / (swine) influenza a/ h n v pandemic the propensity score with continuous treatments. applied bayesian modeling and causal inference from incomplete-data perspectives an easy mathematical proof showed that time-dependent bias inevitably leads to biased effect estimation time-dependent study entries and exposures in cohort studies can easily be sources of different and avoidable types of bias survivor treatment bias, treatment selection bias, and propensity scores in observational research correlation of pandemic (h n ) viral load with disease severity and prolonged viral shedding in children national institute of allergy and infectious diseases collaborative antiviral study group. oseltamivir pharmacokinetics, dosing, and resistance among children aged < years with influenza five years of monitoring for the emergence of oseltamivir resistance in patients with influenza a infections in the influenza resistance information study confounding by indication in epidemiologic studies of commonly used analgesics the association between influenza treatment and hospitalization-associated outcomes among korean children with laboratoryconfirmed influenza ciberesp cases and controls in pandemic influenza working group. clinical features of influenza disease in admitted children during the first postpandemic season and risk factors for hospitalization: a multicentre spanish experience pandemic (h n ) influenza in hospitalized children in manitoba: nosocomial transmission and lessons learned from the first wave toronto invasive bacterial diseases network. antiviral therapy and outcomes of influenza requiring hospitalization in ontario severe morbidity among hospitalised adults with acute influenza and other respiratory infections prognosis of hospitalized patients with h n influenza in spain: influence of neuraminidase inhibitors oseltamivir and influenza-related complications, hospitalization and healthcare expenditure in healthy adults and children risk factors for severe outcomes following influenza a (h n ) infection: a global pooled analysis complications and outcomes of pandemic influenza a (h n ) virus infection in hospitalized adults: how do they differ from those in seasonal influenza? modelling estimates of age-specific influenzarelated hospitalisation and mortality in the united kingdom disclaimer. the findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the uk government or the united states centers for disease control and prevention. the funder has had no role in protocol design, no opportunity to comment on it, and no opportunity to see it other than via the prospero website; no access to any data (and no rights to future access); no role in analysis or interpretation; no opportunity to preview results/findings before entry into the public domain; and no opportunity to contribute to, preview, or comment on manuscripts and presentations arising from this work. the research contract between the university of nottingham and the funder is freely available for inspection (with commercial details redacted) at: http://www.nottingham.ac.uk/research/groups/healthprotection/projects/pride.aspx. no data were provided or funded for collection by pharmaceutical companies.financial support. this work was supported by f. hoffmann-la roche (unrestricted educational grant to the pride study).potential supplementary materials are available at the journal of infectious diseases online. consisting of data provided by the authors to benefit the reader, the posted materials are not copyedited and are the sole responsibility of the authors, so questions or comments should be addressed to the corresponding author. key: cord- -zn na authors: slifka, mark k.; amanna, ian j. title: passive immunization date: - - journal: plotkin's vaccines doi: . /b - - - - . - sha: doc_id: cord_uid: zn na nan passive immunization, passive immunity, and passive immunotherapy all refer to the transfer of antibodies to an unprotected individual for the prevention or treatment of disease. the first formal demonstration of passive immunization for successfully treating diphtheria and tetanus dates back to animal studies published in deutsche medizinische wochenschrift (german medical journal) in . the technique was quickly adapted to clinical use and as early as the mid- s, diphtheria-specific antitoxin was used successfully in the hospital setting to reduce mortality during diphtheria outbreaks. [ ] [ ] [ ] indeed, in emil von behring was awarded the first nobel prize for physiology or medicine for the discovery of this important medical intervention. the significance of this clinical advance cannot be overstated; behring estimated that , lives were saved each year using diphtheria-specific passive immunotherapy in germany alone. in the s, the mortality rate of hospitalized cases ranged from % to %, and the work of emil von behring and his colleague, shibasaburo kitasato, provided the only hope for diphtheria patients in the preantibiotic era. according to behring, the discovery of passive immunization would not have occurred if it were not for his earlier work that focused on characterizing the protective mechanisms of active immunization against diphtheria , and through the work of his collaborator, kitasato, on the mechanisms of vaccine-mediated immunity against tetanus. when guinea pigs were infected with corynebacterium diphtheriae, the animals routinely died of the disease. however, when behring vaccinated animals and they mounted neutralizing antibodies to diphtheria toxin, he found that they were protected from a normally lethal dose of c. diphtheriae. to determine if protection was now an intrinsic property of the immune host that could be transferred to a susceptible host, he injected naïve guinea pigs with diphtheria toxin and then successfully treated them with immune serum from vaccinated animals. likewise, injection of clostridium tetani or purified tetanus toxin was typically lethal, but through a method developed by paul ehrlich, animals could eventually become immune to high doses of tetanus toxin by sequentially inoculating them with lower, nonlethal doses of tetanus toxin. kitasato used this approach to demonstrate that the blood of vaccinated, tetanusimmune rabbits could be transferred to naïve mice and fully protect them from a normally lethal dose of virulent c. tetani or from filtered c. tetani culture supernatant containing tetanus toxin. behring and kitasato may have said it best in the final sentence of their landmark study, "the result of our experiments remind us forcibly of these words: blut ist ein ganz besonderer saft [blood is a very unusual fluid]." technology has advanced substantially in the more than years since behring and kitasato's first formal demonstration of protective passive immunotherapy. in those early days, it was infeasible to use human immune serum to treat diphtheria, so the first large-scale production of polyclonal diphtheria-immune serum was prepared by vaccinating dairy cows. to this day, commercial antisera used to treat a broad range of toxins are still produced in animals (table . ). passive immunotherapy with animal-derived antibody preparations should only be used under close medical supervision or the resulting host immune response to the foreign immunoglobulins and serum proteins may trigger serum sickness, urticaria, and/or anaphylaxis following administration. fortunately, the advent of several innovative technologies that reduce the need for animal-derived antibodies have forged new paths in terms of safety, feasibility, and the protective efficacy afforded by passive immunization. following the discovery of monoclonal antibody technology, , further refinements have been made, including use of various display techniques (e.g., phage display, yeast display) to screen large antibody libraries. other technological advances include the development of chimeric monoclonal antibodies in which the murine antibody is "humanized" by genetically replacing the heavy chain region of the molecule with the human immunoglobulin counterpart and the use of transgenic mice in which the endogenous murine immunoglobulin genes have been replaced by human immunoglobulin genes. this latter approach has the advantage that hybridomas from immunized transgenic mice produce fully human monoclonal antibodies without requiring further genetic modifications. recently, development of epstein-barr virus (ebv)-transformed human memory b cells for the production of monoclonal antibodies has led to yet another surge in the production of new human monoclonal antibodies with rare antigenic specificities to uncommon pathogens and these can be produced directly from immune human subjects. , before the era of antibiotics, antibodybased therapy was the only option available for combating many bacterial diseases. even today, there are only a handful of antiviral drugs available and no therapeutic options exist for most viral diseases. however, new antibody-based therapies are continuing to be developed with the potential to provide protection against a broad array of bacterial and viral pathogens. in this chapter, we describe the role of passive immunity in the protection of the naïve host, discuss the parameters involved with successful immunotherapy, and provide examples of protective efficacy in animal models as well as in human clinical studies. age who were born to mothers who received pertussis vaccination during pregnancy, , thus lending further support to the current recommendations for the vaccination of pregnant mothers against b. pertussis. the age limit of younger than months was chosen as this is the age at which primary pediatric vaccination is recommended and analysis beyond this age might be confounded by the protective effects of direct vaccination of the child. nevertheless, the protection afforded by maternally derived igg against respiratory infections involving viral (e.g., influenza) or bacterial (e.g., b. pertussis) pathogens together demonstrate the broad impact that maternal vaccination and the subsequently increased transfer of maternal antibodies can have on the health of young infants. before vaccines and antibiotics revolutionized modern medicine, antibody-based therapies represented the only effective medical treatment for many life-threatening diseases including diphtheria, scarlet fever, bacterial meningitis, and bacterial pneumonia. , today, most commercial forms of antibodybased immunotherapy for infectious disease still rely on polyclonal antibodies of human or animal origin, with the notable exceptions of the monoclonal antibodies, palivizumab and raxibacumab (see table . ). the main advantage of using polyclonal antibodies for passive immunotherapy is that this approach will include antibodies to multiple epitope specificities that may work in an additive or synergistic manner with the potential contribution of multiple immunoglobulin isotypes and subclasses that have different biological functions (table . ). on the other hand, there are several potential challenges to using polyclonal antibodies for immunotherapy including low antigen-specific activity, supply limitations (especially for rare diseases), variability between manufacturing lots, and safety as well as quality control issues that are often associated with the use of human blood products. in ungulates. these differences also indicate that care should be taken when choosing an appropriate animal model for studying the role of maternal antibodies against infectious disease as the mechanisms may be more species-specific than typically realized. in a comprehensive study involving the analysis of antibodies to viruses using samples from , patients, the relationship between maternal immunity and infant immunity is clear (fig. . ). the prevalence of antibodies to each viral antigen among infants less than month old is remarkably similar to those observed in the -to -year old adults who represented the main age group of the mothers. for instance, immunity to common childhood diseases such as measles and mumps was comparable between newborns and their mothers. immunity to less-common viral pathogens, such as influenza b, was relatively low among infants and adults in the cohorts examined in - , but higher among those sampled in - , - , and - , coinciding with an influenza b epidemic that had occurred in . this shows that the prevalence of maternal antibodies is dynamic and that recent outbreaks involving a specific pathogen will result in a higher frequency of pathogenimmune mothers and a concomitant increase in the number of infants who are likewise bestowed at least transient immunity to that particular microbe. as expected, maternal antibodies wane rapidly during the first months of life and then exposure to pathogens over the following months and years results in an accumulation of different antibody specificities as children reach adulthood (see fig. . ). the overall protective efficacy of maternal antibodies is perhaps most pronounced among children with genetic immunodeficiencies such as severe combined immunodeficiency (scid), resulting in the lack of functional t and b cells or agammaglobulinemia, in which patients lack functional b cells while still having the ability to mount pathogen-specific t-cell responses. the clinical presentation of scid is not apparent at birth but relatively uniform diagnosis occurs at a mean of . months of age, which is also about the age that maternal antibodies have reached their lowest levels (see fig. . ). likewise, agammaglobulinemic patients also begin to present with symptoms of immunodeficiency around this same age. maternal antibodies represent an immunological "doubleedged sword" in the sense that they are known to interfere with live attenuated virus vaccines such as the mmr (measles, mumps, rubella) [ ] [ ] [ ] and rotavirus vaccines, , whereas direct immunization of mothers in the third trimester of pregnancy can significantly increase protection of infants against common respiratory viruses such as influenza. [ ] [ ] [ ] indeed, maternal vaccination may result in a % to % reduction in influenzarelated hospitalizations among infants younger than months of age. [ ] [ ] [ ] likewise, the importance of maternal vaccination against bordetella pertussis (i.e., whooping cough) was recognized as early as the s to s with studies showing higher antibacterial antibody responses and potential protection from exposure to whooping cough among infants born to vaccinated mothers. [ ] [ ] [ ] [ ] recent studies verify these earlier results, demonstrating a % to % vaccine efficacy against whooping cough among infants younger than months of nonlymphoid tissues and to penetrate mucosal sites of infection is likely to explain why it is often considered the best immunoglobulin isotype for routine passive immunization and has shown clinical benefit ranging from reduced clinical symptoms to nearly complete protection from lethal infection in a number of infectious disease models (table . ). over the last century, it has been well established that high specific antibody titers and early timing of antibody transfer in relation to disease onset are the two most important parameters involved with determining the protective efficacy of passive immunization ( fig. . ). in one account of the early days of clinical diphtheria-specific immunotherapy developed by behring and ehrlich, initial failures in patients after treatment with weak or unstandardized diphtheria-immune serum brought ehrlich to describe three points that he believed were important for successful immunotherapy: (a) treatment has to be initiated at the onset of disease; (b) the more the disease has progressed, the higher the serum quantities necessary for cure; and (c) depending on the severity of the case, certain minimal doses can be specified. later studies confirmed these results: if diphtheria immunotherapy was initiated on the first day of disease, there was % mortality (n = ). however, if therapy was delayed to , , or days after disease onset, then the accompanying diphtheria case-fatality rate subsequently increased to . % (n = ), . % (n = ), and . % (n = ), respectively. these results are similar to those observed during antibiotic-based therapy of bacterial sepsis. in an ideal setting, it is recommended that antibiotics be administered within hour of diagnosis of severe sepsis or septic shock as these drugs provide clinical benefit only if administered early in the course of disease and are generally ineffective during late-stage disease. the importance of high-dose immunotherapy given at the earliest sign of disease is not unique to bacterial anti-toxin therapy. the same rules apply to preventing or treating viral infections as well. during a measles epidemic in - , % of exposed individuals (n = ) who received no passive immunization contracted measles. if convalescent serum was administered within days of exposure, then the attack rate was reduced to % (n = ) whereas if therapy was not initiated until to days postexposure, approximately % of contrast, monoclonal antibodies are, by definition, limited to a single epitope specificity but they have several advantages over polyclonal antibodies since they can be manufactured in vitro at large scale, with inherently high specificity and lot consistency (table . ). for example, the combination of . mg of two tetanus-specific human monoclonal antibodies has the same neutralizing capacity observed with administration of to mg of polyclonal tetanus immunoglobulin. likewise, administration of . mg of a vaccinia virus-specific monoclonal antibody provides the same level of protection afforded by mgs of vaccinia immunoglobulin (vig). although neutralization escape mutants are a valid concern when using monoclonal antibody therapy, , this has not yet been a major problem during clinical use of palivizumab for respiratory syncytial virus (rsv). initially, sequencing of rsv isolates demonstrated that there were no mutations in the neutralizing epitope of the f protein. subsequent studies identified rsv escape mutants in approximately % of breakthrough cases, indicating that selective pressure for escape mutations is still relatively uncommon under current conditions of use. this suggests that monoclonal antibodies can remain effective when used clinically in the long-term, as long as they are specific for a stable epitope for that particular pathogen. the functional characteristics of the immunoglobulins used for passive immunization is an important consideration in determining protective efficacy in vivo. for example, serum igg molecules equilibrate into extravascular space whereas igm is largely confined to intravascular space. igm molecules also have a short half-life ( days ) and are typically of low affinity, which is why igm is not an optimal choice for passive immunotherapy. serum iga is monomeric and, although it also equilibrates into extravascular space, it has only a -day half-life and does not appear to contribute significantly to functional iga in the lungs of mice. , human igg on the other hand, has an average half-life of approximately days (except igg , which has a -day half-life), , is typically of high affinity, and transudation across mucosal barriers can protect against pathogens that invade through mucosal routes. interestingly, serum igg (and serum iga) responses elicited in response to vaccination against neisseria meningitidis correlate strongly with the levels of antibacterial antibodies present in the saliva at month and year after vaccination, indicating that circulating serum antibodies may be an important contributor to the antibodies released in mucosal secretions. indeed, after intravenous administration of an hiv-specific monoclonal antibody into rhesus macaques, serum antibody titers of to µg/ml resulted in mucosal antibody titers of to µg/ml in vaginal fluids and provide complete protection against intravaginal challenge with shiv (chimeric simian immunodeficiency virus expressing hiv envelope). influenza virus is another mucosal pathogen with strict tropism to the respiratory tract, but influenza-specific serum antibody titers correlate with protection in humans. in mice, the relative roles of influenza-specific polymeric iga and igg were compared in terms of antiviral protection in the upper respiratory tract versus the lung after influenza challenge. when polymeric iga was transferred hours prior to influenza infection, this prevented pathology in the upper respiratory tract but was not effective in the lung, whereas transfer of igg prevented pathology in the lung, but required higher doses to protect against infection of the upper respiratory tract. the authors concluded that different antibody isotypes may function preferentially at different anatomical sites in vivo. these results are in contrast to experimental influenza infection in humans in which inactivated influenza vaccinederived igg is believed to be a major contributor to protection of the nasal compartment. overall, the ability of igg to enter efficacy of passive immunity decreases with disease progression. full protection from symptomatic disease is best achieved through prophylactic administration of antibody therapy prior to exposure or infection. however, antibody therapy may also be highly effective at early points postexposure, prior to the onset of disease symptoms. passive immunity is generally less effective when administered after the onset of symptomatic disease, and typically shows little to no clinical benefit once severe late-stage disease has occurred. to iu/ml, the postexposure incidence of measles increased from % to % despite either lot being administered within days of exposure. likewise, the timing of passive immunotherapy is also important for enteric (e.g., polio) and respiratory pathogens (e.g., rsv). an outbreak in involving polio patients showed that if convalescent serum was administered within to days of meningitis, then paralysis was reported in . % of patients (n = ). if treatment was delayed until to days after meningeal disease onset, . % reported paralysis (n = ), and if treatment was delayed for more than days, then paralysis was noted in . % of polio patients (n = ). for rsv, polyclonal rsv-immunoglobulin reduced the incidence of rsv-associated hospitalization by contacts subsequently contracted measles (n = ). in a study published in involving cases of measles exposure, % of the individuals who received immunotherapy within to days of exposure contracted measles compared to % for those whose treatment was delayed to to days postexposure. the dose used in these studies was also critical: % of patients who received . ml/kg of gammaglobulin contracted measles whereas only % of patients who received . ml/kg of gammaglobulin contracted the disease. the titer of virus-specific antibodies will often differ between lots of polyclonal immunoglobulin preparations (see table . ). in another study, when the measles-specific titer of gammaglobulin from different lots decreased from iu/ml for animal studies, prophylaxis is defined as antibody administration prior to experimental infection and treatment is defined as antibody administration after infection. for clinical studies, prophylaxis is defined as antibody administration prior to disease onset and treatment is defined as antibody administration after disease onset. b evidence provided through maternal immunization studies. c anecdotal results are defined as small studies that indicate passive immunization may provide clinical benefit but are too limited in scope to be conclusive. d not available, although two studies , demonstrated prophylaxis by direct mixing of mumps virus and antibody prior to inoculation. confirmed lassa fever who received immune serum within days of hospitalization survived ( of ; %). however, if treatment was not initiated until more than days after hospitalization, then only of ( %) patients survived, similar to the untreated group in which only of ( %) patients with virologically confirmed lassa fever survived. although passive immunity against toxins and systemic infections such as measles , , - and smallpox [ ] [ ] [ ] is well established, the impact of this approach for the prevention or amelioration of disease caused by respiratory and enteric pathogens may not be as well recognized. however, several studies support the role of passive immunity against mucosal pathogens (see table . ) , including examples such as influenza (respiratory virus), haemophilus influenzae (respiratory bacterium), rotavirus (enteric virus), and escherichia coli (enteric bacterium). influenza is a significant cause of morbidity and mortality throughout the world, including both seasonal transmission and pandemic outbreaks. [ ] [ ] [ ] [ ] the clinical correlation between homotypic influenza immunity and vaccine-associated protection was recognized early in the development of the influenza vaccine. [ ] [ ] [ ] early animal studies confirmed this result, with passive transfer of antibodies (both systemic and mucosal delivery) able to protect naïve animals against subsequent challenge, or provide therapeutic benefit when administered postexposure. [ ] [ ] [ ] more recent animal studies with defined monoclonal antibodies continue to support and extend these earlier results. , passive immunization against influenza in humans has also been successful. in a comprehensive retrospective metaanalysis of eight passive immunization studies performed during the spanish influenza outbreak ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) , a significant % decrease in mortality ( % confidence interval [ci], - %; p < . ) was observed. subset analysis of studies that recorded early (treatment initiated within days of pneumonia complications) versus late intervention (> days) showed a significant advantage for early treatment, with mortality decreasing from % ( of ) to % ( of ) with earlier intervention, consistent with general considerations for effective passive immunity against infectious diseases (see fig. . ). in a recent double-blinded, randomized controlled study during the influenza pandemic, the use of hyperimmune intravenous immunoglobulin (ivig) (from recovered convalescent donors) was compared to normal ivig in the treatment of severe infection in subjects. the hyperimmune treated group (n = ) demonstrated more rapid viral clearance than the control group (n = ), with a greater than % drop in viral loads by day posttreatment. in those patients receiving immunoglobulin within days of symptom onset (n = ), all who received hyperimmune ivig survived ( of ), whereas only % of patients receiving normal ivig survived ( / , p = . ). h. influenzae type b (hib) is an extracellular gram-negative bacterium that initially infects the host via the respiratory tract and represents another important human pathogen that can be controlled through passive immunization. several early reports described the use of concentrated rabbit immune serum as a successful adjunct therapy to sulfonamide treatment for patients suffering from hib meningitis. - indeed, a full course of serum therapy (in addition to antibiotics) was able to reduce mortality to % ( of ) when compared to % mortality rate ( of ) in those patients only receiving sulfonamides. a more recent study established the prophylactic % among children with a history of prematurity or bronchopulmonary dysplasia. prophylactic administration of a neutralizing monoclonal antibody, palivizumab, was shown to significantly improve clinical outcome by reducing rsvassociated hospitalizations of children with congenital heart disease by %. among premature infants or those with bronchopulmonary dysplasia, rsv-associated hospitalizations were reduced by %. a third palivizumab study confirmed these results by showing a % reduction in hospitalizations among premature infants and infants with chronic lung disease. another monoclonal antibody, motavizumab, demonstrated a further % relative reduction in rsv hospitalizations compared with patients receiving palivizumabbased prophylaxis. in contrast, once rsv infection has been established, the use of palivizumab, motavizumab, or rsvimmunoglobulin shows no clinical benefit, although rsvimmunoglobulin may provide limited protection in the most severe cases. passive immunotherapy can be highly successful for severe, even life-threatening human diseases such as smallpox, or hemorrhagic fever caused by arenaviruses including junin or lassa fever virus (see table . ). successful intervention, however, typically requires initiating treatment before or very shortly after symptom onset. when convalescent serum from smallpox survivors was administered to smallpox patients during the late stages of confluent or hemorrhagic smallpox, there was no clinical benefit observed in comparison to untreated controls ( % vs. % mortality, respectively). when vaccinia-immune gammaglobulin (vig) was administered to smallpox contacts prior to disease onset in addition to postexposure vaccination (i.e., standard of care), the number of smallpox cases was reduced by % compared to contacts who received postexposure smallpox vaccination alone. likewise, administration of vacciniaimmune serum of animal origin along with postexposure vaccination resulted in of cases ( %) of smallpox among close contacts compared to of cases ( %) among controls who received smallpox vaccination alone. during a smallpox outbreak in , of patients ( %) died while undergoing standard clinical care. to determine if addition of passive immunotherapy would reduce mortality after smallpox diagnosis, cases of smallpox were treated with convalescent serum or blood, with no smallpoxassociated deaths reported ( of ). approximately patients were described as having severe or hemorrhagic smallpox at the time of treatment and yet all survived. this appears to be the result of using convalescent serum obtained at the peak of the humoral immune response shortly after recovery from smallpox and the use of an optimized dosing schedule with higher doses administered to patients with the more severe disease manifestations. argentine hemorrhagic fever is caused by infection with the junin virus and untreated cases result in % to % mortality. [ ] [ ] [ ] convalescent serum is protective in animal models of junin infection [ ] [ ] [ ] and when administered within days of symptom onset, the mortality rate among human cases drops to % to %. , likewise, in % to % of hospitalized cases, lassa fever virus causes severe disease including diffuse capillary leakage and hemorrhagic diathesis. prophylactic administration of immune serum protects guinea pigs , and nonhuman primates , from subsequent lethal challenge, indicating that antibodies play a clear role in protection against this virulent viral pathogen. in one small clinical study, if passive immunotherapy was administered within to days after admission to the hospital, of ( %) patients survived whereas if immunotherapy was initiated to days after hospitalization, of ( %) patients survived. in another study, patients with virologically with any new scientific advance, there is controversy. in , when behring demonstrated that immune serum therapy could protect against diphtheria, it went against the current dogma at that time in which the cellular theory of phagocytosis was believed to be the primary mechanism of host protection. there were also skeptics who, as early as , discussed why antibody immunotherapy would not work. however, the science not only prevailed but today a number of passive immunotherapy products are in clinical use (see table . ) and an ever-increasing number of human diseases benefit from the use of this technology (see table . ). some believe that antibody plays a more important role in protection against cytopathic viruses and extracellular bacteria, but that t cells must be required for protection against infection by noncytopathic viruses and other intracellular pathogens. although this is partially refuted by the protective efficacy of maternal antibodies and ivig therapy in scid patients who do not have functioning t cells, it is important to bear in mind that antibody-mediated protection by passive immunotherapy in immunocompetent individuals does not function in isolation, but instead works best in conjunction with other immune defenses, including host t cells, b cells, natural killer (nk) cells, etc. although the role of antibody-mediated protection against intracellular bacteria and chronic viral infections was thought to be relatively minor, there are examples in each of these instances in which passive immunity provides substantial clinical benefit. as noted previously, prior to the advent of antibiotics, passive immunotherapy was the only option for clinical treatment of most bacterial infections including francisella tularensis, a facultative intracellular bacterium that causes tularemia, a severe disease associated with up to % mortality in untreated cases. , when streptomycin became available, a comparative study in was performed with tularemia patients who received only symptomatic treatment, who received immune equine serum, who received hyperimmune equine serum, and who received streptomycin. the untreated tularemia cases required an average of . months to recover and only three modes of therapy showed substantial improvement-treatment with immune serum within days of disease onset ( . months until recovery), treatment with hyperimmune serum ( . months until recovery), and treatment with streptomycin ( . months until recovery). two clinical cases were extensively described, with the following summary: "the clinical responses to each agent [i.e., immune serum, and streptomycin] were similar, prompt amelioration of the symptoms of intoxication-headache, mental dullness or lethargy, sense of prostration and severe malaise; reduction of fever and of the sizes of the buboes, acceleration in the healing of ulcers and in the resolution of pulmonary exudates." in other words, passive immunotherapy appeared in many ways to mimic antibiotic therapy in terms of protective efficacy. however, it was noted that treatment with equine serum caused serum sickness in % of the patients and had a more variable outcome than the antibiotic approach, leading to the recommendation that streptomycin would be the agent of choice for future treatment of this disease. with the recent development of polyclonal and monoclonal antibodies that show protective efficacy against tularemia in animal models, [ ] [ ] [ ] it may be possible to incorporate both passive immunotherapy and antibiotic treatment into clinical practice not only for tularemia, but for other bacterial diseases, especially in cases in which antibiotic resistance is becoming more widespread. , mycobacterium tuberculosis is another intracellular bacterium that, despite the availability of antibiotics, remains one use of human immunoglobulin in at-risk populations. santosham and colleagues administered hyperimmunoglobulin (n = ), or saline placebo (n = ) to infants at , , and months of age and examined the rates of invasive hib. for the first days following the passive immunization protocol, none of the treated infants experienced invasive hib ( % incidence), compared to of placebo-treated children ( . % incidence, p = . ). rotavirus represents an enteric viral pathogen wherein protective passive immunotherapy has been demonstrated. [ ] [ ] [ ] [ ] [ ] [ ] in one example of postexposure treatment in infants, oral administration of hyperimmune antibody (in addition to standard supportive care) was able to efficiently reduce rotavirus shedding compared to placebo controls; treated patients (n = ) exhibited no evidence of viral shedding by day posttreatment as compared to % of controls (n = ). in a separate study, prophylactic passive immunity using orally administered bovine colostrum from immunized animals was tested in a blinded and randomized trial among infant children ( - months old) admitted to a hospital, typically for respiratory conditions. following admission, infants were given a -day course of the bovine colostrum or placebo. infants who received placebo contracted symptomatic rotavirus at a rate of % ( of ) whereas no symptomatic rotavirus disease was observed in the colostrum-treated infants ( of ; p < . ). analysis of rotavirus vaccine failures also indicates that maternally derived antibodies play a role in passive immunity to rotavirus infection. in a study involving vaccinated infants, a strong inverse correlation was observed between maternally derived rotavirus antibodies and the ability of infants to seroconvert following vaccination with a live rotavirus vaccine. this is an important demonstration not only of passive immunity to an enteric pathogen, but also has broader implications on the timing of vaccine administration, especially in developing countries where preexisting immunity is relatively high, and rotavirus vaccine immunogenicity appears impaired. e. coli is a significant enteric pathogen wherein prophylaxis through passive immunity has been demonstrated in several clinical studies. - tacket and colleagues were able to passively protect human subjects against experimentally induced e. coli diarrhea with specific bovine antibody. using heatinactivated or glutaraldehyde-inactivated e. coli for vaccination, pregnant cows were hyperimmunized with a large number of enterotoxigenic o serogroups. milk collected during the first days of lactation was purified, concentrated, lyophilized, and formulated for oral administration. as a control, a similar preparation was made using rotavirus as the immunizing antigen. subjects received daily treatment ( times daily) for days, with e. coli challenge administered days into the treatment regimen. of the subjects who received the e. coli antibody prophylaxis, all remained diseasefree following challenge, compared with clinical diarrhea in of placebo subjects (p < . ). using a closely related clinical protocol, otto and colleagues also demonstrated good efficacy with hyperimmune bovine colostrum tablets. in the first study conducted in this trial, of ( %) of placebo subjects contracted diarrhea following challenge, but this was reduced to only of ( %) in treated subjects (p = . ). in a second study investigating the impact of omitting buffer to the oral prophylaxis, the authors also examined dose sparing. in these studies, the standard dose still conferred significant protection with of ( %) treated subjects contracting diarrhea, compared with of ( %) of controls. interestingly, if the dose was reduced by one-half then disease incidence increased to of subjects ( %), indicating a key role played by treatment dose in achieving successful passive immunotherapy. developed at similar rates among all three groups (p = . ). however, because administration of immunoglobulin is typically only performed during the first months after transplantation and antiviral antibody half-life is estimated to be approximately days, it is not surprising that the protective effects of passive immunotherapy were only maintained through the first year. nevertheless, the inadvertent discovery of the protective role of antibodies in preventing ebv-induced non-hodgkin lymphoma represents a potential breakthrough in clinical management of this vulnerable patient population. despite decades of research aimed at finding a vaccine or a cure for hiv infection, this virus remains a scourge of global proportions. early attempts at passive immunotherapy using first-generation hiv-specific monoclonal antibodies were not highly effective [ ] [ ] [ ] and this approach was not further pursued until a new generation of highly potent and broadly neutralizing antibodies were identified. , in particular, a recent phase i clinical trial involving a single administration of a broadly neutralizing antibody, bnc , has renewed interest in the study of passive immunotherapy for hiv prevention and therapeutic intervention. bnc is an anti-cd binding site antibody that neutralizes of hiv strains comprising six different clades and was tested in a doseescalation study among hiv-positive patients with different levels of viremia. at a dose of or mg/kg, patient viral load was reduced by up to . log (average decline: . log ) in of individuals. the subject that did not respond to antibody treatment at mg/kg was infected with a resistant strain of hiv. although the effect of antibody therapy on viremia was mainly transient after a single administration, the viral load remained lower than their preexisting set point in of patients at days and one subject exhibited viremia levels that remained near the limits of detection throughout the -day study. it is currently unclear if hiv viremia in these patients will eventually rebound to their original levels. similar results were observed during antibody-based therapy of shiv-infected rhesus macaques in which most animals showed a rebound in viral replication after the transferred monoclonal antibodies declined to undetectable levels but a subset of animals maintained virological control in the absence of further infusions. combinations of antiretroviral drugs are currently the standard of care for treatment of hiv infection and it is unlikely that one dose of a single monoclonal antibody will be sufficient to have a long-term clinical benefit among a broad patient base. however, there is growing optimism that combining a cocktail of potent, broadly neutralizing monoclonal antibodies with antiretroviral drugs and/ or agents that activate latent virus reservoirs could theoretically provide long-term reduction in viral load and reduce the rates of transmission. with substantial advances in monoclonal antibody technologies and an increasing appreciation for the role of antibodies in the control of infectious disease, the development of sophisticated new passive immunotherapies is likely to continue at an accelerated pace. antibiotic resistance among clinically relevant bacteria including multidrug-resistant (mdr) and xdr m. tuberculosis, methicillin-resistant staphylococcus aureus (mrsa), and dominant strains of antibiotic-resistant salmonella typhi and other gram-negative bacterial species is a growing concern. , , [ ] [ ] [ ] this, coupled with the knowledge that fewer new antibiotics are moving through the drug pipeline, , may further motivate research into the development of antibody-based therapies to overcome these challenges to clinical intervention against microbial disease. one drawback to passive immunization is that antibody half-life in vivo of the most common human diseases and it is estimated to infect up to one-third of the world's population. the development of strains of extensively drug-resistant (xdr) tuberculosis (tb), some of which are resistant to all current antibiotic therapies, , is also a growing concern, especially as there are few antibiotic drugs in the pipeline. , there is considerable debate over the role of antibodies in controlling tb, with many believing that antibody plays little or no role in protective immunity (reviewed in references and ). in a comprehensive historical review by glatman-freedman and casadevall, the clinical benefit of antibody-mediated immunotherapy, albeit quite variable, provides evidence to suggest that antibody plays a role in protection against tb. in studies reported by paquin in , a group of patients with pulmonary tb confirmed by the presence of bacterium in their sputum showed clinical benefit. after months of passive immunotherapy, % of patients showed reduced cough, reduction in bacterial load in sputum, clearance of pulmonary infiltrates, reduction in hemoptysis, improved appetite, and weight gain. , at months after initiating treatment, all the treated patients were alive and more than half were discharged from the hospital. in contrast, more than untreated tb patients from another ward in the hospital had died within months of starting the study. experimental proof of antibody-mediated protection against tb was also published in by fisch. , after lethal tb challenge of guinea pigs, administration of immune serum was performed on days , , and , with further doses administered every other day for weeks and once a week after that. fisch reported that of treated animals were alive after . months ( % survival). if treatment was delayed until day postchallenge, then of ( %) animals survived but showed signs of illness. if no antibody treatment was performed, then of ( %) of the animals survived past day . the same approach was used to treat patients with pulmonary tb. all of the patients treated at the earliest stages of disease improved rapidly after passive immunotherapy and were tuberculin negative at the end of the study. of the patients treated at the "incipient" stage of disease, % no longer had bacilli in their sputum and were considered cured and % showed substantial improvement in disease symptoms. the patients with advanced tb showed only modest or no improvement after therapy and it was concluded that immune serum was only beneficial in early but not advanced cases of disease. ebv is a common human pathogen that causes a chronic infection and is a leading cause of posttransplant non-hodgkin lymphoma resulting from the uncontrolled proliferation of ebv-infected b lymphocytes in patients undergoing immunosuppressive therapies. in a large retrospective study involving , kidney transplant patients, the effect of prophylactic treatment for cytomegalovirus (cmv) on posttransplant incidence of non-hodgkin lymphomas was examined. the standardized incidence ratio (sir) for non-hodgkin lymphoma was expressed as the number of lymphoma cases per , persons and calculated after normalizing for age, sex, and geographical origin. the , patients who did not receive cmv prophylaxis had a sir = . , which remained unchanged (sir = . , p = . ) among the , patients who received antiviral drugs (acyclovir or ganciclovir). in striking contrast, the patients who received anti-cmv immunotherapy showed a complete absence of lymphomas during the first year after transplantation (sir = , p = . vs. antiviral treatment). the most common anti-cmv immunoglobulin products were shown to contain antibodies against ebv and it is believed that this is the mechanism of action for the protection afforded during the first year posttransplantation. in the subsequent years of follow-up, new cases of lymphoma sufficient for protection or therapeutic intervention of acute or remittent disease, active immunization through improved vaccine design may still be needed to train the host immune system to maintain long-term levels of protective immunity. importantly, examples of successful passive immunization approaches may provide a useful framework for developing new and improved vaccines that elicit the most protective antibody responses. references for this chapter are available at expertconsult.com. often provides only transient protection unless repeated administrations are performed. this may change as new technologies that increase the half-life of monoclonal antibodies are employed. for example, the fc region of an anti-rsv monoclonal antibody, motavizumab, was mutated to increase its binding to the neonatal fc receptor (fcrn), resulting in serum antibody pharmacokinetics in human subjects that increased from 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protection against yersinia pestis human immune response to a plague vaccine comprising recombinant f and v antigens administration of antibody to the lung protects mice against pneumonic plague passive immunity to yersiniae mediated by anti-recombinant v antigen and protein a-v antigen fusion peptide roles of v antigen in promoting virulence and immunity in yersiniae les épidémies de peste en extrême-orient. xiiie congrès international de médecine sur la peste bubonique (sérothérapie) prophylaxis and therapy for chikungunya virus infection chikungunya viruses that escape monoclonal antibody therapy are clinically attenuated, stable, and not purified in mosquitoes case reports of neuro-chikungunya in southern thailand antigenic sites of coxsackie a virus inducing neutralizing monoclonal antibodies protective in mice a murine model of coxsackievirus a infection for anti-viral evaluation effect of intravenous immunoglobulin for neonates with severe enteroviral infections with emphasis on the timing of administration vaccination for the prevention of maternal and fetal infection with guinea pig cytomegalovirus rat cytomegalovirus vaccine prevents accelerated chronic rejection in cmvnaive recipients of infected donor allograft hearts complete protection of mice against lethal murine cytomegalovirus challenge by immunization with dna vaccines encoding envelope glycoprotein complex iii antigens gh, gl and go passive immunization during pregnancy for congenital cytomegalovirus infection prophylaxis of primary cytomegalovirus disease in renal transplant recipients. a trial of ganciclovir vs immunoglobulin cmv-hyperimmune globulin for preventing cytomegalovirus infection and disease in solid organ transplant recipients: a meta-analysis the development of therapeutic antibodies that neutralize homologous and heterologous genotypes of dengue virus type epitope determinants of a chimpanzee dengue virus type (denv- )-neutralizing antibody and protection against denv- challenge in mice and rhesus monkeys by passively transferred humanized antibody development of a humanized antibody with high therapeutic potential against dengue virus type ebola gp-specific monoclonal antibodies protect mice and guinea pigs from lethal ebola virus infection successful treatment of ebola virus-infected cynomolgus macaques with monoclonal antibodies therapeutic intervention of ebola virus infection in rhesus macaques with the mb- monoclonal antibody cocktail treatment of ebola hemorrhagic fever with blood transfusions from convalescent patients. international scientific and technical committee preventive effect of igg from ebv-seropositive donors on the development of human lympho-proliferative disease in scid mice a mouse monoclonal antibody against epstein-barr virus envelope glycoprotein prevents infection both in vitro and in vivo active and passive vaccination against hantavirus pulmonary syndrome with andes virus m genome segment-based dna vaccine dna vaccine-derived human igg produced in transchromosomal bovines protect in lethal models of hantavirus pulmonary syndrome a non-randomized multicentre trial of human immune plasma for treatment of hantavirus cardiopulmonary syndrome by andv the use of human immune serum globulin (gamma globulin) in infectious (epidemic) hepatitis in the mediterranean theater of operations i. studies on prophylaxis in two epidemics of infectious hepatitis prevention of infectious hepatitis with gamma globulin the prevention and attenuation of infectious hepatitis by gamma globulin gamma globulin in the prevention of infectious hepatitis; studies on the use of small doses in family outbreaks preclinical evaluation of two human anti-hepatitis b virus (hbv) monoclonal antibodies in the hbv-trimera mouse model and in hbv chronic carrier chimpanzees hepatitis b immune globulin as a prophylactic measure for spouses exposed to acute type b hepatitis liver transplantation in hbsag-positive hbv-dna-negative cirrhotics: immunoprophylaxis and long-term outcome liver transplantation in hbs antigen (hbsag) carriers. prevention of hepatitis b virus (hbv) recurrence by passive immunization human monoclonal antibody hcv effectively prevents and treats hcv infection in chimpanzees sexual transmission of the hepatitis c virus and efficacy of prophylaxis with intramuscular immune serum globulin. a randomized controlled trial human monoclonal antibody mbl-hcv delays hcv viral rebound following liver transplantation: a randomized controlled study immunotherapeutic potential of neutralizing antibodies targeting conserved regions of the hcv envelope glycoprotein e clinical evaluation (phase i) of a human monoclonal antibody against hepatitis c virus: safety and antiviral activity successful passive and active immunization of cynomolgus monkeys against hepatitis e role of immune serum globulins in pregnant women during an epidemic of hepatitis e passive immune protection by herpes simplex virus-specific monoclonal antibodies and monoclonal antibody-resistant mutants altered in pathogenicity analysis of the role of antibody-dependent cellular cytotoxic antibody activity in murine neonatal herpes simplex virus infection with antibodies to synthetic peptides of glycoprotein d and monoclonal antibodies to glycoprotein b effect of antibody alone and combined with acyclovir on neonatal herpes simplex virus infection in guinea pigs l or more. effect on viral, opportunistic, and bacterial infections. the national institute of child health and human development intravenous immunoglobulin clinical trial study group intravenous immunoglobulins suppress the recurrences of genital herpes simplex virus: a clinical and immunological study antibody and antiretroviral preexposure prophylaxis prevent cervicovaginal hiv- infection in a transgenic mouse model antibody-based protection against hiv infection by vectored immunoprophylaxis hiv therapy by a combination of broadly neutralizing antibodies in humanized mice hiv- suppression and durable control by combining single broadly neutralizing antibodies and antiretroviral drugs in humanized mice passive immunotherapy in aids: a double-blind randomized study based on transfusions of plasma rich in anti-human immunodeficiency virus antibodies vs. transfusions of seronegative plasma delay of hiv- rebound after cessation of antiretroviral therapy through passive transfer of human neutralizing antibodies safety and efficacy of hiv hyperimmune globulin for prevention of motherto-child hiv transmission in hiv- -infected pregnant women and their infants in kampala passive immunotherapy in the treatment of advanced human immunodeficiency virus infection a murine genital-challenge model is a sensitive measure of protective antibodies against human papillomavirus infection in vivo mechanisms of vaccine-induced protection against hpv infection the effectiveness of convalescent plasma and hyperimmune immunoglobulin for the treatment of severe acute respiratory infections of viral etiology: a systematic review and exploratory metaanalysis protection of mice against japanese encephalitis virus by passive administration with monoclonal antibodies passive protection of mice, goats, and monkeys against japanese encephalitis with monoclonal antibodies protection of monkeys against machupo virus by the passive administration of bolivian haemorrhagic fever immunoglobulin (human origin) protection against measles virus encephalitis by monoclonal antibodies binding to a cystine loop domain of the h protein mimicked by peptides which are not recognized by maternal antibodies correlation between epitopes on hemagglutinin of measles virus and biological activities: passive protection by monoclonal antibodies is related to their hemagglutination inhibiting activity smallpox vaccine-induced antibodies are necessary and sufficient for protection against monkeypox virus a protective therapy for mumps mumps; use of convalescent serum in the treatment and prophylaxis of orchitis serum prophylaxis of epidemic parotitis use of human blood in protection against mumps intravenous immunoglobulin therapy for pure red cell aplasia related to human parvovirus b infection: a retrospective study of patients and review of the literature guidelines on the use of intravenous immune globulin for hematologic conditions the relation of the meninges and choroid plexus to poliomyelitic infection passive immunity in poliomyelitis. iv. protection of rhesus monkeys against cerebral challenge experimental poliomyelitis in monkeys seventh note: active immunization and passive serum protection evaluation of red cross gamma globulin as a prophylactic agent for poliomyelitis. iv. final report of results based on clinical diagnoses evaluation of red cross gamma globulin as a prophylactic agent for poliomyelitis. . reanalysis of results based on laboratory-confirmed cases resume of the results of therapy with convalescent serum in poliomyelitis intramuscular use of convalescent serum in treatment of poliomyelitis preparalytic poliomyelitis: observations in one hundred and six cases in which convalescent serum was used recherches sur la vaccination antirabique evaluation of human rabies immune globulin and homologous and heterologous antibody antiserum in the prophylaxis of rabies comparison of an anti-rabies human monoclonal antibody combination with human polyclonal anti-rabies immune globulin use of hyperimmune anti-rabies serum concentrates in experimental rabies laboratory data supporting the clinical trial of anti-rabies serum in persons bitten by a rabid wolf management of rabies in humans development of a humanized monoclonal antibody (medi- ) with potent in vitro and in vivo activity against respiratory syncytial virus quantitative aspects of passive immunity to respiratory syncytial virus infection in infant cotton rats studies of passive immunotherapy for infections of respiratory syncytial virus in the respiratory tract of a primate model isolation of a second recombinant human respiratory syncytial virus monoclonal antibody fragment (fab rsvf - ) that exhibits therapeutic efficacy in vivo respiratory syncytial virus-enriched globulin for the prevention of acute otitis media in high risk children active and passive immunization against rift valley fever virus infection in syrian hamsters topological mapping of antigenic sites on the rift valley fever virus envelope glycoproteins using monoclonal antibodies passive protection against rotavirus-induced diarrhea by monoclonal antibodies to surface proteins vp and vp serum igg mediates mucosal immunity against rotavirus infection a gastrointestinal rotavirus infection mouse model for immune modulation studies rice-based oral antibody fragment prophylaxis and therapy against rotavirus infection prophylaxis of german measles with immune serum globulin prevention of rubella by gamma globulin during an epidemic in barrow, alaska, in trial of high-titre human rubella immunoglobulin rubella epidemic, : effect on , pregnancies passive immunization against rubella: studies on the effectiveness of rubella-immunoglobulin after intranasal infection with rubella vaccination virus human monoclonal antibody as prophylaxis for sars coronavirus infection in ferrets fully human monoclonal antibody directed to proteolytic cleavage site in severe acute respiratory syndrome (sars) coronavirus s protein neutralizes the virus in a rhesus macaque sars model therapy with a severe acute respiratory syndrome-associated coronavirus-neutralizing human monoclonal antibody reduces disease severity and viral burden in golden syrian hamsters passive immunization of newborn rhesus macaques prevents oral simian immunodeficiency virus infection passive immune globulin therapy in the siv/macaque model: early intervention can alter disease profile passive immunotherapy in simian immunodeficiency virus-infected macaques accelerates the development of neutralizing antibodies fc receptor but not complement binding is important in antibody protection against hiv protection of macaques against pathogenic simian/human immunodeficiency virus . pd by passive transfer of neutralizing antibodies determination of a statistically valid neutralization titer in plasma that confers protection against simian-human immunodeficiency virus challenge following passive transfer of high-titered neutralizing antibodies highly potent hiv-specific antibody neutralization in vitro translates into effective protection against mucosal shiv challenge in vivo antibody-mediated immunotherapy of macaques chronically infected with shiv suppresses viraemia passive transfer of modest titers of potent and broadly neutralizing anti-hiv monoclonal antibodies block shiv infection in macaques neutralizing antibody directed against the hiv- envelope glycoprotein can completely block hiv- /siv chimeric virus infections of macaque monkeys pre-and postexposure protection by passive immunoglobulin but no enhancement of infection with a flavivirus in a mouse model passive immunization of mice with monoclonal antibodies raised against tickborne encephalitis virus efficiency of use of immunoglobulin preparations for the postexposure prevention of tickborne encephalitis in russia (a review of semi delayed humoral immunity in a patient with severe tick-borne encephalitis after complete active vaccination combination therapy of vaccinia virus infection with human anti-h and anti-b monoclonal antibodies in a small animal model disparity between levels of in vitro neutralization of vaccinia virus by antibody to the a protein and protection of mice against intranasal challenge protection of rabbits and immunodeficient mice against lethal poxvirus infections by human monoclonal antibodies postexposure prevention of progressive vaccinia in scid mice treated with vaccinia immune globulin prophylactic effect of antivaccinia gamma-globulin against post-vaccinal encephalitis experience of anti-vaccinia immunoglobulin in the united kingdom complications of smallpox vaccination. effects of vaccinia immune globulin therapy prevention of varicella by zoster immune globulin the use of serum gamma globulin antibodies to control chicken pox in a convalescent hospital for children congenital varicella syndrome: the evidence for secondary prevention with varicella-zoster immune globulin a humanized murine monoclonal antibody protects mice either before or after challenge with virulent venezuelan equine encephalomyelitis virus antibody prophylaxis and therapy against west nile virus infection in wild-type and immunodeficient mice efficacy of killed virus vaccine, live attenuated chimeric virus vaccine, and passive immunization for prevention of west nile virus encephalitis in hamster model using high titer west nile intravenous immunoglobulin from selected israeli donors for treatment of west nile virus infection development of a humanized monoclonal antibody with therapeutic potential against west nile virus possible benefit of intravenous immunoglobulin therapy in a lung transplant recipient with west nile virus encephalitis treatment of west nile virus encephalitis with intravenous immunoglobulin lethal d yellow fever encephalitis in mice. i. passive protection by monoclonal antibodies to the envelope proteins of d yellow fever and dengue viruses the duration of passive immunity in yellow fever persistence of yellow fever immunity on the use of immune serum at various intervals after the inoculation of yellow fever virus into rhesus monkeys notes on laboratory infections with yellow fever observations on laboratory and hospital infections with yellow fever in england immunoprotection against systemic candidiasis in mice rats clearing a vaginal infection by candida albicans acquire .e section general aspects of vaccination specific, antibody-mediated resistance to vaginal reinfection a vaccine and monoclonal antibodies that enhance mouse resistance to candida albicans vaginal infection vaccine and monoclonal antibody that enhance mouse resistance to candidiasis immunoglobulin g blocking antibodies to the fungal pathogen cryptococcus neoformans human immunoglobulin g (igg ) and igg , but not igg or igg , protect mice against cryptococcus neoformans infection more is not necessarily better: prozone-like effects in passive immunization with igg phase i evaluation of the safety and pharmacokinetics of murine-derived anticryptococcal antibody b in subjects with treated cryptococcal meningitis enteral human serum immunoglobulin treatment of cryptosporidiosis in mice with severe combined immunodeficiency efficacy of monoclonal antibodies against defined antigens for passive immunotherapy of chronic gastrointestinal cryptosporidiosis prophylactic effect of bovine anti-cryptosporidium hyperimmune colostrum immunoglobulin in healthy volunteers challenged with cryptosporidium parvum demonstration of passive immunity in experimental monkey malaria model for in vivo assessment of humoral protection against malaria sporozoite challenge by passive transfer of monoclonal antibodies and immune serum the importance of human fcgammari in mediating protection to malaria gamma-globulin and acquired immunity to human malaria antibodies that protect humans against plasmodium falciparum blood stages do not on their own inhibit parasite growth and invasion in vitro, but act in cooperation with monocytes monoclonal antibodies to toxoplasma cell membrane surface antigens protect mice from toxoplasmosis generation of a neutralizing human monoclonal antibody fab fragment to surface antigen of toxoplasma gondii tachyzoites protection against experimental toxoplasmosis by adoptive immunotherapy impact of trough igg on pneumonia incidence in primary immunodeficiency: a meta-analysis of clinical studies high-vs low-dose immunoglobulin therapy in the long-term treatment of x-linked agammaglobulinemia history of immunoglobulin replacement use of intravenous immunoglobulin in human disease: a review of evidence by members of the primary immunodeficiency committee of the american academy of allergy, asthma and immunology effect of intravenous gammaglobulin therapy in igg deficient and igg sufficient children with recurrent infections and poor response to immunization with hemophilus influenzae type b capsular polysaccharide antigen intravenous immune globulin for the prevention of bacterial infections in children with symptomatic human immunodeficiency virus infection. the national institute of child health and human developments intravenous immunoglobulin study group polyclonal intravenous immunoglobulin for the treatment of severe sepsis and septic shock in critically ill adults: a systematic review and metaanalysis supplemental immune globulins in sepsis: a critical appraisal prevention of infection in multiple trauma patients by high-dose intravenous immunoglobulins the role of intravenous immunoglobulin for the prevention and treatment of neonatal sepsis immunity in mumps: i. experiments with monkeys (macacus mulatta). the development of complement-fixing antibody following infection and experiments on immunization by means of inactivated virus and convalescent human serum an experimental study of parotitis key: cord- -n axd bq authors: rusoke-dierich, olaf title: travel medicine date: - - journal: diving medicine doi: . / - - - - _ sha: doc_id: cord_uid: n axd bq before travelling to other countries, thorough travel advice should be provided. not only information about diseases of specific countries but also general advice for travelling should be given on this consultation. before travelling to other countries, thorough travel advice should be provided. not only information about diseases of specific countries but also general advice for travelling should be given on this consultation. the following topics should be included in the travel advice consultation: vaccinations (general and country specific) country-specific diseases malaria prophylaxis mosquito prophylaxis (wearing bright long-sleeved clothes, avoiding perfume, staying in air-conditioned rooms, using a mosquito net, using insect repellents, staying inside at dawn and dusk) food consumption and drinking overseas (no consumption of ice cubes, uncooked meals, salads and food, which is exposed to flies, limited alcohol consumption) uv protection (using sun cream, avoiding sun exposure between . and . o' clock, remaining in shaded areas, wearing a hat and covering skin) fitness assessment for travelling, flying and diving challenges of different climates and their effects on the personal health (dehydration, hyperthermia) medications thrombosis counselling counselling on symptoms on return, which require review (fever, skin changes, abnormal bleeding, lymphadenopathy, diarrhoea) sexual transmitted diseases contraception rabies the following items should be asked to enable to give the appropriate advice: risk assessment of the travel in a particular country (transport, area of stay/ rural or resort, reason for travelling, appropriate conduct overseas, pre-existing diseases and medications) vaccination status accomodation and stopovers duration of the stay the vast majority of up-to-date travel information and information about tropical disease are available on who (world health organization) or cdc (centres for disease control and prevention) websites. information on these websites are frequently updated. before giving appropriate advice based on these online resources, it should be checked, which medications are available in the particular countries. hence, recommendations need to be adjusted individually. usually, a medication record is required at the customs. however, it might be sufficient, if the original medication box has the patients and prescribing doctors details (. table . ). malaria is a tropical disease transmitted by the female anopheles mosquito. the distribution of malaria is primarily in the tropics and subtropics of africa, central and south america, asia, papua new guinea and the western pacific islands. as popular diving spots are located in these areas, malaria prophylaxis and advice should be given. the who (world health organization) estimates the worldwide number of people affected by malaria with about million and , , deaths ( ). the plasmodium parasites need temperatures above °c in order to complete the entire growth cycle. therefore, malaria occurs in some places only seasonal. additionally, there are differences in anopheles species regarding the affinity to the host and their local distribution. some genetic factors are protected against malaria. for example, sickle cell anaemia gives a certain protection against p. falciparum and duffy negative blood group against p. vivax. it appears that after recurrent malaria infections, the body adapts to the disease. this means that an infection is possible, but the symptoms of malaria seem to be reduced. children and pregnant women have an increased risk of being affected by malaria. additionally, children have a high mortality rate. during pregnancy the resistance against malaria is reduced. it also poses an increased risk for the unborn child (low birth weight). anopheles is active especially at sunrise and sunset. different kinds of mosquitoes are rather active during the day and can transmit other diseases such as dengue. especially p. falciparum and p. vivax have resistances against antimalaria drugs. there are different plasmodium pathogens: p. falciparum: worldwide tropical and subtropical distribution, mainly in africa; pathogen of severe malaria causes million deaths per year; rapid growth in the blood with haemolysis and emboli due to cytoadherence of affected erythrocytes; - days of incubation, irregular fever spikes. p. vivax: mainly in asia, latin america and some countries in africa; the disease can be activated after months or years. incubation period of - days; fever spikes every days. p. ovale: mainly west africa and the western pacific islands. similar to the p. vivax, it can also infect people with duffy-negative blood group; incubation period of - days; fever spikes every days. p. malariae: worldwide distribution; typical -day cycle, untreated can lead to lifelong chronic malaria; incubation period - days; fever spikes every days. p. knowlesi: southeast asia, mainly infected animals. after the anopheles mosquito aspirates with gametocytes infected blood, the gametocytes develop to gamete in the mosquito's intestines. in the blood of the mosquito, the microgametes (male) penetrate the macrogametes (female), forming zygotes. then cells are changed to an elongated, motile ookinete. this evolves into an oocyst. after the oocyst bursts, sporozoites are released and get in the saliva of the mosquito. the entire cycle inside the mosquito takes - days. if sporozoites enter the human bloodstream through the saliva of the . symptoms of malaria appear after the incubation period. the incubation period varies depending on the pathogen. it can be between a few weeks and also takes up to several months or even a year (p. vivax or occasionally p. ovale). malaria can be divided in three different forms: malaria tertiana: pathogen: p. vivax and p. ovale; fever every second day with one day without fever, spontaneous remission after max. years malaria quartana: pathogen: p. malaria; fever every third day with days without fever, no spontaneous remission malaria tropica: pathogen: p. falciparum, irregular fevers due to the lack of synchronisation of the parasite reproduction, severe form of malaria (malaria maligna) with high fatality, recurrence up to years the fever has a specific pattern. in the first hour, strong rigors and increasing fever typically develop. the fever can reach °c and more for duration of about h. it is often associated with flushing, vomiting and nausea. the fever stage is followed by an approximately -h stage of severe sweating with decreasing fever. severe forms of malaria can be fatal in within few days. causes of death are cerebral malaria, respiratory failure with adrs and kidney failure. the main reason of these complications is the cyto-adherence ("bonding") of the erythrocytes. it results in a failure of the microcirculation followed by ischaemia of vital organs. . the treatment depends on the severity and the pathogen. in complicated malaria, admission to the intensive care should be considered, if more than one of the following criteria exists: inability of the oral intake of medication parasite load of erythrocytes > % severe symptoms of malaria (see table above) the treatment options of complicated malaria are: artesunate (allowed only in some countries): . mg/kg/bw iv; first dose on admission, repeated after and h, minimum duration of therapy h and then once a day, till oral therapy is tolerated. or combination of quinine + doxycycline or clindamycin. quinine: Ȥ first dose: mg/kg/bw iv over h or mg/kg/bw iv over min with subsequent administration of mg/kg/bw iv over h. Ȥ maintenance therapy: mg/kg/bw iv over h three times a day, beginning h after the completion of the first dose. Ȥ exemption: if the patient received three or more doses of quinine in the last h or had an mefloquine prophylaxis in the last h or received a mefloquine treatment in the last days. + doxycycline: mg iv twice daily for days (iv or oral) or clindamycin: Ȥ initial dose: mg/kg/bw Ȥ maintenance dose: mg/bw every h for days (iv or oral) after clinical improvement medication can be changed to a complete cycle of the oral therapy of an uncomplicated malaria (riamet ® or quinine with doxycycline or clindamycin). uncomplicated malaria can be handled on the normal ward. outpatient therapy with close supervision can be considered under the following conditions: parasite load of erythrocytes < %. age > months. no co-morbidity. pregnancy is excluded. ability of oral medication intake. p. falciparum is excluded. clinically stable under medical therapy for the last h. a daily blood smear is necessary during treatment to follow the process of the disease. the patient can be discharged from the hospital and continue treatment at home; if oral therapy is tolerated, a clinical improvement is achieved and the parasite count decreases. a week and a month after discharge, blood smears should be repeated. primaquine as eradication therapy is approved in some countries. it is the only drug that can be used to eliminate hypnozoites, which are the dormant forms of the malaria parasites that occur with p. ovale and p. vivax. because primaquine causes haemolysis in g- -pd deficiency, g- -pd status prior therapy needs to be established. if an eradication with primaquine is required in patients with g- -pd deficiency, a dose up to mg weekly for weeks, with monitoring for haemolysis, could be considered. in children methaemoglobinaemia can be provoked by giving primaquine. a single dose of primaquine mg for p. falciparum, p malaria and p. knowlesi can be given to sterilise the gametocytes. if malaria caused by p. vivax or p. ovale or co-infection with these parasites is suspected, a -day treatment with mg of primaquine twice a day is recommended. before commencing holidays overseas, medical advice should be given in order to assess the malaria risk of the particular country. in nearly all tropical areas, there is a risk of getting infected with malaria. in some tourist areas, this risk might be small, but infection is still possible. in particular day trips to more remote areas pose a risk. some areas have malaria outbreaks and therefore should be avoided. in general, mosquito bites should be avoided to minimise the risk of any mosquitoborne infections. mosquitoes transmitting malaria are mainly active at night, sunrise and sunset. however, mosquito bites are also possible throughout the day. long-sleeved shirts, long pants and closed shoes cover the skin and provide protection against insect bites. insect repellent for the skin and clothes offer additional protection. higher concentrations offer better and longer protection. the protection period of a normal insect repellent lasts usually only - h. slow release products can prolong the effect. mosquitoes avoid air-conditioned rooms. so staying in air conditioned rooms itself provides certain protection. spraying insecticides in rooms and surroundings can be helpful to repel and minimise the quantities of mosquitoes. the bed should be covered with a mosquito net (. fig. . ). chemoprophylaxis is important, because the main cause of malaria deaths is still inadequate chemoprophylaxis. there are different drugs for chemoprophylaxis available. they are subject to the travel location and the parasite's resistances to certain drugs. in addition, they differ in side effects, dosage and cost. except malarone ® , all other drugs for the chemoprophylaxis against malaria have to be taken weeks after leaving the country as they aren't sufficiently effective against the primary liver stages of malaria. mefloquine (lariam ® ) is the only malaria prophylaxis without absolute contraindication in pregnancy. diving (decrease in vigilance); - weeks (at least week) before entering the malaria-endemic country and weeks after return; lariam ® is a category b medication and is the only medication against malaria without absolute contraindication in pregnancy. the use in the first trimester should only be considered, if the expected benefits justify the potential risk to the foetus. however, recent studies suggest that even in the first trimester this medication is safe to take. the dengue virus is an arbovirus. it has four different serotypes (denv - ). dengue has a worldwide distribution in the tropics and subtropics, especially in asia and south america. approximately - million cases and about , with serious complications per year occur. there is a % mortality, which can be reduced to % with timely diagnosis and appropriate treatment. it has an increased risk for children under years and persons with previous dengue infections. the dengue virus is transmitted by the aedes aegypti mosquitoes. these mosquitoes mainly bite at day and in twilight (. fig. . ). z symptoms the incubation period is - days. there is a wide range in severity of dengue symptoms. the majority of infections cause minor symptoms. but dengue infections can be also quite severe (. table . ). in particular recurrent infections with dengue are associated with complications and severity of the disease. it is important for the treating doctor to remember that after the initial fever, the critical phase follows. therefore, the patient must be monitored closely during this time. the disease goes through three stages: fever phase (day - ): sudden high fever °c occasional associated with bradycardia; myalgia mainly in the spine, arms and legs ("breakbone fever"), headache; retrobulbar pain; rigors; metallic/bitter taste; vomiting; and dehydration. . critical phase (day - ): normal temperature with possible mild fever later on, leucopenia, exanthema, petechiae and lymphadenopathy. severe dengue: abdominal pain, spontaneous bleeding, volume shift in to the peritoneal space ("plasma leak"), pleural effusion, hepatomegaly (≥ cm), rapid increase in haematocrit and decreasing thrombocytes, shock (dengue haemorrhagic shock = dhs or dengue shock syndrome = dss), increased bleeding (dengue haemorrhagic fever = dhf) and organ failure (particularly liver). remission (after days lasting sometimes for weeks): risk of hyperhydration is given when extravascular fluid is reabsorbed without reducing the intravenous fluid administration. in particular in long remissions, fatigue and depression may be present. normally there are no long-term damages after a dengue infection, and the vascular changes recover completely. z treatment there is no medication available to treat dengue directly. the diagnosis of dengue can be demonstrated by pcr in the initial phase and using igm and igg a few days later. due to severe complications, the haematocrit, coagulation parameters, leukocytes and platelets have to be tested daily. thrombocytes < , cells/mm can rise the suspicion of dhf. if pleural effusion is suspected, a cxr should be obtained. by tightening a blood pressure cuff petechiae can be provoked (medium pressure of the systolic and diastolic pressure for min). this can be used as a diagnostic tool. an increase of the haematocrit of > %, pleural effusion, ascites or hypoproteinaemia could be a sign for extravascular fluid loss. the extravascular fluid loss is typically found in the initial phase. hence, fluid replacement therapy is crucial in this phase. as the extravascular fluid loss can come to an end quite quickly, a complication of the fluid replacement therapy is hyperhydration. decrease of haematocrit of > % after fluid administration can represent a fluid excess and hyperhydration. hence, careful monitoring of the fluid balance and weight are necessary. the therapy is adjusted according to its severity. if necessary, dic, blood loss or shock require specific treatment. like dengue, chikungunya is a mosquitoborne disease. the species transmitting the chikungunya virus (chikv) are aedes aegypti in the tropics and subtropics and aedes albopictus in colder regions (. fig. . ). these mosquitoes bite day and night, but mainly in the early morning hours and late afternoon. the incubation period is between and days. the symptoms are similar to that of dengue. patients suffer from sudden fever with headache, skin rash, fatigue, strong limbs and muscle pain. affected joints often are swollen. the symptoms generally last for few days but can persist for weeks and years. the disease has no long-term effects. for diagnosis rt-pcr and virological methods can be used in the initial phase. later, it can be diagnosed by igm and igg. igm peaks after - weeks and can be detected up to months. the treatment requires analgesia only. . yellow fever is a disease transmitted mainly by the aedes aegypti mosquito but also by other mosquitoes or ticks. the pathogen is a rnacontaining flavivirus. it has approximately , infections with approximately , deaths annually. % of cases occur in africa and the remaining % in south america. the risk of getting infected with yellow fever is with : - in africa and higher than : in south america (. fig. . ). the transmission occurs in rainforest areas (jungle or sylvatic cycle), where mosquitoes transfer the virus from monkeys to humans, in endemic areas of the savannah (savannah or intermediate cycle) either transferred from monkeys or human to humans via mosquitoes or in urban areas from human to human via mosquitoes. the incubation period is - days. the disease has two phases. the acute phase comes with fever, headache, myalgia, headand backache, loss of appetite, nausea, vomiting and diarrhoea. the second phase occurs only in approx. % of infected humans within the next h. jaundice, abdominal pain and vomiting are rapidly developing, followed by diffuse bleeding (epistaxis and gi bleeding) and multi-organ failure (mainly kidneys). if symptoms of the more severe second phase develop, % of the patients die within the next - days. patients who survive usually recover without significant organ damage. the diagnosis can be made via a blood or tissue biopsy of the liver. there is no cure for yellow fever and only supportive measures can be taken. however, a very effective life-vaccination (stamaril ® ) is available. only authorised doctors are authorised to prescribe and give the vaccine. severe side effects of these vaccinations are severe allergic reaction ( : ), vaccine-associated neurotropic disease/post-vaccinal encephalopathy ( : ) and vaccine-associated viscerotropic disease/ multi-organ failure ( : ). for travelling into countries where yellow fever is endemic, vaccination is mandatory. the side effects seem to be age-related and occur increasingly with progressive age or in young children. the vaccination is contraindicated in children . · other mosquito-borne diseases below month and during pregnancy. analysis of yellow fever vaccines adverse events demonstrated an increased frequency of serious adverse events in persons age years and older. the risk of viscerotropic side effects in < years is : , in a population of - years of age : and in > years of age : . a failure to be vaccinated or being documented can lead to a refusal of entry into other countries or to a certain time in quarantine when leaving the area where yellow fever occurs. if there is a clinical indication against receiving yellow fever vaccine (e.g. children < month or poor immune status), a written medical exemption can be granted, to enable to travel to these countries without vaccination. absolute contraindications for a yellow fever vaccination are: allergy against the vaccine or egg protein age < months immunodeficiency neoplasia transplantations immunosuppressive therapies relative contraindications for a yellow fever vaccination are: age - months age > asymptomatic hiv infections and cd + t lymphocytes - /mm ( - % of the total in children < years of age) pregnancy lactation aedes aegypti spreads also the zika virus. however, it is also sexually, intrauterine and perinatal transmitted. currently the main distribution is countries in south and north america as well as the caribbean islands, singapore and some countries in south pacific islands. symptoms of zika infection may be fever, rash, arthralgia, myalgia, headache and conjunctivitis. but in most cases, an infection is asymptomatic (~ %). these symptoms are lasting for several days to a week. the incubation period is - days but is likely to be a few days to a week. the diagnosis can be made via pcr or serology. blood pcr can be detected only in the first week of the disease. urine pcr can detect the virus up to weeks. there is no specific treatment available. deaths are unlikely. there is a potential risk during pregnancy, as microcephaly or other birth defects (~ %) may develop. the zina virus cane be also transferred via semen and can affect unborn life. ross river virus (rrv) is transmitted by the bites of culex annulirostris, aedes vigilax, aedes normanensis and aedes notoscriptus in australia, papua new guinea, parts of indonesia and the western pacific islands. the main transmission time is in the humid summer month from december till march. the main symptoms are fever, rash, headache, myalgia, arthralgia and fatigue. the initial symptoms with fever last usually for - weeks. myalgia and arthralgia usually last longer. symptoms of fatigue and depression can be late complications. the incubation time is between days and weeks. the diagnosis is made with igm. there is only symptomatic treatment available. barmah forest virus (bfv) is transmitted by the same species as the rrv. it mainly can be found in australia. many people don't develop any symptoms. the incubation time is - days. if symptoms appear, they are similar to the one of rrv. the initial symptoms last for - weeks, and the arthralgia and myalgia may last for months. the diagnosis is made with igm. there is only symptomatic treatment available. sindbis virus (sinv) is related to the chikungunya virus. it is mainly transmitted via the culex and culiseta mosquitoes. it can be found in europe, africa, asia and oceania. the symptoms and the duration of the symptoms are quite similar to rrv and bfv. the diagnosis is made with igm. there is only symptomatic treatment available. the o'nyong-nyong virus (onnv) is related to the chikungunya virus but is restricted to africa. it has similar symptoms as the chikungunya virus but has additionally mainly cervical lymphadenopathy, and the affected joins rarely show signs of an effusion. most of the gastrointestinal tract infections are caused by poor hygienic conditions of the travel destination. occasionally ingested seawater can cause intestinal infections too. the main transmission routes are either food-borne or by contact. however, the most common cause for gastrointestinal infections is eating contaminated food. old, warmed up food, salads, unpeeled fruits, poorly cooked food, contaminated water (ice and already opened bottles with refilled water) and ice cream often have substantial quantities of pathogens and pose a risk. hence, the best protection against gi infections is avoiding contaminated food or drinks. usually gastrointestinal infections last for a few days and are self-limiting. if diarrhoea contains blood or mucus in combination of high fever for more than days, more thorough assessment is required. blood and mucus without fever are most likely related to a parasitic disease. if fever is present, it's most likely a bacterial or viral disease. but also climate change by itself or dehydration may be caused by autonomic dysregulation gastrointestinal symptoms such as nausea, weakness, vomiting and diarrhoea. with dehydration the dci risk increases. rehydration and supply of certain electrolytes such as sodium, chloride and potassium are the most important treatments for gastroenteritis. fatigue is a common associated symptom. tannins of black tea boiled for more than min might be beneficial for diarrhoea. the consumption of bananas is recommended because of the high content of potassium. but the best options are rehydration preparations in form of drinks, powders or icy poles. loperamide may slow down the peristaltic and give some relief from diarrhoea. probiotics may support recovery. a low fibre diet is rec-ommended in the active phase of diarrhoea. administration of antibiotics is rarely necessary and indicated. it only is used for serious illnesses or symptoms. reservoir: poultry or meals prepared with egg incubation: - h symptoms: fever, vomiting nausea, diarrhoea, occasionally blood and mucous in the stool duration: - days treatment: symptomatic; azithromycin g od for days or ciprofloxacin mg bd for days or ceftriaxone g od reservoir: water and food incubation: - weeks symptoms: headache, myalgia, bradycardia, roseola in the abdominal area, continuous fever - °c, porridge -like diarrhoea, intestinal bleeding and decrease of the fever after weeks treatment: symptomatic; azithromycin g od for days or ciprofloxacin mg bd for days or ceftriaxone g od; vaccination available reservoir: human, flies, food and faeces incubation: - days symptoms: fever, diarrhoea, sometimes with blood and mucus in the stool and severe abdominal pain treatment: symptomatic; ciprofloxacin bd for days, norfloxacin mg bd for days or bactrim / mg bd for days reservoir: food and water incubation: - days symptoms: mild to severe diarrhoea with fever and blood and mucous in the stool, most common cause for diarrhoea overseas treatment: symptomatic; norfloxacin mg od and ciprofloxacin mg od reservoir: food (particular strawberries) and water incubation: - weeks symptoms: diarrhoea like raspberry jelly, no fever! blood and mucous in the stool, risk for developing a liver abscess treatment: symptomatic, asymptomatic carrier, paromomycin mg tds for days; invasive, tinidazole g od for days or metronidazole mg tds for to days . . cholera (vibrio cholerae) reservoir: contaminated food and water incubation: - days symptoms: often mild gi symptoms, - % develop severe symptom with nausea vomiting, rice water-like diarrhoea and severe dehydration, mortality risk of - % treatment: rehydration, electrolyte substitution; vaccination available; azithromycin g single dose, ciprofloxacin g single dose reservoir: food (in particular sea food) and water incubation: - days symptoms: initial phase ( - days)flulike symptoms, gastrointestinal, hepatomegaly; hepatic manifestation ( - weeks), no jaundice (approx. %), jaundice ( %) with dark urine, jaundice, pruritus; hepatitis a has no chronic form, rarely fatal (fatality is age dependent) treatment: symptomatic, bed rest, avoidance of liver toxic substances (alcohol, medication); vaccination available japanese encephalitis is caused by a flavivirus, which is transmitted by mosquitoes (culex particularly c. tritaeniorhynchus). the hosts are usually pigs and water birds. in humans there are usually not sufficiently high concentrations of virus to serve as a host. the distribution is the asia, especially in rural areas. epidemics occur every - years (. fig. . ). the transmission can occur throughout the year but frequently peaks in the rainy season. there are about , cases per year. only about % of the patients are symptomatic. however, if symptoms develop, the mortality rate is - %. approx. - % of patients who survive have long-term neurological or psychiatric complications. mild courses of japanese encephalitis may be accompanied by mild fever and headache. severe cases show high fever, neck stiffness, photophobia, headache, disorientation, coma, convulsions, spastic paralysis or death. consequential damages may be behavioural disorders, convulsions, paralysis and speech disorders. the diagnosis can be established with blood tests and lumbar puncture. there is currently no treatment option. the vaccination is usually well tolerated and available for prophylaxis. there are various tropical diseases, which are present in poorer countries causing more or less severe symptoms. these diseases are termed "neglected tropical diseases" (ntd). the more common ntds are summarised in this chapter. there are three main conditions caused by these pathogens. the african trypanosomiasis (sleeping sickness) is transmitted by the tsetse fly. the distribution is only in some countries of the sub-saharan africa. seventy percent occur in the democratic republic of congo. tsetse flies are mainly found in rural areas. there are two forms causing sleeping sickness, t. brucei rhodesiense and t. brucei gambiense. t. brucei gambiense has an incubation period of months to years and t. brucei rhodesiense weeks to months. the initial phase is the haemolytic-lymphatic phase, in which pathogens replicate in tissues, blood and lymphatic tissues. symptoms are intermittent fever, headache, myalgia and pruritus. additionally, a painless, indurated chancre on the skin - days after the bite and lymphadenopathy (axillary and inguinal) can be associated. in the second phase, the cns affected causes continuous headache, behavioural disorders (mood swings and depression), delirium, sensitivity disorders, coordination problems and disruptions of the sleeping cycle (daytime somnolence). the diagnosis is mainly made clinically. only for the t. b. rhodesiense, a blood test (centrifuged or wet preparation) to data . detect the parasite is available. examination of buffy coat increases sensitivity. a biopsy of the lymph node to detect the pathogens can be diagnostic for t. brunei gambiense or be used for a culture and pcr. the card agglutination test for trypanosomiasis (catt) is a field test suitable for mass population screening in endemic areas for t. b. gambienses but has a low specificity and is hence only used for identifying suspected cases. all diagnosed patients need to have their cerebrospinal fluid examined for staging, which influences treatment options (. table . ). the treatment is dependent on the pathogen and the staging. if untreated, infections of both forms lead to coma and death. leishmaniasis has three forms: visceral, cutaneous and mucosal (kala-azar). there are about different pathogens, from which approx. are held responsible for these diseases. the disease is transmitted by mosquitoes or sandflies (phlebotomus and lutzomyia). the cutaneous form is the most common one, which causes skin ulcerations. typically this form appears weeks to months after the initial mosquito bite. initially papules are formed, which later ulcerate. they can be painful or painless. the visceral form affects organs, especially the liver, spleen and bone marrow. therefore, this form can be quite dangerous. the changes occur within months and years. hepatosplenomegaly and pancytopenia develop. the mucus form is rare. ulcerative changes of the mucous membranes (e.g. nose, mouth and throat) are typical for this. endemic areas for leishmaniasis are east africa, some arabic countries, india, bangladesh, brazil and some other south american countries. historically, the diagnosis was made by taking a biopsy (skin, bone marrow or other tissues) for culture. now pcr or serological testing with high sensitivity replaced biopsies for making diagnosis. as the visceral disease is fatal without treatment, it needs to be treated in any case. all other forms require normally no treatment. following medication is available: pentavalent antimonial (sb v ) compounds ( mg per day iv or im for days) liposomal amphotericin b ( mg od iv on day - , and ) miltefosine (in adults > kg mg times daily for days) azoles (fluconazole mg od for weeks, itraconazole mg bd for days, ketoconazole mg od for at least days) paromomycin (uncommonly used) pentamidine isethionate (uncommonly used) the chagas' disease is transmitted via an insect bite ("kissing bug") or by contaminated food. it occurs in central and south america. it has . an acute and chronic phase. in the acute phase within - weeks after the infection, localised swelling of the area of the insect bite (skin or mucous membranes), lymphadenopathy, bilateral orbital oedema, meningoencephalitis and myocarditis can occur. - % of all infections become chronic, causing arrhythmias with risk of "sudden death", cardiomyopathy and enlargement of the oesophagus (megaoesophagus) or of the colon (megacolon) even after years or decades. the cardiomyopathy consists of fibrosing myocarditis, causing arrhythmia (rbbb, left anterior fascicular block, st changes, premature ventricular beats and bradycardia) and ventricular failure. the diagnosis in the acute phase is made by a blood smear (thick and thin) to visualise the parasite. a serological test is also available. treatment is recommended in the acute phase and in patient up to the age of and no advanced cardiomyopathy with chronic chagas' disease (. table . ). in age groups above , benefits and risk need to be outweighed. worm infections are a major problem in underdeveloped countries. they occur mainly in rural areas. these conditions may cause insignificant symptoms but also lead to serious consequences or even cause death. because some dive sites are located far away from tourist centres, these infections should be discussed before travelling. this kind of roundworm is found in the tropical and subtropical regions of africa and southeast asia. the transfer follows on oral intake of eggs by contaminated food. the larvae are entering the bloodstream after hatching in the intestine. they reach the lungs via the blood and penetrate the lung tissue, and the larvae can be coughed up. if the sputum is swallowed again, the larvae reach the intestine, mature there within the next - months and lay eggs, which are then excreted via the faeces. the adult worms live about - years. infection is usually asymptomatic. however, abdominal pain, flulike symptoms, allergic skin manifestations, malnutrition, productive cough and a stridor can occur. the diagnosis can be made by examining the faeces (eggs, worms) or sputum (larvae). hookworms are found in tropical and subtropical regions of africa and latin america. the transmission is percutaneously or orally by ingestion of contaminated soil. in contaminated soil the larva is able to survive for about - weeks. larvae can penetrate the skin and enter the blood and reach the alveoli in the . lungs. from there they ascend in the airways, are swallowed again and finally get into the intestines. there larvae mature to adult worms. the worms attach themselves to the wall of the intestine and feed on blood. the eggs are excreted in the faeces and reach again the soil. the eggs can survive up to years. common symptoms are pruritus and rash at the entry site, abdominal pain, diarrhoea, weight loss, anaemia and extreme fatigue. the diagnosis can be made of the faeces. z filariasis filariasis has a worldwide distribution in tropical and subtropical regions. it is caused by wuchereria bancrofti and brugia malayi. it is transmitted by mosquitoes. the infective filariform grow inside mosquitoes and enter via its saliva during the bite. they migrate to the lymphatic vessels and lymph nodes where they develop into adults. they can live there for about years. the female worms produce microfila, which are circulating in the blood. absorbed by mosquitoes they develop within - weeks to the infective filariform. initially there are no symptoms. later lymph oedema in extremities or genitals is a common symptom. in men hydrocele can develop. the skin typically swells and hardens ("elephantiasis"). the diagnosis is made via the blood. detection in the blood smear has to be performed at night, as larvae only circulate in the blood at night. there is also a serological detection of anti-filaria igg available for diagnosis. the treatment with dec is the drug of choice. concurrent disease of loa loa or onchocerciasis is a contraindication for dec, because of the serious side effects (encephalopathy and deaths). ivermectin is used as a prophylaxis, but not as a therapy. z schistosomiasis (bilharziose) schistosomiasis can be found in tropical and subtropical regions worldwide. in addition to malaria, it is the most common parasitic disease. the parasite schistosoma is housed in freshwater snails. by being exposed to freshwater in these regions, infections can occur. the eggs are excreted in urine or faeces of the host. they hatch under optimal conditions and release miracidia. these miracidia infect freshwater snails and develop into sporocysts. these develop into cercariae and get released into the water, where they can penetrate the skin of the host. there, they shed their tail and become schistosomulae and migrate to the liver. in the liver they mature into adults. the paired adult worms migrate to the bowel and bladder, where they lay the eggs. a rash ("swimmers itch") may develop at the entry site on the skin. suprapubic pain and haematuria, abdominal pain, myalgia, fever, swelling of the lymph nodes, liver and spleen enlargement and eosinophilia can be additional symptoms. the risk of bladder cancer is increased with schistosomiasis. the diagnosis can be made in the stool and urine. the maximum excretion of eggs in the urine is between and pm. z trichuriasis (whipworm) whipworms have a worldwide distribution in the humid tropics. the eggs are orally absorbed via soil or unwashed vegetables or fruits. the whipworm grows in the large intestine. the eggs are excreted via the faeces. in the soil the eggs pass through various stages before getting absorbed again. the symptoms are abdominal pain, chronic diarrhoea, nausea, vomiting, inflammation of the intestine, anaemia and eosinophilia. the diagnosis is made with a stool sample. the treatment on the infection is dependent on the parasite (. table . ). leptospirae are long, motile spirochetes. they have a worldwide distribution, but infections occur more commonly in tropical and subtropical regions. they spread through infected urine, which enters water or soil. leptospires can survive for several weeks and months. infections can be caused by contact with either direct contact with the urine or other body fluids except saliva as well as with contaminated soil and water. the bacteria enter the body through the skin or mucous membranes. a broken skin increases the risk of infection. increased risk is after heavy rainfall or flooding. the incubation period is usually - days, but can range from - days. symptoms vary greatly. usually sudden onset of headaches, fever, chills, myalgia, nausea and vomiting, diarrhoea, rash and jaundice are common signs of the first phase for - days. if the patient doesn't recover the second phase (weil's disease) develops, with renal failure, ards, hepatomegaly, jaundice, haemorrhage and meningitis. this has a fatality rate of - %. untreated symptoms can persist for several months. treatment is either doxycyclin mg bd or benzylpenicillin . g qid or ceftriaxone g od for days. infections caused by rickettsia, orienta, ehrlichia, neorickettsia, neoehrlichia and anaplasma are summarised as rickettsial infections. rickettsias are divided into the typhus group and the spotted fever group. orienta make up the typhus group. the reservoir is found in mainly animals, like rodents, but some species are found in fish. the vector is commonly ticks. in scrub typhus the vectors are larval mites. others have fleas and lice as a vector. infection occurs either by bites of the vectors or by direct contact, inoculation or inhalation of contaminated fluids or faeces. the clinical presentation varies. mild symptoms are headache, myalgia, abdominal pain, cough and rash. some rickettsial infections, . q-fever is a zoonosis caused by the protozoa coxiella burnetii. the bacterium is quite resilient due to its sporelike life cycle and remains virulent for months even up to more than a year. the primary reservoir is cattle, goats, sheep and other wildlife like kangaroos, rats and cats. rarely is it transmitted by tick bites or by ingestion of unpasteurised milk or dairy products. the incubation time is usually - weeks but can range from days to weeks. the initial acute q-fever comes with sudden onset of high fever up to °c, headache (retrobulbar), myalgia, chills, non-productive cough and sweats. the symptoms settle within - days. % of all infections are however asymptomatic. often thrombocytopenia and abnormal lfts are found. complications are ards, endocarditis and meningoencephalitis. the diagnosis is based on detecting phase ii and phase i antibodies (igg) weeks apart. the initial test (phase ii) should be taken at the end of the first week of illness. igm and igg rise almost at the same time. a fourfold rise is diagnostic. an initial negative titre doesn't rule out q-fever. seroconversion occurs usually between days and but is almost always present by days. pcr testing can be used in the first weeks but before antibiotic administration. however, a negative pcr result doesn't rule out q-fever. chronic q-fever develops in . - %. it can result in endocarditis, aneurysms, osteomyelitis, hepatitis, neurogic (mononeuritis, optic neuritis), pulmonary (interstitial fibrosis, pseudotu-mor) and renal (glomerulonephritis) disease. chronic q-fever usually develops shortly after the infection. however, chronic endocarditis may not come apparent until - years or even longer. chronic fatigue syndrome is described in approx. %. typically in chronic q-fever, the initial igg titre is increasing (> : ). the treatment for acute q-fever is doxycyclin mg bd for days or for at least days after fever subsides and until clinical improvement. as serological confirmation takes time, treatment should not be delayed. early treatment is effective at preventing severe complications. for chronic q-fever, months of doxycyclin mg bd and hydroxychloroquine mg tds is recommended as standard treatment. rabies has an almost worldwide distribution. more than % of deaths occur in africa and asia. about % are children under years of age. dogs are the main vectors. in asia, there is also a risk of transmission through monkeys. in addition to other diseases, like the lyssavirus, bats or flying foxes can transfer rabies. it is transmitted by bites or scratch wounds but also by inoculation of saliva onto mucous membranes or eye of an infected animal. thorough cleaning of the wound and vaccination within hours can prevent the disease. the incubation period is usually - months but can be less than week and more than a year. initial symptoms include paraesthesia in the wound area. the disease can pass in two forms. the hyperactive form ( %) shows up with hyperactivity, manic behaviour, paranoia, hallucinations, delirium, hydrophobicity and occasionally aerophobia (triggered by the extremely painful spasms in the larynx area). the paralytic form ( %) is characterised by a slow but steady increasing paralysis. the paralysis begins in the area of the infection. the diagnostics can be established on the animal that has inflicted the wound. the tissue samples of the animal are taken from the brain (brainstem and cerebel-lum). the diagnosis in humans is difficult and unreliable. investigation of blood (antibodies), saliva (pcr), spinal fluid (antibodies) and skin biopsies (rabies antigen) are available. the vaccine and the immune globulin can be given during pregnancy. typical side effects of the vaccine are headache, myalgia, malaise, fatigue and nausea. treatment after potential infection (postexposure prophylaxis pep) includes: irrigation of the wound for a minimum of min and washing of the wound with water, soap, iodine or other disinfecting substances rabies vaccine rabies immunoglobulin into the wound area within days after the first vaccination following data should be recorded when a rabies vaccine is given overseas: address, email and telephone of the practice or hospital date of vaccinations batch number, name of the vaccine and manufacturer how many vaccinations are given application: subcutaneous or intramuscular injection who recommends the following approach with potential rabies after animal contact: vaccination against rabies is recommended for: travellers, who for more than month in areas, in which rabies is present professions that deal with bats or fruit bats professions, in which might get with rabies in contact (e.g., veterinary surgeon or nurse) laboratory workers who handle objects with rabies or lyssavirus after animal contact category + pre-exposure prophylaxis (prep) includes three vaccinations on day , and - . the dose is . ml intramuscularly or subcutaneously. the vaccination lasts for years. follow-up vaccinations (post-exposure prophylaxis = pep) include four vaccinations on day , , and . the dose is . ml intramuscularly. immunocompromised patients should receive five vaccinations with an additional vaccination on the th day. with previous vaccinations, two vaccinations are recommended on day and after exposure. it is not recommended to change the brand or the manufacturer during the course of vaccinations. however, it is possible, if that particular vaccine is not available. immunoglobulin should be administered with the first vaccination. the dose is iu/kgbw. the immunoglobulin preferably should be given in proximity of the wound. the immunoglobulin can be diluted, if the wounds is large, to enable to cover the entire wound area. the immunoglobulin is not recommended, if the first vaccination was given more than days ago, if prep or pep was completed or if an adequate serologic detection of vnab titres (≥ . iu/ml) is present. to avoid infection, no animals should be fed. bringing your own food or carrying items like handbags, water bottles, etc. should be avoided, if you stay in the range of monkeys. distance should be maintained to stray cats and dogs. the middle east respiratory syndrome (mers) is caused by a corona virus. corona viruses can cause mild flulike symptoms but also severe symptoms like the severe acute respiratory syndrome (sars). the mers-cov occurs . · mers mainly on the arabian peninsula (iran, jordan, kuwait, lebanon, oman, qatar, saudi arabia, united arab emirates and yemen). but through international travel, it can spread worldwide. recently it resulted in some cases in korea. mers has % mortality. the disease is transmitted through droplets or direct contact. the mers-cov also has a wide range of symptoms, from mild common cold symptoms and infections of the upper respiratory tract to a rapidly progressive pneumonitis, respiratory failure, septic shock and multi-organ failure. it seems the mers-cov has a low virulence, since the transmission occurs usually only through close contact by human to human, such as the care of a person suffering from mers. camels seem to be the original reservoir. mild forms with fever and mild respiratory symptoms, mers should be considered, if close contact with infected people existed prior to these symptoms. mers can be asymptomatic but also lead to respiratory failure and death. typical symptoms include fever, cough and shortness of breath. pneumonia or pneumonitis is often associated with mers. sometimes gastrointestinal symptoms such as diarrhoea and vomiting can occur. it has a high mortality of %. the treatment depends on the severity of the disease. caution in contact with camels in affected countries should be taken. eating insufficient heated camel meat and milk should be avoided. a suspicion of mers should be considered in individuals with the following risk profile: fever and pneumonia/pneumonitis and stay in endemic areas or contact with a symptomatic person from an endemic area within days before onset of symptoms fever and pneumonia/pneumonitis and hospitalisation in endemic areas or contact with camels and camel products in an endemic area within days before onset of symptoms fever and pneumonia/pneumonitis and contact with a mers diseased person within days before onset of symptoms cluster of patient (especially medical personnel) with severe respiratory symptoms with unclear aetiology tuberculosis is caused by an acid-resistant mycobacterium. m. tuberculosis is responsible for tuberculosis in more than %. it has global distribution but occurs more frequently in countries with low hygienic standards. tuberculosis spreads around the globe through international travel and immigration. it also shows a rising rate of resistances to conventional therapies. the time between the initial infection and tuberculin conversion takes approx. the diagnosis can be made with the tuberculin skin test (tst/mendel mantoux). days after the strictly intradermal injection of the substance, the induration at the injection site is measured. an induration of > mm may be suggestive of tuberculosis. it is considered a positive test if either the patient has a radiological proof, had close contact with someone with tuberculosis, and has symptoms of tuberculosis, is hiv positive or suffers from immunodeficiency. an induration > mm is considered as positive, when the patient who travelled to a country with high tb prevalence is an iv. drug user, homeless and a resident of nursing home or prison and has diabetes mellitus, silicosis, m. hodgkin's or end-stage renal failure. an induration > mm is considered as evidence of tuberculosis without any risk factors or symptoms. the tst can be negative in the first weeks after an infection as well as in patients suffering from miliary tuberculosis, m. hodgkin, sarcoidosis, viral infections, and lowered immunity, receiving an immunosuppressive therapy or at high age. a false-positive test can occur after multiple tsts, after vaccination against tuberculosis and infection of other mycobacteria. the interferon-γ test (quantiferon ® tb gold) offers an alternative testing method. this test has the same sensitivity as the tst but a higher specificity. moreover, this test is a confirmation test and isn't affected by previous bcg-immunisations. it consists of three parts, the control (to determine the baseline-interferon-γ), mitogen control (determining the ability of an immune response) and antigen detection (detection of prior infections). a cxr may demonstrate caverns or hilar lymph nodes, but is not a diagnostic tool to exclude tuberculosis. the treatment duration of uncomplicated tuberculosis is months, of complicated tuberculosis - months (. table . ). it's a combination treatment of different drugs. medications for the tuberculosis treatment are: isoniazid: mg/kgbw, max. mg /d; side effects: elevated serum transaminases, polyneuropathy, prophylaxis to avoid side effects of pyridoxine - mg/d a vaccination bcg vaccine is not recommended due to its side effects and the lack of efficacy. all vaccinations should be given days before travelling. minimum time for a sufficient protection is weeks (. divers alert network (dan) is a non-profit organisation for divers. they provide medical information and articles, diving insurance, life insurance and travel insurance. they also offer courses, support and research. dan has an international hotline for support and coordination of diving accidents but also for general medical advice overseas. european underwater and baromedical society (eubs) is a european organisation for diving and hyperbaric medicine. they provide guidelines for hyperbaric treatment and training of medical professionals for the hyperbaric medicine. the german organisation for diving and hyperbaric medicine is the "gesellschaft für tauch-und Überdruckmedizin" (getÜm). . . single dose certificate is valid for years, a new vaccination may be required after years to renew the certificate they provide guidelines for hyperbaric treatment and training of medical professionals for the hyperbaric medicine. brazil; office: tel: + - - - , emergency-hotline: + - - - . japan: japan marine recreation association, kowa-ota-machi bldg office: tel: + - - - , f ax southern africa: private bag x , halfway house, midrand eubs: webmaster@eubs.org gtuem: c/o bg-unfallklinik, professor-kuentscher-str. , d- murnau spums: st kilda road uhms: us highway , suite dan: www. diversalertnetwork. org dan europe: www. daneurope. org emedicine yellow fever chikungunya virus middle east respiratory syndrome (mers) parasites -african trypamosiasis (also known as sleeping sickness) parasites -american trypanosomiasis (also known as chagas disease) parasites -trichuriasis (also known as whipworm) air embolism of the brain in rabbits pretreated with mechlorethamine an examination of the critical released gas concept in decompression sickness accessed middle east respiratory syndrome (mers) middle east respiratory syndrome coronavirus (mers-cov) key: cord- -msz au b authors: gershan, william m. title: cough date: - - journal: practical strategies in pediatric diagnosis and therapy doi: . /b - - - - . - sha: doc_id: cord_uid: msz au b nan the previous response or lack of response to some therapies for recurrent and chronic cough can provide important information (see table - ). furthermore, some coughs may be caused or worsened by medications (table - ) . a history of accompanying signs or symptoms, whether localized to the respiratory tract (wheeze, stridor) or elsewhere (failure to thrive, frequent malodorous stools) can give important clues (table - ; see tables - and - ) . it is essential to remember that the daily language of the physician is full of jargon that may be adopted by parents but with a different meaning from that understood by physicians. if a parent says that a child "wheezes" or "croups" or is "short of breath," it is important to find out what the parent means by that term. because many disorders of childhood have genetic or nongenetic familial components, the family history can provide helpful information: are there older siblings with cystic fibrosis (cf) or asthma? is there a coughing sibling whose kindergarten class has been closed because of pertussis? similarly, the key to today's problems may be found in the past: was the child premature and, if so, did he or she spend a month on the ventilator, and does he or she now have chronic lung disease (bronchopulmonary dysplasia)? did the toddler choke on a carrot or other food months ago? did the child receive a bone marrow transplant a year ago? is the child immunized? did the infant have a tracheoesophageal fistula repaired in the neonatal period? *infections include upper (pharyngitis, sinusitis, tracheitis, rhinitis, otitis) and lower (pneumonia, abscess, empyema) respiratory tract disease. † anatomic abnormality includes tracheobronchomalacia, tracheoesophageal fistula, vascular ring, abnormal position, or take-off of large bronchi. common; less common; much less common. cf, cystic fibrosis; ger, gastroesophageal reflux. initial inspection often reveals the seriousness of an illness: is the child struggling to breathe (dyspnea)? does the child have an anxious look? can the child be calmed or engaged in play? is the child's skin blue (representing cyanosis) or ashen? does the child appear wasted, with poor growth that may indicate a chronic illness? the respiratory rate is often elevated with parenchymal lung disease or extrathoracic obstruction. respiratory rates vary with the age of the child (fig. - ) and with pulmonary infection, airway obstruction, activity, wakefulness and sleep, fever, metabolic acidosis, and anxiety. odors may also give helpful clues. does the examining room or the clothing smell of stale cigarette smoke? is there a foul odor from a diaper with a fatty stool, which may suggest pancreatic insufficiency and cf? is the child's breath malodorous, as can be noticed in sinusitis, nasal foreign body, lung abscess, or bronchiectasis? it has been said that the examination of the lungs begins at the fingertips. cyanotic nail beds suggest hypoxemia, poor peripheral circulation, or both. the examiner looks for the presence of digital clubbing ( fig. - ) , which makes asthma or acute pneumonia extremely unlikely. the absence of digital clubbing but a history of severe chronic cough in an older child makes cf unlikely. the shape of the chest gives information. is the anteroposterior (ap) diameter increased, which indicates hyperinflation of the lungs from obstruction of small airways (asthma, bronchiolitis, cf)? is this diameter small, as can be seen with some restrictive lung diseases with small lung volumes (muscular dystrophy, spinal muscular atrophy)? the normal infant has a "round" chest configuration, with the ap diameter of the chest about % of the transverse (lateral) diameter. with growth, the chest becomes more flattened in the ap dimension, and the ap-to-transverse ratio is closer to % to %. although obstetric calipers can be used to give an objective assessment of the ap diameter of the chest, most clinicians rely on their subjective assessment of whether the diameter is increased: does the patient look "barrel-chested"? intercostal, subcostal, suprasternal, and supraclavicular retractions (inspiratory sinking in of the soft tissues) indicate increased effort of breathing and reflect both the contraction of the accessory muscles of respiration and the resulting difference between intrapleural and extrathoracic pressure. retractions occur most commonly with obstructed airways (upper or lower), but they may occur with any condition leading to the use of the accessory muscles. any retractions other than the mild normal depressions seen between an infant's lower ribs indicate a greater-than-normal work of breathing. less easy to notice than intercostal retractions is their bulging out with expiration in a child with expiratory obstruction (asthma). contraction of the abdominal muscles with expiration is easier to notice and is another indication that a child is working harder than normal to push air out through obstructed airways. inspection of the spine may reveal kyphosis or scoliosis. there is a risk of restrictive lung disease or static pneumonia if the curvature is severe. palpating the trachea, particularly in infants, may reveal a shift to one side, which suggests loss of volume of the lung on that side or extrapulmonary gas (pneumothorax) on the other side. placing one hand on each side of the chest while the patient breathes may enable the examiner to detect asymmetry of chest wall movement, either in timing or in degree of expansion. the former indicates a partial bronchial obstruction, and the latter suggests a smaller lung volume, voluntary guarding, or diminished muscle function on one side. palpating the abdomen gently during expiration may allow the examiner to feel the contraction of the abdominal muscles in cases of expiratory obstruction. palpation for tactile fremitus, the transmitted vibrations of the spoken word ("ninety-nine" is the word often used to accentuate these vibrations), helps determine areas of increased parenchymal density and hence increased fremitus (as in pneumonic consolidation) or decreased fremitus (as in pneumothorax or pleural effusion). the percussion note determined by the examiner's tapping of one middle finger on the middle finger of the other hand, which is firmly placed over the patient's thorax, may be dull over an area of consolidation or effusion and hyperresonant with air trapping. percussion can also be used to determine diaphragmatic excursion. the lowest level of resonance at inspiration and expiration determines diaphragmatic motion. because lung sounds tend to be higher-pitched than heart sounds, the diaphragm of the stethoscope is better suited to pulmonary auscultation than is the bell, whose target is primarily the lower-pitched heart sounds (table - ). the adult-sized stethoscope generally is far superior to the smaller pediatric or neonatal diaphragms, even for listening to small chests, because its acoustics are better. the two-headed stethoscope enables the user to hear homologous segments of both lungs simultaneously in order to identify instances in which there is a delay in air entry or exit. the traditional single-headed stethoscope is adequate in most children with cough. the ability to recognize normal breath sounds comes with practice ( fig. - ). adventitious sounds come in a few varieties, namely, stridor, crackles, rhonchi, and wheezes. other sounds should be described in clear, everyday language. stridor is a continuous musical sound usually heard on inspiration and is caused by narrowing in the extrathoracic airway, as with croup or laryngomalacia. crackles are discontinuous, representing the popping open of air-fluid menisci as the airways dilate with inspiration. fluid in very common and suggests the diagnosis; ++, common; +, uncommon; -, almost never and makes examiner question the diagnosis. respiratory disorders larger airways causes crackles early in inspiration (congestive heart failure); crackles that tend to be a bit lower in pitch ("coarse" crackles) than the early, higher-pitched ("fine") crackles are associated with fluid in small airways (pneumonia). although crackles usually signal the presence of excess airway fluid (pneumonia, pulmonary edema), they may also be produced by the popping open of noninfected fibrotic or atelectatic airways. fine crackles are not audible at the mouth, whereas coarse crackles may be. crackles is the preferred term, rather than the previously popular "rales." rhonchi, or "large airway sounds," are continuous gurgling or bubbling sounds typically heard during both inhalation and exhalation. these sounds are caused by movement of fluid and secretions in larger airways (asthma, viral uri). rhonchi, unlike other sounds, may clear with coughing. wheezes are continuous musical sounds (lasting longer than milliseconds), caused by vibration of narrowed airway walls, as with asthma, and perhaps vibration of material within airway lumens. these sounds are much more commonly heard during expiration than inspiration. the chest radiograph is often the most useful diagnostic test in the evaluation of the child with cough. table - highlights some of the radiographic features of the most common causes of cough in pediatric patients. radiographic findings are often similar for a number of disorders, and thus these studies may not indicate a definitive diagnosis. chest films are normal in children with psychogenic (habit) cough and in children with sinusitis or gastroesophageal reflux (ger) as the primary cause of cough. a normal chest radiograph indicates the unlikelihood of pneumonia caused by respiratory syncytial virus (rsv), influenza, parainfluenza, adenovirus, chlamydia species, or bacteria. although children with cough resulting from cf, mycoplasma species, tuberculosis, aspiration, a bronchial foreign body, or an anatomic abnormality usually have abnormal chest radiographs, a normal radiograph does not exclude these diagnoses. hyperinflation of the lungs is commonly seen on chest films of infants with rsv bronchiolitis or chlamydia pneumonia, and a lobar or round (coin lesion) infiltrate is the radiographic hallmark of bacterial pneumonia. the diagnosis of sinusitis cannot be sustained with normal sinuses on radiograph or computed tomography (ct) scan. the white blood cell (wbc) count may help exclude or include certain entities for a differential diagnosis, but, with the possible exception of pertussis, can seldom establish a diagnosis with certainty. a wbc count of , with % lymphocytes strongly suggests pertussis, but not every child with pertussis presents such a clear hematologic picture. the presence of a high number or large proportions of immature forms of wbcs suggests an acute process, such as a bacterial infection. immunoglobulins provide supportive evidence for a few diagnoses, such as chlamydial infection, which rarely occurs without elevated serum concentrations of immunoglobulins g and m. specific bacteriologic or virologic diagnoses can be made in a number of disorders causing cough, including rsv, influenza, parainfluenza, adenovirus, and chlamydia pneumonia. in most cases, these diagnoses are based on culturing the organism from nasopharyngeal washings. in some cases, the viruses can be rapidly identified with immunofluorescence or amplification of viral genome through polymerase chain reaction (pcr). in bacterial pneumonia, the offending organism can be cultured from the blood in a small proportion ( %) of patients. a positive culture provides definitive diagnosis, but a negative culture specimen is not helpful. throat cultures are seldom helpful (except in cf) in identifying lower respiratory tract organisms. sputum cultures and gram stains may help guide initial empirical therapy in older patients with pneumonia or purulent bronchitis, but their ability to identify specific causative organisms with certainty (again with the exception of cf) has not been shown clearly. infants and young children usually do not expectorate but, rather, swallow their sputum. specimens obtained via bronchoscopy may be contaminated by mouth flora, but heavy growth of a single organism in the presence of polymorphonuclear neutrophils certainly supports the organism's role in disease. if pleural fluid or fluid obtained directly from the lung via needle aspiration is cultured, the same rules apply: positive cultures are definitive, but negative cultures are not. bacterial antigen detection in serum or urine by various techniques (latex agglutination) can help identify pneumococcus and haemophilus influenzae type b. a number of specific tests can help to establish diagnoses in a child with cough (see table - ). these include a positive response to bronchodilators in a child with asthma; visualizing the red, swollen epiglottis in epiglottitis (to be done only under very controlled conditions, as described later); the bronchoscopic visualization of the peanut, plastic toy, or other offender in foreign body aspiration; a positive purified protein derivative in tuberculosis; and several studies of the esophagus in ger. several imaging techniques, such as ct or magnetic resonance imaging (mri), can help to delineate various intrathoracic anatomic abnormalities. finally, multiple tests can be employed to confirm the diagnosis of cf (table - ). infections are the most common cause of acute cough in all age groups and are responsible for some chronic coughs. the age of the patient has a large impact on the type of infection. viral upper respiratory infections (common cold); croup (laryngotracheobronchitis); viral bronchiolitis, particularly with rsv; and viral pneumonia are the most frequently encountered respiratory tract infections and hence the most common causes of cough in infancy. viral illness may predispose to bacterial superinfection (croup and staphylococcus aureus tracheitis or influenza and h. influenzae pneumonia). cold symptoms and signs usually include stuffy nose, with nasal discharge (rhinorrhea); sore throat and sneezing frequently occur. there may be fever, constitutional signs (irritability, myalgias, headache), or both. cough is common and may persist for to days. the mechanism by which upper respiratory infections cause cough in children is undetermined. in adults, it is generally thought that "postnasal drip"-that is, nasal or sinus secretions draining into the posterior nasopharynx-causes cough and, in fact, may be one of the most frequent causes of cough. indeed, sinus ct in older patients , or the phalangeal depth ratio, is normally less than but increases to more than with finger clubbing. the dpd/ipd ratio can be measured with calipers or, more accurately, with finger casts. the hyponychial angle is measured from lateral projections of the finger contour on a magnifying screen and is normally less than degrees but greater than degrees with finger clubbing. schamroth's sign is useful for bedside assessment. the dorsal surfaces of the terminal phalanges of similar fingers are placed together. with clubbing, the normal diamond-shaped aperture or "window" at the bases of the nail beds disappears, and a prominent distal angle forms between the end of the nails. in normal subjects, this angle is minimal or nonexistent. ( whispering pectoriloquy produces clearer sounding whispered words (e.g., "ninety-nine"). pmi, point of maximal impulse. with colds often reveals involvement of the sinus mucosa. whether this is true in children remains undetermined. other authorities believe that cough in a child with a cold indicates involvement (inflammation or bronchospasm) of the lower respiratory tract. the physician's bias on this matter will probably influence how to treat the child with cough accompanying a cold. in adults, the cough of the common cold may respond to a combination antihistaminedecongestant preparation, presumably from the decreased postnasal drip. it is uncertain whether such treatment is effective or indicated in children, particularly young infants, in whom toxicity of the drugs may be a greater concern than in adults. common viral pathogens include rhinovirus, rsv, and parainfluenza virus. the differential diagnosis includes allergic rhinitis, which often demonstrates clear nasal secretions with eosinophils and pale nasal mucosa, in contrast to mucopurulent nasal secretions with neutrophils and erythematous mucosa. infectious croup (see chapter ) is most common in the first years of life. its most dramatic components are the barking ("croupy") cough and inspiratory stridor, which appear a few days after the onset of a cold. in most cases, the patient has a low-grade fever, and the disease resolves within a day or two. in severe cases, the child can be extremely ill and is at risk for complete laryngeal obstruction. there may be marked intercostal and suprasternal retractions and cyanosis. stridor at rest signifies significant obstruction. diminishing stridor in a child who is becoming more comfortable is a good sign, but diminishing stridor in and of itself is not necessarily good: if the child becomes fatigued because of the tremendous work of breathing through an obstructed airway and can no longer breathe effectively, smaller-than-needed tidal volumes make less noise. low yield on culture in paroxysmal stage. pleural effusion relatively common. blood culture positive in %; needle aspiration of pleural fluid or lung fluid may yield organism; bacterial antigen in urine. in older infants and children, common pathogens include pneumococci and group a streptococci; staphylococcus aureus is rare and may be associated with pneumatoceles or empyema. localized hyperinflation is common; localized atelectasis in common; inspiratory-expiratory films may show ball-valve obstruction. esophageal biopsy specimen shows esophagitis. multilobular or multisegmental, dependent lobes. (?) lipid-laden macrophages from bronchoscopy or gastric washings; barium swallow or radionuclide study showing aspiration. right-sided arch, mass effect on airways, mass identified; magnetic resonance imaging (mri). bronchoscopy; computed tomography; mri. +++, almost always-if not present, must question diagnosis; ++, common; +, less common; -, seldom-if present, must question diagnosis. +bld cult, blood culture may be positive; bronch, bronchoscopy can reveal the foreign body; diff, diffuse or scattered; ↑ eos, increased eosinophil count; esoph ph, prolonged esophageal ph probe monitoring; ge, gastroesophageal; hyper, hyperinflated; ig, immunoglobulin; infil, infiltrates; ↑ ly, increased lymphocyte count; +np cult, nasopharyngeal culture positive for specific organism; paraflu, parainfluenza virus; pcr, polymerase chain reaction; ↑ pmn, increased polymorphonuclear neutrophil count; ppd, purified protein derivative (tb); rad, reactive airways disease; rsv, respiratory syncytial virus; tb, tuberculosis; ↑ wbc, increased white blood cell count. it is important to distinguish croup from epiglottitis in the child with harsh, barking cough and inspiratory stridor because the natural histories of the two diseases are quite different (see table - ). epiglottitis occurs more commonly in toddlers than in infants (see chapter ). treatment of mild croup is usually not needed. for decades, pediatricians have recommended putting a child with croup in a steamy bathroom or driving to the office or emergency room with the car windows rolled down. (it is likely that these remedies are effective because of the heat exchange properties of the upper airway; air that is cooler or more humid than the airway mucosa will serve to cool the mucosa, thus causing local vasoconstriction and probably decreasing local edema.) in a child who has stridor at rest, hospitalization is indicated. symptomatic, often dramatic relief through decreased laryngeal edema can usually be achieved with aerosolized racemic epinephrine ( . % solution, . to . ml/dose). it is essential to remember that the effects of the epinephrine are transient, lasting only a few hours, although the course of the illness is often longer. the result is that when the racemic epinephrine's effect has worn off, the child's cough and stridor will probably be as bad or even worse than before the aerosol was administered. this is not a "rebound" effect: the symptoms are not worse because of the treatment but, rather, because of the natural progression of the viral illness. repeating the aerosol will probably again have a beneficial effect and reduce the likelihood of requiring a tracheotomy or endotracheal intubation. a child who responds favorably to such an aerosol needs to be observed for several hours because further treatment may be needed. a single dose of dexamethasone ( . mg/kg orally, intramuscularly, or intravenously) reduces the severity and hastens recovery. aerosolized steroids (budesonide) may also be effective in patients with mild to moderately severe croup. bronchiolitis is a common and potentially serious lower respiratory tract disorder in infants (see chapters and ). it is caused usually by rsv but on occasion by parainfluenza, influenza, or adenovirus. it occurs in the winter months, often in epidemics. rsv bronchiolitis is seen uncommonly in children older than years. typically, "coldlike" symptoms of rhinorrhea precede the harsh cough, increased respiratory rate, and retractions. respiratory distress and cyanosis can be severe. the child's temperature is seldom elevated above °c. the chest is hyperinflated, widespread crackles are audible on inspiration, and wheezing marks expiration. the most striking laboratory abnormalities are in the chest radiograph, which invariably reveals hyperinflation, as depicted by a depressed diaphragm, with an enlarged retrosternal air space in as many as % of patients, peribronchial thickening in approximately %, and consolidation and/or atelectasis in % to %. the diagnosis is confirmed with demonstration of rsv by immunofluorescent stain or pcr of nasopharyngeal washings. in most cases, no treatment is needed because the disease does not interfere with the infant's eating or breathing. apnea is a common complication of rsv bronchiolitis in young infants and may necessitate close monitoring. in severe cases, often those in which there is underlying chronic heart, lung, or immunodeficiency disease, rsv can be life-threatening. in these cases, hospital care with supplemental oxygen and intravenous fluids is indicated. the effect of aerosolized bronchodilators is not clear but is probably beneficial in some infants. the aerosolized antiviral agent ribavirin may be beneficial for the sickest infants. it is expensive and difficult to administer; it needs to be given to hours per day (some studies advocate hours three times a day) and may block ventilator tubing and valves. ribavirin may improve oxygenation but should not be used in lieu of mechanical ventilation in patients with hypoxia and hypercarbia (respiratory failure). viral pneumonia can be similar to rsv bronchiolitis in its manifestation, with cough and tachypnea, after a few days of apparent upper respiratory infection. there can be variable degrees of fever and of overall illness. infants and children with viral pneumonia may appear relatively well or, particularly with adenovirus, may have a rapidly progressive course, which ends in death within a few days after the onset of illness. frequent symptoms include poor feeding, cough, cyanosis, fever (some patients may be afebrile), apnea, and irt, immunoreactive trypsinogen. respiratory disorders rhinorrhea. frequent signs include tachypnea, retractions, crackles, and cough. cyanosis is less common. the most common agents causing viral pneumonia in infancy and childhood are rsv, influenza, and parainfluenza. adenovirus is less common, but it is important because it can be severe and leave residua, including bronchiectasis and bronchiolitis obliterans. adenovirus pneumonia is often accompanied by conjunctivitis and pharyngitis, in addition to leukocytosis and an elevated erythrocyte sedimentation rate (esr); the esr and leukocyte count are usually not elevated in other types of viral pneumonia. additional viral agents include enteroviruses and rhinovirus. radiographs most often reveal diffuse, bilateral peribronchial infiltrates, with a predilection for the perihilar regions, but occasionally lobar infiltrates are present. pleural effusions are not common. on occasion, if an infant is extremely ill, bronchoscopy with bronchoalveolar lavage may be indicated to isolate the virus responsible for the pneumonia. treatment is largely supportive, with oxygen and intravenous fluids. mechanical ventilation may be necessary in a small minority of infants. in young infants, the afebrile pneumonia syndrome may be caused by chlamydia, ureaplasma, or mycoplasma species; cytomegalovirus; or pneumocystis carinii. in this syndrome, cough and tachypnea are common. severe pneumonia may develop in neonates as a result of herpes simplex. pertussis is an extremely important cause of lower respiratory tract infection in infants and children. the causative organism, bordetella pertussis, has a tropism for tracheal and bronchial ciliated epithelial cells; thus, the disease is primarily bronchitis, but spread of the organism to alveoli, or secondary invasion by other bacteria, can cause pneumonia. the disease can occur at any age, from early infancy onward, although its manifestations in young infants and in those who have been partially immunized may be atypical. most commonly, pertussis has three stages: • catarrhal, in which symptoms are indistinguishable from the common cold • paroxysmal, dominated by repeated forceful, paroxysmal coughing spells; many spells may be punctuated by an inspiratory "whoop," post-tussive emesis, or both • convalescent, in which the intensity and frequency of coughing spells gradually diminish each stage typically lasts to weeks, except the paroxysmal stage, which lasts many weeks. the chinese term for pertussis translates to " days of cough." most children are entirely well between coughing spells, when physical findings are remarkably benign. infants younger than months of age may have the most severe illness, and in this age group, the rate of mortality from pertussis is as high as %. diagnosis can be difficult because the definitive result-namely, culturing the organism from nasopharyngeal secretions-requires special culture medium (bordet-gengou, which must be prepared fresh for each collection). culture specimens are much less likely to be positive during the paroxysmal stage than during the catarrhal stage, when the diagnosis is not being considered. fluorescent antibody stains (for the antigen) of secretions are also helpful if they are positive, but, similarly, they are more likely to be positive before the paroxysmal stage. serum antibodies against b. pertussis may occasionally be helpful, although they are often difficult to interpret in immunized individuals. perhaps the laboratory test that is most helpful is the wbc count, which is typically elevated; values are as high as , to , , with lymphocytes predominating. pcr is also useful. chest radiographic findings are nonspecific. infants with severe disease may require hospitalization. treatment is largely supportive, with oxygen, fluids, and small frequent feedings for patients who do not tolerate their normal feedings. treatment with erythromycin estolate ( mg/kg/day for days, every hours, orally) decreases infectivity and may ameliorate the course of the disease if given during the catarrhal stage. studies suggest that azithromycin or clarithromycin may also be effective. in some patients, aerosolized bronchodilators (albuterol) or systemic steroids may help, although such treatment is controversial. cough suppressants are not helpful, but good hydration, oxygenation, and nutrition, in addition to not disturbing the infant, are important. complications include those related to severe coughing (table - ) and those specific to pertussis, such as seizures and encephalopathy. pertussis is prevented by three primary immunizations (at , , and months of age) and regular booster immunizations at to months and to years of age. pertussis infection produces lifelong immunity. chlamydia trachomatis can cause pneumonia in young infants, particularly those aged to weeks. cough, nasal congestion, lowgrade or no fever, and tachypnea are common. conjunctivitis is an important clue to chlamydial disease but is present in only % of infants with chlamydial pneumonia at the time of presentation. affected infants may have a paroxysmal cough similar to that of pertussis, but post-tussive emesis is less common. crackles are commonly heard on auscultation, but wheezing is much less common than the overinflated appearance of the lungs on radiographs would suggest. the organism may be recovered from the nasopharynx by culture or antigen testing. the complete blood cell count may reveal eosinophilia. chlamydial infection responds to oral erythromycin therapy ( to mg/kg/day, every hours for to days). ureaplasma urealyticum pneumonia is difficult to diagnose but causes cough in some infants. there are no particularly outstanding features to distinguish this relatively uncommon infection from viral pneumonias. bacterial pneumonia is relatively less common in infants than is viral pneumonia but can cause severe illness, with cough, respiratory distress, and fever. chest films are strikingly abnormal; the wbc count is elevated. treatment is with broad-spectrum intravenous antibiotics effective against pneumococci, group a (possibly b) streptococci, and, if illness is severe, s. aureus. cefotaxime with or without nafcillin may be effective. in early childhood, as children attend day care and nursery schools, they are constantly exposed to respiratory viruses to which they have little or no immunity (e.g., rhinoviruses, adenoviruses, parainfluenza, and coxsackievirus). such children may have as many as to or even more colds in a year. the remarks concerning colds and cough in infants (see previous discussion) apply to this older age group. the differential diagnosis of rhinorrhea is noted in table - . the sinuses may become the site for viral and subsequent secondary bacterial infection spreading from the nasopharynx (fig. - ) . the signs and symptoms are usually localized, including nasal congestion, a feeling of "fullness" or pain in the face ( fig. - ) , headache, sinus tenderness, day or night cough, and fever. maxillary toothache, purulent nasal discharge for more than days, a positive transillumination (opacification), and a poor response to oral antihistamines or nasal decongestants are important clues. sinus radiographs or (more accurate) ct scan may facilitate the diagnosis of sinusitis by demonstrating opacification of the sinus with mucosal thickening. sinusitis is thought to be a cause of cough in adults and can probably be listed, with lower certainty, as a cause of cough in children. sinusitis is frequently seen in other conditions known to cause cough, especially cf, asthma, and ciliary dyskinesia. it may be difficult to ascertain whether the cough is a direct result of the sinus infection or the underlying problem (purulent bronchitis in the child with cf or ciliary dyskinesia, exacerbation of asthma). in the first two situations, it may not matter because treatment is the same. in the case of the child with asthma, it is important to treat the asthma with bronchodilating and antiinflammatory agents, as well as to treat the infected sinuses with antibiotics. the treatment of sinusitis involves the use of oral antibiotics active against the common pathogens (streptococcus pneumoniae, nontypable h. influenzae, moraxella catarrhalis, and, in rare cases, anaerobic bacteria or streptococcus pyogenes). treatment regimens include the use of amoxicillin, amoxicillin-clavulanate, cefuroxime, cefpodoxime, or cefdinir. amoxicillin is considered the initial agent of choice. oral (pseudoephedrine, phenylephrine) or topical (phenylephrine, oxymetazoline) decongestants may be of benefit by increasing the patency of the sinus ostia, which permits drainage of the infected and obstructed sinuses. oral antihistamines may benefit patients with an allergic history. treatment with antimicrobial agents should continue for at least days after the patient has responded. this may require to days of therapy. many patients with presumed sinusitis recover without antibiotic therapy. complications of acute sinusitis include orbital cellulitis, abscesses (orbital, cerebral), cranial (frontal) osteomyelitis (pott puffy tumor), empyema (subdural, epidural), and thrombosis (sagittal or cavernous sinus). see previous text and chapter . viral pneumonia. the features discussed for viral pneumonia in infants are relevant for viral pneumonia in older children. the differentiation of viral or atypical pneumonia from classical bacterial pneumonia is noted in table - . bacterial pneumonia. bacterial pneumonia is more common in toddlers and older children than in infants. the most common pathogen is s. pneumoniae; other bacterial causes vary with age ( table - ) . cough may not be as prominent a presenting symptom or sign as tachypnea and grunting, sometimes (especially in infants) with vomiting (see table - ). raised respiratory rates (≥ in infants to months old, ≥ in children to years old) plus retractions and grunting with or without hypoxia (oxygen saturation < %) have a high specificity and sensitivity for pneumonia. chest pain, abdominal pain, headache, or any combination of these symptoms may occur. upper lobe pneumonia may produce meningeal signs, and lower lobe involvement may cause abdominal pain and an ileus. examination of the chest shows tachypnea but may be otherwise surprisingly normal. in older children, there may be localized dullness to percussion, with crackles or amphoric (bronchial) breath sounds over a consolidated lobe. the chest film may be normal in the first hours of the illness, inasmuch as the radiographic findings often lag behind the clinical manifestations. nonetheless, both posteroanterior and lateral views are the main diagnostic tools; lobar consolidation is usual, with or without pleural effusion. in infants, the pattern may be more diffuse and extensive. some clinical and radiographic features may be suggestive of the bacterial cause of pneumonia. children (especially infants) with staphylococcal pneumonia are more likely to have a rapid overwhelming course. staphylococcal pneumonia may be accompanied by more extensive radiographic abnormalities, including multilobar consolidation, pneumatocele formation, and extensive pleural (empyema) fluid. the presence of a pleural effusion is not helpful in indicating the specific bacterial diagnosis because other bacterial pneumonias may be accompanied by pleural effusion. pleural effusions may represent a reactive parapneumonic effusion or an empyema. pleural fluid may be characterized as transudate, exudate, or complicated empyema, the latter necessitating closed chest drainage with a chest tube (table - ). if the effusion is of sufficient size, as demonstrated by a lateral decubitus film or ultrasonography, a thoracentesis is indicated to differentiate the nature of the effusion and to identify possible pathogens. differentiating among the causes of bacterial pneumonia can be done with certainty only with positive cultures from blood, pleural fluid, fluid obtained by direct lung tap, or, in rare cases, sputum. current or previous antibiotic treatment diminishes the yield of such cultures. the presence of bacterial antigens in the urine for s. pneumoniae or h. influenzae provides strong evidence of the causative agent. bronchoscopy with or without lavage may yield helpful specimens from the progressively ill child or the child who has not responded promptly to empirical antibiotics. treatment is with antibiotics. cefotaxime or ceftriaxone is the drug of choice for the previously healthy child who requires hospitalization with lobar pneumonia. for the critically ill child, vancomycin may be considered for possible resistant s. pneumoniae. many children with pneumonia do well with oral antibiotics (amoxicillin, amoxicillin-clavulanate, oral cephalosporins) and respond within hours to the first dose. a smaller number may require hospitalization and intravenous antibiotics along with supportive measures (e.g., oxygen and intravenous fluids). repeated or follow-up chest films may remain abnormal for to weeks after pneumonia and are not indicated for a single episode of uncomplicated pneumonia (i.e., no effusion, no abscess, and good response to treatment). children with suspected pneumococcal pneumonia must be monitored carefully because of the possibility of resistance to penicillin and cephalosporin. mycoplasma pneumoniae is a common cause of pneumonia among school-aged children. the disease often occurs in community outbreaks in the fall months. the illness typically begins with table - ); atypical in terms of extrapulmonary manifestations, low-grade fever, patchy diffuse infiltrates, poor response to penicillin-type antibiotics, and negative sputum gram stain. sars, severe acute respiratory syndrome. extrapulmonary symptoms (i.e., sore throat, myalgias, headache, fever), which then progress to include worsening cough, paroxysmal at times. patients do not often appear acutely ill, but cough may persist for weeks. there may be no specific abnormalities on the chest examination, although a few crackles may be heard, and about one third of younger patients wheeze. the radiographic findings in mycoplasmal pneumonia can mimic almost any intrathoracic disease; scattered infiltrates with nonspecific "dirty" lung fields, predominantly perihilar or lower lobes, are common, and lobar infiltrates and pleural effusion are occasionally seen. laboratory data (complete blood cell count, esr, sputum culture) may not be helpful. a rise in antimycoplasmal immunoglobulin g over to weeks may be demonstrated but is seldom helpful in guiding therapy. a positive immunoglobulin m response may be useful, although it can persist in serum for several months and, consequently, may not indicate current infection. pcr may be helpful. the cold agglutinin test yields positive results in about % of patients with mycoplasmal pneumonia, but they are also positive in other conditions, including adenovirus infection. the more severe the illness is, the greater is the frequency of positive cold agglutinins. the diagnosis is often made from the history of an older child who has a lingering coughing illness in the setting of a community outbreak, unresponsive to most (non-erythromycin) antibiotic regimens. treatment is with erythromycin (azithromycin or clarithromycin are alternatives in children younger than years, whereas tetracycline or doxycycline can be administered to older children), which usually shortens the course of the illness. extrapulmonary complications of mycoplasmal infection include aseptic meningitis, transverse myelitis, peripheral neuropathy, erythema multiforme, myocarditis, pericarditis, hemolytic anemia, and bullous otitis media (myringitis). in patients with sickle cell anemia, severe respiratory failure and acute chest syndrome may develop. infection with chlamydia pneumoniae mimics respiratory disease resulting from m. pneumoniae, inasmuch as it occurs in epidemics, is seen in older children, and produces an atypical pneumonia syndrome and pharyngitis. the incidence of tuberculosis is increasing as a result of acquired immunodeficiency syndrome, homelessness, urban poverty, and immigration from endemic countries. tuberculosis must be considered in the child with chest disease that is not easily explained by other diagnoses, especially if the child has been exposed to an adult with active tuberculosis. nonetheless, tuberculosis is an infrequent cause of cough in children, even in those with active disease. the diagnosis is made primarily by skin testing (purified protein derivative [ppd]); a history of contact with a person who has tuberculosis; and recovery of the organism from sputum, bronchoalveolar lavage, pleural fluid or biopsy, or morning gastric aspirates (table - ). the yield from these procedures is relatively low, even from children with active pulmonary tuberculosis. the patterns of disease in normal hosts include primary pulmonary tuberculosis, with subsequent inactivation usually noted in young children and reactivation pulmonary disease among adolescents. primary pulmonary disease is often noted as a lower or middle lobe infiltrate during the period of t lymphocyte reaction to the initial infection. before resolution, the mycobacterium tuberculosis infection may disseminate to the better oxygenated upper lobes and extrathoracic sites, such as bone, or the central nervous system. if the immune response contains the initial infection, the radiographic findings may be indistinguishable from those of any other pneumonic process. with altered immune function, however, there may be progressive local disease, dissemination to miliary pulmonary disease, or early reactivation (months to years) at distal sites, which produces tuberculous meningitis or osteomyelitis. reactivation of upper lobe pulmonary disease may produce cavities that are similar to the disease among adults. cavitary and endobronchial lymph node involvement are highly infectious, in contrast to the much less contagious nature of the hypersensitivity reaction noted in primary pulmonary disease. treatment of active disease, especially in regions of multidrugresistant tuberculosis, consists of three or four drug regimens, including isoniazid, rifampin, pyrazinamide with or without streptomycin, and ethambutol. risk of infection based on history and ppd induration size are presented in table - . inhaling food, mouth or gastric secretions, or foreign bodies into the tracheobronchial tree causes acute, recurrent, or chronic cough. interference with normal swallowing disrupts the coordination of swallowing and breathing that prevents aspiration. structural causes of disordered swallowing include esophageal atresia (in neonates), strictures, webs, or congenital stenoses. mediastinal lesions (tumors, lymph nodes), including vascular rings, may compromise the esophageal lumen and esophageal peristalsis, increasing the likelihood of aspiration. functional disorders include central nervous system dysfunction (e.g., coma, myopathy, neuropathy) or immaturity, dysautonomia, achalasia, and diffuse esophageal spasm. prior neck surgery, including tracheostomy, may alter normal swallowing. tracheoesophageal fistula and laryngeal clefts are congenital malformations with direct physical connections between the tracheobronchial tree and the upper gastrointestinal tract; oral contents enter the lungs directly. making the diagnosis of aspiration as the cause of cough may be difficult. barium contrast studies during swallowing may help characterize these disorders if barium enters the trachea. because most patients aspirate sporadically, a normal barium swallow does not rule out aspiration. radionuclide studies can be helpful if ingested radiolabeled milk or formula is demonstrated over the lung fields at several-hour intervals after the meal. bronchoscopy and bronchoalveolar lavage that recover large numbers of lipid-laden macrophages suggest that milk aspiration has taken place; however, the finding is neither sensitive nor specific for aspiration. treatment depends largely on the cause of aspiration. because many patients who aspirate do so because of lack of neurologic control of swallowing and breathing, it is often difficult to prevent. even gastrostomy feedings cannot prevent aspiration of oral secretions. in extreme cases, tracheostomy with ligation of the proximal trachea has been employed. this prevents aspiration but also prevents phonation, and it must be considered only in unusual situations. aspiration pneumonia is often treated with intravenous penicillin or, preferably, clindamycin to cover mouth flora of predominant anaerobes. additional coverage against gram-negative organisms (an aminoglycoside or cefepime) may be indicated if the aspiration is nosocomial. any child with cough of abrupt onset should be suspected of having inhaled a foreign body into the airway. toddlers, who by nature put all types of things into their mouths and who have incompletely matured swallowing and airway protective mechanisms, are at high risk. infants with toddlers or young children in the household who may "feed" the baby are also at risk. in older children, it is usually possible to obtain an accurate history of the aspiration event. these events are described as choking, gagging, and coughing while something (e.g., peanuts, popcorn, small toys, sunflower seeds) is in the mouth. the child may come to the physician with cough and wheeze immediately after the event, with a clear history and a straightforward diagnosis. in many children with a tracheobronchial foreign body, however, the initial episode is not recognized; these children may not come to medical attention for days, weeks, or even months (fig. - ). the initial episode may be followed by a relatively symptomless period lasting days or even weeks, until infection develops behind an obstructed segmental or lobar bronchus. at this point, cough, perhaps with hemoptysis, with or without wheeze, recurs. on physical examination early after an aspiration episode, there is cough, wheeze, or both, often with asymmetry of auscultatory findings. there may be locally diminished breath sounds. later, localized wheeze or crackles may be detected. in some cases, the two-headed stethoscope may enable the examiner to recognize that a lobe or lung has delayed air entry or exit in comparison with the other side. the triad of wheezing, coughing, and decreased breath sounds is present in fewer than % of patients. the presence of laryngotracheal foreign bodies often manifests with stridor, retractions, aphonia, cough, and normal radiographs. chest radiographs may be normal in % of patients with intrathoracic foreign bodies but should be obtained in both inspiration and expiration, because in some cases the only abnormality is unilateral or unilobar air trapping, which is occasionally more clearly identified with a view in expiration. in this view, an overdistended lung that had appeared normal on the inspiratory view does not empty, but the normal, unobstructed lung empties normally. this phenomenon causes a shift of the mediastinum toward the emptying lung (away from the side with the obstructing foreign body). in other patients, localized infiltrate or atelectasis may be present behind the obstructing object. in a few patients, it may be possible to identify the foreign body itself; nonetheless, most inhaled food particles are not radiopaque and cannot be seen on radiographs. aspiration is usually unilateral ( %); % to % of the objects are in the right lung (the lobe depends on body position-supine versus standing-but is often the right middle lobe). the definitive diagnostic and therapeutic maneuver is bronchoscopy; either the flexible or rigid open-tube bronchoscope enables direct visualization of the object; the rigid instrument also enables its removal. ger is a common cause of cough in all age groups (see chapter ). the typical patient is an infant in the first months of life who spits up small amounts of milk frequently after feedings. this "regurgitant reflux" most commonly resolves by year of age. however, many toddlers and children continue to have reflux, although it may be "silent" or nonregurgitant (without spitting up). in most people with ger, it is merely a nuisance or not noticed. in some there are sequelae, and this condition is designated gastroesophageal reflux disease (gerd). one manifestation is cough; the mechanisms for the cough are not fully understood. aspiration of refluxed material is one mechanism for cough but is probably not very common in neurologically intact children. a major mechanism for gerd with cough is mediated by vagal esophagobronchial reflexes (bronchoconstriction), stimulated by acid in the esophagus. whether acid in the esophagus is sufficient stimulus to cause bronchoconstriction by itself or whether it merely heightens bronchial reactivity to other stimuli is not yet clear (see chapter ). many children with reactive airways disease have cough or wheeze that is difficult to control until their concurrent ger is also treated. many episodes of cough caused by gerd occur in children with asthma that is difficult to control. the diagnosis of gerd must also be considered in the child with chronic or recurrent cough with no other obvious explanation. the child who coughs after meals or at night, when the supine position may provoke ger, should be evaluated for ger. if ger is confirmed, the next step is a therapeutic trial of antireflux therapy (see chapter ). if the results of the therapeutic trial are negative or equivocal, it may make sense to establish a causal relationship between the ger and the cough, by using the modified bernstein test. during this test, hydrochloric acid and saline are alternately infused into the esophagus through a nasoesophageal tube while the child is observed for cough or wheeze or while the older child undergoes serial pulmonary function tests. if the symptoms occur or if pulmonary function deteriorates during acid but not saline infusion, it is likely that esophageal acidification through ger is the cause of the child's cough or wheeze. treatment in a child whose cough is related to ger may be accomplished by treating the reflux (see chapter ) or by a combination of antireflux and antiasthma treatment (see chapter ). theophylline may worsen ger by lowering the tone of the lower esophageal sphincter, and some drugs that increase lower esophageal sphincter tone may cause bronchoconstriction. on occasion, the cough may be abolished by stopping all antiasthma medications. in such cases, the cough was a manifestation of reactive airways with esophageal acidification as the trigger for bronchospasm; the esophageal acidification was caused by the bronchodilator effects on the lower esophageal sphincter. inhaled bronchodilators are less likely than oral or intravenous drugs to cause ger. cough is frequently the sole or most prominent manifestation of asthma; wheezing may be entirely absent. in fact, reactive airway disease or asthma (see chapter ) is almost certainly the most common cause of recurrent and chronic cough in childhood. some of the features that characterize the cough of a child with asthma are listed in table - . treatment for asthma manifesting as cough is the same as the treatment for asthma (see chapter ). cf is a common cause of recurrent or chronic cough in infancy and childhood. cf occurs in in live births among white persons, is far less common among african americans ( in , ), and is rare among native americans and asians. early diagnosis improves the poor prognosis for untreated cf; if untreated, many patients die in infancy or early childhood. with current state-of-the-art care, median length of survival is to age . cf is a genetic disorder, inherited as an autosomal recessive trait. the cf gene is on the long arm of chromosome ; more than mutations have been identified at the cf locus. of these mutations, one (Δf , indicating a deletion, Δ, of a single phenylalanine, f, at position of the protein product) is the most common, responsible for % to % of all cf chromosomes. the currently recognized mutations account for approximately % of cases. the mutation affects the gene's protein product, termed cystic fibrosis transmembrane regulator, which acts as a chloride channel and affects other aspects of membrane transport of ions and water. not all the consequences of the defective gene and protein have been determined. most explain the long-observed clinical manifestations of the disease, including thick, viscid mucus in the tracheobronchial tree, leading to purulent bronchiolitis and bronchitis with subsequent bronchiectasis, pulmonary fibrosis, and respiratory failure; pancreatic duct obstruction, leading to pancreatic insufficiency with steatorrhea and failure to thrive; and abnormally high sweat chloride and sodium concentrations. the airway disease in cf is characterized by infection, inflammation, and endobronchial obstruction. the infection begins with s. aureus, h. influenzae, escherichia coli, klebsiella species, or combinations of these organisms but eventually is dominated by nonmucoid or mucoid pseudomonas aeruginosa. other organisms, such as burkholderia cepacia, xanthomonas maltophilia, alcaligenes xylosoxidans, aspergillus fumigatus, or nontuberculous mycobacteria may also appear; their significance remains undetermined. in some patients, b. cepacia has been associated with rapid deterioration and death, and in others, aspergillus species has caused allergic bronchopulmonary aspergillosis. the airway inflammation in all patients with cf appears to be the result of toxic substances, including elastase, released by neutrophils as they respond to the endobronchial infection and by similar enzymes released by the invading organisms. cf may manifest at birth with meconium ileus ( % to % of patients) or later, with steatorrhea and failure to thrive despite a voracious appetite, in an apparent effort to make up for the calories that are lost in the stool (see chapter ). the most common presenting symptom is cough, which may appear within the first weeks of life or may be delayed for decades. the cough can be dry, productive, or paroxysmal. cough may respond to antibiotics or perhaps steroids, but it is less likely to improve with bronchodilators (see tables - and - ). although cf is a genetic disease, there is often no family history. furthermore, in atypical cases, patients may not have pancreatic insufficiency (usually present in % to %) and thus may not demonstrate steatorrhea and failure to thrive. in addition, malabsorption may not be evident in the neonatal period. there is no such thing as a child who looks "too good" to have cf; common abnormalities found on physical examination are noted in table - . one of the most important physical findings is digital clubbing. in most patients with cf, clubbing develops within the first few years of life. although the list of conditions associated with digital clubbing (table - ) is long, they are less common than cf, or the incidence of digital clubbing with these conditions is low. there is some relationship between the degree of pulmonary disease severity and the degree of digital clubbing. a child who has had years of severe respiratory symptoms without digital clubbing is not likely to have cf. the diagnosis is confirmed by a positive sweat test or confirming the presence of two cf mutations on chromosome . the sweat test, if not performed correctly in a laboratory with extensive experience with the technique (as, for example, in an accredited cf center), yields many false-positive and false-negative results. the proper technique is to use the gibson-cooke method, with quantitative analysis of the concentration of sodium, chloride, or both, in the sweat produced after pilocarpine iontophoretic stimulation. chloride (and sodium) concentrations higher than meq/l are considered positive indications, and those lower than meq/l are negative (normal). healthy adults have slightly higher sweat chloride concentrations than do children, but the same guidelines hold for positive tests in adults. the non-cf conditions yielding elevated sweat chloride concentrations are listed in table - . false-negative results of sweat tests can be seen in cf children presenting with edema or hypoproteinemia and in samples from children with an inadequate sweat rate. sweat testing can be performed at any age; newborns within the first few weeks of life may not produce a large enough volume of sweat to analyze ( mg minimum), but in those who do (the majority), the results are accurate. indications for sweat testing are noted in table - . in patients for whom sweat testing is difficult (e.g., because of distance from an experienced laboratory, small infants who have not produced enough sweat, patients with extreme dermatitis, or patients with intermediate-range sweat chloride concentrations), dna testing can be useful. demonstration of two known cf mutations confirms the diagnosis. finding one or no known mutation makes the diagnosis less likely but is not exclusive, inasmuch as there are patients with not-yet-characterized mutations. furthermore, commercial laboratories do not identify all of the -plus mutations. recovery of mucoid p. aeruginosa from respiratory tract secretions is strongly suggestive of cf. similarly, pansinusitis is nearly universal among cf patients but is quite uncommon in other children. some states are using a neonatal screen for cf. the cf screen is for immunoreactive trypsinogen (irt) levels, which are elevated in most infants with cf for the first several weeks of life. (some states do genetic testing on dna.) because of the very high sensitivity of this test (almost no one with cf has normal irt levels) and because early institution of treatment is beneficial, this test may come into wider use. its main drawback is that it has relatively poor specificity; as many as % of the positive results on the initial screen are false-positive results. if an infant's irt screen is positive, the test should be repeated; at to weeks of age, which is when the test is repeated, the false-positive rate has fallen dramatically but is still quite high ( %). definitive testing needs to be carried out on infants with two elevated irt levels. in the unusual older child whose appendix is removed and examined carefully by a knowledgeable pathologist, the diagnosis may be suggested by the typical histologic appearance of the appendix (the mucus-secreting glands are overdistended with eosinophilic material). laboratory data that may support the diagnosis of cf include absence of stool trypsin or chymotrypsin. this suggests pancreatic insufficiency, which occurs most commonly in cf but can be seen in other diseases. the test is not perfect even for confirming pancreatic insufficiency, because intestinal flora may produce or destroy trypsin. pulmonary function test findings with an obstructive pattern, incompletely responsive to bronchodilators, are consistent with cf but, of course, can be seen in other conditions. conversely, some patients with cf also have asthma and may show a marked response to a bronchodilator. complications of cf that should suggest the diagnosis are noted in table - . the treatment of patients with cf requires a comprehensive approach, best performed in, or in conjunction with, an approved cf center. several studies have shown survival to be significantly better in center-based care than in non-center-based care. the treatment of the pulmonary aspects of cf involves approaching the obstruction, infection, and inflammation that cause the cough. cough should be monitored closely, and any increase in frequency or in the intensity should be taken as an indication that there is worsening endobronchial infection, inflammation, or both. because active infection and inflammation lead to irreversible lung damage, such changes need to be taken seriously and treated aggressively. this is just as true for the appearance of a mild morning cough in the child who was previously cough free as it is for severe coughing spells that keep a child awake through the night. obstruction is treated with physical means (chest physical therapy, with percussion, vibration, and postural drainage) to dislodge the mucus into the large central airways, where cough can then effectively clear it. studies have shown this rather crude and timeconsuming procedure to be effective in helping to maintain lung function acutely and over a period of years. variations on the physical maneuvers to help with mucus clearance include forced expiratory technique, positive airway pressure face masks, and masks with expiratory flutter valves. the frequency with which any of these physical means of expelling mucus should be used varies but should be increased with signs of active infection and obstruction. other approaches to relieving obstruction in the bronchial tree include the use of inhaled bronchodilators (despite a paucity of studies showing their long-term efficacy) and mucolytic agents. n-acetylcysteine (mucomyst) has been available for years, but it may cause tracheobronchial irritation, with bronchorrhea, bronchospasm, or both, in an unacceptably high proportion of patients. an inhaled drug, dornase alfa, or recombinant human dnase (pulmozyme), is clearly effective in the test tube for liquefying the thick mucus associated with cf. this occurs because % of the mucus viscosity in cf is attributed to dna released from dying polymorphonuclear cells. another drug that appears promising is amiloride. long available as a diuretic, amiloride can bring about a partial correction of the membrane transport defects in cf. amiloride aerosols seem to decrease sputum viscosity and increase cough clearance. in a small -month study, aerosolized amiloride appeared to slow the decline in lung function. the approach to endobronchial infection in children with cf includes prevention and treatment. prevention involves immunizing patients with cf against preventable respiratory pathogens, particularly influenza, measles, and pertussis. prevention also means avoiding unnecessary exposure to respiratory viruses (e.g., at day care centers). it should not mean avoiding school or other social functions and settings, because this approach is invariably futile and can cause severe emotional damage. however, spread of bacteria, especially resistant organisms such as b. cepacia, between patients is a concern. treatment of infection usually proceeds in a stepwise manner. if colonies of h. influenzae or s. aureus are present, appropriate antibiotics should be initiated. if no recent throat or sputum specimens for culture are available, and if the patient is young with very mild lung disease, empirical therapy can also be directed at those organisms. in the older or sicker patient who has any sign of chronic pulmonary involvement, such as pulmonary overinflation, infiltrates on a chest film, digital clubbing, or severe coughing spells, it makes sense to include antibiotics effective against p. aeruginosa (fig. - ; table - ) . treatment of the inflammation associated with cf is evolving. some patients benefit from short-term oral prednisone. a -year study of alternate-day prednisone showed improved pulmonary function but unacceptable side effects (e.g., glucose intolerance, growth failure) in those taking mg/kg/day and similar side effects (although less severe) in those taking mg/kg/day. the beneficial role of oral nonsteroidal antiinflammatory agents has been demonstrated; the role of inhaled topical steroids and α -antitrypsin is being investigated. table - lists the main anatomic abnormalities (most of them congenital) that cause cough. vascular rings and slings are often associated with inspiratory stridor because the abnormal vessels compress central airways, most commonly the trachea (see chapter ). the patient may also have difficulty swallowing if the esophagus is compressed. the diagnosis may be suspected from plain films of the chest, especially those showing tracheal deviation and a right-sided aortic arch. further support for the diagnosis can be found at bronchoscopy (which shows extrinsic compression of the trachea or a mainstem bronchus), barium swallow study (which shows esophageal compression), or both. the definitive diagnosis is made with magnetic resonance imaging, angiography, or magnetic resonance angiography. treatment is surgical. pulmonary sequestration is relatively unusual, occurring in in , children. it occurs most commonly in the left lower lobe and can manifest in several ways (fig. - ; see table - ) . the chest radiograph usually shows a density in the left lower lobe; this density often appears to contain cysts. the feature distinguishing a sequestered lobe from a complicated pneumonia is that the blood supply arises from the aorta and not the pulmonary circulation. doppler ultrasonography and angiography provide the definitive diagnosis. the treatment is surgical removal. cystic adenomatoid malformation is a rare condition. it manifests in infancy with respiratory distress in nearly % of cases; the other half may manifest as cough with recurrent infection later in childhood or even adulthood. the chest film reveals multiple cysts, separated by dense areas. chest ct scans can help make the diagnosis with near certainty. surgical removal is the treatment. congenital lobar emphysema occurs in one of , live births. it can manifest dramatically with respiratory distress in the neonatal period or later (fig. - ) , with cough or wheeze, or as an incidental finding on a chest radiograph. radiography shows localized overinflation, often dramatic, with compression of adjacent lung tissue and occasionally atelectasis of the contralateral lung because of mediastinal shift away from the involved side. the appearance on chest ct scan is typical, with widely spaced blood vessels (as opposed to congenital cysts, for example, which have no blood vessels within the overinflated area). bronchoscopy can document patent bronchi and should probably be performed in older children, in whom congenital lobar emphysema can be confused with acquired overinflation of a lobe as the result of bronchial obstruction, as with a foreign body. if the disease is symptomatic, treatment is surgical. tracheoesophageal fistula is common, with an incidence of about one in live births. of these fistulas, the large majority ( %) are associated with esophageal atresia; only % are the isolated, h-type fistula (a patent esophagus with fistulous tract connecting the esophagus and trachea). a neonate with esophageal atresia experiences respiratory distress, excessive drooling, and choking and gagging with feeding. the h-type fistula causes more subtle signs and may be undiagnosed for months or even years. the child may have only the diagnosis is not challenging in the infant with esophageal atresia; a nasogastric tube cannot be passed, and swallowed barium outlines the trachea. in the older child with h-type fistula, a barium esophagogram may or may not reveal the fistula. bronchoscopy and esophagoscopy should permit direct visualization of the fistula; however, the opening may be hidden in mucosal folds. treatment is surgical. many children born with tracheoesophageal fistula have recurrent cough and lower respiratory tract infection for many years, even after successful surgical correction. the cough is characteristically the harsh cough of tracheomalacia, which is present at the site of the fistula. the infections result from several causes, including ger, with or without aspiration, and altered mucociliary transport. treatment involves regular chest physical therapy and early and aggressive use of antibiotics whenever there is evidence of increased pulmonary symptoms. hemangiomas may be present within the airway and can cause cough, rarely with hemoptysis; stridor (if the hemangioma is high in the airway) and respiratory distress (if the hemangioma is large) may also occur. in rare cases, with very large airway hemangiomas, there may even be dysphagia from extrinsic compression. about % of children with airway hemangiomas have cutaneous hemangiomas as well. the diagnosis is made with bronchoscopy. as with cutaneous hemangiomas, these lesions may resolve spontaneously over the first year or so. however, if they cause symptoms, it may not be advisable or possible to wait for them to resolve. many airway hemangiomas regress with steroid treatment, although others have been shown to respond to interferon-α. laser ablation may be indicated in some refractory cases. in the case of a large subglottic hemangioma, a tracheostomy is frequently performed and maintained until the mass regresses. enlarged mediastinal lymph nodes, such as those resulting from tuberculosis, leukemia, other hematologic malignancies, or other infections, are occasionally a cause of cough in children (tables - and - ). these nodes are usually seen on plain films of the chest. the x-ray study or bronchoscopy may show extrinsic compression of the trachea. treatment is directed at the underlying cause. occasionally bronchial stenosis, either congenital or acquired, may cause cough. the diagnosis is made with bronchoscopy, after suspicion has been raised by the child's having recurrent infiltrates in the same lobe, especially with localized wheeze. treatment may be difficult. in some cases, endoscopic balloon dilatation or airway stent placement is successful; in others, surgical resection of stenotic areas may be necessary. bronchogenic cysts are uncommon, but they can cause cough, wheeze, stridor, or any combination of these. they may also cause recurrent or persistent pneumonia if they block a bronchus sufficiently to interfere with normal drainage of the segment or lobe. radiography may show localized overinflation if the cyst causes a ball-valve-type obstruction. the cyst itself may or may not be seen on plain films. bronchoscopy reveals extrinsic compression of the airway. ct studies often definitively show the lesion. surgical removal is indicated. on occasion, a school-aged child may develop a cough that lasts for weeks, often after a fairly typical cold. this cough occurs only during wakefulness, never during sleep. in many cases, the cough is harsh and foghorn-like. it often disrupts the classroom, and the child is asked to leave. the child is otherwise well and may seem rather unbothered by the spectacle created. there has been no response to medications. it seems that this type of cough, often termed "psychogenic," or "psychogenic cough tic," but perhaps more accurately and humanely thought of as habit cough, has given the child valuable attention. this attention then serves as the sustaining force, and the cough persists beyond the original airway inflammation. in the small minority of cases, there may be deep-seated emotional problems, of which the cough is the physical expression. during the history or physical examination, the child appears completely well and may cough when attention is drawn to the child or when the word "cough" is uttered. the physical examination findings are otherwise completely normal, as are laboratory values. because this may occur in any child, evidence of mild reactive airways disease (history or pulmonary function testing) does not rule out the diagnosis. once a physician has seen a child with this problem, it is usually possible to make the diagnosis with certainty on entering the examining room or, indeed, from the hallway outside the room. treatment can prove more difficult. there are several treatment schools, summarized in tables - and - . one approach is "the bed sheet," in which the child is told that he or she coughs because of weak chest muscles. a bed sheet is wrapped tightly and uncomfortably around the chest "to serve as added support for the muscles … [and] with this support, the muscles would then be able to suppress [the] cough." the child is to go to school wearing the bulky bed sheet under his or her clothes and may not remove the sheet until he or she is certain that the cough will not return. the authors who describe this method call it a "reinforcement suggestion technique." some view this approach as demeaning to the child. whatever its mechanism of action, this method was reported to have been successful in of patients. postnasal drip is thought to be a major cause of cough in adults. the mechanism by which this occurs is unclear, and most pulmonologists believe that this must remain a diagnosis of exclusion for explaining cough in children. bronchiectasis is defined as an abnormal dilation of the subsegmental bronchi and is usually associated with chronic cough and purulent sputum production. it occasionally occurs after severe pneumonias (bacterial or viral); it eventually develops in nearly all patients with cf. diagnosis may, on occasion, be made with plain chest radiographs, but high-resolution ct scanning is the diagnostic procedure of choice, replacing bronchography. treatment of bronchiectasis consists of chest physiotherapy and postural drainage, occasionally bronchodilators and mucolytic agents, and antibiotic therapy during exacerbations. surgical resection may be indicated in cases that are progressive and localized when medical therapy has failed. the prognosis of bronchiectasis depends on the underlying cause. bronchiectasis associated with cf is fatal, although many cases of bronchiectasis remain stable or may even regress with therapy. conditions in which the cilia do not function properly (dysmotile cilia or ciliary dyskinesia) lead to cough, usually because infection (and bronchiectasis) occurs in the absence of normal mucociliary transport. treatment is similar to that for cf, with regular chest physical therapy and frequent and aggressive use of antibiotics at the first sign of airways infection, most commonly increased cough. there are several varieties of interstitial lung disease: desquamative, lymphoid, and "usual" (see chapter ). all are very uncommon in childhood, and little is known about their causes, courses, or treatment. one type of pediatric interstitial lung disease, the lymphoid type, is becoming much more common, inasmuch as it is seen in human immunodeficiency virus (hiv) infection. interstitial lung disease manifests with cough, dyspnea, and crackles on examination. because the diagnosis is based on histologic findings, lung biopsy is required. the only exception to this may be in the child with documented acquired immunodeficiency syndrome who has new pulmonary infiltrates and symptoms, in whom bronchoscopy and bronchoalveolar lavage are initially used to diagnose infection (p. carinii, cytomegalovirus). interstitial lung disease in a patient with a chronic seborrhea-like dermatitis should suggest the diagnosis of histiocytosis x. heart failure can cause cough but seldom as its sole clinical manifestation. pulmonary hemosiderosis is a rare, and often fatal, condition of bleeding into the lung that can manifest with cough. if sputum is produced, it is often frothy and blood-tinged. there may be frank hemoptysis. however, the cough may be nonproductive, or the sputum may be swallowed. some cases are associated with milk perform all possible tests can tell patient and family: "we've reinforces the idea of a physical cause ruled out all physical problems." in one study, resolution followed bronchoscopy ("aversive stimulus"?) apply an aversive stimulus has worked in some patients by definition, this treatment is unpleasant (e.g., an electric shock to forearm) try the "bed sheet" (see text) seems to work in most patients demeans the patient try placebo drugs probably works in some patients is a dishonest technique provide psychotherapy may work in some patients is unnecessary in most patients; labels the patient as having a psychological problem gently explain that there is no physical works in some patients is resented by some families focused on cause and this is a habit that the body an organic cause or treatment has sustained prevent mouth breathing by holding a has worked in some patients not known button between the patient's lips apply speech therapy techniques (see works in many patients: can be presented is resented by some families focused on table - ) as specific therapy; nonthreatening organic cause or treatment treatment is often unsatisfactory; the mortality rate is as high as %. milk products should be eliminated from the patient's diet, and underlying collagen vascular disease should be treated. some affected children seem to respond to corticosteroids or cytotoxic drugs (e.g., azathioprine, cyclophosphamide, and chlorambucil), but the episodic nature of the disease, with some clear cases of spontaneous resolution, makes it difficult to evaluate therapies. see chapter . tumors, which fortunately are rare in childhood, can cause cough, usually because of bronchial blockage, either extrinsic or endobronchial (see table - ). the diagnosis is usually made from bronchoscopy, chest ct, or both. treatment depends on the cell type, but it usually involves at least some surgical removal. chemotherapy or radiation may be used in some cases. isolated tracheomalacia or bronchomalacia is uncommon but can cause cough in some children. the cough of tracheomalacia is typically harsh and brassy. treatment is difficult but, fortunately, is seldom needed. some children, usually preschoolers, may episodically awaken at night with stridor and a harsh, barking cough indistinguishable from that of viral croup. this entity is termed spasmodic croup and is of unclear origin. viral and allergic causes have been postulated. ger may be the cause in some patients. treatment with cool mist or racemic epinephrine is effective in most patients. if ger is the underlying cause, antireflux treatment is beneficial. obliterative bronchiolitis is very rare except in lung transplant recipients. in other instances, it may arise after adenovirus, measles, or influenza pneumonia; after exposure to certain toxins; or in other rare circumstances. children may exhibit cough, respiratory distress, and exercise intolerance. the diagnosis is suggested by the pulmonary function or radiographic evidence of small airways obstruction; however, these findings are not always present. not all chest films show overinflated lungs, and not all pulmonary function tests show decreased small airways function. the definitive diagnosis is histologic via open or transbronchial biopsy. no specific treatment is available. most children with obliterative bronchiolitis recover, but many progress to chronic disability or death. the child who coughs out blood or bloody mucus presents special diagnostic and therapeutic challenges. although hemoptysis is relatively uncommon in children, particularly among those without cf, many conditions can cause it (table - ) . it is important (and not always easy) to distinguish cases in which blood has originated in the tracheobronchial tree (true hemoptysis), the nose (epistaxis), and the gastrointestinal tract (hematemesis). table - gives some guidelines to help localize sites of origin of blood that has been reported or suspected as hemoptysis. none of these is foolproof, partly because blood that has originated in one of these sites might well end in another before being expelled from the body; for instance, blood from the nose can be swallowed and vomited or aspirated and coughed out. infection is among the most common causes of hemoptysis. lung abscess and tuberculosis need to be considered. bronchiectasis can readily cause erosion into bronchial vessels, often made tortuous by years of local inflammation, and produce hemoptysis. other infectious settings are less common and include necrotizing pneumonias and fungal and parasitic lung invasion. foreign bodies in the airway can cause hemoptysis by direct irritation, by erosion of airway mucosa, or by secondary infection. pulmonary embolus is uncommon in children and adolescents, but it needs to be considered in the differential diagnosis of an adolescent with hemoptysis of unclear origin. clues to the diagnosis of pulmonary embolus include a positive family history, severe dyspnea, chest pain, hypoxia, a normal chest film, an accentuated second heart sound, an abnormal compression ultrasonographic study of the leg veins, a positive homans sign, a positive helical ct scan, and a high-probability lung ventilation-perfusion scan. the diagnosis of several causes of hemoptysis is straightforward. for example, hemoptysis that occurs immediately after a surgical or invasive diagnostic procedure in the chest should suggest an iatrogenic problem. the chest film can help suggest lung abscess, pulmonary bronchoscopy can sometimes localize a bleeding site, identify a cause (e.g., a foreign body or endobronchial tumor), or recover an offending bacterial, fungal, or parasitic pathogen. in many instances, bronchoscopy does not help except by excluding some possibilities, because either no blood or blood throughout the tracheobronchial tree is found. bronchial artery angiography may help to identify the involved vessel or vessels. treatment of hemoptysis depends on the underlying cause. it can be a terrifying symptom to children and their parents, and a calm, reassuring approach is essential. because hemoptysis is seldom fatal in children, reassurance is usually warranted. furthermore, hemoptysis most often resolves, and treatment of the bleeding itself is not often needed. what is required is treatment of the underlying cause of the hemoptysis, such as therapy for infection, removal of a foreign body, or control of collagen-vascular disease. when death occurs from hemoptysis, it is more likely to be from suffocation than from exsanguination. in cases of massive bleeding, the rigid open-tube bronchoscope may help suction large amounts of blood while ventilating and keeping unaffected portions of lung clear of blood. interventional radiologists treat as well as localize a bleeding site by injecting the offending vessel with occlusive substances, such as gelfoam or silicone coils. in extremely rare instances, emergency lobectomy may be indicated. cough itself seldom necessitates specific treatment. nonetheless, cough is not always completely benign (see table - ). most complications are uncommon, and most accompany only very severe cough, but some are serious enough to justify treatment of the cough itself. cough suppressants include codeine and hydrocodone (two narcotics) and dextromethorphan (a nonnarcotic d-isomer of the codeine analogue of levorphanol). such agents should be used only for severe cough that may produce significant complications (see table - ). for most diseases, suppressing the cough offers no advantage. disadvantages include narcotic addiction and loss of the protective cough reflex with subsequent mucus retention and possible superinfection. demulcent preparations (sugar-containing, bland soothing agents) temporarily suppress the cough response from pharyngeal sources, and decongestant-antihistamine combinations may reduce postnasal drip and thus cough in adults. evaluation of chronic or recurrent cough the cough and the bedsheet managing cough as a defense mechanism and as a symptom. a consensus panel report of the american college of chest physicians bacterial tracheitis: report of eight new cases and review computed tomographic study of the common cold epidemiology, pathogenesis, and treatment of the common cold does this patient have sinusitis? diagnosing acute sinusitis by history and physical examination report of the committee on infectious diseases chlamydial respiratory infections infant pneumonitis associated with cytomegalovirus, chlamydia, pneumocystis, and ureaplasma: follow-up value of radiological follow-up of childhood pneumonia etiology and treatment of pneumonia report of a workshop on respiratory viral infections: epidemiology, diagnosis, treatment, and prevention pulmonary manifestations of acquired immunodeficiency syndrome standardized diagnosis of pneumonia in developing countries the causes of hospital-treated acute lower respiratory tract infection in children hypoxaemia in young kenyan children with acute lower respiratory infection the evaluation of the child with recurrent chest infections bronchoscopic removal of aspirated foreign bodies in children tracheobronchial foreign bodies subglottic foreign bodies in pediatric patients tracheobronchial foreign bodies cystic fibrosis the cystic fibrosis genotype-phenotype consortium. correlation between genotype and phenotype in patients with cystic fibrosis prospects for gene therapy in cystic fibrosis prediction of mortality in patients with cystic fibrosis wheezing in infants with cystic fibrosis: clinical course, pulmonary function, and survival analysis physiotherapy in cystic fibrosis efficacy and safety of short-term administration of aerosolised recombinant human dnase i in adults with stable stage cystic fibrosis the diagnosis of cystic fibrosis: a consensus statement emerging therapies for cystic fibrosis pseudomonas cepacia: pulmonary infection in patients with cystic fibrosis effect of long-term treatment with inhaled budesonide on adult height in children with asthma a clinical index to define risk of asthma in young children with recurrent wheezing airway responsiveness in early infancy predicts asthma, lung function, and respiratory symptoms by school age low-dose inhaled corticosteroids and the prevention of death from asthma third international pediatric consensus statement on the management of childhood asthma. international pediatric asthma consensus group venous thromboembolic complications in children clinical assessment and management of massive hemoptysis massive haemoptysis: medical management will usually arrest the bleeding pathogenesis and management of hemoptysis in children cough is important because it is a symptom and sign of underlying disease that frequently merits treatment. in the acute setting, severe disease, including massive hemoptysis or profound dyspnea or hypoxemia, warrants immediate attention, rapid diagnosis, and rapid management. certain chronic conditions, including those that suggest cf and those in which symptoms have persisted and interfere with a child's daily activities and quality of life, warrant further evaluation and treatment. finally, a child whose cough fails to respond to what should have been reasonable treatment should be referred to a pulmonary specialist (table - ) . key: cord- -i q gsu authors: nan title: (th) european congress of trauma and emergency surgery: may – , antalya, turkey date: - - journal: eur j trauma emerg surg doi: . /s - - -z sha: doc_id: cord_uid: i q gsu nan introduction and aims: although liver is well protected by the thoracic cage, it is a frequently injured organ especially by penetrating traumas and also rarely by blunt traumas. retroperitoneally located pancreas and duodenum injury with or without liver injury occur rarely but they are seriously life threatening injuries. for these reasons we aimed to investigate the traumatic liver, duodenum and pancreas injuries as a whole. materials and methods: cases of blunt and penetrating traumas occured in our district are included in this study. in these patients parameters of sex, age, etiology, admission time, stability and physical status on admission, concurrent organ injury, operation type, gradings of injuries, were investigated. results: cases ( , %) suffered from liver injury, while cases ( , %) suffered from hepaticopancreaticoduodenal injury. cases ( %) were caused by penetrating injuries. cases of liver injury group had isolated liver injury whereas cases of the group has additional thoracic injury, cases had great vessel injury, case had orthopedic injury and lastly case had head injury in addition to the liver injury. in the combined hepatic injury group mortality rate was , %. conclusions . in hepatoduodenopancreatic injury group blunt and penetrating injury rates are equal. . duodenum-pancreas injuries occur rarely. liver,with injury rates of cases in this study, is the most frequently injured organ. . mortality rate is higher in the subgroups of patients who admitted to hospital late, and who had concurrent thoracic, orthopedic, and head trauma. background: the incidence of blunt bowel and mesenteric injury (bbmi) has increased recently in blunt abdominal trauma and this is possibly due to an increasing number of high speed motor accidents and the use of seat belts. objective: in this study we sought to identify the factors determining the time of surgical intervention and how they affect the outcome of the patient with bbmi. this was achieved by reviewing our experience as a major victorian trauma service in the management of bowel and mesenteric injuries and how this compares to current literature. methods: a retrospective study reviewing consecutive patients who presented to the alfred trauma centre with blunt bowel and mesenteric injuries over years. results: of the patients with bbmi % were male, % were female. % of the patients underwent a laparotomy, % of patients were treated conservatively and % were diagnosed post-mortem. the times from admission to laparotomy were: - h %, - h %, - h %, - h %, - h %, more than h %, respectively. fast (focused abdominal sonography for trauma) was done in and % of this group had a positive fast. while % of patients had a negative fast and % of patients had an equivocal fast. % overall group did not have a fast. computerised tomography (ct) scans were undertaken preoperatively in % of the patients and showed: free gas ( %), bowel wall thickening ( %), fat and mesenteric stranding or hematoma ( %) and free fluid with no solid organ injury ( %). conclusion: the timing of surgical intervention is mostly determined by the clinical examination and the helical ct scan findings in bbmi. fast lacks in sensitivity and specificity in identifying bowel and mesenteric trauma. delayed diagnosis of more than h has significantly higher bowel related morbidity but not mortality. predictors for the selection of patients for abdominal ct after blunt trauma: a proposal for a diagnostic algorithm introduction and objectives: gastrointestinal and mesenteric injuries (gimi) are not common in trauma, and their diagnosis is frequently delayed. our aims were to determine the reliability of ct scan and to assess the clinical significance of a delayed diagnosis. methods: retrospective analysis of cases confirmed at laparotomy. patients were identified at the severe trauma registry of our hospital, between and . results: we found ( , %) gimi out of patients with abdominal trauma, in a registry with . severe trauma cases included. the mean iss and niss were of and , respectively. mortality was of ( , %) patients, of them unexpected. a ct scan was performed in ( %) cases, and only in were there signs suggestive of a gimi. surgery was delayed for more than h in ( %) patients, the most common reason being a false negative result in the ct scan. there was no significant increase of morbidity or mortality in the delayed diagnosis group. conclusion: the overall incidence of gimi was high in our registry ( % in penetrating and . % in blunt trauma). several factors such as the initial lack of symptoms, a low diagnostic sensitivity of the ct ( % false negatives), and the nonoperative management of solid organ injuries, have contributed to a delayed diagnosis in one of every five patients in our series, but this has not led to a significant increase in septic complications in this group. author to editor: ct scan diagnosis of gastrointestinal injuries continues to be a matter of concern. there is controversy on the clinical significance of a delayed diagnosis of small bowel injuries management of rectal injury: reappraisal of old techniques introduction and objectives: due to immunological functions, conservation of injured spleen following abdominal trauma is very important. for this reason nonoperative management (nom) in the last years has been accepted as the ideal treatment in those patents who are hemodynamically stable and do not require a laparotomy; however in case of multiple abdominal solid organ injuries (soi) nom is controversial. methods: we report on a case of a -years-old patient with spleen and renal injury subsequent to blunt abdominal trauma. ct scan revealed a ois iv injury (third degree in graz classification) and an ois iv renal injury. since chances for successful spleen angioembolization were judged poor by radiologist, a laparotomy and partial spleen resection with preservation of one-third of the spleen was performed. immediately after surgery, angioembolization of the renal injury was successfully performed. results: a contrast enhanced ultrasound (ceus) performed on day and day after trauma revealed a hypertrophy of the residual spleen with diffuse distribution of contrast agent in the spleen parenchyma, confirming functional activity of the organ. morphological and functional evolution of left kidney was normal. conclusions: sequential treatment (surgical preservation of the most injured organ followed by immediate angiographic embolization) could be a valid option in case of multiple abdominal soi; furthermore, ceus is an interesting new tool to determine functional activity of residual spleen. introduction: precise timing of cholecystectomy procedure after biliary pancreatitis is still controversial. the major drawback of interval cholecystectomy is the recurrence of pancreatitis within the interval of - weeks. early cholecystectomy (performed prior to discharge), however, have the disadvantages of increased technical difficulty and conversion rates. methods: we reviewed patients with recurrent biliary pancreatitis among a total number of cases of biliary pancreatitis in-between january and january . results: the mean age was . (range - ), and male-to-female ratio was . ( : ). seventeen patients (% ) had a history of previous cholecystectomy. of these patients, (% ) have had early cholecystectomy, and (% ) have had interval cholecystectomy. the rest of the patients (% , n = ) consists of those who have been scheduled for interval cholecystectomy but have had a recurrent episode during the -week interval (% , n = ) or after the -week interval (% , n = ). conclusion: the majority of patients with biliary pancreatitis do not have any recurrent episodes even if they do not have a surgical or an endoscopic treatment. according to our data, however, an influenced percentage of recurrent pancreatitis develops in patients who do not have early cholecystectomy. therefore, we prefer early cholecystectomy in means of reducing the risk of recurrent pancreatitis during or after the -week interval. introduction and aim: nonoperative management (nom) of splenic injury is currently the most common management strategy in hemodynamically stable trauma patients. aim of this study was to asses if the success rates of - % described, mainly in the north-american literature could be confirmed. methods: we conducted a retrospective study of all patients older than year with blunt splenic injury who were admitted to a level i trauma center. a total of patients were identified with blunt splenic injury during the -year study period ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . results: the majority were young men; mean age was years. thirty-three ( %) patients underwent immediate surgical management. sixty-seven ( %) patients were treated with planned nom and ( %) patients underwent angiography and embolization (a&e). we did not encounter early complications following a&e. fourteen patients failed observation due to ongoing bleeding. of these, were treated with splenectomy and three with a&e. the splenic salvage rate after observation was %. the splenic salvage rate after a&e was %. four of the five patients with a rebleeding after initially a&e underwent splenectomy and one patient was treated with reembolization. the overall mortality rate was . %. none of the patients died as a result of splenic injury treatment failure. conclusion: nonoperative management in blunt splenic injuries in our trauma center is a well-tolerated treatment with a success rate of %. the splenic salvage and mortality rate is comparable with the literature which is mainly based on north-american studies. mannheim peritonitis index (mpi) is a scoring system with prognostic significance. we applied mpi to patients with perforative peritonitis (on patients in sri ramachandra medical college) to validate the scoring method. it is a specific score with accuracy and allows prediction of prognosis. aim of the study ( ) to study the incidence and aetiology of perforative peritonitis. ( ) to study the demographics of the study population. ( ) to analyse if mannheim peritonitis index (mpi) is a valid scoring method. p-possum (p < . ) scores in the index surgery. malignancy was the most frequent initial diagnosis in patients with spp and benign diseases in tp. there were no differences on the interval between operations ( ± days tp vs. . ± days spp; p = . ) neither in the number of previous laparotomies (p = . ). tp was associated to emergency index surgery (p = . ) and icu hospitalization (p < . ), mechanical ventilation (p = . ) and vasoactive drugs (p = . ). there were no differences in any of the clinical and biochemical parameters analyzed, neither in sirs (p = . ) or p-possum scores after relaparotomy (p = . ). we found no differences regarding mean hospital stay ( days tp vs. days spp; p = . ) and mortality rate ( % in spp vs. % in tp; p = . ). conclusions: although certain differences exist, the clinical course of postoperative peritonitis seems to depend more on factors other than their secondary or tertiary origin. background and aim: patients with primary acs will often develop a secondary acute respiratory distress syndrome (ards). mechanic pressure is mainly responsibe in pulmonary findings in acs. we aimed the role of aspiration of gastric contents into lower airways in pulmonary complications of acs. methods: the rats were initially divided into five groups (group i-v), and then these groups were divided again into two groups if they are unfed (group ia-va) or fed (group ib-vb). in animals in group i-v intraperitoneal pressure (iap) was applied as follows: , , and cm h o by instillation of isotonic saline solution. results: total scores of lung histopathologic findings were concordant with the degree of iab. when the total scores of histopathologic findings in lungs were compared for each applied iab with control group, the scores were higher in fed animals than unfed animals. histopathologic findings in lungs were observed when increased-iap to mmhg ( cmh o) which was accepted as cut-off value. the comparison of the scores of histopathologic findings in two groups in which the applied iab was lower then the cut-off value were not significantly different from the control group. however comparison of the scores of histopathologic findings equal to or above mmhg were significantly higher then the control group. conclusion: our results show that that pulmonary aspiration related with passive regurgitation in acs has a substantial influence on histopathologic findings seen in this disorder. editor to self: secilmiş bildiri emergency surgery and delayed abdominal closure: results in cases carlos mesquita, marco serô dio, francisco castro-sousa emergency and general surgery departments, coimbra university hospital, coimbra, portugal delayed abdominal closure (dac), in emergency surgery, must be economical, fast to execute and easy to maintain, allowing second look and definitive closure, with minimal prejudices to the abdominal wall. as an alternative to the vacuum closure systems, the aa have been utilising the rotondo and schwab technique (iatsic-dstc course), by the interposition of a plastic towel between abdominal contents and wall. dac has been utilised in patients ( male, female, - ) , median age of ( - ). in five, after abdominopelvic packing for hypovolemic shock conditions. in , after mediastinal and peritoneal decontamination procedures and lavage for septic situations with actual or potential compartment syndrome: three from acute necrotizing pancreatitis, six from dehiscent digestive sutures and two from strangulated hernias. four patients died in the open abdomen situation, one from pancreatitis and three from dehiscent sutures. primary abdominal closure has been possible in : in the cases of packing and in of the of the cases of sepsis. in one case of pancreatitis it has been possible a secondary closure. dac is now accepted like a safe procedure in damage control and compartment syndrome conditions which contributes to ameliorate the results in life threatening situations. than %. this report describes our experience with vacuum assisted closure (vac-)therapy in the management of efs in an oa. materials and methods: nine patients with seventeen high output efs in an oa were treated with vac-therapy from january till january . the abdominal wound was covered with fatty gauzes. small efs were covered with a patch of hydrophilic polyvinylalcohol foam. the entire abdominal wound was covered with polyurethane foam which promotes granulation and seals of the oa preventing further spillage of enteric contents. continuous negative pressure at - mm hg was applied. for large fistulas with protruding mucosa a hole was cut within the polyurethane foam and an ostomy bag was placed over the fistula mouth. surgery with enterectomy was planned - weeks later. results: the vac-dressing was changed every days. three efs closed spontaneously. time between onset of fistulisation and surgery was days (median days). no additional fistulas occured. one patient died postoperatively. conclusions: although previously considered a contraindication to vac-therapy, the oa with efs can be managed with vac-therapy. a taylored application of the foam and a reduced negative pressure seem to allow a safe and reliable way to manage efs. partial enterectomy and abdominall closure is possible after several weeks. introduction: it was the aim of the study to analyze the potential value of microdialysis in the rectus abdominis muscle (ram) compared with conventional monitoring parameters currently in clinical use for the detection of the abdominal compartment syndrome (acs). methods: pigs were anaesthesized, mechanically ventilated and continuously monitored. microdialysis was performed in different abdominal organs, the ram and cervical muscle (distant reference) for glucose, lactate, lactate-pyruvate ratio (lpr) and glycerol. iah was maintained for h. three groups were analysed: control (a), iah mmhg (b) and mmhg (c).cardiopulmonary parameters, urinary output, blood gas analysis and venous lactate were recorded. results: mean arterial pressure and abdominal perfusion pressure remained above clinically defined thresholds during the experiments for groups a and b. in contrast, group c demonstrated a persistent decrease below these thresholds. significant reduction of urinary output was only seen in group c. lactate levels also remained within physiological range in all groups. in contrast, microdialysis revealed a significant increase of lpr in all monitored organs in groups b and c, indicating ischemia and energy failure. of interest, lpr in the ram showed a significant increase already after h of iah in group b. conclusion: microdialysis of the ram detected local metabolic derangements in animals with iah of mmhg while clinically established monitoring tools failed to show organ dysfunction/tissue ischemia. our data suggest that continuous microdialysis in the ram may represent a promising tool for early detecting iah-induced metabolic derangements before manifestation of clinically apparent acs. introduction: to avoid morbidity associated with open abdomen, subcutaneous linea alba fasciotomy (slaf) was introduced for management of abdominal compartment syndrome (acp) in severe acute pancreatitis (sap). we analyzed the efficacy and safety of slaf as a surgical decompressive technique. methods: a retrospective study of a -year period identified patients with sap and acs undergoing slaf. mean age was (range - ) years, were male and had alcohol-induced sap. slaf was performed - days post-admission, in / cases within h. results: the mean (range) preoperative intra-abdominal pressure (iap) was ( - ) mmhg and immediate postoperative iap ( - ) mmhg. the mean decrease was ( - ) mmhg and the decompressive effect was considered sufficient in / cases. two of these developed recurrent acs and required completion laparotomy, as did the with insufficient effect ( - days post-slaf). the mean preoperative sofa score was ( - ) and ( - ) - days postoperatively, the decrease was > in patients with successful slaf. eventually four patients underwent necrosectomy, two following sufficient slaf. the overall mortality and morbidity rates were / and / , no complications were attributed to slaf itself. mean hospital stay was ( - ) days. of the survivors, fascial closure was achieved in two, and planned hernia in four (two with split-thickness skin graft and two with post-slaf hernia). conclusion: slaf is a safe decompressive technique in sap-related acs. it is effective in about - % of cases, but some require completion laparotomy and/or necrosectomy later on. methods: between march and december , patients were managed with vac technique (kci, san antonio). the mean age was . ( - ) , and m/f sex ratio was / . indications were severe abdominal sepsis in patients, mechanical obstruction due to colorectal cancer in patients, pancreatitis in patients, posttraumatic abdominal compartment syndrome patients, evisseration in patients, enterocutaneous fistule in patients. results: as morbidity there were fistulaes and intraabdominal abscess in all patients. four of the patients were died with concomitant disease. there was no mortality related using vac system. thirty five patients ( %) was underwent a delayed primary closure, five underwent secondary healing by granulation, and four underwent split thickness skin grafting. surgical outcomes of severe hepatic injury were retrospectively reviewed. (methods) among patients with hepatic injury treated between and , patients who underwent surgery were included. the study period was divided into early ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) , middle ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) and late ( ) ( ) ( ) ( ) ( ) phases, and type of injury, surgical procedure performed and patients' outcome were retrospectively reviewed. (results) ( ) percentage of patients undergoing surgery: % ( / ) underwent surgery in the early phase, % ( / ) in middle and % ( / ) in late phase. ( ) timing of surgery: the numbers of patients underwent laparotomy in er, urgent laparotomy in or, and delayed laparotomy (after h) were ( %), ( %) and ( %) in early phase; ( %), ( %) and ( %) in middle; and ( %), ( %) and in late phase, respectively. ( ) surgical procedures performed: for type iiib (jast grading) cases, hepatectomy was performed in % and hepatorrhaphy was performed in %, giving a mortality rate of % in early phase, . % in middle and % in the late phase. for iiib + ivc/hv cases, hepatectomy was performed in all patients, giving a mortality rate of % in early phase, % in middle and . % in late phase. (discussion) with the increase in nonsurgical management, surgical treatment for hepatic injury is performed preferably in patients requiring immediate response, such as laparotomy in er. the surgical outcome of hepatic injury has been improving, with a survival rate of approximately % for type iiib cases and % for iiib + ivc/hv cases. rifat tokyay, tolga taymaz amerikan hastanesi, istanbul, turkey objective: the aim of this study was to assess the unexpected returns (ur) within month of the adult patients and the pediatric trauma patients initially seen in the _ istanbul american hospital emergency department. design: all urs between . . - . . were recorded. initial diagnosis, final diagnosis, initial treatment, final treatment, reason for readmission, and last medical condition were noted. results: eighty eight urs were recorded. final diagnosis of of these patients were surgical. forty one of these surgical patients had ur due to error in diagnosis and five due to error in treatment. fifty two of these patients returned on the same day or the next day, between nd and rd days, between th and th days and between th and th days. male to female ratio was to . three of the patients were pediatric trauma patients, were between - years, and were over . missed final diagnosis were: acute cholecystitis ( ), acute appendicitis ( ), missed fractures ( ), pneumothorax ( ) liver mass ( ), urethral stone ( ), ectopic pregnancy ( ), diverticulitis ( ), subarachnoid bleeding ( ), others ( ). conclusions: acute cholecystitis, acute appendicitis, and missed fractures were the most frequent surgical causes of urs after emergency department discharges. liberal utilization of abdominal sonography and abdominal ct scan may reduce missed acute abdomen in abdominal pain patients and appropriate radiological imaging and meticulous evaluation of the x-rays may reduce unnoticed spinal, pelvic and facial fractures in trauma patients. editor to self: seçilmiş bildiri olabilir introduction and aim: bacteremia sepsis and septic shock might develop rapidly for the patients with infection in bile path. early diagnosis, surgical treatment and antibiotherapy decrease mortality. in this study, the relation between choledocholithiasis, cholangitis and pancreatitis and treatment methods have been evaluated. method: the demographic features, the treatments, the intensity of the illness and mortality rate of the patients in afyon kocatepe university general surgery clinic between the years background: enterocutaneous fistula continues to be a serious surgical problem. they are related with major electrolyte imbalances, malnutrition and delayed tissue healing. our recent experience with enterocutaneous fistulas is reviewed hereby. methods: we analyzed the charts of all patients with enterocutaneous fistula from january to december . fistulas were assessed for localization, type, output, etiology, use of somatostatin analog and fibrin glue, nutritional support, type of surgical intervention, wound vac, and endoscopic findings. results: we identified patients. fistulas were localized as gastroduodenal in five patients, jejuno-ileal in seven, and colonic in eight. there were enterocutaneous and entero-atmospheric fistulas. endoscopy was performed in patients. output was low (< ml) in , whereas high (> ) in patients. seventeen patients developed fistulas due to iatrogenic reasons, six patients had an underlying malignancy, and three patients developed fistulas after pancreatitis. somatostatin analogs were used in patients. conservative treatment was performed in patients, primary surgical intervention in patients, and secondary surgical intervention in patients. fibrin glue was used in patients and was of benefit to . healing was achieved in patients ( %) after mean . days (range - ). two ( %) patients were died. conclusion: there appears to be no strict rule for treatment of enterocutaneous fistulas. liberal use of endoscopy, fibrin glue as well as restorative surgical intervention all play a major role, and should be employed selectively on an individual basis in the management of enterocutaneous fistulas. aim: in this study we aimed to evaluate the patients whose admitted to neurosurgery and anesthesiology intensive care unit (naicu) between and . matherial and methods: the patients whose admitted to naicu between january and january evaluated retrospectively. diagnosis, age, gender, mortality rate, staying day in icu of the all patients were determined. head traumas were obtained in trauma and multitrauma patients. results: total number of the patients those are admitted to naicu were , and of them because of head trauma ( . %). of the cases were pure head traumas ( . %) or politraumas accompanied with head traumas (ht).the rate of ht was . % of all traumas.there were men, women. mean age of men were . and women were . . staying icu were obtained as . days. the mortality rate was found as . % ( cases). operated cases were ( . %) and the cases followed without any operation were ( . %). mortality rate between operated cases were . % ( ) and nonoperated cases were . % ( ) . ht cases were evaluated by glascow coma scale (gcs) as severe (gcs £ ),intermediate ,moderate (gcs ‡ ).the cases which had gcs £ were ( . %). operated cases were ( . %) and of them dead ( . %). the mortality rate of operated cases ( cases) which had gcs = - were . % ( cases). the number of cases were which had gcs ‡ and the mortality rate of operated cases ( cases) were . % ( cases) at this group. the mortality rate of nonoperated cases ( cases) were . % ( cases). conclusion: the higher rate was ht cases when the trauma patients evaluated and mortality rate of nonoperated trauma patients were higher then operated trauma cases. author to editor: this study send for giving knowledge about traumas which admitted to kocatepe university school fo medicine at a period of months. introduction and aim: this study has been carried out to compare conservative and surgical treatment for the acute pancreatic. method: the treatment processes and radiologic outlook of the patients with acute pancreatitis in afyon kocatepe university general surgery clinic between the years and have been observed retrospectively. results: the average age of the patients with acute pancreatic is and . % of them were women. while conservative treatment was applied on patients, surgical treatment was applied on patients. while the etiologic reason was based on a known source for the . % of the patients, no reason was found for the . % of the patients. ercp was applied for six patients within the scope of conservative treatment. necrotizing pancreatitis existed in five patients. surgical debritment and abdominal washing were applied for four of the patients. acute pancreatitis were diagnosed for the . % of the patients after tomography. one of the patients which had surgical treatment died ( . %). there was no mortality for the patients having conservative treatment. there was not a substantial distinction between the two treatment methods in terms of mortality. ten of the patients had laparoscopic cholecystectomy, ten of the patients had open cholecystectomy (one of the patients with abdominal washing), one of the patients had choledochal exploration with t tube drainage and open abdomen. conclusion: the conservative treatment should be prefered though the treatment ways of acute pancreatitis under discussion. there is not a distinction between the tow methohds in terms of mortality. mü nevver moran, emre gundogdu, ismail bilgiç, hayrettin dizen, mehmet mahir Ö zmen department of surgery, ankara numune teaching and research hospital, ankara, turkey our aim was to compare to efficiancy of different scoring systems as a prognostic indicator in acute pancreatitis. medical records of patients ( female) with mean (range) age of ( - ) years who are diagnosed as acute pancreatitis during years were evaluated according to age, sex, etiologic factors, sirs, apache ii, balthazar scores and ranson scores at admission and at h in order to evaluate the correlation with mortality. the commonest cause was gallstone seen in ( %) cases followed by idiopathic in ( %), alcohol in ( %) and other in ( %). there were ( , %) cases with mortality and ( %) patients underwent operation. in survivors mean (sd) age was ( ) years, sirs score was . ( ) , ranson scores at admission was . ( . ) , ranson scores at h was . ( . ), apache ii score was . ( . ), balthazar scores was . ( . ). in the nonsurvivors group of ( , %) cases, the mean age (sd) was ( ). admission sirs score was . ( . ), apache ii score was ( . ), ranson score was . ( . ), ranson scores at h was . ( . ). when both groups were compared sirs score, apache ii score at the admission and ranson score at h were found to be statistically significant (p < . , p = . , and p = . , respectively), and no differences observed in reference to balthazarscore, hospital stay and icu stay (p > . ). although admission sirs score, apache-score and h ranson score were all found to be important prognostic indicators, sirs seems better and most promising indicator as it is easy to use and not requires sophisticated tests. normal in patients ( %). the appendix was divided by endo-loop in %, intracorporeal suturing in % and endo gia in % of the patients. the meso-appendix division was performed by endoclip ( %), ligasure ( %) and bipolar cautery ( %) . conversion to open procedure rate was ( %). mean operating time was min ( - ). mean hospital stay was . days . major complications were as follows: right iliac artery injury (n = ), bladder injury (n = ), post operative bleeding (n = ), intraabdominal abscess (n = ), appendiceal stump leakage (n = ). minor complications were trocar site infection (n = ) and mechanical bowel obstruction (n = ).there was no mortality. conclusion: la is associated with considerably decreased morbidity and might be considered as the treatment of choice in aa. hakan yanar, cemalettin ertekin, korhan taviloglu, ali fuat kaan gö k, emre sivrikö z, gü lay sarıçam, recep gü loglu trauma and emergency surgery service, istanbul university, istanbul faculty of mediine, istanbul, turkey background: gastrointestinal stenting is increasingly employed to relieve passage. it provides a palliation in inoperable cases or anastomotic strictures. in left-sided colonic and rectal obstruction, it allows decompression for a definitive surgery to be performed. methods: between may and december , patients with acute mechanical intestinal obstruction were treated with endoscopic stenting. localization of malignancy, stenting complications, and surgical interventions were assessed. results: there were a total of patients undergoing gastrointestinal stenting. sixteen patients received gastroscopic stents, four patients with esophageal, eight patients with gastric, four patients with duodenal tumors. stenting failed in five patients ( %), and surgery was required in four patients. nine patients were referred to adjuvant oncologic treatment. fourteen patients received colonoscopic stents; in one patient with a left-colon, in nine patients with sigmoid colon, and in four patients with rectal tumors. stenting failed in seven patients ( %), and six patients were operated emergently with a need for stoma in two patients. ten patients were referred to adjuvant oncologic treatment. no patient was died related with procedure. conclusion: gastrointestinal stenting is a useful adjunct in the treatment of patients presenting with acute mechanical intestinal obstruction for palliation as well as for decompression before definitive surgical therapy. introduction and objectives: internal hernia (ih) is a rare entity which occurs due to the protrusion of an intraabdominal viscus through a normal or abnormal mesenteric or peritoneal aperture. ih can either be acquired through a trauma or surgical procedure, or constitutional and related to congenital peritoneal defects. intestinal obstruction due to ih is very dangerous and lethal because it may be silent, and delay in diagnosis may cause severe abdominal conditions. in this report, we aimed to present patients with ih. methods: seventeen patients who were admitted to our clinic with the diagnosis of ih between january and january were included. patients' demographic data, type of the hernias, type of surgical procedures, length of hospital stay, and prognosis of the patients are evaluated retrospectively. results: there were nine male, eight female patients. mean age of the patients was . years ( - ) . postsurgical ih were seen in eight, paraduodenal in four, transomental in one, sigmoid mesocolon hernia in one patient, and the remaining three hernias were not classified. laparotomy was performed in patients, laparoscopy in and conversion to open surgery in patient. small bowel perforation was found in three patients. seven patients underwent intestinal resection and anastomosis. mean length of postoperative hospital stay was . days ( - ). there was no mortality. conclusion: ih is a rare cause of small bowel obstruction in adults and often present with complications. a high index of suspicion may lead to early surgical intervention and reduce morbidity and mortality. introduction: esophageal perforation is a serious surgical condition in which delay for surgery results in high mortality. application of covered stents is an alternative for emergency surgery. the aim of this study is to analyze the results of esophageal stent application retrospectively. the clinical data and outcome of patients diagnosed and treated for esophageal perforation by endoscopic stent application between february and december were evaluated. results: the mean age of these patients was ( - ) and male to female ratio was / . causes of perforation was mediastinal abscess (n ¼ ), metal stent application (n ¼ ), and balloon dilatation (n ¼ ). stents were applied immediately after perforation in three patients. remained three patients were referred from other institutions and the mean time of delay was h ( - ). perforations were at proximal (n ¼ ) middle (n ¼ ) and distal esophagus (n ¼ ). self expanding covered metal stents were applied in an appropriate position to bridge perforation area in a fashion to cover minimally cm distal and proximal normal esophageal mucosa to all patients under fluoroscopic control. no contrast leak was observed immediately after application and h later. patients were interned and observed under intravenous fluid and antibiotic therapy. except one patient developing transient subcutaneous emphysema no complication was observed. all perforations were closed and the stents were removed at the end of fourth week. conclusion: at the early phase of esophageal perforations covered esophageal stent application can be a better alternative to surgery. introduction: upper gi bleedings are serious conditions which may be life threatening. in seriously bleeding cases the failure of the endoscopic interventions makes surgical intervention necessary. the aim of this study is to present the success rate of endoscopic interventions for upper gi bleeding performed by surgeons. methods: clinical data and the outcome of endoscopic interventions made to of , upper gi bleeding patients admitted to a large community hospitals single surgical endoscopy center between january and september were analyzed retrospectively. results: hemostasis with endoscopic interventions was achieved in ( . %) at initial (n ¼ ) or at second endoscopy (n ¼ ). patients underwent emerging surgery. there was no mortality at the patients treated by endoscopic interventions where as seven patients died after surgery ( . %). conclusion: the outcome of surgery is poor in upper gi bleeding. thus maximum effort should be given to achieve homeostasis by endoscopy. the success rate of endoscopic interventions in this study performed by surgeons is extremely high and satisfying. naomi beks, mariëlle van gameren, sander ten raa, armand van kanten, gert roukema emergency department, maasstad ziekenhuis, rotterdam, the netherlands analgesia use at the emergency department, how evidence-based do we work when dealing with patient with acute abdominal pain? based on a pilot at our emergency department we concluded that it is still common practice to withheld a patient with acute abdominal pain from analgesia till examined by a surgeon or resident. this in contrary to evidence presented in literature which show no negative effect of analgesia use on accuracy of diagnosis in patients with acute abdominal pain. a total of inquiries were send to nurses, physicians and surgeons working at the emergency department of teaching hospitals in the netherlands. we questioned their standard policy on analgesia use in acute abdominal pain. a total of completed inquiries were retrieved, resulting in a response rate of %. there is a difference between the response of nurses and doctors, versus %, respectively. compared to nurses, doctors are more optimistic about the moment analgesia is given. remarkable is the result that % of patients do not receive any analgesia even after examination by a surgical resident and % of the patients have to wait till they are examined by a surgeon is outshining. patients are still withheld from analgesia till a resident or surgeon examines them even though this is not evidence-based medicine. there is no consensus in the netherlands on analgesia use in patients with acute abdominal pain in the emergency department setting. a national guideline for patients with acute abdominal pain is recommended. introduction and objectives: the benefits of laparoscopic appendectomy remain debated in literature. methods: this is a monocentric, retrospective study to evaluate the differences between open and laparoscopic appendectomy for length of hospital stay, wound infection, major complications. retrospective surgical site infection rate evaluation has been possible only for in hospital stay, no further clinical data has been collected regarding outpatient follow-up. results: from january to october we reviewed patients undergoing surgery for acute appendicitis. patients underwent laparoscopic appendectomy ( . %) (group a), patients open appendectomy ( . %) (group b). two different surgical teams, one for laparoscopy and one for laparotomy, performed the procedures. complicated (perforated or gangrenous) appendicitis were in group a ( . %) and in group b ( . %). mean hospital stay group a was . days, . (p = n.s.) group b. mean hospital stay in complicated appendicitis group (a + b) was . days, in uncomplicated (a + b) was . days (p < . ). laparoscopic appendectomy was associated with lower wound infection rate (group a . % vs. group b . %) (p < . ). infection rate in complicated appendicitis (a + b) was . %, in uncomplicated cases (a + b) was . % (p < . ). no mortality in both groups has been observed. one conversion in laparoscopic group was reported. no cases of deep surgical site infection have been observed. conclusions: laparoscopic appendectomy seems to be associated to a lower rate of wound infection. length of hospital stay and rate of major complication seems to be related to gangrenous or perforated appendicitis and not to the surgical technique. significantly lower on postoperative third and seventh day, respectively. conclusions: in this model of general peritonitis, mb significantly reduced adhesion formation. mb is blocking the tnf alpha early postoperative days. early blocking of the activity of tnf-alpha after peritonitis resulted in lower rates of adhesion formation macroscopically. the tnf-alpha can be an important factor for postoperative adhesion formation. results: laparoscopic surgery was performed in patients due to peptic ulcer perforation. seventy-five patients ( %) underwent laparoscopic repair alone or laparoscopic repair with omentoplasty. in the remaining patients ( %), the procedure was converted to laparotomy. amongst ( men / women) patients who were included into the study, the mean age was . ( - ) . in patients ( %, / ) preoperative diagnosis was unclear and the patients were taken to operating theater due to acute abdomen. in all patients, but one, the duodenal defect was repaired by primary suturing; in one patient, simply intra-abdominal lavage and drainage were performed because the omentum was found to seal the defect. omentoplasty was performed in ( %) patients. one and two abdominal drains were used in ( %) and ( %), respectively. mean hospital stay was . ( - ) days. morbidity was % (n = ). early morbidity included bile leakage in three patients, postoperative intra-abdominal bleeding in one. one patient had trocar site hernia. one patient ( -year-old female) died on postoperative day due to sepsis in the intensive care unit. conclusion: laparoscopic primary repair is a safe and efficient method in peptic ulcer perforation. akın tarım, sedat yıldırım, cem aydogan, gö khan moray, mehmet haberal department of general surgery, baş kent university, ankara, turkey introduction: approximately % of multiple trauma patients sustain concomitant burns. complicated management issues arise in these patients as burn and trauma care often conflict. the purpose of this study was to describe the different types of burn injuries seen in burn patients with additional forms of trauma, and to report the survival rate for this patient group. methods: in this retrospective study, patients were admitted to our center with concomitant burns and trauma from - . this study retrospectively analyzed the types of burn injury, extent of burns, types of other trauma associated with the burns, and outcomes. results: of this study group, were male. average age was . ± . . mechanisms included motor vehicle collisions, electrocutions with subsequent falls, one plane crashes, lpg or oxygen tube explosions and other type of explosions. average burn size was . ± . %. the most common traumatic injury was fracture and head injury ( ). management of fractures in burn patients and resuscitation in head injured burn patient represented the most common conflicts in patient care. there were deaths in this series. conclusion: burns are a rare but significant complication in the trauma patient. outcomes are dependent on rapid trauma evaluation as well as effective resuscitation and wound management. given the complexities of their problems, these patients necessitate a balanced multidisciplinary approach to maximize their potential for full recovery. thoughtful compromise between trauma and burn priorities is frequently necessary. introduction: fournier's gangrene (fg) is a rapidly progressive, polymicrobial, synergistic necrotizing fasciitis. in this study we aimed to determine the risk factors effective on the prognosis of the disease. methods: the files of consecutive patients operated for fg during - were investigated retrospectively. the surviving and mortal groups of patients were compared for demographic data, etiological factors and treatment modality besides length of hospital stay and treatment cost. results: the mean age of the patients was . years and female/ male ratio was / . mortality was seen in ( . ) patients and significantly high in female ( . %) (p = . ). the most frequent comorbid disease was diabetes ( . %), etiological factor was perianal abscess ( . %) and etiological source was anorectal region ( . %); and they did not affect the mortality. the most frequent cultivated microorganism e.coli ( . %) was significantly high in the mortal group (p = . ). imipenem was the antibiotic used in all of the patients. the mean number of debridements was , and intestinal diversion was utilized for . % of the patients. fecal decontamination ( . %) of the patients was performed by surgical ( ) and nonsurgical ( ) methods. the length of hospital stay in surviving group ( . days) was higher than the mortal group ( . days) (p = . ). there was no difference between two groups of patients for the length of hospital stay (p > . ). conclusion: female gender, duration of complaint prior to treatment, fournier gangrene severity point and cultivated microorganism (e.coli) were the factors affecting the mortality. aim: post-traumatic coronary aneurysms (ptca) are extremely rare. we report an asymptomatic ptca in a young patient. case: -year-old male, with no significant previous history. admitted intubated and ventilated after a car runover. he had cerebral, thoracic, abdominal, pelvic and lower extremity trauma. initial assessment disclosed eight left fractured ribs with associated pneumothorax; fast was negative, head ct normal. thoracic ct reveled small bilateral hemothoraces and pulmonary contusion, with no evidence of vascular lesions. he also had a fibular, clavicle, and pelvis fracture. control angio-ct at day showed pleural and pericardial effusions and raised the suspicion of left descending ptca, subsequently confirmed with mri. the patient remained asymptomatic with normal ekg and cardiac enzymes throughout this period. a coronariogram confirmed the ptca, that had undergone spontaneous thrombosis, with no further treatment required. discussion: coronary aneurysms (true or false) may occur after blunt thoracic trauma. ptca normally result from controlled rupture post myocardial infarction or cardiac contusion, with gradual wall rupture. although in this patient the diagnosis was made without any clinical manifestation, suspicion is the main key for diagnosis. aneurysms must be considered as a differential diagnosis in patients with thoracic trauma history associated with arterial emboli, congestive heart failure, arrhythmia, chest pain or dyspnea. conclusion: every trauma victim must be exhaustively evaluated. in any case a careful follow-up must be made in thoracic and abdominal trauma victims to decrease the possibility of missing injuries. aim: acute mesenteric ischemia (aim) continues to be highly morbid cause of emergency. early diagnosis and treatment may reduce severity of the disease. the aim of this study is to investigate causes for morbidity and mortality in ami patients. materials and methods: this retrospective study has patients of ami. the patients were classified according to their age, sex, clinical and laboratory findings, comorbidity, etiology, operative procedures, complications. and effect of these causes on mortality and survival was investigated. the results were statistically evaluated. results: of patients were male and were female. mean age was . for females and . for males. the most common symptom was abdominal pain. only one third of patients had diagnosed correctly before operation. amylase was high in % of patients. plain abdominal graphy showed air-fluid levels in all patients. mortality rate was high in patients aging over years (p < . ). there were no relationship between mortality and gender. the patients those who had massive small bowel and colon resection developed high mortality rates ( %). resection of ileocaecal valve also increased the mortality. five patients all of whom developed perforation died. majority of survivors had surgical intervention during first h of ischemic attack. the patients those died due to perforation had delayed surgical intervention. • there is no benefit of routine laboratory findings in early diagnosis of ami. • massive intestinal resection, absence of ileocaecal valve and stomal procedure increased mortality rate. • delay in diagnosis and treatment also caused high mortality. cem aydogan , yahya ekici , ebru sakallıoglu , sedat belli , mahir kırnap , emin tü rk , mehmet haberal department of generel surgery, baş kent university, ankra, turkey institute of burn, fire and natural disaster, baş kent university, ankara, turkey introduction: more than % of all burn patients can be managed on an ambulatory basis. appropriate management of minor burns minimizes further damage. methods: the epidemiology, demographics, and outcomes of ambulatory acute burn patients were reviewed at our center between and . patients who were in aba referral criteria were excluded from the study. results: the patients' mean age was . ± . years (range, - years) . the percentage of patients whose first admission was to our center was . %; the percentage of those referred from another center was . %. scald burns were the most frequently reported cause of burns ( . %). the house was the most frequently reported place at which the burns occurred ( . %). the percentage of stoverelated burns was . %. the upper extremities ( %) and lower extremities ( %) were the most frequently reported places on which the burns occurred. mean tbsa affected and superficial partial thickness burned area were . ± . % and . ± . %. the mean follow-up and the mean number of dressings applied to the burns were . ± . days (range - days) and . ± . (range - ). four patients ( . %) needed skin grafting, and two patients ( . %) were hospitalized for debridement without grafting. conclusions: close follow-up is important in minor burns to minimize further damage. burn centers must play an active role in the care of all burns. the devastating effects of burns can be prevented and decreased by educational programs. stove-related burns remain a problem in turkey. results: mean age was . ± . years. the percentage of the male patients was . %. the mean tbsa affected was . ± . %. the percentages of high voltage electricity injury, lightning injury, and lowvoltage current injury were . , . , and . %, respectively. place of employments ( . %) and outdoors ( . %) were the most frequently reported places at which the burns occurred. the burns mostly occurred in urban areas ( . %).upper and lower extremities were the most frequently affected regions. the percentages of the patients who underwent debridement, grafting, amputation and fasciotomy were . , . , . , and , %, respectively. the percentage of patients who had additional trauma other than electric burn injury was . %. mean hospital stay of patients was . ± . days. the mortality rate was . %. majority of the patients died from septic complications ( . %) conclusion: aggressive multidisciplinary treatment modalities and early debridment, grafting and/or flaps are very important. special considerations are required for public education about electricity and its hazardous effects. governmental supports are needed both in prevention and in therapy. ahmet erkilic, harun analay, sabri mehmet barazi, halil Ç eliksö z, bayram rü zgar burn center, av.cengiz gö kçek general hospital, gaziantep, turkey early staged excision and autogenous skin grafting or temporarily wound coverage with biologic dressing or allograft until autogenous donor sites are available is now conventional treatment for fullthickness burns. typically, tangential excision is performed with a handheld knife thus it may be difficult to control bleeding from the wound bed and difficult to assess the suitability of underlying for accepting a graft. a hydrosurgery system -versajet Ò is available that can be used for tangential burn wound excision. this device offers an easy and more precise way of excising eschar and is particularly useful excising nonviable tissue from the concave surfaces of hands and feet, as well as the eyelids and ears. totally, hydrosurgical tangential excision (hte) were performed for patients with burn, in our burn center in one and half year. several times performing were needed . % of patients (n = ). wounds of patients with - % total burned body surface were covered autogenous skin grafts subsequent to hte. more extensive wounds were covered with biologic dressings temporarily and wounds as soon as suitable autogenous skin grafting was performed. at this interval, burn wounds were shrunk average - % and donor skin poverty was increased. frequently, delaying to excision and coverage of burn wounds may be awful. early excision and early coverage of the burn wounds must be a golden standard for the current treatment of the burns. also hte is becoming a candidate to golden standard at burn treatment. introduction: in our previous study, we examined the treatment results of burn patients older than years, and found a significant increase in mortality with increasing age groups. the aim of the present study was to reevaluate this patient group and also compare these results with the previous study period of to . patients and methods: one-hundred and fifteen patients older than years were admitted to our burn unit during the last years. these patients were divided to three groups with respect to their ages (group a: - years, group b: - years, and group c: older than years). demographic properties of patients, etiology, and extend of burn injury, co-morbidity, length of hospital stay, and mortality rates were recorded. results: during the last years, demographic properties and etiology of burn injury did not changed significantly. however overall survival rate increased from . to % and ld values for burn injury are significantly increased in all age groups. length of hospital stay is significantly decreased in all age groups, especially in group b (from . to . days). co-morbidities did not change over time and sepsis is the leading cause of death in patients ( %). conclusion: in our burn unit, treatment results in patients older than years showed a significant improvement during the last years. introduction and objectives: patients who has weakness of mental and motor functions are under more risk than normal burned injured population. we would like to focus on burn injured cases that have co-exiting morbidities. methods: comorbid patients who applied to burn unit due to burn between january and july were taken into evaluation. comorbid etiologies were seizures ( case), mental retardation ( case) and down syndrome ( case), respectively. results: during follow-up period, one of the cases had aggrevated petit mal convulsion due to devastating effect of burn injury. in one case there was grade pressure sore and urethral infection who was paraplegic patient. weight loss was observed on a geriatric case that had seizure due to insufficient nutrition. conclusion: burn injured cases that have comorbidity, special care, and additional measures should be taken. psychological, neurological or geriatric causes are the factors that affect the recovery of burn defects and success of operation. detailed evaluation of coexisting disorder and additional care are the key points of the comorbid burn patient. aim: the present study was aimed to evaluate the gender differences of burned children in clinical course and outcome. methods: children (aged - ) admitted to our burn center between august and january were retrospectively evaluated. total burn surface area (tbsa), levels of some acute phase markers, grafting need, and hospitalization time were analyzed. results: sixty three patients [ ( . %) males, ( . %) females] were included in this study. the mean age was respectively . ± . years and . ± . years in males and females (p = . ). the mean tbsa burned respectively . ± . % and . ± . % in males and females (p = . ). the mean wbc count in admission was significantly higher in males than females ( . ± . x - /l vs. . ± . x - /l, p < . ), but there was not any significant difference between females and males in crp count. (p = . ). skin graft operation was performed in ( . %) of males and in ( . %) of females (p = . ) and also, we did not find any significant difference between males and females in hospitalization time ( . ± . days vs. . ± . days, p = . ). conclusion: although many studies have showed that critically ill females have a better outcome than critically ill males, any significant difference was not observed between burned male children and burned female children in most of the clinical parameters, except white blood cell counts. introduction and objectives: the goal of our study was to evaluate the preparedness of hospital physicians, emergency physicians and paramedics in the eu and the usa for a mass casualty incident. methods: an online survey which contained questions was sent to the head of the department of trauma-surgery, emergency medicine and to paramedics by e-mail. among other things we questioned: existence of a hospital emergency-and disaster plan and the yearly exercise of the plan. coordination with the local rescue service as well as existence of decontamination facilities were asked for. replies were analysed statistically with the one-way analysis of variance (anova) test and the turkey-kramer multiple comparisons test. results: altogether, assistant and emergency doctors as well as paramedics answered. % were not conscious of the details of the disaster plan of her hospital while % did not know the plan at all. % of the interviewed doctors did not know her area of responsibility in the case of an internal emergency. % of the interviewed know what to do in case of an mci. % of the interviewed doctors and % of the paramedics did not know her area of responsibility at the treatment of patients contaminated chemically, nuclearly or biologically. conclusions: the preparedness for doctors and paramedics in hospitals and in the preclinical rescue service in the eu and the usa on a mci (mass casualty incident) are insufficient. the emergency medical education of doctors and paramedics should be adapted to the terrorist threats disaster preparedness of chief physicians and hospitals in germany, the eu and the usa for a mass casualty incident introduction and objectives: the goal of our study was to evaluate the preparedness of hospitals in the eu and the usa for a mass casualty incident. methods: an online survey which contained questions was sent to the chief physician of hospitals by e-mail. things we questioned: existence of a hospital disaster plan and the yearly exercise. coordination with the local rescue service as well as existence of decontamination facilities. replies were analysed statistically. results: altogether, senior consultants, of this senior consultants from germany as well as senior consultants from the usa and the eu, answered. all people claimed to have a hospital disaster plan. % of the german hospitals made an exercise of the plan with tabletop exercises. however, % of chief physicians in the usa and the eu made an exercise of the plan regularly with table top exercises. % of the hospitals in the brd did not have any decontamination possibility of nbc (nuclear, biological, chemical) contaminated patients, while % of the hospitals had this possibility on the spot in the eu and the usa. conclusions: the exercise of the hospital disaster plan in germany is insufficient, compared with the hospitals in the eu and the usa. furthermore the german hospitals are badly equipped in the worldwide comparison to decontaminate patients on the spot. we demand for an increase of the ''exercises'' of the hospital disaster plan (also by tabletop exercises) as well as an improved equipment for the decontamination of the injured. in the two big earthquakes that occurred in the north-west of turkey in in short intervals within less than months there were approximately , cases of death and around , were injured. there were several other deadly earthquakes in the whole world the same year. main survival factors in the post-disaster period are prevention from injuries as well as detecting the location of the survivors and the rescued. the reality of the situation of persons who lost their lives in such traps, the severely injured, and the ones who survived must be analyzed. rational prevention methods against possible crush injuries due to collapsing buildings have been con-sidered in the light of the field and simulation experience we gained and suggestions have been presented to reduce mortality and morbidity. our work has been conducted with the aid of medicine based on proof, appropriate observation as well as sampling and experimental methods. a global approach concerning worst case scenario led by earthquakes has been proposed taking into consideration the different models of behavior in different countries and societies to increase the chance of survival to a maximum and to reduce injuries to a minimum level. due to unlimited possibilities of travelling nowadays, it is not possible to estimate the place, the country or the circumstances under which a person could experience a disaster. carlos alberto godinho cordeiro mesquita ordem dos mé dicos, colé gio de competê ncia em emergê ncia mé dica, lisbon, portugal in portugal there are three official ways to differentiate: specialty (vertical), subspecialty (vertical) and competence (transversal). doctors may access to a subspecialty or a competence as a second step, after a specialty. portuguese medical association (ordem dos mé dicos, om) is the official entity that regulates all the medical and surgical activities in portugal, being his duty to protect the public interest. doctors must be registered with to practise medicine or surgery. om also sets the standards and outcomes for basic medical education. after graduating from medical school and completing their foundation training, doctors usually complete a third and even a fourth stage of postgraduate training, whose standards are set by the colleges. these are responsible for promoting the development of postgraduate medical education and training for all, establishing standards and requirements and making sure they are met across the country. emergency medicine exists as a competence since and goes behind the prehospital acute care. this college is strongly interested in the development of an autonomous college of competence on emergency surgery (trauma surgery included) and it exists, since , an official national working group on emergency surgery education (grupo de trabalho para a formaçã o específica em cirurgia de emergê ncia), with representatives of general surgery ( ), neurosurgery ( ), orthopaedics ( ), thoracic ( ), vascular ( ) , urological ( ) and paediatric surgery ( ) . the general surgeons, iatsic members and dstc instructors, also integrate and lead the national steering committee for dstc, after a recently signed memorandum of understanding. author to editor: the point of the situation, from an organisational point of view, about trauma and emergency surgery education in portugal and the importance for the relationship with portuguese speaking doctors around the world introduction and objectives: practical training in emergency medicine should be an important part of undergraduate education, as every physician should be able to handle medical emergencies. however, adequate practical training is time and personal consuming. this work seeks to determine whether medical students (peer to peer education) can be trained as course instructors in emergency medicine training and if there are differences in the training outcome. methods: the undergraduate training consists of both basic life support (bls) and advanced cardiac life support (acls) courses. after both courses, students have to pass a multiple choice test and have to complete a course evaluation. during the instructor training, all candidates, students and physicians were trained together with theoretical and practical training and were furthermore supervised during their first courses. results: until now, bls and acls trainings were conducted of which % (bls) and % (acls) were run by medical students. there were no significant differences in the written examinations nor in the course evaluations ( = very good to = unsatisfactory) between courses by staff ( . for bls and . for acls) or medical students as trainers ( . for bls and . for acls, respectively). conclusions: peer to peer education can be a useful tool in the manpower consuming practical training in emergency medicine without influencing the learning outcomes or the evaluation. background: non-invasive pelvic ring stabilization (pelvic binding, pb) in shocked patients is recommended by state and institutional guidelines regardless the fracture pattern. the purpose of this study was to determine the adherence to the guidelines, radiological efficacy of the technique, and identification of potential adverse effects associated. methods: analysis of the prospective database of a level trauma center on high-energy unstable pelvic fractures. collected data included patient demographics, physiology, fracture classification, application, and timing of pb, associated injuries and outcomes. pre and post-pb radiographs were compared to evaluate the changes in fracture position. the potential effects of pb on soft tissue complications were assessed by independent experts. results: during the -month study period a total of pb was performed on patients with high-energy unstable pelvic ring injuries. stable patients were less likely to get pb ( %) than shocked patients ( %). the adherence to guidelines was %. analyzing fracture types (ao/ota classification) of shocked patients the adherence was: b %, b %, b %, c %, c %, c %. better radiological appearance was detected in b %, c %, c %, c % types. one femoral artery, four bladder and three rectum injuries were identified in patients with pb applied. there were no association between the complications and the pb. introduction and objectives: in our country, the vast majority of circumsicion is stil not done by physicians. in this study, we evaluated the patients who treated for circumsicion complications in our clinic. methods: a total of children who treated for cicumsicion complication in our clinic between and were evaluated. results: mean age during circumsicion was . months ( - years). out of had not been circumsiced by physicians. complication was bleeding in patients, burred penis in , complete glanular amputation in , and urethral fistula in patient. one suture was enough to control bleeding for the majority of patients with this complications, while general anesthesia required for treating other complications. conclusions: significant number of children still undergo circumsicion between and years old (fallic period) in our country. the vast majority of complications occur when circumsicion is not done by physicians; significant number of these complications require revision under general anesthesia. as a result, circumsicion is still a challenging both public and social problem in our country, and results in high morbidity because the majority is not done by experienced hand. arda demirkan , salih ekinci , onur polat , serdar gü rler , mü ge gü nalp , semih baskan department of emergency, ankara university, ankara, turkey department of general surgery, ankara university, ankara, turkey objective: multiple trauma involves at least two systems of body which abdomen, extremities, chest and head-neck. the aim of this study is to show relationship between the severity of injury and electrolyte changes in multiple trauma patients. method: this is a prospective study which adult multiple trauma patients ( male and female) were studied. the median age was . (range - ) . in all cases, serum sodium, potassium and calcium levels and injury severity score (iss) were obtained on admission to emergency department after trauma. severity of injury was estimated with iss. degree of association between variables was evaluated by spearman's correlation coefficient test. results: the mean sodium levels was . mmol/l, the mean potassium levels was . mmol/l, the mean calcium levels was mg/ dl. there was a negative correlation between calcium and iss, and this is statistically significant (p = . ). while other serum electrolytes (sodium and potassium) did not change according to iss. conclusion: electrolyte abnormalities often occurs in critical ill patients, this imbalance has a prognostic importance particularly in multiple trauma patients. electrolyte changes determinated in early period and appropriate resuscitation is indispensable. we suggest that low calcium levels can be considered for the severe injury. this condition may be related to interrupted calcium mechanism in critical trauma patients. introduction and objectives: preparation is essential to meet the challenge of optimal care for a sudden unexpected surge of casualties due to a major incident. by definition, requirements exceed standard care facilities in qualitative and or quantitative respect and interfere with regular patient care. to meet the growing demand for disasterpreparedness a permanent facility to provide structured, prepared relief in such situations was developed. we describe this facility. objectives: the aim of this study is to find out the effects of melatonin on the erythrocyte and kidney malodyaldehyde (mda) and superoxide dismutase (sod) levels in radiocontrast nephropathy. methods: in this study, new zealand type rabbits were included. the test subjects were divided into four groups six rabbits in each (control, sham, hydration and melatonin groups). blood samples of all subjects were taken in beginning of study. renal tissue was obtained in the control group. the rest received ml diatrizoat sodium intravenously. hydration group was given ml/kg/day iv bolus . % nacl. melatonin group was given mg/kg iv melatonin four times with the same dose isotonic. it was blood and renal tissue samples were taken at the th and nd hours. mda levels were determined with ohkawa method, sod enzyme activity was studied with ransod (randox,uk) superoxide dismutase assay kit. results: the mean renal sod value of the melatonin group ( . ± . nmol/g) was significantly higher than in the sham ( . ± . nmol/g), control ( . ± . nmol/g) and hydration groups ( . ± . nmol/g) (respectively p = . , . , . ). the mean renal mda value of melatonin group ( . ± . nmol/g) was significantly lower than sham ( . ± . nmol/g) and hydration groups ( . ± . nmol/g) (p = . , . respectively). conclusion: melatonin has a curative effect on the lipid peroxidation caused by the contrast substance in the kidney. in preventing nephropathy resulting from contrast substance, giving melatonin together with hydration can be more effective than giving hydration alone in the clinic. in addition, all datasets entered with voice recognition were complete and available in the system as soon as the patient left the trauma bay. compared to the retrospective cohort % of the patients had incomplete data concerning the vital parameters. conclusion: the introduction of voice recognition technology real time produces more accurate data more quickly. we are convinced that high tech technology will increasingly assist the trauma surgeon and if we are correct it looks like the prediction of don trunkey will come true viz: ''the current possibilities for using digital resources within medical care are merely limited by our own imagination'' introduction and aims: despite the improvements in the diagnosis and treatment, mortality rates are still high following urgent operation for perforated peptic ulcer (ppu). in this study, we analyzed the factors affecting the survival of the patients operated for ppu. materials and methods: the records of the patients operated due to ppu between january and january were analyzed. age, sex, american society of anesthesiology (asa) score, alcohol consumption, smoking, nonsteroidal antiinflammatory drug (nsaid) usage, the time passed from the onset of symptoms to operation, history of previous peptic ulcer disease, diameter and localisation of the ulcer, surgical technique, length of stay, postoperative complications and mortality rates were determined. results: the mean age was and asa score was . primary suture and omentoplasty was the selected procedure in patients while gastrostomy was added to primary suture to another patients. twenty nine patients received primary suture, truncal vagotomy and gastroenterostomy and seven underwent resection. the mean length of stay was days. three patients suffered from atelectasis and pneumonia, one from empyema, eight from surgical site infection and four from leakage. twenty three of the patients experienced respiratory failure and died of multi organ deficiency ( . %). age and asa score were found as factors significantly affecting survival. abdominal cocoon (idiopatic sclerosing encapsulating peritonitis) is a rare disease of the peritoneum which refers to a condition where there is a total or partial encasement of the small bowel by a dense fibrous membrane. the abdominal cocoon is probably a developmental abnormality, largely asymptomatic, and is found incidentally at laparotomy or autopsy. it is an unusual cause of intestinal obstruction. pre-operative diagnosis cannot be often made correctly. complete recovery is expected after removal of the membrane surgically. a -year-old man presented with abdominal pain, swelling and vomiting of two day's duration. there was no history of peritonitis, abdominal surgery or tuberculosis. physical examination of the abdomen revealed a distended abdomen, hypoactive bowel sounds, tenderness and rigidity in the whole abdomen. a tender lump was palpated in the right lower quadrant. routine laboratory workup revealed a total leukocyte count of cells/ml, and normal serum chemistry. pa x-ray of the chest normal. plain abdominal x-ray showed few air-fluid levels. contrast-enhanced abdomen-pelvis computed tomography showed a dilatation up to . cm in small intestine. emergency laparotomy was performed through a right paramedian incision. in exploration, small bowel was observed to be dilated, its mesentery was edematous and the whole small and large bowel was covered by a dense whitish and approximately mm thick membrane. the membrane was partially removed, and adhesiolisis of the intestinal loops was performed without bowel resection. after surgery, the patient was tolerated diet without any complication and was discharged, on hospital day . methods: the data of al-ain hospital trauma registry were prospectively collected over a period of years ( ) ( ) ( ) ( ) . all trauma patients who were admitted to intensive care unit (icu) were included in the study. univariate analysis was used to compare gender, age, nationality, mechanism of injury, systolic blood pressure and gcs on arrival, the need for ventilation, presence of head or chest injuries, ais for both the chest and head injuries and the iss. significant factors were then entered into a direct logistic regression. results: there were patients ( males). mean (range) age was year. . % were uae nationals. the two most common mechanisms of injury were road traffic collisions ( . %) followed by fall from height ( . %). the median (range) iss was . the mean (sd) icu stay was . ( . ) days while the mean (sd) hospital stay was . ( ). the overall mortality was . %. significant factors that have affected mortality included gcs (p < . ), mechanism of injury (p = . ), age (p = . ) and iss (p = . ). the best gcs that predicted mortality was . while the best iss that predicted mortality was . conclusions: rta is the most common cause of serious trauma in uae followed by falls. gcs is the most significant factor that predicted mortality in icu trauma patients. introduction: glutamine is an antioxidant which enhance glutathione levels. in this study our goal is to assess the safety and efficacy of parenteral glutamine on antioxidant capacity and organ dysfunction in septic patients. methods: prospective, randomized study of the septic patients admitted to the surgical intensive care unit (icu). patients were randomized to receive either glutamine (group glu, n = ) or glutamine + n-acetylcysteine (group nac, n = ) or a control supplement-placebo (group pla, n = ) parenterally up to days. organ dysfunction and clinical outcomes were assessed by daily total sequential organ failure assessment (sofa) score over the -day study period. serum total antioxidant capacity (tac) was measured by cuprac method. also we evaluated procalcitonin (prc) and c-reactive protein (crp) levels as infection markers on days , , , and . results: there was no significant differences between the patients' ages, apache ii, sofa scores and infection markers on the day of admission. group glu and nac showed a significant decline of daily total sofa score (glu: p < . , nac: p < . , pla: p = . ) and crp levels (glu: p < . , nac: p < . , pla: p < . ). but prc levels decreased significantly over time just in group glu (glu: p < . , nac: p = . , pla: p = . ). on the other hand, serum tac measurements were not significant. the mean icu length of stay were glu: ± . , nac: . ± . , pla: . ± . (glu/nac: p < . , glu/pla: p < . ), but in group glu the overall mortality was significantly lower than nac and pla groups (glu: %, nac: %, pla: %). conclusion: in septic patients, parenteral supplementation with glutamine results in significantly better recovery of organ function compared with nac and pla. we coud not find any significant relationship between tac levels and clinical outcomes. background: acute renal failure (arf) requiring renal replacement therapy in icu setting is related to high mortality. the purpose of the study is to assess any indicators of improved survival. materıal and methods: retrospective study of trauma patients, who underwent haemodialysis over a period of years (patients with penetrating, blunt trauma and burns). information on pre-hospital and in-hospital resuscitation, trauma scores and physiological scores and daily icu records were collected. the majority of patients were initially dialysed with cvvhd and later on with sled. results: of the patients, died and overall mortality was . %. this was highest in the group of burn patients ( %). survival in all patients irrespective of mechanism of injury was unrelated to rts, iss, apache ii and triss. the duration of haemodialysis be-tween the three different trauma mechanism groups was not significantly different. age is not a significant predictor of survival. patients with polyuria at time of initiation of haemodialysis had not a better outcome than those who were oliguric/anuric/normouric. conclusions: arf in trauma patients has a low survival rate. controversial conclusions have been presented in the literature. in our study, none of the parameters reported in previous publications to affect survival was proven as correct, although our number of patients was comparable to that of other studies. as we are still at an early stage of understanding the predictors and the behaviour of renal failure in the trauma patients there is a need for the planning multicentric prospective studies. weaning from mechanical ventilation constitutes a dynamic process, and represents one of the most challenging decisions in the management of critically ill patients. success of weaning depends on multiple factors, and wrong decisions result either in prolonged mechanical ventilation, or reintubation and nosocomial pneumonia. many mathematical indexes have been described and used for decision making with varying successes. we have developed a multiparameter fuzzy-logic decision support system for prediction of success of weaning from mechanical ventilator. after fuzzifying relevant numerical variables, this system evaluates the appropriateness of perfusion, arterial blood gases, mechanical properties, and gas exchange, and converts these to a weaning probability. system has been designed using jfuzzylogic package and uses mamdani center of gravity algorithm for defuzzification. after optimization system has been tested over a software that creates random clinical scenarios within a range that can represent challenging patients. for each scenario jabour' weaning index, rapid shallow breathing index (rsbi) and pressure time index have also been calculated and compared with fuzzy-logic system. results indicate that currently used indexes and especially rsbi, disregard many important parameters and shown a potential to fail in many critical scenarios (in % of simulations). additionally we would like to discuss the potential of fuzzy-logic in clinical decision support, and design and optimization issues. trauma scoring systems used for uniform reporting and evaluation of trauma outcomes include physiologic, anatomic and combined systems. these systems have already been evaluated and shown to have accurate performance. we proposed a possible effect of response to resuscitation on the performance of trauma scoring. data necessary for calculation of iss, rts, triss and ascot systems have been retrospectively collected from the records of last consecutive trauma patients admitted to our surgical critical care unit. score and mortality prediction calculations have been performed over a software developed in our department, at three time points, at admission to er, after h of resuscitation, and at icu admission. additionally a fuzzy-logic inference system which uses physiologic variables as input has been designed for trauma related mortality prediction and applied to the same dataset. performances of scoring systems and fuzzy-logic inference system have been evaluated. results indicated that all systems have good discrimination, but variable calibration characteristics. for all systems evaluated response to resuscitation has effected system performance and scores and predicted mortality values calculated after resuscitation have shown better discrimination. fuzzy-logic inference system designed has shown discrimination characteristics comparable but not better then the other systems, which indicate the importance of inclusion of specific organ injuries in trauma scoring and mortality prediction. daily monitoring of immune/inflammatory status is a fundamental procedure in the icu. in small animal disease models such a surveillance is challenging given the limited blood volume available. to validate a new method for daily immuno-inflammatory monitoring in critically ill (septic) mice, we followed their short/longterm survival, organ function and inflammatory status. furthermore, the reliability of complete blood count (cbc) differential was tested in re-suspended blood cell pellet. female of- and cd- mice were subjected to cecal ligation and puncture (clp). ll blood samples were collected (facial vein puncture) from half of each strain daily for days or on day only. additionally, ll (diluted : ) volume was collected (of- only) and divided to compare cbcs in whole versus resuspended blood. there were no differences in / -day clp mortality. for both strains, changes in circulating interleukin- and chemical parameters (alt, ldh, bun, glucose) were comparable between sampled subgroups. ll sampling in of- mice caused a decrease of % in rbc and % in hb (both p < . ). in cd- animals, both rbc and hb showed a similar decrease of % (p > . ). platelet and wbc counts were unaffected. cbc comparison displayed a high correlation for all cell types (r > . , slope > . ) except lymphocytes (r > . ,slope > . ). this was reproduced in non-clp mice. the results indicate the minimal biological effect of daily sampling upon septic mice. cbc differential from resuspended pellet is highly reliable. this newly validated facial vein punture sampling protocol allows multi-directional monitoring in mouse models of critical illness such as acute peritonitis. introduction: a comparison of the amount of procalcitonin (pct) with that of c-reactive protein (crp) during various types of and severities of multiple trauma., and their relation to trauma-related complications, was performed. the aim of this study was to describe the amount of and the time course of pct and crp induction in patients with various types of and severities of high-velocity trauma. background: to provide a score to predict the risk of early mortality after single craniocerebral gunshot wound (gsw) based on three clinical parameters. methods: all patients admitted to baragwanath hospital, johannesburg, south africa, between october and may for an isolated single craniocerebral gsw were retrospectively evaluated for the documentation of (a) blood pressure on admission, (b) inspection of the bullet entry and exit site, and (c) initial consciousness (n = ). results: conscious gsw victims had an early mortality risk of . %, unconscious patients a more than fourfold higher risk ( . %). patients with a systolic blood pressure between and mmhg had a . % risk of mortality. hypotension (< mmhg) doubled this risk ( . %) and severe hypertension ( mmhg) was associated with an even higher mortality rate of . %. patients without brain spilling out of the wound (''non-oozer'') exhibited a mortality of . %, whereas it was twice as high ( . %) in patients with brain spill (''oozer''). by logistic regression a prognostic index (pi) for each variant of the evaluated parameters could be established: non-oozer: , oozer: , conscious: , unconscious: , £rrsys < mmhg: , rrsys < mmhg: , rrsys mmhg: . this resulted in a score ( - ), by which the individual risk of early mortality after gsw can be anticipated. conclusions: three immediately obtainable clinical parameters were evaluated and a score for predicting the risk of early mortality after a single craniocerebral gsw was established. gunshot wounds to the head are associated with poor outcome. we reviewed data to identify prognostic factors. we performed a retrospective study of all patients admitted to a level trauma center with isolated gunshot injury to the head during six and half years. data collected included demographics, mechanism of injury, prehospital and resuscitation room data, and initial ct scan characteristics. the primary outcome measure was the glasgow outcome scale (gos). seventy-two patients with isolated gunshot wounds to the head were admitted. overall mortality was %. the mortality for patients with an initial gcs of < was versus % for those with initial gcs > (p < . ). fifty percent had pupillary abnormalities on arrival at the emergency department. mortality in this group was versus % in those with normal pupillary reflexes (p = . ). elevated plasma lactate was associated with nonsurvival. thirteen percent of survivors were assessed as able to live independently after their injury. civilian gunshot injury to the head is related to high mortality. indicators of outcome are the admission gcs score, pupillary abnormality, metabolic acidosis, and ct pattern of severe injury. introduction and objectives: the aim of this study is to compare the effects of the mannitol and melatonin on the levels of blood and brain malondialdehyde (mda). methods: in the study, new zealand type rabbits were used. the test subjects were divided into four groups; sham (n = ), control (n = ), mannitol (n = ) and melatonin (n = ) groups. blood cerebrum tissue samples were taken to research for mda in the control group. head trauma was applied with feeney method to the rabbits in the other groups. venose blood samples were taken before and after trauma to observe mda. mg/kg melatonin was given to the melatonin group, and g/kg mannitol was given to mannitol ( %), between and in ( . %), and between and in patients ( . %). mortality rate was % (n = ). patients who died had significantly higher iss (p < . ), lower gcs, (p < . ), and higher head ais (p < . ). conclusions: road traffic collision is the leading cause of head injury in our setting. in this study population, head injury was severe, more than one fifth of the cases were admitted to the icu, and gcs was below in %. patients who died had significantly higher iss, lower gcs, and higher head ais. backgrounds and objectives: benefits of emergency burr-hole craniotomy (or evacuation) for patients with critical head trauma remained unclear. our study objective is to compare the effectiveness of burr-hole craniotomy to decompressive craniotomy using data from a large-scaled, multicenter and nationwide registry of hospitalized trauma patients in japan. materials and methods: among a total of records registered in japan trauma data bank, we selected patients with critical head trauma which were scored as ais (critical injury on the abbreviated injury scale) on head and underwent either of burr-hole craniotomy or decompressive craniotomy. parameters of the trauma injury severity score (triss) were used to adjust the baseline trauma severity. univariate analysis and multivariate logistic regression analysis estimated the relative risk of inhospital death. results: a total of zygomatic and/or orbital fractures were identified with subtarsal ( %), subciliary ( %), transconjunctival ( %) incisions, and laceration ( %). the risk of ectropion was highest in subciliary incisions ( . %, p = . ), however, only one case required operative management. entropion was found in two cases after transconjunctival incisions (p = . ); both required operative management. lid edema was present in . % of subtarsal and . % of subciliary incisions (p = . ). one hypertrophic scar was seen with the subtarsal and two cases with the subciliary approach (p = . ). conclusions: lower eyelid malposition occurs after any lower eyelid incisions for facial fracture repair. ectropion is most commonly seen in subciliary incisions, while entropion is rare. a subtarsal incision has a low risk of malposition, however is associated with hypertrophic scars. although choice of incision can be based on surgeon preference, a thorough patient discussion must include potential complications with each approach. in traumatology things happen quickly, data are often incomplete and therefore misleading and there is also pressure for quick decision. in dealing with the matter we distinct among wrong decisions based on insufficient data and errors due to systemic faults or individual incompetence or negligence. possible systemic faults are at every level of treatment: taking history, clinical examination, diagnostics, decision making, treatment procedures and even rehabilitation. most analysed errors occured when patient was handed over to another team or another level of treatment. haste and insufficient or inadequate report leads to wrong assumptions and -if that is not discovered in time -to wrong treatment. on personal level usual mistake was being satisfied when one injury was found and others were missed to insufficient exam or diagnostics. dealing with unfamiliar drugs lead to overdosage and sometimes death of the patient. to avoid such disasters extra training was added to medical school and medical students systematically approach the subject. at the emergency department adherence to protocols is encouraged, especially in cases of unresponsive patients. on hospital level enough time should be provided for attending physicians to make thorough rounds. this should provide much needed redundancy in the age of maximum efficiency. unfortunately we feel it is still not possible to implement measures of self-reporting as known by the airline industry due to inadequate law regulation! author to editor: measures for preventing medical errors in trauma department is showed. background and aim: missed injuries adversely affect patient outcome and damage physician, as well as institutional, credibility. autopsies are useful in uncovering missed injuries or undiagnosed conditions that contribute to death after injury. the aim of this paper is to analyze and compare medical documentation and autopsies findings in searching for missing injuries in trauma fatalities treated in our hospital. patients and methods: we analyzed data for patients died after trauma in years period (january st, -december st, introduction: immune suppression is a compensatory mechanism in acute inflammation e.g. following trauma. multiple mechanisms underlying this phenomenon include decreased cytokine production, shifts in cytokine balance and unresponsive adaptive immunity. we show in a model of acute inflammation that neutrophils, apart from their established pro-inflammatory characteristics, possess multiple mechanisms mediating immune suppression. methods: healthy male volunteers were given ng/kg e. coli lipopolysaccharides intravenously. blood was taken at various time points. neutrophils were stained with antibodies and isolated by facs. neutrophil receptor-expression, phagocytosis and oxidase were measured. lymphocytes were cultured in the presence of neutrophil subsets and cd /cd or pha. proliferation was measured by incorporation of h. results: distinct neutrophil subsets were identified. - h after administration of lps % of neutrophils displayed a two to threefold decreased expression in innate immune receptors, decreased phagocytosis and oxidase production. another neutrophil subset ( %) inhibited lymphocyte proliferation by % (in the presence of cd /cd or pha) in a : ratio independent of il- , tgfb, arginase or indoleamine - . instead direct delivery of h o appeared to be the mechanism of immune suppression. conclusion: in acute inflammation neutrophils utilize multiple mechanisms mediating immune suppression. firstly refractory neutrophils appear in the circulation. secondly another population of circulating neutrophils effectively suppresses adaptive immunity. these observations dictate an important role for neutrophil-mediated immune suppression following conditions such as trauma, contributing to the susceptibility to infections seen in these patients. sham-group) received a single intraperitoneal injection of either zinc protoporphyrin (znpp), an ho inhibitor, hemin, an ho- inducer, or vehicle. h later, rats were anesthetized and subjected to hts, including bleeding, laparatomy, and reperfusion (inadequate and adequate phase) and were sacrificed h later. ho- mrna was determined by real-time pcr and ho activity was determined in liver homogenate. free iron was measured by electron paramagnetic resonance spectroscopy in nonhomogenized liver tissue. ho- mrna was elevated only in the hts-group pretreated with znpp versus the sham-group. ho activity was increased in all hts groups compared to sham groups, with the most distinctive increase seen in the hemin pretreated groups. plasma bilirubin values showed a similar increase in the groups pretreated with hemin. no significant difference was found in free iron concentration among all groups. our data show that changes of ho activity prior to hts are not associated with elevated free iron, late after reperfusion, suggesting that free iron released from ho is efficiently deactivated. introduction: cells of the innate immune system are essential in the development of inflammatory complications. the activation status of this system can be determined by analyzing expression activation markers on neutrophils in peripheral blood. our research group previously showed that a combination of these receptors, the 'priming score', reflected the inflammatory status of individual patients. hypothesis: systemic activation of the innate immune system attracts functional neutrophils into damaged tissues. dysfunctional neutrophils stay behind in the circulation, causing a paralyzed innate immune system and increased susceptibility to late onset sepsis (> days objectives: our study objective is to stratify risk factors of the second (within hours) and third peak (within days) of trauma death independently. materials and methods: , records from japan trauma data bank were retrospectively analyzed. as outcomes for the analysis, we defined the early and delayed death as deaths within days and those after days, respectively. based on the framework of trauma injury severity score (triss), coded glasgow coma scale (cgcs), coded systolic blood pressure (csbp), coded respiratory rate (crr), injury severity score (iss) and coded age (cage) were used as independent variables to determine the outcomes using proportional hazard analysis. conclusions: in our observation, statistically-significant risk factors of early and delayed trauma death differed. physiological severity largely affected the second peak. in contrast, the third peak mainly correlated to anatomical severity and elderly in age compared to risk for the second peak. especially, an initial hypotension might no longer affect the third peak of trauma death independently. regression analysis including all the parameters of rts as explanatory variables showed the odds ratios of categorical sbp variables predicting the inhospital death. results: a total of , records matched the inclusion criteria. score- , , , , a and b in sbp subcategory consisted of , , , , , , and patients, respectively. inhospital mortality of score- , , , , a and b were , , , , and %, respectively. after adjustment for rts, the odds ratios for the inhospital death of score- , , , , a and b were . , . , . , . , . (reference) and . , respectively. isolated head trauma were more frequent in score- b compared to score- a ( vs. %, p < . ). conclusion: a trauma patient with systolic hypertension ‡ mmhg is scored points in sbp category under rts rule, however, exposed to higher mortality rate similar to patients with points in sbp subcategory and maybe related to isolated head trauma. author to editor: to whom it may concern: we have received a e-mail replied from abstractagent.com which alert the exceed in limitations of abstract submission. the e-mail noticed us, the presenting author of this abstract (akira endo) posted or more abstract as a presenting author, however, the authors of ''increased mortality in trauma patients with systolic hypertension'' believed that akira endo in department of accdm, tmdu, japan surely posted this abstract only. the name ''akira endo'' is common in japan. we suppose that ''akira endo'' of the other institutes were doublecounted. editor to self: seçilmiş bildiri background: the united arab emirates (uae) is developing rapidly, with many foreign construction, farm, and industrial workers at risk of injury. aims: to assess external causes, risk factors, severity, and anatomical region of work-related injuries using a trauma registry. methods: surgical admissions / to / were recorded in the registry at the main trauma hospital in al-ain region, population , . prevention-related variables were analyzed using spss and severity quantified by injury severity scores (iss). results: there were work-related injury hospitalisations, equating to an incidence of about / , workers/year. males accounted for %, ages - years %, and nonnationals %, with % of workers from the indian sub-continent. external causes included falls %, falling objects %, powered machines %, animals %, burns %, and other %. at least % of falls were from relatively high levels. median iss was for all six main external causes. extremities were most frequently injured. mean hospitalisation was . days. % (n = ) were admitted to the intensive care unit and % (n = ) died after admission. conclusions: main external causes were proportionately much more frequent than in industrialised countries, and admissions prolonged. priorities include effective countermeasures for falls from height and falling objects, and for machinery injuries. improved work injury data, access to occupational health services, specific regulations and frequent inspections at all construction sites, workshops, and farms, together with appropriate penalties for safety violations, are essential to reduce incidence and severity of occupational injury among vulnerable migrant workers in the uae. introduction and objectives: immobilization of the spine in trauma patients at risk of spinal damage is performed using a rigid long spineboard or vacuum mattress both during pre-hospital and inhospital care. however, disadvantages of these immobilization devices in terms of discomfort and tissue-interface pressures have guided the development of a new soft-layered long spineboard. we compared tissue-interface pressure and degree of comfort during immobilization on a rigid spineboard, a vacuum mattress and a newly developed soft-layered long spineboard. methods: in this randomized cross-over trial, volunteers were immobilized sequentially on all three devices for min per device. tissue-interface pressures were measured using an xsensor pressure mapping device, including the peak pressure and the peak pressure index (ppi). comfort was rated on a visual analogue scale (vas) after min and after min of immobilization. results: tissue-interface pressures were significantly higher on the standard long spineboard and the vacuum mattress than on the softlayered long spineboard. ppi for the sacrum on the soft-layered long spineboard was significantly lower than on both other devices, with an average ppi close to normal diastolic blood pressures. the participants reported significantly more comfort on the soft-layered long spineboard compared to the rigid long spineboard, both after and min (p < . ). conclusion: using the soft-layered long spineboard, which imposes less pressure on the tissue and provides better comfort than the standard long spineboard and the vacuum mattress, means buying time to optimize the patient's treatment while minimizing tissue damage. background: trauma and emergency surgery models differ all across europe. no definitive model was accepted and work and surgical emergency load are different in each region. we performed a cohort study to analyze the impact of emergency (including trauma) surgery in the general surgical practice at a portuguese university hospital. methods: data on emergency surgical cases and admissions to the surgical service over a -month period were collected and analyzed; this included patient demographics, referral sources, diagnosis, operation, and length of stay (los conclusion: emergency workload represents a significant part of the work for the general surgeons. the emergency surgical cases and admissions had a significant impact in the mortality rates of the general surgery admissions. resource planning and training should be based on more comprehensive, prospective data such as these. background: the long-term health outcomes and costs of helicopter emergency medical services (hems) assistance remain uncertain. the aim of this study was to investigate the cost-effectiveness of hems assistance versus emergency medical services (ems). methods: a prospective cohort study was performed at a level i trauma centre. quality of life measurements were obtained at year after trauma, using the euroqol- d as generic measure. health outcomes and costs were combined into costs per quality-adjusted life year (qaly). results: the study population receiving hems assistance was more severely injured than that receiving ems assistance only. the incremental costs for intramural care were e , for hems treated patients compared with patients treated by ems only, which was mainly determined by the costs of the intensive care stay and the used diagnostics. finally, the costs for hems assistance instead of ems assistance were e , per qaly. the sensitivity analysis showed a cost-effectiveness ratio between e , and e , . conclusion: the costs per qaly for helicopter emergency medical services in the netherlands remain below the acceptance threshold. therefore, hems should be considered as cost-effective. author to editor: this study describes the long-term health outcomes and costs of helicopter emergency medical services (hems) assistance. it investigates the cost-effectiveness of hems assistance versus emergency medical services (ems), and may serve as a reference for future quality of life and cost-effectiveness studies on the subject of hems and severely injured patients introduction: in usual multi-trauma care (utc) each partner has its own ''autonomous'' treatment perspective. clinical evidence, however, suggests that an integrated multi-trauma rehabilitation approach ('supported fast-track multi-trauma rehabilitation service': sftrs), featuring earlier transfer to a specialised trauma rehabilitation unit; earlier start of 'non-weight-bearing' training and multidisciplinary treatment; early individual goal-setting; co-ordination of treatment between trauma-surgeon and physiatrist, may be more (cost-)effective. the feasibility of a multi-centre trial examining the (cost-)effectiveness of sftrs was assessed. methods: data from multi-trauma patients (iss ‡ , complex multiple extremity injuries or complex pelvic fractures) were inventoried. patient characteristics, trauma severity, quality of life, health status, anxiety and depression, and cognitive functioning were assessed in two dutch trauma centres providing utc or sftrs. results: no differences in patient characteristics', trauma severity or discharge destination were found between sftrs and utc. discharge destination was 'home' ( . %), 'rehabilitation clinic' ( . %), 'nursing home' ( . %), 'other hospital' ( . %), 'unknown' ( . %). . % of patients died. however, hospital length-of-stay differed: . (sd: . ) days (sftrs) and . (sd: . ) days (utc). conclusion: adequate patient numbers may be recruited, baseline patient characteristics did not differ between collaborating centres, hospital length-of-stay was reduced in sftrs and adequate patient follow-up is possible. based hereupon, a nonrandomised multi-centre clinical trial started. (isrctn ). the trauma-region of north-west netherlands has consensus criteria for mobile medical team (mmt) scene dispatch. the mmt can be dispatched by the ems-dispatch centre or by the on-scene ambulance crew and is transported by helicopter or ground transport. although much attention has been paid to improve the dispatch criteria, the mmt is often cancelled after being dispatched. the aim of this study was to assess the cancellation rate and the noncompliant dispatches of our mmt, and to identify factors associated with this form of primary overtriage. methods: we conducted a retrospective case review of consecutive mmt-dispatches during a months period. by means of chart review, data pertinent to prehospital triage, patient's condition onscene and hospital course were collected and analyzed. all dispatches were evaluated by using the mmt-dispatch and mission appropriateness criteria results: median age was . years and . % of the patients was male. of these, patients were trauma victims ( . % blunt trauma). after being dispatched, the mmt was cancelled times ( . %). statistically significant differences between assists and cancellations were found for overall mortality, mean rts, gcs, and iss, mean hospitalization and amount of icu admissions (p < . ). almost % of all dispatches were neither appropriate, nor met the dispatch criteria. fourteen ( %) missions were appropriate, but did not meet the dispatch criteria. conclusions: nearly a half of mmt-dispatches were cancelled and almost % did not meet the dispatch criteria. dispatch criteria for the mobile medical team in our trauma-region need further refinement and compliance. the ''traumax Ò '' hip screw plate is a new device that allows the treatment the fractures both of the neck and the trochanteric area of the femur, expected subtrochanteric area. this plate conserves the characteristics of a dynamic hip screw (compression of the fracture site, good positioning of the pieces of bone, integrity of gluteus muscles) more specific characteristics: this device is modular, allows to choose the length of the barrel adapted to the length of the head screw, the diaphysal screws are locked by a tech nut according to the patented ''surfix'' system. the locked screw gives a good stability even if the bone has a poor density and allows to use a short plate that preserves the piercing lateral vessels of the femur. this short modular screw plate can be implanted by a cm minimal invasive approach using a particular instrumental pipe. during the presentation we will report the results of a prospective study colligating cases of ten french hospitals. a preliminary study of consecutives cases gives prominence to a few blooding with an average of ml, a operative time of an average of mn, a xr exposing time of an average of s. healing bone has been obtained in all cases. the head screw has been placed at the center or just below in %. no complication dues to the plate has been reported; in all cases only one approach has been used. aim: to assess moderate-term outcomes of silastic joint replacements of the first metatarsophalangeal joint. methods: the patients ( feet) that had silastic implants inserted were reviewed at an average of years and months (ranging months to years and months). the mean patient age was years. these patients answered a subjective questionnaire, had their feet examined clinically and radiographically and a pre-operative and post-operative aofas score was calculated for each. results: the questionnaire revealed that every patient described that their pain had decreased after surgery and feet ( %) were completely pain free. there was a significant improvement in patients' subjective pain scores after surgery (t value £ . ). preoperatively, the mean pain score for all feet was . , whereas post-operative the mean pain score was . . the mean aofas score before surgery was . . this increased to a mean score of . after surgery (p £ . ). this again is a significant improvement. no patient was dissatisfied with the outcome with their surgery. conclusion: these moderate term results are encouraging, with good subjective and objective results. however, long-term follow-up will be required to assess the longevity of this implant • theatre staff should be trained for proper application and cleaning of the exsanguinators • alcohol wipes are good alternative to current practice and should be used for decontamination • we must wash our hands before and after its use • we should use plastic bag over the limb first before using the exsanguinators it is presented one new minimally invasive method for closed fracture reduction and one extramedullary selfdynamisable internal fixator developed by the author. there is no contact between bone and internal fixator in fracture area. it has been widely investigated biomechanically. in clinical use it has been applied to , patients in treatment of femoral fractures. the age of patients was from to years. this internal fixator is applied by two small incisions. reduction is achieved using standard traction table or using special reduction device. this reduction device provides possibility of reduction with minimal using of fluoroscopy or even, after more experience without using of any imaging technique as fluoroscopy, ultrasound or computer navigation. received clinical results are promising, as it has been shown early callus formation and radiological union within the - months. it has been allowed to patients early full weight bearing. during the treatment it has been confirmed working of self-dynamisation concept, which probably all together with d configuration resulted in unexpectedly quick fracture healing. follow up was months ( - ). according to results obtained, it can bee concluded that new biological internal fixator is suitable for minimally invasive technique, without opening of fracture site. it can be used as primary method or soon after external fixation if damaging control concept used. ( ) ( ) ( ) ( ) ( ) and followed-up for a minimum of years formed the study population. a retrospective review of data from electronic patient record (epr), clinical coding, clinic and gp letters was made. age, residential placement, garden's classification of fracture, mode of injury, associated comorbidities, pre-admission mobilisation status, allergies, addictions and anticoagulation status details were collected. an indepth study was conducted to look into delays for surgery, length of stay in hospital, complications and treatment of these complications. reasons for re-admissions, re-operations and comorbidities developing as a result of these interventions was critically analysed. results: the mean age of patients was years (range - years). the incidence of non-union was % and avascular necrosis at year was %. revision surgery was performed in ( %) cases. complications were more principally in patients who had end-stage renal failure ( %), diabetes mellitus ( %), osteoporosis ( %), and steroid use ( %). conclusion: the complications and revision surgery rate was high in patients with particular co-morbidities despite being undisplaced. comorbidities and patient's age were also strong predictors of healing in addition to fracture configuration. outcome of hip fractures is influenced by complex interplay of multiple factors and not only by radiographic appearance. methods: this is a -year of retrospective study. we had included patients to our study ( females and males) with the average age of . . we used bryan and morrey classification system and included type i and type iii fractures. results: there were type i and three type iii fractures. associated injuries were two dislocations with one mcl injury and two radial nerve symptoms. all the patients had orif with screw and two patients had supplementation of fixation with wires. most patients were mobilized early in weeks time. nine of them treated with miniacutrak screw fixation, four with herbert screws and one lag screw (ao miniscrew). the approach was mainly postero-lateral but for five patients, it was antero-lateral. all patients were clinically and radiologically assessed. average time for radiological union was weeks. on the other hand, one patient had revision fixation because of failure of metalwork. additionally, one patient had capsular release for contraction and another one had removal of screw for prominence of metalwork. average follow-up was . months ( - months). mayo elbow score was excellent for seven patients, good for three patients, and fair for three patients. one patient could not be fully scored due to learning difficulties. we recommend open reduction and internal fixation for all type and type fractures so that function can be regained early. objectives: to report the outcome and comparison of calcaneum fracture managements for intra-articular fractures. methods: a prospective study of the patients with intra-articular calcaneum fractures in the foot&ankle unit of a busy trauma hospital. all the patients were followed up with the calcaneal fracture score. we compared the outcome of surgical management sanders type (group a) and type (group b) fractures with conservative treatment (group c) at years and assessed the medium term outcomes of groups a and b. group c were a consecutive series of patients recruited to the study later than a and b, hence the smaller number in that group. results: patients were included in our study. there were in group a, in group b, and in group c. mean follow-ups for the groups were a = years, b = . years, and c = . years. mean -year scores for the groups were a = . , b = . , and c = . , with statistically significant differences between groups a and c (p = . ), and between groups b and c (p = . ), but no significant difference between groups a and b. at medium-term follow-up (> years), the scores for group a and b were . and . , respectively. there were deep, superficial infections and metalwork removals in total. conclusion: on comparing the medium term outcome to the -year one, group a showed some improvement and group b stayed the same. in this series, contrary to published articles, there was a better outcome at years with surgical treatment than conservative treatment. author to editor: all the authors have agreed with content of the abstract. there was not any conflict of interest for this study. objective: to assess the effectiveness of mobile angiography with a digital subtraction angiography (dsa) technology directly into the emergency room (er) for blunt trauma patients with pelvic injury. materials-methods: this is a retrospective review of a cohort of blunt trauma patients with pelvic injury treated after the direct availability of mobile angiography by trained trauma surgeons into the er for resuscitation. data was collected including demographics, hemodynamic variables, resuscitation intervals form admission through completion of hemostasis, metabolic factors (ph and body core temperature), mortality and transcatheter arterial embolization (tae) related complications. results: twenty-nine patients underwent tae in the er. mean age, shock index, and injury severity score were ± years old, . ± . , and ± , respectively. the interval from the decision to perform tae through initiation of tae and the interval from the decision to perform tae through completion of tae were ± min and ± min, respectively. the mean dbody core temperature (bt) from admission through completion of tae was - . ± . °c. and the mean dph from admission through completion of tae was . ± . . there were clinically significant correlations between dbt and resuscitation interval, and between dph and resuscitation interval. tae was successfully performed in all cases and mortality was %. no tae-related complications were observed. conclusion: immediate availability of mobile angiography into the er by trained trauma surgeons was effective to shorten the time required to restore normal physiology of trauma patients with pelvic injury without leaving the er for resuscitation. introduction: tgf-b is a regulatory protein, involved in fracture healing. the purpose of this study was to investigate the role of tgf-b in human fracture healing, and to verify whether tgf-b is a reliable marker of nonunion. methods: serum samples of patients with long bone fractures were collected over a period of months. patients were assigned to groups: first group contained patients with physiological fracture healing. eleven patients with nonunions formed the second group. healthy volunteers served as controls. results: in patients with physiological healing serum concentrations were initially high. serum concentrations then decreased rapidly after weeks and reached a plateau between weeks and . thereafter, another continuous slight increase of the concentrations was observed between weeks and . in patients with impaired fracture healing tgf-b serum concentrations were initially similar to those with normal healing. a significant increase of the concentration was observed between weeks and , followed by a continuous decline of the serum levels for the remainder of the observation period. significant differences between the concentrations in both groups were observed at weeks and . tgf-b as marker would have detected patients with nonunions at weeks after fracture with a sensitivity of % and a specificity of %. distal metaphyseal radial fractures are extremely common fractures in children (% , ). high rates of displacement occurs during conservative treatment. the aim of this study was to determine the effect of kirschner wire application after closed reduction of radial metaphyseal fractures with high risk of redisplacement. in this retrospective study cases were studied in two groups. in group (n = ), k-wire applied after closed reduction. in group (n = ), only cast was applied following closed reduction. the mean follow-up was months. the compared clinical and radiological parameters were; pain, limb deformity, range of motion of the wrist, angulation of the fracture site, radial distal epiphyseal angle and severity of translation. redisplacement rate was % in group and % in group . this shows, kirschner wire fixation had a positive effect in continuity of the initial reduction (p = . ). age (p = . ), gender (p = . ), reduction quality (p = . ) had no effect on redisplacement. concerning the severity of translation, the risk of redisplacement increases in stage ( - %) and stage (> %) fractures (p = . ). concomitant complete ulnar fracture had also redisplacement risk (p = . ). redisplacement risk increases when the distance of fracture line to epiphyseal line was between and mm (p = . ). there was no significant difference between two groups after last evaluation based on radiological parameters and clinical results (p > . ). as a conclusion; this study shows that kirschner wire fixation prevents redisplacement in early follow-up of first weeks but there is no superiority after months follow-up in distal metaphyseal fractures of children. patients in group c showed the best functional results, the greatest ankle range of motion, the fastest full bearing, the fastest walking on toes and heels, and the shortest duration of physical limitations (walking on uneven ground and sports activities) (p < . for all). in group b, there were two reruptures, in group c one, and in group a there were no reruptures. good functional results and a relatively small number of postsurgical complications advocate the usage of surgical techniques. the best and fastest functional recovery was attained in the group treated with the original technique of percutaneous fixation with two embracing and crossed loops. open surgical reconstruction is indicated only in the case of rerupture after percutaneous suturing. introduction: there are different techniques for arthrodesis of endstage arthrosis of the ankle-joint. internal fixation is the favoured method in many institutions. we retrospectively examined the technique and clinical results of external fixation in a triangular frame. patients/methods: from to a consecutive series of patients with end-stage arthritis of the ankle joint was treated. mean age at the index-procedure was . years, patients were male ( . %). via a bilateral approach the malleoli and the joint-surfaces were resected. an ao-fixator was applied with steinmann-nails. follow-up examination at mean . years included a standardised questionnaire and a clinical examination including the criteria of the aofas-score and radiographs. results: in two cases, due to contracture a pes equinus position had to be accepted. in two cases a further bone transplant was performed at and weeks for unsatisfactory bony union. after mean . weeks, radiographs confirmed satisfactory union and the fixator was removed. in four patients a nonunion of the anklearthrodesis developed ( . %). the mean aofas score improved from . to . points. statistical analysis of the insurance status showed that patients insured under a workers injury compensation scheme had a mean score of . compared to . for the remaining (p = . ). discussion: nonunion rates and clinical results of arthrodesis by triangular external fixation of the ankle joint do not differ to internal fixation methods in literature comparison. the complication rate and the reduced patient comfort reserve this method mainly for infected arthritis and complicated soft tissue situations. implants with multidirectional locked screws have theoretical advantages in the treatment of periprosthetic fractures. in osteoporotic bone they provide a high stability. we concluded a retrospective study of a consecutive series of the outcome of vancouver b and c femoral injuries using two specific locked-implants. from to we treated patients with a periprosthetic fracture of the femur with a locked plate. the mean age at the index procedure was . years, patients were female ( %). in cases ( . %) we saw a hip endoprosthesis, in cases ( . %) a knee endoprosthesis and in cases both ( . %). outcome measures were intra-and postoperative complications, bony union, degree of mobility and social status, barthel-mobility-index and ''stand-up&go'' test. union occurred in cases ( . %) after the index procedure. twice the implant failed, we saw four general complications. the mean duration until full weight bearing status in these patients was . weeks. at follow-up patients ( %) had maintained the same social status as before the fracture. regarding the mobility status patients ( %) had regained their previous level, patients walking without aid before now required a cane and patients a walking frame. the mean barthel-index was points of . the mean stand-up&go time was measured as seconds. conclusion: overall failure rates of osteosynthesis after periprosthetic fractures of up to % are reported ( ). with . % implant related failures and % general complications, the presented methods achieve bony union and mobility in a high percentage of cases. arthroscopic-assisted percutaneous figure introduction: we describe a new arthroscopic-assisted reduction and percutaneous tension band wiring technique for patella fractures that combines the advantages of minimally invasive surgery and stable internal fixation. surgical technique: we reduce the fracture percutaneously by towel clips with the patient in the supine position. we insert two . mm kirschner (k) wires in a caudocranial direction under arthroscopic control. we do four stab incisions to assign the inferolateral (il) and inferomedial (im), superolateral (sl) and superomedial (sm) portals besides the k wire tips. we insert a trocar with its cannula from sl portal to sm portal under the k wires. we take the trocar out and leave the cannula inside. we run -gauge cerclage wire through the cannula in sl to sm direction. we take out the cannula. we perform exactly the same steps directed from sm portal to il portal, from il portal to im portal, and from im portal to sl portal, respectively. finally near the sl portal, wires are secured with a single knot. we check the fixation by c scope. results: radiographic consolidation was achieved in all five patients at an average of months. all patients returned to the activity level previous to fracture. conclusion: this technique presents advantages over open techniques. it is minimally invasive and cosmetically pleasing, permits visualization of reduction and stability, allows concomitant intraarticular pathology to be exposed, and facilitates early rehabilitation. although we did not attempted yet, we believe that even comminuted fractures can be fixed with this technique. ( ) timing of the procedure, ( ) accurate technique, ( ) stable implants for early mobilisation. in this study we present our experience in the treatment of ftp with locking plates trying to define the role of a medial plate. materials and methods: from to we treated patients with a ao c ftp by orif with locking plates. indications for a medial plate were: involvement of the medial joint surface, coronal fracture of the medial plateau and irreducible dislocated medial condyle. all the patients have been followed up clinically with the lysholm and rasmussen scores and radiographically until consolidation. results: all fractures united. one patient underwent knee amputation for septic complication. the mean lysholm score was ''fair'' while the rasmussen score was ''good'', that means that the subjective result was worse than the objective one. patients treated by double plating had a worse clinical result that was not dependent on the quality of reduction. we had three cases of malalignment, one rsd, two superficial infections, two transient nerve palsy. conclusion: complications in our series were frequent and the clinical results not particularly good. the right timing and an accurate surgical technique are essential for a good reduction, newer implants control effectively the fragments but the high energy of the trauma remains the major determinant of the bad outcome of these fractures. introduction: the high percentage of failure of fixation systems in periprosthetic fractures depends on the technical difficulty of the procedure, the presence of the cement mantle and the poor quality of the remaining bone. the lcp system offers an enhanced stability that reduce the implant mobilization, and preserves the bone vascularity, fastening the healing time. we present our results in the treatment of periprosthetic fractures with lcp. materials and methods: consecutive patients with vancouver b fractures were operated on using . lcp. a standard open reduction of the fracture through a lateral approach was used. patients were evaluated clinically and radiologically for a mean follow up time of . months. results: all the fractures united except two where a narrow . plate and too many cerclage wires around the fracture were used. all the patients showed at fu an hhs over points. the anatomical reduction of the fracture led to a faster healing. conclusions: the effect of the position of screws and cerclages in relation to the plate and fracture are discussed. the authors conclude that lcp system, has to be considered the golden standard in the osteosynthesis of vancouver type b periprosthetic hip fractures, permitting early weight bearing and healing in physiological time. it is better to avoid narrow . plates and cerclages at the fracture site. suggestions on the plate length and screw and cerclages position are given depending on the fracture type and length. the role of the anatomical prosthesis in the treatment of proximal humeral fractures ló ránt bardó cz, jános csotye pá ndy ká lmá n county hospital, gyula, hungary, traumatology introduction and objectives: we would like to present the results of the treatment of proximal humeral fractures with endoprosthesis. methods: between and we operated patients with endoprosthesis for proximal humeral fractures. were delta prosthesis, the results of these operations are the subject of an other presentation. patients were treated with anatomical shoulder prosthesis. the results of these were controlled by personal examination (constant score, x-ray) and by the base of the clinical documentation. was hemi-and total endoprosthesis. in cases the operation was acute and in cases for chronic cases. the average follow up time was . month. we categorized our patients in different groups, based on the fracture type and the time of the surgery. results: we compared the cs of the operated shoulder with the contralateral one in each patient group. we have to accentuate the importance of patient cathegorization, because the results can be analyzed properly only on base of these. on the x-rays the prosthesis were in good place, we found no evidence of losening. conclusions: when the indication is good, the prosthetic procedure is the choice for acute or chronic fractures of the proximal hunerus, and the results are good. we confirmed the statistically significancy of the efficacy of the treatment methods between the same analyzed groups. aim: to discover if how often lateral x-ray change the management of fracture neck of femur fractures as an adjunct to the standard ap film. method: orthopaedic consultants and registrar grade orthopaedic surgeons were asked to decide the management of neck of femur fracture solely from an ap film. at a second sitting the same films were shown in a different order in conjunction with the associated lateral hip x-ray. the surgeons were asked to comment on the adequacy of the lateral x-ray and their choice of management using the both films to make a decision. results: less than half of the lateral hip x-ray were adequate when reviewed on the monitors and very few operative decisions were changed with the addition of the lateral x-ray. conclusion: a standard ap film is usually sufficient to plan management in a fractured neck of femur fracture and the additional time, money, and discomfort of obtaining lateral films does not seem justified in these circumstances. an sermon, stefaan nijs, barbara bosch, paul broos department of traumatology, university hospitals gasthuisberg, leuven, belgium introduction: humeral head fractures extending into the shaft often are a challenge to the surgeon. although they are a rather rare entity, they often occur in osteoporotic bone and are difficult to stabilize. however, because of their intra-articular extension, a perfect reduction and stable osteosynthesis is needed. methods: between august and august , patients with a combined shaft and humeral head fracture were operated in our department. a long philos plate was used in all cases through an extended deltopectoral approach. postoperatively, immediate mobilization was allowed. mean follow-up time was months. results: there were three preoperatively existing radial nerve palsies of which two completely and one partially recuperated postoperatively. there occurred no radial nerve palsies which did not exist preoperatively. revision surgery was necessary in two patients because of hardware failure and secondary fracture displacement within the first week after surgery. in both cases, again a long philos plate was used. all fractures were radiographically healed within months; there were no cases of avascular necrosis of the humeral head. most of the patients were subjectively satisfied with the functional result although mobilization of the shoulder was only moderate in nearly half of the cases. conclusion: in conclusion we can say the use of long philos-plates for the treatment of combined shaft and humeral head fractures gives good results when carried out by experienced hands. osteosynthesis with the use of locked nails is an efficacious method for the treatment of long bone fractures and nonunions of extremities. however, it is contraindicated in case of infection. one way to obviate this problem is to coat implants with antibiotic-loaded bone cement. the objective of this work was to evaluate the efficiency of antibiotic cement-coated interlocking nails for osteosynthesis of long bones in case of infection (infected nonunions) or at high risk of its development (severe open fractures). in - , nails with antibacterial cement coating were used to treat patients including ones with severe open long bone fractures (gustilo-anderson type iiia-iiib). these fixators were employed both at admittance of the patients (with an isolated injury) and within - days after it (in case of polytrauma). patients of this group underwent one-step surgery combining osteosynthesis and the closure of soft-tissue defects with local muscular flaps. in patients with infected nonunions of long bones, osteosynthesis was performed after seeding fistula discharge for microflora. none of the patients in the group with severe bone fractures suffered deep suppuration and all achieved consolidation of fractures. one case of recurrent infection associated with extensive necrosis of bone was documented in the group of patients with infected nonunions. the remaining patients had resolution of signs of infectious process, and their nonunions consolidated. the use of antibiotic cementcoated interlocking nails is a promising method for osteosynthesis of long bones in case of infection and at high risk of its development. author to editor: severe open fractures and infected nonunions are one of the most difficult problems in trauma orthopedic surgery. we had only one treatment option for this pathology down to resent times. it was an external fixator, but it has many disadvantages. in we start using antibiotic cement-coated interlocking nail, and we have promising first results. this results we would like to present in eurotrauma . hawar akrawi, david gordon hargreaves department of trauma and orthopaedics, southampton university hospitals nhs trust, southampton, the united kingdom introduction: we describe our clinical experience with a new posterior approach for reconstruction of distal intercondylar fractures of humerus. the maserati approach comprises of a midline proximal triceps split in conjunction with elevation of medial and lateral edges of triceps from the condylar ridges. this approach gives adequate access for accurate reduction and internal fixation of distal and intraarticular humeral fractures. methods: a single consultant series of patients with distal humerus fractures (ao grade -a to -c) were treated using the maserati approach and distal humeral locking plates over -year period at level trauma centre. all cases were reviewed. there were female and male patients with age range from to year. average follow-up was months. these patients were assessed for: . accuracy of reduction of fracture fragments. . complications i.e. infection, triceps weakness, triceps lag and fracture union. . elbow function as per the mayo elbow performance score (meps). results: nine patients had anatomical reduction. no cases of infection or nonunion. one case of delayed union. none of the patients exhibited triceps lag or weakness. the meps was - (mean ). discussion: the maserati approach is a safe approach that provides good access to the articular surface of elbow without compromising the triceps muscle. triceps continuity is preserved, allowing early rehabilitation without the possible co-morbidities associated with other posterior elbow approaches (non-union of olecranon, triceps weakness or triceps lag). author to editor: dear sir/madam, i will be very grateful if you could offer me the opportunity to give a podium presentation about this innovative approach. patients with distal humeral fractures are difficult to manage and with oral presentation, i will be able to demonstrate clearly, with media presentation, the full advantage of this new approach. results: improvement of the neurological deficit was observed in cases. ct control at least of years follow up shows good bone integration of the iliac crest bone in majority of the cases. two patients experienced temporary neurological symptoms, which showed complete remission. the endoscopic procedure for reconstruction of the anterior load-bearing spinal column developed to a standard concept in trauma management. the minimal morbidity of the operative approach, good visualisation of the operative field and angle stable implant make it possible to restore the anterior column on a safe technique. full weight bearing (painless) ranged (un) - (ø ) and (rn) - (ø ) weeks. x-ray healing ranged (un) - (ø ) and (rn) - (ø ) weeks. there was one patient with delay union( weeks) in un group. there were any infection; loss of reduction; re-operation and nonunion in both groups. discussion: we started this study because many studies before preferred reamed nailing but we have long term experience with undreamed nail with the comparable results (retrospective analyze). our hypothesis is that the biological advantages of undreamed nail should display if the perfect technical performance is done. conclusion: there are no significant differences between un and rn groups in our study in this time. we expect recruiting more than patients by the year end and during next years we will be able evidence the data completely. this work was supported by the research project moofvz septic arthritis following acl reconstruction péter frö hlich zentralinstitution for sportsmedicine, budapest, hungary infection after arthroscopic anterior cruciate ligament reconstruction is an uncommon complication, which could be a danger not only for joint function, but also for the joint integrity. we have to differentiate by the clinical recognition of this complication from swelling caused by other conditions (for example suffusion). there is no standardized opinion and method in the field of arthroscopic or open procedure, or necessity of aggressive graft removing. from a consecutive case series of , patients, who underwent anterior cruciate ligament reconstruction between and . we report on patients with postoperative septic complication. of these were extraarticular, and intraarticular manifestation. our protocol is based on infection severity classification modified by gä chter. reliability and significance level of diagnostic criteria (clinical evaluation, laboratory tests, synovial fluid analysis, and bacterial culture) were analyzed. the outcome was determined by early recognition and consequent treatment. there is only one patient, whose acl tendon graft has to be removed. the ikdc score shows the following result: a: , b: , c: , d: , it proved to be similar to the multicenter studies. in the last years we have no more postoperative infection following acl reconstruction by the application our protocol. we will review this protocol. introduction: early fixation of long bone fractures in the multiple injured patient has been recognized as beneficial in minimizing secondary lung and remote organ failure. although early fracture fixation is expedient in px with multiple injury etc may be associated with post-traumatic systemic complication. in this study all pz from a consecutive series of trauma patients with truama team activation admitted between / and / to department of emergency of niguarda hospital in milan were included when they fulfilled all of the following criteria: directly admitted, iss of more than , and survival of more than h. patients with fracture of long bones and/or pelvis with a clear indication for operative treatment and the necessity of immediate fracture stabilization where treat according with dco. all other patients fulfilling the inclusion criteria with minor fracture or thus not requiring immediate fixation formed the control group. iss, rts and ps was calculated at the admission and reevaluated later by the trauma leader. all injury was classified with ao and gustilo classification conclusion: the goals of dco include stopping ongoing injury including local soft-tissue injury and remote organ injury secondary to local release of inflammatory mediators further thought to prevent pulmonary complications by allowing patients to avoid the enforced supine position. this study was conducted retrospectively to evacuate the effectiveness of the trauma team organization and to evaluate the concept of dco by immediate external fracture fixation and consecutive conversion osteosynthesis with regards to time saving, effectiveness and safety. introduction: injury of the soft tissue results in a release of numerous cytokines, which activate fibroblasts of the surrounding tissue to proliferate and to undergo a phenotypic transdifferentiation into contractile myofibroblasts (mfs). in this study we analyzed the hypothesis, that human joint capsule mfs are specifically regulated by the cytokine ifn-c via the modulation of alpha-smooth muscle actin (a-sma) which is responsible for the contractile phenotype. methods: joint capsules were obtained from patients undergoing orthopaedic surgeries. to investigate the functional effect of ifn-c, we cultured mfs in a three-dimensional ( d)-collagen gel contraction model. an alamarblue assay in combination with the collagen gels was established to analyze the viability and the proliferative capacity of mfs upon ifn-c treatment. the effect of ifn-c stimulation on the gene expression levels of the specific mf markers a-sma and collagen i is going to be determined by real-time pcr (rt-pcr). this part of the study is in progress. results: mfs cultured in the presence of ifn-c show a reduced proliferative capacity. moreover, the addition of ifn-c reveals a dose-dependent decrease of collagen gel contraction. these effects were specifically blocked by a neutralizing ifn-c antibody. first results of rt-pcr analysis show an inhibition of a-sma and collagen i gene expression by ifn-c. conclusions: ifn-c reduces mf viability and contractility in a dosedependent way, presumably by down-regulating mf specific genes. this study suggests that ifn-c might be effective in attenuating the contraction of soft tissue in fibrocontractive disorders. with an average age of . years old were included and a retrospective database study was performed. the outcome parameters we analysed were the radiological outcome, the functional outcome and the prevalence of complications. results: the fracture healed in an accurate anatomical position in all patients treated with esin ( %). seven patients ( , %) suffered from irritation around the entrance opening and in four patients ( . %) the pen migrated medially. in eight cases ( , %), this resulted in a reoperation, consisting of remodelling, reposition or removal of the pen. in two cases we saw a refracture after removing the pen. the overall complication rate was . %. dash scores showed an average functional outcome of . points (range: - ) at . months follow-up. conclusion: operative treatment with esin in dislocated midclavicular fractures offers good mid-term radiological results and a good dash score. the overall prevalence of complications was . % and in . % a re-operation was required. the results found in the available literature showed a re-intervention rate of %. prospective randomised research is required in order to determine the right surgical indications and to find out what the long-term results of this relatively new method of fixation are. aim: our main aim was to find out whether there is a place for nonoperative treatment as a definitive primary option in patients with significant medical co-morbidity. methods: we did this audit in collating information on , hip fracture patients across nhs hospitals in england. out of , ( . %) patients were treated conservatively. results: there were males and females patients managed conservatively in our study. during hospitalisation, became bedridden and died. among these patients, were deemed physically unfit for surgery by anaesthetists and by medical consultants. the decision was made by orthopaedic consultants in ten cases and by multidisciplinary team in four cases. five patients refused surgery and five patients were palliative due to terminal illnesses. patients who did not proceed to surgery had significantly higher mortality rates (overall mortality rate %) suggesting that they were physiologically much worse group of patients. conclusion: as the average life span of our population increases, some hip fractures are now treated nonoperatively because of the possibility of severe or fatal complications due to surgery. often, refusal of surgery by the patient or the patients' family obligates the need for nonoperative treatment. it might be acceptable not to opt for the surgery if the patients are medically very high risk because of these reasons (e.g. acute cardiac event, severe aortic stenosis, multiorgan failure etc). the burden of patients with pubic rami fractures seems to be increasing. more patients with pubic rami fractures are admitted to hospital due to the absolute increase in the number of elderly people. although pubic ramus fractures are generally considered a benign fracture for its inherent stability experience indicated that this fracture is accompanied with a high morbidity and mortality. in a case-control study patients aged over years old with an isolated single fracture of the pubic rami admitted to the hospital were compared for morbidity and mortality to age-and gender matched hospitalized patients without fractures. data was acquired by the patient files. during years patients, with a median age of . (range: - ) years, were admitted with a median length of stay of days (range: - ). the mortality rates of patients with isolated pubic rami fractures at , , and years were significantly higher in the patient group compared to our control group, being: . , . and . %, respectively (p < . ). one third of the mortality is explained by cardiovascular events. during hospital admission a complication rate of . % was found, which was mainly caused by infectious diseases, including urinary tract infection and pneumonia. thirty-three percent of the patients (temporarily) went to a nursing home, because of the incapability to mobilise independently. in conclusion, patients admitted to the hospital for an isolated pubic ramus fracture have significant morbidity and mortality both during hospital admission and during -year follow-up. purpose: comminute fractures of the radial head are challenging to treat with open reduction and internal fixation. radial head arthroplasty is an alternative treatment. the purpose of this study was evaluating our results of a closely followed cohort of patients in whom an unreconstructible radial head fracture had been treated with modular pyrocarbon/metallic prosthesis. methods: from may to september , patients were operated for traumatic injuries in elbow. there were female and male with mean age ( - years). the follow-up was a mean of months ( - months). fractures of the radial head have been classified by mason with a subsequent modification by johnston. the indication for a radial head replacement are comminuted type iii fractures in cases, type iv in cases, and monteggia variant with olecranon and radial head fractures in cases. results: by using the mayo elbow score, patients had good/ excellent results, with fair and poor outcomes. patients showed an average arc of motion from - º to º. complications were three implant dislocations, needed to remove the implant. asymptomatic radiographic heterotopic ossification in elbow was showed in one case and bone lucencies were found in seven cases. we had not seen persistent instability, infection, synostosis, loosening, severe degenerative changes or impingement. conclusion: the treatment of unreconstructible comminute radial head fracture with noncemented pyrocarbon radial head implant usually gives an optimal result depending on the severity of the initial injury and the presence of associated injuries. methods: this retrospective clinical study is a follow-up examination of bony avulsion fractures of the intercondyloid eminence in adults and adolescents treated in our hospital in the last years. after the medical history was recorded, the course of the accident and type of injury was documented (classification according to meyers and mckeever) . also the type of treatment (conservative, arthroscopic surgery or open surgery) and accompanying injuries were analysed. the clinical follow-up examination took place after more than months after the trauma. during the face-to-face interview, physical and radiological examination, the knee function, and especially the stability of the knee-joint were assessed. furthermore the clinical outcome was determined using the lachmann-test and the lysholm-knee-score. results: the patient group consisted of male and female patients aged - years. the patients showed subjective and functionally predominant good to very good results. despite subjective stability and absence of pain, in some patients remained a mild hyperlaxity of the anterior cruciate ligament. conclusion: fractures of the intercondyloid eminence are a rare but serious injury of the knee. the correct diagnosis, classification, and curative treatment of the fracture is indispensable for the flawless function and stability. an individual approach is necessary in every patient. distal radius fractures are typical and frequent fracture of elderly woman with reduced bone density. the angle stable plate, often also multidirectional is today the most common stabilisation device. because of the introduction of bulky and bended implants as the micronail or targon dr we decided to test the xs radius nail witch is a , mm or , mm straight nail and witch is introduced after guide wire placement and over drilling with a cannulated drill of the same diameter. it is locked parallel to the joint in different directions with angular stability with threaded wires. methods: radius sawbones were osteotomised corresponding to a a fracture and stabilised with a angle stable plate ( ) and xs nail ( ). , alternating load cycles from - n were performed and the deformation was registered. also a fe analysis with the msc patran/marc software were performed. both types of osteosynthesis showed good stability. the deformation of the xs group however was % lower. also the calculated deformation in the fe study was % lower. also deformation amplitude was lower with . mm compared to . mm in the plate group. the differences however were not significant. both devices show good biomechanical results. the xs nail has the advantage of mainly intraosseus position, simple operation technique with introduction over a guide wire from the proc. styloideus radii and over drilling with a cannulated drill of the same size. the exposure of the n rad.superf. must be performed. first clinical evaluation is presented. angioembolization in severe pelvic fractures: experience of a tertiary centre in united arab emirates results: twelve patients (all males) having a median (range) age of ( - ) years were studied. five were vehicle drivers, four passengers, two pedestrians, and one fall from height. seven had abdominal tenderness while four had abdominal guarding. median (range) systolic blood pressure before angioembolization was ( - ) mmhg and ( - ) mmhg after embolization. nine patients had unilateral internal iliac artery embolization, one had embolization of the pubic bone artery, one had pudendal artery embolization, and one had bilateral iliac embolization and liver embolization. six patients had external fixation of the pelvis after the angioembolization. three patients had a laparotomy, the first had intraperitoneal urinary bladder rupture which was repaired, the second had pelvic packing and diverting colostomy for a severe perineal wound, the third had a liver injury and died on the table. one patient had a thoracotomy with interposition aortic thoracic graft. eleven were admitted to the icu having a median (range) icu stay of ( - ) days. the overall median (range) hospital stay was ( - ) days. only one patient died ( . %). conclusions: angioembolization of severe pelvic fractures with haemorrhage was successful in % of cases and played an important role in the initial management of severe pelvic fractures with haemorrhage. there were nine female and eight male patients passed with a mean age of . years. the knees were assessed at regular intervals and the mean follow-up period was . months (range - ). after initial assessment to confirm absence of trochlear dysplasia, the technique involves plication of the medial retinaculum with a nonabsorbable suture passed percutaneously using a long curved needle under arthroscopic vision and a small incision to bury the knot from the plication. post operative rehabilitation was done with flexion restricted to °for the first weeks followed by a gradual return to normal range of movements with vastus medialis obliquus strengthening exercises. results: patients reported good outcomes with no further episodes of dislocations. one patient who had persistent patellar instability requiring further distal bony-realignment procedure to achieve stability. none of the patients had major complications. conclusion: we report good results with this relatively simple technique of medial retinacular plication and would advocate it as an effectiveless invasive surgical option for patients with recurrent patellar instability in the absence of major trochlear abnormality or significant mal alignment. in a lateral (group a) and in a prone position (group b) with no significant difference in age ( . / . years) as well as pre-and insurgery parameters; no patients were excluded. the complication rate was analyzed by medical records, the radiographic outcome by plain x-rays and ct scans after an average of months postoperatively. comparison of the two patient groups utilized t-tests or chisquare testing of pearson as determined by number of data points for each variable assessed. results: the adequacy of fracture reduction had significantly poorer findings according to matta in a (p = . ), resulting in a significantly higher post-traumatic arthrosis rate (p = . ) defined as helfet iii or iv. no revision surgery was needed; no infection was detected in any group whereas iatrogenic nerve damages ( temporary, persistent) were found only in a. there was no significant difference concerning extensive blood loss, femoral head necrosis, epstein grades, heterotopic ossification classified by brooker and secondary surgery needed. conclusions: due to gravity the femoral head in the lateral position may constrain reduction leading to an inferior radiographic outcome. purpose: the incidence of fracture neck of femur (nof) has been increasing worldwide, due to an aging population. the commonest forms of analgesia are opioids and in some units regional blockade. but regional block is skill dependent and opiates are known to have many side effects. paracetamol is an analgesia that is safe and has an excellent side-effect profile within standard doses. intravenous paracetamol has a far higher predictable bio-availability than oral, within standard dosage. this study is to assess the suitability of using intravenous paracetamol as an alternative. method: prospective study: a change in protocol resulted in all nof's admitted under the care of the senior author being prescribed regular intra-venous paracetamol within standard dosage. prn opioids were available for breakthrough pain. nof's admitted under the care of other consultants remained on the established protocol. opioid usage and pain scores ( - ) were measured. results: results of patients were collected, in intravenous paracetamol group and in the original protocol group. there is a % reduction in opiate usage in the intravenous paracetamol group (p value = . ). there is only a . difference in average pain score between groups (p value = . ). conclusion: the use of regular intra-venous paracetamol results in a significant reduction in the need for opioid analgesia. the pain relief within this group was comparable to that in the control group. a simple change in analgesia protocol to a safer, more predictive agent can result in an improved pre/postoperative period. author to editor: funding: the study received no funding from any source. external fixation has already became on the end of last century as routine temporarily method of fracture bone fixation, especially in the light of damage control. but out of damage control, external fixation has been accepted in many developed countries as routine temporarily method in treatment of complex articular fractures (knee, ankle, elbow). the main reason was absence (night time, weekend) of experienced surgeon who can treat these complex particular fractures, as during the night. sometimes, the skin problem can prolong such fixation for three or more weeks. however, external fixation of tibia and distal radius can be method of choose for definitive treatment not only in open but in closed fractures as well. it becomes justified when high mobile and relatively simple external fixation devices have been developed allowing addition correction of reduction. in this paper, we want to present possibility of using already applied, external fixation device as temporarily method. about week after external fixation done (on femur or tibia) we developed technique existing external fixator to be used as a reduction device. once, desirable fracture reduction achieved, internal fixation is very easy and we do not need fluoroscopy control for reduction, just for internal device fixation by minimally invasive method. using this method, we already treated patients with femur fractures and with tibia fractures. from results obtained it can be concluded that external fixator developed by mitkovic is suitable to function as accurate fracture reduction device providing condition for simple minimally invasive internal fixation. results: with the antegrade nailing technique the mean postoperative constant score was . (flexion . °m abduction . °, pain . ). the elbow extension was free in . %. a correct axial alignment was found in %, in % we found a varus deviation of °- °. in % the nail perforated. in complications there was one prolonged bone healing, one pseudarthrosis and one infection. two thirds of the patients were very satisfied with the outcome. in the retrograde nailing technique the mean postoperative constant score was . (flexion . °, abduction . °, pain . ). the elbow extension was free in . %. only % of the patients showed a mild discomfort at the operative approach at the elbow. a correct axial alignment was found in %, in % we found a varus deviation of °- °. in % patients showed a postoperatively detected fracture in the supracondyle region. . % of the patients were very satisfied with their outcome. conclusion: the retrograde nailing technique is a save and sufficient method for treating humeral shaft fractures, especially because the rotator cuff is not disturbed. introduction and objectives: the bony bankart lesion is an avulsion fracture of the glenoid that usually occurs after anterior shoulder dislocation. this injury is frequently missed and often creates shoulder instability. therefore, open reduction and internal fixation (orif) of the fragment is recommended. in this study we looked at shoulder function, instability and pain after this operation. postoperative x-rays were reviewed on anatomical reduction. patients and methods: between and , bankart fractures were operated. they were classified according to ideberg. sixteen patients had an ideberg type b fracture and three a type . these patients received questionnaires with a number of validated scoring systems. we used the ases, rowe shoulder score and the dash questionnaire. results: the response was %. all respondents did get a stable shoulder after surgery. two patients regularly experience mild pain. the average rowe score was . (range - ). the average ases score for adl was (maximum score , adl unlimited). the median dash score on the quality of life was . (where means no loss of quality of life). there was a clear positive relationship between the radiological postoperative congruency of the joint, the shoulder function and quality of life. introduction: traumatic dislocation is the most severe form of ligament injury of knee.the purpose of this study is to report our cases in past years. methods: between and , knees in men and women; patients were treated for traumatic knee dislocation in our trauma center. the mean age was ( - ) years at the time of injury. the mechanism of injury were motor vehicle accident in , fall from high in and industrial accidents in patients. patients had additional extremity trauma. vascular injury detected in knees who required immediate reconstruction by vascular surgeons. the orthopaedic stabilization of the initial injury was bridging external fixation in knees included all vascular injuries. patients had fibular nerve palsy. in knees medial collateral ligament, in knees lateral collateral ligament, in knees anterior cruciate ligament, in knees posterior cruciate ligament and in knees posterol ateral corner lesions were diagnosed. one had tuberositas tibia avulsion. multiligament reconstruction was performed on a delayed basis in patients for a minimum of ( - ) month after the injury all patients had functional rehabilitation for a mean ( - ) weeks. results: at an average follow-up of . ( - ) years they were examined for stability and range of motion. all knees having multiligament reconstruction and of the patients in whom nonsurgical treatment was undertaken were stable. patients having multiligament reconstruction had slightly lower knee range of motion hypothesis: computed tomography (ct) is more accurate than bone scintigraphy for diagnosis of a radiographically occult scaphoid fracture. methods: in a study period of year, consecutive patients with a suspected scaphoid fracture but no fracture on scaphoid radiographs were evaluated with ct within h of injury and bone scintigraphy between and days after injury. the reference standard for a true (radiographic occult) scaphoid fracture was either ( ) diagnosis of fracture on both ct and bone scintigraphy, or ( ) in case of discrepancy, clinical and/or radiographic evidence of a fracture. results: ct showed scaphoid and other fractures. bone scintigraphy showed scaphoid and other fractures. according to the reference standard there were nine scaphoid fractures. the prevalence of true scaphoid fractures among suspected fractures was therefore %. ct had a sensitivity of %, specificity of %, accuracy of %, a positive predictive value (ppv) of % and a negative predictive value (npv) of %. the prevalence corrected ppv was % and the prevalence corrected npv was %. bone scintigraphy had a sensitivity of %, specificity of %, accuracy of %, a positive predictive value of % and a negative predictive value of %. the prevalence corrected ppv was % and the prevalence corrected npv was %. summary: this study could not confirm that early ct imaging is superior to bone scintigraphy for suspected scaphoid fractures. bone scintigraphy remains a highly sensitive and reasonably specific study for the diagnosis of an occult scaphoid fracture introduction: the therapeutic management of scaphoid fractures is still surrounded by controversy. immobilisation for non-or minimal displaced scaphoid fractures results in a union rate of more than %. functional outcome is often measured using clinical examination and radiological consolidation. however, the indication of how successful the treatment has been is the functional outcome of the patient. functional outcome of upper-extremity fractures can be measured reliably using the dash (disabilities of the arm shoulder and hand) outcome measure. materials-methods: consecutive patients with non-or minimally displaced scaphoid fractures, treated conservatively, were included. the trauma mechanism, treatment modality, diagnostic modalities, duration of cast immobilization and complications were analysed for all patients. functional outcome was measured using the dash outcome measure. results: patients showed good clinical and radiologic outcome after weeks of cast immobilization with a mean dash of . . six patients consolidated within weeks with a mean dash of . . three patients with four fractures took more than weeks to achieve clinical and radiologic consolidation and had a mean dash of . . the dash questionnaires showed statistically significant differences between patient age, fracture location and duration of cast immobilization. conclusion: conservative treatment of non-or minimally displaced scaphoid fractures results in good functional outcome after weeks of cast immobilization, particularly in young patients with distal or waist scaphoid fractures. objective: pedicle screw instrumentation is the most common procedure in stabilizing fractures of the throracolumbar spine, but yields an immanent potential for iatrogenic damage due to malpositioned pedicle screws. methods-materials: patients undergoing posterior instrumentations were included. preoparative ct scans were used to determine fracture level and classification. postoperative ct scan were evaluated for screw positions of all pedicle screws. cobb angles were compared to calculate the degree of reduction. the position of all pedicle screws was determined according to the classification proposed by zdichavsky. results: pedicle screws were assessed. pedicle screws were classified as optimal (ia, %), ib, iia, iib, iiia and iiib. malpositions were more often the more cranial pedicle instrumentation was performed ( % increase per level, p < . ). malpositions (ib-iiib) occurred more often on the right side of the patient (p < . ). the mean reduction was °. discussion: this study confirms the hitherto felt but unproven suspicion that malpositioning occurs more often in the upper thoracic spine. even more remarkably is the side-dependency in malpositioning. we attribute the higher rate of malpositioned screws on the right side of the patient to the circumstance that the surgeon usually stands on the left side of the patient and visual control of the direction of the pedicle screw during insertion is probably more difficult on the opponent side. we recommend envisioning this fact and -if navigation is not used -changing the position during the procedure. background: u-shaped sacral fractures are rare and highly unstable pelvic ring injuries. surgical stabilization may facilitate early mobilization and reduce mortality. however, limited evidence has prevented the development of a standard treatment algorithm. furthermore, little is known about the quality of life in these patients. purpose: to assess the injury characteristics, choice of treatment and quality of life of patients with u-shaped sacral fractures. methods: eight patients with u-shaped sacral fractures were identified over a -year period. neurological outcome was classified by gibbons' criteria. quality of life was evaluated using the euroqol- d questionnaire. results: there were five women and three men; the median age was years. the injury severity score ranged from to . definitive internal fixation was established after to days. percutaneous iliosacral screws were used in two patients with relatively stable fractures. transsacral plate osteosynthesis was used in one patient with minor displacement. triangular osteosynthesis with transsacral plating was used in four patients with multilevel sacral fractures, highly unstable fractures or traumatic spondylolysis l -s . one patient with an associated l fracture received a triangular osteosynthesis without transsacral plating. early partial weight bearing was encouraged whenever possible. follow-up ranged from to months (median months). four patients kept severe bowel and/ or bladder dysfunction. in the euroqol- d, pain, mood disorders and mobility problems prevailed. conclusion: u-shaped sacral fractures are rare and complex injuries. operative stabilization is tailor-made on the individual fracture characteristics. outcome is dominated by neurological deficits, pain, mood disorders and mobility problems. background: traumatic amputations are important causes of acute stress disorder and post-traumatic stress disorder. in this study, we aimed to present traumatic amputated patients needed more psychiatric support than the other trauma patients during the hospitalization period in the orthopaedics and traumatology clinic and in the later periods more post-traumatic stress disorder could be observed in this patient group. patients and methods: twenty-two traumatic amputated patients who have been treated in our clinic were evaluated retrospectively. during the early post-traumatic period, between the nd and th day, it was observed whether they needed any psychiatric support treatment. after the th month of the trauma, the patients were referred to the psychiatry department, and it was evaluated whether they needed any psychiatric support treatment by measuring the 'post-traumatic stress disorder scale' (tssb-Ö ). results: twenty-one (% . ) of twenty-two patients were male, one (% . ) of them was female. introduction: intramedullary nailing is challenging in proximal tibia fractures, associated with high rates of malalignment. to date, no studies report the potential of lateral tibia nail insertion to correct primary valgus malalignment, commonly seen in proximal quarter fractures. materials and methods: fresh-frozen cadaver lower extremities were used to simulate an ao/ota -a fracture. six nails (expert tibial nailing system, synthes, salzburg, austria) were inserted at the lateral third, six nails at the middle third and six nails at the medial third of the lateral tibia plateau. after nail insertion, alignment in the coronal plane was recorded. results: mean varus malalignment was dependent on the entry point at the lateral tibia plateau. mean varus malalignment was °if nails were inserted at the lateral third, °at the middle third and °after nail insertion at the medial third. if nails were inserted from the medial third, valgus malalignment was recorded in two specimens. discussion: the effect of correction of coronal malalignment in proximal tibia fractures is dependent on the point of nail entry at the lateral plateau. primary valgus deformation up to °can be corrected by inserting tibia nails at the lateral third of the lateral tibia plateau. surgeons should be aware of possible varus deformity and valgus malalignment despite lateral nail insertion. introduction: treatment of patients with distal radial fractures is primarily based on radiologic parameters. however, correlation between these parameters and functional outcome is questionable. objective: determine the value of radiological parameters for the appropriate treatment of patients with distal radial fractures. methods: a retrospective analysis was performed for a consecutive series of patients with conservatively treated distal radial fractures. axial radial shortening, radial displacement, radial angle, dorsal angle, and dorsal displacement were measured on the postero-anterior and lateral x-rays. functional outcome was measured using the quick dash-score (qds). minimal follow up was months. the radiological findings of patients who met the criteria for conservative treatment were compared to those of patients that met the current criteria for operative treatment (dorsal angulation > °, radial angle > °, radial displacement > mm, radial shortening > mm and step off > mm) but who had been treated conservatively instead. results: in a -year period patients were treated conservatively for a distal radial fracture. the qds was performed in ( %) patients. male female ratio was : , the average age was years (range - ). the mean qds was (sd ± ; range - ). age and female sex associated negatively with the qds. none of the radiologic findings was associated with the qds. half of the patients met the current criteria for operative treatment. the qds of this group corresponded however with that of the correctly conservatively treated patients. introduction: conservative treatment is generally preferred for simple elbow dislocations. in this study, the clinical and radiological results of conservative treatment are retrospectively evaluated. the patients were treated with closed reduction, plaster splint and brace. methods: dislocations of all patients were towards posterior and the average length of immobilization was . days ( - days) after closed reduction. the patients were assessed clinically for range of motion, instability, and atrophy after . months of mean follow up. mayo elbow performance score (meps) was used to evaluate functional outcome. standard elbow x-rays were evaluated for degeneration, heterotopic ossification, and concentric reduction. results: the average age of the patients was . ( - ) years. none of the patients had muscular atrophy. four patients ( . %) reported mild pain with heavy activity. six patients ( . %) had neurological complaints related with ulnar nerve. the average flexion arc and average rotational arc were °and °, respectively. the differences between the contralateral elbow motions were . °for flexion arc and . °for rotational arc. four patients ( %) had minimal residual instability. three patients ( . %) had mild radiographic signs of arthrosis and patients ( . %) showed minimal-mild degree of heterotopic ossification. an average score of . was obtained using meps. only four patients ( %) considered themselves fully recovered. conclusion: closed reduction and immobilization is a universal method for simple elbow dislocations. however, although functional scores were excellent, most of the patients did not consider themselves fully recovered. anterior odontoid screw fixation (aosf) is a valuable treatment after of, reported union rates in the elderly vary between and % when assessed on plain radiographs. in this study union-rates in of treated with aosf in patients aged ‡ years were revisited and risk factors for non-union analyzed. retrospective data review of a prospectively gathered c -fracture patients treated with aosf for of and age ‡ years were included for study. asides demographics and common injury characteristics, injury radiographs and ct-scans were assessed for fracture displacement, type, atlantodental osteoarthritis and particularly focussing on the square surface of of. follow-up ct-scans were assessed for technical failures, odontoid union, number of screws in aosf, square surface of screws used and the related healing surface. there were male ( . %) and female ( . %) patients with a mean age of . ± . years at injury ( - y). mean follow-up with ct-scans was . ± . months ( . - . mo). intervall injury to aosf was . ± . days ( - days). mean square surface of fractures was . ± . mm ( . - . mm ) and mean osseus healing surface was . ± . % ( . - . %). ct-based analysis revealed osseus union in nine ( %), while the remaining nine patients ( %) revealed non-union. in two patients, symptomatic non-union indicated posterior fusion of c - . union-rate significantly correlated with increased fracture surface (p = . ). observable was the trend that using two screws for aosf correlated with increased fusion-rate compared to one screw (p = . ). lifethreathening hemorrhage is often seen in pelvic ring fractures. efficient treatment of this hemorrhage is critical for survival in these patients. the purpose was to analyse the causes of death in hemodynamically unstable patients with a pelvic ring fracture and to determine if standardized treatment will reduce mortality. retrospectively, all data were reviewed of hemodynamically unstable patients with a pelvic ring fracture in the period / / till / / . of all patients, the pathway of treatment was analysed and compared with the standardized treatment protocol in our clinic. all injuries were categorized in injuries in airway, breathing, circulation and disability according to atls Ò principles. death was classified as directly related to the pelvic fracture if the patient required massive transfusions, died within h after admission and had no other body area injury with ais ‡ responsible for persistent hemorrhagic shock. we reviewed the data of patients. / patients died ( %). these patients were significant older and had a significant higher iss and shock class than survivors. two patients died of pulmonary trauma ( %), patients ( %) died of exsanguination(c) and patients ( %) died due to major head trauma. in patients ( %) there was a combination of injuries, which caused death. thus, overall hypovolemic shock contributed to mortality in cases. only in three patients death could be directly related to hemorrhage from the pelvis. two nonsurviving patients ( %) were not treated according to our standardized treatment protocol. in the survivor group this was only one patient. there is no consensus on the treatment of the acute total achilles tendon rupture. treatment modality is chosen on the basis of patient characteristics or the preference of the attending surgeon. using ultrasound, the distance between the two tendon ends in equinus position can be measured. this could form the basis for decision making between conservative-and surgical treatment. this cohort study consists of consecutive patients, between january and january . using ultrasound, patients were assigned to a surgicalor conservative treatment group. a gap of more than mm in maximal equines position was an indication for surgical treatment. seventy-two patients, men and women, received a conservative treatment. in patients the achilles tendon was primarily sutured. in the surgical group the post operative treatment was identical to the conservative treatment. the male-female ratio did not differ significantly (p = . ). the average age was years. sports caused % (n = ) of all injuries. the surgical group showed six re-ruptures versus nine in the conservative group (p = . ). on average, a rerupture occurs after days. no significant difference in major and minor complications (p = . ). outpatient treatment was needed days for the surgical treatment group versus days for the conservative treatment group (p = . ). ultrasound measured distance between the two ends of the achilles tendon in equinus in an acute total rupture can be used as a selection method in making a decision between surgical and conservative treatment. introduction: missile wounds induced by aviation bomb splinters pertain to grave injuries, due to large wound area and high risk of complications. material-methods: patients with large defects, in of casescombined with long bone fractures caused by missile injuries were treated by us in the period of august-november in . every cases were subjected to radical primary debridement with complete drainage. after relevant preparation for soft tissue plastic repair (involving primary radical debridement, primary external fixation, complex drug therapy and repetitive regular debridement) the following repair procedures were undertaken: in four cases, soft tissue defects were covered via rotation of local flaps. in three cases, defects were covered through transplantation of free skin grafts. in four cases, large soft tissue defects were overlayed by vascularized thoraco-dorsal (ld flap). in two of these, bone defect repair was simultaneously performed applying avascular graft taken from hip bone crista. results: in seven cases, transplanted flaps adhered perfectly, without trophic or infective complications. in one case, rotated local flap necrotized due to interrupted perfusion, which was subsequently replaced by free skin transplant. in five cases, fracture consolidation was completed in - months. in remaining two cases (after bone defect repair), consolidation process still proceeds with satisfying rate. conclusion: transplantation of vascularized thoraco-dorsal flap is especially effective for covering large soft tissular defects. soft tissular plastic repair has the double advantage of defect reconstructive ability and prevention from secondary infections, with additional stimulation of bone tissue regeneration. introduction: shoulder arthroplasty remains a valuable treatment for complex fractures of the proximal humerus. however the success of anatomical arthroplasty is mainly dependent of anatomical healing of the tuberosities. even with specific prostheses and fixation techniques in - % of cases anatomical healing is not achieved. using a nonfracture specific trauma prosthesis we achieved better elevation and abduction; however endorotation, exorotation, subjective shoulder rating and complication rate did score poorer than in anatomical arthroplasty. we assumed that the impossibility to refixate the lesser and greater tuberosity fragment, and subsequently the subscapularis and infraspinatus-teres minor tendons, are the main cause for this observation material-methods: we developed a fracture specific reversed shoulder prosthesis allowing for anatomical refixation of the tuberosities. we included patients in the reversed fracture arthroplasty group. function is scored using the constant murley-score. radiographically we evaluate for evidence of scapular notching. complications are recorded. we compare our results to an historical series of delta iii prostheses. results: at months the mean constant score is . points. there was no case of notching. there was one complication, an early infect. the mean constant score in the delta group was points. there was notching present in % of cases. in the delta group there were five reoperations in three patients because of dislocation. conclusion: there is a strong trend to better functional outcome using the fracture specific design. there are less complications and less notching. the possibility to refixate the tuberosities leads to better results. introduction: as fractures of the femur are severe injuries and patients mostly suffer from extensive pain they quickly attract the physician's attention in the emergency room. the literature has shown that injuries to the ipsilateral knee can occur accompanying such injuries. in most cases, these injuries though were diagnosed on delay. excluding cases in which a knee injury was apparent already on admission, we sought to investigate the number and severity of initially undetected lesions to the knee accompanying a femoral shaft fracture and give an overview of the literature. methods: charts and x-rays of patients treated for a femoral shaft fracture from january until december were reviewed. patients, in whom any other injury of the affected limb apart from a midshaft femoral fracture was initially diagnosed, were excluded. also patients, in whom an injury to the knee had been diagnosed on admission, were excluded. results: fifty-three patients with midshaft femoral fractures were available for analysis. an injury to the knee was diagnosed in cases ( %). there was one partial tear of the posterior cruciate ligament and two grade lesions of the medial meniscus. all lesions were conservatively treated. the shoulder is the most mobile joint of the human body. it has a great range of movement that takes place in all three cartesian planes. this is a complex phenomenon. there is considerable controversy over an ideal method for the functional assessment of shoulder joint complex. various methods have been used but they are often inaccurate and unreliable. thus, a better technique, that is reliable as well as repeatable, is required to measure the movements. the aim of this study is to assess the shoulder movement by fastrak Ò and vicon Ò systems and to compare their repeatability. methods-materials: the functional movement of the shoulder joint was assessed by fastrak Ò and vicon Ò systems. a difference between the two systems was determined and a comparison of repeatability was carried out. a population of healthy male volunteers were asked to perform six different tasks that covered all the movements occurring at the shoulder. these tasks were repeated twice on each side on two different days. the measurements were recorded and a custom-made programme, prepared for each system separately, calculated the angles. results: the recorded data was analysed using repeated measure analysis of variance. it was found that the coefficient of repeatability of fastrak Ò was better than the vicon Ò system for each task and there was no significant difference (p < . ) between the two sides. conclusion: the fastrak Ò system is better than the vicon Ò system for assessing shoulder movements. it can be used in clinical practice. ( - ). we applied sarmiento cast without any padding or little padding immediately. we encouraged the patients moving their arms. the treatment ends upon the presence of a bone callus and absence of pain at the fracture site. during the whole therapy the skin condition is monitored and emphasis is put on the prevention of reflex sympathetic dystrophy. we evaluate the result of the treatment with a focus on the any restriction of the range of motion of joints and the presenting any angulation of the humeral shaft. average follow up time was months ( - ). all fractures were healed without any major problem and we did not face any nonunion and no major angulations axis of the humerus. average union time was months ( - ). the results of nonsurgical treatment of the humerus mid and distal thirds shaft fractures are reported as a less complicated way and have a higher rate of union. this method is practical, efficient, cheap, and safe, if a good cooperation with patients is established and close observation is done. ( ). the aim of this study is to evaluate the surgical anatomical aspects of the minimally invasive hip surgery procedure in cadavers. methods: the mis approach was performed on four specially embalmed cadavers. all cadavers had a normal 'range of motion' of the hip joint. the difference in muscle length and work space were measured in all leg positions. additionally the difference in muscle tension in anterior and posterior luxation was compared with regard to the accessibility of the femoral shaft. results: the length of the medial-and minimal gluteal muscles is reduced in abduction. a difference of more than cm was found between °to °abduction and full abduction. the working space ( . · cm), is limited in the maximum ( °) abduction position. posterior luxation gives a better femoral shaft approach and less/ none muscle tension/damage compared to anterior luxation. the optimal approach to the femoral neck during mis of the hip is achieved during °- °abduction of the ipsilateral leg combined with °retroflexion. the best femoral shaft approach for prosthesis insertion is the posterior luxation. no additional damage, excluding the skin and fascia incision, was seen during posterior luxation. posterior luxation and exorotation of the leg enables straight and direct access to the femoral shaft compared to the access obtained during anterior leg luxation. background: it has been stated that acromial morphology plays an important role in the etiology of rotator cuff pathology. the system most widely used to describe the morphology is the bigliani classification. recently nyfeller introduced the acromial index. we wanted to examine whether there is a correlation between these two parameters and the presence of a rotator cuff tear or an impingement syndrome. methods: we assessed both parameters in four groups of patients each. the first group consisted of patients with operatively treated rotator cuff tears (average age . years) and the second group of patients known with impingement syndrome but documented intact rotator cuff (average age . ). for both groups, an age and gender matched control group was constructed. results: type three acromions were significantly more prevalent in the rotator cuff tear group than in the control group (p < . ). the average acromial index was . + . in the rotator cuff tear group and . + . in the rotator cuff control group, which is not statistically significant (p = . ). in the impingement group, the acromial index was . + . and . + . in the impingement control group. this difference was found to be statistically significant (p < . ). conclusions: patients with a rotator cuff tear appear to have more frequently bigliani type three acromion than age and gender matched, asymptomatic patients. there is no correlation between acromial index and acromial type or age. objective: extracorporeal membrane oxygenation (ecmo) is rarely used successfully in trauma. transfusion related acute lung injury (trali) is also rare in plasma containing blood product transfusion. methods: this is a case report of a trauma patient with life-threatening trali following trauma that was rescued successfully using ecmo. a year old patient was struck by an automobile and suffered a grade ii splenic injury, grade iv-v right renal injury as well as multiple orthopedic injuries. an attempt at angiographic embolization failed as the patient required multiple transfusions and became progressively hypotensive. the patient underwent emergent nephrectomy but rapidly became hypoxic with the pao becoming less than mmhg for over an hour. despite aggressive attempts at ventilation and oxygenation, the endotracheal tube was filled with fluid and hypoxia pursued despite low right heart filling volumes. rescue ecmo was instituted with successful oxygenation. after h the patient recovered from trali and was able to have ecmo discontinued. the patient was weaned off the ventilator within days and the patient had full recovery. the patient did not suffer any hypoxic brain insult. conclusions: although it is often thought that ecmo is unsuccessful in trauma patients, this case demonstrates its potential use in trauma patients. author to editor: will also present as poster findings: a total number of patients (all male; . ± . ) were found. injuries were resulting from gun shot fires (n = ; . %) or stab wounds (n = ; . %). injury sites within the heart were the right atrium (n = ; . %), the right ventricle (n = ; . %), the left atrium (n = ; . %), and the left ventricle (n = ; . %) (more than one site was observed in patients). the accompanying injuries were observed in the spleen (n = ; . %), the lung (n = ; . %), the liver (n = ; . %), and the stomach (n = ; . %). in ( . %) patients emergent thoracotomy was clinically decided with suspicious findings of hypovolemic shock or cardiac injury including low blood pressure, jugular fullness, deeply heard heart sounds, filiform pulse, narrowing of pulse pressure. the rest patients (n = ; . %) were operated after major blood drainage from tube thoracostomy. all the injuries were repaired with sutures, and pericardial fenestration was done in all. mortality was observed in two cases ( . %). patients with penetrating regional wounds should be suspected for penetrating cardiac injuries, since immediate surgical intervention may decrease the risk of mortality. introduction: the use of ''pan-ct'' is discouraged in settings of high imaging demand. this study compared clinical and plain chest film findings to determine need for, and results of, chest ct. methods: during recent month period, patients sustained blunt chest injury either isolated or in setting of multisystem trauma. data was tabulated by a combination of prospective and retrospective analysis. initial injury assessment followed atls protocol. supine chest film, followed by chest ct, were performed in all patients and compared with clinical findings. results: significant clinical findings were defined as tachypnea, decreased air entry, chest wall tenderness and initial oxygen saturation less than %. the presence of two or more of these clinical findings occurred in patients ( %). ct findings in this group included multiple rib fractures ± flail chest, sternal fractures, pneumothoraces, hemthoraces, and pulmonary contusions. higher ais and need for interventions occurred in this group. the co-existence of tachypnea and desaturation correlated with the need for tube thoracostomy in / patients( %) - pre-ct, post ct. conclusions: in patients with blunt chest injury, the presence of two or more of the clinical signs -tachypnea, decreased air entry, chest wall tenderness, oxygen saturation < % -is associated with: ( ) significant chest injury demonstrated on chest ct; ( ) higher correlation with ct findings than plain films alone; and ( ) introduction: complex regional pain syndrome (crps) sustained after trauma has a great negative impact on rehabilitation and activities of daily living. treatment is most often unrewarding. aim: to analyze prospectively the efficacy of endoscopic thoracic sympathectomy (ets) in reducing pain and disability associated with crps. patient and methods: over a -year period, patients ( females and males; mean age . ± . ) with posttraumatic crps underwent unilateral ets. the median duration of crps symptoms before ets was . months (range: . - ) . the sympathetic chain was resected from the second to fifth rib. mean postoperative follow-up was . ± . months (range: - . ). pain was assessed, at rest (passive) and during movement (active), using a visual analogue scale (vas) from to . results: one patient ( . %) had a hydrothorax and three patients ( %) complained about contralateral compensatory hyperhydrosis. at month (n = ), months (n = ), months (n = ) and year (n = ) after ets, there was a significant decrease in passive and active vas (p < . ). ten out of patients ( , %) needed less analgesics after surgery, and seven ( %) did not need analgesics at all. the mean sleep duration improved significant from . ± . h preoperatively to . ± . h postoperatively (p < . ). overall, patient satisfaction was % ( out of patients). conclusion: ets is efficient for decreasing pain and improving quality of life, and therefore should be considered in the treatment of crps. author to editor: complex regional pain syndrome (also known as sudeck or reflex sympathetic dystrophy) is a complex disease that trauma surgeons frequently encounter in the post-traumatic period. endoscopic thoracic sympathectomy is not well known among trauma surgeon, although it is an good option in relieving the pain and improving the quality of life. monitoring is accomplished with chest x-ray (cxr), but ultrasound (us) is nowadays established as more sensitive than cxr in detection of ptx. patients and methods: from october , thoracic views for detection of ptx are systematically included in the efast protocol during primary survey for every trauma patients (pts) admitted to our level i trauma center. among hospitalized pts, a selective usguided aspiration for small ptx was applied in three pts (two with a slow reabsorption time, one in a pt requiring hyperbaric oxygen therapy for a soft tissue infection of the leg). in supine position, delimitation of the area of anterior ptx was done with a linear probe, searching for lung points in adjacent intercostal spaces. under local anesthesia, a fr catheter was inserted in the ptx and aspiration monitored in real time by us, until restoration of sliding lung. the day after, after confirmation of normal gliding lung, two pts were discharged and one deemed suitable for hyperbaric oxygen therapy. discussion: small traumatic ptx is generally monitored without treatment. in some pts, drainage is however required, but the procedure is blind if performed on the basis of cxr findings. us allows to precisely define the site and the limits of ptx, insert a small catheter in the right area, monitoring reexpansion of the lung and complete aspiration of ptx and shortening recovery. background and objectives: occult diaphragmatic injuries are associated with significant mortality, if the diagnosis is delayed. we report our experience in diagnostic and therapeutic thoracoscopy in a selected group of patients with penetrating thoracoabdominal injuries. methods: the patients who underwent thoracoscopic management of thoracoabdominal stab injuries between june and june were included into the study. the data were retrospectively analyzed. results: eighteen selected patients with thoracoabdominal stab injuries were managed by thoracoscopy. the procedures were performed under general (n = ) or local anesthesia (n = ). diaphragmatic injuries were repaired by intracorporeal sutures in seven cases and bleeding was controlled in another two cases by electrocautery coagulation. the procedures were simply diagnostic in nine patients. the mean operating time and hospital stay were . min and . days, respectively. there was neither intraoperative or early postoperative complication, nor mortality. in a patient who had intra thoracic adhesions due to prior tuberculosis, unmentioned by the patient preoperatively, adequate exploration could not be achieved during thoracoscopy. the procedure was converted to laparoscopy and laparoscopic gastric and diaphragmatic repairs were performed. conclusion: thoracoscopy seems to be a safe, quick and efficient method in the diagnosis and treatment of diaphragmatic wounds, due to thoracoabdominal penetrating injuries. the nonoperative management is gradually more used in abdominal stab injuries and surgeons can resort to thoracoscopy and laparoscopy as a minimally invasive, diagnostic and therapeutic tool. trauma surgeons should be aware of the benefits of thoracoscopy and must have sufficient skills to carry out this technique. summary: generating acute lung injury by smoke inhalation and analyzing a method to pursuit standardized smoke. methods: a standardized glass, measures of cm width, cm length and cm height used as a closed area. we established a valf system under the glass which allows air inside but does not let it outside. with a hole above the glass, we attached the system to pomp with a hose. and the pomp was attached to a cm radial length balloon by another hose. we put a four ampere electricity owen in to glass and put g cotton to the oven. we burned the cotton for s in the closed area and we fullfilled the balloon with smoke by the pomp in s. rabbits were entubated after being anestesized. we waited seconds for the smoke to reduce down to room tempe rature to avoid thermal damage. after that, we seperated the balloon from the pomp and put it right through rabbits by ambulant air flow and inhalated in min.this procedure repeated for each rabbit. after the procedure ended,the entubation tubes were pulled away and the rabbits were left to spontaneous respiration. rabbits were allowed to standart rabbit bait and water at the th hour. results: we think we used a standardized smoke inhalation model in this study. methods: ten wistar rats were anesthetized and heparinised before the femoral artery was pierced to initiate bleeding. rats were than randomized to control and study groups. mph was poured into the bleeding site and a mass was placed on it. after s, the mass was removed and assessment of hemostasis was done. if bleeding ceased the test was scored as ''passed at s''. if not, additional dose of mph and compression was reapplied for an additional s. if bleeding has stopped after the second application, the test was scored as ''passed at s''. if not, the same procedure was repeated for the last additional s. if bleeding stopped now test was scored as passed at s. similar sequence of trials was done in the control group but without mph. the difference between bleeding periods in two groups was observed. results: application of mph resulted in complete cessation of bleeding in four of five and one of five rats at and s, respectively. in the control group hemostasis could not be achieved in all five rats, even at s. the statistical difference between the groups was significant (p < . ( . - . year) with supracondylar humeral fractures were treated operatively. according to gartland ( %) were type-ii, ( %) were type-iii. at the time of arrival at emergency department, four ( %) children sustained vascular impairment with pink pulseless extremity persisting after reduction. in three cases, a cubital approach was performed. two arteries showed a major lesion (one direct suture, one saphenus vein graft), and one artery showed an entrapment. all lesions showed a normal postoperative pulsation. another three ( %) children sustained a complete paralysis of the radial nerve. these cases were conservatively treated with complete neural restitution. conclusions: urgent anatomical reduction and fixation are crucial. in persisting vascular impairment after reduction, surgical exploration for the restoration of arterial patency should be performed, even in the presence of a pink hand. conversion to open surgical repair was needed in one case due to retroperitoneal bleeding from the iliac arteries. early postoperative mortality was observed in ( %) patients; due to massive coagulation disorder and hemodynamic instabiliy in postop st day and th day. mean follow-up was months (range - months). late mortality was not observed. overall reintervention rate was % (n = ); proksimal re-stenting was needed due to type endoleak in one patient. embolectomy for crossfemoral bypass was needed in one other patient after stenting for aneurysmal abdominal aortic rupture, this patient underwent re-crossfemoral bypass surgery later on. introduction: dislocations of and fractures around the knee are accompanied by injuries of the regional vessels to a certain extent. in any case of suspicion at the scene of accident an immediate transport to an adequate trauma center is the precondition for successful limb salvage. methods: between and , patients with arterial injury after dislocation of or fractures around the knee have been treated. retrospective analysis was performed in order to acquire epidemiologic data. furthermore we investigated the sufficiency of preoperative management and diagnostics. we explored peri-and postoperative complications, such as compartment syndrome, secondary thrombosis, infection and number of revision surgeries and related the data to the final follow up after and months. results: arterial injury was found in four cases of knee dislocation, in seven cases of proximal tibial fracture, and in nine cases of distal femur fracture. seven patients underwent acute angiography, since the year all patients were assessed with cta. seventeen cases were treated with venous interposition, one with a venous patch, and two with direct suture. fasciotomy was performed in all cases. limb salvage was successful in cases. in seven cases secondary amputation was necessary, six of these patients were polytraumatized. discussion: sufficient time management is crucial for the survival of vessel injured extremities, as the time of ischaemia must not exceed h. perfect interdisciplinary coordination and the establishment of specific algorithms are needed in order to decrease the risk of complications and amputations of lower extremities. the survey on the epidemiology of car-motor related accidents in children in kashan, iran iman ghaffarpasand, maneli dorudian tehrani department of surgery, kashan medical university, kashan, iran introduction: the most common cause of death in children is accident and reinforced a lot of taxes on the society. kashan has the second position in trauma ranking of iran so we studied this important issue in the children. methods and material: in this descriptive study, data has been gathered by trained hospital nurses during month in traumatic patients refered to -bed teaching hospital, kashan. the main method is questionnaire filling by direct interviewing. findings: among cases of trauna ( . %) of them was children below years old that cases ( . %) were due to car accident, cases ( . %) were due to motor accident and rest of them ( . %) were pedestrian accident. boys involved . times as girls the most injuries happened was head-injury ( . %). conclusion: these finding suggest that we have to pay more attention to this age group specially - because of the high rate of their involvement. finally as you see the last but not the least, these findings emphasise on protective cap wearing for every persons. managing blunt splenic injury in a level ii trauma center: the laparoscopic option background: the past decades treatment modality of blunt splenic trauma was a point of discussion. where nowadays explorative laparotomy remains the standard of care for hemodynamic unstable patients, treatment of hemodynamic stable patients is less uniform. in this stable population maximum conservative approach seems preferable, though level evidence is still absent. failure of the conservative pathway is backed up by percutanous angioembolisation or laparoscopic salvation. the evolution to minimal invasive access makes laparotomy as a primary care for hemodynamic stable isolated splenic injury superfluous. methods: this paper discusses the initiation of explorative laparoscopy and successive splenectomy in two patients scoring a grade iii posttraumatic splenic injury. grading was based on ct scan imaging using the spleen injury scale defined by the american association for the surgery of trauma (aast). conservative treatment was abandoned because of moderate hemoperitoneum and continuing need for transfusion. results: an uncomplicated laparoscopic splenectomy was performed in both patients. perioperative spleen preserving measures failed because of the extent of the parenchymal lesion. conclusion: performing laparoscopic splenectomy seems a good procedure when conservative treatment for splenic injury fails. this accounts for a rural level ii trauma center where the accommodation to perform safe angioembolisation is missing, knowing that laparoscopic splenectomy is not a straight forward procedure but is made easier because of the growing skills of our surgeons. hepatic portal venous gas (hpvg) is often associated with serious intra-abdominal pathology like ischaemic bowel disease and necrotizing enterocolitis, with reported mortality rates above %, with most requiring urgent operation. however, hpvg has been reported seen on ultrasound or computed tomography (ct) scans immediately after blunt trauma, followed by spontaneous resolution. gastric pneumatosis (gp) has rarely been reported as a trauma-related entity. the combination of hpvg and gp after blunt trauma has been described in very few patients. we report the case of a -year-old woman who presented with an edh requiring craniotomy and an initial abdominal ct scan showing only an ois grade liver injury. a transient increase in serum amylase combined with abdominal distension led to a repeat abdominal ct scan h post injury to rule out pancreatic and duodenal injuries, revealing gp and hpvg. endoscopy demonstrated mucosal erythema of the posterior gastric wall from the fundus to the pylorus. however, the clinical status of the patient was benign, and did not mandate surgical intervention. the patient was treated nonoperatively with nasogastric decompression and antibiotic coverage, and underwent a successful recovery with no abdominal complications. to our knowledge, only one other adult patient has been described with hpvg and gp occurring after an initial normal abdominal ct scan. a gastric resection was performed, and operative treatment was recommended for this combination of entities in trauma patients. our patient shows that treatment strategies in these cases probably should be guided by the clinical status of the patient. introduction and aims: while the number of colorectal injuries due to penetrating trauma are increasing, increased traffic accident rates also cause the number of blunt rectal injuries associated with trauma in traffic accidents to be increased. rectal injuries occur rarely. because of post operative septic complications, morbidity and mortality rates are high. early admission, stability, operation type all play important roles in the fate of the patient. we aimed to investigate these criteria in our patients who have colorectal injuries. material-method: cases who had penetrating or blunt trauma in our district during last years were included in this study. aim of this study is to present three cases with torsion of omentum, that often resemble acute cholecystitis or appendicitis, and the diagnosis is made at the time of exploratory laparotomy. case description: the first case, a -year-old men, presented with a -day history of right hypocondrial abdominal pain, fever and vomiting. the pain increasing in severity while the patient is standing and relieved in supine position. laboratory findings were normal, except for mild leucocytosis ( , /cc). the patient underwent u/s examination, which showed an encysted mass in the right abdomen. a mass, originating from the omentum, was revealed after laparotomy. the mass was excised and an appendectomy was also performed. the second patient, a -year-old female, was admitted in our department with abdominal pain, associated with vomitus. a mild leucocytosis ( , /cc) was observed. an u/s was carried out, which revealed a mass · cm lying besides a stone-free gallbladder. the patient underwent diagnostic laparoscopy and a cystic mass, which was twisted, was resected using bipolar forceps. sixteen of all laparotomies did not reveal any internal organ lesion. of these laparotomies with negative findings, had been operated for stabbing injury and had been operated for gunshot injury. twenty-one cases had single organ injury; whereas, multiple organs were affected in cases. frequencies of organ injuries were as follows: small intestine, colon, stomach, liver, diaphragm, spleen, kidney, and pancreas. the mean duration of hospitalization was . ± days. after surgery, four cases needed intensive care unit; therefore, they were referred to a higher-level healthcare center. among cases whom the treatment was completed in our institution, had complication. conclusion: penetrating abdominal injuries mostly occurred in young males and stabbing injuries were more common. most penetrating injuries can be treated at secondary care centers. however, they should be referred to a higher-level institution after the initial intervention, when necessary. background: both nonoperative management (nom) of blunt hepatic trauma and the damage control laparotomy are significant advances in the management of massively injured trauma victims. methods: this study is a retrospective evaluation of patients admitted with liver trauma during . of them required early surgical procedures, damage control surgery and followed nom. patients were stratified by age, mechanism of injury, ais, initial blood pressure, heart rates, and blood transfusion volume. initial outcome data included major complications, intensive care unit and hospital length of stay, and mortality. readmission data including the number of admissions, surgical procedures, and hospital length of stay were then analyzed. the average age of the study group was , years. almost all of these patients were males ( , %) and car crash was the main mechanism involved ( , %). liver injuries were frequently an element of multiple trauma and was associated with cranio-cerebral trauma ( , %) and spleen lesion ( , %). the overall mortality during the first admission was , %, yet . % attributable to the liver trauma and only . % after damage control. conclusions: damage control surgery offers a simple effective alternative to the traditional surgical management of complex or multiple injuries. phase i can be done at a local hospital before transfer to a major trauma center for resuscitation and definitive repair. reasonable surgical procedures based on classification of liver injuries and damage control principles increase the survival rate of severe liver trauma. background: at our department, a simple scoring system based on three criteria (blood pressure below , be below - . and body temperature below °c) has been used to determine the suitability of individual patients as candidates for dcs. objectives: the present study was undertaken to establish a valid strategy for the treatment of severe pancreatic injury and to test the validity of the scoring system used at our department for identifying suitable candidates for dcs. subjects and methods: the subjects of the study were patients with the grater and equal of grade iii (organ injury scale (ois))pancreatic injury treated surgically (type iii in cases and iv or v in cases). results: resection of the pancreatic body and tail was performed in both the groups to treat type iii injury, and all of the cases with type iii injury had favorable outcomes. among the cases with type iv or v injury, all of those patients satisfying two or fewer than two of the criteria of the dcs scoring system survived dcs, while two patients satisfying all the three criteria of the dcs scoring system died after dcs. the two patients who underwent pancreatic duct-forming surgery needed prolonged hospitalization. discussion: our results suggest that dcs should be selected in cases where at least one of the three criteria of the dcs scoring system is satisfied. as a procedure for radical operation, resection of the distal pancreas may be recommended for type iii, and pancreatoduodenectomy for type iv or v. author to editor: our results suggest that dcs should be selected in cases where at least one of the three criteria (systolic pressure below , severe hypothermia with body temperature below °c, and acidosis with be below - . ) of the dcs scoring system is satisfied. this dcs score is accords with the score of another abstract (abs ref ). we did not show the details of the score in another abstract ( ). please refer in our another abstract (ref iatrogenic and traumatic lesions involving common hepatic duct and duodenum can be treated with a primary and contemporary reconstruction, at the condition of hemodynamic stability. we propose a technique which include the following steps: cholecystectomy with intraoperative cholangiography; transection of the common bile duct above the tear, oversewing its distal part; kocherization of the duodenum; a cm long roux-en-y jejunal loop is constructed and brought up retrocolically in the right sub-hepatic space, orientating its antimesenteric side towards the corresponding duodenal wall; termino-lateral hepatico-jejunostomy with a transanastomotic temporary stent in case of small biliary duct's size; a side-to-side jejuno-duodenostomy performed cm distally; a feeding jejunostomy. we remark the following advantages of this procedure: ( ) the rouxen-y biliary diversion reduces the risks of stenosis and cholangitis, frequent after a direct repair of the common bile duct; ( ) an adequate distance between the biliary and duodenal anastomosis prevent entero-biliary reflux; ( ) the duodeno-jejunal anastomosis appears more appropriate, considering the complications after direct repair of large duodenal tears. more aggressive options, such as duodeno-cephalo-pancreatectomy, pancreas-preserving-duodenectomy and segmental duodenal resection, must be considered more risk solutions. introduction: the liver is the most commonly affected organ in abdominal trauma. in our department, the majority of traumatic liver injuries are treated conservatively. this option involves the monitoring of possible complications, such as late rupture, hemobilia, arterio-venous fistula, pseudo-aneurysm, biloma and abscess formation. case: a year-old patient was admitted after a m fall. established diagnoses were: multiple facial fractures, right pneumothorax with pulmonary contusion, right renal artery thrombosis and grade hepatic laceration. the patient was discharged on the st post-trauma day (ptd), after an uneventful course. on the st ptd, he was readmitted for abdominal pain. thoracoabdominal ct revealed an intra-hepatic arterio-venous fistula. angiographic superselective embolization was performed, and the patient was discharged following a control abdominal ct scan that showed resolution of the fistula. he was again readmitted on the th ptd, with abdominal pain, jaundice and gastrointestinal bleeding. an abdominal ultrasound raised the possibility of hemobilia, confirmed by upper endoscopy. a new angiography did not reveal any active bleeding, and an abdominal ct showed satisfactory evolution of the liver lesion. the patient was discharged on the th ptd, asymptomatic. at month follow-up, the patient presents no complaints, other than a new-onset arterial hypertension of renovascular origin. conclusion: arteriovenous fistulae and hemobilia are relatively uncommon sequelae of abdominal trauma. however, these diagnoses should be actively sought in the presence of abdominal pain, especially when associated with jaundice and gastrointestinal bleeding. a multidisciplinary approach is essential for a successful treatment. diaphragmatic hernias constitute frequent complications after thoracic and abdominal trauma ( . - %), especially on the left side ( %) and the diagnosis is frequently delayed. clinical presentation is variable and may include respiratory distress and abdominal pain, frequently attributed to intestinal obstruction, pancreatitis, biliary colic or peptic disease. the authors present a case report of a right diaphragmatic hernia diagnosed years after a thoracoabdominal blunt trauma. the male patient, years old, was admitted in the emergency room with epigastric pain, bloating, slight abdominal distension with months of evolution and recent worsening. he suffered a previous thoracoabdominal trauma years ago, consecutive to a downfall of about eight meters high with lumbar vertebrae fracture (l ) and was submitted to conservative treatment in an orthopaedic ward; x-ray signs of diaphragmatic hernia were unrecognized. actual chest x-ray revealed an elevated right hemidiaphragm and presence of abdominal content in the right hemithorax. mr demonstrated a right hemidiaphragmatic rupture and the presence of abdominal content in the thoracic cavity. patient was operated by laparoscopic approach; a diaphragmatic hernia grade iii (a.a.s.t. classification) was observed and submitted to prosthetic repair. postoperative period was uneventful. patient remains asymptomatic with no signs of recurrence after years. this case is paradigmatic of the difficulty of immediate diagnosis of diaphragmatic hernias, especially at the right hemidiaphragm. high index of clinical suspicion is needed for its early recognition in context of blunt trauma. laparoscopic treatment revealed to be safe and efficient, with the known advantages of minimally invasive procedures. results: their ages were between and , were male and were female. the type of injury was penetrating in , blunt in and blunt and penetrating in patient. in patients, the left kidney was injured, in the injury was at right kidney and in injuries was bilateral. the average transport time to hospital was min ( min- days). one hundred and seventeen out of patients were explored immediately as they hemodynamically unstable position. remaining patients were evaluated with ultrasonography, intravenous urography and computerised tomography. sixty four of these patients were followed conservatively. the injuries in patients followed conservatively were in patient's grade , in grade , in grade . renal units of patients were operated. nephrectomy was done in , nephropathy was done in and renal artery repairing was done in patient. conclusion: nephrectomy and mortality were high because of the long transport time, frequent high grade and high rate of associated organ injuries. rojnoveanu gheorghe sigmoid volvulus is seen more frequently at elderly ages and early diagnosis and treatment decreases its mortality and morbidity rate. we reviewed sigmoid volvulus cases treated in our clinic. patients hospitalized and treated due to diagnosis ofsigmoid colonic volvulus in dr. lü tfi kırdar kartal education and training hospital during - were analysed. treatment modalities, morbidity and mortality rates were analysed. patients were male, were female. mean age was ( - ). sigmoid colon resection and end colostomy was done to patients, sigmoid colon resection and end to end anastomosis was done to patients and nonoperative colonoskopic decompression was applied to patients with sistemic illness and they were prepared for elective sigmoid colon resection and end to end anastomosis. in one patient with anastomosis, anastomotic leakage was detected and end colostomy was applied. two emergently operated patients with sistemic illness died. mortality rate was% . in conclusion, sigmoid volvulus patients with sistemic illness should be prepared to elective surgery with colonic decompression. we think that the best treatment for early diagnosed cases is sigmoid colonic resection and end to end anastomosis. introduction: onset of world war ii, the report concerning diverting colostomy declared reduced mortality rates for colon injury, compared to world war i. in spite that nearly years has passed away, although all therapeutic options, this method -used for the management for colon injury -still include some controversial points. methods: ninety-five patient's characteristics were compared in two groups (patients with or without diverting stoma). clinical findings and patient's characteristics, injury mechanism, localisation of the wound, blood transfusion requirements, fecal contamination, colon injury score (cis), penetrating abdominal trauma index (pati score), evidence of shock, morbidity rate, mean hospital stay, main and additional surgical procedures of patients who admitted to our clinic from to were reviewed retrospectively. results: we have no mortality in both groups, except the first postoperative h. diversion colostomy was performed in patients and primary repair in patients. median hospital stay for primary repair and diversion groups were and days, respectively, (p < . ). respiratory system, septic complications, clinical anastamosis leakage and other complications were similar in both groups. conclusions: although all articles that prompt primary repair, this approach includes some inconvenient points. it is acceptable in military or war originated injuries. diversion mostly is necessary in wounds, related to highly potent and energic fragments. nevertheless, nearly all of the civilian colonic injuries can be treatment with primary repair without diversion since the mechanism of the wound is different than war injuries. dogan gö nü llü , oguz Ç atal , nilü fer yazgan yıldırım , tayfun yucel , ferda nihat kö ksoy taksim trainig and research hospital, _ istanbul, turkey background: the management of haemodynamic stable penetrating injuries of the flank has not been well defined; laparoscopic exploration, closed abdominal examination and triple contrast computed tomography (ct) are alternative modalities. our aims are to explain our experiences in these cases. methods: we reviewed the patients with isolated penetrating flank trauma admitted between and . the flank was defined as area between the anterior and posterior axillary lines, inferior to the fifth intercostal space superior to the iliac crest. results: there were haemodynamic stable patients ( gunshot and stab injuries). there were three patient groups: laparotomy (g ) (n = ), laparoscopy (g ) (n = ) and only closed clinical observation with triple contrast ct scan (g ) (n = ). patients in the g were gunshot injuries; the other two gunshot injuries were tangential and were included in the g . in the g there were four left diaphragmatic injuries, all repaired laparoscopically. one patient with splenic laceration and another with small bowel injury were converted to an open exploration. there were eight negative laparoscopies ( / ).two patients of g ( / ) with negative tomography were submitted to laparotomy after day of closed observation. the mean length of hospitalization in the groups was respectively . , . and . days. introduction: intra and retro abdominal hemorrhage are common following blind and penetrating abdominal trauma. liver, spleen and kidneys are known to be prone to injury and to bleed after an abdominal trauma. hepatocellular carcinoma is a well known disease. however, a renal mass from a primary origin in the liver is rare. this paper presents a patient, who was treated with right nephrectomy for traumatic bleeding from a ruptured renal mass. end diagnosis was metastatic hepatocellular carcinoma. case: the patient was -years-old man. he had no positive medical and surgical history, and no complaint. he was referred to emergency service after traffic accident. during his initial assessment abdominal rigidity and tenderness were found, which were accompanied with tachycardia and hypotension even after fluid resuscitation. fast revealed that there was free fluid in his abdomen, so we decided to operate him. at laparotomy we observed a bleeding tumoral mass in the right kidney and in his liver. he was treated with right nephrectomy and irregular hepatectomy. pathologic examination demonstrated a metastatic hepatocellular carcinoma. conclusion: hepatocellular carcinoma is a well known disease with its common acute complications such as rupture and bleeding. in this case, we observed hcc metastasis to the right kidney although the patient had no medical and surgical history including hcc. bleeding was induced after a blind trauma, was treated with resection. gall bladder (gb) injuries either following penetrating or blunt abdominal trauma is a rare entity and usually misdiagnosed with a delay in diagnosis. the incidence of gb injury is reported to range between . and . % among the surgically treated patients following abdominal trauma. cholecystectomy is the definitive treatment even in severe contusion of a nonperforated gb. simple suture repair or cholecystostomy are also advocated as alternative surgical interventions by some authors. gb is afforded significant anatomic protection from external trauma, since it is partially embedded in the relatively massive liver parenchyme, cushioned by the surrounding omentum and intestines, and shielded by ribcage. clinical symptoms may be minimal or nil initially but gradual clinical deterioration, related to spillage of bile into the peritoneal cavity, can follow. bilous fluid taken by paracentesis or diagnostic peritoneal lavage can only be helpful after a delay as abdominal computed tomography. an year-old male was admitted to our emergency department for the fifth time because of penetrating abdominal trauma of at the right upper quadrant by a knife in a -day-period. he was hospitalized in three of them and operated on at last, because of acute abdomen, since paracentesis revealed bile coloured free abdominal fluid in addition to abdominal guarding, leucocytosis( , /mm ), and fever.the ultimate ultrasonography and computed tomography revealed large amount of free fluid (bile) and minimal intrahepatic hematoma. at laparotomy; full-cut hepatic and cholecystic perforation (both anterior and posterior surfaces) resulted in cholecystectomy. he was discharged on the fourth postoperative day. since almost all reports about the delayed rupture of gb are usually unrecognized gb perforations,a diagnostic delay can only be avoided by a high clinical index of suspicion. sixty-three patients were treated conservatively, whereas patients had laparotomy and patients underwent angiography. of patients transported by ambulance or helicopter, % arrived at the emergency unit within min after prehospital alert. in % the time on scene were longer than min. in this group only % were diagnosed by ct within min after arrival to the emergency unit. conclusion: low volume in trauma care results in substandard handling time. in hospitals with a low volume exposure to trauma, the prehospital response teams and surgeons achieves limited experience, especially in penetrating trauma. exchange programs must be emphasised. author to editor: this study describes the complete workload in primary handled trauma patients in a typical nothern european universtyhospital with very low incidence of penetrating trauma and low volume of blunt trauma. our trauma registry covers % of patients admitted to the hosptial. it is the only hospital in the area, and patients do not bypass the system and are treated elsewhere. the study will point out that prehosptial responsetime and inhosptial procedures are is acceptable, but emergencyroom handlingtime is to long, due to lack of practice. national or european exchange programs for surgical trauma care must be practiced. introduction: explosives create and energize particles that act as projectiles prone to further fragmentation in the body. these fragments may result in secondary injuries. this has been repeatedly described in the orthopedic and neurosurgical literature. in this paper we demonstrate that such a process is also possible for abdominal injuries during or after fascial penetration. material-method: in all abdominal wall injuries, despite negative physical examination of conscious and alert patients we used local wound exploration as a standard approach. finding a full thickness fascial defect, we assumed an intraperitoneal injury and performed laparotomy. result: using this method, we found hollow organ injuries in of ( . %) patients. in ( . %) of these patients at laparotomy, we found multiple, projectile induced injuries in a sprayed distribution. these injuries were found far from the trajectory, in the absence of bone fragmentation. the mean number of peritoneal defects was . , however, for each peritoneal defect, we found an average of . intraabdominal injuries when through and through injuries were excluded. conclusion: local wound exploration is an accurate indicator of possible intraabdominal injuries. although fragments of projectiles would be expected to be distributed along the trajectory, meticulous exploration of abdomen is mandatory because this is not always true. despite a single peritoneal defect, there may be multiple intraperitoneal injuries due to further fragmentation of the projectile. introduction and objectives: nonoperative management of penetrating abdominal stab wounds has been established as standard care recently. it decreased negative laparotomy rate without any increase in morbidity and mortality. in this study we evaluated the outcome of patients managed due to penetrating abdominal stab wounds. intraabdominal injury due to blunt abdominal trauma usually presents acutely. in the absence of peritoneal irritation findings or shock the patients may be treated conservatively. delayed small bowel obstruction after blunt trauma is very rare clinical entity. it may be caused by subclinical bowel perforation, localized bowel ischemia or mesenteric vascular injury. we present a years old man of blunt abdominal trauma that was treated nonoperatively. despite the success medical treatment, months later, the patient presented with abdominal pain and vomiting. the radiologic studies suggested a mechanical intestinal obstruction. at the operation a conglomerated terminal ileal segment causing obstruction was found and the patient is treated by a resection and primary anastomosis. the operative findings may be explained by a subclinical perforation at the time of the trauma. this kind of complication should be suspected in patients with post traumatic patients which presents with signs of intestinal obstruction in weeks after the trauma. nevin kanan, ayfer Ö zbaş department of surgical nursing, istanbul university, florence nightingale school of nursing, ankara, turkey with traumatic injury, kidneys can be thrust against the lower ribs, resulting in contusion and rupture. up to % of patients with renal trauma have associated injuries of other internal organs. injuries may be blunt (automobile and motorcycle crashes, falls) or penetrating (gunshot wounds). approximately - % of all renal trauma cases are blunt trauma injuries; penetrating renal trauma accounts for the remaining - %. blunt renal trauma is classified into one of four groups which are contusion, minö r laceration, majö r laceration and vascular injury. • with a contusion of kidney, healing may take place with conservative measures (i.e. bed rest) • if minö r laceration is present, the patient is hospitalized and kept on bed rest until the hematuria clears. • depending on the patient's condition and the nature of the injury, major lacerations may be treated through surgical intervention or conservatively (bed rest, no surgery) • vascular injuries require immediate exploratory surgery because of the high incidence of involvement of other organ systems and the serious complications that may result if these injuries are untreated. the patient is often in shock and requires aggressive fluid resuscitation. for the management of patient with renal trauma, nursing diagnoses are: • inefective tissue perfusion (renal) related to interruption of arterial flow • anxiety related to physical injury • acute pain related to physical injury • impaired urinary elimination related to renal damage and shock background: penetrating abdominal buckshot wounds are believed to necessitate emergent laparotomy to rule out any hollow or solid organ injury. recently, nonoperative management has been suggested in selected patients. this paper aims to present two cases with penetrating abdominal buckshot wounds, treated nonoperatively. materials-methods: a chart review has been conducted for patients operated in our institution for abdominal buckshot wounds. demographics, evaluation tools and follow-up parameters has been analyzed and documented. results: a total number of two patients (both male; and years old) were found. both were shot on their left thoracolumbar regions. left and bilateral chest tubes were necessitated after initial examinations, but both denied any abdominal tenderness, although computed tomography showed multiple abdominally located pellets. gastroscopy (n = ), echocardiography (n = ), intravenous pyelography (n = ) were necessitated for further evaluation, but showed no abnormality. the patients were followed up with routine abdominal examinations, vital signs and routine laboratory tests and discharged from the hospital on days and after uneventful recovery periods. discussion: patients with penetrating abdominal buckshot wounds may be followed with nonoperative management instead of routine laparotomy. objective: treatment procedures in cases who were operated due to colon injuries were investigated in this study. material-methods: thirty-two cases who were operated due to colon injuries in our clinic between and were investigated retrospectively. cases were investigated with regard to age, sex, type of trauma, hemodynamic condition, interval between injury and surgery, additional organ injury, transfusion volume, injury site and severity, faecal contamination, surgical procedures, postoperational complications and mortality and factors affecting morbidity and mortality were determined. colonic injury severity scale (ciss), abdominal trauma index (ati) and flint classification were used for evaluating severity of colon injury,severity of additional organ injury and faecal contamination, respectively. systolic blood pressure less than mmhg on admission was referred to as ''shock''. results: males comprised out of cases and mean age was . (range: - ) years. twenty-five cases were injured due to penetrating trauma and left colon injury was the most common ( cases) type of injury. additional intraabdominal organ injury and extraabdominal injury were observed in and cases, respectively. mean interval between injury and surgery was . (range . - ) h. fifteen cases received blood transfusion. five cases had shock on admission. seven cases received stoma surgery while all cases with flint grade more than iii or ati score higher than received colostomy. only cases with high ciss score received resection and anastomosis surgery. complications were observed in cases while mortality occurred in two cases due to hemorrhagic shock. conclusion: routine primary repair cannot always be performed in colon injuries since many factors affect the decision for type of surgery. primary repair may be performed safely in hemodynamicallystable cases with ati score less than and flint grade i-ii. seat belt syndrome is defined as a seatbelt sign associated with lumber spine fracture and bowel perforation. an isolated rectal perforation due to seatbelt syndrome is extremely rare. there is only one case reported in the danish literature and non in the english literature. hereby, we report a -years old male who was a front seat restrained passenger involved in a head-on collision. he has presented with lower abdominal and back pain. seat belt mark was seen transversely across the lower abdomen. initial trauma ct scan was normal except for burst fracture of l vertebra which was operated by internal fixation on the same day of admission. the patient continued to have abdominal pain and distention which became clear on the third day. repeated abdominal ct scan on the third day has shown free intraperitoneal air. exploratory laparotomy has revealed a perforation of the proximal part of the rectum below the recto sigmoid junction. hartmann's procedure was performed with end colostomy. the abdomen was left open and temporarily closed using saline iv bags sandwiched between layers of steri-drape. peritoneal toileting was performed four times under general anesthesia with gradual closure of the abdominal fascia over a period of weeks. postoperatively, the patient had urinary retention due to a quada equina injury although he could walk. the presence of seat belt sign and a lumber fracture should rise to the possibility of a bowel injury. author to editor: seat belt syndrome is defined as a seatbelt sign associated with lumber spine fracture and bowel perforation. an isolated rectal perforation due to seatbelt syndrome is extremely rare. there is only one case reported in the danish literature and non in the english literature. hereby, we report such a case. fuat ipekçi, muharrem karaoglan, hü seyin toptay, hasan Ş ahin department of general surgery, tepecik education hospital, izmir, turkey introduction and aims: meckel's diverticulum results from incomplete degeneration of omphalomesenteric duct. it is usually diagnosed incidentally during appendectomy; however, sometimes perforation or bleeding may lead the surgeon to the diagnosis. we aimed to investigate the frequency of meckel's diverticulum during emergency laparotomy performed for acute appendicitis and clinical and pathological characteristics of the patients with meckel's diverticulitis and appendicitis. material-method: the material consisted of , patients who admitted to our hospital and treated by appendectomy during a -year interval between the years and . of these patients ( , %) were male and remaining ( , %) were female. all patients were investigated for meckel's diverticulum weather they have acute appendicitis or not. results: meckel's diverticulum was found during out of , appendectomies ( . %). of the cases, were asymptomatic but four patients were symptomatic with inflamed diverticulitis. of these four patients two have normal appendix and other two have secondary appendicitis due to meckel's diverticulitis. all four symptomatic cases were treated by diverticulectomy and appendectomy. all asymptomatic cases were treated by appendectomy alone. no mortality or major morbidity was detected. conclusions: despite of its rarity ( . % in our appendectomy series), meckel's diverticulum must be searched weather the appendix is normal or inflamed. introduction: illegal drug smuggling is a widespread problem. drug packs carried inside body cavities may leak its contents and be dissolved inside the body and signs of toxicity (aka. body packer syndrome) become evident. this case was reported to represent the very first proven patient in turkey. case: a year-old man were brought in the emergency department (ed) from the airport because of severe tremor, palpitation, restlessness associated with hypertension and tachycardia. the patient was cooperative and oriented. on examination, his blood pressure (bp) was / mmhg, pulse rate /bpm, whereas other systems were unremarkable. he was put on cardiac monitor and infusion of glycerol trinitrate was instituted ( mcg/min). urinary toxicologic screen was positive for cocaine and benzodiazepine. after admission to the ed he complained of epigastric distension and abdominal pain and admitted that he had swallowed cocaine packs. his abdominal xrays showed gas-fluid levels and opaque round-shaped mass images. a nasogastric catheter was inserted and gastric contents (approximately , ml) were drained. he was consulted with surgery clinic with a diagnosis of an ileus due to swallowed packs. he was hospitalized in the surgical ward. after supportive treatment and repeated enema applications he excreted cocaine packs in days. he was discharged following clinical stabilization and abdominal x-rays were repeatedly normal. conclusion: toxicologic analysis must be employed in patients who are suspected to have intoxication, to identify life-threatening drugs and vasoactive substances. advanced imaging methods must be exercised to exclude bowel obstruction in these patients. background: pseudoaneurysm is a well recognized complication of pancreatitis. angioembolization is considered to be the first option of treatment. to our knowledge, the case we hereby report is the first one with successful re-angioembolization. case: a -year-old man, with aids, history of cns toxoplasmosis, chronic pancreatitis with pseudocyst secondary to alcohol abuse, was hospitalized for pneumonia. during his hospitalization, he developed abdominal pain and hypotension. after resuscitation, ct angiogram of the abdomen revealed active bleeding into a pseudo-aneurysm, near the head of the pancreas, measuring . x . cm and arising from superior and inferior pancreaticoduodenal arteries. this was confirmed by angiogram. angioembolization distal and proximal to the bleeding area was performed using coils. eight days later, the patient became hypotensive and dropped his hemoglobin again. he was taken for an emergency laparotomy which revealed a cm pancreatic pseudocyst with hemorrhage. the pseudocyst was opened through the medial wall of the duodenum, ligation of the bleeding intracystic vessels, and cysto-doudenostomy were performed. his postoperative course was uneventful and he was discharged home on postoperative day . five days later he was readmitted with hematemsis and anemia. celiac angiogram revealed bleeding from the gastrodoudenal artery which was embolized. he died months later due to hiv nephropathy without any evidence of re-bleeding. objectives: any sort of discomfort in the abdominal cavity that lasts less than week is defined as acute abdominal pain. the purpose of the study was to evaluate the outcome of hospitalized patients with unspecified acute abdominal pain following initial clinical and laboratory evaluation. method: from january to december , patients with acute unspecified abdominal pain were admitted to surgery department. gender, age, definite diagnosis, time from hospitalization to surgery and hospital length of stay were retrospectively reviewed. results: fifty-six of the patients with acute unspecified abdominal pain were females ( %) and were males ( %), median age was years (range - ). while definite diagnosis was confirmed in patients ( %), the initial diagnosis was not changed in patients ( %). distribution of new diagnoses were appendicitis (n = ), gastroenteritis (n = ), genitourinary disorder (n = ), familial mediterranean fever (n = ), inflammatory bowel disease (n = ), mesenteric adenitis (n = ), peptic ulcus perforation (n = ), constipation (n = ), diverticular disease (n = ), pneumatosis intestinalis (n = ), hepatobilier disease (n = ) and intra abdominal tumor (n = ). depending on the cause of abdominal discomfort, patients ( %) required surgical intervention. median time from hospitalization to surgery was h (range - the use of temporary skin substitutes (tss) is a useful technique in the treatment of full-and partial thickness burn wounds affecting a large body surface area. early excision of the eschar is mandatory. but if we cannot find sufficient donor site, tss using seems to best choice. the ideal tss must be has some properties: adherence, control of water loss, safety, flexibility, stability on wound surfaces, bacterial barrier, and ease of application, ease storage and cost effectiveness. case report: a -year-old girl was admitted to our burn center with deep flame burns affecting face, thorax, upper and lower extremity ( %). she underwent an early burn excision on day post-burn day. the whole area excised with hydrosurgically was covered with biobrane Ò and compressive dressing. seven days after we removed biobrane from the upper and lower extremities and grafted the wound bed. face healed spontaneously under the tss and tss covering the thorax was rest intact. after days thoracic tss was removed and grafted and we covered the thorax with biobrane Ò over the grafts again. after days a second grafting was needed. patient was discharged from the hospital th post-burn day. the use of biobrane Ò as a tss after burn wound excision was satisfactory, because it enabled us to delay auto grafting until we were sure of good conditions in the wound bed. also it proved to be a good dressing over the meshed autografts. it reduces the healing time and improved the quality of grafts. introduction: endoscopic examination of the colon during the diagnostic or treatment purposes, perforation incidence is reported between . and . %. determination of risk factors may decrease the incidence with early recognition of the serious complications of surgery may reduce interference. method: we have examined retrospectively the patients in whom colon perforation appeared due to endoscopic analysis of colon carried out at endoscopy unit between january and december . results: total colonoscopy and rectosigmoidoscopy were applied to , patients. in patients ( . %) perforation was observed. the median age was . ( - ), m/f: / . all colonoscopys were made for diagnosis; anemia in two, hemorrhodial disease in one, subileus in two, anal prolapsus in one, right colon tumor suspation in one patients. one sigmoid polypectomy was applied, diverticulosis disease of the colon in two patients, dolichocolon in one, one previous pelvic surgery were observed. perforation zone was observed in sigmoid colon in all patients. four patients were diagnosed in the process of colonoscopy ( . %), were diagnosed in - h ( . %), was diagnosed days later. laparotomy was applied to all patients. perforation zones of patients were fixed primarily and these patients were discharged as cured. one patient who was applied to diversionary ostomy was reoperated due to abdomen collection. no mortality was observed. conclusion: colonoscopic perforation is a rare, serious complication. sigmoid colon is the location where the perforations are mostly observed. although primary fixation is generally efficient in cases of early diagnosis, morbidity increases seriously due to late diagnosis. with more than one stomas. eleven patients were discharged with planned ventral hernias. primary abdominal closure succeeded in four patients. fasciitis due to severe peritonitis and stomas prevented primary closure. eighteen of patient died during treatment, were discharged. sixteen of patients with more than one bag were died, five survived (mortality . %). conclusions: morbidity and mortality were higher in patients with more than one stoma than patients with single stoma. second stoma has a negative effect on primary fascial closure. fasciitis due to severe peritonitis also prevents fascial closure. acute diaphragmatic hernia after minimally invasive esophagectomy the aim of this study was to evaluate the disease profile and mortality ratio of patients presenting with acute abdomen. four hundred fifty eight patients who underwent surgery with the diagnosis of acute abdomen were analyzed retrospectively. the effects of age, sex, american society of anesthesiology (asa) class, accompany disease, admission time after the onset of the symptoms, follow up interval before the operation on mortality and length of hospital stay were evaluated. male/female ratio was . , and mean age was . . main causes were biliary system disease ( . %), intestinal obstruction ( . %), peptic ulcer perforation ( %) and acute appendicitis ( . %). median asa class was and . % of the patients had at least one preexisting disease. mortality ratio was . %. asa class, age, preexisting diseases other than malignity, period between the onset of symptoms and admission, follow-up time was significantly effective on mortality. background: resveratrol is a strong antioxidant with antiinflammatory effects. we aimed to investigate the effects of resveratrol on oxidative injury, histopathology and bacterial translocation in induced i/r injury in rats. methods: female wistar-albino rats were randomly allocated into four groups; sham-operated group(laparotomy without i/r injury), i/ r group (laparotomy plus min of ischemia followed by min of reperfusion), alcohol group (only . % ethyl alcohole . ml/day intraperitoneally for both days before surgery and min before ischemia), resveratrol group ( mg/kg resveratrol intraperitoneally both days before surgery and min before ischemia. intestinal tissue samples were obtained for investigation of tissue levels of malondialdehyde (mda), nitric oxide (no), superoxide dismutase (sod), myeloperoxidase (mpo) and histopathologic evaluation bacteriological translocation (bt) in mesenteric lymph node (mln), liver and spleen was also studied. results: resveratrol significantly decreased mda, no and mpo levels in i/r injury (p < . ). sod activity of resveratrol-treated group was significantly lower than sham group and significantly higher than i/r and i/r + alcohol groups (p < . ). histopathologically, the median intestinal injury score in i/r and i/r + alcohol groups was significantly higher than in sham and resveratrol-treatment groups (p < . and p < . , respectively). the incidence of bt differred between the groups i/r and i/r + alcohol in mlm, spleen and liver (p < . ). nevertheless, the treatment with resveratrol reduced bt to mln, spleen and liver, compared to other i/ r groups (p < . gastrointestinal stromal tumors (gists) represent rare neoplasms of the gastrointestinal tract. here we describe a case with gist and thrombocytosis presenting as an acute abdomen. our knowledge, the co-existence of gist and thrombocytosis has not been reported so far. case: a -year old female was admitted to the emergency room with epigastric pain and vomiting over duration of days. physical examination showed abdominal distension, rebound tenderness, and a palpable rlq mass. the laboratory findings were, wbc: . /l, plt · - /l and c-reactive protein . mg/l. a computed tomography scan of the abdomen showed conglomerate of small bowel. the abdominal exploration showed that a · · cm mass was located on small intestine. the mass was completely resected and enteroenterostomy was performed. the histological examination demonstrated whirling sheets of spindle cells which were stained positively for cd (c-kit) and cd , mitotic index > / hpf, while smooth muscle actin and vimentin were focally positive, and keratine, desmin, s- protein were negative. this specific immunophenotype characterized gist. during the post operative follow up, platelets were above normal levels · - /l. therefore, bone marrow biopsy was performed. hiperplasia in megakaryocytes were found. the patient was negative for bcr-abl and philadelphia chromosome. discussion: here we describe a case with gist and thrombocytosis presenting as an acute abdomen. ten percent to % of these tumors are biologically aggressive; signs of malignant potential are metastases and invasion. the current treatment for localized disease is surgical resection. co-existence of thrombocytosis and gist has never been reported. laboratory tests showed no abnormality except white blood cell count of /ll.plain abdominal x-ray and ct did not show any abnormal findings including free air (fig. ) . endoscopic examination of the stomach revealed an ingested toothpick protruding from the prepyloric antrum (fig. ) . the toothpick was deeply fixed into the antral wall. the whole toothpick . cm in length was removed using a loop without damage to the gastrointestinal wall, bleeding or any other complication. after endoscopic removal of the toothpick, her epigastralgia resolved. on the second hospital day, the patient was asymptomatic. medical therapy with proton pump inhibitor was stopped and she was discharged on the third hospital day. conclusion: accidental ingestion of foreign bodies is common and in general harmless. a perforation of the gastrointestinal tract by ingested foreign bodies is rare, occurring in less than % of ingested bodies like toothpicks are involved in less than . %. occasionally, the passage of the swallowed item may stop at one of the anatomic bottlenecks of the gastrointestinal tract, which may lead to perforations that may require operative or endoscopic interventions. results: we analyzed the number, causes and rates of emergency operations. the total number of emergency operations was , and , , for the first and second groups, respectively. we observed an % decrease in number of emergency operations for the second group. we also observed that the cause of majority ( % for the first group, % for the second) of the emergency operations was acute abdomen and the rate between the groups did not change. lower extremity amputation and strangulation hernia operations decreased and %, respectively. the number of operations which are caused by ileus and acute cholecystitis increased and %, respectively. conclusions: difference in distribution of emergency operations between two groups was statistically insignificant. however, we observed both an increase and a decrease in small numbers of some subgroups. it is believed that this is related to the change in patient profile and technological improvements in surgery. aim: we hypothesized that one of the most widely used anesthetic agents, propofol, may reduce inflammatory processes, and organ injury induced with cecal and ligation puncture study design: bacterial peritonitis was induced in rats by cecal ligation and puncture. the rats were randomly assigned to three groups. group (n = ) received propofol, group (n = ) received intralipid, group (n = ) was control, which did not receive any injection. all animals were killed days later so we could assess the adhesion score. tissue antioxidant levels were measured in -g tissue samples taken from the abdominal wall. results: the adhesion score was significantly lower in the propofol group than in the control group (p < . ). the catalase levels were higher in the intralipid and control groups than the propofol groups. conclusions: intraperitoneal propofol reduced the formation of postoperative intra-abdominal adhesions without compromising wound healing in this bacterial peritonitis rat model. propofol also decreased the oxidative stress during peritonitis approximately, min after the onset of the operation, a sudden decrease in end-tidal carbon dioxide from to mmhg was noticed. soon after, both systolic arterial pressure and heart rate decreased dramatically. arterial blood gas measurements showed that pco was mmhg at that moment. surgery and insufflation of gas was stopped, ephedrine mg was given intravenously and ventilation with % o was started. trendelenburg position was achieved immediately. a catheter was introduced through the right juguler vein to the right atrium rapidly and - ml gas bubble was withdrawn. soon, hemodynamic measures were recovered. since substantial amount of blood in the peritoneum was noticed, conversion to laparotomy with subcostal incision was performed. at exploration, through and through tear of mm in inferior vena cava was detected. the defect was sutured with / polypropylene. anesthesiologist and surgeon must be aware of this dangerous complication. the emphasis is given to the prevention and prompt recognition of this event to the use of available tools in the management of cardiovascular complications. aim: obstructive jaundice, develops accompanied with high morbidity and mortality rates. the absence of bile in bowels leads to bacterial translocation and ultimately to endotoxemia and septice-mia. _ in our study, observing changes on bowel level during obstructive jaundice and examining its contribution to bacterial translocation have been aimed. material-methods: the study has been carried out at _ istanbul university _ istanbul faculty of medicine experimental medical research center (detam) with approval of _ istanbul university _ istanbul faculty of medicine ethical board for animals. two groups out of male wistar albino rats have been formed. one hour after injecting d-xylose to first group the rats were put to sleep (anesthetized) and specimens of tissue (liver, spleen, mesenteric lymph nodes) and blood were taken for microbiological and biochemical examinations. in the second group an obstructive jaundice has been established by ligation of common bile ducts. the same specimens were obtained after days. findings: in the first group no proliferation on tissue and blood cultures were detected. an obstructive jaundice has been shown in biochemical investigation of blood. d-xylose was found to be . ± . mg/dl. in the second group, proliferation, of mainly e. coli, were detected on cultures and d-xylose was found to be . ± . mg/dl. statistically significant increases were assigned between groups, between tissue and blood cultures (p < . ) and d-xylose values (p < . ). results: detecting statistically significant increases in d-xylose levels in the second group leads to the conclusion that increases in bowel permeability plays an important role in bacterial translocation. conclusions: while wound infections were higher in open appendectomy procedure group, surgical time was higher in laparoscopic procedure group. the achievement of optimal results will be based on increasing surgical laparoscopic experience. objectives: intraabdominal hypertension (iht) in intensive care units is a common problem. investigation of the effects of dexmedetomidine on respiratory system in rats with iht was aimed. patients and methods: adult wistar-albino male rats were anaesthetized by rata ''ksalazin/ketamin'' combination. experimental model of iht( - mmhg) was induced via pressure cuff. rats were left to spontaneous respiration for h prior to randomly division into four groups. the first group underwent no process (control group). in sf group; cc of . % nacl,in the third group; . lg/kg dxmt and in the last, . lg/kg dxmt were intravenously administered. thereafter min passed to observe the effects of dxmt. the rats were killed via cervical dislocation prior to surgery. lung tissues were fixed in % formalin and stained with he. whereas the other cross sections were stained with tunel method,the rest were stained with anti-caspase , , and anti-fas/fasl antibodies for immunohistochemical analysis. results: histological changes in group were the less. there were no atalectatic changes in the same group. pnl infiltration and interalveolar thickness were higher in the . lg/kg dxmt group than others. in indirect immunohistochemical studies, in the . lg/kg dxmt group, immunoreactivity of caspase and were increased. however, the caspase- immunoreactivity was less than caspase- . these results supported that . lg/kg dxmt administration led apoptosis, even though to be delayed, to start and showed that extrinsic pathways was used through apoptotic pathways. it was concluded that low dose of dxmt caused to delay in apoptosis in the lungs. results: a total of microorganisms were responsible for the cris, of which ( . %) were gram-positive bacteria, ( , %) were gram-negative bacteria and ( . %) were candida species. isolated from the microorganisms were: klebsiella pneumoniae ( %), acinetobacter ( . %), enterobacter ( . %), rroteas mirabilis ( . %) pseudomonas aeroginosa ( %), staphylococcus ( . %). patients ( . %) developed crbsis and in patients with positive blood cultures cris were negative. in our study, femoral venous access was associated with a significantly higher incidence of cri and crbsi than jugular and subclavian access; and jugular access was associated with a significantly higher incidence of cri and crbsi than subclavian access conclusion our results suggest that the order for punction, to minimize the cvc-related infection risk, should be subclavian (first order), jugular (second) and femoral vein (third). introduction and objectives: undescended testis is a risk factor for the testicular carcinoma, especially a seminoma. seminoma can be seen at any age, but it is considerably rare in elderly patients. we describe a patient who presented with acute abdomen secondary to an ileum perforation due to the involvement of seminoma. case: a year-old man complaining with right lower abdominal pain and a palpabl mass with a -week history was evaluated. an abdominal computed tomography was showed a large, solid, welldefined intraabdominal mass, measured about · ·x cm in right quadrant of lower abdomen. an exploratory laparotomy was adjudged to perform. whilst the preoperative investigations for surgery were continued, the patient admitted to the emergency service with acute abdomen symptoms, which was started suddenly. he had peritoneal irritation signs. he underwent an urgent laparotomy and a large mass located on terminal ileum mesenter through the retroperiton was detected. dilated ileum segments with omentum wrapped along the antimesenteric border of the distal ileum was found. on separating omentum from ileum, perforation along the antimesenteric border was noted. extended right hemicolectomy and an end ileostomy was performed. histopathologic examination revealed a classical seminoma with extensive tumor necrosis and showed evidence of vascular invasion. conclusions: undescended testes should be considered in men with an intraabdominal groin mass and should be aware of its potential complications. department with diagnosis of acute cholecystitis and on exploration giant gallbladder with giant stone and gallbladder adenocarcinoma. case: a years old female was applied to emergency department with abdominal pain, nausea and vomiting. on physical examination, right upper quadrant tenderness and defence were detected. murphy sing was positive and gallbladder was palpable on subcostal space. in laboratory tests, white blood cell count was , /mm , glucose was mg/dl and liver function tests were minimally elevated. in hepatobiliary ultrasonography, the gallbladder was hidropic ( · cm) and there was a stone ( cm in diameter) and a mass ( · cm) in the gallbladder.cholecystectomy operation was performed. acute cholecystitis + cholelithiasis + adenocarcinoma were reported in the histopathological evaluation. conclusion: the carcinomas of the gallbladder were associated with gall stones in - % of the patients. we concluded that the presence of the symptoms in our patient was delayed due to the magnitude of the gallstone and the excessive size of the gallbladder. perforation of the gallbladder by trans-gastric migration of a sewing needle _ ingestion of foreign bodies is a common problem, especially in the elderly, pediatric, and psychiatric population, but fortunately, most of them pass spontaneously and uneventfully within week.the perforation and migration of ingested foreign objects into the abdominal cavity is very rare and usually leads to a laparotomy. perforation of the stomach by sewing needle with migration to the gallbladder is extremely rare, and none cases have been reported in the literature. a -year-old woman was admitted because of abdominal pain and a history of a swallowed sewing needle month ago. she had been followed-up at her local hospital and referred to our hospital because of the failure of progression of the foreign body. physical examination showed right upper quadrant tenderness, guarding, and a positive murphy's sign. blood analysis showed increased white blood count. she was submitted to abdominal plain x-rays, which revealed a radio-opaque objects in the liver area with the form of the sewing needles. the patient was clinically stable, and a semi-urgent laparotomy was planned. at laparotomy the needle was in the gallbladder and that the end of the needle could be palpated and the site of gastric perforation. removal of the intra gallbladder needle did not cause any problem. we was performed cholecystectomy and primary gastroraphy. the postoperative period was uneventful and the patient was discharged on seventh day of the operation. if there is a history of sewing needle ingestion and failure of progression and also signs of an acute abdomen, the surgeon must carefully evaluate gallbladder. introduction: sigmoid volvulus is an unusual intestinal obstruction form ( ) . it is most common in the middle aged, elderly, institutionalized or neuropsychiatric patients ( ). patients and methods: twenty-one sigmoid volvulus patients were reviewed retrospectively between and .the recorded data were age,gender,admission symptoms,physical examination,radiological, and operative findings, surgical procedure, postoperative complications, mortality, and hospital stay.there were male and female patients. the mean ages of the patients was . years ( - ).the most common symptoms in acute abdomen patients were pain, and tenderness. abdominal distension were the most recorded sign in patient without peritonitis. the mean admission time was . days ( - ). five patients had a history of sigmoid volvulus ( %). leukocytosis and high fever were found in ( %) patients. radiological evaluation of the patients revealed sign of intestinal obstruction (n = , %),frimann-dahl sign (n = , %) and bilateral free air under diaphragm due to perforation of the twisted sigmoid colon (n = , . %). no patient underwent contrast enema examination of the colon. the mean hospital stay was . days ( - days) . two patients without signs of peritonitis were treated by sigmoidoscopy and operated on elective course.patients with signs of acute abdomen were operated urgently. the patients had several associated diseases such as atherosclerotic heart disease, diabetes mellitus, hypertansion, chronic obstructive pulmonary disease, cerebrovascular disease. eight patients ( %) died due to sepsis. morbidity rate was %. wound infection, evisseration pneumonia, and acute renal failure were found in ( %) patients. the principal strategy in treatment of sigmoid volvulus is early nonoperative detorsion followed by elective surgery consist of colectomy and anastomosis on well-hydrated patient. urgent laparotomy is indicated in case of peritonitis. sigmoidopexy is an alternative option but it is usually ineffective and has high recurrence rate. results: ten men and four (six) female were enrolled in the study. mean age was years (range - ). e.coli and acinetobacter were the common organisms cultured. all patients were treated with a common approach of resuscitation, broad spectrum antibiotics, and wide surgical excision. objectıves: acute appendicitis is one of the most common nonobstetric surgical pathology. clinical symptoms and findings are masked due to anatomical and physiological changes of peregnancy, so diagnose and treatment of acute appendicitis in pregnancy generally late. the curent study reported the cases which were diagnosed acute appendicitis in pregnancy and promptly operated in our general surgery clinic. material-methods: we evaluated sixteen cases' data between october and october who admitted to emergencey department with abdominal pain, vomiting, nausea and anorexia complaints and diagnosed as acute appendicitis in pregnancy and operated. results: the average of the cases were . (range - ) and thirteen of them were second, two of them were third and one of them was in the first trimester. the time interval between the onset of the complaints and operation was . (range - ) days. upon physical examination, there were rebound tenderness present in cases, muscular rigitide in three cases, right lower quadrant pain in nine cases and widely irration of all abdominal guadrant in four cases. there were not any maternal mortality and morbity after operation, however in only one case fetal mortality was observed inevitable abortion due to vaginal bleeding. conclusion: in our cases acute appendicitis was diagnosed frequently in the second of the pregnancy with abdominal pain symptoms and rebound tenderness findings. recognition is important because early diagnose and prompt surgical intervention can reduce maternal and fetal mortality and morbity in acute appendicitis. introduction and objectives: conservative management of penetrating trauma has been mainly advocated in centres with a high incidence and large experience with those injuries. our aim was to assess the preventable death rate in our patient population, and the failure rate of conservative management. introduction and objectives: the data about role of amelogenin that is an extracellular matrix protein, during the healing process of the gastrointestinal anastomosis is lacking. in this study, the effects of amelogenin treatment on normal and ischemic colon anastomosis were evaluated. methods: adult male wistar albino rats weighing - g, were divided into four weight-matched groups: normal colon anastomosis group (n = ); amelogenin treated normal colon anastomosis group (n = ); ischemic colon anastomosis group (n = ); amelogenin treated ischemic colon anstomosis group (n = ). sufficient equal volume of amelogenin to entirely cover the anastomosis area had been applied. all animals were killed on postoperative day . bursting pressure levels were measured. peri anastomotic colon tissue hydroxyproline, catalase (cat), cu-zn superoxide dismutase (sod), glutathione (gsh), malondialdehyde (mda) and nitric oxide (no) levels were assessed to evaluate oxidative stress. results: bursting pressure levels of the ischemic colon anastomosis group is significantly lower than the normal colon anastomosis, the amelogenin treated normal colon anastomosis and the amelogenin treated ischemic colon anastomosis groups respectively (p = . , p = . , p = . ). hydroxyproline level of the amelogenin treated normal colon anastomosis group is significantly lower than the normal colon anastomosis and the ischemic colon anastomosis groups respectively (p = . , p = . ). gsh level of the ischemic colon anastomosis significantly lower than the amelogenin treated normal colon anastomosis group and the amelogenin treated ischemic colon anstomosis group respectively (p = . , p = . ). conclusions: amelogenin treatment could support the physical strength of ischemic colon anastomosis and effect oxidant/antioxidant response positively. introduction: meckel's diverticulum is the most common congenital anomaly of the gastrointestinal tract, occuring in - % of the population. in the majority of patients, meckel's diverticulum is asymptomatic. we report our experience with the management of complicated meckel's diverticulum in adults. methods: between april and january , the data of seven patients ( males and females) aged - years who underwent surgery due to complications of mechel's diverticulum was retrospectively evaluated. results: of the seven patients, three presented with acute surgical abdomen, two had abdominal pain mimicking acute appendicitis, one had incarcerated incissional hernia, and one had intussusception. intraoperative diagnoses were as follows; littre's hernia in one, ileoileal intussusception due to meckel's diveticulum in one, diverticulitis in two, perforation of the diverticulum in three patients. while diverticulectomies were performed in five patients, two had small bowel resections. in addition to, appendectomy was performed in four patient. all the patient had an uneventful recovery except one, who experienced a postoperative wound infection. the hospital stay was - days. ectopic gastric mucosa was found in two cases. in one case, neuroendocrine tumor was detected in the appendix. conclusions: meckel's diverticulum is an uncommon cause of acute abdominal disease in adults. meckel's diverticulum presents distinctive challenges to a clinician, as it is prone to varied complications such as intestinal obstruction, diverticulitis, perforation. the diagnosis of meckel's diverticulum is difficult to establish preoperatively, and index of suspicion is necessary in patients with an acute abdominal illness. introduction: pneumatosis cystoides intestinalis is a pathologhy which is rarely incidentally seen and is characterised with submucosal or subserosal air cysts. there is no surgical indication in asymptomatic cases. surgical treatment is needed in the development of complication or the possibility of risk. a patient who is hospitalized with diagnosis of pyloric stenosis and is detected pneumatosis cystoides intestinalis incidentally at the operation is presented. case: year old male was admitted our emergency department with vomiting weight loss complaints. pyloric stenosis was diagnosed by radiologic and endoscopic examination. he was hospitalized and acute abdominal signs developed. free air was detected in radiologic examination. surgery was performed. pyloric stenosis and pneumotosis cystoides intestinalis in jejenum were diagnosed. biopsy specimen was obtained from the cysts in jejunal serosa. subtotal gastrectomy, gastrojejunostomy and bilateral truncal vagotomy were performed for the pyloric stenosis. result and discussion: there is no surgical indication in asymptomatic cases. pneumotosis cystoides intestinalis commonly accompony pyloric stenosis and perforation of the cysts may bring out acute abdominal symptoms. knowing this pathology, we may avoid unnecessary emercent laparotomies. aim: in urgent surgical procedures for peptic ulcer perforation, there is considerable postoperative morbidity and mortality. this study aimed to describe and analyze the risk factors that determine beforehand morbidity and mortality in cases with perforated peptic ulcer. materıals-methods: age, sex, co-morbid diseases, symptom duration, abdominal air, amount of intra-abdominal liquid, location and diameter of perforation, operation, and the mannheim peritonitis index (mpi) score were prospectively analyzed in cases. significant risk factors that cause morbidity and mortality were determined through a statistical study. results: the study sample consisted of a total of cases ( males and females) with a mean age of (range - ). duodenum and stomach perforations were detected in and . % of the cases. in cases ( . %), a total of complications were detected. the mortality rate was . %. statistical analyses revealed significant relationships between morbidity and > age (p = . ), co-morbid disease (p = . ), perforation location (p = . ), type of operation (p = . ), and mpi score (p = . ). the factors significant for mortality included > age (p = . ), co-morbid disease (p = . ), > h of symptom duration (p = . ), > cc intra-abdominal liquid (p = . ), a perforation diameter of > . cm (p = . ), omentopexy (p = . ), and a mpi score of > (p = . ). conclusion: factors such as age, co-morbid disease, prolonged perforation duration, amount of intra-abdominal liquid, perforation diameter, type of surgical operation, and mpi score were significant for mortality. the present study found that primary suture is a safe procedure for cases with peptic ulcer perforation. introduction: the presence of foreign objects in the rectum is a rare encountered situation. these objects are usually inserted transanally or swallowed as foreign objects. this study was conducted to investigate the results of patients admitted to our clinic with a rectal foreign body. methods: data of patients who admitted to our clinic between and were evaluated retrospectively results: mean age of the population was . . the foreign object was taken out in the proctological position in patients. in patients these methods failed and laparatomy was performed and the objects were taken out transanally without colotomy. in three patients symptoms and signs of peritonitis were significant at admission and all of them were lost because of rectum perforation followed by septic shock. distribution of foreign objects was: six deodorant lids, five glass bottles, two aubergine, a glass, a salt cellar, a piece of plastic pipe, a vibrator, a plastic cover, a chocolate cover, a chicken bone, a fish bone, needles, a spiral, coins and key, a piece of thermometer, teeth prosthesis and soap. mortality was seen in three patients. the presence of foreign objects in the rectum is a rare encountered situation which should always be kept in mind for differential diagnosis. most of these objects can be taken out transanally. if this fails, all efforts must be shown to take it out without opening the colonic lumen. because of potential complications, the surgeon must be careful during intervention. median age of the alive was . median leukocyte number at the moment of appliance was . , median debridement . and median inpatient stay were determined as days. median age of the dead . median leukocyte number at the moment of appliance was . , median debridement . and median inpatient stay were determined as days. the most common reason of the aetiology was determined as perinal abscess. diversionary ostomy was applied to six patients. chronic kidney failure, and type diabetes was exist in four patients of dead-group. in addition, in one patient type diabetes and hypertension was observed. conclusion: chronic kidney failure related to hemodialysis and high level of lekucyte number at the moment of appliance are the important prognastic factors of deaths related to fg. computed tomography (ct) has become the mainstream of evaluating all hemodynamically stable patients with acute problems when the attending doctor, is urging for diagnosis. basing a diagnosis solely on radiological data sometimes ignoring medical history and physical examination may lead to unexpected errors. wrong interpretation of radiological images or images with equivocal findings which may delude the radiologist and technical errors (artifacts) are all potential sources of mistakes. the aim of this study is to draw attention to the danger of the modern imaging diagnostic modalities to misguide the treatment of patients who need emergency care. we present some cases we faced in our clinic where radiological images showed pathologic entities which in fact did not exist (false positive errors) but forced us to inappropriate treatment. two patients underwent negative laparatomies with imaging diagnosis of a ruptured gallbladder in one case and free air under the diaphragm in the other. a patient with a severe head injury and a ct scanning showing pneumocephalous was transferred to a tertiary centre to be proved on repeated images that initial diagnosis was mistaken due to a wrong calibration of the gantry. imaging findings do not necessarily represent reality. almost always surgeons rely on ct scans for treatment decisions. it is a hard task for a surgeon to question or ignore the pictures to treat a patient based on medical history and physical examination. experience of radiologist is essential and close cooperation with the attending surgeon is needed to avoid radiological misfindings in emergency cases. author to editor: to be presented as a poster. a full text is available on demand. intentional own insertion of rectal foreign bodies in a married, claimed to be straight male, using antidepressive medicaments because of sexual orientation disorder, resulted in resurgery with the same reason of mechanical intestinal obstruction after years in the same surgery clinic by the same surgery team as an emergency intervention. failure of the nonoperative measures under local, spinal and general anesthesia led to the surgical treatment of the -year-old patient in and , who is now years old during the second event. large bottles were removed through laparotomies and colotomies followed by primary repair to reverse the ongoing ileus, which resolved on the th postoperative days in both events. a surgeon who is called to see a patient with retained foreign body should answer whether the patient had rectal perforation and whether the foreign body could be removed transanally without regional or general anesthesia with or without surgical intervention. in case of children; habitually self inserting objects in her vagina or sexually aggressive behaviour with others, e.g. for a boy ''humping'' toys in sexual positions can be a behavioural indicator of child sexual abuse or assault. hence message is: if in a patient perforation of sigmoid colon or rectum history after anal insertion of foreign body in an otherwise healthy adult becomes habitual,the patient should be send to psychiatric counselling. discussion of the nonoperative measures to remove rectally inserted objects is also an utmost important opportunity constituting the largest part of the report of the present case. necrotizing fasciitis is a highly morbid and mortal condition. as a result of aggressive debridement, wide tissue defects occur. wound cleaning from infective material, granulation process and grafting of wound requires a long time. recently, a vacuum assisted therapy system has begun to use for this kind of wounds. this study discuss the treatment result of vacuum assisted therapy (vac Ò therapy tm ) in two patients with giant abdominal wall defect in view of current literature. case : a years old man had an operation because of an accident on railway. at the time of admission there was a wide defect with necrotizing fasciitis on the right lombar region and anterior abdominal wall. there was a full thickness defect about · cm after an aggressive debridement. it was successfully treated with vac and the patient has been discharged after tissue grafting on the postoperative day . case : a years old man had an operation because of an accident. he was admitted at postoperative day . he underwent an aggressive debridement because of necrotizing fasciitis. the skin, rectus abdominus, transversus abdominus, internal and external oblique muscles and some part of quadriceps femoris on the left side was excised. the sacroiliac joint was also broken and pubis was separated. vac abdomen has been applied on two different sites and the wound has become available for grafting after days of therapy. as a conclusion, vacuum assisted therapy provides safe and accelerated wound healing, improves proper tissue granulation in patients with giant abdominal defect. introduction: bogota bag (bb) is a device used for the temporary closure of the abdominal wall (aw). despite its potential benefits, their use is not widespread and remains controversial in the present. aım: to describe our experience in its management for the temporary closure of the aw in emergency situations. methods: for a period of years, bb has been used in patients (pts), with an average age of . years. six had a secondary peritonitis, one tertiary peritonitis, two haemoperitoneum and one a compartment syndrome established. the technique consisted of the placement of a bag of sterile serum, stitched to the skin with nonabsorbable material. results: the average of bags placed by year was . . no morbidity was associated with the placement and/or replacement of bb. the average time of hospitalization was . days and the average time of income in the icu was . days. in pts, the bag was replacement one or more times. the average number of surgical interventions by patient during the income was . . the average time of permanence of the patient with the bag was . days. sixty percent of patients are alive today. objectıves: the aim of the current study is to assess the role of ultrasonography in the management of acute appendicitis. methods: ultrasonography was performed to patients with acute appendicitis suspicion between and . appendectomy was performed to patients with acute appendicitis diagnosis according to clinical examination after ultrasonography. patients who had a diagnosis different from acute appendicitis with clinical examination were observed. the histopathological findings of patients with appendectomy were compared with their usg findings. results: of patients had acute appendicitis diagnosis by ultrasonography. hystopathological examination showed acute appendicitis in of these patients. patients did not have acute appendicitis. usg showed that patients did not have acute appendicitis. ten of these patients showed gynecological pathology, and six of them showed urinary pathology, and they were all treated appropriately. in eight patients the appendicitis findings became evident in clinical observation; resulting in appendectomy, and histopathological examination showed acute appendicitis. forty patients showed improvement at follow up. no spesific treatment was needed. misdiagnosis rate was determined as . %. the sensitivity, specificity, positive predictive value, negative predictive value and accuracy percentage of ultrasonography in the diagnosis of acute appendicitis was . , . , . , . and . %, respectively. conclusion: ultrasonography has a high degree of accuracy in the diagnosis of acute appendicitis. however, we also conclude that ultrasonography results should always be interpreted in combination with clinical findings. background: hydatid cyst disease is frequent in some regions of the world, including our country turkey, and is most commonly located in the liver and lungs. the hydatid cysts may rupture spontaneously or as a result of trauma. herein, we describe a rare case of retrovesical hydatid cyst which was resulted from rupture of spontaneous rupture of liver hydatic cyst intraperitoneally. case: fifty-four years old male was admitted to emergency department with complaints of frequent urination and abdominal pain lasting for days. there was general abdominal tenderness on physical examination. there was no history of trauma or operation. in his abdominal ultrasonography and tomography there were primary cyst ( · cm), ruptured cyst ( · cm) and retrovesically located cyst ( · cm). indirect hemagglutination test was positive for echinococcus granulosus ( / , ) . laparotomy was performed and all the cysts were excised by partial cystectomy. there was no postoperative complication. the patient was externalized on postoperative th day with albendazol treatment. conclusion: retrovesical localization of hydatic cyst is a very rare. these cysts mostly occur as a result of surgical inoculation caused by inadequate surgery or free intraperitoneal rupture of primary hydatic cyst. in endemic regions, possibility of hydatic cyst should be kept in mind in differential diagnosis of intrapelvic cysts and masses. background: wegener's granulomatosis (wg) is a systemic necrotizing vasculitis of unknown etiology characterized mainly by involvement of the upper airways, lungs, kidneys and may rarely involve the gastrointestinal tract. intestinal involvement may be asymptomatic. we herein report a wg with massive lower gastrointestinal hemorrhage due to colonic involvement. case: the patient complained of dyspnea which started months ago, fatigue, generalized arthralgia and myalgia together with loss of sensation on right upper extremity was applied to emergency and hospitalized by internal medicine department. physical examination revealed a very ill-looking patient, there were positive lung findings for wg and c-anca was positive. we consulted the patient because of hematochesia with abrupt drop of hemoglobin and platelet count. on colonoscopy whole mucosa was full with fresh blood from sigmoid to anal canal. on angiography multiple foci of bleeding were demonstrated on descending and sigmoid colon. embolectomy was not performed because of multiple foci. hemoglobin decrease continued and his clinical condition deteriorated; an explorative laparotomy and total left colectomy was performed. his melena persisted for days but hemoglobin was maintained at after units transfusion after operation. conclusion: we herein report a case with clinical wg who developed a gastrointestinal hemorrhage and treated by surgery. the uremic state and cytotoxic agents given to patients may detoriated the gastrointestinal bleeding. immunosuppressive therapy might exacerbate gastrointestinal complications. the clinicians should be aware of this situation, therefore treatment of these must be performed in centers where angiography and endoscopy are available. background: the aim of this study is to determine the strength and proceeded efficiency of mda, sod, and catalase levels that are indicators of oxidative stress in generalized peritonitis. material-methods: this study was conducted as prospective and randomized with patients who applied at dicle university, department of general surgery between march-september . patients were composed as group (n = ); generalized peritonitis, group (n = ); laparotomy under elective conditions and not present peritonitis; group (n = ) as control group. in order to measure limits of mda, sod, crp and catalase, blood samples were drawn from the patients in group and group on before operation day (bod), st and rd days. the mda values of group on before operation day, st and rd days were compared to group and , the difference were found statistically meaningful. statistical differences noticed between group and mda values on bod, st and rd days. statistical differences were noticed between catalase values measured bod and rd days when group and values compared to group . the sod values of group and group on day were compared to group , meaningful statistical difference was found. statistically meaningful difference was found between the sod values group and on st day. conclusion: values of sod, mda and catalase were noticed usable parameters for the following and detection of severity of generalized peritonitis sinan cumhur karakoç, gü rkan yetkin, _ ismail ethem akgü n, mehmet uludag, bü lent Ç itgez, hamdi Ö zş ahin, cabbar kartal general surgery departmet, Ş iş li etfal training hospital, istanbul, turkey objectıve: we aimed to evaluate the effects of early cholecystectomy on morbidity and patient comfort in patients with acute biliary pancreatitis. methods: patients who underwent cholecystectomy for acute biliary pancreatitis in our clinic between and were evaluated retrospectively. the patients were divided into three groups as early, late and elective cholecystectomy cases. fındıngs: patients who had undergone cholecystectomy operation in the first days until the administration to hospital were classified as the first group (early cholecystectomy). patients who had undergone cholecystectomy between the nd and th weeks until the administration to hospital were classified as the second group (late cholecystectomy). patients who had undergone cholecystectomy after weeks were classified as the third group (elective cholecystectomy). in group , no patient had pancreatitis attacks; of patients in group had recurrent pancreatitis attack in the preoperative period and treated in our clinic. in order of these data, age, height, weight, gender, sgot, sgpt, amylase, bilirubin and the time for waiting for the operation were compared and evaluated statistically. the time for waiting for the operation was found to be p > . , and it was shown to be significant. results: there is a tendency to perform cholecystectomy in patients with acute biliary pancreatitis, after the acute attack is resolved. we believe that the early cholecystectomy prevents the patient from the additional morbidity in patients with acute biliary pancreatitis, by showing this with a statistically significant result in our study. traumatic right sided diaphragmatic hernia is clinically rare and may present with complications in a later period. on the right side presence of liver is thought to be a protective factor for both development of diaphragmatic injury itself and for its complications. we present a case of right sided diaphragmatic hernia due to blunt trauma, which was asymptomatic for years and has been presented with intestinal obstruction. the patient, years of male, has presented with intestinal obstruction and abdominal pain which has been relieved after nasogastric decompression. despite conservative treatment patient has not shown further improvement and has been operated on a semi-elective basis. significant part of small and large bowel, distal portion of stomach, and almost whole of liver had been herniated and reduced by right thoracoabdominal approach. cm wide defect in diaphragm has been repaired with prolene mesh, laparotomy has not been closed and bogota bag has been applied. in the early postoperative period transaminase levels have increased , u, and ct-angiography has revealed patchy areas of low per-fusion in both lobes of liver. after therapeutic anticoagulation liver function has recovered completely, abdomen is closed and oral feeding commenced. at the th postoperative day respiratory insufficiency has occured after witnessed aspiration of gastric contents, followed by multiple organ failure. this case represents a quite late presentation of right sided traumatic diaphragmatic hernia, for which treatment was complicated. this case clearly shows the importance of detailed evaluation and timely treatment of all traumatic diaphragmatic hernias. cem ibis, dogan albayrak, fedayi calta, eren taskin, mehmet ali yagci, ahmet hatipoglu, irfan coskun department of general surgery, medical faculty, trakya university edirne, turkey introduction: amyand hernia is first described by claduis amyand in london in an year old male. it is a rare condition and described as appendix vermiformis in the hernia sac. we present a case of an incarcerated inguinal hernia with appendix vermiformis inside. case: sixty nine years old male with bulging and pain in the right inguinal region is evaluated. right inguinal hernia was detected. after opening the hernia sac, the appendix and ceacum were observed. lichtenstein procedure was performed. the patient was discharged in the second postoperative day. discussion: although the incidence of appendix vermiformis in the hernia sac is . - %, the incidence of acute appendicitis in the hernia sac is . - . % in various reports. the treatment of amyand hernia is related to the appendix found inside. the application of appendectomy to normal appendix in routine hernia repair procedure is controversial due to infection risk. we do not routinely perform prophylactic appendectomy in such patients. we thought that a patient tailored approach is more acceptable. introduction and objectives: hydatid disease is typically asymptomatic. it can become symptomatic due to expansion, rupture or pyogenic infection. rupture of the cyst is the most common complication, followed by secondary infection, jaundice, and anaphylaxis. methods: in this study, we analyzed demographic and clinical characteristics of the cyst hydatic patients who admitted the emergency service due to complications of the cyst hydatic. the medical records of patients, with a final diagnosis of complicated cyst hydatic were reviewed for demographic information, admission symptoms, laboratory findings, evaluation techniques, and outcome. results: ten patients ( men, women) with final diagnosis of complicated ce (cystic echinococcosis) included the study. all of the patients had abdominal pain. while the pain was diffuse in the entire abdomen in seven patients, it was located in the right upper quadrant in three patients. patient's complaints were nausea, vomiting, jaundice, ileus and urticaria. the clinical signs and symptoms of hc rupture are not always severe, but hydatid fluid can irritate, which can cause peritonitis as occurred in our series of patients, all of whom had acute abdominal signs. in this study, % of the patients with ruptured ce had abdominal pain. thus, the clinical presentation of ce rupture is not always silent. the severe clinical presentation and infrequency of ce perforation has been held partially responsible for the misdiagnosis by the surgeon. conclusion: in conclusion; complicated hc may be admitted to emergency service with different clinical pictures especially in endemic regions and must be considered in differential diagnosis. background: to evalute the changes in the pattern of iatrogenıc bılıary injury and consequentıal effects on treatment strategy and outcome. methods: seventy-three patıents treated for iatrogenıc bılıary injury (ibi) between july and november at a tertıary care center in izmir, turkey were retrospectıvely analysed. results: underlyıng diseases were; missed tumor (n: , . %), biliary surgery (n: , %) and hydatıc dısease (n: , , %). in recent years wıth a gradual increase in the avaılabılıty of endoscopıc and radiologial expertise the majorıty of patıents underwent extensıve preoperatıve diagnostic and therapeutıc procodures includıng endoscopıc retrograd panceratography for cases( . %) and percutaneus transhepatıc cholangıography for cases( %). defınıtıve surgery was performed in all patıents except ( . %) of them. roux-en-y hepatıco-jejunostomy was the primary reconstructıon technıque and performed for cases ( %). there was only one ( . %) hospıtal mortalıty. restenosıs developed in ( . %) cases and was reoperated. percutaneus baloon dilatation was faıled in three patıents as a fırst treatment optıon. none of patıents died of dısease related causes durıng the follow-up perıod. conclusion: increased experınece in laparoscopıc biliary surgery might be caused to attempt more challengıng cases and increased bılary tract injurıes. tolga kafadar, ercan gedik, sadullah girgin, bilsel baç, _ ibrahim halil taçyıldız department of general surgery, dicle university, diyarbakir, turkey the aim our study was to determine the independent risk factors affecting patients with upper gastrointestinal hemorrhage who underwent surgery. materials and methods: the medical records of patients with upper gastrointestinal hemorrhage who underwent operation were reviewed for variables including age, gender, shock, association with co-morbidity, pulse rate, hemoglobin levels, white blood cell count, serum urea, creatinine, sodium and potassium levels, time of opera-tion, number unit of blood transfusion, rockall risk score and length of hospital stay. in order to determine the independent risk factors mortality and morbidity, we carried out entered logistic regression analysis. results: morbidity and mortality rate were . % ( patients) and . % ( patients), respectively. the independent risk factors affecting morbidity were serum albumin level [odds ratio (or) = . , % confidence interval (ci) = . - . , p = . ] and rockall score ‡ (or = . , ci = . - . , p = . ), and the independent risk factors affecting mortality were advanced age (or = . , ci = . - . , p = . ), and high rockall score (or = . , ci = . - . , p = . ). conclusion: to decrease the postoperative morbidity and mortality rates in patients with ugih requiring surgery, patients preoperative risk factors should be demonstrated. we believe that establishment of interventional indication on time and evaluation of intraoperative surgical region and technique in combination with the patient-and disease-related factors in patients requiring surgery would help reduce morbidity and mortality rates. blunt thoracic trauma leads to various clinical conditions, such as hemothorax, pneumothorax, pulmonary contusion, and respiratory tract hemorrhage. especially, respiratory tract hemorrhage resulting from pulmonary contusion is so critical to require a clinical challenge. of our experienced survivors, trauma victims (male / , - years old) with blunt thoracic trauma associated with motorcycle accident were transferred to our emergency departments. they similarly suffered respiratory failure (average respiratory rate of ) and hypotension (average shock index of . ) on arrival. immediate after the rapid-developing respiratory failure in relation to lung contusion and endobronchial bleeding, bronchial blockade device and extracorporeal membrane oxygenation (ecmo) were urgently introduced at an average of and min, respectively, and achieved rapid resolution of their respiratory crisis. all of them withdraw from ecmo within days. pulmonary contusion sometimes follows fatal progress, and we consider that quick bronchus blockade and ecmo introduction is the key of survival. emergency departments (ed) in greece are incorporated to the departments of the hospital and are divided in two major areas: one for internal medicine and one for general surgery. every patient has free access to the (ed). the workload and the conditions treated in ed in greece are geographically and social -economically depended. the national health system is represented by one hospital for each prefecture. the general hospital of trikala, is categorized as an urban hospital, with beds, and is covering a population of approximately , people, living in the town and in villages situated in the surrounding mountain area. the department of general surgery is stuffed by general surgeon specialists and seven residences. during , , patients were examined in the surgical ed. in this study we analyze the characteristics of the patients, the number and causes of admissions in the various departments of our hospital and also the transferals to a tertiary center. aim: pneumotosis cystoides intestinalis is a rare entity, and may be associated with pyloric stenosis. materıals-methods: data of a patient operated for pyloric stenosis and pneumotosis cystoides intestinalis in our institution are presented. results: patient was a year-old addicted male, and his body mass index was . kg/m . he had been suffering from nausea/vomiting, bloating and constipation for a few months. a gastroscopic examination revealed atonic gastric dilatation, duodenal ulcer and related pyloric stenosis, and positive serology for helicobacter pylori. an eradication treatment in conjunction with long term proton pomp inhibitors were given, however the patient readmitted to our department with worsening symptoms including vomiting, pain and weight loss after months. repeated gastroscopies and gastric meal x-ray examination revealed pyloric stenosis and the patient decided to have an operation instead of repeated medical treatment. during laparotomy, subserosal foamy air bubbles were observed on the serosal wall of ileum. a partial resection of ileum was necessitated for the suspicion of perforation. vagotomy with finney pyloroplasty was performed in order to cure the pyloric stenosis. the postoperative period was uneventful and the patient was discharged from the hospital on day . the patient has not have a recurrence, gained weight and have no problem since years postoperatively. conclusion: pneumocytosis cystoides intestinalis may be observed in the presence of a pyloric stenosis and necessitates resection if any doubt for perforation is present. granulosus. in this study, a rare appearance of the disease is presented as an abscess located in the retroperitoneal space. results: the patient was years-old male with several comorbidities admitted to our emergency department with fever and left lumbar pain. he had had operated for hepatic hydatid disease years before the admission. physical examination revealed local tenderness and slight hyperemia on his left lumbar region. his laboratory findings showed leucocytosis, and a computed tomography demonstrated a huge retroperitoneal abscess located between spleen and pelvic entrance and denied any pathological finding regarding to the left kidney or adrenal gland. since the general condition of the patient did not allow an operation under general anesthesia, the abscess was drained through a cm long incision located on the hyperemic area under local anesthesia. after complete removal of the abscess and daughter cysts, a drain was left behind, and removed on day . the patient was discharged out of hospital on day , after an uneventful recovery period. discussion: to best to our knowledge, this is the first hydatid disease case presented as a retroperitoneal abscess in the literature. hydatid disease may be kept in mind as a differential diagnosis in the presence of a cystic retroperitoneal mass in endemic regions. ali uzunkö y , zekeriya sayın harran university school of medicine department of general surgery, sanliurfa, turkey osm ortadogu hospital, sanliurfa, turkey introduction and objectives: giant true splenic artery aneurism is rare lesions. these aneurisms have risk of rupture and bleeding. we have performed a giant true splenic artery aneurism. case: the case is a year old female patient. she applied to hospital with complaints of abdominal pain. at the physical examination, there were a moderate splenomegaly and a pulsatile mass in the left upper abdomen. it was shown a giant splenic aneurism at the abdominal computed tomography and colour doppler ultrasonography. colour-doppler abdominal ultrasonography showed about mm splenic artery aneurism. computed abdominal tomography showed a hypo dense mass situated anterior and superior to the pancreas tall and corpus extending up to the splenic helium. the diagnosis was confirmed by ct angiography. the patient was performed with general anaesthesia and left subcostal incision. at the exploration, splenic arterial dilatation and aneurismal sac was shown and aneurysmectomy with splenectomy was performed. there was no complication intraoperatively and postoperatively. the patient was discharged at the postoperative fifth day. there was no complaint at the control examination at the fifteenth day after discharging. conclusions: although giant splenic artery aneurism is rare, but they have risk of rupture and bleeding. there are two options for treatment of these lesions. one of them is aneurysmectomy. it is frequently performed with splenectomy. other option is embolisation. in our opinion, surgery for giant splenic artery aneurism is performed successfully without important complication. author to editor: saved by lookus introduction: an association between the administration of paracetamol and relative hypotension in critically ill patients has been reported by the staff working in the surgical and trauma intensive care unit of istanbul faculty of medicine. methods: a prospective, observational study was undertaken to investigate the effect of paracetamol on systemic blood pressure in two groups of critically ill patients. a dose of mg of paracetamol was administered intravenously to both groups in min time. blood pressure, heart rate were recorded at baseline, at the end of infusion and then at , , min after administration. the differences occured over the observation period was measured by friedman analyse. results: twenty-eight patients with sepsis, were enrolled to group- (anti-pyretic effect) and postoperative patients were enrolled to group- (analgesic effect). analysis of data from all patients showed that systolic arterial pressure (sap) and mean arterial pressure (map) were reduced significantly over the observation period in both groups (sap:p < . for both, map:group- p < . , group- p < . ). sap and map in group- and group- decreased by an average of approximately and % respectively. however, no significant decrease in dap was noted in group- . conclusions: utilization of the intravenous paracetamol for febrile and/or postoperative patients caused a significant decrease in systemic blood pressure after administration. this drug-induced hypotension was clinically relevant to control the required blood pressure. thus, clinicians should be aware of this potential effect, especially in critically ill patients. yazile sayın faculty of health, surgical nursing division, cumhuriyet university, sivas, turkey background: pain is considered one of the most important symptoms which guide diagnosis, treatment and nursing care in the emergency departments. aım: to discuss pain evaluation by nurses in emergency departments and to attract attention towards nurses' responsibility for pain evaluation. methods: qualitative and quantitative data from studies on pain evaluation by nurses were evaluated. results: all studies reviewed showed that about three fourths of the nurses in the emergency departments did not make pain evaluation based on the standards (using pain rating scales, reporting the conditions likely to affect pain evaluation etc.). the nurses included in studies assigned significantly lower scores for pain than the researchers(p < . ;p < . ). all studies revealed the following reasons why triage nurses did not play an effective role in pain evaluation: insufficient knowledge, the idea that doctors are responsible for pain evaluation, doctors not appreciating the value of pain data provided by nurses, insufficient cooperation among members of the health staff, work overload, time constraints, errors in reporting data on pain evaluation and conflicting attitudes and beliefs concerning pain evaluation. it has been reported that only - % of the patients presenting with pain to emergency departments received effective pain management. the most important reason for this low rate has been shown to be deficiencies in pain evaluation due to insufficient multidisciplinary cooperation. conclusion: it can be concluded that nurses in emergency departments are not efficient enough to use interventions which help to evaluate pain for effective pain management. introduction: diverticulosis of the colon is a common condition. complications of diverticulitis often require surgery. perforated diverticulitis may rarely present with spreading superficial sepsis. case: male, years, history of chronic depression. admitted in the emergency department after a -day history of abdominal pain in the left lower quadrant (llq), associated with asthenia, anorexia and weight loss, without diarrhea, constipation or fever. the patient examination showed edema and thickening of the abdominal wall with swelling and redness in the llq. blood chemistry revealed leukocytosis with neutrophilia and elevated c-reactive protein. a diabetic ketoacidosis was diagnosed. the abdominal ct confirmed abdominal necrotizing fasciitis with an abscess, without other intra-abdominal changes. the patient was then submitted to emergency surgery with debridement of the necrotising fasciitis and drainage of the abscess. he was admitted to the icu. further debridement was necessary h later. at d , fecal contamination of the wound was detected, leading to a subsequent laparotomy with identification of a sigmoid inflammatory mass attached to the site of the fistula's external orifice. a hartmannprocedure was performed (histology confirmed the diagnosis of perforated diverticulitis). the patient developed a sirs complicated with a right-side necrotizing pneumonia requiring multiple antibiotic treatment and pulmonary decortication. death occurred at the th hospitalization day. conclusion: necrotising fasciitis as a consequence of perforated diverticulitis is an uncommon but potentially lethal condition requiring prompt surgical intervention. when accessing an abdominal necrotising fasciitis without recognisable source, an elevated index of suspicion is necessary to link it to complicated diverticulitis. fatih baş ak, kü rş ad Ö ztü rk tc sb bozkir community hospital introduction: care of trauma patients may be difficult in small community hospitals. these hospitals are usually staffed by a small number of general practitioners and, perhaps, a general surgeon, and a significant number of trauma cases are brought to them. the records of minor and major trauma patients who admitted to bozkir community hospital between june and december were evaluated. mortality and transfer rate were recorded. general surgeon was not present in first months. the rates of last months when general surgeon has been present were calculated separately. results: trauma patients were admitted in first months ( . %) of these were transferred to larger centers. treatment of remaining ( . %) patients continued in our hospital. mortality rate of first months was . %. three patients requiring immediate surgery died because of absence of general surgeon. patients were admitted in last months. ( . %) of these were transferred to larger centers. mortality rate of last months was . %. three gunshot wound and one penetrating cardiac wound patients were saved with emergent surgery. conclusions: regardless of the sophisticated techniques for dealing with trauma that exist in larger centers, it is the staff of smaller hospitals that often shoulder the initial burden of trauma care. transfer rate is between and % of all trauma cases. our hospital is . h away from larger centers. presence of general surgeon in last months mainly affected the care of patients that requiring immediate surgical attention. metin kement, hakan acar, ilhami soykan barlas, uygar dü zci, cem gezen burn center, kartal education and research hospital, istanbul, turkey aim: fecal contamination which may result in septicemia, graft loss and wound healing delay is the most serious problem for burns in perineal, gluteal and upper thigh regions. temporary fecal containment devices can be used for diverting feaces from burned area. the aim of this study was to evaluate early results of using of these devices in our burn center. methods: twelve patients, who were applied temporary fecal containment devices in our burn center, were retrospectively evaluated in this study. results: ( . %) of the patients were male.the mean age was . ± . year.the mean tbsa burned was . ± . %. ( %) of the patients had burn in all three regions (perine, gluteus and upper thigh). three ( %) of the patients had burn in upper thigh. and ( %) of the patients had burn in gluteal region. the devices were placed intra-rectally on the first admission days of all patients.the mean application time was . ± . days. except minimal fecal leakage in ( . %) patients, any complication was not observed in our cases. local infection confirmed by tissue culture was observed in ( . %) patients including two patients with fecal leakage. besides, in one of these four patients, septicemia was developed and managed successfully with antibiotics and supportive treatment in intensive care unit of our center.one patient with % burn was died on days of application due to multiple organ failure. conclusion: temporary fecal containment devices aim to protect patients' wounds from fecal contamination by diverting feaces. if the safety of these device is proved in further studies, they may reduce the necessities of diverting stoma operation in burn patient. metin kement, ilhami soykan barlas, uygar dü zci, hakan acar, cem fazlı gezen burn center, kartal education and research hospital, istanbul, turkey aım: reactive thrombocytosis which develops secondary to infection, trauma, malignancy or surgery is the most common ethiology of thrombocytosis. although thrombocytosis is a benign and self-limiting condition in most cases, it may result in some thrombotic and hemorrhagic complications. the aim of this study was to evaluate the reactive thorombocytosis in burn patients. material: thrombocyte counts was retrospectively evaluated in consequent burn patients admitted to our burn center between august and january . the correlations between thrombocyte counts and demographic data, total body surface area burned (tbsa), hospitalization time and levels of some acute phase markers also analysed. results: the mean thrombocyte counts were respectively . ± . /mm , . ± . /mm on admission day and second day (p < . ). the number of patients with thrombocytosis was ( . %) in admission, ( %) of them were children. the rate of thrombocytosis was / ( . %) in children,whereas the rate of thrombocytosis was only / ( . %) in adults (p < . ). the mean thrombocyte counts in children and adults were respectively . ± . /mm , . ± . /mm in admission (p < . ). the mean wbc count was significantly higher in patients with thrombocytosis than patients with normal thrombocyte count (p < . ), but there was not any significant difference in crp count (p = . ). and also,we did not find any significant difference between patients with thrombocytosis and patients with normal thrombocyte count in tbsa and hospitalization time (p = . and . , respectively) conclusion: reactive thrombocytosis is seen more frequently in burned children than burned adults and mostly unrelated to degree of burn. background: electrical injuries are related with multiple organ dysfunction as well as high morbidity and mortality. pulmonary compromise is rare, if compared to other organ dysfunctions related with electrical injuries. in this study, we presented a case with pulmonary hemorrhage associated with electrical injury. case: a -year-old previously health man was brought to our emergency department (ed), h following the accident, with electrical injury. initial examination findings were blood pressure / mmhg, heart rate /min, respiratory rate breath /min. glasgow coma score was . decreased breath sounds, bilateral rales and wheezing were determined. there were small necrotic wounds (typical contact injury) on the first finger of left hand and under the right foot of patient. there was no trauma in thoracic wall. blood gas analysis revealed respiratory and metabolic acidosis. the inr and platelet levels were normal. when chest radiograph and thoracic computed tomography were assessed, air bronchograms and symmetric consolidations were determined in the both lungs. patient was intubated and fresh blood was aspirated from endotracheal tube. mechanical ventilatory support was performed the patient due to lung hemorrhage and respiratory failure. patient died after h of admission in the ed. conclusion: multiple organ dysfunction and necrotic skin lesions could be occurred in electrical injuries. electrical injuries on the chest may cause lung infarction because of the direct effect of the electrical current and vascular embolism. possibility of lung injury should be investigated after electrical injury especially in patients with respiratory failure. nebahat yıldız , aysel gü rkan , _ imren aş ar , ayş e hale uysal trauma and emergency surgery service,istanbul university, istanbul faculty of mediine, istanbul, turkey health science of faculty marmara universty, istanbul, turkey introduction and objectıve: the outcome of burn treatment is measured not only by mortality and morbidity, but also by post-burn psychological factors. the purpose of this study was to investigate whether difference in length of hospitalization exist between burn patients with and without mental health problems and if so, why. methods: the descriptive study was retrospective review of patient with burn injuries who had received care at one burn unit in the istanbul from october to december . socio-demographic features of patients, burn criteria (kind, depth, size, location), duration of hospital stay, and psychological problems were tabulated. results: psychological impairment was found in of hospitalized burn patient. there were acute stress disorder in fifteen patient, anxiety in nine, adjustment disorder together with anxiety in eight, depression in seven, post-traumatic stress disorder in six patient. fortyone ( . %) patient had burns which were between i and ii degree and ( . %) patient had burns which were between ii and iii degree. in patient, burned area has been % or more. patients with psychologocal impairment were longer hospital stay and intensive care unit than patients without psychologocal impairment. sixty-four ( . %) patients with psychologocal impairment had been discharge either getting better or recovering completely but unfortunately ( . %) patients died. conclusion: the presence of psychological problems in burn patients have an impact on their burn care. psychological interventions can contribute towards successful outcomes. introduction and objectives: major burns can cause disseminated intravascular coagulation (dic) and is a serious clinical problem. we would like to present dic cases whose burn rate is % according to total body surface area (tbsa) which developed after late postoperative period. methods: two cases over %, nd and rd degree burn injury admitted to our facility. first case who was year old female developed s. aureus and second case was years old female developed p. aeruginosa sepsis which was confirmed by blood culture. in first case dic developed at postburn day and in second case at postburn day. in both cases dic developed after postsurgery day . results: on patients, bleeding points, as leaking, were detected on all over burn areas. at the same period thrombocyte values decreased sharply ( . k/ul). increase in prothrombin time (pt) ( . second) and active partial thromboplastin time (aptt) ( second) values, decrease in fibrinogen levels was observed. cases were discharged from hospital in th day, without any problem. patient was taken for iu erythrocyte suspension and iu platelet suspension in this time totally. conclusion: dic occurs in early period of burning; but it can be formed in later periods, even after defects were recovered by operation. rapid establishment of dic table just before the discharging term from hospital is an unusual and interesting situation. the patients in our study can be accepted as an example of the necessity of observing coagulation parameters in every periods of burn damage. methods: sphere project handbook reviewed by experts in the field of each section, the terms of our country's adaptation has been made. within the framework of the project dissemination, sphere workshops have been organized in various provinces. the ppt slides were adapted to turkey's needs. the project's outcomes have been observed through the pre-post tests and the workshop evaluation forms. results: expert review and the end of the first study, with a high risk of disaster in our country, the handbook was understood to be necessary and useful. in addition to this, the control lists in details but useful and also, the summary tables are useful to take a decision in emergencies. it is also understood that preliminary results from the project is compatible with literatur data. conclusions: developed in each country is adapting to the local experience of the sphere, significant experience with disasters in our country the right to contribute are welcome. indeed, the first application of the new approach by the sphere project's coordination center is monitored with interest. introduction: ( ) initial assessment of trauma patients is a period with a high frequency of treatment protocol deviations and an elevated number of avoidable complications. ( ) the majority of medical errors are diagnostic or cognitive, whereas operative technical complications accounted for less than %, and ( ) general surgery residents (gsr) do not feel well-trained on the management of major trauma patients. aim: describe initial experience with one approach to foster quality improvement in trauma care modifying the method by which we train surgeons. methods: we integrated in the gsr program, simulation based training sessions with other educational tools as lectures and workshops. the scenario objectives were based on research data indicating major deficiencies in trauma care (tc). we incorporated team training and crisis resource management sessions. to review trauma life support diagnostic and therapeutic standardized protocols we run scenarios to train initial assessment, and head, thoracic and abdominal trauma. after every clinical case, residents participated in a video assisted debriefing session leaded by a specialized instructor. an evaluation interview was made after the course. results: all resident viewed the experience as a ''very good'' training modality. many of them felt their time was better spent in the simulator session than in the operating room, and wanted to do it more often or in a scheduled way. some of them complained about evaluating the mannequin and the equipment when compared to the one in their actual work setting. conclusions: integrating patient simulation with traditional surgical training may strength the approach to tc education. introduction: pulmonary embolism is a life-threatening condition and its diagnosis is generally based on clinical suspicion. case: a years old male had been admitted to another hospital with acute dyspnea and syncope and after initial evaluation he had immediately been undergone an operation due to epidural hematoma. he was referred to our emergency department with early diagnosis of acute coronary syndrome after operation because intraoperative and postoperative tachycardia could not be controlled. in his physical examination gcs: , arterial blood pressure / mmhg, heart rate /min and breath rate /min. ecg, echocardiogram and thorax ct findings complied with pulmonary embolism. venous doppler ultrasonograpy findings complied with chronic deep venous thrombosis. thrombolytic or antiaggregant medication could not be started because of epidural hematoma operation. at postoperative h low molecular weight heparin and at h warfarin was administered. in follow-up period his symptoms regressed and there was no complication due to epidural hematoma surgery. he discharged from hospital at day . conclusion: in trauma patients, one of the important issues that have to be considered during clinical evaluation is the primary reason leading to trauma. in this case, the investigation for syncope etiology revealed the haemorrhage and thrombus diagnosis concomitantly. these two diagnoses have opposite treatment strategies and due to this condition we had difficulty in management of the patient. although there are intracranial haemorrhage cases due to pulmonary embolism treatment (thrombolytic or antiaggregant), a similar case report cannot be found in the available literature. introduction and objectives: different societies have different type of snake bites. _ in our actually series, two patient from u.k. and seven patients from south-eastern part of turkey presented with lıke compartment syndrome result of was bitten by a snake to their fingers. methods: four of nine patients applied to our clinic at the day of event, the other five were referred to us after the emergency treatments have been done. all bites were over or distally to the pip joint. after being bitten by snake, patients admitted to our accident and emergency department because they had like as compartment syndrome on the forearm. two of the patients were referred to us very late stage and one of them had partial necrosis and the other had total necrosis already. none of patients had signs of systemic envenoming. results: two patients with local swelling and no other symptoms were discharged. coverage of the defects were performed with full thickness skin grafting in two patients, cross-finger flap in one patient, reverse dorsal digital arter flap in one patient and dorsal interosseous metacarpal flap in two patients. one patient had amputation. none of patients had fasciotomy. conclusions: this study represents the clinical effects and current approaches for the treatment of snake bites to distal finger. all patients presented with compartment syndrome like symptoms on the hand or forearm. these patients should be followed-up very closely. final wounds should be closed either with skin grafts or local flaps. simultaneously, systemic envenoming should be considered. the aim was to evaluate the geriatric patient with abdominal pain in emergency department (ed). methods: the preliminary retrospective study included the period between january and june , , ankara. data were achieved from registration notebooks, manually. the patients separated within age to three groups as - , - , and over. the finalization of management, hospitalization, operation rate, mortality were studied. results: there were ( . %, annually) patients. the mean age was . ± . ( - ), the mean hospitalization duration was days ( - ). the sex and the age of patients can be seen in table . . % (n = ) of them discharged from ed. abdominal ct and usg usage were . % (n = ), . % (n = ) in ed. . % (n = ) patients had both ct and usg. abdominal ct and usg results are showed in tables , . finalization of patient management was demonstrated in table . the operation rate for all patients was . % (n = ). general surgery hospitalization and operation rate were . and . % (n = , n = ). the mortality rate was . % (n = ) in admission. there were not any significant difference between the groups of - and - according to sex, finalization, ct, usg utilization, operation rate (p = . , p = . , p = . , p = . , p = . ) with spss x test, while the number of advanced geriatrics was unsuitable for statistics. conclusions: females and the - age group were common with a complaint of abdominal pain in ed. most of them had hospitalization indications and the primary yard was general surgery with brid ileus. mortality rate was lower than % introduction: nontraumatic epigastric and left upper caudran pain is a common complaint in emergency department. it can include lifethreatened various reasons as cardiac, respiratory, and serious gastrointestinal problems, rarely. case: a year old man had an emesis with recurrent epigastric and left upper caudran pain admitted as second turn to ed in h. physical examination except a slight epigastric sensitiveness, ekg, urine test and biochemical tests, complet abdominal ultrasonography, x-rays were nonspesific on the first day. wbc was . on cbc. his complaints relieved with semptomatic treatment with an mg ranitidine, mg metoclopramide, serum sale on his observation and discharged with suggestions. in second admission with nonspecific physical examination findings, computerized tomography (ct) revealed splenic unenhanced parenchymal areas consistent with splenic infarcts. computerized tomography angiography (cta) showed a small aneurysm of the celiac trunk, a characteristic pattern of caliber irregularities and arterial wall thickening of the splanchnic arteriesincluding splenic artery, common hepatic, right and left hepatic arteries-, suggesting splanchnic arterial mediolysis (figures and are presented with permission of patient's written consent). he was hospitalized to general surgery and started low molecular weight heparin. as clinical and radiologic findings were degrated, he was discharged without an operation. conclusions: splanchnic (segmental) arterial mediolysis is a rare noninflammatory vascular disease of the abdominal splanchnic arteries with slight symptoms. ct for vasculary and internal organs should be performed to diagnose in recurrent complaints beside observing the physical findings. introduction: it is well documented that healing of peptic ulcer perforation (pup) is possible with conservative therapy in selected cases. thus a spontaneously closed pup diagnosed at exploration may not require surgical repair. methods: study included three patients in which diagnostic laparoscopy suggested spontaneously closed pup between and . suggestion criteria were; fibrin cloth on duodenum with or without subhepatic fluid collection, no visible perforation, otherwise normal exploratory findings. omentum minus was dissected and cautiously observed. the stomach was filled with ml diluted methylene blue fluid via nasogastric tube, operation table was tilted to right and up, a gentle pressure on the stomach was made with the shaft of laparoscopic irrigator to fasciculate the passage while the descending section of duodenum was compressed with the shaft of a grasper. duodenum was cautiously observed for min to detect dye leakage in all patients. if no leak was observed, operation was terminated after abdominal irrigation and inserting a catheter to the subhepatic area. therapy for pup was given postoperatively. results: all patients were male and the mean age was ( - ), no leak of dye was observed at operation. nasogastric tube was removed and food intake was allowed at postoperative second day. all patients were discharged on third day. conclusion: although the perforation site is almost always identified at operation, to meet a spontaneously closed pup is also possible. irrigation and drainage alone may be sufficient for these cases after blue dye test as described in this study. the complicated appendix with/without abscess was delivered through the umbilical incision for an open technique safely. this gave our patients the maximum benefits of the minimally invasive surgery with better visualization, reducing equipment needs, less postoperative pain, rapid discharge, no postoperative infections, and excellent cosmetic results. all patients were quite satisfied during follow-up. conclusions: it is concluded that hybrid appendectomy seems to be feasible and reliable for children with complicated appendicitis not suitable for conventional laparoscopic technique. vata was successfully accomplished with obvious advantages, and avoided conversion to the open fashion. background: appendicectomy remains the most frequent emergency operation. the management of these patients varies between surgeons and hospitals. at our centre, it was a routine to review post operative children at months. aims: is to evaluate the need for a routine follow up in children who had appendicectomy. methods: it is a retrospective observational study for consecutive patients between and . a parallel questionnaire was sent to the parents of all the children. results: the average age was . years. % of the patients were found to have normal appendices. % of the patients were discharged within days. % of the patient had intravenous antibiotics for day and % were discharged with oral antibiotics. % had a routine follow up appointment in months time. in % of cases there was no change in the management. on the questionnaire % of the parents thought they were given enough information regarding the procedure. in terms of routine follow ups, % of the parents found it very useful while % found it a little or not useful. conclusion: this study shows that there is no change of the management or a clinical need for the routine follow up. however the patients and their families like to keep a follow up appointment. it is more convenient for the patients and their family to arrange other sorts of follow up like a phone call conversation or a general practitioner follow up. yavuz savaş koca, mustafa ugur, celal Ç erçi, recep Ç etin department of general surgery, sü leyman demirel university, isparta,turkey the aim of this study was to evaluate the disease profile and mortality ratio of patients presenting with acute abdomen. four hundred fifty eight patients who underwent surgery with the diagnosis of acute abdomen were analyzed retrospectively. the effects of age, sex, american society of anesthesiology (asa) class, accompany disease, admission time after the onset of the symptoms, follow up interval before the operation on mortality and length of hospital stay were evaluated. male/female ratio was . , and mean age was . . main causes were biliary system disease ( . %), intestinal obstruction ( . %), peptic ulcer perforation ( %) and acute appendicitis ( . %). median asa class was and . % of the patients had at least one preexisting disease. mortality ratio was . %. asa class, age, preexisting diseases other than malignity, period between the onset of symptoms and admission, follow-up time was significantly efective on mortality. reliability of ultrasonography for diagnosing acute appendicitis aylin hande gö kçe , acar aren , feridun suat gö kçe , hakan Ö zkan , alper dursun Ş agban , _ ibrahim aydın , gü rhan Ç elik , gü rol kö roglu s.b. _ istanbul eg itim ve araş tırma hastanesi, istanbul, turkey balıklı rum hastanesi, istanbul, turkey purpose: abdominal ultrasonography is the most commonly used diagnostic tool for diagnosing acute appendicitis,which is one of the most common causes of acute surgical abdomen. _ in this study, we examined the reliability of ultrasonography for diagnosing acute appendicitis. in this prospective study we performed abdominal ultrasonography on patients admitted to our surgical emergency department and diagnosed as acute surgical abdomen according to the physical examination and laboratory findings during . these patients were surgically treated by appendectomy and the materials were pathologically examined. results: patients were admitted to this study. of these patients ( . %) were diagnosed as acute appendicitis, and ( . %) of them diagnosed differently. ( . %) of patients diagnosed as acute appendicitis on ultrasonography examinations were reported as acute appendicitis on histopatological examination. ( . %) of patients diagnosed differently on ultrasonography examination were reported as acute appendicitis on histopathological examination. conclusion: the sensivity of abdominal ultrasonography for diagnosing acute appendicitis is high ( %), but the specificity is low (p = . ). we calculated that the specificity is . , positive predictive value is . , negative predictive value . , accuracy is . . abdominal ultrasonography is a helpful diagnostic tool for diagnosing acute appendicitis.however, it should not be seen superior to anamnesis and physical examination findings. poisoning: a case report background: mushroom poisoning is an important clinical problem which may cause serious complications and death. acute pancreatitis is a rare complication of mushroom poisoning. in this study, we presented a case that developed liver damage and acute pancreatitis following wild mushroom ingestion. case: sixty-six years old women admitted to emergency department with complaints of nausea, vomiting and abdominal pain. it was learned that patient was ingested wild mushroom before h of admittance and her complaints were started after - h of ingestion. in initial examination, general appearance and vital signs of patients were normal and there was epigastric discomfort. laboratory findings were leukocyte , /ll ( . - . ), aspartate aminotransferase u/l ( - ), alanine aminotransferase u/l ( - ), amylase u/l ( - ), lipase , u/l ( - ) on admission. liver and pancreas was determined as normal in abdomen ultrasonographic examination. computerized tomography of the abdomen showed minimal peripancreatic fluid. the patient was observed in emergency intensive care unit and symptomatic therapy was performed. hepatic transaminases and pancreatic enzymes were decreased progressively during the observation. the patient was discharged from the hospital after days clinical course, without complication. conclusion: mushroom poisoning and acute pancreatitis have similar gastrointestinal symptoms and sings. therefore, possibility of acute pancreatitis as well as other organ dysfunctions should be investi-gated in patients with mushroom poisoning. early recognition and appropriate therapy for acute pancreatitis and mushroom poisoning may lead to an improved prognosis and complications. mehmet mustafa altıntaş , , ayhan Ç evik , , yekin Ö zcabı , , gü lay dalkılıç , , hü seyin ekinci , , nejdet bildik , dr. lü tfi kırdar kartal education and training hospital, istanbul, turkey general surgery clinic, istanbul, turkey diagnostic emergency laparoscopy is very helpful in diagnosing acute abdomen and evaluating abdominal trauma. parallel to developments in laparoscopic techniques, its emergency applications are increasing. we reviewed our diagnostic emergency laparoscopy procedures applied to patients with acute abdomen and could not be diagnosed after h of follow-up. we applied diagnostic emergency laparoscopy to patients in dr. lü tfi kırdar kartal education and training hospital during - . in patients laparoscopy indication was undiagnosed acute abdomen. there were four acute appendicitis, two peptic ulcus perforation, two small bowel necrosis, one perforated hepatic hydatid cysts, one iatrogenic urinary bladder perforation, one postlaparoscopic cholecystectomy bile fistula and non-surgical adnexial pathologies. diagnostic emergency laparoscopy was performed in five patients with penetrating abdominal injury. there were small bowel injury in two patients, colonic injury in two patients and no injury in one patient. diagnostic emergency laparoscopy was performed in four patients with blunt abdominal injury. there were grade splenic laceration in two patients, grade liver injury in one patients and intraabdominal bleeding in one patient. in conclusion, diagnostic emergency laparoscopy is a suitable technique in undiagnosed acute abdomen patients which could not be diagnosed after physical examination, laboratory, radiology and follow-up and helps surgeon to diagnose the disease. also diagnostic emergency laparoscopy performed by experienced surgeons prevents negative laparotomy especially in abdominal trauma patients. mehmet ali yagcı, atakan sezer, ahmet rahmi hatipoglu, irfan coskun, zeki hoscoskun, aydın altan department of general surgery, trakya university school of medicine, edirne, turkey introduction: appendectomy is known as the most common nonobstetrical operative procedure in pregnant women with an estimated frequency of / , of all pregnancies.pregnancy continues to obscure the accurate diagnosis of acute appendicitis due to gestational physiological changes.diagnostic delay increases the incidence of perforation, hence increasing maternal and fetal morbidity and mortality. patients and results: four patients of appendicitis during pregnancy were concluded in study between to may ( table ). the mean age was (range - ). three patients presented during three trimester and one in first trimester.the mean time interval of symptoms to the admission is h (range - ).abdominal pain, vomiting, and nausea are the most common complaints.rebound was the main sign observed in all patients.fever was noted in two patients. mean value of wbc count was , per l (range , - , ). ultrasonographic examination was performed to all patients with the diagnosis of acute appendicitis.three patients were operated under general anesthesia and one under regional anesthesia. paramedian incision was applied to three patients and mcburney to the other one. the exploration findings were two perforated, one phlegmonous appendicitis and a normal appendix. no maternal or fetal mortality occured. cesarean section was performed on -week pregnancy during appendectomy due to early onset contractions. adhesiolysis was performed in same case because of postoperative ileus. conclusion: the accurate diagnosis of appendicitis during pregnancy requires a high level of suspicion and clinical skills. delay of operation correlates to more inflammatory changes in the appendix and to higher maternal and fetal complication rates. early laparotomy with appropriate preoperative diagnosis will reduce the fetal and maternal morbidity and mortality. introduction: paraesophageal hernias occur most commonly in elderly and account for % in all hiatal hernias [ ] . although the fundus or corpus of the stomach are most commonly the contents of a paraesophageal hernia, we reported a case in which the gastric fundus and corpus incarcerated in the paraesophageal space, followed by perforation. case: -year-old woman admitted to state hospital following sudden onset of abdominal pain.previously she was diagnosed as esophageal hiatal hernia. on physical examination, abdominal distension with mild tenderness was recognized. pulse rate and blood pressure were per min and / mmhg. the initial laboratory investigations revealed wbc , per ml, urea mg/ dl, creatinine . mg/dl. chest graphy revealed unusual gas shadow in the left thorax (fig. ) . ct demonstrated intraperitoneal free air, ascites, and the prolapsed stomach in the left thorax (fig. ). an urgent laparotomy was performed revealing dirty ascites.the gastric fundus and corpus were incarcerated in paraesophageal space (fig. ) . a perforation mm in size was recognized in the fundus. the perforation was sutured primary and cruroraphy was performed. the patient required respiratory support and died on the th postoperative day due to multiple organ failure and septic shock. conclusion: the contents of paraesophageal hernia commonly include the gastric fundus or corpus. paraesophageal hernias can cause lethal complications, including gastric obstruction, strangulation, perforation, and hemorrhage. paraesophageal hernias can usually be repaired easily, even using the most recent laparoscopic technique ( ). thus, because of the very serious potential complications inherent in cases such as ours that can result from an untreated paraesophageal hernia, we recommend that elective repair be carried out, even in asymptomatic patients. introduction and objectives: the solitary fibrous tumor (sft) of peritoneum, especially arising in lesser omentum is extremely rare. we report a case of lesser omentum soliter fibrous tumor, causing pain and abdominal fullness with its mass effect. case: a -year-old male was admitted to our hospital, due to an intraabdominal mass lesion, epigastric pain, abdominal fullness and vomiting episodes. on physical examination, a hard, non-tender mass was palpated in the epigastric region. computed tomography (ct) showed, an approximate . · . · . cm sized solid mass with fibrous capsula between left liver lobe and stomach. at laparotomy, a yellowish brown solid tumor with hard consistency was found on the lesser omentum. the tumor was not adhered to the adjacent structures and could be resected completely. postoperative course was uneventful and no recurrence was determined during follow up. results: histopathologic examination diagnosed the mass as a sft. the tumoral cells were spindle-shaped and did not present mitotic activity or atipies and showed very low proliferation index with ki (< %) and immunohistochemical positivity for cd and negativity for c-kit (cd ), actin, and s- . conclusion: although sft are rare, especially in the abdomen of adults, are generally benign but malignant cases have been reported. in our case, the tumor has a benign character shows neither mitotic activity nor nuclear atypical. this is the third case of soliter fibrous tumor of the lesser omentum described in the english literature. introduction and aims: a single hamartomatous adenoma of stomach is rare. gastric hamartomatous polyps are usually multiple, familial and assosciated with other syndromes. they are also associated with chronic helicobacter pylori infection, acid hypersecretion and predisposition to gastric cancer. this is the first case of gastric hamartoma which is coexistent with duodenal ulcer perforation. case: a -year old male admitted to our hospital with complaints of stomach ache, nausea and vomitting. because there was free air under right subdiaphragmatic surface on chest x-ray, an emergency operation was performed. there was a perforated ulcer on the first part of duodenum and a large quantity of bile mixed with blood in the abdominal cavity. on further exploration a tumoral mass which was about cm in diameter was found on the stomach corpus. because of possibility of malignancy, a subtotal gastrectomy including the perforation zone was performed. histologically the tumor was well circumscribed and it consisted of uniform, clear cells. at first, it was thought to be metastatic lesion from kidneys or other organs. in this context, all body was scanned however no pathology has been identified. later on, the tumor was approved to be hamartomatous adenoma and helicobacter pylori was positive. postoperative course was entirely uneventful. objectıve: the aim of this work is to determine the level of apoptosis, which is believed to hold an important role in septicemia process that affects mortality and morbidity in obstructive jaundice, in lingers of rats that were experimentally subjected to obstructive jaundice. materials and methods: the experimentals were separated into two goups of eight. choledoch was isolated in each group and while surgery was ended at this level in the control group, choledoch was tied with - silk from two different places and cut between ligatures full fold. experiment animals were operated for the second time in the postoperative seventh day for liver sampling and sacrificationaimed histological analysis through the old incision with anaesthesia provided. to exhibit the p expression immunohistochemically, anti-p clone do- was used as the primer antibody and hrp as the secondary antibody. samples taken for the determination of apoptosis were painted by the tunel method. fındıngs: in the evaluation of apoptotic cells in liver cells, apoptotic cells were observed to widely exist in the liver tissue and it was determined that they exhibited dense accumulation in some regions. in the immunohistochemical evaluation made for evaluation of p expression in hepatocytes, p -positive hepatocytes were determined to exist quite widely in the tissue samples taken from the livers of rats in the experiment group. result: consequently, in this study we determined that in the obstructive jaundice group, both apoptotic index and, as a result of the immunohistochemical studies, p expression increases in the liver. introduction: the risk of leakage from an anastomosis is higher in large intestine. in emergent colon operations primary anastomosis is avoided especially on the left colon, and multi-step procedures are preferred if there is a dirty abdomen. the aim of this experimental study was to compare different suture materials in left colonic anastomosis in presence of peritonitis. metods: this study was conducted on wistar-albino rats by dividing them in groups of equal numbers. after median laparotomy, the whole layer of left colon was cut cm over the pelvic peritoneum and fecal contamination was performed. one day later, the abdomen was opened again under general anesthesia. the abdomen was washed with sf before starting colonic anastomosis. for colonic anastomosis; vicryl + silk was used in the st group rats, pds was used in the nd group rats, and coated vicryl plus antibacterial suture and silk was used in the rd group rats. results: tissue hydroksiproline, anastomosis bursting pressures and histopathologic findings on the anastomosis line were evaluated on the th postoperative day. the highest anastomosis bursting pressure was found in group iii (p < . ). the highest tissue hydroksiproline level was found in group iii (p < . group i-iii, group ii-iii). when histopathologic findings were evaluated by comparing three groups, the healing of the intestine tissue score was found to be highest in group iii (p < . , groups i-iii). conclusion: consequently, it was observed that using antibacterial suture increased resection safety in the presence of peritonitis and anastomosis safety in primary anastomosis. introduction and objectives: the chance of finding the vermiform appendix within an inguinal hernia occurs in approximately one percent of the cases, and is known as amyand's hernia. appendicitis within an inguinal hernial sac is rare. materials and methods: we present two amyand's hernia cases: one with a vermiform appendix and one with a perforated appendicitis. case : an -years-old man presented with a years history of bilateral inguinal mass. ultrasound examination described a hernia which contains mobile bowel segments inside, on the right side. the appendix was obsereved edematous and hyperemic in the hernial sac. an appendicectomy was done. further exploration of the bowels revealed a meckel diverticulitis which was managed by a wedge resection. case : a -years-old woman presented with one week history of an inguinal mass, pain and anorexia. abdominal computerized tomography demonstrated an incarcerated right-sided inguinal hernia.the hernia sac was filled with the perforated appendix. appendicectomy was carried out. results: postoperative recovery was uncomplicated, the patients were discharged without any complication. discussion: acute appendicitis or perforation of the appendix within the hernia sac simulates perforation of the intestine, and does not have specific symptoms or signs. preoperative clinical diagnosis is very difficult and the diagnosis is made intraoperatively. since the absence of any pathognomonic radiological features, the value of preoperative computed tomography is limited. treatment of hernial appendicitis is an appendicectomy with suture hernial repair. the management of a non-inflamed appendix is debatable. the usual practice covers reduction of the appendix, and mesh repair. in the immediate post-operative period the patient had a high output jejunostomy and was dependent on total parenteral nutritional support. a bishop-koop procedure was performed on day and by day , the patient was completely independent of any adjuvant nutritional therapy. five months from primary surgery colostomy was closed. introduction and objectives: the management of pancreatic pseudocysts which occur after blunt abdominal trauma in children is still controversial. in this study, we present our experience therapeutic approach of pancreatic pseudocysts that occur after trauma. methods: we evaluated patients with traumatic pancreatic pseudocysts who admitted to our clinic between and . we performed ultrasonography, computerize tomography (ct) and blood amylase level for all patients. results: there were eight males and one female. the average age was . years (range - years). the mechanism of injury was bicycle handle bar injury in four, falls in three, assault in one and motor vehicle accident in one patient. abdominal pain was the most common symptom. the median size of cysts was . cm (range - cm). the time interval between trauma and pancreatic pseudocysts was days (range - days). of the nine patients, four ( . %) occurred in less than weeks. all patients were initially followed up conservatively. three patients ( %) were successfully treated conservatively, while patients ( %) required intervention either by percutaneous radiological drainage ( ), cystogastrostomy ( ) and external drainage with laparotomy ( ). complication developed in two patients (septic shock, persistent hyperamylasemia). no patient died. conclusion: traumatic pancreatic pseudocysts may occur short after traumatic injury in children. all patients with traumatic pancreatic pseudocysts should be managed by conservative approach initially. however, if the cyst is cause of gastric outlet obstruction or the size of cyst is bigger than cm, interventional management may be required. introduction: splenic abscess is a rare entity,with a frequency of . - . % in autopsy series.mortality rate is still high, up to %, and can potentially reach % among patients who do not receive antibiotic treatment. case : year-old woman presented with fever and left upper abdominal pain for days. hepatomegaly and tender splenomegaly were present.ct of the abdomen revealed · cm hypoechoic lesion in the spleen (fig. ) . initial laparoscopic approach was performed but failed due to inappropriate anatomy. conventional splenectomy was done and at exploration there was · cm abscess in spleen. the patient was dischared on the eighth day of operation. case : yearold woman admitted with femoral artery thrombosis.thromboembolectomy and leg amputation was performed by cardiovascular surgeons.she was consultated with fever and left upper abdominal pain on the second day of operation. ct of the abdomen revealed a · cm mass with air fluid levels in the spleen (fig. ) . splenectomy was performed and a · cm abscess was observed in spleen.the patient died on the second day of operation due to sepsis. a proximal stoma after resection of the perforated small bowel and colon, closure of the distal stump in case of severe generalized peritonitis without the possibility to perform a primary anastomosis. a loop ileostomy to prevent bacterial translocation in case of pancreatitis. retrospective analysis of clinical data of patients admitted between and for emergency operation requiring laparotomy and the construction of one or more small-bowel stomas. patients had ileostomies created for temporary fecal diversion after emergency surgery including bowel obstruction was the most frequent cause of peritonitis ( cases),followed by anastomotic leakage and peritonitis ( ), acute mesenteric infarction ( cases), intestinal perforation ( cases), strangulated incisional hernia ( cases), acute abdomen of crohn disease ( cases), peritonitis carcinomatosa and frosen pelvis ( cases), mean age was . years (range - ), being males and females. overall mortality was % ( patients). patients died on the first days postoperatively. indications, morbidity, mortality and problems involving the ileostomies in emergency abdominal surgery urgency are herein discussed. in the majority of patients with acute abdomen doing ileostomies,lacking of vital capacity of bowel wall as well as insufficiency of previously laid sutures were revealed, which forced a surgeon to resort to resection; in such cases the method of choice for decompression should be the application of ileostomy. postoperative jaundice is often multifactorial. a precipitating or causative factor may be identified but seldom can a specific therapy be offered. the late complications were mainly presented by the biliary ducts cicatricial stricture, the jaundice and cholangitis recurrency. in this report, we described an extremely rare case of a -year-old woman presenting with pain in the right upper quadrant, jaundice, and weight loss in whom a whipple procedure was performed. usg and mr cholangiography showed that dilatation of intrahepatic and extrahepatic bile ducts and hepaticojejunostomy line. mrcp also showed that, there was a closed jejunal loop related with hepaticojejunostomy. obstruction by local tumor recurrence and infiltration of the efferent jejunal conduit between the proximal hepaticojejunostomy and the duodenojejunostomy led to closed loop syndrome and jaundice. frozen sections by direct incisional biopsy revealed a recurrent tumor invasion. a previously unreported late complication after whipple resection of the head of the pancreas was recognized as ''closed efferent loop syndrome'' mimicking obstructive jaundice. the case was accepted as inoperable because of tumor invasion to the jejunum, transverse colon, and surrounding tissue. roux-en y type jejunojejunostomy was performed. the patient had an uneventful postoperative course. introduction: the form of mechanical asphyxia where respiration is prevented by the external pressure on the body: a large weight compressing the chest or abdomen, wedging of the body within a narrow space death in large crowds is traumatic asphyxia. case: a -year-old man was found compressed by a motorboat in the garage while he was working for installation of the boat. the face, neck and upper part of the chest were congested and many petechiae were observed on the conjunctivae. ecchymotic bruises were observed on the right cervical, lower chest, upper abdominal regions and open fracture of the right humerus, ecchymotic abrasion on right anterior superior iliac spine line were detected. subcutaneous haemorrhages in the chest wall and bleeding without subcutaneous haemorrhage in the inferior part of the right sternocleidomastoid region were observed during the internal examination. fractures of the right third and fifth ribs which were accompanied by bleeding in the surrounding soft tissues and muscles, and ecchymoses over the right sixth rib without any fracture were also observed. macroscopic examination of the lungs revealed congestion, subpleural superficial bleeding areas and histopathological examination showed hemorrhagic alveolar oedema. all the internal organs and big vessels were intact. there was no hemorrhage in the thoracal and abdominal cavity. toxicological analysis was negative. conclusions: in the presented case, the impact cause of the chest compression was distinctly determined by the autopsy and criminal investigation. death was reported as asphyxia by the thorax compression without other lethal factors. purpose: the purpose of this prospective study was to evaluate safety of early surgical interventions in the repairment of animal bites with tissue injuries. materials and methods: tissue repairment and/or reconstruction were done, total in patients. of them were dogs', of them were horses' or donkeys' biting between the years - . wound sterilization and debridement were made before repairment. rabies and tetanus prophylaxis were done for all patients. tissue repairments after animal biting were made early and promptly. patients having animal injuries, apart from biting were not included in the study. results: of the patients were male and of them were female. the minimum age of the patient was . and the maximum was , and the average age was . in cases head-neck, in eight cases extremities and in two cases body were biting areas. horses' or donkeys' bitings were seen particulary in ears. in these animals' biting tissue lose was emphased. we prefered primary saturation in cases, skin greft in ten cases and repairment with flap in five cases. finger amputation was required in one of the patients. total ear reconstruction was done gradually in a patient. no infections observed in patients after the surgical interventions. conclusion: we concluded that, early tissue repairments may done after wound sterilization and debridement, safely. treatment plan. multidetector computed tomography (mdct) imaging is an improving and being a widely used method recently in many areas of medicine. it is possible to evaluate the peripheric vascular structures, anatomic variations or vascular pathologies with mdct angiography (mdcta). methods: the arcuate foramen is an anatomical variant of the atlas vertebra: anterior and posterior osseous bridges or ponticles can arch over the vertebral artery, to a greater or lesser degree, transforming the arterial groove into a canal. dissection of the vertebral artery leading to thrombotic occlusion or ischaemia from narrowing of the arterial lumen has been described in trauma. there are fistula between a dural branch of the spinal ramus of a radicular artery and an intradural medullary vein in spinal vascular malformations. mdct angiography is feasible and is an alternative technique in diagnosis spinal vaskü ler malformations. the craniovertebral junction (cvj) is a funnel-shaped structure comprised of the clivus and foramen magnum and the upper two cervical vertebrae. the most frequent neoplastic lesions of the craniovertebral junction are meningiomas, neurinomas, chordomas, paragangliomas, epidermoids, dermoids and chondrosarcomas. conclusion: in this presentation, pathologies seen in craniocervical junction (congenital variation, trauma, vascular malformation and tumor) were discussed with figures and compared with the literature. introduction and objectıves:small bowel obstruction (sbo) is very rare. although the diagnosis is straightforward, some patients with intermittant and low-degree symptoms could be misdiagnosed as psychiatric disease. we presented here a patient with intermittant symptoms of ileus treated as psychiatric disease case: a year old male patient was referred from phsyiciatry clinic to our department with complaints of weight loss, nausea and malnutrition. his medical history revealed a laparoscopic appendectomy months ago. he emphasized that his complaints started shortly after the operation and increasingly got worse. he was admitted to hospital days after operation with symptoms of ileus and managed conservatively. the intermittant abdominal pain and nausea continued. since the pain was intensified after meals, patient refused eating. during the period of months he lost kg of weight. after numerous radiological and endoscopic investigations patient was referred to psychiatry due to persistent anorexia. after short psychiatric medication, he was referred to our surgical unit. multislice abdominal computerized tomography and and enteroclysis of small bowel clearly demonstrated an obstruction in the jejunal segment of the intestine. at laparotomy, small bowel obstruction was detected and segmental resection was performed. postoperative period was uneventful and patient was discharged from hospital on postoperative day . conclusions: the diagnosis of anorexia and nausea due to sbo is relatively difficult. the patients were sometimes misdiagndosed as having psychiatric disease. before starting psychiatric medication, they must be reevaluated for all putative causes of sbo. introduction: endoscopically placed biliary stents are a well-established procedure for the treatment of benign and malignant biliary disease. duodenal perforation may occur at the time of insertion of a biliary endoprosthesis or following endoscopic manipulation of such a stent. methods: we report a case of duodenal perforation complicating stenting for biliary fistula in surgery for hepatic hydatid cyst. case: a -year-old man was admitted to a local hospital following the sudden onset of abdominal pain,distension with nausea and vomiting. he developed a biliary fistula after surgery for hepatic hydatid cyst months ago. endoscopically placed biliary stent was performed for the treatment of biliary fistula at the same hospital months ago.on examination, marked abdominal distension with mild tenderness was recognized. his pulse rate and blood pressure were /min and / mmhg, respectively. abdominal x-ray showed two foreign body images and subdiaphragmatic free air. emergency laparotomy revealed dirty ascites and perforation of the third portion of the duodenum by the plastic stents. the second stent was found at pericecal area. after extraction the plastic stents and irrigation with isotonic sodium chloride solution, the site of perforation in the duodenum was primary reparing and triple tube placement performed. conclusion: endoscopic retrograde cholangiopancreatography (ercp) is considered to be the most difficult endoscopic procedure in gastrointestinal endoscopy, and is associated with potentially severe and sometimes life-threatening complications such as duodenal perforation. surgical statistics indicate the importance of early diagnosis and treatment for duodenal perforation. introduction and objectives: ticks play an important role in transmitting several infectious agents, such as viruses, bacteria, spirochetes, rickettsia, and parasites. in this study, we analysed the demographic and clinic characteristics of the patients who admitted to emergency service due to tick bite. methods: in this study, patients were selected from cases of tick bite admitted to the department of emergency medicine of ankara numune hospital during the - periods. detailed histories and some blood tests of patients were taken, and the body of the tick grasped gently avoiding to inject more salivary toxins. results: totally patients admitted to hospital in this period. the most frequent symptoms at administration were malaise, myalgia, and fatigue. hemorrhagic manifestations were observed in patients and bleeding was from multiple sites in patients. other symptoms were watery diarrhoea, skin eruption, macular rash, and petechia-ecchymosis. in the comparison of the clinical features and laboratory results of the surviving and the patients who died, we found that the rates of fever during hospitalization, confusion, neck stiffness, bleeding from multiple sites and presence of petechia/ecchymosis were higher in the patients who died than in the surviving ones. additionally, the mean values of alt, ast, lhd, ck, ptt, international normalized ratio (inr), and urea were also higher and mean plt counts were lower in the patients who died. conclusion: the acute tick-bite reactions show special histologic features, which are unquestionably related to the particular morphology and physiology of the mouthparts of these arthropods. results: totally patients ( men and women) were evaluated. the mean age was . ( - ) years and the mean follow up period was ( - ) months. the localization of the hernias were as follows: inguinal hernias, seven femoral hernias, two umblical hernias, two paraumblical hernias, one epigastric hernia and one inguinal + femoral hernia. all of these strangulated hernias were treated with prosthetic graft repairing. in addition to these hernia repairs, in the same operation sessions three hydrocele repairs, three omentum resections, two partial small intestine resection and anastomosis, one lymphadenectomy, one orchiectomy and one laparotomy were done when necessary. in the early post operative period four patients died because of other diseases not related with the surgical procedures or hernia itself. wound infections were observed in three patients and they were treated with antibiotics and anti inflammatory drugs. we report a rare case of ileal perforation caused by an ingested cm long fork. a -year-old man presented to the emergency department with exhaustion, weight loss and abdominal pain. he had been having pain in the abdomen, nausea and vomiting for the previous days. the patient had received psychiatric treatment, and started to experience weight loss and exhaustion - months previously. no conclusions could be drawn from physical examination for abdominal tenderness and defence. direct x-ray showed an appearance conforming to a fork in the intestine and subdiaphragmatic free gas. the patient was sent for emergency surgery, with a diagnosis of ileal perforation and foreign-body ingestion. most of the ingested foreign bodies that reach the stomach pass through the alimentary tract without complication. perforation occurs in, % of all cases of foreign-body ingestion, usually in the oesophagus. other sites where perforation can occur are the pylorus, the duodenum, the duodenojejunal flexure, the ileocaecal region and any site of congenital anomalies. long, thin or sharp objects, as seen in our case causing ileal perforation. foreign-body ingestion is a possibility to be borne in mind at presentations to the emergency department, especially those with symptoms described in psychiatric cases. appendicectomy is a common emergency operation, its major complications are uncommon. most complications of appendicectomy occur in the early postoperative period and easy amenable to treatment with conservative medical therapy. appendicitis, usually a benign disease, can have its prognosis worsened in case of postoperative fistula. the latter occurs rarely after open appendicectomy but accounts for % of the morbidity rate. schloffer tumor (inflamatory granuloma or abscess in the abdominal wall at the operative scar) is rare complication that usually develop months to years postoperatively and late postoperative enterocutaneous fistula has been described in literature as a rare complication of acute appendicitis. we describe one such case where the patient presented with a tender mass under the incision site six months later after appendicectomy. findings of computed tomography were demonstrated thickening in the abdominal wall and abdominal wall abscess like schloffer tumor. abscess was drained. there were not produced any microorganisms in the wound culture. after conservative therapy healing was completed in a short period. one year later, the patient was admitted with complaints. on the examination, passage of undigested food particles through a sore in the appendicectomy incision site. computed tomography were demonstrated fistula tract extending from appendicectomy site to skin. enterocutanous fistula was occured at the appendicectomy incision year later after operation and successfully treated with en-block fistulectomy and right hemicolectomy. postoperative course was uneventfull. patient discharged from hospital at seventh day after operation. objective: vascular insufficiency may lead to hypoxic injury in intestines. the lesions in the colon are called ischemic colitis. mesenteric ischemia is more prevalent in patients getting hemodialysis. in this study we report hemodialysis patients admitted to the emergency department because of acute abdominal symptoms. case year old woman was chronic hemodialysis patient admitted to the emergency room with acute onset abdominal pain.the initial diagnosis was acute appendicitis and she underwent laparotomy. peroperatively isolated cecum necrosis was seen. right hemicolectomy and ileotransversostomy was performed. she died days after surgery because of sepsis. case year old man was chronic hemodialsysis patient admitted to the er because of abdominal pain persisting for h. with an initial diagnosis of acute abdomen a median incision was performed. peropertively widespread peritoneal adherences and isolated cecum necrosis were seen. cecum was resected and side to end ileocolostomy was performed.he died days after his first operation. case year old man was chronic hemodialysis patient admitted to the er with pain localizing to right inferior abdomen. with an initial diagnosis of acute appendicitis laporotomy through a mc burney incision was performed. there was · cm cecum necrosis. cecum resection and end colostomy and ileostomy was performed. the patient was discharged days after the operation without any problem. discussion: ischemic necrosis of cecum is a rare variant of ischemic colitis. in hemodialysis patients requiring colon resection due to ischemic colitis, primary anastamosis should be avoided, diversion stomies should be preferred. agitation is a non-specific constellation of comparatively unrelated behaviours that possess a risk to the safety of the patient or caregiver, impedes the process of care giving or impairs a person's function. the management of agitated trauma patient contains hospital, prehospital, in emergency department and inside of the hospital transports. the reasons of the agitation hypoxia, hypoglycemia, hypovolemia, pain, traumatic brain injury, anxiety disorder, drug and alcohol abuse, psychiatric disorders. pain management has had a limited role in the management of trauma patients, primarily because of the concern that side effects (decreased ventilatory drive and vasodilatation) of narcotics may aggravate preexisting hypoxia and hypotension. health professionals should monitor pulse oxymetry and serial vital signs if any narcotics are administered to a trauma patient. small doses of benzodiazapine sedatives should be titrated cautiously because of the potential side effects of hypotension and ventilatory depression. to control agitated patients with traumatic brain injury include haloperidol, midazolam, and propofol. in the emergency setting, they are most often indicated to control agitated or psychotic behavior that constitutes an imminent danger to the patient or others. to control agitated patients should be a part of the trauma management. we present a protocol for trauma team. there were males ( . %) and females ( . ). eighty percent of the patients were between and years of age. the overall mortality was . % ( patients). eighty percent of deaths occured in comatose patients (p < . ). comatose state, precence of focal motor signs, respiratory irregularities and hypertansion-bradycardia, pupillary changes were determined as the bad prognostic factors. a midline shift greater than mm, hematoma volume greater than ml, accompanying intracerebral and extracranial traumatic pathologies significantly increased the mortality rate. there was no significant statistical correlation between the outcome and the age, sex of the patient, trauma-to-operation interval, thickness, localization and origin of edh and aetiology. results: the primary factor on outcome is glasgow coma scale scores of the patients at the time of surgery. therefore early surgery is crucial in the management of edh which is a dynamic process. introduction: in this study, we have evaluated the incidence and clinical characteristics of the patients for traumatic brain injury (tbi)-associated coagulopathy after tbi retrospectively. methods: retrospective study of all patients admitted to the trauma and emergency surgery intensive care unit (icu) from january through december with tbi. criteria for tbi-coagulopathy (tbi-c) included a clinical condition consistent with coagulopathy in conjunction with a platelet count < , mm and/or international normalized ratio (inr) > . and/or activated partial thromboplastin time (aptt) > s and/or prothrombin time (pt) > . s. the following potential risk factors were included to identify independent risk factors for tbi-c and its association with mortality, age, mechanism of injury (blunt (b) or penetrating (p)), glasgow coma scale (gcs), injury severity scale (iss), presence of polytrauma, icu length of stay (icu-los). results: a total of patients met study criteria. tbi-c occured in . % (n: ) of all patients (b: . %, p: . %). in patients with tbi-c, mean age was . ± . years. the averages of gcs was . ± . , iss was . ± . , icu-los was . ± . days, polytrauma was considered . % (n: ) and the overall mortality was . %(n: ) in patients with tbi-c. conclusions: in our study, tbi-c occured more frequently among patients sustaining blunt versus penetrating injuries. to our knowledge, tbi patients are at considerable risk of developing coagulopathy and anesthesiologists should be aware of this life-threatening syndrome, especially in tbi patients with blunt injuries. erythropoietin (epo), glycoprotein hormone, is a mainly produced by the kidney that stimulates proliferation, growth and differentiation of erythroid precursors in the bone marrow. recently, anti-inflammatory, neuroprotective, antiapopitotic, angiogenic and vasodilatator effects of epo have been also determinated. the purpose of this study was to investigate the effects of rhuepo in reducing the severity of experimental spinal cord injury (sci). ninety adult sprague-dowley rats weighted g (± ) were used for the study. through a dorsal incision, t - laminectomies performed in prone position and clip compression had made for ischemic injury as tator method. the rats divided in three groups. systemic l ( , u/kg) rhuepo had given h before the trauma in the first group, min. later after the injury in the second group and the third was the control group. the rats were killed with high dose intraperitoneal ketamin h later after the injury. the histological examination of injured spinal cord specimens for the potential neuroprotective effects of rhuepo was done. further more the axial spine sections stained with ttc (triphenyl tetrazolium chloride). the ischemic areas were evaluated with a imaging calculation program. we use wet-dry method for determination of ischemic tissue edema. we concluded that administrating a single dose rhuepo ( , u/ kg) has potential neuroprotective effect on experimental spine injury by reducing severity of inflammation and tissue edema in the secondary ischemic area. it has known both early surgery and high dose steroid treatment prevents the neurological function and viability caused of the traumatic secondary spine injury. we present surgically treated a traumatic rotation-compression spinal cord injury caused by a motor vehicle accident. the patient referred to our clinic h after the injury. at the time of admission, he had a localized pain at the thoracic - vertebrae level, loss motor and sensorial function under the level t classified as asia grade a. he was incontinent. in the radiological evaluation we found loss of height at the thoracic th and th vertebrae body, serious spinal column injury include t - burst fracture, laminas and facet joints fractures with three colon damage (denis f). we detected the spinal instability criteria in . we did not see penetrating injury or primary spinal cord injury signs but spinal canal tightness for percent in ct and mri scans. we took the patient to surgery in unusual classical surgery timing. first, decompressing surgery applied to the t - laminas and posterior stabilization with transpedicular screw-rot system. one day after the first operation, t and t corpectomy applied for anterior stabilization with cage-screw system. mega dose steroid had given also before the first surgery. postoperatively early neurological evaluation, he had asia grade c, after second month asia grade d without incontinence. in our opinion the decompressing surgery that applied in h in the patients without complete primary spine injury, has a positive neurological feedback. introduction: it is a rare occurrence with the rate of % in the subjects with spinal infestation cyst hydatic echinococcus granulosus. intradural hydatic cyst is relatively rare when compared with other spinal hydatic cysts. we are presenting here a -year-old female case who applied to emergency service with backache and paralysed legs and was diagnosed with spinal intradural extramedullary hydatic cyst. case: a -year-old female patient applied to emergency service with complaints of a backache started two days ago, paralyses in both legs and being unable to walk. in her neurological examination, a complete motor power loss in the lower extremities and bilateral sensation loss compatible with t dermatoma were detected. in the torako-lomber spinal magnetic resonance imaging (mri), multiple cystic characterized nodular lesions having peripheral contrast with regular contour including right neural foramen and paravertebral zone at the level of t -t and l in the intradural distance were determined. the patient was diagnosed with common spinal intradural extramedullary hydatic cyst exhibiting bone involvement. as the lesion was very broad had paraplegia, we did not consider operation. conclusions: hydatic cyst infestation is a benign disease. if it is not diagnosed early and treated when it involves in some systems rarely as it did in this study, the results can be serious. diagnosis should be confirmed quickly with increasingly common advanced radiological diagnosis methods. the aim in these cases is to eradicate the cysts surgically, however, chemo-therapy and percutaneous drain methods have become more significant recently. introductıon: several guidelines advocate multiple chest radiographs during primary resuscitation of trauma patients. several local hospital protocols include a repeat radiograph before leaving the trauma resuscitation room (tr). the purpose of this study was to determine the value of routine repeat radiograph. methods: one year data of all radiological imaging in our tr were prospectively collected for all patients presented to the tr of the hospital. we counted and assessed the radiographs and classified our findings as either 'new injury detected', 'presence of intervention equipment', or 'deterioration of previously detected injury'. results: in total, patients were included. more than % had two radiographs. eight ( . %) new injuries without clinical relevance were found on the repeat radiograph after an initial normal radiograph. in total patients ( %), had a repeat radiograph to verify the effect of an intervention or position of equipment. in patients ( %) with two abnormal radiographs, newly diagnosed injuries (n = ) or deterioration of known injuries (n = ) were found. in patients ( %) the results of the repeat radiograph had no clinical consequences. conclusıon: our study supports a strategy of omitting a routine repeat radiograph in trauma patients whose initial radiograph is normal. introduction and objective: the neck region is affected in only about - % of all trauma cases, and isolated neck injuries, especially from a blunt mechanism, is even more rare. our objective was to assess the incidence, disability from spinal cord injuries, and preventable deaths in our patients with isolated neck trauma. material and methods: patients were identified at the severe trauma registry of our hospital, between and . the triss method was used to assess preventable deaths. results: we found ( . %) patients with neck injuries out of . patients included in our registry, ( %) from blunt (bnt) and ( %) from penetrating trauma (pnt). only ( %) bnt and ( %) pnt were isolated. the mean iss of the bnt and pnt groups was of ± and ± . , respectively. in the bnt group, ( %) patients had spinal fractures (with spinal cord injuries with permanent disability), had airway injuries and a vascular injury. in the pnt group, patient had a spinal fracture, had vascular injuries and airway injuries. overall mortality was of ( %) patients, in each group, and only one of them was deemed preventable. conclusions: isolated neck trauma is a rare cause of disability and preventable death in our area. most penetrating injuries have a lowto-moderate degree of anatomic severity (ais £ ). for each group. however about applications increased gradually with a peak at o'clock in all groups. patients treated at ed were mostly stricken ( . %) and the busy period was between - h with two peaks at and o'clock. totally, patients were hospitalized mostly in group iii ( . %) regardless of cause (p < . ). patients referred to another hospital were frequently in group iii ( . %) and also in group iv ( . %). mortality was slightly high in group iii. however higher rate ( . %) was seen among patients in group ii. conclusion: midnight hours seemed safe in terms of mortality and severity of trauma. whether the reason for a higher transportation rate at night hours is the severity of trauma or sedation of ed staff is not clear. introductıon: in this study we aimed to investigate and compare the features of child and adult injuries due to bicycle accidents admitted to our emergency department. patients and methods: the study was carried out retrospectively by searching the files of patients admitted to the emergency department due to bicycle accidents, in the emergency department and archive records between the dates of january and december . the patients were divided into two groups as adults and children. age and sex of patients, season or month of injuries, place and mechanism of injury, injury site of the body, diagnosis and treatment modalities, discharge and hospitalization rates were evaluated. results: totally patients were included in the study. % of the patients were in child age group, % were adults. it was determined that number of accidents increased especially in the summer months. . % of accidents concerning children and all of adult accidents occurred in the streets. falling down from the bicycle was the most common injury mechanism in children ( %) and adults ( %). head and neck region was the most common body site subjected to the injury both in children ( %) and adults ( %). % of child patients and % of adult patients were discharged after emergency department follow up and treatment. there was a significant difference between two groups with respect to injury severity. conclusıon: as a conclusion most of the injuries due to bicycle accidents happen in children, in the streets, in summer months and school vacations. conclusıons: road traffic collision is a major cause of trauma and death in al-ain city. seatbelt compliance is alarmingly low and should be enforced. introduction and objectives: the controversy between the ''scoop and run'' versus the ''stay and play'' approach in severely injured trauma patients has been an ongoing issue for decades. the present study was undertaken to investigate whether changes in prehospital care for patients with severe traumatic brain injury in the netherlands, have improved outcome. methods: in this retrospective study, files were analysed for all patients admitted to one of six hospitals in the limburg region in the netherlands with a gcs < on admittance over the period january -december . all patients had proven traumatic brain damage on ct or mri. relevant prehospital and clinical data from a similar study conducted years ago were compared to data from the present cohort. the main outcome was mortality. results: the two research groups had similar characteristics. in the historic cohort, basic life support (bls) and the 'scoop and run' method in patients with major traumatic brain injury (tbi) was common, with an average time on scene of . min. nowadays, prehospital care is performed mainly on the level of prehospital advanced life support (als), with average time on scene about four times as long as in the historic cohort. however, the overall mortality rate for the current cohort compared to years ago has not decreased. conclusion: despite more on-site als in major tbi nowadays, there was no reduction in mortality. the team is provided to be ready all the time by making monthly and yearly national education exercises. these exercises are planned with two methods: ( ) as demonstration during education ( ) by creating extraordinary condition simulations aim: _ interpret the support of exercises plans on umke operational agility and to accomplish next plans through this way. material -method: umke teams are divided into two parts after geting their basic educations. first group is planned to exercise in education room with demonstrations. the second is planned to exercise the extraordinary situation simulations in which people(not from the groups) made up and acted as injured and moulage is also used in this group. after the exercises, results are compared according to the criteria for assessment. in the first group's demonstrations it is worked by giving roles to team members in the education atmosphere with existing equipments (chair, table, ladder…). in the second group, worked with the moulaged volunteers and extraordinary situation simulations just like the real(wreck, avalanche, fire…) the results are considered statistically by t test. findings: according to the assessment criterias the first group's average point is . and the second is found as . . (p < . ). discussion and result: exercises in a form of extraordinary situations effected team's performance, operational success and involvement positively. planning the exercises with this data will increase the quality of the educations which planned in the future. nurhan babaoglu, tayfun cucioglu, gö khan akbulut national medical rescue team, ministery of health, afyonkarahisar, turkey entry: umke designed as serving medical rescue in extraordinary circumstances. they carries their approaching skills to the top by managing regional and national exercises. the teams in different cities coordinate and share their knowledge and agility by this exercises. aim: after the workshop oriented educations, criteria are needed to improve and decide the affect of the exercises as numerical which supplies standardization of the teams. material-method: teams are evaluated according to criteria and graded from to . after the exercises, results and the importance of criteria shared with teams. month later same teams evaluated again in exercises. criteria: ( ) equipment ( ) team accordance and work discipline ( ) security and to define work risks ( ) approach to the injured ( ) evaluate the injured people ( ) convert the theory to practise ( ) usage of materials correctly and in proper place ( ) packaging ( ) taking out the injured safely ( ) cleanness of the materials and control of medical bag findings: after antalya umke basic education, team's evaluated and average score was . . this results shared with teams and in next exercises in isparta mean score founded as . . (p < . ) discussion and result: when the evaluation criteria and results shared with the teams, it is confirmed that the teams react better in ongoing situations. it is considered that it will also increase the quality and effectiveness of the education. the criteria for evaluation going to help standardization which can be used by all medical rescue teams will provide a common manner between the groups. hasan Ç elik, gö khan akbulut, nurhan babaoglu, tayfun cucioglu national medical rescue team, ministry of health, afyonkarahisar, turkey umke teams are established in in cities in order to act in disasters and extraordinary circumstances as a medical rescue team. members are chosen among the volunteered medical crew. the team's mission is to support the search and rescue teams medically in extraordinary circumstances. team starts with the first intervention and maintain the stabilization of the injured person before the transport so that prevents the second insult. working principles was not obvious during the establishment phase and this caused chaos at the beginning. by designating the teams responsibilities work distribution reached to the standard. national medical rescue team is consisting of medical personnel who are named as leader, logistic, pigeon, squirrel and courier. the team leader who is chosen from doctors who has experienced in disaster medicine and have knowledge about leadership, provides a common manner and motivation among the team. also directs the intervention to the injured person and coordinates with search and rescue teams just after the fast arrive in extraordinary circumstances. squirrel communicates with injured at first and starts his intervention with the direction of the leader. logistic is responsible for all equipment (spin board, medical bags…). courier provides the equipment transportation between logistic and squirrel. pigeon is responsible for photographing, recording and communicating with the center. this organization type performed in regional and national practises from to and also in train accident in kü tahya. _ it helped maintaining standardization and acquired successful results. author to editor: bu yazıyı ulusal medikal kurtarma ekiplerini (umke) tanıtmak amacıyla hazırladık. eg er uygun gö rü rseniz, umke yi tanıtıcı bir stand açıp medikal çantamızı ve dig er kullandıg ımız malzemeleri tanıtabiliriz. ayrıca bu gü ne kadar katıldıg ımız (pakistan depremi, isparta uçak kazası, kü tahya tren kazası) afet, tatbikat ve eg itimlerimizi(ameliyathane konteynırımızı) power point olarak sunabiliriz. helicopter use as a part of trauma care introductıon: rapid transport and persistence of prehospital care is crucial to decrease the mortalities and morbidities of combat related injuries. hence, helicopters are effectively used by the military although they are austere environments that offer limited space, equipment and resources for the crew and requires higher level of skills for prehospital trauma care. materıal-method: the data were collected from consequent casualties, by the helicopter medical team (a surgeon, anesthesiology technician and a paramedic). during the flight, we triaged the casualties according to wound characteristics (severity, mechanism, location), physiological parameters, and provided basic life support stated by trauma resuscitation course (trk). we transmitted these findings to the military trauma center to provide hospital preparedness. result: injury mechanisms were % explosives and % highvelocity weapons. time to hospital admittance was < min after the injury. most frequent sites of injury (ais - ) were extremities ( %) and thorax ( . %); the frequency of ‡ anatomical site injury was %. capillary refill rates were; < seconds . %, > seconds . %. mean sao , gcs, hr, respiratory rate values were . ± . , . ± . , . ± . , . ± . , respectively. during uninterrupted care, ( %) intubations were performed and % of casualties were operated upon admittance without any onboard mortalities. conclusion: the high energy and lethality of the wounding agents in combat render the helicopter evacuations indispensible. additionally, civilian major trauma patients may benefit from expeditious transport to the closest trauma centers or from rural inaccessible areas within the 'golden hour of trauma'. the most important steps for the treatment of the combat injury causalities are to stop or reduce bleeding and to start fluid resuscitation. peripheral intravenous (iv) line placement is one of the most important procedure in the battlefield conditions. most of the time, fluid resuscitation would be the only available medical treatment for the injured combatant because of the prolonged evacuation period in the battlefield. also, this procedure would be very difficult and time consuming especially under hostile gunfire. excessive blood loss and hypotension may cause the peripheral venous collapse and makes the procedure more difficult. here we described a simple method to make this procedure easier. we offer the forward medical team personal to perform the upper extremity peripheral venous mapping of the combatant before the operation. the medical providers (doctor or paramedic) who would perform the first medical intervention would examine the upper extremities of baddy just before the operation. the medical care provider should determine the suitable situations for the iv line placement. then he should remark the both site of the appropriate vein by camouflage paintings, leaving the probable angiocath insertion sites non-painted. we believe that this method would make the peripheral iv line placement easier and faster for the forward medical team personal in the war conditions. one probable disadvantages of this method is the negative psychological effect on the combatant that makes them to estimate the risk of wounded in a few hours. introduction and objectives: ambulance and emergency care technicians are the key personnel for pre-hospital care of trauma. this study reviews the work anxiety states of some of the students in ambulance and emergency care technicians department, vocational school of health services, marmara university by comparing it with those of the students in radiology department of the same school. methods: this study was developed as a sectional type of study and was conducted on volunteer students from the above mentioned departments. the data were analyzed using the spss . software and employing the frequency distribution, t-test for individual groups, and unidirectional variance analysis methods. results: the study group of subjects was . % female and . % male. . % of the subjects expressed anxiety over their employment in the future; . % of them expressed no work anxiety. the work anxiety points of the subjects were compared in terms of their genders, academic years and departments, and said comparison did not reveal any statistically significant difference (p > . ). conclusions: the work anxiety state is one of the major factors having an impact on professional success, and is a negative state having an impact on one's performance, success and, in turn, psychological state. it would be proper to study the issue of work anxiety by obtaining psychological support, and to cooperate with the actors in this sector to develop solutions. it is concluded that further studies should be conducted on work anxiety and its reasons. in general, emergency patients should be transported to the closest appropriate hospital. if the emergency medical services have identified a specific hospital with better resources to treat seriously injured patients, the patient should be transported to that institution, bypassing closer hospitals. the cooperation is expected between the hospitals, and the development of formal transfer agreements, describing all of the legal, economic, and medical aspects of the relationship are encouraged. ideally, the entire trauma system in a city should be designed on the basis of need and existing resources, with all affected parties involved in the planning, development, and implementation. the goal of the system is to match the needs of an injured patient to the resources of the available facilities so that optimal and cost-effective care is achieved. we conduct six essential questions for the preparation of trauma. is there a legal authority to formally designate hospital's trauma response in your city? what sources were used as a basis for standards of the trauma response in your service area? were the number of hospitals identified for your service area limited based on the results of needs assessment? what type of transport practice occurs in your service area when a field assessment identifies a trauma patient with severe injuries that threaten loss of life or limb? is a trauma registry present in your service area? is there a designated trauma advisory committee that evaluates the performance of trauma care delivery within your service area? we evaluated the role of primary hip arthroplasty (consisting of both total hip replacements and hemiarthroplasty) in these comminuted, osteoporotic or neglected fractures. these patients at-risk were in need of a single definitive surgical plan for early ambulation and preventing complications. typically these patients were elderly with poor mobility and had multiple other medical condition to be able to withstand multiple surgeries. there was a need to obtain the best results with the single, rapid procedure for pain relief and early ambulation. excellent to very good results were obtained in about % of these patients. good results were obtained in about % of these patients and poor results in about %. most of the poor results were the outcomes of complicated medical conditions rather than the failure of the orthopaedic procedure itself. we advocate arthroplasty in neglected, osteoporotic or severely comminuted per-trochanteric fractures for immediate mobilization and optimising outcomes. the role of intra-articular steroids or hyaluronic acid injections in early arthritis may be warranted and perhaps safe. but for patients waiting for a knee replacement these can prove positively dangerous. a meta-analysis has revealed that intra-articular injections given in patients waiting for a knee replacement procedure is fraught with dangers. apart from a high risk of post-operative infection and failure of the procedure, several other side-effects or complications make this risky. there is a higher-than-average chance of quadriceps tendon rupture, delayed wound healing, superficial infections and slower rehabilitation. in comparison hyaluronic injections have been found efficacious in the short term and do not contribute to complications normally attributed to steroids. thus intra-articular injections should be used with caution, repeated injections are best avoided and are certainly contraindicated if a procedure is anticipated to be performed within six months. introduction: pediatric forearm fractures are common. the majority has satisfactory outcome. but poor results do occur and malunion can compromise rotation. we belief that the angulation of the fracture depends on the action of the body and that we can reduce the fracture by completing the action. this way we can perceive a stable anatomic reduction without internal fixation. methods: we undertook a prospective study of distal forearm fractures in children. we included children with a non-displaced angulated metaphyseal distal forearm fracture. the angulation was between °and °.we all reduced them by completing the action of the body. this means a volar angulated fracture is reduced by pronation of the hand and a dorsal angulated fracture is reduced by supination. after the reduction they were casted in an upper-arm cast in pronation or supination depending of the reduction manoeuvre. afterwards the all received weeks of upper-arm cast and weeks of lower-arm cast. results: they all healed without loss of reduction and without further treatment. they all had full recovery of function. conclusıon: non-displaced angulated metaphyseal distal forearm fractures in children can be treated conservatively by closed reduction and plaster cast. background: vascular endothelial growth factor (vegf) plays an important role in the bone repair process as a potent mediator of angiogenesis and influences directly the osteoblast differentiation. inhibiting vegf suppresses angiogenesis and callus mineralization in animals. however, no data exist on systemic expression of vegf with regard to delayed or failed fracture healing in humans so far. methods: one hundred fourteen patients with long bone fractures were included into the study. serum samples were collected over a period of months following a standardized time schedule. vegf serum concentrations were measured. patients were assigned to groups according to their course of fracture healing. the first group contained patients with physiological fracture healing. eleven patients with delayed-or non-unions formed the second group of the study. in addition, healthy volunteers served as controls. results: an increase of vegf serum concentration within the first weeks after fracture in both groups with a following decrease within months after trauma was observed. serum vegf concentrations in patients with impaired fracture healing were higher compared to the patients with physiological healing during the entire observation period. however, statistically significant differences were not observed at any time point between both groups. vegf concentrations in both groups were significantly higher than those in controls. conclusıon: the present results show significantly elevated serum concentrations of vegf in patients after fracture of long bones especially at the initial healing phase indicating the importance of vegf in the process of fracture healing in humans. first, dsbls is applied to . cm proximal to most prominent point of medial malleol of tibia. the dsbls was inserted parallel to the joint surface in frontal and horizontal plane. after the dsbls is applied the selected nail is inserted. reamed imn is used for the tibias with narrow isthmus ( ). the success of di is checked following the insertion of nail with set screw on the dslbs. the unsuccessful attempts are repeated after the reason is removed. the di of tibias were successful and were unsuccessful at the first attempt. in unsuccessful cases, the nails were at the posterior ( ), anterior ( ) and lateral ( ) collum femoris fractures accounts . - % of all fractures. however it is very rare in children ( %). in this study we evaluated pediatric patients who were operated due to collum femoris fracture in terms of avascular necrosis and functional outcome. age of the patients ranged from to . there were seven girls and five boys. two of the patients were admitted to the emergency department due to a fall from height, therefore they had multi system trauma. the remaining ten patients had isolated collum femoris fracture. fractures was classified according to delbet classificaion; seven transcervical and five cervicothrochanteric. locking plate-screw fixation was applied to one patient, other fractures were fixed with two or three cannulated screws. open reduction was applied to four patients and closed reduction to eight. five of the cases were operated in the first h of the fracture, however the remaining seven patients were operated after the first h ( - days) due to late admission. range of motion of the hip joint was limited in only one patient who had polytrauma and operated after the first h. there were three avascular necrosis as acomplication. all of them operated after the first h and all the fracture types were cervicotrochanteric. open reduction was applied to two patients and closed reduction to one. pediatric collum femoris fractures are rarely seen in children but treatment is challenging and open to complications. fracture type, surgical methods, did not effect the outcome, but timing of surgery did. author to editor: in this study we discussed the outcome of pediatric collum femoris fractures, which is a very rare fracture in orthopaedic experience. surgical management of humerus shaft fractures is an increasing interest nowadays. we want to discuss the outcome of conservative, open reduction and internal plate fixation (or _ if) and intramedullary nailing (imn) methods in adults ( - years old). patients had conservative treatment with modified custom made sarmiento brace and of them had union with °- °of malunion. none of the nine have complains and the avarage union duration is weeks ( - ). one patients did not tolerate bracing and undergone surgery. patients had or _ if and had gone second operation for nonunion and had elonged wound drainage. all the fractures healed eventually with in weeks ( - ). no neurovascular complication was observed. patients had imn treatment and had delayed union up to months, had undergone reoperation with or _ if for non-union, had intraoperative fracture of elbow and had shoulder problems with impingement and rotatory cuff problems. avarage union duration was found weeks ( - ). surgical treatment is getting more popular for long bones nowadays. early return of work and social life, anatomic reduction, using no sling or such devices and easy follow up protocols are the facts that popularising the surgical management. but in our series, we had seen multiple types complications that are as high as they are mentioned in literature. with the experience of those patients that had been treated with in this year, conservative treatment methods have to be conserned firstly in suitable and tolerable patients for us. intoduction and objectives: correction of sagittal deformity is important in thoracolumbar burst fractures. the clinical maneuvers needed for reduction and the assessment of correction of the fractured vertebra is not well described. in this prospective series we used the length of the interspinous ligaments as reduction parameter. our aim was to evaluate the efficacy of this assessment technique in achieving good correction. methods: from to patients (m/f / , mean age . ) with unstable thoracolumbar burst fractures were treated by posterior fusion with a standard construct by a single surgeon. all patients were treated with segmental posterior instrumentation with two levels above and two levels below the fracture level fixation by means of pre-contoured rods and distraction technique. with these maneuvers the length of the injured level was tried to be equalized to the mean of upper and lower levels. anterior column was assessed by radioscopy. preoperative and postoperative radiographs were analyzed and local kyphosis (lk), farcy's sagittal index (fsi) and compression percentage (cp) were measured. results: the preoperative lk decreased from . °to . °, fsi decreased from . °to . °and cp decreased from to . . after a minimum follow-up time of years all patients continue to do well with no statistically significant decrease in these parameters. conclusions: assessment of thoracolumbar burst fracture reduction with pre-contoured rods and distraction technique can be made safely by intraoperative measurement of the length of the interspinous ligaments. case: an -year old lady was admitted in our emergency department with a neer -part fracture of the right proximal humerus caused by a fall. she was operated on and received a shoulder hemiarthroplasty. during cementation of the stem the patient became bradycard and acute respiratory arrest occurred. she was resuscitated, but eventually died h postoperatively. postmortem examination revealed embolic bone marrow occluding the pulmonary capillaries. comment: pulmonary embolus after upper extremity surgery is a rare complication. fatal pulmonary embolus is even more rare. when reviewing literature there is no previous case of fatal pulmonary embolus caused by fat emboli described. fat embolism syndrome was first described by zenker in , but its frequency today is still unclear. usually it presents as a multisystem disorder. the most often and most seriously affected organs are the lung, brain, cardiovascular system and skin. it is a self-limiting disease, therefore treatment should be mainly supportive. purpose: lack of knee flexion is a possible complication in severe femur fractures. two different techniques for the treatment of this problem were applied. materıals-methods: from to , patients with severely arthrofibrotic knees were managed with two different operative techniques. the mean age of the patients at the time of the operation was years. we recorded the clinical outcome of patient using judet quadricepsplasty with a follow-up of months, and of two patients using extra-articular mini-invasive quadricepsplasty and intra-articular arthroscopic lysis of adhesions during the same anesthesia session with a mean follow-up of months. all patients were evaluated according to the criteria of judet and the hospital for special surgery knee-rating system. results: the average maximum degree of flexion increased from °p reoperatively to °at the time of the most recent follow-up. according to the criteria of judet, the result was good for knees, and fair for one. the average hospital for special surgery knee score improved from points preoperatively to points at the time of the most recent follow-up. a superficial wound infection occured in one patient. conclusions: if you select the appropriate cases, the judet procedure and mini-invasive operation for the severely arthrofibrotic knee can be used to increase the range of motion and enhance functional outcome. purpose: floating knee and elbow injuries are complex injuries. the types of fractures, soft tissue and associated injuries make this a challenging problem to manage. we present the outcome of these injuries after surgical management. materials and methods: two patients with floating knee injuries(classified by blake and mcbryde) and one patient with floating elbow injuries were managed over an average of months. both fractures of the floating knee injury and the three fractures of the elbow injury were surgically fixed using different modalities. the associated injuries were managed appropriately. assessment of the end result used the karlströ m criteria after bony union. results: mechanism of injury was road traffic accidents in two patients (floating knee) and falling from height for one patient (floating elbow). there were associated injuries, patient was tipiia, patient was tipiib. both these patients had intramedullary nailing for femur fractures. patient had ilizarov external fixation for segmenter tibia fractures, patient had a proximal medial plate for proximal tibia fracture. patient had plates afıxed to all fractures.complications were knee stiffness and delayed union of femur in a patient (second operation required). the bony union time average from weeks for femur fractures, weeks for tibia, weeks for upper extremities. according to the karlstom criteria the end results was acceptable. the average elbow score was / (good). patients with tibial bio-screw fixation there is insufficient evidence from randomized trials to determine the optimal intervention in patients with displaced four-part fractures of the proximal humerus: head preserving surgery with problem to obtain and maintain reduction until bone healing, implant failure, avn of the head, ha with > % tuberosities related complications-resorption, displacement, rsa with high complication rate, moderate function due to restricted rotation and insufficient long-time follow-up. in our presentation we will discuss: • new rsa designs, which improve function and lessen complication rates • question of tuberosities fixation to rsa in proximal humeral fractures • literature overlook of rsa in proximal humeral fractures the goal of rsa is to minimize shoulder immobilization and to start functional rehabilitation immediately. indications are same as for ha + tuberosity osteoporosis and comminution + week or absent rc. decision for if, ha or rsa is often intraoperative. tuberosities fixation is debatable (prolonged immobilization, prosthesis dislocation). functional results are more consistent than in ha, but complication rate is higher (it may be lowered by new prosthesis designs). frequent ct scanning due to incomplete -view x-ray imaging of the cervical spine background: conventional c-spine imaging is still widely used, despite increasing replacement by ct scanning. the aim of this study was to analyze the frequency of incomplete c-spine x-rays ( -view series) in blunt trauma patients. methods: during a -year period we analyzed the frequency and value of -view series of the c-spine. secondary we assessed the reasons for subsequent ct scanning after the -view series according to the following classification: inevaluability, incomplete -view series, evaluation of findings on -view series or for unexplained, persistent clinical symptoms. furthermore we evaluated predictors for incompleteness. results: c-spine injuries were diagnosed in blunt trauma patients ( . %). patients ( %) had their c-spine cleared based on the nexus criteria. patients were primarily evaluated with view series and patients primarily with ct scanning. within the population with primarily -view series ( %) were repeatedly incomplete and ( %) were inevaluable. in the major part of the incomplete -view series no apparent reason could be determined. however, the presence of clavicular fractures (resulting in incomplete radiographs in vs. % without a fracture; p < . ) and rib fractures ( vs. %; p = . ) were associated with incomplete -view series. conclusion: in more than a third of the patients primarily assessed with -view series, the results are incomplete or inevaluable necessitating ct scanning. therefore, the diagnostic value of -view series is questionable. in patients with clavicular and rib fractures -view series can be omitted and primary ct scanning is advised. the treatment of open distal tibia fractures is still discussed controversially and they are a great challenge for surgeons. it is still not clear if there should be initial stabilization with an external fixator or primary osteosynthesis with an intramedullary nail or plate. we retrospectively examined patients with ii°and iiia°open distal tibia fractures which were treated during the last years in our level one trauma center. we treated male and female patients with an average age of years. ten patients were treated with an external fixator and patients were treated with an intramedullary nail or plate osteosynthesis in acute surgery. the patients, firstly treated with an external fixator, were stabilized with reamed intramedullary nailing in eight cases and with locked plating in two cases after wound closure. there was no difference in the duration until bony union in any groups. fewer unplaned revisions (n = ) and no deep osseous infections were found in those patients treated with an external fixator in the acute phase of the injury. patients treated with a definitive osteosynthesis underwent unplaned revisions in six cases and developed deep osseous wound infections in four cases. we therefore recommend that initial treatment with an external fixator should be preferred and after consolidation of the soft tissue, the definitive stabilization should be done with a stabile osteosynthesis system. author to editor: this topic remains of a high interest among trauma surgeons, especially now, that angle stable intramedullary fixation systems run the market. fractures of the clavicle shaft are common and have been typically addressed to nonoperative treatment. but favorable results with the precontured anatomic plates are facilitating surgeons for primary surgical treatment. this study reports the surgical results of adult clavicle shaft fractured patients (age range - ) that had been operated with in last months. all fractures were displaced and none of them was open nor had neurovascular injury. avarege healing time was found weeks ( - weeks). all patients had anatomic reduction postoperatively. of the patients fracture site was grafted with dbm. of patients had sterile wound drainage which was lasted for weeks postoperatively (all were grafted with dbm), of them re-operated ( of them for early implant failure and early implant removal for plate disturbance) and one patient was operated for times ( of them was in another center) for early implant failure, nonunion,wound problems and neurovascular complications. of was healed eventually. of patients were satisfied with the treatment and had a full range of motion at final follow-up and were able to return to pre-injury occupational and activity levels. nonoperative treatment of displaced shaft fractures may be associated with a higher rate of nonunion and functional deficits. however, our study shows that surgical treatment also has high complication rates. there is currently considerable debate about the benefits of primary operative treatment of these injuries because it remains difficult to predict which patients will have these complications. platelet rich plasma (prp) is applied in orthopaedic, maxillofacial and plastic surgery with variable outcome. different growth factors and cytokines are stored in platelets, including platelet derived growth factor (pdgf), contributing to the potential positive effects of prp. the aim of our study was to investigate the properties of pdgf administered locally in a rat femoral non-union model. in our experiment a critical sized osteotomy was performed in the rat femur, which was filled with a spacer, inhibiting bone formation for a period of weeks. in a second operation this spacer was removed and the test item was applied into the defect. we compared the pdgf group (d = ng, c = lg/ml of pdgf in fibrin matrix) with the fibrin alone and blank control groups. four weeks after the second operation, specimens were analysed by x-ray, lct imaging and histology. in group pdgf we found a lct confirmed union in of specimens and the lct evaluated bone volume was median . mm (q = . / q = . ). in the control groups there was a bony bridge in of fibrin and in of blank specimens. the bone volumes were median . mm (q = . /q = . ) fibrin and median . mm (q = . /q = . ) blank, respectively. we did not find a strong tendency for new bone formation in the group treated with pdgf. in our model we observed even a tendency to inhibit bone regeneration for pdgf. introduction and objectıves: hand traumas are one of the most common encountered complex traumas. closing the defects on either dorsal or palmar side of the hand is sometime difficult because of limited local tissue and to provide a tissue the tendon glides underneath. in spite of high risk of donor side morbidity and sacrificing a major artery of the hand, radial forearm flap is the most frequent choice to close the defects at this region. method: in a year time, five patients with severe hand traumas who admitted to our clinic, treated with perforator based three radial artery and two ulnar artery adipose-fascial forearm flaps. the adipose-fascial island flap was raised on one or two of these perforators without sacrificing a major vessel.the flap was transposed to defect region and covered with stsg. in all five patients' donor side was closed primarily. results: the biggest flap size was · cm. there was no flap loss except one patient who had partial flap necrosis and it healed secondarily. the donor side was healed uneventfully in all the patients. there was no tendon adhesion. conclusıon: perforator based radial or ulnar artery adipose-fascial flap is a safe and reliable method for closing defects on the hand. it has both less donor side deformity and fascial component of the flap provides better tendon gliding and less tendon adhesion. however, it requires more experience to raise adipose-fascial flap. introduction and objectıves: one of the most common causes of the lower extremity defect in adult is a road traffic accident. the most challenging issues is to close the defect on the / of lower extremity because local tissue is very limited and mostly damaged due to high energy injury. we investigated the difficulties of how we close the defect on one third of the lower extremity particularly in children, in our unit. method: in a year time, patients under years old admitted to our unit. all patients had gustillo iiib injury and the biggest size of the defect was · cm. one patient had different lesions on the heel the other was on the anterior aspect of tibia. after radical debridement, the wound closed with alt free flap with in first week of admission. different defects on a lower extremity were closed with alt and vastus lateralis muscle free flap with a single pedicle. result: the biggest flap size was · cm. an average pedicule length was . cm and the diameter of the vessel was . cm the average operation time was h min. one flap had partial necrosis and healed secondarily. they had uneventful recovery and discharged on average postoperative days. conclusıon: in children even less than years age, one of the good and suitable options for closing the defect on the one third of the lower extremity is alt as a free flap. stable odontoid fractures can be treated with external immobilization using, e.g., a philadelphia collar (pc) or a halo thoracic vest (htv). it is important to delineate the capacity of both orthoses, halo and philly, for immobilization of the atlantoaxial complex (aac), e.g., for their use in odontoid fracture care. in this in-vivo biomechanical comparison volunteers (mean age = . ± . ) were subjected to flexion-extension radiographs immobilized in a modified htv and a pc. radiographs were analyzed for the segmental rotation angle of c - in sagittal plane (sra c - ) and the absolute rotation angle of c - (ara c - ). separation angles (rsra c - and rara c - ) were calculated from flexion-extension views. concerning restriction of subaxial sagittal plane motion, the htv was more effective than the pc. the difference for the rara c - between the pc (mean . °) and htv (mean . °) yielded significance (p = . ). but, concerning restriction of flexion-extension at the aac, there was no statistical significant difference for the rsra c - between the pc and htv (p = . ). pc (mean . °) was superior to the htv (mean . °) in restricting sagittal motion at c - . in comparison to normals atlantoaxial motion was restricted by . % (pc) and . % (htv). the current study demonstrated that there was no significant difference in restriction of sagittal motion at c - between the pc and htv. in light of the current biomechanical data and a selected review of literature it is concluded that the use of a pc is sufficient for the treatment of stable odontoid fractures. introductıon: although most ankle injuries are associated ligamentous structures, some types of fractures mimic to ligamentous sprain and misdiagnosed as well. most of the ankle sprains undergo radiographic examination and some of type fractures easily are missed even x-ray. the aim of this study is to evaluate the missed talar neck fractures and to emphasize the missed fractures. materıals-methods: misdiagnosed cases were included in the study. average age at the time of trauma was ( - ). all cases evaluated prospectively. if the patients had ankle sprain and their initial x-rays show no evident of fracture, they were involved in the study. the diagnosis of the fracture was figured out by control x-ray, ct scan and mri (except case). all patients were evaluated by the scoring system of american orthopaedic foot and ankle society (aofas introductıon and objectıves: treatment of proximal humeral fractures remains controversial, because of complexity of this kind of fractures. the purpose of this study is to present our first experience using angular stable fixation in and part proximal humeral fractures method: in last mounts we treated patients with this method, men and women (mean age ). anterior approach was performed in every case (mis technique in two cases), and every patients underwent to early rehabilitation. periodical clinical and radiographic control were performed. results: short term results are good with satisfaction of the patient, no pain and acceptable range of motion. we have case of deep infection that need revision surgery and antibiotic treatment. preoperative diagnosis of appendiceal diverticulitis is rare. the incidence of appendiceal diverticulitis ranges from . to . %. % of the diverticulitis of colon cases appear above years of age, and they are mostly in the left colon. case: a year-old male, who had a -year history of episodic right lower quadrant abdominal pain was admitted to the surgical emergency department for worsening of his complaints. the physical examination was only notable for right lower quadrant abdominal tenderness. laboratory findings was normal. on ultrasonography examination signs of acute appendicitis was noted. as the radiological findings did not match with the clinical status of the patient, he was followed up. later, acute abdominal symptoms appeared, and the patient was admitted to the operating theatre. two cm long nodules were seen on the appendix preoperatively. appendectomy was done. the patient was discharged on the first postoperative day. the histopatological examination revealed acute appendicitis signs and two mm long diverticula one of which is inflamed in the middle and the other in the distal part of the specimen were reported. conclusıon: the most common cause of acute appendicitis in adult population is fecaloid. lymphoid hyperplasia, carsinoid tumors, mucosel, parasites, fruit and vegetable seeds are other causes. although appendiceal diverticulitis is rare, clinicians should be aware of its occurrence and tendency for appendiceal perforation. introduction and objective: traumatic intracranial hematoma is the most common complication of the head injury requiring emergency intervention. as most of them are located supratentorially, they can be seen less frequently in the posterior fossa. this study aims to evaluates the clinical, radiological and surgical aspects of traumatic posterior fossa hematomas in patients who were treated at our center. methods: the records of patients with of traumatic posterior fossa hematomas that had been treated at our center between and were reviewed. results: of the cases, had cerebellar hematomas and had epidural hematomas. fall was the most common cause, followed by animal kick, assault and traffic accident. diagnosis and management decisions were determined by cranial computed tomography scans. surgical intervention was performed in cases. the outcome was good in patients. three patients died who had low gcs at admission and additional cranial lesion. conclusions: patients with occipital trauma should be evaluated immediately using cranial computed tomography scans. early diagnosis of traumatic hematomas and prompt surgical intervention in those having mass effect provide good results. introduction: transcranial stab wounds made with a knife mostly produce a classic slot skull fracture and underlying tract hematoma, and often cause severe neurological deficits. an unusual case with combined pareses of oculomotor and trochlear nerves due to penetrating stab wound to the brain is presented. methods: a -year-old boy was admitted to our clinic after an altercation that resulted in the patient sustaining stub wound to his head. results: he was conscious. neuro-ophthalmic examination showed that the left eye had limited adduction, supraduction, and infraduction, incomplete convergence and left sided ptosis with dilated pupil. an emergency computed tomographic scan of his brain was obtained, which revealed a left slot fracture at the squamous portion of the temporal bone of the anterior cranial fossa and a frontotemporal intracerebral stub tract hematoma. he underwent emergent surgery. fractured bone pieces and lacerated brain tissue were removed. neurological deficits remained unchanged at months follow-up. conclusions: cranial nerve injury related to the knife wound to the brain is very rare. the penetration site, depth of penetration and trajectory of the object are important in occurring of this injury. prognosis seems to be poor in these cases. introductıon: large number of knee x-rays are done incidentally for patients presenting with knee trauma in accident and emergency. using only one lateral view knee x-ray as a screening tool would reduce the cost by % as per a. verma et al., an interesting proposition. method: we investigated the validity of lateral view knee x-rays alone as a screening tool for detecting fractures around the knee in acute knee trauma. randomly picked x-rays were reviewed. the ap and lateral views were interpreted by a consultant radiologist and the findings used as gold standard for the study. the lateral views alone were independently interpreted on two different occasions by the (a) radiographer (b) emergency nurse practitioner accident & emergency (c) middle grade doctor accident and emergency (d) consultant orthopaedic surgeon. results: there was significant inter observer variation in sensitivity which ranged from to % with the highest sensitivity being achieved by the radiographer. the specificity was generally high with a range from to %. though there was a high validity in the case of the radiographer the sensitivity for the other observers was low. conclusıon: though there could be a significant saving in terms of resources and unnecessary radiation by doing lateral views alone as opposed to the routine ap & lateral views as first line x-rays, we do not recommend using the lateral views alone as a safe screening tool in knee trauma because of high inter observer variation in sensitivity. tk gullett, charalambous p. charalambous, ajay sahu, matt j. ravenscroft stepping hill hospital, stockport, uk introductıon: in distal biceps tendon ruptures, re-attachment to the radial tuberosity should ensure an adequate tendon to bone surface contact to achieve a sound repair and fast tendon to bone healing. method and technique: we are describing a l-configuration reattachment of distal biceps tendon rupture, using a single anterior transverse incision at the cubital fossa crease. each pair of sutures from the most distal anchor is passed through the distal part of the tendon. one strand of each pair is passed in a zig zag fashion through the tendon whilst the other strand is simply passed straight through the tendon in a posterior to anterior direction. the four strands of the proximal anchor are passed so that they form two mattress sutures through the proximal part of the tendon. tightening is then performed in a specific sequence with initially pulling on strand a and b to bring the tendon down to bone and then tightening these to the corresponding suture strand of their pair. the two pairs of sutures are then tied to each other. this second anchor tightening ensures that the tendon is brought down onto the bone in an l configuration increasing the contact surface area between tendon and bone. results: we have used this technique in patients till now with excellent results and no re-ruptures. discussion: our technique is simple to perform and provides a sound repair with a large surface area of contact between tendon and bone. results: out of a % (n = ) response rate, respondents ( male, female) were included in the study. we excluded people with previous hip, knee or back problems. in our study, the symptom scores that is lysholm, oxford and visual analogue scale for pain and function did not show any significant decline with age. on the other hand, the scores measuring activity levels that is tegner and ucla scales declined significantly with increasing age. our normal scores were far ahead of age-matched post operative scores following total knee replacement. there was no difference between males and females. the symptom scores declined with increase in medical problems. conclusıon: our age matched scores were superior to post operative total knee replacement (tkr) scores from the njr. this furthered our motive to create a set of reference knee scores in the normal population which could be used by other studies to compare their results and help improve postoperative outcomes. mesenchymal stem cells (mscs) are multipotent stromal cells that have extensive proliferative potential and the ability to undergo multilineage differentiation. traditionally, osteogenic differentiation of mesenchymal stem cells has been studied in cells isolated from bone marrow and iliac crest. however, these harvest techniques are associated with several problems, including donor morbidity, pain, and limited amount of cells. only a few years ago, adipose tissue has been identified as another source of mulitpotent mscs, which are referred to as adipose derived stem cells (adscs). the aim of our study was to provide a comparative analysis of primary osteoblasts from the iliac crest and osteogenic differentiated mscs from adipose tissue, using osteoblast-specific protein expression. in patients the cells were differentiated into the osteoblast lineage using osteogenic medium (adobs). primary osteoblasts were isolated from iliac crest specimens in patients undergoing osteosynthesis with spongioplasty (female: , male: , mean age ± . ). phenotype marker expression of osteoblast-specific proteins osteocalcin, alkaline phosphase, type i collagen, and cbfa- (runx- ) was analyzed up to days following incubation using rt-pcr, western blot, and immunocytochemistry. additionaly, the following surface proteins of adscs were analyzed: nucleostemin, cd , cd , cd , cd , cd , and cd . rt-pcr analysis revealed that the non-differentiated adscs contained different types of stromal cells with a large variety of cd marker expression. surface protein expression (cd) did not differ significantly in cells isolated from either fat tissue or bone. author to editor: saved by lookus. background: at our department, classification of the responsiveness to fluid resuscitation and a simple and practical damage control surgery (dcs) scoring system have been used to determine the efficacy of the treatment strategy in trauma patients. cases and methods: we examined out of hepatic injury patients, excluding cardiopulmonary arrest cases. the present study was undertaken to establish a valid strategy for the treatment of hepatic injury, and further improvement of the survival rate was evaluated based on the grater and equal of grade iv [organ injury scale (ois)] hepatic injury necessitating emergency room laparotomy. result: interventional radiology (ivr) treatment cases were all stable or responder patients and all survived with effective hemostasis. transient responder or non responder patients that needed hemostasis were treated by emergency laparotomy, and all the cases that eventually expired needed dcs. the mean injury severity score (iss) was . and the mean probability of survival (ps) was . , and hemostasis treatment was started within a mean of . min, yielding a survival rate of . % in the cases with grater and equal grade iv (ois) liver injury that needed emergency room laparotomy. conclusion: our criteria for deciding the therapeutic strategy based on the response to the initial fluid resuscitation seemed to be useful from the viewpoint of hemostasis for liver injury. the key to securing quality regional trauma care is to designate a trauma care hospital as a trauma center and to transport severely injured patients to the center as rapidly as possible. author to editor: we show that our classification of the responsiveness to fluid resuscitation and a simple and practical damage control surgery (dcs) scoring system is very effective for liver injury strategy. fractures of the proximal femur are, more than ever, an important challenge in the field of traumatology. the gamma-nail, a combination of advantages of the sliding screw with the intramedullary nail, represents an efficient technique in the management of these fractures. a series of fractures of the proximal femur in which this nail was used is reported. the average age of patients was . years (range - years). . % ( patients) of the cases were female. the average duration of the operation recorded was min. in all cases closed reduction was achieved. the mean healing time was . weeks in . % of the cases. there were two cases of delayed consolidation but no pseudarthroses. postoperative complications occurred in cases ( . %). one case of migration of the proximal screw was the most important complication. the most frequent complications ( cases) were seromas and hematomas of the surgical wound, which resolved satisfactorily in all cases. superficial infections ( cases) also evolved favorably, once the appropriate antibiotic treatment had been instituted. no breakages or failures due to implant fatigue were seen. the patient's recovery after suffering the fracture and the operation was evaluated and the % ( patients) recovered their previous walking ability. the overall mortality was . % ( patients) with of the deaths occurring while in hospital. in conclusion, this preliminary study has shown that gamma-nail can be safely used by the average surgeon in the average hospital to treat a common and sometimes difficult fracture. valerio ranieri, loris trenti, aldo rossi, antonio manenti departement of general surgery, university of modena and reggio emilia, modena, italy a years old nigerian woman, at the end of the nd pregnancy, was submitted to a caesarean section for uterine atony. post-operative thrombo-prophylaxis was given. from pod , fever, abdominal pain and increasing tenderness in the right lower quadrant with leucocytosis appeared. ultrasonography showed only small amount of fluid in the douglas pouch, while a contrast-enhanced ct and a rmn revealed a dishomogeneus cylindrical mass of . cm in diameter extending from the right parauterine space towards the duodenum, suggestive of thrombosis of the ovarian vein. laparotomy followed: uterus, ovaries, appendix and bowels were normal. after mobilizing the right colon the ovarian pedicle appeared enlarged and firm; it was dissected, starting from the vena cava, and completely excised preserving the adnexa. post-operative course was uneventful. histology confirmed a suppurative thrombophlebitis; the haematological study ruled out any coagulation abnormality. the patient completed a months low-molecular-weight-heparin treatment. ovarian vein suppurative thrombophlebitis can seriously complicate a caesarean section, till to require a surgical treatment. the imaging is essential for a prompt diagnosis. purpose: to prospectively study the mechanism, distribution of injury, and outcome of patients hospitalized with camel bite injury. methodology: all patients admitted to al-ain hospital with a camel bite were prospectively studied over years (october -october . mechanism of injury including behavior of the camel, distribution and severity of injury, patient's demography, and outcome were studied. results: all patients were males having a median (range) age of ( - ). almost half of them were pakistani. twenty-five were camel caregivers while five were camel riders. seven patients were raised up by the camel's mouth and thrown to the ground while the other patients were only bitten. majority of the injuries were in the upper limb ( ) followed by the head and neck ( ). / upper limb injuries had associated fractures. two patients who were bitten at the neck were admitted to the icu. one of them died due to massive left-brain infarction and the other had complete quadriplegia due to spinal cord injury. the median hospital stay was days. one patient died ( %). conclusıon: the behavior of the camel is occasionally unpredictable and the canine teeth of the camel, which are long, can cause severe penetrating trauma despite the small puncture on the skin. care should be taken when handling the camel. author to editor: dear colleague: this is the only prospective clinical study of camel bites in the literature that took us years to collect. the data is very unique and is of great interest. fikri abu-zidan gastrointestinal cytomegalavirus infections occurs predominantly in immunocompromised patients.involvement of the gastrointestinal tract in acquired immunodeficiency syndrome (aids) patients is frequent. however the prevalence of cytomegalovirus appendicitis is exceedingly rare. case: a year-old male infected with the human immunodeficiency virus, who had chronic abdominal pain with subsequent development of acute right lower quadrant tenderness was admitted to the surgical emergency department. his physical examination revealed no other finding than a mass in the right lower quadrant. his abdominal ultrasonography and abdominal ct revealed a plastron appendicitis. so he was hospitalized for medical treatment and discharged after days of treatment. his control abdominal ultrasonography and ct at the second month showed that plastron appendicitis persisted, therefore the patient was rehospitalized. he was discharged after days of medical treatment. after months the patient experienced severe abdominal pain. appendectomy was performed and histopathogic examination revealed a cytomegalovirus infection. the problems related to diagnose cytomegalovirus appendicitis and therapeutic management of cytomegalovirus infections are discussed. conclusion: aggressive use of ultrasound and abdominal computed tomographic scanning, along with early surgical intervention, is recommended. introduction: spontaneous intramural hematoma of intestine due to anticoagulan therapy is an unusual reason for acute abdomen. the first symptom is usually severe abdominal pain, nausea and vomiting. the most useful radiographic methods is computed tomography. the treatment approach is conservative and surgical. we present four patients treated our clinics due to intramural hematom. two patients are treated surgically and two patients are treated conservatively. material and method: we carried out four patients diagnosed and treated for intramural hematoma of small intestine between and years in haydarpasa numune training and research hospital second surgery department. we examine in this patients age, sex, etiologcy, hematologic parameters, the treatment approach (conservative and surgery), hospitalization times. results: the mean age of the patients was . years (range - ). all patients were male. the etiological factor was warfarin treatment due to aort valve replacement in three patient and ischemic cerebral disease in one patient. laboratuary parameters were elevated leukocyte counts in all patients. two patients was treated by surgical treatment due to intestinal obstriction and ishemia two patient was treated conservatively (nasogastric decompression and total parenteral nutrition). median hospitalization time was . day ( - ). discussion: when patients using anticoagulan therapy applied to emergency unit with abdominal pain, physicians must remember intramural hematoma as reason of acute abdomen. first choice is conservative treatment however cases of acute abdomen with intestinal obstriction and ischemia require surgical intervention. introductıon: motorcycle accidents continue to be a source of severe injury. the joy and exhilaration of riding motorcycles brings with it the risk of morbidity and mortality associated with these accidents. case: it concerns a -year-old man that in / / entered the emergency room after suffering a motorcycle accident. at the admission he had pain, swelling and deformity of the left knee. radiographs showed tibial plateau fracture type vi of schatzker. he was submitted to surgical treatment with open reduction and ostheosynthesis with liss plate and was orientated to rehabilitation. six months after, the fracture was healed in correct alignment, had normal gait, normal knee range of motion and returned to work. eight months after surgery he suffered another motorcycle accident with left leg trauma, radiographs showed a supracondylar femoral fracture type .a ao-asif and diaphyseal tibial fracture below the plate. he underwent surgical treatment with open reduction and osteosynthesis of the supracondilyan femoral fracture with lcp plate, extraction of the liss plate and ostheosynthesis with diaphyseal lcp plate. eleven weeks postoperatively, he was able to walk without crutches. five months after had normal range of motion of the left limb and was working. conclusıon: tibial plateau fractures are serious injuries and stable fixation without compromising the soft-tissue envelope is often difficult but with the liss plate we can achieve fixation of an associated metaphyseal/diaphyseal fracture component with minimal approach. multiple consecutive fractures are an important source of limb deformity and impairment, which we could prevent in this case. introduction: the optimum management of non-united humeral diaphyseal fractures remains unclear. a number of implants are available utilising varying operative philosophies and balancing operative complication risks. we present two cases of humeral shaft non-union treated with an intramedullary compression nail, a technique which is previously unreported. cases: case : a year old male with a closed fracture of the humeral diaphysis ( -a ). initial failed open reduction and internal fixation with an anterior placed . mm dynamic compression plate (dcp) was subsequently revised to a posterior . mm dcp plus bone graft months later. one year post revision, the fracture had failed to unite and was referred to the senior author. he underwent a stage reconstruction with the t humeral intramedullary nail in compression mode. at month review the fracture had united and at years postoperatively he had full range, pain free shoulder and elbow movement. case : a year old female with a closed diaphyseal humerus fracture ( -a ) treated conservatively in a u slab and functional brace developed a mobile, painful non-union. she underwent the same procedure as above and at months the fracture had united. she was pain free and had full range of elbow movement. shoulder movement was restricted due to co-existing glenohumeral osteoarthritis. conclusion: key tenets of fracture and non-union surgery include the ability to obtain stability and compression. this paper describes the first reported use of an intramedullary nail in compression mode for humeral diaphyseal non-union. fingertip amputations are the most common type of amputation injury in the upper extremity and they are important because of an often disproportionately long period of convalescence. different surgical procedures are available for reconstruction, but none is absolutely satisfactory. twenty-two cases ( patients) of fingertip amputation have been treated by primary skin closure using the v-y plasty (tranquilli-leali). there were men and women. the average age was . years. the procedure was carried out under regional anaesthesia using a tourniquet. all devitalized tissue was excised and the bone was smoothed. a triangular flap with a distal base was developed. the width of the base should be the same as the amputated edge of the nail or the nailbed, and the length should be a little longer than the width. the flap was mobilized and sutured to the nail or the nailbed. finally the volar gap was closed. the average follow-up period was months, ranging from to months. all of the flaps survived and achieved normal or adequate two-point discrimination. two patients had some loss of distal interphalangeal joint extension and five patients had cold hypersensitivity. rapid return to work was possible in most cases. the technique is simple and presents an excellent method for fingertip reconstruction in allen type i, ii and iii injuries. bilateral anterior shoulder dislocation is rare, and his aetiology is via various traumatic insults, atraumatic occurrences, and through extreme muscular contractions like epilepsy. in epileptic seizures is more common to occur posterior bilateral dislocation. the aim of this work is to describe a rare case of anterior bilateral shoulder dislocation after a convulsive crisis. it concerns a case of a -year-old male, with alcoholism history, who entered the emergency room in / / with a generalized tonic-clonic seizure. after, he had bilateral shoulder deformity and swelling. radiographs demonstrated a bilateral anterior shoulder luxation and bilateral greater tuberosity fracture. the dislocation was reduced and both shoulders were immobilized. month later, radiographs showed bilateral reduction maintenance and bilateral greater tuberosity fracture deviation. the patient had extremely restriction of active and passive ranges of motion in both shoulders: in the left had º of active external rotation and º of abduction; in the right º of active external rotation and º of abduction. at this moment surgical procedure was done with bilateral open reduction and osteosynthesis with ''phylus'' plate and was orientated to physical rehabilitation. at the month follow up, he had significantly improved both shoulders range of motion, and returned to the normal daily activities and months later returned to work. displaced fractures of the greater tuber-osities after shoulder dislocation may result in motion limitation and functional disability. open reduction and stable fixation allows for early passive motion of the joint and early return to activities of daily living. introduction and objectıves: direct inoculation, hematogenous spread or underlying medical illness which can predispose a patient easily for osteomyelitis are the causes of a vertebral infection. this case report represents a vertebral osteomyelitis of a patient seen after spine trauma. case: an year-old girl was admitted to our out-patient clinic with a history of progressive back pain. her inflammatory markers were high, physical examination revealed only spinous tenderness to palpation and she had a spine trauma history when she was at nine. radiological evaluation demonstrated lumbar and mild anterior compression, an incomplete intervertebral fusion and endplate irregularities with an intact spinal cord. bilateral sequential transpedicular drainage from l vertebra was performed without any complication. she has a pain free course of months with negative inflammatory markers. conclusions: the management of vertebral osteomyelitis is often challenging and in case of continuing pain and progressive kyphosis, surgical treatment is indicated. beside aggressive surgical procedures, minimally invasive techniques can be an option for the treatment of such cases. . instead of standard screws with diameter of mm using screws with diameter of . mm . instead of , diameter cannulated tunnel using , mm cannulated tunnel results: in use of this new modified method the time of surgery is shorter, the percutaneous surgical technique is simplified, the blooded lose is minimalizied, the surgery can be performed by two persons: the surgeon and the scrub nurse and few special instruments required. conclusion: based on our results we recommend this modified minimal invasive percutaneous osteosynthesis in case of garden iii femoral neck fractures, in garden iv one, especially immobile patients and patients with poor general conditions (asa score iv). introduction: pelvic fracture is one of the serious skeletal injuries, resulting in substantial mortality. the large amount of kinetic energy necessary to fracture the bony pelvis often leads to concomitant thoracoabdominal injury. pelvic fracture and combined injuries need effective initial resuscitation. however, it is hard to predict the mortality due to the complexity of multiple injuries. therefore, the introduction and objectıves: in this study, we aimed to investigate the distribution of the diagnosis in patients who underwent urgent surgical intervention in the operating room. methods: distribution of the diagnosis in patients who underwent an orthopaedic urgent intervention in the year are evaluated retrospectively from the medical records. results: patients with orthopaedic complaints [ male, female; mean age . ( - ) years] were operated on urgently in the year . patients ( shoulder, hip and lisfranc dislocations) had traumatic acute joint dislocation in which closed reduction was unsuccessful without general anestesia, one had supracondylar humeral fracture, one had distal femoral epiphyseal type ii fracture, one had isolated radial shaft fracture with neurovascular injury, one had t spinal fracture dislocation with paraplegia, one had type iii acromiaclavicular ligament rupture, one had quadriceps muscle laceration due to knife wound, one had tendo calcaneus rupture and one had patellar tendon rupture with medial meniscal injury due to knife injury. the mean time from admission to operation was found . h (range - ). conclusıon: it was concluded that the closed reduction of joint dislocations under general anestesia were the major group in orthopaedic urgent intervention. why ankle should be reduced urgently? shahzad sadiq, tariq mahmood worcester acute hospital, worcester, uk fracture dislocation of ankle is common orthopaedic emergency. it is paramount that to avoid soft tissue damage, the ankle is reduced as soon as possible. despite all efforts ankle dislocations could lead to significant blister formation. we reviewed a case series in which ankle joint was reduced with external fixator until skin healing methods: the cases who were admitted to our emergency department between august and and were exposed to traumatic extremity amputation were studied. the medical records such as age, sex, education level, occupation, the way trauma occurred, the affected anatomic zones, performed interventions and hospitalization duration parameters were evaluated. results: the data of subjects were evaluated in this study. mean age was , the rate of female/male was / . . there was a reverse correlation between the education level and occurrence prevalence. . % of the cases were laborers, . % various free self employed and . % were farmers. according to their occurrences, industrial accidents . %, pinching finger in the doorway . % and home accidents . % formed the first three rank. hand finger amputation was . %, toe amputation . % and others were . %. while cases were treated at the emergency service and discharged, cases were referred to related clinics. five cases were referred to other centers and two subjects willingly left our clinic. the mean length of stay was . days. conclusıons: traumatic amputation concerns particularly the young and the people in active work life. since the majority of the cases have hand injuries, they are striking because they cause workforce lose in addition to cosmetic and functional defects. introduction: distal radius fractures are one of the most common injuries regardless of age group. due to their localization they pose a serious threat to the fine wrist movements. for most of the patients the perfect functional result is of a vital importance. open reduction and stable osteosynthesis may help to produces desired outcome. methods: we have compared distal radius radius fractures treated with open reduction and stabilization with . mm synthes lcp and treated with synthes , mm lcp. we have compared the functional results, neurological damage and patient comfort with questionare form. measurements from x-rays were also compared. we have included patients of age between and years, with distal radius fracture. of them with intraarticular fracture. results: intraarticular fractures of distal radius treated with synthes . mm lcp show better functional results compared to synthes . mm lcp. there is no relevant difference depending on used material in extraarticular fractures. conclusıons: we recommend the use of synthes . lcp for intraarticula distal radius fractures for its greater diversity and abillity to stabilize even a small fragments. introduction and objectives: surgical treatment of fractures by using resorbable implants is not too expanded alternative to classical steel or titanium implants. indication for using are intraarticular and periarticular fractures at first of all. the most advantage is no necessary of implants extraction. another one is propagation of load callus during the degradation of material. possibility of making profitable ct and nmr is indispensable.in this paper author presents experiences with using of resorbable screws. methods: at our department there are resorbable cortical screws . , . and . mm bionx made from polyamide polymer with minimal stronghold for weeks and total absorption after years. this screws are determinated for cancellous bones in periarticular areas. we are using them in cases of fracture posterior wall of acetabulum, distal humeral intraarticular fractures, radial head. it can be used for treatment children¢s fractures too. the follow up is same like in ''classical'' osteosynthesis. results: there were no infection's complications, no malfunction screws in our group of patients. the postoperative and ambulatory treatment including physiotherapy was same like in group with classical osteosynthesis. the only one failure was during surgery -we have wraped screw four times because of insufficient pre-drilling and using too much power during insertion. we could recommend resorbable screws as suitable alternative in some type of surgical treatment intraarticular fractures at most. the indication have to be well look over and way of using has to be well understand as well as careful manipulation during surgery. the benefits are no metal material, no extraction in future and profitable ct and nmr. heart valve lesions in blunt cardiac trauma -mechanism, diagnosis and treatment robert lipovec, granc gregorcic department of cardiac surgery, university clinical center maribor, maribor, slovenia because of the variation in diagnostic criteria, cardiac involvement in blunt chest trauma is estimated at approximately %. in contrast to cardiac contusion which is often difficult to validate, traumatic valvular lesions are usually associated with some degree of hemodynamic impairment. patients with positive findings on clinical examination, ecg, cxr and troponine should be screened for valvular lesions by transthoracic echocardiography. blunt injury to cardiac valves can lead to progressive ventricular failure often requiring surgical management. patients with structural damage to the left sided heart valves usually require immediate surgical repair, while right sided valvular lesions can be managed in a delayed fashion. the management is based on type of structural injury and hemodynamic compromise. valvular reconstruction is usually attempted, if possible. the paper outlines historical perspective, mechanisms of injury as well as our experience with diagnosis and treatment of traumatic valvular lesions. two case reports are presented. one patient had a traumatic mitral chords rupture and the other had a tricuspid papillary muscle rupture. both cases were diagnosed immediately and surgically corrected. the ruptured mitral valve was urgently replaced. the tricuspid valve was repaired by delayed surgery. patients in al-ain city, united arab emirates . %, respectively. only the difference between group iia and iib was found to be statistically significant. dıscussıon: rib fractures increase the pain and have a negative effect on breathing during postoperative course. ineffective breathing may cause athelectasis, fever and infection which is associated with increased morbidity. the incidence of rib fractures are higher in anatomical resections in whom the thoracic cavity should be opened widely. a longer incision and step to step opening of the thoracic cavity may decrease the incidence of this undesirable complication. objectıve: this case report describes a surgical method to treat multiple rib fractures by using arch bars. case: a year old male patient was admitted to emergency unit with bilateral flail chest, bilateral multiple rib fractures, bilateral hemopneumothorax and pulmonary contusion. the patient was initially tachypneic and had a shallow breathing. because of the respiratory arrest he was intubated. physical examination revealed crepitation from subcutaneous and oseeous tissues especially on the left hemithorax. after left sided tube thoracostomy cc hemorrhagical drainage and massive air leak was observed. ct scan showed bilateral rib fractures extending from the first to the eleventh ribs, bilateral hemopneumothorax and bilateral pulmonary contusion (picture , ). therefore tube thoracostomy was also administered on the right hemithorax and cc hemorrhagical drainage and air leak occured. because of the thoracic deformity, persistant hemorrhagical drainage and air leak from the left hemithorax, the patient underwent exploratris thoracotomy and damaged pulmonary parenchyma was repaired. multiple rib fractures which damaged the thoracic wall stability severely were fixed by using arch bars (picture ). the patient required mechanical ventilation for days postoperatively. the latest ct scans of pulmonary parenchyma and thoracic wall after arch bar application are seen in pictures and . conclusıon: in this case the conventional rib fixation procedures with kirschner wires or plate plaques could not applied because of multiple small fractured segments. despite various materials suggested in literature, the use of arch bars to repair flail segments with multiple small pieces are not mentioned. tariq siddiqui, kimball maull the trauma center at hamad, hamad general hospital, doha, qatar introductıon: intrathoracic fluid following blunt chest trauma is almost always blood, and derangement in the patient's cardiorespiratory status is directly related to the volume of blood accumulated in the pleural space and the associated compression of pulmaonary parenchyma. tension chylothorax in the setting of bilateral chylothoraces is a rare cause for such a condition. a year old man fell from a height of three meters and presented with back pain. examination disclosed abrasion and tenderness over the right paraspinal area. he was discharged home. four days later, he returned in severe respiratory distress -hypertensive, with rapid pulse, tachypneic and with peripheral cyanosis. there were no breath sounds on the right side and decreased air entry on the left, and bedside ultrasound showed fluid in the right chest. chest x-ray confirmed complete opacification of the right hemithorax and loss of the costo-phrenic angle on the left side. a right tube thoracostomy yielded , ccs of pinkish-white fluid with immediate improvement in cardiorespiratory status. computed tomography disclosed bilateral th and th rib fractures, spinous process fracture of the th thoracic vertebra and bilateral effusions. a left chest tube brought back ccs of additional similar fluid. diliatation of the cisterna chyli in the abdomen with collapse of the thoracic duct were confirmed by mri. conclusıons: post-traumatic tension chylothorax causing cardiorepiratory compromise is rare. in this report, the patient responded to chest tube decompression and dietary measures without complication. author to editor: this report is complimented by excellent illustrations, including ct and mri findings, showing the anatomy of the injury… conducive to poster display. introduction: blast lung injury (bli) is a unique injury rarely seen in the civilian population. our objective was to assess its severity, prognosis and associated injuries as compared to victims with chest wall trauma following explosions. material and methods: retrospective study of victims of the march terrorist bombings in madrid who were treated at the closest hospital. we compared the group with pure bli (bilateral infiltrates in a butterfly pattern, and absence of chest wall fractures) (group i) with that of patients with peripheral infiltrates and chest wall fractures (group ii). results: of patients included in the registry, ( %) had thoracic injuries. ( %) were included in group i, and ( %) in group ii. the mean iss in groups i and ii was of . ± and . ± . , respectively. among the critical patient population in both groups (n = ), those belonging to group ii were in need of a longer period of ventilatory support and had more ventilator-associated pneumonias. in group i, the most frequent associated injuries were tympanic perforation ( . %), º- º burns ( . %) and abdominal trauma ( %). in group ii, º- º burns ( %), followed by tympanic perforation ( %) and skeletal trauma ( %). one patient died in each group ( . vs. . %). conclusions: pure bli patients had a greater degree of anatomic severity, had more severe burns and abdominal trauma than patients with lung infiltrates and thoracic wall fractures. overall prognosis was excellent in both groups. aım: aim of the study was to determine the rate of injuries detectable by ultrasonography in patients suffering from blunt thoracic trauma. materıals-methods: this study include the patients suffering from blunt thoracic trauma who have not any pathological findings in routine radiological diagnostic procedures. ultrasonography of the thorax was prospectively performed in patients with blunt chest trauma additionally to the routine radiological diagnostic procedures. ultrasound findings referring to the rate of detection of fractures, pneumothorax, pleural effusions, lung contusions, haematomas of the lung and chest wall was performed. results: we studied consecutive patients suffering from blunt thoracic trauma who has any pathological findings in routine radiological diagnostic procedures. the findings detectable by ultrasonography were the following: pleural effusion %, haemopneumothorax %, haematoma of the chest wall %, contusion of the lung %. conclusıon: rib fractures and pleural effusions are commonly diagnosed by ultrasonography in patients with blunt thoracic trauma. this study showed that ultrasonography may have superiority to chest-x-ray in diagnosis of rib fractures, pneumothorax, haemothorax, haematomas of the chest wall and pulmonary contusions in blunt thoracic trauma patients. Ş adiye emircan , Ö zlem kö ksal , fatma Ö zdemir , halil Ö zgü ç department of emergency medicine, uludag university, bursa, turkey department of general surgery, uludag university, bursa, turkey aım: the purpose of this study is to define the epidemiologic properties of patients that have been subject to thorax injuries and general body traumas, analyze their condition when they are brought to our emergency department, to determine the correlation of physiological and anatomical risk factors with the mortality rate, and to ensure early diagnosis of severe trauma. methods: trauma cases that had been subject to general body trauma have been retrospectively examined in this study. epidemiological properties of the cases have been determined, their initial condition during initial admission to emergency department have been analyzed, and cases have been assessed in terms of mortality developments. survival probabilities and unexpected mortality rates have been computed using trauma revised score-injury severity score (triss) methodology. results: mortality rates was . %. univariance analysis revealed that hypotension, age, pathologic respiration pattern, blunt injury, accompanying injury, abdominal trauma, high injury severity score (iss), low glascow coma scale (gcs), revised trauma score (rts), triss were the factors affecting mortality. in logistic regression analysis, presence of blunt injuries, triss < , iss > and gcs < have been found independent prognostic factors. strongest factor indicating mortality has found to be triss. in presence of factors affecting mortality, patients with thorax trauma should be evaluated as being of high risk group and therefore diagnosis and treatment strategies must be aggressive. case analysis based on triss model shall further reveal the mistakes that may be made in patient care and may improve patient care. introductıon: penetrating thoracal and cardiac wounds are asssociated with high mortality. we aimed to present our experience in such cases. materıals-method: twenty three patients with penetrating thoracal stab injury, between and , were investigated retrospectively. gender, age, injured areas, extent of thoracal damage, accompanying organ damages and outcomes of these patients were evaluated. results: all patients, except one, were male with a mean age of . years (between and years). in patients penetrating abdominal injury accompanied thorax trauma and one of these patients died peripoeratively. patients out of thoracal trauma had an additional cardiac stab wound and half of them were only pericardial injury. one of these cases went into emergency coronary artery bypass surgery due to lad injury. only four patients required intensive care postoperatively and four patients were lost perioperatively all of which had additional cardiac injury. conclusıon: the overall mortality rate was %, but mortality of patients with additional cardiac stab injury was higher, with a rate of %. suspect of cardiac injury should be considered in patients who are injured close around cardiac area and one should intervene quickly both in diagnosis and treatment. introduction: abdomen and thorax blunt and penetrating injuries, common cases of emergency surgery, cause less complication with proper analysis and surgical intervention. material and method: we retrospectively evaluated patients operated due to thoraco-abdominal blunt and penetrating trauma in _ istanbul training and research hospital last year. results: median age was . ( - ) and all were male. patients were operated due to blunt abdomen in , penetrating abdomen injury in , abdomen and thorax penetrating injury in by general surgeons. abdominal exploration in ( . %) were negative laparotomy. background: we described a patient with dysfunctions of all the nerves and ruptured brachial artery and vein due to closed injury caused by spontaneously reduced dislocation of the elbow. case: a -year-old man fallen down onto his left elbow with small skin erosion and a large area with ecchymosis on the elbow presented. left radial and ulnar pulses were nonpalpable but no sign of acute ischemia was noticed. he had drop hand and could minimally make flexion, opposition, abduction and adduction of fingers. strength of fingers, wrist flexion and thumb adduction were weak. radiography was normal. emergent surgical exploration was performed with prediagnosis of severe closed soft tissue injury and vascular damage. brachial artery and vein had complete disruption with rupture of brachial muscle and the anterior joint capsule. elbow joint could be posteriorly dislocated. artery and vein were repaired with saphenous vein graft. median and ulnar nerves had normal appearance. at postoperative th hour nerve injuries showed complete recovery. he could have normal range of motion in the wrist and hand. sensorial examination was normal. he had a well perfused arm. conclusıon: spontaneously reduced dislocations of the elbow can be sometimes missed. large hematoma and neurologic dysfunction in closed injury of the elbow indicate severe trauma of joint also in case of normal bone structure in radiography. immediate diagnosis and operative treatment of brachial artery injury is mandatory. closed elbow dislocation and multiple nerve injuries may have good results with conservative treatment. we present the case of a y male, with his left lower limb severely damaged by a caterpillar vehicle. he was admitted in the er about min after the accident. he presented with exposed fractures of the femur and leg bones, extensive soft tissue and muscle damage, class iii shock, and an umbilical clamp in the exteriorized femoral artery in the thigh, placed by a fireman in site. the mess (mangled extremity severity score) calculated for this patient was . after the initial assessment in the er the patient was transfered to the or. he had a complete transection of the femoral artery and vein with a severe ischemic foot. despite the mess score, a vascular and bone repairs have been considered. two temporary shunts were placed in both femoral vessels (artery and vein) followed by external fixation of the femur and leg fractures. the definitive vascular repair of the artery and vein was made with autologous saphenous vein after the bone fixation. some damaged skin and necrotic soft tissues were removed, and the reminder skin was only proximated. the limb was functionally and anatomically preserved, with no obvious neurologic deficit, despite subsequent debridements and skin grafts. the authors concluded that in similar cases: introductıon: trauma is responsible for . million of death, % of them in young people. vascular injuries of the upper extremity represent % of all peripheral vascular lesions, the majority of them at the braquial artery. objectıve: report a case of chemical injury of braquial artery. methods: -year-old man was admitted in the emergency room with third degree sulphuric acid burn in the middle third of arm ( % of total body surface area). the radial and ulnar artery pulses were palpable. at the th day after injury, haemorrhage was noted and disruption of braquial artery was clear. a braquial-radial reversed long saphenous vein interposition graft was performed. after surgery palpable radial and ulnar pulses were present, without evidence of nerve injury. results: the chemical burns severity depends on the concentration, properties of the agent and the duration of skin contact. sulphuric acid causes coagulation necroses, with thrombus formation in the microvasculature. its corrosive properties are accentuated by exothermic reaction with water. its burns are more serious than those compared with strong acids, and, as observed in this case, it causes frequently third-degree injuries. besides this, it has the ability to cause continuing tissue destruction, from th hour to th day after injury. this fact could explain why there was no artery lesion at the admission but at the th day. conclusıon: sulphuric acid burn is potential devastating and tend to be prolonged in time, obliging to a continuous monitoring and multidisciplinary approach. introduction and objectıves: the medicolegal studies show that the most frequent mechanisms of the lethal major vascular injuries were stab wounds followed by gunshot wounds and blunt trauma. during the blunt traumas, simple lethal major vascular injuries without any fracture are seen rarely. we experienced a case of common femoral artery and vein transection as a cause of death without any femoral fractures which were caused by blunt trauma. case: during the transportation of wood blocks, a wooden log fell from the truck over the forester, -year-old man. he sustained a crush injury and died in the emergency service on the same day of the trauma. it was learnt that no medical intervention was performed on the case. ecchymotic bruises on the left abdominal-pelvic, femoral, right inguinal, genital region, deformation under the right knee were observed during the autopsy. it was determined that there was a traumatic transection on the left common femoral artery and vein, which was accompanied by massive bleeding in surrounding soft tissues and muscles without any fracture of the left femur. all the internal organs were intact and showed paleness. death was due to internal hemorrhage caused by the transection of the femoral artery and vein. conclusıons: during the examination of the cases who were exposed to the blunt trauma, peripheral vascular injury must be investigated without any delay. if vascular injury was determined in the early times after the trauma, surgical and medical treatment could be performed successfully and the case could survive. introductıon: traumatic internal carotid artery dissection is a rare and grave cause of embolic strokes occurred especially in young age group. if it is not diagnosed early and required treatment is not given, thrombosis can be a serious trouble with permanent neurological deficit and high mortality rate up to %. case: we presented a delayed diagnosed traumatic carotid artery dissection in a year-old female case. there were no ischemic infarct findings in the cerebral ct on admission, but there were cerebral infarct findings in the cerebral ct taken twice because of the left hemiplegia noticed days later when the patient regained her consciousness. we made the diagnosis of the case, forwarded to our emergency service with acute cerebral infarct diagnosis, certain through arterial doppler ultrasonography, cerebral mri, diffusion mri and mr angiography. we did not consider invasive treatment since the neurological damage was permanent and dissection grade was iv according to angiography findings. we did not administrate anticoagulant treatment considering that the patient can turn her ischemic infarct into hemorrhagic infarct. the case was discharged within a week and advised physiotherapy. conclusıon: although the advances in diagnostic methods, diagnosis with traumatic carotid artery dissection is still missed out or delayed as in the case we presented. early diagnosis enables permanent neurological damage to be decreased or vanished. however, the vital factors for early diagnosis are the obtained anamnesis to direct to radiological examinations, detailed physical examination and high clinical doubts. introduction: acute arterial occlusion is a serious clinical condition resulting death of patient or related organs. these are usually older patients with a lot of comorbid conditions. method: _ in our clinic, we retrospectively examined the records of patients who underwent surgical treatment for acute arterial occlusion between january and december . mean age of patients was . years. ( %) of these patients were female, and ( %) were male. embolic occlusions were found in an upper extremity in ( %) patients and in a lower extremity in ( %). the most common source of these emboli was cardiac origin. atherosclerosis, trauma and arterial catheters were the other causes of emboli. ( %) of patients were admitted less than h preoperatively, ( %) were admitted - h preoperatively, ( %) were admitted after a delay of longer than h preoperatively. ( %) of patients were in sinus rythm, ( %) were in atrial fibrillation preoperatively. motor dysfunction of extremity was found in ( %) of patients preoperatively. diagnosis was based on the findings of physical examinations and emergent doppler ultrasonography. any other invasive evaluation was not performed to decrease acute occlusive ischemic period. surgical intervention had performed immediately results: the overall mortalıty rate was % ( ). _ in ( . %) of patients, after setting of demarcation line, amputation was performed. conclusıon: early diagnosis, catheter embolectomy and use of anticoagulation are very important therapeutic modalities for limb salvage and reduction of morbidity and mortality. there was a comorbidity in all patients and cardiac disease and hypertension were the most common ones. the most common laboratory abnormalities were leukocytosis, hypoalbuminemia, hyperamylasemia. there was superiory vasculary necrosis in patients, inferior vasculary necrosis in one patient.one patient had nonocclusive mesenteric ischemia. segmentery resection was performed to patients. abdominoperineal resection was performed to the patient with inferior mesenter artery occlusion. we performed duodenotransversostomy on two patients and only laparotomy on two patients. reoperation was required in five patients. causes of death was multiorgan insufficiency in seven cases, cardiac death in two cases.one patient died due to short intestine syndrome. results: the patient was discharged on postoperative th hours without any complications. conclusıon: single incision laparoscopic appendectomy is a safe and effective technique that can be performed in well experienced centers success. jorge pereira, luis filipe pinheiro surgery department, sã o teotó nio hospital, viseu, portugal trauma represents one of the most important causes of death and disability of today. the exponential growth of the major cities, the continuous building of roads and the uprising of terrorism, foresee that trauma will keep is importance as a major cause of disease. recently, the management of the trauma patient as been modified, with the introduction of the atls method. this fact has produced great improvement, proven and reproducible, decreasing mortality and morbidity of trauma. the teaching of this new method, albeit its good results, has not seen many changes over the years. however, in recent days, we have seen the introduction of new computer technologies in teaching. this methods use simulation, e-learning and even interaction as learning techniques. taking advantage of the mentioned techniques, the authors produced an animated video, using computer-animated drawings that allow demonstrations difficult to reproduce in real life. using simple software and computer video editing, the authors invite you to watch a trauma patient in the emergency room, since his arrival to the end of the primary survey, watching demonstrations of life saving techniques and the stabilization of the patient. the authors present a video of a young male, years of age, ± kg victim of a motorcycle crash, with a fall over cut branches of trees, min before his admission in the e.r. he sustained an impalement with a stick in the fourth right anterior para-sternal space. at admission he was conscious, gcs = , bp = / , hr = /m, sato = %, hemodynamically normal. breath sounds slightly diminished in the left. a left anterolateral thoracotomy as been done, as well a left subcostal lararotomy, since the stick also had penetrated the left hemidiaphragm. the patient had no significant thoracic or abdominal injuries despite the violence of the trauma mechanism. the ''foreign body'' was successfully removed by combined abdominal and thoracic route, and a left chest tube was put in place. the patient recovered very well and was discharged in the eighth day. author to editor: ''english'' corrections are welcome, please! berker bü yü kgü ral, mehmet bekerecioglu al-marashda , amgad elsherif , hani o. eid , fikri m univariate analysis was used to compare patients who died and those who survived. significant factors were then entered into a backward stepwise likelihood ratio logistic regression. results: out of , patients of the registry, patients ( . %) had chest trauma with a mean (sd) age of . ( . ) years. ( %) were males . ( . %) got injured in the street or highway, ( . %) at work place, and ( . %) at home. the main mechanism of injury was road traffic collision in ( %) fall from height in ( . %). ( . %) were admitted to icu. the median (range) iss was ( - ). ( . ) of patients got isolated chest injury, ( . %) had head injury, ( %) lower limb injury, ( . %) upper limb injury iatrogenic rib fractures during thoracotomy: comparision of posterolateral and anterolateral thoracotomies operations for thoracic trauma, extended lung resections and re-thoracotomies were excluded. posterolateral thoracotomy incision was performed for group i ( patients; . %), and anterolateral thoracotomy incision for group ii ( patients; . %). groups were also divided into two groups for the type of resection the percentages for rib fractures for group ia, ib, iia, and iib were . , . , . , and . damage control principles can a be used in all surgical fields . general surgeons must have experience in vascular repair skills . the reperfusion of the limb joão filipe coutinho vasconcelos , sandrina braga , pedro brandão , daniel brandão , miguel maia , joana ferreira , paulo barreto , vítor martins , a. guedes vaz , leonor rios vila nova de gaia, portugal department of plastic surgery rectal prolapse describes the protruding of the entire rectum or some parts of the rectum from anus. it is caused by the weakening of the ligaments and muscles that hold the rectum in place.it is associated with advanced age, long term constipation or diarrhea, childbirth, previous surgery, and sphincter paralysis. trauma may cause sphincter paralysis and can be associated with rectal prolapse. it usually begins with prolapse of the rectum during defecation or val salva movement and usually progresses to a chronic stage. long term prolapse can cause ulcerations, bleeding and in some cases perforation if not reducted. a -year-old male presented with rectal prolapse, bleeding, abdominal pain. he stated that he could not replace the prolapsed segment for days and has been suffering for years since after he fell from a tree and he had massive bleeding during the last h. physical examination revealed that a cm segment of the rectum was prolapsed with the whole layers. there were ischemic and necrotic areas and active bleeding from the mucosa. reduction trial was not successfull. emergent laparotomy was performed. bimanual reduction failed.thus transanal intervention, with sigmoid resection was performed. end colostomy was preferred. no complications occurred the following months and colorectal anastomosis was performed with a preventive ileostomy. although rectal prolapse is usually a benign condition it may cause fatal complications such as perforation, necrosis if not reduced for a long time and surgery should be performed promptly in these cases.ing to the age, diagnosis, treatment results, mortality rates between the years of and . results: summarised in the table .in conclusion, the most of our multitrauma cases caused by traffical accidents, were young. the mortality rate % for multitrauma cases, the percentage of multitrauma cases were . % of all intensive care patients. preventing the accidents is as much important as treatment strategies for multitrauma cases. arif tü rkmen, ertan gü nal, mehmet bekerecioglu, berker bü yü kgü ral department of plastic and reconstructive surgery, gaziantep university school of medicine, gaziantep, turkeyintroduction and objectıves: as personal problems dealing with health, jobs, financial status and the family problems increasing, more suicide attempt subjects are consulted in emergency rooms day-byday. although gunshots to the oro-facial region form - % of the total victims, it is important that seconder deformities resulted with aesthetic, functional and psychological problems were usually encountered after primary surgery. this study reviews cases of self-inflinct gunshot injuries of face and our experiences in early and late managements over a -year period.methods: this study is based on subjects who attempted suicide resulting in extensive facial deformities, not in death between and . demographic details, mechanism and direction of injury, early and late management and seconder deformities were recorded. results: after establishing the airway control and completing the primary survey, all patients underwent debridement and bleeding control. reconstruction of maxillofacial fractures were performed in patients on the day of admission and the remaining within days of injury. following procedures as scar revisions, rhinoplasty, mandible reconstruction, ectropion operations or coverage of palatal defects etc. were performed after earliest months from primary operation.conclusıons: after stabilization of life-threatening injuries, the goals of early management are regenerate of anatomic form and function to include dental occlusion and mouth opening to prevent scarring, contractures of mobile structures and ankylosis. seconder operations required for aesthetic and functional problems should be performed earliest after month from primary operation that all the scar formations and wound healing's were completed. background: injuries of maxillofacial region in patients with polytrauma are frequent but are rarely treated primarily. in order to achieve satisfactory treatment results trauma treatment team must include a maxillofacial surgeon.materıal-methods: the study shows treatment results of polytraumatized patients with maxillofacial injuries. dominant trauma was: maxillofacial in %, craniocerebral in %, locomotor in %, thoracic in % and abdominal in % of cases. treatment of maxillofacial trauma was in % of cases surgical and in % conservative. treatment of other traumas was operative in % and conservative in % of patients. results: early mortality rate was %. four exitus were recorded during the first h, exitus on the th day and exitus on the th post-trauma day. dominant trauma was in exitus craniocerebral, in exitus thoracic and in exitus severe locomotor. long-term treatment results in remaining patients were: for maxillofacial regiongood in patients ( %), satisfactory in patients ( %) and poor in patients ( %); for other regions -good in patients ( %), satisfactory in patient ( %) and poor in patients ( %). conclusıon: existing maxillofacial trauma in polytraumatized patients usually directs treatment toward conservative methods.reasons for this are insufficient number of maxillofacial surgeons in trauma teams and delay of surgical treatment of other present traumas due to difficult anesthesia application. unfortunately, conservative treatment approach induces inadequate treatment results from both functional and esthetic point of view. however, as revealed by hospitalization, transportation, and mortality data, women were exposed to more severe trauma. in addition, poisoning and fall caused more death. the rate of mortality of women seems to be less when compared to literature. conclusıon: bicyclists in non-fatal frontal crashes with cars suffered the most serious injuries from the impact to bonnet and windshield, likely due to highest energy transformation. bicycle helmets, collision mitigation system that alerts the driver or automatically brakes the car, and external airbags protecting the bicyclists from hitting bonnet and windshield, may reduce injuries.author to editor: this is a complete analysis of mechanism of injury in crashes carfront versus bicyclist. journals were completed with traffic notes from police at scene, patents own history of the crash from the injury database and furthermore interview. the catch area is welldefined with no other hospitals in the area and total cover of all injuries in the database. this gives a good picture of the dynamics of the the crash and mechanism of injury. or street ( ais +). third impact in patients gave injuries ( head/neck) at windshield ( ais +) or street ( ais +). thirteen persons, who hit the street as the fourth impact point, sustained three injuries (zero ais +) as contusions of the pelvis and lower back. conclusıon: pedestrians in non-fatal frontal crashes with a car suffered the most serious head injuries at second impact in bonnet, windshield or street. safer passageways for pedestrians might preclude the crash. mechanisms preventing the pedestrian of hitting the bonnet and windshield, may reduce the injuries. author to editor: this is a complete analysis of mechanism of injury in crashes carfront versus pedestrian. journals were completed with traffic notes from police at scene, patients own history of the crash from the injury database and furthermore interview. the catch area is welldefined with no other hospitals in the area and total cover of all injuries in the database. this gives a good picture of the dynamics of the the crash and mechanism of injury. one of the primary characteristics which professions possess is to make the members of a profession have autonomy in decision making and practice. nursing practice is evaluated in relation to professional practice standards and guidelines, rules, etc… application of professional standards requires that nurses use critical thinking for the good of individuals or groups. critical thinking also requires the use of scientifically based and practiced-based criteria for making clinical judgments. these criteria may be practice based on standards developed by clinical practice guidelines developed by individual clinical agencies. for example, intensive care units (icus) are designed to meet the special needs of acutely and critically ill patients. a patient is generally admitted to the icu for one of three reasons. the patient may be physiologically unstable, at risk for serious complications and require intensive and complicated nursing support. despite the emphasis on caring for the patient who can survive death is common in icu patients. it is reported that % of patients admitted to icus will die, and another % may leave the icu but will not survive to discharge. this suggests a need for caution and coordination of care when transferring patients from icus to general units. in this article, the practice guideline which titled ''patient appropriateness for adult icu admissions and discharge'' will be discussed. the terminology for pelvic fractures and its recent modifiers are confusion to the trainee to say the least. we surveyed orthopaedic trainees in the latter part of their surgical rotations. the same set of radiographs were shown to all trainees and their classifications recorded. the same set of radiographs were shown to the trainees again after a period of days. we found significant inter-observer variability ( %) and wide intra-observer variability ( %). though trainees were adept at identifying basic fractures patterns and identifying individual column or lip/wall fractures the complex fracture patterns seems to generate different answers from the same observer at different times. the ct scan was the most effective tool identified for accuracy of the fractured fragments but the more complex assignments resulted in the trainees grouping them differently. results: twenty-one fractures ( . %) healed without complication including five fractures where external fixation was converted into internal one. the mean time to union was . ( - ) months. there were two pin-track infections, two deep infections, and only one nonunion. the femur length was equal to the healthy side in cases, and was shorter by - cm in five cases. mean active knee flexion was °. knee flexion was more than °in patients. conclusions: external fixation is a useful technique for the stabilization of severe open and close highly comminuted femoral shaft fractures. it is safe procedure to achieve temporary rigid stabilization of femur fracture in critical polytraumatized patients before delayed internal fixation (damage control orthopedics). purpose of this study was to determine the factors predicting mortality.methods: a retrospective study was performed on cases of pelvic fracture who visited to emergency department from january to june . data were collected regarding demographic characteristics, mechanism of injury, injury severity score (iss), abbreviated injury score (ais), simplified acute physiologic score ii (saps ii), transfusion requirements, fluid requirements, the finding of angiography, hemoglobin, platelet, prothrombin time ( fractures were managed by using an intraarticular, chevron-shaped olecranon osteotomy in all patients. methods: the mean age was . years. a straight posterior surgical incision was performed. a thin oscillating saw was used to begin the olecranon osteotomy. a small osteotome was then inserted and the osteotomy was completed through the subchondral bone. the posterior elbow capsule was incised. the olecranon fragment and the triceps muscle were reflected proximally to expose the distal humeral articular surface. osteotomy fixations were performed with two intramedullary kirschner wires and dorsal tension band in patients. in four patients, an intramedullary screw and a tension band were used for fixation. results: at the final control, the jupiter classification system was used for the evaluation of the patients. eighty one percent of the patients revealed good and excellent results at the long-term followup. none of the patients showed osteotomy nonunion. the most frequent complication was skin problem due to subcutaneous prominence of the implants.conclusions: the goals of treatment of distal humerus fractures are anatomic articular restoration and rigid fixation. olecranon osteotomy provides good visualization for rigid fixation especially in type c distal humeral articular fractures. this is a useful method for excellent anatomic reduction of the articular surface. conclusions: there could be some steps during primary treatment for discussion. but real mistake was vacillation and delay of reosteosynthesis and spongioplasty even it was cause by risk for infection and possible failure of flap. our case demonstrate that sometimes too much care could be hurtful. introductıon: the population who applied to the public emergency services due to the injuries related to butchering the sacrificial animals during the feast of sacrifice were evaluated. materıals-method: eighty-nine patients who admitted to the emergency services in kirikkale during the feast of sacrifice in were evaluated according to age, sex, application day and time, state of experience, type and mechanism of injury and medical treatment. results: the age average was ± and % of them were male. eighty-eight percent of the patients admitted in the first day. seventy percent of the injuries were penetrating injuries and % of them were blunt. the average time passed after the trauma was min. almost half of the cases were wounded with a knife, % were wounded unintentionally by the others and % of the cases were due to hit of animals. fifty-seven percent of the patients had butchering experience before. ninety-one percent of the cases were hand injuries. thirty percent of the cases had fractures. nine percent of all cases had tendon injury, % of the cases were treated primarily skin suturation. conclusıon: the injuries related to butchering of the sacrificial animals sometimes can be serious. in extremity injuries, the number of tendon cuts and bone fractures can not be underestimated. both equipments and medical staff support for the injured people should be provided and preliminary arrangements should be done during the feast of sacrifice. every butchering job in this period should be given to professionals. introduction: osteoporotic fractures of the trochanteric area are often treated with a gamma-nail or similar implants utilizing a screw applied into the femoral head. one of the main problems of these techniques is the cut out in the femoral head. we biomechanically evaluated a novel technique of cement augmentation of the bed of the screw in a standardised osteoporotic bone model and its capability to reduce the cut out rate. material and methods: utilizing a polyurethane-foam osteoporotic model that has been previously described (specific gravity . g/cm ), a biomechanical testing of a neck of femur screw (tgn, stryker, duisburg, germany) was performed. the screw was implanted according to manufacturers instruction, the migration characteristics were then biomechanically tested (zwick testing machine) with a static stepwise load increase ( n). first these tests were performed without, in a second series with the augmentation of a fast hardening biopolymer (corthoss, orthovita, usa). each series was repeated five times. the transfer from a stable to an unstable condition was biomechanically determined. results: on average the applied load at the moment of failure with critical cut out was n for the non-augmented screws. with augmentation, the average load was , n, the difference was statistically significant.discussion: it appears in biomechanical testing that augmentation of the femoral head can improve the load bearing capabilities and thereby possibly reduce the rate of cut-out failure in osteoporotic bone. we proceed now with further biomechanical testing, grant of the local ethics committee for human testing has been applied for. introductions and objectıves: the aim of this study was to examine the relationship between childs' favourite cartoon stars who can fly and falling down from a high place in two cases. methods: in this paper we presented two similar cases who were seen with a history of falling down from a high place. the first case was a -year old girl who fell down from the third floor of their apartment. on her examination it was learned that she wanted to fly like her favourite magical cartoon star girls. the second case was a -year old boy who fell down from the second floor. while falling down he was screaming to his friends that he was flying.results: on the physical examination of the first case, deformity and crepitation in right femur were found. x-rays showed right femur distal epiphysis salter harris type iv fracture. she was hospitalized due to the pneumothrax in pediatric surgery intensive care unit. the procedure of closed reduction and fixation with multiple kirschner wires was performed under general anestesia. closed body fracture in the left femur was found in case ii. introductıon: the purpose of this study was to compare the biomechanical properties of different possibilities of screw placement in multidirectional palmar fixed-angle plate in distal radius osteotomy cadaver model under loading conditions. methods: an extra-articular fracture was created in pairs of fresh frozen human cadaver radii. the specimens were randomized into four groups. all radii were plated with a volar fixed-angle plate. there were different possibilities of screw placement in the distal fragment:group a: screws were used in the distal row of the plate. group b: screws were used alternately in the distal and proximal row. group c: screws were used in the proximal row. group d: screws were used filling all screws holes in the distal and proximal row of the plate.the proximal fragment was fixed with screws each. the specimens were loaded with n under dorsal and volar bending and with n axial loading. results: group d had the highest stiffness of n/mm under axial compression and was statistically significant stiffer than the other groups. group b had a stiffness of n/mm followed by group a with n/mm. group c showed only a stiffness of n/mm. there were no statistically significant differences under dorsal and volar bending.conclusıons: occupying all screw holes in the distal fragment offered the highest stability. using only the proximal row with screws showed an unstable situation. it is therefore recommended to use at least screws in the distal fragment. perilunate dislocations are the most common type of carpal dislocation. they can be produced by high-energy injuries. the population primarily at risk is male young adults. in perilunate dislocations, the proximal articular surface of the lunate retains contact with the distal radius. the dorsal-perilunate/volar-lunate dislocation is more common. we performed a retrospective study of perilunate dislocations from to . a total of were reviewed. mean age of the patients was . (range - ). all the patients were male. the trauma mechanism was fall from height in and motor vehicle accident in . all the dislocations were dorsal-perilunate/volar-lunate dislocations. all the dislocations were together with ipsilateral scaphoid fractures. all were closed injuries and all were reduced by closed reduction maneuvers. percutaneous pinning was applied for the dislocation and scaphoid fractures. mean follow-up time was months (range - months). when compared with the non-injured wrist, there was limited range of movement in only one patient.no limitation of range of motion in the other patients could be obtained. the patients did not have pain and instability. radiologically no arthrosis of the wrist could be obtained but in all patients there was scaphoid pseudoarthrosis. functional range of motion of the wrist after a perilunate dislocation is independent of the concomitant scaphoid fractures. bostjan sluga, tomaz malovrh traumatology department, university clinical centre, ljubljana, sloveniainfective complications of tibia fractures result in nonunion, bone defects and soft tissue envelope impairment. several methods of treatment have been described to deal with bone defect including callus distraction, fibula transfer, muscle flap and bone grafting. there are many possibilities to encourage bone healing; bone morphogenic proteins, platelet rich plasma, electrical, ultrasound or shockwave stimulation and hyperbaric oxygen therapy. a patient with both tibias infected nonunion is presented. high energy trauma primarily and inadequate debridement secondarily were probably the cause of the healing complications. a middle-age man was injured in a gas explosion and suffered comminuted closed fractures of both distal tibias. after an immediate external fixation we operated him on the th day after the injury, anatomical reduction and internal fixation on both sides was done. an infection developed after weeks. ankle joint arthrodesis was necessary on one side and implant removal, repetitive debridement with bone grafting on the other. we could not cure the infection and the fracture did not heal. after years, operations, days of ciprofloxacin, days of gentamicin, days of vancomycin, days of implanted gentamicin antibiotic beds and the use of cultivated autogenous steam cells clinically evident nonunion was still present. surgery was performed again, a resection of cm of bone and callus distraction with an unilateral frame. despite a fast progress in knowledge and improvement of methods, a radical debridement, preservation or reconstruction of soft tissue coverage, systemic and local antibiotic therapy and appropriate stabilization is still a keystone in infected nonunion treatment. some people who live in some regions of our country trust in bonesetter's skills more than these ones of professional orthopaedist in the hospitals. the fact that some bonesetter's particular skills to cure the non-operative back pain seems to make them credible on closed reduction too. in this case report, right humerus proximal body fractures due to falling were discussed. the case was -year-old male. in the treatment of this case, velpau bandage, closed reduction and plaster cast-splint has been applied after that he was called to the clinic control, but he did not come to control. the parents of the case were aware of the fact he cannot raise enough the right upper extremity and he was taken along to the hospital. from his anamnesis, it has been learnt that the bonesetter has removed the castsplint and, tried to perform closed reduction. actual physical examination showed that there was an arm pain, crepitation and deformity. a diagnose has been made: there was an union right humerus proximal body fractures, so he has to be hospitalised. under general anaesthesia, closed reduction and bandage velpeau were applied. on the rd day of the hospitalisation, the case was externed and was advised to come for a polyclinic control. because of the importance of epiphysis lines of bones and of other complications from the upper extremities fractures, the treatments have to be performed by the orthopaedists or in accordance with them. about this medical issue, families should be made conscious by healthy authorities. there were women and men. the mean age was . years (range - years) and mean follow-up period was months (range - months). posterior kocher-langenbeck approach was used at patients and ilioinguinal approach was used at two patients.results: there were both column, posterior column with posterior wall, transverse with posterior wall and posterior wall fractures. anatomic reduction was obtained at patients and adequate reduction at patients according to matta criterias. harris scoring system revealed excellent at , good at , moderate at and bad at patients. over % of these patients had satisfactory function. there were any pulmonary embolism, deep infection or nonunion detected. one of four patients whom had developed osteoarthritis, managed with total arthroplasty. postoperative sciatic nerve injury was developed at one patient. conclusıon: secondary arthrosis, nonanatomic reduction, unstable fixation and nerve injuries were associated with poor results. our clinical experience for acetabulum fractures were similar to that reported previously at the literature with over % of satisfactory results sedat kocak, birsen ertekin, esma erdemir, abdullah sadik girisgin, basar cander introduction and objectives: quadriceps muscle tears are usually seen in middle-aged and older people. particularly people with chronic diseases (such as diabetes mellitus, renal failure and gout) are prone to develop quadriceps muscle ruptures. we present a case of partial rupture of the quadriceps muscle in a -year-old girl after intramuscular injections. we thought that this patient could be the youngest patient reported with a quadriceps muscle rupture. methods: patient presented to our clinic with left knee pain, limitation in knee flexion and a localized palpable swelling at the anterolateral side of thigh. there was no blunt trauma but it happened while she jumping on the sofa. in her detailed history we learnt that she had a serious upper tract respiratory infection a week ago and used some parenteral antibiotics (twice a day, intramuscular clindamycine for days).results: plain radiographies were normal. mri showed a partial tear of the vastus lateralis muscle matching with the injection sites. the patient was placed in a long leg half-cast which was maintained for weeks. she treated with conservative treatment successfully.conclusions: mr imaging is useful to diagnose and differentiate in this pathology. multiple intramuscular injections may contribute to damage muscles and make them prone to tears with muscle contractions. quadriceps muscle ruptures in children can be treated successfully with conservative treatment. twenty year old female attempted suicide by jumping from a four story high building, resulting in multiple fractures of the limbs and a complex fracture of the body of the fourth lumbar vertebra (l ) resulting in paralysis of the inferior limbs. the l fracture was treated by a neurosurgeon with the extraction of the body of the vertebra, insertion of a cage device and arthrodeses of the third and fifth vertebras using a metal plate and screws, thereby stabilizing the affected segment and decompressing the medullar channel. the approach was achieved by a general surgeon using the technique of localio, that consists in a paramedian incision of the abdomen and the dissection of the retroperitoneal space without entering the abdominal cavity, dissecting and isolating the left ureter and the main vascular structures (iliac vessels and the left iliolumbar vein) in order to allow a good exposure of the three vertebra bodies involved. the patient recovered the complete function and control over the limbs, resulting no neurological sequelae from the fracture. it is of major importance that this procedure be performed by a multidisciplinary team of surgeons, involving a neurosurgeon and a general surgeon, in this way achieving a better result and a lower risk of complications. josef märz department of surgery, regional hospital karlovy vary, czech republicabdominal ultrasonography or ct were applied to ( . %) patients with blunt trauma and ( . %) patients with penetrating trauma. one ( . %) negative laparotomy was applied to patients with blunt trauma. to splenic injuries was splenectomy. sigmoid perforation, diaphragm rupture, bladder rupture were observed and were fixed primarily. one patient died during surgery due to liver and vena cava injuries. patients with penetrating injury were operated due to firearm injury in ( %) and stab wound in ( %), mortality was not. negative laparotomy was applied to ( . %) patients. multiorgan injury was observed in patients. tube thoracostomy was inserted to patients. of the intestine injuries and stomach injury was fixed primarily. two resection and anastomose and three diversionary ostomy were done. conclusion: proper examination must be considered according to the formation of trauma. _ imaging methods have been used less in penetrating trauma, and negative laparotomy is reported to be applied more than in cases of blunt traumas introductıon: chest tube insertion is frequently used by thoracoabdominal surgeons in urgent conditions. occasionally, this invasive procedure may be associated with lethal complications in inexperienced hands. in this study, we analyzed patients with visceral and/or diaphragmatic injuries due to chest tube insertions. methods: six patients with diaphragmatic and visceral injuries subsequent to chest tube insertions between and were evaluated. the diagnosis was established with roentgenogram, biochemistry of the fluid drained from the chest tube and confirmed with computerized tomography in all patients. results: pleural effusion accompanying respiratory distress was the main indication for chest tube insertion in all patients. in five patients, coexistent gastric perforations with diaphragmatic ruptures were detected, also the esophagus was additionally perforated in one patient. partial gastrectomies were performed in three patients, whereas total gastrectomy in one and primary repair required in two patients respectively. five of the patients died from septic complications. the only survived patients with early diagnosis and primary repair was discharged from the hospital on the th day. conclusıon: penetration of a drainage tube through viscera is a wellrecognized but seldom reported phenomenon. in the majority of patients with diaphragmatic rupture, abnormalities can be found at initial chest radiography. if transdiaphragmatic herniation is missing, diaphragmatic rupture is difficult to diagnose by chest radiography alone. computed tomography is often necessary to reveal the correct diagnosis. early diagnosis and treatment are extremely important in the management of these patients. bronchobiliary fistula is a rare condition, arising as a complication of hydatid disease of the liver, hepatic tuberculosis, hepatic malignancy, chronic pancreatitis, hepatic trauma or surgery. conservative treatment is directed at non-surgical approaches of relieving biliary obstruction to allow for normal flow of bile into the duodenum via endoscopy or percutaneous routes. however in complicated cases which failed conservative non-surgical therapy, surgical intervention is usually required. we report a -year-old man who presented with bilioptysis from a bronchobiliary fistula resulting from firearm injury after days. for his current admission, the patient reported a -day history of cough productive of yellow-green sputum coupled with fevers and malaise.this was successfully treated surgically with a right medial lobectomy and t-tube drainage. paget-von schroetter syndrome(pss) refers to spontaneous thrombosis of the subclavian vein and constitutes . - % of all venous thromboses. it is prevalent among young and healthy adult males who engage in sports. a -year-old male presented with pain and swelling of the left arm after a sequence of intense, repetitive weight lifting exercises. upon questioning, he disclosed that he had been engaged with weight lifting for a long time and had complaints for a while. bases on these findings, upper-extremity effort thrombosis was suspected. contrast-enhanced mr angiography revealed near-complete occlusion of the proximal left subclavian vein and collateral formations in the distal were observed. color doppler us showed a heterogeneous thrombotic mass that filled almost the entire proximal segment of the left subclavian vein thrombosis extended into the proximal segment of the left internal jugular vein. furthermore, extensive venous collateral formations were present the left proximal cervical localization. both mr angiographic and sonographic findings were consistent with pss. as the patient had already developed extensive venous collaterals, no surgical intervention was performed. instead, treatment with lowmolecular weight heparin and anticoagulants, was initiated and was continued along with the follow-up for bleeding parameters. as of years clinical follow-up the patient is doing well, and treatment is continued with oral anticoagulants and acetylsalicylic. pss should be considered in the differential diagnosis of effort induced upper extremity pain and swelling. conservative non-operative treatment is acceptable and can be successfully used with favorable long-term outcomes. although, blunt trauma of the extremities is a common diagnosis in emergency clinics, compartment syndrome associated with vascular injury following blunt trauma may be difficult to diagnose. urgent diagnosis and treatment of compartment syndrome is of particular importance for limb salvage or even to save the patients' life. years old male patient was referred to emergency clinic due to blunt trauma of the right lower extremity. right thigh was echimotic and swollen. pallor, coldness and severe pain were present at the lower part of the trauma level. distal pulses were not palpable. acute compartment syndrome of the right thigh was diagnosed that led to an emergent operation. intraoperatively, popliteal artery rupture was diagnosed and repaired with end-to-end anastomosis. fasciotomies were performed at the anteromedial and anterolateral portions of the right leg and anteromedial part of the thigh for the treatment of compartment syndrome. in early postoperative period, distal pulses were palpable. preoperatively present pallor and coldness improved in the first few h. fasciotomies were closed with skin grafts at the th postoperative day. patient was discharged at the th postoperative day with palpable distal pulses and failure of dorsal flexion of the right ankle representing mild neurological injury. possible vascular injury should be kept in mind in a patient with compartment syndrome following blunt trauma of extremities. success of surgical repair depends on the early diagnosis and treatment. late repair may result in neurological complications or even the loss of extremities.conclusıon: acute mesenteric ischemia is highly mortal emergency which should always be suspected in elderly patients with cardiac disease suffering from abdominal pain. acute ischemia of the lower member after injury by firearm -case report patient with years, male sex, admitted at the urgency department after injury of the left lower member by firearm. at the admission presented loss of substance and hemorrhage in the medial and lateral faces of left leg and foot with signs of ischemia. an arteriography of the member was carried out showing infrapopliteal arterial lesions of the three axes. during surgery, fracture and losses of peroneum substance was observed with macroscopic tibial and peroneal common nerves integrities. he was submitted to tibial interposition grafts with subsequent reversed contralateral internal saphena vein bypass.in the th postoperative day it was carried out surgical debridement and plastia with partial skin graft. he presented good cicatricial evolution, with hospital discharge days after, oriented to external consultations of vascular surgery, plastic surgery, physical/ rehabilitation medicine and pain consult. five months after surgery, pain was controlled with the medication instituted, with improvement of the left lower member limitations with physiotherapy, good cicatricial evolution and posterior tibial and dorsalis pedis pulses palpables. dıscussıon: the incidence of arterial wounds following penetrating injury of the members is %. the vascular trauma occurs more frequently in the lower extremities, being the most common clinical presentation acute isquemia. the most frequent causes are vehicle accidents, falls and firearm wounds. in the united states, injuries by firearm represents the first cause of death in young individuals of male sex. the arterial bellow-knee injuries by firearm remain like a challenge, with an associated rate of amputation of to %. jorge pereira, luis filipe pinheiro surgery department, sã o teotó nio hospital, viseu, portugaltrauma represents one of the most important causes of death and disability of today. the exponential growth of the major cities, the continuous building of roads and the uprising of terrorism, foresee that trauma will keep is importance as a major cause of disease.recently, the management of the trauma patient as been modified, with the introduction of the atls method. this fact has produced great improvement, proven and reproducible, decreasing mortality and morbidity of trauma. the next stage of treatment implies surgery. the dstc course, and other similar ones, allow the teaching of surgical damage control to surgeons. in this courses, the surgeon not only learns the theoretical basis of the surgical techniques but also acquires the skills to perform them. more importantly, he learns trauma pathophysiology, so he can perform the difficult task of surgical decision-making. using the same computer-animated drawing technique as in a previous video (primary survey), the authors continue to present a trauma patient, after the stabilization of the primary survey, at the operating room. the patient has a severe abdominal trauma and needs damage control of his lesions, for he is already suffering from the deadly triad: hypocoagulation, acidosis and hypothermia. a year-old male patient was admitted to our hospital for severe abdominal pain. thoracoabdominopelvic ct scan demonstrated incarcerated bowel loops in the right hemithorax. strangulated transverse colon segment and omentum through the defect at the dome of right diaphragma was found at diagnostic laparoscopy. diaphragmatic hernia was primarily repaired with endostitches, and supported with a polipropylene mesh fixed with endotuckers subsequent to reduction of strangulated organs to the abdomen. resection of necrotic intrabdominal organs and a side-to-side stapled colocolonic anastomosis was performed through a subcostal minilaparotomy. drainage of right hemithorax was provided with a tube thoracostomy. the patient was discharged on the th post-operative day without any major complications. introduction and objectıves: single incision laparoscopic procedures are accepted as a step towards pure natural orifice transluminal endoscopic surgery. however, loss of requirement of any perforation of visceral organ and an endoscopic equipment make this technique more popular and easily performable. here in we report our first appendectomy case who was performed with single incision laparoscopic surgery (sils) technique. methods: years old male patient with the diagnosis of acute appendisitis underwent single incision laparoscopic appendectomy. a key: cord- -hqs hfa authors: simpson, william m. title: pesticides date: journal: agricultural medicine doi: . / - - - _ sha: doc_id: cord_uid: hqs hfa nan before discussing individual chemicals, a few principles of pesticide poisoning management should be addressed. the most important issue is proper diagnosis. without it, all other interventions are potentially ineffective and possibly harmful. whenever possible, get the label of the suspected poison. it will contain principles of management and contact information for the manufacturer. the local poison control center and the national pesticide telecommunications network ( - - - monday to friday : a.m. to : p.m.) are also available for further advice. if coworkers have not been able to identify the suspect chemical, cooperative extension service agents may also serve as a resource for commonly used chemicals at particular times of the year on specific crops. remember that careful decontamination of the patient is necessary to prevent possible further injury to the patient and possible injury to emergency department staff. physical decontamination by removing clothing that has been in contact with the chemical, washing the skin with soap and water, and copiously irrigating the eyes is important. recent evidence-based position statements from the american academy of clinical toxicology and the european association of poisons centres and clinical toxicologists suggest that gastric lavage, activated charcoal, cathartics, and ipecac should not be used routinely in poisoned patients. they can be considered within minutes of presentation if a potentially life-threatening amount of poison has been ingested. even in this circumstance, contraindications exist for the use of each: lavage is contraindicated in hydrocarbon ingestion; cathartic in volume depletion, hypotension, electrolyte imbalance, or ingestion of a corrosive substance; activated charcoal in an unprotected airway, a nonintact gastrointestinal (gi) tract or hydrocarbon ingestion; and ipecac in a nonalert patient or with ingestion of a hydrocarbon or corrosive substance ( ) . the most widely used pesticides in the world, herbicides are designed to kill plants and attack plant metabolic pathways that do not exist in humans and other animals. therefore, in general, they have relatively low animal toxicity. there are hundreds of herbicides and herbicide mixtures on the market in the united states and throughout the world. seven of the top pesticide active ingredients (by amount used) are herbicides. chlorophenoxy herbicides are plant growth regulators. they are commonly used for broadleaf weed control on cereal crops and pastures. common chlorophenoxy herbicides include , -d; dicamba; and silvex. many products available to consumers include a mixture of salts in a petroleum base. most toxicity from contact with skin or eyes or ingestion involves mucous membrane irritation. very high dose exposure may result in neurological symptoms including muscle twitching, seizures, and coma. renal and hepatic dysfunction may occur with large ingestions. long-term health effects of low to moderate exposure include alleged, but not confirmed, carcinogenicity, teratogenicity, and reproductive abnormalities. although no specific antidote is known, alkaline diuresis has been reported to be of value in severe overdose. otherwise, aggressive supportive care including protection of the airway, correction of hypotension, and treatment of arrhythmias, hyperthermia, and seizures may be required ( ) . atrazine and glyphosate, triazine, and phosphonate herbicides are also widely used for weed control. glyphosate was developed specifically as a much safer alternative to paraquat (discussed in a subsequent paragraph). mucous membrane irritation is the most common adverse reaction to exposure to these chemicals and their many relatives. gastrointestinal tract erosions were the primary adverse events in large-volume ingestions (all accidental or intentional), but renal, hepatic, central nervous system, and pulmonary involvement was sometimes noted. since no antidote is known, supportive care is also indicated for these groups of agents ( , ) . carbamate herbicides, unlike carbamate insecticides, do not produce inhibition of cholinesterase enzymes or the "all faucets on" cholinergic syndrome. toxicity is uncommon. common generic names for carbamate herbicides include asulam, terbucarb, butylate, pebulate, triallate, and thiobencarb. mucous membrane irritation is the most common adverse effect. after removal of the chemical by soap and water, flushing the eyes, and increased fluid intake, treatment is supportive. urea-substituted herbicides are photosynthesis inhibitors, mainly used for weed control in noncrop areas. chemicals in this class have names ending in "-uron" or "-oron"-e.g., chlorimuron, diuron, siduron, tebuthioron, and tetrafluoron. urea-substituted herbicides have low systemic toxicity based on animal feeding studies; they may, however, produce methemoglobinemia with heavy ingestion. methemoglobin and sulfhemoglobin levels should be measured in patients with dyspnea or cyanosis and a history of urea-substituted herbicide ingestion. otherwise treatment of these ingestions is decontamination and supportive care. the most dangerous group of herbicides is the bipyridyls. paraquat is the most important of the bipyridyl group. others in the group include diquat, chlormequat, and morfamquat. bypyridyls exert their herbicidal activity by interfering with reduction of nicotinamide adenine dinucleotide phosphate (nadp) to reduced nicotinamide adenine dinucleotide phosphate (nadph) during photosynthesis, producing superoxide, singlet oxygen, and hydroxyl and peroxide radicals. this eventually destroys lipid cell membranes, including those in the lungs, leading to late and irreversible pulmonary fibrosis. major local effects of paraquat are due to its caustic properties. corneal ulceration has been reported after paraquat concentrate was splashed in the eyes. gastrointestinal tract ulceration including esophageal ulceration with perforation has occurred. after ingestion of > mg/kg of paraquat concentrate, pulmonary, cardiac, renal, and hepatic failure can occur within hours. ingestion of ml/kg or more may cause renal failure, resulting in impaired paraquat excretion and higher serum concentrations. pulmonary involvement is the major target of ingested paraquat with an adult respiratory distress syndrome (ards)-like syndrome developing to days after ingestion, progressing to pulmonary fibrosis in a few days. treatment of paraquat ingestion is aimed at several points along the toxicity pathway-removing toxin from the gi tract, increasing excretion from the blood, and preventing pulmonary damage with anti-inflammatory agents. cautious aspiration with a nasogastric tube is appropriate if the patient presents within the first hour after ingestion. because of the possibility of severe toxicity, some authorities still recommend activated charcoal ( to g/kg) if the patient is seen within to hours, repeated hours later. hemodialysis is effective for removing paraquat from the blood. pulmonary damage is increased by oxygen supplementation, so low-oxygen breathing mixtures are recommended. immunosuppression has been attempted with corticosteroids and cyclophosphamide or other similar agents, with limited success. deferoxamine and n-acetylcysteine have been used as antioxidants. prospective studies supporting immunosuppressive and antioxidant therapies are lacking. diquat is felt to have much less pulmonary toxicity, but pulmonary fibrosis may also occur, especially if oxygen supplementation is used. chlormequat toxicity resembles organophosphate toxicity but should not be treated as such (see the discussion of organophosphate pesticides in the next section). treatment is by gi decontamination and supportive care. morfamquat is rarely used. no human or animal toxicity has been reported with morfamquat, but poisoning with the chemical should probably be treated initially as a paraquat poisoning ( ). organophosphates are still the most widely used insecticides in the united states and the world, but botanical insecticides and insect growth regulators are becoming much more widely used, due to their lower toxicity. also included in this category are the organochlorines (such as ddt), the carbamates, and insect repellants (deet and p-dichlorobenzene). organophosphates (ops) are the most common cause of insecticide poisoning and cause a few deaths each year in the united states. ops are used for suicide in both the united states and particularly in the third world, where more than , people per year are estimated (by the world health organization) to take their own lives using this group of chemicals. organophosphates are so widely used because of their effectiveness against a wide variety of insects and their lack of persistence in the environment (compared to organochlorines). the toxicity of ops varies greatly-a drop of the op nerve agents vx, soman, or sarin may be lethal, while malathion has an oral median lethal dose (ld ) of approximately g/kg. most of the ops are rapidly absorbed by all routes. they may be classified as direct (the nerve gases) or indirect (most commercially used crop, animal, and home products) cholinesterase inhibitors. metabolism, primarily by the cyp system, is required to activate the indirect inhibitors. direct inhibitors may have almost immediate effects, or up to to hours delay after dermal absorption. indirect inhibitors may not produce symptoms until to hours after exposure. the toxicologic effects of ops are almost entirely due to inhibition of acetylcholinesterase in the nervous system, which causes acetylcholine to accumulate in the synapses and myoneural junctions. muscarinic, central nervous system, and nicotinic effects are produced as outlined in table . , usually in that order. the most common clinical presentation is a patient with an odor similar to garlic, with miosis, increased airways secretion, lacrimation, bradycardia, and gi complaints ( ). this constellation of findings should be managed as op poisoning until proven otherwise ( ) . serum and red blood cell (rbc) cholinesterase levels should be obtained early, but therapy should not be delayed pending laboratory confirmation. treatment should include attention to the airway and adequate oxygenation with atropine administered until secretions dry. the initial dose of atropine should be to mg for adults and . mg/kg for children, administered intravenously if possible, and repeated every to minutes until signs of atropinization develop (flushing, drying of secretions, and dilation of pupils, if they were miotic at presentation). atropine may be required for hours and should be tapered, rather that abruptly stopped. pralidoxine ( -pam) is a specific op antidote. it should be administered as soon as possible in all ( , ) . carbamates are also cholinesterase inhibitors, producing the syndrome of cholinergic crisis as described for ops. the syndrome is of shorter duration and more benign than with ops because carbamates dissociate from the cholinesterase much more readily than ops, producing a reversible inhibition. carbamates also poorly penetrate the central nervous system (cns), rarely producing seizures, ataxia, and central depression of the respiratory and circulatory centers. red blood cell and serum cholinesterase levels return to normal within hours of exposure. treatment of carbamate poisoning is also with atropine (in doses identical to those used for ops but for only to hours because of the shorter duration of enzyme inhibition) and oxygen supplementation. pralidoxime is not indicated in pure carbamate poisoning, but if the poison is not known for certain and cholinergic symptoms exist, it can be used, pending identification of the poison. because of their persistence in the environment, organochlorine insecticides are in limited use in the united states. they are, however, used around the world in mosquito control. lindane is still used in the united states as a general garden insecticide, for control of ticks, scabies, and lice and for extermination of powderpost beetles. it is absorbed by inhalation and ingestion and less well by dermal contact, unless the skin is abraded or treated repeatedly. lindane interferes with normal nerve impulse transmission by disruption of sodium and potassium channels in the axon membrane, leading to multiple action potentials for each stimulus. clinically this may result in confusion, apprehension, tremors, muscle twitching, paresthesias, dizziness, seizures, or coma-usually in the face of a history of repeated treatment for scabies or lice. wheezing, rales, or cyanosis may be found if hydrocarbon (a frequent vehicle) aspiration has occurred. diagnosis is based on a history of exposure or intentional ingestion with physical manifestations of cns hyperexcitability. treatment is decontamination with supportive and symptomatic care. seizures may require lorazepam or diazepam. arrhythmias should be treated with lidocaine. commonly used botanical insecticides include pyrethrum, nicotine, rotenone, and bacillus thuringiensis. other botanicals are used in small quantities but are rarely associated with adverse health effects. pyrethrum is the oleoresin extract of dried chrysanthemum flowers. it contains about % active insecticidal ingredients known as pyrethrins. synthetic derivatives of these compounds, called pyrethroids, are much more widely used today. most insecticides containing pyrethroids also contain piperonyl butoxide, a synergist that increases their effectiveness by retarding enzymatic degradation of the active ingredient. pyrethrum-based insecticides are considered to have low toxicity, but they can produce nausea, vomiting, diarrhea, tremors, muscle weakness, and paresthesias. very high levels of exposure can produce temporary paralysis and respiratory failure. treatment is supportive. allergic reactions to the pyrethroids are more common, with about % of patients sensitive to ragweed, and cross-reacting to pyrethrum. pyrethrum and the pyrethroids are well absorbed from the gi tract and minimally absorbed from dermal exposure. they are rapidly metabolized by the liver, leading to their relative lack of systemic toxicity in humans. persons exposed to prolonged contact with high concentrations of pyrethroids report paresthesias in unprotected skin. vitamin e oil has been reported to relieve these paresthesias, by an unknown mechanism. otherwise treatment of toxicity is symptomatic and supportive. allergic symptoms are treated as with other allergens, by avoidance and antihistamines for mild symptoms, and corticosteroids and epinephrine for severe bronchospasm ( ) . nicotine, usually derived from tobacco, was used as an insecticide in the past. now rarely used, most nicotine poisoning is as a result of ingestion of tobacco products or incorrect use of nicotine patches, gum, or nasal sprays. decontamination is the treatment of choice. care is supportive, since there is no specific antidote for nicotine. severe hypersecretion or bradycardia may be treated with atropine. rotenone, prepared from the roots of derris, lonchocarpus, and tephrosia plants, is used as a household and horticultural insecticide. piperonyl butoxide is also used as a synergist with this compound. toxic to fish, bird, and insect nervous systems, it has produced little human toxicity in decades of use. however, fresh derris root from malaya has been used for suicides. numbness of mucous membranes has been reported in exposed workers, along with dermatitis and respiratory tract irritation. treatment of these symptoms is with decontamination and supportive care. several subspecies of bacillus thuringiensis (bt) are pathogenic to some insects. the product is used both as a spray to be applied to certain food crops and, incorporated into the genetic material of certain plants as a "builtin" insecticide. infections of humans with these organisms is extremely rare. one volunteer ingesting a bt variety not used as a pesticide developed fever and gi symptoms. a single corneal ulcer has been associated with a splash of bt suspension in the eye. the gi symptoms resolved spontaneously; the ulcer resolved with antibiotic treatment ( ) . insect repellants are intended for human use and are therefore designed to be nontoxic in routine use. two insect repellants have produced poisoning syndromes: deet (n,n-diethyltoluamide) and p-dichlorobenzene. deet is minimally absorbed through the skin and is rapidly eliminated, primarily in the urine. excessive use of high concentrations of this compound has been associated with a idiopathic toxic encephalopathy, particularly in girls and female infants. symptoms may include lethargy, anxiety, opisthotonos, athetosis, ataxia, seizures, and coma. ingestion of ml of high concentration deet ( % to %) has produced coma, seizures, and hypotension within an hour of ingestion and death in at least two cases. irritant contact dermatitis and conjunctivitis have also been reported, as has an anaphylactic reaction in one case. there are no characteristic physical findings. treatment is symptomatic and supportive. originally used as a moth repellant and insecticide, p-dichlorobenzene is now more commonly used as a deodorizer. ingestion is fairly common when children eat a part of a deodorant cake in a toilet bowl or diaper pail. it is a mucous membrane irritant and can produce allergic symptoms. massive ingestions may produce tremors and hepatic or renal injury. there are no characteristic features on physical examination or laboratory studies. diagnosis is by history of ingestion, and treatment is supportive. widely used in industry, agriculture, home, and garden, fungicides are used for many purposes-protection of seed grain during storage, transport, and germination; protection of crops, seedlings, and grasses in the field, in storage, and during shipment; suppression of mold; control of slime in paper processing, and protection of carpets and fabrics. fungicides, used properly, rarely cause severe poisonings. most have inherently low mammalian toxicity and are absorbed poorly (at least partly because they are formulated as suspensions of wettable powders or granules). most are applied using methods that intensively expose only a few individuals. irritant injuries to skin and mucous membranes are relatively common in heavily exposed individuals, however ( ) . of the substituted benzene herbicides, only hexachlorobenzene has produced systemic toxicity. this occurred when hexachlorobenzene-treated seed wheat was used instead for human consumption. in years, approximately persons developed porphyria due to impaired hemoglobin synthesis. most affected individuals recovered, but some infants nursed by affected mothers died. thiocarbamates, unlike the n-methyl carbamates, have little insecticide activity. instead they are used to protect seeds, turf, ornamentals, vegetables, and fruit from fungi. bisdithiocarbamates, represented by thiram, are structurally similar to disulfuram. with heavy exposure an antabuse-like reaction can be produced if alcohol is ingested subsequently. this reaction is characterized by flushing, sweating, headache, tachycardia, and hypotension. other thiocarbamates-ziram, ferbam, and metam-sodium-should theoretically predispose to the antabuse reaction, but no occurrences have been reported. metam-sodium decomposition in water yields methyl isothiocyanate, a gas that is extremely irritating to mucous membranes. inhalation of the gas may cause pulmonary edema. metam-sodium is considered a fumigant and should be used in outdoor settings only. persons caring for a victim with metam-sodium ingestion should avoid inhalation of evolved gas. treatment of exposure is with skin and gi decontamination, oxygen supplementation, fluid support, and avoidance of alcohol. ethylene bisdithiocarbamates (ebdc compounds) are another group of fungicides that may irritate skin, respiratory tract, and eyes. maneb, zineb, nabam, and mancozeb represent this class. treatment of the irritant effects of these chemicals is by decontamination. thiophthalimides, represented by captan, captafol, and folpet, are agents used to protect seed, field crops, and stored produce. all of these fungicides are moderately irritating to the skin, eyes, and respiratory tract. they may produce skin sensitization. no systemic poisonings have been reported with these chemicals. copper compounds, both inorganic and organic, are irritating to skin, respiratory tract, and eyes. soluble copper salts, such as copper sulfate and acetate, are corrosive to mucous membranes and the cornea. systemic toxicity is low, probably due to limited solubility and absorption. treatment of poisoning is with gi and skin decontamination. ophthalmologic consultation should be obtained if eye irritation persists after flushing the eyes with saline. intentional ingestions of large volumes of these compounds may result in hemolysis with circulatory collapse and shock, with renal and hepatic failure. in these severe cases, fluid replacement, alkalinization of the urine, chelating agents, and hemodialysis may be required. organomercury compounds have been used primarily as seed protectants. toxicity has occurred primarily when methyl mercury-treated grain intended for planting was consumed in food. poisonings have also occurred from eating meat from animals fed mercury-treated seed. organic mercury is efficiently absorbed from the gut and is concentrated in the nervous system and red cells. early symptoms of mercury poisoning are metallic taste, distal paresthesias, tremor, headache, and fatigue. further symptoms target the cns with incoordination, slurred speech, spasticity, rigidity, and decline in mental status. treatment is by skin and gi decontamination and chelation. cadmium has been used to treat fungal diseases of turf and bark of orchard trees. cadmium salts and oxides are very irritating to mucous membranes of the respiratory and gi tracts. inhaled cadmium dust or fumes can produce a mild, self-limited respiratory illness with fever, cough, and malaise, similar to metal fume fever. more severe symptoms with labored breathing, chest pain, and hemorrhagic pulmonary edema are associated with heavier exposure and resemble chemical pneumonitis. cadmium ingestion may produce severe nausea, vomiting, diarrhea, abdominal pain, and tenesmus. chronic obstructive pulmonary disease (copd), renal and hepatic injury, and pathological fractures have been associated with chronic cadmium exposure. treatment is skin and gi decontamination, respiratory support, and chelation therapy (for severe, acute poisoning, though the possibility of inducing renal failure with a large load of cadmium exists). a long list of miscellaneous organic fungicides is in use in many crop, ornamental, and turf applications. reports of adverse effects on humans are rare or absent entirely. as with all pesticides, following label directions for use is the key to prevention of adverse events, even with these low-risk chemicals. rodenticides are designed to kill nuisance rodents such as rats, mice, moles, voles, ground squirrels, gophers, and prairie dogs. these animals may damage crops in the field or in storage and can transmit disease to humans and other animals through their droppings or bites. a wide variety of organic and inorganic chemicals have been used to control rodents. plant-derived materials such as strychnine and red squill or inorganic compounds such as thallium or arsenic trioxide were among chemicals used early for rodent control. newer agents tend to be synthetic organic compounds. all pose particular risks for accidental poisonings. since these agents are designed to kill mammals, their toxicity is often similar for the target rodents and for humans. also, since rodents often share environments with humans and other mammals, the risk of accidental exposure to the rodenticide is high because of their placement in those environments. as rodents have become resistant to some chemicals, more toxic chemicals have been developed, exposing those applying them and those living in areas where they are used to increased risk of toxicity. there are over trade name rodenticides in the united states alone, many with very similar names. while important for all poisonings, in rodenticide poisoning, having the label to guide therapy is critical. long-acting anticoagulants are responsible for nearly % of human rodenticide exposures reported in the united states. introduced in the s, they have essentially replaced warfarin-based products. they have the same mechanism of action as warfarin but are more potent and have longer halflives. they are effective in a single feeding (or a limited number of feedings) and in animals that have developed resistance to the older anticoagulants. treatment of superwarfarin ingestion depends on the dose. a child who ingests a few pellets or grains of the material can be observed at home for the development of bleeding. a person with a bleeding disorder or who takes an anticoagulant is at much greater risk of excess bleeding, even with a small exposure. patients with large ingestions (> . mg/kg) should have gastric decontamination if they are seen within an hour or two of the ingestion. if there has been a longer delay, activated charcoal is indicated. prothrombin time (pt) and partial thromboplastin time (ptt) should be measured at and hours after a significant ingestion. if any value is elevated, phytonadione (vitamin k ) should be started ( to mg for children and to mg for adults) by subcutaneous injection and repeated as necessary. critically ill adults can be given to mg via slow intravenous infusion ( . mg/min). the pt and ptt should be checked every hours until stable and then every hours. once the pt and ptt are stable, the phytonadione may be switched to the oral form ( to mg daily for adults, to mg for children), tapering the dose as the pt levels decline to normal (over a period sometimes as long as months). warfarin-based products are still available, but single exposures, unless large amounts (> . mg/kg) are ingested, can be observed without therapy. recent large exposures should be treated with activated charcoal. the pt and ptt should be measured at and hours. if the pt is two times normal or more, phytonadione should be given ( to mg for children, mg for adults orally or intramuscularly and repeated as necessary. the pt should be measured every hours until stable, then every hours until normalized ( ) . bromethalin, a relatively new rodenticide introduced in , is a neurotoxin that produces its effect by uncoupling mitochondrial oxidative phosphorylation. this results in increased intracranial pressure, decreased nerve impulse conduction, paralysis, and eventual death. no human exposures have been reported. its effectiveness as a rodenticide is based on the rodent's consuming a relatively larger dose per kilogram than other larger animals. there is no antidote, so treatment of poisoning would be symptomatic and supportive. cholecalciferol (vitamin d ) takes advantage of the fact that rodents are sensitive to small percentage changes in calcium levels in their blood. cholecalciferol increases serum calcium by mobilizing calcium from bone, resulting in calcium deposition in tissues and nerve and muscle dysfunction and cardiac dysrhythmias. ingestion of several bait pellets or treated seeds should not be toxic, and no treatment is necessary. larger ingestions should be treated with gastric lavage if recognized early and activated charcoal in several doses if after to hours of ingestion. serum calcium should be checked at and hours and treatment initiated if hypercalcemia develops. forced diuresis with furosemide and a low-calcium diet should be initiated along with prednisone ( to mg every hours). calcitonin and/or mithramycin may be necessary for patients unresponsive to above measures. red squill is a botanic rodenticide derived from the red sea onion (urginea maritima). it contains two cardiac glycosides that produce effects similar to digitalis. treatment of ingestion is the same as for digitalis toxicity, including the use of digibind. strychnine is another botanical, found in seeds of strychnos nux-vomica, a tree native to india. used in germany in the th century as a poison for rats and other animals, it is still available in many rodenticides. it is a neurotoxin, producing twitching of facial (risus sardonicus) and neck muscles, reflex excitability and generalized seizures. treatment should include activated charcoal and anticonvulsants (diazepam, phenobarbital, or phenytoin if unresponsive to diazepam). stimulation of the patient should be minimized; respiratory support including intubation and mechanical ventilation may be required. thallium rodenticides are not used in the united states, but are available around the world. treatment of poisoning is difficult. gastric decontamination should be attempted with lavage and activated charcoal. fluid support with potassium chloride theoretically displaces thallium and increases its excretion. zinc and aluminum phosphides are used to protect stored grains from rodents and other pests. on contact with moisture, phosphides release phosphine gas, which is the primary cause of toxicity. oral exposures to phosphides occur as a result of intentional ingestion for suicidal purposes. phosphine inhibits oxidative phosphorylation, leading to cell death, manifested by severe gi irritation, hypotension, and cardiac and respiratory dysfunction. management is by activated charcoal and gastric lavage. intragastric sodium bicarbonate and/or potassium permanganate have been suggested to decrease phosphine gas release. oxygen should be supplemented ( % via rebreather). treatment is otherwise symptomatic and supportive ( ) . the fifth edition of recognition and management of pesticide poisoning, edited by drs. routt reigart and james roberts of the medical university of south carolina, contains a table that lists manifestations caused by specific pesticides, which may be useful in evaluating possible pesticide exposures and toxicities. the entire textbook is available on the environmental protection agency web site at http://www.epa.gov/pesticides/safety/healthcare/ handbook.htm (see "index of signs and symptoms" or pages to ) by request from the environmental protection agency, office of prevention, pesticides, and toxic substances at - - . the liquids in which pesticides are dissolved and the solids on which they are adsorbed are chosen by the manufacturers to make handling and application easy and to achieve maximal stability and effectiveness of the active ingredient. the most commonly used solvents are petroleum distillates. the petroleum distillate may produce toxicities in itself in large-volume ingestions. most adjuvants (emulsifiers, penetrants, and safeners) are potentially skin and eye irritants but with very low or no systemic toxicity. about pesticides. u.s. epa - pesticide market estimates european association of poisons centers and clinical toxicologists. position statements herbicide safety relative to common targets in plants and mammals safety evaluation and risk assessment of the herbicide roundup and its active ingredient, glyphosate, for humans acute poisoning with a glyphosate-surfactant herbicide: a review of cases paraquat and the bipyridyl herbicides the role of oximes in the management of organophosphorus pesticide poisoning diagnosis in an acute organophosphate poisoning: report of three interesting cases and review of the literature the organophospates and other insecticides pyrethroid insecticides: poisoning syndromes, synergies, and therapy skin reactions to pesticides anticoagulant rodenticides non-anticoagulant rodenticides key: cord- -kx kmdej authors: herbers, alexandra; de pauw, ben e. title: acute myelogenous leukemia and febrile neutropenia date: - - journal: managing infections in patients with hematological malignancies doi: . / - - - - _ sha: doc_id: cord_uid: kx kmdej aggressive chemotherapy has a deleterious effect on all components of the defense system of the human body. the resulting neutropenia as well as injury to the pulmonary and gastrointestinal mucosa allow pathogenic micro-organisms easy access to the body. the symptoms of an incipient infection are usually subtle and limited to unexplained fever due to the absence of granulocytes. this is the reason why prompt administration of antimicrobial agents while waiting for the results of the blood cultures, the so-called empirical approach, became an undisputed standard of care. gram-negative pathogens remain the principal concern because their virulence accounts for serious morbidity and a high early mortality rate. three basic intravenous antibiotic regimens have evolved: initial therapy with a single antipseudomonal β-lactam, the so-called monotherapy; a combination of two drugs: a β-lactam with an aminoglycoside, a second β-lactam or a quinolone; and, thirdly, a glycopeptide in addition to β-lactam monotherapy or combination. as there is no single consistently superior empirical regimen, one should consider the local antibiotic susceptibility of bacterial isolates in the selection of the initial antibiotic regimen. not all febrile neutropenic patients carry the same risk as those with fever only generally respond rapidly, whereas those with a clinically or microbiologically documented infection show a much slower reaction and less favorable response rate. once an empirical antibiotic therapy has been started, the patient must be monitored continuously for nonresponse, emergence of secondary infections, adverse effects, and the development of drug-resistant organisms. the averageduration of fever in serious infections in eventually successfully treated neutropenic patients is – days. adaptations of an antibiotic regimen in a patient who is clearly not responding is relatively straightforward when a micro-organism has been isolated; the results of the cultures, supplemented by susceptibility testing, will assist in selecting the proper antibiotics. the management of febrile patients with pulmonary infiltrates is complex. bronchoscopy and a high resolution computer-assisted tomographic scan represent the cornerstones of all diagnostic procedures, supplemented by serological tests for relevant viral pathogens and for aspergillosis. fungi have been found to be responsible for two thirds of all superinfections that may surface during broad-spectrum antibiotic treatment of neutropenic patients. antibiotic treatment is usually continued for a minimum of days or until culture results indicate that the causative organism has been eradicated and the patient is free of major signs and symptoms. if a persistently neutropenic patient has no complaints and displays no evidence of infection, early watchful cessation of antibiotic therapy or a change to the oral regimen should be considered. only years ago, dealing with a patient with a disseminated malignant disease was relatively simple. there were no curative options and information on the inevitable dismal prognosis was not shared with the patient or his family. the mid sixties of the twentieth century witnessed the first successes of chemotherapeutic agents. this encouraged investigators to explore this route further, thereby escalating the dosage of the cytostatic drugs in the expectation of better results. it became rapidly clear that the destructive effects of cytotoxic compounds were not limited to malignant cells. infection has emerged as a prominent complication of chemotherapy, which was particularly worrisome in the sixties, a decade without powerful broad-spectrum antimicrobial agents. since a possible cure of the cancer was seen as the primary goal, complications of rigid cytotoxic regimens were taken for granted and when they occurred, treatment was more or less improvised. this situation remained unchanged until bodey [ ] pointed out that patients in remission of their underlying disease could die suddenly of an overwhelming infection during cytotoxic therapy-induced neutropenia. neutropenia was and remains defined as an absolute neutrophil count of less than . × /l ( /mm ) or a count less than . × /l ( , /mm ) expected to fall below . × /l ( /mm ) [ ] . he even showed a positive correlation between the severity and duration of neutropenia and the risk of acquiring a life-threatening bacterial infection. this risk appeared even more pronounced in individuals who were treated for an acute leukemia or lymphoma as these disorders interfered directly with vital components of the immune system. next to gram-negative bacilli, staphylococcus aureus earned a notably bad reputation [ ] . a few years later, schimpff and co-workers demonstrated convincingly that early administration of antimicrobial agents covering the above suspected pathogens while waiting for the results of the blood cultures saved lives. his so-called empirical approach became an undisputed standard of care [ ] . however, better options to manage infections encouraged hematologists to intensify their antileukemic regimens further in an attempt to improve the remission rates in previously refractory cases. these intensifications, in turn, inspired more thorough clinical research into potentially more effective antimicrobial regimens, which was facilitated by the booming development of new antimicrobial agents such as broad-spectrum synthetic penicillins, third and fourth generation cephalosporins, fluoroquinolones, and carbepenems in conjunction with a keen eagerness of the respective pharmaceutical companies to put their compounds to test in large clinical trials that were usually conducted by cooperative trial groups [ , ] . a cycle of several subsequent rounds of broader-spectrum antibiotics and further intensification of chemotherapeutic regimens has eventually lessened the mortal risk of neutropenia to only one of many problems in today's clinical practice. modern anti-leukemic therapy is inherently associated with ulceration of the pulmonary and gastrointestinal mucosa thereby allowing micro-organisms originating from the damaged mucosal tracts easy access to the body [ , ] . these pathogens may be part of the original indigenous flora but are commonly acquired during hospitalization [ ] . in the s, it was considered logical to prevent invasion of the body by indigenous flora by prophylactic administration of anti-infective agents. since such prophylactic agents were mainly targeted against the gram-negative enterobacteriaceae, a shift from gram-negative to gram-positive micro-organisms, including coagulase-negative staphylococci, viridans streptococci, and enterococci, as the primary cause of fever in neutropenic patients was seen [ ] [ ] [ ] [ ] [ ] [ ] [ ] . in the meantime, therapeutic regimens in the treatment of hematological malignancies have become so complex that use of surgically implanted venous access devices became universal in spite of the risk of catheter-associated infections and thrombosis [ , ] . an epidemiological survey among hospitalized patients treated for hematological malignancies between and in the united states showed that approximately % ( % in and % in ) of all microbiologically confirmed febrile episodes were due to gram-positive bacteria and % ( % in and % in ) due to gram-negative bacilli [ ] . this change in pathogens was facilitated by increased use of central venous catheters and other medical devices. introduction of immunomodulatory monoclonal antibodies into the therapeutic arena has extended the treatment-related immunodeficiency to t-cell functions and innate immunity. this, in turn, has brought viral and fungal infections, including pneumocystis jeroveci, into play, particularly when impaired cellular immunity coincided with prolonged, severe neutropenia [ , ] . the modern chemotherapeutic regimens designed to treat acute lymphoblastic leukemia incorporate high doses of corticosteroids. as a result, patients treated with such regimens are at increased risk of infections typically related to an impaired cellular immunity. in addition, allogeneic bone marrow transplantations have become a fully accepted treatment modality for many hematological malignancies. nowadays, infections still account for substantial morbidity and mortality among patients who undergo myeloablative therapy for a hematological malignancy. in spite of all changes in the spectrum of infectious agents, gram-negative pathogens remain the principal concern because their virulence accounts for serious morbidity and high early mortality rate [ , ] . administration of potentially curative chemotherapy is the starting point in treating acute leukemias. giving cytotoxic drugs is relatively straightforward since internationally accepted antitumor protocols have defined the optimal dosages. once the chemotherapy has been administered, the hematologist must wait patiently for the desired outcome a few weeks later. however, while the scientist in the hematologist has completed this first task, the general clinician in him or her has to step forward to monitor the patient, as the natural host defense system gradually disintegrates. close surveillance of the patients with attention to the emergence of infectious complications is mandatory. management of infections during this time of danger must be individualized because fixed protocols and algorithms are of limited usefulness given the complexity of infectious diseases management [ , ] . it is here that the science and art of medicine meet; listening to the patient's complaints and meticulous physical examinations constitute the crucial factors for timely therapeutic interventions and eventual success. this applies to both patients who are treated with intensive chemotherapeutic regimens and to recipients of a stem cell transplant. during this period of neutropenia, appropriate coordination of information coming from different sources is important, since, next to the patient, family members, nurses, microbiologists, pulmonologists, radiologists, and pathologists can assist in the timely discovery of an emerging complication. different cancer centers approach these tasks in different ways but it occurs to us that the hematologist who is responsible for treating the underlying hematological disease must also act as the captain of the ship. this coordinating role obliges him or her to have at least some basic knowledge of likely infection problems and, perhaps even more importantly, to have fine communication skills to keep all parties on board as well as incorrect on the same course. since the symptoms of an incipient infection are usually rather subtle due to the absence of granulocytes, teamwork is crucial to ensure that antibiotics are administered at the first signs or symptoms of infection [ ] . in most cases, fever defined as a single oral temperature of more than , °c ( °f) or a temperature of more than , °c ( , °f) for more than h, will serve as a trigger for action. at the onset of fever, attempts to identify the cause of fever deserve absolute priority (see table - ), immediately followed by institution of appropriate broad-spectrum antibiotic therapy preferably within one hour of fever [ ] . fever in a neutropenic patient is a warning sign that should be taken very seriously because self-limiting infection is virtually • consider determination of crp, galactomannan antigen, and viral serology nonexistent in neutropenic patients irrespective of whether they have been treated for acute leukemia or lymphoma or received a stem cell transplantation. in anticipation of the results of the diagnostic evaluation, fever denotes infection until proven otherwise. absence of phagocytic cells in combination with a damaged skin and mucosal surfaces allows micro-organisms residing at a superficial site of infection easy access to the bloodstream. under these circumstances, a relatively small inoculum, that easily can escape detection when limited volumes of blood are sampled for culturing, can cause a serious septic syndrome [ ] . therefore, withholding antibiotics while waiting for a blood culture to become positive is a bad idea, even though fever can be of noninfectious origin [ ] . a sudden onset of fever accompanied by chills, tachycardia with or without a drop in blood pressure, and tachypnea is associated with a higher rate of positive blood cultures. shock at the onset of fever is an ominous clinical sign but neither clinical manifestations nor the pattern of fever during neutropenia can serve as an indicator of a particular causative agent, not even when the most notorious pathogens such as pseudomonas aeruginosa or staphylococcus aureus are involved [ , ] . a substantial minority of patients with true infections will have an insidious onset of fever. although more frequently related to noninfectious causes than acute fever, a slow rise of temperature does not exclude an infectious origin, although gram-negative rods, viridans streptococci, and staphylococcus aureus are less prevalent amongst these patients. acute fever following transfusion is often related to the presence of irregular blood group antigens or to cytotoxic antibodies acquired during previous transfusions or a pregnancy [ ] . of note, relative bradycardia in patients who did not receive antiarrhythmic medication suggests either a viral or noninfectious origin of the fever. a possible relation between fever and frequently used drugs such as allopurinol, antibiotics, bleomycin, and cytarabine or with the underlying disease process itself should always be kept in mind [ , ] . a dysfunctional immune system is presumed to be responsible for the high rate of drug allergy in patients with active acute leukemia; the allergy may abate when complete remission is achieved [ ] . this phenomenon is well known in patients with infectious mononucleosis or acquired immunodeficiency syndrome. until recently, coagulase-negative staphylococcal bacteremia was thought to be entirely related to the use of central venous catheters but recent work points at mucosal sites as important portals of entry [ ] [ ] [ ] . the clinical spectrum of catheter-related infections ranges from asymptomatic bacteremia as a manifestation of intraluminal colonization or a process confined to the site of insertion to marked inflammation of the tunnel tract and septicemia with metastatic emboli in the skin and other organs. suspicion of a tunnel or exit line infection should arise when the catheter tract becomes painful, red, or swollen or when signs of inflammation are visible at the exit site. malfunction of the catheter, illustrated by problems drawing blood through the line, is a common first warning of a possible lumen infection [ , ] . in the selection of the initial antibiotic regimen, one should consider the type, frequency of occurrence, and antibiotic susceptibility of bacterial isolates recovered from other patients at the same hospital. in addition, the use of certain antibiotics may be limited by special circumstances, such as drug allergy, liver function disturbances, or renal insufficiency. despite numerous clinical studies, since the s, no single empirical antibiotic regimen has been shown to be superior for initial treatment of patients who become febrile during a neutropenic episode after therapy with chemotherapy drugs for hematological malignancies (see table - ) [ , , [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] . however, there is world-wide consensus that any initial antibiotic regimen should include drugs with reliable activity against escherichia coli, pseudomonas aeruginosa, klebsiella species, other enterobacteriaceae, and staphylococcus aureus [ ] . three basic intravenous antibiotic regimens have evolved: initial therapy with a single b-lactam, the so-called monotherapy; a combination of two drugs, a b-lactam with an aminoglycoside, a second b-lactam or a quinolone but without a glycopeptide; and, thirdly, a glycopeptide in addition to b-lactam monotherapy or combination. numerous extensive studies have shown that traditional combinations, consisting of an antipseudomonal b-lactam and an aminoglycoside, are not more effective than monotherapy in the empiric treatment of uncomplicated episodes of fever in neutropenic patients. a third or fourth generation cephalosporin, a carbapenem, as well as piperacillin-tazobactam, have been found to be effective single agents in the majority of cases [ , ] . it appears appropriate to reserve two-drug regimens for complicated cases or if antimicrobial resistance is a potential problem. the major disadvantages of an aminoglycoside are nephrotoxicity and ototoxicity, and the necessity to monitor serum levels [ ] [ ] [ ] . combination of drugs such as amphotericin b, cyclosporine, and cisplatinum with an aminoglycoside is best avoided because of their additive renal toxicity, whereas high sodium content may limit the simultaneous use of two b-lactam antibiotics in elderly patients. an extensive study by european organization for research and treatment of cancer -national cancer institute of canada [ ] showed unambiguously that vancomycin can be withheld and not administered empirically for persistent fever despite appropriate initial monotherapy or combination antibiotic treatment until the results of the cultures indicate the need for vancomycin. vancomycin must be included in an initial empiric regimen for patients known to be colonized with penicillin-and cephalosporin-resistant pneumococci, viridans streptococci, or methicillin-resistant staphylococcus aureus or in situations where b-lactam resistance is likely such as a catheter-associated cellulitis where coagulase-negative staphylococci predominate . the choice to implement a particular antibiotic regimen is, at least partly, based on the results of clinical trials as reported in the literature. yet, the results of such trials should be interpreted with great caution. definitions for response as well as inclusion and exclusion criteria for clinical study protocols are usually very rigid and quite different from common clinical practice [ , ] . conduct of clinical trials in febrile neutropenic patients was a booming business in the mid-seventies and eighties when many new broad-spectrum antibiotics became available. the data derived from these trials expanded our knowledge of the possible infectious complications tremendously. for instance, analyses of these studies revealed that only half of the patients who develop fever during neutropenia will have a clinically or microbiologically documented infection, the majority being pulmonary infiltrates and bacteremias (see table - ) [ , ] . furthermore, it was obvious that neutropenic patients without a documented infection generally defervesced within a few days, whereas those with a clinically or microbiologically documented infection showed a much slower and less frequent fever defervescence rate [ , , ] . this very consistent observation suggests that it might be prudent to select different antibiotic regimens for patients with different symptoms. although there is no statistically valid evidence to support a more individually tailored approach, it appears reasonable to assume that patients might benefit from timely administration of the antibiotics with the highest intrinsic potency against a given micro-organism. a known or suspected focus of infection, if present at the time of initial fever, could help in the selection of additional case-specific anti-infective agents because the location of an infection is, at least to a certain extent, predictive of specific infective pathogens (see table - ) [ ] . likewise, results of surveillance cultures and knowledge of clinically documented infection fever accompanied by a clinical infection, but pathogens cannot be identified, e.g., cellulitis, pneumonia microbiologically documented infection fever accompanied by a localized infection and microbiologically plausible evidence, or fever without a localized infection, but infectious agents can be demonstrated in a (blood) culture the common complications associated with particular antileukemic regimens may offer valuable input to individualizing appropriate initial treatment of a neutropenic patient with fever. a damaged integument probably plays a major etiologic role in virtually all infections that occur following aggressive cytoreductive therapy for a hematological malignancy but its involvement is most obvious in infections of the skin and gastrointestinal tract. the use of high-dose cytarabine in conjunction with the occurrence of diarrhea were found to be independent risk factors for streptococcal infections among patients evaluated during first episodes of neutropenic fever [ ] . it has been recognized that bacteremias due to oral streptococcus mitis and streptococcus oralis may result in serious complications such as sepsis or adult respiratory distress syndrome, which carry high mortality [ ] [ ] [ ] . similarly, bacteremias due to staphylococcus aureus, pseudomonas aeruginosa, and clostridium species as well as candidemias are more frequently encountered in patients with acute leukemia who suffer from neutropenic enterocolitis or typhlitis, the most serious disturbance of the delicate balance between mucosal damage and microbial flora in the setting of prolonged exposure to antibiotics after intermediate or high-dose cytarabine chemotherapy. the signs and symptoms of chemotherapy-induced enterocolitis or typhlitis vary considerably from patient to patient and include nausea, vomiting, abdominal cramps, and severe abdominal pain with virtually no formed bowel movements but accompanied by profuse, watery diarrhea. many patients are in such pain that they only gain relief from narcotic analgesics which, in turn, induce constipation by reduction of bowel movements. this may create a very alarming situation as the clinical picture in severe cases resembles that of gut perforation, acute pancreatitis, or even toxic megacolon. because there is a high mortality rate for surgical interventions in neutropenic and thrombocytopenic patients with acute leukemia, it is essential for physicians to be aware of the existence of neutropenic enterocolitis/typhlitis with the accompanying symptoms. ultrasonography or ct, showing pathological thickening of the bowel walls, may be useful to establish the diagnosis of typhlitis. patients treated for acute myeloid leukemia with a bowel wall thickness of more than mm had a significantly higher mortality rate than did those with a bowel thickness of less than mm [ ] . disproportional bacterial overgrowth in the gastrointestinal tracts of neutropenic patients with damaged mucosa can serve as a source of bacteremia for the endogenous gastrointestinal flora as well as for otherwise exclusively enteric pathogens such as clostridium septicum [ , ] and bacteroides fragilis. in contrast, salmonella species are rarely found in the stool or blood of granulocytopenic patients; these organisms are obviously not major players in this field. this is also true for pathogens like campylobacter and shigella species. therefore, an adequate antibiotic regimen for patients with abdominal symptoms should cover gramnegative rods but due consideration should be given to the use of compounds with activity against anaerobes. next to glycopeptides and carbapenems, metronidazole is an attractive adjunct to a standard monotherapy/combination regimen under these circumstances. pseudomembranous colitis caused by clostridium difficile [ ] [ ] [ ] [ ] [ ] constitutes a related but distinct entity that can be severe and even fatal. the stool should be tested immediately for clostridium difficile toxin if the diagnosis is suspected. enteric clostridia infections necessitate oral antibiotic therapy with either vancomycin or metronidazole. relapses are frequent and may follow cancer chemotherapy or courses with antibiotics such as clindamycin. relapse is harder to document because toxin may persist in the stool of successfully treated patients. diagnostic problems account for underestimating enteric viruses as causative agents in gastrointestinal infections. although a compromised cell-mediated immunity is known to predispose for parasitic and protozoan infections, their incidence is surprisingly low in patients who are treated for a hematological malignancy [ , ] . folliculitis and cellulitis are the most common manifestations of infectious processes in the skin. sometimes it is difficult to differentiate infectious lesions from drug-induced toxic skin eruptions. infection-associated erythema and swelling are usually mild but, if left untreated, infiltration and abscess formation will involve extensive areas of the skin with necrosis and gangrene. since the lesions associated with the various organisms are rather alike, a simple needle aspiration or biopsy should be performed to establish an accurate diagnosis as early as possible in the course of the disease. causative micro-organisms include streptococci, staphylococci, and, less commonly, gram-negative bacilli and fungi [ ] [ ] [ ] [ ] . localized infections of the skin, particularly in the face, are usually caused by gram-positive bacteria that arise more frequently in carriers of organisms like staphylococcus aureus. none of the standard empiric regimens is the optimal choice for treating skin infections caused by the prevalent but usually indolent nons. aureus gram-positive cocci that are often methicillin-resistant, but the morbidity from these infections should not be underestimated either. pseudomonas aeruginosa acquired in a hot jacuzzi may cause a folliculitis that occasionally progresses to a destructive ecthyma gangrenosum [ ] . this characteristic entity should be distinguished from similar lesions caused by other rare pathogens, such as actinomyces, stenotrophomonas maltophilia [ ] and fungi [ , ] as well as from pyoderma gangrenosum, a noninfectious cutaneous process in patients with a myeloid malignancy [ , ] . sweet's syndrome, a dense, tender infiltration by neutrophils of the dermis on the head, neck, and upper extremities is associated with a leukocytosis [ ] . varicella zoster is the leading dermatologic complication in patients with impaired cell-mediated immunity [ ] [ ] [ ] . if skin or mucous membrane lesions due to herpes simplex or varicella-zoster viruses are present, even if they are not the cause of fever, treatment with valacyclovir or another suitable antiviral is indicated with the intention to speed healing of lesions that could become potential portals of entry for bacteria and fungi. the results of several prospective studies do not indicate a general need for a glycopeptide as part of the front-line therapeutic regimen unless one has a particular reason to suspect the presence of methicillin-resistant staphylococcus aureus or penicillin-resistant viridans streptococci on the basis of local patterns of resistance or surveillance cultures. nevertheless, most physicians intuitively prefer an up-front glycopeptide-containing regimen to cover catheter-related infections as these are frequently due to coagulase-negative staphylococci, although early glycopeptide treatment does not contribute to improved survival from these usually indolent infections. hence, when coagulase-negative staphylococci are involved, a few days of watchful waiting for a possible clinical response and the results of the cultures will have no detrimental impact. most catheter-associated infections will respond to antibiotic therapy without the removal of the catheter. rotation of antibiotics through each lumen of multilumen catheters to avoid microbial sequestration in one of the lines and the use of antibiotic-containing heparin lock solutions to supplement systemic therapy have been proposed by some investigators but such practices remain controversial. pulling the catheter is most likely to be required for the cure if a concurrent venous thrombosis is found, the tunnel tract appears involved, or if the infection, regardless of the etiology, is recurrent, or if after several days of therapy an eventual response to antibiotics appears doubtful [ ] . gingivostomatitis and periodontal lesions occur frequently in patients with acute leukemia [ ] . oral mucositis is characterized by pain, edema, erythema, superficial lesions, pseudomembranous formation in conjunction with excessive mucous production, reduced saliva secretion, and bleeding. a wide array of pathogens can be found and include herpes simplex, gram-negative bacilli, streptococci, anaerobes, and candida species [ ] . with the introduction of aggressive chemotherapeutic regimens, hitherto unusual pathogens such as stomatococcus and aerococcus are increasingly seen in patients with mucositis. mixed and polymicrobial infections are more or less standard [ , ] . given the range of prevalent pathogens, there is little need to deviate from one of the standard regimens, although, on theoretical grounds one might prefer to select a carbapenem, fourth generation cephalosporin, or extendedspectrum penicillin given their superior intrinsic activity against viridans streptococci and pneumococci. the course of herpes simplex stomatitis is usually prolonged in patients treated for leukemia or lymphoma, and relapses are common [ ] . herpes simplex lesions are most commonly white painful plaques with or without serpiginous borders on the gums, tongue, buccal mucosa, or oropharynx and may be difficult to discriminate from oropharyngeal candidiasis and, indeed, co-infections do occur. swallowing can be so painful that saliva is expectorated and intake of food and fluids drastically reduced. it is not uncommon for oropharyngeal herpes simplex and candida infections to extend to the esophagus. although neither herpes nor candidiasis belong to the category of diseases that requires an empiric approach, it is generally accepted that early treatment with valacyclovir and fluconazole, respectively, is important to prevent extension into the esophagus and further dissemination, particularly among bone marrow transplant recipients. when the paranasal sinuses are involved in the infectious process, moulds have to be considered as possible causes. direct inspection of the nasal turbinates and a computer-assisted tomographic scan of the sinuses can be helpful to establish or reject the diagnosis. management of pulmonary infiltrates that are responsible for % of all fatal infections in febrile neutropenic patients is complex [ ] [ ] [ ] . the importance of classic clinical complaints of cough, pain, and dyspnea should not be neglected but bronchoscopy and radiological examination of the chest by a computerassisted tomographic scan represent the cornerstones of all diagnostic procedures. typically, chest radiographs performed early in the evolution of infection in patients with profound granulocytopenia fail to show infiltrates. it may take more than days for the infection to generate enough necrosis with hemorrhage and edema to produce a visible infiltrate. the critical decision faced by the clinician at the bedside of patients with pulmonary infiltrates is whether to undertake invasive procedures such as bronchoscopy with or without bronchoalveolar lavage, transbronchial biopsy, transthoracic aspiration, thoracoscopy-guided biopsy, or open lung biopsy. the exact role of these diagnostic procedures in the optimal management of patients is still controversial because the yield depends on the collaboration and skills of various specialists. moreover, concurrent thrombocytopenia precludes simple invasive diagnostic procedures such as transbronchial biopsies in many patients. the radiologic pattern of a possible infiltrate is often suggestive of its cause. a diffuse opacity, usually of both lungs, is seldom of bacterial or fungal origin. although viruses and pneumocystis jeroveci typically cause diffuse, bilateral pulmonary infiltrations, it should be kept in mind that a similar picture of pneumonitis can be seen secondary to radiation, fluid overload, cytotoxic drugs such as methotrexate, cytarabine and bleomycin, and in pulmonary hemorrhage. pneumocystis jeroveci pneumonia is manifested in patients with deficient cellular immunity as fever, progressive hypoxemia with dry cough, and dyspnea, typically beginning after discontinuation of corticosteroid therapy given for other reasons [ ] . high-dose trimethoprim-sulfamethoxazole with adjuvant corticosteroids for hypoxemic patients (po < mmhg) has become the preferred therapy for these infections [ ] . alternatives include intravenous pentamidine, oral dapsone in combination with trimethoprim, or oral atovaquone suspension alone. antiviral drugs are indicated only if there is clinical or laboratory evidence of viral disease. with the exception of a cytomegalovirus-related pneumonitis in allogeneic bone marrow transplant recipients with graft-versus-host disease, there appears to be no need for empiric coverage of respiratory viruses, such as respiratory syncytial virus, influenza [ , ] , and adenoviruses. ganciclovir, valganciclovir, and foscarnet have established activity in the treatment of cytomegalovirus infection and their timely use might be lifesaving. mycoplasma pneumoniae with or without cold agglutinins is remarkably infrequent in patients treated for leukemia. in more acutely ill patients, the possibility of acute lung injury following transfusion of a cellular blood product or respiratory distress syndrome related to streptococcal sepsis should be considered. patients with an infection by streptococcus mitis, which has been linked with severe mucositis and high-dose cytarabine are at particular risk [ , ] . the incidence of acute respiratory distress syndrome in such cases is more than % and mortality is substantial. the pathophysiology of adult respiratory distress syndrome following streptococcal bacteremia in a neutropenic patient is poorly understood. probably several factors are involved, such as deleterious effects of sepsis superimposed on preexisting tissue damage. even patients who had received appropriate antimicrobials at the onset of fever were reported to experience shock and death [ ] [ ] [ ] . therefore, in addition to antibiotics, corticosteroids should be considered in the management of patients affected by ards and streptococcal bacteremia. bacterial infections of the lung, accompanied by bacteremia in about % of cases, usually create infiltrates on a computer-assisted tomographic scan that are confined to one or more lobes. pneumonias caused by pseudomonas aeruginosa and staphylococcus aureus do have a bad reputation but enterobacteriaceae [ , ] , haemophilus influenzae and streptococcus species are hardly less dangerous. given the uniformly poor outcomes of pulmonary infections in clinical trials, the empiric use of a combination of antibiotics is recommended with the addition of vancomycin in centers that face resistance of s. pneumoniae to penicillin and macrolides. outbreaks of legionella pneumophila, an infection characterized by patchy interstitial or nodular pulmonary infiltrates and sometimes accompanied by headache or gastrointestinal symptoms, have been observed among compromised patients in units with contaminated water systems [ ] . therefore, if a case of legionellosis is encountered, other patients with similar symptoms on the same ward should be treated with a macrolide or a fluoroquinolone from the start of antimicrobial therapy. a nodular pattern of pulmonary infiltrates should lead the physician to consider the possibility of atypical pneumonia or, more commonly, a pulmonary fungal infection. in the latter case, diagnostic procedures rather than immediate institution of antifungal drugs should be given priority. especially in patients with concomitant impairment of the cell-mediated immunity, pulmonary aspergillosis has to be distinguished from tuberculosis. infections with mycobacterium tuberculosis in patients with impaired cell-mediated immunity are manifested as either localized pulmonary disease or devastating miliary tuberculosis. nontuberculous mycobacteria are still rather rare in patients with acute leukemia, but the introduction of purine analogues such as cladribine and fludarabine, which cause severe and prolonged depression of cellular immunity, may change this picture in the near future [ ] . urinary tract infections are astonishingly uncommon in patients who are treated for leukemia or lymphoma and, since gram-negative bacteria are the predominant urinary tract pathogens, the choice for a single broad-spectrum b-lactam is fully justified. malignant otitis externa is a very serious infectious complication that can emerge after administration of aggressive chemotherapy for a hematological malignancy. at the outset, the patient will complain of a painful, discharging ear, and physical examination will reveal a reddened edematous ear canal. local maceration and humid conditions favor the growth of pseudomonas aeruginosa which, indeed, can be isolated frequently from swabs taken from superficial lesions of the external canal. untreated, the infection will penetrate into underlying soft tissues, threatening the retromandibular and parotid area. likewise, spread to the middle ear, the mastoid air cells, and adjacent temporal bone is possible. once osteomyelitis becomes established, extension to the base of the skull with invasion of the cranial nerves and local thrombosis poses a direct danger to the patient's life. a computer-assisted tomographic scan may be helpful to identify tissue damage in the early phase. prolonged antibiotic therapy with ceftazidime, ciprofloxacin, or other antipseudomonal antibiotics in combination with surgical debridement constitutes the treatment of choice [ ] . occasionally, a similar clinical picture can be the result of an infection by staphylococcus aureus or aspergillus fumigatus. in such cases, surgery should be combined with an antistaphylococcal penicillin or vancomycin, or with voriconazole, respectively. an insidious onset of fever accompanied by headache and confusion might be indicative of meningitis when causation by leukemia or lymphoma has been excluded by cytologic examination of the cerebrospinal fluid. in cases of infection, the cerebrospinal fluid is usually clear with moderate protein elevation. the prevalent pathogens are listeria monocytogenes, cryptococcus neoformans, and toxoplasma gondii [ ] . recovery of one of listeria monocytogenes [ ] and cryptococcus neoformans from blood cultures should, provided that no intracranial hypertension is detected, always prompt a lumbar puncture even in the absence of neurological symptoms. considering their low incidence and the relatively reliable diagnostic possibilities, there is no need to cover for these infections with a specific empiric regimen. outpatient management of infections in patients with hematological malignancies is discussed in more depth in chap. . when potent oral broad-spectrum antibiotics became available in the late eighties, many clinicians felt tempted to use these drugs in the treatment of febrile neutropenic patients. several groups around the world assessed the options and limitations of this seemingly revolutionary approach [ ] [ ] [ ] systematically. these analyses showed that it is possible to define risk factors that can be used to classify patients into low or high-risk categories. in fact, these studies offered nothing more than identification of objective parameters that corroborate the gut's feeling of the experienced clinician. since the time of bodey [ ] , it was already obvious that patients with absolute neutrophil count between , and . × /l ( - /ml) carry a minor risk compared to those with a granulocyte count of less than . × /l ( /ml). but now other risk factors have been identified. patients with concurrent mucosal damage or impaired cellular immunity, as well as those with clinically documented infections or unstable vital signs, are at high risk and deserve increased vigilance. patients with these additional risks cannot be considered candidates for antibiotic treatment on an out-patient basis. the vast majority of patients with acute leukemia are considered high-risk patients and should continue to receive intravenous broad-spectrum antibiotics in the hospital or similar setting. the remaining low-risk patients, namely those with unexplained fever who are clinically stable, may be safely treated with oral antibiotics provided that they have been seen at a qualified medical center promptly after the onset of fever [ , ] . the possible use of antibiotic prophylaxis does not pre-empt the need for a thorough check-up but limits the choice of drugs that can be used for treatment. patients with increasing granulocyte counts are considered to be better candidates for outpatient therapy than are patients without an indication of bone marrow recovery. among the oral regimens that have been evaluated are ofloxacin, ciprofloxacin, and ciprofloxacin plus amoxicillin-clavulanate. it is crucial to make sure that the patient is informed about the risk of unremitting fever during a neutropenic episode and that he or she fully understands the importance of seeking immediate medical advice in case any unexpected incident occurs. vigilant observation at home by a relative or professional health care worker and prompt access to appropriate medical care must be available h per day, days a week [ ] [ ] [ ] [ ] . as an alternative to initial outpatient therapy, early discharge with continued outpatient therapy for selected patients may be considered after a brief admission during which intravenous therapy is initiated, fulminant infection is excluded, and appropriate culture specimens are taken [ , ] . two studies have demonstrated that children who lack signs of sepsis and severe mucositis, who are afebrile for > h, who have neutrophil counts of > cells/mm (> . × /l), and who are at low risk for complications may have their intravenous antibiotic treatment safely stopped to be substituted by oral cefixime [ , ] . after starting empiric antibacterial treatment, fevers will persist or return in about one third of patients. the average duration of fever in serious infections, in eventually successfully treated neutropenic patients is - days (table - , fig. - ) [ , , , , [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] . although fever can be inconvenient for the patient, it is important to realize that it is part of the body's defense system [ ] . indeed, some retrospective studies have suggested that fever is associated with improved survival and shortened disease. uncontrolled studies have reported an association of increased mortality with the absence of fever in polymicrobial or gram-negative sepsis and in elderly patients with community acquired pneumonia [ , ] . so, when the body temperature remains above normal during or days on apparently effective broad-spectrum antibiotics, this should not be considered a complete waste of time, particularly not if the time is used for an appropriate diagnostic work-up. it should be kept in mind that empiric administration of antibiotics is only meant as an immediate cover for rapidly fatal bacteria such as gram-negative rods and staphylococcus aureus, thereby, so to say, buying time for consideration of the next therapeutic interventions and for waiting for the results of the diagnostic procedures. when the results of the cultures become available and the infection has had time to blossom clinically, there is a more solid basis for decisions on necessary adjustments of an antibiotic regimen. unfortunately, all large, randomized clinical trials on empiric antibiotic therapy in the febrile neutropenic patients during the past years have been pharmaceutical company-driven for purposes of attaining governmental agency approval [ , ] . as a consequence, the design of these studies focused primarily on the efficacy of a particular drug in comparison with another drug or combination of drugs. according to the protocols for these trials, only patients who survived the febrile episode without a change in the allocated regimen could be labeled as successes, whereas any change in therapy, independent of the trigger, was denoted a failure, even if the patient survived unscathed and the infection was eradicated. therefore, modification of the test regimens was discouraged, which constitutes a rather artificial situation, as clinicians are inclined to adjust an antibiotic regimen for no other reason than a subjective feeling of unease with the original choice of antibiotics. changes often reflect impatience, nervousness, and lack of confidence on the part of the clinician concerned over the still febrile neutropenic patient rather than any deficiency in the original antibiotic regimen used. when restrictions surrounding a clinical trial do not apply, juggling antibiotics against an undulating line on a temperature chart is a well-known frequent occurrence on a ward full of patients suffering with hematological malignancies. indeed, in daily practice, many modifications are not based on objective criteria and are made outside office hours, i.e., by less experienced physicians on call [ , ] . however, it is generally recognized that exposure to many different antibiotics as a result of haphazard changes of regimens enhances the risk of drug-related adverse events and seldom improves the outcome of the patient under treatment. moreover, such a policy of endless therapeutic trials of antibiotic changes might wrongly decrease the perceived need for further diagnostic procedures in poorly responding patients. since there is evidence from clinical trials on what to do after the empiric phase, some experts have been promoting the so-called algorithms of planned progressive antibiotic therapy to treat neutropenic patients with fever. a planned progressive strategy involves adjustment of therapy every - days, until the patient becomes febrile or until all the potential causes of infection are covered by the best available microbial agents, irrespective of the development of additional symptoms. it is clear that algorithms featuring planned progressive therapy are destined to lead to overtreatment with unnecessary expenses and drug exposures [ ] . it appears more intellectually attractive not to rely on fixed algorithms but to weigh several different, patient-specific parameters, including fever and clinical response, as a guide for modification of an empiric regimen. it goes without saying that spending time at the bedside is crucial for those who feel attracted to the role of attending physician because careful observation often provides early clinical clues for a rational adaptation of the original empirical antibiotic regimen. the need for individualization is not only dictated by variations in the signs and symptoms of the patient that accompany persisting fever but also by differences in skills and expertise amongst attending specialists in various centers. for example, centers with excellent and interested departments of medical microbiology and pathology will rely more heavily on their findings than do centers with poorly functioning departments, whereas units with an active radiology service may benefit from the locally available know-how in this particular field. once an empiric antibiotic therapy has been started, the patient must be monitored continuously for nonresponse, emergence of secondary infections, adverse effects, and the development of drug-resistant organisms. this implies that the start of antibacterial agents cannot be seen as an impetus to stop diagnostic procedures. daily blood cultures are certainly justified as long as patients remain febrile and when a new temperature peak occurs because breakthrough bacteremia or fungemia may develop. close monitoring of sites that are prone to infection should start before the onset of fever and has to be continued after empirical antibacterial therapy has commenced. subtle changes must bring diagnostic tools into play to confirm or exclude the presence of an infectious focus. regular ct-scans of the chest, preferably in combination with serological monitoring for aspergillosis antigen, have an established value in patients who are at increased risk of fungal infections [ ] . as a rule, approximately % of patients without a focus of infection, which includes % overall with positive blood cultures, will show some clinical improvement after days of broad-spectrum empiric coverage in spite of persisting fever. in most cases, defervescence will follow rapidly. elements that should be incorporated in clinical decision making include the course of fever and clinical condition with special attention to the vital signs, evolving symptoms of infection in relation to the granulocyte count, c-reactive protein levels, antigen monitoring, and risk for relapses of latent viral infections determined by pretreatment antiviral titers. the results of all cultures taken at the onset of fever have to be assessed and it is recommended to analyze surveillance cultures, if any, to identify possibly colonizing resistant organisms. without clinical deterioration or proof of an infection caused by a micro-organism resistant to the initial antibiotic regimen, persisting fever after - h of empiric therapy in and of itself is an unsatisfactory basis for changing the original empirical antibacterial regimen. it is better to alter the regimen only when there are objective reasons to do so: deterioration of vital signs, isolation of a resistant pathogen without clinical improvement, persistence of a pathogen, antibiotic-related adverse events, occurrence of a new focus of infection or progression of an existing focus in the absence of granulocyte recovery, unexplained fever persisting for more than days, new fever, a new pathogen or recognition of a local outbreak with a resistant organism (tables - and - ). in most patients, antimicrobial therapy can be adjusted objectively on the basis of clinical or microbiologic findings but such an individually tailored approach requires careful daily assessment of all possible parameters collaborating with consulting specialists, including microbiologists, pulmonologists, and radiologists. in contrast to the moment of the onset of fever, there is ample time for deliberation and contemplation in a situation where the patient's fever persists for or more days while on antibiotics because the origin of fever is obviously not a rapidly fatal microorganism that needs immediate treatment. fever that persists for more than days suggests that the patient has a nonbacterial infection, a resistant bacterial infection, a second infection, or a drug fever [ , ] . despite extensive cultures, only around % of all febrile patients will be shown to have microbiologically defined infections. in % of patients, organ involvement is already apparent with the initial fever and an additional % will show clinically defined infection within the next h (see fig. table - ) . patients belonging to each of these three categories may have either a microbiologically documented infection, a clinically documented infection, or an explained fever. all these factors that are partly subjective and partly objective can be exploited to steer the modification of an empiric regimen when there is a perceived need to do so. ultimately, only - % of patients with a persisting unexplained fever should require a continued empirical rather than a clinical or microbiologically directed approach after h of broad-spectrum antibacterial therapy. whichever modification is planned, it cannot be overemphasized that maintenance of appropriate antigram-negative cover is mandatory as long as a patient is febrile and neutropenic. when the patient is improving or stable, there appears to be no imminent need to adjust an antibiotic regimen. depending on the micro-organism isolated, a change to an oral regimen could be considered with caution. when a gramnegative isolate is identified, broad-spectrum antibiotic coverage should be maintained in full dose. whereas the clinical relevance of a blood culture positive for gram-negative bacilli is never a matter of controversy, the implication of recovery of particular gram-positive cocci is less clear. single blood cultures positive for s. aureus, s. pneumoniae, or enterococcus faecalis in neutropenic patients should be regarded as significant and indicative of the need for further treatment. viridans group streptococci, with an average mortality of - %, are perhaps the most feared among the bacteremias today [ ] [ ] [ ] . although viridans streptococci are common blood contaminants in the general population, positive blood cultures in patients with oral mucositis should not be disregarded, certainly not when s. mitis or related streptococci are isolated [ , ] . isolation of rare micro-organisms should prompt evaluation of the appropriateness of the starting antibiotic regimen, especially when the patient is not responding optimally. on the other hand, isolation of in vitro resistant organisms such as coagulase-negative staphylococci and, more rarely, stenotrophomonas maltophilia, from the blood of a clinically, evidently improving patient, pose an interesting challenge. many would be inclined to modify the initial regimen but in many cases other bacteria that were not recovered on the culture plate may have been the culprits in the current fever. a blood culture that yields candida species or another fungus should be taken very seriously and dictates immediate institution of antifungal therapy [ ] [ ] [ ] . the availability of the candins has extended the therapeutic options [ ] [ ] [ ] . adaptations of an antibiotic regimen in a patient who is clearly not responding is relatively straightforward when a micro-organism has been isolated; the results of the cultures, supplemented by susceptibility testing, will assist in selecting the proper antibiotics. all clinical trials so far have demonstrated consistently that patients diagnosed with a clinically documented infection respond much slower and remain febrile for a longer time than those without a focus of infection [ , , ] . moreover, due to problematic penetration into avascular sites, infections associated with abscesses or prosthetic devices usually respond poorly to antimicrobial therapy. attending physicians should, therefore, be more hesitant to change antibiotics in patients who are not deteriorating. on the other hand, there are indications that early addition of specific agents might be useful for more rapid control of clinically documented infections. for instance, considering the probable involvement of anaerobes, switching to a carbapenem, if not given initially, or addition of metronidazole to a standard anti-gram-negative regimen, appears a logical choice when fever is accompanied by abdominal symptoms. in cases with a clinically documented site who do not improve or stabilize, coverage of micro-organisms known to prevail at the involved site of infection (see table - ) appears appropriate. clinically documented infections that emerge later during the course of febrile neutropenia carry a dismal prognosis and are presumed to be related to the occurrence of resistant microorganisms, including invasive fungi, in combination with persisting immunodeficiency often as a result of a refractory underlying disease. if the patient with an unexplained fever clinically improves or remains stable after h of empirical treatment and re-evaluation by physical examination and diagnostic tests yields no new information, and no isolate was found, the initial antibiotic regimen can be continued or can be switched to an oral compound. the latter option is more reasonable clinically if neutropenia is expected to resolve within the ensuing days. if vancomycin is a component of the initial antimicrobial regimen, withdrawal of the drug should be considered if the results of the cultures do not support its use. deteriorating cases without any microbiological or clinical sign of infection pose a dilemma. unexplained fever accompanied by deterioration can imply that the patient has a nonbacterial infection or a noninfectious cause of fever, but foremost, a resistant bacterial infection or the emergence of a second infection should be taken into account [ , ] . an initial response rate of about % may be expected in patients with shock, compared with % in patients without shock, which suggests the possible presence of an undetected toxin-producing pathogen in the former. addition to the original empirical antibacterial regimen is mandatory in critically ill patients, independent of the level of fever. escalation might include filling theoretical gaps in antibiotic spectrum and enhanced monitoring for any changes in the patient's condition. under these circumstances, the selection of agents should be guided by knowledge of locally prevalent virulent pathogens and actual susceptibility patterns, which implies the necessity of close cooperation with the local microbiology laboratory. addition of vancomycin appears reasonable in view of the fact that the spectrum of antibacterial drugs in traditional empiric regimens usually does not cover coagulase-negative staphylococci, methicillin-resistant staphylococcus aureus, enterococci, and some strains of penicillin-resistant s. pneumoniae and viridans streptococci. on the other hand, liberal use of vancomycin has confronted the medical community with vancomycin-resistant enterococci and staphylococci, which has led to increasing use of new agents like quinupristindalfopristin and linezolid in the treatment of febrile neutropenic patients. when the starting regimen consists of a single, broad-spectrum b-lactam, addition of an aminoglycoside is an attractive option to provide a better coverage when infections by resistant gram-negative rods are suspected. however, it has to be emphasized that development of resistance during therapy is extremely rare and that aggressive gram-negative organisms typically cause the infection to deteriorate rapidly to a stage beyond cure within a few days after first fever in most cases. hence, if the local resistance pattern or a particular concern in an individual patient prompts the use an aminoglycoside for resistant gram-negative bacteria, then aminoglycosides should be prescribed from the start in optimal doses with monitoring of the peak and trough serum levels. clinical deterioration in a persistently neutropenic patient with unexplained fever is an important but rather rare event in daily practice and applies to only a quarter of the overall % of cases that deteriorate while on broadspectrum antibacterial treatment. moreover, it is noteworthy that the success rate of empiric modifications is less than %, whereas more than % of cases will respond to specifically customized modifications [ ] . invasive fungal infections are encountered in up to % of autopsies in patients with hematological malignancies. fungi have been found to be responsible for two thirds of all superinfections, which surface during broad-spectrum antibiotic treatment of neutropenic patients. more than years ago, when diagnostic capabilities were virtually nonexistent and the choice of effective antifungal agents limited, two prospective, randomized trials laid the scientific foundation for the addition of systemically active antifungals even though neither study was adequately powered to reach a statistically valid conclusion [ , ] . this strategy appeared to reduce the incidence of invasive fungal infections in patients without any further sign of a clinically documented infection. solid statistical evidence to support the validity of this empiric approach was never obtained subsequently in further placebo-controlled trials because empirical antifungal treatment had become widely accepted as the standard of care. this so-called empiric antifungal therapy has remained popular as it seemed to make life easy for clinicians. the lack of reliable diagnostic tools combined with very poor outcomes of invasive fungal infections that were not timely treated contributed greatly to this popularity [ ] [ ] [ ] . however, in most cases in , antifungals prescribed empirically for fever alone are unnecessary because invasive fungal infection is present in a minority of cases. a better understanding of the pathophysiology of invasive fungal disease in combination with use of better diagnostics allows for a more individualized approach [ , ] . an optimal diagnostic work-up in conjunction with careful clinical observation will likely render routine empiric antifungal therapy superfluous in most cases because appropriate application of presently available diagnostic tools enables timely pre-emptive institution of appropriate antifungal therapy by experienced clinicians [ ] [ ] [ ] . the most common initial presentation of invasive aspergillosis is unremitting fever despite broadspectrum antibacterial treatment, accompanied eventually in most patients by pulmonary infiltrates or sinusitis. clinicians should suspect the diagnosis in a patient with pleuritic pain, hemoptysis, or a localized pleural rub. the halo sign (a dense central nodule with surrounding less dense infiltrate) on a computer-assisted tomographic scan of the chest, though not pathognomonic, is highly suggestive of an early phase of pulmonary aspergillosis or other mould pneumonia in immunosuppressed patients [ ] [ ] [ ] . even when gramnegative pathogens, including pseudomonas aeruginosa and enterobacter cloacae, are isolated from the sputum or blood of such patients, aspergillosis should be the leading consideration when nodular chest ct findings are present. if no infiltrate is found in a high-risk patient with persisting fever, the investigation should be repeated within a few days, preferably supported by bronchoalveolar lavage if indicated and additional assays such as screening for the presence of galactomannan in the blood [ ] . even in patients with aspergillosis who are responding adequately to antifungals, the computerassisted tomographic chest scan will usually show some enhancement of the lesion when the neutrophils return with eventual development of cavitation within the infiltrate, the so-called air-crescent sign [ ] [ ] [ ] . this finding is suggestive of aspergillosis, although mucormycosis and other moulds may cause an identical picture. whether the increased incidence of non aspergillus mould is due to more extensive use of the new azoles like voriconazole or to the use of more intensive immunosuppressive treatment schemes remains to be seen [ , ] . isolation of an aspergillus species from sputum or bronchoalveolar lavage specimens connotes either invasive infection or bronchial colonization, the latter conferring high risk for invasive aspergillosis. when voriconazole or posaconazole have been used as prophylaxis, it is sensible to select an antifungal compound with a different mode of action when therapy becomes mandatory [ , ] . surgery is indicated for patients in whom lesions near the pulmonary hilus pose a direct threat of invasion of a major vessel with the risk of fatal hemorrhage or for debridement of dead tissue after a period of antifungal therapy [ ] . low risk patients who test negative for aspergillus in all diagnostic procedures do not need to be started on intravenous antifungals. treatment should be stopped for those patients started on antifungals pending diagnostic test results. a more conservative wait-and-see approach can be implemented successfully once clinicians learn to accept that negative diagnostic results constitute sufficient evidence that there is no fungal infection in many persistently febrile neutropenic patients [ , ] . fluconazole given as prophylaxis has virtually eliminated infections with candida albicans. however, candida species or other fungi are still occasionally identified as causes of disseminated infections in humans, albeit with a shift from candida albicans to nonalbicans species [ , ] . a candidemic patient typically presents with an irregular fever sometimes accompanied by polymyalgia and polyathralgia. in about % of cases, characteristic pinkishpurple, nontender subcutaneous nodules may arise anywhere on the body. biopsy specimens should be cultured and histologically screened at multiple levels in an attempt to establish a final diagnosis. candida ophthalmitis is seldom seen in leukemic patients since the distinctive retinal exudates are the result of an inflammatory response that involves granulocytes. upon the return of the neutrophils or tapering of corticosteroids, complaints of abdominal discomfort and elevation of alkaline phosphatase levels with or without hepatosplenomegaly may emerge. at this stage, an abdominal ultrasound or computer-assisted tomographic scan will display rather distinctive multiple abscesses in the liver and/or spleen, known as "bull's-eyes" [ , ] . mortality from an invasive yeast infection may be as high as %, particularly when the start of antifungal therapy has been delayed. trichosporonosis and fusariosis can produce a clinical syndrome identical to candidemia [ ] [ ] [ ] . up to now, empirical antimicrobial therapy has been the backbone of improving survival of febrile neutropenia in leukemic patients. hematopoietic growth factors have been studied as adjunctive therapy for febrile neutropenic patients in several randomized, controlled trials. g-csf (filgrastim) and granulocytemacrophage colony-stimulating factor (sargramostim) when used as part of the treatment of febrile neutropenic patients were shown to consistently shorten the duration of neutropenia defined as a neutrophil count below . × /l ( /ml). however, the duration of absolute neutropenia, i.e., count of less than . × /l ( /ml), was not influenced, which might help to explain why neither a decrease in infection-related mortality rates nor a significant effect on morbidity, including duration of fever and use of anti-infectives, were observed [ , ] . therefore, the use of growth factors should be restricted to complicated cases for which there appears to be no rational alternative therapeutic option [ ] [ ] [ ] . this concept also applies to the use of granulocyte transfusions. transfusion of high numbers of granulocytes harvested after administration of g-csf, with or without dexamethasone, to a donor is done by some clinicians without there being any unequivocal evidence of its efficacy. patients with prolonged profound neutropenia and an uncontrolled clinically documented infection, such as severe cellulitis or sinusitis, appear to be the primary candidates for treatment with granulocyte transfusions, whereas administration of a colony-stimulating factor (g-csf) should be preferred when a return of the neutrophils is imminent. significant toxicities in granulocyte-transfusion recipients include transmission of cytomegalovirus, alloimmunization associated with fever, graft-versus-host reactions if granulocytes are not irradiated, progressive platelet refractoriness, and, possibly, respiratory insufficiency associated with concomitant administration of amphotericin b. new approaches with agents designed to protect the mucosa, like recombinant human interleukin and keratinocyte growth factor palifermin, show promising results in terms of reducing severity of mucositis and occurrence of fever and bacteremia in neutropenic patients [ ] [ ] [ ] . it is widely believed that antibiotic treatment should be continued for a minimum of days or until culture results indicate that the causative organism has been eradicated, infection at all sites has resolved, and the patient is free of major signs and symptoms. ideally, the neutrophil count should be > mm ( . × /l) before treatment is stopped [ ] . when no infection has been identified after days of treatment and the patient has become afebrile for h in association with a neutrophil count that has exceeded cells/mm ( . × /l), antibiotic therapy may be stopped. in addition, if a persistently neutropenic patient has no complaints and displays no clinical, radiological, or laboratory evidence of infection, cessation of antibiotic therapy or a change to oral antimicrobials should be considered after days without symptoms. if antibiotics are discontinued while the patient is still neutropenic, the patients must be monitored closely and intravenous antibiotics restarted immediately with recurrence of fever or any other evidence of bacterial infection, since the initial infection may have only been suppressed, not eradicated. one should consider continuous administration of antibiotics throughout the neutropenic period in patients who have profound neutropenia, mucous membrane lesions of the gastrointestinal tract, or any other identified risk factor. some experts suggest, in patients in whom hematological recovery cannot be anticipated, a change from the therapeutic regimen to a prophylactic scheme after weeks of therapy with intravenous antimicrobials. when the suspicion of a noninfectious cause of the fever is high, interruption of antibiotic therapy after ~ days seems warranted in clinically well patients without any evidence of infection apart from persisting fever. under these conditions, meticulous monitoring has to be maintained to guarantee the patients timely protection against subsequent infections that are likely to occur. the decision to start antifungals may appear complex but is not as difficult as the decision to discontinue. if a systemic fungal infection has been identified, the course of antifungal therapy will be determined by the causative agent and the extent of the disease. in patients with pulmonary infiltrates or other suspicious lesions, it is essential to see a clinical and, preferably, a radiological response before one ponders cessation of antifungal therapy. however, if no fungal infection is found, it is not clear how long antifungal drugs should be administered [ ] . for clinically well patients with prolonged neutropenia, it is suggested that antifungal agents can be stopped after weeks of treatment, provided that no conspicuous lesions can be found by clinical evaluation or by computer-assisted tomographic scanning of the chest and the abdominal organs. in the patient who appears ill or is at high risk, continuation of antifungal therapy throughout the neutropenic episode is recommended. conversely, when neutropenic fever subsides, the patient is clinically well and computer-assisted tomographic scan of the abdomen and chest reveals no suspicious lesions; antifungals may be discontinued, particularly when the criterion for commencing antifungal therapy had been simply fever unresponsive to antibiotics. this approach also applies when the presumptive diagnosis becomes questionable during the course of granulocytopenia. when a patient diagnosed with and treated for a proven or probable invasive fungal disease requires further chemotherapy or bone marrow transplantation, protection against the offending pathogen has to be provided, even if the patient responded completely to initial antifungal therapy. the risk of relapse of invasive fungal disease is so high that secondary prophylaxis is warranted, requiring that a full dose of the most effective antifungal is administered [ , ] . after introduction of routine ct scanning it became apparent that solitary lesions caused by invasive fungal disease are rare and this observation reduced the enthusiasm for surgical interventions. however, if the number of lesions is limited or a difficult-to-treat pathogen, such as a zygomycosis, has been found, surgical excision has to be considered, especially when the lesions are located close to a large vessel [ ] . modern chemotherapy offers hope of a cure to many cancer patients, but it confronts the medical community with new challenges continuously. infection remains an inevitable side-effect of the myeloablative therapy for acute leukemia and is the principal cause of morbidity and mortality amongst these patients. optimal care can be delivered only by those who pay scrupulous attention to the patient's clinical condition and are aware of the evolving therapeutic and diagnostic modalities. it cannot be denied that time remains an important factor in the management of infectious complications but we must try to distinguish more accurately between patients truly in need of immediate therapy and those who are not. fixed treatment algorithms are only acceptable if they allow individual interpretation and reasonable deviations. maintaining guidelines that dictate second line treatment of a population in which more than half of the patients do not have true infection is not justifiable in view of potential adverse events and the economical burden. the demand for an alternative strategy, built on clinical skills, modern and more accurate laboratory tests and imaging techniques, has become apparent and a broad application of this principle may change the approach to antimicrobial treatment in neutropenic patients completely. overuse of antimicrobial agents, both antibacterial and antifungal, has become all too common in the belief that broader coverage will benefit the patient. unfortunately, prescription of antimicrobials according to a preset scheme may give a false sense of security with reduced or delayed diligence in pursuing a diagnosis. diagnostic considerations should prevail whenever patients do not respond satisfactorily to an antibacterial regimen. in addition, neutropenia can no longer be seen as the major compass to steer antimicrobial therapy in a febrile patient because neutropenia is not the one and only factor predisposing for infection. a damaged integument and impairment of t cell-mediated immunity have altered the incidences of causative micro-organisms. this change not only has consequences for the selection of antimicrobial agents but may also foster development of totally different future treatment modalities such as biological response modifiers that might reduce the need for antimicrobial agents. undoubtedly, unwarranted widespread use of antibiotics 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haematological malignancies recombinant human interleukin and bacterial infection in patients with haematological malignant disease undergoing chemotherapy: a double-blind placebo-controlled randomised trial palifermin for oral mucositis after intensive therapy for hematologic cancer palifermin: a keratinocyte growth factor that reduces oral mucositis after stem cell transplant for hematological malignancies can antibacterial therapy be discontinued in persistently febrile granulocytopenic cancer patients? duration of antifungal treatment and development of delayed complications in patients with candidaemia an approach to intensive antileukemic therapy in patients with previous invasive aspergillosis impact of previous aspergillosis on the outcome of bone marrow transplantation surgical resection of persistent pulmonary fungus nodules and secondary prophylaxis are effective in preventing fungal relapse in patients receiving chemotherapy or bone marrow transplantation for leukemia key: cord- -cz ruqxx authors: scott, danny w.; miller, william h.; griffin, craig e. title: dermatoses of pet rodents, rabbits, and ferrets date: - - journal: muller & kirk's small animal dermatology doi: . /b - - - - . - sha: doc_id: cord_uid: cz ruqxx nan subcutaneously and repeated every weeks until the disorder being treated is cured. it has also been reported that ivermectin is effective topically (one or two drops applied between the scapulael.fv " special precautions must also be observed when using topical medications. first, these animals routinely remove topical agents through their grooming behaviors. second, these small creatures are prone to hypothermia after shampooing and dipping, thus, aqueous solutions should be kept at body temperature, and the animals must be kept warm and dry and away from drafts after treatment. avoid alcohol-based sprays. in addition, inhalation/aspiration pneumonia is a potential problem. thus, the face is best avoided when dips are administered. the structure and function of small exotic mammal skin are similar to those described in chapter , hair growth in rodents (not guinea pigs) and rabbits occurs in periodic orderly waves originating on the ventrum between the front legs and spreading dorsally and caudally. in some rabbits, thickened patches of skin can be associated with the variation in hair growth cycles. this is more common in young rabbits and becomes less obvious with increasing age. the mean thickness in these patches is mm as compared with mm in normal skin. histologic examination of the patches reveals increased size of hair follicles and increased vascularity. notable histologic differences include ( ) the absence of epitrichial sweat glands in rodents and ( ) the structure of the tail epithelium of the mouse and rat, which features orthokeratosis with a stratum granulosum at the follicular osia and parakeratosis without a stratum granulosum in the interfollicular areas. hamsters have large glands on either flank, which are visible as dark brown patches that are more prominent in male animals. these flank or hip glands are sebaceous and are used for marking territory. in sexually aroused males, the haircoat over the glands becomes matted from secretions and readily visible, and the animals scratch the areas as if they are pruritic. these findings may be interpreted as signs of skin disease by some owners. gerbils have a yellowish tan, midventral scent gland, which is also sebaceous, more prominent in male animals, and occasionally mistaken as a cutaneous abnormality. rabbits have a mental or chin gland (which is sebaceous in nature) with which they mark their territory, normal ferrets typically have visible accumulations of brownish cerumen around the external auditory meatus. in addition, normal ferrets can have several comedones on the tail. most rodents are burrowing animals that spend most of their time in the wild seeking food and escaping predators. when they are placed in sterile environments with ad libitum feeding and no danger of predators, they are left with little to do except to chew on themselves or on others. in addition, male rodents tend to be territorial and aggressive. self-inflicted trauma or that inflicted on cagemates can be triggered or amplified by crowding. some other normal behaviors may be misinterpreted as pruritus. a rabbit rubbing its mental, or chin, gland on a cage or furniture is only marking its territory. likewise, a guinea pig scooting or dragging its perineal area on the ground is usually scent-marking, although in some male animals, the glandular secretions can become impacted and cause irritation. male hamsters may clean and fuss with their flank glands. staphylococci, especially staphylococcus aureus , are frequently isolated from the skin, the ears, the nostrils, and the haircoat of rodents and rabbits." , not surprisingly, s. aureus is a common opportunist and cause of skin infections in these species. finally, these small creatures, especially mice, rats, guinea pigs, and rabbits, are frequently used for studying models of human diseases (e.g., hereditary hypotrichoses and ichthyoses in mice and rats), for examining the pathogenesis of various dermatoses also seen in humans (e.g., contact hypersensitivity and candidiasis in guinea pigs), for evaluating therapeutic agents used in various human dermatoses (e.g., treatment of malassezia dermatitis in guinea pigs and the use of retinoids in rhino mice), for studying percutaneous absorption and various aspects of dermatopharmacology (e.g., the mouse tail assay for studying epidermal drug effects), and for screening the potential irritancy or sensitization of topical agents (e.g., the guinea pig draize test for contact allergens and the rabbit skin test for topical irritants)." in the wild, chinchillas keep their haircoats clean and healthy by bathing in fine volcanic dust.!? a similar dust is commercially available (chinchilla dust, or fuller's earth) and should be provided daily." , , the dust is poured to ern deep in a metal pan and left in the animal's cage for about minutes. chinchillas deprived of their dust baths are prone to abnormalities of the haircoat and skin. chinchillas kept in a warm (warmer than °f) humid environment develop matted fur. ferrets have active sebaceous glands that contribute to their distinctive odor and somewhat greasy feeling coat. occasional small, red-brown waxy deposits can be found on normal skin. during breeding season, intact males have increased sebaceous secretions, to the point of having a yellowish discoloration of the undercoat, a very oily fur, and quite a musky odor. frequent bathing may strip essential oils from the skin, resulting in keratinization disorders and pruritus.!? owners should be encouraged to use mild shampoo no more frequently than once monthly, if possible. bacterial skin infections are uncommon in the ferret and are usually caused by s. aureus or streptococcus spp." infections are usually secondary to bite wounds (especially on the neck of female ferrets during breeding season, perpetrated by aggressive male animals as a prelude to coitus) or the pruritus associated with ectoparasites. there may be superficial and follicular (fig. - ) lesions or deep abscesses and fistulae, staphylococcal or streptococcal cellulitis of the neck may be associated with dental disease and mandibular osteomyelitis.f' diagnosis is based on cytologic examination. treatment consists of a regimen of various combinations of topical antimicrobials ( % hydrogen peroxide or . % to % chlorhexidine), surgical drainage, and the administration of systemic antibiotics (table - ) . actinomycosis ("lumpy jaw") is rarely reported in ferrets.!" affected animals have nodules or abscesses in the neck, and fistulae and discharge of thick green-yellow pus may be seen. dermatophytosis appears to be rare in ferrets." m. canis and t. mentagrophytes are the most common causes, and young animals are most frequently affected. lesions consist of annular areas of alopecia, broken hairs, scale, and varying degrees of erythema and crusting. pruritus is usually absent. diagnosis is confirmed by microscopic examination of affected hairs and fungal culture. therapy consists of topical application of antifungal agents and environmental clean-up as described for cats. griseofulvin is usually not needed. dermatophytosis in ferrets is a potential zoonosis. blastomycosis was diagnosed in a ferret with chronic cutaneous plaques and ulcers. i? histoplasmosis was diagnosed in a "see references , , , , , , , . • ferret with multiple subcutaneous nodules." coccidioidomycosis was diagnosed in a ferret with a persistent draining tract of the stifle. an outbreak of otitis extema and pinnal necrosis in association with mites (otodectes?) and yeast (malassezia?) infection was reported." a painful, rapidly progressing crusting and necrosis of the pinnae spread, if untreated, onto the face. mites and yeast were found in smears. histopathologic findings included suppurative epidermitis, numerous surface yeast, and hemorrhagic necrosis with thrombosis. treatment with ketoconazole ( mg/ferret, q h, per os) and a polypharmaceutical otic preparation was rapidly effective. otodectic mange (ear mites) is common in ferrets. , , , affected ferrets may manifest no clinical signs or variable degrees of excessive cerumen production. pruritus, inflammation, and secondary bacterial infection are uncommon. diagnosis is confirmed by finding otodectes cynotis in ear swabs. treatment is accomplished with topical acaricides or topical ivermectin ( jlg/kg divided between the two ears);'? injectable ivermectin is the treatment of choice. in one study, a topical treatment with either tresaderm ( drops in ears q h for days, sequence repeated after a week of no treatment) or ivermectin (ivomec diluted : in propylene glycol; jlg/kg divided equally in both ears, repeated in weeks) was more effective than the subcutaneous administration of ivermectin ( jlglkg, repeated in weeks). ivermectin should be used with caution in pregnant jills.l" . when ivermectin was administered at to weeks of gestation, an increased incidence of congenital defects, such as cleft palates, was seen. however, when ivermectin was administered after weeks of gestation, no problems were noted. fleas (especially ctenocephalides felis felis) are commonly found on ferrets.'? animals may be asymptomatic or have cutaneous reaction patterns similar to flea bite hypersensitivity in cats. ferrets manifesting presumed flea bite hypersensitivity have a pruritic papulocrustous dermatitis over the rump, ventral abdomen, and caudomedial thighs, or a self-induced, symmetric alopecia over the rump, flanks, ventral abdomen, or medial thighs (fur-mowing) in which the skin appears normal. treatment strategies must include the ferret; in-contact ferrets, cats, and dogs; and the environment, as described for cats. fipronil spray has been found to be safe and effective for ferrets." sarcoptic mange is uncommon in ferrets and has two clinical presentations: ( ) intense pruritus and dermatitis over the face, the pinnae ( fig. - a) , and the ventrum and ( ) pruritic pododermatitis. . in the pododermatitis form, the feet are swollen, erythematous, and crusted, and the claws may be dystrophic. affected ferrets may actually slough claws or digits. diagnosis is confirmed by finding sarcoptes scabiei mites in skin scrapings. however, mites can be extremely difficult to find, so response to miticidal therapy is often used as a diagnostic procedure. treatment includes % lime sulfur dips (weekly until weeks after clinical cure) or ivermectin injections. demodicosis was reported in two unrelated ferrets that were living in the same household and receiving long-term treatment with a glucocorticoid-containing otic ointment.p' the ferrets exhibited excessive cerumen in the ears and pruritus, alopecia, comedones and orange discoloration of the skin behind the ears and on the ventrum. skin scrapings and ear smears revealed numerous short mites that resembled demodex gatoi. amitraz dips were curative, and no side effects were reported. ferrets housed outdoors may occasionally have cysts, abscesses, or fistulae in the neck associated with infestation by hypoderma sp. or cuterebra sp. larvae. , treatment includes careful surgical removal of the larva and routine wound care. flystrike (especially wohlfahrtia vigil) can be a problem for commercial ferret ranchers and outdoor ferrets." eggs are commonly laid on the face, neck, and flanks of young ferrets, causing irritation and subcutaneous abscesses. ticks may occasionally be found on ferrets, especially around the head and the ears.!? treatment is as described for cats. ferrets can be experimentally infected with dracunculus insignis and have been used as an animal model for studying dracunculiasis.t? lesions consist of tender swellings, which abscess and develop fistulae. lesions occur most commonly on the legs. the ferret is susceptible to canine distemper virus." , , typical cutaneous findings include an erythematous rash under the chin and in the inguinal region; swelling and brownish crusts on the chin, lips, nose, and the periocular area; and swollen, hyperkeratotic nose and footpads ( fig. - ) . some ferrets develop an orange-tinged dermatosis on the anus and inguinal region. adrenocortical neoplasia and hyperplasia are the most common causes of progressive bilaterally symmetric alopecia in the ferret. , , a, , two authors indicated that this disorder accounted for about % of all the ferrets examined in their practice.v the condition was initially diagnosed as cushing's syndrome. however, other classic clinical signs (polyuria, polydipsia, and polyphagia) and hematologic, biochemical, or urologic abnormalities associated with cushing's syndrome are rarely present. in addition, basal plasma cortisol levels are usually within the normal range and adrenal function tests (adrenocorticotropic hormone [acth] stimulation, dexamethasone suppression) have not been useful in separating normal from diseased ferrets.l" , , , the contralateral adrenal gland is not atrophied. these considerations in concert with the common occurrence of vulvar enlargement in affected female ferrets and return to male sexual behavior in castrated male ferrets suggested that the endocrine abnormality was in the adrenocortical production of sex hormones." median plasma concentrations of -hydroxyprogesterone, androstenedione, and estradiol are significantly higher in ferrets with hyperadrenocorticism than in normal ferrets." ninety-six percent of affected ferrets had a high concentration of at least one of these three hormones, but only % had high concentrations of all three hormones. these concentrations decreased after adrenalectomy. the etiology of hyperadrenocorticism in ferrets is unknown, but several hypotheses have been put forth. , early neutering may lead to metaplasia of undifferentiated gonadal cells in the adrenal capsule, in a dutch study, a significant linear correlation was found between the age at neutering and the age at the time of diagnosis, a hyperadrenocorticism in ferrets is common in the united states, but apparently rare in the united kingdom, suggesting that diet (prepared foods in the united states, whole prey in the united kingdom), photoperiod (housed indoors in the united states, outdoors in the united kingdom), and genetics (u,s, population more inbred) may also playa role, clinical signs are seen between and years (average ) of age and with equal frequency in females and males. in most cases, clinical signs are first noted in the spring. the initial abnormality is usually a bilaterally symmetric, noninflammatory alopecia that usually begins on the tail and tail base ( fig. - ) and progresses to the ventral abdomen, caudomedial thighs, dorsal surface of hind paws, lumbosacral region, and shoulder blades. in some animals, the alopecia may come and go. in such cases, clinical signs appear in the spring and spontaneously regress in the autumn. however, clinical signs recur with increasing severity each spring and eventually persist.l? , most affected males and females have a strong musky odor. vulvar enlargement is common in female animals , as is return to male sexual behavior in castrated males. in more chronic cases, the back of the neck, top of the head, and trunk become alopecic, and the body skin becomes thin and hypotonic ( fig. - ). about % to % of affected ferrets are reported to have varying degrees of pruritus, mostly over the dorsum between the shoulder blades. , , a when present, pruritus is often severe and unresponsive to glucocorticoids and antihistamines. numerous comedones are occasionally found on the tail, and phlebectasias may be seen. lethargy, muscle atrophy, splenomegaly, and return to male behavior (in neutered males) occur in about %, %, %, and %, respectively, of the cases.f mammary gland hyperplasia has been reported, and stump pyometras are not uncommon. stranguria may be present in up to % of affected males. a the enlarged adrenal gland can be palpated in about % of cases. diagnosis is usually confirmed by ultrasonographic examination or exploratory laparotomy.lo· . ultrasonography may fail to diagnose about % of the cases and may not be cost-effective in a practice situation." in rare instances, the adrenal glands appear normal on both ultrasonographic examination and exploratory laparotomy.t- urinary cortisol: creatinine ratios were significantly higher in ferrets with hyperadrenocorticism than in normal ferrets.p however, this is not specific for hyperadrenocorticism, and affected ferrets can have normal ratios.v' eighty-four percent of affected ferrets have unilateral adrenal tumors, whereas % have bilateral adrenal tumors." of the unilateral tumors, over % are in the left adrenal gland. . . a histologically, % of the tumors are nodular hyperplasia, % are adenocarcinomas, % are adenomas, and % are "normal." all tumors larger than ern diameter were adenocarcinornas.v in % of the patients with bilateral tumors, each gland had a different histologic type of tumor.s- a all male ferrets with a return of male sexual behavior had adenocarcinomas." in one study, % of the ferrets with hyperadrenocorticism had concurrent insulinomas. this emphasizes the importance of performing a complete exploratory. the "adrenal panel" (clinical endocrinology laboratory, department of comparative medicine, university of tennessee, knoxville, tn, - - ) may give diagnostic results in % of the cases.s" however, results are not always diagnostic, and the test may not be cost-effective in a practice situation.f- a in most animals, the treatment of choice is unilateral adrenalectomy. . , clinical improvement is evident within to weeks, and complete recovery is usually seen within months. hair regrowth usually occurs in the opposite direction to which it was lost. in two cases in which a unilateral adrenalectomy was performed and no hair growth had occurred for to months, a secondary exploratory revealed tumors on the remaining adrenal.p seventeen percent of the animals with unilateral tumors develop tumors on the remaining adrenal, resulting in a recurrence of clinical signs within months." ferrets with bilateral adrenal tumors should have the largest adrenal gland completely removed, along with % to % of the other one (subtotal bilateral adrenalectomyi.v- a even following subtotal bilateral adrenalectomy, % of the ferrets had recurrence of clinical signs within to months.f> medical treatment has been used, usually unsuccessfully, when surgery could not be performed, or when, after surgical removal of a neoplastic adrenal, the remaining adrenal gland also became neoplastic and clinical signs recurred.!? mitotane (o,p'-ddd) has been used at mg orally, once daily for days, then every days until clinical cure. administration of the drug is then stopped. if clinical signs recur, o,p'-ddd is given at a weekly maintenance dose of mg. to facilitate administration, the o,p'-ddd is mixed with com starch and -mg doses are put in gelatin capsules. however, mitotane is rarely effective.!" a ketoconazole has been ineffective when given orally at mglkg every hours. o • a anecdotal reports indicate that leuprolide (lupron, tap pharmaceuticals), when given at jlglkg subcutaneously, every days, is very effective for the treatment of hyperadrenocorticism in ferrets. response is usually seen by the third injection and is complete by months. once maximum response is achieved, the interval between injections is extended. ferrets with aggressive adrenal carcinomas may not respond. hyperestrogenism is well recognized in the female ferret.l" . . however, this disorder is rare because large-volume ferret breeders are neutering and descenting the animals at weeks of age. an ovarian remnant may be suspected in a neutered female with signs of estrus. jills allowed to remain in estrus during the breeding season are susceptible to the toxic effects of estrogen on bone marrow. affected jills develop pancytopenia and varying degrees of alopecia. clinical signs accompanying the pancytopenia include pale mucous membranes, petechial or ecchymotic hemorrhages, anorexia, depression, and weight loss. the alopecia is bilaterally symmetric, beginning on the tail, the perineum, the abdomen, the medial thighs, and the rump and progressing cranially ( fig. - ) . vulvar enlargement is a constant finding. untreated animals die of infectious or hemorrhagic complications. treatment is often unrewarding. ovariohysterectomy; intravenous blood transfusions; administration of dexamethasone, anabolic steroids, and systemic antibiotics; and supportive care have rarely been reported to result in recovery, but transfusions may need to be repeated several times for to months.!" . . testicular neoplasia is rare, because most large-volume breeders neuter male ferrets at weeks of age. a sparse haircoat and a bald tail were reported in association with an interstitial cell carcinoma of the testicle in one ferret.!? total body alopecia and pruritus were reported in association with a testicular sertoli's cell neoplasm in another ferret.'? breeding season alopecia is commonly seen, especially in the female and less frequently in the male ferret, during the period of sexual activity from march through august. , . . , photoperiod plays an important role in this condition, because even neutered ferrets are affected. bilaterally symmetric alopecia affects the tail, the perineum, the ventral abdomen, the rump, and occasionally, the periocular region and the paws. affected ferrets are otherwise healthy, and spontaneous hair regrowth occurs in the fall. seasonal shedding is seen in spring and early summer.f- , , variable degrees of hypotrichosis or alopecia may be seen over the trunk and resolve spontaneously within a month or two. telogen defluxion is occasionally seen to months after a stressful circumstance (high fever, severe illness, surgery, and anesthesial.l"' bilaterally symmetric hypotrichosis or alopecia is most prominent on the trunk ( fig. - ) . although anecdotal reports suggest that hypothyroidism is a common cause of endocrinelike alopecia in ferrets," the authors and others , l have never made such a diagnosis, and know of no documented cases. some data have been published on basal serum thyroxine and triiodothyronine levels and thyroid function tests in normal ferrets. l • some authors believe that the most common cause of alopecia and dull, dry haircoat in ferrets is poor dietary practices." food passage averages to hours in ferrets; thus, diets high in protein and fat but low in fiber are important. a low-fat diet may result in a dry, dull haircoat. biotin deficiency (from excessive feeding of raw eggs) can result in bilaterally symmetric alopecia in ferrets." , , severe intestinal parasitism (especially toxascaris leonina) can produce variable degrees of hair loss and scaling in ferrets." contact dermatitis can occur with frequent use of shampoos or insecticide sprays.p focal areas of alopecia have been seen at the site of previous injections.p the authors have seen an occasional ferret with presumptive atopy. affected animals manifested symmetric, nonlesional pruritus over the trunk, the rump ( fig. - ), and the paws. fleas were not present, hypoallergenic diets were ineffective, and response to glucocorticoids or chlorpheniramine was good. one of the authors (whm) has seen one food-hypersensitive ferret with the same clinical signs. the ferret was normal when fed a commercial hypoallergenic diet for cats (innovative veterinary diets [ivd] venison). erythema annulare centrifugum was reported in a ferret with hyperadrenccorticism." parallel linear bands of erythema were present over the dorsolateral lumbosacral area and encircling the tail (fig. - ) . the dermatitis disappeared after days of treatment with a commercial omega /omega fatty acid-containing product (derm caps). the blue ferret syndrome is an unusual idiopathic condition affecting ferrets of either sex, neutered or intact." the abdominal skin shows bilaterally symmetric bluish discoloration. affected ferrets are asymptomatic. the condition regresses spontaneously during a few weeks. in the authors' experience, this condition is most commonly seen in ferrets that have been clipped for surgery or to provide access to veins during the resting phase of the hair cycle. the clipped area remains hairless for a long time, then suddenly begins to tum blue. it appears that hair follicles are making melanin, which will be incorporated dermatoses of pet rodents, rabbits, and ferrets • figure - . a, self-induced alopecia over the rump of a ferret with a pruritic dermatosis resembling atopy. b, same ferret. self-induced hypotrichosis of hind paw. into growing hairs. soon after the ferret's skin turns blue, hair regrowth begins (within to weeks). self-inflicted facial excoriations (burrowing) may be seen in ferrets that have inadequate bedding, nesting material, or hiding spots.'? intact females may pull out hair to use as bedding.'? skin neoplasms are fairly common in the ferret, and the majority are benign. lo, in one large survey." the skin was the third most common site for primary neoplasms in ferrets (about % of all neoplasms). one of the most frequent of these is the mast cell tu-mollo, , lesions may be solitary or multiple and may come and go over time. mast cell tumors present as papules or nodules (see fig. - b), which vary from skin colored to yellow, brown, or red. they may be firm, soft, or cystic. some lesions are pruritic. lesions may occur anywhere, but are most commonly reported on the neck and dorsal trunk. similar to the situation in cats, most cutaneous mast cell tumors in the ferret are benign.p: basal cell tumors and sebaceous gland neoplasms (especially on the head, neck, limbs, tail and the shoulder [see fig. - c)) are also common in ferrets.!" , most previously diagnosed "basal cell tumors" were probably sebaceous epitheliomas.l? epitrichial sweat gland carcinomas (especially on the tail and the groin), chondromas (especially on the tail), chondrosarcomas (especially on the tail), and squamous cell carcinomas (especially on the digit and the lip [see fig. - d) ) have also been reported on numerous occasions.fv'" cutaneous epitheliotropic lymphoma was reported in an -year-old ferret with a month history of progressive alopecia and pruritic dermatitis." the ferret had generalized alopecia and erythema, excoriations, erosions, crusts, and ulcerated plaques on the head, trunk, limbs, paws, footpads, and tail. the nasal planum and footpads were depigmented, and the claws were onychogryphotic. isotretinoin ( mglkglq h, per os) produced a marked improvement after days, but the ferret was euthanized due to renal failure associated with pyelonephritis. other cutaneous neoplasms reported in ferrets include papilloma, fibroma, fibrosarcoma, malignant fibrous histiocytoma, histiocytoma, hemangioma, hemangiosarcoma, neurofibroma, neurofibrosarcoma, myxoma, myxosarcoma, ceruminous gland adenocarcinoma, lymphoma, and rhabdomyosarcoma. the treatment of choice for cutaneous neoplasms is surgical excision. bacterial skin infections, usually associated with s. aureus, are common in gerbils. , , these infections are virtually always secondary to other perhaps less obvious conditions, especially trauma (cage-related injuries and bite wounds), ectoparasite infestations, and accumulated harderian gland secretions.v infections resulting from cage-related injury are typically seen on the nose and the muzzle (from rubbing on the cage and equipment or burrowing in abrasive litter), whereas those caused by bite wounds typically occur around the head, the tail, the rump, and the perineal area. those secondary to accumulated harderian gland secretion typically begin on the nose and the periocular area." staphylococcal infections may be superficial (alopecia, erythema, oozing, crust, and scale) or deep (abscess, fistula, and ulcer), and are usually nonpruritic. treatment of bacterial dermatitis includes some combination of eliminating predisposing causes, daily topical cleaning with a % hydrogen peroxide or . % to % chlorhexidine, and administration of systemic antibiotics (see table - ). demodicosis has rarely been reported in gerbils. , lesions occurred on the face, the thorax, the abdomen, and the limbs and were characterized by alopecia, oozing, crusts, scales, and secondary bacterial infection. demodex merioni was isolated in skin scrapings. details concerning pathogenesis and treatment are presently unpublished. a dermatosis associated with acarus farris was reported.v' alopecia, scaling, and thickening of the skin began on the tail, spread to the hind paws, then to the head. pruritus and excoriation were seen with chronicity. ivermectin injections were ineffective, but environmental changes (decreased humidity, new litter, new food) and a single application of fipronil spray were curative. although gerbils tolerate crowding better than do most rodents, they chew or "barber" the hair of cagemates," the affected areas appear clipped or shaved, and rarely are any actual skin lesions present. the dorsum of the tail and the top of the head are most frequently involved. bald nose describes a clinical condition common to the gerbil, which is characterized by alopecia on the muzzle and the dorsum of the nose." , , , there are usually no skin lesions. the alopecia has been attributed to mechanical trauma associated with rubbing against cages and cage equipment, and burrowing in abrasive bedding. placing animals in a smooth-sided enclosure or aquarium with soft bedding such as shredded paper may be curative. bald nose may also be an early stage of the nasal dermatitis (sore nose [see fig. - e]) associated with accumulated harderian gland secretion." , , , these secretions are rich in porphyrins and accumulate about the nasal and facial areas, and apparently lead to the development of an irritant contact dermatitis and secondary staphylococcal infection. the animal's failure to groom the areas adequately leads to irritation, which can then lead to self-inflicted trauma and secondary infection. the stress of overcrowding and high humidity may contribute to the development or the severity of the condition. this condition is common in research colonies and commercial breeding colonies. the earliest clinical sign is the accumulation of a reddish brown discharge and crust around the nose, the lips, and less frequently, the eyes. this porphyrin-rich secretion exhibits an orange fluorescence when viewed under ultraviolet light (wood's light). there is frequently protrusion of the nictitans. this is followed by alopecia and, if not treated, dermatitis, pruritus, and secondary staphylococcal infections. lesions can then spread to the paws, the legs, and the ventrum. therapy consists of topical or systemic antibiotic therapy for secondary staphylococcal infection, if present, and housing with access to sand. surgical removal of the harderian gland is effective but less practical.s an occasional litter of gerbils is born with abnormalities of hair growth and pigmentation," typically, the back is completely bald, the surrounding haircoat is thinned or patchily alopecic, and the haircoat shows profound leukotrichia. the majority of affected animals fail to thrive and die at the time of weaning. surviving gerbils develop a normal haircoat as they mature. the etiopathogenesis of this condition is unknown. the ventral scent gland in gerbils can become inflamed from being rubbed against wood chips or other abrasive bedding.' in addition, impaction of these glands can lead to self-mutilation. when relative humidity is greater than %, the normally sleek and smooth gerbil haircoat often appears greasy and stands out." pine shavings can also cause this appearance." a gerbil's tail skin is very thin, and easily peels off. if the tail skin is lost, the exposed tail becomes necrotic and sloughs off. , alternatively, the bare tail can be surgically removed where the skin stops. the skin is the second most common site of neoplasms in gerbils. , skin neoplasms are typically seen in aged animals ( to years of age). the most commonly reported skin neoplasms in the gerbil are melanocytomas and melanomas (especially of the paw and the pinna), , sebaceous gland adenomas (especially of the ventral scent gland), , and squamous cell carcinoma (especially of the ventral scent gland [see fig. - f] and the pinna)." . other reported skin neoplasms in gerbils include papilloma, fibrosarcoma, and neurofibroma." diagnosis of skin neoplasms is based on exfoliative cytologic study or biopsy, and the treatment of choice is surgical excision. bacterial skin infections are common in guinea pigs. - . these infections are virtually always secondary to other factors, especially trauma (cage-related injuries and bite wounds) and ectoparasites. those secondary to bite wounds are typically found around the head, the tail, the rump, and the genital area and are associated with s. aureus. abscesses are occasionally associated with corynebacterium kutscheri, streptococcus zooepidemicus (especially abscesses on the neck), streptobacillus moniliformis, or yersinia pseudotuberculosis,": , . a staphylococcal cellulitis characterized by thickening and hyperkeratosis of the lips was associated with feeding of tough, fibrous hay.!" treatment of these infections includes elimination of predisposing factors, surgical drainage, daily topical applications of % hydrogen peroxide or . % chlorhexidine, and systemic antibiotic administration (see table - ). an exfoliative dermatitis resembling staphylococcal scalded skin syndrome was reported in a guinea pig colony, chiefly among female animals in the late stages of gestation.!? bacterial contamination and the abrasive effects of rusty cage floors were suggested as initiating factors. alopecia was first noted on the ventral abdomen. after a few days, the skin became acutely erythematous and painful. affected skin subsequently fissured and large thick flakes were desquamated. the condition spontaneously resolved after a course of to days. s. aureus was isolated from the skin, the pharynx, the trachea, and nasal washings of affected animals. skin biopsies revealed intragranular acantholysis and cleavage within the epidermis with minimal inflammation. an exfoliative toxin produced by the staphylococci was reported to cause the skin lesions. the most common skin disease associated with s. aureus infection (occasionally corynebacterium pyogenes) in the guinea pig is pododermatitis (bumble foot). - . predisposing factors include trauma to the footpad, poor sanitation, obesity, aging, and vitamin c deficiency, affected animals react vigorously when the feet are palpated. the footpad is markedly enlarged, edematous, and erythematous (see fig. - g) . crusts, ulcers, and hemorrhages may be present on the volar surfaces. in chronic or severe cases, the disease process extends to phalangeal and metatarsal or metacarpal bones and joints. most guinea pigs with pododermatitis have a poor prognosis, because treatment is difficult and systemic amyloidosis is a frequent consequence of chronic infection. pododermatitis can be prevented by frequently cleaning cages and changing bedding, using cages with smooth surfaces, instituting individual weight control, and providing routine foot care. early lesions may respond to management changes and daily topical therapy (povidoneiodine or chlorhexidine scrubs, soaks, and ointments under a bandage). extensive infections also necessitate systemic antibiotics (see table - ). dermatophytosis is common in guinea pigs and is almost always caused by t. mentagrophytes. lo lesions typically begin as scaling, broken hairs, and alopecia on the nose, which spread to the periocular, forehead, and pinnal areas. in severe cases, the dorsal lumbosacral area is also affected (fig. - ), but the limbs and the ventrum are usually spared. pruritus is usually minimal or absent. some animals have more inflammatory lesions characterized by erythema, follicular papules, pustules, crusts, and pruritus. diagnosis is confirmed by microscopic examination of affected hairs and fungal culture. treatment is usually accomplished with the topical application of antifungal agents ( % lime sulfur, % chlorhexidine, or . % enilconazole dips weekly until the animal is cured). - . griseofulvin is not usually needed, but can be given at mg/kg every hours orally until the animal is cured. - o • the administration of griseofulvin should be avoided in pregnant animals .. s, dermatophytosis in guinea pigs is an important zoonosis.!? cryptococcosis was reported in a single guinea pigy the animal had a plaque on the dorsum of the nose, which became crusted and ulcerated, and spread into the nostrils. skin biopsy was diagnostic, and the animal was euthanized. guinea pigs have been used as an experimental model for studying the pathogenesis of cutaneous candidiasis., skin lesions are readily produced by the application of candida albicans under occlusion and consist of erythema, pustules, oozing, and crusts. guinea pigs have also been used as an experimental model for studying the pathogenesis and treatment of malassezia dermatitis.p skin lesions are readily produced by the application of inocula of malassezia (pityrosporum) ovale and consist of erythema, edema, crusts, and scales. hairless guinea pigs have been used as an experimental model for studying the pathogenesis of recurrent herpes simplex infection." intracutaneous inoculation of herpes simplex virus produces pustules and crusts, which spontaneously resolve and can be reactivated by local trauma. poxvirus-like virions were demonstrated during the electron microscopic examination of specimens from two guinea pigs with a chronic, crusting cheilitis."? trixacarus (caviacoptes) caviae is a burrowing sarcoptiform mite and, arguably, the most common cause of ectoparasitic skin disease of guinea pigs. . . . trixacariasis is always the first differential diagnostic suspect in intense pruritus in guinea pigs. the mite is similar to s. scabiei in appearance but is smaller in size (average, ilm in length), and the female mite has a dorsal rather than terminal anus. t. caviae is similar in size and appearance to notoedres spp. but differs by lacking prominent, sharp, dorsal cuticular spines. the areas most commonly affected include the dorsal neck and the thorax (see fig. - h ), but in severe cases, the entire body may be involved (fig. - a) . early clinical signs include pruritus, erythema, and traumatic alopecia. chronic lesions include lichenification, hyperplgmentation, crusts, thick, whitish to yellowish scales (see fig. - b) , and brittle, easily epilated hair. the extreme irritation and self-mutilation cause lethargy, anorexia, progressive emaciation, and death associated with bacterial infection or immune-mediated renal disease. hyperesthesia, behavior such as furiously running in circles and blindly walking into objects, and seizures can be seen and may be triggered by examining the affected animal. resorption of fetuses and abortion may be seen in breeding animals. diagnosis may be confirmed by skin scrapings (fig. - a ), but it is not unusual for these to be negative. treatment consists of % lime sulfur dips (once weekly until cure is achieved) or ivermectin injections. orally administered ivermectin is not effective in guinea pigs. • t. caviae can temporarily infest humans, producing a pruritic papular dermatitis in areas contacted by the guinea pig (arms, thighs, and abdomen). chirodiscoides caviae is the guinea pig fur mite.l" , infestation is uncommon, and clinical disease is probably rare. heavy infestations can cause pruritus, alopecia, erythema, scaling, and crusting, especially on the dorsolateral lumbosacral area (see fig. - c ) and the perineum. diagnosis is confirmed by the microscopic identification of the mites (see fig. - b) , which are often found attached to hair shafts. treatment is as described for lice. although injections of ivermectin have been reported to eliminate c. caoiae.» , others found this form of therapy to be ineffectlve.v other mites rarely reported to affect guinea pigs and produce clinical syndromes characterized by pruritus and dermatitis, which is most prominent on the face, the pinnae, and the dorsum, include s. scabiei, notoedres muris, and myocoptes musculinus.p diagnosis and treatment are as described for t. caviae infestation. lice are commonly encountered in guinea pigs. , the guinea pig may be parasitized by two different biting lice, with gliricola porcelli (the slender guinea pig louse) (see fig. - c ) being much more frequently encountered than gyropus ovalis (the oval guinea pig louse). trimenopon hispidum is a biting louse rarely isolated from guinea pigs. most infestations occur without clinical signs, but heavy infestations may produce a roughened, disheveled haircoat, scaling, crusting, alopecia, and pruritus, especially around the ears and over the dorsum (see fig. - d) . heavy infestations are more commonly encountered in young animals and those with decreased resistance and under poor management. diagnosis is confirmed by gross or microscopic visualization of lice or nits. treatment can be accomplished with pyrethrin-or pyrethroid-containing flea powders or sprays approved for cats, % lime sulfur dips, or ivermectin lnjections.s" , cage sanitation is important. pelodera dermatitis is rarely reported in guinea pigsp affected animals have ventral dermatitis consisting of erythema, papules, oozing, crusts, and alopecia. skin scrapings and skin biopsy reveal the presence of the nematode pelodera strongyloides. removing contaminated bedding and maintaining a clean, dry cage environment are curative. cheyletiellosis is rarely reported in guinea pigs. affected animals have scaling and variable degrees of hypotrichosis and pruritus on the dorsum. skin scrapings reveal the mite cheyletiella parasitivorax. treatment is as described for rabbits. demodicosis is rare in guinea pigsp lesions occur most commonly on the trunk (fig. figure - - ) and consist of alopecia, erythema, papules, and crusts. pruritus is variable. diagnosis is confirmed by finding numerous demodex caviae mites in skin scrapings (see fig. - d) . amitraz dips ( ppm, every week until weeks after skin scrapings are negative) are reported to be an effective treatment. fleas (c. felis) and ticks may be rarely encountered on guinea pigs. . treatment is the same as that described for cats. nutritional deficiencies, other than vitamin c deficiency, are unlikely to be encountered in pet guinea pigs. experimental production of nutritional deficiencies with resultant cutaneous abnormalities have been reported and are briefly mentioned here. protein deficiency produces generalized alopecia.v fatty acid deficiency results in generalized alopecia, scaling, and dermatitis.s pyridoxine deficiency produces alopecia, scaling, and dermatitis, which is most prominent on the limbs, the face, and the pinnae.v vitamin c deficiency is associated with cutaneous petechiae, ecchymoses, hematomas, generalized scaling, and a rough, unkempt hatrcoat.v . , vitamin c deficiency is common and is most commonly seen in animals being fed a commercial rabbit chow or an outdated commercial guinea pig chow as the sale diet or in anorectic animals, telogen defluxion is frequently seen in the last trimester of pregnancy or during lactation. , , the alopecia is most prominent on the lumbosacral area and the flanks. marked shedding during stress is common in guinea pigs. when guinea pigs are sick, it is often easy to epilate an entire area of haircoat when tenting the skin. guinea pigs establish male-dominated social hierarchies, and animals of low social ranking or young animals may lose considerable amounts of hair, especially on the head, the rump, the perineum, and the prepuce owing to barbering or receiving bite wounds.v " . ear chewing can be a problem, resulting in ear margin notches or actual cropping close to the head. guinea pigs may also self-barber, producing hair loss in only those areas that they can reach with their mouth (the fur on the head, the neck, and the anterior shoulders is intact). hair loss due to barbering appears irregular in length and clipped. the underlying skin is usually normal in appearance. in some cases, the addition of long-stemmed hay resolves the barbering, suggesting that the cause was boredom or a need for fiber." , , necrosis of digits and paws is occasionally seen when owners put objects such as cloths and socks in cages with guinea pigsy segments of these materials become wrapped around distal extremities and serve as constricting bands or tourniquets. tissues distal to the constriction become swollen and painful, then necrotic, and then they slough ( fig. - ). apparent ergot poisoning was characterized by the sudden onset of anorexia, lethargy, and lameness." the feet became discolored, desiccated, insensitive to touch, and woodlike. thinning of the haircoat is common near the time of weaning in neonates and spontaneously resolves." hereditary hairlessness has been reported in guinea pigs (fig. - ) , bilaterally symmetric alopecia over the flanks and trunk has been seen in guinea pigs with cystic ovaries (fig. - ) . , , affected females usually present with progressive enlargement of the abdomen, and ovarian cysts may be palpable as discrete, large, rounded masses in the dorsal middle abdomen. ultrasonographic examination may be diagnostic." ovariohysterectomy is curative. sebaceous glands are especially abundant around the anus, in the folds of the perianal and genital regions, and in the dorsal sacral skin, especially in sexually mature male animals." . excessive accumulations of sebaceous debris, and occasionally bedding material and feces, may become entrapped in these folds or mat down the dorsal sacral haircoat. intertrigo, secondary bacterial infections, and unpleasant odors may intervene in this situation. these areas should be cleaned as needed with % hydrogen peroxide, . % chlorhexidine, or a mild astringent (aluminum subacetate) to prevent the aforementioned sequelae. heavy guinea pigs, especially those maintained in wire-bottom cages, frequently develop hyperkeratosis and cutaneous horns of the footpads." these horny growths are most commonly observed on the ventral aspect of the front paws. they can be removed with scissors and an emery file. replacement of cage surfaces with smoother materials retards or prevents further hyperkeratoses. overgrown claws are a frequent problem in pet guinea pigs. , frequent examination and trimming prevents traumatic and infectious complications. the skin is the second most common site of neoplasia in the guinea pig. , , , , the most common cutaneous neoplasm is the trichofolliculomay this tumor is most commonly encountered as a benign, solitary lesion over the dorsal lumbar area (see fig. - £). the overlying skin is usually alopecic and crusted. frequently, a central pore is seen, through which keratinous material or dark, hemorrhagic exudate is discharged. other cutaneous neoplasms reported in guinea pigs include sebaceous adenoma, fibroma, fibrosarcoma, lipoma, liposarcoma, schwannoma, and lymphoma.v bacterial skin infections are uncommonly reported in hamsters. s, aureus and pasteurella pneurrwtropica have been recovered from isolated cases of skin abscesses and bite wounds." hamsters are prone to periodontal disease and dental caries, and any facial abscess located ventral or cranial to the eye may be a tooth root abscess.'? treatment of bacterial dermatitis includes elimination of predisposing causes, surgical drainage, daily topical cleaning with % hydrogen peroxide or . % chlorhexidine, and occasionally systemic antibiotic administration (see table - ) . experimentally, the hamster is susceptible to infection with treponema pallidum subsp. endemicum, the agent of endemic syphilis of humans." intradermal injection of the spirochete results in erythematous papules and ulcers, which eventually heal but are followed by perioral ulcers and an erythematous maculopapular rash on the paws and the trunk and death. this form of hamster syphilis has been proposed as a useful model for the study of the immune response, antibiotic therapy, and vaccination techniques in human venereal and congenital syphilis. dermatophytosis is rare in hamsters and is caused by t. mentagrophytes. , , . , , - diagnosis is confirmed by microscopic examination of affected hairs and fungal culture. treatment is as described for the other rodents. demodicosis is the most common ectoparasitism of the hamster. , demodex criceti and d. aurati are both normal residents of hamster skin.!? d. aurati is long and tapered (average, /lm long) and inhabits hair follicles, whereas d. criceti is short and stubby (average, /lm long) and inhabits the keratin and pits of the epidermal surface. clinical demodicosis is seen in aged hamsters, is usually associated with d. aurati, and is usually associated with conditions that suppress immune responses (e.g., malnutrition, concurrent disease, cancer, and exposure to carcinogensj.v b, . lesions are most commonly seen over the dorsal lumbosacral area but may be generalized (fig. - ). moderate to severe alopecia is accompanied by variable degrees of scaling, erythema, and small hemorrhagic crusts. pruritus is usually absent. diagnosis is confirmed by skin scrapings. treatment of demodicosis in hamsters has not been extensively evaluated or reported. the authors and others , were successful with ppm of amitraz applied as a whole-body dip once weekly until weeks after skin scrapings are negative. notoedric mange is rarely reported in hamsters.f- , lesions are characterized by thick yellowish crusts, erythema, and alopecia on the pinnae, the muzzle, the tail, the genitalia, and the paws. pruritus is severe, and self-mutilation can be extreme. diagnosis is confirmed by finding notoedres sp. mites in skin scrapings. treatment with % lime sulfur dips (whole-body application weekly until two treatments after clinical cure) or ivermectin injections is effective. s. scabiei, t. caviae, and ornithonyssus bacoti are reported to be rare causes of pruritus and dermatitis in hamsters.'? clinical signs, diagnosis, and treatment are the same as that described for notoedric mange. fleas (c. felis felis) are rarely encountered on hamsters." treatment is the same as that described for cats. female hamsters are generally more aggressive than are males.v !" aggressive behavior in male hamsters is testosterone dependent and is markedly reduced by castration.v the establishment of social dominance among male hamsters is positively correlated with the weight, size, and degree of pigmentation of the flank glands." aggression-related bite wounds are most commonly seen around the head, the tail, and the perineal area. aggression can produce severe wounding, such as the complete removal of the flank glands of the victim.!" nutritional deficiencies are unlikely to be seen in pet hamsters. however, one author" indicates that hair loss in hamsters is associated most often with continuous feeding of low protein (less than %) feed, such as is commonly found in pet stores. experimental production of nutritional deficiencies with resultant cutaneous abnormalities have been reported and are briefly mentioned here. pantothenic acid deficiency produces exfoliative dermatitis, depigmentation of the haircoat, and the accumulation of porphyrin-rich secretions around the nose, the mouth, and the eyes. , riboflavin deficiency produces alopecia, scaling, and dermatitis, which are most evident on the extremities.s pyridoxine deficiency results in generalized alopecia and depigmentation of the haircoat.v niacin deficiency produces a generalized alopecia.v fatty acid deficiency results in generalized alopecia, scaling, and the production of profuse amounts of cerumen.v copper deficiency results in alopecia and depigmentation.f foreign body granulomas associated with bedding consisting of wood shavings and sawdust were reported on the paws and the shoulders of hamsters.!? the problem was eliminated by using shredded paper as bedding. swelling and pruritus of the face and the paws has been reported in several hamsters." in all instances, owners had recently purchased a fresh bag of cedar or pine shavings produced by a leading pet company or bulk shavings from landscaping or nursery outlets. when affected animals were housed on plain newspaper, the lesions spontaneously regressed. presumably, the shavings had been treated with some chemical that produced a contact dermatitis. hereditary hairlessness has been reported in hamsters.!? hyperadrenocorticism is rarely reported in hamsters.s clinical signs include bilaterally symmetric alopecia, hyperpigmentation, and thinning of the skin. the baseline plasma cortisol value in one affected hamster was elevated (approximately twofold increase) compared with that in one normal hamster. one hamster was treated with metyrapone ( mg orally q h for month), and hair regrowth was complete after weeks. a second hamster was treated with o,p'-ddd ( mg orally q h for month), then metyrapone as described previously, and responded to neither drug. this hamster was euthanized, and a chromophobe adenoma of the hypophysis and bilateral adrenocortical hyperplasia were found at necropsy. the flank scent glands of the hamster can become inflamed from being rubbed against wood chips or other abrasive cage equipment.' in addition, impaction of these glands can lead to self-mutilation. ' ringtail is occasionally seen in the hamster (see rat in this chapter)." skin neoplasms are rare in hamsters.v , , the most frequently reported cutaneous neoplasms are melanomas and melanocytomas.s , these tumors occur much more frequently in male hamsters and most commonly on the back, the head, the neck, and the flank gland. epitheliotropic lymphoma (mycosis fungoides) is the second most common cutaneous neoplasm of the hamster.s , affected animals have an exfoliative erythroderma (see fig. - f) , which is generally pruritic, and go on to manifest peripherallymphadenopathy, lethargy, anorexia, emaciation, and death. some animals also have cutaneous plaques and nodules (fig. - ) , which may become ulcerated and crusted. light and electron microscopic examinations demonstrated an epitheliotropic lymphoma in which many cells show the typical features of sezary cells." immunohistochemical studies showed that the neoplastic cells are t lymphocytes." therapeutic trials have not been reported. other cutaneous neoplasms reported in hamsters include basal cell carcinoma, squamous cell carcinoma, keratoacanthoma, papilloma, epitrichial sweat gland adenoma, fibrosarcoma, and plasmacytoma.v , bacterial skin infections are uncommon in pet mice, are usually caused by s. aureus, and are secondary to trauma (cage-related injuries and bite wounds) or self-inflicted (the pruritus associated with ectoparasites)." , , , infections resulting from cage-related injury are typically seen on the nose and the muzzle, whereas those associated with bite wounds typically occur around the head, the tail, the rump, and the perineal area. staphylococcal infections may be superficial (alopecia, erythema, oozing, and crust) or deep (abscess, fistula, necrosis, and ulcer) and are usually nonpruritic. submandibular and periorbital granulomas were associated with bacterial pseudomycetuna (botryomycosis) due to s. aureusl? other bacteria occasionally isolated from cutaneous abscesses and pyogranulomas in mice include streptococcus sp., p. pneumotropica, actinobacillus sp., actinomyces sp., and klebsiella. , , treatment of bacterial dermatitis includes some combination of elimination of predisposing causes, surgical drainage, daily topical cleaning with % hydrogen peroxide or . % to % chlorhexidine, and systemic antibiotic administration (see table - ). surgical excision may be the best treatment for abscesses." s. rrwniliformis is a rare cause of epizootics of edema and cyanosis of the extremities. , , c. kutscheri (murium) is a rare cause of epizootics of furunculosis and cutaneous pyogranulomas, which may progress to necrosis and sloughing of extremities.v , the mouse has been used as an experimental model for staphylococcal scalded skin syndrome. , mycobacterium chelonae infection caused nodular, granulomatous lesions on the tails of immunocompromised mice. a dermatophytosis is uncommon in mice and is usually caused by t. mentagrophytes. i - , , - this dermatophyte can be isolated from the haircoat of up to % of clinically normal mice in pet shops and represents an important zoonosis. lesions are most commonly seen on the face, the head, the tail, and the trunk and consist of annular areas of alopecia, broken hairs, scales, and variable degrees of erythema and crusting. pruritus is usually minimal to absent. diagnosis and treatment are the same as that described for guinea pigs. mouse pox (infectious ectromelia) causes epizootics in research colonies but is rarely, if ever, seen in practice.t- , - , , skin lesions include a generalized papular dermatitis with eventual swelling, necrosis, ulceration, and even sloughing of digits, pinnae, and tail. diagnosis is confirmed by skin biopsy, electron microscopic examination of crusts, viral isolation of the orthopoxvirus, and polymerase chain reactiony· reovirus type infection of suckling mice causes severe illness and an oily haircoat.v , animals that survive past weaning experience alopecia. sialodacryoadenitis virus infection causes eye rubbing and scratching, periorbital swelling, and red tears (chromodacryorrheal.vv myobia musculi is a mite commonly found on mice. - , , - some animals are asymptomatic carriers, whereas other animals show varying degrees of skin disease and pruritus. severely inflammatory and pruritic forms of the infestation are associated with genetic susceptibility and mite-related hypersensitivity reactions.!" immature mice or those that are immunocompromised may be more susceptible to severe forms of the disease. clinical signs may be mild and include patchy alopecia, slight erythema, and minor scaling on the head and the muzzle. other mice may show intense pruritus and self-mutilation of the face, the head, the pinnae, the neck, and the shoulders (see fig. - g) . severely affected animals can become debilitated and die. diagnosis is confirmed by skin scrapings (see fig. - e) . the treatment of choice is subcutaneous injections of ivermectin.v , , , ivermectin administered topically or in drinking water is less effective : . , , myocoptes musculinus is a mite commonly found on mice. - , , - some animals are asymptomatic carriers, whereas others manifest varying degrees of skin disease and pruritus. lesions are most severe on the back and the ventrum. unlike the case with m, musculi infestations, severe ulceration is not seen with m. musculinus infestations. diagnosis is confirmed by skin scrapings (see fig. - f) ; however, the mites are often difficult to find. the treatment of choice is subcutaneous injections of ivermectin every weeks until the animal is cured." , , , ivermectin administered topically or in drinking water is less effective.p: , other mites that are rarely found on mice include radfordia affinis, psorergates simplex, . bacoti, s. scabiei, n. muris, and trichoecius romboutsi.i:" , , , fleas (especially c. felis felis) may be recovered from pet mice maintained in households frequented by dogs and cats. - , , the sucking louse polyplax serrata is occasionally found on pet mice. - , , , , some animals may be asymptomatic carriers, but others manifest varying degrees of dermatitis and pruritus. young animals, debilitated animals, and animals in poor management situations are more likely to be affected. lice and related dermatoses are most commonly found on the neck and back. treatment can be accomplished with topical insecticides or ivermectin injections. nutritional deficiencies are unlikely to be encountered in pet mice. experimental production of nutritional deficiencies with resultant cutaneous abnormalities have been reported and are briefly mentioned here. zinc deficiency produces exfoliative dermatitis, alopecia, and depigmentation of the haircoat." pantothenic acid deficiency results in exfoliative dermatitis and depigmentation of the haircoat.v riboflavin deficiency produces alopecia, scaling, and dermatitis, especially on the extremities.v pyridoxine deficiency results in exfoliative dermatitis, especially on the face, the ears, the limbs, and the taij. · biotin deficiency causes exfoliative dermatitis." fatty acid deficiency produces an exfoliative dermatitis.v male mice are aggressive. - • . . barbering and bite wounds are frequently seen, especially on the muzzle, the whiskers, the face, the head, the rump, the tail, and the perineum. these behaviors can be exacerbated by crowding, stress, and boredom. mice frequently rub the hair off the muzzle as they stick their face through slotted feeders or wire bars. mice develop numerous types of hereditary hairlessness and keratinization defects, which are probably never seen by the practitioner.v , . . some of these conditions have been used as laboratory models for the study of various aspects of cutaneous pathophysiology and pharmacology, such as ichthyosis, asebia, rhino, and blotchy (similar to the menkes kinky hair syndrome in humans) and flaky skin (similar to psoriasis in humansi.i" . , . ringtail is rarely reported in mice (see rat in this chapter)." idiopathic dry gangrene of the pinna is sporadically seen in young mice." the incidence appears to increase when the mice are exposed to cold temperatures and when the ears are traumatized by excessive grooming in attempts to remove lice. the condition progresses rapidly from initial erythema of the distal one third of the pinna to necrosis and slough. rarely, the distal one third of the tail is also involved. perianal pruritus is seen in association with pinworms (syphacia obvelata). . , , , infected mice often mutilate the base of the tail. diagnosis is confirmed by microscopic examination of strips of cellophane (scotch) tape that have been applied to the perineum. the eggs of s. obvelata are banana shaped and about /lm by /lill. treatment with ivermectin injections is curative. a spontaneous immune complex vasculitis was reported to affect up to % of certain strains of aged mice." mice developed multiple crusts between the scapulae or on the dorsal neck. these lesions rapidly evolved into irregular ulcers and spread laterally and caudally on the body. pruritus was intense. histologic examination revealed leukocytoclastic vasculitis and igg, igm, and fibrinogen were demonstrated in dermal blood vessel walls. alopecia areata was reported in the c hihej mouse and proposed as a model of the human disease." although mice are sensitive to the induction of various skin neoplasms by the topical or systemic administration of chemical carcinogens or ultraviolet light exposure, spontaneous skin neoplasms are rare.s , , , the most commonly reported cutaneous neoplasms are papilloma, squamous cell carcinoma, and fibrosarcoma. , other reported cutaneous neoplasms include hair follicle tumors, sebaceous gland tumors, mast cell tumors, hemangiomas, hemangiosarcomas, melanomas, lymphomas, and a solitary epitheliotropic lymphoma resembling pagetoid reticulosis in humans.!": , pasteurellosis (snuffles) is the most common bacterial disease of the rabbit." most rabbits carry pasteurella multocida asymptomatically in the nasal cavity, and under conditions of stress, the bacteria multiply and cause disease. subcutaneous abscesses develop as a result of septicemia, external wound contamination, or direct extension from deeper sties. the abscesses are variable in size, are usually firm on palpation, and are filled with a thick, white to tan exudate. diagnosis is confirmed by microscopic examination of direct smears of exudate and culture. in the rabbit, subcutaneous abscesses are due to pasteurellosis until proven otherwise. other causes of abscesses include s. aureus, fusobacterium, pseudomonas aeruginosa, streptococcus sp., and c. pyogenes." abscesses on the head may be secondary to dental disease, a tooth root abscess, or an oral foreign body. abscesses in rabbits are typically filled with thick, caseated pus and are surrounded by a thick capsule. these two attributes make the use of drainage, drains, and topical and systemic antibiotics unsuccessful in most cases.v- , the treatment of choice is surgical excision and at least weeks of antibiotic treatment (see table - ). , , if this is impossible, radical debridement, flushing, and antibiotics for several weeks may be effective.?" in some rabbits, abscesses continue to recur in the same spot or at some other sites in an apparently healthy individual.'? some of these rabbits may require lifetime antibiotic therapy to prevent recurrences. necrobacillosis (schmorl's disease) is a sporadic bacterial infection of rabbits caused by fusobacterium necrophorum. t it is characterized by inflammation, necrosis, ulceration, and abscessation, especially on the face, the head, and the neck. diagnosis is confirmed by culture. treatment is accomplished with surgical debridement, topical antimicrobial applications, and systemic penicillin or tetracycline administration. p. aeruginosa causes a localized moist dermatitis (sore dewlap) and, occasionally, subcutaneous abscess in areas of skin that are continuously wet. t the muzzle, the dewlap (see fig. - h) , the flank, and the haunches are most commonly involved. the affected skin is moist, erythematous, edematous, alopecic, and often ulcerated. the fur is often clumped, creating a spiked appearance. the most striking clinical feature is the blue-green color of the fur in animals with white fur, which is caused by a water-soluble pigment (pyocyanin) produced by the bacteria. diagnosis is confirmed by microscopic examination of direct smears from oozing areas and culture. treatment includes clipping, gentle cleaning, and application of astringents (aluminum acetate) and topical gentamicin sulfate ointment. prevention is directed at removing the cause of continued wetness of the fur. the most common cause is the constant drooling ("slobbers") associated with dental disease.l" leaking water valves or water bottles should be replaced. water bowls or pans should be replaced by water bottles with sipper tubes. malocclusion of the teeth should be corrected to prevent drooling. wet bedding should be changed more frequently. ulcerative pododermatitis (sore hocks) is a common disorder in rabbits. § genetic predilection is important, as large body size and thinner plantar fur pads are important predtsposing factors. unsanitary cage conditions, rough cage surfaces, and obesity also contribute to pressure necrosis and secondary bacterial infection with s. aureus. lesions commonly occur unilaterally or bilaterally on the plantar aspect of the metatarsal region or, less commonly, the volar surface of the metacarpal area. focal inflammation, oozing, crusts, and alopecia progress to ulcers, hemorrhage, and abscesses. in severe infections, the disease may extend to the bony structures of the foot and result in septicemia. treatment includes correction of predisposing conditions, surgical drainage, topical antimicrobial applications, and systemic antibiotic administration (see table - ). severe cases usually do not respond. venereal spirochetosis (treponematosis, rabbit syphilis, or vent disease) is uncommon. frequently seen on the nose (fig. - a) , the lips, the chin, the face, the eyelids, the ears, and the paws as well as the genitalia. lesions consist of vesicles, papules, erythema, edema, oozing, erosions, and brownish crusts. focal ulcers and hemorrhage may be seen. diagnosis is confirmed by skin biopsies, the venereal disease research laboratory (vdrl) slide test, and the rapid plasma reagin (rpr) card test. treatment with penicillin g benzathine or penicillin g procaine is curative ( , iulkg, subcutaneously, once a week for three treatments). tetracycline or chloramphenicol is also effective.". an outbreak of s. aureus infection in a rabbitry was associated with a pustular, exudative dermatitis in the young and mastitis in lactating does.p" a cellulitis due to s. aureus infection is occasionally seen and is characterized by the acute onset of fever, and painful edematous swelling, especially over the head, neck, and thorax." necrosis and slough may occur. dermatophytosis is common in rabbits. t. mentagrophytes is the most common dermatophyte isolated, but m. canis, m. gypseum, m. audouinii, t. verrucosum, and t. schoenleinii have been reported." t. mentagrophytes can be isolated from the haircoat and skin of approximately % of clinically normal rabbits, representing an important potential zoonosis. the disease is most common in young animals and where husbandry and management are suboptimal. lesions are characterized by patchy alopecia, broken hairs, erythema, and yellowish crusting, and typically first appear on the bridge of the nose (see fig. - b) , the eyelids, the pinnae, and the paws, and occasionally, on many body sites. the condition is usually pruritic. diagnosis and treatment are the same as that described for the guinea pig. griseofulvin is teratogenic, and should not be used in breeding does. a modified live t. mentagrophytes vaccine may prove useful in prophylaxis.!? aspergillosis of the lungs and skin was reported in a whole litter of -week-old rabbits.!" multiple -to -mm papules were present all over the body. histologically, the papules were cystic follicles distended with necrotic debris and dichotomously branching hyphae. aspergillus sp. was isolated in culture. the animals were raised on moldy grass hay bedding material. a change in nesting materials prevented further occurrences. myxomatosis is occasionally observed in domestic rabbits. t the myxoma virus (a poxvirus) is transmitted from reservoir wild rabbit hosts by mosquitoes. there are several strains of virus with variable virulence. in domestic rabbits, severe disease and high mortality are frequently produced. affected rabbits are febrile, lethargic, and depressed. in the acute form of the disease, there is edema and erythema of the anus, the genitalia, the lips, the nares, and the eyelids. less virulent strains of the virus produce numerous skin tumors (see fig. - c ). myxomatosis appeared in the depilated skin of angora rabbits.'? lesions were a few millimeters to em in diameter, erythematous, and plaquelike, and became hemorrhagic and necrotic. morbidity was low and mortality infrequent. diagnosis is based on distinctive clinical signs, biopsy, and virus isolation. there is no effective treatment, and control of insect vectors and screening of enclosures are paramount in endemic areas. heterologous vaccine may be useful. rabbit pox is infrequently reported in domestic rabbits. t the causative poxvirus is closely related to vaccinia virus. initial clinical signs of profuse nasal discharge, depression, and fever are followed in to days by a generalized, erythematous, macular to papular to nodular eruption. the rabbits have extensive edema of the face and perineum. diagnosis is confirmed by biopsy and virus isolation. shope fibroma virus and shope papilloma virus are oncogenic (see neoplasia). psoroptes cuniculi, a nonburrowing mite, is the most common ectoparasite of the rabbit, and all rabbits should be considered infected until proven otherwise." rabbits are also susceptible to p. ovis (cattle and sheep).'? p. cuniculi is transmitted by direct contact with infected rabbits, fomites, and contaminated environment. starving mites survive for approximately days off the host over the usual range of temperatures ( to °c [ to °f]) and relative humidities ( % to %), crusts dislodged into the environment contain many mites. the mites pierce skin to feed, and hypersensitivity to mite-related antigens may be important in the pathogenesis of the dermatitis and pruritus.!" p. cuniculi typically produces otitis extema (otoacariasis, ear canker, and ear mites) (see fig. - d) . affected rabbits shake their heads and scratch at the head and ears. alopecia, excoriations, and secondary bacterial infection may be present around the head, neck, and ventrum.f: in early stages, a dry, whitish gray to tan crusty exudate forms inside the vertical ear canal. later, a dry, crusty material with a layered appearance accumulates in the ear and the lateral surface of the pinnae. a secondary bacterial infection may complicate the parasitic otitis extema, contributing to the foul odor and pain. occasionally, mites may produce lesions on the face, the head, the neck, the limbs, the abdomen, and the back.n, , diagnosis is confirmed by finding the mites in ear swabs or skin scrapings (see fig. - g) , in one report in which natural infections were studied and mite numbers were quantitated, affected animals harbored to , mites per rabbit. the treatment of choice is the subcutaneous injection of ivermectin.l" , , do not attempt to clean out the crusts and debris, because this causes pain and bleeding. the cage and environment should be sanitized, and reducing the relative humidity to less than % while increasing the temperature to °c ( °f) is of benefit in this regard.n, in one report.v? an incontact guinea pig also developed psoroptic mange. s. scabiei var. cuniculi, a burrowing mite, is a rare ectoparasite on rabbits in north america but is commonly found in some other parts of the world, such as africa and india. t typical lesions include tan to yellow, often powdery crusts, alopecia, erythema, and excoriation on the muzzle, the lips, the bridge of the nose, the eyelids, the head, the margins of the pinna, the paws, and the external genitalia. pruritus is intense. severe infestations can lead to anorexia, lethargy, emaciation, and death. these mites can transiently produce lesions in humans. diagnosis is confirmed by finding s. scabiei mites in skin scrapings. however, mites are often difficult to demonstrate, and response to therapy is a frequently used diagnostic test. the treatment of choice is iverrnectin." , , cheyletiella parasitovorax, a nonburrowing mite, is a common ectoparasite on rabbits. - , , . - most rabbits harbor the mites without overt signs of skin disease. with heavy infestations or in hypersensitive hosts, a variably pruritic dermatosis is seen. lesions consist of scaling, crusting, and variable degrees of erythema, alopecia, and greasiness over the withers, the back (see fig. - e) , and the ventral abdomen. occasionally, lesions are limited to the face. these mites can produce skin lesions in humans. diagnosis is confirmed by finding c. parasitovorax in skin scrapings or acetate tape preparations. the treatment of choice is ivermectin. listrophorus (leporacarus) gibbus is a common fur mite of rabbits, which is rarely associated with clinical skin disease.t" , , - , ., . most affected rabbits are asymptomatic. the mite is usually found attached to hair shafts, especially on the back, the groin, and the ventral abdomen. occasional rabbits may manifest a variably pruritic, scaly, erythematous, alopecic dermatitis in the aforementioned sites. some animals only manifest pruritus and traumatic alopecia with no skin lesions. diagnosis is confirmed by finding l. gibbus in skin scrapings and acetate tape preparations (see fig. sulfur dips is curative.i" a, a ivermectin may also be effective.'? fipronil spray was reported to be effective.?' one author reported treating over rabbits with fipronil spray ( mllkg) with no adverse effects.?? however, the therapeutic index for this product is fairly narrow in rabbits, possibly due to the isopropyl alcohol content." company representatives received a number of reports of suspected adverse reactions to fipronil spray in rabbits, and recommended that the product not be used in this species." notoedres cati, a burrowing mite, is a rare ectoparasite on rabbits in north america, but is commonly found in other parts of the world, such as india." clinical signs, diagnosis, and treatment are identical to those described for s, scabiei. fleas (especially c, felis felis) are occasionally found on rabbits, especially those in households with dogs and cats. - , , , - , a in the united states, rabbits may also be infested with cediopsylla simplex (common eastern rabbit flea), especially around the head and the neck, and odontopsyllus multispinosis (giant eastern rabbit flea), especially over the rump, clinical signs, diagnosis, and therapy are the same as that described for cats. the rabbit sucking louse haemodipsus ventricosus is uncommon in the united states, - , , , - pediculosis is usually associated with poor management. lice are most commonly found on the dorsum and may produce intense pruritus, severe infestations in debilitated animals may produce anemia, weakness, emaciation, and death, h. ventricosus is a vector of tularemia, therapy is the same as that described for cats, demodex cuniculi mites have been isolated from rabbits with generalized pruritus and scaling, but their pathogenic significance is in doubt.!? members of the fly genus cuterebra occasionally produce myiasis in domestic rabbits reared outdoors or in nonscreened enclosures, t among those fly species reported in the united states are cuterebra cuniculi, c, buccata, and c, horripilum. larvae and, therefore, lesions appear in the summer and early fall. the incidence of infestation decreases with age, which correlates with the development of immediate and delayed-type hypersensitivity reactions to larval antigens, c, horripilum prefers the ventral cervical region, whereas c. buccata larvae localize in the interscapular, axillary, inguinal, or rump area, initial lesions include subcutaneous cystlike structures, as the larvae (warbles) enlarge, a "breathing hole," or fistula, is produced. the surrounding haircoat is moist and matted, secondary bacterial infection is common, and the lesions are often painful. treatment consists of surgical removal of the larvae (one should not crush or otherwise damage the larvae), routine wound care, and occasionally, administration of systemic antibiotics, prevention and control are aimed at eliminating contact with the warble fly, flystrike (maggots) is most commonly seen in the perineal region, and may spread dorsally onto the rump.!? moist dermatitis and fur matting are present, rabbits that are sedentary, overweight, or that have perineal dermatitis (urine scald) may be predisposed, treatment includes cleansing and one injection of ivermectin.l'' nutritional deficiencies are unlikely to be encountered in pet rabbits, experimental production of nutritional deficiencies with resultant cutaneous abnormalities have been reported and are briefly presented here, copper deficiency results in alopecia and a depigmented haircoat.v zinc deficiency produces alopecia, scaling, and a depigmented haircoat. , several days before parturition, the female rabbit undergoes a generalized loosening of the fur, , , is especially prominent on the abdomen, chest, forelegs, and hips. some rabbits pull out fur as a behavioral vice.v other rabbits rub fur off against the cage surface or feeders." does in heat and rabbits on low-fiber diets may barber their own hair.'? the barbered rabbit typically has patches of broken-off hairs over the head and back.'? seasonal molts can result in haircoat irregularities and thinning." compulsive self-mutilating behavior was encountered in % to % of the rabbits in a colony of checkered crosses." extensive auto mutilation of digits and pads of the front feet was observed. the behavior could be interrupted by giving the rabbits haloperidol ( . mglkg m qi h), a dopamine antagonist. because the condition was never seen in animals of other breeding lines kept in the same building under identical conditions, and the affected animals came from highly inbred stock, it was hypothesized that the disorder was genetically determined. hereditary alopecias (fig. - ) are rarely described in rabbits'? but are unlikely to be seen by practitioners. cutaneous asthenia has been reported in rabbits (fig. _ ). . . the animals had a history of skin fragility and repeated spontaneous skin tears, and were covered with scars. the skin extensibility index (see chap. ) in two rabbits was % to % in the affected rabbits as compared with a mean of % in normal rabbits. light microscopic examination was unremarkable, but electron microscopic examination revealed distorted and tangled collagen bundles with collagen fibrils being of different diameters and having a loose, frayed appearance. hutch bum is a contact dermatitis caused by urine scalding of the perineal region because of an unclean environment or an inability of the rabbit to void urine without soiling itself, such as after an orthopedic or neurologic injury, or with obesity." washing the area frequently with antimicrobial agents and applying a protectant cream, such as zinc oxide, are helpful. frostbite may be seen in rabbits that are suddenly exposed to cold climates without a period of acclimatization.!" erythema, acrocyanosis, necrosis, and sloughing are typically seen on the pinna (see fig. - f) . both male and female rabbits possess two sebaceous scent glands on either side of the vulvar or testicular area that secrete a brown waxy debris." this secretion can build up and can be easily removed by gentle traction or soap and water. the authors have seen a condition resembling alopecia areata in rabbits. affected animals presented with one or more areas of noninflammatory annular alopecia, especially on the black-furred areas of the pinnae. spontaneous recovery was accompanied by the regrowth of white fur (fig. - ) . sebaceous adenitis was reported in domestic rabbits. • a the animals varied from lf to years of age. lesions began around the neck or face, remained localized for several months, then became generalized. all rabbits eventually had a generalized, nonpruritic exfoliative dermatosis with patchy to coalescing areas of alopecia. skin biopsies were diagnostic. no response was seen to antibiotics, glucocorticoids, ivermectin, griseofulvin, fatty acids, azathioprine, or oral retinoids. facial eczema has been reported in young suckling rabbits.'! the condition is sporadic and of unknown etiology. areas of alopecia and slight erythema occur on the bridge of the nose and the periocular region. affected animals are otherwise healthy. the condition responds rapidly to topical glucocorticoid therapy. spontaneous nonviral cutaneous neoplasms are rare in rabbits." papilloma, basal cell carcinoma, squamous cell carcinoma, sebaceous carcinoma, melanoma, osteosarcoma, and lymphoma have been reported. shope papillomas are uncommon in domestic rabbits. t in the united states, the disease occurs in the southwest and along the mississippi river. shope papilloma virus (a papovavirus) commonly infects wild rabbits, with insects serving as vectors. lesions are characterized by multiple hornlike growths from a single site, especially about the eyelids and the pinnae. removal of the papillomas usually results in healing, and recovered rabbits are resistant to reinfection. spontaneous regression of lesions occurs within months. experimental infection of domestic rabbits resulted in malignant transformation to squamous cell carcinoma within to months in a high percentage of the inoculation sites. a program of screening animal enclosures and vector control should be instituted in endemic areas. shope fibromas are uncommon in domestic rabbits.] shope fibroma virus (a poxvirus) commonly infects wild rabbits in north and south america and is transmitted via insect vectors. lesions consist of single or multiple flat, firm, subcutaneous nodules, especially on the genitals, the perineum, the ventral abdomen, the paw, the nose, the pinna, and the eyelid. newborn rabbits are more susceptible than are older animals and have more extensive lesions. experimentally infected adult rabbits often show spontaneous involution of their fibromas within months through necrosis and sloughing. mosquito eradication and enclosure screening is indicated to prevent infection in endemic areas. cutaneous lymphoma was reported in domestic rabbits from weeks to / years old. b most had early internal organ involvement and systemic disease. lesions consisted of multifocal areas of alopecia, scale, erythema, and plaques. histologically, the lymphomas were epitheliotropic and cd +. one rabbit was unsuccessfully treated with oral isotretinoin and interferon-a. bacterial skin infections are uncommon in pet rats, are usually caused by s. aureus, and are secondary to trauma (cage-related injuries and bite wounds) or self-inflicted (the pruritus associated with ectoparasitesl.p" , [ ] [ ] [ ] [ ] rats are more resistant to experimental wound infection with s. aureus than are mice or hamsters.!? infections resulting from cage-related injury are typically seen on the nose and the muzzle, whereas those associated with bite wounds typically occur around the head, the tail, the rump, and the perineal area. staphylococcal dermatitis may be superficial (alopecia, erythema, oozing, and crust) or deep (abscess, fistula, necrosis, and ulcer) and is usually nonpruritic. granulomas occurred on the trunk and mammary gland in association with infection by an atypical slow-growing s. aureus . other bacteria occasionally isolated from cutaneous abscesses and pyogranulomas in rats include streptococcus sp., p. pneumotropica, klebsiella pneumoniae, p, aeruginosa, and mycobacterium lepraemurium (rat leprosy). , , [ ] [ ] [ ] [ ] treatment of bacterial dermatitis includes some combination of elimination of predisposing causes, surgical drainage, daily topical cleaning with % hydrogen peroxide or . % to % chlorhexidine, and systemic antibiotic administration (see table - ). s. moniliformis is a rare cause of epizootics of edema and cyanosis of the extremities. , , c. kutscheri (murium) is a rare cause of epizootics of furunculosis and cutaneous pyogranulomas, which may progress to necrosis and sloughing of extremities.v dermatophytosis is rare in rats and is usually associated with t. mentagrophytes. - , , , - this dermatophyte can be isolated from the haircoat of clinically normal rats and is a potential zoonotic agent. lesions are most commonly seen on the neck, the back, and the base of the tail and consist of annular areas of alopecia, broken hairs, scales, and variable degrees of erythema and crusting. pruritus is usually minimal to absent, diagnosis and treatment are as described for guinea pigs. sialodacryoadenitis virus (a coronavirus) infection causes eye rubbing and scratching, periorbital swelling, and red tears (chromodacryorrhea) (see fig. - g) . , , poxvirus infection has been described in laboratory white rats.!? skin lesions consisted of erythematous papules, which became crusted and occurred mainly on the glabrous areas of the body (tail, paws, and muzzle). sometimes, the affected portions of paws and tail underwent necrosis and sloughing. diagnosis was confirmed by biopsy, electron microscopy, and viral isolation. n. muris occasionally causes a severely pruritic dermatitis in rats. - , , , - lesions are most commonly present on the pinnae, the nose, the paws, and the ventrum and consist of erythema, papules, yellowish hyperkeratotic crusts, and excoriations, diagnosis is confirmed by skin scrapings. treatment is accomplished with topical % lime sulfur dips (once weekly until weeks after cure) or subcutaneous injections of ivermectin. other mites that are rarely found on rats include radfordia ensifera, . bacoti (tropical rat mite), s. scabiei, trixacarus diversus ( fig. - h) , t. caviae, m. musculi, and demodex sp." fleas (especially c. felis felis) may be recovered from pet rats maintained in households frequented by cats and dogs. - , , the sucking louse polyplax spinulosa is occasionally found on pet rats. t some animals may be asymptomatic carriers, and other animals manifest varying degrees of dermatitis and pruritus. young animals, debilitated animals, and animals in poor management situations are more likely to be affected. lice and related dermatoses are most commonly found on the neck and back. treatment can be accomplished with topical insecticides or ivermectin injections. nutritional deficiencies are unlikely to be encountered in pet rats. experimental production of nutritional deficiencies with resultant cutaneous abnormalities has been reported, and these are briefly mentioned here. zinc deficiency produces exfoliative dermatitis, alopecia, and depigmentation of the hairco at, , pantothenic acid deficiency results in exfoliative dermatitis, depigmentation of the haircoat, and excessive harderian gland activity with increased porphyrin secretion resulting in red tears and blood-caked whiskers.v riboflavin deficiency produces alopecia, scaling, and dermatitis, especially on the extremities." pyridoxine deficiency results in exfoliative dermatitis, especially on the face, the ears, the limbs, and the tail. ' biotin deficiency causes exfoliative dermatitis and periocular alopecia." niacin deficiency causes alopecia and excessive harderian gland activity, increased porphyrin secretion, and blood-caked whiskers.v essential fatty acid deficiency produces an exfoliative dermatitis and, occasionally, necrosis of the tail. , protein deficiency causes alopecia, exfoliative dermatitis, and depigmentation of the haircoat." barbering and bite wounds are frequently seen when rats are housed together. - , , these behaviors can be exacerbated by crowding, stress, and boredom. areas most commonly affected include the muzzle, the whiskers, the face, the head, the rump, the tail, and the perineum. rats may also rub the hair off the muzzle as they stick their face through slotted feeders or wire bars.!? rats have numerous types of hereditary hairlessness that are probably never seen by the practitioner (fig. - ) . ringtail is a poorly understood condition seen in rats. - , the incidence of the disorder increases as the relative humidity falls below % and is especially common in young unweaned animals housed in cages with wire mesh bottoms, on hygroscopic bedding, and in rooms with excessive ventilation. in the northern hemisphere, most cases are seen from november to may, when heating systems often cause marked reductions in relative humidity. some strains of rats seem more susceptible than others. the condition usually occurs after months of reduced relative humidity. one or more annular constrictions develop in the tail, which becomes edematous, inflamed, and necrosed distal to the constrictions (fig. - ). ringtail is prevented by maintaining a relative humidity of at least %. perianal pruritus is seen in association with pinworms (syphacia muris). , , , infected rats occasionally mutilate the base of the tail. diagnosis is confirmed by microscopic examination of strips of cellophane (scotch) tape that have been applied to the perineum. the eggs of s, muris are banana shaped and about p.,m by us«. ivermectin is effective treatment. auricular chondritis has been described in rats.!" the condition has occurred spontaneously and in association with the placement of metal ear tags or immunization with type ii collagen. typically, both ears are affected, although one ear may be affected days to weeks before the other. the pinnae are swollen, erythematous, and nodular, and they become thickened and deformed. pain and pruritus are rare. histologically, there is a multifocal granulomatous chondritis with progressive destruction of cartilage. systemic hair embolism has been reported subsequent to intravenous injections in rats.!? cutaneous lesions consist of focal areas of necrosis and ulceration on the ventral aspect of the body. histologic examination reveals granulomatous and necrotizing dermatitis and panniculitis, and intravascular hair shaft fragments. the fur of the aged rat frequently turns yellow and becomes more coarse.f the cause is unknown. alopecia areata was reported in debr rats and proposed as a useful model of the human disease."? brownish scales were observed to occur on the skin of rats, mainly on the dorsum and tail and were more numerous in males and with increasing age. the scales also occurred in strain-dependent patterns. gonadectomy produced a fading of the scales in males, whereas the administration of androgen to gonadectomized males and to females produced a darkening of the scales. spontaneous cutaneous neoplasms are uncommon in rats. - . . . mesenchymal neoplasms are more common than are epithelial neoplasms. the most common are fibromas, fibrosarcomas, and lipomas. the face, the shoulder, the flank, the tail, and the paws are typically affected. other reported skin neoplasms in rats include papilloma, keratoacanthoma, sebaceous gland tumors, squamous cell carcinoma, basal cell carcinoma, hair follicle tumors, hemangiosarcoma, melanoma, and malignant fibrous histiocytoma. dermatophytes in clinically healthy laboratory 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small rodents chinchilla . hoefer hl: chinchillas. vet clin north am ferret . ackerman j: ultrasonographic detection of adrenal gland tumors in two ferrets biology and medicine of the ferret skin diseases of ferrets yeast infection in ferrets coccidioidomycosis in three european ferrets biology and diseases of the ferret evaluation of urinary cortisol: creatinine ratios for the diagnosis of hyperadrenocorticism associated with adrenal gland tumors in ferrets superficial spreading pyoderma and ulcerative dermatitis in a ferret university sydney postgraduate foundation veterinary cutaneous lymphoma in a ferret (mustela putorius furo) neoplastic diseases in ferrets: cases - ) demodicosis in ferrets (mustela putonus fum) guide du furet domestique comparison of three treatments for control of ear mites in ferrets cutaneous epitheliotropic lymphoma in a ferret hyperadrenocorticism associated with adrenocortical tumor or nodular hyperplasia of the adrenal gland in ferrets: cases ( - ) evaluation of plasma androgen and estrogen concentrations in ferrets with hyperadrenocorticism adrenal gland diseases in ferrets complex ceruminous gland adenocarcinoma in a brown-footed ferret (mustela putonus [uro) bilaterally symmetric alopecia associated with an adrenocortical adenoma in a pet ferret figurate erythema resembling erythema annulare centrifugum in a ferret with adrenocortical adenocarcinoma-associated alopecia correlation between age at neutering and age at onset of hyperadrenocorticism in ferrets clinical aspects and surgical treatment of hyperadrenocorticism in the domestic ferret: cases ( - ) surgical treatment and long-term outcome of ferrets with bilateral adrenal tumors or adrenal hyperplasia: cases ( - ) jacklin mr: dermatosis associated with acarus farris in gerbils guinea pig . bobrowski pj, et al: latent herpes simplex virus reactivation in the guinea pig. an animal model for recurrent disease apparent spontaneous ergot-induced necrotiting dermatitis in a guinea pig acariose a chirodiscoides caviae et dermatophytie a microsporum canis chez un cobaye ivermectin treatment of a colony of guinea pigs infested with fur mite (chirodiscoides caviae) guinea pigs haematological and pathological responses to experimental trixacarus caviae infection in guinea pigs trixacarus caviae infestation in a guinea pig: failure to respond to ivermectin administration mechanisms involved in elimination of organisms from experimental cutaneous candida albicans infections in guinea pigs the in vitro antifungal activity of ketoconazole, zinc pyrithione, and selenium sulfide against pityrosporum and their efficacy as a shampoo in the treatment of experimental pityrosporosis in guinea pigs prevalence of dermatophytes in asymptomatic guinea pigs and rabbits hyperadrenocorticism in three teddy bear hamsters epidermotropic cutaneous t-cell lymphoma (mycosis fungoides) in syrian hamsters (mesocricetus auratusi. a report of six cases and the demonstration of t-cell specificity mouse . abbott dp, et al: a condition resembling pagetoid reticulosis in a laboratory mouse immune complex vasculitis with secondary ulcerative dermatitis in aged c bu nnla mice the effectiveness of ivomec and neguvon in the control of murine mites the use of repeated treatment with ivomec and neguvon in the control of murine mites and oxurid worms hemangiomas and hemangiosarcomas in inbred laboratory mice the mouse in biomedical research the mouse epidermis as a model in skin pharmacology: influence of age and sex on epidermal metabolic reactions and their circadian rhythms spontaneous vulvar carcinomas in j mice granulomatous inflammation in the tails of mice associated with mycobacterium chelonae infection specific detection of mousepox virus by polymerase chain reaction the inflammatory and immune response to mousepox (infectious ectomelia) virus treatment with ivermectin in drinking water against myobias musculi and myocoptes musculinis mange in naturally infected laboratory mice inherited mouse mutations as models of human adnexal, cornification, and papulosquamous dermatoses inherited mouse mutations: models for the study of alopecia alopecia areata in humans and other mammalian species l'utilisation d'ivermectin pour ie traitement des acariens, myobia musculi et myocoptes musculinus, dans une colonie de souris transgeniques diagnostic exercise: head and neck swelling in aljcr mice rabbit . arlian lg, et al: sarcoptes scabiei: the circulating antibody response and induced immunity to scabies sarcoptes scabiei: histopathological changes associated with acquisition and expression of host immunity to scabies abnormalities of collagen fibrils in a rabbit with connective tissue defect similar to ehlers-danlos syndrome caring for rabbits: an overview and formulary use of frontline spray on rabbits ectopic psoroptes cuniculi infestation in a pet rabbit rabbit husbandry and medicine how to handle respiratory, ophthalmic, neurological and dermatologic problems in rabbits experimental staphylococcal dermatitis in rabbits hillyer ev: pet rabbits malignant melanoma in two rabbits hereditary compulsive self-mutilating behavior in laboratory rabbits skin disorders of the rabbit diagnosis and prevalence of leporacarus gibbus in the fur of domestic rabbits in the uk use of levamisole for the treatment of mange due to notoedres cati in rabbits clinicotherapeutic efficacy of amitraz against notoedres cati infestation in rabbits. indian generalized exfoliative dermatosis with sebaceous adenitis in three domestic rabbits an evaluation of ivermectin oral preparation in the treatment of sarcoptic mange in rabbits use of frontline spray in rabbits the biology of the laboratory rabbit ii cutaneous staphylococcosis in rabbits leporacarus gibbus and spilopsyllus cuniculi infestation in a pet rabbit a case of ehlers-danlos-like syndrome in a rabbit with review of the disease in other species therapeutic efficacy of ivermectin in rabbits (orydolagus cuniculus) experimentally infected with psoroptes cuniculi the biology of the laboratory rabbit sebaceous adenitis in four domestic rabbits (orydalagus cuniculus) lymphoma with cutaneous involvement in three domestic rabbits (onjdolagus cuniculus) rat . binhazim aa, et al: spontaneous hemangiosarcoma in the tail of a long-evans rat carrying the elcer mutation behandlung med ivermectin mot springmask och piilskvalster hos laboratorieratta: strategisk program i en produktion-sanhet granulomatous dermatitis and mastitis in two spf rats associated with a slowly growing staphylococcus aureus-a case report mange in domesticated rats development of pigmented scales on rat skin: relation to age, sex, strain, and hormonal effect key: cord- - p rwp authors: nan title: escp th european symposium on clinical pharmacy ‘implementing clinical pharmacy in community and hospital settings: sharing the experience’, istanbul, turkey – october ; abstracts date: - - journal: pharm world sci doi: . /s - - - sha: doc_id: cord_uid: p rwp nan pharmacy, groupe hospitalier pitié salpétrière, paris, france background and objective: strongyloides stercoralis infects each year millions of persons worldwide. in immunocompromised patients, this intestinal nematode can disseminate and cause a fulminant fatal illness: hyperinfection syndrome. oral ivermectin is the principal treatment. since one of the features of s. stercoralis hyperinfection is the development of an ileus and small bowel obstruction, the drug absorption is impaired and thus a reduced efficacy is noted. no parenteral antihelminthic drug is licensed for human use, but parenteral ivermectin is commonly used in veterinary medicine. we report two cases of s. stercoralis hyperinfection syndrome that were refractory to oral drugs and, as a life saving therapy, were treated with a veterinary formulation of parenteral ivermectin (ivomec Ò , merial) after agreement from the french drug administration (afssaps). design: case report. setting: pneumology and neurochirurgical intensive care units, university hospital, paris, france. main outcome measures: case report. results: patient a -year-old african man has been hospitalized in august for a degradation of his condition in neurosarcoidosis with hydrocephalus, associated with enterococcus faecalis meningitis. he underwent ventriculo-peritoneal shunt and was treated with corticosteroids (prednisone mg/day). his condition worsened on september , with the diagnosis of a disseminated strongyloidiasis with paralytic ileus. he was initially treated with ivermectin ( mg bid) via the nasogastric tube. antibiotics were added on day to control the sepsis. on day albendazole ( mg/day) was added. subcutaneous ivermectin was then obtained and administered on day ( lg/kg) in association with ivermectin via nasogastric tube while albendazole was discontinued. the patient's condition improved during the following days. he completed days of ivomec Ò and days of oral ivermectin. he returned home months later. patient a -year-old african man was hospitalized in november because of a kg weight loss. he was diagnosed with hiv, meningeal tuberculosis, urinary and pulmonary infections and s. stercoralis hyperinfection treated with oral ivermectin. on january he was admitted in pneumology intensive care unit with melena on severe immunodepression. on february he developed a septic shock with ards on an important bowel obstruction. therefore, among other antiinfectious therapies, a veterinary formulation of subcutaneous ivermectin was administered ( lg/kg/day). the sepsis was controlled, but on february he died of an acute haematological deterioration. conclusions: as the occurrence of malabsorption is a frequent complication of disseminated strongyloidiasis, a parenteral formulation of ivermectin would be really helpful, especially as the efficacy of the subcutaneous form has been proved in the literature. keywords: strongyloides stercoralis, hyperinfection, parenteral ivermectin • each pharmacy received three covert sp visits over six weeks. verbal and written feedback was provided to the pharmacy staff after each sp visit. no pharmacy was visited by the same sp more than once. each pharmacy was visited by the same pe throughout the study. background and objective: heart failure (hf) is a common disease with an estimated prevalence of . to % in europe. patients with hf have frequent episodes of exacerbation. non-compliance to medical and dietary advice is a significant clinical problem as is suboptimal treatment. one example of factors influencing the ability to comply with a treatment plan is impaired comprehension. the objectives were to construct a medication assessment tool and to establish face validity for its use in this project, to construct an interview schedule in order to identify non-compliance, poor patient comprehension and suboptimal treatment, to conduct a survey and to report the findings to the clinic. design: a cross-sectional study performed during april -may . setting: the emergency department and medical wards at malmö university hospital. main outcome measures: comparison of compliance, comprehension and optimal treatment on a population basis between men and women, younger (\ years) and elderly ([ years) patients, and patients in different new york heart association (nyha) classes, in order to assess if exacerbation could have been caused by any of these factors. results: of the patients included, % reported high compliance. in the subgroup analysis, women and elderly patients reported a significant higher compliance than men and younger patients. comprehension on self-care was poor. only % weighed themselves regularly and % did not limit the amount of fluids. no more than % reported they would contact a health care provider in case of experiencing more symptoms. suboptimal treatment was also found to be a great concern with only % being treated with angiotensinconverting enzyme inhibitors (acei) or angiotensin ii receptor blocker (arb), % with beta blockers, and % with aldosterone receptor antagonists, but no consideration to other co-morbidities has been taken into account. the majority treated with recommended agents had not achieved target dose as recommended in guidelines. conclusions: poor patient compliance and comprehension as well as suboptimal treatment could contribute to hf exacerbation and efforts should be made to improve these factors in order to reduce hf exacerbation. keywords: heart failure, compliance, sub-optimal treatment background and objective: adherence with inhaled corticosteroids has repeatedly been reported to be poor. poor adherence could lead to inadequate control of asthma complaints. monitoring of repeat prescriptions by a pharmacist could offer an opportunity to reach concordance with the patient and improve adherence. the objective of this study is was to improve asthma control by optimizing use of asthma medicines. design: retrospective follow up study. all pharmacy dispensing records concerning respiratory medication (r ) from st october to th september were collected. between st october to th september monitoring of repeat medication was conducted by a pharmacist. pharmacists discussed asthma complaints and use of asthma medicines with all patients calling for repeat prescriptions. when indicated the pharmacist proposed adjustments of asthma medicines to the gp after this telephone consultation. setting: community pharmacy and one gp practice ( gp's) in leiden, the netherlands, serving a community of . patients. main outcome measures: self-reported use of short-acting betaagonists (saba) by intervention patients. defined daily doses (ddds) of short-acting beta-agonists (saba), long-acting beta-agonists (laba) and inhaled corticosteroids (ics). results: consultations were registered for intervention patients. for patients more than consultation was registered. at the first consultation only of patients ( %) reported use of pharmaceutical sciences, strathclyde institute of pharmacy and biomedical sciences, university of strathclyde, glasgow, united kingdom background and objective: to test a method to quantify adherence of medication use to clinical guideline recommendations in a primary care setting. design: retrospective survey to field-test a -item instrument (mat-cvd) based on earlier studies of quality of medication use in cardiovascular disease (cvd) . setting: a database of patients [ % male, mean (sd) aged ( ) years] coded with circulatory system disease (read code 'g*') was drawn from computerised records of all patients receiving care from a single community pharmacist and general medical practitioner (gp) collaboration (n = , ). the pharmacist worked as a supplementary prescriber and had remote access to the electronic records of the gp. patients had diagnoses of diabetes (n = ), hypertension (htn; n = ), ischaemic heart disease (ihd; n = ), other ischaemic vascular disease (cerebrovascular n = ; peripheral vascular n = ), heart failure (hf; n = ), atrial fibrillation (af; n = ), were anticoagulated (warfarin, n = ) or otherwise identified as potential candidates for primary prevention of cvd (n = ). main outcome measures: adherence (%) to criteria based on guideline recommendations on primary and secondary prevention of cvd, treatment of htn, ihd, hf, af and warfarin therapy; overall applicability of criteria and quantification of insufficient data; interrater agreement of application of individual mat-cvd criteria and of the overall tool (cohen's r) results: a total of criteria were applicable and for ( %) of these there was insufficient data to apply the standard. the guideline adherence ( % ci) overall was ( - )%. highest adherence was to 'primary/secondary prevention of cvd' [ ( - )% adherence, n = criteria]. lowest adherence was to 'treatment of af' [ ( - )% adherence, n = criteria]. non-adherences were found to at least one criterion in ( %) and to c criteria in ( %) patients. inter-rater agreement was assessed on the application of the tool to all patients by two independent raters. all six sections and the overall tool were found to have inter-rater agreement r [ . and a percentage agreement [ %. among the ( %) of individual mat criteria that were applicable to c patients showed r [ . . in two of the remaining seven criteria the base-rate problem was responsible for r \ . and when taken into account the number of individual criteria with acceptable inter-rater agreement was ( %). conclusions: the application of the mat-cvd to routine primary care records in a scottish primary care setting is feasible and reliable; the tool has potential use in continuous quality improvement of prescribing in primary care. pc- self-management of complications in diabetic patients: a pharmaceutical care program in community pharmacies pharmacy, general medicine unit, university medical outpatient clinic, lausanne, switzerland background and objective: seamless care refers to continuity of patient care in the health system across caregivers. the objectives of the present study were ( ) to identify barriers to seamless information between a given hospital and an outpatient clinic in switzerland and ( ) to propose tools for improving pharmaceutical seamless care. design: this is a retrospective study with a convenient sample of patients for mapping the information flow network. the inclusion criteria were: ( ) at least one stay lasting more than hours in the hospital in , ( ) regular checkups with a gp in the outpatient clinic and ( ) medication delivered by the community pharmacy of the outpatient clinic months prior to months after the hospitalization. setting: both hospital and outpatient clinic are independent and run their own pharmacy. the hospital pharmacy is implied in drug production and distribution without generalized pharmaceutical care activities, and the community pharmacy delivers rx or otc medication for outpatients. geographic and computer proximity between both entities constitutes an ideal setting for seamless care projects. main outcome measures: ( ) to map medical or administrative information between community pharmacy, gp and hospital and ( ) to find opportunities to improve pharmaceutical seamless care. results: sixteen patients met inclusion criteria ( women, men, average years, mean visits/patient/year with gp: , and with community pharmacist: , i.e. -time more with pharmacist than gp). we observed that administrative information is computerized on a common database for both hospital and outpatient clinic. in contrast, clinical information is mainly handwritten and difficult to share between hospital and outpatient clinic caregivers. patient medication database is managed by a community pharmacy software not linked to medical information. however administrative information flows in one direction from the administrative to the community pharmacy database. we identified potential tools easily available to the community pharmacy to improve pharmaceutical seamless care in the center: ( ) an alarm through the administrative database connection if a patient is hospitalized to allow pharmacist to contact hospital physician for medication history and ( ) an access to patient discharge letter and lab results to improve rx validation process. conclusions: clinical information is not easily shared between caregivers of the hospital and the outpatient clinic. if global seamless care still remains a long term goal, initial actual steps promoted by community pharmacists can be easily implemented. keywords: seamless, information, community pk- implementation of a protocol for pharmacokinetic monitoring of high-dose methotrexate background and objective: to quantify the impact of the implementation of a protocol for the pharmacokinetic monitoring of patients receiving high-dose methotrexate. design: prospective experimental study, in which the hospital pharmacy department designed a specific protocol for the pharmacokinetics follow-up of these patients and for gathering the data required for a correct rescue. results were compared between three months before and three months after implementation of this new protocol. setting: -hr infusions of methotrexate at a dose of c g/m were evaluated in adult patients admitted to the oncohaematological area of a tertiary level hospital. main outcome measures: number of infusions started at the correct time, number of missed blood extractions, number of missed leucovorin doses, calculation of the elimination half-life, and measurement of the urinary ph (dichotomous variables). degree of compliance with the leucovorin rescue dosage protocol was measured on a scale of - points, with all items carrying the same score (correct loading dose, dosage as function of body surface area, and dosage as function of the concentrations of methotrexate obtained). results: the number of infusions started at the correct time increased from % to %. the number of missed blood extractions fell from . to . extractions per course; and missed leucovorin doses dropped from . to per course. the elimination half-life could be calculated in only % of courses in the first study period versus % of courses after protocol implementation. urinary ph changed from not being measured in any cycle to being measured in % of cycles. compliance with rescue dosage protocol was scored with . points before versus . points after implementation. background and objective: to quantitatively evaluate the safety of the current injectables medication process, from prescription to administration, in the paediatric and neonatal intensive care units. to compare the potential impact of safety measures on the risk. to classify these measures from a pharmacoeconomic point of view. design: assessment by a prospective risk analysis according to the failure modes, effects and criticality analysis (fmeca) method [ ] by a multidisciplinary team: one physician, two nurses, three pharmacists. three drugs chosen as models (gentamicin; morphine; dopamine). failure modes (fm) defined during brainstorming and criticality indexes calculated on the basis of their likelihood of occurrence, potential severity for the patients and detectability. impact of ten safety measures on the criticality indexes of the selected three drugs, extrapolation to all drugs injected daily and calculation for each measure of the investment in euros per year to improve the safety by quali (- point of criticality) per day. setting: university hospital, fifteen nicu beds and ten picu beds. main outcome measures: mean criticality indexes; gain in qualies per day; cost-efficacy ratios for each safety measure. results: in the current situation, the sum of mean criticality indexes of thirty-one identified fm was , for the selected three drugs. we gain , qualies ( , by extrapolation to all drugs injected daily) with civas (centralized intravenous additives services), , ( , ) with a clinical pharmacist, ( , ) with double check by nurses, ( , ) with cpoe (computerized physician order entry), ( , ) with in-line filters, ( , ) with vial of dilution, ( , ) with horizontal laminar airflow hood, ( , ) with intermediate dilution, ( , ) with simple additional measures of asepsis and ( ) with a drug planer. the best cost-efficacy ratios were obtained by a clinical pharmacist ( quali = . euros) or by double check by nurses ( quali = . euros) or by civas ( quali = . euros). the highest ratio was obtained with cpoe, due to the very high costs investment ( quali = . euros). conclusions: the use of a prospective risk analysis allowed us to quantitatively evaluate the relationship between the medication process of injectables and the paediatric patient safety and to build a strategy for continuous quality improvement, by selecting the most appropriate evolutions. based on the results of the pharmacoeconomic analysis, development of clinical pharmacy and civas for some drugs will be discussed with the paediatric department background and objective: studies show that up to % of patients starting treatment with antidepressants fill only a single prescription at the pharmacy, apparently not accepting treatment. the aim of this study was to determine characteristics and reasons associated with non-acceptance of ssri treatment. design: retrospective questionnaire study. patients presenting a gp prescription for a newly started ssri treatment to a community pharmacy were selected. 'non-accepters' were defined as those patients filling only a single ssri prescription, and patients who received at least three prescriptions were defined as 'accepters'. setting: community pharmacies in the netherlands. main outcome measures: characteristics evaluated included sociodemographic (e.g. level of education), disease (e.g. reason for use) and treatment (e.g. type of ssri) characteristics. 'non-accepters' were also asked for the reason not filling a second prescription. results: 'non-accepters' and 'accepters' were included in the analysis. 'non-acceptance' was more common among patients with a low level of education (or . ; ci . - . ) and in patients who reported aspecific symptoms like fatigue, stress and restlessness as the reason for ssri use (or . ; ci . - . ). in addition, there was a trend that 'non-acceptance' was more common among patients over years of age (or . ; ci . - . ) . of all 'non-accepters', . % (n = ) did not start ssri use, while . % (n = ) discontinued ssri use within two weeks. fear of side effects and the actual occurrence of side effects are main reasons for not accepting ssri treatment. in addition, a considerable number of 'non-accepters' indicated that they felt an aversion towards medicine use, were feeling better meanwhile or disagreed the gp's diagnosis. of the 'nonaccepters', . % discontinued treatment without informing the gp. conclusions: acceptance of ssri treatment is a decisive moment in compliance to treatment initiated by gps, and deserves more attention. gps and pharmacists should address issues related to the use of ssris especially in groups who are at risk for non-acceptance. keywords: antidepressants, discontinuation, nonadherence edu- pharmaceutical interventions by pharmacists working within surgery and medicine departments julie prince , stephanie diallo , eric grandsire , anne lecoeur , caroline fijalkowski , michelle lebas-certain , franck le mercier pharmacy, ambroise pare hospital ap-hp, boulogne-billancourt, france background and objective: since , our pharmacy department set up a nominative daily drug distribution system without computarization. in each pharmaceutical unit localized in clinical departments, the prescriptions are screened daily by a pharmacist, then the drugs are delivered by a technician. our objective was to compare the frequency and content of pharmaceutical interventions in surgery and medicine departments. pharmacy, haematology, nurses' management, cancer centre henri becquerel, rouen, france background and objective: while several studies have evaluated the frequency and the consequences of medication errors, few have explored their causes. in particular, knowledge of nurses regarding treatment of their patients has been scarcely studied. this survey has been carried out to determine how nurses master medications prescribed to the patients they care for, and how often they access drugs database. design: this work is a prospective study carried out from february to april . we have decided to focus on the clinical audit method, following french health authorities recommendations. a questionnaire has been elaborated and submitted to nurses during semistructured interviews. setting: french cancer centre: nurses from an oncology department and from a haematology department. main outcome measures: data collected were: nurses' profile (age, length of service, competencies' self-assessment), knowledge on drugs prescribed to their patients (usage, administration, side-effects, drug interactions…), use of existing tools (i.e. drugs database) and possible tools to be developed by the pharmacy ward to help them in their daily practice. results: twenty out of twenty six nurses (mean age: , mean length of service: years) consider their medical knowledge as intermediate level. % of pharmaceutical classes are quite well known ( % of the indications are known). only % of drugs' inn are given and more than half of the generic drugs' names are not mastered. administration conditions and conservation are known for respectively % and % of the products. however, side-effects ( %), contraindications ( %) and drug-drug interactions ( %) are not acquired. in their daily routine, nurses face problems mainly related to: drug administration ( %), drug conservation ( %), and dealing with generic drugs and therapeutic equivalence ( %). % of nurses refer to a drug database several times a week when only % more than once a day. pharmacy ward is considered to give information on drugs on a 'regular' basis. three tools have been identified for their potential to help nurses: summarized data on drugs (card format), drugs administration and conservation tables. conclusions: this study has helped to define nurses' difficulties regarding patients' treatment, and their needs for information on drugs. it is also useful for the pharmacy ward to improve its relationships with clinical wards and feedback on treatments. training sessions will shortly be organised to improve the above results. results: the aim of the vita (vienna transdanubia aging) study is the early detection of alzheimer dementia and the discovery of its risk factors. at basic examination, dementia was diagnosed in out of patients ( %) at an age of years. in % of these cases dementia was classified as alzheimer disease. in addition, a clinically relevant depression was diagnosed in % of patients at basic examination, but only % of them were treated accordingly. the first re-examination after . years included those patients, who showed no or only mild signs of cognitive disorders at basic examination. % of these patients developed dementia within the period of . years. the first reexamination also revealed a rapid increase of patients with depression ( % vs. %). the incidence for the development of dementia was % in patients, who have never suffered from depression. however, in patients with the diagnosis depression at basic examination, the risk for dementia was doubled. we aimed to prove whether there is a statistically significant correlation between long-term medication with selected drugs and the development of depression. eleven classes of drugs were investigated, including calcium channel blockers, beta-and alpha-blockers, corticoids, statines, non-steroidal anti-inflammatory drugs, h -blockers, neuroleptic drugs, benzodiazepines, levodopa and opiates. medication was documented from those patients pharm world sci ( ) : - ( male, female) without dementia and depression at basic examination, and without dementia at first re-examination. at first reexamination of them were depressive ( % male, % female), and had no depression (control group). for each class of drug, patients were divided into groups according to gender and duration of medication. a statistically significant (p \ . ) correlation was found between the treatment with benzodiazepines (c months) as well as beta-blockers (c months) and the development of depression in both male and female. conclusions: in elderly long-term therapy with benzodiazepines and beta-blockers can aggravate the development of depression. background and objective: pharmacogenomic studies aim to elucidate the genetic bases for interindividual differences and use such genetic information to predict the efficacy, response rate and safety of a selected drug. to date, the prognostic value of fccr polymorphisms as markers to predict treatment outcome in nhl is still being studied. our goal was to determine whether there is any correlation between fccriia polymorphisms and clinical response to rituximab in patients with nhl. design: in the present study we analysed fccriia polymorphisms in the genomic dna isolated from peripheral blood of patients with nhl who have undergone immunotherapy with rituximab. genotype analysis was based on a polymerase chain reaction (pcr) method followed by a restriction fragment length polymorphism (rflp) study. data were analysed using the computer software spss for windows (version . ) and treatment outcomes of the patients were compared using chi-square or fisher's exact test. a cut-off p-value of . was adopted for all the statistical analysis. survival estimates were calculated using the kaplan-meier method. the curves were examined by the log-rank test. setting: unit of molecular oncology of instituto português de oncologia, porto, portugal. main outcome measures: the response to therapeutics with rituximab was evaluated according to physical examination and computed tomography images. responses were scored according to international working group consensus. overall response rate (orr) was considered as complete response (cr), unconfirmed complete response (cru) and partial response (pr). overall survival (os) duration was defined as the period of time between st treatment with rituximab and either death or the last clinical evaluation of the patient. event-free survival (efs) was defined as the time interval between st treatment with rituximab and the occurrence of an event (recurrence or death) or the time of the last clinical evaluation of the patient. results: the orr for hh genotype was % and for r allele was % (p = . ). however, our results demonstrate that all patients carrying the hh genotype had complete responses to rituximab therapy. complete response rate for hh genotype was % and for r allele was % (p = . ). when comparing the fccriia genotypes, hh genotype or r allele does not have a significant impact on os at -year (p = . ) or on efs at -year (p = . ). conclusions: this study demonstrates that fccriia polymorphism is predictive of complete response to regimens containing rituximab in nhl patients, but is not predictive of overall or event-free survival. based on the current observation, rituximab has in some way an fccriia-dependent mechanism of action which is ameliorated in patients with hh genotype. we hypothesize that hh genotype increases affinity of fccriia receptor not only for naturally occurring igg , via antibody-dependent cellular cytotoxicity but also ameliorate connection with chimeric igg rituximab. keywords: non-hodgkin lymphoma, rituximab, pharmacogenomics pt- platinum salts, cancer and renal insufficiency. sub-group analysis of the irma study xavier pourrat , nicolas janus , stéphane oudard , isabelle ray-coquard , jean-philippe spano , jospeh gligorov , jean-françois morere , philippe beuzeboc , gilbert deray , vincent launay-vacher pharmacy, hôpital trousseau, tours, nephrology, gh pitié-salpêtrière, medical oncology, hôpital européen georges pompidou, paris, medical oncology, centre léon bérard, lyon, medical oncology, gh pitié-salpêtrière, medical oncology, hôpital tenon, paris, medical oncology, hôpital avicenne, bobigny, medical oncology, institut curie, paris, france background and objective: the irma study reported the high prevalence of renal insufficiency (ri) in solid tumour patients: mean age . , mean weight . kg ( . % between and kg), glomerular filtration rate (gfr) \ ml/min for - % [ ] . we present the results for irma patients who received a platinum salt (ps) as part of their chemotherapy. design: data were retrospectively collected for in and outpatients with cancer presenting over two periods in (february st- th and october st- th). setting: anticancer centers in france. main outcome measures: subgroup analysis of irma patients who received ps. data collected: sex, age, weight, serum creatinine (scr), type of tumor and anticancer drugs. the prevalence of scr [ lmol/l was assessed. gfr was estimated with cockcroft-gault (cg) [ ] and amdrd [ ] formulae. chi-square test was used to compare the prevalence of ri between patients who received ps and patients who did not. results: patients were included: mean age . and weight kg, men. the prevalence of scr [ lmol/l was . %. gfr \ ml/min was . % with cg and % with amdrd. the prevalence of ri was significantly higher in patients who received ps as compared to patients who did not receive ps (p = . ). there were prescriptions: . % carboplatin, . % cisplatin and . % oxaliplatin. . % of patients received carboplatin or cisplatin, the two drugs of this class needing dosage adjustment and being nephrotoxic. conclusions: ri is highly frequent in cancer patients receiving ps. appropriate evaluation of renal function necessitates cg or amdrd calculation. in addition, two third of those patients with pre-existing ri are at risk for iatrogenic acute renal failure still receive nephrotoxic ps. consequently, appropriate methods for the nephrotoxicity prevention of those drugs should be used as recommended for cisplatin by the escp special interest group on cancer care [ ] . [ ] prevalence of renal insufficiency in cancer patients and implications for anticancer drugs management: the irma study. cancer (in press). [ ] prediction of creatinine clearance from serum creatinine. nephron, ; : - . [ ] a simplified equation to predict glomerular filtration rate from serum creatinine [abstract] . j am soc nephrol ; : - . pharmacy, hospital la candelaria, tenerife, spain background and objective: to describe an quantify the pharmaceutical interventions in patients on total parenteral nutrition (tpn)and the drug related problems (drp)in patients on this type of nutritional support. to know the acceptance degree of the interventions and its relevance on patients' care and quality of life. design: prospective longitudinal study for four months (from january to april ). all patients on tpn were included. the registered data were: patients number, hospital departments, type of interventions and modifications on the tpn. setting: the pharmaceutical interventions were classified in: indication, effectiveness, safety and adherence according to the cipolle and cols methodology in order to identify de drp related to the tpn and/ or to the drugs. main outcome measures: all interventions were recorded both in the patient medical record and in a excel database in the pharmacy department. results: patients were evaluated and interventions were recorded. that means an average of interventions per patient and a duration average per nutrition of . ± . days. the drp were: indication . %, safety . %, effectiveness % and adherence . %, being the drp the most representative. the drp were listed in: nutritional assessment ( . %), monitoring ( . %) and individualized tpn ( . %). a total of patients ( . %) was favoured through some type of pharmaceutical intervention, being the most implicated hospital departments the neonatology and digestive surgery departments. a % of the interventions were focus on monitoring and optimization of nutritional support and % on drugs (diuretics, insulin, digoxine, enalaprile, and propofol). the acceptance degree of the interventions was %. conclusions: the individual monitoring of the patients with tpn represents an improvement of their clinical outcome and a lower incidence of drp. therefore, with this method we contribute to a lower hospital stay and it also may prevent the appearance of new adverse effects. main outcome measures: the number of interventions carried out and accepted, items concerned: regulation problems, nitrogenous and calorie intake, electrolytic intake, prescription omissions and eventually other fields. results: altogether, parenteral nutrition prescriptions were analyzed for one month in five pediatric units. the pharmaceutical analysis, which consumes hours a day for pharmacists, generated interventions for prescribers: % concerned electrolytic intake, more than half of which concerned potassium and sodium, the main dangerous electrolytes; % were prescriptions omissions; % about nitrogenous and calorie intake; % about other fields (weight error, incompatibility of lipids with divalent ions). of these interventions, which concern exactly prescriptions, were accepted by prescribers, that is %, leading to prescription modifications. conclusions: putting in place a systematic pharmaceutical analysis of parenteral nutrition prescriptions has ensured the detection and the correction of prescription errors. these errors concern mainly non adjustment of electrolytes to the biological results of the child. pharmaceutical interventions are important for safety of the patient and represent a privileged way to communicate with prescribers and their acceptance is, on the whole, satisfactory. background and objective: the number of elderly intensively increases and the fact that they consume a great amount of pom and otc drugs makes them a significant group of patients that need pharmacy care. unfortunately pharmacists often find their interaction with elderly clients very difficult and determined by many factors such as the sensory and physical limitations that accompany the aging process. to test the readiness of the elderly patients to communicate with the pharmacist, to assess the barriers that hinder the proper communication process and to provide a communication skills training in order to be improved the communication process. design: an experimental design involving two stages -assessment and education. setting: setting: the elderly patient center (hospice) and private community pharmacies both situated in the city of sofia, bulgaria. participants: patients aged + ( community pharmacy patients and patients from the elderly center). main outcome measures: an initial interview with the patients and questionnaire with the selected pharmacists to assess the level of communication and to clarify the hinders. communication skills training leaflets provided to the pharmacists. test of the newly received skills. final interview with the patients to be assessed the level of their satisfaction. results: the trained pharmacists that have passed the education process are more facilitated in providing pharmaceutical care that leads to the elderly patients' satisfaction (about %). additionally, the elderly patients obtained significantly more information from their pharmacists that leads to better care and avoidance of nearly half of the drug-related problems (drps) for this age. conclusions: pharmacist communication skills' training appears to be an effective means of enhancing the communication process in the pharmacy. background and objective: as the hospital has no pharmacists working in the multidisciplinary teams on the wards, we wanted to introduce and evaluate a clinical pharmacy service. design: a month prospective pilot study with three aims: . identify drug related problems (drps) (data collecting period of eight months). . design drug related information sheets and teach nurses. . evaluate the service by questionnaire. suggest cost-effective measures. setting: paediatric ward with beds, national university hospital. main outcome measures: the acceptance rate of the drps identified and suggested by the pharmacist, the number of drug information sheets introduced and lectures given to nurses. physicians' and nurses' views on the service. results: the pharmacist identified drps in ( %) of the charts that was screened. immediate action was taken in ( %) of the cases, the physician considered ( %) of the suggestion rational but no immediate action was taken due to various reasons, and ( %) of the suggestions were not approved by the physician. the most commented drp was ''dosage'' ( %), which included too low or too high dose, non-optimal administration time or inappropriate formulation. the pharmacist designed six drug information sheets and gave five lectures. cost-effective measures were suggested for drug handling and specific drugs. seven out of eight physicians and all nurses (n = ) considered the pharmacist a natural participant in the multidisciplinary team. conclusions: quality assurance of drug treatment may be performed by a clinical pharmacist, not only by the traditional way of identifying drps, but also by designing drug information sheets and teaching. the clinical pharmacist is also capable of suggesting cost-effective measures. physicians and nurses considered the clinical pharmacist a natural participant in the multidisciplinary team. as a result of this project, the clinical service will continue and also be introduced to one of the other paediatric wards. keywords: drp, paediatrics, quality assurance pc- iatrogeny and drug dispensations for outpatients: implication of a hospital pharmacy emilie degris , isabelle peyranne , anne laure sarda , nadine malric , brigitte bellon pharmacie, hôpital paule de viguier, chu toulouse, toulouse cedex , france background and objective: in france, some drugs are not available in community and outpatients have to go to hospital to obtain their treatment. our objective was to assess the role of the pharmacist in prevention of iatrogeny when dispensing drugs, in particular medication errors at high risk for the patient. design: a month retrospective study, from december to may setting: pharmacy of paule de viguier, teaching hospital of toulouse, france main outcome measures: each error encountered was recorded and analysed. first, we determined the number of errors avoided and the number of errors effective (divided into groups: non avoided and created by pharmacy). then, we quantified the frequency ( = once, = from twice to ten times, = more than ten times) and the severity ( = no risk, = weak, = moderate, = high) of each error. the multiplication of those two parameters gave us the level of the risk of error for the patient ( = no risk, to = weak risk, and = moderate risk, = high risk). finally, for each type of error we noted the actors. results: we made dispensations during the period of the study. we recorded errors ( . %): ( for dispensations) were avoided by the evaluation of the pharmacist, were not avoided ( for dispensations) and were created ( for dispensations). among the avoided errors, ( . for ) were at high risk ( ), ( for ) at moderate risk ( or ), ( . for ) at weak risk ( or ). the actor of of them was the prescriber (mainly lack of information on the prescription like no dosage). among the effective errors, ( . for ) were at moderate risk ( or ), ( . for ) at weak risk ( to ), ( . for ) had no risk ( ). the actor of of them was the pharmacy. conclusions: the errors for the activity ''retrocession'' are not numerous. the majority of them are stopped by the evaluation of the pharmacist, in particular those at high risk for the patient. we implemented curative and preventive measures to decrease the number of errors made both by prescribers and pharmacy. background and objective: despite improved treatments and guidelines, asthma control remains suboptimal. in a recent observational study, we described the asthma control test Ò (act) as an easy tool to measure asthma control of patients presenting at community pharmacies ( ) . the present randomised controlled trial was set up to study the hypothesis that a pharmacist intervention, focused on optimal use of asthma medication and tailor-made to the patient's current asthma control, would result in improved asthma control in adult patients. design: a -month randomised controlled trial in asthma patients: patients in the control group (c) and patients in the intervention group (i). patients in the control group received usual care. patients in the intervention group received a protocol defined pharmacist intervention, mainly focusing on inhaler technique and adherence to controller medication. setting: randomly selected community pharmacies in flanders (the dutch speaking part of belgium). main outcome measures: primary outcome was the level of asthma control, as measured by the asthma control test Ò . secondary outcomes included rescue medication use, night-time awakenings due to asthma, patients' peak expiratory flow, inhalation technique, adherence to controller medication, quality of life, knowledge on asthma and smoking behaviour. results: mean act scores did not change from baseline for both study groups (act at baseline for c: . , i: . -act at months for c: . , i: . ). however, a predefined subgroup analysis of patients having insufficiently controlled asthma at baseline showed that the intervention significantly increased act scores during the course of the study compared with usual care (p = . ). the intervention also significantly reduced reliever medication use (p = . ) and the frequency of night-time awakenings due to asthma (p = . ). inhalation technique (p = . ) and adherence to controller medication (p = . ) were significantly better in the intervention group. these findings suggest that the more effective use of asthma medication is responsible for the improvements in symptom control. there were no differences between control and intervention group in peak expiratory flow, quality of life, knowledge on asthma and smoking behaviour. conclusions: a pharmacist intervention can significantly improve outcomes for asthma patients (clinicaltrials.gov number nct ). background and objective: patients admitted to surgery departments receive multiple drugs before, during and after surgical procedures. drug-related problems (drp) are the most common cause of injury to hospitalized patients. in pharmacotherapeutic follow-up (ptf) a pharmacist is responsible for drug-related patient needs by detecting, preventing and solving drug-related problems (drp) aiming at specific results to improve patient quality of life. drp are pharmacotherapy negative outcomes leading to failed therapeutic goals or undesirable events. when a drp appears, it affects not only older hip fracture patient health, but also the effectiveness of hospital health care. the general objective of this study was to demonstrate that ptf improves the hip fracture assistential process quality, comparing some quality indicators of this process between patients in study group (sg) and control group (cg). design: cuasi-experimental study with control group. ptf was the intervention. setting: two traumatology wards in a large teaching hospital, ''hospital san cecilio'', granada, spain. the period of study was from january to july (sg) and the same period but in (cg). main outcome measures: incidence and types of drp; drp solved in sg; differences in lengh of stay, six-months mortality and threemonths readmissions between study and control groups. results: the incidence of drp was % in sg (n = ) and . % in cg (n = ). in sg, more than % of drp were resolved. in sg and cg the % and % of drp were related to medication need, % and % to effectiveness, and % and % to safety, respectively. mean length of stay was days in sg and . in cg. in general, patients with drp had a significative longer length of stay ( . d) than those without drp ( d); but in sg, patients in which drp were solved had the same length of stay than those without drp. sixmonths mortality was . % in sg and . % in cg, and readmissions was . % and . % respectively. . % (n = ) of patients reported an aspirin allergy that triggers their asthma attacks. . % (n = ) had never used aspirin before and did not know whether they had any sensitivity to aspirin. . % (n = ) of subjects could correctly describe and distinguish between preventor and releiver drugs. . % (n = ) confused the terms, while . % (n = ) had no idea about these terms. % (n = ) of asthmatics had received previous inhaler usage education from a specialist (doctor, nurse or pharmacist). of these patients had ineffective inhalator usage although they had ostensibly received education. the inhaler technique of the remaining who had been previously educated was accepted as successful. % (n = ) of the patients had never received inhaler usage education before a specialist. of these patients demonstrated successful technique but of failed. conclusions: the results of this pilot study indicate that some asthmatics are ignorant of their condition. in addition most of them seem to have no comprehension of the concepts of preventor or reliever therapy. despite prior education about half (n = ) were unable to demonstrate successful technique. furthermore cigarette smoking may be a detremental factor to the lives of asthmatic patients. this results of this study suggest the potential benefit of an innovative pharmacist led patient education service among asthmatic patients in turkey. background and objective: according to a recent meta-analysis, drug-related morbidity leads to . % of preventable hospital admissions causing enormous expenditures. in austria, there are only data on the incidence of adverse drug reactions (adrs) of psychiatric drugs. clinical pharmacy is not widely practised at hospital ward level. with this study, we aim to evaluate and document adrs leading to or occurring during hospital admissions. to improve the co-operation of doctors and pharmacists in an austrian hospital, to enhance doctors sensitivity in detecting drug-related morbidity, to increase patient safety and lower costs by reducing hospital admissions. design: two study nurses especially instructed about typical symptoms of adrs identify and document these cases prospectively in cooperation with doctors on selected internal wards for a period of three months. these cases are evaluated by a clinical pharmacist by means of a computer tool and data-base specialised on detecting causality and severity of adrs. results and outcomes form the basis for structured feedback to doctors. setting: university teaching hospital. main outcome measures: quantity and quality of adrs connected with hospital admission. results: during the first six weeks, patients were screened. sixty three adrs ( female) were identified ( . % of admissions). more than % of adrs occurred in patients more than years old. reasons: polypharmacy (mean number of drugs on admission . ) and reduced renal function (mean creatinine clearance . ml/min). diuretics, oral anticoagulants, nsaids, digoxin and antibiotics were most frequently associated with drug-related problems. water-electrolyte imbalance, overantigoagulation with or without bleeding, gastrointestinal problems and bradycardia are some of the most common problems. results concerning the severity of adrs will be available in september . conclusions: adrs are frequent in austria. incidences are comparable to numbers given in the literature. mainly older patients are affected. the impact on clinical practice is yet unknown. background and objective: adherence to cardiovascular treatment, particularly in the first year, is low and can result in serious complications. depression is associated with a fold increased risk of nonadherence with medical treatment. therefore, our aim was to investigate whether illness and treatment perceptions were associated to depressive symptoms in patients starting treatment for cardiovascular diseases. design: cross-sectional study with mailed questionnaire. setting: patients, who were dispensed at least a first prescription for a cardiovascular disease (anti-thrombotics excluded), were selected from pharmacies in the netherlands. main outcome measures: the questionnaire comprised the illness perception questionnaire-brief (ipq-b), beliefs about medicines questionnaire (bmq), the medication adherence report scale (mars) and the centre for epidemiological studies depression scale (ces-d). descriptive statistics and associations between depressive symptoms and the other study variables were assessed by bivariate correlations. results: sixty two ( . %) of eligible patients returned our questionnaire. the mean age was . yr ± . (range - ) and . % was female. patients reported to have hypertension ( . %), cardiac arrhythmia ( . %) and hypercholestereamia ( . %). the mean score on ces-d was . ± . and median self-reported adherence (mars) was . reports of depressive symptoms increased with emotional response (ipq-b emotional response, r = . ), the perceived consequences (ipq-b consequences, r = . ) and increased experience of symptoms (ipq-b identity, r = . ) attributed to their cardiovascular disease. depressive symptoms correlated with concerns about medication (bmq, r = . ), but not with self-reported adherence. adherence was relatively high, as . % of the sample had the maximum mars score of . conclusions: in patients who started cardiovascular treatment, perceptions about cardiovascular disease and concerns about medication are associated with report of depressive symptoms. depressive symptoms did not correlate with self-reported adherence. the majority of patients reported excellent medication taking behaviour, which might reflect their awareness of the importance of adherence or reluctance to report deviant behaviour rather than their actual behaviour. further research is needed to clarify this finding. results: fifteen nurses completed the questionnaire. % of the nurses were aware of the purpose of controlled release formulations. pharmaceutical codes added to brand names such as uno, zok, la and ocas related to prolonged activity were not recognised in % of cases. in contrast, retard and cr were linked to slow release by % of the responders. the purpose of enteric coated (ec) drugs was only known by %. in general, the nursing staff did not pay a lot of attention towards the prevention of drug-nutrient and/or drug-tube interactions. the recommended time interval between administration of enteral feeding and drugs was not respected. % of the responders would crush drugs together (in the same mortar) when multiple drugs are prescribed. based on the results of the survey, an intervention plan has been developed. this consisted of information rounds, a poster related to the topic and implementation of the use of a website dedicated to crushing medication developed by the flemish association of hospital pharmacists. background and objective: the detection and solution of drugrelated problems is an important activity within pharmaceutical care. this study focused on drug-related problems (drps) detected during dispensing of new prescriptions in community pharmacies and aimed to explore frequency as well as nature and the pharmacist's management of them. design: during their pharmacy internships fifth-year pharmacy students collected consecutively hospital discharge and primary care prescriptions. after training, they documented drps and interventions on an adapted pcne classification form. inclusion criteria were: age over , at least one new medication, at least prescribed drugs. setting: swiss community pharmacies affording the opportunity of internships for fifth year pharmacy students. main outcome measures: prevalence, nature and management of drps in community pharmacies assessed with an adapted pcne classification form. results: the patient's median age was years (iqr ) and they received a median of (iqr ; range - ) different drugs. prescriptions of patients ( ( . %) discharged from hospital) were analysed. in ( . %) of all prescriptions at least one drp was detected. the most frequent drps were potential interactions ( . %), wrong/improper application or time of drug intake ( . %), inappropriate drug ( . %) or inappropriate drug form for indication ( . %), no clear indication for drug use ( . %) and too high or too low dosage ( . %). these drps led to a total of interventions (multiple answers): patient counselling ( ); request of information from prescriber ( ); change of drug ( ; there from after consultation with physician), drug form ( ), dosage ( ), instruction for application ( ) or deliverable drug amount ( ); drug stopped ( ); start with new drug ( ); referral to a physician ( ); others ( ). out of all interventions . % could be managed by the pharmacist without any contact to the prescriber. there were no differences between hospital discharge and primary care prescriptions. conclusions: in the delivery process of new prescribed drugs drps are frequently observed prompting many interventions. most drps can be managed by the pharmacy. further studies are needed to analyse relevance of the problems and impact of according interventions. the main selection criteria were clinical relevancy (patient centred initiatives) reproducibility of clinical and economical outcome, outcome indicators and multidisciplinary approach. an approval by the hospital board and medical council must underline the willingness to integrate the clinical pharmacy in the patient care team. results: projects has submitted (on a total of hospitals). a total number of hospitals were selected to receive funding for clinical pharmacy activities. projects were quoted for a full time equivalent and projects for a half time clinical pharmacist. the projects described different fields or a combination of different aspects of pharmaceutical care like e.g. the transfer of information on medication use on admission and discharge conclusions: the funding of the belgian health authorities triggered a very high response rate, which proves the increasing attitude from the belgian hospitals to the positive impact of clinical pharmacy. the funding was complementary to other national projects to improve overall safety of medical treatment. also, many hospital administrators took the opportunity to enhance more economical and rational use of drugs. financial support by the belgian authorities of clinical pharmacy and the results of the projects could trigger a further integration of the hospital pharmacies into a patient care team. background and objective: the task of assisting patients in selfmedication practice is an important component of pharmaceutical care in spain. in order to provide appropriate self-medication counselling pharmacist should be able to distinguish between a minor ailment and one that it is not, and should, consequently, refer patients as necessary to gps. nevertheless, there are no criteria for referral to gp in spain. the objectives were:( )to identify the most relevant minor ailments, agreeing on the specific criteria for referral to the gp.( )to select the non-prescription drugs, with evidence of safety and effectiveness, for the treatment of the identified minor ailments design: qualitative study with an expert panel which was made up of primary care physician from semfyc and six community pharmacists (two members of sefac and four members of giaf-ugr). the expert panel held two meetings, of five hours each. it was established which minor ailments were considered most relevant within the framework of community pharmacy in spain. subsequently, the expert panel, reach an agreement on the general content that should be included in the protocols for the management of each selected minor ailment. finally, a working team composed of gps and three community pharmacists prepared the protocols, which were compiled into a guide for self-medication counselling. setting: university of granada, spain during . main outcome measures: identified minor ailments, content of the protocols for each minor ailment, non prescription drugs selected. results: it was selected minor ailments, allocated as follows; respiratory (rhinitis, cough, cold, flu), pain (period pains, sore throat, headache, backache, toothache), gastrointestinal (heartburn, diarrhea, constipation, vomiting, hemorrhoids), skin and mucous membrane (aphthae, acne vulgaris, cutaneous wounds, burns, stings, urticaria, herpes labialis, eczema lesions) and others (vaginitis, varicose veins, fever, conjunctivitis, insomnia). the following sections were specified in each protocol: banal and serious reasons or conditions that can lead to the symptom (including drugs); referral criteria according to the duration of the symptom and associated signs; drug treatment and non-pharmacologic therapies. it was selected a total of different non prescription drugs. conclusions: a total of minor ailments were identified as the most frequently demanded in community pharmacies in spain. referral criteria were based mainly in the duration of the symptom and other associated symptoms that are indicative of illness. for the treatment of these minor ailments, different non prescription drugs were selected. keywords: non-prescription drugs, minor ailment, community pharmacy services mareike kunkel , matthias ganso , irene kraemer pharmacy, johannes-gutenberg-university hospital, mainz, germany background and objective: in clinical pharmacy service was implemented in three surgical clinics (inclusive icu). drug related problems (drp) were identified by medication review and discussed with the physicians. from january to june all pharmaceutical interventions (pi) from pharmacists ( fte) were recorded (paper based) and classified according to drp (with the pi-doc Ò -system, which was modified to comply the requirements for hospital use ), intervention type, outcome and clinical relevance. the pis were documented and evaluated with an access Ò database. design: retrospective study of pis in surgical patients, identification of drp by medication review. setting: departments of neurosurgery, accident surgery and general/abdominal surgery ( , and beds, respectively), university hospital. main outcome measures: drp, intervention type, outcome, clinical relevance, drugs and admission diagnoses being at risk for drps. results: within six month patients were admitted. drps were identified in % (n = ) of the patients. patients with drps were older (mean = y sd ± vs. y sd ± ) and had an increased length of stay (mean = d sd ± vs. d sd ± ). pis were made. the acceptance by the physicians was . %. pis were classified to the outcome subcategory patient safety and clinical relevance was estimated as major (n = ) or moderate (n = ) by pharmacists. further data are based on these pis. the most often addressed drps categories were overdose ( %), no or insufficient drug monitoring, when necessary ( %), untreated indication ( %) and increased risk of an adverse drug reaction ( %). the type of recommended intervention varied: change dose/time of application ( %), stop drug ( %) and conduct drug monitoring ( %). drps related with the outcome patient safety and at least moderate clinical relevance were caused by drugs ( %). the most affected drugs were vancomycin ( %), diclofenac ( %), potassium ( %), acetaminophen ( %), digitoxin ( %), phenytoin ( %) and theophylline ( %). the incidence of the most frequently admission diagnoses of patients with relevant drp differed from the incidence of diagnoses of all admitted patients (incidence icd- (cost-)effectiveness has started to emerge ( ) . a literature review was carried out that a) summarized the findings of pharmaco-economic studies; b) evaluated the methodology employed by studies; and c) suggested how future research has to be designed to meet the requirements of a pharmaco-economic analysis. design: studies to be included are identified by searching electronic databases. due to limited relevance of older studies, the scope is limited to studies published between and . mainly three techniques can be used to conduct an economic evaluation: costeffectiveness analysis, cost-utility analysis and cost-benefit analysis. ( ) all studies are reviewed regarding results and methodological quality. nineteen out of studies met our eligible criteria. setting: clinical pharmacy services provided in a hospital setting. main outcome measures: results were analyzed in terms of number of preventable adverse drug events (ade), length of stay (los) and financial savings. methodological quality was assessed with respect to perspective, scope and measurement of costs and consequences, sources of data on costs and consequences, and application of an incremental analysis. results: a) nearly all studies conclude a financial benefit based on direct cost saving and estimated cost avoidance as a measure of prevented ade or shortened los. b) methodologically there are a number of shortcomings: e.g. not including the wage of the personnel, lack of control groups, use of expert panels to estimate savings and costs, possible selection bias, no valorization of health effects. c) a methodology for conducting a prospective economic evaluation of an observational study is proposed. conclusions: it is not obvious to calculate the net savings of a clinical pharmacy program or to compare different programs because there are no common guidelines for this type of assessment. the ideal protocol is hard to achieve, so best practice will be more realistic. addition of direct cost saving, labor cost and economic value of prevented ade and shorter los results in a lucrative service. these savings are higher for specific inverventions (like preventing ade, switch therapy) or disciplines (e.g. intensive care unit versus geriatrics background and objective: the contribution of pharmacists to the delivery of public health in scotland is recognised in national pol-icy , . the new community pharmacy contract with its emphasis on public health will provide a new framework in which the contribution of community pharmacy to improving health in scotland can be delivered. the objective was to define the core public health competencies applicable to community pharmacy practise, using the 'skills for health public health practice competency framework' . design: a web based delphi methodology was used to achieve consensus on which competencies, from the 'skills for health public health practice competency framework', should be met or aspired to by practising community pharmacists using a multidisciplinary group of expert stakeholders. two rounds took place. setting: primary and secondary healthcare and academia. main outcome measures: panel members rated their extent of agreement/disagreement that each community pharmacist should achieve or be striving to achieve that particular competency. consensus was defined as c % rating a competency as strongly agree/ agree. results: ten organisations ( % of those invited) and organisation members ( % of those invited) agreed to participate. responses were received from ( %) individuals in round and ( %) in round . consensus was achieved for / ( %) competencies in round and a further / ( %) in round . competencies achieving consensus predominantly focused on health improvement activities at individual and local community levels and ethical management of self, rather than those relating to surveillance and assessment, strategic leadership or research and development. conclusions: this research has identified that many of the competencies in the 'skills for health' document can be applied to community pharmacy. research has since been carried out, using focus group and questionnaire methodology, to investigate the views of practising community pharmacists. background and objective: in spain, off-label drug utilization (nonapproved indications, patient population, doses, administration route, association), must be derived to compassionate use, which requires a prior national health authorities (nha) approval and a monitoring plan and follow up information provided to them. request to nha includes circumstances of case and patient protection measures, including: physician assessment, informed consent and institutional clearance. the objective of this study is to analyse the strength of recommendation, strength of evidence and clinical efficacy of drugs prescribed outside the terms of product licence (off-label) in paediatric patients of our hospital. design: literature review to evaluate the evidence level: micromedex healthcare series, cochrane library, pub-med, embase, expert opinion or consensus. sample: % off-label drugs used in at least paediatric patients (prior spanish nha treatment approval required for every patient). years, retrospective observational study ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . setting: paediatric hospital ( beds) and pharmacy department ( pharmacist) in a large general teaching hospital ( beds, pharmacists). main outcome measures: categorisation of evidence-based medicine according to thomson ratings of recommendation (class i-iii), evidence (category a-c) and efficacy (class i-iii). results: paediatric patients ( % total patients: adults and paediatrics) used off-label drugs ( % total drugs: adults and paediatrics). out of this off-label drugs, % ( / ) only approved for adults, % ( / ) outside of license in terms of indication for adults and paediatric patients and % ( / ) both causes. off-label drugs for indications were used in at least paediatric patients: % anti-infective agents, % haematopoietic growth factors, % cytokines, % hormone therapy, % antiarrhythmics, % other therapeutic groups. the categorisation according to evidence-based medicine was: a) strength of recommendation class: % i, % iia; % iib, % iii and % indeterminant; b) strength of evidence category: % a, % b, % c and % no evidence; c) clinical efficacy class: % i, % iia, % iib and % indeterminant. conclusions: a higher proportion of off-label prescriptions is observed among paediatric patients, most of them related to nonapproved indications in this population. there is a broad range of therapeutic groups involved. the evidence of most off-label therapies are based on meta-analyses of randomized controlled trials with conflicting conclusions, small numbers of patients or significant methodological flaws or nonrandomized studies and, although the weight of evidence favors efficacy of the treatment for a specific indication, the therapy may be useful and indicated in some, but not most, cases. keywords: medicine-based evidence, off-label, paediatrics background and objective: there is an increasing demand towards the involvement of the community pharmacists in health promotion. it has been reported that community pharmacists have a successful role in providing services, which help to improve and promote health with regard to smoking cessation, coronary heart disease, skin cancer prevention, drug misuse, sexual health, immunization, mental health, diabetes, nutrition and physical activity [ ] . the aims of this study were to describe the current practice of community pharmacists with regard to their provision of health promotion activities, identify their willingness to participate in health promotion and identify the barriers that may limit their participation. design: a descriptive cross sectional study, which included community pharmacies that selected via stratified and systematic random sampling. data were collected via face-to-face structured interview of the respondents using a pre-tested questionnaire. setting: community pharmacies in khartoum state. main outcome measures: the extent of the pharmacists' involvement in counselling patients about health promotion topics, their preparation to counsel patients in health promotion topics, and their success in changing the patients' health behaviour. results: the response rate was . %. seventy five ( . %) of the study participants were strongly involved in counselling patients on health promotion related to medications, but less involved in counseling them on the other personal health behaviours such as tobacco use ( . %), alcohol use ( . %) and exercise habits ( . %). seventy two ( . %) of the respondents perceived themselves as very prepared to counsel patients on taking drugs and less very prepared to counsel them on other personal health behaviours. fifty two ( . %) claimed a high level of success in helping patients to change their behaviour with regard to medications, but not in relation to other personal health behaviours. ninety eight percent of respondents indicated their willingness to participate in continuing education programs to gain more knowledge and skills about health education and promotion. the main barriers facing the community pharmacists' participation in health promotion as perceived by respondents were lack of information and/or training ( . %) and lack of pharmacists' time ( . %). conclusions: community pharmacists reported to achieve considerable success in helping patients to change their behaviours in relation to medications, but were less successful of their ability to change personal health behaviours. the majority of the respondents have the interest and willingness to be a prime source of advice and support on health promotion. results: during the first study period, inpatients were exposed to major or moderate pddis. ( %) of these pddis were judged clinically relevant by the pharmacist. recommendations including pddi information, and simply information leaflets were handed out to the physicians. % ( of ) of the recommendations were accepted. at hospital discharge, in % ( of reviewed instances, which were accepted) the drug changes due to the recommendations were implemented. during the second study period, patients at hospital discharge were exposed to major and moderate pddis. ( %) pddis were assessed as clinically relevant by the pharmacist. recommendations including pddi information, and simply information leaflets were sent to the physicians. % ( of ) of the recommendations were accepted. one year after hospital discharge, of drug changes due to recommendations were still existent. overall, in % and %, respectively, of all major and moderate pddis detected by pharmavista, clinical management was adapted accordingly. conclusions: the management of clinically relevant pddis can be improved by physicians' advice of clinical pharmacists. changes in medication due to pddis were found to persist up to one year after hospital discharge. background and objective: current treatment options for metastatic renal cell carcinoma (mrcc) are limited and there is a need to identify novel and effective therapies. sunitinib is an oral multitargeted tyrosine kinasa inhibitor, which has shown activity in cytokinerefractory metastatic rcc patients. this agent inhibits vascular endothelial grown factor receptor and platelet derived growth factor receptor. the purpose of this study is to analyse the efficacy and safety profile of this agent in patients with mrcc. design: retrospective assessment in seven patients treated with sunitinib as second-line treatment in mrcc. data were obtained from clinical histories and informatic records from the oncology pharmacy department. setting: oncology and pharmacy department. la paz university hospital. madrid. spain. main outcome measures: assessment of clinical response and adverse events. results: seven patients were evaluated ( men, women), median age was ( - ). six of them presented bone, lung, brain or liver metastases, all patients were treated with vinblastine and ifn-alpha as first-line therapy. patients received sunitinib at a starting dose of mg per day in repeated -week cycles for consecutive weeks followed by weeks off treatment. they started therapy with sunitinib because of progressive disease in patients and adverse events in patients on previous therapy. sunitinib was discontinued in four of them, causes were: adverse events ( patient), volunteered dropout ( patient) and progressive disease ( patients). the median progression-free survival was . months. the median number cycles received was six and of the patients are still in treatment at the time of data analysis. dosage was reduced mg daily because of unacceptable toxicity: hand-foot syndrome( patient) and hypothyroidism ( patient). the most common adverse events experienced were: asthenia ( patients), diarrhea ( patients), damaged nails( patients), insomnia ( patients), dermatitis ( patients)and dehydration ( patients). conclusions: in our experience, sunitinib has demonstrated an acceptable efficacy and safety profile as a single agent in second-line therapy for patients with mrcc. (ii) validated questionnaire to guide discussion; (iii) fostering group interaction to generate data; (iv) post-interview analysis of verbatim transcripts with specialized software (qsr nvivo . for windows Ò ), based on the grounded theory approach (classification of emerging themes). setting: groups: prescribing physicians ( ), nurses ( ) , and laboratory technicians ( ) , all involved in antibiotic tdm as performed in orthopaedic surgery, general surgery, neurosurgery, vascular surgery, haematology, and pulmonary wards in a beds teaching hospital. main outcome measures: (i) issues causing poor antibiotic overall tdm performance, (ii) approaches for optimizing tdm performance supported by group consensus results: key identified issues: (i) nursing work overload; (ii) insufficient education to pharmacokinetics and lack of specific training; (iii) insufficient information communication and lack of coordination and involvement of all stakeholders; (iv) conflicting guidelines; (v) lack of perception of positive benefit/risk ratio. approaches for optimization (consensus): (i) continuous education of all stakeholders; (ii) daily multidisciplinary collaboration with infectious disease physicians and clinical pharmacists; (iii) simplification and uniformization of guidelines and procedures; (iv) implementation of a simpler administration scheme (v) increased staffing. conclusions: correct performance of tdm and its implementation in routine clinical care needs to be critically assessed and appears to be mainly dependent on non laboratory-related parameters. background and objective: new data published at the end of and the beginings of the , suggest not to exceed a haemoglobin level of g/dl to avoid cardiovascular morbility-mortality in patients with anaemia and chronic kidney disease (ckd) treated with recombinant human erythropoietin (rhuepo). before these evidences the optimal target haemoglobin levels was greater than g/dl. our aim is to evalue if these new published evidences have changed the clinical practice in pre-dialysis ckd patients. design: retrospective observational study. all the pre-dialysis patients who received rhuepo were including. in order to evaluate the possible changes in clinical practice, we measured the levels of haemoglobin prior to the publication of evidences (march-may of : group ) and after the publication of these evidences (march-may of : group ). we made a descriptive analysis of independent data. setting: department of hospital pharmacy. main outcome measures: the main outcome measures were: age, sex, mean glomerular filtration rate (gfr), mean haemoglobin level, mean haematocrit and type of rhuepo used. results: we studied patients ( in group and in group ). patients age ranging between to years (median = years). the proportion of women was . %. mean gfr for both years located around ml/min and the most frequent stages of renal injury were and . the most rhuepo used was darbepoetin alfa ( . % of patients). mean haemoglobin level for group was . g/dl (sd = . ) and . g/dl (sd = . ) for group . mean haematocrit was . % (sd = . ) and . % (sd = . ) for group and , respectively. conclusions: our nephrologist are cautious about of prescribing rhuepo, not only after the publication of the new scientific evidences on this subject, but before this too. it s worth questioning if clinical practice in ours hospital is different from the published evidences. background and objective: tacrolimus (tac)-based immunosuppression is effective in adult renal transplant patients with acute or chronic rejection or cyclosporin (cya)-related toxicity. the conversion from cya to tac resulted in improved cardiovascular risk profile and increased prevalence of post-transplant diabetes mellitus (ptdm)compared with treatment with cya. the aim of this study was to review clinical documents for renal transplant patients and assess patients' outcomes. design: a retrospective review of clinical data. excluded from the study were patients converted to tac less than months posttransplantation. statistical analysis (one sample paired -tailed t test) was performed using microsoft office excel . the graft survival was analysed with kaplan-maier survival curve using xl stat software. the study was approved by the northern ethics committee, auckland, new zealand. setting: tertiary care setting. main outcome measures: mean serum creatinine, incidence of ptdm, mean total cholesterol, hdl cholesterol, ldl cholesterol, total/hdl cholesterol ratio, mean blood pressure and antihypertensive scores, graft survival censored for death. results: forty-four patients were converted to tac more than months post-transplantation from to june . mean serum creatinine (scr) increased in the months prior to conversion from lmol/l ( % ci - ) to lmol/l ( % ci - ) at months post conversion to tac (p-value = . ). thirty-four patients were taking cya for more than months. the mean scr increased from lmol/l ( %ci - ) at the months prior to conversion to lmol/l ( %ci - ) at months post conversion (p-value . ). if scr for seven patients who had an acute rejection episode were excluded, the mean scr did not show any change in slope after conversion and showed a tendency to gradually increase from lmol/l ( %ci - ) to lmol/l ( %ci - ) months post conversion (p-value . ) eleven out of patients were affected by diabetes mellitus. six patients were diabetic pre transplantation and remained diabetic post transplantation and post conversion to tac. two patients developed new onset ptdm post transplantation and two became glucose intolerant. after conversion to tac, glucose intolerance resolved in one patient and one patient ( %) developed new onset ptdm. in patients converted to tac more than months post transplantation, mean total cholesterol was reduced from . to . mmol/l (p-value . ) and mean ldl cholesterol from . to . mmol/l (p-value . ). in june , / patients ( . %) were taking tac with a mean scr of +- lmol/l. four patients ( %) lost their grafts. mean graft survival time was . months. -year graft survival was . %. conclusions: conversion from cya to tac was beneficial with respect to renal function and cardiovascular risk profile. the conversion had no added benefit on renal function in patients with stable renal function taking cya more than months post transplantation. the reported incidence of ptdm was found to be low ( %). background and objective: most of the cancer patients suffer from severe pain especially during the terminal phase of the disease. it is essential to monitor these patients to achieve adequate and successive pain management, not just because of the importance of the effects, side effects and overdose problems; but also to improve quality of life. the aim of the study was to evaluate oncology pharmacist interventions on pain management. design: numeric pain scales was conducted prospectively among the cancer patient who were over years old and were selected randomly. patients were separated into two groups: of the patients was control group, pharmacist had been effectively included to the rest patient's pain management strategies, which was pharmacist intervention group. all of the patients had been evaluated by numeric pain scales (time ). the patients who were on pharmacist intervention group were monitored by pharmacist on treatment effectiveness and side effect profile every three days during the study. after one month, numeric scales were repeated (time ). the interventions that pharmacist done were pain evaluation, suggestion on appropriate pain reliever, dose management, patient education and patient monitoring. our therapy recommendations were made on the basis of the world health organization's analgesic ladder following the results of assessments. setting: oncology outpatient unit of a university hospital main outcome measures: the demographic and diagnostic information of the patients were collected. the results of the evaluations via numeric pain scales were calculated by using arithmetic mean value. results: the mean of pain intensity was significantly decreased in pharmacist intervention group when compared with control group ( . ± . vs. . ± . , p = . ) and between time and time ( . ± . vs. . ± . , p = . ). the mean of pain's effect on daily activity was significantly decreased in pharmacist intervention group when compared with control group ( . ± . vs. . ± . , p = . ) and between time and time ( . ± . vs. . ± . , p = . ). the mean of drug effectiveness was significantly increased in pharmacist intervention group when compared with control group ( . ± . vs. . ± . , p = . ) and between time and time ( . ± . vs. . ± . , p = . ). conclusions: the harmonious working of the pharmacist with the other health care staff working in oncology unit, helped patients to achieve more effective pain management. in this study; pain intensity was decreased, pain interfered less with daily activities was, and the reported effectiveness of drugs was increased in the pharmacist intervention group compared to the control group. all these outcomes show that the clinical pharmacists have an important role in oncology services, especially pain management. background and objective: to investigate and compare the frequency and nature of prescrbing errors requiring contact with the prescriber at community pharmacies in norway, estonia and sweden. design: a protocol, based on a scheme originally presented by rupp ( ), revised and developed by kennedy ( ) and translated and transformed to the nordic context by haavik ( ), was used in all three settings. in norway the protocol was self-completed by the pharmacists; in sweden and estonia observers (trained students) recorded and classified the interventions. setting: norway - community pharmacies in southern and western norway; estonia - community pharmacies in three cities; sweden - community pharmacies in swedish cities and public pharmacies at hospitals in sweden. main outcome measures: prescriptions with errors or ambiguities where the pharmacist decided to contact the prescriber to correct, clarify or complete the information on the prescription. results: the total numbers of dispensed prescriptions were: norway , , estonia , , sweden , (community pharmacies) and , (public pharmacies at hospitals). the proportion of handwritten prescriptions and prescriptions where pharmacists contacted the prescriber was higher in estonia than the other countries. administrative problems -reimbursement issues; prescriber data and distribution and licensing issues -were the reason for more than one third ( - %) of all contacts with the prescribers in all settings. however, the patterns of prescription problems with potential clinical hazards varied -in estonia and norway, errors concerning strength, administration form and number of doses were the most common errors and constituted and % of the problems. in sweden, errors concerning the prescribed dosage were the most common reasons. conclusions: the proportion of problem prescriptions requiring a clarifying contact with the prescriber was higher in estonia compared to norway and sweden. the main reason may be that most prescriptions in estonia were handwritten. administrative problems (reimbursement and availability of prescribed products) constituted a similar large portion in the three countries. however, prescription problems with potential clinical consequences for the patients, varied. , presenting with salmonella bacteremia and neurological deterioration due to cerebral toxoplasmosis was admitted to the intensive care unit. he was immediately intubated. to treat toxoplasmosis, cotrimoxazole was started in a dose of mg smx/ mg tmp qd. days later the patient developed leucopenia (absolute wbc count: . /l, neutrophils: . /l). folinic acid mg od was associated to restore white blood cell count. neutrophils further dropped to attain its nadir ( . /l) on day of cotrimoxazole therapy. cotrimoxazole was stopped and clindamycin mg td was used instead. neutrophil count restored, normalizing on day after stopping cotrimoxazole. this event was attributed to the administration of cotrimoxazole. the time relation between the administration of cotrimoxazole and the onset of neutropenia as well as the normalisation of neutrophils was clear. other explanations, such as the contribution of concomitant medication (ranitidin, ceftriaxon, ethambutol, isoniazid, rifampicin, aciclovir, amphotericin b, enoxaparin)could be ruled out. the naranjo score, which estimates the probability of adverse drug reactions, is . the use of folinic acid as rescue therapy in association with cotrimoxazole is controversial, as it can theoretically antagonise the anti-infective action of cotrimoxazole. therapeutic failure in aids patients, receiving this combination for pneumocystis jiroveci pneumonia, has been reported. nevertheless, we decided to start folinic acid to further prevent nosocomial infections in this severe immunocompromised host. we don't know whether folinic acid contributed to quick recovery of neutrophil count in our patient. further studies are necessary to clarify its role as rescue agent during treatment with folic acid antagonists. conclusions: this case report illustrates that cotrimoxazole, frequently used in opportunistic infections, can be associated with agranulocytosis. this dangerous complication in immunocompromised patients with severe infections must be prevented, although the effectiveness of folinic acid as rescue therapy is still a matter of debate. background and objective: intravenous immunoglobulin (ivig) therapy is increasingly used in inflammatory and autoimmune disorders, because of its therapeutic benefit and its good safety profile. cutaneous adverse events are rare and include prurit, rash, alopecia and eczema. in the literature, about cases of eczematous skin reactions have been reported. most of the cases were treated for a neurological or neuromuscular disease. erythematous eruptions on hands and feet have been notably reported after high-dose infusion. in most of the cases, the eruption was progressively extending to involve the entire body. when ivig were readministered, eruptions were more rapid and more intensive. we report an eczematous skin reaction of the palms after ivig infusion without extensive eruption, in spite of three administrations. design: case report. setting: neurology ward, university hospital, grenoble, france. main outcome measures: a -year-old man was treated with ivig (tegeline Ò , lfb, france) for an inclusion body myositis. he developed a skin reaction, days after the end of a days ivig infusion (dose of . g/kg was given daily for consecutive days). the eruption was a non-pruriginous erythematous maculopapulovesicular rash located on the palms. this reaction occurred th day after completing the second therapy and did not extend. the lesions regressed progressively with topical application of fatty ointment. three days after the third infusion, the same lesions reappeared, and regressed the same way. results: clinical pharmacist with the help of pharmacovigilance experts and doctor worked collaboratively: because of the chronology of exposure to other treatments, intrinsic imputability and recurrence on reintroduction, we ruled out an adverse drug reaction to any other medication. we decided not to interrupt the infusion. we advised the patient to continue fatty ointment application and to tell the healthcare team if the reaction became more serious. conclusions: dermatologic adverse reactions such as eczematous skin reactions are rare and usually mild. there is no reason to limit the use of ivig in a case like this one, as long as the treatment is effective. however, a narrow clinical and biological follow-up is required. if necessary, this adverse effect can be prevented by antihistamines or even steroids. anticoagulants must be monitored closely by physicians, because this products have a narrow therapeutic index. numerous interactions with herbs are documented, either increasing or decreasing the anticoagulant effect. our main objective is to identify this interactions in our surgery and if they are clinically significant. design: six months observational study; interviewing patients with their inr alterated about herbs that they were taking at that moment. literature review. setting: the anticoagulant oral treatment surgery. main outcome measures: the two oral anticoagulant drugs available in spain are acenocoumarol and warfarin. the international normalized ratio (inr) is the laboratory test used to measure therapeutic efficacy and safety of vitamin-k antagonists. a control test is done every four weeks and if necessary it can be done earlier. results: among patients with inr [ , six of them were taking herbs at the same time, and we could relate the increase of the effect of oral anticoagulants to those products. one of this patients who was taking dandelion (tarxacum officinale) had a inr. an other one who was taking chamomille (matricaria capensis) and passion flower (passiflora incarnata) had a . inr. all of these products have coumarins compounds. two patients who were taking equinacea (equinacea purpurea, equinacea angustifolia) also had their inr test altered: one had a . inr and the other one . . an other one was taking bilberry (vaccinium myrtillus) and had a . inr. both, equinacea and bilberry inhibit different isoenzimes of cytochrome p . the last patient was taking garlic oil (allium sativum) and had a inr. garlic increases the anticoagulant effect. conclusions: it is commonly believed that herbal products are inofensive, that is the reason why mainly of the patients do not take medical advise before starting a treatment with them. however, there can appear interactions with the usual treatment. if we fix on the vitamin-k antagonists the risk resides on the hemorragic or strokes events. in conclusion, we believe that patients should be educated about the potential risk of using herbal products while being treated with vitamin-k antagonists. a year-old man, treated with clopidogrel after coronary stenting, is hospitalized for aa (neutrophils: g/l ( . - g/l); haemoglobin: . g/dl ( - g/dl); platelets: g/l ( - g/l)). his permanent medications were insulin, perindopril, omeprazole, atorvastatine, bisoprolol, and acetylsalicylic acid. clopidogrel ( mg/d) was prescribed weeks before aa occurence. clopidogrel is withdrawn and aa therapy is started, consisting in the sequential association of anti-thymocyte globulin therapy ( mg/kg) and ciclosporin ( mg/ kg/d) in a filtered-air room. but the severe co-morbidities lead to early stop ciclosporin, then relayed by androgen therapy (norethandrolone). finally, at weeks from the diagnosis, the evolution ends to a resolution of aa, but with platelet-transfusion dependance. after the elimination of the other aetiologies, iatrogenic cause is envisaged. to blame clopidogrel is difficult with regard to the other drugs, especially perindopril and omeprazole known to induce bone marrow failures. four arguments lead to target clopidogrel: (i) the length of treatment by perindopril and omeprazole without complications, (ii) the timing between the onset of aa and the addition of clopidogrel to treatment, (iii) the resolution of aa whereas neither perindopril nor omeprazole were withdrawn, and (iv) the support of the literature. conclusions: clopidogrel seems to be responsible of this side effect. we unfortunately lack in specific biological tests to prove it. keywords: clopidogrel, side-effects, pharmacovigilance background and objective: informing patients on their medicines is a patient right. what does current information provision on antidepressants to patients with a depression admitted to a psychiatric hospital look like? what is the current practice of health care professionals? what are the experiences of patients? this study aims to explore current practice on drug information provision in psychiatric hospitals. design: a qualitative study consisting of semi-structured interviews with separate interview guides for health care professionals and for patients. interviews were tape recorded, verbatim transcribed and analyzed using nvivo software. setting: eight flemish psychiatric hospitals. main outcome measures: identification and evaluation of current approaches to drug information provision on antidepressants from the point of view of health care professionals as well as patients. results: patients get information on antidepressants, firstly, through psychiatrists and, secondly, through nurses. hospital pharmacists have a supporting role. the approach in giving information depends on patient characteristics and his/her mental state. information is provided mainly orally. leaflets are not frequently distributed to patients. patients also get information on antidepressants during psycho-educational sessions. on request, patients can read a package insert under supervision of a health care professional. health care professionals consider non-verbal cues of patients to verify if information has been understood. information is repeated when the first instruction was not clear for patients. there are no systematic interdisciplinary contacts on information interventions. patients as well as health care professionals are satisfied with current practice on information provision. health care professionals reported lack of time and lack of interdisciplinary contacts as negative aspects. patients indicated that health care professionals take too little initiative to give information about medicines. positive aspects reported by health care professionals are the hospitals' openness and the opportunity for patients to ask their questions to psychiatrists as well as nurses. suggestions for improving practice are: providing more medication information to patients, in particular on side-effects; enhancing the availability of easy readable information; and organizing continuing education for nurses on medicines. patients are informed about their antidepressants through various pathways. however, there seems to be room for improvement as a number of suggestions were formulated to support these pathways of drug information. keywords: medication information, antidepressant, psychiatry claire chapuis , christine chevallier , céline villier , pierrick bedouch , benoît allenet , jean calop , gérard besson pharmacy, pharmacovigilance, neurology, university hospital, grenoble, france background and objective: the use of intravenous immunoglobulin (ivig) is expanding. the risk for adverse effects can be minimized by taking some precautions. there are yet no standardized practice guidelines for prevention and management of adverse effects occurring during the infusion, and there is a need for it. the purpose was to conduct a study of their knowledge among the nurse community and to make a review of the best practices. design: we search in medline and carried out a questionnaire for nurses. we evaluated knowledge and practices of nurses in neurology, pneumology and haematology units, experienced in intravenous immunoglobulins administration, in order to define their role and the prescribers role in ensuring patients safety during therapy. we used all information and synthesized it in a table. for every type of adverse reaction, we indicated mechanism, frequency, seriousness, risk factors, practical guidelines of management and prevention and actor. the guidelines were reviewed by experts (pharmacist in charge of human derivative products, pharmacovigilance experts and neurologists). setting: university hospital, grenoble, france. main outcome measures: formalisation of practical guidelines on prevention and management of intravenous immunoglobulin adverse effects, for prescribers and nurses in the local hospital network and possibly other hospitals. results: nurses always checked the doses before administration ( / ), always prepared the product aseptically ( / ), warmed up the product until it reached room temperature ( / ), but only few recorded the patients tolerability during the infusion ( / ), and very few knew that most adverse events could be minimized first by slowing down the rate of infusion ( / ). all nurses called a doctor as an adverse effect appeared. conclusions: nurses must be involved in the management of adverse effects, even if the prescriber remains the one who makes the prevention by evaluating risk factors, co-medications, dosing and frequency of treatment and the one who makes the decision to interrupt the treatment if an adverse effect occurs. the clinical pharmacist in care units works collaboratively with both prescriber and nurse. he plays a central role for preventing drugs' adverse effects while counselling every member of the healthcare team background and objective: fludrocortisone tablets - lg (f) is mainly used in the treatment of adrenocortical insufficiency. it may also be used in treatment of orthostatic hypotension. f is manufactured by ageps (public special-order manufacturer) and dispensed to outpatients by hospital pharmacies, as a ''hospital preparation''. in order to follow gmp guidelines, a patient information leaflet for f was elaborated in our pharmacy outpatient unit. the leaflet was approved by our regulation unit. to evaluate the usefulness of this leaflet and to improve its quality, we performed a patient satisfaction survey. design: during days, for every dispensation of f, a leaflet was presented to the patient and an anonymous satisfaction survey was performed. setting: pharmacy outpatient unit, agence générale des equipements et produits de santé (ageps) (ap-hp), paris, france. main outcome measures: the questionnaire consisted of three items: general information about patient and its treatment; patient's knowledge of f before reading the leaflet (uses, precautions, adverse events, storage); patient satisfaction of leaflet (general presentation, language simplicity, information volume, utility). results: patients answered the questionnaire. the mean age was years ( - years). mean f treatment duration was years ( months- years). % of patients were already informed about f: % by physicians and % by associations and internet. % knew the indication ( % adrenocortical insufficiency and % orthostatic hypotension). % knew about precautions, % knew about side effects, and % knew about storage conditions. % of patients did not read the leaflet and had no opinion about satisfaction items. % were satisfied of general presentation. language was understandable for %, and non understandable for %. information volume was sufficient for %, insufficient for %, and too large for %. leaflet was useful for % of pts. patients who found the information insufficient suggested the following items: results of clinical trials, management of acute situations due to disease or f, and contacts of qualified centres in case of serious events. conclusions: nearly half of the patients were informed about f by their physicians, but information is communicated orally without written support. the majority of patients treated by f knew about precautions, side effects, and storage conditions. however, patients were satisfied of our information leaflet and find it useful. leaflet appears to be a good tool to communicate information from the pharmacist to the patient when not available in the packaging. of these recommendations taken into account ( %), within a period of days for most (n = ), involved the intervention of a pharmacy student, were given only via the computer software, and via a telephone call. conclusions: computerisation of prescriptions is an indispensable tool in order to make the pharmaceutical distribution circuit safer. however, its use as a vehicle for pharmaceutical interventions is limited, as shown by this study. it is impossible to analyse a nonresponse of our recommendations: is our advice even red, is it considered as inadequate? a discussion with the clinician (via pharmacy students or on the telephone) allowing a constructive exchange of knowledge, leads to a better transmission of recommendations. background and objective: in hospital setting, employees may be exposed to hazardous drugs. risks and protective measures needed when handling parenteral cytotoxic drugs are well described, whereas information related to drugs like monoclonal antibodies or antivirals are lacking. we developed a standardized method to evaluate drugs potential toxicity and occupational risks taking into account the pharmaceutical forms of the drugs to balance the risks. design: development of an algorithm for toxicity evaluation using material safety data sheet (risk and safety phrases), international agency for cancer research (iarc) classification and official manufacturers' data. . evaluation of chronic toxicity (mutagenicity, carcinogenicity), acute toxicity (sensitisation or irritation in contact with skin, eyes or by inhalation) and toxicity to reproduction . balancing of toxicity according to the pharmaceutical forms . assessment of protective measures (centralization of drug preparation in the pharmacy, wearing of mask, gloves and/or glasses) centralization of drug preparation in the pharmacy is recommended only in case of documented mutagenicity and carcinogenicity and when there is a risk of respiratory or cutaneous exposure related to the pharmaceutical form. setting: university hospital ( beds). main outcome measures: • chronic (r , r , r or iarc group , a or b), acute toxicity (r - , - , - ; s - , - ) and toxicity to reproduction (r - ; cat.d,x) • pharmaceutical forms associated with a risk of respiratory (e.g. tablets crushing), cutaneous (e.g. drug in solution) or ocular contact (e.g. inhalation) results: occupational risks of parenteral monoclonal antibodies, oral and parenteral antivirals, oral cytotoxics and other drugs forms were analysed. according to our algorithm, crushing of % of the tablets forms should be done in the pharmacy (e.g. valganciclovir). only parenteral antiviral should be reconstituted at the pharmacy (ganciclovir). monoclonal antibodies were found not to be at risks of mutagenicity or carcinogenicity and only gloves will be recommended for their manipulation. no ''class-effect'' has been pointed out (e.g. only a few antivirals were found to be hazardous). products were at risks for pregnant women. protective measures to be taken by pregnant nurses or those wishing to have a baby will be discussed institutionally. conclusions: toxicity evaluation of hazardous drugs handling in hospital should take the pharmaceutical forms into account as some toxic drugs may not be associated with occupational risks (e.g. coated tablets). our method allows a standardized way to evaluate whether a drug should be treated as hazardous or not. results will be discussed institutionally in order to implement applicable policies and procedures. results: lidocaine % injectable solution is indicated for tracheobronchial anesthesia, via bolus of mg in adults, and to mg in children. the maximal dose is restricted to mg/kg in adults and - mg/kg in children. epinephrine is indicated in hemorrhagic complications occurring during interventions; the solution is diluted to mg/ ml with nacl . %; a lg bolus is injected and can be repeated up to mg. terlipressine can be used in heavy bleedings; the powder should be reconstituted with nacl . %, at mg/ ml; mg is injected, repeated if necessary. mesna is used to dissolve mucous plugs, especially in patients with cystic fibrosis. the solution is diluted to mg/ml with nacl . %; bolus of ml are injected to allow visibility in the lower airways. there are no data available on the maximal dose. all preparations have to be compounded aseptically and extemporaneously by the nurse when requested by the physician, because of the lack of stability studies in those ranges of concentrations. conclusions: these guidelines are intended to standardize flexible bronchoscopy procedures between the different units, in order to minimize the occurrence of medication errors. almost half of the enquiries ( . %) were about stability and incompatibility in intravenous (iv) admixtures. the frequency of these calls was significantly higher than the calls came from other health professionals (p \ . ). the following types of enquiries were about dosage ( . %) and availability of pharmaceutical products ( . %). while . % of enquiries were answered by hizbim in less than minutes, in % of all calls took more than day to gather and tailor which requires more literature search. the mostly ( . %) used references in retrieving information was general references followed by micromedex ccis inc. with . %. • hizbim has been consulted by nurses in a rising pattern. this means that this service is of importance for them because of its rapidity, accuracy and currency • the preparing iv admixtures that has been left to nurses' responsibilities in practice in our country can be reconsidered by pharmacists since this service has been fulfilled by ''drug experts'', namely pharmacists in many countries. • drug information centers can provide not only emergent information for nurses but also education such as seminars and conferences in some topics they need. the establishment of drug information centers in hospital settings will be of use to stimulate the frequency of consultations by nurses and to improve patient care provided by them. background and objective: the concept of pharmaceutical care (pc) is capturing the attention of a growing number of pharmacists. the strategy followed by us to spread out the implementation of pc in pharmacies involves the utilization of internet tool as an innovation of traditional education. design: to do so, we designed an on line pc course with interactive cases. the specific goals of the course are: • the enhancement of the pharmacy practice. • the promotion of practice research. • the personal and professional development of pharmacists. the objective was to analyse the evolution of the program, whose pedagogical design was based in a process of teaching-learning in the field of the clinical pharmacy and pharmaceutical care that permit the training of the future pharmacists in the use of medicines. design: all the classes were designed with practical-theoretical modality including workshops, reading and analysis of the bibliography, discussion of cases and utilization of virtual simulators. setting: clinical pharmacy. department of biological sciences main outcome measures: students evaluation was carried out by tests of the general contents, degree of active participation during the workshops, resolution exposition and discussion of the cases. results: the development of clinical pharmacy education began in . the students appreciated this experience and the % of them are satisfied with the process of teaching-learning employed. this teaching system improved them the adequate and rational use of the medicines. in these two years the % of the students has approved the examination. the students also realized two poster presentations during this period, namely: . ''comparative study of the information supplies in the leaflet of tablets of omeprazol mg'', in and . ''study of the information supplied by the pharmaceutical laboratories in the television media'' in . conclusions: we consider the importance of the incorporation of clinical pharmacy in the new pharmacy curricula, because the students have major task about the practical education involvement patients and related to their professional future. background and objective: clinical trials' managing and dispensation is one of the obligatory missions of a hospital pharmacy. the respect of good clinical practices is necessary to ensure proper trial performance and to be aware of errors in prescription and in drugs dispensation. the aim of our study was to analyse the nonconformities in the steps of prescription and dispensation and to evaluate their severity. design: the pharmacy department manages clinical trials for all clinical wards with a pharmacist and a technician who change every four months. there is no specific computerized system but an excel software for data filing. we realized a retrospective study of ongoing clinical trials. all the prescriptions were reviewed and we focussed on all the items required for the prescription (e.g., identification of the protocol, the patient, the investigator, the dosage) and for the dispensation (e.g., identification of the drug, the quantity dispensed, batch number, expiry date) setting: results: gps participated to the survey. they agreed (median = , iqr = - ) that the following concepts are crucial in a patientcentred approach: the need of a specific training in counselling in under and post graduate education; the necessity of working with patients to develop mutually agreed-upon goals; the role of information in the decision making process, the ability to understand patients readiness to make change, and to identify barriers to change, the importance to recognize that patients are the experts when it comes to their own behaviour related issues. for only one item (time dedicated to the consultation) iqr changed (iqr = - ) indicating some difficulty in implementing this aspect in practice. conclusions: for benevento community gps, a patient-centred approach is a useful way to help change and promote behaviour. knowing how to support it is an important skill for all care professionals, but education is needed to shift from theory to practice. type ii and gestationnal diabetes. the average age was years and for the half of these patients, the pathology developed since more than years. patients were painful and patients presented a positive score to dn questionnaire. symptoms frequently observed were: pins and needles, prickles, and numbness. among these patients, were treated by antidepressants (amytriptiline) or antiepileptics (clonazepam, gabapentine, tegretol, carbamazepine or pregabaline) or both. the average number of molecules received by patients was . . the average number of lines of treatment was: . . first intention treatment insisted of an anti-epileptic monotherapy in patients. second line treatment involved the introduction of another anti-epileptic or an anti-depressant drug. the drugs have been well tolerated except a respiratory depression under clonazepam. among the not-treated patients, only one benefitted from a treatment initiation. conclusions: patients are treated by ''old'' molecules with a large prescription of clonazepam but their efficacy is very variable. the physicians have been sensibilised to dn questionnaire and they concluded that it is easy to use. however there is a lack of physician's informations about the management of neuropathic pain; besides they are hesitant to initiate a treatment. the relationship between pharmacists and physicians and the development of clinical pharmacy seems important to optimize the management of this pain. background and objective: pharmacy education in the faculty of pharmacy and biochemistry of the university of buenos aires is taught as a product-oriented profession with a focus on the basic sciences. however in pharmaceutical care and clinical pharmacy was integrated as an optional course into the pharmacy curriculum by resolution cd / . the object of the emphasis was on the students' ability to provide clinical pharmacy and pharmaceutical care upon graduation. hence, therapeutic plays a significant role in building students' knowledge and skills in preparation for clinical practice. design: theoretical education and program for students and collaborative implication in the hospital activity or in the community pharmacy. the development of the program is carried out in two phases. in the first phase the clinical activities of the pharmacists, the unidose drug distribution, the role of the drug information centers, pharmacoepidemiology and surveillance studies are explained. in the second phase the concept of pharmaceutical care is introduced and its implementation in different pathologies is developed. an active approach of the patient and contact with the treating physician was considered as tool in a strong learning environment. setting: undergraduate pharmacy students at university of buenos aires. main outcome measures: the students find them abilities to identify drug related problems and to assess patient care and follow-up. results: more than students have attended pharmaceutical care and clinical pharmacy to: % passed and % failed. students option was that the strongest aspect are the case discussion and the weakest the very few number of hours not enough to discuss other important illnesses. they also say that many topics should be taught sooner in the career and it was not considered an emphasis an the clinical and patient oriented-aspects of the profession. conclusions: an approach to clinical pharmacy education in which the integration of teaching and learning are collaborative creates an atmosphere that is conducive to effective student learning. moreover the clinical pharmacy is a valued and important tool of the general practice team regarding quality improvement in drug therapy. all of the most popular cpd linked pharmacy activities were from the competency-'participation as a member of the multidisciplinary team'. telephone interview findings showed pharmacists cited 'priority for their service development' as the principle reason for cpd identification. no pharmacist identified a cpd need for: 'supporting patient/family motivation'; 'ecording problems in blood glucose control requiring balancing food intake and insulin dose'; 'sharing reflections of where your performance leaves room for improvement within a pharmacists group' and 'taking part in a local multi-disciplinary mentoring group.' conclusions: currently cpd workbooks appear not to be widely used within the pharmacy profession in the uk although there are examples of successful use of reflective portfolio. , almost half of the participants chose the workbook as a means of support leading to a substantial number of identified cpd issues. for community pharmacists to deliver high quality care for diabetes, more attention is required to forms of training and to both uniprofessional and multiprofessional peer support. setting: we retrospectively reviewed all prescriptions of ivig issued from three infectious disease departments ( beds) in a french bed university hospital. main outcome measures: for each ivig prescription, the following data were collected: patient identification, name of ivig product, quantity of ivig issued, date of ivig release, indication for treatment and level of relevance. these levels are determined as follows. level : indications approved by health authorities or for which comprehensive guidelines have been published (high level of proof). level : relevant indications based on scientific publications. level : off-label indications more difficult to prove on a scientific basis (few or no high quality randomized controlled clinical trials). results: during the studied period, grams of ivig were administered for a total of patients and prescriptions. . % ivig used saccharose as a stabilizing agent, other products contain either glucose ( . %), or maltose ( . %). the purpose of this study is to produce an evaluation focus on the risk profile and counselling activities concerning therapeutic and lifestyle change. design: descriptive study. individual measurements were recorded by pre graduation students on a standardized datasheet. blood pressure was measured using a digital wrist device. blood glucose monitoring systems of two different brands were used. setting: the screening was made in the street using passer-by volunteers. in the course of a single day in may , a total of subjects ( . % males and . % females, mean age . years, sd = . ) had glycaemia and blood pressure measured. main outcome measures: age, gender, medication taken, cigarette smoking, body mass index (bmi), blood pressure, capillary blood glucose results: . % of the sample presented bmi [ kg/m. . % had elevated systolic blood pressure values and . % elevated diastolic blood pressure values. . % had elevated occasional blood glucose. . % are cigarette smokers. systolic (t = - . ; p = . ) and diastolic (t = - . ; p = . ) blood pressure values were significantly higher in smokers than in non-smokers. concerning patients taking diabetes medication, fewer patients with blood glucose controled and more patients blood glucose uncontrolled were found than those expected, suggesting either low compliance or lack of efficiency of medication (v = . ; p \ . ). concerning the hypertension medication, similar results were found. more patients under therapy with blood pressure uncontrolled were found than expected. the concordance within the two measures of the blood glucose with different monitorizing system was found to be strong and significant (k = . ; p \ . ). positive and significant correlation between bmi and diastolic blood pressure was found. however, no significant correlation between bmi and systolic blood pressure was found. conclusions: events such as this screening improves the quality of education, as well as develops the interests and opinions of students. as well as it shows face to face were can be apply their knowledge of clinical pharmacy furthermore, events such as these are found by the students to be invaluable in acquiring training in similar-to-professional setting and expertise in field work. background and objective: nhs education for scotland (nes) has worked with the scottish executive health department (sehd) to develop training packages to support the use of validated needs assessment tools (nat) for several longterm conditions. consequently a specific training package was then developed to support and standardise needs assessment and pharmaceutical care delivery by palliative care pharmacists in the local networks set up in scotland. additional support materials (trainers package) was developed for representatives from the scottish palliative care pharmacists' association to deliver the training to their local network pharmacists in a consistent manner. design: development and evaluation of a training package and course for palliative care pharmacists. evaluation of the outcomes from using a nat for delivery of care. identification of issues %; relevance of questions %; time to complete nat - mins; barrier -time; benefits -care issues identified by nat; care issues -counselling and compliance issues, side-effects identified (nausea, dry mouth, constipation), pain relief not adequate. conclusions: nes are proactively supporting national policy and practice through a process of identifying and meeting the educational needs through direct and self-directed learning for continuing professional development (cpd). the needs of palliative care patients are seen as an appropriate target group for pharmaceutical care. the evaluation and feedback from the courses, training pack and outcomes from the use of the nat in practice have been very positive and amendments will be made for further implementation in scotland. background and objective: pharmacy students represent a broad spectrum of learning preferences and styles. this diversity presents a responsibility for the lecturers and instructors to meet the educational needs of all students. in order to develop appropriate learning approaches the instructors need to know the students learning preferences. therefore, the aim of this study was to identify the learning preferences of pharmacy students. design: the visual, auditory, reading/writing, kinesthetic (vark) questionnaire identifies student's preferences for particular modes of information presentation. the vark questionnaire is freeware that can be completed online. however, we administered the vark questionnaire as a hard copy at the end of the 'clinical pharmacy practices' final exam to the fourth-grade pharmacy students. setting: marmara university -faculty of pharmacy. main outcome measures: the frequency of students' preference for modes of information presentation. results: we administered the vark questionnaire to students and ( %) returned the completed questionnaire. almost half of the students ( . %) preferred a single mode of information presentation. among these students, % preferred visual (learning from graphs, charts, and flow diagrams), . % preferred auditory (learning from speech), and . % preferred printed words (learning from reading and writing), and % preferred using all their senses (kinesthetics: learning from touch, hearing, smell, taste, and sight). the other half ( . %) preferred multiple modes [ modes ( . %), modes ( . %), or modes ( . %)] of information presentation. a total of ( . %) students preferred 'kinesthetic' learning solely or in a multimodal combination. conclusions: the students represented a variety of learning styles. student motivation and performance improves when instruction is adapted to student learning preferences and styles; so, it is the responsibility of the instructor to address this diversity of learning styles and develop optimum learning approaches. escitalopram, fluoxetine and mirtazapine were rarely prescribed. the posology and taking plan were generally respected. however, some improvements in terms of treatment optimization could have been brought. they could have lead to actions of clinical pharmacy within the framework of prospective study: posology optimizations and taking plan optimizations. nineteen patients ( %) had an adjustment in their antidepressant treatment: nature and dosage. for all the antidepressants, a sufficient duration was respected before increasing the doses. an average number of interactions by prescription were . but none was clinically significant. conclusions: therapeutic strategies corresponded to guidelines recommendations. the dosage adjustments and duration before increasing the doses respected the indication of antidepressants. in the future, to optimize the medicinal treatment, decision-making tools carried out could facilitate psychiatrists' prescriptions. the pharmaceutical validation of prescriptions will be facilitated by complying with them within the framework of clinical pharmacy activity. background and objective: al-amal hospital is a bed oncology/ hematology hospital. al-amal hospital is now the first hospital in qatar to be accredited by the joint commission international (jci), the worldwide leader in improving the quality of healthcare. the objective is to implement clinical pharmacy services in al-amal hospital in the state of qatar by training the pharmacists about clinical pharmacy services. design: a pharmacist designed the training program and took the initiative and responsibility for training other pharmacists in aah about clinical pharmacy. the department of medical oncology/ hematology, the hospital administration and the pharmacy department agreed that the pharmacists should have central responsibility for antineoplastic agents and other drugs related problems. pharmacists for the program were selected from the existing staff. the healthcare team is consisting of two pharmacists rotating every months. each pharmacist join teams consisting of a pharmacists, a consultant, a specialist, a resident, a rotating resident, nurses, a dietitian, physiotherapist, social worker and a psychologist. we used to have oncology teams and hematology team. both pharmacists participate in the medical rounds and morning report days per week. the pharmacists provide clinical pharmacy services including chart review, pharmacy patient profile review, laboratory tests, therapeutic drug monitoring, antibiotics monitoring, interviews with patients and/or relatives. drug related problems were identified, resulting in interventions. setting: in patient wards, al-amal hospital, qatar. main outcome measures: to identify drug related problems, which well result in interventions and to help the medical team and the patients to reach their treatment goals. patient outcomes were evaluated by follow up with the medical team or by patient interview. we refer patients to the dietitian, physicians, the clinical psychologist as needed. results: more time is needed to evaluate the clinical pharmacy services provided by the pharmacists as the program was just started. patient and physicians were satisfied by starting the training program. conclusions: hematology/oncology setting provides an excellent opportunity to involve pharmacists. a. leads to encephalopathy and progressive neurodegeneration in the infant who is not treated. early diagnosis and dietary management can prevent complications and may allow for normal intellectual development. however, neurologic function may deteriorate rapidly at any age because of acute metabolic decompensation. these severe episodes are caused by catabolism of endogenous protein, which may be provoked by physiological stress (infections, post-surgery). during these crisis, the patient must have immediately intravenous glucose infusion and enteral nutrition free of b.c.a.a. design: case report. setting: department of pharmacy, hospital charles nicolle, rouen. main outcome measures: case report results: one patient with classical m.s.u.d. is followed in our establishment since many years. his disease has been diagnosed in neonatal period. a diet free of b.c.a.a. has been instaured. this diet is successful, now this patient is years old and had a normal development except myalgia and hypoesthesy of the left leg. however, when the diet is not well followed or when he's infected, acute episode occurs (on average or times per years). as the crises starts, the patient is sleepy and confused. in order to be able to treat him very quickly, the medical staff decided to set up an emergency protocol, which include an adapted enteral nutrition formulation. the pharmacy is implicated in this protocol to prepare the mixture. the formula includes: m.s.u.d mix, dextrin maltose, oligoelements, ions, lipids (sunflower oil), vitamins and water. the pharmacy must be able to carried out the preparation at any time and the components must be always available. conclusions: because m.s.u.d is an unherited disease, published report of treatment are rare and they are no consensus for the treatment of acute decompensation. since years, this protocol is successful: b.c.a.a. levels decrease between to days after the setting-up and the patient always recovered rapidly. this formula is administrated by nasogastric tube and avoid the use of hemodialysis which is the last solution to remove b.c.a.a. this is an example that a personnal follow-up program (with plan for clinical and metabolic evaluations) during common intercurrent illnesses can have optimal outcomes. keywords: leucinosis, metabolic decompensation, adapted enteral nutrition nutr- ensuring phosphorus adequacy of human-milk-fed preterm babies canadell laura , cañete carmen , pardo rocio , albujar mar , valldeperez cinta , carretero juan , gallart m jesus , closa ricardo pharmacy service, neonatology, hospital universitari joan xxiii, tarragona, spain background and objective: human milk is the feed of choice for preterm infants both for nutritional and non-nutritional reasons. phosphorus levels in human milk are insufficient for most premature infants. this deficit is the major cause of osteopenia in prematurity. fortification with a commercial multinutrient product should only be considered after weeks of mother's milk feeding, however, phosphorus supplement must be given initially. to describe a standardized scheme for early nutritional support with phosphorus of very preterm infants (\ - g)and describe the phosphorous oral solution we use as a supplement is the aim of this study. design: clinically relevant reports were reviewed to establish a standardized scheme for early nutritional support with phosphorus of the very preterm infants. a standardized formula of oral phosphorous was established to diminish the medical errors when the addition of this mineral is required. setting: pharmacy service and neonatology unit of a third level hospital. main outcome measures: to describe the scheme of adding phosphorous to human milk as well as the standardized formula we use, ''phosphorous oral solution'' ( mg p/ ml). results: phosphorous oral solution procedure: composition, stability and the scheme of addition to human milk to ensure the requirements for bone substrate needs in preterm infants to avoid osteopenia of prematurity. conclusions: various methods have been tested to decide when additional supplements must be given. individual adjustment is not possible due to the delay of laboratory results on milk analysis and the fast changes in infants' requirements. therefore, it is necessary to make a standard adjustment scheme on the dose of the fortifier that needs to be added. shortly to the pancreaticduodenectomy, total parenteral nutrition (tpn) was started ( kcal in progress until reaching his energy requirements). in addition to parenteral nutrition, supplementation enteral nutrition was delivered via jejunostomy along four postoperative days. on post day , transition to a complete enteral formula was achieved (standard formula, ml = kcal: kcal/d). on day , patient complained of colic pain in upper hemiabdomen. an emergency tc revealed presence of liquid in the abdominal cavity from anastomosis pancreatogastric. with the suspect of a leak from jejunostomy, the catheter was removed. tpn was reintroduced and kept as the only way of nutrition until later when oral tolerance was started. during hospital stay ( days) periodic blood controls were performed. main methabolic complication was high blood sugar, needing the administration of insuline. from day to , mean plasma levels of albumin ( . vs . g/dl), total proteins ( . vs . g/dl), total serum cholesterol ( vs mg/dl), total lymphocite count ( . vs . %) and prealbumin ( . vs . mg/dl) increased significantly conclusions: the leak of artificial nutrition to the abdominal space in patients with jejunal feeding is a frequent complication of ne. its incidence is probably related to the length of the tube inserted into the lumen. protocols are need to prevent complications like tube displacement and to encourage early enteral nutrition. increase in plasma concentrations of nutritional parameters suggests effective uptake admixtures might be either prescribed and made ''a la carte'' according to the newborn's needs or provided by pharmaceutical companies as standard formulations. the aim of the study is to review individual pn prescriptions in a neonatology care unit in order to assess the potential for using standardized pn instead. design: prospective study one day per week during weeks. setting: neonatal intensive care unit, strasbourg university hospital. main outcome measures: the major criteria for the comparison are carbohydrate concentration and then amino acid intake. results: prescriptions were analysed and compared with a standardized formulation, pediaven Ò (fresenius kabi). the first point of comparison based on carbohydrate concentration resulted in an exclusion of % ( / ) of the total prescriptions because their carbohydrate concentration was less than g/ ml or more than g/ ml (pediaven Ò glucose concentration, g/ ml). among the prescriptions retained, only prescriptions whose amino acid concentration was less than . g/ ml were included (pediaven Ò : . g/ ml background and objective: it is known that propofol protect myocardial tissue against global myocardial ischemic-reperfusion injury in the isolated rat heart model. the aim of this study was to investigate whether propofol, at a clinically relevant concentration infused during both preischemia and reperfusion (peri-ischemic) period, also provide protective effect against regional myocardial ischemic-reperfusion injury in vivo. design: mail sd rats weighing between and g were anesthetized with mg/kg of ketamine and mg/kg of xylazine. a haparinized g catheter was placed in the left femoral vein. the trachea was intubated and then mechanically ventilated with room air using a volume-controlled rodent ventilator. a left thoracotomy was performed, and the pericardium was opened. for the ischemia-reperfusion experiments, a snare was passed around a left anterior coronary artery territory to induce regional myocardial ischemia. coronary occlusion was produced by pulling the snare and clamping it with a mosquito hemostat. reperfusion was produced by releasing the clamp. setting: rats were subjected to minutes of coronary artery occlusion followed by hours of reperfusion. propofol or intralipid was administrated during minutes starting minutes before the onset of ischemia until minutes after the onset of reperfusion. main outcome measures: the micro-manometer catheter was advanced into the left ventricle via right internal carotid artery and hemodynamic function was checked after hours of reperfusion. infarct size was determined by triphenyltetrazolium staining after hours of reperfusion. results: propofol administration during both preischemia and reperfusion (peri-ischemic) period showed protective effects on myocardial function and infarct reduction. in the control group, the peak rate of ventricular pressure rise (+dp/dtmax) and the peak rate of intraventricular pressure decline (-dp/dtmin) significantly decreased than sham group. in the propofol group, the +dp/dtmax and -dp/dtmin significantly improved than conrol group. infarct size was . % of the area at risk in control group, and was reduced markedly by administration of propofol during peri-ischemic period to . % in the propofol group (p \ . ). infarct size of intralipid group was . % of the area at risk, intralipid had no effect on infarct size compared with the control group. conclusions: propofol, at a clinically relevant concentration infused during peri-ischemic period, provided protective effect after regional myocardial ischemic-reperfusion injury at in vivo rat heart model. the results showed hemoglobin level of less than g/dl in . % of the subjects, transferrin saturation (tsat) of less than % in . % of the hd patients, tsat \ % and ferritin \ ng/ml in . % of the patients, serum alb level of less than g/dl in % of the patients, serum p level of more than . mg/dl in . % of the subjects, ca p product of more than in % of the patients, parathyroid hormone (pth) \ pg/ml (adynamic bone disease) in . % of the subjects and serum pth concentration of more than pg/ml (uncontrolled secondary hyperparathyroidism) in . % of the subjects. the results showed that more than half of the hd patients need erythropoietin and ferrous dose adjustment or follow up for resistant anemia, more than half of the subjects need phosphate binders dose adjustment or replacement and about % of he patients need rocaltrol dose adjustment. we are planning to compare these results with the findings following the participation of a clinical pharmacist in this hd center rounds and monitoring of hd patients. since enough management of complications of crd patients and their drugs monitoring are necessary to improve quality of life of hd patients, clinical pharmacist may have a major role in hd centers. background and objective: computerization of our drug circuit has been deployed gradually to every hospitalisation units of our hospital since . pharmacists coordinated the extension, the installation and the support for starting. they were the first interlocutors to analyze dysfunctions and to help solving them. difficulties encountered by nurses were often notified to head nurses and transmitted to pharmacists. the objective was to study as a whole difficulties of users and to bring a workable solution to their problems. design: a working subgroup depending on the drug commission was created. it was composed with nurses from different departments (intensive care, infectious, pediatric and rehabilitation departments), head nurses and pharmacists. several meetings, organized between october and december , made it possible to the participants to announce their difficulties. reports were written and diffused for validation. to evaluate the pharmacist -patient communication and the level of counseling for otc and prescription drugs dispense; to improve the professional relationship between the patient and the community pharmacist; to assess the effect of clinical pharmacist intervention over those parameters. design: interventional study (visits done by clinical pharmacists, especially employed for), repeated after weeks and again after months. setting: chain pharmacies from bucharest, romania. main outcome measures: the investigation was conducted using a multiple sections protocol. the assessed parameters were: pharmacist's attitude toward the patients, his/her availability to communication and the level of counseling when otc or prescription medication is released. results: during the first visit, in sixteen pharmacies only ( %) the pharmacists greet the patients. two weeks later after the intervention, this number increased to ( %), although after six moths it decreased to pharmacies ( %). in more than % of the chain pharmacies, the professionals had a positive attitude toward the patients. as an example, an empathic approach has been encountered initially in pharmacies ( %), then in pharmacies ( %) and finally raised up to pharmacies ( %) after months. although the clinical pharmacist's intervention (therapeutic counseling) had positive impact, the extent of minimal counseling at otc or prescription drugs dispensing was found to be low at the first visit, since it increased from to pharmacies ( to %) only, during the study period. the processed data showed a very low level of minimal counseling ( % at the end of surveillance period). by considering the patients benefits (quality of life, better control and management of chronic diseases, reduction of medication costs), the pharmacist interventions are imperatively needed in bucharest chain community pharmacies. background and objective: to compare the level of minimal consultation services in chain community pharmacies located in city center or district of bucharest (capital city) vs. independent pharmacy in a country town (cluj-napoca). design: prospective, months, multicenter study. setting: pharmacies accepted to fill in the study protocols. both shifts were covered, monday to friday (week-end days not included). main outcome measures: the investigation was conducted using a multiple sections protocol. the assessed parameters were: the level of minimal consultation when otc and prescription medications are dispensed and the extent of chronic medication release without a medical prescription. at the end of trial period, the results were centralized on weekly and monthly protocols. the interpretation of the collected data was done using percentile calculations. results: to evaluate the minimal consultation, the percentage of counseled patients from the monthly total was calculated, separately for otc and for prescription drugs dispense. the period of the study (from june to january ) was divided in various slices of consecutive months, when certain pharmacies were compared. the level of otc medication counseling in the five studied pharmacies is different and varies from to % (maximum level reached in the country town pharmacy). the counseling level for medication on prescription varied from to %. by counting separately, the percentage of patients who requested chronic medication without presenting a prescription is as high as up to %. conclusions: the level of counseling, especially for otc drugs (recommended or auto-medication), was generally low in the studied pharmacies and may threat the health state of the patients, due to improper administration. as a third of patients come in pharmacy and request chronic medication without a physician's prescription, this commonly leads to complications which aren't discovered and treated in time. background and objective: the quality of medication use in nursing homes (nhs) is subject to growing concern. focus should not only be on appropriateness of prescribing, but also on correct pharm world sci ( ) : - administration of the medication. the aim of this study was to investigate ) the type and frequency of medication administration errors in nhs, ) their clinical relevance and ) whether a training session by a pharmacist on good medication administration practices can contribute to the prevention of the detected errors. design: the study had a pre-post design. during the first phase (pre), medication administration was observed during days per ward by pharmacists (barker method). phase (intervention) consisted of a general information session on good medication administration principles provided by the pharmacists to the nursing staff. moreover, the observed errors were discussed with the head nurse of each ward. phase (post) took part one month after the intervention and consisted again of a -day observation on each ward. finally, in the last phase (phase ), the clinical relevance of the detected errors was scored by an expert panel (geriatrician and clinical pharmacist). setting: volunteering nhs with different medication distribution systems. in total, medication administration was observed for residents. results: the number of detected errors was considerably lower in nh than in nh . however, the type of errors did not differ. besides the unnecessary or forgotten preparation of medication, most problems occurred during the administration stage. . % of crushed medications indeed were not suitable for crushing. the same applied to . % of the opened capsules. moreover, the crushing hygiene was problematic: all medications for one resident were crushed together and the crushing device was not cleaned between different residents. inhalation techniques were inadequate in almost all cases (insufficient inhalation by the resident, coordination problems or expiration in the device). furthermore, specific administration moments were not taken into account. for example, the administration of alendronate (fosamax Ò ) was observed in a horizontal position after breakfast, while it should be administered minutes prior to breakfast in a vertical position. the nursing staff experienced the training course by the pharmacists as very interesting. . % of the attendants found that the discussed topics were not sufficiently covered during their education. background and objective: the off-label use of intravitreal injection of bevacizumab (iib) for the treatment of macular edema (me) requires the approval of its use by health authorities. pharmacy department (pd) participates in that process, assessing each treatment request and preparing a sterile syringe for intravitreal administration. our aim is to evaluate the short term anatomic and visual acuity (va) response after iib in patients affected of me due to diabetic retinopathy or retinal vein thrombosis. the aim is to give an answer within hours. setting: all three pharmacists are working in the virga jesse hospital, a large peripheral hospital of beds in belgium. main outcome measures: implementation of the clinical helpline in the entire hospital. to make sure clinical pharmacy services are known by every physician and nurse and are easy to contact. results: we made an e-mail address and a schedule, so every day another clinical pharmacist is responsible for answering the questions. to let the physicians and nurses on the ward know we exist, we made flyers with the address and the explanation of the service. on a patient safety congress in the hospital, the clinical pharmacists presented a lecture concerning the advantages of clinical pharmacy services. the main aim is to explore other ways of delivering clinical pharmacy services. in belgium, the hospitals don't have a tradition of clinical pharmacy and there is no governmental support for this pharmaceutical function. with the clinical helpline we try to spread our services without having a clinical pharmacist on every ward. in the pharmacy we prepare the question thoroughly on paper. the clinical pharmacist has computerized access to all necessary medical information and pharmaceutical data. afterwards the pharmacist goes to the ward, to see the patient and to have a discussion with the physician. the physician can decide if he agrees with the given pharmaceutical advice or not. the clinical pharmacist has only an advisory function and doesn't do any therapeutic changes in the prescription. by collaboration of several caregivers, the patient receives a more complete and optimal therapy in our hospital. conclusions: by implementation of a clinical helpline, by an e-mail address, it is possible to spread our clinical pharmacy services over the entire hospital, without having a clinical pharmacist on every ward. the aim is to make an advice and go to the ward to discuss it with the doctor. not only physicians can use this e-mail address, also nurses can ask their questions. in this way we reach every caregiver. % of these pi was followed by modification of the prescription few days later. this study showed that % of the opinions were related to psychotropic drug overdose (often confirmed by psychiatrists after pi), especially neuroleptics, the most prescribed therapeutic class on the establishment. . % of the pi was related to inappropriateness to available guidelines. we note an important proportion of no respect of correct use recommendations of long-acting rispéridone injection: no respect of posological equivalence, patients not stabilized by oral way, insufficient period of co-administration oral/im during the initialization of treatment… . % of pi was guiding to drug management and to clinical and biological monitoring. drug related problems still under estimated without clinical and biological data accessible to pharmacists. however, pi may identify the risks related to therapeutic, to prevent potential problems, to reinforce the clinical and biological monitoring. comparison with a similar retrospectif study in shows that the number of prescriptions was increased ( in vs ), and number of pi doubled. however, nature and type of pi are virtually the same. conclusions: in order to reduce drp of overdose (the most frequent problem), an information strategy targeted to psychiatrists was developed and a updated list of maximal psychotrops posology was diffused and put on line. our study doesn't include problem of second -generation atypical antipsychotics association, this association still increasing despite fewer evidence and lucid guidelines; a second study will be soon conducted to identify pi having a significant clinical impact. conclusions: this study showed that clinical practices don't change even after reminding guidelines. information by fact sheet is not the best tool to spread guidelines. study's results will be submitted to an interactive presentation in medical staff, and clinical trials with iva are discussed and changed with acetaminophen oral route. the proportion of gp's that received, reviewed and returned the patient selection to the pharmacist, and the proportion of long-term users that received the informative letter. results: substantially more pharmacists in the intervention ( %) than in the control group ( %) handed over the patient selection to their gp's. % resp. % of the gp's received (n.s.), and % resp. % of the gp's reviewed and returned the list (n.s.). substantially more pharmacies in the intervention group got back any lists ( % vs %) and sent any letters ( % vs %). % and % of all longterm users received the informative letter in the intervention resp. control groep (n.s.). conclusions: the maximal implementation strategy was effective in getting the pharmacists started. the main outcome measures were not significantly different in both groups, though the realized effect on a large scale was relevant in practice. of the participants, total of . % has heard of the term 'pharmacovigilance' in the period- , which is entirely the academicians, while it is increased to . % in the period- (chi-square test with yates correction, p \ . ), which are mainly expressed by the hospital ( . %) and academician ( . %) pharmacists. during the period- , only % of the participants know where to report any adrs ( . % academicians and . % hospital pharmacists), whereas during the period- , this figure is increased to % ( . % academicians, % hospital and . % community pharmacists) (p [ . ). the participants preferred to report any adrs mainly by the internet ( . % vs %) and by the telephone ( % vs . %) at the period- and the period- , respectively (p [ . ). in terms of having reported any adrs among the participants, it is indicated that none of the pharmacists reported adrs at the period- , but only three hospital pharmacists reported an adr at the period- . conclusions: by the national regulations for pharmacovigilance, the pharmacists are entitled to report any adrs to the turkish pharmacovigilance centre. although this study is limited by the small number of pharmacists and location, it shows that there is an increased awareness and knowledge about pharmacovigilance. by the provision of pharmaceutical care, pharmacists' involvement in detecting and reporting adrs will improve, mainly in hospital and in community settings. background and objective: in france, global drug dispensing (gdd) is the common way to dispense drug inpatient. after an experience of implementation of individual drug dispensing (idd) the objective of the department of pharmacy was to prove the benefit offered by this system in comparing the clinical impact of the intercepted dispensing errors of both dispensing system. design: thirty days prospective study. setting: orthopaedic surgical care unit; department of pharmacy. main outcome measures: data related to drug preparation were collected by two pharm d students over a days period and analysed. identified preparation errors were classified in four groups: discordance between prescription and drug administration, exceeding or missing treatment and, unidentified delivered drugs. then errors were classified in potential or effective errors. at last, pharmacist and prescriber have quote this errors. preparation errors were classified according to their clinical impact from (no clinical impact) to (life threatening). results: drugs units were prepared with gdd vs with idd. eighty effectives errors ( . %) were observed with gdd and ( . %) with idd. clinical impact were ( %), ( %), ( %) for gdd and ( %), ( %) and ( %) for idd. a khi test highlight a difference between the dispensing system for clinical impact and (p \ . ). moreover, the mean value of weighting was about . with gdd vs . with idd (p \ . ). conclusions: this study shows the major benefit offered by idd versus gdd. errors weighting represent a relevant parameter for physicians. the results provided by this study highlight the role of the pharmacy staff, to reduce the incidence of medication errors and to promote a rational use of medicines. this work was the second step of our quality medication process; the next step will be the development of idd in several care unit by use and test automated process for preparing doses. for each prescription we collected information about the patient, the prescribed drug, the steps involved in its preparation and its administration. results: we collected prescriptions ( different drugs) concerning children (average age: years). sixty-two percent of medications were oral forms: % liquids, % tablets, % capsules. thirty-two percent of the tablets were cut; only % of those were authorized. due to the age, % of the tablets were crushed to facilitate administration whereas grinding was allowed in only % of the cases. most of the capsules were opened ( %) and % fractionated for an adapted dose. opening of capsules was possible in % of the cases. intravenous drugs represented %, the average injection was . % of the vial; in %, less than a quarter was given. conclusions: about % of pediatric preparations were inappropriate. the results of this study highlight the need to provide drugs adapted to pediatric care, which is one of the main tasks of the pharmacy. we are thus developing more appropriate pharmaceutical formulations for children, such as oral suspensions. a comparative statement of solubilization rates in liquid of crushed tablets or capsules after opening has to be established. moreover if a pharmacist is present in the care units, most medication error will be avoided. background and objective: the world's population is aging. the elderly have many chronic disorders and consequently use more drugs than any other age group. safe, effective pharmacotherapy is one of the results: fifty patients received antibiotics according to several schemes. nineteen patients received prophylactic treatments during . days on average. the employed molecules were mostly part of beta-lactams' family ( . %) including . % of co-amoxiclav. the prophylactic treatment seemed to be effective in . % of case because it wasn't followed by other treatment. thirty-one patients received probabilistic treatment: . % of them received quadruple therapies, . % received triple therapies, . % bitherapies, and . % monotherapies (only beta-lactams). the average duration of the probabilistic treatment was days. twenty-three patients got curative treatment. compared with the probabilistic treatment or with the treatment at the entry, the curative treatment corresponded to a reduction of the spectrum in % of cases with mainly an arrest of the vancomycin ( %). monotherapy was the most prescribed ( . %) and especially beta-lactams ( . %). then came bitherapies ( . %) and triple therapies ( . %). the most frequent isolated germs were escherichia coli ( cases), staphylococcus aureus ( cases), pseudomonas aeruginosa ( cases) and pneumococcus sp. ( cases) alone or associated, including . % of multiple-drugsresistant bacterias. the monitoring of aminosids and vancomycin was globally well carried out. only . % of vancomycin's dosages and . % of aminosides' dosages were not done. thirty-two patients increased their transaminases and/or their creatininemy. these increases were often physiopathological, related to multiviscérales failures or to septic shocks. the antibiotics could be clearly blamed in only one case. conclusions: in the surgical intensive care unit, antibioprophylaxy is longer than in recommendations. the probabilistic treatments used often associate active molecules on multiple-drugs-resistant bacterias. this can be explained by the gravity of infections, and the increased risk of bacteriologic resistances due to former treatments. moreover, bacteriological tests are systematically done, so antibiotics can quickly be adapt to the germs' resistances. background and objective: most of proton pump inhibitors (ppis) do not have legal mention for a paediatric use. however these drugs are largely prescribed to children. one disadvantage resides in the absence of liquid form which causes problems for their administration in nasogastric tubes. indeed, the absence of use recommendations involves many misuses responsible for inefficiency and/or tube obstruction. we tried to evaluate if ppis can be administered through paediatric nasogastric tubes. design: to quantify the transit of different ppis through paediatric nasogastric tubes and to optimise their modes of administration. setting: laboratory of clinical pharmacy and biotechnics. faculty of pharmacy. main outcome measures: we administered four ppis (mopral Ò , ogast Ò , inexium Ò , ogastoro Ò ) through nasogastric tubes by respecting their positioning in a child in a °elevation. for each ppi a study plan was drawn up to assess the influence of different variables: the volume of water to dissolve or put in suspension the ppis ( or ml), the rinse volume ( . or ml), the length ( or cm) and the diameter ( or french) of the polyurethane tubes. for every tests (n = ) we carried out an analysis of each active ingredient at the tube outlet by uv spectrometry. results: all f tubes were obstructed by ppis. through f tubes, we observed a mean recovery of active ingredient of % for ogastoro Ò , . % for inexium Ò but only . % for ogast Ò and . % for mopral Ò . the length of the tubes had no significant influence on the loss of ppi at the outlet of the tube. a water volume of ml instead of ml increased only the final concentration of inexium Ò (+ %). a rinse volume of ml improved significantly the transit of mopral Ò , ogast Ò and ogastoro Ò (+ . %, + . %, + . % respectively). this rinse volume allowed to obtain a . % recovery of lanzoprazole for ogastoro Ò whatever the water volume employed for its administration. conclusions: the most satisfactory results were obtained with ogastoro Ò : an administration volume of ml and a rinse volume of ml allowed a near-complete transit of lanzoprazole. under these conditions only % of inexium Ò was recovered. it is disadvised using mopral Ò and ogast Ò through f nasogastric tubes because no condition ensure the transit of an efficient concentration of active ingredient. keywords: nasogastric tubes, proton pump inhibitors, children background and objective: feeding tube occlusion is a frequent problem. practices to make the clogging off are very varied and are not the subject of any consensus. no study have assessed the impact of the different products on the inner surface of the tubes. in this context, it seams to be important to evaluate if these products are safe in order to rationalize the practices. design: to study the inner surface of nasogastric feeding tubes after contact with various products used to unblock them. setting: laboratory of clinical pharmacy and biotechnics. faculty of pharmacy. main outcome measures: we have put in contact f nasogastric tubes made of silicone or polyurethane with the following products: water, . % sodium bicarbonate, orange juice, pineapple juice, cola, papain syrup, pancreatic enzymes. an analysis of the inner surface of the tubes was carried out after , and days by scanning electron microscopy (sem). photos of unexposed tubes were used as negative controls. photos of tubes exposed to heat, ether or sodium hydroxide were used as positive controls. results: the analysis by sem shows that the silicone tubes are not altered by the different products tested. on the other hand, the surface of polyurethane tubes is modified in the presence of . % sodium bicarbonate and pancreatic enzymes. the papain syrup seems to settle on the surface of the tubes without altering it. water, fruit juices and cola do not modify the biomaterial whatever the exposure time. conclusions: . % sodium bicarbonate, pancreatic enzymes and even papain syrup should not be used in practice to unblock the feeding tubes. the orange and pineapple juices as well as cola can be recommended because of their harmlessness with biomaterials. keywords: nasogastric feeding tubes, occlusion, scanning electron microscopy pc- assessment of administration practices of extemporaneous formulation pediatric capsule preparations helene richard , anne jalabert , sylvie hansel-esteller pharmacy unit, lapeyronie and arnaud de villeuneuve hospitals, montpellier, france background and objective: to assess administration practices of pediatric capsules made as an extemporaneous formulation preparation by the laboratory of the pharmacy unit, in pediatric units. design: a questionnaire was designed and filled in by asking questions directly to nurses about their administration practices, from february to april . setting: altogether, six pediatric units were consulted, corresponding to the units for which the laboratory carries out the most pediatric extemporaneous formulation preparations. main outcome measures: the questionnaire concerned the ten most made up pediatric preparations, which are: amiodarone, warfarine, captopril, propranolol, ursodesoxycholic acid, omeprazole, fludrocortisone, spironolactone, hydrocortisone and calcium carbonate. items filled in were: hygiene rules, the existence of administration procedures in units, preparation conservation, and practical administration details. results: in months, questionnaires were filled in. concerning hygiene rules, nurses wash their hands before every manipulation, % wear gloves, % wear a mask or a mobcap. no administration procedures were available in units and more than % of nurses would like to have one. in every unit, preparations were conserved at room temperature, in a dry place, and % in a light-free place. for amiodarone, propranolol, fludrocortisone, spironolactone and hydrocortisone capsules, nurses use sweetened water (g %) to dilute capsule contents, sometimes milk (especially in newborns units). for the other drugs, the vehicules the most used were: sweetened water ( %), solid vehicules like yogurt, apple sauce, jam ( %), fruit juice or syrup ( %), milk ( %), and coca-cola ( %). the vehicule volume used fluctuates between ml and cl. nurses administer capsules by syringue into the mouth ( %), per os ( %), or by enteral nutrition ( %). conclusions: most of the administration practices of pediatric preparations are homogeneous in the different units (except the vehicule volume used). in the absence of administration procedures, the administration of preparations is more adapted to the child than to the drug. the aim of this study is to provide pediatric units with guidelines about good use of extemporaneous formulation pediatric preparations. services compared to a pharmaceutical care model. items pertaining to pharmacists' communication with the patient and the physician as well as the pharmacists potential to manage drug therapy were assessed. results: of the patients approached, ( %) response rate was achieved. cronbach's alpha = . (expectations) and . (satisfaction). females were ( %), married ( %) and % had post-secondary education. some % expect accurate dispensing of their medications, % expect pharmacists to simplify their medications and % expect the pharmacist to spend as much time as possible with them. expectations were resolved into components: humaneness, friendly attitude and professional competence. only % were satisfied with the professional appearance of the pharmacy, the rest of the items received dissatisfaction rating. two principal components of satisfaction were identified as humaneness and professional competence. marital status and level of education were associated with satisfaction scores. conclusions: patients' expectations of pharmaceutical care services were high but the satisfaction with current services compared to pharmaceutical care was below average. professional competence and humaneness were important dimensions of both patient expectations and satisfaction. there is a need to introduce pharmaceutical care. results: fourteen criteria were defined. a yes, no or not applicable answer has been given to each criterion according to the guidelines. drawing lots have been realised to set up a representative sample of twenty patients among those included in the study: six males, fourteen females, average age: . years old. two patients are below the average. the average mark of the patients is . %. hemoglobin level of % patients is inferior to the targeted hemoglobin level ( g/dl) at the end of the study. six criteria obtain a score superior or equal to %. five criteria obtain a score under %. the three criteria which obtain the best results concern the monitoring of the hemoglobin levels during correction phase and maintenance phase, and the maximum weekly dose of erythropoetin. the three criteria which obtain the lowest results concern the assessment of iron status before erythropoetin therapy starts ( %), the rate of increase in hemoglobin levels which should be - g/dl per month ( %) and the adjustment of total weekly erythropoetin dose. conclusions: the average grade obtained by the patients highlights the deviation from the guidelines. this indicates the needs of improving the anemia management in our haemodialysis unit. so it is necessary to make another time the team of doctors and nurses aware of the problem and to reinforce the pharmaceutic implication into the haemodialysis unit. a re-evaluation of practices (in the guise of clinical audit) must be planned in order to estimate the impact of the setting up of correctional measures. inclusion criteria were: oral and injectable drugs' prescriptions concerning patients who were present in the ward since more than hours. results: medical records were analyzed. patient age varied from to years old and the average duration of the hospitalisation from . to days. omitted variables were: patient's weight in all cases, prescriber's quality in % of cases, prescription's hour in % and prescriber's signature in . %. for each patient, all drugs prescribed since the beginning of the hospitalization in the unit was studied i.e. lines of drugs. we have noted the inn was absent in % of the cases, pharmaceutical form in % and administration route in %. only one prescription had all variables. thus, the global rate of prescription conformity was %. in the wards, nurses write the original prescriptions on a card-index (ci). then, drugs administrations are written on a temperature chart (tc) and on pharmacy's book (pb) for drugs order. we have compared documents one by one, for each drug. conformity rates are . % (prescription/ci), . % (ci/ tc) and % (ci/pb). the noted differences are multiple(modification of the administration or hour route, increase or dicrease of dosage…). the clinical relevance of non conformity was not studied. conclusions: from this study, it can be concluded that many prescriptions do not comply to the regulation and many retranscriptions are not identical to original prescriptions. it constitutes of course a potential iatrogenic impact. the development of computerized physician order entry (cpoe) in our hospital should be a corrective measure. the next stage will consist of realizing this study with cpoe and compared the studies. anne-claire buire , emilie prevost , françois lebargy , bertrand gourdier pharmacy, pneumology, reims teaching hospital, reims, france background and objective: assessment of antibacterial prescriptions regarding community-acquired lower respiratory tract infections and comparison with national guidelines. design: patients treated with antibiotics were included each day, during the analysis of the computerized prescriptions in the pharmacy. then, a report sheet was indicated in the unit with the prescribers for each patients with pneumonia or exacerbation of chronic obstructive lung disease. one month prospective study (in april ) included all patients hospitalised for pneumonia or exacerbation of chronic obstructive pulmonary disease (ecopd) in a unit of the pneumology department and treated with antibiotics. setting: pneumology department -reims university hospital. main outcome measures: for each patient the following data were assessed: age, hospitalization duration, diagnosis, severity factors, comorbidities and antibiotic prescriptions were analyzed. treatments were thought consistent when following the national guidelines [ ; ] . results: new patients were hospitalized during this month. ( %) were treated with antibiotics: with no pulmonary pathology and with pulmonary infection ( patients with pneumonia, with ecopd, with pleurisy, with exacerbation of asthma, with chest secondary infection, with acute respiratory infection, with thoracic pain and with cough). then, the study focused on patients: pneumonia and ecopd (m/f = / , mean age: years old). hospitalization duration was about days. patients ( %) had at least one co-morbidities factor (the majority: with pulmonary antecedents) and ( %) a severity factor (the majority: with an attack of the vital functions). antibiotic treatments were initiated in the unit and out ( in emergency department and by general practitioner). all treatments initiated in the unit were consistent with the recommendations and revaluated with the bacterial results (except one treatment) or changed because of bad tolerability. bacteriological documentation was always researched and the results were significant for patients ( %): streptococcus pneumoniae, pseudomonas aeruginosa, proteus mirabilis with morganella morganii and haemophilus influenzae. when it was possible, per os relay was realized in the at hours, except for patients (relay in the days). conclusions: in this survey, the management of pneumonia and ecopd was globally consistent with the national guidelines. nevertheless, the bacterial documentation is poor and the antibiotics prescriptions for bronchopulmonary infections are difficult and need using molecules with large spectrum. collaborate with all of the health care professionals and patients and to identify causes of errors. the unique position and possibilities of a pharmacist enable him to follow up the errors, from a fact that he is an expert on medication properties and is basically the last in a row who deals with drugs before their administration to the patients. the aim of this study was to describe and evaluate the role of pharmacist in identification and dealing with medication errors in czech pharmacy. design: pharmacists identified and recorded all medication errors over a period of six months of pharmaceutical care. basic characteristic of pharmacists: mean age . years; mean length of pharmaceutical practice . years; of them worked in the hospital pharmacy. of them got the first grade of attestation in pharmacy (by years of working experience in pharmacy and by passing exams). pharmacists collected the following data: types and causes or errors, their interventions, drugs and time concerning errors, subjects making errors and patient's characteristics as age, gender, other drugs used and co-morbidities. all the data were processed by descriptive statistics. background and objective: there is no standard of care to prevent oral mucositis for patients with cancer treated by chemotherapy. most common treatment is local (mouthwashes). no commercial mouthwash solution is available. special preparations are compounded by clinical units. a new . % sodium bicarbonate solution presentation was recently proposed for local treatment. our hospital drug committee decided to evaluate the clinical practices of oral mucositis prevention related to anti-neoplasic agents. design: an observational study conducted in pitié-salpétrière hospital. interview of nurses and physicians by pharmacy students about mouthwashes prescription and practice. data recorded on pre-established questionnaire and analyzed in pharmacy department using microsoft excel Ò . setting: study performed in oncology, hematology and radiotherapy clinical departments and in clinical units with oncologic activity (gastroenterology…). during one year, more than patients received anticancer chemotherapy. main outcome measures: questionnaire items were: use of a specific mouthwash procedure within the service, use of a single agent or in combination. data collected from the nurse point of view were: preparation and administration practices; from the physicians' perspective: circumstances of prescription and duration of the treatment. results: questionnaires were analyzed (nurses: , physicians: ) from clinical units. there was a standard written procedure in only one clinical unit. several formulations were used: each physician proposed his own, including antifungal prophylaxis (amphotericin b, nystatin), antimicrobial agents (povidone, chlorhexidine), mucosal surface protectant (sucralfate), alkalin solution (sodium bicarbonate), anti-inflammatory agent (aspirin), anaesthetic drugs (lidocaïn) and other agent (glycothymoline). preparations were not systematically labelled with patients name, formulation, date of preparation and stability duration. these were administered from to times daily regardless the stability compounding. for physicians, prescriptions of mouthwashes were done for patients with specific toxic anticancer drugs ( -fu, anthracyclin, capecitabin and sunitinib), were concomitant with chemotherapy and systematic after radiotherapy. conclusions: there are variations among clinical units in terms of mouth care regimen used. treatment efficacy was never evaluated. drug committee worked on guidelines in order to prescribe antifungal therapy only for curative aim or avoid anaesthetic drugs (swallowing difficulties). good practices included, before chemotherapy, dental hygiene. maintenance is realized by the patient himself (mouthrinses with alkalin solution or chlorhexidine). analgesics can be taken orally in case of mouth pain. design: the open, randomized, single-blind two-sequence, two-period crossover study design was performed. setting: under fasting conditions, each subject received a single oral dose of mg olanzapine tablet as a test or reference formulation on treatment days. the treatment periods were separated by a oneweek washout period. main outcome measures: the plasma concentrations of drug were analyzed by a rapid and sensitive hplc method with uv detection. results: the pharmacokinetic parameters included auc - h, auc -infinity, cmax, t / , and ke. the mean auc -infinity of olanzapine was . and . ng h/ml for the test and reference formulation, respectively. the maximum plasma concentration (cmax) of olanzapine was on average . ng/ml for the test and . ng/ml for the reference product. no statistical differences were observed for cmax and the area under the plasma concentration-time curve for test and reference tablets. % confidence limits calculated for cmax and auc -infinity of cefixime were included in the bioequivalence range ( . - . %). conclusions: therefore, the two tablet formulations were considered to be bioequivalent. conclusions: clinical pharmacists effectively validate % of these prescriptions but one third of prescriptions will inevitably remain validated by pharmacist residents during night and week-ends. performance criteria must be proposed to measure impact of pharmaceutical improvement initiatives (validation procedures writing, continuous education for example). we suggest to test clinical pharmacy activities related to economic indicators and to medication events reduction. background and objective: education of patients with type diabetes is a key point of non-medical management of that disease. thus objective was evaluation of patients' knowledge about their disease and its management for further development of pharmaceutical care protocols. design: prospective cohort control study. total patients casually were divided in two equivalent groups: study group (n = ), age . ± . , diabetes duration . ± . who were questioned by face-to-face technique and received pharmaceutical care during the interview; control group (n = ), age . ± . , diabetes duration . ± . and filled in questionnaires without clinical pharmacist. inclusive criteria were: presence of type diabetes mellitus, duration of the disease was not considered as criteria. patients were inquired once following standardized questionnaire. all included patients could read and write. two groups controlled their diabetes mostly by oral antidiabetics, only n = in study group and n = in control used insulin. setting: out-patient setting of lviv clinical hospital no , endocrinologist's office. main outcome measures: assessment of patients' knowledge about diabetes and self-monitoring in study and control groups. results: only . % and . % of inquired patients in both groups respectively stated that they possess good knowledge about diabetes. but as it was shown by evaluation of their level of knowledge through assessment of keeping to diet, regular physical activity, self monitoring it didn't conform completely. diet was implemented by almost % of patients in two groups, while regular physical activity was declared only by . % in study and % in control groups. smoking was reported by . % and . % respectively. next step was evaluation of self-monitoring. it has been revealed that only . % and . % of patients in two groups performed blood glucose monitoring at home; body weight was controlled by . % and . % respectively; blood pressure by . % and . % as well. target level of blood pressure was achieved by . % of subjects in study group and in . % -in control. in study group foot examination was performed everyday by . % of patients when in control only by . %. no one from both groups evaluated glycated haemoglobin regularly as it is recommended by american diabetes association, those they couldn't state their present or previous parameter. conclusions: it was estimated that knowledge about necessity of diet following, regular physical activity, and particularly -self-monitoring was very poor in diabetic patients, no regarding compliance which possibly also will be low. even if patients stated good knowledge about the disease they had problems with self-monitoring. it is obvious that patients of this out-patient setting require adequate education, which should be a component of pharmaceutical care program implemented by the clinical pharmacist. protocols of pharmaceutical care for these patients must be developed and include standard procedure of type diabetes patients' education. pharmacy department, hospital universitari vall d'hebron, pharmacy department, pharmacy department, hospital universitari vall hebron, barcelona, spain background and objective: patients who are admitted for a programmed orthopedic surgery in a tertiary hospital are usually elderly and present high co-morbidity which makes therapy complexity increase. the objective is to evaluate whether a pharmaceutical care is necessary before patients hospital admission. design: we analysed the domiciliary treatment in patients who attended to a pre-surgery visit. a form designed by the pharmacy department and validated by anaesthesiology unit was delivered to the patient to fill in with domiciliary therapy. the average of prescribed drugs was . per patient, being this reduced to . drugs in patients younger than and increased to . in patients older than . over one third of patients ( / ) were taken orally nonsteroidal anti-inflammatory drugs (nsaids). from ai, would need a pharmacological evaluation in the preoperative. those were included in drugs, meaning the . % of the different drugs prescriptions. this percentage belonged to patients. conclusions: the fact that a high percentage of patients over with an orthopedic pathology take a considerable amount of drugs at home makes it necessary to monitories the therapy in order to minimise the iatrogenic problems during the admission. we have seen that this situation is so frequently ( %) in our study, so the pharmacy department has established a collaborative job with anaesthesiologist unit to reduce as much as possible therapy problems. levation. through each tube, a ml nutritive solution was delivered on h each day during one week. after dissolution in ml water the ppis were administered once a day after stopping of the enteral nutrition and rinsing of the tube with ml of water. the tubes were then rinsed with ml of water and the nutrition was started again. during each administration of ppi the suspension was collected at the tube exit in order to quantify the ppi by uv-spectrometry. results: no tube was obstructed. the enteral nutrition mixture did not adversely affect the transit of lansoprazole through f nasogastric tubes. the transit of lansoprazole through the tube was complete and regular during the days of the study ( . ± . ). for esomeprazole the mean recovery of active ingredient was of . ± . (coefficient of variation: %) this variability can be explained by the incomplete and inconstant dissolution of esomeprazole because of the low volume of water usable in paediatry. conclusions: orally disintegrating tablet of lansoprazole can be administered through f nasogastric tubes in a concomitant way to an enteral nutrition mixture. for esomeprazole there is a variability of the administered active ingredient. however enteral nutrition doesn't seem to affect the esomeprazole transit. low volumes of water used in paediatry seem to be responsible for the variability. results: we analyzed pharmacological treatment in patients, with a mean age of years old ( - ). the average of drugs per patients was ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . after checking the sources we detected possible pi ( severe, moderate and slight), observed times. pi were detected in of patients and mean per patient was . ( - ) . the following pi were described: increase of sedation ( patients), risk of bleeding ( patients), serum potassium levels alteration ( patients), hypotension ( patients), risk of hepatotoxicity ( patients), increase of creatin kinase levels and risk of myopathy ( patients). from all these, only two were observed: sedation which was observed in all patients and hypotension which permitted the reduction of patient antihypertensive treatment. conclusions: the most frequent pi was sedation which is considered beneficial in order to reduce anxiety in sci patients. arterial tension, electrolytic balance, hepatic and renal function, as well as risk of bleeding, are regularly controlled in the sci unit. this way, if one of these parameters was altered it would be easily detected. to conclude, it would be important to carry out regular checking to detect pi, especially for those drugs that are not usual and for those symptoms that are not controlled regularly in the sci unit. background and objective: pharmacists' individualized counselling of patients has positive impacts on the management of hyperlipidaemia, including improved compliance and better treatment endpoints. the objective was to evaluate patient knowledge on hypercholesterolemia and its treatment and to assess impact of pharmacist intervention at the lipid clinic. design: one hundred and fifty statin-treated patients were recruited by convenience sampling. following completion of a scored pre-intervention questionnaire, the pharmacist provided education on hypercholesterolaemia and the use of statins. a leaflet was prepared, evaluated and distributed to the patients. the patients completed again the same questionnaire after the intervention (post-intervention). results: patient demographics: % ( ) were males, % ( ) were females, mean age was years (range - years). a response rate of % was achieved with patients completing both questionnaires. following the educational intervention by the pharmacist, knowledge regarding the correct action to be taken if muscle pain or tenderness occur during statin therapy increased by % (p = ). the awareness regarding the normal total blood cholesterol level increased by % (p = . ) and the knowledge regarding the need for low-fat diet consumption during statin therapy increased by % (p = ). face and content validity of the patients' leaflet were strong. the average gunning fog index obtained for the leaflet was . indicating good readability for individuals. the leaflet was endorsed by the local health promotion department and copies were printed and distributed to patients. background and objective: in order to assess the performance of bayesian individualization of busulfan (bu) dosage regimens, venoocclusive disease (vod) rate was monitored for paediatric patients undergoing allogeneic bone marrow transplantation (bmt). design: consecutive patients undergoing allogeneic bmt with bu as conditioning regimen during five years period (january to febuary ) were retrospectively reviewed ( patients). setting: vod was major outcome variable. preconditioning risk of vod was estimated for each patient using a scoring system that included type of transplant, recipient cmv-positive status and total parenteral nutrition provided pretransplantation. a risk-adjusted cumulative sum method was used to compare observed versus predicted outcome by assigning a risk score, based on log-likelihood ratios, to each patient. main outcome measures: the cumulative scores were sequentially plotted with preset control limits for ''signalling'' where results were substantially different than expected (doubling or halving of odds ratio). results: sixty-six children received bmt after oral busulfan-based conditioning regimen with median age . years, . % of male. median preconditioning risk of vod was . range ( . - . ). observed vod rate was . % (n = ) which was . % ( patients) fewer than the expected number estimated by the risk score. the resulting risk-adjusted score for each patient was plotted sequentially. this plot adopted early a negative slope, crossing the lower control limit twice, after and patients, indicating improved results compared to those expected. background and objective: geriatric patients use numerous drugs; because they have several concurrent diseases. % of those years old and over have at least one chronic disease, % have or more chronic diseases ( ) . the purpose of this study is to evaluate data on the geriatrics' drug usage, assess the appropriateness of their drug treatment and identify their pharmaceutical care requirements. design: patients, who were years old and over and live in a nursing home in the anatolian part of istanbul, were included in our study. by interviewing the patients, individualized information was obtained regarding the drugs they used, dose and frequency of drugs, the purposes of medication use and side effects, and who suggested or prescribed the drug. the patients at risk of drug induced problems were defined and a risk map was developed. patients who have or more risk factors were accepted as being in a high risk category. setting: a nursing home. main outcome measures: the demographic, clinical and drug data of the patients were recorded. the pills count that patients used daily and totally; side effects of the drugs; knowledge of patient's diseases and drugs; risk category of patients were assessed. results: polypharmacy was identified in % of those included in the study (total of patients who take drug therapy). generally it was observed that the drugs were prescribed at an appropriate dosage and time; however % of the patients didn't know for what they were taking drugs. just ( . %) of the patients were aware of the conditions under which they should take drugs. of the patients ( . %) were not aware on how to and when they should receive their drugs. patients ( . %) were using their drugs by self-administration. the drugs of patients ( . %) were administered by their nurse. . % of the patients were receiving no medication. mean of number of drug used by patients was . ± . . . % of patients were in a high risk category. conclusions: as a result, drug effects alter due to polypharmacy, physiological and psychological changes. drug treatment should be individualized and monitored in geriatrics. according to our results, patients have lack of knowledge on drug use and they have never been educated in this matter. it is necessary to begin meeting their factor analytical technique can be either exploratory or confirmatory. exploratory factor analysis (efa) remains one of the standard and most widely used methods to demonstrate construct validity of new instruments. it is used to help development of the instrument by revealing items that may be made redundant from the questionnaire because they contribute little to the presumed construct. the seip consists of items in five domains and is scored on a four-to-fivepoint likert scale. the aim of the study was to assess further psychometric property of the seip using principal component factor analysis (pca). the strength of the inter-correlations among the items will be assessed by the presence of coefficients greater than . in the correlation matrix. if few correlations above this level are found, then factor analysis may not be appropriate. issues were identified including related to inr controls not performed and due to a poor/no adjustement of the oat dosage. % of the issues resolved following the pharmacist recommandations conclusions: computerized follow-up system allows to check inrs at the right date and to reduce the loss of results. pharmacists' recommendations were well accepted by physicians. the impact of the follow-up on the reduction of the overdose incidence will have to be evaluated. indications were hip (n = ) and knee (n = ) total replacement, other orthopaedic surgery of lower limbs (n = ) and pulmonary embolism treatment (n = ). indications were ''off label'' for patients with allergic reaction to heparine and were not documented. at least one of the haemorrhagic risks factors was identified in patients ( %). conclusions: fondaparinux is mainly used in approved indications. within the patients with haemorrhagic risks factors, no haemorrhagic accident was notified in the pharmacovigilance records of our hospital. nevertheless, fondaparinux has to be administred cautiously in this population of patients for whom the . mg dose will be necessary and hopefully available in a few month. diagnose group a streptococcal (gas) acute pharyngitis. this study aimed to evaluate the service; examine whether current clinical records were adequate; and test hypotheses investigating the association between clinical prediction rules (center criteria, cc), rapid antigen detection tests (radt) and antibiotic prescription. design: initially, a semi-structured interview was conducted to gain an insight into the service. data was retrospectively obtained from a standardised template (apef), completed by a pharmacist at the time of each patient visit. patient demographics and symptoms, radt results, cc scores and follow up rates were analysed. chi squared analyses were performed to investigate the aforementioned hypotheses. setting: jones pharmacy, spokane, washington dc. main outcome measures: establishing adequacy and effectiveness of clinical records and relationships between clinical prediction rules, radt and the antibiotic prescription. results: out of a total of patients (mean age = ; male = ) there were children (mean age = . ; male ) and adults (mean age = ; male = ). ten ( . %) of the negative radt results amongst children were referred to a primary healthcare provider. out of patients, ( . %) needed a radt to be performed. only ( . %) out of patients were followed up. significant association existed between radt outcomes and the prescription of antibiotics (p = . , p \ . ). conclusions: the findings from this study indicate that pharmacists need to be educated on the importance of a comprehensive clinical record. inconsistent practices occur amongst pharmacists due to the conflict between us guidelines, particularly relating to the referral of children with negative radt results to a primary care provider. the template was an efficient tool for data collection. jones did not tailor their data collection for the purpose of the study: with improved data collection, jones can yield information demonstrating the value of this service in future studies. only % of the rhophylac prescriptions. lg of anti d ig were administered when natead was available, whereas lg with rhophylac excepted times where , or lg were administered. times the pharmacist has induced a modification of the posology. however, none prescription was made according to the afssaps recommendations. prescriptions were made for children in hematology unit concerning boys and girls. among prescriptions of lg natead, % were correct and % for the rhophylac. the dose administered was not standard ( , or lg) and none prescription was conformed to the recommendations. conclusions: this study shows that since rhophylac was commercialized (more expensive than natead), the doses administered have doubled and the national recommendations (existent for adults only) are not followed. the reason is that hematologic patients may have a lot of transfusions so they want to protect them from any immunization, despite they are immunocompromised patients. new recommendations are needed, more applied to the practice and precising doses for children. the role of the pharmacist is then to remind physicians good practices of prescription. pharmacy, chu bicêtre, le kremlin bicêtre, france background and objective: computerized prescriptions are settled in clinical wards of our hospital. as pharmacist we have to validate those prescriptions and make recommendations to change part of the prescription such as dose, drug drug interactions. the objective of this study is to evaluate what kind of pharmaceutical interventions physicians really pay attention to. design: the prescriptions had been analysed for three months in three medical care units by two pharmacists. one of them take part in the physician round in order to integrate particular medical practices. pharmacist's interventions were recorded and categorized. the ratio of accepted interventions by the physicians was assessed. setting: three medical care units: internal medicine services (acute care unit: beds and long term hospitalisation: beds) and acute geriatric unit ( beds) in a -bed french university hospital. main outcome measures: description and analysis of pharmacist's interventions in clinical wards. results: we analysed prescriptions. interventions were performed and categorized. it should be noticed that % of pharmaceutical interventions were for misused of the new software: wrong selection of unit ( %) and redundant order ( %). the other % interventions were related to the prescription, our suggestions were as follow: time of administration ( %), adequate drug formulation ( %), dose adjustment ( %), therapeutic drug monitoring or biologic follow up ( %), to stop treatment ( %), route of administration ( %). among these recommendations, % were the consequence of drug-drug interaction. % of the interventions led to change in the prescription. % of the physicians maintained their prescription despite the recommendations, mainly for staggered administration to avoid drug interaction. background and objective: sliding scale insulin therapy (ssi) is a commonly used method of adjusting insulin in an attempt to control a patient's blood glucose levels. previous research investigating ssi use in the hospital setting has determined that ssi therapy leads to poor glycaemic control and poor patient outcomes. therefore, a corrective schedule for ssi therapy is recommended by the american diabetes association (ada). the aims of this study were therefore to determine, for the first time whether ssi recipients experience problems in the home care setting and whether ada guidelines on ssi use are being adhered to. design: eligible patients were identified through electronic records of patients admitted from st january to st december . the list was utilised to obtain medical charts of the patients. relevant information including patient demographics, blood glucose readings and documented problems were recorded using a standardised data collection form. chi-squared statistical analysis was determined using spss version . . setting: the visiting nurses association (vna) home care agency, spokane, washington state, usa. main outcome measures: use of 'traditional ssi therapy' versus 'corrective' version recommended by ada. results: of the total (male = , female = ; mean age = . , age range = - ) patient medical records examined in this study, . % (n = ) had at least one problem documented with their insulin regimen. the most common problem that affected over a quarter of the population, . % (n = ) was 'lack of control' which included any hyper-and hypoglycemic events. more than a third of sliding scale recipients, . % (n = ) had preprandial blood glucose levels above mg/dl. in total . % (n = ) of patients were prescribed the non-recommended traditional ssi therapy and only . % (n = ) were using the recommended corrective ssi therapy. conclusions: the findings of this study support previous concerns that ssi use is prone to problems and poor glycaemic control. furthermore, this study has established the lack of adherence to the ada recommended use of the corrective ssi schedule in the home care setting. it is hoped that this study will influence use of ssi in hospital and home care agencies as well as national and international guidelines. background and objective: prolonged (more than hours) mechanical ventilation (mv) is the most important factor associated with nosocomial pneumonia ( ) . nosocomial pneumonia (np) is differentiated in to ventilator-associated pneumonia (vap) if the process arose after the patient has been receiving at least h of mv ( ) . vap is defined as an inflamation of the lung parenchima caused by infectious agents not present or incubating at time mv was started ( ). design: longitudinal, prospective and observational study. setting: we made a prospective evaluation of the clinical files of a patient population of cases with vap diagnosed between april and december , who were assisted in hospital garcia de orta. a total of patients, % male and % female, aged ± years were diagnosed with vap. vap was defined as new positive respiratory culture after at least hours of mv. main outcome measures: these data sugest that the increase of pcr for documented vap caused by pseudomonas aeruginosa ocurred more frequently with ceftazidim than other antibiotics. results: in all vap episodes, an aetiologic microrganism, was isolated from hemocultures and bronchic secretions. the gramnegative bacteria were the most commonly isolated microorganisms ( %). we collected pcr and leucocytes data of seven documented schedules (n = ) for erradication of pseudomonas aeruginosa: ( ) ceftazidime ( g q h) + gentamicin ( mg/kg qd), ( ) ceftazidime ( g q h) + ciprofloxacin ( mg q h), ( ) piperacillin-tazobactam ( g/ mg q h) + aztreonam ( g q h), ( ) piperacillintazobactam ( g/ mg q h) + gentamicin ( mg/kg qd), ( ) piperacillin-tazobactam ( g/ mg q h) + amikacin ( mg/kg qd), ( ) imipenem-cilastatine ( mg q h) + gentamicin ( mg/kg qd), ( ) meropenem ( g q h) + gentamicin ( mg/kg qd). the mean duration of antibiotic therapy was days. there was an increase of the pcr values of the patients who were scheduled with ceftazidim but in the other groups there was a decrease of this parameter. the number of leucocytes didn't have any impact of the pcr variation (p [ . , t-test). considering the group of the patients, % ( ) of the positive cultures for pseudomonas aeruginosa which were sensitive to either ceftazidim or a carbapenem or piperacillin-tazobactam were treated with ceftazidim instead. conclusions: this approach provides useful information on the relation of host defenses and the clinical outcome. it is also useful to study the prevalence of acquired resistance to several antibiotics that may be used in documented antibiotherapy for pseudomonas aeruginosa. background and objective: rfviia is increasingly used as rescue therapy in uncontrolled bleeding, however little information is available regarding its safety and efficacy in this indication. -indication for use: massive bleeding when first-line treatment (surgical control of bleeding, use of blood products) has failed; -to achieve the correction of factors that may interfere with coagulation (hypothermia, severe acidosis, hypocalcemia); -before administration of rfviia the patient or his family should be informed about the treatment; -the prescription of fviia should be initialized by a referent physician -to conform the dose of mu/kg in cardiac surgery patient. conclusions: several solutions have been proposed to the physicians to improve their professional practices: to develop an algorithm for use of rfviia, to fill in a checklist before administration of rfviia to be sure to follow the guidelines, … this study will be extended in others departments using rfviia as gastroenterology and traumatology. pharmacy, administração regional de saúde de lisboa, pharmacy, administração regional de saúde de lisboa, lisboa, portugal background and objective: the pharmacist can contribute to the maintenance and recovery of population health conditions participating in patient house visit s health teams. pharmaceutical care at this level may also have a real impact on the health system costs. the aim of this project is to establish a pathway at this care level in which all aspects of pharmaceutical care are explained and defined. design: program description. participation of the pharmacist in health care teams. definition of field areas, between the pharmaceutical hospital care and the community pharmacy and health care centers. articulation between the hospital pharmacist, the health care center pharmacist and this new ''home pharmacist''. definition of the different types of pharmaceutical care to be implemented in this setting. background and objective: hip fracture is a major public health problem with a high incidence and prevalence in people aged years and older. changes in body composition and organ function, drug-drug interactions, and co-morbidities should be taken into account in the pharmaceutical care of this group of patients. the aim of this study is to analyse pharmacological treatment of elderly patients ongoing hip fracture in order to improve pharmaceutical care in this group of patients. design: a prospective pilot-study was performed during one month, (may-june ) in patients admitted in a tertiary hospital ongoing hip fracture. these variables were recorded for each patient: sex, age, body mass index (bmi), diseases antecedents, serum creatinine and creatinine clearance estimated by cockroft-gault formula, serum albumin levels, lymphocytes count, sodium and potassium levels. drug treatment was recorded from pharmacy database. setting: patients with hip fracture admitted in a tertiary hospital. main outcome measures: prescription profile in elderly patients with hip fracture. results: of patients, were female. mean age was . years old ( - ). mean bmi was . (n = , range - ). albumin levels were lower than . g/dl in patients. sodium levels were out of the normal range in patients. five patients had creatinine clearance lower than ml/min, of them less than ml/min. we analysed prescriptions which included drugs. they were classified in categories: not adjustment required ( drugs), adjustment required ( ) , inappropriate based in beer's criteria ( ), precaution in elderly people ( ) and not enough information available in geriatric population ( ) . mean number of drugs per patient was ( - ). of prescriptions revised, required adjustment and of them were correctly adjusted. of prescriptions in precaution group were correctly prescribed. conclusions: dosage adjustment or precaution was required in % of prescriptions. of these, % ( / ) needed dosage adjustment according to renal function. besides, % of patients had renal function alteration. thus, it is important to improve pharmaceutical care in this group of patients specially for those drugs that need dosage adjustment in renal failure. keywords: pharmaceutical care, hip fracture, elderly patients pc- hospital pharmacists and community pharmacists: an experiment of pharmaceutical information transmission carried out in an anticancer center anne lebreton , erwin raingeard , christelle audeval , sophie rochard anticancer center, centre rené gauducheau, nantes, france background and objective: to evaluate a programme of pharmaceutical information transmission from hospital pharmacists to the community pharmacists about drugs, particularly anticancer drugs, dispensed until then by hospital pharmacy and now distributed by them. design: while doing the last dispensation by the hospital pharmacy, an informative fax was sent to the community pharmacists indicating the name of the patient, prescribed drug and its posology, date and quantity dispensed, approximate date of the next dispensation and general information about the delivered drug. one month later a questionnaire was sent to the pharmacists to get their appreciation about this document. in the case of having no answer from them, the same questionnaire was re-sent. setting: pharmacy of french anticancer center, centre rené gauducheau, nantes. -appropriateness of the way of transmission -pertinence of information sent -efficiency of the programme results: out of patients treated ( vinorelbine oral, erlotinib, sorafenib, sunitinib), ( . %) were registered in this study, involving pharmacists. six pharmacists ( . %) answered after the first sending of the questionnaire and ( . %) answered after they received the remainder. fourteen pharmacists ( . %) did not answer. all the pharmacists were satisfied with the way of transmission. however, one of them suggested having the information sent by e-mail. seventeen professionals ( %) thought information was useful and ( %) thought that it was sufficient for their practice. only pharmacists ( %) encouraged us to continue the programme; the others did not express any opinion about its efficiency. moreover, none of them called us even though we suggested so. conclusions: this experiment seems to be interesting and to correspond to the needs of the pharmacists. it would also be an easy way to make dispensation safe. nevertheless, many problems appeared: much time spent and the difficulty making an exhaustive follow-up of all the patients thus limiting the application of this kind of programme to larger cohort. background and objective: to make a proposal of software that facilitates the analysis of clinical relevance of antiretroviral drug interactions, in the medical prescription, dispensation and dader methodology of pharmaceutical care study phase. design: pubmed and other databases evaluate revision. antiretroviral drug interactions were classified in four levels according to probability and severity of the interaction. the probability was grouped in categories: defined, probable and possible. so, severity was grouped in categories: serious, moderate, and slight. the levels are: level (serious and defined or probable); level (serious and possible, moderate and defined or probable); level (moderate and possible, slight and defined or probable) and level (slight and possible). we used the pubmed and database review for identified and organized the information to software elaboration. were by the enzymatic inhibition. antiarrhythmics, antihistaminics, ergot alkaloids, prokinetics, benzodiazepins, statines, calcium channels antagonists, phosphodiesterase inhibitors, azoles antifungics, selective serotonin reuptake inhibitors, opioid analgesic, immunosuppressants, macrolides, classic anticonvulsivants, and riphamicins were the most common drug therapeutic groups with anti-retroviral drug interactions. conclusions: interactions were classified, which % were drug-drug interactions; as well, . % were pharmacokinetics interactions and in their majority ( . %) were mediated by the enzymatic inhibition. about . % of interactions were level and , this levels of greater clinical relevance and whose the alert generated by software are contributions that help to analyze and take decisions with respect to the handling from the same ones. outcomes (e.g. mortality, morbidity, adverse drug reactions.); a profile of patients and clinical activities; an update of task description based on evidences and context. results: studies demonstrate that pharmacists have an impact on selected clinical outcomes following clinical pharmacy activities (e.g. drug therapy monitoring, pharmacokinetics and education for medical and paramedical professional). patients admitted in the intensive care unit have a higher level of complexity of care than average patients in the hospital, but a similar length of stay. for pharmacy services, their drug cost per admission is higher ( $cad vs $cad), as the number of pharmacist paid hours per admission ( . vs . ) and the number of pharmaceutical interventions per admission ( . vs . ). the approach helped us to identify solutions to problems like the nonparticipation to the cardiology patient's round, the absence of a medication reconciliation process or the inconstant documentation of interventions. a revised task description will be tested by both clinicians. conclusions: this study illustrates an approach for the evaluation of a pharmaceutical care model in a pediatric intensive care unit. background and objective: from , an increase in the consumption of biological and synthetic glues was noted in the cardiac service of surgery. these are drugs and expensive medical devices, which represent an expenditure of more than k€. the impact of their use was evaluated on the post-operative bleedings, the duration and the cost of stay by the way of a economic medical study. design: an observational exploratory study was carried out between january and march . all the operated patients were included. setting: the computerized consultation of the patient files made it possible to identify the following criteria of judgement: indication, surgeon, type of glue used, catch of platelet aggregation inhibitors or oral anticoagulants, volume of drainage, number blood transfused, duration of hospitalization. the statistical analysis related to two groups of patients, treated or not by glues, with a stratification on the hemorrhagic factors of risk. main outcome measures: the comparison of the averages of the various parameters was carried out by tests of student, for the large samples presenting comparable variables, and of fisher in the other cases. the cost of each hospitalization was calculated from the numbers of stays. results: during the three months of study, patients, whom average age was years [ - ], were operated. the two principal indications were the valvular replacement ( . %) and aorto-coronary bridging ( %). on all six surgeons, % of the interventions were dealt with by three. on the whole, patients receive a glue ( %), of biological type with tissucol Ò ( . %), and synthetic with bioglue Ò ( %), arista Ò ( %) and the grf Ò ( %). some patients received two types of glues ( . %). no significant difference between the two groups appeared in the total analysis. among the patients who received a pre-operative anticoagulant treatment ( %), only % were treated by a glue, for which the number of transfused globular bases and the duration of stay in reanimation were significantly lower (p \ . ; p \ . ), compared to untreated patients. conclusions: in general, the use of glues in cardiac surgery does not decrease the post-operative bleedings, but increases the cost of the stay. it however finds its utility with patients at the hemorrhagic risk. a standardization of the local practices of the surgeons is in progress because there is not any national consensus. these results should be confirmed by randomized studies on a large scale. although za is times more expensive than pa, it seems more effective with a shortened administration time ( minutes vs - hours). in respect of the contract of good use (cbu), our objective was to evaluate the real cost of a daily hospital (hdj) session per patient treated with bp, and to compare it with the one obtained from the national study of costs (enc) in order to determine if whether our hospital gained or loosed benefit from this new refunding status. design: retrospective study. setting: conception hospital, bd baille, marseille ce-dex , france. main outcome measures: for every hdj session, we accounted pharmacy direct expenditures (including implants, medical devices or drugs), medical technical acts, and structure and logistic supports costs. moreover, we evaluated matching of prescriptions with the cbu criteria. we analyzed data together with the public health and medical information ward and the department of management control. results: real costs of hdj session amounted to € without bp, and increased to € and € with pa and za administration, respectively. according to enc results, each session including intravenous bp was refunded for . €. in , on a total of hdj sessions ( patients), sessions had bp administration ( . %) and concerned patients ( . %). real costs of hdj were € ( € and €, for and hdj sessions with pa and za, respectively). if bp administrations were integrated in the ghs at this time, the sessions would have been refunded for € ( € and € with pa and za, respectively) resulting in a profit of € for the hospital. among bp prescriptions, % matched approved indications, . % were part of temporary protocol of use and . % were medical publication-based. internal medicine ward initiated % of the prescriptions. conclusions: using pamidronic acid compensates the deficit generated by zoledronic acid use. in respect with the cbu, zoledronic acid use will be restrained to approved indications in outpatients and pamidronic acid will be preferred in all others indications. keywords: biphosphanate, refund, economy pec- evaluation of the implementation of automated medication-dispensing system in an intensive care ward gregory gaudillot , marie antignac , fabien heck , nadine casimir , robert farinotti pharmacy, groupe hospitalier pitié-salpétrière, paris, france background and objective: the development of the implementation of automated medication-dispensing system in french hospitals is the main aim, defined in the ''good use'' contract voted in . the purpose is to improve the safety around the drug dispensing by the nurses. the objective of this work was to evaluate this implementation in thrusts: safety, economic and organization. design: comparison between two different organization ways: before the implementation (pharmacy order by nurses chief) and months afterwards (automated order and arrangement by a chemist assistant). setting: surgery intensive care unit ( beds) in the pitie-salpétrière hospital (ghps), a large teaching hospital. main outcome measures: study ''before and after'': follow up of prescribing and dispensing matches, analysis of time repartition between nurses and chemist assistants, follow up of line of emergency order, analysis of the results of a nurses satisfaction survey and costs study of drug consumption and drug storage. results: this study, performed over days, showed very small differences between prescribing and administered medications ( % before versus % afterwards = no significant difference). organization: implementation of automated device allowed a better division of activities, the management by nurses chief of the pharmacy order decreased (from % to % of their weekly working time), because this part was attributed to the chemist assistant ( % of their weekly working time). satisfaction: % of nurses preferred the automated system and especially because they find that this system was safe. in the same time, % of them appreciate with the new relationship with the pharmacy department. costs study: a huge decrease of the storage: - % of cost ( , € versus , €) and - % of references number ( versus ). in the same time, over months, the drug consumption of the unit has been reduced by % (- , €). conclusions: even if the study did not demonstrate a decrease of the number of medication errors (due to the tiny number of them as much before than afterwards the implementation), this automated system allowed a safety access to the drugs (biometric system) and contributed to reduce the risk of medication errors. the other great interest is the real involvement of the pharmacy in the clinical wards. the presence of the chemist assistant ensures a better management of drug storage (decrease of emergency order), a direct follow up and allowed a contact with nurses. results: in in france, intracranial stents with various technical characteristics are available (steel or nitinol, learning curve: to procedures, follow-up of patients is from months to years). stents with a hight radial force are used for intracranial artery angioplasty. more precisely, those devices are implanted in patients with recidive stroke, with an intracranial stenosis c % and who had failed medical therapy. two stents are identified in this therapeutic use: wingspan Ò (boston) and pharos Ò (micrus). about implantations are estimated for in france, whom implantations (cost = , €) in paris hospitals. the need is not actually clearly identified: the number of eligible patients is not already known and not systematically searched by neuroradiologists. so number of implantations will evolve. intracranial stents are used in combination with detachable coils embolization in patients with wide-necked cerebral aneurysms: léo Ò (balt), neuroform Ò (boston), entreprise Ò (cordis) and pharos Ò (micrus, double therapeutic use). for , about to implantations are estimated in france ( to % of endovascular treatment of intracranial aneurysm), whom implantations (cost = €) in paris hospitals. those data might increase. indeed, there is evidence of the effectiveness of stent implantation in intracranial aneurysm which generates lower rate of aneurysm recanalisation. conclusions: intracranial stents has been identified in precise therapeutic uses. however, an exact quantitative assessment can not be realised: those medical devices are innovating and are actually changing the management of patients concerned. those quantitative results might evolve. further similar studies will be necessary in order to follow up those innovating therapeutic uses in neuroradiology departments and to estimate their cost impact, actually negligible. keywords: stent, intracranial angioplasty, intracranial aneurysm, implantable medical device, cost evaluation pec- feasibility of economical impact of management of cytotoxic remainders in a centralized cytotoxic unit hélène corneau , déborah schlecht , sébastien bauer , sylvie froger , jacqueline grassin background and objective: the french law forecasts to reimburse the most expensive cytotoxic drugs to the real quantity administered to the patient. so to set up a secured procedure to use remainders of cytotoxic drugs in a centralized cytotoxic preparation unit in order to conform to the french law. design: prospective study. setting: clinic unit of oncologic pharmacy. main outcome measures: this procedure was tested during ten weeks and had concerned the three most expensive cytotoxic drugs used in digestive cancers. generated remaining quantities are conditioned inside isolator in radio-sterilized bags, and identified with the number of register of prescriptions, the drug's name, the remaining quantity, the conservation' conditions, the opening date, the duration of physico-chemical stability according to the data of the literature. bags are joined when they are gone out of the isolator. a theoretical differential is daily established between the doses which are prepared with or without management of remainders. results: the management of remainders involves that a rigorous manipulation during the conditioning and a daily management of the out-of-dates. the average of realized savings € a week, that represents , € extrapolated to one year and a decrease of . % of expenses for these three drugs. pharm world sci ( ) : - our software of the preparations of drugs is adapted for the use of the remainders. but the invoice-software allows only one invoice for one flask, which involves with the management of the remainders an unequal invoicing system for the patients conclusions: the management of remainders generates a real financial profit. but the really administered quantity cannot be imputed to the patient because the software of inventory control and invoicing does not manage the fraction of flasks. nevertheless, according to the french law we must express under fractional shape the quantities of cytotoxics, which are administered by stay to the patients for the most expensive drugs. background and objective: since july , financing of drugs in belgian hospitals is based on a lump-sump system. this decision favours efforts leading to more rational use of medication like for example the sequential treatment. efforts like posters, recommendation letters and information rounds were part of the strategy. since - - a clinical pharmacist puts also attention on this subject by contacting physicians and nurses regarding individual drug therapies. documenting the results of interventions suggested by a clinical pharmacist is often quite difficult. the number of ddd of intravenous administered drug versus the total amount of ddd [oral + iv] of the particular drug administered has been described. this parameter can be disturbed by the use of the oral form over a long period of time or by the early discharge of patients combined with a continuation of the therapy at home. to follow up the sequential treatment on the emergency department, this parameter seems to be accurate by the fact that the stay of the patient here is between and days. cost savings by sequential treatment of paracetamol and levofloxacin were euro and euro, calculated from the start of the activities the clinical pharmacist (for months). old habits are difficult to change among them the administration of drugs by intravenous route. almost every medical and surgical patient admitted to the emergency department receives an intravenous line, so the threshold for intravenous administration is low. furthermore a wide variety in patients' medical conditions added to a rapidly changing timetable for technical examinations and surgery necessitates an individual approach of the most suitable route of drug administration. official letters and posters may be useful. however this report confirms the importance of a clinical pharmacists' permanent presence on the ward for maintaining awareness of sequential treatment. results: applications for compassionate use treatment were processed ( . processings/ inhabitants). the higher number of applications has corresponded to gynecology unit, processings of misoprostol to use in delayed curettage. secondly, botulinum toxin was processed in cases, . % of them corresponding to anaesthesic and reanimation unit for miofascial pain. active substance that has caused a higher impact on the hospital s budget was inhalated tobramicin, processed for a total of patients with bronchiectasias colonized by pseudomonas aeruginosa. the expenses for this indication has added up to , € during . secondly, as regards to economic impact we found botulinum toxin which raised up to , €, expenses that were attributed in % to anaesthesic and reanimation unit. the highest cost/treatment by patient during corresponded to inhalated tobramicin that has increased up to , €, followed by infliximab approved for hydrosadenitis treatment which accounted for , €. total cost of treatments for compassionate use has involved approximately . % of total consumption for drugs during . conclusions: the higher number of processings in corresponds to misoprostol requested by gynecology unit although its economic impact on the consumption of medicinal products for compassionate use is very low. inhalated tobramicin utilization for colonized bronchiectasias involves the highest global cost and the highest cost/treatment on total medicinal products for compassionate use. the percentage accounted for medicinal products for compassionate use on total consumption of medicinal products is low. it would be interesting to perform a multicenter study in order to value economic impact in last years of medicinal products for compassionate use. the vacuum-assisted closure (vac) therapy: a -months medico-economic retrospective study stéphanie roche , nathalie herment , sandrine havet , amélie pruvost , willemin jean-claude , frances carole pharmacie, reims teaching hospital, reims, france, background and objective: in the management of wounds care, spectacular results have been achieved through the application of negative pressure wound therapy. this approach known as vacuum-assisted closure (vac) involves the use of a defined controlled negative pressure (delivered by an ambulatory motor) over a polyurethane or polyvinyl sponge (which are considered as consumables) placed in the wound. in our hospital, this therapy was first introduced for acute traumatic wounds. in june , the interdisciplinary wound and cicatrisation group decided to extend indications to chronic wounds. to improve management regarding this larger and complex use through all units, a specific prescription form associated with recommendations was set up. this document is available as well as paper or electronic form. the purpose of this study was to evaluate conditions of use and global costs of vac therapy. design: a -months retrospective study was based on the analysis of nominative prescriptions of vac consumables (canisters with gel, small, medium or large foam dressing kits and y connectors . the cost of consumables was estimated to . euros per day per patient. total cost over the study period amounted to euros, including the hiring of the vac system ( . euros per day). these data indicate that the use seems to be appropriate and optimized without overuse. conclusions: facing the high cost of this technical therapy, its use must be closely managed. this study suggests that the multidisciplinary collaboration in our hospital between medical staff and pharmacist unit contributes to guarantee the optimal use of this specific therapy. to analyze the effectiveness of an educational programme to increase the adrs reports during this period. design: clinically relevant events possibly caused by exposure to drugs have been analysed in a retrospective study for a period of five months. we analysed the prevalence of adrs reported, the medical conditions of the patients, the relationship between adr and the suspected drug using karch-lasagne algorithm and the severity of the reaction using who criteria. during this period, we implemented a pharmacovigilance programme in order to increase the reports and to estimate the prevalence of adr in this unit. setting: pharmacy service and critical care service of a general hospital main outcome measures: to evaluate prevalence, characteristics, nature and severity of adrs in uci. to measure the effectiveness of an educational programme to improve the awareness and detection of adrs. results: a total of patients were hospitalized during this period, adrs were detected ( . %). severe sepsis and cardiac arrest were the most frequent diagnosis in this group of patients. . % males and . % females, . years in average. dermatologic effects as urticaria rashes and haematological effects as pancytopenia were the most frequently noted, with more than % each. therapies most often associated with the reported events were antibiotics (piperacillin/tazobactam, ertapenem, azitromicin) in . % of cases and nitroglycerin in . % of them. the adr reported were classified as low severity in . % of cases, medium in . % and high severity in % of them. level of causality more frequent was ''probable'' in a . % of the reports followed by ''possible'' in . % of them. since the implementation of the educational programme the number of reports of adr have increased from . % to . %. the high level severity of adrs reported has increased in this period from % to %. conclusions: communication and educational programmes should be implemented to promote detection, identification, reporting and evaluation of adrs. the analysis to determine the probability, causality and severity of adr is necessary to establish the measures needed to improve the security and the quality of health attention. background and objective: ace inhibitors are used for controlling blood pressure, treating heart failure and preventing kidney damage in people with hypertension or diabetes. although ace inhibitors are generally well-tolerated by the most individuals, they are not free of side effects. dry cough is one of the most common side effects seen in patients during ace inhibor therapy. in this study, we have evaluated the incidence of dry cough that appears during the ace inhibitors therapy and relationships with the other coughing factors and the other side effects that may appear. design: the questionnaire was applied on ambulatory patients ( m/ f) who have used or been using ace inhibitors and hypertension patients as control group who use also anti-hypertensive drugs except ace inhibitors. ace inhibitors, and the reactions against the dry cough were determined by pharmacist's questionnaire on the patients who come to the community pharmacy. results: dry cough was observed on the patients out of , during their using of ace inhibitors ( %). % of male patients and % of female patients were having a cough. the patients out of ( %) from control group were having a cough. the incidence of dry cough that appears on the patients who use ace inhibitors were; silazopril %, ramipril %, lisinopril %, fosinopril %, qinapril %, perindopril %, enalapril % and trandolapril %. the treatments of patients out of who complain from coughing during the therapy of ace inhibitors were changed with angiotensin receptor antagonists and calcium antagonists by their physician. treatment changes were resulted in increasing in the cost by . ytl monthly if it was calculated on the base of generics. conclusions: as a conclusion, the incidence of dry cough from ace inhibitors was found to be % in the blacksea region of turkey. the pharmacist can play an important role in determining side effects such as dry cough and refer the these patients to physician. patient counselling and drug therapy monitoring in the community pharmacies will increase the compliance and provide better outcomes in many chronic diseases. setting: community in _ istanbul main outcome measures: visual analouge scale (vas) was used for assessment of pain. the universe of the study consisted of randomly selected women and men (n = ). a pilot study was run on individuals from different occupation groups to determine the validity and intelligibility of the questionnaire. results: the data were analyzed using a spss . program. the level of significance was accepted as p \ . . the results show that women experience more intense pain than men; their mean vas score is higher than men ( vs ). headache is the most common type of pain ( . %) and also its vas scores reached the highest level ( ) ( ) . this pain is especially caused by migraine and hypertension. in addition, % of questionees prefer to take an analgesic drug in order to manage their pain problem. it was recorded that especially non-steroidal antiinflammatory drugs (nsaids) and preparations containing paracetamol are the first choice in pain management. most respondees took analgesics when pain begun ( . %), when pain increased ( . %) or when was intolerable ( . %). conclusions: the majority of those who participated in the study took their analgesic medication without consulting a health professional. this indicates a high level of self medication in our population. this gives rise to a number of potential drug problems such as nsaids usage in gastrointestinal disorders, hypertension and renal failure. although many participants used their drugs in a rondom and improper way, unfortunately the pharmacist was rated second to last as a drug consultant. background and objective: many patients visit the pharmacy for their oral problems like toothache and ask for appropriate pain relievers. the purpose of this study is to examine the attitude and role of pharmacists, dentists and non-health workers towards solving of dental and oral health (like management of toothache). design: different questionnaires were applied randomly on pharmacists, dentists and non-health workers. setting: canakkale -turkey. main outcome measures: dentists' and pharmacists' approach to patients with toothache, drug usage evaluation in dental problems, the type of information given by pharmacists, patient behaviors. results: % of non-health workers (n = ) indicated that if they complain about toothache they choose their pharmacist as their consultant. % of non-health workers (n = ) indicated that they use various medications without consulting a dentist ( % naproxen sodium, % paracetamol, % methimazole, % flurbiprofen, % amoxicillin, % carnation essence). the most common suggested antibiotics was amoxicillin ( %) by pharmacists and amoxicillinclavulanate ( %) by dentists. the most common suggested pain relievers were naproxen sodium by both pharmacists ( %) and dentists ( %). only % of dentists declared that they consult with a pharmacist about drug usage. % of dentists indicated the importance of consultation of patients by pharmacists. conclusions: according to our results; pharmacists must take an important role in prevention and management of oral and dental health problems including informing the patients about convenient drug usage. also collaboration between dental staff and pharmacists need to be improved. background and objective: in hibbard and smithells suggested a link between inadequate maternal intake of folic acid and neural tube defects in their offspring ( ) . consequently, it has been recommended that all women planning to become pregnant should consume additional folic acid before conception and during the first weeks of pregnancy. despite these recommendations, periconceptional intake of additional folic acid is still low in many developed countries and a substantial percentage of women are not aware of its benefits ( ) . design: a questionnaire was used in a face-to-face encounter. setting: postnatal wards of a teaching and a private hospital in iran. main outcome measures: awareness of the effects of folic acid on the fetus was evaluated among women. the questionnaire included questions about demographic information, folic acid supplementation before and during pregnancy, its effects and the most susceptible periods in pregnancy and the source of information regarding the drug's effects during pregnancy. results: the mean age of women was . (± . ) years old. the majority of the subjects had more than high-school education ( % vs. %). out of subjects, ( . %) took folic acid supplement before and during pregnancy. only . % believed that its usage was unnecessary, . % believed in its positive effects. in the subjects' opinion, the most important time for taking this supplement was the first trimester ( . %), then prior to pregnancy ( . %). the second and third trimester were noted important by . %. . % believed in the importance of this supplement during all nine months. the advisor for taking this supplement was doctors ( . %), health visitor ( . %), self-medication ( . %), tv and radio ( . %), family members and friends ( . %) and pharmacist ( %). conclusions: awareness of the value of periconceptional folic acid was high among women of iranian nationality compare to similar studies ( ) . the majority of the participants believed in the positive effects of folic acid. the advices provided by doctors and pharmacists had the greatest and least effect on the use of this medication. regarding the best time of usage of this supplement, the most emphasis was on the first trimester and next on prior to pregnancy. background and objective: diabetes mellitus type-ii is a metabolic disorder that is primarily characterized by insulin resistance, relative insulin deficiency, and hyperglycemia. before type ii diabetes stage, people almost always have ''pre-diabetes''; in which blood glucose levels are higher than normal but not yet high enough to be diagnosed as diabetes. while some people with type-ii diabetes have symptoms, the majority may go - years without apparent symptoms. because some of the symptoms for diabetes mimic other diseases or conditions, makes it harder to predict an precise diagnosis without any additional information. the purpose of this study is early diagnosis of pre-diabetes, prevention or delay of the complications with a collaboration of community pharmacists and patients. design: pharmacists used a structured questionnaire containing questions concerning demographic data and informations which indicate prediabetes symptoms. setting: four community pharmacies in istanbul. main outcome measures: data: age, gender, body mass index (bmi), genetic predisposition, blood pressure, pysical activity and hypoglycemia symptoms. results: one hundred people were screened for undiagnosed diabetes. and the risk for pre-diabetes is evaluated according fasting plasma glucose (fpg) and total oral glucose tolerance (ogtt) test results. blood glucose level between and mg/dl with the fpg test and and mg/dl with ogtt test are considered as pre-diabetes. conclusions: diagnosis of pre-diabetes can prevent the development of type ii diabetes and making changes in nutrition and increasing the level physical activity may even be able to return the elevated blood glucose levels to the normal levels. pepi- awareness among pregnant women of the effects of drugs on the fetus and mother maryam dilmaghanizadeh , simin mashayekhi , masoud naghizadeh , zahra fardiazar , roghaiieh bamdad moghaddam pharmaceutics department, the faculty of medicine, tabriz university of medical sciences, tabriz, iran (islamic republic of) background and objective: since the talidomide catastrophy [ ] concern about the safety of drugs in pregnancy has been increasingly evident. studies have revealed that pregnant women continue to take considerable quantities of drugs. however, all pregnant women worry about whether to take any medications. because of an estimated % of birth defects resulted from maternal drug exposure [ ] , this fear is well justified. little is known about the knowledge of pregnant women regarding the safety of medications during pregnancy. to our knowledge the present study is the first performed in iran. design: a questionnaire was used in a face-to-face encounter. setting: postnatal wards of a teaching and a private hospital in iran. main outcome measures: awareness of the safety of drug use during pregnancy among women. the questionnaire included questions about demographic information, drugs use before and during pregnancy, information regarding the safety of drugs during pregnancy and the most susceptible periods in pregnancy, the source of information regarding drugs' safety during pregnancy. results: the mean age of women was . years old. only an . % and . % used conventional medications and herbal remedies during pregnancy, respectively. a great percentages ( . %) believed in harmfulness of drugs during pregnancy, but only a . % believed in harmfulness of herbal remedies. the first trimester and the second trimester were believed to be the most and the least susceptible period, respectively ( . % vs. . %). the sources of information for the subjects regarding the safety of medications was specialist doctors ( . %), general practitioner ( . %), pharmacist ( . %), midwives ( . %), health center ( . %), media and books ( . %) and friends and family member ( %). discussion: a common concern about the care of pregnant women involves the medications, which led us to establish a special initiative to review available knowledge among our general population. the present study highlights weakness of the role the pharmacists play in providing the information to this vulnerable and eligible group of people, who nourishing our next generation. conclusions: a common concern about the care of pregnant women involves the medications, which led us to establish a special initiative to review available knowledge among our general population. the present study highlights weakness of the role the pharmacists play in providing the information to this vulnerable and eligible group of people, who nourishing our next generation. ayce celiker , nergiz nemutlu , gulru ozkaya hacettepe drug and poison information center, hacettepe university, ankara, turkey background and objective: poisoning casualties require be approached with utmost attention due to their ''medico-social emergency'' nature. children are more vulnerable because of their inherent interests for knowing the environment besides ignorance and carelessness of adults. drugs are among the leading offending agents in children poisonings. the services of drug and/or poison information centers have been regarded as one of the main challenge areas of clinical pharmacy practice. being a pioneer in turkey, hacettepe drug and poison information center (hizbim), has been run for years in working hours basis. objective: the objective is to evaluate the demographic and epidemiological characteristics of drug poisonings in children, thus, to contribute to clarify the actual ''intoxication profile'' and identify necessary measures for the children in turkey. design: the data of childhood (aged \ years) poisoning enquiries received by hizbim between january , and december , were collected retrospectively and analyzed with spss . Ò setting: hizbim is affiliated to hacettepe university, faculty of pharmacy main outcome measures: categorization and comparison of data of children intoxicated with drugs during ten years results: children were involved in % of all poisoning cases and % of those cases were due to drugs. there was no gender difference among very young children, however, girls dominated as the age increases (p \ . ). % of the cases were accidental, and analgesics were involved in % of the accidental poisonings (p \ . ). while the most offending agent group was analgesics in children younger than years (p \ . ), multiple drug ingestions were the main causes of the cases involved older children (p \ . ). multiple drugs were mostly encountered ( %) in suicidal attempts where the dominant gender was girls ( %) (p \ . ). the most frequently reported symptoms indicated central nervous system involvement almost in all intoxication cases and in all age groups. conclusions: pediatric poisonings are rather high in turkey like many other countries and drugs are accounted for mostly in those injuries whether accidental or suicidal exposures. some regulations, the attitudes of physicians, pharmacists, and parents and other care givers make contributions to that outcome. in the prevention of childhood drug intoxications it is essential to make cooperation between drug manufacturers, regulatory authorities, health professionals, and families, besides increasing social awareness. drug and/or poison information centers stimulate rational drug use through providing accurate and rapid information to health care providers, educating people directly, documenting current epidemiological data. recently, we noticed a great interest of pharmaceutical companies in drugs such as monoclonal antibodies or in diseases such as inflammatory rheumatism. the aim of this study is to put in evidence the orientations of biomedical research. we particularly analysed the pathologies concerned, the type and the target of the experimental drugs, and the aim of the biomedical researches. design: analysis of the protocols and of the investigator's brochures of the ongoing clinical trials in january . setting: clinical trials sector of lapeyronie-arnaud de villeneuve hospital, montpellier. main outcome measures: methodological aspects were first analysed: aim of the study, phase, type of sponsor, type of binding, inclusion rate. then, we focused on the experimental drugs involved: type of drug, target, therapeutic area concerned. results: % of clinical trials are promoted by pharmaceutical companies. % are phase trials, % are open-label trials. objectives can be found: testing a new molecule on a new target ( %), testing a new molecule in an known pharmacological group ( %), testing a new formulation ( %), testing an known molecule in a new indication ( %), evaluating a therapeutic strategy ( %). % concern rheumatology, % pneumology, % infectiology, % haematology, and % nephrology. the most frequent pathologies concerned are inflamatory rheumatism ( %), malignancies ( %), asthma/cobp ( %), hiv infection ( %), and post renal transplantation immunosuppression ( %). the percentage of patients included (number of patients in the trials concerned/total number of included patients) and the inclusion rate (real number of inclusions/ number of expected inclusions)are respectively % and % in rheumatology, % and % in pneumology, % and % in haematology, % and % in infectiology and % and % in nephrology. % of experimental drugs are injectable. % are little molecules obtained by chemical synthesis, and % are issued from biotechnologies: monoclonal antibodies ( %), peptide ( %), and gene therapy ( %). the new targets ( % of clinical trials) are receptors ( %), enzymes ( %), gene transcription ( %), cytokines ( %). conclusions: this analysis gives an idea of the future commercialized drugs. it puts in evidence the development of drugs in therapeutic areas which concern a lot of patients and whose financial rentability is high. furthermore, only % of clinical trials concern new drugs and new targets. development of me-too and optimization of therapeutic strategies are the most frequent clinical trials. background and objective: the increasing use of performanceenhancing substances and methods in sport threatens not only the meaning and the ethical value of the sport itself, but also the health of the athletes. this study aims to assess the drug utilization profiles of the amateur football players, as well as their attitudes and knowledge on ''performance enhancing drugs''. design: this study was conducted on male players of the amateur football league. the players were asked to fill in a standard questionnaire, where information about their drug utilization profiles as well as their attitudes and knowledge on ''performance enhancing drugs'' were sought through various questions. setting: various amateur football clubs in turkey. main outcome measures: drug consumption rates of the players. answers to the pre-prepared questions. results: the age of the players ranged between and years. forty-four ( %) players thought that drugs have a positive impact on sports performance; while % did not share this idea. the resource of this idea was a team-member for . %, the trainer for . %, sports magazines for . % and a family-member for . %. the players were asked to name the drugs that could be used for performance enhancement and . % replied as vitamins, while . % replied as central nervous system (cns) stimulants and . % replied as anabolic steroids. thirty-six players ( . %) reported that they use various drugs with the aim of performance enhancement. the drug utilization profile was as follows: vitamins were consumed by . % of the players; where cns stimulants, anabolic steroids, diuretics and growth hormone were consumed by . %, . %, . % and . % of the players, respectively. the players reported the reasons referring them to drug-use as follows: . drugs always have a positive impact on sports performance ( . % of the drug-users); . drugs are necessary in case of inadequate training ( . % of the drug-users); . performance enhancement leads to individual success in the team and this brings prices and rewards in return ( . % of the drug-users). about % of the players thought that cns stimulants have the main effects of increasing the heart rate, endurance and strength. the main potential adverse effects of the cns stimulants were reported as gastrointestinal problems, dependency and tachycardia. about % of the players thought that anabolic steroids increase muscle volume, endurance and strength. the main potential adverse effects of the anabolic steroids were reported as hypertension, hepatotoxicity and dependency. conclusions: the results of the questionnaire suggests that drug-use with the aim of performance-enhancement was common among the amateur football players; and the players were not adequately and properly informed on the effects and adverse effects of the (so called performance-enhancing) drugs. this reality yields new responsibilities in this challenging area of practice, for the clinical pharmacist. background and objective: psychiatric disorders and opiate misuse are associated with chronic pain syndromes, but their incidence in fibromyalgia (fms) is unknown. the aim of this study was to identify if the incidence of affective disorders, and opioid misuse, was more common in patients with fms than those with other forms of nonmalignant chronic pain. design: a prospective, cohort study was carried out involving patients, who were internally referred to a chronic pain management program. subjects with a working diagnosis of fms were matched by age (mean = ) and sex ( % female) and compared to a control group of patients with alternative forms of non-malignant chronic pain. individuals were compared using urine toxicological screens, drugrelated criminal convictions, diagnoses of affective disorders, and responses to the following inventories: screener and opioid assessment for patients in pain, the pain disability index, the personal health questionnaire and the fibromyalgia impact questionnaire. patients also underwent a standardised physical examination using american college of rheumatology (acr) guidelines to diagnose fms. setting: this was a quantitative, hypothesis-testing cohort study, conducted in an academic general internal medicine practice. main outcome measures: diagnosis of fibromyalgia, clinician's awareness of acr guidelines, pain intensity and impact of fibromyalgia on physical and psychosocial activity. results: response rate was % (n = ; mean age = , median = , age range = - ; male = ); the most common background and objective: the increase in the frequency of the metabolic syndrome and its implication, in the development of ischemic cardiovascular disease and type ii diabetes mellitus, represent a real public health problem and of much interest in the medical field. otherwise, the cardiovascular pathologies are twice more frequent among chronics psychotics patients, for that reason we were interested in the prevention of these pathologys. this phenomena have been accentuated with the arrival of second generation antipsychotic drugs which were associated with weight gain, disorders of glycemia and lipidemia. in the aim to elaborate recommendations, at first we proceeded to the assessment of biological and clinical follow-up of the patients hospitalized in the saint-egreves hospital. design: literature review, months prospective study. setting: we asked doctors of each unit ( ) to answer questionaries corresponding to patient files. we worked out a general questionary to avoid revealing our objective. main outcome measures: blood pressure, body weight, height, abdominal perimeter, glycemia, total cholesterol, triglyceridemia, cholesterol's fractions(hdl and ldl). results: our results showed a good clinical follow-up but the frequency of biological control was not sufficient. the blood pressure and weight were evaluated respectively in and % of the patients, the total cholesterol, glycemia and triglyceridemia were in % of patients. on the other hand, cholesterol's fractions (hdl and ldl) were rarely evaluated. as for the abdominal perimeter, where the increase is predictive of cardiovascular disease, is never measured. conclusions: it seems difficult to evaluate the risk of either cardiovascular disease or metabolic syndrome of these patients or to determine if there is any possible relationship between the nombre of cardiovascular risk factors and the apparition of this syndrome. these findings imply to identify these high risk subjects and to define the optimal preventive, or curative, management strategy of metabolic syndrome and this, through simple measurements to realize in clinical practice. background and objective: availability of a medicine in western markets can be delayed either due to differential submission strategies of companies or differences in review process between countries. the aim of this study was to examine delays in patient access to medicines for compounds approved by two or more authorities (us fda, eu emea, australian tga, health canada and swissmedic), by characterising potential drivers for new active substances (nas) approved between and , from both a company and regulatory agency perspective. design: nass approved by fda since were compared to nass approved by the other agencies. this data was analysed comparing the difference between submission and approval dates and characterised by; type of approval route, company size, and therapy area. setting: data on nas's approved by the authorities was collected from agencies and from public domain sources. main outcome measures: the difference in patient access to new medicines in different countries and factors influencing such differences. results: nass have been approved by fda and one or more of the agencies studied. the median time ranged between submissions to fda and another authority from days at emea to days at tga. the difference between approval dates ranged from a median of days at emea to at health canada. however these differ depending on company size, therapy area and approval route. conclusions: availability of a new medicine is a mixture of company submission strategies and approval process, although therapeutic profile of submissions and company size are also influencing factors. in europe the main driver to patient access is review timelines rather than delay in submission by companies. main outcome measures: data on sex, age, origin of ppi prescription and indication were collected by a standardized questionnaire and were retrospectively analysed. results: men and women were reviewed. the median age was years (range, - ). % of patients received ppi therapy by pantoprazole (available in our hospital) when hospitalized. % of patients received daily mg of pantoprazole and % received mg a day. % of the prescriptions were validated. the main off-label indications were prevention of hemorrhagic risk of antiplatelet agent ( %), hemoglobin decrease( %), anticoagulant co-prescription( %), steroids co-prescription( %). conclusions: this prospective study confirms the large prescription of ppi therapy in a department of internal medicine. nevertheless, this study highlights the difficulties to interrupt this well tolerated therapy after the first prescription by family physicians. clinical pharmacist interventions in the department consist of explaining the difference of indications between pantoprazole mg and pantoprazole mg, he makes physicians aware of prescribing ppi therapy with a cautious reweighted cost/benefit consideration. background and objective: to develop and validate a system for regulatory authorities to provide feedback to companies on the quality of their submissions while companies report to authorities on the quality of the review. a standardised report format will allow performance comparisons within and across companies and agencies. design: draft scorecards were tested in a study on the same four compounds, each reviewed recently by the agencies in australia, canada and switzerland. the agencies provided feedback on the quality of submissions and sponsors, astrazeneca, gsk, novo nordisk and pfizer gave views on the conduct of reviews. background and objective: adherence with chronic medication such as inhaled corticosteroids (ics) has repeatedly been reported to be low. non-adherence could be related to inadequate knowledge of ics' actions and lack of ics' instructions on the use of inhalers. this has not been reported previously to our knowledge among new users of ics who discontinued ics treatment early. the aim of the study is therefore to describe, among new users of ics that discontinued, their knowledge of ics' actions and whether they were instructed on the use of their inhaler. design: a cross-sectional study among new users of ics that discontinued use. patients were interviewed by telephone and their gp received a mailed questionnaire. automated dispensing records of all patients were retrieved. setting: community pharmacies in the netherlands. main outcome measures: by use of conditional logistic regression the association between knowledge and study variables was assessed. results: from eligible patients, ( . %) were interviewed. the majority ( . %) of these new users of ics who discontinued ics early was not aware of the anti-inflammatory actions of ics. most patients ( . %) were instructed on the use of their inhaler, predominantly by the gp ( . %). after adjusting for symptom experience by acq, asthma diagnosis, having persistend asthma or use of medication only age (or . % ci . - . ) and male gender (or . % ci . - . ) were associated with unawareness of anti-inflammatory actions. conclusions: this study shows that a substantial number of new patients that did not refill their ics prescriptions, were unaware of ics' inflammatory actions. surprisingly only age and gender seemed associated with awareness of ics actions. most patients were instructed on the use on their inhaler by a health care provider. physicians and pharmacists could cooperate in identifying and motivating these patients to continue ics use. background and objective: to assess the quality of antibiotic therapeutic drug monitoring (tdm) in routine hospital practice and establish baseline status for rationally defining future actions aimed at improving it (by implementation of clinical pharmacy services). design: months prospective observational study with validated data collection form using predefined criteria for tdm quality assessment. descriptive statistics performed with spss . for windows Ò . setting: orthopaedic surgery, general surgery, neurosurgery, vascular surgery, haematology and pulmonary wards of a beds teaching hospital, using vancomycin twice daily and amikacin once daily administration schemes. main outcome measures: adherence to predefined criteria for sample timing, information transmission, and follow up of dose adjustment recommendations. criteria: (i) sampling time: less than ± min (amikacin) and ± min (vancomycin) deviation from preset time for peak levels; less than ± min for trough levels; (ii) information transmission: patient's full name, dose, schedule of administration, time of previous and current dose, actual time of peak and trough level sampling; (iii) quality of the analysis [internal and external controls]; (iv) acceptance of dose adjustment (more than %) recommendations. results: inclusion: patients ( vancomycin and amikacin courses). correct sampling times: (i) peak levels: % (n = ) for vancomycin and % (n = ) for amikacin, (ii) trough levels: % (n = ) for both antibiotics. correct information transmission: % (n = ). no issue noted for the quality of the laboratory analyses. implementation of recommendations: % (n = ) for vancomycin and % (n = ) for amikacin. conclusions: incorrect sampling times and deficiencies in communication between the ward and the laboratory are key factors affecting the quality of tdm, leading to dosage adjustment recommendations that are only infrequently implemented. the companion abstract examines the underlying reasons for such poor performance of the tdm process using a qualitative approach. corresponding values of d were: background and objective: to evaluate the relation between vancomycin and amikacin pharmacokinetic (pk) parameters in an intensive care unit population. design: data from intensive care unit patients were collected over a -month period, through a retrospective review of medical records and therapeutic drug monitoring (tdm) reports. patients were included only if at least two blood samples, at steady state conditions, had been drawn. data were first evaluated for completeness and consistency of recorded sampling and dosing times. individual pk parameters were estimated (bayesian analysis) using a one-compartmental pk model for amikacin and a two-compartmental pk model for vancomycin (pks Ò abbot). phase i of the study determined relationships between vancomycin and amikacin pharmacokinetic parameters, mainly clearance and volume of distribution. for that purpose, linear regression analysis of data from out of patients (analysis dataset) was performed. phase ii tested the predictability of the developed equations in an additional sample of patients (validation dataset) by comparing predicted pk parameters from equations (predeq) to those estimated by bayesian analysis (predbay) . t-test between predeq and predbay from each antimicrobial was performed. bias and precision were evaluated calculating the mean prediction error (mpe) and mean absolute error (mape), respectively (s-plus ). setting: intensive care units. tertiary university hospital. main outcome measures: patients demographics, clinical and tmd records, creatinine clearance by cockcroft-gault, vancomycin and amikacin blood levels and pk parameters. results: eighty-three critically ill patients ( females, males)were recruited for the study (mean values: age . yr, weight: . kg, cr: . mg/dl). a correlation between vancomycin and amikacin regarding their cl was found (clvancomycin = . clamikacin + . ; r = . ). however, no correlation was observed for vd (r = . ). concerning phase ii, differences in demographic data from both datasets were not statistically significant. no significant differences were observed when performing predeq versus predbay t-test. nevertheless, boxplot graphs for predeq and predbay residuals showed a wide variability of the values distribution and a lack of precision for both antimicrobials. conclusions: in our patient population this studied approach reveals an existing relation between amikacin and vancomycin pk parameters (or vice versa). however, the poor precision and large bias of residual values prevents us from recommending the use of these equations as pk parameters predictors (or regimen dose predictors) in intensive care patients. further studies with larger samples are definitely required in such an heterogeneous population. they were asked to identify which items of the ashp guidelines and gedefo they considered that must be filled in, in a prescription or in an identification label. consensus was defined as an agreement rate c %. prescriptions/labels evaluation: all breast or colon intravenous chemotherapy prescriptions, from a central hospital, have been evaluated from january to december (n = ), based on the parameters identified in the consensus document. a two month analysis of identification labels was performed. results: consensus document: a total of hospital pharmacists ( . %) completed the rounds of the delphi. consensus was obtained for . % of the prescription items and for . % of the labels items. prescriptions/labels evaluation: more than / of the analysed prescriptions were for breast cancer ( %) and the rest for colon. none of the analysed prescriptions had all the consensus items filledin. information that allowed the validation of the prescription by the pharmacist (ex: height, weight, body surface or number of cycle) was present in less then % of the prescriptions. no one had the prescriptor telephone, or the justification for dose reduction (when appropriate). only . % ( / ) of the labels mentioned the full identification of the solvent ( % miss the concentration) used and none of them stressed out the need for filter use when applicable. conclusions: consensus was obtained about a large number of items, which may constitute a difficulty in daily practice the evaluation of prescriptions highlights the lack of information that could allow confirmation by the pharmacist. labels do not seem to alert about special administration conditions. background and objective: background: the ministerial advisor on hepatitis c in catalonia has established a series of recommendations concerning hepatitis c treatment distinguishing between two groups: viral genotypes and , and viral genotypes and . in genotypes and it is necessary to evaluate treatment continuity after and weeks, depending on viral load and it is also necessary to prolong the treatment to weeks if there is viral response. in genotypes and it has not to be longer than weeks regardless of viral load. objective: to evaluate the adequacy of hepatitis c treatment and analytic monitoring, following the recommendations of the catalonian ministerial advisor. design: observational and retrospective study. setting: patients that started treatment with peg-interferon plus ribavirine in this hospital during . the information obtained was: viral genotype, the beginning and the end of treatment, quantitative basal rna (in all genotypes), quantitative rna ( weeks) and qualitative rna ( weeks) in genotypes and and at the end of the treatment in all genotypes. main outcome measures: the application of global advices ranges from % to % according to viral genotype and established recommendation. results: the compliance degree in genotypes and : % application of quantitative basal rna and % after weeks. % of treatments were discontinued with quantitative rna positive after weeks, % with qualitative rna positive after weeks and % the treatment was continued longer than weeks. in genotypes and : % application of quantitative basal rna, % application of qualitative rna after weeks and % the treatment was continued longer than weeks. conclusions: following the recommendations on viral response evaluation after and weeks allows the early suspension of therapy in non-responsive patients. this leads to and improvement in patients' quality of life, a reduction in adverse side-effects and savings in medical care costs. treatment monitoring by hospital pharmacist provides medical decision support. in consequence these patients constitute a target group to establish pharmacy care programs focused on hospital outpatients. topical application of mitomycin . % during two minutes and postoperative stenting for a period of four-ten weeks were used, no second application of mitomycin was used. the follow-up was years in bilateral case and six months for the unilateral case. setting: pharmacy and otorhinolaryngology service. hospital universitari joan xxiii de tarragona. spain. main outcome measures: the success of the repair was measured according to the following items: endoscopic evaluation of the patency of the choanae, respiratory distress and nasal drainage. results: bilateral membranous choanal atresia was surgical repaired five days after birth, using transnasal endoscopic approach and topical mitomycin . % during de proceeding. no operative complications occurred and stents were removed four weeks after repair. the choanae was inspected endoscopically to asses healing and no presence of re-estenosis was found. no clinical symptomatology. unilateral mixted atresia on the left side was diagnostic at six years old and surgical repaired because of association of respiratory distress and nasal mucus drainage symptomatology. no restenosis has appeared and syntomatology has improved. nome patient required surgical revision. conclusions: although, the exact role of the topical application of mitomycin . % must to be further investigated, the use of this drug as an adjunct to the surgical repair of choanal atresia may offer decreased need for revision surgery due to re-estenosis. keywords: mitomycin . %, choanal atresia pt- adherence to clinical guidelines for upper respiratory and ear infections in out-of-hours primary carea retrospective study sara claesson biofarmaci, uppsala university, täby, sweden background and objective: infections in the upper airways and ears are a frequently occurring reason for patients to visit primary care settings. prescribing adherence to local guidelines for handling infections of ears and upper airways and antibiotic prescribing is of both local and national concern. increasing antibiotic resistance is one reason, cost and patient quality of care are others. the objective of this study was to investigate physician adherence to clinical guidelines at the out-of-hours primary care clinic in täby. design: a retrospective study. clinical case notes were scrutinised for all patients seeking care for problems with ear, nose, throat, fever, cough or cold between january and march . data was analysed for patients who were diagnosed with specified ear or upper respiratory infections. laboratory tests taken and antibiotic prescriptions were anonymously documented. antibiotic prescription filling dates were investigated. setting: husläkarjouren, the out-of-hours primary care clinic in täby. main outcome measures: adherence to and fulfillment of local therapeutic guidelines and professional quality criteria was defined with respect to immediate, delayed or no prescription, drug choice, dose and duration and the use of diagnostic tests. adherence was defined as complete or not, and deviations from the guidelines were separately analysed. prescription filling was analysed with respect to time from clinic visit to pharmacy visit. results: data from patient visits were analysed. adherence to local guidelines was disappointingly low. general treatment of infections was only according to guidelines in % of the cases and only laboratory testing met the quality criteria. adherence to antibiotic prescribing guidelines was even lower, only % of antibiotic prescriptions were completely according to local guidelines. % of all antibiotic prescriptions were filled within one day from the visit to the clinic. conclusions: communicating guidelines to prescribers and continuous follow up of prescribing behaviour is essential for improving patient care and decreasing the risk of antibiotic resistance in the community. this study exposes gaps in the quality of care that may not be picked up by traditional follow up measurments. studies with a wider scope and in depth analysis of reasons for nonadherence to guidelines are warranted if antibiotic use is to be improved. . lines after other therapies. before bortezomib one patient received therapeutic with thalidomide/dexametasone, one vad, one cyclophosphamide (ctx), three followed by vad, one mp followed vad and followed ctx, and another with vad followed by ctx. the therapeutic selection followed the nccn guidelines in all patients. the average number of cycles with bortezomib has . . from the patients, stopped, one had a generalized face oedema bortezomib related, although the disease was in remission, and another died by sepsis not related with this drug. in relation to bortezomib's effectiveness, ( %) patients had a very good response, since the immunoglobulin decreased and three ( %) of these patients are actually at consolidation cycles ( th and th). conclusions: the use of bortezomib in our hospital was according the nccn guidelines and the experience was very positive. nevertheless, and considering also the high cost of this therapeutic, we consider very important to continue to follow up this group in order to evaluate the rate of response to bortezomib during time. pt- evaluation of the time interval between admission on the emergency department and administration of the first dose of antibiotics background and objective: when patients are admitted with a proven or suspected infection on the emergency department, adequate antibiotic treatment must be started as soon as possible. literature reveals that the time between admission and administration of the first dose of antibiotics can reach about hours and this can influence the prognosis of the patient. international guidelines for community acquired pneumonia (cap) and bacterial meningitis define this time interval of hours( ) and less than hours( ) respectively. to evaluate the practice on the emergency department of our hospital, with an average daily admission of patients, a study on this interval was carried out. . % of all administered antibiotics is in adherence to the local guidelines; however this was only evaluated by the clinical pharmacist. a possible explanation for the relatively short time intervals could be that the antibiotics which are frequently used are available at the emergency department and that the guidelines are at all time available on our hospital intranet. the time intervals of cap and bacterial meningitis are shorter than the defined international guidelines.( , ) conclusions: the time interval, found in our study, between admission on the emergency department and administration of the first dose of antibiotics is short, compared with similar conducted studies.( , ) pharmacy, otolaryngology, de octubre university hospital, madrid, spain background and objective: a woman diagnosed with laryngeal papillomatosis. treatment consisted of laser excision of the granulomatous lesions, followed by mitomycin c instillation over the surgical bed. description of the preparation and utilization of mitomycin c instillation over the surgical bed for the treatment of laryngeal papillomatosis. design: request by the ent service for compassionate use of mitomycin c. following authorization from the health authorities, a literature search was made. after determining the dose/day for the patient, elaboration was carried out according to the literature references. setting: vials of mg of mitomycin c were used as starting material, with -ml syringes to facilitate instillation in the operating room. dilution was made to double the standard in our centre ( ml). main outcome measures: two -ml syringes were prepared per cycle, with a mitomycin c solution of . mg/ml for instillation, though finally in all cases only one of them was used. stability was established as hours at room temperature, without special considerations regarding light exposure, as specified by the literature. the entire procedure was carried out in a laminar flow chamber, in compliance with the specifications for manipulating cytostatic agents. results: the patient received a total of three cycles of mitomycin c, the last two being maintenance cycles. the patient has experienced no papilloma relapse, and only right vocal cord hyperaemia is observed, probably secondary to surgery. conclusions: collaboration between the service of pharmacy and the ent service allowed adequate treatment and recovery of the patient, without apparent adverse effects. swollen and tender joints over joints evaluated, and the value of erythrocyte sedimentation rate, comparing the das from one patient on two different time points; eular response, that classifies patients in groups according to treatment response, and decrease in mhaq (modified health assessment questionnaire), that indicates patient's awareness of disability. data were recollected at beginning and at weeks of initiating treatment with rituximab. differences between b-lymphocyte count at beginning and at weeks was of initiating treatment was used as a secondary variable. results: we collected data of patients, all being females, was rf positive and were anti-ccp positive. at women) a . % of patients received adjusted prophylaxis to their degree of risk ( . % with heparin prescription and . % without it) from all . % of inadequate prescription ( % of the patients with lmwh prescription); patients lost follow up. patients submitted to cancer surgery ( surgeries, men, women), % received apropiate prophylaxis ( . % with lmwh and . % without it). same percentage of patients ( %) was not adapted to correct prophylaxis ( % patients with lmwh); patients lost follow up. conclusions: there is a greater percentage of choledoco surgery patients with lmhw prescription in compliance with published guidelines than oncology surgery patients, however it will be necessary carry out a better implementation among healthy professionals in order to increase this percentage of patientes. results: prescriptions of these broad-spectrum antibiotics were collected and analysed. % of the prescriptions were initiated by residents, % by senior physicians. vancomycin was the most prescribed antibiotic ( %), mainly in the orthopaedic surgery unit. the indications of antibiotics were osteomyelitis ( %), septic arthritis ( %), prosthetic joint infections ( %) and pneumonia ( %). only % of antibiotic doses were not correctly adapted to creatinine clearances or to plasmatic vancomycin rates. the initial choice of antibiotic was considered appropriate in % of cases. regarding bacteriological results (bacteria, antibiogram), the continuation of the treatement was acceptable in % of cases. however in % of prescriptions, an adjustment of therapy with a more narrow spectrum antibiotic could have been done. conclusions: these results have to be extended with further investigation (at least months). were systematically reviewed to retrieve prospective trials describing esa doses in dialysis pts who converted from rhuepo to da. search words included: ''epoetin, darbepoetin, esrd, ckd, and dialysis.'' the inclusion criteria required a study to have dose data available during the evaluation period for both rhuepo and da. study selection and data extraction were performed by independent reviewers and verified by a rd. relative doses and dose changes after conversion from rhuepo to da were estimated using an initial rhuepo:da : conversion ratio (aranesp Ò eu label). study quality assessment was performed using the downs-black checklist, a standard method used to assess the quality of a study using ebm principles. setting: meta-analysis. main outcome measures: dose efficiency. results: the search yielded studies meeting the inclusion criteria. upon further review, studies were excluded ( had unextractable data, were retrospective analyses, and had predialysis pts). the remaining studies were analyzed: rcts with parallel control groups, cross-over trials, and observational conversion studies (table) . the studies yielded data on , rhuepo and , da pts, with a mean treatment duration being weeks. we found the average study quality was %, with rcts (n = ) having a higher quality score ( %) than crossover ( %; n = ) or observational ( %; n = ) studies. there was a notable dose efficiency observed when pts were converted to da from rhuepo. this effect was greater in the rcts ( . %) than in crossover ( . %) or observational ( . %) studies. conclusions: we found a notable da dose efficiency (up to %) in pts who were converted from rhuepo to da using a : conversion ratio. additionally, studies with the highest quality scores (eg rcts) had the greatest observed dose efficiency while non controlled studies scored lowest in both quality and dose efficiency. background and objective: the purpose of this study is to evaluate the frequency of otitis media and the assessment of its relationship to patients' socio-demographic characteristics and determination of systemic and topical drug profiles in otitis media. design: this retrospective study included the assessment of patients diagnosed with otitis media, who admitted to the study hospital during a months period (march-may ). demographic, clinical and prescription data of these patients were collected and analyzed. setting: the ear-nose-throat out-patient clinic of a states hospital. main outcome measures: the socio-demographic data of patients; the frequency of otitis media; type and percentage of prescribed drugs; the most used treatment regimens. results: patients ( women and men), who were diagnosed with otitis media, were included in our study. patients were diagnosed as chronic otitis media or serous otitis media or acute otitis media or external otitis media at rates of . %, . %, . %, and . %; respectively. in children, the acute and serous otitis media were seen more often than in adults (p \ . ). however, chronic otitis media were seen more frequently in adults (p \ . ). all patients were administered drug therapy for their diseases. it was observed that antibiotics (oral and/or topical), analgesics, decongestants, and topical corticosteroids were prescribed at rates of . %, . %, . %, and . %; respectively. prescribed oral antibiotics were cephalosporins [cefixime ( . %), cefuroxime axetil ( . %) and cefaclor ( . %)], amoxicillin-clavulanate, and floroquinolones [levofloxacin ( . %) and ciprofloxacin ( . %)] at rates of . %, %, and . % respectively. rifampin and ciprofloxacin were prescribed as topical antibiotics at rates of . %, . % respectively. when the number of drug used by the patients was evaluated, were on quadri-therapy, on tri-therapy, on dualtherapy and on mono-therapy. patients were treated with the combination of antibiotic-analgesic-decongestants. conclusions: our study indicated that the most frequently prescribed drugs were antibiotics in otitis media. clinical pharmacists have a potential role in rational antibiotic use by providing clinical pharmacy services such as antibiotic selection, drug monitoring and patient education; so that they would reduce both antibiotic resistance and treatment costs. background and objective: the sampling method is crucial for the physical and chemical quality control of antineoplastic chemotherapies. this step acts upon the dosage correctness and may lead to risk of needle-stick or cytotoxic drug projection during its achievement. beyond, the sampling time must be as short as possible and the sample be directly placed on the analysis machine. this work evaluates a new and improved sampling method, specially worked out for this application. design: this study was designed to ensure the vial airtightness and the volume sampling. a cost and time study was also performed. setting: the vial is an hplc type, chromacol Ò ml, mm dp = hpa, (interchim Ò , montluçon, ). the vial is airtight thanks to a ptfe silicon septum set with an aluminium collar. the vials are vacuum-packed in a pvc bag (didop Ò , compiègne, ). a void test was led on unpacked vials up to months, to ensure a maximum conservation, and showed a filling volume of ± ll, very close of the ll target. main outcome measures: one week samples have been weighed to calculate the filling volume in real conditions of use. this volume is ± ll ranging from to ll. since this sampling method has been set up, the percentage of refusal for insufficient volume is lower than . %. this technique was compared to the previous method in terms of cost: vial, sampling adjuncts, handlingtime and waste. the vials are filled with a secured double-needle eclipse Ò , mm, / (becton-dickinson Ò , le-pont-de-claix, ). results: about , chemotherapies controls are made each year in the hospital. the vial and the sampling device costs are higher than the previous ( € versus . €, and . € versus . €). on the contrary, the handling-time for sampling was estimated minute lower (which corresponds to . € less per sample). furthermore, the waste weight is gram lighter with the new devices, which costs . € less in the waste disposal. the total cost difference is . € higher per sample. an estimation of a needle-stick accident has been carried out, with the human cost (pharmacist technician's compensation and medical consulting) and the equipment including gloves, sterilization devices and post-sterilization check; the lowest estimation cost of an accident is . €. conclusions: the secured needle makes the sampling operation easier for the workers and it lowers the risk of needle-stick. besides, this closed system avoids completely the antineoplastic contact for the manipulators during the confection and the control. moreover, this system allows to secure the sample library. background and objective: the prevalence of diabetes mellitus in kuwait ranks amongst the highest in world at about %. diabetes is a well recognized independent risk factor for cardiovascular disease (cvd). the increased prevalence of several other known risk factors for cvd in kuwaiti diabetics further increases the risk. since cvd is the leading cause of death in kuwait, the high incidence of diabetes has major social and economic impact. diabetics aged years or older have, in general, an increased -year risk of developing cvd compared to younger patients but there have been no audits involving this group of patients in kuwait. the objective of this study was therefore to audit achievement of cvd risk factor goals according to pt- pharmacotherapy of first-episode psychosis in the psychiatry clinics of the north estonia regional hospital (nerh) and the tartu university hospital (tuh) jana lass , agnes männik , simon j. bell pharmacy department, north estonia regional hospital, tallinn, institute of pharmacy, university of tartu, tartu, estonia, faculty of pharmacy, university of helsinki, helsinki, finland background and objective: treatment guidelines provide recommendations for the evidence-based treatment of schizophrenia. adherence to these guidelines is often sub-optimal. our aim was to compare and contrast the pharmacotherapy of first-episode psychosis at the nerh and tuhs, with respect to both treatment location and evidence-based guidelines. design: retrospective study. case notes for consecutive patients with schizophrenia, schizotypal or delusional disorders (icd- ) admitted to the nerh and tuh between september and september were retrospectively reviewed. setting: psychiatry clinics of two tertiary care hospitals -nerh and tuh. main outcome measures: outcome measures included the choice and daily dose of antipsychotics, incidence of antipsychotic polypharmacy and reasons for changes in therapy plan. results: patients form nerh and from tuh were included in the final analyses. median age (sd) of the patients was ( . ) in the nerh and ( . ) in the tuh patients were hospitalised for longer in the nerh than in the tuh, ( . ) vs. ( . ). the most frequently prescribed antipsychotic was risperidone at both study locations - % of prescriptions in the nerh and % in the tuh. conventional antipsychotics were administered twice often in the nerh than in the tuh. in the tuh olanzapine was administered in higher prescribed daily doses than in the nerh. the number of antipsychotics prescribed per patient was higher in the nerh than in the tuh - . vs . . the prevalence of antipsychotic polypharmacy was . % among the patients in the nerh, whereas only one patient was treated with antipsychotic polypharmacy in the tuh. conclusions: analyses revealed significant differences in the pharmacotherapy of first episode psychosis at the nerh and the tuh. mechanisms to facilitate improved adherence to the evidence-based treatment guidelines should be investigated. pharmacy, hospital universitario de getafe, getafe, spain background and objective: to analyze the use of tnf-alfa inhibitors in rheumatoid arthritis diagnosed patients in a bed hospital. design: retrospective study of patients with anti-tnf-alfa during year . the following data were compiled: age, sex and anti-tnfalfa prescription including dosage and duration of treatment. setting: hospital universitario de getafe. main outcome measures: dosage and duration of treatment. results: a total of patients were included. patients ( . %) received just one anti-tnf-alfa drug, ( . %) needed two lines of treatment and ( . %) of them needed three. patients who were treated with just one drug had a median age of . years and those who required two lines of treatment had a median of . years. the first line drug was etanercept in . %, infliximab in . % and adalimumab in . % of patients. second option was etanercept in . %, adalimumab in . % and infliximab in . % of patients. the average duration of treatment with etanercept as forward edge was days. the treatment was suspended in . % of patients. when infliximab was used as first line, average duration was days, and treatment was interrupted in . %. with adalimumab, average duration was days and treatment was interrupted in % of patients. conclusions: those of our patients who need an only one treatment line are younger than those who need or , due to the chronic and progressive course of the disease. etanercept is used as much in first option (followed by infliximab) as in second one (followed of adalimumab), although these differences are not statistically significant and it would be necessary to make a study including more patients. the duration of treatment with infliximab is the longest, as this was the first drug available. regarding treatment failure, etanercept shows the greatest percentage. this should be taken into account when establishing first line treatment. background and objective: plantar warts are hyperkeratotic lesions on the plantar surface caused by infection with human papillomavirus. lesions caused by warts are commonly refractory to therapy and may become large and painful in immunodeficient patients. cidofovir is a cytidine analogue with activity against a broad spectrum of dna viruses. it is indicated for the treatment of cytomegalovirus retinitis in patients with acquired immunodeficiency syndrome and without renal dysfunction. we describe a case of plantar warts that was treated with topical cidofovir in a highly immunodeficient patient. design: case report, evaluation and discussion based in clinical chart and literature review. setting: pharmacy department, general teaching hospital. main outcome measures plantar warts regression, which was evaluated on the basis of change in overall surface area of the treated lesions compared with baseline. to evaluate the organoleptics properties of the galenic formulation. results: a years old woman, who received kidney transplant in , presenting plantar warts refractory to conventional therapy since last four years. she was treated with topical % cidofovir cream twice daily. the treatment was authorised as compassionate use by the national regulatory agency on drugs. the glomerular filtration rate (gfr) was monitored in order to detect nephrotoxicity due to cidofovir. the % cidofovir ointment was compounded as follows: -cidofovir mg/ml ml vial .…….. ml -anhydrous lanolin ……………………….. g -beeler base …..sufficient to produce g it was packaged and labelled in a light-resistant containers and we assumed an expiration date of months based on the duration of treatment and published studies. the quality controls of organoléptics properties were made according to the good manufacturing practice (gmp) after weeks of therapy the patient did not show any improvement and developed severe local erosion, so treatment with cidofovir was withdrawn. two weeks later this local erosion disappeared spontaneously. no systemic side effects were observed. the colour, texture and smell organoleptics characters were complied with gmps. conclusions: there are not formal studies of optimal formulations or treatment regimens and further studies are needed to elucidate the role of cidofovir in treatment of plantar warts. the immunodeficiency of the patient and the large wart area could be related with the failure to the treatment. background and objective: hypersensitivity reactions (hr) to platinum salts can be serious and should lead to interrupt chemotherapy regimen. skin tests may be used to confirm diagnosis of hr. usually, these tests are prick tests and intradermal tests performed with diluted solutions of platinum salts. there is no standard solutions for these drugs, which local toxicity depends on concentration. the main objective of this study was to assess the safety of platinum salts skin tests performed in our hospital. the secondary objective was to assess their efficacy to verify the allergic nature of the reactions observed. design: pilot study of skin tests preparations between january and june . these preparations were dilutions ( / , / , / ) of a primary platinum salt solution, which concentration was roughly the one used in the chemotherapy regimen of most patients. the compatibility of platinum salts with dilution solvent was checked, and all solutions were prepared extemporaneously in a centralised cytotoxic drug preparation unit, in order to protect handlers. setting: allergology department and pharmacy department in a university hospital. main outcome measures: skin tests results: positive if a papule appeared, negative if there was no reaction, local toxicity if an irritative reaction happened. results: patients with clinical symptoms of hr with a chemotherapy regimen containing platinum salts were explored by skin tests. drugs assessed were: oxaliplatin ( patients), cisplatin ( ), and carboplatin ( ) . no patient developed local toxicity. tests results were positive in cases ( oxaliplatin and cisplatin), and negative in cases. patients received both cisplatin and oxaliplatin skin tests: patients had a single positive reaction with no cross reaction between the two drugs, and the third had no reaction. in cases, tests results and clinical history of hypersensitivity mismatched. conclusions: this study shows that these skin test solutions were safe. their efficacy was judged correct: positive reactions confirmed the diagnosis of hypersensibility for patients. the main limit of the results is the absence of control subjects. these tests allowed to explore patients' hr, and to help oncologists to choose the more appropriate treatment for them. stability studies are still needed to assess the pharmaceutical quality of these diluted solutions. these preparations have now been standardized in our hospital. background and objective: guidelines regarding appropriate use of prophylactic antibiotics have been implemented at university hospitals leuven. however, the degree of compliance with these guidelines is unknown. the aim of this study is to develop a method to quantify compliance with antibiotic prophylaxis guidelines and to apply this method to the clinical areas of appendectomy and heart valve surgery. design: a retrospective case series was carried out of all prophylaxis episodes related to appendectomy and heart valve surgery at university hospitals leuven between august and february . four grades of compliance with antibiotic prophylaxis guidelines were identified: grade compliance, reflecting administration of the antibiotic proposed by the guidelines in a dosage within - % of the recommended dosage; grade compliance, defined as the administration of the antibiotic proposed by the guidelines in a dosage outside - % of the recommended dosage; grade compliance, referring to the administration of an antibiotic equivalent to the antibiotic proposed, but not mentioned by the guidelines; and grade compliance, representing any other antibiotic prophylaxis scheme. setting: divisions of abdominal and cardiac surgery, university hospitals leuven. main outcome measures: the percentage of prophylaxis episodes that satisfy each grade of compliance with antibiotic guidelines. results: prophylaxis guidelines relating to appendectomy ( , episodes) recommend administration of three times cefazolin g and a single dose of metronidazol . g. the proportion of episodes that satisfied grade , , and of compliance with guidelines amounted to %, %, %, and %, respectively. cefazolin g and metronidazol . g was used in episodes. prophylaxis guidelines applying to heart valve surgery ( , episodes) recommend administration of cefazolin g. the proportion of episodes that satisfied grade , and of compliance amounted to %, % and %, respectively. grade does not apply to heart valve surgery as no equivalent antibiotics were identified. the difference in compliance with prophylaxis guidelines between both surgical procedures could be explained by differences in infectious pathology, the peri-operative adaptation of the antibiotic regimen by the abdominal surgeon, and the use of a second regimen related to the severity of the appendicitis. a case can be made for combining grade - compliance with respect to appendectomy, resulting in a higher compliance rate. conclusions: our proposed method to measure compliance needs to be validated by future research. the method can be applied to different surgical procedures, thereby stimulating surgeons to explain differences in compliance between procedures and promoting the development of instruments to enhance compliance. closer interaction with surgeons is required to further develop the measurement of compliance with antibiotic prophylaxis. keywords: antibiotic prophylaxis, compliance, guidelines pt- non-specific immunoglobulins for immune neonatal thrombopenia nuria ibañ ez , maria del pilar m. p. bautista , ana maria a. m. iglesias , roberto r. ortiz , javier j. sanchez-rubio , maria del carmen m. c. giron , marta m. arteta pharmacy, pediatry, hospital universitario de getafe, madrid, spain background and objective: non-specific human immunoglobulins are being used at the moment in neonatal population for treatment of immune thrombopenia. the dosis commonly used varies between mg/kg and g/kg from one to five days. corticoids and platelet transfusions can be used jointly. to study the effectiveness and safety of non-specific human immunoglobulins in a neonatal unit for treatment of immune thrombopenia. design: retrospective study of neonatal patients diagnosed with immune thrombopenia during and treated with non-specific human immunoglobulins. a revision of clinical histories is made and following data are collected: sex, gestational age, born weight, age at the moment of infusion, administered dose and duration of treatment, use of corticoids and platelet transfusions, number of platelets/ll before infusion, at , at hours of initiate the treatment and at discharge. possible adverse reactions is also considered. setting: hospital universitario de getafe. main outcome measures: the effectiveness and safety of nonspecific human immunoglobulins for treatment of immune neonatal thrombopenia. results: three children were included in the study, two of them were males. thrombopenia was diagnosed from probable alloimmune origin, including positive confirmation study in one of the cases. gestational ages ranged from + to + weeks. born weight ranged between . kg and . kg. immunoglobulin treatment was initiated between first and sixth day of life. administered dose varies between mg/kg/day and g/kg/day from two to five days. all children needed platelet transfusions, while only one of them was treated with corticoids. the number of platelets/ll before infusion of immunoglobulins, at hours, at hours and at discharge was: children : , , , , , and , platelets/ll. children : , , , , , and , . children : , and , platelets/ll hours after initiation of treatment, there were no analytical data at hours, but number of platelets at discharge was , . no adverse effects were observed in any children. conclusions: although eventually the three children recovered the number of platelets, it can not be concluded that this was due to immunoglobulin treatment, because it is overlapped with administration of platelet transfusions and corticoids. a higher number of patients is required to evaluate efficacy and safety of non-specific human immunoglobulins in treatment of neonatal thrombopenia. background and objective: pulmonary hypertension (ph) is one of the most difficult childhood disease to treat. in spain, oral sildenafil has recently been approved in adults to treat ph, but it s an off-label drug for children (its utilization must be derived to ''compassionate use'', which requires a prior national health authorities approval for every children), and an oral suspension must be formulated at the pharmacy department for them. the objective of this study is to analyse the use of oral sildenafil for ph in paediatric patients. design: years retrospective study. % paediatrics patients with oral sildenafil for ph. clinical data review. setting: paediatric cardiology unit and pharmacy department ( pharmacist) in a paediatric hospital ( beds), in a large general teaching hospital ( beds, pharmacists). main outcome measures: patient data (diagnosis, age, weight). treatment description (dose, length of treatment). treatment effectiveness: peripheral arterial oxygen saturation and six-minute walk test. treatment security: side effects registered. results: children ( girls). age: months to years, median . years. diagnosis: / ph secondary to surgery due to congenital heart disease and / primary ph. sildenafil doses ranged from . mg/kg/ h to mg/ h; median length of treatment was . months ( month- . years). children have used the oral suspension formulated and monthly dispensed at the pharmacy department. other treatments: spironolactone ( ), furosemide ( ) , captopril ( ), acenocoumarol ( ), aspirin ( ), ranitidine ( ) and propranolol ( ). patients have experimented clinical improvement and are on treatment. sildenafil was withdrawn in patients because it was indicated to ameliorate the effects of inhaled nitric oxide withdrawn. patients died. no data available in patient. only patient experimented occasional headache. mensual treatment cost range from - €/patient. conclusions: oral sildenafilo seems to be a safe and effective therapy for paediatric patients with pulmonary hypertensión. due to the lack of an oral formulation for paediatrics patients, it should be elaborated at the pharmacy department. background and objective: we will describe the case of a bi-pulmonary transplant women who developed an invasive aspergillosis located in the lungs and the brain. she received intravenous voriconazole during days. she was then diagnosed with an aspergillus endophthalmitis. even though a dual therapy consisting of caspofungin and posaconazole was initiated, the patient underwent a partial vitrectomy. this therapeutic failure could be explained by a late diagnosis and insufficient vitreous and aqueous humor penetration of the systemic drugs. design: a retrospective analysis of an endophthalmitis management. setting: clinical unit in a french teaching hospital main outcome measures: to secure a high ocular concentration, the ophtalmologist recommended voriconazole intravitreal injections. his prescription was based on several case reports. results: we found articles dealing with animal testing: one concluded that voriconazole was a safe intravitreal agent which may be injected in human eye. another study described the successfull use of intra-ocular voriconazole to treat a fungal endophthalmitis: it allowed a significant improvement in visual acuity and the patient's recovery. however, further studies are needed to assess the optimal dosage and frequency of administration. we prepared voriconazole syringes under a horizontal laminar air flow hood, as follows: -preparation of a mg/ml solution with ml of water for injection and dilution in ml of water for injection, to obtain a mg/ml solution pharm world sci ( ) : - -we sampled . ml of this solution in a ml syringe, which was closed with an occluder, labelled and refrigerated. since we had no data regarding stability, it was administrated extemporaneously. conclusions: intravitreal injections failed to prevent deterioration. had they been introduced precociously, they might have been more efficient. an early diagnosis and prompt management might improve the extremely poor visual prognosis of this devastating condition. were are currently studying the preparation stability. pharmacy service, hospital universitario de getafe, getafe, spain background and objective: in professionals were alerted about an elevated frequency of early virological failure in patients treated with tenofovir (tdf) and didanosine (ddi) associated to lamivudine. in similar results related to the administration of tdf and ddi, in association with a non-nucleoside reverse transcriptase inhibitor (nnrti) were notified. therefore similar events can be observed when tdf and ddi are co-administered in combination with other antiretroviral classes, such as protease inhibitors (pi). subsequent pharmacokinetic studies have shown that tdf when co-administered with ddi increases ddi plasma concentrations leves by up to - %, with a higher risk of didanosine-related adverse events, like pancreatitis and lactic acidosis. the administration of a reduced dose of didanosine ( mg) to avoid over-exposure to didanosine may also contribute to a higher rate of virological failure and emergence of resistance at early stage. the objective of the study is to asses the rate of virological failure in patients treated with tdf and ddi associated to a pi. results: during the study period patients had prescription for drotrecogin alfa for sepsis syndrome; . % were male and the mean age was . years (range - years). all patients had proven infection: . % had pneumonia (n = ), . % pyelonephritis(n = ), . % soft tissue infection(n = ) and . % abdominal infection(n = ). the main isolated micro-organisms were klebsiella pneumonia(n = ), escherichia coli(n = ), pseudomonas aeruginosa(n = ), enterococcus faecium(n = ), staphylococcus aureus(n = ), legionella pneumophila(n = ), proteus vulgaris(n = ), enterococcus faecium(n = ), klebsiella oxytoca(n = ). all patients started treatment within h of the onset of severe sepsis. the treatment was not completed in one patient due to adverse events. contraindications were present in patients: platelet count \ . /l (n = ), age under years (n = ) and major surgery (n = ). the mean organ failures was . (range - organs). adverse reactions were present in patients: thrombocytopenia (n = ), pancytopenia (n = ), bleeding (n = ) and elevation of activated partial thromboplastin time (n = ). mortality at days was found to be % (n = ). conclusions: despite the presence of some contraindications, in most patients drotrecogin alfa was used according to current guidelines. nevertheless, since apache ii score was not determined, the real risk of death is unknown and there can be no extrapolation to literature results. upon these findings, a systematic evaluation of apache ii score must be implemented in order to optimize patient selection and the risk-benefit ratio, improving the use of drotrecogin alfa. pharmacy, oncology, hôpital tenon aphp, paris, france background and objective: it is necessary to focus on side effects for pharmaceutical analysis. dosage reductions are commonly used in cancer chemotherapy. however, little is known concerning the way these reductions are performed in clinical practice. the objectives were to evaluate the incidence, the reason and the percentage of dosage reduction. design: prospective four-week study during which we analysed prescriptions with dosage reductions. setting: pharmacy and clinical oncology department in a paris university hospital. main outcome measures: we focused on prescriptions with dosage reduction and we recorded : -patient information -cancer localisation -chemotherapy regimen -dosage reduction characteristics (date, reduction percentage, reason) the toxicities were classified according to the nci-ctc criteria (grade to ). individual interviews were performed in order to assess how physicians decided the reduction ratio. results: patients ( % women; mean age years) have been treated during that period. diagnosis majority were breast ( %), colorectal ( %) and lung ( %) cancer. patients required a dosage reduction (incidence %). hematological toxicities were the main cause of reductions ( %). the hematological toxicities observed were thrombopenia ( %), neutropenia ( %) and neutropenia-thrombopenia associations ( %). the toxicities observed were grade ( %) or ( %). the other major causes of reductions were neurological ( %) and gastrointestinal ( %). the average percentage of reductions was between % and %. the individual interviews have shown that physicians didn't base the dosage reductions on literature results (established criteria) but on their own clinical practice (experience). conclusions: % of the prescriptions showed a decrease of the regimen. even if there is few literature, clinical trials recommend a decrease of % of the usual dosage of the drugs. the percentage in practice is lower than the one defined by clinical trials. the choices of reduction percentage were not standardized. recommendations for dosage reductions are still needed. keywords: dosage reduction, anticancer chemotherapy, toxicity pt- interdisciplinary approach to dose adjustment in patients with renal impairment in secondary care liekweg a, hinnerkort a, ebeling g, braband s, dreischulte t, heilenkötter k, sander s, schiffmann s, schrimpff u, siems m, wagner k, weiland t, zeigermann g, melzer s hospital pharmacy of the asklepios kliniken hamburg gmbh background and objective: as part of a unit dose dispensing system, patient medication profiles are routinely entered in an electronic database. medication profile and laboratory data are accessible online by clinical pharmacists. the project was conducted in order to optimise pharmacotherapy in patients with renal impairment and to integrate the clinical pharmacist in the therapeutic team. setting: unit-dose supplied wards (n = ) in four asklepios hopitals in hamburg with approximately patients per day. the project was conducted in cooperation with clinical pharmacists, physicians and the laboratory department over a period of . months ( / - / ). programm description: clinical pharmacists receive a list of all patients with an estimated glomerular filtration rate (egfr) \ ml/ min/ , m (mdrd) from the laboratory department on a daily basis. they screen medication profiles daily with regard to apparently inappropriate dosing of renally excreted drugs (q o \ . ). critical cases are reported to physicians by phone or entry in medical case notes. following an interdisciplinary discussion with the physician the drug dose or dosing interval is either adjusted, the medication is stopped or paused or an alternative is started. during the pilot phase the number of altered medications as a result of pharmacists' recommendations was documented. results: a prevalence of % of patients with a egfr \ ml/min/ . m was found in the examined setting. during the pilot phase of prescribed drugs ( %) were renally excreted or considered nephrotoxic. antibiotics ( %), antidiabetics ( %), diuretics ( %) or nsais ( %) were predominantly involved. overall, of pharmaceutical recommendations ( %) were accepted and acted upon by physicians. conclusion: the number of recommendations demonstrates the importance of this service in optimising pharmacotherapy. clinical pharmacists' contributions in matters of dose adjustment in patients with renal impairment is well received by physicians especially in non-nephrologic departments. the new service was found to be feasible in daily practice and has become part of the clinical routine. background and objective: the sources and availability of drug information for patients are growing, e.g. through the internet and official patient information leaflets (pils). however, the quality of the information on the internet might be questioned. furthermore, pils are not standardized, the layout is not reader friendly and the information covers all approved indications for the drug, some of them not relevant for rheumatic patients. also, over the years various information leaflets for drugs have been developed in the departments of rheumatology in norway. these are not standardized and the accessibility is limited. the objective was to develop a system for producing and maintaining reader friendly patient information leaflets about antirheumatic drugs, which takes the quality assurance aspect into account, and is easily accessible for the users. design: development project, consensus method. a national multidisciplinary project group was set up in december , with members from the social leagues (two members), pharmacists' organization (four) and rheumatologists' organization (two). mandate and regulations were approved by the organizations, as well as a legal disclaimer. the pharmacists make a draft for each drug which is e-mailed to all the members of the group. based on the comments a revision is made followed by another hearing until consensus is reached. the rheumatologists approve the leaflet. setting: national multidisciplinary consensus including patients associations main outcome measures: establishment of a dedicated website. number of leaflets published. results: a web address for publication of the leaflets is set up on the home page of the norwegian society for rheumatology: www.legeforeningen.no/nrf. there is a link to this address on the home pages of the social leagues and the norwegian association of hospital pharmacists. during the first year different drug leaflets have been developed and published on the web site. it is possible to search by trade name, generic name and groups of drugs such as ''antiinflammatory drugs'', so the numbers of hits adding up to . conclusions: this national multidisciplinary approach has made it possible to develop a system for making patient information leaflets about anti-rheumatic drugs, which are standardized and easily accessible. keywords: patient information leaflets, drugs in rheumatic diseases, multidisciplinary the need for pharmaceutical care in the prevention of coronary heart disease; an exploratory study in acute myocardial infarction patients the right medicine: a strategy for pharmaceutical care in scotland pharmacy for health: the way forward for pharmaceutical public health in scotland. glasgow: phis . . the sector skills council for health. skills for health: public health practice competences qualitative research: consensus methods for medical and health services research prescribing problems and pharmacist intervention in community practice a dictation system for reporting prescribing errors in community pharmacies a competency framework for the care of a person with diabetes pharmaceutical care of the patient with type diabetes mellitus: a consensus model for delivery of structured pharmaceutical care by community pharmacists in scotland development of a leadership course tailored for pharmacists in scotland pharmacy students attitudes and views about portfolio-based learning: a questionnaire survey using portfolios to learn about prescribing: qualitative insights into students experiences implementing clinical pharmacy services in an outpatient oncology clinic an evaluation of pharmacist contribution in oncology ward in a swedish hospital evaluation of clinical pharmacy services in a hematology/oncology outpatient setting rheumatic illness (ri): ( . %), multiple sclerosis (ms): ( . %), hepatitis c (hc): ( . %). : cfk: ( . %), others: ( . %), ri: ( . %), hiv: ( . %), ms: ( . %), hc: ( . %). : cfk: ( . %) total economic impact (tei): , € valorisation of clinical pharmacy activities: validation of a standard tool for routine interventions quotation in french hospitals keywords: drug related problems hiv-infected patients' perceived satisfaction with an outpatient pharmaceutical care unit (opcu) quality perceived by outpatients at the pharmaceutical care clinic antibiothérapie par voie générale en pratique courante au cours des infectons respiratoires basses de l'adulte et de l'enfant éme conférence de consensus en thérapeutique anti-references simultaneous determination of olanzapine, clozapine and demethylated metabolites in serum by on-line column-switching comparative study and optimisation of the administration mode of three proton pump inhibitors by nasogastric tube is the administration of esomeprazole through a nasogastric tube modified by concomitant delivery of a nutrition mixture? gerontology and geriatric medicine the clinical implications of platelet transfusions associated with abo or rh(d) incompatibility platelet transfusion: products, indications anti-d ig pc- pharmacist's interventions in three medical care units: analysis and impact on the physicians' prescriptions ventilator-associated pneumonia epidemiology and outcomes of health-care-associated pneumonia keywords: pseudomonas aeruginosa, antibiotherapy, vap (ventilator-associated pneumonia) folic acid metabolism and human embryopathy folic acid in general medicine and dermatology folic acid awareness and intake survey in the united arab emirates keywords: pregnancy, folic acid, neural tube defects pepi- pre-diabetes screening program: a proactive study in istanbul community pharmacies www.diabetes.org keywords: type-ii diabetes years later…where do we stand? over-the-counter medications in pregnancy north american association for the study of obesity. consensus development conference on antipsychotic drugs and obesity and diabetes second-generation (atypical) antipsychotics and metabolic effects. a comprehensive literature review keywords: metabolic syndrome, second-generation antipsychotic, biological and clinical follow-up references analysis of taurine in blood plasma of epileptic patients using an improved isocratic hplc method for amino acids cardiovascular actions of taurine pharmacokinetics and pharmacodynamics of the effects of taurine on human blood pressure and heart rate references criteris d'indicació en el tractament de les hepatitis víriques. direcció general de recursos sanitaris peginterferon-alpha a and ribavirin combination therapy in chronic hepatitis c prevalence, incidence and predictors of severe anaemia with zidovudine-containing regimens in african adults with hiv infection within the dart trial the anemia prevalence study group. prevalence of anemia and correlation with biomarkers and specific antiretroviral regimens in human-immunodeficiency-virus-infected patients: findings of the anemia prevalence study clinical pharmacy and medication safety keywords: clinical pharmacist, chronic kidney disease, treatment safety reference nccn clinical practice guidelines in oncoloy for multiple myeloma a phase study of bortezomib in relapsed keywords: antibiotics, emergency department the use of mitomycin-c for respiratory papillomas: clinical, histologic and biochemical correlation mitomycin c: prevention and treatment of anterior glottic synechia preliminary results of intraoperative mitomycin-c in the treatment and prevention of glottic and subglottic stenosis airway complications from topical mitomycin c. otolaryngol head neck surg keywords: mitomycin c, laryngeal papillomatosis, papillomas pt- effectiveness of rituximab in rheumatoid arthritis background and objective: to assess the response to rituximab in patients with rheumatoid arthritis (ra) who were refractory to anti-tnf treatment. design: observational, cross-sectional study. performed on patients diagnosed of ra according to acr criteria the main variables used to assess clinical evolution were: decrease in das -esr, considering the number of references noss eh et al. rituximab as therapy for refractory polymyositis and dermatomyositis treatment of early and refractory dermatomyositis with infliximab: a report of two cases keywords: dermatomyositis, rituximab, infliximab were included in the study. main outcome measures: percentage of patients achieving optimum and minimum audit standards for serum total cholesterol, ldl-c, glycosylated haemoglobin (hba c), bp and take up of aspirin of these, optimum treatment standards for total cholesterol (\ mmol/l) and ldl-c (\ mmol/l) were achieved by . % (n = ) and . % (n = ), respectively. patients within the minimum audit goal for total cholesterol (\ mmol/l) and ldl-c (\ mmol/l) were joint british societies' guidelines on prevention of cardiovascular disease in clinical practice pt- pediatric use of infliximab: retrospective study vanida brunie reference french guidelines for assumption of responsibility of candida sp. and aspergillus sp. invasive infections. french society of anesthesia and reanimation keywords: assessment, antifungal agents comparisons of psychotropic drug prescribing patterns in acute psychiatric wards across europe to score personal risks factors ( to : standard risk, to : high risk) design of a therapeutic scheme following asco's guidelines, as follow. day : aprepitant mg per os h before chemotherapy ondansetron mg iv min before chemotherapy methylprednisolone (mp) mg iv min before chemotherapy days and : aprepitant per os mg methylprednisolone per os mg b.i.d. for the beam strategy, this treatment is given on day (carmustine) and on day (melphalan). the course of corticosteroid was reduced on purpose for clinical oncology guideline for antiemetics in oncology: update . kris and coll keywords: aprepitant, emesis, hematology pt- use of anti-tnf-alfa in rheumatoid arthritis intravitreal voriconazole for the treatment of endogenous aspergillus endophthalmitis intravitreal voriconazole for drug-resistant fungal endophthalmitis: case series fungal endophthalmitis caused by aspergillus ustus in a patient following cataract surgery intravitreal voriconazole: an electroretinographic and histopathologic study management of endogenous fungal endophthalmitis with voriconazole andcaspofungin histological examination of an eye with endogenous aspergillus endophthalmitis treated with oral voriconazole: a case report aspergillus endophthalmitis: an unusual complication of disseminated infection in renal transplant patients maria eugenia martínez nú ñ ez , javier sánchez-rubio ferrández , noelia garrido peño , carolina apezteguía fernández background and objective: zidovudine (zdv) is the first drug that approved for treatment of hiv infected patients and now has wide use in haart regimens. this drug can cause hypoproliferative anemia bone marrow toxicity. the object of this study is evaluation of incidence of anemia in iranian hiv positive patients that received zdv in haart regimens. design: in a prospective study, hiv positive patients were referred to iranian hiv research center that start zdv in haart combination were entered the study and have followed for at least one year. baseline and monthly hematological parameters were recorded. setting: iranian hiv research center. main outcome measures: patients demographic parameters, route of infection exposure, stage of disease, cd counts, cbc, and hematological parameters. results: twenty nine ( ) patients were excluded from the study because of impossible follow-up. from patients, of them have anemia (hemoglobin less than g/dl for female and less than g/dl for male). thirty there ( ) patients have anemia before starting haart. thirty four ( ) patients have showed anemia following received zdv. twenty ( ) patients have improved anemia after were changed zdv to stavudine. conclusions: about % of hiv positive patients that were received zdv have experienced anemia.background and objective: in june , the use of infliximab has been approved by emea for the treatment of severe active crohn's disease in pediatric patients aged to years old, who have not responded to conventional therapy (corticosteroid, immunomodulator and nutrition therapy). however, pediatricians were already using infliximab for patients with inflammatory bowel syndrome (ibd) such as crohn's disease (cd), ulcerative colitis (uc) and indeterminate colitis (ic). the goal of the study was to analyze infliximab prescriptions for children and to evaluate changes in prescriptions of corticosteroid due to the introduction of infliximab. design: retrospective study in ibd patients in a pediatric teaching hospital. setting: gastroenterology unit and pharmacy department. main outcome measures: indications, infliximab dosage, anterior treatments, reason of therapeutic change (non-tolerance or inefficiency of anterior treatment and/or cortico-dependance), evolution of corticosteroid dosage and months after the introduction of infliximab. results: thirty-three children were treated by infliximab: cd, uc and ic. age for diagnosis was an average of years old ( . - . ) and . years old ( - ) for the beginning of infliximab. previous treatment to infliximab was immunomodulators, single therapy for patients (azathioprine n = , mercaptopurine n = , methotrexate n = ) or dual therapy (n = azathioprine + methotrexate), with corticosteroids (n = ) and/or mesalazine (n = ). various etiologies justified infliximab administration: corticodependance (n = ), corticoresistance (n = ), non compliance to corticotherapy (n = ), insufficient efficacy of previous treatment (n = ), non tolerance to previous treatment (n = ). at the beginning, dosage of infliximab was mg/kg. dosages were increased ( mg/kg) for patients due to insufficient clinical results. one patient also had to be switched for adalimumab because he developed human antichimeric antibody (haca). among corticodependant patients ( ), corticosteroids have been stopped after or months, ( %) and patients ( %) respectively. for patients, corticosteroids were continued without reduction of dosages, six months after the introduction of infliximab. conclusions: infliximab is the only therapeutic alternative for children who are non tolerant or non respondent to conventional treatment. moreover, this treatment permits the use of decreased dosage of corticosteroids, limiting their side effects, especially on children growth. however, haca occurrence could limit its use in a long-term disease. keywords: infliximab, inflammatory bowel syndrome, pediatrics chemotherapy indication was autologous bone marrow transplant (bmt) ( %), leukaemia chemotherapy induction or consolidation ( %), leukaemia intensive chemotherapy ( %), myeloblastic allogeneic bmt ( %) and mini allogeneic bmt ( %).treatments were prophylactic ( %), empirical ( %) or curative ( % for aspergillus sp but no for candida sp infections); % of the prescriptions related to local candidosis and % remained unknown.although % of prescriptions were in accordance with internal guidelines concerned antifungal drug indication, % had wrong dosages e.g. no loading dose for voriconazole. moreover, only % of the prescriptions were in accordance with french recommendations: neither voriconazole is approved in prophylaxis of aspergillosis in patients with autologous bmt nor antifungal drugs associations (ten prescriptions). nevertheless, it may be a good way of medical management as hopeful patients outcomes have been obtained.conclusions: hematology department guidelines should be reviewed in accordance with french recommendations, department's ecology and the state-of-the-art about treatment of fungal infections in patients with haematological malignancies. the accordance to further recommendations should be regularly assessed as well as resistance emergence. background and objective: to evaluate the efficacy and safety of rituximab (rtx) for the treatment of refractory autoimmune cytopenia, including autoimmune hemolytic anemia (aha) and immunemediated thrombocytopenia (idiopathic thrombocytopenic purpura itp and thrombotic thrombocytopenic purpura ttp) design: descriptive, retrospective study based on rituximab prescriptions analysis. patients were identified through medical reports delivered by compassionate use program. data collection was made through the pharmaco-therapeutic profile and medical chart review setting: general teaching hospital ( beds) main outcome measures: patients who received any course of rtx for refractory immune cytopenia from january to may were evaluated. data recorded included patients details, diagnosis, previous treatment, rtx schedule, number of courses and baseline hemoglobin (hb) and platelet count (pq) values. effectiveness and tolerance were also considered. response was evaluated according to criteria found in the literature: clinical symptoms resolution and a normal pq count of . /mm for itp/ttp or an hb level [ g/ dl achieved and maintained for at least months for aha. additional response criteria for aha was an hb increase [ . g/dl month after the last dose of rtx. results: patients ( men), doses rtx; average age years (range - ). diagnosis: aha ( cases cold agglutinin disease), itp and ttp. in patients cytopenia (aha) was associated with chronic lymphocytic leukemia. all patients had been previously treated with steroids and had received or more other treatment modalities ( splenectomy, immunosupressive agents, intravenous immunoglobulin). patients received - rtx infusions at a standard dose of mg/m once per week, in combination with steroids therapy in cases. no serious infusion-related effects occurred, but patients reported hematologic toxicity (fever and infection). all patients with aha ( / ) and patients with itp ( / ) responded to the first course of rtx. one patient aha had relapse after months and responded to retreatment. itp responders achieved durable response ( and months) and were offered second course of rtx after relapse ( patients did not respond to retreatment). after months follow-up, patient with ttp remained with acceptable pq counts. hb levels increased by a median of . g/dl (range - , ) among the aha responders. itp + ttp responders achieved a median increase in pq count of . /mm (range - ). only responders who reached a months follow-up were considered for response duration assessment: aha, ttp, itp ( retreatment). median response duration was months (range - ) for aha and months (range - ) for itp + ttp conclusions: most of the literature findings for rtx in this setting were related to small series or isolated case descriptions. despite the common limitation of the number of patients, our results showed that rtx appears to be a promising agent for the treatment of refractory autoimmune cytopenia. key: cord- -ebj v o authors: marini, robert p.; otto, glen; erdman, susan; palley, lori; fox, james g. title: biology and diseases of ferrets date: - - journal: laboratory animal medicine doi: . /b - - / - sha: doc_id: cord_uid: ebj v o nan ferrets (mustela putorius furo) belong to the ancient family mustelidae, which is believed to date back to the eocene period, some million years ago. the taxonomic groups in the family mustelidae, as recognized by corbet and hill ( ) , include species from north, central, and south america, eurasia, and africa. no other carnivore shows such diversity of adaptation, being found in a wide variety of ecosystems ranging from earlier references to ferrets are probably the basis of the belief that ferrets originated in north africa (thomson, ) . evidently they were bred specifically for rabbiting (rabbit hunting) and were muzzled before being sent into rabbit burrows. this practice was later introduced into europe, asia, and the british isles, where the sport is still practiced today. although the ferret has been historically used for hunting, more recently it has been increasingly used in biomedical research and is popular in north america as a pet. it is most likely a domesticated version of the wild european ferret or polecat (m. putorius or m. furo) (thomson, ) . alternatively, it may be related to the steppe polecat (m. eversmanni), which it closely resembles in skull morphology (walton, ) . the domesticated ferret, although introduced to north america by the early english settlers some years ago, has not established feral colonies on this continent. the ferret was not recognized as having potential as an animal model for biomedical research until the s. early studies utilized the ferret in classic experiments with influenza virus pathogenesis (pyle, ) . its use was cited infrequently; an article published in , detailing the use of ferrets in research, cited only publications (pyle, ) . literature reviews undertaken in , , , and , however, revealed an increasing appreciation for the ferret's usefulness and versatility in the study of human physiologic, anatomic, and disease mechanisms (hahn and wester, ; marshall and marshall, ; shump et al., ; frederick and babish, ) . in , a bibliography containing "selected" literature citations on the ferret and its use in biomedical research was published (clingerman et al., ) . the document was designed to serve as a reference tool for individuals involved in the care or use of ferrets in the laboratory setting. although not comprehensive, the document provides extensive coverage of ferret biology, diseases, and use as an animal model. the domesticated ferret has been and continues to be used extensively in studies involving virology, reproductive physiology, anatomy, and endocrinology, as well as other areas of biomedical research (morgan and travers, ) . the ferret is also being used to replace the cat in some types of neuroendocrinology, neuroanatomy, and cardiology experiments. the ferret's increasing popularity in research and as a pet is mainly a result of large-scale commercial production. for example, commercial farms have been raising ferrets for almost years. biomedical researchers in the united states can request animals of a specific sex, weight, and age for individual experiments. investigators in other countries may acquire fer-rets from fur operations or may make arrangements with commercial vendors in the united states. even though the ferret is nonstandardized with regard to exact genotype and pedigree, its routine availability in a clinically healthy state has aided immeasurably its acceptance as a research animal. readily available commercial stocks, based on coat color, are albino, sable (or fitch), siamese, silver mitt, and siamese-silver mitt (siamese with white chest and feet) (mclain et al., ) . the fitch or so-called wild coat color is the most common, recognized by yellow-buff fur with patches of black or dark brown, particularly on the tail and limbs (andrews and illman, ) . the production of ferrets by large commercial operations has raised concern by some that inbreeding of these animals has made the ferret more susceptible to diseases, e.g., endocrinerelated disorders. this topic is covered in more detail in chapter . housing of ferrets in a research facility is similar to that of other small carnivores such as cats (fox, c) . ferrets tolerate low temperatures well and high temperatures poorly; the recommended temperature range for juvenile and adult animals is - ~ (hammond and chesterman, ) . ferrets less than weeks of age should be housed at > ~ c. kits under this age require a heat source if separated from the dam; older kits that are group-housed do not. elevated temperatures (> ~ cannot be tolerated by ferrets, because they have poorly developed sweat glands and are susceptible to heat prostration. signs of hyperthermia include panting, flaccidity, and vomiting. the preferred humidity is - %. for nonbreeding animals that will remain in the facility for a short time, a conventional dark-light cycle at : hr is adequate. lighting may be altered to control breeding cycles. breeding and lactating jills should be exposed to hr of light daily. ferrets that are maintained for breeding or for use beyond months should be exposed to "winter" lightw weeks per year of hr of dark dailywto maintain physiologic normalcy. it is also essential that researchers receiving time-pregnant jills preserve the photoperiod to which jills were exposed prior to shipment. failure to do so may cause inappetence, with subsequent negative energy balance and pregnancy toxemia. similar to other laboratory animal species, ferrets should be housed with - air changes per hour (usdhhs, ) . it is important to use nonrecirculated air because of the strong odor of ferrets and the susceptibility to respiratory tract infections. the ferret odor should not overlap into any rodent housing areas, because rodents have an instinctive fear of ferrets, and the ferret scent can disrupt rodent breeding and physiology (fox, c) . female ferrets can be housed singly or in groups, but estrous females that are cohoused may become pseudopregnant (beck et al., ) . males should be housed individually after weeks of age. molded plastic caging used to house rabbits works very well for ferrets. the solid bottom is perforated with holes and is readily sanitizable. an absorbable paper liner may be used in the pan beneath the cage to facilitate daily disposal of urine and feces. in a research setting, the plastic caging should be washed weekly to avoid excessive soiling. the spacing of grid walls should be . x . inches apart, or . inch if using wire mesh. ferrets like to lick and bite at their enclosures, so sharp edges and galvanized metal should be avoided. zinc toxicosis has been reported from licking galvanized bars from which metals had leached during steam sterilization (straube and walden, ) (table i) . ferrets can be trained to use a litter box because they repeatedly urinate or defecate in one corner of the cage. clay litters have been reported to cause chronic upper respiratory irritation parameter (jenkins and brown, ) . ferrets prefer sleeping in a soft isolated area, and in a research facility this can be accomplished by providing a washable "snooze tube" (fox, c) . the thorax of the ferret is narrow and elongated, and as a result the trachea is proportionally long. this makes the ferret an ideal species for studies of tracheal physiology. the tracheal size and laryngeal anatomy make endotracheal intubation somewhat challenging, and as a result the ferret has been advocated as a species suitable for use in pediatric intubation training (powell et al., ) . the lungs are relatively large, and the total lung capacity is nearly times that which would be predicted based on body size, as compared with other mammals. this characteristic, together with a higher degree of bronchiolar branching and more extensive bronchial submucosal glands (as compared with the dog), makes the ferret an attractive model for pulmonary research studies (vinegar et al., ) . although a previous report (willis and barrow, ) commented that the carotid arterial branching pattern in the ferret is unusual, it is actually typical for a carnivore. as is the case in the dog and the cat, the paired common carotid arteries arise from the brachiocephalic trunk (sometimes called the innominate artery) at the level of the thoracic inlet (andrews et al., b) . the ferret's gastrointestinal tract is specialized to fit its carnivorous nature. the simple monogastric stomach is similar to that of the dog. there is no cecum present, and the indistinct ileocecal transition makes it difficult to identify the junction of the small and large intestines during a gross examination. the overall length of the alimentary tract is very short relative to the body size, resulting in a gastrointestinal transit time as short as hr (bleavins and aulerich, ) . as in other mustelids, the paired anal scent glands of the ferret are well developed. although not as potent as those of the skunk, the secretions of the ferret are sufficiently odoriferous that many pet or research ferrets are descented. surgical techniques for this procedure have been described (creed and kainer, ; mullen, ) . ferrets, especially intact males and estrous jills, may possess a distinctive musky odor even after a successful descenting, because of normal sebaceous secretions. ferrets lack well-developed sweat glands for use in thermal regulation, and as a result they are predisposed to heat prostration when ambient temperatures reach ~ ( ~ f) (ryland et al., ) . extramedullary hematopoiesis is commonly found during histological examination of the spleen, and in some cases it may result in a grossly evident splenomegaly (erdman et al., ) . this must be differentiated from splenomegaly that can arise from a variety of pathologic conditions or from isoflurane administration (see section iii,e). experimental evidence suggests that ferrets have no naturally occurring antibodies against unmatched erythrocyte antigens, and that none develop even in the face of repeated transfusions . ferrets are seasonal breeders, and the resulting pronounced physiological variations in body weight, behavior, and gametogenesis are utilized in scientific studies of photoperiod responses and neuroendocrine control. prolonged estrus in unbred females can cause an aplastic anemia, an effect that can be reproduced with exogenous estrogen administration . the male has a radiographically evident os penis, and, contrary to some earlier reports, a prostate gland is present in males (evans and an, ) . newborn ferret kits weigh - gm at birth and will grow to gm by the time they are weaned at - weeks (shump and shump, ) . in sexually intact populations, males ( . - . kg) can be twice the size of females ( . - . kg). the adult weight of nonobese male and female ferrets that have been gonadectomized prior to weaning and raised in captivity will generally fall between . and . kg (brown, a) . adult animals (especially those that are sexually intact) may be subject to seasonal fluctuations in body fat percentage, which can cause body weight to fluctuate by - % (fox and bell, ) . the approximate life span for the ferret is - years, but on rare occasions they may live as long as years (table ii) . normal hematology and serum chemistry values have been reported for the ferret (thornton et al., ; lee et al., ; fox, e) . these values are not greatly dissimilar from those of other domestic carnivores. one distinctive hematological characteristic of the ferret is the presence of a relatively robust erythron, characterized by hematocrit, hemoglobin, and total erythrocyte and reticulocyte counts that are generally higher than those of the dog or cat. reported neutrophil-lymphocyte ratios range from . : to . : . representative hematology and chemistry ranges from one of our studies (fox et al., b) are shown in tables iii and iv, but for diagnostic purposes any laboratory that evaluates ferret samples should develop its own set of specific normal ranges. a low-grade proteinuria may be identified by urinalysis in normal, healthy ferrets (thornton et al., ) (table v) . ferret diets have been formulated both empirically and based upon the nutrient requirements of other mustelids (fox and mclain, ) . specific requirements for various life-cycle stages have not been determined experimentally. available commercial diets are certainly capable of supporting growth, reproduction, and maintenance in conventional settings. in the (fox et al., b) . bfour-to -month-old ferrets (loeb and quimby, ) . cnd, not done. absence of careful analysis, however, it is uncertain whether the proportion and quantity of ingredients in these diets is optimal. ferrets are strict carnivores with a high requirement for dietary fat and protein. their short digestive tract and rapid gastrointestinal transit time ( - hr) require protein to be readily digestible. there is general agreement that ferrets should not be given diets high in complex carbohydrates or fiber. diets that are high in fish products are also not recommended for ferrets (fox and mclain, ) . the use of any raw chicken, beef, or other meats is strongly discouraged because of the potential contamination by campylobacter, salmonella, listeria, mycobacterium, and streptococcus (fox, a) . daily maintenance energy consumption for ferrets is - kcal/kg body weight. calorie-percent protein ratios have been determined for mink (mustela vison) kits up to and after weeks of age (sinclair et al., ; allen et al., ) . a ratio of and a caloric density of kcal/ gm of feed, corresponding to % protein, provided optimum growth for male kits up to weeks. after weeks, ratios of and , corresponding to % and % protein, respectively, were recommended. diets containing - % fat and - % carbohydrate have been used successfully to maintain ferrets. one author recommends - % protein and - % fat for adult, nonbreeding animals and a minimum of % protein and % fat for reproductively active animals and those that have notreached sexualmaturity (brown, a) . the long-term impact of diets containing high levels of fat and protein are unknown. ferrets have been used to investigate the absorption, metabolism, and interaction of the dietary micronutrients [ -carotene and vitamin e. ferrets, like humans, convert [ -carotene to vitamin a in the gut and absorb ~-carotene intact (fox and mclain, ) . in intestinal perfusion experiments in ferrets, it was demonstrated that [ -carotene, retinol, and retinyl esters are absorbed intact into lymph and that cleavage products, including [ -apo- '-carotenal, [ -apo- '-carotenal, and retinoids, accumulate in the intestinal mucosa (wang et al., ) . the intestinal mucosa is capable of converting [ -carotene into retinoic acid and other polar metabolites, which are then transported via the portal vein to the liver (wang et al., ) . [ -carotene absorption is enhanced by co-perfusion with a-tocopherol, and the perfusion of the latter is unaltered by the presence of [ -carotene. the conversion of [ -carotene into retinol is also enhanced by the presence of a-tocopherol (wang et al., ) . these and other findings have established the ferret as an important model for the study of these antioxidants. adult ferrets drink - ml of water daily, depending on the dry-matter content of the feed (andrews and illman, ) . fresh water can be provided ad libitum in stainless steel bowls or water bottles with sipper tubes. ferrets are playful and will overturn bowls or water bottles that are not well secured. features of ferret reproduction may be found in table vi for males, corresponding temporally to increasing day length. ferrets born in the late spring or early summer and maintained under natural lighting will not assume an adult pattern of gonadal activity (i.e., puberty) until the following season (baum, ) . under artificial illumination, jills that are maintained at hr light- hr dark reach puberty at - months. stimulatory photoperiods may be used, however, in the laboratory or intensive production setting, as a method of breeding ferrets out of the natural season. however, the transfer from short to long photoperiods should not occur prior to days of age, because jills that are prematurely transferred will remain anestrous (hammond and chesterman, ) . management practices in one breeding facility are such that jills commence breeding at - months, average . litters a year, and are cycled out of reproduction after litters. in another strategy, ferrets are exposed to a : hr photoperiod at weeks of age, are bred at weeks during their first estrus, and whelp at v months. vulvar swelling is the hallmark of estrus in jills. the ease with which estrus is detected in the ferret, as well as the size of the ferret and ease of its maintenance in captivity have made the ferret a model for study of neuroendocrine events and their gonadal correlates. along with the hamster, the ferret has contributed extensively to an understanding of the photoperiodic influences on the hypothalamic-pituitary-gonadal axis (baum, ) . as in females of other species, estradiol concentrations are responsible for controlling the development of the female reproductive tract and secondary sexual characteristics, and the tonic inhibition of luteinizing hormone (lh) secretion by the anterior pituitary during both prepubertal life and anestrus. the sensitivity of the hypothalamic gonadostat to negative feedback inhibition by estradiol changes at the time of puberty, and under the influence of increasing light exposure, lh levels rise despite estradiol (ryan, ) . similarly, age differences in the sensitivity of negative feedback inhibition of the hypothalamic secretion of gonadotropin-releasing hormone (gnrh) by testosterone, or to estrogenic compounds derived from the aromatization of testosterone, appear to be essential in determining puberty and seasonality of reproduction in the male (baum, ) . estrus in jills is characterized by dramatic vulvar swelling from an anestrous diameter of - mm to an estrous diameter of - mm. changes in vaginal cytology have also been described for the ferret and other mustelid species, but these changes are seldom used to determine onset of estrus or to schedule breeding (williams et al., ) . after a -to -week proestrus, estrus occurs. estrus onset is not associated with elevated serum fsh in the ferret, as it is in the rodent. once estrus has occurred, it may terminate in coitus-induced ovulation and pregnancy, pseudopregnancy after infertile mating, pharmacologic termination (by injection of human chorionic gonadotropin (hcg) or gnrh), death due to estrogen-induced aplastic anemia, or spontaneous remission and anestrus due to reduced photoperiod. waves of follicular development occur in estrus, and - ova are ovulated approximately - hr after coitus. female ferrets are brought to the male approximately days after vulvar enlargement. females and males copulate many times and for prolonged periods of time; they are typically left together for days. both intromission and neck restraint by the male are apparently required for induction of ovulation (baum, ). an lh surge accompanies coitus in females, but the same is not true of males (carroll et al., ) . implantation occurs days after mating; both a functional corpus luteum and the anterior pituitary are required for implantation and maintenance of pregnancy. placentation is typical of carnivores and is zonary and endotheliochorial (morrow, ) . pregnancy may be detected by ultrasonographic demonstration of - discrete nonechogenic structures as early as day (peter et al., ) , by palpation as early as day , or by radiographic demonstra-tion of calcified fetal skeletons at approximately days of gestation. jills within weeks of parturition should be singly housed and provided with a secluded place in which to deliver their kits. when rabbit cages are used for housing, nest boxes may take the form of polypropylene rat cages or other plastic boxes (cat litter box or dishpan). nest boxes should have bedding provided for warmth and comfort. materials suitable for bedding include pieces of fabric (towels), ripped cageboard, shredded paper, or cotton batting. the nest box should be at least inches deep and should prevent the kits from wandering from the jill. entrance to the nest box should be smooth, to avoid injury to the teats and mammary gland. at our institution, jills are provided a stainless steel rectangular box with a smooth-surfaced plastic entrance ( fig. ) . a retractable steel roof panel and a guillotine side panel exposing a plexiglas sidewall allow access to the jill and permit observation with minimal disturbance. one major supplier of ferrets uses sunken tubs filled with bedding to promote a sense of security and isolation of the jill. most jills will leave the nest box to eat and drink. if the jill will not leave, however, low-sided food bowls should be placed within the nest box. parturition occurs rapidly in ferrets and may last as little as - hr. primiparous jills typically deliver on day of gestation whereas multiparous jills deliver on day . there are few signs of impending parturition, although abdominal enlargement and mammary development do occur in the last week or two. small litters (fewer than three) may result in inadequate stimulus for parturition. jills that pass their due date without delivery should be palpated for fetuses. kits remaining in utero beyond the rd day typically die; kits with congenital malformations such as cyclopia and exencephaly may also delay the initiation of labor. dystocia is common in ferrets because of positional abnormalities and fetal oversize and should be treated by cesarean section. jills tolerate cesareans well and will nurse kits delivered in this way. if small littel: size is responsible for delayed parturition, prostaglandins ( . - . mg lutalyse) may be used, followed by . ml oxytocin ( u) after hr (fox and bell, ) . failure to deliver within hr of administration of prostaglandin is an indication for cesarean section. jills should be provided heat, energy, hydration, and analgesia following cesarean. kits will attempt to nurse soon after parturition, but jills experiencing difficult labor may not allow them to nurse until all kits are delivered. jills that are not attentive to their kits should be palpated for the presence of additional, undelivered kits. oxytocin may be used to facilitate delivery of remaining kits. offering the jill regular chow mixed with warm water may promote maternal acceptance. kits should be kept warm pending acceptance by the jill. jills should be left undisturbed for the first several days postpartum to avoid their cannibalizing the litter. cross-fostering to other jills may be successfully accomplished, provided that the kits are warm and that the foster jill has kits of similar age. kits to be fostered should be allowed to mingle with the foster jill's own kits while their dam is absent so that rejection due to olfaction will not occur. kits are born in an altricial state, covered by lanugo hair and with their eyes closed. by days of age, albino ferrets retain their white hair whereas pigmented ferrets acquire a gray coat. they are completely dependent on the jill for the first weeks of life. defecation and urination are stimulated by jills through anogenital licking of the kits. kits are born weighing - gm, double their weight in days, and triple it in days to a weight of gm. the -week-old male kit should weigh at least gm. sexual dimorphism in size is apparent by week and persists into adulthood. developmental landmarks include ability to hear at days, opening of the eyes at days, eruption of deciduous teeth at days, eruption of permanent canines at - days, and displacement of deciduous canines by - days (fox and bell, ) . gender may be distinguished in neonatal ferrets, as in other species, by anogenital distance, with the distance being much shorter in females than in males. in males, the urogenital opening is seen just caudal to the umbilicus. the prominent midline raphe penis overlying the palpable os penis is also a distinctive feature in the male. ferrets are typically weaned at weeks of age. early weaning may be encouraged by making a slurry of the jill's chow available at - weeks; fat may be added to achieve a fat content of %. the fatty acid supplement linatone (lambert kay, cranberry, new jersey) is recommended by one author (brown, a) . the diet should contain approximately % fat and % protein. the slurry should be fed twice daily for a restricted time and then removed to avoid having kits walking through and defecating in the diet. unthrifty kits over days of age may be supplemented with canine or feline milk replacers administered per os by tygon-tipped pasteur pipette . weaned ferrets are best housed in groups until sexually mature. males over weeks old may begin to fight if exposed to greater than hr light per day. jills may return to estrus during the second or third week of lactation if they have fewer than kits or weeks after weaning if the litter is of normal size. jills should be rebred or administered hcg to terminate estrus, even if still lactating. a highquality, calorie-dense diet is required for lactation and to maintain pregnancy. if maintained on a stimulatory photoperiod and adequate nutrition, jills may have - liters of or more kits yearly until they are years old (fox and bell, ) . a nonstimulatory photoperiod should be used weeks per year to rest the ferret and preserve maximum fertility; a maintenance diet can be given at this time. jills return to estrus approximately weeks after reinstitution of the longer photoperiod. artificial insemination is not commonly performed in ferrets but has been studied in the context of providing strategies for species perpetuation of the endangered black-footed ferret (wildt et al., ) . synchronization of estrus as practiced in rodent production is not used as a tool of reproductive management in the ferret. synchronization ofjills may be approximated, however, by manipulation of photoperiod. with natural illumination in outdoor housing, jills all come into estrus within a -to -week period (baum, ) . in the laboratory setting, when jills are maintained in a nonstimulatory photoperiod ( hr light- hr dark) for - weeks, followed by reversal of the cycle ( hr light- hr dark), estrus will follow in weeks (immature jills) or weeks (mature jills) after the change (carroll et al., ) . this correlates with follicular development and increased plasma estradiol. the occurrence of infectious disease affects animal health and well-being and may complicate research efforts. a program combining good animal husbandry, optimal nutrition, health monitoring practices, and clinical care is essential to maintaining a healthy ferret colony. etiology. the etiologic agent is clostridium perfringens type a (clostridium welchii). epizootiology and transmission. clostridium perfringens is ubiquitous and is present in the intestinal contents of humans and animals. clostridium perfringens type a has been associated with the occurrence of acute abdominal distension, dyspnea, and cyanosis in weanling ferrets (field and laboratory service veterinary staff, ) and an outbreak of gastroenteritis in weanling black-footed ferrets (schulman et al., ) . the exact cause of these conditions is uncertain, but predisposing factors such as overeating, sudden changes in diet, the prolifer-ation of c. perfringens type a, and the production of overwhelming amounts of toxins are suspected (field and laboratory service veterinary staff, ; schulman et al., ) . the alpha toxin is the principal lethal toxin. it is hemolytic and necrotizing and possesses the ability to split lecithin or lecithinprotein complexes, leading to destruction of cell membranes and subsequent necrosis. reported cases have involved weanling animals exclusively. clinical signs. ferrets may present with acute abdominal distension, dyspnea, and cyanosis or may be found dead and bloated (field and laboratory service veterinary staff, ; schulman et al., ) . diagnosis. isolation of c. perfringens type a from gastric and small-intestinal contents is required. toxin identification may be performed by the use of a mouse protection assay (smith, ) . necropsy findings. gross findings include markedly distended stomachs and intestines containing a large amount of gas and a moderate amount of brown, semiliquid ingesta, and subcutaneous emphysema with minimal or no putrefaction (field and laboratory service veterinary staff, ; schulman et al, ) . histologic findings observed in weanling black-footed ferret cases included the observation of abundant gram-positive bacilli in smears of gastric and intestinal contents. other findings included varying degrees of gastrointestinal mucosal necrosis, numerous gram-positive bacilli lining the denuded mucosal surface and extending into the gastric glands and intestinal crypts; lymphoid necrosis of lymph nodes, spleen, and thymus; mild to moderate dilatation of central hepatic sinusoids with mild, acute, centrilobular hepatocellular dissociation and multifocal aggregates of small numbers of necrotic neutrophils within portal areas (schulman et al., ) . and feeding practices is the primary means of control. in the reported cases of c. perfringens type a-associated gastroenteritis in black-footed ferret weanlings, supportive care and gastric trocharization were unrewarding. the occurrence of the condition was eliminated by restricting feeding of weanlings to twice a day instead of times daily. etiology. campylobacteriosis is caused by infection with campylobacter jejuni. epizootiology and transmission. campylobacter jejuni is a gram-negative, spirally curved microaerophilic bacterium that is recognized as a significant cause of human enteritis and is as-sociated with diarrheic illness in several animal species, including dogs, cats, cows, goats, pigs, mink, ferrets, and sheep (carter et al., ) . it also known to cause mastitis in cows, infectious hepatitis of chickens, and abortion in cattle, sheep, goats, dogs, and mink (carter et al., ) . the organism may also be cultured from the feces of normal asymptomatic dogs, cats, and ferrets carter et al., ) . transmission occurs by ingestion of organisms through direct contact with feces or contaminated food and water (carter et al., ) . there have been reports linking the disease in humans to pets. many of these outbreaks were associated with dogs, puppies, and kittens recently obtained from animal shelters or pounds and displaying diarrhea before the human illness occurred . isolation of campylobacter jejuni from asymptomatic ferrets also implies a potential for zoonotic transmission (fox et al., . clinical signs. experimental oral inoculation of ferret kits with various strains of c. jejuni produced a self-limiting diarrhea that ranged in character from very mild to watery manning, a, ) . the presence of mucus and/or blood was also noted in the feces of affected animals. anorexia, dehydration, and tenesmus with watery diarrhea were also observed. intravenous inoculation of pregnant mink and pregnant ferrets resulted in reproductive failure, ranging from fetal resorption to expulsion of dead or premature living kits . oral inoculation resulted in abortion in a majority of the infected animals . diagnosis. diagnosis is based on history, clinical signs, and culture of affected animals. reports of spontaneous cases in ferrets require diagnostic confirmation and differentiation from cases of proliferative bowel disease and other infectious and noninfectious causes of diarrhea. campylobacter jejuni grows slowly and has specific culture requirements that involve the use of selective media or filtration techniques, and a requirement for thermophilic ( ~ and microaerophilic conditions (fox, a) . cultures should be examined every hours for round, raised, translucent, and sometimes mucoid colonies (fox, a) . campylobacter jejuni revealed small focal neutrophilic infiltrates in the lamina propria of the colon of relatively few infected animals . bell and manning ( ) noted mild to moderate enterocolitis with neutrophilic infiltration of the lamina propria, which was most severe in kits with concurrent cryptosporidiosis. placentitis was the most notable histologic finding in pregnant ferrets and mink after experimental inoculation of a strain of an abortion storm-associated isolate of c. jejuni . erythromycin is the drug of choice for treatment of human campylobacteriosis (fox, a) . in a study to eliminate the carrier state in ferrets, erythromycin was ineffective even though in vitro isolates of c. jejuni were sensitive to the antibiotic . according to the author, reasons for therapeutic failure included dose selection, interspecies differences in pharmacokinetics and possible reinfection. supportive care should be instituted, and choice of antibiotic therapy in confirmed diarrheic cases should be based on culture and sensitivity. in addition, because of its zoonotic potential, isolation of affected animals and good hygienic practices are recommended. reculture of animals after treatment to ensure elimination of the organism is recommended. epizootiology and transmission. in , a gastric helicobacter-like organism was isolated from the margins of a duodenal ulcer of a ferret and named helicobacter mustelae (fox et al., a (fox et al., , a . subsequently, in the united states, gastritis and peptic ulcers have been routinely reported in ferrets colonized with h. mustelae (fox et al., b (fox et al., , a . every ferret with chronic gastritis is infected with h. mustelae, whereas specific pathogen-free (spf) ferrets not infected with h. mustelae do not have gastritis, gastric ulcers, or detectable igg antibody to the organism (fox et al., , a . helicobacter mustelae has also been isolated from the stomachs of ferrets living in england, canada, australia and, most recently, from ferrets in new zealand (forester et al., ; tompkins et al., ) . koch's postulates have been fulfilled: by oral inoculation of h. mustelae into naive ferrets uninfected with h. mustelae, the infection induced a chronic, persistent gastritis similar to that observed in ferrets naturally infected with h. mustelae (fox et al., b) . it is now known that h. mustelae colonizes nearly % of ferrets shortly after weaning. feces from weanling and adult ferrets have been screened for the presence of h. mustelae to determine whether fecal transmission could explain the % prevalence observed in weanling and older ferrets (fox et al., b (fox et al., , b . helicobacter mustelae was isolated from the feces of of nine-week-old and of eight-month-old ferrets. ferrets placed on proton pump inhibitors, which raise gastric ph, have a statistically higher recovery of h. mustelae from feces when compared with age-matched untreated control ferrets . clinial signs and pathology. helicobacter mustelae-infected ferrets examined in our laboratory are usually asymptomatic. ferrets with gastric or duodenal ulcers can be recognized clinically by vomiting, melena, chronic weight loss, and lowered hematocrit. clinical signs in ferrets with h. mustelae-associated gastric adenocarcinoma have consisted of vomiting, anorexia, and weight loss, signs that may be confused with gastric foreign body. diagnosis. gastric and duodenal ulcers are observable endoscopically. it is interesting that the ferret is the only domesticated animal to date that has naturally occurring helicobacterassociated ulcer disease. the h. mustelae isolated from ferrets has similar but not identical biochemical features to those of h. pylori, particularly in regard to the production of large amounts of urease. gastric samples collected by endoscopy or necropsy are minced with sterile scalpel blades and inoculated onto blood agar plates supplemented with trimethoprim, vancomycin, and polymixin b (remel, lenexa, kansas). the plates are incubated at ~ or ~ in a microaerobic atmosphere ( % n , % h , and % co ) in vented jars for - days. bacteria are identified as h. mustelae on the basis of gram-stain morphology; production of urease, catalase, and oxidase; resistance to cephalothin; and sensitivity to nalidixic acid. necropsy and findings. the histopathological changes occurring in the stomach closely coincided in topography with the presence of h. mustelae . a superficial gastritis present in the body of the stomach showed that h. mustelae was located on the surface of the mucosa but not in the crypts. inflammation occupied the full thickness of the distal antral mucosa, the so-called diffuse antral gastritis described in humans (fig. a,b) . in this location, h. mustelae was seen at the surface, in the pits, and on the superficial portion of the glands. in the proximal antrum and the transitional mucosa, focal glandular atrophy, a precancerous lesion, and regeneration were present, in addition to those lesions seen in the distal antrum. also, deep colonization of h. mustelae was observed focally in the affected antral glands. animals infected with helicobacter spp. may also be susceptible to gastric cancer yu et al., ) . there is recent documentation of the presence of argyrophilic bacteria, compatible in location and morphology to h. mustelae, within the pyloric mucosa of male ferrets with pyloric adenocarcinoma . in humans, epidemiologic data strongly support the association between h. pylori and development of gastric adenocarcinoma. similarly, we have recently documented a series of h. mustelae-infected ferrets with gastric mucosa-associated lymphoid tissue (malt) lymphoma that parallels the same syndi'ome found in humans. lymphoma was diagnosed in the wall of the lesser curvature of the pyloric antrum, corresponding to the predominant focus ofh. mustelaeinduced gastritis in ferrets. gastric lymphomas demonstrated characteristic lymphoepithelial lesions, and the lymphoid cells were igg positive in all ferrets (erdman et al., ) . these findings and their parallels in h. pylori-infected humans implicate the involvement of h. mustelae in the pathogenesis of gastric cancer in ferrets. treatment. studies in ferrets indicate that triple therapy consisting of oral amoxicillin ( mg/kg), metronidazole ( mg/ kg), and bismuth subsalicylate ( . mg/kg) (pepto-bismol original formula, procter and gamble) times a day for - weeks has successfully eradicated h. mustelae . clinical improvement, including increased appetite and resolution of melena, may occur within hr of initiation of triple therapy. a new treatment regimen being used to eradicate h. pylori in humans has also been used successfully for eradication of h. mustelae from ferrets . ferrets received mg/kg ranitidine bismuth and . mg/kg clarithromycin per os times daily for weeks. culture of tissue collected by gastric endoscopic biopsy at , , and weeks after termination of treatment indicated that long-term eradication was achieved in all ferrets. eradication was associated with decrease in anti-h, mustelae igg antibody titers, results that are consistent with findings in humans after h. pylori eradication. omeprazole in ferrets at an oral dose of . mg/kg once daily effectively induces hypochlorhydria and may be used in conjunction with antibiotics to treat h. mustelae-associated duodenal or gastric ulcers. cimetidine at mg/kg tid per os can also be used to suppress acid secretion. acute bleeding ulcers must be treated as emergencies, and fluid and blood transfusions are essential. etiology. proliferative bowel disease is caused by intracellular campylobacter-like organisms, closely related to desulfovibrio spp., that are now classified as lawsonia intracellularis in proliferative enteropathy of swine (fox, a) . the organisms are gram-negative, comma-to spiral-shaped bacteria. epizootiology and transmission. proliferative bowel disease is a common clinical disease observed in young ferrets. fecaloral spread is suspected. the disease typically involves the large bowel, although it has been observed to affect the small bowel (rosenthal, ) . campylobacter species, coccidia, and chlamydia have been isolated from some cases of proliferative bowel disease in ferrets (li et al., b) . the role, if any, of copathogens in this disease is unclear. clinical signs. clinical signs include chronic diarrhea, lethargy, anorexia, weight loss (which is often marked), and dehydration. diarrhea may be blood-tinged, may contain mucus, and is often green in color. rectal prolapse may be observed in affected animals. ataxia and muscle tremors have also been observed (fox et al., ) . diagnosis. diagnosis is based on clinical signs, a palpably thickened colon, and colonic biopsy. it is important to rule out other causes of diarrhea and weight loss through diagnostic tests that include but are not limited to a complete blood count, chemistry profile, radiographs, and fecal analysis and culture. necropsy findings. gross findings include a segmented, thickened lower bowel, usually the terminal colon but occasionally including the ileum and rectum (fox et al., ; fox, a) . histologic examination consistently reveals marked mucosal proliferation and intracytoplasmic l. intracellularis demonstrated with silver stain within the apical portion of epithelial cells in the hyperplastic epithelial cells (fox et al., ; fox, a) (fig. a,b) . other common histologic changes observed include the presence of a mixed inflammatory infiltrate that is variable in severity, reduced goblet cell production, hyperplasia of the glandular epithelium, glandular irregularity with penetration of the mucosal glands through the muscularis mucosa, and an increase in thickness of the tunica muscularis (fox et al., ; fox, a) . translocation of proliferating glandular tissue to extraintestinal sites, including regional lymph nodes and liver, has been described in two ferrets (fox et al., b) . differential diagnosis. proliferative bowel disease should be differentiated from other diseases that may cause diarrhea and wasting, including dietary changes, eosinophilic gastroenteritis, gastric foreign bodies, lymphoma, aleutian disease, and gastric ulcers (bell, b) . a complete physical exam that includes palpation of the abdomen should reveal a palpably thickened intestine in cases of proliferative bowel disease. treatment and control. supportive care, including fluid therapy and nutritional support, should be provided. treatment with chloramphenicol ( mg/kg bid po, sq, im) or metronidazole ( m/kg bid po) for weeks is reported to be effective (krueger et al., ; bell, b) . clinical improvement may be apparent within hr. etiology. tuberculosis can be caused by a variety of mycobacteria, including mycobacterium bovis, m. avium, and m. tuberculosis. epizootiology and transmission. mycobacteria are aerobic, gram-positive, nonbranching, non-spore-forming, acid-fast rods. natural infections with mycobacterium bovis and m. avium have been reported in the ferret. ferrets are also susceptible to experimental infection with human tubercle bacillus. most reports of tuberculosis in ferrets are in animals that were used for research in england and the rest of europe between the years of to and were likely related to the feeding of raw poultry, raw meat, and unpasteurized milk to ferrets during this time (fox, a) . the feeding of commercially prepared diets and widespread tuberculosis testing and elimination in livestock and poultry have resulted in the reduced incidence of the disease in ferrets. mycobacterium avium-infected wild clinical signs and necropsy findings. clinical signs and lesions are dependent on the infective strain. systemic infection with the bovine strain in ferrets results in disseminated disease with weight loss, anorexia, lethargy, death, and miliary lesions involving the lungs and other viscera (fox, a) . progressive paralysis has also been reported in a case of spontaneously occurring bovine tuberculosis in a ferret (symmers and thomson, ) . mycobacterium bovis lesions contain numerous acid-fast bacilli within macrophages with little cellular reaction (fox, a) . in contrast, infection of ferrets with the human tubercle bacilli results in localized infection, often confined to the site of injection and adjacent lymph nodes; microscopically few organisms are observed. an impaired cell-mediated response may account for the large number of organisms observed in m. bovis lesions. vomiting, diarrhea, anorexia, and weight loss were observed in a pet ferret with granulomatous enteritis caused by m. avium (schultheiss and dolginow, ) . granulomatous inflammation characterized by large numbers of epithelioid macrophages containing numerous acid-fast bacilli were present in the lamina propria and submucosa of the jejunum and pylorus. other sites of granulomatous inflammation included peripancreatic adipose tissue, mesenteric lymph nodes, spleen, and liver. a source of infection was not identified in this report. pulmonary infection with m. avium has also been reported in ferrets in a zoo in france (viallier et al., ) . diagnosis. definitive diagnosis of tuberculosis requires isolation and identification of the organism from suspect tissue specimens. great care should be exercised in handling suspect clinical specimens, and an appropriately equipped laboratory should be identified for culture and identification of the organism. although there has been some experimental work in the area of the intradermal tuberculin skin-test response in ferrets and its apparent use in controlling tuberculosis in a breeding colony of ferrets, a tuberculin skin-testing regimen, including dose and type, has not been definitively characterized for clinical use in ferrets (kauffman, ) . treatment and control. because of the zoonotic risk, ferrets infected with m. bovis and m. tuberculosis should be euthanized (fox, a) . recurrent m. bovis infection involving the palmar aspect of the wrist of a -year-old man, which developed after he was bitten by a ferret at the age of , was reported and demonstrates the zoonotic potential (jones et al., ) . mycobacterium avium infection is not reportable but may pose a risk to immunocompromised patients (fox, a) . personnel at risk should be followed up by a physician for appropriate diagnostic testing (fox, a) . etiology. salmonellosis is caused by infection with organisms of the genus salmonella. epizootiology and transmission. salmonella is a gram-negative, non-spore-forming, facultative anaerobic rod in the family enterobacteriaceae (carter et al., ) . infection is by the oral route. transmission may be direct from infected carrier animals or humans or through contaminated food products or water (carter et al., ) . several salmonella serovars have been isolated from mink with gastroenteritis and abortion (gorham et al., ) . contaminated raw meat products were suspected as the source in one outbreak. salmonella typhimurium was isolated in ferrets in an outbreak of clinical disease (coburn and morris, ) and several serotypes including s. hadar, s. enteritidis, s. kentucky, and s. typhimurium were isolated from the feces of ferrets surveyed in a research colony (fox et al., a) . clinical signs and necropsy findings. clinical signs of an outbreak of s. typhimurium in ferrets included conjunctivitis, rapid weight loss, tarry stools, and febrile temperature fluctuations (coburn and morris, ) . gross findings in ferrets days after inoculation with s. typhimurium of ferret origin included marked tissue pallor, petechiae in the gastric mucosa, and the presence of melena in one and a dark-colored fibrinous exudate in the large intestine of the other ferret (coburn and morris, ) . studies involving experimental inoculation with s. enteritidis, s. newport, and s. choleraesuis via the oral route to healthy, distemper-infected, and feed-depleted ferrets and mink showed a fairly high resistance to infection (gorham et al., ) . only animals of in the diet-restricted group-- ferret and minknshowed clinical signs of infection after feeding s. newport culture. signs included lethargy, anorexia, trembling, and fecal blood. the gastrointestinal tract showed a large amount of mucus containing red blood cells; bits of desquamated epithelium and few mononuclear cells overlying the gastric mucosa; an exudate in the small intestine consisting of mu-coid material, red blood cells, and desquamated small intestinal villi; edematous villi in the ileum; and a diffuse infiltrate of the small intestinal mucosa with lymphocytes and macrophages. necrotic foci in the liver, spleen, and, less commonly, the kidney, as well as splenomegaly and visceral lymphadenopathy, were observed in chronic fatal infections (coburn and morris, ) . abortion and gastroenteritis have been reported in mink (gorham et al., ) . diagnosis. diagnosis is based on history, clinical signs, and isolation of the organism. the organism can be cultured on enrichment and selective media and then characterized serologically. samples of blood, feces, exudates, tissues, and intestinal material may be cultured. treatment and control. coburn and morris ( ) treated of ferrets experimentally infected with s. typhimurium with sulfathalidine in the feed (coburn and morris, ) . salmonella typhimurium was isolated in of control animals and none of the treated animals days after the administration of the last dose. sulfathalidine was administered by the same authors to a colony of ferrets in which an outbreak of salmonella occurred. the group was surveyed days after sulfathalidine treatment and showed weight gain, improvement in condition, and a reduction in the number of salmonella-infected ferrets (coburn and morris, ) . salmonella spp. isolated from ferrets may show resistance to a number of antibiotics (fox, a) . treatment includes appropriate use of antimicrobials and supportive care, which may include fluid therapy, nutritional support, maintenance of electrolyte balance, treatment of concurrent diseases, recognition of and attention to shock, and reduction of stress (fox, a) . etiology. streptococcus zooepidemicus and other group c and g streptococci, escherichia coli, klebsiella pneumoniae, pseudomonas aeruginosa, and bordetella bronchiseptica have been reported as primary and secondary bacterial pathogens in pneumonia in ferrets (fox, a) . epizootiology and transmission. bacterial pneumonia may occur secondary to megaesophagus in the ferret. an influenza virus-bacteria synergism has been the subject of several studies in ferrets (fox, a) . debilitated and immunosuppressed animals and animals with concurrent diseases such as influenza may be more susceptible to bacterial pneumonias (fox, a) . clinical signs. clinical signs may include nasal discharge, dyspnea, lethargy, anorexia, increased lung sounds, cyanosis, and fever (rosenthal, ) . fulminant pneumonia may progress to sepsis and death (fox, a) . diagnosis. diagnosis is based on history, clinical findings, a complete blood count, culture and cytology of a tracheal wash or lung wash, and radiographs (rosenthal, ) . differential diagnosis. diagnostic rule-outs include dilatative cardimyopathy, heartworm disease, mycotic pneumonia, pneumocystis pneumonia in immunosuppressed animals, neoplasia, and influenza. treatment and control. treatment should consist of appropriate antimicrobial therapy and supportive care, which may include the administration of oxygen, fluid therapy, and force feeding (rosenthal, ) . etiology. a variety of bacteria have been associated with abscesses and localized infection of the lung, liver, uterus, vulva, skin, mammary glands, and oral cavity. these include staphylococcus spp., streptococcus spp., corynebacterium spp., pasteurella, actinomyces, hemolytic escherichia coli, and aeromonas spp. (fox, a) . epizootiology and transmission. abscesses in ferrets may result from wounds that are inflicted secondary to biting during fighting, playing, mating, or chewing sharp objects. clinical signs. localized or subcutaneous abscesses present as swellings with or without draining tracts. the swelling may be fluctuant. in most cases, the abscess is walled off and does not result in systemic signs (fox, a) . abscesses or infection involving visceral organs may give rise to organ-specific and/or systemic signs. diagnosis. cytologic and gram staining of an aspirate of a suspect subcutaneous swelling will aid in the definitive diagnosis. culture and sensitivity of the aspirate should also be performed to identify the causative organism and guide appropriate antibiotic therapy. differential diagnosis. differential diagnosis of a subcutaneous swelling in a ferret should include myiasis, granuloma, hematoma, and neoplasia. treatment and control. prevention of ferrets from exposure to sharp objects in the cage and feed, and limiting the exposure of male and female during breeding, can minimize the occurrence of abscesses. treatment of localized abscesses should include appropriate antibiotic therapy and establishment of drainage and debridement if necessary. bacterial culture and sensitivity of the exudate should be performed. a broad-spectrum antimi-crobial may be used pending results of culture and sensitivity (orcutt, ) . etiology. gram-positive cocci such as streptococcus spp., staphylococcus aureus, and coliforms such as hemolytic e. coli are the most frequently associated organisms (bernard et al., ; bell, a) . although the exact pathogenesis of mastitis in ferrets is not clear, a number of factors may play a role and include the stress of lactation, injury to mammary glands by the kits' teeth, environmental contamination, and the virulence of the organism. in one report, the causative organism, hemolytic e. coli, was cultured from the feces of mastitic and healthy ferrets and the oral cavity of suckling kits (liberson et al., ) . the high level of perineal contamination and the presence of the organism in the oral cavity of suckling kits may enhance transmission and introduction of this organism into mammary tissue. in another outbreak, the causative organisms were cultured from bovine meat fed prior to the outbreak, and the meat was suspected as a possible source. clinical signs. mastitis occurs in nursing jills and has been characterized as acute or chronic (bell, a) . the acute form is reported to occur soon after parturition or after the third week of lactation. examination of affected jills reveals swollen, firm, red or purple, and painful glands. affected glands may quickly become gangrenous. the chronic form, which may occur when kits are weeks old or as a sequela to the acute form, is characterized by glands that are firm but not painful or discolored. diagnosis. diagnosis is based on history, clinical signs, physical examination findings, and isolation of the causative organism. necropsy findings. in acute mastitis, grossly affected glands are swollen, and the skin overlying the gland may be discolored. surgical biopsies and necropsies of ferrets with mastitis caused by hemolytic e. coli (liberson et al., ) revealed extensive edema, hemorrhage, and coagulative and liquefactive necrosis involving the glandular tissue as well as surrounding subcutaneous tissue. other findings included the presence of a mixed leukocytic infiltrate composed primarily of polymorphonuclear leukocytes; large numbers of bacteria; and thrombosis and necrosis of vessels within and immediately adjacent to areas of inflammation (liberson et al., ) . in an outbreak of mastitis in mink due to staphylococcus aureus and escherichia coli, histologic examination of affected glands revealed an acute suppurative mastitis with desquamation of alveolar epithelium, edema of the connective tissue stroma, alveoli filled with neutrophils and cellular debris, and lactiferous ducts filled with purulent exudate and mats of bacteria within lobules (trautwein and helmboldt, ) . treatment. broad-spectrum antibiotic therapy may be instituted pending culture and sensitivity results of the milk. enrofloxacin ( . mg/kg bid po after a loading dose of . mg/kg im) is often effective. jills may require aggressive care, because acute mastitis may progress rapidly and animals may become septicemic and moribund (liberson et al., ) . oral antibiotic administration to kits nursing affected jills is recommended (bell, a) . surgical resection and debridement of affected glands and supportive care may be necessary for jills with acute mastitis. supplementation of kits with milk replacer may also be necessary, because jills with acute mastitis are reluctant to nurse, and jills with the chronic form have diminished lactation as milk-producing tissue is replaced by scar tissue (bell, a) . maintaining thorough personal hygiene practices when handling affected jills is important in minimizing spread to other lactating jills. cross-fostering kits may be required; however, kits may spread infection to healthy jills. it is reported that jills with the chronic form of mastitis should be culled (bell, a ). etiology. canine distemper (cd) is caused by a paramyxovirus of genus morbillivirus that is related to measles and rinderpest (budd, ) . there are several strains, including a ferret-adapted strain of canine distemper virus (cdv), that vary in incubation, clinical signs, and duration . the virus can be inactivated by heat, light, and various chemicals, including phenol, roccal, sodium hydroxide, and formalin (shen and gorham, ; budd, ) . infectious virions have been recovered from fomites after min at room temperature. canine distemper is the most serious viral infection of ferrets. mortality approaches %, making appropriate husbandry and vaccination imperative. the disease has a catarrhal phase and a neurological, or central nervous system (cns), phase. the catarrhal phase is - days postinfection and involves anorexia, pyrexia, photosensitivity, and serous nasal discharge. an erythematous pruritic rash spreads from the chin to the inguinal region. it is suspected that the rash results from cell-mediated immunity to infected endothelial cells, similar to the response seen in humans with measles (norrby and oxman, ) . hyperkeratosis of footpads, called hard pad, is an inconsistent feature. secondary bacterial infections result in mucopurulent ocular and nasal discharge and possibly bacterial pneumonia. the cns phase, with ataxia, tremors, and paralysis, may or may not be preceded by the catarrhal phase. death occurs in - days from ferret strains of cdv and up to days with canine strains. infection is uniformly fatal. epizootiology and transmission. virus is shed from infected hosts from conjunctival, nasal, and oral exudates, urine, feces, and sloughed skin (gorham and brandly, ) . transplacental infection is not reported in ferrets. attenuated cdv vaccine strains have not been recovered from the body secretions of ferrets following vaccination (shen et al., ) . unvaccinated dogs and other canids, mustelids, and procyonids may serve as reservoirs of infection. viremia is detectable days postinfection and persists until the ferret dies or mounts a neutralizing antibody response (liu and coffin, ) . the primary site of replication is the respiratory and lymphatic systems, and cdv has been recovered from the nasal secretions of ferrets - days postinfection. a decrease in lymphocyte subsets is detectable - days postinfection. clinical signs and necropsy findings. histologically, intracytoplasmic and intranuclear inclusion bodies may be observed in tracheal, bronchial, epithelia, and bile duct as well as transitional epithelium in the bladder (liu and coffin, ) (fig. ) . the eosinophilic (hematoxylin-eosin) inclusions appear orange using pollack's trichrome stain. diagnosis and differential diagnoses. presumptive diagnosis is based on clinical observation, questionable vaccination history, and exposure. a fluorescent antibody test can be used on peripheral blood and conjunctival mononuclear cells to detect infection. reverse transcriptase-polymerase chain reaction (rt-pcr) has also been used to detect experimental infection (stephensen et al., ) . differential diagnoses should include infection with influenza virus or bordetella bronchiseptica. influenza does not rapidly progress to mucopurulent ocular and nasal discharge as cd does. during an outbreak, clinically affected ferrets should be isolated and the remainder of the colony vaccinated. distemper infection can be prevented by vaccination with modified live vaccine of chicken embryo tissue culture origin (cetco) administered subcutaneously or intramuscularly. kits should be vaccinated every - weeks, starting at age weeks, until weeks and annually thereafter . it is important to adhere to the prescribed vaccination protocol, because ferret deaths have been reported following double-dose vaccination (carpenter et al., ) . inactivated distemper vaccines do not elicit consistent, effective immunity and are not recommended. it is important to know the vaccination schedule of your ferret supplier and to vaccinate supplementally as appropriate. new ferrets should be held in quarantine for weeks prior to introduction into the resident colony. ferrets have been experimentally infected with feline panleukopenia, canine parvovirus, canine parainfluenza virus, mink enteritis virus, respiratory syncytial virus, transmissible mink encephalopathy, and pseudorabies, but natural infection with these viruses has not been reported . etiology. aleutian disease virus (adv) is a parvovirus with strains of varying virulence and immunogenicity. mink-derived strains are more virulent to mink than are ferret-derived strains . epizootiology and transmission. aleutian disease (ad) is a chronic progressive illness that was first described in mink (oxenham, ) . it was originally named hypergammaglobulinemia (hgg) because of this remarkable finding. infection may be subclinical for years. because the immunomodulation associated with adv infection is disruptive to biomedical research, it is important to seek sources of adv-free ferrets . transmission between ferrets may be direct or via aerosol of urine, saliva, blood, feces, and fomites (kenyon et al., ; gorham et al., ) . vertical transmission is established in mink but is unproven in ferrets. clinical signs. ferrets infected with adv as adults develop persistent infection but rarely disease, although chronic progressive weight loss, cachexia, malaise, and melena have been described (porter et al., ) . ad may also cause ataxia, paral-ysis, tremors, and convulsions (oxenham, ; welchman et al., ) . the lesions are typically immune-mediated, and there is elevation of the gammaglobulins to generally greater than % of the total proteins (porter et al., ; fig. ). the precise mechanism of immunomodulation is unknown, but in mink there is depression of b-and t-cell responses. necropsy. ferrets may have no lesions upon necropsy, or infrequently they may have hepatosplenomegaly and lymphadenopathy. the most consistent histological finding is periportal lymphocytic infiltrates (fig. ). bile duct hyperplasia and periportal fibrosis have also been reported. membranous glomerulonephritis has been described (ohshima et al., ) . although lesions are subtle, use of adv-infected ferrets in biomedical research is contraindicated because histological lesions interfere with the interpretation of study results . diagnosis and differential diagnoses. presumptive diagnosis is based on hgg and chronic weight loss. diagnosis is confirmed by immunofluorescent antibody (ifa) or counterimmunoelectrophoresis (ciep) for antibody to adv antigen (palley et al., ) . pcr-based assays have also been used (erdman et al., b; saifuddin and fox, ; erdman et al., ) . differential diagnoses include the neurotropic form of cd, as well as chronic wasting diseases such as neoplasia, malabsorption, maldigestion, and bacterial enteritis . vaccination against adv would be contraindicated because of the immune-mediated reaction, and a vaccine is not available. chemical disinfection may be achieved tp - . g/dl /globulin = . g% , .. with formalin, sodium hydroxide, and phenolics (shen et al, ) . there is no treatment for ad, and infected ferrets should be culled from the colony. etiology. influenza is caused by an orthomyxovirus that is transmissible from humans to ferrets and ferrets to humans (smith and stuart-harris, ) . human influenza viruses a and b are pathogenic to ferrets . ferrets are also susceptible to avian, phocine, equine, and swine influenza, although only porcine influenza causes clinical signs. because the viruses can be readily transmitted from humans to ferrets, handling precautions such as wearing masks and gloves should be in place to minimize transmission. epizootiology, transmission, and clinical signs. influenza virus generally remains localized in nasal epithelium in ferrets but may cause pneumonia. clinical signs appear hr postinfection and include anorexia, fever, sneezing, and serous nasal discharge. conjunctivitis, photosensitivity, and otitis are also sometimes seen . secondary bacterial infection by streptococcus sp. and occasionally bordetella bronchiseptica may prolong recovery. transmission occurs via aerosol and direct contact. diagnosis. diagnosis is based on typical clinical presentation and recovery within days, unlike with cd, which progresses to more severe disease and death. hemagglutination inhibition antibody titers on acute and convalescent sera are rarely needed. treatment and control. antibiotic therapy may be instituted to preclude secondary bacterial infection. animal technicians and investigators suffering from influenza should avoid contact with ferrets. ferrets have been used extensively as a model for influenza research because the biological response to infection is similar to that in humans . ferrets have been used in influenza a research to study pathogenesis, to investigate reye's syndrome, and to evaluate vaccine trials (deshmukh, ; sweet et al., ) . etiology. rabies is caused by a rhabdovirus. rabies infection is infrequently reported in ferrets, and until recently, research on rabies in ferrets was lacking . ferrets in a well-managed facility would have low risk of exposure to rabies virus. a usda-approved, killed rabies vaccine given subcutaneously at ages months and year and annually thereafter is recommended to protect ferrets against rabies (rupprecht et al., ) . modified live vaccine (mlv) is not recommended, because there is at least one case of rabies in a ferret that was vaccinated with mlv rabies vaccine . there is no treatment for rabies. clinical signs and pathogenesis. clinical signs of rabies infection in ferrets may include anxiety, lethargy, and posterior paresis. in one experimental infection, of ferrets died, and negri bodies were seen in the brain of only of the (blancou et al., ) . there is conflicting data on the isolation of rabies virus from the salivary glands following experimental infection. in one study using raccoon variant of rabies for infection, more than half of the ferrets had rabies isolated from the salivary glands . ferrets at risk for exposure to rabies virus that bite or scratch a human should be placed under quarantine for not less than days of observation. veterinarians and facility managers should seek assistance from state public health officials. diagnosis and differential diagnoses. differential diagnosis includes the neurotropic form of cd. diagnosis is based on direct ifa of brain tissue. because rabies in ferrets is poorly understood, the head from ferrets that exhibit signs compatible with rabies and that have exposure histories that raise concerns about rabies should be shipped to the state public health authority for confirmation. etiology. rotaviruses cause diarrhea in young of many species, including humans, calves, pigs, sheep, and rats. diarrhea in ferret kits is thought to be caused by a poorly characterized, atypical rotavirus that has not been cultivated in vitro (torres-medina, ) . atypical rotaviruses lack the rotavirus common antigen. epizootiology, transmission and clinical signs. clinical disease may occur in kits as young as - days old or in older animals up to weeks of age. diarrhea soils the perineum and possibly the fur and nest material. mortality rates are agedependent, with high mortality occurring in young kits and lower mortality occurring in kits over days of age (bell, a; fox et al., b) . secondary bacterial infection may influence the severity of diarrhea. necropsy andpathogenesis. lesions are restricted to the gastrointestinal tract. yellow-green liquid or mucous feces may be seen in the terminal colon on necropsy. subtle small-intestinal villous atrophy and epithelial cell vacuolation are detectable histologically. diagnosis and differential diagnoses. clinical diagnosis can be confirmed by using clarified and ultracentrifuged fecal pel-lets for electron microscopy. the ferret rotavirus does not crossreact with commercially available enzyme immunoassays (torres-medina, ) . it is desirable to avoid sources that are known to be infected with ferret rotavirus. affected kits may be supplemented with kitten milk replacer, using a medicine dropper. mortality is reduced if the kits continue nursing. treatment of secondary bacterial infections may reduce severity of the diarrhea, and supportive care, including subcutaneous fluid administration for young kits, may be required . jills develop immunity to rotavirus infection, and subsequent litters are protected. infectious bovine rhinotracheitis (ibr) was isolated from the liver, spleen, and lung of clinically normal ferrets (porter et al., ) . raw beef was suspected as the source of infection, reinforcing the need to exclude raw meat products from the diet of ferrets used for research. ibr does cause significant respiratory pathology in experimentally infected ferrets (porter et al., ) . a transmissible diarrhea, referred to as epizootic catarrhal enteritis, has been observed in adult ferrets several days after direct contact and fomite exposure to affected ferrets . clinically the diarrhea is green and bile-tinged, and the ferrets become rapidly dehydrated. mortality is low. some ferrets develop elevated liver enzymes. treatment involves aggressive oral and systemic fluid therapy. a recent study implicates a coronavirus as the cause of this disease (williams et al., ) . a. protozoa i. enteric coccidiosis etiology. three species of the genera isospora and eimeria have been reported to infect the ferret: isospora laidlawi, eimeria furonis, and e. ictidea (blankenship-paris et al., ) . tion of sporulated oocysts. clinical signs. coccidiosis in ferrets is usually subclinical but has been reported to be associated with diarrhea, lethargy, and dehydration in one ferret (blankenship-paris et al., ) . clinical signs are often seen in young, newly acquired ferrets and are more common after a stressful event (rosenthal, ) . rectal prolapse can also develop in association with coccidial infection (rosenthal, ) . diagnosis. diagnosis is generally made by any of the fecal flotation methods commonly used in veterinary practice or by direct wet mount of feces and microscopic examination for sporulated or unsporulated oocysts. because coccidial oocysts are small, slides should be examined under higher magnification. necropsy findings. diagnosis is usually performed antemortem. pathologic lesions associated with enteric coccidiosis in a laboratory-reared ferret that was euthanized were described in one published report (blankenship-paris et al., ) . microscopic lesions were confined to the jejunum and ileum and consisted of villous and epithelial thickening. parasitic cysts and microorganisms within epithelium, and a mild granulomatous inflammation in the villar lamina propria, were also observed. a recent report documents clinical and anatomic pathology associated with biliary coccidiosis in a weanling ferret (williams et al., ) . differential diagnosis. diarrhea may be observed in ferrets that present with gastroenteritis secondary to gastrointestinal foreign bodies and dietary indiscretion, as well as other nutritional, inflammatory, infectious, or other systemic diseases. infectious causes such as proliferative colitis, salmonellosis, giardiasis, rotavirus, and campylobacteriosis should be considered. diarrhea may also be seen in eosinophilic gastroenteritis, an uncommonly reported condition in ferrets. good husbandry practices that include sanitation and frequent disposal of feces reduce the number of oocysts in the environment. cleaning cages with a strong ammonium hydroxide solution is reported to be effective (kirkpatrick and dubey, ) . heat treatment of surfaces and utensils may also be effective (kirkpatrick and dubey, ) . treatment of ferrets with sulfadimethoxine at mg/kg orally once and then mg/kg orally every hr for days is recommended (rosenthal, ) . as in dogs and cats, the complete elimination of a coccidial infection requires an immunocompetent host. ii. cryptosporidiosis etiology. cryptosporidiosis is caused by infection with cryptosporidium spp. epizootiology and transmission. cryptosporidium is a protozoan in the class sporozoa, subclass coccidia, that inhabits the respiratory and intestinal epithelium of birds, reptiles, mammals, and fish (regh et al., ) . it is known to cause gastrointestinal tract disease in many species, including rodents, dogs, cats, calves, and people (hill and lappin, ) . it has a life cycle similar to other coccidian parasites and is transmitted by ingestion of sporulated oocysts. autoinfection is also a characteristic of the life cycle. transmission may occur through consumption of contaminated food or water. cattle, dogs, and cats, shedding oocysts, are reported to be potential sources of human infection (hill and lappin, ; fox, g) . immunosuppressed people are at greatest risk of developing severe fulminating gastrointestinal disease (hill and lappin, ) . the finding of cryptosporidiosis in two ferrets that died from unrelated causes in one animal facility resulted in a survey of the existing ferret population and new arrivals into the facility to determine the prevalence and incidence of infection (regh et al., ) . findings indicated that % of the resident population and - % of new arrivals had oocysts in their feces but showed no clinical signs. clinical signs. only subclinical infection has been reported in both immunocompetent and immunosuppressed ferrets (regh et al., ) . diagnosis. diagnosis is based on the identification of the organism in feces. the oocysts are small when compared with other coccidia and may be overlooked or mistaken for yeasts (kirkpatrick and dubey, ) . yeasts are oval, whereas cryptosporidium oocysts are spherical or ellipsoidal. additionally, yeasts will stain with iodine and are not acid-fast, whereas cryptosporidium has the opposite staining characteristics. the oocyst residuum is seen as a refractive dot under phase-contrast microscopy, a structure lacking in yeast (kirkpatrick and dubey, ) . sugar-solution centrifugation and fecal sedimentation using formalin-ether or formalin-ethyl acetate are effective di-agnostic concentration techniques (hill and lappin, ) . oocysts may then be viewed with phase-contrast or bright-field microscopy of specimens stained with an acid-fast method. a direct fecal smear may be methanol-or heat-fixed and stained with an acid-fast method (hill and lappin, ) . necropsy findings. histologic evaluation reveals the presence of organisl ns, spherical to ovoid in shape and from to ~tm in diameter, associated with the brush border of the villi. a mild eosinophilic infiltrate was observed in the lamina propria of the small intestine in most animals. the ileum was the most common and heavily infected section of small intestine (regh et al., ) . there is no known definitive treatment for cryptosporidiosis (fox, g) . supportive and symptomatic care should be provided in clinical cryptosporidiosis. infections are self-limiting in immunocompetent patients (fox, g) . control is aimed at eliminating or reducing infective oocysts in the environment and avoidance of contact with known sources. because of the potential for zoonotic transmission, restricting contact of children and immunosuppressed individuals with infected ferrets and practicing good hygiene may help reduce the potential for infection. drying, freeze-thawing, and steam cleaning inactivate the organism (hill and lappin, ) . there are few effective commercial disinfectants. i. sarcoptic mange etiology. sarcoptic mange is caused by infection with sarcoptes scabiei. epizootiology and transmission. transmission occurs through direct contact with infected hosts or contact with fomites. this parasitic infection is rare under research conditions. clinical signs. infection of ferrets with s. scabiei may occur in a generalized or a pedal form (bernard et al., ) . in the generalized form, lesions consist of focal or generalized alopecia with intense pruritus. in the pedal form, lesions are confined to the toes and feet, which become swollen and encrusted with scabs. nails may be deformed or lost if the condition is left untreated. diagnosis. diagnosis is made by finding the mites in skin scrapings or removing crusts, breaking them up, and clearing with % koh for microscopic examination (phillips et al., ) . false-negative results are possible; multiple scrapings may be necessary. differential diagnosis. differential diagnosis should include other pruritic external parasitic conditions, including flea infes-tation. demodicosis has been reported to cause mild pruritus and alopecia in ferrets (noli et al., ) . in the pedal form, treatment consists of trimming the claws and removing the scabs after softening them in warm water (bernard et al., ) . treatments that have been used include ivermectin, . - . mg/kg, administered subcutaneously and repeated every - days until mites are gone; shampoos or soaks to reduce the pruritus; and topical or systemic antibiotic administration for treatment of secondary bacterial dermatitis (hillyer and quesenberry, b) . alternatively, weekly dips in % lime sulfur until weeks after clinical cure have been shown to be effective (fox, a) . treatment of all affected animals as well as contact animals, and decontamination of enclosures and bedding, are recommended. ii. demodicosis etiology. demodicosis is caused by infection by demodex spp. epizootiology and transmission. the parasite is found in normal skin of almost all dogs and is not considered contagious. predisposing factors such as immunologic or genetic conditions have been suggested (kwochka, ) . one clinical report describes demodicosis in two adult ferrets that had been treated with an ear ointment containing triamcinolone acetonide for recurrent ear infections daily for periods of months each during the course of a year (noli et al., ) . clinical signs. in the report mentioned above, the ferrets presented with alopecia, pruritus, and orange discoloration of the skin behind the ears and on the ventral surface of the abdomen and an accompanying seborrhea (noli et al., ) . diagnosis. deep skin scrapings should be performed to demonstrate mites. finding a large number of live adult mites or immature forms and eggs is necessary to confirm the diagnosis. in very chronic cases, the skin may be so thickened that scrapings may be unrewarding. in these cases, a skin biopsy may be diagnostic (kwochka, ) . necropsy findings. histologic evaluation of skin biopsies obtained in the case report described above revealed mites with a short, blunted abdomen similar to that of demodex criceti and located in the infundibulum of hairs. the epidermis was slightly hypertrophic, and there was a mild superficial orthokefatotic hyperkeratosis. a very mild superficial and perivascular mixed cellular infiltrate was also observed in the dermis. differential diagnosis. generalized demodicosis should be differentiated from sarcoptic mange and flea infestation. primary or secondary bacterial dermatitis or pyoderma should also be considered. treatment and control. the ferrets in the above-mentioned clinical report were treated initially with a suspension of . % amitraz applied as a dip times at -day intervals for treatments. two drops of the same solution were applied in each ear every other day. after the initial treatment, the ferrets were reexamined, and treatment was continued with the same concentration of solution applied once every days, while the tail was washed with a higher concentration of amitraz ( . %) once every other day. thereafter, final treatments with . % amitraz every days for the body, and every other day for the ears and tail, were administered. the ferrets were evaluated and skin scrapings were performed regularly during treatment and posttreatment to monitor response to therapy. treatment of any associated pyodermas, systemic illnesses, or management problems should also be included as part of the therapeutic regimen. iii. ear mites etiology. the ear mite, otodectes cynotis, which commonly infects dogs and cats, is also a common clinical problem in ferrets (fox, g) . epizootiology and transmission. ear mites are transmitted through direct contact with infested ferrets, dogs, or cats (fox, g) . the entire life cycle is completed in weeks. clinical signs. ear mite infestation in the ferret is usually asymptomatic (orcutt, ) . however, clinical signs may include head shaking; mild to severe pruritus with inflammation and excoriation; secondary otitis interna with ataxia; circling; torticollis; and horner's syndrome (orcutt, ; fox, g) . a brownish black waxy discharge is often present. diagnosis. diagnosis is based on direct observation of mites via otoscopic examination or microscopic identification of the ear mite or any of the life-cycle stages of the mite in exudate from the ear canal. treatment and control. several treatment regimens, including topical and injectable mitocidal treatments, have been recommended (orcutt, ; fox, g) . a recent study using three treatment regimens--two topical and one injectable--revealed that topical treatments were more efficacious than the injectable in reducing or eradicating ear mites (patterson et al., ) . efficacy was evaluated by microscopic evidence of ear mites in debris from aural swabs taken weekly for an -week period. topical % ivermectin (ivomec, merck agvet division, rahway, new jersey), diluted " in propylene glycol at a dosage of ~tg/kg body weight divided equally between the two ear canals and administered on days and of the study, was the most effective treatment. all susceptible animals in a household should be treated. ears should be gently cleaned prior to initiating treatment (orcutt, ) . high doses of injectable iver-mectin ( . ml of % ivermectin) administered to jills at - weeks of gestation resulted in high rates of congenital defects (orcutt, ) . iv. fleas etiology. ctenocephalides species can infest ferrets. epizootiology and transmission. transmission requires direct contact with another infested animal or a flea-infested environment. clinical signs. flea infestation may be asymptomatic or may cause mild to intense pruritus and alopecia of the dorsal thorax and neck (timm, ) . differential diagnosis. sarcoptic and demodectic mange should be included in the differential diagnosis of pruritic skin disease in the ferret. close examination of the pelage for fleas or flea excrement should be performed. skin scrapings may be indicated. as with flea infestation in dogs and cats, concurrent treatment of the environment, as well as all animals in the household, is essential for effective flea control. compounds approved for flea control in cats such as rotenone or pyrethrin powders or sprays may be used in ferrets (hillyer and quesenberry, a) . ferrets may develop systemic disease from blastomyces, coccidioides, cryptococcus, and histoplasma. the reservoir of most of these fungi is the soil, however, making infection unlikely in a research facility. in production facilities, exposure can be minimized through careful selection of source animals, appropriate sanitation, and control of pests, particularly birds. pneumocystis carinii has been recently reclassified as a fungus. although p. carinii inhabits the lungs of many different species, recent transmission studies suggest that these fungi are highly species-specific (gigliotti et al., ; fox et al., b) . clinical disease is evident only in immunocompromised ferrets and can be induced using high doses of exogenous steroids (stokes et al., ) . lesions include interstitial pneumonitis with mononuclear cell infiltrates; cysts and trophozooites are evident with gomori methanamine-silver nitrate and giemsa on bronchoalveolar lavage. treatment with trimethoprim sul-famethoxazole probably controls but does not eliminate infection . ferrets are susceptible to secondary fungal infection of the outer ear canal with absida corymbifera or malassezia spp. (dinsdale and rest, ; fox, d) . the fungi are widespread in the environment and will cause a secondary fungal infection in the ears of ferrets infested with otodectes cynotis. the yeasts can be visualized by impressions of ear exudates. treatment involves eradication of the underlying mite infestation followed by oral and topical ketoconazole, miconazole, and polymyxin b. dermatomycoses in ferrets are caused by microsporum canis and trichophyton mentagrophytes. dermatophytes are transmissible to humans and are a zoonosis; thus affected animals should be quarantined and removed from the facility to minimize risk (dinsdale and rest, ; scott et al., ; fox et al., b) . control of infection includes general disinfection and destruction of contaminated bedding. lesions are circumscribed areas of alopecia and inflammation, which begin as small papules that spread peripherally in a scaly inflamed ring. the yellow-green fluorescence of m. canis under ultraviolet light helps distinguish it from t. mentagrophytes. skin scrapings digested with % potassium hydroxide reveal characteristic arthrospores. treatment with griseofulvin causes clinical remission but may not clear infection. other ectoparasitic infections observed to occur in ferrets include cutaneous myiasis and tick infestation. granulomatous masses in the cervical region caused by the larval stage of hypoderma bovis have been reported in ferrets (fox, g) . cuterebra larvae, although uncommonly observed in ferrets, may cause subdermal cysts found in the subcutis of the neck (orcutt, ) . infestation with the flesh fly has been reported as a problem in commercially reared mink and ferrets housed outdoors (fox, g) . ticks may be found on ferrets housed outdoors or on those used for hunting rabbits (fox, g) . ticks should be removed carefully with hemostats or tweezers, ensuring that the entire head and mouthparts are removed from the skin. appropriate caution should be exercised in tick removal, because ticks are responsible for transmission of various zoonotic pathogens; gloves should be worn. etiology. the ferret is susceptible to natural and experimental infection with dirofilaria immitis. epizootiology and transmission. dirofilaria immitis is a filarial parasite that is transmitted by mosquitoes, which serve as the intermediate host and vector. microfilaria are ingested by mosquitoes and, after two molts, become infective third-stage larvae. infective larvae are deposited onto the skin when mosquitoes feed, and larvae find their way into the body of the final host through the bite wound and migrate subcutaneously to the thorax and eventually to the heart (knight, ) . the primary reservoir of infection is dogs, but heartworm may be found in a variety of mammals, including humans. all other species except wild and domestic canids, domestic felines, ferrets, and the california sea lion are considered aberrant hosts (knight, ) . clinical signs. the following clinical signs have been reported in clinical reports describing cases of d. immitis in the ferret: weakness, lethargy, depression, dyspnea, cyanosis, anorexia, dehydration, cough, and pale mucous membranes (miller and merton, ; parrott et al., ; moreland et al., ) . moist lung sounds and/or muffled heart sounds were revealed by thoracic auscultation in many of these cases. pleura/or abdominal effusion may be observed radiologically. the ferrets described in these cases were housed outdoors and either died or were euthanized. diagnosis. diagnosis of heartworm is based on clinical signs, radiographic findings, and testing for circulating microfilariae and heartworm antigen. microfilaremia is not consistently observed in naturally occurring and experimental cases of heartworm infection in ferrets (fox, g) . testing for heartworm antigen appears to be more diagnostically useful (stamoulis et al., ) . in a study to determine the minimum oral dose of ivermectin needed for monthly heartworm prophylaxis in ferrets, the use of an antigen test (uni-tec canine heartworm test, pitman-moore co., mundelein, illinois) detected infection in more untreated control animals than did the modified knott test for detection of circulating microfilaria in the same ferrets (supakorndej et al., ) . necropsy findings. cardiomegaly, pleural and/or abdominal fluid, and pulmonary congestion are common findings at necropsy. grossly, adult worms have been observed in the right atrium, right ventricle, pulmonary artery, and cranial and caudal vena cava. microscopically, microfilaria may be seen in small and large vessels of the lung. differential diagnosis. differential diagnosis should include primary cardiac diseases, such as dilatative cardiomyopathy, and other systemic or pulmonary diseases. control is best directed at prevention through the administration of heartworm preventative and it is recommended that ferrets in heartworm-endemic areas receive monthly oral ivermectin throughout the year (stamoulis et al., ; fox, g) . the dosage recommended for ferrets by the american heartworm society is . mg/kg body weight monthly (fox, g) . housing ferrets indoors, particularly during the mosquito season, would help minimize exposure. successful adulticide treatment in ferrets has been described and includes the administration of thiacetarsemide, with the same precautions used in dogs: antithrombotic therapy, treatment for heart failure, and strict cage confinement (stamoulis et al., ) . one should follow up with heartworm antigen tests until negative and resume heartworm prevention month after adulticide treatment (stamoulis et al., ) . ferrets are also susceptible to infection with the following nematodes: toxascaris leonina; toxocara cati; ancylostoma spp.; dipylidium caninum; mesocestoides spp.; atriotaenia procyonis; trichinella spiralis; filaroides martis; and spiroptera nasicola (rosenthal, ; fox, g) . a day of their due date should include cesarean section and intensive postoperative support, including force-feeding a gruel of high-quality cat food and ferret chow, nutritive pastes, intravenous fluids containing glucose, and supplemental heat. cesarean section should be performed under isoflurane anesthesia because hepatic dysfunction prolongs the metabolism of injectable agents. agalactia is common after cesarean section, and kits may require hand feeding with kitten or puppy milk replacers, administered per os by fine-tipped syringe times daily for the first hr. cross fostering is an effective method of enhancing kit survival; hand rearing of kits if the jill fails to nurse within a day postoperatively is energy-consuming and generally unrewarding. for jills that develop pregnancy toxemia before day of gestation, fluids and nutritional support must be provided until viable kits can be delivered by cesarean. pregnancy toxemia may be avoided by close monitoring of appetite of jills in late gestation, provision of a highly palatable diet with > % fat and > % crude protein, and avoidance of stress and dietary change. water should be made available in both bowls and water bottles, and food should be provided ad libitum in several bowls. pregnancy toxemia in the ferret occurs predominantly in primiparous jills carrying large litters. an inadvertent fast in late gestation is sometimes implicated. at least % of jills carrying more than kits will develop pregnancy toxemia if subjected to hr of food withdrawal in late gestation (bell, a; batchelder et al., ) . any jill with or more kits may develop pregnancy toxemia because abdominal space is not adequate for both the gravid uterus and the volume of food required to support it. pregnancy toxemia of the ferret is of the metabolic type and shares features with similar conditions in pregnant sheep, obese cattle, pregnant camelids, obese guinea pigs, and starved pregnant rats, as well as with the condition feline idiopathic hepatic lipidosis. it is characterized by abnormal energy metabolism with consequent hyperlipidemia, hypoglycemia, ketosis, and hepatic lipidosis. in this condition, energy demand exceeds intake, leading to excessive mobilization of free fatty acids and a chain of metabolic events that culminates in a shift from fatty acid metabolism and export to ketosis and hepatic lipidosis. clinical signs include anorexia, lethargy, melena, dehydration, and easily epilated hair. differentials include dystocia, metritis, pyometra, septicemia, renal failure, and helicobacter mustelae-induced gastric ulcer. in a recent study of ferrets with pregnancy toxemia, consistent clinical chemistry abnormalities included azotemia ( %), hypocalcemia ( %), hypoproteinemia ( %), and elevated liver enzymes ( %) (batchelder et al., ) . anemia was found in % of ferrets tested. necropsy findings include tan or yellow discolored liver, gastric hemorrhage, and gravid uterus. treatment forjills within ferrets are induced ovulators and may remain in persistent estrus if they are not bred or if estrus is not terminated chemically or via ovariohysterectomy (bell, a) . jills that remain in estrus for more than month are at risk for developing estrogeninduced anemia. hyperestrogenism from persistent estrus causes bone marrow hypoplasia of all cell lines in approximately half of ferrets in prolonged estrus (ryland et al., ) . clinical signs include vulvar enlargement, bilaterally symmetric alopecia of the tail and abdomen, weakness, anorexia, depression, lethargy, weight loss, bacterial infection, and mucopurulent vaginal discharge. hematology findings may vary from an initial neutrophilia and thrombocytosis early in the disease course to lymphopenia, thrombocytopenia, neutropenia, and anemia. the anemia begins as normocytic normochromic but progresses to macrocytic hypochromic (sherrill and gorham, ) . coagulopathy associated with hepatic dysfunction and thrombocytopenia combine to produce extensive manifestations of bleeding, pallor, melena, petechiation or ecchymosis, subdural hematoma, and hematomyelia (hart, ; fox and bell, ) . at necropsy, tissue pallor, light tan to pale pink bone marrow, hemorrhage, bronchopneumonia, hydrometra, pyometra, and mucopurulent vaginitis may be seen. histopathology may reveal cystic endometrial hypoplasia, hemosiderosis, diminished splenic extramedullary hematopoiesis, and mild to moderate hepatic lipidosis (sherrill and gorham, ; bell, a) . treatment consists of terminating estrus while supporting the animal with antibiotics, blood transfusion, b vitamins, and nutritional supplementation. estrus may be terminated by injection with - iu of human chorionic gonadotropin (hcg) or ~tg of gonadotropin-releasing hormone (gnrh), repeated week after initial injection if required. ovariohysterectomy may be considered for ferrets that are stable and have adequate numbers of platelets and red cells. ferrets with a packed cell volume (pcv) of % or greater have a good prognosis and require only termination of estrus for resolution of aplastic anemia. jills with a pcv of - % may require blood transfusions and have a guarded prognosis. ferrets with a pcv of less than % have a poor prognosis and require aggressive therapy with multiple transfusions. the lack of identifiable blood groups in ferrets makes multiple transfusions uncomplicated by potential transfusion reactions . estrogen-induced anemia may be avoided by ovariohysterectomy. of nonbreeding females, use of vasectomized hobs, or pharmacologic termination of estrus initiated days after estrus onset. a -to -day pseudopregnancy then follows, except in the case of ovariohysterectomy. repeated administration of hcg may result in sensitization and anaphylaxis. after several administrations, hcg is unlikely to be effective in termination of estrus. anaphylaxis is manifest as incoordination, tremor, vomiting, and diarrhea and may be reversed by prompt administration of diphenhydramine. arginine-free diets are unlikely to be fed in the laboratory setting, but administration of such a diet to young ferrets fasted for hr leads to hyperammonemia and encephalopathy within - hr (thomas and desmukh, ) . exacerbation of signs may be achieved by challenging young ferrets with influenza virus and aspirin (desmukh et al., ) and constitutes a model of reye's syndrome in children. lethargy and aggressiveness yield to prostration, coma, and death in affected ferrets. hyperammonemia presumably occurs because of the inability of ferrets to produce adequate amounts of ornithine from non-arginine precursors. detoxification of ammonia is thereby compromised. ferrets more than months old are unaffected by arginine-free diets. ferrets of all ages are susceptible to zinc toxicosis, and the condition has been documented in two ferret farms in new zealand (straube and walden, ) . leaching of zinc from steam-sterilized galvanized food and water bowls was implicated. clinical signs included pallor, posterior weakness, and lethargy. definitive diagnosis requires demonstration of elevated concentrations of zinc in kidney and liver. at necropsy, kidneys are enlarged, pale, and soft; livers are orange, and gastric hemorrhage may be seen. histopathology reveals glomerular collapse, tubular dilation, tubular proteinaceous debris, focal cortical fibrosis, hepatic periacinar infiltration, and depression of the erythroid series. avoidance of galvanized materials precludes the development of zinc toxicosis. umbilical entanglement may occur in ferrets on the day of parturition and has been associated with fine-particle bedding, large litters, and short kit-birth intervals (bell, a; fox et al., a) . jills may neglect to clean placentas from their kits, or kits may be born so rapidly that there is not adequate time for the jill to clean the kits of placental membranes, thereby predisposing to entanglement. entangled kits may succumb to dehydration, hypothermia, and hypoglycemia because they are unable to nurse and the jill cannot curl around them. detailed dissection with fine scissors and forceps under a heat lamp or on a heated surface can free the kits. occasionally, kits may need to be rotated on their umbilical pedicle to achieve adequate clearance to cut the cord; cords should be cut as far from the umbilicus as possible. the use of warm saline or water may help soften the mass. some kits in the tangle may present with dark, swollen extremities or prolapsed umbilical cords and may require euthanasia. parturition should be supervised, if possible, to avoid umbilical entanglement. hydronephrosis may occasionally occur in the ferret and is most commonly associated with inadvertent ligation of the ureter during ovariohysterectomy. ovarian remnants are another potential sequela to ovariohysterectomy. ovarian remnants in ferrets may be associated with estrus, vulvar enlargement, and alopecia. appropriate diagnostic procedures include ultrasonography and plain and contrast radiography for hydronephrosis and ultrasonography and serum hormone concentrations for ovarian remnants. exploratory celiotomy confirms the diagnosis, and unilateral nephrectomy or ovariectomy is indicated if the remaining kidney is normal and the ferret is otherwise healthy. over the last few decades, increasing numbers of ferrets have been used in research or kept as pets, and as these animals have received veterinary care, it has become evident that ferrets are subject to a wide variety of neoplastic conditions . however, four categories of cancer account for the majority of ferret neoplasms: pancreatic islet cell tumors, adrenocortical cell tumors, lymphoma, and skin cancers. functional pancreatic islet cell tumors (insulinomas) are the most common neoplasm diagnosed in ferrets . disease may be evident in ferrets as young as years old, but later onset (at - years of age) is typical (caplan et al., ; ehrhart et al., ) . nonspecific presenting signs include weight loss, vomiting, and ataxia. weakness is often evident, ranging from lethargy to posterior paresis or outright collapse (caplan et al., ) . hypoglycemia caused by excess production of insulin by neoplastic cells may cause tremors, disorientation, or seizures (fox and marini, ) . excessive salivation (ptyalism) or pawing at the mouth is a frequent finding. clinical signs are often intermittent or episodic. other common findings include splenomegaly and lymphocytosis. presumptive diagnosis is made based on clinical signs in conjunction with the demonstration of hypoglycemia. blood glucose determinations for the diagnosis of insulinoma are most useful when taken after a hr fasting period. fasting glucose concentrations below may be diagnostic for the condition (quesenberry and rosenthal, ) , whereas values between and are suspect and the test should be repeated (fox and marini, ) . other potential causes for hypoglycemia should be ruled out, including anorexia, starvation, hepatic disease, sepsis, and nonpancreatic neoplasia (antinoff, ) . demonstration of concurrent hyperinsulinemia aids the diagnosis (caplan et al., ) . medical management using prednisone and/or diazoxide along with dietary modification such as frequent feeding of high-protein meals can minimize or control clinical signs but will not affect the underlying tumor (quesenberry and rosenthai, ) . surgical exploration of the pancreas and tumor excision are recommended for animals that are healthy enough to be subjected to anesthesia and surgery. histological examination of the tissue removed can provide a definitive diagnosis, and although the effect may be transient, clinical signs are often reduced or eliminated after surgical debulking (figs. and ) (ehrhart et al., ) . histologically, these tumors reveal ma-lignant proliferation of pancreatic cells, and local recurrence or metastasis to lymph nodes, mesentery, spleen, or liver may occur (caplan et al., ) . adrenocortical cell tumor is the second most common type of neoplasia in ferrets and is generally diagnosed between and years of age. if clinical signs are present, they often include weight loss and a bilateral, symmetric alopecia. pruritus is a variable finding (quesenberry and rosenthal, ) . although ferrets with this syndrome have been called "cushingoid," it is rare to diagnose elevated resting levels of glucocorticoids or an abnormal response to adrenocorticotropic hormone (acth) stimulation or dexamethasone suppression testing. elevation of adrenal sex hormones (e.g., androstenedione, -hydroxyprogesterone, and/or estradiol) is more likely, and these may lead to characteristic changes such as estruslike vulvar swelling in spayed females and prostatic changes in males coleman et al., ) . rule-outs for enlarged vulva include estrus in an intact female or functional ovarian remnants in a spayed female. abdominal palpation may reveal cranial abdominal masses, and ultrasound may be useful (barthez et al., ) . serum assay for abnormal levels of the sex hormones listed above should be considered (lipman et al., ; wagner and dorn, ; rosenthal and peterson, ) . in many cases the alopecia begins as a seasonally intermittent partial hair loss that becomes more severe as time goes on (fig. ) . even severe manifestations of this endocrine alopecia can spontaneously reverse in the absence of specific therapy, as demonstrated in a group of ferrets referred to our facility for diagnostic workup. in each of these ferrets, near total alopecia resolved within a few months of being housed in a research environment. despite being asymptomatic at the end of the study, all were shown to have histologic evidence of adrenocortical neoplasia. although this phenomenon is mediated by hormonal effects, anecdotal reports such as this suggest that the alopecia may be significantly modulated by environmental factors (e.g., photoperiod or diet). surgical exploration and removal of enlarged adrenals are commonly performed to establish the diagnosis and to remove hyperfunctional tissue. unilateral adrenalectomy early in the disease may be curative, but because bilateral neoplastic involvement is not uncommon, full or partial removal of both glands may be required. adrenolytic agents such as mitotane have been used with limited success (quesenberry and rosenthai, ) . histologically, adrenocortical adenomas are generally cm or less in diameter and are composed of well-differentiated cells with a granular or vacuolated cytoplasm. adrenal cell carcinomas are less commonly found and are larger, with a more pleomorphic and invasive character . metastasis to nearby tissues can occur. in our experience, adrenal cortical hyperplasia with or without neoplasia is an extremely common finding in aging ferrets, even in those not showing clinical signs. in one retrospective survey of our necropsy records it was found that more than % of ferrets greater than years of age had hyperplastic or neoplastic adrenal changes when examined (data not shown). for this reason, careful considerations of other possible disease processes should be made before attributing clinical signs solely to adrenal enlargement. lymphoma can affect ferrets of almost any age. ferrets younger than years of age often present with mediastinal lymphoma and/or leukemia, whereas those older than years of age often develop multicentric solid tumors . the early age of onset in some ferrets and reports of case clustering have led to investigation into potential infectious etiologies for lymphoma in the ferret (erdman et al., b) . earlier reports of feline leukemia virus (felv) seroconversion in affected animals have not been substantiated. however, experimental and epidemiological evidence suggests that a retrovirus that is distinct from felv may be involved . in one study, whole or filtered lymphoma cells from a -year-old ferret with spontaneous lymphoma were injected ip into recipient ferrets . two of the ferrets were euthanized after months, but the remaining developed splenomegaly, lymphocytosis, and lymphoma. one ferret that received cell-free materials developed multicentric lymphoma with prominent cutaneous lymphoma nodules. elevated reverse transcriptase activity and retrovirus-like particles evident by electron microscopy were seen in the donor and all of the affected recipient ferrets. other potential etiologies that have been considered include two infectious agents that are known to cause chronic immune stimulation in affected ferrets, the aleutian disease virus (adv) and helicobacter mustelae. a link with adv has not been proven, but h. mustelae seems to be responsible for the development of a very specific type of gastric b-cell lymphoma (erdman et al., ) . affected ferrets may exhibit localizing signs (e.g., dyspnea in a ferret with mediastinal involvement or peripheral lymphadenopathy in an animal with a multicentric distribution) but as is the case in many species, lymphoma is a "masquerader," and affected ferrets often present with chronic, nonspecific signs. weight loss, anorexia, and lethargy are often reported. splenic and/or hepatic enlargement may be evident. cutaneous involvement has been documented (li et al., ; rosenbaum et al., ) . although hematological examination typically reveals anemia and lymphopenia, lymphocytosis may be found, especially in younger ferrets. atypical lymphocytes are identified in the circulation in some cases. antemortem definitive diagnosis of lymphoma can be made by cytological examination of specimens obtained via fine-needle aspiration or excisional biopsy. tan-colored masses involving lymph nodes, spleen, liver, or other organs are commonly found at necropsy (fig. ) . diffuse involvement may lead to uniform enlargement of these organs or to a thickening of the wall of the stomach or intestines. as in other species, histological evaluation reveals neoplastic lymphocytes in affected tissues, generally evident as a monomorphic population (fig. ) . although surgery and radiation therapy may be useful in certain cases, most attempts to treat ferret lymphoma have utilized chemotherapeutic regimens with dosages extrapolated from other domestic animals or humans. treatment generally results in a remission that may last from months to years (brown, b; erdman et al., ) . mast cell tumors are among the most commonly reported integumentary tumors in ferrets (parker and picut, ; . cutaneous mastocytomas may occur anywhere on the body and present as firm, nodular skin lesions - mm in size that are often associated with alopecia or crusty ulceration of the overlying skin. pruritis is common (stauber et al., ) . histologically, they are composed of well-differentiated mast cells with metachromatic cytoplasmic granules that may be difficult to detect in sections stained with hematoxylin-eosin, but are more evident in toluidine bluestained sections. a variety of tumors of epithelial origin occur in ferrets, and they can appear at any site on the body. the most common are the basal cell tumors, which present as firm plaques or pedunculated nodules that are white or pink (parker and picut, ) . they may grow rapidly and become ulcerated. the percentage of basiloid cells present in these tumors, and the degree of associated squamous or sebaceous differentiation can vary, resulting in a spectrum of tumor subtypes and associated histological diagnoses (orcutt, ) . however, as is the case with mastocytomas, most are benign and will not recur after excision. resected tumors should be examined histologically to rule out less common tumors that might have a more guarded prognosis, such as squamous cell carcinoma or apocrine gland adenocarcinoma. chordomas are not epithelial tumors, but they often present as readily evident firm masses on the tail that may cause ulceration of the overlying skin. these neoplasms arise along the axial skeleton from notochord remnants and are typically slow-growing (dunn et al., ) . tumors involving the tail generally do not recur after amputation of the affected region, but a wide surgical margin should be maintained by removing several vertebrae proximal to the tumor. the prognosis is guarded for those rare chordomas that arise in the cervical region, and metastasis has been documented (williams et al., ) . congenital defects identified in ferrets include a variety of neural tube defects, gastroschisis, cleft palate, amelia, corneal dermoids, cataracts, and supernumerary incisors (willis and barrow, ; ryland and gorham, ; mclain et al., ; besch-williford, ) . cystic or polycystic kidneys have been observed (andrews et al., a; dillberger, ) . cystic genitourinary anomalies associated with the prostate, bladder, and/or proximal urethra most likely develop secondary to aberrant hormone secretion by adrenocortical tumors coleman et al., ) . newborn ferrets are normally born with a closed orbital fissure and are prone to developing subpalpebral conjunctival abscesses. treatment involves surgically opening the lids (a minor procedure) to establish drainage and to allow topical antibiotics to be administered (bell, a) . cardiomyopathy is a common cause of disease in aging ferrets. the dilatative form of disease is most commonly diagnosed. affected animals commonly present with lethargy, weight loss, and anorexia. physical examination may reveal signs of congestive heart failure such as hypothermia, tachycardia, cyanosis, jugular distension, and respiratory distress (lipman et al., ) . auscultation may reveal a heart murmur and/or muffled cardiac sounds. hepatomegaly and splenomegaly are often identified. radiographs may reveal an enlarged cardiac silhouette and evidence of pulmonary edema or pleural effusion (greenlee and stephens, ) . electrocardiography and echocardiography can help make the definitive diagnosis. medical therapy (supportive care, diuretics, and inotropic drugs) may relieve clinical signs and improve the qual-ity of life for a period of months (stamoulis et al., ) . the long-term prognosis for survival is guarded to poor. splenomegaly is a common finding in ferrets. in many cases the enlarged spleen appears to be a secondary manifestation of another disease (e.g., insulinoma, cardiomyopathy, or adrenal tumor) and is of unknown significance (stamoulis et al., ) . histologic examination of affected organs has revealed that the most common cause for splenic enlargement (in the absence of a neoplastic infiltrate) is extramedullary hematopoiesis (emh) (erdman et al., ) . this may be an incidental finding, but it has been suggested that in some cases a pathologically enlarged spleen may play a role in chronic anemia that may respond to splenectomy, a syndrome known as hypersplenism (ferguson, ) . splenomegaly can also be commonly found in conjunction with lymphoma, with or without intrasplenic neoplastic lymphoid accumulations. in anesthetized ferrets, splenomegaly may be caused by splenic sequestration of erythrocytes (marini et al., (marini et al., , . because this is a transient effect, the normalization of splenic size upon recovery from anesthesia can help in the differentiation of anesthetic-induced splenomegaly from that due to other causes. eosinophilic gastroenteritis is an idiopathic disorder characterized by peripheral eosinophilia ( - % of circulating leukocytes), hypoalbuminemia, and diffuse infiltration of the gastrointestinal tract with eosinophils (fox et al., a) . presenting signs for this syndrome generally include chronic weight loss, anorexia, diarrhea, and occasionally vomiting. eosinophilic granulomas have been found in the mesenteric lymph nodes of most affected ferrets, and in some cases other organs (e.g., lung or liver) may be involved. an interesting finding in many ferrets is the presence of splendore-hoeppli material in the inflamed lymph nodes, a histological phenomenon that has been associated in other species with helminths, bacteria, fungi, and foreign bodies (fig. ). an etiological agent has not been identified; consequently, therapy consists largely of supportive care to treat the chronic enteritis (fox, b) . based on the biology of eosinophils, however, the use of corticosteroids or ivermectin has been attempted and may be beneficial (bell, b) . megaesophagus has been diagnosed in ferrets presenting with a variety of signs, including weight loss, anorexia, difficulty in eating, or repeated regurgitation. the cause is generally unknown, and the prognosis is poor, despite efforts at supportive care (blanco et al., ) . gray, yellow, or white small raised lesions may be found on the surface of ferret lungs at gross examination. histologically, these lesions are composed of a superficial thickening of the lung tissue with mononuclear cell infiltration and varying degrees of fibrosis, with or without cholesterol-like clefts. the etiology of this condition (known as subpleural histiocytosis, pleural lipidosis, or lipid pneumonia) is unknown, and it appears to be an incidental lesion (fox, f) . energy: protein relationships in the diets of growing mink. can the phylogeny of mustelids and the systematics of ferrets some observations of anatomical abnormalities and disease states in a population of ferrets (mustela furo) some aspects of the physiology and anatomy of the cardiovascular system of the ferret, mustela putorius furo ufaw handbook on the care and management of laboratory animals musculoskeletal and neurological diseases ultrasonography of the adrenal glands in the dog, cat, 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alopecic ferrets with adrenal gland tumors the ferret intestinal uptake and lymphatic absorption of [ -carotene in ferrets: a model for human [ -carotene metabolism intestinal perfusion of [ -carotene in the ferret raised retinoic acid level in portal blood vitamin e enhances the lymphatic transport of [ -carotene and its conversion to vitamin a in the ferret aleutian disease in domestic ferrets: diagnostic findings and survey results semen characteristics and testosterone profiles in ferrets kept in a long-day photoperiod, and the influence of hcg timing and sperm dilution medium on pregnancy rate after laporoscopic insemination biliary coccidiosis in a ferret (mustela putoriusfuro) cervical chordoma in two ferrets (mustela putorius furo) coronavirus-associated epizootic catarrhal enteritis in ferrets comparative vaginal cytology of the estrous cycle of black-footed ferrets (mustela nigripes) the ferret (mustela putorius furo) as a laboratory animal effect of helicobacter mustelae infection on epithelial cell proliferation in ferret gastric tissues key: cord- -d e art authors: friedberg, joseph s.; kucharczuk, john c. title: pleura: anatomy, physiology, and disorders date: journal: surgery doi: . / - - - - _ sha: doc_id: cord_uid: d e art disorders of the pleura and pleural space reflect some of the oldest diseases encountered in surgical history. hippocrates described the symptoms of empyema years ago: “empyema may be recognized by the following symptoms: in the first place the fever is constant, less during the day and greater at night, and copious sweats supervene. there is a desire to cough and the patient expectorates nothing worth mentioning.” he also described an open drainage procedure: “when the fifteenth day after rupture has appeared, prepare a warm bath, set him upon a stool, which is not wobbly, someone should hold his hands, then shake him by the shoulders and listen to see on which side a noise is heard. and right at this place, preferably on the left, make an incision, then it produces death more rarely.” , beyond providing less-wobbly stools, few advances were made for more than years that allowed surgeons to routinely enter the pleural cavity, the fear being a potentially fatal pneumothorax. with the advent of positive pressure ventilation in the early s, pneumothorax was no longer a prohibitive risk, and the era of surgical intervention in the pleural cavity had begun. embryologically, the pleural cavity is created during a month, starting in the third week of gestation. initially, the lateral plate forms two layers, the splanchnopleura and the soma topleura, which subsequently develop into the visceral and parietal pleura, respectively. eventually, it is the visceral pleura that surrounds the lung and the parietal pleura that lines the remainder of the chest cavity. the different embryological origins of the visceral and parietal pleura are responsible for the separate vascular, lymphatic, and neural supplies of these two structures as seen in the adult. by the end of the seventh week of gestation, the diaphragm has separated the thoracic cavity from the peritoneal cavity, and by the third month of gestation the two pleural cavities have expanded sufficiently to encase the pericardium. in the adult, both pleural surfaces are approximately to l m thick and are composed of a single layer of mesothelial cells with an underlying layer of connective tissue. depending on their location, the mesothelial cells may be flat, cuboidal, or columnar. mesothelial cells characteristically have numerous microvilli that playa role in phagocytosis as well as contributing to the lubricious nature of the pleural surfaces. surfactant molecules, produced by the mesothelium, line the pleural surfaces and, secondary to similar electrical charge, repulse each other and facilitate sliding, analogous to the lubrication achieved with graphite. it is these apposing layers of mesothelial cells that form the potential space of the pleural cavity and that glide over each other during respiration. the connective tissue layer contains the neurovascular and lymphatic supply of the pleura. there are certain important differences in this layer between the visceral and parietal pleura. for the visceral pleura, the connective tissue layer is functionally continuous with the fibroelastic network of the lung itself. functionally, it is this relationship that prevents the visceral pleura from being surgically separated from the surface of a normal lung. pathological disruption of this connection, however, may result in subpleural air collections known as blebs. s the connective tissue layer for the parietal pleura may also be tightly adherent to the underlying structures, as is characteristic of the diaphragmatic pleura. around the skeletal portion of the thorax, however, the pleura is bound to the underlying tissue by another connective tissue layer called the endothoracic fascia, which forms a natural cleavage plane. it is this plane that the surgeon develops when performing an "extrapleural" dissection. the blood supply to the visceral pleura in humans is thought to reflect that of the lung itself, with a dual arterial supply from both the pulmonary and bronchial arteries and singular venous drainage into the pulmonary veins. the blood supply to the parietal pleura is from systemic arteries only and drains, predominantly, into peribronchial and intercostal veins, but it may also drain directly into the azygous vein and vena cava. the visceral pleura is innervated by vagal and sympathetic fibers but has no somatic innervation and is therefore insensate. the parietal pleura is also innervated with sympathetic and parasympathetic fibers, but it is also somatically innervated. thus, the parietal pleura is capable of sensing and transmitting the sensation of pain. "pleurisy" from inflammation and pain from chest tubes, during insertion and subsequently as well, are attributable to the somatic intervention of the parietal pleura. there are also differences in the lymphatic drainage between the two pleural layers. the visceral pleura drains through a lymphatic network into the pulmonary lymphatics, which eventually flow toward the pulmonary hilum. this lymphatic system is richer in the lower lobes than the upper lobes. the parietal pleural lymphatics drain to different locations. the mediastinal pleura drains to the mediastinal and tracheobronchial nodes. the chest wall drains anteriorly to the internal thoracic chain and posteriorly toward the intercostal nodes near the heads of the ribs. the diaphragmatic pleura drains to the parasternal, middle phrenic, and posterior mediastinal lymph nodes. there are also transdiaphragmatic lymphatic communications that allow some degree of lymphatic flow from the peritoneum to the pleural space. the parietal pleura also differs from the visceral pleura by virtue of the presence of kampmeier foci and stomata. kampmeier foci are collections of activated mesothelial and lymphoreticular cells, centered about a lymphatic core, that augment the pleura defensive capabilities. they are concentrated in the lower mediastinal region of the parietal pleura. , stomata are -to -~m pores that communicate directly with the parietal pleural lymphatics. during inspiration, these pores have the capacity to stretch, and their architecture is such that they form functional one-way valves. thus, they provide for a very effective system for draining both fluid and particles, including both red blood cells and macrophages. it is the presence of these pores on the parietal pleural surface that makes it predominantly, if not exclusively, responsible for clearance of cells and particulate matter from the pleural space. it should be noted that although stomata are well studied and characterized in sheep and other mammals, the definitive presence of stomata in humans is less well established. in each hemithorax, the visceral pleura is a continuous surface that completely envelops the entire lung, including the fissures. at the pulmonary hilum, it continues on as the parietal pleura to line the mediastinum, chest wall, diaphragm, and cupola of the chest cavity. in humans, the pleural cavities are completely separate, coming into contact with each other for a short distance behind the upper half of the body of the sternum (fig. . ). it is this pleural separation of the right and left chest cavities that prevents bilateral pneumothoraces from occurring as the result of a unilateral chest injury. at the costophrenic and costomediastinal sinuses, the parietal pleural folds back on itself, providing a potential space into which the lungs can expand during inspiration. superiorly, the pleura extends above the bony thorax into the base of the neck (fig. . ). this fact explains why pneumothorax may complicate internal jugular central line placement as well as subclavian central line placement. anteriorly, the pleura extends to the sixth rib, to the ninth rib laterally, and to the twelfth rib posteriorly ( fig. . ). in the living patient, the lung can fill the entire posterior recess. in a review of chest radiographs, % of patients were found to have lung present at or below the level of the th rib, and in % it was seen at the level of the first lumbar vertebra. these external landmarks of the pleural space are of practical clinical significance, particularly when evaluating a patient with penetrating trauma. the pulmonary ligament is a double fold of the mediastinal pleura that tapers down from the root of the lung, where it is in continuity with the visceral pleura, to the caudal mediastinum. this ligament is one of the structures that must be divided to perform a pneumonectomy or lower lobectomy. it is also routinely divided to its superior border, the inferior pulmonary vein, when attempting to provide mobility to the lower lobe after resecting the upper or middle lobes. the lymph nodes within the pulmonary ligament are the level nodes, which are n lymph nodes, and should be routinely harvested when performing a resection for lung cancer. the pleura has both mechanical and physiological functions. it transmits negative pressure from the thorax to the lung, thereby opposing the lung's natural elastic recoil and maintaining pulmonary expansion. during respiration, this function is performed in an environment of very low friction, thereby allowing the lungs to glide smoothly over the internal thoracic surfaces as they expand and contract. the pleura also controls the environment of the chest cavity by maintaining fluid homeostasis, preventing or removing air collections and keeping the space sterile. under normal conditions, the pleural cavity is a potential space with a thickness ranging from to f..lm. the lung is maintained in an expanded state by the maintenance of negative pressure in the pleural space; this allows the expandable chest cavity to overcome the opposing forces exerted by the natural elastic recoil of the lung. the resting pressure in the pleural space, when the lung is at its functional residual capacity, is slightly negative at - to - cm h . when measured in an upright posture, there is more negative pressure in the apex of the chest than at the diaphragm, likely a gravitational effect. the negative pressure continues to increase through inspiration, with the pressure ranging from - to - cm h at the vital capacity. disorders that decrease the compliance of the lung or increase airway resistance further increase the negative pressure in the pleural space with inspiration. , initially, it would seem curious that gas is not drawn out of solution into the pleural space by the negative pressure in the space. it is the lower partial pressure of gases on the venous side of the pleural circulation, as opposed to the arterial side, that prevents spontaneous pneumothorax from occurring under normal conditions. this difference in partial pressures between the two sides of the circulation is mainly a result of oxygen absorption. unless the pressure in the pleural space decreases to significantly less than -socm h , the sum total of the forces under normal conditions favors absorption of gas out of the pleural space. this diffusion gradient also accounts for reabsorption of gas that is introduced into the pleural space. the clearance rate of gases introduced into the pleural space is dependent on the concentrations of those gases with respect to their partial pressures in the pleural circulation. as the partial pressure of nitrogen is the greatest in the air we breathe, it therefore constitutes the highest partial pressure of the gases that form a pneumothorax. nitrogen also has the highest partial pressure of the gases in our circulation; this can be decreased by altering the composition of inspired gases. thus, administration of supplemental oxygen decreases the partial pressure of nitrogen in the bloodstream and thereby increases the nitrogen pressure gradient between the circulation and the pneumothorax, favoring more rapid reabsorption of the trapped gas. this relationship serves as the rationale for placing a patient on supplemental oxygen to facilitate reabsorption of a pneumothorax that is not being externally evacuated. under normal conditions, the pleural space contains very little fluid, estimated at approximately . ml/kg. the fluid is generally hypooncotic, with a protein content of approximately g/dl. the mechanisms of fluid production and reabsorption are complicated and not completely understood. numerous forces interact from both the parietal and visceral pleura, including their respective hydrostatic and on co tic pressures. respiratory movement and gravity are both thought to have roles in maintaining the fluid dynamics of the pleural cavity. the predominant factor, however, is thought to be the uptake of fluid into the parietal pleural lymphatics. these lymphatics tend to be concentrated in the dependent portions of the chest cavity. under normal conditions, this flow rate has been estimated at . to o.lsml/kg/ h. the lymphatic flow rate has the capacity to increase and has been estimated to reach as high as ml/h, approximately ml/day in an average-size individual. when the dynamics of this equilibrium are unbalanced beyond the rate at which the lymphatics are able to compensate, pleural effusion accumulates. , , it is interesting to note that the exact purpose of the pleura is still not fully understood. empirically, it is clear that the pleura maintains fluid and gas homeostasis, mechanically couples the lungs to the bellows mechanism for respiration, and maintains sterility in its described space. to accomplish this, however, it is not clear how important it is to have the configuration of two opposing layers with a small amount of intervening fluid. it has been observed, for instance, that there is little change in pulmonary function tests in patients before and after fusion of the pleural space. it is interesting to note that some mammals do not have a pleural space, similar to patients who have undergone pleurodesis, but that these animals clearly function normally. thus, the exact necessity for having two pleural membranes defining a potential space remains somewhat of a mystery. there are a large number of pleural disorders. the majority lead to symptoms as a result of mechanical compression of the lung, although many may be asymptomatic or may present with constitutional symptoms or pain. in most cases, the pathology results from the presence of something in the pleural space, which as previously described, is normally a potential space. therefore, in an effort to organize this large number of disorders, they are grouped according to what abnormal phase of material is occupying the pleural space, that is, gas, liquid, or solid. when gas enters the pleural space, it is referred to as a pneumothorax. when liquid enters the pleural space, it may sometimes be broadly referred to as an exudative or transudative effusion but is frequently classified according to the type of liquid, such as hemothorax, chylothorax, or empyema. last, solid masses may occupy the pleural space. most benign masses are pleural plaques, but there are also rare benign tumors of the pleura, some of which may reach enormous size. malignant masses of the pleura are usually cancers that have metastasized to the pleura, but there are also some rare primary tumors, most commonly mesothelioma. sometimes, the groups may overlap, with more than one abnormal phase of material filling the pleural space. such examples include air and blood, a hemopneumothorax, after trauma or air and pus, a hydropneumothorax, which may be seen with empyemas resulting from a bronchopleural fistula. frequently, however, there is a predominant, if not sole, etiology for the abnormal accumulation; thus, the following sections review disorders of the pleura according to the state of matter that is abnormally occupying the spacegas, liquid, or solid. pneumothorax is defined as air in the pleural space. it may occur traumatically, iatrogenically, or spontaneously. spontaneous pneumothorax may be subclassified as primary or secondary, with primary spontaneous pneumothorax arising in an otherwise healthy patient and secondary spontaneous pneumothorax arising as a complication in a patient with known underlying pulmonary disease. essentially any pneumothorax resulting from pleural disruption can present as a tension pneumothorax. this condition represents a true emergency and is discussed separately. pneumothorax presentation and diagnosis pneumothorax may cause pain or dyspnea, or it may be asymptomatic, depending on its size and the underlying pulmonary function of the patient. physical findings may range from none to the classic findings seen with a tension pneumothorax: contralateral tracheal deviation, ipsilateral absent breath sounds, and percussive hyperresonance. electrocardiographic changes may be present, including diminished voltage, right-axis deviation, or t-wave changes that may mimic a subendocardial myocardial infarction. ' except for tension pneumothorax, most cases require an upright chest radiograph to establish the diagnosis. as the pneumothorax occupies a greater proportion of the chest cavity at expiration than inspiration, the former is more sensitive for detecting the diagnostic pleural line. a computed tomographic (ct) scan of the chest is the most sensitive test and may demonstrate a small amount of air in the pleural space that is not visible on the plain radiograph. for all pneumothoraces, the common goal is removal of air from the pleural space. depending on the etiology, however, prevention of recurrence may also be an objective of the treatment. options for treatment range from observation to thoracotomy. selection of the appropriate modality depends on a number of factors, including, but not limited to, presentation, previous history, comorbidities, need for positive pressure ventilation, associated effusion, and even the patient's lifestyle. in addition, the size of the pneumothorax can also play a significant role in determining the appropriate treatment. the following sections review the basic technique and indications for the different treatment options that are available and give specific recommendations for different pneumothoraces to be described in the following section. observation is generally reserved for patients who are asymptomatic and are diagnosed with a small primary spontaneous pneumothorax or a simple iatrogenic pneumothorax. in such situations, the patient is followed with serial radiographs to ensure that the pneumothorax is decreasing in size. when a patient is breathing room air, gas is absorbed from the pleural cavity at approximately . % of the pleural volume/day, approximately to ml/day.' supplemental oxygen, by mechanisms reviewed in the physiology section, can increase this rate up to . %/day.is as it is a minimal intervention, it is reasonable to place all hospitalized patients on supplemental oxygen if they are being observed for a pneumothorax. there are several factors to weigh when considering observation alone for a patient with a pneumothorax. the first is that deaths have been reported in patients with pneumothorax who were being observed. development of umecognized tension pneumothorax was believed to have played a role in these cases. this fact highlights the selectivity and judgment required to simply follow these patients, particularly on an outpatient basis. another consideration is that a lung that has not fully expanded by weeks is at risk for fibrous peel deposition and subsequent entrapment. correction of this situation commits the patient to a surgical procedure that might have been avoided by initial evacuation of the pneumothorax. it is recommended that observation be considered only for patients with a simple pneumothorax whose size involves % or less of the volume of the chesty if the pneumothorax has not resolved within to weeks, intervention to achieve full expansion should be instituted. another factor to consider, particularly with primary spontaneous pneumothorax, is that observation alone does nothing to decrease the chance of recurrence. last, in this age of economic constraints, it may be more cost-effective to definitively treat a pneumothorax on presentation. simple aspiration can be considered in the case of a simple pneumothorax in which there is no suspicion of an ongoing air leak and the patient is not on positive pressure ventilation. some authors believe that in select situations aspiration is the treatment of choice." the goal of aspiration is to remove air from the pleural space. it conveys no protection from an ongoing leak or recurrence in the future . the procedure is performed in a manner similar to that used for decompressing a tension pneumothorax. after sterilely preparing the skin and infiltrating with a local anesthetic, a -or l -gauge intravenous catheter is placed into the pleural space in the midclavicular line over the superior surface of the second rib. the needle is then withdrawn, and the catheter is connected to a short length of intravenous tubing capped with a threeway stopcock. a -ml syringe is then used to aspirate air from the chest cavity . when air can no longer be aspirated, the catheter is withdrawn, and the first chest x-ray is obtained. if l of air are aspirated and no resistance is met, there is an ongoing air leak, and a chest tube should be placed . percutaneous tube thoracostomy is a good option for a simple pneumothorax. many consider this the procedure of choice for simple pneumothoraces. cited advantages are therapeutic and cost-effectiveness as well as less trauma compared to standard tube thoracostomy. depending on the size and etiology of the pneumothorax, success rates for these catheters are reported in the % to % range ." the catheters range in size from to french and are placed using a catheter-overneedle or seldinger technique. the kits (e.g., arrow pneumothorax kit, arrow international, reading, pa) are usually equipped with all the necessary supplies to insert the catheters and an adapter such that the catheter can be connected to a heimlich valve or a standard suction device such as pleur-evac (dsp worldwide, fall river, mal. thes e tubes are limited by their size and would be a poor choice for a patient with a large air leak . the principal factor in determining the flow rate through a tube is the diameter of the tube . thus, a patient with a massive air leak, especially on positive pressure ventilation, should have a standard chest tube placed . as a general guide, it takes at least a -french tube to accom-modate approximately l l/min of flow at -locm h suction." a standard chest tube should be placed for failure of a percutaneous tube, a pneumothorax associated with significant fluid collection, or a pneumothorax for which the leak is expected to overwhelm a small-caliber tube, more likely in the setting of positive pressure ventilation. such tubes are generally placed under local anesthesia and sedation, employing sterile technique. apical tubes, as employed for drainage of air, are best placed in the mid-or anterior axillary line in the third or fourth intercostal space. it is generally recommended to tunnel the tube subcutaneous up one interspace before entering the pleural cavity. the tunnel serves two purposes. first, it forms a flap valve that helps prevent entrance of air into the chest after the tube is removed. second, the tunnel allows the surgeon to control the direction of the tube, anteriorly when placed for air or posteriorly when placed to drain fluid . the tube can then be placed for passive or active drainage. passive drainage may be achieved by connecting the tube to a heimlich flutter valve or waterseal on a pleur-evac. for active drainage, most surgeons use a threebottle system ( fig. . , generally unified as a commercially available unit such as pleur-evac. active drainage expedites and facilitates full expansion of the lung . although also reported with passive drainage, the rare complication of reexpans ion pulmonary edema appears to be more common with active suction. , generally viewed as a "floor procedure," chest tube placement should be given all the consideration of a major operation. although it can be performed with minimal discomfort, utilizing intravenous sedation and strategic local anesthesia, a chest tube placed by an inexperienced operator without expert supervision can be a horrific experience for a patient. in addition to the discomfort, chest tube placement may be accompanied by a number of complications including empyema, lung injury and bleeding, and death." therefore, coagulation profiles and immunocompetency should be taken into consideration for all patients considered for this procedure . intravenous analgesia, a short-acting benzodiazepine, or both should be used for an elective chest tube placement. proper use of local anesthesia is critical for patient comfort during the procedure. the amount of local anesthetic that can be administered is limited by toxicity. a small amount of anesthetic is injected for the skin incision, and the remainder is accurately injected along the course of the tunnel that will be created to place the tube. this step allows the surgeon both to locate the superior surface of the rib and, by aspirating, to identify the parietal pleura. a small bolus of anesthesia can be injected at the level of the parietal pleura, and if adequate time is allowed after injection of the pleura, the discomfort of the tube placement can be limited to "pressure" and not sharp pain. as with all procedures under local anesthesia, it is also important to prepare the patient for any anticipated sensations, particularly the entrance into the pleural space as well as the possibility for triggering severe coughing if a collapsed lung is rapidly reexpanded. with the exception of those patients with a large open pneumothorax, essentially all patients considered for surgical treatment for a pneumothorax already have a chest tube in place. with a progressive air leak, tension physiology is imminent once positive pressure ventilation is instituted unless there is a pathway for egress of air from the pleural space or intubation is performed directly with a double-lumen endotracheal tube such that the leaking lung can be immediately isolated. specific surgical procedures are discussed under the appropriate sections, but it is worth noting that there are two surgical approaches available, video-assisted thoracoscopic surgery (vats) or standard thoracotomy. general indications for surgical intervention for a pneumothorax are failure of less-invasive therapy or occurrence of the pneumothorax in the context of additional indications for chest exploration. a vats approach can be employed, at least initially, for most pneumothoraces. examples of contraindications to a vats approach are a pneumothorax secondary to an esophageal perforation, major airway disruption, or a pneumothorax accompanied by significant ongoing bleeding or concomitant trauma to other thoracic organs. pneumothoraces can be broadly grouped as spontaneous or traumatic. spontaneous pneumothoraces can be further subclassified as primary or secondary, with primary arising in patients with no known underlying pulmonary disease and secondary spontaneous pneumothoraces arising as a complication of known underlying pulmonary disease. traumatic pneumothoraces can be subclassified as those that are the result of blunt or penetrating trauma to the chest or those that are iatrogenically induced secondary to an invasive procedure or barotrauma from positive pressure ventilation. in this chapter, the former are referred to as traumatic pneumothoraces and the latter as iatrogenic pneumothoraces. primary spontaneous pneumothorax most commonly occurs in tall young men but may occur in anyone at any age. the peak incidence has been reported to occur for both men and women to years old. it is approximately six times more common in men than women. it is thought that the final common pathway for most primary spontaneous pneumothoraces is rupture of subpleural blebs. it is also thought that inflammation of the distal airways plays a significant role in the pathogenesis of this disorder. the lack of communication between these blebs and the distal airways, and hence the inability to rapidly decompress, may explain the increased incidence of primary spontaneous pneumothorax associated with significant drops in atmospheric pressure. the role of inflammation may explain why spontaneous pneumothorax is much more common in smokers. in fact, there appears to be a dose-response relationship, with light smokers (fewer than cigarettes/day) running a risk times that of nonsmokers and those smoking more than cigarettes/day at least times more likely to have a spontaneous pneumothorax than nonsmokers." it is generally accepted that recurrent spontaneous pneumothoraces become increasingly likely with each successive occurrence. the exact statistics vary, but it is estimated that the risk of recurrence in the absence of aggressive preventive measures is in the range of % after the first recurrence and % after the second recurrence.p the chance of recurrence is very much related to the treatment undertaken for the initial spontaneous pneumothorax. cessation of smoking also decreases the risk of recurrence. selection of treatment remains an area of controversy. a consensus statement was released to provide guidance in treatment selection." observation alone should be selected for treatment on the initial presentation of a small, asymptomatic primary pneumothorax in a patient without any associated comorbidities. it should be reserved for patients who have no barotrauma risks and have ready access to medical help. this treatment may be particularly appropriate for patients who present with heavy cigarette abuse and are willing to stop smoking. aspiration is another option, but it confers no significant protection from recurrence. once the decision has been made to violate the pleura for aspiration, it is probably worthwhile leaving a catheter through which air can be continuously aspirated and subsequent pleurodesis can be performed. if a large air leak is anticipated or if there is significant effusion associated with the pneumothorax, then a standard -french chest tube should be placed. neither technique, without pleurodesis, seems to convey significant protection from recurrence. surgical treatment remains the gold standard in preventing recurrence of spontaneous pneumothorax. some of the indications for surgical treatment of a spontaneous pneumothorax include a second pneumothorax (ipsilateral recurrence or a new pneumothorax on the contralateral side); tension physiology; synchronous bilateral pneumothoraces; associated hemothorax (likely secondary to a tom adhesion and complicating approximately % of spontaneous pneumothoraces); failure of tube thoracostomy; and lifestyle factors. surgery should be considered if a leak persists for more than h. lifestyle issues that are accepted indications for surgical therapy at the initial presentation of a primary spontaneous pneumothorax include occupational exposure to barotrauma (scuba diving or flying nonpressurized high-altitude aircraft) and poor accessibility to medical care. the surgical procedure for spontaneous pneumothorax is resection of the blebs that are usually present, most commonly located in the apex of the upper lobe or the superior segment of the lower lobe. resection of the blebs is performed with a pulmonary stapling device. most surgeons also perform a mechanical pleurodesis of the pleura, utilizing an abrasive material such as an electrocautery scratch pad, or perform parietal pleurectomy. currently, vats is considered the preferred surgical approach . a standard triad of video ports can be employed in most cases ( fig. . ). use of a °thoracoscope facilitates visualization at the apex of the chest. the thoracoscope is introduced through the inferior port with a grasping device, and the thoracoscopic stapler is introduced through the two superior ports. a sponge stick or folded electrocautery scratch pad can be used for the pleurodesis, with or without a parietal pleurectomy of the bony hemithorax. at the conclusion of the operation, a single -french chest tube , with additional ports cut through the radioopaque line , can be placed posteriorly to the apex of the chest. a rongeur is useful for cutting extra holes in chest tubes. if the surgeon is more comfortable placing an anterior and posterior chest tube, two video ports can be created low in the chest at the future chest tube sites, and a single port can be placed in line with a potential thoracotomy incision for grasping and stapling. in skilled hands, the entire lung can be well visualized and mobilized for stapler application, mechanical pleurodesis, and if necessary, pleurectomy ( fig. . ). for most of these cases, thoracotomy offers little advantage with respect to visualization or performance of the bleb resections, pleurectomy, and pleurodesis. secondary spontaneous pneumothorax is a more serious condition than primary spontaneous pneumothorax because of its occurrence in patients who likely have significantly less pulmonary reserve than the typical patient presenting with a primary spontaneous pneumothorax. as opposed to primary spontaneous pneumothoraces, secondary spontaneous pneumothoraces are associated with a significant mortality." historically, the most common cause of secondary spontaneous pneumothorax has been chronic obstructive pulmonary disease (copd). there are many other causes of secondary spontaneous pneumothorax, including, but not limited to, cystic fibrosis, asthma, cancer, many types of infection, sarcoid, collagen vascular diseases, and catamenial pneoumothorax. the principal factor affecting choice of treatment in these patients is the nature of the underlying pulmonary disease. if the patient is symptomatic, which is far more likely with this patient population, there is no role for observation. furthermore, an increase in the pneumothorax could possibly place the patient's life in jeopardy. therefore, observation of a secondary spontaneous pneumothorax is not recommended. tension physiology is frequently unnecessary to cause clinical decompensation in these patients. any consideration of employing positive pressure ventilation in a patient with a secondary pneumothorax should serve as an indication for thoracostomy tube placement. earnest consideration should be given to sclerosis for prevention in most of these cases. an important exception is the patient who is awaiting lung transplantation because adhesions resulting from sclerosis can significantly complicate explantation of the native lung at the time of transplantation. another consideration is the nature of the underlying pulmonary disease. if the pneumothorax occurs in the setting of a disease, such as certain malignancies or infections, it may not be possible to staple the lung or to achieve total lung expansion . in these cases, particularly if the patient is terminally ill, consideration should be given to sending the patient home with a chest tube and a heimlich valve if this provides adequate palliation. iatrogenic pneumothorax may be the most common cause of pneumothorax." the most common causes include transthoracic needle biopsy, central line placement, thoracentesis, figure . . intraoperative photograph taken through the videothoracoscope demonstrates an apical bleb (within the grasping forceps iin a patient presenting with a recurrentprimaryspontaneous pneumothorax. the bleb was then resected with a thoracoscopic stapling device, introduced through the third port incision. subsequently, a parietalpleurectomy of the entire chest wall pleura and a mechanical pleurodesis of the mediastinal and diaphragmatic pleura were performed. a single chest tube was then inserted through the lowest incision, which had been used for the videothoracoscope duringthe procedure. transbronchial pulmonary biopsy, and positive pressure ventilation. the management of an iatrogenic pneumothorax must take into account a number of factors, including the etiology, symptoms, and size of the pneumothorax and ventilatory status of the patient. it is logical to consider those patients with pneumothorax secondary to positive pressure ventilation, barotrauma, separately from those who developed pneumothorax secondary to violation of the visceral pleura. the development of a pneumothorax as a result of barotrauma is an indication for immediate placement of a standard chest tube. this indication is also true for a procedure-induced pneumothorax in a ventilated patient because positive pressure ventilation can rapidly lead to a tension pneumothorax. the clinician should always consider pneumothorax as a cause for instability in a ventilated patient who recently underwent thoracentesis or central line placement. the majority of iatrogenic pneumothoraces are procedure induced. these pneumothoraces differ from spontaneous pneumothoraces in that the patient is not at an increased risk for recurrence. for small, asymptomatic pneumothoraces, observation is appropriate, and thoracostomy tube placement and sclerosis are not indicated. for larger pneumothoraces or symptomatic pneumothoraces in ambulatory patients, simple aspiration or temporary placement of a small percutaneous catheter is the preferred approach of many clinicians. any closed pneumothorax arising from visceral pleural disruption has the potential to develop into a tension pneumothorax. tension pneumothorax occurs when air accumulates in the pleural space in excess of intrapleural pressure and actively compresses the ipsilateral lung. this tension physiology will eventually lead to contralateral mediastinal shift and, in addition to pulmonary embarrassment, can severely limit venous return and compromise cardiac output. untreated, tension pneumothorax may lead to cardiopulmonary arrest and for this reason is a life-threatening emergency. tension pneumothorax is believed to occur when a pleural disruption forms a functional one-way valve allowing air to escape from the lung but not reenter. such physiology is occasionally well tolerated in a healthy adult and can await chest tube placement under urgent, but controlled, conditions. if, however, the patient is in distress and the diagnosis is suspected, placement of a -or is-gauge intravenous catheter over the second rib, in the midclavicular line, will convert the tension pneumothorax to an open pneumothorax. after decompression has been achieved, a chest tube can then be placed in the usual manner. this procedure should always be performed immediately in any patient who is decompensating and for whom tension pneumothorax is in the differential diagnosis. it is a mistake to wait for a confirmatory chest xray in such a situation. although pneumothorax is a disorder of air that has entered into the pleural space, blebs and bullae are also disorders of abnormal air collections, but still contained within the lung. only blebs can be considered a true pleural disorder. blebs arise when air escapes from the pulmonary parenchyma and is trapped in the visceral pleura. simply stated, blebs are subpleural collections of air. they are usually small, less than em, and tend to occur at the apex of the upper lobe or the apex of the superior segment. the significance of blebs is uncertain. by themselves, it is doubtful that they cause any significant effect on pulmonary function. their primary clinical significance lies in the fact that they appear to be involved in the pathogenesis of spontaneous pneumothorax. no specific treatment is indicated for the finding of pulmonary blebs in the absence of pneumothorax. cessation of smoking, as always, is recommended. bullae are air collections measuring at least em, but may become so large that they occupy the greater part of the hemithorax. as opposed to blebs, bullae are formed by destruction and coalescence of alveoli. they may demonstrate trabeculated lumens formed by the residual structural elements from the lung parenchyma they replaced. blebs may be an incidental finding in patients with otherwise normal lungs, but bullae are likely to be associated with some form of pulmonary disease, most likely emphysema. bullous disease is also frequently asymptomatic. in such cases, cessation of smoking and annual chest x-rays are sufficient. in the setting of known underlying lung disease, treatment of that disorder is the priority. pneumothorax, infection, or hemoptysis can prompt surgical intervention. surgical intervention can also be indicated for compression of normal lung tissue to improve pulmonary function. generally, very good results can be anticipated if the bulla is occupying more than / of the hemithorax, compressing well-perfused parenchyma. pleural effusions are a very common disorder encountered by the clinician. there are many potential causes of effusions (table . ). occasionally, it is possible to deduce the etiology in the context of the patient's chest radiograph and concurrent morbidities. frequently, however, the fluid must be sampled to yield a diagnosis. there is a normal composition of pleural fluid (table . ) and a host of tests that can be performed on the fluid in pursuit of a diagnosis (table . ). once the fluid is sampled, it will fall into one of two categories, transudative or exudative, and / of exudative effusions will demonstrate at least one of the following characteristics: pleural fluid protein/serum protein ratio greater than . , pleural fluid lactate dehydrogenase (ldh)/serum ldh greater than . , or pleural fluid ldh more than twothirds of the upper normal limit for serum ldh. transudative effusions result from a perturbation in the hydrostatic or oncotic forces that affect fluid formation and turnover in the pleural space, as described in the physiology section. this imbalance results in fluid accumulation in the pleural space. for transudative effusions, the goal is to drain the effusion for symptomatic relief, if necessary, but to focus on the systemic disease. exudative effusions result from diseases that involve the pleura and may be broadly grouped as benign or malignant. the treatment of an exudative effusion is disease specific. pleural effusions may be asymptomatic or may cause the patient to present with shortness of breath, secondary to compression of pulmonary parenchyma, as well as other symptoms. a nonspecific sign that is compatible with an effusion is the presence of a nonproductive cough. if the disorder causing the effusion has provoked an inflammatory response in the parietal pleura, the patient may complain of pain with respiration, known as pleuritic chest pain. restricted chest wall movement or change in the contour of the hemithorax may be evident, depending on the nature of the effusion and its effect on pleural pressure. if the effusion is unilateral and massive, the trachea may deviate to the contralateral side. absence of vocal fremitus, dullness to percussion, and decreased breath sounds are all characteristic apf/s, pleural fluid-to-serum ratio. biu, concentration in international units. findings on physical examination. if the pleura is inflamed, there may be an audible rub. a rub is likely to precede a significant effusion that will separate the roughened pleural surfaces and diminish or resolve the rub. in the case of a hydropneumothorax, there may be an audible ii splash," as originally described by hippocrates. plain radiographs of the chest remain the most common test obtained to evaluate a suspected effusion. if the effusion is free flowing, the lateral costophrenic angle may be blunted on an upright posteroanterior radiograph. the lateral radiograph is more sensitive than the posteroanterior view, but neither is as sensitive as the lateral decubitus projection. additional studies that are commonly used to obtain more information about a suspected effusion include ultrasound and ct scan. ultrasound is helpful in distinguishing pleural thickening from pleural fluid and determining if an effusion is complex or simple, and it has the advantage of portability. it can be used to help direct the clinician to the best area to perform a thoracentesis at the bedside. ct scans give the most information with respect to exact location of an effusion and may be particularly helpful in distinguishing effusion from pleural disease or parenchymal disease. if the clinical scenario warrants diagnosis of the effusion, then the next step is to perform a thoracentesis to obtain a specimen for analysis and, possibly, to drain the effusion for relief of symptoms. the decision to perform such a procedure should be taken seriously for the complications can be significant and include pneumothorax, hemothorax, and conversion of a sterile effusion into an empyema. thus, it is important to make sure the patient is not coagulopathic, and if there is any question regarding the appropriate site to insert the needle, a bedside ultrasound should be performed. sterile technique must be observed. the procedure is most easily accomplished with the patient in the sitting position and leaning over a bedside table that has been padded with one or two pillows. for a diagnostic tap, a long -gauge needle can be used to infiltrate with lidocaine and can be used as a finder needle. a -gauge needle is then used to perform the aspiration. if a therapeutic tap is indicated, a similar technique is employed, except that a catheter is placed into the chest cavity and connected via tubing to a three-way stopcock, which in tum is connected to a syringe or a vacuum bottle. a number of commercial kits are available for this purpose. regardless of the technique, it is generally recommended that not more than l of fluid should be aspirated at one time as this increases the chances of developing reexpansion pulmonary edema. the exact etiology of this syndrome is not fully understood and may be accompanied by / mortality." treatment for reexpansion edema is supportive care. if the effusion is transudative, then it is most likely secondary to congestive heart failure, hepatic insufficiency, or renal insufficiency. pleural effusions secondary to congestive failure are the most common transudative effusions.f most of these effusions are bilateral. the presence of a unilateral effusion or bilateral effusions of significantly different sizes does not exclude this diagnosis, but would be unusual. the disorder is thought to result from increased pressure at the pulmonary capillary level secondary to left heart failure. the treatment is the same as for other transudative effusions and is directed at the underlying cause, in this case, congestive failure. if the etiology is unclear or if the effusion remains unchanged after the congestive heart failure has improved, a diagnostic thoracentesis should be performed. occasionally, it is necessary to perform a therapeutic tap for symptomatic relief. approximately % of patients with hepatic cirrhosis will develop pleural effusions as a result of their disease." twothirds of cirrhotic pleural effusions are right sided. usually, the patient will have ascites in addition to the pleural effusion. the pleural effusion is thought to result from a one-way communication and fluid flow from the peritoneum, across the diaphragm, to the pleural space. the treatment should be directed at the liver failure and ascites, with diuresis and salt restriction as the initial steps in management. decompression of the portal circulation, percutaneously or surgically, may be indicated to treat the underlying disease. if the pleural effusion is unresponsive to these measures, or if pulmonary symptoms necessitate intervention, the options include drainage and pleurodesis. sometimes surgical intervention is indicated, combining closure of a demonstrated peritonealpleural communication with pleurodesis, this has been accomplished using vats techniques as well as thoracotomy. , shunting ascites to the venous system is another option; however, these patients are generally poor surgical candidates unless their liver failure is corrected. it is best to avoid placement of a chest tube for drainage of a pleural effusion secondary to cirrhosis as the high drainage rates from decompression of ascites across the diaphragm can make these tubes difficult to remove. nephrotic syndrome is another disorder associated with pleural transudates. these effusions tend to be bilateral and result from decreased plasma oncotic pressure. again, treatment should be aimed at the primary disorder. in severely symptomatic patients, drainage and sclerosis can be considered. other conditions that may provoke a transudative effusion include, but are not limited to, pulmonary embolism, superior vena cava obstruction, peritoneal dialysis, myxedema, glomerulonephritis, meigs syndrome, and sarcoidosis. exudative effusions can be broadly grouped into benign and malignant effusions. the malignant effusions arise most commonly from metastatic disease but can also herald the presence of a primary malignancy of the pleura. the benign causes of exudative effusion include a long list of conditions, including, but not limited to, infectious diseases, pulmonary embolism, collagen vascular diseases, drug-induced disorders, bleeding, chyle leak, subdiaphragmatic infections, pancreatitis, and esophageal perforation. if the cause is not obvious, then a thoracentesis should be the next step in diagnosing the etiology of the effusion. the following sections discuss the conditions most likely to be encountered by the surgeon. malignant effusions represent one of the most common indications for chest tube placement. the tumors most frequently associated with a pleural effusion include lung cancer, breast cancer, ovarian cancer, and lymphoma. dyspnea from pulmo- if the patient's lung does not expand, or if pleurodesis has failed, then chronic drainage becomes the next option. the options include internal or external drainage. for external drainage, the patient may undergo repeat therapeutic thoracenteses or placement of a long-term drainage catheter. intermittent thoracentesis may be the best for a patient who is minimally symptomatic or has a very short life expectancy. indwelling catheter placement for intermittent drainage pro- a large number of agents are available for pleural sclerosis. talc is the most popular chemical sclerosant used. a large metaanalysis reviewing randomized controlled trials including over patients concluded that: "the currently available evidence supports the need for chemical sclerosants for successful pleurodesis, the use of talc as the sclerosant of choice, and thoracoscopic pleurodesis as the preferred technique for pleurodesis based on efficacy. there was no evidence for an increase in mortality following talc pleurodesis. ,, doxycycline is the cheapest of the sclerosing agents. it is also the one that most commonly causes significant discomfort. it is administered dissolved in to ml sterile saline and mg lidocaine via chest tube. bleomycin generally causes little discomfort but is the most expensive agent. it is administered dissolved in ml of sterile saline via chest tube. although generally well tolerated, intrapleural bleomycin is absorbed systemically and is therefore not recommended for patients who are receiving chemotherapy, are immunosuppressed, or have renal failure. support can be found in the literature for using any of these agents in nearly any situation. a rational approach is to use talc for pleurodesis of malignant effusion and doxycycline for benign indications if the patient can safely tolerate significant sedation with intravenous narcotics and benzodiazepines or if the patient already has an epidural catheter in place. even with instillation of intrapleural lidocaine, patients will commonly describe doxycycline pleurodesis as one of the most painful experiences of their lives. an argument can be made to avoid the use of talc when there is potential contamination of the pleural space, either primarily or secondarily by some other site of active infection. talc, as a permanent foreign body, can serve as nidus for infection and result in chronic empyema. in a patient with a malignant effusion, in whom there is concern for possible contamination of the pleural space, bleomycin pleurodesis would be a reasonable option. if the lung expands completely when fluid has been drained, then pleurodesis is an option. if the lung does not expand, pleural apposition cannot occur, and injection of a sclerosant will not work. in fact, the sclerosant may further hinder the absorptive mechanisms of the pleura, thereby making the effusion worse. the literature does not support the belief that the pleural drainage must be less than is ml/day to achieve effective sclerosis. equal results and greater cost-effectiveness appear to occur if the sclerosis is performed as soon as the lung is fully expanded, regardless of the volume of drainage." there is also no support for the time-honored tradition of "rolling" the patient to achieve even distribution of the sclerosing agent. a prospective, randomized study utilizing instillation of mtc-sestamibi-labeled talc suspension has demonstrated that the dispersion of talc suspension and the overall success rate in patients with malignant effusions is not influenced by the position of the patient." nary compression is the most common symptom produced by a malignant effusion. malignant effusions are exudative and frequently sanguinous in appearance. the diagnosis can frequently be established by cytological demonstration of cancer cells in the fluid, although up to / of effusions yield nondiagnostic cytology." thus, if malignancy is suspected and the fluid cytology is nondiagnostic, a pleural biopsy should be considered. the approach of choice is vats if surgery is required to establish a diagnosis. depending on their surgical risk, patients may be well served by going to the operating room early in their course for diagnosis and drainage. under general anesthesia, a single chest tube incision can be created through which the effusion can be drained and the thoracoscope introduced for examination and photodocumentation of the pleural cavity. pleural biopsies can then be performed through the same incision by sliding the camera port out of the incision onto the proximal scope and sliding a biopsy forceps alongside the scope, through the same incision. a s-mm °thoracoscope is particularly helpful for this procedure as it allows the surgeon to look over the surfaces of the chest cavity and to move the scope off to the side, which facilitates manipulation of the biopsy forceps. if the lung demonstrates the ability to fully expand and a malignant diagnosis is confirmed, intraoperative talc poudrage can be considered. all this can be accomplished through a single -to is-mm incision. once the etiology of the malignant effusion is established, a treatment strategy can be formulated." surgical debulking of metastatic pleural tumor is generally not part of the treatment algorithm outside an experimental protocol. most patients are relegated to chemotherapy, radiation therapy, or palliative measures directed at preventing further fluid accumulation. some tumors, such as small cell lung cancer, breast cancer, ovarian cancer, and lymphoma, may respond well to chemotherapy, including resolution of the pleural effusion. mediastinal radiation therapy may also be indicated in treatment of the patient's tumor, especially if the tumor has involved the thoracic duct and resulted in a chylothorax. if the patient is not receiving treatment for the underlying malignancy or reaccumulates the effusion in spite of treatment, an alternative strategy must be considered if the effusion is causing symptoms. the first choice is pleurodesis, with other options for failure of this technique. vides good palliation." commercial kits such as the pleurex catheter (denver biomedical, denver co) are available. another option would be placement of a pleuroperitoneal shunt for internal drainage of the pleural space and decompression of the lung. internal drainage can be accomplished by implanting a shunt, such as the denver shunt (denver biomaterials), which has a pumping chamber that the patient can press to transfer fluid across the negative pressure gradient from the pleural cavity to the peritoneal cavity. there are a number of downsides to this option. placement requires an operation, usually under general anesthesia; a small percentage of the shunts will obstruct; and the patient must actively pump the shunt to transfer fluid. thoracotomy with decortication, in the presence of a malignant effusion, is rarely indicated. although highly variable, the average survival of a patient with a malignant effusion from lung cancer is on the order of months, whereas for breast or ovarian cancer it may be more in the range of to months.f thus, recovery from such an operation is likely to result in decreased quality of life for a significant portion of the patient's remaining time. effusions associated with pneumonia (parapneumonic effusions) are the most common cause of benign exudative effusions. they result from visceral pleural inflammation that alters the normal fluid balance of the pleural space. these effusions may initially be sterile, but if the parenchymal infection spreads to the effusion, an empyema results. there is a continuum that reflects the natural history of untreated parapneumonic effusions, from a thin, clear sterile collection to an infected fibrous peel encasing the lung. the first stage is the exudative stage, characterized by fluid exuding from the lung into the pleural space, likely from the pulmonary interstitial space. this stage should resolve with antibiotic therapy and generally does not require drainage. normal ph and glucose with a low ldh and white blood cell count are characteristic of the fluid at this stage. untreated, the effusion is likely to progress to the [ibtopurulent stage, characterized by increased fluid that is heavily laden with white blood cells, microorganisms, and cellular debris. fibrin is deposited on the pleural surfaces, and the stage is set for pulmonary entrapment. at this point, the fluid ph and glucose level fall, and the ldh rises. chest tube drainage is indicated but becomes more difficult as the effusion loculates with fibrinous septae. the final stage is the organizational stage, during which fibroblasts grow into the effusion, laying down a thick fibrous peel that encases the lung and results in entrapment. the remaining effusion is thick and infected and may necessitate through the chest wall or into the lung. the presentation of a parapneumonic effusion or empyema depends, to a certain extent, on the organism causing the infection. for aerobic organisms, the presence of the effusion has little impact on the clinical picture, which is that of a bacterial pneumonia: fever, chest pain, and a productive cough. an anaerobic infection, frequently as a result of aspiration, is more likely to present in a subacute manner. a patient with an anaerobic empyema may have symptoms for more than a week before seeking medical help, and significant weight loss may be a chief component of their presentation. true empyema thoracis is simply defined as pus in the pleural space, a clear indication for drainage. for a small simple parapneumonic effusion in a patient being treated with and responding to appropriate antibiotics, there is no indication for drainage. the issue is how to identify the effusion that is not yet frankly purulent but will require drainage to resolve. if the patient with pneumonia continues to have a large or increasing effusion, then a thoracentesis should be performed. the fluid from the tap should be sent for analysis of glucose, ph, ldh, amylase, protein, complete blood count with differential, gram stain, aerobic/anaerobic bacterial cultures, and if indicated, special microorganism cultures and stains. if malignancy is suspected, cytology should also be sent. as seen in table . from the american college of chest physicians parapneumonic effusions panel evidence-based guideline," the risk outcome can be stratified and used to determine whether drainage is warranted. these remain, however, only guidelines, and sound clinical judgment is essential. once the decision has been made to drain the fluid collection, a number of options are available: aspiration, chest tube drainage, vats drainage, limited thoracotomy and open drainage, or full thoracotomy with drainage and decortication. for diagnosis and initial treatment of a free-flowing pleural effusion, aspiration is an appropriate initial step. if the clinical situation mandates further drainage, then the clinician has several options. if the effusion is free flowing, then placement of a standard chest tube is a reasonable option. if the effusion is loculated, ultrasound guidance may be helpful either for marking the ideal location for thoracentesis or thoracostomy tube placement or for placement of a percutaneous drainage catheter. the use of intrapleural streptokinase or urokinase has been advocated if drainage fails due to loculations." in several well-constructed studies, however, it has been shown that enzymatic treatment will increase the volume of chest tube output but not affect the clinical course. the role of these agents for treatment of empyema remains undefined." there are several surgical options for patients with an empyema. the goals of surgical therapy are to establish drainage and, depending on the situation, to eliminate space in the pleural cavity. space elimination can be accomplished by decortication to allow the lung to expand, collapsing the chest wall with a thoracoplasty, or transposing muscle flaps to fill the space. a critical component is always to establish drainage. the least-invasive option is to explore the chest cavity thoracoscopically, disrupt loculations, debride the visceral pleura, and strategically place chest tubes. frequently, it is possible to accomplish this procedure utilizing the patient's existing chest tube sites as video ports. this option is most likely to be successful if performed in the exudative or early fibrinopurulent stages." once in the organizational stage, the lung is encased in a fibrous peel that most often requires an open thoracotomy to adequately remove. if the patient is able to tolerate such a procedure, then this represents the most effective treatment of the problem. the goal in such a situation is to drain the infection and obliterate any space with reexpanded lung 'h is the preferred pleural fluid chemistry test, and ph must be determined using a blood gas analyzer. if a blood gas analyzer is not available, pleural fluid glucose should be used (po glucose> mgjdl; pi glucose < mgjdl). the panel cautions that the clinical utility and decision thresholds for ph and glucose have not been well established. "clinical experience indicates that effusions of this size do not require thoracentesis for evaluation but will resolve. tissue. if a portion of the lung has already been removed or if the infection has rendered portions nonviable, mandating resection, then space may become an issue. the favored option is to transpose muscle flaps into the chest cavity to obliterate any residual space that exists after the lung has been decorticated and reexpanded. the commonly used muscle flaps are serratus, latissimus, and pectoralis. omentum is also a good option. a good approach in these cases is to enter the chest through a vertically oriented muscle-sparing thoracotomy such that both serratus and latissimus are spared and can be harvested if necessary. after a drainage procedure, the clinician is faced with the management of the chest tubes. the classic treatment of a chest tube placed into an empyema is to leave it to closed suction drainage for to weeks. thereafter, the tubes are taken off suction and converted to open drainage, slowly withdrawing them over the course of several more weeks. another option is to leave the tubes in place for approximately week on suction. if the lung is fully expanded, drainage is minimal «soml/day), and the patient has no further signs of infection, then the tubes may be removed. the critical point is that the lung must be fully expanded. cases in which this strategy is safe and effective usually demonstrate full expansion of the lung on the chest x-ray and "walling off" of the chest tube, characterized by essentially no drainage and lack of respiratory variation in the waterseal chamber of the pleur-evac. for patients with chronic empyema or empyema with bronchopleural fistula or patients unable to tolerate thoracotomy, an open drainage procedure may represent the best option. these procedures involve localizing the most dependent portion of the empyema cavity and resecting a portion of the overlying rib. the cavity is then entered, the pleural space debrided, and if possible, the lung decorticated. depending on the size of the cavity, it may close spontaneously or may require reconstruction, usually with a muscle flap. in an elderly or infirm patient, the cavity may be left open. given enough time, even cavities of substantial size will commonly close. almost any organism can cause an infection associated with a pleural effusion. tuberculosis may cause a pleural effusion that tends to be unilateral and of moderate size. they can be difficult to diagnose based on chemical and microbiological evaluation of the pleural fluid but usually demonstrate granulomatous pleuritis on closed pleural biopsy if the diagnosis is in doubt. the effusion usually responds to appropriate antibiotic therapy and, unless symptomatic or part of a mixed empyema, usually does not require drainage or surgery. viral effusions usually elude diagnosis and are self-limited. human immunodeficiency virus (hiv) does not appear to cause pleural effusions, but patients with hiv are more likely to develop pleural complications associated with a bacterial pneumonia. effusions may accompany any of a number of fungal pulmonary infections. the primary treatment is appropriate antibiotic therapy and, depending on the infection, drainage. of note, aspergillus empyemas are almost always associated with a bronchopleural fistula, or a history of previous treatment of tuberculosis with artificial pneumothorax, and almost always require surgical evacuation as part of their treatment. although relatively uncommon in the united states, the clinician should be aware that pleural effusions frequently accompany a number of parasitic infections. again, appropriate drug therapy is essential. of note, rupture of pleural or hepatic cysts into the pleural space can present with acute symptoms and, as in the case of echinococcus, may represent an indication for urgent thoracotomy to debride and drain the pleural space and to drain the original cyst. pleural effusions may accompany pulmonary emboli in / to / of cases. although the majority of these effusions are exudative, approximately one-quarter may be transudative. this is likely to be determined by the relative contribution to the effusion by the two mechanisms thought to be primarily responsible for the effusion. transudative effusions are thought to exude from the parietal pleura secondary to right heart failure. exudative effusions are thought to arise from the visceral pleural secondary to release of local factors from the emboli that increase capillary permeability. the treatment for pulmonary emboli with effusion is the same as for pulmonary emboli without effusion, and as always, the key factor is to consider the diagnosis in a patient with any of the symptoms suggestive of pulmonary embolus. inflammation or malignancy below the diaphragm can cause exudative pleural effusions as well as transudative effusions secondary to hepatic or renal dysfunction, as discussed in the transudative effusion section. acute pancreatitis generally leads to a left-sided effusion, likely as a result of transdiaphragmatic transfer of exudative ascites arising from pancreatic inflammation. the fluid almost always has an elevated amylase, and that amylase is frequently higher than the serum amylase. the fluid generally resolves with resolution of the pancreatic inflammation. pancreatic abscess can also cause a pleural effusion; again, the treatment is the usual treatment of a pancreatic abscess. a pancreatic pseudocyst can decompress into the pleural space, forming a pancreaticopleural fistula. these effusions tend to be large, usually left sided, very high in amylase, and usually accompanied by chest, not abdominal, symptoms. this finding is thought to be secondary to decompression of the pseudocyst into the thorax. treatment of this disorder is conservative, the same as the initial treatment of any pancreatic pseudocyst. the role of drainage of the effusion remains controversial, and the clinician should be aware of the risk of infection and the fact that the drainage is likely to be massive and to reaccumulate rapidly until the fistula has closed. should conservative treatment fail, a percutaneous or surgical drainage procedure should be planned. subphrenic abscess from any number of intraabdominal sources can lead to an exudative effusion. the effusions rarely are culture positive and tend to have a very high white cell count, yet the ph is usually above . , and the glucose is usually greater than mgjdl. treatment of the effusion should be symptomatic as the approach is treatment of the abscess and its underlying cause. the effusion usually resolves with these measures. the clinician is advised always to consider esophageal perforation in the diagnosis of a pleural effusion, particularly after instrumentation of the esophagus or retching. iatrogenic injury accounts for two-thirds of these injuries, and the patient frequently complains of chest pain. the condition usually presents with a left-sided effusion, but it may be either side or bilateral and accompanied by, or replaced with, a pneumothorax. the fluid is almost always high in amylase from saliva that has leaked into the pleural space. the mortality rate is high, up to / , which underscores the imperative of prompt diagnosis. if the diagnosis is being entertained, a contrast swallow study should be obtained. treatment depends on how early the disruption is diagnosed and ranges from primary repair to esophageal exclusion. pleural drainage, cessation of ongoing pleural soilage, nutritional support and antibiotics are necessary components of the treatment strategy. chylothorax is an exudative effusion caused by disruption of the lymphatics in the chest, most commonly the thoracic duct, and subsequent drainage of chyle into the pleural space. the initial presentation of a chylothorax is determined by the size of effusion and its mechanical effects within the hemithorax. once a chest tube is in place, the symptoms are determined by the persistence of the drainage. the longer the drainage continues, the more dangerous it becomes, with the consequences being dehydration, nutritional depletion, and immunocompromise." more than % of chylothoraces are secondary to ductal obstruction and disruption by tumor, with lymphoma accounting for % of these cases. approximately / of chyle leaks are traumatic, with iatrogenic trauma the most common. of the iatrogenic causes, esophageal resection is the leading cause and is more common with transhiatal esophagectomies than transthoracic esophagectomies. the diagnosis is established by analysis of the fluid. although classically thought of as milky in appearance, chyle may appear serosanguinous, particularly in the fasting state. a triglyceride level in the fluid greater than mgjdl is highly suggestive of chyle, whereas a level below mgjdl essentially excludes the diagnosis of chylothorax. intermediate values require a lipoprotein analysis to prove the presence of chylomicrons to establish the diagnosis." some believe that the most reliable test is to give an oral challenge of cream and to observe the tube drainage for gross changes. the treatment of chylothorax remains controversial; some authors advocate a generous period of conservative treatment, while others recommend early intervention. all agree that a prolonged, high-output leak can be devastating. conservative therapy involves pleural drainage and total parenteral nutrition. if the leak is secondary to a malignancy, then chemotherapy or radiation therapy may be the treatment of choice. for other chylothoraces, surgical intervention is indicated when conservative measures have failed. the timing of such intervention is debatable, but most authors agree it is unwise to wait more than week in the setting of an unremitting leak. it is important not to wait until the patient is immunocompromised and nutritionally depleted before deciding to operate as this would unnecessarily increase the risk of the surgery. at the time of surgery, heavy cream is administered via nasogastric tube immediately after intubation; this makes the duct more visible and may also identify the area of leakage. a number of surgical options are available, including parietal pleurectomy, direct ligation of the leak, and mass ligation of the duct. mass ligation offers at least an / chance of resolving the leak." many advocate performing a ligation of the duct on the right side, just as it emerges from the diaphragm, regardless of the side of the chylothorax. this ligation has traditionally been performed through a small thoracotomy incision in the sixth or seventh interspace. this procedure is figure . . intraoperative photograph through a video thoracoscope shows probe under the thoracic duct, which has been dissected free at the level of the diaphragm on the right side. note thoracic duct, aorta, lung, and diaphragm . this duct was clipped and ligated via this vats(video-assisted thoracoscopic surgery] approach through three lo-mm incisions that resulted in immediate and complete resolution of the patient's chyle leak. readily accomplished thoracoscopically, utilizing three . -to .s-cm port incisions (fig. . ). this procedure seems to offer less morbidity and equal efficacy to the open procedure. if the expertise exists , occlusion of the duct by interventional radiologists may be an option and would be the intermediate step to consider between failure of conservative therapy and surgical ligation of the duct . should all other measures fail, or if the right chest is hostile, the duct can be approached transabdominally in the aortic hiatus. the overwhelming majority of hemothoraces are caused by trauma, including iatrogenic trauma. there are other, significantly less common, causes, including bleeding from metastatic tumors involving the pleura, hemorrhage during anticoagulation therapy for pulmonary emboli, and catamenial hemothorax. the potential consequences of an undrained hemothorax include conversion to an empyema, provocation of a pleural effusion, and conversion to a fibrothorax with lung entrapment. the initial treatment of any hemothorax should be pleural drainage with a large-bore ( -or -french) chest tube. if the tube becomes clogged or is inadequate, additional tubes should be strategically placed . up to % of hemothoraces will become infected. this complication is more common in patients admitted in shock, with gross contamination of the pleura at the time of injury, with prolonged chest tube drainage, and with concomitant abdominal injuries. the pleural effusion associated with hemothoraces may occur after the blood has been evacuated and the chest tubes are removed . if the fluid is infected, it should be treated accordingly. if not , these effusions tend to be self-limited and require no further intervention. use of vats is safe and effective in evacuating blood from the chest cavity. in a prospective randomized trial, early vats drainage of retained hemothorax was found to decrease duration of tube drainage, hospital stay, and cost ." the earlier clot evacuation is attempted, the more likely vats evacuation will be completely successful. in addition, if intervention is insti-tuted early, the entire operation can frequently be performed through the existing chest tube incisions, occasionally requiring one additional videoscopic port incision. collagen vascular disorders may be associated with pleural effusions. in each case, the treatment of the effusion is symptomatic, with the primary therapy treatment of the underlying disorder. the two most common diseases are rheumatoid arthritis and systemic lupus erythematous. rheumatoid disease may involve the pulmonary parenchyma as well as the pleura. there are numerous other causes of exudative effusions. these include but are not limited to cardiac surgery, lung transplantation, asbestos exposure, dressler's syndrome, meigs syndrome, yellow nail syndrome, sarcoid, postpartum state, trapped lung, radiation exposure, ovarian hyperstimulation, amyloidosis, acute respiratory distress syndrome (ards), electrical bums, and uremia. a limited number of benign and malignant solid disorders affect the pleura. the most common benign conditions are fibrothorax, pleural plaques, diffuse pleural thickening, and benign fibrous tumors of the pleura. the most common malignancies are tumors metastatic to the pleura. the primary malignancy of the mesothelium is mesothelioma, and numerous cancers, such as liposarcoma and fibrosarcoma, may arise from any of the elements forming the connective tissue layer of the pleura. fibrothorax results from deposition of a thick fibrous layer along the pleural surface . this layer may cause entrapment of the lung as well as contraction and immobility of the skeletal hemithorax. the most common causes of fibrothorax are hemothorax, tuberculosis, and bacterial pneumonia. the treatment of fibrothorax is decortication, which is generally a major operation requiring a full thoracotomy. patients who are being considered for decortication should be low-risk surgical candidates who are symptomatic from their restriction and have pulmonary parenchyma that is anticipated to expand on release. generally, the indication is significant pulmonary compromise in a patient whose fibrothorax is stable or has been worsening for at least several months (fig. . ) . the pathogenesis of pleural plaques remains unclear. they are thought to be predominantly caused by asbestos, perhaps secondary to release of local factors in response to the foreign body after macrophage phagocytosis. pleural plaques are hard, raised, discrete areas involving the parietal pleura, particularly in the lateral, posterior portion of the hemithorax; % of pleural plaques that are due to asbestos are bilateral, with the majority of unilateral plaques thought to be secondary to other causes. pleural plaques do not appear to be predecessors of mesothelioma.f diffuse pleural thickening, like pleural plaques, appears to be predominantly related to asbestos exposure. other causes, such as drug reaction, hemothorax, and tuberculosis a figure . . anteroposterior radiograph of the chest (ai demonstrates scoliosis and volume loss resulting from a flbrothorax caused by a tuberculous empyema . computed tomographic cross section (b) demonstrates the thick parietal pleural peel entrapping healthy lung have been reported. unlike pleural plaques, however, diffuse pleural thickening affects the visceral pleura. its exact etiology also remains unclear, but it is thought that inflammatory factors are likely to play a major role, particularly in the setting of a resolving asbestos-induced pleural effusion. there appears to be an initial decrease in pulmonary function associated with diffuse pleural thickening that tends to remain stable over time. again, there is no specific treatment recommended, just routine surveillance. the benign fibrous tumor of the pleura is rare and primary. these tumors arise from the visceral pleura, are not associated with asbestos, and are frequently discovered incidentally on chest x-ray. these tumors may reach enormous size, thereby causing symptoms by virtue of compression of other structures ( fig. . ) . surgery is the treatment of choice and is almost always curative. the most common malignancies of the pleura are metastatic, predominantly from lung, breast, or colon primaries (fig. . ). there are rare primary sarcomas arising from the connective tissue elements of the pleura, but the most common primary malignancy of the pleura is mesothelioma. essentially all malignancies of the pleura portend a grim prognosis as a result of either their conferment of metastatic status or the recalcitrance of the vast majority of de novo pleural malignancies to current treatments. mesothelioma is a rare tumor, with only to cases per year in the united states, but is thought to be on the rise in both the united states and intemationally. this is thought to be primarily related to the -to so-year lag between asbestos exposure, with which there is a clear causal link, and the relatively recent or lax restrictions on the use of asbestos.p'" another epidemiological factor of great concern is the link between the simian vacuolating virus (sv ) and mesothelioma. the virus has been demonstrated in human mesotheliomas and is capable of inducing meso-b parenchyma. notice contraction and overlapping of ribs in both radiographs. the patient underwent a decortication with dramatic improvement of her scoliosis and pulm onary funct ion. thelioma by itself in animal models . it has been identified as a contaminant in millions of vaccines administered in the united states and may be a predisposing factor to mesothelioma formation in humans." pleural mesothelioma is almost always unilateral and is diagnosed by pleural biopsy. from the time of diagnosis, the median survival is to months. the tumor usually presents with dyspnea secondary to a pleural effusion but may also present with chest pain or constitutional symptoms. the cancer tends to line the chest cavity as a thick, plaque-like mass, fusing the two pleural layers and invaginating between the lobes of the lung (fig. . ). it progresses inexorably in a locoregional manner, invading lung, diaphragm, pericardium, and chest wall. contrary to popular belief, the disease also has the capacity to metastasize, but the lethality of the locoregional disease tends to preclude the clinical manifestation of any metastatic disease unless the natural history of the cancer is altered by a successfullocoregional treatment. although a number of staging systems exist, none has been universally adopted, although most incorporate the usual characteristics of the tnm system. this is likely a reflection of the small number of patients and even smaller number of centers investigating this disease. a staging system should accurately stratify prognosis, and this aspect of a staging system continues to evade researchers. as an example, cell type of mesothelioma (epithelial, sarcomatous, or mixed) is not currently part of any staging system, although some of the best results to date have been reported in patients restricted to the epithelial cell type, with % -year survival for patients treated with surgery, radiation, and chemotherapy." as a result of this deficiency in macroscopic staging, researchers are looking toward innovative technologies, like genetic profiling, in an effort to better determine prognosis and which patients might benefit from aggressive treatment protocols." there remains no accepted treatment for mesothelioma. because of the tumor's diffuse nature, complex anatomic presentation, and inherent recalcitrance to most treatment this patient presented with compla ints of bilateral lower-extremity swelling that proved secondary to inferior vena cava compression. photograph (e) shows the resected mass that arose from the visceral pleura of the right middle lobe and that was readily separated from the remainder of the lung with a small wedge resection of the affected area. modalities, it is an extremely difficult cancer to treat. because of encasement of the lung and potential pulmonary toxicity, there is no role for radiation as single-modality definitive treatment. radiation can be used with curative intent, as an adjuvant treatment combined with surgery in which the lung has been removed, or in a palliative manner for localized areas of symptomatic invasion. mesothelioma has proven to be one of the most chemoresistant tumors that oncologists face. cytotoxic agents have rarely yielded response rates greater than % . there have, however, been some encouraging results with newer chemotherapeutic agents , especially antimetabolites, which have shown response rates as high as % when used in combination with platinum-based conventional chemotherapy." to date, the treatments that have met with the greatest measure of success for pleural mesothelioma are those that combine surgery, for debulking, and other modalities to address the residual disease that almost certainly exists, even after the most /i complete" resection. the adjuvant treatments that have been performed, some intraoperatively, include radiation, photodynamic therapy, and hyperthermic chemotherapy intracorporeal lavage. systemic chemotherapy or immunotherapy have been used in adjuvant and neoadjuvant capacities. almost all surgery-based multimodality strategies that are performed with curative intent mandate removal of the lung as part of the debulking and preparation for the adjuvant treatments. some strategies, such as employment of photodynamic therapy for killing residual local disease after surgical debulking, may permit the option of performing lungsparing procedures." many cancers can metastasize to the pleural space, but one of the most frequently encountered is non-small cell lung cancer (nsclc), as either bulky disease or a malignancy.t -" in the absence of distant metastases, the presence of pleural dissemination confers an international system for staging lung cancer stage of iiib based on the pleural disease being considered a t tumor." the median survival for patients with this subset of stage iiib nsclc has been reported from months to greater than year but is generally within the -to -month range. - in fact, the survival rate for this subset of stage iiib patients is so poor that it has been suggested that this disease should be upstaged to stage iv because of the similar survival rates." the standard of care for patients with nsclc with pleural dissemination remains palliative chemotherapy, assuming the patient is able to tolerate this treatment, and some intervention to palliate effusion if it is symptomatic. radiotherapy is rarely administered to these patients because of the pulmonary toxicity from hemithoracic radiotherapy; surgery has been shown to have little impact on survival for these patients and is accompanied by a local failur e rate as high as % . there are anecdotal reports of long-term survivors after surgery, but it is safe to say that there should be no role for surgery outside of some type of multimodality protocol approach as with mesothelioma.p:" two recent studies have reported encouraging results for surgery-based multimodality approaches to this disease but require validation in larger studies. in one study, the investigators operated on patients, performing extrapleural pneumonectomies on all , but in they also performed intraoperative hyperthermic chemotherapy perfusion. all patients were staged as mo, and the groups were evenly split with respect to nodal status, with the majority being no( / and / ) and the remainder being n ( / and / ) or n ( / and / ) in the study and control groups, respectively. all patients received adjuvant chemotherapy. the group of evenly matched patients who did not receive intraoperative b (b) is a section through an extrapleural pneumonectomy specimen of a resected mesothelioma showing the same pathology as seen on the scan . hyperthermic chemotherapy perfusion had a median survival of months. the group who received intraoperative hyperthermic chemotherapy perfusion had a median survival of months. another recent study employed systemic chemotherapy, in a neoadjuvant capacity, and intraoperative photodynamic therapy to address microscopic locoregional disease after surgical debulking. the median survival for all patients enrolled was months from the time of surgery, with of the patients having pneumonectomy; the remainder had parenchymal sparing anatomic resections ranging from bilobectomy to segementectomy. in of the patients having intraoperative photodynamic therapy, n disease was present." both of these studies emphasize the importance of clinical trials that utilize a multimodality approach to cancers involving the pleura and the importance of a component to specifically address the residual microscopic disease that remains after even the most aggressive surgical resection. the medical works of hippocrates classic descriptions of disease eloesser . milestones in chest surgery embryology and anatomy of the pleura thoracic surgery exchanges through the pleura distribution of lymphatic stomata on the pleural surface of the thoracic cavity and the surface topography of the pleural mesothelium in the golden hamster respiratory physiology: the essentials baltimore: lippincott, williams and wilkins oxygen therapy for spontaneous pneumothorax the rate of formation and lymphatic removal of fluid in pleural effusions the impact of pleurodesis in malignant effusion on respiratory function the electrocardiographic manifestations of spontaneous left pneumothorax spontaneous pneumothorax and its treatment noninvasive treatment of pneumothorax with oxygen inhalation civilian spontaneous pneumothorax. treatment options and long-term results management of spontaneous pneumothorax spontaneous pneumothorax. comparison of thoracic drainage vs. immediate or delayed needle aspiration treatment of pneumothoraces utilizing small caliber chest tubes the performance of four pleural drainage systems in an animal model of bronchopleural fistula focal reexpansion pulmonary edema after drainage of large pleural effusions: clinical evidence suggesting hypoxic injury to the lung as the cause of edema reexpansion pulmonary edema complications in cardiothoracic surgery smoking and the increased risk of contracting spontaneous pneumothorax treatment of spontaneous pneumothorax: a more aggressive approach? management of spontaneous pneumothorax secondary spontaneous pneumothorax significance of iatrogenic pneumothoraces pulmonary diseases and disorders pleural effusions: the diagnostic separation of transudates and exudates focal reexpansion pulmonary edema after drainage of large pleural effusions: clinical evidence suggesting hypoxic injury to the lung as the cause of edema transudative effusions hepatic hydrothorax outcome analysis of cirrhotic patients undergoing chest tube placement recurrent pleural effusion complication liver cirrhosis cytologically proved malignant pleural effusions: distribution of transudates and exudates management of malignancyassociated pleural effusion: current and future treatment strategies efficacy of short term versus long term tube thoracostomy drainage before tetracycline pleurodesis in the treatment of malignant pleural effusions distribution of talc suspension during treatment of malignant pleural effusion with talc pleurodesis pleurodesis for malignant pleural effusions (cochrane review) outpatient management of malignant pleural effusion by a chronic indwelling catheter survival and talc pleurodesis in metastatic pleural carcinoma, revisited. report of cases medical and surgical treatment of parapneumonic effusions: an evidence-based guideline for the american college of chest physicians parapneumonic effusions panel intrapleural streptokinase for empyema and complicated parapneumonic effusions ongoing search for effective intrapleural therapy for empyema: is streptokinase the answer? video-assisted thoracoscopic surgery for fibrinopurulent pleural empyema in patients the lipoprotein profile of chylous and nonchylous pleural effusions chylothorax: an assessment of current surgical management early evacuation of traumatic retained hemothoraces using thoracoscopy: a prospective, randomized trial pleural diseases. baltimore: lippincott williams and wilkins solitary fibrous tumor of the pleura the role of alimta in the treatment of malignant pleural mesothelioma: an overview of preclinical and clinical trials malignant mesothelioma-the uk experience malignant pleural mesothelioma new developments about the association of sv with human mesothelioma multimodality management of malignant pleural mesothelioma gene expression profiles predict survival and progression of pleural mesothelioma chemotherapy for malignant pleural mesothelioma: past results and recent developments chemotherapy for malignant pleural mesothelioma: past results and recent developments phase it trial of pleural photodynamic therapy and surgery for patients with non-smallcell lung cancer with pleural spread recursive partitioning analysis of radiation therapy oncology group (rtog) patients with locally-advanced non-small-cell lung cancer (la-nsclc): identification of five groups with different survival prognostic value of pleural effusion in patients with non-small cell lung cancer revisions in the international system for staging lung cancer indications for pleurectomy in malignant effusion neoadjuvant chemotherapy and operations in the treatment of lung cancer with pleural effusion malignant pleural effusion in non-small cell lung cancer-time for a stage revision multimodality treatment programs for malignant pleural mesothelioma using highdose hemithorax irradiation extrapleural pneumonectomy for lung cancer with carcinomatous pleuritis prognosis of resected non-small cell lung cancer patients with carcinomatous pleuritis of minimal disease implications of staging in lung cancer intraoperative intrapleural hypotonic cisplatin treatment for carcinomatous pleuritis pleuropneumonectomy and postoperative adjuvant chemotherapy for carcinomatous pleuritis in primary lung cancer: a case report of long-term survival comparison of pleuropneumonectomy and limited surgery for lung cancer with pleural dissemination phase it trial of pleural photodynamic therapy and surgery for patients with non-smallcell lung cancer with pleural spread gray's anatomy minimal access surgery in oncology chemical pleurodesis for malignant pleural effusion key: cord- -ungitgh authors: sergueef, nicette title: clinical conditions date: - - journal: cranial osteopathy for infants, children and adolescents doi: . /b - - - - . - sha: doc_id: cord_uid: ungitgh nan this chapter addresses some clinical conditions than can be effectively treated using manipulative procedures. such treatment, however, is not intended to replace defi nitive medical or surgical treatments. rather this therapeutic option is offered as a gentle, alternative, non-invasive approach, with essentially no untoward side effects, to be employed as a fi rst line of therapy. patients respond quickly to a specifi c technique when it is appropriately applied following a precise diagnosis. it is the responsibility of the practitioner to ensure that underlying pathologies requiring more aggressive medical or surgical treatment have been ruled out or appropriately addressed. it should also be borne in mind that when a patient fails to respond to treatment as anticipated, they should be completely reassessed. if the osteopathic practitioner does not see a signifi cant functional change in the patient's condition by the third to fi fth treatment, the probability of misdiagnosis is likely. for each clinical condition, the specifi c features of the condition are addressed. for the basic treatment protocols and descriptions of individual procedures, see chapters (examination of the patient) and (treatment of the patient). congenital muscular torticollis and plagiocephaly are the most frequently occurring asymmetries of infancy. brachial plexus injury, fracture of the clavicle, pectus excavatum and carinatum, scoliosis, kyphosis and vertebral somatic dysfunctions are other commonly encountered conditions with structural and functional consequences that can be addressed with osteopathic manipulative treatment. torticollis may be subdivided into congenital torticollis and congenital muscular torticollis (cmt). the patient with congenital torticollis presents at birth with their head tilted toward the involved side and rotated toward the opposite side. they commonly have associated medical conditions, such as osseous malformations, basilar impression or atlantooccipital anomalies, and neurologic disorders such as arnold-chiari malformations. these underlying conditions should be diagnosed and appropriate treatment initiated before osteopathic manipulation is considered. the patient with cmt, on the other hand, is symmetric at birth, and the asymmetry develops in the fi rst weeks of life. cmt presents with a tight sternocleidomastoid (scm) muscle, causing the child's head to be tilted toward the side of the tight muscle and rotated in the opposite direction. a mass, or fi bromastosis colli, can eventually be palpated within the muscle. the incidence of cmt ranges from . to . %, but is as high as . % when cases are diagnosed sonographically. cmt occurs more often among boys than girls. , some authors report a higher incidence on the right side, , whereas others report that it is more frequently encountered on the left. primiparity, assisted delivery , and breech presentation , frequently appear in the birth history. the larger the infant, birth body length and shoulder width, with more associated delivery trauma, the higher the incidence of cmt. multiple theories to explain the etiology of cmt have been proposed. van roonhysen ( ) postulated abnormal uterine pressure as a cause of torticollis. pommerol, in the th century, attributed the unilateral shortening of the scm to abnormal fetal position. these 'intrauterine' theories have also attempted to explain the presence of several other deformities present at birth. many authors have commented on aberrant constraint of the infant within the uterus and the association between torticollis, plagiocephaly, bat ears, scoliosis and congenital hip dislocation, [ ] [ ] [ ] [ ] or hip dysplasia. other theories link cmt to birth trauma. the high incidence of breech presentation associated with cmt may document the role of birth trauma in its occurrence. others suggest that intrauterine torticollis predisposes the infant to breech presentation or forceps delivery. it has been proposed that birth trauma with injury of the scm and a resultant hematoma, which is then replaced with fi brous tissue, causes cmt. histologic studies have, however, failed to support this proposition. proposed compressive arterial occlusion as an etiology has also been dismissed. vascular compromise does not occur because there is abundant arterial and venous supply to the scm that follows no regular or segmental pattern and has multiple anastomoses. among more recent theories, cmt is proposed as the sequela of an intrauterine or perinatal compartment syndrome. a bilateral imbalance of structures responsible for control of head posture may play a role -for example, as may be the case for the interstitial nucleus of cajal, a neural integrator for head posture. because the torticollis is not present at birth but appears later, it is possible that it results from improper handling of the child or incorrect positioning as in a car seat. resultant dysfunction of the occipito-atlanto-axial joints may, therefore, occur and has been proposed as a cause for cmt. several clinical variants are observed. the scm mass is not always present. smaller masses may be found on the occipital bone below the superior nuchal line. when an scm mass is palpable, usually in the fi rst months of life, it appears well circumscribed within the muscle, is located in the midportion of the scm and ranges in size from to . mm on maximal transverse diameter and from . to . mm in length (measured with ultrasound). this mass typically disappears during the st year of life without any correlation with the resolution of the cmt. although the fi ndings of head tilt toward the involved side with head rotation toward the opposite side are consistent, the amount of rotation can differ between subjects. contractures of the semispinalis capitis and the splenius capitis are sometimes present. cmt is probably the consequence of several concomitant factors. the problem may begin with a faulty intrauterine position that weakens the scm, making it vulnerable to birth trauma and thus creating the dysfunction. osteopathic practitioners use their knowledge of anatomy to develop a rationale for treatment. the scm arises, by two heads, from the sternum and clavicle ( fig. . . ). the medial (or sternal) head has its origin on the upper part of the anterior surface of the manubrium sterni and the lateral (or clavicular) head arises from the anterior surface and superior border of the medial third of the clavicle. initially, the two heads are separated from one another. they gradually join, below the middle of the neck, to form the body of a thick, rounded muscle. the scm is inserted into the lateral surface of the mastoid process by a strong tendon and into the lateral half of the superior nuchal line of the occipital bone by a thin aponeurosis. the two heads of the scm consist of different types of fi ber, the sternal head being more tendinous and the clavicular head being composed of fl eshy and aponeurotic fi bers. the clavicle is more mobile than the sternum and is subject to signifi cant stress during the birth process, which may explain a different strain being put on the two parts of the scm. a distinction between 'sternal torticollis' and 'clavicular torticollis' has been proposed. the insertion of the scm covers the occipitomastoid suture; therefore, scm tightness should be released whenever attempting to treat this suture. conversely, somatic dysfunction between the temporal and the occipital bones will affect the scm. the jugular foramen -located at the anterior end of the occipitomastoid suture, between the petrous portion of the temporal bone and the occiput -will also be affected. the jugular foramen contains the inferior petrosal sinus and the sigmoid sinus that unite to form the internal jugular vein. it also contains the glossopharyngeal (cn ix), the vagus (cn x) and the accessory (cn xi) nerves. cn xi provides the motor supply to the scm, its proprioceptive fi bers passing through branches from the anterior divisions of the second and third cervical nerves to innervate the scm. thus, sutherland stated: 'you will probably fi nd the source of the torticollis to be entrapment neuropathy of the eleventh cranial nerve at the jugular foramen.' jacquemart and piedallu, in , recommended that osteopathic manipulation for cmt be directed at somatic dysfunction of the occiput and upper cervical spine. the mastoid process is not fully developed in the newborn and is totally covered by the tendon of the scm from its apex to its superior border. the development of the mastoid process is linked to the traction of the scm; asymmetric sidebending and rotation of the head, as in cmt, will cause the mastoid processes to develop asymmetrically. cephalometric analysis demonstrates that, left untreated, persistent torticollis can lead to skull and facial asymmetry. when it occurs, the cranial base deformation appears early, the changes being more signifi cant in the posterior cranial fossa, whereas the facial deformity will develop later in childhood. both the cranial base and facial deformities tend to increase with age. furthermore, the asymmetric function of the neck muscles stresses the mechanisms of postural control. abnormal sensory input to the cns and a sense of instability occurs that has to be compensated for with vision. this can affect the infant's developing visual function. to prevent these sequelae, osteopathic procedures should be employed to address cmt as early as possible. observe the child for spontaneous rotation and sidebending of the cervical region. a good way to evaluate the range of motion in rotation and sidebending is to have the baby visually follow a toy moved in the directions to be tested. the child can also be held in the arms of the practitioner, facing the parents. the practitioner then pivots to the right and to the left, holding the infant in such a way that, in order to continue to observe their parents, the child must actively turn their head fi rst to the left in response to the practitioner's pivoting right, and then to the right in response to the practitioner's pivoting left. having the parents participate in this procedure allows them to understand the extent of the child's restriction of motion; repeating the procedure after treating the child allows one to evaluate the effect of the treatment. the size of the scm mass (when present) and the tension of the muscle fi bers should be evaluated. palpate the infant to identify membranous, myofascial and interosseous somatic dysfunction, particularly in the upper thoracic spine, pectoral girdle, cervico-occipital area and cranium (temporal bone, occiput, occipitomastoid suture and jugular foramen). treatment should use indirect principles. because the mass associated with cmt often develops at the conjunction of the two heads of the scm, in order to release the dysfunction the bones to which the muscle is attached (clavicle, sternum, occiput and temporal bone) should be balanced. indirect myofascial release of the scm may be employed. if the infant is treated early, before a dysfunctional pattern becomes engrained, osteopathic manipulation can rapidly alleviate the asymmetry of scm. the caregiver should be taught an active positioning program to be employed at home. for example, approaching the infant from the side opposite the rotation during daily activities, such as feeding and playing, head turning and lengthening of the scm can be facilitated. the infant should be placed in a sleeping position that avoids reinforcement of the scm shortening. it is improper to attempt to accomplish this by propping the infant's head with a pillow in such a way as to lengthen the scm. although this may appear to hold the head in the desired position, it induces a stretch refl ex in the tight muscle, maintaining the shortening. gentle stretching exercises that induce active scm stretching can be taught. these should be employed to rotate the head toward, and sidebend the neck away, from the side of the tight scm. such exercises are indicated until a full range of movement has been obtained. the term plagiocephaly -derived from the greek plagios (oblique) and kephalê (head) -indicates distortion of the head and refers clinically to cranial asymmetry. cranial deformations have been (and still are) produced intentionally, depending on the period and country, as signs of distinction, beauty, health, courage, freedom and nobility. the oldest known example is from iraq, c. bc, and the earliest written reference is from hippocrates, around bc (airs, waters, places), describing the macrocephales who practiced head deformation. inten-tional plagiocephaly was obtained by pressure applied to an infant's skull, either through manual molding or with boards, pads or stones. different deformities were induced depending on the methods employed. the use of cradleboards and the wearing of headdresses are examples of other traditions that also resulted in head deformation. non-intentional plagiocephaly can be associated with premature sutural closure or craniosynostosis. premature synostosis of one or several cranial sutures may be the result of genetic or metabolic conditions. , the fused suture does not allow bone growth and the shape of the skull refl ects this anomaly: a brachycephaly develops when the coronal suture fuses, a dolichocephaly or a scaphocephaly when the sagittal suture fuses, and a trigonocephaly when the metopic suture fuses. unilateral synostosis of the lambdoid or coronal suture (fig. . . ) results in a posterior or anterior plagiocephaly, respectively. although any suture may be involved in synostotic plagiocephaly, true lambdoid synostosis with posterior plagiocephaly rarely occurs and represents only . % of all synostoses. in the general population, the incidence of craniosynostosis has been estimated to be as low as in - live births; , however, it is imperative that the diagnosis of synostotic plagiocephaly, which is most specifi cally accomplished by radiologic means, be made when the condition is present. children presenting with craniosynostosis should be monitored closely by a pediatric neurosurgeon for signs and symptoms of increased intracranial pressure. treatment may require surgery, particularly for severe cases. non-synostotic plagiocephaly (nsp), also referred to as functional plagiocephaly, must be differentiated from craniosynostosis. the prevalence of nsp is estimated to be as high as . % of all children under the age of months. nsp is identifi ed as either frontal or occipital (figs . . and . . ) depending on the site of the deformation. in , the 'back to sleep' campaign was instituted in the usa for prevention of sudden infant death syndrome (sids). parents were encouraged to put infants to sleep in the supine position. following this, a shift occurred in the location of the deformity of nsp, from frontal plagiocephaly being more frequently encountered before the 'supine' directive, to occipital plagiocephaly more commonly encountered now. nsp results from a variety of extrinsic and intrinsic factors affecting the infant before, during and after birth. these various factors may be isolated or may exert a cumulative effect. associated risk factors for nsp include premature birth, fi rstborn, , prolonged labor, unusual birth position, use of forceps and vacuum extraction. male gender is also a risk factor because fetal distress during labor, with a consequently higher incidence of operative delivery, is more common with males than with females. before birth, nsp may result from abnormal constraint on the fetal head in the intrauterine environment, as with a unicornuate uterus, uterine fi broids or oligohydramnios. multiple births are another risk factor, with deformational plagiocephaly being frequently encountered in these children. extrauterine constraints placed on the fetus can be responsible for nsp. this may be the result of pressure from neighboring abdominal organs. with athletic mothers, increased tonus of the abdominal muscles can compress the uterus back against the spine. lack of abdominal muscle strength, on the other hand, will produce an increase in the already increased lumbar lordosis that is very common in late pregnancy. the increased lordosis is associated with anatomic fl exion of the sacrum that displaces the sacral promontory forward, with resultant external pressure on the uterus. during the birth process, the uterus contracts regularly to allow the descent of the fetus through the birth canal. prolonged periods of uterine contraction may increase the mechanical forces applied to the infant's head. when the head enters the pelvic cavity, anatomic extension between the sacrum and the pelvic bones normally occurs to increase the diameters of the pelvic outlet. dysfunction of the maternal sacroiliac joints can result in a reduction of that increase and further constraint on the infant's head. in the left occiput-anterior position -the most frequent birth presentation -the right side of the infant's occipital bone is in contact with the maternal pubic symphysis while the left frontal bone is compressed against the sacrum (fig. . . ). asynclitism further increases the pressure of the infant's head against the pelvic bones with resulting occipital fl attening on the right and frontal fl attening on the left. the reverse -occipital fl attening on the left and frontal fl attening on the right -would result from the left occiput-posterior position. at the end of the descent, the head contacts the pelvic fl oor and turns in such a way as to position the occiput under the pubic symphysis. in the left occiput-anterior position, the right side of the occiput and the occipitomastoid area can be exposed to greater pressure. later, during expulsion, compressive forces are applied on the occiput by the pubic symphysis. after birth the pressure of the mattress on the infant's head is thought to contribute to occipital fl attening. sleeping habits affect the cranial shape. when infants consistently sleep supine, as in asiatic countries, posterior fl attening of the skull occurs. babies should be able to turn their head symmetrically to both sides. asymmetric cervical rotation should be considered anomalous and, if present, should be resolved by weeks of age. although a preferred rotation of the head to the right side is present at birth in % of infants, this does not seem to be related to the fetal position. often, infants may demonstrate asymmetric preferential motions, but a preferred motion should be differentiated from somatic dysfunction. concern should arise when a rotational dysfunction is present. early restriction of cervical motion is an identifi ed risk factor for positional plagiocephaly, particularly if the child is less active, staying in the same position to the point where an area of alopecia develops on the scalp. upper thoracic and cervical restrictions, and scm imbalance or torticollis, very often accompany plagiocephalies. , , furthermore, when the fl attening has developed, it reinforces the preferential positional pattern with automatic positioning of the head on the fl at area. by defi nition, plagiocephalic children have irregularly shaped heads. since infants now sleep supine because of the 'back to sleep' campaign, the most commonly encountered forms of plagiocephaly are posterior, with either medial or lateral occipital deformity. when compressive forces are applied to the squamous portion of the occiput, usually in the area of the lambda (superior angle of the occiput), the posterior portion of the head is fl attened and assumes a brachycephalic shape. in severe cases, the fl attening can demonstrate a slight depression, usually near the superior part of the occiput. an asymmetric plagiocephaly results when dysfunctional rotation of the head is associated with the compressive forces. because of the rotation, pressure from the weight of the infant's head on the mattress is asymmetric, and the occipitoparietal area on the side toward which the head is chronically rotated becomes fl attened, while the other side develops excessively. this results in occipital fl attening on one side and occipital bossing on the other. anteriorly, the skull demonstrates frontal bossing on the same side as the occipital fl attening, with frontal fl attening on the opposite side. when the head is seen from above, it has a 'parallelogram' shape ( fig. . . ) . the parallelogram cranial shape is commonly described in allopathic medical literature , , [ ] [ ] [ ] [ ] as well as in osteopathic medical literature. [ ] [ ] [ ] this pattern is also referred to as 'cranial obliquity'. in the cranial concept, the parallelogram cranial shape is associated with a pattern of lateral strain in the sphenobasilar synchondrosis (sbs) (fig. . ) . shearing between the posterior part of the body of the sphenoid, which is displaced laterally, and the anterior part of the occiput, displaced in the opposite direction, is lateral strain of the sbs and is found in children with nsp. the temporal bones of three parts. when occipital fl attening occurs, the deformity is obvious in the squamous portion of the occiput where the compression has occurred; however, the compressive forces have also been directed against the non-visible parts of the occipital bone, i.e. the anterior intraoccipital synchondrosis that lies between the two parts of the condylar facets. when such a compression of the occipital condyles occurs, it most often occurs asymmetrically. the hypoglossal canals are located bilaterally in the anterior intraoccipital synchondroses, between the basiocciput and the bilateral exocciputs. they contain the hypoglossal nerves that provide the motor supply to the tongue. compressive force on one side can have an impact on tongue motor function, with resultant problems such as suckling diffi culties. asymmetry of the cranial base can also affect the shape of the foramina therein, with potential for various entrapment neuropathies and vascular compressions. the jugular foramen, the right usually being larger than the left, contains the glossopharyngeal nerve (cn ix), the vagus nerve (cn x), the accessory nerve (cn xi) and the inferior petrosal and sigmoid venous sinuses. a broad spectrum of functions depends on these structures. compression of cn ix is associated with altered sensation of the pharynx, fauces, palatine tonsil, pharyngotympanic tube (pt) and the posterior third of the tongue. disturbances of cn x result in a wide range of symptoms including dysautonomia, colic and regurgitation. according to magoun, 'the occipitomastoid suture and the jugular foramen should be considered as of signifi cance with "pukey" parallelogram shape of the head, with the basilar portion of the occiput displaced away from the side of the posterior fl attening. the relationship between the cranial bones is disturbed, as described in lateral strain of the sbs, but this is not the only dysfunction associated with nsp. the compressive forces responsible for nsp can affect the relationship between different portions of the cranial bones, producing intraosseous dysfunctions. the occiput and temporal bones are the most common bones that demonstrate intraosseous dysfunction in the presence of nsp. at birth, the occipital bone is composed of four parts and each of babies'. compression of cn xi can compromise the motor supply to the upper and middle portions of the trapezius and to the scm. the trapezius receives a portion of its motor supply from cn xi; the scm depends mainly on cn xi. cn xi can also affect swallowing through its impact on the pharyngeal constrictor muscles that receive their nervous supply from the cranial portion of the accessory nerve. with the resultant asymmetry in the cranial base, a difference in tension between the two scm muscles is palpable. there are multiple myofascial attachments on the cranial base that can be similarly affected, resulting in a multiplicity of dysfunctional patterns in distant areas. asymmetric tensions in the trapezius and semispinalis capitis muscles can cause thoracic spine dysfunction, asymmetries of the stylopharyngeus and stylohyoideus muscles can affect the pharynx, and the styloglossus muscle can dysfunctionally infl uence the tongue. the compressive forces applied to the fetal head also affect the temporal bones. when occipital fl attening occurs on one side, the ipsilateral temporal bone and attached ear are moved forward and the mastoid portion is compressed. this deformation can be demonstrated with computerized tomography of the skull base. the long axis of the petrous portion of the temporal bone is displaced in the direction of the coronal plane, thus placing the temporal bone in a position resembling external rotation. embedded in the petrous portion of the temporal bone are the bony portion of the pt and the vestibular apparatus. compressive forces affecting the temporal bone may increase the risk of otitis. the bony portion of the pt, the vertical portion of the tensor veli palatini and the mastoid air cell system have been found to be smaller than normal in children with secretory otitis. temporal bone dysfunction may have further implications. children with nsp present with a higher risk of auditory processing disorders, which is thought to lead to subtle problems of cerebral dysfunction later at school. these problems include language disorders and learning disabilities, as well as attention defi cits. plagiocephalic children also have a higher incidence of sleep disorders. nsp infants have been described as less active when sleeping on their backs than non-nsp infants, who move actively, turning their head and torso when developmental landmarks are achieved. on the other hand, infants who sleep supine do not need to use their upper trunk and shoulder girdle muscles as much. consequently, there is a delay in acquisition of early motor milestones. tripod sitting, creeping and crawling are particularly delayed, which contributes further to weakening of the core muscles. scoliosis has been associated with plagiocephaly where sleeping supine was identifi ed as a causative factor. , , in the netherlands, where the supine sleeping position has been encouraged since , approximately . % of - -yearold children have cervical restriction of motion and/or plagiocephaly. interestingly, the habit of always bottle feeding a child on the same side seems to contribute to the pattern of asymmetric cervical rotation. alternating right-and left-sided bottle feeding is consequently an imperative for every baby, particularly nsp infants. the facial skeleton adapts to the cranial base asymmetry. facial asymmetries and facial disharmonies are associated with nsp. , , on the side of the occipital fl attening, the maxillary bone develops less well, with less distance separating the nasion and the temporomandibular joint. this reduction is proportional to the amount of posterior occipital deformation. the growth of the neurocranium and the viscerocranium occurs at different rates. consequently, compensatory developmental disorders of the viscerocranium will appear later in childhood than the original nsp, and the association, therefore, is not commonly recognized. it is a common observation that infants will sleep preferentially with their head turned toward one side, and that will be the side of the occipital fl attening of the nsp. daily activities such as diffi culty nursing or accepting bottle feeding bilaterally will also refl ect dysfunctions because of diffi culty in turning the head to both sides. associated disorders such as regurgitation, colic or sleep disorders are also often present. otitis media can be part of the picture if the child is over months of age. while taking the history, the infant's appearance, posture and range of motion are studied. when observing the child, the osteopathic practitioner assesses what dysfunctional mechanics are involved in the present nsp. where is the dysfunction? is it only in the cervical spine or are other areas involved? what is the primary dysfunction? three mechanisms are quite frequent: occipitocervical somatic dysfunction, thoracic somatic dysfunction and cranial somatic dysfunction: . is there a pattern of restricted cervical spinal rotation that has obliged the child to lay their head on one side that explains the head fl attening? if the head moves freely in all clinical conditions directions, no cervical spinal dysfunction is present. . is there a pattern of thoracic somatic dysfunction? does the child rotate their head with a movement involving only one side of the pectoral girdle, indicative of thoracic dysfunction? in this case, asymmetry of the movements of the arms may also be present. . is there a cranial dysfunction, such as a lateral strain of the sbs that explains the parallelogram shape of the head? these questions should be kept in mind in the following examination. observe the relationship between the head and the pelvis. in the presence of a 'total body' dysfunctional pattern, the pelvis and the head of the child are rotated in opposite directions on the vertical axis of the spine. palpation and motion testing will confi rm these observations and treatment should be applied accordingly. evaluate the skull. infants usually do not present with thick hair as encountered in most adults, making observation of the neurocranium easier. look for any bald spots that indicate chronic contact between that area of the head and the bed during sleep. look for posterior and anterior fl attening; in the presence of posterior plagiocephaly these are usually on opposite sides. this results in a parallelogram-shaped head that is easier to see from above when the child is held on the practitioner's or parent's lap. observe the child's face and frontal bones. a pattern of compressive forces applied directly to the frontal bone, with no occipital deformity, would indicate a frontal dysfunction. frontal fl attening opposite to the occipital fl attening is consistent with a pattern of lateral strain of the sbs. symmetry of the frontal bone with occipital deformity on one side is an indication of synostotic posterior plagiocephaly, where the forehead may be symmetric or fl attened on the side of the occipital fl attening. when a frontal dysfunction is present, this may affect the eyes. observe the size and shape of the orbital cavities, as well as the ocular bulbs. the orbital diameter is the distance between the superior medial and inferior lateral angles of the orbit. an increase in the orbital diameter results in an orbital cavity that appears to be wider than it is high and is associated with a cranial fl exion-external rotation pattern. conversely, if the orbital cavity appears to be narrower, this is associated with a cranial extension-internal rotation pattern. frontal dysfunction, in turn, affects the rest of the facial bones and is particularly important when problem solving dysfunctions of the nasal bones and the maxillae. observe the positions of the ears. they are very indicative of the positions of the temporal bones. in cases of nsp, the ear located on the side of the occipital fl attening is displaced more anteriorly than the contralateral ear. if the ear is displaced more posteriorly on the fl attened side, further diagnostic investigation is warranted because the displacement might be a sign of synostotic plagiocephaly. this sign, however, is not an exclusive indicator and synostotic plagiocephaly may also present with an anterior ear position. , observe the size and shape of the ears. usually, on the side of the occipital fl attening of nsp, the ear may, for example, have been compressed against the uterine wall and, therefore, may be smaller. in this instance, expect to fi nd intraosseous dysfunctions of the temporal bone on that side. this is the ear that the child will usually rub and that eventually may present with an otitis media. after observation, the osteopathic practitioner gently palpates (i.e. caresses) the child's head, looking for depressions, bossing and irregularities of contour. sutures are palpated for ridges, overlapping or irregularities in shape. a thick ridge over a suture calls for attention, because it may be a sign of a synostotic suture. flattenings are the result of compressive forces. tissues are palpated to evaluate for tissue texture abnormality and increased tenderness. palpation of osseous tissues gives a sense of density that might be different between the two sides of the suture; increased tenderness is usually proportional to the strength of the compressive forces. posterior occipital muscles are evaluated by palpation for tension and asymmetry. although the vault and the back of the head, the parietals and the squamous portion of the occiput are quite accessible to palpation, palpation of the frontal and facial bones necessitates a little more patience and delicacy in order to avoid disturbing the child. the base of the skull is not directly accessible to palpation for structure. the lateral parts of the occiput or exocciputs and the basilar part, as well as the sphenoid bone and the petrous portions of the temporal bones, should be assessed by palpating for function. to visualize these areas correctly while palpating them, knowledge of anatomy is of paramount importance. motion testing will confi rm the fi ndings of palpation and observation. dysfunctional head rotation is a treatment priority. it is of considerable importance that the child leaves the offi ce with a freer range of motion and an increased ability to turn their head. if not treated, the dysfunctional rotation will maintain the nsp. look for any somatic dysfunction of the occipitocervical junction and the cervical and thoracic spine, and treat utilizing indirect principles. structure will follow function, and if bilateral rotation is recovered, the traction of the muscles that insert on the occipital squama will help to reshape the fl attened areas. membranous patterns of the cranial mechanism should be assessed and dysfunctions balanced. particular attention should be given to the poles of attachment of the dura, the falx cerebri on the occipital squama and the tentorium cerebelli on the superior borders of the petrous portions of the temporal bones. motion of the sbs, occipitomastoid and lambdoid sutures should be assessed and treated accordingly. check the frontal bones and their relationships with the facial bones. any dysfunction should be treated. special attention should be directed at the cranial base, with the assessment and treatment of the compressed occipital condyles and compressed jugular foramina, when present. molding procedures can be applied, with intraosseous balancing of the occiput, temporal bones, frontal bones, sphenoid and parietal bones as dictated by the patient's needs. very often parents will comment on the fact that the fl attening was not present at birth and say that they do not understand why nsp has developed. to succeed in the treatment of plagiocephaly, it is worthwhile explaining the mechanism of nsp and stressing the importance of parental participation in the following months. explain that the initial asymmetry may have been present at birth in a very subtle way that has been exacerbated by a persistent positional preference. explain that it is of paramount importance to encourage the child in activities that promote bilateral cervical rotation, as well as promoting sleeping positions that avoid pressure on the already fl attened area. successful treatment depends on this. proper sleeping position may be obtained by elevating one side of the bed approximately cm ( inches). this can be accomplished by placing a rolled bath towel beneath the entire length of the mattress, on the side of the occipital fl attening. this will encourage the infant to turn their head in the other direction. toys and other attention-getting objects, soliciting the rotation of the child's head when lying supine, should be placed on the side opposite to the occipital fl attening. encourage play in the prone position. it can be explained to the parents that activities in the prone position stimulate the posterior axial musculature. muscular extension of the neck results in traction on the squamous portion of the occiput, helping to create a round head. to stimulate the child's curiosity and open them to the world, while encouraging them to turn their head symmetrically left and right, carry the child facing forward, held in the midline of the parent's chest. one parental hand should support the child's bottom while the other hand contacts the front of the child's torso, holding them against the parent's chest. the prolonged use of a car seat or other similar such carrying device should be discouraged because it tends to maintain the child in a chronic position, usually that of the dysfunctional asymmetry. thumb sucking should be discouraged because the child assumes an asymmetric position while preferentially sucking one thumb. if oral gratifi cation is necessary, an orthodontically shaped pacifi er should be employed. encourage the parents to gently caress the child's head bilaterally, behind the ears, in the areas over the occipitomastoid sutures and over the superior nuchal line of the occiput. this will help to reduce any dysfunctional tenderness. scoliosis is a lateral deviation of the spine. a structural scoliosis is a spinal deformation that is not totally reducible, while a functional scoliosis is totally reducible. the diagnosis of scoliosis is confi rmed by radiographic analysis. a functional scoliosis is usually associated with pelvic or postural asymmetry, a difference in the length of the lower limbs or vestibular or visual disorders. a structural scoliosis presents a spinal deformation in the three planes of space involving sidebending, rotation and fl exion or extension of the vertebrae. the side of convexity of the spinal curve defi nes the scoliosisfor example, a left scoliosis consists of a spinal curve that is convex on the left side. cobb's angle is a measurement of the degree of scoliosis between the most tilted vertebrae above and below the apex of the curve. this angle is obtained by measuring the angle of intersection between lines drawn perpendicular to the top of the most superior vertebra, and the bottom of the most inferior vertebra, of the curve. a scoliosis is identifi ed as idiopathic when no recognizable pathology explains its origin. it is identifi ed as secondary in the presence of spinal anomaly or neuromuscular dysfunction. the classifi cation of scoliosis is based on the age of the patient when the spinal curvature is fi rst identifi ed: congenital scoliosis is present at birth, infantile scoliosis is diagnosed under the age of years, juvenile idiopathic scoliosis between and years, and adolescent idiopathic scoliosis (ais) between years and the end of skeletal growth. the cause of idiopathic scoliosis has not been established, but seems to be a multifactorial interaction of environmental and genetic factors. studies have shown scoliosis as a single-gene disorder that follows the simple patterns of mendelian genetics. , traits can be dominant or recessive. genetic links exist, with % of parents and % of siblings having a scoliosis. further, a correlated incidence of scoliosis has been described in twins. older maternal age is a risk factor for greater progression of the curve of ais. maternal age of years or more at the time of the child's birth is associated with a higher incidence of ais, whereas paternal age has no significant effect. changes in the extracellular matrix of the connective tissues (e.g. collagen distribution and elastic fi bers) have been found among patients with scoliosis, but most researchers do not consider these changes to be the etiology of the deformity. similarly, a change in muscle fi ber composition or chronic muscle overuse might explained the hyperintense signal intensity shown on mri in the multifi dus muscle on the concave side of the scoliosis associated with greater degrees of curve severity. myopathy involving impaired calcium pump activity is among other proposed etiologies that require further study. the progression of ais is associated with increased calmodulin (calcium-binding receptor protein) levels in platelets, with a possible modulation of the calcium-activated calmodulin by melatonin. the level of melatonin has been proposed as a predictor for progression of spinal curvature in idiopathic scoliosis. melatonin is produced and released by the pineal body at night, and its production is inhibited by environmental light. it is proposed that a deficiency of melatonin could disturb equilibrium and postural mechanisms. neurologic origins have also been proposed as etiologies of scoliosis. hearing-impaired children who have a high incidence of vestibular dysfunction have signifi cantly less idiopathic scoliosis than children with normal hearing, resulting in the suggestion that idiopathic scoliosis has a neural etiology. a sensory input defi ciency of the spatial orientation system, involving visual and vestibular dysfunction, is believed to cause motor cortex and axial posture control disturbances. , another hypothesis is that developmental disorders in the central nervous system, followed by asymmetry of the spinal rotators and other trunk muscles, results in ais. a less effi cient postural regulation system with a diminished quality of standing stability has been demonstrated in some scoliotic patients. developmental disorders have also been considered at the level of the spinal cord. differences between the growth of the vertebral column and the growth of the spinal cord -'uncoupled neuro-osseous growth' -either with asymmetric nerve root tension or with reduced growth of the cord, are suggested etiologies for scoliosis. more rapid growth of vertebral bodies that occurs through endochondral ossifi cation, as well as slower circumferential growth of the vertebral bodies and pedicles that occurs through membranous ossifi cation, is observed in ais patients. furthermore, the length of the vertebral canal is shorter than the length of the vertebral column. this leads to the hypothesis that the thoracic spine is tethered by a tight spinal cord, with a resultant diminution of the kyphosis. this, in turn, results in a displacement of the spinal cord to one side of the vertebral canal with an associated sidebending of the spine and lastly a rotation of the vertebral bodies to allow for their growth while the vertebral canal stays in the midline. the base of the vertebral canal remains at a right angle to the sagittal plane of the patient, in its original position, and does not follow the rotation of the vertebral body. the tension of the core link -the strong dural membranes covering the cord, between the pelvic and cranial bowls -may play a role in this mechanism. the relationships between the different parts of the craniosacral mechanism, therefore, should be considered, and any dysfunction of the dura and/or the vertebral ligaments should be treated. biomechanical factors can affect spinal alignment. sidebending-rotation and torsion of the sbs, for example, can modify the level position of the orbits through the sphenoid and thereby modify the occipital neutral position, again altering balance mechanics in the spine below. pelvic obliquity is considered a cause of imbalance in the axial skeleton. pelvic obliquity has been associated with unequal leg length. if this imbalance appears early in the growth process, it will result in abnormal asymmetric weight-bearing pressures on the vertebrae. a 'dangerous triad' of joint laxity, delayed growth and persistence of asymmetric overloading of the spine has been described in rhythmic gymnasts who develop scolioses. this group shows an incidence of scoliosis of %, compared to . % in the general population of the same age group. pelvic obliquity has also been associated with the 'molded baby syndrome', where intrauterine molding determines a vertebral curve, having a sacral tilt inferiorly on the side of the spinal convexity. mechanical compressive forces acting on the infant during the prenatal, perinatal and postnatal periods have been proposed as an etiology for scoliosis. more breech presentations have been found among infants developing scoliosis during the fi rst months of life. plagiocephaly is frequently associated with infantile scoliosis. , - a facial and cranial distortion, always on the side of the curve of the scoliosis and linked to the intrauterine position, has been described. mcmaster noted that the scoliosis was rarely present at birth and, like plagiocephaly, develops very often within the fi rst months of life. he proposed an explanation for the association between plagiocephaly and scoliosis, as follows. infants prefer to turn toward their right side when in a supine position. light but asymmetric pressures from the mattress on the skull as well as on the growing spine can create asymmetries, particularly when applied over a prolonged time or during a critical period of growth. with chronic right rotation of the head, the back of the head will fl atten on the right, allowing growth of the skull on the left. the thorax follows the same pattern, the left side expanding freely backwards with a left rotation of the thoracic vertebrae. infantile scoliosis is sometimes found in association with imbalance of the occiput or with dysfunction of the sbs. intraosseous dysfunction of the occiput can produce asymmetry of the occipital condylar parts, resulting in altered balance mechanics in the spine below. the compressive forces applied to the occipital bone at the time of delivery have been described and suggested to be the causes for future compensatory scoliotic curves. , thus, the child may prefer to sidebend their head slightly to one side and, as time goes on, with potential new injuries and therefore more diffi culties for compensation, the adolescent will develop a scoliosis. ventura et al. state: 'even small deformities present at, or soon after, birth may get worse in infants whose connective tissues do not have a potential for recovery.' to this we could add one or more of the components described above -the etiology is multifactorial. congenital scoliosis may be associated with neurologic pathology or a vertebral structural defect (failure of formation and/or segmentation), as well as associated abnormalities of the head, neck, pelvis and hips. a thorough medical examination should be performed to rule out these disorders. hemivertebra is the most common anomaly that causes nonidiopathic congenital scoliosis and is sometimes associated with posterior midline cutaneous abnormalities. neural axis abnormalities have been demonstrated in . % of otherwise asymptomatic patients with infantile scoliosis. congenital scoliosis is more common in females than in males, occurring in the ratio of . : . among children with congenital spinal anomalies, - % have other anomalies located most commonly in the genitourinary tract, cardiovascular system, spinal cord or cervical spine. since the time of hippocrates, congenital and infantile scolioses have been described as potentially the result of mechanical factors operating during fetal life. these scolioses are more common in males, presenting more often as a left thoracic curve. , some resolve spontaneously, while others progress. harrenstein in , quoted by mehta, stated: 'spontaneous correction does occur without treatment but at the moment it is not possible to distinguish between the two at the time of the diagnosis.' thus, in order to differentiate between progressive and non-progressive congenital and infantile idiopathic scoliosis, mehta proposed a method of measurement of the rib-vertebra angle (rva). in an anteroposterior radiograph, the rva is 'the angle formed between each side of the apical thoracic vertebra and its corresponding rib'. the rvas are equal on a normal spine and a gap of - mm normally separates the head of the rib and the upper corner of the adjacent vertebra. mehta states that the most progressive infantile scoliosis presents an rva difference between the two sides equal to or greater than °. when this radiographic measurement is repeated after months, the rva remains unchanged or increases with a progressive scoliosis, whereas it decreases with a resolving curve. furthermore, with time, in the anteroposterior radiograph, a progressive scoliosis demonstrates overlap of the rib shadow with the upper corner of the vertebra. the relationship between the rib and the vertebra and the tissue response to any stress during growth periods is of great importance. curve progression is the major concern in every type of scoliosis, and the differentiation between progressive and non-progressive congenital scoliosis and infantile idiopathic scoliosis has been confi rmed through sequential comparisons of rvas over time. , when spontaneous resolution occurs in non-progressive infantile scoliosis, it does so between the ages of and months. spontaneous resolution of infantile idiopathic scoliosis varies between % and %. therefore, it is appropriate to detect the scoliosis at its earliest stage and to treat all affected babies within the fi rst months of life. it is typical to employ a wait-and-watch approach to the progressive category because orthopedic treatment is complex and diffi cult to initiate before the age of months. osteopathic procedures, on another hand, may be begun immediately, with potentially good results being obtained in cases of congenital and infantile idiopathic scoliosis. observe the baby for spontaneous positioning and areas of restricted mobility. look for positional asymmetries of the torso, head and neck, arms and legs. look also for a bulky back on the convex side of the thorax and creases in the skin laterally on the concave side. skin creases are a sign of fi xed scoliosis. observe the baby for clumsy movement in the maintenance of head position and in general coordination. palpate the infant to identify membranous, myofascial and interosseous somatic dysfunction contributing to the visually observed functional restrictions. the infant may be treated utilizing indirect principles to release any restriction of motion, particularly in the pelvis, upper thoracic spine, ribs, sternum, thoracic diaphragm, pectoral girdle, cervico-occipital area and cranium. intraosseous dysfunctions -most commonly encountered in the sacrum, lumbar and thoracic vertebrae and occiput -may be addressed using molding procedures. at home, following treatment, it is important to avoid movements and positions that will reinforce the scoliotic pattern. in considering daily activities, such as feeding and play, and when putting the infant to sleep, encourage the parents to position the infant correctly and to solicit movement from the infant that promotes symmetry. a child should sleep on their back to prevent sids, but should play in the prone position to develop the vertebral musculature of tonic posture. prevention is the best therapy. osteopathy, as a non-invasive treatment, facilitates the spontaneous recovery process or regression as quickly as possible. this allows the child to progress through the developmental milestones of infancy without interference from a dysfunctional musculoskeletal system. scoliosis is present between and years of age in - % of children. these patients differ from those with infantile scoliosis in that there is predominance among females and for the curvature to be a right thoracic curve. , the vertebral rotation is associated with a 'rib hump' on the side of the convexity, with most curves convex on the right in the thoracic area and on the left in the lumbar area. cobb's angle is sometimes debated as a true assessment of the scoliosis. ais is a three-dimensional deformity of the spine, with morphologic changes in the trunk and rib cage. vertebral rotation should be considered in the evaluation. the presence of severe pain or neurologic symptoms would be atypical for idiopathic scoliosis and should raise concern for spinal cord pathology. idiopathic scoliosis, if left untreated, increases in adult life. the period of puberty should be considered as a high-risk interval, and regular screening is recommended. a signifi cant correlation between growth in height and progression of cobb's angle has been found, with a possible increase until . years after menarche. current studies have indicated that the younger the patient at the time of diagnosis by pubertal or skeletal maturation landmarks, the greater the chance of curve progression. a curve measuring less than ° at skeletal maturity is least likely to progress, whereas curves measuring - ° may gain another - °. thoracic curves deteriorate most, followed by thoracolumbar curves and double curves. less than % of adolescent idiopathic scoliosis resolves without treatment. orthopedic treatment with a cast or a brace might be indicated to limit the progression of the curve and to employ surgery to correct the scoliosis. bracing for at least hours per day appears to be optimal for interdicting progression of the curve. watchful waiting is suggested as an alternative treatment to bracing because bracing does not decrease the incidence of surgery and often results in adverse psychological effects. manipulative treatment associated with exercise has been shown to stop curve progression in ais. , exercise may be used to effectively reverse the signs and symptoms of scolioses and to prevent progression of spinal curves in children and adults. as scoliosis is a risk factor for the impairment of physical wellbeing and quality of life, treatment is important. the physical examination begins with observation of the patient standing. observe placement of the feet for asymmetries. from behind, note the level of the iliac crests and the symmetry of the pelvis and waist triangles. leg length discrepancy as a contributing factor should be considered. further, observe the relationship between the pelvic and pectoral girdles, and look for shoulder and scapular asymmetries. elevation of the right shoulder compared to the left is associated with a thoracic curve convex on the right. note the position of the patient's head. a vertical line dropped from the external occipital protuberance should fall in the middle of the intergluteal crease. the patient is next observed in profi le for increased or decreased thoracic kyphosis, forward head posture and lumbar lordosis. the adam's forward bending test is employed to help identify scoliosis. the child bends forward, holding palms together with arms extended. the examiner looks from behind and from the side, along the horizontal plane of the back, to detect an asymmetry as a rotational deformity or 'rib hump' (fig. . . ) . this deformity is associated with spinal curves and may be further delineated with radiographic evaluation. with the child remaining forward bent, observe the distance between tips of the fi ngers and the ground as an indication of general spinal fl exibility. the palpatory examination of the patient with ais is directed at the identifi cation of membranous, myofascial and interosseous somatic dysfunction. the patient may be treated utilizing indirect principles to address any identifi ed dysfunction. begin by treating the area of greatest motion restriction. this will often be in the upper thoracic and craniocervical regions. the presence of proprioceptive sensory endings in the ligaments and fascia of the upper cervical area contributes to postural balance. primary high cervical somatic dysfunction can consequently impact postural balance. somatic dysfunction in the upper thoracic region can result in compensatory dysfunction in the upper cervical spine. once these areas have been treated, dysfunction of the thoracic spine, ribs, lumbar spine, sacrum and pelvis should be addressed. normalization of the diaphragm, to increase vital capacity, should always be part of the treatment of scolioses. dysfunction of the thoracic diaphragm, because of the attachments of the crura on the lumbar spine, affects the mobility of the spine and may be linked to dysfunction in the pelvic and cranial diaphragms through the core link. any dysfunctional pattern present in the skull should be treated. dysfunction in the occiput can affect the proprioceptive input from the craniocervical region. the vestibular apparatus located inside the petrous portions of the temporal bones contributes to balance mechanics and symmetric muscle tension. dysfunction between the sphenoid, occiput and temporal bones should, therefore, be treated. by virtue of the fact that fusion of the sbs does not typically occur before late adolescence, there remains mobility in the base of the skull of younger ais patients, making them particularly receptive to cranial treatment. cranial dysfunction may also affect the scoliotic patient through the reciprocal tension membranes. dysfunctional tensions in the dura have been proposed as an etiology of scoliosis. equilibration of intracranial and intraspinal membranes should, therefore, be employed. in younger patients where active bone growth is still present, intraosseous dysfunctions -most commonly encountered in the sacrum, lumbar and thoracic vertebrae and occiput -may be addressed using molding procedures. exercises are an important component of the treatment protocol. a properly employed exercise program should teach the patient to breathe effectively, increasing vital capacity and enhancing thoracic cage mobility. it should facilitate the establishment of the fullest range of motion possible and the development of symmetry of movement, particularly spinal rotation, while strengthening the core musculature and stabilizing the spine. it should allow the patient to develop proprioception and establish good postural habits. kyphosis is an increase of the spinal curve in the sagittal plane that results in a greater than normal posterior convexity (anterior concavity). an increased kyphotic curve is encountered more often in the thoracic spine, where it produces a rounded upper back, or 'humped back'. in the cervical and lumbar spines, normal curves present with posterior concavity or lordosis. under dysfunctional circumstances, the lumbar and cervical curves are reversed and become kyphotic. at the lower portion of the spine, a kyphosis can be ascribed to the sacrum, when its usual posterior convexity is increased. a thoracic kyphosis of > ° is considered pathologic. congenital kyphotic deformities are infrequent and can be caused by a failure of formation of the vertebral body or a failure of segmentation, for which the treatment is surgical. in the infant, tumor of the spine is also a potential cause of kyphosis that requires specifi c medical attention. in the juvenile period, scheuermann's disease is a cause of kyphosis resulting from an alteration of the vertebral development. wedging of the vertebral bodies, the posterior height being greater than the anterior height, produces the kyphotic deformity. boys are more frequently affected and the resultant back pain might be the trigger for an x-ray where the diagnosis is made. irregularities in the endplates of the vertebrae can be observed, particularly at the level of the lower thoracic and upper lumbar spine. scheuermann's disease may also be associated with scoliosis. because kyphosis is a spinal deformity, it should not be confused with poor posture. when examining an infant who is seated without support, it is normal to fi nd a kyphosis of the thoracic and lumbar spine. proprioception and muscular tone develop with age to maintain adequate sagittal balance. sagittal spinal curves change as a child grows. , the thoracic kyphosis is more pronounced in males, at a mean age of . years. more often, the exaggerated kyphotic curve is associated with dysfunctional posture. juvenile and adolescent kyphosis can be the result of poor posture, as a compensatory pattern to an extension dysfunction elsewhere. anterior displacement of the occipital bone on the superior articular surface of the atlas will project the chin forward, and the ensuing postural compensation will result in an increased thoracic kyphosis. this pattern is commonly found in individuals who demonstrate oral breathing. when encountered in a child, an apparent kyphosis may also be the result of protraction of the pectoral girdle. in this case, the thoracic curve is not fi xed in the kyphotic position and spinal backward bending can be achieved on demand, although lack of fl exibility is common. the child is usually shy, and an extension-internal rotation pattern may be present, either at the level of the pelvis or at the level of the sbs, the temporal or occipital bones. a thoracoabdominal diaphragmatic dysfunction is very often associated with diminished thoracic fl exibility and reduced vital capacity. the areas of the diaphragmatic attachments onto the inferior portion of the sternum and adjacent ribs might be the causative dysfunctional agents. an increased thoracic kyphotic curve is usually compensated for by an increase in the lumbar lordosis. kyphosis and lumbar lordosis generally compensate each other. a correlation between these two spinal curves has been found in most age groups. the cervical and lumbar regions are normally lordotic. hyperlordosis is an increase of the lumbar lordosis and is considered pathologic. it can be associated with other conditions, such as developmental dysplasia of the hip or neuromuscular disorders. there may be a family history of hyperlordosis, but it can also follow trauma, commonly from athletic activities, particularly highly competitive sports, during periods of growth. adolescents may also present with hyperlordosis as a consequence of a developmental spondylolisthesis. with this disorder, studies have shown an increase of hyperlordosis and sacral inclination, but a decrease of thoracic kyphosis. the degree of lumbar lordosis is correlated with sacral position. sacral anatomic extension (craniosacral fl exion) is normally associated with decreased lordosis; sacral anatomic fl exion (craniosacral extension) is associated with increased lordosis. the global amplitude of the vertebral curves, cervical lordosis, thoracic kyphosis and lumbar lordosis changes with growth, but the association with the position of the sacrum is constant under normal conditions. the relationship between the cranial and the pelvic bowls, through the core link, is a fundamental principle within the cranial concept. cranial fl exion is associated with sacral craniosacral fl exion, and cranial extension is associated with sacral craniosacral extension. the vertebral anteroposterior curves are decreased when fl exion of the cranial base is present; conversely, there is an increase of the lordotic or kyphotic curves with extension of the cranial base. early detection of kyphotic and lordotic curves is important for successful treatment. the child should be considered from a total body approach and the posture of the whole body should be evaluated in the standing position: • observe the pattern of weight-bearing mechanics. • observe the feet for a pattern of inversion or eversion. a pattern toward eversion of the feet, and eventually fl at feet, is consistent with increased sagittal curves and cranial extensioninternal rotation. • observe the knees. genu valgum is consistent with increased sagittal curves and cranial extension-internal rotation. • observe the pelvis for an increase of anterior tilt, with the sacrum in craniosacral extension. • observe for pelvic asymmetry and any difference in the greater trochanter and innominate crest heights. • observe the spine for an increase of the anterior-posterior curves. a pattern involving all of the curves might be the consequence of a cranial or sacral dysfunction with extension and internal rotation. a pattern of increased curvature limited to a portion of the spine may be associated with a dysfunction within the curve, in an adjacent spinal curve or adjacent junctions between the spinal ap curves. • observe the pectoral girdle for protraction or an associated asymmetric pattern. a difference in shoulder heights is common. this suggests somatic dysfunction in the thoracic spine with associated sidebending and rotational components. • observe the position of the head in relation of the rest of the body, in both the frontal and the sagittal plane. forward displacement of the head is often associated with somatic dysfunction of the craniocervical or upper thoracic vertebrae. next, observe the child while they are moving. if necessary, have the child demonstrate active fl exion-extension, sidebending and rotation of the spine to confi rm previous observations. muscles may show a difference in tension between anterior and posterior groups. hyperlordotic children will present with increased tension in the hamstrings and hip fl exors, while at the same time their abdominal muscles will lack tension. tests of listening are performed on the innominates, the sacrum, the lumbar and cervical vertebrae and the cranium. the treatment of any identifi ed dysfunctional areas should follow using indirect principles. the postural response to effective manipulation is almost immediate. you should be able to see improvement in the posture of the child after the fi rst treatment. simple exercises may be recommended, particularly if poor posture is present. pelvic tilt is useful, as are stretching the hamstrings and proprioceptive exercises to increase body posture awareness. the child should be encouraged to judiciously practice athletic activities, such as swimming and tai chi, which will strengthen and balance the core muscles and improve fl exibility and coordination. advice should be given that appropriately addresses daily living conditions. for example, the patient should avoid carrying a backpack on one shoulder; rather, they should carry it using both shoulders. they should avoid reading and writing on a fl at horizontal surface and should work instead on a surface that is tilted approximately ° to limit cervicothoracic fl exion. once the problem has been effectively addressed, the child may then be treated as needed, but they should be followed on a regular basis, at least annually, until they have stopped growing. pectus excavatum is a deformity of the anterior thoracic cage in which the sternum is depressed in a concave shape, whereas in pectus carinatum the sternum is protruded in a convex shape. these deformities may or may not be associated with genetic disorders or with scolioses. decreased thoracic cage compliance and reduced vital capacity may be present, although the heart and lungs develop normally. pectus excavatum and pectus carinatum are present at birth, but the parents usually do not become aware of the deformity until it becomes more apparent with growth. severe cases often result in signifi cant psychological impact, usually in early adolescence. pectus excavatum is frequently associated with an sbs extension pattern. this results in internal rotation of the paired structures, specifi cally the pectoral girdle. these individuals may also demonstrate direct mechanical derangement of the internal fascial structure of the thoracic cage and intraosseous dysfunction of the ribs and sternum. a diaphragmatic dysfunction is almost always associated with this condition. in pectus carinatum, similar mechanisms exist but with a tendency for sbs fl exion. the evaluation of the patient commences by examining the interrelationship between the sternum and the thoracic spine, and between the sternum and the occiput. next, examine all myofascial structures attached to the sternum, including the pectoral girdle and the diaphragm. the anterior abdominal wall should be evaluated for dysfunctional tension, and, if present, contributory mechanics should be sought out in the lumbar spine, sacrum and pelvis. visceral abdominal dysfunction should also be considered. treatment consists of myofascial release applied to identifi ed dysfunctions. if possible, molding procedures directed at the sternum should be employed simultaneously with the myofascial release modalities to enhance the effi cacy of both. the application of these procedures should be done in synchrony with, and with the intent to enhance, the inherent motility of the body. the younger the patient when treatment is initiated, the greater the potential for positive outcome. vertebral somatic dysfunction in infants and children can be found at any level of the spine. it will, however, be more commonly encountered in the lumbar, upper thoracic and cervical regions. it usually results from the day-to-day physical activities and traumas of childhood. in younger children, dysfunction in the cervical region will often present as cervical pain and, eventually, as torticollis. in the lumbar region, somatic dysfunction may remain quiescent for a protracted period, in time manifesting through a somatovisceral mechanism as abdominal pain. in older children and adolescents, the initial complaint from vertebral dysfunction is usually localized or referred musculoskeletal pain. because of the young patient's ability to compensate for somatic dysfunction, any vertebral somatic dysfunction should be thoroughly evaluated to rule out a viscerosomatic origin. the mechanics of vertebral somatic dysfunction manifest in children and adolescents is the same as that encountered in adults, showing the coupled relationships between fl exion-extension, sidebending and rotation as described by fryette. however, because of the fl exibility of the soft tissues in these young patients, dysfunctional barriers are more compliant, lending to the application of indirect techniques in their treatment. somatic dysfunction may also exist as a refl ex manifestation of visceral dysfunction and disease. although the precise locations of viscerosomatic refl exes in infants and young children have not been specifi cally reported, it is reasonable to anticipate locations similar to those in adults. the facilitated state of the segmental spinal cord in the presence of visceral input can, in turn, result in a somatovisceral response. a listing of viscerosomatic locations as they have been reported in the osteopathic literature is summarized in box . . . because of the growth potential of these patients, vertebral somatic dysfunction can exert disproportionate impact on their developing posture as well as on the viscera through somatovisceral refl exes. -the parasympathetic refl ex from the gastrointestinal tract proximal to the mid-transverse colon is vagal, occiput, c , c ; the parasympathetic refl ex from the distal half of the transverse colon to the rectum is sacropelvic s -s -the esophagus has a right-sided sympathetic refl ex from t to t -the stomach has a left-sided sympathetic refl ex from t to t -the duodenum has a right-sided sympathetic refl ex from t to t -the small intestine sympathetic refl ex is bilateral from t to t -the appendix and cecum sympathetic refl ex is from t to t on the right -the ascending colon sympathetic refl ex is from t to l on the right -the descending colon to rectum sympathetic refl ex is from l to l on the left. the clavicle is the bone most frequently fractured during the birth process. clavicular fractures occur in about . % of all vaginal deliveries , and . % when considering all live births. both males and females are affected equally, with equal left versus right-sided incidence. there is, however, a slightly increased incidence of right-sided fractures in left occiput-anterior deliveries. reported risk factors for clavicular fractures include increased duration of the second stage of labor, increased birth weight and neonatal length (macrosomia), instrumental delivery and shoulder dystocia. in cephalic presentation, the compression of the infant's anterior shoulder against the maternal symphysis is responsible for the trauma. direct pressure or torsion applied to the clavicles to facilitate delivery can also result in fracture. complete or incomplete greenstick fractures are most frequent. they present with edema, crepitus, a palpable bony bump and tissue texture changes over the fracture site. decreased or absent movement of the affected arm is present, as may become apparent when eliciting the moro refl ex. asymptomatic or incomplete clavicular fractures may not be initially identifi ed until after discharge from the hospital. usually, the caregiver will notice that the child demonstrates irritability with discomfort and pain when putting the child's arm through the sleeve of a garment or when lifting the child by holding them under their arms. they are also liable to report that the child cries when positioned on the affected side. shoulder dislocation, humeral fracture and brachial plexus injury are part of the differential diagnoses. the diagnosis is confi rmed radiographically. associated complications, such as erb's palsy, are present in . % of newborns with fractures of the clavicle, although clavicular fracture may actually reduce the potential nerve injury from traction on the brachial plexus. usually no orthopedic treatment is necessary for asymptomatic and incomplete clavicular fractures. when the neonate presents with pain or discomfort, the affected arm may be immobilized by pinning the sleeve to the front of the shirt for - days. a large callus typically forms at the fracture site within a week, and recovery is usually considered to be complete. osteopathic procedures may be employed to assist the recovery process and address the dysfunctions usually associated with a fracture of the clavicle. the clavicle is of importance because of its myofascial attachments. it serves as a junction between the fasciae of the thorax, arm and neck. the investing layer of the deep cervical fascia completely surrounds the neck. superiorly, it is attached to the external occipital protuberance and the superior nuchal line, the mastoid processes, zygomatic arches and the inferior borders of mandible. it splits to surround the trapezius and sternocleidomastoid muscles. inferiorly, it is attached to the manubrium of the sternum, the acromion and the spine of the scapula. the clavicle is the link in the fascial continuity between the investing layer of the deep cervical fascia and the fascia of the thorax and the arm. the clavipectoral fascia attaches on the clavicle, as does the deltoid fascia. the deltoid fascia is in continuity with the brachial fascia. the clavicle, therefore, plays an important role in the equilibrium of the fascia of the thorax, arm and neck, and should be balanced, as should the myofascial structures attached to it. forces applied during the delivery that are great enough to fracture the clavicle also affect the neck and upper thoracic vertebrae of the neonate. therefore the osteopathic practitioner should evaluate these structures and treat any dysfunctions accordingly, using indirect principles. furthermore, because of pain from the fractured clavicle, the child will prefer to lie on the opposite side, thereby fostering the development of asymmetric fascial tensions. these asymmetries can, in turn, induce the child to select a chronic position of comfort, long after the clavicle has healed. the chronic asymmetric positioning can then predispose the child to the development of plagiocephaly. fractures of the clavicle that occur during childhood are usually the result of rough play or athletic activities. in childhood, the forces that result in clavicular fractures are usually violent, most often involving impact on the hand with the arm extended or impact on the shoulder. in % of cases the site of fracture involves the medial third of the bone. the standard orthopedic treatment reduces the displacement at the fracture site by maintaining the shoulder in an upward and backward position with a bandage or plaster. osteopathic procedures applied to the older child follow the same anatomic principles as for the infant, i.e. to alleviate myofascial imbalances and upper thoracic and cervical dysfunction. the acromioclavicular junction may demonstrate somatic dysfunction; it should, therefore, be evaluated and treated following indirect principles. it is of importance to allow for normal function of the growing upper extremity. acromioclavicular dysfunction is the source of many adult shoulder disorders. a brachial plexus injury occurs most commonly as a result of a diffi cult birth, fetal malpresentation, shoulder dystocia, macrosomia or assisted vaginal delivery. fracture of the clavicle(s) or humerus, shoulder dislocation, torticollis, hematomas of the sternocleidomastoid muscle or paralysis of the diaphragm may be associated with injury of the brachial plexus. a commonly believed etiology of brachial plexus injury is excessive traction on the fetal head during birth. in vaginal delivery, during the attempt to deliver the anterior shoulder, the applied downward traction can damage the brachial plexus. this theory, however, is questionable because, in almost half the cases of brachial plexus injury, delivery of the shoulders occurs without diffi culty. therefore, an in utero, atraumatic theory is also proposed. when asymmetry and diminished movement of the arm are observed on the fetal ultrasound, a vulnerable plexus may be injured without traction during delivery. the brachial plexus is formed by the union of the anterior divisions of the lower four cervical nerves and part of the anterior division of the fi rst thoracic nerve. in addition, the fi fth cervical nerve frequently receives a branch from the fourth cervical, and the fi rst thoracic a branch from the second thoracic. the plexus extends from the inferior aspect of the side of the neck to the axilla. the fi fth and sixth cervical nerves unite to form the upper trunk; the eighth cervical and fi rst thoracic nerves form the lower trunk, while the seventh cervical nerve runs out alone as the middle trunk. these three trunks pass beneath the clavicle and split into the anterior and posterior divisions. the plexus is attached to the fi rst rib and to the coracoid process by the costocoracoid membrane and is subject to any force that disturbs the relationship between the cervical vertebrae, the fi rst thoracic vertebra and ribs, the clavicle and the scapula (fig. . . ) . most of the time brachial plexus injury is unilateral and immediately recognizable. brachial plexus injury can affect different spinal nerve roots and is identifi ed as follows: • upper type, with involvement of c and c , or erb-duchenne palsy that affects muscles of the shoulder and elbow. the child presents with adduction of the upper extremity and internal clinical conditions rotation of the shoulder, but grasp remains intact. it represents most of the brachial plexus paralyses and is considered to have a good prognosis. • lower type, with involvement of c , c and t , or klumpke's palsy that affects muscles of the forearm and hand. the child presents with a paralysis of the hand and wrist. the presence of an ipsilateral horner's syndrome (anhidrosis, miosis and ptosis) indicates an involvement of the sympathetic fi bers associated with an intraspinal avulsion of the root of t . • whole arm type, with involvement of c -t , with no movement of the upper extremity and often associated with sensory loss. extreme lateral fl exion and traction of the head may be responsible for the stretch applied to the brachial plexus. the injury results in anything from a mild edema or hemorrhage within the affected nerves, to tearing of the nerve(s) that could be as extensive as to produce a total avulsion of the complete plexus. the c and c spinal nerves are located in the sulcus nervi spinali of the transverse processes. in that location they are strongly attached by various fi brous slips as extensions of the prevertebral fascia and surrounding structures attached to the spinous processes, and are, therefore, more likely to be ruptured. the c and t spinal nerves may, more often, be subject to avulsion. neuronal injury associated with brachial plexus injury may be of different degrees of severity: • neuropraxic lesions are failure of conduction without the axon having been affected, and are reversible. • axonotmetic lesions involve disruption of both the myelin sheath and the axon, but with the surrounding neuronal elements kept intact. wallerian degeneration of the axon distal to the injury occurs. • neurotmetic lesions are total sectioning of the nerve with its myelin sheath and supporting connective tissue. • avulsion is a separation of the plexus from the spinal cord. obstetric brachial plexus palsy occurs in . - . per live births with an upper root (c -c ) involvement in % of cases; c , c and c involvement in %; and the whole plexus in %. , , neuropraxic and axonotmetic lesions have better prognoses. the diagnosis is made by physical examination. the moro refl ex is asymmetric and the biceps' deep tendon refl ex is absent. the grasp refl ex is, however, normal. the child should be moved very gently: the injuries are painful and the tissues very fragile. initial treatment is usually conservative with regular assessment. if the patient fails to show signifi cant improvement by months of age, surgical opinion should be sought. physical therapy, consisting of gentle passive mobilization, may be employed to maintain range of motion and prevent contractures while the infant is recovering active motion. specifi c motor training can be initiated within the fi rst weeks, with facilitation of active movement. the persistent neurologic defi cits may result in the development of internal rotation and adduction contractures of the arm. gentle stretching of internal rotators should be performed to reduce this risk while avoiding reinforcement of forearm supination. osteopathic procedures should be employed as early as possible in the treatment of brachial plexus injury. traumatic forces may have injured the brachial plexus, but other areas, such as the upper thoracic spine, the fi rst rib, the cervical spine, clavicle and all of the myofascial components of the thoracic outlet, have been stressed as well. dysautonomia may also be present because somatic dysfunction of the cranial base and occipitoatlantal region can affect the parasympathetic tone through the vagus nerve, while somatic dysfunction in the upper thoracic spine can affect sympathetic nervous function. direct compression of the venous and lymphatic drainage of the brachial plexus, as well as somatovisceral refl exes, should be considered when attempting to facilitate nerve regeneration. osteopathic procedures aim to promote fl uid, electrolyte and metabolic exchange within the tissues to facilitate drainage of edema and to prevent or reduce tissue scarring. treatment is intended to optimize nerve regeneration and prevent the development of muscular imbalance. recuperation of the common motor defi cits, such as the absence of active external rotation, fl exion and abduction of the shoulder, and function of the biceps should be addressed to minimize bony deformities and joint contractures. the neonate with possible brachial plexus injury may be examined on the treatment table. observe for spontaneous movements of the head, trunk, pelvis and limbs. check for subtle facial palsy that may be found as a concomitant result of birth trauma. inspect shoulders and limbs for deformities. evaluate range of motion of every joint of the affected limb. palpate for tissue texture changes in the upper extremities. look for signs of shoulder instability such as a palpable or audible click during movement. palpate for tissue texture changes in the suboccipital, neck and upper thoracic areas. the connective tissues are responsible for the maintenance of shape against both external and internal stresses. mechanical forces contribute to the development and evolution of the extracellular matrices found in the connective tissues. as tissue texture changes follow trauma, osteopathic procedures should help in resetting structure and function of traumatized connective tissues. evaluate, through tests of listening, the function of the humerus, scapula, clavicle, sternum, upper thoracic spine, fi rst ribs, cervical spine and craniocervical joints. this method of assessment is of particular value with this type of pathology because it is so gentle. anatomic visualization is, as always, important. as you evaluate the patient, visualize the different layers of soft tissue: fascia superfi cialis, cervical fascia, costocoracoid membrane, sternocleidomastoid and scalene muscles. evaluate and visualize the different bones involved. listen to the inherent motions in order to defi ne the dysfunctional area. study the relationship between the shoulder and the vertebral column. for instance, in the case of a klumpke's palsy, place the pad of the fi ngers of one hand on the spinous processes of c , c , t and t , and place the other hand on the ipsilateral shoulder. listen, and look for dysfunctional motion. one vertebral segment may be more dysfunctional than others. the relationship between the humerus and the shoulder should also be balanced. treat the dysfunctions you identify by applying indirect principles. improvement should be rapid and most cases have a favorable prognosis. injuries involving the fi fth and sixth cervical nerve roots have the best prognosis, whereas lower plexus and total plexus injuries have a poorer prognosis. signifi cant defi cit persisting after months should be explored surgically. prognosis is excellent if antigravity movement of biceps and shoulder abductor is present by months of age. assessment may be performed by testing the biceps' strength in a supine position while simultaneously palpating the muscle. bicipital activity should not be confused with fl exion of the elbow obtained by the action of the supinator muscle. surgery is considered by some authors when antigravity movement of the biceps is not present by months of age. surgery is considered to be justifi ed by others when an initial involvement of the c nerve root is present, with a birth weight above the th percentile and there is only poor elbow fl exion at and months of age. the plasticity of the glenohumeral joint in the newborn makes it subject to shoulder dysplasia and, in more severe cases, dislocation. these disorders may be compared to similar disorders occurring in the hip joint -hip dysplasia and hip dislocationand in some cases the etiology may be similar. intrauterine forces applied to the fetus can result in shoulder dysplasia. during the latter part of pregnancy any compression of the upper fetal torso within the uterus may affect the glenohumeral joint and the surrounding soft tissues. stresses during the birth process can also contribute to the development of shoulder dysplasia. increased duration of the second stage of labor, greater than hours, has been described as a factor contributing to shoulder dystocia. additionally, macrosomia that results in a size discrepancy between the fetal shoulders and the maternal pelvic inlet can, in severe cases, lead to signifi cant neonatal morbidity including asphyxia and trauma, particularly to the brachial plexus. a large fetal trunk, or increased bisacromial diameter, prevents the rotation of the fetal shoulders into the oblique pelvic diameter during delivery. as a consequence, certain obstetrical maneuvers may have to be employed to alleviate the impaction of the fetal shoulders within the maternal pelvis. as stressful as such a disproportionate relationship between the fetus and the maternal pelvis can be, it does not always result in overt trauma to the brachial plexus. it can, however, cause injury to the shoulder that can lead to shoulder dysplasia. this type of injury to the shoulder can occur even from the stresses of an otherwise normal delivery. dysplasia of the shoulder may also result from postpartum conditions. the presence of dysfunctional asymmetries in the newborn, congenital muscular torticollis, non-synostotic plagiocephaly and brachial plexus injuries may contribute to abnormal development of the glenohumeral joint. contractures of the muscles of internal rotation in neonatal brachial plexus palsy are responsible for posterior dislocation of the humerus from the glenoid fossa, - requiring orthopedic repair. milder cases of dysplasia without dislocation may be treated using osteopathic procedures. if untreated, these glenohumeral dysfunctions can increase with age, becoming the cause of adult scapulothoracic problems. therefore, the scapula and the glenohumeral joint should be evaluated at birth for any signs of dysplasia, as precisely as the pelvis is evaluated. particular attention should be directed at the identifi cation of signs of shoulder instability, such as a palpable or audible click during movement. observe and compare the size and shape of both shoulders. the examination may reveal asymmetry in the number of skin folds in the proximal part of the arms. observe the freedom and range of motion of both shoulders. note any restriction, stiffness of movement and asymmetry in movement, particularly external rotation and abduction of the arm. the malposition of the humeral head may result in an apparent difference in the length of the arms, with the arm on the side of the dysplasia appearing to be shorter. compare the anterior and posterior aspects of the shoulders and look for any posterior fullness that may be indicative of a posteriorly displaced humeral head, necessitating orthopedic attention. treat any somatic dysfunction identifi ed using indirect principles. stabilization of the humeral head in the glenoid fossa may be facilitated when myofascial procedures are applied to the periarticular muscles of the shoulder. nursemaid's elbow, also called pulled elbow, is a radial head subluxation that occurs in younger children when traction is applied suddenly to their hand or forearm. this commonly occurs when an adult is attempting to lift a child up by pulling upward while holding the child's hand. traumas such as falls or when the infant initiates rolling over are other possible causes of this condition. the head of the radius articulates with the radial notch of the ulna and the surrounding annular ligament. under normal conditions, the annular ligament encircles the head of the radius with a certain amount of tension that maintains the contact with the radial notch. the normal movements of the head of the radius, within the ring formed by the annular ligament and the radial notch of the ulna, are anterior and posterior motion. pronation is associated with posterior radial motion and supination with anterior radial motion. in nursemaid's elbow a subluxation of the developing radial head from the annular ligament of the elbow joint occurs. a combination of pronation and traction on an extended elbow causes a proximal slip of the annular ligament over the top of the radial head with resultant interposition of some fi bers of the anterior joint capsule between the two bones. the most common symptoms of nursemaid's elbow are immediate pain and an inability to move the arm. the child will have a partially fl exed elbow with pronation of the forearm. most of the time anxiety is also present. the intention of osteopathic treatment is to restore motion between the head of the radius and the radial notch of the ulna and surrounding annular ligament. ligamentous articular strains may be balanced utilizing indirect principles that apply perfectly to this condition. balancing the annular ligament and the radial collateral ligament of the elbow may prevent recurrence of a posterior radial head subluxation. the caregiver should be told to avoid pulling or lifting their child by the arms or hands. a frequent complaint in an osteopathic practice is intoeing, i.e. the child's feet turn in when walking or running. malposition of the feet, developmental dysplasia of the hip and toe walking are among the other complaints encountered with infants, while sprains are more frequently encountered with the older children and teenagers. metatarsus adductus is an adduction of the forefoot that occurs in : live births. the classic view of it resulting from intrauterine positioning is debated, since genetic factors may contribute. sleeping in the prone position also seems to promote it. this is a frequent cause of intoeing during the fi rst year of life and is more frequently encountered on the left side. normally, in the neutral position, the heel-bisector line drawn through the midline axis of the hindfoot passes through the forefoot at the second web space. in cases of metatarsus adductus, the line passes lateral to the third toe. therefore, an angulation exists medially between the forefoot, or metatarsals, and the hindfoot. sometimes a transverse crease is present on the medial side of the foot and the lateral border of the foot is convex (fig. metatarsus adductus associated with an inversion of the foot is named metatarsus varus and adduction of the fi rst metatarsal is metatarsus primus varus. metatarsus adductus is frequently associated with internal tibial torsion. metatarsus adductus associated with retracted equinus -the inability to dorsifl ex at the ankle -is indicative of a diagnosis of clubfoot. dysfunctions of the feet might not seem grave, but left untreated they will lead to postural dysfunctions and compensatory dysfunctions of the feet, with diffi culty wearing shoes and the development of bunions and hammer toes. a group of children with metatarsus varus, followed an average of years, showed that % maintained a moderate, although asymptomatic, deformity and % demonstrated residual deformity and dysfunction (stiffness). the opinion is that metatarsus adductus left untreated will persist into adulthood in - % of cases. , furthermore, some cases only appear to be clinically improved because of a compensatory pronation of the midtarsal joints and rearfoot. metatarsus adductus is classifi ed according to its fl exibility. normally, an infant should extend and abduct the foot when being tickled (e.g. with a toothbrush) along the lateral border of the foot, particularly over the fi fth metatarsal head. the inability of the infant to react in such a way is indicative of metatarsus adductus. the physician should consider the total body approach and treat any dysfunctional mechanics, particularly of lisfranc's joints (tarsometatarsal) following the principles of functional procedures. the parents should be encouraged to stimulate abduction of the forefoot, using a toothbrush or similar stimulus, as described above. in more severe cases it should be proposed that stretching exercises be practiced several times a day (e.g. at each diaper change). the calcaneus is maintained between the thumb and index fi nger, while the forefoot is gently pulled into a corrected position, holding the correction for seconds and repeating the process about fi ve times. it should be stressed that this exercise should be done properly, without creating a valgus of the hindfoot. if these treatments fail, and also in cases of clinical conditions severely rigid feet, a series of casts are used to gradually straighten out the deformity. ctev, or clubfoot, is a complex deformity of unknown pathogenesis with several etiologic hypotheses that range from genetic to intrauterine factors. the head-body angle of the talus (declination angle) which normally increases after the th week of gestation has been found to be decreased in ctev, associated with hypoplasia of the talus. more recently, studies indicate that talar deformity is not the primary lesion, but follows loss of spatial orientation of the deltoid and spring ligaments and tibialis posterior tendon insertion, with contracted soft tissues. ctev is a relatively common congenital deformity that occurs with geographical differences ranging from . : live births in japan to : in the south pacifi c ( . : live births among caucasians). about % of the cases are bilateral. the male-to-female ratio for affected children is . : . , clubfoot deformity presents with different components: hindfoot equinus (inability to dorsifl ex), hindfoot varus and metatarsus adductus. the fl exibility of the deformity is important to determine the degree of severity. classic treatment consists of manipulation of the foot followed by casting. generally, casting is attempted for months; if unsuccessful, surgery is planned. osteopathic procedures should be employed as early as possible for best results. every bone of the hindfoot -the calcaneus, talus, navicular and cuboid bones -should be evaluated and treated to release any dysfunctional relationships between them and to equilibrate the soft tissues surrounding them. the deltoid and plantar calcaneonavicular (spring) ligaments are of particular importance and should be balanced with gentle fascial release procedures. pes cavus, or high-arched or hollow foot, should fi rst make you think of ruling out an underlying neurologic disorder as the primary etiology. anterior pes cavus, where both the medial and lateral longitudinal arches are high, is benign. medial pes cavus is more severe, often with claw foot deformity of the toes. the two may be differentiated by dorsifl exing the foot. in the presence of medial pes cavus the claw foot deformity of the toes increases with dorsifl exion of the foot. the position and range of motion of the hindfoot bones, particularly the talus, should be evaluated. hollow foot is often associated with a fl exionexternal rotation pattern of the craniosacral mechanism. you must differentiate total fl at foot or total hollow foot from partially fl at foot or partially hollow foot. in the latter, only the posterior portion of the longitudinal arch is involved, resulting from an imbalance of the subtalar, calcaneocuboid or cuneocuboid articulation. a rigid pes planus is a pathologic fl at foot, also named tarsal coalition, in which one or more of the tarsal bones that should have a joint between them become fused. in infants the fused joints are cartilaginous and are still relatively fl exible. thus the condition is typically not symptomatic before adolescence. physiologic pes planus is a loss or reduction of the longitudinal arch ( fig. . . ) that can be reestablished when the child stands on their toes. physiologic pes planus is fl exible and often associated with generalized ligamentous laxity. in a sample of primary school children, . % demonstrated fl at feet, and being overweight was shown to increase the prevalence of the condition. because of ligamentous laxity and/or obesity, the child's ankles cave in. the plantar calcaneonavicular ligament plays an important role in maintaining the arch of the foot ( fig. . . ). it supports the head of the talus and is part of the astragalonavicular joint. any dysfunction of the plantar calcaneonavicular ligament affects the head of the talus that tends to be displaced downward, medially and forward by the weight of the body. the tibialis posterior, an inversion muscle, lies directly below the plantar calcaneonavicular ligament and participates considerably in maintaining the longitudinal arch of the foot. in cases of dysfunction of these structures, the foot becomes fl attened, expanded and turned laterally. this condition has been suggested as a cause for tarsal tunnel syndrome. it has also been suggested as contributing to back and knee problems later in life, but no evidence supports this contention. flat feet and dysfunction of the spine are, however, very often two components of the same problem, where postural mechanics are involved. flat foot is usually associated with an extension-internal rotation pattern of the craniosacral mechanism. the treatment of physiologic pes planus with orthotic devices is controversial. insole arch supports diminish some of the muscular activity that maintains the arch and tend to weaken the muscles. two studies suggest an association between wearing shoes at an early age and fl at feet. , this stresses the importance of allowing the feet to grow and develop without constraint. parents should be reassured about their concerns regarding the child's appearance and gait. this condition tends to improve between and years of age. to promote optimal growth without dysfunctional mechanics, the osteopathic practitioner should consider the global posture of the child. check for rearfoot valgus by assessing the position and freedom of the calcaneus and talus. check also for internal rotation dysfunction of any of the tarsal bones. encourage the child, through their parents, to maintain a healthy lifestyle, to go barefoot as much as possible and not to become overweight. physical activities that strengthen foot inversion, such as walking on the lateral borders of the feet or picking objects with the toes, should be recommended. positional calcaneovalgus, the result of intrauterine malposition, is a fl exible dorsifl exion of the ankle with a mild subtalar joint eversion. it is frequently associated with external tibial torsion and has the appearance of fl at feet. treatment follows the principles of functional procedures to address the subtalar dysfunction. sprains and strains are common in the pediatric population. young athletes are particularly vulnerable. activities that involve jumping and landing, as in skateboarding, often result in such injuries. these injuries are, however, not limited to young athletes. young children can sustain sprains and strains with activities of daily living, such as ascending or descending stairs. these injuries may be overlooked because of the child's tendency to get up and resume activity unless severely injured; however, if not properly addressed, such injuries can be the source of functional asymmetry and somatic dysfunction, often with sequelae in other anatomic areas at a later date. following a foot or ankle sprain that causes excessive or prolonged midfoot pronation, abnormal patellofemoral mechanics may result. traumatic twisting of the forefoot, most often inversion, commonly causes ankle injuries, often resulting in, but not limited to, sprains or strains involving the tibia, fi bula and talus. it should be remembered that these stresses may also result in specifi c dysfunctions between the fi bula and talus, the talus and calcaneus, the talus and navicular bone, and the calcaneus and cuboid, as well as dysfunctions between any of the other adjacent tarsal and metatarsal bones (figs . . , . . ). on physical examination, the acutely injured ankle presents with pain and swelling and, with more severe injuries, ecchymosis. ecchymosis indicates possible ligamentous tears or bony fracture necessitating radiographic evaluation. further, if the subject is not willing to bear weight on the injured ankle, or if signifi cant edema is present, radiographic evaluation is also appropriate to evaluate the extent of injury. once bony fracture has been ruled out, soft tissue injuries may be treated with osteopathic manipula-tion by employing indirect principles. under these circumstances, the patient should experience no aggravation of discomfort during the treatment procedure and will often feel a signifi cant reduction of pain and swelling following the intervention. posttreatment reduced weight bearing and avoidance of stressful activities should be recommended. immobilization of the injured area with strapping methods should be considered for adolescents and individuals likely to be involved in weight-bearing activities. when there is no more pain for a week, a rehabilitation program can be organized to work the injured ankle in full range of motion with progressive resistance exercises. exercises with a balance board, to strengthen proprioception, function and coordination, are also indicated. the patient places the foot on the board and fi rst does fl exion-extension movements, followed by rotation of the ankle around the ball (fig. . . ) . a thorough history and physical examination should be performed to rule out diagnoses such as cerebral palsy, which can present with rotational misalignment of the legs. internal tibial torsion is said to be the result of intrauterine positioning or from the child's habit of sitting on their feet. this is often noticed by the parents between and years of age and is a common cause of intoeing in children under years of age. internal tibial torsion is more often bilateral; when unilateral, the deformity most commonly affects the left side. parents complain that their child is clumsy, trips and falls easily, although intoeing in athletes has been suggested as benefi cial in activities like sprinting. about - % of all torsional deformities resolve spontaneously by maturity. when it does not resolve, however, dysfunctional rotation results in improper alignment of the lower limb and is associated with arthrosis of the hip, knee and ankle. external tibial torsion is usually diagnosed later and demonstrates a tendency to increase with age. it is associated with conditions of the extensor apparatus as unstable patellofemoral joints and osgood-schlatter disease. , examination of rotation of the tibia is best done with the child in the prone position with their knee fl exed to °. this allows measurement of the footthigh angle, the angle formed between the long axes of the femur and the foot. the osteopathic practitioner should consider a total body approach with specifi c attention to intraosseous and myofascial tensions in the lower limbs. the relationships between the fi bula and the tibia, as well as between the tibia and the femur and the tibia and the talus, should be balanced. osteopathic procedures directed at functional alignment and balance of the lower extremity improve function and should reduce stressful compensatory patterns that may later result in patellar tendonitis and arthritis. femoral torsion is defi ned by the angle between the femoral neck axis and the transcondylar axis of the distal femur. femoral torsion can be internal (femoral anteversion) or external (femoral retroversion) and results in the knees pointing toward or away from each other, respectively. a normal femur is anteverted, i.e. the femoral head and neck are rotated anteriorly with respect to the femoral condyles. babies have ° of femoral anteversion. this decreases by about . ° per year to reach ° in adult life. femoral anteversion is also a very common cause of intoeing in children under years of age, the child being obliged to internally rotate the femurs in order to re-center the femoral heads in the acetabula. observation of the child's gait allows one to differentiate between intoeing that is the result of internal tibial torsion as compared to femoral anteversion where the patellae are positioned more medially on the knees. the child trips and falls frequently and does not like to sit with their legs crossed, preferring to sit in a 'w' position (fig. . . ) . parents note that the child's shoes are very quickly worn out in an asymmetric pattern. studies in adults in whom the condition remained uncorrected found a correlation between femoral anteversion and arthritis of the knee. normally, hip range of motion shows greater amplitude in medial rotation than in lateral rotation. abnormal femoral anteversion can be predicted (± sd from the mean) if the difference between medial and lateral rotation is ° or more. the osteopathic practitioner should consider a total body approach and release intraosseous and myofascial tension in the lower limbs. the pelvis should be diagnosed and treated if necessary, as well as the coxofemoral joint. somatic dysfunction of the innominate, particularly during periods of growth, is signifi cant because of the infl uence it can have on the position of the femur. genu varum and genu valgum -also known as bowlegs and knock-knees, respectively -are common angular deformities of the lower extremities in children. all babies are born bowlegged. between the ages of and years the bowlegging gradually decreases, and by years the average child is maximally knock-kneed. the knock-kneeing straightens minimally over the next several years and, by age years, most children have reached the typical adult confi guration, which is slightly knock-kneed. persistent genu varum is better tolerated functionally than valgus, which causes stress to the medial aspect of the knee joint with the subsequent development of pain. the wider the varus or the valgus, the greater the shear stress (lateral-medial forces) on the joint. an angular deformity is not physiologic when it is asymmetric or painful and radiographs might be necessary. bilateral varus is associated with craniosacral fl exion of the sacrum, and bilateral valgus with a sacrum in craniosacral extension. unilateral varus problems are very often associated with fl exion-external rotation patterns on the same side at the level of the pelvis, the temporal bone or the occipital bone. similarly, unilateral valgus problems are associated with extension-internal rotation patterns of these same areas. using indirect procedures from a total body perspective, treatment is directed at specifi cally diagnosed dysfunctional mechanics. the distance between the knees (with the ankles together) of children who have varus, or between the ankles (with the knees together) of children who have valgus, can be measured to follow the response to treatment. the knee can also present minor strains. a commonly found pattern occurs when an increased medial femoral torsion is combined with excessive lateral torsion of the tibia. this is found more often as the result of physical activities, such as in skiing, when the ski is stuck in the snow, slightly abducted, and the rest of the body moves forward. the relationship between the tibia and the femur should be balanced to address these strains. congenital dislocation of the patella is rare and may be isolated or associated with other limb malformations. patellar instability is not a congenital condition, although anatomic confi gurations such as patella alta, trochlear dysplasia and ligamentous laxity are thought to participate in the instability. mri permits visualization of the nonosseous components of the patellofemoral articulation in the child. the cartilaginous composition of the articulation provides less restraint to lateral movement of the patella that allows instability. the trilaminar soft-tissue structures surrounding the patella present interconnections with the fi bers of the iliotibial tract, lateral hamstrings and lateral quadriceps retinaculum. tightness in these structures has been suggested as causing excessive posterior and lateral pull, contributing to patellar instability, especially if the medial patellofemoral ligament is injured and cannot stabilize the knee. these structures are linked to the pelvic bone, and recurrent dislocation of the patella can be associated with pelvic dysfunctions that interfere with the balance transmission of weight-bearing forces. osgood-schlatter disease occurs mainly in athletic adolescent boys. it is suggested that a welldeveloped and inelastic quadriceps creates a traction apophysitis on the tibia, with the development of loose ossicles and elongation of the patellar ligament leading to patella alta. patients with osgood-schlatter disease also present with increased external tibial torsion that, in association with other factors, has been suggested to predispose to the onset of the disease. the osteopathic practitioner will consider a total body approach and release the pelvis, the hips, the knees and the patellofemoral articulations ( fig. . . ). myofascial release should be considered for the thigh and patella. gentle and pain-free stretch-ing exercises should be done at home on a regular basis and should address tension in the quadriceps, the upper and lower iliotibial tract, the hamstrings, the hip fl exors, the hip abductors, the gastrocnemius and the soleus. a long-term maintenance program should include strengthening in terminal knee extension in association with isometric exercises of the above muscles. patellar knee sleeves are sometimes useful. they might have proprioceptive effects offering support. patients feel less pain and the support provides some kind of reassurance. different terms describe hip dysfunctions. 'developmental displacement of the hip' (ddh) is proposed in replacement for 'congenital dislocation of the hip' to stress the fact that the condition can occur prenatally or postnatally. the different variants of the abnormalities of the hip joint include shallowness of the acetabulum and capsular laxity with resultant instability and propensity for dislocation. ddh refers to a defi cient development of the acetabulum that could lead to subluxation and dislocation. the femoral head remains well covered by the acetabulum in the early fetal period (between and weeks) and dislocation does not occur at this early time. however, at birth, the human acetabulum is shallower than at any other time during development and is consequently vulnerable for hip instability. mechanical factors seem to play a role in neonatal hip instability. moderate loading of the hips at ° of fl exion maintained for hours has been shown to distend the articular capsule and to produce deformation and dislocation of the joint resembling that found in ddh. modifi cations in the pressure on the cartilaginous acetabulum are thought to interfere with normal bone growth. uterine constraint is proposed by numerous authors as an explanation for the association between ddh and other deformations. foot deformity, congenital torticollis, congenital postural scoliosis , and plagiocephaly are frequently associated with ddh. the sleeping position of the infant, with a preference to lie on one side (the 'side-lying syndrome'), has also been proposed as a contributing factor to ddh. leg postures, associating extension and lateral rotation, critically predispose the infant to hip dislocation during fetal life and at birth. interestingly, the newborn psoas muscle is totally relaxed in full abduction, fl exion and lateral rotation. this muscle is always a lateral rotator of the hip, but exerts a much greater effect when the femur is abducted. extending the hip results in a levering action that is potentially critical if associated with other contributing factors such as acetabular or femoral ante-version and dysplasia. caution should, therefore, be exerted when moving the leg into combined extension and lateral rotation. ddh occurs in : live births and is more frequently encountered on the left side. being female, fi rst-born, having been carried or delivered in the breech position , , and having a family history of acetabular dysplasia or ligamentous laxity are the main risk factors. dislocation of the hip requires orthopedic attention. clinical examination reveals asymmetries in the number of skin folds on the thigh and the inability to completely abduct the thigh when the knee and hip are fl exed. the malposition of the femoral head may cause the leg on that side to look shorter than the other. barlow and ortolani positive tests confi rm the diagnosis and are performed with the child supine on a fl at pad, placing the fi ngers on the baby's greater trochanters and the thumbs on the inside of the lower portion of the thighs and knees. the hips and knees are fl exed to °. the barlow test consists of adducting the legs and pushing down gently on the knees in an attempt to disengage the femoral head from the acetabulum. a 'clunk' will be felt as the femoral head dislocates. the ortolani test relocates a dislocated hip and is performed by slowly abducting the thighs while maintaining axial pressure. the fi ngers on the greater trochanter exert a movement in the opposite direction to assist the return of the femoral head to the acetabulum. the examiner will again feel, and hear, a 'clunk.' diagnostic ultrasonography may be carried out after - weeks and radiographs after - months; before these ages there is insuffi cient ossifi cation for the tests to be diagnostic. different methods of treatment are proposed for ddh, with good results. abduction devices (pavlik harness) and traction followed by plaster immobilization are always done with special care because of the risk of aseptic necrosis of the femoral head. a program of home abduction-adduction exercises administered by the parents has been successful in infants with limited abduction and acetabular dysplasia without dislocation. developmental dysplasia of the hip -insuffi cient depth of the acetabulum to accommodate the femoral head -in the infant can be associated with pelvic imbalance, such as intraosseous dysfunction of the innominates and sacrum, coxofemoral dysfunctions and eventually with craniosacral dysfunctions. the innominate bone needs to be in a neutral position in order to provide a satisfactory acetabular placement. an internally rotated innominate results in a higher position of the acetabulum, leading to an apparently shorter leg on that side. this can be confused with the apparent inequity of leg length found in association with hip dislocation. osteopathic procedures attempt to balance the craniosacral mechanism of these children. the relationship between the sacrum and the occiput, the temporal bones and the innominates should be balanced. special care is given to myofascial structures responsible for pelvic tensions or pelvic asymmetry. myofascial procedures should be applied to the periarticular muscles of the hip, in particular the iliopsoas, the adductors and the abductors, to release contracture of the joint and improve restrictions of motion in adduction or abduction. the treatment of dysplasia is intended to stabilize the femoral head in the acetabulum and to allow the growth of a symmetric pelvis with a balanced sacrum, innominates and hips. dysfunctional interosseous relationships between the sacrum and the innominates, and between the innominates and the femurs, should be identifi ed and treated. any dysfunctional intraosseous relationship between the ilium, ischium and pubes should be also balanced, and, if present, intraosseous dysfunction of the sacrum treated. clinical examination of these children should be repeated during the st year, with an annual follow-up, until full skeletal maturity. dysplasia may result in early development of osteoarthritis of the hip. [ ] [ ] [ ] [ ] treatment should be directed at promotion of function and prevention of future degenerative changes. by the age of years children should be walking with a heel-toe gait. after this age, toewalking is abnormal and can be due to an underlying neurologic disorder. a tight achilles tendon may be present, but in other cases nothing will be found. look for any extension dysfunction of the craniosacral mechanism. balance the sacrum and the craniocervical junction. release the posterior myofascial components of the spine and inferior limbs. teach the child to walk heel-toe. because serious medical and orthopedic conditions may be responsible for limping, any such underlying pathology should be ruled out before using manipulation as a primary treatment. for example, a limp or a waddling gait between the ages of and years might be associated with a congenital coxa vara, where the angle between the femoral neck and the femoral shaft is less than normal (< °). coxa valga is an increase in that angle (> °) and, in this case, the child may present with increased internal rotation and adduction of the hips. observation of the child while walking allows one to determine what area is dysfunctional. it is better to have the child bare legged to best visualize the different components of the lower extremity. observe the foot angle, the direction in which the child's feet point when they walk. observe for tibial and femoral torsions and the movements of the hips. determine which part is not following the global movement of the limb or if one side does not contact the fl oor in the same fashion. the postural balance should be evaluated and any dysfunctional asymmetries treated. an asymmetry of leg length might be present as the cumulative result of several dysfunctions. for example, an innominate in external rotation on the right side, combined with an innominate in internal rotation on the left side, will give the appearance of a longer leg on the right side. evaluate the range of motion of the different joints of the lower limbs and, utilizing appropriate manipulative procedures, treat any dysfunction identifi ed. otitis media (om) is among the most common of illnesses affecting preschool children. almost every child experiences om at least once before their third birthday and % of children experience recurrent om. its prevalence has increased considerably recently, resulting in an enormous economic burden to society. clinical classifi cations include acute otitis media (aom) and chronic otitis media with effusion (come). aom is a viral or bacterial infection, commonly secondary to an upper respiratory infection and usually occurring in young children from the age months to years. it presents with a sudden infl ammation in the middle ear, fever, pain and irritability. an incomplete resolution of aom or an obstruction of the pharyngotympanic tube (pt), also called the eustachian or auditory tube, may lead to an effusion in the middle ear containing common pathogenic bacteria. repeated episodes of acute symptoms are considered to be recurrent aom. come is a chronic infl ammation of the middle ear mucosa, with the retention of fl uid within the middle ear space that lasts more than months. it is a condition wherein irreversible changes have occurred, affecting the tympanic membrane, the pt or the middle ear. the multitude of studies attempting to identify the causative factors of om have provided multiple, and often opposite, results. this is probably because the etiology of individual cases of om is often multifactorial, including genetic, environmental, nutritional and behavioral factors. thus, the number of variables necessary for consideration makes such studies extremely diffi cult. the following have, however, been identifi ed as risk factors for the onset of om: genetic predisposition, , low birth weight, male gender, number of siblings, day-care attendance, not being breastfed, use of a pacifi er, , season of the year, , passive exposure to smoking and low socioeconomic status. on the other hand, breastfeeding, even for periods as short as months, has been shown to reduce the incidence of om in childhood. anatomic factors should also be considered. the ear, particularly the middle ear, and adjacent structures provide a site where genetic, environmental, nutritional and behavioral factors can interact, resulting in the development of om. the three parts of the ear -external, middle and internal ( fig. . . ) -are related anatomically and functionally to the temporal bone. the external ear consists of the auricle (pinna) and external acoustic meatus. the auricle on the lateral aspect of the head, at the level of the temporal bone, refl ects the global position of the temporal bone. a protruding auricle, for example, are often associated with external rotation of the homolateral temporal bone. the auricle functions to collect sound waves. the external acoustic meatus terminates in the tympanic membrane. its lateral part is membranous, continuous with the auricle. the medial part is surrounded by the squamous portion of the temporal bone above and the tympanic portion in front and below. the middle ear or tympanic cavity, an air-fi lled space, is located between the tympanic membrane laterally and the lateral wall of the internal ear medially. it contains three bones, or ossicles -the malleus, incus and stapes -that transmit vibrations from the tympanic membrane to the cochlea of the internal ear. the tympanic cavity is open posteriorly to the mastoid antrum, an air sinus located in the petrous portion of the temporal bone, and to the interconnected mastoid air cells. anteriorly, the tympanic cavity communicates with the nasopharynx through the pt. a mucosa covers the complete cavity, including its contents, the three ossicles and the two muscles (tensor tympani and stapedius), and forms the inner layer of the tympanic membrane. this mucosa is in continuity with that of the pharynx. the mastoid cavity, mastoid antrum and auditory ossicles are nearly completely developed at birth. the internal ear consists of several bony cavities, the vestibule, the semicircular canals and the cochlea that form the bony labyrinth. it contains the membranous labyrinth with the organ of hearing (the cochlear duct) and the organs of balance (the semi-circular ducts). the membranous labyrinth fl oats in the perilymph, the fl uid fi lling the bony labyrinth. the structures that form the internal ear are also nearly completely developed at birth. most of the above structures of the ear can be found nesting within the petrous portion of the temporal bone. in diseases of the ear such as om, as well as in balance and hearing disorders, this anatomic relationship confers great signifi cance on the temporal bone and its function and dysfunction. the temporal bone is formed by the squamous, petromastoid, tympanic and styloid parts. the petromastoid part develops in the cartilaginous otic capsule of the cranial base. the squamous and the tympanic portions are ossifi ed from mesenchyme. the tympanic portion (the tympanic ring) unites with the squama just before birth. total fusion of the temporal bone, except the distal part of the styloid, is complete by the end of the st year. nevertheless, the mastoid portion is completely fl at at birth. the mastoid process, a postnatal petrous development, begins to develop with the growth of the mastoid air cells and because of the traction from the tendon of the sternocleidomastoid (scm) muscle. the development of the mastoid process is dependent on the child's ability to lift their head (extend their cervical spine) and to rotate their cervical spine symmetrically. for this reason the prone position, recommended in the statement 'back to sleep, prone to play' is important. in this case, function determines structure, and children with torticollis will present with asymmetry in the shape and size of the mastoid processes. alternatively, infants with non-synostotic plagiocephaly may present with a fl attening in the area of the occipitomastoid suture, where compressive forces inhibit mastoid development. the expansion of the mastoid process is of particular signifi cance. the mastoid air cells that develop inside the mastoid during the growth period are important components of the complex system that regulates and buffers the fl uctuations of middle ear pressure. the volume of the mastoid air cells is about times the volume of the tympanic cavity. often compared to an air reservoir, the mastoid cavity is an active space for gas exchange through its submucosal capillary network the submastoid cell structure in humans is histologically similar to that found in the pulmonary alveolar and nasal membranes, and, therefore, is suitable for gaseous effusion and diffusion. the production of gas within the tympanomastoid cavity keeps the internal pressure at the same level, or higher, than atmospheric pressure. swallowing allows gas to be expelled through the pt into the pharynx. this positive pressure gradient prevents bacteria from entering the tympanomastoid cavity. the depth of the mastoid air cell system has been found to be shorter in children with secretory om compared with healthy individuals. decreased mastoid pneumatization has been proposed as a prognostic indicator for chronic infl ammation of the middle ear, as has poor outcome with om when the mastoid is poorly pneumatized. the mastoid cells connect to the tympanic cavity and through the pt to the nasopharynx. both mastoid cells and pt are of paramount importance in the normal function of the ear and, consequently, the pathogenesis of om. the pt connects the middle ear to the nasopharynx, balances pressure between the middle ear and ambient air, clears debris and secretions toward the nasopharynx and also protects the middle ear against nasopharyngeal secretions and noxious agents from the airways. it begins on the anterior wall of the tympanic cavity and extends forward, medially and downward to the nasopharynx posterior to the inferior meatus of the nasal cavity (figs . . , . . ). because of these close relationships between the middle ear and the nasopharynx, om, frequently described as a complication of rhinitis, may be considered to be a disease of the upper respiratory tract. descriptive and functional anatomy of the nose and nasopharynx is discussed in 'rhinitis' and 'sinusitis' below. the pt is shaped like two cones joined together at their apices. the posterolateral cone, shorter, approximately one-third of the pt, is osseous (protympanum), located inside the petrous temporal bone. it ends at the junction of the petrous and squamous parts of the temporal bone, immediately posterior to the foramen spinosum. the remaining two-thirds of the pt are fi brocartilaginous, partially fi xed to the cranial base, in a furrow following the sphenopetrosal synchondrosis, between the petrous portion of the temporal bone and the posterior border of the greater wing of the sphenoid. the upper border of the cartilaginous pt is arched laterally and looks like a hook on transverse section. a fi brous membrane completes the tube. the tubal isthmus, where the pt diameter is smallest, joins the two cones of the pt. the cartilaginous portion has a greater vertical inclination than the osseous portion. the length of the pt in the adult is approximately - mm. the pt in the newborn is approximately half its adult length and reaches approximately % of its adult length by years of age. the ratio of the length of the cartilaginous and junctional portions of the pt to the length of the bony portion is : in infants and : in adults. the pt in infants is not only shorter, it is also more horizontal, and, therefore, the clearance function is less effective. additionally, when the bony portion of the pt of children with secretory om is compared to that of healthy children, it is found to be even shorter. the pt connecting the middle ear and nasopharynx has been compared to the bronchial tree connecting the lung to the nasopharynx. the mucosal lining of the pt contains mucus-producing cells, ciliated cells, infants and children demonstrate an increase in the density and size of the folds in the tissues lining the pt and it has been suggested that this plays a role in protecting the middle ear. the gas exchange through the submucosal connective tissue seems to be accelerated when the submucosal vasculature dilates and blood fl ow is augmented due to middle ear infl ammation. alternatively, gas exchange can be diminished when the mucosa thickens and submucosal tissue proliferates due to extended infl ammation. in normal tubal function at rest, the pt is usually collapsed, fulfi lling its protective role against retrograde infection from the nasopharynx. the tensor veli palatini (tvp), the dilatator tubae (dt), the levator veli palatini (lvp) and the salpingopharyngeus muscles are all attached to the pt. the tvp arises from the scaphoid fossa, from the spina angularis of the sphenoid and from the lateral wall of the cartilage of the auditory tube. it then descends verti-cally, becomes tendinous and inserts onto the pterygoid hamulus, the lower extremity of the medial pterygoid plate of the sphenoid, and medially onto the posterior border of the hard palate to form part of the palatine aponeurosis. the dt is attached above to the pt, particularly to its membranous portion. it intermingles below with the tvp and rounds the pterygoid hamulus. most authors agree that contraction of the tvp opens the pt lumen and therefore ventilates the middle ear; , this action is particularly signifi cant for the fi bers of the dt. the lvp arises from the medial lamina of the cartilaginous pt and from under the apex of the petrous portion of the temporal bone. it extends into the palatine velum, its fi bers broadening to the middle line, where they blend with those of the opposite side. the salpingopharyngeus arises from the inferior part of the pt, is directed downward and blends with the posterior fasciculus of the pharyngopalatinus ( fig. open it -for example, swallowing, crying or yawning. this balances the pressure gradient between the atmosphere and the tympanic cavity. when the mechanism of swallowing is dysfunctional, opening of the pt is not effi cient. sustained collapse follows with the development of negative middle ear pressure and retraction of the tympanic membrane. the subsequent potential for aspiration of nasopharyngeal secretions into the middle ear may result in om. furthermore, dysfunctional swallowing may also cause gastroesophageal refl ux, another risk factor for om. in addition, if present, the frequent use of a pacifi er may encourage infantile deglutition, i.e. forward tongue thrust when swallowing. although the use of a pacifi er does not increase the incidence of respiratory infections, there is evidence that constant use affects the occurrence of aom, possibly because of alteration in the pressure equilibrating function of the pt. dysfunction of the pt may result in negative middle ear pressure that, in turn, impairs auditory sound conduction to the cochlea of the internal ear affecting hearing. pt dysfunction can also affect hearing through its impact on the tensor tympani muscle. the tensor tympani muscle is continuous with the tvp. it arises from the cartilaginous portion of the pt and the adjoining sphenoid, and inserts on the manubrium of the malleus. , tensor tympani contraction draws the malleus medially, increasing tympanic membrane tension while pushing the incus and stapes medially against the fenestra vestibuli. this results in an increased intravestibular pressure that, under normal circumstances, serves to dampen violent noises. consequently, dysfunction of the pt may be associated with both negative middle ear pressure and spasm of the tensor tympani with resultant disturbance of hearing. anatomic developmental delays such as immaturities of the pt and surrounding structures or of the neuromuscular system may result in dysfunctional opening of the pt in infants and children. most of the time, the dysfunctional opening of the pt improves with age as the base of the neurocranium and the viscerocranium develop. this too, however, can contribute to the complex interaction of phenomena that predispose the child to develop om. the base of the skull (figs . . , . . ) goes through signifi cant developmental changes during the fi rst years of life. two critical phenomena participate in this development. first, the diverse stimulation produced by normal orofacial functions, such as suckling and swallowing, spurs the growth of structures, particularly the pterygoid processes in which the involved muscles insert. secondly, but concomitant with the above, the progressive fl exion of the cranial base, associated with the anteroposterior growth of the skull, contributes to positional changes of both the pterygoid processes, which become longer and more vertical, and the petrous portions of the temporal bones, which become externally rotated. additionally, several changes occur in the viscerocranium, such as the increase in height of the vomer that accompanies the expansion of the nasal cavity. these developmental changes are concomitant with the development of the pt and its associated muscles. therefore, any structural imbalance that develops in association with the development of the base of the skull or viscerocranium may adversely affect the ventilation and drainage of the ear. a dysfunctional tongue posture may affect the tongue's pumping function on the palatine aponeurosis and, therefore, the associated pt ventilation that occurs during swallowing. tongue posture adapts to oral development and pt function appears to be diminished in long-faced adenoidal children. additionally, children with signifi cant overbites are found to be more predisposed to develop pt dysfunction. body position also seems to infl uence pt opening. evidence shows a correlation between the lateral recumbent position, where one ear is positioned downwards, and a lower pt opening function on that side. this reinforces the need to avoid the repeated use of the same sleep position for infants. any cranial somatic dysfunction of the base of the skull may disrupt its developmental sequence as well as affecting tongue posture, with resultant impact on pt growth and function. this may be a cranial somatic dysfunction of the bony constituents of the cranial base, the occiput, sphenoid and temporal bones, or dysfunction of any component linked to the vascular supply and innervation of the myofascial structures involved in suckling and swallowing. the tvp and the tensor tympani are innervated by branches from the otic ganglion, located immediately below the foramen ovale, on the medial surface of the mandibular nerve (cn v ). the glossopharyngeal nerve (cn ix) innervates the stylopharyngeus, and the accessory nerve (cn xi) innervates the palatal muscles through the pharyngeal plexus. they both exit the skull through the jugular foramen. the hypoglossal nerve (cn xii) innervates the intrinsic and extrinsic tongue muscles. it exits the skull through the anterior intraoccipital synchondrosis, the site of the hypoglossal canal of the occipital bone when ossifi cation occurs. consequently, effi cient pt function requires equilibrium among surrounding bony structures, such as the temporal bones, occiput, sphenoid and mandible. it also requires that associated myofascial structures be free of dysfunction. a dysfunctional pt creates a terrain where other risk factors are reinforced. recurrent bilateral om with effusion develops when poor pt function is allied with diminished immune status. the allergic infl ammatory response that often occurs in the nasopharynx also occurs in the middle ear, and the prevalence of allergic rhinitis is signifi cantly higher in children with om with effusion than in healthy children. , the allergic infl ammation in atopic children is not localized in one area only, but manifests itself in the middle ear on both sides, as well as in the nasopharynx, demonstrating totally the united airways concept. mucosal infl ammation with release of histamine and other mediators following nasopharyngeal exposure to an allergen may, consequently, be responsible for pt obstruction and dysfunction. chronic allergic infl ammation of the upper airway may lead to lymphoid hypertrophy with increased size of adenoidal and tonsillar tissue. in such a case, with edema and infl ammation of the posterior nasopharynx, the enlarged adenoids may obstruct the pharyngeal ostium of the pt. tubal tonsil hypertrophy is a possible etiology for om, when recurrence appears after adenoidectomy. the pt mucociliary apparatus contains components that have an important role in eliminating middle ear debris by moving it toward the nasopharyngeal orifi ce. additionally, specialized epithelial cells express and secrete surface-active materials that appear to facilitate the muscular action of the pt opening and to protect the middle ear against infections. conversely, many viruses impair the mucociliary function of the pt epithelium and perturb the nasopharyngeal bacterial fl ora, increasing the adherence of bacteria to the epithelial cells. bacteria and respiratory viruses (e.g. the respiratory syncytial virus or infl uenza viruses) are common causes of middle ear infection. [ ] [ ] [ ] because of the connection between the upper and lower airways, the pathophysiologic site of origin is frequently the nasal pathway. babies born in the fall begin their lives during the peak seasons for viral exposure and the development of respiratory infections, a risk factor for om. additionally, impaired or decreased nasal mucociliary activity may also cause pt mucociliary dysfunction. thus osteopathic procedures that facilitate the clearance of secretions and the mucociliary action of the pt and upper airways are indicated. blood fl ow to the region should also be improved. gastroesophageal refl ux may also predispose to bacterial infection. possibly because of refl ux, infants fed in the supine position demonstrate abnormal postfeeding tympanographic results compared to infants fed in the semi-upright position. signs of aom include fever, insomnia and the presence of pus in the middle ear with a tympanic membrane that appears bulging and erythematous when observed by otoscopic examination. ear infections may be painful, causing irritability, rubbing of the affected ear, loss of balance and impaired hearing with lack of response to moderate sounds. although it is generally thought that om causes permanent hearing loss, this has not been demonstrated. transient mild to moderate hearing loss associated with om has, however, been shown to cause delays in communicative development. osteopathic considerations for the treatment of om are directed at augmenting the body's defenses against infection and its recuperative power after infection is present. mainstream medical interventions are often fraught with controversy. because the infectious agents responsible for om are both viral and bacterial, antibiotic therapy, although appropriate for bacterial infection, is not universally effective. guidelines for determining when to employ antibiotics and other modalities are available. , , , the use of tympanostomy tubes is controversial. , consequently, non-toxic interventions like osteopathic treatment, which appear to reduce the need for antibiotics, have been shown to be of potential benefi t as adjuvant therapy for children with recurrent aom. diagnosis should begin with observation. start with an overall evaluation of the child's posture. look at the pectoral girdle, often protracted in patients with ent infections. observe the cervicothoracic junction, the cervical spine and its relationship to the skull for lack of mobility and vertical compression. these patients may demonstrate a shrugged shoulder posture, with the appearance of a shortened neck. observe the auricles of the ear bilaterally for deformity, asymmetry of position and relative external or internal rotation. the appearance of the ear follows the temporal bone which, in turn, affects the function of the pt. examine the parietomastoid and occipitomastoid sutures bilaterally. look for fl attening or compression of the area. because ear position refl ects temporal bone position, asymmetry of the ears is often associated with asymmetry of cranial shape. non-synostotic plagiocephaly has been shown to be associated with an increased incidence of om. enquire if the child repeatedly pulls at one ear. this will often occur on the side of compression of the parietomastoid and occipitomastoid suture. study the face. open mouth facies are indicative of mouth breathing and nasal obstruction, predisposing to om. diagnosis and treatment of dysfunction in this area is discussed in part . , 'mouth breathing'. next, perform a palpatory examination. begin by evaluating the upper thoracic spine, ribs and pectoral girdle for somatic dysfunction. the viscerosomatic refl exes from the upper respiratory tract, including the ear, are to be found at level of t -t . somatic dysfunction in this area results in increased sympathetic tone with vasoconstriction affecting the ears, nose and throat through somatovisceral refl exes. mechanical dysfunction of the upper thoracic spine (t and t ), associated ribs, sternum and clavicles impairs lymphatic drainage from the head and neck. further evaluate the remainder of the thoracic cage and thoracoabdominal diaphragm which, when dysfunctional, can also impair lymphatic circulation. utilizing indirect principles, treat any dysfunction identifi ed in the above areas. examine the cervical region for somatic dysfunction. pay particular attention to the occipitoatlantal and atlantoaxial articulations, to the myofascial structures for their relation to lymphatic nodes and vasculature, and to the scm muscles that, when dysfunctional, impact the function of the temporal bone. treat any identifi ed dysfunction. evaluate the skull. begin by assessing the cranial base, paying attention to the sphenobasilar synchondrosis and temporal bones. the articulations of the temporal bones should be examined. the occipitomastoid sutures are important for their impact on the contents of the jugular foramen: cranial nerves ix, x and xi. the petrobasilar suture and sphenopetrosal synchondrosis are often dysfunctional in the infant's skull. dysfunction of these articulations may affect the petrous portion of the temporal bone containing the osseous part of the pt. furthermore, the cartilaginous portion of the pt is located beneath the sphenopetrosal synchondrosis and free motion of the petrous portion of the temporal bone, in external and internal rotation, facilitates the clearance of secretion from the pt. next, evaluate the temporal bones for intraosseous dysfunctions between the petrous, squamous and tympanic portions. palpate for the cranial rhythmic impulse (cri) at the level of the mastoid. intraosseous mastoid cranial respiration may promote mastoid cell function. examine the relationship between the mandible and the temporal bones. there is usually tenderness in the area. any temporomandibular dysfunction can affect the mobility of the temporal bones and the myofascial structures of the anterior neck below. the pt is commonly cleared by the actions of swallowing and yawning. these actions can be impaired by dysfunction of the mandible and its relationship to the tongue and soft palate. treat identifi ed dysfunction. specifi c attention should be paid to the effi cient clearance of secretions from the pt and mastoid cavities. this activity may be stimulated by the mastoid pump procedure and the galbreath technique. when possible, the rate and amplitude of the cri should be monitored during the above procedures. following the cri during the mastoid pump enhances the effi cacy of the procedure. the specifi c treatment of cranial dysfunctional patterns will augment the amplitude of the cri, improving fl uid mobility and affecting low frequency oscillations in autonomic nervous system (ans) physiology. counsel the caregivers to maintain a healthy lifestyle for the child. maintain a regular sleep-wake cycle. provide a balanced diet with adequate hydration and avoiding refi ned carbohydrate as much as possible. bottle feed and nurse in a semi-upright position and never put the infant to bed with a bottle. as much as possible, limit pacifi er use to moments when the infant falls asleep and try to eliminate its use after the age of months. avoid exposure to passive smoke. when bathing the infant, limit the amount of water entering their ears. caregivers should be instructed to lay the child on their side, with the problem ear up. they should then massage the mandibular region, applying gentle skin traction from the area anterior to the ear in the direction of the chin. this tends to open the pt and the position employs gravity to facilitate drainage. they can also gently caress around the ear, particularly over the mastoid region. these actions allow the caregiver to actively participate in the child's recovery. they sensitize the caregiver to the health status of the child and promote relaxation for the child. encourage the caregiver to play with the child in a fashion that promotes mimicry of the production of sounds in the throat and the clicking of the tongue by pulling it quickly from the hard palate. all activities encouraging action of the myofascial structures connected to the pt will tend to open it and facilitate its drainage. rhinitis is the infl ammation of the nasal mucous membranes. acute rhinitis may be the consequence of a viral infection, whereas allergic rhinitis is caused by an immune-mediated response to any one or more of a myriad of allergens. other classifi cations include atrophic rhinitis and vasomotor rhinitis. although these conditions are the result of differing etiologies, they are all affected by the presence of somatic dysfunction. it is an established osteopathic dictum that the body possesses the inherent ability to heal itself. the presence of somatic dysfunction can predispose the individual to develop rhinitis or interfere with the body's recuperative mechanisms. knowledge of the anatomy and physiology of the nasal cavities and the mucosa lining their walls is absolutely necessary to understand the etiologies of nasal dysfunction and how osteopathic principles may be applied to promote health in this area. the nose is divided by the nasal septum into two cavities, or fossae. the two nasal cavities open anteriorly by way of the anterior naris, or nostril. they are continuous posteriorly by way of the posterior nasal apertures, or choanae, into the nasopharynx. the nasal septum represents the medial wall of each nasal cavity. it is formed by the perpendicular plate of the ethmoid, the vomer and the septal cartilage ( fig. . . ) . the roof of the nasal cavities is formed anteriorly by the nasal spine of the frontal bone and the two nasal bones. the cribriform plate of the ethmoid, with numerous perforations for the olfactory nerves, is located behind the nasal bones. more posteriorly, the anterior aspect of the body of the sphenoid causes the roof of the nasal cavities to slope downward. the sphenoidal sinuses open into the nasal cavities from above, on each side of the nasal septum ( fig. . . ). the fl oor of the nasal cavities is the upper surface of the osseous palate. the maxillary palatine processes form the anterior two-thirds, while the palatine horizontal plates form the posterior one-third ( fig. . . ). the lateral walls of the nasal cavities demonstrate numerous structures. they are formed anteriorly by the maxilla, posteriorly by the palatine bone and superiorly by the ethmoid labyrinth and lacrimal bone. the inferior, middle and superior nasal conchae (turbinates), the most central portion of this lateral wall, by virtue of their curled shape add a great amount of surface area to the nasal cavities. the space below each turbinate is referred to as a meatus (fig. . . ) . the nasal vestibules, just inside the nares, are the anterior-most aspect of the nasal cavities. the nares and vestibules are bounded laterally by the alar and lateral cartilages, and medially by the cartilaginous septum and the connective tissue septum, the columella (fig. . . ) . the vestibule is lined with skin that contains sebaceous and sweat glands and coarse hairs (vibrissae) that assist in air fi ltration. the nasal cavities are completely covered with a lining that varies histologically in different areas. at the anterior part of the nasal cavities, in the vestibules, the lining is continuous with the facial skin. above, at the level of the upper border of the alar cartilages, the limen nasi defi nes the beginning of a lining formed by a non-keratinizing stratifi ed squamous transitional epithelium that evolves further into a pseudostratifi ed ciliated epithelium, the respiratory mucosa. this mucosa covers the remaining surface of the nasal cavities, except for the olfactory area that is covered with olfactory epithelium. this mucosa is also present in many other parts of the upper respiratory tract. several additional cavities communicate with the nasal cavities and demonstrate a continuum of the nasal respiratory mucosa. each of the nasal cavities communicates directly with the nasopharynx below, the nasopharynx continues to become the oropharynx, the laryngopharynx and the esophagus. the mucous membrane of the pharynx is continuous with that lining the mouth and larynx, as well as, through the trachea and bronchi, into the lungs. this continuum is a perfect example of the interrelationship between the different structures of the human body and exemplifi es the concept of the body as a unit. the respiratory mucosa plays a signifi cant part in the physiology of the nose, as well as in its pathologies, as is the case in rhinitis. the mucosa acts as a selective barrier, essential for the defense of the airways against inhaled pathogens. the respiratory pseudostratifi ed ciliated epithelium is formed by ciliated columnar or cuboidal epithelia with goblets cells, non-ciliated columnar cells and basal cells. mast cells and migrating lymphocytes, mainly t cells, are also present. under the basal lamina of this epithelium, the submucosa is adherent to the periosteum of the adjacent cranial bones and includes a fi brous layer with diffuse lymphoid tissue and a layer of mucous, seromucous and serous glands. an abundant mucous fi lm is produced by these glands and by the goblets cells. additional plasma exudation may occur, particularly in the presence of infl ammatory states. this fi lm gathers the particles and debris from the air that is inspired to sweep them away. almost all particles greater than μm and about % of those between and μm are collected. they end up either in the nasopharynx and oropharynx to be periodically swallowed, or in the anterior nasal vestibules. mucociliary clearance depends on the beating function of the respiratory cilia. they beat about times per minute. the frequency of the mucociliary transport rate is subject to various infl uences, such as mucus viscoelastic properties, airway epithelia alkalization that appears to be a stimulator or airway epithelia acidifi cation that decreases the rate. healthy function of the respiratory cilia results in constant motion of the mucous fi lm. the nasal ciliary beating propels the mucus secretions posteriorly in the direction of the nasopharynx. conversely, dysfunction of the drainage of the nasal respiratory epithelium leads to stasis and the accumulation of secretions within the nasal cavities. cranial somatic dysfunction -particularly of the frontal bones, sphenoid, ethmoid, maxillae and vomer, with resultant loss of their inherent motility -is a possible cause of mucociliary stasis. septal deviations are known to infl uence the dynamics of the nasal cavity and are often associated with a 'stuffy' nose. histologic studies confi rm this observation. loss of cilia, increased infl ammation and decreased density of the glandular acini are reported affecting the mucosa on the concave side of the septal deviation. the vasculature of the respiratory epithelium contributes signifi cantly to the function and dysfunction of the nasal cavities. the nasal mucosa contains a profuse subepithelial capillary network that supplies nutrients and water that through its evaporation contributes to the conditioning of inspired air. the vascular supply also includes a number of different capacitance vessels, i.e. the veins, venules and cavernous sinusoids that modulate blood fl ow. constriction and relaxation of these sinusoid vessels produce shrinkage or swelling of the mucosal surfaces that consequently regulates airfl ow and alters nasal patency. most of the venous cavernous sinusoids are located on the inferior conchae, major sites for nasal congestion. air conditioning is a major function of the nose. on inspiration, the air contacts the nasal mucosa and is brought to the appropriately conditioned temperature and humidity. by virtue of their contour, the conchae, located on the lateral walls of the nasal cavities, provide an increased surface area for the fl owing air to be in contact with the nasal mucosa. during expiration, some of the heat may be returned to the mucosa. when an individual is in a setting of °c, the nasal cavities warm the inspired air to °c. the air is also humidifi ed and this allows gas exchange within the alveoli of the lungs that takes place at °c and % relative humidity. therefore, nasal air conditioning requires large amounts of heat and water for conditioning the inspired air and the capacitance vessels seem perfectly designed to fulfi ll that need. they might also operate as a short-term reservoir, either for heat or for water. special conditions (e.g. hyperventilation) call for these reserves in order to provide cooling and evaporation. under normal circumstances and normal vasculature, a healthy nose succeeds in warming and humidifying the inspired air in order to protect the lungs. conversely, paucity in blood supply or moistening may reduce the effi ciency of the air conditioning system of the nasal cavity. the nasal vasculature also contains an extensive system of arteriovenous anastomoses. this allows for the rapid passage of blood through the mucosa without reducing the nasal patency. great amounts of arterial blood may fl ow through these anastomoses, providing heat exchange similar to hot water in a radiator. brain cooling appears to be the result of several mechanisms including a possible nasal and paranasal convection process. this latter process involves the transfer of cool venous blood from the respiratory mucosa to venous structures of the brain, such as the superior sagittal sinus between the parietal bones or the cavernous sinuses on each side of the body of the sphenoid, where arterial thermoregulation may then occur. on both sides, the cavernous sinus drains venous blood from the skin of the face and from the nose and mouth areas, and is in intimate contact with the internal carotid artery. the direction of fl ow in these sinuses is reversible. countercurrent mechanisms are suggested, where the arteriovenous anastomoses, present in the nasal vasculature, may also participate, allowing enhanced thermoregulation and brain cooling in hot conditions. changes in craniofacial morphology have been observed as adaptations to weather conditions. wider nasal cavities and larger paranasal sinuses are considered to be adaptive mechanisms that, under hot conditions, offer more evaporating surface and consequently greater cooling capacity, thus protecting the brain. orofacial dysfunction may alter nasal breathing and consequently the above functions. body position also affects the nasal vasculature. the supine position increases vascular congestion, thus decreasing nasal patency and the ability of the clinical conditions nose to condition cold, dry air. conversely, the upright position decreases vascular congestion. consequently, it is appropriate to enquire if the patient experiences excessive increased nasal congestion when they lie down as it may result in snoring and sleep disorders. furthermore, the nasal vascular supply is under the infl uence of hormones, psychological stress and diverse substances (e.g. gases or infl ammatory molecules) that once in contact with the nasal mucosa seem to produce vascular congestion with edema and plasma exudation. it should be noted that children and teenagers often report nasal vascular congestion as nasal obstruction. an alternation of breathing between the two nares is known as the nasal cycle. it has been observed as early as years of age, with the duration of a cycle ranging from to minutes. alternation of the side of nasal breathing has been associated with the central mechanism regulating the dominance of the cerebral hemispheres. increased sympathetic activity in the nasal mucosa appears to be linked to greater sympathetic tone in the ipsilateral hemisphere and thus with decreased blood fl ow and mental activity in that hemisphere. changes in the tone of the nasal vascular supply are regulated by the ans. parasympathetic nerves are vasodilator, sympathetic nerves are vasoconstrictor. therefore, predominance of parasympathetic activity causes a vasodilatation and nasal congestion, whereas increased sympathetic activity produces a vasoconstriction that decreases nasal airfl ow resistance. the preganglionic fi bers of the cranial portion of the sympathetic nervous system originate from axons of somata in the lateral gray column of the upper thoracic spinal segments. the fi bers enter the superior cervical ganglion adjacent to the second and third cervical vertebrae where they synapse. the postganglionic fi bers ascend, following the course of the internal carotid artery, forming the internal carotid plexus. the greater petrosal nerve, a branch of the facial nerve (cn vii), contains the preganglionic parasympathetic fi bers traveling to the pterygopalatine (sphenopalatine) ganglion. located deeply in the pterygopalatine fossa, between the pterygoid process and maxilla, anterior to the pterygoid canal, the pterygopalatine ganglion is one of the major peripheral parasympathetic ganglia. at the level of the foramen lacerum, the greater petrosal nerve is joined by the deep petrosal nerve from the internal carotid plexus (sympathetic) to form the nerve of the pterygoid canal (vidian nerve). these fi bers synapse in the pterygopalatine ganglion; the postganglionic parasympathetic fi bers are secretomotor and supply the glands of the nasal mucosa. additionally, the nasal cavities are densely innervated by the sensory nervous system. nerves are present in respiratory mucosa, particularly in the walls of the venous vessels and the gland acini. glands are innervated by both parasympathetic and sensory nerve fi bers. sensory nerves are stimulated by mechanical, thermal or chemical stimulation and afferent fi bers run in the trigeminal nerve. sensory nerve stimulation instigates different refl exes, such as the sneeze refl ex. nasal thermal stimulation, as occurs with inhalation of cold dry, dry or moist air, produces a nasopulmonary bronchoconstrictor refl ex in normal healthy individuals, inducing changes in airway resistance. activation of temperaturesensitive nerve endings in the nasal mucosa generates this response and the decrease of airfl ow through the nose and trachea protect the lungs from insufficiently conditioned air. the ans controls several aspects of nasal function, i.e. nasal secretions, mucociliary function, blood fl ow, microvascular permeability, release of infl ammatory cells and nasal patency. the modulation and balance of nasal functions necessitate an interaction between the sympathetic and parasympathetic systems, as well as a well-tuned sensory nervous system. dysfunction may lead to pathologic nasal syndromes. because of the relationships between the sympathetic nervous system and the upper thoracic spinal segments, the second and third cervical vertebrae, and between the parasympathetic nervous system and the sphenoid, maxilla or palatine bones, somatic dysfunction of any of these vertebral and cranial areas can result in dysfunction of the ans with impact on nasal function. furthermore, because of the role of the trigeminal nerve, particularly the fi rst and second divisions, in the sensory function of the nose, the temporal bone should be added to that list. osteopathic procedures may be applied to balance the ans and promote healthy nasal functions. unpaired and paired structures form the nasal cavities, as in the remainder of the skull. as such, during the prm inspiratory phase, the midline unpaired structures of the nasal cavities (i.e. the sphenoid, ethmoid, vomer and septal cartilage) demonstrate cranial fl exion and the paired structures (i.e. maxillae, palatine, nasal and lacrimal bones and conchae) externally rotate. in the reciprocal prm expiratory phase, the midline structures move in the direction of cranial extension and the paired structures internally rotate. therefore, in health, the nasal cavities follow each cycle of the prm, with a resultant widening of the cavities during fl exionexternal rotation of the inspiratory phase and narrowing during extension-internal rotation of the expiratory phase. cranial somatic dysfunction very frequently follows asymmetric patterns. thus, the nasal cavity will be wider on one side than on the other. this can be observed by nasoscopic examination, as well as by simply looking at the patient to note asymmetry in the facial features. it may also be observed by comparing the relative size of the nares. one side is usually more open than the other. the open side is the side of the external rotation, whereas the other side is associated with internal rotation. the patient often reports more nasal congestion on the smaller side and in cases of small children the mothers comment on the increase of nasal secretion on that side. the alternation of cranial fl exion and extension, with all cranial structures free to follow this movement, is necessary to ensure effective tissue perfusion of the nasal mucosa. it also promotes venous and lymphatic drainage of the nose, as well as the removal of secretions from the nasal cavities and sinuses. under these circumstances, mucosal infl ammation and hyperreactivity associated with rhinitis may be reduced. in neurogenic infl ammation of the upper airway mucosa, such as in chronic rhinosinusitis, sensory nerves are excited and mediators are released, including histamine, prostaglandins and various neuropeptides such as substance p. they may then cause vasodilatation, vascular congestion, extravasation of plasma with edema, and recruitment and activation of infl ammatory cells. secretion from the submucosal glands may also be increased. these exaggerated sensory and parasympathetic defensive refl exes form the pathophysiologic basis of rhinitis. acute rhinitis, one of the symptoms of the common cold, is the result of a viral infection. numerous viruses cause infections in the respiratory tract and any region of the tract may be infl amedthe nose, the paranasal sinuses, the throat, the larynx, the trachea and the bronchi. acute rhinitis represents one of the most frequent upper respiratory infections. allergic rhinitis is considered to be the most common allergic airway disease, with about % of the population experiencing this condition. allergic rhinitis is common in children and most of the time this condition fi rst develops during childhood or adolescence. typical behaviors are usually observed such as grimacing and picking of the nose. older children are likely to blow their noses more often than younger children who present with constant clearing of the throat because of postnasal drip, frequent sniffi ng or snorting. rhinorrhea, nasal obstruction, sneezing, itching of the eyes, nose and palate, and watery eyes are typical symptoms associated with allergic rhinitis. the disease results from exposure to various allergens including foods, pollens, molds, dust mites and animal dander. two groups are described: seasonal allergic rhinitis, often the result of pollen exposure, and perennial allergic rhinitis, lasting for at least months of the year. allergic individuals demonstrate a decreased capacity to warm and humidify inhaled air. they also are prone to develop other diseases of the upper and lower respiratory tract such as sinusitis, otitis media with effusion and asthma that may complicate allergic rhinitis. although the reason why individuals develop allergic rhinitis is uncertain, a genetic predisposition to develop the allergic response has been suggested. it is thought that these individuals probably have a greater sensitivity to allergens and are predisposed to develop mucosal infl ammation and hyperreactivity. a 'microfl ora hypothesis' has also been suggested. it is thought that the disturbance of the normal microbiota in the gastrointestinal tract, in part due to the use of antibiotics and dietary changes in industrialized countries over the past two decades, is a factor that may lead to modifi ed airway tolerance to allergens and atopic disorders. genetics and microbiotic disruption would then be considered as predisposing factors, increasing an individual's susceptibility to develop airway hypersensitivity and allergy. the nasal dysfunction associated with allergic rhinitis results in various symptoms. nasal congestion with increased airfl ow resistance, particularly in the supine position, causes sleep-disordered breathing. it is a risk factor for snoring, affecting teenage males more frequently than females. it is also linked to various systemic symptoms such as headaches, irritability and fatigue that diminish functional capacity. thus, allergies are one of the main reasons for missed school days in the us. school performance may be decreased because of inattention and decreased concentration. physical and emotional impairments associated with the allergic condition make it a whole body dysfunction. because allergic rhinitis can affect the patient's quality of life to such an extent, and because of its economic impact, prevention and treatment are essential. osteopathic procedures may be seen as a valuable complement to traditional medical treatment. the examination for somatic dysfunction is begun by observing the global postural pattern and/or how the cervical and thoracic regions are, or are not, integrated into this pattern. the child should be observed from behind, from the side and from the front. from behind, observe upper body postural mechanics. look for cervical and thoracic sidebending, occipitocervical rotation and slumping of the pectoral girdle. from the side, observe cervical and thoracic anteroposterior mechanics. there is often upper thoracic fl exion with increased cervical lordosis. in this position, the head will very commonly be thrust forward with signifi cant tension placed on the anterior cervical soft tissues. observe specifi cally the submandibular myofascial structures and the position of the hyoid bone. the child with rhinitis may have to compensate by mouth breathing. as such, they may demonstrate the associated mouth breathing posture to a variable degree, depending on the chronicity of the condition. a double-chin appearance and the demonstration of a slack-jawed posture are indicative of chronic mouth breathing. from the front, observe and confi rm the sidebending and rotation observed from behind. again look for the presence of mouth breathing and the associated orofacial characteristics. children who mouth breath demonstrate a lack of tonicity of their facial tissues. the lower lip is typically everted and the tongue slightly protruded. observe the relationship between the tongue and the teeth. persistent protrusion of the tongue results in anterior displacement of the upper incisors with an eventual overbite. the child with allergic rhinitis will demonstrate puffi ness of the facial soft tissues, particularly noticeable around the eyes, as well as darkening of the tissues beneath the eyes. the nasion is often recessed in the face. because of the chronic lack of nasal breathing, the bony structures of the nasal cavities are small, resulting in narrowed nasal apertures. children with persistent nasal congestion demonstrate an observable transverse crease in the skin across the lower third of the nose, at the junction between the nasal bones and cartilages. this develops as the result of repeatedly rubbing and pushing the tip of the nose vertically or laterally with their fi ngers or hand in response to nasal itching -the 'allergic salute'. following observation, the palpatory examination is best performed with the child supine. begin by palpating the upper thoracic region for structure and employ the tests of listening to assess function, paying particular attention to the motion of the vertebrae and ribs. examine the clavicles in similar fashion. next, evaluate the cervical spine, with attention to the structural and functional relationships between the occiput, c , c , c and c . palpate the soft tissues in this area for the presence of edema. in acute upper respiratory conditions, the trigeminally mediated upper cervical refl ex (occiput, c ) will result in acute tissue texture changes. assess the anterior cervical soft tissues and midline structures with attention to the hyoid bone. identify somatic dysfunction and treat it using the principles of indirect technique. examine the cranial base. note the pattern demonstrated between the sphenoid and occiput. sbs compression and inferior vertical strain are often encountered in association with nasal dysfunction. note the relationship between the occiput and temporal bone. visualize how this relationship impacts the jugular foramina and consequently cn x. the functional status of the sphenoid bone exerts significant infl uence on the frontal bone and the facial bones below, and should be assessed. also assess the frontal bone. any dysfunctional motion restriction will result in diminished movement, and consequently diminished drainage, of the nasal cavities. in particular, dysfunctional frontal internal rotation causes the ethmoidal notch to be narrowed, restricting the movement of the ethmoid below. when evaluating the relationships between the sphenoid, frontal bone and the facial bones with the tests of listening, fi rst assess the global motion of the region and then proceed to assess the individual bones and their interosseous relationships. during this assessment, localized motion restriction may be perceived that requires further identifi cation through visualization. the following sutures are potential sites of interosseous dysfunctions: frontoethmoidal, frontomaxillary, frontonasal and sphenoethmoidal. the relationships between the vomer and the sphenoid, ethmoid, maxillae and palatine bones, as well as the articulation between the two maxillae, should be evaluated. the nasal cartilages should be assessed in their relationship with the nasal bones and perpendicular plate of the ethmoid. following indirect principles, treat any dysfunctions found. address the upper thoracic and cervical regions for their effect on the ans. treat cranial dysfunctions for their effect on the autonomic and sensory nervous systems, venous and lymphatic drainage, and to promote the production and drainage of nasal secretions. treatment of nasal structures will affect the total body through the cranial mechanism. the nasal septum consists of the vomer and the perpendicular plate of the ethmoid. posteriorly, it is continuous with the sphenoidal sagittal septum that divides the body of the sphenoid into two sinus cavities. posteriorly and superiorly, it is continuous with the falx cerebri and falx cerebelli. these structures combined constitute a vertical septum that separates the paired structures of the head and unites the viscerocranium and the neurocranium and, through the core link, the body below. the nasal mucosa contains a rich supply of nerve endings and a dense network of microvasculature. for these reasons, it is highly sensitive. this should be kept in mind during the physical examination and treatment. it makes tests of listening and methods of treatment employing indirect principles the techniques of choice. further, to follow the prm, its rhythm and potency within nasal tissue, and to employ treatment when appropriate to enhance its potency, may help to modulate the autonomic dysfunction present in rhinitis, as well as help to reduce stasis and edema on a macro level in the mucosa and a micro level in the neuronal synapses. recurrent and chronic rhinitis is commonly triggered or aggravated by environmental circumstances. as such, the caregiver should be provided with information as to potentially irritating conditions and substances that will allow them to identify and remove these triggers from the child's environment. allergens should be sought out, identifi ed and, if possible, removed. the most common allergens include pollens, foods, molds, dusts and animal dander. a detailed list of these substances may be found by doing an internet search. conversely, dietary considerations and respiratory exercises may be employed to improve the function of the immune system. it has been suggested that disruption of the normal microbiota in the gastrointestinal tract contributes to decreased airway tolerance to allergens. refi ned foods should be avoided as much as possible, while a diet rich in fresh fruit and vegetables and antioxidants such as vitamins c and e should be recommended. a diet high in probiotics that promote the growth of benefi cial bacteria (bifi dobacterium, lactobacillus, bacteroides) is recommended. this includes prebiotic carbohydrates such as inulin and oligofructose, plant carbohydrates that are not digestible in the small intestine but rather are fermented by bac-teria in the colon. lactose intolerance should be considered. respiratory exercises are intended to enhance nasal breathing, promote mucus drainage and reduce vascular stasis in the nasal mucosa. they should be initiated in such a way that they can be successfully performed and yet avoid frustrating the child. nasal congestion impairs nasal respiration and if the child is simply told to breathe through their nose, the diffi culty of the experience usually limits the success of the exercise. the child will feel frustrated at best, and at worst may experience anxiety and a sense of suffocation. and they will stop doing the exercises. begin by explaining to the child the importance of nasal breathing. explain that breathing through their nose cleans the air they breathe and gives them more oxygen in their blood, and that this will, in turn, enhance their performance in school and in sports. next, have the child breathe through their nose and become aware of the sensation of nasal airfl ow. have them palpate the lateral aspects of the nasal cartilages as they breathe. teach them to actively fl are the nose by contracting the dilatator nostril muscles as they inhale. palpating the nose during this process reinforces their awareness of nasal fl aring. after or minutes of active nasal breathing the child should observe the difference in the sensation of nasal airfl ow. they may now be instructed to repeat the above process at home, exercising for minutes at least three times daily. the child should also be taught to breathe using their thoracoabdominal diaphragm. successfully implementing these exercises not only allows the child to improve nasal respiratory function, it further teaches them a sense of control over their own respiration. this will reduce and eventually eliminate the sense of suffocation the child experiences when they attempt to breathe through congested nasal passages because, even thought they may experience nasal congestion, they will have been empowered to alleviate it. it is estimated that children get an average of six to eight colds annually, and that - % of all upper respiratory tract infections are complicated by sinusitis. the application of osteopathic principles in the treatment and prevention of sinusitis in children should be utilized, as it is particularly effi cient. it is based on an understanding of the anatomic and functional aspects of the nasal cavities and sinuses as part of the upper respiratory tract. a description of the nasal cavities, mucosa and its main characteristics has already been provided in 'rhinitis' above. we shall, therefore, only consider the description of the paranasal sinuses and the pathophysiology that explains their dysfunction. many speculative theories exist concerning the function of paranasal sinuses. some years ago, galen hypothesized that they were 'porous bones' reducing the skull's weight. since then, other theories have described the paranasal sinuses as shock absorbers, resonance chambers, air conditioning areas or the result of the evolutionary process and parts of the facial development. there are four paranasal air sinuses associated with each nasal cavity: the ethmoidal, frontal, sphenoidal and maxillary sinuses, all of which open into the lateral walls of the nasal cavities by small apertures that differ from one individual to another. the lateral wall of the nasal cavity is formed anteriorly by the frontal process of the maxilla and the lacrimal bone; centrally by the ethmoid, maxilla and inferior nasal concha; and posteriorly by the vertical plate of the palatine bone and the medial pterygoid plate of the sphenoid. three meatuses are located in this wall. they consist of three irregular passages directed anteroposteriorly -the superior, middle and inferior meatuses of the nose. the superior meatus is the smallest. located between the superior and middle nasal conchae, it occupies the middle third of the lateral wall of the nasal cavity. the middle meatus is between the middle and inferior conchae. the inferior meatus is the largest of the three. it lies in the space between the inferior concha and the fl oor of the nasal cavity. only the nasolacrimal duct drains into the inferior meatus in the anterior part of the nasal cavity. the ethmoidal sinuses, on each side, are formed by - air cells, fi lling the ethmoidal labyrinth. they are divided into three groups: anterior, middle and posterior. the anterior and middle ethmoidal cells drain into the middle meatus, whereas the posterior ethmoidal cells drain into the superior meatus. the frontal sinuses are the highest. each frontal sinus develops from an anterior ethmoidal cell that extends posteriorly along the medial part of the orbital roof and laterally above the internal part of the eyebrow at about or years of age. on each side, through the frontonasal duct and the ethmoidal labyrinth, the frontal sinus drains into the middle meatus. the maxillary sinuses are the largest. they form large pyramidal cavities within the bodies of the maxillae and drain into the middle meatus on each side. the sphenoidal sinuses are within the body of the sphenoid, their apertures being on the upper portion of the anterior walls of the sphenoidal body. the sphenoid sinuses drain into the superior meatus, near the roof of the nasal cavities (figs . . , . . ). the pneumatization of the paranasal sinuses occurs at different rates, with a great deal of variation between individuals. the maxillary and sphenoidal sinuses are the fi rst ones to develop in the fourth gestational month, followed by the frontal and ethmoid cells that appear in the sixth month. at birth, the parasinuses are quite small. the ethmoid cells measure - mm in diameter while the maxillary sinuses appear as furrows mm in length and mm in width. the sphenoid sinuses are usually pneumatized around years of age and the frontal sinuses have developed to the extent that they are radiographically apparent by about the age of . around this time, the growth of the cerebral mass slows down. the inner table of the frontal bone is stabilized while the outer table is still dragged forward by nasomaxillary growth. a space forms between both plates, where the frontal sinus expands. mechanical forces associated with mastication and the actions of growth hormones are linked with the increase in the size of the sinus. sinusal development normally continues until late adolescence. the paranasal sinuses are innervated by branches from the trigeminal nerve (cn v). the frontal and sphenoidal sinuses are innervated by branches from the ophthalmic nerve (cn v ), the maxillary sinuses from the maxillary nerve (cn v ), and the ethmoid cells from both the ophthalmic and maxillary nerves. as in the remainder of the nasal cavity, described previously, the paranasal sinuses are lined with a respiratory mucosa, ciliated and mucus-secreting, that is continuous with that of the respiratory tract. additionally, the paranasal sinuses seem to be an anatomic source for the excretion of nasal nitric oxide (no). mammals lacking paranasal sinuses (e.g. baboons) demonstrate lower exhaled concentrations of this molecule. no is involved in vasodilatation, neural transmission and immunologic activity, and appears also to participate in local host defense, even before allergens reach the respiratory mucosa. it may also regulate the mucociliary motility of the respiratory mucosa, thereby participating in the drainage of nasal secretions and the defense mechanisms of the mucosa. from the paranasal sinuses, no may also play distal functions. throughout normal nasal breathing, no is constantly excreted into the upper airway, acting as an 'aerocrine' messenger. it follows the airfl ow to the lungs where it modulates pulmonary function through regulation of blood fl ow and oxygen uptake. nasal breathing, therefore, becomes crucial for these vital functions. when compared to oral breathing in healthy individuals, nasal breathing results in an improvement of arterial oxygenation with a reduction of pulmonary vascular resistance. in this manner, no would be an airborne messenger. it is of prime importance to improve nasal respiration in infants and children as soon as possible. nasal breathing promotes healthier conditions in association with inspiration. additionally, it stimulates the development of the maxillofacial skeleton and, therefore, of the nasal cavities. the paranasal sinuses are a common site for infection in children and adolescents. the most common sinusitis is maxillary, followed by ethmoidal and then frontal sinusitis. the tendency to develop sinusitis can be explained in part by anatomy. proper ventilation is critical for preservation of sinus integrity. the maxillary sinuses are ventilated, but the ostium of each sinus is positioned high on the lateral wall of the nasal cavity. this encumbers gravitational drainage and probably predisposes patients to infections of the maxillary sinus. the frontal sinus is ventilated and because of the location of its ostium at its base, this sinus benefi ts the most from gravity. sphenoidal sinusitis rarely occurs as an isolated infection, being found more often as a part of complete sinusal involvement. viral infections of the upper respiratory tract commonly result in an infl ammation of the sinuses and nasal mucosa to produce the rhinosinusitis. bacterial infections with purulent nasal drainage are most often located in the paranasal sinuses. viral rhinosinusitis precedes about % of bacterial sinus infections while the remaining % most often follow allergic rhinitis. persistence of nasal symptoms, such as discharge or congestion, cough and headaches, particularly when awakening, for more than days is defi ned as chronic sinusitis. the sinus ostium is a common structure shared by all of the paranasal sinuses. its function has been compared to that of the pharyngotympanic tube. they both permit drainage. the ostia of the sinuses allow drainage of the paranasal sinuses whereas the pts drain the tympanic cavities. therefore, following the same principles as those used to treat otitis media, osteopathic procedures may be applied to affect the bones of the paranasal sinuses to improve their compliance and promote sinus drainage. interand intraosseous techniques for the frontal bones, ethmoid, sphenoid and maxillae are very effi cient in the treatment of sinusitis. the normal size of the sinus ostia is approximately . mm. the ostia are lined with mucosa and infl ammation and swelling of that mucosa may decrease or occlude ostial patency and consequently the drainage of the paranasal sinuses. obstruction of a paranasal sinus ostium will initially produce an increase of the pressure within the sinus. this is followed by intrasinusal gas absorption that consequently results in negative pressure within the sinus. this condition predisposes aspiration of bacterialaden secretions into the ethmoid or maxillary sinuses from the nasal cavity, particularly when an individual sniffs or blows their nose. obstructed drainage generates stasis of mucus in the paranasal sinuses that, in turn, becomes an ideal culture medium for bacteria. more infl ammation follows, with a self-perpetuating condition that leads to chronicity. additionally, somatic dysfunction may contribute to impaired nasal secretion. parasympathetic stimulation results in vasodilatation and increased activity of the seromucous glands and goblet cells, with symptoms such as rhinorrhea and nasal congestion. on the other hand, increased sympathetic activity produces vasoconstriction and dryness of the nasal mucosa. cranial somatic dysfunction of the maxilla, palatine bone and sphenoid can affect the pterygopalatine ganglion and both parasympathetic and sympathetic supply of the nose and paranasal sinuses (see 'rhinitis' above). dysfunction of the cranial base and craniocervical junction will refl exly affect the trigeminal nerve and, through it, sympathetic and parasympathetic refl exes. somatic dysfunction in the cervical and upper thoracic spine can affect sympathetic activity, as well as lymphatic drainage of the facial area. once again, normal motion of skeletal structures, functional ciliary motion and autonomic regulation are required for a healthy upper respiratory system. it should be stressed that cranial somatic dysfunction, although it may originate very early in life, may not manifest until years later. nasal septal asymmetry may affect as many as % of newborns as the result of compression of the tip of the baby's nose during vaginal delivery. nasal suction bulbs or nasogastric tubes may also be traumatic to the nose. a nasal septal deviation may affect the middle concha and predispose to the obstruction of the osteomeatal area. cranial base dysfunction and vertebral somatic dysfunction may result from diffi cult labor. obviously, for all these reasons, a whole body osteopathic evaluation and treatment of the newborn should be performed, including attention to the facial bones, particularly those of the nose. left untreated, facial somatic dysfunction may restrict full development of the paranasal sinuses. furthermore, nasal obstruction will lead to mouth breathing and sleep-disordered breathing. sore throat and sinusitis may follow. nasal obstruction is frequently associated with chronic maxillary sinusitis, adenotonsillar hypertrophy and otitis media as well as dental malocclusion and facial maldevelopment. later in childhood and adolescence, somatic dysfunction can occur as the result of traumatic forces from physical bumps, falls, athletic strains and the like. the resultant dysfunction, depending on the direction of the traumatic force, may be established in the pattern of the individual's underlying postural balance or completely independent of it. somatic dysfunctions of the facial bones and upper thoracic region are of particular consequence in the development and maintenance of sinus dysfunction. the cranial respiration of the prm differs from the thoracoabdominal respiration. however, they may entrain each other. this happens during states of relaxation, where the rate of the pulmonary respiration decreases to that approximating the rate of the prm. thereby, the two respirations combine their action to affect the entire body. this principle is particularly signifi cant in the upper airway to promote movement of the nasal secretions, the gaseous contents of the paranasal sinuses, blood and lymph. the normal cranial motion associated with the prm consists of an inspiratory phase (fl exionexternal rotation) during which the paranasal sinuses as paired structures expand laterally and decrease in height. conversely, during the expiratory phase of the prm (extension-internal rotation), the sinuses decrease their lateral dimension and increase their height. during cranial inspiration, the maxilla and the zygomatic bone move in external rotation, but at the same time a slight twisting occurs between them that contributes to the drainage of the maxillary sinus. the movements of all bones in association with the biphasic prm may be described as the result of the combined movements in the three cardinal planes. the twisting between the zygomatic bone and the maxilla occurs predominantly in the sagittal plane. during external rotation, the zygoma demonstrates a component of anterior rotation, while the maxilla simultaneously demonstrates posterior rotation. the reverse occurs during internal rotation. this motion may be compared to the wringing out of a wet rag. the zygomatic bones are an interface between the greater wing of the sphenoid, the maxilla, the frontal and the temporal bones. their position is strategic and they play a key role in the balance of the face. the vomer is located between the sphenoidal body and the hard palate. its inferior border articulates anteriorly with the intermaxillary suture between the palatine processes of the maxillae and posteriorly with the interpalatine suture between the horizontal plates of the palatine bones. the vomer rotates posteriorly during cranial fl exion or inhalation, when the body of the sphenoid rotates anteriorly. conversely, the vomer rotates anteriorly during cranial extension or expiration, when the body of the sphenoid rotates posteriorly. accordingly, sutherland stated: 'during inhalation the zygomatic bones and the vomer function somewhat like a plumber's plunger on the sphenoidal sinus and the maxillary sinuses.' every component of the facial skeleton is involved as part of the global functional pattern and should be assessed. again according to sutherland, even the smallest structures should be considered: 'see the turbinates on the side of the nose as they are in the living body, curling and uncurling during inhalation and exhalation.' the treatment of sinusitis is intended to promote the prm. the osseous structures as well as the potency of the prm should be considered. manipulative treatment of the somatic dysfunction associated with sinusitis should be employed in conjunction with standard medical treatments. the sooner it is initiated, the more rapid and successful the response. failure to treat chronic sinusitis effectively will result in altered growth patterns of the viscerocranium. nasal breathing will be impaired with concomitant malposition of the tongue and resultant dental malalignment. osteopathic examination and treatment of sinusitis are very similar to that of rhinitis. examination is directed at the identifi cation of somatic dysfunction that affects normal mucociliary clearance and impairs blood and lymphatic circulation, as well as ans function. for this and the associated treatment discussion, the reader is directed to 'rhinitis' above. manipulative treatment for sinusitis should focus on the reduction of mucosal edema, which will increase osteal patency. procedures should be employed to drain the sinuses and provide symptomatic relief. treatment should also include procedures that address sympathetic and parasympathetic somatovisceral refl ex activity affecting the sinuses. the sympathetic supply of the paranasal sinuses emanates from the upper thoracic spine. when examining the child with sinusitis, it is all too easy to become focused on dysfunction of the viscerocranium and forget this signifi cant area. additionally, when working with children it is less intrusive to begin in an area away from the face. perform tests of listening to evaluate the motion of the upper thoracic vertebrae and associated ribs. because of its relationship with the trigeminal nerve, the occipitocervical region should also be assessed. the rhythmic motion of the cranial bones under the infl uence of the prm signifi cantly facilitates sinus drainage. it is, therefore, appropriate to examine the global cranial pattern, looking specifically for dysfunction that reduces the motion of the sphenoid, ethmoid, vomer, palatine and zygomatic bones, maxillae and conchae. observe the face of the child, looking for puffi ness in the nasal area. look for asymmetry of the nares and asymmetric nasal respiration. compare the degree of nasal alar fl are with inspiration. in addition, inspect the nasal cavity, noting secretions, edema and erythema of the mucosa. observe the child for open mouth posture that may be indicative of enlarged adenoids. listen to the child's speech for hyponasality. utilizing tests of listening, evaluate the sphenoid and frontal bones. proceed to assess the facial bones, paying particular attention to the ethmoid, maxillae and zygomatic bones. the function of the vomer, palatine bones and conchae should also be considered. the zygomatic bones are easily accessible and their manipulation readily results in drainage of the maxillary sinuses. this procedure (see chapter ) is straightforward and easily mastered by the novice. manipulation of the zygoma, in turn, affects the ipsilateral maxilla and greater wing of the sphenoid. the motion of the sphenoid should be assessed. it exerts signifi cant infl uence on the facial bones and on proper drainage of the sphenoid sinuses whose ostia are located in the upper portion of the anterior walls of the sphenoidal body. the ethmoid bone is a common site of dysfunction in children and adolescents, and should be assessed in its relationships with the frontal bones, sphenoid and maxillae. proper motion of the ethmoid bone is necessary to facilitate the emptying of secretions from the ethmoid air cells. intra-and interosseous motion of the maxilla should be assessed because it is necessary for the effective drainage of the maxillary sinus. additionally, in conjunction with the pterygoid process of the sphenoid and the palatine bone, it forms the pterygopalatine fossa where the pterygopalatine (sphenopalatine) ganglion is located. any dysfunc-tion of these bones may affect the ganglion and its effects on mucosal secretions. the vomer's contribution is very important to the mechanism of the pumping action of the paranasal sinuses. its assessment is often performed with one fi nger placed intraorally. when treating very young children, this procedure should be done only when absolutely necessary and then only with the greatest delicacy. the examiner should never attempt intraoral palpation of the vomer if the child is not completely cooperative. an alternative procedure is to employ visualization of the vomer while palpating the anterior edge of the nasal septal cartilage. treat any dysfunctional areas identifi ed. treatment is normally performed in continuity with assessment. because indirect treatment procedures are used preferentially for children and adolescents, the effective treatment of a given area results in further relaxation of the patient, thereby facilitating the treatment of the next area to be evaluated and treated. furthermore, when performing indirect techniques, tissue responses are continuously monitored, so that in acute conditions the patient's tolerance to the procedure is also continuously assessed. the tissues dictate the treatment; they guide your actions and determine the dosage. the upper thoracic region should be treated for its sympathetic somatovisceral effects, to facilitate lymphatic drainage of the head and neck, and for functional reasons because it is the foundation on which the above structures rest. the occipitocervical junction should be treated for its refl ex impact on the trigeminal nerve and its relationship to the cranial base. the sphenoid, frontal and facial bones should be treated for their direct effect on the paranasal sinuses. paranasal sinuses are intraosseous cavities and their drainage is dependent on the inherent motility of their respective bones: frontal, sphenoid, ethmoid and maxillae. as such, intraosseous dysfunctions of any of these bones can impact the associated sinus. specifi cally pumping the individual bones may be employed to facilitate drainage of their sinuses. positioning the patient contributes to the drainage of the paranasal sinuses by using gravity. drainage of the sinuses is best performed as follows: • drainage of the frontal sinus in the seated position • drainage of the sphenoidal sinus in the seated position with the head of the patient bent forward • drainage of the maxillary sinus in the supine position with the patient's head rotated to the opposite side so that the sinus to be drained is up. when treating the vomer, if the child resists the digital intraoral approach, the child's pacifi er, if they have one, may be utilized. by allowing the child to actively suck on the pacifi er the resultant alternation of intraoral pressure and tongue movement, pressing the pacifi er on the roof of the child's mouth, may be employed to manipulate the vomer, while the practitioner works on the adjacent sphenoid and ethmoid bones. the caregiver should be encouraged to maintain a healthy lifestyle for the child, including a balanced diet with adequate hydration and the avoidance, as much as possible, of refi ned carbohydrate. respiratory exercises including nasal respiration and diaphragmatic breathing may be taught. vocal activities such as humming can be benefi cially employed to increase sinus ventilation. the pharynx is a musculomembranous half-cylinder that connects the nasal and oral cavities with the larynx and esophagus. it extends from the base of the skull to the level of the sixth cervical vertebra where it joins the esophagus. the pharynx is divided into three portions: the nasopharynx located above the hard palate, the oropharynx that extends from the hard palate to the base of the epiglottis and the laryngopharynx from the base of the tongue to the larynx. the oropharynx can be further subdivided into the retropalatal or velopharynx from the hard palate to the caudal margin of the soft palate and retroglossal from the most inferior tip of the soft palate to the base of the epiglottis (fig. . . ) . the pharyngeal wall consists of an internal mucous layer, an intermediate fi brous layer and an external layer of skeletal muscle. in the superior part of the pharynx, the pharyngobasilar fascia is the thickest portion of the intermediate fi brous layer of the pharyngeal wall and is fi rmly attached to the base of the skull. the attachment forms an irregular u-shaped line. the anterior part inserts on the posterior margin of the medial plate of the sphenoidal pterygoid process. it then curves under the cartilaginous part of the pts where it inserts onto the petrous part of the temporal bone and continues to the pharyngeal tubercle of the occipital basilar part to meet the attachment from the other side (fig. . . ) . the anterior part of the pharyngeal wall is not continuous; rather, it has multiple attachments to the medial pterygoid plate, the pterygomandibular raphe, the mandible, the tongue, the hyoid bone, and the thyroid and cricoid cartilages. six muscles contribute to constitute the pharyngeal wall. the bilateral superior, middle and inferior constrictor muscles constrict the pharyngeal cavity and, on each side, three longitudinal muscles -the stylopharyngeus, salpingopharyngeus and palatopharyngeus -elevate the pharyngeal wall and participate in swallowing (figs . . , . . ) . the fi bers of the three constrictor muscles fan out posteriorly into the median pharyngeal raphe, a fi brous band that is attached above to the pharyngeal tubercle of the occipital basilar part. the pharyngeal raphe descends to the level of the sixth cervical vertebra where it blends into the posterior wall of the esophagus. a thin retropharyngeal space fi lled by loose areolar tissue connects the pharynx with the cervical portion of the vertebral column and the prevertebral fascia covering the longus colli and longus capitis muscles. the pharynx is the common route for air and food, and seven cavities communicate with it: the two nasal cavities, the mouth, the larynx, the two tympanic cavities and the esophagus (fig. . . ) . the nasal cavities open posteriorly into the nasopharynx through the choanae. the oral cavity also opens posteriorly through the oropharyngeal isthmus the internal mucous layer of the pharyngeal cavity is continuous with that of the mouth and larynx and that lining the nasal cavities and pts. it contains a large collection of lymphoid tissue, arranged in a circular orientation around the wall of the throat, the waldeyer's tonsillar ring that represents the primary defense against pathogens at the entry of the upper respiratory and alimentary tract. the constituent parts of this defensive annulus are the nasopharyngeal, palatine, tubal and lingual tonsils, plus lymphoid tissue in the intertonsillar intervals. the nasopharyngeal tonsil is located in the area of the nasopharyngeal roof and posterior wall, where the mucosa covers the inferior part of the sphenoidal body and the basilar part of the occipital bone. the palatine tonsil constitutes the major part of waldeyer's ring. the paired palatine tonsils are located in the lateral wall of the oropharynx, in the tonsillar fossae, posterior to the base of the tongue between the anterior and posterior pillars, the palatoglossal and palatopharyngeal folds, respectively. they can be observed through the open mouth with the tongue depressed (fig. . . ). they are located slightly higher in the neonate and descend during the nd and rd years of age. the lingual tonsils are multiple lymphoid nodules situated on the posterior one-third of the tongue while additional small nodules beneath the mucosa of the pt form the tubal tonsils. the nasopharyngeal tonsil increases in size in the fi rst years of life to reach its peak around years of age. thereafter, it starts to involute until almost completely atrophied by puberty. when the nasopharyngeal tonsil is enlarged it is referred to as adenoid or adenoids; 'tonsils' is usually the common name for the palatine tonsils. waldeyer's tonsillar ring is located at a strategic point where numerous antigens, both foodsupported and airborne, fi rst come into contact with the body. thus, it plays an important role in the immune system as a site of antigen recognition and synthesis of antibodies, including ige. the nasopharyngeal and palatine tonsils are major sources of t lymphocytes that participate in cell-mediated immunity and b lymphocytes that produce immunoglobulins. the nasopharyngeal tonsil also seems to participate in immune peripheral tolerance to harmless foreign antigens commonly inhaled or present in digested nutrients. bacterial, or less frequently viral, infections are most often responsible for tonsillitis, where the tonsils may be acutely infl amed. bacterial infections are often streptococcal, usually from group a streptococci, the most virulent species in humans. differential diagnosis between viral and bacterial infection, based on physical examination alone, is diffi cult. tonsillitis is characterized by sore throat and pain, particularly during swallowing, which may involve the ears. headaches, vomiting and high fever may be associated. it should be noted that bacterial infections are correctly treated with appropriate antibiotics and that in these instances the diagnosis and treatment of somatic dysfunction should be considered as adjunctive. pharyngitis, an acute infl ammation of the pharynx, is usually the result of a viral infection, although it may be bacterial. the pharyngeal mucous membranes may be infl amed with purulent exudates. sore throat and pain during swallowing are also present, associated with fever, cervical adenopathy and leukocytosis. susceptibility to infections differs between individuals. host genetic components that adjust immune responses to pathogens seem to play an important role. , nevertheless, the peritonsillar location is the most common of head and neck space infections in children in % of cases. the american academy of otolaryngology-head and neck surgery currently proposes adenoidectomy as a guideline after ' or more infections of tonsils and/ or adenoids per year despite adequate medical therapy'. adenoidectomy is currently one of the most common operations performed on children in the united states. , besides bacterial and viral infections, allergies such as allergic rhinitis are considered to be common risk factors for adenoid hypertrophy. the continuity between the internal mucous layer of the pharyngeal cavity, the nasal cavities, the mouth, the larynx, the tympanic cavities and the esophagus explains the interrelationship and diversity of clinical presentations in allergic conditions. increased immune activity results in hypertrophy of waldeyer's tonsillar ring, in particular at the level of the nasopharyngeal tonsil. chronic nasal airway obstruction may follow a condition quite common in childhood that leads to a persistent mouth-open posture and mouth breathing. adenotonsillar hypertrophy has also been associated with a myriad of symptoms such as obstructive sleep disorder syndrome, nocturnal snoring, rhinosinusitis, hyponasal speech and impairment of the ability to smell. furthermore, hypertrophy of the nasopharyngeal tonsil or adenoids predisposes the individual to recurrent otitis media or otitis media with effusion, in part because of the diminution of the patency of the orifi ces of the pt, located just laterally to the nasopharyngeal tonsil. tonsillectomy and adenoidectomy in children is reported to improve symptoms associated with obstructive sleep apnea syndrome, such as snoring and restless sleep, as well as behavioral, emotional and neurocognitive diffi culties. these procedures are also associated with improvement of the nasal cavity geometry by reducing the venous stasis and congestion of the inferior turbinate present in adenotonsillar hypertrophy. nasopharyngeal tonsil hypertrophy and the associated mouth breathing are usually believed to impact craniofacial development. experiments conducted in primates have established that a persistent mouth-open posture and associated oral respiration leads to dental malocclusions such as cross-bite. mouth-breather children may present with a narrow, elevated palate and a decreased nasopharyngeal space. in such cases, they may demonstrate a receding chin (retrognathia) with crowding of the maxillary and mandibular teeth, and increased lower anterior vertical face height. following adenoidectomies and establishment of nasal breathing, changes are reported, with a more anterior growth of the mandible, improvement of retrognathia and diminution of lower anterior vertical face height. the commonly used terminology 'adenoid' facies to describe longer lower face heights, open mouth and more retrognathic mandibles has led people to believe that adenoid hypertrophy was solely responsible for mouth breathing and associated disorders. this is an overly simplifi ed conclusion. once again, a multifactorial approach to diagnosis and, consequently, treatment may be necessary. a study of children years after adenotonsillectomy showed that upper airway narrowing during sleep was still present, although some resolution of sleep disturbance was obtained months postoperatively. not all children who snore demonstrate adenotonsillar hypertrophy and such hypertrophy is not the only cause of sleep apnea. pharyngeal collapsibility is implicated with anatomic predisposition such as changes in the longitudinal tension within the pharyngeal airway. although adenoidectomy is considered to be an effective treatment for children who are mouth breathers, recurrence of breathing diffi culties in these individuals occurs and has been attributed to their craniofacial anatomic pattern. in upper airway narrowing, sleep apnea, mouth breathing and adenotonsillar hypertrophy, the craniocervical membranous, myofascial, ligamentous and interosseous somatic dysfunction may contribute to the pharyngeal dysfunction. the upper part of the pharynx is attached to the sphenoid, the temporal bones and the occiput. through the prevertebral fascia the pharynx is linked to the cervical spine and movements of the cervical spine are associated with changes of pharyngeal size: cervical fl exion decreases clinical conditions oropharyngeal size; cervical extension does the opposite. [ ] [ ] [ ] any dysfunction of the cervical spine or of any of the structures on which the pharynx is inserted can impair normal pharyngeal function. movement is necessary to mobilize body fl uids, particularly lymph, and somatic dysfunction affecting the structures surrounding lymph nodes and vessels is associated with impaired motion and can thus interfere with lymph fl ow. lymphatic vessels from the pharynx drain into the deep cervical lymph nodes through the retropharyngeal, paratracheal and infrahyoid nodes. the retropharyngeal nodes consist of a median and two lateral groups located in front of the lateral masses of the atlas. they are positioned between the pharyngeal and prevertebral fasciae and drain the nasopharynx and pt, as well as the two upper cervical joints. the deep cervical lymph nodes are beneath the scm muscle. among them, a large node surrounded with several small ones forms the jugulodigastric group that receives drainage from most of the lymphatic vessels from the tonsil. the tonsils differ from the lymph nodes in that they do not receive afferent lymphatic vessels. small lymphatic vessels organize as efferents from the tonsils that traverse the superior constrictor muscle before draining to the jugulodigastric nodes. located against the posterior belly of the digastric muscle, these nodes swell during tonsillitis and may be palpable in front of the anterior border of the digastric muscle, below the mandibular angle. the vessels that supply the pharyngeal wall come from the external carotid artery. the tonsillar branch of the facial artery (external maxillary) is the main blood supply to the palatine tonsil. the veins of the pharynx drain through the pterygoid plexus in the infratemporal fossa and into the facial and internal jugular veins. because the pharynx is so intimately linked to the cervical spine and the cranial base, as well as associated muscles and fasciae, optimal pharyngeal function necessitates that these areas are unimpaired. the upper thoracic spine is the anatomic origin of the sympathetic supply to the pharynx and, consequently, along with associated ribs, should also be considered when addressing pharyngeal dysfunction and disease. finally, the functional freedom of the clavicles, thoracic inlet and cervical spine, together with associated soft tissues above, is necessary to facilitate lymphatic drainage of the pharynx. having performed a total body structural examination to identify the global postural pattern and its relationship to the pharyngeal complaint, with the child in a supine position, it is appropriate to begin the local examination by evaluating the cervical and upper thoracic regions. first, palpate for tissue texture abnormalities in the paravertebral muscles and superfi cial soft tissues, looking for areas of muscular tension and subcutaneous edema. similarly, palpate the anterior and lateral aspects of the neck. observe and palpate the location of the hyoid bone and larynx that should be in the midline. palpation of the anterior neck structures should be done with great delicacy to prevent irritating already infl amed tissues and because this is an area of increased sensitivity, particularly in infants who were born with a nuchal cord. assess the anterior and lateral cervical musculature, paying specifi c attention to the scm muscle because of its relationship to the deep cervical lymph nodes. follow the scm inferiorly to its attachment on the clavicles and assess clavicular motion. evaluate the cervical vertebrae, noting the alignment of the spinous processes. clinical experience has shown a strong association between pharyngitis and cervical articular somatic dysfunction that, when treated, appears to prevent recurrent pharyngitis. next, evaluate the upper thoracic vertebrae and associated ribs. assess the functional status of the cranial base, noting the relationships between the occiput, temporal bones and sphenoid. the pharynx is suspended beneath the skull and tone of the pharyngeal musculature is impacted by cranial dysfunction. for proper function, the pharyngeal muscles require precise interrelationships between their origins and insertions. dysfunctional mechanics that affect these relationships will impair function of the pharynx and associated waldeyer's tonsillar ring. the pharyngeal tonsil is located directly beneath the cranial base, at the level of the sphenobasilar junction. as such, freedom of motion of the cranial base may facilitate lymphatic drainage of the adenoids. mandibular function should also be examined. dysfunction of the mandible may impact anterior cervical myofascial function, contribute to impaired lymphatic drainage of the jugulodigastric node and participate in chronic mouth breathing. apply indirect principles to treat any identifi ed articular dysfunction of the spine, ribs and clavicles. myofascial release techniques may be employed to address pharyngeal, anterior cervical and spinal muscular dysfunctions. normalizing the cranial and thoracoabdominal diaphragms and the thoracic inlet may be employed to promote lymphatic and venous circulation. following the inherent motility of the prm may enhance all of these interventions. this slow, gentle rhythm is soothing to the child and is integral in the maintenance of homeostasis. . humans may breathe through their noses, mouths or intermittently through both. it is commonly held that, between birth and at least months of age, infants breathe exclusively through their noses. this belief has, however, been challenged and some authors propose that infants are 'preferential nasal breathers' rather than 'obligate nasal breathers'. in older children and adults, under normal conditions and at rest, the nasal respiratory route is used, and oronasal breathing occurs typically when a higher degree of ventilation is necessary, as during exercise. in order to breathe through the nose, the nasal airway (nostril, nasal cavity and nasopharynx) should be patent. nasal obstruction consists of partial or complete blockage of one or more of these components of the air passages. in the newborn, the posterior nasal aperture may be blocked by choanal atresia. because of the infant's preferential nasal breathing route, such total nasal obstruction is a medical emergency. in the young infant, and later in life, several other factors can cause nasal airway obstruction. 'stuffy nose' or rhinitis is a common cause of nasal obstruction in young infants that results in mouth breathing (see p. ). viral upper respiratory tract infections, foreign body, deviated nasal septum, hypertrophy of the inferior turbinates and nasal polyps are other factors that can also predispose to mouth breathing and produce an open mouth posture. nasal endoscopy may be necessary to assess children with severe nasal obstruction that may require surgical repair. tonsillar hypertrophy is believed by many to be the main cause of nasal obstruction in children. the pharyngeal tonsil, or adenoids, is a large collection of lymphoid tissue located beneath the roof of the nasopharynx, at the level of the sbs. enlargement of the pharyngeal tonsil commonly occurs as the result of frequent bacterial or viral infections and can obstruct the nasopharyngeal route so that mouth breathing is the only possible alternative. 'tonsils' is the common name for the palatine tonsils, which are lymphoid tissue located laterally on the oropharyngeal walls, just posterior to the base of the tongue. children with enlarged adenoids are described as having 'adenoidal facies' (long faces). they share common features with other mouth breathers, having low body weight and short stature, circles around their eyes, receding chins, small mouths, dry, large lower lips and short upper lips that are held apart from one another. they also tend to have multiple allergies and to demonstrate a specifi c postural confi guration, the most commonly described feature of which is the anteriorly displaced or extended position of the head. effi cient respiration is the result of multiple intricate neurophysiologic processes and several anatomic structures contribute to this complex system. the extended, or forward, head posture may follow nasal obstruction as a solution to compromised nasal breathing. experimental studies have shown that cervical extension increases maximum oropharyngeal airway size. therefore, children with nasal obstruction will spontaneously tend to assume the extended or forward head posture. an extended head position is associated with an anterior displacement of the condyles of the occiput on the superior articular surfaces of the atlas, while the squamous portion of the occiput is lowered. the distance between the occiput and dorsal arch of the fi rst cervical vertebra has been shown to be decreased in mouth breathers. the condyles of the occiput are convex and the superior articular surfaces of the atlas are concave. extension of the head for the shift from nasal to mouth breathing results in anterior and ascending displacement of the occipital condyles on the superior articular surfaces of the atlas. this causes the horizontal line of sight of the orbits to be angled upward, with resultant shift of the visual fi eld and the need for postural compensation. one way to accomplish this, which is commonly observed in mouth breathers, is to increase the thoracic kyphosis. another way -possible with young children when the synchondroses of the cranial base are still patent -is to increase the amount of fl exion in the cranial base. such an increase of cranial base fl exion is present in mouth-breathing children. interestingly, an increase in cranial base fl exion in primates has been shown to result in a decrease of the anteroposterior length of the nasopharynx and shortening of the anteroposterior length of the mandibular ramus. the decrease of the anteroposterior length of the nasopharynx reinforces the tendency for mouth breathing, while the shortening of the anteroposterior length of the mandibular ramus correlates with the receding of the chin (retrognathia) that is observed in children who are mouth breathers. adenoidectomy is considered to be an effective treatment for children with enlarged adenoids who are mouth breathers. however, recurrence of breathing diffi culties in these children has been observed and is attributed to their craniofacial anatomic pattern. an extended craniocervical junction, or any dysfunctional pattern in the surrounding myofascial structures, may, therefore, be considered a primary dysfunction that could, in turn, predispose the child to chronic mouth breathing. this is confi rmed by clinical observations that some children present with chronic mouth breathing secondary to nasal airway obstruction, while others tend to be mouth breathers without any obvious obstruction of the nasal airway. mouth breathing has also been correlated with an inferoposterior displacement of the hyoid bone and an anteroinferior positioning of the tongue. , , the hyoid bone, a 'u-shaped' bone with an anterior convexity, is not directly articulated with any other skeletal structures. through its myofascial attachments it acts as an interface between the tongue, the pharynx, the larynx and the skull and thorax. therefore its position is infl uenced by dysfunction of any of these related structures and it can, in turn, exert infl uence on them. in mouth breathers, both the hyoid bone and the tongue are displaced to a position lower than normal. chronic mouth breathers often demonstrate premature molar eruption. mouth breathing also infl uences the growth of the mandible, resulting in anterior mandibular rotation and increase of the gonial angle between the ramus and the body of the mandible. consequently, the vertical height of the lower face of mouth breathers is usually increased, with a resultant open bite that is an augmentation of the vertical dimension separating the jaws. nose breathing performs several functions of importance, such as warming and humidifi cation of the inspired air, facilitation of arterial oxygenation and regulation of pulmonary function. nasal obstruction is linked to obstructive sleep apnea in children as well as in adults. therefore, nasal obstruction is a signifi cant dysfunction and osteopathic procedures can often be applied to improve the patency of the nasal airway. preventive treatment should be carried out for infants and toddlers to ensure normal development of the cranial base and craniocervical junction. mouth breathing is present with and without nasal obstruction and the child should be evaluated to determine if nasal obstruction is present. in severe cases, nasal endoscopy and medical treatment may be necessary. hyponasal speech usually indicates an obstructed airway. a simple way to check for nasal patency is to ask the child to breathe, at least times, through their nose while keeping their mouth closed. the child should be able to perform this test without becoming short of breath. diffi culty in achieving the test may be associated with rhinitis or chronic sinusitis. successfully completing the test indicates that the prognosis for a positive response to manipulative treatment is good. an alternative method to assess nasal patency is to hold a mirror under the nostrils of the subject. normally patent nasal respiration will fog the mirror. if nasal obstruction is not demonstrated, the child should be examined to defi ne somatic dysfunction possibly responsible for mouth breathing. identifi ed somatic dysfunction should be treated and then procedures to establish nasal breathing should be taught to the child. the objective of treatment is to obtain optimal posture, improve function of the cervical and thoracic spine, balance the cranial base and its relationships with the hyoid bone and mandible, and facilitate nasal passage patency. as the pharyngeal tonsil is located immediately below the cranial base, at the level of the sphenobasilar junction, augmentation of the motion of the cranial base may increase tonsilar lymphatic drainage. when treating the child it is best to begin by addressing their global standing posture. observe the relationship between the head and the remainder of the body. look for any asymmetries of cervical rotation and sidebending. look for an exaggerated position of cervical extension or fl exion and for increased thoracic kyphosis and lumbar lordosis. next, with the child in the supine position, palpate for tissue texture change in the suboccipital area and in the cervical and thoracic spine below. palpate the soft tissue in the submandibular area; look for any lack of tonicity of the genioglossus muscles. palpate for texture change in the tissues surrounding the mouth and the nose. assess the motion of the suboccipital area, cervical and thoracic spine. the cranial base, sphenobasilar synchondrosis and sphenoid should be evaluated next. the motions of the frontal bone, ethmoid and facial bones, particularly the maxillae, are considered next. identify any membranous myofascial dysfunction that might also be present and treat accordingly, following indirect principles. teaching the child activities for the rehabilitation of normal breathing habits should complete the treatment. the child should be trained to breathe through their nose. they should be taught to control the nasalis muscle that compresses the nasal aperture with its transverse part and laterally opens the nostril with its alar part. with their index fi nger and thumb bilaterally contacting their nose, lateral to the nasal ala, they can be taught to feel the expansion of the nares when breathing. next, they can be encouraged to open their nostrils more dynamically during inhalation while palpating the resultant nasal expansion. encouraging them to smell pleasant odors such as fl owers or favorite foods may further increase awareness of nasal function. small children may be taught to intermittently fl are and relax their nostrils by telling them to move their noses as a rabbit does, while keeping their mouths closed, but not so tight as to purse their lips by constricting the orbicularis oris muscle. the upper airway is a very complex area that participates in several physiologic functions as diverse as deglutition, vocalization and respiration. multiple anatomic structures take part in the mechanics of respiration. consequently, more than one specifi c site of the upper airway can be blocked in obstructive disorders such as sleepdisordered breathing (sdb) where the different parts of the pharynx, the base of the tongue and the esophagus may be involved. in sdb, several factors may be present along with the obstructive phenomenon. these include abnormalities or diseases of the paranasal sinuses, tonsilses, soft palate and tongue, as well as obesity. [ ] [ ] [ ] a review of the development and relationships between the multiple constituents of the upper respiratory system is helpful in understanding the dysfunctional patterns of the region. the respiratory system consists of the larynx, trachea, bronchi, lungs and pleura. the larynx is situated between the trachea and the root of the tongue. it forms the lower part of the anterior wall of the pharynx and is the organ of voice. in the infant, during the fi rst months of life, the larynx is located in a high position and, throughout both deglutition and respiration, contact is maintained between the epiglottis and the soft palate. by approximately months of age, however, this contact is maintained only during deglutition and separation occurs during respiration. the larynx progressively descends from a high position in the neck at the level of c -c during the fi rst ½- years of life to a lower position in the adult, where it is located between the upper border of c and the upper border of c . during the fi rst years of life the descent of the larynx is associated with important changes in the relationships of the structures that constitute the pharynx. in the newborn and the very young infant, the tongue is located totally within the oral cavity. as the larynx descends, the posterior part of the tongue is drawn posteriorly and inferiorly to participate in the constitution of the superior part of the anterior wall of the pharynx, i.e. the oropharynx. the pharynx is shaped like a funnel, having a length of about . cm. the upper wide end of the pharynx is tipped forward and consists of the oral and nasal cavities, whereas the lower part, at about the level of c , is continuous with the esophagus. superiorly, it is attached above to the base of the skull on the posterior borders of the medial plates of the pterygoid processes of the sphenoid bone, on the petrous parts of the temporal bones and on the pharyngeal tubercle of the occipital bone. laterally, the pharynx is connected to the styloid processes of the temporal bones and posteriorly to the cervical spine and the prevertebral fascia that envelops the longus colli and longus capitis muscles. the anterior portions of the pharynx are attached to the medial pterygoid plates of the sphenoid bone, the pterygomandibular raphes, the mandible, the tongue, the hyoid bone, and the thyroid and cricoid cartilages. the pharyngeal wall consists of two groups of muscles, the constrictor muscles and the longitudinal muscles, grouped according to the arrangement of the muscle fi bers. the three constrictor muscles -the inferior, middle and superior -function to constrict the pharyngeal cavity. the longitudinal muscles are the paired stylopharyngeus muscles that connect the pharynx with the styloid processes of the temporal bones, the salpingopharyngeus muscles that connect the pharynx with the cartilaginous part of the pharyngotympanic tubes and the palatopharyngeus muscles that connect the pharynx with the soft palate. the three longitudinal muscles elevate the pharyngeal wall. the pharyngeal muscles are innervated by the vagus nerve (cn x), except for the stylopharyngeus muscles that are innervated by the glossopharyngeal nerve (cn ix). the pharynx consists of three parts: the nasopharynx into which the choanae of the nasal cavity open, the oropharynx that constitutes the posterior portion of the oral cavity and the laryngopharynx into which the superior portion of the larynx opens. the soft palate is located between the nasopharynx and the oropharynx. the soft palate is a determining factor in the establishment of the breathing route. it is compared to a curtain hanging from the posterior border of the hard palate, i.e. the posterior borders of the two palatine bones. the soft palate extends downwards and backwards between the mouth and pharynx. it consists of muscular fi bers, aponeurosis, vasculature, nerves, adenoid tissue and mucous glands enclosed in a fold of mucous membrane. its posterior surface is convex and is continuous with the fl oor of the nasal cavities. its anterior surface is concave and is continuous with the roof of the mouth (fig. . . ) . the position of the soft palate determines the route of breathing. it acts as a valve hanging over the oropharyngeal isthmus. in its more horizontal position it separates the nasopharynx from the oropharynx, its posterior tip being closer to the posterior wall of the pharynx, facilitating the oral route of breathing. when it is depressed against the base of the tongue, the oropharyngeal isthmus is closed and the nasal breathing route is made possible. when respiration is through both mouth and nose, the position of the soft palate is shown to be between the tongue and the posterior pharyngeal wall. the soft palate is under the control of fi ve pairs of muscles. the levator veli palatini (lvp) and tensor veli palatini (tvp) arise from the base of the skull. the lvp originates from the apex of the petrous part of the temporal bone and from the cartilage of the pt and spreads in the palatine velum to blend with the muscle of the opposite side. the tvp arises from the scaphoid fossa of the medial pterygoid plate, from the spina angularis of the sphenoid and from the lateral wall of the cartilage of the pt. it descends vertically and then turns around the pterygoid hamulus to insert into the palatine aponeurosis. the musculus uvulae is related to the uvula. the palatopharyngeus arises from the pharynx and the palatoglossus from the tongue. all the soft palate muscles are innervated by the vagus nerve (cn x) except the tvp that is innervated by the mandibular nerve (cn v ) . the tvp muscles tense the soft palate; the lvp muscles elevate the soft palate and, therefore, close the nasopharynx. the palatopharyngeus muscles depress the soft palate and participate in the closing of the oropharyngeal isthmus. the palatoglossus muscles depress the soft palate caudally and ventrally and elevate the root of the tongue. the function of the soft palate is supposed to be actively determined, with dominant activity of the palatoglossus muscle when a subject is breathing quietly, and more activity from the lvp muscle during forced expiration. some activities such as breathing exercises or singing require both the nasal and oral breathing routes and the position of the soft palate consequently adapts to the situation. normal breathing relies on a patent nasal and pharyngeal airway. this patency depends on neural regulatory mechanisms as well as normal anatomic structures. the neural regulation is in part under the control of refl exes mediated through the trigeminal nerve (cn v) or the vagus nerve (cn x). the role of the vagus nerve is of paramount importance in the preservation of pharyngeal airway patency and any dysfunction of the upper cervical spine, in particular at the level of the jugular foramen, should be considered when airway patency is functionally compromised. considering the anatomic structures, the soft palate has been found to be the most common site of obstruction in infants presenting with signifi cant obstructive sleep apnea (osa). furthermore, an increase of cranial base fl exion has also been demonstrated in mouth breathing or sdb children. one can assume that, because of the insertion of the soft palate muscles, a dysfunction of the cranial base would lead to modifi ed soft palate mechanics. the soft palate occupies a strategic position, an intersection between the muscles arising from the base of the skull and the muscles connected to the tongue and the pharynx. considering these relationships, it is logical that any disturbance in the anatomic features infl uencing the soft palate, the tongue and the pharynx may also play a role in the development of sdb. adenotonsillar hypertrophy is described as being the most common cause of osa in children; its importance correlates with the dimension of the adenoids. osa, the result of airfl ow obstruction, occurs in older children as well as in infants, where symptoms may include apneic spells. pharyngeal collapse is involved and it is proposed that airway muscle dysfunction or anatomic alterations predispose to that collapse. loss of longitudinal tension within the pharyngeal airway is suggested as being responsible for the collapsibility. subtle abnormalities in upper airway neuromuscular function or structure are proposed additions to the etiology of adenotonsillar hypertrophy. , the craniocervical junction is under great stress in the infant and dysfunction of the pharynx, which is attached to the base of the skull and to the cervical spine and prevertebral fascia, may be associated with any somatic dysfunction of the craniocervical junction and cranial base. the position of the cervical spine is correlated with pharyngeal changes: cervical fl exion reduces oropharyngeal size; cervical extension increases it. , , studies have demonstrated that patients with obstructive sdb present a narrower or more obstructed oropharynx and laryngopharynx than controls, particularly during sleep. besides the effect of cervical posture, alteration of refl exes due to sleepiness may play a role. when present, nasal obstruction also disturbs nasopharynx refl exes, mediated through the trigeminal or vagus nerves, which may result in decreased patency of the oropharynx. multiple sites are considered as potential causes for sdb. in view of the intricate anatomic relationships of the soft palate, the pharyngeal wall, the tongue and the mandible, any dysfunction of one affects the associated structures and their positions. biomechanical interactions between the tongue and lateral pharyngeal walls have been described and displacement of the mandible also affects oropharyngeal size. mouth opening reduces oropharyngeal size. the modifi ed mandible position affects the function of the genioglossus, one of the tongue muscles that protrude the anterior part of the tongue out of the mouth. this, in turn, increases upper airway collapsibility, the position of the tongue being a strong determinant of the patency of the oropharynx. this explains why mouth breathers present with snoring and sdb. alterations in the electromyographic activity of the geniohyoid and genioglossus muscles follow experimental nasal obstruction in monkeys with affected mandibular growth as a result. similar mechanisms are believed to exist in humans where mouth breathing in children, associated with sdb, may cause developmental facial abnormalities. maxillary and mandibular protrusions are smaller in children with osa and the position of the hyoid bone is lower. mouth breathing generates the development of a craniofacial type that includes an increased value of the anterior facial height and an open bite. the increased respiratory effort that these children must exert is responsible for functional impairment and eventually structural changes in their craniofacial anatomy. osa is also associated with poor sleep quality, failure to thrive, impaired daytime psychomotor performance, irreversible developmental delay and enuresis. osteopathic procedures should consequently be employed at the earliest possible time to avoid the establishment of dysfunctional patterns and their sequelae. begin by assessing for, and treating, any dysfunctional imbalances in the global postural pattern, particularly the craniocervical junction and upper aspects of the thoracic region including clavicle, sternum, upper thoracic vertebrae and associated ribs. next, attention should be paid to the mechanics of the hyoid bone, including the infra-and suprahyoid muscles because of their relationship with the pharynx and tongue. the synchondroses of the cranial base, the occipitomastoid sutures and the relationship between the sphenoid and temporal bones should be considered next. any dysfunction of the temporal bones should be addressed in the treatment of sdb because of the connection between the longitudinal muscles of the pharynx and the styloid processes of the temporal bones. evaluate the temporomandibular joint, the mandible and surrounding myofascial elements. the inferior part of the pharynx is continuous with the esophagus that connects the pharynx to the stomach. possible stomach as well as tracheal visceral dysfunctions may affect the pharynx, either through mechanical imbalance or through disturbed vagal refl ex; therefore, they should be treated if present. teaching the child activities that strengthen and tone the soft palate and tongue can complete the treatment. vocal exercises employed in singing are benefi cial. the tongue, particularly the genioglossus muscles, can be strengthened by having the child alternately attempt to touch the tip of their tongue up to the tip of their nose and down to their chin. bronchiolitis is an acute viral infection of the lower respiratory tract that affects infants and young children. in europe, australasia and north america, an average of % of all children born every year present with bronchiolitis. respiratory syncitial virus (rsv) and infl uenza a virus are the most important viral causes of lower respiratory tract infection in young children. infections with infl uenza viruses b and coronavirus may also be common. infl uenza viruses are highly contagious and are responsible for epidemics presenting various degrees of severity, although only a small proportion of children infected with the virus develop severe disease. risk factors are childcare attendance, exposure to environmental pollutants, school-aged siblings, congenital abnormalities of the airways and neuromuscular disease. rsv is so named because, in tissue culture, it grows as a giant syncytia, a mass of protoplasm containing several nuclei. multiple genotypes of rsv cocirculate every year, along with an important variability in infl uenza virus occurrence from year to year. the infecting virus fi rst establishes in the upper respiratory tract and then spreads to the medium and small bronchi and bronchioles, resulting in infl ammation of the epithelium with edema and bronchial obstruction that manifests principally during expiration. air is trapped within the alveoli and hyperinfl ation of the lungs follows. respiratory distress appears with tachypnea and tachycardia. expiration is diffi cult and prolonged, and when the infant presents with severe tachypnea, breath is rapid and short, with poor air exchange. wheezing, crepitus and fever may be present. rsv is an important childhood pathogen in infants younger than months of age. once infected, an infant does not develop complete immunity and recurrence of infection is common. pneumonia and bacterial superinfections of the respiratory tract are frequent complications. rsv may be severe in infants under months of age and is an important cause of hospitalization for acute lower respiratory tract infection in infants and young children. bronchiolitis, particularly when due to rsv, may be a precursor of the later development of asthma. allergic rhinitis also exacerbates bronchial infl ammation and may be a risk factor for the development of asthma. young children who have more than three episodes of infectious bronchiolitis, and those with a family history of asthma who have more than two episodes of infectious bronchiolitis, may also be predisposed to asthma. widespread respiratory viruses like rsv are also possible factors in the cause of acute otitis media in young children. , consequently, preventive considerations should be applied. the primary defense against common pathogens of acute lower respiratory infections is waldeyer's (circumpharyngeal) tonsillar ring, a collection of lymphoid tissue in the mucosa of the nasopharynx. it consists of the pharyngeal tonsil, the palatine tonsils and the lingual tonsil that are the multiple lymphoid nodules located on the posterior part of the tongue, plus small other nodules in the pt and lymphoid tissue in the intertonsillar intervals. the nasopharyngeal tonsil increases in size in the fi rst years of life, are largest at years and atrophies by the time of puberty. the efferent lymphatics of these mucosa-associated lymphoid tissues start in plexuses surrounding every lymphoid follicle and drain through the retropharyngeal lymph nodes or directly into the upper deep cervical nodes. the retropharyngeal nodes consist of three groups, two of which are located on either side, anterior to the lateral masses of c , following the lateral borders of the longi capitis. somatic dysfunction of the cervical spine, the frontal bone, the maxillae, the ethmoid bone, the nasal bones and the zygomatic bones can alter the function of the upper respiratory tract as a primary defense against common pathogens. dysfunction of the thoracic cage and diaphragm can impair effi cient return of lymph to the general circulation and the ciliary clearance current of mucus in the bronchial tree. thus, somatic dysfunction can contribute to the creation of a fertile environment wherein pathogens can thrive. it has been shown that osteopathic manipulative treatment (omt), particularly the lymphatic pump, results in decreased morbidity and mortality in patients with infl uenza. , the ans is of prime importance in the regulation of bronchial secretion and its dysfunction may facilitate bronchiolitis. the sympathetic postganglionic fi bers between t and t stimulate bronchial and bronchiolar dilatation and decrease fl uidity of the secretions. the pulmonary branches of the vagus nerve are motor to the muscles fi bers of the bronchi and bronchioles and are consequently bronchoconstrictor. thus, somatic dysfunction of the upper thoracic, upper cervical and cranial regions can affect the lower respiratory tract through somatovisceral refl ex action. the objective of osteopathic treatment in the acutely ill, non-emergent child with bronchiolitis is to stimulate the expectoration of mucus, reduce air trapping and promote homeostasis by balancing the ans and enhancing the venous and lymphatic drainage of the lungs. furthermore, it is important to reduce somatic dysfunction that can predispose the child to the recurrence of the illness. observe the chest and the way the child is breathing, paying particular attention to the mobility of the ribs and sternum. children with respiratory obstruction may demonstrate suprasternal, infrasternal, subcostal and intercostal retraction when breathing. on percussion, the chest is hyperresonnant. prolonged expiration, wheezing, and fi ne moist crackles may be observed at auscultation. it is important to auscult the lungs before and after the osteopathic treatment. using indirect principles, restore thoracic spine and rib motion. thoracic pumping may be used to loosen mucus, stimulate expectoration and decrease bronchial obstruction. the thoracic diaphragm and thoracic inlet should be evaluated and treated as fi ndings dictate. rib raising and sternal molding may be applied to further mobilize the thoracic cage, increase ventilation, loosen mucus and stimulate expectoration. sympathetic activity should be balanced by treating any dysfunction of the upper thoracic spine (t -t ). parasympathetic tone can be normalized with treatment of the suboccipital area. using indirect principles, treat any cervical somatic dysfunction that is present. improve lymphatic drainage from the upper deep cervical lymph nodes with soft tissue techniques applied to the cervical myofascial structures. observe the child's face. the frontal bone, the maxillae, the ethmoid bone, the nasal bones and the zygomatic bones form the upper respiratory tract. look for asymmetries of these structures and for any tissue texture change. palpation and motion testing will confi rm these observations and treatment should be applied accordingly. it is imperative that the child is breathing through their nose, so any dysfunction that impairs nasal respiration should be addressed. following manipulative treatment it is important to re-evaluate the child. re-evaluate the musculoskeletal areas treated and auscult the lungs again to check clearance of the secretions and progress of airfl ow. it is important to maintain hydration of the respiratory tract. the caregivers should be advised to encourage consumption of fl uids and to maintain suffi cient humidifi cation of the child's environment. asthma is the most frequently encountered chronic disease in childhood. allergic disorders and asthma in childhood have increased in prevalence in many countries over the past - years. , asthma is characterized by chronic infl ammation leading to airway hyperreactivity and recurrent reversible airfl ow obstruction. a multifaceted interaction of genetic and environmental factors appears to cause asthma. a genetic predisposition seems to exist , , and the risk is greater if both parents present with the disease. in the predisposed host, immune responses to different exposures such as allergens and air pollutants may trigger pathogenic infl ammation. children from lower socioeconomic groups more often present with asthma, rhinitis and allergic sensitization, especially to food allergens. different factors may explain this susceptibility, the quality of food being one of them. evaluation of different diets demonstrates the asthma preventive effect of dietary management for children with a family history of asthma. of demonstrable benefi t are diets with increased anti-infl ammatory 'n- ' polyunsaturated fatty acids (omega- polyunsaturated fatty acids), alone and in combination with house dust mite allergen prevention. there is also some evidence that dietary omega- polyunsaturated fatty acid supplementation during pregnancy and early childhood may potentially reduce infant atopy and asthma. , the controversial 'hygiene hypothesis' was developed in the late s to explain the high prevalence of allergic diseases and asthma in industrialized countries. the attention to hygiene in these countries is associated with reductions in microbial exposures and decreased incidence of infectious diseases. microbial encounters in infancy and early childhood stimulate the development of the immune system and the 'hygiene hypothesis' states that atopic disorders are the consequences of the lack of early life infections. alternatively, the use of antibiotics in the st year of life may increase the risk of asthma. opposite to the hygiene hypothesis, however, there is evidence that the pathogenesis of asthma may include early exposure to viruses and bacteria. , a high frequency of respiratory tract infections in the st year of life is a predictor of asthma between the ages of and years. , elevated ige levels at months are also a predictor. alternatively, the association of atopy with asthma is controversial and the onset of eczema during the st year of life is not always found to be associated with the later development of asthma in childhood. a clinical association between rhinosinusitis and asthma is strongly suggested. furthermore, effective treatment of rhinosinusitis has a positive effect on concomitant asthma. elements that contribute to the concept of 'united airway' disease include the dissemination of postnasal drip of infl ammatory cells into the lungs. a vascular circulatory route with the migration of infl ammatory cells to the lungs is another suggested pathway to explain the connection. another possible link between the upper and lower airways is through the nervous system, with naso-pharyngo-bronchial refl exes involving the trigeminal and the vagus nerves. upper airway infl ammation may have an effect on receptors in the nose and pharynx. afferent (sensory) fi bers from these receptors participate in the constitution of the trigeminal nerve that connects with the dorsal vagal nucleus in the brainstem through the reticular formation. the vagus sends parasympathetic efferent fi bers to the bronchi to preserve bronchial muscle tone and modulate bronchospastic responses. in asthmatic children, bronchoconstriction and mucus secretion is increased due to augmented parasympathetic nerve activity. a neurogenic infl ammation activated by infl ammatory mediators and environmental irritants along the neural refl ex pathway may be the cause of a neuronal dysfunction. the osteopathic principle of holistic integration of the different parts of the body applies perfectly to this hypothesis where an initial body reaction is followed by distant manifestations. the theory of 'one airway -one response' states that the common histopathology in both upper and lower airways results in a global allergic infl ammation of the whole airway. the total body allergic response is also illustrated through interactions between the respiratory system, the skin and the gastrointestinal tract. the lung and the gut are part of a unifi ed mucosal system. the circulation of cells of the blood, from the bone marrow and the mucosal lymphoid tissue explain a possible interaction between these different areas and allergens. the intestine is one of the most signifi cant immune organs of the body. the composition of its microfl ora differs between infants with and without atopy, and the differences are verifi able before the occurrence of some clinical manifestation such as asthma. alternatively, there is a link between the mode of obstetrical delivery and the maturation of the humoral immune system. infants delivered by cesarean section demonstrate a delay in intestinal colonization. the initial stimulation by the gut microfl ora may possibly be more signifi cant than that of a sporadic infection and there is evidence of a relationship between cesarean section delivery and increased occurrence of atopic asthma. there is another connection between the lung and the guts with asthmatic patients. about - % of adults and children with asthma present with gastroesophageal refl ux -refl ux of gastric contents into the esophagus -which may not be clinically obvious. intracellular acidifi cation diminishes the ciliary beat frequency of the epithelial cells of the human tracheobronchial apparatus. this point is signifi cant in asthma, as well as in other respiratory dysfunction, as a factor contributing to decreased mucociliary clearance. the lungs and esophagus are both innervated by the vagus and upper thoracic distribution of the sympathetic nervous system. autonomic dysfunction may explain symptoms related to both gastroesophageal refl ux and asthma. under normal conditions, the parasympathetic nervous system through the vagus sustains bronchial muscle tone while sympathetic fi bers evoke bronchodilatation. sympathetic nerve fi bers also innervate the bronchial and gutassociated lymphoid tissue that seems to be essential in neuroimmune interactions. the parasympathetic visceral sensory system collects internal information that, in turn, infl uences emotions as much as emotional states impact autonomic function. the infl uence of stress is potentially negative on neuroimmunoregulation. in asthmatic patients, there is evidence that stress experienced prenatally or in the st years of life may participate in the development of asthma. , increased psychological stress may impact respiratory illnesses in children and contribute to immune deregulation. there is evidence that stress facilitates susceptibility to infections and may be associated with the development of asthma. very often, asthmatic children present with anxious facial expression. most of the time, an asthmatic reaction is triggered by exposure to numerous environmental agents. asthmatic children have hyperresponsive or hyperreactive airways. various stimuli such as dust mites, pollutants and tobacco smoke produce an exaggerated bronchoconstrictor response with sensations of shortness of breath and chest tightness. there is evidence that the pathogenic development occurs early in the lungs, producing architecturally altered lungs later in life. treatment, therefore, should be initiated as soon as possible. asthma presents in different forms. the patient may demonstrate prodromal symptoms such as itching over the upper part of the chest and associated dry cough. this can be followed by episodes of dyspnea, tachypnea and tightness in the chest with wheezing and coughing that result from exposure to allergens, air pollution or exercise. in asthmatic patients, a bronchoconstrictor response follows nasal inhalation of cold air. other patients present with chronic coughing and wheezing, associated with shortness of breath and decrease of vital capacity. anxiety may occur related to the sensations of shortness of breath and chest tightness. osteopathic considerations for the treatment of asthma, although directed as a whole body intervention, are specifi cally focused on somatic dysfunctions of the thoracoabdominal diaphragm, thoracic cage, upper thoracic spine, cervical spine, sacrum, cranium and face. the goals of treatment are to encourage expectoration of mucus, reduce the mechanical impact of somatic dysfunction, enhance the recuperative effect of balanced sympathetic and parasympathetic tone, and facilitate the arterial, venous and lymphatic components of tissue perfusion. because signs and symptoms are often observed fi rst by the parents, these children may present to the osteopathic practitioner before the diagnosis of asthma has been formally made. it must be stressed that asthma is a potentially life-threatening condition, and although the treatment of somatic dysfunction can greatly benefi t the patient, , the need for other methods of medical management should never be dismissed. the earlier somatic dysfunction is effectively addressed, the better the possible outcome. manipulative treatment should begin with the area most easily accessible without distressing the child. the sequence of treatment is determined by the patient's acceptance of the intervention. older children are commonly tolerant and treatment may be begun on the treatment table. for younger children, it is often easier to begin with the evaluation and treatment of the upper thoracic cage because this can be done with the child seated, even in the caregiver's lap. after a trusting physicianpatient relationship has been established, the child may then be transferred to the treatment table for further treatment. with the child seated or supine, observe the upper thoracic cage, looking for decreased compliance to respiratory excursion, i.e. tension of the scalene, trapezius and sternocleidomastoid muscles in the region of the supraclavicular triangle. evalu-ate sternoclavicular motion and fl exibility of the sternum for dysfunction. articular motion of this region becomes mechanically discrete as the skeletal structures become more developed around years of age. palpate the thoracic spine and ribs for somatic dysfunction, paying attention to the area from t to t because of viscerosomatic input and somatovisceral impact with the lungs in this region. utilizing indirect principles, treat identifi ed somatic dysfunctions. following this, with the child, if possible, in the supine position, evaluate the lower thoracic cage and thoracoabdominal diaphragm. observe the mechanical pattern of respiration. asthmatic children tend to demonstrate forced expiration. palpate for lower thoracic cage compliance, comparing the inspiratory and expiratory phases of respiration. greater resistance will typically be appreciated during the expiratory phase and the child will often manifest shallow, rapid respiration. palpating the lower thoracic cage bilaterally, evaluate for general tension and asymmetry in the excursion of the thoracoabdominal diaphragm. assess the lumbar spine for dysfunction that can impact the diaphragm through the diaphragmatic crura. examine the sacrum and pelvis to identify dysfunctional mechanics that can affect the asthmatic through the core link. treat identifi ed somatic dysfunction with indirect procedures. entraining the movement of the manipulative treatment with the patient's breathing allows the practitioner to follow and gradually augment the amplitude of respiratory excursion. next, evaluate the cervical spine and myofascial structures of the neck. after general screening for dysfunction, attention should be directed at the upper cervical spine because of the viscerosomatic and somatovisceral vagal infl uence of the area. treat identifi ed dysfunction. examination can now proceed to the cranial base. using your preferred hand placement, evaluate the motion of the sbs. anecdotally, children with asthma and eczema seem to present frequently with sbs compression and decreased amplitude of the cri. assess the relationship between the occiput and temporal bones for compromise of the jugular foramen with its potential to interfere with vagal function. evaluate the temporal bones where part of the tentorium cerebelli attaches. dysfunction at this level affects the respiratory breathing pattern. an external rotation of one temporal bone tends to limit the freedom of expiration. examine the relationship between the sphenoid, frontal and facial bones. the bones of the face -ethmoid, lacrimal, maxillary and nasal bones, which contribute to the structure of the nasal airway -are suspended beneath the frontal bones. additionally, the ethmoid bone articulates posteriorly with the sphenoid. it is not uncommon to encounter compression between the frontal bones and the bones of the face. treat specifi cally identifi ed dysfunctional patterns. it is important that the nasal airway is unobstructed because of the effect of nasal respiration on inspired air and thoracopulmonary function. the interrelationship between rhinosinusitis and asthma further stresses the importance of appropriate function of the facial bones in asthmatic children. treatment of the cranial mechanism with attention to the inherent rhythm augments the cri with a resultant total body effect. following manipulative treatment, various activities can be prescribed to facilitate the results of the intervention. for small children the caregiver should be encouraged to regularly gently stroke the thoracic paravertebral region, particularly t -t , bilaterally. the child can be encouraged to perform expiratory activities like blowing soap bubbles. older children can be taught breathing exercises to improve lung function to increase vital capacity, facilitate the clearing of airway secretions and enhance the quality of life. begin by encouraging the child to breathe slowly and deeply, employing the thoracoabdominal diaphragm and with the least possible utilization of the accessory muscles of respirationscalene, sternocleidomastoid, trapezius and abdominal wall muscles. they should learn to breathe on demand with particular attention to control of expiration. further, they should be taught to hold their breath in the most relaxed possible way. this allows them to experience apnea without anxiety. as they become experienced in these activities, they can be encouraged to practice this method of respiratory relaxation at the fi rst perception of an asthma attack. because controlled breathing is an integral part of singing, they may benefi t from participation in a choral group. teach them to maintain good posture. a simple procedure is to have the child walk with a book balanced on the top of their head. finally, children and adolescents with asthma should participate in regular physical activity. , diet considerations should be initiated. daily intake of fresh fruit and vegetables should be recommended. processed sugars and foods that increase gastric acidity should be limited. dairy products (e.g. ice cream) which increase mucus production should be consumed moderately and preferably before p.m. to facilitate gastric emptying before bedtime and avoid gastroesophageal refl ux. approximately % of infants demonstrate symptoms of imperfect lacrimal drainage during their fi rst months of life. most of the time spontaneous resolution takes place and by their st birthday only about . % of infants still present with the condition. congenital nasolacrimal duct obstruction (dacryostenosis) may result from an abnormality in the lacrimal drainage system or from an infection. the diagnosis of congenital nasolacrimal duct obstruction is clinical. it is based on a history of epiphora (tearing), mucopurulent discharge, or both, in the presence of non-infl amed conjunctiva, usually affecting only one eye and occurring in the fi rst few weeks of life. the condition may be continuous or intermittent and crusting on the lid margins is common. parents will often report that the eyelids are stuck together on the child's awakening or that the child has a persistently watering or sticky eye. digital pressure applied medial to the eye over the lacrimal sac will produce increased discharge from the excretory puncta. there is much debate regarding a standard medical approach for the management of congenital nasolac-rimal duct obstruction. the availability of multiple therapeutic approaches for any given condition indicates that none of them works particularly well in all cases. the list of procedures that are employed as standard to correct symptomatic nasolacrimal duct obstruction includes probing and irrigation, intubation with a silicone tube, balloon dilatation of the nasolacrimal duct and infracture of the inferior turbinate. osteopathic manipulation offers an alternative approach and, since it is benign, it should be attempted before more aggressive procedures are employed. the earlier the infant or child is treated, the better the chance of rapid resolution of the obstruction. additionally, a good mental image of the anatomy of the nasolacrimal duct and lacrimal drainage system, on the part of the practitioner, will provide the basis necessary to improve the effi cacy of manipulation. the lacrimal apparatus consists of several parts that develop simultaneously. the lacrimal gland secretes the tears and the excretory ducts (lacrimal canaliculi) deliver the fl uid to the surface of the eye, while the lacrimal sac and the nasolacrimal duct collect and transport the fl uid into the nasal cavity. the lacrimal gland consists of two portions: the superior orbital part and the inferior lacrimal part. the superior orbital part is located in the lacrimal fossa, in the superolateral part of the orbit, on the medial side of the zygomatic process of the frontal bone. shaped like an almond, it is connected to the periosteum of the orbit and rests on the levator palpebrae superioris and the lateral rectus. the inferior lacrimal gland is separated from the superior by a fi brous septum and projects into the lateral part of the upper eyelid. although the lacrimal gland reaches full development at about - years of age, the production of tears in infants is similar to that in adults. on each eyelid, the lacrimal canaliculus originates at a lacrimal punctum, a minuscule orifi ce on the medial margins of the lids. the superior canaliculus is the smaller and shorter. first it goes up, then turns at an acute angle to meet the lacrimal sac, while the inferior canaliculus descends, then turns upward toward the lacrimal sac ( fig. . . ). at their angles the canaliculi are dilated and form ampullae. their mucous lining is covered by stratifi ed squamous epithelium, positioned on a basement membrane. the external wall consists of a layer of skeletal muscle fi bers, continuous with the lacrimal part of the orbicularis oculi. the lacrimal sac is the upper dilated end of the nasolacrimal duct. it is located in a fossa formed by the lacrimal bone, the frontal process of the maxilla and the lacrimal fascia. it measures from to mm in length and extends to form the nasolacri-mal duct. its superfi cial surface is sheltered by the lacrimal fascia (an extension of the orbital periosteum) and by the medial palpebral ligament. its deep surface is crossed by the lacrimal part of the orbicularis oculi, which is attached to the posterior lacrimal crest on the lacrimal bone. the lacrimal sac is lined by a mucosal membrane continuous with the conjunctiva through the lacrimal canals and with the nasal cavity through the nasolacrimal duct. the relationship with the orbicularis oculi is of particular interest. this muscle surrounds the circumference of the orbit, with osseous attachments on the frontal bone, the frontal process of the maxilla and the lacrimal bone. when it contracts, as during 'blinking', compression of the lacrimal sac occurs through the lacrimal part of the muscle, pushing fl uid into the nasolacrimal duct to drain into the inferior meatus of the nasal cavity. during muscular relaxation, fl uids are drawn into the canaliculi and the expanded lacrimal sac. the nasolacrimal duct extends from the lacrimal sac caudally to open in the inferior nasal meatus. both ends of the duct are wider than its middle portion, where it is enclosed in an osseous canal formed by the maxilla, the lacrimal bone and the inferior nasal concha. it is directed downward, backward and slightly laterally. the nasolacrimal duct is formed embryologically from ectodermal cells enclosed between the maxillary and lateral nasal processes. during the rd month of gestation a canal appears in the center of this epithelial cord. it will develop progressively in a cephalocaudal direction from the th month of gestation until birth. in the third trimester of gestation the lower portion of the duct opens into the inferior meatus of the nasal cavity to constitute the nasolacrimal duct, while the epithelium from the nasal cavity invests the duct in a caudocephalad direction. a mucosal fold -the valve of hasner -is located just above the nasal opening of the nasolacrimal duct. total canalization of the epithelial cord may fail to occur with the persistence of membranous tissue that should normally disappear at birth or in the fi rst days of life. in congenital nasolacrimal duct obstruction, the lower part of the duct may be closed at birth by fusion of the mucosa covering the nasal folds. the resultant obstruction is usually observed in infants at about the th or th day of life. nasolacrimal duct obstruction is frequently associated with dysfunction of the bones forming the osseous canal in which the nasolacrimal duct is located, i.e. the maxilla, the lacrimal bone and the inferior nasal concha. it frequently follows compression of the frontal bone and may also be associated with an inferior vertical strain of the sbs. consequently, the relationships between the frontal bone, maxilla and lacrimal bone are affected, potentially modifying the patency of the nasolacrimal duct. this type of compression occurs frequently during pregnancy, diffi cult labor or delivery and appears to be a prediposing factor. furthermore, dysfunction of the frontal bone, maxilla and lacrimal bone changes the relationship between the points of attachment of the orbicularis oculi, predisposing to muscular dysfunction. when treating nasolacrimal duct obstruction, the delicacy of the intervention necessitates that the infant moves as little as possible. this may be accomplished by arranging to see the infant at a time that coincides with their nap time. the best approach is to have the caregiver arrive with the infant about minutes before the scheduled appointment. place the infant and caregiver in a quiet examining room and allow the infant to have their bottle or to nurse. allow suffi cient time thereafter for the infant to go to sleep, preferably in a supine position on the examining table. once the infant is asleep, quietly commence treatment. first observe the frontal bones. often the frontal bone on the side of the lacrimal duct obstruction will be found to be lower than the other side. look next at the area of the nasion, nasal bones and frontal processes of the maxillae, noting asymmetry and compression of these structures. the forces commonly involved in lacrimal duct obstruction are most often vertical compression between the frontal and nasal bones, sometimes with sidebending and rotation of the facial block beneath the frontal bone, with the obstruction on the side of the facial concavity. confi rm the observations with tests of listening, paying close attention to the frontal bones, nasal bones, maxillae and lacrimal bones. keep a mental picture of the minute details of the area to help this process. defi ne areas of restricted motility and employing the inherent forces of the prm and its rhythm, utilize the most delicate indirect treatment procedure. the treatment procedure should be so gentle as not to awaken the infant. encourage the caregiver to regularly clean the secretions from the eye to avoid the development of an infection. to promote drainage into the nasolacrimal duct, the caregiver can milk the lacrimal sac by intermittently applying gentle digital pressure medial to the punctum of the eye in a superior to inferior direction. actively playing with the child to encourage facial expression stimulates the function of the orbicularis oculi. if the child is old enough, have them blink tightly and make faces. contracting the orbicularis oculi promotes drainage by placing pressure on the lacrimal sac. strabismus -the deviation of the alignment of one eye in relation to the other -is a condition frequently encountered in infants and children. it is a very complex subject and its complete discussion is beyond the focus of this text. however, the treatment of somatic dysfunction can prove very beneficial in certain presentations of the condition. strabismus must be taken seriously and signifi cant underlying pathologies, such as congenital cataract and retinoblastoma, ruled out. it is imperative that, on presentation, every case of strabismus, no matter what the age of the patient, has a thorough ocular examination, including cornea, lens, retina and optic nerve, as well as the neurologic status of the eye and extraocular muscles (eom). treatment of strabismus should be initiated at the earliest possible time to avoid loss of the ocular stimulation that normally contributes to the maturation of the visual system. the eyeball -the organ of sight -is contained in the skeletal cavity of the orbit, which provides a protective space for the eyeball and associated structures, i.e. fasciae, eyelids, conjunctiva, lacrimal apparatus and eom. the eyeballs start to develop from neuroectoderm of the lateral aspects of the forebrain as a pair of diverticulae at approximately the nd day of gestation. at the th day, two optic vesicles are formed. around the th week, they invaginate and create the optic cups in which mesenchymal and vascular tissues enter the globe. the different parts of the future eyeball and surrounding orbital cavity are intimately interrelated. at the beginning of the fetal period -the end of the nd month of gestation -eom are present, surrounding the eyeball. growth will continue with a signifi cant correlation between gestational age and fetal eye biometry, including lens, orbital diameters, circumferences and surfaces. surrounding the eyeball, the constituents of the orbital cavity consist of the frontal, lacrimal, palatine and zygomatic bones, ethmoid, maxilla and sphenoid. they develop in membrane and are quite responsive to the growth stimulation of the eyeball. thus, the orbital cavity is growing as a result of the increase of the volume of the eyeball and the activity of the eom, with more and more elaborate eye movements. from this time up to years of age, the eyeballs will continue to grow, acting continuously as a growth stimulator for the skeletal cavity of the orbit. at birth, the orbit height is already % of its adult height. at years of age it is %, while at years of age it is about %, nearly its adult size. evidence of the importance of this stimulating factor is demonstrated by conditions like microphthalmia, where the development of the eyeball does not occur correctly, or when an individual is enucleated in early childhood. underdevelopment of the orbital cavity is typically associated with these conditions. an anophthalmic bony orbit may be . % smaller when compared to the other orbit. the concept that function affects structure, one of the basic osteopathic principles, is perfectly illustrated in this instance. at the same time, structure affects function. in this case, the structures forming the orbital cavity may affect the ocular function of sight, associated vascular and neurologic aspects, and extra-and intraocular muscular activity. therefore, it is appropriate to consider the protective case for the eye, i.e. the orbital cavity, and to see how its osseous components play a part in the etiology of ocular dysfunction. the orbits are located in the upper and anterior part of the viscerocranium. they are shaped like pyramids, with their apices and long axes directed backward and medially. each orbit consists of a roof, a fl oor, a medial and a lateral wall, a base and an apex. the roof is concave, directed downward and slightly forward. the orbital plate of the frontal bone forms most of the roof, while the lesser wing of the sphenoid forms its posterior part. therefore, there is a suture on the roof of the orbital cavity between the frontal bone and the lesser wing of the sphenoid. the lacrimal fossa for the lacrimal gland is located laterally on the orbital surface of the frontal plate. medially, below and behind the end of the supraorbital margin of the frontal bone, is the trochlear fovea for the attachment of the cartilaginous pulley of the superior oblique muscle. this feature is of particular interest in understanding ocular dysfunction, since the frontal bone is frequently under stress from fetal positioning, diffi cult labor or trauma sustained by young children, such as a fall on the head. although most of this anatomy is not directly palpable, the supraorbital margin of the frontal bone is completely accessible and its position should always be evaluated in strabismus. the fl oor of the orbit is directed upward and laterally. it consists mostly of the orbital surface of the maxilla; behind that and medially, the orbital process of the palatine; and in front and laterally, the orbital process of the zygomatic bone (fig. . . ) . the maxilla articulates with both the palatine and the zygomatic bones. the lacrimal notch is located anteriorly, on the medial border of the maxilla, and provides the superior opening of the nasolacrimal canal. on this border the maxilla articulates with the lacrimal bone and the ethmoid's orbital plate behind. a depression situated just lateral to the lacrimal notch is the location of the origin of the inferior oblique muscle. the posterior border of the maxilla forms most of the anterior edge of the inferior orbital fi ssure, discussed further below. the medial wall of the orbit is formed anteriorly by the frontal process of the maxilla, the lacrimal bone, the orbital plate of the ethmoid and a tiny part of the body of the sphenoid in front of the optic foramen. the lacrimal groove for the lacrimal sac is located anteriorly. it is limited behind by the posterior lacrimal crest, from which the lacrimal part of the orbicularis oculi arises. three vertical sutures -the lacrimomaxillary, lacrimoethmoidal and sphenoethmoidal -are present, while the frontomaxillary, frontolacrimal, and frontoethmoidal sutures are situated between the superior border of the medial wall and the orbital roof. the lateral wall of the orbit is directed medially and forward. it consists of the orbital process of the zygomatic and the orbital surface of the greater wing of the sphenoid. the sphenozygomatic suture unites them. this is another site of particular interest since the zygomatic bone is easily palpable. through palpation of the zygoma one can visualize, indirectly assess and treat the less accessible greater wing of the sphenoid. the sphenozygomatic suture ends below at the anterior end of the inferior orbital fi ssure. the upper end of the sphenozygomatic suture meets with two other sutures, creating a sutural crossroads for consideration in the treatment of any ocular dysfunction. anteriorly, the frontozygomatic suture can be observed, and posteriorly the suture between the frontal bone and the greater wing of the sphenoid. just under the frontozygomatic suture, on the orbital process of the zygomatic bone, is a tubercle for the attachment of the levator palpebrae superioris' aponeurosis. the inferior orbital fi ssure lies between the lateral wall and fl oor of the orbit, posterior to the zygomaticomaxillary suture. it communicates with the pterygopalatine and infratemporal fossae, and transmits the infraorbital vessels, the maxillary nerve (cn v ) and the ascending branches from the pterygopalatine ganglion. the superior orbital fi ssure separates the roof and lateral wall of the orbit in its medial portion. the oculomotor (cn iii), the trochlear (cn iv), the ophthalmic division of the trigeminal (cn v ) and the abducent (cn vi) nerves enter the orbital cavity through this fi ssure, accompanied by some fi laments from the cavernous sympathetic plexus and the orbital branches of the middle meningeal artery. additionally, the superior ophthalmic vein drains into the cavernous sinus through this fi ssure. the apex of the orbit corresponds to the medial end of the superior orbital fi ssure, close to the origin of the eom, just below the optic foramen. the cylindrical optic canal forms by surrounding the optic nerve and ophthalmic artery where the two roots of the lesser wing of the sphenoid join the sphenoidal body. through the optic canal and superior orbital fi ssure, the cranial cavity communicates with the orbital cavity. the cranial dura mater lines the internal surface of every cranial bone, with a fi rm adhesion at the sutures, and extends outside the cranial cavity through foramina and fi ssures, forming tubular sheaths for the cranial nerves as they leave the neurocranium. thus, the endosteal layer of the cranial dura mater is continuous through the superior orbital fi ssure with the orbital periosteum. in addition, a tubular dural sheath from the meningeal layer of the dura surrounds the optic nerve as it passes through the optic canal. this dural layer blends with the ocular sclera and adheres intimately to the common annular tendon of the four recti muscles. there is an anatomic continuity between the dura and the lining and structures of the orbital cavity, such as the eyeball and the eom. the seven extraocular, or extrinsic, muscles include the levator palpebrae superioris, superior rectus, inferior rectus, medial rectus, lateral rectus, superior oblique and inferior oblique muscles (fig. . . ) . they control the movements of the upper lid and eyeball. all the eom are tied together in a complex fashion by fascial sheaths. there are also intrinsic muscles within the eyeball that are responsible of the shape of the lens and size of the pupil. the levator palpebrae superioris arises from the lesser wing of the sphenoid, above and in front of the optic foramen, from which it is separated by the origin of the rectus superior. from a narrow tendon it soon broadens into a fl at, triangular shape that ends anteriorly in a wide aponeurosis. the superficial fi bers are prolonged forward, piercing the orbicularis oculi muscle, to insert on the deep surface of the skin of the upper eyelid. the deepest fi bers blend with an expansion from the sheath of the rectus superior. some fi bers also attach to the upper margin of the superior tarsus and are referred to as the superior tarsal muscle. a thickening of the sheath of the levator palpebrae superioris is referred to as the superior transverse ligament of whitnall. it extends laterally and medially to insert in the orbital walls just behind the superior orbital rim. medially, it attaches to the trochlea of the superior oblique muscle and to the frontal bone. laterally, it is fi xed to the capsule of the lacrimal gland and to the frontal bone. when the levator palpebrae superioris contracts, it raises the upper eyelid. it is innervated by a superior branch of the oculomotor nerve (cn iii). interestingly, the superior tarsal muscle is innervated by postganglionic sympathetic fi bers from the superior cervical ganglion. therefore, a complete ptosis refl ects the loss of oculomotor function, whereas a partial ptosis is associated with loss of sympathetic supply. the four rectus muscles arise from a fi brous ring -the common tendinous annulus of zinn -that extends across the superior orbital fi ssure and clinical conditions surrounds the upper, medial and lower margins of the optic foramen, where it adheres strongly to the tubular dural sheath surrounding the optic nerve. the common tendinous annulus consists of two parts. superiorly, the tendon of lockwood gives origin to the superior rectus muscle, part of the medial rectus and the upper fi bers of the lateral rectus; inferiorly, the tendon of zinn gives origin to the inferior, medial and lateral rectus muscles. at their origin, the rectus muscles are tightly set in zinn's annulus and start to separate at about mm anterior to the optic canal. the medial rectus is the broadest while the lateral rectus is the longest. the four rectus muscles go forward and insert through tendinous expansions into the sclera, the superior and inferior recti passing anterolaterally. the superior oblique muscle originates from the body of the sphenoid, above and medial to the margin of the optic foramen and origin of the superior rectus. it passes forward, ending in a round tendon, which goes through a fi brocartilaginous ring or trochlea attached to the frontal bone. from that point, the tendon turns backward, laterally and downward beneath the superior rectus to insert into the sclera, behind the equator of the eyeball in its superolateral posterior quadrant. the inferior oblique muscle originates from the orbital surface of the maxilla, just posterior to the orbital rim and lateral to the lacrimal groove. it tra-verses the fl oor of the orbit in a lateral, backward and upward direction, and inserts into the inferolateral posterior quadrant of the eyeball. the eom produce mobility of the eyeball with extreme amplitude in all directions (fig. . . ) . this is because the type of attachment they demonstrate to the periorbita -an interlocking of tendinous and muscular fi bers -provides them with a strong anchor. the contraction of the eom rotates the eyeball according to their insertions and the orientation of their fi bers. however, in all cases it should be remembered that these muscles function together and not as isolated entities. the ocular movements of individual muscles can be simplifi ed as follows: • the superior and inferior recti adduct the eyeball, in association with elevation and intorsion from the superior rectus and depression and extorsion from the inferior rectus. • the medial rectus adducts the eyeball while abduction is the result of contraction of the lateral rectus. • the superior oblique is considered to act from the trochlea. • both the superior and inferior oblique abduct the eye, with a component of depression and intorsion from the superior oblique and elevation and extorsion from the inferior oblique. being described in . this capsule is a fascial sheath completely covering the eyeball. it extends from the optic nerve to the corneoscleral junction and separates the eyeball from the orbital fat. it is perforated by the tendons of the eom on which it refl ects to form tubular sheaths. tenon described this capsule as a 'muscle pulley'. after much controversy, this theory is again accepted, and further studies have established that each rectus and inferior oblique muscle passes through a pulley formed by a ring or sheath of collagen, elastin and smooth muscle that is located close to the equator of the eyeball, in tenon's capsule. in this manner, the rectus and the inferior oblique muscles have their paths constrained by pulleys that serve as functional origins for the muscles, in a fashion similar to that of the trochlea for the superior oblique muscle. thus, the position of a pulley insertion relative to the eyeball affects the forces of the eom, and a translation of the eyeball of . mm modifi es the pulling direction of the rectus muscle by °. these pulleys are under active muscular control, allowing for constant ocular adjustments. conversely, their instability and modifi cation of location are associated with ocular dysfunction. the eom connective tissue sleeves that act as pulleys are fi rmly attached to each other and, through extensions, to the orbital walls. those from the lateral and medial rectus are anchored to the orbital tubercle of the zygomatic bone and posterior to the lacrimal crest of the lacrimal bone, respectively. they are referred to as check ligaments. this point is of great signifi cance. the zygomatic bone should not be overshadowed as a site of insertion for the eom sheaths by the sphenoid on which the common tendinous annulus of zinn inserts. in subjects with it should be noted that while the longitudinal axis of the orbit deviates laterally in a posterior to anterior direction, the axis of the eyeball approximates the sagittal plane (fig. . . ) . therefore, muscular activity between medial and lateral muscles is not equal. at birth, infants tend to demonstrate intermittent ocular misalignments. this is associated with lack of maturity in visual function. it should disappear by months of age when orthotropic ocular alignment and sensory binocularity should be present. transitory esotropic misalignments are usually considered to be typical in infants. however, if the condition is permanent with a fi xed restriction of any of the eom movements, or if it persists after months of age, further evaluation is necessary. in any case, osteopathic examination and treatment are indicated to balance the bony components of the orbit and their relationship with other parts of the skull. dysfunction can also manifest through myofascial and membranous components. entrapment neuropathy can result. evaluation and treatment of these components are indicated to promote the best possible muscular activity and ocular function. although the study of eom function is complex, it is imperative that it includes the orbital connective tissues that sheath the muscles. these tissues have long been recognized, the capsule of tenon clinical conditions strabismus or other ocular misalignments, the consideration of the orbital bones on which the eom insert should include the zygomatic bone. its location makes it vulnerable to being struck during the course of normal childhood activities. this may, in turn, affect the diameter of the orbit and the functional balance of the eom, particularly the lateral rectus. another site of importance is the trochlea for the superior oblique muscle on the frontal bone. frontal dysfunctions are often found in infants, with one side lower than the other resulting in frontal trochlear asymmetry. this may be seen with a superior-medial deviation of the eye encountered with dysfunction of the superior oblique muscle. dysfunction of the maxilla can also infl uence visual activity through its effect on the insertion of the inferior oblique muscle. through these complex interactions the orbit functions as a unit and each part, when dysfunctional, is a potential site for muscular instability and resultant ocular dysfunction. the somatic components of ocular dysfunction also involve oculomotor supply. the oculomotor nerve (cn iii) exits the brain medially to the cerebral peduncles. it traverses the dura at the top of the clivus, enters the cavernous sinus and courses forward in the lateral wall of the cavernous sinus where it receives sympathetic fi bers from the internal carotid plexus and connects with the ophthalmic division of the trigeminal nerve (cn v ). it then divides into two branches that enter the orbit through the superior orbital fi ssure. the general somatic efferent fi bers of the oculomotor nerve innervate nearly all of the eom. the superior division innervates the superior rectus and the levator palpebrae muscles, whereas the inferior division innervates the medial and inferior rectus and inferior oblique muscles. the general visceral efferent fi bers of cn iii are part of the parasympathetic ans and supply the sphincter of the iris that regulates the size and shape of the pupil and the ciliary muscle that modulates the shape of the lens. the trochlear nerve (cn iv) is the only cranial nerve to emerge from the dorsal surface of the brainstem. it curves around the midbrain, pierces the dura between the lesser and greater circumferences of the tentorium cerebelli, enters the lateral border of the cavernous sinus, receives sympathetic fi bers from the internal carotid plexus and traverses the superior orbital fi ssure to the orbit. it carries somatic efferent fi bers to the superior oblique muscle. the abducent nerve (cn vi) emerges from the brainstem between the pons and medulla oblongata. it pierces the dura covering the clivus and passes over the ridge of the petrous apex of the temporal bone through an osteofi brous canal underneath gruber's petrosphenoidal ligament. it then enters the cavernous sinus where it receives sympathetic fi bers from the internal carotid plexus and the orbit through the medial end of the superior orbital fi ssure and within the annulus of zinn. cn vi carries somatic efferent fi bers to the lateral rectus muscle. additionally, the eom contain proprioceptive receptors that provide input as to the position and movement of the eye in the orbit. this contributes to the control of eye's movements and facilitates central control of the direction of gaze and the relationship of the child to their environment. these afferent fi bers appear to travel with the motor cn iii, iv and vi before joining the ophthalmic branch of cn v to enter the cns. afferent input from these receptors not only affects static eye position but can also modify linear visual tracking, saccadic eye movement and the vestibulo-ocular refl ex. each of these nerves is subject to intracranial entrapment from osseous compression, membranous tension, ligamentous pull or the pressure of edema from venous congestion. the anterior attachments of the tentorium cerebelli are a site with particularly great potential to cause such neurologic dysfunction. the ganglion of the trigeminal nerve may become entrapped by the tentorium in the trigeminal cave formed at the apex of the petrous part of the temporal bone. bilaterally, the anterior fi bers of the tentorium twine on each side as the fi bers of the lesser circumference attach to the anterior clinoid processes and the fi bers of the greater circumference attach to the posterior clinoid processes. between these two attachments, the fi bers of the tentorium cerebelli are oriented horizontally and contribute to the formation of the roof of the cavernous sinus. cn iii and iv pierce the dura at this level to enter the cavernous sinus. any dural membranous strains in these areas can result in entrapment neuropathy and each bone on which the tentorium cerebelli attaches should be considered as potentially critical in the development of ocular dysfunction. the petrosphenoidal ligament is another signifi cant site under which cn vi may be compressed. furthermore, as the nerve bends sharply in its course over the petrous ridge, it is, therefore, vulnerable to the changes in position of the petrous portion of the temporal bone. adequate arterial supply and drainage are necessary for healthy nervous function. edema and stasis encumber this function, as is the case with a jugular foramen dysfunction and impediment of the drainage from the cavernous sinus, resulting in venous congestion. this, in turn, will affect the cranial nerves passing through the cavernous sinuses to the orbits. the same rationale applies to the superior orbital fi ssure. intraosseous dysfunction in infants between the greater and lesser wings of the sphenoid, or narrowing of the fi ssure because of greater wing dysfunction with surrounding structures, such as the temporal bone, impairs venous drainage or impulse conduction of the nerves passing through the fi ssure. additionally, lymphatic stases outside the skull can also entrap nerves at their foramina of exit. multiple theories exist concerning the cause of non-paralytic or concomitant strabismus, including sensorimotor, anatomic and mechanical or muscular origins. prematurity and diffi cult labor are considered to be risk factors. a supranuclear developmental abnormality in the cns is thought to be the cause of strabismus occurring in the fi rst months of life. impaired vision and amblyopia may also cause strabismus. it is abnormal for an infant or child to have strabismus and, if present, a thorough ocular and neurologic examination by a specialist should be performed. osteopathic procedures may, however, be applied to provide balance to the musculoskeletal and nervous systems. such balance improves the self-healing capacities of the body and contributes to the success of other treatments. osteopathic treatment should be initiated at the earliest possible time because the prognosis of strabismus is correlated to the time when the strabismus fi rst appears and the time when treatment is initiated. additionally, early treatment may positively impact the vestibulo-ocular refl exes and thereby the child's posture. young children and infants are most likely to present for the treatment of strabismus. as such the following treatment description must be appropriately adapted to fi t the age of the patient. the following is not intended to treat organic pathologies of the eye; it is directed at problems of functional balance. the examination and treatment for the eye should address different levels of anatomic dysfunction. these include osseous, myofascial, neurologic and vascular dysfunction and the intrinsic structure of the eye. observation and palpation are directed at determining on which of these levels treatment should focus. observe the relationship between the eye and the functional pattern of the skull. if the functional pattern of eye position and movement is consistent with the dysfunctional pattern of the skull, the focus of treatment should be on the cranial dysfunction. if eye position and movement is not consistent with the pattern of the skull, treatment should focus directly on the eye, eom and associated fascial structures. start with observation of the bony orbit, relative to how it fi ts the global pattern of the skull. look at the shape of the face and skull of the child to determine if a global pattern of cranial fl exion-external rotation, extension-internal rotation, sidebendingrotation or torsion is present. observe the orbital diameter, the distance between the superior medial and inferior lateral angles of the orbit. it is increased with cranial fl exion-external rotation, resulting in an orbital cavity that is wider. cranial extensioninternal rotation decreases the orbital diameter, with a resultant orbital cavity that is narrower. look for asymmetry between the visible constituents of the bony orbits, specifi cally the frontal bones, zygomae and maxillae. look at the eyes and observe for difference in size and shape. cranial fl exion-external rotation is associated with a prominent eyeball and an almondshaped eye. in cranial extension-internal rotation, the eyeball is less prominent, with a smaller, rounder shaped eye. epicanthus -a vertical fold of skin covering the medial portion of the eye -may give the impression of esotropia. active motion testing will, however, demonstrate normal function of the eye. next, observe the spontaneous movements and neutral resting position of the eyes. note the direction of gaze, the presence of esotropia or exotropia. the easiest way to evaluate the ocular movement of younger children is to hold a toy or some interesting object in front of the child to catch their attention. move the object horizontally, vertically and in both diagonals, and observe the movement of the child's eyes as they follow the moving object. note any asymmetric movement of the cervical spine that can be employed to compensate for the absence of ocular movement. this may be a sign of amblyopia that requires further evaluation. if possible, assess both eyes together and each eye separately by covering one eye with the child's or caregiver's hand and pretending to play 'peek-a-boo'. comparatively note the speed and ease with which the eyes move to follow the object. convergence may be determined by observing as the toy is brought closer to the infant's face. this procedure tests the actions of the eom and normal responses are illustrated in figure . . . determine if a correlation exists between the dysfunction of the eom and the pattern of cranial dysfunction. the two most commonly encountered types of strabismus that are amenable to cranial clinical conditions manipulation are the consequence of dysfunction involving the superior oblique muscle and the lateral rectus. a superior-medial-oblique deviation of the eye resulting from dysfunction of the superior oblique muscle may be associated with ipsilateral dysfunction of the frontal bone affecting its relationship to the muscle at the trochlea. medial deviation of the eye resulting from dysfunction of the lateral rectus may be associated with ipsilateral temporal bone or sphenoid dysfunction that affects cn vi as it passes beneath the petrosphenoidal ligament. palpate for function to confi rm the above observations. tests of listening should be performed with specifi c attention to the anatomic structures associated with the eyes in order to defi ne the dysfunctional area responsible for ocular deviation. areas of specifi c interest include the bones on which the eom are attached: the sphenoid, frontal, maxillae and zygomae. assess the anatomic areas of neurovascular passage to the orbital cavity. these include the superior orbital fi ssure between the greater and lesser wing of the sphenoid and the cavernous sinus for their contents. also evaluate the apex of the petrous portion of the temporal bone and the sphenoid for their relationship to the petrosphenoidal ligament. in actual practice, these assessments and the treatment of identifi ed dysfunction fl ow seamlessly into one another. diagnostic palpation of the sphenoid, and to a lesser degree of the frontal bone, is complex because the movements of the eom are transmitted to these bones. these additional movements on top of the biphasic prm create multifaceted palpatory sensations that can be confusing to the inexperienced examiner. consequently, it is desirable to evaluate the child when they are quiet with minimal eye movement. this occurs most readily when the child is sleeping. if the examiner is skilled with indirect procedures, the act of palpation will often soothe the child enough to bring them to a quiet state. complete examination of the sphenoid is somewhat diffi cult because of the limited surface area of the bone that is available for direct palpation. the areas of contact over the lateral-most aspects of the membranous greater wings, because of their fl exibility, transmit an incomplete representation of the movement of the body of the sphenoid. for this reason, the lightest touch must be employed when evaluating the sphenoid and even then information about the body must be obtained indirectly. to assess the sphenoid body and associated lesser wings more effectively, visualize the relationship between the frontal bone and the sphenoid behind. the body and lesser wings of the sphenoid are in continuity with the orbital plates of the frontal bone. when palpating, one hand can be placed transversely on the frontal bone with the thumb and middle fi nger contacting the greater wings on either side. the movement of the lesser wings and body of the sphenoid is transmitted through the orbital plates of the frontal bone. this provides a method of augmenting the palpatory sensations from the body of the sphenoid through the frontal bone. similarly, the sensation of movement of the greater wings of the sphenoid may be enhanced through the zygomatic bones and their relationship with the greater wings at the sphenozygomatic sutures. these visualization procedures may be employed during both tests of listening and treatment, and require that the bones being palpated in association with the sphenoid are themselves free of somatic dysfunction. in infants and younger children, intraosseous dysfunctions of the frontal bone and sphenoid should be considered. listen to the movement between the two halves of the frontal bone. palpate for deformation affecting the trochlea of the superior oblique muscle. visualize and listen to the synchondroses between the greater wings and the body of the sphenoid. listen to the relationship between the greater and lesser wings at the superior orbital fi ssure, visualizing the neurovascular content, and try to promote the inherent forces of the prm in the area. similarly, assess the cavernous sinus because of its relation with the nerves and venous drainage of the eyes. visualize the dura that constitutes the walls of the cavernous sinus and its relationship to the remainder of the reciprocal tension membranes. finally, if the child permits, and while utilizing the gentlest of indirect methods, palpate the globes of the eyes. evaluate the tone and quality of the myofascial structures surrounding the eyeballs. identify the functional point of balance between the eom. treat any dysfunction as identifi ed above, using indirect principles. only after any osseous, membranous and fascial dysfunctions have been treated, and the eom have been balanced, employ myofascial rehabilitation. in the patient with ocular deviation, the eom provide dysfunctional proprioception to the cns. the child should learn to experience the sensations of the normal range of ocular movements. older children can be taught to move their eye while the practitioner gently applies digital contact intended to guide the eye through the normal range of ocular movements. in this exercise, particular attention should be directed at establishing awareness of the sensation of eye movements in the directions that they are defi cient. the process of myofascial rehabilitation is accomplished with greater ease once pre-existing osseous, membranous and fascial dysfunctions have been treated. a description of the anatomy of the bony orbit and the eom has already been provided in 'strabismus' above. we shall, therefore, only consider the description of the eyeball and somatic dysfunction as they relate to the pathophysiology of astigmatism, myopia and hyperopia. the eyeball occupies the anterior part of the cavity of the orbit. it is surrounded by the eom and embedded in the fat of the orbit. two spheres of different diameters form the eyeball. the anterior cornea is smaller, transparent, bulging outward and represents approximately one-sixth of the eyeball. posteriorly, a larger opaque sphere constitutes the rest of the eyeball. anatomically, the eyeball may be described as being formed by three tunics or walls that are, from front to back, the fi brous tunic, the vascular pigmented tunic and the nervous tunic, and by internal components or refracting media, the aqueous humor, the vitreous body and the crystalline lens. the outside fi brous tunic of the eyeball is formed by the sclera and cornea. in the front, the sclera is continuous with the cornea at the sclerocorneal junction. the sclera is a dense and fi rm membrane that preserves the shape of the eyeball. it is covered with a fascial membrane, the capsule of tenon, posteriorly from the optic nerve to the corneoscleral junction anteriorly. this fascial membrane refl ects onto each of the eom tendons as they perforate tenon's capsule to attach on the sclera. posteriorly, the sclera is pierced by the nervous fi laments of the optic nerve (cn ii), forming the lamina cribrosa sclerae. the sclera is continuous with the fi brous sheath of cn ii and, therefore, with the meningeal layer of the dura mater. several small apertures exist around the lamina cribrosa sclerae for the ciliary vessels and nerves. the central artery and vein of the retina pass through cn ii. the cornea projecting in front of the sclera is almost circular, with its width slightly greater than its height. its anterior convexity demonstrates varying degrees of curvature throughout life and between individuals. a rapid change in the corneal curvature occurs during the fi rst - weeks of life. this rate of change then decreases considerably after the th week. the corneal curvature usually stabilizes at approximately the end of the st year of life. its coating of tears constitutes the most important site of refraction of the eyeball. the middle tunic of the eyeball is a vascular pigmented layer consisting of the choroid posteriorly and the ciliary body and iris anteriorly. the choroid is a thin, highly vascular membrane that constitutes approximately the posterior fi ve-sixths of the globe. its outer surface adheres fi rmly to the sclera while its inner surface is attached to the retina. this layer provides a signifi cant percentage of the vascular supply to the retina. the ciliary body consists of the ciliary processes and the ciliary muscle. the ciliary processes are circularly arranged as a ruche behind the iris surrounding the lens. they are continuous at their periphery with the layers of the choroid and anteriorly with the periphery of the iris. posteriorly, they are connected with the zonule that is the suspensory ligament of the lens. the ciliary muscle plays an important role in accommodation. it adjusts the shape of the lens in order to change the focus of the eye. when the ciliary muscle contracts, it draws forward the ciliary body, thus reducing tension in the fi bers of the suspensory ligament. this results in a relaxation of the lens' capsule with resultant increased convexity of the lens. the parasympathetic stimulation of fi bers from cn iii produces contraction of the ciliary muscle. the iris is a thin, circular, contractile disk, located between the cornea and lens, and continuous peripherally with the ciliary body. the iris differs in color among individuals, and at birth is light blue because of a lack of pigment. iris pigmentation is well developed at months of age. the iris divides the space between the cornea and lens into an anterior and a posterior chamber that communicates through the center of the iris, the pupil. pupillary dilatation or constriction results from the contraction of the dilatator or sphincter pupillae. responses to light and accommodation produce the two dominant pupilloconstrictor refl exes. axons from preganglionic parasympathetic fi bers course with cn iii to the ciliary ganglion, located behind the eyeball. from there, postganglionic fi bers supply the smooth muscle of the iris; this may result in pupillary constriction. inhibition of the tonic activity of the oculomotor system in the midbrain edinger-westphal nucleus leads to pupillary dilatation. extreme pupillary dilatation is referred to as mydriasis, extreme constriction as miosis. the nervous tunic, i.e. the retina or inner layer of the walls of the eyeball, is truly a sensory extension of the brain. during embryogenesis, the optic vesicles develop from the lateral aspects of the forebrain. when they invaginate, forming two optic cups, the inner walls of the cups become the retinal sensory mesh and send axons back to the optic stalk. on activation of the receptors of this sensory stratum, brain activity starts the visual sensory processing. light and images of external objects are received on the retinal receptors, stimulating a chemical reaction and action potentials transmitted through the optic nerve to the visual cortex within the occipital lobe. the vascular supply of the retina comes partly from the choroid that is in contact with the external layer of the retina. internally, the retina lies in contact with the vitreous body. the thickness of the retina varies, its thickest portion being located in the back of the eye, near the central retinal area or macula lutea. the fovea centralis, the center of the macula lutea, is a point of maximum vision and could be considered as the posterior point of the eyeball's axis. it is approximately - mm lateral and mm inferior to the center of the optic disc, a point where the retina is insensitive to light, referred to as the blind spot. the macula continues to develop until - weeks after birth. fully developed visual acuity is normally established by years of age. light passes through various refracting media in the eye, the aqueous humor, the lens and the vitreous body. the aqueous humor fi lls the anterior and posterior chambers of the eyeball. it is secreted into the posterior chamber by the ciliary processes. it fl ows into the anterior chamber through the pupil and is absorbed into the scleral venous sinus between the iris and cornea. the lens is situated directly behind the iris and in front of the vitreous body. it is a transparent, biconvex structure surrounded by a capsule and is connected to the ciliary muscle through the suspensory ligament. it measures approximately mm in diameter at birth and from the fi rst years of life offers excellent refractive power. as the child grows, more layers are added on the lens periphery, and around years of age it reaches its adult size. from then on, progressively, it will loose its hydration and thereby its fl exibility and refractive power. accommodation, normally occurring when tension of the lens' capsule decreases, becomes more diffi cult. this leads, for most individuals in their fi fties, to the need for glasses to compensate. the postrenal (vitreous) chamber forms about four-fi fths of the eyeball and is fi lled with the vitreous body (vitreous humor) that is situated between the retina and the lens. it is transparent, of a gel-like consistency, and is composed of about % water. when light enters the eye, the cornea and crystalline lens normally focus the rays of light through accommodation specifi cally on the retina. when properly functioning, this is referred to as the emmetropic state and requires that normal ocular growth occurred resulting in normal eye biometry. the central point of the anterior curvature of the eyeball is referred to as the anterior pole; the central point of the posterior curvature is the posterior pole. a line joining the two poles is referred to as the optic axis. the optic axes of the two eyeballs are almost parallel, approximating in the sagittal plane, while the longitudinal axes of the orbits are directed forward and laterally (fig. . . ) . therefore, for each eye, these two axes are aligned in different directions. the optic nerves enter the orbit with the ophthalmic artery, through the optic canal, and follow the direction of the axes of the orbits. this explains why the optic disc is medial to the fovea centralis in the center of the macula lutea. the transverse and anteroposterior diameters of the eyeball are slightly greater ( mm) than its vertical diameter ( . mm). at birth the anteroposterior diameter is about . mm and at puberty is between and mm. ocular growth and refraction are dynamic processes evolving during infancy and childhood, well through adult life. color vision develops rapidly after birth and in most individuals some color vision is usually present at months of age. although diffi cult to evaluate in infants, normal visual acuity is thought to be present by years of age. even though complete anatomic and functional maturity of the visual system is reached around years of age, many important milestones occur during the fi rst years of life. for these reasons, when examining and treating infants and children, an osteopathic practitioner should pay close attention to any somatic dysfunction that may potentially alter the normal shift of the refractive state of the eye to emmetropia. the sites of dysfunction with potential for alteration of the visual system are the different bony components of the orbit, the eyeball, eom and surrounding fascial and dural sheaths. because the vestibulo-ocular refl exes link the individual's posture with ocular function, the axial skeleton and postural balance of the child should also be addressed. any disturbance in the visual components may alter vision, usually asymmetrically. if this occurs during the developmental process, the resulting absence of stimulation in the visual part of the cortex will cause partial loss of sight, or amblyopia. this could be associated with an important difference of visual acuity between both eyes. normally orthotropic ocular alignment and sensory binocularity should be present by months of age. if there are signs of misalignment and lack of sensory binocularity, further evaluation should be carried out. emmetropization allows a distant object to be projected as a focused image on the retina without accommodative effort. this is possible when the optical power and the axial length of the eye are balanced. normally, in the emmetropic eye with relaxed accommodation, objects are focused on the retina. if the point of focus falls behind the retina, increased accommodation is necessary to bring the point of focus on the retina. this occurs with hyperopia and has been associated with decrease of the axial length of the eyeball. conversely, in myopia, the point of focus falls in front of the retina and this is associated with increase of the axial length of the eyeball (fig. . . ). some compensation usually occurs in these conditions, since eyes with decreased axial length are associated with a more rounded cornea, whereas increased axial length is associated with fl attening of the cornea. typically, infants demonstrate hyperopic eyes that tend to improve with ocular growth and, by the age of - years, they are emmetropic. by age years, only a few children are myopic, but between the ages of and years, myopic children have the fastest progression of all age groups. myopia is a common condition affecting approximately . % of caucasian children, . % of hispanics and demonstrates the highest prevalence in asians ( . %). this condition and its progression are infl uenced by various factors such as demography and the environment . the etiology of myopia seems to be multifactorial, with a genetic component since myopic individuals are more likely to have myopic parents. a greater reading exposure in childhood has often been suggested as a contributing factor and is especially associated with myopia in asian children, more often encountered around - years. intrinsic ocular factors are also associated with myopias. greater dimensions are present in myopic eyes than in emmetropic eyes when the vitreous chambers are measured along the axial direction, i.e. the optical and visual axes. , heavier newborns with large heads have longer optical axial lengths, deeper vitreous chambers and fl atter corneas. however, refraction is maintained and satisfactory, suggesting the presence of accommodative mechanisms in the cornea that compensate for the longer axial length. myopia usually develops because of a lack of coordination between postnatal growth and the refractive power of the eyeball components. there is some probability that the cns infl uences the development of myopia. unequal curvature(s) along the meridians of the refractive surfaces of the eye -cornea, anterior or posterior surfaces of the lens -result in astigmatism. thus, when light enters the eye, instead of having the cornea and the crystalline lens focusing the rays of light at a single point on the retina, they are spread out as a line in one direction or another. the orientation of the axis of corneal astigmatism is affected by the mode of delivery. infants delivered vaginally when compared to those delivered by cesarean section demonstrate a higher frequency of with-the-rule astigmatism, with the greater curvature of that astigmatism tending to be in the vertical meridian. these astigmatic corneas usually fl atten signifi cantly by the age of months. because astigmatism, myopia and hyperopia are associated with anatomic variations in the biometry of the eye, any form of treatment that may affect the refractive power and shape of the eye is desirable. this is particularly important in children less than year of age, when the eye is still growing and the ocular refl exes are not totally developed. prevention of the ocular complications of myopia, such as retinal detachment and glaucoma, may be facilitated by relaxation of tension in surrounding ocular structures. addressing somatic dysfunction of the upper thoracic and cervical vertebrae may further assist relaxation of ocular tension. for these reasons, osteopathic procedures may be applied directly to the eyeball itself or the structures surrounding the eyeball including the orbit and its myofascial contents. procedures may also be employed to affect the control of refractive mechanisms through the impact that the ans has on the intrinsic ocular muscles. the osteopathic structural examination of the eye and orbit for the patient with astigmatism, myopia and hyperopia is essentially the same as that described above for strabismus. the patient should be thoroughly evaluated for dysfunction affecting the component bones of the orbit, the eom and associated fascial sheaths. in addition, because these ocular conditions involve changes in the shape of the eyeball, the physical evaluation of the individual with myopia or hyperopia should specifi cally include the search for any somatic dysfunction that affects the axial length of the eyeball. for the patient with astigmatism, somatic dysfunction responsible for changes in orbital shape and tension of myofascial structures that affect the curvatures along the meridians of the refractive surfaces of the eye should be identifi ed. cranial fl exion-external rotation is associated with a decrease of the orbital depth, whereas extension-internal rotation is associated with increased orbital depth. for these reasons, potentially contributory craniosacral somatic dysfunction should be sought out and treated. this includes dysfunction involving the sbs and bony components of the orbit as well as all components of the craniosacral mechanism, including, but not limited to, the sacrum and pelvis. a posture in which the child projects their head forward may be the result of poor sight. on the other hand, dysfunction affecting the posture, because of its effect on the cervical myofascial structures, particularly those attaching to the base of the skull, will tend to impair the inherent motility of the skull and potentially the components of the orbit. a craniosacral somatic dysfunction of the sacrum in fl exion will produce a decrease of spinal ap curves and a tendency toward cranial fl exion. this can, in turn, favor decreased orbital depth that is particularly signifi cant in infants and young children at a time when ocular growth is occurring. as such, a complete postural assessment is appropriate when examining a child with ocular dysfunction. it is also appropriate in these individuals to begin working on the global postural pattern because vestibulo-ocular refl exes link posture with ocular function. using an indirect approach, begin with the treatment of postural dysfunction. because of their action on the prm, the use of indirect techniques will relax the patient. the treatment of ocular dysfunction requires the most delicate touch and as the patient relaxes it becomes easier to treat the eyes. after addressing the global postural pattern, proceed to the examination of the neurocranium and viscerocranium. assess the sbs with tests of listening, then progress to observe the size and shape of the orbit. look at the relationship of the eyeball to the orbit. prominence of the eyeball is associated with a wider orbit and a pattern of cranial fl exion-external rotation, whereas a recessed eye is associated with a narrower orbit and cranial extension-internal rotation. also observe the patient in profi le bilaterally, comparing the amount of corneal curvature. determine if the dysfunctional mechanics identifi ed at the sbs is consistent with the pattern of orbit and eyeball. if so, treat the sbs; if not, look for dysfunction in the orbit. (note: in infants the state of development of the frontal bone with small brow ridges causes the eyeballs to appear as if they are bulging.) next, assess the different bones that constitute the orbit, particularly the frontal bone, zygomae, maxillae and sphenoid. the effect of cranial dysfunction on the depth and shape of the orbit is signifi cant in astigmatism, myopia and hyperopia. the apex of the orbit is situated at the medial end of the superior orbital fi ssure between the lesser and greater wings of the sphenoid, near the origin of the eom and inferior to the optic foramen. thus, the length and direction of the orbital axes are infl uenced by the sphenoid. dysfunctions of the sphenoid that can affect the orbit include dysfunction of the sbs, dysfunction between the sphenoid and the bones articulating with its wings and intraosseous dysfunction. with cranial fl exion the apex of the orbit moves forward, thus decreasing the ap orbital diameter, whereas in extension the apex is displaced posteriorly, increasing the ap orbital diameter. with sbs torsion or sidebending-rotation, on the side of associated external rotation, the ap orbital diameter is decreased and on the side of associated internal rotation it is increased. intraosseous dysfunctions of the sphenoid have variable effects on the orbit and eyeball. they must be identifi ed and treated as early as possible, sphenoid ossifi cation being essentially complete by year of age. dysfunction of the frontal bones, zygomae and maxillae, either individually or in conjunction with the sphenoid, can affect the shape of the orbit and, when present, should be treated using indirect principles. an extension of the dura surrounds the optic nerve and is attached to the optic canal. intraosseous dysfunction of the sphenoid can affect the cylin-drical optic canal that is formed where the two roots of the lesser wing of the sphenoid join the sphenoidal body. the dura also extends through the superior orbital fi ssure and blends with the orbital periosteum. consequently, membranous strain can affect the sphenoid and through the sphenoid the shape of the orbit. dural membranous dysfunction should thus be sought out and treated at the youngest possible age. to ensure autonomic balance for the orbital contents, the rhythmic motility of the orbit and neurocranium is necessary. change of the ap diameter of the orbit is associated with altered tension of the intraorbital soft tissues with resultant stasis, edema and compression. this, in turn, will affect the function of nervous structures, in this case cn iii and the ciliary ganglion. treatment of regional dysfunction, ensuring the rhythmic fl exion-extension of the prm in the orbit, fi ssures and foramina, provides a pumping action mobilizing the extracellular fl uids surrounding the nerves and facilitating their function. the sympathetic supply to the orbit originates in the upper thoracic spine and, through the upper cervical ganglia, reaches the ciliary ganglia via the carotid plexus. somatic dysfunction affecting these structures in the upper thoracic and cervical spine and the cranial base should be sought out and treated to ensure optimal sympathetic function. sucking and swallowing are complex activities that are partially conscious and partially unconscious. they require the participation of many structures, including a signifi cant percentage of the cranial nerves, and should be considered in the context of a sensory-motor complex that begins to develop well before birth. swallowing appears in utero after weeks with movements of the fetal tongue visible after weeks. at that time, fetuses suck their thumbs refl exively in response to oral stimulation from the digital extremities. protrusion of the upper lip appears after the th week of gestation and protrusion of the lower lip at the th week. the real activity of sucking is seen at the th week. after that time, sucking and swallowing become more and more developed and appear as coordinated movements around weeks. at term, the fetus swallows about - ml of amniotic fl uid per day. this daily exercise stimulates the maturation of oral structures, including the tongue, lips, soft palate and pharynx, and, therefore, prepares the fetus to perform the orofacial functions that will be vital at birth. sucking is one of the primitive refl exes that are totally present at birth in term infants. in the fi rst days of life, oral feeding is almost entirely refl ex, apparently without suprabulbar activity for rooting, latching, sucking and swallowing. these refl exes are functionally important in infants to ensure successful ingestion. the primitive sucking refl ex lasts for about a year, and then becomes more diffi cult to obtain because of central nervous system maturation and the development of voluntary motor activity. the tongue is one of the major participants in the process of sucking. it is a muscular structure with intrinsic and extrinsic muscles. the intrinsic muscles allow the precise movements necessary for sucking, swallowing and speech. they are the superior longitudinal, inferior longitudinal, transverse and vertical muscles. the extrinsic muscles originate from other parts of the skull and hyoid bone, and consist of four paired muscles: • the genioglossus muscles originate from the mandible, attach to the hyoid bone and blend with the intrinsic muscles of the tongue • the hyoglossus muscles originate from the hyoid bone and insert into the tongue • the styloglossus muscles originate from the styloid processes of the temporal bones and insert into the lateral part of the tongue • the palatoglossus muscles originate from the soft palate aponeurosis and insert into the lateral part of the tongue. a midline fi brous sagittal septum divides the tongue into two halves and attaches to the body of the hyoid bone. additionally, on the undersurface of the tongue, the frenulum linguae -a vertical fold of mucous membrane -connects the tongue to the fl oor of the mouth. as such, although anchored at its root, the tongue is mobile, allowing the different functions of sucking, suckling, latching, swallowing and eating, and later speech. in infants, the tongue is totally contained in the oral cavity, although it is quite wide in proportion to the container and protrudes beyond the alveolar gum pads. however, its development is far from being complete and its position will go through many changes before the end of adolescence. one of the biggest changes occurs in the fi rst years of life, as the child grows, the posterior third of the tongue descends following the larynx. when evaluating tongue malposition in children, the bony attachments of the tongue muscles should be evaluated for somatic dysfunction. dysfunction of the mandible, the temporal bones through the styloid processes and the hyoid bone may potentially interfere with the position of the tongue. one of the most common lingual dysfunctions is forward and inferior displacement of the tongue. this predisposes to malocclusion and mouth breathing. mouth breathing and a low posture of the tongue are also associated with an inferoposterior displacement of the anterior convexity of the hyoid bone. [ ] [ ] [ ] to ensure the lingual mobility necessary in the infant for feeding and the development of proper speech, the frenulum linguae should not be too short. ankyloglossia, or tongue-tie, is a congenital anomaly characterized by an unusually short frenulum linguae. breastfeeding is more diffi cult in the presence of ankyloglossia, and children have more diffi culty pronouncing lingual and sibilant sounds such as t, d, z, s, th, n and l. furthermore, the tongue affects the growth and development of the maxillae and mandible and, therefore, the teeth in the alveolar processes, acting as a natural orthodontic appliance 'for better or for worse'. its position should be unencumbered as early in life as possible in order to play a satisfactory functional role. as such, clipping of the frenulum (frenuloplasty) may be necessary in association with osteopathic procedures to ensure a correct tongue placement. sucking has been classifi ed in two categories: nutritive and non-nutritive sucking (nns). nutritive sucking results in the delivery of milk and exhibits a slower rate of sucks that are continuous, whereas nns consists of a series of bursts of rapid sucks, approximately twice the rate of nutritive sucking, followed by rest periods. during breastfeeding, before the initiation of sucking, the tongue protrudes beyond the lower gum and then retracts, repeating this protrusive and retrusive displacement of the tongue to draw the nipple into the mouth. if the newborn recognizes the odor of the breast's nipple, frequent sucking is initiated that, in turn, will stimulate the mechanism of lactation. the mother's milk odor results in increased sucking and stronger pressure than when the infant is fed formula or water. successful sucking is produced by a peristaltic wave in the medial portion of the tongue moving from the front to the back of the tongue. , this is the result of successive contraction and relaxation of the genioglossus and transverse muscles of the tongue. at the same time, a repetitive thrust of the mandible participates in the compressive action on the nipple to produce milk. sucking results from the combined actions of the masseters, orbicularis oris and buccinator muscles, as well as from the muscles of the tongue and the mandible, in particular the lateral pterygoid muscles. this activity of the pterygoid muscles is important. at birth the pterygoid processes of the sphenoid are not fully developed, and because the activity of sucking requires a signifi cant effort from the infant, the stimulation produced contributes to their development. at approximately the th month of life, a new sucking pattern appears. it resembles that of later years, as when sucking from a straw, and demonstrates less movement of the tongue. refl exes are of paramount importance in the actions of the oral cavity. they facilitate various vital functions, including suckling and swallowing, but also breathing, eating and drinking. sucking elicits a swallowing refl ex in the infant by stimulating the lips and the oral cavity. this refl ex results from sensory input that induces a series of motor responses. it is mediated through neural receptors located on sensory fi bers, the afferent pathway of sensory fi bers, central synaptic connections and interneurons, and the efferent pathway composed of motoneurons or autonomic postganglionic neurons innervating the effector organ. in a somatic refl ex, the effector is the striated muscle innervated by the alpha motoneuron. in an autonomic refl ex, the effector includes a peripheral neuron extending its postganglionic axon to visceral structures. in sucking and swallowing, the sensory receptors -the tongue, gums, palate and pharynx -are located in the oral cavity. the sensory input passes through the superior laryngeal nerve, trigeminal nerve (cn v) and glossopharyngeal nerve (cn ix) to the brainstem, in the nucleus tractus solitarius (nts) and adjacent reticular formation. from there, second order neurons engage brainstem deglutitive pharyngeal and laryngeal motoneurons in the nucleus ambiguus and in the facial, trigeminal and hypoglossal nuclei. the palate and palatopharyngeal muscles respond, separating the mouth from the nasal cavity to prevent passage of food from the oral cavity to the nasal cavity during the swallowing process. the integrity of the infant's oral cavity is of signifi cance when considering the development of orofacial refl exes. the concept that structure affects function, and vice-versa, is perfectly illustrated in this area. the different structures that constitute the oral cavity evolve as the infant is developing, thus producing changes in function that will, in turn, further affect those structures. conversely, malposition of any of the structures contributing to the oral cavity, such as lingual malposition, will affect function and consequently viscerocranial development in infants and children. breastfeeding differs from bottle feeding. breastfed infants have better control of the amount of milk obtained than bottle-fed infants. bottle feeding is greatly infl uenced by the force of gravity, with higher volumes resulting in faster fl ow of milk. in order to control this increased fl uid fl ow, the newborn tends to adapt with a lingual and mandibular posture that is less protrusive. this decreases muscular participation and bottle-fed infants demonstrate a reduction of masseter muscle activity. the positive effect of muscular traction on bony development and thus on orofacial development is decreased and may, in turn, contribute to malocclusion. the type of nipple employed during bottle feeding, i.e. its material, density and location of holes, requires different adaptive patterns from the infant. most of the time, the root of the tongue does not come up to the tip of the nipple, as is the case with breastfeeding, but rather demonstrates a more posterior position. sucking is considered to be a determining factor in orofacial morphogenesis. it infl uences mandibular growth through the traction of myofascial attachments. the upper head of the lateral pterygoid muscle inserts into the developing condyle of the mandible. active sucking as produced by breastfeeding is considered to be of paramount importance in mandibular development. it contributes to the change from the retrognathic mandibular posture seen in infants to a more centered position at year of age. , during breastfeeding, the shape of the breast and the sucking pressure of the infant's tongue against their palate has a modeling effect on the palate. the pressure of the tongue on the anterior portion of the palate produces a pattern of cranial fl exion-external rotation. the rhythmic sucking pressure on the infant's palate results in a pumping action that may contribute to the balancing of their skull and cranial mechanism. additionally, breastfeeding seems to have a positive effect on orofacial morphogenesis, and a protective effect for the development of posterior cross-bite in deciduous dentition. human milk is a complex fl uid that contains more than components and is highly effective for the health and wellbeing of the infant. breastfeeding provides multiple benefi ts, such as decreased gastrointestinal and respiratory infections in childhood, in particular otitis media, as well as protection against atopic disease. , it also seems to reduce pain in infants and to enhance cognitive and visual development, as well as to have a potentially positive impact on the mother's health. breastfeeding is thus recommended as the optimal source of nutrition for infants during the fi rst months of life. although thought of as a natural process, it is not always easy, and some infants demonstrate diffi culties. such is the case for preterm infants, or infants with developmental anomalies such as micrognathia or ankyloglossia. nursing diffi culties may also be related to developmental anomalies of the mother's breast or variations of nipple size or shape that reduce the effectiveness of sucking. when developmental anomalies are not present, but nursing diffi culties persist, an evaluation for somatic dysfunction should be performed. the oral structures, including the mandible, should be assessed, and the function of the tongue should be checked. the intrinsic muscles of the tongue are all innervated by the hypoglossal nerve (cn xii), as are all the extrinsic muscles, with the exception of the palatoglossus muscle which is innervated by the vagus nerve (cn x). the hypoglossal nerve leaves the skull through the hypoglossal canal, situated in the anterior intraoccipital synchondrosis, between the basiocciput and the exocciput. the hypoglossal nerve may be subject to compressive forces during a diffi cult labor, with consequent impact on tongue motor function and resultant suckling diffi culties. feeding is a highly complex activity in young infants since it requires the integration of sucking, swallowing and breathing. normally, coordination of the buccopharyngeal functions takes place by weeks postconceptional age, although refl ex swallowing occurs when sucking stimulates the lips and the oral cavity. a spoon of food placed on the tongue of term infants will also produce a refl ex where the tongue pushes against the spoon. it is only around the th or th month of age that infants open their mouth when a spoon is brought before them or touches their lips, and approximately weeks later that they use their tongue to move food to the back of the mouth to swallow. the mechanism of deglutition is divided into oral, pharyngeal and esophageal stages. the oral stage occurs when the milk or food is in the mouth and when the child tastes, plays, experiments with the food and forms a bolus to be pushed into the pharynx and esophagus. at that time, the anterior part of the tongue presses against the hard palate, while in infants the buccinator muscles participate with resultant suction. next, the tongue propels the bolus in the back of the mouth into the pharynx and the swallowing refl ex is elicited. multiple receptors around the opening of the pharynx are stimulated by the bolus, resulting in sensory impulses conducted to the swallowing center via cn v, ix and x. consequent motor activity is triggered by cn ix and x. during this pharyngeal stage, while the tongue propels the bolus posteriorly, the hyoid is displaced anteriorly, the larynx superiorly and anteriorly toward the base of the tongue, and the epiglottis moves to cover the superior opening of the larynx. the displacement of the epiglottis and the approxi-mation of the vocal cords of the larynx combine to prevent the passage of food into the trachea. thus, the bolus passes into the pharynx, dividing around the epiglottis while the soft palate moves against the posterior pharyngeal wall to close the nasopharyngeal entrance. the stylopharyngeus muscles draw the sides of the pharynx superiorly and laterally. this stretches the opening of the esophagus, and the bolus, always under the infl uence of gravity and contractions of the pharyngeal constrictors, enters into the esophagus. this third stage of the mechanism of swallowing -the esophageal phase -is totally under the infl uence of the ans via the vagus nerves and the cervical and thoracic sympathetic ganglia. several differences in the coordination of swallowing are observed between infants and adults. human infants, like non-human primates, demonstrate the ability to breathe and suckle simultaneously with swallowing phases between respirations ( fig. . . ). they will keep this ability until approximately years of age when the neuromuscular system matures. at that time, the larynx and tongue have completed their descent and the posterior third of the tongue is more vertical, forming the upper anterior wall of the pharynx. the larynx and hyoid bones are involved in the descent, with separation of the epiglottis away from the uvula of the soft palate. the tip of the epiglottis is located at the level of the fi rst cervical vertebra at months of age and at the level of the third vertebra between and months of age. nasal cavity in infants, swallowing is immature, different from that of the adult and characterized by an important anterior displacement of the posterior pharyngeal wall. during immature swallowing, the tongue protrudes over the lower lip with active contraction of the facial muscles, in particular the orbicularis oris and mentalis muscles. with progression of time, the teeth erupt in surroundings that can have an infl uence on their development, as much as they can infl uence the adjacent structures. therefore, with maturation, the tongue rests lower in the mouth and is located between the teeth. now, during swallowing, the tip of the tongue is posterior to the incisors, the lips are sealed and facial muscles relaxed. infantile or immature swallowing should disappear around - years of age, and the positioning of the tongue against the palate will contribute to the development of a broad palate and a well-developed facies. the act of swallowing is complex, involving the lips, jaw, tongue, palate, pharynx, larynx and esophagus, and each of these structures may be affected by somatic dysfunction. conversely, the functions of sucking and swallowing are of paramount importance for the development of structures to which they are related. oropharyngeal development is infl uenced by the functional posture of the tongue, lips and jaws. the pharynx is attached superiorly to the base of the skull, the pterygoid processes of the sphenoid bone, the petrous portions of the temporal bones and the pharyngeal tubercle of the occipital bone. laterally, the pharynx is connected to the styloid processes of the temporal bones and posteriorly to the cervical spine. consequently, any dysfunction of the cranial base, cervical spine, hyoid bone and mandible should be considered when evaluating dysfunctional swallowing. craniocervical dysfunctions are very frequently associated with an anterior displacement of the tongue, predisposing the individual to tongue thrusting. furthermore, because cn ix and x trigger the motor activity of swallowing, the relationship between the occiput and temporal bones should be assessed for its effect on the jugular foramina. the process of maturation of swallowing is not always established, leading to swallowing dysfunction or immature swallowing. many individuals swallow with their tongues barely touching the palate or with their tongues between their teeth, in a dysfunctional manner. swallowing occurs between and times a day, and, when dysfunctional, the thrusting force applied on the incisors with every swallow results in labial tilting. the child or adolescent who swallows immaturely also demonstrates some contraction in the orbicularis oris and mentalis muscles, failure to contact the molars and tongue protrusion when swallowing. furthermore, they have a narrow, high, palatal arch, and thus do not benefi t from the pumping action of the tongue on the palate, and the palatine aponeurosis, which is suggested as being necessary for aeration of the pharyngotympanic tube (eustachian tube). begin by observing the face, specifi cally noting the proportion between the upper, middle and lower thirds of the face. the lower two regions are proportionately smaller in newborns than in older children, adolescents and adults. observe the tonicity of the lips and note whether or not pursing is present. observe the tonicity of the perioral musculature. have the child open the mouth and observe the position of the tongue; note any protrusion and if the tongue is at rest or demonstrates slight muscular activity. assess the length of the frenulum linguae. it may be too short, inserting near the tip of the tongue, sometimes giving the tongue a heart-shaped appearance due to it. observe the movements of the tongue and, if the child is old enough, have them protrude the tongue to note its mobility. ask them to pretend they are going to touch the tip of their nose with their tongue to observe its undersurface. with severe ankyloglossia, the tongue will tend to curl under during protrusion and will not be able to protrude because the tip is tied down by the short frenulum. in infants, test the suck response by introducing a cotted fi nger, with the palmar surface in the direction of the hard palate, into the infant's mouth and allow them to suckle. the infant should respond by latching tightly. feel coordination and strength of tongue movements. note any oral habits, such as tongue sucking, thumb or fi nger sucking, pacifi er sucking or nail biting. when present, observe the position the child assumes when sucking a fi nger, thumb or pacifi er and note in what direction the object being sucked is oriented. these positions will usually be taken to reinforce a dysfunctional pattern. for example, placement of an index fi nger relatively vertically in the mouth is associated with a narrow, high, palatal arch. thumb sucking with the index fi nger curled over the nose is consistent with a cranial pattern in extension because the ethmoid bone is placed in anterior rotation as during extension. utilizing tests of listening, assess the cranial base, noting the movement of the occiput and the temporal bones. intraosseous dysfunction of the occipital bone at the anterior intraoccipital synchondrosis will compress cn xii in the hypoglossal canal, while interosseous dysfunction between the occiput and temporal bones can affect the jugular foramen, entrapping cn ix and x. also examine the temporal bones because they affect the position of the mandible and because of the insertion of the styloglossus muscles on the styloid processes. assess the mandible, temporomandibular joint, hyoid bone and cervical spine. these areas should be balanced to ensure satisfactory function of the associated myofascial structures. patient education should be approached in three steps: . instruct them to consciously keep their tongue in their mouth. . they must learn to swallow with their lips closed. . while keeping their lips closed, they must learn to swallow with the tip of their tongue resting against the palate behind their upper incisors. an exercise to accomplish this is to place a small piece of food between the tongue and palate and keep it there while attempting to swallow several times. this may be repeated up to the point where swallowing with the tip of the tongue resting against the palate becomes an automatic refl ex. in young children with minor ankyloglossia, have them perform exercises to mobilize the tongue as much as possible in order to stretch the frenulum. stress that mispronunciation often associated with baby talk may appear to be cute, but that it is actually dysfunctional and should not be encouraged. insist, when speaking, that the child repeats incorrectly articulated sounds as correctly as possible to improve tongue mobility. have them play soundmaking games where they repeat certain sounds that cause the tongue to make a clicking noise against the palate. be aware that functional asymmetries are often associated with repetitive asymmetric activities, such as unilateral bottle feeding or thumb sucking. educate the caregiver and patient to lose these habits. the use of a pacifi er should be limited as much as possible. suggest that pacifi ers should be used only during the fi rst months of life, when the need for sucking is strongest. gastroesophageal refl ux (ger) is the retrograde fl ow of gastric contents into the esophagus and above. it is rather frequent during infancy and is often considered as 'physiologic' under months of age with a benign prognosis in the majority of cases. however, it is a problem of considerable concern for the parents that ranges from minimal regurgitation with the bringing up of small amounts after feeds, to signifi cant vomiting with failure to thrive. because the latter may be indicative of a serious condition, it requires further medical evaluation. ger is one of the most recurrent symptomatic clinical disorders affecting the gastrointestinal tract of infants and children, and regurgitation in infancy is a complaint in . % of children seen in osteopathic practice. daily regurgitation is present in % of infants in the fi rst months of life, with a peak incidence at months. most of the time, the condition resolves before the end of the st year and only % of infants still bring up their food between and months of age; however, when the condition is present for at least days before years of age, children are predisposed to demonstrate ger symptoms into middle childhood. there is no association with gender, , nor with the mode of feeding the infant, breast or bottle; nevertheless, a genetic component seems to be present and a correlation exists between maternal symptoms of ger and the occurrence of regurgitation in infancy and ger in middle childhood. additionally, there is a stronger prevalence of ger among caucasian infants. , normal gastroesophageal function is a complex mechanism where the relaxation and contractility of the lower esophageal sphincter are important factors. the esophagus is a tube connecting the pharynx and stomach, with muscular sphincters -the upper and lower esophageal sphincters. the upper portion of the esophagus (the cervical esophagus) consists of skeletal muscle; the remainder (the thoracic esophagus) consists of smooth muscle. after swallowing, the bolus of food passes through the pharynx to enter the esophagus. a primary wave of contraction starts in the pharynx and travels along the whole length of the esophagus, reinforced by secondary waves in the body of the esophagus. these peristaltic waves assist gravity to propel the bolus through the esophagus and into the stomach. normally, at the gastroesophageal junction (gej), the lower esophageal sphincter (les) relaxes to allow the bolus of liquid or food to pass into the stomach. in ger, the gej is a critical site. the les is formed by circular smooth muscle surrounding the terminal esophagus. the les is under tonic contraction that relaxes during swallowing as well as following esophageal distension by a bolus of liquid or food. additionally, the crura of the diaphragm participate in this sphincteric mechanism. the esophagus traverses the diaphragm through an opening in the right diaphragmatic crus, the esophageal hiatus, which is located between the central tendon and the hiatus aorticus. the two vagus nerves (cn x) also traverse the diaphragm through the esophageal hiatus. at this hiatus, one crus, most often the right crus, surrounds the esophagus forming an external sphincter; however, the fi bers from the crus are not directly connected to the esophageal wall. rather, fi bers coming from the transversalis fascia, and thus continuing to form a fascia under the diaphragm, pass into the esophageal hiatus and surround the esophagus to blend into its walls - cm above the gej. some of the elastic fi bers of the fascia extend into the esophageal submucosa. this connection between the diaphragm and esophagus is called the phrenoesophageal ligament. this ligament simultaneously allows gej mobility, permitting the displacement associated with respiration and swallowing, while providing restriction of upward movement of the esophagus. additionally, during pulmonary inspiration, the diaphragmatic esophageal hiatus contracts in response to increased intra-abdominal pressure. the fascial relationships between the esophagus and the diaphragm must be balanced when addressing dysfunction of the gej. the transversalis fascia is a vast layer of fascia lying between the peritoneum and the abdominal walls, in continuation below with the pelvic fasciae, behind with the thoracolumbar fascia and above with the fascial sheet covering the undersurface of the diaphragm. the phrenoesophageal ligament, described above, consists of fi bers extending from this layer to form the cone surrounding the gej. furthermore, the stomach is connected to the diaphragm through the gastrophrenic ligament, i.e. the portion of the greater omentum that extends from the greater curvature of the stomach to the inferior surface of the diaphragm. from a functional point of view, the diaphragm must be balanced to allow satisfactory gej function. the smooth muscle of the les generates a tonic pressure at the gej that is the major barrier to refl ux of gastric contents into the esophagus. thus, refl ux of acidic fl uid backward, out of the stomach and into the esophagus, is normally controlled at the gej. at birth, neuromuscular activity and esophageal and les peristalsis are undeveloped, resulting in frequent retrograde spilling out of gastric contents. the achievement of full development of the les occurs as the infant matures, with the pressure at the les reaching adult levels between and months of age. at the same time, the average capacity of the stomach at birth, i.e. around ml, will rise to ml at the end of the fi rst month and will reach ml in the adolescent. in order to act as a protective barrier against refl ux from the stomach, pressure in the gej has to be higher than in the adjacent stomach or esophagus. inhibitory and excitatory factors infl uence the tone of the les. as mentioned above, a bolus of liquid or food initiates the relaxation of the sphincter in response to esophageal distension. this mechanism is under the control of intramural plexuses of the enteric nervous system. the motor fi bers start in the dorsal motor nucleus of the vagus and the nucleus ambiguus, and the neural release of nitric oxide and vasoactive intestinal peptide among others by postganglionic fi bers triggers the relaxation of the les. additionally, neurological activity from the dorsal motor nucleus of the vagus and nucleus ambiguus is also sent to the crura of the diaphragm. thus, both the esophageal and crural musculature are inhibited. embryologically, both the esophagus and stomach develop from the foregut. the dilatation of the foregut for the stomach starts in the sagittal plane at weeks of gestation. several spatial changes occur before the stomach reaches its fi nal position. because growth is greater along the dorsal border of the stomach, the greater and lesser curvatures are formed. this is followed by rotation, with the greater curvature moving to the left and the lesser curvature moving to the right. the two vagus nerves follow this rotation. thus, the right vagus becomes posterior and supplies the dorsal part of the stomach, while the left vagus is anterior and supplies the ventral part of the stomach. some torsion of the stomach occurs between the lower part of the esophagus and the pyloric canal, which are consequently no longer in the same plane. this has been suggested as a risk factor for ger. this developmental process results in what is felt when the stomach is palpated. the identifi cation of a strong torsional sensation in this region of the gut is an indication for osteopathic treatment that should be directed at the alleviation of the identifi ed torsional dysfunction. the etiology of ger is multifactorial, with often more than one factor being present in children with this condition. however, a transient les relaxation (tlesr) as the result of a vasovagal refl ex appears to be frequently associated with ger, producing a complete relaxation of the les without pharyngeal swallowing. , other factors for ger include ineffective esophageal motility or delayed gastric emptying. a high fat diet can contribute to an increase in the number of episodes of tlesr. additionally, in infants, gravitational and positional factors associated with the supine position may exacerbate the refl ux. most infants spend more time in this recommended position since the 'back to sleep' campaign to prevent sudden infant death syndrome (sids). the return of the gastric acid contents into the esophagus predisposes the infant and the child to esophagitis; for these patients, crying becomes common. acid refl ux into the esophagus can reach the upper esophagus, the pharynx and larynx, and may possibly be aspirated into the trachea. chemoreceptors in the mid or upper esophageal mucosa are stimulated, resulting in refl ex respiratory inhibition, hypertension and bradycardia. approximately % of infants demonstrate refl ux-induced apnea with airway closure or laryngospasm. the severity of these reactions may lead to sids. bronchospasm may also occur and, in turn, accentuate the symptoms of asthma, although ger does not seem to increase the risk of developing asthma. recurrent bronchitis or pneumonia is frequent and can be caused by repeated pulmonary aspiration of acid refl ux. ent problems such as nasal obstruction are sometimes related to ger, with secondary infl ammation and narrowing of the posterior nasal apertures. , with premature infants, the most common complication of recurrent ger is failure to thrive. in children and adolescents, ger is frequently associated with abdominal pain in the midepigastrium, eventually substernal heartburn and possible chronic irritative coughing. furthermore, regurgitation of gastric contents into the oral cavity is responsible for dental erosion and dental caries. the vagus nerve (cn x) is essential in the control of les tone. it contains both motor and sensory fi bers, with a course and distribution more widespread than any of the other cranial nerves, passing through the neck and thorax to the abdomen. about % of vagal fi bers are afferent fi bers and may be general somatic, general visceral or special afferent. they provide signifi cant sensory input from the viscera. in infants, children and adolescents with ger, there is a defi nitive dysfunctional viscerosomatic and/or somatovisceral component. this may, in turn, lead to altered behavioral responses. possible dysfunction affecting cn x in its extensive course may facilitate ger. critical sites are the jugular foramina and the passages through the diaphragm at the esophageal hiatus. additionally, the stomach and esophagus may demonstrate visceral dysfunction in relation to somatic dysfunction in the surrounding structures, i.e. diaphragm, fasciae and ligaments. the osteopathic approach to ger consists, therefore, of addressing any dysfunction that can impede the vagus, balancing the stomach and esophagus together and in their relationships with surrounding structures -the diaphragm, fasciae and ligaments. inspect the abdomen, noting its shape, contour and movement with respiration. the abdomen should be rounded and dome-shaped in infants because of the lack of abdominal muscular tone. observe for abdominal asymmetry, noting areas of tension under the inferior border of the thoracic cage, in particular under the xiphoid process. note if the umbilicus is centered or displaced or if it is protruded. in children and adolescents, observe the inside of the mouth for dental caries. examine and treat the craniocervical junction, with particular attention to the relationship between the occiput and temporal bones because compression of the jugular foramen can impact the exit of cn x. check and balance the cervical area (c , c , c ) because of the phrenic nerve and its action on the diaphragm. examine and treat identifi ed somatic dysfunction affecting the thoracolumbar junction because of its potential to affect the crura of the diaphragm. evaluate and treat the diaphragm, paying particular attention to the freedom and symmetry of its excursion and its attachment around the xiphoid process as well as its anterior costal attachments. balance the fasciae at the level of the les by balancing the area below the xiphoid process with the diaphragm. balance the relationship between the stomach and diaphragm. the stomach itself demonstrates curling and uncurling movements, similar to those that created its curvatures. palpation should reveal a balance between these curling and uncurling movements. a predominance of one phase can be treated using indirect procedures. balance the torsional relationship between the stomach and the esophagus. address somatic dysfunction related to both viscerosomatic and somatovisceral refl exes: occiput, c , c for the vagus; upper thoracic for the esophagus; midthoracic for the stomach. infants should have small and frequent feeds, and should be fed in a semi-upright position. feeding should occur under calm circumstances. instruct children and adolescents to eat slowly and to avoid swallowing air. they should eat and drink small amounts to prevent distension of the stomach. they should also be instructed to avoid the consumption of fatty foods, caffeinated beverages and chocolate. lifestyle changes such as avoiding eating before bedtime and, if appropriate, weight loss should be encouraged. the term colic is derived from the greek, kblikos, meaning in relation to the colon. in the list of the most frequent gastrointestinal (gi) dysfunctions encountered in infants, colic is second only to regurgitation. it occurs in - % of infants [ ] [ ] [ ] and is one of the most common complaints for which parents seek professional advice. the colicky infant presents with abdominal distension, frequent gas emissions, apparent abdominal pain, irritability and excessive crying. the mechanisms that explain this disorder are not entirely understood. they may be discussed in anatomic or physiologic terms, refl ecting dysfunction at one or more levels of the brain-gut axis. additionally, because the ontogeny of the gi system is under multiple infl uences -genetic heritage, intrinsic development, endogenous regulatory mechanisms and the environment -the etiology of colic is commonly multifactorial. thus, various etiologies have been proposed, including gi diseases such as allergy to cow's milk protein, lactose intolerance and intestinal hyperperistalsis, as well as neurodevelopmental dysmaturation or psychological diffi culties in the parent-child relationship. on average, it is estimated that infants cry for . hours per day during the fi rst months of life, with a peak around weeks of age. crying time then slowly decreases to less than hour a day by weeks of age. the 'rule of three' proposed by wessel et al. in is usually the reference employed to identify colicky children. these children are said to cry for more than hours per day, more than days per week and for longer than weeks. colic usually starts in the st month of life and may persist until or months of age. crying is commonly concentrated in the late afternoon and evening, occurs in prolonged bouts and is unpredictable and spontaneous. colicky children are described as crying without identifi able cause, fussing and hard-to-soothe, although being otherwise healthy infants, well fed and showing no signs of failure to thrive. individual variation may be present in the cries, such as duration or intensity, associated fussing or the resulting parental distress, adding complexity to the defi nition. colic cries convey acoustic information that the infant is highly aroused or distressed. during a crying episode, the infant usually positions their legs fl exed over their abdomen, in association with a hard distended abdomen, gurgling noises from the abdomen (borborygmi), sometimes gas and regurgitation, as well as facial grimacing and clenched fi sts. this presentation is indicative of a gi etiology for colic. when evaluating the colicky infant, several aspects of gi development and associated neurohormonal factors should be considered. bacterial colonization of the sterile gi tract of the neonate starts quickly on delivery. a fl ora develops, resulting from microbial and host interactions. the main factors that infl uence this developing microbial population are the maternal intestinal fl ora, the use of antibiotics by the mother during pregnancy and when nursing, the mode of delivery (vaginal or cesarean) and the mode of feeding (bottle feeding or breastfeeding). the bacterial fl ora in breastfed infants is composed typically of bifi dobacteria, whereas in bottle-fed infants anaerobic bacteria as well as aerobic species are present. it is also recognized that the fl ora of breastfed infants includes far fewer species that are liable to be pathogenic. the developing bacterial fl ora usually becomes stable by the end of the fi rst week of life. by years of age the infantile fl ora resembles that of the normal adult. this process is one of the main components, along with host cells and nutrients, that form the complex ecosystem of the intestine. the intestinal lumina are lined by a very large surface of mucosa that is the principal interface with the external environment. besides its function of digestion and absorption of the nutrients contained in food, the intestinal mucosa forms a protective barrier against foreign substances and potentially pathogenic microorganisms from the external environment. the mucosal barrier consists of cellular and stromal components covered by a mucus layer. within the mucosal barrier various secretions form a viscoelastic gel, creating a site for bacteria-bacteria interactions. thus, the microbiota play an important role in the development of the endogenous barrier mechanism in the gut and are involved in the maturation of humoral immunity in humans. the intestine can be considered the primary immune organ, housing more than % of all immune cells. the gut-associated lymphoid tissue (galt) develops through innate and acquired immunity and consists of organized and diffuse lymphoid tissues that constitute the aggregated lymphoid follicles (peyer's patches) and the mesenteric lymph nodes. this arrangement permits rapid response to any challenge in order to maintain the integrity and protective functions of the immune barrier at the gi mucosal surface. the galt contains b lymphocytes, implicated in the synthesis of secretory antibodies of the immunoglobulin a (iga) class, and t lymphocytes. in this ecosystem, the equilibrium of the microbiota is important in the maintenance of homeostasis and intestinal immune responses. it is also of paramount importance in the prevention of food allergies, and it is during the fi rst years of life, when the infantile fl ora is not well diversifi ed, that food allergies and enteropathies are more apt to be established. particular circumstances in infants, such as prematurity, cesarean section delivery and antimicrobial treatment, delay intestinal colonization and its important immunostimulating effect. , on the other hand, breastfeeding is considered to confer benefi cial effects on the microbiota, explaining its protective role against atopic disease, although it does not appear to have a protective effect on the development of colic. differences in the gut microbiota of breastfed colicky infants have been shown to exist when compared to non-colicky, and lactobacilli are present less than in controls. that breastfed infants may suffer from colic might be explained by the fact that breast milk contains intact proteins similar to those of cow's milk and that colic often appears to be related to a food allergy, particularly to cow's milk protein. , this exposure would trigger the production of specifi c ige to milk protein and may be considered a manifestation of an allergic predisposition. this is, however, subject to debate because no data support the hypothesis that infantile colic leads to an increased risk for subsequent allergic disease or atopy, although more irritability during the th week and colic-type crying during the th week has been observed in children with atopic disease at years of age. furthermore, lactose intolerance also contributes to infantile colic. incomplete lactose absorption encourages bacterial growth with resultant fl atulence and cramping. as the etiology of infantile colic is multifactorial, cow's milk protein elimination may be an effective treatment for infantile colic, and for colicky breastfed infants a maternal diet free of cow's milk may be considered. other maternal dietary modifi cations during breastfeeding should include reduction of cruciferous vegetables, onion and chocolate, foods that are associated with colic symptoms in infants. hyperperistalsis is another theory included in the gi disorder etiology to explain abdominal cramping and colic. intestinal smooth muscle normally generates rhythmic peristaltic activity. movements of the intestine with the regulation of gut motility are the result of complex neural and muscular interactions that take place at several levels and under the infl uence of neurotransmitters and hormones. the innervation of the gut consists of intrinsic and extrinsic nerves. ganglionated and non-ganglionated plexi, part of the enteric nervous system (ens), form the intrinsic innervation, while the vagus, splanchnic and pelvic nerves form the extrinsic innervation. the intrinsic afferent neurons project within the myenteric and submucous plexuses and information from activated sensory receptors reaches the cns through vagal and spinal afferent nerves. the gut interacts constantly with the cns through either somatic or autonomic neurons (brain-gut axis). consequently, the cns modulates the gut motor activity through the ans (sympathetic and parasympathetic), maintaining the normal rhythm of activity in the gi tract as well as adjusting autonomic output to accommodate any external challenge. the release of acetylcholine by the parasympathetic fi bers increases gut motility, whereas the release of norepinephrine, somatostatin and neuropeptide y by sympathetic fi bers decreases the motility. multiple factors, such as emotion, stress, nervousness, fasting or eating, can also infl uence the activity of the ans. additionally, communication occurs between the different parts of the gi tract through myogenic and neurogenic signals along the gut, and through refl ex arcs transmitted via autonomic neurons. individual differences are present in the functioning of the cns. accordingly, an increased sensitivity to stimuli, such as distension of the gut, is demonstrable in patients with functional gi disorders, and excessive crying in colicky infants may be the result of hypersensitivity in the perception of gut stimuli or excessive afferent responses to these stimuli. genetic susceptibility to functional gi disorders may exist. supporting this theory, a correlation is found between high responsiveness of the newborn during neurobehavioral assessment in the fi rst days of life and crying behavior at home. additionally, intestinal hypersensitivity may alter motility of the gi tract by increasing intestinal afferent-efferent refl exes. cranial osteopathy offers a therapeutic option for these patients. osteopathic treatment of colicky infants has been demonstrated to decrease crying and increase sleep time. somatic dysfunction affects the ans. the resulting state of facilitation, in turn, increases the perception of either mechanical or chemical intestinal stimuli, and visceral hypersensitivity or dysfunction follows. somatic dysfunction can involve any osseous, articular, ligamentous, membranous, fascial, muscular, visceral and vascular component associated with the gi tract. vagal viscerosensory neurons have their cell bodies in the inferior ganglion located under the jugular foramen. the spinal sensory input takes place through perivascular nerves passing through the prevertebral ganglia to the dorsal horn of the spinal cord, and these neurons have their cell bodies in the dorsal root ganglia. pain perception is thought to be mediated essentially by the spinal innervation. the craniocervical junction (parasympathetic), the thoracic and thoracolumbar spine (sympathetic) and sacropelvic region (parasympathetic) may be sites of somatic dysfunction resulting in somatovisceral dysfunction. treating these areas may contribute to balance the gut function of the colicky infant. changes in internal sensory states, acting in a bidirectional manner between the viscera and the brain, are obviously related to interoception and visceral hypersensitivity, and are considered as the key pathogenetic factors underlying the emotional state present in subjects with functional gi disorders. stress, in a broad sense, as with any menace to one's individual homeostasis, may come from the external or internal environment. as such, visceral hypersensitivity, milk allergy or somatic dysfunction may be stressful, and colicky infants are quite often described as demonstrating diffi cult temperament. an infant who is crying is expressing distress without indication of its origin. this can be a signifi cant source of stress for parents and caregivers. they respond differently to these cries according to cultural and sociodemographic factors that, in turn, may affect the amount of infant crying. responses of mothers to infant crying diverge from putting the child to bed, to holding and carrying them, riding around in the car, rocking or swaddling. globally, fi rst-born babies are usually reported as crying more excessively, and the western caregiving style is associated with a higher incidence of reported crying. , touching, holding and caressing a child results in positive effects on the emotion regulation and stress reactivity in the infant. maternal care facilitates the development of central corticotropin-releasing factor (crf) systems which regulate the expression of behavioral, endocrine and autonomic responses to stress. it is well established that infant-maternal contact is of paramount importance in mediating infant emotional reactivity. gut-brain peptide cholecystokinin (cck) and endogenous opioid analgesic agent production are increased following contact. this contributes to the development of attachment through the 'interactive regulation of biological synchronicity between organisms'. under normal conditions, this relationship between mother and infant contributes to the wellbeing of both. conversely, infantile irritability can prove to be a major source of distress to caregivers. in extreme circumstances the irritability of the child can prove so stressful as to create an impulse to shake the child. a potential psychosocial etiology for colic in the st year of life is associated with pre-existing maternal anxiety. if the caregiver is stressed, the child will cry more, and the caregiver will be further worried by their incapacity to help the child. furthermore, a baby is frequently described as crying excessively when the crying distresses the parents. infants' cries can also be indicative of a behavioral problem resulting from a less than optimal parentinfant interaction. this complex interrelationship between the child and caregiver has led to a behavioral hypothesis for the etiology of colic where interventions such as modifying parental responsiveness, using motion and sound to calm the baby, and reducing stimuli have been suggested. these caregivers do not need to be told that they are bad parents; they need to be supported and managed with understanding. the circumstances must be discussed and the caregiver given the opportunity to vent their anxiety and frustration. behavioral adaptations, when appropriate, should be encouraged. maternal smoking may contribute to the disorder. one hypothesis for colic suggests that it is the result of transient developmental dysmaturation based on the fact that infantile colic often stops after or months. it is important, nonetheless, to treat these children and help the parents, because persistent behavioral diffi culties, including crying, sleeping or feeding behavior in infancy, are precursors of hyperactivity or behavioral problems and academic diffi culties in childhood. it is important to perform a thorough physical examination to rule out other causes for persistent crying to ensure that there is no organic cause for the crying. once this has been done, osteopathic manipulation may be employed to reduce the somatic afferent load of somatovisceral refl exes into the cns as well as to alleviate the mechanical impact that somatic dysfunction can have on the gi tract. treatment is appropriate not only for infants, but also for children and adolescents, because colic may persist later in life as a functional gi disorder. the osteopathic component of the examination should begin with observation of the infant's posture. the infant may position themselves with their legs fl exed to their chest. if the patient is a child, they might present with an apparent increased lumbar lordosis that occurs when bowel dysfunction creates a distended abdomen with consequent relaxation of the abdominal muscles. observe the abdomen to see if it is tense with bowel distension from fl atulence. note the power and rhythm of the inherent motility of the prm in the head and throughout the body, particularly noting the abdomen. somatic dysfunction should be sought out, especially in the regions of, but not limited to, the posterior neurocranium; the occipitocervical junction and upper cervical spine; the thoracic spine, ribs and upper lumbar spine; the thoracoabdominal diaphragm, the anterior abdominal wall and the sacrum and pelvis. treatment should employ indirect principles and manipulation should be directed at somatic dysfunction, when identifi ed, involving the temporooccipital relationship for its impact on the jugular foramen, and the occipitocervical junction and upper cervical spine for their effect on the vagus and parasympathetic somatovisceral refl exes. somatic dysfunction of the thoracic spine, ribs and upper lumbar spine may be treated to affect sympathetic somatovisceral refl exes. in acute cases, practice inhibition in the lumbothoracic area. avoid active massage of the abdomen which can be irritating. dysfunction of the thoracic spine, ribs and thoracoabdominal diaphragm should be addressed for its impact on the lymphatic and venous drainage of the contents of the abdomen. diaphragmatic, abdominal wall and pelvic dysfunction should be treated to alleviate the impact of dysfunctional fascial tensions on the gi tract. dysfunction of the thoracoabdominal diaphragm is related to the function of the mesenteric plexus. sacropelvic somatic dysfunction may be treated to affect pelvic splanchnic parasympathetic somatovisceral refl exes. using indirect principles, release the periumbilical area and intestine. in every treatment procedure pay attention to the inherent motility of the prm as manifest throughout the body. treating this mechanism affects the ans and probably facilitates tissue perfusion, reducing congestion. the caregiver should be encouraged to create an environment of comfort, calm and relaxation for the infant. gently caressing the frontal area of the neurocranium will often facilitate this. obtaining relaxation of the infant will also have a calming effect on the caregiver(s) that will, in turn, further relax the infant. this relaxation will often make it easier to obtain such a state of calm in the future and will also demonstrate to the caregiver(s) that it can be obtained. avoid, however, active massage of the abdomen which can be irritating. dietary considerations may be employed to improve the function of the gi and the immune system. breastfeeding should, if at all possible, be encouraged. the mother should pay attention to her diet, avoiding cow's milk, cruciferous vegetables, onion and chocolate. in colicky children, lactose intolerance should be considered. a diet rich in fresh fruit and vegetables and antioxidants such as vitamins c and e should be recommended, while refi ned foods should be avoided as much as possible. constipation is the chief complaint in % of all pediatric outpatient visits and defecation disorder is present in - % of children referred to pediatric gastroenterologists. constipation in children is usually defi ned as abdominal pain, diffi culty or pain when passing stool, with the passage of feces that are either large and too hard or in small pebble-like pieces, with diffi culty defecating and a frequency of two times or less per week. the fi rst intestinal discharge, meconium, is passed in healthy newborns within hours. after that, the mode of feeding determines the frequency and quality of stools. bottle-fed infants demonstrate less frequent stools than breastfed infants, who have soft yellow stools up to fi ve times a day. however, breastfed infants may go for or more days without defecation. weaning -the commencement of nourishment with food other than milk -usually occurs between and months of age and results in fi rmer feces. although the frequency of bowel evacuation varies from one infant to another, it is generally admitted that a frequency of less than one stool a day before months of age, and three times or less per week after months, may be considered as pathologic. in preschool children, constipation is present when the child has less than two stools per week. most of the time, constipation is functional, without any objective evidence of an underlying pathologic condition and a thorough history and physical examination are suffi cient to make the diagnosis. it is, however, important to rule out failure to thrive or endocrine, metabolic or structural disease such as hirschsprung's disease. children presenting with this latter condition, characterized by the total absence of ganglion cells in meissner's and auerbach's plexuses, suffer from constipation with massive colonic dilatation proximal to the segment of affected bowel. the onset, however, occurs at birth with delayed passage of meconium and children suffering from the disease demonstrate poor growth. functional constipation has also been described as functional fecal retention, voluntary withholding, psychogenic megacolon or idiopathic constipation. it affects boys more often than girls, contrary to the adolescent and adult populations where women suffer more often from constipation. another difference between children and the adult population is the presence of fecal incontinence in children, which is not present in adults with functional constipation. during the fi rst months of life, infants may present with dyschezia, i.e. diffi culty in defecation. in this case they experience severe problems when trying to defecate and strain and scream during prolonged endeavors. this behavior may last up to minutes, until they successfully pass stools that are usually soft or liquid. the cause is hypothesized to be the failure to coordinate the augmentation of intra-abdominal pressure with the relaxation of the pelvic muscles. painful defecation quite often results in chronic fecal retention with fecal impaction (the immovable collection of compressed or hardened feces in the colon or rectum) and resultant fecal soiling (the passage of liquid stool around the impaction). more than % of school-aged children suffering constipation have a history of painful defecation before months of age. toddlers may succeed in avoiding defecation for several days. the evacuation that then occurs is often painful and may be associated with bleeding, thereby strengthening the behavior of fear and retention. fecal retention, in turn, is associated with subsequent abnormal contraction of the anal sphincters (anismus) and contraction of the pelvic fl oor during attempted retention. the child develops a retentive posture with contraction of the gluteal muscles. with overstretching of the rectal wall and muscle fatigue in the pelvic fl oor, incompetent anal function results in spontaneous relaxation of the sphincters, with consequent fecal soiling with soft or liquid stool. fecal soiling often follows constipation facilitated by rectal distension. constipated children demonstrate several associated symptoms including irritability, abdominal cramps and decreased appetite. most of the time, children with constipation have a withholding type of behavior and very often feel ashamed. they demonstrate more behavioral problems than children who are not constipated; however, these accompanying symptoms disappear immediately following the effective treatment of constipation. the role of psychological and emotional components in the etiology of defecation disorders is subject to debate. it is uncertain which problem comes fi rst: the emotional disorder or the defecation disorder. toilet training is normally initiated between the ages of months and years. when conducted in an overly coercive and stressful fashion, the associated stress has been proposed as a cause of fecal retention. however, when hard bowel movements or painful defecation are present in association with stool toilet training refusal, constipation should be considered because the fi rst episode of constipation in children usually occurs before stool toilet training refusal. familial environmental factors, or added parental anxiety because they want their child to be able to go to school, may add a psychological factor to a physical predisposition to constipation. a decrease in colonic peristalsis has been proposed as a cause of constipation in childhood. it is well recognized that reduction of physical activity and reduction of fl uid intake in adults can be associated with constipation. because children tend to be normally physically active, inactivity is not a major cause of constipation for this population. however, food allergy, particularly cow's milk allergy with cow's milk protein hypersensitivity, seems to be associated with constipation in children. , constipation may certainly be multifactorial. the behavioral approach does not explain every case of constipation. furthermore, children with constipation demonstrate a higher incidence of bladder disorders such as urinary incontinence, bladder overactivity, dyscoordinated voiding, large bladder capacity, poorly emptying bladder, recurrent urinary tract infection and vesicoureteral refl ux. this constitutes a syndrome, an aggregate of associated symptoms and signs that may be addressed by an osteopathic approach. most cases of functional constipation respond well to osteopathic manipulative procedures. defecation is a complex process that involves a mixture of voluntary and involuntary actions. it is triggered by the excitation of anorectal mechanoreceptors sensitive to distension of the rectum. it is followed by coordinated voluntary activity of the abdominal and pelvic musculature and involuntary relaxation of anal sphincters. as the fecal mass moves, the pelvic fl oor muscles relax in order to allow alignment of the rectum with the anal canal. defecation can be inhibited by voluntary contraction of the external anal sphincter and pelvic fl oor muscles. normally, the anal canal is occluded by the internal and external anal sphincters. additionally, the puborectalis muscle, the medial part of the levator ani muscle, contributes to the loop surrounding the anorectal junction by mixing some of its fi bers with the deep part of the external sphincter of the anal sphincters. additional fi bers of the levator ani muscle join the conjoint longitudinal coat that surrounds the anal canal between the internal and external canal. behind the rectum, the pubococcygeal fi bers of the levator ani muscles attach to the anterior surface of the coccyx. the internal anal sphincter has an autonomic innervation: the sympathetic fi bers are from the hypogastric plexus and the plexuses located around the superior rectal artery; the parasympathetic fi bers are from the pelvic splanchnic nerves (s -s ). the external sphincter has a voluntary motor supply that comes from the inferior rectal branch of the pudendal nerve (s -s ) and the perineal branch of the fourth sacral nerve. if the child is old enough to be standing and walking, observe their postural mechanics, noting particularly the degree of abdominal protrusion, thoracolumbar mechanics as they relate to psoas muscle mechanics, the degree of lumbar lordosis as it relates to abdominal protrusion and psoas muscle mechanics. with the patient supine, observe the abdomen, noting its contour and possible distension. palpate the abdomen, looking for tension in the abdominal wall and for palpable stool. in many cases of chronic constipation, stool will be palpable throughout the colon. defi ne stool consistency and assess the quantity of the rectal fecal mass by looking at the height of transabdominally palpable stool above the pelvic brim. diagnostic digital rectal examination should be performed gently to avoid perpetuation of dyschezia. maneuvers that result in rectal stimulation produce potentially noxious sensory experiences and should be discouraged. specifi cally look for somatic dysfunction affecting the thoracolumbar junction that can be associated with psoas muscle dysfunction and sympathetic somatovisceral refl exes. examine the sacrum, coccyx and pelvis for dysfunction that can affect the pelvic fl oor and also be the source of parasympathetic somatovisceral refl exes. the general medical treatment approach includes dietary changes with behavioral modifi cation techniques (cognitive and behavioral interventions such as toilet training, which diminishes phobia and provides positive reinforcement through a rewards system). this approach is often combined with prolonged courses of laxatives. treatment is usually successful, but may take up to - months. when somatic dysfunction has been identifi ed, the correct osteopathic treatment can result in signifi cantly faster results with a resolution of constipation, often in one or two treatments. therefore, treat any somatic dysfunction as identifi ed. treat somatic dysfunction of the sacrum for its relation with pelvic splanchnic nerves and the pudendal nerve. release sacroiliac joints and surrounding myofascial structures. it is important to remember that the sacrum is not completely ossifi ed in infants and children and that intraosseous dysfunction may be present between the different sacral segments. in the infant the sacral molding procedure often provides good results. treat somatic dysfunction of the coccyx, paying attention to its relationship to the insertion of the levator ani muscles. treat somatic dysfunction of the thoracolumbar area for its somatovisceral effect on the sympathetic output to the intestine. with hypersympathetic drive, the bowel becomes less active and may result in constipation. it is also important to be sure that child's posture is balanced, without dysfunctional tension at the level of the psoas for its relationship with the sympathetic chain near the psoas muscle origin. it is important to increase the amount of fl uid that the child drinks every day. infants may be given fruit juices such as prune and pear which contain fructose and sorbitol for their mild laxative effect. if the child is old enough to be eating solid foods, increase bran cereal and fruits and vegetables that are high in fi ber. encourage the consumption of meals at regular times. if the child is relatively sedentary, as tends to occur these days with the playing of computer games, encourage increased physical activity. tell the parents to watch for infrequent, diffi cult or painful defecation that heralds the recurrence of constipation. when identifi ed, they should respond quickly, encouraging the child to go to the bathroom more frequently and modifying the child's diet and physical activities. in a holistic approach to health care, any one area of the body is linked directly or indirectly to all the other areas of the body. consequently, observation of the oral cavity not only provides information about the mouth, it also provides knowledge as to many other aspects of the individual. the oral cavity provides access to the posterior nasal cavity, pharynx, esophagus and lower respiratory tract. it contains an ecosystem that refl ects the overall health status of the individual. dental occlusion refl ects the functional balance of the musculoskeletal system, both locally and at distant areas of the body. muscular tone, facial expression and orofacial habits mirror the individual's psychoemotional status. the oral cavity is also an area that allows communication with others through facial expression and speech. it is the major point of entry for nutrition and hydration and a secondary portal for respiration. optimal function of the area is essential for the very survival of the individual. the main osseous structures of the oral cavity are the mandible, maxillae and palatine bones. the latter two bones are part of the viscerocranium and as such their growth and development extend through adolescence. this process is under genetic infl uence as well as epigenetic factors in which orofacial functions play a signifi cant part. the long period through which development occurs allows extensive opportunities for dysfunction to be established. thus, a thorough understanding of the structure and function involved in this evolution, combined with attentive observation of the infant and growing child, is imperative to identify somatic dysfunction, the effective treatment of which is necessary to promote health and balance. the oral cavity, the mouth, is surrounded by the lips and cheeks and consists of two parts: the oral cavity proper and the vestibule. the oral cavity proper is limited anteriorly and laterally by the alveolar arches, teeth and gums, and above by the hard and soft palate; posteriorly, it communicates with the pharynx through the oropharyngeal isthmus. it includes the tongue, which is totally contained in the oral cavity in infants. as the child grows, only the anterior two-thirds remain in the oral cavity while the posterior third descends following the larynx. the vestibule is located between the lips and cheeks externally, and the gums and teeth internally. it connects with the outside through the oral fi ssure between the lips. the entire oral cavity is covered by mucosa, starting at the labial margins and consisting of three portions: the lining and the masticatory and specialized mucosae. these portions demonstrate different properties according to their location. the oral mucosa is in continuity with the pharyngeal mucosa at the oropharyngeal isthmus. several bones within the viscerocranium defi ne the oral cavity. the maxillae are the fi rst to come to mind; together with the mandible, they are among the largest of the facial bones. nevertheless, all of the components that constitute the skeletal framework of the oral cavity must be taken into consideration. myofascial structures attached to this framework affect it and are, in turn, affected by it. besides the mandible and maxillae, these bony boundaries include the paired palatine and temporal bones, and unpaired sphenoid and hyoid bones. the maxilla consists of a body with zygomatic, frontal, alveolar and palatine processes. bilaterally their bodies contain the maxillary sinuses, the largest of the paranasal sinuses. although these cavities are large in the adolescent, at birth they are small furrows mm in length and mm in width. consequently, in the infant, the vertical diameter of the maxilla is smaller than the transverse and anteroposterior diameters. the maxillary body is shaped as a pyramid, having four surfaces: anterior, posterior (infratemporal), superior (orbital) and medial (nasal). the lower part of the anterior surface demonstrates multiple eminences above the roots of the teeth. several facial muscles insert on the anterior surface of the maxilla and their traction during orofacial activities such as sucking and chewing contributes to the development of the maxilla. the depressor septi nasi muscle arises above the eminences of the incisor teeth. a slip of the orbicularis oris muscle is attached on the alveolar border below this incisive fossa, and the nasalis muscle is attached superiorly. the levator anguli oris muscle arises from the canine fossa, lateral to the incisive fossa. above the canine fossa is the infraorbital foramen, the anterior end of the infraorbital canal, which transmits the infraorbital vessels and nerve. above the foramen on the margin of the orbit is attached part of the levator labii superioris. the nasal notch medially limits the anterior surface of the maxilla and nearby the nasalis and depressor septi muscles are attached. bilaterally the two nasal notches join to form a pointed process, the anterior nasal spine. laterally, the convex infratemporal surface of the maxilla forms the inferior part of the infratemporal fossa. the maxillary tuberosity forms the lower part of this surface and on its medial side articulates with the pyramidal process of the palatine bone. inconstantly, it articulates with the lateral pterygoid plate of the sphenoid and gives origin to a few fi bers of the medial pterygoid muscle. just above this is the pterygopalatine fossa, with a groove for the maxillary nerve. the maxillary orbital surface forms part of the fl oor of the orbit. medially, behind the lacrimal notch, the margin articulates with the lacrimal bone, the ethmoid's orbital plate and the palatine's orbital process. posteriorly, it constitutes the poste-rior border of the inferior orbital fi ssure. anteriorly it forms part of the orbital margin, which is continuous medially with the frontal process and laterally with the zygomatic process. anteriorly and medially, the inferior oblique muscle originates just lateral to the lacrimal groove. on the nasal surface is the maxillary hiatus, the large opening of the maxillary sinus. the superior border of the maxillary nasal surface articulates with the ethmoid and lacrimal bones. the inferior meatus of the nasal cavity is located below the maxillary hiatus and behind a surface for articulation with the perpendicular plate of the palatine bone. a groove crosses this surface, running obliquely downward and forward, and forms, with the palatine bone, the greater palatine canal. anterior to the maxillary hiatus a deep groove forms part of the nasolacrimal canal. the zygomatic process of the maxilla is triangular and is situated at the convergence of the anterior, posterior and orbital surfaces. the frontal process forms part of the lateral boundary of the nose projecting posterosuperiorly. it gives attachment to part of the orbicularis oculi and levator labii superioris alaeque nasi. its medial surface forms part of the lateral wall of the nasal cavity. the upper border articulates with the frontal bone, the anterior border with the nasal bone and the posterior border with the lacrimal bone. the alveolar process is very thick, being broader behind than it is in front. it contains eight deep cavities for the roots of the teeth. these cavities vary in size and depth: the cavities for the canine teeth are the deepest; the cavities for the molars are the widest. the alveolar processes of the maxillae articulated together form the alveolar arch. the buccinator muscle arises from the lateral surface of the alveolar process, as far forward as the fi rst molar. the palatine process projects horizontally and medially from the nasal surface of the maxilla. it constitutes an important part of the fl oor of the nasal cavity and the roof of the mouth. its inferior surface is concave and forms, with the palatine process of the opposite side, the anterior three-quarters of the osseous plate of the palate. in young skulls, a fi ne linear suture, the incisive suture, may be observed. it extends from the incisive fossa, behind the incisor teeth, to the space between the lateral incisor and canine teeth. the small part in front of this suture forms the premaxilla (os incisivum) that contains the sockets of the incisor teeth. the two palatine processes join to form the median intermaxillary palatal suture. the margins are sometimes raised and form a prominent palatine torus. the medial border of the superior surface of the palatine process forms a ridge, the nasal crest. with the opposite side, it forms a groove for the vomer. the posterior border is articulated with the horizontal plate of the palatine bone (figs . . , . ) . the maxilla ossifi es in a mesenchymatous sheet. the number of ossifi cation centers is debated and between two and four such centers may appear during the th week of fetal life. they form a premaxilla (os incisivum) and a maxilla that start to unite at the beginning of the rd month of development. the identifi cation of the junction between these two parts as a suture is also debated, and information is lacking to demonstrate its role as a growth site. a line or cleft, however, may be observed in the anterior part of the palate until the middle decades of life. this site -be it suture, line or cleft -is of consequence in osteopathic practice because it provides a hinge-like location where intraosseous maxillary somatic dysfunction can develop. such dysfunction is commonly found in infants and children as the result of activities such as thumb sucking and from falls where the area is injured. if not treated, this dysfunction will have a signifi cant impact that can only increase as the structures grow. orofacial dysfunctions such as malocclusion or speech disorders may follow. the maxillary sinus, described as a small furrow at birth, reaches its full size after the second dentition. as such, the size of the maxillary body at birth is small, the teeth sockets located almost at the level of the fl oor of the orbit. the relatively small length of the maxillary vertical dimension, when compared to that of the adult, gives the infant the appearance of having large eyes. augmentation in volume of the maxillary sinus and development of the alveolar processes will contribute to an increase in the vertical dimension of the maxillary body ( fig. . ). the maxilla articulates with nine bones including the frontal, ethmoid, zygomatic, nasal, lacrimal, inferior nasal concha, palatine, vomer and the opposite maxilla. the articulation with the orbital surface or with the lateral pterygoid plate of the sphenoid is inconstant. on the other hand, the mandible articulates only with the two temporal bones. it consists of a curved horizontal body and two perpendicular portions, the rami. it is the largest and strongest bone of the face and contains the alveoli for the roots of the lower teeth. its shape and position determine the positional arrangement of the lower teeth and as such it contributes to the relationship between the occlusal surfaces of the maxillary and mandibular teeth when they are in contact. the mandibular body has two surfaces and two borders. in the midline of the external surface is a small ridge, the remnant of the line of fusion between the two halves of the mandible at the symphysis menti. this ridge divides inferiorly to surround the mental protuberance. the mentalis muscle and a small portion of the orbicularis oris are inserted below the incisor teeth on either side of the ridge. laterally, the depressor labii inferioris, depressor anguli oris and platysma muscles are attached. the internal surface is concave and the paired superior and inferior mental spines are situated on either side of the symphysis menti. the genioglossi muscles have their origins on the superior spines and insert on the lingual fascia beneath the mucous membrane and on the hyoid bone. they depress and protrude the tongue. if their origin on the mandible is dysfunctionally positioned, their leverage will be altered and consequently their effect on the tongue will, in turn, be dysfunctional. the geniohyoid muscles insert on the inferior mental spines, and the anterior belly of the digastric insert below the mental spines, on either side of the midline. on either side, an oblique line, the mylohyoid line, runs from a point inferior to the mental spine upward and backward to the ramus behind the third molar tooth. it gives attachment to the mylohyoid muscle, the lower-most part of the superior constrictor of the pharynx, and the pterygomandibular raphe. the superior constrictor, pterygomandibular raphe and buccinator are intimately joined together to the mandibular periosteum. furthermore, they form a continuous band that unites the orofacial structures with the cranial base and cervical spine (fig. . . ) . thus, postural imbalances in the axial skeleton can affect the orofacial structures, potentially leading to orofacial dysfunction and malocclusion. the upper or alveolar border contains cavities for the roots of the teeth. on either side, the buccinator muscle is attached on the outer lip of the superior border, as far forward as the fi rst molar tooth. the buccinator has its origin posteriorly on the lateral aspect of the maxilla and oblique line of the mandible, the pterygoid hamulus and pterygomandibular raphe (figs . . , . . ). it inserts anteriorly on the angle of the mouth, the middle fi bers of the muscle crossing in the region of the modiolus, the lower set passing to the upper lip, the upper set to the lower lip. the modiolus located near the corner of the mouth represents a convergence of several muscles of facial expression and, as such, observation of this area is highly indicative of the psychoemotional state of the individual. the fi bers of the buccinator muscle are interspersed with more horizontal portions of the orbicularis oris muscle. the buccinator fl attens the cheek, retracts the angle of the mouth and plays an important role in mastication in conjunction with the tongue and orbicularis oris muscle to form a belt on each side of the oral cavity, preventing food from accumulating in the oral vestibule. the quadrilaterally shaped mandibular ramus consists of two surfaces, four borders and two processes. the lateral surface is fl at and gives attachment to the masseter muscle. the masseter muscle is attached above on the inferior border of the anterior two-thirds of the zygomatic arch and the medial surface of the zygomatic arch. it inserts inferiorly on the lateral surface of the ramus and the coronoid process of the mandible. it elevates the mandible and its function is of paramount importance in the development, growth and maturation of the mandibular condyles and fossae. a reduction of masseter muscle activity in bottle-fed babies has been observed and, with the loss of chewing behavior, may predispose to chewing/swallowing disorders and malocclusions. located on the medial surface of the mandibular ramus, approximately in its center, is the mandibular foramen leading to the mandibular canal. it contains the alveolar nerve and vessels. a sharp spine on the anterior margin of the foramen, the lingula (spix spine), provides attachment for the sphenomandibular ligament. this site is of particular interest in mandibular kinematics because mandibular motion is centered on a point located near the lingula. the vascular-neural bundle is, therefore, protected from injury caused by normal mandibular motion. the medial pterygoid muscle inserts below the mandibular foramen, on the medial surface of the mandibular angle. thus, the mandibular angle is affected by the action of the masseter laterally and medial pterygoid medially. traction from these muscles dynamically infl uences the growth of the mandible. this infl uence has to be balanced unilaterally between the masseter and medial pterygoid, as well as bilaterally. the coronoid process is a thin, fl attened piece that forms the anterior limit of the mandibular incisure. the temporalis and masseter muscles are attached on its lateral surface; the temporalis also covers part of the medial surface and anterior border of the ramus. the temporalis muscle has its origin on the temporal fossa and functions to elevate the mandible and close the jaw. its posterior, almost horizontally oriented fi bers are the primary retractors of the protruded mandible. these muscles determine chewing action and, when dysfunctional, can have signifi cant impact on the mandible. the condylar process provides an articular surface with the disk of the temporomandibular joint (tmj). its long axis is slightly oblique and directed medially and posteriorly. the neck that unites the head or condylar process to the ramus has the pterygoid fovea (anteriorly) for the attachment of the lateral pterygoid muscle. this masticatory muscle has two heads: the inferior head has its origin on the lateral plate of the pterygoid process; the superior head originates on the infratemporal crest and adjacent greater wing of the sphenoid. in addition to its insertion on the mandible, some of its fi bers join the articular disk and capsule of the tmj. it acts to protrude the lower jaw and also contributes to the opening of the mouth. unilateral pterygoid contraction deviates the chin laterally, enabling grinding motion for chewing. this muscle is important in the development of children's orofacial structures, where unilateral functional patterns will stimulate growth in an asymmetric fashion. alternatively, structural asymmetries may, in turn, prevent the individual from having symmetric functional patterns. ossifi cation of the mandible occurs in the fi brous membrane covering the outer surfaces of meckel's cartilages. these cartilages develop bilaterally in the fi rst pharyngeal arches. the primitive tmj starts to organize during the th week of development, concomitantly with the emergence of muscular activity in the masticatory apparatus. at birth the mandible consists of two parts separated by a cartilaginous symphysis menti not yet ossifi ed. the body, although rather underdeveloped, is much larger than the rami. it consists of relatively thin cortices with tooth buds almost totally occupying its volume. each side contains the sockets of the two incisors, the canine and the two deciduous molar teeth. the angle between the body and the ramus is obtuse ( °), and the coronoid process, of rather large size, projects above the level of the condyle. at birth, the tmj is slack. the mandibular fossa of the temporal bone in which the condylar process of the mandible is located is almost fl at, providing little stability. during the fi rst years of life growth will occur through bony deposition and resorption. bone deposition occurs on the mandibular labial side, whereas resorption occurs on the lingual side, thus allowing for elongation of the mandible and more space for the deciduous dentition. the two halves of the mandible join during the st year, although a line of separation may still be seen in the beginning of the nd year. concomitant development of mastication stimulates growth of the alveolar and subdental portions of the mandibular body, allowing in turn more powerful traction from the masticatory muscles. during the fi rst years of life, mandibular bicondylar width grows rapidly, in synchrony with cranial base growth. it is the fastest growth period of the mandible. with the development of permanent dentition, the angle becomes less obtuse - ° at about the th year. crown formation of the permanent teeth, and their following eruption, is a time of possible occlusal instability, lasting up to - years of age when the majority of the permanent teeth have erupted. after puberty, the mandibular angle is ° (fig. . . ) . development of the teeth, like the development of the other components of the craniofacial complex -jaws, dental arches, tongue and myofascial structures -is under the infl uence of genetic and environmental factors. this development is largely infl uenced by the surrounding structures of the cranium, particularly the temporal bones with which the mandible articulates, and the sphenoid and hyoid bones that are part of the skeletal framework of the oral cavity. at the root of the zygomatic process, in the squamous portion of the temporal bone, is the mandibular fossa, with which the condylar process of the mandible articulates. this fossa, also called the glenoid cavity, is a deep hollow in the adult but is almost fl at in the infant. a disk separates the mandibular condylar process from the temporal glenoid cavity, and a fi brous capsule and synovial membrane surround the joint. the position of the condylar process of the mandible is greatly infl uenced by the position of the mandibular fossa of the temporal bone. the relationship can be potentially dysfunctional if one or several components of the tmj demonstrate somatic dysfunction. in the cranial concept, during cranial external rotation, the mandibular condyles move somewhat posteromedially, following the mandibular fossae of the temporal bones, and the chin recedes. concomitantly, the mandibular angles move laterally. the opposite occurs during cranial internal rotation when the mandibular fossae of the temporal bones move anteriorly. as a result, the mandible moves anteriorly, with the chin becoming more prominent. the deep cervical fascia and stylomandibular ligament also contribute to the relationship between the temporal bones and mandible. the deep fascia of the neck is divided into an external or investing layer and a pretracheal layer. the former surrounds the neck and encloses the trapezius and sternocleidomastoid muscles. above, it fuses with the periosteum along the superior nuchal line of the occipital bone, on the mastoid and styloid processes of the temporal bone and the complete base of the mandible. the stylomandibular ligament, a condensation of the deep cervical fascia, extends from the tip of the styloid process of the temporal bone to the posterior border of the angle of the mandible. this fascia links the mandible to the base of the skull. thus, dysfunction of the cranial base may affect the mandible, and vice versa. it is of great signifi cance in the fi rst years of life, when structures have not yet completed their growth. as such, torticollis or plagiocephaly, if untreated, may predispose to somatic dysfunction of the mandible and viscerocranium, leading to malocclusion. as it belongs to the cranial base, the sphenoid also infl uences the mandible through its muscular and ligamentous relations. the sphenomandibular ligament is of particular importance. this fi brous band, a remnant of meckel's cartilage, runs from the spine of the sphenoid's greater wing to the lingula of the mandible. it constitutes the primary passive support of the mandible, with the area of the lingula acting as an anchor. an artifi cial axis passing through the two lingulae may be proposed, around which motions of the mandible occur. these motions include depression of the mandible during opening of the mouth and elevation during closure, as well as protraction and retraction. the mandible may be compared to a swing hanging under the sphenoid's greater wings. this comparison is particularly valid in infants and young children, where the tmj is quite loose and the sphenomandibular ligament well defi ned. other links between the mandible and sphenoid include the bilateral pterygomandibular raphe and pterygoid muscles joining the pterygoid process to the mandible. the pterygomandibular raphe, also referred to as the pterygomandibular ligament, is a thickening of the buccopharyngeal fascia. it separates and gives origin to the buccinator muscle anteriorly and the superior constrictor of the pharynx posteriorly. the pterygomandibular raphe is attached superiorly to the pterygoid hamulus, the hookshaped inferior extremity of the medial plate of the pterygoid process. below, it is attached above the mylohyoid line behind the third molar tooth. indeed, multiple infl uences exist between the cranial base and the facial bones, potentially affecting the orofacial structures. the human profi le and the position of the mandible have been correlated postnatally with the basicranial shape. furthermore, facial morphology is more related to variation of the lateral part of the basicranium than to fl exion occurring in the midline. epigenetic factors play a signifi cant role in this process. this role is largely fulfi lled by several orofacial functions that start as early as the fi rst weeks of development. it is hypothesized that, around weeks of development, early mandibular movement participates in the differentiation of the primary mandible from meckel's cartilage. consideration of orofacial function is of great signifi cance in the understanding and treatment of any orofacial disorder or malocclusion. to a large extent, orofacial function, interconnected with the musculoskeletal apparatus in a complex system, contributes to the formation of the oral cavity and viscerocranium. deglutition, sucking, ventilation, facial expression, mastication and speech are the sequential events that, through dynamic processes, constantly infl uence the growth and development of the orofacial components. for most of these activities, the tongue plays a central and vital part. in feeding, it moves food through the oral cavity for chewing and then to the pharynx for swallowing. in respiration, its position, relative to the posterior pharyngeal wall, determines the dimensions and shape of the airway for air to fl ow between the palate and the posterior tongue. with the larynx, the tongue contributes to the production of sounds and speech. finally, the tongue seems to play an important proprioceptive role that, in turn, functionally or dysfunctionally regulates all of these activities. the tongue consists of a mass of muscle covered by mucous membrane, where the papillae of the gustatory organ are located. the lingual musculature is divided into intrinsic and extrinsic muscles. the intrinsic muscles, which are totally contained inside the tongue, are the bilateral superior and inferior longitudinal, the transverse and the vertical lingual muscles. conversely, the extrinsic muscles extend outside the tongue and consist of the genioglossus, hyoglossus, styloglossus and palatoglossus muscles. the lingual musculature matures quite early in life, transforming the tongue into a powerful growth stimulator for the surrounding structures. at birth, the infant tongue is totally intraoral and its extrinsic muscles are short. in the infant, the tongue fi lls the oral cavity, contacting the soft and osseous palates, the cheeks and lower lip. although mobile, the tongue is solidly anchored at its base on the mandible by the paired genioglossi and on the hyoid bone by the genioglossi and hyoglossi muscles. in addition, the lateral surfaces of the tongue are suspended from the soft palate by the palatoglossi and from the styloid processes of the temporal bones by the styloglossi muscles. the fi bers of these muscles blend with the superior portion of the tongue. as in other primates, the larynx of the newborn is positioned high, with the epiglottis in direct contact with the soft palate. during the fi rst years of life, in association with the growth of the cervical spine, the hyoid bone migrates from the level of c -c at birth to c -c after puberty. the posterior third of the tongue follows this caudal migration, consequently stretching its superior attachments. this contributes to change the orientation of the soft palate from horizontal in the infant to more vertical in the adult. although the positional changes occur mainly during the fi rst years of life, the reciprocal infl uences, from the cranial base and hyoid bone acting on the tongue and soft palate, should be kept in mind, no matter the age of the patient. normally, at about or years of age, after the descent of the larynx and tongue, the tongue rests lower in the mouth. at this time it forms part of the fl oor of the oral cavity and part of the anterior wall of the oropharynx. it is contained inside the mandibular arch and the functions of swallowing, sucking, ventilation, facial expression, chewing and phonation should be performed without diffi culty. dysfunction develops when lingual mobility and function are impaired. this may be the result of somatic dysfunction affecting the cranial base, hyoid bone or mandible, or accommodation of these areas to dysfunction in more distant body areas. tongue-tie, or ankyloglossia, is a partial or complete adhesion of the tongue to the fl oor of the mouth. because of abnormal shortness, the frenulum linguae tethers the tongue to the fl oor of the mouth, impairs lingual mobility and, in severe cases, prohibits its extension beyond the lower gum. although it may present as part of several craniofacial syndromes, in most cases the child is perfectly healthy. ankyloglossia is, however, associated with up to . % of serious breastfeeding problems. it is also a potential etiology for speech disorders and dental problems, such as diastasis between the lower incisors due to the lingual pressure. furthermore, impaired lingual mobility is related to diffi culty with intraoral toileting and later with the playing of wind instruments. although surgical treatment (frenuloplasty or tongue-tie division) remains debated, in specifi c indications it is reported to improve diffi cult breastfeeding and to protect the maternal nipple, and to alleviate speech disorders and improve tongue mobility. swallowing, or deglutition, is one of the fi rst orofacial functions to appear in utero and has been observed after weeks, when the child refl exively swallows amniotic fl uid. at birth, new habits develop with feeding, allowing the evolution of the pattern of deglutition. in the infant, sucking and swallowing are the results of a pumping action in the hyolingual complex, with a rhythmic tongue thrust, the tip of the tongue showing regularly between the alveolar processes. musculoskeletal growth and maturation of the neuromuscular system result in the development of a more mature or adult swallowing pattern. at around - years of age, at rest and during swallowing, the apex of the tongue is normally located on the palate, behind the upper incisor teeth. when swallowing, the lips are closed, but the perioral musculature, particularly the orbicularis oris and mentalis muscles, is relaxed. lingual pressure applied against the palate contributes to the development of a broad palate and well-developed maxillae. the tongue works as a natural orthodontic appliance 'for better or for worse'. in the cheeks, the muscular bands formed by the buccinator and superior constrictor muscles, joined together through the pterygomandibular raphe, bilaterally act to constrain the tongue within the oral cavity. thus, functional balance or dysfunction of the cervical spine and cranial base, the sites of origin of the superior constrictor, contributes significantly to lingual posture. in addition, because the tongue is anchored on the mandible, it affects and is affected by mandibular position and growth. when mature or adult swallowing does not develop successfully, immature or atypical swallowing will continue. chewing forces also contribute to maxillofacial growth. first, mastication occurs purely in the sagittal plane, with the mandible moving up and down, and demonstrating propulsion and retraction. then, progressively, an alternating unilateral chewing pattern appears, with diagonal movements of the mandible. the masticatory muscles develop in response to this demand. at around months of age, a child can chew soft food and keep it in their mouth; year later they can chew more solid foods. as such, their diet should include food that requires suffi cient chewing to allow satisfactory occlusal force per chew that can, in turn, stimulate periosteal growth. symmetric chewing is a requisite for adequate muscular stimulation of the digastric, temporal and pterygoid muscles. the traction of these muscles will, in turn, stimulate bone growth. at this time cranial balance is necessary to facilitate the establishment of symmetric masticatory patterns that are learned and practiced throughout the rest of life, making early identifi cation and treatment of somatic dysfunction essential. besides swallowing and chewing, ventilation, speech and facial expression also contribute to the development and growth of the maxillofacial structures. ventilation, as a vital function, is present from birth onwards. in the fi rst months, the infant is normally a nasal breather. at this time, observed respiration should be unencumbered. it is imperative that airfl ow be quiet and through both nares equally. dysfunctional nasal respiration will impact the development of the orofacial structures, potentially leading to mouth breathing. establishment of the route of respiration is partly under the control of the soft palate. this muscular fold, suspended from the posterior border of the bony palate, extends inferiorly and posteriorly into the oropharynx. under normal circumstances the soft palate and tongue act in apposition to close the oropharyngeal isthmus; conversely, when the soft palate rises and contacts the posterior pharyngeal wall, the nasopharynx is closed. thus, the position of the soft palate determines the route of respiration and regulation of airfl ow through the nose or mouth. the soft palate is united with the tongue through the palatoglossi muscles and with the pharynx through the palatopharyngei muscles. for optimal function of all of the structures that contribute to upper airway respiration, somatic dysfunction affecting the sites of origin of these muscles should be identifi ed and treated. for optimal breathing, the cranial base, hyoid bone and mandible should be balanced. it is well established that an inferoposterior displacement of the hyoid bone and an anteroinferior positioning of the tongue are correlated with mouth breathing. [ ] [ ] [ ] normally, the tongue demonstrates large movements in all three planes of space. in the production of sounds and speech, the tongue must change shape and the dorsum of the tongue must contact the palate. shortening of the base of the tongue results from anterior displacement of the hyoid bone, whereas lengthening of the base of the tongue results from its posterior displacement. by employing the activity of the lingual muscles, speech contributes to the overall function and development of the orofacial cavity. although the hyoid bone has no direct articulation with other skeletal structures, it is an interface between the mandible and tongue above and the upper thoracic area below. consequently, its position and motion are infl uenced by changes occurring at the level of the mandible or anywhere in the thorax. a hyolingual complex -a 'kinetic chain' -may be described, part of a more global oropharyngeal complex where every structure is interdependent with others as part of the system. begin by noting the relationship between the head and the remainder of the body. the skull should be centered above the spine. note any tension in the posterior, lateral and anterior (submandibular) cervical musculature. divide the viscerocranium into three regions: frontal, nasal and buccal. observe the relationship between these three regions and the relative harmony between them. in newborns, the lower two regions are proportionately smaller than in older children, adolescents and adults because the paranasal sinuses are not yet developed and the teeth have not erupted. observe facial expression and orofacial functions such as breathing, sucking (in infants) and swallowing. look for coordination of the tongue and orofacial musculature, the rate of sucking if the patient is a baby, and possible tongue sucking or tongue thrusting. note the ease of swallowing without any concomitant inappropriate muscular contraction if the patient is a child. if they are old enough to respond, ask them to describe the location of the tip of their tongue during swallowing; normally it should contact the hard palate behind the upper incisors. observe the resting respiration. nasal patency of airfl ow can be assessed easily with a wisp of cotton held adjacent to each nasal aperture or look for fogging with exhalation on the convex side of a cold metal spoon or a cold mirror. observe the midline of the face, the metopic suture, nose and symphysis menti. all of these landmarks should be aligned in a straight line observe the maxillae and compare size and shape: in external rotation the maxilla appears wider; in internal rotation it appears narrower. observe the position of the mandible. note its relationship with the maxillae, particularly its centric position. observe the location of the gnathion; newborns are normally retrognathic. with the infant, an open mouth posture with tongue forward may be observed with dysfunction of the cranial base, mandible or hyoid bone. with children, observe the mouth area and the lips for symmetry and tonicity. the upper lip refl ects the functional pattern of the maxillae, whereas the lower lip refl ects the mandible. look for the capacity to keep the lips closed and in soft contact. there should be no tension, in particular in the orbicularis oris or mentalis muscle, and no protrusion, retraction or pursing of the lips. note any abnormal perioral muscle function or nervous habits such as fi nger and nail picking or nail biting. compare the nasolabial sulci for depth and obliquity. increased sulcus depth is associated with external rotation of the ipsilateral maxilla and/or the zygoma, whereas decreased depth is associated with internal rotation of these bones. look inside the mouth. assess the position and function of the tongue. note the presence of a large frenulum linguae. if the child is old enough to voluntarily open the mouth, look at the relative position of the tongue within the oral cavity. it should be inside the mandibular arch and should not cover the lower teeth. again, if possible, have the child slightly protract their tongue to look for the presence of dental imprints on the lateral aspects of the tongue, unilateral or bilateral, indicating lingual malposition and/or dental malalignment. with the tongue protracted, look for tongue deviation. assess the mobility of the tongue, looking for limitation of movement. dysfunctional tongue posture is often accompanied by decreased tone and eversion of the lower lip. observe the teeth as to position, dental attrition and progression of dental development according to the child's age. observe clenching of the teeth and observe the occlusion of the teeth. the upper and lower midline between the incisors should be in alignment. normally, the upper incisors should slightly override the lower incisors and upper molars should rest on the lower molars. note misalignment or protrusion of the upper or lower incisors. note any crowding of the teeth. if asymmetric crowding is present, look to see if there is ipsilateral cranial internal rotation. note the potential association with impaired ipsilateral nasal breathing and/or dysfunctional mastication. observe the shape and symmetry of the palate: a lower, fl attened palate with everted teeth is associated with external rotation; a high arched palate with inwardly directed teeth is associated with internal rotation. observe the mandible. it should appear balanced under the cheeks. if not, differentiate between asymmetry of position and asymmetry of size and shape. asymmetry of mandibular position is associated with asymmetry of the temporal bones: external rotation of the temporal bone results in posterior displacement of the mandibular fossa; internal rotation results in anterior fossa displacement. the chin will be displaced toward the side of temporal external rotation. if asymmetry of mandibular size and shape is noted, look for a potential cause. structural asym-metry may result from intraosseous mandibular dysfunction, dental malalignment or asymmetric orofacial function, such as mastication occurring only on one side. note the consistency between orofacial fi ndings and the cranial pattern. if they are in concordance, a cranial osteopathic approach may be indicated. palpation for function and treatment of identifi ed dysfunction should follow. when treating orofacial problems, don't forget to check and treat somatic dysfunction of other areas, frequently the cranial base, craniocervical junction and upper thoracic area. cranial procedures directed at release of the global membranous strain pattern, the sbs, vault and facial bones to ensure optimal freedom of movement are anecdotally associated with facilitation of the teething process. it is also important to remember that all tooth buds are present in the maxillae and mandible, even though not yet erupted. any fi nger or object placed inside the mouth of a child can act as an orthodontic device and move the teeth. therefore, it is inappropriate to employ force when examining the patient or using osteopathic manipulation to treat children's orofacial somatic dysfunction. the earlier osteopathic treatment of orofacial dysfunction is initiated, the better. results may be enhanced when osteopathic treatment is employed in conjunction with appropriate orthodontic treatment. dental development begins in the rd month of intrauterine life and ends at approximately years of age. throughout this period profound occlusal events occur, resulting in potential sources of stress for the orofacial structures. to understand the evolution of the occlusal mechanism, it is important to begin with the infant and to follow the eruption and arrangement of the teeth along the dental arches. during the fi rst months, the absence of teeth allows total freedom in the displacement of the mandible and the child can experiment and discover objects surrounding them by bringing everything to their mouth. the lower central incisors are normally the fi rst to appear between and months of age. when the upper central incisors emerge, the fi rst occlusal relationship appears, associated with new constraint for mandibular mobility. the upper and lower lateral incisors are almost completely erupted at around months, the time when the fi rst molars appear. just before the end of the nd year of life, the central and lateral incisors and the fi rst molars are in occlusion, the canines have erupted and the second molars are beginning to emerge. in the nd year of life, the deciduous teeth are present, with occlusion between the incisors, canines and fi rst molars. at the same time, the child's orofacial functions have matured and their food is becoming more solid. mouthing (active oral interaction with the environment by sucking different objects) is still quite frequent up to years of age. several explanations -from a means of exploring their environment to proactively exposing the naive gi tract to environmental antigens -have been offered for this behavior. whatever the reason, mouthing effectively contributes to dental attrition, thereby eliminating any dysfunctional occlusal contact and facilitating functional adaptation. smoothing of the occlusal surfaces results in proprioception important in establishing functional balance of mandibular motion patterns. conversely, any dysfunctional occlusal contact will result in dysfunctional mandibular motion patterns and stimulate abnormal mandibular and maxillary growth. it will also prevent the establishment of alternating unilateral mastication. the teeth develop in sockets in the alveolar parts of the maxillae and mandible. they are each held in their respective socket by a periodontal ligament. this anchors the teeth solidly while still allowing micromovements. it is also the site for periodontal innervation that is of paramount importance in the development and control of orofacial praxis. proprioceptive input from the periodontal ligament in association with proprioception from the tmj and surrounding myofascial structures provides constant information to the cns. this allows the individual to adjust to the challenges of mastication as well as to global postural mechanics. deciduous teeth are small, with thin enamel coverage, allowing rapid wearing out. on the other hand, permanent teeth are the hardest of all tissues in the body. each consists of a crown and a root, meeting at the cervical margin. dentine forms most of the tooth, with a central pulp cavity ending in a pulp chamber and canal. the side of the tooth in contact with the lips and cheeks is the labial or buccal surface while the side in contact with the tongue is the lingual or palatal surface. when the jaws are brought together the teeth meet, or occlude; thus, dental occlusion occurs. occlusion is qualifi ed according to the respective positions of the teeth. a centric occlusion takes place when the relation of opposing occlusal surfaces of mandibular and maxillary teeth provides the maximum contact, or inter-cuspation. in such circumstances, the mandible is in centric relation to the maxillae. infants usually demonstrate a retrusive mandibular position. when the fi rst teeth erupt, the relationship will tend to show a horizontal protrusion, or overjet, of upper incisors beyond the lower incisors. however, at this early age tongue thrusting will result in a functional edge-to-edge repositioning of the teeth. in the fi rst years of life, during eruption of the deciduous teeth, changes in the orofacial osseous and myofascial structures normally allow suffi cient space for the teeth to emerge. typically, by approximately years of age, there is occlusion between all deciduous teeth that already gives a good idea of the occlusal pattern of the future permanent teeth. the overjet and overbite relationship should have resolved in order to allow for freedom of mandibular diduction, which is only possible if the mandible can slide forward slightly. this sequence occurs as the result of an alternating chewing pattern, enhanced by chewing the solid foods found in the correct type of diet. it is important for the osteopathic practitioner to observe the oral cavity and teeth in order to identify their eruptive pattern, position, occlusal contacts and any asymmetric wear that may be associated with cranial somatic dysfunction. in addition, any asymmetry of function that predisposes the child to mouth and then chew using only one side, as might occur with a neurologic impairment, a child with one handicapped upper extremity or simply a child with a torticollis, will result in asymmetric wear of the occlusive surfaces of the teeth and eventually asymmetric mandibular growth. the permanent incisors are signifi cantly wider than the deciduous incisors that they have replaced by approximately years of age. there might be a tendency for overjet or overbite, either positive or negative. while a horizontal protrusion of upper incisors beyond the lower ones is named overjet, a vertical overlap is named overbite (fig. . . ). at this age, the child's temporary canines, the two temporary molars and the fi rst permanent molars are in occlusion. around years of age, occlusion exists between the permanent incisors, the temporary canines and the fi rst permanent molars. at years of age, occlusion is typically present between the permanent incisors, permanent canines and fi rst permanent molars. in mixed dentition, if the child has developed an asymmetric pattern of chewing, with a tendency to chew only on one side, they may wear out the teeth in a way that will not allow functional and symmetric development. unsatisfactory occlusal contact will create points of resistance that will, in turn, control and guide the movement of the mandible in asymmetric patterns. the masticatory, perioral and craniocervical muscles, as well as the highly elaborate tmj structures, result in engrams of the repetitive dysfunctional pattern. if no change occurs, this will be the permanent pattern ingrained in the cns. thus, it is important to recognize asymmetric patterns and to identify and treat any underlying somatic dysfunction. because patterns of function become fi xed as the child ages, for the best therapeutic outcomes the cranial osteopathic approach should be employed at the earliest opportunity. at the end of the th century, edward angle proposed that a defi nitive nomenclature was necessary in orthodontia as in anatomy. he felt that the term malocclusion was far more expressive than 'irregularities of the teeth' to describe not only the relationship between the maxillary and mandibular arches, but also of the individual teeth to one another. as a result, a classifi cation was born, referred to as angle's classifi cation. angle's classifi cation is based on the mesiodistal relationship of the permanent molars. in dentistry, distal means away from the median sagittal plane of the face, following the curvature of the dental arch, while mesial means proximal. three classes of dental arrangement are described. class i identifi es the normal relationship of the jaws, where the mesiobuccal cusp of the maxillary fi rst molar occludes in the buccal groove of the mandibular fi rst molar. in the individual with normal dentition and centric occlusion, the lower incisors bite against the lingual surfaces of the upper incisors, the crowns of the lower incisors being covered in their superior third. in addition, from the canine teeth backwards, each lower tooth is slightly in front of its upper fellow. classes ii and iii categorize variations of malocclusion. in class ii, all the lower teeth occlude distal to normal, wherein the distobuccal cusp of the maxillary fi rst molar occludes in the buccal groove of the mandibular fi rst molar. in addition, this class is further subdivided into division , labioversion of maxillary incisor teeth, and division , linguoversion of maxillary central incisors. this may occur unilaterally of bilaterally. class ii is the most frequently encountered type of malocclusion. in class iii, all the lower teeth occlude mesial to normal, wherein the mesiobuccal cusp of the maxillary fi rst molar occludes in the embrasure between the mandibular fi rst and second permanent molars. class iii may further be classifi ed as a unilateral condition. the origin of malocclusion is highly debated, again with multifactorial origins proposed. besides the genetic aspect of malocclusion, in particular for class iii, malocclusal patterns are felt to result from an imbalance between intrinsic forces such as from the tongue and lips and extrinsic forces such as stressful orofacial habits. a large number of studies have considered the infl uence of epigenetic factors such as the orofacial functions of deglutition, sucking, ventilation, mastication and phonation (see below). in fact, it is more the orofacial dysfunctions and parafunctions or orofacial habits that are the source of malocclusion. edward angle said: 'orthodontic treatments are very unlikely to succeed, if the functional disorders are still going on.' class ii malocclusion represents a heterogeneous collection of conditions with malocclusion that may be the result of purely skeletal or combined skeletal and dental origin; they are, however, more often purely dental in nature. the teeth and alveolar bone constitute an interface between opposing forces and pressures, primarily from muscular function -the perioral musculature of the lips and cheeks on the one hand and intraoral forces from the tongue on the other. pressures are applied to the teeth with varying distribution according to the oral function involved. under appropriate circumstances these pressures should affect the teeth from multiple, yet balanced, directions. when dysfunction results in chronically repeated patterns of activity, limiting the directions that these muscular pressures are applied to the teeth, dental malocclusion can be the result. the development of class ii malocclusion has also been correlated with non-nutritive sucking habits such as thumb sucking. [ ] [ ] [ ] [ ] [ ] in the early years of life the premaxillae may be easily pushed forward by non-nutritive sucking, pushing the upper incisors along with them. thumb sucking creates an anterior opening between the dental arches, which facilitates the forward displacement of the tongue that occurs during tongue thrusting. it consequently results in dysfunctional forward placement of the tongue. this will, in turn, promote maxillary prognathism because, with every deglutition, which occurs approximately times per day, the tip of the tongue will move forward between the teeth, applying pressure to the premaxillae and upper incisors, pushing them forward. for similar reasons, the sucking of a pacifi er is also commonly associated with malocclusion, followed by the practice of sucking fi ngers. prolonged pacifi er habits result in changes to the dental arches with a prevalence of posterior cross-bite and increased amount of overjet. until the age of - years the risk of developing a dysfunctional occlusion may be reduced proportionally to the reduction of time that the child uses the pacifi er, and under these circumstances the dental arches should be regularly evaluated. signifi cant maxillary prognathism has also been correlated with persistent digit sucking habits. , among other sucking habits, a trend toward association of bottle feeding with the need for orthodontic treatment has been found. on the other hand, breastfeeding seems to have a positive effect on orofacial morphogenesis, , with a protective effect for the development of posterior crossbite in deciduous dentition. not only the mode of feeding but also the type of food is associated with malocclusion. there are suggestions that changes in diet and food processing are associated with variations in facial size and shape. the prevalence of occlusal disorders in subjects born in the s has been found to be lower than in individuals born in the s. it is thought that this is probably because of dietary habits resulting from the increased consumption of processed foods. at the same time, there is an increased prevalence of allergies that result in mouth breathing. there is a % incidence of mouth breathers in individuals born in the s and % in those born in the s. when mouth breathing is associated with nasal obstruction, it results in an inferior position of the mandible. in addition, the tongue is maintained lower in the oral cavity (fig. . . ). this posture is associated with compensations in the perioral musculature, such as hypotonicity, as well as compensations at the level of the vertebral spine. mouth breathers tend to assume an extended or forward head posture. respiratory dysfunctions are also associated with malocclusion. premature molar eruption is often present in chronic mouth breathers. mandibular growth is affected, with resulting anterior mandibular rotation and an increase of the mandibular angle. thus, the vertical dimension of the lower face is increased, with resultant open bite. the term 'adenoidal facies' (long faces) describes infants with an open mouth, a short upper lip and prominent and crowded anterior teeth. lip hypotonicity -decreased tonicity of the orbicularis oris muscle -is typically found in patients with class ii, division malocclusion. in this presentation, hypotonicity of the orbicularis oris muscle is balanced by compensatory contraction in the mentalis muscles. it is this aspect that can be observed in patients with 'adenoidal facies' syndrome. in addition, the maxillae are narrow and the palate high arched with concomittant increase in the mandibular angle; thus the face appears longer. these individuals also demonstrate a lack of development of the masseter muscles as well as of the maxillary bones. alternatively, hypertonic and bulbous masseter muscles with reduced facial height are correlated with a tendency to clench the teeth. these fi ndings are commonly identifi ed in association with cranial somatic dysfunction involving the temporal bones and/or tmjs. the cranial concept lends itself well to the understanding of functional orofacial disorders. children who have dysfunctional extension of the sbs will present with a long narrow head. the resultant internal rotation of the maxillae is associated with a palate that is narrow and high arched. this orofacial cranial pattern fails to provide suffi cient space for the teeth in the dental arches, predisposing the child to dental crowding. in young children, class ii malocclusion may be found in association with an intraosseous dysfunction between the premaxilla and the maxilla. the premaxilla can be pushed forward or backward as the result of stress patterns occurring during intrauterine life or at the time of delivery. postpartum behaviors, such as thumb sucking, can also push the premaxilla forward, while a fall forward striking the face, particularly the upper incisors, will push the premaxilla in a posterior direction. cranial maxillary dysfunction can be the beginning of a sequence of events that act to reinforce each other. maxillary dysfunction can reduce nasal patency and predispose to mouth breathing. it can affect the dental arch with potential consequences for occlusion. maxillary dysfunction can also trigger a compensatory pattern in the position and development of the mandible. the mandible itself may demonstrate several types of dysfunction. similar to maxillary dysfunction, mandibular dysfunction may result from strains or traumas. it can also occur as accommodation to internal or external rotation dysfunction of the temporal bones. temporal bone dysfunction may be unilateral or bilateral, with the mandible moving anteriorly on the side of temporal internal rotation or posteriorly on the side of temporal external rotation. the resultant mandibular displacement will, in turn, affect occlusion. in fact, any facial strain or trauma may impact the symmetry of the occlusal pattern. the area of the nasion -the junction between the frontonasal and internasal sutures -as well as the frontomaxillary sutures, may suffer compression from intrauterine pressures or as the result of a diffi cult delivery. the nasal bones should be attentively evaluated. with the maxillae, they are suspended from the frontal bone and as such will demonstrate restriction of movement following any trauma of the frontal bone. furthermore, an impact on the frontal bone may result in a decrease in the vertical height of the maxillae with potential intraosseous dysfunction and resultant compromise of nasal respiration. discrepancy in size between the maxilla and mandible may result from insuffi cient growth of these structures, potentially producing overjet or overbite. positioning of the child during the fi rst months of life infl uences the growth pattern of the cranial bones. non-synostotic plagiocephaly is associated with chronic sleep position and is most often visible in the fi rst months of life. it has also been 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posture of the head, the hyoid bone, and the tongue in children with and without enlarged tonsils upper airway obstruction and craniofacial morphology anatomical basis of sleep-related breathing abnormalities in children with nasal obstruction ankyloglossia: does it matter? la langue, appareil naturel d'orthopédie dentofaciale 'pour le meilleur et pour le pire the serial organization of sucking in the young infant antenatal olfactory learning infl uences infant feeding ultrasound demonstration of tongue motions during suckle feeding ultrasonographic analysis of sucking behavior of newborn infants: the driving force of sucking pressure neonatal sucking behaviour and its development until months relationship between respiratory control and feeding in the developing infant reduction of masseter muscle activity in bottle-fed babies infl uence of breast feeding on facial development approche fonctionnelle de l'allaitement et malocclusions morphogenèse temporo-mandibulaire structure fonctionnelle du condyle mandibulaire humain en croissance does breast-feeding protect against malocclusion? an analysis of the child health supplement to the national health interview survey breast feeding, bottle feeding, and non-nutritive sucking; effects on occlusion in deciduous dentition exclusive breastfeeding protects against bacterial colonization and day care exposure to otitis media promotion of breastfeeding intervention trial (probit): a randomized trial in the republic of belarus the 'microfl ora hypothesis' of allergic diseases breastfeeding reduces pain in neonates feeding behaviors and other motor development in healthy children ( - months) developmental change in a basicranial line and its relationship to the upper respiratory system in living primates postnatal descent of the epiglottis in man. a preliminary report oral habits -studies in form, function, and therapy middle ear effusion: an orthodontic perspective a pacifi er increases the risk of recurrent acute otitis media in children in day care centers palpatory diagnosis of plagiocephaly prevalence of symptoms of gastroesophageal refl ux during infancy. a pediatric practice-based survey. pediatric practice research group natural history and familial relationships of infant spilling to years of age ethnicity and gender related differences in extended intraesophageal ph monitoring parameters in infants: a retrospective study gastroesophageal refl ux disease: review of presenting symptoms, evaluation, management, and outcome in infants embryonic origins of the relation of gastroesophageal refl ux disease and airway disease transient lower esophageal sphincter relaxation overview of the mechanisms of gastroesophageal refl ux gastric emptying: a contributory factor in gastro-oesophageal refl ux activity? the natural course of infantile refl ux regurgitation: a non-western perspective gastroesophageal refl ux in childhood an overview of refl ux-associated disorders in infants: apnea, laryngospasm, and aspiration gastroesophageal refl ux disease and asthma: a longitudinal study in uk general practice consultation with the specialist: diagnosis and management of the newborn and young infant who have nasal obstruction humans are born too soon: impact on pediatric otolaryngology dental erosion in children: a literature review osteopathic family practice: an application of the primary care model eléments cliniques du diagnostic de coliques du nourrisson. enquête chez nourrissons âgés de à jours systematic review of the occurrence of infantile colic in the community paediatric study group on gastrointestinal symptoms in infancy. gastrointestinal symptoms in infancy: a population-based prospective study the ontogeny of the small intestinal epithelium crying in infancy paroxysmal fussing in infancy, sometimes called colic excessive infant crying: the impact of varying defi nitions what is distinct about infants' 'colic' cries? intestinal microfl ora in early infancy: composition and development the intestine and its microfl ora are partners for the protection of the host: report on the danone symposium "the intelligent intestine importance of intestinal colonisation in the maturation of humoral immunity in early infancy: a prospective follow up study of healthy infants aged - months factors infl uencing the composition of the intestinal microbiota in early infancy infant colic: empirical evidence of the absence of an association with source of early infant nutrition intestinal microfl ora in breastfed colicky and non-colicky infants effectiveness of treatments for infantile colic: systematic review infantile colic and small intestinal function: a nutritional problem? relation between infantile colic and asthma/atopy: a prospective study in an unselected population extent of fussing and colic type crying preceding atopic disease improvement of symptoms in infant colic following reduction of lactose load with lactase cow's milk as a cause of infantile colic in breast-fed infants maternal intake of cruciferous vegetables and other foods and colic symptoms in exclusively breast-fed infants neurohumoral control of gastrointestinal motility principles of applied neurogastroenterology: physiology/motility-sensation changing our understanding of infant colic individual differences in responsivity to a neurobehavioural examination predict crying patterns of -week-old infants at home role of the brain and sensory pathways in gastrointestinal sensory disorders in humans a preliminary assessment of the impact of cranial osteopathy for the relief of infantile colic understanding and controlling the enteric nervous system central nervous system involvement in functional gastrointestinal disorders mothers' reports of infant crying and soothing in a multicultural population crying, feeding and sleeping patterns in to -month-old infants emotion regulation and touch in infants: the role of cholecystokinin and opioids the role of corticotropin-releasing factor-norepinephrine systems in mediating the effects of early experience on the development of behavioral and endocrine responses to stress attachment and the regulation of the right brain infantile colic: maternal smoking as potential risk factor colic and crying syndromes in infants persistent infant crying and hyperactivity problems in middle childhood clinical conditions the clinical signifi cance of disaccharide maldigestion the primary respiratory mechanism childhood functional gastrointestinal disorders times of fi rst void and fi rst stool in newborns gastrointestinal motility in neonatal and pediatric practice painful defecation and fecal soiling in children constipation and toileting issues in children colonic transit times and behaviour profi les in children with defecation disorders during toilet training, constipation occurs before stool toileting refusal intolerance of cow's milk and chronic constipation in children review article. chronic constipation and food hypersensitivity -an intriguing relationship functional constipation in children gray's anatomy, th edn pediatric skull base surgery. . embryology and developmental anatomy incisive suture (fi ssure) in the human fetus: radiographic and histologic study prémaxillaire et croissance faciale ans après the anatomy of buccinator -insights from functional casts of the oral vestibule reduction of masseter muscle activity in bottle-fed babies approche fonctionnelle de l'allaitement et malocclusions acquisition et exercice de la fonction masticatrice chez l'enfant et l'adolescent the pediatric mandible: i. a primer on growth and development a propos de l'articulation temporo-mandibulaire du nouveau-né. les relations oto-méniscales remodeling reversals in anterior parts of the human mandible and maxilla skeletal and functional craniofacial adaptations in plagiocephaly post-natal growth of the human skull base facial heights: evolutionary relevance of postnatal ontogeny for facial orientation and skull morphology in humans and chimpanzees prenatal development of the human mandible developmental change in the upper respiratory system of human infants développement de l'oropharynx: évolution de la paroi ventrale du pharynx developmental change in a basicranial line and its relationship to the upper respiratory system in living primates orodigitofacial syndromes type i and ii: clinical and surgical studies ankyloglossia: assessment, incidence, and effect of frenuloplasty on the breastfeeding dyad the effect of ankyloglossia on speech in children tongue-tie ankyloglossia: does it matter? tongue tie division in infants with breast feeding diffi culties ankyloglossia: the adolescent and adult perspective la langue, appareil naturel d'orthopédie dentofaciale 'pour le meilleur et pour le pire feeding behaviors and other motor development in healthy children ( - months) posture of the head, the hyoid bone, and the tongue in children with and without enlarged tonsils upper airway obstruction and craniofacial morphology anatomical basis of sleep-related breathing abnormalities in children with nasal obstruction the part played by the tongue in mastication and deglutition tongue movements in feeding and speech infant mouthing behavior: the immunocalibration hypothesis deciduous dentition and the establishment of functional occlusal patterns the effect of occlusal alteration and masticatory imbalance on the cervical spine classifi cation of malocclusion morphologic determinants in the etiology of class iii malocclusions: a review angle's system, th edn. philadelphia: s.s. white dental manufacturing company skeletal maturation and cephalofacial development muscular forces exerted on the normal deciduous dentition tongue thrust classifi cation oral habits -studies in form, function, and therapy cephalometric characteristics of class ii division and class ii division malocclusions: a comparative study in children effects of oral habits' duration on dental characteristics in the primary dentition breast feeding, bottle feeding, and non-nutritive sucking; effects on occlusion in deciduous dentition relação entre hábitos bucais e má oclusão em pré-escolares duration of nutritive and nonnutritive sucking behaviors and their effects on the dental arches in the primary dentition sucking, chewing, and feeding habits and the development of crossbite: a longitudinal study of girls from birth to years of age a cephalometric evaluation of patients presenting with persistent digit sucking habits bottle-feeding and malocclusion: is there an association? does breast-feeding protect against malocclusion? an analysis of the child health supplement to the national health interview survey early weaning: implications to oral motor development effects of food processing on masticatory strain and craniofacial growth in a retrognathic face tooth wear in the mixed dentition: a comparative study between children born in the s and the s effects of upper lip closing force on craniofacial structures the nose and sleep-disordered breathing: what we know and what we do not know middle ear effusion: an orthodontic perspective observations on a recent increase in plagiocephaly without synostosis skull morphology affected by different sleep positions in infancy cranio-facial surgery: international society for craniomaxillofacial surgery importance of early recognition and treatment of deformational plagiocephaly with orthotic cranioplasty diagnosis and management of positional head deformity artifi cial deformation and cranio-facial asymmetry in ancient peruvians head posture and craniofacial morphology growth changes in head posture related to craniofacial development the application of cephalometrics to cinefl uorography: comparative analysis of hyoid movement patterns during deglutition in class i and class ii orthodontic patients commonly observable by the non-trained examiner before several years of age. facial asymmetries are, however, frequently associated with plagiocephalies. [ ] [ ] [ ] with asymmetric occipital deformation, compensatory changes may occur in the maxillae, with resultant mandibular asymmetry. the relationship between the neurocranium, cranial base and viscerocranium has been studied extensively. an increase in anterior facial height is observed in subjects maintaining a forward-bent head position; a decrease is associated with a backward-bent head posture. , changes in the position of the hyoid bone are observed in class ii malocclusion where the hyoid bone is higher and more forward relative to the mandible. the posture of the cervical spine changes in response to changes in the occlusal plane as well as to imbalance between right and left masticatory muscles. modifi cations of the cranial base are linked to class iii malocclusion where a decrease in the angle between the clivus (surface from the dorsum sellae of the body of the sphenoid to the foramen magnum) and the cribriform plate of the ethmoid has been observed. the child's occlusal pattern should be assessed. if abnormal occlusion or malocclusion is identifi ed, the somatic dysfunction that may be responsible should be sought out and treated. the etiology of malocclusion is multifactorial and osteopathic procedures may be employed when cranial somatic dysfunction contributing to the establishment of the malocclusive pattern is present. to be effective, these procedures should be employed at the earliest possible age. cranial manipulation is in no way intended to be a replacement for standard orthodontic treatment. however, orthodontic treatments are less likely to be fully successful if somatic dysfunction affecting the child's occlusal pattern persists.when examining the child with malocclusion, the principles of examination discussed above in 'oral cavity and orofacial functions' apply. in addition, when looking for contributory somatic dysfunction, the practitioner should pay attention to the standing postural mechanics and their impact, particularly on the upper thoracic and occipitoatlantal areas. even in cases where orthodontic treatment has been initiated, the child's posture should be addressed. the identifi cation and treatment of dysfunctional postural mechanics resulting in functional balance of the orofacial complex will accelerate the effect of the orthodontic treatment. furthermore, orthodontic treatment in itself serves as a source of stress, affecting the overall mechanics of the body. thus, the release of existing dysfunctional mechanics will provide comfort to the child, making the orthodontic process more tolerable, as well as facilitating the effect of the orthodontic procedure.with the child seated, it is appropriate to observe the occlusal pattern. have the child actively open their mouth while observing for displacement of the symphysis menti. this motion normally should follow a straight vertical path, without a distorted pattern. next, have the child move their mandible laterally to the right and left sides to compare ease of movement and degree of displacement bilaterally. if appropriate, give the child some chewing gum to observe the presence or absence of an alternating masticatory pattern. observe and note the presence of a dominant side to the masticatory pattern. check the presence of immature swallowing by observing and asking the child to describe the location of the tip of their tongue within their mouth during swallowing. assess the musculature of the lips and cheeks by placing your thumbs inside the child's mouth, such that their palmar surfaces are in contact with the inside of the cheeks. ask the child to close their mouth and swallow, and with your thumbs appreciate the strength of contraction of the buccinator muscles. next, with the child lying supine, palpate the clavicles, sternum and hyoid bone, assessing their myofascial attachments. go on to assess the myofascial structures of the upper thoracic and cervical spine for somatic dysfunction, noting the relationship between the occiput and atlas. palpate the myofascial structures of the skull, paying attention to the orofacial muscles and tmj area for dysfunctional asymmetric tension. check the tmjs and proceed with tests of listening. evaluate the cranial base, looking for patterns of predominant cranial fl exion or extension, as well as torsion, sidebending-rotation, compression and strain patterns. by placing one hand on the frontal bone with the index and middle fi ngers controlling the greater wings of the sphenoid and the other hand cradling the mandible, note the balance between the mandible and greater wings of the sphenoid. listen to the different bones of the skull that may be involved in the malocclusion, paying particular attention to the temporal bones, sphenoid, frontal bones and maxillae, looking for intra-and interosseous cranial somatic dysfunctions. treat all identifi ed somatic dysfunction using indirect principles. intraosseous molding may be considered if the child is young enough.all of these relationships are often reciprocal and illustrate the integration of all parts of the body, local and distant, into a united system. osteopathic treatment may be employed to address the somatic dysfunction that is found in association with orofacial dysfunction. when indirect principles of treatment are respectfully employed, these procedures may be used to treat from the very youngest patient on through adolescence. the earlier the dysfunction is recognized, the younger the patient and the more plastic the tissues, the greater the possibility to affect the structure and to re-establish satisfactory functional patterns, thereby activating the body's inherent ability to heal itself. involve the parents or caregivers; empower them to help the child to succeed in dealing with the dysfunction. take the time to explain to the child why it is necessary to breathe through the nose and eat slowly. encourage the child to promote correct function, such as nasal breathing and learning how to blow their nose. encourage the child to practice activities that promote breathing, such as singing with good articulation of the words.young children with dysfunctional tongue mechanics or with minor cases of ankyloglossia can perform exercises to mobilize the tongue and to stretch the frenulum as much as possible. encourage the parents or caregivers to correct the child when there is mispronunciation. it may appear to be cute, but is actually dysfunctional. the child should repeat incorrectly pronounced words as correctly as possible to improve tongue mobility. infants can be encouraged to play sound-making games by repeating sounds that cause the tongue to make a clicking noise against the palate.teach effi cient swallowing without tongue thrusting by instructing the child to consciously keep their tongue in their mouth and to learn to swallow with the tip of their tongue resting against the palate behind their upper incisors. to practice this, the child can hold a small piece of food between the tongue and palate while attempting to swallow several times. this exercise should be repeated until the act of swallowing with the tip of the tongue resting against the palate becomes automatic.insist on alternate unilateral mastication and that the child takes suffi cient time to chew their food thoroughly. those children who are old enough should be encouraged to eat food that is as unrefi ned as possible. soft refi ned junk food often does not require suffi cient chewing.caution the parent or caregiver to watch for functional asymmetries that are associated with repetitive asymmetrical activities, such as unilateral bottle feeding or thumb sucking. instruct the parent or caregiver and the patient, when old enough to understand, to avoid these activities or perform them in a fashion that alternates sides. key: cord- -bi jyz r authors: wilson, audrey e; siddiqui, ali; dworkin, dr. ian title: spatial heterogeneity in resources alters selective dynamics in drosophila melanogaster date: - - journal: biorxiv doi: . / . . . sha: doc_id: cord_uid: bi jyz r environmental features can alter the behaviours and phenotypes of organisms and populations evolving within them including the dynamics between natural and sexual selection. experimental environmental manipulation, particularly when conducted in experiments where the dynamics of the purging of deleterious alleles are compared, has demonstrated both direct and indirect effects on the strength and direction of selection. however, many of these experiments are conducted with fairly simplistic environments when it is not always clear how or why particular forms of spatial heterogeneity may influence behaviour or selection. using drosophila melanogaster, we tested three different spatial environments designed to determine if spatial constraint of critical resources influences the efficiency of natural and sexual selection. we conducted two allele purging experiments to ) assess the effects of these spatial treatments on the selective dynamics of six recessive mutations, and ) determine how these dynamics changed when sexual selection was relaxed and the spatial area was reduced. we found that allele purging dynamics depended on spatial environment, however the patterns of purging rates between the environments differed across distinct deleterious mutations. we also found that for two of the mutations, the addition of sexual selection increased the purging rate. understanding mating systems and the dynamics between the sexes can illuminate how sexual selection acts within populations, driving many organisms' behaviours and phenotypes. key work in the theory of mating systems conducted by bateman ( ) , trivers ( ) , and emlen and oring ( ) has led many studies being dedicated to examining male and female interactions across different species and populations. the mating systems of numerous species have been shown to vary due to local adaption or ecological constraints due to environmental factors (miller and svensson ) . for example, ungulate species that inhabit open environments tend towards group mating systems while those within closed or forested environments tend to adopt small group or pair mating systems (carranza ; bowyer et al. ) . this variation in behaviour can occur within species as well, as seen in the mating system of prunella modularis, which has been shown to shift between polygyny, polygynandry, and polyandry depending on food distribution (davies and lundberg ) . environmental features such as spatial size, structure, resource abundance, and climate can alter the strength of sexual selection and conflict (both intra-and inter-) on an individual, in turn leading to fitness payoffs for certain phenotypes. in sancassania berlesei, increasing environmental complexity changes the fitness differences between the fighter and scramble male morphs which was believed to be a result of reduced encounters between fighter males (lukasik et al. ) . another example can be found in certain populations of katydid, where sex role reversal occurs under conditions of low resource abundance, placing a greater influence of inter-and intra-sexual selection on females (gwynne and simmons ) . since environmental variation can impact fitness, it is important to keep environmental context in mind when studying the strength of natural selection, sexual selection and sexual conflict. along with the environment, understanding the interaction between sexual selection and other components of natural selection (fecundity and viability) is important for determining an organisms' or a populations' phenotypic and behavioural origins. since the term was introduced by darwin ( ), studies have focused on how traits under strong sexual selection (weaponry, ornaments, and mating behaviours) arise and persist within populations. when sexual conflict is present, mutations may be beneficial in one sex but deleterious in the other (antagonistic pleiotropy), allowing for the maintenance of conditionally deleterious alleles. in many species, an extreme case of this is males harming females during copulation, either through mating itself or ejaculates, in order to prevent re-mating, further securing the males' paternity (johnstone and keller ) . however, while often portrayed as being at odds with one another, individuals of higher overall condition will on average receive more mates, resulting in sexual selection working in tandem with other components of natural selection. for instance in ungulates, males of overall higher condition tend to have the largest weaponry and are better able to obtain fertilizations along with access to females themselves (preston et al. ; hoem et al. ; vanpé et al. ; emlen ) . a common way of determining how various factors influence natural and sexual is to conduct allele purging experiments. within these experiments, deleterious mutations are introduced into populations at a known frequency (or via induced mutations) and the rate they are removed from the populations over time is recorded or populations undergo various fitness assays. experimental conditions are manipulated (thermal stress, dietary stress, population density, environmental complexity, and mate choice (sharp and agrawal ; wang et al. ; young et al. ; hollis et al. ; maclellan et al. ; laffafian et al. ; hollis and houle ; mcguigan et al. ; arbuthnott and rundle ; clark et al. ; maclellan et al. ; singh et al. ; colpitts et al. ) and purging rates (or fitness) are compared to obtain estimates of the effects these conditions have on selective dynamics. while several kinds of these studies have been conducted, many show contrasting results in reference to whether sexual selection aids natural selection in the removal of deleterious alleles. one potential reason for such inconsistencies is that most experiments are performed in small, simple environments (i.e. small vials) at relatively high densities, and it is not clear the degree to which this may influence the strength and orientation of selection. such simple and high-density environments likely constrain individuals in terms of mating strategies available in more natural conditions. alternative mating strategies are density-dependent in several species (greenfield and shelly ; höglund and robertson ; kokko and rankin ) , and particularly for drosophila melanogaster, territorial defence strategies by males are less likely to occur when the population is at a high density (hoffmann and cacoyianni ) . simple environments may also influence female strategies in that they may accept more mates due to being unable to seek refuge or escape from constant male harassment (byrne et al. ) . creating a more "complex" environment consisting of a larger space, multiple food cups, and additional spatial structure to alter the interactions between the sexes, yun et al. ( ) showed that female harassment of high quality d. melanogaster females was greater in the simple fly vial environments used in many experiments, exaggerating the effects of sexual selection to reduce variance in female fitness. since yun et al.'s ( ) experiment, there have been several studies conducted to determine how natural and sexual selection changes within simple (high density in single vials or bottles) versus "complex environments" (lower density cages with multiple resources for interactions to occur). in a later study, yun et al. ( ) found flies that had mating opportunities within "complex" environments adapted more quickly to novel larval environments as opposed to those mating in simple environments or lacking mate competition. using a similar environmental design but creating a larger, lower density simple environment, colpitts et al. ( ) demonstrated that "complex" environments aided the purging of two deleterious mutations that had previously been found to have no difference in purging rate while manipulating opportunity for mate choice (arbuthnott and rundle ) . singh et al. ( ) showed increased purging rate of deleterious alleles from populations evolving within these "complex" environments, while macpherson et al. ( ) revealed that low quality females experienced a greater reduction in fitness due to male harm compared to high quality females but only in "complex" relative to simple environments. these studies exemplify that with even modest changes in spatial environment (increasing space and lowering density of individuals), the dynamics of natural and sexual selection can vary vastly. complexity without the manipulation of overall environment size has been shown to influence female fitness in terms of offspring production (malek and long ) , but this has not been used to test overall population fitness. while these studies potentially show how these forces interact in a way that may be more representative of what is seen in nature, the types of environments employed are still simple and largely reflect changes in density. however, it is important for such experiments to explicitly consider factors that are known to influence mating strategy as well, such as territory availability and spatial heterogeneity of resources. increasing the environmental complexity in which populations evolve may reveal new patterns of how sexual selection acts, particularly for d. melanogaster, which as a species shows considerable variability in mating strategy in different spatial contexts. typically displaying scramble competition in the lab, territorial behaviours and resource defense polygyny have been observed when d. melanogaster males are given a desirable resource (hoffmann ) . males also appear to display this behaviour more often when females are present, when there is a low density of males, and the resource is readily used by females for oviposition and resource patches are in a range of sizes (~ mm diameter) (hoffmann and cacoyianni ) . within laboratory experiments, where aggressive interactions amongst d. melanogaster males are observed, it is typical that larger males or males that hold residence of a territory first, have greater reproductive success (hoffmann ) . considering this, if populations are within an environment that allows males to benefit from territorial behaviour, these populations may show an increase in overall fitness, and more variation in mating strategies. yet to date, most experimental evolution and purging experiments have not considered these explicit factors in their design. while the previous work outlined above has made considerable contributions to our understanding of the interplay between environmental complexity and selective forces, the environments used in these experiments are relatively simplistic when considering the plasticity of animal mating behaviour. we conducted a series of short term allele purging experimental evolution assays where environmental complexity and the accessibility of d. melanogaster to critical resources were manipulated with these factors in mind. in the first part of this experiment we looked at how differences in resource patch size and accessibility influenced the purging of six recessive deleterious mutations from populations being held within a series of complex environments. specifically, we provided multiple resource patches of high (to maximize female fecundity) and low quality. in each treatment high quality patch size and accessibility varied according to how they should potentially influence aspects of territoriality. in the second experiment, we examined how the rate of removal for two of these mutations differed between the complex environments and two simple environments in which we additionally manipulated opportunity for mate choice (via forced monogamy). we expected that if natural and sexual selection were aligned, we would see an increase in purging rate as accessibility to resources decreased and that the purging rate overall would be greater when sexual selection was allowed to act in the form of mate choice than when it was removed. images of the environmental treatments and an illustration of general set up are provided in figure . three environments were created in order to test the effects of desirable resource availability on the removal of deleterious mutations from populations. within each environment there were both "high quality" resources of a yeast-rich food (see table s ) and a % dilution (in water/carrageenan) of this food as a "low quality" resource. high quality food was determined based on previously published nutritional geometry studies (lee et al. ; jensen et al. ) , that maximized female fecundity. based on previous studies, the intent of these high quality food resources was to entice females to use these patches for oviposition and potentially lead males to defend these resources to maximize their own mating success. the diluted medium provided resource patches, such that individuals are not competing for survival per se, but for the desirable resources that females may prefer to maximize their fecundity. for each replicate environment described below, mesh bugdorm m cage ( cm ) were used. the "nonterritory" treatment environment (nt) consisted of a single drosophila culture bottle ( ml), with a surface area of . cm ( mm x mm base) containing ~ ml of high quality food with the addition of four drops of a yeast-paste and orange juice mixture on top (to attract females (dweck et al. )), as well as a bottle only with ml low quality food. these represent "typical" drosophila lab environments where apparent scramble competition is commonly observed (spieth ) , although subtle interference competition may be occurring as well (baxter et al. ). the "unconstrained territory" spatial treatment (uct) consisted of eight open vials (height of mm, mm diameter, . cm surface area) each filled with ~ ml of high quality food with a single drop of yeast-paste/orange juice mixture on top and a single bottle with the low quality food . finally, the "spatially constrained territory" treatment (sct) had the same set-up as the uct treatment except each vial had a d printed cap ( mm diameter, mm height, mm opening, see supplemental fig ) to further restrict ease of access to high quality food patches. these d printed caps were designed and tested with several specific features in mind. first, that it was relatively difficult to gain access, but would be relatively easy (given positive photo-taxis and negative geo-taxis in drosophila (markow and merriam ) ) for an interloper to be chased out. second, that the aperture was of sufficient size that two large d. melanogaster individuals could pass one another, but one individual could still harass or chase the other in this space. finally, the cap was designed so that if an individual did display territorial behaviours, it had multiple places to survey or defend (food surface, inner aperture, and outside top of aperture). pipe cleaners were wrapped around the tops of bottles and vials to provide additional perching substrate for individuals. to examine deleterious allele purging rates, six mutations with known morphological defects were used across each of the three spatial treatments. each allele was picked because of previous work examining the effects of selection on them in the context of either spatial manipulations or varying degrees of sexual selection (arbuthnott and rundle ; colpitts et al. ). three of these mutations are autosomal (brown , vestigial , and plexus ) and three are x-linked (white , yellow , and forked ). the mutations plexus , white , yellow , and forked were obtained from bloomington stock center while brown and vestigial were obtained from stocks kept in the lab. these alleles were chosen for their wide array of phenotypic effects with two influencing eye colour (white and brown ), two influencing wing morphology (plexus and vestigial ), one affecting body colour and behaviour (yellow ) and one affecting bristle morphology (forked ). to create experimental populations, individuals were backcrossed into a large outbred domesticated lab population (census size of - individuals) originally collected from fenn valley winery (fvw), michigan (gps co-ordinates: . , - . ) in . this population was chosen to potentially minimize confounding effects of lab adaptation in this experiment (harshman and hoffmann ) , i.e. it is expected that this population has already had considerable opportunity to adapt to our lab environment (~ generations prior to initiation of this experiment). to generate experimental populations, the following procedure was used. for autosomal mutations, mutant female virgins were crossed with fvw males. f was then crossed to each other and mutant homozygote females were collected. for x-linked mutations, mutant males were crossed with wildtype females. the heterozygous females from this cross were then crossed back to wildtype males, the mutant offspring from this cross were then collected and the process was repeated. for each mutation, backcrossing was conducted for five generations and on the final generation, offspring from the final cross were mated together to create mutant males and females. fifty pairs were used to generate each cross. for each mutation, nine replicate populations were created and three of each randomly assigned to one of the three environmental treatments. initial populations consisted of males and females with starting allele frequencies of . for their respective mutation. populations were maintained at l: d cycles at °c with % relative humidity in a conviron walk in chamber (cmp ). each generation, adults were placed into their respective treatments and allowed to mate and lay eggs for three days. after the three day period, adults were removed from the environments and discarded. eggs were allowed to develop for days, after which the next generation of adults was collected by bringing the adults to the cold room kept at °c and gently knocking them into vials. after this initial collection, males and females from each replicate were phenotyped under light co and placed into their respective environments with fresh food. this cycle was repeated for generations. due to a laboratory bacterial infection in one replicate of the brown population for the nt treatment, this replicate was discarded after generation . a fourth replicate was created with the same starting allele frequencies ( . ) in order to account for the missing data. this replicate was therefore five generations behind the rest of the experiment and was continued for generations. in order to get an estimate of allele frequencies for autosomal mutations during this experiment, monogamous pairings of phenotypically wildtype females and mutant males were conducted at generations and , for brown and plexus populations and at generations and for vestigial populations. after the collection of adults for the next generation, for each population virgin females were phenotyped over light co . of the females, those that lacked the mutation (i.e. could be homozygous or heterozygous for the wild type alleles) were placed singularly into vials with a mutant male. offspring were analyzed from these vials over days after emergence. if a vial contained only wildtype offspring, the female parent was scored as homozygous for lacking the mutation, if the vial contained a mixture of wildtype and mutant offspring, the female parent was scored as heterozygous for the mutation. for the x-linked mutations, allele frequencies were estimated from the frequency of the mutation in males. to determine the effects of sexual selection on purging rates, we re-ran the experiment using white and vestigial with the addition of two new treatments. the first treatment, deemed "vial no choice" (vnc), consisted of randomly assigning individual pairs into vials to mate (i.e forced monogamy). the second treatment, "vial choice" (vc), consisted of randomly assigning male and female adults into vials of mixed sex pairs. after three days of mating for each treatment, males were removed and females were placed into environments similar to the nt treatment. after three days the females were removed and eggs were allowed to develop for - days. emerging female virgins and adult males were collected similar to above and the process was repeated. nt, uct, and sct treatments were conducted the same as above except females were collected as virgins and males and females were held separately for three days after collection in order to align with the experimental schedule of the vnc and vc treatments. this experiment was conducted for only four generations as it was disrupted by a lab shutdown brought about by the covid- pandemic. one replicate of the sct vestigial treatment did not have any surviving adults at generation four. the rate of mutant allele loss in each population over multiple generations for each component of the experiment was analyzed by fitting generalized linear mixed effect models with binomial distribution (i.e. a logistic mixed model). since each allele was started at a known frequency, and the intercept was known, models were fit without estimating a global intercept (but included offsets). main effect for allele or treatment were also not included (as all treatments started with the same frequency for a given allele). fixed effects included in the model were thus generation x mutation type, generation x treatment, and generation x mutant type x treatment. random slopes for generation was included across replicate lineages, and the intercept was offset to . for allele frequency (or . for autosomal and . for sex-linked mutations when modelling mutant genotypic frequencies). fixed effects were further examined for significance with a two way anova (type ii wald χ test) and treatment contrasts averaged over mutant type were examined by comparing estimated marginal means within each model. for analyzing purging rates across environmental treatments, models were generated with and without the third sct replicate for the forked mutation due to this replicate having mutant allele frequencies approaching fixation consistently throughout the experiment ( figure s , table s and table s ). results presented exclude this replicate unless otherwise indicated. selection coefficients for each mutation were estimated using the allele frequency data. selection coefficient per generation was calculated as s = -(q'/q), and these estimates were then averaged across generation and replicate for each mutant type. all statistical analyses were performed in r v. . . (r core team ) using glmer() (lme package v . - (bates et al. ) ), anova() (car package v . - (fox and weisberg )), and emtrends() (emmeans package v. . . (lenth )). all plots were generated with ggplot v. . . (wickham ) . as expected, average allele frequency declined over generations for all six mutations types, indicating these alleles to be deleterious (fig ) . we observed substantial differences in rates of purging (as assessed by genotypic frequencies) based on the identity of the mutation. anova shows significant effects for all interactions of generation with mutant type and treatment, however significant effects may be restricted to certain mutation types as contrast estimates between treatments among all mutant types are non-significant (table and table ). across the six mutation types, there was no consistent overall pattern in purging rate between the nt, uct, and sct environmental treatments. similar results are shown when analyzing males and females separately. when examining estimated allele frequencies, only the interactions between generation and mutant type, and generation and treatment are significant (fig , table ). however, treatment contrasts are still not significantly different from one another ( table ) . overall trends of significance from anova and treatment contrasts are the same when including the third sct replicate for the forked mutation. estimated selection coefficients are of differing strengths for each mutant type, however these estimations also indicate no consistent pattern in strength of selection of treatment types across mutations (fig ) . overall the results suggest that while there are effects of the three spatial treatments on rates of purging (fig s ) , they are relatively modest in comparison to the effects of individual mutants and their interactions with the spatial treatment. in the second experiment, we replicated the above experiment with two alleles and added additional treatments with explicit manipulations of sexual selection. the addition of sexual selection for both white and vestigial mutant populations increased purging rates (fig , table ). while the forced monogamy treatment (vnc) treatment showed the slowest purging rate for both mutations, between the treatments that include sexual selection there is no consistent pattern in purging rate by treatment across the two mutant types. the anova shows significant effects of the interaction between generation and mutant type, and generation and treatment but not for the interaction between all three fixed effects. treatment contrasts show that the vnc (vial no choice) treatment (i.e. forced monogamy) is significantly different from the other treatments but vc, nt, uct, and sct are not significantly different from each other. when analyzing the sexes separately, only the interactions between generation and treatment, and generation and mutant type were significant for males whereas the interactions between generation and treatment, and generation, treatment and mutant type were significant for females. treatment contrasts were similar between male and female models with only the vnc treatment showing a significant difference from other treatment types when looking across all mutation types (table ). spatial heterogeneity in the environment can alter many aspects of an organisms' phenotype including mating strategy which in turn influences how selection acts on a population including the degree to which allelic effects may be concordant or antagonistic across fitness components. analyzing the directions and magnitudes of the components of natural selection has been investigated in many contexts, however many empirical studies teasing apart these elements in varying environments fail to recognise the influence of mating strategies. we created populations with known mutation frequencies and allowed them to evolve in environments differing in spatial constrains for resource accessibility to determine how environmental complexity influences the removal of deleterious mutations. we found environmental complexity did influence purging rates, but these rates depended greatly on mutation type. we reanalyzed the purging rates of two of these mutations in the same environments but also including treatments allowing different opportunities for mate choice within a more "simple" environment. again, we found that purging rates between treatments varied with mutation type, but for both mutations a lack of mate choice (forced monogamy) decreased purging rates. for each of the six mutations, we expected that with increased variance in resource accessibility there would be an increase in purging rate and therefore the highest purging rate would be seen in the sct treatment, with the lowest being in the nt treatment. this prediction rested on several assumptions including that natural and sexual selection are aligned, high quality food patches in the sct treatment would initiate territorial behaviour within males, and males of the highest quality would be able to hold and defend these food patches with the most success, leading to the most mates. while the sct treatment showed the highest purging rate among treatment types for plexus populations, this pattern does not hold for other mutant types. this discrepancy between our predictions and the data could be due to inaccurate assumptions or other unknown factors. despite evidence that drosophila melanogaster among other drosophila species can show context dependent territoriality (hoffmann ; hoffmann and cacoyianni ) , considerable uncertainty exists in the extent of what factors influence it and how it ultimately influences the fitness of an individual. it should also be noted that evolutionary stable strategy theories predict that a behavioural strategy will only be adopted by an individual or population if it is advantageous (maynard smith ) . while our environments were designed based on theory that would suggest our assumptions provide the most advantageous strategy (emlen and oring ; emlen ) , this cannot be known without further empirical testing and observation and other strategies may have been implemented that cause the discrepancy between our expectations and results. the lack of consistency between mutant alleles and the difference between treatments could be due to populations not using the environments as predicted. the nt environment was designed to resemble environments that promote scramble competition in drosophila, with uct having characteristics that promote territorial behaviours. the sct environment was designed to provide greater opportunity for one-on-one contests to occur between individuals due to limited entry to the desirable resource. individuals in the uct and sct environments were provided mm diameter high quality food patches with potential densities of males per high quality food patch (if the males within each environment were equally distributed across patches). while these conditions have been shown to increase the rate of territorial behaviour and the success of those males that defend territories (hoffmann and cacoyianni ) , these results were found over short-term experiments (up to hours) and these behaviours may not persist in d. melanogaster populations over longer time periods like the three days we allowed in our experiment. although not observed, other unexpected uses of the environments such as the majority of copulations occurring outside of food patches, and skewed patch use could have caused the disparity between our predictions and results. also, the addition of cap in the sct treatment was expected to aid males in further defending their resource patches. however due to the novelty of these environments, the behaviours these environments were meant to encourage may not have been used or had the opportunity to evolve. if the behaviours did evolve but at a point in the experiment where the allele frequencies for the mutations were low, genetic drift could have masked their effects. although our results do not show any consistent pattern of purging rate across treatment types between mutant types, inconsistent results are common to many purging experiments. many studies that analyze multiple mutations find that each mutation acts differently to experimental treatments not only in magnitude but also direction and thus mainly focus on the overall patterns among mutation types (sharp and agrawal ; maclellan et al. ; arbuthnott and rundle ; clark et al. ; maclellan et al. ; colpitts et al. ; singh et al. ). these differences are also reflected in our calculated selection coefficients, where higher selection coefficients lead to faster purging rates but the environmental treatment that has the highest selection coefficient changes depending on mutation type. differences between how these mutant individuals interact within their environment can likely explain these variances. for example, the mutant vestigial has a wing phenotype that influences both its movement and courtship signalling (pezzoli et al. ) putting it at a greater disadvantage compared to wildtype individuals in the same population, which is likely why it has the most drastic purging rate across environmental treatments among all the mutations analyzed in this study. further investigation into the behaviours of these mutant types may give an indication as to why these results differ between mutant types. while we wanted to explore how resource accessibility and environmental complexity influence populations through purging rates, we also wanted to evaluate how these compared to the purging rates of populations that lacked sexual selection and populations that had simple mating environments. as expected, the addition of sexual selection increased the purging rate for both mutations tested. however, there was no difference between the simple and relatively complex environments in purging rate for either mutation. this contradicts previous work of colpitts et al. ( ) where polygamous populations of mutant white d. melanogaster showed increased purging rates in complex environments. while the overall ideas between our experiments are similar, key differences in experimental design could explain these differences. firstly, due to the alignment of the experimental schedule, virgins from the vnc and vc treatments were able to mate more quickly than the virgins in the nt, uct, and sct treatments that were initially held separately before mating. this difference in waiting times to mate could have caused virgins from the nt, uct, and sct treatments to be more receptive to potential mates (pavković-lučić and kekić ). this could also explain why we see differences in the overall trends between the nt, uct, and sct environments compared to our initial experiment. secondly, our experiment had a much shorter mating period ( days versus ) and all eggs laid during this time period were kept to potentially contribute to the next generation for the nt, uct, and sct treatments, but not for the vnc and vc treatments. this could potentially lead to lower quality offspring from early matings with lower quality males being kept within the experiment, decreasing the purging rates within the complex mating treatments. overall our study adds to the recently growing body of literature considering "environmental complexity" while breaking down "complexity" further to accommodate for changes in mating strategy by environment. figure s : schematic for d-printed cap design. caps were created using filament material. sexual selection is ineffectual or inhibits the purging of deleterious mutations in drosophila melanogaster intra-sexual selection in drosophila fitting linear mixed-effects models using lme mating success in fruit flies: courtship interference versus female choice evolution of ungulate mating systems: integrating social and environmental factors effect of a refuge from persistent male courtship in the drosophila laboratory environment environmental effects on the evolution of mating systems in endotherms relative effectiveness of mating success and sperm competition at eliminating deleterious mutations in drosophila melanogaster the purging of deleterious mutations in simple and complex mating environments the descent of man and selection in relation to sex food distribution and a variable mating system in the dunnock, prunella modularis olfactory preference for egg laying on citrus substrates in drosophila reproductive contests and the evolution of extreme weaponry the evolution of animal weapons ecology, sexual selection, and the evolution of mating systems an {r} companion to applied regression. second alternative mating strategies in a desert grasshopper: evidence of density-dependence experimental reversal of courtship roles in an insect laboratory selection experiments using drosophila: what do they really tell us? fighting behaviour in territorial male roe deer capreolus capreolus: the effects of antler size and residence a laboratory study of male territoriality in the sibling species drosophila melanogaster and d. simulans territoriality of drosophila melanogaster as a conditional strategy chorusing behaviour, a density-dependent alternative mating strategy in male common toads (bufo bufo) sexual selection accelerates the elimination of a deleterious mutant in drosophila melanogaster populations with elevated mutation load do not benefit from the operation of sexual selection sex-specific effects of protein and carbohydrate intake on reproduction but not lifespan in drosophila melanogaster how males can gain by harming their mates: sexual conflict, seminal toxins, and the cost of mating lonely hearts or sex in the city? density-dependent effects in mating systems variation in the strength and softness of selection on deleterious mutations lifespan and reproduction in drosophila: new insights from nutritional geometry emmeans: estimated marginal means, aka least-squares means structural complexity of the environment affects the survival of alternative male reproductive tactics dietary stress does not strengthen selection against single deleterious mutations in drosophila melanogaster sexual selection against deleterious mutations via variable male search success the effects of male harm vary with female quality and environmental complexity in drosophila melanogaster spatial environmental complexity mediates sexual conflict and sexual selection in drosophila melanogaster phototactic and geotactic behaviour of countercurrent defective mutants of drosophila melanogaster the theory of games and the evolution of animal conflicts reducing mutation load through sexual selection on males sexual selection in complex environments influence of mating experience on mating latency and copulation duration in drosophila melanogaste females fitness components in a vestigial mutant strain of drosophila melanogaster overt and covert competition in a promiscuous mammal: the importance of weaponry and testes size to male reproductive success r: a language and environment for statistical computing. r foundation for statistical computing mating density and the strength of sexual selection against deleterious alleles in drosophila melanogaster environmental complexity and the purging of deleterious alleles courtship behaviour in drosophila parental investment and sexual selection. pp. - in sexual selection and the descent of man antler size provides an honest signal of male phenotypic quality in roe deer selection, epistasis, and parent-of-origin effects on deleterious mutations across environments in drosophila melanogaster ggplot : elegant graphics for data analysis the effect of pathogens on selection against deleterious mutations in drosophila melanogaster competition for mates and the improvement of nonsexual fitness the physical environment mediates male harm and its effect on selection in females we thank dr. tony frankino and christine sikes for their assistance with the design and development of d-printed caps used in this study. funding for this research was provided by the natural sciences and engineering research council (nserc) of canada and mcmaster university to id. key: cord- - etvgoxc authors: ellis, christine title: ferrets date: - - journal: saunders manual of small animal practice doi: . /b - - - / - sha: doc_id: cord_uid: etvgoxc nan m clinical techniques restraint • most pet ferrets are gentle, tractable, and are easy to restrain without assistance. often only minimal restraint is needed when performing a physical examination. some ferrets may be lightly restrained on the examination table. others will need to be restrained in a firmer manner. • tractable ferrets can be lightly restrained on an examination or treatment table by placing one hand under the chest and lifting slightly. • energetic ferrets may be restrained by scruffing ( fig. - ). use one hand to grasp the skin over the back of the neck and lift the ferret up, suspending all the limbs. stroke the abdomen with a downward motion to relax the ferret. the ferret's back may be supported with the other hand, or the ferret may then be reclined along the forearm of the arm used to scruff the ferret. most ferrets will become very relaxed, although some young ferrets and some females may resist. • firm restraint is often required when administering vaccinations or when performing treatment procedures. control the head by scruffing, or by cupping the back of the ferret's neck and placing the thumb and fingers along the caudal border of the mandibles. place the other hand over the pelvis to restrain the hindquarters on the table top with the hind legs underneath the body; do not pull the legs back. • aggressive ferrets, such as nursing females, kits, or ferrets raised with little human contact, are uncommon. restrain these ferrets by the scruff of the neck, using the techniques previously described. avoid using leather gloves, which are awkward. use sedation if necessary. there are several suitable sites for blood collection in ferrets: • • cephalic or lateral saphenous venipuncture may be used to obtain small amounts of blood (< . ml) for a packed cell volume (pcv), blood glucose, complete blood cell count (cbc), or serum biochemistry analysis. • the jugular vein, cranial vena cava, cephalic vein, or ventral tail artery may be used to collect larger volumes of blood. • use the jugular vein to collect blood for transfusion. christine ellis figure - . "scruffing" a ferret for restraint. • sedation: collection of blood from the jugular veins, cranial vena cava, or ventral tail artery may require sedation and/or the assistance of two people for restraint. sedation is rarely required for venipuncture of cephalic, lateral saphenous, or jugular veins. • if necessary, clip the hair over the venipuncture site to see the vein. • the normal hematocrit of ferrets is high; draw three times as much blood as the volume of plasma or serum required. (see tables - and - for blood values reported in normal ferrets.) • the pcv, red blood cell count (rbc), hemoglobin, white blood cell count (wbc), and plasma proteins often rapidly decrease after induction of isoflurane anesthesia. cephalic vein • collect blood from the cephalic vein in ferrets using the same restraint technique described for dogs and cats. • use an insulin syringe with a -gauge needle or a cc tuberculin syringe with a -gauge needle to collect volumes of blood up to . ml. larger volumes of blood may be collected with a cc syringe and a -gauge needle. • alternatively, place a -gauge needle in the vein and collect blood directly from the hub into small blood collection tubes. ‡these white blood cell counts are higher than those currently seen in clinical practice. at our laboratories, the normal white blood cell count is - ¥ /ml, and most are - ¥ /ml. adapted with permission from lee ej, moore we, fryer hc, minocha hc: hematological and serum chemistry profiles of ferrets (mustela putorius furo). lab anim : - , ; and thornton pc, wright pa, sacra pj, goodier tew: the ferret, mustela putorius furo, as a new species in toxicology. lab anim : - , . copyrights and lateral saphenous vein • the lateral saphenous vein runs diagonally across the lateral surface of the hindleg, just proximal to the hock. • use an insulin syringe with a -gauge needle or a -ml syringe with a -gauge needle to collect small blood samples (< . ml). • several methods are described for jugular venipuncture: • the ferret may be placed in sternal recumbency at the edge of the table. extend the head dorsally with the front legs held down, out of the path of the venipuncturist. • alternatively, wrap the ferret in a towel with the front legs drawn back along the thorax, leaving the head and neck extended from the towel. position the ferret in dorsal recumbency, and extend the head and neck by scruffing. • restrain the ferret in the same manner described for the cranial vena cava (see below). • ferrets that struggle should be sedated for this procedure. • use a -ml or -ml syringe with a -to -gauge needle for sample collection. • this procedure is referred to as cranial vena cava venipuncture, but, in reality, blood is collected from the jugular vein as it passes into the thoracic cavity at the thoracic inlet. m key point blood collection from the cranial vena cava requires complete immobilization of the ferret; otherwise, do not attempt the procedure. use sedation or the help of two assistants for restraint. • do not use this site if intrathoracic disease (e.g., mediastinal mass, mega-esophagus) or coagulopathy is suspected. . place the ferret in dorsal recumbency. one assistant restrains the head and neck in extension while holding the forelegs alongside the thorax. a second assistant restrains the hindquarters without pulling the rear legs back. precise positioning facilitates the procedure. . palpate the manubrium and locate the "notch" on either side where the manubrium and the first rib meet. . insert a -ml syringe with a -gauge, / -inch needle at either notch and direct the needle at a shallow angle (< degrees) along an imaginary line running from the notch toward the opposite rear leg. . insert the needle to the hub and gently aspirate while withdrawing the needle. . if the ferret struggles, abort the procedure, and do not make a second attempt until the ferret is quiet. ferrets that struggle persistently should be sedated for this procedure. • venipuncture at this site may be painful. . scruff the ferret and place it in dorsal recumbency (wrapping it in a towel may help with restraint), or anesthetize the ferret and place it in dorsal recumbency. . prepare the site aseptically. . use a -or -cc syringe and a -to -gauge needle for sample collection. . insert the needle on the ventral midline of the tail at -degree angle toward the body approximately to cm from the anus. . advance the needle to the bone; withdraw it slowly while applying a slight vacuum to the syringe. . apply direct pressure to the site for several minutes after the needle is withdrawn. a detailed discussion of the techniques used for blood collection for transfusion and blood transfusion is presented in the hematopoietic system section in this chapter. • use standard radiographic techniques (see chapter ), including sedation for correct positioning and to limit exposure of the technician, as well as high detail radiographic film and cassettes. • when interpreting films, it helps to think of the ferret as an elongated cat. • the kidneys are relatively short (about two lumbar vertebrae in length). • splenomegaly is a common radiographic finding. • for barium-contrast radiography of the gastrointestinal (gi) tract, give ml/kg of % barium solution po via syringe feeding or lavage tube. most ferrets will accept syringe feeding of barium. normal gi transit time is about to hours. • echocardiography may be used to evaluate the heart in ferrets with suspected cardiac disease (see "cardiovascular disease"). • other uses of ultrasound in ferrets include investigation of intra-abdominal or intra-thoracic masses, organomegaly, paraurethral cysts, or prostatic cysts. • the indications, guidelines, and techniques for bone marrow sampling are the same as those described for dogs and cats. (see chapter ) • preferred sites include the proximal femur and humerus. the iliac crest may be used for sample collection as well, but can be a difficult site to access. • sedation is required for bone marrow aspiration. use a -or -gauge spinal needle with stylet for sample collection. fine-needle aspiration of the spleen has been performed successfully in ferrets and is a rapid means of evaluating splenic cytology. in ferrets, the only contraindication is suspected hemangiosarcoma of the spleen. sedation is rarely necessary, but is recommended if the ferret persistently struggles. . two assistants are recommended for restraint. place the ferret in dorsal recumbency. one assistant should restrain the head and neck by scruffing the ferret with one hand. the other hand is used to restrain the forelimbs. a second assistant restrains the hind limbs by placing one hand around the pelvis. . palpate the spleen and position it against the left lateral or ventral body wall. . clip and prepare the site aseptically. . insert a -gauge needle attached to a -ml syringe to the hub at a perpendicular angle to the skin and aspirate from the spleen. . when a small amount of bloody fluid is visualized in the needle hub, withdraw the needle and prepare slides routinely for cytology. • urine may be collected by cystocentesis using the same technique described for the cat. • a -or -gauge needle on a -or -cc syringe may be used for sample collection. • anesthesia is recommended if the ferret is difficult to restrain. m key point sedation is often required for placement of a butterfly or indwelling intravenous (iv) catheter, or for small-volume iv therapy. • for small-volume iv therapy ( . - . ml), use an insulin syringe. the cephalic or lateral saphenous veins are the preferred sites for injection. sedation may not always be required for a single injection. • a -gauge butterfly catheter may be used to administer larger, single-dose volumes into the cephalic vein. • an indwelling catheter can be placed in the cephalic, lateral saphenous, or jugular vein. sedation is usually required. • flush indwelling catheters with small volumes of heparinized saline solution to maintain catheter patency. • peripheral indwelling catheters can be placed rapidly and are useful in emergency situations and for surgery. • restrain the ferret by scruffing. some ferrets may require two people for restraint. • sc injections may be given in the loose skin over the shoulders. • im injections may be given in the quadriceps, the semimembranosus-semitendonosus muscles of the hind limbs, or in the expaxial muscles of the lower back. • limit the volume of the im injections, due to the small muscle mass of the ferret. • fluids may be administered sc, iv, or io, depending on the needs of the patient. • the daily fluid requirement for ferrets has not been reported but can be estimated at to ml/kg/ day. adjust for dehydration and fluid loss. • administer sc fluids over the dorsal shoulder and thoracic region. • iv or io fluid therapy is used for a wide range of medical and surgical situations, and is recommended for ferrets that are > % dehydrated. • iv or io fluids must be administered with an infusion pump. fluids may be given as a continuous infusion, may be administered by continuous infusion, or may be given in to bolus doses over a -hour period. • ferrets may require the addition of dextrose to fluids because hypoglycemia is common. • oral medications are most easily given to ferrets in liquid form. • if possible, compound medications formulated in tablet or capsule form into liquid suspensions, or crush and mix them with a sweet-tasting substance such as nutri-cal (evsco pharmaceuticals) feline hairball laxative, or fruit-flavored syrup, and administer by syringe. • ferrets suffering from insulinoma should not be given sugar-based treats or medications if at all possible. hide medications in fatty acid supplements, vegetable oil, whipping cream, or meat baby food. • supplemental feeding is important in the management of anorectic or critically ill ferrets, and in the treatment and prevention of hypoglycemic episodes associated with insulinoma. • most ferrets can be force-fed dietary supplements by syringe. once they acquire a taste for a given supplement, it may be possible to offer it in a bowl. • feed ferrets as much food as they will take comfortably ( - ml) to times daily. • foods useful for force-feeding include the following: meat baby foods, slurried cat or ferret food, and science diet a/dliquid soy-based formulas (e.g. deliver . , mead johnson nutritionals) may be added to the mixture to increase the calorie content and improve palatability. • use of all medications is considered off-label for the ferret; there are no approved drugs available for ferrets in the united states. • several exotic animal formularies are commercially available that include drug dosage information on ferrets. • when dosing information is not available, use feline dosages with the following exceptions: • chloramphenicol: ( mg/kg) bid, iv, sc, im, or po. • aspirin: ( - mg/kg) bid-tid po (canine dosage). • many ferrets become lethargic when placed on enalapril (enacard, merck agvet) for cardiac disease. start with a very low dose ( . - . mg/kg) q h po. some ferrets cannot tolerate more than every-otherday therapy. • ivermectin ( . mg/kg) q d po for heartworm prevention; ( . mg/kg) once to weeks after adulticide treatment as a heartworm microfilaricide; ( . - . mg/kg) po, sc, repeat in days for sarcoptic mites; ( mg/kg) instill half the calculated dose into each ear and repeat in days for ear mites. a detailed discussion of the techniques used for blood collection for transfusion and blood transfusionis presented in the hematopoietic system section in this chapter. • sedation or isoflurane anesthesia facilitates urinary catheterization. the procedure may be difficult in ferrets with urethral disease or urethral calculi. . position in ventral recumbency with the hindquarters elevated and use a tomcat catheter or a . -fr. feeding tube with or without a stylet. . the urethral orifice is located on the ventral floor of the vaginal vault. catheterize the urethra blindly or after identification using a vaginal speculum. • the catheter may only pass part way into the urethra (often to the pelvic flexure). this may be sufficient to allow retrograde flushing of urethral calculi into the bladder, or to empty the bladder of a ferret with urethral obstruction secondary to prostatic enlargement. m key point isoflurane administered by face mask is the most convenient method to immobilize a ferret for procedures such as venipuncture and radiography. induction and recovery are rapid. doses for parenteral agents used in ferrets are listed in table - . • acepromazine is useful for sedation. • butorphanol tartrate has been used at sc, im, iv, but can cause very profound sedation in some ferrets. • ketamine alone does not produce effective muscle relaxation. use in combination with acepromazine for minor surgical procedures, or with diazepam for more complicated procedures. • medetomidine is not analgesic; animals will respond to painful stimuli. use with an analgesic agent. this agent is reversible (atapamazol). • tiletamine-zolazepam (telazol, fort dodge) gives variable muscle relaxation but is useful for immobilization for procedures such as venipuncture, radiography, and electrocardiography. recovery may be prolonged. • xylazine may cause bradycardia or vomiting, and is not recommended for use. • premedicate with parenteral agents followed by facemask induction. alternatively ferrets may be given • isoflurane is the inhalant anesthetic most commonly used in small mammal practice. sevoflurane is used in some practices as well. pharmacokinetic and pharmacologic isoflurane and sevoflurane are very similar; sevoflurane smells better and is better tolerated during face-mask induction. • isoflurane does not provide analgesia. administer an analgesic pre-or intra-anesthesia if a painful procedure is to be performed. analgesic agents commonly used in ferrets include buprenorphene ( . - . mg/kg q - h sc, im, iv), butorphanol ( . - . mg/kg q - h sc, im), carprofen ( mg/kg q - po), and flunixin meglumine ( . - . mg/kg q - h im, iv). • intubate ferrets to facilitate intermittent positive pressure ventilation (ippv). a . to . mm endotracheal tube usually is suitable. • the same planes of anesthetic depth reported for dogs and cats occur in the ferret. • follow basic principles of anesthesia for small animals, (see chapter ) and provide supplemental heat during surgery; administer iv fluids (isotonic electrolyte solutions supplemented with . - % dextrose) during long procedures and for insulinoma surgery. canine distemper and influenza are the two most common viral diseases of the ferret. influenza is zoonotic between humans and ferrets, and is typically passed from humans to ferrets. canine distemper is % fatal in the ferret, making distemper vaccination imperative. • the canine distemper virus (cdv) is a paramyxovirus. transmission occurs through direct contact with infected animals of any species, and through contact with fomites such as in shoes or clothing. • the incubation period for cdv in the ferret is typically to days; however, incubation for some strains of cdv may take up to days. (for discussion of cdv in dogs, see chapter ). • early in the disease the only clinical sign may be a mild unilateral or bilateral conjunctivitis. • pyrexia (> °c), anorexia, and profuse mucopurulent naso-ocular discharge develop as the disease progresses. • vaccinate all ferrets in the household or facility. currently only two vaccines are approved for use in ferrets: purevax (merial, athens, ga), and fervac-d (united vaccines, inc., madison, wi). give ml sc, using the following schedule: • if the dam is vaccinated: vaccinate kits at weeks of age and repeat vaccination every to weeks until the kits are weeks of age. • if the dam is unvaccinated: vaccinate the kits at weeks of age and repeat every to weeks until the kits are weeks of age. • revaccinate annually. sources claim that immunity lasts for years; however, outbreaks have been known to occur months after vaccination. • use of serum titers as a method to evaluate an animal's current immunological status is unsubstantiated. • quarantine new ferrets and canines for weeks before exposure to other resident animals. vaccinate new animals immediately after acquisition at the beginning of the quarantine period. • use of galaxy d (schering-plough animal health co., omaha, ne) for distemper vaccination has been described. use of this product in ferrets is extra-label. this product has proved effective in preventing canine distemper in young ferrets; however, duration of immunity is unknown. • do not use cdv vaccines that contain canine parvovirus, adenovirus, or other viruses. it is not necessary to vaccinate for leptospirosis unless there is exposure to wild rodents. the influenza virus is an orthomyxovirus. ferrets are susceptible to influenza a and b; this is the only documented zoonotic disease of the ferret. human-to-ferret transmission is more common than ferret-to-human transmission. transmission occurs by direct contact with naso-ocular discharges, and via inhalation of aerosolized droplets. • the incubation period is typically to days postexposure. • the clinical course of the disease is typically to days. m key point influenza typically causes only mild illness and discomfort, and is usually self-limiting in an otherwise healthy animal. • clinical signs may include any combination of the following: • sneezing with a clear, serous nasal discharge. • mild conjunctivitis with serous ocular discharge. crusting around the eyes may occur rarely. • a nonproductive cough that may be loud and paroxysmal, and often occurs more frequently at night. • diarrhea. vomiting may occur in rare cases. • partial to total anorexia, listlessness, and fever. • pneumonia, severe illness, or death may occur in neonates, geriatric patients, and in ferrets with concurrent diseases such as lymphosarcoma or insulinoma. • ferrets with underlying immunosuppressive disorders, especially lymphosarcoma, may develop repeated or cyclic episodes of influenza. rule out lymphosarcoma by performing a complete blood cell count (cbc), bone marrow biopsy/cytology, or a peripheral lymph node biopsy (see lymphoma in this chapter). diagnosis is based primarily on the clinical signs, history, and physical examination. • the history often indicates recent exposure to a human or another ferret with influenza or signs of upper respiratory tract disease. • the overall physical condition often remains good, although slight or moderate dehydration may be present if the animal is not eating or drinking normal amounts. • differential diagnoses include the very early stages of canine distemper, gi rotavirus infection, and lymphosarcoma. if mucopurulent nasal or ocular discharge is noted, consider early cdv or a secondary bacterial infection. • supportive care generally is sufficient. • encourage the ferret to eat and drink. offer to tablespoonfuls of hill's science diet a/d or strained meat baby food bid-qid if the animal refuses the regular diet. • if indicated, give an oral electrolyte solution that is palatable to ferrets. • if sneezing or coughing is excessive and interferes with eating or sleeping, give an antihistamine such as chlorpheniramine ( . - . mg/kg) bid-tid po, or diphenhydramine ( . - . mg/kg) bid-tid po. nasal solutions containing phenylephrine may be used to relieve nasal congestion. • antibiotics are not necessary unless secondary bacterial infection is present. • antiviral medications such as amantadine ( mg/kg) bid po (symmetrel, endo pharmaceuticals, chadds ford, pa) may be useful in the treatment of ferrets with influenza. zanamivir ( . mg/kg) once intranasally (relenza, glaxosmithkline, research triangle park, nc) has been shown experimentally to prevent influenza infection. good hygiene is the key to prevention. • discuss the zoonotic potential with the client. advise clients to wash their hands frequently, and to avoid holding the ferret near the face. • in the veterinary hospital, do not allow influenzainfected personnel to handle ferrets, especially if the animal is a neonate, a geriatric patient, or a patient debilitated by serious disease. • vaccination is not recommended; only short-term immunity results, and the wide variation of the influenza virus makes appropriate vaccination difficult. rabies is caused by a rhabdovirus that results in fatal disease in ferrets. it is transmitted via contact with an infected animal's saliva (see chapter ). this is a zoonotic disease; however, there has never been a report of ferret-to-human rabies transmission. experimentally, the incubation period is to days. m key point very little is known about rabies in naturally infected ferrets. • it is known that ferrets may become naturally infected; however, there is some question as to how easily they can contract the disease and the length of the incubation period. information about clinical signs is derived primarily from literature associated with laboratory-infected ferrets. signs are variable and include: • behavioral abnormalities that range from anxiety and hyperactivity to lethargy. • neurologic signs such as ascending paralysis, ataxia, hyperparesthesia, and posterior paresis. diagnosis is based on clinical signs, and/or a history of known or potential exposure to rabies. • history may include a recent bite wound or exposure to a rabid animal. • the ferret may be unvaccinated; however, development of rabies in vaccinated individuals has occurred in other animal species. • differential diagnoses include aleutian disease, botulism, brain hypoxia from severe seizures, cns neoplasia, insulinoma, intervertebral disc disease, and viral or bacterial encephalitis. • postmortem laboratory testing of brain tissue (fluorescent antibody staining [fas] or virus isolation) confirms the diagnosis (see chapter ). • there is no treatment for rabies. • euthanize the suspect animal to protect humans and other animals in its environment. submit animal for postmortem fas testing of brain tissue. m key point it has not been demonstrated that ferrets are carriers of rabies. many public health facilities now recognize and accept the -day quarantine period for ferrets; however, in some states, unvaccinated ferrets involved in biting incidents will be euthanized and submitted for rabies testing. it is important to be familiar with state and local laws regarding vaccination requirements and the laws following a biting incident. m key point the compendium of animal rabies prevention and control recommends that ferrets be confined and observed for days following human exposure. if signs compatible with rabies develop, the animal should be euthanized and protocols for rabies testing should be followed. vaccinated ferrets exposed to a potentially rabid animal should be revaccinated and quarantined for days. euthanize any unvaccinated ferret exposed to a rabid animal. • vaccination is the only prevention, and is mandatory in some states. • imrab (rhone merieux) is an inactivated rabies vaccine that is currently the only rabies vaccine approved for use in ferrets. administer at a dose of ml sc. • vaccinate initially at months of age. revaccinate annually. aleutian disease (adv) is caused by a parvovirus that affects both mink and ferrets. transmission occurs by direct contact or via contact with fomites contaminated with any infected body fluid, including blood. adv produces a progressive immune-mediated disease accompanied by the deposition of antigen-antibody complexes in multiple organs of the body. the virus is prevalent in the ferret population, but the percentage of ferrets that develop clinical illness is low. in one survey of ferrets, % were serologically positive, but only two animals developed clinically active disease. some ferrets may be asymptomatic carriers, while others may have natural immunity to the disease. m key point the clinical signs of aleutian disease are extremely variable, and the incubation period can be as short as day or as long as to days. • ataxia, mild incoordination, posterior paresis, or tremors may be the initial presenting signs. initially ferrets often continue to eat, and appear bright and alert. as the disease progresses, paresis progresses to the forelimbs, and wasting develops that may continue for weeks or months. • anorexia, lethargy, melena, and urinary incontinence are seen in later stages of the disease. • a slow wasting disease existing without neurologic signs may also occur. • diagnosis may based on the history, clinical signs, physical examination findings, the presence of high serum total protein and hypergammaglobulinemia, and a positive adv test. diagnosis is confirmed with histopathology. • differential diagnoses include bacterial or viral encephalitis, cns neoplasia, canine distemper, lymphosarcoma, gastric foreign body, tuberculosis, intervertebral disc disease, systemic mycoses, and rabies (in cases with behavioral changes and sudden paralysis). • exposure history is often not helpful because of the prevalence of asymptomatic carriers. • high serum total protein may be present. serum protein electrophoresis may demonstrate hypergammaglobulinemia (> % of the total serum protein). • blood samples may be submitted for counterimmunoelectrophoresis testing (united vaccines, inc., madison, we) or enzyme-linked immunosorbent assay (elisa) testing (avecon diagnostics, bath, pa). an in-house saliva sample kit is available as well (avecon diagnostics, bath, pa). • histopathology demonstrates lymphocytic plasmacytic infiltration and perivascular cuffing in many organ systems. the kidneys, liver, lymph nodes, and spleen are often affected. m key point there is no effective treatment for aleutian disease. provide supportive care and do not allow contact between clinically ill animals and healthy ferrets. euthanasia is usually indicated only for clinically affected animals. should not be euthanized because they may never become clinically ill. infected ferrets may remain asymptomatic for life, but can remain persistently infected. other ferrets may develop nonpersistent, self-limiting disease and fully recover. • administration of corticosteroid therapy and supportive care may prolong the life of some ferrets with clinically active disease. breeding colonies • breeding colonies should be closed. new animals should be adv tested and quarantined prior to introduction. • test all resident ferrets and remove serologically positive animals from the population. • adv-negative animals should be retested in months, before adding them to the colony, due to the potentially long incubation period. • it is not necessary to test a pet ferret unless it has been exposed to a clinically ill animal. • it is not necessary to euthanize a clinically normal, non-breeding adv-positive ferret or remove it from contact with other pet ferrets. advise the client, however, that there is a slight possibility that the pet may develop clinical illness. • do not house ferrets in close proximity to mink. • retest adv-positive animals in months since some animals may eventually eliminate the virus and become negative. rotavirus causes gastrointestinal infection and a bright green or yellowish-green diarrhea. rotavirus is described in the "gastrointestinal system" section in this chapter. lymphosarcoma is common in the ferret, and is discussed in the "neoplasia" section in this chapter. staphylococcus, streptococcus, escherichia coli, and other common bacteria from the environment can be introduced through penetrating wounds, punctures, abrasions, contact with mucous membranes, and by inhalation or ingestion. • abscessation is an uncommon form of bacterial infection in ferrets. • an abscess may occur in any part of the body, including the anal glands, mammary tissue, mouth, mucous membranes, reproductive tract, respiratory tract, subcutis, and prostatic tissue. • body temperature may be £ °c if bacterial sepsis is present. • bacterial dermatitis causes thickened, irritated areas of skin. affected ferrets may lick and chew these areas until they become denuded and ulcerated. • bacterial conjunctivitis causes a thick mucopurulent ocular discharge and swelling of the conjunctiva; corneal ulcerations may be present. • bacterial pneumonia causes lethargy, fever, anorexia, and dyspnea, and is often accompanied by mucopurulent nasal discharge and coughing. • bacterial mastitis occurs primarily in the lactating jill, and is accompanied by depression, fever, and anorexia. one or more mammary glands are swollen, discolored, and warm to the touch. • bacterial metritis may or may not cause a vaginal discharge; depression, fever, and partial or total anorexia are often present. • bacterial vaginitis causes a thick mucopurulent yellow-to-green vaginal discharge with little odor. fever is usually absent, and the animal does not appear clinically ill. • presumptive diagnosis is based on clinical signs, physical examination, demonstration of bacteria on routine cytology, results of bacterial culture, and sensitivity of the affected sites. the total wbc may demonstrate a marked leukocytosis (> , ). • treatment should consist of appropriate antibiotic therapy based on culture and sensitivity results, and surgical drainage or excision of the affected tissue when appropriate. • begin treatment with a broad spectrum antibiotic pending the results of culture and sensitivity testing, or when obtaining a culture is not feasible. • provide supportive treatment as needed, such as fluid therapy and nutritional support. • lance and thoroughly flush with an antiseptic solution. keep the area open and flush twice daily until healing occurs by second intention. • administer oral antibiotics until signs of infection are gone and a healthy bed of granulation tissue is present. see mastitis in the reproductive disease section in this chapter. see uterine infection in the reproductive disease section in this chapter. • if possible, perform a tracheal wash and submit samples for cytology, bacterial culture, and sensitivity testing. • if pleural effusion is evident on radiography, perform thoracocentesis. submit samples for cytology, bacterial culture, and sensitivity testing. • start oral broad-spectrum antibiotic therapy immediately, pending culture and sensitivity results. if pleural effusion is present, consider treating with a combination of clindamycin and cephalosporins (use cat dosages). • use of bronchodilating agents and/or nebulization therapy may be beneficial treatment modalities as well. • treat conjunctivitis with a broad-spectrum ophthalmic ointment. • perform a fluorescent corneal staining test to rule out corneal ulcers. (see chapter ) • submit samples for bacterial culture and sensitivity testing. • begin treatment with broad-spectrum oral antibiotics. modify treatment based on culture sensitivity results. • instruct owners to hot pack the affected area to minutes bid-tid. • treat until infection and swelling resolve, then perform anal sacculectomy. • continue antibiotic treatment to days postoperatively. • campylobacter spp. typically causes gi disease (see "gastrointestinal system"). • salmonella spp. may rarely cause gastroenteritis in ferrets (see "salmonella" within "gastrointestinal system"). • botulism is a rarely encountered disease in the domestic ferret caused by the ingestion of food contaminated with the clostridium botulinum toxin. c. botulinum is commonly found in the soil. • uncooked food or food contaminated with soil can be the source of the infection. • clinical cases of tuberculosis in the ferret are reported infrequently; however, ferrets are susceptible to bovine, avian, and human mycobacterium spp. infections. • the disease can be transmitted by ingestion of contaminated meat (poultry or meat), unpasteurized milk, or food contaminated by the droppings of infected wild or pet birds (see chapter for information about tuberculosis in dogs and cats). • clinical signs include chronic weight loss, and diarrhea that is unresponsive to treatment. vomiting may occur as well in some cases. • diagnosis is based on history, clinical signs, and the exclusion of other diseases; it is confirmed by intestinal biopsy. histopathologically granulomatous inflammation and acid-fast bacteria are identified. infection may also be confirmed by culturing the organism, and with polymerase chain reaction (pcr) testing. • because of the zoonotic potential of this disease, treatment is not recommended. affected animals should be euthanized. dermatophytosis is rare in the ferret and is typically caused by microsporum canis and trichophyton mentagrophytes. dermatophytes are transmitted by direct contact with infected animals or contaminated bedding, caging, and fomites. m key point ferrets are usually not carriers of these organisms. clinical disease is typically selflimiting. the most common source of infection of the pet ferret is the household cat. • young, debilitated, or geriatric ferrets are the most commonly affected. • lesions are consistent with those described in other species (see chapter ). alopecia with erythema, inflammation, hyperkeratosis, superficial crusting, lichenification, and erythema are present. pruritis is common and may lead to self-trauma and secondary pyoderma. • diagnosis is based on the identification of the fungal agent on skin scrapings, fungal culture, or a positive wood's light examination (m. canis). (see chapter ). • dermatophytosis is often self-limiting and may resolve without therapy. however, due to the zoonotic potential, treatment is recommended. • topical treatment includes the use of keratolytic shampoos, and/or lime sulfur dips. (see chapter ). • oral therapy consists of the administration of grisofulvin ( mg/kg) po sid for to days. perform a cbc every days while the ferret is receiving treatment. • disinfect the home by steam cleaning, the application of dilute ( : ) bleach or chlorhexidine solutions, and vacuuming thoroughly to remove infectious spores. dispose of the vacuum cleaner bag after vacuuming is complete. a thorough cleaning of the heat ducts and air conditioner/heater filters is also recommended. systemic mycoses are rare in the ferret; however blastomycosis, histoplasmosis, cryptococcosis, coccidioidomycosis, and aspergillosis have been reported. • consider these infections in the differential diagnosis of any systemic disease that is refractory to treatment and involves wasting, granulomatous lesions, persistent or recurring draining wound tracts, and respiratory tract disease. • diagnosis is based on the histopathological or cytological demonstration of the fungal organism in biopsies or aspirates (see chapter ). • complement fixation and precipitation tests have been used with variable success. • treatment is the same as described for the dog and cat (see chapter ). primary disease of the spleen is uncommon. splenomegaly is often a common incidental finding in a healthy adult ferret, or it may occur in association with a wide variety of disease conditions. perform a complete medical evaluation in all splenomegaly cases. • splenomegaly may be a normal or incidental finding in some patients. • pathological causes of splenomegaly may include chronic immune stimulation, erythroid bone marrow insufficiency, extra-medullary hematopoiesis (emh), hypersplenism, heart disease, and neoplasia. • splenomegaly can occur concurrently with adrenal gland disease and insulinoma, but it is usually an incidental finding. • extramedulllary hematopoiesis (emh) may cause enlargement of the spleen. the etiology of emh is unclear; compensation for myeloid insufficiency and chronic immune stimulation have been suggested as causes. ferrets with emh typically do not show evidence of hematological abnormalities. grossly the spleen has a normal shape and color, but it appears enlarged. • hypersplenism may cause enlargement of the spleen, but is rare in the ferret. • destruction of one or more blood cell lines by the splenic reticuloendothelial system occurs; affected ferrets will have anemia, leukopenia, thrombocytopenia, or pancytopenia. • bone marrow may be normal or hyperplastic in affected patients. • lymphoma is the most common neoplasia of the ferret spleen. hemangioma or hemangiosarcoma may occur as well. • when splenic lymphoma is present the spleen typically has irregular borders and a nodular texture. white or tan nodules may be noted grossly on the surface of the spleen and in the parenchyma. metastasis may be present. • splenic torsion and abscessation are rare in the ferret. • the normal ferret spleen measures approximately cm ¥ cm ¥ cm, and may be palpated in the left cranial abdominal quadrant. the texture of the spleen should be slightly firm, smooth, and the edges should be sharp. • an enlarged spleen is often noted on abdominal palpation as a firm, elongated smooth mass extending down the left side of the ferret abdomen, or crossing diagonally across the ventral abdomen from the left cranial abdominal quadrant to the caudal right abdominal quadrant. • abdominal distention may occur. • occasionally the spleen is so large and pendulous that the ferret can barely lift its abdomen off the ground. • abdominal discomfort due to splenomegaly appears to be uncommon in ferrets. • perform a cbc, platelet count, serum biochemical analysis, bone marrow cytology, and whole body radiography. • diagnosis of hypersplenism is based on the presence of one or more cytopenias, normal to hypercellular bone marrow cytology/biopsy, and the absence of blood loss, infection, or neoplasia. • obtain whole body radiographs to delineate the borders of the spleen and to rule out other abnormalities such as cardiomegaly or hepatomegaly that may contribute to splenomegaly. • splenic aspiration or biopsy may be performed. perform fine-needle aspiration of the spleen using a -gauge needle (see "clinical techniques"). do not perform splenic aspiration if hemangiosarcoma is suspected. • perform an abdominal ultrasound to evaluate the spleen. when the splenic parenchyma appears irregular, an ultrasound-guided biopsy or fine-needle aspiration may be performed. • perform a splenic biopsy during abdominal exploratory surgery, particularly if the spleen is irregular or discolored. treatment depends on the primary disease condition. usually splenectomy is not necessary. m key point indications for splenectomy are the same as for other species and include hypersplenism, splenitis, splenic abscess, torsion, rupture, neoplasia, and discomfort caused by excessive splenomegaly. • to perform a splenectomy, follow the surgical guidelines for splenectomy in dogs and cats (see chapter ). • anemia may result after splenectomy; the decision to perform splenectomy should be made cautiously, and with consideration to the health of the ferret as a whole. • administer antibiotics and fluid therapy pre-and postoperatively. • monitor asymptomatic ferrets with splenomegaly with periodic physical examination, cbc evaluation, imaging, and splenic aspiration. the clinical approach to anemia in ferrets is the same as for other species. anemias are classified as regenera-tive or nonregenerative; treatment is directed at the specific cause. there are many causes of anemia in ferrets; decreased erythropoiesis, destruction of red blood cells, and blood loss contribute to anemia. • nonregenerative anemia (normocytic, normochromic, nonregenerative anemia) occurs when bone marrow hematopoiesis is disrupted. bone marrow cytology of affected ferrets may appear normal. • decreased erythropoiesis may be caused by chronic metabolic disease (renal, hepatic), chronic inflammation, hyperestrogenism, bone marrow suppression, and neoplasia. • anemia of chronic disease can occur whenever long-term illness is present and is caused by decreased erythrocyte survival, decreased availability of iron, or a decreased response to the anemia treatment. • anemia associated with chronic inflammation is mediated by sustained inflammatory cytokine release. • hyperestrogenism may cause nonregenerative anemia due to estrogen-induced bone marrow suppression. unspayed female ferrets, female ferrets with ovarian remnants, or hyperestrogenism associated with chronic adrenal disease may contribute to this syndrome. • myeloid and leukemic neoplasias can cause suppression of bone marrow erythropoiesis due to replacement of normal bone marrow by neoplastic or fibrotic changes. • erythrocyte destruction may cause anemia; causes include immune-mediated disease, toxins, parasitism, or septicemia. • idiopathic immune-mediated hemolytic anemia, and immune-mediated hemolysis secondary to viral disease or blood parasites have not been reported in the ferret. • drug-induced hemolysis and heavy metal toxicosis (including zinc) are potential causes of hemolytic anemia. • anemia secondary to blood loss may be secondary to trauma, hemostatic disorders, bleeding lesions, and parasitism. • bleeding lesions may be internal or external. • bleeding ulcers may lead to anemia, and may be associated with h. mustelae gastritis, gastrointestinal foreign body, or chronic use of ulcerogenic drugs. • parasitism is uncommon in the ferret. coccidiosis in the young ferret or severe flea infestation may cause anemia. • hemostatic disorders include thrombocytopenia associated with estrogen toxicity, rodenticide poisoning, and liver disease. • clinical signs include weakness, pallor, lethargy, and inappetence. jaundice may be seen if hemolysis is present. • a soft systolic murmur is common in anemic ferrets. • a swollen vulva is present in ferrets with persistent estrus, an ovarian remnant, and in some cases of adrenal gland disease. hair loss may also be present on the shoulders and flanks. • ferrets with estrogen toxicity may have signs of thrombocytopenia such as petechiae, ecchymoses, and melena. • melena may be noted if gi bleeding is present. • palpate the spleen. splenomegaly may be caused by hypersplenism and subsequent anemia. • check carefully for fleas. perform a fecal examination. • diagnosis is based on the medical history, the physical examination findings, and a complete diagnostic work-up that includes a cbc, reticulocyte count, serum biochemical analysis, whole-body radiographs, and bone marrow cytology if indicated. • obtain a careful history regarding possible blood loss, toxicity, and foreign body ingestion. determine the duration of vulvar swelling (if present). • characterize the anemia based on rbc parameters and hemoglobin concentration. • the normal hematocrit for the ferret is % to %, higher than that of other animals. the erythrocyte count is higher as well; erythrocyte counts as high as . ¥ cells/µl have been reported. • the normal reticulocyte count may be as high as %. reticulocyte counts greater than % are indicative of a regenerative bone marrow response. • regenerative anemia is often the result of blood loss or hemolysis. • perform bone marrow aspiration (see clinical techniques), particularly if the anemia is nonregenerative, to identify infiltrative processes and assess the morphology of rbc precursors. bone marrow cytology from animals affected with anemia of chronic disease may be normal. bone marrow cytology is also indicated in ferrets with nonregenerative anemia that is unresponsive to treatment after to days. • obtain blood for blood lead concentration if lead poisoning is suspected. • whole-body radiographs are indicated to rule out abdominal neoplasia, gi foreign body, and thoracic neoplasia. a gi contrast study may be helpful to rule out the presence of gi ulcers. ultrasound may be helpful based on the rule outs established. m key point anemia in an intact female ferret with a swollen vulva for more than weeks most likely is due to estrogen toxicity. the objectives of treatment are to treat both the anemia and the underlying cause. • general supportive care includes oxygen therapy, subcutaneous fluids, and nutritional supplementation. • specific supportive care includes whole blood transfusion, iron dextran therapy, and the administration of erythropoietin. • oral iron supplements may be administered to replenish whole-body iron stores. • erythropoietin may be used to treat ferrets with nonregenerative anemia. administer u/kg three times per week until the pcv is stable, then administer to times a week. continue to monitor the pcv, and titrate the dose as needed. • indications for blood transfusion include the clinical status of the patient, a low packed-cell volume (pcv) of < %, the specific cause of the anemia, and the potential for continued blood loss. • ferrets lack specific blood types; transfusion reactions are rare in the ferret; up to three transfusions from the same donor and transfusions from multiple donors are considered safe. • the normal blood volume of an adult ferret may be calculated as % of the body weight. • the ideal value of the pcv post-transfusion would be within the normal reference range; a more likely goal is % to % higher than the pre-transfusion pcv. for dosage guidelines, see chapter . • before transfusion, administer a rapid-acting corticosteroid, such as dexamethasone sodium phosphate ( - mg/kg once iv) or prednisolone sodium succinate ( mg/kg once iv), as a slow bolus infusion, and administer an antihistamine such as diphenhydramine ( . - mg/kg iv, im, sc) to the recipient ferret. • the normal blood volume of ferrets has not been reported, but is estimated to be % to % of the total body weight (approximately ml/kg). twenty percent of the estimated blood volume (approximately ml) may be collected from healthy ferrets. • the jugular vein is the preferred site for the collection of large volumes of blood for transfusion. • sedate the donor ferret and place it in dorsal recumbency. • use a butterfly catheter to collect the blood into a syringe containing an anticoagulant such as sodium citrate ( . ml citrate per . ml blood) or acid-citratedextran (acd) ( ml per ml blood collected). • transfer the blood immediately to the recipient. blood should be filtered as it is transfused to the recipient. • administer fresh blood transfusions through an indwelling catheter or via a butterfly catheter into the cephalic or jugular vein. if a vein is inaccessible, administer into the peritoneal cavity or via the intraosseous route into the proximal femur. • whole blood is commercially available from marshall farms (marshall pet products inc., wolcott, ny). • hemoglobin substitutes such as oxyglobin (bioprure corporation, cambridge, ma) ( - ml/kg) iv or io over hours may be used if whole blood is unavailable. • administer oxyglobin slowly in normovolemic patients and in patients with renal disease, heart disease, or when the risk of pulmonary edema is present. • stop bleeding (internal or external). • correct the underlying cause of gi bleeding, including medical therapy for gi ulceration (see "gastrointestinal system"), surgery to remove gi foreign body, and antibiotics and supportive care for enteritis/colitis. • for anemia of chronic disease, treat the underlying primary disease process. • address metabolic disease (renal, hepatic) if present. • to correct estrogen toxicity in the intact female, terminate estrus (see below) and provide supportive care until the bone marrow is functional. broad-spectrum antibiotic therapy is important for the control of sepsis in leukopenic patients. estrogen toxicity associated with ovarian remnants is treated by surgical removal of the remnants when the ferret is stable enough for surgery. estrogen toxicity associated with adrenal gland disease is treated by adrenalectomy. preoperative care is the same as that described for the intact female (see below). (for diagnosis and treatment of adrenal tumors see "adrenal gland disease.") • treat fleas with any product that is safe for use in cats (see chapter ). • treat lead poisoning following the same protocols recommended for cats (see chapter ). • anemia secondary to neoplasia is associated with a poor prognosis. some cases of lymphoma may respond to treatment (see "neoplasia"). • administer human chorionic gonadotropin (hcg) in a single injection of iu (or usp) im. repeat this dose in to weeks if vulvar swelling has not diminished. • alternatively, give gonadotropin-releasing hormone (gnrh) at a dose of mg im or sc; repeat in weeks if necessary. • gnrh and hcg are effective only after the th day of estrus. bone marrow toxicity is not immediately reversible with termination of estrus; the pcv continues to fall for days to weeks. • monitor the pcv as a useful guide to therapy and prognosis: • pcv > %-the prognosis is good and termination of estrus is the only therapy required. • pcv % to %-the prognosis is guarded because the pcv level can decrease further after termination of estrus. • pcv < %-the prognosis is poor and aggressive supportive care is indicated, including multiple blood transfusions until bone marrow function is restored. • some causes of anemia in ferrets can be prevented. educate owners about proper husbandry techniques to avoid flea infestation, foreign body ingestion, and trauma. m key point to prevent estrogen toxicity, spay all female ferrets not used for breeding. insulinoma (pancreatic beta-cell tumor) is one of the most common neoplasias of the ferret. disease is most common in ferrets over years of age, and results in progressive, cyclic, or persistent hypoglycemia. • the incidence of insulinoma is typically higher in ferrets in the united states than in ferrets in other countries. the cause(s) are unknown. • possible etiologies include a limited genetic pool and diet. ferrets in the united states are typically fed processed foods containing large amounts of cereal grains. ferrets in other countries are typically fed a more natural diet consisting of meats and whole prey items. • early signs may be subtle and transient. cyclic or progressive episodes of profuse hypersalivation and pawing at the mouth (which is indicative of nausea), lethargy, depression, "stargazing," and posterior paresis may be seen during periods of hypoglycemia. • as the disease progresses, or during periods of inadequate food intake, symptoms become more pronounced and may progress to stupor or coma. seizures may occur. • splenomegaly is a common, unassociated finding on physical examination (see "splenomegaly" under "hematopoietic system" in this chapter). • adrenal disease is often identified concurrently in many ferrets with insulinoma (see "adrenal neoplasia" in this chapter). m key point base a presumptive diagnosis of insulinoma on the history, clinical signs, and repeated evidence of hypoglycemia in the presence of normal or elevated blood insulin levels. make a definitive diagnosis via surgical removal and histopathology of a pancreatic tumor or biopsy. • differential diagnoses include hepatic disease, sepsis, starvation, and laboratory error. • a carefully monitored fast of to hours is sufficient. • if necessary, obtain several samples over a period of several days. • normal fasting serum glucose concentration is to mg/dl. ferrets with insulinoma often have a fasting serum glucose of to mg/dl. ferrets with fasting serum glucose between to mg/dl are considered suspect and should be monitored. • do not fast the animal for more than hours. discontinue fast if signs of hypoglycemia occur. prolonged fasting may lead to collapse, coma, or seizures. feed the ferret a high-protein and high-fat meal as soon as possible after collection of blood. • measurement of blood insulin concentration is not consistently reliable in the ferret. • false positive results may occur if liver disease, nonislet cell tumors, or sepsis are present. • blood insulin concentrations greater than pmol/ liter (or mu/ml) are considered elevated in ferrets. however, if the ferret is severely hypoglycemic at the time of sample collection, the blood insulin value may be normal because insulin and glucose are in a constant dynamic state. • the serum biochemical profile is typically normal except for the presence of hypoglycemia. • the cbc is typically normal. • a slight elevation in alanine aminotransferase (alt) and aspartate aminotransferase (ast) may be noted. the cause is unknown and may incidental, or may indicate hepatic lipidosis due to chronic hypoglycemia or some hepatic pathology. m key point insulinoma is a progressive disease in ferrets. educate owners how to recognize the signs of hypoglycemia and how to manage hypoglycemia at home (see "medical therapy" and "hypoglycemia episodes"). • treatment options include medial therapy and/or surgical therapy. • medical therapy will need to be adjusted as the disease progresses. • surgery is used as a management tool and is not curative. insulinoma is a progressive disease, even after surgical intervention. medial therapy is often effective in controlling symptoms associated with insulinoma for to months. frequent feeding is the first step in treatment. add prednisone and diazoxide as clinical signs and hypoglycemia worsens. • feed high-quality protein and high-fat meals frequently, especially after exercise or a long sleep. avoid foods containing sugar or excessive carbohydrates (except to treat hypoglycemic episodes); these foods cause short term hyperglycemia followed by a period of hypoglycemia to hours later. • to tablespoons of hill's science diet a/d or meatbased baby foods may be given twice daily and as needed. • chromium has been anecdotally reported to stabilize blood glucose and insulin levels in humans. brewer's yeast, which is a rich source of chromium, has been beneficial in some ferrets with insulinoma. surgical therapy is the treatment of choice even though surgical removal or debulking of pancreatic tumors or partial pancreatectomy is palliative and provides only temporary remission of signs ( to months). • follow canine preoperative protocols (see chapter ). fast the ferret for only to hours preoperatively to avoid hypoglycemia. • administer iv or io isotonic fluids containing dextrose ( . - . %) to hours preoperatively if possible, during surgery, and continue postoperatively until the ferret is stable and is eating and drinking. • evaluate the blood glucose concentration pre-, intra-, and postoperatively if possible. • see chapter for information about the surgical removal of insulinoma. m key point perform a complete abdominal exploratory; insulinomas can metastasize to the regional lymph nodes, liver, and spleen (uncommon). concurrent adrenal tumors (see adrenal gland disease) are common. • if the spleen is enlarged and appears irregular or mottled, consider performing a complete or partial splenectomy and submit for histopathology. • postoperatively monitor the blood glucose concentration bid-tid until the ferret is discharged from the hospital. many ferrets become euglycemic immediately after surgery. some ferrets may remain hypoglycemic. rarely, ferrets may become transiently hyperglycemic after surgery. • most ferrets will require resumption of medical therapy to months after surgery. some ferrets will need medical therapy immediately postoperatively. • monitor blood glucose levels for to days after surgery and at to day intervals. • iatrogenic pancreatitis is rarely a problem in ferrets; however, as a precaution, withhold food and water for hours postoperatively; give . % to . % dextrose iv during this period. monitor blood glucose to times daily. • transient diabetes mellitus may occur postoperatively. hyperglycemia and glucosuria may be present for to days postoperatively; generally no treatment is required. • histopathologic examination of the pancreatic mass may reveal hyperplasia, adenoma, and/or adenocarcinoma of the pancreatic beta cells, even within a single tissue specimen. • the prognosis is guarded, but with surgery and medical treatment, ferrets have had a good quality of life for more than year after diagnosis of insulinoma. the median survival time was months (range, . - months) in one study of ferrets treated with surgery, medical management, or both. adrenal tumors are common in ferrets, and occur with approximately the same frequency as insulinomas. adrenal neoplasia and insulinomas often appear concurrently. adrenal tumors have been identified in ferrets as young as year of age, although they typically occur in ferrets > years of age. • adrenal gland disease in ferrets is not cushing's disease. excessive sex steroids, not corticosteroids, are produced by a hyperplastic or neoplastic adrenal gland. • the etiology is unknown. possible causes of adrenal disease in ferrets include early neutering, genetic factors, and lack of exposure to normal seasonal photoperiods. the incidence of adrenal neoplasia is higher in ferrets in the united states. in the u.s., ferrets are typically neutered at weeks of age, and are housed indoors under artificial light cycles. ferrets in europe and australia are typically housed outside, and are not neutered until months of age. • adrenal neoplasia in ferrets causes a variety of clinical signs, and appears to be the result of excessive secretion of estrogens and androgens, not cortisol. pituitary-dependent hyperadrenocorticism has not been documented in ferrets. • adrenal tumors most commonly arise from the adrenocortical tissue. common histopathological findings include hyperplasia, adenoma, and adenocarcinoma. • signs include progressive, bilaterally symmetric alopecia, usually starting at the tail base and progressing cranially. hair loss often starts in the early spring or fall. there may be a history of alopecia and spontaneous hair regrowth as well. • pruritis often is reported, along with excessive dryness of the skin and small excoriations. thinning of the skin is common. • an enlarged vulva, mimicking estrus, may be the only clinical sign in spayed females. mucoid or mucopurulent vulvar discharge may be noted. castrated males may exhibit territorial marking and sexual behaviors, and may develop the strong body odor and oily hair coats of intact males. mammary hyperplasia can occur in either sex. • male ferrets may present with partial to complete urinary obstruction. persistent elevation of adrenalderived androgenic hormones may cause development of prostatic hypertrophy, prostatic cysts, or periurethral cysts, which cause narrowing of the urethra. affected ferrets may present with stranguria, dysuria, azotemia, and severe metabolic derangement. male ferrets that are described as straining to urinate should be treated as an emergency (see "urinary system"). • atrophy of abdominal musculature and mobilization of fat to the ventral abdomen, leading to a pendulous appearance, may be seen. • atrophy of hind limb musculature and rear limb paresis can occur. • polyuria/polydipsia is uncommon but has been reported. • collapse, anemia, and petechiation resembling estrogen toxicity have been described in male and female ferrets with chronic or advanced adrenal disease (see hematopoietic system). • enlarged adrenal glands may occasionally be noted on the physical examination. the left adrenal gland is easier to palpate than the right. • radiographs are not typically helpful in confirming this disease. ultrasonography may be useful for identification of adrenalmegaly. • cbc is typically unremarkable unless estrogen toxicity-like anemia is present. the serum chemistry profile is typically within normal limits unless insulinoma is present. m key point a history of symmetric truncal hair loss suggests the diagnosis. differential diagnosis includes seasonal alopecia, which typically appears in the spring or fall, affects only the tail, and resolves after several weeks. • female ferrets often present with a swollen vulva. differential diagnoses include an intact female ferret, a female ferret with an ovarian remnant, and seasonal alopecia. perform a serum steroid panel or administer human chorionic gonadotropin ( iu) im to determine if a female ferret is unspayed or has an ovarian remnant. • a plasma steroid hormone assay may be used to support the diagnosis. elevated plasma concentration of estradiol, androstenedione, and/or -hydroxyprogesterone is a reliable indicator of adrenal gland disease (see table - ). a hormone panel is commercially available through the clinical endocrinology laboratory of the department of comparative medicine at the university of tennessee. • the adrenocorticotropic hormone (acth) stimulation test and the low-dose dexa-methasone suppression test are not useful in ferrets. ferrets with adrenal gland disease do not produce abnormal concentrations of cortisol, and adrenal gland disease in the ferret appears to be independent of acth. urine cortisol/creatinine ratio does not appear to be a specific indicator of adrenal gland disease. • perform exploratory surgery to confirm the diagnosis. • adrenal tumors can be managed medically or surgically. surgical management is preferred and recommended. • medical treatment may cause clinical signs to regress, but will not stop growth of the adrenal tumor. the goal of medical treatment is to decrease or eliminate the clinical signs of adrenal gland disease. medical therapy will not stop or prevent the growth of an existing tumor, and should be reserved for ferrets that are poor surgical candidates, ferrets with inoperable bilateral adrenal tumors, or ferrets with recurrent adrenal gland disease. • medical treatments described in the literature include mitotane, ketoconazole, androgen receptor blockers, aromatase inhibitors, and gonadotropinreleasing hormone analogs. • gonadotropin-releasing hormone analogs. there are two general types of gnrh analogs: gnrh agonists and gnrh antagonists. to date only gnrh agonists such as leuprolide acetate (lupron depot, tap pharmaceuticals inc., lake forest, il) have been used to control the signs of adrenal disease in the ferret. of the medical treatments described, anecdotal reports suggest that leuprolide acetate has been most effective in alleviating dermal and urogenital signs of adrenal disease. administer the month depot formulation of leuprolide acetate at a dose of ( µg/kg) im every days. • androgen receptor blockers theoretically block the actions of androgens at the receptor site, and decrease or reverse the signs of adrenal gland disease. in human medicine these drugs are used to treat men with prostatic carcinoma or prostatic hyperplasia. flutamide (eulexin, schering corporation, kenilworth, nj) and bicalutamide (casodex, astrazeneca pharmaceuticals lp, wilmington, de) have been used, primarily in male ferrets. results are variable. • aromatase inhibitors such as anastraozole (arimidex, astrazeneca pharmaceuticals lp) inhibit aromatase, an enzyme involved in estrogen production. some ferrets show decreased evidence of adrenal gland disease symptoms when treated with this drug. • mitotane ( ,p'-ddd) (lysodren, bristol-myers squibb oncology, princeton, nj) is rarely effective in ferrets with adrenal gland disease, presumably because ferrets do not develop pituitary-dependent hyperadrenocorticism. if clinical signs do resolve, they will often recur as soon as the mitotane therapy is withdrawn. m key point perform a fasting blood glucose test before starting mitotane therapy. do not use mitotane if blood glucose is low (indicative of concomitant insulinoma). mitotane causes a decrease in endogenous cortisol production; if insulinoma is present, serum glucose levels also may fall, causing a hypoglycemic crisis. • give mitotane ( mg/kg) po q h for days, then q h until clinical signs start to resolve. at that time decrease to q h until signs are fully resolved, then maintain the ferret on mg/kg once q - d as necessary. • mitotane must be compounded in -mg aliquots in # capsules. capsules must be administered intact. have owners coat the capsules with vegetable oil, push into the back of the throat, and follow with a palatable liquid or blenderized cat food to promote swallowing. • the most common side effect of mitotane is hypoglycemia. teach owners to recognize the signs of hypoglycemia, and have prednisone available at home. if side effects occur, discontinue mitotane and administer prednisone ( . - . mg) po. • if continuation of mitotane therapy is desired after a hypoglycemic crisis, administer concomitantly with prednisone (see insulinoma). • ketoconazole is not effective in the treatment of adrenal disease in the ferret. follow the adrenalectomy preoperative protocol described for dogs (see chapter ). • fast the ferret to hours preoperatively. place an indwelling iv or io catheter preoperatively, and administer fluids pre-, intra-, and postoperatively. if insulinoma is present concurrently treat and monitor appropriately. • perform a ventral midline laparotomy. palpate and visualize both adrenal glands carefully. normal adrenal glands are to mm ¥ - mm in size, are pale pink in color, and are typically surrounded by fat. • the left adrenal gland lies in a fat pad cranial to the left kidney. the right adrenal gland is located cranio-medial to the right kidney under the caudate liver lobe adjacent to the vena cava. it may be necessary to transect the hepatorenal ligament to fully visualize and palpate this gland. • adrenal changes may be subtle, especially in younger ferrets and because the adrenal glands are surrounded by fat. visual changes, such as dark circular lesions and small raised cysts, may be present instead of gross enlargement. • one or both adrenal glands may be affected. if only the left adrenal gland is affected, removal is relatively straightforward. if the right adrenal gland is affected, removal can be difficult because of the gland's proximity to the vena cava and liver (see chapter ). • if both adrenal glands are affected, remove the left adrenal gland and debulk the right adrenal gland. bilateral adrenalectomy has been described in the ferret, but should be done with caution. monitor postoperatively for development of acute adrenal hypocorticism. if acute ahc develops, treat as described for dogs (see chapter ). m key point always perform a complete abdominal exploratory. observe and palpate the pancreas at surgery for insulinomas, which often are found concurrently with adrenal neoplasia. • monitor fasting serum glucose levels every to days during mitotane therapy and after adrenalectomy, even if no pancreatic nodules were evident during surgery. • the prognosis following successful surgery is good. a full resolution of clinical signs can be expected in many cases. • recurrent or continued symptoms of adrenal gland disease may be associated with development of a tumor on the remaining adrenal gland, or recurrence of an adrenal tumor due to metastasis (which is rare). • even without treatment, ferrets may survive up to years or longer after diagnosis, although the hair loss is generally progressive. • potential sequelae to chronic adrenal gland disease include prostatic disease, bone marrow suppression, or mechanical interference with the vena cava (right adrenal gland). pheochromocytomas are adrenal tumors that arise from the adrenal medulla and produce excessive amounts of catecholamines. pheochromocytomas have been reported in ferrets, but are rare. treatment of choice is surgical removal of the affected gland. lymphosarcoma (lymphoma) is common in ferrets of all ages, and is similar in presentation to the disease in cats and dogs (see chapter ). three presentations may occur in the ferret and include lymphosarcoma, lymphocytic, and lymphoblastic forms. • a viral etiology has been hypothesized. clinical signs are variable, depending on the form of lymphoma present and the organ system involved. • lymphosarcoma: solid tissue tumors are present in the organs or lymph nodes. • lymphocytic lymphoma: adult ferrets are most commonly affected. the course and survival time can be long. peripheral lymphadenopathy is typically present and metastasis to visceral organs may occur. the neoplastic cell identified on cytology or histopathology is a mature, well-differentiated lymphocyte. • lymphoblastic lymphoma: young ferrets are most commonly affected. leukemia and neoplasia in visceral organs occur early in the course of this form of the disease. large immature lymphocytes are noted on cytology or histopathology. • other forms: cutaneous lymphoma may occur in the ferret. • clinical signs that may accompany any form of lymphoma include: • inappetence, lethargy, splenomegaly, and weight loss despite a normal appetite • dyspnea, tachypnea, and exercise intolerance • peripheral lymphadenopathy and/or abnormal cbc • acute collapse, often with pyrexia • fever of unknown origin • cutaneous masses • chronic diarrhea and/or rectal prolapse • some ferrets are asymptomatic; lymphoma may be an incidental finding during evaluation for another medical problem. • lymphoma tends to be a more acute, fulminant disease in younger animals. the method of diagnosis depends on the organ system involved. • obtain a thorough history and physical examination. • perform a cbc, platelet count, and a serum biochemistry profile. if the ferret is anemic, perform a reticulocyte count. • often the cbc and differential wbc counts are not diagnostic for lymphoma. the cbc may be normal or may reveal an absolute or relative lymphocytosis. anemia, leukopenia, and thrombocytopenia may be seen. abnormal lymphocytes may occasionally appear in the differential count. • persistent absolute lymphocyte counts greater than or a relative lymphocytosis (> %) are considered suspicious; repeat the cbc in to weeks and perform a bone marrow biopsy and/or lymph node biopsy if the cbc results are repeatable or if lymphadenopathy is present. • the serum chemistry profile may disclose elevated liver enzymes if the liver is involved; paraneoplastic syndromes are uncommon in the ferret. • perform thoracic and abdominal radiography and ultrasonography to evaluate for intra-thoracic and intra-abdominal masses. • perform fine-needle aspiration or biopsy of affected tissues for histological and cytological examination. fine-needle aspiration of the spleen is usually inconclusive. • lymph node biopsy is often the most helpful diagnostic tool for diagnosis of lymphoma. if possible, biopsy an enlarged lymph node. when lymphadenopathy is not present, biopsy the popliteal lymphnode. the popliteal lymph node is the most accessible peripheral node for biopsy. avoid biopsy of intra-abdominal lymph nodes if possible. • perform bone marrow aspiration to identify infiltration by neoplastic cells and the disease (see "clinical techniques"). • if the spleen is involved, perform a splenectomy (see chapter ) to reduce the overall tumor load. chemotherapy for lymphoma may be successful (approximately % remission rate). in general, protocols have been adapted from feline medicine (see chapters and ). • success of chemotherapy may be affected by the age of the ferret, concurrent disease (e.g., adrenal gland disease, insulinoma), concurrent medication, inappropriate use of and resistance to chemotherapeutic agents (ferrets treated with prednisone prior to chemotherapy), and the type of lymphoma present. • ferrets with bone marrow involvement or with solid tumors involving organs typically have a poor prognosis. • longer periods of remission tend to occur in individuals with adult onset or lymphocytic lymphoma. • iv chemotherapeutic agents are given via butterfly catheter or small-gauge needle with the ferret under sedation; face-mask administration of isoflurane is the most convenient and rapid method of sedation. • one chemotherapy protocol is outlined in table - . m key point monitor the cbc weekly. if the wbc falls below wbc/ml, or the rbc falls below ¥ /ml discontinue vincristine for week or more until the wbc count increases to at least wbc/ml. • palliative therapy may be attempted by administering oral prednisone ( . mg/kg) po q h. • supportive care is important (see "nutritional support for insulinoma"). • consider referral to an oncologist if experience with chemotherapeutic agents is limited. • chordoma: chordomas are tumors that arise from notochord remnants. tumors occur most often at the tip of the tail, but may occur in the cervical region as well. • git: gastric adenocarcinoma. • other tumors reported in ferrets include chondroma, chondrosarcoma, fibroma, fibrosarcoma, hepatic adenocarcinoma, hemangioma, hemangiosarcoma, mast cell tumor, mesothelioma, osteoma, osteosarcoma, schwannoma, squamous cell carcinoma, thymoma, and renal and pancreatic carcinomas. ferrets may experience dramatic seasonal changes in the haircoat triggered by photoperiod changes. this change is most apparent in the intact animal. if one is unfamiliar with these changes, normal coat changes may be interpreted incorrectly as a medical problem. m key point individual animals may exhibit different patterns of coat change each successive year. • a normal, diffuse, gradual thinning of the coat typically occurs in the spring when the photoperiod is increasing and continues through the summer. the coat typically becomes shorter and darker at this time, and the face mask may appear or disappear. focal alopecia should not be present. • some ferrets may experience a dramatic -day loss of the undercoat. • a normal, but dramatic, loss of body weight (up to %) may occur at this time as well. • hair growth will reverse in the fall and winter. coats typically become longer, thicker, and lighter. body weight may change (up to %) as well. • females in estrus and males "in season" may show an even more marked hair loss but should not have areas of alopecia. • males typically lose hair in the inguinal area because of constant rubbing to mark territory; the mid-and caudal abdomen is often wet with urine. • neutered ferrets or ferrets kept under artificial lighting conditions often experience no coat changes. • neutering or spaying may cause temporary, diffuse alopecia hair thinning postoperatively, particularly if the animal was reproductively active at the time of surgery. the preoperative color pattern may not return. • at any time of the year, regrowth of hair that has been shaved for medical procedures is slow. this is particularly true in the winter and summer when no active hair growth is occurring. • hair regrowth (regardless of the cause of alopecia) is often preceded by a blue to purple discoloration of the skin that can alarm the owner. this discoloration is caused by new hairs growing through the dermis, and is most noticeable on the abdomen and face. • intact jills may exhibit a bluish discoloration of the skin during estrus. if ovariohysterectomy is performed while a jill is in estrus, this discoloration may occur approximately days postoperatively. • pseudonails associated with hyperkeratosis of the footpads may occur in ferrets older than years of age that are housed on carpet or linoleum surfaces. trim pseudonails as necessary. rub a small amount of petroleum jelly or vitamin e oil into the pads daily to help prevent lesions. cutaneous bacterial infections in ferrets are typically manifested as abscesses or as a diffuse, ulcerative pyoderma. • abscesses may develop secondary to puncture wounds, bites, or may develop in the inguinal fat after traumatic injury (e.g., being stepped on). for diagnosis and treatment of abscesses, see "infectious diseases." ulcerative pyoderma is the second most commonly encountered form of bacterial dermatitis in the ferret. • various bacteria can cause ulcerative pyoderma. the most common agents are staphylococcus and streptococcus spp. • focal alopecia with diffusely hyperemic, thickened, ulcerated skin may occur over any area of the body. • perform a cutaneous punch biopsy (see chapter ) to rule out diffuse cutaneous mast cell tumor, which may have a similar gross appearance. • perform bacterial culture and sensitivity testing. • administer systemic antibiotics based on culture and sensitivity testing. antibiotics effective in the treatment of pyoderma in ferrets often include amoxicillin-clavulanate (clavamox, smithkline) ( - mg/kg) q h po and cephalosporins (use feline dosages). • topical treatments include twice-weekly cleansing with an antibacterial shampoo containing chlorhexidine or benzoyl peroxide. daily application of an antibacterial cream may be beneficial if the lesion is small and localized. dermatologic lesions are quite prominent with cdv infection in ferrets. • dermatologic signs typically begin with hyperemia around the lips, chin, eyes, and sometimes the inguinal area. with time, crusts and skin thickening may appear. • hyperkeratosis of the foot pads occurs as the disease progresses. • see infectious diseases in this chapter for a detailed discussion of cdv in ferrets; also see chapter for a discussion of cdv in dogs. • microsporum canis and trichophyton mentagrophytes are the most common causes of superficial mycotic infections in the ferret. • see "infectious diseases" in this chapter for diagnosis and treatment. • flea infestation may be encountered in pet ferrets. clinical signs are similar to those seen in cats (see chapter ). • flea shampoos, dips, or powders containing pyrethrin may be used. products containing lindane or organophosphates are not recommended for use in the ferret. • imidacloprid (advantage, bayer corporation, shawnee mission, ks) ( . ml) topically every weeks has been reported to be effective. no adverse effects have been noted. this drug may be used in conjunction with lufenuron. • lufenuron (program, norvartis animal health, greensboro, nc) ( mg) po every weeks has been anecdotally reported to be effective. advise clients that there is a -to -week period before flea numbers are observed to decline. • fipronil (frontline, merial ltd., iselin, nj). half the cat dose has been anecdotally reported to be effective. this drug may be used in conjunction with lufenuron. • selamectin (revolution, pfizer, new york, ny). administration of the cat dosage has been anecdotally reported to be effective. • flea collars are not recommended because they come off easily and small pieces can be ingested. • treat the environment for fleas. ear mite infection in ferrets is caused by otodectes cyanotis, the same parasite that infects cats and dogs. • ferrets rarely exhibit pruritis, even with heavy mite infestation. • • when chronic ear mite infestation is present, lichenification and a bluish pigment may appear on the inner surface of the pinnae. these changes are caused by a response to chronic irritation, and usually regress after treatment. • rarely, o. cyanotis may colonize other parts of the body. • examine all ferrets for ear mites; the incidence of infestation is high in some populations. • mites in the ear canal can often be visualized using an otoscope; however, otoscopic examination is often difficult because of the uncooperative nature of the patient and small size of the ear canal. • tresaderm (merck agvet, rahway, nj) may be used to treat ear mites in ferrets. administer drops in each ear q h for days, stop for days, then repeat. this medication has been reported to be effective in treatment of ear mites in the ferret. • selamectin may be used for treatment of ear mites in the ferret. use at the dose described for treatment of fleas. • bathe the ferret within to hours after treatment. wash all bedding and treat all other potential hosts in the household (see chapter ). • topical treatments may not be effective due to the narrow size of the ear canal, and patient resistance to treatment. • persistent infections may be due to the presence of ear mites on the body, or failure to deliver the topical agent effectively. in such cases, parenteral administration of ivermectin ( . mg/kg) sc every to days for treatments may be necessary. do not use topical and parenteral ivermectin together. • lesions are typically confined to the feet, which become hyperemic, swollen, and intensely pruritic. crusting often occurs around the nails, and in severe cases the nails may slough. • generalized alopecia, accompanied by intense pruritis, occurs rarely. • a positive diagnosis is based on clinical signs, exclusion of differential diagnoses, and positive skin scrapings obtained from several sites (false negative results do occur). • a common differential diagnosis is contact allergy. similar lesions have been observed in ferrets housed on plastic-floor cages. these lesions resolve when the cage bottom is changed to wire or wood. • advise clients of the zoonotic potential of this parasite. • treatment may need to be based on differential diagnoses; mites may be difficult to identify on skin scrapings. • administer ivermectin ( . mg/kg) sc every weeks for three treatments. • lime sulfur dips may be used instead of ivermectin. dip ferrets in % lime sulfur every days until signs have resolved for weeks. • wash all bedding and treat all potential contact hosts in the household. demodicosis is rare in the ferret. • otitis externa has been associated with demodicosis. this may be the only presenting sign. • localized alopecia accompanied by pruritis may occur. • mites may be identified on routine skin scrapings and examination of ear canal debris. • treatment can be difficult. use ivermectin at the daily dose described for dogs (see chapter ). • do not use mitotane. the etiology of tail alopecia in the ferret is unknown but is suspected to be caused by hormonal fluctuations because the disease responds to changes in the photoperiod. hair loss occurs most commonly at the time of the fall molt, when the photoperiod is becoming shorter, but may be seen any time of year under artificial lighting conditions. hair regrowth usually occurs in - weeks. the same pattern of alopecia is not always repeated annually. • hair loss, ranging from diffuse hair thinning to complete alopecia, occurs from the base of the tail to the tip. m key point alopecia occurs only on the tail. if alopecia extends to the body, suspect another form of endocrine disease, such as adrenal gland disease. • comedones and a brown, waxy scale may accompany the alopecia. • diagnosis is based on clinical signs. • differential diagnoses include the early stages of adrenal gland disease; however, hair loss on the body typically occurs as well when this condition is present. • no treatment is necessary. hair regrowth will occur when the photoperiod changes. • artificially lengthening the photoperiod may speed hair regrowth, although not reliably. • if the tail exhibits excessive amounts of waxy scaling or comedones, clean the tail weekly with a mild shampoo. alopecia may be seen in intact females that have been in estrus for month or longer. • bilaterally symmetrical hair loss over the shoulders and flanks, which eventually progresses to involve the entire body. hairs epilate easily, and the underlying skin appears normal. • a grossly enlarged vulva indicates a state of estrus. be aware that the ferret also may be anemic and thrombocytopenic (see "anemia"). • diagnosis is based on clinical signs in an intact female. • perform an ovariohysterectomy (see chapter ) if the ferret is stable enough for the procedure, or induce ovulation with hcg (see "termination of estrus"; "anemia"). • hair regrowth will recur rapidly after surgery or ovulation; however, changes in hair length, color, or thickness are common. • bilateral, symmetrical alopecia is a common sign of adrenal disease in the ferret (see "adrenal gland disease"). • hypothyroidism has not been documented in ferrets. neoplasia of the skin is the third most common neoplasia reported in the ferret and commonly occurs in ferrets year of age and older. complete removal of skin masses using wide surgical excision followed by histopathology is recommended. mast cell tumors are the most common skin masses encountered and are typically benign in the ferret. • individual tumors typically appear as slightly raised, flat, button-like cutaneous masses ranging in size from to mm. the tumors are often tan in color or may be hyperemic with a dark flaky crust. tumors may also appear as raised, ulcerated areas, or as diffuse areas of erythema and crusting. pruritis may be present at the site. • mast cell tumors have occasionally been associated with diffuse or generalized areas of alopecia that resolve with surgical removal of the tumor. • metastasis is rare but has been reported in the lung and gallbladder (see chapter for information about mast cell tumors in dogs and cats). • these tumors may also be referred to as haral cell tumors or sebaceous adenomas and are common in the ferret. • tumors may appear as wart-like, ulcerated, or cystic masses ranging in size from . to cm. • excision is usually curative. recurrence is rare, and metastasis is not reported. • other, less common neoplasms of the skin and subcutaneous tissues include: basal cell carcinoma, basi-squamo-sebaceous carcinoma, hemangioma, histiocytoma, leiomyosarcoma, lymphoma, myxosarcoma, neurofibrosarcoma, perianal gland adenocarcinoma, sebaceous gland adenocarcinoma, and squamous cell carcinoma. • adenocarcinomas often metastasize to regional lymph nodes, liver, and lungs. • diagnosis, treatment, and prognosis for these tumors in ferrets are the same as for dogs and cats (see chapter ). • cardiac auscultation is centered more caudally in the thorax than are auscultations in cats. • the heart extends from the sixth rib to the caudal border of the seventh or eighth rib (compared with cats, where it extends from the second to the sixth rib). • the heart rate averages to beats per minute. • a pronounced sinus arrhythmia and pronounced bradycardia are common during auscultation. • cardiac disease is relatively common in the ferret. quality of life and long-term prognosis for ferrets with cardiac disease depends on the type and severity of cardiac disease present, and the initial response to treatment. many ferrets do well for months on the appropriate medications. • ferrets appear to compensate well for early cardiac insufficiency, perhaps because a slight decrease in activity is not readily apparent to owners. • ferrets with congestive heart failure (chf) may present with clinical signs that resemble symptoms associated with other disease entities, such as anorexia, ascites, coughing, dehydration, dyspnea, exercise intolerance, generalized weakness, hindlimb weakness, hypothermia, lethargy, tachypnea, and weight loss. • pale or cyanotic mucus membranes and a prolonged capillary refill time (crt) may be noted on physical examination. • jugular pulses may be present when right-sided chf is present. • femoral pulses may be weak, irregular, or normal. • ascites, hepatomegaly, or splenomegaly may be noted on abdominal palpation. • murmurs may be noted on auscultation, and are typically associated with valvular insufficiency. • history and physical examination findings are important in the diagnosis of heart disease. • perform a complete physical examination, including auscultation of the heart, and evaluation of the capillary refill time. observe for tachypnea or dyspnea and auscult the lungs. palpate the abdomen and examine for ascites. m key point proceed with further testing only if the ferret is stable. otherwise, administer furosemide and oxygen therapy. • diagnosis requires information obtained by radiography, ecg, and echocardiography. • obtain whole-body radiographs. the cardiac silhouette typically appears enlarged and globoid in shape with rounded right and left ventricles. ascites, hepatomegaly, pleural effusion, and pulmonary edema may be present as well. • evaluate a cbc, serum biochemical profile, and urinalysis to determine if azotemia, electrolyte abnormalities, or other systemic diseases are present. perform a heartworm test if the history is supportive for potential exposure. • if thoracic or abdominal effusion is present, perform thoraco-or abdominocentesis and submit fluid for cytologic examination. perform centesis as described for cats; take into consideration the relatively caudal position of the heart in ferrets. sedation is usually necessary. a modified transudate is typically associated with chf. • perform standard six-lead electrocardiography (ecg) if possible (table - lists normal ferret ecg parameters). sedation may be necessary. electrocardiography may reveal atrial premature contractions, atrial tachycardia, atrial fibrillation, ventricular premature contractions, and ventricular tachycardia. m key point sedation with isoflurane is recommended when necessary. sedation with ketamine or a ketamine-diazepam combination raises the heart rate. the heart rate tends to decrease with ketamine-xylazine sedation; therefore, avoid using xylazine in ferrets with suspected cardiac disease. • echocardiography is the most useful diagnostic tool in the ferret. the same echocardiographic changes observed in the dog and cat are seen in the ferret. (table - ) . m key point treatment of acute chf should focus on improving oxygenation and reducing cardiac preload and afterload. • place the ferret in an oxygen-rich environment. administer supportive care such as subcutaneous fluids (e.g. . % saline and . % dextrose), and provide nutritional support for ferrets that are anorexic. • administer diuretics such as furosemide ( - mg/kg) im or iv bid-tid. • nitroglycerin % ointment may be applied to the skin in the axilla, inguinal area, or on a hairless body surface. • angiotensin-converting enzyme (ace) inhibitors may be given to reduce afterload and preload. give enalapril (enacard, merck agvet division) ( . mg/kg) po q h, then titrate up to q h if possible. ace inhibitors may cause hypotension in ferrets, titrate to effect. • when diuretics and ace inhibitors are used together it is important to monitor for azotemia. • perform thoracocentesis or abdominocentesis when indicated. • monitor body weight, crt, heart rate and rhythm, hydration status, mucous membrane color, respiratory rate, respiratory effort, bun, creatinine, and serum electrolytes. m key point chronic therapy typically includes the use of ace inhibitors, and diuretics with the addition of digoxin in ferrets with dilated cardiomyopathy. whenever possible, try to titrate the diuretic dose to the lowest possible dose without recurrence of pleural effusion or pulmonary edema. • administer digoxin elixir ( . mg/kg) po sid-bid to ferrets with dilated cardiomyopathy. • side effects associated with digoxin include anorexia, arrhythmias, diarrhea, lethargy, and vomiting. • serum digoxin levels should be monitored every to weeks. normal values have not been published for the ferret; reference values for dogs and cats are used for interpretation. • use of antiarrhythmic drugs such as atenolol or diltiazem is not well documented in the ferrets, but may be useful in the treatment of ferrets with hypertrophic cardiomyopathy. • salt-free diets may be beneficial; however, they are often unpalatable to ferrets. instruct the owner to avoid feeding snacks, treats, or food items with a highsalt content. • management includes periodic reevaluation of heart rate and rhythm, serum electrolytes, and renal values. radiographs should be used to monitor for the development of pulmonary edema or changes in the cardiac silhouette. ecg and echocardiography should be repeated periodically as well. cardiomyopathy may occur in ferrets years of age or older. dilated (congestive) and hypertrophic forms can occur; the dilated form is more common. the cause of dilated cardiomyopathy (dcm) in the ferret is unknown. • abdominal enlargement secondary to ascites, anorexia, dyspnea, lethargy, and weight loss are often noted. • ascites, heart murmur, pale mucous membranes, tachycardia, and weakness may be noted on physical examination. • moist rales and increased respiratory sounds may be noted when pulmonary edema is present. • pleural effusion may be present, and may cause an increased inspiratory effort. the heart may sound muffled on auscultation. • coughing generally is not noted. • see the chf section in this chapter. • treatment is the same as that described for chf. • taurine supplementation does not appear to have any effect on dcm in the ferret. • see the chf section in this chapter. the cause of hypertrophic cardiomyopathy (hcm) is unknown. • clinical signs may be compatible with those described for chf or dcm (see above). • other clinical signs are similar to those described for the cat, and include acute onset of congestive heart failure and/or sudden death. • follow the same guidelines described for dcm. • include hcm on the rule-out list when evidence of cardiac disease is noted on the physical examination or diagnostic evaluation. • radiographs may not be beneficial in the diagnosis of hcm. • echocardiography should be used for definitive diagnosis. • treatment should be aimed toward alleviating signs of chf and improving the diastolic efficiency of the left ventricle. • administer beta-adrenergic blocking drugs such as atenolol ( . - . mg) po sid. titrate to effect. • administer calcium channel blockers such as diltiazem ( . - . mg) po bid. titrate to effect. • diuretics are indicated if symptoms of chf are present (see above). • follow-up is the same as that described for chf and dcm. natural and experimental heartworm infections have been reported in ferrets (see chapter ). the clinical presentation of heartworm disease typically resembles that of cats; however, the life cycle of dirofilaria immitis in ferrets is similar to the life cycle present in the dog. reported adult worm burdens range from to . the presence of only one adult worm in the heart can be lethal. • heartworm disease is caused by the canine heartworm dirofilaria immitis, a filarial nematode that is transmitted via mosquitoes. • ferrets that are housed outdoors in endemic areas are at greatest risk of infection; however, ferrets kept indoors also can become infected. • clinical signs include coughing, dyspnea, hepatomegaly, inappetence, lethargy, melena, weakness, and symptoms associated with right-sided chf (pulmonary edema, pleural effusion, ascites). sudden death due to pulmonary artery obstruction may also occur. • microfilaria may be present in the blood of approximately % of infected ferrets. • diagnosis is based on the history, clinical signs, heartworm test results, radiographs, and echocardiography. • if the history is compatible with cardiac failure, inquire about possible mosquito exposure. • physical examination findings resemble those of heart failure (see above). m key point minimize stress in ferrets suspected of heartworm disease. if symptoms of congestive heart failure are present, delay further diagnostic evaluation until the patient is stabilized (see "treatment of congestive heart failure"). • obtain whole body radiographs. thoracic changes may include cardiomegaly with enlargement of the right atrium, caudal vena cava, and right ventricle. pleural edema and pleural effusion may be present as well. radiographic changes in the peripheral pulmonary arteries are not typically noted because the worms tend to reside in the right side of the heart and in the main pulmonary artery. abdominal changes often include hepatomegaly, splenomegaly, and ascites. • if possible, draw blood for the modified knott's test for microfilaria. microfilaria are identified in approximately % of infected ferrets. • submit blood for an enzyme-linked immunosorbent assay (elisa) for dirofilaria antigen. antigen is produced by adult female heartworms; there is a potential for false negative test results in ferrets with low worm burdens. a commercial assay (snap heartworm antigen test kit; idexx laboratories inc., portland, me) has been used to detect heartworm infection in the ferret. • perform a cbc, serum biochemical profile, and urinalysis to rule out the presence of other systemic diseases. • if pleural or abdominal effusion is present, submit fluid for cytology. a modified transudate is typically noted when chf is present. • echocardiography may be used to visualize heartworm(s) in the pulmonary artery, right ventricle, and right atrium; dilation of the right ventricle and right atrium may be assessed as well. doppler echocardiography may be used to evaluate the patient for the presence of pulmonary hypertension. • treatment of heartworm disease in ferrets is difficult. success is dependent on early diagnosis, diligent supportive care, and long-term antithrombotic therapy in conjunction with adulticide therapy. • if signs of chf are present, treat this first, and stabilize the patient (see the chf section). • if the patient is symptomatic and microfilaremia positive: • administer microfilaricidal therapy: ivermectin ( µg/kg) sc every days until clinical signs and microfilaremia resolve. • follow with adulticide therapy: melarsomine (immiticide, rhone merieux, athens, ga) using a two-stage protocol: stage : administer a single dose of melarsomine ( . mg/kg) im. stage : month later, administer two injections of melarsomine ( . mg/kg) im given hours apart. • transient swelling at the site of injection is common. • administer prednisone ( . mg/kg) po sid-tid during adulticide treatment and for as long as clinical signs persist. • if pleural effusion is present administer diuretics (see the chf section). • cage confinement is important for to weeks after treatment. • perform a post-treatment elisa for heartworm antigen months after adulticide therapy. repeat every days if results are positive. most ferrets become seronegative months after treatment. • begin heartworm prevention month after adulticide treatment. • if ferrets are microfilaria negative, administer adulticide therapy as described above. m key point because of the high mortality associated with heartworm disease, recommend preventive therapy for all ferrets in heartworm-endemic areas. • ivermectin may be given as preventive therapy beginning month before and continuing months after mosquito season. liquid ivermectin % may be diluted in propylene glycol ( . ml ivermectin in ml propylene glycol) and administered at a dose of ( . ml/kg) po every month. this solution must be stored in an amber glass bottle out of sunlight. feline heartguard (merck agvet) may be administered using the dose appropriate for a -to -lb cat. • if possible, house all ferrets in endemic areas within structures with mosquito-proof screening. • follow the same recommended guidelines for heartworm prevention in dogs and cats. valvular heart disease may occur in ferrets > years of age. • clinical signs depend on the severity of the underlying disease process. • mitral regurgitation may be ausculted as a systolic murmur in the left apical region. • tricuspid regurgitation is ausculted in the right parasternal region. • dyspnea and moist rales may be noted on auscultation of the lungs if chf is present. • obtain thoracic radiographs to evaluate the size of the heart and to determine if chf is present. pulmonary edema typically appears as a mixed alveolar and interstitial pattern in the caudodorsal lung lobes. • electrocardiography (ecg) may be normal or may demonstrate evidence of atrial arrhythmias. • echocardiography typically demonstrates thickening of affected valves and atrial enlargement. • doppler echocardiography may be used to identify and quantify the degree of regurgitation present. aortic regurgitation is often noted in ferrets and is considered an incidental finding. • treatment is recommended if chf is present, or if cardiac enlargement is significant (see the chf section). myocarditis occurs when the myocardium is infiltrated with inflammatory cells, resulting in the development of reduced myocardial function, arrhythmias, and replacement of the normal myocardial tissue with fibrous tissue. • causes include sepsis, systemic vasculitis, parasitic, bacterial or viral infection, and autoimmune disorders. • aleutian disease can cause fibrinoid necrosis and mononuclear cell infiltration of the arterioles of the heart. • antemortem diagnosis is difficult. • suspect myocarditis if arrhythmia and/or acute myocardial dysfunction is noted in association with multisystemic illness. • definitive diagnosis is made by histopathological evaluation of affected myocardial tissue. • treatment should be directed at identifying and treating the underlying systemic disease. • cardiovascular support should be provided and may include the use of diuretics or antiarrhythmic drugs (see the chf section). as clinical experience with pet ferrets increases, other types of cardiac disease are likely to be recognized. third-degree heart block (of unknown etiology) and various forms of valvular disease, including mitral and tricuspid insufficiency and endocarditis, have been seen in ferrets. • the approach to these conditions in ferrets is the same as for other companion animals; use the drug dosages given previously for cardiac myopathies. • the permanent teeth erupt between and days of age. • the dental formula is (i / , c / , pm / , m / ). • the third upper premolar (carnassial tooth) has three roots. the second lower molar has one root. all other premolars and molars have two roots. • the ferret is an obligate carnivore with a simple stomach, short intestinal tract, no cecum or ileocolic valve, and a short colon. • the duodenum terminates at the jejunoileum; there is no gross anatomic distinction between the jejunum and the ileum. • the junction of the jejunoileum and the colon is determined by evaluating the pattern of anastomosis between the jejunal artery and the ileocolic artery. • gi transit time is approximately to hours. • the anal sacs are located between the external and internal anal sphincter muscles at and o'clock. the ducts are located near the mucocutaneous junction. • the exact nutritional requirements of the ferret have not been determined. • the diet of the ferret must contain predominantly animal protein and fat. • due to the short digestive tract and rapid gi transit time, the ferret requires a concentrated maintenance diet high in protein ( - %) and fat ( - %), and low in fiber. the protein quality should be % to % digestible. • breeding ferrets and kits may require diets higher in protein and fat. • meat, poultry, meat and poultry meals, and other animal-based proteins should appear first, then several more times on the food ingredient list. • complex carbohydrates (starch, fiber) are not readily digested by the ferret. high-fiber diets can induce a relative protein-calorie deficiency; the ferret cannot eat enough of a low-density food to meet its high maintenance requirements. • premium cat foods and ferret diets typically meet the ferret's nutritional requirements for growth and reproduction. • treats and supplements should not exceed more than % of the daily diet. acceptable treats include meat baby foods, and moist cat or ferret diets. high-sugar or carbohydrate treats should be limited, especially if insulinoma is present. • fatty acid supplements should be given in measured amounts (a few drops per day). administration of large quantities of fatty acid supplements may reduce the intake of the balanced diet. • canine diets should not be fed to ferrets; the protein, fat, and carbohydrate content is not appropriate, and the diets often contain high percentages of grain and vegetable matter. • the long-term effect of formulated dry and canned diets on the long-term health of ferrets is controversial among some practitioners. • some practitioners feel that feeding commercial diets containing large quantities of plant-based ingredients contributes to the development of eosinophilic gastroenteritis, inflammatory bowel disease, insulinoma, urolithiasis, and general untriftiness. for example, most ferrets in the united states are fed dry kibbled diets, and the incidence of insulinoma is high. many ferrets in europe and australia are fed whole prey items (e.g., a "natural diet), and the incidence of insulinoma is low. • a correlation between diet and the development of certain diseases in ferrets is hypothetical at this time; however, this controversy demonstrates the need for longer-term diet studies in the ferret. • the canine teeth are often worn or broken at the tips due to biting and gnawing. • broken canine teeth typically are not painful unless the dental pulp is exposed. • dental tartar and periodontal disease are common in ferrets over years of age. • soft, moist diets may predispose ferrets to the development of dental disease. • tartar typically accumulates first on the second and third upper premolars. • dental abscesses are not common, but may be noted, even in young ferrets. • follow the basic medical and surgical treatment principles described for dental diseases in dogs and cats (see chapter ). • ferrets have five major pairs of salivary glands: the parotid, submandibular, sublingual, molar, and zygomatic. • salivary mucocele occurs secondary to trauma or infection of a salivary gland. • salivary mucocele typically presents as a soft to firm swelling in the region of the orbit, oral commissure, or mandibular lymph node. aspiration of the swelling often yields a clear to serosanguinous or mucinous fluid; microscopic examination demonstrates amorphous debris and occasional rbcs. • treatment of choice is surgical excision of the affected gland (see chapter ). • advise clients that recurrence is possible. megaesophagus is rare in ferrets. • the etiology of megaesophagus in ferrets is unknown (see list of possible causes in dogs in chapter ). • clinical signs resemble those described for the dog and include: lethargy, anorexia, dysphagia, coughing, choking, dyspnea, weight loss, and regurgitation. • clients may indicate that the ferret vomits up large boluses of food. • diagnosis may be based on clinical signs and radiographic evidence of megaesophagus. • obtain thoracic radiographs. the esophagus is often dilated and filled with air in the cervical and thoracic regions. food may be present within the lumen of the esophagus. • perform a barium contrast study to delineate the esophageal mucosa and to identify potential mural lesions, strictures, or obstructions. • aspiration pneumonia may be visible radiographically. • follow canine treatment protocols. the prognosis is poor; response to therapy is usually not successful. • gi promotility agents such as metoclopramide • administer antibiotics if indicated for aspiration pneumonia. • supportive care includes feeding high-calorie, highprotein slurried diets to times per day, and elevating the ferret for to minutes immediately after feeding. • ferrets, like other carnivores, are able to vomit. • differential diagnoses to consider for vomiting include esophageal and gastroenteric disorders (see below). • ferrets often demonstrate symptoms associated with nausea or vomiting when gastroenteritis, gi disease, gastric ulcers, helicobacter mustelae gastritis, or gi foreign bodies are present. hypoglycemia may cause signs of nausea as well (see discussion of insulinoma in this chapter). • signs of nausea include hypersalivation and pawing at the mouth. • ferrets may demonstrate bruxism (grinding of the teeth) when abdominal discomfort is present. • gi parasites are uncommon in the ferret. coccidiosis and giardiasis are occasionally seen. nematodiasis is rare. • routine fecal testing is still recommended, especially in young animals and ferrets with diarrhea or rectal prolapse. • young ferrets with coccidiosis may have diarrhea and may be severely dehydrated. • cryptosporidiosis may occur in ferrets, but typically does not result in clinical disease. the zoonotic potential is unknown; however, it may be prudent to warn immunosuppressed owners of the potential for zoonosis. • treat with appropriate anthelmentics following the protocols and dosages used for cats (see chapter ). • obtain fasting whole-body radiographs to help rule out the presence of a gi foreign body or trichobezoar. • a barium study may be used to demonstrate gi ulceration. • exploratory laparotomy/gastrotomy is often required for a definitive diagnosis. • diagnosis of h. mustelae gastritis is often a diagnosis of exclusion. definitive diagnosis requires the finding of organisms along typical histological lesions on gastric biopsy specimens. • debilitated, anorexic ferrets may require hospitalization for supportive care. • if the patient is vomiting, withhold food for to hours. administer iv fluids containing dextrose, and monitor for signs of hypoglycemia. when vomiting has resolved begin to offer small, bland meals. • feed small meals of a bland, moist diet tid-qid (see diet recommendations in "insulinoma" section). avoid feeding high-fiber dry foods. • administer broad spectrum antibiotics if the ferret is debilitated. • administer a gastric protectant. options include: • gi obstruction caused by foreign body ingestion or hairballs is one of the most common problems in pet ferrets. • foreign bodies typically occur in ferrets younger than year of age; trichobezoars (hairballs) are common in ferrets older than years of age. m key point suspect the presence of a gi foreign body in any young ferret presented for anorexia, even if no vomiting is reported. • rubber and foam objects are the most common foreign bodies. obstruction with a hairball (older ferrets), cloth, or plant material also may occur. • lethargy, partial or total anorexia, hypersalivation, bruxism, pawing at the mouth, weight loss, and diarrhea are the most common clinical signs of gi foreign body. hindlimb weakness, dehydration, and melena may be noted as well. • vomiting is uncommon; however, if the ferret is vomiting, be suspicious that a gi foreign body may be present. • diagnosis is based on the history, physical examination findings, radiographs, or exploratory laparotomy. • history: identify possible types or causes of foreign body ingestion. ask the owners if hairball preventative is used routinely. • physical examination: large gastric foreign bodies are often palpable. small foreign bodies in the small intestine may be associated with localized pain. • obtain fasting ( - hours) plain whole body radiographs. radiographs may reveal segmental ileus, and marked gaseous distention of the stomach and/or bowel. occasionally a foreign body or trichobezoar can be identified. • obtain a gi barium contrast study to identify small foreign bodies and to rule out gi ulceration. • perform a cbc and serum biochemical panel to rule out hepatic lipidosis and other systemic diseases. surgical removal is the treatment of choice. if the ferret is debilitated, begin supportive therapy, and perform surgery as soon as possible. • surgery: follow routine preoperative, operative, and postoperative procedures for gastrotomy or enterotomy (see chapters and ). ferret tissues are more delicate than those of a puppy or kitten of equivalent weight. use - or - suture material to close the gi tract. • perform gastric biopsy to rule-out underlying h. mustelae infection, and other gi diseases. perform biopsy of the liver. • evaluate the entire abdominal cavity prior to closure. older ferrets often have concurrent diseases such as insulinoma or adrenal gland disease. • the prognosis following gastrotomy is good with prompt therapy. m key point instruct owners to "ferret proof" the house if ferrets are allowed to roam. in particular, restrict access to rubber toys and rubber objects. • to prevent trichobezoars, administer a feline hairball laxative product ( - cm) po to times per week. epizootic catarrhal enteritis (ece, "green slime disease") is a highly infectious diarrheal disease that first appeared in . the etiological agent is thought to be a coronavirus. ece can spread rapidly through a ferret population, often affecting % of ferrets within hours. histological examination of intestinal biopsy samples reveals lymphocytic enteritis with villous atrophy and blunting, and degeneration of the apical epithelium. • the history often includes recent exposure of an older ferret to a new or young ferret that appears healthy. often within hours the older ferret becomes anorexic and lethargic. • four clinical syndromes are typically seen: . ece may cause relatively mild diarrhea that lasts several days in young ferrets with no underlying disease. . ece may cause severe diarrhea lasting for several days that may be followed by an acute onset of severe bloody diarrhea in older ferrets or ferrets with concomitant disease. anemia may develop as a sequelae. . a wasting disease with abnormal stools that have the appearance of bird-seed or of being grainy. these stools may develop in ferrets that initially appear to have recovered from the diarrheal phase. . voluminous green, watery diarrhea and occasional vomiting followed by chronic wasting may occur in some ferrets. • the clinical course of disease can be prolonged in some ferrets, and may last weeks to months. affected ferrets typically appear to recover, but continue to have persistent, intermittent diarrhea. • the disease may recur in previously affected ferrets; an asymptomatic carrier state appears to be possible. • do not house ferrets that have had ece with ferrets that have not had the disease. • rotavirus has been associated with several outbreaks of diarrhea and high mortality in ferret kits to weeks of age; it is often referred to as "ferret kit disease." • rotavirus also causes diarrhea in the young of several other species, including humans, cattle, swine, sheep, and rats. • in adult ferrets, rotavirus infection is rarely fatal, but may cause bright green mucoid diarrhea that lasts for several days. • there is no readily available antemortem test for the rotavirus infection; rotavirus particles can be identified in feces by electron microscopy. • treatment consists of supportive care. administer fluids, antibiotics, and nutritional support. salmonellosis is rare in the ferret, and is typically associated with exposure to contaminated raw meat and meat by-products. salmonella typhimurium, s. newport, and s. choleraesuis may be associated with clinical disease. • clinical signs include anorexia, lethargy, fever, and diarrhea (usually bloody). conjunctivitis and anemia have also been reported. • diagnosis is based on clinical signs and a positive fecal culture. multiple fecal samples must be collected, and selective media is used for culture. • treatment includes aggressive supportive care and antibiotic therapy. • ferrets may be presented in shock. iv fluids and administration of rapidly acting intravenous corticosteroids may be necessary for treatment of these patients. • other details of salmonellosis, including its public health significance, are discussed elsewhere in this text. eosinophilic gastroenteritis (ege) is an inflammatory bowel disease that occurs in ferrets and other animals. no specific etiological agent has been identified in the ferret, but food allergy is implicated in humans and other animals. • chronic diarrhea with or without mucus or blood, and weight loss are the most common signs. inappetence, intermittent vomiting, and skin lesions may be seen as well. • on physical examination, the mesenteric lymph nodes may be enlarged and the intestines may feel thickened. • a marked peripheral eosinophilia is often present on the cbc differential. • presumptive diagnosis is based on history, clinical signs, physical examination findings, the presence of a peripheral eosinophilia, and/or the presence of eosinophils on fecal cytology. • definitive diagnosis is based on histological examination of intestinal biopsy specimens. mild to extensive eosinophilic infiltration of the mucosa, submucosa, and muscularis of the stomach and small intestines are noted. focal eosinophilic granulomas maybe identified in the mesenteric lymph nodes. • treatment is similar to that described for treatment of dogs and cats. • begin corticosteroid therapy with prednisone ( . - . mg/kg) po sid every days. perform a recheck examination and cbc weeks after the last dose. if the ferret has improved clinically and the peripheral eosinophilia is resolving, decrease the prednisone dose by % every days, and recheck again. continue the prednisone taper at -week intervals until the ferret is tapered to the lowest possible dose, or withdrawn from the steroids altogether. • although food allergy has not been identified as a definitive etiological cause of ege, changing the ferret to a hypoallergenic diet, such as a feline lamb and rice-based diet may be helpful in resolution of signs. • there have been reports of ferrets with peripheral eosinophilia (up to %), and erythema and crusting of the feet, ears, and face. histological lesions in biopsy specimens from affected skin were consistent with allergic dermatitis. these ferrets were treated with corticosteroids, and did respond to treatment. one also responded to diet change. inflammatory bowel disease (ibd) can occur in the ferret. the etiology is unknown; dietary factors, hypersensitivity reactions, or an immune-mediated cause have been considered. • clinical signs can be subtle and include diarrhea; nausea; occasional vomiting; soft, malformed stools that resemble bird seed; and weight loss. these signs often resemble ece, ege, and helicobacter gastroenteritis. • affected ferrets are often young or middle-aged adults. • elevation of liver enzymes and serum globulins may be noted on serum biochemistry analysis. • lymphocytosis may be noted on the cbc. • diagnosis is based on the history, clinical signs, and diagnostic work-up. • definitive diagnosis is made by histological examination of gastric and intestinal biopsy samples. mild to severe lymphoplasmacytic gastritis and enteritis are noted on histopathology. • administer corticosteroids such as prednisone ( . - . mg/kg) po sid every days initially, and taper in a manner similar to that described for ege. some ferrets respond poorly to steroid therapy. • azathioprine (imuran, prometheus laboratories, san diego, ca) ( . mg/kg) po q - h may be used as an alternative to steroid treatment. • hypoallergenic diets may offer some benefit. proliferative bowel disease (pbd) in ferrets was first reported in , and is similar to the pbd that occurs in swine and hamsters. pbd was a commonly encountered disease in the late s and early s, but is relatively uncommon now. pbd is caused by lawsonia intracellularis, an intracellular bacteria that cannot be propagated by routine culture methods. • this disease affects primarily young ferrets to months of age. • acute and chronic forms of the disease can occur. • diarrhea is present and often contains mucus and blood. defecations are frequent and small; ferrets often cry out when they defecate. the rectum may be partially prolapsed. • other signs include lethargy, depression, inappetence, weight loss, dehydration, and pyrexia. • neurologic signs such as ataxia and muscle tremors may be present. • the intestines may feel firm or thickened on abdominal palpation. • a tentative diagnosis of proliferative bowel disease is based on clinical signs and physical examination. definitive diagnosis requires intestinal or colonic biopsy, but this rarely is warranted because response to therapy usually is good if initiated early. • a polymerase chain reaction (pcr) assay specific for the swine isolate, and an indirect fluorescent antibody test (ifa) are available. • necropsy lesions include gross thickening and discoloration of the small intestine and/or colon. ridges of proliferative tissue that are distinct from normal adjacent tissues are present on the mucosal surface. • histological examination of biopsy samples or necropsy specimens typically demonstrate epithelial proliferation, hypertrophy of the muscularis, and infiltration of the bowel wall with monocytic or granulocytic inflammatory cells. silver-stained tissues reveal intracellular, comma-shaped organisms in crypt epithelial cells. glandular hyperplasia consisting of irregular, branching proliferative glands that lack goblet cells, and necrotic debris may be identified in the crypts. severe glandular hyperplasia may resemble neoplasia and can metastasize. • treat mild cases on an outpatient basis. • hospitalization for supportive care (fluid therapy, nutritional support) may be necessary when severe disease is present. • administer chloramphenicol ( mg/kg) q h, po, iv, im, or sc as the drug of choice. treat for at least weeks; longer therapy often is necessary to prevent relapse. • metronidazole ( mg/kg) q h, po may be effective. • the prognosis is good with timely therapy. • some ferrets improve temporarily and then relapse at the end of the treatment period. use a long-term course of antibiotic therapy in these animals. • rectal prolapse is usually a disease of young ferrets, and is often associated with diarrhea. • possible causes of rectal prolapse include colitis, diarrhea, gi parasitism (e.g., coccidiosis), pbd, and other diseases that may cause straining or diarrhea. • other differentials include gi lymphoma, benign intestinal polyps, and postoperative complications of anal gland removal. • perform direct fecal and fecal flotation tests to screen for parasites. • medical treatment is similar to that described for other species. administer anthelmentics and antibiotics when indicated. • the prolapse may resolve without surgical intervention when the underlying disease process is resolved. • surgical correction is usually unnecessary (see below). • if indicated, perform a biopsy of the prolapsed tissue to rule out lymphoma. • flush the prolapsed tissues with sterile saline and replace them into the rectum. • place a purse-string suture in the anus with a small opening to allow passage of feces. keep the pursestring suture in place for to days. • in ferrets with chronic prolapse, surgery may be necessary to reduce the size of the anal opening. excise a small triangular wedge of anal mucosa and routinely close the defect by suturing. alternatively, consider abdominal exploratory surgery and colopexy (see chapter ) • clinical signs and physical examination findings in ferrets with an abscessed anal sac are the same as those described in dogs and cats. • the recommended treatments include antibiotic therapy, lancing and drainage of the abscess, or surgical removal of both anal sacs (see chapter ). anal sacculectomy is performed as a treatment for anal sac abscesses, or to decrease the musky "ferret" odor. for odor reduction, neutering should be performed simultaneously because the apocrine, perianal, sebaceous, and scent glands in the skin are under hormonal control and contribute to the overall musky odor. some clinicians believe that neutering is sufficient to decrease odor and that routine anal sacculectomy should be discouraged. . grasp the anal sac duct and hold it closed with mosquito forceps. make a circumferential skin incision around the duct opening. . apply gentle caudal traction to the anal sac, and use a scalpel blade or gauze to tease away the surrounding fascia. . leave the surgical sites open, and allow to heal by second intention. . make small, arc-like incisions just lateral to the duct openings. . dissect the subcutaneous tissues bluntly to reveal the neck of the anal sac; grasp the opening and hold it closed with mosquito forceps. . dissect the sac free of surrounding tissues, using gentle traction. . do not suture the incisions. ferrets reach sexual maturity during the first breeding season after birth. the breeding season runs from march to august under natural lighting conditions. • the opening of the prepuce is located just caudal to the umbilical area. • males (hobs) have a j-shaped os penis. • during the breeding season (march-august), testicle size is twice that noted in the fall and winter months. • prostatic tissue is located at the base of the urinary bladder and surrounds the urethra. prostatic disease associated with adrenal gland disease may occur in middle-aged and geriatric male ferrets (see "adrenal gland disease" and "prostatic disease"). • female ferrets (jills) are seasonally polyestrous and are induced ovulators. ovulation typically occurs to hours after mating. • the vulva is located in the perineal region ventral to the anus. in non-estrous females the vulva is small, and looks like a slit; during estrus (or when adrenal gland disease is present), the vulva becomes swollen and is easily visualized. • if mating is unsuccessful, pseudopregnancy results and lasts to days. • approximately % of females remain in estrus if they are not bred. the resultant prolonged elevation of serum estrogens can cause bone marrow toxicity and pancytopenia (see the discussion of anemia under "hematopoietic system" in this chapter). • submit blood for a cbc and platelet count if the ferret has been in estrus for more than days. • termination of estrus is recommended (see "termination of estrus in the hematopoietic".) • most pet male ferrets in the united states have already been neutered prior to weeks of age. • castrate intact male ferrets at to months of age in order to reduce aggressive behavior and odor. • castration is performed using techniques similar to those used in cats (see chapter ). • make an incision in the scrotum over each testicle. • most pet female ferrets in the united states have already been spayed prior to weeks of age. • spaying intact female ferrets is recommended to prevent estrogen-induced bone marrow hypoplasia. • ovariohysterectomy is similar to the procedure performed in cats (see chapter ). • the ventral midline incision is made approximately cm caudal to the umbilicus, and may be extended as necessary. • the uterus is bicornuate, and is located dorsal to the bladder. • ovarian vasculature may be difficult to locate due to the large amount of body fat typically present in this region. • pyometra and metritis are uncommon in pet ferrets in the united states because they are usually spayed prior to being sold as pets. • clinical signs may include anorexia, lethargy, pyrexia, and vulvar discharge. polyuria and polydipsia are not usually noted. • persistent estrus may predispose ferrets to pyometra. • preoperatively perform a cbc and a serum biochemical analysis to rule out estrogen-induced bone marrow hypoplasia (see "anemia" in "hematopoietic system"). • provide appropriate supportive care pre-and postoperatively. • perform ovariohysterectomy when the patient is stable (see chapter ). • start the ferret on broad-spectrum antibiotic therapy preoperatively, and continue postoperatively for to days. use broad-spectrum antibiotics. organisms commonly associated with pyometra include staphylococcus spp, streptococcus spp, corynebacterium spp, and e. coli. • vulvar swelling is an external sign of estrus in female ferrets. • in a spayed female, a swollen vulva indicates a remnant of ovarian tissue, or another source of estrogens and estrogen precursors such as adrenal gland disease (see "adrenal gland disease"). • ovarian remnants typically induce signs of estrus in ferrets younger than years of age. • administer hcg ( iu) im. vulvar swelling should subside if an ovarian remnant is present. if no changes occur, adrenal gland disease is probably the cause of the clinical signs. • perform exploratory laparotomy to remove the ovarian remnant (see chapter ). evaluate for uterine remnants and adrenal gland disease as well. • preoperatively evaluate a cbc to rule out estrogeninduced bone marrow hypoplasia. • pregnancy toxemia is a potentially life-threatening condition that occurs in late pregnancy. primiparous females are most commonly affected. • the disease results in high mortality of jills and kits. • toxemia can be induced if an accidental fast occurs in the last week of gestation. • pregnancy toxemia may also develop in primiparous jills that are carrying large litters due to nutritional compromise induced by the size of the gravid uterus and the resultant reduced capacity of the stomach. • advise owners that pregnant jills must have access to food and water al lib during pregnancy. • suspect pregnancy toxemia if acute lethargy develops in the last week of gestation. other clinical sings include dehydration, melena, hypoglycemia, ketonuria, and azotemia. • affected ferrets usually are presented in an acute state of shock. • treatment includes aggressive supportive care including iv or io fluids containing dextrose. perform an immediate cesarean section (see chapter ). • postoperative care includes continued supportive care, including frequent feedings of high-calorie critical care diets. • jills that survive pregnancy toxemia often do not produce milk. kits can be difficult to hand rear; if a foster jill is not available, attempts may be made to hand rear the kits using a kitten milk replacer (see below). kits born before days of gestation often do not survive. • the prognosis is usually poor, even with aggressive treatment. • do not breed females with a history of mastitis. • abrasions to the mammary tissue and nipples can cause mastitis. prevent trauma from occurring by providing a large nest box opening with smooth edges that allows the jill to pass through easily. • mastitis may be acute or chronic. • acute mastitis typically occurs immediately after whelping or during the third week of lactation. • affected glands appear swollen, firm, red to purple in color, and are painful. gangrene can develop within hours of clinical signs. • treatment must be aggressive. administer broadspectrum antibiotics, and apply hot packs to the affected area to times per day for days. debride necrotic tissue if present. provide supportive care and analgesic therapy. • submit a sample for bacterial culture and sensitivity testing. modify antibiotic therapy based on test results. • if there is no clinical response to medical therapy in days, or if gangrene rapidly develops, consider surgical removal of the affected mammary tissue. because of the potential for severe toxicity and life-threatening disease, do not delay surgery if gangrene is already present, or if there is no improvement with medical therapy. • if the jill continues to lactate, leave the kits with her. supplement feed the kits with a kitten milk replacer if necessary. do not foster the kits with another jill because this may result in mastitis in the foster jill. • ingestion of infected milk may cause gastroenteritis in the kits; kits may need to be treated with antibiotics as well. • chronic mastitis is often difficult to diagnose. the affected jill often appears normal, while the kits lose weight or fail to thrive. • mammary glands appear firm but are not painful or discolored; often the glands are presumed to be full of milk. • affected mammary glands become scarred and are no longer functional. affected jills should be culled from the breeding program. • hand-rearing kits from birth is difficult. prognosis is poor for survival. • it may be necessary to provide supplemental feeding for kits if the jill's milk production is reduced, or if the litter size is large. • whenever possible, foster kits with another lactating jill. most jills will accept kits of any size or age. • kits require a milk supplement that contains a high fat content ( %). kitten milk replacers mixed with cream may be used. • feed kits as much as they will eat times per day with a dropper or small pet nurser. • begin to mix solid food with the enriched milk replacer when kits are weeks of age. this mixture may be offered in a shallow dish or bowl. • kits may be weaned onto a solid diet at to weeks of age. feline or ferret growth diets are recommended. • the right kidney lies cranial to the left kidney. the cranial end of the right kidney often lies under the caudate lobe of the liver. • the bladder is small, and can hold up to ml of urine. • male ferrets have a small prostate gland that surrounds the urethra at the base of the bladder. • urinalysis: • the normal urine ph is . for ferrets on a meatbased diet. • normal values for urine-specific gravity have not been reported. • there is evidence that proteinuria may be normal in ferrets ( - mg/dl in males; - mg/dl in females) and that bilirubinuria can occur in the absence of liver disease. renal disease in not common in ferrets, but may occur. • clinical signs are similar to those described in other animals, and include ataxia, bruxism, halitosis, hindlimb weakness, inappetence, melena, mucus membrane ulceration, polyuria/polydipsia, vomiting, and weight loss. • physical examination findings may include cachexia, dehydration, irregularity in the shape and size of the kidneys, pale mucous membranes, and oral ulceration. • diagnosis is based on clinical signs, physical examination, and cbc, serum biochemical analysis, and urinalysis results. m key point hyperphosphatemia, hypocalcemia, and high bun may be noted on serum biochemical analysis. serum creatinine concentration is often normal or only moderately elevated. • treatment should address the underlying cause, if possible. • nonspecific treatment includes fluid therapy, nutritional supportive care, and antibiotic therapy based on culture and sensitivity when indicated. • prognosis is guarded, depending on laboratory findings and response to treatment. unilateral or bilateral renal cysts are relatively common in ferrets (see chapter for a description of this disease in dogs and cats). the condition is usually an incidental finding in middle-aged and older ferrets, although clinical signs associated with this condition can occur at any age. • the cause of renal cysts in the ferret is unknown. • heredity does not appear to be a factor. renal cysts are not associated with hepatic or biliary cysts. • renal cysts typically present as one or more smooth masses on the surface of the kidney. on abdominal palpation affected kidneys feel smoothly enlarged or irregular. • polycystic disease is unusual in the ferret. when present, affected kidneys appear rough and irregular; multiple cysts are often distributed throughout the renal tissue. cysts may be present in other organs as well. • usually there are no clinical signs associated with renal cysts. • rarely, there may be enough disruption of normal renal parenchyma to lead to renal failure, and subsequent clinical signs. • palpate the kidneys for irregular shape. • perform a cbc, serum biochemical profile, and urinalysis. • abdominal radiography usually is not helpful unless the kidneys are very irregular. intraosseous fluid therapy in small exotic animals exotic animal formulary biology and diseases of the ferret. philadelphia: lea & febiger ferret husbandry, medicine and surgery essentials of pet ferrets: a guide for practitioners ferrets, rabbits, and rodents: clinical medicine and surgery ferrets for dummies. indianapolis • perform an abdominal ultrasound to detect renal cysts, to evaluate renal architecture, and to rule out other conditions such as renal neoplasia.• intravenous pyelography or nuclear scintigraphy may be used to evaluate renal function.• renal cysts may be an incidental finding during abdominal surgery. • there is no specific treatment for renal cysts. no treatment is necessary in asymptomatic animals.• monitor affected ferrets by periodic abdominal palpation, serum biochemical profile, urinalysis, and ultrasound, if indicated.• if an affected kidney becomes very large, consider unilateral nephrectomy (if the opposite kidney is functional) (see chapter ).• symptomatic ferrets may be managed using the same supportive care methods used in dogs and cats with chronic renal failure.• the prognosis is grave for ferrets in renal failure. • hydronephrosis is uncommon in ferrets. iatrogenic hydronephrosis may occur as the result of inadvertent ligation of a ureter during ovariohysterectomy (see chapter for information about hydronephrosis in dogs and cats). • bacterial cystitis without urinary calculi is rare in pet ferrets. follow treatment protocols for cystitis in dogs (see chapter ). urinary calculi was a common cause of stranguria in ferrets at one time; improvement in the quality of ferret diets has decreased the incidence of calculi. calculi are usually composed of calcium oxalate or struvite (magnesium ammonium phosphate hexahydrate). cysteine calculi also have been reported. • the cause of urinary calculi is unknown; however, diet is believed to be a factor.• diets containing plant proteins or poor quality meatbased proteins may be associated with the development of urinary calculi. urolithiasis is uncommon in ferrets maintained on a high-quality feline or ferret diet containing high-quality animal-based proteins.• other factors may include urinary tract infection, metabolic, genetic, and congenital factors. clinical signs depend on the location of the urolith(s) and may include dysuria, stranguria, hematuria, persis-tent wetness in the perineal region, and frequent licking of the perineum.• urethral calculi may cause obstruction in both male and female ferrets. • ferrets with urethral obstruction often strain and cry as they attempt to urinate. • if complete obstruction is present ferrets often appear lethargic and anorexic, and may not demonstrate obvious signs of dysuria. • palpate the bladder to identify cystic calculi. the urinary bladder wall may be thickened; in ferrets with urethral obstruction, the bladder is distended and firm.• obtain abdominal radiographs to confirm the presence of radiopaque urinary calculi. cysteine calculi are not radiopaque and require contrast radiography or ultrasonography for diagnosis.m key point small stones located at the base of the os penis can be very hard to identify.• renal calculi may be an incidental finding on whole body radiographs, or may be associated with renal failure. m key point urethral obstruction is an emergency.severe metabolic derangement, coma, and death may occur if urethral obstruction is not diagnosed and treated quickly.• stabilize non-obstructed ferrets by providing supportive care, fluids, analgesics, and antibiotics (if indicated) prior to performing cystotomy to remove the urolith(s).• cystic calculi may be removed surgically via cystotomy; the procedure is similar to that used in cats and dogs (see chapter ). close the bladder wall with - or - absorbable sutures.• submit a urolith sample for analysis and bacterial culture/sensitivity testing.• administer antibiotics for a minimum of to days. use results of follow-up urinalysis, and urine culture/sensitivity testing to determine when to discontinue antibiotic therapy.• begin conversion to a high-quality-animal, proteinbased feline or ferret diet. urinary acidifies are not usually necessary once the ferret is on a high-quality animal, protein-based diet, since this diet alone will cause the urine to be acidic.• feline calculi-dissolving diets and preventative diets may be offered to ferrets; however, many ferrets do not find these diets palatable. • renal calculi can often be managed medically by administering antibiotic therapy and changing the diet. m key point the bladder is very fragile in ferrets.handle ferrets with obstruction gently to avoid bladder rupture.• urinary obstruction in the male ferret can be difficult to manage. catheter placement is challenging due to the small size of the urethra and the j-shaped os penis. (see urinary catheterization in the techniques section of this chapter.)• to facilitate placement of the urinary catheter, empty the bladder via cystocentesis prior to catheterization. submit urine samples for urinalysis and bacterial culture/sensitivity testing.• use either a ferret urinary catheter (slippery samferret urinary catheter, cook veterinary products), a standard tom cat catheter, or a . -fr red rubber catheter for catheterization.• inhalant anesthesia with isoflurane or sevoflurane is strongly recommended to facilitate catheter placement.• if the urinary catheter placement is not successful, consider emergency cystotomy, and attempt to perform anterograde flushing of the urethra via the cystotomy site.• perineal urethrostomy may be considered if cystotomy is unsuccessful (see chapter ). • feed a high-quality, animal protein-based feline or ferret diet. prostatic disease and subsequent urethral obstruction is a potentially life-threatening condition of middle-aged and geriatric male ferrets. this condition typically occurs in association with adrenal gland disease. • prostatic disease and prostatic cyst formation are presumed to be the effect of excessive androgens on the prostate. excessive androgen production occurs with adrenal gland disease.• squamous metaplasia of prostatic glandular epithelium occurs and may subsequently lead to the development of cysts ranging in size from to cm or larger. secondary bacterial infection and abscessation may occur.• prostatic abscesses associated with transitional cell tumor of the bladder, prostatic seminoma, and pro-static carcinoma have also been reported in the ferret, but are rare. • clinical signs associated with prostatic disease may include symptoms associated with a urinary tract infection, urethral obstruction, or urinary incontinence.• signs of adrenal gland disease are often present (see "adrenal gland disease"). • on physical examination, a large, firm, often painful caudal abdominal mass is usually palpable. with careful palpation, this mass is found to be bilobed, representing the urinary bladder and a cystic structure. ferrets with mild to moderate prostatic disease may appear to have a normal-sized prostate on abdominal palpation, yet are still symptomatic. it is important to remember that adrenal gland disease is usually the cause of prostatic disease. perform a complete diagnostic work-up that includes whole-body radiography, cbc, serum biochemistry analysis, and urinalysis. a plasma steroid hormone assay, and abdominal ultrasound may be indicated as well.• obtain abdominal radiographs; prostatic enlargement or prostatic cysts appear as mass lesions dorsal to the bladder.• perform abdominal exploratory surgery for a definitive diagnosis. • address urethral obstruction if present (see "urolithiasis").• manage medically until the ferret is stable for adrenalectomy and surgical drainage of the cysts.• medical management includes maintenance of urinary catheterization for several days, administration of fluids, antibiotic therapy, anti-inflammatory and analgesic therapy, and nutritional support as needed.• consider administration of an androgen receptor blocker (see "adrenal gland disease").• consider administration of leuprolide acetate -day depot formulation (lupron depot, bristol-myers-squibb oncology, princeton, nj) ( ug/kg) im; prostatic tissue shrinkage may occur within hours in some individuals. some ferrets have been maintained successfully on monthly injections of this drug, although results are highly variable.• perform adrenalectomy and drainage of the cysts.large cysts may require debulking. m key point omental pull-through procedures and marsupialization have been described as means of prostatic abscess management in the ferret. these procedures should be used with some caution. prostatic abscesses and prostatic cysts can be difficult to differentiate from paraurethral cysts. paraurethral cysts communicate with the urethra or bladder neck. consider performing contrast radiography to determine if there is communication between the cyst/abscess and the bladder prior to performing these procedures.• administer postoperative antibiotic therapy for a minimum of to days, along with androgen receptor blockers or leuprolide acetate.• base the decision to discontinue antibiotic therapy and androgen receptor blocker/leuprolide acetate therapy by monitoring changes on physical examination, follow-up radiography, and follow-up urinalysis. • the long-term prognosis is good if prostatic changes regress, and if subsequent adrenal gland disease does not occur in the remaining adrenal gland.• some ferrets may need to be maintained on androgen receptor blockers or leuprolide acetate indefinitely. paraurethral cysts are thin-walled single or multiple cysts present on the dorsal aspect of the bladder and proximal urethra. these cysts appear to also be associated with adrenal gland disease and can cause urethral obstruction.it is important to differentiate between prostatic cysts and paraurethral cysts when planning the surgical protocol. • paraurethral cysts have been reported in male and female ferrets.• clinical signs are similar to those described for prostatic disease, and include symptoms associated with a urinary tract infection, urethral obstruction, urinary incontinence.• clinical signs of adrenal gland disease are usually present (see "adrenal gland disease"). • a large, firm caudal abdominal mass is often palpable dorsal to the bladder, just cranial to the pelvic inlet. • perform a complete diagnostic work-up that includes whole-body radiography, cbc, serum biochemical analysis, and urinalysis.• because adrenal gland disease is usually the underlying etiology, consider performing a plasma steroid hormone assay.• radiographically, paraurethral cysts appear as mass lesions dorsal to the bladder.• ultrasonography may be useful in evaluation of the paraurethral cysts and adrenal glands. • surgical drainage and debulking of the cysts is the treatment of choice.• marsupialization is an alternative, but may lead to a formation of a permanent cystotomy.• do not perform an omental pull-through procedure. key: cord- -vf xbaug authors: dysko, robert c.; nemzek, jean a.; levin, stephen i.; demarco, george j.; moalli, maria r. title: biology and diseases of dogs date: - - journal: laboratory animal medicine doi: . /b - - / - sha: doc_id: cord_uid: vf xbaug nan status as a cooperative companion animal of reasonable size. dogs were used in the mid- s by william harvey to study cardiac movement, by marcello malpighi to understand basic lung anatomy and function, and by sir christopher wren to demonstrate the feasibility of intravenous delivery of medications (gay, ) . the use of dogs continued as biomedical research advanced, and they were featured in many noteworthy studies, including those by pavlov to observe and document the conditioned reflex response and by banting and best to identify the role of insulin in diabetes mellitus. for a comprehensive but concise review of the use of the dog as a research subject, the readers are directed to the manuscript by gay ( ) . the breed of dog most commonly bred for use in biomedical research is the beagle. some commercial facilities also breed foxhounds or other larger-breed dogs for use in surgical research studies. some specific breeds with congenital or spontaneous disorders are also maintained by research institutions (see specific examples below). random-source dogs used in research are most frequently mongrels or larger-breed dogs (e.g., german shepherd, doberman pinscher, labrador and golden retrievers) that are used for surgical research and/or training. according to a computerized literature search for beagle for the years - , approximately % of the biomedical scientific publications identified were in the fields of pharmacology or toxicology. especially common were studies focusing on pharmacokinetics, alternative drug delivery systems, and cardiovascular pharmacology. the next most common areas of research using beagles were dental and periodontal disease and surgery ( % of publications), orthopedic surgery and skeletal physiology ( %), and radiation oncology ( %). other research areas that utilized beagles included canine infectious disease, surgery, imaging, prostatic urology, and ophthalmology. most large-sized dogs (either purpose-bred or randomsource) are used in biomedical research because of their suitability for surgical procedures. anesthetic protocols and systems for dogs are well established, and the organs of larger-breed dogs are often an appropriate size for trials of potential pediatric surgical procedures. surgical canine models have been used extensively in cardiovascular, orthopedic, and transplantation research. there are also some unique spontaneous conditions for which dogs have proven to be valuable animal models. a colony of gray collies is maintained at the university of washington (seattle) for the study of cyclic hematopoiesis. this condition is manifested by periodic fluctuations of the cellular components of blood, most notably the neutrophil population. these dogs are used to study the basic regulatory mechanisms involved with hematopoiesis, as well as possible treatments for both the human and the canine conditions (brabb et al., ) . golden retrievers affected with muscular dystrophy have been used as models of duchenne muscular dystrophy in human children. duchenne muscular dystrophy is caused by an absence of the muscle protein dystrophin, inherited in an x-linked recessive manner. the dystrophy in golden retrievers is caused by absence of the same protein and is inherited in the same way. the clinical signs (such as debilitating limb contracture) are also similar between the canine and human conditions (kornegay et al., ) . bedlington terriers have been used to study copper storage diseases (such as wilson's disease), and the development of spontaneous diabetes mellitus and hypothyroidism in a variety of dogs has also been studied for comparisons with the human conditions. although historically the dog has been a common laboratory animal, the use of dogs in research has been waning over the past few years. according to the u.s. department of agriculture ( ) , the number of dogs used in research has declined from a high use of , in , in to only , in . this decrease was caused by a variety of factors, including (but not limited to) increased cost, decreased availability, local restrictive regulations, conversion to other animal models (such as livestock or rodents), and shift in scientific interest from pathophysiology to molecular biology and genetics. dogs used for research are generally segregated into two classes: purpose-bred and random-source. purpose-bred dogs are those produced specifically for use in biomedical research; they are intended for use in long-term research projects and/or pharmacologic studies in which illness or medication would require removal from the study. usually these dogs are either beagles or mongrel foxhounds, although other breeds may be available. purpose-bred dogs typically receive veterinary care throughout their stay at the breeding facility. they are usually vaccinated against canine distemper virus, parvovirus, adenovirus type , parainfluenza virus, leptospira serovars canicola and icterohemorrhagiae, and bordetella bronchiseptica. rabies virus vaccination may also be included. purpose-bred dogs are also usually treated prophylactically for helminths and ectoparasites, intestinal coccidia, and bacterial ear infections (r. scipioni and j. ball, personal communication, ) . random-source dogs are not bred specifically for use in research. they may be dogs bred for another purpose (e.g., hunting), retired racing dogs, or stray dogs collected at pounds or shelters. the health status of these dogs can be the same quality as purpose-bred dogs, or it can be an unknown entity. randomsource dogs that have been treated and vaccinated in preparation for use in research are termed conditioned dogs. these dogs are then suitable for long-term studies or terminal preparations that require unperturbed physiologic parameters. conditioned dogs are often tested for heartworm antigen because of the implications that infestations can have on cardiovascular status and surgical risk. nonconditioned random-source dogs are useful only in a limited number of research studies, such as nonsurvival surgical training preparations. options for procurement of dogs for biomedical research typically include purchase from a u.s. department of agriculturedesignated class a or class b licensed dealer or directly from a municipal pound. the requirements for usda licensure are detailed in code of federal regulations (cfr), title , chapter ( - - edition), subchapter a, animal welfare, . , definitions, and . , requirements and application. briefly, class a licensees are breeders who raise all animals on their premises from a closed colony (suppliers of purpose-bred dogs are typically class a dealers). class b licensees purchase the dogs from other individuals (including unadopted animals from municipal pounds) and then resell them to research facilities. there are additional regulations that apply to class b dealers (such as holding periods and recordkeeping documentation) because of the public concern that stolen pets could enter biomedical research facilities in this manner. regulations regarding the sale of pound dogs to research facilities or class b dealers vary from state to state and include some bans on this practice. the best resource for identification of possible vendors is the "buyer's guide" issue of the periodical lab animal. typically the last issue of each year, the "buyer's guide" lists sources for both purpose-bred and random-source dogs and denotes such features as pathogen-free status, documentation of health status, and availability of specific breeds and timed pregnant females. some suppliers also have separate advertisements within that issue of the journal. welfare act ( cfr . , . , and . [g] ) are described in cfr chapter ( - - edition), subchapter a, animal welfare. regulations pertaining specifically to the care of dogs used in research are found in subpart a, specifications for the humane handling, care, treatment, and transportation of dogs and cats, of part (standards) of subchapter a. particular attention should be paid to section . c (primary enclosures--additional requirements for dogs), because the space required for housing dogs is calculated using the length of the dog rather than the body weight (which is used for other species and also for dogs, according to national research council (nrc) guidelines). section . (exercise for dogs) describes the requirements that dealers, exhibitors, and facilities must follow in order to provide dogs with sufficient exercise. the institute of laboratory animal research (ilar) has written the "guide for the care and use of laboratory animals" (seventh edition, ) . the "guide" is the primary document used by institutional animal research programs to develop and design their programs, as well as by the association for assessment and accreditation of laboratory animal care international (aaalac international) and other animal care evaluation groups to facilitate site visits and inspections. the ilar committee on dogs has also written "dogs: laboratory animal management " ( ) . this publication describes "features of housing, management, and care that are related to the expanded use of dogs as models of human diseases" and includes "an interpretive summary of the animal welfare regulations and the requirements of the public health service policy on humane care and use of laboratory animals." the reader is encouraged to use these publications to obtain further information on care and husbandry of dogs in the biomedical research setting. growth data for beagles from a purpose-bred dog breeding facility are provided in table i . table ii features hematology data from beagles from the same commercial facility. table iii lists serum and urine chemical data for beagles. normal physiologic data for dogs (no breed specified) are provided in table iv . the information presented in the tables represents a range of normal values that can vary, depending on the analytical method and equipment used as well as the age, breed, gender, and reproductive status of the animal. federal regulations promulgated by the animal and plant health inspection service, usda, in response to the animal good nutrition and a sound, balanced diet are essential to the health, performance, and well-being of the animal. the basic nutrient requirements for dogs have been compiled by the nrc and represent the average amounts of nutrients that a group of animals should consume over time to maintain growth and prevent deficiencies (national research council, ) . the reader is referred to these guidelines for useful reference points for management of an animal's diet during various physiologic states (e.g., gestation, lactation, maturational age). most commercially available balanced dog diets are "closedformula" diets, in which the labeled specific minimum requirements for protein and fat, and the maximum values for ash and fiber, are met. these diets do not necessarily provide the identical composition of ingredients from batch to batch. ingredient composition varies, depending on the cost relationships of the various ingredients as the manufacturer attempts to achieve the label requirements at the lowest ingredient cost. an "openformula" (or "fixed-formula") diet provides more precise dietary control. in these diets the ingredients are specified, and the percentage of each ingredient is kept constant from batch to batch. "semipurified" diets provide for the strictest control of ingredients and are formulated from the purified components: amino acids, lipids, carbohydrates, vitamins, and minerals. the animal care provider should be aware of the manufacture date of the diet, which should be clearly visible on the bag. as a general rule, diets are generally safe for consumption up to months following the manufacture date when stored at room temperature. refrigeration may prolong the shelf life, but the best strategy is to use each lot based on the date of manufacture in order to prevent food from expiring and to ensure that only fresh diets are fed. specifications for feeding and watering of dogs are provided in the regulations of the animal welfare act. recommendations for feeding the appropriate amount of diet are determined by the dog's metabolic requirements. the basal metabolic rate, or basal energy requirement (ber), refers to the amount of energy expended following sleep, - hours after food consumption, and during thermoneutral conditions (kleiber, ; lewis et al., ) . the maintenance energy requirement (mer) is the amount of energy used by a moderately active adult animal in a thermoneutral environment, which in the dog is approximately twice the ber (lewis et al., ) . for dogs weighing greater than kg, the mer may be calculated using this simplified linear equation: mer (metabolizable kcal/day) = ( weightkg + ) (national research council, ; lewis et al., ) . the quantity of a correctly balanced diet to be fed to each dog can then be determined by dividing the mer by the energy density of the diet. fat provides three major dietary functions, including absorption of fat-soluble vitamins (a, d, e, and k), enhancement of palatability, and provision of essential (unsaturated) fatty acids. dietary fat is an excellent, highly digestible energy source, providing . times more energy on a per weight basis than either soluble carbohydrates or proteins (lewis et al., ) . however, fats are not needed for this purpose when adequate carbohydrate and protein are present. consumption of fat in excess of an animal's ability to metabolize it results in steatorrhea and has been related to the development of acute pancreatitis, whereas lack of dietary fat may lead to a fatty acid/energy deficiency. fatty acid deficiency is associated with poor growth, poor physical performance, reduced reproductive performance, and weight loss. dogs are considered to be "easy keepers," because they do not have as many absolute nutritional requirements as their domestic counterpart, the cat. however, they do possess a unique requirement for certain polyunsaturated fatty acids, a deficiency of which may predispose them to decreased growth rates and dermatologic abnormalities, such as "hot spots." dogs require linoleic (f - ) acid, an essential fatty acid (national research council, ) , and more recently it has been demonstrated that the f - fatty acids may play a role in maintaining healthy skin (logas and kunkle, ) . supplementation with a balanced essential fatty acid product (e.g., derm caps) may alleviate allergy-related dermatoses such as flea-bite dermatitis and pyoderma (logas and kunkle, ; miller, ) . essential fatty acid deficiency can occur in dogs receiving low-fat dry dog food that has been stored too long, particularly under warm, humid conditions (lewis et al., ) . there are a-amino acids, of which cannot be synthesized in sufficient quantity to meet a dog's normal metabolic demands for growth and maintenance. hence, as their name implies, these essential amino acids are required by all dogs and must be provided in the diet. the essential amino acids and the minimal requirements for growth are listed elsewhere (lewis et al., ) . chronic excessive protein intake may be detrimental to the kidney by contributing to accelerated renal aging and subsequent glomerulosclerosis (lewis et al., ) . conversely, inadequate protein intake results in retardation of growth and adata graciously provided by r. scipioni and j. ball of marshall farms usa, inc., north rose, new york. beagles tested for period / / - / / . b s.d., standard deviation; wbc, white blood cells; rbc, red blood cells; hgb, hemoglobin; hct, hematocrit; mcv, mean corpuscular volume; mch, mean corpuscular hemoglobin; mchc, mean corpuscular hemoglobin concentration; rdw, red cell distribution width; hdw, hemoglobin distribution width; plt, platelets; mpv, mean platelet volume; neut, neutrophils; lymp, lymphocytes; mono, monocytes; eos, eosinophils; baso, basophils; luc, large unstained cells; li, lobularity index; mpxi, mean peroxidase activity index reduction in production and/or performance. protein deficiency, a potential consequence of decreased food intake, results in decreased energy intake. as a compensatory mechanism for a lack of fat or carbohydrate, body protein catabolism ensues in order to meet energy demands, thus exacerbating the negative protein balance and contributing to the clinical signs of edema/ascites, unkempt appearance, lethargy, and weight loss. thus, caloric needs must be met before protein needs (lewis et al., ) , an important concept to bear in mind in the event of research experiments that may predispose to anorexia. in general, providing a good quality commercial diet that supplies the required amount of amino acids and caloric requirements of the animal, while avoiding excess protein, will ensure nutritional stability and promote longevity. appropriate mineral balance in the diet is very important. the best approach in the laboratory setting is to feed a commercial diet that has been formulated with the proper amount and balance of minerals for normal growth. the recommended amount of dietary minerals and the major causes and clinical signs of deficiencies are published elsewhere (lewis, ) . determining the specific mineral involved in an imbalance can be a diagnostic challenge, because the clinical signs for several excesses/ . (basal) . (anestrus) . c < . c - c - r (continues) deficiencies are similar and nonspecific. a definitive diagnosis is often made only after the diet has undergone analysis of the mineral components. once the imbalance has been identified, the safest resolution to the problem is to discard the entire lot of misformulated diet. attempting to correct the imbalance through oral supplementation is likely to be more harmful than beneficial, and it risks intensifying the problem by creating additional mineral imbalances. vitamins function as enzymes that regulate a wide variety of physiologic processes. they are divided into two groups based on their solubility. the fat-soluble vitamins include a, d, e, and k, whereas the rest are water-soluble. a list of the vitamins, their requirements, and clinical signs associated with deficiencies and toxicities is published elsewhere (lewis et al., ) . cases of dietary deficiency are rarely encountered in the research setting, because laboratory dog chows are fortified with vitamins. additional vitamin supplementation may occasionally be required during prolonged clinical illnesses, such as polyuria or diarrhea, which predispose to loss of water-soluble vitamins (b complex and c) (lewis et al., ) . however, as with minerals, routine supplementation of vitamins may induce inadvertent toxicity and exacerbation of an imbalance. management of a breeding colony requires broad knowledge of the dog's anatomy, reproductive physiology, and behavioral needs during breeding, gestation, and parturition. although a comprehensive discussion of the biology of canine reproduction is beyond the scope of this chapter, essential features of the broad topics noted above are presented. this section is largely based on information assimilated from texts such as "miller's anatomy of the dog" (evans and christensen, ) , "veterinary reproduction and obstetrics" (arthur et al., ) , and an issue of veterinary clinics of north america: small animal practice devoted to pediatrics of puppies and kittens (hoskins, ) . the ovaries of the bitch are attached to the dorsolateral walls of the abdominal cavity caudal to the kidneys by the broad ligaments and are not palpable abdominally. the uterus consists of the cervix, uterine body, and uterine horns. the cervix is an abdominal organ, located approximately halfway between the birchard and sherding ( ) . ovaries and the vulva. when the bitch is in proestrus and estrus, the cervix can be distinguished during abdominal palpation as an enlarged, turgid, walnut-shaped structure. catheterization of the cervix is usually not possible in the normal bitch at any stage of the reproductive cycle, except during or immediately following parturition. thus, semen is deposited at the external cervical os during natural or artificial insemination. the vagina is a long musculomembranous canal that extends from the uterus to the vulva. when the vagina is examined, the gloved finger or examination instrument should be introduced through the dorsal commissure of the vulva so as to avoid the deep ventral clitoral fossa. examination should proceed at an angle of approximately ~ until the instrument or fingertip has passed over the ischial arch, after which it can be directed further craniad toward the cervix. the bitch has a monoestrous cycle, with clinical estrus occurring predominantly in january or february and again in july or august (although it can occur at any time of year). the estrous cycle consists of four stages: proestrus, estrus, diestrus, and anestrus. the average duration of proestrus is days. during this stage the vulva is enlarged, turgid, and firm, and a sanguinous vaginal discharge is present. endocrinologically, proestrus is the follicular stage of the cycle, and estrogen levels peak at this time. estrus generally lasts days, and the vulva is softer and smaller than in proestrus. a vaginal discharge persists during estrus and may remain serosanguinous or become straw-colored. the endocrine feature of estrus is the luteinizing hormone (lh) surge, followed by ovulation within - hours. diestrus begins approximately days after the onset of standing heat. the end of this stage is days later, which would be coincident with whelping if the bitch had become pregnant. serum progesterone levels peak during diestrus. the duration of anestrus is approximately months. anestrus is the stage of reproductive quiescence, characterized by an absence of ovarian activity and serum progesterone levels of less than ng/ml. components of the canine spermatic cord include the ductus deferens, the testicular artery and vein, the lymphatics and nerves, and the cremaster muscle. the cremaster muscle and pampiniform plexus aid in thermoregulation of the testicles, which are maintained at ~ lower than basal body temperature. sweat glands in the scrotum assist in lowering the scrotal temperature through evaporation. the penis is a continuation of the muscular pelvic urethra and is attached to the ischiatic arch by two fibrous crura. it is composed of fibrous tissue and three cavernous sinuses: corpus cavernosum, corpus spongiosum penis, and corpus spongiosum glandis. the accessory sex glands of the dog consist of only a well-encapsulated prostate gland that surrounds the pelvic urethra, and ampullary glands at the termination of the vas deferens in the urethra. the dog does not have seminal vesicles or bulbourethral glands. the onset of puberty ranges from to months of age and is affected by breed, season, and nutritional and disease status. testicular growth is rapid at this time, and the seminiferous tubules begin to differentiate. the sertoli cells form the bloodtestis barrier, the tubules become hollow, and spermatogenesis commences. this process is initiated by the secretion of lh from the anterior pituitary, which stimulates the production of testosterone by the interstitial, or leydig's, cells. secretion of follicle-stimulating hormone (fsh) by the anterior pituitary stimulates the production of other key hormones by the sertoli cells, including inhibin, androgen binding protein, and estrogen. fsh stimulates spermatogenesis in the presence of testosterone, while inhibin and estrogen play a role in a feedback loop on the pituitary gland to decrease fsh production. spermatogenesis in the dog is completed in days, with subsequent maturation of sperm occurring in the epididymis for approximately days. thus, the entire process from initiation of spermatogonial mitosis to delivery of mature sperm to the ejaculate is days. a breeding soundness exam should be conducted to assess the probability of a male dog's successful production of offspring. factors affecting male fertility include libido, ability to copulate, testicular size, and quality and number of sperm produced. problems with libido may occur in dogs due to early weaning, isolation, or inherited abnormalities that suppress sexual behavior. animals with poor hindlimb conformation or with trauma to the back or hindlimbs may be unable to properly mount the female. there is a positive correlation with the size of the testicles as measured by scrotal circumference and the number of sperm produced. finally, parameters used to assess the quality of sperm include motility, morphology, volume, and concentration. an ejaculate ( ml) that contains approximately million progressively motile sperm without significant morphological abnormalities (such as a kinked tail) is a good indicator of normal male fertility. in general, erection, which involves muscular contractions and increased arterial blood flow to the penis, is controlled by the parasympathetic nervous system, whereas ejaculation is under sympathetic control. on mounting, the initial thrusting and ejaculation of semen last about minute. the bulbus glandis becomes enlarged, which lodges the penis in the female reproductive tract. the male then dismounts and brings one hindleg over the female, and the two continue to be joined "rear to rear," a position classically termed "the tie." ejaculation of the accessory gland fluid continues for - minutes. the continued expulsion of prostatic fluid during the "tie" may serve to propel the semen from the vagina through the cervix into the uterus. fertilization occurs in the oviduct and may occur as late as days after coitus, because of the long life span of sperm in the dog. however, once ovulated, oocytes generally remain viable for only - hours. therefore, the bitch should be bred prior to ovulation to ensure the presence of sperm for fertilization of live oocytes. cells of the vaginal epithelium mature to keratinized squamous epithelium under the influence of estrogen. because of the rise in estrogen throughout proestrus, with peak levels occurring just prior to the onset of standing heat, the vaginal smear can be used as an indicator of the bitch's readiness for breeding. the smear will not confirm the presence of ovulation, nor is it of prognostic value in normal bitches during anestrus. the percentage of vaginal epithelial cell cornification is an index of estrogen secretion by the ovarian follicles. as cornification of vaginal epithelial cells proceeds, the cells become larger, with more angular borders. the nuclear-cytoplasmic ratio decreases until the nuclei reach a point where they no longer take up stain (coincident with the onset of estrus). the cells appear "anuclear" and are classified as "cornified" or "anuclear squames." cornification occurs approximately days prior to the estrogen peak and days prior to standing heat. the percentage of cornified cells (of the total number of epithelial cells) decreases gradually to zero after the onset of diestrus. the vaginal cytology smear of the bitch changes from predominantly cornified to noncornified days after ovulation. the day of this change is the first day of diestrus. other epithelial cell types noted on vaginal cytology include superficial cells (large, angular cells with small nuclei); intermediate cells (round or oval cells with abundant cytoplasm and large, vesicular nuclei); and parabasal cells (small round or elongated cells with large, well-stained nuclei, and a high nuclear-cytoplasmic ratio). based on vaginal cytology, the estrous cycle is classified as follows: although vaginal cytology is a useful tool, it is not a substitute for observation of behavioral estrus, which is the best criterion to use in breeding management. during proestrus the male is attracted to the bitch and will investigate her hindquarters, but she will not accept breeding. the behavioral hallmark of estrus is standing receptivity toward the male. during this stage the bitch will exhibit "flagging," or elevation of her tail with muscular elevation of the vulva to facilitate penetration by the male. in order to maximize the conception rate, and the number of pups whelped per egg ovulated, it is recommended to breed the bitch on days , , and of the standing heat. fertilization is completed in the mid-to distal oviduct. implantation is evident by areas of local endometrial edema - days after breeding. there is no correlation between the number of corpora lutea and the number of fetuses in the corresponding uterine horn, suggesting transuterine migration of embryos. the dog has endotheliochorial placentation. the endothelium of uterine vessels lies adjacent to the fetal chorion, mesenchymal, and endothelial tissues, so that maternal and fetal blood are separated by four layers. the canine placenta is also classified as zonary and deciduate, indicating that the placental villi are arranged in a belt and that maternal decidual cells are shed with fetal placentas at parturition. the length of gestation is - days. luteal progesterone is responsible for maintaining pregnancy, and canine corpora lutea retain their structural development throughout gestation. serum progesterone rises from less than ng/ml in late proestrus to a peak of - ng/ml during gestation, then declines to - ng/ml just prior to parturition. progesterone is essential for endometrial gland growth, secretion of uterine milk, attachment of the placentas, and inhibition of uterine motility. pregnancy detection can be performed by abdominal palpation of the uterus days after breeding. the embryos and chorioallantoic vesicles form a series of ovoid swellings in the early gravid uterus. they are approximately inches in length at - days, the time at which pregnancy is most easily and accurately diagnosed. by day the uterus begins to enlarge diffusely, so that the vesicles (and, therefore, pregnancy) are difficult to identify by palpation. fetal skeletons become calcified and are radiographically evident by day . bitches in which a difficult whelping is anticipated should be radiographed in late pregnancy to determine the litter size and to evaluate the size of the fetal skulls in relation to the bony maternal birth canal. real-time ultrasound can be utilized for pregnancy detection of vesicles as early as - days. an abrupt drop in body temperature to less than ~ indicates impending parturition within - hours. the process of parturition has been divided into three stages, stage of labor lasts - hours and is characterized by uterine contractions and cervical dilation. during this stage, the bitch may appear restless, nervous, and anorexic. other common clinical signs include hard panting and increased pulse and respiration rates. fetal expulsion occurs during stage , which lasts approximately - hours. as the fetus engages the cervix, the neuroendocrine system induces the release of oxytocin; this is referred to as the ferguson reflex. oxytocin strengthens the uterine contractions and may elicit voluntary abdominal contractions as well. the bitch is usually recumbent during stage but is able to inhibit this stage if labor if disturbed. the chorioallantois ruptures either during passage of each neonate through the birth canal or by the bitch's teeth at birth. interestingly, posterior presentation is common in dogs but does not predispose to dystocia. the time interval between delivery of each pup is irregular, but the average time lapse is less than hour between pups until parturition is complete. veterinary assistance is necessary if the bitch remains in stage for more than hours without delivering the first pup, or for more than hours before delivering subsequent pups. the placentas are expelled during stage of labor, immediately following delivery of a pup, or up to minutes thereafter. if two pups are delivered from alternate uterine horns, then the birth of both puppies may precede expulsion of the respective placentas. the bitch will lick the newborn vigorously to remove the membranes from its head and to promote respiration. she will also sever the umbilical cord. the bitch may ingest the placentas, although they confer no known nutritional benefit and may induce a transient diarrhea. thermal support should be provided prior to parturition. dogs housed on grated flooring should be provided with mats, and those on solid floors would benefit from blankets placed in a corner of the primary enclosure. shavings are discouraged as they have the potential to coat the umbilical cord, which may predispose to ascending infections. heat lamps may be placed hours prior to parturition and remain until all neonates dem-onstrate vigorous and successful suckling behavior. however, the use of heat lamps necessitates strict supervision in order to prevent thermal burns. if possible, whelping bitches should be housed in a quiet corridor in order to decrease periparturient stress, especially in primiparous or young mothers. thus, monitoring of parturition is important, but human intervention should be minimal in order to prevent stress-induced cannibalism. weak or debilitated puppies may be cannibalized by the bitch before the research staff recognizes the need for veterinary attention. the postpartum use of oxytocin is required only in the event of uterine inertia, stillbirths, or agalactia. in these cases, - units of oxytocin may be administered intramuscularly. uterine involution occurs during anestrus within - weeks of parturition. during this time a greenish to red-brown vaginal discharge, or lochia, may be noted. although lochia is normal, the presence of an odiferous, purulent discharge, accompanied by systemic signs of illness, indicates metritis or pyometra. desquamation of the endometrium begins by the sixth postpartum week, with complete repair by months. newborn puppies are easily sexed by examination of the anogenital distance. in female puppies the vulva is evident a short distance from the anus, whereas the prepuce of male puppies is nearly adjacent to the umbilicus. eyes are open at approximately days, and ears are patent at approximately - days. solid food can be introduced between . and weeks of age, and puppies can be weaned at - weeks. artificial insemination (ai) is indicated when the male is physically incapable of mounting or penetrating the bitch, when there are vaginal abnormalities such as strictures, or when the bitch refuses to stand for breeding. semen for ai is collected using a plastic centrifuge tube and rubber latex artificial vagina. the male is introduced to the bitch's scent and manually stimulated. after collection of the first two fractions, a sufficient amount of the third fraction, which consists predominantly of prostatic fluid, is collected to bring the total semen volume to - ml. the semen is then drawn into a sterile or ml syringe attached to a sterile disposable insemination pipette. the bitch is inseminated either standing or with raised hindquarters. a gloved index finger is inserted into the dorsal commissure of the vulva and directed craniodorsally until it is over the ischial arch. the tip of the insemination pipette is introduced and guided by the gloved finger toward the external cervical os. the semen is injected, and - ml of air are then flushed through the syringe and pipette. the pipette is withdrawn, and the gloved finger is used to feather the ceiling of the vagina until contractions of the vaginal musculature are palpable. the bitch's hindquarters are subsequently elevated to promote pooling of semen around the external cervical os. as with natural breeding, ai should be performed on days , , and of standing heat, or on the days of maximal vaginal cornification. the bitch should be palpated for pregnancy approximately weeks after the first insemination. false pregnancy (pseudocyesis), a stage of mammary gland development and lactation associated with nesting or mothering behavior, is common in the bitch. the condition occurs after the decline in serum progesterone toward the end of diestrus. there is no age or breed predisposition. pseudopregnancy does not predispose the bitch to reproductive disease or infertility. however, in the event of extreme discomfort due to mammary gland enlargement, bitches may be treated with mibolerone (cheque drops) at an oral dose of ~tg/kg q hr for - days (brown, ) . reproductive performance in the bitch is optimal prior to years of age. although normal cycle lengths are reported to occur up to the ages of - years, the interestrous interval tends to increase by years of age. cycling does not completely cease; however, after years of age, bitches demonstrate significant decreases in conception rate and number of live pups whelped. by - years of age, pathologic conditions of the uterus, such as cysts, hyperplasia, atrophy, and neoplasia are extremely common. beagles have been a popular animal model because of their docile nature. they are easily handled and for the most part respond favorably to repetitive manipulations such as body weight measurements, physical examination, electrocardiogram (ecg) recordings, oral gavage, and venipuncture. dogs are sexually mature by - months of age, but they are not socially mature until - months of age. the socialization process should begin early during development, when puppies are receptive to conspecific and human contact. for example, from - weeks of age, puppies are most capable of learning about how to interact with other dogs. between weeks and , puppies are most capable of learning how to interact with people. by - weeks of age dogs voluntarily wander and explore new environments. thus, early handling and mild stress (such as vaccination) appear to be extremely beneficial components of a dog's social exposure. the extent to which breed affects behavior has been the subject of popular speculation but is difficult to prove. in general, breed-specific patterns do tend to emerge. for example, it appears that beagle pups are very motivated by food reward (overall, ). this is not surprising, because the breed was selected to work with its nose, and this may be a useful attribute for laboratory investigations that are predicated on food restriction. canid social systems use signals and displays that minimize the probability of outright aggression. these behavior patterns are most likely elicited during distressful situations, such as strange environments, being handled by strange people, or encountering new animals. an excellent, illustrated discussion of normal canine behavior patterns can be found in the third chapter of "clinical behavioral medicine for small animals" (overall, ). by virtue of the dog's status as a companion animal, there are many veterinary publications and reference texts on the diagnosis, medical management, pathology, and epidemiology of the disorders that can affect this species. the authors of this chapter have chosen to emphasize those diseases that are more frequently encountered in the research setting. especially noted in this chapter are infectious diseases associated with the use of random-source dogs that have unknown vaccination history and have had intensive contact with other similar animals at pounds and/or shelters, or conditions seen frequently in the beagle, the most common breed used in biomedical research. for more thorough and detailed discussion of these diseases, as well as those not discussed in this chapter, the reader should consult standard veterinary textbooks, such as the "current veterinary therapy" series (j. d. bonagura and r. w. kirk, eds.), "veterinary internal medicine" (s. j. ettinger and e. c. feldman, eds.), and "infectious diseases of the dog and cat" (c. e. greene, ed.) . full citations of some chapters from these texts are listed in the references (w. b. saunders co. of philadelphia publishes all three texts.) canine infectious tracheobronchitis (kennel cough complex) etiology. infectious tracheobronchitis (itb) is a highly contagious illness of the canine respiratory tract that usually manifests as an acute but self-limiting disease. several organisms have been incriminated as causative for this condition: bordetella bronchiseptica; canine parainfluenza virus (cpiv); canine adenovirus types and (cav- , cav- ); canine herpesvirus; canine reovirus types , , and ; and mycoplasms and ureaplasms. clinical signs. clinical infectious tracheobronchitis can be subdivided into mild or severe forms. the mild form is the more common presentation and is characterized by an acute onset of a loud, dry, hacking cough. increased formation of mucus sometimes results in a productive cough, followed by gagging or retching motions. cough is easily elicited by tracheal palpation and may be more frequent with excitement or exercise. otherwise the dog is typically asymptomatic, with normal body temperature, attitude, and appetite. mild tracheobronchitis usually lasts - days, even if left untreated. the severe form of tracheobronchitis generally results from mixed infections complicated by poor general health, immunosuppression, or lack of vaccination. secondary bronchopneumonia can occur and may be the determinant of severity (sherding, ) . animals are clinically ill and may be febrile, anorexic, and depressed. productive cough and mucopurulent naso-ocular discharge are more common than in the mild form. these cases require more aggressive treatment and may be fatal. bordetella bronchiseptica is considered to be the respiratory tract of infected animals (bemis, ) . this bacterium is very easily spread by aerosol and direct contact, and fomite transmission is also possible (bemis, ) . transmission is favored by confined housing of multiple animals. in experimental studies, b. bronchiseptica transmission to susceptible individuals was % (thompson et al., ; mccandlish et al., ) . the incubation period is - days. cpiv and cav- are also spread by aerosols. of these two viruses, cav- is the most persistent, lasting for up to several months in the environment, whereas cpiv is fairly labile (hoskins, a) . both viruses can be destroyed by quaternary ammonium disenfectants. pathogenesis. the most common clinical isolates are cpiv and bordetella bronchiseptica. however, b. bronchiseptica may be a commensal organism, and it is often recovered from asymptomatic animals. in cases of clinical infection, b. bronchiseptica attaches to the cilia on the mucosal surface of the upper airway epithelium, causing suppurative tracheobronchitis and bronchiolitis. infections with cpiv or cav- alone are usually subclinical; coinfections with b. bronchiseptica or other microbes may result in clinical itb (keil and fenwick, ; wagener et al., ) . the characteristic lesion from cpiv or cav- infection is necrotizing tracheobronchiolitis (dungworth, ) . pathogenic infection of the upper airways typically results in inflammation and ciliary dysfunction. diagnosis and differential diagnosis. diagnosis of infectious tracheobronchitis is often based on clinical signs. isolation of bordetella bronchiseptica or mycoplasma by nasal swabs allows only a presumptive diagnosis. viral isolation or paired serology can be done but is often impractical and expensive. if cough persists for more than days, other disease conditions should be considered. canine distemper virus infection, pneumonia, heartworm disease, tracheal collapse, and mycotic infections are differential diagnoses for dogs with similar signs. bronchial compression as a result of left atrial enlargement, hilar lymphadenopathy, or neoplasia may also elicit a nonproductive cough (johnson, ) and should be considered as a differential for itb. prevention. prevention is best achieved by avoiding exposure to infected animals, but this is oftentimes not practical. dogs should be vaccinated prior to, or at the time of, admission to the animal research facility. intranasal vaccine combinations for bordetella bronchiseptica and cpiv are preferred. intranasal vaccines protect against both infection and disease, can be given to dogs as young as weeks of age, and can produce immunity within days. control. sanitation and ventilation are critical for control. the animal care staff must practice proper hygiene to prevent fomite transmission. symptomatic animals should be isolated, and animal-to-animal contact avoided. kennels should be disinfected with agents such as bleach, chlorhexidine (nolvasan) or quaternary ammonium chloride (roccal-d). proper ventilation and humidity are important in controlling spread of these infectious agents; - air changes per hour at % relative humidity are recommended (sherding, ) . no specific treatment is available for viral infections. bordetella bronchiseptica is typically sensitive to potentiated sulfas, chloramphenicol, quinolones, tetracyclines, gentamicin, and kanamycin. use of antibiotics is indicated when severe or persistent clinical signs occur, and it should be continued for days. use of empirical antibiotic treatment in mild cases may hasten the resolution of clinical signs. for severe or unresponsive infection, treatment should be based on bacterial culture sensitivity patterns; nebulized gentamicin may be helpful. cough suppressants (e.g., dextromethorphan) should be avoided if the cough is bringing up mucus (productive); however, their use is indicated if coughing is causing discomfort or interfering with sleep. bronchodilators such as aminophylline, theophylline, or terbutaline can be helpful in reducing reflex bronchoconstriction and minimizing discomfort. tis results in altered respiratory tract histology and impaired mucociliary clearance, infected animals should not be used for pulmonary studies. animals with clinical disease would also be poor surgical candidates. etiology. [ -hemolytic lancefield's group c streptococcus (streptococcus zooepidemicus) is a gram-positive non-spore-forming coccus and an etiologic agent for pneumonia and septicemia in dogs. clinical signs. clinical signs vary based on the organ system affected. pneumonic disease is typically associated with coughing, weakness, fever, dyspnea, and hematemesis. peracute death without clinical signs has been reported in a previously healthy research dog (bergdall et al., ) , and conjunctivitis can also be caused by this organism (murphy et al., ) . epizootiology and transmission. lancefield's group c streptococci have been isolated as commensal flora in the upper respiratory tract and the vagina of clinically normal dogs (olson et al., ) . epizootics have been reported in both racing greyhounds and research colonies (sundberg et al., ; garnett et al., ) . in these epizootics, and in the reported case of peracute death (bergdall et al., ) , recent transportation (within days) was associated with the disease. as such, lancefield's group c streptococcus may be an opportunistic pathogen in dogs. pathologic findings. in the peracute case reported (bergdall et al., ) , hemorrhage from the mouth and nose and within the pleural cavity was the most striking lesion. ecchymotic and petechial hemorrhages were seen on other organ surfaces. the lungs were heavy and wet, and blood oozed from cut surfaces. "bull's-eye" lesions were observed on the pleural surface of affected lung lobes, similar to ischemic lesions seen with fungal infections (fig. ) . histologically, the lungs were characterized by areas of hemorrhage surrounding foci of degenerative neutrophils, blood, and necrotic debris. gram-positive cocci were seen in both the lung and the tonsils. pathogenesis. the pathogenesis for disease caused by lancefield's group c streptococcus is unclear. strain variation with respect to virulence and host immune factors is probably significant. diagnosis and differential diagnosis. definitive diagnosis is made based on bacterial culture and identification. any cause of pneumonia and/or peracute death in dogs needs to be considered as a differential diagnosis. bacterial pneumonias or septicemias can be caused by other pathogenic streptococcus spp., staphylococcus spp., escherichia coli, pasteurella multocida, pseudomonas spp., klebsiella pneumoniae, and bordetella bronchiseptica. nonbacterial causes include rodenticide intoxication, coagulopathies, heartworm disease, pulmonary thromboembolism, ruptured aneurysm, and left-sided congestive heart failure. prevention and control. too little is known about the pathogenesis of lancefield's group c streptococcus to make any recommendations about prevention and control. treatment. antibiotic therapy should be provided, based on culture and sensitivity. intravenous fluids are indicated for febrile or systemically ill patients. for dyspneic patients, oxygen therapy and strict activity restriction are required. research complications. clearly, dogs with severe hemorrhagic pneumonia or septicemia are not appropriate for any research study. the association between epizootics of this disease and transportation shipment supports the philosophy of providing acclimation periods to animals upon arrival at research facilities to evaluate health status and enable the animals to normalize physiologically. etiology. serovars of the spirochete leptospira interrogans sensu lato cause canine leptospirosis. disease in dogs is primarily due to serovars canicola, icterohemorrhagiae, grippotyphosa, pomona, and bratislava. clinical signs. leptospirosis may present as either an acute or a chronic problem. clinical signs are nonspecific and include lethargy, depression, abdominal discomfort, stiffness, anorexia, and vomiting. animals may be febrile and may be reluctant to move, because of muscle or renal pain or meningitis. icterus, congested mucous membranes, or signs referable to disseminated intravascular coagulation (petechial/ecchymotic hemorrhages, melena, epistaxis, or hematemesis) are also possible. animals with peracute leptospirosis are characterized by septicemia, shock, vascular collapse, andrapid death. uveitis, abortions, and stillbirths have also been associated with leptospirosis. epizootiology and transmission. vaccination and reduced exposure to reservoir hosts have markedly decreased the prevalence of leptospirosis over the past years. wild animals, cattle, and rodents are reservoirs for leptospira. the epidemiology of the disease is not static, and recent changes have been observed. serovars pomona, grippotyphosa, and bratislava are becoming more common causes of canine disease, with canicola and icterohemorrhagiae becoming less common. this may be due to vaccination practices and increased movement of wildlife reservoirs (raccoons, skunks, and opossums) into urban/suburban areas. rats have been implicated as important in the transmission of serovars canicola and icterohemorrhagiae (rentko et al., ; brown et al., ; kalin et al., ) . transmission occurs primarily by environmental contact, and not directly from animal to animal. infected hosts shed leptospires in urine, thereby contaminating the environment; naive animals are infected when the organisms contact mucous membranes or abraded skin. recovered animals may shed organisms in their urine for months to years. the organisms are actually labile in the environment; moisture, moderate temperatures, and alkaline soil favor survival and subsequent transmission. close contact, bites, ingestion of infected meat, and transplacental and venereal transmission are also possible. leptospirosis is a zoonotic disease. pathologic findings. the kidneys consistently have gross and microscopic lesions. in the acute phase of the infection, kidneys are swollen and have subcapsular and cortical ecchymotic hemorrhages. petechial or ecchymotic hemorrhages and swelling of the lungs and liver may also be noted. hepatic lesions during the acute phase consist of diffuse hemorrhage and focal areas of necrosis (searcy, ) . in chronic stages of leptospirosis the kidneys become small and fibrotic. endothelial cell degeneration and focal to diffuse lymphocytic-plasmacytic interstitial nephritis are the characteristic histopathological findings. pathogenesis. infection occurs after the leptospires penetrate a mucous membrane or abraded skin. the organisms then invade the vascular space and multiply rapidly. several days postinfection the renal tubular epithelium (and, to a variable extent, the liver) is colonized. the hematogenous phase lasts - days. acute renal failure or progressive renal failure leading to oliguria or anuria may occur. the most common clinical syndrome is chronic or subclinical infections after recovery from the acute phase (greene, ) . the nephritis may or may not be accompanied by hepatitis, uveitis, and meningitis. icterus, if it develops, is most common in the acute phase. the combination of azotemia and icterus should alert the clinician to the possibility of leptospirosis. disseminated intravascular coagulation is often a secondary complication. the severity and course of leptospirosis depend on the causative serovar and the age and immune status of the patient. diagnosis and differential diagnosis. zinc toxicity in dogs most closely mimics the clinical syndrome of leptospirosis. other causes of acute and chronic renal failure, icterus, and acute hepatic failure must also be considered. paired serology is the most reliable means of definitive diagnosis; however, seroconversion may not occur until after the first week of infection. prevention and control. vaccination for leptospirosis is standard veterinary practice. bivalent inactivated bacterins for serovars of l. interrogans canicola and serovars of l. interrogans icterohemorrhagiae are commercially available. however, immunization does not prevent development of the carrier state or protect against other serovars. for outdoor-housed dogs, an effective program to prevent contact with wildlife reservoirs is important. control requires identification and either treatment or elimination of carrier animals. treatment. penicillins are the drugs of choice for treating leptospiremia, and prompt use reduces fatal complications. aggressive fluid therapy and supportive care may also be needed. elimination of renal colonization and the carrier state can be accomplished with dihydrostreptomycin or doxycycline administration. should not be used in research studies because of the effects of the disease on renal and hepatic function. etiology. campylobacteriosis in dogs is caused by campylobacter jejuni, a thin, curved or spiral, microaerophilic, thermophilic motile gram-negative rod. clinical signs. most adult animals infected with c. jejuni are asymptomatic carriers; clinical signs are most commonly noted in dogs that are less than months of age (greene, ; burnens et al., ) . in cases of clinical illness, small volumes of mucoid or watery diarrhea, with or without frank blood, are most commonly noted. these signs are usually mild, may be intermittent, and typically last - days. tenesmus, inappetance, vomiting, and a mild fever may accompany the diarrhea. epizootiology and transmission. the role of c. jejuni as a primary pathogen has been questioned; it may require a coenteropathy to produce disease (sherding and johnson, ) . clinical signs of disease most often occur in dogs less than months of age, although any age may be affected. stress or immunosuppression may make animals more susceptible to clinical disease. pound and shelter populations have the highest rates of fecal excretion of c. jejuni (sherding and johnson, ) . transmission is via the fecal-oral route, mostly through fecally contaminated food or water. unpasteurized milk, poultry, and meat are other sources of infection. campylobacter jejuni can be zoonotic; children and immunocompromised individuals are at the greatest risk. pathologic findings. the actual lesions observed depend upon the mechanism of the enteropathy (van kruiningen, ) . enterotoxin production results in dilated fluid-filled bowel loops, with little or no histopathologic alteration. in cytotoxin-mediated disease, hyperemia and a friable, hemorrhagic mucosal surface are noted. on histopathology the mucosal surface is irregular and ulcerated, and a lymphocytic-plasmacytic ileitis or colitis may be seen. when translocation occurs, the lamina propria becomes edematous and congested, with focal accumulation of granulocytes in the crypts and lamina propria. focal areas of epithelial hyperplasia and decreased numbers of goblet cells are also noted. with warthin-starry silver staining, c. jejuni may be seen between enterocytes but only rarely inside them. pathogenesis. clinical disease may be produced by several different mechanisms after the campylobacter has populated the intestinal tract (van kruiningen, ) . after colonization of the enterocyte surface, c. jejuni can produce an enterotoxin that causes a secretory diarrhea. campylobacterjejuni can also cause an erosive enterocolitis by invasion of the ileal and colonic epithelium along with production of a cytotoxic agent; this may be the mechanism that causes hematochezia. in addition, c. jejuni can produce illness by translocation, i.e., multiplication in the lamina propria and transportation to regional lymph nodes by macrophages. this causes mesenteric lymphadenitis. diagnosis and differential diagnosis. fresh feces (per rectum) are best for ensuring an adequate diagnostic sample. presumptive diagnosis may be made by demonstration of highly motile curved or spiral organisms with dark-field or phase-contrast microscopy. gram-stained c. jejuni appear as gull-winged rods. definitive diagnosis requires isolation of the organism (sherding and . culture requires selective isolation media, and growth is favored by reduced oxygen tension and a temperature of ~ any disorder that can cause diarrhea in dogs should be considered as a differential diagnosis, including canine parvovirus, coronavirus, distemper virus, giardia, and salmonella infections; helminth infestations; and hemorrhagic gastroenteritis. clinical signs. based on experimental infections in dogs, three phases to the disease have been described: acute, subclinical, and chronic. clinical signs observed vary with the phase of the disease, and the acute and subclinical phases are often missed or misdiagnosed (c. g. couto, personal communication, ; waddle and littman, ; woody and mcdonald, ) . a history of tick exposure may be noted prior to onset of signs. in the acute phase, clinical signs range from mild to severe and may last - weeks. they include inappetance, lethargy, fever, generalized lymphadenopathy, hepatosplenomegaly, exercise intolerance or dyspnea, petechial or ecchymotic hemorrhages, and peripheral edema. central nervous system (cns) signs may also be present such as hyperaesthesia, myoclonus, and cranial nerve deficits. clinical laboratory abnormalities noted during the acute phase include thrombocytopenia, anemia, neutropenia or neutrophilia, and bicytopenia or pancytopenia. hyperplastic bone marrow, mild hyperglobulinemia, and elevated hepatic enzymes may be noted during this phase (kuehn and gaunt, ) . clinical signs are generally absent during the subclinical phase. mild thrombocytopenia, anemia, or leukopenia may be seen. the chronic phase develops - months after the initial infection, and signs may be subclinical to severe. an extremely varied clinical picture can emerge during this time and can mimic several other clinical syndromes. the following constellation of clinical signs may be observed: chronic lethargy, weight loss, inappetance or anorexia, fever, generalized lymphadenopathy, hepatosplenomegaly, petechial or ecchymotic hemorrhages, epistaxis, hematuria, melena, pallor, anterior or posterior uveitis, chorioretinitis, peripheral edema, ataxia, upper and lower motor neuron deficits, altered mentation, cranial nerve deficits, and seizures. persistent thrombocytopenia is the most consistent laboratory abnormality noted for all three stages. many other hematologic abnormalites may be found, such as regenerative or nonregenerative anemia (more frequently the latter), positive coombs' test, bicytopenia or pancytopenia, and splenic plasmacytosis or lymphocytosis. on bone marrow evaluation, plasmacytosis along with hypoplasia of erythroid, myeloid, and/or megakaryocyte lines may be seen. hyperglobulinemia as a result of polyclonal or occasionally monoclonal gammopathy has been noted in - % of e. canis seropositive or infected dogs (kuehn and gaunt, ; breitschwerdt et al., ; shimon et al., ) . proteinuria and/or hypoalbuminemia have also been seen. epizootiology and transmission. ehrlichia canis is an obligate intracellular parasite that infects mononuclear cells. the definitive hosts are arthropods; domestic and wild canids are parasitized secondarily. the primary vector and reservoir is the brown dog tick, rhipicephalus sanguineus. ehrlichia canis is found worldwide and follows the distribution of the vector. infection in dogs is most prevalent in tropical and subtropical areas (greene, ) . in the united states, cases are concentrated in the southeastern and southwestern states but have been reported in almost every state (breitschwerdt, ) . transmission is primarily by tick bites, but it can also occur via blood transfusions from dogs infected for as long as years. ticks become infected by feeding on an infected dog that is in the first - days of an acute infection (lewis et al., ) , and ticks can shed the organisms for up to months. within the tick population, e. canis is transmitted transstadially (within developmental stages) but not transovarially (from female to offspring) (groves et al., ) . pathogenesis. in experimental infections, the incubation period prior to the onset of the acute phase is - days. during the acute phase, which can last from - weeks, the bacteria replicate within circulating and tissue monocytes, resulting in lymphoreticular hyperplasia in affected tissues. infected monocytes then spread hematogenously to other organs in the body, in particular the lungs, kidney, and meninges. infected cells adhere to the vascular endothelium and induce vasculitis, which is the primary mechanism whereby the organism causes disease. the thrombocytopenia during the acute phase is due to both sequestration and destruction, and the development of anemia is a result of red blood cell destruction and suppression of erythrocyte production. the subclinical phase of the disease occurs - weeks after initial infection. during this stage, dogs that can mount an effective immune response clear the infection. those that cannot mount such a response progress to the chronic stage. infection does not confer protective immunity in dogs that recover. german shepherds and doberman pinschers seem to be more severely affected than other breeds. pathologic findings. gross lesions are varied and change, depending on the phase of the disease. the most common findings are petechial and ecchymotic hemorrhages and edema of dependent tissues (woody and hoskins, ) . the most common histologic abnormality noted is lymphocytic-plasmacytic inflammation of numerous organs. mononuclear phagocytic system hyperplasia, extramedullary hematopoiesis, and splenic erythrophagocytosis may also be seen. diagnosis and differential diagnosis. the most sensitive, specific, and commonly employed method for diagnosing e. canis infections is the indirect fluorescent antibody (ifa) test. antibodies can be detected as early as days postinfection, although some dogs may not seroconvert until days postinfection (buhles et al., ) . cross-reaction may occur between e. canis, e. chaffeensis, and e. ewingii. titers greater than : are considered positive and indicative of infection and may persist for up to year. effective treatment typically produces seronegative results in - months. in some cases, asymptomatic dogs may remain seropositive for years after treatment or may be seropositive with a persistent hematologic abnormality (bartsch and greene, ) . the exact mechanism for this finding has not been elucidated. ehrlichia canis morulae can be demonstrated in circulating monocytes of giemsa-stained blood smears. however, this method is labor-intensive and has low sensitivity, as morulae are present transiently and in low numbers. using buffy coat smears from capillary blood may increase the diagnostic yield. polymerase chain reaction (pcr) assays are also available to identify e. canis. differential diagnoses include immune-mediated hemolytic anemia/thrombocytopenia, multiple myeloma, chronic lymphocytic leukemia, and lymphoma. prevention. preventing laboratory animals from contacting ticks is the primary means to avoid monocytic ehrlichiosis in research dogs. avoid exercising dogs in areas infested with ticks. use topical acaricides to prevent tick infestations. keep kennel areas tick-free. dogs used as blood donors and dogs from unproven sources should be tested for e. canis. treatment. doxycycline is the drug of choice for treating monocytic ehrlichiosis. oral doses of either . - mg/kg q hr or mg/kg q hr for days are very effective at eliminating the organism. tetracycline, chloramphenicol, and enrofloxacin are also effective antibiotics; however, chloramphenicol should not be used in animals with cytopenias. in chronic cases, antibiotic treatment should be extended for an additional - weeks. research complications. the most significant research complication is the thrombocytopenia that persists for all stages of the disease. additionally, there is probable alteration in immune function and increased susceptibility to infectious agents. for these reasons, dogs positive for antibodies to e. canis should not be used in research. etiology. this disease, caused by ehrlichia platys, was first described as cyclic thrombocytopenia by harvey et al. in . clinical signs. in most cases, infection with e. platys results in subclinical disease. a generalized lymphadenopathy may be noted. epizootiology and transmission. the vector for e. platys is assumed to be a tick; however, this mode of transmission has not been established. experimental studies by simpson et al. ( ) failed to demonstrate rhipicephalus sanguineus as a vector for e. platys. coinfection with e. canis has been reported, which suggests a common vector for both organisms (french and harvey, ; kordick et al., ) . dogs have been experimentally infected by inoculation with infected blood or infected platelets from other dogs (harvey et al., ; gaunt et al., ) . the geographic distribution of thrombocytic ehrlichiosis is assumed to follow that of other ehrlichia organisms. the highest concentration of cases seems to be in southeastern states, but isolated cases have been reported as far north as michigan and as far west as oklahoma (wilson, ; mathew et al, ) . the prevalence of seropositive dogs can be high in some parts of the country. a study by bradfield et al. ( ) reported that % of the dogs entering a research institute's quarantine facility from sources in eastern north carolina were seropositive for e. platys. hoskins et al. ( ) reported a . % seropositive prevalence in healthy dogs from kennels in louisiana. pathologic findings. gross and histopathologic findings during experimental e. platys infection in dogs have been described by baker et al. ( ) . generalized lymphadenopathy was the only gross lesion noted. follicular hyperplasia and plasmacytosis were the predominate findings in lymphoreticular tissues. all dogs also had extramedullary hematopoiesis, erythrophagocytosis, and crescent-shaped hemorrhages in the spleen. multifocal kupffer's cell hyperplasia was noted in the liver, and mild multifocal lymphocytic-plasmacytic interstitial inflammation was seen in the kidneys. pathogenesis. the pathogenesis of e. platys in dogs has primarily been determined through experimental infection (harvey et al., ) . after inoculation the organism directly infects platelets. thrombocytopenia occurs by day - and fluctu-ates, along with parasitemia, at to day intervals. in some cases the rebound may be within the normal range for thrombocyte counts. the nadir can be lower than , platelets/~d. concurrent with low platelet counts is the development of megakaryocytic hyperplasia in the bone marrow. interestingly, despite extremely low platelet counts, spontaneous bleeding has not been reported in cases of e. platys infection. the mechanism responsible for the cyclic nature of the infection has not been elucidated. diagnosis and differential diagnosis. ehrlichia platys infection may be diagnosed on stained blood smears by visualization of the organisms within platelets. however, this method is very unreliable due to the cyclic nature of the parasitemia and the low numbers of infected thrombocytes. available ifa assays are much more sensitive and specific, and there is reportedly no serologic cross-reaction with other ehrlichia species. dogs usually develop detectable titers - weeks postinfection. pcr assays for e. platys have now been developed as well (chang and pan, ; mathew et al., ) . differential diagnoses for thrombocytic ehrlichiosis include e. canis infection, immunemediated thrombocytopenia, and disseminated intravascular coagulation (dic). platys is the same as described for e. canis, above. research complications. ehrlichia platys infection may increase the risk of bleeding during surgical or traumatic procedures. coinfection with e. platys may potentiate the pathogenicity of other infectious agents, in particular e. canis (breitschwerdt, ) . etiology. lyme disease is caused by borrelia burgdorferi sensu lato, a microaerophilic spirochete that is primarily an extracellular pathogen. clinical signs. clinical signs may be highly variable; lameness due to polyarthritis has been reported as the most common sign. the onset of lameness may be acute or chronic, shift from limb to limb, and be accompanied by swelling and joint pain. synovial fluid analysis from affected joints is consistent with a diagnosis of suppurative arthritis. other clinical signs include fever, anorexia, lethargy, lymphadenopathy, and weight loss. over the course of the disease, signs may wax and wane over a period of weeks to months. dogs rarely develop erythema chronicum migrans (the characteristic rash seen in infected people) and do not exhibit the severe arthritis and neurologic sequelae seen in human beings (greene, ; manley, ) . hematologic and biochemical profiles are generally unremarkable. lyme disease is thought to be the most common arthropod-borne disease of human beings (and possibly of dogs) in the united states. it affects humans and dogs worldwide. the geographic distribution of canine borreliosis is assumed to follow that of the human disease and is related to the range of the arthropod vectors. three major endemic foci that have been identified in the united states account for % of reported human cases (appel and jacobson, ). the distribution of these cases is as follows: northeast/mid-atlantic focus, %; midwestern focus (michigan, wisconsin, minnesota, iowa, illinois, and missouri), %; and california and oregon, %. for the most part, dogs in the remainder of the country are not at risk for contracting lyme disease. borrelia burgdorferi is transmitted exclusively by ixodes ticks. other arthropod hosts may carry the organism but have not as yet been implicated in the transmission of disease. ixodes scapularis, a three-host tick with a to year life cycle, is the prototypical vector for north america. the spirochetes are spread by tick bites from both nymphs and adults. ticks become infected by feeding on an infected mammal and by transstadial transmission (transovarial passage is rare). in endemic areas, - % of adult ticks may be infected (appel and jacobson, ) . the primary reservoir for the organism is the whitefooted deer mouse, peromyscus ieucopus, which can carry spirochetes for its life span without becoming ill. evidence also indicates that the eastern chipmunk, tamias striatus, is an important reservoir (slajchert et al., ) , and birds may also be a significant reservoir. deer, however, serve only as hosts for the tick vectors and not as a reservoir for the spirochete. pathogenesis. the pathogenesis of lyme disease is poorly understood, primarily because of a lack of good animal models and the chronic nature of the disease. infection can be induced experimentally by the bite of a single infected tick. clinical signs develop - days postinfection. some evidence points to the host's inflammatory response to the organism as etiologic for disease (pershing et al, ; greene, ) . seroconversion in dogs occurs - weeks after infection with b. burgdorferi. antibody titers may remain extremely elevated for at least months. igm titers also remain elevated for several months and are indicative of neither acute nor active infection (appel and jacobson, ) . because antibiotic treatment may not eliminate the organism, persistent infections in dogs (treated for days with antibiotics) can be reactivated by steroid treatment up to days postinfection (straubinger et al., ) . diagnosis and differential diagnosis. appel and jacobson ( ) recommend that three of the following four criteria be met to establish a diagnosis of lyme disease in dogs: ( ) history of exposure to ixodes ticks in an endemic area, ( ) characteristic clinical signs, ( ) positive serology, and ( ) rapid resolution of clinical signs with antibiotic therapy. ifa or elisa tests for borrelia antibodies are the assays of choice. it should be re-membered, however, that a positive titer in an endemic area indicates exposure and not necessarily disease and that vaccinated dogs will also have a positive titer. responses to vaccine versus infection may be distinguished by western blot. culture or identification of the organism provides a definitive diagnosis but is very difficult to perform. differential diagnoses include immune-mediated polyarthritis and septic arthritis from other etiologic agents. prevention and control. prevention and control are the same as for the other tick-borne diseases (see discussion of monocytic ehrlichiosis, section iii,a,l,e above). a vaccine against b. burgdorferi is available but should not be necessary in a research setting. treatment. doxycycline is the drug of choice for treating lyme borelliosis. a typical dosing regimen is mg/kg q hr for - weeks. amoxicillin, tetracycline, and the quinolones are also effective. of significant note is that antibiotic treatment results in resolution of clinical signs but may not result in elimination of the organism. (fox and lee, ) . "helicobacter heilmannii" and h. bizzozeronii are thought be the same species, with the latter being the updated nomenclature. this species, as well as h. rappini and h. canis, is considered to be zoonotic (fox and lee, ) . clinical infections may present with vomiting, diarrhea, fever, and anorexia, pica, or polyphagia. epizootiology and transmission. the epizootiology and transmission of helicobacter spp. in the dog remains to be elucidated. the prevalence of canine helicobacter infections in colony or shelter situations has been reported to range from % to almost % (fox, ; hermanns et al., ) . both oral-oral and fecal-oral routes for transmission have been suggested. pathologic findings. no gross lesions are noted; the primary lesion is that of histologic gastritis. this is typically characterized by reduced mucus content of the surface epithelium; vacu-olation, swelling, karyolysis, and karyorrhexis of parietal cells; and multifocal infiltrates of plasma cells and neutrophils into the subepithelium, primarily around blood vessels and between the gastric pits (hermanns et al., ) . focal areas of lymphocytic inflammation and lymphoid follicles may also be seen. pathogenesis. some helicobacter spp. colonize the gastric epithelium exclusively and other species colonize lower parts of the gastrointestinal tract. helicobacter felis and "h. heilmannii" infections have been linked to gastric lesions in laboratoryraised beagles (fox and lee, ) . the mechanism by which these organisms cause disease may be related to the host's inflammatory response to colonization and the helicobacter's ability to produce urease. urease splits urea into ammonia and bicarbonate; ammonia is toxic for the epithelial cells, and bicarbonate may help the organism survive the acidic environment (marshall et al., ; shimoyama and crabtree, ). diagnosis and differential diagnosis. any of the numerous causes of acute or chronic vomiting and diarrhea in the dog (including canine distemper, viral or bacterial gastroenteritis, and ingested toxicants) should be considered as differential diagnoses. definitive diagnosis for dogs requires either endoscopic or surgical biopsy. confirmation of infection with helicobacter spp. requires demonstration of the organism in biopsy samples by histopathology, culture, or recognition by pcr. a positive urease test on a biopsy sample may give a presumptive diagnosis, but only for those species that produce urease. the use of warthin-starry silver stain may increase the sensitivity for histopathologic diagnosis. prevention and control. until more is known about the epizootiology and transmission of helicobacter spp. in the dog, specific recommendations cannot be made about prevention and control in this species. treatment. combination therapy has proven to be the most effective method for treating helicobacter spp. infections in dogs. combination therapy of amoxicillin ( mg/kg q hr), metronidazole ( mg/kg q hr), and sucralfate ( . - . mg/kg q hr) for days has been suggested for dogs (hall and simpson, ) . replacing the sucralfate with famotidine ( . mg/kg q hr), omeprazole ( . mg/kg q hr), or bismuth subsalicylate ( . ml/kg q - hr) may also be effective (marks, ; jenkins and bassett, ; denovo and magne, ) . the benefits of antimicrobial therapy in dogs still need to be established by controlled therapeutic studies. research complications. helicobacter spp. infections could result in altered gastrointestinal responses to drugs and toxic or carcinogenic compounds. therefore, dogs used in gastric physiology or oral pharmacology studies should be free from helicobacteriosis. clinical signs. clinical signs of canine parvovirus usually appear days after inoculation by the fecal-oral route and are characterized by anorexia, fever, depression, and vomiting. profuse, intractable diarrhea ensues, which may become hemorrhagic. approximately % of affected dogs develop severe leukopenia, with a total granulocyte/lymphocyte count ranging from - wbc/~d or less. repeated hemograms may provide prognostic value, because rebounds in leukocyte counts are indicative of impending recovery. terminally ill dogs may develop hypothermia, icterus, or disseminated intravascular coagulation due to endotoxemia. parvovirus can infect dogs of any age, but puppies between and weeks of age appear to be particularly susceptible. puppies less than weeks of age are generally protected from infection by passive maternal antibody. adult dogs probably incur mild or inapparent infections that result in seroconversion. pathogenesis. canine parvovirus has an affinity for rapidly dividing cells of the intestine and causes an acute, highly contagious enteritis with intestinal crypt necrosis and villus atrophy. the virus also has tropism for the bone marrow and lymphoid tissues; thus leukopenia and lymphoid depletion accompany the intestinal destruction. diagnosis and differential diagnosis. parvovirus can be detected in fecal samples with a commercially available elisa from cite. at necropsy, diagnosis is based on gross and histopathologic evidence of necrosis and dilatation of intestinal crypt cells with secondary villous collapse. other lesions include myeloid degeneration and widespread lymphoid depletion. parvovirus can also be demonstrated in frozen sections by fluorescent antibody techniques. differential diagnoses should include other viral enteritides, salmonellosis, and small intestinal obstruction. prevention and control. prevention of transmission begins with isolation of affected animals and quarantine for week after full recovery. disinfection of potentially infected kennel and diagnostic areas with diluted bleach ( : ) or commercially prepared disinfectant (such as kennesol, available from alphatech, lexington, massachusetts) is essential for elimination of the virus. six-week-old puppies should be vaccinated every - weeks with a commercially available modified live vaccine until - weeks of age. young rottweilers and doberman pinschers appear to be predisposed to parvoviral enteritis and should be vaccinated every weeks ( times) from - weeks of age. treatment. treatment is largely supportive and is aimed primarily at restoring fluid and electrolyte balance. research complications. infection with parvovirus obviously precludes the use of a particular dog in an experimental protocol. given the potential for significant discomfort of the affected animal, and the cost of therapy, humane euthanasia is usually the option chosen in a research setting. canine coronavirus infection is usually inapparent or causes minimal illness. this epitheliotropic virus preferentially invades the enterocytes of the villous tips, resulting in destruction, atrophy, and fusion and subsequent diarrhea of varying severity. subclinical infections are most common, but abrupt gastrointestinal upset accompanied by soft to watery, yelloworange feces is possible. definitive diagnosis by virus isolation or paired sera is usually not made, because supportive therapy generally results in rapid resolution of the diarrhea. inactivated coronavirus is present in commercially available combination vaccines, which are administered immunoprophylactically at - , - , and - weeks of age and then annually thereafter. the role of these vaccines in protection from coronaviral infection is unknown, because the virus typically causes inapparent or mild illness (hoskins, ) . etiology. canine distemper virus (cdv) belongs to the family paramyxoviridae, within the genus morbillivirus, which includes human measles virus and rinderpest virus of ruminants. although there is only one serotype of cdv, there is a wide difference in strain virulence and tissue tropism. some strains produce mild clinical signs that are similar to tracheobronchitis, whereas other strains cause generalized infections of the gastrointestinal tract, integument, and central nervous system, resulting in enteritis, digital hyperkeratosis, and encephalitis, respectively. other factors contributing to the severity and progression of clinical signs include environmental conditions, immune status, and age of the host. a transient subclinical fever and leukopenia occur - days after exposure, with a subsequent fever spike - days later, accompanied by conjunctivitis and rhinitis. other clinical signs associated with acute distemper include coughing, diarrhea, vomiting, anorexia, dehydration, and weight loss. secondary bacterial infections can cause progression to mucopurulent oculonasal discharge and pneumonia. an immune-mediated pustular dermatitis may develop on the abdomen; this is usually a favorable prognostic sign (greene and appel, ) , because dogs that develop skin lesions often recover. neurologic complications of distemper infection may occur weeks to months after recovery from an acute infection. dogs that develop late-onset disease are usually immunocompetent hosts, suggesting that the virus may have escaped complete elimination by the immune system, possibly because of protective effects by the blood-brain barrier. classic neurologic signs that may occur in acute or chronic cdv infection include ataxia, incoordination, vocalization, "chewing gum" seizures, and myoclonus with or without paresis of the affected limb. canine distemper is the most common cause of seizures in dogs less than months of age. dogs with extensive neurologic involvement often have residual clinical deficits, including flexor spasm and olfactory dysfunction. cdv has also been associated with two forms of chronic encephalitis in mature dogs: multifocal encephalitis and "old dog encephalitis." epizootiology and transmission. the virus is highly prevalent and contagious to dogs and other carnivores, especially at the age of - months, coincident with the waning of maternal antibody. transmission is primarily by aerosolization of infective droplets from body secretions of infected animals. pathologic findings. the predominant histopathologic lesion in neurologic forms of distemper is demyelination, which may .. be accompanied by gliosis, necrosis, edema, and macrophage infiltration. acidophilic cytoplasmic inclusions can be found in epithelial cells of mucous membranes, reticulum cells, leukocytes, glia, and neurons, while intranuclear inclusions are often present in lining or glandular epithelium and ganglion cells. diagnosis and differential diagnosis. diagnosis of cdv is based on history of exposure and clinical signs. young dogs who have not received routine immunoprophylaxis (or similarly, mature dogs with a questionable vaccination history) and present with rhinitis, mucopurulent oculonasal discharge, plus or minus hyperkeratosis of the footpads and neurologic signs, are highly likely to have cdv. ophthalmologic examination may reveal chorioretinitis with acute disease or retinal atrophy in chronic cases. definitive diagnosis of acute infection can be made by fluorescent antibody testing of intact epithelial cells from conjunctival and mucous membranes. attenuated strains of cdv, found in modified live vaccines, are not disseminated from lymphoid tissue to epithelial cells and thus are not detected by the fluorescent antibody. serologic testing is usually not useful, because dogs frequently fail to mount a measurable immunologic response. because of the variety of clinical signs, there are many differential diagnoses for canine distemper. an important differential diagnosis for respiratory illness is infectious tracheobronchitis (kennel cough). bacterial, viral, and protozoal causes of gastroenteritis must be considered for cases presenting with vomiting and diarrhea, and rabies, pseudorabies, bacterial meningitis, and poisonings are differential diagnoses for dogs with central nervous system disorder. prevention and treatment. a series of three immunizations from to weeks of age, followed by yearly boosters, is a recommended preventative. treatment is largely supportive, but because of the profound immunologic effects and significant morbidity of cdv, humane euthanasia is usually undertaken in the research setting. etiology. canine herpesvirus (chv) infection causes a generalized hemorrhagic disease with a high mortality rate in newborn puppies less than weeks of age. in adult dogs, chv causes a persistent, latent infection of the reproductive tract with recrudescence and shedding during periods of physiologic stress. clinical signs. clinically affected puppies do not suckle, cry persistently, become depressed and weak, and fail to thrive. petechial hemorrhages of the mucous membranes and erythema of sparsely haired regions such as the caudal abdomen and inguinal area are evident. older puppies, aged - weeks, develop less severe clinical signs and are likely to survive with neurologic sequelae such as ataxia and blindness resulting from reactivation of latent infection. infection in adult dogs may result in stillbirths, abortions, and infertility. lesions in adult bitches include raised vesicular foci in the vaginal mucosa, accompanied by mild vaginitis. adult males have preputial discharge due to vesicular lesions at the base of the penis and on the preputial mucosa. passage of puppies through the birth canal or venereally in adult dogs. puppies can also be horizontally infected by littermates. entire primiparous litters may be lost, with subsequent litters protected by colostral antibody. pathologic findings. pathologic findings include multifocal ecchymotic hemorrhages of the kidneys, liver, lungs, and gastrointestinal tract. basophilic intranuclear inclusions in necrotic areas of parenchymal organs are characteristic findings. diagnosis and differential diagnosis. diagnosis of canine herpesvirus infection in adult dogs is based on a history of reproductive infertility and the presence of genital vesicular lesions. differential diagnoses for stillbirths, abortions, and infertility include canine brucellosis, canine distemper virus and parvovirus infections, and pyometra. the diagnosis in infected puppies is usually made based on clinical history and characteristic lesions (multifocal systemic hemorrhages) (carmichael and greene, ) . differential diagnoses for the disease in neonates would include canine ehrlichiosis and causes of disseminated intravascular coagulation, including bacterial endotoxemia. there is no effective curative treatment. supportive therapy is unrewarding, and death usually ensues within hours in in-fected neonates. in general, adult bitches that have multiple abortions, stillbirths, or persistent infertility should be culled from the breeding colony. examination of these animals may reveal raised vesicular lesions on the vaginal mucosa. adult male dogs that have vesicular lesions on the base of the penis and preputial mucosa should be similarly culled. adult dogs would obviously interfere with production operations, and affected animals should be culled based on the criteria noted above in the discussion of prevention and treatment. because of the severity of clinical illness in puppies, such animals should be humanely euthanatized. etiology. rabies virus is a member of the rhabdovirus family and is essentially contagious to all species of warm-blooded animals. clinical signs. clinical progression of neurologic disease occurs in three stages. the first, or prodromal, stage is characterized by a change in species-typical behavior. the loss of the instinctive fear of humans by a wild animal is a classic sign of impending rabies. in the second, or furious, stage animals are easily excited or hyperreactive to external stimuli and will readily snap at inanimate objects. the third, or paralytic, stage is characterized by incoordination and ascending ataxia of the hindlimbs due to viral-induced damage of motor neurons. death usually occurs within - days of the onset of clinical signs, due to respiratory failure. epizootiology and transmission. wild animals such as raccoons, skunks, and bats are common reservoirs of infection for domestic animals, which in turn are the principal source of infection for humans. transmission occurs primarily by contact of infected saliva from a rabid to a naive animal (or human), usually via bite wounds. pathogenesis. the incubation period for rabies is generally - weeks from the time of exposure to the onset of clinical signs but can range from week to year. bites of the head and neck typically result in shorter incubation periods because of the proximity to the brain. following infection, the virus migrates centripetally via peripheral nerve fibers to the central nervous system and eventually to neurons within the brain, resuiting in neurologic dysfunction. on reaching the brain, the virus migrates centrifugally to the salivary glands, thus enabling shedding and subsequent transmission. diagnosis and differential diagnosis. diagnosis of rabies is based on clinical signs; differential diagnoses include pseudorabies, canine distemper, bacterial meningitis, and toxicants that affect neurologic function. definitive diagnosis is based on fluorescent antibody demonstration of the virus in negri bodies of hippocampal cells. prevention and treatment. puppies should be vaccinated at - months of age, "boostered" in year, then vaccinated annually or triennially, depending on state and local laws and which vaccine product is used. treatment of rabies is not recommended, because of the risk of human exposure. research complications. in a research setting, dogs are often not vaccinated for rabies, because of the low incidence of exposure to wild-animal reservoirs. a healthy, purpose-bred dog that bites a human in a research facility should be quarantined for days and observed for signs of rabies. this quarantine interval is based on the knowledge that dogs do not shed rabies in the saliva for more than a few days before the onset of neurologic disease. a random-source dog with an unknown vaccination history that bites a human should be immediately euthanized. the brain should be examined for rabies virus to determine if the dog was infected, and if the test is positive, postexposure immunization should be initiated for the human patient. a rabies vaccine licensed for use in humans is available, and immunoprophylaxis is recommended for animal care and research personnel who may have high work-related risks of exposure. a. protozoa i. giardiasis etiology. giardiasis is a small-intestinal disease of the dog caused by giardia duodenalis (lamblia), a binucleate flagellate protozoan. clinical signs. most giardia infections are subclinical. when dogs are clinically affected, diarrhea is the most prominent sign. the diarrhea is a result of intestinal malabsorption and is often characterized as voluminous, light-colored, foul-smelling, and soft to watery. weight loss has also been associated with clinical infection. clinical illness is more often seen in young animals. epizootiology and transmission. giardia has a direct life cycle. dogs (and people) typically become infected when they consume water (or food) contaminated with giardia cysts. the ph change from the stomach (acid) to duodenum (neutral) causes excystation. trophozoites migrate to the distal duodenum and proximal jejunum and attach to the villus surface. eventually the trophozoites encyst and pass in the feces to perpetuate the life cycle. pathologic findings. giardiasis is rarely fatal. on histopathology of duodenal or jejunal specimens, giardia trophozoites can be seen attached to enterocytes. mucosal inflammation and ulceration, and villous atrophy, have been observed. pathogenesis. the exact pathogenesis of giardia-induced illness is unknown. it is thought that tissue invasion, although occasionally observed, is unimportant for pathogenesis. it is suspected that illness is caused by physical obstruction of enteric absorption, enterotoxicity, competition for nutrients, excess mucus production, and/or secondary bacterial overgrowth. diagnosis and differential diagnosis. definitive diagnosis requires observation of the organism in fecal or intestinal samples. direct fecal smears are considered best for observing trophozoites, and zinc sulfate flotation is preferred for detection of cysts. commercial elisa kits and direct immunofluorescent tests are available to detect fecal giardia antigens, but the diagnostic specificity and/or sensitivity of these tests may not be sufficient to warrant substitution for the less expensive direct fecal examination or zinc sulfate preparation (barr, ) . differential diagnoses for giardiasis include bacterial and protozoal enteritis, coccidiosis, and whipworm infestation. prevention. high-quality water sources will eliminate the possibility of infection developing within an animal research facility. use of dogs with a known husbandry and medical background will minimize the chances of giardiasis developing in a research colony. control. once giardiasis has been diagnosed in a canine population, segregation of infected animals will help to reduce further infection (provided other dogs were not preinfected at the same source location as the signal case). disinfection with quaternary ammonium compounds, bleach, or steam is usually successful in eradication of giardia cysts. treatment. the most common treatment for giardiasis is metronidazole (flagyl) at - mg/kg per os twice per day for - days. quinacrine hydrochloride (atabrine) at mg/kg per os once per day for days, furazolidone (furoxone) at mg/kg per os twice per day for - days, and the anthelmintics albendazole and fenbendazole have been proposed for use against metronidazole-resistant strains of giardia. a bendazole is recommended at mg/kg per os q hr for days, and fenbendazole at mg/kg per os q hr for days. fenbendazole was thought to be safer for both puppies and pregnant females (nonteratogenic) (barr, ) . research complications. typical asymptomatic infections probably have no consequence on research protocols, with the exception of intestinal physiology or immunology studies. clinical diarrhea would clearly need to be treated before a dog could be used as a research subject. ii. coccidiosis etiology. intestinal coccidia that have been associated with enteropathy in dogs include cystoisospora canis, c. ohioensis, c. burrowsi, and c. neorivolta. clinical signs. dogs are typically asymptomatic when infected with intestinal coccidia, and oocysts are an incidental finding on fecal flotation or direct smear. dogs that are clinically infected usually develop diarrhea, which can vary from soft to watery and may contain blood or mucus. vomiting, dehydration, lethargy, and weight loss can also be seen. epizootiology and transmission. cystoisospora oocysts are typically spread by fecal-oral transmission, usually by ingestion of fecal-contaminated food or other objects in the environment. an indirect form of transmission is also possible, whereby the dog consumes a rodent or other animal that is serving as a transport host. once inside the small intestine, the cyst releases sporozoites that infect enteric epithelium. several generations of asexual reproduction can occur in the enterocyte before sexual reproduction produces gamonts. the gamonts fuse to become a zygote, which encysts, ruptures the enterocyte, and passes in the feces. once in the environment the cyst sporulates and is now an infective stage for ingestion by another host. pathologic findings. dogs with coccidiosis may have hyperemia or fluid retention at affected intestinal segments. the mucosa may appear normal, raised, or ulcerated. histologically, there may be necrosis of enterocytes, hyperemia, and submucosal inflammation. the oocysts are usually readily apparent within the epithelial cells (van kruiningen, ) . pathogenesis. intestinal coccidia are opportunistic organisms; they do not typically cause illness unless other predisposing factors are present. such factors include immunodeficiency, malnutrition, and/or concurrent disease. overcrowding and unsanitary conditions can also promote clinical coccidiosis by providing a high population of infective oocysts to stressed animals. diagnosis and differential diagnosis. diagnosis is somewhat difficult, as coccidian oocysts (of both cystoisospora and non-cystoisospora spp.) can be seen on fecal examinations of clinically healthy dogs, as well as animals with diarrhea. other causes for diarrhea (e.g., parvovirus, roundworms, giardia spp., campylobacter jejuni, and inflammatory bowel disease) should be excluded before a coccidial etiology is implicated. prevention. clinical coccidiosis can be readily prevented by adhering to proper sanitation guidelines, reducing any over-crowding, and providing as stress-free an environment as possible. treatment. treatment for the presence of coccidial oocysts may often not be necessary, because cystoisospora infections are typically self-limiting and clinically insignificant. treatment may, however, help to limit the number of oocysts shed in a kennel housing situation and may be necessary in cases of protracted clinical illness. possible choices for treatment include daily administration of sulfadimethoxine ( - mg/lb per os for days), trimethoprim sulfa ( mg/lb per os for days), or quinacrine ( mg/lb per os for days). amprolium, which is not labeled for dogs, can also be used as a coccidiostat. it can be given in gelatin capsules for - days at a daily dose of mg for small-breed pups and mg for larger breeds. research complications. as with any enteric disease, the presence of clinical coccidiosis can cause aberrations in gastrointestinal physiological parameters. dogs used in intestinal pharmacokinetic studies should be confirmed to be free of cystoisospora infections. b. nematodes i. ascarids etiology. the most common ascarid of dogs is toxocara canis. toxascaris leonina can also infect both dogs and cats. clinical signs. ascarid infestations are most commonly subclinical. however, large worm burdens can cause diarrhea, vomiting, dehydration, and abdominal discomfort with vocalization. puppies may have a classical "potbellied" appearance and dull hair coat. heavy infestations can cause intussusception and/or intestinal obstruction, in which case the young dogs may be found dead. visceral larval migrans caused by toxocara canis can cause pneumonia. epizootiology and transmission. toxocara canis typically infects puppies. in fact, a unique characteristic of t. canis is its ability to infect prenatal puppies by transplacental migration, and neonatal puppies by transmammary migration. ingestion of infective eggs that have been shed in the feces is another common route of transmission, and infection by ingestion of a transport or intermediate host is also possible. pathologic findings. puppies that die from ascarid infestations typically have large worm populations in the lumen of the small intestine. such populations can cause intestinal obstruction and may also result in intussusception or intestinal perforation. puppies that experience lung migrations of large larval worm populations can have severe pulmonary parenchymal damage and develop fatal pneumonia. pathogenesis. the infective stage of t. canis is the third-stage larva (l ). infections initiated by ingestion of infective eggs have three possibilities for larval migration: liver-lung migration (which leads to intestinal infection), somatic tissue migration, and intestinal wall migration. older dogs that become infected typically have an age-related resistance to liver-lung migration and instead experience the other two migratory patterns. these larval migrations are often asymptomatic, and progression of the l larvae is arrested in the tissues. it is these larvae that become reactivated in a pregnant bitch, thus establishing the transplacental and transmammary routes of transmission. if the source of infection is transplacental, puppies may be born with l larvae in their lungs, because larval migration is already in progress (sherding, ). diagnosis and differential diagnosis. the characteristic large ( - ~tm in diameter) and relatively round ascarid eggs can be readily diagnosed by standard fecal flotation methods. prevention and control. monthly administration of milbemycin or ivermectin plus pyrantel pamoate (heartgard plus) is recommended for prevention and control of canine ascarid infestation (hall and simpson, ) . treatment. most anthelmintics are effective for treatment of ascariasis. pyrantel pamoate (nemex) and fenbendazole (panacur) are commonly used. treatment should be started early in puppies ( , , , and weeks) because of the possibility of prenatal or neonatal infection. pyrantel pamoate, dosed at mg/kg per os, is safe for puppies and is also effective in treatment of hookworms (see section iii,a, ,b,ii). in breeding colonies in which ascarid infestation is a known problem, treatment of the pregnant and nursing bitch may be advantageous. extended fenbendazole therapy ( mg/kg per os twice per day for days or once per day from day of gestation through day of lactation) has been shown to be experimentally safe and effective in decreasing ascarid burdens in puppies. research complications. puppies with large worm burdens make poor research subjects and should be treated aggressively before placement on an experimental study. ii. hookworms etiology. the most common and most pathogenic hookworm of dogs is ancylostoma caninum. other, less pathogenic canine hookworms found in north america are a. braziliense, which can be found in the american tropics and southern united states, and uncinaria stenocephala, which is distributed in the northern united states and canada. clinical signs. only a. caninum infestation typically results in clinical illness, because of the amount of blood that it con-sumes. puppies with a. caninum infestations are typically pale and weak (from anemia), with bloody diarrhea or melena. other clinical signs include lethargy, anorexia, dehydration, vomiting, and poor weight gain. epizootiology and transmission. infective larvae (l ) are typically ingested by puppies and develop directly in the intestinal tract. ingestion can be from the bitch's milk (transmammary migration occurs with a. caninum), from food or objects contaminated with infective larvae, or from ingestion of a paratenic host. transplacental migration does occur with a. caninum, but to a much lesser extent than is seen with toxocara canis. larvae can also penetrate intact skin, migrate to the lung via somatic or circulatory routes, and be coughed and swallowed to reach the intestine. the prepatent period is weeks. pathologic findings. infected puppies often have severe anemia and eosinophilia. the anemia can be from acute blood loss or can also be an iron-deficiency anemia caused by chronic blood loss coupled with limited iron reserves. on gross necropsy, the small-intestinal tract contains worms admixed with intestinal contents containing fresh or digested blood (fig. a) . ulcerative enteritis caused by hookworm attachment is evident on histopathologic examination, and worms with mouthparts embedded in the mucosa can be identified in some sections (fig. b) . pathogenesis. the severe pathogenicity of a. caninum is a direct result of its voracious consumption of blood and body fluids. each adult hookworm can consume . - . ml of blood; thus an extensive infection could deplete a puppy of ml of blood per day, which is approximately % of the blood volume of a . kg animal. in contrast, a. braziliense and u. stenocephala consume . and . ml per worm, respectively. diagnosis and differential diagnosis. diagnosis of ancylostomiasis is made by identification of eggs or larvae from fecal samples by either flotation or direct smear. parvovirus should be considered for puppies with bloody diarrhea, and autoimmune hemolytic anemia should be considered in the diagnosis of a young dog with anemia. prevention and control. purchase of purpose-bred animals will limit the exposure to hookworm larvae, and effective sanitation programs will easily eradicate the infective larvae. unlike ascarid eggs, hookworm eggs are readily killed by drying, sunlight, or cold; however, they do survive readily in warm, moist environments. monthly administration of milbemycin or ivermectin plus pyrantel pamoate (heartgard plus) is recommended for prevention and control of canine ascarid infestation (hall and simpson, ) . treatment. pyrantel pamoate (nemex) is the anthelmintic of choice because it is safest in young ill animals and is also effective against ascarids and other enteric helminths. because of the possibility of transplacental or milk-borne infection, puppies should be treated every weeks from weeks - . a follow-up treatment at weeks is recommended to kill any larvae that have migrated and matured since the initial therapy. severely ill puppies may require supportive fluid therapy and possibly whole blood transfusions and iron supplementation. research complications. anemic puppies with large worm burdens make poor research subjects and should be treated aggressively before placement on an experimental study. iii. strongyloides etiology. strongyloides stercoralis is a small strongyle that can cause hemorrhagic enteritis in puppies. it is found in warm, humid climates such as the southeastern united states. fects dogs and other animals by third-stage larval penetration of the skin or mucous membranes. larvae migrate via the circulatory system to the lung and then are coughed and swallowed to initiate the intestinal parasitism. the eggs of s. stercoralis hatch within the gut lumen, and so it is the first-stage larvae that pass in the feces and need to be identified by diagnostic examination. once passed, the larvae can either develop into the infectious third-stage larvae or mature into free-living, nonparasitic adults. diagnosis and differential diagnosis. the baermann procedure is usually performed on fresh feces in order to detect the motile first-stage larva ( - ~tm x - ~tm). the larvae must be distinguished from larva of filaroides hirthi and hatched ancylostoma caninum. treatment. the usual treatment for s. stercoralis is fenbendazole (panacur) at mg/kg per day for days. iv. whipworms etiology. trichuris vulpis, the canine whipworm, can cause acute or chronic large-intestinal diarrhea. the adult whipworm typically resides in the cecum or ascending colon. clinical signs. most whipworm infections are subclinical. in symptomatic cases, the typical clinical sign is diarrhea with blood and/or mucus. abdominal pain, anorexia, and weight loss are also seen. dogs may have eosinophilia, anemia, and/or hypoproteinemia on clinical hematology. severe dehydration with electrolyte imbalance has occurred occasionally as an acute crisis episode. life cycle. adult worms residing in the canine large intestine intermittently release eggs that pass in the feces. the eggs are very hardy and can persist for years. in optimal conditions, the eggs develop into an infective embryo within days. after ingestion by a dog, the larvae hatch in the small intestine, burrow into the small-intestinal mucosa, and then reemerge several days later to travel and burrow into the cecal and colonic mucosa. the prepatent period is typically - months long. pathologic findings. dogs do not typically die from whipworm infestations. lesions seen as incidental findings feature adult worms embedded into the colonic and cecal mucosae, causing local granulomatous inflammatory reactions and mucosal hyperplasia. pathogenesis. the penetration of the adult worm into the enteric mucosa, and the associated inflammation, can lead to the clinical development of diarrhea. factors that influence the possible.development of clinical symptoms are the number and location of adult whipworms; the severity of inflammation, anemia, or hypoproteinemia in the host; and the overall condition of the host. diagnosis and differential diagnosis. whipworm infestation is diagnosed by the presence of characteristic trichurid eggs on fecal flotation. these eggs are barrel-shaped, with thick walls and bipolar plugs. because of the intermittent release of eggs by the adult female worms, negative fecal flotation does not exclude the possibility of clinical whipworm infection. adult worms can be seen on colonoscopy (jergens and willard, ) . differential diagnoses for whipworm infestation include giardiasis, coccidiosis, and bacterial enteritis. prevention and control. trichuris eggs are resistant to disinfection, making control difficult. dessication or incineration is the only completely effective means to eradicate whipworm eggs from the environment. treatment. fenbendazole, oxibendazole, and milbemycin have all been recommended for treatment of whipworms. treatment for whipworm infestation should be at monthly intervals for months (jergens and willard, ) . treatment is also suggested in cases wherein whipworm infestation is suspected but not confirmed by multiple fecal flotation. rapid response to treatment would be indicative of a correct diagnosis; lack of response should prompt further diagnostic efforts. research complications. whipworm infestation has not been documented to interfere with research protocols, although one would anticpate that aberrations in local enteric immune function and absorptive functions of the large intestine could result from trichuriasis. etiology. heartworm disease of dogs is caused by the filarial worm, dirofilaria immitis. adult heartworms reside in the pulmonary artery; severe infestations can result in the presence of worms in the right ventricle and atrium. microfilariae, the immature worms produced by the adults, circulate in the bloodstream until a mosquito (intermediate host) ingests them. clinical signs. most heartworm infestations are asymptomatic. the most common clinical signs observed are coughing and dyspnea. clinical signs of exercise intolerance and rightsided heart failure can be seen in severe infestations. epizootiology and transmission. successful heartworm transmission requires the presence of mosquitoes. for this reason, random-source dogs or dogs housed in outdoor kennels are much more likely to have heartworm infestations than indoor, purpose-bred dogs. mosquitoes become infested with heartworm microfilariae when they take a blood meal from the dog. the microfilaria progress through several larval stages within the mosquito, eventually terminating at the third stage. this stage is then returned to the canine bloodstream during feeding. this stage matures within the dog's circulatory system, and the adults reside in the pulmonary artery. male and female heartworms will then sexually reproduce to create more microfilariae and propagate the parasitic life cycle. in the united states, transmission of heartworm by mosquitoes occurs over a month or shorter period, except for the southeastern and gulf coast states. here, climatic conditions enable longer survival of the mosquitoes (possibly year-round), thus resulting in the highest prevalence of heartworm infestation (knight, ) . pathologic findings. on necropsy, the small, slender worms can be seen in the pulmonary artery, right ventricle, and/or right atrium (fig. a ). there may be no histologic abnormalities associated with a minor worm burden, although typically the arterial endothelium in these areas is hyperplastic (fig. b) . endothelial cell hyperplasia, vascular smooth muscle hyperplasia, inflammation, and thrombosis of the pulmonary arteries and arterioles characterize more significant infestations. severe infestations can lead to right-sided heart failure and its pathologic sequelae of ascites, pleural effusion, hepatomegaly, and right heart and pulmonary artery enlargement. verminous pulmonary embolism can result from treatment of dogs with anthelmintics when a worm burden is present. immune responses to circulating microfilariae can cause pathologic lesions, most commonly glomerulonephritis. pathogenesis. the physical presence of the worms in the pulmonary artery is partially responsible for clinical signs observed in severe cases. however, the host immunologic response to this infestation, coupled with secretion by the heart-worms of physiomodulative factors, contributes significantly to the complications seen with this disease. endothelial cell proliferation, damage, and sloughing stimulates periarteritis and proliferation of the vascular media of pulmonary arteries and arterioles. these changes lead to thrombosis of these vessels and the arterial truncation that can be seen radiographically in severe infestations. the heartworms also release circulating factors that affect vascular tone and can promote bronchoconstriction (dillon, ) . these factors are discussed in more detail below, under "research complications." diagnosis and differential diagnosis. for dogs used in biomedical research, diagnosis of asymptomatic heartworm disease is important, especially if the dogs are used in cardiovascular, pulmonary, or long-term studies. a diagnosis of dirofilariasis is typically made by detection of adult heartworm antigens in a blood sample. use of adult heartworm antigen tests has virtually eliminated the historical status of "occult" heartworm disease, which was caused by infestation of adult worms without corresponding microfilarial circulation. commercial test kits that assay for the presence of adult heartworm antigens, and designed for use by veterinary practitioners, are readily available. false-negative results can occur during the prepatent period after initial infection (first - months), and when the adult worm burden is light or predominantly male. infections consisting of more than three mature female worms are usually detected by antigenic serology (knight, ) . a significant feature of these tests for circulating antigen is that they have a very high specificity (low rate of false-positive resuits). if a dog were negative on initial testing because of prepatency or small worm burden, it will more than likely be detected on a follow-up test months later. examination for circulating microfilariae could be used to confirm an antigenic diagnosis of dirofilariasis or to establish that microfilarial production had occurred. microfilarial detection can be done by microscopic examination of the buffy coat of a microhematocrit tube or by concentration techniques, such as the modified knott test and filter tests. tests that examine for microfilariae have the inherent problem of false positives caused by microfilariae of dipetalonema reconditum, a nonpathogenic filarial worm. other serologic diagnostic tests that were more common historically, and that may still be useful, include detection of antibodies to either adult heartworm antigens or microfilarial antigens. these same techniques can be used to diagnose clinical heartworm disease. additional diagnostic tests that can augment a diagnosis of clinical heartworm disease include thoracic radiography (pulmonary artery and right-heart enlargement), electrocardiography (right-heart enlargement), and hematology (eosinophilia). differential diagnoses for symptomatic heartworm disease (coughing, dyspnea, and exercise intolerance) include canine distemper, canine infectious tracheobronchitis (complicated), streptococcal or other bacterial pneumonia, nocardiosis, and congestive heart failure. prevention and control. for dogs used in biomedical research, prevention is primarily via insect control and housing of the dogs in a controlled, indoor environment. purpose-bred dogs reared in such an environment are usually free from dirofilariasis. however, any dog (random-source or purposebred) exposed to mosquitoes could become inoculated with infective larvae and, if untreated, could develop adult heartworm disease. there are many commercial anthelmintic preparations used to prevent heartworm infestation by killing the larval stages in the canine bloodstream before they become adult worms (e.g., ivermectin, milbemycin, and diethylcarbamazine). these could be used in a research setting in which heartwormnegative dogs are housed outdoors and thus could potentially be infected through mosquito bites. if a research facility is conditioning random-source dogs for long-term use, the presence of circulating adult heartworm antigen should disqualify an animal from the conditioning program. treatment. treatment for eradication of heartworms (adults, juveniles, and microfilaria) is a long process that can pose a significant risk to the patient with regard to both drug side effects (hoskins, ) and immunologic reactions to dead worms lodged in the pulmonary vasculature. for this reason, medical treatment of heartworm disease is not usually attempted in research dogs. in a rare instance when such treatment was in the best interest of a long-term canine experiment, thiacetarsamide (caparsolate) and ivermectin (ivomec) were used to eradicate adults and microfilariae, respectively (authors' personal experience). alternative choices include melarsomine (immiticide) as an adulticide and milbemycin (interceptor), levamisole (levasol), or fenthion (spotton) as microfilaricidal agents. dosing regimens for these agents are detailed in dillon ( ) . research complications. the physiomodulative properties of heartworm infection have been studied. such studies have looked at factors released by adult heartworms, as well as changes in the function of host tissues in response to the worm presence. probably the most consistent finding is that endothelial cell-dependent relaxation of pulmonary arterial smooth muscle is depressed in heartworm-infected dogs as compared with control dogs, indicative of alterations in local endothelial cell behavior (maksimowich et al., ; matsukura et al., ; mupanomunda et al., ) . the extension of this effect on peripheral arteries (in vivo and in vitro) has been supported in some studies (kaiser et al., ) but refuted in others (tithof et al., ) . it is thought that the endothelium is perturbed by a factor released from the adult dirofilaria, possibly a cyclooxygenase product such as prostaglandin d (kaiser et al., (kaiser et al., , . these products have also been demonstrated to cause constriction in in vitro rat tracheal ring preparations (collins et al., ) , suggesting that bronchoconstriction could be an aspect of the pathogenesis of the infestation. platelet reactivity was also been found to be enhanced in dogs naturally infected with dirofilaria, when compared with uninfected controis (boudreaux and dillon, ) . based on these data, dogs that are positive for adult heartworm antigen should be considered inappropriate for use as research subjects and, if used, should be restricted to nonsurvival preparations that do not require physiological measurements. etiology. several species of cestodes (tapeworms) parasitize the small intestine of dogs. the most common is dipylidium caninum. other species include taenia pisiformis and, more rarely, echinococcus granulosus, multiceps spp., mesocestoides spp., and spirometra spp. clinical signs. most cestode infestations are subclinical. severe infestations with dipylidium can be associated with diarrhea, weight loss, and poor growth. epizootiology and transmission. the cestode life cycle requires an intermediate host. for dipylidium caninum, the intermediate hosts are fleas and lice. thus this species of tapeworm can be readily transmitted by ingestion of arthropods that are canine parasites in and of themselves. taenia pisiformis requires small ruminants, rabbits, or rodents for intermediate hosts, so spread is less likely, especially in a research setting. echinococcus granulosus uses not only sheep as an intermediate host but also human beings, and thus the zoonotic potential of this cestode must be considered. pathologic findings. adult cestodes in the small intestine are usually an incidental finding at necropsy. diagnosis and differential diagnosis. definitive diagnosis is usually made by the identification of egg capsules or proglottids (tapeworm segments) on the surface of the feces or around the anus. dipylidium egg packets are large ( x bm) and contain - eggs per packet (hall and simpson, ) . prevention and control. the most significant means to limit cestode infestation is to control the population of fleas and/or lice infesting the colony. see the sections on these ectoparasites for effective means to treat infested dogs and kennels. treatment. praziquantel at - . mg/kg orally or subcutaneously is the standard treatment for cestodiasis, especially taenia or echinococcus species. fenbendazole, mebendazole, or oxfendazole may also be effective against dipylidium caninum (hall and simpson, ) . clinical signs. most lung fluke infestations are inapparent, but coughing can develop in cases that prompt a strong inflammatory response. pneumothorax has been a sequela of cyst rupture, in which case dyspnea with reduced lung sounds would be the typical presentation. epizootiology and transmission. the lung fluke life cycle requires two intermediate hosts: a snail and then a crayfish. dogs become infested after eating crayfish, which essentially limits this disease to random-source dogs. on ingestion, the immature flukes (metacercariae) migrate to the lungs and encyst in the pulmonary parenchyma. eggs produced by adult flukes are passed into the bronchioles, coughed up, swallowed, and passed in the feces to complete the life cycle. pathologic findings. grossly, the trematode cysts containing adult flukes can be seen in the lung parenchyma. areas of eosinophilic inflammation surround the cysts, and eosinophilic granulomas can also be seen encircling released eggs. pleural hemorrhages may also be caused by the migrating metacercariae (lopez, ) . pathogenesis. clinical illness is usually a result of a severe eosinophilic inflammatory response, pneumothorax caused by cyst rupture, or secondary bacterial pneumonia. diagnosis and differential diagnosis. definitive diagnosis of paragonimus infestation requires identification of the characteristic ovoid eggs ( - ~tm long) with a single operculum in either the feces or a transtracheal wash. identification from fecal samples requires sedimentation techniques. other causes of coughing in dogs (e.g., infectious tracheobronchitis, dirofilariasis, congestive heart failure) need to be considered. radiographically, the appearance of (multi)focal densities within the air-filled lung field needs to be differentiated from pulmonary neoplasia (primary or metastatic) or systemic fungal pneumonias. prevention. use of purpose-bred dogs virtually eliminates the chance of pulmonary trematodiasis in a research animal. treatment. praziquantel (at mg/kg q hr x days) or fenbendazole ( - mg/kg q hr x - days) are recommended for treatment of canine paragonimus infestation (hawkins, ) . effectiveness is monitored by fecal sedimentation tests for eggs and resolution of radiographic lesions (which may never resolve entirely). early diagnosis of pulmonary trematodiasis should warrant discontinuation of a dog from a long-term study because of the possibility of more serious clinical sequelae, such as pneumothorax. research complications. experimental studies involving the immune system, especially eosinophilic or local pulmonary responses, would be significantly affected by even minor infestations. clinical illness would complicate almost any research project and makes dogs poor anesthetic risks. radiographic lesions may confound diagnostic evaluation for pulmonary metastasis of tumors. e. mites i. demodicosis etiology. canine demodicosis is caused by demodex canis, a commensal mite that lives in the hair follicles. it is considered to be normal fauna of dog skin, but certain conditions (i.e., immunosuppression) cause development of clinical illness. clinical signs. demodex canis infestation is typically asymptomatic. clinical demodicosis presents with variable and nonspecific clinical signs, such as alopecia, erythema, pruritus, crusts, and hyperpigmentation. it can occur anywhere on the body but is often seen on the feet and the face and around the ears (demanuelle, a). secondary bacterial pyoderma is a common complication. epizootiology and transmission. demodex canis mites pass to nursing pups from the dam. they live their entire lives on one dog and are not considered contagious to other dogs or humans. certain breeds are predisposed to the generalized form of demodex dermatitis (see "pathogenesis," below). beagles are among the predisposed breeds, as are german shepherds, doberman pinschers, old english sheepdogs, collies, boxers, and shorthair brachycephalic breeds (muller et al., ) . pathologic findings. histologically, demodex infections are characterized by perifolliculitis and folliculitis with mites and keratin debris visible in the hair follicles. cases with generalized demodicosis (see "pathogenesis," below) may have a minimal cellular response with no eosinophils, indicative of severe immunosuppression . pathogenesis. when clinical demodicosis develops, it is classified into "localized" or "generalized" (e.g., more than one foot affected, or five or more small areas, or one large body area). localized demodicosis is typically seen in juvenile dogs (< months) and usually resolves without treatment as natural immunological control develops. generalized demodicosis can develop in juvenile or adult populations. juvenile-onset generalized demodicosis occurs in dogs with a genetic predisposition, thought to be an inherited t-lymphocyte dysfunction. adult-onset generalized demodicosis is usually indicative of an underlying endocrine (hyperadrenocorticism, diabetes mellitus, hypothyroidism) or neoplastic disorder or can develop as a result of immunosuppressive therapy (such as corticosteroid administration). diagnosis and differential diagnosis. demodex is readily identified from deep skin scrapings of lesioned areas (campbell, ; noli, ) . demodex canis has a characteristic "cigar shape," with short, stubby legs on a body - ~tm long. differential diagnoses for local demodicosis include dermatophytosis, allergic contact dermatitis, and seborrheic dermatitis. the primary differential diagnosis for generalized demodicosis is primary bacterial pyoderma; remember, however, that bacterial pyoderma is a common secondary complication of the generalized form of this parasitism. prevention and control. dogs with generalized demodicosis should not be maintained in a breeding colony. treatment: ivermectin (ivomec) at - ~tg/kg and oral milbemycin (interceptor) at - mg/kg/day have been found to be effective treatments. these parasiticides are probably the most practical to use in a research setting, although they are not labeled for treatment of demodex canis. amitraz (mitaban) dips ( ppm every days) can be used for more problematic cases. treatment duration can be extensive and must be accompanied by repeated skin scrapings. research complications. dogs with generalized demodicosis should not be used in research studies, because this disease is indicative of another underlying disorder (endocrine or immunological). dogs that receive immunosuppressive agents or paradigms could develop generalized demodicosis as an unexpected consequence of the experimentation. ii. sarcoptic mange etiology. canine sarcoptic mange is caused by sarcoptes scabiei var. canis. clinical signs. the most common clinical sign is an intense pruritus, usually beginning at sparsely furred areas such as the ear pinnae, elbows, and ventral thorax and abdomen. lesions are characterized by alopecia and yellowish dry crusts with a macular papular eruption. these lesions may be exacerbated by excoriation due to the pruritic nature of the condition. epizootiology and transmission. sarcoptes mites live their entire lives in the stratum corneum of the host animal; however, they can survive for - weeks away from the host, and it is this ability that enables them to spread from dog to dog. sarcoptes scabiei var. canis can also infect cats and humans. pathologic findings. histologic examination can be unrewarding because mites are rarely seen on tissue sections, and the associated dermatitis is nondiagnostic: perivascular and interstitial dermatitis with hyperkeratosis, with or without eosinophilic infiltration. suggestive histopathologic lesions are epidermal "nibbles," small foci of edema, exocytosis, degeneration, and necrosis . pathogenesis. lesions and illness are a result of the female mites burrowing through the epidermal layers to deposit eggs, and the larvae migrating back to the surface. the typical locations of mange lesions are a result of the mite's preference for relatively hairless areas. diagnosis and differential diagnosis. sarcoptic mange can be difficult to diagnose because multiple skin scrapings can yield negative results with this parasitic disorder. hopefully, adult mites, mite eggs, or mite feces can be observed on superficial skin scrapings. even if scrapings are negative, however, a therapeutic trial should be initiated if the clinical signs and history suggest a sarcoptes etiology. demonstration of anti-mite ige in either the serum or via an intradermal antigen test can be used as a diagnostic aid (campbell, ). an important differential diagnosis is flea allergy dermatitis; in contrast, mange is nonseasonal and contagious. prevention and control. use of purpose-bred dogs limits the possibility of having research animals with sarcoptic mange. for random-source dogs, an ectoparasite control program should be in place to limit possible infestations. many institutions use ivermectin as a means to control both endoparasites and ectoparasites. treatment. unless treatment would interfere with research objectives, all dogs with sarcoptic mange (no matter how minor the lesions) and their kennel mates should be treated because of the contagious nature of the disease and its zoonotic potential. in research colonies, the usual means of treatment is either ivermectin (ivomec) at - ~tg/kg q days or milbemycin (interceptor) at oral doses of mg/kg q days . neither of these agents is approved for treatment of sarcoptic mange, but they are considered to be effective. acaricidal dips (e.g., lime sulfur, organophosphates, amitraz) can also be used. research complications. the local skin inflammation and systemic immune response to sarcoptic mange probably make infected dogs poor subjects for dermatologic and immunologic studies. f lice and ticks i. lice etiology. dogs can be infested by one species of sucking louse (linognathus setosus) and two species of biting lice (trichodectes canis and heterodoxus spiniger). clinical signs. mild cases of pediculosis may be asymptomatic or may cause pruritic areas of dry skin. more severe infestations can cause significant pruritus and produce alopecia, papules, and crusts. these lesions lead to excoriation and secondary bacterial dermatitis. severe linognathus infestations could cause anemia, because this species feeds on blood. epizootiology and transmission. louse infestations are uncommon in both pet animal practice and the research setting. they would most likely be seen in random-source dogs that were obtained from a pound or shelter. transmission is usually by direct contact, for lice spend their entire lives on the host species. lice are host-specific and not zoonotic. pathogenesis. the biting lice usually cause more local irritation than the sucking louse and therefore are more apt to induce clinical dermatologic signs. trichodectes canis can serve as vector for the canine tapeworm dipylidium caninum. the most severe complication of infestations by the sucking louse is the potential anemia. diagnosis and differential diagnosis. pediculosis is diagnosed by direct observation of the lice or nits (eggs) on the dog's skin. cellophane tape can be used to pick up surface debris from skin lesions, which may include nits or immobilized lice (muller et al., ) . differential diagnoses include dermal acariasis, flea allergy dermatitis, and seborrhea. prevention. use of high-quality conditioned dogs for research should prevent pediculosis from ever being seen within a research facility. random-source dogs should be shampooed or treated prophylactically with topical insecticide before being permitted to enter the research colony. treatment. most commercially available insecticide shampoos and dips readily treat louse infestations. treatment should be repeated in - days, because any nits that were not killed would have hatched by that time (muller et al., ) . there is probably minimal interference with research, unless severe linognathus infestations cause anemia. ii. ticks etiology. ticks are obligate arachnid parasites that require vertebrate blood as their sole food source. except for the brown dog tick (rhipicephalus sanguineus), ticks have a wide host range and are not especially host-specific; so any number of tick genera and species can be found on dogs. genera that more commonly infest dogs in the united states include species of rhipicephalus, dermacentor, and ixodes. the primary significance of tick infestation is the tick's ability to be a vector for many other infectious diseases, including rocky mountain spotted fever (caused by rickettsia rickettsii), lyme disease (borrelia burgdorferi), and the canine forms of ehrlichiosis (ehrlichia canis and e. platys), babesiosis (babesia canis), haemobartonellosis (haemobartonella canis), and hepatozoonosis (hepatozoon canis). clinical signs. as an entity unto itself, tick infestation causes minimal clinical signs. most infestations are subclinical, although some dogs may lick and bite at the site, aggravating the local lesion. some dogs can develop a hypersensitivity reaction after several tick bites; these dogs develop a more granulomatous response at the location of the bite (merchant and taboada, ) . some species of ticks (primarily dermacentor andersoni and d. variabilis) produce a salivary neurotoxin that can cause an ascending flaccid paralysis (malik and farrow, ) . the paralysis develops within - days of tick attachment and can result from a single tick. this paralysis is fatal once the respiratory musculature is affected. epizootiology and transmission. in dogs used for biomedical research, tick infestation may occasionally be seen in randomsource dogs, because these dogs are more likely to have been in tick habitats than purpose-bred dogs. ticks commonly reside in wooded areas until they contact a suitable host for a blood meal. the brown dog tick may reside within kennels (attics, bedding, wall insulation) (garris, ) . pathologic findings. under most circumstances, tick infestation will be an incidental finding on necropsy (unless tick paralysis was the cause of death). pathogenesis. tick-bite paralysis is caused by the presence of a salivary neurotoxin released by female ticks of certain genera (e.g., dermacentor) while consuming a blood meal (malik and farrow, ) . interestingly, dogs seem to be most affected by this condition, whereas cats appear to be resistant. the primary dysfunction appears to be at the neuromuscular junction, as stimulation of the motor nerves fails to elicit a response, but direct stimulation of the muscle tissue results in contractions. tick bites can also transmit pathogen microorganisms to the dog, because ticks serve as vectors for several infectious diseases, including lyme borreliosis, ehrlichiosis, babesiosis, and rocky mountain spotted fever. diagnosis and differential diagnosis. for uncomplicated tick bites and tick-bite paralysis, definitive diagnosis is made by identification of the offending arachnid (and improvement of paralysis after removal). differential diagnoses for tick-bite paralysis include botulism, snakebite, polyradiculoneuritis, and idiopathic polyneuropathy (malik and farrow, ) . prevention. purpose-bred dogs should be free from all ectoparasites, but ticks can occasionally be seen on randomsource animals. research dogs should not be exercised in outdoor areas infested with ticks, and kennels must be cleaned properly and regularly so as to remain free of ticks and other parasites. treatment. removal of the offending tick is the primary treatment for both local inflammation as well as tick-bite paralysis. dogs with tick-bite paralysis usually show improvement within hr, with complete recovery within hr (malik and farrow, ) to remove an attached tick from a dog, forceps should be used to grasp the tick as close to the dog's skin as possible. the tick should not be grabbed by the body, as this may cause the parasite to either rupture or inject its body contents into the dog. the tick should be pulled away from the dog with steady pressure. many of the diseases transmitted by ticks are zoonotic so precautions, such as wearing gloves, should be taken. use of topical acaricide/insecticides on newly arrived random-source dogs should help to limit infestations. probably have minimal impact on research variables. the significant concern for tick infestation is the possible development of tick-bite paralysis or of any one of a number of systemic diseases spread by ticks (see sections iii,a,l,e-g). g. other i. flea infestation etiology. fleas are laterally flattened wingless insects that feed on animal blood. the most common flea to infest dogs is ctenocephalides felis, the cat flea. other fleas that can affect dogs are ctenocephalides canis, pulex irritans, and echidnophaga gallinacea. the fleas are speciated by the shape of their head and by the presence or absence of ctenidae (spiny combs on or behind the head) (campbell, ) . clinical signs. flea infestations usually cause foci of alopecia and pruritus. dogs that are hypersensitive to antigenic proteins in flea saliva develop the more severe "flea allergy dermatitis," which features papules and crusting. acute moist dermatitis ("hot spots") can also be seen in these cases, and secondary pyoderma or seborrhea can develop. lesions from flea allergy dermatitis generally appear in the dorsal lumbosacral region, as well as the flanks, thighs, and abdomen (muller et al., ) . the lesions are typically worse in the summer and autumn months and are progressively more severe as the dog ages. epizootiology and transmission. fleas are readily transmitted between animals and even between host species. they move readily between the host and the environment, making transmission easy and control difficult. because fleas require host blood for food, they can survive off of a host for only - months (muller et al., ) . pathologic findings. biopsy samples are usually nondiagnostic in cases of flea allergy dermatitis. lesions are typically characterized by perivascular eosinophilic inflammation and may feature pustules and folliculitis if secondary pyoderma develops (muller et al., ) . pathogenesis. fleas are parasites that require animal blood for their meals. when they bite host animals, they inject some saliva into the host's skin. if the host develops an allergic response to the flea saliva, it will develop the more pruritic flea allergy dermatitis. fleas can also transmit or serve as vectors for other pathogens (e.g., dipylidium tapeworms). flea allergy dermatitis are definitively diagnosed by observing the fleas on the host's skin. given that this may be difficult because of the mobility of the flea and the majority of the time it spends off of the host, diagnosis is often based on clinical signs, history, and lesion distribution. sometimes the presence of flea excrement ("flea dirt") on the dog's skin can support a presumptive diagnosis (demanuelle, b) . circulating eosinophilia is seen in some dogs with flea allergy dermatitis. differential diagnoses include mite and louse infestations, bacterial folliculitis, and allergic or atopic conditions that present with skin lesions in dogs (e.g., food, drug, or contact hypersensitivity). prevention. most dogs obtained from high-quality purposebred facilities should be free from flea infestations. dogs received from pounds, shelters, or licensed dealers would be more likely to be affected by fleas (or any ectoparasitism). thorough knowledge of prevention, control, and treatment measures at these facilities should be obtained, and dogs from sources where proper prevention and/or therapy are not practiced should be evaluated and/or empirically treated upon arrival at the facility. control. thorough cleaning of the dog's housing environment should remove the risk of perpetuating or transmitting flea infestation in the colony. treatment. treatment for fleas needs to address treatment of both the dog and the environment. many insecticide formulations such as shampoos, sprays, dips, powders, and oral systemics can be used for initial treatment of the individual dog. the active ingredients include pyrethrins, pyrethroids, carbamates, and organophosphates. flea control in the kennel may need to include outdoor areas in warm climates. typically combinations of adult insecticides and juvenile growth regulators are used for environmental treatment. directed sprays are the most effective means of treating housing areas, because flea "bombs" or foggers do not penetrate adequately into tight areas where fleas might hide (demanuelle, b) . in addition to insecticide therapy, dogs with flea allergy dermatitis may also require anti-inflammatory medication to relieve clinical signs. oral prednisone or prednisolone at . mg/kg q hr for - days has been proposed as a starting therapy (muller et al., ) . the use of hyposensitization with flea-bite antigens is controversial and not practical for the research setting. research complications. mild flea infestation probably has minimal impact on most research protocols, and treatment measures may in fact be more detrimental to the experimental objective than the actual ectoparasitism. in a research setting, the residual effects of insecticides may preclude their use in experimental animals. such treatments should be used judiciously to ensure that experimental results are not more seriously affected by the therapy rather than the infestation. dogs with flea-allergy dermatitis are more severely affected by the flea infestation and should be treated apigropriately; however, systemic corticosteroids may also interfere with experimental objectives, especially in studies involving functions of the immune system. the ability of fleas to transmit other parasitic diseases must also be considered. etiology. dermatophytoses ("ringworm") are fungal skin infections, which in dogs in the united states are usually caused by either microsporum canis, m. gypseum, or trichophyton mentagrophytes (muller et al., ) . clinical signs. uncomplicated superficial dermatophytoses are characterized by circumscribed circular areas of alopecia, usually with minimal to no inflammation. these skin lesions are usually seen around the face, neck, and forelimbs but can be found anywhere on the body. secondary bacterial infections can develop; these lesions are called kerions and are selflimiting, for the fungus cannot survive in inflamed skin (muller et al., ) . ep&ootiology and transmission. the fungi that cause skin infections are very contagious and readily transmissible between dogs and other species (including human beings), but they can also be obtained from the soil. pathologic findings. on close inspection of skin samples, broken hair shafts (and not complete hair loss) would be seen with uncomplicated dermatophytosis. histologically, fungal elements can be seen within the stratum corneum or in and around the hair and hair follicles (muller et al., ) . stains that facilitate visualization of fungal elements include periodic acid-schiff (pas) or gomori methenamine-silver. the pattern of inflammation in the affected foci is very variable and can feature folliculitis, perivascular dermatitis, hyperkeratosis, and/or vesicular dermatitis. pathogenesis. the dermatophytes typically infect the hair shaft itself, the hair follicle, and possibly the skin around the affected hair. the hair follicle is not destroyed (unless by secondary bacterial infection), but the hair itself becomes brittle and breaks. this causes short stubbly hair to be seen within the lesion. as the lesion progresses, the hairs in the center recover from the infection, thus leading to the classic "ringworm" appearance of the alopecic areas. it is postulated that the inflammatory process produces an environment that is unfavorable for dermatophyte survival, whereas the periphery of the lesion still enables continued fungal growth (muller et al., ) . diagnosis and differential diagnosis. diagnosis of dermal fungal infection is typically made by scraping the affected area to obtain hair and superficial epidermal cells. these scrapings are then digested with potassium hydroxide to facilitate observation of fungal elements. fungal elements can also be seen on skin biopsy samples. for speciation of a fungus, skin scrapings can also be inoculated onto agars that promote fungal growth, such as sabouraud's medium or dermatophyte test medium (dtm). incubation should be at ~ with % humidity for - days. lesions caused by m. canis may fluoresce when inspected using a wood's ( . nm ultraviolet) light. unfortunately, some strains of m. canis do not fluoresce, and neither does m. gypseum or t. mentagrophytes. differential diagnoses for dermatomycosis include seborrhea, localized demodecosis, folliculitis, histiocytoma, and acral lick dermatitis (muller et al., ) . prevention. purpose-bred dogs are typically free of infectious dermatophytes, but ringworm may be diagnosed on randomsource animals. control. in cases of dermatophytosis, isolation of the affected animal(s) is prudent, because the fungi are easily spread to other dogs, as well as to people. treatment, if acceptable, should be started immediately. treatment. topical antifungal therapy is most commonly used. shampoos, rinses, and creams containing miconazole, ketoconazole, enilconazole, or chlorhexidine are commercially available to treat ringworm (stannard et al., ) . severe cases may require systemic therapy with griseofulvin, ketoconazole, itraconazole, or fluconazole. however, these systemic antifungal agents may have considerable side effects (such as vomiting and teratogenicity with griseofulvin). many of the newer agents are also expensive and not labeled for use in dogs. impact on most research applications for dogs. unfortunately, the zoonotic implications of dermatophytoses force the issue of aggressive treatment, and many antifungal agents may not be compatible with biomedical research studies. systemic fungal infections disseminate to multiple organ systems from a single mode of entry (usually through the respiratory tract). dogs are susceptible to several fungi that characteristically cause systemic mycosis, including blastomyces dermatitidis, histoplasma capsulatum, coccidioides immitis, and cryptococcus neoformans var. neoformans. these diseases are not typically seen in the research setting, because of the low overall incidence and noncontagious nature of these disorders and because of the use of purpose-bred animals. these conditions could, however, present in the rare random-source dog that was subclinical at its point of origin, especially if the animal becomes immunosuppressed (either naturally or by virtue of experimental manipulation). typical clinical signs include weight loss, fever, lymphadenopathy, and cough and dyspnea (if the lungs are affected). the reader is advised to read veterinary medical text chapters (e.g., taboada, ) for more complete information on these disorders and their possible treatments. although the incidence of hypothyroidism in the canine population is not high (kemppainen and clark, ) , deficiency in thyroid hormone can significantly affect basal metabolism and immune function. because these factors are important in many biomedical research studies, it is imperative that laboratory animal veterinarians be able to recognize, diagnose, and treat this problem. etiology. the majority of cases of canine hypothyroidism are due to lymphocytic thyroiditis, an autoimmune disorder, or idiopathic atrophy of the thyroid gland. both of these causes result in a gradual loss of functional thyroid tissue (kemppainen and clark, ) . lymphocytic thyroiditis is the major cause of hypothyroidism in laboratory beagles and appears to be familial in that breed (tucker, ; beierwaltes and nishiyama, ; manning ) . rarely, congenital defects or nonfunctional tumors may cause hypothyroidism (peterson and ferguson, ; kemppainen and clark, ) . clinical signs. because it affects metabolism in general, hypothyroidism can produce a large number of clinical signs referable to many organ systems. an individual dog with hypothyroidism may have one or any combination of clinical signs. hypothyroidism reduces the dog's metabolic rate, which then produces such signs as obesity, lethargy, cold intolerance, and constipation. additionally, hypothyroidism can produce several dermatologic abnormalities, including alopecia, hyperpigmentation, seborrhea, and pyoderma (peterson and ferguson, ; panciera, ) . several clinicopathologic abnormalities have also been reported in a large percentage of hypothyroid dogs. these aberrations include increased serum cholesterol and triglycerides due to a decrease in lipolysis and decreased numbers of low-density lipopolysaccharide receptors (peterson and ferguson, ; panciera, ) . normocytic normochromic nonregenerative anemia and increased serum alkaline phosphatase and creatine kinase have also been reported in a significant number of hypothyroid dogs (peterson and ferguson, ; panciera ) . neurologic signs of hypothyroidism, which include lameness, foot dragging, and paresis, may be caused by several mechanisms such as segmental nerve demyelination or nerve entrapment secondary to myxedema (peterson and ferguson, ) . mental impairment and dullness have also been reported in hypothyroid dogs, secondary to atherosclerosis and cerebral myxedema (peterson and ferguson, ) . hypothyroidism has been implicated in other neurological abnormalities such as horner's syndrome, facial nerve paralysis, megaesophagus, and laryngeal paralysis; however, these conditions do not always resolve with treatment (bischel et al., ; panciera, ) , and so the relationship between hypothyroidism and these problems has not been completely defined (panciera, ) . myopathies associated with hypothyroidism are caused by metabolic dysfunction and atrophy of type ii muscle fibers and can present with signs similar to neurological disease (peterson and ferguson, ) . hypothyroidism can also cause bradycardia as a result of decreased myocardial conductivity. abnormalities that may be detected by ecg include a decrease in p and r wave amplitude (peterson and ferguson, ) and inverted t waves (panciera, ) . these electrocardiographic abnormalities are caused by lowered activity of atpases and calcium channel function. several reports have suggested that hypothyroidism is associated with von willebrand's disease and bleeding abnormalities. however, the relationship is probably one of shared breed predilection and not a true correlation. it has been demonstrated that dogs with hypothyroidism are not deficient in von willebrand's factor when compared with other dogs. in addition, the replacement of thyroid hormone in dogs did not increase the levels of vwf:ag in naturally occurring (panciera and johnson, ) or experimentally induced (panciera and johnson, ) hypothyroidism. epizootiology. the prevalence of hypothyroidism in the general canine population has been reported to be less than % (panciera, ) . the disorder occurs most often in large-breed dogs but has been reported in several other breeds as well as mongrels. doberman pinschers and golden retrievers appear to have a higher incidence of hypothyroidism when compared with other breeds (panciera, ; peterson and ferguson, ; scarlett, ) . there have been several reports about hypothyroidism in laboratory colonies of beagles (manning, ; tucker, ; beierwaltes and nishiyama, ) . in general, the problem is usually recognized in middle-aged animals, and some reports state that there is a higher incidence of hypothyroidism in spayed female dogs (panciera, ; peterson and ferguson, ). diagnosis and differential diagnosis. because of the large number of clinical manifestations in dogs, the recognition of hypothyroidism is not always straightforward. likewise, the diagnosis of hypothyroidism can be difficult because of the lack of definitive diagnostic tests available for the dog. the tests currently available and in popular use will be discussed further. however, a complete understanding of the diagnosis of hypothyroidism requires a familiarity with thyroid hormone metabolism and function that is beyond the scope of this writing. for additional information, the reader is referred to one of several manuscripts available (peterson and ferguson, ; ferguson, ) . currently, the ability to diagnose hypothyroidism relies heavily on the measurement of serum total t (thyroxine) and free t (peterson and ferguson, ; ferguson, ) . t serves primarily as a precursor for t in the body and is heavily proteinbound. free t represents the unbound fraction that is available to the tissues (peterson and ferguson, ) . using the measurement of serum total t and free t , hypothyroidism can usually be ruled out if the values are within the normal range or higher. if both hormone concentrations are low, it is highly likely that the patient has hypothyroidism, and a therapeutic trial is in order (peterson and ferguson, ) . however, it must be noted that nonthyroidal illnesses and some drugs (e.g., glucocorticoids, anticonvulsants, phenylbutazone, salicylates) can falsely lower these values (peterson and ferguson, ; ferguson, ) . therefore, low values do not always indicate that hypothyroidism is present, and animals should not be treated solely on the basis of serum hormone levels if clinical signs are absent. if the clinical signs are equivocal or if only total t or free t is decreased, further diagnostic testing is warranted (peterson and ferguson, ) . although t is the most biologically active form of thyroid hormone in the body, the measurement of serum t levels is an unreliable indicator of hypothy-roidism (peterson and ferguson, ; ferguson, ) . like t , serum t can be falsely lowered by many nonthyroidal illnesses and many drugs (see above). in addition, t may be preferentially released, and conversion of t to t may be enhanced in the hypothyroid dog (peterson and ferguson, ; ferguson, ) . t was within normal limits in % of the hypothyroid dogs in one study (panciera, ) . autoantibodies can be responsible for false elevations in the concentrations of t and t found in these respective assays. it has been recommended that free t , measured by equilibrium dialysis, be assayed in dogs that are suspected of hypothyroidism and have autoantibodies with normal or high t and t . autoantibodies have been found in less than % of the samples submitted to one laboratory (kemppainen and behrend, ) . other means of diagnosing hypothyroidism have been described. in humans, endogenous tsh (thyroid-stimulating hormone) levels provide reliable information on thyroid status, and an assay for endogenous tsh is now available in dogs. however, tsh levels can be normal in some dogs with hypothyroidism, and high tsh levels have been noted in normal dogs. therefore, it is recommended that tsh levels be considered along with other information (clinical signs, t ) prior to diagnosis and treatment (kemppainen and behrend, ) . tsh stimulation testing using exogenous bovine tsh provides a good and reliable method for establishing a diagnosis. unfortunately, the availability and expense of tsh limit the use of this diagnostic tool (peterson and ferguson, ; ferguson, ) . another drawback of tsh testing is that the test must be postponed for weeks if thyroid supplementation has been given (peterson and ferguson, ) . when tsh is available for testing, there are several recommendations for dosage, routes of administration, and sampling times. one recommendation is . u of tsh per pound of body weight (up to a maximum of u) to be administered iv. for this protocol, blood samples are taken prior to administration of tsh and hours after. a normal response to the administration of tsh should create an increase of t levels at least ktg/dl above the baseline levels or an absolute level that exceeds ~tg/dl (peterson and ferguson, ; wheeler et al., ) . treatment. the treatment of choice for hypothyroidism in the dog is l-thyroxine (sodium levothyroxine). a recommended dosing regimen is . mg/kg once a day or . mg/m (body surface area)/day for very small or very large dogs. if drugs that decrease thyroxine levels are being administered concurrently, it may be necessary to divide the thyroxine dose for twice daily administration. after the supplementation has begun, the thyroid hormone level should be rechecked in - weeks, and blood samples should be drawn - hours after the morning pill. a clinical response is usually seen in - weeks and would include weight loss, hair regrowth, and resolution of other signs (panciera, ) . ecg abnormalities also return to normal (peterson and ferguson, ) . for dogs with neurologic signs, the prognosis is guarded, because the signs do not always resolve with supplementation (panciera, ) . weight gain and eventual obesity are also frequent findings in dogs in the research environment. because obesity can adversely affect several body systems as well as general metabolism, the laboratory animal veterinarian must be aware of the development of obesity and the potential effect that it can have on research. etiology. obesity is defined as a body weight - % over the ideal. in general, obesity occurs when the intake of calories exceeds the expenditure of energy. excessive caloric intake resuits from overeating or eating an unbalanced diet. overeating is a common cause of obesity in pet dogs and may be triggered by boredom, nervousness, or conditioning (macewen, ) . in addition, pet animals are often subjected to unbalanced diets supplemented with high-fat treats. in the laboratory animal setting, overeating is less likely than in a household, because access to food is more restricted and diets are usually a commercially prepared balanced ration. however, obesity can still be a problem if specific guidelines for energy requirements are not followed. in addition, the necessary caging of dogs in the research environment and thus the limitation to exercise reduces energy expenditure and predisposes dogs to weight gain. it is also important to realize that other factors may predispose dogs to obesity, even when guidelines for caloric intake and energy expenditure are followed (butterwick and hawthorne,. ). as in humans, genetics plays an important role in the development of obesity in dogs. it has been established that certain breeds are more predisposed toward obesity. in a study of dogs visiting veterinary clinics in the united kingdom, labrador retrievers were most likely to be obese. other breeds affected included cairn terriers, dachshunds, basset hounds, golden retrievers, and cocker spaniels. the beagle was also listed as a breed predisposed to obesity in the household environment (edney and smith, ) . in addition to genetics, several metabolic or hormonal changes are associated with obesity. it has been well established that neutering promotes weight gain. in one study, spayed female dogs were twice as likely to be obese when compared with intact females (macewen, ) . the authors proposed that the absence of estrogen promotes an increase in food consumption. a similar trend toward obesity was found in castrated male dogs (edney and smith, ) . in addition, hypothyroidism and hyperadrenocorticism may present with obesity as one of the clinical signs (macewen, ) . epizootiology. ewen, ) . obesity affects up to % of pet dogs (mac-diagnosis and differential diagnosis. the diagnosis of obesity is somewhat subjective and relies on an estimate of ideal body weight. the ideal body condition for dogs is considered to be achieved when the ribs are barely visible but easily palpated beneath the skin surface. when the ribs are not easily palpated and/or the dog's normal function is impaired by its weight, the animal is considered obese. there are few objective, quantifiable methods for establishing this diagnosis. ultrasound has been evaluated for measurement of subcutaneous fat in dogs, and measurements taken from the lumbar area can be used to reliably predict total body fat (wilkinson and mcewan, ) . after a diagnosis of obesity has been made, additional diagnostic tests should be performed to determine if there is an underlying cause for the problem. a complete physical exam should be performed to look for signs of concurrent disease and to establish if obesity has adversely affected the individual. serum thyroid hormones should be evaluated (see section iii,b,l,a), and serum chemistry may reveal an increased alkaline phosphatase associated with hyperadrenocorticism. treatment. restricting food intake readily treats obesity, and this is easily done in the research setting. it has been suggested that a good weight loss program involves restriction of intake to % of the calculated energy requirement to maintain ideal body weight. it has been shown that restriction of calories down to % produces no adverse health effects. however, t levels will decrease in direct proportion with caloric intake. ideally, weight loss will occur at a rate of - % of body weight per week (laflamme et al., ) . with more severe calorie restriction and more rapid weight loss, the individual is more likely to rebound and gain weight after restrictions are relaxed. there has been agreat deal of attention in humans as to the correct diet to be fed to encourage weight loss. likewise, the type of diet fed to dogs has been examined. as mentioned above, the restriction of calories is most important, and feeding less of an existing diet can do this. alternatively, several diet dog foods are available, and there is some evidence that these diets are superior to simple volume restriction (macewen, ) . there has been much concern about the addition of fiber to the diet in both humans and animals as a method for reducing caloric intake while maintaining the volume fed. studies in dogs have examined the addition of both soluble and insoluble fibers to calorierestricted diets. these studies have shown that the addition of fiber does not have an effect on satiety in dogs and therefore does not have a beneficial effect in weight loss protocols (butterwick and thorne, ; butterwick and thorne, ) . it is important to control weight gain in research animals, because of the association of obesity and several metabolic changes. although an association between obesity and reproductive, dermatologic, and neoplastic problems has been reported (macewen, ) , this relationship is not consistently apparent (edney and smith, ) . obesity in dogs over years of age appears to be related to an increase in cardiovascular problems (edney and smith, ) , and obesity has been linked to hypertension. joint problems including osteoarthritis and hip dysplasia have also been related to obesity (macewen, ; kealy et al., ) . in addition, diabetes mellitus has been linked to obesity, and obesity induces hyperinsulinism in several experimental models (macewen, ) . in the laboratory setting, the majority of traumatic wounds will be small in size. in facilities with good husbandry practices and a diligent staff, traumatic wounds will generally be observed quickly and attended to promptly. under these conditions, proper initial treatment will lead to uncomplicated wound healing. complications such as infection and delayed healing arise when wounds are not noticed immediately or. when the basic principles of wound management are not followed. to aid in the description of wounds and in decision making about wound therapy, several classification systems have been developed for traumatic injuries. at one time, decisions about wound therapy were largely based upon the length of time since wounding, or the concept of a "golden period." it is now recognized that several factors must be considered prior to initiating wound care, including (but not limited to) the type and size of the wound, the degree of wound contamination, and the capability of the host's defense systems (swaim, ; waldron and trevor, ) . one of the most widely used classification systems is based upon wound contamination and categorizes wounds as either clean, clean-contaminated, contaminated, or dirty (see table v ). the vast majority of the wounds seen in the laboratory setting will fall into the clean and clean-contaminated categories. these wounds may be treated with the basic wound care described below and primary closure of the wound. contaminated and dirty wounds, which are seen infrequently in the laboratory setting, require more aggressive therapy. dirty wounds can occur as postsurgical infections or complications of initial wound therapy. when one is in doubt as to the classification of a wound, the worst category should be presumed in order to provide optimal therapy and reduce the chance for complications. the initial treatment of a wound is the same regardless of the wound's classification. when first recognized, the wound should be covered' with a sterile dressing until definitive treatment is rendered. bleeding should be controlled with direct waldron and trevor ( ) . pressure; tourniquets are discouraged because of the complications that may arise with inappropriate placement (swaim, ) . it is best to avoid using topical disinfectants in the wound until further wound treatment (culture, debridement, lavage) has been performed (swaim, ) . when the treatment of a wound begins, anesthesia or analgesia may be necessary, and the choice of anesthetic regimen will depend on the size and location of the wound as well as the preference of the clinician. if the wound is contaminated or dirty, bacterial cultures, both aerobic and anaerobic, should be performed at this time. then a water-soluble lubricant gel may be applied directly to the wound. a wide margin of hair should then be clipped from around the wound, using a # blade. after the clipping, a surgical scrub is performed around the edges of the wound. povidone-iodine alternating with alcohol or chlorhexidine gluconate scrub alternating with water is most often recommended for surgical preparation of the skin surface (osuna et al., a,b) . simple abrasions that involve only a partial thickness of the skin do not generally require further treatment. full-thickness wounds require further attention, including irrigation with large quantities of a solution delivered under pressure. two solutions, . % chlorhexidine diacetate in water (lozier et al., ) and % povidone-iodine in saline, are most often recommended for wound lavage (waldron and trevor, ) . the chlorhexidine solution may offer the advantage of greater bactericidal activity but does not significantly alter wound healing when compared with povidone-iodine (sanchez et al., ) . actually, the type of solution chosen may not be as important to wound care as the volume and pressure at which the solution is delivered. it has been suggested that psi is required to obtain adequate tissue irrigation, and this may be achieved by using a ml syringe and an -or gauge needle (waldron and trevor, ) . for wounds that are contaminated or dirty, debridement is an important part of initial therapy. debridement usually proceeds from superficial to deeper layers. skin that is obviously necrotic should be removed. although it is often recommended to remove skin back to the point at which it bleeds, this may not be feasible with large wounds on the limbs. in addition, other factors such as edema or hypovolemia may reduce bleeding in otherwise viable skin (waldron and trevor, ) . if one is unsure about tissue viability in areas that are devoid of extra skin, the tissue may be left (swaim, ; waldron and trevor, ) , and nonviable areas will demarcate within - days (waldron and trevor, ) . necrotic fat should be resected liberally, because it does not have a large blood supply and will provide an environment for infection. often, resection of subcutaneous fat is necessary to remove debris and hair that could not be removed during wound irrigation. damaged muscle should also be liberally resected (swaim, ) . the wound should be irrigated several times during debridement and again after completion. after initial wound treatment, the options concerning wound closure must be weighed. the principles of basic surgery are discussed in several good texts, and readers are encouraged to pursue additional information. primary wound closure is defined as closure of the wound at the time of initial wound therapy and is the treatment of choice for clean and clean-contaminated wounds. closure is performed in two or more layers, carefully apposing tissues and obliterating dead space. if dead space will remain in the wound, a drain should be place d. subcutaneous closure should be performed with absorbable suture such as polydioxanone (pds), polyglactin (vicryl), or polyglycolic acid (dexon). it is best to use interrupted sutures and avoid leaving excess suture material in the wound. it may be necessary to choose tension-relieving suture patterns, such as horizontal mattress. skin closure is generally performed with nylon ( - or - ). in situations where gross contamination cannot be completely removed, closure of the wound should be delayed or avoided. after debridement and irrigation, the wound should be bandaged. initially, the wound can be covered by gauze sponges soaked in saline or chlorhexidine to create a wet-to-dry bandage. when the sponges are later pulled from the wound, dried exudates will also be removed. when the wound appears clean, the layer in contact with the wound may be changed to a nonadherent dressing such as vaseline-impregnated gauze (swaim, ) . the contact layer is covered by cotton padding, and the entire bandage is covered by a supportive and protective layer. the bandages should be changed once or twice daily, depending upon the amount of discharge coming from the wound. wound closure within - days of wounding (prior to the formation of granulation tissue) is considered delayed primary closure. when the wound is closed after days, this is considered secondary closure (waldron and trevor, ) . secondintention healing involves allowing the wound to heal without surgical intervention. this type of healing is often used on limbs when there is an insufficient amount of skin to allow complete closure (swaim, ) . it is important to note that second-intention healing will take longer than surgical repair of a wound, and in the case of large wounds it will be more expensive because of the cost of bandaging materials. several factors must be weighed concerning the use of antibiotics in traumatic wounds, including the classification and site of the wound, host defenses, and concurrent research use of the animal. when wounds are clean or clean-contaminated, antibiotics are seldom necessary unless the individual is at high risk for infection. when wounds have been severely contaminated or are dirty, antibiotics are indicated, and the type of antibiotic will ultimately depend on culture and sensitivity results. until such results are available, the choice of antibiotic is based on the most likely organism to be encountered. in skin wounds, staphylococcus spp. are generally of concern, whereas pasteurella multocida should be considered in bite wounds. cephalosporins, amoxicillin-clavulanate, and trimethoprim sulfas are often recommended for initial antibiotic therapy (waldron and trevor, ) . etiology. pressure sores (decubital ulcers) can be a problem in long-term studies that require extended periods of recumbency. decubital ulcers usually develop due to continuous pressure from a hard surface contacting a bony prominence such as the elbow, the tuber ischii, tarsus, or carpus. the compression of the soft tissues between the hard surfaces results in vascular occlusion, ischemia, and ultimately tissue death (swaim and angarano, ) . several factors that increase pressure at the site and/or affect the integrity of the skin will predispose an individual to develop pressure sores. these factors include poor hygiene, self-trauma, low-protein diet, preexisting tissue damage, muscle wasting, inadequate bedding, and ill-fitting casts or bandages (swaim and angarano, ) . clinical signs. at first, the skin at the developing site will appear red and irritated. over time, constant trauma can result in full-thickness skin wounds and can progress to necrosis of underlying structures such as bone. the severity of the sores may be graded from i to iv, according to the depth of the wound and the tissues involved, from superficial skin irritation to bone necrosis. epizootiology. the problem usually occurs in large-breed dogs, but any type of dog can be affected. prevention and control. minimizing or eliminating those factors that can predispose to decubital ulcers is important to both the prevention and the control of this condition. if the dogs are going to experience long periods of recumbency, adequate bedding or padding must be provided. skin hygiene is of the utmost importance when trying to prevent or treat pressure sores. the skin should be kept clean and dry at all times. if urine scalding is a problem, the affected area should be clipped, bathed, and dried thoroughly at least once or twice daily. finally, an appropriate diet to maintain good flesh and adequate healing is also important (swaim and angarano, ) . treatment. the treatment of pressure sores must involve care of the wound and attention to the factors causing the wound. the extent of initial wound management will largely depend on the depth of the wound. for simple abrasions and small wounds involving the skin only, simple wound cleansing and openwound management provide adequate treatment. when wounds involve deeper tissues, including fat, fascia, or bone, more aggressive therapy must be performed. the affected area should be radiographed to assess bone involvement, and the wound should be cultured. all of the damaged tissue should be debrided, and wound management guidelines should be followed (see section iii,c, ). when a healthy granulation bed has formed over the entire wound, a delayed closure over a drain may be performed (swaim and angarano, ) . with extensive lesions, reconstruction with skin flaps may be necessary. bandaging should be performed on all full-thickness wounds; however, it is important to remember that ill-fitting or inadequately padded bandages or casts may worsen the problem. the area over the wound itself should not be heavily padded, because this will increase the pressure over the wound. the wounded area should be lightly covered and then a doughnut, created from rolled gauze or towel, should be fitted around the wound. this will displace the forces acting on the wound over a larger area and over healthier tissue. then the doughnut is incorporated into the bandage. if a cast has been applied to the area for treatment or for research purposes, a hole can be cut over the wound to reduce pressure in that area and allow treatment of the wound (swaim and angarano, ). bandages should be removed at least once or twice a day to allow wound care. after wound care has been initiated the causative factors for the pressure sore must be addressed (see "prevention and control," above). recumbent animals should be moved frequently to prevent continuous compression on the wound. if the dog tends to favor a position that aggravates the problem, splinting the body part to reduce contact with hard surfaces may be necessary. etiology. acral lick granuloma is a psychodermatosis, a skin lesion caused by self-trauma. in a few cases, self-trauma begins because of identifiable neurologic or orthopedic causes (tarvin and prata, ) . however, the majority of the cases begin because of repetitive licking by dogs that are confined and lack external stimuli (swaim and angarano, ) . it has been theorized that the self-trauma promotes the release of endogenous endorphins, which act as a reward for the abnormal behavior (dodman et al., ) . the laboratory setting is an environment that could promote this abnormal behavior and lead to acral lick granuloma. epizootiology. the lesions associated with acral lick granuloma are seen most often in large-breed dogs, but any type of dog can be affected (walton, ) . clinical signs. at first, lesions appear as irritated, hairless areas usually found on the distal extremities (swaim and angarano, ). the predilection for the limbs may be due to accessibility or possibly may be caused by a lower threshold for pruritus in these areas. as the lesions progress, the skin becomes ulcerated, and the wound has a hyperpigmented edge. the wounds may partially heal and then be aggravated again when licking resumes. diagnosis and differential diagnosis. acral lick granulomas must be differentiated from several other conditions, including bacterial or fungal infection, foreign bodies, and pressure sores. in addition, mast-cell tumors and other forms of neoplasia can mimic the appearance of acral lick granuloma. many of these problems can be ruled out by the history of the animal. when in doubt, a biopsy should be taken. an uncomplicated acral lick granuloma would feature hyperplasia, ulceration, and fibrosis without evidence of infection or neoplasia (walton, ) . prevention and control. behavior modification and relief of boredom are important aspects of preventing (and treating) acral lick granuloma. the environment of a dog with this problem can be enriched with exercise and the introduction of toys. in addition, the relief of boredom or anxiety can be attempted through the use of drugs such as phenobarbital, megestrol acetate, and progestins. these drugs may produce side effects, however (swaim and angarano, ) , and may interfere with experimental results. treatment. several treatments have been reported for acral lick granuloma, and none of them have been proven to be successful in ah cases. one of the most important aspects of treatment is to break the cycle of self-trauma. mechanical restraint with an elizabethan collar is one of the easiest methods to accomplish this goal. several direct treatments have been examined, including intralesional and topical steroids, perilesional cobra venom, acupuncture, radiation, and surgery (swaim and angarano, ; walton, ) . opioid antagonists have been used in an attempt to treat acral lick granuloma by blocking endogenous opioids. in one study, either naltrexone ( mg/kg sq) or nalmefene ( - mg/kg sq) successfully reduced the excessive licking behavior in of dogs; however, lesions returned after the drug was discontinued (dodman et al., ) . the use of a mixture of flunixin meglumine, steroid, and dimethyl sulfoxide ( ml of banamine [schering] mixed with ml of synotic [diamond laboratories]) applied topically twice daily has also been shown to be effective (walton, ) . the prognosis for acral lick granuloma should be considered guarded, because the lesions often recur or new lesions develop when treatment is discontinued. etiology. hygromas are fluid-filled sacs that develop as a result of repeated trauma over a bony prominence. the area over the olecranon is most frequently affected, but hygromas have been reported in association with the tuber calcis, greater trochanter, and stifle (newton et al., ) . epizootiology. elbow hygromas are most frequently reported in large and giant breeds of dogs around - months of age (johnston, ; bellah, ) . elbow hygromas are seen infrequently in the laboratory animal setting because the commonly affected breeds are seldom used in research. however, the housing environment for research dogs predisposes them to hygromas, because these animals spend a large amount of time on hard surfaces such as cage bottoms or cement runs. for this reason, laboratory animal veterinary and husbandry staff should be familiar with this condition. clinical signs. a dog with an elbow hygroma presents with a unilateral or bilateral, painless, fluctuant swelling over the point of the elbow. the animals are not usually lame. over a long period of time, elbow hygromas may become inflamed and ulcerated. if the hygroma is secondarily infected, the animal may exhibit pain and fever (johnston, ; bellah, ) . pathology. the fluid-filled cavity in the hygroma is lined by granulation and fibrous tissue. hygromas lack an epithelial lining and therefore are not true cysts. the fluid within the cavity is yellow or red and is a serous transudate. this fluid is less viscous than joint fluid, and elbow hygromas do not communicate with the joint (johnston, ) . treatment. the treatment of elbow hygromas should be conservative whenever possible, and surgical options should be reserved for complicated or refractory cases. conservative management of the elbow hygroma is aimed at relieving pressure at the point of the elbow by providing a padded cage surface and/or bandaging the elbow in a manner similar to that used to treat pressure sores (see section iii,c, ). more aggressive therapy, including needle drainage and the injection of corticosteroid into the hygroma, has been described but is not recommended, because infection is a serious complication of this treatment (johnston, ) . likewise, simple surgical excision of elbow hygromas can be associated with complications such as wound dehiscence and ulceration (johnston, ) . a technique that has been used successfully involves placement of multiple penrose drains. the drains are kept in place for - weeks, and the limb remains bandaged for weeks with this technique (bellah, ) . another technique has been described that involves the removal of a crescent-shaped piece of the skin and capsule. the remaining dead space is closed with mattress sutures over stents, and then the wound is closed in a routine fashion. the stents are removed in - days, and the wound is bandaged until suture removal in - days (newton et al., ) . regardless of the method used to treat an elbow hygroma, recurrence of the problem is likely unless the predisposing factors are identified and relieved. etiology. in the research environment, corneal ulcers are most often associated with either direct trauma, contact with irritating chemicals, or exposure to the drying effects of air during long periods of anesthesia. chronic or recurrent corneal ulcers may also be associated with infection or hereditary causes in some breeds of dogs; however, these cases would be rare in the laboratory setting. clinical signs. the signs of corneal ulceration are blepharospasm, epiphora, and photophobia. the eye may appear irritated and inflamed. in minor cases, the cornea may not appear abnormal; however, in cases of deeper ulceration, the cornea may appear roughened or may have an obvious defect. in addition, the periocular tissues may be swollen and inflamed because of self-inflicted trauma from rubbing at the eye. a tentative diagnosis of corneal ulcer or abrasion may be based on the clinical signs. a definitive diagnosis of corneal ulcers may be made by the green appearance of the cornea when stained with fluorescein dye. when a corneal ulcer has been diagnosed, the eye should be inspected for underlying causes such as foreign bodies or abnormal eyelids or cilia. treatment. the treatment of corneal ulcers will depend on the depth and size of the affected area. deep ulcers may require debridement and primary repair. in such cases, a third eyelid or conjunctival flap may be applied to the eye until experienced help can be obtained. superficial abrasions are generally treated with topical application of antibiotics. a triple antibiotic ointment that does not contain steroids given times a day for - days usually provides adequate treatment. ointments are preferred over drops, because use of the former requires less frequent. simple corneal ulcers are restained with fluorescein after days and should show complete healing at that time. if the ulcer is not healed, this may indicate that the ulcer has an undermined edge impeding proper healing. topical anesthetic should be applied to the eye, and a cotton-tipped applicator can be rolled over the surface of the ulcer toward its edge. this will remove the unattached edge of the cornea and healing should progress normally after debridement. in all cases, an elizabethan collar or other restraint may be necessary to prevent additional trauma to the eye. indwelling intravascular catheters, including intracaths and vascular access ports, often play a vital role in research protocols. the catheters are most often placed in a central vein or artery where they may be used for repeated blood sampling, administration of anesthetics and experimental compounds, or measurement of hemodynamic parameters. although catheters vary in composition, number of ports, and port placement, the basic principles of their implantation and maintenance are similar. it is important that the laboratory animal veterinarian be familiar with these principles and the potential complications of catheter use. when appropriately maintained, indwelling catheters may remain functional for months without serious complication. the actual incidence of complications associated with indwelling vascular catheters in dogs is unknown. this is due largely to the fact that many of the problems may be incidental findings or related to a particular research protocol. one study (hysell and abrams, ) examined the lesions found at necropsy in animals with chronic indwelling catheters (exact vascular locations not specified). the lesions found were categorized as traumatic cardiac lesions, visceral infarcts, and fatal hemorrhages. the traumatic cardiac lesions consisted primarily of masses of fibrin and inflammatory cells on the heart valves. the visceral infarcts were noted in the spleen, kidney (fig. ) , and brain and resulted from fibrin embolization from either the valvular lesions or the catheter tip. fatal hemorrhages were most often found in animals with experimentally induced hypertension. these animals developed clinical signs of sepsis and later ruptured a major vessel associated with mycotic infection and aneurysm. etiology. the leading complication associated with the use of indwelling vascular catheters is infection, either systemic or local at the point of entry through the skin. septicemia may develop from bacterial colonization of either the tract around the catheter or the catheter lumen. clinical signs. the signs and treatment of systemic infection are covered in section iii,d, . problems with the skin defect associated with the catheter port vary from mild skin irritation to obvious infection. the signs may include redness and swelling of the skin around the external port, discharge from the skin wound, or even abscess formation. prevention. because indwelling catheters play an important role in many research protocols, it is highly desirable to prevent catheter complications that may result in loss of the device. the catheter should be made of nonthrombogenic material. in addition, it is recommended that catheters be as simple as possible. a catheter with extra ports or multiple lumens requires addi- tional management and supplies more routes for infection. the use of vascular access ports that lie entirely under the skin eliminates many problems with infection. it has also been found that a long extension of tubing connected to the port may actually reduce the potential for infection of the catheter (ringler and peter, ) . the initial placement of an indwelling catheter must be done under aseptic conditions by individuals who are familiar with the procedure. the placement of the catheter should be verified by radiography. catheters that are used for delivery of drugs or blood sampling should be positioned in the vena cava and not in the right atrium, thereby minimizing trauma to the tricuspid valve. after catheter placement, the animals should be observed daily for signs of either local or systemic infection. the catheter entry site should be disinfected, coated with antibiotic ointment, and rebandaged every other day. once a month, the catheter line may be disinfected with chlorine dioxide, as described below (see "treatment"). throughout the life of the catheter, injections into and withdrawals from the catheter should be done in a sterile manner, and the number of breaks in the line should be kept to a minimum. treatment. the treatment of catheter infections almost invariably involves removal of the catheter, as demonstrated in both dogs and monkeys (ringler and peter, ; darif and rush, ) . superficial wound irritation or infection may be treated locally with antibiotic ointment, sterile dressing changes and efforts to minimize catheter movement; however, more extensive problems require aggressive therapy. systemic antibiotic therapy should be initiated for a -day period. the choice of drug will ultimately be based on previous experience and culture results. aerobic and anaerobic cultures of blood and locally infected sites should be performed (ringler and peter, ) . localized abscesses or sinus tracts may be managed by establishing drainage and flushing with chlorhexidine. again, the catheter should be removed. if retention of a catheter is important, the catheter lumen may be disinfected by filling with chlorine dioxide solution. it has been shown that there are no adverse effects from the use of chlorine dioxide in catheters (dennis et al., ) . the solution is removed after min and replaced with heparinized saline. all of the extension lines and fluids used in the catheter should be discarded. the blood cultures should be repeated days after the antibiotic therapy has ceased. if bacteria are still cultured, the catheter must be removed. intestinal access ports have been used to study the pharmacokinetics of drugs at various levels in the intestinal tract. these catheters are usually vascular access ports with several modifications to allow secure placement in bowel (meunier et al., ) . when placed and managed correctly, these ports may remain in place for months without complications. the most frequently reported complication associated with these catheters is infection around the port site (meunier et al., , kwei et al., . these infections lead to removal of the catheters despite treatment with local lavage and systemic antibiotics. there have also been reports of catheters dislodging from the intestinal tract and resulting in peritonitis. this complication has largely been eliminated with the improved security afforded by a synthetic cuff added to the end of the catheter (meunier et al., ) . the chapter authors have also seen migration of the catheter end within the lumen of the intestine (caused by peristaltic motion to egest the catheter), extensive intra-abdominal adhesions, and intestinal torsion (figs. a,b) as complications of intestinal access ports. the procedures for placement and maintenance of the catheters are similar to those outlined previously for indwelling vascular catheters. it is important that the catheters be firmly secured to the intestine to prevent migration or dislodgment. an omental patch placed over the site of entry may help form a firm adhesion. in addition, it is important to place the proper length of catheter within the peritoneal cavity; excess catheter length can promote adhesion formation, whereas insufficient catheter length to account for visceral organ motion can result in detachment. the placement and patency of the catheters can be verified periodically by contrast radiography using iodinated contrast material or by fecal occult blood testing after a small amount of blood has been injected through the catheter (meunier et al., ) . etiology. sepsis is defined as the systemic response to infection. most often, sepsis is a result of infection with gramnegative bacteria; however, sepsis may also be associated with gram-positive bacteria and fungi. in laboratory animals, sepsis is seen as a complication of surgical procedures or associated with chronic implants. sepsis may also be seen as a complication of infectious diseases such as parvovirus. clinical signs. the signs of sepsis can vary, depending on the source of the infection and the stage of the disease. early in the course of sepsis, dogs will present with signs of a hyperdynamic response, including an increased heart rate, increased respiratory rate, red mucous membranes, and a normal to increased capillary refill time. systemic blood pressure and cardiac output will be increased or within the normal range. the animals will often be febrile. later in the course of the syndrome, the animals will show the classic signs of septic shock, including decreased temperature, pale mucous membranes, and a prolonged capillary refill time. cardiac output and blood pressure are decreased as shock progresses. peripheral edema and mental confusion have also been reported (hauptman and chaudry, ) . pathogenesis. the pathophysiology of sepsis is complex and is mediated by immune responses involving mediators such ~ as cytokines, eicosinoids, complement, superoxide radicals, and nitric oxide. the body responds to overwhelming infection with an attempt to optimize metabolic processes and maximize oxygen delivery to tissues. however, if inflammation is left unchecked, the system may be unable to compensate, and the result is cardiovascular collapse. diagnosis. in general, a presumptive diagnosis of sepsis is made based on the occurrence of several in a group of signs, including altered body temperature, increased respiratory and/or heart rate, increased or decreased white blood cell count, increased number of immature neutrophils, decreased platelet count, decreased blood pressure, hypoxemia, and altered cardiac output. however, extreme inflammation without infection (e.g., pancreatitis, trauma) may create similar signs. one study examined the diagnosis of sepsis in canine patients at a veterinary hospital based on easily obtainable physical and laboratory findings. that study found that septic individuals had higher temperatures, wbc counts, and percentage of bands than nonseptic individuals, whereas platelet counts were lower in the septic dogs. there were no differences in respiratory rate or glucose levels between the groups. using these criteria, the results had a high sensitivity and a tendency to overdiagnose sepsis (hauptman et al., ) . ultimately, the presence of a septic focus simplifies diagnosis greatly; however, the focus may not be obvious. if the signs of sepsis are evident but the focus is not, several systems should be evaluated for infection, including urinary tract, reproductive tract, abdominal cavity, respiratory tract, teeth, and heart valves (kirby, ) . treatment. the treatment of sepsis has three aims. the first aim is to support the cardiovascular system. all septic animals should be treated with fluids to replace deficits and to maximize cardiac output. crystalloids are most frequently used to maintain vascular volume, primarily because of their low cost. colloids offer the advantage of maintaining volume without fluid overload and may have other positive effects on the cardiovascular system. acid-base and electrolyte imbalances should also be addressed. after the animal has stabilized, the treatment of sepsis should be aimed at removing the septic focus. obvious sources of infection should be drained or surgically removed. if an implant is associated with the source of infection, the implant should be removed. antibiotic therapy should also be instituted. the choice of antibiotic will ultimately depend upon the results of culture; however, the initial choice of antibiotics is based on previous experience, source of infection, and gram stains. the organisms associated with sepsis are often gram-negative bacteria of gastrointestinal origin or are previously encountered nosocomial infections. ideally, the antibiotic chosen for initial therapy should be a broad-spectrum, bactericidal drug that can be administered intravenously. second-or third-generation cephalosporins provide good coverage, as does combination therapy with enrofloxacin plus metronidazole or penicillin. finally, the treatment of sepsis is aimed at blocking the mediators of the systemic response. several studies have examined the effects of steroids, nonsteroidal anti-inflammatory drugs, and antibodies directed against endotoxin, cytokines, or other mediators of the inflammatory response; however, none of these treatments have proven greatly effective in clinical trials. consequently, there is no "magic bullet" for the treatment of sepsis at this time. successful therapy remains dependent on aggressive supportive care coupled with identification and elimination of the inciting infection. etiology. in research animals, aspiration into the lungs may occur accidentally during the oral administration of various substances or by the misplacement of gastric tubes. aspiration of gastric contents may also occur as a complication of anesthesia. in pet animals, aspiration is often seen as a result of metabolic and anatomical abnormalities; however, such occurrence would be rare in the research setting. clinical signs. the signs of aspiration lung injury may include cough, increased respiratory rate, pronounced respiratory effort, and fever. when respiration is severely affected, the oxygen saturation of blood will be decreased. the diagnosis of this problem is based on a history consistent with aspiration and the physical findings. classically, radiographs of the thorax demonstrate a bronchoalveolar pattern in the cranioventral lung fields. however, these lesions may not appear for several hours after the incident of aspiration. in addition, the location of the lesions may be variable, depending on the orientation of the animal at the time of aspiration. pathogenesis. aspiration of gastric contents or other compounds can create lung injury of variable severity, depending upon the ph, osmolality, and volume of the substance. the compounds aspirated can produce direct injury to lung tissue, but more importantly, the aspiration provokes an inflammatory response probably mediated by cytokines. the result is a rapid influx of neutrophils into the lung parenchyma and alveolar spaces. the inflammation leads to increased vascular permeability with leakage of fluid into the alveolar spaces and can eventually lead to alveolar collapse. if the condition is severe, it may result in adult respiratory distress syndrome and respiratory failure. it should be noted that infection is not present in the early stages of this condition but may complicate the problem after - hr. treatment. the treatment of aspiration lung injury is largely supportive and depends upon the severity of the inflammation and the clinical signs. in cases in which a small amount of a relatively innocuous substance (e.g., barium) has been aspirated, treatment may not be necessary. when severe inflammation is present, systemic fluid therapy should be instituted. support of the cardiovascular system should be performed judiciously; fluid overload could lead to an increase in pulmonary edema. the use of colloids is controversial because of the increase in vascular permeability that occurs in the lungs. oxygen therapy is also controversial, because it may increase lung injury if administered at high concentrations for long periods of time (nader-djahal et al., ) . several studies have addressed the use of anti-inflammatory agents to reduce lung injury associated with aspiration; however, none are used clinically in human or veterinary medicine at this time. in humans, antibiotics are reserved for use in cases with confirmed infection, in order to prevent the development of antibiotic-resistant pneumonia. it has been suggested that dogs should be treated with antibiotics immediately when the aspirated material is either not acidic or has potentially been contaminated by oral bacteria associated with severe dental disease. amoxicillin-clavulanate has been recommended as a first line of defense, reserving enrofloxacin for resistant cases (hawkins, ) . the presence of pneumonia should be verified by tracheal wash and cultures. etiology. in laboratory animals, accidental burns usually result from thermal injury (heating pads, water bottles) or harsh chemicals (strong alkalis, acids, disinfectants). the insult to the skin results in desiccation of the tissue and coagulation of proteins. in addition, the severely injured area is surrounded by a zone of vascular stasis, which promotes additional tissue damage. even small burns can result in significant inflammation that could affect the outcome of some research investigations and cause considerable discomfort to the animal. the proper and immediate treatment of burn wounds can reduce the effects of the injury on both the individual and the research. clinical signs. the clinical signs vary with the type and degree of burn injury. initially, the injury may not be noticed. the first signs may be oozing from the skin and matting of the overlying hair. within a couple of days, progressive hair and skin loss may be observed (johnston, ) . the wounds may vary in severity from very superficial (involving only the epidermis) to those in which the epidermis and dermis are completely destroyed. superficial wounds appear as red, inflamed skin similar to sunburn in humans. the pain associated with these injuries usually subsides in - days, and the wound reepithelializes without complications in - days. deeper burns develop a thick covering, or eschar, composed of the coagulated proteins and desiccated tissue fluid. the wound heals by granulation under the eschar, which eventually sloughs or is removed to allow further healing by contraction and reepithelialization. within - days of injury, the burn wound will be colonized by grampositive bacteria that rapidly cover the entire wound. several days later, gram-negative organisms can appear in the burn wound (johnston, ) . at this point, signs of wound infection and sepsis may occur (see section iii,d, ). treatment. appropriate and timely treatment of a burn wound will reduce the extent of the injury. thermal injuries should be immediately cooled to reduce edema and pain (demling and lalonde, ) . chemical burns should be thoroughly lavaged for min after wounding. the damaged tissues may be unable to mount appropriate responses to changes in temperature; therefore, the lavage should be performed with warm water to prevent hypothermia. after the initial treatment, all burn wounds should be gently cleansed - times a day (demling and lalonde, ) . burns involving the epidermis and part of the dermis can be extremely painful, and analgesia should be addressed throughout the treatment period. systemic antibiotics are unable to penetrate eschar and are not adequately distributed through the abnormal blood supply of burned tissues. therefore, topical wound dressings are recommended in the early stages of treatment. a thin film of a water-soluble broad-spectrum antibiotic ointment should be applied to the wound surface after each cleaning. silver sulfadiazine has a broad spectrum, penetrates eschar well, and is often the preparation of choice for burn wound therapy. povidone-iodine ointment will also penetrate thin eschar and provides a broad spectrum. mafenide has a good spectrum that covers gram-negative organisms well and is often used to treat infected wounds, although it is associated with pain upon application (demling and lalonde, ) . when signs of wound or systemic infection are present, systemic antibiotics should be employed, and their ultimate selection should be based on culture and sensitivity results. after the topical antibiotic has been applied, a nonadherent dressing should be placed on the wound. burn wounds covered in such a manner tend to epithelialize more rapidly and are less painful than uncovered wounds. when the eschar over a burn wound has formed and become fully defined, a small or moderately sized wound may be completely resected. prevention. obviously, prevention of burn wounds is preferable to a long course of treatment. care should be taken to prevent direct exposure to harsh chemicals. tables, floors, and other surfaces should be rinsed thoroughly after chemical use, prior to allowing any animal contact. electric heating pads should be avoided, and only heated water blankets or circulating warm-air devices should be used to provide warmth to the animals. in rare instances, heated water blankets have also caused burns; therefore these devices should be carefully monitored. as a precaution, a thin towel may be placed between the animal and the water blanket. etiology. research and/or anesthetic protocols may require the intravenous injection of various solutions. when these substances have a ph or osmolarity significantly different from that of the surrounding tissues, the accidental perivascular extravasation of the solutions may result in tissue damage. several drugs have been shown to cause problems when injected perivascularly, including pentobarbital, thiamylal, thiopental, thiacetarsemide, vincristine, vinblastine, and doxorubicin (swaim and angarano, ; waldron and trevor, ) . clinical signs. the immediate signs of perivascular injection are swelling at the injection site and withdrawal of the limb or other signs of discomfort. later, the area may appear red, swollen, and painful as inflammation progresses. often there will be eventual necrosis of the skin around the injection site. in cases of doxorubicin extravasation, signs may develop up to a week after the injection, and the affected area may progressively enlarge over a to month period. this is because the drug is released over time from the dying cells (swaim and angarano, ) . prevention. because the degree of injury and extensive treatment associated with perivascular extravasation of a drug can be detrimental to research protocols and can cause severe discomfort to the dog, prevention of these injuries is preferred. prior to the use of any substance, the investigator should be aware of its chemical composition and the potential for problems. if a potentially caustic compound is to be used in a fractious subject, sedation of the dog is warranted if this will not interfere with the research protocol. whenever possible, insertion of an indwelling catheter is extremely important. access to a central vessel such as the cranial or caudal vena cava is preferred over the use of peripheral vessels. when peripheral catheters are used, the injection should be followed by a vigorous amount of flushing with saline or other physiological solution and removal of the catheter. additional injections are best given through newly placed catheters in previously unused vessels. the repeated use of an indwelling peripheral catheter should be approached cautiously and done only out of necessity. prior to use, the catheter should be checked repeatedly for patency by withdrawal of blood and injection of saline. any swelling at the catheter site or discomfort by the subject indicates that the catheter should not be used. treatment. the treatment of perivascular injections will depend on the amount and type of substance injected. in most cases, dilution of the drug with subcutaneous injections of saline is recommended. in addition, steroids may be infiltrated locally to reduce inflammation. topical application of dimethyl sulfoxide (dmso) may also be helpful in reducing the immediate inflammation and avoiding the development of chronic lesions (swaim and angarano, ). the addition of lidocaine to subcutaneous injections of saline has been used in cases of thiacetarsemide injection (hoskins, ) , and local infiltration of hyaluronidase accompanied by warm compresses has been suggested for use in cases of vinblastine injection (waldron and trevor, ) . despite these treatments, necrosis of skin may be observed and would require serial debridement of tissues with secondary wound closure or skin grafting. in cases of doxorubicin extravasation, early excision of affected tissues is advocated to prevent the progressive sloughing caused by sustained release of the drug from dying tissues (swaim and angarano, ) . in all cases, the condition can be painful, and analgesia should be addressed. etiology. hepatic encephalopathy is the result of the derangements in metabolism associated with abnormal liver function. this condition may be seen in young dogs with congenital portosystemic shunting of blood flow. however, in the research setting, encephalopathy occurs more often in canine models of hepatic disease that lead to liver failure. a well-developed knowledge of the pathophysiology of liver disease is necessary for the initial treatment and long-term management of hepatic encephalopathy. pathogenesis. when the liver function is severely impaired because of either portosystemic shunting of blood flow or loss of metabolically active hepatic tissue, the result is an accumulation of ammonia, toxic amines, aromatic amino acids, and short-chain fatty acids (hardy, ; center, ) . these compounds have several toxic effects that result in a decrease in cerebral energy metabolism and a decrease in excitatory neurotransmitter synthesis. concurrently, there is an increase in the concentration of false neurotransmitters and the inhibitory substance -aminobutyric acid (gaba). clinical signs. the signs of hepatic encephalopathy include lethargy, depression, muscle tremors, and convulsions. diagnosis and differential diagnosis. a presumptive diagnosis of hepatic encephalopathy may be based on the appearance of clinical signs following experimental manipulation of the liver. additional diagnostic tests to verify the loss of liver function can be performed to confirm the diagnosis. serum glucose and protein levels may be low if hepatic function is severely impaired. a low serum urea nitrogen level suggests that the normal hepatic metabolism of ammonia into urea has been impaired. elevated levels of serum bile acids and blood ammonia also verify the loss of liver function (hardy, ) . measurement of serum hepatic leakage enzymes are nondiagnostic, because they can be low, high, or normal. treatment. because of the severity of hepatic encephalopathy, treatment may be initiated based on a presumptive diagnosis. during initial treatment, supportive care with fluids and electrolytes should be instituted, based on the results of serum chemistry and blood gas analysis. the majority of animals with hepatic dysfunction will be hypokalemic, alkalotic, and hypernatremic; therefore, either . % sodium chloride or . % sodium chloride with . % dextrose, supplemented with potassium chloride, is recommended (hardy, ) . the type of drug to be used for seizure control is controversial. the short halflife of diazepam makes it an attractive choice compared with barbiturates, which have prolonged metabolism when hepatic function is impaired (maddison, ) . however, endogenous benzodiazepines mediate some of the cns signs seen with hepatic encephalopathy. therefore, the use of diazepam has been discouraged in favor of phenobarbital (johnson, ) . the drug selected for seizure control should be titrated carefully, given the altered liver metabolism. most importantly, the treatment of dogs with hepatic encephalopathy must be aimed at reducing the levels of toxic metabolites in the bloodstream. because protein metabolism is a major source of ammonia, all oral food intake should cease until the signs of hepatic encephalopathy have abated. because gastrointestinal bleeding may occur in individuals with liver failure and this is also a source of protein, the use of h blockers such as cimetidine or ranitidine is suggested (swalec, ) . in addition, lactulose retention enemas should be performed ( - ml/lb of a % solution in water, retained for - min) (hardy, ) . lactulose is an indigestible semisynthetic sugar that is metabolized in the gut to lactic and other acids. the decrease in colonic ph reduces ammonia levels in the bloodstream by converting intestinal ammonia into less diffusible ammonium ions. lactulose will also cause an osmotic diarrhea. antibiotics such as neomycin ( mg/lb, - times/ day) or metronidazole ( mg/lb, times/day) should also be used to reduce the intestinal load of urease-producing bacteria responsible for splitting urea into ammonia (hardy, ) . when the signs of hepatic encephalopathy have resolved, the dog may be fed a low-protein diet. diets suitable for dogs with renal insufficiency are recommended initially. this type of diet is not suitable for long-term use, however, because it appears that individuals with some types of hepatic disease actually have increased protein requirements. these requirements may be met by slowly increasing protein in the diet as long as signs of hepatic encephalopathy do not recur. to maintain the appropriate balance of aromatic and branched-chain amino acids, the diet should be based on vegetable and dairy protein instead of meat or fish protein (center, ) . in addition, the antibiotics suggested above should be continued to reduce the effects of increasing dietary protein levels. the prevalence of cancer in the general canine population has increased over the years (dorn, ) . this can be attributed to the longer life spans resulting from improvements in nutrition, disease control, and therapeutic medicine. because of these changes, cancer has become a major cause of death in dogs (bronson, ) . in a lifetime cancer mortality study of intact beagles of both sexes, albert et al. ( ) found death rates similar to the death rate of the at-large dog population (bronson, ) . approximately % of the male beagles died of cancer. the majority of the tumors were lymphomas ( %) and sarcomas ( %), including hemangiosarcomas of the skin and fibrosarcomas. of the female beagles dying of cancer ( % of the population studied), three-quarters had either mammary cancer ( %), lymphomas ( %), or sarcomas ( %). of the sarcomas in females, one-third were mast cell tumors. in addition to these tumors that cause mortality, the beagle is also at risk for thyroid neoplasia (hayes and fraumeni, ; benjamin et al., ) . because of the popularity of the beagle as a laboratory animal, discussion of specific neoplasms will focus on the tumors for which this breed is at risk, as well as tumors that are common in the general canine population. fine-needle aspirates are generally the first diagnostic option for palpable masses, because they can easily be performed in awake, cooperative patients. this technique allows for rapid differentiation of benign and neoplastic processes. in cases where cytologic results from fine-needle aspirates are not definitive, more invasive techniques must be used. needle-punch or core biopsies can also be performed in awake patients but typically require local anesthesia. an instrument such as a tru-cut needle (travenol laboratories, inc., deerfield, illinois) is used to obtain a mm x to . cm biopsy of a solid mass. a definitive diagnosis may be limited by the size of the sample acquired using this technique. incisional and excisional biopsies are utilized when less invasive techniques fail to yield diagnostic results. excisional biopsies are the treatment of choice when surgery is necessary, because the entire mass is removed. surgical margins should extend at least cm around the tumor, and cm if mast cell tumors are suspected (morrison et al., ) . incisional biopsies are performed when large soft-tissue tumors are encountered and/or when complete excision would be surgically difficult or life-threatening. when performing an incisional biopsy, always select tissue from the margin of the lesion and include normal tissue in the submission. etiology. lymphomas are a diverse group of neoplasms that originate from lymphoreticular cells. whereas retroviral etiologies have been demonstrated in a number of species (e.g., cat, mouse, chicken), conclusive evidence of a viral etiology has not been established in the dog. in humans, data implicate the herbicide , -dichlorophenoxyacetic acid ( , -d) as a cause of non-hodgkin's lymphoma, but studies in dogs with similar conclusions have come under scrutiny (macewen and young, ) . clinical signs. multicentric and alimentary lymphomas account for most cases of canine lymphoma. in multicentric lymphoma, animals usually present with enlarged lymph nodes and nonspecific signs such as anorexia, weight loss, polyuria, polydypsia, and lethargy. when the liver and spleen are involved, generalized organomegaly may be felt on abdominal palpation. alimentary lymphoma is associated with vomiting and diarrhea, in addition to previous clinical signs. less commonly, dogs develop mediastinal, cutaneous, and extranodal lymphomas. dogs with mediastinal lymphoma often present with respiratory signs secondary to pleural effusion. hypercalcemia is most frequently associated with this form of lymphoma and may result in weakness. cutaneous lymphoma varies in presentation from solitary to generalized and may mimic any of a number of other skin disorders. the tumors may occur as nodules, plaques, ulcers, or dermatitis. approximately half of the cases are pruritic. a number of extranodal forms of lymphoma have been reported, including tumors affecting the eyes, central nervous system, kidneys, or nasal cavity. clinical presentation varies, depending on the site of involvement. epizootiology. the incidence of lymphoma is highest in dogs - years old, accounting for % of cases. although the neoplasm generally affects dogs older than year, cases in puppies as young as months have been reported (dorn et al., ) . pathologic findings. enlarged neoplastic lymph nodes vary in diameter from to cm and are moderately firm. some may have areas of central necrosis and are soft to partially liquefied. the demarcation between cortex and medulla is generally lost, and on cut section, the surface is homogenous. the spleen may have multiple small nodular masses or diffuse involvement with generalized enlargement. the enlarged liver may have disseminated pale foci or multiple large, pale nodules. in the gastrointestinal tract, both nodular and diffuse growths are observed. these masses may invade through the stomach and intestinal walls. histologically, the most common lymphomas are classified as intermediate to high grade and of large-cell (histiocytic) origin. the neoplastic lymphocytes typically obliterate the normal architecture of the lymph nodes and may involve the capsule and perinodal areas. pathogenesis. all lymphomas regardless of location should be considered malignant. a system for staging lymphoma has been established by the world health organization. the average survival time for dogs without treatment is - weeks. survival of animals undergoing chemotherapy is dependent on the treatment regimen as well as the form and stage of lymphoma (macewen and young, ) . hypercalcemia is a paraneoplastic syndrome frequently associated with lymphoma. the pathogenesis of this phenomenon is not fully understood but may be a result of a parathormone-like substance produced by the neoplastic lymphocytes. diagnosis and differential diagnosis. differential diagnoses for multicentric lymphoma include systemic mycosis; salmonpoisoning and other rickettsial infections; lymph node hyperplasia from viral, bacterial, and/or immunologic causes; and dermatopathic lymphadenopathy. alimentary lymphoma must be distinguished from other gastrointestinal tumors, foreign bodies, and lymphocytic-plasmacytic enteritis. in order to make a definitive diagnosis, whole lymph node biopsies and full-thickness intestinal sections are frequently needed. treatment. therapy for lymphoma typically consists of one or a combination of several chemotherapeutic agents. the treatment regimen is based on the staging of the disease, the presence of paraneoplastic syndromes, and the overall condition of the patient. macewen and young ( ) provide a thorough discussion of therapeutic options for the treatment of lymphomas in the dog. research complications. given the grave prognosis for lymphoma with or without treatment, euthanasia should be considered for research animals with signifcant clinical illness. etiology. the fibrosarcoma group of tumors encompasses not only malignant tumors of fibroblasts but also a number of indistinguishable tumors, all of which are capable of collagen production (pulley and stannard, ) . frequently classified in this group are undifferentiated leiomyosarcomas, liposarcomas, malignant melanomas, and malignant schwannomas. clinical signs. although these neoplasms can arise throughout the body, they are most commonly found in the skin, subcutaneous tissues, and oral cavity. fibrosarcomas are extremely variable in size and can grow to be quite large. in general, they are irregular and nodular, poorly demarcated, and nonencapsulated, and they frequently invade deeper tissues. epizootiology. most fibrosarcomas develop in adult and aged animals but can affect dogs as young as months or less. pathogenesis. fibrosarcomas exhibit rapid, invasive growth, recurring frequently after excision. metastasis occurs in only one-fourth of cases, usually by the bloodstream to the lungs. less frequently, spread to local lymph nodes is observed. diagnosis and differential diagnosis. differential diagnoses for fibrosarcomas vary with the location of the tumor. histopathologic exam should be used to distinguish these tumors from round cell tumors (mast cell tumors, histiocytomas, transmissible venereal tumors), papillomas, and other neoplasms. treatment. treatment of any soft-tissue sarcoma would begin with wide surgical excision. if the tissue margins indicate incomplete resection, radiotherapy could be used. for any highgrade tumors, adjuvant chemotherapy would be recommended (see macewen and withrow, a , for a complete discussion). research complications. because fibrosarcomas are locally invasive and often recur, dogs with these neoplasms should not be considered good subjects for long-term studies. etiology. neoplasms of lipocytes and lipoblasts are welldifferentiated tumors referred to as lipomas. clinical signs. these growths can be found as single or multiple round, ovoid, or discoid masses in the subcutaneous tissues of the lateral and ventral thorax, abdomen, and upper limbs. generally they are well circumscribed, encapsulated, and soft on palpation. further, the skin is freely movable over the tumor. epizootiology. lipomas occur principally in aged animals (average years), and the incidence increases with age (pulley and stannard, ) . the tumors are most commonly seen in overweight female dogs, but no breed predisposition is observed. pathologic findings. histologically, lipomas are indistinguishable from normal adipose tissue except when a fibrous capsule is present. pathogenesis: lipomas are typically slow-growing and do not recur after complete surgical excision. diagnosis and differential diagnosis. lipomas are not frequently confused with other tumors but can sometimes be difficult to distinguish from normal adipose tissue. generally, the distinction can be made from the clinical history. treatment. treatment for lipomas is not usually necessary unless the mass is causing problems with normal ambulation. in such cases, surgical excision is usually curative. research complications. lipomas usually do not complicate research studies unless they are interfering with other systemic functions or ambulation. etiology. histiocytomas are benign skin growths that arise from the monocyte-macrophage cells in the skin. some debate exists as to whether this growth is actually a neoplasm or a focal inflammatory lesion (pulley and stannard, ) . clinical signs. the most frequent sites for histiocytomas are the head (especially the pinna) and the skin of the distal forelegs and feet. the masses are usually domelike or buttonlike (often referred to as "button tumors") and usually measure - cm in diameter. epizootiology. histiocytomas are the most common tumors of young dogs, mostly occurring in dogs less than years of age. pathologic findings. histologically, these tumors contain round to ovoid cells with pale cytoplasm and large nuclei. the cells infiltrate the dermis and subcutis, displacing collagen fibers and skin adnexa. despite being benign lesions, histiocytomas characteristically have a high mitotic index. pathogenesis. this tumor typically exhibits rapid growth ( - weeks) but does not spread. most histiocytomas will spontaneously regress in less than months. diagnosis and differential diagnosis. histiocytomas must be distinguished from potentially metastatic mast cell tumors. this is accomplished by staining with toluidine blue, which would stain the cytoplasmic granules of mast cells red or purple. treatment. although most histiocytomas will spontaneously resolve, conservative surgery or cryosurgery will provide an expeditious resolution. research complications. histiocytomas should not interfere with most studies. etiology. neoplastic proliferations of mast cells are the most commonly observed skin tumor of the dog (bostock, ) . mast cells are normally found in the connective tissue beneath serous surfaces and mucous membranes, and within the skin. clinical signs. well-differentiated mast cell tumors are typically solitary, well-circumscribed, slow-growing, to cm nodules in the skin. alopecia may be observed, but ulceration is not usual. poorly differentiated tumors grow rapidly, may ulcerate, and may cause irritation, inflammation, and edema. mast cell tumors can be found on any portion of the dog's skin but frequently affect the hindquarters, especially the thigh and in-guinal and scrotal areas. mast cell tumors usually appear to be discrete masses, but they frequently extend deep into surrounding tissues. epizootiology. these tumors tend to affect middle-aged dogs but have been observed in dogs ranging from months to years (pulley and stannard, ). pathologic findings. because of the substantial variation in histologic appearance of mast cell tumors, a classification and grading system described by patnaik et al. ( ) has become widely accepted. in this system, grade i has the best prognosis, and grade iii the worst prognosis. grade i tumors are well differentiated, with round to ovoid uniform cells. the nuclei are regular, the cytoplasm is packed with large granules that stain deeply, and mitotic figures are rare to absent. grade ii (intermediately differentiated) mast cell tumors have indistinct cytoplasmic boundaries with higher nuclear-cytoplasmic ratios, fewer granules, and occasional mitotic figures. grade iii (anaplastic or undifferentiated) mast cell tumors have large, irregular nuclei with multiple prominent nucleoli. the cytoplasmic granules are few, but mitotic figures are much more frequent. in addition to skin lesions, mast cell tumors have been associated with gastric ulcers. these lesions are most likely secondary to tumor production of histamine. histamine stimulates the h receptors of the gastric parietal cells, causing increased acid secretion. gastric ulcers have been observed in large numbers (> %) of dogs with mast cell tumors (howard et al., ) . the ulcers can be found in the fundus, pylorus, and/or proximal duodenum. although all mast cell tumors should be considered potentially malignant, the outcome in individual cases can be correlated with the histologic grading of the tumor. grade iii tumors are most likely to disseminate internally. this spread is usually to regional lymph nodes, spleen, and liver and less frequently to the kidneys, lungs, and heart. diagnosis and differential diagnosis. mast cell tumors can be distinguished histologically from other round cell tumors (such as histiocytomas and cutaneous lymphomas) by using toluidine blue, which metachromatically stains the cytoplasmic granules of the mast cells red or purple. treatment. initial treatment for mast cell tumors is generally wide surgical excision ( to cm margins). even with wide surgical margins, approximately % of mast cell tumors may recur. if the site is not amenable to wide surgical excision, debulking surgery and radiation therapy may be used. other alternatives include amputation (if on a limb) or radiation therapy alone. as an adjunct to surgery, grier et al. ( grier et al. ( , found that deionized water injected into surgical margins reduced tumor recurrence by hypo-osmotically lysing any mast cells left behind. this technique has recently been refuted by jaffe et al. ( ) . for systemic mastocytosis, and nonresectable or incompletely excised mast cell tumors, chemotherapy can be used. treatment options would include oral prednisolone, intralesional triamcinalone, and the combination of cyclophosphamide, vincristine, and prednisolone (graham and o'keefe, ) . research complications. because of the possibility of systemic histamine release and tumor recurrence, dogs with mast cell tumors are not good candidates for research studies. grade i mast cell tumors may be excised, allowing dogs to continue on study; however, monitoring for local recurrence should be performed on a regular basis (monthly). grade ii tumors are variable; animals that undergo treatment should be monitored for recurrence monthly, and evaluation of the buffy coat should be performed every - months for detection of systemic mastocytosis. because of the poor prognosis for grade iii tumors, treatment is unwarranted in the research setting. etiology. hemangiosarcomas are malignant tumors that originate from endothelial cells. clinical signs. these tumors may arise in the subcutis but are more commonly found in the spleen and the right atrium. clinical signs are associated with the site of involvement. vascular collapse is frequently observed secondary to rupture and hemorrhage from splenic masses. heart failure can be observed secondary to tumor burden or hemopericardium. when found in the skin, hemangiosarcomas are poorly circumscribed, reddish black masses that range in size from to cm in diameter. the most common cutaneous sites are the ventral abdomen, the prepuce, and the scrotum. epizootiology: hemangiosarcomas occur most frequently in -to -year-old dogs. the german shepherd dog is most commonly affected. pathologic findings. grossly, splenic hemangiosarcomas resemble nodular hyperplasia or hematomas (fig. ) . the masses are spherical and reddish black and can range in size up to - cm in diameter. on cut section the masses may appear reddish gray or black and have cavernous areas of clotted blood. when the masses are found in the heart, the endocardium may be covered by a thrombus, giving the to cm tumors a reddish gray or yellow appearance. histologically, hemangiosarcomas are composed of immature endothelial cells that form vascular channels or clefts. these spaces may be filled with blood or thrombi. the neoplastic cells are elongated with round to ovoid, hyperchromatic nuclei and frequent mitotic figures. pathogenesis. hemangiosarcomas can be found in one or many sites. in cases where multiple sites are involved, it may be impossible to identify the primary tumor. this neoplasia is highly malignant and spreads easily. metastasis occurs most frequently to the lungs but can be found in any tissue. diagnosis and differential diagnosis. splenic hemangiosarcoma may resemble nodular hyperplasia or some manifestations of lymphoma. when the heart is affected, other causes of heart failure must be ruled out. echocardiography is a valuable tool for identifying the primary lesion. histopathology should be used to differentiate dermal hemangiosarcoma from hemangiomas and other well-vascularized tumors. treatment. surgery is generally the first choice of treatment for hemangiosarcoma. dermal tumors are treated with radical resection, splenic tumors by total splenectomy, and heart tumors by debulking and pericardiectomy. because of the high likelihood of metastasis, adjunct chemotherapy should always be considered. research complications. dogs with dermal hemangiosarcoma may be cured after complete resection with margins, but monitoring should be done regularly for recurrence. the other forms of hemangiosarcoma have a much poorer long-term prognosis, and treatment is typically unwarranted in the research setting. etiology. also known as infectious or venereal granuloma, sticker tumor, transmissible sarcoma, and contagious venereal tumor, the transmissible venereal tumor is transmitted to the genitals by coitus (nielsen and kennedy, ) . the origin of this tumor is still unknown but has been described as a tumor of lymphocytes, histiocytes, and reticuloendothelial cells. although this tumor has been reported in most parts of the world, it is most prevalent in temperate climates (macewen, ) . clinical signs. the tumors are usually cauliflower-like masses on the external genitalia, but they can also be pedunculated, nodular, papillary, or multilobulated. these friable masses vary in size up to cm, and hemorrhage is frequently observed. in male dogs, the lesions are found on the caudal part of the penis from the crura to the bulbus glandis or on the glans penis (fig. ) . less frequently, the tumor is found on the prepuce. females typically have lesions in the posterior vagina at the junction of the vestibule and vagina. when located around the urethral orifice, the mass may protrude from the vulva. these tumors have also been reported in the oral cavity, skin, and eyes. epizootiology and transmission. transmissible venereal tumors are most commonly observed in young, sexually active dogs. transmission takes place during coitus when injury to the genitalia allows for transplantation of the tumor. genital to oral to genital transmission has also been documented (nielsen and kennedy, ) . extragenital lesions are believed to be a result of trauma prior to exposure to the tumor. pathogenesis. tumor growth is rapid after implantation but later slows. metastasis is rare (< % of cases) but may involve the superficial inguinal and external iliac lymph nodes as well as distant sites. diagnosis and differential diagnosis. transmissible venereal tumors have been confused with lymphomas, histiocytomas, mast cell tumors, and amelanotic melanomas. cytology may be of benefit in making a definitive diagnosis, so impression smears should be made prior to processing for histopathology. prevention. thorough physical examinations prior to bringing new animals into a breeding program should prevent introduction of this tumor into a colony. control. removing affected individuals from a breeding program should stop further spread through the colony. treatment. surgery and radiation can be used for treatment, but chemotherapy is the most effective. vincristine ( . - . mg/m ) iv once weekly for - treatments will induce remission and cure in greater than % of the cases (macewen, ). research complications. experimental implantation of transmissible venereal tumors has been shown to elicit formation of tumor-specific igg (cohen, ) . this response may occur in natural infections and could possibly interfere with immunologic studies. etiology. dogs are susceptible to a wide variety of mammary gland neoplasms, most of which are influenced by circulating reproductive steroidal hormones. clinical signs. single nodules are found in approximately % of the cases of canine mammary tumors. the nodules can be found in the glandular tissue or associated with the nipple. masses in the two most caudal glands (fourth and fifth) account for a majority of the tumors. benign tumors tend to be small, well circumscribed, and firm, whereas malignant tumors are larger and invasive and coalesce with adjacent tissues. epizootiology. mammary tumors are uncommon in dogs under years of age with the incidence rising sharply after that. median age at diagnosis is - years. mammary tumors occur almost exclusively in female dogs, with most reports in male dogs being associated with endocrine abnormalities, such as estrogen-secreting sertoli cell tumors. pathologic findings. based on histologic classification of mammary gland tumors, approximately half of the reported tumors are benign (fibroadenomas, simple adenomas, and benign mesenchymal tumors), and half are malignant (solid carcinomas, tubular adenocarcinomas, papillary adenocarcinomas, anaplastic carcinomas, sarcomas, and carcinosarcomas) (bostock, ) . extensive discussions of classification, staging, and histopathologic correlations can be found in macewen and withrow ( lb) and moulton ( ) . pathogenesis. mammary tumors of the dog develop under the influence of hormones. receptors for both estrogen and progesterone can be found in - % of tumors. futher, schneider et al. ( ) showed that the risk of developing mammary tumors increased greatly after the first and second estrus cycles. dogs spayed prior to the first estrus had a risk of . %, whereas dogs spayed after the first and second estrus had risks of % and %, respectively. malignant mammary tumors typically spread through the lymphatic vessels. metastasis from the first, second, and third mammary glands is to the ipsilateral axillary or anterior sternal lymph nodes. the fourth and fifth mammary glands drain to the superficial inguinal lymph nodes where metastasis can be found. many mammary carcinomas will eventually metastasize to the lungs. diagnosis and differential diagnosis. both benign and malignant mammary tumors must be distinguished from mammary hyperplasia and mastitis. prevention. mammary tumors can effectively be prevented by spaying bitches prior to the first estrus. this is commonly done in the general pet population at months of age. recently, the topic of spaying sexually immature dogs ( - weeks of age) has received much attention for the control of the pet population. kustritz ( ) reviewed the techniques for anesthesia and surgery, as well as possible pros and cons of spaying at this young age. treatment. surgery is the treatment of choice for mammary tumors, because chemotherapy and radiation therapy have not been reported to be effective. the extent of the surgery is dependent on the area involved. lumpectomy or nodulectomy should be elected in the case of small discrete masses, while mammectomy and regional or total mastectomies are reserved for more aggressive tumors. at the time of surgery, axillary lymph nodes are removed only if enlarged or positive on cytology for metastasis. inguinal lymph nodes should be removed any time the fourth and fifth glands are excised (macewen and withrow, lb). research complications. because % of mammary tumors are benign, treatment may be rewarding, allowing dogs to con-tinue on study. if removed early enough, malignant masses could yield the same results. all dogs should be monitored regularly for recurrence and new mammary tumors. etiology. beagles are among the breeds with the highest prevalence of thyroid carcinomas. benjamin et al. ( ) reported a correlation between lymphocytic thyroiditis, hypothyroidism, and thyroid neoplasia in the beagle. clinical signs. thyroid carcinomas generally present as palpable cervical masses. affected animals may experience dysphagia, dyspnea, and vocalization changes. precaval syndrome resulting in facial edema is also observed in some cases. epizootiology and transmission. the mean age of dogs presented with thyroid carcinomas is years, with equal distribution of cases between the sexes. pathologic findings. grossly, thyroid carcinomas are multinodular masses, frequently with large areas of hemorrhage and necrosis. they tend to be poorly encapsulated and invade local structures such as the trachea, esophagus, larynx, nerves, and vessels. the masses are unilateral twice as often as bilateral (capen, ) . histologically, thyroid carcinomasare divided into follicular, papillary, and compact cellular (solid) types (see capen, , for complete discussion). pathogenesis. thyroid carcinomas tend to grow rapidly and invade local structures. early metastasis is common and occurs to the lungs by invasion of branches of the thyroid vein. diagnosis and differential diagnosis. nonpainful cervical swellings such as seen with thyroid tumors are also consistent with abscesses, granulomas, salivary mucoceles, and lymphomas. often a preliminary diagnosis can be made by fineneedle aspirate. treatment. surgery is the treatment of choice for thyroid carcinomas that have not metastasized. when the tumor is freely movable, surgery may be curative. surgical excision may be difficult for tumors that adhere to local structures, requiring excision of the jugular vein, carotid artery, and associated nerves. when bilateral tumors are observed, preservation of the parathyroid glands may not be possible. in such cases, treatment for hypoparathyroidism will be necessary. both chemotherapy and radiation therapy have been suggested for extensive bilateral tumors and/or after incomplete excision, but no controlled trials have been performed (ogilvie, ) . in the research setting, treatment of this tumor may not be rewarding. only freely movable tumors can be practically treated without seriously affecting research efforts. euthanasia is warranted in the more advanced cases when clinical illness is apparent. beagles are subject to many of the inherited and/or congenital disorders that affect dogs in general. in a reference table on the congenital defects of dogs (hoskins, b) , disorders for which beagles are specifically mentioned include brachyury (short tail), spina bifida, pulmonic stenosis, cleft palate-cleft lip complex, deafness, cataracts, glaucoma, microphthalmos, optic nerve hypoplasia, retinal dysplasia, tapetal hypoplasia, factor vii deficiency, pyruvate kinase deficiency, pancreatic hypoplasia, epilepsy, gm gangliosidosis, globoid cell leukodystrophy, xx sex reversal, and cutaneous asthenia (ehlers-danlos syndrome). in addition, there are defects that affect so many breeds that the author simply lists "many breeds" for the breeds affected by those disorders. thus these defects could also affect beagles and include pectus excavatum, polydactyly, radial and ulnar dysplasia, hypoadrenocorticism, entropion, lens coloboma, factor viii deficiency (von willebrand's disease), renal agenesis or ectopia, and developmental defects of the reproductive and lower urinary tracts. at a commercial breeder of purpose-bred beagles, the most common birth defects were umbilical hernia ( . % of births) and open fontanelle ( . % of births) (r. scipioni and j. ball, personal communication, ) . other defects observed include cleft palate and cleft lip, cryptorchidism, monorchidism, limb deformity, inguinal hernia, diaphragmatic hernia, hydrocephaly, and fetal anasarca. each of these other congenital defects occurred at less than . % incidence. etiology. cataract is an opacification of the lens or the lens capsule. it is the pathologic response of the lens to illness or injury, because the lens has no blood supply. cataracts can be caused by metabolic, inflammatory, infectious, or toxic causes and can be congenital, juvenile, or degenerative. nuclear sclerosis is an apparent opacification of the lens caused by the compression of older lens fibers in the center of the lens (nucleus) as a consequence of the production of new fibers. because the nucleus increases in size as the animal ages, the sclerosis is more apparent in older animals and may be mistaken as a senile cataract. the ability to see the fundus during ophthalmoscopy persists with nuclear sclerosis but is obstructed by a true cataract. clinical signs. the first clinical sign is typically the ability to visualize the opaque lens through the pupil of the dog's eye. dogs have an impressive ability to tolerate bilateral lens opacity (especially when development is gradual), and often visual impairment is detected late in the development of the condition (helper, ) . moderate vision loss may cause the dog to be hesitant in moving in new surroundings or unable to locate movable objects (such as a toy). rapid cataract development can result in a sudden vision loss, such as can occur with diabetic cataracts. epizootiology and transmission. certain dog breeds can be predisposed to the development of juvenile or senile cataracts or to metabolic disorders that result in cataract development, such as diabetes mellitus. dogs in studies for diabetes mellitus should be observed regularly for cataract development. toxicological studies may also induce formation of cataracts. pathogenesis. lens fibers respond to all biological or chemical insults by necrosis and liquefaction (render and carlton, ) , because they have no blood supply with which to recruit an inflammatory and repair process. disruption of these fibers by any means, therefore, leads to opacification. the exact processes by which the varieties of congenital and juvenile cataracts are produced have not been determined. in diabetic cataracts, the excess glucose is metabolized to sorbitol and fructose. as these alcohols and sugars accumulate in the lenticular cells, they produce an osmotic imbalance, which brings fluid into the cells, causing swelling and degeneration of lens fibers and resultant opacity (capen, ) . diagnosis and differential diagnosis. the ability to visualize the retina and fundus during ophthalmoscopy differentiates true cataracts from nuclear sclerosis. dogs with cataracts should be evaluated for possible causes, especially diabetes mellitus. diabetes mellitus will typically affect middle-aged dogs and feature rapid cataract formation, whereas juvenile and senile cataracts are slow to develop and affect younger and older dogs, respectively. progressive retinal atrophy can also cause secondary cataract formation; pupillary light response is maintained with primary cataracts (even if the lens is completely opaque), whereas this reflex is obtunded by retinopathy. prevention. most forms of cataracts cannot be prevented, for their exact etiologic pathogenesis is unknown. diabetic cataracts, however, can be prevented by proper regulation of blood glucose concentrations with insulin therapy and proper diet. treatment. because dogs do not need to focus visual images as accurately as human beings, proper lens clarity and function are not necessary for an adequate quality of life. many dogs adjust quite well to the visual impairment caused by persistent cataracts. lens removal can be performed for dogs seriously affected by cataracts, but this would not be anticipated for dogs in the research setting. information on surgical lens extraction procedures can be found in helper ( ) or other veterinary ophthalmology textbooks. research complications. research complications would be minimal with cataracts, unless the dogs were intended for use in ophthalmologic or visual acuity-based studies. etiology. hip dysplasia is a degenerative disease of the coxofemoral joint. a specific etiology is unknown, but the development of hip dysplasia has a strong genetic component (pedersen et al., ) , modified by age, weight, size, gender, conformation, rate of growth, muscle mass, and nutrition (smith et al., ) . clinical signs. the initial clinical abnormality caused by hip dysplasia is laxity of the coxofemoral joint. this may present as a gait abnormality without any indication of lameness or stiffness. eventually, affected dogs will have periods of lameness and, in protracted cases, will be rendered immobile by severe pain. epizootiology and transmission. hip dysplasia has been seen in most dog breeds, but it typically affects larger breeds of dogs. in the research setting, it is primarily a condition of randomsource large-breed dogs used for surgical research. diagnosis and differential diagnosis. hip dysplasia is classically diagnosed by radiography of the pelvis and hip joints. radiographic abnormalities consistent with hip dysplasia include shallow acetabula with remodeling of the acetabular rim, flattening of the femoral head, subchondral bone sclerosis (caused by erosion of articular cartilage and exposure of underlying bone), and osteophyte production around the joint (pedersen et al., ) . hip dysplasia needs to be differentiated from other musculoskeletal or neurological conditions that can cause unusual gaits and/or lameness. this may be somewhat difficult, because clinical signs of hip dysplasia may develop before radiographic abnormalities. radiographic calculation of the distraction index (di) to measure joint laxity has proven to be a good means to predict future hip dysplasia before other radiographic changes are evident (smith et al., ) . prevention. because of the genetic component, dogs with hip dysplasia should not be used in breeding colonies. dogs should be provided a good plane of nutrition but not be allowed to become overweight. dogs that were limit-fed at % of the food amount eaten by ad libitum-fed dogs had lower body weights and decreased severity of radiographic lesions of hip dysplasia (kealy et al, ) . treatment. in the stages when clinical signs are episodic, cage rest and analgesics for several days can be used to treat the symptoms. more advanced cases may require continuous analgesia. sectioning of the pectineus muscle or tendon may provide some pain relief but does not affect the progression of the disease (pedersen et al., ) . surgical treatments for hip dysplasia include femoral head ostectomy and total hip replacement. neither surgical treatment is likely in a research setting. research complications. long-term studies using large-breed dogs may be affected by the eventual development of hip dysplasia. in studies where hip dysplasia would be a serious complication or confounding variable (e.g., orthopedic research), dogs should be radiographed upon arrival to assess possibility of early coxofemoral joint degeneration and suitability for use in the study. etiology. benign prostatic hyperplasia (bph) is an agerelated condition in intact male dogs. the hyperplasia of prostatic glandular tissue is a response to the presence of both testosterone and estrogen. clinical signs. bph is often subclinical. straining to defecate (tenesmus) may be seen because the enlarged gland impinges on the rectum as it passes through the pelvic canal. urethral discharge (yellow to red) and hematuria can also be presenting clinical signs for bph. epizootiology and transmission. bph typically affects older dogs (> years), although it has been seen as early as years of age. pathologic findings. in its early stages, canine b ph is hyperplasia of the prostatic glandular tissue. this is in contrast to human bph, which is primarily stromal in origin. eventually, the hyperplasia tends to be cystic, with the cysts containing a clear to yellow fluid. the prostate becomes more vascular (resulting in hematuria or hemorrhagic urethral discharge), and bph may be accompanied by mild chronic inflammation. pathogenesis. bph occurs in older intact male dogs because increased production of estrogens (estrone and estradiol), combined with decreased secretion of androgens, sensitizes prostatic androgen receptors to dihydrotestosterone. the presence of estrogens may also increase the number of androgen receptors, and hyperplastic prostate glands also have an increased ability to metabolize testosterone to a-dihydrotestosterone (kustritz and klausner, ) . diagnosis and differential diagnosis. bph is diagnosed in cases of nonpainful symmetrical swelling of the prostate gland in intact male dogs, with normal hematologic profiles and urinalysis characterized by hemorrhage, at most. differential diagnoses include squamous metaplasia of the prostate, paraprostatic cysts, bacterial prostatitis, prostatic abscessation, and prostatic neoplasia (primarily adenocarcinoma). these differential diagnoses also increase in frequency with age and, except for squamous metaplasia, can also occur in castrated dogs. as such, these conditions do not necessarily abate or resolve when castration is used for treatment of prostatic enlargement. prevention. castration is the primary means for prevention of benign prostatic hyperplasia. treatment. the first and foremost treatment for b ph is castration. in pure cases of b ph, castration results in involution of the prostate gland detectable by rectal palpation within - days. for most dogs in research studies this is a viable option to rapidly improve the animal's condition. the alternative to castration is hormonal therapy, primarily with estrogens. this may be applicable in cases in which the dog is a valuable breeding male (e.g., genetic diseases), and semen collection is necessary. if the research study concerns steroidal hormone functions, then neither the condition nor the treatment is compatible. newer drugs marketed for human males have also shown promise in treating canine bph. finasteride (proscar) is a a-reductase inhibitor that limits metabolism of testosterone to a-dihydrotestosterone. treatment at daily doses of - mg/kg has been effective in causing prostatic atrophy without affecting testicular spermatogenesis (kustritz and klausner, ) . dogs given . mg/kg were proven to still be fertile. there are also indications that lower doses may be effective in relieving b ph. androgen receptor antagonists (flutamide and hydroxyflutamide) have also been studied in the dog and found to be effective for treatment of bph while maintaining libido and fertility (kustritz and klausner, ) . unfortunately, both the areductase inhibitors and the androgen receptor antagonists are not presently labeled for use in male dogs in the united states. research complications. bph can cause complications to steroidal hormone studies, in that the condition may be indicative of abnormal steroidal hormone metabolism, and neither castration nor estrogen therapy is compatible with study continuation. it is presently unknown whether the use of the newer antihyperplastic agents systemically alters physiologic parameters outside of the prostate itself. the development of tenesmus as a clinical sign may also affect studies of colorectal or anal function. etiology. juvenile polyarteritis syndrome (jps) is a painful disorder seen in young beagles (occasionally reported in other breeds). the lesion consistent with the syndrome is systemic necrotizing vasculitis. the cause of the vasculitis has not been established, but it appears to have an autoimmune-mediated component and may have a hereditary predisposition. clinical signs. clinical signs of jps include fever, anorexia, lethargy, and reluctance to move the head and neck. the dogs tend to extend the neck ventrally. most dogs seem to be in pain when touched, especially in the neck region. the syndrome typically has a course of remissions and relapses characterized by - days of illness and - weeks of remission (scott-moncrieff et al., ) . there may be a component of this condition that is subclinical, given that a vasculitis has been diagnosed postmortem in beagles that had no presenting signs. epizootiology and transmission. jps typically affects young beagles ( - months), with no sex predilection. pathologic findings. on gross necropsy, foci of hemorrhage can be seen in the coronary grooves of the heart, cranial mediastinum, and cervical spinal cord meninges (snyder et al., ) . local lymph nodes may be enlarged and hemorrhagic. histologically, necrotizing vasculitis and perivasculitis of small to medium-sized arteries are seen. these lesions are most noticeable in the three locations where gross lesions are observed, but they may be seen in other visceral locations. the perivasculitis often results in nodules of inflammatory cells that eccentrically surround the arteries (fig. a) . the cellular composition of these nodules is predominantly neutrophils, but it can also consist of lymphocytes, plasma cells, or macrophages (snyder et al., ) . fibrinous thrombosis of the affected arteries is also seen (fig. b) . a subclinical vasculitis has also been diagnosed in beagles postmortem; it is not known whether this subclinical condition is a different disorder or part of a jps continuum. this subclinical vasculitis often affects the coronary arteries (with or without other sites). pathogenesis. the initiating factors for jps are unknown. it was once presumed to be a reaction to test compounds by laboratory beagles, but this may have been coincident to the fact that the beagle is the breed most often affected with jps. immune mediation of jps is strongly suspected, because the clinical signs have a cyclical nature and respond to treatment with corticosteroids, and the affected dogs have elevated a -globulin fractions and abnormal immunologic responses. there may be hereditary predisposition, given that pedigree analysis of some affected dogs has indicated that the offspring of certain sires are more likely to be affected, and breeding of two affected dogs resuited in / affected pups (scott-moncrieff et al., ) . diagnosis and differential diagnosis. differential diagnoses include encephalitis, meningitis, injury or degeneration of the cervical vertebrae or disks, and arthritis. in the research facility, the disorder may be readily confused with complications secondary to the experimental procedure, or with postsurgical pain. beagles with jps that were in an orthopedic research study were evaluated for postsurgical complications and skeletal abnormalities prior to the postmortem diagnosis of systemic vasculitis (authors' personal experience). are known at this time. no prevention and control measures brane (third eyelid). this is not considered a congenital anomaly, but there is breed disposition for this condition, including beagles. a specific etiology is not known. clinical signs. the glandular tissue of the nictitating membrane protrudes beyond the membrane's edge and appears as a reddish mass in the ventromedial aspect of the orbit (fig. ) . excessive tearing to mucoid discharge can result, and severe cases can be associated with corneal erosion. treatment. clinical signs can be abated by administration of corticosteroids. prednisone administered orally at . mg/kg, q hr, was associated with rapid relief of clinical symptoms. maintenance of treatment at an alternate-day regimen of . - . mg/kg was shown to relieve symptoms for several months. however, withdrawal of corticosteroid therapy led to the return of clinical illness within weeks. pathologic findings. typically the glandular tissue is hyperplastic, possibly with inflammation. rarely is the tissue neoplastic. pathogenesis. prolapse of the gland may be a result of a congenital weakness of the connective tissue band between the gland and the cartilage of the third eyelid (helper, ) . research complications. because of the potentially severe clinical signs and the need for immunosuppressive treatment, jps is often incompatible with use of the animal as a research subject. it is unknown whether subclinical necrotizing vasculitis causes sufficient aberrations to measurably alter immunologic responses. etiology. "cherry eye" is a commonly used slang term for hyperplasia and/or prolapse of the gland of the nictitating mem-prevention. hyperplasia of the third eyelid cannot be prevented, but dogs that develop this condition unilaterally should have the other eye evaluated for potential glandular prolapse. preventative surgical measures might be warranted. treatment. corticosteroid treatment (topical or systemic) can be used to try to reduce the glandular swelling. however, surgical reduction or excision of the affected gland is typically required to resolve the condition. in the reduction procedure, the prolapsed gland is sutured to fibrous tissue deep to the fornix of the conjunctiva (helper, ). if reduction is not possible (as with deformed nictitating cartilage) or is unsuccessful, removal of the gland can be performed. such excision is fairly straightforward and can be done without removal of the nictitating membrane itself. the gland of the third eyelid is important in tear production; although the rest of the lacrimal glands should be sufficient for adequate tear production, keratoconjunctivitis sicca is a possible consequence after removal of the gland of the nictitating membrane. research complications. in most cases, research complications would be minimal, especially if treated adequately. either the presence of the hyperplastic gland, or its removal, might compromise ophthalmologic studies. etiology. interdigital cysts are chronic inflammatory lesions (not true cysts) that develop in the webbing between the toes (fig. ). the cause for most interdigital cysts is usually not identified unless a foreign body is present. bacteria may be isolated from the site, but the lesions may also be sterile (hence the synonym "sterile pyogranuloma complex"). clinical signs. dogs with interdigital cysts are usually lame on the affected foot, with licking and chewing at the interdigital space. exudation may be noticed at the site of the lesion. the lesion appears as a cutaneous ulcer, usually beneath matted hair, with possible development of sinus tracts and purulent exudate. epizootiology and transmission. interdigital cysts are common in a variety of canine breeds, including german shepherds. beagles have been affected in the research setting. interdigital cysts usually occur in the third and fourth interdigital spaces (bellah, ) . pathologic findings. histopathologically, interdigital cysts are sites of chronic inflammation, typically described as pyogranulomatous. pathogenesis. initial development of the cysts is unknown, except for those cases in which a foreign body can be identified. diagnosis and differential diagnosis. bacterial culture swabs and radiographs should be taken of the cysts to rule out bacterial infection, and radiopaque foreign bodies or bony lesions, respectively. a biopsy should be taken if neoplasia is suspected. treatment. if a foreign body is associated with the lesion, then removal is the first order of treatment. if biopsy of the site provides a diagnosis of sterile pyogranuloma complex, then systemic corticosteroid therapy (e.g., prednisolone at mg/kg ql h) can be initiated and then tapered once the lesion heals. interdigital cysts that are refractory to medical therapy require fig. . interdigital cyst between the third and fourth digits of the forelimb of a research beagle. surgical removal. excision includes removal of the lesion and the interdigital web, and a two-layer closure of the adjacent skin and soft tissues is recommended (bellah, ) . the foot should be put in a padded bandage and a tape hobble placed around the toes to reduce tension when the foot is weightbearing. the prognosis for idiopathic interdigital cysts is guarded, because the cysts tend to recur (bellah, ) . research complications from the cysts are minimal, unless the dogs need to be weight-bearing for biomechanic or orthopedic studies. treatment with systemic steroids could be contraindicated with some experimental designs. post-therapy antibody titers in dogs with ehrlichiosis: follow-up study on patients treated primarily with tetracycline and/or doxycycline dog thyroiditis: occurrence and similarity to hashimoto's struma surgical management of specific skin disorders bordetella and mycoplasma infections in dogs and cats associations between lymphocytic thyroiditis, hypothyroidism, and thyroid neoplasia in beagles diagnostic exercise: peracute death in a research dog saunders manual of small animal practice neurologic manifestations associated with hypothyroidism in four dogs neoplasms of the skin and subcutaneous tissues in dogs and cats neoplasia of the skin and mammary glands of dogs and cats platelet function, antithrombin-iii activity, and fibrinogen concentration in heartworm-infected and heartworm-negative dogs treated with thiacetarsamide pancreatic adenocarcinoma in two grey collie dogs with cyclic hematopoiesis ehrlichia platys infection in dogs the rickettsioses monoclonal gammopathy associated with naturally occurring canine ehrlichiosis variation in age at death of dogs of different sexes and breeds leptospira interrogans serovar grippotyphosa infection in dogs efficacy and dose titration study of mibolerone for treatment of pseudopregnancy in the bitch tropical canine pancytopenia: clinical, hematologic, and serologic response of dogs to ehrlichia canis infection, tetracycline therapy, and challenge inoculation comparison of campylobacter carriage rates in diarrheic and healthy pet animals. zentralbl advances in dietary management of obesity in dogs and cats effect of level and source of dietary fiber on food intake in the dog effect of amount and type of dietary fiber on food intake in energy-restricted dogs external parasites: identification and control tumors of the endocrine glands thomson's special veterinary pathology infectious diseases of the dog and cat nutritional support for dogs and cats with hepatobiliary disease specific amplification of ehrlichia platys dna from blood specimens by two step pcr detection of humoral antibody to the transmissible venereal tumor of the dog dirofilaria immitis: heartworm products contract rat trachea in vitro dogs: laboratory animal management management of septicemia in rhesus monkeys with chronic indwelling catheters client information series: canine demodicosis client information series: fleas and flea allergy dermatitis management of the burn wound chlorine dioxide sterilization of implanted right atrial catheters in rabbits current concepts in the management of helicobacter associated gastritis dirofilariasis in dogs and cats use of narcotic antagonists to modify stereotypic self-licking, self-chewing, and scratching behavior in dogs epidemiology of canine and feline tumors epizootiologic characteristics of canine and feline leukemia and lymphoma study of obesity in dogs visiting veterinary practices in the united kingdom miller's anatomy of the dog update on diagnosis of canine hypothyroidism helicobacter-associated gastric disease in ferrets, dogs, and cats the role of helicobacter species in newly recognized gastrointestinal tract disease of animals serologic diagnosis of infectious cyclic thrombocytopenia in dogs using an indirect fluorescent antibody test hemorrhagic streptococcal pneumonia in newly procured research dogs control of ticks platelet aggregation studies in dogs with acute ehrlichia platys infection health benefits of animal research: the dog as a research subject soft tissue sarcomas and mast cell tumors textbook of veterinary internal medicine infectious diseases of the dog and cat canine lyme borreliosis mast cell tumor destruction by deionized water mast cell tumour destruction in dogs by hypotonic solution transmission of ehrlichia canis to dogs by ticks (rhipicephalus sanguineus) textbook of veterinary internal medicine diseases of the liver and their treatment cyclic thrombocytopenia induced by a rickettsia-like agent in dogs shock evaluation of the sensitivity and specificity of diagnostic criteria for sepsis in dogs textbook of veterinary internal medicine canine thyroid neoplasms: epidemiologic features magrane's canine ophthalmology helicobacter-like organisms: histopathological examination of gastric biopsies from dogs and cats thiacetarsamide and its adverse effects infectious diseases of the dog and cat pediatrics: puppies and kittens canine viral diseases textbook of veterinary internal medicine antibodies to ehrlichia canis, ehrlichia platys, and spotted fever group rickettsia in louisiana dogs mastocytoma and gastroduodenal ulceration complications in the use of indwelling vascular catheters in laboratory animals deionised water as an adjunct to surgery for the treatment of canine cutaneous mast cell tumours helicobacter infection textbook of veterinary internal medicine textbook of veterinary internal medicine hygroma of the elbow in dogs thermal injuries dirofilaria immitis: do filarial cyclooxygenase products depress endothelium-dependent relaxation in the in vitro rat aorta? depression of endotheliumdependent relaxation by filarial parasite products three cases of canine leptospirosis in quebec cvt update: interpretation of endocrine diagnostic test results for adrenal and thyroid disease etiopathogenesis of canine hypothyroidism five-year longitudinal study on limited food consumption and development of osteoarthritis in coxofemoral joints of dogs role of bordetella bronchiseptica in infectious tracheobronchitis in dogs kirk's current veterinary therapy : small animal practice the fire of life kirk's current veterinary therapy : small animal practice coinfection with multiple tick-borne pathogens in a walker hound kennel in north carolina tarsal joint contracture in dogs with golden retriever muscular dystrophy clinical and hematological findings in canine ehrlichiosis early spay-neuter in the dog and cat textbook of veterinary internal medicine chronic catheterization of the intestines and portal vein for absorption experimentation in beagle dogs evaluation of weight loss protocols for dogs the brown dog tick rhipicephalus sanguineus and the dog as experimental hosts of ehrlicha canis the clinical chemistry of laboratory animals double-blinded crossover study with marine-oil supplementation containing high-dose eicosapentaenoic acid for the treatment of canine pruritic skin disease thomson's special veterinary pathology effects of four preparations of . % chlorhexidine diacetate on wound healing in dogs transmissible venereal tumors kirk's current veterinary therapy : small animal practice soft tissue sarcomas tumors of the mammary gland canine lymphoma and lymphoid leukemias kirk's current veterinary therapy : small animal practice effect of heartworm infection on in vitro contractile responses of canine pulmonary artery and vein tick paralysis in north america and australia saunders manual of small animal practice thyroid gland and arterial lesions of beagles with familial hypothyroidism and hypedipoproteinemia bacterial gastroenteritis in dogs and cats: more common than you think urea protects helicobacter (campylobacter) pylori from the bactericidal effect of acid characterization of a new isolate of ehrlichia platys using electron microscopy and polymerase chain reaction decreased pulmonary arterial endothelium-dependent relaxation in heartworm-infected dogs with pulmonary hypertension vaccination against canine bordetellosis: protection from contact challenge dermatologic aspects of tick bites and tick-transmitted diseases a chronic access port model for direct delivery of drugs into the intestine of conscious dogs clinical trial of dvm derm caps in the treatment of allergic diseases in dogs: a nonblinded study diagnosis of neoplasia tumors of the mammary gland dirofilaria immitis: heartworm infection alters pulmonary artery endothelial cell behavior survey of conjunctival flora in dogs with clinical signs of external eye disease hyperoxia exacerbates microvascular injury following acid aspiration nutrient requirements of dogs surgical closure of elbow hygroma in the dog tumors of the genital system practical laboratory methods for the diagnosis of dermatologic diseases walker's mammals of the world tumors of the endocrine system beta hemolytic streptococcus isolated from the canine vagina comparison of three skin preparation techniques in the dog comparison of three skin preparation techniques in the dog. part : clinical trial in dogs clinical behavioral medicine for small animals hypothyroidism in dogs: cases ( - ) plasma von willebrand factor antigen concentration in dogs with hypothyroidism plasma von willebrand factor antigen concentration and bleeding time in dogs with experimental hypothyroidism canine cutaneous mast cell tumor: morphologic grading and survival time in dogs joint diseases of dogs and cats target imbalance: disparity of borrelia burgdorferi genetic material in synovial fluid from lyme arthritis patients textbook of veterinary internal medicine tumors of the skin and soft tissue thomson's special veterinary pathology canine leptospirosis: a retrospective study of cases dogs and cats as laboratory animals effects of chlorhexidine diacetate and povidoneiodine on wound healing in dogs epidemiology of thyroid diseases of dogs and cats factors influencing canine mammary cancer development and postsurgical survival muller and kirk's small animal dermatology systemic necrotizing vasculitis in nine young beagles thomson's special veterinary pathology textbook of veterinary internal medicine canine infectious tracheobronchitis (kennel cough complex) saunders manual of small animal practice serum protein alterations in canine erhlichiosis bacterial factors and immune pathogenesis in helicobacter pylori evaluation of rhipicephalus sanguineus as a potential biologic vector of ehrlichia platys role of the eastern chipmunk (tamias striatus) in the epizootiology of lyme borreliosis in northwestern illinois evaluation of risk factors for degenerative joint disease associated with hip dysplasia in dogs pathologic features of naturally occurring juvenile polyarteritis in beagle dogs textbook of veterinary internal medicine clinical manifestations, pathogenesis, and effect of antibiotic treatment on lyme borreliosis in dogs streptococcus zooepidemicus as the cause of septicemia in racing greyhounds trauma to the skin and subcutaneous tissues of dogs and cats chronic problem wounds of dog limbs portosystemic shunts textbook of veterinary internal medicine lumbosacral stenosis in dogs experimental respiratory disease in dogs due to bordetella bronchiseptica dirofilaria immitis: depression of endothelium-dependent relaxation of canine femoral artery seen in vivo does not persist in vitro thyroiditis in a group of laboratory dogs: a study of beagles of agriculture, animal and plant health inspection service thomson's special veterinary pathology a retrospective study of cases of naturally occurring canine ehrlichiosis role of canine parainfluenza virus and bortedella bronchiseptica in kennel cough management of superficial skin wounds serum concentrations of thyroxine and , , '-triiodothyronine before and after intravenous or intramuscular thyrotropin administration in dogs use of ultrasound in the measurement of subcutaneous fat and prediction of total body fat in dogs ehrlichia platys in a michigan dog ehrlichial diseases of dogs canine ehrlichiosis. miss albert, r. e., benjamin, s. a., and shukla, r. ( ). life span and cancer mortality in the beagle dog and human. key: cord- -iuu yes authors: mainous, arch g.; hueston, william j. title: upper respiratory infections and acute bronchitis date: - - journal: management of antimicrobials in infectious diseases doi: . / - - - - _ sha: doc_id: cord_uid: iuu yes upper respiratory infections include the following: uncomplicated upper respiratory infections also known as the “common cold,” acute otitis media, pharyngitis/tonsillitis, and acute sinusitis. these conditions, along with acute bronchitis, are very common illnesses that are commonly seen in outpatient settings and are widely treated with antibiotics. in fact, these conditions are the primary indications for outpatient antibiotic prescriptions. these conditions tend to have overlapping clinical characteristics yet evidence regarding the utility of antimicrobial treatments varies across conditions. upper respiratory infections include the following: uncomplicated upper respiratory infections also known as the "common cold," acute otitis media, pharyngitis/tonsillitis, and acute sinusitis. these conditions, along with acute bronchitis, are very common illnesses that are commonly seen in outpatient settings and are widely treated with antibiotics. in fact, these conditions are the primary indications for outpatient antibiotic prescriptions. these conditions tend to have overlapping clinical characteristics yet evidence regarding the utility of antimicrobial treatments varies across conditions. uncomplicated upper respiratory infections (uris) are characterized by rhinorrhea, nasal congestion, sneezing, sore or "scratchy" throat, and cough [ ] . the incubation period varies between and h. while a low-grade fever in some cases is present, in adults, temperature elevation is rare. early symptoms may be minimal and limited to malaise and nasal symptoms. the nasal discharge is initially clear and watery. there is a subsequent transition period where the nasal discharge becomes viscous, opaque, and discolored (white, yellow, green) [ ] . the color of the secretions is not predictive of a bacterial infection. the clinical presentation is similar in both adults and children. the episode tends to be self-limited. the median duration of a cold is week, with most patients improving by the th day; however, lingering symptoms may last up to weeks. uris, or the "common cold," are exactly as the name implies -common. uris are consistently one of the five most common diagnoses in ambulatory physician office visits [ , ] . adults have two to four uris annually, and children in day care have as many as six or seven [ , ] . the significant costs of uris can be conceptualized as both direct and indirect costs. the direct costs of uris include the costs associated with the substantial number of office visits. uris account for more than million physician office visits a year [ ] . in addition, microbiologic and laboratory diagnostic tests are sometimes performed but are of dubious clinical value and, therefore, contribute unnecessarily to the cost of uris [ ] . the total economic impact of non-influenza-related uris has been estimated to approach $ billion annually (direct costs, $ billion per year; and indirect costs, $ . billion per year) in the united states [ ] . indirect costs for uris include productivity losses related to lost workdays for adults who are sick as well as adults who have to deal with sick children. other indirect costs that are many times overlooked are the impact of uris on missed opportunities to immunize young children. although the interpretation of guidelines by the american academy of pediatrics and the advisory committee on immunization practices, particularly for fever and moderate illness, rests with the clinician [ , ] , a large proportion of children are not immunized on schedule due to visits for uris [ ] . this finding also suggests additional visits for immunizations thereby requiring additional direct costs and indirect costs inherent in taking children to the physician's office. the mechanisms of transmission suggest that uris can be spread through contact with inanimate surfaces [ ] and hand-to-hand contact [ ] . uris have a seasonal variation with an increased prevalence in the united states between september and march. it is unclear why this variation exists, although it may be related to increased crowding of indoor populations in the colder months. temperature is not the key to seasonal variation without the presence of a pathogen. evidence from antarctica showed that spacious well-ventilated rooms reduced transmission of uris as compared to crowded poorly ventilated rooms regardless of temperature [ ] . viruses have been shown to be the major pathogens in uris [ ] . one study established viral etiology in % of uris [ ] . rhinoviruses were found in % of the patients by viral culture or pcr assay. coronaviruses were the second most common group of causative agents, followed by influenza a or b virus. identified bacterial pathogens were chlamydia pneumoniae, haemophilus influenzae, streptococcus pneumoniae, and mycoplasma pneumoniae. none of the patients had beta-hemolytic group a streptococcus. in terms of bacterial pathogens, infections without evidence of a viral infection occurred in only . % of the cases. a variety of studies in the s showed a high rate of prescribing antibiotics for uris [ , ] . more recent data have indicated a drop in the prescribing of antibiotics; however, the use of antibiotics is still far from optimal [ ] . controlled trials of antimicrobial treatment of uris have consistently demonstrated no benefit [ , ] . in eight trials of antimicrobial treatment of uris, six found no difference between the groups either in terms of improvement or in terms of complications. complications tend to be minimal and occur at a rate of - %. one trial found some slight benefit in decreasing the presence of purulent rhinitis [ ] . another found a decrease in rhinorrhea at day but no difference between the groups at day [ ] . similarly, an additional trial attempted to isolate "bacterial colds" for which antibiotics might be effective treatments [ ] . although there was some indication of patient improvement at day , the differences were gone by day . it is important to remember that the normal presentation of a uri is a week to days. few successful treatments have been identified. vitamin c, zinc gluconate, and echinacea have all shown mixed results [ , ] . antihistamines, with a few exceptions, have not been shown to be effective treatments [ ] . the most effective symptomatic treatments are over-the-counter decongestants [ ] . acute sinusitis has considerable overlap with uris in its constellation of signs and symptoms. one half to two thirds of patients with sinus symptoms seen in primary care are unlikely to have sinusitis [ ] . in patients who presented with a uri, % had radiographic evidence of maxillary sinusitis but had no symptoms of sinus infection [ ] . uris are often precursors of sinusitis, and, at some point, symptoms from each condition may overlap. sinus inflammation from a uri, without bacterial infection, is also common. in a series of children undergoing computerized tomography (ct) for non-sinus-related diagnoses, % had evidence sinus inflammation with no clinical signs of sinusitis and with complete resolution following their viral illness [ ] . acute sinusitis tends to start with a uri that leads to sinus ostial obstruction. the signs and symptoms that increase the likelihood that the patient has acute sinusitis are a "double sickening" phenomenon whereby the patient seems to improve following the uri and then deteriorates, exhibiting symptoms such as maxillary toothache, purulent nasal discharge, poor response to decongestants, and a history of discolored nasal discharge [ , ] . other authors have stressed that the symptoms need to persist longer than week to distinguish sinusitis from a uri [ ] . it should be pointed out that the commonly used sign of facial pain or swelling has low sensitivity for acute sinusitis [ ] . since sinusitis is most often a complication of upper respiratory viral infections, it follows the same seasonal pattern as colds. this pattern produces a winter peak with more cases seen than those exposed to upper respiratory tract infections. in children seen in a large health system, sinusitis is frequently found as a comorbidity with otitis media. nearly half of all children with sinusitis also had otitis media [ ] . children are also more likely to have posterior ethmoidal and sphenoid inflammation, while adults have mainly maxillary and anterior ethmoidal sinusitis [ ] . some medical conditions may increase the risk for sinusitis; these include cystic fibrosis, asthma, immunosuppression, and allergic rhinitis [ ] . cigarette smoking may also increase the risk of bacterial sinusitis during a cold because of reduced mucociliary clearance. sinus inflammation can be caused by viral, fungal, and bacterial infections as well as allergies. the majority of acute sinusitis is caused by viral infection. as indicated above, many cases of the common cold have concomitant sinus inflammation. the inflammation associated with viral infections clears without additional therapy. bacterial superinfection of uris is rare and occurs in only . - % of colds. studies examining the treatment of sinusitis confirm that response rates to antibiotics are either small [ ] . when sinusitis is confirmed by a ct scan, response rates to antibiotics are improved [ ] . cultures of material obtained from patients with sinusitis show that the most prevalent organisms are strep. pneumoniae and, especially in smokers, h. influenzae. these two organisms are present in % of cases of bacterial acute sinusitis [ ] . when antibiotics are used for the treatment of bacterial sinusitis, the selection of antibiotics should include sufficient coverage of these two organisms. fungal sinusitis are very rare and usually occur in immunosuppressed individuals or those with diabetes mellitus [ ] . antibiotics are commonly prescribed for adult patients who present with complaints that are consistent with acute sinusitis. the effectiveness of antibiotics is unclear. three recent placebo-controlled, double-blind, randomized trials in general practice settings have yielded mixed results [ , , ] . two of these trials showed no beneficial effect of antibiotics [ , ] ; the third trial, however, demonstrated a significant effect of penicillin and amoxicillin [ ] . the trial showing an effect used more stringent enrollment criteria than the other two; the criteria in the trial are more consistent with those used in daily practice by primary care physicians. these data suggest that patients with more severe signs and symptoms may benefit from an antibiotic. if an antibiotic is to be used, some evidence with trimethoprim/sulfamethoxazole suggests that short-duration treatment (e.g., days) is as effective as longer treatment [ ] . further, narrow-spectrum agents seem as effective as broad-spectrum agents [ ] . in patients with severe signs and symptoms, antibiotics have some utility in treating acute sinusitis. if antibiotics are to be used, then short-course therapy with narrow-spectrum agents is recommended. the key to the judicious use of antibiotics is to first make an accurate diagnosis of sinusitis rather than overtreating uris. the evaluation and management of otitis media has been subject to a wide variance in approaches. the variation in management of otitis media is typified in an examination of the management of otitis media in nine countries in the mid- s [ ] . in this study, antibiotics were used over a wide range ( - %) of episodes of otitis media with similar variation in the types of antibiotics used and duration of therapy. to help bring some consensus to the process, the american academy of pediatrics issued a guideline for the evaluation and treatment of otitis media in [ ] . while the guideline suffers from a lack of definitive evidence in several areas of care, the recommendations are an effective tool for bringing some clarity to an issue that has suffered from a wide variation in management strategies. the aap guideline recommends that the diagnosis of otitis media requires three essential components: an acute onset of illness, presence of a middle ear effusion, and signs and symptoms of middle ear inflammation. middle ear effusion is evident in children with bulging of the tympanic membrane, reduced or absent mobility of the membrane with pneumatic otoscopy, an air-fluid level behind the membrane, and pain in the effected side. inflammatory signs noted in the report include erythema of the tympanic membrane along with pain on that side. in considering all these factors, the combination of reduced mobility, erythema, and a bulging tympanic membrane is the best predictor of otitis media. the most essential step in managing otitis media is assuring that the diagnosis is correct. otitis media may be overdiagnosed, especially in younger children, which complicates the evaluation of treatment effectiveness. studies show that a physician's certainty about the diagnosis of otitis media is dependent on the patient's age. in a multinational study, it was found that physicians were certain of the diagnosis in only % of children under the age of [ ] . this increased to % in those between year and months of age and up to % in those over months of age. historically, acute otitis media has been one of the most common pediatric conditions seen in primary care. however, since the introduction of vaccines against common respiratory pathogens, there is evidence that the frequency of this problem has decreased considerably. in the netherlands, visits to general practitioners for otitis media with effusion in children under the age of fell by % between and [ ] . a similar decrease in visits for acute otitis in children has been reported in a large health system in the united states [ ] , with a smaller reduction in visits noted in the emergency department setting [ ] . the introduction of h. influenzae b vaccine in the s, followed by universal childhood immunization with conjugated strep. pneumoniae, may be responsible for the reduction in otitis media cases encountered. since otitis media is a complication of an upper respiratory infection, it has a peak incidence in the winter when colds are most likely to occur. unlike sinusitis, which is more likely to affect adults, otitis media is predominantly a disease of younger children with a peak incidence between and months of age [ ] . otitis media occurs with varying frequency in children. in a large population study, it was found that during the first years of life about a third of children never had otitis media and another third had one or two episodes, while the remaining third had three or more episodes. otitis media occurs more often in males, children in lower socioeconomic groups, and in certain ethnic groups such as native americans. because of differences in the mechanics of the posterior pharynx and eustachian tube, children born with craniofacial congenital abnormalities such as cleft lip/palate and those with trisomy also are more likely to have otitis media as a complication of a cold. otitis media arises from eustachian tube dysfunction that accompanies uris or allergic rhinitis. inflammation of the eustachian tube and middle ear results in tube occlusion and fluid accumulation in the middle ear space. eustachian tube obstruction is more common in younger children because of less cartilage support of the tube making collapse more likely. the eustachian tube obstruction not only causes entrapment of existing fluid but also produces a negative pressure in the middle ear that results in additional fluid accumulation that characterizes serous otitis media. contamination of this fluid with bacteria results in acute suppurative otitis media. suppurative otitis media is most often caused by the same organisms that result in sinusitis. studies of middle ear aspirates suggest that strep. pneumonia is the most common bacterial cause of otitis media and is found in about % of effusions. h. influenzae accounts for approximately another %. b. catarrhalis and staphylococcus aureus each make up fewer than % of cases. in neonates, gram-negative species also should be considered as potential etiologic agents. otitis media also may result from noninfectious obstruction of the eustachian tube. allergic rhinitis, as noted above, is one such mechanism. other causes include enlargement of the adenoids and posterior pharyngeal tumors. treatment recommendations from the aap/aafp guidelines for the management of acute otitis media suggest that observation rather the initial use of antibiotics is appropriate depending on the child's overall health, age, severity of illness, and likelihood that they can follow-up if necessary. for healthy children over the age of , antibiotics are recommended only if the child is severely ill; if the child is mildly ill or if the diagnosis is uncertain, then observation is acceptable. for children younger than this, antibiotics are recommended for a certain diagnosis of otitis media and for those under age months where the diagnosis is uncertain. antibiotics are not recommended for use in healthy children between months and years who have an uncertain diagnosis (aap subcommittee). if patients who are observed fail to improve in - h, then antibiotic therapy is recommended. based on the aap/aafp guidelines, routine observation or "wait and see protocol (wasp)" as an alternative to universal antibiotic use has been evaluated in emergency room setting. a randomized trial of the wasp approach compared with routine antibiotics showed that antibiotic use was reduced from to % with no differences in prolonged fever, ear pain, or unscheduled subsequent visit for the ear infection [ ] . despite evidence that the wasp or observation period is effective, primary care physicians have been slow to adopt this in practice [ ] . when antibiotics are selected for the management of acute suppurative otitis media, selection of an agent should provide coverage for the two most common organisms, the aap/aafp recommends initial treatment with amoxicillin at a dose of - mg/kg per day. second, the duration of antibiotic treatment is unclear. in a meta-analysis of trials that compared short-duration antibiotic therapy with the traditional day course, no benefit was found of using longer courses of treatment; however, methodologic problems may complicate the interpretation of these results [ ] . in their guidelines, the aap/aafp recommends that a - day course of antibiotics should be sufficient for treatment. in addition to short-course therapy, a single intramuscular dose therapy of ceftriaxone has been shown to be equally beneficial to longer courses of amoxicillin [ ] , cefaclor [ ] , or trimethoprim-sulfamethoxazole [ ] for the treatment of acute suppurative otitis media. where antibiotic resistance to s. pneumonia is high or where patient compliance is an issue, ceftriaxone may be a viable alternative. in addition, some studies have evaluated the use of a single dose of azithromycin ( mg/kg) for treatment of uncomplicated otitis media. in a review of these studies, the overall success rate was % [ ] . macrolide resistance to s. pneumoniae was the largest impediment to success. based on this, it was suggested that single-dose azithromycin may be an alternative in areas with resistance to s. pneumoniae is uncommon. the primary concern in the treatment of otitis media is a primary treatment failure (i.e., persistent illness or an early recurrence of disease following initial therapy of a new otitis episode) [ ] . a meta-analysis of randomized trials supports initial antibiotic use demonstrated no significant differences in failure rates when comparing "standard" or first-line (penicillin, amox/ampicillin, erythromycin, and sulfamethoxazole) and "extended-spectrum" or second-line antibiotics or with duration of therapy. the only factor that appears to be consistently linked to a higher likelihood of a primary treatment failure is a child's age [ , ] , with children younger than years of age having treatment failures in - . % of cases. for older children, treatment failures occur in - % of episodes [ , ] . also of concern is how to manage a new case of otitis media when a previous treatment failure has occurred. in a study that examined failure rates in new infections for children who had a previous treatment failure, there was no benefit of starting therapy with an extended-spectrum agent compared to "first-line" drugs. thus it appears that in a case of previous treatment failure, new cases should be managed with narrow-spectrum agents such as amoxicillin or tmp-smx [ ] . the use of second-line antibiotics when a first-line agent will suffice creates two problems. first, in most cases the use of broad-spectrum drugs adds significant expense to therapy. others have reported that use of second-line agents compared to amoxicillin or smx-tmp adds % to the overall cost of the episode [ ] . since the results of this study show comparable failure rates for first-and second-line antibiotics, there appears to be no justification for this additional cost. second, the injudicious use of broad-spectrum antibiotics may increase the potential for future development of antibiotic resistance. the overuse of antibiotics has been proposed as one reason for the observed growth in antibiotic resistance reported in common childhood organisms such as s. pneumoniae. otitis media is a condition in which antibiotics are frequently prescribed for children and where broad-spectrum antibiotics may be used unnecessarily. limiting the use of broadspectrum drugs to situations in which they are beneficial (i.e., managing the resistant case of otitis) may help reduce further development of drug resistance in children. sore throat is a common reason that patients consult with a physician. most of these are viral infections related to upper respiratory infections, but about - % are secondary to infection with group a beta-hemolytic streptococcus. the primary role of the physician is to differentiate streptococcal pharyngitis from viral illnesses. since most patients with sore throats probably do not visit their doctor, it is difficult to state with any certainty how often sore throats occur in healthy populations. however, pharyngitis is one of the most common diagnoses for physician office visits. estimates from suggest that more than million visits in the united states each year are for pharyngitis [ ] . frequently antibiotics are prescribed for these conditions without evidence of a bacterial etiology. both viral and group a streptococcal pharyngitis have peak occurrences in the winter and early spring. streptococcal infection, in particular, can be recognized in epidemic patterns frequently affecting groups that spend considerable time together in close quarters such as day cares, schools, and places of employment. strep throat also is related to patient age. while infection in the very young (< year old) is uncommon, the peak occurrence for strep throat is between and years of age with diminished risk over the age of . the most common causes of pharyngitis are respiratory viruses. adenovirus and the rhinoviruses account for about % of cases of sore throat in children that are seen by physician [ , ] . coxackievirus, herpesvirus, and epstein-barr virus can cause tonsillitis but are less common that adenovirus [ ] . adenovirus, coxackievirus, and epstein-barr virus can cause exudative pharyngitis that can mimic the appearance of streptococcal infection. while exudative tonsillitis is thought to be a hallmark of group a streptococcal infection, this sign is actually present more often from adenovirus than streptococcus. it is important to identify group a streptococcal infections because trials of antibiotics in undifferentiated sore throat populations show little benefit [ ] . group a beta-hemolytic streptococcus can cause an acute tonsillopharyngitis and may colonize the oropharynx without symptoms. the asymptomatic carrier rate of group a strep ranges from about to % of healthy children, a rate that nearly matches the true infection rate [ , ] . this means that in testing for group a streptococcus, positive tests are just as likely to occur from carriers of group a strep who have a concomitant virus as those actually infected with the organism. in contract to group a streptococcal tonsillopharyngitis, treatment of the carrier state is not necessary and does not reduce symptoms or reduce complications [ ] . the reasons for antibiotic treatment of beta-hemolytic group a streptococcal pharyngitis are to alleviate symptoms, reduce the spread of disease, and reduce the risk of suppurative and nonsuppurative complications. although some authors have suggested that antibiotics are not justified to reduce the risk of rheumatic fever, a complication of beta-hemolytic group a streptococcal pharyngitis, the american heart association in still recommends antibiotic treatment [ , ] . differentiating group a streptococcal pharyngitis from viral disease is the most vexing problem in the management of acute sore throat. the clinical impression of the treating physician has been shown to be fairly inaccurate at making this differentiation [ ] [ ] [ ] . a clinical prediction rule for presence of strep throat that has some utility uses the presence of tonsillar exudate, pharyngeal exudate, or exposure to strep throat infection and the absence of tender anterior cervical nodes, tonsillar enlargement, or exudate. no individual element of history-taking or physical examination is accurate enough by itself to rule in or rule out strep throat [ ] . another dilemma in identifying group a strep in patients with pharyngitis is the sensitivity of rapid group a antibody kits compared to a throat culture. many studies have shown that a rapid test is less sensitive than the culture for identifying the presence of group a strep. the rapid tests have a high degree of specificity, but their sensitivity in clinical practice can be unacceptably low. sensitivities for the rapid test compared to a standard blood agar culture vary considerably but are generally in the range of - %. studies also have demonstrated that in circumstances when the colony counts are low, rapid tests are more likely to miss the presence of group a streptococcus. however, when the seroconversion of aso titers is used as the gold standard for infection, rapid tests perform very well [ ] . it is likely that rapid tests miss patients who have a small number of organisms and who are likely to be colonized instead of infected. thus, rapid testing may be more specific in identifying patients with actual strep-related disease than cultures, which also identify those who are likely to be carriers. this comparison suggests that follow-up throat cultures are not necessary and may actually confuse treatment decisions. rapid strep testing without culture also has been shown to be the most cost-effective approach to managing acute pharyngitis [ ] . as indicated above, reports regarding the role of chlamydia and mycoplasma indicate that these two organisms also may be associated with acute pharyngitis. however, there have been few treatment trials that demonstrate any benefit of treating non-group a streptococcus with antibiotics that would treat either of these organisms. in a study using erythromycin to treat non-group a strep pharyngitis [ ] , patients who received placebo had the same speed of symptom resolution as those treated with active antibiotics. once group a streptococcus has been implicated in the infection, the choice of antibiotic is controversial. with only scant evidence that treatment reduces the symptomatic period and a low risk of complications from untreated group a streptococcal pharyngitis, some investigators suggest that antibiotic treatment carries more risks than not treating and encourages future health seeking and antibiotic expectations for future sore throats [ ] . however, formal decision analyses suggest that in cases of moderate probability of strep throat ( - %) with symptom duration of days or less, rapid strep testing and treatment is beneficial [ ] . selection of an appropriate antibiotic and duration of therapy are important considerations in treating strep pharyngitis. penicillin v resistance in group a strep as well as erythromycin resistance has led to investigations of other drugs for management of strep throat. since streptococcal pharyngitis is a self-limited problem even without antibiotic therapy, much of this resistance has been based on positive throat cultures following the termination of treatment. this may be misleading since colonized patients may continue to harbor streptococcus even after therapy. when drug failure rates are examined with penicillin, cultures remain positive in - % of treated patients [ , ] . however, single-dose therapy with amoxicillin at mg/kg/day for days appears to be very successful resulting in excellent clinical responses and low rates ( - %) of posttreatment carrier rates [ , ] . treatment with other agents such as azithromycin and clarithromycin produces no better results than amoxicillin or penicillin v [ ] [ ] [ ] ; however, these treatments amount to a much greater expense. attempts at "short-course" therapy have been studied with azithromycin [ ] . both short-course treatment with azithromycin and days of cefaclor have exactly the same clinical cure rates ( %) by day of therapy. however, patients treated with cefaclor were less likely to become recolonized with group a strep over the next days than those treated with the short course of azithromycin ( % vs. %). since the significance of rapid recolonization is still unclear, shortcourse therapy with azithromycin or other antibiotics still requires additional investigation. while the carrier rate does not require treatment [ ] , some clinicians attempt to eradicate those colonized by group a strep to prevent spread to other family members and close contacts. a regimen of intramuscular penicillin v plus oral rifampin has been shown to reverse the carrier status in % of patients treated [ ] . there have been no studies performed more recently that have explored whether this regimen remains effective with increased group a strep resistance to penicillin. despite evidence that chlamydia and mycoplasma may be associated with acute pharyngitis, there have been no studies that have shown a benefit from treatment of patients with non-group a streptococcal pharyngitis with antibiotics: studies with penicillin [ ] , which would not be expected to cover these agents, and macrolides [ ] , which would have not shown any significant improvement over placebo. until specific tests that can rapidly identify these organisms are developed which would allow for targeted treatment and studies can demonstrate that treatment reduces symptoms and complications, indiscriminate antibiotic therapy for non-group a strep pharyngitis should be avoided. acute bronchitis is an inflammatory condition of the tracheobronchial tree usually associated with a generalized respiratory infection. cough begins early in the course of the illness and is the most prominent feature of the condition. an initially dry cough may later result in sputum production which characteristically changes from clear to discolored in the later stages of the illness. the cough may last for a significant time. although the duration of the condition is variable, one study showed that % of patients had a cough for more than weeks and % had a cough for more than weeks [ ] . patients with acute bronchitis usually have a viral respiratory infection with transient inflammatory changes that produce sputum and symptoms of airway obstruction. acute bronchitis is essentially a diagnosis of exclusion. the history should include information on cigarette use, exposure to environmental toxins, as well as medication history (e.g., use of angiotensin-converting enzyme inhibitors). the chronicity of the cough should be established to distinguish acute bronchitis from chronic bronchitis since they have different treatments. both acute bronchitis and pneumonia can present with fever, constitutional symptoms, and a productive cough. while patients with pneumonia often have rales, this finding is neither sensitive nor specific for the illness. when pneumonia is suspected on the basis of a presence of a high fever, constitutional symptoms, severe dyspnea, and certain physical findings or risk factors, a chest radiograph should be obtained to confirm the diagnosis. asthma and allergic bronchospastic disorders can mimic the productive cough of acute bronchitis. when obstructive symptoms are not obvious, mild asthma may be diagnosed as acute bronchitis. further, since respiratory infections can trigger bronchospasm in asthma, patients with asthma that occurs only in the presence of respiratory infections resemble patients with acute bronchitis. asthma should be considered in patients with repetitive episodes of acute bronchitis. patients who repeatedly present with cough and wheezing can be given full spirometric testing with bronchodilation or provocative testing with a methacholine challenge test to help differentiate asthma from recurrent bronchitis. finally, nonpulmonary causes of cough should enter the differential diagnosis. in older patients, congestive heart failure may cause cough, shortness of breath, and wheezing. reflux esophagitis with chronic aspiration can cause bronchial inflammation with cough and wheezing. bronchogenic tumors may produce a cough and obstructive symptoms. acute bronchitis in the otherwise healthy adult is one of the most common medical problems encountered in primary care [ , ] . the prevalence of acute bronchitis peaks in the winter and is much less common in the summer. viral infection is considered the primary cause of most episodes of acute bronchitis. a wide variety of viruses have been shown as causes of acute bronchitis including influenza, rhinovirus, adenovirus, coronavirus, parainfluenza, and respiratory syncytial virus [ ] . nonviral pathogens including mycoplasma pneumoniae and c. pneumoniae (twar) have also been identified as causes [ , ] . the etiologic role of bacteria like h. influenzae and s. pneumoniae in acute bronchitis is unclear since these bacteria are common upper respiratory tract flora. sputum cultures for acute bronchitis are therefore difficult to evaluate since it is unclear whether the sputum has been contaminated by pathogens in the nasopharynx. usually, laboratory and imaging tests are not needed in the diagnosis of acute bronchitis. however, a new test under consideration might be helpful in differentiating viral acute bronchitis from more serious bacterial infections such as pneumonia. by measuring procalcitonin, a precursor to the hormone calcitonin, christ-crain and colleagues have been able to distinguish patients at high risk for bacterial infections (those with higher procalcitonin levels) from those with low risk for bacterial infection. evaluation of this method in the emergency department has led to reductions in antibiotic prescribing without any differences in clinical outcomes for patients presenting with acute cough syndromes [ ] . while a point-of-care version of the test for procalcitonin has been developed that can be done quickly in a physician's office, the test is still expensive and has not been evaluated outside the emergency department. antibiotic treatment for acute bronchitis is quite common with evidence indicating that - % of adults visiting a doctor for acute bronchitis receiving an antibiotic [ , ] . clinical trials of the effectiveness of antibiotics in treating acute bronchitis have had mixed results. one reason for the lack of consensus is that in each of the nine trials, different antibiotics were used as well as different outcomes. in an effort to quantitatively review the data, two different meta-analyses were recently conducted [ , ] . in the fahey et al., meta-analysis resolution of cough was not affected by antibiotic treatment and neither was clinical improvement at reexamination. importantly, the side-effects of antibiotics were more common in the antibiotic groups compared to placebo. the smucny et al., meta-analysis concluded that antibiotics may be modestly effective for a minority of patients with acute bronchitis, although it is unclear which subgroups might benefit. the conclusion of both meta-analyses was that the benefits or antibiotics are marginal and are not useful for the general group of patients with acute bronchitis. recent data from clinical trials suggest that bronchodilators may provide effective symptomatic relief to patients with acute bronchitis [ , ] . treatment with bronchodilators demonstrated significant relief of symptoms including faster resolution of cough, as well as return to work. one study evaluated the effect of albuterol in a population of patients with undifferentiated cough and found no beneficial effect [ ] . since a variety of conditions present with cough, there may have been some misclassification in generalizing this to acute bronchitis. • upper respiratory infections and acute bronchitis are common illnesses that are account for a large proportion of total outpatient healthcare utilization as well as nearly % of prescribed outpatient antibiotics. • evidence does not support the use of antibiotics for the common cold, acute bronchitis, initial cases of otitis media with effusion, and non-group a streptococcal pharyngitis. these conditions are self-limited and currently are optimally treated with symptomatic medicines. • although the data are mixed regarding the utility of antibiotic treatment for acute sinusitis, otitis media, and group a streptococcal pharyngitis, antibiotics may have some benefit. short-course therapy with narrow-spectrum antibiotics appropriate for the likely pathogen is recommended. rhinovirus infections in an industrial population. ii. characteristics of illness and antibody response the common cold national ambulatory medical care survey: summary. vital health stat ( ) advance data from vital and health statistics clinical trial examining effectiveness of three cough syrups ineffectiveness of recombinant interferon-beta serine nasal drops for prophylaxis of natural colds national ambulatory medical care survey: summary microbiology and laboratory diagnosis of upper respiratory tract infections the economic burden of noninfluenza-related viral respiratory tract infection in the united states report of the committee of infectious diseases general recommendations on immunization: recommendations of the advisory committee on immunization practices the contribution of missed opportunities to childhood underimmunization in baltimore chemical disinfection to interrupt transfer of rhinovirus type from environmental surfaces to hands potential role of hands in the spread of respiratory viral infections: studies with human parainfluenza virus and rhinovirus rhinovirus infections in an isolated antarctic station. transmission of the viruses and susceptibility of the population viruses causing common respiratory infections in man viruses and bacteria in the etiology of the common cold antibiotics and upper respiratory infection: do some folks think there is a cure for the common cold? antibiotic prescribing for adults with colds, upper respiratory tract infections, and bronchitis by ambulatory care physicians declining antibiotic prescriptions for upper respiratory infections antibiotics and chemotherapeutic agents in the treatment of uncomplicated respiratory infections in children evaluation of orally administered antibiotics for treatment of upper respiratory infections in thai children amoxycillin and co-trimoxazole in presumed viral respiratory infections of childhood: placebo-controlled trial randomised controlled trial of antibiotics in patients with cough and purulent sputum effects of antibiotic treatment in the subset of common-cold patients who have bacteria in nasopharyngeal secretions vitamin c for preventing and treating the common cold non-antibiotic treatments for upper-respiratory tract infections (common cold) randomized controlled tiral of clemastine fumarate for treatment of experimental rhinovirus colds usual care and outcomes in patients with sinus complaints and normal results of sinus roentgenography correlation of clinical sinusitis signs and symptoms to imaging findings in pediatric patients use of symptoms, signs and blood tests to diagnose acute sinus infections in primary care: comparison with computed tomography does this patient have sinusitis? diagnosing acute sinusitis by history and physical examination introduction and definition of sinusitis prevalence of clinical sinusitis in young children followed up by primary care pediatricians prevalence of sinusitis signs on mri in a non-ent paediatric population a -year report on childhood sinusitis: clinical presentations, predisposing factors and possible means of prevention primary-case-based randomised placebo-controlled trial of antibiotic treatment in acute maxillary sinusitis randomised, double blind, placebo controlled trial of penicillin v and amoxycillin in treatment of acute sinus infection in adults diagnosis and management of sinusitis the end of antibiotic treatment in adults with acute sinusitis-like complaints in general practice? a placebo-controlled double-blind randomized doxycycline trial randomized controlled trial of vs days of trimethoprim/sulfamethoxazole for acute maxillary sinusitis antimicrobial treatment in acute maxillary sinusitis: a meta-analysis diagnosis and antibiotic treatment of acute otitis media: report from international primary care network diagnosis and management of acute otitis media trends in doctor consultations, antibiotic prescription and specialist referrals for otitis media in children trends in otitis media treatment and relapse national trends in emergency department antibiotic prescribing in children with acute otitis media otitis media in children: to treat or not to treat? wait-and-see prescription for the treatment of acute otitis media: a randomized controlled trial management of acute otitis media by primary care physicians: trends since the release of the treatment of acute otitis media with a shortened course of antibiotics single-dose intramuscular ceftriaxone for acute otitis media in children single-dose ceftiraxone versus days of cefaclor for otitis media comparison of ceftriaxone and trimethoprimsulfamethoxasole for acute otitis media single-dose azithromycin for the treatment of children with acute otitis media overall cost in the treatment of otitis media acute otitis media: who needs post treatment follow-up? follow-up visit after acute otitis media treatment of recurrent otitis media after a previous treatment failure: which antibiotics work best? streptococcal pharynfitis in the general population controlled studies of streptococcal pharyngitis in a pediatric population sore throat, tonsillitis, and adenoiditis open randomised trial of prescribing strategies in managing sore throat prevalence of chlamydia trachomatis and mycoplasma pneumonia in children with and without pharyngitis diagnosis of streptococcal pharyngitis: differentiation of active infection from the carrier state in the symptomatic child effect of antibiotic therapy on the clinical course of streptococcal pharyngitis protective effect of antibiotics against serious complications of common respiratory tract infections: retrospective cohort study with the uk general practice research database prevention of rheumatic fever and diagnosis and treatment of acute streptococcal pharyngitis towards a better diagnosis of throat infections (with group a beta-hemolytic stretococcus) in general practice a clinical score to reduce unnecessary antibiotic use in patient with sore throat a scoring system for predicting group a streptococcal throat infection the rational clinical examination. does this patient have strep throat does culture confirmation of high-sensitivity rapid streptococcal tests make sense? a medical decision analysis the effect of erythromycin on resolution of symptoms among adults with pharyngitis not caused by group a streptococcus reattendance and cmplications in a randomised trial of prescribing strategies for sore throat: the medicalising effect of prescribing antibiotics management of children with acute pharyngitis: a decision analysis once daily therapy for streptococcal pharyngitis with amoxicillin randomized, single-blinded comparative study of the efficacy of amoxicillin ( mg/kg/day) versus standard-dose penicillin v in the treatment of group a streptococcal pharyngitis in children comparison of clarithromycin suspension and amoxycillin syrup for the treatment of children with pharyngitis and/or tonsillitis azithromycin versus penicillin v in the treatment of paediatric patients with acute streptococcal pharyngitis/tonsillitis. paediatric azithromycin study group evaluation of the efficacy, safety and toleration of azithromycin vs. penicillin v in the treatment of acute streptococcal pharyngitis in children: results of a multicenter, open comparative study. the swiss tonsillopharyngitis study group azithromucin versus cefaclor in the treatment of pediatrci patient with acute group a beta-hemolytic streptococcal tonsillopharyngitis penicillin plus rifampin eradicates pharyngeal carriage of group a streptococci a randomized controlled trial of doxycycline in the treatment of acute bronchitis common colds and related diseases mycoplasma pneumoniae and adenovirus respiratory illnesses in military and university personnel chlamydia pneumoniae (twar): a common agent in acute bronchitis effect of procalcitonin-guided treatment on antibiotic use and outcome in lower respiratory tract infections: clusterrandomized, single-blinded intervention trial current management of acute bronchitis in ambulatory care: the use of antibiotics and bronchodilators are antibiotics effective treatment for q acute bronchitis? a meta-analysis quantitative systematic review of randomised controlled trials comparing antibiotic with placebo for acute cough in adults symptomatic effect of inhaled fenoterol in acute bronchitis: a placebo-controlled double-blind study albuterol delivered by metered-dose inhaler to treat acute bronchitis a randomized controlled trial of oral albuterol in acute cough key: cord- -l nlrv h authors: chauvenet, alienor; buckley, ralf; hague, leah; fleming, chris; brough, paula title: panel sampling in health research date: - - journal: lancet psychiatry doi: . /s - ( ) - sha: doc_id: cord_uid: l nlrv h nan carsten hjorthøj and colleagues question the extent to which the effects of cannabidiol as a pharmacological treatment for cannabis use disorder might be clinically meaningful. as they pointed out, and as discussed in our article, the phase a trial was not designed to estimate the magnitude of efficacy. however, phase a trials can be valuable when testing a novel indication with no previous evidence on what doses might be efficacious or safe. we found that cannabidiol mg and cannabidiol mg were more efficacious than placebo according to both primary endpoints (reduced urinary -nor- -carboxy-δ- tetrahydrocannabinol:creatinine ratio and increased days with abstinence from cannabis during treatment) based on a priori bayesian criteria. we did not make inferences about clinical relevance in our article and it would be premature to do so because our phase a trial was not intended to address this question. larger phase b or phase trials are needed to determine how efficacious and clinically meaningful the effects of cannabidiol are at the doses we identified in our trial. we used a -week treatment design, similar to the first randomised clinical trial of cannabidiol for the treatment of psychosis. more research is needed to test different dosing durations and formulations. three randomised clinical trials have investigated nabiximols (low dose cannabidiol and tetrahydrocannabinol). [ ] [ ] [ ] only one trial found a reduction in cannabis use compared with placebo, and none of the trials reported increases in sustained abstinence compared with placebo. hjorthøj and colleagues believe that a change in paradigm is needed in the treatment of cannabis use disorder, away from a focus on reduction in use and towards complete abstinence. their views contrast with expert consensus on clinical outcomes for cannabis use disorder trials, published in : the primary recommendation is that sustained abstinence from cannabis should not be considered the primary outcome for all cannabis use disorder clinical trials because it has multiple limitations. furthermore, given the absence of any recommended pharmacotherapies at present, a treatment that consistently reduces cannabis use would represent a major achievement towards decreasing the global burden of cannabis use disorders. we declare no competing interests. the lancet psychiatry, matthias pierce and colleagues , identify the importance of sampling in studying mental health effects of covid- . we found that a mental health survey using a com mercial panel (of approximately people) overrepresented mentally unhealthy respondents by approximately · times. this over representation occurred despite multiple measures to ensure representativeness: pre specified demographic and geographical sampling quotas; post-collection checks on the distribution of socioeconomic parameters; and adjustments for mismatches between clinical psychological scores and use of health-care services. further random subsampling, before ana lysis, was required to correct for this sampling bias. it seems that self-selected commercial survey panels in general might be biased towards mentally unhealthy or unhappy individuals. commercial survey organisations operate through networks of subcontractors who hold customer contact lists. individuals self-select to take part, for a small financial incentive. this might create bias towards people who are in difficult financial circumstances, and hence are under mental stress. the turnover in these self-selected panels is high. it is now easy to target precise population segments using social media, but difficult to obtain random representative population samples. political and personality representativeness have been tested. surveys measuring mental health specifically can correct for bias during analysis. however, commercial surveys are also widely adopted in physical and social health research, and these might risk invalid results if they omit mental health measures. we declare no competing interests. school of environment and science (ac, rb), school of applied psychology (lh, pb), and school of business (cf), griffith university, gold coast campus, qld , australia characteristics of participants who successfully adhere to the treatment, those who start medication again without relapse, and those who have a severe relapse and irreversible consequences such as treatment resistance and functional decline. third, observational data such as nationwide population-based registers could be used to emulate a hypothetical target trial if randomisation is not feasible. a target protocol describes the ideal, but unachievable randomised clinical trial. this trial can be emulated by exploiting the natural variation in observational data, which would allow causal inference by adjustment for confounders and selection bias. the concept has been increasingly applied in pharmaco-epidemiology and provides reliable answers in the comparative effectiveness of research. fourth, n-of- trials should be used to develop personalised decision making. these recommendations are proposed to avoid pitfalls of the current approach to precision medicine. a common pitfall is to split variance around an estimate, in the so-called responders and non-responders, using arbitrary definitions on a continuous outcome. using these arbitrary categories as true, and looking for prognostic factors predicting the response, is a simplistic and often misleading way to develop personalised risk models because all control conditions are completely ignored. by using the n-of- design, the same individual is acting as their own control by comparing periods when on medication with periods when not on medication. in conclusion, we know from cohort studies that a substantial proportion of individuals can manage without antipsychotic medication, and will not relapse. therefore understandably, many try to stop medication at some point to find out if they belong to this group. the duty of clinicians is to provide knowledge about the risks the pressure to find answers has been felt worldwide and three large randomised clinical trials (eudractct - - , e u d r a c t c t - - , actrn ) have been initiated by the authors of this correspondence. however, none of these trials are progressing as expected. the first problem is insufficient recruitment. despite great interest in the discontinuation of antipsychotic medication, few individuals can equally accept either treatment group in a randomised discontinuation trial, because the decision to maintain or discontinue is too important to be left to randomisation. low recruitment leads to small sample sizes with a high risk of type errors and excludes the possibility of developing personalised risk profiles. the second problem is poor adherence to the treatment arm. despite agreeing to participate, participants' strong personal preferences lead to high rates of crossover between the treatment groups. poor adherence to the allocated treatment arm leads to data with less clinical use because describing differences in outcomes between similar treatment arms has no real value to the patient. in fact, weak adherence to treatment might create data that are approaching observational, where confounding is a major limitation for causal inference. we suggest four recommendations using alternative designs for future research that could shed light on the questions about maintenance treatment with antipsychotic medication. first, to reach a sufficient number of participants in randomised clinical trials, international consortia should be established to enable recruitment within a reasonable timeframe. second, clinical cohort studies including individuals who discontinue antipsychotic medication should be done to generate precise knowledge about the proportion and there is a pressing need for knowledge about the effects of discontinuing antipsychotic medication in patients with remitted psychosis. patients usually ask how long they will have to continue, and many stop taking medication, hoping that they can manage without it. as health-care professionals, we are responsible for providing evidence-based coun selling for the initiation and discontinuation of medication, to help patients make informed choices. however, the two randomised trials , that have compared a maintenance strategy with an early dose reduction strategy after remission in patients with first-episode psychosis, have reported contradictory results. the dutch mesifos study found that more patients achieved long term functional remission in the group who were assigned to early discontinuation of antipsychotic medication after months of remission, compared with those who were assigned to maintenance treatment. however, a recent study from hong kong did not replicate this finding in a larger sample. says who? the significance of sampling in mental health surveys during covid- mental health before and during the covid- pandemic: a longitudinal probability sample survey of the uk population economic value of protected areas via visitor mental health recruiting large online samples in the united states and india: facebook, mechanical turk, and qualtrics personality biases in different types of internet samples can influence research outcomes key: cord- -e ayh authors: bohner, lauren; maus, melanie; kleinheinz, johannes; hanisch, marcel title: -ncov: measures adopted at the departments of oral surgery and radiology during the period of an uncontrolled transmission increase date: - - journal: dent j (basel) doi: . /dj sha: doc_id: cord_uid: e ayh a new mutation of -ncov emerged and has been spreading worldwide. dental practices are an important person-to-person transmission route. in this regard, preventive measures are required to avoid the cross contamination among professionals and patients. this report brings recommended measures for dental assistance during the pandemic phase. the clinical protocol applied at the department of oral maxillofacial and surgery, such as at the department of radiology, hospital university münster, is described. a management protocol was applied to prevent the transmission route of -ncov. patients infected with -ncov are treated only in emergency situations. the use of protective equipment and dental office isolation were the major points to avoid the contact between infected and non-infected patients. preventive measures should be taken in order to reduce the spread of -ncov infection. since the end of , a pneumonia infection has been emerging and widely spreading around the world. the novel mutation of coronavirus, known as -ncov, has reached more than , cases, resulting in approximately , deaths [ ] . the mechanism of -ncov consists on the binding between angiotensin-converting enzyme (ace ) and sars-cov- . this interaction can damage the alveolar cells of the lung, resulting in systemic complications, which in most severe cases may lead to death [ ] . clinical symptoms are fever, cough, fatigue, muscle pain and dyspnea. headaches, hemoptysis and diarrhea can also be present [ , ] . as respiratory syndrome, anemia, heart injuries and secondary infections may occur, the treatment consists on mechanical ventilation, antibiotics, antiviral therapy and corticosteroids [ ] . to date, no established protocol is available. thus, preventive measures, such as the use of protection equipment, personal hygiene and ventilated rooms, are essential to avoid contamination [ ] . the disease transmission occurs through direct or indirect contact with infected persons, regardless of the presence of clinical symptoms. thus, not only patients presenting clinical symptoms, but also those asymptomatic or in the incubation period can be a source of transmission [ ] . considering that dental assistance can be an important transmission route, dental clinicians should be aware of preventive managements to protect professionals and patients [ , ] . the purpose of this report is to describe the protocol adopted by the departments of oral surgery and radiology, hospital university münster, to avoid the cross infection of professionals and patients during the phase of an uncontrolled transmission increase. while the disease control is not yet possible, elective treatments should be avoided. emergency treatments of infected patients should be performed, when possible, in an isolated dental office. thus, the first step is to identify the infected patient. before the consultation, a questionnaire about acute clinical symptoms should be included in the medical history. additionally, information regarding travels performed on the last days, as well as social contact with infected persons, should be investigated. the measurement of body temperature is also essential to identify a febrile phase [ ] . if the patient responds "no" to all questions and does not present fever, conventional treatment protocol might be applied. by responding "yes" to one of these questions but in the absence of fever, it is recommended to perform the treatment days after the related event. in cases on which the patient´s body temperature is higher as . • c, a quarantine period is required [ ] . hand disinfection measures should be applied before and after each dental treatment. furthermore, direct hand touch on eyes, mouth and nose should be avoided. usual measures, such as use of personal protective equipment (ppe) and disinfection protocol after each patient consultation, should be respected. ppe includes the use of gloves, masks, eyewear, caps and coats. when treating infected patients, the use of a special mask, ffp- or ffp- , is strongly recommended [ ] [ ] [ ] . the department of oral and maxillofacial surgery, hospital university münster, comprises maxillofacial physicians and dentists specialized in oral surgery. a protocol was adopted in order to ensure the health of clinicians, assistants, and patients during the pandemic phase. a classification provided by the occupational health service has been used to determine the risks to which professionals were exposed, as well as the required measures to avoid infection (table ) . to avoid contact consultation with the physician the first step was to control the entrance of patients in the clinic. during the uncontrolled covid- spread, only patients with a scheduled consultation are allowed to enter the dental clinics. furthermore, the entrance of accompanying persons is not permitted. at the moment of the outbreak, elective treatments were suspended for all patients, regardless the diagnosis with -ncov (table ) . non-elective treatments, as acute pain, abscess and head and neck tumors operation, are being performed as usually. further conditions, as temporomandibular disorders or oral mucosal diseases, are analyzed according to the clinical situation. for instance, acute pain caused by a temporomandibular disorder, such as lesions that remain more than days in oral cavity, are considered emergencies. after controlling the acute phase, elective treatments are postponed to the end of the uncontrolled situation. the proper use of ppe is required throughout treatment, as well as during the room disinfection. all patients arriving at the clinic are screened based on a covid- questionnaire covering the items described above (see section . ). likewise, patient´s body temperature is checked with a non-contact thermometer. patients are considered of high risk when reporting fever, cough, breathing complications, personal contact with a -ncov patient or travel history on the last two weeks. in case of a positive response, the treatment need is analyzed and, if required, a covid test is taken. conversely, when all questions are responded with no and the body´s temperature is lower than . • c, the patient is considered of low-risk. prior to the treatment, the patient is advised to rinse with an alcohol-based mouthwash. for patients who do not tolerate alcohol, a chlorhexidin . % mouthrinse is given. treatments generating aerosols are avoided, being performed only under slightly conditions. for instance, an abscessed tooth is treated with incision and pharmacological therapy rather than tooth trepanation. likewise, for -ncov-patients at the acute phase, only non-elective treatments are performed. in order to avoid contact with patients who are not infected by the virus, -ncov-patients are treated in a separated dental office, away from both waiting room and conventional dental offices. during the patient management, dentists and assistants use all ppes, including n -masks (minimal ffp ) and disposable coats. as soon as the patient arrives the clinic, the department is advised to prepare the room. the patient is taken to the clinic at the time of the consultation, reducing exposure risks in the waiting room. on the entrance door there is a closet where the patient receive a disposable coat, gloves and a regular mask. the patient only removes the mask during the treatment. after the dental procedure, assistants wearing personal protective equipment decontaminate the room with an alcohol-based disinfection solution (incidin plus . %). also, the room is not used in the next hour, if possible, to ensure the complete room disinfection. control measurements are applied for all cases on which a radiograph is required. when possible, panoramic radiographs are preferred in order to prevent stimulate salivary flow caused by intra-oral radiographs. a dental assistant accompanies the patient to the radiology center. during the exam, a radiology technician uses the same protective equipment described above. in order to ensure the absence of contamination, patient´s gloves are changed as soon as the patient enters to the radiology center. as usual, the patient receives a protective gown and the radiograph exam is taken in accordance with a new protocol. in many cases, patient can continue to use the mask during the exam. frankfurt horizontal plane and mid-sagittal plane are ensured by the patient positioning device. however, the use of a bite-block is avoided to prevent intra-oral manipulation. instead, the patient is requested to bite on the anterior border of the tongue and, subsequently, to move the jaw anteriorly. this protrusion position simulates the bite conventionally taken on the bite-block. radiographic exams are taken from -ncov patients in a separated room, away from further radiological devices. this measurement is intended to avoid the contact of the patient with those who are not infected. preventive measures had to be taken to prevent the spread of -ncov infection. a special protocol was adopted to attend covid and non-covid patients during the phase of an uncontrolled disease control. however, measures should be modified according to each social and pandemic local situation. in summary, best practices should be improved during the uncontrolled disease increase. all patients should be considered to be infected, and some aspects must be taken into consideration during the dental treatment: -patient´s screening, as the avoidance of contact between covid and non-covid patients, are important measures to prevent spread of the disease; - the correct use of ppe should be reinforced. when possible, a ffp-mask (minimal ffp ) should be used; -a special attention must be given for the use of ppe and disinfection protocols. hand hygiene and room disinfection must be performed between dental treatments; -aerosol generation should be avoided and conservative treatments should be preferred. understanding of covid- based on current evidence the origin, transmission and clinical therapies on coronavirus disease (covid- ) outbreak-an update on the status clinical features and treatment of covid- patients in northeast chongqing compounds with therapeutic potential against novel respiratory coronavirus. antimicrob. agents chemoter. , in press covid- ): emerging and future challenges for dental and oral medicine transmission routes of -ncov and controls in dental practice centers for disease control and prevention. guidelines or infection control in dental health care settings- the authors declare no conflict of interest. key: cord- -e hzcag authors: nan title: ribavirin date: - - journal: meyler's side effects of drugs doi: . /b - - - - . - sha: doc_id: cord_uid: e hzcag nan the synthetic triazole nucleoside, ribavirin ( -beta-d-ribofuranosyl- , , -triazole- -carboxamide, tribavirin, virazole), has a broad spectrum of antiviral activity, including dna as well as rna viruses. ribavirin closely resembles guanosine and is converted intracellularly to mono-, di-, and triphosphate derivatives, which inhibit virally induced enzymes involved in viral nucleic acid synthesis [ ] . of the dna viruses, ribavirin is active against herpes simplex virus and hepatitis b virus; among the rna viruses, good activity has been observed against hepatitis c virus, orthomyxoviruses, paramyxoviruses, arenaviruses, and bunyaviruses. although active against hiv in vitro and in vivo [ ] , ribavirin is not widely used in the treatment of hiv infection. oral ribavirin has been successfully used in the treatment of lassa fever [ ] , crimean congo hemorrhagic fever [ ] , and in combination therapy with interferon alfa for hepatitis c infection [ ] . several publications have suggested enhanced efficacy of the combination of interferon alfa with ribavirin when compared with monotherapy with interferon alfa. there is also evidence that re-treatment with the combination may succeed in controlling or eliminating viremia when monotherapy has failed. although the combination may lead to some increase in the adverse reactions normally associated with interferon alfa (dyspnea, pharyngitis, pruritus, nausea, insomnia, and anorexia) [ ] , there is no doubt that oral ribavirin adds to the overall toxicity of the combination by causing hemolytic anemia, which is usually mild. ribavirin is well absorbed orally, but it can be given in aerosol form for the treatment of respiratory syncytial virus (rsv) infections in immunocompromised patients, and in those with cardiopulmonary abnormalities, or in infants receiving mechanical ventilation [ , ] . adverse reactions to interferon and ribavirin in the treatment of hepatitis c infection have been reviewed [ ] . since ribavirin is almost always used in combination with interferons, it can be difficult to know whether adverse events, if drug-induced, are due to one or the other. in many cases authors do not even discuss this problem, often attributing the supposed adverse reactions to the interferon. in some cases withdrawal of one of the agents can provide evidence, and in other cases there may be other clues. for example, in cases of skin pigmentation at the site of injection of interferons, the adverse reaction may be presumed to be due to interferon [ ] , a type ii between-the-eyes adverse reaction [ ] . in one case hemolytic anemia was attributed to interferon rather than ribavirin because the patient had previously taken a course of interferon without adverse reactions [ ] ; presumably the inference was that the patient had been sensitized by the previous course. a systematic review of cases in which the drugs were used together and individually can also yield useful information, as in the case of pneumonitis in patients being treated with interferon and ribavirin, attributed to interferon [ ] . similarly, in cases of ocular myasthenia [ ] , pleural effusion [ ] , and cataract [ ] the interferon was blamed because no previous cases were found in association with ribavirin alone. in cases in which the adverse event persists for some time after the withdrawal of pegylated interferon and ribavirin, the long half of peginterferon is cited as a possible explanation, but this is weak evidence in such cases. in some cases it may be impossible to tell whether the adverse event, if druginduced, was due to one or other of the drugs or to the combination. observational studies the combination of interferon þ ribavirin causes the same adverse reactions in patients who are co-infected with hepatitis c and hiv as in those who have hepatitis c only. however, in one series of patients some unexpected adverse reactions were recorded [ ] . one subject developed pancreatitis and four others developed asymptomatic hyperamylasemia, which disappeared after withdrawal. all of them were taking concomitant didanosine. secondly, lactate concentrations increased slightly in two individuals, both of whom were taking stavudine. significant weight loss ( . kg on average within months) may be another adverse effect resulting from the interaction of ribavirin and hiv nucleoside analogues. the mechanism of the beneficial effect of adding ribavirin to interferon is not fully understood. ribavirin monotherapy is not effective in hepatitis c. however, adding ribavirin to interferon increases the number of patients with a virological response although it also increases the number of adverse events. both the benefits and harms of adding ribavirin to interferon for patients with chronic hepatitis c should be considered before therapy is started. hepatitis c virus (hcv) rna kinetics have been studied on day in patients (nine and six of genotypes and non- respectively) and at weeks , , and in patients ( and of genotypes and non- respectively) during treatment with ribavirin þ pegylated interferon alfa- a [ ] . patients with a sustained virological response (svr) had a significantly more pronounced mean log decline from baseline in hcv rna amounts at weeks and compared with patients who failed to achieve a sustained response, whereas there was no difference after day . for patients with a log reduction in hcv rna amounts on day , the positive predictive value for a sustained virological response was %, whereas week was the best time point for predicting a later non-response in patients who failed to achieve a log fall. in patients with genotype non- and a log fall in hcv rna amounts the positive predictive value for a sustained virological response was % at week , and % at weeks and . the corresponding negative predictive values for patients with genotype non- were %, %, and % respectively. of the patients, one withdrew from treatment after the second dose of pegylated interferon alfa- a, four withdrew prematurely, one each at treatment weeks , , and for unknown reasons, and one at week for psychiatric reasons. one other patient withdrew at week because of arthralgia. dosage reduction was required in three patients because of thrombocytopenia or neutropenia, and in three others the dosage of ribavirin was reduced because of anemia. combination treatment of interferon-alfa þ ribavirin for chronic hepatitis d does not induce virological responses at a sufficient rate, despite its partial effectiveness in improving biochemical responses, and is not superior to interferon-alfa monotherapy. patients with chronic hepatitis d (n ¼ ) were treated with interferon alfa- b ( million u three times/week subcutaneously) and ribavirin ( - mg/day orally) for months, with follow-up for at least months (range - ) [ ] . all had compensated liver disease, raised transaminase activities, and hepatitis d virus rna positivity at baseline. genotypic analyses showed hepatitis d virus genotype i and hepatitis b virus genotype d. there were biochemical responses in eight patients ( %) at the end of treatment and in seven patients ( %) at the end of follow-up. only eight patients at the end of treatment and four at the end of follow-up had sustained virological responses. there were flu-like symptoms, generally mild or moderate, in most of the patients. two patients required a short-term dosage reduction from to mu because of leukopenia and thrombocytopenia and two patients had a drop in hemoglobin, which was managed with a reduction in the dosage of ribavirin. in two prospective, open trials in hiv/hepatitis c virus co-infected individuals who received peginterferon alfa- b or alfa- a þ ribavirin for weeks, responders were defined as those with a fall in hepatitis c virus rna by at least log units [ ] . of the patients who developed psychiatric adverse reactions, were responders and other adverse reactions, such as anemia and adverse reactions in the eyes, were also more frequent in responders. this suggests that the dosages may not have been high enough in the non-responders. it has been postulated that there is a risk of increased severity of recurrent hepatitis c virus infection in living donor liver transplantation (ldlt) patients. preventive therapy for this has been studied in patients [ ] . all received interferon-alpha b and ribavirin month after transplantation and for months after the first negative hcv rna test. they were then observed without therapy for months (group ). therapy was continued for at least months when the hcv-rna test remained positive (group ). they were removed from the protocol if they could not continue therapy for months because of adverse reactions or could not start therapy because of early death. eight patients were removed from the protocol (three died and two could not start because of their poor general condition). nine patients were assigned to group and the other six to group . the sustained virological response ratio was % ( / ). there was a significant difference between the groups in the histological activity score year after therapy. no details were given of the adverse reactions in the eight patients who were withdrawn. pegylated interferon and ribavirin have been used successfully to treat fulminant hepatitis c infection; there were only mild self-limiting adverse reactions, such as hemolytic anemia [ ] . high-dose ribavirin during an outbreak of severe acute respiratory syndrome in toronto was associated with a high rate of adverse events: anemia (or ¼ . ; % ci ¼ . , . ), hypomagnesemia (or ¼ ; % ci ¼ . , ), and bradycardia (or ¼ . ; % ci ¼ . , . ) [ ] . the risks of anemia, hypomagnesemia, and bradycardia attributable to ribavirin were %, %, and % respectively. the authors concluded that the use of high-dose ribavirin is appropriate only for the treatment of infectious diseases for which ribavirin has proven clinical efficacy, or in the context of a clinical trial. they further stated that ribavirin should not be used empirically for the treatment of viral syndromes of unknown origin. in patients taking ribavirin þ peginterferon alfa- b, nine patients reported flu-like symptoms, four developed anemia, three pancytopenia, three gastrointestinal symptoms, and one paresthesia, pruritus, and tremor [ ] . all resolved after the end of treatment. in a retrospective audit of patients taking ribavirin þ peginterferon alfa the following adverse events were reported: fatigue ( %), fever ( %), weight loss ( %), irritability ( %), and body pain ( %) [ ] . two, large, randomized, placebo-controlled comparisons of interferon alfa- b alone with the combination of interferon alfa- b plus ribavirin have been published. in the initial treatment of chronic hepatitis c, patients were randomly assigned to receive standard-dose interferon alfa- b alone or in combination with ribavirin ( or mg/day orally, depending on body weight) for or weeks [ ] . as expected, dosage reduction for anemia was necessary in % of patients taking the combination therapy and in none of those treated with interferon alone. dyspnea, pharyngitis, pruritus, rash, nausea, insomnia, and anorexia were adverse effects that were reported more often during combination therapy with ribavirin [ ] . in patients whose chronic hepatitis had relapsed after therapy with interferon alfa- b alone, patients were randomized to receive standard-dose interferon alfa- b alone or in combination with ribavirin ( or mg/day orally, depending on body weight) for months [ ] dosage reduction for anemia was required in / patients assigned to combination therapy and in none assigned to interferon alone. as was the case in the initial therapy study, dyspnea, nausea, and rash were significantly more common in patients treated with the combination of interferon and ribavirin [ ] . ribavirin mg/kg/day plus interferon alfa in teenagers has been compared with interferon alone in [ ] . there was no difference in dropout rate, but viral clearance was achieved in % of the patients who took the combination treatment versus % of those who took monotherapy. adverse events were similar in the two groups. there was mild hemolytic anemia at the end of the first month in most of the children who took ribavirin, but four had moderate to severe hemolysis and two had to stop taking ribavirin. severe hemolysis in a patient with thalassemia warranted withdrawal of ribavirin within months. in a meta-analysis of trials with a total of patients, ribavirin plus interferon significantly reduced morbidity plus mortality (or ¼ . ; % ci ¼ . , . ) and significantly improved sustained viral clearance in treatmentnaive patients (rr ¼ . ; % ci ¼ . , . ), relapsers (rr ¼ . ; % ci ¼ . , . ), and non-responders (rr ¼ . ; % ci ¼ . , . ) [ ] . this gave the following numbers needed to treat for beneficial effects (nnt b ): for reduction in mortality/morbidity ( % ci ¼ , ); for clearing of hcv-rna ( , ); and for improving the histological response ( , ) . this analysis also gave information about the increased toxicity of adding ribavirin, with the following numbers needed to treat for one harm to occur (nnt h ): anemia ( , ); leukopenia ( , ); rash ( , ) ; pruritus ( , ) ; insomnia ( , ) ; dermatitis ( , ) ; dyspnea ( , ) ; fatigue/weakness ( , ) ; dry skin ( , ) ; anorexia/nausea ( , ) ; dyspepsia ( , ) ; pharyngitis ( , ) ; cough ( , ) . there were also values of nnt h for dosage reductions ( , ) and stopping treatment ( , ) . treatment with peginterferon alfa- b þ ribavirin can achieve a complete clinical response in about % of patients with hepatitis c-related vasculitis. a complete clinical response correlates with the eradication of the virus and requires a shorter treatment period than that previously reported for interferon alfa plus ribavirin ( months) [ ] . the short course was well tolerated, although one patient withdrew because of neutopenia [ ] . cough occurs more commonly in patients taking a combination of interferon þ ribavirin compared with interferon alone. in four patients who developed a chronic cough while taking peginterferon þ ribavirin for chronic hepatitis c infection a capsaicin cough challenge test showed that cough reflex sensitivity was significantly increased during treatment; the cough resolved within - weeks after withdrawal and reflex sensitivity improved [ ] . in a prospective study of spirometry at , , and weeks in patients taking ribavirin þ peginterferon for chronic hepatitis c, reported dyspnea, but there were no associated changes in forced vital capacity (fvc), forced expiratory volume in second (fev ), or the ratio of fev /fvc [ ] . a -year-old man developed progressive dyspnea over months, progressing to a cough followed by frequent and abundant elimination of bronchial casts. the symptoms resolved days after withdrawal and no other causes were found [ ] . a -year-old man with chronic hepatitis c was given peginterferon alfa- a þ ribavirin and after weeks developed dyspnea on extreme exertion, with episodes of coughing followed by voluminous expectoration consisting of large pieces (up to . cm in length) of mucus-like material mimicking bronchial casts [ ] . he was given prednisone and partially improved. later, when peginterferon þ ribavirin was withdrawn, the respiratory complaints completely resolved. in a systematic review of case reports of pneumonitis in patients receiving peginterferon and ribavirin for chronic hepatitis c infection, cases were traced [ ] . pneumonitis presented with any of the combination of fever, dyspnea, and cough and was fatal in % of cases, exclusively with peginterferon alfa- b. headache is a frequent adverse reaction to combination therapy with ribavirin þ interferon. however, headaches have not been reported in early controlled trials of ribavirin monotherapy for chronic hepatitis c, and the frequency of this adverse reaction is comparable in patients treated with interferon and ribavirin and in interferon monotherapy. of patients treated with combination therapy for chronic hepatitis c, seven developed new severe migraine headaches and two had worsening of pre-existing migraine [ ] . the symptoms mostly started with a delay of several weeks to months. in seven patients, the migraine improved considerably or resolved when ribavirin was withheld or the dose was reduced. all of them had a recurrence when they were re-challenged with full-dose ribavirin. a causal link between ribavirin and migraine appears plausible, but has not been proven. progressive multifocal leukoencephalopathy in an hiv negative patient has been attributed to pegylated interferon alfa- a þ ribavirin [ ] . a -year-old man developed parkinsonism while taking peginterferon alfa- a and ribavirin for chronic hepatitis c and did not improve when the drugs were withdrawn; he responded to co-beneldopa [ ] . this may have been coincidental. a -year-old man with chronic hepatitis c related to intravenous drug use developed a unilateral facial nerve palsy after taking ribavirin mg/day þ peginterferon for weeks [ ] . the facial weakness persisted during weeks of therapy and resolved weeks after completing treatment. in a retrospective analysis of the win-r trial, a randomized, controlled comparison of fixed versus weightbased ribavirin doses, eight of patients developed seizures during therapy [ ] . three had a generalized tonic-clonic seizure and the seizure type was unknown in five. one patient had taken long-term antiepileptic drugs before therapy and one started therapy for seizure recurrence. none had recurrent seizures after completion of treatment. retinal vein thrombosis has been associated with peginterferon alfa b þ ribavirin in a -year-old man with chronic hepatitis c [ ] . visual complications were prospectively analysed in patients taking ribavirin þ peginterferon alfa for chronic hepatitis c [ ] . retinopathy was reported in patients, with retinal hemorrhages and significant visual impairment in eight and four patients respectively. withdrawal of therapy in six patients did not result in resolution. two spanish patients developed transient visual disturbances due to retinopathy during treatment with ribavirin and peginterferon alfa [ ] . in one case the symptoms resolved spontaneously despite continuation of treatment and in the other the symptoms resolved after withdrawal. permanent visual loss due to retinopathy also occurred in a -yearold man who took ribavirin þ peginterferon alfa for weeks; there were multiple cotton-wool spots bilaterally and visual acuity failed to improve months after withdrawal [ ] . a -year-old man who took ribavirin þ peginterferon alfa for chronic hepatitis c developed branch retinal artery and central retinal vein occlusion [ ] . acute bilateral retinal detachment occurred in two patients taking ribavirin þ peginterferon alfa; withdrawal of both agents and high-dose glucocorticoids only led to partial improvement in one case [ ] . inflammatory retinal detachment (vogt-koyanagi-harada disease) occurred in a -year-old woman with concomitant hypertension who took ribavirin mg þ weekly interferon; her visual symptoms improved only partly on withdrawal of both drugs following high-dose oral glucocorticoids [ ] . a -year-old man developed ischemic optic neuropathy after taking ribavirin mg/day þ peginterferon alfa for months; his visual acuity and field defect failed to improve despite withdrawal of interferon and therapy with high dose systemic steroids [ ] . it is a notable feature of most of these reports that the visual defects did not resolve or resolved only partly after withdrawal. this suggests that either the drugs were causative and the effects were irreversible (as may have been the case in retinal detachment) or that the effects were coincidental and not due to the drugs at all. a -year-old black man with a history of substance abuse developed chronic hepatitis c and was given interferon and ribavirin [ ] . after month he developed bilateral cotton wool spots and retinal hemorrhages in the left eye. the retinopathy persisted for several months but resolved in both eyes before the treatment was withdrawn. he had no visual complaints or changes in visual acuity. it is not clear that the drugs were responsible for the adverse reaction in this case. sensorineural hearing loss has been attributed to interferon plus ribavirin [ ] . a - year-old man developed vertigo, tinnitus, bilateral hearing loss and postural intolerance temporally related to the administration of pegylated interferon alfa- b þ ribavirin for chronic hepatitis c viral infection. he had bilateral high-frequency sensorineural hearing loss, vertigo with saccadic intrusions during fixation and smooth visual pursuit, supine hypertension and orthostatic hypotension with inadequate reflex compensatory cardiovascular responses, and a hemolytic anemia. audiometry showed changes that suggested damage to the cochlear outer hair cells. withdrawal of therapy resulted in rapid clinical resolution with mild residual hearing loss and tinnitus. transient sensorineural hearing loss has been described in two patients with chronic hepatitis c who took ribavirin þ peginterferon alfa [ ] . a -year-old man developed unilateral sensorineural hearing loss during therapy with ribavirin þ interferon for weeks; despite withdrawal of both agents there was no recovery after months [ ] . the fact that the hearing loss was unilateral and did not resolve after drug withdrawal suggests that it was not drug-related. other similar cases have been reported, albeit in some cases with unilateral effects [ , ] , which suggests that the drugs may not have been responsible. in patients with chronic hepatitis c genotype infection, all of whom were given peginterferon alfa- b þ ribavirin, sensitivity to salt and sweet tastes was impaired after weeks and bitter tastes were described as being more unpleasant than before; appetite was also impaired [ ] . cognitive dysfunction has been studied in patients with chronic hepatitis c during treatment with peginterferon alfa þ ribavirin for weeks in standard doses; cognitive performance was significantly impaired after weeks compared with controls [ ] . in patients with chronic hepatitis c taking peginterferon alfa- a or alfa- b and ribavirin all aspects of attention were impaired after weeks and the dysfunction did not resolve weeks after withdrawal [ ] . the authors hypothesized that there may have been irreversible damage to the dorsolateral prefrontal cortex or anterior cingulate cortex. in a prospective study of patients who were hepatitis c-positive and took long-term ribavirin þ peginterferon alfa, with or without escitalopram, there were psychiatric symptoms (low mood, anxiety, impaired concentration, hostility, and depression) in , , , , and patients respectively without escitalopram. [ ] . there were lower incidences in those who took concomitant antidepressants. in a prospective study of depressive symptoms in patients taking ribavirin þ peginterferon alfa there was a rise in the average beck depression inventory score, particularly in patients with subclinical depressive symptoms before treatment [ ] . a - year-old man developed severe depression with suicidal ideation after taking ribavirin mg/day þ interferon for months; he failed to improve despite antidepressant therapy but his symptoms improved after withdrawal of both agents [ ] . of patients taking peginterferon þ ribavirin for hepatitis c infection ( men and women), fulfilled the diagnostic criteria of dsm-iv for major depression, which was more common in the women [ ] . somatic symptoms were common, including myalgias, headache, joint pain, nausea/vomiting, abdominal pain, and bouts of palpitation. of patients with non-cirrhotic chronic hepatitis c, who were given interferon plus ribavirin for weeks, developed thyroid dysfunction compared with controls awaiting treatment [ ] . women were at a higher risk (rr ¼ ). hypothyroidism was more common than hyperthyroidism. in a retrospective study of patients who received interferon þ ribavirin for hepatitis c infection % developed a suppressed serum tsh ( . % graves' disease, . % transient thyroiditis) and % developed a raised serum tsh; . % developed permanently hypothyroidism and requiring levothyroxine [ ] . women had a relative risk of thyroid dysfunction of . ( % ci ¼ . , . ). a serum tsh of . mu/l or more and a positive thyroid peroxidase antibody titer before therapy were associated with relative risks of . ( % ci ¼ . , ) and . ( % ci ¼ . , . ) respectively. the combination of baseline tsh and thyroid peroxidase antibody data predicted progression to thyroid dysfunction with a sensitivity of %. a -year-old woman with chronic hepatitis c developed hashimoto's thyrotoxicosis followed by type diabetes mellitus after the addition of ribavirin mg/day to long-term peginterferon alfa [ ] . she continued to take both agents, but required long-term insulin and thyroxine replacement. of patients taking ribavirin þ peginterferon alfa developed autoimmune or non-autoimmune thyroiditis [ ] . levothyroxine replacement was required in all cases. in a prospective investigation of the incidence of thyroid disorders in patients with chronic hepatitis c before and during treatment with ribavirin þ peginterferon thyroid function was studied in anti-hcv and viral rnapositive patients [ ] . in patients thyroid dysfunction occurred within the first weeks, and developed thyroid disorders by weeks, seven with thyroid dysfunction and with antithyroid peroxidase antibodies. type diabetes mellitus and thyroid disease reportedly develop in . - . % and - % of patients treated with combined interferon-alfa þ ribavirin for chronic hepatitis c, but rarely coexist; however, both conditions have been reported in a -year-old woman [ ] . in another case, a -year-old woman developed type diabetes and had a recurrence of graves' disease during treatment with peginterferon alfa þ ribavirin for chronic hepatitis c [ ] . there were serum anti-glutamic acid decarboxylase antibodies and the authors suggested that she had autoimmune polyglandular syndrome type iii. time-dependent and dose-dependent hemolytic anemia (eventually associated with hyperbilirubinemia and a high reticulocyte count) is the only major toxic reaction associated with oral or intravenous ribavirin and is reversible on withdrawal. a -year-old man who took long-term ribavirin þ peginterferon alfa for chronic hepatitis c developed an autoimmune hemolytic anemia after weeks of therapy and required transfusion and withdrawal of both agents [ ] . of eight children aged - years with la crosse encephalitis treated with high-dose intravenous ribavirin ( mg/kg loading dose, followed by mg/kg -hourly for days and then mg/kg -hourly for days), four developed a hemolytic anemia necessitating drug withdrawal [ ] . another seven children who received lower doses ( mg/kg loading dose, followed by mg/kg -hourly for days) did not develop hemolytic anemia. of adults treated with ribavirin þ interferon, ( %) developed symptomatic anemia during the first - weeks of treatment; of them were given erythropoietin and required dosage reduction or withdrawal of therapy [ ] . pure red cell aplasia can also be associated with ribavirin and pegylated interferon alfa as well as with hepatitis a, b, or c infections. anemia due to pure red cell aplasia was reported in a -year-old man who took ribavirin mg/day þ peginterferon [ ] . ribavirin-associated pure red cell aplasia is fully reversible after withdrawal [ ] . a -year-old man with chronic hepatitis c infection developed activated protein c resistance, increased factor viii activity, a raised fibrinogen concentration, and hyperhomocysteinemia after taking peginterferon alfa þ ribavirin for months, when he had a pulmonary embolism [ ] . the hematological abnormalities returned to normal - months after drug withdrawal. in patients taking ribavirin plus interferon alfa- b the average fall in hemoglobin is - g/dl. of patients taking ribavirin mg/day were randomized to a high dose of peginterferon alfa- b once a week ( micrograms/kg for week, . micrograms/kg for weeks, and . microgram/kg for weeks) and patients were randomized to receive a low dose ( . micrograms/kg) for weeks; three patients required reduced doses of ribavirin because of anemia [ ] . in patients with nipah virus infection there was no difference in the incidence of adverse reactions between those who elected to have ribavirin treatment and those who refused [ ] . dosing was based on recommendations used to achieve the same approximate concentrations as those seen with - mg/day in the treatment of hepatitis c. anemia occurred in % of the ribavirin-treated patients and in the same number of controls. in patients receiving peginterferon alfa þ ribavirin, mean platelet count at baseline was  /l in noncirrhotic patients (n ¼ ) and  /l in those with cirrhosis (n ¼ ) [ ] . the mean fall in platelet count during treatment was % (from to  /l) and there was severe thrombocytopenia (platelet counts below  /l) in patients; nine developed platelet counts below  /l. the were instances of bleeding in patients, only one of which, due to gastrointestinal angiodysplasia, was severe in a patient without severe thrombocytopenia at the time. minor bleeding was more common when platelet counts were below  /l. the anemia associated with peginterferon þ ribavirin is thought to be a mixed form of ribavirin-induced hemolysis and interferon-induced myelosuppression. however in an -week study of patients receiving peginterferon þ ribavirin, while the mean hemoglobin fell significantly from . to . g/dl the serum erythropoietin responses were lower than seen in historical controls with iron deficiency [ ] . the mean dosage of ribavirin was reduced from to mg/day. only % maintained their dosage of ribavirin. detailed studies of the effects of ribavirin on erythrocyte atp content and on the hexose monophosphate shunt have been conducted in vitro. atp concentrations were significantly reduced and the hexose monophosphate shunt increased, suggesting erythrocyte susceptibility to oxidation. in vivo, ribavirin, alone or in combination with interferon, was associated with significant reductions in hemoglobin concentrations and a marked increase in absolute reticulocyte counts. erythrocyte na/k pump activity was significantly reduced, whereas k/cl co-transport and its dithiothreitol-sensitive fraction and malondialdehyde and methemoglobin concentrations increased significantly. ribavirin-treated patients showed an increase in aggregated band , which was associated with significantly increased binding of autologous antibodies and complement c fragments, suggesting erythrophagocytic removal by the reticuloendothelial system [ ] . in a randomized controlled trial of high-dose interferon alfa- b plus oral ribavirin for or months in patients with chronic hepatitis c, the sequential effects of treatment on hemoglobin, leukocytes, and platelets were recorded [ ] . there was a fall in hemoglobin, and the lowest concentrations were recorded after months of treatment in both groups. all hematological measurements returned to normal after the end of treatment. in a genome-wide association study of patients with chronic hepatitis c, two functional variants in the itpa gene, which cause inosine triphosphatase (itpase) deficiency, protected against ribavirin-induced hemolytic anemia in patients [ ] . the polymorphisms rs and rs were associated with a reduction in hemoglobin and the minor alleles of each variant were protective. in a genome-wide study in japanese patients with hepatitis c virus b infection treated with peginterferon þ ribavirin, a variant located upstream of the inosine triphosphate pyrophosphatase gene on chromosome p was significantly associated with treatment-induced anemia [ ] . several snps were strongly associated with the fall in hemoglobin, including the non-synonymous snp rs . another snp, the splicing variant-related rs , was not polymorphic in the japanese population. stratified analysis based on the rs genotype showed that inosine triphosphate pyrophosphatase expression does not correlate with the fall in hemoglobin, suggesting that rs is a direct causal variant in the japanese population. factors that could help predict hematological abnormalities in patients with chronic hepatitis c taking pegylated interferon and ribavirin have been studied in patients over years, of whom developed neutropenia (n ¼ ), anemia (n ¼ ), or thrombocytopenia (n ¼ ). genotype , a history of hypertension, a low baseline platelet count, a low baseline hemoglobin, and a raised serum creatinine concentration were significant factors [ ] . a low pretreatment platelet count, the dose of interferon alfa, and the haptoglobin phenotype are susceptibility factors for ribavirin-induced anemia, and the fall in hemoglobin is independent of dose in the therapeutic range [ ] . in five patients with chronic hepatitis c on hemodialysis who received subcutaneous interferon alfa- b and oral ribavirin for weeks, the dose of ribavirin was titrated based on hemoglobin, with bone marrow support by erythropoietin [ ] . there was significant bone marrow toxicity in all five. a dose of mg/day produced a steady-state auc comparable to that obtained with - mg/day in historical controls with normal renal function. more severe anemia was possibly due to chronic renal insufficiency in addition to the prolonged effects of ribavirin. treatment of ribavirin-induced hemolytic anemia with recombinant human erythropoietin has been described in patients [ ] . the hemoglobin concentration increased from a nadir of . g/dl to a median of . g/dl and ribavirin treatment did not have to be withdrawn. tongue hyperpigmentation has been described during therapy with ribavirin þ peginterferon alfa in chronic hepatitis c [ ] . hyperpigmentation of the oral mucosa and tongue has been reported in a -year-old caucasian woman with hepatitis c infection who had taken peginterferon alfa- a - micrograms/week plus ribavirin g/ day for weeks; she had tongue discomfort and noticed irregular black patches on the lateral surface of the tongue and oral mucosa [ ] . a -year-old woman developed numerous asymptomatic dark brown macules on her tongue and oral mucosa after taking peginterferon alfa- a and ribavirin for months [ ] . a -year-old woman developed dark brown, asymptomatic pigmentation on the dorsum of the tongue after taking peginterferon alfa plus ribavirin for weeks; her lesions resolved within months after withdrawal [ ] . a -year-old woman developed lingual hyperpigmentation while taking ribavirin þ pegylated interferon for hepatitis c virus infection [ ] . she had dark gray macules on the bilateral dorsolateral surfaces of her tongue, but no oral erosions or any other nail or cutaneous abnormalities. the only new medications that she had begun in close temporal proximity to the onset of the discomfort were peginterferon alfa- b and ribavirin, both of which she had taken for months. a man with hepatitis c took ribavirin þ peginterferon alfa and developed malabsorption [ ] . histological and serological investigations confirmed celiac disease. the symptoms improved following a strict gluten-free diet and withdrawal of both agents. a -year-old woman with hepatitis c infection was given peginterferon micrograms/week and ribavirin . g/day. after weeks she developed a neutropenia of  /l and a secondary enterocolitis, with bowel wall thickening involving the cecum and proximal ascending colon; she responded to broad-spectrum antibiotics, supportive treatment, and g-csf (filgastrim) [ ] . liver damage has been attributed to ribavirin þ interferon. a - year-old woman with stable chronic hepatitis c developed fulminant hepatitis while taking ribavirin þ peginterferon alfa [ ] . jaundice and clotting deteriorated despite withdrawal of interferon and the use of high-dose glucocorticoids, and she required liver transplantation. a -year-old woman with chronic hepatitis c took ribavirin þ interferon for weeks and developed persistently abnormal biochemistry (raised aminotransferases, alkaline phosphatase, and gamma-glutamyl transferase) despite remaining seronegative for hepatitis c virus [ ] . a liver biopsy showed cirrhosis, which was attributed to the antiviral drug therapy. as part of a multicenter, randomized, double-blind, placebo-controlled trial of ribavirin in patients with hepatitis c virus infection, liver biopsies were studied for iron deposition [ ] . increased total iron deposition, preferentially in hepatocytes, occurred during a -month course of ribavirin. the deposition had no apparent effect on the biochemical or histological response to ribavirin therapy. ribavirin can cause hemoglobinuria, resulting in black urine [ ] . irreversible alopecia has been associated with ribavirin þpeg-interferon [ ] . the addition of ribavirin to interferon therapy may be associated with an increased risk of adverse skin reactions [ ] . the adverse cutaneous events that can occur in patients taking interferon plus ribavirin have been reviewed [ ] . photosensitivity after administration of ribavirin has been described [ ] . a well-documented photoallergic reaction in a woman who was taking both ribavirin and interferon alfa provided evidence that ribavirin is a potential photosensitizer for uvb, a problem that may become increasingly relevant in patients with chronic hepatitis c taking combination therapy for - months with interferon alfa and ribavirin [ ] . occasional rashes in areas of drug contact and conjunctival irritation occurred when aerosolized ribavirin was used for months in an infant with immunodeficiency [ ] . pruritus, xerosis, and mild skin eruptions, such as eczema and lichen planus, are common ( %) during ribavirin plus interferon therapy [ ] . in three cases oral lichen planus worsened during treatment of chronic hepatitis c with pegylated interferon and ribavirin [ ] , and a -year-old woman developed a lichenoid eruption on the hands after taking interferon alfa- b and ribavirin for days; the lesions resolved within week after withdrawal [ ] . control of these symptoms mostly requires sustained therapy with moderately potent to potent topical glucocorticoids, combined with baseline emollients throughout the combination treatment period. however, there are occasional reports of marked erythematous maculopapular eruptions starting - days after the start of combination therapy [ ] . although this form of skin reaction (which is probably t cell mediated) is rare, it should be emphasized that it can occur early during treatment and can evolve into stevens-johnson syndrome. dermatitis occurred in patients who were given ribavirin þ pegylated interferon [ ] . half of the patients had clinical symptoms within the first month of combination treatment, and the first signs typically appeared distant from the sites of peginterferon injection. all complained of generalized itch, and most had xerosis and erythematopapulo-microvesicular lesions with a predilection for the extensor surfaces of the limbs and skin sites exposed to friction. seven had skin biopsies with a superficial dermal perivascular inflammation with spongiosis and parakeratosis; erythrocyte extravasation, sparse keratinocyte necrosis, and extension of the inflammation to the interface were variable; the last of these occurred in the clinically more severe cases. two patients developed specific skin signs that differed from the eczema-like pattern described above. one patient with generalized eczematous skin changes eventually developed malar hypertrichosis lanuginosa and bullous skin lesions with milia on the backs of both hands, leading to a diagnosis of porphyria cutanea tarda; one patient developed a bullous eruption with histological features of acantholytic dermatitis with a non-specific immunohistological profile. five cases of meyerson's syndrome (halo dermatitis), a benign eczematous rash around a pre-existing nevus, have been reported during treatment for hepatitis c [ , ] . this syndrome has been reported with interferon-alfa- b but not ribavirin in other conditions and resolved on withdrawal of therapy. there is a well-established association between hepatitis c virus infection and porphyria cutanea tarda. however it is thought that ribavirin increases the risk by increasing iron overload via hemolysis. two cases of porphyria cutanea tarda have been reported after treatment with ribavirin and interferon [ ] . there have been reports of cutaneous sarcoidosis associated with pegylated interferon alfa plus ribavirin treatment [ ] . sarcoid granulomata have been attributed to ribavirin þ peginterferon alfa. a -year-old woman who took ribavirin þ peginterferon alfa for months developed sarcoid granulomas at the site of previous insertion of a facial cosmetic filler [ ] . the lesions regressed after months after withdrawal of both agents. a -year-old man who took ribavirin þ interferon alfa for weeks developed widespread subcutaneous nodules on the legs, elbows, and groin month after completing therapy [ ] . a skin biopsy showed epithelioid granulomas consistent with sarcoidosis. a ct scan showed paratracheal, subcarinal and hilar adenopathy and serum ace and calcium were elevated. the symptoms and radiographic evidence of sarcoidosis resolved over years without treatment. a -year-old man developed rheumatoid arthritis months after completing a -month course of ribavirin þ peginterferon for chronic hepatitis c [ ] . there was symmetrical erosive polyarthritis in the wrist and the metacarpophalangeal joints, which required long-term treatment with methotrexate and sulfasalazine. in a -year-old man taking ribavirin and pegylated interferon for hepatitis c, the percentage of progressive spermatozoa and the number of motile sperm per ejaculate fell during treatment [ ] . the round cell/spermatozoa ratio, a measure of abnormal spermatogenesis, rose from . % to % and returned to baseline months later. the sperm dna fragmentation index increased markedly during treatment from % to % at months and was still raised months later. in men with chronic hepatitis c infection receiving peginterferon alfa- a þ ribavirin, ribavirin concentrations were higher in seminal fluid than in serum. abnormalities of spermatozoa (asthenoteratozoospermia: n ¼ ; asthenozoospermia: n ¼ ; teratozoospermia: n ¼ ) were common at baseline, and sperm density, percentage motility, and the percentage of sperm with normal morphology fell during antiviral therapy [ ] . vogt-koyanagi-harada disease, a disease of melanocytecontaining organs, characterized by uveitis, poliosis, vitiligo, and meningitis, also known as uveodermatologic syndrome, thought to be due to t helper cell-mediated autoimmunity, has been associated with interferon alfa þ ribavirin in two men with chronic hepatitis c infection [ , ] . the susceptibility factors for bacterial infections have been studied in patients co-infected with hiv and hepatitis c virus taking pegylated interferon with or without ribavirin [ ] . there were bacterial infections in of the patients who received at least one dose of study medication. there were two cases of pyelonephritis and one case of prostatitis (escherichia coli), one case of diarrhea (klebsiella oxytoca), two of septicemia (one due to salmonella enterica and one to staphylococcus aureus), one case of streptococcus pneumoniae meningitis, eight lower respiratory tract infections (two in the same patient), one case of sinusitis, and two cases of cellulitis. factors that were independently associated with the risk of bacterial infection were related to the duration of hepatitis c infection and to markers of liver fibrosis but not to neutropenia or characteristics of the hiv infection, including cd cell count. a - year-old man, who had had a splenectomy at age years but had not been immunized against streptococcus pneumoniae, developed pneumococcal meningitis while taking interferon and ribavirin for chronic hepatitis c [ ] . a similar case has been reported in a -year-old woman, with a fatal outcome [ ] . ribavirin is a category x product in the us fda's classification and is contraindicated in women who are or may become pregnant [ ] . it is also contraindicated in men whose partners may become pregnant. the us ribavirin pregnancy registry is a surveillance system for exposure to ribavirin during pregnancy or within months after treatment is stopped; it relies on patients and health-care providers to provide voluntary outcome data [ ] . ribavirin is teratogenic and embryotoxic in laboratory animals and should not be given to pregnant women. concern has been expressed about the safety of people in the same room as patients being treated with ribavirin by aerosol, particularly women of child-bearing age. however, no ribavirin was detected in the urine, plasma, or erythrocytes of nurses exposed to ribavirin administered via ventilator, oxygen tent, or oxygen hood over days [ ] . the voluntary ribavirin pregnancy registry was established in to monitor pregnancy exposures to ribavirin and to evaluate the potential human teratogenicity of prenatal exposure [ ] . it documents pregnant women who have been exposed to ribavirin during pregnancy or during the months before conception either directly (by taking ribavirin) or indirectly (through sexual contact with a man taking ribavirin). after more than five years, live births after direct exposure and live births after indirect exposure have been documented, including six cases of birth defects (three direct exposures and three indirect), all among live-born infants: two cases of torticollis and one each of hypospadias; polydactyly and a neonatal tooth; glucose- -phosphate dehydrogenase deficiency; ventricular septal defect and cyst of the fourth ventricle of the brain. in a study of single-nucleotide-polymorphisms in adults taking ribavirin þ peginterferon, there was a rapid fall in hemoglobin concentrations during the initial weeks of treatment in patients with the rs genotype cc in the inosine triphosphate pyrophosphatase (itpa) gene [ ] . hemoglobin concentrations in genotype cc patients stabilized by week and did not fall further. similarly, in patients taking telaprevir and ribavirin þ interferon [ ] . the fall in hemoglobin was highest in those with genotype cc in the itpa gene at weeks , , and , although outcomes after the end of treatment were not recorded. the clearance of ribavirin is impaired in patients with renal dysfunction, and it is not removed by hemodialysis. it is therefore not recommended for patients with a creatinine clearance under ml/minute. however hepatitis c infection is associated with renal complications, such as membranoproliferative glomerulonephritis with or without cryoglobulinemia, membranous glomerulonephritis, and focal segmental glomerulosclerosis. of seven patients treated with interferon six became hcv-rna pcr negative, four maintained both virological and renal remission, and one maintained virological and partial renal remission [ ] . ribavirin-induced anemia was managed in five patients with low-dose iron and erythropoietin. the authors concluded that ribavirin can be used, with reasonable safety, in hcv-related vasculitis and glomerulonephritis irrespective of renal function. transient acantholytic dermatosis (grover's disease) was first described by grover in as a pruritic, self-limiting, popular, or papulovesicular eruption, mainly distributed on the trunk of white middle-aged men. the histopathological hallmark is suprabasal acantholysis at different levels of the epidermis. its origin is uncertain; most cases are related to sunlight, heat, or sweating. grover's disease has been attributed to ribavirin [ ] . a - year-old man with chronic hepatitis c presented with a pruritic papular eruption on the trunk lasting weeks. he had multiple, erythematous, excoriated papules on the neck, trunk, upper arms, and thighs. the lesions appeared weeks after combination therapy with oral ribavirin and subcutaneous interferon alfa- b. he had previously been treated with interferon alfa alone (in the same dosage). on withdrawal of ribavirin the lesions gradually faded, but they returned week after reintroduction. the intracellular triphosphorylation and pharmacokinetics of lamivudine, stavudine, and zidovudine have been assessed in patients co-infected with human immunodeficiency virus and hepatitis c virus receiving peginterferon alfa- a micrograms/week plus either placebo or ribavirin mg/day; there was no difference [ ] . in a retrospective review of the medical records of eight patients who developed severe pancytopenia after administration of azathioprine, interferon alfa, and ribavirin, bone marrow suppression reached a nadir after a mean interval of . weeks, at which time the mean platelet count was  /l, the mean hemoglobin . g/ dl, and the mean neutrophil count  /l [ ] . all had a normal thiopurine methyltransferase genotype. in two patients in whom azathioprine metabolites were measured, myelotoxicity was accompanied by raised total methylated metabolite concentrations and reduced tioguanine nucleotide concentrations. pegylated interferon alfa and ribavirin were withdrawn and the full blood count returned to normal. there was no recurrence when peginterferon was reintroduced with ribavirin or azathioprine alone. the authors concluded that the combination of inosine monophosphate dehydrogenase inhibitors with purine analogues should be avoided. another similar case has been reported [ ] . an interaction of warfarin with ribavirin has been reported [ ] . in a -year-old white man with chronic hepatitis c, who took interferon plus ribavirin, the dosage of warfarin had to be increased by about % (from to mg/week) in order to maintain the desired degree of anticoagulation. this effect was reproduced on rechallenge with ribavirin. the mechanism of this supposed interaction is not known. for example, ribavirin is cleared by intracellular phosphorylation and its metabolites by the kidneys, warfarin by cyp isoenzymes in the liver; warfarin is highly protein bound, ribavirin is not. however, an effect on warfarin absorption or its action on clotting factor synthesis is possible. multisystem organ dysfunction and lactic acidemia occurred in two of patients with hiv and hepatitis c infections who received interferon alfa, didanosine, and ribavirin [ ] . co-administration of didanosine with ribavirin can lead to increased toxicity secondary to raised intracellular concentrations of phosphorylated didanosine [ , ] . thus, the evidence suggests that the combination of didanosine plus ribavirin increases the risk of lactic acidosis. in a randomized -week study, patients co-infected with human immunodeficiency virus (hiv) and hepatitis c (hcv) were given interferon alfa- b together with either a full course of ribavirin or placebo for weeks, followed by ribavirin [ ] . more than % of the patients in both groups also took haart and - % took zidovudine. significantly more patients in those who took the full -week course of ribavirin had to reduce the dose of ribavirin because of anemia ( % versus %). of those who also took zidovudine, only those who took the full course of ribavirin had to reduce the dose of ribavirin for any reason ( % versus %) or for anemia ( % versus %). zidovudine, but no other nucleoside analogue, was associated with a significantly lower hemoglobin concentration ( . versus . g/dl) and a significantly larger fall (- . versus - . g/dl). however, there was no pronounced association between leukopenia or neutropenia and zidovudine. the combination of zidovudine with interferons and ribavirin should be avoided if possible. the hb a c concentration was falsely reduced by joint ribavirin and peginterferon alfa- b therapy in a -yearold man with type diabetes mellitus; after treatment was withdrawn the hb a c returned to baseline [ ] . the management with epoetin alfa and danazol of anemia during therapy with interferon and ribavirin has been reported [ ] . a - year-old african-american man with chronic hepatitis c was initially given subcutaneous interferon alfa- b ( mu three times/week) and oral ribavirin mg/day. the pre-treatment hemoglobin was . g/dl. there was a good therapeutic response, but the hemoglobin fell firstly to . g/dl and then to . g/dl by week . this prompted a reduction in the dosage of ribavirin to mg/day, and the hemoglobin rose to . g/dl. the antiviral therapy was withdrawn at week and reintroduced months later for a relapse. he was given subcutaneous peginterferon alfa- a ( micrograms/week) and oral ribavirin mg/day plus subcutaneous epoetin alfa u/week to prevent anemia and therefore the need to reduce the dose of ribavirin. serum hemoglobin at the start of the second course of therapy was . g/dl and it remained stable throughout the first weeks of therapy. however, at week , there was an abrupt fall in hemoglobin from . to . g/dl. the ribavirin was immediately withdrawn, the dosage of peginterferon was reduced, and the dosage of epoetin alfa was increased to u/week. at week , the hemoglobin fell to . g/dl and the peginterferon was withdrawn. at week , the hemoglobin reached a nadir of . g/dl, requiring transfusion with three units of packed erythrocytes. the patient continued to require about one unit of blood every week despite continuing epoetin alfa, which was finally stopped at week . erythropoietin antibodies became detectable by week and peaked at week . danazol mg bd then mg bd was started weeks after the withdrawal of epoetin alfa. the hemoglobin then became stable at - g/dl for weeks. in a systematic review of the use of plasma ribavirin concentrations to monitor therapy in patients with chronic hepatitis c ( studies), a previously published nine-step decision-making algorithm was used to help determine whether measurement is warranted [ ] . some studies have supported and others have refuted the usefulness of ribavirin measurement; most had methodological limitations, such as small sample size, retrospective analyses, and lack of p value adjustment for multiple analyses. antiviral agents and viral diseases of man a phase-i study of the safety, pharmacokinetics, and antiviral activity of combination didanosine and ribavirin in patients with hiv- disease. aids clinical trials group protocol team effective therapy with ribavirin crimean congo-haemorrhagic fever treated with oral ribavirin interferon alfa- b alone or in combination with ribavirin as initial treatment for chronic hepatitis c. hepatitis interventional therapy group interferon alfa- b alone or in combination with ribavirin for the treatment of relapse of chronic hepatitis c. international hepatitis interventional therapy group aerosolized ribavirin treatment of infants with respiratory syncytial viral infection. a randomized double-blind study a controlled trial of aerosolized ribavirin in infants receiving mechanical ventilation for severe respiratory syncytial virus infection adverse effects and other safety aspects of the hepatitis c antivirals iatrogenic hyperpigmentation in chronically infected hepatitis c patients treated with pegylated interferon and ribavirin anecdotes that provide definitive evidence severe autoimmune hemolytic anemia complicated with liver decompensation and invasive aspergillosis in a patient with chronic hepatitis c during treatment with peg-interferon-a and ribavirin pneumonitis as a consequence of (peg)interferon-ribavirin combination therapy for hepatitis c: a review of the literature development of ocular myasthenia during pegylated interferon and ribavirin treatment for chronic hepatitis c pleural effusion associated with pegylated interferon alpha and ribavirin treatment for chronic hepatitis c pegylated interferon and ribavirin therapy for hepatitis c causing cataract pegylated ifn-alpha b plus ribavirin as therapy for chronic hepatitis c in hiv-infected patients hepatitis c virus rna kinetics during the initial weeks treatment with pegylated interferon-alpha a and ribavirin according to virological response alpha interferon and ribavirin combination therapy of chronic hepatitis d hiv/hepatitis c virus-coinfected virologic responders to pegylated interferon and ribavirin therapy more frequently incur interferon-related adverse events than nonresponders do should living donor liver transplantation be offered to patients with hepatitis c virus cirrhosis? successful treatment of fulminant hepatitis c by therapy with alpha interferon and ribavirin adverse events associated with high-dose ribavirin: evidence from the toronto outbreak of severe acute respiratory syndrome mü ller v. the effect and safety of the treatment of recurrent hepatitis c infection after orthotopic liver transplantation with pegylated interferon a b and ribavirin side effects of the therapy with peginterferon and ribavirin in chronic hepatitis c: a small audit does interferon and ribavirin combination therapy increase the rate of treatment response in children with hepatitis c? effects of adding ribavirin to interferon to treat chronic hepatitis c infection: a systematic review and meta-analysis of randomized trials treatment of hepatitis c virus-related systemic vasculitis pegylated interferon alfa- b and ribavirin treatment in patients with hepatitis c virus-related systemic vasculitis chronic cough associated with interferon/ribavirin therapy for hepatitis c dyspnoea in patients with chronic hepatitis c treated with pegylated interferon and ribavirin bronchial casts attributed to the use of pegylated interferon and ribavirin expectoration of large bronchial casts secondary to the treatment of chronic hepatitis c with pegylated interferon and ribavirin severe migraine headaches are caused by ribavirin but not by interferon alpha- b in combination therapy for chronic hepatitis c progressive multifocal leukoencephalopathy as a complication of hepatitis c virus treatment in an hivnegative patient recovery after l-dopa treatment in peginterferon and ribavirin induced parkinsonism bell's palsy associated with chronic hcv infection before and during peginterferon alfa and ribavirin therapy seizures during pegylated interferon and ribavirin therapy for chronic hepatitis c: observations from the win-r trial trombosis venosa retiniana asociada a peginterferó n alfa b má s ribavirina en un paciente con hepatitis c cró nica incidence and risk factors of retinopathy in egyptian patients with chronic hepatitis c virus treated with pegylated interferon plus ribavirin retinopatía asociada a interferó n pegilado y ribavirina en pacientes con hepatitis c retinopathy associated with pegylated interferon and ribavirin causing permanent visual impairment in a patient with chronic hepatitis c branch retinal artery occlusion and central retinal vein occlusion associated with pegylated interferon plus ribavirin combination therapy for chronic hepatitis c serous retinal detachments complicating interferon-alpha and ribavirin treatment in patients with hepatitis c vogt-koyanagi-harada disease occurring during pegylated interferon-alpha b and ribavirin combination therapy for chronic hepatitis c anterior ischemic optic neuropathy in a patient with hepatitis c treated with interferon-alpha and ribavirin retinopathy associated with pegylated interferon and ribavirin treatment for chronic hepatitis c interferonalpha- b/ribavirin-induced vestibulocochlear toxicity with dysautonomia in a chronic hepatitis c patient reversible sudden sensorineural hearing loss during chronic hepatitis c treatment with pegylated interferon/ ribavirin pegylated interferon/ribavirin-associated sudden hearing loss in a patient with chronic hepatitis c in brazil a case of sudden-onset hearing loss in a patient treated with peginterferon alpha- b and ribavirin for chronic hepatitis c a case of hearing loss associated with pegylated interferon and ribavirin treatment ameliorated by prednisone lichtań ski p, błoń ska-fajfrowska b. taste disturbances during therapy with pegylated interferonalpha b and ribavirin in patients with chronic hepatitis c pegylated interferon alpha and ribavirin therapy may induce working memory disturbances in chronic hepatitis c patients zaburzenia procesow poznawczych obserwowane u pacjentow z przewleklym zapaleniem watroby typu c w trakcie terapii pegylowanym interferonem alfa i rybawirynq. [attention abnormalities in patients with chronic hepatitis c after pegylated interferon alpha and ribavirin treatment randomised clinical trial: escitalopram for the prevention of psychiatric adverse events during treatment with peginterferon-alfa- a and ribavirin for chronic hepatitis c changes in depressive symptoms and impact on treatment course among hepatitis c patients undergoing interferon-alpha and ribavirin therapy: a prospective evaluation ifnalpha- a (interferon) and ribavirin induced suicidal attempt in a patient of chronic hcv: a rare case report frequency of depression and somatic symptoms in patients on interferon alpha/ribavirin for chronic hepatitis c effects of combined interferon alpha and ribavirin therapy on thyroid functions in patients with chronic hepatitis c thyroid dysfunction in a uk hepatitis c population treated with interferon-alpha and ribavirin combination therapy pegylated interferon-alpha b and ribavirin combination therapy induces hashitoxicosis followed by type diabetes mellitus thyroid hormonal disturbances related to treatment of hepatitis c with interferon-alpha and ribavirin thyroid disorders in patients with chronic hepatitis c using interferon-alpha and ribavirin therapy occurrence of diabetic ketoacidosis and autoimmune thyroiditis in a patient treated with pegylated interferon-alpha b and ribavirin for chronic hepatitis c a case of type diabetes onset and recurrence of graves' disease during pegylated interferon-a plus ribavirin treatment for chronic hepatitis c autoimmune hemolytic anemia in a case of chronic hepatitis type c weeks after initiation of second line treatment with pegylated interferon alpha b/ribavirin combination therapy safety and pharmacokinetics of ribavirin for the treatment of la crosse encephalitis team aas. the incidence, predictors and management of anaemia and its association with virological response in hcv/hiv coinfected persons treated with long-term pegylated interferon alfa a and ribavirin. aliment pure red cell aplasia caused by pegylated interferon-alpha- a plus ribavirin in the treatment of chronic hepatitis c ribavirin-induced pure red-cell aplasia during treatment of chronic hepatitis c mozer-lisewska i. zatorowość płucna u -letniego chorego z przewlekłym zapaleniem wą troby typu c podczas leczenia interferonem-a i rybawiryną . [pulmonary embolism in a year-old man with chronic hepatitis c during therapy with pegylated interferon-a and ribavirin viral kinetics in genotype chronic hepatitis c patients during therapy with different doses of peginterferon alfa- b plus ribavirin treatment of acute nipah encephalitis with ribavirin thrombocytopenia and the risk of bleeding during treatment with peginterferon alfa and ribavirin for chronic hepatitis c hcv natural history study group. erythropoietic response to anemia in chronic hepatitis c patients receiving combination pegylated interferon/ribavirin hemolytic anemia induced by ribavirin therapy in patients with chronic hepatitis c virus infection: role of membrane oxidative damage combined treatment of relapse of chronic hepatitis c with high-dose alpha b interferon plus ribavirin for or months variants in the itpa gene protect against ribavirin-induced hemolytic anemia and decrease the need for ribavirin dose reduction itpa polymorphism affects ribavirin-induced anemia and outcomes of therapy-a genome-wide study of japanese hcv virus patients predictors of hematological abnormalities in patients with chronic hepatitis c treated with interferon and ribavirin basl steering committee. factors influencing ribavirin-induced hemolysis safety of interferon and ribavirin therapy in haemodialysis patients with chronic hepatitis c: results of a pilot study treatment of ribavirin/interferon-induced anemia with erythropoietin in patients with hepatitis c tongue hyperpigmentation resulting from peginterferon alfa- b and ribavirin treatment in a patient with chronic hepatitis c tongue hyperpigmentation resulting from peginterferon alpha- a and ribavirin treatment in a caucasian patient with chronic hepatitis c jaé n p. tongue hyperpigmentation during interferon-alpha and ribavirin therapy corrê a me. tongue hyperpigmentation resulting from peginterferon alfa and ribavirin combination therapy: a case report lingual hyperpigmentation from pegylated interferon and ribavirin treatment of hepatitis c celiac disease manifested during the treatment of chronic hepatitis c by pegylated alpha interferon and ribavirin neutropenic enterocolitis: an unusual complication of hcv combination therapy with peg-ifn and ribavirin autoimmune fulminant hepatic failure in chronic hepatitis c during peginterferon-alpha b plus ribavirin treatment showing histological heterogeneity a case with chronic hepatitis c who developed liver cirrhosis due to liver dysfunction caused by pegylated interferon plus ribavirin treatment despite negativity of serum hcv rna, during therapy bodenheimer hc jr increased hepatic iron deposition resulting from treatment of chronic hepatitis c with ribavirin hemoglobinuria with ribavirin treatment a case of irreversible alopecia associated with ribavirin and peg-interferon therapy high prevalence of cutaneous reactions to interferon alfa plus ribavirin combination therapy in patients with chronic hepatitis c virus a review of adverse cutaneous drug reactions resulting from the use of interferon and ribavirin photoallergic skin reaction to ribavirin long-term therapy with aerosolized ribavirin for parainfluenza virus respiratory tract infection in an infant with severe combined immunodeficiency cutaneous side-effects of treatment of chronic hepatitis c by interferon alfa and ribavirin exacerbation of oral lichen planus lesions during treatment of chronic hepatitis c with pegylated interferon and ribavirin erupció n liquenoide en un paciente con hepatitis cró nica por el virus de la hepatitis c tratado con interferó n y ribavirina. [lichenoid eruption in a patient with chronic hepatitis c virus infection treated with interferon and ribavirin erythematous maculopapular eruption due to ribavirin administration in a patient with chronic hepatitis c clinical and immunological features of hepatitis c treatment-associated dermatitis in prospective cases meyerson s phenomenon induced by interferon-alfa plus ribavirin in hepatitis c infection meyerson s naevi induced by interferon alfa plus ribavirin combination therapy in hepatitis c infection occurrence of porphyria cutanea tarda during peginterferon/ribavirin therapy for chronic viral hepatitis c sarcoidosis associated with pegylated interferon alfa and ribavirin treatment for chronic hepatitis c: a case report and review of the literature granulomas sarcoideos en material de relleno facial inducidos por interferó n a y ribavirina en paciente con hepatitis c. [sarcoid granulomas in facial cosmetic filler material: induction by interferon-a and ribavirin in a patient with hepatitis c cutaneous sarcoidosis developing after treatment with pegylated interferon and ribavirin: a new case and review of the literature rheumatoid arthritis following a treatment with ifn-alpha/ribavirin against hcv infection ribavirin and pegylated interferon treatment for hepatitis c was associated not only with semen alterations but also with sperm deoxyribonucleic acid fragmentation in humans seminal fluid ribavirin level and functional semen parameters in patients with chronic hepatitis c on antiviral combination therapy syndrome de vogt-koyanagi-harada au cours d'une hé patite c chronique sous interfé ron alpha et ribavirine. [vogt-koyanagi-harada disease associated with interferon-alpha and ribavirin therapy for chronic hepatitis c infection vogt-koyanagi-harada disease occurring during interferon-alpha and ribavirin therapy for chronic hepatitis c virus infection anrs hc -riba-vic study team. risk factors for bacterial infections in hiv/hepatitis c virus-coinfected patients treated with interferon plus ribavirin pneumococcal meningitis during antiviral treatment with interferon and ribavirin in a splenectomized patient with chronic hepatitis c-do not miss vaccination before starting therapy case of overwhelming postsplenectomy infection (opsi) with chronic hepatitis type c during peginterferon/ribavirin combination therapy food and drug administration assessing ribavirin exposure during pregnancy: the ribavirin pregnancy registry environmental exposure of primary care personnel to ribavirin aerosol when supervising treatment of infants with respiratory syncytial virus infections the ribavirin pregnancy registry: findings after years of enrollment common genetic polymorphism of itpa gene affects ribavirin-induced anemia and effect of peg-interferon plus ribavirin therapy influence of itpa polymorphisms on decreases of hemoglobin during treatment with pegylated interferon, ribavirin, and telaprevir interferon and ribavirin treatment in patients with hepatitis c-associated renal disease and renal insufficiency grover's disease secondary to ribavirin effect of ribavirin on intracellular and plasma pharmacokinetics of nucleoside reverse transcriptase inhibitors in patients with human immunodeficiency virus-hepatitis c virus coinfection: results of a randomized clinical study interaction of ribavirin with azathioprine metabolism potentially induces myelosuppression azathioprine plus ribavirin treatment and pancytopenia inhibition of warfarin activity by ribavirin increased mitochondrial toxicity with ribavirin in hiv/hcv coinfection mitochondrial toxic effects and ribavirin mitochondrial toxic effects and ribavirin treatment of chronic hepatitis c in hiv/hcv-coinfection with interferon alpha- b þ full-course vs. -week delayed ribavirin falsely low hemoglobin a c levels in a patient receiving ribavirin and peginterferon alfa- b for hepatitis c antibody-mediated pure red cell aplasia due to epoetin alfa during antiviral therapy of chronic hepatitis c the utility of therapeutic drug monitoring for ribavirin in patients with chronic hepatitis c-a critical review key: cord- - pvg apl authors: titov, nickolai; dear, blake f; nielssen, olav; wootton, bethany; kayrouz, rony; karin, eyal; genest, ben; bennett-levy, james; purtell, carol; bezuidenhout, greg; tan, rheza; minissale, casey; thadhani, priti; webb, nick; willcock, simon; andersson, gerhard; hadjistavropoulos, heather d; mohr, david c; kavanagh, david j; cross, shane; staples, lauren g title: user characteristics and outcomes from a national digital mental health service: an observational study of registrants of the australian mindspot clinic date: - - journal: lancet digit health doi: . /s - ( ) - sha: doc_id: cord_uid: pvg apl background: interest is growing in digital and telehealth delivery of mental health services, but data are scarce on outcomes in routine care. the federally funded australian mindspot clinic provides online and telephone psychological assessment and treatment services to australian adults. we aimed to summarise demographic characteristics and treatment outcomes of patients registered with mindspot over the first years of clinic operation. methods: we used an observational design to review all patients who registered for assessment with the mindspot clinic between jan , , and dec , . we descriptively analysed the demographics, service preferences, and baseline symptoms of patients. among patients enrolled in a digital treatment course, we evaluated scales of depression (patient health questionnaire- [phq- ]) and anxiety (generalized anxiety disorder -item scale [gad- ]), as primary measures of treatment outcome, from the screening assessment to post-treatment and a month follow-up. the kessler psychological distress -item plus scale was also used to assess changes in general distress and disability, and course satisfaction was measured post-treatment. outcomes: a total of screening assessments were started, of which ( · %) were completed. the mean age of patients was · years (sd · ) and ( · %) were women. based on available assessment data, ( · %) of participants had never previously spoken to a health professional about their symptoms, and most people self-reported symptoms of anxiety ( [ · %] of ) or depression ( [ · %] of ), either alone or in combination, at baseline. patients started treatment in a therapist-guided online course, of whom ( · %) completed treatment (≥four of five lessons). key trends in service use included an increase in the proportion of people using mindspot primarily for assessment and information, from · % in to · % in , while the proportion primarily seeking online treatment decreased, from · % in to · % in . effect sizes and percentage changes were large for estimated mean scores on the phq- and gad- from assessment to post-treatment (phq- , cohen's d effect size · [ % ci · – · ]; and gad- , · [ · – · ]) and the month follow-up (phq- , · [ · – · ]; and gad- , · [ · – · ]); proportions of patients with reliable symptom deterioration (score increase of ≥ points [phq- ] or ≥ points [gad- ]) were low post-treatment (of respondents, [ · %] had symptom deterioration on the phq- and [ · %] on the gad- ); and patient satisfaction rates were high ( [ · %] of respondents would recommend the course and [ · %] of reported the course worthwhile). we also observed small improvements in disability following treatment as measured by days out of role. interpretation: our findings indicate improvement in psychological symptoms and positive reception among patients receiving online mental health treatment. these results support the addition of digital services such as mindspot as a component in contemporary national mental health systems. funding: none. mental disorders and substance use disorders are major contributors to the burden of disease in australia and worldwide, , with only a minority of those affected see king or receiving evidence-based treatments. , barriers to care include stigma, cost, and availability of services. the covid- pandemic has created additional challenges, as many traditional mental health providers stopped pro viding face-to-face service. as a result, interest is increasing in the digital delivery of psycho logical services. digital mental health services (dmhs) remotely deliver mental health information, assessments, and treatment, via the internet, telephone, or other digital channels. dmhs are already part of routine care in several coun tries, operating either as stand-alone services or in con junction with traditional face-to-face care. , for example, the improving access to psychological therapies (iapt) service of the national health service (england) provides both faceto-face and digital services to patients with anxiety or dep ression; a stepped-care approach that allows patients to move from low-intensity intervention (such as guided self-help) to high-intensity intervention (tradi tional face-to-face therapy). stepped care is not a common feature of stand-alone dmhs, in which patients often report being un willing or unable to access traditional face-to-face therapy. in this paper, we report outcomes from the australian mindspot clinic, which by volume of patients, is one of the world's largest publicly funded dmhs. the mindspot project was launched in december, , and is funded by the australian department of health as part of the australian government's e-mental health strategy. mindspot provides information about symptoms and local mental health services, brief psychological assess ments, and therapist-guided treatments delivered via the internet and telephone to adults with symp toms of anxiety, dep ression, or chronic pain. we have previously reported results from months and months of operations, characteristics of service users during the covid- pan demic, and treatment outcomes for specific populations, including aboriginal and torres strait islander (indig enous) people and people born overseas. in this paper, we aimed to provide a summary of demographic charac teristics and treat ment outcomes for patients registered with mindspot over its first years of operation, including service use and symptom severity, and examined trends in these characteristics over time. this study was designed as an observational study and is reported according to strobe guidelines. we evaluated all patients who registered for assessment or treatment with the mindspot clinic between jan , , and dec , . ethical approval for the collection and use of patient data was obtained from the macquarie university human research ethics committee (macquarie university, sydney, nsw, australia; approval number ) and registered on the australian and new zealand clinical trials registry, actrn . mindspot is funded by the australian government as a project and recruitment is ongoing as patients continue to access the service. as mindspot is funded by the australian department of health, patients seeking assessment or treatment must complete an online registration questionnaire and meet the following eligibility criteria: australian resident eligible for publicly funded health services (ie, medicare-funded services); aged years or older; and self-reported principal complaint of anxiety, depression, or chronic pain. patients are also provided with the terms of use explaining that non-identifiable, aggregated data could be used for reporting and service evaluation purposes. patients are required to consent to the terms this study describes the characteristics and treatment outcomes of a large sample of consecutive users (n= ) of the national australian dmhs, mindspot clinic, from data collected over its first years of operations. we provide information about the demographic characteristics, service preferences, symptoms, and treatment outcomes for people using this particular model of digital service. we found that clinic users represented a broad cross-section of the australian population, and used mindspot for a variety of reasons, with most seeking a confidential assessment rather than treatment. we also found that people who engaged in treatment achieved significant reductions in symptoms, which were sustained months after treatment completion. importantly, these findings confirm the role of dmhs in providing evidence-based assessment and treatment to large numbers of people, many of whom are not accessing other services. the present findings contribute to the evidence base for dmhs in reducing barriers to care, and confirm the utility of dmhs as an important component of contemporary mental health systems. of use, either online or by telephone, before proceeding with assessment and treatment. the people register with mindspot by creating an account and completing a screening assessment, online or by telephone. the screening assessment includes questions on demographic and service use information, and symptoms and current stressors. participants are also asked about suicidal thoughts and plans. those who disclose suicidal plans or intent and who can subsequently be contacted by telephone are administered a structured risk assessment aligned with the new south wales government best practice guidelines, and safety plans are developed for all users to assist them to stay safe while seeking treatment or in the event of an increase in symptoms during treatment. those unable to be contacted are referred to local police for a welfare check. people who continue to express suicidal intent are referred to local mental health services or emergency services, depending on the urgency of the situation. however, patients with suicidal thoughts can also continue to access mindspot services if they agree to a safety plan. mindspot operates under compre hensive internal and external oversight and reporting that includes clinical, organis ational, and infor mation technology governance frameworks. the clinical governance frameworks align with australian national standards for mental health services and include policies, systems, and protocols for identifying patients or others at risk, their management, clinical escalation in the event of increased risk, and training and supervision of staff. people who do not complete an assessment are sent information about managing symptoms, contact details for crisis services, and are invited to contact mindspot. people who complete the assessment are invited to discuss their results with a therapist by tele phone (appendix p ), who provides tailored advice over the appointment of approxi mately min. an assess ment report that identifies clinically significant symptoms and includes information about how to access mental health services (including those offered by mindspot) or other services, is sent by the therapist to the patient and, if requested by the patient, to a nominated health pro fessional, usually a general practitioner. information is also provided about evidence-based techniques for self-managing symp toms. participants who complete an assessment and elect for a mindspot digital treatment course are then enrolled, unless they are considered ineligible for digital treatment by the therapist because their clinical presentation suggests the need for compre hensive or urgent face-to-face assessment. those cases are sup ported to access specialist services. mindspot delivers seven digital treatment courses, which were developed and validated in a series of randomised controlled trials at the macquarie university online research clinic, the ecentreclinic. four of the treatment courses are based on transdiagnostic principles recognising that people often experience symp toms of anxiety and depressive disorders simul taneously, and that similar psychological skills are used to treat these symptoms. the four transdiagnostic courses offered by the mindspot clinic are mood mechanic (for individuals aged - years), the wellbeing course ( - years), wellbeing plus (> years), and the indigenous wellbeing course (for aboriginal and torres strait islander people). , [ ] [ ] [ ] [ ] these four interventions comprise evidencebased psychological treatment components, including psycho education about mediators and moderators of symptoms, cognitive therapy, behavioural activation, graded exposure, sleep training, communication and inter personal skills, problem solving, and relapse prevention. , mindspot also offers disorder-specific courses for obses sive compulsive disorder, post-traumatic stress disorder, and chronic pain. patients can choose a treatment course based on symptoms and demo graphic characteristics, and via telephone consul tation with a mindspot therapist. all courses consist of five lessons delivered over weeks. each lesson comprises a series of slides that presents the principles of psychological treatment for the target symp toms via text and images, based on an instructional design that accommodates both didactic and case-based learning. course completion is defined as completion of four or more lessons. courses are delivered online with regular support initiated from the therapist once a week, either via telephone, secure email, or both. the therapist is also available at any time throughout the course. the approximate amount of therapist time per patient per course ranges from around · h to h. therapist time includes all contact with patients, pre paration time for each patient including reading and responding to messages, and administration for the ecentreclinic see www.ecentreclinic.org for the australian department of health national standards for digital mental health services see https://www. safetyandquality.gov.au/ standards/national-safety-andquality-digital-mental-healthstandards see online for appendix and super vision time during treatment and during follow-up. course materials are available online, although around % of people elect to receive materials via a printed workbook, sent by postal mail. in addition to the therapist-delivered treatment courses, a month trial of telephone-based counselling was conducted in , and a self-guided version of the wellbeing course was introduced in , the results of which will be reported elsewhere. standardised and validated symptom questionnaires are administered to patients at the screening assessment and throughout treatment. for the purposes of this study, treatment out comes on the patient health questionnaire- (phq- ), generalized anxiety disorder -item scale (gad- ), and kessler psychological distress -item plus scale (k- +) were analysed as treatment outcomes. the phq- consists of nine items measuring symptoms of major depressive disorder according to criteria of the diagnostic and statistical manual of mental disorders, th edition. scores range from to , with a score of or more indicating a diagnosis of depression. the gad- consists of seven items and is sensitive to the presence of generalised anxiety disorder, social phobia, and panic disorder. scores range from to , with a score of or more indicating the probable presence of an anxiety disorder. the k- + was used as a secondary outcome measure to assess general psychological distress and disability. the first ten items comprise the kessler psychological distress -item scale (k- ), with scores ranging from to and scores of or more associated with the presence of anxiety and depressive disorders. the k- + contains four additional questions used to assess the functional effect of the psychological distress. in the current analysis, we used two of the additional questions to assess the number of full and part days a person had been out of role (unable to do usual duties and activities) in the past month. we also report the quantifiable k- score. patients are admin istered the phq- and gad- at the screening assessment, once a week during treatment (days , , , , , , and ), post-treatment (day ), and at a month follow-up (day ). patients complete the k- + at the screening assessment, the start of treatment (day ), midtreatment (day ), post-treatment (day ), and the month followup (day ). patients also complete a satisfaction questionnaire post-treatment. the satis faction questions we report on are: "would you recommend this course to others?" and "was it worth your time doing this course?" all questionnaires are delivered online and patients have weeks to complete the post-treatment and follow-up questionnaires before they are considered closed. we did descriptive analyses of demographics, service preferences, and baseline symptoms for the total sample and for each year. for categorical variables, χ² analyses of linear-by-linear associations were used to examine trends with time. anova was used to examine the significance of changes to continuous variables with time. χ² values represent changes in categorical variables over time, and f-values from anova represent significant differences in dependent variables, with years as the independent variable. generalised estimating equation (gee) models with wald's χ² as the test for significance were used to examine changes in symptom measures from assessment to post-treatment and the month follow-up. con sis tent with the principles of intention-totreat analy ses, we imputed missing data for all patients starting treatment, using separate gee models that assumed data were missing at random, and adjusted for baseline symptoms and lesson completion. an unstructured working correlation matrix and maximum likelihood estimation were used, and gamma distribution with a log link response scale was specified to address positive skewness in depen dent variable distributions. we calculated the clinical significance of change in phq- , gad- , and k- measures using per centage change in symptoms from baseline and within-group cohen's d effect sizes, based on the esti mated marginal means derived from gee modelling at the screening assessment, post-treatment, and the month follow-up. reliable recovery was calculated as the proportion of patients whose scores were higher than the clinical cutoffs of primary measures (phq- ≥ or gad- ≥ ) at assess ment and lower than the cutoffs post-treatment, with evidence of reliable change. reliable change was defined as a change of at least points on the phq- and at least points on the gad- . , reliable deter ioration in patients who completed treatment was defined as a score increase of at least points on the phq- and at least points on the gad- post-treatment. data were analysed with spss (version . ). a significance level of · was used for all tests, with the bonferroni correction applied for multiple comparisons. there was no funding source for this study. during the first years of clinic operation from jan , , to dec , , a total of online screening assessments were started, of which ( · %) were completed (figure). the number of people starting an assessment at mindspot increased consistently from to , and subsequently plateaued at around per annum as directed by funding contracts. a breakdown of completed assessments by year is available in the appendix (p ). demographic characteristics of the total sample and by year, representing all those who started the screening assessment, are shown in table . the mean age of patients in the total sample was · years (sd · ) and ( · %) were women. during the years of clinic operation, small but significant changes were observed in the age, sex, indigenous status, employment, education, and mar ital status of people initiating an assessment. for age, we observed a slight increase in the proportion of people aged - years with time, and less change in the proportion aged years and older (appendix p ). the proportion of women fluctuated between · % and · %, and the proportion of people married decreased from · % in to · % in . the proportion of patients born in australia remained around · %, while the proportion identifying as aboriginal or torres strait islander increased from · % in to · % in . we observed some change in employment status over time, particularly in the proportion of students ( · % in to · % in ), and a concurrent increase in the proportion of people with a university degree ( · % to · %). the proportion of patients living outside capital cities remained relatively stable ( · % for the total sample of - ). proportions of patients from each state and territory are shown in the appendix (p ). almost a third of respondents were from new south wales. reported psychological symptoms and stressors at the time of the screening assessment by year are shown in table . in years of clinic operation, significant fluctuations were observed in symptoms. mean scores at assessment (baseline) on the phq- decreased from · (sd · ) in to · ( · ) in , with a con current decrease in the proportion of people self-reporting current difficulties with depression during that period. mean baseline scores on the gad- remained close to the mean for the whole period ( · [ · ]; with the exception of · in the first year), although the pro portion reporting anxiety or worry increased over the years. mean baseline k- scores decreased slightly, from · ( · ) in to · ( · ) in . based on a series of questions specifically about suicidal thoughts, intentions, and plans, the proportion of people reporting thoughts relating to suicide fluctuated between · % and · %, while the proportion reporting both suicidal thoughts and current intent or a plan increased from · % in to · % in . signi ficant changes over time were also observed in reported psycho social stressors. the proportion of people repor ting relationship difficulties increased, while the pro portions of people reporting vocational, physical health, or financial difficulties decreased (table ) . service use and preferences by year are reported in table . significant changes were observed in the main reported purpose of using mindspot among patients during the first years of clinic operation. from to , the proportion of people using mindspot primarily for assessment and infor mation increased from · % in to · % in , while the prop ortion primarily seeking online treatment decreased, from · % in to · % in . table also reports the reasons participants gave for using an online service rather than a face-to-face service. since intro duction of the question in , around a third of respondents consistently reported convenience and (absence of) cost, and another third reported privacy and anonymity as their main reason. over years, · % to · % patients reported that they had never previously seen a mental health professional. · % to · % patients reported speaking to a general practitioner about their mental generalized anxiety disorder -item scale kessler psychological distress -item scale data are mean (sd) or n/n (%), where numerators are the number of positive responses and denominators are the number of patients who provided an answer to that question. *questions introduced july, . †questions regarding the duration of symptoms (anxiety or depression > months) were introduced sept, ; for both, the denominator is the number of people who reported current relevant symptoms and provided a response to the duration question. ‡missing data for the last quarter of due to system changes. gee analyses showed significant overall symptom reductions in phq- (wald's χ²= · , p< · ), gad- (wald's χ²= · , p< · ), and k- (wald's χ²= · , p< · ). pairwise comparisons showed that scores on all measures decreased significantly from assessment to post-treatment and from assessment to follow-up (all p< · ). analyses of the clinical significance of treatment outcomes by year revealed consistent results, with symptom reductions post-treatment for all years on all measures (appendix pp - ). this study described the demographic characteristics, service preferences, and symptoms of more than users of a national dmhs, collected during years of clinic operations. users of the service repre sented a broad cross-section of the australian popu lation, many of whom were seeking a confidential assessment rather than treatment. those who did engage in treat ment achieved significant reductions in symptoms that were sustained for up to months. the results confirm the efficacy and efficiency of mindspot in provi ding evidence-based assessment and treatment to large numbers of people, data are n/n (%), where numerators are the number of positive responses and denominators are the number of patients who provided an answer to that question. *missing data from july to dec, , due to system changes. †data available from july, . ‡question introduced april, ; missing data for due to system changes. table : mental health service preferences and use at assessment many of whom are not accessing other services. our findings contribute to the evidence in support of dmhs within contemporary mental health systems. consistent with reports before , , mindspot has continued to serve a broad and geographically dispersed cross-section of the australian population. some changes in demographics and symp toms have occurred with time, including an increase in the proportion of young adult users, an increase in the proportion identifying as aboriginal or torres strait islander, and an increase in people reporting anxiety. a key observation was the increase in proportions of people reporting a primary purpose for contacting mindspot was to receive an assessment rather than treatment. many patients reported to therapists that a confidential assessment was the only intervention required at the time of consultation. this finding suggests that a dis cussion with a therapist about the nature of symptoms and treatment options is valued by many people, and can serve as a brief therapeutic intervention in itself. the data also raise important questions about engagement and attrition in digital and traditional mental health services, and whether all patients accessing a service can be assumed to be treatment-seeking. these results confirm our view that dmhs should align with patient-centred models of care, and offer a range of services, including education, assessment, triage, support to access urgent help for people in crisis, and referral, as well as providing evidence-based treatment. with regard to treatment outcomes, the overall magnitude of clinical improvements obtained across the mindspot treatment courses remain consistently high, with greater than % symptom reductions in anxiety and depression post-treatment, which were sustained for up to months. outcomes compare favourably with bench marks relating to substantial clinical improvement, low rates of deterioration, and high patient satisfaction with dmhs in other countries, including when offered in primary care, and via other initiatives for large-scale implementation of psychological treatment in australia and the uk. this study has several limitations. we report on characteristics and outcomes of patients registering for assessment or treatment with mindspot, which restricted our sample to a small proportion of visitors to the mindspot website (> per year), and limits the generalisability of our results. we also acknowledge the issue of missing responses, which is a limitation of many studies, particularly those reporting outcomes obtained in routine care, in which patients are receiving a service rather than participating under controlled trial con ditions. the absence of a control group also means that we are unable to account for natural remission or the effect of missing data. however, this limitation was mitigated by the weekly collection of symptom scores during treatment and by conservative statistical modelling, and we found no indication of systematic bias in trends over time due to missing data. a post-hoc analysis did find some evidence that young patients and those with severe symptoms are not necessarily continuing to or completing treatment (appendix p ), which might affect the generalisability of our results. generally, we found that several key demographic factors, such as the proportion of people born overseas, distribution by states and territories, indigenous status (aboriginal and torres strait islander), and proportion living in rural or remote regions, closely matched national statistics. however, we acknowledge that other factors might be under-represented or over-represented in our sample. for example, the proportion of men contacting mindspot was always less than %, an underrepresentation consistent with reports that men are less likely to seek help for anxiety and depression from traditional mental health services, despite having higher rates of suicide than women. , the question of how to engage men in both traditional mental health services and dmhs remains important and might require new service models. despite these limitations, our results show that a high-volume digital mental health service can be successfully implemented as part of routine care. the main stren gths of this study are the analyses of comprehensive data on a large consecutive sample, combined with the regular measurement of symptoms to monitor treatment effects. furthermore, treatment results over years match those reported in earlier papers, confirming the robust nature of the digitised clinic procedures and clinical effects. as of , mindspot has been operating for more than years. in that time, the delivery of health care, including some forms of mental health care, via digital technology has become increasingly acceptable. services such as mindspot have shown that digital deli very of care increases accessibility and convenience for patients and can reduce other barriers to care such as stigma. other key learnings from mindspot are that dmhs could have an important role in contem porary mental health care, not only by providing treat ment, but also by providing infor mation and assessment services to diverse groups of people that often under-utilise traditional health services, including indigenous australians, and people living in rural and remote regions. , we maintain that dmhs are not a panacea and should not replace existing services, but instead can complement those services by reducing barriers and delivering evidence-based care to large numbers of patients in an efficient and cost-effective way. , people who do not respond to dmhs can then be supported to seek more intensive treatment, consistent with a stepped-care approach. an important feature of dmhs is the potential for systematic measurement of progress via treatment and outcomes, which is rarely implemented with existing service models. by providing services to large numbers of people and routinely collecting and reporting data about user characteristics and clinical outcomes, dmhs are not only providing valuable benchmarking data, but are having a growing influence on the planning of mental health systems across an increasing number of countries. the routine collection and reporting of user data, with the exception of the uk's iapt model, is not typical of publicly funded psychological services. thus, such reporting by dmhs is not only increasing unde rstanding among policy makers on the relative strengths and limitations of different service models, but is likely to lead to increased expectations from funders and policy makers for similar reporting from traditional services. in the long term, this influence might lead to policy and funding decisions based more on evidence than traditional practice, but in the short term this will require change in the culture and operations of services that do not routinely collect or report these kind of data. developing, delivering, and evaluating dmhs is challenging, requiring complex procedures and ongoing evaluation in the context of ever-changing technology and a rapidly evolving governance and regulatory envi ronment. despite the challenges, we no longer need to question whether dmhs will become part of the frame work of mental health services. the new question is, how will this integration occur and how do we best integrate dmhs with existing face-toface services? based on the preferences of many patients for more easily accessible, confidential mental health care, we believe that a need will be ongoing for stand-alone services, which provide the option of assessment and treatment and are not always linked with an existing provider. ideally, existing mental health services should receive support to deliver both face-toface and digital mental health care, and we strongly recommend engagement during the development and implementation of these services with patients and other stakeholders, including policy makers and funders, to ensure that services are not only effective but also acceptable. mental health professionals could then be trained and equipped to use digital tools with their own clients, to improve both quality of care and collection of treatment outcome data. without such training and support, patients are unlikely to receive consistently high-quality care, and funders are unlikely to receive data on clinical outcomes to guide service or programme improvements. the mindspot project has become one of the leading providers globally of dmhs as part of routine care and has deli vered mental health services with proven effectiveness to a large number of australians in its first years. the consistency of results provides support for the adoption of this model of care within the national mental health system, particularly in the present context of increased consumer acceptance of digital and telephone health-care services. nonetheless, we maintain that the role of dmhs is to provide consumers and referrers with an additional choice of service model. the prevalence and burden of mental and substance use disorders in australia: findings from the global burden of disease study addressing mental health needs: an integral part of covid- response global, regional, and national incidence, prevalence, and years lived with disability for diseases and injuries for countries, - : a systematic analysis for the global burden of disease study estimating treatment rates for mental disorders in australia has increased provision of treatment reduced the prevalence of common mental disorders? review of the evidence from four countries barriers to mental health treatment: results from the national comorbidity survey replication advantages and limitations of internetbased interventions for common mental disorders from research to practice: ten lessons in delivering digital mental health services transparency about the outcomes of mental health services (iapt approach): an analysis of public data the first months of the mindspot clinic: evaluation of a national e-mental health service against project objectives australian government department of health and ageing mindspot clinic: an accessible, efficient and effective online treatment service for anxiety and depression rapid report: early demand, profiles and concerns of mental health users during the coronavirus (covid- ) pandemic a comparison of indigenous and non-indigenous users of mindspot: an australian digital mental health service a comparison of the characteristics and treatment outcomes of migrant and australian-born users of a national digital mental health service the strengthening the reporting of observational studies in epidemiology (strobe) statement: guidelines for reporting observational studies mental health triage policy procedures for risk management and a review of crisis referrals from the mindspot clinic, a national service for the remote assessment and treatment of anxiety and depression transdiagnostic versus disorder-specific and clinician-guided versus self-guided internet-delivered treatment for generalized anxiety disorder and comorbid disorders: a randomized controlled trial disorder-specific versus transdiagnostic and clinician-guided versus self-guided treatment for major depressive disorder and comorbid anxiety disorders: a randomised controlled trial internet-delivered treatment for older adults with anxiety and depression: implementation of the wellbeing plus course in routine clinical care and comparison with research trial outcomes internet-delivered treatment for young adults with anxiety and depression: evaluation in routine clinical care and comparison with research trial outcomes the phq- : validity of a brief depression severity measure a brief measure for assessing generalised anxiety disorder: the gad- anxiety disorders in primary care: prevalence, impairment, comorbidity, and detection short screening scales to monitor population prevalences and trends in non-specific psychological distress primary mental health care minimum data set. scoring the kessler- plus to gee or not to gee: comparing population average and mixed models for estimating the associations between neighborhood risk factors and health wish you were here": examining characteristics, outcomes, and statistical solutions for missing cases in web-based psychotherapeutic trials measurement of symptom change following web-based psychotherapy: statistical characteristics and analytical methods for measuring and interpreting change the first months of the mindspot clinic: evaluation of a national e-mental health service against project objectives icbt in routine care: a descriptive analysis of successful clinics in five countries evaluation of the practitioner online referral and treatment service (ports): the first months of a state-wide digital service for adults with anxiety, depression, or substance use problems australia's better access initiative: an evaluation the australian version of iapt: clinical outcomes of the multi-site cohort study of newaccess why are australia's suicide rates returning to the hundred-year average, despite suicide prevention initiatives? reframing the problem from the perspective of durkheim the cost-effectiveness of the online mindspot clinic for the treatment of depression and anxiety in australia the mindspot clinic is a project funded by the australian government. the authors gratefully acknowledge the patients for allowing the use of their data and the efforts of staff at macquarie university (access macquarie, mq health, mindspot clinic, and ecentreclinic) in launching and operating the clinic. all authors contributed equally to the manuscript. nt and bfd are authors and developers of the treatment courses used at the mindspot clinic but derive no personal or financial benefit. bw coauthored the obsessive compulsive disorder course used at the mindspot clinic with nt and bfd but derives no personal or financial benefit. nt serves as chair of an expert advisory group appointed to support the australian commission for safety and quality in health care to develop a national standards and certification framework for digital mental health services. all other authors declare no competing interests. access to de-identified data might be provided on reasonable request. requests are subject to the establishment of appropriate data governance, and the approval of an independent and recognised human research ethics committee. requests must be made in writing to dr lauren staples, mindspot clinic, macquarie university, sydney, nsw , australia (lauren.staples@mq.edu.au). key: cord- - cjogxz authors: nan title: th annual meeting of the austrian society of surgery. vienna, june – , . guest editors: albert tuchmann, erhard schwanzer, benedikt walzel date: journal: eur surg doi: . /s - - - sha: doc_id: cord_uid: cjogxz nan die transinguinale präperitoneale hernioplastik wurde in ihren grundzügen bereits in den er jahren beschrieben. im deutschsprachigen raum erfuhr das verfahren durch die arbeiten von schumpelick eine gewisse bedeutung. pelissier entwickelte basierend auf diesen grundlagen einen patch, welcher mit einem memory-ring armiert wurde und alle hernienkompartimente der leiste abdeckt. basierend auf durch die autoren seit oktober durchgeführten hernienreparationen wurden die daten prospektiv erfasst und unter anderem die komplikationen und rezidive analysiert. hinsichtlich der intraoperativen komplikationen ergaben sich , % probleme wie blasenläsion und verletzung der epigastrischen gefäße. postoperative komplikationen wurden in fällen ( , %) beobachtet. insgesamt wurden rezidivhernien diagnostiziert (bis monate nach implantation), wobei die verteilung der rezidive uneinheitlich ist. es besteht bislang kein signifikanter unterschied zwischen fixierung mit resorbierbarem oder nicht resorbierbaren nahtmaterial. ungeschlitzte netze zeigen häufiger rezidive. die beschaffenheit des patches begü nstigt im einzelfall wahrscheinlich die rezidiventstehung. netze wurden wegen einer schmerzsymptomatik im bereich des schambeines entfernt ( - d post op), netz wegen schmerzen am netzoberrand m nach implantation. bezü glich der allgemeinen komplikationen unterscheidet sich das verfahren nicht von den gängigen hernienreparationen, die rezidivrate ist auch im längeren beobachtungszeitraum gering. es werden die problemzonen des patches diskutiert. klinisch diagnostizierte hernien ohne peritoneale ausstülpung c. hollinsky, s. sandberg kh floridsdorf, chirurgische abteilung, vienna, austria grundlagen. bei der laparoskopischen transabdominalen präperitonealen meshplastik (tapp) kö nnen leistenoder femoralhernien hinter einem intakten peritoneum verborgen sein. methodik. in einer prospektiv kontrollierten studie wurden alle laparoskopischen hernienoperationen der letzten jahre analysiert. präoperativ wurden alle hernien vom operateur klinisch untersucht und bei unklarem befund wurden ergänzend ultraschall sowie in seltenen fällen ein mrt durchgeführt. intraoperativ wurden alle suspizierten hernien auf das vorliegen eines peritonealen herniensacks untersucht sowie die im präperitonealraum eingesehene pathologie dokumentiert. in einer multivariaten regressionsanalyse wurden eventuelle risikofaktoren auf deren zusammenhang mit einer hernie ohne peritonealdefekt ermittelt. ergebnisse. bei , % der hernien war intraoperativ kein peritonealer herniensack ersichtlich. dabei handelte es sich in erster linie um femoralhernien sowie durch präperitoneales fett ausgefüllte inguinalhernien. bei der multivariaten regressionsanalyse zeigte sich neben der femoralhernie sowohl die bruchpfortengröße als auch das alter als signifikante risikofaktoren für hernien ohne peritonealbeteiligung. schlussfolgerungen. aufgrund dieser ergebnisse sollte bei klinisch diagnostizierten hernien der inguinalregion intraoperativ der präperitonealraum inspiziert werden. feasibility and potential advantages of transporous mesh fixation by a laparoscopic spray system (lss) in inguinal hernia repair excellent fixation accompanied by a reduction of the amount of fs required. investigation of a new self-gripping mesh for hernia repair in a rat model in der modernen hernienchirurgie verdrängen netzbasierte therapien zunehmend die klassischen nahttechniken. in dieser untersuchung haben wir ein neues selbstfixierendes netz (parietene progrip) im tiermodell ratte im vergleich zu einem standardnetz (parietene light) erprobt. ziel war der vergleich der zugfestigkeit tage und monate nach aufbringen der netze auf die bauchmuskulatur. die fixierung erfolgte bei dem progrip-netz nur durch mikrohaken, bei dem parietene light mittels titanklammern, gewebekleber oder ohne fixierung. im zugversuch wurde die scherfestigkeit ermittelt. außerdem erfolgte eine histologische untersuchung auf entzü ndliche reaktionen sowie eine elektronenmikroskopische untersuchung auf materialdegradation. nach tagen zeigten progrip-und stapler-fixierung ähnlich gute zugfestigkeiten ( , n/cm ; , n/cm ), wohingegen mit gewebekleber fixierte netze genauso wenig halt hatten wie unfixierte netze ( , n/cm ; , n/cm ; p < , ). nach monaten waren die progrip-netze signifikant besser auf dem gewebe fixiert verglichen mit stapler, kleber und ohne fixierung ( , n/cm vs. , n/cm ; , n/cm und , n/cm ; p < , ). die histologische untersuchung zeigte nach tagen entzündliche reaktionen im fremdkörperbereich bis in das umgebende bindegewebe. nach monaten ist diese gewebsreaktion deutlich zurückgegangen, es sind kaum noch entzündliche zellen zu finden. stattdessen ist das netzmaterial vermehrt von riesenzellen umhüllt. die progrip-mikrohaken reichen deutlich in die muskulatur und sorgen dort für eine gute verankerung. die elektronenmikroskopische untersuchung konnte keinerlei materialveränderungen nach tagen oder monaten im vergleich zu neuem netzmaterial feststellen. schlussfolgerungen. das progrip netz zeigte eine deutlich bessere fixation im gewebe als der hernienstapler oder der fibrinkleber und ist zu diesen vergleichsfixationen eine kostengünstige alternative. grundlagen. der verschluss von trokarinzisionen ü ber mm wird empfohlen aufgrund des risikos einer narbenhernienentstehung. insbesondere bei adipösen patienten ist dieser verschluss mit herkömmlichen methoden oft schwierig oder nicht durchfü hrbar. in der literatur finden sich hinweise auf eine deutlich erhöhte narbenhernieninzidenz im bereich von trokarstellen nach laparoskopischer narbenbruchoperation. methodik klinik für allgemein-und visceralchirurgie, bassum, germany grundlagen. sonographisch lassen sich präzise befunde zur pathologie der leiste als auch zur postoperativen situation resp. komplikationen erheben. fragestellung. bringt der routinemäßige postoperative einsatz der sonographie zusätzliche relevante befunde zur verlaufskontrolle? methodik. leistenhernien wurden nach transinguinaler präperitonealer hernioplastik (tipp) versorgt und im rahmen der routinemäßigen postoperativen kontrolle nach - tagen zusätzlich sonographisch standardisiert nach netzlage, hämatomen/seromen und samenstrangdurchblutung untersucht. ergebnisse. in allen fällen fand sich eine korrekte netzlage, es fand sich kein rezidiv. in fällen lag eine vermehrte netzwellung vor ( , %), meist medial, selten lateral. in / fällen ( , %) fanden sich hämatome/serome > cm schichtdicke, deutlich häufiger > mm ( / ), kleinere hämatome noch häufiger. keines der tiefen hämatome musste revidiert/punktiert werden, oberflächliche hämatome wurden revidiert, patienten wurden ein-oder mehrfach punktiert. postoperative hydrocelen wurden beobachtet. die durchblutung von samenstrang oder hoden war sonographisch in allen fällen intakt. schlussfolgerungen. die routinemäßige sonographie-kontrolle nach leistenhernienoperation (hier tipp) hat nur gelegentlich therapeutische konsequenzen fast immer zusammen mit dem klinischen befund. aufgrund der ergebnisse sollte daher ein on-demand-vorgehen als ausreichend angesehen werden. in hinblick auf die bestätigung des frühen postoperativen befundes wird die routinemäßige sonographische kontrolle von den meisten patienten aber als positive bestätigung angesehen. das video zeigt eine neue onkoplastische technik beim mammakarzinom. die tumorquadrantektomie wird dabei im rahmen einer reduktionsplastik mit superior gestieltem pedikel durchgefü hrt. der inferiore pedikel, der normalerweise reseziert wird, wird dabei zur defekdeckung genutzt. ist eine resektion des tumors mit darü berliegender haut nötig wird der inferiore pedikel nicht komplett de-epithelisiert, sondern mit hautinsel in den defekt eingeschwenkt. die technik erlaubt rekonstruktion auch von kleinen und mittelgroßen brü sten, sowie von defekten im inneren quadrant der kontralateralen brust. oncoplastic surgery: the use of a breast reduction to improve cosmetic outcome for breast conserving surgery (video) oncoplastic techniques have increasingly been used in the last years in europe and the united states. several techniques have been described. beside the use of local and free flaps after mastectomy the use of breast reduction techniques solved several problems for breast conserving surgery. this video demonstrates one possible technique to improve breast symmetry during breast conserving surgery. skin-sparing mastektomy and immediate reconstruction of the breasta videopresentation grundlagen . die erhaltung der kosmesis im rahmen der chirurgischen therapie des mammakarzinomes ist von zentraler bedeutung. trotz der vielfachen möglichkeit einer brusterhaltenden therapie, zwingen spezielle indikationen auch heutzutage noch zu einer kompletten entfernung des brustdrü dengewebes. dabei kommen immer häufiger hautsparende techniken bis hin zur erhaltung der areola oder sogar der mamille zur anwendung. im rahmen einer videopräsentation soll die technik der skin-sparing mastektomie und sofortrekonstruktion der brust veranschaulicht werden. methodik. von patientinnen, die seit mai an unserer abteilung eine brustrekonstruktion erhielten, konnten in fällen hautsparende techniken angewendet werden. zur präsentation der technik der skin-sparing mastektomie mit sofortrekonstruktion der brust wurde ein operationsvideo angefertigt. ergebnisse. die im video präsentierte technik führt zu einem kosmetisch ansprechenden ergebnis für die patientin. schlussfolgerungen. um fü r die patientinnen optimale postoperative resultate erreichen zu können, sollte die vorgestellte technik einen integralen bestandteil des therapiekonzeptes des mammakarzinoms darstellen und den patientinnen schon nach der diagnosestellung offeriert werden. the treatment of nonhealing and infected sternotomies following cardiac surgery is a challenging task, with increased rates of mortality and morbidity, as well as high costs. local vacuum therapy (v.a.c. system) permits the treatment of deep sternal infections due to continuous aspiration and a sealed dressing which stimulates granulation tissue formation. aggressive vacuum-assisted closure treatment of the sternum in postoperative deep wound infection enhances sternal preservation and the speed of potential rewiring. after some weeks of v.a.c.-therapy a complete preparation of the substernal structures is necessary. in this context laceration of the right ventricle is a rare, but lifethreatening complication. we describe a new technique for sternal closure after vacuum-assisted wound treatment using nitinol clips which can prevent these severe complications. without any preparation of the substernal tissue the clips can be inserted in the parasternal space with consecutive proper stabilization of the sternum. this new method represents an easy, low-cost and complication-free procedure. der gelegentlich oder ungelegentlich angemahnte ,,hippokratischer eid'' ist kaum wegweiser für chirurgie, keineswegs weltweite norm, operationen werden ausdrücklich verboten. chirurgie muss also auf die praktische ethik zurückgreifen und daraus gültige moralische und wissenschaftliche (cochrane; ) prinzipien ableiten. diese prinzipien beruhen heute auf partnerschaftliche arzt-patient-beziehung, schadensvermeidung, dem bewusstsein und der daraus folgenden demut, dass der eingriff als schwere körperverletzung, unter dem aspekt der möglichen heilung, durchgeführt wird und gerechtigkeit -handeln ohne ansehen der person. darauf basierend wird in der neuzeit gelehrt. dies sollte auch mitverantwortlichen spitalsökonomen vermittelt werden. grundlagen. immer wieder ist man in der ärztlichen tätigkeit mit den begriffen offlabel, offlicence, compassionate use, orphan drug, individueller heilversuch und experimentelle behandlung konfrontiert. leider gibt es für die wenigsten dieser begriffe gesetzliche definitionen im österreichischen recht, sie werden deshalb oft widersprüchlich und manchmal falsch verwendet. ziel dieser arbeit ist es diese begriffe klar darzustellen und ihre gesetzlichen grundlagen aufzuzeigen. methodik. identifikation der gesetzlichen grundlagen mit hilfe des österreichischen rechtsinformationssystems, pubmed suche und google suche. diese daten werden verknüpft und zur begriffsbestimmung verwendet. es werden die jeweiligen rahmenbedingungen zur anwendung dargestellt und die auswirkungen auf die ärztliche haftung aufgezeigt. ergebnisse. auflistung der entsprechenden österreichischen gesetze sowie eu verordnungen und richtlinien. die begriffe offlabel und offlicence sind im österreichischen recht als rechtsbegriffe fremd, dennoch finden sich im arzneimittelgesetz entsprechend anwendbare rahmenbedingungen, dem jedoch zum teil die bestimmungen im allgemeinen sozialversicherungsgesetz gegenüber stehen. die begriffe compassionate use und orphan drug sind durch eu verordnungen und richtlinien geregelt. experimentelle behandlung ist nach dem arzneimittel-und medizinprodukte gesetz nur im rahmen klinischer prüfungen zulässig. schlussfolgerungen. alle angeführten modalitäten sind unter bestimmten rahmenbedingungen, vor allem die qualifizierte einwilligung, in Ö sterreich zulässig. allerdings kann dabei die haftung vom hersteller vollständig auf den behandelnden arzt/ Ä rztin übergehen. grundlagen. abseits von klassischen arzneimittel-(amg) und medizinprodukt-(mpg) studien gibt es immer wieder unklarheiten ob die ethikkommission zu beschäftigen ist oder nicht. die vorliegende arbeit analysiert dazu die gesetzlichen grundlagen Ö sterreichs, der eu und internationaler organisationen, sowie zusätzliche bestimmungen der österreichischen medizinuniversitäten. methodik. identifikation der gesetzlichen grundlagen mit hilfe des österreichischen und eu-rechtsinformationssystems, pubmed suche und google suche. die ergebnisse werden nach rechtlicher bindung vom nationalen recht bis zu internationalen empfehlungen dargestellt. es werden die strafbestimmungen im zusammenhang mit studien analysiert. ergebnisse. in Ö sterreich gibt es drei arten von ethikkommissionen: forschungs-, klinische-und bio-ethikkommission. für die klinische forschung beschränkt sich die weitere analyse auf die forschungs-ethikkommission. die österreichischen gesetzlichen grundlagen reichen vom arzneimittelgesetz (amg) bis zum universitätsgesetz (ug), hinzu kommen die universitären gsp bestimmungen und zahlreiche sonderfälle von anwendungsbeobachtungen bis zu biodatenbanken. auf eu ebene ist die rl / /eg und rl / /eg maßgeblich, international die ich, gcp und who richtlinie für ethikkommissionen. fü r die publikation können zusätzliche anforderungen wie z.b. von wame (world assocation of medical editors) und icmje (international committee of medical journal editors) gestellt werden. die strafbestimmungen im österreichischen recht werden aufgezeigt. schlussfolgerungen. die dargestellte rechtliche situation ist überaus komplex, deshalb wird es notwendig sein an universitäten aber auch extrauniversitär entsprechende beratungsstellen einzurichten. die zunehmenden anforderungen werden zu einer Ü berhäufung der ethikkommissionen mit anträgen führen. ein möglicher ausweg ist die trennung in begutachtungspflicht (für amg/mpg studien) und beratungspflicht wie in deutschland sowie die einführung von institutional review-boards als filter zwischen forscherinnen und ethikkommissionen. background. egfr-targeted therapies are a novel and very effective chemotherapeutic approach for advanced nsclc. how-ever, the predictive factors for therapeutic response are not entirely known. one of the reasons of therapy failure might be the change of egfr status during the course of disease, or an altered egfr status in metastases as compared to the primary tumor. using autopsy material, we compare here systematically the egfr status of nsclc metastases with the primary tumor. methods. autopsy cases from our institution with metastatic nsclc have been retrieved from the archive. the specimens of primary tumor and of all metastases have been stained by anti-egfr and re-evaluated by two independent observers. in addition, basic clinical parameters have been retrieved from the charts. the egfr status in primary tumor and metastases has been compared by statistical means. results. we examined a total of patients. the mean age at death was . years; the male:female ratio was : . most patients suffered from adenocarcinoma ( . %). most patients were in stage iv with multiple metastases at different body sites. while all primary tumors were egfr-positive, only in cases metastases were egfr-negative. both egfr staining intensity and extension of egfr-positive cells were in most cases identical. thus, statistical analysis failed to detect a significant difference in staining behavior between primary tumor and metastases. conclusions. the expression of egfr in metastases of nsclc is almost identical to egfr expression in the primary tumor. thus, in egfr-positive advanced nsclc egfr-targeted therapy is reasonable. grundlagen. es erfolgte eine retrospektive analyse der stationär und operativ behandelten handinfekte an unserer abteilung der letzten jahre. methodik. die krankengeschichten aller patienten die an unserer abteilung wegen eines handinfektes zwischen und operiert wurden sind retrospektiv ausgewertet worden. die patienten wurden in gruppen eingeteilt (panaritien, spritzenabszesse und phlegmonen) und miteinander verglichen. ergebnisse. es wurden patienten ( männer, frauen) mit einem durchschnittsalter von jahren operiert. am häufigsten zeigten sich panaritien ( ) gefolgt von phlegmonen ( ) und spritzenabszessen ( ). die jüngste patientengruppe war mit durchschnittlich jahren bei der operation jene der spritzenabszesse. Ä tiologisch dominierten traumata bei den panaritien und phlegmonen bzw. drogeninjektionen bei den spritzenabszessen. als grunderkrankung zeigte sich bei den panaritien und phlegmonen eine häufung von diabetes und immunsuppression. von patienten mit spritzenabszess waren hepatitis c positiv, von patienten hiv ipositiv. es wurden bis zur vollen abheilung bzw. rekonstruktion insgesamt operationen durchgefü hrt. dies entsprach einer durchschnittlich erforderlichen op-anzahl von , bei panaritien, , bei phlegmonen und , bei spritzenabszessen. die durchschnittliche aufenthaltsdauer war mit tagen bei den panaritien am kürzesten (phlegmone tage, spritzenabszesse tage). insgesamt waren lappenplastiken und amputationen notwendig. schlussfolgerungen. an unserem stark vorselektionierten krankengut zeigte sich das panaritium als die häufigste infektion an der hand mit der geringsten anzahl an notwendigen eingriffen und der kürzesten aufenthaltsdauer. phlegmone mussten wegen des teilweise sehr ausgedehnten befundes bis zu x operiert werden. durchschnittlich sind operationen bis zur völligen abheilung bzw. rekonstruktion nötig. in der gruppe der spritzenabszesse fanden sich in % staphylokokken, % streptokokken, % andere grampositive und gramnegative keime, % anaerobier, , % mischflora und in % kein wachstum. in der gruppe der phlegmonen fanden sich in % staphylokokken, in % streptokokken, in % andere grampositive und gramnegative keime, in % fand sich mischflora und in % zeigte sich kein wachstum. schlussfolgerungen. die kenntnis des keimspektrums ermöglicht eine adäquate kalkulierte therapie bis zum eintreffen des abstrichergebnisses. im rahmen unserer untersuchungen zeigten sich deutliche unterschiede zwischen den keimspektren von patienten mit panaritien, phlegmonen und spritzenabszessen. diese erkenntnis sollte bei der wahl des geeigneten antibiotikums berücksichtigung finden. grundlagen. grundprinzip der plastisch-chirurgischen infektchirurgie ist seit jeher das radikale chirurgische debridement, gefolgt von anfänglicher offener wundbehandlung. seit jahren kommt das v.a.c.-system zur wundkonditionierung erfolgreich zur anwendung. der defektverschluß erfolgt erst bei beherrschung des infektes durch auffüllung des totraumes durch gut durchblutetes gewebe, meist lappenplastiken, bei reiner weichteilbeteiligung auch durch einfache spalthauttransplantate. problematisch wird es, wenn aufgrund der anatomischen situation ein radikales debridement nur bedingt möglich ist bzw. eine keimpersistenz zu erwarten ist. methodik. das v.a.c.-instill + ermöglicht ein -stufenprogramm: instillation -einwirkzeit -vakuumtherapie kommen zyklusartig zur anwendung. bei unseren patienten kam ausschließlich ein lokales antiseptikum zur anwendung. das patientengut hatte eines gemeinsam: debridement und geplante defektdeckung schienen für eine infektsanierung unzureichend. wir berichten über patienten, die wegen hämatogenem handgelenksempyem mit beteiligung aller handwurzelknochen an unserer abteilung in behandlung waren. zur anwendung kam der polyvinylalkoholschwamm. die instillationsdauer war unmittelbar von der wundgröße abhängig. die therapiedauer betrug maximal o tage, der v,a,c,-wechsel wurde drei-bis viertägig durchgeführt. die defektdeckung erfolgte durch lokale oder gestielte lappenplastiken. ergebnisse. in allen fällen konnte trotz eingeschränkter radikalität eines chirurgischen debridements eine infektsanierung erzielt werden. schlussfolgerungen. das v.a.c.-instill + stellt für uns ein wertvolles instrument zur infektsanierung in anatomisch problematischen zonen und eingeschränkter möglichkeit eines radikalen chirurgischen debridements dar. grundlagen. handinfektionen wie panaritien und phlegmone stellen eine große gefahr fü r die integrität der hand dar. der schritt zur chirurgischen sanierung muss sorgfältig gestellt werden und richtet sich nach klinischen sowie radiologischen gesichtspunkten. trotz hohen inzidenzen sind nur wenige daten zum langzeitoutcome von chirurgischen eingriffen bezü glich der verbleibenden funktionalität der hand vorhanden. methodik. um das effektive outcome von solchen eingriffen evaluieren zu können wurden alle patienten chirurgisch sanierter handinfektionen an unserer abteilung im zeitraum von - erhoben und anschließend zu einer nachuntersuchung eingeladen. im rahmen der nachuntersuchung wurden sensibilität, kraft und bewegungsumfang der betroffenen extremität untersucht. mittels eines fragebogens wurden subjektive parameter bezüglich der betroffenen region dokumentiert. ergebnisse. von den ausgehobenen patienten erschienen patienten ( %) zur nachuntersuchung. die durchschnittliche patientenzufriedenheit auf einer skala von - lag bei , , eine deutliche einschränkung der bewegungsfreiheit war nur bei patienten evaluierbar ( %). eine objektivierbare bewegungseinschränkung ging stets mit einer verminderung der kraft, sowie sensibilitätsstörungen im bereich der finger einher. generell kann gesagt werden, dass eine weit fortgeschrittene entzündung, die meist durch zuwarten der patienten zustande kam, das outcome verschlechtert. schlussfolgerungen. je nach ausprägung zeigt sich einerseits eine herausforderung an die chirurgische sanierung, anderseits verlängert sich bei zunehmender schwere der infektion die rekonvaleszenzzeit deutlich und eine restitutio ad integro ist meist nicht mehr möglich. immunhistochemische untersuchungen zur pathogenese posttraumatischer und postinfektiöser sehnenadhäsionen logischer narben. ziel dieser studie war, die rolle des immunsystems bei der entstehung von sehnenverwachsungen zu beleuchten. untersucht wurde sehnenscheidengewebe von patient-innen, die sich einer tenolyse unterzogen. sehnenscheidengewebe von frischen leichen diente als kontrolle. immunsuppressive therapie, neoplastische oder infektiöse erkrankungen sowie chronisch entzündliche erkrankungen waren in beiden gruppen ausschlusskriterien. an gefrierschnitten wurden mit hilfe von monoklonalen antikörpern gegen t-lymphozyten und makrophagen immunhistochemische untersuchungen durchgeführt. dabei wurden die t-lymphozyten subtypisiert und ihr aktivierungsgrad bestimmt. im vergleich zur kontrollgruppe zeigte sich eine statistisch signifikante erhöhung von t-lymphozyten im patientengewebe. auch die zahl der zytotoxischen t-lymphozyten war signifikant erhöht, während die erhöhung der zahl der helferzellen nicht signifikant war. auch die zahl der aktivierten t-lymphozyten war signifikant erhöht. im patientengewebe fanden sich auch vermehrt makrophagen, wobei diese erhöhung nicht statistisch signifikant war. die ergebnisse unserer untersuchungen weisen auf eine zentrale rolle der t-lymphozyten bei der entstehung von sehnenverwachsungen hin. weitere untersuchungen zum aktivierungsweg, zur interaktion zwischen makrophagen und t-lymphozyten sowie zur rolle dendritischer zellen in diesem geschehen sollen zu einem weitergehenden verständnis dieser vorgänge führen. der tiefe infekt der hand -diagnostik und therapie am beispiel zweier fallberichte j. erhart, v. vécsei univ.-klinik für unfallchirurgie, wien, austria grundlagen. der tiefe handinfekt ist vital bedrohlich und beinträchtigt die funktion der hand. diese hängt von einem adäquaten therapeutischen konzept ab. methodik. anhand zweier fallberichte wird das management der tiefen handinfektion dargestellt. fall . nach einem bagatelltrauma ohne hautläsion kommt es zu einem tiefen infekt der hand eines mädchens. aufgrund der unklaren Ä tiologie wird ein mrt der hand angefertigt, alle möglichen ursachen ausgeschlossen, die hand der patientin dorsal und palmar debridiert und mit einem vacuumverband behandelt. im abstrich finden sich dorsal und palmar ß-hämolisierende strektokokken. es wird lediglich ein revisionseingriff zum sekundären weichteilverschluss benötigt. zur durchführung der ergotherapie bedarf es eine maximale schmerzausschaltung unter psychotherapeutischer betreuung. sie erlangt eine sehr gute funktion der hand. fall . ein ausgedehnter defekt der weichteile und knochen der handwurzel und des handrü ckens ist nach tagen septisch. die wunde wird debridiert, die defekthöhlen mit septopalketten gefü llt, mit einem radialislappen gedeckt und zur ausheilung gebracht. nach infektsanierung wird das handgelenk arthrodetisiert, die streckfunktion aller langfinger durch interposition von adduktorensehnen wiederhergestellt. schlussfolgerungen. durch die präsentation des ersten falles weisen wir auf das seltene auftreten eines spontanab-szesses der kindlichen hand hin. trotz der dringlichkeit der operation sollte eine sorgfältige abwägung der lokalisation der inzisionen erfolgen, um eine rasche infektbeherrschung durch radikales, in diesem fall beidseitiges debridement zu erzielen. wir weisen auf die extrem aufwändige nachbehandlung hin. der zweite fall ist wegen der doppelfunktion der regionalen lappenplastik zur gleichzeitigen weichteildeckung und infektbeherrschung erwähnenswert. er zeichnet sich durch einen sicheren erhalt der hand und die vollständige wiederherstellung der fingerfunktion aus. free tissue transfer for complex infections of the handa retrospective analysis grundlagen. schwere infektionen im handbereich bedürfen nach ausgedehntem radikalen débridement und bannung der infektion häufig einer komplexen defektdeckung. diese retrospektive analyse umfasst patienten ( männlich, weiblich), welche zwischen juni und märz mit ausgedehnten infektionen an der hand operiert worden sind. ergebnisse. infektursache war in drei fällen ein hundebiss und in zweien ein bagatelltrauma. in zwei fällen war der hautweichteilinfekt auf den handrü cken, in einem auf die hohlhand beschränkt. zwei patienten zeigten einen kombinierten dorsalen und palmaren infekt. bei einem patienten fand sich neben einer ausgeprägten streck-und beugeseitigen infektlokalisation auch ein handgelenksempyem mit bereits stattgefundener knochenzerstörung. der patienten wurden vor der einweisung in die spezialklinik auswärtig durch stichinzisionen mit drainagen und/oder begrenzte nekrosektomien chirurgisch vorbehandelt. bei drei patienten wurde nach einmaligem débridement, bei zweien nach mehrfachdébridements die indikation zur mikrochirurgischen defektdeckung gestellt. diese wurde mit splited-lat.-dorsi-lappen, serratus-ant.-lappen und lat.-oberarm-lappen durchgefü hrt. alle lappenplastiken zeigten einen unkomplizierten primären heilungsverlauf; in zwei fällen erfolgte eine operative nachkorrektur im sinne von kontrakturauflösung, lappenausdü nnung und liposuktion. der patienten verzeichneten nach intensiver postoperativer ergo-und physiotherapie bereits ab der . postoperativen woche einen vollständigen aktiven faustschluss, sowie spitz-und schlü sselgriff. die rom an hand-und sämtlichen fingergelenken betrug zu diesem zeitpunkt % der nicht betroffenen hand. schlussfolgerungen. der mikrochirurgische transfer von fasziokutanen-oder muskel-lappenplastiken stellt eine zuverlässige methode der defektdeckung bei ausgedehnten handinfekten dar. abhängig von ausdehnung und lokalisation des defektes steht die lappenauswahl zum erreichen eines zufriedenstellenden funktionellen und ästhetischen ergebnisses im vordergrund. background. oncolytic viral therapy may offer a promising alternative in highly aggressive tumors such as malignant pleural mesothelioma (mpm), that are insensitive to established chemotherapy and radiation regimes. in the following study, the oncolytic efficacy of newcastle disease virus (ndv (f aa)-gfp) on mpm is tested and investigated by bioluminescence imaging. methods. ndv(f aa)-gfp was tested for viral cytotoxicity at different multiplicities of infection (moi) against several mesothelioma cell lines in vitro. for in vivo studies, msto h cells were transduced with firefly (photinus pyralis) luciferase (fluc)encoding cdnas (msto td h). tumor-bearing animals ( e cells injected intrapleurally) were treated with either single or multiple doses of ndv(f aa)-gfp ( e plaque-forming units pfu should be given as log ) at different time points (days , , and ) and followed by bioluminescence imaging. results. mesothelioma cell lines exhibited susceptibility to ndv lysis in the following order of sensitivity: msto h > msto td h> h- > vamt > jmn (no effect in the cell lines h- , h- , and hmeso) . in vivo studies with msto td h cells showed complete response to viral therapy in > % of the animals, resulting in eradication of tumor detected by bioluminescence. % of the virally treated animals survived > days after tumor injection. no signs of toxicity were observed in the treatment group. in addition, multiple treatments showed a significantly better response compared with single treatment (p ¼ . ). conclusions. ndv appears to be an efficient viral oncolytic agent in therapy of malignant pleural mesothelioma in a murine model, and warrants further investigation as a potential therapeutic agent. university clinic for surgery, graz, austria; institute for pathology, graz, austria background. isolation by size of epithelial tumour cells (iset) is an innovative method for the detection of circulating tumour cells in blood. we want to report our preliminary experiences with this method. methods. blood of patients with liver metastases from colorectal cancer and of five patients with benign liver lesions was analyzed for the presence of circulating tumour cells. therefore blood samples were filtrated through a translucent polycarbonate filter. epithelial cells were retained on the filter due to their large size and thus separated from smaller blood particles. afterwards the filter was stained and evaluated by light microscopy. tumour cells were identified by cytomorphological criteria's. results. no patient with a benign liver lesion had detectable tumour cells in blood, but eight of the twenty patients with liver metastases. see the following table. the difference concerning the recurrence rate between the two groups was statistically significant (p < . ). conclusions. it is possible to detect circulating tumour cells in blood on basis of their size. the most important advantage of this method is the ability to isolate the tumour cells without damaging their morphology. so the isolated cells can be used for further analysis. grundlagen. höhere konzentrationen im tumorgewebe durch drug targeting erhöhen die responserate sowie das gesamtüberleben. einen neuartigen experimentellen ansatz stellt die applikation von in erythrozyten verkapselten chemotherapeutika ( -fu) dar. im lebertumortragenden modell sollten in erythrozyten verkapseltes -fu erstmals appliziert werden. zielsetzung war die technische machbarkeit einer verkapselung von -fu, die bestimmung der biokompatibilität der -fu-erythrozyten sowie die messung der -fu-konzentration im tumorgewebe. methodik. als tiermodell dienten wag-ratten, denen cc -tumorzellen der leber subkapsulär appliziert wurden. nach ausbildung makroskopisch fassbarer solitärtumoren folgte die applikation von verkapselten erythrozyten der ratte, die nach einem hypoosmotischen dilutionsprozeß mit -fu beladen worden waren. es erfolgte die unterteilung in vier gruppen und zeitpunkten, wobei die applikation von unverkapseltem und verkapseltem -fu systemisch und lokal via arteria hepatica erfolgte. tumorgewebskonzentrationen wurden mittels hplc (high performance liquid chromatography) bestimmt. ergebnisse. es konnte eine ausreichende beladung der erythrozyten mit -fu erreicht werden. der nachweis gelang durch zentrifugieren der erythrozyten und anschließender lyse der erythrozytenmembranen. der Ü berstand wurde dann per hplc gemessen. die tumorkonzentration war signifikant (p < , ) gesteigert durch die verkapselung in erythrozyten sowie durch lokoregionäre applikation. die tumorkonzentration wurde als konzentrationszeitkurve (area under the curve auc) vom zeitpunkt - h dargestellt. freíes -fu -fu verkapselt , mg/ml Á min , mg/ml Á min systemische appl. , mg/ml Á min , mg/ml Á min arterielle appl. schlussfolgerungen. die chemische verkapselung von -fu in erythrozyten der ratte ist möglich, wobei ein hoher grad der beladung der erythrozyten erreicht werden kann. es zeigten sich signifikant höhere -fu-tumorkonzentrationen bei der lokoregionären gegenüber der systemischen sowie bei der verkapselung in erythrozyten. expression of integrin-linked kinase and the progression of early-stage nsclc: a pilot study background. although radical resection of early-stage nonsmall cell lung cancer (nsclc) should warrant cure in almost every case, clinical experience teaches that recurrences appear in up to % of cases. therefore, the prognosis is probably codetermined by additional risk factors, which are not described by the tnm scheme. integrin-linked kinase (ilk) is a known molecular risk factor for metastatic progression. in this study we attempt to verify its role in the progression of early-stage nsclc. methods. all stage ia pulmonary adenocarcinoma patients operated until in our institution have been retrieved from the clinical archive, and a follow-up has been conducted. the pathological specimens of the primary tumor have been stained against ilk, two blinded observers have scored the ilk expression. the results have been compared with the clinical data adopting a basic kaplan meier statistics. results. we examined a total of patients ( males, females) with a mean age of years. median follow-up was . years. twenty-eight patients ( %) were ilk-positive, only four ( %) were ilk-negative. eleven ilk-positive patients experienced a recurrence within five years; from those patients, ten died. this corresponds to a -years recurrence-free survival of ae % and a -years overall survival of ae % in ilk-positive cases. conversely, none of the ilknegative patients had a recurrence nor died within five years. conclusions. ilk-negative stage ia nsclc patients have apparently a better tumor-related prognosis than ilk-positive patients. however, these observations have to be extended unto a larger patient cohort. biliverdin reductase: a crucial enzyme in bile pigment mediated tumor inhibition? background. maximization of liver regeneration represents a promising strategy to improve outcomes after extensive liver resection. here, we investigate the role of lipocalin in liver regeneration. methods. lcn þ=þ , lcn þ=À and lcn À=À mice were subjected to / partial hepatectomy. hepatic proliferation was measured by brdu and pcna immunohistochemistry. hepatic lcn expression was analyzed by qrt-pcr and western blots. serum levels of lcn , il- , and tnf-were determined by elisa. results. hepatic regeneration in lcn þ=þ mice was analyzed at , , and h after partial hepatectomy. the peak of hepatic proliferation as indicated by the number of brdu-and pcna-positive cells was confirmed to be at h post surgery. analysis of hepatic lcn expression showed a -fold upregulation only h after liver resection in lcn þ=þ animals with a stepwise reduction during the observation period ( h . -fold, h . -fold, h . -fold). western blots confirmed significant lcn protein over-expression h after partial hepatectomy. also, serum lcn levels were significantly elevated upon liver resection. to determine the biological relevance of lcn induction on liver regeneration, hepatocyte proliferation was analyzed in lcn þ=À and lcn À=À mice h after partial hepatectomy. the number of brdu-and pcna-positive cells did not differ significantly between the groups. however, lcn À=À animals exhibited a significantly elevated baseline liver regeneration ( . -fold lcn À=À vs lcn þ=þ , p < . ). conclusions. up-regulation of lcn after murine partial hepatectomy is striking but without significant impact on hepatocyte proliferation. our results imply that lcn induction upon liver resection either constitutes a redundant pathway or simply displays an epiphenomenon. effect of the probiotic mixture vsl# on epithelial barrier function, tight junction protein expression, and apoptotic ratio in a murine model of colitis background. changes in epithelial tight junction protein expression and apoptosis increase epithelial permeability in inflammatory bowel diseases. the effect of the probiotic mixture vsl# on the epithelial barrier was studied in dextran-sodium-sulphate (dss)-induced colitis in mice. methods. acute colitis was induced in balb/c mice ( . % dss for days). mice were treated with either mg vsl# or placebo via gastric tube once daily during induction of colitis. inflammation was assessed by clinical and histological scores. colonic permeability to evans blue was measured in vivo. tight junction protein expression and epithelial apoptotic ratio were studied by immunofluorescence and western blot. results. vsl# treatment reduced inflammation (histological colitis scores: healthy control . ae . , dss þ placebo . ae . , dss þ vsl# . ae . ; p ¼ . ). a pronounced increase in epithelial permeability in acute colitis was completely prevented by vsl# therapy (healthy control . ae . (ext./g), dss þ placebo . ae . , dss þ . ae . ; p ¼ . ). in acute colitis, decreased expression and redistribution of the tight junction proteins occludin, zo- , claudin- , - , - , and - were observed, whereas vsl# therapy prevented these changes. vsl# completely prevented the increase of epithelial apoptotic ratio in acute colitis (healthy control . ae . (apoptotic cells/ epithelial cells), dss þ placebo . ae . , dss þ vsl# . ae . ; p ¼ . ). conclusions. probiotic therapy protects the epithelial barrier in acute colitis by preventing ( ) decreased tight junction protein expression, ( ) increased apoptotic ratio. background. to prospectively compare the accuracy of liver fat quantification using chemical shift imaging and h mr-spectroscopy at . tesla field strength in patients undergoing major hepatic surgery. methods. the study was approved by our local irb and a total of patients, planned for metasectomy, were prospectively included after signing informed consent. preoperative . tesla mri (trio, siemens) of the liver included t w d gre single breath hold in-and opposed phase sequences (te . / . ms) and a single breath hold single voxel h mr-spectroscopy (voi cm ; te ms). with chemical shift imaging liver fat was quantified with the relative loss of the liver-to-spleen signal intensity ratio on the opposed-phase images compared to the inphase images. with h -spectroscopy liver steatosis was quantified by calculating the integral of the water and fat spectra. the standard of truth was defined by histopathological analysis of the surgical specimens according to a five-point scale ( -no steatosis; -severe steatosis). spearman's rank correlation was used for statistical analysis. results. both h -spectroscopy and chemical-shift imaging showed a high correlation of the liver steatosis grading compared to the histopathological analysis (r ¼ . and . ). the difference between both techniques was not significant (p > . ). conclusions. both, h mr-spectroscopy and chemical shift imaging at . tesla, allow for a noninvasive preoperative assessment of liver steatosis with high correlation to histopathology. the addition of bevacizumab to xelox/folfox is concidered as standard in the neoadjuvant treatment of colorectal cancer liver metastases. since bevacizumab does not exert direct cytotoxicity, the concept of tumor response as indicator of efficacy upon neoadjuvant therapy containing bevacizumab is being challanged. cytotoxic therapy of liver metastases results in pathologic response of various grades, however the effect of bevacizumab on pathologic response is unclear. we retrospectively analyzed specimen of liver metastases of patients treated with xelox/folfox or xelox plus bevacizumab. we report that bevacizumab, when combined with xelox/folfox, increases the extent of necrosis and decreases the amount of fibrosis in colorectal liver metastases compared to xelox/folfox alone. however, bevacizumab does not change the radiologic response according to recist. we conclude that bevacizumab improves pathologic response which has no counterpart in radiologic response. role of hepatic lymph node involvement within the hepatic pedicle in patients with colorectal liver metastases background. hepatic lymph node involvement in patients with colorectal liver metastases is an important prognostic factor, but the role of lymphadenectomy, especially of the hepatic pedicle, is still unknown. methods. at the medical university graz patients, who underwent liver resection because of colorectal liver metastases between and , were retrospectively reviewed. results. out of patients , % ( patients) underwent combined hepatectomy and node dissection of the hepatic pedicle, whereas patients underwent hepatectomy only. , % ( of patients) were microscopically node positive within the hepatic pedicle and , % ( of patients) were node negative. the -year survival rate for the whole group ( patients), for the node positive group ( patients) and the node negative group ( patients) was , %, , % and , % with a median survival time of days, days and days respectively. the difference was significant (p ¼ , ). tumor recurrence was found in patients ( , %) with a disease free survival (dfs) of days in the whole group, days in the node positive and days in the node negative group. conclusions. patients with positive lymph nodes in the hepatic pedicle are at high risk for a shorter dfs and a decreased -year survival rate and can be safely identified by lymphadenectomy in this area. grundlagen. das kolorektale karzinom führt in % der fälle zu einer synchronen leberfiliarsierung -weitere % der patienten entwickeln vornehmlich in den ersten beiden jahren nach operation des primärtumors metastasen. die radikale chirurgie der lebermetastasen stellt bis dato die einzige chanche auf heilung dar mit -jahres Ü berlebensraten von - %. die rezidivrate nach leber-erstresektionen beträgt - % und nur % dieser patienten sind einer weiteren radikalen leberresektion zugänglich. methodik. die eigenen ergebnisse wurden retrospektiv analysiert und mit den daten der gängigen literatur verglichen. im zeitraum von / - / erfolgten an patienten insgesamt n ¼ leberteilresektionen wegen metastasen eines kolo-rektalen karzinoms; n ¼ patienten wurden einmal und n ¼ patienten mehrfach reseziert. ergebnisse. bei den patienten handelte es sich um männer und frauen in einem durchschnittlichen alter von jahren. bei n ¼ patienten erfolgten eine oder mehrere -bis maximal re-resektionen, wobei in allen fällen eine r- situation erreicht wurde. mortalität und morbidität waren hierbei gering ( bzw. %) und führten zu einem durchschnittlichen stationären aufenthalt von . tagen. inzwischen sind n ¼ patienten -bei einem mittleren Ü berleben von monaten (min , max monate) -verstorben; n ¼ patienten, bei einem mittlerem Ü berleben von monaten (min , max monate) sind tumorfrei am leben. schlussfolgerungen. auch wiederholte leberteilresektionen bei metastasen eines kolo-rektalen karzinoms sind mit einer niederen mortalität und morbidität durchführbar; entscheidend für das langzeitüberleben ist die r- resektion. background. laparoscopic liver surgery has been proven feasible and safe for the treatment of benign and malign liver diseases. however, the complexity of resections and the limitations in instrumentation hamper broad acceptance for advanced liver surgery. herein we describe different technical procedures for minimally invasive liver surgery adding safety to major laparoscopic hepatic resections. methods. three patients ( female, male; age: , , ) underwent laparoscopic major hepatic resections for primary and secondary liver malignancy, respectively. the entire operation was guided by laparoscopic ultrasound to define the resection planes. vascular control of the hepatic inflow and outflow was achieved for the impaired part of the liver. dissection of the parenchyma was carried out utilizing in particular laparoscopic radiofrequency ablation, the harmonic scalpel and laparoscopic staplers. specimen were retrieved in a bag through an enlarged trocar incision. the technique is discussed. results. laparoscopic liver resection was completed in all patients. the operative time was - min. no intraoperative adverse events were observed. blood loss yielded insignificant in and ml in one patient, respectively. specimen were retrieved in a bag through a widened trocar incision. no significant perioperative complication was noticed. histological evaluation revealed sufficient resection margins to the malignant tumours. oral diet was resumed on the first postoperative day. patients were discharged on day , and (due to additional surgery not related to the liver resection). conclusions. we present our technique for laparoscopic major hepatic resections by use of standard laparoscopic instrumentation. comparison of preoperative indocyanine green clearance in patients with colorectal liver metastases pretreated with systemic chemotherapy background. preoperative systemic chemotherapy has become an essential tool in downsizing colorectal liver metastases (clm), helping to render patients with initially irresectable disease resectable and to prolong progression free survival in initially resectable patients. histopathologic examinations of resected non-tumoral liver tissue have raised concerns about chemotherapy-associated liver injury, which might impair the function of the remnant liver. we therefore tried to evaluate whether indocyanine green plasma dilution rate (pdr, % Á min À ), which can easily be measured preoperatively, helps to assess chemotherapy-induced liver damage. methods and results. data of liver resections for clm performed between january and december were analyzed. onehundred-fifteen patients were treated with chemotherapy prior to surgery, patients were resected without pretreatment. patients who received preoperative chemotherapy had a significant lower pdr ( . ae , versus . ae . ; p ¼ . ) reflecting an impaired liver function. the percentage of subjects with an abnormal pdr (pdr ) was significantly higher among those who were treated with chemotherapy prior to liver resection ( . % versus %; p < . ). patients with a pdr stayed longer in the intensive care unit compared to those with a pdr > ( . ae . versus . ae . ; p ¼ . ) and had a significantly longer postoperative hospital stay ( . ae . versus . ae . ; p ¼ . ). the incidence of postoperative complications was increased in those with an abnormal pdr ( . % versus . %; p ¼ . ). conclusions. assessing the pdr preoperatively may help to indentify patients with an impaired liver function after preoperative chemotherapy. grundlagen. die radiofrequenztherapie ist mittlerweile ein etabliertes verfahren zur lokalen tumorkontrolle bei nicht oberflächennahe lokalisierten primären und sekundären lebertumore mit einer maximalen größe von cm. wir eine technik entwickelt, die es ermöglicht große tumore oberflächennahe und damit in unmittelbarer nachbarschaft zu anderen organen, wie magen, colon, niere oder zwerchfell laparoskopisch so zu isolieren, so dass sie anschliessend computerunterstützt abladierbar sind. die ergebnisse und komplikationen werden hier präsentiert. methodik. alle patienten, die im zeitraum von / bis / nach laparoskopischem liver packing radiofrequenzabladiert wurden, wurden eingeschlossen und retrospektiv analysiert. patientendaten, komplikationen, und follow-up sind dokumentiert worden. ergebnisse. patienten (f ¼ , m ¼ ) mit einem mittleren alter von . jahren sind im beobachtungszeitraum wegen eines ccc (n ¼ ), hcc (n ¼ ) und metastasen (n ¼ , colon, rektum, mamma, neuroendokrines karzinom, melanom, rcc) operiert und abladiert worden. die perioperative mortalität betrug , % (n ¼ ) aufgrund eines postoperativen leberversagens. die beobachtete morbidität betrug , % (n ¼ ) und beinhaltete pulmonaembolien, dü nndarmverletzungen mit intraoperativer Ü bernähung, mods, ards, durchgangssyndrom, cervikale plexusläsion, intraparenchymatöse blutung mit angiographischer blutstillung, par-tielle pfortaderthrombose, spätabszess und ein erysipel am unterarm. leichtes fieber und transienter transaminasenanstieg trat bei allen patienten auf. bei patienten wurde wegen eines rezidivs eine neuerliche rft mit liver packing notwendig, patienten wurden ohne packing ein zweites mal abladiert und ein patient unterzog sich einer linksseitigen hemihepatektomie nach rechtsseitiger ablation. schlussfolgerungen. das laparoskopische liver packing ermöglicht eine ablative therapie der leber in patienten, die mit den herkömmlichen möglichkeiten nicht lokal therapierbar sind. die technik ist mittlerweile standartisiert mit geringer mortalität und morbidität durchführbar. grundlagen. ablationsverfahren nehmen einen festen platz in der therapie von lebermetastasen ein. entscheidend fü r den onkologischen erfolg einer ablation ist die erzeugung einer ausreichend großen thermoläsion, die die metastase mit einem ausreichenden sicherheitsabstand vollständig zerstört. ziel dieser studie war es, bei patienten die aufgrund von kolorektalen lebermetastasen eine ablative therapie erhielten mögliche faktoren herauszuarbeiten, die eine unvollständige thermoablation verursachen. methodik. patienten mit irresektablen kolorektalen lebermetastasen. ab erhielten die patienten eine laserinduzierte thermotherapie (litt), ab eine bipolare radiofrequenzablation (rfa). ausschlußkriterien: metastasenanzahl > , metastasendurchmesser > cm, extrahepatische tumormanifestation. bei den offen-chirurgischen ablationen erfolgte eine sonografische punktionskontrolle, die perkutanen ablationen erfolgte ct-oder sonografiegestützt in lokalanästhesie. zur kontrolle der vollständigen ablation (,,r '') erhielten alle patienten - h postinterventionell eine km-gestützte mrt. in abhängigkeit der erreichten ,,r -ablation'' erfolgte die einteilung der patienten in zwei gruppen: gruppe i: ,,r -ablation'', gruppe ii: keine ,,r -ablation''. ,,r -ablation'' ¼ sicherheitsabstand von allseits cm in der postinterventionellen mr-untersuchung. ergebnisse grundlagen. die chirurgische versorgung der leistenhernie galt lange zeit als wenig interessanter standardeingriff und wurde nicht selten dem jungen ausbildungsassistenten überlassen. in den letzten jahren hat sowohl die wissenschaftliche auseinandersetzung als auch das interesse an ergebnisorientierter qualitätssicherung deutlich zugenommen. methodik. in zusammenarbeit mit dem zürser hernienforum wurde an unserer abteilung ein herniendokumentationssystem entwickelt. als basis diente ein software-programm, das für die qualitätssicherungsstudie des bÖ c im jahr geschrieben wurde. dieses wurde im expertengremium auf heutige anforderungen adaptiert und von der hausinternen it in das krankenhaussystem sap integriert. die eingegeben daten können über eine access-datenbank analysiert und ausgewertet werden. ergebnisse. das system ist an unserer abteilung seit . . in betrieb. die dateneingabe erfolgt zu zeitpunkten (im op, nach entlassung, bei follow-up kontrolle) und ist an einer abteilung eines ordenskrankenhauses mit limitierter mitarbeiter-zahl gut zu bewerkstelligen. schlussfolgerungen. nach erfolgreichem testbetrieb kann das herniendokumentationssystem anderen interessierten abteilungen zur verfügung gestellt werden. die anwendungsmöglichkeiten reichen von der eigenen qualitätskontrolle bis zur häuserübergreifenden analyse neuer medizinischer produkte oder op-methoden. laparoscopic ventral hernia repair with ipomexperience from the first cases abteilung für chirurgie, bruck/mur, austria grundlagen. bereits wurde von k. leblanc erstmals ü ber den verschluss einer bauchwandhernie in laparoskopischer ipom (intraperitoneales onlay mesh)-technik berichtet. erst mit der entwicklung verschiedener kunststoffnetze, die immer besser die speziellen anforderungen fü r eine intraabdominelle platzierung erfü llen, kam es zu einer zunehmenden verbreitung dieser technik. es wird ü ber unsere erfahrungen aus den ersten fällen berichtet, wobei das besondere augenmerk den rezidiven und ihren möglichen ursachen gilt. methodik. verwendet wurde in allen fällen ein dreidimensionales, multifaser polyestermesh mit resorbierbarer beschichtung. die eingriffe wurden von operateuren durchgefü hrt. je nach operateur erfolgte die befestigung entweder mit spiraltacks oder einer kombination aus spiraltacks und transfaszialen nähten. ergebnisse. unsere ergebnisse bestätigen, dass in erster linie eine ausreichende Ü berlappung der bruchlücke das rezidivrisiko niedrig hält. dies ist ein grund warum die laparoskopische technik derzeit hinsichtlich bruchlückengröße und lokalisation der hernie noch grenzen aufweist. schlussfolgerungen. unsere erfahrungen mit den ersten durchgefü hrten operationen zeigen, dass mit ausreichender minimal invasiver erfahrung und entsprechender patientenselektion die laparoskopische ipom-technik einen wichtigen platz in der optimalen versorgung von bauchwandhernien einnehmen kann. erfahrungen mit konsekutiven laparoskopischen narbenhernienoperationen grundlagen. die reparation von narbenhernien stellt einen der häufigsten eingriffe dar. in letzter zeit kommt die laparoskopische intraperitoneale onlay mesh technik (lap. ipom) vermehrt zum einsatz. unsere erfahrungen mit dieser methode werden dargestellt. methodik. in einer single center studie wurden patienten, die von august bis november einer lap. ipom unterzogen wurden, retrospektiv untersucht. (demographische daten, comorbiditäten, art und größe der narbenhernien und netze, art der fixation, operationszeiten, stationärer aufenthaltsdauer, komplikationen, rezidive.) ergebnisse. es wurden patienten in die studie eingeschlossen. das durchschnittliche alter der patienten betrug jahre; der mittlere bmi lag bei . % aller patienten litten an diabetes, während % eine copd aufwiesen. die mittlere operationszeit betrug minuten. in % aller patienten wurde ein polyester netz verwendet, in % ein eptfe netz. bei patienten traten insgesamt komplikationen auf. die häufigsten komplikationen waren serome ( , %) und hämatome ( %). , % aller patienten wiesen postoperativ länger andauernde schmerzen auf. in , % kam es zum auftreten eines ileus aufgrund von adhäsionen oder inkarzeration. netzinfektionen und netzausrisse traten jeweils bei , % aller patienten auf. netzinfektionen fü hrten stets zum operativen ausbau der implantate. ein patient verstarb am vierten postoperativen tag an einem multiorganversagen aufgrund einer darmperforation. nach einem medianen follow-up von monaten kam es bei % der patienten zu einem rezidiv. schlussfolgerungen. die komplikations-und rezidivrate in dieser ersten serie ist mit den in der literatur angegeben vergleichbar. wir erachten die lap. ipom technik für eine interessante alternative zu herkömmlichen verschlusstechniken. comparison of different fixation elements for the ipom procedure in a rat model background. long-time complications after the laparoscopic ipom techniques are adhesion formation and recurrence. because of the intraperitoneal position of the foreign body, adhesions could lead to severe complications like ileus or fistula formation. equally insufficient fixation produces recurrent hernias. study design. forty sprague-dawley rats were used in this two-phase, prospective randomized study. polypropylene mesh (parietene composix) samples were positioned intraperitoneal bilaterally to the midline. the randomized mesh fixation groups were suture (su), protack (pt), absorba tack (at) and i-clip (ic). half of the rats in each group were sacrificed and analyzed one week after implantation while the second half were sacrificed and analyzed after two months. measured parameters were strength of incorporation (soi) and adhesion formations. results. after one week the soi of the su fixation was significantly higher than for all other groups. between pt and at the soi was equally and significantly higher than in the ic group. after two months again the soi from the su was significantly stronger than the two fixation groups pt and at. ic was poorly incorporated resulting in few soi. inflammatory reactions were considerably more severe after one week than after two months. adhesion formations were significantly stronger in the groups su and pt compared to at and ic. conclusions. ic showed unacceptable soi and should not be used for mesh fixation. at leads only to few adhesions compared to the nonabsorbable su and pt. to have a good fixation and less adhesions, a combination of different fixation systems should be used. background. research in hernia repair has targeted new atraumatic mesh fixation techniques like surgical adhesives to reduce major complications like chronic pain and adhesion formation. the efficacy and safety of two adhesives, e.g. artiss + fibrin sealant (fs; iu thrombin, baxter, austria) and bioglue + (bg; cryolife, usa) were evaluated in this study. study endpoints were tissue integration and foreign body reaction. adhesion formation formed the secondary outcome parameter. methods. twelve rats were randomized to groups (n ¼ ). groups of onlay hernia repair -mesh fixation with fs (group ) or bg (group ), one group of ipom repair -mesh fixation with sutures and bg (group ). follow up was days. native rat tissue served as control. macroscopical and histological assessment was performed. results. onlay meshes fixed with fs showed excellent results in all evaluation criteria (group ). samples fixed with bg (group , ) showed extensive scar formation. no dislocation and no seroma formation was seen. all of these samples showed moderate to severe signs of inflammation with abscess formation in all samples of group . adhesion formation was scored moderate to severe in all samples of group . histological signs of a moderate foreign body reaction as well as detritus and remnants of bg were seen in all samples fixed with bg (group , ). conclusions. artiss + showed excellent mesh fixation and biocompatibility in onlay hernia repair. bioglue + yields high adhesive strength, but our macroscopical and histological results indicate a reduced biocompatibility. treatment of mesh graft infection following abdominal hernia repair -risk factor evaluation, role of the v.a.c. system and influence of the type of mesh useda retrospective analysis of operations background. commonly, mesh graft infections after hernia repair are treated by rapid removal of the mesh causing high morbidity. new materials of mesh grafts and new procedures of wound management now further challenge the need for mesh removal. risk factor based choice of patients selected for initial hernia repair might partially avoid such complications. methods. four hundred and seventy-six mesh grafts implanted for hernia repair were retrospectively analyzed to determine risk factors for development of a graft infection. we further evaluated the outcome of infected mesh grafts (n ¼ ) treated by best supportive care including vacuum assisted closure system. results. risk factors for mesh graft infection were body mass index (bmi), operation time for hernia repair and the size of the hernia. % of infected mesh grafts could be preserved by conservative means. preservation was possible for % of polyglactin/polypropylene mesh as compared to - % for non-absorbable types of meshes (p < . ). preserved mesh graft showed no recurrent hernias at the site of infection. conclusions. conservative treatment is a valid option for mesh graft infection. polyglactin/polypropylene mesh grafts might be preferentially used for open hernia repair. hernia repair should be preferentially performed when hernias are still small and when high bmi is reduced. biomeshes in experimental ipom repairan overview of own trials background. biomeshes (bm) are a new family of implants designed for the reinforcement of ventral hernias. their use is gaining widespread attention in the usa and some european countries. despite the recommendation to use them specifically in contaminated wound fields and giant hernias, experimental data on their biocompatibility and tissue integration is still scarce. our study group has investigated several biomeshes and tested new methods to possibly enhance the tissue integration (additional perforations; fibrin sealant bm fixation). methods. porcine small intestine submucosa (sis), porcine collagen (pc) and bovine pericard (bp) implants have been tested (n ¼ per group) in a model of open ipom repair. bm were  cm in size and fixated with non resorbable sutures (synthofil, ethicon, germany) to the peritoneum. observation period was days in all groups. primary outcome parameters were adhesion formation, tissue integration and dislocation. foreign body reaction was a secondary outcome parameter assessed in histology (he staining). results. sis, pc and bp showed controversial results when indirectly compared with the established standards of synthetic meshes in ipom repair. problematic findings were obtained for tissue integration and foreign body reaction. conclusions. different bm differ distinctively in terms of important outcome parameters. in our hands they were not superior to synthetic meshes. the potential for improvement for the use of bm will be presented by the authors. mesh coating with vital human amniotic membrane reduces early adhesion formation in experimental ipom repair background. the laparoscopic intraabdominal peritoneal onlay mesh repair (ipom) is an increasingly popular technique for the repair of incisional hernias. the intraabdominal use of synthetic meshes cavity often leads to adhesions between bowel and the implant or fixation devices. this study was designed to assess the impact of vital human amniotic membrane (ha) to cover polypropylene meshes in order to prevent adhesion formation (vitamesh + , vm, proxy biomedical, ireland) in experimental ipom repair. vitality of this biomatrix is considered to preserve its desired physiological characteristics. avital ha has been suggested for this purpose by other study groups. methods. thirty-two rats were assigned to the implantation of vm fixated with non resorbable sutures (synthofil, ethicon, germany) to the peritoneum. vm was covered with with ha. vm was cm in diameter and implanted in open ipom by a laparatomy. the observation period was and days (n ¼ / ). adhesions were rated with the score by vandendael. histology was performed. results. ha markedly reduced adhesions when compared to a historical control group (vm w/o coating). adhesions were found at structures which were not fully covered by ha (protruding sutures, mesh fibers at the edges of vm). ha formed a highly effective barrier preventing adhesions. tissue integration in histology was good. conclusions. vital ha yields anti-adhesive efficacy and showed good biocompatibilty in a xeno model. further research has to elucidate a potential clinical application. biological mesh in complex abdominal wall repairlong term results of use of permacol tm (porcine dermal collagen) in a single institution r. d. pullan, d. j. devon torbay hospital, torquay, uk background. abdominal wall repair (awr) if poor tissues, contamination, intestinal fistula, anastomosis, stoma and mesh impingement on bowel represent formidable surgical challenges. synthetic mesh or suture repair is inappropriate. biological meshes are biocompatible, offer resistance to contamination, minimal adhesion or fistula formation but retain strength. we use permacol tm -crosslinked porcine dermal collagen -in these cases and present data with long follow up. methods. retrospective review of patients treated with permacol tm for: . recurrent incisional hernia ae mesh; . post laparostomy; . enterocutaneous fistula; . contamination by anastomosis; . parastomal hernia. results. twenty-nine patients were identified. with acute or chronic abdominal defects; with parastomal hernia. defects sizes from to cm . median age (range - ) years and follow up ( - ) months. eleven cases awr - with anastomosis, paracolostomy hernia. eight enterocutaneous fistula with deficient abdominal wall; with fistula associated with mesh, all with anastomosis. four recurrent of parastomal hernias. repairs by onlay, inlay and sublay. sixteen cases had no complications. major complications in patients - early deaths (myocardial infarct and multiorgan failure); recurrent hernia, colonic ischaemia requiring relaparotomy and intra abdominal abscess requiring percutane-ous drainage. seven minor complications comprised wound infections, sinus and seroma. there were no mesh rejections and no further complications. conclusions. in difficult anterior abdominal wall repair permacol tm is effective, biocompatible, resistant to infection, contamination and can sit in contact with bowel. background. rectoanal repair (rar), a combination of mucopexy and haemorrhoidal artery ligation (hal), is proposed an ''anorectal lifting'' alternative to stapled haemorrhoidopexy. we retrospectively investigated efficacy and safety for this technique in our center. methods. rar was performed under general anaesthesia in patients ( female, male) with symptomatic haemorrhoids iii ( %) or haemorrhoids ii-iii with simultaneous mucosal prolapse ( %) from march to october . previous anal surgery was recorded in five patients. mucopexy was performed using a conventional anal dilator and vicryl - absorbable sutures at the prolapse sites (median , range - , sutures) with secondary hal (median , range - ) according to the arterial signal detected by a commercial ultrasound device. all patients were discharged on postoperative day with stool softeners and pain medication on demand. median follow up was weeks (range - ). results. the most common adverse event was pain in the first postoperative month, but no severe bleeding complication was reported. persisting pain due to perianal thrombosis was observed in six patients ( %) . two patients ( %) showed residual haemorrhoids ii , one requiring further intervention (rubber band ligation). in eight patients ( %) marginally hyperptrophied but asymptomatic haemorrhoidal piles were still visible. fecal continence did not deteriorate postoperatively. conclusions. rectoanal lifting is a safe and effective and minimally invasive technique for haemorrhoids ii-iii with simultaneous rectal mucosal prolapse. future prospective, randomized studies should investigate the particular benefit of a specially designed doppler-guided proctoscope in rar. therapie der komplizierten rektovaginalen fistel mittels modifizierter martiusplastik ergebnisse. insgesamt traten ( , %) infektionen auf. ( , %) dieser infektion waren rein oberflächlich die haut betreffend, ohne dass eine weitere chirurgische intervention nötig war. in ( , %) fällen kam es zu einer tiefen den patch (dacron , polyurethan ) betreffenden infektion. die tiefen infektionen traten in einem zeitraum von monat bis jahre nach der primären operation auf. in allen fällen wurde eine explantation des kunststoff-patches durchgefü hrt und dieser durch einen venen-patch ersetzt. bei diesen revision traten weder interoperativ noch postoperativ weitere komplikationen auf. keinerlei infektionen zeigten sich in der gruppe der carotiseversionen. schlussfolgerungen. in der carotischirurgie sind infektionen seltene komplikationen. infektionen traten bei uns ausschließlich bei operationen mit durchgeführter patchplastik auf, wobei der polyurethan patch vorteile gegenüber dem dacron patch zu haben scheint. standardtherapie bei einer patchinfektion ist die explantation und der ersatz durch einen venen-patch. die wertigkeit homologer spendervenen in der shuntchirurgie bei ausoperierten dialysepatienten ergebnisse. der erhalt des gefährdeten beines gelang bei patienten ( %), bei konnten durch die urokinasinfusionen ursprünglich nicht dargestellte gefäße zumindest teilweise wiedereröffnet werden. dadurch ergaben sich endovaskuläre therapieoptionen, die vor urokinase nicht möglich waren. lediglich bei einer patientin wurde eine unterschenkelamputation notwendig. die ergebnisse bei diabetikern waren erwartungsgemäß besser. schlussfolgerungen. die systemische urokinasetherapie stellt für bisher als austherapiert eingestufte patienten eine erfreuliche zusätzliche therapieoption dar. unsere ergebnisse insbesondere die beinerhaltungsraten von über % und komplikationsraten sind mit den in der literatur beschriebenen vergleichbar und insgesamt als erfreuliche alternative zu sehen. wir haben aber auch gesehen, dass mit einer solchen ,,induktionstherapie'' wieder neuen optionen einer invasiven therapie möglich werden. die vorteile der urokinasetherapie sind in der guten verträglichkeit den überschaubaren kosten sowie in einer erweiterung der multimodalen gefäßtherapie zu sehen. background. pulmonary retransplantation remains the only therapeutic option in some cases of severe primary-graft-dysfunction (pgd), advanced bronchiolitis-obliterans-sydrom (bos) as well as in some cases of severe airway problems (awp), mainly cicatriceal stenosis. however its value has been questioned due to overall scarcity of donor organs and reports on unsatisfying outcome. we analysed our institutional experience with pulmonary retransplantation to evaluate its value for different indications. methods. we retrospectively analysed all patients undergoing retransplantation out of consecutive primary lung or heart-lung transplantations performed in our department from / - / . we stratified patients according to indication for retransplantation and analysed the outome. results. forty-six patients (mean age ae years, male, female) underwent retransplantation ( bltx, sltx) for pgd (n ¼ ), bos (n ¼ ) and awp (n ¼ ). mean time to retransplantation was ae days in the pgd-group, ae days in the bos-group and ae days in the awpgroup. thirty days, -year and -years-survival after retransplantation were . %, . and . % in the pgd-group and . %, . and . % in the bos-group. all patients in the awp-group are still alive (p bos/pgd ¼ . ; p bos/awp ¼ . ; p pgd/awp ¼ . ). conclusions. retransplantation for bos offers long-term survival-rates in the range of primary lung transplantation for selected patients. long-term survival-rates for retransplantation due to pgd are significantly lower, warranting restrictive use in this indication. in our experience with a limited number of patients, retransplantation for awp has excellent results. pulmonary retransplantation for chronic problems is a worthwhile effort, provided that patients are carefully selected. retransplantation for pgd should be avoided. ecmo support in extended thoracic procedures background. for extended pulmonary resections and complex tracheo-bronchial reconstructions cpb is the standard way for extended cardio-respiratory support. given the extensive experience with ecmo support in lung transplantation in our department, we introduced ecmo also for selected cases of general thoracic surgery (gts). methods. all patients undergoing gts on ecmo support in our institution between may and january . results. nine patients ( female and male with a median age of years, range - ) underwent extended procedures using ecmo. both central (n ¼ ) and peripheral (n ¼ ) cannulation was used. in two cases, ecmo was introduced under emergency conditions due to life-threatening tracheobronchial injury, and was prolonged into the postoperative period after trachebronchial reconstruction. in seven cases the procedure was elective for surgery of bronchogenic carcinoma. ecmo bypass was performed for aortal resection (n ¼ ), for pure carinal resection (n ¼ ), or in combination with central resection of left pulmonary artery (n ¼ ), with reinsertion of left main bronchus to trachea (n ¼ ), and with upper bilobectomy and reinsertion of right lower lobe into the left main bronchus (n ¼ ). no deaths occurred during the first postoperative days. conclusions. this study confirms the safety of ecmo in gts instead of cpb. avoiding cross-table ventilation facilitates visibility and precision. the closed ecmo circuits prevent tumour cell spilling from the operating field. full heparinisation can be avoided, and bleeding complications can be prevented. ecmo support can also be prolonged into the postoperative period. background. the aime of this retrospective study is to underline that a surgical tool respective videothoracocscopy helps to find diagnosis quick! methods. one hundred and ten patients were included in the study male and female, mean age . a (range from to a). indication for inclusion in the study effusion under monitoring, multiple punction without any result. causes for effusion was in all cases unknown before intervention. patients transferred to the surgical unit for diagnosis and therapy were origin in all cases from pulmologists or conservative departments. patients were treated the day after admission by videothoracoscopy combined with sampling, frozen section and if available following therapy immediately intraoperative or the following days. discharge from hospital was done after removal of chest tube and aftercare was in the outpatient department. results. diagnosis was possible in all cases, the gap in between admission on the surgical department and beginning of treatment range from to days mean days. gap in between symptoms, multiple punction and suction without diagnosis range from to days mean . days. in comparison early surgical intervention as videothoracoscopy helps to achiev quick diagnosis and therapy. conclusions. in conclusion we emphasize that early surgical intervention after short conservative try show up with diagnosis and successful therapy. first series of robotic pulmonary lobectomy background. surgical resection is the primary treatment for early stage non-small cell lung cancer (nsclc). different minimally invasive approaches are currently under investigation: in addition to conventional video-assisted thoracoscopic surgery (vats), the robotic technology with the davinci system has emerged over the last years. methods. twenty-seven patients ( women, men; mean age . years) underwent a robotic lobectomy for early stage nsclc (clinical stage ia or ib). results. distribution of resected lobes were left upper lobes , left lower lobes , right upper lobes and right lower lobes . there were intraoperative conversions to open thoracotomy (one major bleeding, two minor bleedings, one variant course of the pulmonary artery). postoperative complications included prolonged air leak ( ) , colonic perforation ( ), and intermittend atrial fibrillation ( ) . length of hospital stay was median ( - ) days. -day mortality was one ( . %). overall median operative time was h and min (range : h to : h, mean : h). after the first seven patients the initial posterior approach was switched to an anterior one, thus enabling an easier hilar dissection. another technical modification during this first series was the introduction of a new vessel-sealing device (hem-o-lok + -clip) instead of ligation/stapling of the major pulmonary vessels. conclusions. robotic lobectomy has been proven to be feasible and save in our initial series in a learning curve setting. longer follow up and randomized controlled trials are necessary to evaluate a potential benefit over open and conventional vats approaches. background. acute post intubation laceration of the trachea is a rare, but serious complication. we report our experience with the transcervical approach and direct correction of the tear through a t-shaped anterior tracheotomy. methods. in a retrospective study we analyzed the course of patients ( female, male; median age . , range - years). in eight patients the tracheal injury was due to emergency intubation and in two patients it occurred during percutaneous tracheostomy. the lesions were located in the membranous part of the trachea and the mean length was , (range - ) cm. all patients underwent surgical repair immediately after diagnosis. the repair was carried out through a cervical transversal and longitudinal t-shaped tracheotomy allowing the exposure of the laceration in the posterior wall of the trachea which was mended by intraluminal running suture with - pds. results. all patients recovered well and were discharged from the hospital. the endoscopic follow-up at , and months shows no evidence for tracheal stenosis or fistula. conclusions. transcervical t-shaped tracheotomy is a minimally invasive approach for the repair of postintubation tracheal injury. this technique allows exposure of the entire length of the trachea and direct suturing of the tracheal wall with excellent results. we recommend this approach for repair of iatrogenic postintubation tracheal lesions requiring surgery. totalrekonstruktion der trachea ( ) mit thoraxtrauma nach jahren the importance of risk management for patient safety in surgery s. kriwanek background. although the concept of risk management is rather new in surgery it is gaining importance to ensure increased patient safety. methods and results. the process of risk managements consists of evaluation, assessment, and reduction of different risks. different analytic procedures as the -f method ( factors method) or the fmea (failure mode and effect analysis) help to stratify risks and classify the urgency of risk-reducing actions. the first and most important application of risk management in surgery must concern operative procedures. conclusions. the concept of risk management represents a new and interesting approach in order to increase patient safety in surgery. grundlagen. mit der kostenreduktion bestehen im krankenhauswesen tendenzen zur verkürzung der stationären verweildauern. bei der bedarfs-und ressourcengerechten aufnahmeund belegungsplanung haben sich in der chirurgie patientenmanagement systeme etabliert und bewährt. die umsetzung eines patientenorientierten entlassungsmanagements ist häufig nicht ohne probleme; beispielsweise ist die aktionsfähigkeit innerbetrieblicher sozial-und medizinischer dienste wegen administrativer und externer reglementierungen blockiert. kann eine anspruchs-und zeitgerechte qualitativ abgesicherte poststationäre häusliche nachversorgung nicht gewährleistet werden, bedeutet dies für patienten egal welcher chirurgischer disziplin ,,krisenmanagement''. methodik. auf der grundlage der konzeption von hospitalto-home + -mobile gesundheitsservices und in zusammenarbeit mit der regional zuständigen kassenärztlichen vereinigung wurde ein klinik-und mobilitätsgestützter gesundheitsservice für das stationäre entlassungs-und poststationäre ,,home-care'' management an der chirurgischen klinik eines universitätsklinikum, hier unter der projektbezeichnung ,,medmobil'' evaluiert. ergebnisse. die zeitgerechte klinikentlassung unter abgesicherter poststationärer weiterversorgung kann mit diesem konzept selbst in komplizierte umständen, wie z.b. bei postoperativen wundheilungsstörungen erfolgen. die fragmentierung von ökonomischer und medizinisch chirurgisch erforderlicher ,,in-time'' leistungserbringung und postoperativer gewährleistung häuslicher versorgungsnotwendigkeiten kann so am ende der prozesskette in übergreifendem interesse gestaltet werden. schlussfolgerungen. unter klinikbedingungen ist das konzept der projektgruppe von hospital-to-home + -mobile gesundheitsservices eine patientenorientierte konsequenz auf die anforderungen des drg-system; insbesondere auch seitens der patienten. interessen der medizinischen leistungserbringer, der krankenhaus-und der versicherungsträger werden auch vor dem hintergrund eines patientenseitigen ,, return-to-invest'' reflektiert. background. skin rejection in composite tissue allotransplantation (cta) is the pace-limiting obstacle for wider adoption in clinical practice. this study aims to identify cytokine network dynamics mediating acute rejection in cta, with focus on skin. methods. using a brown-norway to lewis rat hind-limb allotransplant model, syngeneic [n ¼ ] and allogeneic [n ¼ ] transplants without immunosuppression were studied. skin and muscle biopsies were taken at defined time points between day and . protein levels of cytokines known to be relevant in cellular inflammatory responses were assessed by luminex tm . expression (Ápg/ml) was read by measuring significant differences among pairs of slopes (w/matlab) for characterization of a cytokine network profile. results. in syngeneic transplants, il- a and il- were expressed in skin throughout the period of observation, with highest levels on pod at an average il- a concentration of pg/ml (>  Á from biopsy control (bc), standard deviation (sd) ¼ . %) and il- at pg/ml (> .  Ábc, sd ¼ . %). in allogeneic transplants, il- a and il- levels were similar to the syngeneic. at pod , allogeneics expressed il- b at pg/ml (> .  Ábc, sd ¼ . %), il- at pg/ ml (> .  Ábc, sd ¼ . %) and gro/kc at pg/ml (> .  bc, sd ¼ . %). conclusions. most prevalent cytokines at different time points during skin rejection were identified. this analysis helps understand the pathogenesis, provides a basis for early detection of rejection, and identifies novel targets for therapeutic intervention. disclosure. none. project funded by the austrian science fund (fwf). targeting e-and p-selectin for treatment of skin rejection in limb transplantation background. skin rejection episodes are a frequent problem seen after human hand transplantation. we therefore investigate the expression of e-þp-selectin in skin of human hand allografts and the effect of efomycine-m, a special inhibitor of selectin in a rat limb-transplant-model. methods. skin biopsies from three bilateral hand transplants were assessed by h&e-histology and immunohistochemistry (anti-e-þp-selectin-antibody). efomycine-m was investigated for its effect on skin rejection in an orthotopic rat hind-limb-allotransplant-model (bn-lew). animals received either efomycine-m alone ( mg/kg/weekly s.c. into the graft) or in combination with als ( . ml, pod þ ) and tacrolimus ( . mg/ kg/day for days). untreated animals and animals receiving als þ tacrolimus alone served as controls. skin rejection was assessed by daily inspection and he-histology. results. e-and p-selectin expression in the vascular endothelium were significantly upregulated and correlated well with severity of rejection in human hand allografts. in the experimental trial animals receiving efomycine-m alone rejected on day ae . these animals didn't show prolongation of graft survival in contrast to untreated animals. animals receiving als and tacrolimus rejected on pod ae and histology showed necrosis and massive infiltration of lymphocytes in all tissues. additional treatment with efomycine-m resulted in long term ( days) allograft survival. histology on day showed a lymphocytic infiltrate in the dermis and epidermis and a myointimal proliferation consistent with rejection grade . conclusions. selectins are upregulated upon skin rejection after human hand transplantation. local administration of a selectin-blocker in combination with als þ tacrolimus results in significant prolongation of graft survival but doesn't prevent chronic rejection in a rat limb-transplant-model. xenotransplantation of microencapsulated porcine islet cells in diabetic rats background. xenotransplantation of microencapsulated porcine islet cells might be a possibility to overcome the shortage of human donor organs for pancreas transplantation. several materials for microencapsulation of cells are described in literature which all show severe disadvantages. nacs is easy to produce, does not show any cytotoxicity and cell lines survive for a nearly unlimited time-spam after microencapsulation. however, this material has not been tested for microencapsulation and xenotransplantation of porcine islet cells. methods. porcine islet cell isolation and purification was performed according to a newly modified ricordi method and microencapsulated with nacs. diabetes was induced in sprague dawley rats by intraperitoneal injection of stz. microencapsulated porcine islet cells were transplanted under the kidney capsule of the animals. blood sugar levels were monitored on a weekly basis, porcine c-peptide levels and insulin levels were measured using elisa. after months, the animals were sacrificed, the kidney containing the microencapsulated porcine islet cells was retrieved and processed for histological and immunohistochemical examination. results. after xenotransplantation of microencapsulated porcine islet cells diabetes was reversed in rats. animals stayed normoglycaemic up to four months. functionality of transplanted porcine islet cells was detected by insulin measurement and detection of c-peptide. viability of microencapsulated porcine islet cells after explantation was proven by immunohistochemical viability stains. conclusions. rats stayed normoglycaemic until the end of the study period. no signs of fibrosis could be detected in the surrounding tissue. nacs seems to be a promising material for microencapsulation of porcine islet cells in order to treat diabetes. introducing the cuff technique for hind limb transplantation in rats background. current models for orthotopic hind limb transplantation traditionally utilize a time-consuming, technically demanding micro-vascular suture technique for vascular anastomoses. our objective was to introduce a new simplified vascular ''cuff technique'' which substantially accelerates the surgical procedure and is well suited to study ischemia/reperfusion injury in reconstructive transplantation. methods. syngenic hind limbs were transplanted orthotopically using lewis rats employing either the conventional microsuture technique (n ¼ ) or the new ''cuff technique'' (n ¼ ) for vascular anastomosis. results. all grafts in the microsuture technique and out of grafts in the ''cuff technique'' group survived the endpoint of the study (postoperative day ). microangiography on postoperative day showed no stenosis or occlusion of anastomoses, skin and muscle histology demonstrated normal appearing tissues. conclusions. our newly introduced cuff technique enables for significantly reduced operating time (cuff group: ae min, vs conventional group: ae min), low postoperative morbidity and mortality ( %) and excellent functional results after orthotopic hind limb transplantation. a quantitative analysis of the sensory and sympathetic innervation of the human pancreas the delineation of pancreatic nerve innervation during fetal life may contribute to our understanding of pancreatic pain modalities after birth. to define the peripheral sensory and sympathetic fibers involved in transmitting and modulating pancreatic pain, immunohistochemical detection was used to examine the sensory and sympathetic innervation of the head, body and tail of the normal human fetal pancreas using specimens from fetuses ( - weeks of gestation) following intrauterine death or legal interruption of pregnancy. myelinated sensory fibers were labeled with an antibody raised against neurofilament (nf) and post-ganglionic sympathetic fibers were labeled with an antibody raised against tyrosine hydroxylase (th). choline acetylase (chat) at cholinergic synapses was labeled with a conventional antibody. nf. th, and chat immunoreactive fibers were present in parenchyma of the head, body and tail of the pancreas at variable density, but the relative density of both nf and chat expressing fibers seemed to be increasing head > body > tail, whereas for th, a relatively even distribution was observed. in addition to this set of sensory and sympathetic nerve fibers that terminate in the pancreas, there were large bundles of en passant nerve fibers in the dorsal region of the pancreas that were associated with the superior mesenteric plexus. these data suggest that the pancreas receives a significant sensory and sympathetic innervation during fetal life. understanding the factors and disease states that may alter the distribution of nerve structures can be of significance for the development of therapies in pancreatic disorders of child and adulthood. background. electrospinning of polymers offers an interesting approach to fabricate nanostructured vascular substitutes which match the biomechanical and structural properties of native vessels. in this study we investigated the in-vivo behaviour of electrospun, small diameter conduits in a rat model. methods. vascular grafts with an inner diameter of . mm were fabricated by electrospinning polyether-urethane. prostheses were implanted into the abdominal aorta of rats for either days, weeks, or months. retrieved specimens were evaluated by conventional histology, immunohistochemistry and scanning electron microscopy. results. the overall patency rate of the electrospun conduits was %; neither foreign body-type reactions nor gross evidence of degradation were observed. within month after implantation, midgraft regions were completely covered with endothelial cells. immunohistochemistry revealed a significant immigration of cd þ cells from the luminal side of the graft into the prosthesis wall. within months, vascular specific smooth muscle cells (actin þ , desmin þ ) repopulated half of the conduit wall. conclusions. nanostructured electrospun polyurethane conduits offer biomechanics and bioinertness comparable to native vessels and promote the immigration and differentation of vascular specific cells in-vivo. diskussion. die coloskopische mukosektomie hat den nachteil des meist fragmentierten präparates, gefahr des hinterlassens von kleinen adenomresten, implementierung mehrfacher sitzungen und der narbenstenose durch die fehlende naht. die tem ermöglicht im gegensatz zur coloskopischen mukosektomie die zusätzliche resektion von submukosa und muskularis und somit eine entfernung des adenomrezidivs in toto mit primärer naht. die transanale excision nach parks hat eine - fach höhere rezidivrate als die tem, weshalb der tem unbedingt der vorzug zu geben ist. mit der laparoskopischen vorderen resektion kann wie mit der tem das adenomrezidiv sicher komplett entfernt werden, sie hat aber den nachteil der höheren morbidität, letalität und der schlechteren funktionellen spätergebnisse. im eigenen krankengut hat sich die tem als optimales therapieverfahren zur behandlung von rektumadenomrezidiven bewährt. schlussfolgerungen. die tem ist bei der behandlung des rektumadenomrezidivs alternativen therapieverfahren ü berlegen. the impact of computed tomography in acute appendicitis and obese patients m. von der groeben, v. neuhaus, o. schöb background. acute appendicitis is diagnose by clinical examination, ultrasound and laboratory tests. however, ultrasonography may not be sufficient for a definite diagnosis in obese patients and in the case of meteorism. in this study, the clinical relevance of computed tomography to diagnose acute appendicitis, especially in obese patients, was evaluated in a retrospective study. methods. patients suffering from acute pain in the right underbelly were examined for appendicitis by means of clinical examination, ultrasound imaging and laboratory tests. in case of definite diagnostic findings (n ¼ ), appendectomy was accomplished by laparoscopy. in case of negative ultrasonography findings (n ¼ ), patients were reexamined by ct the same day (n ¼ ) or by ultrasound imaging and laboratory tests the next day after admission (n ¼ ). results. patients with negative initial ultrasonography findings (n ¼ ), duration of anamnesis ranged from to h and ( . %) of these patients were considered as obese due to their body mass index (bmi ! kg/m ). in comparison, only . % of the patients with positive ultrasonography findings were obese. among the patients further examined by ct, ( . %) showed a bmi ! kg/m . duration of anamnesis ranged from to h. in contrast, among the patients reexamined by ultrasound imaging, only two showed a bmi ! kg/m . conclusions. to enhance diagnosis of acute appendicitis in patients with increased bmi ( ! kg/m ) suffering from acute pain in the right underbelly and short duration of anamnesis, it is advisable to directly perform ct of the abdomen instead of ultrasound imaging. outcome of emergency bowel resection for acute mesenteric ischemia background. due to vague early symptoms and lacking specific laboratory values, acute mesenteric ischemia (ami) is often detected late when bowel necrosis has occurred. methods. in a -month period, all consecutive patients with clinical symptoms of mesenteric ischemia were screened for inclusion in this retrospective study. patients with secondary causes for ischemia (strangulation ileus/post resection) were excluded. results are reported as mean ae sd or total number (%). results. sixty-two patients ( . % female; mean age . ae . years) were enrolled. twenty-two patients ( . %) had preoperative arrhythmia. lactate levels upon diagnosis were . ae . mg/dl, leucocyte count . ae . g/l and creactive protein . ae . mg/dl. fifty-one patients ( . %) underwent a ct scan, ( . %) an ultrasound and ( . %) an angiography, which diagnosed mesenteric vessel occlusion in ( . %). fifty-five patients ( . %) underwent surgery, five patients ( . %) were managed non-operatively, and two patients ( . %) died before surgery. revascularization was only possible in patients ( . %). forty-five patients ( . % of operated patients) underwent bowel resection, with primary anastomosis in and stoma creation in patients. second look operation was performed in patients ( . %). in-hospital mortality was . % ( patients). preoperative arrhythmia (p ¼ . ), renal failure (p ¼ . ), vasopressor demand (p ¼ . ), intraoperatively instable patients (p ¼ . ), diffuse bowel ischemia without resection (p ¼ . ), and bowel resection during second look operation (p ¼ . ) were associated with mortality. conclusions. despite modern diagnostic tools, acute mesenteric ischemia is still often diagnosed late. mortality remains high in unstable patients, or when no resection of necrotic bowel is possible during primary surgery. background. intrahepatic cholangiocellular carcinoma (icc) accounts for % to % of primary liver cancer cases. aggressive resection is the mainstay of treatment. methods. between and total patients ( % male, mean age . (ae . ) years) operated for icc at our department were followed up postoperatively. eleven right hemihepatectomies (eight extended), seven left hemihepatectomies (three extended), one segmental resection, two bisegmentectomies (ii iii), and four non-anatomical resections were performed. the median observation period was . (range: . - . ) years. analysis focused on age, sex, tumor size, operating time, histologic resection margin, tumor-node-metastasis (tnm) stage, reoperations, postoperative complications, tumor recurrence, survival rate. we also assessed p protein accumulation, ki index and muc positivity. results. median operating time was . h. mean diameter of the resected tumor was . (range: . - ) cm. histology showed r resection for three patients. eighteen patients ( %) underwent lymph node dissection. major postoperative complications occurred in ten patients ( %). there was one in-hospital death from liver failure. seventeen patients ( %) showed tumor recurrence. median time to tumor recurrence was . ( . - . ) months. total patients ( %) died. median time from operation to death was . ( . - . ) months. survival rate after one year was %, after three years % and after five years %. we found no correlation between p accumulation/high ki index counts/muc positivity and icc prognosis. conclusions. our study shows that outcome after icc is generally poor and only a small number of patients are really cured. lymphknoten-ratio als prädiktiver faktor nach kurativer resektion wegen intrahepatalem cholangiokarzinom für die lymphknotenchirurgie, es konnte auch bisher kein Ü berlebensvorteil für diese eingriffserweiterung gezeigt werden. methodik. zwischen und wurde patienten an unserer institution wegen eines icc operiert. aus dieser kohorte wurden patienten ermittelt, die mit kurativer resektion und lymphadenektomie behandelt wurden. aus diesem kollektiv wurde eine uni-und multivariate analyse prognostischer faktoren für rezidiv (rfs) und Ü berleben (os) durchgeführt. ergebnisse. sowohl tumorgröße als auch uicc stadium waren sowohl für rezidiv als auch Ü berleben prognostisch. ein erhöhter quotient von positiven zu gesamt entfernten lymphknoten (lymph node ratio, lnr) war für die patientengruppe mit positiven lymphknoten prognostisch für rezidiv und Ü berleben (hr für os ¼ . , % ci . - . ; hr für rfs ¼ . , % ci . - . ). in der multivariaten analyse bestätigte sich lnr als ebenso starker prognostischer faktor (adjusted hr [lnr] für os ¼ . , % ci . - . ; hr für rfs ¼ . , % ci . - . ). die anzahl der entfernten lymphknoten hatte keinen einfluss auf Ü berleben oder rezidiv. schlussfolgerungen. lnr ist ein neuer prognostischer faktor für Ü berleben und rezidiv nach kurativer resektion wegen icc. die therapeutische relevanz dieser beobachtung sollte in einer prospektiven untersuchung geklärt werden. background. patients with advanced cholangiocarcinoma have a poor prognosis and until now, no standard palliative chemotherapy has been defined. the purpose of this prospective single-centre phase ii study was to investigate the therapeutic efficacy, safety and k-ras status dependence of cetuximab in combination with gemox in the palliative first line treatment of these patients. methods. patients with locally advanced, metastatic cholangiocarcinoma or gallbladder cancer were treated with cetuximab mg/m followed by mg/m gemcitabine (day ) and mg/m oxaliplatin (day ) every second week. results. from october until july thirty patients ( male, female) with a median age of were enrolled. the overall response rate of evaluable patients ( ) was , %, including three patient with a complete radiological response. patients ( . %) achieved stable disease and only patients ( %) progressed under chemotherapy. nine initially unresectable patients underwent a curative resection after major response was observed ( %). five patients are currently without evidence of disease after a median follow-up of , months post curative liver resection. k-ras mutation was detected in patients ( %). all three patients did not progress under chemotherapy. neither pfs nor os were affected by k-ras status. the median pfs of all patients was . months and median os was . months. conclusions. cetuximab in combination with gemox induces impressive response rates which were unrelated to kras status. pfs and os were remarkably improved and therefore cetuximab in combination with gemox deserves further evaluation in prospective randomized trials. methodik. es wurde eine retrospektive analyse anhand einer pro-spektiv geführten datenbank an der abteilung für unfallchirurgie durchgeführt und jene patienten ermittelt, die im anschluss an ein ausgedehntes trauma im bereich der oberen extremität neben einer knöchernen versor-gung mit einer freien lappenplastik versorgt wurden. der erfasste zeitraum lag zwischen . jänner und . jänner . ergebnisse. die auswertung der datenbank ergab patienten ( weiblich), bei de-nen eine solche freie lappenplastik durchgeführt wurde. jede operation wurde gemeinsam mit einem kollegen der plastischen chirurgie und der unfallchirurgie durchgeführt. in fällen kam es zu einem lappenverlust, wobei daraus in einem fall ein zweiter erfolgreicher freier lappen resultierte und in dem anderen fall eine amputation des betroffenen daumens. im rest der patienten wurde mit der initialen operation das operative ziel erreicht. schlussfolgerungen. die implementierung mikrochirurgisch-rekonstruktiver verfahren an einer großen unfallchirurgischen abteilung führte zu einer deutlichen steigerung in der versorgungsqualität bei patienten mit komplexem trauma im bereich der oberen extremität. trotz eines mitunter sehr aufwändigen operativen verfahrens konnte die zeit bis zur kompletten abheilung deutlich verkürzt werden. facial edema and petechiae, subconjunctival hemorrhage, and occasionally neurological symptoms. case report. a -year-old men was admitted to the emergency department after the heavy metal door had fallen on his chest. his head, neck and upper chest were cyanotic and edematous with subconjunctival hemorrhages. computer tomography of the thorax revealed multiple fractures of the ribs on the left side and signs for pulmonary contusion. on the eight day the facial cyanosis and petechiae almost disappeared, only subconjunctival hemorrhage persisted. discussion. the symptoms are attributed to thoracoabdominal compression or to forceful compression of the thoracoabdominal muscles against a closed glottis. a reflux of blood from the heart through the valveless great veins of the head and neck occurs, the increased pressure is transmited to the capillaries. the blood stagnates and desaturates. characteristic appearance and the patient's history are the most important elements for diagnosis. laryngeal swelling can be severe enough to make the endotracheal intubation difficult. tinnitus or temporary deafness, transient or permanent vision disturbances and lethargy may occur. conclusions. morbidity and mortality are usually determined by the presence and severity of associated injuries. treatment should be directed toward associated injuries. any sign of airway compromise requires early intervention. grundlagen. in dieser retrospektiven studie wird der frage nachgegangen, ob die klinischen und radiologischen langzeitergebnisse den prothetischen ersatz des radiuskopfes in fällen von nicht rekonstruierbaren radiuskopffrakturen sowie von komplizierten luxationsfrakturen des ellbogengelenkes rechtfertigen. methodik. innerhalb eines zeitraumes von jahren ( ) ( ) ( ) ( ) ( ) ( ) ( ) wurden patienten mit derselben bipolaren metallprothesentype (tornier sa, fr) in zementierter technik versorgt. die indikationen waren: isolierte radiuskopftrümmerfrakturen (mason iii; fälle, gruppe ), ellbogenluxationen mit begleitenden radiuskopffrakturen (mason iv; fälle, gruppe ) und monteggia-verletzungen ( fälle, gruppe ). in fällen erfolgte der prothetische ersatz primär, in fällen nach vorangegangener osteosynthese. bei patienten wurde eine radiologische und klinische nachuntersuchung nach durchschnittlich jahren ( - jahre) durchgeführt. das funktionelle ergebnis wurde anhand des scores von geel und palmer (corr ) erhoben. ergebnisse. radiologisch zeigte sich in keinem fall ein hinweis auf eine veränderung der prothese bzw. deren position. im bereich des humeroradialgelenkes fanden sich nur in einzelnen fällen angedeutete zeichen einer arthrose, das capitulum radiale humeri wies in wenigen fällen eine zentrale abflachung auf. das proximale radioulnargelenk war in allen fällen radiologisch unauffällig. geringgradige periartikuläre verkalkungen fanden sich hauptsächlich im bereich der ventralen gelenkskapsel. unter anwendung des o.a. klinischen scores, der sich aus den kriterien bewegungsumfang, gelenksstabilität, kraft und schmerzen zusammensetzt, fanden sich exzellente resultate bei allen patienten der gruppen und . bei keinem dieser patienten bestand eine gelenksinstabilität. die patienten der gruppe (monteggia-verletzungen) schnitten etwas schlechter ab (gutes resultat). hauptverantwortlich dafü r waren einschränkungen in der streckung und den umwendbewegungen. subjektiv waren alle patienten mit dem ergebnis zufrieden und konnten ihre vorherigen beruflichen und freizeitaktivitäten ohne wesentliche einschränkung wieder ausü ben. schlussfolgerungen. obwohl die implantation einer radiuskopfprothese eine sehr selten durchgeführte operation ist, beweisen die guten resultate die sicherheit der methode. die ergebnisse scheinen eher durch die schädigung des ellbogengelenkes infolge des initialen traumas als durch die prothese selbst beeinflusst zu werden. die radiuskopfprothese sollte daher bei entsprechender indikation im sinne einer primären definitivversorgung eingesetzt werden und ihren festen platz im implantatlager jeder größeren unfallabteilung finden. background. gastric bypass after vbg often is a technically difficult and demanding procedure. postoperative morbidity and mortality is significantly higher compared to primary bypass. massive adhesions and scar formation at the gastro-esophageal junction are responsible for the difficulties in this procedure. scopinaro's procedure (a distal gastrectomy with gastro-ileostomy) offers the great advantage of sparing the gastro-esophageal junction and avoiding staple lines through scary tissues. this operation may represent a safe alternative to gastric bypass after vbg. a video of scorpinaro's procedure after vbg will be presented. trotzdem kann durch eine operation nicht in allen fällen ein rezidiv verhindert werden. diese beobachtung und das streben nach noch geringerer invasivität führten zur entwicklung endovenöser therapien. allen gemein ist, dass sie ultraschallgesteuert durchgeführt werden. es kommt zur induktion einer thermischen oder chemischen phlebitis, die in weiterer folge zu einer obliteration der vene führt. der vorteil dieser neuen therapieoptionen ist, dass sie in lokaler oder tumeszenzanästhesie ambulant durchgeführt werden können. die kurz-und mittelfristigen ergebnisse nach laser-und radiofrequenzablation sind in prospektiven und retrospektiven untersuchungen mit den ergebnissen nach einer ,,klassischen varizenoperation'' vergleichbar. langzeitbeobachtungen über jahre liegen nur nach solchen -schritt-varizenoperationen vor. die schaumsklerosierung ist eine wenig invasive und billige therapieoption, hat aber eine hohe rezidivrate. somit stellt die klassische varizenoperation aufgrund der guten kurz-, mittel-und langfristigen ergebnisse immer noch den ,,goldstandard'' in der therapie eines varizenleidens dar. die -schritt-varizenoperation wird heute gering invasiv, kosmetisch orientiert, mit endovaskulären gewebsschonenden stripping-operationstechniken und sicherer präoperativer therapie durchgeführt. sd , ) schmerzen in verlauf der behandelten vene und nahmen im mittel , schmerztabletten (sd , ) ein. im mittel konnte nach , tage ( - tage; sd , ) die täglichen aktivitäten normal wieder aufgenommen werden. bei keinem der behandelten fällen trat eine schwerwiegende komplikation (z. b. tiefe beinvenenthrombose) auf. in % bestanden im bereich der behandelten stammvenen nach monaten parästhesien. in der bare-fiber gruppe bestand eine tendenz zu mehr schmerzhaftigkeit, bei ebenfalls % iger verschlussrate und ansonsten vergleichbarem outcome. schlussfolgerungen. zusammenfassend lässt sich anhand der hier vorliegenden studie zeigen, dass die therapie von vsm mittels elt mit -nm-diodenlaser und radialfaser eine sowohl minimalinvasive als auch sichere und effiziente therapieoption darstellt und eine hohe frühzeitige erfolgsrate bei niedrigem schmerzniveau aufweist.in weiteren studien muss geprueft werden, ob aehnlich gute resultate auch bei weiterer absenkung des energienivaus zu erreichen sind. ergebnisse. es gab keine signifikanten unterschiede bezüglich geschlecht, alter, ceap stadium, bmi oder venendurchmesser in den beiden gruppen. in beiden gruppen wurden vergleichbare mengen an tla verwendet. in gruppe a lag die mittlere efe (endovenous fluence equivalent) bei j/cm und in der gruppe b bei j/cm . in beiden gruppen lag die verschlussrate bei %. die durchmesserreduktion der vsm cm distal der sapheno-femoralen crosse lag bei . auf . cm nach monat und , cm nach monaten. das c der ceap klassifikation verbesserte sich signifikant in beiden gruppen. gruppe a verwendete signifikant weniger schmerztabletten, an weniger tagen. in gruppe a gab es außerdem einen trend zu weniger postinterventionellen schmerzen. ecchymosen waren in beiden gruppen selten ( % in gruppe a, % in gruppe b). schlussfolgerungen. die laserpower beeinflusste nicht die verschlussrate bei der verwendeten hohen efe in beiden gruppen. in beiden gruppen waren ecchymosen und schmerzen seltener als in studien mit - nm. w laserpower reduzierte signifikant die schmerzmitteleinnahme. in beiden gruppen fanden sich gute ergebnisse, es fand sich nur ein geringer, kurzfristiger vorteil für die lasertherapie (kleinere hämatomfläche) bei im weiteren verlauf nahezu gleichem patientenkomfort. die hohen kosten der lasertherapie können somit nur schwer gerechtfertigt werden. eine kombination von crossektomie und laserablation ist eher nicht sinnvoll. die laserablation kann als minimal invasive alternative zum standardverfahren stripping nach umfassender und objektiver patienteninformation (fehlende langzeitergebnisse, mögliches leistenrezidiv durch weglassen der crossektomie) angeboten werden. endovasculäre verfahren in der behandlung der rezidivvarikositas a. j. flor grundlagen. das leistenrezidiv nach crossektomie ist ein häufig zu beobachtendes phänomen und mittels farbcodiertem ultraschall gut nachzuweisen. als ursache sieht man eine neovaskularisation von gefäßstümpfen ausgehend, welche in der literatur mit einer häufigkeit bis zu % angegeben wird. in vielen fällen zeigen sich im ultraschall reanschlüsse an intrafaszial gelegene stammgefäße. methodik. es erfolgt eine eingehende evaluierung mittels farbultraschall. finden sich insuffiziente intrafaszial gelegene stammgefäße, erfolgt die entscheidung, solch ein gefäß mittels elves-verfahren ( nm diodenlaser, in selektierten fällen mit radialsonde) oder mittels farbduplexgezielter schaumverödung zu behandeln. ergebnisse. die endolaser-obliteration mittels elves-verfahren fü hrt in mehr als % zu einem primären komplettverschluss des insuffizienten stammgefäßes. in der ultraschallkontrolle zeigt sich das kontrahierte gefäß, welches sich in weiterer folge zu einem fibrotischen strang umwandelt, um schlussendlich komplett zu verschwinden. die farbduplexgezielte schaumverödung zeigt in vielen fällen rekanalisationen, zum teil mit reflux. in vielen fällen muss die farbduplexgezielte schaumverödung mehrfach wiederholt werden. auffallend ist, dass sich der venendurchmesser im zuge der behandlung mittels schaum deutlich weniger reduziert als beim endolaserverfahren. schlussfolgerungen. endolaser und farbduplexgezielte schaumverödung eignen sich gut zur behandlung insuffizienter stammgefäße bei der behandlung der rezidivvarikositas. sie können in vielen fällen recrossektomien und andere chirurgische zugänge ersparen und sollten somit gerade bei der behandlung der rezidivvarikositas nicht als 'lifestylephänomen' abgetan werden. insbesondere die endolaserbehandlung kann intrafaszial gelegene neovarizen suffizient in einer sitzung schnittfrei verschließen. ergebnisse. auf einer skala von - ( -sehr gut, -nicht genügend) ergaben sich durchnschnittliche werte von . (trokarplatzierung), , (nadelplatzierung), (führungsdrahteinlage), (faszienverschluss), . (lernkurve). schlussfolgerungen. der neue tic -faszienverschlusstrokar ist als leicht erlernbares, verlässlisches system zum verschluss von trokarinzisionen über mm geeignet. langzeiterfahrungen bleiben abzuwarten, jedoch erscheint insbesondere die anwendung bei adipösen patienten und im rahmen von bariatrischen eingriffen sinnvoll. biological mesh in complex abdominal wall repairlong term results of use of permacol tm (porcine dermal collagen) in a single institution torbay hospital, torquay, uk background. abdominal wall repair (awr) if poor tissues, contamination, intestinal fistula, anastomosis, stoma and mesh impingement on bowel represent formidable surgical challenges. synthetic mesh or suture repair is inappropriate. biological meshes are biocompatible, offer resistance to contamination, minimal adhesion or fistula formation but retain strength. we use permacol tm -crosslinked porcine dermal collagen -in these cases and present data with long follow up. methods. retrospective review of patients treated with permacol tm for: . recurrent incisional hernia ae mesh; . post laparostomy; . enterocutaneous fistula; . contamination by anastomosis; . parastomal hernia. results. twenty-nine patients were identified. with acute or chronic abdominal defects; with parastomal hernia. defects sizes from to cm . median age (range - ) years and follow up ( - ) months. eleven cases awr - with anastomosis, paracolostomy hernia. eight enterocutaneous fistula with deficient abdominal wall; with fistula associated with mesh, all with anastomosis. recurrent of parastomal hernias. repairs by onlay, inlay and sublay. sixteen cases had no complications. major complications in patients - early deaths (myocardial infarct and multiorgan failure); recurrent hernia, colonic ischaemia requiring relaparotomy and intra abdominal abscess requiring percutaneous drainage. minor complications comprised wound infections, sinus and seroma. there were no mesh rejections and no further complications. conclusions. in difficult anterior abdominal wall repair permacol tm is effective, biocompatible, resistant to infection, contamination and can sit in contact with bowel. the new flexible conductive bipolar loop-electrode for continuous neuromonitoring of the recurrent laryngeal nerve by vagus nerve stimulation -first experience with the rd and th generation background. ascites leaks (al) in patients with end stage liver disease (esld) are commonly associated with recent interventions or ruptured hernias and are associated with significant morbidity and mortality regardless if they are medically or surgically managed. methods. in a pilot study, esld patients with a median meld score of (range - ) underwent treatment of als with topic fibrin glue injection around the leak after failing conservative therapy. results. mean age of the ten men and four women was (range - ) years. underlying eslds were chronic hepatitis c (n ¼ ), alcoholic ld (n ¼ ), cryptogenic cirrhosis (n ¼ ) miscellaneous (n ¼ ). there were six leaking incisions post emergent hernia repair (one inguinal, two umbilical, one ventral), two leaking/ruptured umbilical hernias, four leaking paracentesis sites, one leaking jp drain canal and one leaking laparoscopy trocar site. average ascites leak volume per day was ml (range ml- ml). all leaks were immediately resolved with a - cc fibrin glue injection. five recurred requireding re-injection ( within h). following injection, albumin levels, mental status and meld-scores improved in the majority of patients within one week. five patients underwent (liver transplantation) lt median (range - ) days post-injection. three patients died (two from sepsis one from metastatic cancer), the remaining patients were not accepted as lt candidates. conclusions. fibrin glue injection is a cost effective, simple and safe bedside procedure that resolves als for several months and allows for recovery in anticipation of lt and definitive repair. background. laparoscopic live donor nephrectomy requires meticulous dissection. therefore we have tested the endosite di digital vision system (viking systems + , biomedica, vienna) for applicability, ergonomic aspects and improved spectral depth perception in live laparoscopic donor nephrectomy. methods. the -dimensional visualisation system combined with high definition head displays (viking + , biomedica, vienna) was used for live donor uretero-nephrectomies in patients. side of nephrectomy was chosen according to selective renal function and vascular anatomy (right side, n ¼ and left side, n ¼ ). standard laparoscopic access was gained through trokars. for the left side, vessels were clipped and transsected laparoscopically. in order to gain length of the renal vein on the right side the graft was retrieved in a ''semi-open'' fashion as described previously by our group. results. mean age of the female patients was ae years. mean operation time, warm ischemia time and length of hospital stay were ae min., ae min. and . ae . days. upon discharge, creatinine levels, urea and c-reactive protein levels were . ae . mg/dl, . ae . mg/dl and . ae . mg/dl, respectively. there was no major complication or any procedure related morbidity such as infections or postoperative lymphatic leaks. conclusions. the -d laparoscopic system offers ergonomic advantages and improved spectral depth perception particularly in complex laparoscopic procedures like live donor nephrectomy. this system couples -d visualisation with traditional laparoscopy thus offering ergonomic advantages for less than one-tenth the cost of the da vinci system which may be of significant importance for the broad spectrum of minimally invasive surgery. background. obesity and vascular anomalies have been considered relative contraindications for living donor kidney transplantation. however, successful transplantation of laparoscopically retrieved kidneys with accessory renal vessels incidentially found upon operation, increasing body mass index (bmi) and donor age rise the question for the limits of live donation. methods conclusions. although a significant proportion of patients in our series qualifiy as ''marginal donors'' lldn is feasable and safe. however, adapted surgical technique and careful monitoring of postoperative renal function is mandatory in these patients. clinical feasibility of a new colonic access device (megachannel tm ) for interventional procedures at colonoscopy: a prospective, multicenter trial background. megachannel tm is a new colonic access system that was originally developed for colonoscopic appendectomy. once in place, the channel protects the colon from perforation risks during rapid, multiple passes of the colonoscope to the right colon. the mm working channel allows rapid and safe delivery of bulky instruments, as the removal of large specimens. methods. the device ( outer diameter, cm in length) was constructed of a wire reinforced polyvinylchloride plastisol tube with a thermoplastic distal tip and a proximal hub with integrated scope-seal. a rounded introducer-plug was fitted onto the distal tip and formed a smooth solid surface between the overtube and colonoscope to prevent tissue entrapment. results. the megachannel tm was applied in patients undergoing colonoscopy. the cecum was reached in / patients within min, with cm ( to cm) of the overtube being inserted into the colon. mild tissue bruises were observed in patients, mild to moderate pain in patients. in patients the megachannel assisted the removal of multiple polyps. in one patient a eus scope was delivered for evaluation of tumor wall infiltration before submucosal resection, in another patient a suction cap was successfully delivered to the right flexure for removal of an incomplete-lifting polyp. conclusions. this new colonic access system (megachannel tm ) can be safely applied into the right colon and is useful for a variety of colonic interventions that require multiple insertion of the scope or delivery of bulky instruments. this instrument might support notes procedures and removal of colonic stents. fast track surgery in acute ileus -first results background. fast track rehabilitation (ftr) is well established in elective surgery, but there is little experience with this concept in emergency colorectal surgery. we present our data of application of ftr in patients with acute ileus. methods. patient were included prospectively, ( . %) with ileus. all patients received a resection (colon / , rectum / ) by laparatomy with primary anastomosis in ( . %) patients. the median age was y ( - ). the level of chronic comorbidity was high: ! asa iii / ( . %). results. the essential modules of ftr could be applied successfully intra-and postoperatively: -thoracic epidural catheter: ( . %) -nasogastric tube removed at the end of operation: ( . %) -necessity of replacement of nasogastric tube: ( . %) -bowel stimulation: ( . %) -normal food intake at st day: ( . %) -normal bowel movement at postoperative day (m): ( - ) -days of stay in the icu (m): ( - ) the rates of major complications were: -insufficiency of anastomosis: ( . %) -wound infection: ( . %) -pneumonia: ( . %) -overall mortality: ( . %) conclusions. -the high mortality was due to the elderly population and concomitant diseases. -no deaths were seen from surgical complications. -based on good acceptance, low rates of major complications and excellent results in gi recovery ftr is suitable for emergency colorectal surgery and can be recommended for therapy of acute ileus. mit der accent ii studie hat die anti-tnf-alpha-therapie einen zentralen stellenwert insbesonders beim fistulierenden m. crohn etabliert [ ] . in weiterer folge stellte sich die frage, inwieweit die notwendige operative therapie des fistulierenden anorektalen m. crohn durch die anti-tnf-alpha-anwendung positiv oder negativ beeinflusst werden könnte [ , ] . als weiteren schritt sehen wir die anwendung dieser therapie mit infliximab, beim schweren anorektalen m. crohn, um voraussetzungen zu schaffen, den operativen eingriff zu minimieren oder weiterreichende auch rekonstruktive eingriffe in dieser region zu ermöglichen. unsere erfahrungen beziehen sich auf insgesamt patienten mit schwerem anorektalem m. crohn, von denen einer anti-tnf-alpha-therapie zugeführt wurden. insgesamt wurden an diesen patienten abszessdrainagen, fistelspaltungen, fistelexzisionen, sowie exzisionen mit mucosa-flap durchgeführt. bei patienten musste wegen schwerer abszedierung oder destruktion eine hartmann-deviation angelegt werden. patienten konnten einer intestinalen rekonstruktion, patienten einer sphinkterrekonstruktion zugeführt werden. bei patienten konnte, bei bestehender fistel, eine größere operation, durch minimierung der symptomatischen belastung der lebensqualität, vermieden werden. wir sehen heute die anti-tnf-alpha therapie als zusätzliche option einerseits weiterreichende operative eingriffe zu vermeiden, oder aber andererseits rekonstruktiv zu ermöglichen. methodik. unter laparoskopisch-assistiert operierten patienten waren ( weiblich), die entweder ein crohnrezidiv ( ) nach offener oder laparoskopischer voroperation oder komplikationen durch vorbestehende entero-enterale, entero-vesicale oder entero-vaginale fisteln ( ), abszesse ( ), gedeckte perforation ( ) oder entzündliche konglomerattumoren ( ) background. hyperthermic intraperitoneal chemotherapy (hipec) combined with cytoreductive surgery (crs) is an important treatment option for patients with peritoneal surface malignancies. for close to ten years the kantonsspital st. gallen has been offering this therapy. methods. since , patients with peritoneal surface malignancies were treated with crs and hipec as described by sugarbaker. hipec was performed using the open coliseum technique with mitomycin ( mg/m ) or cisplatin ( mg/m ) at c for min. results. indications for crs/hipec were pseudomyxoma peritonei ( patients), colorectal cancer ( ), ovarian cancer ( ), mesothelioma ( ) and other rare tumors ( ) . median age of the patients was years, with % males and % females. the mean and median surgical time was min and median postoperative hospitalization days. in-hospital mortality was . %. % of the pmp patients had a second crs/hipec treatment months (median) after the primary treatment. major complications requiring re-surgery occurred in %. over-all survival for pseudomyxoma peritonei patients after primary surgery was % after year and % after years, for patients with ovarian cancer % and %, respectively. conclusions. crs combined with hipec is a valuable addition to oncological surgery. due to the high morbidity, patients have to be carefully selected and surgeons have to learn which patients can profit from the treatment. the list of indications is still expanding and the outcome continues to improve, particularly at high volume centers specializing in this treatment. die praeoperative kombinierte radio/chemotherapie beim rektumkarzinom ab dem stadium t bzw. nþ gilt heute als standardisiertes neoadjuvantes therapiekonzept. voraussetzung ist ein exaktes praeoperatives staging um ein overtreatment zu vermeiden. in den letzten jahren werden vor allem unter chirurgen vermehrt stimmen laut um durch eine exaktere aussage der infiltrationstiefe in hinblick auf die mesorektale schicht und eine hohe chirurgische qualität die anzahl der erforderlichen bestrahlungen zu vermindern. wir berichten anhand der prospektiven colorektalen datenerfassung der patienten an der universitätsklinik für chirurgie der pmu salzburg aus den jahren - über unsere onkologischen ergebnisse, operationsverfahren, kontinenzerhaltungsraten, morbiditäts-und mortalitätsstatistik und tumorremissionsraten auf das strikt eingehaltene interdisziplinäre neoadjuvante therapiekonzept. anhand unserer erhobenen daten mit international vergleichbaren onkologischen resultaten, akzeptabler morbidität und zufriedenstellenden funktionellen ergebnissen wollen wir die sinnhaftigkeit dieses behandlungsalgorythmus unterstreichen. stellenwert der radiotherapie im onkologischen therapiemanagement die radiotherapie nimmt einen fixen stellenwert in der onkologischen gesamtbehandlung ein. der einsatz der strahlentherapie wird nach interdisziplinärer entscheidung -abhängig von der tumorentität, der tumorklassifikation, der tumorlokalisation, der geplanten behandlungsregime und der patientenbefindlichkeit -zeitlich koordiniert. die postoperative strahlentherapie wird generell am häufigsten eingesetzt. bei gastrointestinalen tumoren, hier vor allem beim rektumkarzinom, hat die neoadjuvante radiotherapie die nebenwirkungsreichere postoperative bestrahlung weitgehend abgelöst. durch das neoadjuvante therapiemanagement ist ein deutlich höheres tumoransprechen durch die bessere tumoroxygenierung bei deutlich geringeren spätfolgen, vor allem im dünndarmbereich, bestätigt. die entscheidung über den einsatz einer kurzzeitvorbestrahlung (  gy in tagen) oder einer langzeitbestrahlung (  , gy in wochen) ist abhängig von der tumorgröße, tumorlokalisation und notwendigkeit einer konkomitanten chemotherapie. steht die organ-und funktionserhaltung, vor allem beim analkarzinom, im vordergrund, kommt die definitive radiotherapie mit oder ohne chemotherapie zum einsatz. die chirurgische intervention dient bei dieser indikation als salvage-methode. der intraoperative einsatz der strahlentherapie kann abhängig von der entität und den gerätetechnischen möglichkeiten eine behandlungsoption darstellen. durch die moderne gerätetechnik gelangen zunehmend hochpräzisionsbestrahlungen (intensitätsmodulierte radiotherapie, dynamische arc-radiotherapie), unter anwendung moderner bilddarstellungen am linearbeschleuniger (image-guided-radiation therapy), zum einsatz. background. postoperative morbidity remains a significant clinical problem and may alter´long term outcome particularly after neoadjuvant chemoradiation in patients with locally advanced low rectal cancer. the aim of the present study was to identify a potential long-term effect of postoperative morbidity. methods. analysis of prospectively collected data of ninety consecutive patients who underwent neoadjuvant chemoradiation and curative mesorectal excision for locally advanced (ct / , nx, m / ) adenocarcinoma of the mid and low third of the rectum during a seven-year period ( ) ( ) ( ) ( ) ( ) ( ) ( ) . results. major postoperative complications occurred in , % and minor complications in . % of patients. hospital mortality and -day mortality was %. infectious complications were seen in . %. the leading causes of infectious complications were anastomotic leakage and perineal wound infection. postoperative morbidity was statistically significantly associated with gender (p < . ), pre-therapeutic haemoglobin level (p < . ), asa score (p < . ), hospitalisation (p < . ), and clinical long-time course (p < . ). moreover, early postoperative morbidity was proven as an independent prognostic factor concerning disease free (p < . ) and overall survival (p < . ). conclusions. early postoperative morbidity in patients with preoperative chemoradiation due to locally advanced low rectal cancer is demonstrated as an independent prognosticator. gender, pretherapeutic haemoglobin level, and asa score indicate patients at risk for early postoperative complications and may therefore serve as predictive features. ergebnisse. bei patienten mit primären ct cn -und ct cn -tumoren wurde bei klinischer kompletter tumorremission nach neoadjuvanter radiochemotherapie ganz auf die operation verzichtet. nach einer medianen nachbeobachtungszeit von monaten ( - ) ergaben sich lediglich in einem fall fernmetastasen der leber und nebenniere. bei zwei patienten mit lokalrezidiven jeweils jahre nach radikaler operation kam es zu kompletter remission nach radiochemotherapie. ein patient blieb ohne reoperation über monate tumorfrei, im zweiten fall mit bekannten lebermetastasen bildeten sich zusätzlich lungen-und knochenmetastasen, jedoch kein lokalrezidiv mehr. nach transanaler vollwandexzision fand sich bei einem patienten nach jahren ein lokalrezidiv mit lebermetastasen. nach radiochemotherapie und kompletter lokaler remission kam es zu zusätzlichen lungenfiliae, jedoch keinem lokalrezidiv. zwei weitere patienten blieben trotz r -resektion des primärtumors nach neoadjuvanter radiochemotherapie ohne nachresektion tumorfrei. schlussfolgerungen. in selektiven fällen von rektumkarzinomen und rezidivtumoren ist durch radiochemotherapie eine vollremission zu erzielen, die langfristig anhält und ein abwartendes verhalten unter engmaschiger kontrolle rechtfertigt. neoadjuvante und adjuvante therapie des rektumkarzinoms im klinischen alltageine aktuelle analyse des im tumorzentrum erfassten patientengutes k. dommisch, j. sauer, k. sobolewski neoadjuvante und adjuvante therapieverfahren beim rektumkarzinom sollen zur verbesserung der lokalen tumorkontrolle und zur hemmung dissiminierter tumorzellen beitragen. diese aussage gilt als allgemein akzeptiert und wird in form der therapieempfehlungen vertreten. die deutsche studie konnte in einer phase- -studie eindeutig zeigen, dass der präoperativen strahlentherapie im vergleich zur postoperativen strahlentherapie der vorzug gegeben werden muss, da sowohl kurzzeit-als auch langzeittoxidität postoperativ signifikant höher waren. die analyse des im tumorzentrum schwerin erfassten patientengutes ( patienten) zeigt, dass nur zwischen - % der betroffenen patienten im durchschnitt in derartige multimodale therapiekonzepte gelangen. das eigene patientengut der letzten jahre umfasste patienten. davon hatten patienten ein rektumkarzinom im unteren und mittleren drittel im uicc-stadium ii und iii. letztlich erhielten patienten ein komplettes neoadjuvantes the-rapieschema ( ¼ %). für eine adjuvante therapie kamen patienten in frage ( mit falsch negativem staying, notfallpatienten und mit einem karzinom im oberen drittel), eine adjuvante therapie konnten aber nur patienten in anspruch nehmen. mit den ursachen und hintergründen dieses doch ernüchternden ergebnisses setzt sich der vorliegende beitrag auseinander. die entwicklungsdynamik in der anwendung dieser therapiekonzepte innnerhalb des letzten jahrzehntes wird differenziert in bezug auf die eigene klinik und die im tumorzentrum erfassten kliniken von unterschiedlichen versorgungsebenen dargestellt. auch werden die patientenseitig vorhandenen gegebenheiten hinsichtlich der durchführbarkeit der diskutierten therapieverfahren angesprochen. background. tetrahydrobiopterin (bh ) is an essential cofactor for nitric oxide synthases (nos) and thus a critical determinant of no production. bh depletion during cold ischemia leads to uncoupling of nos and contributes to reperfusion injury (iri) due to increased superoxide formation. the role of bh during warm ischemia is still largely unknown. methods. ischemic renal injury was induced by clamping the left renal artery for min in male lewis rats immediately after right-side nephrectomy. reperfusion was studied at r (no reperfusion), min(r ), h(r ) and days(r ). animals received either bh ( mg/kg/bw) prior to reperfusion (groupi) or saline(groupii). sham operated animals served as controls(groupiii). renal function was determined by plasma creatinine/urea. bh tissue levels were assessed by hplc. morphologic changes were quantified by h&e histology. peroxynitrite formation was assessed by nitrotyrosine-immunostaining, kidney microcirculation was analyzed by means of functional capillary density and capillary diameters uing intravital microscopy. results. bh tissue levels significantly decreased after min of warm ischemia (p < . ) up to two days(r ,r ) when compared to non-ischemic controls. additional bh treatment prior to ischemia significantly improved renal function at all time points studied following reperfusion (all p < . ). furthermore, bh reduced ischemia induced histologic damage (increased inflammation, interstitial edema, hemorrhage, tubular atrophy and focal areas of necrosis) and diminished peroxynitrite formation and hence nitrotyrosine staining(r -r ).subsequently, microcirculatory changes correlated with kidney peroxynitrite generation, and improved considerably through bh treatment. conclusions. bh treatment significantly improves post-ischemic renal function as well as histologic and microcirculatory function and might be a promising novel therapeutic strategy in attenuating iri. grundlagen. bei der behandlung einer peripheren traumatischen nervendurchtrennung konnte bisher trotz anwendung modernster techniken keine zufriedenstellende funktionelle regeneration erzielt werden. die verzögerte nervenregeneration und die daraus folgende verlangsamte signalüberleitung stellen eine erhebliche einschränkung der muskelfunktion am endversorgungsgebiet der betroffenen nerven dar. ziel der studie ist es, ein neues nervenkoaptationssystem unter verwendung einer neuartigen künstlichen prothese mit der im klinischen alltag verwendeten klassischen nahtkoaptation zu vergleichen. neben der zeit und grad der nervenregeneration wird auch der einfluss der elektrostimulation getestet. methodik. es wurde an weibliche göttinger minipigs mit einem durchschnittsgewicht von ca. - kg der nervus ischiadicus durchtrennt. während die tiere in der gruppe i mittels mikrochirurgischer koaptationsnaht versorgt wurden, wurden die tiere der gruppe ii mit der neuartigen nervenprothese behandelt. die hälfte der tiere in jeder gruppe wurde eine postoperativen nervenstimulation zugefü hrt. das postoperative kontroll-und stimulationsschema beträgt monate, in denen die aussprossung der axone in monatlichen abständen evaluiert wird. ergebnisse. nach den vorliegenden ersten daten konnten wir feststellen, dass mit der nervenprothese ähnlich gute ergebnisse erzielbar sind, ohne dabei sich einer relativ aufwendigen mikrochirurgischen nahttechnik bedienen zu müssen, und in zukunft dadurch auch kein spezielles zentrum für mikrochirurgische operationen aufgesucht werden muss, sonder in jedem chirurgisch tätigem krankenhaus diese prothese eingesetzt werden kann. schlussfolgerungen. falls die ergebnisse der studie die vorläufigen resultate bestätigen sollten, wäre die implantation dieser nervenprothese eine neue und von jederfrau/mann bedienbare therapeutische option zur versorgung peripherer nervenverletzungen. prevention of oxidative stress induced organ damage in a porcine brain dead donor model background. the ''autonomic storm'' initiated after brain death is known to induce a cascade of chemokine and cytokine release which induces oxidative stress and consecutively causes cell damage and diminished organ quality. methods. brain death was induced in pigs by trepanation of the skull and increasing intracranial pressure until brain stem herniation occurred. h after brain death diagnosis, the pigs were randomized in two groups (n ¼ ). group was infused ml of a solution containing alpha-ketoglutaric acid and -mmf over h whereas group received ml nacl. blood samples were taken at defined time points, h after brain death multiorgan donation was performed and tissue samples were taken immediately after organ retrieval and after cold ischemia time (cit). histology and immunohistochemistry were performed to quantify occurrence of apoptosis and of oxidative stress induced cell damage. results. analysis of the blood samples allowed us to describe exactly the chemokine and cytokine cascades initiated during the ''autonomic storm'' in this pig brain dead donor model. histology and immunohistochemistry revealed significantly lower apoptotic cells as well as lower anti-nitrotyrosine positive cells in group when compared to group immediately after explanation and after cit. conclusions. we could diminish oxidative stress induced cell damage and prevent the detrimental effects of the ''autonomic storm'' by applying a solution containing alpha-ketoglutaric acid and therefore achieved better organ quality after multiorgan donation in a pig brain death model. establishing a brain death donor model in pigs background. several factors influencing organ quality and recipient survival after multiorgan donation and transplantation are still unknown and difficult to investigate in humans. therefore the need for an animal model that imitates human conditions might be useful not only to be able to monitor pathomechanisms of brain death and biochemical cascades in the organisms after brain death but also to be able to investigate novel strategies to ameliorate organ quality and functionality after multiorgan donation. methods. in pigs brain death was induced by inserting a catheter into the intracranial space after trepanation of the skull and augmenting intracranial pressure until brain stem herniation occurred. intracranial pressure was monitored continuously and after min brain death diagnostics was performed by a neurologist including eeg examination and clinical examination. donor care was performed according to standard guidelines for h. results. min after brain death induction neurological examination and eeg examination confirmed brain death. all animals showed typical signs of brain death. all symptoms could be treated using standard medication. after h of brain death successful multiorgan donation was performed. after organ retrieval, abdominal and thoracic organs could be analysed for tissue damage and organ quality. conclusions. using this method, a suitable brain death donor model could be establish that will enable us not only to investigate in detail effects and pathophysiology after occurrence of brain death but also to evaluate new strategies to ameliorate organ quality and even to enlarge the donor pool for multiorgan donation. behandlung von gastrojejunalen anastomosenleaks nach roux-n-y magenbypass mit einem oder zwei überlappenden beschichteten metallstents im schweinemodell methodik. in hausschweine wurde eine roux-n-y magenbypass hergestellt. in vier tieren wurde die gj mit einem cm leak an der pouchhinterwand (retrogastrisch) hergestellt. in zwei tieren wurde ein stent platziert, die anderen beiden tiere wurden ohne stent belassen. in vier tieren wurde eine gj mit leak an der pouchvorderwand (anterogastrisch) angelegt, in zwei dieser tiere wurde ein stent und in zwei tieren jeweils überlappende stents platziert. nach wochen erfolgte die euthanasie und obduktion. ergebnisse. die stentplatzierung war in allen tieren erfolgreich. in der retrogastrischen gruppe überlebten beide tiere ohne stents ohne komplikationen mit abheilung der leaks, während die tiere mit stents am . und . postoperativen tag aufgrund von kinking mit obstruktion und drucknekrosen des roux-schenkels verstarben. in der anterogastrischen gruppe überlebte ein tier mit abheilung des leaks, jedoch mit stentmigration nach distal. die übrigen tiere verstarben zwischen dem . und . postoperativen tag. in allen fanden sich durch das distale stentende bedingte drucknekrosen. in einem tier mit einem stent fand sich peritonitis bei persistierendem leakage. in tieren mit zwei stents fand sich einem ein leck der fußpunktanastomose und in dem anderen eine obstruktion durch kinking des roux-schenkels. grundlagen. während lokale verschiebelappen die besten ergebnisse bezüglich der hauttextur ergeben, ist bei ausgedehnten defekten mit lokalen verziehungen und formgebungsproblemen zu rechnen. mikrovaskuläre ferntransplantate zeigen im gegensatz dazu häufig eine andere spenderregion-abhängige hauttextur. der submentale insellappen bietet im gegensatz dazu eine alternative zu den genannten verfahren. in diesem vortrag wird dieser insellappen zur deckung von kinndefekten vorgestellt und über vor-und nachteile gegenüber anderen rekonstruktionsverfahren diskutiert. methodik. bei patienten mit defekten des untergesichts nach ablativer tumorchirurgie erfolgte die defektdeckung mit einem ,,sub-mental-artery-perforator-island-flap''. sechs patienten zeigten primär ein ausgedehntes basaliom der kinnregion. nach doppler-sonographischer identifikation von ein bis zwei submentalen perforator-gefäßen erfolgte die submentale inzision und präparation der perforatoren im bereich der durchtrittsregion des musculus digastricus. der gefäßstiel wurde bis zum gefäßursprung aus der arteria facialis präpariert und das transplantat dimensionsgerecht gehoben. nach transposition in den defektbereich wurde der haut-fett-lappen eingenäht und die entnahmeregion nach lokaler subkutaner unterminierung direkt verschlossen. die klinischen und radiologischen nachkontrollen erfolgten tage, ein, drei, sechs und zwölf monate postoperativ. ergebnisse. alle insellappen konnten komplikationsfrei gehoben werden. der postoperative heilungsverlauf war ebenfalls unauffällig. alle patienten waren im beobachtungszeitraum rezidivfrei. das ästhetische und funktionelle ergebnis war durchwegs zufriedenstellen. schlussfolgerungen. der ,,sub-mental-artery-perforator-island-flap'' ist für die weichteilrekonstruktion im kinnbereich nach basaliomentfernung gut geeignet. die lokalen gewebequalitäten paaren sich mit einer weitgehend freien transpositionierbarkeit des transplantierten gewebes. fallbericht. bei einem -jährigen patienten bestand ein ausgedehnter defekt der frontobasis und des os frontale betont linksseitig nach schussverletzung. im rahmen der primärversorgung erfolgte eine verplattung der orbitaringe, teilentfernung des frontalhirns, eines großen anteils der frontalen calvaria und ein duradefekt-deckungsversuch mit allogenen materialien. in der folgezeit kam es zu einer persistierenden rhinoliquorhoe und einer osteomyeltis der refixierten freien calvariaanteile. in kooperation mit der neurochirurgie erfolgte dann die revision der frontobasis. zur wiederherstellung der frontobasis und des os frontale wurde ein mikrovaskuläres osteoperiostales transplantat vom distalen femur unter einbeziehung proximaler tibiaanteile verwendet. nach der angleichung an die defektsituation wurde das transplantierte periost zur basalen duranarbe und zu einem lokalen calvaria.perioslappen vernäht und mit miniplatten zur übrigen calvaria fixiert. danach wurde der transplantatstiel mit der zur arteria und vena temporalis superficialis anastomosiert und der wundschluss durchgeführt. in einem nachbeobachtungszeitraum von monaten kam es zu keiner erneuten liquoroe oder infektion dieser region. es konnte eine wesentliche verbesserung der schädelform erzielt werden. schlussfolgerungen. das mikrovaskuläre osteoperiostale femurtransplantat kann unter besonderen bedingungen durch die miteinbeziehung distaler tibiaanteile extendiert werden. die gefäßversorgung über das rete articularis gewährleistet eine gute perfusion des medialen proximalen tibiaperiosts. das transplantat ist somit für die deckung ausgedehnter calvariadefekte geeignet. grundlagen. die therapie von patienten mit lippen-kiefer-gaumenspalten birgt fü r chirurgen und kieferorthopäden große herausforderungen. einerseits zeigt sich häufig operationsnarben bedingt ein eingeschränktes sagittales wie transversales oberkieferwachstum, andererseits erschweren zahnnichtanlagen, sowie das fehlen von knochen im kieferspaltenbereich das therapeutische vorgehen. segmentosteotomien sind eine erprobte methode in der behandlung von dysgnathien, sowie zahnfehlstellungen können aber nur eingeschränkt beim wachsenden kind zum einsatz kommen. segmentdistraktion erlaubt eine entsprechende therapie auch beim wachsenden kind. methodik. kinder mit kompletten lippen-kiefer-gaumenspalten wurden untersucht. alle kinder zeigten sehr breite kieferspalten mit zum teil multiplen zahnnichtanlagen. zum schluss der kieferspalten wurden die spaltfernen segmente osteotomiert und mittels individuell angefertigter distraktoren mesialisiert. am fünften postoperativen tag wurde mit der distraktion von mm pro tag begonnen. ergebnisse. bis dato ist die kieferchirurgisch/kieferorthopädische therpie bei zwei patienten abgeschlossen. bei drei patienten ist die distraktionsphase abgeschlossen, nicht aber die kieferorthopädie. schlussfolgerungen. segmentdistraktionen sind ein probates mittel zum lückenschluss bei spaltpatienten mit ausgedehnten kieferspalten, sowie nichtanlagen. der vorteil der distraktion ist, dass die therapie während des wachstums durchgeführt werden kann. die ersten ergebnisse der durchgeführten segmentdistraktionen bei patienten mit kompletten lippen-kiefer-gaumenspalten sollen präsentiert werden. is a sarme possible without detachement of nasal septum? abteilung mund-, kiefer und gesichtschirurgie, graz, austria objectives. die chirurgische gaumennahterweiterung ist ein bewährter eingriff zur lösung der sutura palatina mediana bei einer transversalen größendiskrepanz der kiefer. ziel der untersuchung war die evaluierung einer möglichen bewegung des nasenseptums im rahmen einer chirurgischen gaumennahterweiterung. study design. der chirurgische eingriff wurde als laterale osteotomie und mediane osteotomie ohne lösung des septum nasi durchgeführt. anhand von gewählten radiologischen referenzpunkten wurde die position des nasenseptums im prä-und postoperative ct vermessen und mögliche abweichungen erfasst. conclusions. bei einer durchschnittlichen erweiterung von mm wurde einer winkeldifferenz von , zwischen sagittaler und axialer ebenen gemessen. die sagittalen ebenen erfahren eine abweichung von . die nasalen atemwege zeigen eine zunahme an volumen, ohne eine signifikante Ä nderung der anatomischen gegebenheiten, so erweist sich die chirurgische gaumennahterweiterung als suffizienter eingriff. using bisphosphonates in the treatment and management of systematic illnesses e.g. plasmocytom and metastasizing illnesses is undisputed. however one of the most feared side effects of this systemic therapy is osteonecrosis of the jaw. estimates of the cumulative incidence of bronj range from . - %. with increased recognition, duration of exposure, and follow-up, it is likely that the incidence will rise. pathogenisis seems to be multifactorial. besides prophylaxis the spectrum of therapy of bronj reaches from conservative meassures to radical-surgical rehabilitation by plastic reconstruction with local and microvascular flaps. furthermore experiences of our own patients were compared to relevant literature. summary. concerning our patients ( cases)the biggest percentage of relapse-free patients could be reached through radical surgical rehabilitation, where the obtained defect is to be reconstructed plastically. the results after reconstruction with microvascular iliac crest flap proved to be most effective. the same results could be seen in relevant literature. in case of surgical decortication plastic reconstruction proved to be less difficult but long-term results were not satisfying. concluding there is to say that the present staging system should be changed into a more comprehensive staging system, which would enable us to make even more accurate judgements about risk, prognosis, treatment selection, and outcome for patients with bronj. therefore more prospective clinical studies are required in the future. das calcitonin-nasenspray therapieresistente reparative riesenzellgranulom -ein fallbericht klinische abteilung für mund-, kiefer-und gesichtschirurgie, graz, austria grundlagen. das reparative riesenzellgranulom wurde wegen seinem aggressiven wachstum und seiner progredienz, zwar als nicht neo-plastische veränderung beschrieben, jedoch seine morphologische Ä hnlichkeit mit einem riesenzelltumor rechtfertigte letztendlich eine radikale chirurgische therapie. eine chirurgische entfernung zeigte trotz einer additiv angesetzten calcitonin-nasenspraytherapie ein rezidiv. beim reparativen riesenzellgranulom handelte es sich um eine seltene intraossäre läsion, welche vor dem . lebensjahr auftrat und eine rasche indolente auftreibung des kieferknochens zeigte. methodik. bei einer jährigen patientin war im november ein langsam wachsender schmerzloser tumor im kieferwinkel links diagnostiziert worden. im februar wurde eine exstirpation des tumors durchgeführt und die zähne , wurden extrahiert. die patientin erhielt postoperativ additiv einen calcitonin-nasalspray mit i.e täglich. bei regelmäßigen kontrollen zeigte sich trotz regelmäßiger einnahme des medikamentes nach monaten ein doppelt so großes rezidiv im unterkiefer links. ergebnisse. das rezidiv wurde teilreseziert und operativ mit einem mikrochirurgisch anastomisierten beckenkammknochen im unterkiefer links rekonstruiert. die calcitonin-nasenspraytherapie wurde postoperativ sofort abgesetzt. diskussion. die radikale chirurgische entfernung der läsion unter erhaltung der funktion war eine effiziente therapie, zeigte jedoch bei der entstehung eines rezidivs in diesem fall keinen weiteren anhalt für die fortsetzung des calcitonin-nasensprays additiv. schlussfolgerungen. es wurde anhand eines fallberichtes bei einer -jährigen patientin die therapie einer exstirpation des tumors mit additiver therapie eines calcitonin-nasensprays, dem einer radikalen chirurgischen behandlung, bei einem reparativen riesenzellgranulom, gegenübergestellt und diskutiert. ein rezidiv bei dieser patientin erforderte eine radikale chirurgische teilresektion und rekonstruktion des unterkiefers, wobei eine additive calcitonin-nasenspraytherapie keine vermeidung eines rezidivs bewirkte. die funktion des kieferknochens kann durch neoadjuvante, adjuvante und auch alleinige radiotherapieoptionen ausgelöst verloren gehen, pathologische frakturen und osteoradionekrosen sind als folgen dieser behandlung von patienten mit kopf-halstumoren bekannt. bestrahlungsdosierungen beruhen dabei vor allem auf empirischen konzepten -erfahrungen bei der therapie früherer patienten. in der literatur ist wenig darüber bekannt inwieweit bestrahlter knochen auf stimulierende reize noch reagieren kann, ob die für die knochenhomöostase essentiellen mesenchymalen stammzellen (mscs) die bestrahlung tolerieren und ihr differenzierungspotential darunter leidet. im rahmen der bestrahlung werden neben dem eigentlichen zielvolumen ,,entartete krebszellen'' auch alle gesunden zellen samt den im knochen eingebetteten mscs getroffen. in dieser studie wurden deshalb einerseits humane mscs und andererseits porcine mscs vom unterkiefer des sus scrofa domestica auf ihre bestrahlungssensitivität in vitro und im gewebeverband in drei stufen analysiert. zunächst wurden humane und porcine mscs isoliert und in vitro bestrahlt. einerseits zeigte sich, wie erwartet, eine kohärente abnahme der proliferationskapazität mit zunehmenden dosen, aber andererseits blieb die osteo-und adipogene differenzierungsfähigkeit erhalten, annähernd ähnlich den unbestrahlten kontrollproben. anschliessend wurden die unterkiefer von sus scrofa domestica mit einer dosis von  gy im wochenabstand bestrahlt. zu verschiedenen zeitpunkten (nach , , und wochen) wurden die mscs aus knochenbiopsien gewonnen. interessanterweise bestanden keine signifikanten unterschiede zwischen bestrahlten und unbestrahlten mscs hinsichtlich proliferations-als auch osteogenem differenzierungsverhalten. deshalb wurden in einer weiteren analyse unterkiefer mit und gy bestrahlt und am gleichen tag mscs aus dem bestrahlten knochen entnommen. es zeigte sich kein signifikanter unterschied zwischen gy-proben (unbestrahlt) und gy-proben bezüglich proliferationsverhalten und osteogener differenzierung. aber bei den gy-proben nahm die osteogene differenzierungsfähigkeit signifikant ab. innerhalb von wochen nahm auch die proliferationsfähigkeit bei den gy-proben deutlich ab. danach zeigten sie ein proliferationsverhalten wie die anderen proben. die ergebnisse dieser aufwändigen interdisziplinären kooperation von mkg-chirurgie, anästhesie, strahlentherapie und grundlagenforschung überraschen, da die mscs im knochen bis zu einer bestimmten dosis der bestrahlung widerstehen, jedenfalls besser als ursprünglich erwartet. weitere untersuchungen sind erforderlich, um auszuleuchten, ob mscs durch das umgebende gewebe oder ihre nische etwa geschützt sind oder ob doch periphere mscs neu einwandern und damit die knochenfunktion aufrecht erhalten werden kann. funding: oenb-jubiläumsfondsprojekt nr. . background. gastroesophageal reflux causes dysfunction of the lower esophageal sphincter (les) and columnar lined esophagus (cle) resulting in gastric appearance: this is the dilated end stage esophagus (dese ¼ cle within endoscopically visible gastric folds interposed between squamous epithelium and oxyntic mucosa of the proximal stomach). we report intermediate follow-up data of patients who underwent modified laparoscopic nissen fundoplication (lnf) for gastro-esophageal reflux disease (gerd) with fundic wrap placement around the dese. methods. twenty-nine gerd patients [age . ( . - . ), female)] underwent assessment of quality of life, endoscopy with multilevel biopsies from the esophagogastric junction (for assessment of dese length), esophageal manometry and (impedance-) ph-monitoring before and ( - ) months after lnf ( þ intraoperative endoscopy). the distal limit of the fundic wrap was placed at the level of the peritoneal reflection ( ¼ anatomic esophagogastric junction) and extended proximally over a length of . cm. results. intraoperative endoscopy revealed adequate wrap placement in all patients. follow-up data. background. laparoscopic antireflux surgery is a well established treatment of gastroesophageal reflux disease (gerd). persistent or recurrent reflux, gas-bloat syndrome or dysphagia may result in repeated surgical treatment which are at higher risk of perioperative morbidity and mortality. methods. from march until april , in patients antireflux procedures were performed because of gastroesophageal reflux disease and hiatal hernia. in patients ( %) of which patients were male ( %) repeated antireflux surgery was necessary. retrospective data collection was analysed for postoperative course, perioperative morbidity and mortality after redo-fundoplication. results. redo-fundoplications were made on the ground of recurrent reflux (n ¼ ), herniation of the wrap (n ¼ ) or scarred adhesions and dysphagia (n ¼ ). all procedures were completed laparoscopically. the mean operation time was min ( - min). in patients nissen and in patients toupet fundoplication were performed. intraoperatively there occured in patients lesions of the wrap and in one patient a lesion of the pleura. in one patient laparoscopic revisions with suture was necessary. there were no postoperative in-hospital deaths. the median length of hospital stay was days ( - days). at discharge no patient had relevant symptoms of gastroesophageal reflux. conclusions. reoperative surgery after fundoplication is known to be very technical challenging because of scarred tissue. so it is associated with higher morbidity and mortality. in our case study laparoscopic redo-fundoplication was feasible and with low incidence of perioperative morbidity and no mortality. background. giant leiomyomas of the esophagus bear the risk of malignancy. treatment is a function of size, small tumors might be removed endoscopically with the ever present risk of hemorrhage. large tumors require surgery, the approach depending on the tumor site and size. methods. we report on a symptomatic male patient ( a) suffering from a giant leiomyoma (  cm) in the esophagus. preoperative testing comprising contrast swallow, endoscopy, endoscopic ultrasound, ct, and true-cut biopsy confirmed the diagnosis. patient was found eligible for thoraco-laparoscopic esophageal resection. results. the minimal invasive procedure was carried out with the patient in the left-lateral position. thoracoscopic resec- tion utilized four trocars. the azygos vein was divided with an endo-gia. after transection of the esophagus at the level of the thoracic apex the table was tilted to the right to perform laparoscopic preparation of the gastric conduit. thereafter the stomach was pulled up into the thorax. enlargement of trocar sites was necessary for specimen retrieval. intra-thoracic circular stapled anastomosis was done transorally (orvil + , covidien). procedural time lasted in total seven hours. blood loss yielded insignificant and no intraoperative complication was observed. histology yielded no malignancy. patient started with oral diet on postoperative day and was discharged on day . follow-up after three months was uneventful. conclusions. giant leiomyoma of the esophagus require surgical resection. we present our technique for thoraco-laparoscopic esophageal resection. background. robot assisted laparoscopic surgery is an increasing field. laparoscopic microsurgery, difficult maneuvers like intracorporeal hand sewn anastomoses or a narrow operating field are ideal indications for the operation robot. methods. tertiary referral center with large expertise in robotic surgery. five patients with achalasia, ( m/ f), mean age ( - ), underwent a robot assisted laparoscopic cardiomyotomy (rac) with a partial posterior (toupet) fundoplication. detailed description of the operation technique and review of the literature. results. the rac was feasible without any particular problem and the postoperative course of all five patients was uneventful. the mean operation time was min and min setup-time of the robot. on follow-up six months postoperatively, all patients were free of significant dysphagia and free of reflux symptoms and had a significant weight gain. there are several reports, series and trials about rac available in literature. the general conclusion is that this operation is easy to perform in experienced hands with a significantly lower rate of mucosal perforations, but at higher overall costs. a longer operation time has to be taken into account during the learning curve. discussion. the avoidance of mucosal lacerations and its possible consequences has to be weighted against higher overall costs. conclusions. the rac is the first ''standard laparoscopic'' operation where a clear advantage for the application of an operation robot has been proven. where available, the operation robot should be used for laparoscopic cardiomyotomies. methodik. bei schockraumadmissionen im beobachtungszeitraum mit polytraumata finden sich stumpfe und penetrierende verletzungen des abdomens und/oder des thorax. nach klinischer diagnostik mit obligater sonographie und -bei hämodynamischer stabilität, sowie fehlendem peritonismus oder eviszeration -ct-traumaspirale lässt sich das procedere festlegen: observanz und konservative therapie (n ¼ ), laparo-/ thorakotomie (n ¼ ) oder laparo-/thorakoskopie (n ¼ ). ergebnisse. schussverletzungen wurden regelhaft offen versorgt. alle diaphragmalen läsionen wurden im ct oder per laparotomiam erkannt und therapiert. in lediglich fällen kam eine laparoskopische bzw. thorakoskopische versorgung sicher und sinnvoll -selbst bei mehrfachverletzungen -zur anwendung: es handelte sich um atypische pulmonale segmentresektionen bei stichverletzungen, je eine milzklebung, eine colonübernähung, einen umstieg auf offene milzerhaltende prozedur, eine perikardfensterung und eine rein diagnostische laparoskopie, wobei keine verfahrensabhängigen komplikationen beobachtet werden mussten. schlussfolgerungen. penetrierende verletzungen der brustund/oder leibeshöhle stellen für die chirurgische versorgung eine herausforderung dar: einerseits darf der diagnostik keine läsion entgehen, andererseits muß eine Ü berversorgung mit dem eigenrisiko einer negativen explorationslaparotomie vermieden werden. klinische, sonographische und computertomographischeggf. wiederholte untersuchungen -lassen nur in hochselektiven situationen eine endoskopische annäherung sinnvoll erscheinen, zumal den therapeutischen endoskopischen verfahren technische grenzen gesetzt sind. unbestreitbar ist allerdings ihr wert bezüglich einer harten forensischen dokumentation. bmi , ( , ) kg/m ) mit einer itp laparoskopisch splenektomiert. in einer univariaten analyse wurde der einfluss von alter, bmi, asa-score, krankheitsdauer, medikamentöser therapie, op-dauer, konversion, komplikation, milzgewicht, präoperativen thrombozytenzahlen, thrombozytenanstieg und blutproduktsubstitution auf das langzeitergebnis ausgewertet (anova mit bonferroni post hoc test, kruskal-wallis-test). ergebnisse. die erkrankungsdauer lag bei , ( , - ) jahren. das milzgewicht betrug ( - ) g. die operationsdauer betrug ( - ) minuten. konversionen erfolgten in %. die thrombozytenzahl stieg um % (präoperativ ( - ) tsd/ml, bei entlassung ( - ) tsd/ml). die morbidität war , %, die letalität %. die liegezeit betrug ( - ) tage. das mediane follow-up betrug monate ( , - , jahre). dauerhaft normwertige thrombozytenzahlen konnten bei , % der patienten erzielt werden. patienten zeigten keinen thrombozytenanstieg nach splenektomie, während patienten nach ( - ) monaten eine rezidiv-thrombopenie entwickelten. patienten mit einer primären postoperativen thrombozytopenie < . /ml waren therapieversager ( / ), postoperative thrombozytenwerte zwischen . /ml und . /ml resultierten in partieller ( / ) und kompletter ( / ) remission, während thrombozyten > . /ml überwiegend zu einer kompletten remission ( / ) führten. schlussfolgerungen. die laparoskopische splenektomie ist ein sicheres verfahren bei selektionierten patienten und gilt als chirurgisches standardverfahren bei der therapierefraktären itp. die ansprechrate liegt bei %. die postoperativen thrombozytenwerte sind ein prediktor für den langzeitverlauf, während periopereative komplikationen keinen einfluss auf die rezidivrate haben. grundlagen. die verwendung von sogenannten perforator-lappen in der plastischen chirurgie konnte in der rezenten vergangenheit zum einen zu einer massiven reduktion der hebedefektmorbidität und zum anderen zu einer größeren flexibilität im lappendesign beitragen. vorallem im bereich der mammarekonstruktion ist der deep-inferior-epigastric-artery-perforator-falp (dieap-flap) mittlerweile zu einem operativen standard geworden. in der vorliegenden untersuchung soll die bedeutung der präoperativen darstellung der perforatorgefäße mittels ct-angiographie untersucht werden. methodik. insgesamt wurden an unserer abteilung bei von patientinnen seit mai mammarekonstruktionen mittels dieap-flaps durchgeführt. bei von patientinnen wurde präoperativ eine ct-angiographie zur darstellung der perforatorgefäße vorgenommen. anhand von beispielen sollen sowohl die praktikabilität als auch die vorteile der untersuchung verdeutlicht werden. ergebnisse. in keinem der fälle mit präoperativer ct-angiographie kam es zu einem lappenverlust. die operationsdauer der lappenhebung konnte verkürzt werden, sowie das lappendesign anhand der untersuchungsergebnisse individuell angepasst werden. schlussfolgerungen. die präoperative ct-angiographie der perforatorgefäße zur hebung eines dieap-flap trägt zu einer reduktion der operationsdauer bei und hat einen positiven einfluss auf die realibilität der lappendurchblutung. roughly % of pediatric tumors are present at birth. with the increased use of prenatal imaging these tumors are detected at earlier stages of fetal development and pose a diagnostic and therapeutic challenge as of how to proceed in a situation of potential malignant grow. methods. if on routine prenatal ultrasound a tumor was suspected, axial, coronal and sagittal t -w and t -w sequences were obtained using a . tesla mri. the mri's were performed between the nd- th gw (median gw). no sedation or contrast enhancement was used for this study. results. between and , tumors were diagnosed after exclusion of hemangiomas, lymphangiomas, ovarian cysts and ccam. were teratomas localized to the face ( ), neck ( ), mediastinum( ) sacrococcyx( ). the remaining tumors were a hepatoblastoma, a cystic neuroblastoma, a adrenal cyst and a malignant glioma/pnet. three cases posed a special therapeutic dilemma. the facial teratoma that due to rapid tumor growth had to be delivered by c-section at gw so that chemotherapy could be initiated. one of the cervical immature teratomas had rapid extension and should have been delivered earlier. the fetus with hepatoblastoma had rapid tumor progression and required a hemihepatectomy in the first week of life. conclusions. prenatally detected tumors pose a diagnostic and therapeutic challenge. location, size, extension and vascularity of the tumor will determine the viability of the fetus and therapeutic options including time and mode of delivery. consensus has to be taken by an interdisciplinary team (obstetrician, neonatologist, oncologist, surgeon) and the parents. background. burns are very common in pediatric patients. most children are very young ( < years of age). a variety of none degradable products are available for closed wound management. suprathel tm is a degradable alternative. it is composed of polylactic acid in combination with other biocompatible polymers. it can be used for nd and partial rd degree burns, split skin donor sites and large-area abrasions. methods. between november and november , we treated children between months and years of age, most of them with a and b burns. suprathel tm was used in cases ( %). debridement was performed without undue delay. three days later we applied suprathel tm and two layers of fat gauze to prevent adhesions. in to days intervals the superficial dressing was changed, leaving suprathel tm and the deeper gauze in place. results. changing of the superficial dressing was easy and painless. inspection of the healing progress was possible as suprathel tm becomes translucent. time spent in hospital was reduced, wound healing speeded up, no wound infection was recorded and the cosmetic results were excellent. suprathel tm came off naturally within to days after application. discoloration of the overlying fat gauze was observed and was never caused by infection. occasionally suprathel tm did not adhere initially. conclusions. suprathel tm handling is very simple. the most important benefits are no pain and less change of dressing with good cosmetic results. it is a considerable improvement of the management of nd and partial rd degree burns in children. erfahrungen in der kinderwundambulanz der kinderchirurgischen abteilung der lfkk linz grundlagen. eine der potentiellen anwendungen des monitorings von angiogeneseparametern ist die verwendung als tumormarker. ziel dieser studie ist, etablierte tumormarker wie ca - den angiogeneseparametern unter neoadjuvanter therapie mit bevacizumab gegenüberzustellen. untersucht wurden der pro-angiogene faktor vegf (vascular endothelial growth factor), der durch bevacizumab inaktiviert wird, sowie der angiogeneseinhibitor tsp- (thrombospondin- ). methodik. patienten mit lokal fortgeschrittenem pankreaskarzinom wurden mit zyklen (q wochen) gemcitabin sowie -wöchentlich mit bevacizumab behandelt. blutproben wurden alle wochen jeweils direkt vor der bevacizumab-applikation abgenommen. die angiogenesefaktoren wurden im plasma bestimmt. ergebnisse. im verlauf der therapie kam es zu einem kontinuierlichem abfall von ca - (p ¼ , ). die vegf-spiegel korrelierten positiv mit der bevacizumab-therapie und stiegen bereits mit der ersten behandlung signifikant an (p ¼ , background. endoscopic thoracic sympathetic block (etsb) provides excellent outcome for palmo-axillary hyperhidrosis (hh). the aim of the study was to investigate the long term effects of etsb . methods. between and patients (mean age ae years) underwent etsb procedures in a prospective study. satisfaction rates and two validated quality of life (qol) questionnaires were assessing postoperative outcome (keller: - and milanez de campos: - ; : no symptoms; or : maximal symptoms), respectively. mean follow up was . ae . months. results. one hundred and sixty-two patients ( . %) had palmar and patients ( . %) axillary hh. all patients with palmar hh were completely or almost dry postoperatively whereas patient ( . %) developed recurrence of the primary disease at follow up. among patients with axillary hh, recurrences appeared in . % within six weeks and rose up to . % at follow up. compensatory sweating (cs) and gustatory sweating were observed in . % background. at the time when notes techniques struggle on diverse problems a novel single incision laparoscopic method is developed utilizing the umbilicus as embryonic natural orifice. three intra-umbilical trocars allow a minimal invasive procedure which results in a non-visible postoperative scar. methods. twenty-four patients (age: - a) underwent single incision laparoscopic cholecystectomy ( / - / ) for gallbladder stones and/or cholecystitis. the entire operation was carried out transumbilically following the standardized principles of the laparoscopic technique. one or two (in the initial patients) intraperitoneal suspension sutures helped to expose the anatomical structures. results. in all but two patients single incision transumbilical surgery could be completed. in both cases placement of one and two additional trocars, respectively, was necessary due to severe adhesions from previous surgery. the operative time was in median (range - ) min. no intraoperative adverse events were noticed. estimated blood loss yielded minimal in all cases. cholangiography was successfully carried out in two patients. all returned to oral diet after six hours. they were discharged in median on postoperative day in accordance with local custom. an optimal postoperative and cosmetic result without apparent scar was documented at follow-up. conclusions. this initial series presents for the first time a novel laparoscopic technique for e-notes cholecystectomy utilizing a single ''scar-less'' intraumbilical approach which minimizes the surgical trauma. background. during the past decades anecdotic reports on single incision laparoscopic appendectomy were published. the scientific interest in notes procedures led to a renaissance of this technique in the surge for a minimal invasive approach. we developed a novel laparoscopic transumbilical method utilizing three instruments exclusively through the embryonic ''non-visible'' scar. methods. two patients (both a) underwent single incision laparoscopic appendectomy ( / - / ). the entire operation was carried out transumbilically following the standardized principles of the minimal invasive appendectomy technique. results. both patients underwent surgery for acute appendicitis with perifocal peritonitis. after dissection of the appendicular artery the appendix was transected by use of a loop and a stapler, respectively. the operative time was min and min. no additional trocar had to be placed. no intraoperative adverse events or significant perioperative complication was noticed. estimated blood loss yielded minimal in both cases. one patient suffered from infectious enteritis and mild wound infection postoperatively. oral diet was resumed immediately after the operation. at follow-up patients presented with an outstanding cosmetic result without apparent scarring. conclusions. for the first time instrumental developments allow a novel laparoscopic technique for appendectomy utilizing flexible instruments through a single intraumbilical approach resulting in a non-visible scar. methods. twenty-three patients ( female/ male; age: - a) underwent single incision laparoscopic inguinal hernia repair ( / - / ). the entire operation was carried out transumbilically following the standardized principles of the tapp technique. results. sixteen patients underwent single site surgery ( primary/ recurrence procedures), whereas bilateral hernia repair was necessary in seven patients. the operative time was - min and - min for single and bilateral repair, respectively. one additional trocar had to be placed for dissection or suturing in four patients. no intraoperative adverse events or significant perioperative complication was noticed. estimated blood loss yielded minimal in all cases. in one patient redolaparoscopy was carried out after days for undefined lower abdominal pain. oral diet was resumed immediately after the operation. patients were discharged on postoperative day to in accordance with local custom. at follow-up patients presented with an optimal postoperative and cosmetic result without apparent scarring. conclusions. this feasibility study presents for the first time presents a novel laparoscopic technique for tapp groin hernia repair utilizing a single ''scar-less'' intraumbilical approach which allows further reduction of the surgical trauma. background. on the way to ''no-scar'' techniques we developed a novel method for colorectal resection utilizing three intraumbilical trocars which results in a non-visible postoperative scar. methods. four patients ( female/ male; - a) underwent laparoscopic colorectal resection for diverticulitis and infiltrating endometriosis of the rectosigmoid colon, respectively. the entire operation was carried out transumbilically following the standardized principles of colorectal resection. results. the operative time ranged in total from min to min and for dissection only - min, respectively. no intraoperative adverse events or significant perioperative complications were noticed. specimen retrieval was carried out through the umbilicus. segments measured in length cm to cm. circular stapled anastomosis was performed transanally. estimated blood loss yielded minimal in all cases. oral diet was resumed on postoperative day . patients were discharged on postoperative day to . at follow-up patients presented with an optimal cosmetic result without apparent scarring. conclusions. for the first time a novel laparoscopic technique for sigmoid colon resection utilizing a single intraumbilical approach is presented. this new method is restricted to a limited number of patients but allows further reduction of the surgical trauma and to obviate any visible scar. background. besides the considerable advantages of laparoscopic ventral hernia repair one of the most severe complication is the incisional hernia of the trocar site. one of the key benefits of notes-procedures is to avoid surface incisions leading to a decrease of postoperative pain, infection and port site hernia. the aim of this experimental study was to assess the feasibility of the ipom repair in ventral hernia by transgastric access in a pig model. methods. under laparoscopic control a transgastric approach was utilized to create abdominal wall defects in female, domestic nonsurvival and survival pigs respectively. titanized polypropylene meshes (tisure + ) armed by polypropylene sutures in the four corners were transferred via the umbilical trocar. after suture fixation of each mesh additional endoscopic transporous fibrin sealant fixation (tissucol + ) using a single lumen catheter was performed. the closure of the gastric access was achieved by applying endoclips in nonsurvival and by laparoscopic suturing in case of survival pigs respectively. results. the survival pigs were euthanized at day , and postoperatively. the macroscopical evaluation revealed excellent integration of the meshes without signs of shrinkage or increased inflammation. only in cases out of a total of meshes minimal adhesions in the region of suture fixation were observed. histology confirmed the macroscopical findings. conclusions. the initial results of our experimental study demonstrate the feasibility of a notes repair of abdominal wall hernias. anticipating technical advances of notes-devices this new technique could be auspicious for the future. medical university, lviv, ukraine; childrens hospital, lviv, ukraine recent advances in medicine brought to noticeable growth of premature newborns' survival value. but this fact brought to growth of necrotic enterocolitis morbidity of newborns that often occurs on the background of congenital bowels pathology. from to we treated children with necrotic enterocolitis. the average gestational age of patients was . þ . weeks, average body weight - þ g. seven patients were operated with a stage of necrotic enterocolitis. large intestine hypoplasia was intraoperatively revealed in cases; and after its biopsy congenital agangliosis was diagnosed. the signs of partial bowel obstruction kept after reduction of necrotic enterocolitis effects in from non-operated patients with b- a stages of necrotic enterocolitis; large intestine biopsy of those patients revealed intestinal neuronal displasia type a in one case, intestine neuronal displasia type b in two cases, congenital agangliosis in one case. conclusions. different forms of disgangliosis can be one of the trigger mechanisms for the development of newborns' necrotic enterocolitis. at the same moment necrotic enterocolitis can be one of the first manifestations of congenital disgangliosis. that's why the visual large intestine hypoplasia or keeping of partial bowel obstruction signs after the reduction of necrotic enterocolitis effects of newborns must be the reason for the large intestine biopsy and histochemical investigation of biopsy material for this group of patients. zur angeborenen dilatation von intestinalsegmentenein beitrag zu einem seltenen krankheitsbild accidental ingestion of foreign bodies is a common problem in infants and childhood, but ingestion of magnetic construction toys is very rare. when multiple parts of these magnetic construction toys are ingested, they may attract each other through the intestinal walls, causing pressure necrosis, perforation, fistula formation or intestinal obstruction. a -month old boy presented with a three day history of abdominal pain and bilious vomiting. physical examination revealed a slighted distended abdomen. the white blood cell count was normal, but the c-reactive protein was elevated. ultrasound and x-ray of the abdomen showed a distended bowel loop in the right upper, a moderate amount of free intraperitoneal liquid and four foreign bodies. emergency laparotomy was performed and two perforations in the ileum could be detected. the perforation was caused by a magnetic construction toy and two iron globes. the fourth foreign body was a glass marble. the foreign bodies were removed, both perforations were primary sutured. the child was discharged on postoperative day after an uneventful recovery. parents should be warned against the potential dangers of children's constructions toys that contain these kinds of magnets. interdisziplinärer zusammenarbeit bei kindern mit anorektalen malformationen -erfahrungen des colorektalen teams in linz landes-, frauen-und kinderklinik, linz, austria bei kindern mit anorektalen malformationen besteht eine sehr hohe wahrscheinlichkeit, auch an anderen stellen fehlbildungen aufzuweisen. dies erfordert nicht nur bei der abklärung sondern auch bei der behandlung und nachbetreuung eine enge zusammenarbeit mit anderen fachabteilungen und der pflege. an unserer kinderchirurgischen abteilung in der landes-, frauen-und kinderklinik hat sich ein colorektales team aus Ä rzten und pflegepersonen gebildet, das zum einen die anorektalen malformationen der kinder operiert und nachbetreut, zum anderen als interdisziplinäre drehscheibe zu anderen abteilungen fungiert. mehr bereits bei der abklärung der patienten mittels endoskopie spielt der kinderchirurg eine wesentliche rolle. bewährt hat sich die anwesenheit des gastroenterologen während der endoskopie. sind die indikationen zur operativen intervention beim mb. crohn klar, ist bei der colitis ulcerosa nur die behandlung des toxischen megacolons eindeutig. im allgemeinen wird der chirurg erst am ende der konservativen therapie beigezogen, wenn sich der patient bereits in schlechtem allgemeinzustand befindet oder komplikationen von seiten der nicht ganz harmlosen medikation eingetreten sind. anhand eines -jährigen mädchens mit ausgeschöpfter therapie (sandimun, imurek und prednisolon) möchte ich unser vorgehen darstellen. trotz maximaler konservativer therapie konnten die blutungen nicht gestoppt werden. wegen grundlagen. die pilonidalsinus-erkrankung ist eine in der rima ani lokalisierte granulomätöse erkrankung, verifizierbar mittels ,,blickdiagnose''. trotz ihres häufigen vorkommens gibt es für die erkrankungsstadien der affektion keine allgemein gültigen therapieempfehlungen. methodik. während der letzten jahre wurden kinder/ jugendliche ( mädchen, männliche kinder/jugendliche (alter zwischen und jahren)) wegen einer pilonidalsinus-erkrankung behandelt. waren asymptomatisch, der prozess wurde exzidiert und der defekt linear verschlossen. hatten ein chronisch-entzündliches geschehen: nach exzision des herdes wurde bei einem eine limberg-lappendeckung, bei eine offene wundbehandlung und bei eine karydakis-defektdeckung durchgeführt. die ,,restlichen'' patienten mit abszedierendem pilonidalsinus wurden nach abszessinzision/exkochleation offen wundbehandelt; bei wurde tage später eine karydakis-operation angeschlossen. ergebnisse. bei der patienten mit den defektverschlüssen verheilten die wunden innerhalb von wochen, bei den restlichen (nach karydakis-operation) innerhalb von wochen. die offenen wundbehandlungen führten nach einer behandlungsdauer zwischen / und wochen zu einem adäquaten wundverschluss, davon entwickelten ein sinus-pilonidalis-rezidiv, das exzidiert und neuerlich offen behandelt wurde. diskussion background. as the elderly population is growing, the incidence of patients being diagnosed with pancreatic cancer at the age of and above is rising. even overall morbidity and mortality rates for pancreatic resection decreased the last decades, the indication of major pancreatic surgery in elderly patients is still discussed controversial. methods. during the last ten years patients at the age above a underwent pancreatic resection for adenocarcinoma of the pancreas at the surgical department of the muw. perioperative outcome, histopathological findings and overall survival was investigated and compared to younger patients. results. between and patients ( female and male) at the age of - and patients ( female and male) a and older, had pancreatic resection with curative intent. the pancreatic head was the predominant location within both groups. % of the elderly patients had duodenopancreatectomy almost equal to % of the patients younger than a. there was no significant difference in perioperative morbidity ( . % old vs. . % young) and mortality ( . % old vs. . % young). mortality and morbidity were % and . % in the group of patients a and older. the median postoperative stay in hospital was days (old) and days (young) respectively. there was no observed difference in the mean survival for both groups ( months old vs. months young). conclusions. an aggressive surgical approach for pancreatic cancer is justified in elderly patients, as they can benefit from resection similarly to younger patients. is preoperative tissue diagnosis mandatory for suspect lesions of the pancreas? background. it is still controversial if pretherapeutic cytohistological diagnosis is mandatory for patients with suspect leasions of the pancreas. even transgastric endosonographic biopsy is a save technique, with a sensitivity of - %, a negative result does not rule out malignancy. methods. medical records of patients who underwent surgery at our department, between and , for suspected or biopsy proven pancreatic adenocarcinoma were analysed and literature on preoperative biopsy of suspect pancreatic tumors was reviewed. results. of patients with ductal adenocarcinoma had a biopsy prior to surgical resection. of these % (n ¼ ) were histological diagnosed as adenocarcinoma. patients underwent surgery even after negative cyto-histological workup. patients had partitial pancreatic resection without preoperative biopsy. of patients receiving neoadjuvant chemotherapy % (n ¼ ) had histological diagnosis prior to therapy. on the other hand patients with suspect pancreatic lesions showed pancreatitis and no malignancy after resection. % of them had biopsy with negative result but underwent operation due to preoperative radiological findings and or ca - level. conclusions. preoperative biopsy of potentially respectable suspect pancreatic masses is not mandatory as malignancy cannot be ruled out with adequate reliability. only in patients undergoing neoadjuvant therapy extended effort in receiving positive biopsy cyto-histological result is indicated. wie schlecht sind ,,low volume hospitals''? eine kritische analyse der ergebnisqualität von pankreaskopfresektionen an einer peripherieabteilung dynamic graciloplasty in patients with severe anal sphincter lesiona method still up-to-date? background. until recently the dynamic graciloplasty (dgp) was one of the most effective techniques to create a neo-sphincter despite its complexity. nowadays it has been replaced by less invasive methods in order to treat the fecal incontinence. however dgp still plays an important role and this prospective study shows the results of reconstructive surgery. methods. from january until december seven female patients (average age of . years, range - years) were enrolled in the study. inclusion criteria were severe faecal incontince after failed conservative treatment diagnosis was confirmed by rectoscopy, endo ultrasonography and anal manometry in preoperative form according to the study protocol and the fecal incontinence was recorded using the wexner-score. postoperative complications were classified in four levels according to dindo et al. results. five patients suffered a postpartum sphincter lesion ( > in circumference) and two a congenital atresia of the sphincter muscle. postoperatively, one patient suffered level iii (reoperation) and three others level i complications (hypaesthe- sia distal to extraction area of the m. gracilis, extended aches due to sores in the neurostimulator and electrode area). after completion of the muscle conditioning (eight weeks postoperative) the median wexner-score was reduced from preoperatively (range - ) to ( - ). conclusions. all that exists today for the dgp is a modified indication list. in young patients with irreparable sphincter lesion or congenital atresia of the sphincter muscle the dgp remains an effective method in therapy with moderate morbidity. grundlagen. die versorgung von narbenhernien mittels offener oder laparoskopischer technik kann in wundkomplikationen und hernienrezidiven resultieren. mittels notes techniken könnten diese komplikationen verhindert werden. methodik. in hausschweinen erfolgte die herstellung einer ventralen bauchhernie durch resektion eines runden cm im dm haltenden muskulären defektes. nach wochen erfolgte der transgastrische verschluß der resultierenden hernie mittels eines über einen overtube eingebrachtem biologischen netzes mit cm allseitiger Ü berlappung und fixation mit transfascialen nähten. nach zwei wochen erfolgte eine explorative laparoskopie und nach weiteren wochen wurden die tiere euthanasiert und obduziert. ergebnisse. die größe der hernien lag zwischen und cm . in allen tieren konnte ein hernienverschluss mit einer mittleren operationszeit von ae minuten durchgefü hrt werden. die größe der implantierten netze lag zwischen  und  cm. ein tier verstarb unmittelbar postoperativ an hypoxie. bei der laparoskopischen exploration nach wochen fanden sich in allen tiere massive adhäsionen, ein tier wurde aufgrund einer netzinfektion euthanasiert. die ü brigen tieren ü berlebten die vierwöchige beobachtungszeit. in allen tieren fand sich bei der obduktion ein erfolgreicher hernienverschluss. alle tiere hatten netzinfektionen. schlussfolgerungen. der transgastrische verschluss von großen ventralen bauchwandhernien ist technisch machbar. das sterile transgastrische einbringen des netzes und die verhinderung von netzinfektionen stellen derzeit die größten hürden dar die überwunden werden müssen, bevor dieser eingriff bei menschen in erwägung gezogen werden kann. background. transgastric notes procedures remain difficult due to the lake of innovative flexible endoscopic technology. in particular, independent movement of the instruments from the visual axis has been described as an essential part of complex notes procedures. methods. we present our experience using the endo-samurai tm (olympus) newly designed prototype platform for advanced endoscopic surgery, which is mm in od and which allows of freedom at the instrument tips with a variety of instrument configurations, in an animal model to perform transgastric cholecystectomy. results. a porcine model was used to perform transgastric cholecystectomy with the new device. gastric exit was easily performed using an overtube and needle knife in min. the gallbladder was easily identified and dissected in a manner similar to laparoscopic procedures using graspers and hook cautery instruments with of freedom. good user ergonomics were recorded and the gb was removed without spillage in min. gastric closure was attempted with intracorporeal suturing but was still difficult due to grasping strength of the needle holders and visualization due to loss of pneumo-gastrium. conclusions. the new endosamurai tm device offers substantial advantage to the performance of transgastric notes procedures and may represent the configuration of operating flexible endoscopes of the future. background. laparoscopic cholecystectomy has become standard procedure. natural orifice transluminal endoscopic surgery (notes) will further decrease the operative trauma to the abdominal wall and reduce postoperative pain, wound infection, risk of hernia and hospital stay. we report the first results of transvaginal hybrid-notes cholecystectomy in switzerland. methods. from july to december , women were treated by transvaginal hybrid-notes cholecystectomy. pneumoperitoneum was created through a mm incision in the umbilicus. two rigid trocars ( mm and mm) were inserted in the posterior fornix of the vagina. patient data, operative time, complications and postoperative course were recorded prospectively in each patient. results. the average age of the patients was . years ( - years) and the mean body mass index was . kg/m . all operations were performed without intraoperative complications. the mean operative time was min ( - min). the mean hospital stay was . days ( - days). non steroidal antiinflammatory drugs and paracetamol or metamizol were administered for analgesia. the postoperative course was uneventful. no complications were recorded during the further postoperative follow-up after weeks. conclusions. the transvaginal hybrid-notes cholecystectomy is a feasible and probably safe procedure. operative time was despite of any expected learning courve effects not significantly longer than in laparoscopic cholecystectomy. the posterior colpotomy is a simple approach to the abdominal cavity and wound healing is very rapid. using rigid instruments and techniques wellknown for laparoscopic techniques transvaginal cholecystectomy seems feasible with low operative risk. background. the latency time to develop colonic carcinoma in patients with uretersigmoidostomy (ursig) is usually more than ten years. we present a case of carcinoma in-situ of the colon in which a ursig was present less than six months. method. retrospective chart review. case report. an eighteen-year-old male born with bladder exstrophy underwent a ursig at age of months after a failed bladder closure. four months later the ursig was converted to an incontinent uretero-ileostomy. at eighteen years of age during an operation to construct a continent reservoir carcinoma in-situ of the rectosigmoid was incidentally discovered. the involved bowel was resected and a continent reservoir with the ileal segment and descending colon was created. the patient remains disease free for the next years. conclusions. colonic carcinoma can develop even after very short time with a ursig. when ursig is taken down, the involved colonic segment should be removed. adrenal tumors in children a. pereyaslov , a. dvorakevich , l. burda medical university, lviv, ukraine; regional children hospital, lviv, ukraine adrenal tumors are the rare cause of arterial hypertension in children. prolonged period of diagnosis determines inadequate treatment of arterial hypertension with the development of lifetreating complications. in this study summarized results of treatment children with adrenal tumors during -years period. there were ( . %) children with benign adrenal tumors, including children with hormonally active (cushing's syndrome - , virilizing tumor - , feminizing tumor - , pheochromocytoma - , conn syndrome - ) and -with non-functioning tumors. five ( . %) patients had malignant adrenal tumors: patients had adrenocortical cancer, one -malignant corticochromoblastoma, and one -chromoandroblastoma. adrenalectomy was performed in ( . %) patients. conventional lumbotomy was applied in ( . %) patients and in ( . %) -laparoscopic adrenalectomy. laparoscopic removing of adrenal tumors was performed in children with pheochromocytoma, in -with adrenal cyst and in -with myelolipoma. the retroperitoneal approach was applied in patients and transperitoneal -in patients. there was no conversion during laparoscopic adrenalectomy. two ( . %) children with corticochromoblastoma and chromoandroblastoma did not operated due to the disseminated metastasis at the time of admission and they died at the follow-up. all patients who underwent adrenalectomy were discharged with normal blood pressure and no patient required adjuvant therapy. surgery remains the method of choice in the management of children with adrenal tumors and laparoscopic adrenalectomy may applied in patients independently of tumors' functional activity. damage to the ureter by an iatrogenic injury is a devastating occurrence. congenital ureteral anomalies present an increased risk of injury. case report. we report a -month-old baby that underwent right nephrectomy for a multicystic kidney. the left ureter had been damaged as an interlaced left and right ureter had not been recognized. repair of the damaged ureter had failed and the left kidney had to be drained by a j-stent through the retroperitoneal space into the bladder. the child was transferred to our institution at months. results. we interposed the appendix from the left renal pelvis to the bladder. a double j stent was inserted for four weeks. two years afterwards this child is thriving normally without urinary tract infections and normal renal function. discussion. ureteral trauma if not timely recognized can lead to urosepsis and renal failure. several techniques have been described for the replacement of long ureteral segments: the use of urinary tract tissue, the psoas-hitch technique, pedicled intestinal segments and the yang-monti technique. the appendix is similar in size and length to the ureter and can be easily implantated with an antireflux technique. electrolyte absorption and mucous production by the appendix are negligible. conclusions. only a few case reports exist in which the appendix is used as a replacement of the left ureter. this case adds to those reports and suggests that ureteral reconstruction using the appendix vermiformis seems a viable technique even when used as a replacement of the left ureter. hypospadia is one of the most common deformities of the uro-genital system. a great diversity of procedures for correction of hypospadias is suggested. at our department we use for correction of the so called ''distal'' hypospadia mainly one method: the y-v glanuloplasty modified mathieu technique after hadidi. we investigated the outcome of patients with distal penile hypospadia regarding to complications, voiding function and cosmetic satisfaction. the mean age is located in between the international recommended correction time of - month. the mean observation time is months. beside a good cosmetic appearance with an erectly shape and a wide meatus, we found an adequate voiding function. fistulas occurred after failure of wound-healing in two cases. the use of an additional layer of connective tissue between neo-urethra and skin seemed to be beneficial against occurrence of fistulas. in contrast to other urethroplasties, we do not use any stent or catheter in the y-v glanuloplasty modified mathieu technique and the patients void immediately after the surgical procedure through the neo-urethra. the crucial element is, in our opinion, an adequate pain relief during the first two days so that the patient won't get a voiding problem. the mean hospital stay was - days. all over, we think that the patients benefit from the y-v glanuloplasty modified mathieu technique as for this method we do not use urethral stenting nor any kind of dressing. background. during laparoscopic cholecystectomy (lc) for symptomatic gallstone disease injury of the gallbladder with spillage of stones occurs frequently. subphrenic abscess after lc is a rare complication of this condition and may cause diagnostic dilemmas and delayed treatment. methods. we present a case report of a patient with subprenic abscess formation due to a lost gallstone and a review of the current literature. case. after a stay in india a year old female patient presented with a subprenic abscess formation mimicking a liver abscess and pleural effusion. her medical history implied a hysterectomy for cervical cancer and a lc. the diagnostic and therapeutic management is exactly processed. results. spillage of stones at lc occurs in , - %. in a systematic review the complication rate of lost gallstones is stated to be - %. a large variety of complications, some with serious morbidity, has been described. only cases of subphrenic abscess have been reported previously. conclusions. every effort should be made to extract lost gallstones at lc laparoscopically. no conversion to an open procedure is necessary because of a low incidence of complication rate. composition of gallstones and bacteriological culture of bile is beneficial for prognosis of possible complications and their treatment. lost stones should be noticed in the operation report and the patient should be informed that in the case of complications the diagnostic and therapeutic way can be easier and performed in a shorter time. conservative treatment has a high failure rate. outcome of laparoscopic incisional hernia repair in immunocompromised patients following liver transplantation background. incisional hernias occur in up to % of patients following liver transplantation (ltx). laparoscopic incisional hernia repair (lihr) is well established in immunocompetent patients, and has been increasingly used in transplant patients. we report on our experience with lihr after ltx. methods. in a -month period, all patients undergoing lihr after ltx were included in this retrospective study. results are reported as mean ae sd or total number (%). results. fifteen patients ( . % female; age . . years) were included. mean time from ltx to lihr was . . months. hernia location was midline in ( . %), laterally in ( %) and both in patients ( %). immunosuppression was calcineurin-inhibitor based (tacrolimus % / cyclosporine %) with a tapered steroid regimen in all patients. hernia repair was technically successful in all cases using a polyester mesh ( . . square centimetres) anchored by transmuscular corner sutures and multiple spiral staples. perioperative antibiotic prophylaxis was routinely administered. no complications occurred in the early postoperative course, aside from one subfascial hematoma ( . %). mean length of stay was . ae . days. highest c-reactive protein levels during hospitalization were . ae . mg/dl. after a mean follow-up of . ae . months, ( . %) patients developed recurrent hernias, which were repaired in cases ( open, lihr). conclusions. with the use of perioperative antibiotic prophylaxis, lihr is safe in patients following ltx. no infectious complications occurred, however % of our patients developed a recurrent hernia after a mean follow-up of months. added benefit of diagnostic laparoscopy in patients with suspected acute appendicitis methods. we defined a clinical pathway for diagnosis and treatment in patients with suspected acute appendicitis. in this pathway diagnostic laparoscopy is an early step whereas ultrasonography is not part of the diagnostic steps. the aim of this study was to know the positive predictive value for acute appendicitis and experience the outcome of these patients concerning the diagnostic value of a laparoscopy. results. between apr. and dec. , patients were prospectively recorded. the correct diagnosis was found in ( %) patients. in ( %) patients either the cause of the abdominal pain remained unclear ( patients; %) or a different diagnosis was found ( patients; %). in these patients a list of different diagnoses was found. in ten patients ( . %) even a malignoma was found. conclusions. our defined pathway for diagnosis and treatment in patients with suspected acute appendicitis allows finding the cause of the abdominal complaints in % and in % acute appendicitis was confirmed. due to consequent diagnostic laparoscopy a broad list of differential diagnosis was found including malignant tumours in . %. therefore, diagnostic laparoscopy should be an early diagnostic step in patients with suspected acute appendicitis. ergebnisse. der spitalaufenthalt betrug zwischen und tagen (mittelwert: , tage). in , % der fälle war kein schmerzmittel notwendig, , % benötigten schmerzmittel bis zu tage, , % länger (mittelwert: , tage). die hauptbeschwerden reduzierten sich bei blutungen von , % (präoperativ) auf , % ( monate postoperativ), bei durch prolaps hervorgerufener verschmutzter unterwäsche von , % auf , %. von den bis jetzt nachuntersuchten patientinnen gaben nach monaten , % eine hohe zufriedenheit und beschwerdefreiheit an. bis jetzt erfolgte eine rezidivoperation, vier weitere wegen erneuten prolaps folgen. mit ausnahme von zwei postoperativ aufgetretenen abszessen mit fistelbildung gab es bislang keine nennenswerten komplikationen. schlussfolgerungen. obwohl langzeitergebnisse noch ausstehen, ist diese methode der hämorridenoperationen als komplikationsarm, sphinkterschonend und somit sehr empfehlenswert zu bewerten. sie zeichnet sich zudem aus durch eine hohe patientinnenzufriedenheit, einen kurzen krankenhausaufenthalt, einen geringen schmerzmittelbedarf und eine rasche reintegration in den alltags-und arbeitsprozess. observational study on grade-dependent treatment for hemorrhoidal diseasea single center experience background. hemorrhoidal disease is one of the most common health disorders in western civilization. the aim of this study was to retrospectively analyze the outcome of grade-dependent treatment of hemorrhoidal disease (i-iv) in a single center. methods. all patients suffering from hemorrhoidal disease referred to our unit between july and december were included in this analysis. the patients' medical records were studied in detail. a standardized telephone interview was conducted in all patients who had open hemorrhoidectomy or stapled hemorrhoidopexy. results. a total of patients ( female, male; mean age . , range - years) were assessed. conservative treatment was applied in ( . %) cases, while surgery was performed in patients ( . %) following a grade-dependent strategy. most common comorbidities were skin tags and simultaneous mucosal prolapse. postoperative complications comprised pain ( . %), bleeding ( . %) and fecal incontinence ( . %). patients undergoing stapled hemorrhoidopexy showed significantly higher recurrence rates than after open hemorrhoidectomy ( % vs. %, p ¼ . ). urgency was more common in the stapled hemorrhoidopexy group ( . % vs. . %) and the incidence of anal stricture lower than in the open hemorrhoidectomy group ( . % vs. %). conclusions. grade-dependent treatment of hemorrhoidal disease with respect to the clinical appearance and the extent of prolapse should be standard today. stapled hemorrhoidopexy appears to be an intervention with less postoperative pain and faster recovery than open hemorrhoidectomy, but long-term results include a higher recurrence rate and a higher incidence of fecal urgency and fecal incontinence. background. anal sepsis of cryptoglandular origin might be challenging for patients and surgeons due to recurrences and postoperative fecal incontinence. methods. patients with anal sepsis operated on between january st and december st at the department of general surgery, medical university vienna were retrospectively analyzed in terms of recurrence and postoperative fecal incontinence by chart review and by telephone interview using the vaizey incontinence score. results. operative treatment was given to male and female individuals ( % vs. %) with a median age of years ( - ). patients were availabe for follow-up investigation. after a median of months, patients ( %) had no recurrence after a single surgical procedure. a median of operations ( - ) was performed in patients with multiple procedures. in patients ( %), a fistula-in-ano was detected. vaizey score was in patients with single i þ d procedure. in patients with single i þ d plus fistulotomy, mild incontinence was seen in % and severe incontinence in %. in patients with muliple procedures, mild fecal disturbances were assessed in % and severe disturbances in %. conclusions. treatment of anal sepsis and fistula-in-ano is associated with a high recurrence rate and a substantial risk of fecal incontinence in this analysis. data suggest that a search for a fistula-in-ano should be performed already at the primary operation. in a case of recurrence, high transsphincteric, suprasphincteric or complex fistula-in-ano a specialized coloproctologist should be involved to avoid damage to the anal sphincter muscle. die hohe und rezidivierende analfistel background. studies have reported excellent healing rates for the treatment of cps with different skin flaps. the cosmetic outcome is less investigated. the aim was to enlighten the body image changes and patients satisfaction after limberg flap. methods. from august to december consecutive patients, mean age of . years (ae . ) with cps underwent excision and closure with limberg flap. at days morbidity and time off work were accessed. late infection, recurrence rate, selfesteem (worst , best ), cosmesis ( , ) , body image ( , ), and patients satisfaction ( , ) at one year were analyzed prospectively. results. no major complications such as flap necrosis occurred. minor complications occurred in %, including superficial infection and partial suture dehiscence. mean time off work was . days (ae . ). in patients ( %) occurred a late local infection in the first months. the recurrence rate was . % after one year. self-esteem before and after the operation remained almost unchanged (before . , after . ) (p ¼ . ). mean cosmesis and body image were acceptable, . (ae . ) and . (ae . ) respectively. % estimated their change of body image as acceptable (> ). % of the patients were highly satisfied with the procedure (> ) and mean patients satisfaction was . (ae . ). conclusions. morbidity and recurrence rate after treatment with limberg flap is low and compares favorably to other treatments. change of body image and cosmesis are acceptable in most patients, but are a problem in some and should be addressed preoperatively. background. there are more than a hundred different techniques to operate on a rectal prolapse. for old and frail patients the perineal approach is preferred. the rehn-delorme procedure and the altemeier rectosigmoidektomy are currently the most popular perineal procedures. both are demanding and time consuming. the aim was to develop a procedure, which is easy and fast to perform and has a good outcome. methods. internal rectal redundancy has recently been successfully treated with transanal resection using the contour + transtar tm stapler. this technique has been modified to the perineal stapled prolapse resection (psp). the prolapse is completely pulled out and then axially cut open at three o'clock in lithotomy position with a straight stapler. thereafter the prolapse is stepwise resected with the curved contour + transtar tm stapler. at the end of the circular resection the beginning of it is reached again at three o'clock. the staple line falls spontaneously into place and is oversewed with absorbable monofil sutures to strengthen it and ensure hemostasis. results. in a feasibility study has been shown, that the psp procedure is easy to perform, safe and doesn't need a lot of time [ ] . we present the correct operation technique. important steps are emphasized and pitfalls explained. conclusions. the video shows the psp procedure and how it's done. clinical investigations proved the feasibility of the transtar procedure. it is a safe and effective treatment for patients with ods. the aim of the presented study is to access the functional outcome after the procedure and its impact on quality of life. methods. female patients presenting with ods were enrolled prospectively for the transtar procedure. intussuseption and/or anterior rectocele were confirmed by clinical investigation and by mrdefecography. functional outcome was measured by ods-score, severity of symptoms score (sss) and wexner score at months postoperatively. quality of life was accessed by the cleveland clinical obstipation score (ccos), the gastrointestinal quality of life index (glqi), the american society of colorectal surgeons score (ascrs) and the sf- months postoperatively. results. between january and november consecutive patients, median age years (range - ) were included. eleven patients complained preoperatively fecal incontinence. functional scores improved significantly: ods decreased from a median of ( - ) to ( - ) after weeks (p < . ) and ( - ) after months. sss decreased form ( - ) to ( - ) after weeks (p < . ) and ( - ) after months. median wexner score was pre-and postoperatively (range - and - ). at weeks patients presented fecal incontinence and patients complained of fecal urgency. at months patients were still incontinent, two received a succesfully sacral neuromodulation. fecal urgency persisted in patients. quality of life improved significantly: ccos (p < . ), glqi (p < . ) and sf- (p < . ). in ascrs self-esteem improved (p < . ), the other aspects didn't change significantly. conclusions. the transtar procedure is an effective treatment for patients with severe ods and improves quality of life significantly. however, some patients suffer of incontinence and fecal urgency in the first weeks after the operation. in most of these the symptoms dissolve without further operative treatment. background. in gastric cancer, peritoneal carcinomatosis is a frequent finding and associated with a poor prognosis. the enhanced expression of phosphoglycerate-kinase- (pgk ) and its signalling targets chemokine-receptor- (cxcr ) and its ligand cxcl seem to play a crucial role in enabling diffuse primary gastric tumours to develop peritoneal dissemination. methods. comparative microarray analysis was conducted investigating human specimens from consecutive gastric cancer patients with peritoneal carcinomatosis versus gastric cancer samples without peritoneal carcinomatosis. subsequently selected target genes were evaluated using quantitative real-time polymerase chain reaction (qrt-pcr). further ,,genesilencing'' (sirna-knock-down) concerning cxcr and pgk and transfection (overexoression) of pgk was performed. the obtained results were further confirmed using western-blot, facs-analysis and invasion assays. results. the microarray analysis revealed a significant overexpression of pgk , cxcr and its ligand cxcl in specimens from gastric cancer patients with peritoneal carcinomatosis. further ,,genesilencing'' of pgk and cxcr showed a significant co-regulation on expression and protein level in vitro. the transfection (overexoression) of pgk also revealed a significant upregulation of its signalling targets cxcr and its ligand cxcl on expression and protein level. in addition the transfected cells showed a -fold distinctive property in the invasion assay compared to cancer cells without pgk overexpression. conclusions. overexpression of pgk and its signalling targets cxcr and cxcl in peritoneal disseminated primary gastric carcinomas sustainable indicate a promising regulationpathway promoting peritoneal dissemination. this data may provide new prognostic markers and/or potential therapeutic targets to prevent migration of gastric carcinoma cells into the peritoneum generating peritoneal carcinomatosis. here, we investigated the expression of dkk- protein in gastric cancer and its potential value as a prognostic marker. methods. dkk- expression was analyzed by immunohistochemistry in tumour samples and was correlated with microvessel density (mvd), tumor stage and grading, as well as the clinical outcome of the patients. results. dkk- expression was detected in endothelial cells of the tumour vessels but not in normal vessels in / ( . %) and in tumor cells in / ( . %) respectively. mvd was high and low in ( . %) and ( . %) specimens. in tumor cells, overexpression of dkk- was found in ( . %) and was correlated significantly to pt-stage (p < . ) and uicc stage (p < . ). survival analysis regarding dkk- expression in tumor endothelial cells showed that dkk- is an independent predictor of disease-free survival (p < . ) conclusions. dkk- expression in tumor vessels of patients with gastric cancer identifies a population of patients with relatively favorable prognosis. methodik. bei nach den international anerkannten kriterien (igclc -international gastric cancer linkage konsortium) gegebenen verdacht auf ein hereditäres diffuses magenkarzinomsyndrom wurde eine e-cadherin-mutationsbestimmung (cdh ) erstgradiger familienmitglieder durchgeführt. acht von neun untersuchten familienmitgliedern waren positiv für die cdh keimbahnmutation. in allen fällen konnte präoperativ das vorliegen eines karzinoms durch eine ausgiebige endoskopie ausgeschlossen werden. fünf träger der mutation entschlossen sich nach einer ausführlichen, chirurgischen beratung zur prophylaktischen operation. in einem fall wurde präoperativ eine mukosektomie einer ektopen magenschleimhaut im oesophagus durchgeführt. ergebnisse. aufgrund der indikationsstellung mit verzicht auf eine lymphadenektomie entlang der gefäße des trunkus coeliacus wurde die gastrektomie mit lk-dissektion d- in laparoskopische technik durchgefü hrt. in systemischer aufarbeitung des ganzen magens konnte in allen fällen ein intramukosales monozellulär verschleimendes magenkarzinom nachgewiesen werden. eine lymphknoten-oder gefäßinvasion konnte nicht nachgewiesen werden. es konnten zwischen bis lymphknoten untersucht werden (im durchschnitt untersuchte lk). schlussfolgerungen. die gastrektomie in laparoskopischer technik ist ein onkologisch korrektes, sicheres und für diese indikation gutes verfahren. wir sahen bis auf eine wundheilungsstörung an einer trockareinstichstelle keine chirurgischen probleme. alle vorteile der laparoskopischen technik konnten umgesetzt werden. background. incisional trauma is major factor contributing to perioperative morbidity and mortality. cosmesis and body awareness also play an increasing role in patients' acceptance of cardiac surgery. during the last years it was our effort to increase the percentage of minimally invasive operations. methods. cardiac surgical operations of the last years were evaluated regarding conventional (median sternotomy) approach and minithoracotomy or total endoscopic surgery. indications for either procedure were identified. results indications were extended to complex valvular, bivalvular and other combined procedures. major contraindications are severe calcifications and aortic dilatation. tecab could be performed for single and double vessel revascularisation as well as hybrid procedures including pci. conclusions. an increasing percentage of cardiac surgical operations can be performed minimally invasive. however this evolution has still to be more widespread especially in the era of interventional valve procedures. the heartport access for increased patient mobility and satisfaction t. fleck, w. wisser median sternotomy is the gold standard in cardiac surgery, as it enables superior exposure for nearly all surgical procedures. however, there are disadvantages, namely the risk of sternal dehiscence with or without infection with an incidence of - % and the immobility of the patient for the healing process of the bone. since a total of patients (mean age years) underwent cardiac surgery through a mini right thoracotomy in the icr without rib spreading. the underlying pathology was mvd n ¼ , tvd n ¼ , asd n ¼ , myxoma n ¼ (mean es . ). cpb was established through a . cm incision in the right groin. the aorta was occluded with an endoballon. exposure was satisfactory in all patients. especially in redo procedures (n ¼ ) the necessity of dissection of the entire heart was avoided and this reduced the amount of bleeding and the known risks of redo sternotomy. the indented surgical procedures could be preformed in all patients: mvr n ¼ , asd closure n ¼ , myxoma resection n ¼ , tvr n ¼ . complication and mortality rate was . %. mean icu stay was days, hospital stay days. with the avoidance of a median sternotomy, the mobility of the patient postoperatively is increased. furthermore the patients appreciated the cosmetic aspect and the possibility to return to daily activity, sports and job in a shorter time. from a surgical point of view, the same technical standard of surgical performance can be maintained through this approach after the surgeon becomes accustomed to the instruments and exposure. background. atrial septal defects (asd) apply for - % of congenital heart disease. the standard surgical approach used to be median sternotomy. we reviewed our experience on the development of a minimally invasive surgical technique and its introduction into clinical routine. methods. we reviewed all patients who underwent surgical asd-closure at our institution from / - / . analysis was performed concerning asd-pathology, patient characteristics and operative variables. results. from / through / , patients underwent isolated asd-closure. in that period, operations were performed in a minimally invasive technique through a right-sided minithoracotomy and remote-access perfusion through the right groin. in , the development of the technique started using the heartport-perfusion system ( pts). thereafter we started to use chitwood-clamp. defects were closed by direct suture, by patch closure. during the last three years, the number of patients undergoing minimally invasive surgery, is rising steadily ( : pts, : pts, : pts) . in , the first sinus venosus defect was successfully treated in that fashion. furthermore, the technique is also applicable for treatment of dislocated interventional occluding devices ( pts). the mean age of the patients was . years ( - yrs), mean weight was . kg ( - kg). mean aortic crossclamp time was . min. there was no operative death and no patient had to be converted to median sternotomy. conclusions. minimally invasive asd-closure via a right-sided minithoracotomy has successfully been introduced into clinical routine at our institution. with growing experience even sinus venosus defects and dislocated occluding devices can be operated on safely and with good results. background. the levitronix centrimag device is a centrifugal pump designed for short term support in cardiogenic shock. it is implantable both in adults and also in pediatric pts. we report our experiences using the centrimag device in all forms of cardiogenic shock (postoperative lcos, myocarditis, pre-htx, right heart failure post htx, acute myocardial infarction) in the adult population. methods. we have implanted in a four-year period the centrimag device in adult pts (mean age . years). the cumulative experience was years. the device was implanted in cases as femoro-femoral bypass, in the cases intraoperatively by cannulating the left atrium and the ascending aorta and in the remaining three cases by cannulating the right atrium and the pulmonary artery (right heart failure after htx). the mean support time was . days ( - days) . results. fifty-eight patients ( %) could be successfully weaned from device. in cases ( %) the centrimag was used as a bridge to a more sophisticated device (cardiowest , dura-heart , ventrassist , thoratec , heartmate ii , incor and novacor ). at least pts. ( . %) died on device, mainly caused by multiorgan failure. three pts underwent htx, pts are on support at this moment. conclusions. the levitronix centrimag seems to be safe and effective in the treatment of nearly all kinds of cardiogenic shock achieving rapid and sufficient circulatory support and ventricular unloading. bridge-to-recovery, bridge-to-bridge or bridge-totransplant are possible. grundlagen. das ziel dieser prospektiven studie war es, perioperative klinische parameter zwischen der minimal extrakorporalen zirkulation (mecc) und der konventionellen extrakorporalen zirkulation zu vergleichen. methodik. unter verwendung des mecc-systems wurde eine koronare revaskularisation bei randomisierten patienten (mittleres alter , jahre ( - jahre), (gruppe i) durchgeführt. in der vergleichs-gruppe ii (n ¼ , mittleres alter , jahre ( - jahre) wurden die patienten mit einer konventionellen extrakorporalen zirkulation perfundiert. die einstammerkrankungen, sowie die notfalleingriffe wurden exkludiert. ergebnisse. in den beiden gruppen zeigte sich kein signifikanter unterschied der mittleren aortenklemmzeit ( ae , min vs ae , min), der mittleren extrakorporalen perfusionszeit ( ae , min vs ae , min), der mittleren anzahl der distalen anastomosen sowie in der anzahl der verwendeten erythrozythenkonzentrate. es kam zu keiner tage mortalität. ebenso zeigten die nach , und stunden postoperativ gemessenen laborparameter (troponin t, kreatinin, ck, ck-mb, thrombozyten, leukozyten, hämoglobin, hämatokrit) keinen statistisch signifikanten unterschied. die gemessene laktatwerte zeigten im gegensatz dazu (intraoperativ , vs , , stunden postoperativ , vs , , stunden postoperativ , vs , ) statistisch signifikante vorteile für das mecc-system. die aufenthaltsdauer auf der intensivstation war in der gruppe i signifikant kürzer als in der gruppe ii ( , tage vs , tage). schlussfolgerungen. zusätzlich zu der aus der literatur bekannten reduktion von entzündungsmediatoren finden sich signifikante hinweise einer optimierten perfusion. der mecc-patient ist postoperativ aktiver, leider fehlt dazu ein objektiver parameter. training surgeons to establish a robotically assisted totally endoscopic coronary surgery program background. since ist introduction totally endoscopic coronary surgery (tecab) was standardized during the past decade. additionally younger surgeons needed training in robotically assisted cardiac surgery. methods. in out of robotically assisted (da vinci tm telemanipulator, intuitive inc., sunnyvale, ca) coronary operations parts of the procedure were performed by surgeons trained in endoscopic cardiac surgery. the distinct parts of the tecab procedure were: lima/rima preparation, lipectomy, pericardiotomy, ima to lad anastomotic suturing. conclusions. we conclude that the tecab procedure can well be trained in a stepwise approach. the establishment of a robotically assisted coronary surgery program is feasible after adequate training. obesity has no effect on operative times and perioperative outcome of patients -undergoing totally endoscopic coronary artery bypass surgery background. more and more patients undergoing coronary artery bypass grafting (cabg) are overweight. even though in these patients there is no clear evidence of increased perioperative mortality, it has been shown that they suffer from superficial-and deep wound healing problems more often than normal-weight patients. therefore, avoiding sternotomy in obese patients by using an endoscopic technique could be a promising approach. robotic technology enables totally endoscopic coronary artery bypass grafting (tecab) procedures. we investigated whether the intraoperative times or perioperative outcome after tecab-procedure are negatively affected by obesity. methods. patients (n ¼ , male, female, median age ( - ) years), undergoing arrested-heart tecab procedure were enrolled. the median bmi in this patient cohort was ( - ). in detail, patients were normalweight(bmi kg/m ), patients were overweight(bmi: . - kg/m ), patients were obese (bmi . - . kg/m ) and patients were morbidly obese (bmi ! kg/m ). the heartport/cardiovations tm (n ¼ ) or the estech-rap tm system (n ¼ ) were used for arrested heart tecab procedure with remote access perfusion and aortic-endoocclusion. results. there was no correlation between bmi ( ) left internal-mammary-artery-takedown-time(r ¼ . ; p ¼ n.s.), ( ) lipectomy and pericardiotomy-time (r ¼ . , p ¼ n.s.) ( ) total operative-time (r ¼ À . : p ¼ n.s.), ( ) cardiopulmonary-bypass-time (r ¼ À . ; p ¼ n.s.), ( ) aortic-endoocclusiontime (r ¼ À . ; p ¼ n.s.), ( ) mechanical-ventilation-time (r ¼ . , p ¼ n.s.) ( ) length of icustay (r¼ . ; p ¼ n.s.), ( ) length of hospital-stay (r ¼ . ; p ¼ n.s.). or ( ) occurrence of intraand/ or postoperative adverse events. conclusions. in overweight, obese but also morbidly obese patients the tecab procedure did not increase operative times or the rate of intra-or postoperative complications. this patient groups, therefore, benefits from this less traumatic version of coronary surgery. background. selective decontamination of the digestive tract is still not widely accepted, although it reduces the incidence of nosocomial infections. in a previous retrospective study we have shown a clear reduction of nosocomial infections in patients with esophageal anastomoses receiving selective decontamination. we thus started to apply selective decontamination routinely for esophageal anastomoses. here we report the outcome of a case series of patients receiving this treatment and compared them to historic controls. methods. from , patients with esophageal anastomosis were prospectively registered. patients received polymyxin, tobramyxin, vancomycin (ptv) and mycostatine four times a day orally on average for days starting on the day before surgery. outcome was compared to a historic control treated before without selective decontamination (n ¼ ), which did not differ significantly in age, gender, bmi and asa score. results. a total of patients received selective decontamination. the average age was . years and asa score was . the pulmonary infection rate was . % ( % ci: . - . %) clearly lower than in the historic control ( . %, % ci: . - . %, p ¼ . ). anastomotic leakage rate was . % ( % ci: . - . %) compared to . % ( % ci: . - . %, p ¼ . ) without selective decontamination. the perioperative mortality was only . % ( % ci: . - . %) compared to % ( . - . %, p ¼ . ) previously. conclusions. selective decontamination of the digestive tract significantly reduces perioperative morbidity and mortality in patients with esophageal anastomosis. anastomotic leakage rate could be reduced resulting in a much lower mortality. we suggest that selective decontamination to be used routinely in patients having an esophageal anastomosis. marienhospital, ruhr-universität bochum, herne, germany die therapie des Ö sophaguskarzinoms ist inzwischen zu ca. % multimodal ausgerichtet. jedoch ist immer noch unklar welche modalität zur welcher zeit und in welcher reihenfolge angewandt werden soll. beim lokal fortgeschrittenen plattenephithelkarzinom des Ö sophagus wird generell die neoadjuvante radio-chemotherapie als standard angesehen, teilweise wird diese nach einer so-genannten induktionstherapie durchgeführt. dieses vorgehen ist bis heute jedoch in keiner randomisierten abschließend studie bewiesen, auch wenn eine kürzlich publizierte meta-analyse einen marginalen vorteil der multimodalen therapie beschreibt. nach kürzlich publizierten daten (bedenne et al., asco, , stahl et al. jco ) scheint der vorteil der resektion sich vor allem auf die patienten zu beschränken, die auf die multimodale therapie nicht oder nur unzureichend ansprechen. anders verhält es sich bei den adenokarzinomen des distalen Ö sophagus. nach drei randomisierten studien, die mehrheitlich barrett karzinome einschlossen, ist die neoadjuvante chemotherapie bei lokal fortgeschrittenen adenokarzinomen als internationaler standard angesehen. neuere studien untersuchen derzeit den einfluss der präoperativen radio-chemotherapie auch bei adenokarzinomen des distalen Ö sophagus sowohl auf das rezidiv-freie als auch auf das langzeitüberleben nach resektion. nach ersten daten schient die resektion nicht mit einer erhöhten morbidität oder letalität einherzugehen. im vortrag werden die aktuellen studien und der derzeitige therapiestandard der multimodalen therapie bei karzinomen des Ö sophagus dargestellt. prognose bedeutend verbessert und in zunehmender häufigkeit ist auch eine kurative therapie möglich. besondere fortschritte gab es in der medizinisch onkologischen therapie, wodurch mittlerweile mediane Ü berlebensraten von über jahren erreicht werden können. die chirurgische therapie ist bedeutend sicherer geworden, erlaubt große resektionen auch bei chemotherapeutisch vorbehandelten patienten mit geringer morbidität und schließlich wurde das therapeutische armamentarium durch interventionelle radiologische, nuklearmedizinische und strahlentherapeutische möglichkeiten erweitert. deshalb background. lipocalin- (lcn- , ngal) was recently shown to be highly expressed in various human cancers and increased protein levels were associated with worse survival of patients with breast, gastric or oesophageal cancer. the main focus of this work was to analyze the possible implication of lcn- upregulation in colon cancer development. methods. expression of lcn- was analyzed in various colorectal carcinoma cell lines, paired colorectal carcinoma tissues and normal mucosas by western blot. lcn- immunostaining was performed in colorectal carcinoma resection specimens (intensity score - ) and correlated with clinical parameters. colorectal carcinoma cell lines were treated with various concentrations of recombinant lcn- protein and monitored for growth and survival. results. western blot analysis of colorectal carcinoma cell lines and tissues clearly demonstrated lcn- overexpression in carcinomas compared with normal mucosas in all colorectal carcinoma tissue pairs analysed. immunostaining revealed lcn- overexpression in ( . %) of colorectal carcinoma tissues. intense immunoreactivity was significantly correlated with tumor grading (p < . ). cancer samples of the right hemicolon showed significantly higher lcn- expression decreasing in the left hemicolon and the rectum (p < . ). addition of various concentrations of recombinant human lcn- protein to colorectal carcinoma cell lines did not have any influence on cell growth and survival in vitro. conclusions. our data provide evidence that lcn- expression is upregulated with tumor progression. the correlation of lcn- expression with localisation in the colon gives molecular biological evidence for distinguishing subsites of colorectal cancer. targeting lcn- might be a new therapeutic strategy in colorectal carcinoma. qualitätskontrolle der primären rektumkarzinom -chirurgie in einem nicht selektionierten, konsekutiven patientengut an unserer klinik wurden in zehn jahren patienten neoadjuvant radiochemotherapiert ( wochen) und anschließend mittles tme radikal operiert. die -j-Ü r betrug %. von synchron metastasierten patienten, welche nach therapie des primums metastasektomiert wurden, entwickelten % ein tumorrezidiv, allerdings wesentlich früher als die primär nichtmetastasierten patienten. die hälfte der synchron metastasierten patienten mit tumorrezidiv konnten kurativ re-operiert werden, nur ein patient blieb tumorfrei. aufgrund der schlechten prognose wird in den letzten jahren -analog zum kolonkarzinom -beim synchron metastasierten rektumkarzinom zunehmend eine Ä nderung der behandlungsstrategie diskutiert. die vorstellung, dass eine systemische erkrankung eine systemische behandlung benötigt, wird dadurch bekräftigt, dass eine sekundäre resektabilität von marginal operablen/inoperablen lebermetastasen in bis zu % gegeben ist und auch patienten mit operablen metastasen durch die neoadjuvante chemotherapie einen Ü berlebensvorteil aufweisen. zudem haben wir erfahrungen mit patienten, welche ,,liver first'' therapiert wurden und im falle eines ,,response'' auch das primum eine regression zeigte. sollte somit beim metastasierten rektumkarzinom auf die scheinbar ,,optimale'' neoadjuvante lokaltherapie zugunsten einer systemischen chemotherapie und einer ,,liver first'' taktik verzichtet werden? ist im falle eines ,,response'' auch die chemotherapie in der lage, eine ausreichende lokalkontrolle zu gewährleisten? können wir patienten selektionieren, welche unter systemischer therapie progredient sind, und diesen die neoadjuvante lokaltherapie und operation ersparen? bis dato bleibt die behandlungsstrategie beim synchron metastasierten rektumkarzinom kontrovers. ergebnisse. insgesamt entwickelten % der patienten ein tumorrezidiv, während % rezidivfrei blieben ( -jahres-krankheitsfreie-Ü berlebensrate: %). die in der nachsorge diagnostizierten asymptomatischen rezidive traten bis jahre nach primärbehandlung auf; nahezu die hälfte ( / ; %) dieser patienten konnte in kurativer absicht re-operiert werden. davon blieben % ( / ) innerhalb der nachbeobachtung rezidivfrei. in einer multivariaten analyse zeigten das uicc-stadium (p ¼ . ) und das grading (p < . ) eine signifikante korrelation zum rezidivauftreten. die -und -jahres-Ü berlebensraten dieses kollektivs waren % bzw. %. in bezug auf das Ü berleben war in der multivariaten analyse nur das ypt-stadium (p < . ) ein signifikanter parameter. schlussfolgerungen. bei patienten mit lokal fortgeschrittenem rektumkarzinom können gute onkologische langzeitergebnisse erzielt werden. dazu ist neben der multimodalen therapie auch ein intensives nachsorgeprogramm notwendig, welches asymptomatische rezidive frühzeitig erkennen lässt und kurative re-operationen ermöglicht. background. transcatheter based aortic valve replacement (avr) is a promising procedure to reduce operative risk especially in old patients with significant comorbidities. we report the initial series of transapical and transfemoral-avr including years follow up. methods. access was either antegrade through a anterolateral thoracotomy with direct puncture of the apex or retrograde through the femoral artery. after initial balloon-valvuloplasty the balloon-mounted crimped bioprosthesis was introduced and positioned under fluoroscopic and echo control. since march fifty-nine patients underwent transapical-avr and patients underwent transfemoral-avr. mean age was ae . years, the logistic euroscore predicted risk for mortality was . ae . %. results. implantation was performed on beating heart with a period of rapid pacing for deployment of the valve. cardiopulmonary bypass was used only in the initial patients. in the transapical group patients had to be converted to conventional avr because of malpositioning. thirty days mortality for transapical was %, in the transfemoral group %. echocardiography showed excellent gradients (pmax . ae mmhg) at discharge and years after implantation. small paravalvular leaks without hemodynamic importance were observed in patients ( %) in the transapical group and in all transfemoral patients. conclusions. transcatheter avr with the sapien-edwards bioprosthesis can be performed in high risk patients successfully. complications may be attributed to the high risk profile of the elderly patients and the learning curve of this new procedure. the valve exhibits excellent hemodynamics up to years. however, longer-term valve performance and durability needs to be monitored. drei herzchirurgische notfälle nach percutanen aortenklappenimplantationen background. in symptomatic patients with severe aortic stenosis (as), operative aortic valve replacement is the treatment of choice. however, not only symptomatic as becomes more prevalent in elderly patients but also comorbidities that increase the risk for operative valve replacement. therefore, percutaneous aortic valve replacement (pavr) might be an alternative therapy for high-risk patients. methods. in our institution, patients ( male, female; mean age ae years) with symptomatic severe as and a logistic euroscore > % underwent pavr between may and january . the procedure was performed in the catheterization laboratory via a bifemoral percutaneous approach under local anesthesia and analgesic sedation without surgical cut-down and hemodynamic support. after balloon valvuloplasty, the self-expanding corevalve prosthesis (diameter mm, n ¼ ; mm, n ¼ ) was implanted using the current french delivery catheter system. results. acute procedural success rate was %. device implantation resulted in a significant increase of calculated aortic valve area ( . ae . vs. . ae . cm , p < . ). postprocedural aortic regurgitation was trivial or mild in patients and moderate in seven patients. permanent pacemaker implantation was necessary in four patients due to complete atrioventricular block. major complications were myocardial infarction (n ¼ ), stroke (n ¼ ) and pericardial tamponade (n ¼ ). actually, allcause mortality rate is . % at days and . % after one-year follow-up. conclusions. pavr with the self-expanding corevalve bioprosthesis is an emerging alternative treatment for high-risk patients with symptomatic severe as. complication rate is acceptable and mortality rate lower than predicted by risk calculation. results. median length of stay was days in conventional open repair encomprising days on the intensive care unit. median length of stay in stent-graft placement was days. the day rate on the normal ward is estimated at . . d and the day rate on the intensive care unit is estimated at . . d . median number of stent-grafts used was . . despite substantial higher procedural costs of stent-graft placement ( . . d versus . . d ), total cost performance was lower ( . . d versus . . d ) resulting in a cost difference of . . d . as a consequence, the cost advantage of stent-graft placement turned out to be . %. conclusions. despite substantially higher procedural costs as compared to conventional open repair of descending thoracic aortic aneurysms, endovascular stent-graft placement is cost efficient mainly due to the preventable intensive care stay and the shorter in-hospital stay. background. supra-aortic transpositions followed by endovascular stent graft placement are now an established tool in the treatment of aortic arch pathologies. results remain to be determined. methods. from through , patients (median age, years) presented with aortic arch pathology (aneurysms, n ¼ ; type b dissections, n ¼ ; penetrating ulcers, n ¼ ; traumatic lesions, n ¼ ; aneurysms based on prior surgery for aortic coarctation, n ¼ ). strategy for distal arch disease was subclavian-to-carotid transposition (n ¼ ) or autologous double-vessel transposition through upper hemisternotomy (n ¼ ). for entire arch disease, total supra-aortic rerouting with a reversed bifurcated prosthesis was applied (n ¼ ). endovascular stent graft placement was performed metachronously. results. in-hospital mortality was . % (n ¼ ). persistent early type i and iii endoleak rate was . %. persistent late type i and iii endoleak rate was . %. overall actuarial survival was %, %, and % at , , and years. mean follow-up is months (range, to ). early and late endoleak formation was independently predicted by the number of prostheses. survival was independently predicted by higher logistic euroscore levels. conclusions. results after supra-aortic transpositions followed by stent graft placement for the treatment of aortic arch pathologies are promising. endoleak formation is directly related to the number of prostheses and may be reduced by longer devices. each type of arch rerouting has turned out to be effective. extended application of these combined treatment strategies substantially augments the therapeutic options. grundlagen. im rahmen einer aortendissektion typ a wird bei herkömmlichen operationsmethoden die aorta aszendens und teile des aortenbogens ersetzt, die absteigende aorta bleibt jedoch unbehandelt. das falsche lumen der thorakalen aorta bleibt in bis zu % der fälle perfundiert. wir berichten über ein kombiniertes chirurgisches und endovaskuläres verfahren für die behandlung komplexer typ a dissektionen unter verwendung einer hybridprothese. methodik. zwischen / und / wurde patienten ( , ae , jahre; männlich, weiblich) mit aortendissektion typ a ( akut, chronisch) die e-vita open endoluminal stentgraftprothese im kreislaufstillstand in moderater hypothermie mit selektiver antegrader hirnperfusion implantiert. der gestentete teil der prothese wird über den eröffneten aortenbogen in die aorta deszendens vorgeschoben, anschließend wird mit der dacron hälfte der prothese der aortenbogen und die distale aorta aszendens ersetzt. ergebnisse. alle patienten überlebten den eingriff ohne neurologischem defizit. eine computertomographie der thorakalen aorta wurde innerhalb der ersten zwei wochen nach der operation durchgeführt, dann im abstand von , und monaten. nach monaten zeigte sich bei von patienten ( , %) eine komplette thrombosierung des falschen lumens bis auf höhe des stentgrafts. ein patient mit chronischer typ a dissektion erhielt monate nach dem ersteingriff einen thorakoabdominellen aortenersatz. der durchmesser der aorta deszendens war in der kontrolle nach monaten bei patienten rückläufig. schlussfolgerungen. bei noch geringer fallzahl zeigen die positiven ergebnisse, dass der simultane chirurgische und endovaskuläre zugang für die erweiterte therapie der typ a dissektion eine gute behandlungsmöglichkeit darstellt, ohne das perioperative risiko zu erhöhen. from trunk to trunkstent-graft coverage of the entire thoracic aorta background. aim of this study was to determine safety and practicability of stent-graft placement in patients requiring coverage of the entire descending aorta. methods. from through , patients (male ¼ , mean age a) underwent stent-graft placement from brachiocephalic to celiac trunk. all patients underwent rerouting of the supraaortic branches to gain sufficient proximal landing zone. indications for stent-graft placement were aneurysms (n ¼ ) and penetrating ulcers (n ¼ ). csf drainage was initiated only in case of neurologic symptoms. in all patients mean blood pressure was kept above mmhg for hours after stent-graft placement. results. arch rerouting and stent-graft placement were performed successfully in all patients. one early type iii endoleak was observed and treated by overstenting. no late endoleaks occured. symptoms of spinal cord malperfusion were observed in patients ( . %). in one patient paraplegia was seen, resolving after csf drainage ( . %). another patient developed signs of chronic spinal cord ischemia ( . %). this patient had undergone replacement of the abdominal aorta years prior to stent-graft placement. in all other patients no signs of spinal cord malperfusion could be detected. conclusions. this study outlines the safety and practicability of the complete coverage of the descending aorta from trunk to trunk. the low number neurologic complications could be explained by aggressive rerouting procedures resulting in sufficient collateral flow from the left subclavian artery and the intended elevation of postoperative blood pressure. csf drainage is not required on a regular basis in these patients. endovascular stent-graft placement in atherosclerotic aneurysms involving the descending aortalong-term results background. to determine long-term durability and need for reinterventions after endovascular stent-graft placement in atherosclerotic aneurysms involving the descending aorta. methods. we performed a prospective follow-up analysis of a consecutive series of patients (n ¼ ) undergoing endovascular stent-graft placement due to atherosclerotic aneurysms involving the descending aorta between and . outcome variables included death, occurrence of early and late type i and ii endoleak formation, the rate of reintervention due to early and late endoleak formation and the survival of the patients. median follow-up was ( - ) months. results. in-hospital mortality was %, whereas two third of these patients underwent stent-graft placement in the acute setting. assisted primary endoleak rate was %. assisted secondary primary rate was %. actuarial survival rates at , and years were %, % and % respectively. a short proximal landing zone and a high number of implanted stent-grafts were identified as independent predictors of the occurrence of early and late endoleak formation. the occurrence of late endoleak formation appeared to be an independent predictor with regard to survival. conclusions. long-term durability of endovascular stentgraft placement in atherosclerotic aneurysms involving the descending aorta is satisfying and the need for reintervention is acceptably low. an extensive landing zone and a low number of stent-grafts are mandatory for early and late success. background. swedish adjustable gastric banding (sagb) is an effective treatment for morbid obesity. the aim of this study was to assess the efficacy and safety of sagb in older patients aged ! years. methods. between / and / , patients were aged ! years. two groups of patients were analyzed: group (n ¼ ) patients aged - years and group (n ¼ ) patients aged - years. results. one hundred and thirty-four patients ( . %) out of entered the study. mean % ewl was . at year and . at years, bmi fell from . to . at years. in the patients, there were patients with complications ( . %) and patients with no complication ( . %). the most common complications were esophagitis, esophageal dilation, port problems and pouch dilation. in group , mean % ewl was . at year and . at years. bmi fell from . to . at years. in the patients, there were patients with complications ( %) and a reoperation rate of . %. in group , mean % ewl was . at year and . at years. bmi fell from . to at years. in the patients, there were ten patients with complications ( %) and a reoperation rate of . %. there was no mortality. conclusions. at -year follow-up, for older patients, sagb is an effective bariatric procedure for achieving weight loss. nevertheless, based on the high complication and reoperation rate, a gastric band-specific patient selection will be necessary. background. study aim was to retrospectively assess whether patients were able to maintain their weight after gastric band removal or deflation and how they felt about gastric banding. methods. total patients ( % female, mean age . (sd . ) years) were included in this study: patients who had their band removed/deflated without further surgical intervention (group , n ¼ ), those who later underwent a second bariatric operation (group , n ¼ ). we evaluated weight gain after band removal/during the time between band removal and second bariatric operation. results. of our patients ( %) suffered a complication ( late pouch dilatations, six band infections, five band migrations, two band leaks) requiring band removal. ten patients wanted their band removed (six) or emptied (four). mean time after band removal, when patients had neither a band nor a second bariatric operation, was . (sd . ) years. five ( . %) patients maintained their weight, four of whom experienced a learning effect, all others gained weight. mean bmi for both groups after the period without a band was . (sd . ) kg/m (vs. . (sd . ) at removal) and excess weight loss (ewl) was . (sd . ) % (vs. . (sd . ) % at removal). of our patients % stated they would not agree to gastric banding again. according to baros, long-term outcome of patients following band removal was a ''failure'' in % of patients. conclusions. long-term outcome following band removal is unsatisfactory in many patients. nevertheless, a minority of patients was able to maintain its weight loss. background. in bariatric surgery studies show that a better quality of life is correlated to increased weight loss. the question remained which type of surgery is superior in quality of life independently from weight loss. methods. in our study we recruited bariatric patients, operated between and ( women/ men) at the mean age of . years (sd ¼ . ) and with a mean bmi of . kg/m (sd ¼ . ). patients eligible for investigation were patients with laparoscopic gastric bypass and patients with adjustable gastric banding (agb). the patients were reviewed in the interval of , , , , , and months after operation. the bariatric analysis and reporting outcome system (baros) was used for the quality of life investigation which has been international established for obesity surgery outcomes. results. with a minimum of years follow-up our patients showed a mean bmi of . kg/m (sd ¼ . ). the statistical analysis (linear regression) showed a positive correlation between quality of life and weight loss, depending on operation method. additionally we used a partial correlation to rule out the influence of weight loss and remarked a significant result (r ¼ . , p ¼ . ). with a t-test it could be demonstrated, that patients with a laparoscopic gastric bypass observed a significant different quality of life, than patients with an agb independent from weight loss (t ( ) ¼ . , p ¼ . ). conclusions. independently of the amount of weight loss, quality of life is different between surgical procedures. wir haben versucht, mit einem standardisierten modifizierten v.a.c. + -system und einer physikalisch-technischen analyse die anwendungstechnik zu optimieren und die suffizienzrate zu erhöhen. methodik. im rahmen einer versuchsanordnung wurden die physikalischen grundlagen untersucht background. the application of the abdominal vacuum assisted closure (v.a.c.) system has become a promising treatment strategy in critical ill patients with abdominal sepsis requiring surgical therapy and open abdomen. however, fascial retraction and high rates of incomplete fascial closure up to % with subsequent high incidence of incisional hernia have been reported in literature. the aim of this study was to analyse the application of the abdominal v.a.c. therapy in patients with abdominal sepsis regarding rate of fascial closure and v.a.c. associated morbidity. methods. the study retrospectively includes all patients with abdominal sepsis requring emergency laparotomy with application of abdominal v.a.c. therapy between november and november at our department ( patients, male/ female; median age , range to ). results. the lenght of v.a.c. therapy ranged from to days (median days) with to v.a.c. changes (median ). complete fascial closure of the abdomen was feasible in patients ( %), partial closure with mesh graft implantation (vicryl, goretex) in patients ( , %), no closure in patients ( . %), and patients died with the v.a.c. system in situ ( . %). incisional site infections and intraabdominal abscesses were observed postoperatively, v.a.c. associated morbidity was . % with enterocutaneous fistulas and bleeding complications. conclusions. the study confirms the feasibility of abdominal v.a.c. therapy in patients with severe abdominal sepsis guaranteeing a high rate of fascial closure and low morbidity. methods. retrospectively reviewed patient records between august and december patients with moderate or high volume output gi fistulae, where conventional treatment had failed to prevent skin excoriaton, had been included. they underwent the fistula-v.a.c. + procedure using the v.a.c. system sized from standard sponge supplies, topical negative pressure (at most mmhg) and ostomy appliances. the v.a.c. + dressing was changed every two days. results. the v.a.c. system was found to be highly effective in controlling the fistula effluent and in promoting healing of excoriated skin. complete healing of fistula was achieved in five patients, intestinal reanastomosis in five patients, palliative care using fistula ostomy appliance in two of twelve patients. conclusions. the modified fistula v.a.c. + system can be an effective and economically viable method of containing fistula effluent and protecting the skin of patients with enterocutaneous fistulae. the v.a.c. + system may also actually promote spontaneous healing. background. surgical site infection (ssi) rates for colorectal surgery range between and %. we performed a surveillance to determine our rate and to identify risk factors. methods. in cases with colon surgery according to the nnis·colo definition or a rectal resection were collected prospectively. ssi was diagnosed following cdc guidelines. followup lasted for days, discharged patients were contacted by phone. results. one hundred and twenty-nine colon and rectal surgeries were surveyed. ssi rate for colon surgery was . % %) . ssi rate after properly timed antibiotic prophylaxis ( - min pre·op) was . % ( . - . %). otherwise the rate was significantly increased: > min pre·op ¼ . % ( . - . %), < min pre·op ¼ . % ( . - . %) or no prophylaxis ¼ . % ( . - . %) (mainly due to antibiotic treatment before surgery). higher bmi or body surface were linked with a higher infection rate (bmi < ¼ . %, ! ¼ . %, p ¼ . , body surface < . m ¼ . %, ! . m . %, p ¼ . ). conclusions. our colo ssi rate is higher than reported by nnis ( . %), but similar to rates obtained under study conditions. since data contribution to nnis is voluntary, a strong bias cannot be excluded. incorrect timing of antibiotic prophylaxis was the key risk factor for wound infections. bolus administration of antibiotics could explain the influence of body size on the ssi rate. patients with a big body size have a lower plasma concentration resulting in higher infection rates. in summary strict adherence to proper timing of antibiotic administration can drastically reduce colorectal ssi rates. first experience about treatment of chronic leg ulcers using ducest (dual cell stimulation) therapy t. payrits, s. viragos, a. ernst, g. klein, f. längle background. ulcus cruris describes a complex medical condition which affects the quality of life of patients considerably. this report refers first results about the treatment of patients with chronic leg ulcers with varied underlying causes. aim. the aim of this study is to achieve granulation tissue by using endogenous growth factors and improving wound perfusion, where other methods failed. the ducest therapy associates the application of prf (platelet rich fibrin) with targeted stimulation of the vagal nerv to encourage peripheral blood flow by use of p-stim. methods. prf combines autologous fibrin sealant and platelets. this biomatrix protects endogenous growth factors against proteolytic degradation and thereby preserves their biological activity. we draw ml blood from the patient to gain ml prf solution. we apply the prf-biomatrix with a spraypen provided by vivostat. for patients with ulcus cruris who have an impaired blood flow in the wound, we use p-stim to improve circulation in the limbs. the p-stim is a miniaturized device designed to administer auriculo point stimulation treatment over several days. the mobility of the patient is a main benefit of this therapy. results. so far we treated patients with refractory ulceras. patients achieved wound healing or a clear improvement of their wound situation. in one patient we could stop the worsening of the ulcer. the lack of woundhealing in that case was due to the non compliance of the patient. conclusions. based on these favorable findings we will evaluate the ducest therapy in a prospective study. background. endo-vacuum assisted treatment (endo-vac) represents a novel approach to treat patients with anastomotic dehiscence following anterior resection for rectal surgery. yet, limited data are available to predict success, compatibility with radio-and/or chemotherapy as well as acceptance by the patients. methods. between september and june patients suffering from anastomotic leakage after anterior rectal resection (n ¼ ) or suffering from leakage of rectal stump following hartmann's procedure (n ¼ ) were treated by endo-vac. we recorded clinical outcome and patient's comfort using a ten point visual analogue scale (vas). results. median time of endo-vac treatment was weeks (range, - ). there were no minor or major complications. in ( . percent) patients the anastomotic leakage healed successfully. three patients showed no response and needed further surgical intervention. the lack of success was due to complexity of leakages, which comprised either more than degree of the circumference or consisted of distant fistulas. formation of granulation tissue was unaffected by chemotherapy. for the question ''alteration in daily life activity'' a median score of (range, - ) was found. measuring ''pain sensation'' during end-vac treatment patients scored a median of (range, - ). conclusions. endo-vac treatment can be recommended as an alternative approach to treat pelvic sepsis following anastomotic dehiscence or rectal stump insufficiency. extended leakages should be treated by different approaches having little probability of successful healing but can lead to discomfort for the patient. radiochemotherapy does not cause a problem for application of the endo-vac. background. carcinoid tumors of the vermiform appendix are reported to be a rare occasion and to contribute to classical ''carcinoid syndrome'' only in the case of distant spread. however, these tumors may present clinical signs even in absence of metastases. methods. one hundred thirthy one appendix carcinoids were identified out of more than , histological specimen, i.e. in . % of all appendectomies. six ( . %) were found at colonic resection for caecal carcinoma and angiodysplastic syndrome. all patients were operated for the the clinical signs of acute or chronic appendicitis. all carcinoid tumors were revised retrospectively for their medical history. results. / ( . %) cases were found in combination with acute inflammation of the appendix, but / ( . %) did not show pathological findings except the endocrine tumor. almost all had hormones of the midgut group as serotonin, nse and chromogranin a in immunochemistry, only one case expressed acth most tumors were located in the tip ( . %), only % infiltrated the mesenteriolum or penetrated the serosa. when the endocrine parameters (serotonin. chrom ogranin a) were determined preoperatively in a group of cases, we failed to establish elevated serum levels in the presence of an carcinoid tumor. conclusions. only fourty per cent of appendix carcinoids present in combination with acute inflammation and are ''incidental findings'' in appendectomy. sixty per cent present with typical signs of appendicits but without any histological proof of inflammation. so the endocrine tumor causes clinical symptomes per se besides carcinoid syndrome. background. net of the appendix makes a part of % of all gastrointestinal net. they mostly appear in younger people and major part is benign, because of little diameter and leak of hormon production. if diameter is about centimetres or above, patients are running a significant risk to produce distant metastasis, generally without a carcinoid syndrome. the recently discussed entity is the goblet cell carcinoid (gcc), whose existence is to accentuate, because of the necessity to treat them like an adenocarcinoma. methods. from to we have done appendectomies. . percent or patients had a net of the appendix. mean age was years, men in proportion to women. most part (n ¼ ) had surgery because of acute appendicitis. only five patients described a long period of pain with cramps and diarrhoe. most part (n ¼ ) of net was located at the tip of the appendix with a diameter range from to mm. results. net was never diagnosed intraoperatively, although % of appendectomies have been done by specialists in surgery. in two cases right hemicolectomy was done primary because of an ileus, in four cases it was done secondary, belonging to tumor size, patients age and gcc. only one patient showed metastatic disease, when having done a second look. all net's immunehistochemically showed an expression of chromogranin a and synaptophysin. conclusions. although diagnose of net was not known when doing appendectomy, prognosis of patients outcome was not influenced in a negative way. why have neuroendocrine tumors (net) of the gut such a bad prognosis? nets in the gut mostly present multifocal disease with predominance of terminal ileum and coecum. diameter of the net mostly is above centimetres, and tumor tissue already infiltrates muscularis mucosae, with or without lymph node metastasis. belonging to the desmoplastic reaction, obstruction of intestine is not rather seen. - % of all net's of the gut are diagnosed by doing surgery because of an ileus. - % have liver metastasis with carcinoid syndrome. in a period from till we operated patients because of guts net. half of them were operated electively within a few days; the others had an acute operation within a few hours in case of ileus. median age was similar with about years. all operations have been done by specialists. in none of the cases diagnose was felt preoperatively. histological results of planned operations all showed well differentiated carcinomas with rate of distant metastasis of %, lymph node metastasis of %, contrary to acute operations, which showed bad differentiated carcinomas in % with rate of distant metastasis and lymph node metastasis of %. according to the enet classification mean part of tumors belonged to stage iiib and iv. median survival in the first group was . ae . , in the acute group ae . months. because of an a priori more radical surgery in planned operations, survival is considerably better. perhaps this point might be the solution in order to improve prognosis of guts net. gastrointestinale frühkarzinome des oberen gi-trakts: eine viszeralmedizinische herausforderung innere medizin , hsk-kliniken, wiesbaden, germany die endoskopische therapie von prämalignen und malignen läsionen im oberen gastrointestinaltrakt hat in den letzten jahren zunehmend an bedeutung gewonnen. dabei war und ist die technische weiterentwicklung im bereich der diagnostik (einsatz einer hochauflösenden videoendoskopie unter einbeziehung einer virtuellen oder realen chromoendoskopie) die integrale voraussetzung, um eine detektion von frü hen neoplastischen veränderungen zu ermöglichen. ebenso stehen dem endoskopiker therapeutisch diverse neue verfahren zur verfügung (resektionsmesser, neue ablationstechniken z.b. halo-ablation), die eine invasive und sichere endoskopische therapie ermöglichen. in einem kürzlich von unserer arbeitsgruppe veröffentlichten -jahres-follow-up von patienten mit einer hochgradigen neoplasie im barrettösophagus bzw. einem barrettfrühkarzinom konnten wir eine erfolgreiche therapie in über % der patienten dokumentieren. bezüglich des plattenepithelfrühkarzinoms des Ö sophagus wurden aus arbeitsgruppen -jahres-Ü berlebensdaten publiziert; hier zeigte sich ein -jahresüberleben von % in der lyoner gruppe vs. % der wiesbadener patienten vs. % in einem japanischen kollektiv. eine weitere arbeit aus japan, in der das technische vorgehen der endoskopische therapie (esd vs. er) evaluiert wurde, konnte in % der patienten ein -jahres-Ü berleben dokumentieren. die in den letzten jahren publizierten langzeitdaten von patienten mit t -tumoren der speiseröhre und des magens beweisen, dass eine endoskopische therapie in kurativer intention bei einhaltung definierter histologischer kriterien die therapie der wahl ist. zusätzlich können die arbeiten belegen, dass es sich hierbei um ein sicheres und komplikationsarmes therapieverfahren handelt, dass entsprechend mit einer niedrigen morbidität und mortalität verknüpft ist. while the use of breast conserving surgery increased during the last century due to strong scientific data regarding oncologic safety, only little has been done to improve the real goal of breast conservation, cosmetic outcome. oncoplastic surgery is the next important development to fulfill the goal of breast conservation. however, only few scientific outstanding original manuscripts are available. this talk gives you an overview about scientific data, future perspectives and possible borders. cariatide study: evaluation of the effect of an educational approach on compliance and adherence to adjuvant aromatase inhibitor therapy for postmenopausal women with hormone sensitive breast cancer the efficacy of ai on reducing breast cancer recurrence, but also aspects of health economy, is bound to the adherence of regular and long-term intake of the medication. aim. the cariatide study evaluates the influence of supporting educational material on compliance and retention time under ai therapy in hormone receptor positive breast cancer patients. furthermore, the study will try to explore which patients -and for what reason -fail to be compliant, and how long it takes until they quit ai therapy. study design. cariatide is an international, randomized, multicentre observational study that will include approx. patients from more than centers in countries. patients will be randomized to either standard adjuvant ai therapy or to standard ai therapy plus additional educational material, which will provide information about attributes of breast cancer, the risks and benefits of endocrine therapy, the risk of relapse and management of long-term endocrine treatment and its side effects. the material includes questionnaires to objectify patient's conception of the disease and its treatment. conclusions. randomization is ongoing and will be finalized by march ; so far, patients have been included in austria. the study will help to identify patients susceptible to compliance failure, to understand the personal reasons of compliance or non-adherence and offering possibilities to improve communication and the design of information material. grundlagen. das -genexpressionsprofil (mammaprint ?? ) ist als unabhängiger prognostischer marker beim lymphknotennegativen und -positiven mammakarzinom etabliert. der prädiktive wert für das ansprechen auf zusätzliche chemotherapie gegenüber hormonaler therapie alleine wird sowohl im adjuvanten als auch im neoadjuvanten setting präsentiert. methodik. tumoren aus studien mit bekannten tumorcharakteristika und therapiedaten wurden unterteilt in niedriges oder hohes risiko entsprechend dem mammaprint profil. die mediane nachbeobachtungszeit war , jahre. der zusatznutzen adjuvanter chemotherapie (cmf oder anthrazykline ae taxan-basiert) wurde mittels gepoolter analyse für metastasenfreies (ddfs) und krankheitsspezifisches Ü berleben (bcss) berechnet. zusätlich wurde die pathologische komplett-remissionsrate (pcr) bei patientinnen nach neoadjuvanter chemotherapie analysiert. ergebnisse. in der adjuvanten analyse wurden mittels genexpressionsprofil % der patientinnen in niedrigrisiko und % in hochrisiko unterteilt. frauen wurden mit hormontherapie alleine behandelt und zusätzlich mit chemotherapie. in der hochrisiko-gruppe zeigte sich ein beträchtlicher zusatznutzen durch chemotherapie: ddfs hazard ratio (hr) , ( , - , ), p < , und bcss hr , ( , - , ), p < , . bei multivariater analyse mit bekannten klinisch-pathologischen prognostischen faktoren waren die ergebnisse konstant. demgegenüber zeigte die niedrigrisiko-gruppe keinen signifikanten vorteil zusätzlicher chemotherapie gegenüber hormontherapie alleine: ddfs p ¼ , und bcss p ¼ , . im neoadjuvanten setting zeigte sich eine pcr-rate von % ( / ) für die hochrisiko-gruppe, während bei niedrigrisiko-patientinnen keine pcr ( / ) beobachtet wurde. schlussfolgerungen. das -genexpressionsprofil mamma-print ist nicht nur ein unabhängiger prognostischer marker; zusätzlich zeigt sich auch der prädiktive wert zusätzlicher chemotherapie sowohl im adjuvanten als auch im neoadjuvanten setting. während die hochrisiko-gruppe signifikant von einer chemotherapie zu profitieren scheint, kann ein niedrigrisiko-profil patientinnen selektieren, die mit hormonaler therapie ausreichend behandelt erscheinen. grundlagen. angiosarkome sind mit nur - % aller weichteilsarkome sehr seltene maligne tumore. ein zunehmendes problem stellen die sekundären angiosarkome nach brusterhaltender therapie eines mammakarzinoms und postoperativer bestrahlung dar. der erfolg einer chemotherapie ist zum heutigen zeitpunkt noch nicht abzuschätzen, nur eine frühzeitige mastektomie erscheint die prognose zu beeinflussen. wir berichten über zwei patientinnen, welche nach brusterhaltender therapie eines mammakarzinoms ein sekundäres angiosarkom der brust entwickelten. kasuistik. im ersten fall wurde eine jährige frau zur beurteilung von neu aufgetretenen vaskulären läsionen an der brust nach quadrantenresektion und wächterlymphknotenbiopsie eines mammakarzinoms im stadium i und postoperativer radiatio zugewiesen. die stanzbiopsie der läsion ergab ein gering differenziertes angiosarkom. im präoperativen staging konnten keine fernmetastasen festgestellt werden. die patientin wurde mastektomiert und erhält adjuvant eine anthrazyklin-monotherapie. bei einer weiteren jährigen patientin wurde im rahmen der onkologischen nachsorge nach brusterhaltender therapie und adjuvanter radiatio eines mammakarzinoms im stadium i ein weit fortgeschrittenes angiosarkom diagnostiziert. der tumor wuchs teilweise invasiv in die tiefe bis zum perikard und bis zur pleura. diese patientin erhielt noch zyklen eines liposomalen doxorubicins, verstarb aber einen monat später. schlussfolgerungen. das sekundäre angiosarkom der brust nach brusterhaltender therapie wird immer häufiger beobachtet, da heute mammakarzinome zunehmend brusterhaltend operiert werden. diese ehemals seltene erkrankung sollte nicht unterschätzt werden. früherkennung ist die einzige möglichkeit, die Ü berlebensraten dieser erkrankung zu verbessern. zur anwendung der intraoperativen sonographie bei der chirurgischen behandlung des mammakarzinoms grundlagen. mammakarzinome werden in den letzten jahren zunehmend in einem frühen stadium mit nicht oder unsicher tastbaren tumoren entdeckt. im ultraschall sind bis zu % aller mammakarzinome gut sichtbar und abgrenzbar. mit hilfe der intraoperativen anwendung des ultraschalls durch den chirurgen selbst können der patienten die unangenehme präoperative nadelmarkierung erspart werden, zudem bietet sie neben vielen organisatorischen vorteilen auch eine wertvolle orientierung bei der tumorektomie. methodik. zwischen juli und dezember wurden am landeskrankenhaus feldkirch mammakarzinome operativ behandelt. in fällen ( %) erfolgte primär eine tumorektomie, intraoperativ kam der ultraschall bei oder % aller dieser eingriffe zur anwendung. in fällen ( %) war der tumor nicht tastbar, bei den restlichen unsicher. intraoperativ erfolgte die begutachtung der schnittränder allein makroskopisch durch den pathologen, nicht jedoch histologisch. ergebnisse. nicht oder unsicher tastbare tumore konnten in allen bis auf fälle sicher aufgefunden werden. metachrone nachresektionen waren mal ( %) erforderlich. davon fanden sich in fällen ( %) im nachresektat keine hinweise mehr für malignes gewebe, in fällen ( %) in-situ-formationen, mal ( %) in-situ-zusammen mit invasiven karzinomstrukturen. bei den nicht auffindbaren tumoren handelte es sich um t a und t b-tumore, die bereits durch die stanzbiopsie schon großteils entfernt waren. schlussfolgerungen. der intraoperative ultraschall in der hand des chirurgen hat sich zum auffinden von nicht tastbaren tumoren und zur orientierung bei der tumorektomie bewährt. die ausdehnung des tumorgeschehens wird jedoch relativ häufig unterschätzt, insbesondere was die in-situ-anteile betrifft. da das brusterhaltende konzept im mittelpunkt der chirurgischen versorgung des mammakarzinoms steht, stellt die postoperative bestrahlung einen goldstandard dar. strahlungsinduzierte tumore als folge dieser therapie sind eine absolute rarität. wir möchten patientinnen präsentieren. beim ersten fall handelt es sich um eine jährige patientin, die vor jahren wegen eines invasiv duktalen mammacarzinoms nach einer brusterhaltenden operation einer bestrahlung zugeführt wurde. vor monaten wurde eine derbe struktur im bereich der op narbe entfernt. die histologie ergibt ein angiosarkom. nach abklärung wurde diese patientin umgehend einer chirurgischen therapie zugeführt. es erfolgte eine ablatio der betroffenen brust. etwas aufwendiger gestaltet sich der . fall. auch hier wurde eine jährige patientin vor jahren wegen eines invasiv duktalen mammacarzinom einer brusterhaltenden operation mit anschließender radiatio unterzogen. vor monaten kam es zum auftreten eines knotens in der axilla der operierten brust. man dachte primär an ein lokalrezidiv und entfernte dies. die histologie ergab ein malignes fibröses histiozytom. die resektion erfolgte damals nicht im gesunden. innerhalb weniger monate kam es zu einem neuerlichen rezidiv. dieses nahm nun die axilla, den gesamten m. pectoralis sowie die thoraxwand im bereich der . und . rippe ein. nun wurde eine resektion unter mitnahme der thoraxwand durchgeführt sowie einer deckung mittel myokutanen lappens. auch wenn diese fälle selten sind, so zeigen sie doch die aggressivität dieser tumorentitäten. daher muss unsere sensibilität dafür feinfühliger werden, um früher zu diagnostizieren und rasch radikal chirurgisch versorgen zu können. darin ist die größte chance zum Ü berleben zu sehen. background. after aortic valve replacement using a tissue valve,patients are treated with coumadin for months. if sinus rhythm is evident, therapy is changed to mg of aspirin a day. these are sts, acc/aha and esc guidelines. clopridigel is well known in cardiology after coronary stenting and also in peripheral vascular surgery. methods. in our -year retrospective analysis patients were treated with clopridogel after biological valve replacement (bavr). the therapy started on the fifth day after surgery and ended after months. in our group we had also patients with combined surgery like valve replacement plus cabg or carotid surgery. all patients underwent echocardiography before dismission and after months. results. in our study group we could not detect any signs of thrombembolic complications or neurological disorders. we found regular function of the valve prosthesis in all cases. one patient had to be re-operated cause of endocarditis of the prosthesis and died after prolonged ventilation problems. in the control group ( patients) we found to cases of intracerebral haemorrhagia,which caused to death. both of them were older then years. conclusions. in the last years the clinical use of tissue valves has increased because of longer durability. many post-operative regimes have been described. clopridogel mg a day is an excellent alternative therapy after bilogical valve replacement. we all know the compliance of elder patients after cardiac surgery. so we have an easy treatment for this group of patients. grundlagen. die zunahme des perkutanen aortenklappenersatzes, berechtigt die notwendigkeit zur evaluation der Ü berlebensrate nach operativem biologischen aortenklappenersatz mit und ohne zusätzlichen aortokoronaren bypass bei patienten ! jahren. in dieser studie wurden risikofaktoren, die die -jahres mortalität beeinflussen, untersucht. methodik. retrospektiv wurden im zeitraum von jänner bis dezember einhundertvierundfü nfzig patienten ( w, m) mit einem medianen alter von , ae , jahren ( - jahre), einen biologischen aortenklappenersatz mit (n ¼ ) oder ohne (n ¼ ) aortokoronaren bypass unterzogen. mittels chi-square test und mann-whitney test wurden die einflussfaktoren auf die Ü berlebensrate untersucht. ergebnisse. das -jahres follow-up zeigte eine Ü berlebensrate von , %. nach isoliertem aortenklappenersatz sind patienten ( , %) und nach einem kombinationseingriff mit koronarem bypass patienten ( , %) verstorben. die präoperativen risikofaktoren in bezug auf die mortalität, wie renale insuffizienz ( , % vs. , %, p ¼ , ), copd ( , % vs. , %, p ¼ , ), diabetes mellitus ii ( , % vs. , %, p ¼ , ), cavk ( , % vs. , %, p ¼ , ), pavk ( , % vs. , %, p ¼ , ), logistischer euro score (median , vs. , , p ¼ , ) und kombinationseingriff ( , % vs. , %, p ¼ , ) wurden evaluiert. die einzelnen risikofaktoren zeigten keinen signifikanten einfluss auf die mortalitätsrate bei patienten ! jahren. schlussfolgerungen. die vorliegenden daten zeigen gute ergebnisse der Ü berlebensraten nach operativem aortenklappenersatz bei patienten über jahren in einem beobachtungszeitraum von einem jahr. results. mean baseline hematocrit serum levels were . ae . %. the mean decrease of hematocrit serum levels was . ae . % after surgery. the mean decrease of hematocrit serum levels in patients undergoing cabg without cpb was . ae . % and . ae . % in patients after isolated valve replacement. one patient died during the operation. four patients died in the postoperative period due to anemia. during followup, being ae months to date, no cardiovascular related adverse event has been observed. conclusions. the decrease of hematocrit serum levels is significantly characterizing the postoperative period of open heart surgery in jehovah's witnesses. in patients undergoing cabg without cpb and in patients undergoing isolated valve replacement, decrease of hematocrit serum levels was lowest. therefore, these techniques should be considered for first choice when appropriate. furthermore, highly normal preoperative hematocrit serum levels and a meticulous surgical technique remain the mainstay of therapy in these patients. grundlagen. routinemäßige intraoperative flussmessung von bypassgrafts dient der qualitätssicherung koronarer revaskularisation. ziel unserer studie war die evaluierung der flussmessung als indikator für langzeitmortalität. methodik. wir messen routinemäßig intraoperativ die flussgeschwindigkeit in bypassgrafts mit dem doppler-flowmeter (cardiomed + ) und speichern die daten in der archimed datenbank. fü r diese studie analysierten wir retrospektiv flussmessungen von cabg patienten, euroscore, lvef, alter, geschlecht fü r den beobachtungszeitraum - . flussmessungen < ml/min > ml/min wurden exkludiert. wir unterteilten die patienten in gruppen: cabg i (gruppe a), cabg ii (gruppe ii), cabg iii (gruppe iii). mittlerer beobachtunszeitraum war , jahre. die datenerfassung war vollständig und mit dem Ö sterreichischen sterberegister abgeglichen. ergebnisse. gruppe a: mittlerer es ( - ) und mittlere lvef ( - ) hatte eine mittlere flussgeschwindigkeit von ml/ min ( - ), mit arteria mammaria interna (ima) ml/min ( - ), ohne ima . ml/min ( - ). altersdurchschnitt . jahre ( . - . ). m/w ¼ %/ %. langzeitmortalität von gruppe a war %. gruppe b: mittlerer es ( - ) und mittlere lvef ( . - ) hatte eine mittlere flussgeschwindigkeit von ml/min ( - ). altersdurchschnitt . jahre ( - . ). m/ w ¼ %/ %. langzeitmortalität von gruppe b war . %. gruppe c: mittlerer es ( - ) und mittlere lvef ( - . ) hatte eine mittlere flussgeschwindigkeit von ml/min ( - ). altersdurchschnitt . jahre ( - . ). m/w ¼ %/ %. langzeitmortalität von gruppe c war . %. gesamtlangzeitmortalität war . %. schlussfolgerungen. zwischen den gruppen zeigte sich kein signifikanter unterschied bezü glich es, lvef oder flussgeschwindigkeit und keine signifikante korrelation derer zur mortalität. flussgeschwindigkeit ist kein indikator fü r langzeitmortalität. the radial artery as arterial bypass graft in coronary surgeryreport of an angiographic evaluation with -or multi-slice computed tomography k. mészáros, a. yates, f. dobaja klinische abteilung für herzchirurgie, graz, austria background. since , the radial artery, additionally to lita and rita, was used as arterial bypass graft material in cabg pts at our institution. the aim of this study is the evaluation of radial artery patency and stenosis with ctangiography. methods. before scanning, all patients were clinically examined and had to fill in a questionnaire concerning their current nyha-and ccs-state, their medication and risk factors. all patients were examined for presence of restrictions resulting from radial artery harvesting in the concerned arm (fine motor skills, sensibility, perfusion etc.). after that, the recent creatinine-level was analyzed in all patients. ct was performed in one group with a new -slice ct-scanner and in the other group with a -slice scanner, depending on the availability of the scanner. graft patency and stenosis was analyzed in cooperation of cardiac surgeons and radiologists in several reconstruction techniques. results. preliminary data of pts showed radial artery occlusions, in all other cases ( %), radial artery was widely patent after a mean follow up of ae months. conclusions. at present, the examination is still under proceeding. first results showed quite satisfying results in radial artery patency, data from all pts will show statistical significant factors impairing radial artery patency. these data will help us to improve long term patency rate of radial bypass conduits. surgical therapy options in ebstein's anomaly in adults n. reiss, u. schütt, r. körfer, j. gummert background. ebstein's anomaly is a rare congenital malformation of the heart, the basic feature of which is dislocation of the tricuspid valve into the right ventricular cavity. the onset of the symptoms and the diagnosis depend on the severity of the valve dysfunction and the right ventricular function and size. the age at diagnosis ranges from birth to adulthood. we report our experience with surgical treatment of ebstein's anomaly in adults. methods. twenty-three pts ( male, female, mean age years, to years) underwent surgical treatment in ebstein's anomaly (tricuspid valve repair in various techniques ¼ , tricuspid valve replacement ¼ ( st. jude medical, hancock), and heart transplantation ¼ ). all pts with mechanical tricuspid valve replacement were introduced in inr-self-management. only four of the patients had previous cardiac surgery. results. twenty pts recovered well after surgery. three pts developed cardiac low-output-syndrome, which was treated by implantation of mechanical circulatory support systems ( thoratec, cardiowest). one pt could be weaned, one pt was successfully bridged to htx and one pt died on device because of multiorgan failure. after a mean time of . years % of pts were in nyha class i or ii. conclusions. surgical therapy of ebstein's anomaly can be performed with good results in the adult population. when valve repair is not feasible we prefer implantation of mechanical valves with consecutive inr-self management. reduction of sternum instability after cardiac surgery with a newly designed thorax support vest methodik. in einer prospektiv randomisierten studie wurden patienten untersucht, die einem herzchirurgischen eingriff unterzogen wurden. die patienten wurden in zwei gruppen stratifiziert: gruppe a wurde unmittelbar nach der herzoperation mit der posthorax + herzweste (fa. epple, wien) zur stabilisierung des sternums behandelt. gruppe b wurde wie bisher mit einer elastischen bandage versorgt. alle patienten wurden durch einen präoperativen risikoscore evaluiert. zahlreiche operative, laborchemische und klinische daten wurden anlaysiert. ergebnisse. die beiden randomisierten gruppen waren bis auf das vorliegen von diabetes, der in der gruppe a häufiger zu beobachten war, seitens der demographischen, laborchemischen und operativen variablen vergleichbar. ( , %) patienten der kontrollgruppe ohne weste entwickelten komplikationen im bereich der sternumwunde, die eine reoperation erforderte. in der gruppe a musste ein patient wegen einer oberflächlichen infektion der sternumwunde reoperiert werden ( , %). dies bedeutet einen signifikanten unterschied zwischen den beiden gruppen bezü glich des auftretens von sternumproblemen (exact fisher's test: , ). interessanterweise traten % der komplikationen nach dem spitalsaufenthalt innerhalb von tagen auf. schlussfolgerungen. der gebrauch der posthorax + herzweste zeigt in dieser prospektiv randomisierten studie eine deutliche senkung der komplikationen im bereich des sternum nach herzchirurgischen eingriffen. background. sine the quantity of icd implantations is steadily increasing the numbers of complications is rising too. one of the issues is how to deal with damaged or infected leads. we report our experience with icd and pm lead extraction, possibility and complications. methods. in a retrospective analysis percentage of lead extraction in icd patients, duration of operation and complications were evaluated. complications were defined as death of patient, surgery repair of vessel, sternotomy, blood transfusion, pericard effusion, infection, pneumothorax, embolic event and bleeding with surgical revision. extraction was done either by manual traction or by extraction tool. results background. to evaluate histopathological findings of intraoperatively gained aortic specimens. methods. between january and october , aortic specimens were evaluated in patients including ( %) thoracic aortic aneurysms, ( %) thoracic aortic dissections as well as ( %) abdominal aortic aneurysms. mean age was ae years. ( %) patients were over years of age and ( %) patients were over years of age. results. medial degeneration was diagnosed in ( %) patients. of these ( %) had thoracic aortic aneurysms, ( %) thoracic aortic dissections and ( %) abdominal aortic aneurysms. severe medial degeneration was found in ( %) patients including ( %) thoracic aortic aneurysms, ( %) thoracic aortic dissections and ( %) abdominal aortic aneurysms ( % of diagnoses in patients < years of age vs. % of diagnoses in patient over years of age). extensive arteriitis was diagnosed in ( %) patients including ( %) thoracic aortic aneurysms, ( %) thoracic aortic dissections and ( %) abdominal aortic aneurysms. marfan's syndrome was diagnosed in ( %) cases ( thoracic aortic aneurysms, thoracic aortic dissection). giant cell arteriitis was found in one thoracoabdominal aortic aneurysm. conclusions. medial degeneration was the most frequently observed histopathological diagnosis irrespective of location and clinical presentation. aging is associated with a higher degree of medial degeneration as well as with a higher percentage of inflammatory disease of the aortic wall. Österreichische gesellschaft für adipositaschirurgie: chirurgie der adipositas und metabolischer erkrankungen teil intermediate weight loss after sleeve gastrectomy s. ali-abdullah, m. schermann, a. landsiedl, s. kriwanek background. the long term effects of sleeve gastrectomy have not been described to the present date. case series report significant reoperation rates due to inadequate weight loss, weight regain, or gastro-esophageal reflux disorder. the aim of our study was to analyze intermediate results to years after sleeve gastrectomy methods and results. twenty-nine patients ( women, men) were operated between or . a standardized procedure was applied. calibration of the sleeve was achieved with a f bougie. one complication (staple line leak) occurred and was treated by a reoperation. at follow up the average excess weight loss was percent. six patients ( %) were converted to a gastric bypass in cases due to weight regain and in patients because of reflux problems ( ). one patient was reoperated after a first step sleeve gastrectomy. conclusions. in our experience sleeve gastrectomy seems to be an effective weight loss operation but reoperation rates are significantly higher compard to roux y gastric bypass. background. the positive long term effects of bariatric surgery on obesity -associated comorbidities and survival depend on minimal postoperative morbidity and mortality. patient safety has therefore, gained a high level of attention in bariatric surgery in the last years. methods and results. patient safety is increased by a variety of steps including correct selection and preparation of patients, implementation of clinical pathways, application of a universal protocol concerning verification of patients and procedures during a ''time out'' at the beginning of every operation, structured intra-und postoperative communication (briefing, debriefing), high awareness of possible complications, guidelines for the diagnosis and treatment of complications, standardized follow-up, and systematic training of safety agenda during education. conclusions. a systematic approach to ensure optimal patient safety is mandatory to enable late benefits of overweight surgery. grundlagen. in der literatur wird die wahrscheinlichkeit einer bandmigration nach ,,gastric banding'' mit ca. % beschrieben. praktisch immer liegt eine bandinfektion zugrunde. fall. wir präsentieren eine jährige patientin mit einem zu % in den magen migrierten magenband. die indikation zur endoskopischen entfernung mittels schneidedraht wurde gestellt. hierbei wurde der port entfernt, der schlauch in der freien bauchhöhle versenkt und anschließend das band endoskopisch mittels schneidedraht (ami) durchtrennt. während der versuche, das impaktierte band endoskopisch herauszuziehen, bemerkten wir eine massive auftreibung des abdomens. aufgrund massiv freier luft (perforationsverdacht) wurde die indikation zur laparoskopie gestellt. nach einbringen des optik -trokars imponierten mm hg druck intraabdominell. laparoskopisch kein hinweis auf hohlorganperforation. somit kann man davon ausgehen, dass die luft während der gastroskopie über das zuvor durchtrennte schlauchsystem in den bauchraum gelangte. die dauer der intraabdominellen druckerhöhung betrug stunde. postoperativ kam es zu einem akuten leberversagen mit massivem transaminasenanstieg (got > , gpt > , ldh > ) und abnahme der lebersyntheseleistung (inr bis , ), wohl infolge der druckbedingten portalen minderperfusion, jedoch ohne enzephalopathie. sonographisch konnte eine adäquate leberperfusion nachgewiesen werden. nach peak am . postoperativen tag waren die laborparameter rückläufig bis zur völligen normalisierung. im rahmen einer exakten leberdiagnostik konnte schließlich eine nash diagnostiziert werden. schlussfolgerungen. eine kurzzeitige portale minderperfusion der leber kann bei bereits vorgeschädigtem organ ausreichen, um zu einem funktionsausfall/akuten leberversagen zu führen. um so eine situation in zukunft zu vermeiden, haben wir be-schlossen, das schlauchsystem einzuknoten, bevor es in die freie bauchhöhle versenkt wird. background. due to the rising numbers of obese patients treated by roux-en-y bypass the problem of choledocholithiasis is of increasing importance. for anatomical reasons endoscopic access to the bile tract may prove difficult or impossible. methods and results. four patients who presented symptoms of choldeocholithiasis after roux-en-y bypass were successfully treated by laparoscopy-assisted transgastric ercp. in cases this procedure was combined with a laparoscopic cholecystectomy. there were no complications related to the procedures. conclusions. in our opinion ''reversed-notes'' is a safe and effective way of treating choledocholithiasis in patients after roux-en-y gastric bypass. korrekturoperationen nach erfolgloser adipositaschirurgie p. beckerhinn, s. schöppl, f. hoffer grundlagen. das laparoskopisch implantierte verstellbare magenband (agb) ist der häufigste bariatrische eingriff in europa. langzeit-komplikationen wie band-slippage, pouch-oder Ö sophagus-dilatationen und mangelnder gewichtsverlust erfordern neuerliche operationen. die offene vertikale band-verstärkte gastroplastik (vbg) war eine der beliebtesten adipositas-operationen der er und er jahre. klammernahtrupturen führten wegen neuerlicher gewichtszunahme zu reinterventionen. der magenbypass (rygbp) ist der häufigste eingriff nach erfolglosen bariatrischen operationen. wir untersuchten die ergebnisse nach korrektur-operationen. methodik. die daten aller patienten wurden prospektiv erfasst. die postoperativen veränderungen bezü glich gewicht, begleiterkrankungen und lebensqualität wurden untersucht. ergebnisse. zwischen und wurden operationen an frauen und männern nach erfolgloser bariatrischer erst-operation durchgefü hrt. das durchschnittsalter betrug zum zeitpunkt der operation jahre, der durchschnittliche bmi kg/m . die erstoperationen waren in fällen ein agb, mal ein vbg, sleeve-gastrektomien und ein magenschrittmacher. dreimal war das band bereits vor der korrekturoperation entfernt worden. revisionseingriffe wurden laparoskopisch begonnen, zweimal musste konvertiert werden. mal wurde nach entfernung des magenbandes in der selben sitzung ein rygbp angelegt. laparoskopische sleeve-gastrektomien wurden durchgefü hrt, dreimal wurde ein neues sagb eingebracht, drei bänder konnten repositioniert werden. revisionspflichtige komplikationen beobachteten wir bei patienten ( %) ( blutungen, trokarhernien, innere hernien, andere). keine leckagen oder todesfälle traten in dieser serie auf. schlussfolgerungen. korrektureingriffe nach erfolgloser adipositas-operation haben eine höhere komplikationsrate als erstoperationen. die guten erfolge in bezug auf die gewichtsreduktion, die verbesserung der assoziierten erkrankungen und die lebensqualität rechtfertigen das etwas erhöhte risiko. grundlagen. rund . Ö sterreicherinnen leiden unter einer adipositas permagna (grad iii) mit einem bmi > bei steigender tendenz. entsprechend nimmt die anzahl der bariatrischen operationen und in weiterer folge die notwendigkeit von konturverbessernden operationen zu. das untere bzw. das obere bodylift bieten die möglichkeit einer straffung von abdomen, oberschenkel, hü fte, gesäß und rü cken bzw. von oberem rumpf, der brü ste und der oberarme in einer sitzung. methodik. anhand von fallbeispielen werden das perioperative management und die einzelnen operationsschritte eines unteren bodylifts in der modifizierten technik nach ted lockwood bzw. eines oberen bodylifts in der technik nach al aly vorgestellt. ergebnisse. bei allen patienten konnte eine deutliche verbesserung der körperkontur erreicht werden. schwerwiegende komplikationen (thrombose, pulmonalembolie) traten nicht auf. schlussfolgerungen. das bodylift ermöglicht das gleichzeitige straffen von mehreren körperarealen mit fließenden konturübergängen in einer sitzung. dies führt nicht nur zu einem besseren ästhetischen behandlungsergebnis, als es die isolierten straffungen der einzelnen körperareale könnten. sondern es trägt auch zu einer reduzierung der sozioökonomischen kosten durch verkürzte spitalsaufenthalte und krankenstände im vergleich zu einzelstraffungen bei. durch das standardisierte behandlungskonzept lässt sich eine hohe patientensicherheit und -zufriedenheit erreichen. integriert in ein interdisziplinäres team aus bariatrischen chirurgen, plastischen chirurgen, internisten, psychologen, ernährungsberatern und sportmedizinern steht eine solche operation am schluss einer langen behandlungsreihe und erleichtert dem patient die rückkehr in ein normales leben. background. thyroid autonomy shows functional and/or autonomous nodular growth. should surgical therapy remove affected tissue radically or selectively, with risk of hypothyroidism or risk of functional/nodular recurrence. methods. a prospective study was conducted from to . pts were stratified in groups. first results in outcome were at months, and after years. late results are available years postoperatively. results. in standard bilateral radical resection, a % need for t -medication is overt, after and years in less than %, with a % risk of recurrence. in selective nodule removement a lower rate of hypothyroidism with a % risk of recurrence is noted. conclusions. aftt should be treated by adequate bilateral resection, selective nodular removement has a high risk of functional and nodular persistance or recurrence. evaluation of parathyroid hormone screening before thyreoidectomy methodik. eine perioperative pth-bestimmung wurde bei konsekutiven normocalcämischen patientinnen durchgeführt. ergebnisse. von patientinnen ( , %) wiesen erhöhte pth-spiegel auf (gruppe a), durchschnittlich , pg/ml (normalbereich - pg/ml, range , - ), bei patientinnen mit normalem pth (gruppe b) lag der wert bei , (range , ) . die ca-werte waren in beiden gruppen gleich (gruppe a , mmol/l, range , - , , gruppe b , mmol/l, range , - , ). bei den patien-tinnen der gruppe a wurden schilddrü senlappen operiert. (von ) nebenschilddrü sen konnten exploriert werden, ohne pathologischen befund, einmal wurde ein nebenschilddrü senadenom als ausdruck eines primären hpt gefunden. postoperativ wies die gruppe a einen durchschnittlichen pth-wert von , pg/ml bei einem durchschnittlichem ca-wert von , (range , - , ) auf, gruppe b einen durchschnittlichen pth-wert von , bei einem durchschnittlichem ca von , (range , bis , ). schlussfolgerungen. präoperativ erhöhte pth-spiegel bei normocalcämie sind bei jedem zehnten patienten zu finden; dabei liegt nur selten ein normocalcämischer primärer hyperparathyreoidismus vor, sondern ü berwiegend eine reaktive hyperparathyrinämie. ein generelles pth screening kann daher nicht empfohlen werden, es ist aber sinnvoll, wenn das präoperativ obligate calcium im oberen normbereich liegt. eine exploration der nebenschilddrü sen ist im rahmen der geplanten schilddrü senoperation angezeigt, eine ausweitung des eingriffs zur -drü senexploration, ,,en principe'' allerdings nicht. reoperation in recurrent goiter is associated with an elevated morbidity predominantly related to recurrent laryngeal nerve palsy between and %. a benefit of intraoperative neuromonitoring (ionm) in reoperative surgery focusing on the recurrent laryngeal nerve palsy rate has not been demonstrated clearly. in a retrospective analysis ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) of nerves at risk (nar) in reoperative thyroid surgery at our institution by using neuromonitoring ( nar) or visual nerve identification ( nar) transient recurrent laryngeal nerve palsy rate was comparable between both groups ( . and . %). however a clear reduction in permanent recurrent laryngeal nerve palsy by using neuromonitoring from . to . % was evident. after standardizing ionm in our clinic, we started a prospective study to confirm this finding and to define the influence of ionm on transient recurrent laryngeal nerve palsy rate. all reoperations in thyroid diseases by using neuromonitoring ( nar) from january were included in this analysis with respect to the transient and permanent recurrent laryngeal nerve paralysis rate. the prospective evaluation of nar in reoperative thyroid surgery shows a decreased transient ( . %) and permanent ( . %) recurrent laryngeal nerve palsy rate by using ionm. ionm decreases the transient and permanent recurrent laryngeal nerve palsy rate in reoperative thyroid surgery and should therefore be mandatory. das intraoperative neuromonitoring (ionm) wird bereits in zahlreichen kliniken zur identifikation des n. laryngeus recurrens (nlr) eingesetzt. während der der präparation ist die funktionsüberprüfung des nerven nur punktuell möglich. methodik. eine neu entwickelte vagussonde (v ; fa. inomed. teningen, deutschland) wird vor der präparation der grenzlamelle in der gefäßnervenscheide zwischen der a. carotis und der v. jugularis in engem kontakt zum n. vagus platziert. die schwellenwerte bis zur maximalen signalstärke der ableitungen über die tubuselektrode werden zu beginn und am ende der operation ermittelt. die stimulation erfolgt mit einer frequenz von hz und einer stromstärke unterhalb der maximalen signalantwort. die ergebnisse einer konsekutiven serie von beidseitigen resektionen (n ¼ nerves at risk) werden dargestellt. ergebnisse. der schwellenwert zur supramaximalen stimulation lag zwischen , und ma. diese werte unterschieden am beginn und am ender der operation um maximal , ma. passagere recurrensparesen wurden in fällen beobachtet. in beiden fällen fiel während der präparation das signal des kontinuierlichen ionm aus, die schädigungsstelle konnte bei erhaltener kontinuität des nerven exakt lokalisiert werden. in beiden fällen zeigte sich ein stimmbandstillstand unmittelbar postoperativ, eine vollständige wiederherstellung der beweglichkeit nach tagen und wochen. die stimulationsdauer des einzelnen nerven lag intraoperativ zwischen und minuten. schlussfolgerungen. das kontinuierliche ionm scheint störungen der leitfähigkeit des nlr sehr empfindlich anzuzeigen. konsequenzen für die operationstaktik müssen in weiteren anwendungen evaluiert werden. aspekte der sicherheit für den motorischen nerven durch eine elektrische dauerstimulation werden diskutiert. grundlagen. diagnostik und therapie der choledocholithiasis werden in der Ä ra der laparoskopischen cholecystektomie unterschiedlich gehandhabt. an unserer abteilung sind indikation und zeitpunkt der ercp/ept abhängig von anamnese, labor, sonographie und routinemäßiger intraoperativer cholangiographie. methodik. zwischen . . und . . wurden an unserer abteilung laparoskopische cholecystektomien ( , % aller galleneingriffe) durchgeführt. bei dieser patienten ( , %) wurde auch eine choledochuspathologie (papillenstenose, choledocholithiasis) diagnostiziert und prae-, intra-oder postoperativ mittels ercp/ept behandelt. schlussfolgerungen. in unserem krankengut hat sich die prae-, intra-und postoperative ercp/ept im rahmen der laparoskopischen cholecystektomie bei cholecysto-und choledocholithiasis sehr bewährt. die routinemäßige intraoperative cholangiographie führte bei , % der patienten zur diagnose und therapie unerwarteter choledochuskonkremente! randomized controlled trial to assess feasibility and efficacy of co insufflation during colonoscopy in moderate and deep sedated patients background. air insufflation during colonoscopy is the considered standard method in most endoscopic centers. notably, several studies reported reduced abdominal pain during and after colonoscopy by using co insufflation in unsedated as well as light sedated patients. the study was designed to assess the feasibility and efficacy of co during and after colonoscopy in moderate and deep sedated patients. the secondary endpoint was to evaluate whether co is able to enhance patient's compliance to undergo colonic cancer screening. methods. three-hundred consecutive patients allocated for colonoscopy were randomly assigned to either co or air insufflation. patients were titrated to a level of deep sedation by propofol alone or to moderate sedation when combined with midazolam. postinterventional pain and satisfaction were registered by a visual analogue scale (vas). colonic cancer screening compliance was questioned separately. results. co insufflation was used in patients, whereas in patients conventional air was applied during colonoscopy. both groups were comparable in regard to age, sex and bmi. neither major nor minor complications were observed. painsensation was significantly lower in the co group min, min as well as h after colonoscopy (p < . ). twelve hours after endoscopy no difference was observed. in contrast, satisfaction level did not show any significant difference. voluntary colonic cancer screening seemed not to be influenced by the type of insufflation gas. conclusions. co insufflation in deep and moderated sedated patients during colonoscopy significantly reduced postinterventional abdominal pain. interestingly, patient's satisfaction was equal in both groups. review: optimal biopsy protocol in gerd patients background. endoscopy in patients with gastroesophageal reflux disease (gerd) aims to assess presence or absence of reflux and cancer risk. remains to be questioned which biopsy protocol adequately meets these requirements. methods. review on a novel histopathology based biopsy protocol. results. in keeping with recent endoscopy and biopsy studies coming from others and our group, gerd causes a specific morphology within the distal esophagus: columnar lined esophagus (cle). cle is interposed between the squamous lined esophagus and the oxyntic mucosa of the proximal stomach. the assessment of cle proofs the presence of reflux and includes oxyntocardiac, cardiac mucosa ae intestinal metaplasia (barrett's esophagus). over a sequence involving low-and high-grade dysplasia (intraepithelial neoplasia) intestinal metaplasia may progress towards esophageal adenocarcinoma ( . % annual risk). accordingly barrett's esophagus is recognized as having a cancer risk justifying endoscopic surveillance. based on the zonation of the mucosal types within cle (cardiac mucosa ae intestinal metaplasia and oxyntocardiac mucosa favor the proximal and distal segment of cle, respectively), biopsies obtained from the squa-mocolumnar junction have the highest yield for assessment of intestinal metaplasia (proofing reflux and cancer risk). thus the biopsy protocol should include at least quadrant biopsies from the squamocolumnar junction and biopsies obtained at . cm increments from endoscopically visible tongues or segments of cle. conclusions. four quadrant biopsies obtained from the squamocolumnar junction have the highest yield for the assessment of reflux and cancer risk and should be included into the routine biopsy protocol in gerd patients. variceal bleeding. a danish expirience with the ella-danis stent gastroenheden, hvidovre hospital, hvidovre, denmark background. despite effective treatment modalities such as vasoactive drugs, banding therapy and sclerotherapy, a fraction of the esophageal varices continue to bleed. until recently, the sengstaken-blakemore tube has been the method of choice for those patients. there are, however, numerous disadvantages with the tube. methods. the first seven patients treated with the ella-danis stent (e-ds) in our institution are presented. in all patients other methods to achieve bleeding control had failed. all patients had alcoholic liver cirrhosis. results. in all patients the placement of the e-ds was uncomplicated and variceal bleeding stopped immediately. the e-ds was in place from to days. the removal of the stent was done under endoscopic control by means of an overtube and a biopsy -or rotating forceps. no complications were encountered. conclusions. the e-ds is excellent as rescue therapy in patients with bleeding esophageal varices in cases where other treatments have failed. internet platform for novel gerd management: www.igerd.com background. currently a mixture of symptoms, data obtained from endoscopy, histopathology, function tests and radiology define gastroesophageal reflux disease (gerd). recently an histopathology based concept for gerd diagnosis and management has been introduced (paull-chandrasoma classification). we aimed to create a platform for these novel developments. methods. design of an interactive, easy to use internet-based platform on gerd management for physicians and patients. results. igerd for physicians compares the currently used concept with the novel, histopathology based concept for gerd diagnosis and management. the information is presented using text, images, slide shows and video pod casts (topics: endoscopy videos, biopsy protocol, histopathology, manometry, ph monitoring, impedance technology, treatment algorithms). igerd news summarizes recently published papers on gerd. in addition, igerd provides patient informations. the content is monthly updated by members of the scientific board. igerd can be followed within the internet (www.igerd.com) or the content can be downloaded on a personal computer (pc, mac) and transferred to ipod and iphone, using itunes. with these tools videos and slide shows can be followed using the interactive stop and go function. thus igerd meets the requirements of the present time: actuality, mobility and flexibility. conclusions. igerd represents an interactive internet-based information and e-learning platform for gerd management designed for physicians and patients. temporary placement of self-expanding oesophageal stents as bridging for neoadjuvant therapy background. placement of self-expanding stents is the most commonly applied palliation for dysphagia in non-resectable esophageal or proximal gastric cancer (aeg ii, aeg iii). the aim of this analysis was to assess the efficacy of temporary stent placement for dysphagia relief enabling neo-adjuvant treatment strategies for locally advanced disease. methods. thirty-eight patients scheduled for neo-adjuvant chemo(radio)therapy for locally advanced esophageal cancer (n ), cardia cancer (aeg ii; n ¼ ) or subcardial gastric cancer (aeg iii; n ¼ ) underwent stent placement due to severe dysphagia and weight loss using self expanding plastic stents (n ¼ ) or covered metal stents (n ¼ ). results. stent placement led to an instant dysphagia relief in ( %) of the patients. dysphagia scores were reduced from median . ae . before stent placement to . ae . thereafter. among those patients, ( %) underwent resection of the tumor after completion of the neo-adjuvant therapy, patients ( %) underwent primary resection without receiving chemotherapy and patients ( %) had only chemo(radio)therapy but no surgery. all of them were exclusively nourished orally at least until restaging or surgery. stent related complications were observed as perforation at stent placement (n ¼ ), mediastinitis (n ¼ ), tracheo-esophageal fistula (n ¼ ), bleeding (n ¼ ) and jejunal perforation caused by a migrated stent (n ¼ ). four patients underwent placement of a second stent and patient had bouginage due to stent migration (n ¼ ). conclusions. placement of self-expanding stents is highly effective for instant dysphagia relief enabling adequate oral nutrition during neo-adjuvant therapy, but is limited by a high re-intervention rate. background. anastomotic leak is a potentially life-threatening complication after upper gastrointestinal resektions and bariatric surgery requiring long, cost-intensive and frequently failed treatment. this study has been undertaken to evaluate, whether endoscopic sealing with autologous fibrin glue is an effective treatment for persistent postoperative fistula. methods. between september and january patients who developed non-healing upper gastrointestinal leaks after oncologic (n ¼ ) and non-oncologic oesophageal (n ¼ ), gastric (n ¼ ) or bariatric (n ¼ ) surgery were treated by endoscopic vivostat + autologous fibrin sealing. fibrin sealant was applied in patients without systemic or advanced local sings of infection with a sufficient external drainage of leakage site. location was cervical (n ¼ ), intrathoracic (n ¼ ) and abdominal (n ¼ ). previous leak treatment included surgery, external drainage or/and endoscopic stenting. endoscopic sealing occured after a median interval of days (range - ) after primary surgery. results. fourteen of sixteen patients had complete healing of the anastomotic leak or fistula after one ( patients), two ( patients), tree ( patients) or five ( patient) sealing procedures. in six procedures sealing was completed by simultaneous implantation of a stent. in two patients treatment failed and the healing of the abdominal fistula was achieved by following insertion of a stent on the leakage site. conclusions. autologous fibrin sealing could be successfully used for management of persistent upper gastrointestinal fistula and promotes healing. results after different treatment modalities for achalasia background. achalasia is an esophageal functional disorder with esophageal body amotility and impaired lower esophageal sphincter (les) relaxation causing dysphagia, heartburn and regurgitation. methods. retrospective analysis of patients with manometrically proven achalasia ( females; ae years) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . management included primary dilatation (stark dilator; n ¼ ), primary laparoscopic myotomy and anterior fundoplication (n ¼ ), secondary myotomy following dilatation (n ¼ ), a mix of botox administration and dilatation (n ¼ ) and is unknown in patients. results. follow up manometry was available in / , / and / patients after dilatation, primary and secondary myotomy, respectively. after dilatation les resting pressure decreased from . ( . ; . ; % ci) to . ( . ; . conclusions. primary dilatation is recommended for achalasia, primary myotomy may be considered in younger patients. grundlagen. osteosarkome sind die häufigsten primär malignen, nicht hämatopoetischen tumoren des knochens. ihre inzidenz beträgt , - , pro . einwohner pro jahr. während die Ä tiologie primärer osteosarkome unklar ist, können prädisponierende faktoren wie vorangegangene bestrahlung oder paget's disease sekundäre osteosarkome (mit-)verursachen. das ziel der vorliegenden studie waren die berechnung der inzidenz für Ö sterreich sowie eine analyse möglicher trends während der letzten jahre. methodik. die autoren führten eine retrospektive populationsbasierende analyse der inzidenz von osteosarkomen in Ö sterreich während der letzten jahre grundlagen. präoperatives serum-crp konnte bereits für viele neoplasien als signifikanter prognosefaktor nachgewiesen werden. für das osteosarkom konnte bislang kein serologischer parameter als eindeutiger prädiktor identifiziert werden. ziel dieser studie war es, die prognostische bedeutung des präoperativen serum-crp bei patienten mit osteosarkom zu untersuchen. methodik. aus dem prospektiven wiener geschwulstregister konnten an einem osteosarkom erkrankte patienten ( frauen und männer mit einem durchschnittsalter von , jahren) mit vollständiger dokumentation der prä-und postoperativen crp-werte und nach ausschluß einer begleitenden infektion hinsichtlich ihres gesamtüberlebens und ihrer infektionsrate im rahmen einer retrospektiven datenbankanalysenachuntersucht werden. ergebnisse. der präoperative crp-wert betrug durchschnittlich , mg/dl ( , bis , ) und korrelierte signifikant mit gesamtüberleben, operationsalter und histologischem subtyp, nicht jedoch mit geschlecht, tumor-grading, ansprechrate auf chemotherapie nach salzer-kuntschik, metastasierungsrate und postoperativer infektionsrate. patienten mit parostalem osteosarkom zeigten signifikant höhere crp-werte als in fällen von klassischen osteosarkomen. in der multivariaten analyse hatten sowohl alter als auch der präoperative crp-wert einen signifikanten einfluß auf das gesamtü berleben. patienten mit präoperativen crp-werten < mg/dl zeigten ein -jahresgesamtü berleben von % gegenü ber % fü r patienten mit crp-werten > mg/dl. präoperatives serum-crp war sowohl ohne als auch mit landmark-analyse kein prognosefaktor fü r protheseninfektion bei patienten, die mit tumorporthesen versorgt waren. schlussfolgerungen. präoperatives serum-crp ist ein unabhängiger prädiktor für das gesamtüberleben bei patienten mit osteosarkom. inwiefern es in diesem zusammenhang auch einen prädiktor für das chemotherapieansprechen darstellt und welche prognostische rolle dem protheseninfekt zukommt, erfordert aufgrund der geringen inzidenz größere datenbankanalysen im rahmen von multicenter-studien. methodik. alle gemeldeten fälle von weichteilsarkomen (entsprechend der standard intnernational classification of diseases for oncology, icd-o- ) aus dem krebsregister der statistik austria wurden in unseren datensatz aufgenommen und die altersstandardisierte inzidenz, alters-und geschlechtsverteilung sowie geographische unterschiede analysiert. ergebnisse. insgesamt wurden fälle registriert, mit einem verhältnis männer/frauen von , . die häufigsten entitäten waren: sarkom (nos) ( %), leiomyosarkom ( %), liposarkom ( %), malignes fibröses histiozytom (mfh, %) und fibrosarkom ( %). die durchschnittliche altersstandardisierte inzidenzrate lag bei , / . /jahr. die analyse der jährlichen sowie über drei jahre gemittelten inzidenzen ergab keinen anstieg der inzidenzraten (jährlicher gradient: À , ). im bundesländervergleich zeigten sich regionale unterschiede, mit der höchsten inzidenzrate in tirol ( , / . /jahr). schlussfolgerungen musculoskeletal tumours are rare with an incidence of - patients/year/ million. before any imaging procedure clinical assessment has to be carried out. the first pitfall is a delayed diagnosis. bone tumours are often accompanied with early pain and swelling and these symptoms lead the patient and the physician to perform further investigation. for soft tissue sarcomas, especially for the retroperitoneal localisation, first symptoms lack or are noticed after the tumour has achieved an important extension. another important pitfall is the diagnosis ''haematoma''. every tumour has to be considered as malign until malignancy is excluded in further imaging investigation. there is a number of frequently encountered and management pitfalls in the diagnosis of musculoskeletal tumours and limits in the diagnostic possibilities even for an experienced physicians. interpretation of an mri of a suspected neoplasm can be extremely difficult. this reveals how important an interdisciplinary approach, for the example the tumour board, in the diagnosis is. the final diagnostic skill is the adequate biopsy. biopsy is the key step in the diagnosis of musculoskeletal tumours. possible pitfalls are: the suspected lesion missed, the biopsy is done of the reactive zone of the tumour is and the sampling error. inadequate approach and surgical technique of the biopsy can complicate the tumour resection or even make a limb spearing procedure impossible and necessitate amputation to obtain adequate resection margins. this workout reviews various errors in the diagnosis of bone tumours, soft tissue sarcomas and metastasis and points out how important biopsy is. grundlagen. das Ö sophaguskarzinom wird häufig in einem stadium festgestellt, in dem lediglich palliation möglich ist. hier liegt der hauptfokus an der wiederherstellung der schluckfunktion, manchmal ist auch die abdichtung einer ösophagotrachealen und/oder -bronchialen fistel notwendig. ziel des eingeladenen vortrages ist es, einen Ü berblick über die endoskopischen palliationsmöglichkeiten zu geben. methodik. zusammenfassung publizierter erfahrungen und eigener daten bezüglich der endoskopischen palliation beim inoperablen Ö sophaguskarzinom (ablative und lumenerweiternde techniken, Ö sophagusstents, peg). ergebnisse. in ausarbeitung (eingeladener vortrag). schlussfolgerungen. bei der mehrzahl der patienten sollte eine weitgehend unabhängige schluckpalliation zu erreichen sein. probleme ergeben sich vor allem bei hohem tumorsitz und bei bestehender ösophagotrachealer oder -bronchialer fistel. implikation gefäßmedizin -gastroenterologie und chirurgie Österreichische gesellschaft für gefäßchirurgie, wien, austria die zunehmende spezialisierung und zum teil freiwillige isolation der fachgebiete der medizin, führt dazu, dass die auswirkungen der entwicklungen eines fachgebietes von den übrigen fächern nicht mehr wahrgenommen werden, sodass folgen einer therapie oder prophylaxe nicht richtig erkannt und damit auch nicht richtig behandelt werden. bedauerlicherweise führt die isolierung der fächer auch dazu, therapieempfehlungen ohne rücksichtnahme auf, nicht unmittelbar zugehörende organsysteme, zu erlassen. Ö konomische interessen des medizinalhandels fördern mitunter diese entwicklung. in dem referat wird versucht, einerseits auf die komplikationen, die sich in konsequenz moderner interventioneller endovaskulärer techniken oder sogenannter hybridtechniken ergeben können, hinzuweisen. mit diesen komplikationen sind gewöhnlich primär gastroenterologen und viszeralchirurgen konfrontiert. eine verzögerte richtige reaktion auf die ersten symptome verschlechtert die prognose der betroffenen patienten drastisch, daher ist es essenziell, die möglichen unerwünschten folgen endovaskulärer gefäßprothesen oder stents zu kennen. andererseits führen gelegentlich auch gastroenterologische und viszeralchirurgische interventionelle verfahren zu nachhaltigen gefäßchirurgischen problemen. ein gemeinsamer kongress ist die beste gelegenheit fachübergreifend konsensuell diese probleme zu diskutieren. im zweiten teil des referates wird die prophylaktische cardio-vasculäre gerinnungshemmende medikation kritisch betrachtet. der ü berbordenden zahl der publikationen, die sich mit den vorteilen der gerinnungshemmenden medikation befassen, steht nur eine verschwindend kleine zahl jener publikationen gegenü ber, die auf die adverse events, letalen blutungen und gefahren hinweisen, mit denen vor allem die gastroenterologen, chirurgen und gefäßchirurgen konfrontiert sind. kaum eine gastroenterolgische, oder chirurgische abteilung hat jedoch so eine große fallzahl prophylaktischmedikamentös bedingter blutungen, dass eine wissenschaftlich gewichtige arbeit entstehen kann. nach schätzungen gibt es jährlich weltweit . tote als folge der immer einschneidender in das gerinnungssystem eingreifenden prophylaktischen maßnahmen. wie gehen gastroenterologen und chirurgen mit patienten um, die einer dringenden intervention bedü rfen und wegen eines drug-eluting stents eine kombination dreier gerinnungshemmender medikamente einnehmen mü ssen, da es beim absetzen dieser therapie im ersten jahr nach stentimplantation mit großer wahrscheinlichkeit zu einem sofortverschluss und damit zu einem infarkt background. in , a survey answered by members of the austrian society of surgery revealed severe problems in the working conditions and a serious concern on trainee shortage in surgical disciplines. methods. our results are compared to those of a recent survey in the united states (mailed to all surgeons certified by the american board of surgery in surgery in , surgery in , surgery in , surgery in and respondents; presented at the american college of surgeons th annual clinical congress by kathrin m. troppmann). results. both surveys comprised more than twenty questions each; only selected examples can be given in this abstract. in the u.s. survey, the leading areas requiring improvement in surgeons' quality of life were reimbursement ( %), litigation ( %) and emergency calls ( %). in our survey, a clear majority worked - h per week or more, in the u.s. the average respondent worked a median of h a week, but regarded h per week as ideal. in our survey, only % were satisfied with payment, in the u.s. % were content with their reimbursement with respect to the total number of hours worked, but only % were satisfied in view of their unpredictable schedule and % when considering their responsibility for patients' health and lives. conclusions. although circumstances vary, the results of these two surveys show that many pressing questions are the same and must be tackled in order to overcome the prevailing problems in working conditions and the threat of trainee shortage/resident attrition in surgical disciplines. working models in surgery grundlagen. in den letzten jahren gelang es deutliche fortschritte in der personalisierten krebstherapie zu erzielen. praediktive marker wurden entdeckt die bei manchen patienten ein ansprechen auf eine bestimmte therapie erwarten lassen bzw. anderen patienten eine sinnlose, teure und belastende therapie ersparen. aber auch mit bildgebenden verfahren ist eine beurteilung des therapiansprechens möglich geworden. die auswirkungen dieser entwicklungen auf die onkologische chirurgie werden diskutiert. methodik. die wissenschaftliche literatur und ergebnisse entsprechender studien werden evaluiert und im kontext der eigenen erfahrungen beurteilt ergebnisse. es gibt zahlreiche ansätze um das therapieansprechen für den einzelnen patienten vorherzusagen. dies gilt für vor allem für systemische (neoadjuvante, adjuvante oder palliative) therapien aber auch für die strahlentherapie. die bedeutung für den rein chirurgischen teil des multidisziplinären managements dieser patienten ist allerdings limitiert. dabei sind unterschiedliche entscheidungen zu treffen, für patienten die mit primär unresektablen tumoren behandelt werden und resektabel werden, für patienten die unter einer neoadjuvanten therapie progredient sind und patienten mit bereits primär resektablen tumor die einen guten respose auf eine neoadjuvante therapie zeigen. schlussfolgerungen. die individualisierte onkologische therapie ist von eminenter bedeutung für die behandlung unserer patienten hinsichtlich vermeidung unnotwendiger nebenwirkungen und sinnloser und teurer therapien bzw. für das gesamte onkologischem management. für die chirurgie ergeben sich außer im rahmen der multidisziplinären planung derzeit noch wenig konsequenzen. anforderungen an die chirurgie durch individualisierung der therapie mittels genexpressionsanalyse beim mammakarzinom die chirurgie im zentralen case management bei der behandlung des mammakarzinoms steht neuen und wachsenden anforderungen gegenüber. die individualisierte therapie hat mit bestimmung von hormonrezeptoren und her /neu-status erst begonnen -in den letzten jahren haben techniken wie genexpressionsanalysen die erstellung einer individuellen und besseren prognose als mit klassischen klinisch-pathologischen parametern ermöglicht. genexpressionsanalysen werden in vielen institutionen bereits routinemäßig durchgefü hrt und wurden zum teil bereits in therapierichtlinien integriert (nccn þ asco-guidelines). die indikationen fü r diese tests werden jetzt zunehmend erweitert: während einerseits auch diejenigen kleinen tumoren, welche metastasieren können, z.b. durch das -genexpressionsprofil mammaprint identifiziert und einer notwendigen adjuvanten therapie zugefü hrt werden können, gibt es andererseits auch in hochrisikogruppen wie her -positiven karzinomen einen teil mit guter prognose, der vielleicht kei-ner chemotherapie bedarf. diese multigenassays erweisen sind nicht nur als prognostisch, sondern zunehmend auch als prädiktiv fü r das ansprechen auf (neo)adjuvante chemotherapie und wir wissen immer mehr, wer von welcher therapie profitiert, was essentiell sein wird fü r die notwendige kosteneindämmung und vermeidung von unnötigen nebenwirkungen. in der chirurgie verändert sich die logistik von diagnostik und therapie grundlegend. die schaffung strukturierter tumorbanken wird notwendig, wobei präoperative planung und operation die ersten wichtigen schritte darstellen. in hochrisikosituationen laut genexpressionsanalyse ist eine optimierte lokalbehandlung essentiell und bei hoher wahrscheinlichkeit auf pathologische komplettremission eine präzise prätherapeutische markierung des tumors. die resultate dieser genexpressionsanalysen bringen eine individualisierte adjuvante chemo-und/oder hormontherapie mit sich. jede(r) chirurgin muss sich mit möglichkeiten und grenzen dieser revolutionären techniken befassen, um weiterhin integrativ im tumorboard die besten entscheidungen fü r unsere patientinnen treffen zu können. background. peritoneal carcinomatosis defines tumor dissemination onto the peritoneal surface. hyperthermic intraperitoneal chemotherapy (hipec) after cytoreductive surgery seems becoming the standard treatment in peritoneal carcinomatosis avoiding the risk of tumor cell inoculation after surgery. subsequent adhesion of free tumor cells to human peritoneal mesothelial cells (hmcs) -the first line defense within the abdominal cavity -might lead to the formation of intraabdominal metastases. we investigated within an invitro-model the blockage of tumor cell adhesion by simvastatin (sim), an inhibitor of the -hydroxy- -methylglutaryl (hmg) coenzyme a reductase. methods. hmcs were isolated by enzymatic disaggregation from human omentum majus and expanded in vitro. confluent hmc-monolayers were incubated with fluorescent labelled tumor cells in the presence or absence of sim. in time course experiments, adhesion of skov- (ovarian tumor) and ht- (colorectal tumor) cells to hmcs were determined either by fluorescence microscopy or reader. results. simvastatin reduced the number of adherent skov- and ht cells to hmcs significantly. at concentrations ranging from . to mm, simvastatin reduced the adherence of tumor cells to hmcs up to %. conclusions. our findings suggest that simvastatin might be a novel therapeutic approach in order to reduce the risk of peritoneal metastasis due to tumor cell dissemination during cytoreductive surgery. further investigations also have to include the mechanism on the molecular level. einleitung her- /neu (c-erbb ) Ü berexpression ist assoziiert mit einem höheren angiogenetischen potential und einer erhöhten expression des vaskulären wachstumsfaktors vegf beim mammakarzinom. vorklinische studien haben gezeigt, dass her- /neu eventuell eine zusätzliche rolle bei der regulierung der expression des lymphatischen wachstumsfaktors (vegf-c) und damit bei der lymphatischen metastasierung spielt. sinn dieser studie, war es diesen zusammenhang zwischen der her- /neu expression, der expression des lymphatischen wachstumsfaktors vegf-c, dem ausmaß des lymphangiogenetischen potentials (lmvd) sowie der spezifischen lymphogenen invasion (lvi) in einem kollektiv von lymphknoten-positiven mammakarzinomen zu ü berprü fen. methodik immunhistochemie und insitu-hybridisierung fü r vegf-c, den lymphatischen endothelzellmarker podoplanin sowie fü r her- /neu wurden durchgefü hrt. weiters wurde eine her- /neu fish analyse bei allen karzinompräparaten angewendet. ergebnisse lmvd korrelierte signifikant mit lvi (p . ) und der vegf-c expression (p ¼ . ). weiters konnte eine positive, statistisch signifikante korrelation zwischen der her- /neu-und vegf-c proteinexpression gefunden werden (p ¼ . ). patienten, deren tumore eine höhere her- /neu expression aufwiesen, exprimierten auch signifikant mehr vegf-c und wiesen ein höheres lymphangiogenetisches potential (lmvd) auf. diskussion unsere daten geben den ersten hinweis auf einen klinisch relevanten zusammenhang zwischen vegf-c und her- /neu beim lymphknotenpositiven brustkrebs und damit einen direkten zusammenhang zwischen dem ausmaß einer her- /neu expression und dem lymphatischen metastasierungspotentials beim mammakarzinom ab. diese daten unterstü tzen die bedeutung des her- /neus als konduktor eines aggressiven phenotyps beim mammakarzinom und liefern mögliche hinweise auf die wirkungsweise assoziierter therapien wie dem trastuzumab (herceptin). background. gerd affects up to % of the population in the western world. despite morphological changes in the esophagus, gerd causes significant impairment of the quality of life (qol). we aimed to identify the qol in patients with gerd and to assess the midterm effect of treatment on the qol-scores. in addition we aimed to compare data obtained by esophageal function tests (eft) between the two groups and with pre-interventional qol-scores. methods. ninty-seven patients with gerd symptoms underwent esophageal manometry and h ph-monitoring or combined ph-multichannel-intraluminal-impedance. the patients received either medical or surgical treatment. qol was assessed using the german version of the sf . results. significantly lower pre-interventional sf scores were found for of the dimensions compared with the published normative data for the general us population. conservative treatment could not improve patients qol whereas surgery significantly improved the score for bodily pain. after year significantly better scores for dimensions were found in the surgical group. for of the chosen eft-categories the surgical group showed significantly worse values. when comparing sf scores with data obtained by eft no significant differences in the qol between patients with normal values and those with abnormal findings were found. conclusions. qol represents a reliable tool for assessment of severity of disease and outcome following therapy in persons with gerd. regarding patients qol surgical treatment seems superior to conservative treatment. der hiatus Ösophageuswie groß ist er wirklich? ergebnisse. es wurden männer und frauen obduziert. mittleres alter: j (range - j). gewicht: kg (range - kg), größe , m (range , m), bmi , (range , ) . thoraxumfang , m (range , m) . die mittlere hsa betrug , cm (range , - , cm ). bei allen leichen war die z-linie intraabdominal, der abstand zum his winkel betrug im mittel cm (range , - , cm) . der linke und rechte zwerchfellschenkel war bei allen exakt gleich lang, im mittel , cm (range , - , cm), der querdurchmesser (segment der Ö ffnung) im mittel , cm (range , - , cm). schlussfolgerungen. der durchschnittliche hiatusflächeninhalt beträgt , cm . er ist direkt proportional dem thoraxumfang und unabhängig von größe, gewicht, bmi und geschlecht. background. in patients with gastroesophageal reflux disease (gerd) esophageal acid exposure is assessed with a ph probe placed cm above the manometric lower esophageal sphincter (les). we compared acid exposure within and cm above the les. methods. between / and / , patients with gerd symptoms ( . % females; age . ae years) underwent multilevel ph monitoring ( days off antisecretory therapy) with a catheter including ph probes cm above (level þ ), at (level ) and . cm distal (level À . ) to the proximal les-limit; % time ph < . ( cm above les) < . % was considered normal. les length was > cm in all patients. results. cm above the les, ( . %) and ( . %) patients (no age difference, p ¼ . ) had normal and abnormal acid exposure, respectively. more women had normal acid exposure ( % vs. . %; p ¼ . ). in those with normal acid exposure, time ph conclusions. acid exposure is maximal within the les and may explain why reflux is missed by probe placement cm above the les. normative values or multilevel ph monitoring from asymptomatic persons are required. stellenwert der ösophagealen kombinierten h-impedanz-ph-metrie zur refluxdetektion bei ph-metrie negativen patienten grundlagen. die ösophageale -stunden-ph-metrie gilt als gold-standard zur abklärung der gastro-ösophagealen refluxkrankheit (gerd). sie vermag allerdings nur saure refluxe zu detektieren (ph < ). neuerdings wird die diagnostik zunehmend um die ösophageale kombinierte h-impedanz-ph-metrie erweitert, mit der auch schwach saure oder nicht saure refluxe registrierbar sind. wieviele refluxpatienten bisher mit der alleinigen -stunden-ph-metrie unentdeckt blieben, ist unklar und soll durch die vorliegende studie berechnet werden. methodik. retrospektive analyse aller patienten, bei welchen zur gerd-abklärung u.a. eine ösophageale kombinierte stunden impedanz-ph-metrie durchgeführt wurde. verwendet wurde ein comfortec + mii/ph katheter (fa. sandhill scientific,inc; nr. zan-bs- ) mit einem ph-sensor bei cm, sowie ringelektroden bei drei, sieben, neun, fünfzehn und siebzehn zentimetern von der sondenspitze. vor platzierung der impedanzsonde wurde eine Ö sophagusmanometrie durchgeführt, u.a. zur längen-und lagebestimmeng des les. die platzierung des ph-sensors erfolgte dann cm über dem oberrand des les. die auswertung erfolgte computerunterstützt (,,bioview + '', version z - ; sandhill scientific, inc.) die messdauer betrug jeweils stunden. ergebnisse. es wurden kombinierte stunden impedanz-ph-metrien durchgeführt. bei patienten ( , %) lag der demeester-score im normbereich (< , ). dreizehn dieser patienten mit physiologischem demeester-score zeigten eine pathologische anzahl von > refluxen in stunden ( , %; das entspricht , % der gesamten patientenpopulation). d.h., bei , % der patienten wurde eine pathologische refluxaktivität durch eine alleinige h-ph-metrie nicht erfasst. schlussfolgerungen. bei vorliegen einer unauffälligen ösophagealen h-ph metrie sollte, wenn verfü gbar, noch eine ösophageale h-impedanzmessung angeschlossen werden, um weitere , % der patienten vor einer möglichen fehldiagnose zu bewahren. reflux characteristics and symptoms off and on proton pump inhibitor medication: an impedance-ph-study in patients with gastroesopheal reflux disease background. the influence of proton pump inhibitor (ppi) medication on results of multichannel intraluminal impedance and ph monitoring (mii-ph) is controversial. aim of this study was to investigate the effect of esomeprazole mg bid on mii-ph results. methods. fifty patients ( f, . a, range - a) with heartburn or regurgitation underwent h mii-ph off (ppi paused for days) and on ppi (esomeprazole mg bid for days). patients recorded symptoms, meals and recumbent periods. tracings were automatically analyzed and manually reviewed. variables for comparison were number of acid and nonacid refluxes, heartburn and regurgitation episodes and symptom to reflux correlation by symptom index (si). results. see tables and . conclusions. esomeprazole mg bid resulted in significantly lower numbers of acid but not total number of refluxes. peristant regurgitation on medication was more frequent than persistant heartburn. on ppi reflux monitoring has a lower diag-nostic yield, but contains more clinically useful information in patients with symptoms persisting on ppi medication. the incidence of gastroesophageal reflux after transthoracic esophagocardiomyotomy without fundoplication: a long term follow-up background. evaluation of the long term results of heller's myotomy performed over a lateral thoracotomy without additional fundoplication. methods. fourty patients ( males, females; mean age . years; range: - years) were operated between and . preoperative evaluation included clinical scoring of symptoms, esophagogram, endoscopy, manometry and -hours ph-metry. at the follow-up investigation, the preoperative evaluation was repeated in all patients, adding a histological workup of the distal esophageal mucosa. the mean duration of follow-up after surgery was . years, ranging from to years. results. the clinical scores improved significantly: excellent relief from dysphagia was present in %, little or no regurgitation was found in %, little or no retrosternal spasms were reported by % of the patients. esophagogram showed an overall esophageal dilatation in all patients but no significant obstruction at the esophagogastric junction. endoscopically, . % had candida-esophagitis, % showed signs of a gerd i, . % had a macroscopically insuspect esophageal mucosa. histologically, % showed a mild chronic inflammation. manometry demonstrated distinct hypomotility of the esophagus in all cases, yet no elevated pressure of the lower sphincter; ph-metry showed moderate reflux in %. conclusions. transthoracic cardiomyotomy is a valid method for the treatment of achalasia, but it will not improve the esophageal motility, which slowly deterioriates in these cases. the patient's subjective assessment of the postoperative result was positive in the majority of cases. although fundoplication was not done in any of these patients, none of them showed signs of clinically relevant reflux. methods. review on the dilated end stage esophagus. results. anatomy and biopsy studies in gerd patients revealed the presence of cle within the proximal portion of the endoscopically visible gastric type folds over a length ranging from < . to . cm, where cle (cardiac mucosa ae intestinal metaplasia, oxyntocardiac mucosa) transitioned towards the oxyntic mucosa of the proximal stomach, irrespective of the presence or absence of endoscopically visible cle within the tubular esophagus. fusion of histopathology and function test data indicated that this condition results from a mechanism involving gastric distention induced damage of the lower esophageal sphincter causing reflux, damage and columnar metaplasia with proximal dislocation of the squamocolumnar junction. loss of sphincter function causes gastric type folding of the cle thus giving it a gastric type appearance during endoscopy. this is the dilated end stage esophagus, which is frequently taken for hiatal hernia during endoscopy and may cause the formation of the adenocarcinoma of the cardia (siewert type ii). conclusions. in gerd patients, endoscopy without biopsy sampling of the proximal portion of the endoscopically visible gastric type folds misses the dilated end stage esophagus. differentiation of the dilated end stage esophagus from proximal stomach (hernia) requires the histopathology of biopsies. background. differences in the prevalence of the morphologic manifestations of gastroesophageal reflux disease (gerd), columnar lined esophagus (cle) and barrett's esophagus (be; . % annual cancer risk) in those with and without gerd symptoms is not known. methods. esophagogastroduodenoscopy (egd) with multi level biopsies from the esophagogastric junction ( . cm, . cm above, at and . cm, . cm distal to the level of the rise of the gastric folds) was prospectively conducted in asymptomatic patients (controls; n ¼ ; . %) and gerd patients (n ¼ ; . %); aged between - years ( ae . ) and . % females. columnar lining above the level of the rise of the gastric folds was categorized as endoscopically visible cle (clev). histopathology of cle included cardiac mucosa ae intestinal metaplasia (¼be) and oxntocardiac mucosa; squamous epithelium and oxyntic mucosa (om) were considered as normal lining of the esophagus and the proximal stomach. prevalence of clev and histopathology proven cle was compared between controls and gerd patients. results. there were no significant age-, gender-differences between the groups (p > . ). prevalence of clev (p ¼ . ), histopathology proven cle (p > . ), cle length (p ¼ . ) and intestinal metaplasia (controls: . %; gerd: . %; p ¼ . ) was indifferent between controls and gerd patients. dysplasia and cancer have not been assessed. conclusions. the prevalence of cle and barrett's esophagus was comparable in patients with and without gerd symptoms. our findings may justify to consider screening endoscopy for barrett's esophagus. the aim was to evaluate long-term results of revascularization in significant coronary artery disease (cav). the group contained patients ( % male). the mean htx age was ae yrs (range from to yrs). the mean donor age was ae years. the mean follow-up time after revascularization was ae months. the cumulative incidence of significant focal cav was %. the mean time to development of significant focal cav was ae months (range from months to years). a total of lesions were treated. balloon angioplasty was performed times ( . %). a total of ( . %) bare metal stents (bms) and ( . %) drug eluting stents (des) were implanted. five patients underwent coronary bypass graft surgery. forty four percent of restenosis manifested in the first months after intervention. restenosis was diagnosed during the long-term follow-up time in . % lad, . % in cx and . % in rca stents. within the first months after intervention the mean restenosis rate in bare metal stents counted % and in des %. after months . % of stented lesions remained patent ( . % bms vs. . % des). diabetes mellitus turned out to be the only independent predictor for early restenosis. the cumulative incidence of cav is low. lad is affected by the highest rate of restenosis. intervention of focal lesions in cav patients is feasible and effective as it is in non-transplant coronary artery disease. a trend towards improved patency with des could be observed. background. this study was designed to determine the posttransplant outcome of elective, lvad and urgent patients undergoing cardiac transplantation. methods. the post-transplant outcome of elective, lvad (debakey, duraheart, heartware lvad) and urgent patients (hu) undergoing cardiac transplantation between and was retrospectively analyzed. survival, incidence of rejection, severe infections, cmv-disease and graft vasculopathy (cav) were compared. all patients received immunosuppressive therapy consisting of thymoglobuline, tac/cyclo þ mmf/evl and low dose steroids. kaplan-meier analysis was performed to test differences between the groups. results. patients in the three groups were comparable with regard to primary disease. urgent patients were younger ( ae yrs) than elective ( ae yrs) and lvad ( ae yrs) patients (p < . ). actuarial survival of elective ( %, %, %), lvad ( %, %, %) and hu ( %, %, %) patients was comparable , and years post-transplant (log-rank . ). furthermore, freedom from rejection episodes (elective: %, %, %, lvad: %, %, %, hu: %, %, %; log-rank . ), severe infections (elective: %, %, %, lvad: %, %, , hu: %, %, %; log-rank . ), cmv disease (elective: %, %, %, lvad: %, %, %, hu: %, %, %; log-rank . ) and cav (elective: %, %, %, lvad: %, %, %, hu: %, %, %; log-rank . ) was comparable between elective, lvad and hu patients , , and years posttransplant. conclusions. despite the increased risk of lvad and urgent patients post-transplant outcome is excellent and compares to elective patients. the low incidence of rejections and cav underlines the importance of induction therapy and individualized immunosuppression. background. pgd is a major cause of morbidity and death early after cardiac transplantation. extracorporeal membrane oxygenation (ecmo) is a mechanical support system to support hemodynamics in case of acute heart failure. the aim of this study was to evaluate ecmo as support system for pgd. methods. between and out of ( %) patients, who underwent cardiac transplantation, experienced pgd and received ecmo support. survival, rate of recovery and complications were analysed. results. overall survival was % after weeks follow up. patients ( . %) could be weaned from ecmo and in-hospital survival of these patients was %. duration of ecmo support was days. early experience ( ) ( ) ( ) ( ) with ecmo was significantly worse (survival: % vs. %; p ¼ . ) than later experience ( - ). overall complication rate was %. most frequent complications were bleeding (n ¼ , %; cannulation area (n ¼ ) and hematothorax (n ¼ )) and infections (n ¼ , %), (others: schreib eventuell alle in klammer nach 'others' auf und die gesamtzahl und % dazu, oder ganz weglassen) time of ecmo implantation had no impact on patient survival (problems during weaning off bypass: %; inability to wean off bypass: %, sudden pgd in icu: %; p ¼ . ) conclusions. ecmo is a valuable tool to overcome pgd after cardiac transplantation. bigger experience improves results significantly. however, complications can occur and proper management is of uttermost importance. the aim of the study was to evaluate the pattern of brain natriuretic peptide (bnp) concentration in heart transplant (htx) recipients and its relation to the degree of significant transplant coronary artery disease (cav background. minimally invasive follicular thyroid carcinoma (miftc) is defined to be an encapsulated tumor demonstrating limited unequivocal vascular and/or capsular invasion. considering the indolent behavior of these tumors the necessity of a radical treatment with routine lymph node dissection is questionable. methods. we evaluated our data in periods of time focusing on the necessity of lymph node dissection in miftc: in the first period from to our pathologists reviewed all fol-licular thyroid carcinomas (ftc) and identified those tumors appropriate to the criteria used for diagnoses of miftc. the patients were followed for . years on average. in the second period from to we observed all ftcs demonstrating lymph node involvement. results. in the first group of patients affected with miftc no lymph node metastases could be detected neither at time of diagnosis nor during follow-up time. no distant metastases or recurrent diseases were observed. the few tumors of the second period inducing lymph node metastases were all of widely invasive pattern of growth, none of them was minimally invasive. conclusions. lymph node involvement is generally rare in ftc. the absence of lymph node metastases in our series suggests no need for lymphadenectomy in miftc. we present an unusual case of a metastatic thyroid tumor, of which the primary cancer was an infiltrative high grade transitional cell carcinoma of the urinary bladder. the time from the diagnosis of primary tumor to metastasis was months. the appearance of the thyroid metastasis was like a primary thyroid disease. diagnosis of thyroid metastasis as a consequence of urinary bladder carcinoma was confirmed by intraoperative biopsy, histopathological and immunohistochemical findings. the treatment consisted of radical thyroidectomy in addition to systemic adjuvant chemotherapy. report after -year follow up. diagnosis of hashimoto's thyroiditis: discrepancy between preoperative antitpo-autoantibodies and histological grading in thyroid tissue methodik. bei konsekutiven weiblichen patienten wurden vor der schilddrüsenoperation prospektiv präoperative anti-tpo-bestimmungen durchgeführt und bei der histologischen aufarbeitung speziell auf die bewertung der lymphozytären infiltration und der graduierung (grad - ) geachtet. ergebnisse. von ( , %) patienten wiesen präoperativ erhöhte antitpo-spiegel auf, von ( , %) histologische zeichen einer thyreoiditis. bei den antitpo-positiven patienten wiesen grad , grad , grad und grad auf, zeigten keine lymphozytäre infiltration. bei jenen patienten mit his-tologischen entzündungszeichen ohne pathologischem antitpo-spiegel wurde grad in , grad in und grad in fällen gefunden, kein patient wies grad auf. der schweregrad der thyreoiditis zeigte eine signifikante positive korrelation (p < , ; r ¼ , ) mit der höhe der antitpo-spiegel. schlussfolgerungen. nur % der histologisch verifizierten thyreoiditis-patienten konnten präoperativ durch serologische antitpo-bestimmung erkannt werden. die daten zeigen, dass speziell die milden verlaufsformen der thyreoiditis hashimoto serologisch nicht verlässlich zu diagnostizieren sind. late onset paralysis of the recurrent laryngeal nerve after thyroidectomya rare phenomenon grundlagen. nach postoperativ regulärer stimmbandfunktion kann es in seltenen fällen auch erst im spätpostoperativen verlauf zum auftreten einer recurrensparese kommen. da dieses phänomen in der literatur nur kasuistisch beschrieben ist, wird hier über eine patientenserie berichtet. methodik. vor und nach schilddrüsenoperation wird standardisiert eine laryngologische untersuchung an der eigenen hno-ambulanz durchgeführt. jene patientin, die unsere abteilung -nach unauffälligem postoperativen hno-befund-wegen spätpostoperativ einsetzender stimmstörung aufsuchen, wurden analysiert. ergebnisse background. objective cosmetic analyses are important to reproducibly evaluate the cosmetic outcome after breast surgery and radiotherapy. so far, only subjective irreproducible scores have been used such as the harris scale. we have developed an objective tool to reproducible analyse digital pictures, the ''breast analysing tool'' (bat). the aim of this study was to compare subjective with objective breast cosmesis scores. methods. digital pictures (frontal view) from breast cancer patients ( from porto and from vienna) after breast conserving therapy and radiotherapy were analyzed with the above described software. all calculations were transferred to a breast symmetry index (bsi) ranging between (excellent cosm-esis) and (bad cosmesis). the same pictures were analyzed by experts (surgeons) and non-experts (students) using the harris scale (subjective score from to ; excellent, good, fair and poor cosmesis). these subjective scores were correlated with the objective scores from the bat software using the pearson correlation test. results. all subjective scores significantly (p < . ) correlated with the bat score with a pearson correlation coefficient of . (non-experts), . (experts) and . (overall). conclusion: the technical modifications of the bat-software have lead to the achievement of accurate and reliable results. this qualifies the use of bat in prospective and retrospective trials on breast cosmesis. offen-chirurgische intervention mit hohem komplikationspotential und langem krankenhausaufenthalt zu vermeiden. local hyperthermia combined with external radiation therapy as anti cancertreatment in recurrent breast cancer hyperthermia combined with radiation therapy has been confirmed in several randomised studies to be more effective than radiation therapy alone in various cancers. we evaluated the potential synergistic effect of local hyperthermia and conventional external beam radiation. we used a wave-guide applicator (bsd) with a typical emitting diameter of cm and a frequency of - mhz with a therapeutic depth of cm. hyperthermia was performed for min for at total of six sessions, twice weekly, the temperature was exactly calibrated between and c. immediately after hyperthermia external radiation with gy was applied in a daily fraction of . gy. no major side effects were observed during hyperthermia. patients were treated and followed for during - months. ten of the tumours responded to the treatment ( cr, pr), two patients died of distant metastases within one year. local hyperthermia combined with conventional radiation therapy may be useful tool to promote tumor regression and the local recurrence-free survival in cases of recurrance breast cancer. we conclude that hyperthermia and radiation therapy is effective in treatment breast cancer treatment and should be used in selected cancer patients. sentinel-node biopsy und lymphatic mapping von malignen tumoren mittels eines fluoreszenz-tracers (icg) the potential of plasma proteomics in predicting response to neoadjuvant chemotherapy in breast cancer patients using d-dige resistance to chemotherapy is still a major problem in oncology. especially for hormone receptor negative tumours there are no biomarkers available which identify patients who will not profit from treatment. such a selection would allow for a switch to another more effective chemotherapeutic regimen for these patients. chemotherapy not only leads to the destruction of tumour cells, but also affects actively proliferating healthy tissues as well as the immune system. as shown in another abstract of our group, neoadjuvant chemotherapy of breast cancer patients with epirubicin and docetaxel leads to expression changes of distinct plasma proteins within days. based on these results, we investigated whether such changes can be correlated with the final response to chemotherapeutic treatment assessed weeks later. therefore, plasma was prepared from breast cancer patients before and - days after receiving the first course of neoadjuvant chemotherapy. after the removal of major abundant plasma proteins by affinity chromatography, proteomic analysis was performed using d-dige. eight out of protein spots showed a higher chemotherapy-induced increase in expression (p < . ) in responders (n ¼ ) compared to non-responders (n ¼ ), whereas one protein behaved vice versa. these proteins might be useful in future for an early identification of those patients who will not benefit from this kind of treatment. for further investigation these protein spots will be identified by mass spectrometry and for verification of the d-dige results quantitative d western blots are planned. background. demeester's composite score (cs) is a convenient parameter to assess gastroesophageal reflux activity by h ph-monitoring. ingestion of acidic foods has been reported to compromise the reliability of this parameter. aim of this study was to evaluate the impact of meals on cs. methods. in a consecutive ph-studies exclusion of meals resulted in cs values . higher to . lower than including meals. the range of differences (cs . - . ) was used as a reference for selection of risk group to cross the cut-off value when analyzed without meals. results. of patients with clinical signs of gerd who underwent ph monitoring during one year, had a cs . - . and their studies were reanalyzed. median cs was . ( . - . ) including and . ( . - . ) excluding meals. in eleven patients the cut-off was crossed depending on analysis type. multivariate logistic regression including gender, oesophageal motility, recumbent periods, meals' duration and number of acidic foods/beverages were performed to identify risk factors for changing cs interpretation. prolonged meal duration significantly contributed to changing from normal to abnormal score (or . ; % ci . - . , p ¼ . ). the number of acidic foods consumed significantly raised the probability to change from abnormal to normal score when meal periods were excluded (or . ; % ci . - . , p ¼ . ). conclusions. the exclusion of meal periods from h phmonitoring rarely resulted in a different interpretation of cs. ingestion of acidic foods/beverages and long meal periods were identified as counteracting independent risk factors for crossing the cut-off value. colokutane fistel nach peg-anlage mittels introducer-technik mit gastropexie background. with a part of percent of all malignant gastrointestinal lesions and an incidence of - new diseases referring to persons, gastrointestinal stromal tumors (gist) are rather rare. nevertheless the number of cases is increasing, belonging to better endoscopic and radiological methods, but also because of the better knowledgement in histopathologic and moleculargenetic examinations. methods. in a group of two surgeons and two oncologists, started to discuss about a national registration of patients suffering from gist in austria. criterions for registration were discussed and fixed up in a sheet. also an informed consent for the patients registration was conceived. our concept, aims and visions were presented at the commission of ethics in lower austria, and a positive votum was given at the end of . so we started our official work at the first of january . results. as well the oncologist team as the surgeon group contacted as much centres as possible by phone call or by letter, inviting them to support the registry by bringing in their data. in a short time about centres and also the contact persons were registered. in a second announcement we want to enlarge this number in order to get better results. conclusions. gist registry was started to find out incidence of disease, but also the way of diagnosis and therapy in patients in austria. do we have similar strategies in the (neo-) adjuvant setting and in treating metastatic ore advanced disease or not? colonic retrosternal esophagoplasty in young children with pure esophageal atresia r. kovalskyy , a. kuzyk , o. leniv , i. avramenko lviv regional children hospital ''ohmatdyt'', department of pediatric surgery, lviv, ukraine; department of pediatric surgery, lviv national medical university, lviv, ukraine background. pure esophageal atresia is observed in - % of the newborn with the mentioned pathology. there is still a search for the optimal problem solving of the esophagus patency correction in such patients. this concerns both the choice of methods and the age of the children. methods. since till colonic retrosternal esophagoplasty have been done. the newborns weight was - g. children-born prematurely. newborns had pneumonia. diastases between the esophagus segments equaled - cm. at the moment of operation the children were of - weeks old. body weight was - g. during the first three weeks the newborns had the distal esophagostomy in the necks and gastrostomy. when the weight was stably increasing, the patients had a laparotomy, the segment of colon was chosen for transplantation. usually it was a colon transversum and a part of colon descendens with a. colica sinistra. transplant was put behind the stomach and located retrosternally in anterior mediastinum. proximal transplant ending was sewed in the anterior wall of stomach, distal-was delivered to the neck next to esophagostoma, in - weeks-the anastomosis with esophagus. results. four patients had an anastomotic breakdown in the neck. two of them had the repeated cervical anastomosis, the others had fistula, which closed by itself. the children had a good passage in the transplant. conclusions. to treat the children with pure esophageal atresia without fistula it is possible to use successfully colonic retrosternal esophagoplasty in the early age. background. gastroesophageal reflux disease is associated with columnar lined esophagus (cle). we aim to summarize the novel developments regarding our understanding of cle. methods. review of the recent literature ( - ) on cle. results. gastroesophageal reflux causes damage and columnar metaplasia of the squamous mucosa of the esophagus resulting in the formation of columnar lined esophagus (cle). recent evidence indicates that cle results from refluxinduced genetic changes within the stem cells of the esophageal epithelium inducing the switch from squamous to cardiac mucosa (cm) mediated via bone morphogenetic protein . cm may progress towards oxyntocardiac mucosa (ocm) by inclusion of parietal cells (mediated via sonic hedge hog, ssh, promoting parietal cell maturation) or to intestinal metaplasia (im ¼ barrett's esophagus) by inclusion of goblet cells (mediated via cdx ). shh and cdx pathway is stimulated by acidic and alkaline ph, respectively. thus the proximal location of intestinal metaplasia within a given cle segment is considered to reflect the ph gradient with acidic and alkaline ph in the distal and proximal cle segment, respectively. while shh mediated ocm does not progress towards intestinal metaplasia and cancer, the cdx pathway favors progression of intestinal metaplasia towards dysplasia and cancer. expression of cdx within cle is reduced to control values following elimination of reflux after an effective anti reflux surgery. conclusions. cle results from milieu-dependent esophageal epithelial stem cell changes activated during gastroesophageal reflux. these findings are suggested to explain why antireflux surgery favors regression of barrett's esophagus. successful interdisciplinary management of simultaneous mesenchymal tumor manifestations with synchronous resectionrare and challenging combination of a gastric ''high-risk'' gist and retroperitoneal liposarcoma methodik. anhand eines außergewöhnlichen exemplarischen fallberichtes wird eine -jährige patientin mit einem gist an der kleinen magenkurvatur und einem monströsen retroperitonealem liposarkom links-abdominal mit infiltration der linken niere dargestellt. der gist wurde durch eine tangentiale magenwandteilresektion und das liposarkom in toto zusammen mit der linken niere aufgrund der tumorinfiltration entfernt. im anschluss folgte eine kombinierte radiochemotherapie für das liposarkom. ergebnisse. beide tumoren wurden weitestgehend komplett entfernt. der technisch schwierige eingriff sowie der postoperative verlauf gestalteten sich komplikationslos. histologisch wurde beim magenwandtumor die r -resektion bestätigt und dieser aufgrund seiner größe( , cm durchmesser) und einer mitotischen aktivität( mitosen/ hpf) als ,,high-risk''-gist eingeordnet. die neoplasie des linken retroperitoneums wurde als myofibroblastisch-dedifferenziertes liposarkom (grad nach coindre) mit dem tumorstadium pt b g r im sinne eines unabhängigen mesenchymalen zweitmalignoms klassifiziert und damit ein metastasierungsgeschehen ausschloss. bei histologisch gesicherter r -resektion des liposarkoms erfolgten postoperativ eine additive radiochemotherapie nach vaia-protokoll (adriamycin, ifosfamid, vincristin) und eine bestrahlung des retroperitonealen tumorbettes von , gy gesamtdosis. in der radioonkologischen verlaufskontrolle nach jahren zeigte sich kein anhalt für ein tumorrezidiv. schlussfolgerungen. die komplette tumorresektion stellt die therapie der wahl bei mesenchymalen tumoren dar (ziel: r ). je nach histologischer tumorklassifikation und -sensitivität bzw. resektionsstatus ist eine nachfolgende radiatio und oder chemotherapie erforderlich, was im vorliegenden fall trotz r -resektion des liposarkoms und ,,high risk''-gist eine bisher jährige tumorfreie Ü berlebenszeit ermöglichte. schlüsselwörter. gist, liposarkom, radiatio, vaia-protokoll. surgical aspects of pneumatosis cystoides intestinalis: report of two cases e. schröpfer, l. scheele, c. wichelmann, c. t. germer, t. meyer univ.-klinik würzburg, würzburg, germany pneumatosis cystoides intestinalis (pci) is a rare disease usually caused by an underlying condition. it is defined as air filled cysts within the wall of the gastrointestinal tract. the true incidence is unknown, pci is often an incidental finding on radiographs. we report on two different cases of pneumatosis cystoides intestinalis. both patients underwent surgical treatment in our department. the first patient, a year old white european girl, with down syndrome and leucopenia due to chemotherapy for acute lymphatic leukemia was admitted to our surgical department with acute septic conditions and air filled cysts in the intestine wall. explorative laparotomy revealed acute ischemia of the right colon and resection of the affected intestine was performed. after a short interval in the intensive care unit the patient was referred to the pediatric department. the second patient, a -year old, white european man with urothelial carcinoma of the bladder and carcinoma of the prostate underwent radical cysto-prostatectomy in the department of urology. after several operations due to obstruction of the right common iliac artery the patient presented an acute abdomen and computer tomography revealed pneumatosis intestinalis and ileus of the colon. only adhesiolysis was performed and the patient was discharged into rehabilitation a few weeks after. patients with the radiographic diagnosis of pci should receive a thorough history and physical examination. we discuss the surgical management of pci according to literature and developed an algorithm. gastrointestinale stromatumore (gist): modifizierte therapeutische strategien durch pet/ct background. the liver is a frequent site for metastases of colorectal cancer. due to new chemotherapy agents, strategies and targeted agents response rates and respectability rates have improved. moreover, some patients with neoadjuvant chemotherapy have complete response of the liver tumors and the lesions are no longer visible by preoperative ct-scan or intraoperatively. methods. we report a case of a years old female who underwent right hemicolectomy for caecal cancer in an outside hospital. owing to synchronous liver metastasis in segment iv b neoadjuvant chemotherapy was administered. follow-up ctscan revealed complete response and no tumor was visible in the liver. patient was then referred to our center for further investigations. results. ct-scan and mri showed no visible tumor. with the aid of the ct-scan before neoadjuvant chemotherapy the tumor was measured out and preoperatively a ct-guided hook-wire was placed at the position of the presumptive lesion. afterwards the patient was brought into the operating room and an atypical liver segment resection around the pike of the wire was performed. the operative and postoperative course was uneventful. the histologic specimen was tumor-free also presenting complete pathologic response. after close follow-up of months the patient is free of tumor. conclusions. our approach with the ct-guided wire marking could potentially be a way to remove colorectal liver metastases with complete response to neoadjuvant chemotherapy. to leave lesions in place which are not visible could not be the goal, only a curative resection which removes all metastases should be the aim. rechtsseitiger oberbauchschmerz -ein klarer fall? background. breast cancer metastases to the liver are associated with a poor prognosis. in contrast to colorectal metastases, there are as yet no established guidelines for liver surgery for breast cancer secondaries. methods. our retrospective study compared patients with an average age of . years (range - years) who underwent hepatic resection. both solitary and multiple liver metastases that seemed to be resectable by r were treated. six patients underwent chemotherapy before and patients after the liver resection. nine women received hormone treatment, before and after liver surgery. results. we performed major (hemihepatectomy or more than segments of the liver) and minor (less than segments) resections. the median interval between primary operation and liver resection was . years (range months to years). fifty percent of the women had a solitary metastasis with a median size of cm. there were liver secondaries in both lobes in patients and in one lobe in . no patient died after liver resection. five of the women had a liver recurrence. the -and -year survival rates were calculated as % and %, respectively. conclusions. for selected patients with liver secondaries from breast cancer, surgical resection in combination with chemotherapy can be a safe option with low morbidity and mortality. ergebnisse. innerhalb der neoadjuvanten avastin therapie stiegen tems und cecs signifikant an (p ¼ , bzw. p ¼ , ). ebenso beobachteten wir im vegf verlauf einen rapiden anstieg (p ¼ , ), der einem deutlichen cea abfall gegenüberstand. in der adjuvanten therapie war wiederum ein vergleichbarer vegf anstieg (p ¼ , ) zu beobachten, wohingegen sich sowohl cecs und tems als auch cea kaum veränderten. schlussfolgerungen. der vegf anstieg unter neoadjuvanter und adjuvanter therapie scheint den einfluss von avastin auf die systemische angiogenesebalance widerzuspiegeln. dies steht dem ausschließlich in der neoadjuvanten therapie auftretenden anstieg der cecs und tems gegenüber, welcher nach tumorresektion nicht mehr zu beobachten ist. die vorliegenden daten deuten darauf hin, dass die angiogenese assoziierten zellpopulationen mit der tumormasse in zusammenhang stehen, sich unter therapie signifikant verändern und daher ein potenzial im monitoring der kombinierten avastin-chemotherapie besitzen. rescue approach for unexpected portal vein thrombosis during orthotopic liver transplantation d. kniepeiss, h. müller, d. wagner, e. jakoby, s. schaffellner, f. iberer, k. tscheliessnigg thanks to innovative surgical techniques, portal venous thrombosis no longer is a contraindication for liver transplantation. in case of extensive portal and mesenteric venous thrombosis, cavoportal hemitransposition has been described as a salvage technique but experience is still limited and there is a high risk of serious complications. we present an alternative management of portal vein thrombosis during liver transplantation. a -year-old man with liver cirrhosis underwent liver transplantation. although preoperative doppler ultrasound showed portal perfusion, severe portal vein thrombosis was found during transplantation. obviously, the flow of one variceal vein located cranial to the hepatic artery was interpreted as portal vein flow in the pretransplant ultrasound examination. as a salvage measure, the variceal collateral vein was used for portal end-to-end anastomosis. postoperatively, primary graft function was acceptable and improved day by day. moderate renal failure as defined by the k/doqi-guidelines improved gradually and dialysis was never indicated. persistent ascites required repeated paracentesis during the first month after liver transplantation but medical treatment sufficed thereafter. six months after transplantation the patient has normal liver function and adequate renal function. colour doppler ultrasound shows normal flow in all vessels. there are no ultrasonographic signs of ascites and diuretics are not required. we conclude that when there is portal vein thrombosis, a collateral vein of sufficient calibre in the hilum can be used if present for portal vein anastomosis. in our case the surgical procedure was uneventful; postoperative complications were not serious and were controllable with medical therapy. an in-vitro role of mtor proteins in the protection of hcv infected cells from apoptosis has been proven. the aim of this cohort study was to evaluate the effect of sirolimus as mtor inhibitor on hepatitis c recurrence in liver recipients. hepatitis c virus positive patients were followed up prospectively regarding transaminases, immunosuppressive target levels, hcv rna and influence of donor and recipient factors on viral recurrence and survival. viral recurrence was defined as elevated liver enzymes combined with active hepatitis defined as increasing viral load and/or biopsy proven hcv relapse in the transplanted organ. hcv-positive patients were included received a sirolimus including regimen, patients stayed on calcineurininhibitors. sirolimus patients showed a significant decrease in the hcv pcr levels (p < , ). survival of the sirolimus patients was significantly higher (p < , ) as compared to the other patient cohort. sirolimus has shown to be a potent immunosuppressive agent for patients after liver transplantation. nothing is known about its effect on hcv. this analysis suggests a potential of sirolimus to be evaluated as immunosuppressant for hcv positive liver transplant candidates to suppress viral recurrence. langerhans' cell sarcoma of the spleensurprising diagnosis of a very rare tumor entity during the septic course of a patient background. ccc is a rare tumor disease in western europe with a poor prognosis. these tumors develop from cells of the bile duct epithelia and can appear in several locations along the biliary tract. methods. between and a total of patients were reported at our surgical department because of malign bile duct tumor. patients with histologically confirmed cholangiocarcinoma were included in this study. gall bladder and papillary cancer were excluded. patients were classified into groupsintrahepatic, perihilar and distal-based on the tumor classification established by the john hopkins hospital. data was obtained retrospectively from the surgical, histopathological and clinical records of the patients. results. out of the patients suffered from an intrahepatic ( %), a perihilar ( %) and a distal ccc ( %). the overall resectability rate was % ( % intrahepatic, % perihilar and % distal). the overall perioperative mortality rate was % ( %, % and % respectively). the -, -and -year survival rates in all groups after curative resection were %, % and %; %, % and %; and finally %, % and %. the overall recurrence rate was %. conclusions. cholangiocarcinoma is a malign tumor disease with poor prognosis. tumor location has a decisive influence on the resectability rate and determines therefore the prognosis of the patient. however, when resectability is provided in all groups, location has no effect on the prognosis. das j -ganzkörperszintigramm (gk) ergab multiple speicherungen in der sd-loge und der oberen thoraxapertur, einem rezidiv entsprechend. weiters wurden im abdomen mehrere speicherherde erkannt, die sich im spect/ct in der leber lokalisieren ließen. die sonographie bestätigte den verdacht auf lebermetastasen und auf einen weiteren, paracaval liegenden herd (lymphknoten). aufgrund des massiv erhöhten tg-wertes und der deutlichen speicherung im j-gk-scan wurde eine weitere hochdosierte rjt ( mbq) unter exogener tsh-stimulation veranlasst. posttherapeutisch fanden sich analog zum diagnostischen jod-scan deutliche anreicherungen im hals-und abdomen im sinne von jod-aviden speicherherden. schlussfolgerungen. dieser fallbericht demonstriert, dass bei der nachsorge eines ftc an sehr selten vorkommende tumorlokalisationen wie lebermetastasen gedacht werden sollte. zum anderen zeigt dieser fall auch, dass anatomische besonderheiten im rahmen medizinischer interventionen (z.b. tracheostoma, peg-sonden, div. katheter, etc.), pathologische speicherungen maskieren können. hier stellt die anatomisch/metabolische bildgebung mittels spect/ct ein probates mittel für die differentialdiagnose dar. chemotherapeutic treatment of cancer patients is aimed at eradication of the tumor. in the recent years it became clear that also the immune system contributes substantially the removal of tumor cells. tumor infiltrating leukocytes, however, are commonly suppressed by the tumor in their function which reduces the success of a chemotherapeutic treatment. in a recently published study we demonstrated that replication defective influenza a vaccine virus mutant delns is able to boost the cytotoxic response of peripheral blood mononuclear cells (pbmc's) to tumor cells ''in vitro''. here we investigated whether such a treatment could be used to overcome an immunosuppressive state of pbmc's. pbmc's from healthy volunteers were treated with lps for h. this is known to promote formation of unreactive m -macrophages. then those pbmc's where added to mcf- and panc tumor cells in presence or absence of chemotherapeutic drugs (gemcitabine and cisplatin). lps-treated pbmc's showed a significant lower cytotoxic effect on tumor cells in comparison to untreated cells. this effect was detectable with and without chemotherapy. pre-incubation with delns boosted the cytotoxic capacity of pbmc's and abolished the effect of lps-pretreatment. these data indicate that pretreatment of patients leukocytes with delns might be useful to increase the effect of chemotherapy. background. pancreatic necrosis is a serious complication of acute pancreatitis. the identification of laboratory tests to detect subjects at risk of pancreatic necrosis may direct management and improve outcome. soluble thrombomodulin (stm) has been identified as a marker of poor prognosis in the critically ill. circulating (cell-free) dna in serum or plasma has been investigated as a non-invasive diagnostic tool in a variety of clinical conditions. methods. we studied patients with acute pancreatitis ( -mild, -severe). a thrombomodulin level was determined by elisa. serum creatinine was analyzed on biochemical analyzer. dna was calculated by real time pcr. the degree of pancreatic necrosis was classified by ct balthazar criterion. results. the levels tm, free dna and creatinine of the severe acute pancreatitis group were significantly higher. free serum dna was in correlation with the extent of pancreatic necrosis. increase in creatinine within the first h is strongly associated with the development of pancreatic necroses. pearson correlation coefficient between the degree of necrosis and tm values and between the apache ii score and tm values was statistic significant. conclusions. the plasma tm, free dna may use for identify pancreatic necrosis. high level of creatinine within the first h indicates a high risk of pancreatic necrosis in patients with acute pancreatitis. need an aggressive surgical approach fpr management of giant cystic pancreas neoplasm? resection or palliation? s. dubecz, h. heuberger, m. prager, h. hudler, p. hoffmann, k. vetter the histologically unproven giant cystic pancreas malignancy is a common problem for the diagnostic team and the surgery also. his histological confirmation at the asymptomatic neoplasm are more important the differentiation between of benign or malignant desaeses. in a rare situations, like the presented case, an extremely rare malignant tumors (acinar cell carcinoma) can be resected without any preoperative confirmation. a year old man presented with loss of appetit, history with icterus and changes in bowel habits and negative value with tumour markers. the praeop. investigations were the follows (ct: cm large inhomogen pancreashead tumour, with well anhancing wall, without liver and ln metastases, ercp: cysticmucinous giant tumour in the papilla region, with double duct occlusion, bileduct stanting was not available, histology:any praeop. biopsy was notmalignant). at the exploration we found a large cystic tumour in the pancreashead without propagation to the great wessels: the frozen histology was also negative. instead of originally planed palliation we performed a whipple operation. the early and postoperative period was also complicationsfree ( month follow-up). we demonstrating in details the macro-, and microscopic path investigations (pancreastumor with central haemorrhage and necrosis, solid tubulo-cribriform tissue, cells with hyperchromatic nuclei and granular, with pas pos cytoplasm, with few cells are reactive with chromogranine and synaptophysine). also demonstrating the literature of the this very rare pancreas malignancy. it seems to be possible to achieve a curative result with an aggressive surgical approach at older patient also with a giant benign or semimalignant pancreas neoplasm. minimally invasive methods and surgery at the management of pancreatic pseudocyst methods. two hundred and forty-seven patients were undergo to percutaneous puncture of ppc under ultrasonographic guidance resulted in drainage in patients. transpapillary and transmural approaches for endoscopic internal drainage were used in and patients, respectively. sixty-eight patients were undergo to opened surgery: internal ( ) or external ( ) drainage of ppc, distal pancreatectomy with cystectomy ( ), enucleation of the cyst ( ). results. ppc have been disappeared after percutaneous procedures in . % patients with mature and in . % patients with immature ppc. total success rate of endoscopic drainage of ppc was , %. four patients after surgery have died ( . %) because of bleeding, abscess and retroperitoneal phlegmon. obtained results and experience let us to propose the algorithm for the management of ppc. conclusions. both percutaneous and endoscopic methods are good minimally invasive alternatives for surgery in selected patients, but percutaneous procedures result in higher morbidity and longer hospital stay. the number of successful laparoscopic common bile duct exploration in patients with acute cholecystitis range from % to % because of changes of hepatoduodenal ligament anatomy. background. the purpose of study was to prognosticate possible difficulties and problems for laparoscopic choledochoscopy and bile duct clearance in patients with acute cholecystitis. methods. patients underwent to laparoscopic cholecystectomy because of acute calculous cholecystitis. by usage of blood tests, ultrasonography, x-ray examination of the gastrointestinal tract, ct, mri, endoscopy in ( . %) patients choledocholithiasis, stenosis of vater's papilla or peripapillary diverticulum were revealed and they underwent pre-or intraoperative common bile duct (cbd) exploration. results. prognostic factors for difficult and/or failed laparoscopic cbd exploration were hard masses in the hepatoduodenal ligament (ultrasonographical echopositive paravesicular masses close to the gall bladder neck and/or hyperechogenic strips, that usually occurs in - days after onset of acute cholecystitis), paravesical abscesses, thick ( . mm and more) wall of cbd, multiple stones in the cbd, large stones that completely filling up the cbd, peripapillary diverticulum, sludge with microcholelithiasis. ( . %) patients had conversion because of problems with cbd exploration. conclusions. laparoscopic cholecystectomy with cbd exploration and stone extraction is the method of choice in the treatment of patients with acute cholecystitis complicated with choledocholithiasis. in patients with predicted difficult laparoscopic cbd exploration the preoperative endoscopic retrograde resolution of intracholedocheal problems is favourable. operative treatment of pancreatic cancer: our experience y. i. havrysh , y. i. shavarow , m. p. pavlovskyy , a. t. chykaylo lviv regional hospital, lviv, ukraine; lviv medical university, lviv, ukraine in our surgical department from to we treatment patients with cancer of pancreas. we executed : whiplle procedure, left pancreatectomies, palliative operations, patients were not operated. we diagnosed invasion of pancreatic tumors into colon in patients, into stomach - , into v. portal - , into hepatic artery - . from patients for which one was executed whiplle procedure: male- , female- . age was from to years. we observed mechanical icterus in patients. we used bilio-enteric anastomosis as first stage of the operation in patients and conduction of stent implants in patients. we performed pancreatectomy whiplle in two stages: -resectional stage, -reconstructional stage. conduct a reconstruction on the isolated loops for roux-en-y. we made drainage outside of common bile duck and pancreatic duck. we imposed anastomosis by single-row knotty suture: bilioenteric, gastro-enteric, pancreato-enteric, entero-enteric. post operative complications: bleeding in patients, acute pancreatitis in patients, peritonitis in patients. we observed incapability of stitches of pancreato-enteric anastomosis in a patients. we performed relaparotomy in patients. died - patients: patients died in result of postoperative bleeding, patients -from acute pancreatitis, patients -after peritonitis. life duration of our patients after operation: died till year persons, died till years persons, lived more than years persons, lived more than years patients. endoscopic papillectomy is feasible and safe in suspicious lesions of the papilla of vater (case series of patients) diabetic gastroparesis (dgp) represents a chronic gastrointestinal disorder defined by delayed gastric emptying in the absence of mechanical obstruction. following successful pancreas transplantation dgp remains a major concern in one third of these patients. here we report on the application of intrapyloric injection of botulinum toxin a (botox) in six pancreas recipients. all six patients (four males) with stable graft function suffered from severe and persistent gastroparesis. symptoms of gastroparesis were quantified by the patient-assessment-of-gastrointestinal-symptom (pagi-sym#) severity-index before injection and during follow-up. likewise quality-of-life was assessed (pagi-qol#). total score varies from to . to exclude other possible underlying causes gastric emptying was determined by x-ray and scintigraphic examination prior to treatment. botoxtherapy consisted of u injected equally distributed over the four quadrants of the pylorus. control x-ray was performed h later. clear effects were evident within two weeks following botox-injection in all patients. while the mean symptom score before botox-application was . (range . - . ) early after treatment it decreased to . ( . - ). similarly mean pagi-qol#-index decreased from . ( . - . ) to . ( - . ). two patients required a second injection due to recurrent symptoms. no adverse events were observed. after a follow-up of . days ( - ) five of six patients experience substantial improvements in dgp symptoms and four report considerable amelioration of their quality-of-life. intrapyloric botox-injection should be considered in pancreas transplant recipients suffering from severe dgf if they are refractory to prokinetic and anti-emetic medication. # johnson&johnson pharmaceutical services, llc. abscess in abdominal wall containing calculus -cholecystocutaneous fistula secondary to perforation of gall bladder: a case report background. complications of calculus cholecystitis include abscess up to perforation of gallbladder, which has been classified into acute (free perforation: type ), subacute (abscess walled off by adhesions: type ) and chronic (fistuleous communication in other viscus: type ) perforation refering to modified niemeiers classification. primary manifestation of chronic perforated gallbladder could be presented as cholecystocutaneous abscess/fistula extremely infrequent, whereas fistula in general occurs in less than % of patients with biliary calculus (most likely cholecystoduodenal > %). methods. we encountered a years old patient presenting with swelling at right upper abdomen with slightly elevated wbc and normal liver function test, sonography and ct-scan confirmed abscess and gallbladder adherent to abdominal wall. after cutaneous drainage with spilling of calculus and conditioning with antibiotics preoperatively secondary laparoscopic cholecystectomie and fistulectomie were performed. conclusions. in contrary to frequent cholecystocutaneous fistulas in former times, abscess in abdominal wall as a result of perforation in calculus cholecystitis is a rare entity nowadays due to the advent of sonography, antibiotics and early surgical treatment of biliary tract disease. diagnosis of cholecystocutaneous abscess or fistula might be difficult due to the lack of clinical specifity. anyway it should be considered and kept in mind as important differential diagnosis, therefore be affirmed aided by fistulogram, accurate ultrasonographic and ct-scanfindings and clinched with findings of bilious fluid on drainage. increased preoperative awareness for diagnosis of this condition as well as percutaneous drainage prior to subsequent surgical intervention will diminish rate of morbidity and mortality of the disease. background. acute sigmoid diverticulitis is a very frequent disease in western and industrialized countries. immunosuppressed patients show an increased incidence of complicated diverticulitis and a high risk of colonic perforation. the clinical presentation can range from non-specific signs of abdominal discomfort with delayed diagnosis of perforation to life-threatening abdominal sepsis. the standard surgical management mainly consists of hartmann procedure or primary anastomosis, but is still very controversial due to high morbidity and mortality in both cases. we present four case reports from our department with a short review of literature. methods. between and four patients after organ transplantation (lung  , kidney, liver) were admitted to the department of surgery for acute sigmoid divertculitis with free perforation ( male patients; median age , range - ). two patients underwent a hartmann procedure, two patients had a primary anastomosis. results. the time interval between transplantation and perforation ranged between months and years with two patients having a history of diverticulitis. a dehiscence after laparotomy and an anastomotic leakage required revisional surgery in two patients. postoperative morbidity included acute rejection, pneumonia and acute renal failure. two patients died with mods following pneumonia and acute rejection (bilateral lung transplantation). conclusions. sigmoid perforation in transplant recipients is a rare, but life-threatening event with a high mortality. elective surgical interventions should be considered in patients with high risk of perforation (history of diverticulitis, steroid immunosuppression and heart/lung transplantation). außergewöhnlicher kasus der ausbildung von kolorektalen karzinomen an lokalisationen bei pancolitis ulcerosa eines jungen patienten es ist hinreichend bekannt, dass die colitis ulcerosa als präkanzerose für die generation eines colonkarzinoms gilt. bei einem -jährigen patienten wurde im rahmen einer koloskopie wegen persistierender abdominalbeschwerden eine pancolitis ulcerosa diagnostiziert, die außerdem intraepitheliale neoplasien nachwies. erkrankungsassoziierte incompliance mit temporärer therapieablehnung für jahr führte zu einer beträchtlichen verzögerung der indizierten proktokolektomie, die letztlich ein inzidentelles, simultanes kolorektales karzinom an lokalisationen ergab [  pt c pn ( / ) m ]. eine adjuvante radiochemotherapie konnte aufgrund von wundheilungsstörungen und nebenwirkungen nur verzögert und nicht zeitgerecht durchgeführt werden. der patient war monate postoperativ rezidivfrei, erlag jedoch im verlauf nach einer notoperation bei bridenileus einer sepsis. trotz bekannter prädisposition bei colitis ulcerosa ist die ausbildung eines kolorektalen karzinoms noch immer ein relevantes pathogenetisches geschehen im krankheitsverlauf. insbesondere können diagnoseverzögerung und incompliance das risiko der manifestation maligner läsionen, wie im vorliegenden fall mit multiplen karzinomen, deutlich erhöhen und zu vermeidbar schweren ausmaßen mit sekundären krankheitsbildern führen. mit diesem aussergewöhnlichen fallbericht wird herausgehoben, dass aufgrund multilokulären, lokal fortgeschrittenen (nþ) tumorstadiums trotz erfolgreicher operation und stadiengerechter adjuvanter therapie eine engmaschige onkochirurgische verlaufsbeobachtung und frühe inrervention bei erhöhtem rezidivrisiko dringend verfolgt werden muss. das primäre amelanotische melanom des rektums background. a new surgical technique, the perineal stapled prolapse resection (psp), for external rectal prolapse was introduced by a feasibility study in . this study now presents the first results of a larger patients number with functional outcome in a midterm follow-up. methods. from july to december the psp was performed on patients with external rectal prolapse. the prolapse was completely pulled out and then axially cut open at three o'clock in lithotomy position with a straight stapler. finally the prolapse was stepwise resected with the curved contour + transtar tm stapler at prolapses' uptake. perioperative morbidity and functional outcome was prospectively documented by different scores. results. in all patients, median age years (range - ), psp was performed with no intraoperative complications. % postoperative complications occurred, two patients had a first degree complication (¼ no specific treatment necessary), one patient a second degree (¼ need special medication) and one a third degree (¼ interventional treatment necessary). no mortality. the median operation time was min , the median hospital stay days ( - ). in two patients a reccurence of the prolapse was observed ( %) and treated with a second psp procedure. functional result of of ( %) of the patients were available after a median time of months ( - ) the median reduction of the wexner score was from ( - ) before surgery to . ( - ) postoperatively, p < . . conclusions. the psp is an elegant, fast and safe procedure, with good functional results. colorectal adenocarcinoma in heart transplant recipients background. conflicting data exist whether patients undergoing heart transplantation (htx) are at increased risk for developing colorectal adenocarcinoma (crc). specifically, data on the age matched incidence are rare. methods. the vienna heart transplant database was queried to configure a list of eligible patients. exclusion criteria included: age less than years at the time of transplant, diagnosis of colorectal cancer or patient death less than month posttransplant, and pretransplant history of colorectal cancer. results. a total of patients with htx were eligible for analysis from / through / . the mean follow-up was . years. we identified cases of crc. nine of those patients were between and years of age at diagnosis of crc. thus, the incidence of crc in htx recipients in this age groups is . / , which is -fold higher than the incidence in the general austrian population for crc in this age group. the latter is . / , derived from statistic austria. there was no difference in the incidence of crc in other age groups between the austrian population and htx recipients. median time from transplant to cancer diagnosis was . years. the median survival postcancer diagnosis was . years. conclusions. with the limitation of small numbers of htx recipients and crc available in our study, the incidence of colorectal adenocarcinoma in heart transplant recipients from to years appears to be markedly increased than the general population. our data warrant an intensified crc screening program for htx recipients in this age group. there is growing evidence that chemotherapeutics induce an inflammatory response during the very first course of treatment. we investigated the diagnostic history of patient with either breast or colon cancer. due to their underlying disease they receive different regimes of chemotherapeutic treatment. our standard neoadjuvant treatment of breast cancer is epirubicin and docetaxel whereas patients suffering from colon cancer receive oxaliplatin, irinotecan and -fluoruracil. we hypothesize that chemotherapeutic treatment should be mirrored within the blood plasma proteome. for this reason, blood was taken from both groups on the day before and - days after receiving the first course of chemotherapy. plasma proteomic analysis using d-differential in gel electrophoresis (dige) was performed. differentially expressed proteins were identified by mass spectrometry. using investigations of plasma proteome analysis we validated our findings using western blot. twenty-six out of protein spots showed a more than . fold (p < . ) change within days of chemotherapy, including complement factors c , c and c , alpha hs glycoprotein and alpha -anti chymotrypsin in the breast cancer collective. in contrast, in colon cancer patients the expression level of only out of proteins was affected by the treatment. future investigations will show whether this difference in the treatment induced protein expression changes were related on different chemotherapeutic treatment or different patient collective. lösliches cytokeratin -m -hat potential als postoperativer surrogate marker für den nachweis einer systemischen erkrankung beim kolorektalen karzinom bei einem jahre alten männlichen patienten trat nach einer notwendigen parenteralen infusionstherapie am handrücken eine phlegmone auf, die primär unbehandelt blieb. es kam jedoch zu einem fortschreiten der infektion. schließlich musste eine incision durchgeführt werden, trotz der incision kam es jedoch zu einem handtellergroßen hautdefekt am handrücken rechts mit konsekutivem abriss sämtlicher strecksehnen. der patient war in stark reduziertem allgemeinzustand (zustand nach beckenfraktur, postantibiotische enterocollitis, demenz). trotz des schlechten allgemeinzustandes musste eine rekonstruktion der sehnen und deckung des hautdefektes durchgeführt werden, da sonst der patient in weiterer folge sich selbständig nicht mehr versorgen hätte können. es erfolgte in vitaler indikation die rekonstruktion sämtlicher strecksehnen durch strecksehnenplastik und die deckung des hautdefektes durch einen gestillten hautlappen. gleichzeitig musste eine antibiotische therapie mit metronidacol durchgeführt werden. es erfolgte anschließend eine ruhigstellung und durch diese therapie konnte eine völlige wiederherstellung der handfunktion erzielt werden. zusätzlich kam es zu einer besserung des allgemeinzustandes und der patient kann sich nun selbst versorgen. es wird auf die therapie und auf die ergebnisse eingegangen. neuropathien der oberen extremität präsentieren klinisch oft mit sehr ähnlichen symptomen, obwohl oft sehr unterschiedliche Ä tiologien zu einem eng gefassten klinischen zustandsbild gefü hrt haben können. dies kann entweder zu einer glatten fehldiagnose und entsprechender fehlbehandlung fü hren oder den behandelnden arzt in ein diagnostisches dilemma bringen. bei einer klaren anamnese, welche eine mechanische ursache, wie trauma oder chronische kompression nahe legt, ist natürlich die therapie klar vorgegeben. bei patienten mit unklarer Ä tiologie und klinischer präsentation sollte auch an den seltenen fall einer isolierten neuritis gedacht werden. diese spontan auftretenden lähmungen können auf unterschiedlicher höhe des armnervengeflechtes und den entsprechenden armnerven auftreten und dem unerfahrenen als typische nervenkompressionskasuistik imponieren. bei genauer begutachtung zeigt sich jedoch eine spontan aufgetretene rein motorische lähmung mit entsprechender anamnese und typischen prodroma. die elektroneurographie zeigt eine deutlich erniedrigte spa mit denervationspotentialen als reflexion der rein axonalen schädigung des motorischen systems. in diesem bericht werden wir die typische klinik der häufigsten neuritiden der oberen extremität und deren therapie anhand von fallbeispielen präsentieren und einen diagnostischen und therapeutischen algorithmus vorstellen. die zweizeitige beugesehnenrekonstruktion c. pazourek, u. mildner-deutschmann, p. aspalter, a. pachucki lk mostviertel amstetten, amstetten, austria wir zeigen an mehreren fallbeispielen einen algorithmus zur rekonstruktion von beugesehnen der hand sowie deren sehnenscheiden und ringbänder im rahmen eines zweizeitigen verfahrens unter intermittiernder verwendung eines silastikstabes. wir gehen auf einzelne indikationen ein und entwickeln in der folge ein schema zum zeitlichen ablauf. die op-technik wird beschrieben, ebenso wie zu gewährtigende komplikationen. visceral heme oxygenase- expression is determined by hip to waist ratio and linked to insulin sensitivity grundlagen. das diffuse intravaskuläre b-zell-lymphom (ivl) ist eine seltene, maligne erkrankung, charakterisiert durch eine intravaskuläre proliferation von lymphomzellen mit konsekutiven thrombosen der kapillaren und kleinen gefässe mit nachgeschalteten nachgeschalteten organischämien. jedes organsystem kann davon betroffen sein, die diagnosestellung erfolgt ausschließlich histologisch. eine jährige patientin zeigte seit drei monaten b-symptomatik mit fieberschüben bis zu c, reizhusten und müdigkeit. zusätzlich lagen eine hepatosplenomegalie mit hypoperfusion der milz, erhöhte entzündungsparameter mit anämie, sowie eine hsv-infektion und ein pulmonaler hypertonus vor. methodik. im thorax-ct wurden konfluierende infiltrate in beiden oberlappen und in den apikalen unterlappenanteilen verifiziert, im pet-scan fand sich kein pathologischer fdg-uptake. aufgrund von candida albicans im tracheobronchialsekret bestand der verdacht einer pulmonalen mykose. zur histologischen diagnostik erfolgte eine thorakoskopische keilresektion im segment rechts. ergebnisse. histologisch zeigte sich ein diffuses intravaskuläres großzelliges b-zell-lymphom mit lambda-positivität, positiver immunhistochemischer reaktion auf vegfr und vegfr , sowie cd -koexpression. typischerweise wiesen die arteriolen, venolen und kleinen peripheren gefässe eine vollständige thrombosierung durch tumorzellen auf. die patientin entwickelte peri-operativ ein sirs-artiges bild mit nicht beherrschbarer sepsis, welche den sofortigen beginn einer chemotherapie nicht zuließ. sie verstarb am . postoperativen tag an den folgen des multiorganversagens. in der obduktion fanden sich als ursache des mov tumorzellembolien in allen parenchymatösen organen. schlussfolgerungen. das diffuse intravaskuläre b-zell lymphom zeigt im vergleich zur kutanen manifestationsform eine extrem ungünstige prognose. das Ü berleben ist wesentlich von der frühzeitigen diagnose und dem sofortigen therapiebeginn abhängig. bei ischämischen organläsionen in verbindung mit fieber sollte daher immer an das vorliegen eines intravaskulären lymphoms gedacht werden. die auswirkung von präoperativem aufwärmen auf die performance von unerfahrenen und erfahrenen chirurgen bei der laparoskopischen cholezystektomie das aufwärmen vor der eigentlichen tätigkeit gehört in vielen bereichen, etwa dem spitzensport oder der fliegerei, zur täglichen routine. wir haben die auswirkung von präoperativem aufwärmen an einem laparoskopie -simulator auf die operationsergebnisse bei einer laparoskopischen cholezystektomie, sowohl fü r junge als auch erfahrene chirurgen, untersucht. chirurgen ( mit über jähriger dienstzeit, am beginn ihrer ausbildung) führten jeweils cholezystektomien an einem tübinger boxtrainer, mit beziehungsweise ohne minütigen präoperativem aufwärmen an einem laparoskopie -simulator (lapsim, surgical science), durch. in das ergebnis flossen die operationszeit, die anzahl der instrumentenwechsel, die der leberschäden und jene der gallelecks ein. es zeigte sich, dass die jungen chirurgen bei allen parametern, bis auf die anzahl der instrumentenwechsel von präoperativem aufwärmen profitierten. bei den erfahrenen chirurgen hingegen zeigte sich ein anderes bild: sie benötigten zwar in beiden gruppen gleich lang, wechselten die instrumente gleich oft und es kam zu gleich vielen leberschäden, allerdings kam es in der gruppe mit präoperativem aufwärmen zu mehr gallelecks. präoperatives aufwärmen scheint einen positiven einfluss auf die operationsperfomance von jungen chirurgen zu haben. sie profitieren in hinblick auf die operationszeit, die anzahl von gallelecks und leberschäden. erfahrene chirurgen hingegen scheinen von präoperativem aufwärmen nicht zu profitieren. quality of life after sympathetic block at t for facial hyperhidrosis: results of a disease-specific evaluation background. endoscopic thoracic sympathectomy at the nd thoracic ganglion (t ) is the treatment of choice for patients with erythrophobia according to the lin telaranta classification. unfortunately, the incidence of compensatory sweating (cs) was reported to be higher in case of t sympathectomy. therefore, clip application (endoscopic sympathetic block, esb) has been introduced as it provides potential reversibility. the aim of the study was to analyze the outcome of patients treated by esb at t with special emphasis on the severity of cs. methods. between and patients (mean age ae years) prospectively underwent procedures. satisfaction rates and visual analogue scales (vas) from (no symptoms) to (maximal symptoms) have been evaluated. mean follow up was . ae . months obtainable from all patients. results. the preoperative vas scores ameliorated from . ae . to . ae . six weeks after operation and remained stable during follow up (p < . ). patients ( . %) were free of symptoms, ( . %) improved, whereas unchanged blushing was found in patients ( . %). cs was observed in patients ( . %) with a mean vas score of . ae . at follow up. twelve patients ( . %) rated cs as severe and another patients ( . %) as unbearable. two patients underwent clip removal with improvement of cs. overall, . % would recommend this surgical procedure. conclusions. esb at the nd ganglion presents satisfying postoperative results for the vast majority of erythrophobic patients. furthermore, clip removal offers reversibility of unbearable side effects as cs mainly embarrasses patients' quality of life and satisfaction. experiences of using v.a.c. in the treatment of a complicated, recurring fistula on the small intestine after severe peritonitis p. metzger, m. bergmann, p. herbst, h. rola, f. messenbäck schlussfolgerungen. da es kaum möglich ist unterschiedliche wunden miteinander zu vergleichen konnte kein signifikanter unterschied zwischen den einzelnen systemen gefunden werden. auch bei gleichartigen wunden, bei demselben patienten konnte kein wesentlicher vorteil eines spezifischen systems herausgearbeitet werden. die unterschiede beschränken sich somit auf bedienerfreundlichkeit, schmerzmanagement, patientenkomfort und auf die kostenfrage. background. around one percent of people in industrialised countries will suffer from a leg ulcer at some time. the majority of these leg ulcers are due to venous problems and are so called venous ulcers. the main treatment has been a firm compression and classical wound dressings. additional methods like vacuum assisted closure (v.a.c.) are established in the management of acute and chronic wounds. we report on a case where v.a.c. was used in a -years old female patient with severe sepsis. methods. the patient was transferred to our hospital with a haemorrhagic shock due to a bleeding of a giant septic venous leg ulcer. we performed haemostasis and initial necrectomy under high dose antibiotic therapy followed by two weeks v.a.c. therapy. in two consequent operations we performed mesh grafting of the defect. results. grafts showed complete take-rate. after a total stay of two months the patient was discharged from hospital in good condition and with totally healed ulcer. conclusions. v.a.c. therapy was rapidly efficacious in cleaning the wound, promoting angiogenesis and the formation of healthy tissue. negative-pressure wound treatment may accelerate closure of large leg wounds even in septic ulcers. a close monitoring in these patients is mandatory. in such situations v.a.c. can be seen as a salvage procedure to avoid amputation of the lower extremity and to maintain patients' quality of life. further reports in large series are necessary to confirm our results. schwerste arm-und brustbandphlegmone nach insektenstich: behandlungskonzept offene wundbehandlung nach eröffnung sämtlicher nervenengstellen und debridement der nekrotischen gewebe a. obiltschnig bei einem immunsupprimierten patienten kam es nach einem insektenstich am ellbogen zu einer massivsten rasch auftretenden phlegmone des gesamten arms und der brustwand. der patient wurde zur therapie ins zentralkrankenhaus eingeliefert. es hätte primär nur eine exarticulation im bereich des rechten schultergelenkes durchgeführt werden können. hier wäre die hautdeckung jedoch immens schwierig gewesen. aus diesem grund wurde primär eine ausgedehnte nekrektomie im bereich des gesamten armes durchgeführt. zusätzlich die eröffnung sämtlicher nervenengstellen in der höhe des handgelenkes, des ellbogengelenkes und in der axilla. postoperativ wurden die vitalparameter in der intensivstation überwacht und eine gezielte antibiose durchgeführt. mit unterstützenden hilfsmaßnahmen (niere, lunge) konnte eine normalisierung der entzündlichen parameter erreicht werden. die nachbehandlung der hand erfolgte offen. es erfolgten keine hauttransplantationen, sondern nur die offene wundbehandlung. mit dieser behandlung (waschung -lokalmaßnahmen) konnte ein völliger verschluss der wunde erreicht werden und es wurde auch die funktion der hand wiederhergestellt. anhand dieses fallbeispieles sollte eben die offene wundbehandlung bei infektionen auch mit eröffnung der nervenengstellen diskutiert werden. methods. a retrospective review was performed on patients, who suffered a bite injury during january to december . there were males and females, average age of . years (range - years). the most frequent site of injury were the face and the upper extremities, more than half of the victims were bitten by their pets. bite injuries ranged from relatively minor wounds to major injuries, that included open fractures, nerve and tendon laceration or loss of tissue. the incidence of dog-bites is higher in young children, involving the head, face or neck. in two-thirds of cat bites the upper extremities were effected, usually the hands and fingers. - % of human bite wounds, concerning the middle hand, resulted in an infection. details of their injury treatment and outcome were recorded. results. there were cases of primary infection within h after the bite injury and cases of delayed infection ( - h after bite injury). thirty-two patients required surgery like debridement of devitalized tissue to minimize the wound infection after thorough disinfection and intravenous antibiotic therapy. conclusions. the aim of immediate surgical repair is to obtain a satisfactory cosmetic result with a minimal risk of wound infection. antibiotic prophylaxis makes sense in immunsuprimized patients, children up to two years, bite injuries of the head, face, hands and fingers, and feet. background. we report on three diabetic foot patients suffering from verrucous skin lesions. all patients were suffering from neuropathy and other complications. in two patients partial forefoot amputation had been performed before, followed by split thickness skin grafting. one patient developed atypical malum perforans with verrucous surface with a pea-sized ulcer embedded in macerated horny material over the first metatarsal head. methods. in all three patients verrucous carcinoma of the skin was suspected. clinical findings showed slowly developing cauliflower-like warty tumours with deep sinuses and foul smelling thick greasy material. punch biopsies, respectively histological examination of derided tissue were performed. in all patients histological findings showed verrucous carcinoma. results. two patients were simultaneously suffering from deep neuropathic ulcers and underlying osteomyelitis requiring surgical intervention. transmetatarsal amputation was performed to heal osteomyelitis and to obtain a stable weightbearing foot stump. in one patient deep ulcer debridement was performed followed by offloading. healing was achieved in all patients. final histological findings showed pseudoepitheliomatous hyperplasia with focal papillomatosis according to papillomatosis cutis carcinoides, in case of diabetic neuropathy called vsldn (verrucous skin like lesions in diabetic neuropathy). conclusions. vsldn and diabetic foot ulcers are closely related in their aetiology and pathogenesis, whereas therapeutic strategy has not yet been established. in case of accompanying osteomyelitis required surgical procedure enables histological exclusion of verrucous carcinoma. in case of lacking surgical indication, offloading, professional foot care and compression to avoid friction is the main strategy for therapy and prevention of vsldn. survived suicide shooting through the cavities of pleura, pericard and peritoneum auch wenn die retrograde kontrastfüllung im ct nicht diagnostisch ist! die laparoskopie bietet sich sowohl diagnostisch wie therapeutisch an und ist möglicherweise dem offenen verfahren vorzuziehen. außergewöhnlicher fall eines dermatofibrosarcoma protuberans -ein fallbeispiel mit literaturübersicht grundlagen. das dermatofibrosarcoma protuberans (dfsp) ist ein mesenchymaler maligner tumor, der nur selten metastasiert und durch eine oftmals späte diagnosestellung und langsam infiltrativem wachstum gekennzeichnet ist. die resektion mit einem ungenü genden sicherheitsabstand resultiert in einem lokalrezidiv. berichte ü ber dfsp sind selten aufgrund der geringen inzidenz von weniger als . % aller malignome. in der vorliegenden arbeit wird die bedeutung eines ausreichenden sicherheitsabstands zur vermeidung eines lokalrezidivs aufgezeigt. methodik. ein -jähriger patient stellte sich mit einem an grösse zunehmenden knoten medial des linken schulterblattes vor. klinisch zeigte sich ein  cm großer, derber, subkutan liegender knoten, der gut verschieblich, leicht überwärmt und hämangiom-artig imponierte. ergebnisse. die klinischen befunde ergaben den verdacht auf ein atherom. daraufhin erfolgte eine spindelförmige exzision. intraoperativ präsentierte sich ein kugelig-glattes, prall-elastisches, gräuliches und hämorrhagisches gebilde. auf grund der für ein atherom untypischen befunde wurde eine histologische untersuchung veranlasst. diese zeigte ein unvollständig exzidiertes dfsp. es erfolgte die empfohlene nachresektion mit einem sicherheitsabstand von cm mit der histologischen dokumentation der radikalen exzision. im bisherigen verlauf keine hinweise auf ein lokalrezidiv. schlussfolgerungen. hinter der verdachtsdiagnose eines atheroms kann sich seltenerweise ein dfsp verstecken. die histologische untersuchung eines resektates mit ,,auffälligem'' aspekt ist ein chirurgischer grundsatz. nur so kann ein rezidivfreies Ü berleben erreicht werden und exzessive resektionen mit plastisch-chirurgischer deckung vermieden werden. hydrogen sulphide is a colourless, highly toxic, flammable and mucosal irritating gas which mainly originates during breakdown of organic matter in the absence of oxygen. after inhalation hydrogen sulphide binds to the mitochondrial respiratory enzyme preventing oxydative phosphorylation, thereby causing reversible inhibition of aerobic metabolism and cellular anoxia. the therapeutic use of hyperbaric oxygen for hydrogen sulphide intoxication is not standardised and its use is still controversial. victims of occupational hydrogen sulphide intoxication were referred to our centre between / and / . before admission, % oxygen had been was given by mask (n ¼ ) or by endo-tracheal tube (n ¼ ). two patients had been resuscitated at the site of the accident, in the six severe cases -dimethylaminophenol was administered as antidotal therapy. hyperbaric oxygenation was done immediately after admission in all patients by using the schedule otherwise applied in carbon monoxide-intoxication. out of patients ( . %) died of irreversible cerebral ischemia or pulmonary edema, respectively. the remaining patients recovered without any neurological sequelae and were discharged for outpatient care after a median of . days (range - days). no antidote-related adverse effects were observed. in hydrogen sulphide intoxication hyperbaric oxygenation ensures quick re-oxygenation and counteracts the decrement in oxygen carriage caused by methemoglobinemia due to antidoteadministration. in our experience, hyperbaric oxygenation alone or in combination with -dimethylaminophenol therapy proved a safe tool in the management of mild or severe hydrogen sulphide intoxication, respectively. influence of a new self-fixing hernia mesh on the ductus deferens in the rat model inferior vena cava-associated tumor lesionschallenging vascularsurgical management in a representative case series of patients methodik. anhand einer außergewöhnlichen kasuistik wird die seltene konstellation eines abdominalen fibromyxoiden sarkoms mit nicht vorbeschriebener manifestation im greisen lebensalter, wesentliche aspekte des perioperativen diagnostischen und therapeutischen managements dargestellt und ins verhältnis zu verfügbaren literaturangaben gesetzt. ergebnisse. eine -jährige multimorbide patientin fiel durch erhebliche obstipationneigung mit subileus auf (nebenerkrankungen: z.n. lungenembolie, diabetes, khk, hypertonie, beginnend dekompensierende chronische niereninsuffizienz). anamnestisch z.n. punktion unklarer lebertumorläsion jahre zuvor (histologie: sklerosiertes hämangiom)-klinisch monströse resistenz im mittelbauch. sonographie und ct: monströse teils zystisch, teils mit liquiden anteilen bzw. solide imponierende tumorläsion zwischen leber und magen ohne organzugehörigkeit; angiographisch keine pathologischen tumorgefäße (venöse abflussbehinderung). die transcutane fnp erbrachte keine diagnosesicherung. therapeutisch wurde eine tumorexstirpation in toto mit resektion des omentum majus und atypischer leberresektion im segment ausgeführt. nach histomorphologischem aspekt von leberkapsel ausgegangenes, niedrig malignes sarkom (durchmesser: cm; gewicht: , g). keine leberinfiltration, ü berwiegend myxoider background, spindelzellige, teils pleomorphe tumorzellen mit hyperchromasie, faseriges stroma (immunhistochemisch: glattmuskuläres aktin: þ; desmin/s /Ö strogen-und progesteronrezeptor/cd /cd /cd : negativ). lymphknoten tumorfrei. monate nach tumorresektion war kein tumorrezidiv zu verzeichnen. schlussfolgerungen. der bisher älteste berichtete patient ist jahre alt. der vorliegende fall steht also, insbesondere im hinblick auf das fortgeschrittene alter der patientin und die lokalisation eine ausgesprochene rarität dar. grundlagen. die elektrische impedanz-tomographie (eit) stellt eine nicht invasive methode zur darstellung der lokalen lungenventilation sowie der lungenwasserverteilung dar. intrapulmonale flüssigkeitsverschiebungen können beobachtet werden bei lageveränderungen des körpers oder als pathologische veränderungen wie sie zum beispiel im rahmen eines lungenödems auftreten. interessanterweise kann auch ein direkter einfuß der regionalen lungenventilation zur lage des körpers im raum dargestellt werden. weiters zeigten mehrere studien das lungenteile die unter einem höheren mechanischen stress stehen besser ventiliert werden als die restlichen lungenregionen. methodik. die messungen wurden an gesunden männlichen probanden durchgeführt mithilfe des ,,multichannel impedance spectroscope mxs (osypka medical gmbh). für die dauer der messung wurden die probanden in ein rotierendes bett (rotorest -kci austria gmbh)platziert mit einer kontinuierlichen rotationsgeschwindigkeit von annähernd pro minute. die messungen beinhalteten die waagrechte position sowie einen schwenk jeweils nach links und rechts und endeten wieder in der waagrechten für minuten. mittels image -rekonstruktion konnte der zeitpunkt der ventilation verschiedener areale dann bildlich dargestellt werden. ergebnisse. bei allen probanden konnte bewiesen werden das immer der mechanisch am stärksten belastete lungenabschnitt (linksrotation -linke lunge, rechtsrotation-rechte lunge, waagrechte -posteriore lungenabschnitte) bevorzugt ventiliert werden. schlussfolgerungen. die ergebnisse dieser studie zeigen das eit zukünftig als ausgezeichnete nicht invasive untersuchungsmethode zur beurteilung der lungenventilation dient. mögliche einsatzorte wären zum beispiel intensivstationen, wo auf relativ einfache weise der erfolg von kinetischen therapien verifiziert werden kann. background. lichtenstein hernioplasty is a very common technique for repairing an inguinal hernia and foreign body reaction after mesh implantation is a very rare complication. case report. a -year-old patient with an inguinal hernia came to our department. we did a lichtenstein hernia repair with a paritex polyester mesh ( . cm). five months later the patient came again because of right inguinal pain and swelling. ultrasonography and a ct-scan were done. it showed three liquid formations in the right inguinal region. blood test showed signs of a moderate inflamation, no feaver. we described antibiotics and nsar. a few days later we did a punction which showed pus. a reoperation was performed. an abscess formation subcutaneously was laid open. the smear culture was steril. during the first month post operation the patient felt well, but there was still serous secretion from a fistulous tract. two and a half months post operation an mri scan was performed which showed a abscess formation involving the inguinal canal. at re-operation we found serous fluid, an intact mesh surrounded by inflamated tissue. we removed the mesh, a bassini's procedure was performed and the patient got antibiotics. in the smear culture we couldn't find any microorganismus. histologically a chronic granulomatous foreign body reaction was found. the finding was a proof for a foreign body reaction. in the following controlls the patient didn't have any further problems. methods. we report on two patients, who developed massive postoperative pe and received sildenafil as an adjuct to thrombolytic therapy. results. the first patient underwent gastric wedge resection for a large perforated gastric ulcer after initiation of interferon/stroid therapy for multiple sclerosis. on the evening after discharge, she was admitted to the emergency room with acute dyspnea and cardiac failure and diagnosed with massive pe. she underwent mechanic-pharmacological clot fragmentation (angio-jet device in conjunction with tpa using the power pulse technique). on the intensive care unit, oral sildenafil was started ( mg twice daily), which resulted in significant improvement of right heart failure. the patient suffered renal and hepatic failure, however, ultimately recovered with restored organ function. she is well and alive after more than one year. the second patient developed acute pe four days after liver transplantation for primary biliary cirrhosis. she was treated with systemic thrombolysis. application of sildenafil resulted in significant improvement in cardiac output and right heart failure which caused congestion of the liver allograft. she later developed takotsubo cardiomyopathy and renal failure, however, recovered from these complications and is alive with good graft function after months. conclusions. although the two cases suggest that sildenafil may be a useful pharmacologic intervention in acute massive postoperative pe, a controlled trial is necssary to confirm our findings. chirurgische therapie des katamenialen pneumothorax w. kolb, r. kuster, w. nagel klinik für chirurgie, st. gallen, switzerland grundlagen. der katameniale pneumothorax ist eine seltene ursache eines spontanpneumothorax, der durch eine abdominale bzw. thorakale endometriose verursacht wird. methodik. wir berichten ü ber drei patientinnen, die aufgrund eines rezidivierenden mensassoziierten rechtsseitigen spontanpneumothorax an unserer klinik behandelt wurden. in der vergangenheit waren zwei patientinnen bereits thorakoskopisch mittels einer lungenspitzenwedgeresektion behandelt worden. aktuell erfolgte bei allen drei patientinnen zunächst eine diagnostische thorakoskopie zur diagnosesicherung. in allen fällen erfolgte bei ausgedehntem befall des zwerchfelles eine zwerchfellteilresektion ü ber eine rechtsseitige thorakotomie, in einem fall erfolgte die implantation eines kunststoffnetzes zur defektdeckung. die operationen verliefen durchwegs komplikationslos. histologisch konnte bei allen patientinnen anhand des operationspräparates die präoperativ gestellte diagnose eines katamenialen pneumothorax bestätigt werden. postoperativ wurde eine konservative therapie mit ovulationshemmern begonnen bzw. fortgesetzt. ergebnisse. im rahmen der nachbeobachtungszeit von nunmehr monaten ist bei einer patientin nach pausieren des ovulationshemmers ein neuerliches rezidiv eines spontanpneumothorax aufgetreten, welches durch einlage einer thoraxdrainage behandelt werden musste. die beiden anderen patientinnen sind beschwerde-und rezidivfrei. grundlagen. benigne fibröse tumore der pleura sind in der literatur kaum beschrieben. zu % gehen diese von der viszeralen pleura aus. methodik. an der abteilung für herz-thorax-und gefäßchirugie im lkh klagenfurt wurde ein jähriger männlicher patient aufgrund rezidivierender pleuraergüsse rechts bei bekanntem zwerchfellhochstand rechts vorgestellt. klinisch präsentierte sich der patient mit geringer dyspnoe (nyha ii) nach bereits erfolgten mehrmaligen pleurapunktionen, welche in der zytolgischen diagnostik keine besonderheiten zeigten. ein durchgeführtes pet ct ergab keinen keinen pathologischen fdg uptake, allerdings eine raumforderung beziehungsweise ein fragliches hämatom im bereich des rechten lungenunterlappens sowie den bekannten erguss. ergebnisse. zur weiteren abklärung führten wir eine videoassistierte thorakoskopie (vat) durch. nach endoskopischer absaugung der flüssigkeit konnte ein solitärer tumor, ausgehend vom rechten lungenunterlappen identifiziert werden. die resektion gestaltete sich technisch einfach. der pathologische befund zeigte einen fibrösen pleuratumor ohne malignität ausgehend von der pleura viszeralis mit einer größenausdehnung von , : , : , cm. schlussfolgerungen. benigne fibröse tumoren der pleura sind selten. eine chirurgische resektion sollte angestrebt werden, rezidive werden kaum beschrieben. indikation zur onkologischen resektion und lymphknotendissektion bei acthsezernierendem net der lunge grundlagen. nach histologischem nachweis eines acthexprimierenden malignen neuroendokrinen tumors mittels thorakoskopischer lungen-wedgeresektion wird die indikation zur onkologischen lungenresektion mit mediastinaler lymphadenektomie anhand eines fallberichtes diskutiert. ergebnisse. ein jähriger patient mit dem klassischen bild eines zentralen morbus cushing wies bei unauffälliger craniocerebraler magnetresonanztomographie in der thora-duced by pulmonary vascular endothelial cells, playing a role in the pathophysiology of pulmonary edema. whether pretransplant pulmonary tissue et- mrna could predict pgd in ltx is unknown. et- mrna expression was examined by real time rt-pcr in lung tissue biopsies of donors (mean age ae years) and recipients (mean age ae years) obtained shortly before ltx. the mean ischemic time of the graft was ae minutes. the underlying disease in recipients was chronic obstructive pulmonary disease (n ¼ ), cystic fibrosis (n ¼ ), emphysema (n ¼ ), primary pulmonary hypertension (n ¼ ) and retransplantation (n ¼ ). in % of patients, pgd was diagnosed and scored by oxygenation and radiological characteristics according to ishlt guidelines. expression levels of et- mrna were significantly increased in both donor (p < . ) and recipient (p < . ) tissue in the patient group developing pgd. moreover, donor and recipient et- gene expression correlated with the grading of pgd severity (r s ¼ . ; p < . ). neither pgd grade nor et- expression correlated to patient age or ischemia time of the graft. this study indicates for the first time that pre-transplant et- mrna overexpression in both donor and recipient mediates pgd development due to alteration of pulmonary vascular resistance and permeability. assessment of et- tissue gene expression is thus a sensitive and specific predictor of pgd in ltx and might be beneficial in donor selection and in the prophylactic treatment of recipients by using targeted et- antagonists. surgical closure of the asd was possible with near-normalized paps after ten months of ''conditioning'' medication with bosentan ( mg/day). the patient could be discharged from the hospital on post-operative day under ongoing bosentan treatment. eight months thereafter the patient was in good clinical condition with residual mild pulmonary hypertension. the traditional rule of inoperability of an asd with severe pulmonary hypertension was recently challenged by case reports where asd could be closed after long-time conditioning therapy with prostacycline. we now present a similar case treated with bosentan (an endothelin antagonist), which has several advantages compared to epoprostenol. because it is an oral drug, there are no complications related to an intravenous delivery system which are common under long-time prostaglandin therapy. we conclude that a pre-operative bosentan treatment of a patient with asd ii and severe pah is feasible and may allow surgical correction. lung compression and cardiac displacement resulting from the caved-in chest. in the second case, a -year-old woman that received chemotherapy for an aggressive undifferentiated tumor of the sarcoma group, infiltrating clavicle, humeroclavicular and acromial joints, was chosen for forequarter amputation with resection of thoracic wall. reconstruction also involved a myocutaneous armflap. in the third case, a -year-old woman with a chondrosarcoma of the sternum underwent a subtotal resection of the sternum. reconstruction was performed with an additional dualmesh. the fourth case is about a -year-old woman with a giant tumor of the thoracic wall (fibrosarcoma) treated with radiacal resection ( th to th rib) and a dualmesh patch. the use of the stratos tm system represents a safe and practical approach for the correction of chest wall deformities and the reconstruction of the chest wall after tumor removal. artery disease. the underlying mechanism remains largely unknown. methods. endothelial cells and fibroblasts were established from rat hearts. additionally h c -cardiomyocytes were used. a water bath was designed to avoid distracting physical effects. adherent cells in cell culture flasks filled with culture medium were dunked into the bath. sw ( . mj/mm ) were applied. analysis were performed over a period of days. results. sw stimulate every cardiac cell type to a different extent. each cell type reacts at another timepoint. the distance between applicator and cells, as well as the energy flux density have an influence on the cells' behaviour. between days and the duplication time of treated cells was significantly higher compared to controls. significant differences in the gene expression of mmps, timps and collagen were shown. treated cells do alter their cytoskeleton (vimentin, tubulin, beta-actin), show significantly more proliferation (ki- ) and changes in the expression of adhesion molecules (cd ) as well as connexins , , . no apoptosis was found in the treatment group. conclusions. sw activate proliferation of cardiac cells. moreover cells alter the assembly of microfilaments, thus seem to ameliorate cell migration. changes of the mmp and timp levels and the expression of adhesion molecules seem to be strongly involved in the sw tissue regenerative effect on ischemic myocardium. idiopathic dilated cardiomyopathy (dcm) is characterized by ventricular wall remodeling and an increased incidence of apoptosis. apollon is a member of the inhibitor of apoptosis protein (iap) family that promotes cell survival by ubiquitination facilitating the degradation of pro-apoptotic molecules. traf belongs to the tnf-receptor-associated family ubiquitinated by other iaps after pro-apoptotic stimuli. whether the apollon/ traf system may mediate programmed cell death in dcm is unknown. apollon and traf protein expression was examined in left ventricular biopsies of explanted failing hearts using western blotting in dcm patients and controls. human cardiac cells were transfected with a plasmid containing the human apollon cdna or control vector and were subsequently stressed by hypoxia. apollon and traf mrna expression was then measured in cell lysates by real time rt-pcr and tunel assays were used to determine the apoptotic index. in dcm myocardial tissue, apollon expression was downregulated and traf was upregulated compared to control hearts (p < . ). cell stress resulted in increased apoptosis in cardiac cells in vitro with downregulation of apollon and upregulation of traf mrna expression compared to control cells (p < . ). transfection with apollon increased apollon and decreased traf mrna expression in cell lysates (p < . ) and completely abolished hypoxia-induced apoptosis. these results suggest for the first time that apollon regulates the level of traf and that both apollon and traf are involved in the programmed cell death associated with dcm. upregulation of apollon with subsequent traf suppression might therefore constitute a novel strategy in dcm treatment. monalvenen durchgeführt. zur kontrolle des operationserfolges wurde zusätzlich ein permanenter loop-recorder medtronic reveal tm xt implantiert. ergebnisse. es konnten ganglien isoliert und selektiv abliert werden. postoperativ trat normofrequenter sinusrhythmus ein, ein postoperatives -stunden holter zeigte durchgehenden sinusrhythmus mit einer frequenz von - /min. bei den kontrollen nach und monaten ergab die abfrage des loop recorders einen stabilen permanenten sinusrhythmus ohne aufgezeichnete vorhofflimmerepisoden. schlussfolgerungen. die selektive isolation und ablation der autonomen ganglien im rahmen der vorhofablation bei vorhofflimmern kann zu einer verbesserung der operationserfolges führen, wobei bei unserem patienten die normale sinusknotenfunktion erhalten blieb. perioperative antibiotikaprohyplaxe bei herzchirurgischen eingriffendas erfolgreiche regime der grazer herzchirurgie grundlagen. weichteilinfektionen sind in der herzchirurgie eine bekannte komplikation. in der literatur kommt es in % zu oberflächlichen infektionen, in , % zu tiefen steruminfekten, in - % der fälle wird von postoperativer mediastinitis mit einer sternumdehiszenz berichtet. die mortalität bei den mediastinalen infektionen ist mit - % hoch, die kosten für patienten mit sternalen wundinfekten sind , mal so hoch wie für patienten mit unkompliziertem postoperativem verlauf. methodik. an der herzchirurgie graz wird seit folgendes antibiotisches regime angewendet: eine stunde präoperativ wird cefuroxim iv gegeben, unmittelbar vor hautschnitt teicoplanin, die zweite dosisgabe der beiden antibiotika erfolgt noch an der hlm. das cephalosporin wird für h postoperativ bei cabg verabreicht, bei klappenoperationen bis zum . postoperativen tag. die daten beziehen sich bis zur entlassung ins rehabilitationszentrum. bei langliegern werden antibiotika nur nach vorliegendem antibiogramm verabreicht. alle patienten werden präoperativ auf mrsa mittels nasenabstrich (positiv bei n ¼ ) gescreent. ergebnisse. kam es weder zu postoperativer mediastinitis noch zu chirurgisch behandlungsbedürftigen oberflächlichen sternalen wundinfekten, an der beinwunde war die inzidenz für weichteilinfekte , % (n ¼ ), bei diesen patienten wurden mit einem v.a.c.-system behandelt, in einem fall musste der defekt mit einer spalthaut gedeckt werden. in sechs fällen ( , %) wurde eine sterile sternumdehiszenz noch am tag der wundrevision recercliert. bei keinem patienten wissen wir von chronisch offenen wunden. die mortalität aufgrund von wundinfekten war %. schlussfolgerungen. nach jahren kam es nicht zu resistenzen. die rate an wundinfektionen ist erfreulich gering. unverständlicherweise kommt dieses grazer antiobiotische regime kaum zur anwendung. grundlagen. morbus castelman (angiofollikuläre lymphknotenhyperplasie) ist eine seltene erkrankung vornehmlich der cervikalen und mediastinalen lymphknoten. klinisch imponieren lymphknotenschwellung mit b-symptomatik, splenomegalie und hepatomegalie. die diagnosesicherung erfolgt durch biopsie. wir berichten über eine jährige patientin, welche nach vorangegangenem respiratorischen infekt akute hämoptysen und dyspnoe zeigte. bronchoskopisch fanden sich zeichen einer stattgehabten blutung. im labor waren leukozytose und crp erhöhung auffällig. methodik. im thorax ct fand sich eine ausgedehnte diffuse, tumoröse infiltration des oberen und mittleren mediastinums und beider hili mit umscheidung der supraaortalen Ä ste, der aorta ascendens, vena cava superior sowie der beiden vorhöfe. infolge völliger einmauerung des rechten pulmonalarterienhauptstammes bestand rechts keine perfusion. keine dieser strukturen zeigte eine speicherung im pet, nur an der mesenterialwurzel fand sich ein hypermetaboler herd. der versuch einer mediastinoskopie zur diagnosesicherung scheiterte an der fehlenden darstellbarkeit der strukturen im extrem derb-fibrotischen gewerbe. Ü ber thoracotomie gelang es aus einzelnen, in die fibrösen massen eingelagerten hilären lymphknoten eine diagnose zu stellen. ergebnisse. es fand sich die seltene, plasmazellreiche variante des mb. castleman mit ausgeprägter hyalinisierung und fibrosierung. diese form ist multifokal und zeigt verstärkte il expression und in deren folge unspezifische entzündungszeichen. eine koinfektion mit hhv bzw. mit hiv (in ca. % zu beobachten) konnte ausgeschlossen werden. schlussfolgerungen. durch die einleitung einer therapie mit einem monoklonalen chimären antikörper (rituximab; mabthera + ) wurden eine signifikante besserung der klinischen symptomatik sowie eine deutliche befundregredienz erreicht. germany ziel der untersuchung war es, machbarkeit, therapieergebnisse & ,outcome'' der endoskopischen papillektomie zu untersuchen. methodik. Ü ber einen definierten behandlungszeitraum wurden alle konsekutiven patienten mit tumor-ähnlichen papillenläsionen mit möglicher endoskopischer papillektomie in diese systematische klinische ,bicenter''-beobachtungsstudie einbezogen & in gruppen entsprechend des endoskopischen & eus-befundes sowie der pathohistologischen diagnose eingeteilt. machbarkeit & behandlungsergebnisse wurden durch r -resektionsrate, morbidität (z.b. rate/spektrum von komplikationen) & mortalität charakterisiert; outcome wurde durch rezidivrate & tumor-freies Ü berleben eingeschätzt jahre) eingeschlossen. vor der papillektomie wurde die eus in / ( , %; n ¼ ) der patienten durchgeführt gr. (karzinom/neuroendokriner tumor, n ¼ ): , % (n ¼ ) mit r -resektion gr. (adenomyomatosis, n ¼ ). gr. (nicht einführbarer katheter in die papille bei hochrisikopatienten mit papillenkarzinom jedoch ohne hinweise auf ein tief infiltrierendes tumorwachstum kann sie als sinnvolle therapieoption mit niedrigem risiko & einer ca. % -wahrscheinlichkeit hinsichtlich rezidivfreiheit angesehen werden, wenn r erreicht wird die toxizität des antikörpers (ak) unterscheidet sich von der traditionellen chemotherapie. eine zwar seltene aber schwerwiegende ak-spezifische komplikation ist die gastrointestinale (gi) perforation, die mit hoher morbidität/letalität einhergeht. das ziel bestand darin, an hand eigener exemplarischer und publizierter erfahrungen befund-bezogene besonderheiten dieser außergewöhnlichen pathogenese einer perforationsbedingten peritonitis nach ak-therapie einschließlich therapeutischem ,outcome'' darzustellen. methodik. es wurden patienten mit einer bevacizumab-induzierten perforationsbedingten peritonitis seit klinischer einführung (i) aus dem eigenen patientenklientel recherchiert (design: prospektive fallserie), (ii) literaturangaben gegenübergestellt (historische[retrospektive] vergleichsgruppe) und (iii) hinsichtlich der ergebnisse des chirurgischen managements frauen: n ¼ ; geschlechtsverhältnis: m:w ¼ : ). die durchschnittliche behandlungsdauer bis zum auftreten der komplikation betrug durchschnittlich d patienten verstarben ohne operative versorgung an den peritonitisfolgen. die perioperative gesamtmorbidität betrug , % (n ¼ / ) in allen fällen mit primärer anastomose (n ¼ ) trat im verlauf eine anastomoseninsuffizienz auf ( %). die rate der wundheilungsstörungen betrug die peritonitis nach gi-perforation infolge einer bevacizumab-therapie stellt eine seltene akassoziierte, aber ernstzunehmende, da lebensbedrohliche komplikation dar. die im zusammenhang mit der neoangiogeneseinhibition gestörte wundheilung bedingt abweichungen im management gi-perforationsereignisse im vergleich zur etablierten chirurgischen standardversorgung klinik für viszeral-, transplantations-und thoraxchirurgie das amelanotische melanom des rektums (amr) ist eine seltene erkrankung, dessen chirurgische therapie derzeit kontrovers diskutiert ist. die transrektale ultraschalldiagnostik (eus) besitzt in der diagnostik und nachsorge eine entscheidende bedeutung der literatur wurden innerhalb von jahren anhand von repräsentativen fallberichten für amr im rahmen einer klinischen bicenterbeobachtungsstudie zur qualitätssicherung in der rektumchirurgie wird über das therapeutische spektrum dieser seltenen befunde und maßnahmen in abhängigkeit vom individuellen verlauf berichtet die patientin verstarb jedoch monate nach der erstdiagnose. schlussfolgerungen. die prognose des amr ist unabhängig von der chirurgischen therapie schlecht. die lokale tumorresektion mit einem sicherheitsabstand von cm ist das primäre verfahren der wahl, die apr hingegen sollte den verbleibenden fällen vorbehalten bleiben severe facial hyperhidosis (fh) bothers patients' every day life and leads to human withdrawal and social phobia. the aim of the study was to assess pre-and postoperative quality of life (qol) using a disease-specific qol questionnaire after limited endoscopic thoracic sympathetic block at t (esb ) for fh. methods. fifty patients underwent esb procedures in a prospective study between and at a mean follow up of . ae . months. a validated disease-specific qol questionnaire by milanez de campos ( - ) and a visual analogue scale (vas; - ) concerning the extent of fh were evaluated by annual telephone calls ( : no symptoms; or : maximal symptoms). results. vas scores decreased from . ae . preoperatively to . ae . postoperatively and to . ae . at long term follow up (p < . ). patients ( %) were completely or almost dry postoperatively. side effects, such as compensatory sweating (cs) and gustatory sweating were each ae . at a year follow up (p < . ) endoscopic sympathetic block at t reduces fh efficiently and improves qol. cs impairs qol substantially emphasizing the importance of clip removal induce clip removal as final retreat strategy -cava-inferior(vci)-assoziierte tumorläsionen stellen eine außerordentliche herausforderung im interdisziplinären behandlungskonzept von viszeral gefäßwandinfiltration und (iii) intraluminalen tumorzapfen mit alteration des blutstroms im gefäßchirurgischen patientenklientel eines chirurgischen zentrums prospektiv erfasst und retrospektiv ausgewertet. ergebnisse. es wurden insgesamt patienten operativ behandelt: leiomyosarkome der vci ( , %), retroperitoneale tumore (seminommetastase, paraganglion; , %) als auch von außen infiltrierende tumore und cholangiozelluläres karzinom mit vci-adhäsion ( , %) und tumorzapfen ( , %; nierenzell-/ nebennierenrindenkarzinom). die tumorresektionsrate betrug %. op-technisch wurde die vci entweder ü ber die tumorbefallene strecke komplett durch eine gefäßprothese ersetzt, eine partielle wandresektion mit anschließender patchplastik, die tangentielle resektion mit primärer naht oder die ausschälung des cavathrombus nach cavotomie vorgenommen. die tumorzapfen wurden mit/ohne vci-resektion erfolgreich reseziert eine operation vci-assoziierter tumore ist nur bei aussichtsreicher r -resektion sinnvoll patients underwent -or -mm mechanical aortic valve replacement, receiving either a carbomedics top hat valve (n ¼ ; mean age, ae years) or a standard carbomedics one (n ¼ ; mean age, ae years) at our institution. median follow-up time was . months. we performed echocardiographic follow-up austria neben dem angeborenen av-block haben zunehmende fortschritte der herzchirurgie mit tendenz und notwendigkeit, immer komplexere operationen zu immer frü heren zeitpunkt auszufü hren, zwangsläufig zu einem gelegentlichen bedarf postoperativer schrittmacherimplantation im säuglingsalter gefü hrt angeborene herzfehler bestanden bei säuglingen und erforderten herzoperationen mit folgender, meist iatrogener rhythmusstörung bei allen säuglingen wurde der generator zunächst in einer submuskulären tasche des rechten mittel-oder unterbauches eingebracht, die elektroden entweder epikardial platziert oder über die rechte a. subclavia ( ) bzw. die a. jugularis ( ) eingebracht, in einem fall transatrial. im kollektiv mit angeborenem av-block gab es keine perioperativen todesfälle, bei angeborenem herzfehler sind patienten ( , %) verstorben: ein neugeborener mit g körpergewicht und komplexem syndrom nach verschluss eines ductus botalli und im insgesamt wurden bei diesen patienten bislang folgeeingriffe vorgenommen ( , /patient): vorrangig wachstumsbedingte anpassungen des systems sowie aufrüstung im betriebsmodus. die moderne schrittmacherchirurgie gewährleistet auch im neugeborenen-und säuglingsalter eine uneingeschränkte entwicklung mit hervorragender lebensqualität, nur durchbrochen von hauptsächlich wachstumsbedingt erforderlichen folgeeingriffen acknowledgments. this study was supported by mammamia. we also thank all experts and non-experts for their time-consuming subjective evaluation. methodik. der -jährige bechterew -patient wurde aufgrund einer perforierten sigmadivertikulitis mit stercoraler peritonitis notfalllaparotomiert, wobei eine stomasituation nach hartmann angelegt werden musste, sowie eine dünndarmteilresektion mit einem endständigen ileostoma erfolgte. es entwickelte sich eine stercorale peritonitis, welche mit einem ,,kci-v.a.c.-abdominaldressing'' im sinne eines laparostomas behandelt wurde. weiter entwickelte sich eine dünndarmfistel. nach frustranen reoperationsversuchen entschied man sich, die gegebene fistelsituation seitens des therapieansatzes als zweites stoma zu behandeln und arbeitete daher auf einen entsprechenden bauchdeckenverschluss hin.um eine schnellere abheilung zu erreichen, entschied man sich schließlich nach der v.a.c.-versorgung für eine defektdeckung mittels mesh-craft-transplantat. dieses konnte mittels v.a.c.-verband zum anheilen gebracht werden.nach klinischer stabilisierung erfolgte eine dünndarm-reanastomosierung. allerdings entwickelte sich in der folge erneut eine anastomoseninsuffizienz mit ausbildung einer dünndarmfistel. eine konservative verbandstechnik gestaltete sich in dieser situation als schlichtweg unmöglich. da aufgrund der vorgeschichte eine erneute spalthautdeckung der wieder klaffenden bauchwunde nicht möglich erschien, kam wieder eine versorgung mit einem v.a.c.-system zum einsatz.ergebnisse. die wundfläche konnte damit in wenigen wochen auf fast die hälfte reduziert und mittels stomaplatte versorgt werden. die verbandstechnik erlaubte es, dass durch eingeschultes pflegepersonal eine verbandsüberwachung und sogar neuanlage möglich wurde.schlussfolgerungen. die erreichten ergebnisse bei diesem primär lebensbedrohlichen krankheitsbild und der rezidivierenden entwicklung von dünndarmfisteln wären ohne innovative chirurgisch-pflegerische betreuung und der wochenlang durchgeführten v.a.c.-therapie wohl kaum zu erzielen gewesen, das verfahren konnte klar überzeugen. unterdrucktherapiebesteht ein qualitativer unterschied zwischen den verschiedenen systemen? tumor-induced bleeding by affection of the axillar artery due to recurrent tumor growth of breast carcinoma with successful endovascular treatment grundlagen. die tumor-induzierte blutung aus einem stammgefäß ist ein seltenes ereignis, kann jedoch lebensbedrohlich in erscheinung treten.methodik. es wird die suffiziente alternative option der blutstillung bei einem außergewöhnlichen casus mit fortgeschrittenem tumorleiden und infiltrationsbedingter blutung demonstriert, die kaum konventionell angehbar erschien.fallschilderung und therapieergebnis. eine -jährige patientin wurde mit hämorrhagischem schock intubiert und beatmet ü ber die rettungsstelle eingeliefert und reanimiert. in der anamnese war ein z.n. operativer spaltung eines schweißdrü senabszesses links-axillär vor jahr mit chronischer wundheilungsstörung (mikrobiologischer abstrich: gram-negative stäbchen, candida) bei inflammatorischem mamma-karzinom links (histologisch durch tumor-pe gesichert) und erfolgter palliativer strahlenchemotherapie bekannt. die sofortige notfallangiographie via a. femoralis sinistra erbrachte eine blutung aus dem proximalen segment der a. axillaris sinistra. in gleicher sitzung wurde interventionell-radiologisch ein selbstexpandierender endoluminaler stent (  mm viabahn + , gore, flagstaff, usa) ü ber die arterienläsion hinweg platziert, die eine umgehende suffiziente blutstillung erbrachte. die abschließende kontrollangiographie zeigte die korrekte stentlage mit sicherer peripherer perfusion im brachialen abstromgebiet ohne weiteren blutungsnachweis. am . postinterventionellen tag wurde die patientin nach zwischenzeitlicher antiseptischer wundpflege links-axillar entlassen.schlussfolgerungen. die endovaskuläre versorgung umgrenzter arterieller läsionen ist eine geeignete option, in schwierig zugänglichen arteriensegmenten aufgrund der anatomischen lokalisation, begleiterkrankungen und therapiekonsequenzen eine suffiziente blutstillung herbeizuführen und eine aufwändige, grundlagen. ,,omphalozele'' und ,,Ö sophagusatresie'' sind als einzelfehlbildungen häufig mit zusätzlichen malformationen vergesellschaftet. Ä ußerst selten ist das gleichzeitige vorkommen von omphalozele und Ö sophagusatresie, in der internationalen literatur sind nur einige wenige fallberichte zu finden.methodik. bei einem feten wurde sonographisch in der . ssw eine omphalozele diagnostiziert. die chromosomenanalyse (normaler weiblicher karyotyp) war unauffällig. das organscreening und die verlaufskontrollen ergaben keinen hinweis auf assoziierte fehlbildungen. bei der postpartalen untersuchung des neugeborenen war, abgesehen von der omphalozele und einem präaurikuläranhang rechts, klinisch und bildgebend keine zusätzliche malformation festzustellen. während der bauchwanddefektkorrektur kam es plötzlich zu beatmungsproblemen, zurückzuführen auf eine Ö sophagusatresie typ iii b nach vogt. nach anlage einer ,,schusterplastik'' wurde die tracheoösophageale fistel durchtrennt und, da das kind stabil blieb, eine endzu-end-Ö sophago-Ö sophagostomie angeschlossen.ergebnisse. der postoperative verlauf gestaltete sich, abgesehen von einer sich spontan schließenden leckage der Ö sophagusanastomose, komplikationslos. drei zusätzlich diagnostizierte kleine ventrikelseptumdefekte blieben asymptomatisch. das kind entwickelte sich in der folge aufgrund einer schweren schluckstörung allerdings nur bescheiden.diskussion. die intrauterine realisierung von mehrfachfehlbildungen ist schwierig. aber auch postpartal gelingt der nachweis einer fehlbildungskombination nicht immer. im seltenen fall kann eine gravierende fehlbildung gleichzeitig mit einer zweiten korrekturbedü rftigen, u.u. erst intraoperativ verifizierbaren anomalie vorkommen. die kombination von omphalozele und Ö sophagusatresie, einhergehend mit ventrikelseptumdefekten und einem präaurikuläranhang, ist ungewöhnlich und konnte keiner/m der in frage kommenden fehlbildungsassoziationen/-syndrome (vacterl-assoziation, charge-syndrom, schisis-assoziation) zugeordnet werden.schlussfolgerungen. wenn bei einem neugeborenen eine komplexe fehlbildungskombination zu keiner/m assoziation/ syndrom ,,paßt'', ist die prognoseeinschätzung in hinblick auf outcome und zukünftige entwicklung des betroffenen kindes schwierig. background. the prognosis of colorectal cancer is primarily determined by anatomic extend of disease and by amenability to radical resection. results of treatment in patients who underwent resection for colon and rectal cancer in two time periods were compared, before and after introduction of multidisciplinary tumor board in the second period. methods. in order to improve the results of colorectal cancer, a multidisciplinary tumor board was set up and beside the strict adoption of tme principles, an oncological treatment has been systematically included in the management. patients with colorectal cancer underwent a potentially curative resection between and . results were analyzed for two groups of patients given different diagnostic approach and treatment regimens during two consecutive year periods.results. the -year survival rate of r resected patients with colon cancer stage i and iii in the period - was significantly higher than of patients operated on between and (stage i: % vs. %; stage iii: % vs. %). similarly, the -year survival rate for r resected patients with stage iii rectal cancer between and was significantly better than that for patients operated on during the early period ( % vs. %).conclusions. patients who underwent r resection for colon and rectal cancer during the period - showed a significantly improved -year survival rate compared to those operated on between and . improved survival in these patients is to a great extent attributable to improvements in clinical practice combining surgery with other modalities of treatment. schlussfolgerungen. trotz der oft schwerwiegenden grunderkrankung der patienten und dem aggressiven infektionsmuster der zygomycosen und der daraus resultierenden schlechten prognose kann eine solche infektion bei chirurgischen handeln gepaart mit einer optimalen antimykotischen und intensivmedizinischen therapie überlebt werden. context. adipose tissue (at) macrophages are key suspects to cause obesity-associated insulin resistance. besides inflammatory mediators promoting insulin resistance, at macrophages express the hemoglobin scavenger receptor cd and the downstream enzyme heme oxygenase- (ho- ) that protect from free hemoglobin-induced oxidative stress and metabolize hemoglobin to anti-inflammatory mediators, respectively. background. aim of this study was to evaluate the association of cd and ho- expression in visceral and subcutaneous at with obesity, metabolic parameters, body fat distribution, and at inflammation.methods. morbidly obese patients (bmi > kg/m ) who underwent laparoscopic surgery for gastric banding (n ¼ ) were matched for age and sex to lean control subjects (bmi < kg/m; n ¼ ).main outcome measures. cd and ho- as well as the macrophage marker cd mrna expression was analyzed in visceral (omental) and subcutaneous at. moreover, serum concentration of soluble cd was determined by elisa.results. cd expression was highly upregulated in human at and soluble cd serum concentration was elevated in obesity. also ho- was upregulated in at and expressed exclusively in macrophages. while cd expression strictly correlated with macrophage abundance as assessed by cd expression, ho- upregulation by obesity exceeded the increase of cd , indicating a regulation within macrophages. strikingly, waist to hip ratio negatively correlated with relative visceral expression of ho- (p ¼ . ) and visceral ho- expression negatively correlated with homa-ir (p ¼ . ).conclusions. visceral ho- expression is determined by body fat distribution and attenuates obesity-induced insulin resistance. do we need to substitute vitamin b parenterally after gastric sleeve resection? background. daily oral multivitamin supplementation is recommended for patients after restrictive bariatric surgery, whereas after malabsorptive procedures or major gastric resections, parenteral substitution of vitamin b (vitb ) is mandatory.sleeve gastrectomy (sg), a mainly restrictive procedure, has been established in many bariatric surgical centers in the last few years, either as a definitive measure or as a first step before major malabsorptive procedures. the resected stomach volume has been reported between and ml. sg therefore amounts to a subtotal ( - %) gastrectomy.we analyzed serum values of vitb in order to assess the need for parenteral vitb supplementation in sg patients.methods. between jan. and aug. , patients ( females, males) underwent sg at our department. postoperatively, all patients were advised to take a multivitamin supplement daily. serum values of vitb were obtained after a median follow-up of months (range, . to months).results. fifty-two of patients displayed serum values of vitb within the normal range ( - pmol/l according to our laboratory). the median serum level of vitb was pmol/l (range, to pmol/l). neurological symptoms of vitb deficiency or macrocytosis were not observed.conclusions. vitb deficiency after sg is rare. on the other hand, the median serum level in our sg patients was far below the median laboratory value ( pmol/l), and eight values were within the so-called ''gray area'' ( - pmol/ l). this perhaps indicates incipient vitb deficiency and warrants further observation of rbc indices and serum vitb values in sg patients. grundlagen. die perforation der neoblase, nach zystektomie, ist selten. in der literatur sind solche spontanrupturen als einzelne case reports beschrieben. als ursache sind ischämien der neoblase oder mal-compliance des patienten bei der ,,blasenent-leerung'' zu nennen. in der vorliegenden arbeit wird erstmalig die laparoskopische neoblasen-Ü bernähung beschrieben. methodik. ein -jähriger patient, mit status nach zystektomie mit orthotoper anlage einer ,,ileumblase'' wegen rezidivierendem blasenkarzinom (t g ), präsentierte sich mit zunehmender dysurie, und fehlender vollständiger blasenentleerung. es zeigte sich bei der notfallaufnahme ein akutes abdomen, mit generalisierter peritonitis. in der computertomographie des abdomens fand sich freie flüssigkeit, jedoch keine freie luft und eine prall gefüllte ersatzblase. die katheterisierung der blase brachte keine beschwerdeverbesserung, auch war die retrograde füllung mit kontrastmittel nicht diagnostisch. laborchemisch bestand eine leukozytose von , g/l bei einem crp von mg/l.ergebnisse. in der notfallmäßig angeordneten diagnostischen laparoskopie zeigte sich im bereich des unterbauches freie flüssigkeit und fibrinauflagerungen im bereich der ersatzblase. nach füllen der neoblase mit ca. ml methylenblau konnte eine ,  , cm messende perforationsstelle, welche laparoskopisch übernäht werden konnte. der postoperative verlauf war unauffällig, entlassung des patienten mit klarer instruktion zur regelmässigen blasenentleerung nach tagen.schlussfolgerungen. das auftreten einer spontanruptur der neoblase ist selten. daran denken und die diagnose erzwingen background. posters are used widely at surgical meetings to present news of clinical and scientific research. posters are presented in special areas preferably at meeting points and provide a relaxed environment for exchanging ideas. especially for young scientists and surgeons poster presentations often are the first scientific contacts to the surgical community. many societies award ''best poster prices'' however mostly without uniformly agreed assessment methods. we generated poster assessment guidelines in a checklist to evaluate posters at surgical meetings.methods. according to well published guidelines for the designing and presentation of posters we constructed an evaluation checklist consisting of three main parts: presentation, design of the poster, background and purpose of the poster (scientific impact).results. the table shows our recommendation for the checklist in three parts.conclusions. awarding poster prices are stimuli especially for young scientists to participate at surgical conferences and meetings. however it can be very disappointing if great efforts have been applied to prepare posters and presentations and it is not possible to see through the evaluation process.therefore the evaluation process has to be objective as well as open and above board. the posters should be evaluated by independent scientist of different institutions. our assessment guidelines and checklist meet these mentioned requirements.an examination of the quality will show if this tool is applicable or not. background. complications after extensive thoracic surgery can be complex and life threatening, and diagnostic pathways are potentially difficult. we present the case of a years old patient who postoperatively developed an acute displacement of mediastinal structures by abdominal viscera after extrapleural pneumonectomy. methods. the patient was treated with extrapleural pneumonectomy in a curative intention. diaphragm was reconstructed with an artificial mesh implant after a major part of the diaphragm had to be resected. the mesh was fixed with interrupted non-absorbable sutures.results. due to failure of the diaphragmatic reconstruction and subsequent displacement of abdominal strucutes, acute displacement of the mediastinal structures occurred. initial x-ray led to the false diagnosis of suspected tension pneumothorax with a classical picture of mediastinal shift. the correct diagnosis was diagnosed by ct scan only. the treatment of choice therefore was operative revision and not the placement of a chest tube for decompression.conclusions. this rare but very dangeours complication after extensive cytoreductive surgery for malignant pleural mesothelioma is important to know for every general surgeon. interestingly the displaced stomach was massively bloated due to ''air trapment'', which led to the false diagnosis. only retrospectively, a very thin line in conventional x-ray was found being the stomach wall. in situations of postoperative impairment of a patient's condition after extensive thoracic surgery, we recommend to perform further diagnostic measures with early ct scan. in this situation placement of a chest tube would have been potentially harmful to the patient who recovered without further complication. erfolgreiche konservative therapie des postoperativen chylothoraxein klinischer algorithmus grundlagen. der chylothorax nach thorakalen chirurgischen eingriffen ist eine seltene aber wegen seiner metabolischen und nutritiven konsequenzen gefürchtete komplikation. die optimale therapie -konservativ versus operativ -wird kontrovers diskutiert. chirurgische reinterventionen sind häufig, neben dem nochmaligen operativen trauma und einer potentiellen versagensrate, mit einer erhöhten morbidität und mortalität assoziiert.methodik. alle konsekutiven patienten, die in unserer einrichtung während eines -jahreszeitraumes eine abdomino-thorakale Ö sophagusresektion wegen eines Ö sophaguskarzinoms erhielten, wurden in dieser studie prospektiv erfasst und im rahmen des internen qualitätsmanagements auf ihr komplikationsspektrum untersucht. bei diagnose eines postoperativen chylothorax' erfolgte primär die konservative therapie entsprechend eines an unserer einrichtung inaugurierten und etablierten therapiealgorithmus'.ergebnisse. von dezember bis november unterzogen sich patienten einer subtotalen Ö sophagusresektion wegen eines Ö sophaguskarzinoms. insgesamt drei patienten entwickelten einen postoperativen chylothorax, jeweils rechtsthorakal. dieser konnte nach klinischer und laborchemischer diagnosebestätigung (detektion von chylomikronen, triglyceridlevel > mg/dl) in allen fällen erfolgreich mittels ( ) totaler parenteraler ernährung, ( ) nahrungskarenz, ( ) pleuraler drainage sowie, ( ) subkutaner octreotidgabe, gefolgt von einer, ( ) speziellen oralen diät (mct-fette) therapiert werden. die mittlere behandlungsdauer dieser konservativen therapie betrug tage.schlussfolgerungen. beim vorliegen eines postoperativen chylothorax' sollte zunächst konservativen therapiemaßnahmen im stufenschema der unbedingte vorzug gegeben und diese ausgeschöpft werden. das chirurgische vorgehen hingegen ist frühzeitig bei versagen konservativer therapien sowie beim auftreten von komplikationen zu favorisieren. operability of advanced central lung tumors usually is limited and the prognosis is dismal. however, combination of chemoradio induction therapy owns the potential for significant downs taging of the tumor and can bring the patient back to operability, even in advanced tumor situations.we present the case of a years old patient with nsclc (t , n , m ; stage iiib) of the right upper lobe and infiltration of the carina. induction therapy with cycles of gemzar and cisplatin combined with gy local mediastinal radiation resulted in a major clinical response (yt , yn , m ; stage iib). this was followed by surgical resection (upper bi-lobectomy, resection of the carina, end to end anastomosis of the left main bronchus into the trachea, re-implantation of the right lower lobe into the left main bronchus; all performed under temporary ecmo support). pathological investigation revealed a complete response with no vital tumor cells left.this report demonstrates the potentials of modern combination therapy of extended lung tumors, emphasizing the value of aggressive induction therapy, followed by a technically demanding operation, in case of good clinical response. response to induction therapy, together with completeness of surgical resection, remains the most significant prognostic parameters for outcome.keywords. nsclc, carinal resection, ecmo, neoadjuvant chemo-radiotherapy, complete response. pulmonary benign metastasizing leiomyomatosis (bml) is a rare smooth muscle cell disorder of the lung. the prevailing treatment option is a primary excision of the nodules or if unresectable a long-time hormone therapy. herein, we present a case of bml in which a wait-and-see strategy after diagnosis has been decided.a -year-old female was admitted to the medical university of vienna presenting with multiple, bilateral suspect pulmonary tumor masses in . subsequent diagnostic workup revealed a bml. the patient refused a surgical intervention and hormone treatment was abandoned because of the patient's heavy menopausal disorders. as malign transformation of bml is uncommon a wait-and-see strategy was agreed upon. however, the patient was lost to follow-up, until in , years later, she developed expiratory rhonchus. a thoracic-ct revealed eleven intrapulmonary circumscribed circular foci. in addition the left lower-third was filled up with tumor mass and a giant cyst (diameter cm) extended into the thoracic cave. the nodules and the tumor mass were excised and the patient fully recovered without any evidence of a remaining disease. pulmonary bml nodules have been shown to stay constant for a long time. if resectable, a surgical excision is recommended as first line therapy. our case report indicates that a wait-and-see strategy is feasible but could lead to severe complications. we therefore conclude that a primary excision of bml tumor masses is preferable in order to avoid complications leading to more extended surgical interventions. background. pulmonary re-transplantation (prt) remains the only therapeutic option in some cases of severe primary graft dysfunction (pgd), advanced bronchiolitis obliterans sydrome (bos), and in some cases of severe airway problems (awp), mainly cicatriceal stenosis. however, its value has been questioned due to the overall scarcity of donor organs and reports indicating unsatisfactory outcome. we analyzed our institutional experience with prt to evaluate its value for different indications.methods. we retrospectively analyzed all patients undergoing prt in our department from august to august . we stratified patients according to indication for prt and analyzed the outcome.results. forty-six patients (mean age ae years, male and female) underwent prt ( bilateral lung-transplantations, single-lung-transplantations) for pgd (n ¼ ), bos (n ¼ ) and awp (n ¼ ). mean time to re-transplantation was ae days for pgd, , ae days for bos and ae days for awp. thirty-days, -year and -years survival rates after prt were . , . and . % for pgd; . , . and . % for bos. all patients with awp are presently alive (bos vs. pgd: p ¼ . ; bos vs. awp: p ¼ . ; pgd vs. awp: p ¼ . ). long-term survival rates for prt due to pgd are significantly lower, warranting restrictive use in this setting. in our experience prt for awp has shown excellent results.prt for chronic problems is a plausible approach, provided that patients are carefully selected. prt for pgd should be avoided.herzchirurgie /chirurgie der thorakalen aorta grundlagen. hämodynamisch wirksame stenosen der aorta, insbesondere am thorakoabdominellen Ü bergang sind eine seltene entität. Ü bliche behandlungsstrategie ist die konventionelle, chirurgische versorgung, neben der weiteren option einer axillo-bifemoralen bypassoperation. die endovaskuläre stent-graft insertion dient als behandlungmethode erster wahl für zahlreiche thorakale und abdominelle aortenpathologien. insbesondere bei älteren und multimorbiden patienten zeigt sie ihre vorteile.methodik. wir berichten von zwei patienten, die aufgrund von angina abdominalis, sowie claudicatio intermittens an unser zentrum transferiert wurden. in der computertomographie zeigte sich jeweils eine symptomatische stenose der aorta am thorakoabdominellen Ü bergang (,,coral-reef aorta''). aufgrund des hohen operationsrisikos, das sich insbesondere in den euroscores (numerisch bzw. ) zeigte, wurden beide patienten mittels transfemoraler, endovaskulärer stent-graft insertion versorgt.ergebnisse. beide patienten konnten wenige tage nach dem eingriff entlassen werden. die abschließenden kontrollen mittels computertomographie zeigten jeweils den stent-graft in korrekter position und voller entfaltung, sowie distal davon vollständig wiederhergestellte, antegrade perfusion. die patienten waren zu diesem zeitpunkt beschwerdefrei und zeigten auch in einer ct-kontrolle nach monaten keine veränderung dieser situation.schlussfolgerungen. gleich anderen aortenpathologien, wie perforierende ulcera, ist diese sogenannte korallenriffaorta das fortgeschrittene stadium eines obliterativen, atherosklerotischen chronisch-systemischen prozesses. gerade deshalb ist der allgemeinzustand dieser patienten meist sehr schlecht, weshalb minimal invasive therapieoptionen vorteilhaft erscheinen. obgleich wenig erfahrung mit der endovaskulären versorgung der aortenstenose am thorakoabdominellen Ü bergang existiert, könnte diese option zur behandlungsstrategie erster wahl werden, indem sie minimale invasivität mit maximaler effektivität vereint.paraplegia after thoracic surgery has been reported in the literature. the paraplegia rate after intrathoracic operations ranges between . and % overall. after vascular surgery for ruptured aneurysm of the thoracic aorta paraplegia has been reported up to %. however; this specific complication is greatly reduced for planned surgery ( . %). the thoracoabdominal approach for oesophageal resection is associated with a risk of . %. it is unclear, whether thoracotomy alone, regardless the extent of other surgical procedures bears a risk for paraplegia. the blood supply of the spinal cord in adult is highly variable. we report on a case of paraplegia after an uneventful thoracotomy in a year-old man. indication for surgery was an epiphrenic diverticulum of the oesophagus. paraplegia after thoracotomy is a rare but typical complication and should be mandatory included in informed consent. background. total supra-aortic rerouting as well as double vessel transposition followed by endovascular stent graft placement are now an established tool for the treatment of various aortic arch pathologies. however, details about the motion of the aortic arch after this procedure remain unknown. moreover, no perfectly fitting risk stratification score exists for outcome prediction of this specific patients.methods. we applied a fully automated method to quantify the deformation patterns of the aortic arch in a gated ct sequence. the aorta is detected and segmented by an active surface approach, that accurately identifies the vessel wall in all frames. the correspondences of landmarks on the vessel wall are established by tracking the deformation during the cardiac cycle, resulting in a dynamic deformation model of the structure.results. with help of this model, global and local deformation properties like stretching and bending were measured. after registering the models acquired pre-treatment, post-transposition, and post-stent-graft-placement we compared these local properties and were able to quantify the change caused to the aortic arch motion.conclusions. this new method of automated computational motion analysis of the aortic arch may establish a risk stratification score for outcome prediction after supra-aortic rerouting followed by endovascular stent-graft placement. background. simultaneous surgical repair and endovascular treatment are now a common approach for various aortic pathologies. for minimizing the risk of an untreated descending aorta after surgical repair of ascending aorta in acute stanford type a dissections a new type of bare-metal stents was established.methods. from august to january we performed combined surgical and endovascular treatment with the djumbodis dissection system in patients (mean age ) suffering from acute type a dissections.results. early results after treatment obtained by gated ct scans were satisfactory. nevertheless, thrombosis of the false lumen was not enhanced in most patients. combined surgical and endovascular approaches need stent devices with a self expanding capability, since the djumbodis stent seems to be not that attached to the aortic wall during systolic excursion.conclusions. additional implantation of the non-covered, non-self-expanding djumbodis device in the distal arch and the proximal descending aorta does in most cases not enhance thrombosis of the false lumen in patients undergoing surgery for acute type a dissections. the most limiting factor seems to be the non self-expanding capability of the device. the purpose of this study was to evaluate outcome in patients with a small aortic root receiving either a standard carbomedics or a top hat mechanical aortic valve. cox regression analysis revealed age, previous cardiac surgery, additional procedures at the time of valve replacement, nyha iv and severely impaired lvef to be independent predictors of survival.mechanical aortic valve replacement in the small aortic root is associated with substantial perioperative mortality. nevertheless, long-term outcome is satisfying. because the type of prosthesis does not predict outcome in the multivariate cox model, we conclude that use of the top hat prosthesis can be recommended for the challenging cohort of patients with a small aortic root. klinische abteilung für herz-thoraxchirurgie, wien, austria stumpfe thoraxtraumen können unabhängig vom unfallmechanismus und schweregrad des traumas zu mitralklappeninsuffizienz führen. die unterscheidung zwischen vorbestehender schädigung und traumatischer genese ist unter begutachtungsmedizinischen aspekten von großer bedeutung.kasuistik: ein jähriger gendarm wurde im rahmen einer Ü bung in knie-ellenbogen-position mit auf dem rü cken stehendem kollegen von einer mauer aus einer höhe von meter herab fallenden sandsäcken getroffen und erlitt ein hws-und bws-trauma. erst monate später wurde erstmalig ein herzultraschall durchgefü hrt und ein sehnenfadenabriss mit höhergradiger mitralinsuffizienz diagnostiziert und drei jahre nach dem trauma ein mechanischer herzklappenersatz vorgenommen.als häufigste ursache fü r eine posttraumatische insuffizienz der mitralklappe besteht ein papillarmuskel-abriss, seltener ein ausschließliches trauma der sehnenfäden. die literatur der jahre bis enthält berichtete fälle von isoliertem abriss von sehnenfäden mit höhergradiger mitralinsuffizienz, zwei davon als autoptische diagnose. das alter der in % männlichen betroffenen lag zwischen und jahren, im mittel , jahre. als unfallursache dominierten verkehrsunfälle unterschiedlicher art (n ¼ ; %) und in einzelfällen sturz aus meter höhe, gegen ein boot oder vom pferd sowie ein pferdetritt. das intervall zwischen ereignis und operativer versorgung durch rekonstruktion oder prothetischen ersatz lag zwischen tagen und jahren, in % ( von ) jedoch unter einem monat.die frage der ursächlichkeit ist meist retrospektiv zu beantworten. häufig sind fokussierte untersuchungsbefunde nicht verfügbar und bleibt die genese letztlich spekulativ. daher sollten nach jedem thoraxtrauma eine echokardiographie und anlässlich jeder herzoperation nach anamnestischem ereignis eine detaillierte makroskopische und histologische befundung durchgeführt werden. simultaneous mitral valve and lung surgery for complicated endocarditis and abscessing pneumonia over a thoracotomy approach a -year-old man developed severe sepsis after a blunt chest trauma. the patient suffered from presternal and cervical abscesses, mediastinitis, septic arthritis of the right shoulder, abscesses in the right and severe infective endocarditis of the mitral valve. after subcutaneous and mediastinal abscess drainage, hemodynamic stabilisation,and control of sepsis, biological mitral valve replacement and concomitant resection of the right lower pulmonary lobe were performed over a muscle sparing cm right anterior-lateral thoracotomy. restoration of the shoulder could be performed days later. the patient was discharged after weeks and is well one year after surgery. asd repair after a -month treatment with bosentan in a patient with severe pulmonary arterial hypertension large congenital type ii atrial septal defect (asd ii) can lead to precapillary pulmonary hypertension (pah) if not repaired in early childhood. once severe pulmonary hypertension or eisenmenger's syndrome have developed, asd closure is problematic due the increased risk of right ventricular failure and pulmonary hypertensive crisis. however, single case reports have demonstrated that a surgical correction of an asd is feasible, but requires long-time pre-and post-operative prostacycline treatment.we report the case of a patient with asd ii (  mm) and severe pulmonary hypertension (mpap mmhg). successful background. sternal wire fixation was first used in and since then was the preferred method for sternal closure, as it is inexpensive, fast and effective.however, as cardiac surgery patients get older and more debilitated, the risks of wire closure, namely breaking or cutting through porous bone often resulting in sternal nonunion and wound infection. therefore, alternatives are needed to ensure a reliable sternal closure.methods. during january to december a total of patients with am mean es of (mean age . years) underwent closure with the sternal talon. indication was copd and adipositas in patients each, delayed sternal closure in , parasternal sternotomy in and secondary closure after sternal wound infection and v.a.c. therapy in patients.results. all patients had combined procedures (cabgx and ake or mkr or both) with a mean operating time of min. the sternal talon was easy and convenient to use, with a mean implantation time of min. none of the patients developed a sternal nonunion or wound infection during follow up.conclusions. the sternal talon offers the advantage of a rigid sternal fixation without injuring the bone as it pulls the two sternum halves together, without cutting or screwing through the bone, thus preserving the bone integrity. full sternal closure is achieved in a minimum of time in contrast to other rigid fixation devices. through the non touch technique, patients experience less pain and can be mobilized in a shorter time. we want to share our experiences with the application of the stratos tm system (strasbourg thoracic osteosyntheses system) for the correction of chest wall deformities and reconstructive surgery of the chest wall after tumor removal.this system uses a titanium implant consisting of two adaptable rib clips and a length connecting bar.we will discuss one case of a benign condition and three cases of reconstructive surgery of the chest wall after radical resection of malignant tumors that were treated with the above described system. ergebnisse. im schnitt wurden , venensegmente bevorzugt vom oberschenkel entnommen.bei gleichzeitiger präparation der linken arterie mammaria tritt durch die endoskopische venenentnahme kein zeitverlust auf.in ( , %) fällen kam es zu einer verletzung der vsm. bei ( , %) patienten war eine konversion aufgrund einer starken blutung notwendig und bei eingriffen ( %) zusätzliche inzisionen.postoperativ beobachteten wir lediglich eine wundinfektion ( , %), welche mittels v.a.c. + system und anschließendem sekundärem wundverschluss behandelt wurde.schlussfolgerungen. die endoskopische entnahme der vsm ist eine sichere und mit weniger postoperativen komplikationen verbundene methode im vergleich zur konventionellen präparation.dies sollte einen routinemäßigen einsatz weiter fördern. prophylactic low-energy shock wave therapy improves wound healing after vein harvesting for coronary artery bypass graft surgery background. wound healing disorders after vein harvesting for cabg surgery increase morbidity and lower patient satisfaction. low-energy shock wave therapy (swt) reportedly improves healing of diabetic and vascular ulcers by overexpression of vascular endothelial growth fractor and downregulation of necrosis factor kappab. in this study, we investigate whether prophylactic low-energy swt improves wound healing after vein harvesting for coronary artery bypass graft surgery.methods. one hundred consecutive patients undergoing cabg surgery were randomly assigned to either prophylactic low-energy swt (n ¼ ) or control (n ¼ ). low-energy swt was applied to the site of vein harvesting after wound closure under sterile conditions using a commercially available swt system (dermagold; tissue regeneration technologies, woodstock, ga). a total of impulses ( . mj/mm( ); hz) were applied per centimeter wound length. wound healing was evaluated and quantified using the asepsis score.results. patient characteristics and operative data including wound length (swt ae cm versus control ae cm, p ¼ . ) were comparable between the two groups. we observed lower asepsis scores indicating improved wound healing in the swt group ( . ae . ) compared with the control group ( . ae . , p ¼ . ). interestingly, we observed a higher incidence of wound healing disorders necessitating antibiotic treatment in the control group ( %) as compared with the swt group ( %, p ¼ . ).conclusions. as shown in this prospective randomized study, prophylactic application of low-energy swt improves wound healing after vein harvesting for coronary artery bypass graft surgery. myocardial regeneration by shock wave therapyan in-vitro examination background. inflammation and thrombogenicity are important issues in cardiovascular tissue engineering. this in-vitro study was designed to investigate the influence of platelet alpha granule release on polymorphonuclear leukocytes (pmn) adhesion and activation on the decellularized porcine matrix.methods. cryostat sections of decellularized porcine heart valves were sequentially incubated with platelet-rich plasma (prp) and isolated, autologous pmn. to block -granule release platelets were pre-incubated with either cytochalasin d (cytd) or iso-butyl-methyl-xanthine (ibmx). to investigate the involvement of the complement system, specimens were exposed to prp that had been pre-incubated with mm edta. at the end of the incubations, specimens were fluorescently stained for cd , thrombospondin- (tsp- ), cd , cd b, and the complement factor ic b.results. laser scanning microscopy revealed the binding of multiple platelet aggregates to the decellularized porcine tissue surface. platelet adhesion was associated with up regulated expression of tsp- . pre-treatment of tissue specimens with prp induced a strongly enhanced binding and activation of subsequently added pmn. inhibition of platelet -granule release by either cytd or ibmx markedly reduced the secretion of tsp- correlating with a decreased pmn adhesion and cd b expression. although inhibition of complement activation by addition of edta to prp inhibited ic b deposition, it failed to prevent pmn binding.conclusions. the decellularized porcine heart valve matrix represents a high thrombogenic surface. activated platelets induce subsequently pmn adhesion and activation. the platelet/pmn interaction seems therefore to play a key role in the early, non-specific inflammatory response towards the decellularized xenogenic matrix independent from complement activation. acute cellular allograft rejection (acr) remains a significant problem in cardiac transplantation. calreticulin (crt) is a ca þ binding chaperone suppressing activity of the sarcoplasmic/endoplasmic reticulum ca þ -atpase (serca a) responsible for ca þ homeostasis in cardiac muscle. acr is associated with apoptosis and crt induces apoptosis in mature cardiomyocytes. whether myocardial crt expression plays a role in ca þ -dependent apoptosis in acr is unknown.crt and serca a mrna expression was quantified by real time rt-pcr in routine endomyocardial biopsies (embs) of transplanted patients (n ¼ ) at , , , , , , and weeks post-transplant and when clinically indicated. the apoptotsis was assessed in embs with tunel assays. graft rejection was histologically diagnosed and scored according to ishlt guidelines.myocardial mrna expression of crt was significantly increased (p < . ) while serca a mrna levels were decreased (p < . ) in acr grades r- r compared to embs with grade at all post-transplant weeks. moreover, crt mrna expression were significantly elevated in acr grades r- r compared to grade r (p < . ). in addition, significant positive correlation between increased crt expression (r s ¼ . ; p < . ) and negative correlation between decreased serca a (r s ¼ À . ; p ¼ . ) and the degree of emb apoptosis was observed.these results suggest that crt is involved in disruption of intracellular calcium regulation and mediates ca þ -dependent cellular apoptosis in cardiac grafts with acr. moreover, assessment of crt levels could be an accurate and quantitative method to diagnose and score acr. further studies are necessary to establish the benefit of targeting crt in the cardiac acr treatment. methodik. im tierexperiment wurde bei schafen am kardiopulmonalen bypass die aorta ascendens geklemmt und kristalloide kardioplegielösung infundiert. nach min wurde nachkardioplegiert. in der gruppe i (n ¼ ) wurde nadh zur kardioplegielösung beigegeben. in der kontrollgruppe (gruppe ii, n ¼ ) wurde kardioplegie ohne nadh zusatz verwendet. nach min wurde die aortenklemme geöffnet und das herz reperfundiert. nach einer reperfusionsphase von min und stabilisierung der hämodynamischen und elektrophysiologischen parameter wurde der kardiopulmonale bypass beendet. nach weiteren min wurden myokardstücke aus dem linken ventrikel entnommen und mit patch-clamp technik untersucht. weitere stücke wurden mit der gefrierzange entnommen und in flüssigem stickstoff bis zur weiteren analyse gelagert.ergebnisse. in gruppe i kam es zu einem signifikanten atp anstieg (p < , ) im vergleich zur kontrollgruppe. der unterschied an atp werten spiegelt eine verbesserung des metabolischen zustandes in der nadh gruppe wider. weiters wurde der ladungszustand der zellen, der den energiestatus repräsentiert, verbessert.schlussfolgerungen. nadh zusatz könnte durch seine positiven effekte auf den metabolismus in herzmuskelzellen ein potenter pharmakologischer und therapeutischer ansatz sein. isolation und selektive ablation von autonomen ganglienplexus bei linksatrialer vorhofablationcase report grundlagen. autonome ganglien-plexus haben als trigger einen einfluss auf die entstehung von vorhofflimmern. durch selektive ablation dieser ganglien im rahmen der pulmonalvenenisolation konnte gezeigt werden, dass der erfolg der ablation von % auf % zunimmt.methodik. bei einem -jährigen patienten wurde im rahmen der mitralklappenrekonstruktion wegen permanentem vorhofflimmern eine linksatriale vorhofablation mit medtronic cardioblate + maps durchgeführt. intraoperativ wurden die autonomen ganglien am rechten und linken atrium durch hochfrequenzstimulation am schlagenden herzen epikardial isoliert. als positive antwort wurde eine verlängerung der rr-intervalle um mindestens % gewertet. diese stelle wurde mit dem cardioblate + maps pen selektiv abliert. anschließend wurde am offenen herzen die endokardiale ablation mit isolation der pul- key: cord- - ht cqhu authors: smith, silas w. title: drugs and pharmaceuticals: management of intoxication and antidotes date: - - journal: molecular, clinical and environmental toxicology doi: . / - - - - _ sha: doc_id: cord_uid: ht cqhu the treatment of patients poisoned with drugs and pharmaceuticals can be quite challenging. diverse exposure circumstances, varied clinical presentations, unique patient-specific factors, and inconsistent diagnostic and therapeutic infrastructure support, coupled with relatively few definitive antidotes, may complicate evaluation and management. the historical approach to poisoned patients (patient arousal, toxin elimination, and toxin identification) has given way to rigorous attention to the fundamental aspects of basic life suppport — airway management, oxygenation and ventilation, circulatory competence, thermoregulation, and substrate availability. selected patients may benefit from methods to alter toxin pharmacokinetics to minimize systemic, target organ, or tissue compartment exposure (either by decreasing absorption or increasing elimination). these may include syrup of ipecac, orogastric lavage, activated single- or multi-dose charcoal, whole bowel irrigation, endoscopy and surgery, urinary alkalinization, saline diuresis, or extracorporeal methods (hemodialysis, charcoal hemoperfusion, continuous venovenous hemofiltration, and exchange transfusion). pharmaceutical adjuncts and antidotes may be useful in toxicant-induced hyperthermias. in the context of analgesic, anti-inflammatory, anticholinergic, anticonvulsant, antihyperglycemic, antimicrobial, antineoplastic, cardiovascular, opioid, or sedative-hypnotic agents overdose, n-acetylcysteine, physostigmine, l-carnitine, dextrose, octreotide, pyridoxine, dexrazoxane, leucovorin, glucarpidase, atropine, calcium, digoxin-specific antibody fragments, glucagon, high-dose insulin euglycemia therapy, lipid emulsion, magnesium, sodium bicarbonate, naloxone, and flumazenil are specifically reviewed. in summary, patients generally benefit from aggressive support of vital functions, careful history and physical examination, specific laboratory analyses, a thoughtful consideration of the risks and benefits of decontamination and enhanced elimination, and the use of specific antidotes where warranted. data supporting antidotes effectiveness vary considerably. clinicians are encouraged to utilize consultation with regional poison centers or those with toxicology training to assist with diagnosis, management, and administration of antidotes, particularly in unfamiliar cases. the challenges to effective evaluation and management of a patient poisoned by drugs and pharmaceuticals are diverse. the circumstances surrounding exposure are often incompletely accessible. poisoning signs or symptoms may be subtle or delayed. patient-specific factors -pharmacogenetics and unique susceptibilities, drug-drug interactions, cultural or geographic practices, and underlying comorbidities -may complicate presentation, response to treatment, and outcome. polypharmacy or mixed exposures may confuse the clinical presentation. compared to the near-inexhaustible list of products and possible combinations, few specific antidotes exist. the toxicological profiles of newly intro-organ injury. specific management of toxicant-induced hyperthermias follows later. hypothermia may require active or passive rewarming techniques. clinical hypoglycemia, which implies neuroglycopenia, must be rapidly reversed with administration of . - . g/kg of age-appropriate dextrose-containing solutions (d in adults, d in children, and d in neonates). benzodiazepines (e.g., diazepam, midazolam, and lorazepam) are generally well tolerated and are first line agents for drug-and withdrawal-induced seizures and agitation. persistent or refractory seizures should prompt consideration of empiric administration of pyridoxine and barbiturates (phenobarbital, pentobarbital), propofol, or ultimately, general anesthesia. coincident endotracheal intubation may be required. phenytoin and non-barbiturate anticonvulsants are typically ineffective or harmful in toxin-induced seizures [ , ] . altered mental status should also prompt parenteral administration of mg thiamine hydrochloride. alcohol-dependent patients without clinically apparent wernicke's encephalopathy may require at least mg of parenteral thiamine to improve neurological symptoms; overt wernicke's encephalopathy necessitates a minimum of mg thiamine hydrochloride three times daily for - days [ ] . naloxone use is considered in a separate section. toxidromes (toxic syndromes) are characteristic signs and symptoms that correlate with exposure to certain xenobiotics. identifying toxidromes suggests the etiology of the patient's condition and helps guide management. "classic" class-effect toxidromes include anticholinergic, cholinergic, sedative-hypnotic, sedative-hypnotic withdrawal, opioid, and opioid withdrawal. these should be actively sought and managed if identified. while the patient is being stabilized, diagnostic investigations including a complete and thorough history and physical examination, laboratory analyses, and radiological studies may be undertaken to further characterize the exposure and effect. for significantly compromised patients, a typical "chemistry panel" (providing electrolytes, blood urea nitrogen, creatinine, and indirectly the anion gap), a complete blood count, arterial (or venous) blood gas, and lactate are reasonable studies. urine or serum ketones may be required to determine the etiology of acidemia. female patients benefit from an assessment of pregnancy status. it is useful to determine a serum acetaminophen concentration in suicidal patients or those with altered consciousness, as patients with significant acetaminophen poisoning may present without a toxidrome. serum acetaminophen is detectable in - % of patients without a reported history of ingestion; treatable concentrations are found slightly less frequently [ , ] . toxin-specific studies and other serum determinations are often not rapidly returned and should be obtained only if suggested by the history, physical examination, or bedside testing. urine drug screening (uds) is of minimal use in the acute management of intoxication. results are not typically returned for hours; a reported "positive" substance may not be the proximate cause of the presenting condition (as the measured metabolites may persist in urine for days to weeks); and the uds lacks sensitivity and specificity (particularly for opioids, benzodiazepines and other sedative-hypnotics, and amphetamines). selected patients may benefit from methods to alter toxin pharmacokinetics -limiting exposure. a discussion of these modalities and their risks and benefits occurs in the following section. ultimately, patients will require disposition depending of severity of presentation and anticipated sequelae, which may range from admission to intensive care units, cardiac monitoring (telemetry) units, ward beds, continued emergency department evaluation, to discharge. a psychiatric assessment and social assessment, when appropriate, should precede release from medical care. appropriate and early consultation with medical toxicologists or regional poison centers may also assist with diagnosis and management. in the u.s., this has been simplified by a uniform telephone number ( . . . ) for regional poison center consultation. the international programme on chemical safety (ipcs) maintains a world directory of poison centers (http://www.who.int/ipcs/poisons/centre/directory/en/). adjuncts to alter toxicant pharmacokinetics aim to minimize systemic exposure (either by decreasing absorption or increasing elimination) or to minimize exposure of a target organ or tissue compartment. in practice, this is achieved by expulsion or removal from the upper gastrointestinal tract (induced emesis, gastric lavage, or endoscopy); intraluminal binding to adsorptive materials (activated charcoal); or increasing intestinal transit time (cathartics and whole bowel irrigation). endogenous elimination may be improved by more effective urinary clearance (urinary alkalinization and forced diuresis), improved hepatobiliary clearance, or "gut dialysis" with multiple-dose activated charcoal. rarely, hepatic metabolism is altered to preclude ultimate toxicant formation (e.g., cimetidine to mitigate production of dapsone's methemoglobinemia inducing metabolite). exogenous clearance utilizes hemodialysis, charcoal hemoperfusion, continuous renal replacement therapies, and exchange transfusion. all the adjuncts attempt to shift where a patient lies upon a particular dose-response curve (fig. ) . drug recovery following gastrointestinal emptying techniques has been inconsistent; human studies attempting to demonstrate a survival benefit of any decontamination modality are inconclusive. randomized trials in which a control group might not receive any decontamination could be considered unethical; volunteer studies using sublethal doses of xenobiotic cannot show mortality benefit. as might be anticipated from the fact that supportive care suffices for the majority of poisoned patients, a typical study of routine administration of charcoal following oral overdose of primarily benzodiazepines, acetaminophen, and selective serotonin reuptake inhibitors could not demonstrate benefit [ , , ] . past studies have suffered from significant exclusions. recommendations are based both on theoretical grounds (animal and in vitro studies demonstrating lower peak serum concentration or faster serum drugs and pharmaceuticals: management of intoxication and antidotes clearance) and human studies with surrogate endpoints such as marker studies or area under the curve of plasma concentration versus time (auc) improvement. aggressive detoxification may be required for certain lethal toxins for which few antidotal options exist. most gastric emptying techniques are thought to be relatively ineffective beyond hour. these constraints diminish possible benefit. for example, the median time from ingestion to arrival at a health care facility is on the order of hours, and only about % of patients can be lavaged within the idealized -hour time frame [ ] . although in ideal situations (patients presenting early to experienced health care providers with readily available ipecac syrup) pill retrieval averages - %, ipecac's benefits can be completely negated when administration is delayed as briefly as min [ ] [ ] [ ] [ ] . when orogastric lavage is performed by experienced providers within min of ingestion, clinical manifestations of ingested xenobiotics have been prevented [ ] . practically, efficacy of tablet retrieval rates reduces to % in some cases and improvements in auc vary from zero to % (averaging ~ %) [ , [ ] [ ] [ ] . similarly, restricting activated charcoal (ac) administration to patients presenting to health care within the first hour post ingestion would exclude up to % of poisoned patients from the potential benefits of ac when administered beyond an hour [ , ] . earlier administration of ac is more efficacious [ ] . however, home and prehospital use of ac decreases the time to treatment, but has not improved clinical outcomes [ ] . drugs with opioid or anticholinergic properties that decrease peristalsis or particularly large ingestions, which independently decrease intestinal motility, may modify decision making in delayed presentations [ , ] . figure . adjuncts to alter toxicant pharmacokinetics attempt to shift where a patient lies upon a particular (idealized) dose-response curve. risk will likely outweigh benefit if the patient begins at point a (negligible morbidity and mortality) and systemic exposure is reduced to b. this is the case for many drug poisonings which are managed effectively by supportive care alone. decontamination might provide significant benefit if the patient lies upon the steep aspect of the curve [reduction from c to d -the same fixed amount as from a to b (although a percentage reduction could also be envisaged)]. with overwhelming overdose (point e), despite decontamination, benefit would be unlikely (point f). independent of side effects, the efficacy of one modality over another or combination therapy is debated. some studies rate ipecac syrup more efficacious than orogastric lavage, but most studies have found little or no difference, and neither has been shown to be more effective than spontaneous emesis [ , , , ] . ac has demonstrated ~ % better reductions in auc than ipecac, which may improve or worsen its efficacy [ , , ] . gastric lavage adds no benefit to ac, except for the most critically ill patients [ , , ] . compared directly, ac has better impact than lavage on auc and clinical effect [ , , ] . data are equivocal regarding whole bowel irrigation's ability to function similar to multiple-dose ac (mdac) as a medium for "gut dialysis" [ , ] . syrup of ipecac is obtained from a root extract of the amazonian flowering plant psychotria ipecacuanha [ ] . its active alkaloid components, cephaeline and emetine, induce emesis via local irritation and central stimulation of -hydroxytryptamine (serotonin) -ht receptors [ ] . following appropriate dose ( ml for infants, - ml for children under , and ml otherwise), roughly % of patients have a first episode of emesis within min [ , ] . patients average three episodes in min [ ] . however, since ipecac's removal from most homes, the median time to administration in the acute care setting is delayed on the order of an hour, with only one-third of patients successfully vomiting within the first hour post ingestion [ ] . indications for ipecac are limited. a routinely cited example is a patient known to have taken multiple lithium tablets, which do not bind ac and may not fit through a lavage tube, who presents early to health care [ ] . the american academy of pediatrics no longer recommends ipecac syrup for home use; ipecac use does not impact outcomes or decrease utilization of emergency services [ , ] . ipecac may or may not have a role in other rare ingestions that mandate gastrointestinal decontamination, but are not amenable to orogastric lavage, ac, whole bowel irrigation, or an antidote; the patient must present alert and early (< min post ingestion) to medical care [ ] . unsurprisingly, ipecac's most common side effect is persistent emesis. as many as eight emetic episodes occurring more than min after ipecac administration have been reported [ ] . this impairs administration of oral therapeutic agents, as induced emesis can last up to several hours [ ] . prolonged vomiting associated with induced sedation or absent airway reflexes increases the risk of aspiration bronchospasm, pneumonitis, and pneumonia [ , ] . other life-threatening side effects have been reported, including bradycardia, cns depression, mallory-weiss esophageal tears, pneumomediastinum, pneumoretroperitoneum, and intracranial hemorrhage [ ] . emesis of caustics reexposes damaged esophageal mucosa to the caustic agent. analogous pulmonary aspiration concerns accompany induced emesis of hydrocarbons. orogastric lavage is performed via a large bore orogastric tube (adults, [ ] [ ] [ ] [ ] [ ] french; children, - french) with fenestrae large enough to accommodate whole tablets [ ] . serial -ml aliquots ( - ml in pediatric patients) of normal saline or lactated ringer's solution are administered and suctioned until retrieved liquid is clear. orogastric lavage can be expected to have its best risk-to-benefit ratio when patients present early enough to have a significant gastric burden, and when severe toxicological effects are manifest or expected to become manifest [ , ] . because advancement of stomach contents does occur despite proper left lateral decubitus positioning [ ] , ac (see below) is sometimes provided prior to crystalline lavage [ , ] . introduction of a large, relatively rigid tube requires a cooperative patient with a protected airway (typically an endotracheal tube if the patient is ill enough to warrant gastric lavage). orogastric lavage risks hypoxia, dysrhythmia, laryngospasm, hypothermia, gastrointestinal or pharyngeal traumatic laceration or perforation, fluid and electrolyte abnormalities, and vomiting with subsequent aspiration pneumonia [ , , ] . ac is a convoluted macromolecule created via pyrolysis of carbonaceous material and subsequently "activated" with steam to further increase surface area [ ] . the multiple pores of various size on the surface of each macromolecule of ac account for its high adsorptive affinity for a multitude of xenobiotics -particularly chemical species that are nonionized, aromatic, and/or branched [ , , ] . maximal xenobiotic binding occurs in - min [ ] . ac decreases auc by as much as %, seems to improve clinical outcomes for critically ill patients, and may benefit in certain poisonings such as acetaminophen [ , , , ] . it also increases the rate of endogenous clearance of drugs with long half-lives and some degree of entero-enteric or enterohepatic circulation [ , , ] . those findings suggested the use of mdac as a "gut dialysis" for toxins with slow pharmacokinetics [ , ] . a meta-analysis of volunteer studies demonstrated increased clearance of xenobiotics with longer half-lives, but not necessarily improved clinical outcome [ , ] . mdac has enhanced amitriptyline, carbamazepine, dapsone, dextromethorphan, phenobarbital, phenytoin, quinine, and theophylline elimination, although without definitive clinical benefit in controlled trials [ , , ] . two studies provided conflicting results for survival benefit of mdac for yellow oleander poisoning [ , ] . the fraction of unbound xenobiotic decreases as the charcoal-to-toxin ratio increases from . : up to : , although the yield curve levels off near : [ , ] . in theory, the dose of ac administered to a poisoned patient would be ten times the mass of ingested xenobiotic, but those values are unknown in most clinical situations [ ] . ac is practically dosed based on the patient's weight ( g/kg), which can be divided into multiple smaller doses to be administered every - hours [ ] . although optimum dosing is unclear, mdac is administered hourly, every hours, or every hours at a dose equivalent to . g/hour [ ] . pediatric charcoal doses are lower due to generally smaller ingestions and gut capacity. the total dose administered is the major determinant of efficacy particularly for larger overdoses, and can be administered continuously [ ] . emesis occurs in up to % of patients receiving ac; patients receiving ac via nasogastric tube or who vomited previously are at greater risk for emesis [ , ] . rarer complications include aspiration and intestinal obstruction or perforation [ , , , ] . aspirated ac may produce bronchiolitis obliterans, acute respiratory distress syndrome (ards), and death [ ] . ac adheres to mucosa and obscures endoscopy; mineral acids and bases will not adhere to charcoal. ac poorly adsorbs short chain alcohols and metals such as iron, lead, and lithium [ ] . ac administration requires an intact mental status or protected airway. flavoring agents increase the palatability of ac for volunteers, but poisoned patients do not show increased compliance/tolerance with flavored ac [ ] . cathartics induce watery evacuation of bowel within a few hours. hyperosmotic cathartic agents such as sorbitol are non-absorbed, osmotically active substances that draw water into the lumen, where increased intestinal volume and pressure promote peristalsis. so-called "saline" cathartic agents such as magnesium salts also directly stimulate smooth muscle to induce peristalsis [ ] . cathartics alone are not recommended for ingested poisons [ ] . cathartics have many adverse effects, including volume depletion, hypernatremia, hypermagnesemia, hyperphosphatemia, hypocalcemia, metabolic alkalosis, pain, nausea, emesis, and flatus [ , ] . sorbitol or laxatives are sometimes used in conjunction with the first dose of ac. while theoretically beneficial -minimizing the possible constipation of ac or promptly delivering ac to the duodenum, they do not increase the efficacy of ac [ , , ] . sorbitol is implicated in the fluid/electrolyte changes that occur with mdac: hypermagnesemia, hypernatremia, and volume depletion [ , , ] . repetitive cathartic doses have been associated with rectal prolapse and death [ , ] . whole bowel irrigation (wbi) employs polyethylene glycol (peg), a large, non-absorbable organic polymer and an electrolyte lavage solution (els) is-drugs and pharmaceuticals: management of intoxication and antidotes osmotic to serum. large peg-els volumes are introduced into the alimentary canal with less risk for fluid and electrolyte shifts caused by traditional cathartics. peg-els provides non-viscous bulk for rapid transit of material in a normally functioning gastrointestinal tract. wbi should induce evacuation within min, but requires hours on average for complete effect. reported improvements in auc are modest given the more rapid absorption time for most pharmaceuticals [ ] . however, reduction in auc can be as high as % with poorly absorbed products or modified release preparations [ ] . wbi might be considered for slowly absorbed significant ingestions such as iron, lead, and lithium, as well as modified-release preparations of β-adrenergic antagonists, bupropion, calcium-channel antagonists, carbamazepine, and theophylline [ ] [ ] [ ] [ ] . wbi is also employed to rid patients of enterally transported illicit substances which produce toxicity upon packet rupture or leakage (e.g., cocaine, heroin, and methamphetamine) [ ] . standard dosing protocols are . - l/h ( ml/kg per h) enterally until rectal effluent is clear [ ] . at this point, intestinal contents are assumed to have been displaced, although this is not always true [ , ] . nasogastric tube placement is generally required to sustain compliance with the large volume requirements, and pretreatment with an antiemetic is prudent [ ] . wbi may produce nausea, vomiting, cramping, and flatus. peg-els for colonoscopy has precipitated colonic perforation [ ] . unintentional bronchial administration of peg-els can produce acute lung injury [ ] . ileus, obstruction, perforation or threatened perforation should preclude wbi; a protected airway is required. desorption of toxins from ac by peg has been demonstrated in vitro and in vivo [ , ] . support for endoscopic therapy consists of limited case reports of retrieval in ingestions of cocaine packets, lead pellets, and medication such as sustained release calcium channel antagonists, clomipramine, iron, and meprobamate [ ] [ ] [ ] [ ] [ ] . the procedure might be warranted for certain ingestions or cases of pharmacobezoar formation of toxic substances. complications include perforation, aspiration, hemorrhage, and anesthetic-associated hemodynamic changes. when endoscopy fails, surgery may be required for definitive removal [ , ] . surgery may be required in patients with enterally transported illicit substances either due to failure of passage (with or without wbi), obstruction, or severe toxicity upon packet rupture or leakage [ , ] . weak acids in an alkaline environment exist predominantly in ionized form. biological membranes are relatively impermeable to these charged molecules. alkaline serum thus inhibits the diffusion of acidic toxins (low pk a ) across cellular membranes. similarly, an alkaline urinary ph promotes renal sequestration (or "ion-trapping") of acidic species from the systemic circulation. the relative intolerance of biological systems to acidosis limits the effectiveness of converse urinary acidification (via ascorbic acid or diluted hcl solutions) for renal sequestration of weak bases. critically ill patients may have reduced drug clearances due to decreased hepatic and renal perfusion, and thus interventions that increase clearance/ elimination have the potential to significantly reduce toxicity [ ] . alkalinization improves renal elimination of chlorpropamide, , -dichlorophenoxyacetic acid, diflunisal, fluoride, mecoprop, methotrexate, phenobarbital, and salicylate [ ] . urine alkalinization is considered first line therapy in patients with moderate salicylism who do not meet hemodialysis indications. dosing of - meq/kg of . - . % bicarbonate provided over - min is followed by "normal" bicarbonate infused at double the standard rate of i.v. fluid maintenance. the "normal" bicarbonate solution is prepared by adding three ampules of sodium bicarbonate (totaling - meq) in l % dextrose in water (d w). the rate is titrated to maintain an alkaline urinary ph, without exceeding a serum ph of . [ ] . alkalemia decreases ionized calcium. volume overload may occur, particularly in patients with congestive heart failure, acute renal failure, or end-stage liver disease. bicarbonate treatment induces hypokalemia. as the proximal renal tubular cells conserve serum potassium by exchanging protons for urinary potassium, this defeats urinary alkalinization. therefore, maintaining a normal serum potassium, with frequent monitoring and supplemental administration and/or inclusion in the bicarbonate solution, are important components of urine alkalinization. saline diuresis is utilized to improve excretion and minimize toxicity of overdose of ions such as magnesium, calcium, and lithium in patients who do not meet hemodialysis indications [ ] [ ] [ ] . hypermagnesemia may occur with excessive antacid use, gargling or ingesting magnesium sulfate compounds, and iatrogenic error [ , ] . hypercalcemia can result from excess calcium (in antacid tablets) or vitamin d ingestion or parenteral administration [ , ] . renal lithium toxicity presumably results from cytotoxic accumulation of lithium entering via the apical epithelial sodium channel [ ] . ensuing nephrogenic diabetes insipidus, characterized by increased water and sodium diuresis, can result in dehydration, hyperchloremic metabolic acidosis, and renal tubular acidosis. in volume depletion, activation of the reninangiotensin-aldosterone axis leads to active resorption of sodium, and thus lithium, from the distal convoluted tubules. therefore, adequate volume repletion with saline is prerequisite for effective renal elimination of lithium. boluses of . % sodium chloride are administered until the patient is clinically euvolemic. saline infusion is then provided at . - times a standard maintenance rate. throughout treatment renal function, urine output, and electrolytes are monitored. congestive heart failure, renal failure, or end-stage liver disease moderate volume administration and make saline diuresis less attractive than hemodialysis in significant ingestions. loop diuretics such as furosemide inhibit sodium resorption in the proximal convoluted tubules, and would theoretically promote elimination of lithium as natriuretics. however, these effects are countered by the action of the renin-angiotensin-aldosterone axis on the distal convoluted tubules, and diuretics do not seem to improve outcomes in lithium overdose or radiographic contrast exposure [ , ] . in hemodialysis (hd) the patient's blood is pumped through a circuit that includes a cartridge consisting of thousands of semi-permeable, membranelined capillary tubes. the blood traverses the cartridge counter-current to a circulating buffered salt solution (a.k.a. dialysate) before returning to the patient's venous circulation. diffusible molecules flow down their electrochemical gradient from the serum to the dialysate. hemoperfusion (hp) employs a similar circuit, but the cartridge is enveloped with ac (rather than a circulating dialysate) to adsorb xenobiotics regardless of plasma protein binding, and leave serum electrolytes largely unchanged. continuous arteriovenous or venovenous hemofiltration (cavh or cvvh) employ lower pressures and flow rates than hd over longer sessions for patients unable to tolerate hd or to remove xenobiotics with slow tissue redistribution [ , ] . peritoneal dialysis (pd) is ineffective in poisoning management, given its inherently slow kinetics and the availability of hd [ ] . extracorporeal therapies may be warranted when criteria are met for both the xenobiotic and the patient [ ] . favorable dialyzable toxin properties include low volume of distribution (v d ), relatively low molecular weight, and poor serum protein binding (or binding that worsens in overdose, as is the case for salicylate and valproate) [ ] . patient characteristics suggesting extracorporeal therapy include signs or symptoms of significant end organ toxicity; impaired elimination secondary to baseline comorbidities or critical illness-induced hypoperfusion; inability to tolerate or refractory to antidotal strategies (such as bicarbonate or saline); inadequate response to supportive care measures; concurrent electrolyte derangements (e.g., metformin-associated lactic acidosis); or serum drug concentrations historically associated with severe outcome [ ] . traditionally, charcoal hp was used for xenobiotics significantly bound to plasma proteins, but its use is declining while (high-flux membrane) hd increases. methanol, ethylene glycol, salicylates, lithium, halides, theophylline, and metformin-associated lactic acidosis are commonly treated with dialysis [ ] . hd is used for valproate and carbamazepine poisoning; however, in the absence of high-flux dialysis membranes, the characteristics of charcoal hp may more appropriately address the larger v d and protein binding [ ] . common side effects of extracorporeal elimination include hypotension, bleeding, and infection. enhanced clearance of therapeutic medications and antidotes (e.g., antibiotics, fomepizole, n-acetylcysteine, water-soluble vitamins) may occur. the need for dialysis must be anticipated early; several hours of preparation time may be required to secure vascular access, equipment, and personnel. exchange transfusion is a total blood volume exchange administered in small aliquots. serial frequent phlebotomy of a small amount of circulating blood occurs with simultaneous transfusion of equivalent donor blood. this process is repeated until two to four vascular volumes have been exchanged. while the procedure is very rarely used for toxin removal, exchange transfusion is more familiar to clinicians treating severe hemolytic diseases of the newborn, hyperbilirubinemia without hemolysis, and sickle cell crisis. exchange transfusion removes xenobiotics that are large or bound to plasma proteins, such as thyroxine, iron, or theophylline [ , ] . for lifethreatening ingestions, exchange transfusion is a viable option for neonates and infants whose immature vasculature cannot tolerate extracorporeal elimination modalities or in institutions lacking pediatric dialysis capacity. exchange transfusion has been successfully employed in pediatric iron, isoniazid, phenobarbital, salicylate, theophylline, and vincristine overdose [ ] [ ] [ ] [ ] [ ] [ ] . it has also been suggested for refractory drug-induced methemoglobinemia [ ] . whole blood exchange was utilized in an adult with a fold cyclosporine dosing error [ ] . anticipated complications arise from vascular access, bleeding, hypoglycemia, hypotension, and blood product administration (immune-mediated reactions, blood incompatibility, and infections). several hyperthermic syndromes are caused by xenobiotics. these are generally spectrum disorders, whose features may overlap with other conditions such as cns infection, agitated delirium, and sepsis. malignant hyperthermia (mh) occurs in patients with an autosomal-dominant defect in genes encoding the skeletal muscle ryanodine receptor (ryr- ) or the voltage-gated calcium channel (cav . ) who are exposed to volatile anesthetics or depolarizing muscle relaxants (succinylcholine) [ ] . hypomagnesemia may increase the probability and possibly severity of an mh event [ ] . the subsequent rapid increase in myoplasmic calcium concentration increases muscle metabolism and heat production and produces muscle contractures and hyperthermia. neuroleptic malignant syndrome (nms) is characterized by high fever, autonomic instability, altered mental status, and muscle rigidity. potent antipsychotics (neuroleptics) such as haloperidol and other medications (metoclopramide, droperidol, and promethazine) with significant dopamine antagonism, as well as abrupt cessation of dopaminergic agents such as those used in parkinsonism, can precipitate this life-threatening syndrome [ ] . nms typically develops over several days and is characterized by ''lead-pipe'' rigidity [ ] . drugs that impair serotonin breakdown or re-uptake, those that act as serotonin precursors or enhance its release, or those that are serotonin agonists may lead to serotonin syndrome. like nms, serotonin syndrome is a spectrum disorder for which various signs and symptoms have been proposed to establish diagnosis (e.g., sternbach and hunter criteria) [ , ] . in its most severe form it consists of high fever, autonomic instability, altered mental status, and may have associated diaphoresis, shivering, tremor, diarrhea, or spontaneous clonus. in serotonin syndrome, onset of symptoms is usually rapid, with % of patients with the serotonin syndrome presenting within hours of drug exposure, and tremor and hyperreflexia predominant in the lower extremities may be a prominent feature [ ] . sympathomimetic-associated hyperthermia, seen with acute intoxication with cocaine, amphetamines, substituted amphetamines, and phencyclidine, may be clinically indistinguishable from serotonin syndrome [ ] . additionally, the agitated delirium engendered by these agents may be difficult to distinguish from that induced by hyperthermia itself. patients with anticholinergic-associated hyperthermia will generally present with a compatible "toxidrome" -agitation; mydriasis; dry, hot, and erythematous skin; hypoactive bowel sounds; and urinary retention. while rare, thyrotoxicosis factitia, the ingestion of excess thyroid hormones due to inadvertent intake (pharmaceutical or food contamination), misuse (dieting), or significant intentional ingestion may produce hyperthermia [ , ] . hyperthermia may accompany toxicity with agents that uncouple oxidative phosphorylation (e.g., salicylates, dinitrophenol, pentachlorophenol) [ ] . multiple medications can also complicate or contribute to environmental hyperthermia. several reviews and epidemiological data from major heat waves have demonstrated that anticholinergics, antiepileptics, antihistamines, antihypertensives in general and diuretics in particular, antipsychotics, and others contribute to excess morbidity and mortality [ , ] . conversely, exogenous heat stress can increase mortality from specific xenobiotics. in an urban setting at ambient temperatures above . °c, the mean daily number of fatal cocaine overdoses increased markedly [ ] . regardless of the cause for the hyperthermic syndrome, cessation of any possible offending or contributing agents and rapid cooling is critical. the degree of hyperthermia produced correlates with death and neurotoxicity in animal models, and temperature normalizing intervention is critically impor-tant in attenuating cns injury and mortality [ ] . studies from the chicago and france heat waves show that this is rarely done in a timely manner (if at all) in cases of environmental hyperthermia, with devastating results [ , ] . the benefits of rapid cooling by ice water immersion were demonstrated over years ago [ ] . a large review concluded that cooling methods based on evaporative heat loss are less efficient than immersion in ice water in dissipating heat [ ] . additional studies demonstrate that cooling rates of up to . - . °c/min can be achieved with immersion, two to three times that of evaporation [ , ] . regardless of the method used, effectiveness should be repeatedly assessed. sedation with benzodiazepines and rigorous supportive care are necessary adjuncts in significant cases. this is primarily accomplished with titrated doses of benzodiazepines to inhibit muscle rigidity and control agitation. animal models have demonstrated the benefit of benzodiazepines in prolonging survival, preventing seizure, and attenuating agitation in the toxicological hyperthermias [ , ] . phenytoin is ineffective in animal models [ ] . phenothiazines and butyrophenones, while reported, may have delayed onset and compromise mental status, lower seizure threshold, impair heat dissipation, and worsen hypotension [ ] . neuromuscular paralysis may be required to limit further heat generation in cases of nms, serotonin syndrome, and sympathomimetic-associated hyperthermia. as the pathophysiology of mh is beyond the neuromuscular junction, paralytics are unlikely to provide benefit. rapid i.v. administration of dantrolene, a direct-acting skeletal muscle relaxant, is the only drug proven effective for prevention and treatment of mh. dantrolene disrupts the pathogenic excitation-contraction coupling by acting at ryr- to suppress depolarizationinduced sarcoplasmic reticulum calcium release and normalize the voltage dependence of contractile activation [ ] . reversal of increased myotube sensitivity may also play a role [ ] . intravenous - mg/kg dantrolene is repeated until symptoms are controlled or mg/kg (or more) has been administered. following initial treatment, - mg/kg i.v. or per os is given every hours for - hours to prevent recurrence. dantrolene is packaged in vials containing mg dantrolene sodium; thus, multiple vials are needed for treatment of adult patients. a large review of nms cases did not suggest a beneficial role for dantrolene, although one case-controlled analysis found benefit [ , ] . bromocriptine, a dopamine agonist, has been used (off-label) to treat nms at doses ranging from to mg every hours [ ] . common side effects include hypotension, dyskinesia, erythromelalgia, and hallucinations. cyproheptadine, developed as an antihistamine, additionally antagonizes -ht receptors. cyproheptadine for serotonin syndrome (off-label) is initially used in a dose range of - mg, followed by mg every hours for persistent symptoms; upon symptom control, mg maintenance dosing is provided every hours [ ] . the tablet form necessitates administration orally or crushed via nasogastric tube. n-acetylcysteine (nac) provides an effective means of prevention and treatment of acetaminophen (n-acetyl-p-aminophenol, apap; paracetamol)induced hepatotoxicity. nac is also employed to preclude radiographic contrast-induced nephropathy [ ] . the ultimate toxicant of apap, n-acetyl-pbenzoquinone imine (napqi) generated primarily by cyp e and cyp a , depletes glutathione (gsh), binds intracellular components, and, through an incompletely understood process, produces hepatic injury, centrilobular necrosis, or hepatic failure [ , ] . nac works by multiple mechanisms. it augments apap sulfation to a nontoxic metabolite, it acts as a glutathione precursor or glutathione substitute to detoxify napqi, and possibly reverses napqi oxidation [ , ] . nac provides substantial benefit even in cases of delayed presentation following overdose [ ] . extra-hepatic benefits of nac include improving cardiac index and systemic mean oxygen delivery despite decreasing systemic vascular resistance [ ] . in a range of hepatic disorders, nac improved baseline oxygen delivery, oxygen consumption, and dye clearance in a majority of patients [ ] . liver blood flow and cardiac index improved in septic shock patients provided nac [ ] . only l-nac is beneficial. animal experiments demonstrate that the l-isomer, derived from physiological l-cysteine, prevents hepatotoxicity and provides prolonged elevations of hepatic glutathione [ ] . nonphysiological d-nac cannot increase glutathione stores or prevent hepatotoxicity, despite increasing acetaminophen sulfation [ ] . according to rumack [ ] , the oral nac dosing strategy was reached by estimating the absorption and turnover rate of glutathione at mg/kg per h and an fda safety factor of , to yield mg/kg every hours [ (mg/kg per h) × (h) × (safety factor) = ≈ mg/kg every h]. there were several assumptions as to "normal" hepatic glutathione levels and apap to napqi conversion. a mg/kg loading dose was added to provide an early high hepatic dose. the -hour duration of oral therapy was based on previous observations of multiple patients with prolonged apap half-lives and a desire to implement a protocol that would accommodate those with half-lives longer than hours (anticipating disappearance after five half-lives). while many have suggested that the -hour oral course is excessive, particularly after apap has disappeared from the serum, the optimal duration of therapy is unclear. studies assessing a shortened or "patient-tailored" approach have been small or methodologically limited [ , ] . the rumack-matthew nomogram guides initiation of nac therapy in single acute ingestions. the "treatment line" is anchored at an apap serum concentration of either μg/ml (" line") or μg/ml (" line") at hours post ingestion and decreased by % every hours. the slope of the treatment line does not reflect apap kinetics. the " line" is utilized in all patients in the u.s. and australia; in the u.k. and elsewhere the " line" is employed, with a " line" modification for an array of individuals deemed at "high-risk": ethanol tolerant, those at risk for glutathione depletion (malnutrition, hiv, eating disorders, cystic fibrosis), pregnancy, and those prescribed enzyme-inducing drugs (carbamazepine, phenytoin, phenobarbitone rifampacin, isoniazid, etc.) [ , ] . the u.s. multicenter study substantiated the safety and efficacy of its approach [ ] . proponents of the " line" point to the fact that . - . % of patients above the " line" but below the " line" developed biochemical hepatotoxicity (aspartate aminotransferase, ast > iu/l at any time during their course) in the u.s. multicenter trial and that patient deaths have occurred in untreated patients "between the lines" [ , ] . in patients presenting near hours after ingestion, or if a level is not available before hours post ingestion, nac is begun while awaiting apap results and then continued or stopped once the results are available and have been plotted on the nomogram. if the time of ingestion is unknown or more than hours has passed, nac is administered. when apap concentration and transaminase results are obtained, if transaminases are elevated or if measurable apap exists, a full course of treatment is provided. with normal aminotransferases and without detectable apap, treatment is not required. concentrations obtained less than hours post ingestion are not useful except to completely exclude ingestion (i.e., it is useful only if the apap concentration is undetectable). ongoing absorption may place individuals above the line at hours, or metabolism or charcoal administration may result in a patient falling below the nomogram at hours. in cases of chronic ingestion (> . g/day in adult), laboratory evaluation and treatment are provided as for an unknown time of ingestion. with elevated transaminases or measurable apap, nac is provided. oral nac is cheap and familiar to clinicians. it has minimal side effects (other than vomiting and odor) and is preferred in patients with bronchospastic disease. its use can become problematic in cases where oral delivery is compromised, e.g., in patients with depressed mental status, significant vomiting, or impaired gastric motility. use of an anti-emetic is encouraged. intravenous nac appears to be similarly efficacious to oral nac and eliminates many delivery issues. it has a much shorter therapy course ( hours), expediting medical and psychiatric disposition. it avoids first pass metabolism in cases where the liver is not the only target or interest, such as those with cerebral edema or pregnancy. while i.v. nac is slightly more expensive, total hospital charges may be less due to decreased treatment time. histamine-mediated anaphylactoid reactions are more commonly seen with rapid i.v. loading and in patients with lower apap levels [ ] . mild reactions have been treated by slowing the infusion rate and providing i.v. diphenhydramine, although this might alter nac and apap kinetics. dosing complexity - mg/kg in ml of % dextrose over hour, followed by mg/kg in ml of % dextrose over hours ( . mg/kg per h), and then mg/kg in ml of % dextrose over hours ( . mg/kg per h) -yields frequent administration errors [ ] . the supplied % solution was too concentrated for children, and dilution according to adult guidelines resulted in excess free water, and cases of hyponatremia and seizures [ ] . the current u.s. package prescribing information (http://www.acetadote.net/pi_acetadote_revised_apr .pdf) and dosage calculator website (http://www.acetadote.net/dosecalc.shtml) provide dosing and administration guidelines in patients of less than kg. in a study limited by different comparison groups, data acquisition methodology, treatment location and several other factors, -hour only i.v. nac was favored in patients with early presentation (< hours), whereas late presentation favored oral -hour nac [ ] . however, continuous i.v. infusion in delayed presentations with apap-induced fulminant hepatic failure showed clear benefit in a prospective study [ ] . whatever the route, prior to cessation of nac therapy, negative apap concentrations and normal transaminases must be ensured, particularly in cases of massive ingestion; hepatotoxicity may follow premature cessation of therapy [ , ] . the -hour maintenance dose is continued in patients receiving i.v. nac until apap is undetectable and transaminases are normal (or at baseline). experimental evidence and human case reports demonstrate both delayed absorption, delayed increase following initial decline, and "crossing the nomogram" with extended-relief, opioid-or anticholinergic-containing apap products, or co-ingestants [ , ] . in cases of hepatic failure, i.v. nac is continued until resolution, transplant, or death. historically, physostigmine (eserine), a reversible carbamate inhibitor derived from the seed (calabar bean) of the vine physostigma venenosum balfour, was used in the ancient trial by ordeal [ ] . medicinal use of physostigmine was first reported in to reverse severe atropine poisoning [ ] . naturally available (-)-physostigmine is over times more effective in inhibiting acetylcholinesterase and butylcholinesterase in tissue, erythrocytes, and serum in humans and animal models than its stereoisomer [ , ] . this activity depends upon interactions within the hydrophobic pocket of the acetylcholinesterase active center, which is distinct from the catalytic site [ ] . additionally, physostigmine binds nicotinic receptors close to, but distinct from, the acetylcholine binding site on the α-subunit [ ] . at low doses, physostigmine functions as an ineffective nicotinic receptor agonist, while at higher doses it produces marked channel blockade. physostigmine's nonspecific analeptic properties [ ] are no longer considered useful in overdose, given the clear benefits of supportive care. indiscriminate use of physostigmine and an incomplete understanding of the pathophysiology of tricyclic antidepressant (tca) poisoning was associated with bradydysrhythmias including asystole, seizure, and several deaths [ , ] . in animal models, physostigmine is ineffective in attenuating tcainduced seizures [ ] . it failed to abolish dysrhythmias, decreased blood pressure, and at high doses enhanced tca toxicity [ ] . physostigmine is currently recommended as a diagnostic and therapeutic agent for antimuscarinic poisoning [ ] . patients should have clear peripheral or central manifestations of the anticholinergic toxidrome. as a tertiary amine, physostigmine can cross the blood-brain barrier to reverse the central effects. an ecg should exclude sodium or potassium channel blockade (qrs or qt prolongation). excessive physostigmine will produce a cholinergic syndrome, with muscarinic and nicotinic effects. as the adverse effects of bradycardia and bronchorrhea can produce significant morbidity, continuous cardiac monitoring and immediate access to atropine are recommended during physostigmine administration. physostigmine, - mg in adults and . mg/kg (maximum . mg) in children is infused slowly over at least min [ ] . repeat doses every - min can be provided if an adequate response does not occur and adverse effects are absent. re-bolusing may be required in the setting of antimuscarinics with a prolonged duration of action. the anticonvulsants include carbamazepine, ethosuximide, felbamate, gabapentin, lacosamide, lamotrigine, levetiracetam, oxcarbazepine, phenobarbital, phenytoin, pregabalin, primidone, tiagabine, topiramate, valproic acid (vpa), vigabatrin, and zonisamide. these drugs enjoy widespread approved and offlabel use for additional conditions, e.g., fibromyalgia (pregabalin); neuropathy and neuropathic pain (carbamazepine, gabapentin, lamotrigine, levetiracetam, and pregabalin); panic disorder (tiagabine); migraine prophylaxis and treatment of obesity, ethanol dependence, and depression (topiramate); and bipolar disorder (carbamazepine, lamotrigine, and vpa). treatment of anticonvulsant overdose is largely supportive, with particular attention to the cns-depressant and cardiovascular effects of some of these agents. l-(r)-carnitine exists as the sole specific antidote in this class for significant vpa (di-n-dipropylacetic acid, -propylpentanoic acid) poisoning. patients with drug-associated mitochondrial toxicity (particularly from nucleoside analogs) and anthracycline cardiotoxicity might also benefit from its administration [ , ] . the anticonvulsant properties of vpa derive from its ability to increase γ-aminobutyric acid (gaba) availability via inhibition of gaba transaminase and succinic semialdehyde dehydrogenase, to attenuate n-methyl-daspartate (nmda)-type glutamate receptor excitatory effects, and to slow the rate of recovery from sodium channel inactivation [ ] [ ] [ ] . additionally, vpa appears to affect inositol levels similar to lithium. therapeutic concen-trations are - mg/l. potentially toxic concentrations are greater than mg/l. oral absorption of vpa is excellent [ ] . peak plasma concentrations are generally seen in - hours, although this may be markedly delayed by overdose, enteric coating, or meals [ ] . manifestations of significant vpa toxicity include cns effects (lethargy, seizure, coma, cerebral edema), respiratory depression, metabolic derangement (hypernatremia, hyperammonemia, hypocalcemia, metabolic acidosis, carnitine deficiency), gastrointestinal effects (nausea, vomiting, and abdominal pain), pancytopenia, pancreatitis, and hepatotoxicity [ , ] . valproate toxicity is seen both in intentional acute overdose and in those on chronic therapy, either without adequate carnitine supplementation or on complex regimes. cells attempt to metabolize the vpa that is not directly excreted or glucuronidated in a manner similar to other fatty acids (fig. ) . thus, vpa is conjugated with coenzyme a (coa). carnitine enters via an atp-dependent transporter. vpa is then transferred to carnitine, the normal mechanism for fatty acids entry into the mitochondrion. however, vpa-carnitine both inhibits the carnitine transporter and also diffuses out of the cell to be lost via renal excretion [ ] . renal resorption of carnitine is also impaired [ ] . these factors contribute to intracellular carnitine depletion. once vpa-carnitine is shuttled into the mitochondrion, it is reattached to coa. it then undergoes β-oxidation, in an attempt to generate -carbon molecules for entry into the krebs cycle. the -en-vpa-coa product is neurotoxic with a prolonged half-life. the terminal -keto-vpa product traps coa, leading to its mitochondrial depletion. decreased mitochondrial coa yields decreased atp production, diminishing usable cellular energy currency and further limiting carnitine entry into the cell (via an atp-dependent carnitine transporter). once carnitine is depleted, normal fatty acid metabolism cannot occur [ ] . fatty acid build up is thought to underlie the reye's-like steatohepatitis, which can be seen in toxicity [ ] . coa is also needed to make n-acetylglutamate, an activator of carbamoylphosphate synthetase i (cps i), a critical enzyme in the urea cycle. when its effectiveness is limited due to inadequate activator, ammonia cannot be incorporated, and consequently, its concentrations increase. furthermore, as coa is depleted, β-oxidation shifts to omega (ω), or terminal carbon oxidation. this creates (among others) the hepatotoxic -en-vpa product. -en-vpa additionally inhibits cps i, further preventing nitrogen elimination and contributing to hyperammonemia. l-carnitine (levocarnitine) supplementation has been recommended to reverse the adverse metabolic effects of vpa in cases of vpa-induced hepatotoxicity, vpa overdose, and primary carnitine-transporter defects [ , ] . hyperammonemia and serum and muscle carnitine deficiency are well described in patients chronically taking vpa [ ] [ ] [ ] . several studies and case reports demonstrate that carnitine supplementation reverses clinical symptoms, hypocarnitinemia, hyperammonemia, and vpa half-life prolongation in patients with toxicity due to chronic administration [ ] [ ] [ ] . in patients with acute vpa overdose, limited clinical and laboratory data derived from case reports also suggest that reversal of metabolic derangements and improvement in clinical symptoms occurs when carnitine is provided [ ] [ ] [ ] . a single large retrospective analysis showed a significant survival benefit with i.v. carnitine supplementation (with vpa cessation) in patients with valproate-induced hepatotoxicity [ ] . l-carnitine dosing for cases of overdose is not currently evidence based. an oral or i.v. dose of mg/kg per day, divided and given every hours (maximum daily dose g), is provided to those patients with acute overdose and [ , , , , ] . asymptomatic hyperammonemia or hepatotoxicity in the absence of cns depression or metabolic derangement [ ] . symptomatic patients with hyperammonemia or symptomatic hepatotoxicity should receive mg/kg l-carnitine i.v. over min (maximum g), followed by mg/kg every hours over - min until clinical improvement occurs [ , ] . others have supplemented at the higher dosing strategy when vpa concentrations exceed mg/l [ ] . in addition, given the decrease in protein binding that occurs, hemodialysis or hemoperfusion is recommended for patients with vpa concentrations exceeding - mg/l or with severe clinical symptoms [ ] . l-carnitine is generally well tolerated. side effects associated with carnitine supplementation are nausea, abdominal discomfort, dose-related diarrhea, and fishy body odor [ ] . a small retrospective chart review found no adverse effects or allergic reactions in vpa overdose patients administered carnitine [ ] . the current l-carnitine package inserts have no warnings or contraindications, but note that seizures have been reported to occur in patients, with or without pre-existing seizure activity, who received either oral or i.v. l-carnitine [ ] . up to mg/kg per day for days has been provided without complications [ ] . the d-isomer and the racemate (d,l-carnitine) are contraindicated. historic use of racemic d,l-carnitine was associated with myasthenialike syndromes and cardiac dysrhythmias, which disappeared after l-carnitine administration [ ] . d-carnitine also competitively depletes cardiac and skeletal muscles and kidneys of l-carnitine [ ] . dextrose dextrose (d-glucose) is indicated to rapidly reverse organic or toxin-induced hypoglycemia (e.g., from sulfonylureas, insulin, ethanol, salicylates, β-adrenergic antagonists, quinolines, pentamidine, ritodrine, and disopyramide) [ , ] . hypoglycemia onset may be significantly delayed with certain agents (e.g., long-acting insulin or sulfonylureas). limited cns glycogen stores (in astrocytes) and the inability to acutely use free fatty acids make the cns particularly vulnerable to hypoglycemia [ ] . patients (and providers) may be unaware of hypoglycemia in the absence of objective testing; both the counter-regulatory autonomic response and overt neurological deficit may be absent [ , ] . additionally, significant neuroglycopenia and hypoglycemia-associated delirium (particularly in salicylism) may occur despite a "normal" peripheral blood glucose [ ] . a wide range of clinical presentations have been described, including diaphoresis, nausea, tachycardia, tremor, hypothermia, focal neurological deficits, and cns agitation, confusion, or depression. these are generally reversible upon prompt treatment. untreated hypoglycemia may result in seizure, coma, and death. hypoglycemic seizures increase cerebral metabolic rate, contribute to atp depletion, and produce irre-versible brain damage [ , ] . for these reasons, when bedside testing is unavailable, a risk-benefit calculation has generally favored empiric dextrose administration in the absence of a very clear alternative history or explanation for altered mental status. following a determination of absolute or relative hypoglycemia, . - . g/kg i.v of age-appropriate dextrose containing solutions should be provided immediately -d w ( g/ ml) in adults, d w ( g/ ml) in children, and d w ( g/ ml) in neonates. frequent re-evaluation of response to therapy is required. glucose uptake and distribution, hyperglycemia-induced insulin secretion in those with a competent pancreas, and ongoing toxin exposure may cause recurrent hypoglycemia and necessitate repeat dosing. feeding, which provides significantly more calories than each ml ampule of d w ( kcal according to one manufacturer [ ] ), should be commenced as soon as practicable. while d w "maintenance" solutions may be subsequently required, at an infusion rate of ml/h, this concentration only provides kcal per hour. continuous infusion of more concentrated solutions (e.g., d w) requires a central venous catheter for administration. only the d-isomer is clinically useful. most glucose transporters (gluts) and the specific transporter required for facilitated diffusion of glucose across the blood-brain barrier, glut (slc a ), have a high affinity for d-glucose and negligible affinity for l-glucose [ , ] . d-glucose is also generally favored over other d-glucose epimers such as d-mannose or d-galactose. d w is hypertonic and may cause phlebitis or thrombosis at the site of injection. extravasations of solutions containing as low as % dextrose have caused significant tissue injury and necrosis, particularly in young children [ ] . pseudoagglutination of red blood cells may occur if concentrated dextrose solutions without electrolytes are administered simultaneously with blood through the same infusion set [ ] . hypertonic dextrose administration may also induce generally clinically irrelevant hypophosphatemia [ ] . octreotide acetate, a synthetic somatostatin analogue, is now favored in cases of refractory hypoglycemia due to sulfonylureas or quinine. it is fda approved for treatment of acromegaly, carcinoid tumors, and vasoactive intestinal peptide tumors [ ] . it is a more potent inhibitor of insulin secretion than the natural hormone [ ] . in pancreatic β-islet cells, atp generated from glucose uptake and subsequent metabolism normally induces closure of the atp-dependent potassium channel by binding to its pore subunit (fig. ) . sulfonylureas similarly induce channel closure after binding to a regulatory (sur ) subunit. increased intracellular potassium triggers calcium entry through voltage-dependent calcium channels, leading to increased cytosolic calcium and insulin exocytosis [ , ] . additionally, atp contributes to insulin vesicles movement and provides a substrate for protein kinase a (pka)-mediated phosphorylation. octreotide binds to the somatostatin receptor (primarily sstr ) [ ] . the subsequent effects continue to be explored and include inhibitory calcium channel effects, inhibition of adenylyl cyclase, and dephosphorylation of specific proteins required for movement and/or docking of vesicles [ , , ] . octreotide effectively suppresses endogenous insulin release in controlled studies in diabetics and in cases of sulfonylurea overdose, but does not (and would not be expected to have) an effect on exogenously administered insulin [ ] [ ] [ ] . several factors support octreotide usage following failure of initial dextrose administration and feeding. bolused dextrose may produce hyperglycemia and thus subsequently stimulate an exaggerated insulin response, particularly when figure . pancreatic β-islet cell mechanisms of insulin release and octreotide action (see text for details). enzymes and substances: ac, adenylyl cyclase; atp, adenosine triphosphate; camp, cyclic adenosine monophosphate; glut , glucose transporter ; pka, protein kinase a; sfu, sulfonylurea; sstr, somatostatin receptor. symbols: ⊕, agonism or co-factor; ⊗, antagonism. data used can be found in [ ] [ ] [ ] [ ] . sulfonylureas persist. this contributes to recurrent (sometimes more significant) hypoglycemia. a vicious cycle of serum glucose concentrations is described in case reports and controlled trials following dextrose administration after sulfonylurea exposure [ ] [ ] [ ] . additionally, as has been demonstrated, classic neuroglycopenic symptoms may not be present, and patients may need to be admitted during periods when circadian sleep patterns would complicate assessment. octreotide administration also obviates the concern of excess water administration in pediatric patients receiving i.v. dextrose solutions. relatively few trials are available to judge the efficacy of octreotide for sulfonylurea-induced hypoglycemia. in one study, glipizide was used to induce induced hypoglycemia ( mg/dl) in eight healthy volunteers, who were then resuscitated with dextrose infusion, diazoxide, or octreotide [ ] . dextrose requirements were markedly less in patients provided octreotide and hypoglycemic events were markedly attenuated after all therapies were stopped. one retrospective chart review of nine patients demonstrated that octreotide significantly reduced the number of recurrent hypoglycemic events and dextrose requirement [ ] . one prospective randomized controlled trial in poisoned patients, despite a failure to control for carbohydrate intake and having an unusual dosing strategy (a single octreotide μg dose subcutaneously), demonstrated consistently higher glucose values for the duration for which octreotide would be expected to be effective ( - hours) [ ] . controlled animal studies with - μg octreotide demonstrated a similar decrease in hypoglycemic events [ ] . the remainder of human clinical experience of the effectiveness of octreotide in sulfonylurea overdose comes from abstracts, case reports, and case series (e.g., [ , , [ ] [ ] [ ] ). pediatric experience in sulfonylurea overdose comes only in the form of limited abstracts and case reports in children aged months to years [ , [ ] [ ] [ ] . however, octreotide has been used for prolonged periods to treat persistent hyperinsulinemic hypoglycemia of infancy [ , ] . two human studies examined the effectiveness of octreotide in quinineinduced hypoglycemia. in one study of nine healthy volunteers, μg/hour octreotide as a continuous i.v. infusion abolished quinine-induced insulin release [ ] . the authors reported resolution of hypoglycemia in an additional patient being treated with quinine for plasmodium falciparum malaria. a subsequent study in eight patients with p. falciparum malaria confirmed octreotide suppression of quinine-induced hyperinsulinemia [ ] . optimal dosing of octreotide has not been definitively determined. initial doses of - μg subcutaneously in adults have been reported, although μg every - hours is commonly provided [ , ] . in children, an initial dose of . - . μg/kg is used, although up to . μg/kg (or more) has been reported [ , ] . peak serum concentrations are achieved within min after subcutaneous administration and within min after a short ( min) i.v. infusion [ ] . the elimination half-life (by either route of administration) is approximately . hours. in patients with severe renal impairment (which may have contributed to sulfonylurea-induced hypoglycemia in the first place), the plasma clearance is reduced by % [ ] . the subcutaneous route is recommended due to longer duration of effect, as i.v. administration has resulted in treatment failure [ ] . side effects are generally minimal. octreotide does inhibit gallbladder contractility and decreases bile secretion in normal volunteers [ ] . when octreotide has been used to reverse sulfonylurea-induced hypoglycemia, bradycardia, hypokalemia, anaphylactoid reaction, and hypertension and apnea have been reported [ , ] . other adverse events include nausea, abdominal cramps, diarrhea, fat malabsorption and flatulence [ ] . octreotide also suppresses glucagon release, although hypoglycemia has been a concern only in patients on long-term therapy for organic hyperinsulinemia [ ] . glucagon is not generally recommended to correct hypoglycemia. glycogen stores are frequently depleted by the time toxin-induced hypoglycemia manifests; glucagon's half-life (less than min) is inadequate given the prolonged duration of the effect of sulfonylureas; and glucagon may exacerbate hyperinsulinemia [ ] . diazoxide, an antihypertensive agent, which reduces insulin release by opening the atp-dependent potassium channel, is now of historical interest due to associated hypotension, reflex tachycardia, nausea and vomiting, and fluid retention [ , ] . since its introduction in , isoniazid (inh, isonicotinic hydrazide, pyridine- -carbohydrazide) has remained a mainstay for treatment and prophylaxis of mycobacterial infections [ ] . the adult single tablet, mg daily dose ( . mg/kg in a kg individual) targets a peak plasma concentration of - μg/ml [ ] . acute inh toxicity may occur following ingestion of mg/kg inh; it is common above - mg/kg [ ] . the relatively narrow therapeutic window poses a significant risk for those with suicidal intent and for those who ingest extra pills to "catch up" after a brief period of incomplete compliance [ ] . historically, death rates of % were reported [ ] . seizures refractory to typical therapy, severe metabolic lactic acidosis, and coma may occur as early as min post ingestion due to the rapid and nearly complete absorption of inh from the gastrointestinal tract. seizures may occur at lower doses in those with pre-existing susceptibility. associated respiratory failure, hypotension, and rhabdomyolysis may ensue. in patients provided . - . g ( - mg/kg) inh due to medication error, all experienced nausea or vomiting, vertigo, and coma within min to hours after ingestion [ ] . abnormal generalized discharges as sharp and slow waves were seen on eeg in all patients. chronic inh toxicity may present with nausea, vomiting, hepatitis, hemolytic anemia, and neurological findings (restlessness, neuropathy, cerebellar findings, and psychosis). the acute clinical effects are a product of the multiple biochemical actions of inh, which lead to pyridoxine depletion and subsequent neuronal hyperexcitability (fig. ) [ , [ ] [ ] [ ] . inh hydrazones inhibit pyridoxine phosphokinase, which activates pyridoxine. inh hydrazines and hydrazides inactivate active pyridoxal -phosphate. inh metabolites also complex with pyridoxal -phosphate, leading to increased urinary elimination. glutamic acid decarboxylase (gad) and gaba transaminase (gaba-t) both require pyridoxal -phosphate as a co-factor. inhibition of gad exceeds that of gaba-t [ ] . the resulting gaba depletion and loss of neuronal inhibition is thought to underlie seizure activity. metabolic acidosis may be profound -survival has been reported with a ph of . [ ] . seizure-associated lactate generation is substantial; inh-induced metabolic acidosis does not develop in paralyzed dogs (despite eeg evidence of seizure) [ ] . importantly, merely correcting the acidosis (e.g., by bicarbonate) does not prevent additional seizures or terminate inh toxicity [ , ] . inh also impairs lactate conversion to pyruvate (fig. ) . increased metabolism of fatty acids due to impaired glucose metabolism with hyperglycemia and ketonuria has been reported [ , ] . inh also impairs cellular reduction-oxidation capacity via competitive inhibition of nad [ , ] . pyridoxine deficiency also appears to play a role in inh-induced mental status changes (coma and lethargy) [ , , ] . appropriately dosed pyridoxine (vitamin b ) has been the mainstay of antidotal therapy for inh intoxication since the early reports of benefit versus his- figure . mechanisms of isoniazid (inh) toxicity (see text for details). enzymes (italicized): gaba-t, gaba transaminase; gad, glutamic acid decarboxylase; got, glutamic-oxaloacetic transaminase; ldh, lactate dehydrogenase; ppk, pyridoxine phosphokinase; and sr, serine racemase. substances: gaba, γ-aminobutyric acid; and ssa, succinic semi-aldehyde. symbols: ⊕, agonism or co-factor; ⊗, antagonism. data used can be located in [ , [ ] [ ] [ ] ] . drugs and pharmaceuticals: management of intoxication and antidotes torical controls [ ] . exogenous vitamin b provides the necessary precursor for the co-factor for gaba regeneration. clinical experience with pyridoxine comes from case series, case reports, and animal data [ , , , , [ ] [ ] [ ] . clinical trials are absent due to ethical considerations. vitamin b (as pyridoxine hydrochloride) is provided on a gram per gram basis for each gram of inh ingested, to a maximum of g or mg/kg (the empiric dose in ingestions of unknown quantity) [ , , ] . a repeat dose can be provided if necessary. due to the large amount of pyridoxine required, inadequate stocking and depletion of institutional and entire regional supplies have been widely reported [ , , ] . in the convulsing patient, pyridoxine is administered i.v. at . g/min ( g maximum) until seizure termination, with the remainder over - hours. pediatric dosing should not exceed mg/kg ( g maximum). large doses of pyridoxine have been safely administered; however, sensory neuropathy may occur with massive acute doses (> g) or chronic large daily doses [ ] . co-administration of benzodiazepines is synergistic in controlling seizures [ , ] . massive inh ingestion may require additional sedative hypnotics or anesthetic agents to suppress seizures [ ] . inh is dialyzable, and hemodialysis has been used successfully in cases refractory to antidotal treatment, in those with extremely high plasma inh concentrations, and in patients with renal failure [ , ] . pyridoxine also appears to rapidly reverse the impaired consciousness seen in inh overdose [ , ] . the cns excitatory neurotransmitters include glutamate and d-serine, which with glutamate is a co-agonist of the nmda receptor [ ] . examination of the metabolic pathways affected by pyridoxal -phosphate depletion (fig. ) suggests that inadequate stores of these neurotransmitters (due to inadequate co-factors for glutamic-oxaloacetic transaminase and serine racemase) might be contributory, in addition to general substrate or catecholamine deficiency. pyridoxine therapy is also recommended for poisoning through other hydrazines or hydrazine precursors (e.g., gyrometra mushrooms, monomethylhydrazine, and unsymmetrical dimethylhydrazine fuel). pyridoxine is effective in treating the chronic inh-associated neuropathy, particularly in patients with renal failure. doses of - mg pyridoxine/day have typically been used in the chronic setting [ ] . pyridoxine has no effect in prevention or treatment of inh-associated hepatic injury. antineoplastic agents are used for the treatment of a variety of benign and malignant neoplasms. some antineoplastic agents (such as the antifolates) have an expanded spectrum that includes use in rheumatology, dermatology, and obstetrics and gynecology. toxicity may be due to the agent itself or delivery of the agent to an unintended target (e.g., extravasation). several antidotes are used in a prophylactic fashion or on chronic basis. amifostine (wr- ) -which is dephosphorylated by alkaline phosphatase to an activated, protective thiol form -is approved to decrease toxicity associated with radiotherapy and renal injury associated with cisplatin [ ] . it has also been used to reduce chemotherapy-induced neutropenia; genitourinary injury associated with cyclophosphamide; and transfusion requirements, gastrointestinal and hepatic toxicity in pediatric patients [ , ] . cyclophosphamide and ifosfamide induce bladder toxicity (hemorrhagic cystitis) via their metabolite acrolein. mesna ( -mercaptoethane sulfonate), a thiol agent that complexes with and inactivates acrolein, is provided orally or i.v. as prophylaxis [ ] . diethyldithiocarbamate (ddtc), the major metabolite of disulfiram, is an investigational agent for prevention of neuropathy from cisplatin and its analogs; it increased nephrotoxicity in one study [ ] . granulocyte colony-stimulating factor (g-csf), granulocyte-macrophage colony-stimulating factor (gm-csf), erythropoietin (hemopoietin) and its derivatives, oprelvekin (recombinant interleukin- ), and other stimulating factors are employed as adjuvants to reconstitute various hematopoietic lines damaged by chemotherapy and radiation [ , ] . palifermin (recombinant truncated human keratinocyte growth factor) is used to prevent severe mucositis in patients receiving stem-cell transplantation with a total body irradiation conditioning regimen [ ] . the remaining section focuses on antineoplastic antidotes used in the acute setting. a dreaded complication of administration of vesicant chemotherapeutic agents is extravasation. risk factors for extravasation include small, fragile, or sclerosed veins, obesity, comorbid conditions (diabetes, circulatory disorders, impaired sensory perception), use of rigid i.v. catheters, and clinicians' lack of knowledge and skills [ ] . redness, burning pain, and swelling may portend later blistering, ulceration, and necrosis. dexrazoxane is u.s. fda approved for treatment of extravasation resulting from i.v. anthracycline chemotherapy, to diminish tissue damage and the need for surgical excision of necrotic tissue [ ] . clinical efficacy data comes from two simultaneously reported openlabel, single-arm, prospective multicenter studies in which only out of patients with biopsy-proven extravasation required surgical debridement [ ] . additional instances of successful dexrazoxane treatment of anthracycline extravasation are provided as case reports ( [ ] and others). dexrazoxane is provided once daily for consecutive days, with the first infusion initiated as soon as possible. daily doses are as follows: day , mg/m (maximum mg); day , mg/m (maximum mg); day , mg/m (maximum mg) [ ] . the dose is reduced by % in patients with creatinine clearance of less than ml/min. in mice, efficacy rapidly decreased when dexrazoxane was provided beyond hours after extravasation [ ] . dexrazoxane's mechanism of action appears to involve reversible inhibition of topoisomerase ii and inhibition by its metabolite, an ethylenediamintetraacetic acid (edta) analogue, of free radical formation via iron removal from the iron-doxorubicin complex [ ] . topoisomerase ii-independent effects have also been described [ ] . in contrast, some authors have encouraged the nonconcurrent, off-label use of topical dimethyl sulfoxide (dmso) for anthracycline extravasation because of the risk of infection, neutropenia, and thrombocytopenia associated with dexrazoxane [ ] . dexrazoxane is also used prophylactically to limit anthracycline-associated cardiomyopathy [ ] . in , methotrexate (mtx) joined the oncological armamentarium for leukemia [ ] . mtx treatment of solid cancers was reported in , and it gained fda approval for psoriasis in [ , ] . mtx is now used intramuscularly, intrathecally, i.v., and orally for a range of dermatological, rheumatological, obstetric, and gynecological conditions. the dose ranges from . - mg orally once weekly for psoriasis or rheumatoid arthritis to - g/m or more for osteosarcoma, leukemia, and lymphoma [ ] [ ] [ ] . mtx poisoning may result from intentional overdose; unintentional ingestion, prescription, dispensing, administration, and patient errors; or renal insufficiency leading to persistent mtx in patients receiving high-dose chemotherapy regimens [ , ] . mtx antagonizes folate metabolism (and rapidly proliferating cells) via multiple mechanisms. dihydrofolate reductase inhibition by mtx and its polyglutamated metabolites ensures that neither dihydrofolate nor active tetrahydrofolate can be generated from folate, nor can existing dihydrofolate be recycled. thymidylate synthase inhibition compromises thymidine synthesis. purine ring synthesis is impaired by inhibition of the participating enzymes amidophospho-ribosyltransferase (ppat) and -aminoimidazole- -carboxamide ribonucleotide transformylase (aicart) [ , ] . maintenance of brisk urinary elimination with i.v. hydration and urinary alkalinization are standard therapies for patients receiving mtx. mtx is ten times more soluble in alkalinized urine (i.e., ph . ) than at ph . [ ] . folate (folic acid) is an ineffective therapy for mtx poisoning. while folate will inhibit renal resorption of mtx, persistent dihydrofolate reductase inhibition by mtx inhibits folate's activation. leucovorin (folinic acid, -formyltetrahydrofolic acid, citrovorum factor) sustains the folate cycle by bypassing the blocked dihydrofolate reductase pathways. addition of leucovorin "rescue" permitted the administration of very-high-dose mtx chemotherapy [ ] . however, in patients receiving mtx chemotherapy, -hour mtx concentrations greater than × - m ( μmol/l), -hour concentrations greater than × - m ( μmol/l), or -hour concentrations greater than × - m ( . μmol/l, nm), or those with evidence of renal dysfunction are considered at high risk for toxicity [ ] . in the setting of mtx persistence or toxicity, leucovorin i.v. doses are increased to mg/m or mg/m every hours according to established nomograms; doses and as high as g/day have been used [ , ] . leucovorin therapy continues until mtx concentration are less than . × - - . × - m ( . - . μmol/l, - nm) [ ] . however, adequate leucovorin concentrations cannot be achieved for competitive reversal of mtx toxicity when mtx concentrations are persistently above - μmol/l; other antidotal strategies are then considered [ ] . treatment of patients ingesting mtx should not be delayed pending mtx concentrations. inhibition of dna synthesis is nearly complete when mtx plasma concentrations are greater than × - m ( . μmol/l, nmol/l) [ ] . therefore, leucovorin is provided until mtx concentrations are less than × - m in patients receiving mtx for non-oncological indications or in patients not receiving mtx therapeutically [ ] . only leucovorin's s-form [levoleucovorin, ( s)-leucovorin] is active and rapidly metabolized to usable, reduced folates; the inactive isomer is slowly eliminated by renal excretion during i.v. administration [ ] . leucovorin was available in the u.s. only as a racemate until , when levoleucovorin received fda approval. levoleucovorin at one-half of the usual racemic dose (as it is entirely active) appears to provide similar rescue therapy in high-dose mtx chemotherapy [ ] . oral rescue is not routinely recommended as leucovorin's bioavailability is poor above mg due to saturation of active intestinal transport [ ] . the calcium content of leucovorin ( . meq calcium/mg leucovorin) mandates that infusion should not exceed mg/min. intrathecal administration of leucovorin is contraindicated, as death may result [ ] . glucarpidase (carboxypeptidase g , cpdg ) is undergoing evaluation as an additional antidote for mtx toxicity. u.s. or european marketing approval for glucarpidase has not been granted at the time of writing. competitive and complete reversal of mtx toxicity by leucovorin may not be possible at mtx concentrations above μmol/l (and perhaps even lower) [ , , ] . patients with systemic mtx toxicity (significant mucositis, gastrointestinal distress, myelosuppression, hepatitis, or neurotoxicity), persistent serum mtx, and renal impairment following high-dose mtx have been considered for glucarpidase therapy in addition to leucovorin. recommendations for glucarpidase above certain mtx concentrations have varied by malignancy, degree of renal impairment, initial mtx dose, and serum mtx concentration (e.g., clinical trials nct , nct , and [ , [ ] [ ] [ ] ). purification of "carboxypeptidase g", a pseudomonad zinc-dependent enzyme capable of mtx cleavage, was reported in [ ] . its antidotal potential was suggested in . in mice injected with lethal mtx doses, carboxypeptidase g rapidly decreased mtx concentrations and improved survival [ ] . cpdg selectively eliminated systemic mtx in patients treated with high dosages targeting cns malignancy, and rescued a patient receiving mtx with renal failure in [ , ] . after the original enzyme source of cpdg was lost, a revived recombinant cpdg product demonstrated success in both i.v. and intrathecal rescue of mtx overdose in non-human primates [ ] [ ] [ ] . successful use in multiple case reports and human trials in adult and pediatric patients with i.v. and intrathecal mtx overdose emerged [ , , , , [ ] [ ] [ ] . glucarpidase is a dimerized protein with two domains -a zinc-dependent catalytic domain that removes c-terminal glutamate residues of folate and folate analogues and a β-sheet interaction site [ ] . glucarpidase splits mtx and its -hydroxy-mtx metabolite into inactive -{[ , -diamino- -(pteridinyl)methyl]-methylamino}-benzoic acid (dampa) and hydroxy-dampa plus glutamate [ , ] . mtx serum concentrations decline by - % within minutes after glucarpidase [ , , , , , ] . intracellular, intraluminal (gastrointestinal tract) and intracerebral mtx is unaffected, creating the potential for rebound concentrations and persistent cytotoxicity [ , , , [ ] [ ] [ ] . leucovorin therapy must continue after carboxypeptidase administration. dampa's poor urinary solubility also requires ongoing alkalinization and saline diuresis to prevent renal precipitation [ , ] . anti-glucarpidase antibodies have been detected in patients receiving glucarpidase, although patients have been successfully treated with additional doses of glucarpidase for persistently elevated mtx concentrations [ , , , , , , ] . hplc must be used to determine actual mtx concentrations after glucarpidase as both mtx metabolites, -hydroxy-mtx and dampa, interfere with immunoassay techniques [ ] . glucarpidase has an affinity for mtx approximately -to -fold higher than it does for leucovorin; however, its affinity for folate and -methyltetrahydrofolate are similar [ , ] . glucarpidase eliminates active levo-( s)-leucovorin about % faster than nonphysiological dextro-( r)-leucovorin [ ] . a study to address the clinical consequence is ongoing. because of the stereoselective destruction of active leucovorin and its metabolites, many protocols attempt to separate leucovorin administration from glucarpidase administration by - hours. administration of glucarpidase more proximate to leucovorin administration, and which antidote to provide should glucarpidase become available at a leucovorin dosing interval, requires a thoughtful benefit-risk assessment. countryspecific information on obtaining glucarpidase, institutional review board protocol, and consent issues have been made available online (www.btgplc.com/ btgpipeline/ /voraxaze.html; and www.fda.gov/cder/cancer/singleind. htm). cardiovascular pharmaceuticals comprise a wide variety of agents including anti-dysrhythmics, β-adrenergic antagonists (β-blockers, bbs), angiotensin antagonists, calcium channel antagonists (ccbs), cardioactive glycosides, and imidazoline derivatives. overdose of these agents alone or in combination can generate potentially lethal combinations of impaired conduction, dysrhythmia, vasodilatation, and negative inotropy. management of severe cases may necessitate diagnostic adjuncts such as echocardiography and right heart catheterization (swan-ganz measurements). in cases refractory to routine supportive care, vigorous gastrointestinal decontamination, and pharmacological intervention, aggressive measures including cardiac pacing, intra-aortic balloon counter-pulsation, or extracorporeal circulation (cardiopulmonary bypass) may be required until toxin elimination can be achieved [ ] . cardiac pacing may improve heart rate without increasing cardiac output if inotropy is compromised. use of naloxone in the management of overdose of clonidine and angiotensin receptor antagonists and angiotensin converting enzyme inhibitors is provided in the opioid antagonists section. strategies to mitigate the anticoagulant toxicity of vitamin k antagonists (i.e., coumadin) including exogenous oral or i.v. vitamin k, fresh frozen plasma, prothrombin concentrates, and recombinant factor vii are detailed in the american college of chest physicians evidence-based clinical practice guidelines [ ] . the guidelines also address protamine sulfate for reversal of heparin anticoagulation and use of nonheparin anticoagulants for treatment and prevention of heparininduced thrombocytopenia [ , ] . atropine (d,l-hyoscyamine) is familiar to clinicians due to its use in several advanced cardiac life support (acls) algorithms [ ] . atropine is a centralacting, competitive antagonist of muscarinic acetylcholine receptors (m -m ) [ ] . it is used to counteract bradycardia from bbs, ccbs, cardioactive glycosides, and clonidine. atropine increases basal heart rate; it does not affect the basal force of contraction [ ] . positive chronotropy alone may not produce systemic benefit in severe poisoning, and conduction system poisoning may limit responsiveness to atropine [ ] . for symptomatic bradycardia, atropine . - . mg (pediatric dose: . mg/kg) i.v. is provided every - min to a maximum dose of mg. paradoxical parasympathetic response may occur during slow infusions or doses less then . mg ( . mg minimum in children) [ ] . in slowing gastrointestinal motility, atropine may impair decontamination with wbi or ac. ccbs antagonize l-type calcium channels, slowing entry of calcium ions during myocyte depolarization; however, intracellular calcium release is not directly affected. this disrupts calcium-mediated excitation-contraction coupling, action potential generation and conduction, and vascular smooth muscle tone [ ] . exogenous i.v. calcium is indicated in cases of ccb and bb toxi-city [ ] . in animal models, calcium salts reverse ccb-induced deficits in contractility, blood pressure, and cardiac output [ ] . multiple uncontrolled cases reports document the effectiveness of calcium salts; however, interpretation of effectiveness is complicated by the co-administration of other modalities. some authors advocate aggressive high-dose calcium therapy, providing large amounts of calcium without apparent ill effect [ ] . this approach does carry a risk of death from hypercalcemia [reported concentration, . mg/dl ( . mmol/l) after g calcium] [ ] . others recommend a bolus dose followed by continuous infusion to maintain physiological calcium levels [ ] . peripheral administration as calcium gluconate decreases the risk of extravasation and tissue necrosis. a standard container of ml of % calcium gluconate provide . meq ( mg) elemental ca + ; ml of % calcium chloride ( g total cacl ) yields . meq elemental ca + [ ] . a suggested approach is to initially administer a . ml/kg ( . meq/kg) bolus of % calcium gluconate ( . ml/kg % cacl ) over - min [ , ] . empirically, this is roughly one vial ( g) of % cacl or three vials ( g) of % calcium gluconate i.v. the bolus may be repeated several times. due to bolus dissipation, most patients are placed on an infusion of % calcium gluconate at . - . ml/kg per hour ( . - . meq/kg per hour) or . - . ml/kg per hour [ , ] . serum phosphate, calcium, and hydration status should be closely monitored. calcium administration for hyperkalemia has been generally contraindicated in cases of cardioactive glycoside toxicity, out of concern for dysrhythmias or systolic arrest (also known as "stone heart") [ ] . while more recent studies have challenged this assertion, it is advisable to withhold calcium until the definitive cardiac glycoside antidote, digoxinspecific fab fragments, has been provided [ ] . digoxin and cardioactive glycosides inhibit the cardiac sodium-potassium atpase. the subsequent accumulation of sodium in the cytoplasm dissipates the driving force for calcium expulsion via the sodium-calcium exchanger. increased intracellular calcium enhances actin-myosin coupling, myocyte contraction, and inotropy. in overdose, the excess calcium may result in membrane hyperexcitability and delayed after-depolarizations. increased vagal tone decreases conduction through the av node. the combination of increased automaticity and vagotonicity may yield lethal ventricular escape rhythms. digoxin-specific antibody fragments bind free digoxin in serum to decrease digoxin serum concentrations to undetectable levels within minutes [ ] . successful reversal of digoxin toxicity with digoxin-specific fab was first reported in [ ] . the results of a prospective multicenter study demonstrated significant effectiveness in reversing life-threatening digitalis toxicity, and more recent studies confirm ongoing fab fragment utility [ , ] . digoxin-specific fab were also shown to be effective in children [ ] . digoxin-specific fab are produced from purified ovine-derived immunoglobulin g. cleaving the fc antibody portion significantly improves renal excretion of the complex, decreases immunogenicity, and facilitates diffusion of remaining free fab into tissue [ ] . reflecting digoxin redistribution from target organs of toxicity, the initial response to digoxin-specific fab was min ( - min), and complete reversal of systemic toxicity occurred on average by min ( - min) [ ] . indications for therapy include life-threatening or progressive dysrhythmia or shock; potassium greater than . meq/l (acute poisoning); chronic poisoning with other end-organ manifestations such as altered mental status, significant gastrointestinal symptoms or renal impairment; or serum digoxin concentration > ng/ml or greater than ng/ml beyond hours after ingestion. hyperkalemia is rapidly reversed by digoxin-specific fab [ ] . one vial neutralizes approximately . mg of digoxin (or digitoxin). dosing is based either on amount ingested [number of vials = amount ingested (in mg) × . (oral bioavailability) / . ], or a serum concentration [number of vials = serum digoxin concentration (ng/ml) × patient weight (kg) / ]. the number of vials is rounded up and administered i.v. over min. empiric therapy is - vials for adult or pediatric patients in acute poisoning or - vials ( - vials in children) in chronic poisoning. partial reversal is recommended by some authors [ ] , but is not common u.s. practice due in part to concern for recrudescent toxicity with inadequate therapy [ ] . following treatment, free digoxin concentrations may rebound upwards within - hours, most likely reflecting tissue redistribution into the vascular space [ ] . this provides a measure of protection against development of significant congestive heart failure (chf) in patients dependent upon digoxin for inotropy, although exacerbation of chf may occur [ ] . clinically significant late rebound of digoxin concentrations and toxicity have occurred in patients with marked renal dysfunction [ ] . immunogenicity from repeat digoxin-specific fab has generally not been significant, although allergic reactions have been infrequently reported with administration [ ] . digoxin-specific fab has been used clinically or experimentally to treat poisoning by other cardiac glycosides -yellow oleander (thevetia peruviana), nerium oleander, chan su and "love stone" (extract of the bufo bufo gargarizans toad) [ , ] . higher dosing may be required due to poor binding affinity. bbs competitively antagonize catecholamine effects at cardiac β-receptors, leading to decreased inotropy and slowed conduction through the av node. bradycardia, conduction delay, hypotension, and decreased cardiac output may accompany significant poisoning. bb interference with gluconeogenesis and glycogenolysis may lead to hypoglycemia, as well as blunt the catecholamine response that is important in its recognition. glucagon, a -amino acid peptide hormone secreted by pancreatic α-cells, counteracts hypoglycemia and the actions of insulin; regulates gastrointestinal motility; and mediates the rate of renal filtration, urea excretion, and water resorption [ ] . the current glucagon product is now produced in non-pathogenic e. coli by recombinant techniques [ ] . myocardial binding occurs at a distinct glucagon receptor (gcgr) coupled with the β-agonist binding site. antidotal (off-label) use of glucagon thus bypasses β-receptor blockade to directly induce g-protein-mediated stimulation of adenylate cyclase to convert atp to camp [ ] . camp, in turn, activates protein kinase a (pka), which promotes the phosphorylation and opening of dormant l-type calcium channels to improve calcium-dependent excitation-contraction coupling [ ] . another proposed mechanism is c-terminal cleavage of glucagon to miniglucagon, which has a direct effect on sarcoplasmic reticulum calcium stores via arachidonic acid [ ] . in human volunteers evaluated by cardiac catheterization, glucagon increased heart rate, cardiac index, and mean atrial pressure, but not left ventricular end-diastolic pressure (edp) or systemic vascular resistance (svr) [ ] . clinical experience in overdose consists primarily of case reports [ , ] . due to the complex nature of overdose, glucagon is often used in combination with other agents in severe bb overdose. additionally, several ex vivo experiments, controlled animal studies, and uncontrolled case reports have demonstrated that glucagon can be beneficial in ccb exposure [ ] [ ] [ ] . the recommended initial bolus dose of glucagon is - μg/kg, which may be repeated after - min [ ] . a continuous infusion corresponding to the total effective bolus reversal dose is then provided per hour (e.g., if clinical response was observed following administration of mg, mg, and finally mg, the hourly infusion would be mg/hour). the effects of glucagon administered i.v. begin within - min, peak at - min and last for approximately min [ ] . nausea and vomiting are common and should be anticipated. this may complicate management of patients with depressed mental status or airway concerns. flushing, transient hyperglycemia, and smooth muscle relaxation, and ileus may also occur. since ccbs antagonize the l-type calcium channel in pancreatic islet cells, a subsequent decreased insulin production can produce hyperglycemia [ ] . animals poisoned by ccbs have impaired myocardial fatty acid uptake (leaving them dependent upon carbohydrate metabolism), impaired uptake of glucose, and myocardial insulin resistance [ , ] . in humans, intracoronary verapamil increased glucose release and altered myocardial lactate use from consumption to release [ ] . decades ago, glucose-insulin-potassium (gik) was proposed as adjuvant therapy for acute myocardial infarction, with the intent of suppressing uptake of free fatty acids, improve myocardial energy production, and stabilize intracellular potassium [ ] . randomized trials of gik therapy in patients with acute myocardial infarction (ami) have not shown benefit, although the insulin doses tend to be low (in general, ≤ . u/kg) [ ] . experience in the surgical literature in cases where much higher insulin doses have been used has been somewhat different [ ] . patients undergoing aortic valve replacement and coronary artery bypass who received high-dose insulin at unit/kg per hour demonstrated more rapid lactate clearance, lower glucose, lower dobutamine requirements, a trend for improved cardiac indices, and potential anti-inflammatory benefit (lower c-reactive protein and free fatty acid levels) [ ] . insulin doses of . units/kg were tolerated without excess increase of insulin-induced potassium elimination [ ] . in combination with dopamine, insulin units/kg was used to significantly augment cardiac output and decrease systemic vascular resistance in post-coronary artery bypass graft (cabg) patients without generating excess in oxygen demand [ ] . additional benefits of high-dose insulin included overcoming insulin resistance, increased expression of glucose transporters, and improved turnover of sodium-potassium-atpases [ ] . the basis for high-dose insulin euglycemia therapy (hiet) (off-label) in overdose has been explored in a series of animal models of ccb and bb toxicity [ , , [ ] [ ] [ ] . hiet increased myocardial lactate uptake and improved systolic and diastolic heart function. insulin outperformed epinephrine and glucagon [ ] [ ] [ ] . multiple human cases of successful management of ccb overdose with hiet have been described [ , ] . because the beneficial cardiovascular effects of hiet are not seen for - min after initiation, it must be considered early, before patients become unsalvageable [ ] . a proposed dosing scheme includes a bolus dose of regular insulin of . units/kg, followed by an infusion of . - . units/kg per hour, titrated upwards as necessary [ ] . a dextrose bolus is also provided unless significant hyperglycemia exists, followed by an infusion of . - . g/kg per hour to maintain blood glucose between and mg/dl. persistent physician reticence to utilizing the high-dose insulin out of concern for excess hypoglycemia presents an obstacle for implementation of adequate hiet [ ] . this ignores a body of physiological data that demonstrate that the insulin transport follows saturation kinetics [ , ] . alternatively, it has also been demonstrated that insulin-stimulated glucose clearance reaches a maximum in both lean and obese subjects [ ] . taken together, this suggests that, from a therapeutic standpoint, since insulin effect via insulin receptors appears saturable, additional mechanisms must be at work. the effects of hiet may include counteracting ccb-mediated insulin impairment or shockinduced hyperglycemia, improving myocardial substrate utilization, and improving myocardial metabolism [ ] . from an adverse-effects standpoint, once adequate and ongoing glucose has been provided, hypoglycemia should not present an excessive risk [ ] , although frequent serum glucose and potassium evaluation are obvious components of hiet therapy. due to the high dosing, insulin may persist after the infusion cessation and necessitate ongoing supplemental dextrose beyond insulin infusion. as hypokalemia is an intracellular result of shift, it is supplemented cautiously. during administration of local anesthetics, severe toxicity may result from systemic absorption or unintended intravascular administration. loss of consciousness, dysrhythmia, cardiovascular collapse, seizures, and lactate-associated acidemia may rapidly ensue [ ] . furthermore, in animal models, for some of the local anesthetics (bupivacaine, levobupivacaine, and ropivacaine), treatment with "standard" advanced cardiac life support (acls) drugs such as epinephrine may precipitate ventricular dysrhythmia [ ] . following a serendipitous observation that pretreatment with a lipid emulsion altered the dose-response to bupivacaine-induced asystole, murine and canine studies provided evidence of survival benefit with lipids in bupivacaine toxicity [ , ] . case reports of successful resuscitation of patients severely affected by bupivacaine, levobupivacaine, mepivacaine, prilocaine and ropivacaine (alone or in combination) followed [ , [ ] [ ] [ ] . pediatric experience is limited to a case of successful resuscitation following lidocaine/ropivacaine toxicity from a posterior lumbar plexus block [ ] . lipid therapy has been successfully applied in human bupropion toxicity and combined quetiapine and sertraline overdose [ , ] . animal models have suggested a possible benefit in clomipramine, propranolol, thiopentone, and verapamil poisoning [ ] [ ] [ ] [ ] . an understanding of lipid's mechanism of action is incomplete. it may act as a "circulating lipid sink" in which excess lipophilic drug may dissolve; modulate intracellular processes; or provide an alternative myocardial energy supply [ ] . presumably due to central sympathetic activation, human volunteers given a -hour lipid emulsion ( %) infusion had increased systemic vascular resistance, blood pressure, muscle sympathetic nerve activity, and concentrations of insulin and aldosterone, without increased cardiac output [ ] . lipid emulsion increased inotropy in both spontaneously beating and paced isolated rat hearts poisoned with levobupivacaine [ ] . dosing guidelines for the off-label use of lipid emulsion in resuscitation are provisional, as optimal bolus and continuous infusion therapy and timing are still being explored. the association of anaesthetists of great britain and ireland recommends an i.v. bolus of . ml/kg intralipid ® ( %) over min, which may be repeated twice at -min intervals if an adequate circulation has not been restored [ ] . following the initial bolus, an infusion is commenced at . ml/kg per min (which may be increased to . ml/kg per min in inadequate circulation). propofol is an inadequate substitute [ , ] . ongoing lipid therapy may be required as recrudescence may occur [ ] . hyperamylasemia may be anticipated. additional concerns include pancreatitis, allergic reactions, acute myocardial infarction, fat embolism, and altered coagulation [ ] . in lapine and porcine models of asphyxial cardiac collapse (pulseless electrical activity or arrest), lipid emulsion was markedly ineffective [ , ] . in vitro, lipid affinity for both bupivacaine and ropivacaine is also adversely affected by low ph (by a factor of . in a ph drop from . to . ) [ ] . these data suggest that ventilatory status must be aggressively addressed early in toxicity. due to their physicochemical characteristics and structure, many non-antiarrhythmic drugs are able to antagonize or alter expression of the myocardial potassium delayed rectifier channel (herg, kcnh , lqt ). with channel block, potassium efflux is compromised, and the repolarizing cardiac i kr current is impaired. the surface ecg reflects this as qt prolongation. age, female gender, comorbidities such as structural heart disease, electrolyte disturbances such as hypokalemia, and heart rate (bradycardia) may provide additional risk. certain antibiotics, antihistamines, antipsychotics, antidepressants, and methadone are prone to induce qt prolongation. qt prolongation is associated with torsade de pointes, a polymorphic ventricular arrhythmia that can degenerate into ventricular fibrillation, cardiac arrest and sudden death [ ] . if significant qt prolongation (qtc > ms) is detected, administration of - g magnesium sulfate i.v. (pediatric dose, - mg/kg) over to min (depending on urgency of presentation), followed by an infusion of - mg/min is suggested [ ] . rapid infusion may cause hypotension, and magnesium should be administered cautiously in renal failure. a second bolus can be provided - min later [ ] . magnesium sulfate i.v. is effective in arrhythmias occurring due to early or delayed depolarization-induced triggered activity [ ] . acceleration of the heart rate with isoproterenol or transvenous pacing (overdrive pacing) may be needed to preclude recurrence of torsade de pointes while correction of underlying risk factors (hypokalemia and hypocalcemia) ensues. immediate non-synchronized defibrillation is required for unstable polymorphic ventricular tachycardia or ventricular fibrillation. severe cardiovascular toxicity may result from blockade of cardiac sodium channels by tricyclic antidepressants (tcas) -leading to conduction delays, dysrhythmias, and myocardial depression. tcas adversely affect maximum upstroke velocity (v max ), which approximates the magnitude of sodium entry [ ] . the sodium channel blockade displays rate dependence. at slow rates the tca has time to disassociate, allowing channel recovery. at faster rates, block progressively worsens. given the anticholinergic effects of tcas that speed the heart rate, this is a significant concern. however, attempts to decrease heart rate with propranolol produced hypotension and lethality in canine studies [ , ] . with progressive sodium channel block, ventricular impulse propagation becomes delayed. sodium channel blockade manifests on the surface ecg as qrs widening. a qrs equal or greater than ms is a significant predictor of seizure; a qrs ≥ ms predicts ventricular dysrhythmia [ ] . the right bundle branch has a relatively longer refractory period, and it is affected disproportionately by impaired intraventricular conduction delay. rightward terminal axis shift or outright bundle branch block may be present [ ] . these rightward terminal forces may also produce terminal r waves in leftwarddirected leads [ ] . acidemia secondary to hypoperfusion or seizure may generate progressively worsened block. in an acidemic environment, free tca concentrations increase as binding to α- acid glycoprotein decreases, the tca ionized fraction increases, and sodium channel blockade worsens [ ] . seizures are severe and consequential, leading to qrs widening and hypotension [ ] . administration of sodium bicarbonate improves v max and action potential amplitude by increasing extracellular ph and sodium concentration [ ] . consequentially, compromised myocardial inotropy, conduction aberrations, and dysrhythmia are reversed. several animal studies have demonstrated these beneficial effects [ , ] . both the sodium and alkalemia induced by sodium bicarbonate improve cardiac performance [ ] . the enhanced inotropy with sodium bicarbonate is independent of and additive to vasopressor treatment [ ] . hyperventilation-induced alkalinization similarly narrows the qrs [ ] . sodium bicarbonate outperformed hyperventilation in a swine model, although hypertonic saline was superior to both [ ] . this approach has been reported clinically [ ] . while sodium bicarbonate is recommended for qrs widening in tca evidence-based consensus guidelines for out-ofhospital management, actual human studies are not as extensive as one might suspect [ , ] . initially, hypertonic sodium bicarbonate - meq/kg i.v. is provided, preferably with continued ecg monitoring of the qrs. institutions usually stock either an . % solution ( meq/ml sodium and bicarbonate ions) or a . % solution ( . meq/ml sodium and bicarbonate ions). rarely, a % solution may be encountered ( . meq/ml). a "standard" -ml ampule of . % or . % solutions would deliver or . meq of nahco . several boluses may be required, either initially or as the bolus effect declines due to redistribution [ ] . ongoing alkalinization should be provided as discussed previously, with a goal of serum ph . . if sodium bicarbonate administration is problematic due to fluid load, hyperventilation and/or hypertonic saline may be required [ , ] . due to mechanistic similarities, sodium bicarbonate has been recommended for qrs widening seen in poisoning by vaughn-williams class ia and ic antidysrhythmics, cocaine, diphenhydramine, carbamazepine, and propoxy-phene [ ] [ ] [ ] [ ] . treatment of bupropion-induced qrs widening with sodium bicarbonate has met with both success and failure [ ] . sodium bicarbonate has also been suggested to treat qrs widening from venlafaxine; similar effects seen with lamotrigine might also be amenable [ , ] . sodium bicarbonate therapy may have a role in taxus species (yew berry) toxicity [ ] . treatment of amantadine-induced qrs widening with sodium bicarbonate may be complicated by concurrent profound hypokalemia [ ] . naloxone is a competitive opioid antagonist at all receptor subtypes [ ] . it can prevent or reverse the effects of opioids, notably cns and respiratory depression. massive doses of naloxone ( . mg/kg with . mg/kg per hour infusion) have been administered safely in non-opioid tolerant individuals suffering from spinal cord injury [ ] . however, indiscriminate use of naloxone in opioid-tolerant individuals can precipitate acute opioid withdrawal, with attendant acute lung injury, seizure, hypertension, or cardiac dysrhythmia [ ] . these are likely associated with the abrupt, significant, and sustained increases in plasma catecholamine concentrations (epinephrine and norepinephrine) that accompany narcotic reversal, particularly in the setting of hypercapnia [ ] . withdrawal-induced vomiting may compromise the airway in patients with concomitant sedative-hypnotic ingestion. precipitated withdrawal-associated agitation and violent behavior may require chemical restraint, leading to a vicious cycle of compromised cns and cardiopulmonary function as naloxone wears off. self-release and relapse following naloxone administration is also a concern in opioids with prolonged duration of effect (methadone, controlled-release oxycodone hydrochloride, etc.). naloxone is no longer recommended as the initial resuscitation of newborns with respiratory depression in the delivery room; precipitation of acute neonatal opioid withdrawal may produce severe consequences [ ] . sudden cardiac arrest has occurred in preterm neonates given naloxone to reverse opioid overdose [ ] . naloxone is utilized in those individuals with clear evidence of the opioid toxidrome. those with a respiratory rate ≤ or hypopnea are likely to benefit [ ] . the goal of therapy is titration to adequate ventilatory status without withdrawal. after normocapnia is achieved by supported ventilation, this can be done with i.v. administration of . - . mg initially (e.g., ml of . mg naloxone in ml diluent or mg naloxone in ml diluent). due to rapid onset, effectiveness can be assessed, and if required, the dose can be titrated upwards incrementally to . mg, mg, or even mg. patients without response to mg naloxone are unlikely to have opioid-induced respiratory depression. nonopioid-dependent adults are administered . - mg i.v. pediatric dosing for infants and children from birth to years of age or less than kg body weight is . mg/kg; children older than years of age or weighing more than kg are provided mg [ ] . for longer acting opioids, following adequate initial opioid antagonism, two-thirds of the initial naloxone reversal bolus is provided as a continuous i.v. infusion [ ] . naloxone can successfully antagonize buprenorphine overdose in children, although prolonged therapy and monitoring may be required [ ] . higher doses may be required due to reverse buprenorphine effects because of its high affinity for opioid receptors [ ] . naloxone has also been used to reverse clonidine toxicity, although this is not always the case [ ] . it has been postulated that patients with higher hyperadrenergic tone (who have higher concentrations of endogenous opioids) or those in whom clonidine induces more endogenous opioid release may respond best to naloxone [ ] . mental status, blood pressure, and heart rate may respond differently. naloxone has been employed in angiotensin converting enzyme inhibitor overdose. one author reported that a . mg bolus of naloxone followed by repeat mg bolus reversed hypotension due to overdose with mg captopril [ ] . naloxone has been ineffective in reversing hypotension in other cases complicated by co-ingestants [ ] . the mechanism may relate to antagonism of endogenous opioids [ ] . co-administration of . mg/kg naloxone mitigated captopril-related decreases in systolic and diastolic blood pressure in healthy volunteers [ ] . a placebo-controlled study of healthy men found that naloxone pretreatment with mg followed by . mg/hour infusion precluded systolic blood pressure decrease induced by captopril ( mg) [ ] . under different experimental conditions [naloxone, . mg bolus and a -hour continuous infusion ( . mg/hour), and captopril ( mg)], no difference was observed [ ] . analogous to naloxone antagonism at opioid receptors, flumazenil competitively antagonizes benzodiazepine receptors -allosteric sites located at the macromolecular gaba a receptor complex, which regulate chloride ion flux within the associated ion channel [ ] . flumazenil reverses the sedative, psychomotor, and amnestic effects of benzodiazepines [ ] . flumazenil's effectiveness depends upon the number of benzodiazepine receptors that can be occupied according to the mass-action law, the affinity of a particular benzodiazepine for the receptor, and the free benzodiazepine concentration near the receptor [ ] . in contrast, antagonism of benzodiazepine-induced respiratory depression is inconsistent, and acute tolerance may develop to large doses [ ] [ ] [ ] . flumazenil administration can reverse bispectral index (bis) depression and permit earlier emergence from anesthesia in patients provided non-benzodiazepine anesthesia (propofol/remifentanil) [ ] . postulated mechanisms included intrinsic cns stimulant activity or antagonism of endogenous benzodiazepine-like ligands (endozepines). under certain experimental conditions, flumazenil may also demonstrate partial agonist or even inverse agonist activity [ , ] . the appropriate utilization of flumazenil as an antidote in patients with benzodiazepine overdose is still a matter of debate. patients who ingest benzodiazepines alone or in combination generally have acceptable outcomes with supportive care alone. proponents argue that awakening is therapeutic and diagnostic, obviates requirements for investigatory procedures, and limits complications of sedation. opponents point to the low risk of mortality with benzodiazepine ingestion, frequent co-ingestants for which flumazenil is ineffective or contraindicated, relapse, and risks of reversal. while flumazenil can be administered safely, indiscriminate flumazenil administration may produce an acute withdrawal syndrome in benzodiazepine-dependent patients, seizures, dysrhythmias, vomiting, and agitation [ ] [ ] [ ] [ ] . flumazenil is not recommended in cases complicated by co-ingestants capable of inducing seizures or dysrhythmias (e.g., bupropion, carbamazepine, chloral hydrate, chlorinated hydrocarbons, chloroquine, cocaine, cyclic antidepressants, cyclosporine, isoniazid, lithium, methylxanthines, monoamine oxidase inhibitors, phenothiazines, and propoxyphene) [ , , ] . as might be anticipated with an antidote of lesser half-life than many benzodiazepines, clinical condition may deteriorate following initial improvement, mandating ongoing monitoring. in one study, patients with primarily benzodiazepines ingestion remained awake for ± min following flumazenil; this was markedly decreased to ± min with co-ingestants [ ] . this may be problematic in patients who, once aroused, demand release from medical care. after excluding co-ingestants of concern, vital sign abnormalities, and an aberrant ecg, and considering the risk-benefit ratio, flumazenil is administered slowly i.v., titrated to clinical effect ( . mg/min, max ≤ mg) [ ] . offlabel continuous infusions of . - . mg/hour have been provided to preclude relapse. patients poisoned by pharmaceuticals present many challenges to the treating clinicians. they generally benefit from aggressive support of vital functions, a careful history and physical examination, specific laboratory analyses, and a thoughtful consideration of the risks and benefits of decontamination and enhanced elimination. data on the effectiveness of certain antidotes ranges from isolated case reports to robust clinical trials. clinicians are encouraged to liberally utilize consultation with regional poison centers or those with toxicology training to assist with diagnosis, management, and administration of antidotes, particularly in unfamiliar cases. no outside funding or support was received. the author has no financial interest in any products mentioned or the companies that produce them. use of trade names is for identification purposes only and does not constitute endorsement by the author, the nyu school of medicine, the new york city poison control center, or the new york city department of health and mental hygiene. within the medical literature, pharmaceuticals, pharmaceutical combinations, and other products are used offlabel as antidotal therapies; off-label uses are referred to in this review. this is for discussion purposes only and does not constitute endorsement of off-label use by the author, the nyu school of medicine, the new york city poison control center, or the new york city department of health and mental hygiene. as medicine is an ever-changing science, readers are encouraged to confirm the information contained in this review -by consulting product and safety information sheets, regional poison centers, those 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evidence-based clinical practice guidelines treatment and prevention of heparininduced thrombocytopenia: american college of chest physicians evidence-based clinical practice guidelines pharmacotherapy considerations in advanced cardiac life support muscarinic receptors in the mammalian heart calcium channel blocking drug overdose: an australian series management of β-adrenergic blocker and calcium channel antagonist toxicity a fatal case of iatrogenic hypercalcemia after calcium channel blocker overdose management of calcium channel antagonist overdose calcium gluconate injection, usp % assessment of the synergistic relationship between serum calcium and digitalis case files of the medical toxicology fellowship of the california poison control system-san francisco: calcium plus digoxin-more taboo than toxic treatment of severely digitalis-toxic patients with digoxin-specific antibody fragments reversal of advanced digoxin intoxication with fab fragments of digoxin-specific antibodies treatment of cases of life-threatening digitalis intoxication with digoxin-specific fab antibody fragments. final report of a multicenter study digoxin-specific fab fragments as single first-line therapy in digitalis poisoning the use of digoxin-specific fab fragments for severe digitalis intoxication in children review of clinical experience with digoxin immune fab (ovine) digoxin-specific antibody fragments: how much and when? pharmacokinetic aspects of digoxin-specific fab therapy in the management of digitalis toxicity late rebound digoxin toxicity after digoxin-specific antibody fab fragments therapy in anuric patient recurrent digoxin overdose and treatment with digoxin-specific fab antibody fragments successful treatment of oleander intoxication (cardiac glycosides) with digoxin-specific fab antibody fragments in a -year-old child: case report and review of literature efficacy of digoxin specific fab fragments (digibind) in the treatment of toad venom poisoning benefits and limitations of reducing glucagon action for the treatment of type diabetes information for the physician. glucagon for injection (rdna origin) treatment of poisoning caused by β-adrenergic and calcium-channel blockers arachidonic acid drives mini-glucagon action in cardiac cells cardiovascular effects of glucagon in man towards evidence based emergency medicine: best bets from the manchester royal infirmary. glucagon for the treatment of symptomatic β blocker overdose glucagon use in symptomatic β blocker overdose treatment of verapamil overdose with glucagon in dogs amelioration of nifedipine poisoning associated with glucagon therapy glucagon antagonism of calcium channel blockerinduced myocardial dysfunction myocardial metabolism dur-drugs and pharmaceuticals: management of intoxication and antidotes ing graded intraportal verapamil infusion in awake dogs beneficial myocardial metabolic effects of insulin during verapamil toxicity in the anesthetized canine myocardial lactate 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safety of hyperinsulinaemia/euglycaemia therapy in the management of calcium channel blocker overdose: a prospective observational study tarka(r) (trandolapril/verapamil hydrochloride extended-release) overdose the effect of insulin dose on the measurement of insulin sensitivity by the minimal model technique. evidence for saturable insulin transport in humans interstitial insulin during euglycemic-hyperinsulinemic clamp in obese and lean individuals dose-response characteristics of insulin action on glucose metabolism: a non-steady-state approach levobupivacaine-induced seizures and cardiovascular collapse treated with intralipid cardiac resuscitation after incremental overdosage with lidocaine, bupivacaine, levobupivacaine, and ropivacaine in anesthetized dogs lipid emulsion infusion rescues dogs from bupivacaine-induced cardiac toxicity resuscitation with lipid versus epinephrine in a rat model of bupivacaine overdose intravenous lipid infusion in the successful resuscitation of local anesthetic-induced cardiovascular collapse after supraclavicular brachial plexus block successful resuscitation of a patient with ropivacaineinduced asystole after axillary plexus block using lipid infusion reversal of central nervous system and cardiac toxicity after local anesthetic intoxication by lipid emulsion injection successful resuscitation after ropivacaine and lidocaine-induced ventricular arrhythmia following posterior lumbar plexus block in a child early treatment of a quetiapine and sertraline overdose with intralipid use of lipid emulsion in the resuscitation of a patient with prolonged cardiovascular collapse after overdose of bupropion and lamotrigine intralipid outperforms sodium bicarbonate in a rabbit model of clomipramine toxicity intralipid infusion ameliorates propranolol-induced hypotension in rabbits hemodynamic effects of intravenous fat emulsion in an animal model of severe verapamil toxicity resuscitated with atropine, calcium, and saline intralipid ameliorates thiopentone induced respiratory depression in rats: investigative pilot study non-esterified fatty acids increase arterial pressure via central sympathetic activation in humans the effects of lipid infusion on myocardial function and bioenergetics in l-bupivacaine toxicity in the isolated rat heart the association of anaesthetists of great britain & ireland ( ) guidelines for the management of severe local anaesthetic toxicity intravenous lipid emulsion for local anesthetic toxicity: a review of the literature recurrence of cardiotoxicity after lipid rescue from bupivacaine-induced cardiac arrest intralipid infusion diminishes return of spontaneous circulation after hypoxic cardiac arrest in rabbits a comparison of the combination of epinephrine and vasopressin with lipid emulsion in a porcine model of asphyxial cardiac arrest after intravenous injection of bupivacaine binding of long-lasting local anesthetics to lipid emulsions in-hospital cardiac arrest is associated with 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toxicology fellowship at the toxikon consortium in chicago: cocaine-associated wide-complex dysrhythmias and cardiac arrest -treatment nuances and controversies acute carbamazepine toxicity associated with a widened qrs interval treated with intravenous sodium bicarbonate bupropion-associated qrs prolongation unresponsive to sodium bicarbonate therapy a fatal case of venlafaxine overdose self-poisoning with lamotrigine management of isolated yew berry toxicity with sodium bicarbonate: a case report in treatment efficacy cardiotoxicity after massive amantadine overdose naloxone in opioid poisoning: walking the tightrope a randomized, controlled trial of methylprednisolone or naloxone in the treatment of acute spinal-cord injury. results of the second national acute spinal cord injury study adverse events after naloxone treatment of episodes of suspected acute opioid overdose narcotic reversal in hypercapnic dogs: comparison of naloxone and nalbuphine the ilcor consensus on science with 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(benzodiazepine receptors): comparison with bretazenil and flumazenil flumazenil: us clinical pharmacology studies clinical pharmacology of flumazenil sedative and ventilatory effects of midazolam infusion: effect of flumazenil reversal the effects of large-dose flumazenil on midazolam-induced ventilatory depression effect of flumazenil on benzodiazepineinduced respiratory depression effect of flumazenil on bispectral index monitoring in unpremedicated patients electrophysiology of benzodiazepine receptor ligands: multiple mechanisms and sites of action characterization of the analgesic effects of the benzodiazepine antagonist, ro - empiric use of flumazenil in comatose patients: limited applicability of criteria to define low risk use of flumazenil in the treatment of drug overdose: a double-blind and open clinical study in patients flumazenil and seizures: analysis of cases treatment of benzodiazepine overdose with flumazenil. the flumazenil in benzodiazepine intoxication multicenter study group a risk-benefit assessment of flumazenil in the management of benzodiazepine overdose valproic acid and metabolites: pharmacological and toxicological studies the author is indebted to lewis s. nelson, md, facep, facmt for manuscript review. key: cord- - zrmgxq authors: bergman, scott j.; ferguson, mckenzie c.; santanello, cathy title: interferons as therapeutic agents for infectious diseases date: - - journal: infectious disease clinics of north america doi: . /j.idc. . . sha: doc_id: cord_uid: zrmgxq this article explains the rationale for development of interferons as therapeutic agents, and describes commercial products available today. it also provides a summary of studies that have been performed with interferons for use as exogenous biological response modifiers in viral infections. overall, the best data exist for treatment of viral hepatitis b and c, for which interferons are a cornerstone of therapy. although infections with human papillomavirus and common cold viruses sometimes respond favorably to interferons, their outcomes are far from ideal. finally, the role of interferons as vaccine adjuvants is still being explored but could be promising. replication in vitro at concentrations as low as pg/ml-the development of ifns as clinically useful drugs has been largely disappointing. this fact can be attributed partly to their short half-life in vivo and their extensive side effects. in fact, many symptoms of viral infections such as influenza can be blamed on endogenous ifn release. the adverse effects prevalent at therapeutic doses include fever, myalgia, and headache, dubbed "flulike symptoms," along with bone marrow suppression leading to leukocytopenia and thrombocytopenia, plus central nervous system manifestations including depression. ifns have been studied for the treatment or prevention of herpes zoster, herpes simplex, and cytomegalovirus infections, but the successful development of acyclovir and ganciclovir gave clinicians safer and more effective alternatives for dealing with these viruses. , ifns can also be used in the treatment of multiple sclerosis and certain cancers, but this article reviews the therapeutic applications of ifns for infectious diseases, focusing on viral infections. ifns are not absorbed orally because of their large amino acid sequence, which is susceptible to the proteolytic enzymes in the digestive tract. however, ifn-a is readily absorbed after both intramuscular and subcutaneous injection. this rapid absorption combined with a short half-life means that frequent injections are needed to maintain adequate concentrations in the body. both commercially available ifn-a products in the united states have now been chemically attached to polyethylene glycol (peg) to enhance their half-life and make once-weekly dosing possible. this coupling not only makes administration easier, but also reduces side effects by having a predictably lower peak concentration of the exogenous cytokine. both pegylated inf-a a (pegasys) and ifn-a b (peg-intron) are obtained from escherichia coli by recombinant methods. these agents consist of naturally occurring small proteins with molecular weights of , to , da. each is considered a first-line option for the treatment of chronic hepatitis c virus (hcv) infection in combination with ribavirin. more details on this use and others are described later in this article. along with the list of additional indications approved by the food and drug administration shown in table , ifn-a was shown to be an effective treatment for the symptoms of an aggressive case of chronic active epstein-barr virus, but did not eliminate infection entirely. therefore, additional studies would need to be performed before recommendation for this use. human leukocyte derived ifn-an (alferon n) injection contains a spectrum of a ifns, and is only approved for the treatment of refractory or recurring condylomata acuminata in adult patients. a low-dose oral version is in development for use in the treatment and prevention of influenza. both versions have been studied against human immunodeficiency virus (hiv)- infection, but with little success. , ifn alfacon- (infergen) is considered the synthetic "consensus interferon" because it contains a nonnatural sequence of ifn-a amino acids all chosen for the highest activity against viral hepatitis. to date, no pegylated formulation of this product has been brought to market. all the a ifns include a black-box warning in their prescribing information about how their use .may cause or aggravate fatal or life-threatening neuropsychiatric, autoimmune, ischemic and infectious disorders. patients should be monitored closely with periodic clinical and laboratory evaluations. therapy should be withdrawn in patients with persistently severe or worsening signs and symptoms related to side effects. in many, but not all cases, these resolve after stopping therapy. , ifn-b a (avonex or rebif) and ifn-b b (betaseron) are recombinant proteins with and amino acids, respectively. these b ifns have antiviral and immunomodulatory properties too, but their use at this time is limited to treatment of multiple sclerosis, not infections. ifn-g b (actimmune) injection is used regularly for the prevention of infections in patients with chronic granulomatous disease along with antibacterials and antifungals. its mechanism of action for this purpose is not entirely known, but long-term studies show a definite benefit. ifn-g can also be used as a salvage therapy for mycobacterial infections, but is not routinely used for treatment of this or other infections. topical imiquimod % (aldara) and . % (zyclara) creams do not have inherent antiviral activity alone, but instead induce ifn-a, ifn-b, and ifn-g plus tumor necrosis factor (tnf)-a through toll-like receptors (tlrs). local application to external genital and perianal warts results in an immunomodulatory response that stimulates cytokines, which have antiviral action and cause a reduction in both viral load and wart size. chronic infection with hepatitis b virus (hbv) and hcv affects over million people worldwide. [ ] [ ] [ ] chronic viral hepatitis is a leading cause of cirrhosis, liver transplantation, and hepatocellular carcinoma. with the development of a vaccination series for hepatitis b in the mid- s, along with increased public education and awareness, acute infection rates of both hbv and hcv in the united states have declined steadily. hbv is a double-stranded dna virus whereas hcv is a single-stranded rna virus, both of which are capable of significant morbidity and mortality in chronic infection. the exact mechanisms of hepatic injury from hbv and hcv infection are not completely understood. because asymptomatic carriers with normal liver transaminases exist, it is likely multiple immune-mediated mechanisms result in hepatocyte damage as opposed to the virus itself being directly cytotoxic. following acute viral infection, the innate immune response initiates formation of nk cells, followed by virus-specific cd t cells and cd cytotoxic t lymphocytes. nk cells stimulate production of ifn-a/b and promote cellular clearance of viral proteins through disruption of the replication process. following successful clearance, either spontaneously or by treatment with ifn, peripheral cytotoxic t lymphocytes and cd t-cell response persists. chronic infection is likely a result of failed innate and adaptive immunity. specifically, chronic infection with hcv has been associated with impaired t-cell and nk-cell response. [ ] [ ] [ ] [ ] genetic factors also likely influence progression of disease and predisposition to adverse effects. although an abundance of research has investigated the immune response in relation to chronic viral hepatitis, many areas of uncertainty still exist. standard ifn-a, the first approved ifn for viral hepatitis, lacked several desirable pharmacokinetic properties. the addition of peg created an ifn that has a slower rate of absorption, reduced elimination, and a longer half-life, necessitating less frequent dosing and fewer adverse effects. furthermore, the peg moiety results in reduced immunogenicity and sterically hinders the antigenic binding site. , although pegylated ifn has replaced standard ifn-a in treatment of chronic hbv and hcv, as many as % to % of patients still fail to respond to treatment. successful response depends on many factors including but not limited to viral genotype, viral load, and degree of liver fibrosis. chronic hepatitis b and c are treated similarly with peginterferon (pegifn); however, only pegifn-a a is fda-approved in the united states for treatment of hbv. both pegifn products are administered as subcutaneous injections once weekly for durations up to weeks, dependent on viral genotype and early viral response for treatment of hcv. pegifn-a b is dosed based on body weight ( . mg/kg once weekly) whereas pegifn-a a is a fixed dose ( mg/wk). ribavirin is used in combination with pegifn for treatment of hcv. the exact mechanism of action of ribavirin as an adjunctive antiviral agent in hcv is not completely understood. , some studies have proposed ribavirin to act as an ifn-stimulated gene inducer to improve second-phase viral decline. protease inhibitors (boceprevir and telaprevir) are recently approved adjunctive oral agents for the treatment of chronic hcv with pegifn and ribavirin. to date, all studies of protease inhibitors have been conducted in patients with hcv genotype , and have shown an increase in sustained virologic response (svr) rates particularly for patients previously unresponsive to ifn therapy. [ ] [ ] [ ] [ ] [ ] [ ] [ ] the use of ifn for the treatment of chronic hbv and hcv has represented a mainstay of treatment for several decades. the specific mechanisms behind the antiviral effects of ifn for hepatitis are complex. ifn-stimulated genes are induced by ifn and disrupt viral replication. hundreds of ifn-stimulated genes are thought to exist. viperin, isg and protein kinase r (pkr) are just a few of the most commonly cited. it is also highly possible that ifn-stimulated genes work synergistically to produce antiviral activities. , a lack of pkr can lead to an environment conducive to hcv replication, though it may not be a good predictor of exogenous ifn response. the study of ifn-stimulated genes and their role in determining who responds to ifn therapy has been evaluated in several studies. , , additional studies of ifnstimulated gene expression are needed to clarify which are directly involved in successful viral response, in what capacity they affect response, and whether pharmacotherapy directed at induction of ifn-stimulated genes can help improve treatment response. chronic hbv infection can be successfully treated with ifn monotherapy. loss of viral dna and antibody formation are successful outcomes associated with ifn treatment. the mechanism of ifn antiviral activity varies depending on hepatitis be antigen (hbeag)-positive or hbeag-negative disease. in hbeag-positive patients, an immune response is stimulated by ifn whereas in hbeag-negative disease, ifn acts directly as an antiviral. hbeag-negative disease tends to be more difficult to treat, and is associated with a longer duration of disease and a higher likelihood of complications such as cirrhosis. several oral nonnucleoside reverse transcriptase inhibitors are also available for treatment of hbv (entecavir, tenofovir, adefovir, lamivudine, and telbivudine). although ifn is still considered a first-line alternative and provides the advantage of defined treatment duration rather than potentially lifelong administration, these oral agents are often used in therapy because of their ease of use and reduced number of side effects associated with treatment. the ability of hcv to evade the host immune response has produced a complex rna virus capable of lingering infection, ultimately resulting in opportunities for increased risk of transmission and complications from advanced liver disease. much of the research regarding the use of ifn for chronic viral hepatitis has focused on use in hcv. following treatment with ifn, a decline in hcv rna occurs over several phases. a rapid inhibition of rna production within the first to days of treatment is followed by a second, slower phase associated with clearance of infected cells. , , the interferons for infectious disease immune response to endogenous ifn produced by innate immunity and that administered exogenously can differ in terms of antiviral activities based on the phase of viral decline. studies have shown that response to ifn-based treatment for hcv may be affected by differences in ifn signaling and induction. it is likely that hcv has mechanisms to avoid recognition by the innate immune response, and as such inhibits the ability of hcv-infected cells to generate ifn. , , early studies conducted in nonresponders to current therapy showed wide genetic diversity, with many showing no common traits to predict nonresponse to ifn therapy. , , however, in several major studies were published associating a singlenucleotide polymorphism (snp) just upstream from interleukin- b gene (il b) with ifn response in patients with hcv genotype . [ ] [ ] [ ] [ ] [ ] additional evidence points to the fact that the il b polymorphism is also linked to spontaneous clearance of hcv. , the il b variant encodes for ifn-l , a type iii ifn belonging to the interleukin (il)- superfamily, which function in a manner similar to type i ifns, resulting in ifn-stimulated gene induction. [ ] [ ] [ ] the genome-wide association study conducted by ge and colleagues evaluated more than treatment-naïve hcv genotype patients, the majority of whom originated from the ideal study. results from logistic regression showed that the il b polymorphism was a stronger predictor of svr than baseline viral load, ethnicity, or degree of fibrosis. further research in this area is needed to clearly identify a future role for genotype testing and further clarify whether it may influence response to therapy in other hcv genotypes. a multicenter, randomized, controlled study by mangia and colleagues analyzed caucasian patients with hcv genotype (n ) and (n ). out of % of patients who achieved rapid virologic response (rvr), il b genotype was not associated with svr, whereas in those patients who did not achieve rvr a significant difference in svr was noted based on il b genotype. at this time genotype testing for il b is not routinely recommended for all hcv patients planning to undergo treatment, but it may be in the future. if done, it should not be used as the only factor when choosing a treatment strategy. the complexity of viral defense mechanisms and subsequent effect on the host response has led not only to development of chronic infections but also to a lack of a viable vaccine. hcv viral polymerase lacks a proofreading capability, creating a more diverse target for vaccine development. additional challenges include the lack of a suitable animal model to mimic a human environment and medium for viral growth. one of the major limitations to ifn therapy is adverse effects. malaise, gastrointestinal effects, neuropsychiatric effects, neutropenia, and anemia can all limit the effectiveness of treatment by necessitating dosage reductions or treatment discontinuation. for newer ifn therapies to be successful, they must induce an antiviral response while at the same time limiting adverse effects. albinterferon is a new ifn therapy currently in development for the treatment of chronic hcv. this product is a combination of ifn-a b fused to recombinant human albumin. one of the advantages with this product is that it only requires once or twice monthly dosing. not much is known at this time about the immunomodulating effects of albinterferon in hcv. it has been shown to have similar svr and adverse event rates to traditional pegifn when used in combination with ribavirin. [ ] [ ] [ ] research into ifn-l as an agent to treat hcv has also been initiated. it is hypothesized that l ifns may be associated with less adverse effects than ifn-a because ifn-l receptors are primarily found in hepatocytes. , specifically, research into new investigational pharmacotherapy in the form of pegylated il- (ifn-l ) in patients with hcv genotype who relapsed following traditional treatment with peg-ifn-a and ribavirin appears promising. , both ifn-l and ifn-l share a common receptor and have a similar sequence identity. a -week, open-label study conducted in patients with chronic hcv genotype was designed to assess pegifn-l in combination with ribavirin. it was a dose escalation study conducted in parts. parts and evaluated patients who relapsed following treatment with ifn-a, and part included treatment-naïve patients. in part , pegifn-l monotherapy ( . mg/kg or mg/kg) was administered subcutaneously every weeks or weekly. in parts and , a range of pegifn-l dosages ( . mg/kg, . mg/kg, . mg/kg, or . mg/kg) were administered weekly in combination with ribavirin twice daily ( mg if weight < kg and mg if weight ! kg). the primary outcomes were safety and tolerability. pharmacokinetics and viral load reduction were evaluated as secondary end points. commonly reported adverse effects with pegifn-l included fatigue ( %), nausea ( %), myalgia ( %), and headache ( %). most adverse events were mild or moderate in severity. four patients ( %) experienced treatment-related toxicity and required doses to be withheld. one patient experienced grade thrombocytopenic purpura and another patient had elevated alanine aminotransferase, aspartate aminotransferase, and bilirubin levels. both events were considered to be related to treatment with pegifn-l. aminotransferase elevations occurred most often in patients who received high-dose ( mg/kg) pegifn-l monotherapy. no clinically relevant decreases in absolute neutrophil count occurred. also, hemoglobin values remained consistent with known effects in patients who received ribavirin therapy. viral activity decreased in the majority of patients who relapsed with previous treatment, with of patients achieving at least a greater than -log reduction in hcv rna. six of treatment-naïve patients achieved a similar reduction in viral load and achieved undetectable hcv rna levels. kinetic data showed a linear relationship between dose and exposure independent of body weight, which may prompt future research to evaluate a fixed dose of pegifn-l. larger, longer, controlled, and blinded studies of ifn-l as a viable treatment option in hcv are needed to define its place in therapy and benefits over existing ifn therapy. studies in other hcv genotypes are also needed. in addition, with the advent of protease inhibitors, more research will be necessary to evaluate how direct antivirals and il b genotyping interact in guiding treatment decisions. adjunctive therapy with agents that induce or restore ifn-stimulated gene expression has recently been evaluated in patients with hcv. s-adenosylmethionine (same) given orally was evaluated in an open-label study in patients with chronic hcv, genotype who were considered nonresponders to previous ifn and ribavirin treatment. same was administered at a dose of mg twice daily in combination with pegifn-a a ( mg/kg weekly) and weight-based ribavirin ( mg if weight < kg and mg if weight ! kg). the primary outcome was change in firstphase and second-phase viral decline. treatment response and ifn-stimulated gene expression were also evaluated after up to weeks of treatment. results showed significant improvement in second-phase viral decline assessed at weeks. svr was also evaluated; however, this study was not powered to detect differences in virologic response rates. furthermore, at the time of publication not all patients had reached weeks post treatment, so the full effects on svr were not fully known. the addition of same showed greater induction of ifn-stimulated genes, including viperin, myxovirus resistance protein, and isg , compared with control. adverse effects noted with same were mild and mostly related to gastrointestinal upset, likely as a result of lactose in the tablet preparation. additional research is aimed at investigating structure-activity relationships, and preliminary pharmacokinetic studies on oral ifn inducers that act on tlrs in the treatment of hcv. upper respiratory tract infection in the form of "the common cold" can be caused by a variety of viruses including rhinovirus, coronavirus, influenza, parainfluenza, respiratory syncytial virus, adenovirus, coxsackie, and echovirus families among others. symptoms may include rhinorrhea, nasal obstruction, cough, fever, and sore throat. the disease is usually mild and self-limited, but several trials have addressed treatment or prevention of the common cold with therapeutic agents. ifns were once one of the most popular prospects for this purpose, but the minor benefit that was derived from them was counteracted by the adverse effects inflicted. an early double-blind trial with ifn-a b intranasal drops did demonstrate that with use for several days before experimentally induced rhinovirus infection, common cold symptoms were significantly fewer in study participants compared with placebo-drop users. administration of the drops times daily was superior to a higher dose given once daily at preventing infection. short-term use was well tolerated, but obviously it is not realistic for everyone to use intranasal drops times daily throughout the entire cold season. in an attempt to prevent natural infection during the period of increased acute respiratory tract virus activity, a twice-daily nasal spray was studied in volunteers over days. there was a significant decrease in the number of rhinovirus infections noted, but not in any other types of viral respiratory tract infections including parainfluenza. adverse events with the ifn formulation were common in this placebocontrolled trial. during the first week alone, % of participants receiving ifn spray reported nosebleeds. this number increased to % by the end of the study. providing ifn prophylaxis for family members of those infected with common cold viruses is a more targeted approach to therapy. several studies have addressed the usefulness of ifn nasal sprays in this scenario. seven days of use did significantly reduce rhinovirus infections in different trials when compared with placebo for both individuals ( . % vs . %) and their families ( . % vs . %, both p<. ), but not in other studies when lower doses were given for a shorter -day course. [ ] [ ] [ ] [ ] overall, the intranasal dose of ifn needed to protect against upper respiratory tract infection appears to cause significant unwanted effects. infection with coronavirus and respiratory syncytial virus has also been an object of investigation for ifn-a b nasal sprays, but with little success. , a study of intranasal human lymphoblastoid ifn-an (wellferon) suggested lower prophylactic activity for influenza than it did for rhinovirus. because results of prophylactic trials with ifns for common cold viruses were not favorable, use in the treatment of infection seemed a logical application for this biological response modifier. although some benefit was originally seen with twice-daily ifn-a b intranasal drops for treatment of experimentally induced rhinovirus, no advantage was clear when an intranasal spray was used once daily for days to treat natural infection. increased rates of blood in the mucus were again noted for participants receiving the intervention, and the ifn group experienced more secondary complications requiring prescription of antibiotics. the investigators concluded that intranasal ifn was ineffective for treating the common cold and was associated with clinically significant side effects. similar trials with ifn-b-serine and ifn-g formulations, although initially positive, have shown equally disappointing clinical results. [ ] [ ] [ ] [ ] even though the prospects of further study on ifns for upper respiratory tract infection appear limited, one modern trial did demonstrate an added benefit of intranasal ifn-a b in combination with an antihistamine (chlorpheniramine) and nonsteroidal anti-inflammatory drug (ibuprofen) at reducing common cold symptoms, showing that at least one group is still interested in studying the topic. investigators have also recently begun research on an alternative therapeutic approach for rhinovirus infections using the ifn and tnf-a inducer, imiquimod. application of this intranasal cream in primates has shown promising results in terms of enhancing cytokine response, but human trials have not yet been published. human papillomaviruses (hpvs) are now known to be the cause of cervical cancer and are also responsible for genital warts. hpvs are nonenveloped, double-stranded dna viruses that invade mucosal and epithelial tissues during sexual contact with an infected partner. it is estimated that more than % of the sexually active american population has been or will be infected with hpv at one point in their lives. when hyperproliferation of infected cells occurs, this can lead to genital warts or cancer of the cervix, vagina, vulva, and penis, among others. there are more than different types of hpv and approximately of them infect genital mucosa. fifteen carcinogenic types of hpv have been identified, but of them are associated with % of cervical cancers. two vaccines have recently been introduced that prevent infection with these most common high-risk types of hpv, and . one of these vaccines can also induce protection against the most prevalent hpv types that have a low risk of malignancy, but instead cause genital warts: hpv- and hpv- . hpv has the ability to persist in stratified epithelia for decades because of mechanisms that avoid immune eradication. ifn plays a large role in this cycle. ifns are normally secreted by keratinocytes, but hpv reduces their expression. introduction of low-level ifn can actually increase early gene transcription and hpv replication, which may explain why use of the agent therapeutically has had mixed results. overall outcomes have been positive more often for cases of genital warts than reduction of hpv lesions associated with cancers. a study comparing the in vitro activity of ifn-a b and ifn-an on oncogenic hpv- , hpv- , and hpv- b demonstrated that increasing concentrations did not always correlate with a stepwise inhibition of hpv replication. meanwhile, a meta-analysis recently analyzed locally used and systemic ifn for genital warts. seven randomized studies of ifn intralesional injection or topical gel met criteria for inclusion, and overall there was a benefit in complete response rates over placebo ( . % vs . %, relative risk . , % confidence interval . - . ). however, there was no difference in outcomes for trials comparing systemic ifns with placebo. in comparison, clearance of genital and perianal warts occurs in % of patients with the topical ifn inducer imiquimod, usually after to weeks of use. the % imiquimod cream (aldara) should be applied to affected areas times a week for up to weeks, whereas the newer . % cream (zyclara) can be applied once daily for as little as weeks to treat external genital warts caused by hpv. systemic ifn therapy may be useful when hpv affects areas of the body other than the anogenital region. successful treatment with systemic pegifn-a and a topical retinoid has been reported for mucosal carcinomas from epidermodysplasia verruciformis, a genetic abnormality leading to persistent and widespread hpv infection of the skin. recurrent respiratory hpv infection has also been effectively treated with ifn-a ( of patients), although it had no effect on viral load or replication. a -year follow-up of patients treated with ifn-a for recurrent respiratory papillomatosis confirmed better response rates for hpv- than hpv- , which had a higher likelihood of malignant transformation. for recurrent conjunctival papilloma, topical plus systemic or intralesional ifn has been effective with partial excision. , the rapid resolution of significant hpv-associated warts on the hand, foot, and face has also occurred in an hiv-infected patient on antiretrovirals while being treated for hepatitis c with pegifn-a b and ribavirin. case reports of treatment with the topical ifn inducer, imiquimod, have shown promise for its use in focal epithelial hyperplasia (heck disease), a rare disorder caused by specific types of hpv ( , , , and ) affecting oral mucosa primarily in children. in addition, imiquimod % cream has been used successfully in the treatment of plantar warts, a smoother, flatter manifestation of hpv- , hpv- , and hpv- on the foot. of interest, the oral h -antagonist cimetidine, along with reducing stomach acid, also induces production of ifn-g and il- , which eliminates viral warts in some patients. in the future the improved application of more effective topical ifns may become a reality, which could provide a valuable treatment for hpv infections without the systemic side effects of current injectable formulations. adjuvants (adjuvare, latin for "to help") are substances that augment the immunogenicity of an antigen when mixed with the antigen for use in a vaccine. adjuvants ( ) stimulate granuloma (which is a macrophage-rich mass), ( ) enhance costimulatory signals, ( ) stimulate nonspecific lymphocyte production, ( ) prolong the antigen concentration in a site for lymphocyte exposure, and ( ) induce cytokines. , research in vaccine development has shown that one of the most promising uses of ifns is as an adjuvant with specific antigens in prophylactic vaccines. toporovski and colleagues provide a current review of the use of ifn-a, ifn-b, ifn-g, and ifn-l in vaccine studies that focus primarily on murine, avian, porcine, and nonhuman species. regardless of the species, the use of ifns as adjuvants seems to improve the efficacy and safety of most vaccines while providing the immunomodulatory effect of stimulating the t-helper response. in humans, ifn-a, predominantly produced by plasmacytoid dendritic cells, plays a large role in the body's immune response against viruses. it induces plasma cell differentiation from b cells causing an increase in the serum level of influenzaspecific immunoglobulins, and channels antigen-presenting cells (apcs) to the site of infection. most research on ifn-a adjuvant activity and its subsequent use in approved vaccines seems to indicate that it is a potent adjuvant. when mixed with the influenza vaccine and injected intramuscularly, it is a highly effective adjuvant. oromucosal administration of recombinant ifn-a, like that of natural oromucosal ifn production, has been shown to provide immunity against viral infection and tumor cell growth. nonresponders low responders to a previous vaccine showed an improved immunoglobulin response with a recombinant ifn-a and hbv vaccine. although research is also focused on the other classes of ifns as adjuvants, thus far they have not yielded results as promising as that of ifn-a. the use of ifn-b has yielded mixed results; ifn-g has been used primarily in dna vaccines; and even less is known about the use of ifn-l in vaccines. nevertheless, the use of ifns as adjuvants shows great promise in augmenting vaccine efficiency, and should continue to be a top priority in the development of vaccines. ifns have been tested repeatedly against infectious diseases, but injections are used mostly for the treatment of viral hepatitis c and prevention of infections in patients with chronic granulomatous disease clinically. intralesional ifn and topical inducers are effective in reducing the manifestations of genital warts, but they do not eliminate cancer-causing hpv from the body. ifn has not proved to be consistently effective for treatment of respiratory tract infections from the common cold or influenza viruses, and prophylactic use is not currently feasible. the severity and quantity of adverse effects from systemic ifn therapy make it unattractive for many uses. several infections, including herpes simplex, herpes zoster, cytomegalovirus, and even viral hepatitis b have other effective pharmacologic treatments. ifn has been successfully used as a vaccine adjuvant, and further research may allow for its additional use for this application in the future. mim's medical microbiology goodman & gilman's the pharmacological basis of therapeutics role of endogenous biological response modifiers in pathogenesis of infectious diseases interferons at age : past, current and future impact on biomedicine immunoglobulins, vaccines or interferon for preventing cytomegalovirus disease in solid organ transplant recipients interferon: mechanisms of action and clinical value interferon-alpha therapy for chronic active epstein-barr virus infection: potential effect on the development of t-lymphoproliferative disease fda authorizes alferon ldo clinical study for treatment and prevention of influenza a multicenter, randomized, controlled trial of three preparations of low-dose oral alpha-interferon in hivinfected patients with cd counts between and cells/mm( ). division of aids treatment research initiative (datri) study group vitro activity of interferon-alpha n (alferon n) against hiv- . interscience conference on antimicrobial agents and chemotherapy nj: pegasysÒ (peg-interferon alfa- a) nj: peg-intronÒ (peginterferon alfa- b) a controlled trial of interferon gamma to prevent infection in chronic granulomatous disease. the international chronic granulomatous disease cooperative study group long-term interferon-gamma therapy for patients with chronic granulomatous disease biological response modifiers as adjunct treatment for refractory localized mycobacterium avium complex infections fact sheet: world health organization viral cancers: world health organization surveillance for acute viral hepatitis-united states antiviral drugs (other than antiretrovirals) cytoskeleton rearrangement induced by tetraspanin engagement modulates the activation of t and nk cells natural killer cells: primary target for hepatitis c virus immune evasion strategies? interferon-alpha-induced trail on natural killer cells is associated with control of hepatitis c virus infection impaired effector function of hepatitis c virus-specific cd t cells in chronic hepatitis c virus infection association of genetic polymorphisms with interferon-induced haematologic adverse effects in chronic hepatitis c patients reducing the immunogenicity and improving the in vivo activity of trichosanthin by site-directed pegylation pegylated interferons: what role will they play in the treatment of chronic hepatitis c? ribavirin improves early responses to peginterferon through improved interferon signaling boceprevir for previously treated chronic hcv genotype infection boceprevir, an ns protease inhibitor of hcv antiviral effects and safety of telaprevir, peginterferon alfa- a, and ribavirin for days in hepatitis c patients antiviral activity of telaprevir (vx- ) and peginterferon alfa- a in patients with hepatitis c sch , a novel hepatitis c virus protease inhibitor, plus pegylated interferon alpha- b for genotype nonresponders telaprevir with peginterferon and ribavirin for chronic hcv genotype infection telaprevir and peginterferon with or without ribavirin for chronic hcv infection the interferon inducible gene: viperin identification of three interferon-inducible cellular enzymes that inhibit the replication of hepatitis c virus the induction of type i interferon production in hepatitis c-infected patients a treatment algorithm for the management of chronic hepatitis b virus infection in the united states: update effect of ribavirin on hepatitis c viral kinetics in patients treated with pegylated interferon s-adenosyl methionine improves early viral responses and interferon-stimulated gene induction in hepatitis c nonresponders the interferon inducing pathways and the hepatitis c virus genetic variability of hepatitis c virus before and after combined therapy of interferon plus ribavirin a new era of hepatitis c therapy begins genetic variation in il b predicts hepatitis c treatment-induced viral clearance il b is associated with response to chronic hepatitis c interferon-alpha and ribavirin therapy genome-wide association of il b with response to pegylated interferon-alpha and ribavirin therapy for chronic hepatitis c genetic variation in il b and spontaneous clearance of hepatitis c virus hepatitis c pharmacogenetics: state of the art in pharmacogenetics of hepatitis c therapy snipping away at hepatitis c. hepatology an il b polymorphism determines treatment response of hepatitis c virus genotype or patients who do not achieve a rapid virologic response albinterferon alfa- b dosed every two or four weeks in interferon-naive patients with genotype chronic hepatitis c safety and antiviral activity of albinterferon alfa- b dosed every four weeks in genotype / chronic hepatitis c patients albinterferon alfa- b was not inferior to pegylated interferon-alpha in a randomized trial of patients with chronic hepatitis c virus genotype or albinterferon alfa- b was not inferior to pegylated interferon-alpha in a randomized trial of patients with chronic hepatitis c virus genotype phase b study of pegylated interferon lambda with or without ribavirin in patients with chronic genotype hepatitis c virus infection design and optimisation of orally active tlr agonists for the treatment of hepatitis c virus infection the common cold alpha -interferon for the common cold intranasal interferon alpha for prevention of rhinovirus infection and illness intranasal interferon-alpha b for seasonal prophylaxis of respiratory infection prophylactic efficacy of intranasal alpha -interferon against rhinovirus infections in the family setting prevention of natural colds by contact prophylaxis with intranasal alpha -interferon ineffectiveness of postexposure prophylaxis of rhinovirus infection with low-dose intranasal alpha b interferon in families intranasal interferon (rifn-alpha a, ro - ) for contact prophylaxis against common cold: a randomized, doubleblind and placebo-controlled field study tolerance of one-month intranasal interferon prevention of experimental coronavirus colds with intranasal alpha- b interferon the efficacy of intranasal interferon alpha- a in respiratory syncytial virus infection in volunteers wellferon") prophylaxis against rhinovirus and influenza virus in volunteers intranasal interferon-alpha treatment of experimental rhinoviral colds intranasal recombinant alfa- b interferon treatment of naturally occurring common colds tolerance and efficacy of intranasal administration of recombinant beta serine interferon in healthy adults ineffectiveness of recombinant interferon-beta serine nasal drops for prophylaxis of natural colds interferon-beta ser as prophylaxis against experimental rhinovirus infection in volunteers recombinant human interferongamma as prophylaxis against rhinovirus colds in volunteers combined antiviral-antimediator treatment for the common cold immune responses induced by intranasal imiquimod and implications for therapeutics in rhinovirus infections genital hpv infection-fact sheet epidemiologic classification of human papillomavirus types associated with cervical cancer update on human papillomavirus vaccines: life saver or controversy magnet? clin microbiol newslett human papillomaviruses and the interferon response interferon-beta treatment increases human papillomavirus early gene transcription and viral plasmid genome replication by activating interferon regulatory factor (irf)- efficacy of two commercial preparations of interferon-alpha on human papillomavirus replication interferon for the treatment of genital warts: a systematic review successful treatment of disseminated human papillomavirus infection with pegylated interferon and ribavirin epidermodysplasia verruciformis with multiple mucosal carcinomas treated with pegylated interferon alfa and acitretin human papillomavirus, viral load and proliferation rate in recurrent respiratory papillomatosis in response to alpha interferon treatment use of interferon-alpha in recurrent respiratory papillomatosis: -year follow-up topical alpha-interferon in recurrent conjunctival papilloma resolution of recurrent conjunctival papilloma after topical and intralesional interferon alpha b with partial excision in a child treatment of human papillomavirus with peg-interferon alfa- b and ribavirin treatment of focal epithelial hyperplasia with topical imiquimod: report of three cases plantar warts treated with an immune response modifier: a report of two cases cimetidine treatment for viral warts enhances il- and ifn-gamma expression but not il- expression in lesional skin topical delivery of interferon alpha in human volunteers and treatment of patients with human papillomavirus infections new york: w.h. freeman and co advances in vaccine adjuvants interferons as potential adjuvants in prophylactic vaccines plasmacytoid dendritic cells induce plasma cell differentiation through type i interferon and interleukin adjuvant activity of interferon alpha: mechanism(s) of action oromucosal interferon therapy: marked antiviral and antitumor activity randomized comparative trial of interferon-alpha versus placebo in hepatitis b vaccine non-responders and hyporesponders key: cord- -qxya cs authors: bryant, everett title: biology and diseases of birds date: - - journal: laboratory animal medicine doi: . /b - - - - . - sha: doc_id: cord_uid: qxya cs nan the domestic fowl has been the most useful in experimental axonomy trials. the fast maturing and highly inbred chicken can be used with great statistical confidence. diseases can be prevented most avian species used for research purposes fall within ? a n d i s o l a t i o n r e a r j n g j s n e j t h e r d i f f i c u , t n q r ^, three orders: galliformes, which includes domestic fowl, quail, pheasants, turkeys, partridges, grouse, guinea fowl and brush turkeys; anseriformes, which includes ducks, geese, swans, and screamers; and the columbiformes, which includes c · availability of chickens for research pigeons, doves, and sand grouse. the bird fits into the overall taxonomic scheme as follows: specific pathogen-free (spf) fertile eggs, day-old chicks, or kingdom, animal; phylum, chordata; class, aves; order, started pullets are available for use in research. specific pathoorders with approximately species. a clear outline of the gen-free chickens or eggs come from breeding stock negative avian orders listing the common names of birds in each may be to diseases caused by mycoplasmas, newcastle disease, infecfound in steiner and davis ( ) . tious bronchitis, avian encephalomyelitis, infectious bursal disease, quail bronchitis, salmonellosis, pasteurellosis, and in fectious coryza. somes ( ) lists the sources of specialized lines, strains, mutations, breeds, and varieties of chickens, turkeys, and ja panese quail. chromosome linkage maps for the three species and modes of inheritance are also given for most genetic traits. bickford, ; woodard et al., ; schwartz, ) quality animal welfare and optimal comfort for birds is nec essary to insure reliable research data. the ability periodically to observe birds on experimental test through a glass window is ideal; however, if an observation point is not available, the animal technician should check the birds at least twice a day for paleness, dehydration, and other signs indicative of diseases. death before weeks of age may be due to chilling, over heating, crowding, and omphalitis. mortality at - weeks in research chickens may be due to coccidiosis or one of the enteritides. brooding temperature for -day-old chicks should be be tween °- °f and gradually reduced to °- °f by the third week. chicks will constantly peep if too hot or too cold. lowered humidity will cause poor feathering, and if the en vironment is too moist, disease problems will be more pro nounced. a relative humidity of - % is ideal. therefore, frequent monitoring to control temperature and humidity should be practiced. fresh air, without drafts, helps to mini mize moisture accumulation. stale air retards growth of birds and enhances respiratory diseases. the density of broilers and layer replacements may vary with the experimental procedure, but table i will serve as a guideline. there are many kinds of feeders, waterers, and brooders available. the simplest and least expensive may be the best for experimental work. while adjusting to the feeders newly hatched chicks and poults should be fed on papers from day to day . trough feeders work well for birds raised on the floor. it is important to have an adjustable feeder. the level of the feed in the trough should be equal to the level of the back of a standing chicken. this allows the bird access to the feed and prevents waste of feed. tube feeders that hang from the ceiling have the advantage of holding more feed without waste. they are adjustable, and the feed should be at the same level, as described for trough feeding. too many feeders of either type impede available floor space for the chickens. two -ft trough feeders or two tube feeders are adequate for birds at any age. waterers should provide clean, fresh water ad libidum. birds should never be without water. there are many types, but a simple gallon jug with a plastic bottom containing a groove circling the jug is ideal for birds from to days of age. an automatic trough waterer, one -ft long per hundred birds, is adequate. automatic waterers can stop working, run over, and make it difficult to measure water consumption. therefore, large can-type waterers or open pan-type waterers may be bet ter for some types of trials. they are more easily cleaned and control water intake better. incidence of candidiasis in a flock of birds is directly related to the level of water sanitation, and proper attention to water quality greatly reduces this disease in research birds. commercially available cage equipment will also have feeders and waterers and sometimes a heat source. daily clean ing of fecal material from cages enhances the level of sanita tion. external and internal parasitism is increased in birds reared in dirty cages. for heat and ventilation, brooder stoves fueled by gas, oil, coal, and electricity are available. for small groups of birds, heat lamps are adequate. supplementary room heat is neces sary for small groups in colder climates. air conditioning may be necessary during extremely hot weather. an exhaust fan is necessary to ensure removal of stale air. for young chicks, è ft /min will exchange air quite well and for older birds, ft / min is adequate. modern animal facilities meeting the criteria for the nih ' 'guide for the care and use of laboratory ani mals" will provide acceptable heat, ventilation, and air condi tioning needs (see chapter ). nests are needed for laying birds. adequate nests should be provided to ensure one nest for every four birds. nests should be constructed of metal for ease of cleaning and should be well ventilated. lack of sharp corners minimizes trauma, and dry materials, such as shavings, sawdust, or peanut hulls, make excellent nest material. a completely sanitized and disinfected room with sterilized equipment is necessary for research purposes. birds are coprophagic, and many diseases of the digestive tract are trans mitted in this manner. physical cleaning of room surfaces with high pressure of hot water will remove fecal material, mucus, and other debris from walls and floors. cages should be sani tized in appropriate cage washers. while the pen is still warm and wet, fumigation with formaldehyde gas is quite effective. the temperature should be °f and the humidity % or high er to be most efficient. formaldehyde vapors have a potential health risk to humans, and the reader should refer to the discus sion of disinfectants by hofstad et al. ( ) before using this product. once the area and equipment are cleaned, iodines, quatern ary ammonium compounds, chlorines, or other agents can be used to disinfect the premises. no one should be admitted to isolation areas without a show er, clean clothing, and clean boots. doors should be locked at all times, and animal technicians should not be assigned to care for any other birds. birds have pneumatic bones, with air spaces and channels, which add buoyancy in flight. this system of pneumatic bones provides direct channels from the air sacs through the bones so that air carrying infecting organisms may travel throughout the bird rather rapidly. certain respiratory infections and parasites use these channels for distribution of the microorganisms. small birds lack teeth; the organ of mastication is the gizzard which contains grit or gravel, thereby enabling grinding of hard grains. if the feed is an all-mash or all-pellet diet, no grit is needed in the diet. most birds possess a crop, a dilatation in the midesophageal region. pigeons and pet birds regurgitate and feed their young on crop milk. this process allows transmission of parasites to the young from healthy adult carriers. only the left ovary and oviduct are functional in the hen. frequently a cyst, the remnant of the right oviduct, is found; however, this causes no pathological disturbance. b. applied physiology (see sturkie, ) birds can stand extreme variations of environmental tem perature for short periods of time. as the relative humidity increases, the temperature tolerance of the chicken decreases. normal heart rate for the chicken is about beats/min and will increase substantially during excitement and periods of stress. the normal respiration for the chicken is approximately /min, and will also increase rapidly as the temperature goes up. artificial light is important. fourteen to hr of light per day is needed for optimum egg production. the optimum tem perature for egg production is between °- °f. any varia tion thereof may cause a decrease in egg production. growth rate has improved so rapidly that textbooks cannot keep up-to-date. feed conversions of less than . are being reported on a lb average weight broiler at days of age. these are under excellent field management with optimum nu trition, genetics, and freedom from disease. egg production flocks have also improved their efficiency. the average flock today will peak above % by the time they reach weeks of age. for a complete treatment of avian hematology, the reader is referred to sturkie ( ) . blood volume in the bird is about % of total body weight. this will vary according to age, sex, and species. an atlas on avian hematology is also available (lucas and jamroz, ) . data shown in table ii were taken from olson ( ) . chickens, turkeys, and other birds require the six major nu trients: carbohydrates for energy, fats for energy and essential fatty acids, protein for meat and egg production, minerals for bones and shells, vitamins for chemical catalysts, and water. birds should have a complete and balanced ration with very little supplementation. unnecessary supplementation may create other deficiencies. age and functional status of the flock will determine the for mula needed. table iii lists approximate types of formulas needed for various ages and classes of birds. high quality protein is necessary for growth and mainte nance of birds. all the essential amino acids must be present in the diet as the bird cannot convert them from raw protein. min erals and vitamins must be provided in balance. calcium and phosphorus should be in a ratio of : for young growing chickens. antioxidants should always be used to prevent oxidation of fats and fat-soluble vitamins. feed additives, especially arsenicals and certain drugs, should be fed according to the manufac turer's directions. consumption of eggs from these birds dur ing this time should be avoided. for a more detailed account of nutrition in birds, the reader is referred to the specific texts by scott et al. ( ) , by the national research council of the national academy of sciences ( ) , and to the chapter in hofstad ei a/. ( ) . specific nutritional deficiencies will be discussed in section viii. poultry and other birds are easily startled. flashing lights, loud noises, and shadows will cause birds to pile up on each other causing the pen mates underneath to suffocate. hysteria, caused by sudden fright, will result in birds flying against the wall for no apparent reason. many experts argue that a sudden change in air pressure will cause hysteria. when the author has encountered this disease, the birds have usually been raised in a filtered-air, positive-pressure facility. b. clinical signs and lesions. escherichia coli may be a primary infectious agent; clinical onset is rapid and daily mor tality can approach . - . %. the usual lesions noted are air sacculitis, fibrinous pericarditis, and fibrinous perihepatitis. rarely is the trachea involved. colîgranuloma (hjarre's dis ease) may be caused by a pathogenic e. coli serotype. avian tuberculosis may be confused with colibacillosis. granulomas of the intestine are differentiated from tuberculosis by the use of the acid-fast stain. escherichia coli, of course, is not acid fast. other lesions caused by e. coli include arthritis leading to lameness and death, navel infection leading to high mortality, and foot pad infections. c. epizootiology. hens with e. coli infection, especially of the oviduct, contaminate the egg shell. bacteria may then penetrate the egg shell and the chick is hatched with a yolk sac infected with e. coli. d. diagnosis. escherichia coli should always be consid ered a potential pathogen in birds. if an air sacculitis syndrome develops, with no isolation of pasteur ella sp., mycoplasma sp., or hemophilus sp., it is essential to consider e. coli as the potential pathogen. isolations of e. coli from yolk sacs, joints, or bone marrow should always be considered a primary cause of disease. e. prevention. good management of the chicks must in clude proper ventilation and the proper care of hatching eggs. this is the most important means of preventing navel ill. dirty, contaminated eggs should never be used for hatching. /. treatment. as with all bacterial infections in poultry, antimicrobial susceptibility testing should be used to determine the treatment of choice for any generalized e. coli infection. g. research implications. escherichia coli infection will damage experimental flocks, causing uneven growth. a. etiology. the cause of coryza is hemophilus paragallinarum. it is a gram-negative, bipolar staining rod and can easily be demonstrated in sinus exudate. b. clinical signs. signs include a sudden onset with high morbidity, reduction in feed intake and growth, and depressed egg production. uncomplicated coryza is a disease of the up per respiratory tract causing ocular and nasal discharge, facial edema, and swollen infraorbital sinuses. c. epizootiology and transmission. transmission is ac complished mainly by ill or recovered carrier birds. inhalation of infectious material and ingestion of contaminated feed and water provide the best means of transmission. d. necropsy findings. at necropsy, there is conjuncti vitis, cheesey exudate in the conjunctival sac, nasal discharge, and a catarrhal inflammation of the nasal passages and sinuses. the infraorbital sinuses may be filled with exudate. e. diagnosis. history, signs, and lesions will suggest coryza. a gram-stained smear of sinus exudate showing gramnegative bipolar rods warrant a strong presumptive diagnosis of coryza. incubation in a c atmosphere of a culture of the exudate on blood agar with a staphylococcus nurse colony will confirm the presence of//, paragallinarum. f. prevention. depopulation of all birds before introducing chicks is essential, and a complete sanitizing and disinfecting of the brooder facilities is also necessary. a bacterin is avail able and can be used in birds weeks of age or older with a booster every weeks. several injections are necessary to con fer protective immunity. g. treatment. continuous medication appears to suppress clinical infection, but when removed relapses occur. medica tions used with success include streptomycin, erythromycin, spectinomycin, tylosin tartrate, and sulfadimethoxine. h. research complications. a diagnosis of h. paragallinarum infection in a research unit would warrant termina tion of the experiment. salvage of an experiment with this dis ease would provide questionable research data at best. the chronicity of the disease and the recovered carrier bird would further jeopardize a research colony. a. etiology. the important etiological agents appear to be clostridium septicum and staphylococcus aureus (frazier et al., ) . the host is likely to be immunosuppressed, and probably undergoing a simultaneous outbreak of infectious bursal disease. (see section iv,b.) b. clinical signs. signs in -to -week old chickens and turkeys include a sudden increase in morbidity and mortality. wet, gangrenous areas can be seen in the skin of the wings and legs. c. epizootiology and transmission. skin wounds of chickens are a common occurrence, and secondary infections are expected. however, gangrenous dermatitis appears to be a specific disease complicated by the presence of heavily con taminated environment containing clostridium spp. and staphylococcus spp. the syndrome was rare until immunosuppression caused by bursal damage from infectious bursal disease virus, mycotoxins, and possibly other factors became more common. d. necropsy findings. usual findings include necrosis of the skin and underlying areas of the thigh, breast, wing tips, hip, and back. hemorrhagic, necrotizing myositis has also been described. e. pathogenesis. it would appear that the toxin of the staphylococcus species causes necrosis and anerobiosis; the clostridium then multiplies and contributes to the gangrene. /. differential diagnosis. signs and bacterial cultures from the lesions will give a presumptive diagnosis. selenium deficiency that causes an exudative diathesis may mimic gang renous dermatitits. eliminating all causes of skin trauma and improving the sanitation plus instituting an immunization pro-gram for infectious bursal disease will help prevent the disease. h. treatment. a susceptibility test for the staphylococcus isolated will suggest the antibiotic of choice. most broad-spec trum drugs will aid the recovery of affected birds. i. research complications. widespread gangrenous der matitis in birds may compromise the study. because this dis ease is often a complication of infectious bursal disease im mune competence may have been altered; therefore research data collected on affected bird may be unreliable. a. etiology. the cause of necrotic enteritis is thought to be clostridium perfringens. other inciting factors may be neces sary, but have eluded investigators studying this disease. the disease is seen mostly when high energy, broiler-type rations are used. b. clinical signs. necrotic enteritis is usually seen in broilers; many times only the males, at about - weeks of age, are affected. birds show profound depression, and mor tality may start at % per day and last about week (helmboldt and bryant, ). c. epizootiology and transmission. it appears that trans mission is direct and via the feces. d. necropsy findings. a fibrinonecrotic enteritis is noted, and the entire small intestine becomes dilated with fluid debris and becomes very friable. e. pathogenesis. there is evidence that a toxin damages the villus tips, and eventually the integrity of the rest of the intestinal wall is lost. /. differential diagnosis. this disease can be differenti ated from ulcerative enteritis (quail disease) by isolation and identification of the clostridium perfringens. eimeria brunetti may be present as a secondary problem. g. prevention. sanitation, disinfection, and isolation will provide the best protection against necrotic enteritis. low level feeding of antibiotics at gm per ton ( mg/lb) of feed from to weeks of age will totally prevent the disease. h. treatment. the organism is very easily treated with high levels of tetracyclines, furazolidone, streptomycin, or bacitracin. i. research complications. diagnosis of disease in a pen warrants instituting a low level antibiotic therapy for succeed ing flocks. a. etiology. clostridium colinum, a gram-positive, sporeforming bacillus, is the cause of ulcerative enteritis. this bac terium is best recovered from fresh liver cultured on tryptose agar or the yolk sac of - day embryos. b. clinical signs. affected quail exhibit high morbidity with mortality sometimes approaching %. chickens and turkey poults, on the other hand, may experience low mor talities of only - %. listlessness, drooping wings, ruffled feathers, and diarrhea are typical signs of this disease. c. epizootiology and transmission. the disease is highly contagious among quail. it spreads mainly through feces from ill or recovered carrier birds. f. differential diagnosis. coccidiosis caused by eimeria brunetti may produce a necrotizing enteritis of the large intes tine, which resembles ulcerative enteritis. scrapings of the in testinal mucosa will usually reveal oocysts of e. brunetti. nec rotic enteritis caused by clostridium perfringens can also mimic quail disease. histologically, necrotic enteritis produces no ulcers, and the intestinal lesion is villus tip loss and cystic dilatation of the deeper glands. g. prevention. birds should be reared in a clean, disin fected and isolated environment. low level of antibiotics, - gm per ton of feed, will prevent the disease. strep tomycin, bacitracin, terramycin, aureomycin, and furazoli done are therapeutically effective. h. treatment. all of the above antibiotics at gm per ton of feed ( mg/lb) will curtail and in some cases termi nate the mortality. /. research complications. substantial morbidity and mortality would terminate most experiments. preventive levels of antibiotics are indicated from to weeks in birds housed in a building where the disease was previously encountered. a. etiology. the ingestion of the toxin produced by clostridium botulinum is the cause of botulism. the lethal tox in, which must be produced under anaerobic conditions, is found in decaying feed, dead birds, and maggots. clostridium botulinum organisms per se are not considered pathogenic. b. clinical signs. drowsiness, weakness, and a progres sive paralysis of the legs, wings, and neck are all suggestive of botulism. c. epizootiology and transmission. the ingestion of pre formed toxin is necessary to produce the disease. poultry or wild birds should not be allowed to ingest wet, moldy feed. accidental water spillage in a research unit could result in con ditions necessary for the development of the toxin. d. necropsy findings. the absence of lesions may be the best indication that the birds are dying from botulism. the of fending decayed matter containing the toxin may be found in the crop, proventriculus, or intestine. e. differential diagnosis. history, signs, and the presence of decaying feed may help identify the disease. gizzard or in testinal contents may be washed and some of the fluid inocu lated into mice, half of which have been previously protected with c. botulinum antiserum, for a definitive diagnosis. tran sient paralysis, a mild form of marek's disease, can produce signs similar to botulism. in pheasants, paralysis caused by eastern encephalomyelitis virus could be confused with botulism. /. prevention. if birds are raised under clean conditions, botulism is rare. g. treatment. type a and c antitoxin may be indicated when valuable animals are affected. laxatives may also be used with some success. it is important to provide fresh, clean water in a botulism outbreak. h. research complications. it would be a rare to encoun ter this disease under research condition. a. etiology. the cause of erysipelas is erysipelothrix rhusiopathiae, a gram-positive, pleomorphic rod. it primarily affects turkeys, though chickens can be infected. b. clinical signs. usually the disease starts with sudden onset followed by depression, diarrhea, lameness, and a rapidly increasing morbidity and mortality. the snood of the male turkey often becomes swollen. c. epizootiology and transmission. fecal shedding of e. rhusiopathiae occurs in recovered turkeys and continues for about weeks. the oral-fecal route is a significant source of transmission. cutaneous injuries of the snood and head also may allow entry of the bacterium, and fighting among males is a common method of transmitting this disease. d. necropsy findings. the lesions are those of a septicemia and vasculitis. there is a degeneration and hemorrhage in pericardial fat. the heart muscle, kidney, spleen, and liver may also show hemorrhage. fibrinopurulent exudate in the joints, vegetative endocarditis, and dark, crusty skin lesions are also common. e. differential diagnosis. history, signs, lesions, and cul ture of e. rhusiopathiae will aid in a diagnosis of erysipelas. it should be differentiated from colibacillosis, fowl cholera, salmonellosis, and possibly a velogenic strain of newcastle disease. /. prevention. turkey poults should be raised away from older turkeys, sheep, and swine. poults should be vaccinated with a bacterin at - weeks of age. raw fish meal may harbor e. rhusiopathiae organisms and should be avoided. g. treatment. penicillin and erysipelas bacterin may be in jected simultaneously in an outbreak. tetracyclines in the feed or water will also help reduce losses. h. research complications. erysipelas is a septicémie dis ease; therefore, it will significantly retard growth and weight gain in animals recovering from the disease. a. etiology. predisposing causes of omphalitis may in clude excessive humidity and excessive fecal contamination of the incubator. fecal contamination of eggs used for hatching purposes will also contribute to omphalitis. as the navel fails to close at hatching, a route of entry for bacteria, such as e. coli, pseudomonas, and proteus, as well as staphylococci is available. chilling or overheating baby chicks may also pre cipitate or exacerbate this condition. b. clinical signs. depression, drooping of the head, and huddling near a heat source are usual signs. a scab over the unhealed navel is often present, and mortality usually is high-est on the third and fourth days posthatching, sometimes reach ing - % during the first week. c. epizootiology and transmission. the disease is trans mitted through infection of the yolk sac prior to hatching. it is not contagious from chick to chick. d. necropsy findings. infected navels, large unabsorbed yolks, and extensive peritonitis are the common lesions com monly noted. e. differential diagnosis. isolation and identification of the bacteria from infected yolk will pinpoint omphalitis and its cause. /. prevention. proper hatching egg management, empha sizing care and sanitation of the incubators will reduce the inci dence of omphalitis. there is no treatment for omphalitis except removing affected chicks. effective drug levels cannot eradi cate the infection in the yolk sac. h. research complications. affected chicks usually die during the outbreak. those that do survive, appear to grow well. a. etiology. fowl cholera, an acute septicémie disease of poultry, turkeys, waterfowl, and wild birds, is caused by pasteurella multocida, a gram-negative, bipolar rod (panigraphy and glass, ) . thirteen serotypes of this bacterium have been identified. b. clinical signs. fowl cholera usually affects young adults. birds affected with the acute form of fowl cholera may show no signs other than sudden deaths. hens may die while laying an egg and will be found dead on the nest. in less acute cases, birds will show depression, anorexia, and cyanosis. a white-green diarrhea is usually present. in the chronic form, localized infections of the joints, wattles, foot pads, sinuses, and middle ear is clinically manifested by lameness and torticollis. c. epizootiology and transmission. ingestion of decaying carcasses, contaminated feed and water, and feces from re covered carriers are sources off*, multocida. wild birds, and rodents are also potential transmitters. transovarian transmis sion does not play a role in transmission. d. necropsy findings. peracute deaths may preclude the presence of gross lesions. pinpoint hemorrhages are common in the coronary fat suggesting an acute septicemia. in birds that die less acutely, pericarditis and perihepatitis are usually found. cheesy exudate may also be seen around the oviduct. chronic lesions consist of inflammation of the wattles, joints, conjunctival sac, infraorbital sinus, middle ear, and sometimes the bones of the skull. fibrinous pneumonia is common in turkeys. e. pathogenesis. fowl cholera is a septicemia with the agent spreading via the bloodstream to many organs. /. differential diagnosis. isolation and identification of the organism is necessary to differentiate this disease from erysipelas in turkeys and colibacillosis in hens. birds reared in clean, isolated premises usually are free of pastuerella infections. addition of birds with unknown health status to a clean flock should be avoided. healthy-appearing birds can carry p. multocida and are a com mon source of introduction of the organism to a premise. bacterins are protective in hens. the key to successful production of immunity is to use the correct serotype for immunization. two doses, about month apart, are necessary for adequate protection. live oral cultures of the pasteurella are available for use in endemic areas; however, use of this product may cause disease in unvaccinated birds. h. treatment. drugs will arrest mortality, but will not cure the disease. sulfaquinoxaline will work well but will depress egg production. therapeutic results are obtained with tetracycline at gm per ton ( mg/lb) of feed for about weeks. however, it is important to note that not all pasteurella isolates are susceptible to the tetracyclines. improved sanita tion, immediate removal of sick and dead birds, and preven tion of cannibalism are necessary to control the disease. /. research complications. research birds affected with pasteurella sp. do not yield reliable research data; termination of the experiment, therefore, is recommended. a. etiology. the cause of fowl typhoid is salmonella gallinarum; it also cross-agglutinates with salmonella pullorum. salmonella gallinarum is a gram-negative rod with no spores or capsule. b. clinical signs. affected chickens have ruffled feathers, pale heads, and shrunken combs. in turkeys, listlessness and a greenish diarrhea are often recognized clinically. c. epizootiology and transmission. egg transmission via the yolk or shell surface often perpetuates the disease from dam to offspring. d. necropsy findings. a bile-stained liver, bronzed in ap pearance and greatly swollen, is the most distinguishing lesion of fowl typhoid. all other lesions are similar to pullorum disease. e. differential diagnosis. this disease is now rare in the united states and must be differentiated from pullorum disease and paratyphoid infections. isolation and identification of salmonella is necessary for a diagnosis. /. prevention. the purchase of pullorum-typhoid-clean chicks from the national poultry improvement program hatch eries is necessary for research. no treatment is effective. it is a reportable disease to the state veterinarian, and depopulation will be recommended. h. research complications. salmonella-infected birds should not be used for research purposes. a. etiology. the cause of pullorum disease is salmonella pullorum. it is a gram-negative bacillus and cross-reacts with s. gallinarum. b. clinical signs. infected adults may show no signs but transmit the agent through their eggs. young chicks and poults will show white pasting around the vents, and huddling near the heat source. mortality may reach - %. c. epizootiology and transmission. egg transmission through the yolk and hatchery transmission via the infected eggs and chicks in the incubators and hatchers are the usual methods of transmitting s. pullorum. d. necropsy findings. myocarditis, pericarditis, and atro phied ovaries are classical lesions of pullorum disease in adults. in young birds, gray nodules may appear on the spleen, peritoneum, lung, liver, heart, and intestine. as with any salmonella infection, cecal cores are commonly seen. an en larged spleen is present, but this is a nonspecific lesion since it is usually seen with many bacterial infections. e. differential diagnosis. a positive serum agglutination plus isolation, identification, and typing of the agent from the yolk sac, gallbladder, spleen, or cecal tonsil will confirm the diagnosis of s. pullorum. /. prevention. the purchase of pullorum-typhoid-clean chicks and poults is essential for research. no treatment is available. the disease is reportable to the state veterinarian, who when notified will prob ably insist on depopulation. h. research complications. salmonella-infected birds should not be used for research purposes. a. etiology. any species of a large group of salmonella sp. may infect birds and mammals and are not host specific. the most common one isolated from birds is salmonella typhimurium. other common serotypes include s. enteritis, s. oranienberg, s. montivideo, s. newport, s. anatum, s. derby, and s. bredeny. many others exist and may cause mortality. b. clinical signs. dehydration, pasting of the vents, and huddling near the heat source are signs of a salmonella out break. high morbidity and mortality are usually the first signs. c. epizootiology and transmission. diarrhea in the breeders will cause contamination of the qgg shells, and salmonella is often transmitted in this way. contaminated feed ingredients such as meat scraps may also transmit infection. transovarian transmission is possible, and human carriers may also be a factor in transmission (see chapter by fox et al.). d. necropsy findings. dehydration, enteritis, and focal necrosis of the intestinal mucosa are common lesions. pigeons usually have joint infections and conjunctivitis. cheesy cores in the ceca, common in all salmonella infections, will usually be found. e. differential diagnosis. the isolation and identification of the offending bacterium is essential for diagnosis. all salmonella infections may have similar signs and lesions. in addi tion, coccidiosis and blackhead will produce cheesy cores in the cecae. /. prevention. use clean birds free of salmonella. isolate the new brood and feed only pelleted feed or crumbles to pre vent introduction of salmonella via the feed. g. treatment. attempts to treat the infection usually have been discouraging. most cases do not respond to therapy and carrier birds are produced. furazolidone in pigeons is partially effective. sulfa drugs will suppress mortality but will not cure the disease. h. research complications. salmonella-infected birds should not be used for research purposes. a. etiology. avian tuberculosis is caused by mycobacterium avium, an acid-fast, very resistant bacterium. it is sepa rate and distinct from human and cattle types, but will infect swine and sensitize cattle to the bovine tuberculin test. b. clinical signs. emaciation in the presence of good feed intake may suggest tuberculosis. diarrhea and lameness is common. birds appear very pale, especially the comb and wattles. c. epizootiology and transmission. transmission is by in gestion of m. avium. association of young chicks with their dams during the growing period in backyard flocks ensures transmission of the bacteria to susceptible birds. d. necropsy findings. extreme emaciation, nodules along the intestinal tract, and discrete granulomas in liver and spleen are typical of tuberculosis. granulomas may also be found in the bone marrow and more rarely in the lung. e. differential diagnosis. coligranuloma can mimic avian tuberculosis. the presence of acid-fast bacilli in liver or spleen impression smears will confirm the presence of m. avium. f. prevention. an all-in, all-out system of poultry rearing will prevent avian tuberculosis. g. treatment. because of drug resistance and the possible public health significance of this disease, treatment is dis couraged. depopulation is recommended by the state's veteri nary authorities. no tuberculosis-affected birds should be used for research purposes. turkeys] (see jordan, ) a. etiology. the primary cause of crd is mycoplasma gallisepticum, but the following agents will enhance effects of m. gallisepticum and cause a complicated respiratory syn drome with high mortality: infectious bronchitis virus, infec tious laryngotracheitis virus, newcastle disease virus, escherichia coli, pasteur ella multocida, hemophilus gallinarum, and others. b. clinical signs. hens reaching the age of full egg pro duction ( weeks) will not reach peak egg production referred to as genetic potential for that specific strain. coughing and sneezing may be noticed, particularly at night. the disease is more pronounced in broilers. chronic respiratory disease plus secondary bacterial infection, will produce high mortality, high morbidity and high condemnations due to air sacculitis, pericarditis, and perihepatitis. turkeys may have sinusitis, with exudate in the infraorbital sinuses. c. epizootiology and transmission. transovarian trans mission is the most important method of transmitting m. gallisepticum. lateral spread through aerosols from infected off spring occurs in the hatchers or brooders. wild birds and fomites can also be a source of agent transmission. d. necropsy findings. thickened air sacs, mucus in the trachea, sinusitis, and air sacculitis are the common lesions in uncomplicated chronic respiratory disease. in chronic respira tory disease with secondary bacterial infection, the classic le sions include air sacculitis with fibrinous hepatitis and perciarditis. e. differential diagnosis. many of the respiratory dis eases of poultry appear similar and are differentiated with diffi culty. a positive m. gallisepticum agglutination test in at least ten birds from a previously known m. gallisepticum negative flock would strongly suggest a diagnosis of chronic respiratory disease. histology of the trachea, lungs, and air sacs will show hyperplastic lymphoid follicles if m. gallisepticum is present; however, this lesion is not pathognomonic. isolation of the mycoplasma is the best means of establishing a diagnosis of chronic respiratory disease. /. prevention. mycoplasma gallisepticum-ïrzt chicks are easy to obtain; therefore use of positive chicks in experimental work is not warranted. controlled exposure using the live cul ture of the "chick f " strain is not recommended except in multi-age, egg-producing flocks. it is not recommended in breeders or experimental trials. g. treatment. improved management and broad-spectrum antibiotics may help control the losses due to secondary bac teria. tylosin is the most effective drug against m. gallisepticum. h. research complications. positive mycoplasma birds should not be used in research trials. a. etiology. the cause is mycoplasma meleagridis, an egg-transmitted mycoplasmal agent of turkeys. the usual man ifestation is air sacculitis in young poults, but since organisms are shed in semen as well as yolk it can also be considered a venerai disease of this species. b. clinical signs. the signs are usually found only in young growing turkeys. mild respiratory signs, poor growth, crooked necks, and leg weaknesses are considered signs of this infection. c. epizootiology and transmission. transovarian trans mission is of primary importance. semen contains the mycoplasma organism, so toms as well as hens serve to transmit m. meleagridis. lateral spread is similar to other mycoplasmas in that stresses and/or other infections seem to enhance the severity of this disease. h. research complications. turkeys infected with m. meleagridis should not be used for research since birds free of the disease can be purchased. a. etiology. the cause of infectious synovitis is mycoplasma synoviae. it can be isolated in broth media or in -to -day-old embryonating chicken eggs. isolates of m. synoviae vary in their pathogenicity and also in their susceptibility to drugs. b. clinical signs. lameness and crouching are the most common signs. usually morbidity and mortality are low, but retarded growth is a common finding. c. epizootiology and transmission. the transovarian route is the most important means of transmitting the agent from dam to progeny. it is thought that a small number of infected eggs are laid and positive offspring spread infection to pen mates during the growing period. d. necropsy findings. lesions include yellow exudate in the leg and wing joints but may also be found in the tempormandibular joint, shoulder, and keel bursa. foot pads are usu ally swollen and hot. the liver will be greenish due to bile retention. air sacculitis may also be present. b. clinical signs. in mild cases, slight respiratory signs and diarrhea will be seen. in severe turkey cases, depression, weakness, anorexia, and reduced weight are noted. mortality may reach %. in pigeons, conjunctivitis is a feature of the disease, while in the psittacine caged birds, depression, anorexia, diarrhea, rales, and death may be seen. c. epizootiology and transmission. transmission appears to be by direct contact with infected carriers. inhalation and ingestion of feces are the two most important means of trans mission of chlamydia psittaci. d. necropsy findings. an enlarged congested spleen is al most always found in chlamydiosis in all avian species. le sions of air sacculitis, pericarditis, and perihepatitis are com monly noted. unfortunately, these are the same lesions noted in turkeys suffering from mycoplasmosis. e. differential diagnosis. history, clinical signs, and gross lesions aid in the diagnosis. the findings of intracytoplasmic inclusion (lcl bodies) in impression smears of the air sacs or cut surface of the spleen stained by the macchiavello or giemsa method will suggest a diagnosis of chlamydiosis. isolation and identification of the agent should not be attempted by an inexperienced person or without proper hoods and facilities to protect laboratory personnel. this agent, in laboratory culture, is easily transmitted to research technicians. /. prevention. avoid any cross-exposure of research birds to caged pet birds or wild birds. an all-in, all-out system will successfully prevent chlamydiosis. all new arrivals of psit tacine birds should be treated for days at gm per gallon of drinking water with tetracycline or with pellets containing an equivalent level of antibiotic. g. treatment. chlamydiosis is a reportable disease and all infected flocks and their treatments should be reported to the proper authorities. chlamydia psittaci should be used for research purposes. a. etiology. infectious bronchitis affects only chickens and is caused by a coronavirus. it does not hemagglutinate erythrocytes. many serotypes exist, but the two most common are massachusetts and connecticut. b. clinical signs. in young chicks, a sudden onset of coughing, sneezing, and rales occurs. the birds are weak and crowd toward the source of heat. feed intake may drop by % in broiler-type birds. in adults, severe respiratory signs accom panied by a severe drop in egg production are evident. egg quality, as evidenced by watery albumen and soft shells with sandpaperlike ends, renders the flock economically useless for egg production. c. epizootiology and transmission. aerosol transmission over long distances is common. recovered carriers and con taminated premises may serve as a source of the virus for days or more. d. necropsy findings. air sacculitis and excessive tra chéal mucus are the most common findings. in very young chicks, bronchi can be filled with yellow exudate (fig. ). e. differential diagnosis. isolation of the virus in -to day-old chick embryos will confirm the diagnosis. determina tion of infectious bronchitis immunity with a serum neutraliza tion test using acute and convalescent serum will also help de termine the presence of infectious bronchitis virus. /. prevention. isolation of research birds may prevent in troduction of infectious bronchitis. however, it is one of the most widespread and contagious diseases of chickens. vac cines are very effective. they are given at days to weeks of age in the drinking water. correct serotypes must be se lected for the strain of agent present in the area. g. treatment. antibiotics will usually stimulate feed con sumption. increased pen temperature and improved ventilation are helpful in aiding recovery of young birds. h. research complications. adult laying flocks should be terminated because they will not return to normal egg production. a. etiology. infectious bursal disease is caused by a virus loosely placed in the orbi virus category. it damages primarily b lymphocytes in the bursa of fabricius, thymus, spleen, and cecal tonsil. infection with this agent reduces and sometimes totally eliminates humoral immunity. b. clinical signs. the age incidence is usually - weeks, but it may occur at a later age. birds are depressed and droopy, with ruffled feathers. morbidity is high, and mortality also may be high. vent picking and a bloody diarrhea are some times noted. c. epizootiology and transmission. transmission by di rect contact is rapid. the agent is resistant and lives in the environment for long periods of time. d. necropsy findings. the bursa of fabricius will first en large and later atrophy (fig. ) . serum-colored edema may be present on the surface of the bursa. the bursa may also contain yellow exudate and hemorrhages. hemorrhages also may be present in the skeletal muscles, and the kidneys can contain urate crystals. e. differential diagnosis. signs and lesions provide a pro visional diagnosis. a serum neutralization test and histopathology will usually confirm a diagnosis of the infectious bursal disease. /. prevention. drinking water vaccines are available and give adequate protection. a program for highly susceptible, antibody-free, -day-old research chicks require vaccination or possibly none at all depending on exposure risk and degree of isolation. under field conditions, maternal antibodies interfere with vaccines administered early in life. to overcome this, some of the vaccines are quite pathogenic and should not be used in highly susceptible chicks. complications. an outbreak would dictate termination of most experiments, especially when immu nologie data is important. a. etiology. epidemic tremor is caused by a picornavirus. it will grow in the embryos from a susceptible flock, but will not cause lesions unless it becomes egg "adapted." b. clinical signs. signs of ataxia, paralysis, and fine tremors of the head and neck will usually be seen between and weeks of age. turkeys, quail, and pheasants, as well as chickens, may be affected. growing birds, past weeks of age, show no clinical signs, although recovered birds may sometimes have cataracts. c. epizootiology and transmission. the virus is usually spread through fecal shedding. adult hens may shed virus in a small percentage of their eggs during infection. chicks hatch infected with the agent or become infected by fecal contact. d. necropsy findings. there are no gross lesions, but histologically a nonpurulent encephalomyelitis is present. sec tions of the brain, proventriculus, and pancreas should be ex amined microscopically. central chromatolysis and lymphoid aggregates are seen in the cerebellum and proventriculus, re spectively (butterfield et ai, ) . e. differential diagnosis. signs, especially head tremors, will suggest avian encephalomyelitis. histopathology will usu ally confirm the diagnosis. direct fluorescent antibody tests, serum neutralization tests, and isolation of the virus are used to diagnose the disease. avian encephalomyelitis signs are simi lar to those of newcastle disease and encephalomalacia. in pheasants, avian encephalomyelitis must be differentiated from eastern equine encephalomyelitis. /. prevention. to protect baby chicks, the dams must be immunized. both live and inactivated virus vaccines are available. g. research complications. chicks from immune dams will be satisfactory research birds. however, chicks encounter ing an outbreak of avian encephalomyelitis are not reliable for research purposes. a. etiology. eastern equine encephalomyelitis is caused by a togavirus, originally classified as an arbovirus. wild birds appear to be the natural host of this agent, and serve as a reser voir of infection for man, horses, and swine, in addition to pheasants. b. clinical signs. pheasants and horses are the primary animals affected, but in epizootics, chickens, wild turkeys, sparrows, domestic turkeys, quail, and doves may be infected. incoordination, paresis, and progressive paralysis are seen in about - % of a flock. if the flock is debeaked, mortality and morbidity will be markedly reduced. if the flock is not de beaked, feather picking and cannibalism are common. c. epizootiology and transmission. clinical cases are usu ally found near swamps and lowland areas, especially during a season with a high mosquito population. birds are bitten by the mosquito culiseta melanura, whereas the disease in mammals is usually transmitted by aedes and mansonia spp. horses are a monitor of the impending danger of eastern equine encepha lomyelitis to humans, since horses have equal susceptibility but a much greater risk of exposure. d. necropsy findings. no gross lesions are seen; micro scopically, there is a nonsuppurative encephalitis characterized by perivascular infiltrates, diffuse gliosis, and vasculitis with vascular infiltrates. e. differential diagnosis. signs, histopathology, and virus isolation are required for a diagnosis as other viruses may produce encephalitis in domestic fowl. newcastle disease, avi an encephalomyelitis in poults, and marek's disease in poults and pheasants must also be considered in the differential diagnoses. /. prevention. it is important to protect against mosquitoes with screens and sprays and to discourage cannibalism with debeaking and spectacles. vaccination at - weeks may re duce mortality, but this method has not been as successful in birds as it has in horses. should be terminated if an outreak of eee develops. a. etiology. infectious laryngotracheitis (ilt) is caused by a herpesvirus producing type a intranuclear inclusion bodies in epithelium lining the trachea. similar inclusions are produced in epithelium of the chorioallantoic membrane of ex perimentally infected fertile eggs. domestic fowl, pheasants, and pea fowl may be naturally infected (crawshaw et al., ) . b. clinical signs. marked dyspnea with "pump handle" breathing followed by coughing and moist rales are the promi-nent signs. shaking of the head and expectoration of blood also are common. mortality in adults rarely exceeds %. related or identical to the virus of hemorrhagic enteritis of turkeys. c. epizootiology and transmission. recovered carriers are a common source of infection for susceptible birds. it ap pears that fomites are more important in ilt transmission than most of the other respiratory diseases. d. necropsy findings. the larynx and trachea are acutely inflamed and sometimes filled with blood clots, or later, case ous cores (fig. ) . there is usually sinusitis and conjunctivitis. histopathology of the trachea will reveal intranuclear inclusion bodies in the epithelial tags pulled from the necrotic lining. e. differential diagnosis. signs, lesions, and virus isola tion are the main methods of arriving at a diagnosis. the pres ence of inclusion bodies in trachéal epithelium are pathognomonic. /. prevention. a modified live ilt vaccine is available and is relatively safe. it will spread to susceptible birds in the same pen but usually not to other pens. all birds should be vaccinated at the same time and quarantined for - weeks (bryant, e. differential diagnosis. clinical signs and gross lesions suggest the diagnosis. intranuclear inclusions in the spleen will further support msd as a diagnosis (wyand et al., ) . agar gel precipitin tests may be used to identify antibodies as an indication of prior infection. no commercial vaccine is available, but avirulent strains of hemorrhagic enteritis virus are being uti lized in experimental vaccines. h. research complications. this disease is usually found on range flocks. infected birds would not contribute valid ex perimental data. a. etiology. the cause of marble spleen disease of pheas ants is an avian adenovirus (iltis et al., ) . it is closely '£^< ;:^^# a. etiology. the causative agent is an avian adenovirus, the type strain referred to as celo (chick embryo lethal or phan) virus. it causes very high mortality in young bobwhite quail. b. clinical signs. in quail under weeks, coughing, sneezing, rales, and huddling are common. mortality may range from to %, but usually ranges between and %. c. epizootiology and transmission. chickens, turkeys, and other birds may be inapparent carriers. airborne and me chanical transmission are thought to be important means of spread. d. necropsy findings. trachéal and bronchial mucus is present. cloudy air sacs, conjunctivitis, and infraorbital si nusitis are quite characteristic lesions of this disease. e. differential diagnosis. isolation of virus is necessary for a definitive diagnosis. pulmonary aspergillosis may present similar signs but the microscopic lesion would be a fungal granuloma and easy to differentiate from that produced by quail bronchitis virus. /. prevention. isolation, sanitation, and good husbandry should prevent quail bronchitis. g. research complications. the mortality in quail would cause termination of any research trial. a. etiology. newcastle disease is the result of a paramyxovirus infection. there are three major strains as distinguished by their pathogenicity: (a) lentogenic, mild disease, used as vaccine, an example is serotype b- ; (b) mesogenic, moderate disease, domestic newcastle disease usually seen in the united states; (c) velogenic, very pathogenic, exotic newcastle dis ease. newcastle disease virus hemagglutinates chicken erythrocytes and forms the basis for the hemagglutination inhi bition test for anti-ndv antibodies. b. clinical signs. a sudden onset of anorexia and respira tory signs will develop in adults. the eggshells of brown-egglaying hens will often turn white. egg production and egg quality will be diminished. in young chicks with no parental immunity, central nervous system signs are seen. mortality will be high. torticollis ("star-gazers") is very common. se vere dypsnea, diarrhea, paralysis, and acute death are the signs of velogenic strains. mortality may reach %. caution must be advised regarding velogenic newcastle disease since spe cies of pet birds may be inapparent carriers of velogenic strains. c. epizootiology and transmission. newcastle disease has a wide host range. many wild birds can transmit newcastle virus to domestic birds. it affects many wild birds, pet birds, and most game birds. aerosol transmission is the important means of spread. contaminated feed, water, and equipment are almost as important. egg transmission occurs but only for the first few hours during the acute onset of infection in breeders. velogenic newcastle disease may be brought into the country with pet birds and fighting cocks. the latter are often smuggled into the country. d. necropsy findings. the mesogenic strains produce le sions characteristic of a tracheitis and a "frothy type" air sacculitis. velogenic strains, on the other hand, produce massive hemorrhages in all the visceral organs especially the gi tract. e. differential diagnosis. signs, lesions, and hi tests are usually adequate for diagnosing newcastle disease. immunofluorescence tests may be done very quickly to detect the presence of the virus at the time of disease onset. all avian respiratory diseases must be differentiated from newcastle dis ease. histopathology will serve to differentiate the cns form of newcastle disease from those produced in avian encephalomyelitis and encephalomalacia. /. prevention. excellent newcastle disease vaccines are available for immunization of laying hens, breeders, and broilers. one-day-old chicks are given water vaccines and are given boosters several times before sexual maturity. g. control. eradication has been practiced by the united states department of agriculture for the velogenic viscerotropic type of newcastle disease. all newcastle disease outbreaks should be reported if high mortality is a feature. pet birds should be kept separate from poultry, turkey, or game bird flocks. h. research complications. a researcher may immunize the flock or raise birds in strict isolation. the latter is ideal but not always successful as newcastle disease can be transmitted through aerosols. if an outbreak occurs, the trial should be terminated. a. etiology. pox is caused by a large dna virus. the fol lowing commonly encounted strains infect their respective spe cies: fowl pox, turkey pox, pigeon pox, and canary pox. pox virus is very resistant in the environment and spreads slowly through a flock. b. clinical signs. two forms exist. skin pox affects the comb, head, and vent regions; wet pox affects mucous mem-branes of the larynx and can cause choking. viremia exists in both forms, and decreased ^gg production is present for ex tended periods. c. epizootiology and transmission. scabs and skin debris that contaminate the litter feed and water are the usual source of virus. mosquitoes and cannibalism are secondary means of spread. d. necropsy findings. scabs on the comb and other unfeathered areas of the body are suspect pox lesions. diphtheri tic lesions of the pharynx, larynx, and trachea are common in wet pox. the laryngeal opening is usually plugged with a tight ly adhered plaque. if cannibalism is a simultaneous problem, the vents may show severe skin necrosis. e. differential diagnosis. demonstration of intracytoplasmic inclusion ibodies in cutaneous and oral lesions are pathognomonic for pox. virus inoculation onto the chorioallantoic membrane of embryonating eggs will also produce pocks and cytoplasmic inclusions. pox must be differentiated from can nibalism, infectious laryngotracheitis and mycoplasmosis. trachéal plugs are seen in the latter if the strain is highly pathogenic. /. prevention. vaccination by the wing-web stick method is recommended for pigeons and chickens. turkeys should be vaccinated by the thigh-stick method. an experimental vaccine is available for canaries. the pigeon pox strain of vaccine is preferred in areas of low incidence, thus preventing spread of the fully virulent fowl pox vaccine to susceptible birds. g. research complications. it would be unwise to collect data from pox-infected birds. a. coccidiosis a. etiology. coccidiosis is caused by a protozoan parasite. there are nine species of coccidia affecting chickens, six affect turkeys, but only three are pathogenic. in geese, three species affect the gastrointestinal tract, and one affects the kidney. the duck and pheasant, each have at least one species that is patho genic for the gastrointestinal tract. all species in the genus rimeria appear to be host specific with no cross-transfer. each species has a characteristic size and shape and specific life cy cle. immunity is usually specific for one species only and af fords no cross-protection against other species of coccidia. b. clinical signs. signs may include pale legs and beaks, ruffled feathers, and listlessness. birds infected with certain species of coccidia may have bloody fecal droppings. poor growth and high mortality are the effects of coccidia multiply ing in intestinal epithelial cells. c. epizootiology and transmission. ingestion of the sporulated oocysts from feces and litter is necessary for transmis sion. each gram of feces may contain about , oocysts. each sporulated oocyst will produce eight sporozooites, first generation merozoites, second generation merozoites, and will damage about , , intestinal host cells. d. necropsy findings. table iv illustrates the complexity of diagnosing coccidiosis by gross lesions (see also fig. ). e. pathogenesis. disease is based on the interrelation of age of host, species of coccidia, and dose of organism (degree of exposure). an unsporulated oocyst in the presence of oxy gen, % moisture, and room temperature will become an in fective oocyst in - hr. the infective oocyst is ingested by a susceptible host, and the life cycle begins. the prepatent period varies by species from to days. /. differential diagnosis. a differential diagnosis in the chicken and turkey must include various species of coccidia in addition to salmonellosis and histomoniasis. the signs and le- from bryant and helmboldt ( ) . sions of ulcerative and necrotic enteritis are similar to coc cidiosis. direct scrapings of the gut accompanied by histopathology will aid in the diagnosis. prevention of coccidiosis must include re ducing the number of infective oocysts. dry pens and good sanitation practices and/or wire floors will prevent coccidiosis. immunity is species specific. vaccines will protect birds but require skillful maintenance of litter at % moisture postvac cination to ensure cycling of coccidia for immunization. coccidiostats are efficacious. amprolium, coban, and others are available. they are administered continuously at a dose of . % to allow low level infection but protect against severe disease. h. treatment. amprolium, sulfa drugs, and the nitrofurans have all been used with good success. /. research complications. used for research purposes coccidiostat. all birds from to weeks should be fed a low level a. etiology. the cause of histomoniasis is histomonas meleagridis, a protozoan flagellate that inhabits the cecal lumen. b. clinical signs. turkeys, chickens, and pea fowl with this disease exhibit anorexia, droopiness, listlessness, yellow diarrhea, and cyanosis of the head and face. morbidity and mortality may be high in young poults. c. epizootiology and transmission. fresh feces contain the histomonad and may be ingested. more often, the histomonad is contained within the cecal worm (heterakis gallinarum) and the worm is ingested. a third possiblity is heterakis larvae contained within earthworms which in turn may also be ingested. d. necropsy findings. the liver will show discrete, irreg ular, depressed areas of focal necrosis. the thickened walls of the cecal lumen surround laminated, yellow, caseous cores (fig. ). e. differential diagnosis. hematoxylin and eosin sections of the liver and cecal wall are best for demonstrating the histomonads. direct smears and scrapings may also reveal the organism. /. prevention. the continuous use of antihistomonal drugs is the most effective way to prevent blackhead. hepzide, histostat and emtryl will all prevent the disease. g. treatment. the above drugs serve as effective thera peutic agents at the recommended treatment level. h. research complications. poults and game birds, es pecially pea fowl, should be administered anithistomonal drug until - weeks of age. a. etiology. ascaridia species are found in most birds. the following species have been reported: ascardia galli, chicken; ascaridia numidae, guinea fowl; ascaridia columbae, pigeon; ascaridia dissimilis, domestic and wild turkeys; ascaridia compar, bob white quail. b. clinical signs. decreased egg production, poor growth and vigor, diarrhea, and visible presence of worms in the feces are often noted. c. epizootiology and transmission. the life cycle is di rect. infective eggs are swallowed and hatch in the proventriculus or anterior portion of the intestinal tract. larvae live for - days in the lumen and then enter the mucosal wall and produce damage. on the seventeenth to eighteenth day, young worms again enter the lumen and remain there until maturity, usually days postingestion. d. necropsy findings. evidence of anemia and retarded growth is seen. the presence of ascardia sp. is the most out standing feature. a complete intestinal blockage is sometimes present (fig. ). e. differential diagnosis. the presence of intestinal roundworms may not be the primary cause of clinical disease, especially when mortality is a common feature. further exam ination may reveal capillariasis, coccidiosis, or bacterial infec tions in combination with ascaridia infestation. /. prevention. a complete depopulation and disinfection will usually prevent recurrence of the disease in the next flock. dirt floors or ranges are impossible to clean and should be rotated annually. a. etiology. capillaria obsignata infests the chicken, tur key, and probably other bird hosts. capillaria columbae is as sociated with pigeons. in game birds, c. contorta is found in the crop and esophagus. b. clinical signs. a sudden drop in egg production and an unthrifty appearance of the flock may often be the result of capillaria infestation. c. epizootiology and transmission. the life cycle is di rect. eight-day embryonated capillaria eggs are ingested by the host, and larvae penetrate the duodenal mucosa. adult worms are found within - days postingestion of embryonated eggs (fig. ) . slight enteritis may be present. nematodes washed from mucosal scrapings will confirm the diagnosis. e. prevention. clean facilities will prevent capillaria infestations. e. prevention and treatment. the continuous feeding of thiabendazole has been very effective. more recently, levamizole hydrochloride in the water has been used with success as a treatment. rotating ranges for pheasants will also help mini mize infection. c. epizootiology and transmission. spores of a. fumigatus are found in great numbers in old litter. when the spores are inhaled, they produce typical respiratory signs and lesions. d. necropsy findings. yellow plaques are found in the lungs, air sacs, tracheas, and peritoneal surfaces (fig. ) . the brain also may contain foci of fungal growth. histopathology will reveal the presence of hyphae in granulomas stained with periodic acid-schiff or gridley stain. e. differential diagnosis. signs and typical histologie le sions of lung and air sacs will confirm the presence of the aspergillus spp. /. prevention. use clean, dry litter. wet sawdust may con tain numerous spores of aspergillus fumigatus, and its use is contraindicated. g. treatment. commercial poultry and turkey flocks are not usually treated. individual, valuable birds may be treated with nystatin or amphotericin b. h. research complications. flocks infected with as pergillosis should be depopulated. a. etiology. candida albicans, a yeastlike fungus, is the causative agent of crop mycosis. it grows well on sabouraud's agar at room temperature. it is cautioned, however, that c. albicans can be a normal floral inhabitant of the crop and lower digestive tract. b. clinical signs. depressed egg production and diarrhea are the two most commonly observed signs. c. epizootiology and transmission. unsanitary waterers and warm humid weather will often combine to produce the necessary environmental conditions for the development of disease. indiscriminate use of antibiotics may alter normal bac terial flora allowing the yeast to multiply and ellicit disease. d. necropsy findings. the crop and esophagus are cov ered with a diffuse, white exudate. often the pharnygeal mucosa is involved. enteritis with a white, pseudomembrane covering duodenal and jejunal mucosa may sometimes be found. e. differential diagnosis. culture of the yeast and histo pathology will confirm the diagnosis. /. prevention. optimum sanitation of waterers and feeders especially during hot, humid weather is necessary. disinfec tants such as chlorine, iodine, and quaternary ammonium com pounds are needed to keep the yeasts and fungi from multiply ing in the drinking water. depression and emaciation characterize visceral involvement. palpable muscle tumors may also be noted. c. epizootiology and transmission. the virus is released in association with dander from feather follicles, which then contaminates the environment. d. necropsy findings. tumors of various visceral organs, skin, or muscle may be seen. swollen sciatic and brachial nerves are common. microscopic lesions feature pleomorphic cellular infiltrates of plasma cells, macrophages, lymphocytes, and lymphoblastic cells. nerves may have inflammatory or proliferati ve lesions or a combination of both types. e. differential diagnosis. marek's disease must be differ entiated from lymphoid leukosis (ll). for many years, both these diseases were thought to be caused by a common agent. marek's disease occurs prior to sexual maturity, but both may occur after sexual maturity. only marek's disease affects the nerves and thus causes paralysis. both produce tumors and en larged visceral organs. gray eyes, feather follicle inflamma tion, and muscle tumors are found only in marek's disease. tumors of the bursa of fabricius are rare in md, but are an invariable finding in ll. /. prevention. depopulation and thorough disinfection be fore introducing a new flock is recommended. baby chicks should be vaccinated at day of age with the nononcogenic turkey herpesvirus if it is not possible to provide strict isola tion. genetic resistance varies among strains of chickens, and is effective in reducing losses in marek's disease virus-ex posed birds. h. research complications. herpesvirus of turkeys (hvt) marek's vaccine should be administered to all birds at day of age to prevent the disease. a. etiology. lymphoid leukosis is caused by an oncogenic retrovirus. it is a member of the leukosis-sarcoma group. sub groups a and b occur in commençai chickens. various virus strains may cause a variety of neoplasms of mesodermal tissues in addition to typical ll. b. clinical signs. sudden death of adult chickens may be the only sign. an enlarged abdomen due to a swollen liver is also a common finding. thickening of the leg bones as a result of osteopetrosis is another possible consequence of infection with some strains of leukosis virus. other lesions may include erythroid or myeloid leukemias, hemangiomas, or nephroblastomas. c. epizootiology and transmission. egg transmission is the most important means of introducing the virus into a flock. lateral spread from infected saliva and feces then ensues. ear ly infection is generally required for tumors to develop. findings. an enlarged liver, sometimes sig nificantly displacing other abdominal organs, is a common finding. tumors in the spleen and kidney are also seen. the bursa of fabricius will usually reveal a discrete, nodular tumor that constitutes the primary lesion. other sites are thought to become involved as the result of métastases from the bursa. e. differential diagnosis. lymphoid leukosis does not de velop until - months of age. in contrast, marek's disease may be seen as early as - weeks of age. both diseases can simultaneously occur in the same bird. the presence of a bursal tumor frequently indicates ll, whereas nerve, skin, or muscle involvement indicates md. /. prevention. lymphoid leukosis-free chicks are avail able. a rigid isolation rearing system should be followed. h. research complications. if birds are not kept until the age of sexual maturity, little or no ll should be encountered. a. etiology. vitamin a is necessary for growth, normal vision, and integrity of epithelium lining the respiratory, diges tive, urinary, and genital tracts. severity of deficiency signs and age of incidence will vary with the vitamin a levels in the feed and the maternal reserve of vitamin a passed onto the chick. breeders on adequate vitamin a diets store this vitamin in the egg yolk, which provides the chick with sufficient vi tamin a to last for several weeks. chicks hatched with margin al reserves of vitamin a and placed on a deficient diet will have clinical signs by - days of age. however, if chicks are hatched from hens receiving adequate vitamin a, they have no signs or lesions until about weeks. b. signs. signs of vitamin a deficiency include pale head, muscles of the thigh, and skin. weakness, lethargy sometimes associated with ataxia, and lacrimation with conjunctivitis are other signs noted. decreased sperm counts and reduced sperm motility are reported to be a common finding in vitamin adeficient roosters. cartilage and bone development may be de pressed. the incidence and severity of blood spots in eggs are increased as dietary vitamin a is reduced. recovery from in testinal diseases is improved when the level of vitamin a in the feed is increased. c. gross lesions. lesions of vitamin a deficiency consist of small white pustules in the nasal passages, mouth, esopha gus, pharynx, and crop. in addition, there may be marked ac cumulation of urates in the renal tubules. d. histopathology. histopathology reveals cytoplasmic atrophy and loss of cilia of the respiratory tract epithelium. there is marked karyorrhexis of nuclei. chronic vitamin a deficiency results in squamous metaplasia in epithelial lining of the nasal cavities, trachea, bronchi, and submucous glands (bryant and helmboldt, ) . e. prevention. the normal requirement for vitamin a in chicks from day old to weeks of age is iu/lb of feed. for growing chickens and turkeys ( - weeks of age), iu/lb of feed is recommended. for laying hens, iu/lb of feed, and for breeding hens and turkeys, iu/lb of feed is needed. five thousand iu/lb feed is also recommended for pheasants, pigeons, and quail. /. treatment. treatment levels for vitamin a deficiency is iu/lb of feed. a. etiology. vitamin d is needed for metabolism of cal cium and phosphorus in the formation of bones, egg shells, beaks, and claws. vitamin d stimulates the gastrointestinal ab sorption of calcium. serum alkaline phosphatase is elevated when vitamin d-deficient diets are fed even in the presence of sufficient calcium and phosphorus. b. signs. retarded growth, poor feathering, and soft bones (rickets) are features of vitamin d deficiency in young chicks - weeks of age. the chicks are unsteady and walk only a short distance before falling, or affected chicks may sit on their hocks and rest for several minutes (bryant, ) . adults will lay a large percentage of thin-shelled and softshelled eggs leading eventually to a decrease in total egg pro duction. signs from a deficiency of vitamin d usually occur about months after vitamin d is withheld. hatchability is also reduced. c. lesions. characteristic lesions in young birds include soft pliable bones, beaded ribs, and s-shaped keel bone. the beak and long bones can be bent without breaking. an in dented rib cage is evident and causes pressure on the lungs and the heart. in adults, the lesions seen in young birds are present but usually to a lesser degree. pathological fractures of the ribs and vertebrae may be a feature. the histological features of vitamin d deficiency include an enlarged parathyroid gland with a diffuse hyperplasia. a decrease of normal calcified bone with an excess of osteoid tissue in the long bones is also seen. poor calcification is best identified at the epiphysis of the tibia or femur. turkeys of all ages should receive vitamin d in the amount of iu/lb of feed. hens and young chicks require iu/lb, while growing chickens, - weeks of age, should have iu/lb of feed. pheasants, quail, and pigeons will grow well on iu/lb of feed. e. treatment. the feeding of a one-time, very high dose of vitamin d , approximately , iu/lb of feed, will pro vide the most effective therapy. this should be given in a sin gle dose, as hypervitaminosis d can result. dystrophie cal cification of the aorta and certain arteries, in addition to kidney tubules, is one complication of hypervitaminosis d. vitamin d (irradiated ergosterol) is a poor form of vitamin d for birds and can even be toxic at high levels. a. etiology. vitamin e is necessary for normal egg pro duction, fertility, and hatchability. multiple problems result if a deficiency of vitamin e occurs in birds. i. encephalomalacia ("crazy chick disease"). this con dition is a vitamin e deficiency characterized by ataxia, back ward retraction of the head, increased incoordination, and death. it is usually seen between and weeks of age. if the breeder flock is deficient in vitamin e, signs may be seen dur ing the first week posthatching. grossly, the cerebellum ap pears wet with petechial hemorrhages. histologically, ische mie necrosis as a result of capillary thrombosis is the main feature. this disease must be differentiated from avian encephalomyelitis (ae) in which the neurons show central chromatolysis. this condition is characterized by cells appearing pale in the center due to loss of the nissl substance (helmboldt), ). ii. exudative diathesis. this condition is characterized by subcutaneous blood-tinged edema of young birds caused by an abnormal permeability of capillary walls. it appears that tissue peroxides increase causing damage to capillary membranes. vitamin e and glutathione peroxidase, a selenium-containing enzyme, protect the capillary endothelium against damage by peroxides, thus explaining the dual role of vitamin e and se lenium in preventing exudative diathesis. hi. nutritional muscular dystrophy. dystrophie muscles in chickens, ducklings, and turkeys at approximately weeks of age is caused by vitamin e deficiency, as well as by a defi ciency of sulfur-containing amino acids. it is primarily seen in breast muscle but may be found in any of the skeletal muscles. grossly, there are separated muscle fiber bundles that appear light in color. the microscopic lesions consist of typical zenker's necrosis, which include hyaline degeneration, pro liferation of muscle nuclei and fibroblasts, disruption of mus cle fibers, and edema containing heterophiles. vitamin e defi ciency and selenium deficiency in the turkey may show heart and gizzard myopathy. iv. enlarged hocks. turkeys on a vitamin e-deficient diet have enlarged hocks and bowed legs at - weeks of age. the same condition is produced by a deficiency of phosphorus, choline, glycine, nicotinic acid, zinc, and biotin. b. prevention. the recommended level of vitamin e for chickens and laying hens is iu/lb of feed; for breeding hens . iu/lb is recommended. poults from to weeks require iu/lb, and breeder turkeys need iu/lb of feed. c. treatment. therapeutic levels of vitamin e and se lenium, iu/lb and . ppm, respectively, will prevent en cephalomalacia, exudative diathesis, and gizzard myopathy. a. etiology. vitamin k is needed to synthesize prothrombin, an important component of the blood clotting mechanism. if vitamin k is deficient, prolonged blood clotting time is noted. b. signs and lesions. diets deficient in vitamin k can cause cutaneous hemorrhage of the legs, wings, and breast in addition to hemorrhage into body cavities. anemia is often seen due to blood volume loss and a hypoplastic nonregenerative bone marrow. embryos will die during egg incubation from hemorrhages. c. prevention. vitamin k deficiency is rare and hard to reproduce. the dietary requirement for all birds at any age is mg/lb of feed. d. treatment. a normal clotting time returns within hr after treatment with menadione sodium bisulfite. cutaneous hemorrhages and anemia usually take several days to resolve once adequate vitamin k levels are fed. e. thiamin deficiency (vitamin b,) a. etiology. thiamin is important in carbohydrate metabo lism. signs of thiamin deficiency include polyneuritis, extreme anorexia, and death. b. signs and lesions. vitamin b, deficiency can be seen in chicks and adults. usual signs are weight loss, ruffled feath ers, leg weakness, and unsteady gait followed by muscle paral ysis. due to anterior neck muscle paralysis, retraction of the head results in a typical posture referred to as "star gazing." c. treatment. the requirement of thiamin is mg/lb of feed for birds of all ages. oral therapy with thiamin results in a rapid clinical recovery if the birds are eating; however if anorexia is present, force feeding or injection of thiamin may be necessary. a. etiology. riboflavin is an important component of many enzymes associated with oxidation-reduction reactions and cell respiration. b. signs and lesions. signs in chicks may include poor growth, weakness and emaciation, diarrhea, and refusal to walk. appetite is not affected. toes will curl medially (bryant, ) . in laying hens decreased egg production and hatchability occurs. increased fat content of the liver is also noted. embryos are dwarfed and edematous. in turkeys, riboflavin deficiency results in a dermatitis with defective down feathers similar to pantothenic acid deficiency in chickens. micro scopic nerve lesions in chicks show degenerative changes in the myelin nerve sheath. c. prevention. the normal requirement for riboflavin in all birds is to . mg/lb of feed. d. treatment. the administration of adequate riboflavin will usually cure the deficiency rapidly. a. etiology. pantothenic acid is part of coenzyme a, which is involved in the metabolism of carbohydrates, pro-everett bryant teins, and fats. it is required for hatchability and will prevent edema and subcutaneous hemorrhages in the embryos. b. signs and lesions. changes noted in pantothenic acid deficiency include a severe dermatitis, perosis, broken feath ers, poor growth, and death. poor hatchability with the em bryos dying during the last days of incubation is typically noted. c. prevention and treatment. six to mg/lb of feed is needed for a normal diet. for therapeutic effect, - mg/lb of feed administered for a few days either orally or by injection is needed. biotin deficiency causes a dermatitis around the beak, eye lids, and feet. biotin deficiency also can cause perosis. ap proximately . mg/lb of feed will prevent the dermatitis and perosis caused by biotin deficiency. a. etiology. vitamin b is involved in nucleic acid syn thesis, methyl synthesis, and metabolism of carbohydrates and fats. b. signs and lesions. signs include retarded growth, poor feed efficiency, mortality, small egg size, and reduced hatchability. vitamin b x -deficient embryos may have hemor rhages, edema, perosis, and fatty livers. c. prevention and treatment. the inclusion of . mg/lb of feed will prevent deficiency of vitamin b i . therapy includes the addition of mg/ton of feed into the breeding ration. a. etiology. calcium is essential for bone formation, egg shell production, normal blood clotting, normal striated mus cle, and maintenance of acid-base balance. phosphorus is required for carbohydrate and fat metabolism, calcium trans port, bone formation, and eggshell production. b. signs and lesions. calcium and/or phosphorus defi ciency will cause signs and lesions of rickets, decreased egg production, and increased numbers of soft shelled and shellless eggs (also see section vii,b on vitamin d deficiency). c. prevention and treatment. the recommended levels are as follows: for nonlaying chickens, % calcium and . % available phosphorus; for laying and breeding hens, . % cal cium and . % available phosphorus; for nonlaying turkeys, . % calcium and . % phosphorus; and for laying turkeys, . % calcium and . % phosphorus. the above levels used therapeutically will correct any deficiency. a. etiology. sodium is found in the blood and body fluids and is associated with regulation of the hydrogen ion con centration of blood. it is also necessary for normal physiologi cal activity of the heart. b. signs. poor growth, softening of the bones, corneal keratinization, gonadal inactivity, decrease in cardiac output, hypotension, hemoconcentration, and uremia are signs of so dium deficiency. in adults, a sodium deficiency results in de creased egg production and egg size in addition to loss of weight and cannibalism. c. prevention and treatment. levels of . % sodium and . % chlorine are recommended for optimum growth and egg production. salt toxicity develops at a level of gm/kg of body weight. intense thirst, weakness, convulsions, and death are the signs associated with salt toxicity. a. etiology. manganese is essential for growth, egg pro duction, and prevention of perosis. b. signs. results of a manganese-deficient diet include poor quality eggshells, thickened and shortened leg bones, lowered hatchability, and chondrodystrophy in embryos. c. prevention and treatment. the normal requirement of manganese is - ppm. this level is also used therapeu tically to treat manganese-deficient birds. a. etiology. iodine is necessary for the normal function of the thyroid gland. thyroxine is % iodine and regulates body metabolism. with iodine deficiency, the thyroid gland en larges and is referred to as "goiter." b. prevention and treatment. the recommended level of differential diagnoses in avian medicine, i. diseases of the central nervous system a program for eradication of infectious laryngótracheitis from new england poultry flocks differential diagnosis in avian medicine. ii. diseases of the digestive system differential diagnoses in avian medicine. iii. diseases of the respiratory system an epizootic of eastern equine encephalomyelitis in connecticut studies on avian encephalomyelitis. iv. early incidence and longevity of histopathologic lesions in chickens a bibliography of avian mycosis infectious laryngótracheitis in pea fowl and pheasants gangrenous dermatitis of chickens the pathology of necrotic enter itis in domestic fowl histopathologic differentiation of diseases of the nervous system of the domestic fowl (gallus gallus) isolation and identification of avian pathogens diseases of poultry demonstration of an avian adenovirus as the causative agent of marble spleen disease avian microplasmas. in "the mycoplasmas nutrient requirements of poultry variations in the cells and hemoglobin content in the blood of the normal domestic chicken outbreaks of fowl cholera in quail diseases of cage and aviary birds poultry health handbook nutrition of the chicken international registry of poultry genetic stocks caged bird medicine avian physiology avian disease manual ja panese quail husbandry in the laboratory marble spleen disease in ring-necked pheasants: histology and ultrastructure key: cord- -due tloa authors: nan title: ecr , part a date: - - journal: insights imaging doi: . /s - - - sha: doc_id: cord_uid: due tloa nan percutaneous needle biopsy has been a mainstay of oncologic diagnosis for almost three decades, since the advent of ultrasound and ct. the basic principles of fine-needle aspiration and core needle biopsy can be applied to almost any site in the body, with subtle differences in technique depending on the organ being investigated and the imaging modality utilised. while excisional biopsy is still appropriate in certain cases, percutaneous needle biopsy has become the standard of care in the diagnosis of most tumors throughout the body and is also used to diagnose noncancerous conditions, such as infection. percutaneous biopsy is also beneficial in the staging of patients with cancer, particularly when another treatment method may be more appropriate than surgical resection. the advantages of percutaneous biopsy over surgical excisional biopsy include time and cost savings and reduction in morbidity. the aim of this course is to discuss the practical aspects of biopsy, needle selection, and guidance techniques and to show how to approach difficult lesions and avoid complications. imaging after treatment of breast cancer is for confirmation of lesion removal, identification of postprocedural fluid collections, detection of residual or recurrent cancer and screening for metachronous cancers. posttherapy changes -which include fluid collections, edema, skin thickening, architectural distortion, scarring and calcifications -are mainly due to surgery, axillary dissection and radiotherapy. the greatest treatment-related changes occur - months after therapy, and mammographic stability is achieved after two to three years. for mammography, pre-and all posttherapeutic images have to be compared. ultrasound is the method of choice for evaluation of fluid collections. mri is for problem solving (i.e. differentiation between scar and relapse) and should not be performed prior to months after therapy to avoid false-positive diagnoses. dystrophic calcifications may develop in areas of fat necrosis mimicking malignancy. fat necrosis predominantly occurs at the treated site; however, it can develop anywhere in the ipsilateral breast. its appearance may be indistinguishable from cancer at all imaging modalities. to differentiate between fat necrosis and other common post-treatment changes from relapse, it is important to know the timeline when these changes occur and schedule follow up imaging accordingly. mammography serves as the basis for postoperative surveillance. ultrasound is helpful in the early postoperative phase, whereas mri is the method of choice, especially for differentiation of scar and relapse in the later postoperative phases. breast radiologists need to be familiar with post-treatment imaging findings in patients with breast cancer, but often patients are also imaged after a diagnosis of benign entities which are treated surgically (fibroadenomas, radial scars, papillary lesions) or after a percutaneous diagnosis of a high-risk lesion which has undergone a surgical biopsy to avoid underestimation (atypical ductal hyperplasia, lobular neoplasia or flat epithelial atypia). these procedures will leave an imprint on the breast which can be a cause of concern due to the surgical scar. furthermore, imaging findings after plastic surgery for mastopexy, reduction mastoplasties, implants or auxiliary techniques (lipofilling, hyaluronic acid) are becoming frequent in our daily practice and have their peculiarities that can overshadow breast cancers. interventional percutaneous procedures can also be a cause of tissue distortion. there are advanced systems for biopsy (bles) and for percutaneous removal of benign lesions (fibroadenomas, papillomas), which use large-gauge needles and have to be accounted for due to their trace in the breast tissue. endoscopy is currently considered the reference standard for the evaluation of colonic disease activity in patients with inflammatory bowel disease (ibd). however, it only allows evaluation of the mucosal surface and is not always complete. it cannot, therefore, help to estimate the depth of involvement of transmural inflammation and extraluminal complications, both characteristics of ibd. an evolving role for cross-sectional imaging in the evaluation of patients with ibd is increasingly recognised, especially in the setting of crohn's disease (cd) since the cross-sectional imaging has been demonstrated to have a high diagnostic accuracy not only for assessing the presence and extension of luminal disease, but also for evaluating the cd-related acute or chronic complications. available evidence suggests that ultrasound, computed tomography and magnetic resonance have similarly high diagnostic accuracy in the detection of disease activity, location, severity and complications: in particular, the penetrating and stricturing lesions which are characteristic of cd. thus, the choice of the technique for assessing cd may be influenced by local availability or expertise. in the case of ulcerative colitis, cross-sectional imaging, although less evaluated, may also be helpful in certain circumstances. there is evidence indicating that cross-sectional imaging is an alternative problem-solving tool to endoscopy whenever tissue sampling is not required and can provide valuable guidance for performing medical and surgical treatment with maximised efficacy and safety. overall, findings from crosssectional imaging accurately reflect disease activity and provide reliable information for decision-making and patient care optimisation. learning objectives: . to learn about optimised examination protocols for ulcerative colitis and colonic crohn's disease in the acute, subacute and chronic disease setting. . to become familiar with the criteria for the assessment of disease activity through ct, mri and ultrasound. . to learn about an integrated approach to the use of cross-sectional imaging in colonic inflammatory bowel disease. liver transplantation is the accepted treatment of patients with irreversible liver cell failure and some metabolic disorders and in a selected group of patients with hepatocellular carcinomas. over the last decade, major transplant centres have reported improving survival rates, though during this period they have developed more complex surgical techniques, including split-liver, auxiliary and live-related transplantation, and have treated more marginal higher risk patients. this successful outcome has been dependent on appropriate recipient selection, robust surgical technique, improvements in immunosuppression and intensive care management and the prompt recognition and treatment of complications. diagnostic and interventional radiology have been core specialties in achieving the goals of improved graft and patient survival. improvement in surgical techniques has decreased the more common vascular and biliary complications, but the newer techniques present differing diagnostic and interventional challenges, particularly in paediatric recipients. developments in mr and mdct allow many of these vascular, biliary and infective complications to be diagnosed non-invasively. vascular techniques of angioplasty and stent placement may reverse the sequel of graft ischaemia or portal hypertension. mrc allows the diagnosis of biliary strictures that may be treated by dilatation or stent placement. imaging is also important in the diagnosis of recurrent disease and the acquired diseases of prolonged immunosuppression including atypical infections and the post-transplant lymphoproliferative disorders (ptld). this interactive session will present these appearances by case example and provide guidance of the appropriate diagnostic and treatment paradigm. learning objectives: . to understand the common imaging findings after liver transplantation. . to recognise significant complications following liver transplantation. a- : b. imaging of treated liver tumours i. bargellini; pisa/it (irenebargellini@hotmail.com) imaging findings after systemic and loco-regional treatments vary greatly depending on baseline features of the treated tumour and treatment modality. conventional uni-dimensional and bi-dimensional criteria (such as recist . and who criteria) have been extensively validated in metastatic lesions treated with conventional chemotherapy. however, their prognostic value is limited in patients treated with new molecular targeted therapies and after locoregional treatments. in the setting of hepatocellular carcinoma (hcc), specific response criteria (such as easl and mrecist) have been proposed that take into account variation in the size of the viable tumour. these criteria have been extensively validated, although their interpretation could be troublesome after some specific treatments, such as molecular targeted agents and y radioembolisation. on the other hand, there is no consensus regarding tumour response criteria for metastatic lesions after loco-regional treatments. the role of morphological criteria and several imaging biomarkers (such as those provided by diffusion and perfusion imaging, fdg activity, dual source ct) is under investigation, being able to provide additional information on tumour activity and biology. while new drugs with different mechanisms of action and new treatments are becoming available, the work of radiologists is changing and there is increasing evidence that tailored radiological response criteria are required for these new targeted and tailored treatments. learning objectives: . to understand the common imaging findings after chemotherapy for liver tumours. . to recognise common imaging findings after radiofrequency ablation of liver tumours. . to be aware of the common imaging findings following transarterial treatment of liver tumours. vessel size is practical, since it is related to the pathological changes as well as to the clinical and radiological presentation. the two main large vessel vasculitides are giant cell arteritis and takayasu arteritis. behcet disease may combine large and small vessel vasculitis. imaging plays an important role in primary vasculitis. chest radiographs are not especially useful in large vessel vasculitis. contrast ct and mri further detect and especially help in the characterisation of large vessel vasculitis. vessel wall changes are well detected with both techniques. contrast enhancement, distribution of vessel involvement and morphological vascular changes should be considered. today, pet/ct is the recommended imaging technique in the assessment of vessel wall inflammatory changes and in the evaluation of treatment response. although the clinical scenario differs usually between takayasu and giant cell arteritis, the radiologist should combine the imaging findings with clinical and laboratory data to suspect a specific vasculitis. therefore, this presentation will concentrate on the basic signs and associated findings in large vessel vasculitis, pathologic correlation, imaging protocols and the differential diagnosis. the term vasculitis refers to a variety of clinico-pathological entities. the most widely used chapel-hill classification divides the vasculitis syndromes into three groups based on the size of vessels primarily involved. small vessel vasculitis such as anca-associated granulomatous vasculitis (wegener's disease), churg-strauss granulomatosis and microscopic polyangitis are most often associated with pulmonary abnormalities. the spectrum of hrct findings is quite variable and differs by entity. the hrct findings will be discussed together with clinical and laboratory findings to be integrated into a multidisciplinary diagnostic approach. the typical findings in wegener's granulomatosis include solitary or multiple, often cavitary nodules or masses, or focal or diffuse consolidations, churg strauss is dominated by interlobular thickening or transient multifocal and nonsegmental consolidations frequently in subpleural distribution. all types of pulmonary vasculitis may present with focal or diffuse pulmonary haemorrhage that produces pulmonary ground glass or consolidations in various distributions. a number of collagen vascular diseases (e.g., lupus erythematosus) or other granulomatous diseases (e.g. sarcoidosis) may affect the small pulmonary vessels causing haemorrhage or pulmonary hypertension. per disease entity, the course will review typical and more rare hrct features and key features that allow for diagnosis and classification, discuss side-to-side overlapping of morphologic features important for differential diagnosis and illustrate the findings of other diseases that represent the most challenging differential diagnosis, e.g. oedema, infection or malignant diseases. learning objectives: . to learn when hrct is of value in investigating pulmonary vasculitis. . to appreciate the different appearances of pulmonary vasculitis on hrct. a- : d. inflammation and remodeling a.a. bankier; boston, ma/us (abankier@bidmc.harvard.edu) the presentation will lay out the pathological and pathophysiological basis for the complex processes of inflammation and remodelling. the implications of these processes for imaging will be discussed and illustrated by selected pathologies. finally, the presentation will indicate how the imaging reflections of these processes could be used in the future as imaging biomarkers for the diagnosis, follow-up, and outcome evaluation of disease. at (marcus.hacker@meduniwien.ac.at) appropriate diagnosis and therapy of coronary artery disease (cad) frequently require information about both the morphological and functional status of the coronary artery tree. thus, combined imaging consisting of invasive coronary angiography (ica) plus spect myocardial perfusion imaging (mpi) is practiced in clinical routine diagnostic of patients with stable angina since many years and can therefore be accepted as the reference standard in the diagnosis of hemodynamically relevant coronary artery stenoses. both morphological and functional information are mandatory for the decision of performing an interventional therapy or initiating/maintaining medical treatment in numerous symptomatic patients. the hemodynamically relevance of coronary artery lesions is a major condition to decide whether an interventional therapy should be performed or not. a non-invasive concept providing both information could provide accurate allocation of perfusion defects to their determining coronary lesion and specific morphological and functional classification of patients with coronary artery disease. in symptomatic patients, a normal stress mpi confers a very low short-term risk for cardiac death and/or acute myocardial infarction. however, a normal mpi does not exclude the presence of underlying coronary atherosclerosis, which may be extensive although not yet flow-limiting. in this regard, ct will unmask a sizeable subgroup of patients with coronary atherosclerosis who should receive more intensive antiatherosclerotic intervention than would have been indicated by mpi results alone. knowledge regarding the presence and extent of subclinical coronary atherosclerosis in patients who do not have ischemia by mpi can be of importance in patient management. learning objectives: . to appreciate the scope of information a spect/ct cardiac study can deliver. . to become familiar with protocols of spect/ct studies. . to learn a structured approach to performing and reporting a spect/ct study. a- : c. mr/pet: do we really need it? h.h. quick; erlangen/ de (harald.quick@imp.uni-erlangen.de) following pet/ct and spect/ct, mr/pet hybrid imaging is the most recent addition to the palette of hybrid imaging modalities. mr/pet synergistically combines the excellent soft tissue contrast and detailed image resolution of mr with metabolic information provided by pet. integrated mr/pet systems furthermore offer the ability to acquire hybrid imaging data simultaneously. this can be applied to mr-based motion correction of pet data. these features open up several cardiac applications, e.g. evaluation of cardiac function and viability, diagnosis of cardiac inflammatory diseases and tumorous diseases. to fully assess the diagnostic potential of mr/pet, however, several technical challenges have to be considered: attenuation correction (ac) of the patient tissues in mr/pet has to be based on mr-images and is currently hampered by a limited number of tissue classes and undercorrection of bone tissue. cardiac radiofrequency coils and ecg gating equipment are currently not considered in ac. consequently, quantification of pet data therefore might be biased. the clinical workflow is rather complex and needs to be tailored to cardiac examinations. few research groups currently explore this new hybrid imaging modality in selected cardiac applications. cardiac mr/pet: do we really need it? considering the sparse clinical experience that is available today, it is quite early to answer this question yet. however, once the remaining technical hurdles are overcome and the diagnostic potential can be fully exploited clinically, the answer is most likely positive. the majority of malignant bone tumours can be detected on plain radiography. the age of the patient, location of the tumour in a bone and history of a preexisting bone abnormality should be included in determining the likely diagnosis. careful analysis of the pattern of bone destruction, periosteal reaction and matrix mineralisation allow for characterisation of most cases of osteosarcoma, ewing's sarcoma, chondrosarcoma and adamantinoma. mri is the best imaging technique for staging by displaying . the extent of bone marrow involvement, including epiphyseal infiltration and skip lesions, . the presence and extent of extraosseous soft tissue mass, . involvement of the neurovascular bundle, muscle compartments and adjacent joint. this allows to find the best biopsy approach and establish the feasibility of limb salvage as opposed to amputation. longitudinal non-contrast t sequences are the most accurate for determining intraosseous extent. axial fat-suppressed pd or t sequences optimally demonstrate soft tissue extension, and dynamic contrastenhanced mri is useful for differentiation of extraosseous tumour from edema and for assessment of tumour response to chemotherapy. chest ct is the most sensitive modality for detection of pulmonary metastases, and technetium skeletal scintigraphy is still frequently used for detection of osseous metastases. the most valuable, readily available and easy-to-use techniques to assess response to radiation therapy and chemotherapy are dynamic contrast-enhanced mr imaging, diffusion mri and colour-doppler ultrasound. to evaluate local control of disease and for detection of local recurrence, mri is usually the best imaging technique. plain radiography may detect complications of prosthesis. learning objectives: . to consolidate knowledge on malignant primary bone tumors on plain radiography, ct and mri. . to understand the principles of tumour staging and monitoring chemotherapy. . to become familiar with imaging findings following chemotherapy and surgery. oncologic approach to malignant primary bone tumours c. dhooge; ghent/be (catharina.dhooge@ugent.be) the most common bone sarcomas are osteosarcoma (os) and ewing sarcoma. os occurs primarily in long bones, ewing sarcoma occurs also in the pelvis, spine or chest wall. localised disease confers a % cure rate, and initially metastatic disease %. a multidisciplinary approach which includes neo-adjuvant systemic chemotherapy and local control measures for primary and metastatic sites followed by adjuvant chemotherapy has become the standard of care. complete surgical excision is mandatory in os; in ewing, radiation can also be used. standard chemotherapy for os is based on a combination of cisplatin, doxorubicin and high-dose methotrexate. ifosfamide and etoposide will be further considered (euramos). systemic therapy for ewing includes vincristine, doxoribicin, cyclofosfamide, ifosfamide and etoposide. high-dose chemotherapy with autologous stem cell reinfusion is evaluated in intermediate prognosis and metastatic disease (euro-ewing). among the different prognostic factors, response to neo-adjuvant chemotherapy by measuring chemotherapy-induced necrosis is a powerful indicator of outcome in bone sarcomas. patients who achieve a good histological response to pre-operative chemotherapy, defined as < % viable tumour at the time of tumour resection, have a better survival than those who show poor response (>= % viable tumour). five-year survival for good responders is o- % compared to - % for poor responders. however, the outcome for malignant bone tumours has improved little in the last years. large international studies exploring new drugs such as biologic agents (interferon) or mechanisms conferring drug resistance (topoisomerase inhibitors) in randomised controlled trials will hopefully lead to therapeutic innovation. learning objectives: . to become familiar with the principles of chemotherapy in malignant primary bone tumours. . to understand what the oncologist expects from the radiologist. . to recognise the value and limits of chemotherapy in malignant primary bone tumours. thursday a- : surgical approach of malignant primary bone tumours g.m.l. sys; ghent/be (gwen.sys@ugent.be) in primary malignant bone tumours, three surgical procedures are necessary: biopsy, resection and reconstruction. whether a biopsy is performed in an open or a percutaneous way is a matter of preference, but in each case it should provide sufficient and representative material for pathological investigation without compromising the following treatment. the area of interest and the trajectory should be determined preoperatively in a multidisciplinary meeting. as the biopsy tract has to be removed during the resection surgery, it should be close to the planned approach for the subsequent resection. if a biopsy is performed improperly, the diagnosis may be wrong or the following resection may be impaired because of extensive contamination of compartments, resulting in a severe functional deficit. surgery planning is based on clear imaging and a multidisciplinary discussion of tumour extension, aiming for a wide resection of the tumour with clear margins. correct perioperative measurements are based on predefined fixed bony landmarks that should preferably be visible on the same image as the tumour. an amputation is performed if a surgical limb-salvage procedure is expected to result in a non-functional limb. nowadays, several reconstruction techniques for bones (bone grafts or prostheses), tendons (artificial or human ligaments) and skin (skin flaps or grafts) are available. invasion of the soft tissues such as the neurovascular structures, muscles and skin, will determine which reconstruction technique (s) are necessary to restore the patient's function. each reconstruction technique bears inherent complications requiring a regular follow-up. we outline the current opportunities and threats in diagnostic radiology: traditional diagnostic radiology has been rapidly replaced by clinical radiology and the role of the radiologist is changing from image interpreter to clinical manager of imaging data. to care for the patient`s medical problem and not only his images is important. this contains great opportunities for radiology to develop and for the radiologist to become a central player in patient management. however, this requires not only clinical knowledge and involvement, but also visibility and sometimes even / availability. the need for " only" image reporting is declining as clinical subspecialisation easily brings image interpretation into the domain of non-radiologists. to understand the importance of identity, visibility is very important. visibility can be achieved by being part of mdt s and also in many other ways. clinical radiology is an idea which, after all these years, has not been very well embedded in current radiology and radiology training. to understand the importance of certified training, maybe the most important action we have to undertake now is to capitalise on our radiological expertise. image interpretation in a clinical context can only be done or franchised (to non-radiologist) under conditions of certification and accreditation by radiology. we should never let the primate of education and certification slip to non-radiologists. radiology certification should be a quality standard, recognised by international and national medical bodies, such as medical chambers and specialist societies. the latter should have high priority. session objectives: . to learn about the current opportunities and threats in diagnostic radiology. . to understand the importance of identity. . to acknowledge the importance of certified training. where are the turf battles in diagnostic imaging? g.m. bongartz; basle/ch (georg.bongartz@usb.ch) turf battles in radiology are a foreseeable development for most imaging techniques which evolve push-button methods and readily interpretable imaging results. we as radiologists must learn to accept competition. turfs should rather be seen as challenge than as threat. predominantly, nonirradiating techniques like ultrasound and mri have become progressively easier to apply (us) or to understand (mri), where the final image in some standardised areas (eg joints) can readily be interpreted by medical specialists in this field. but also x-ray diagnostics in dental medicine or orthopedic imaging is largely applied outside the radiologic department. ct today seems still relatively excluded because of its complexity. but with increasing resolution, optimal d reconstruction and fast accessibility, it is only a question of time when the added value of the radiologist will be under question. radiology has changed. we must become experts with respect to patho-anatomy and radiological differential diagnosis. this requires profound education, both initial training and ongoing education. radiology must be advertised internally and externally. in radiological publications, outcome studies are still underrepresented. demonstration of our dedicated skills, fostering our special expertise and offering this as support to our medical colleagues will preserve radiology for the future. cooperation with partners seems the only way out of a turf battle -we need to search for alliances and integrate our partners to create a win-win situation. a- : beating threats in europe with radiological training a.k. dixon; cambridge/uk (akd @radiol.cam.ac.uk) by introducing radiology to medical students, it is hoped that they will begin to appreciate how difficult it is! likewise, when teaching residents, they must come to understand the basic anatomy and principles better than their clinical colleagues; this is very much the tenet of subspecialty training. they should also appreciate that patient care is optimal when there is close collaboration between clinicians and radiologists. passing of an examination (national or edir) offers some proof that a radiologist has attained a certain standard, but the principle of testing oneself formally or informally at regular intervals again provides a measure of continuing competence. such certification can be of value in the case of litigation. radiology is one of the fastest growing specialties and the techniques that we learn during training are quickly outdated; hence, the need for life-long learning and effective continuing professional development. learning objectives: . to understand how to teach radiology to undergraduate medical students. . to become familiar with the principles of self-assessment. . to appreciate the necessity for life-long learning. history of ultrasound in radiology: lessons learned l.e. derchi; genoa/ it (derchi@unige.it) the relationship between radiology and us has never been an easy love story, and still isn't. in the early s this new imaging field was not readily covered by radiologists and many other colleagues established us sections within their departments. then, important fields of us (cardiology, obstetrics, gynecology) became almost exclusive domain of non-radiologists. in the s, the increasing success of us initiated turf battles with other clinicians. nowadays, clinical specialists perform > % of us examinations wordwide. in europe, most in-hospital us examinations is still performed in radiology, but this is not the case in all countries. a strong practice in us is quite important since this is often the first approach to patients. if initial us referrals are kept, radiologists will continue to guide decisions in subsequent imaging workup. furthermore, us keeps close to patients; in europe the examination is usually done directly by radiologists or, if by sonographers, the radiologist usually checks the case with limited directed us imaging. this clearly shows our role as physicians. to maintain a key role in us radiologists need to: ) have the best specialists in us; attention must be given to us in residency programs. ) invest in us technology (as examples: ceus, elastography, d/ d). ) invest in us research. ) have high visibility in the us community, keeping close contact with all clinical colleagues. ) present higher visibility of us within radiology, with leaders supporting us within the radiological community and each radiologist promoting us in his/her environment. learning objectives: . to understand why ultrasound has moved out of the hands of radiology in some subspecialties. . to learn what this means for daily radiology practice and the quality of work. . to know about the threats and how we should deal with them. thursday a- : interdisciplinary cooperation without losing identity m.f. reiser; munich/de recently, major shifts in the paradigms of patient care took place: interdisciplinary counseling and including the patient in the decision making process for diagnostic and therapeutic measures. the new concept is that the patient no longer comes to the specialist, but the specialists come jointly to the patient. this is reinforced by the competition among health care providers, political decision makers and the public. in many hospitals this general trend has resulted in the establishment of various centers and boards such as the breast cancer centers, vascular centers and tumor boards for several cancer entities to name only few. at the university hospital of munich centers and boards have been implemented up to now. in almost all of them the participation of radiologists is required. this results in a major challenge in terms of personal resources. together with the regular clinical-radiological rounds the time necessary for these activities equals full-time radiologist posts. the participation of radiologists has many beneficial aspects: acknowledgement of radiology as an important clinical discipline and of the radiologist as a clinical consultant; participation in and influence on the creations of sops and (internal) guidelines; opportunity to advocate appropriate radiological methods for diagnosis and interventions; increase of knowledge in clinical medicine and new concepts of therapy; close personal links with our clinical partners. in order to prevent radiologists from losing their identity as radiologists it is mandatory that they remain firmly integrated in the radiology department and to strengthen the position of radiology as the central institution for providing cost-effective imaging and interventional services. moreover it must be taken care to offer attractive career options within the field of radiology. at (michael.fuchsjaeger@medunigraz.at) ultrasound (us) is the adjunct method of choice to mammography in breast imaging. over the past two decades, us technology has undergone profound advancements and refinements. us has, therefore, become an assessment tool with a defined field of indications as well as a unique set of diagnostic descriptors for breast lesion differentiation. the acrin study has demonstrated the special benefit of us in patients at risk with dense breast tissue. the bi-rads lexicon for ultrasound, in its second edition, expanded the role of breast us. further enhancement of image quality as well as the recent advent of automated breast us has even fueled scientific discussions on the potential role of us for breast cancer screening. automated breast us, which is based on computed generation of a d imaging data set obtained from many parallel d images, offers a different approach with a variety of benefits. images are obtained by the sonographer in standardised fashion, whole breast data sets can be reviewed at any time after the examination, reducing operator dependence, and image fusion with, i.e. mri is easily possible. the basic physical background, the significance as well as important aspects of practical use of handheld and automated breast us will be explained and illustrated by the respective imaging examples. emphasis will be laid on strengths and potential weaknesses of both us technologies with regard to breast imaging. the terms "complicated cyst" and "complex-cystic lesion" are based on breast ultrasound (us) terminology. the simple cyst is a fluid-filled, clearly defined, anechoic lesion without any suspicion of a solid intracystic mass. if a simple cyst is complicated by echogenic fluid, it is called complicated cyst. this echogenic fluid can be caused, e. g., by cell debris. thin echogenic septa are common in complicated cysts. vascularisation can never be found in these echogenic components. a complicated cyst has no solid component and no thickened wall or thickened septa. the expected probability of malignancy is %. the us criteria of a complex-cystic lesion following berg et al. categorise it into types: type , thick outer wall and thick internal septa (alone or in combination of both); type , one or more intracystic masses; type , mass of mixed cystic and solid components (at least % cystic); type , predominantly solid with eccentric cystic foci (at least % solid). complex means there is a suspicion of a tumour inside a cyst or a solid tumour with cystic components. a complicated cyst will usually be followed by us after months. a complexcystic lesion needs a correlation with mammography. us-guided large core needle biopsy in combination with a us and mammography visible marker placement is useful in type and in type complex-cystic lesions. in type and type complex-cystic lesions, a preoperative hook wire placement and excision surgery is the typical procedure. learning objectives: . to learn about the us appearance of complicated cysts and complex-cystic lesions. . to consolidate knowledge on differential diagnosis for these respective lesions. . to understand the diagnostic algorithm for a work-up of these lesions. renal colic is the most frequent non-obstetric cause for abdominal pain and subsequent hospitalisation during pregnancy. intervention is necessary in patients who do not respond to conservative treatment. ultrasound (us) is widely used as the first-line diagnostic test in pregnant women with nephrolithiasis, despite that it is highly nonspecific and may be unable to differentiate between ureteral obstruction secondary to calculi and physiologic hydronephrosis. magnetic resonance imaging (mri) should be considered as a second-line test, when us fails to establish a diagnosis and there are continued symptoms despite conservative management. moreover, mri is able to differentiate physiologic from pathologic dilatation. in fact in the cases of obstruction secondary to calculi, there is renal enlargement and perinephric oedema, not seen with physiological dilatation. in the latter, there is smooth tapering of the middle third of the ureter because of the mass effect between the uterus and adjacent retroperitoneal musculature. when the stone is lodged in the lower ureter, a standing column of dilated ureter is seen below this physiological constriction. mri is also helpful in demonstrating complications such as pyelonephritis. in the unresolved cases, computed tomography remains a reliable technique for depicting obstructing urinary tract calculi in pregnant women, but it involves ionising radiation. nephrolithiasis during pregnancy requires a collaboration between urologists, obstetricians, and radiologists. learning objectives: . to list the us, mr and ct imaging findings of urolithiasis and urinary tract infections. . to discuss the role and the appropriate uses of us, mr and ct for imaging these suspected conditions in pregnancy. . to discuss how imaging can influence the management of nephrolithiasis during pregnancy. oncology t.f. hany; zurich/ch (thomas.hany@gmail.com) in malignant tumours, pet/ct imaging using -fluoro-deoxyglucose (fdg) is widely used nowadays. fdg-uptake is an unspecific process and results in physiological as well as pathological malignant and non-malignant tissue uptake. to properly understand and interpret pet/ct imaging, knowledge of the mechanism and pathways of fdg in different tissue types like brain and the gastrointestinal tract is key. intrinsic as well as extrinsic factors influence uptake pattern not related to oncological disease like uptake in brown fat in patients exposed to cold ambient temperature and psychological stress or increased muscular uptake in nonfasting patient. typical treatment-related changes occur during and after treatment and must be recognised correctly so as not to overstage patient disease. a systematic analysis and knowledge of all these factors facilitate and improve the reading of oncological clinical cases. learning objectives: . to understand pattern of physiological fdg-uptake. . to learn about the pattern of non-pathological uptake in several tissue types. . to understand the influence of chemotherapy and other agents on fdguptake in the body. radiologists mostly prefer to use the comparative technique while evaluating radiological images, especially when the anatomy is identical for both sides. comparative analysis mostly works if the anatomic details are not complex or the right resembles the left. however, the complex anatomy and relatively high incidence of individual variations in head and neck may hinder this way of interpretation. variable pneumatisation of paranasal sinuses and temporal bone may cause difficulty. vascular system, especially venous structures may be sources for pseudolesions. for example, asymmetrically enlarged jugular vein or venous plexuses at any location may be misinterpreted as mass of any origin. veins may also become problematic on mr imaging due to entry slice phenomenon, in-plane flow, and flow turbulence effects and can have variable enhancement. normal anatomical structures such as facial nerve may enhance and can be mistaken to be pathologic on mri. technical issues can be considered as a group that may cause pseudolesions. images of the improperly positioned patient may become problematic while evaluating tiny structures. pet and pet-ct carry their own risks for pitfalls. normal structures may confound interpretation and result in false-positive findings. the situation may become much more complicated when there is asymmetry. similarly, atrophy and unilateral absence of a structure may be misread as a mass on the contralateral side. because of the complex anatomy and relatively high incidence of individual variations, head and neck imaging demands much more attention and careful analysis. the appropriate imaging technique and detailed knowledge of anatomy are essential to recognise pseudolesions. as a general rule, detailed knowledge of the patient's clinical history is essential before any imaging study is performed, to evaluate the appropriateness of the indication, tailor the acquisition protocol and correctly interpret the study. in head and neck imaging, this rule particularly fits in the emergency setting. in certain circumstances, the swelling and enhancement of soft tissues produced by infectious lesions may mimic a neoplasm. even more so, in patients already treated with surgery or chemoradiation. in these patients, the challenge is double: to identify any abnormality in the new anatomy produced by treatment and to discriminate between inflammation, complication and relapse. these can be very difficult without knowledge, for example, of the reconstructive procedure after surgery. previous images are extremely useful, not only because they help detect abnormalities, but also because through indirect information on the growth rate of the lesion they are crucial for correct interpretation of findings. tablets in radiology represent a novelty. since the introduction of the tablets on the market, the radiological field has been probably the first medical discipline to discover the many advantages of these devices. in fact, many applications for image management have been made available on the app stores (apple and android), and allow radiologists and non-radiologists to handle dicom images on the tablet, as part of the patient's record. however, the emerging applications are driving the process from the simple dicom image viewing to the full integration of the tablet with the pacs, allowing the handling of a patient's full record and presumably the possibility to report. in view of this rapid technological development, again radiology falls in the middle of a storm and is asked to find a solution to problem: are tablets suitable to read and report dicom images? and if so, which kinds of images (ct, mri, x-ray, etc) .? how can we manage the portability of patients' data (security issues, data loss, etc).? what will be the impact on teleradiology? these issues will be addressed by the panel of experts who will speak in the refresher course. session objectives: . to appreciate the current state of tablet technology and its practical use in radiology. . to understand the pros and cons of the use of tablets. . to learn about specific critical areas of utilisation (dicom images reading and teleradiology). a. tablet-computers: a technical overview j. fernandez-bayo; sabadell/es (jfernandezb@cspt.es) since their introduction in , tablet pcs have evolved extensively. they have become very popular, filling the gap between laptop computers and smart mobile phones. we will review technical aspects like the processors, storage space and memory, size and weight, connectivity and networking, software, autonomy, and battery life in different devices. special focus will be on the displays and different possible uses in radiology. for diagnostic purposes, different technical aspects must be taken into consideration, like the display size, resolution, pixel size (pixel pitch or pixels per inch), luminance, and contrast. displays in radiology normally have sizes between " and " and resolutions up to mpx, with luminance that ranges from cd/m to cd/m . by contrast, tablets have screen sizes between " and " and resolutions up to mpx, with luminance that ranges from cd/m to cd/m . due to their screen size, tablets score better in pixel pitch, with around ppi versus ppi in medical displays. the two systems have similar contrast ratios. other technical aspects of display that we should take into consideration are the number of distinguishable grays that can be represented, which in tablets correlates with the number of colours that can be displayed (color gamut) and colour accuracy (delta-e). additionally, we should take into consideration that displays should be calibrated for medical diagnostic purposes and tools to calibrate tablets have recently become available. learning objectives: . to learn about the pc evolution: from desktops, to laptops and tablets. . to appreciate the versatility features of a tablet. . to understand the hardware features with a specific focus on display. . to understand the hardware features with a specific focus on networking. a- : b. reading dicom images on the tablet o. ratib; geneva/ch touch screen tablets are becoming widely available, providing convenient mobile solutions for physicians and health-care providers. this is particularly attractive in medicine to "nomad" physicians, who need to be able to access relevant patient data and images anywhere-anytime in their daily practice where they are rarely at a single location. while they may not always be adequate for routine diagnostic tasks, they provide a convenient mobile solution for on-call and remote consultations. there are different types of software architecture that can be implemented for such tasks. two different major designs are: ( ) online web-based applications where the device serves as a "thin-client" to display images rendered and manipulated on a remote computer and ( ) local applications that reside on the mobile device and can run independently after images have been downloaded on the device. the first solution requires the user to be constantly connected to the network, while the second solution can continue to function after being disconnected from the network. most pacs vendors are starting to provide web access to their imaging solutions that can be accessed from mobile devices. web access can however be slow and dependent on reliable access to wireless network. we chose to develop a stand-alone companion application to our open source imaging platform osirix. with the increasing capacity and computing power of mobile devices, users will soon be able to perform most of the processing and image manipulation functions that are today only feasible on desktop or laptop computers. learning objectives: . to learn which dicom readers are available for tablets. . to appreciate the different approaches to dicom reading (local vs remote) and the pacs/tablets integration. . to understand the pros and cons of dicom image reading with the tablet in regards to image quality and displays. the optimisation of clinical breast cancer care comprises the prevention of over-diagnosis, reduction of over-treatment, and avoiding unsuccessful treatments. these goals are targeted in the vph-prism project by seven european and two us partner institutions. from the prospectively collected data, we will derive optimised imaging protocols that comprehensively take a woman's history and risk factors into account. the tight integration of radiological and histopathological images enables joint assessment of quantitative tissue parameters from microscopic and macroscopic imaging. more informed therapy decisions can be taken by such enhanced multidisciplinary data, backed by a powerful case database. the reduction of overtreatment, and highly individualised diagnosis and therapy decisions are closely related. we ultimately aim at deriving predictive parameters from the multi-modal and multi-disciplinary database to select the treatment option with the best chance of enduring recurrence-free survival. prospectively collected data, personal risk factors, and corresponding imaging data fed into the database from three large cohort studies are expected to provide insights into the individual preconditions and factors affecting disease progression. to optimise therapy, the decision between therapy options is key. this will be addressed by a decision support system using the project database. for surgical excision planning, vph-prism will aim at providing better estimates of tumour size, and with visual planning aids supporting radiologists and surgeons. for chemotherapy, quantitative lesion parameters, tracked over time during therapy, may help to detect success or failure of the treatment early on, such that a chemotherapy regime can for a non-responder be switched to a different regime in due time. quantitative imaging biomarkers in dementia; the fp vph-dare@it project w.j. niessen; rotterdam/nl (w.niessen@erasmusmc.nl) the number of individuals suffering from dementia today is roughly million. due to ageing societies, this number is predicted to increase to million by . worldwide annual costs are estimated to be € billion. in , the who declared dementia a global health priority, highlighting the urgent need for improvements in this area. vph-dare@it's aim is to enable more objective, earlier, predictive and individualised diagnoses and prognoses of dementias to cope with the challenge of an ageing european society. the expected impact of vph-dare@it will influence the scientific, clinical and industrial communities across europe and internationally to improve health care of dementia patients. in this presentation we will introduce the vph-dare@it project. we will then focus on the development, validation and implementation of quantitative imaging biomarkers for the early detection and differential diagnosis, which will take place as part of the project. author disclosure: w.j. niessen: advisory board; part-time detached to quantib bv as scientific director. shareholder; co-founder and shareholder of quantib bv. horizon : improving diagnosis and medical interventions and support to medical imaging j.-l. sanne; brussels/be (jean-luc.sanne@ec.europa.eu) research and innovation contribute to increasing europe's competitiveness. at the same time, research and innovation help make people's lives better by improving things like healthcare. in january the european union launches horizon , the biggest eu research and innovation programme ever, with a budget of € billion (current prices) over seven years ( ) ( ) ( ) ( ) ( ) ( ) ( ) . eu support for research and innovation helps drive international projects across the european union and beyond, and promotes the progress of knowledge and technology. one of the three key pillars of horizon will be tackling societal challenges (priority ) such "health, demographic change and well-being". one feature is the development of new and more effective diagnostics. relevant tools and technology innovations will be supported in view to improve disease outcomes through earlier, more accurate diagnosis and by allowing for more patient-adapted treatment. support will be provided through the work programme - of societal challenge "health, demographic change and wellbeing". additional opportunities are offered in the work programme - of priority (industrial leadership) "leit -information and communication technologies". practically, all imaging modalities have been used in space research since a long time ago. first of all, radiology is targeted in research activities, because by definition all cosmonauts and astronauts are healthy persons. the biggest volume of examinations had been performed on crew members for studies of organs and functions of the human body before and after long-term flights. health effects of zero gravity were of special interest. for example, multiple studies with involvement of both russian and international specialists were done on bone mineralisation (bone densitometry), muscle volume (mri) and metabolism (mr-spectroscopy) both in astronauts and healthy control subjects. first, ultrasound (us) examinations were conducted in space onboard russian orbital stations in . complex us studies were done by the author himself during his flight as a crew member of "salut- " orbital station in . the author had found some complex changes in blood and fluid dynamics under weightlessness. teleradiology was used for data transfer to medical specialists on the earth. today, we are continuing to use radiology for research on astronauts. for example, applications of sophisticated brain mri and fmri methods are of special interest for studies of subtle brain changes in space travellers. among our targets are flights to the moon, mars and large asteroids. to be better prepared for that task, we need better diagnostic tools. new versions of mobile us systems, miniature x-ray and ct machines suitable for use inside spaceships are under development. there are several mri pitfalls that should be recognised when imaging the female pelvis. mri appearances of uterus and ovaries are dependent on the phase of menstrual cycle/use of exogenous hormone therapy. normal postsurgical and post-radiation appearances of the pelvis can sometimes mimic tumour recurrence. it is important to become familiar with these appearances to avoid potential pitfalls. one very common pitfall is differentiation of transient myometrial contraction from adenomyosis. interrogation of all imaging planes over the duration of the entire mri examination can be useful to distinguish between the two, although myometrial contractions can last up to min. the choice of the correct imaging plane is crucial for the precise classification of uterine anomalies (coronal oblique) and accurate evaluation of parametrial invasion (axial oblique) in patients with cervical cancer. both dynamic contrast-enhanced mri and diffusion-weighted mri improve the accuracy of mri in the evaluation of malignant pelvic conditions. however, certain pitfalls related to each technique should be recognised to avoid misinterpretation. it is crucial to be familiar with the anatomy of the uterovesical (uv) ligament, as it is often the site of pelvic lymphoma (such as bladder or cervix lymphoma). however, some benign conditions such as endometriosis can involve the uv fold and invade both bladder and uterine wall. certain mri features can be helpful in making the correct diagnosis. learning objectives: . to become familiar with normal variations in mri appearances of female pelvis resulting from physiological conditions (e.g. different phases of menstrual cycle) and treatments (including exogenous hormone therapy, surgery and radiation) potentially mimicking disease. . to consolidate knowledge on the role of the correct mr imaging plane in avoiding potential mis-classification of uterine anomalies and parametrial invasion in patients with cervical cancer. . to learn about certain pitfalls related to dynamic contrast-enhanced mri and diffusion-weighted mri. a- : b. pitfalls in ultrasound k. kinkel; chêne-bougeries/ch (karen.kinkel-trugli@wanadoo.fr) pitfalls of sonographic findings in the pelvis can be related to technical issues, interpretation errors or to the patient's specific condition or pathology. common problems consist of insufficient bladder filling, misinterpretation of posterior enhancement or shadowing according to the anatomical structure and pathology of a size that goes beyond the field of view of the probe. organspecific problems will be illustrated in interactive questions, particularly for the uterus and the ovaries. identification of diseases can be difficult in many areas of abdominal imaging and therefore misses are easily made, also by the more experienced radiologist. it is difficult in the mesentery and peritoneum, covering a large area but being a very thin structure where abnormalities are easily missed. therefore, knowledge of the peritoneal anatomy and pathophysiology of peritoneal diseases is not widespread and differential diagnosis can be difficult. hence, special attention should be paid to prevent misses. another difficult area is diagnosing occult gastrointestinal bleeding. here, the choice of the proper imaging method is crucial as well as understanding the pros and cons of the method. the technique used should be optimised, as otherwise sometimes subtle signs of bleeding are missed. the presence of bowel dilatation itself is often correctly diagnosed, but the extent of the obstruction, the cause of the obstruction and especially complications (ischaemia) might be misdiagnosed. ct is the preferred technique for evaluation of bowel dilatation. care should be taken to scrutinise the examination for principal findings in patients with bowel obstruction. a. mesentery and peritoneum d. akata; ankara/tr (dakata@hacettepe.edu.tr) imaging findings of neoplastic or inflammatory diseases within the peritoneal cavity and the mesentery sometimes overlap and cause difficulties in interpretation. even disease processes in the peritoneum, mesentery or omentum may not be recognised on radiological examination, causing major difficulties in the management. peritoneal anatomy and physiopathology of peritoneal diseases must be well understood for better evaluation. ct is the best modality to assess the whole cavity. mr is equally sensitive with better contrast resolution; however, both modalities have advantages and limitations. ultrasound has a complementary role in evaluating the peritoneal fluid content. the presence of lacelike mobile thin septa is highly significant for tuberculosis. for better diagnosing the pathology, systematic approach is needed such as assessing the presence or absence of fluid in the peritoneal cavity, its character and location, accompanying soft tissue densities and their location. some inflammatory or infectious causes, such as acute pancreatitis and tuberculosis, involve typically parietal peritoneum and certain peritoneal reflections. peritoneal carcinomatosis involves typically both visceral and parietal peritoneum as well as subdiaphragmatic space. contrast enhancement patterns of the peritoneal membranes and the mesentery also have a complementary role in differentiating a variety of diseases. learning objectives: . to learn about the imaging characteristics of peritoneal and mesenteric masses and their differentials. . to appreciate the potential and limitations of imaging techniques in the detection of such lesions. . to understand the common pitfalls in diagnosis. a- : a. filippone; chieti/ it (a.filippone@rad.unich.it) patients with persistent, recurrent, or intermittent bleeding from the gastrointestinal tract for which no definite cause has been identified by initial oesophagogastroduodenoscopy, colonoscopy, or conventional radiologic evaluation are considered to have an occult gastrointestinal bleeding (ogib). the management of ogib is clinically challenging, since the causes of such a bleeding frequently arise in the small bowel (sb), until now considered as the ''dark continent''. conventional barium contrast studies allow only a limited evaluation of sb, whereas angiographic diagnosis is strictly related to active bleeding. the introduction of capsule endoscopy (ce) as well as of crosssectional imaging dedicated to the sb visualisation, such as multidetector-row computed tomography enteroclysis (cte) and magnetic resonance enteroclysis (mre), represents significant technological advances that have overcome the limitations of older diagnostic tests. although ce is recommended as a first-line investigation in ogib patients, cte or mre are alternative diagnostic tools when ce is contraindicated due to suspected/known obstruction or stricture. moreover, in patients in whom a tumour is suspected, cte or mre may be the preferred initial test. therefore, radiologists have to be familiar with cte and mre techniques, in terms of bowel distension, scanning parameter selection, contrast administration as well as with specific imaging findings. similarly, they have to be aware of the potential pitfalls such as suboptimal bowel distension, artefacts due to peristalsis or breathing, intraluminal food debris and previous surgery. learning objectives: . to understand the causes of gi bleeding and underlying pathophysiology. . to appreciate the strengths and limitations of the imaging techniques used in diagnosis. . to learn about common pitfalls in diagnosis. dilatation. presently, ct takes a major place in this setting with a reduced role for plain films. sonography is an alternative method when ct is not recommended. the questions of mondor in were pointed before the advent of cross-sectional imaging; these are still valid and have to be answered: ) is this a true occlusion (how to differentiate it from adynamic ileus)? ) does the obstruction concern the small bowel or the colon (impacting on the decision to operate or not)? ) what is the cause of the obstruction? ) are there signs of bowel ischaemia? the key points to avoid missing imaging diagnoses in bowel dilatation are to make the distinction between true mechanical obstruction and adynamic ileus (an early sign of mesenteric infarct) and to detect signs of strangulation leading to ischaemia (such imaging findings are present despite normal blood tests). in this setting, ct is the preferred technique; if it is not available, plain films and sonography can help in an optimal medical decision. the national lung screening trial (nlst) found a % reduction in lung cancer mortality with three annual screens using helical ct relative to chest xray. the us preventive services task force has issued draft recommendations to provide annual ct screening to high risk individuals defined by age and smoking criteria. questions remain regarding the implementation of ct screening: the determination of risk to identify those who should be screened, the frequency and duration of screening, definitions of screen positivity based on detected nodule characteristics, diagnostic algorithms for the follow-up of positive screens, overall societal costs of screening, and methods to adequately diffuse this technology across all socioeconomic groups at risk. answers to these questions are being addressed by several groups through ongoing research and secondary analyses of trial data. several models exist to identify individuals at highest risk of lung cancer (and lung cancer mortality), which may be enhanced if validated molecular markers are included. ongoing analyses of nodule features and likelihood of lung cancer will better inform screening interpretation guidelines and diagnostic algorithms. estimates from the nlst suggest that screening as performed in the nlst will be cost effective: the base case estimates $ , per quality adjusted life year gained (qaly). subset analyses suggest that screening is much more cost-effective in women than men, in higher versus lower risk groups, and in current versus prior smokers. while several variables influence cost-effectiveness, major drivers of cost are the cost of ct screening exams as well as the number of follow-up ct scans per positive screen ( . in nlst). while the national lung screening trial (nlst) had shown a significantly reduced lung cancer-specific mortality and all-cause mortality, the current results from the various european trials do not show such positive results. the dutch-belgian nelson trial, the german lusi trial and the british ukls have not yet published their results. so far, more cancers were detected in the screening arm of published danish and italian trials, but the positive effect on cancer mortality could not yet be shown. the italian mild trial even showed higher mortality in the yearly screening arm, and no difference between yearly screening and the control arm. this presentation discusses the implications of these findings and the consequences on implementation on screening in clinical practice. while limited in number of participants, european trials used advanced approaches that are most likely to be used if screening will ever be implemented. this presentation will discuss issues such as growth assessment and volumetry as critical factors for nodule assessment, handling of sub-solid lesions, computer aided detection and evaluation, and use of nonradiologists for reading and standardised follow-up. the goal is to provide an insight into how the european trials have affected our idea on practical implementation of lung cancer screening. the discussion will address the following issues: . are there sufficient data to support the implementation of individual lung cancer screening in clinical practice? . if yes, how to move from efficacy to effectiveness: what are the most optimised risk profiles for screening? what is the minimum level of infrastructure support and organisation required? how should subjects be informed about screening? what are the optimal follow-up duration and screening interval? what are the technical and positive screen management requirements? . what about the alternatives of waiting for additional data from ongoing trials or the validation of new biomarkers of lung cancer, permitting better selection of screened population before implementing individual lung cancer screening? attendees' opinions will be collected interactively. the speakers will be asked to comment and debate. treatment of prostate cancer depends strongly on the stage of the disease at the time of detection. however, treatment is controversial, even in prostate cancers found through early detection. this presentation will be based on a careful recent literature review. early detection of prostate cancer by use of psa testing leads to a significant reduction of at least % of disease-related mortality in screened men. this is however at the price of - % of overdiagnosis, usually resulting in overtreatment. diagnostic developments which reduce overdiagnosis and the proper identification of cases which may not require treatment are central issues of current research and will be addressed by referring to available evidence. active observation of potentially nonaggressive cancers is an option in the management of this disease until, preferably, the diagnosis of such cases can be avoided all together. radical prostatectomy and radiotherapy are the options for treating those cancers which are judged to be aggressive. treatment recommendations for prostate cancer continue to evolve and are affected by technological advances in surgery, new discoveries in tumour biology, and the development of predictive and prognostic biomarkers. with the increased complexity of treatment decision-making, the role of mri is also evolving. the more individualised and targeted the treatment approach, the greater is the role of imaging in treatment selection, planning and follow-up. mri is especially crucial for planning technologically sophisticated treatment approaches such as robotic surgery, igrt, or focal therapy and in assessing patients' eligibility for active surveillance. though needs for uniform interpretation and standardised reporting remain unresolved, the value of mri in pretreatment staging of prostate cancer, particularly for evaluating extracapsular extension and seminal vesicle invasion, has been documented. not only the tumour stage, but also its size, volume and grade (aggressiveness) are important factors that influence treatment selection. therefore, the introduction of functional mr is essential. when added to t weighted mri, diffusion-weighted mri, dynamic-contrast-enhanced mri, and mr spectroscopy, in addition to improving tumour detection, can provide an indication of tumour aggressiveness. mri performance on all sequences is dependent on lesion size/volume and grade, and this should be considered when applying mri results to treatment selection and planning. while it has been shown that multiparametric mri is generally more accurate and informative than anatomic mri alone, evidence-based guidelines specifying which combinations of sequences are essential for specific indications in patients with prostate cancer are yet to be developed and validated in welldesigned studies with robust outcome measures. in major trauma, it is essential to immediately recognise life-threatening conditions and to initiate early treatment. the majority of these patients succumb at the site of the injury to severe injuries of the central nervous system, heart and great vessels. however, there is another peak of early deaths within the first four hours after the injury. in the majority, these patients are at risk due to haemorrhage which is basically controllable by early minimally invasive treatment. consequently, this means that the vast majority of internal injuries can be survived as long as bleeding control is achieved within the first four hours after an injury. minimally invasive interventional techniques are already in use at a very early stage of the clinical decisionmaking process. particularly, we have witnessed a major paradigm shift in the treatment of blunt aortic injuries. endovascular repair has replaced open repair in many trauma centres. in appropriately selected patients, this adoption of endovascular stent grafts has resulted in a reduction in perioperative mortality, stroke and paraplegia, as compared to open repair. this entire session will provide knowledge about indications, requirements, standard procedures, and outcome of vascular emergencies, pardon me, urgencies. a. aortic emergencies m. cejna; feldkirch/ at (manfred.cejna@lkhf.at) aortic emergencies can be classified into several categories. "acute aortic syndrome": acute aortic syndrome is an entity of changes of the aortic wall. these include aortic dissection, intramural thrombus, and penetrating atherosclerotic aortic ulcer. besides coronary malperfusion and aortic valve insufficiency (type a dissection), emergency presentation is often due to visceral/limb ischaemia. sequelae of aortic syndromes are pseudoaneurysm formation and potentially aortic rupture. endovascular treatment has been established as the treatment option in at least type b dissections and penetrating aortic ulcers. aortic aneurysm rupture: with increasing diameter, aneurysms in the thoracic, thoraco-abdominal and abdominal aorta are prone to rupture. signs of impending aortic rupture are pain and imaging signs are sometimes subtle just like blurred contours of the aorta and (blister like) vascular wall deformation. endovascular treatment is an alternative to vascular surgery. aortic trauma: in severe thoracic trauma (mostly deceleration trauma), pseudoaneurysm formation and aortic rupture occur at the level of the aortic isthmus. endovascular treatment is considered the treatment of choice. inflammation, mycotic aneurysms and aorto-enteric fistulae: with acute and chronic inflammation, aneurysm and pseudoaneurysm formation and fistulae to enteric structures can occur. endovascular treatment is more often considered as bridging to vascular surgery instead of being a definitive cure. iatrogenic aortic injuries: besides accidental aortic injury during operations or interventional procedures, transaortic valve replacement and placement of aortic balloon pumps can result in iatrogenic trauma. endovascular treatment may be a minimally invasive approach. the focus will be on systematic presentation of aortic emergencies and the role of endovascular treatment. there are a number of vascular visceral emergencies that may be traumatic or nontraumatic in origin. the degree of urgency or potential for urgency varies with each condition and the subsequent management and intervention techniques will vary accordingly. an understanding of the natural history, pathophysiology, diagnostic tests and interventional techniques for these conditions will aid the diagnostic and interventional radiologist in identifying the pathology and knowing when to refer or initiate definitive treatment. i talk about embryonal development and anatomical differentiation of cardiovascular system, with special attention to the peripheral vascular system. the goal of this part of presentation would be to understand the anatomical structure and architecture of arteries and capillaries. we will discuss the casual classification of different kinds of peripheral arterial emegencies; e.g. congenital, posttrauma, arteriosclerotic and iatrogenic. the audience will learn about different therapy approaches, interventional and non-interventional, with accent on pad (classification, pathophysiology, risk factors, statistical facts and therapy). at the end, we will review different studies about combination therapy (conventional and interventional) with different possibilities and outcomes. modern cancer research and increasing therapy are mechanism based with the development of disease-modifying therapies that target the hallmarks of cancer. modern imaging tools enable the visualisation and quantitative assessment of the expression of molecular targets, of their interaction with potential ligands, as well as of the functional consequences of interactions at a molecular, cellular, metabolic, physiological, and morphological levels in a temporo-spatially resolved manner. the ability to gather such information from the intact organism renders imaging highly attractive for biomedical research and drug development. the determination of cell proliferation with radiolabelled thymidine is a wellestablished method in various life science branches where [ h]thymidine has been used for more than years and still represents the gold standard for the assessment of tumour cell proliferation. since non-invasive determination of this parameter is required in clinical studies, considerable efforts have been made in radiopharmaceutical research. the synthesis of a large series of proliferation markers resulted therefrom mostly focussing on pyrimidine nucleosides. the labels used were gamma as well as positron emitting radionuclides. here, [ f]flt ( '-deoxy- '-fluorothymidine) is examined and discussed with respect to its preclinical and clinical application. since apoptosis is an important mechanism of cell death in tumours responding to treatment, the non-invasive assessment of apoptosis with tracers for the detection of phosphytidyl-serine presentation and/or caspase activation could be used as surrogate marker for therapeutic efficacy. several approaches have been followed during the last years; their potential and limitations will be presented. angiogenesis is one of the hallmarks of cancer that is considerably easy to characterise with many different imaging modalities and methods. it is not only crucial for invasive and metastatic tumour growth, but is also a prerequisite for the accumulation of anticancer drugs and highly impacts the success of radiotherapy. this talk summarises our experiences in microstructural, functional, and molecular imaging of tumour angiogenesis. the microarchitecture of vessels can longitudinally be studied using high-resolution ( )ct. dce mri and hf-us are introduced as favourable tools to characterise perfusion, vessel permeability and vessel maturation during antiangiogenic treatments. using targeted probes, it is shown that "fluorescence molecular tomography (fmt)", mri and us are capable of estimating the expression of angiogenic marker molecules on tumour vessels and of matrix-associated enzymes in the interstitial space during vascular remodelling. additionally, examples are also given for epr-based nano-sized theranostics and it is shown how us can aid in better accumulating them at the target site by inducing vascular permeation. many of these novel imaging concepts and tools can relatively easily be translated into clinics. thus, one can expect them to play a major role in the clinical management of tumour treatments soon. mammography technique from the point of view of radiographic compression and positioning is no different from film screening and radiologists ignore this at our peril. we will discuss the danger areas at the edges and the back of the breast and help you to find lesions only seen on one view. with digital capture the technologist can view images immediately, but the temptation is for them to repeat exposures to obtain radiographic perfection on otherwise clinically acceptable images. however, the task of assessing quality cannot be left to them, as viewing conditions on the 'lower resolution' acquisition monitor in a bright x-ray room is not enough. there is now evidence from population screening programmes that poor image quality can reduce cancer detection from between % in france to % in ontario. 'quality' can be lost at keys points in the imaging chain: the x-ray beam and dose, the detector and finally display. in flanders, poor detector performance was compensated for by increasing the x-ray dose by % and by meticulous quality control. postprocessing is less well understood, but reader studies now show different algorithms will affect performance particularly for the detection and classification of micro-calcification. finally, it does not matter how good all the equipment is if we try and read the images with the lights on full. mammography is the most important breast imaging technique allowing the visualisation of masses and micro-calcifications. however, in conventional mammography the three-dimensional breast tissue is reduced to a twodimensional image. therefore, small lesions may be undetectable due to superimposed glandular tissue. digital breast tomosynthesis (dbt) has emerged as a new imaging modality to overcome this limitation. several lowdose mammographic projections are performed over a limited angle of up to degree using a standard mammography system. the average glandular dose of a tomosynthesis scan is somewhat higher compared to one-view mammography, but lower compared to a standard mammography in two projections. based on the low-dose projections, a stack of cross-sectional images covering the entire breast is reconstructed with an interslice distance of about mm. several studies have shown that tomosynthesis improves both tumour detection and the characterisation of focal masses. due to the crosssectional nature of dbt, the techniques allow on the one hand the reliable differentiation of true focal masses from summation artefacts. on the other hand, tomosynthesis improves the detailed analysis of the lesions' border to differentiate benign lesions and carcinomas. additionally, contrast-enhanced spectral tomosynthesis may allow analysing signal-intensity time curves. in conclusion, dbt adds important information to standard two-projection mammography and can replace spot compression and rolled views as problem solver for difficult cases. however, the impact of tomosynthesis on breast cancer screening has to be investigated in larger clinical trials. reading screening mammograms is not the same as reading diagnostic mammograms. the vast majority of women attending a screening programme are usually asymptomatic and do not have abnormalities associated with a malignancy. the task of a mammogram reader is to scan a mammogram and perceive any possible abnormalities that could be associated with a malignancy. in other words, we are talking about perception and not diagnosis of a finding. examples will be shown about this crucial step. in modern population-based screening programmes, we use computerised reading and recording systems. since the work flow is rather quick, we have to ensure basic steps such as identity control and see that both ris and pacs are synchronised so that decisions of screening readings are recorded in both the systems of one and the same patient. in computerised screening programmes, we use standard reports informing a woman that no signs of malignancy have been detected on her screening mammograms. in case of findings that need further assessment, there are several ways to deal with this situation. the most common way is via a phone call, but this can also be done with a letter. a screening report should be short and concise and should only inform whether we see signs of a possible abnormality that can be associated with a malignancy. extensive reports describing the contents of a breast or findings of no clinical relevance should not be part of a screening report. emergency radiology services are very much on the rise in the last decade. medical emergencies and trauma are of enormous importance and a leading cause of death in all age groups. the use of radiological imaging in emergency departments showed an exponential increase since the s. the annual growth rate in ct is - % per year depending on the institution. even for advanced level ° medical centres running an own emergency radiology unit, it is a challenge to integrate advanced radiology services in an interdisciplinary team treating patients with acute traumatic and non-traumatic emergencies. general principles: radiology and radiological imaging procedures should be integrated in an interdisciplinary team. imaging should be guided by interdisciplinary clinical algorithms or guidelines (e.g. nexus or canadian cspine rule). many clinical diagnoses relay today on a early and thorough initial radiological diagnostic workup -mostly based on mdct. emergency radiology (er) is still a relatively young subspecialty in european radiology -it deserves specific training. the lecture will cover: the development of emergency radiology and its future perspectives; the use of conventional radiography, ultrasound and mdct; logistics and management of the patient; clinical guidelines and mdct in the primary patient survey (e.g. using atls for trauma) and advanced scanning protocols for mdct. infants and children with abdominal emergencies present special diagnostic challenges because of similarities in clinical findings between various paediatric conditions. imaging is frequently a critical part of the diagnostic process, but the choice of the best imaging modality can be controversial. patient age and safety issues such as radiation exposure must be taken into consideration when planning imaging. because certain pathologies are more likely to occur in specific age groups, patient age is a primary determinant of the imaging approach. this presentation will illustrate the differences in pathology between several paediatric age groups and discuss effective imaging algorithms for congenital and developmental, inflammatory, and obstructive conditions. the optimal use of radiographs, ultrasound, ct, and mri will be discussed. pitfalls that should be avoided in ultrasound and ct will be emphasised. in diagnostic imaging, we tend to focus on radiation protection, justification and optimisation, as the primary opportunity for radiographers and radiologists to ensure the safety of patients, both adults and children; however, this ignores some other important issues. this session aims to raise awareness amongst medical imaging professionals of some key considerations in relation to a number of child protection issues. when imaging a child in case of suspected non-accidental injury, every detail of that examination from conversations with the child and their parents or guardians, technical aspects of the examination, observations during the examination and the language used following the examination need to be carefully considered. another area of medical imaging requiring attention is how we communicate any radiation risks associated with examinations or procedures with children and their parents. there is evidence that while consent processes for invasive procedures are usually in place, these often lack focus on the risks associated with a high exposure to ionising radiation. these two medico-legal areas, suspected non-accidental injury and risk communication, are commonly encountered by radiographers and radiologists and as such it is important to make sure that we operate at the highest possible professional standards and in keeping with both regulations and best practice including the production of witness statements/contemporaneous notes. on rare occasions, we may find ourselves involved in legal proceedings as a witness or expert witness and it is thus important that we are all aware of the key considerations in this regard. session objectives: . to appreciate the need for radiographers to focus on more than just the imaging procedure in paediatric examinations. . to understand the extremely vulnerable nature of paediatric patients and the need for all health professionals to pay particular attention to this. a. professional responsibilities: an international perspective m. davis; dublin/ie (michaela.davis@ucd.ie) radiographers play a vital role in imaging children with suspected nonaccidental injuries. this session will also explore the wider role that radiographers have in child protection. current legislation and its implications will be explored from a variety of countries including those outside europe. in addition, case studies will be presented focussing upon child protection issues that have arisen in the x-ray department during imaging procedures. several of the barriers to radiographers becoming involved in child protection will be explored. radiographers and their contribution to child protection will be discussed and practical examples given. learning objectives: . to become familiar with current legislation and guidelines which have particular relevance to radiographers from an international perspective. . to appreciate best practice in child protection and the need for all radiographers to be aware of this. . to learn about child protection case reports involving imaging, radiologists and radiographers. a- : b. risk communication in paediatric examinations j.l. portelli; msida/ mt (jonathan.portelli@um.edu.mt) medical imaging plays a vital role in the diagnosis and treatment of numerous medical conditions for millions of patients worldwide. however since most medical imaging examinations utilise ionising radiation, the associated risks of radiation exposure also need to be acknowledged, especially since high doses of radiation are known to cause adverse biological effects. medical imaging professionals should have a good understanding of the benefits and risks associated with the imaging examinations they perform, so as to ensure a high benefit-risk ratio for all patients undergoing diagnostic imaging procedures, and to be able to appropriately communicate such information to patients, their families and other healthcare professionals. this may be particularly more important when imaging paediatric patients, who are relatively more susceptible to the effects of radiation and receive a higher effective dose per unit of radiation when compared with adults undergoing the same medical imaging examination. indeed, following worldwide media attention about radiation incidents and their adverse effects, some parents/legal guardians may be concerned and reluctant to pursue important medical imaging examinations requested for their child, as they may have a misconception of the risks involved. in this regard, this lecture will seek to enhance awareness about the radiation doses associated with common paediatric imaging examinations; highlight the importance of medical imaging professionals having an appropriate understanding of benefits and risks associated with these examinations; and encourage such professionals to improve patient care by making use of this knowledge to have better discussions with referring clinicians, patients and their families. learning objectives: . to appreciate the frequency and radiation dose associated with certain paediatric imaging examinations. . to become familiar with the current status quo in the communication of radiation dose-related risks. . to understand best practice and potential considerations in providing accurate information to referring clinicians, patients and their families. c. what to do if you find yourself being called to give evidence m.d. viner; london/uk radiology is a powerful tool in the investigation of cases of suspected nonaccidental injury and suspicious death in children. the evidence obtained can be pivotal in bringing successful prosecutions against suspects and protecting the child and others from further harm. it is essential that evidence is obtained, recorded and presented in accordance with applicable rules of evidence in order to be admissible in court. it is thus important that those undertaking such examinations are appropriately trained, conversant with standards of evidence and maintain continuity of evidence throughout the investigation. this presentation will review rules of evidence for cases of suspected child abuse and their application to imaging examinations. it will examine the role of the radiographer and the importance of training and familiarity with legislation and guidelines that underpin forensic practice, highlighting the pitfalls that lawyers may exploit if procedures have not been followed. drawing on examples, it will discuss best practice from the radiographer's perspective, detailing the importance of continuity of evidence and maintenance of contemporaneous notes and witness statements. it will address key considerations for radiographers and others who provide evidence or act as an expert witness. imaging professionals play a pivotal role in the investigation of suspected child abuse. it is essential that this evidence is obtained, recorded and presented with regard to the applicable standards of evidence. for those called to give evidence, the importance of appropriate imaging protocols and procedures, detailed documentation and thorough preparation cannot be understated. learning objectives: . to understand the importance of contemporaneous notes and witness statements if involved in any forensic or suspected non-accidental injury examination. . to become familiar with the importance of continuity of evidence in forensic examinations. . to appreciate the key considerations if you are asked to provide evidence or act as an expert witness in court. brain tumours are the second most common neoplasms in children after leukaemia. as "paediatric brain is not just a small brain", paediatric brain tumours are not the same as tumours in adults. mri is a method of choice in their diagnosis in accordance with the principle alara in the paediatric population. by the age of approximately years, supratentorial tumours dominate; later ( - years of age), the majority of children show infratentorial neoplasms which are pilocytic astrocytomas, most often found in the hemispheres, and medulloblastomas or ependymomas -in the fourth ventricle. after the age of , both groups are diagnosed with equal frequency. cerebral hemispheric tumours include astrocytoma which is the most frequent, teratoma in neonates, and in older children atypical teratoid/rhabdoid tumour, ependymoma, pnet, ganglioglioma and dnet. in the midline, we deal with chiasmatic or hypothalamic glioma, craniopharyngioma and germ cell tumours of the pineal region. extraparenchymal tumours are uncommon in the paediatric population. apart from the location, imaging pattern in various sequences, and contrast enhancement of the tumour, advanced mri techniques are helpful in establishing the diagnosis. dwi helps to differentiate between tumours of high and low cellularity showing low adc values in case of medulloblastoma and high in astrocytoma. mrs, pwi and dti also add important information to the diagnosis. mri of the spinal canal is obligatory in case of these primary brain neoplasms that have a high propensity to metastasise to other parts of the central nervous system such as medulloblastomas, ependymomas, high-grade gliomas, cerebral neuroblastomas, and pineal region neoplasms. learning objectives: . to learn about the difference between paediatric and adult brain tumours. . to understand the imaging strategy for the paediatric population. . to become familiar with the most common paediatric brain tumours. pancreatic endocrine tumours (p-nets) include both pancreatic neuroendocrine tumours associated with a functional syndrome (functional p-nets) and those associated with no distinct clinical syndrome (non-functional p-nets). non-functional p-nets may show immunohistochemical positivity for hormones which may be produced, but not secreted, which are clinically inert and whose serum concentrations are insufficient to induce symptoms. among functional p-net, the most common are gastrinomas and insulinomas, whereas those secreting vasoactive intestinal peptide, glucagon, somatostatin and other hormones are considered together as a group called rare functional p-nets. non-functional p-nets are classified, according to the who classification, in well-differentiated neuroendocrine tumours and poorly differentiated neuroendocrine carcinomas (necs) of small or large cell type. well-differentiated neuroendocrine tumours are then divided according to a grading scheme based on mitotic count or ki index in nets-g (with a mitotic count < per high-power fields (hpf) and/or % ki index), and nets-g (with a mitotic count - per hpf and/or - % ki index). all poorly differentiated neuroendocrine carcinomas are graded g (with a mitotic count > per hpf and/or > % ki index). most pancreatic nonfunctional p-nets are well-differentiated tumours, whereas poorly differentiated neuroendocrine carcinomas are uncommon. pancreatic endocrine tumours (p-net) are divided into functional p-nets and non-functional p-nets. diagnostic imaging of these tumours includes detection, characterisation and staging. there are significant differences when dealing with functional p-nets and non-functional p-nets. in fact, in the first case the main aim of diagnostic imaging modalities is the detection of the tumour, while for non-functional p-nets the main aim is the characterisation and the differential diagnosis with other tumours of the pancreas, mainly with pancreatic adenocarcinoma. staging is also important for both tumours, but mainly for non-functional p-nets. a large number of imaging modalities are available, both "morphological" and "functional". we can arbitrarily divide the imaging modalities for the diagnosis of p-nets into three levels: the first level includes us (with contrast-enhanced us), mdct, mri and nuclear medicine techniques; the second, endoscopic us, angiography and venous sampling; the third, intra-operative us. functional p-nets are represented mainly by insulinomas and gastrinomas which are small in size in most cases. their detection is still difficult, but significant improvements have been made with us, mdct and mri, so that these tumours are detected in most cases if appropriate imaging techniques are performed. however, still, no single modality is % effective. non-functional p-nets can be differentiated from pancreatic adenocarcinoma, since they are hypervascular and usually large in size. since they are potentially malignant, they require accurate staging by imaging modalities, both morphological (mdct, mri) and functional (pet/ct) to plan surgery and chemotherapy. there is worldwide consensus about surgical treatment of resectable p-nets in the following clinical situations: proven malignancy, whenever it is possible to remove the primary tumour and at least % of liver metastases (debulking); p-nets associated with a clinical syndrome caused by hormonal hypersecretion (insulinomas and gastrinomas mainly); non-functional p-nets with a size larger than cm. vice versa, there are different expert opinions about the surgical treatment of functional and non-functional p-nets in men syndromes and in sporadic non-functional p-nets less than cm in size. in men all insulinomas should be resected, while for gastrinomas the extent of resection is patient tailored, deserving standard whipple for selected cases. in the most common sporadic small incidentalomas, where long-term prognosis is favourable, surgical treatment has to be weighted with co-morbidities and morbidities of the patient and the procedure planned. these tumours have a risk of node metastases at the time of diagnosis in less than % of patients. whenever possible, mini-invasive approach with pancreas-sparing operations should be recommended. in elderly patients, a first period of follow-up should be preferable and surgery should be offered only if the size of the tumour demonstrates increasing trends. the "acute aortic syndrome" includes three closely related emergency entities of the thoracic aorta: aortic dissection, intramural hematoma and penetrating atherosclerotic ulcer. as these conditions present with similar symptoms, cross-sectional aortic imaging is essential for diagnosis, triage and treatment planning. initial imaging features of these pathologies including typical early complications as well as their differential diagnosis will be reviewed. as nowadays several of these patients will undergo early endovascular thoracic aortic repair, an update on its indication, the different technical options and their clinical results will follow. finally, the focus will be on repair-related late complications and progression of aortic disease. imaging follow-up protocols, features of chronic complications and their interventional repair will be discussed. a. pre-therapeutic radiological evaluation j. ferda; plzen/cz (ferda@fnplzen.cz) the acute thoracic aorta syndrome covers patients suffering from acute chest pain and those injured during high-energy trauma. despite the similar symptoms, the aortic pathologies are heterogeneous, including acute aortic injury, intramural haematoma, aortic dissection, and ruptured thoracic aortic aneurysm and mycotic aneurysms. the diagnostic approaches could include the whole pallete of the imaging modalities: chest x-ray, transesopheageal echocardiography (tee), multidetector ct angiography (mdcta), mri and pet/ct. because of some disadvantages of tee, like problems with intubation in injured patients or problems of mri with seriously ill patient monitoring, mdcta has become the most used modality due to its ability of discrimination between aortic and non-aortic pathologies, and also due to its high sensitivity, specificity, availability and especially superior geometrical resolution and potential of d imaging. the proper pre-therapeutic mdcta protocol is using sub-millimeter isotropic resolution covering the entire aorta with pelvic arteries. when the pathology of thoracic aorta is found during the triple rule-out triage protocol, additional mdcta of the rest of the aorta and pelvic arteries has to be completed. ecg triggering could be an important advantage in the reduction of pulsation-derived artefact. the volume of applied contrast material used should be as small as possible to plan applications during endovascular treatment. d reconstruction of the thoracic aorta with its side branches and advanced vessel analysis have a crucial role in the measurement of the aortic diameter, diameter profile and lengths in the selection of proper stent graft type and size. they can be accommodated even in patients with small vessels and tortuous anatomy. calcified arteries can be no longer considered absolute exclusion criteria. some devices are designed to reduce the incidence of endoleaks, improving sealing capabilities by the use of a polymer to better adjust to the variable morphology of the proximal neck or to fill the aneurysmatic sac completely. more importantly, the introduction of fenestrated devices has resolved the problem of facing difficult anatomies when the aneurismatic pathology involves renal or visceral arteries. obviously, the use of these new devices requires a learning curve. beyond an increase of cost, they permit treating those patients who in the past were considered unfit candidates for evar. the evar new frontier requires performing the procedure in an outpatient fashion. a multicentre study was conducted on patients who were discharged / hours after uncomplicated stent-graft implantation. cases ( %) with access vessel complications required additional procedures and patients were hospitalised overnight. the -day readmission rate was % for access vessel stenosis or false aneurysm. from the time of the first evar procedure, significant improvements have been achieved but there is still room for further progress. the standard imaging modality after endovascular treatment for thoracic aortic pathology (tevr) is ct angiography (cta). cta enables the radiologist to assess for the patency of the endografts, the presence of any complications after tevr, and the development of any new pathology related not only to the aorta, but elsewhere above and below the diaphragm. the role of mr is reduced compared with cta, particularly in the presence of stainless steel endografts. however, good images can be obtained by mri and mra if nitinol endografts have been inserted. mr is a useful modality for follow-up in young patients who require lifelong follow-up and, therefore, limited exposure to ionising radiation. ultrasound has no practical role in the follow-up after tevr, and although plain thoracic radiographs are routinely performed by some centres post-tevr, in practice almost equivalent information can be obtained by ct. the main complications after tevr are endoleaks, type a dissection, paraplegia and stroke. the classification of endoleaks is similar to the classification for evar. type and type endoleaks require treatment by additional endograft coverage with or without supraaortic or visceral artery bypass. other treatment options include the use of branched, fenestrated endografts or the use of chimneys and snorkels. type endoleaks are less common than post-evar. similar to the evar population, intervention is mandated for an enlarging aortic diameter and involves embolisation in most cases. interventional oncology is a discipline that uses imaging-guided procedures in the treatment of cancer patients. when the malignant disease in not curable, interventional techniques such as biliary and oesophageal stenting can provide useful palliation and improve the patient's quality of life. in patients with potentially curable tumours, thermal ablation, cryotherapy and radioembolisation provide useful alternatives to radiotherapy and surgery in carefully selected patients. interventional radiologists who treat patients with cancer should practise as clinicians, participating in multidisciplinary meetings where treatment choices can be discussed with specialists from other oncological disciplines. they should involve themselves in all stages of clinical practice, including pre-treatment consultations, ward rounds and patient follow-up. radiation oncology and interventional oncology have much in common, including the potential for curing cancer using minimally invasive techniques. interventional oncologists can usefully adopt many of the principles and methods of practice in radiation oncology, including quality assurance and the collection of robust outcome measures. an alliance between these disciplines would be beneficial to clinical practice and research in both disciplines. session objectives: . to understand the contribution of interventional radiology to oncology. . to appreciate the areas of overlap between radiation oncology and interventional oncology. . to understand the need for a clinical pattern of practice in interventional radiology in oncology. the current scope and future challenges j.i. bilbao; pamplona/es (jibilbao@unav.es) together with chemotherapy, surgery and radiotherapy, interventional radiology (ir) is the fourth pillar in oncology. transcutaneous and endovascular procedures, guided by imaging, constitute a fundamental knowledge essential for the multidisciplinary management of oncologic patients. the range is wide and covers most of the needs in patient´s care. in short: obtaining samples for making an accurate diagnosis and also to know more about its specific biology (biomarkers); ir covers any possibility needed for vascular access; percutaneous needle ablation is the best alternative in selected patients; endovascular embolisation with "vehiculisation" of therapies is an outstanding method for selective treatment, and sometimes precise ablation, of different tumors; ir is a unique way to offer palliation in a wide range of tumoral complications, such as embolisation for bleeding, stenting for vein obstructions or drainage of fluid collections. there is an obvious need of continuous technical refinement. image-guided therapy is a continuous process that implies many disciplines and that includes every step, from staging through guidance of the procedure to the evaluation of the outcomes, both immediately, during and in the follow-up. future developments in ir may be focused towards the personalisation of therapies to each patient and to a better understanding of the biological mechanisms of tumour response or progression and their image expression. finally, radiologists must be actively involved in the whole process of clinical trials, from the creation of new lines to the performance of therapy until the evaluation and diffusion of the data. radiation treatment has a fundamental role in the multidisciplinary management of people with cancer. the evidence base for radiation therapy is robust and approximately % of people diagnosed with cancer will benefit from radiation treatment. most of this benefit comes from an increase in cure. the technical quality of delivery of radiation treatment is of great importance in avoiding a geographic miss and also in reducing the amount of normal tissue being irradiated unnecessarily. as well as the excellent technical delivery of any treatment offered, of paramount importance is the intelligent integration of care with attention to evidence base choices for both local and systemic treatment. multidisciplinary teams are in the best position to integrate surgery, radiation treatment, interventional oncology and systemic therapy in a planned and deliberate fashion. best practice: how to organise an interventional oncology unit a. gangi, j. garnon, g. tsoumakidou; strasbourg/fr (gangi@unistra.fr) interventional oncology is a fast growing field. interventional oncology is a clinical and technical speciality. solid clinical knowledge associated with the technical skills is mandatory for a successful practice. the technical skills should be associated to the clinical part. the knowledge of all treatment modalities and the participation of a multidisciplinary team is vital for the best practice. every single patient should be seen by the interventional oncologist and followed-up. the interventional oncologist is part of a multidisciplinary team, taking care of the patient. the team includes oncologists, radiotherapists, pain specialists, psychologists, surgeons, and anesthesiologists. the interventional oncology unit should include specialised nurses, technician, anesthesiologist, anesthesiologist nurses, and the interventional radiologist. the team should be able to take care of the patient's follow-up and eventual complications. to summarise, high-quality interventional oncology services are essential for safe and effective patient care. the technical skills of the interventional oncologist should be associated with an excellent clinical knowledge of the disease. a multidisciplinary team work is mandatory for a successful interventional team. harmonisation of training and appropriate credentialing is required for clinical services of the best quality. interventional radiologists continuously improving their skills and knowledge, patient access to safe and effective minimally invasive treatment options is increasing. whereas cardiac ct and mri are routine examinations for specialised radiologists, it has been necessary to wait for the introduction of fast scanning techniques to modify the behavior of nonspecialised radiologists regarding the interpretation of cardiac cavities. the objective of this session is twofold. first, cardiac radiologists will underline the role of these imaging modalities in the assessment of congenital heart disease but also in ischaemic and nonischaemic cardiomyopathies. in the second part of this session, chest radiologists will focus on the diagnostic information accessible at the level of the right ventricle, known to be the target of numerous respiratory disorders. two practical situations will illustrate this approach: pulmonary thromboembolic and chronic respiratory diseases. accurate assessment of the right ventricle (rv) is crucial for the management of congenital heart disease. echocardiography can provide some information, but as the rv sits directly behind the sternum and as many patients have undergone multiple operations, visualisation can be difficult. furthermore, for long-term follow-up and treatment planning, accurate measurement of ventricular size and mass, and valvular flow (tricuspid and pulmonary), and assessment of anatomy in d and d are vital. this presentation will outline the role of cross-sectional mri and ct for assessing the rv, and describing the indications, imaging protocols, technical pitfalls and relevant information for treatment planning. right heart failure in ischaemic and non-ischaemic cardiomyopathies m. grothoff; leipzig/de (matthias. grothoff@herzzentrum-leipzig.de) the role of the right ventricle (rv) has been underestimated for many years. today, we know that the rv is of importance for keeping up a sufficient circulation and that right heart failure in both ischemic and non-ischemic cardiomyopathies can result in hemodynamic compromise. rv ischemia has a higher in-hospital morbidity and mortality but post-infarction chronic right heart failure is a rare finding. as the rv has a different physiology from the left ventricle (lv), also the pathophysiology of ischemia is different here. using our standard cmr tools t weighted imaging for detection of edema and late gadolinium enhancement imaging for detection of necrosis/scar we can find that the rate of myocardial salvage is much higher in the rv than in the lv and that rv failure in the acute phase is basically caused by reversible ischemic effects. in non-ischemic cardiomyopathies like hcm and dcm changes in the rv myocardium mostly resemble changes of the lv. in arrhythmogenic right ventricular cardiomyopathy/dysplasia (arvc/d) however, there are specific findings in the rv and the role of imaging in diagnosing arvc has been strengthened by the revised task force criteria published in . cine imaging should be performed carefully for detection of rv akinesia, dyskinesia or small aneurysms as well as the planimetry of the rv. findings like the detection of fibrosis in lge imaging and the detection of fat in t imaging can provide additional information, but are not diagnostic for arvc. learning objectives: . to learn about the different ct and mri techniques for evaluating right heart morphology and function. . to understand the prognostic impact of right heart involvement in ischaemic heart disease. . to learn about the basic morphological and functional features of different non-ischaemic cardiomyopathies. right heart and chronic respiratory diseases: can ct be used as a onestop-shop? m. remy-jardin; lille/fr (martine.remy@chru-lille.fr) over the last decade, ct technology has evolved towards fast scanning capabilities and high temporal resolution, enabling improved evaluation of the heart and surrounding structures in the course of routine thoracic ct imaging. this has progressively modified the radiologist's implication in the interpretation of chest ct examinations. firstly, it is more and more common to integrate the physiological interactions between heart and lung when analysing the ct features depicted on a given examination. secondly, it is now possible to integrate cardiac functional information into a diagnostic ct examination of the chest, providing prognostic information in the management of patients with a wide variety of chronic respiratory disorders. the purpose of this presentation is to provide non-specialised radiologists with some practical guidelines in the choice of the scanning protocols and range of functional information that can be deducted from chest ct examinations. right ventricular dysfunction and levels of pressure within the pulmonary circulation are the key points of such approaches. learning objectives: . to appreciate the clinical impact of a cardiothoracic evaluation from the same ct examination. . to learn about the scanning protocols enabling such a combined analysis. . to understand its compatibility with other non-invasive modalities. rv and prognosis in pulmonary thromboembolic disease n.j. screaton; cambridge/uk (nicholas.screaton@papworth.nhs.uk) right ventricular failure is the most common cause of early death following acute pulmonary embolism and in patients with chronic thromboembolic pulmonary hypertension. echocardiography is sensitive in diagnosing and quantifying rv dysfunction. ct is the reference standard for the diagnosis of acute pe diagnosis and has the potential to provide comprehensive evaluation of the pulmonary arteries, heart and lung parenchyma. ct signs of right ventricular dysfunction which have shown predictive value for adverse outcome include: flattening of the inter-ventricular septum or bowing towards the left ventricle, reflux of contrast medium into the ivc, relative rv/lv diameter ratios on transverse and -chamber reconstructions, and ventricular volumetry as assessed both on routine non-gated ctpa and ecg-gated ct. in patients with cteph, mri permits imaging of the pulmonary vasculature and functional evaluation of the right ventricle and pulmonary circulation, enabling both morphological assessment and prognostic evaluation. learning objectives: . to learn about clinical and imaging factors associated with prognosis of thromboembolic disease. . to understand the benefits and weaknesses of different imaging modalities in predicting prognosis in thromboembolism. . to discuss the merits of comprehensive imaging evaluation in the routine diagnostic workup of suspected thromboembolic disease. multimodality imaging including ultrasound has within recent years been introduced in several anatomical regions. pet, ct and mri datasets can after an initial co-registration be fused and shown either side by side or using overlay on screen while doing real-time ultrasound; thus, the pet, ct or mri dataset is reformatted in a projection to fit the real-time ultrasound images. several methods of aligning the images are available and have been shown to have a high accuracy. image fusion involving ultrasound has been tested in phantoms, animals and in patient studies, mainly in abdominal imaging. by combining several imaging modalities, it is possible to benefit from the strengths of each modality. it is useful for characterisation of and intervention on liver lesions, abscesses containing air and lesions in areas with poor overview by ultrasound. also, the method is useful for characterisation and biopsy of pet-positive lesions, especially in patients with a history of cancer. the background of the method and clinical examples, mainly from abdominal applications, will be covered. also, perspectives and future research topics will be highlighted. contrast-enhanced ultrasound (ceus) has proved to improve the detection and characterisation of pathologies compared to conventional ultrasound, ct and mri in a number of indications. ultrasound contrast agents (uca), which are purely intravascular, do not show any interstitial diffusion or glomerular filtration like iodinated complexes or gadolinium chelates. dynamic contrastenhanced ultrasound (dce-us) allows to display the enhancement of a lesion with a high frame rate after bolus or infusion administration of uca, and to compare enhancement profiles between normal and abnormal tissue. quantification of dce-us is useful to quantify tumour enhancement and to limit intra-and interobserver variability. mathematical models with several perfusion parameters can be used. dce-us has shown to be of interest after antiangiogenic therapies as it allows an earlier evaluation of tumour response than usually done with ct and mri, which remain mainly based on the recist criteria. the common perception of d ultrasound (us) is of surface-rendered images, especially of the foetus. the same approach, enhanced by new transducer technology and software, can be used to take ultrasonography to another level in general body imaging, providing different image presentations and working practices similar to those of ct and mr. the technology involved in a us volume acquisition was represented initially by mechanical d transducers, and more recently by purely electronic, matrix probes. this latest technology allows bi-plane real-time acquisitions, fast switch to volume acquisition up to degrees, and d acquisitions with acceptable frame rates. protocols have been described for major abdominal and retroperitoneal organs, with fast optimisation of acquisition settings. the technology supports contrastenhanced ultrasound (ceus). after volume acquisition, interpretation for volume us datasets requires a post-treatment phase, including multi-planar reconstruction, multislice imaging, and volumetric analysis. virtual cystoscopy and volume ceus quantification are new options. the implementation of this new, efficient us modality in a radiology department supposes deep changes in the daily practice with delayed post-treatment reporting times. it should represent a more effective way for comparison between different examinations and a better communication tool with clinicians. the proven and potential benefits, in terms of clinical accuracy, training, workflow and overall efficiency, will be discussed. the purpose of this lecture is to emphasise some pitfalls in liver imaging. morphologic changes in the liver are usually attributed to chronic liver disease where liver cirrhosis represents the most important cause. however, noncirrhotic diseases may also induce atrophy-hypertrophic changes of the liver. the most common mechanisms are related to venous obstruction (either portal or hepatic venous) and biliary obstruction. multidetector ct and mr imaging are essential to highlight these abnormalities. when dealing with liver tumours, the most important question that has to be solved is tumour characterisation. yet, it is often difficult to assess whether a large tumour is intra-or extrahepatic. imaging findings that might be helpful will be shown. last, some liver lesions can mimic liver tumors. vascular disorders and focal fatty changes or focal fatty sparing are the most common causes. some other conditions can be also mimickers and such cases will be shown. the technique and the anatomy of the bile duct and pancreatic duct will be described. the anatomical variants of the biliary duct and the pancreatic duct system will be analysed and their possible role in generating diagnostic imaging pitfalls described. strategies to avoid pitfalls in diagnostic imaging of the bile duct and the pancreatic duct system will be illustrated, considering the possible source of pitfalls. diagnostic imaging findings of different diseases involving the biliary ducts and pancreatic duct system will be illustrated, as well as the diagnostic imaging criteria useful for the differential diagnosis. over the last two years, the number of ct and mri units has increased by %, and modern pet centers and leading centers for radiotherapy have been built. we can identify an approximately % increase in the number of radiological research projects--mainly ultrasound, ct, and mri investigations. during the last ten years the total number of vascular interventions and mr studies has increased by ten times, four times for ct, and the annual growth of us and x-ray investigations is about %. unfortunately, these technical innovations are not always accompanied with pacs and ris installations; this is a reason why all advantages of digital equipment are not achieved. we see rapid development of private medicine; new private hospitals and ambulances have grown by more than % and investment companies are looking for new projects in this field. however, the professional education of radiologists is not enough to work with new diagnostic equipment. this is a reason why in we will start a pilot project to create a new system of continuing medical education in clinical medicine, including diagnostic radiology. we hope, this pilot project will increase the efficiency of clinical practise. differential diagnosis (dd) including tumour and non-tumour brain pathologies is an integral part of neuroradiological diagnostics and in some cases is a challenge to experienced neuroradiologists. more than patients with different cns pathologies have been investigated in the department of neuroradiology, burdenko neurosurgical institute since . in the vast majority of the cases, there were tumours. we used deconvolution method for bv, bf, mtt and ps maps reconstruction on commercially available software (perfusion . . , . protocols, adw, ge). ct perfusion has demonstrated high level of information in determining the degree of malignancy in glial brain tumours. a strong correlation between bv and ps and tumour degree has been demonstrated. the use of ct-pwi makes it possible to successfully carry out dd between radiation necrosis and tumour progression. some histological types of brain lesions are characterised by unique haemodynamic properties which enable using this method as non-invasive "biopsy". ct-pwi has been especially useful in dd of the skull base region, bone and extracranial pathologies. the absence of artefacts created by the skull base bones makes this method especially valuable as compared to the mri t *-and asl-perfusions. ct-pwi makes it possible to successfully differentiate tumours and a number of non-tumour cns lesions including demyelinating diseases, infectious and non-infectious granulomas, etc. ct-pwi is a powerful method for differential diagnosis of brain pathology. t-pwi can provide unique functional information regarding tumour pathophysiology and haemodynamics, which are not available with routine ct and mri. learning objectives: . to become familiar with the technique of brain perfusion ct. . to understand the added diagnostic value of perfusion ct. . to learn about input of ct perfusion for assessment of treatment. interlude: development and use of web-based teleradiology in russia o.s. pianykh; newton highlands, ma/us (opiany@gmail.com) the largest territory in the world, russia, presents a perfect teleradiology use case of extremely unevenly distributed health care, concentrated in moscow and spread thin outside over an enormous area and sparse population. this unevenness deeply affects the quality and availability of radiological services, and cries out for efficient and practical teleradiology solutions. however, the same unevenness in medical expertise, financing and it infrastructure frequently acts against the advancement of teleradiology projects, blocking their natural progress. as a result, technical, financial, educational and clinical matters, interleaved into the nascent russian teleradiology ventures, require serious and predictable solutions, based on analysis and adaptation of already developed, internationally proven strategies. currently, russian teleradiology simply takes advantage of whatever is available to make its progress better, but needs to develop itself up to the tasks it faces. tuberculosis in russia: a challenge for a national radiological service i.e. tyurin; moscow/ ru (igortyurin@gmail.com) approximately, . billion people worldwide are infected with mycobacterium tuberculosis, of which million are active cases. the reasons for resurgence of tb infection include the hiv epidemic, a rise in reactivation disease in the elderly, a growing migrant population and spread of drug-resistant strains. the incidence of atypical tb infection is also on the rise, of which mycobacterium avium intracellulare is the most important human pathogen. the pathologic form of the pulmonary infection depends on the sensitivity of the infected host and is classified as primary or postprimary. primary tb pattern represents infection resulting from recent contact with the pathogen. postprimary tb pattern results from reactivation of a dormant focus within the lungs. thoracic tuberculosis produces a broad spectrum of radiographic abnormalities. the radiological patterns had been described as parenchymal, airway, vascular, mediastinal, pleural, and chest wall lesions. common causes of a missed diagnosis of thoracic tuberculosis are failure to recognise hilar and mediastinal lymphadenopathy as a manifestation of primary disease in adults, overlooking of minimal productive lesions or reporting them as inactive, and failure to recognise that an upper lobe or superior segment of lower lobe mass might be tuberculosis. in aids patients, the imaging features depend on the degree of immune suppression. a pattern of postprimary tb is also usually seen among patients with decreased immunity due to alcoholism, renal failure, diabetes mellitus, ageing, malignancy, and renal and cardiac transplantation. learning objectives: . to understand the scope of the problem with tuberculosis screening in the russian federation. . to learn about the changing imaging patterns of thoracic tuberculosis. . to appreciate the current role of imaging in the differential diagnosis and follow-up of this pathology. interlude: mystery of denisov's cave and paleoradiology m. mednikova; moscow/ ru (medma_pa@mail.ru) this study focuses on the anatomical identification of fossil bones from altai highland in southern siberia, their radiological description, and parallels among other hominin fossils. methods describe the small and isolated tubular bones. we used microct versaxrm- by xradia inc. and digital microfocus x-ray. denisova cave is the best studied paleolithic cave in north asia. archaeological data suggest that about thousand years before the present, a group of humans migrated to southern siberia from the west. their descendants had lived in the altai mountains in relative isolation for thousand years. the taxonomic status of the early inhabitants of southern siberia was clarified thanks to palaeogenetic studies. it was concluded that the altai hominin was genetically twice further from modern humans than were neanderthals. phylogenetic analysis suggests that this clade diverged from that ancestral to humans and neanderthals very early -about billion years ago. descendants of this clade apparently survived in the altai refugium until the period - thousand years ago. due to structural patterns of preserved pedal and manual phalanxes, humans from denisova cave could be expected to be the bearer of "archaic" traits. the extraordinarily thick walls of tubular bones in adults reflect a high level of occupational stress. radiological volumetric microscopy of the denisovan girl phalanx gave evidence for the histological estimation of the developmental age. radiological methods seem to be the perspective approach in the study of rare and fragmentary fossil human remains, differentiating between archaic and modern humans. advances in imaging of pancreatic masses g.g. karmazanovsky; moscow/ru (karmazanovsky@ixv.ru) modern diagnostic radiology allows not only to detect pancreatic tumours, but also to carry out their differential diagnosis with high accuracy. this is especially important because many benign tumours of the pancreas do not require immediate surgery. at the same time, many benign tumours may become malignant. the differential diagnosis of the pancreatic cystic lesions using endoscopic ultrasound and magnetic resonance pancreaticocholangiography has now become particularly accurate. contrast enhancement allows detecting signs of tumor invasion into the main blood vessels and adjacent organs. modern developments of radiology help to use extended operations for malignant tumours and sparing surgery with minimal removal of intact functioning pancreatic tissue in benign tumours. learning objectives: . to become familiar with major types of pancreatic masses and their radiological manifestations. . to understand approaches to the selection of diagnostic pathways in pancreatic tumours. . to become acquainted with new developments in diagnostic imaging of pancreatic tumours. interlude: an artistic view of ct a.l. yudin; moscow/ ru (prof_yudin@mail.ru) radiology is a specialty based largely on figurative perception of diagnostic imaging. the radiological picture of many symptoms reminds one of objects and environmental phenomena (for example, vanishing lung, draped aorta, geographic liver, porcelain gallbladder, dirty fat and others). training of creative mentation promotes lasting assimilation of educational material at the associative level. metaphorical thinking skills can also be improved by searching for amusing fragments in radiological images similar to the objects in everyday life; animals, cartoon characters, and others. the essential help in the study of the physical foundations of radiology and functional capabilities of workstations provide the execution and study of x-ray films, ct or mri of fruits and vegetables, flowers, various artifacts and other objects in the environment. eventually, it is just beautiful. ultrasound of the breast is an established imaging technique with several advantages. it has been used to differentiate solid from cystic breast lesions for a long time. it has also been increasingly used to visualise small lesions in mammographically dense breasts and is the initial imaging method of the breast in young women. the features of the lesions that need to be analysed are: shape, relation to anteroposterior to laterolateral diameter, margins, internal structure and absorption of sound (distal acoustic phenomena). color doppler enables the thorough assessment of flow within the breast lesions. elastography is established as a useful method to differentiate breast lesions on the basis of their stiffness, which can be quantified. the accurate staging of axillary disease is an important aspect in the management of patients with breast cancer. it is recognised, however, that underlying malignancy can be found in lymph nodes that appear morphologically normal. a variety of morphological features that may be seen in pathological nodes have been described (cortical thickness of > . mm and absence of a fatty hilum). the automated breast ultrasound technique has been known for a long time, but with recent improvements now may play an important role. the automated breast volume scanner (avbs) employs frequencies of - mhz. avbs has various major advantages, such as being independent of the experience of the operator as well as supplying consistent and reproducible results. additionally, for the first time it has become possible to obtain coronal images of the complete breast, which greatly assists in the planning of surgical interventions. to study the technical basics in breast ultrasound (us), a breast scanning phantom helps to understand different us settings of greyscale imaging. typically, breast us work has a linear array transducer with a minimum field of view of . cm and a high frequency of minimum mhz. a broadband transducer (e.g. - mhz) with different bands is preferred. in the central axillary area, a lower frequency band offers a deeper penetration depth. high frequencies improve the tissue contrast and optimise the axial and lateral resolution. the transmitter focus is adapted to the region of interest. highly sensitive color doppler detects slow flow rates ( cm/s and less). for frequencies and power settings used in diagnostic greyscale and color doppler studies, no safety limitations have to be considered. breast us is mainly used as a second-line imaging tool to mammography (mg). a correlation between both imaging modalities is crucial. skin markers and additional mgs may help to solve the correlation problem. in bi-rads or us lesions with unclear correlation in mg, a marker placement after us-guided large-core needle biopsy helps to clear the problem. the pathomorphological growth pattern of a lesion is the basis to understand different imaging aspects with different modalities. second-look us after mri is an important correlation of lesions, which were first visible with mri. understanding the complementary imaging criteria will help to reduce the number of false-positive results. a practical imaging approach to brain and neurovascular trauma will be reviewed, with an emphasis on understanding the correlation between pathophysiology and imaging signs. guidelines on when to order acute neurovascular studies will be presented. special technical considerations to help optimise ct and mr imaging protocols for suspected brain injury, cns haemorrhage, and arterial dissection will be discussed. neurological emergencies are often associated with high morbidity and mortality, and thus require prompt diagnostic and therapeutic action. nontraumatic emergencies may however have a subacute onset, and radiological signs may be subtle, which can lead to delay in diagnosis and treatment. since clinical features are often nonspecific, the radiologist may be the first to point the clinician in the direction of the correct diagnosis. it is therefore of great importance that the radiologist is aware of and familiar with the various imaging findings, on both computed tomography (ct) and magnetic resonance imaging (mri), of non-traumatic neurological emergencies. these include vascular, infectious and inflammatory diseases. commonly encountered emergencies are ischaemic and haemorrhage stroke, venous thrombosis, arterial dissection, abscess, acute disseminated encephalomyelitis (adem), and encephalitis. radiological findings in rarer diseases may mimic those in the more commonly occurring diseases, but need to be correctly interpreted as therapeutic strategies and prognosis may be entirely different. such entities include for instance posterior reversible encephalopathy syndrome (pres), reversible cerebral vasoconstriction syndrome, susac's syndrome, and status epilepticus. furthermore, initial findings of (impending) complications of brain disease, such as hydrocephalus and herniation of brain structures, may be subtle, while early recognition allows for prompt and adequate intervention. finally, diagnostic and therapeutic interventions performed in an emergency setting may interfere with the diagnosis and interpretation of clinical and imaging findings. associated limitations and pitfalls therefore need to be recognised to avoid false-negative or false-positive diagnosis, respectively. learning objectives: . to learn about the modalities (ct/mri) and protocols for non-traumatic neurological emergencies. . to learn how to diagnose the main non-traumatic neurological vascular and non-vascular emergencies. . to become aware of the pitfalls and limitations of clinical presentation and imaging findings in non-traumatic neurological emergencies. the current century has brought with it new challenges in radiation protection, many of which follow the development of mdct which greatly enhanced diagnostic capabilities and substantially reduced scanning time to just a single breath-hold for chest ct, making ct scanning both patient-friendly and the physician's preferred tool. ct has also been added to nuclear imaging systems to create hybrid scanners (pet/ct; spect/ct image gently years later: lessons learned in radiation protection for children. the alliance for radiation safety in pediatric imaging was founded in to promote radiation protection for children worldwide through awareness, education and advocacy. comprising over medical professional societies and agencies, the alliance seeks to change practice locally for improved paediatric patient safety in medical imaging. since its inception, the alliance has had campaigns in ct, diagnostic and interventional radiology, nuclear medicine, digital radiography and an outreach campaign to parents and educational summits. yet, there is still work to be done. there is a need for parents and patients to receive information about their imaging test prior to the performance of imaging procedures, particularly those involving ionising radiation. the paediatric medical imaging community should work tirelessly with the manufacturers of imaging equipment to tailor equipment for children to optimise the study and ensure that the users of the equipment are knowledgeable in its safe use in children. the routine display of size-specific dose estimate on ct scanners will better estimate patient dose for quality improvement within facilities and in dose registries. finally, there is a need for diagnostic reference levels in paediatric radiology. this presentation will update the audience in progress to date regarding these challenges. the image wisely programme continues to move forward, guided largely by its steering committee, composed of two representatives each from acr and rsna and one representative each from aapm and asrt. the image wisely website (www.imagewisely.org) has educational content for imaging professionals (radiologists, medical physicists, and technologists) and referring physicians. a patient tab features links to radiologyinfo.org and the image gently website. a tab for "my equipment" links visitors to radiation dose-related 'microsites' developed by ge, hitachi, philips, siemens and toshiba. as of august , , , individuals, facilities and associations have taken the image wisely pledge. to attract traffic to its website, image wisely has recently instituted 'news' and 'top reads' sections on the splash page highlighting recent articles and announcement, highlighting breaking news coverage and journal publications on relevant topics. in , content on nuclear medicine procedures was finalised, completing two of the three targeted foci of the initial action plan_ct and nuclear medicine. in october , a launch meeting will initiate the process of developing content for the third target area, fluoroscopy. in and , image wisely has concentrated on efforts to engage referring physician communities, with particular interest in paediatricians and emergency medicine physicians. progress has been slow, but has recently gained traction with emergency medicine in the form of radiologist participation in a symposium, diagnostic imaging in the emergency department: a research agenda to optimise utilisation, organised by the society of academic emergency medicine. learning objectives: . to learn about the image wisely campaign for radiation protection of adults. . to understand the lessons learnt while communicating messages. lessons from a national approach to patient safety in radiation protection p. cavanagh; taunton/uk (petecavanagh@gmail.com) in considering a european campaign on radiation awareness, it is useful to gain information from similar campaigns in health care. there have been a number of national patient safety campaigns based on the institute for healthcare improvement (ihi) , lives campaign initiated in the usa in . following the success of this, a similar campaign was launched in england. part of this process included an analysis of the success of the programme and the key interventions and drivers that were considered essential at both the national and local level. these included strong leadership, . bone (pseudo)-tumours: the majority of bone tumours can be detected on plain radiography. the age of the patient, location of the tumour in a bone and history of pre-existing bone abnormality should be included in determining the likely diagnosis. careful analysis of pattern of bone destruction, periosteal reaction and matrix mineralisation allow for characterisation of most bone tumours and differentiation from pseudotumours. ct may be useful for osteoid osteoma and mri is the best imaging technique for further diagnosis and staging by displaying tumour composition and extent of bone marrow involvement, including skip lesions, presence and extent of extraosseous soft tissue mass, and involvement of neurovascular bundle, muscle compartments and adjacent joint. this allows to find the best biopsy and surgical approach. to evaluate local control of disease and for detection of local recurrence, mri is usually the best imaging technique. . soft tissue (pseudo)-tumours: the majority of soft tissue tumours can be detected on ultrasound. except for cysts and subcutaneous lipoma, mr will be the next imaging technique for diagnosis, local staging, and eventually to find the best biopsy and surgical approach. the age of the patient, location of the tumour and careful analysis of the signal characteristics on mri allow for characterisation of many soft tissue tumours and differentiation from pseudotumours. plain radiography and ct may be useful for detection of calcifications and myositis ossificans. to evaluate local control of disease and for detection of local recurrence, ultrasound and mri are the best imaging techniques. in this honorary lecture, i will review a number of personal impressions that may contribute to the successful performance of research projects in cardiovascular radiology. also, issues and obstacles in performing successful research in the field of radiology will be considered. key factors for success include guidance by inspiring mentor, genuine interest and motivation, some creativity and serendipity. radiology has developed tremendously with many innovative modalities over the last years, providing ample opportunity to participate in clinical research. potential issues that should be addressed are subspecialisation, turf battles, competition from other clinicians/ imaging specialists and adequate training in radiology research. the field of imaging research includes traditionally more clinically oriented research by focussing on developing and testing of new modalities and applications, now becoming more basic by including molecular imaging, population imaging, outcome studies and alike. silicone-filled implants (single or double lumen) require a dedicated sequence where silicone exhibits a high signal intensity, whereas signals from fatty and fibro-glandular tissues are cancelled. diagnosis of intracapsular rupture relies on the detection of a linguine sign (direct sign) or multiple "key-hole" and/or " teardrop" images (indirect signs). extracapsular rupture is defined as the presence of silicone outside the capsule (breast, soft tissues, lymph nodes). breast reconstruction after mastectomy may involve autologous tissue flaps (skin, fatty tissue, muscle and fascia). the transferred muscle is inserted in front of the major pectoralis muscle and enhances after contrast medium injection. the most common benign findings seen in such reconstructed breasts and also after a breast-conserving treatment are oedema, seroma, haematoma, fat necrosis and fibrosis. diffuse thickening of the skin and trabeculae is usually observed the first year after completion of radiation therapy. small focal areas (less than mm) of non-mass-like enhancement and thin linear or rim enhancement at the lumpectomy site can all be expected findings. these benign findings decrease progressively, but residual enhancement may be observed in % of women at or more years. in patients who were switched from tamoxifen to aromatase inhibitors, a stronger or re-appearance of a background enhancement may be observed. before classifying such findings as benign or probably benign, clinical examination and standard imaging data must be taken into account. highly suspicious lesions in such patients are similar to bi-rads lesions in the nontreated breast. prevention strategies for women at high lifetime risk of breast cancer are usually adapted to the individual woman's risk of breast cancer. women at high risk (brca mutation carriers or women with a % likelihood of brca-heterzygosity) are offered primary prevention, which includes chemoprevention by tamoxifen or surgery (risk-reducing mastectomy and/or salpingooopherectomy, where the latter also helps reduce the risk of subsequent breast cancer by %). if women opt for secondary prevention (active surveillance/screening), this has to start at at the latest. mri is considered a compulsory component of all programs worldwide. due to the very limited added cancer yield of mammography in this subset of women, and because of the still unsettled issue of possibly increased radiosensitivity of brca-mutation carriers, mammographic screening is not recommended until the age of . there is broad agreement that (at least) an annual screening is important; especially for brca mutation carriers, screening every months may be more appropriate. we recommend interleaved screening, with annual mri and annual ultrasound (± mammography) phase-shifted by months. there are important differences between brca -and brca -associated cancers in terms of age distribution and incidence rates, histologic features, but also specific imaging features which must be known by radiologists. mri screening protocols must be adjusted to the specific needs of this (usually very young) screening population. this presentation will review the current evidence with respect to screening of women at high familial risk of breast cancer and will provide information on all aspects mentioned above. chest trauma is directly responsible for % of all trauma deaths and is a major contributor in another % of all trauma mortality. blunt trauma, accounting for % of chest injuries, is the third most common site of injury in polytrauma patients. plain radiographs still have a role in recognition of some acute thoracic pathology that requires immediate further management, either diagnostically and/or therapeutically, such as tension pneumothorax, major transdiaphragmatic herniation, large hemothorax or obvious mediastinal hematoma. mdct of the chest is now typically included in a whole body scan with iv contrast to facilitate rapid diagnosis on polytrauma cases using less radiation than selected segmental scans. mdct is the well-proven diagnostic gold standard for chest injury evaluation. the major advantages of mdct over other modalities include identification of active bleeding, direct signs of trachea or esophageal injury, direct evidence of major arterial vascular injury, such as pseudoanurysms, pneumo and hemopericardium, location and extent of lung contusion and laceration, and assessment for thoracic spine, shoulder girdle and rib fractures. diaphragm injuries are well depicted by mdct, especially on the left by identifying both the torn diaphragm edges, herniation and constriction of abdominal contents at the level of the torn diaphragm (collar sign), and direct contact of herniated structures with the posterior chest wall (dependent viscera). tracheal injuries are suggested by diffuse and progressive pneumomediastinum, dilated tracheostomy cuff, ectopic endotracheal tube, and direct connection of mediastinal air with the trachea lumen. ct-angiography eliminates the majority of indications for diagnostic catheter angiography. pulmonary symptoms such as chest pain, shortness of breath or wheezing are common non-traumatic symptoms prompting er visits. because clinical symptoms are very non-specific, imaging plays a major role in differentiating life-threatening from less severe diseases and forming a diagnosis. the chest radiograph remains the first imaging despite its limited sensitivity for certain diseases and being prone to inter-observer variability. comprehensive cardiothoracic ct examinations using most modern ct equipment are well evaluated in their diagnostic accuracy to determine the presence of vascular life-threatening events such as aortic dissection, acute coronary disease or pulmonary embolism. protocols and literature evidence will be discussed. the main focus of the course, however, will lie on the analysis of pulmonary ct findings and its contribution to the differential diagnosis of pulmonary emergencies (e.g. pneumonia, oedema, pneumothorax, exacerbation of fibrotic or obstructive lung diseases) and how to further integrate imaging findings, laboratory findings, patient history and clinical information to tackle the differential diagnosis. imaging findings will be discussed by clinical case studies, key findings and also overlapping morphological features of other differential diagnosis will be discussed side by side, illustrating the options and also limitations of imaging findings. mentor was first introduced in greek mythology, and in its modern usage first recorded by a french writer, françois fénelon, in . since then, this concept has been widely used in the development of mentoring, mentorship and more recently of mentees, with an overarching principle based on accompanying, sowing, catalysing, showing and harvesting. this concept remains today as a fundamental one in all teaching activities and implies generally a close contact between the mentor and the mentee. however, the development of internet with concomitant e-learning capabilities, which are hugely increasing, raises the very challenging necessity to re-think this concept and to adapt it to this new era. the esr is very concerned by this endeavour in the context of the striking development of esor, on one hand, and with the launching of its e-library, on the other. n. gourtsoyiannis; athens/gr (gournick@gmail.com) the presentation "esor in action" gives an overview on all esor activities in and . a detailed report on the esor courses and teaching programmes in is presented, containing statistics about the number of course participants and of scholarship and fellowship grants. additionally, all educational activities in , including dates, venues, topics and local organisers, are announced. evidence-based radiology: the basics evidence-based medicine (ebm) was derived from clinical epidemiology during the last century. it "is the conscientious, explicit, and judicious use of current best evidence in making decision about the care of individual patients" (dave l. sackett, ) . this means integrating ( ) individual clinical expertise with ( ) the best available external evidence from systematic research and ( ) patient's values and preferences. when considering evidence-based radiology (ebr), the needed expertise is not only clinical, but also technical, while ( ) radioprotection issues assume a relevant value according to the "as low as reasonably achievable" (alara) principle. ebm (and ebr) can be practised according to the "top-down" model, when using guidelines issued by governmental, professional, or academic bodies, or the "bottom-up" model, when local physicians ( ) formulate an answerable question, ( ) search for the best evidence; ( ) appraise critically; ( ) apply findings to practice; and ( ) evaluate the performance. a hierarchy of radiological studies has been established according to the investigated matter: . technical performance; . diagnostic performance; . diagnostic impact; . therapeutic impact; . patient outcome; . societal impact. different degrees of recommendations are based on different levels of evidence, with experts' opinion as the lowest level and meta-analyses of high-quality homogeneous studies and multicenter studies being the best level of evidence. to practise ebr, radiologists should be familiar at least with basic statistics and epidemiology as well as of methods for study design, thus recognising the principal types of bias which can limit the value of published studies. learning objectives: . to understand the historical development and general principles of evidence-based medicine (ebm) with its top-down and bottom-up approaches. . to learn how to apply ebm principles to radiology (evidence-based radiology, ebr) and to illustrate the main reasons for the relative delay in developing ebr, including the challenges of fast technological innovation in medical imaging. . to learn about the relationship between levels of evidence and the strength of recommendations for diagnostic imaging and interventional radiology. . to learn how radiologists could play a stronger role in building the evidence in favour of diagnostic imaging and interventional radiology, taking the patient's interest as the primary aim of clinical practice and science. education in research: action plan j. hodler; zurich/ch a survey regarding education in research has been commissioned by the esr and published in insights imaging ( ) : - . the results indicate that education in research, associated with career models, needs promotion. the research committee of the esr is working on possible future steps to promote research through education. several problems will have to be addressed, most notably inhomogeneity within europe, motivation issues, illdefined career paths as well as funding issues. several stakeholders will play an important role, including scientific societies, although this is the core business of academic radiology chairmen. most young professionals starting a career in academic institutions are eager to expand their professional and personal aptitudes. an effective way to support young professionals in this regard is by mentoring. mentorship is a relationship where the mentor supports a junior faculty member (mentee) in personal and professional development. the mentee benefits from early determination and initiation of career-relevant steps, greater productivity in research and publishing activity and developing techniques in networking and collaboration. moreover, the mentee gains perspectives on how his/her discipline operates academically, socially and politically, improves self-efficacy and deals more confidently with challenging intellectual work. the mentor, a knowledgeable, experienced and regarded person, benefits from fresh ideas, energy and curiosity of mentees, as well as through acceptance as a mentor an enhanced status in the department. it is a trusted relationship of dialogue, learning and challenges, based on mutual interests. however, the mentor is not automatically the best friend or the sole exclusive advisor of the mentee. more and more academic medical institutions offer facilitated mentoring programmes, which help the mentoring pairs to create an effective mentoring relationship to accomplish the desired skills. evaluation of faculty mentoring programmes in academic medical institutions demonstrates the importance of mentoring in research and academic development as well as in patient care. especially in radiology where over many years there have been challenges in recruiting and retaining talented young professionals, mentoring is considered as an essential way for preparing the next generation of scientific and intellectual leaders. pitfall: "a hidden or unexpected danger or difficulty". imaging methods can provide an extraordinary amount of useful data to specialists treating head and neck (cancer) patients. it is crucial that these data are used to full advantage of individual patients. the most important factor in this process is mutual cooperation between the physicians in charge of patient care and the diagnostic imaging specialist. pitfalls in the head and neck may present in various ways: normal variants may look like disease, incidental findings are frequently encountered and suboptimal technique may obscure important findings. moreover, many pitfalls are directly related to technical errors. the presentation aims to familiarise general radiologists, who have an interest in head and neck imaging, with common pitfalls encountered on ct and mr studies focussing on the neck. in an interactive setting, examples from daily practice will be discussed. imaging of the skull base and maxillofacial skeleton requires a meticulous imaging technique and a good knowledge of normal anatomy and possible anatomical variants. asymmetry in the pneumatisation of the paranasal sinuses, skull base or temporal bone is a common reason for misinterpretation. for example, hypoplasia of the maxillary sinus may be misinterpreted on conventional radiography as maxillary sinusitis or orbital blowout fracture, depending on the context; asymmetric pneumatisation of the petrous apex or mastoid bone may mimic, respectively, a cholesterol granuloma and fluid effusion in the non-pneumatised side on mri. vascular variants may also cause interpretation problems. for example, turbulent flow in a large jugular bulb may mimic a jugular foramen tumour on mri. variants in the vascular plexus surrounding the trigeminal or facial nerve may occur, and cause asymmetric findings on mri, possibly mimicking neuritis or perineural tumour spread. incomplete maturation or arrested development of skull base structures may also cause confusion. examples are the cochlear cleft, not to be confused with otosclerosis, or arrested pneumatisation of the sphenoid sinus, possibly mimicking a tumoural lesion in the central skull base. to avoid problems, one should keep in mind the existence of such variants, while correlating the imaging findings with the clinical problem; in some cases, an additional imaging study may be needed to exclude a pathological process more confidently. this short -min introduction by the session chairman will give an overview of the current state of cardiac computed tomography (ct) for diagnosis and prognosis. in addition, the introduction will provide the basis for the subsequent dedicated lectures covering low radiation dose, diagnostic accuracy, and incidental findings in cardiac ct. what are the protocols with the lowest radiation dose in clinical practice? j.-f. paul; le plessis robinson/fr (pauljf@ccml.fr) the radiation dose delivered for coronary ct angiography using retrospective gating is high, because only a small part of the total radiation delivered is used for the reconstruction of the image in the retrospective mode. on average, % of the radiation burden is used to reconstruct one phase of the cardiac cycle. ecg-triggered tube current modulation allows reducing the nominal dose by up to % in the systolic phase. another approach for reducing radiation exposure is to use prospective, sequential acquisition, with this approach being associated with % dose reduction compared to the spiral retrospective acquisition. exposure time may be also shortened by an increase of pitch, in particular on the dual-source ct. however, applicability to each dose-sparing technique depends on the heart rate and its regularity. dose-sparing strategies should be modified in case of high or irregular heart rate and radiation dose reduction may be less effective. for coronary ct angiography, individually weight-adapted protocols have been successfully applied, by adjusting mas to patient's weight. more recently, settings of kv and even kv have been successfully used for cardiac studies, especially in slim patients or children. reduction of exposure time and individual adaptation have an additive effect on dose reduction: it has thus been possible to scan down under msv in selected, slim patients, using this combined approach. in many cases, using the latest technology, radiation dose may be lower than the mean radiation dose associated with conventional angiography. learning objectives: . to understand various protocols to lower radiation dose in cardiac ct with regard to the clinical situation and the risk of image quality impairment. . to learn how to tailor the radiation dose level to each patient in terms of morphology. . to become familiar with modulating exposure windows in regards to a patient's ecg. how accurate and prognostically valid is coronary ct angiography? f. cademartiri, e. maffei; monastier di treviso/it (filippocademartiri@gmail.com) the role of cardiac computed tomography in cardiovascular diseases is becoming increasingly important. cct is a robust and reliable investigation for the detection and exclusion of significant coronary artery disease. in addition, cct provides reliable noninvasive information concerning coronary plaque burden (severity, distribution, type), morphology and function of left and right ventricle, valves, aorta, and so forth. in the past years, the prognostic role of cct has been established. the prognostic information that can be extrapolated from cct is very diverse and most of it is still under investigation. there are converging evidences that cct can stratify cardiovascular risk better than conventional clinical methods, especially in symptomatic patients. for asymptomatic individuals, the role is still controversial since coronary calcium score alone has a very important role already. several aspects of cct information seem to have importance for prognostic stratification: plaque presence, obstruction, plaque type and distribution. more recent studies have started showing the relationship between cct and pharmacological treatment. this is a very new and appealing topic, since the evidence is towards the fact that the most effective pharmacological treatment (e.g. statin) should be restricted to patients with at least some nonobstructive cad as detected by cct. this might become a revolutionary concept in cardiovascular medicine with several implications. learning objectives: . to learn about and integrate the prognostic information from coronary ct angiography into conventional methods. . to learn about coronary ct angiography and conventional methods. . to appreciate the prognostic impact of coronary ct angiography and conventional methods. incidental findings in cardiac ct: how to report and proceed s. leschka; st. gallen/ch (sebastian.leschka@kssg.ch) rapid advances in computed tomographic (ct) technology have facilitated the widespread use of ct for cardiac imaging worldwide, and can be considered nowadays an essential part of the clinical workup of patients with suspected coronary artery disease. albeit that the performed ct study is focussed on the cardiac structures and the coronary arteries, adjacent noncardiac structures are in the field of view whenever a patient undergoes cardiac ct to quantify coronary calcium or to perform a noninvasive coronary angiogram. in addition, the location of the heart near other anatomic regions, including the lungs, mediastinum, upper abdomen, and bones, necessitate that these structures are included when acquiring coronary ct angiographic images. several publications have demonstrated a high frequency of incidental findings on coronary ct angiography. the availability of this information is part of an ongoing clinical debate. while some radiologists believe that every image should be interpreted completely, others believe that examining noncardiac structures reveal too many incidental findings of uncertain clinical significance, which may harm because additional testing increases risk, cost, and patient anxiety. the aim of this lecture is to separate solid facts from opinions and beliefs. the diagnosis of pulmonary embolism (pe) is usually established by a combination of clinical assessment, d-dimer testing, and imaging with either pulmonary ventilation-perfusion (v/q) scintigraphy or pulmonary multidetector ct angiography (ctpa). v/q scintigraphy is a functional imaging method using isotopes for the visualisation of ventilation and perfusion distribution in the lungs. in recent years, the imaging techniques for diagnosing pe have improved. many nuclear medicine centres have adopted the single photon emission computed tomography (spect) technique as opposed to the planar technique when diagnosing pe. the introduction of -dimensional v/q spect technology instead of -dimensional planar v/q scintigraphy has resulted in fewer indeterminate results and a higher diagnostic value. the latest improvement is the addition and combination of a low-dose ct without contrast to the v/p spect (spect/ct) technique. the spect/ct in combination has been compared to ctpa, planar scintigraphy and spect alone, and one study has shown that spect/ct in combination had the highest diagnostic accuracy for pe diagnosis. spect in combination with low-dose ct without contrast enhancement is superior, especially for small subsegmental emboli; however, consensus is lacking regarding the clinical impact and treatment. spect and spect/ct may provide alternative diagnosis if pe is refuted and are feasible in almost all patients, because there are no definitive contraindications. in the present lecture, spect and spect in combination with low-dose ct are discussed in the context of diagnosing pe. over the last few years, emergency radiology (er) has been a subspeciality with growing interest. because of rapid developments in technology, ct has become the most useful tool in evaluating trauma and other emergency patients. in this lecture, the basics of planning and organising an er department are presented and discussed. besides optimising technical equipment and protocols for imaging, different logistic concepts have to be considered in planning and organising er departments. first of all, logistic concepts have to be considered for obtaining an optimal workflow: the radiology department has to be in close proximity to the emergency department and the admitting area, in particular. the whole workflow must be optimised for speed and accuracy. this also mandates having dedicated and standardised examination and viewing protocols for ct. in contrast to the usa where dedicated emergency radiology departments are well established, nonspecialised radiologists still frequently do the reading of emergency radiology cases in european countries. the radiologic staff involved has to be trained for interpretation of trauma and other emergent cases. this does not only account for residents, but also for consultants and attending radiologists. since a large number of cases will arrive during after hours and on weekends, staffing has to be adjusted to this fact, which includes attending radiologists to be available during these hours on call or, preferably, on-site. this lecture will give an overview of logistic concepts and organisation of an emergency department and will also discuss critical issues in polytrauma imaging. at least during the radiological training in hospitals, every radiologist will personally be confronted with the treatment of polytraumatised patients. it is a fact that standardised whole body mdct (wb-ct) as an independent predictor is able to save around % of patient lives. thus, wb-ct is the major diagnostic tool and should be performed as fast as possible. some institutions bypass the emergency room and directly start patient stabilisation in the ct cabinet. however, radiographs and focused ultrasound remain important in general settings as long as they are performed in a way which does not delay ct diagnostics. after scanning, specially trained radiologists support the whole interdisciplinary team with correct, appropriate and prioritised diagnoses. besides optimisation of parameters like logistics, patient positioning preferably 'feet first', reading and communication, 'choosing the right protocol' is a crucial factor for ideal radiological patient care. four types of protocols should be differentiated: there is a wide agreement that for patients with polytrauma, integrating whole body computed tomography (ct) scan into early trauma care significantly increases the probability of survival. therefore, ct is today considered the most important imaging technique in the diagnostic workup of polytrauma patients. the downside of whole body ct represents the relatively high radiation exposure. to overcome this handicap, the following measures can be taken: . positioning of the arms during whole body ct above the head results in reduction of radiation dose; . adaption of scan parameters, especially reduction of tube voltage to kv reduces radiation dose; . installation of recent technical improvements like iterative reconstruction algorithm reduces noise in the image, allowing a downward adjustment in radiation dose to obtain standard diagnostic quality images; . installation of dose control software enables optimisation and improved dose management over time. another disadvantage of high-resolution whole body ct is the amount of acquired data. to optimise the workflow in the evaluation of a couple of thousand submillimetre images it is necessary to connect the mdct scanner with a dedicated workstation for volume image reading, which offers the possibility of quick multiplanar online evaluation. in this introduction i will define the connectome (a comprehensive map of neural connections in the brain) and related concepts such as scaling, structural and functional connectivity as well as the integration-segregation paradigm. the development of mri-based techniques such as white matter tractography and segmentation of white and gray matter has played a crucial role in the emergence of connectomics by providing tools to map in vivo the entire human structural connectivity at a macroscopic scale. i will explain these methods and how from mr imaging a human connectome can be mapped and represented as a network (set of nodes and edges). finally, i will also review the validation work related to those techniques and mention the foreseen technical advancements in the field. session objectives: . to learn what the human connectome is and how it is affected by brain disease. . to understand how the human connectome can be imaged and characterised with mri. . to become familiar with the network formalism and its interpretation. . to understand the relationship between brain function and underlying structural connectivity. . to understand the conceptual ideas behind connectomics. . to learn about the general workflow, from diffusion imaging to mapping a structural brain network. . to become familiar with the robustness of the technique by reviewing validation studies and getting a glimpse of the technical challenges. the economics of brain networks e. bullmore; cambridge/ uk (etb @cam.ac.uk) we review the methods and recent results of network analysis of human neuroimaging data. human functional mri and structural mri data can be analysed using mathematical tools drawn from graph theory to quantify the complex (non-random) topological properties of brain networks. these results can be substantiated by meta-analysis of prior neuroimaging results and analysis of non-human nervous systems. brain networks consistently express complex topological features, such as small-worldness, hubs, modules and rich clubs. some of these features entail disproportionate biological cost, but may be "worth it" by supporting integrative information processing and adaptive behaviours. highly connected hub nodes are high cost/high value network components that likely also represent special points of vulnerability for diverse brain disorders. these economical principles of brain network organisation are expressed at the microscopic scale, e.g., in the nervous system of the nematode worm c. elegans, and may therefore provide a new axis for translation between macro and micro systems neuroscience. neuroimaging can be used to elucidate the economical principles of human brain network organisation in health and disease. connectomics in brain pathology m.p. van den heuvel; utrecht/nl (m.p.vandenheuvel@umcutrecht.nl) healthy brain function depends on efficient functional communication within a complex network of structural neural connections, a network known as the connectome. conversely, damage to the brain's network, disrupting local neuronal processes and/or global communication between remote functional systems may lead to brain dysfunction. in the last few years, emerging evidence from a wide variety of studies suggests that connectome abnormalities may indeed play an important role in the aetiology of several brain disorders. in my talk, i will discuss the results of recent studies suggesting an important role for affected connectome organisation in a number of neurological and psychiatric disorders. in particular, i will highlight the findings of affected functional and structural brain network in neurodegenerative disorders such as alzheimer's and als, as well as discuss how the application of network science and connectomics may aid our understanding of the biological basis of psychiatric disorders such as autism and schizophrenia. learning objectives: . to understand the role of connectome architecture in (cognitive) brain function and dysfunction using diffusion mri/functional mri. . to become familiar with connectomics as a tool for examining disease pathology in a wide range of neurological and psychiatric brain disorders. linking structure and function: the role of modeling in understanding the pathophysiology the interplay of the brain's intrinsic activity and the external world has seen a revival in the last decade, especially in neuroimaging. a long-held assumption in many of these studies has been that ongoing brain activity is sufficiently random that it averages out in statistical analysis. hence, imaging studies are termed 'activation' paradigms, where experimental manipulation results in the activation of cerebral circuits that are necessary for performing the task. nevertheless, a large amount of recent literature reports a body of observations that there are consistently distributed patterns of activity during rest. this fact has led to the suggestion that it might be possible to characterise network dynamics without needing an explicit task to drive brain activity. indeed, numerous neuroimaging experiments have evidenced the solid existence of spontaneous long-range correlations, i.e. functional connectivity (fc), by fmri, meg, and eeg techniques. the functional connectivity is defined as the statistical dependence between remote neurophysiological dynamics. the emergence of resting functional connectivity is intrinsically linked with the underlying anatomical connections between those areas, i.e. the structural connectivity. whole brain modeling can indeed establish a direct link between structure and function. furthermore, the modeling can shed light on the origin of pathological functional disfunction by making the link with the underlying anatomy explicit. we will show how, structural dti tractography, functional imaging and modelling studies can be combined for reaching this goal. traumas to the paediatric pelvis and hip include traumatic dislocations of the hip, fractures of the femoral neck, fractures of the pelvic ring, acetabular fractures and apophyseal avulsion fractures. traumatic dislocations of the hip, fractures of the femoral neck, fractures of the pelvic ring and acetabular fractures are rare in children (less than % of paediatric fractures), as compared to adults. these fractures are commonly the result of high-energy trauma. imaging is based on plain radiographs, but ct and mri are very useful to precisely assess bone (ct) and cartilage and soft tissue (mri) lesions. imaging enables accurate diagnosis, appropriate treatment and detection of potential complications (femoral head osteonecrosis, premature physeal closure …). in contrast with the previous injuries, apophyseal avulsion fractures of the hip and pelvis are common in children and adolescents, usually associated with athletic activities. in most cases, these fractures are of good prognosis and can be treated conservatively when minimally displaced. plain radiographs confirm avulsion injuries to ossified apophyses, but mri and ultrasound are the modalities of choice to demonstrate injuries to nonossified apophyses and to assess apophyseal displacement. the elbow is a very common site for fractures in a child. the challenge for the radiologist is to differentiate normal variants of growth from possible injury and this is usually achieved by having good-quality radiographs and an understanding of normal growth. it is important to recognise those fractures which require surgical intra-operative treatment. in a small number of cases when assessing for vascular integrity, intra-articular extent and injury to cartilaginous structures, ultrasound and mr imaging have a valuable role. this lecture will give an overview of the radiographic appearance of fractures, highlight the features which require orthopaedic intervention and illustrate the use of additional imaging modalities. learning objectives: . to become familiar with the types of injuries seen in the paediatric elbow. . to understand the strengths and weaknesses of different imaging modalities. a- : the diagnosis of c-spine injury is more complex in children than in adults. early diagnosis is crucial since delayed diagnosis results in high morbidity and mortality. leading mechanisms of pediatric c-spine trauma are motor vehicle accidents, sports and pedestrian injuries. due to their anatomy, children are prone to different types and locations of injuries. children < yeas of age are more likely to injure the spinal cord itself and are prone to dislocations and high (c -c ) bony injuries. children > years of age more often sustain c-spine fractures. in children under the age of years, radiographs are rarely helpful. ap and lateral radiographs are helpful in children aged between and years. in children aged > years, additional lateral and odontoid views are obtained. anatomical variants such as pseudosubluxation of c -c , widening of the atlantodental interval and ossification centres may appear to be of concern on imaging, but are normal. abnormal radiographic findings require additional imaging to differentiate them further with ct on the area of concern. mri is mandatory if signs of atlantorotary subluxation and spinal cord injury without radiologic abnormality (sciwora) are present. mri identifies injuries to the spinal cord that are not apparent with other modalities, and should be used when a child presents with a neurologic deficit but normal radiographs on ct scan. nowadays, ultrasound (us) has become the first choice for performing most breast biopsies. the main advantages of this technique are non-ionising radiation, full control of the needle position in real time and widespread use of us equipments at all centres. us allows access to difficult places (such as the axilla or near the nipple), multiple lesions can be safely biopsied in one single session, the breast is not compressed, there is excellent comfort for patients and radiologists, local anaesthesia and haematoma do not hide the lesion and it is a cost-effective technique. however, the main limitation is that the lesion must be visible on us. us-guided fine-needle cytology was widely used in the past, but today its use has decreased. us-guided core-needle biopsy has proven to be a reliable technique to perform a biopsy for breast lesions, showing a sensitivity value of about %. furthermore, it can be safely used for performing biopsies of axillary lymph nodes. vacuum-assisted devices can be used not only for diagnostic purposes, but also for therapeutic ones, because small palpable benign lesions (such as fibroadenomas), papillomas and radial scars can be completely removed. stereotactic breast biopsy is the performance of tissue sampling under mammographic guidance. as with any imaging technique, some lesions are only seen with mammography. when these lesions are suspicious (e.g. birads or higher), there are no imaging techniques that can downgrade this suspiciousness directly, although for birads lesions follow-up might be a viable alternative. in mammography, most lesions that are only visible on the mammogram consist of clusters of microcalcifications. these harbour a likelihood of around % being malignant and should thus be classified as birads . this implies that tissue sampling is mandatory. different from ultrasound-guided biopsy, it is not possible to perform a real-time biopsy under mammographic guidance. rather, stereotactic biopsy uses triangulation to assess the depth of a lesion within the breast, while the lesion location in the xand y-plane is assessed on a scout view. the needle is positioned using the coordinates thus obtained. since there is no real-time feedback of the accuracy of needle positioning, it is necessary to obtain substantially more tissue than under ultrasound guidance. therefore, vacuum-assisted systems are essential. in case of calcified lesions, the biopsy result is controlled by x-ray. calcifications should be present in the sample. biopsy complications that occur under stereotactic guidance are usually limited. most common is the formation of large haematomas. scarring may also occur. breast magnetic resonance (mr) imaging is the most sensitive modality available to evaluate the breast for cancer. it can detect lesions that are occult at mammography and ultrasound. it has a limited sensitivity and the positive predictive value ranges between and %. histopathological assessment of mr-detected lesions is therefore mandatory. some of these lesions will be visible at second-look ultrasound and can be biopsied sonographically. a significant number however will only be discernable on mr, and mr-guided biopsy is therefore the sampling technique of choice. mr biopsy has become an essential component of any breast imaging practice. several mr-biopsy techniques are available including the grid-localising, pillar and post and the freehand techniques. the technique for preparing and performing a mr-guided vacuum-assisted biopsy using the grid-localising technique is reviewed. potential complications, limitations of mr breast biopsy and actions to prevent failure are discussed. imaging-histologic correlation is essential to ensure accurate sampling. clip placement and follow-up imaging should be performed to ensure sampling, including ultrasound correlates. finally, new developments in mr-guided therapeutic interventions are discussed. abdominal injuries require a timely and reliable diagnosis to prevent potentially lethal outcomes. the armoury of clinical tools (physical examination, lab tests) does not fulfil these criteria, since they are either not fast or not reliable. imaging diagnostic modalities help the clinician to acquire the necessary amount of information to initiate focused and effective treatment. however, the selection of the appropriate imaging algorithm, modality and technique, as well as the precise detection and interpretation of essential imaging findings are frequently challenging, especially because the circumstances, under which these examinations are performed (open wounds, bandages, non-removable life-supporting equipment, lack of patient cooperation, etc)., are frequently less than optimal. knowledge of critical imaging signs, symptoms and the role they play in the evaluation of the patient's condition, as well as fast decision-making and ability to closely cooperate with the clinicians are skills of key importance for radiologist members of the trauma team. this presentation will describe the technique and important findings for ct stone studies as well as the accuracy of this study. an explanation of when iv contrast should be given to augment a ct stone study and findings of gu and non-gu diseases that can mimic symptoms of stone disease will be provided. examples and descriptions of acute mesenteric vascular abnormalities, bowel obstruction and infectious conditions will be included. ways to differentiate and categorise emphysematous infections for proper treatment will be described. lower tract emergencies will also be illustrated and described. a systematic approach to evaluating abdominal cts will be described to avoid mistakes. using cases and an audience response system, this segment of the course will go over the optimal imaging approach for patients presenting with acute abdominal pain and abdominal injuries. ct findings will be emphasised. key imaging findings of traumatic and nontraumatic causes of acute abdominal pain including gastrointestinal tract and urinary tract pathology will be explained. a systematic approach for the imaging evaluation of patients with abdominal emergencies will be illustrated and explained including proper scan protocols and analysis of imaging findings. imaging diagnosis of blunt and penetrating abdominal injuries, urinary tract obstruction, infection, bowel obstruction, and ischemia will be emphasised. transcatheter renal denervation represents a novel therapy for treating patients with treatment-resistant hypertension, leading to higher risk of major cardiovascular events. an overview of sympathetic nervous system anatomy, physiology and physiopathology will be followed by a description of the technical aspects of renal denervation. first, results in patients with therapyresistant hypertension look very promising. however, these data need to be confirmed. importantly, long-term efficacy and safety need to be assessed. as a consequence, the treatment cannot be considered, at the moment, standard therapy. future studies need to address other disease conditions characterised by sympathetic hyperactivity, including heart failure, chronic kidney failure and others. it is a general opinion that in the near future the treatment will also be applied to lesser severe hypertensive patients. future studies should also include formal cost-effectiveness analyses. renal denervation can be achieved by a number of different techniques that include radiofrequency ablation, intraluminal and high-intensity focussed ultrasound ablation, chemical ablation and radiation ablation. radiofrequency and ultrasound ablation are currently the most commonly used techniques. most of the evidence to date is derived from studies and trials based on devices that use radiofrequency ablation technology. there are a number of currently ce-marked devices available and each device differs in the catheter design, generator design and energy delivery. these device types include single-point ablation, multi-point ablation, balloon-mounted systems and irrigated technology. the indications for renal artery denervation have been formulated by various international and european societies based on the various clinical trials and studies. these indications include patients with true resistant hypertension, age - years, egfr > ml/min/ . m (mdrd formula), single renal arteries with diameter > - mm with a landing zone of - mm depending on the device, no significant renal artery stenosis > %, no renal artery aneurysm, no previous renal artery angioplasty or stenting and the absence of significant valvular heart disease where lowering blood pressure will be dangerous. renal denervation of the sympatic nerves around the renal arteries is a new catheter technique to treat patients with resistant hypertension. resistant hypertension is seen in about %- % of all patients with hypertension. the mechanism of sympatic nerve driven resistant hypertension will be explained. the available techniques for rdn will be discussed, focusing on the pros and cons of each technique. currently, rf ablation, hifu and cryo-ablation are the techniques under investigation. the technique and physics of renal denervation with radiofrequency ablation will be explained in more detail, focusing on available devices in the market. patient selection and nonresponders will be discussed. the current evidence from the available trials will be reviewed. the future of rdn and the role of radiology and the radiologist will be illuminated. the adrenal glands are composite endocrine organs consisting of the steroid hormone-producing cortex and the catecholamine-synthesising medulla. the increased use of imaging modalities has demonstrated the presence of varying sized mass lesions in up to % of individuals subjected to ct studies for reasons unrelated to adrenal dysfunction. most of these incidentally discovered lesions are non-functioning benign lesions of cortical origin. however, incidentalomas may also represent functioning lesions and malignant masses. clinical diagnostic and biochemical evaluation is used to further subdivide functional and non-functional adrenal lesions. f-dopa has been found to be of high sensitivity and specificity in pet imaging of pheochromocytoma. ct and mr imaging are first choice in characterisation of adrenal lesions. techniques of dual energy ct and histogram analysis may offer additional information. pet-ct has been shown to contribute to the diagnostic power, especially in oncologic patients. knowledge of the physiologic appearance of adrenal glands in -fdg pet is necessary to correctly identify pathologic processes. fdg-pet also has the ability to detect metastatic lesions in non-enlarged adrenal glands. in addition, fdg-pet has the advantage of simultaneously detecting metastases at other sites. the role of mr-dwi and mr-spectroscopy in characterising adrenal masses has to be defined by further studies. differentiating benign from malignant adrenal masses using non-invasive imaging methods can reduce the need for percutaneous adrenal biopsy in patients with underlying malignant disease and the follow-up imaging of incidentally detected adrenal adenomas. renal cell carcinoma (rcc) is the most common malignant tumour of the kidney. as response rates to radiation and nonantiangiogenic chemotherapy are low, surgical excision, i.e. radical nephrectomy has been the treatment of choice. however novel treatment options have emerged, so that imaging of rcc is of increasing interest. nephron sparing partial nephrectomy has become an accepted operative option and antiangiogenic agents such as inhibitors of tyrosine kinase (tk) and mammalian target of rapamycin (mtor) have been approved for treatment of advanced rcc. thus, it has become important to perform correct local staging and identify patients suitable for partial nephrectomy using standardised scoring systems such as renal or padua. furthermore, optimal imaging strategies for monitoring of advanced and metastatic rcc are discussed, as current antiangiogenic therapy evaluation in clinical routine is based only on morphological imaging information, but changes in tumour size may lag behind functional changes. finally, common side effects, i.e. pneumonitis, of vascular disruptive agents are addressed. characterisation of renal masses can be performed using three categories with respect to the lesion size and gross architecture: the indeterminate very small masses, the cystic, and solid renal masses. lesions with diameters below mm are usually difficult to classify due to partial volume effect that prevents accurate ct attenuation measurement. in the general population, these lesions are likely to be microcysts and do not require further workup. better characterisation remains needed in selected patient populations such as patients with hereditary renal tumour disease and previous history of renal carcinoma. in this case, mri combining t w, diffusion-weighted imaging and dynamic contrast enhanced sequences or contrast-enhanced us may help differentiate very small cysts from solid neoplasms. cystic renal mass characterisation still relies on bosniak's classification with categories: benign (i) and minimally complicated (ii) cysts, indeterminate cystic lesions (iif and iii) and malignant cystic masses (iv). some cystic masses remain unclassified at ct because of atypical attenuation characteristics or enhancement properties. us, contrast-enhanced us, and mri are now playing a key role by providing additional diagnostic information that help distinguish between atypical fluid filled masses and atypical solid neoplasms, especially poorly enhancing solid papillary rcc. the characterisation of small solid renal tumours starts at ct with the identification of macroscopic fat, a typical feature of angiomyolipoma. in the case of non-fatty indeterminate renal neoploasms, percutaneous-guided biopsy can be performed when accurate characterisation is needed before surgery or when renal metastases or lymphoma are suspected. drug development being a complex and costly process, there is an increasing need for imaging biomarkers to take go/no go decisions in the early clinical phases. the recist criteria based on tumour size measurements at ct are currently used for this purpose. however, additional functional and molecular biomarkers have been developed to assess the early biological effect of drugs on tumours. development of imaging biomarkers is a structured process in which new biomarkers are discovered, validated and qualified against biological processes and clinical end points. the validation not only concerns the determination of the sensitivity and specificity, but also the measurement of reproducibility. reproducibility assessments, standardisation of the acquisition and data analysis methods and quality control are crucial when imaging biomarkers are used in multi-centre trials. functional and molecular parameters obtained at perfusion imaging, diffusion-weighted mr imaging and pet are being developed and validated. the perspectives (earlier assessment of response to treatment) and limitations (limited validation and standardisation) of these imaging biomarkers in cancer drug development will be presented. more recently, pharmacodynamic imaging biomarkers such as fdg-suv and k trans have been introduced. drug developers are reluctant to use more exploratory unvalidated imaging biomarkers (i.e. cannot distinguish a true negative from a false negative). the extensive literature on biomarker validation mostly refers to biochemical biomarkers extracted as analytes from biospecimens and is unhelpful to radiologists. unlike biospecimen biomarkers, the quality and validity of imaging measurements as biomarkers depend crucially on the use of a diagnostic imaging device, in the presence of the patient, in a manner for which the device (a) was not designed, (b) has not received regulatory approval and (c) may be unfamiliar to the user in the trial site. technical validation and biological validation are orthogonal activities. ''technical validity'' is confidence that the imaging biomarker can be measured reliably anywhere in the world. ''biological validity'' is confidence that the biomarker correctly reports some underlying biology that is important to the patient's future clinical outcome. since the physician always has access to the patient's clinical status and history, the biomarker is only useful if it provides a better forecast than clinical data alone. (if the forecast is near perfect, the biomarker might be a surrogate end point). technical and biological validations are massive undertakings best achieved by consortia, and in particular publicprivate partnerships, of which the innovative medicines initiative in europe and the biomarkers the standard imaging assessment of tumour response relies on size measurements, which, with predominantly cytostatic targeted agents, may not reflect the drug effect. functional imaging biomarkers have the potential to quantify the biological characteristics of tumours and measure on-target and off-target effects that indicate early likelihood of response to a specific therapy, which can then be used to guide the optimal biological dose and drug schedule. serial, non-invasive assessments of whole tumour are possible. this is particularly important in the context of inter and intra-patient tumour heterogeneity, as different parts of the tumour and primary vs metastatic lesions may be biologically different and these characteristics may change with treatment. however, functional imaging end points suffer from variability, which can be very significant in a multicentre setting. strict quality assurance and quality control measures need to be implemented at the start of a trial and the variability across centres documented. data acquisition protocols need to take account of equipment variations. data analysis methodology needs standardisation of software, central review and preferably double reading of scans. automation may not always prove the most robust and reliable option. this presentation will focus on the factors that are crucial in determining the compatibility of data in multicentre trials with functional imaging end points. learning objectives: . to learn about the potential role of quantitative imaging in processes related to tumour growth such as cell metabolism, cell death, and vascular function in the assessment of tumour response. . to become familiar with the issues of accuracy, reproducibility and standardisation for using functional imaging biomarkers in drug development. quantitative nuclear medicine in drug development w. weber; new york, ny/us nuclear medicine techniques can detect and quantify very low concentrations of radiolabelled pharmaceuticals in the human body. this allows investigators to use nuclear imaging for various purposes during drug development. nuclear imaging can visualise drug targets that are only present in nanomolar concentrations and can thus identify patients most likely for therapies directed against these targets. a recent example is folate receptor spect imaging for the selection of patients for treatment with a folate-targeted drug conjugate. in addition, nuclear imaging and specifically pet can measure the concentration of pharmaceuticals within tumour and normal organs over time. nuclear imaging can also be used to monitor target inhibition, for example the blocking of oestrogen receptors by anti-oestrogens. finally, nuclear imaging can assess tumour response to therapy by measuring changes in tumour metabolism or proliferation, e.g. with fdg-and flt pet/ct. this allows an earlier and more sensitive detection of tumour response than morphologic techniques. since pet is a whole body imaging technology, pet imaging can also be used to study the heterogeneity of target expression, tissue pharmacokinetics, target inhibition and response. pet imaging is now widely available in many countries and has become internationally standardised. it is therefore a robust clinical technique that will increasingly be used during drug development. there are about . patients per year in europe who lose their leg. about % are due to diabetic ischaemic and ulcerative leg problems. in diabetic patients the prevalence of foot ulcerations is about % and the risk for developing foot ulcerations is increased four times. diabetic foot problems may be due to neuropathy and malperfusion or a combination of both. the neuropathic ulcer and the neuroischaemic ulcer are usually at the plantar pedis, have a punched-out appearance and are painless. bone deformities (charcot foot) may be associated. the arterial ulcer is usually at the toe, forefoot and ankle, with pale, cold skin and it may be painful. patients need a multimodality approach involving a diabetologist, vascular specialist (angiologist, vascular surgeon, interventional radiologist) and podiatrist. pain control, antibiotic and antithrombotic treatment and the treatment of cardiovascular risk factors and other co-morbid disease have to be done first. in case of ischaemic pain and ulceration imaging such as mra and cta is the next step. patients should be referred to a team of vascular specialist early in the course of their disease to plan for revascularisation options. revascularisation is the optimal treatment for patients with an ischaemic and neuroischaemic diabetic foot. a. pathophysiology of the diabetic foot v. bérczi; budapest/hu (berczi@hotmail.com) the incidence of diabetes mellitus, associated with both predisposing genetic and environmental factors, is increasing globally. several major clinical trials have proved that complications may occur many years following proper glycaemic control. besides peripheral arterial disease, sensory and motor neuropathy along with an altered response to infection is of crucial importance. recent studies have showed that microvascular occlusive arterial disease is not a major factor affecting the diabetic foot; infrapopliteal macrovascular disease and microvascular dysfunction (e.g. arteriovenous shunting, precapillary sphincter malfunction, capillary leakage, venous pooling) are major components of impaired perfusion of diabetic foot. there are no randomised controlled trials analysing the major outcome following endovacular or open bypass surgery. the major outcomes, however, were similar in the case series: -year limb salvage showed a median of % (interquartile range - %) and % (interquartile range . - . %) following open surgery and endovascular treatment, respectively. limb salvage rate, however, was considerably higher with either type of revascularisation compared to medical therapy. negative pressure wound therapy, hyperbaric oxygen therapy, effective off-loading or nonweight-bearing therapies (total contact casts rather than removable devices) have also shown promising results in recent publications. endovascular arterial revascularisation is today a solid option in the management of cli with low complication rates and limb salvage rates comparable with surgery. the restoration of adequate blood flow to the foot is crucial to facilitate wound healing, provide pain relief, and avoid whatever amputations. the angiosome concept was first introduced in by taylor and further developed by attinger for planning treatment of ischaemic lesions of the foot. they divided the foot into six distinct angiosomes, arising from tibial and peroneal arteries. planning the procedure on the basis of this concept will yield the best local results of wound healing, compared with the indirect intervention. a proper pre-procedure assessment through colour doppler us and dsa of lower limbs is mandatory for guiding the procedure through the vessels of the foot. several studies have evaluated the efficacy of pta in the btk and the reliability of the angiosome model, approaching % with a limb salvage rate of up to % at months. on the basis of these data, we can conclude that pta in diabetic patients with btk disease is a safe and effective technique. the first endovascular treatment option is related to the angiosome model, but when not feasible the indirect technique is also a valid and similarly effective procedure. to face technical failures, up to % in crural chronic total occlusion a decade ago, different approaches and dedicated devices and technologies have been developed in the last few years. furthermore, percutaneous revascularisations are gaining more interest, particularly in patients with critical limb ischaemia not only as first-line treatment, but also as the only possible treatment for complex lesions and high-risk patients. special techniques for crural endovascular revascularisations are by design techniques rarely used in routine practice, but could offer wide possibilities for the interventional radiologist to solve challenging situations and manage complex lesions. these techniques include options for arterial access (trans-popliteal, trans-tibial, trans-pedal), approaches for crossing chronic total occlusion (assisted endoluminal, lambda technique, re-entry technologies) and uncommon routes for angioplasty/recanalisation (trans-metatarsal loop technique, trans-collateral techniques). combined antegrade and retrograde approaches have also been developed as well as related methods for successful re-entry. deciding when the patient/lesion is a potential candidate for special techniques is also a crucial issue. the interventional radiologist should be able to convert at any time if necessary the strategy of treatment to another one. he should also be able to select the most appropriate technique for the patient in planning revascularisation. continuous medical education and training is however mandatory and for some techniques the learning curve is relatively long. pathology of the eye and orbit is rare in the radiologist's practice. however, differential diagnosis is not too difficult if the compartment model is applied. in the orbit, different anatomical structures like the optic nerve as part of the cns, muscles for moving the globe, vascular structures and glandular tissue are present in a very small space. each anatomical structure is found in a special compartment; each compartment may give rise to a different group of pathologies, and only to these pathologies: glioma in the optic nerve, rhabdomyosarcoma in the eye muscles, varix in the venous vessels (intraconal compartment) and pleomorphic adenoma in the lachrymal gland. understanding the compartments in the orbit is therefore the key to differentiating different pathological entities. this presentation explains the orbital anatomy, how the compartments are differentiated, and what changes in anatomy treatment may induce. orbital congenital lesions are uncommon. they can be diagnosed prenatally, at birth or later during childhood. several orbital components can be involved. we will focus on congenital globe lesions (such as staphyloma, coloboma, persistent hyperplastic primary vitreous, coats disease), the developmental cysts such as epidermoids and dermoids, and vascular malformations such as lymphangioma and vascular tumours, e.g. capillary haemangioma. orbital inflammatory and infectious lesions are on the other hand common. orbital pseudotumour can involve any area of orbit, being one of the great mimickers in the orbit. if located in the orbital apex and/or cavernous sinus, it will be called tolosa-hunt syndrome. other inflammatory processes in the orbit are sarcoidosis and wegener and sjogren syndrome. among infections the most common is the orbital cellulitis, mostly secondary to a sinusitis and frequent in the urgency setting. the role of the radiologist is to assess whether it is preseptal or already postseptal or complicated by a subperiosteal phlegmon or abscess. also of importance is to know and evaluate the possible intracranial complications. finally, we will focus on inflammatory and infectious lesions of some specific regions such as the globe and lachrymal gland and give some clues for their differentiation. as more than pathologies can be seen in the orbit, a systematic approach is very important to come to the right diagnosis. the main and most helpful criteria of differential diagnosis of any orbital pathology is the definition of the affected orbital compartment, as some tumours may only or preferentially involve specific orbital structures. the criteria of the most frequent masses of the globe, malignant melanoma and retinoblastoma are presented as well as those of cavernoma and lymphoma, the main representatives of intraconal tumours. there are numerous extraconal neoplasms, only few arising from the nasal sinuses, and only a little number of tumours of the optic nerve. the presentation will include the most frequent as well as rare, but important tumours. the routine practice of oncologic imaging requires standardisation, which means that we need to harmonise technical protocols and agree on the meaning of selected words for the radiological report. the words "response, "progression" and "stable disease" are precisely defined according to internationally accepted thresholds and criteria. although the rules are quite simple and rather easy to apply, they are very efficient in the classification of the response to treatment, and therefore for the medical decisions. however, the role of the radiologist is not limited to measurements and calculation. the detection of new lesions may be challenging and requires experience. the differential between cancer progression and complications of the treatment might be very difficult and requires an adequate communication with the referring clinician. overall, most of the decisions taken by the clinician will be related to imaging results, stressing the importance of adequate protocols and reports. in solid as well as non-solid tumours, pet/ct imaging using -fluorodeoxyglucose (fdg) has demonstrated the ability to a) correctly stage disease, b) demonstrate therapy response and c) predict therapy outcome. fdg uptake can be measured objectively; however several factors in the standardisation processes of tracer application, image acquisition and post-processing are needed for reproducibility. the term standard uptake value (suv) measurement is used for compensating the influence of injected dose, decay time and body mass and represents fdg uptake in any selected pixel of the image. for therapy assessment, drop in fdg uptake represents tumour cell kill, notably a negative pet scan does not exclude viable tumour cells but overall has a better outcome. pet response criteria in solid tumours (percist . ) have been introduced to refine previously established pet response criteria by eortc. major changes concern the use of lean body mass-based suv (sul), sulpeak measurement in a fixed roi, use of only a single target lesion and normalization to liver uptake. metric measurements in ct component of the pet/ct as an intrinsic asset like in recist . have not yet been introduced, but might be crucial in the future. the proposed percist . criteria are not yet standard, since several limitations hamper its general use but may improve metabolic tumour response assessment. malignant gliomas (who grade iii and iv) are the most common primary tumours of the brain. according to consensus guidelines, the standard of care of these tumours includes maximal safe surgical resection followed by combined treatment with chemoradiotherapy. radiological assessment is critical in the follow-up and should be performed at four different times: . within hours after surgery, an early post-operative mri must be done to evaluate residual tumour and to be used as baseline for follow-up. . two to six weeks after completing radiotherapy, a new mri examination is recommended to evaluate the response to treatment. four possibilities are envisaged according to the rano criteria: complete response, partial response, stable disease or progressive disease. the evaluation of this first mri examination after rt is challenging and the pseudoprogression phenomenon can appear. advanced mr techniques may be of help in this respect. . additional follow-up should then be performed by mri every to months to rule out clinically silent progression. . in any case, an mri examination must be completed when there is a clinical suspicion of progressive disease. several options for treatment can be offered when progressive disease is detected, including antiangiogenic drugs. evaluation of response to these drugs is challenging too, and the pseudoresponse phenomenon can then appear. due its complexity, it is recommended that the management of malignant gliomas be performed in the context of multidisciplinary teams and that the radiologists are strongly involved in these teams. we are facing complex times with no parallel in human history. the worldwide economic crisis, in combination with a non-regulated process of globalisation, is pressuring countries to change their social and political model. these changes are affecting academic institutions and the health-care sector. higher education was always more internationally open than most sectors because of its immersion in knowledge, which was never worried about country juridical boundaries. it is well recognised that it was the knowledge created by universities research that contributed to the development of societies. we, as european citizens, must be able to transmit the message that having more knowledge and being capable of understanding better the world we live in will make us stronger, more successful and more competitive. european academic institutions must be prepared for this shift of paradigm and understand that they are no longer educating only for their country but for the globalised world. it is also important to bear in mind that developed health-care systems are suffering several pressures and a call for a new inter-professional collaboration concept is needed, based on each one's roles and responsibilities, towards a better and more efficient health-care delivery for the patients. in this session, the invited speakers will give us an overview about the challenges that academic institutions will face in the near future and the way they must adapt to become more attractive and at the same time guarantee that radiographers and radiologists are educated and trained according to the highest professional standards. session objectives: . to appreciate the challenges that academic institutions must face in order to educate graduates with the ability to work internationally and to actively contribute to the healthcare sector of the future. . to explore innovative approaches in education and assessment. . to highlight the importance of inter-professional collaboration in order to ensure that graduates are ready to meet the demands of the modern healthcare sector. challenges in undergraduate education l.j.o.c. lanca; lisbon/pt (luis.lanca@estesl.ipl.pt) radiographers operate a wide range of sophisticated equipment and perform a range of techniques in several radiological procedures. they are responsible for the radiation delivered to the patient while assuring safety and image quality at an acceptable level for an accurate diagnosis. education and training in radiography, in line with the constant technological developments, is a requirement to be fulfilled by higher education institutions (hei). this is of major importance in undergraduate education where radiographers learn to play an effective role as healthcare providers in planning, preparing and performing accurate and safe radiological procedures within the diagnostic or therapeutic field. the european qualifications framework (eqf) for radiography, in terms of the development of knowledge, skills and competences, provides a european standard for the development of radiography learning outcomes at eqf level . this constitutes an opportunity to develop, tune, advance and promote standards of radiographic practice, education and research throughout europe. the eqf provides guidance to increase the educational and professional recognition of radiography in europe. at a european level, the cooperation between hei in undergraduate radiography education would be an opportunity to provide discussions of mutual concern, explore new perspectives and views of different cultures, and also share learning and teaching methods. international cooperation is an opportunity to improve and provide the harmonisation of education regarding a professional group that plays an effective role in healthcare in their field of competence and expertise. there is a vast amount of evidence available from the published literature that higher education institutions continue to explore innovation in both teaching and assessment practices. this is especially true of health professional programmes as evidenced by the abundance of literature relating to medicine, nursing, radiography and other allied health professions. such higher education, health professional programmes would appear to be more innovative than many other disciplines often as a direct attempt to mirror the dynamic clinical environment in which most graduates will work. there are, however, challenges associated with any such educational innovations and novel approaches to delivery and assessment. these specific challenges must be carefully considered in parallel with the larger challenges facing higher education institutions, both nationally and internationally, along with the professions which they contribute to. through a case study approach, supported by published peer-reviewed literature, institutional reports and research, this presentation will consider international best practice in education along with the value of collaborative, inter-professional approaches to teaching and assessment. haemodialysis accesses have become the most commonly performed type of vascular surgical procedure. however, only % of all haemodialysis accesses remain patent at years. autogenous fistulas have a higher rate of primary failure compared to prosthetic grafts ( % vs. %), but the long-term patency of fistulas is superior to that of grafts. autogenous fistulas fail after a median of to years, whereas prosthetic arteriovenous grafts fail after a median lifetime of only to months. the pathogenic stenoses causing access failure occur in various locations, but the most common site in prosthetic arteriovenous grafts is at the anastomosis between the graft and outflow vein, as identified in % ( , ) to % of cases, or in the outflow vein itself in autogenous arteriovenous fistulas. clinical assessment alone will detect a large number of failing fistulas. by assessment of the thrill, pulse character, palpation of the fistula itself, excessive bleeding and difficulty needling a fistula may all indicate a failing fistula. if the venous pressures during haemodialysis exceed mm hg, fistula flow falls to< ml/min, graft flow decreases to< ml/min, or access blood flow falls by more than %. a fistulogram is recommended if monitoring or surveillance suggests that thrombosis is either imminent or has already occurred. duplex can be used to assess the fistula, but cannot visualise the central veins. mr and ct venography has also been used in many patients successfully. treatment of symptomatic stenosis of vascular access is essential as it can lead to thrombosis and loss of vascular access. but treatment can lead to restenosis. the treatment of stenosis remains a challenge which requires a good knowledge of different materials (guidewire, catheters, balloons and stents). though the pathophysiological mechanism of stenosis is different for native fistulas, grafts or restenosis, the treatment technique remains the same. the basic principle is the use of high inflation pressure balloon angioplasty. whatever the material used, the key is to have no residual stenosis greater than %. so far, no study has demonstrated the superiority of the "new" tools (cutting balloon, drug-eluting balloon, cryotherapy) regarding restenosis. except perhaps for anastomotic grafts stenosis, stents should be reserved to treat complications or failure of balloon angioplasty. the stents indications are residual elastic stenosis, wall obstructive damage, acute rupture during angioplasty, aneurysm or restenosis. complications of stenosis treatment are rare, but can lead to the loss of vascular access. the main complications are thrombosis and acute rupture. as with any treatment, there have been contraindications: infection, distal ischaemia, high flow, newly created or surgically revised access (< weeks). when dealing with a vascular stenosis access, never compromise on the future, but think about the surgical alternative. so, the management of stenosis vascular access must also be multidisciplinary. percutaneous treatment of a thrombosed dialysis access can be extremely challenging. the major concern does not stem from the fact that the procedure can be complexly long, but arises rather from the management of its complications, which can be serious particularly when the access is branched onto the brachial artery. access infection is an absolute contraindication. temporary contraindications include fluid overload and severe hyperkalaemia. percutaneous thrombectomy of grafts is very well standardised and predictable: size of mm, well palpable wall which is easy to needle, small average clot burden, and an underlining stenosis almost always found at the venous anastomosis. thrombectomy of avfs is subject to variations in approach and technical difficulties depending on their anatomical particularities. all techniques employed follow rules: first, the removal of thrombi and, second, dilation of the stenosis responsible for the thrombosis. heparin and antibiotics must be injected. the basic principle is to place in the arterialized vein or graft introducer sheaths in opposite directions to work on both the venous outflow and arterial inflow. thrombus lysis or removal can be achieved by mechanical, pharmacological and pharmaco-mechanical methods. all techniques may work in grafts given that the modest amount of thrombus ( . ml on average) can be simply pushed into the lungs. prosthetic grafts are thus easier to declot than native fistulas, but they are much more prone to early rethrombosis. thrombi located at the arteriovenous anastomosis form a firm and rubbery plug, frequently and notoriously resistant to thrombolysis. drug-induced lung disease is an increasingly common cause of morbidity and mortality. the diagnosis is based on clinical history and consistent radiologic findings. lung biopsy is performed in a small percentage of cases. highresolution ct may demonstrate different parenchymal patterns including diffuse alveolar damage, acute or chronic alveolar haemorrhage, nonspecific interstitial pneumonia (nsip), hypersensitivity pneumonitis, organising pneumonia, and eosinophilic pneumonia. the imaging and histologic manifestations are often nonspecific. a systematic approach to the radiological evaluation of drug-related lung diseases is essential and includes not only chest imaging pattern recognition, but also integration of available clinical information. in this interactive session, we will present and discuss several cases illustrating thoracic changes after instrumental procedures in the thorax such as surgery, radiofrequency ablation, interventional endoscopy, and intensive care. radiologists have an important role in assessing the results of these procedures as well as in depicting the complications. however, knowledge of the normal appearance after those procedures has to be presented. the initial imaging workup of polytrauma patients remains challenging. besides hardware requirements, workflow issues continue to evolve, with the current focus on the introduction of whole body ct into the early resuscitation phase of severely injured patients as a standard and basic diagnostic imaging method. this session is aimed at a thorough discussion on the requirements for advanced imaging in the early clinical situation in emergency radiology. focus is directed on the issues of radiation dose as well as on ct and contrast media protocols. a. chest and abdomen m. scaglione; castel volturno/it (mscaglione@tiscali.it) thoraco-abdominal injuries are a significant cause of death in the polytraumatised patients. early recognition and communication of lifethreatening thoraco-abdominal injuries is the major task of the radiologists involved in the emergency room. although most of these patients reach the hospital prior to dying, lethality continues to remain high. heart, thoracic great vessels, trachea, bronchus, pleura, lung, diaphragm, abdominal/retroperitoneal, vascular and solid organ injuries are potential cause of death. any appropriate surgical/interventional management approach must be carried out "around the clock", before thoraco-abdominal injuries reach the level of clinical evidence. on the other hand, non-operative management has actually become the standard of care for the most serious thoraco-abdominal injuries. these goals become feasible if a correct contrast-enhanced mdct diagnosis, in a dedicated facility in which the trauma team works effectively h a day, days a week, is performed. thus, in this lecture, the most serious thoraco-abdominal injuries will be illustrated, with special emphasis on vascular/injuries as well as the value of post-processing techniques, protocols, pitfalls, tips and tricks. furthermore, the importance of a rational and integrated imaging approach will be pointed out and, finally, the role of the radiologist in the emergency room will be emphasised. spinal and musculoskeletal trauma account for significant morbidity in severely traumatised patients. traumatic injuries to the spine encompass a variety of frequently occurring disorders and primarily result in stable injury. although rare, unstable disorders comprise injuries to the bone, the discs, and the ligaments. in the majority of cases, spinal cord injuries result in devastating medical and social consequences. severe musculoskeletal disorders usually are the result of high-impact accidents, such as motor vehicle accidents and falls from a height. for instance, the injured pelvic ring causes one of the most life-threatening conditions that the trauma team must handle. pelvic injuries are often associated with severe arterial, venous, and/or osseous bleeding. radiography is no longer recommended as the primary screening modality in spinal and pelvic trauma for adults. despite the radiation dose burden of ct, patients with a high risk of spine injury receive mdct imaging, as it is the method of choice. mr imaging is indicated primarily when patients present with myelopathy, and to search for spinal cord pathology. interventional radiology plays a major role in the therapy of complex traumatic pelvic disorders. extremity injuries in patients after polytrauma can be complex and are initially often difficult to be fully diagnosed. emergency radiology diagnosis is today mostly based on a standardised whole body ct (wbct), which can be extended with cta and adapted to cover extremity injuries. extremity injuries comprise: fractures of ( ) long bones, ( ) articular joints, ( ) complex fractures of hands and feet, ( ) vascular, ( ) soft tissue, ( ) nerve and plexus injuries and ( ) amputations. imaging protocol: *mdct is indicated in all major and complex bony fractures and is carried out early or integrated with wbct. cta using mips and mprs enables a thorough workup. * the role of us and cr is limited. * the role of mr and mra (in stable patients only) is to evaluate unstable articular injuries, injuries of tendons or major ligaments and nerve and plexus injuries). * the role of dsa is mostly for intervention. clinical findings and findings from wbct determine how to proceed, "first things are done first" in a priority-oriented clinical algorithm. treatment of extremity injuries must therefore be priority oriented and carefully planned in the context of possible concurrent injuries and a possible risk of multi-organ failure (mof). systemic drugs can be used for the treatment of cns and non-cns diseases. both classes can affect the brain inadvertently. common general drugs that affect the brain in a bystander manner are steroids (~ % brain volume reduction), recreational drugs (alcohol, cocaine, heroin, xtc), metronidazole and anti-epileptic drugs (corpus callosum demyelination) and immunosuppressants like cyclosporine/tacrolimus (pres/rpls) and methotrexate. mechanisms of action include neurovascular compromise, fluid/metabolite shifts and toxic effects to myelin of other tissue components. among cns-targeted drugs, especially immunomodulating agents may cause specific side effects. cytokine-release syndromes may occur with broad-acting agents such as general t cell antibodies. specific side effects may occur in multiple sclerosis, where treatment with natalizmumab may cause reactivation of jc virus leading to progressive multifocal leukencephalopathy (pml). upon withdrawal of therapy, this may then evolve into an immune reconstitution inflammatory syndrome (iris). in alzheimer disease, novel antibodies or vaccinations against amyloid may cause amyloid related imaging abnormalities (aria), which may present with microhaemorrhage on t * images, or with edema and effusion on flair. the objective of this session will be to review the diagnostic value of conventional sequences as well as the use of contrast in the monitoring of brain tumours, with special attention to gliomas. also, we will address the advantages and limitations of advanced techniques: perfusion, diffusion, and spectroscopy. immediately after surgery, the main objective of neuroimaging is the detection of the remaining tumour. it may also be necessary to rule out complications such as haemorrhage, ischaemia or infection. the fundamental technique is mri with contrast in the first hours and also diffusion sequences. in late follow-up, the goal is to differentiate the changes secondary to treatment of those related to tumour progression or recurrence. in these cases, conventional sequences present important constraints and are useful studies of diffusion, perfusion and spectroscopy. during follow-up after chemoradiotherapy, the objective is to assess tumour response. the response according to the new rano criteria will be revised. the combination of chemotherapy and radiotherapy, as well as the use of anti-angiogenic drugs causes changes that complicate the assessment of the response to treatment, with cases of pseudoprogression and pseudoresponse. in these cases, perfusion techniques, diffusion and spectroscopy can provide relevant information, although it is necessary to standardise the quantification to make its wide use possible. the speakers in this course will update the audience on contrast media safety such as steps to be taken before contrast administration and present the newest safety guidelines. the first speaker will cover new concepts of non-renal reactions to contrast media explaining which hypersensitivity reactions are allergic and non-allergic. the audience may learn assessing symptoms according to the ring and messmer classification and understand the importance of tryptase sampling and skin testing in the follow-up. the second speaker will address nsf. the presentation will review the pathophysiology, risk factors, recent recommendations and prevention of nsf. patients with gfr less than ml/min/ . m have increased risk of developing nsf. lowstability gadolinium contrast media show the strongest association with nsf. following existing guidelines on the use of gadolinium contrast agents minimises the risk of nsf. potential long-term harm from gadolinium accumulation in the body and legal issues are discussed. the last speakers will cover contrast medium-induced nephropathy with more recently published guidelines related to that issue. the presentation will include the definition of cin and the choice of contrast medium and prophylactic measures. recent changes in esur guidelines will be explained. the risk of cin is considered significantly lower following iv. cm administration and patients referred for enhanced ct are genuinely at risk if they have an egfr < ml/min/ . m . volume expansion with isotonic saline or sodium bicarbonate may be used for preventing cin in at-risk patients. acute immediate hypersensitivity reactions occur within the hour following the administration of contrast media. they can be seen with iodinated and gadolinium-based contrast agents. over the last ten years, new concepts have emerged in the way of understanding, managing and exploring hypersensitivity reactions. the clinical appearance is best classified by the ring and messmer scoring, from grade (cutaneous and subcutaneous signs) to grade (cardiovascular arrest). the mechanisms involve either true ige-mediated hypersensitivity or non-allergic hypersensitivity. the differential diagnosis in favour of allergy is made on a triad: clinical signs (the more severe, the more are the chances to be allergic), elevated tryptase levels in the plasma (indicating mastocyte triggering) and positive skin tests performed one month after the reaction. these new concepts induce important consequences in managing hypersensitivity reactions: be prepared to treat the patient adequately, be prepared to draw blood after the reaction to dose tryptase levels, send the patient to a dedicated allergologist, and forget about the preventive role of premedication against severe reactions. the authorities have introduced several restrictions on the use of high-risk agents, which will be followed by every physician in the eu. the agents are contraindicated in ) patients with severely reduced renal function including dialysis, ) acute renal insufficiency, ) neonates and ) pregnant women. they may only be used with caution in patients with moderately reduced renal function and children less than year old. there must be at least days between injections in those patients. renal function must always be determined by laboratory methods before use of high-risk agents. women should stop lactation for hours. these agents should never be given at doses higher than . mmol/kg per examination in any patient. for the intermediate and low-risk agents, the restrictions are significantly less; they should only be used with caution in patients with severely reduced renal function including dialysis. if a physician does not follow these rules, he or she will have legal problems as they have been introduced into the spc by the authorities. the contrast media safety committee (cmsc) of the esur has updated its guidelines on contrast medium-induced nephropathy (cin). the acr recently updated its guidelines as well. new guidelines were produced by nephrological societies. the topics reviewed include the definition of cin, the choice of contrast medium, and the prophylactic measures used to reduce the incidence of cin. the cmsc considered it appropriate to keep the definition of cin that was agreed in . however, nephrologists have recently agreed on a new definition. in the previous guideline, a number of risk factors were listed (raised s-creatinine levels, particularly secondary to diabetic nephropathy, dehydration, congestive heart failure, age over years, concurrent administration of nephrotoxic drugs). the significance of these risk factors has been confirmed and new risk factors were added. the cmsc agreed that the risk of cin was significantly lower following intravenous cm administration and concluded that patients referred for enhanced ct were genuinely at risk if they had an egfr < ml/min/ . m . the previous cmsc guideline suggested the use of low or iso-osmolar cm in patients with risk factors for cin and the cmsc considered that this previous guideline should not be changed. the cmsc considered that there was enough evidence to recommend that either volume expansion with isotonic saline or sodium bicarbonate may be used for preventing cin in at-risk patients, while the efficacy of nac and other drugs in reducing the incidence of cin remained unproven. guidelines produced by other societies provide very similar suggestions, thus further validating these recommendations. jia is the most common rheumatic entity in childhood and includes a subset of childhood arthritis, all of which are characterised by chronic synovitis with a potential risk of progressive joint destruction. radiological investigations in jia should ideally be able to determine the presence and degree of active inflammation, precursors of bony destructions and established erosions. however, there are many pitfalls in the interpretation of joint pathology in children. ultrasonography is often the initial tool in the assessment of arthritis and can depict joint fluid and synovitis. erosions and cartilage destruction of small joints may also be seen. the major problems are standardising the imaging technique and the lack of normal standards of anatomy in us in children. radiographs can show bone erosions and may depict cartilage loss indirectly through joint space narrowing, but are insensitive to inflammation and early joint destruction. mri is the only imaging modality that can assess all relevant anatomical structures in joint inflammation and is sensitive to early inflammation and destruction. however, large variations in the amount of joint fluid, bone marrow oedema-like lesions and changes resembling erosions are seen in children and also in healthy individuals. the differentiation between true pathology and normal findings on mri in children remains a challenge, particularly in early disease. in this lecture, the role of radiographs, ultrasound and mri and the typical radiological findings in joint pathology in jia will be presented. current knowledge on validity and reliability of the different imaging techniques in jia will be discussed. brain mri plays an important role in those criteria, as it can demonstrate the classical dissemination in time and space and helps earlier diagnosis, which is of major importance since the present recommendation in children is to start immunomodulating treatments as soon as diagnosis is established. among paediatric ms, % begin before the age of years and % before the age of years, frequently with an adem presentation in young children as initial manifestation of ms. however, only % of the adem indicate ms onset and the most predictive factors should be known, i.e. periventricular, deep white matter, corpus callosum high t signal lesions and black holes on t sequences. mri evaluation is also instrumental in differential diagnoses such as nonrelapsing adem, vasculitis, immunogenetic diseases and occasionally leukodystrophies. finally, brain mri is useful to evaluate the risk of more severe ms. the obesity epidemic represents one of the most significant european and public health challenges in the st century with prevalence of the disease having tripled in many countries during the past years. this is resulting in an ever increasing cost to healthcare systems including hospital and in particular radiology services which face unique challenges when imaging this group of patients. obesity significantly increases the patient's risk of various comorbid diseases including the incidence of cancer, diabetes, and cardiovascular and liver pathology with a multidisciplinary team approach mandatory for optimal patient care. this multidisciplinary symposium will review the implications of the epidemic with cutting edge, in-depth lectures presented by european experts addressing the epidemiology, role of imaging in the bariatric surgical patient as well as the importance of abnormal fat deposition in the liver. session objectives: . to learn about the impact of the obesity epidemic on european healthcare. . to appreciate the value of imaging techniques in the management of the post-operative bariatric patient. . to understand the role of radiology in fatty liver disease and the importance of imaging during subsequent patient surveillance. obesity: causes and consequences to the patient r. batterham; london/uk (r.batterham@ucl.ac.uk) obesity is one of the greatest st century public health challenges. its prevalence has tripled in many european union (eu) countries since the s. currently, % of eu adult population is overweight and % obese, and the numbers of those affected continue to rise. overweight and obesity are risk factors for numerous health problems, including hypertension, diabetes, cardiovascular diseases, respiratory problems, musculoskeletal diseases and some forms of cancer. mortality also increases sharply once the overweight threshold is crossed. because obesity is associated with higher risks of chronic illnesses, it is linked to significant additional health care costs and is already responsible for - % of health costs. changes in our environment are the main driver for this increase in overweight/obese. however, a person's genetic make-up can either increase or decrease their chances of becoming overweight. the gastrointestinal tract is the body's largest endocrine organ producing hormones that regulate bodyweight. dietary modifications, such as caloric restriction, are the first-line obesity treatments. however, dieting produces only moderate weight-loss with poor weight-loss maintenance. compensatory gut hormone changes induced by dieting are thought to contribute to the failure of dieting. in contrast, bariatric surgery is an efficacious treatment modality for obesity, producing durable weight-loss, amelioration of obesity-associated co-morbidities and reduced mortality. consequently, the number of bariatric procedures undertaken within europe has doubled in the last years with , procedures undertaken in . there is increasing evidence that surgically-induced alterations in circulating gut hormones mediate the weight-loss and metabolic beneficial effects of bariatric surgery. learning objectives: . to understand the epidemiology of obesity and its impact on european healthcare provision. . to appreciate the aetiology of obesity and the scientific rational for surgical treatment. . to learn about the effects of obesity on health. imaging of modern surgical procedures and their complications m. rengo; latina/ it (marco.rengo@gmail.com) we will illustrate the common bariatric procedures, in particular their normal appearance on different diagnostic technique as well as their early and late complications. we will illustrate the correlation between conventional barium studies and advanced imaging with mdct and mr. we will explain how to optimise mdct and mr acquisition protocol according to the clinical indication. we will explain what to evaluate before redo surgery, in particular quantitative and functional analysis. we will illustrate the role of interventional radiology in the management of early postoperative complications, in particular in the management of patients subjected to gastric banding. non-alcoholic fatty liver disease comprises a variety of pathological disorders ranging from simple steatosis to steatohepatitis. this condition is common in the western population and is typically associated with obesity and the metabolic syndrome. its incidence increases dramatically. diagnosis of fatty liver and distinction between simple steatosis and steatohepatitis are keys because the latter can lead to extensive fibrosis and cirrhosis with an increased risk of hepatocellular carcinoma (hcc). imaging plays a crucial role in diagnosing fatty liver. the two most important imaging modalities are ultrasound and mr imaging. ultrasound can exclude major steatosis but lacks accuracy to precisely quantify fat, while mr is the most accurate for quantification. the technique of reference is mr spectroscopy, but sophisticated sequences based on chemical shift principle have been shown as accurate as mr spectroscopy. unfortunately, imaging has still limitations to assess the presence of fibrosis and inflammation which are associated with steatohepatitis and functional tools could be of interest. today, imaging is combined with clinical and biological biomarkers to evaluate the risk of steatohepatitis. due to the increased risk of hcc and cirrhosis-related complications in patients with steatohepatitis, patients at risk should be enrolled in the surveillance programme. learning objectives: . to understand the pathophysiology of fatty liver disease and its link to cirrhosis. . to become familiar with the role of imaging in the detection and quantification of fat in the liver. . to learn about the importance of imaging in the surveillance of patients with fatty liver disease. the concept of breast cancer units originates from the need for making available to all women in europe high-quality breast services where breast disease could be looked after by specialists working as teams. such teams have to provide all the services related to breast cancer, including genetics and prevention, treatment of the primary tumour, care of advanced disease, palliation and follow-up of previously treated women. the breast unit is made up of a group of dedicated breast cancer specialists including a radiologist, radiographer, surgeon, reconstructive surgeon, pathologist, medical oncologist, radiation oncologist and breast care nurse. the specialists involved in breast cancer units have access to all the facilities required for high-quality care and spend most of their working time dealing with breast cancer. in our hospital, we routinely work as a team and to make it possible we organise weekly meetings involving specialists from different disciplines to evaluate and plan patient care at any step of the diagnostic and therapeutic process. each year, we take care of about . newly diagnosed patients with primary breast cancer and of . patients in follow-up. about are patients who undergo rt. after a short introduction from our fellows from pathology, surgery, oncology and radiation therapy, who will discuss their role in the breast unit, we will try to give a practical demonstration of the everyday work of breast units with particular emphasis on the role of the radiologist. the european society of urogenital radiology (esur) published, in , the new clinical guidelines for evaluation of the multi-parametric mri of the prostate. this structured reporting/scoring system (pi-rads) is based on literary evidence and consensus of experts' opinions. the pi-rads scoring system is similar to that already employed by breast imaging (bi-rads) and reflects the probability of a prostatic lesion to be significant. each lesion can be scored in all sequences used in the multi-parametric prostate mri protocols (t -and diffusion weighted imaging, dynamic contrast enhanced imaging and mr spectroscopy) based on defined mri criteria, which are specific for each sequence. based on the scoring in the particular sequences a final pi-rads score for each lesion can be assessed. for each lesion a five-grade scoring systems was created where, for example, the score means that clinically significant disease is highly unlikely to be present and score clinically significant disease is highly likely to be present. this lecture elucidates the principles of this scoring system and its impact on the target definition for the invasive diagnostics and therapy. prostate cancer screening with psa and extended systematic biopsy protocols have led to the over-detection and over-treatment of small and well differentiated cancers, considered clinically insignificant. these cancers cover up to % of the overall prevalence and may not be of any threat. multiparametric (mp)-mri has shown recently its value in the detection, localisation and characterisation of prostatic tumour foci larger than . cm, and may be of value to address the issue of over-detection and over-treatment. an mri-targeted biopsy strategy alone, without any additional systematic biopsies, has been suggested to decrease the detection rate of insignificant tumours while increasing that of potentially aggressive tumours. in patients with no evidence of lesion on mp-mri, the biopsy may probably be deferred. in patients with localised prostate cancer, mp-mri may also become a cornerstone in the selection, guidance and surveillance of patients managed with focal therapy. the rational for this new modality of treatment is to decrease over-treatment by destroying exclusively the index lesion detected on mp-mri. the precision of such treatments may be increased with mritransrectal ultrasound image fusion, allowing for real time navigation during the procedure. the accuracy of multiparametric mri has greatly improved the ability of localising tumour foci of prostate cancer. this property can be used to perform a trus-mr image registration, a new technological advance, which allows for an overlay of an mri onto a trus image to target a prostate biopsy towards a suspicious area. three types of registrations have been developed: cognitivebased, sensor-based and organ-based registration. cognitive registration consists of aiming at a suspicious area during biopsy with the knowledge of the lesion location identified on multiparametric mri. sensor-based registration consists of tracking in real time the trus probe with a magnetic device, achieving a global positioning system which overlays in real time prostate image on both modalities. its main limitation is that it does not take into account prostate and patient motion during biopsy two systems (artemis and uronav) have been developed to partially circumvent this drawback. organbased registration (koelis) does not aim at tracking the trus probe, but the prostate itself to compute in a d acquisition the trus prostate shape, allowing for a registration with the corresponding d mri shape. this system is not limited by prostate/patient motion and allows for a deformation of the organ during registration. the pros and cons of each technique and the rationale for a targeted-biopsy only policy are discussed. radiotherapy of the prostate typically takes the form of either external beam radiotherapy or alternatively, brachytherapy using radioactive seed implants. in both cases, the use of ultrasound has been proven to be highly useful and this presentation will give an current state of the art overview of ultrasound in external beam and radioactive seed radiotherapy. in the case of external beam radiotherapy, accurate localisation of the prostate is essential to ensure adequate target coverage with minimal damage to normal tissue. dedicated ultrasound scanners are able to provide sub millimeter localisation of the prostate superior to the imaging traditionally obtained using ct scanners. this positional information can be obtained daily. in addition, ultrasound allows the imaging of patients with metal hip implants which are normally difficult to image using ct. apart from the benefits of the technique, some pitfalls will also be highlighted. in the case of prostate brachytherapy, the use of ultrasound in the -d volume imaging of the prostate both prior and during treatment will be discussed. in both cases, some time will be spend discussing the quality assurance requirements for ultrasound imaging systems. image-guided radiation therapy (igrt) with onboard kilovoltage cone-beam ct (cbct) allows image guidance during radiotherapy treatments for patient setup and dose replanning. all these items will be discussed in connection with other topics: organ dose and image quality. it is compulsory to convert cbctimage's pixels from arbitrary grey scale to hounsfield unit (hu). this conversion was obtained using a catphan phantom. the same phantom is used for image quality evaluation; standard ctdi head and body phantoms and a farmer chamber were used to measure the cbdi to estimate organ and effective doses by monte carlo software of different protocols of acquisition. ctdosimetry software (ver. . . -impact) and pcxmc . rotation software were used. to verify the dose replanning techniques by cbct, horizontal and vertical dose profiles were compared with the same obtained from ct. patient replanning was verified using cbct vs ct in terms of conformity index. image quality parameters of cbct (in comparison with ct images) are fine for spatial resolution, but are less useful for low contrast. cbdi of . mgy/ mas was measured; msv effective dose, mgy prostate dose and mgy bladder dose were evaluated and discussed during the presentation. replanning on cylindrical phantom shows a mean percentage difference for each profile % and a variation on d mean in all inserts < %. the mean percentage difference between parameters characterising ct and cbct-based plan values is less than %. the replanning showed a substantial agreement with doses evaluated on the reference ct-image; patient dose must be evaluated for all radiation sources. cranial nerves i-vi have an anteroposterior course and are best examined in the coronal plane. cranial nerves vii-xii run in an anterolateral direction and are therefore best examined in the axial plane. these two planes also allow left-right comparison which makes lesion detection easier. lesions involving the cranial nerve nuclei can be detected on axial proton-density/t /multi-echo-ge images and diffusion-weighted images can exclude acute infarction. the cisternal segment of the cranial nerves is best detected on heavily t -weighted images (drive/fiesta/ d-tse/ciss). at -tesla, d-sequences (e.g. b-ffe) can be used and it is often possible to cover the cisternal segments of all cranial nerves. in the cavernous sinus, the cranial nerves can only be evaluated on coronal gadolinium-enhanced high-resolution t -weighted images and similar axial images are needed to evaluate the nerves in the jugular foramen and hypoglossal canal. axial and coronal gd-enhanced highresolution t -weighted with or without fat suppression are used to image the extracranial course of the cranial nerves. today, the tse-dixon sequences provide non-fatsat and fatsat images simultaneously, making cranial nerve imaging faster and easier. time-of-flight images can be used to study neurovascular conflicts, although these can also be detected on submillimetric gd-enhanced t images. of course, it is important to know the major anatomy of the cranial nerves and the most frequently occurring lesions. the abovementioned imaging techniques, the most important anatomy and the most frequently occurring lesions will be demonstrated and discussed in this lecture. mri study of the lower neck space includes the study of anatomy and pathologies of the thoracic outlet, or cervicothoracobrachial junction, extending from the cervical spine and the mediastinum to the lower border of the pectoralis minor muscle, the brachial plexus and the supraaortic vessels (carotid, subclavian arteries and veins). for this, use of a dedicated head and neck coil is fundamental to avoid frequent artefacts arising from air and the passage between different surfaces. only in case of thoracic outlet evaluation, a dynamic angio-mri study should be performed and this means the use of a surface coil. mri protocol of the lower neck should include t -and t weighted sequences. both fat-saturated proton density and t with stir sequences can be used to overcome the inhomogeneity of the magnetic field, especially with large fov. sand bags can be placed on either side of the neck and suprascapular region of the patient to improve image quality. also, flow saturation bands can be utilised to limit blood flow artefacts. also, volumetric sequences are in common use to obtain a quick examination. breath or cardiac gating can be helpful. abnormal findings of brachial plexus consist of nerve signal abnormalities with mild or marked hyperintensity on t -weighted, being aware of magic angle effects and swelling. in case of thoracic outlet syndrome, mri protocol should define the compression of brachial plexus components arteries and or veins, both in indifferent and dynamic mri acquisition. learning objectives: . to learn how to overcome difficulties in performing a lower neck study. . to understand how to avoid the most common pitfalls. . to become familiar with differential diagnosis. c. ct and mri of temporal bone: user's guide f. veillon; strasbourg/fr ct and mr imaging of the temporal bone must be performed with a precise technique. in ct it is important to locate the box of the study above and not in the orbit to avoid the lenses. irradiation is divided by compared with a study through the orbit. the axial sections must be parallel to the lateral semicircular canal the coronal, sagittal sections are completed by oblique coronal views through the long process of the incus and the head of the malleus to get the ossicular v. double oblique sections through the componants of the v permit a view of the stapes and also the malleus and incus in d (mip : mm). mri must be performed parallel to the roof of the orbit permiting very good axial sections in the plane of the lateral semicircular canal (t and t ). the internal auditory meatus and the inner ear must be analysed with mm axial sections (se) after intravenous gadolinium injection completed by a high resolution t (gradient echo or se) . - . mm, depending on the machine ( t, , t). the middle ear in chronic otitis media must be studied with t , diffusion and high resolution t . there is no need of contrast medium injection apart from the complication: fistula of the lateral semicircular canal, thrombosis of the sigmoid sinus. the different pathologies are then discussed: external auditory meatus and middle ear pathologies: ct first. mri is useful for postoperative cholesteatomas. inner ear malformations, otosclerosis, trauma: ct. labyrinthitis, inner ear hemorragia, schwannomas, internal auditory canal content: mri. revascularisation time windows for patients with acute ischemic stroke are generally restricted up to . hours in the anterior and up to hours is the posterior perfusion area. later treatment attempts require more accurate prediction of risk and benefit, as safety and efficacy at these time strata are less well. thus, rapid and effective imaging is important for decision-making concerning intrarterial catheter based recanalisation and/or thrombolytic therapy. advanced imaging techniques identify irreversible infarction as well as tissue at risk. diffusion-weighted mri detects ischemia within minutes of onset, whereas perfusion-weighted mri and ct perfusion studies disclose the ischemic penumbra. combined, they provide information on mismatched tissue, i.e. potentially salvageable brain. in addition, non-catheter angiographic techniques like ct or mr angiography are a useful adjunct to localise arterial occlusion. as an attempt to a reliable emergency examination, the following protocol has been proven to be robust: for the anterior perfusion area, a non contrast ct may exclude cerebral bleeding and is followed by ct angiography (including supraaortic and intracranial vasculature). if technical available, ct perfusion should be performed in addition. in ischaemic strokes of the vertrebrobasilar region, cta is essential to exclude basilary stenoses or thrombotic occlusion. if the stroke onset remains unclear or might extend the above mentioned time window, mr stroke imaging (i.e. diffusion, flair and perfusion sequences) is suggested as mr offers a higher sensitivity. anyway, the best method for each emergency stroke imaging center is depending on clinical availability h/ days, technical equipment and -finally -individual experience of the emergency team. some recent publications have questioned interventional treatment of stroke as an alternative to iv thrombolysis only. these papers -albeit published in highranking sources -usually do not describe the modern concepts of interventional stroke treatment. interventional radiologists, therefore, are convinced by their practical experience that the modern concept of combining iv thrombolysis with mechanical thrombectomy by stent retrievers offers a benefit to a subgroup of patients with severe stroke. this includes anatomical level of occlusion -basilar artery or single vertebral artery, proximal carotid occlusion with distal tandem occlusion, carotid t obstruction and m occlusion. m occlusions are debatable. besides location, the clinical status of the patient before stroke and time of onset, absence of early ct signs of stroke or bleeding and clinical contraindications to iv thrombolysis such as recent surgery influence the decision-making. more difficult than the description of technical success is prediction of clinical success. there are a couple of scores such as thrive available that may be used for outcome forecasting. the amount of collateral flow is frequently used as a decision tool, but is not always easy to quantify. mismatch scores and penumbra have been questioned recently. in conclusion, anatomical factors are pretty easy to identify to indicate treatment, but the clinical and functional setting still lacks quick and reliable parameters that allow a clear decision-making, particulary in borderline cases. the refresher course addresses the current state-of the-art use of different mechanical revascularisation strategies, devices and potential complications. in addition, multimodal imaging applications with a focus on patient selection for endovascular recanalisation therapies, as well as new techniques to guide endovascular therapy within the angio suite are presented. finally, some organisational aspects important for providing an interdisciplinary interventional stroke service are discussed. the ultimate goal of an acute endovascular stroke intervention is neurological recovery or improvement. recanalisation of an arterial occlusion is key in achieving this goal. clinical data suggest that endovascular stroke treatment results in higher recanalisation rates and may provide superior clinical outcomes when compared with intravenous thrombolytic therapy only. however, these higher recanalisation rates are far away in being paralleled by equally higher rates of favourable outcomes in recanalised patients. thus, patient selection remains crucial. besides the careful neurological assessment, brain imaging is here of major importance. the case presentations illustrate that imaging may help in patient selection for subsequent thrombolytic/endovascular therapies by differentiation of patients who may profit from intravenous or interventional therapy in an even extended time window from those who do not. there are a number of key areas supported by evidence-based medicine necessary for a high-level interventional stroke service. as a precondition, a neurointerventional stroke service has to be organised within a multidisciplinary acute stroke team. inside the hospital, it is all about streamlined pathways. any possible delays should be minimised at every step. sacroiliac joint pain may arise from a number of conditions including inflammatory arthritis, degeneration, fractures and tumours. studies suggest a prevalence of % to % pain arising from the joint in patients with positive clinical signs. temporary effect is provided by a mixture of local anaesthetics with steroids with a response varying between % and % in reported series. dual blocks using agents of differing duration are considered more precise, but are less often used in practice. imaging including mr and scintigraphy are of limited predictive value. injections may be into the synovial joint, around the joint or adjacent to the nerve innervation of the joint. there is evidence that para-articular sources of pain are common and injection outside the joint may be more effective. sl-joint injections are performed through a dorsal approach guided by ultrasound, fluoroscopy or low-dose ct. shortacting agents may have lasting benefit, but radiofrequency ablation has been employed in an attempt to obtain long-term response. the evidence for lasting therapeutic response to intra-articular or periarticular injection of steroids and conventional radiofrequency neurotomy is weak. there is fair evidence of longterm response to cooled radiofrequency neurotomy. facet joints account for - % of all low back pain. they are affected by osteoarthritis, joint space narrowing, intra-articular vacuum phenomenon/fluid, osteophytes, synovial cyst and ligament hypertrophy. conservative therapy is initially proposed. percutaneous facet joint steroid infiltrations are minimally invasive procedures involving injection of corticosteroid with or without local anaesthetic inside the joint. they also can provide diagnostic verification of a certain facet joint acting as the pain source. the injectate usually contains a long-acting corticosteroid mixed with a local anaesthetic. sodium hyaluronate solutions or ozone were tested; however more and extensive studies are necessary. other options are either percutaneous ablation or surgical arthrodesis. fluoroscopy, computed tomography or magnetic resonance can be used for guidance. fluoroscopy has the advantage of real-time imaging. cone-beam ct can also be used. computed tomography provides better anatomy information, but has increased radiation dose for the patient. magnetic resonance has higher cost and longer duration. a recent study concluded that it is twice the cost of ct-guided infiltrations. mri can be used in combination with focal ultrasound for ablation, a technique which is still under investigation. success depends upon patient selection ( - % immediate and - % long-term relief). the level of evidence is moderate for lumbar spine concerning short-and long-term improvement. however, the most recent guidelines released (american society of pain physicians) state that it is the oldest and most commonly used technique. the success rates with its safety profile and least invasiveness seem to make it an attractive therapy. although promising for early assessment of response to treatment, these newer functional biomarkers need extensive validation and standardisation for their wide clinical use. validation includes the assessment of reproducibility and accuracy, whereas standardisation concerns image acquisition and postprocessing. the added value of the more complex functional biomarkers relative to the viability parameters should also be shown. viability and functional imaging biomarkers are evolving and emerging parameters for the early assessment of response to treatment. mri biomarkers must be able to show how tumours respond to specific treatment. they need to allow assessment of the effectiveness of new treatment more rapidly than classical clinical end points. these biomarkers must be easy to obtain to facilitate a large spread of the technique. they have to be reproducible. the longest diameter of the tumour remains the easiest biomarker that can be obtained from any kind of morphologic acquisition with no need of post-processing. additional information about the tissular organisation and cellularity can be now easily obtained using modern scanners through diffusion-weighted sequences. the ease with which those sequences are obtained for a while masked the necessity to perform a more complex postprocessing than the one initially done to get reliable biomarkers. there are numerous mri biomarkers of microcirculation, reflecting o consumption, blood volume, blood flow, vessel permeability and extravascular volume. to get them, we need more sophisticated acquisitions and image processing that take into account the t of the tissue, arterial input function, respiratory motion, etc. most of these new mri biomarkers are now used in research and in phase i studies, but have not been validated in more advanced clinical trials or in clinical practice. to use them widely and reliably, we need to perfectly understand the consequences of the choices we make during the acquisition and post-processing of these biomarkers. new targeted treatments in cancer can be effective without significantly reducing tumour size. there are already a large number of targeted treatments that are licensed to treat a range of cancers. for some of these cancers, there is currently no reliable method to tell whether the drug is effective and new response, predictive and prognostic biomarkers are required. functional imaging techniques such as diffusion-weighted mri, dynamic contrastenhanced mri and fdg-pet imaging are being developed or applied as response biomarkers. however, for these to be useful in a wider multi-centre setting, the measurements need to be precise, repeatable and reproducible. we discuss these properties in the context of emerging imaging response biomarkers. learning objectives: . to understand imaging biomarker precision (repeatability and reproducibility) and accuracy and how it is evaluated. . to learn how to interpret biomarker precision and accuracy in the context of the biomarker's intended use. coronary artery disease (cad) and its related cardiac disorders are still the number one cause of death in the usa and the western world. up to date, single photon computed tomography (spect) using traditional radiotracers like thallium- or tc- m sestamibi is the most utilised imaging technique for the assessment of myocardial perfusion. however, over the past decade, there has been a growing interest in cardiac imaging with positron emission tomography (pet) and, indeed, a paradigm shift has been witnessed in the use of myocardial perfusion imaging (mpi) with pet taking advantage of the superior imaging properties of pet over spect. therefore, pet mpi is now being increasingly used for routine clinical evaluation of patients with known or suspected cad. furthermore, it is being used not only at large academic institutions, but also at community hospitals and even in private practice. several factors contribute to this shift in the use of pet mpi, including the growing availability of combined pet and computed tomography (ct) systems, mainly driven by oncological applications, radiotracer, like rubidium- or fflurpiridaz, which can be used in clinical routine, changes in reimbursement, and the increasing clinical evidence supporting the value of pet/ct mpi. the lecture "pet for evaluation of perfusion, absolute myocardial blood flow and coronary flow reserve" will cover several aspects of the growing field of pet mpi. besides the visualisation of coronary morphology, computed tomography (ct) has shown feasibility to also assess myocardial perfusion. currently, there are two different approaches to ct-based myocardial perfusion imaging: singleshot and dynamic, sequential acquisitions over a predefined scan time. the presentation will cover basic concepts of both approaches and highlight protocol details and findings in these stress acquisitions. also, emerging scientific results with respect to diagnostic accuracy, the detection of hemodynamically relevant coronary stenosis and prognostic implications will be discussed. over the past few years, cardiovascular magnetic resonance imaging (cmr) has been increasingly established as an important method in the diagnosis of cardiovascular disease. many studies have shown the equality or even superiority of cmr compared to other imaging modalities (e.g. nuclear medicine and echocardiography). cmr offers important advantages like the absence of ionising radiation, high spatial resolution, and the combination of perfusion imaging with tissue characterisation. the main clinical applications in the assessment of coronary artery disease (cad) include ventricular function, myocardial viability and perfusion. in clinical routine, myocardial perfusion is determined by contrast-enhanced first-pass perfusion techniques during pharmacological stress using coronary vasodilators (e.g. adenosine) or ßadrenergic agents (e.g. dobutamine). non-invasive characterisation of myocardial microcirculation is thought to reflect myocardial tissue supply much better than mere luminographic detection and quantification of epicardial coronary stenosis, and has been shown to be useful for planning of revascularisation procedures and cardiac risk stratification. in several studies on the prognostic value of cmr in cad assessment, normal stress perfusion cmr was highly predictive for a good prognosis, thus able to identify patients in whom invasive angiography can be deferred safely. the purpose of this lecture is to demonstrate how it is possible to sensitise the mr signal to water molecules diffusion in tissue and how to use calculated indices to reflect structural integrity. the concept of diffusion-weighted imaging will be introduced with particular emphasis on the pulsed gradient spin echo (pgse) sequence. methods to calculate the apparent diffusion coefficient (adc) will be described and the concept of the diffusion tensor (dt) will be explained. image processing of diffusion data includes steps like eddy current distortion correction, model fitting and potentially registration of maps to a reference space. indices that are reproducible and rotationally invariant will be described, such as fractional anisotropy (fa), mean diffusivity (md), axial diffusivity (ad) and radial diffusivity (rd). examples of when to use the adc maps or the dt indices will be given in relation to pathologies such as stroke, multiple sclerosis and neurodegenerative diseases. strategies for result presentation such as region of interest approach, histogram analysis and tractbased methods will be shown. limitations and advantages of diffusion imaging methods such as dt do not preclude the use of this technique in research and clinical radiology for investigating structural changes in disease. diffusion imaging methods have a lot of potential to be used in clinical practice. however, although diffusion-weighted imaging has been increasingly applied, clinical use of diffusion tensor imaging is limited to date. this is in part due to the lack of standardisation and the need for more complex analysis tools to evaluate the data. during this lecture, an overview will be provided of some analysis methods for diffusion-weighted and tensor imaging. i will discuss the different parameters that can be obtained as well as some advantages and limitations of the different analysis methods. it is highly recommended to include diffusion-weighted imaging (dwi) in the routine protocols for mri of the brain. dwi as well as automatically calculated apparent diffusion coefficient (adc) map is used for evaluation. the adc values of gray and white matter are identical in the adult brain. restricted diffusion (high signal on dwi and low signal on adc) is seen not only in acute stroke, but can also be present in some brain tumours, the necrotic centre of abscesses, some acute mr plaques, some contusions, encephalitis, creutzfeldt-jakob disease, metabolic diseases, etc. this finding is thus not specific, but is very helpful combined with clinical information and the signal pattern on other sequences. acute stroke has restricted diffusion during the first - days and the diffusion gradually increases to become very high in a chronic infarct. the diffusion changes in ischemic brain and spinal cord tissue are usually irreversible, but may be reversible. brain tumours with high cellularity, such as lymphoma, glioblastoma multiforme, medulloblastoma and metastases from small cell lung carcinoma, usually have restricted diffusion. the surrounding vasogenic oedema has increased diffusion. in the central necrosis of a pyogenic abscess the diffusion is restricted, while it is increased in the necrotic centre of a malignant brain tumour. reversible diffusion restriction in the cortex, the hippocampi and thalami can be seen in patients with status epilepticus. diffusion tensor imaging has so far had limited clinical use, but may be useful, e.g. for the preoperative evaluation of brain tumours. learning objectives: . to understand the differential diagnostic possibilities of high signal intensity lesions on diffusion weighted images (dwi) of the brain and spinal cord. . to become familiar with the appearance of acute, subacute and chronic stroke on dwi. . to learn about the appearance of cerebral tumours, infection/inflammation, neurodegenerative diseases and traumatic lesions on dwi. . to understand the present use of diffusion tensor imaging (dti) and diffusion tensor tractography (dtt) in clinical neuroradiology. the signal intensity in diffusion-weighted imaging (dwi) reflects the cell density in the tissue. dwi, including apparent diffusion coefficient (adc) maps, can therefore be used to differentiate highly cellular from acellular regions of tumours, distinguish cystic from solid lesions, and monitor change in tumour cellularity over time, reflecting response to therapy. in general, tumours have high signal intensities in dwi, but low corresponding adc values compared to normal/benign/reactive tissues. dwi has a wide range of clinical applications, which includes cancer imaging, imaging of infections and inflammations, evaluation of trauma and visualisation of peripheral nerves. of these, the most promising application appears to be in oncological imaging. there is, e.g. now evidence to recommend inclusion of dwi in mri protocols for lesion detection and characterisation in the liver. the advent of whole body (wb) mri including wb-dwi (from root of the neck to groin) has introduced tumour imaging with a systemic approach compared to established multi-modal diagnostic algorithms. it has been found valuable for staging, therapy evaluation and surveillance of tumours, especially in children. however, dwi is generally recommended to be incorporated into oncologic mri protocols of both wb-mri and of selected organs, because it provides additional valuable information to the conventional mr sequences. dwi of the body is frequently prone to imaging artefacts, which can obscure or mimic lesions. to minimise misinterpretations, analysis of the raw b-value images directly in conjunction with adc maps and conventional coregistered sequences is recommended. spinal surgery is most frequently performed to decompress (disc herniation, stenosis, malignant infiltration), fuse and stabilise (particularly following trauma or infiltrative destructive processes) and correct deformity. often, there may be a combination of these procedures at one operation. surgical instrumentation or bone graft is sometimes employed. patients may present themselves with symptoms early or late following the procedure. this interactive session seeks to address the variety of surgical procedures undertaken and subsequently imaged post-operatively because of symptoms. the session aims to help one to understand and become familiar with the expected post-operative imaging appearances related to the surgical procedure, learn about abnormal pathological features as a cause of symptoms in the acute and more chronic situation and explore the diagnosis and differential diagnosis. this may include post-operative fibrosis versus recurrent disc herniation versus post-operative infection. failure of fusion due to failure of instrumentation or inadequate take of bone graft can give rise to pseudoarthrosis. recurrent stenotic symptoms may relate to an inadequate decompression, recurrent disc herniation, postoperative haematoma, extension of a malignant process or ischaemic damage. joint replacement surgery for the treatment of arthritis most often offers the patient excellent results. however, there are potential complications that a radiologist should know about. it is essential to understand the importance of pre-and postoperative imaging for evaluating patients. most commonly, standard radiographs are used to assess the patients after joint replacement. however, ct, nuclear medicine methods as well as mr imaging play an increasing role in such patients. the radiologist should be aware of the most common type of prosthesis and the most common complications after joint replacement. these complications include postoperative prosthesis loosening, prosthesis fractures, periprosthetic fractures, postoperative infection, rotation failure of the prosthesis, and soft tissue abnormalities such as surrounding tendon tears. this interactive session seeks to address the variety of joint replacements which are undertaken and subsequently imaged postoperatively as a result of symptoms. the session aims to help one to understand and become familiar with the expected postoperative imaging appearances related to joint replacement, learn about abnormal pathological features as a cause of symptoms and explore the diagnosis and differential diagnosis. learning objectives: . to learn about changes related to surgery. . to understand changes related to non-surgical treatments. serbia is a beautiful country where east and west merged and often collided for centuries, and where nowadays eastern cultural heritage meets and mixes with the western heritage in a lovely and unprecedented way, with a lot of charm and with a variety of extraordinarily natural beauty and plenty of both traditional and gastronomical wonders to explore. it extends from the edges of the pannonian flatland in the north, over the danube and sava rivers to the gradually growing wonderful mountains in the south. already in , the first x-ray unit was installed, and only twenty years later x-ray units are present in most state-owned and private hospitals in serbia. nowadays, slightly more than half of the thousand radiologists in serbia perform a broad variety of diagnostic imaging and interventional techniques in different radiological units, including numerous ct, mri, and few pet/ct units distributed in five university centers, a number of public clinical centers and hospitals, and also in the private sector. several centers are fully equipped with pacs and ris systems, and are capable of performing teleradiology services. there are still significant challenges in serbian radiology in the field of education and research, planning and implementation of national radiology networks, improvement of standard clinical practice and financing the new equipment. yet since radiologists' enthusiasm overwhelms most of the difficulties, radiology in serbia provides nowadays a broad variety of modern and competent diagnostic and interventional procedures, improving the management and treatment of our patients. radiology in serbia, since its beginning, has been inextricably linked to european radiology. there are written documents testifying to the fact that the first x-ray appliances in serbia had emerged and had been used for medical purposes only two years after wilhelm conrad röntgen discovered x-rays in . the real beginnings of diagnostic radiology in serbia can be linked to the establishment of the general state hospital in , where the first x-ray cabinet was installed. later discoveries in the field of radiological techniques, materials and contrast agents were also immediately accepted by the serbian radiology community. the first cerebral angiography was performed in , which may be considered as the beginning of neuroradiology in serbia. the second half of the twentieth century is characterised by the introduction and wide application of ultrasound, ct and mr diagnostics and outbreak of vascular and nonvascular interventional radiology procedures in the areas of neuroradiology, uroradiology, and cardiovascular and gastrointestinal radiology. for years, serbian interventional radiology has successfully kept pace with achievements of the most relevant centres worldwide. nowadays, serbian radiologists monitor and enforce the most complex modern procedures in different areas of radiology. the rapid development of science and information technology has enabled the daily monitoring of all modern developments, methods and approaches and their increasingly faster introduction into practice. non-ischaemic cardiomyopathies (nicm) refer to myocardial diseases caused by mechanical and/or electrical disorder in the absence of significant coronary artery disease, valvular heart disease, hypertension, or congenital heart disease. nicm often present with genetic mutations, but no clinically apparent disease. in some cases, the presence of fibrotic tissue could cause adverse events and, therefore, the use of late enhancement (le) post-gadolinium technique is necessary in evaluating these patients. le suggestive of fibrotic tissue could be found in up to % of patients with nicm. in the majority of cases (up to %), midwall/subepicardial enhancement could be found; patchy enhancement, often at septal junctions, has been registered in % of patients, while the least common pattern of le was subendocardial ( %). in ischaemic cardiomyopathy (icm), subendocardial or transmural is a typical pattern of hyperenhancement and is related to coronary artery distribution. furthermore, le has the potential to provide important information for risk stratification in clinical practice. in nicm, the extent of fibrosis has been shown to be independently associated with increased rates of future adverse events including all-cause mortality, while in icm myocardium with le in more than % of wall thickness is unlikely to recover contractile function following coronary revascularisation. as many nicm disorders are associated with the presence of scar tissue, le in nicm is nonspecific and should be correlated with clinical presentation and history, which is critical in the evaluation of these patients. interlude: hop-on, hop-off sightseeing tour of serbia s. stojanovic; novi sad/ rs (tupsons@gmail.com) in the interlude between scientific lectures, you are most welcome to hop on a sightseeing tour around serbia during which we shall stop at a few stations where the natural and cultural heritage of our country will be shown. nota bene: some of the sights will be visible to everyone and some only to radiologists. ten thousand years of human effort and five billion years of european soil refinement will blink in front of your eyes through the window we have made with red churches' walls, azure skies and a silver sparkle of our spirit. all the time, a bit of grayscale shadow will supplement the picture as we in radiology are so used to. fragments of past and present will make a mosaic, the glance of which will hopefully light up your day. when you hop off our tour, we believe, some pictures will become part of your emotional memory and maybe will make you wish to see them in vivo. the role of prenatal mri in foetal central nervous system abnormalities: a case-based pictorial review k. koprivsek; sremska kamenica/rs (katarina.koprivsek@gmail.com) mri provides a unique opportunity for studying in vivo central nervous system development. its higher contrast resolution compared with prenatal sonography allows better visualisation of sonographically occult normal cns structures as well as structural abnormalities. in clinical praxis, prenatal mri has become a mandatory tool in evaluating: a) foetuses that have abnormalities suspected on the basis of foetal sonography; b) foetuses with increased risk for brain abnormalities even in the setting of a normal prenatal sonogram (family history of cns anomalies or a genetic/metabolic disorder); c) foetuses potentially at risk due to maternal illness; d) foetuses with congenital malformation, which are candidates for prenatal or neonatal surgical treatment; e) foetuses that could not be evaluated by sonography due to oligohydroamnion, maternal obesity, difficult position of the foetal head, or us reverberation on foetal calvaria in advanced gestational age. we will present a selection of foetal cns abnormalities detected in our institution during the last years, including ventriculomegaly, abnormalities of the posterior fossa, agenesis of the corpus callosum, cerebral cortex developmental abnormalities, spine developmental abnormalities and a variety of encephaloclastic lesions. in all previously listed cases, prenatal mri could provide either crucial or additional information, which can lead to the accurate diagnosis of different cns developmental abnormalities (cortical, commissural and posterior fossa malformation), specific disorder or syndrome, further enabling adequate pregnancy management and parents' counselling. this lecture will cover the standard mammographic views required, the reporting systems for mammograms together with birads and other european systems, breast density, feature analysis, information the clinician requires in a cancer case and how to approach a b lesion. acr practice guidelines ( ) recommend obtaining previous mammograms as you can dismiss an abnormality that is unchanged for years or that has been previously worked up and are able to detect subtle new lesions more easily, although this has not been confirmed in the screening situation. in a structured report the following information is recommended: indication, breast density, description of lesion, size, location, comparison to previous findings, overall assessment, management recommendations and a score to indicate the level of suspicion. examples of different common conditions seen on mammography will be shown including soft tissue masses, microcalcification, architectural distortion and asymmetry. breast ultrasound is one of the main imaging modalities in breast radiology, it allows us to characterise lesions and also guide interventional procedures. the bi-rads categorisation of ultrasonographic findings facilitates the diagnostic approach and also helps the radiologist to use a common language, understood not only by the rest of the radiological community, but also by other breast cancer professionals. ultrasound can be a diagnostic procedure on its own, but is mainly a modality that characterises the findings of other modalities (mammography and mri) and, as such, correlation between all these techniques is the mainstay of everyday clinical practice. this act of correlating and integrating the information of all modalities is what makes a breast radiologist a key actor in the diagnosis, staging and follow-up of breast cancer and other benign or high-risk entities. the final product of this integration will be the radiological report, the means by which we convey all the information we have gathered through all the procedures to our clinical colleagues. this report shall also follow some composition rules to be clear and concise. as with any other modalities, breast magnetic resonance imaging (mri) examinations should be reported in a structured way following the guidelines of the respective national, continental or international societies. adequate nonclinical information (i.e. patient name, date and type of examination, etc). is indispensable. any breast imaging report has to follow a stringent structure including indication, clinical history, clinical findings, brief description of technology used, assessment of parenchymal density, detailed description of significant findings, comparison with previous imaging studies and final assessment according to bi-rads. indications and contraindications of breast mri will be discussed. significant findings at breast mri include foci (small contrast-enhancing spot, nos, < mm), mass lesions, "non-mass-like enhancement" (no mass lesion, partly diffuse regional contrast enhancement of various size) and associated findings. furthermore, as breast mri is a functional study, the different appearance patterns of kinetic contrast enhancement will be presented. the current status and the appropriate use of the bi-rads mri lexicon will be discussed. any breast mri report should not only follow the guidelines, but also follow a red thread, be consistent, express confidence and be comprehensible to clinicians. the overall final bi-rads assessment is based on the most worrisome finding, taking into account both breasts and all imaging methods (mammography, ultrasound, mri) evaluated. furthermore, adequate communication of the result, as well as do's and don'ts of the report wording will be discussed. the prostate is a small glandular organ, whose main function is to secrete seminal fluid. in young men it comprises of mainly the peripheral zone ( %) and a smaller central gland. however, the central gland enlarges with age to form the larger part. the main diseases of the prostate are inflammation, hyperplasia, and cancer (the most important). approximately % of cancers arise in the peripheral zone. the main applications of mri are for cancer detection, staging, and recurrence. mri is increasingly used for radiotherapy planning owing to its good soft-tissue contrast when compared with ct scanning. endo-rectal rf receiver coils, usually inflated with air or perfluorocarbon but sometimes of a rigid design, improve signal detection of the prostate. phased-array surface coils may also be used or (preferably) in combination. t -weighted imaging helps to distinguish haemorrhage caused by biopsy. on t -weighted images the peripheral zone appears brighter, owing to a larger proportion of prostatic ducts, while tumours generally appear darker. more sophisticated mr methods are increasingly used to help diagnosis. in diffusion-weighted images (dwi) tumours appear relatively bright, but dark in the corresponding calculated map of apparent diffusion coefficient (adc), owing to the more cellularly-dense nature of tumours, and hence, reduced diffusion. in dynamic contrast-enhanced mri (dce-mri) tumours appear bright owing to increased vasculature. magnetic resonance spectroscopic imaging (mrsi) of normal prostate is dominated by high levels of citrate from the prostatic ducts; in cancer this is reduced while choline is increased. prostatectomy samples allow one to verify image contrast against histology. recent studies on prostate cancer have provided a number of relevant targets for imaging and treatment purposes. today, imaging plays an important role in different aspects of the disease, but its role should grow in answering clinical questions at various phases of the disease. relevant targets for imaging include metabolites (including glucose, acetate, choline, and amino acids), antigens (including prostate-specific membrane antigen), receptors (grp receptor, cxcr , androgen receptor), proliferation, angiogenesis, and hypoxia. in this presentation, a range of radiotracers for potential use in the imaging of prostate cancer will be discussed, as well as options to tailor nuclear imaging tracers to the various phases of the heterogeneous disease. the fusion of morphologic (ct and mri) and functional (pet, spect) imaging modalities (pet, spect) has become widely available and part of the standard diagnostic workup in cancer patients. for many years, neurosurgeons have already relied on multimodal imaging data during brain tumour surgery to identify hyper-or hypometabolic tissue. the availability of pet and spect data during percutaneous ablation procedures may also be helpful to facilitate treatment planning, probe placement, probe re-positioning, and early detection of residual disease following percutaneous image-guided ablation of cancer. however, up to now conventional us-and ct-guided thermal ablation procedures rely on morphologic information only. intraoperative implementation of multimodal data requires the application of frame-based or frameless stereotactic techniques, both relying on the establishment of an accurate relationship between the patient's preoperative image space and the intraoperative physical space. in image-guided neurosurgery, ct/mrt/spect/pet data are registered to the patient using rigid body transformation. due to respiratory motion and different patient positioning during image acquisition and the actual intervention, soft tissue deformations in the liver occur. thus, the images and the surgical presentation do not match between preoperative imaging and intervention, leading to an extensive degradation of spatial guidance. this presentation illustrates solutions for these fundamental problems that occur during d-navigated liver interventions, including patient immobilisation and repositioning, respiratory triggering and intraoperative imaging. r. bale: equipment support recipient; isys has supported the section of microinvasive therapy with testing equipment. patent holder; rb is a (co-) inventor of the atlas aiming device and the bodyfix immobilisation device and a (co-)shareholder in its financial returns. the goal of ultrasound-triggered, image-guided drug delivery is to increase the therapeutic index and decrease adverse effects of drugs. the bio-effects of focused ultrasound can lead to local tissue heating, cavitation, and radiation force, which can be used for ) local drug release from nanocarriers circulating in the blood, ) increased extravasation and cellular uptake of drugs and/or carriers, and ) enhanced diffusivity of drugs. thermo-sensitive liposomes have been suggested for local drug release in combination with local hyperthermia more than years ago. microbubbles may be designed to enhance cavitation effects. real-time imaging methods, such as magnetic resonance, as well as optical and ultrasound imaging have led to novel insights and methods for ultrasound-triggered drug delivery. image guidance of ultrasound can be used for: ) target identification and characterisation; ) spatio-temporal guidance of actions to release or activate the drugs and/or permeabilise membranes; ) evaluation of biodistribution, pkpd; ) physiological read-outs to evaluate the therapeutic efficacy. liposomes may carry both hydrophilic and hydrophobic drugs in their aqueous interior and lipid bilayer membrane, respectively. the circulation half-life may be increased by incorporating polyethylene glycol (peg)-lipids in the bilayer. recent publications have shown that ultrasound-triggered delivery is feasible. realtime imaging methods, such as magnetic resonance, optical and ultrasound imaging may lead to novel insights and methods for ultrasound-triggered drug delivery. up to now, the success of surgical tumour resection has always been limited by the surgeon´s vision. the human eye is not an accurate detector of small cancer cell clusters and it cannot accurately differentiate cancerous from healthy tissues due to lack of "visible" contrast. by combining a fluorescent probe targeting the folate receptor and a multi-spectral real-time fluorescence camera to observe the operating field, we found that, using fluorescence molecular imaging, -fold more lesions can be identified compared to conventional surgery. these first in-human results point to molecular-based clinical decision-making in surgical and endoscopic procedures as a paradigm shift over decision-making based on human vision. the talk describes current progress with instruments, methods and applications in the field of intraoperative imaging. pre-clinical and clinical results are presented and the advantages and limitations of the method as well as future directions will be discussed. the emerging field of multispectral optoacoustic tomography (msot) is also outlined. mysteries of the human brain unveiled: imaging of white matter microstructure and neuroplasticity p.m. parizel; antwerp/be (paul.parizel@uantwerpen.be) the human brain remains one of nature's great mysteries, and is considered science's final frontier. this greyish lump of tissue with a weight of . kg contains some billion neurons, each of which are connected to thousands of other nerve cells in an intricate network of white matter fibers. in the previous century, the brain was perceived as a fixed three-dimensional landscape, with brain functions confined to certain locations (e.g. motor and sensory cortex, visual cortex, auditory cortex). this concept of neurolocalisationism was in line with the philosophy that there should be "a place for everything, and everything should be in its place". advanced quantitative mri techniques for acquisition and data analyis (fmri, dwi, dti, vbm), help to unravel white matter connectivity of the human brain, and are able to show that the brain can modify its structure and function in response to changing circumstances (such as learning, memory, hormones). this process, which is known as neuroplasticity, occurs at different levels and different time scales. for example, in response to injury, changes may occur at cellular level as well as on a larger scale with cortical remapping. some processes may take months or years (e.g. physical therapy and training) whereas some forms of neuroplasticity happen within hours or days (e.g. changes in brain volume and connectivity during the female menstrual cycle, which have been linked to behavioral changes). in summary, quantitative mri techniques help to unveil the mysteries of the human brain and have opened exciting new fields of active research such as white matter connectivity and neuroplasticity. there are a host of inflammatory and infective insults that can manifest focally or diffusely within the musculoskeletal system. the appearances of the underlying pathological processes in both the soft tissues and skeleton cover a very wide imaging spectrum. the appearances vary, depending on the timing and degree of inflammatory insult and the host response in the involved tissues. the approach of this lecture will cover the imaging manifestations using all modalities covering radiography, ultrasound, ct, scintigraphy and magnetic resonance imaging. the basic knowledge that is required will be displayed in major musculoskeletal categories covering disorders involving the soft tissues, joints, bones and entheses. the imaging manifestations will also be linked with the evolution of the pathological processes covering acute, sub-acute and chronic stages of the inflammatory/infective disorders. by the end of the session the audience should have a clear understanding in making best use of the imaging modalities in the correct diagnosis of a wide variety of inflammatory and infective conditions that can affect the musculoskeletal system. arterial pta and stenting is firmly established as primary treatment in the management of athero-occlusive disease, particularly of peripheral limb arterial disease (pad). patients are selected on the basis of symptoms such as short distance claudication or critical limb ischaemia for lower limb disease or appropriate ischaemic symptoms in other territories in the renal and mesenteric territories and head and neck vessels. commonly used grading systems such as the fontaine or rutherford scores can be useful in patient selection. where treatment is required, noninvasive imaging is utilised to look for the site, severity and extent of arterial disease. most centers use duplex imaging as the primary imaging modality; mra or cta are often used with a higher sensitivity and specificity; and invasive angiography is reserved for problem solving or immediately prior to intervention. the tascii classification has been devised to select patients for either endovascular or surgical intervention. however, most centres will adopt an endovascular approach first. all patients should be on good medical therapy, i.e. aspirin and statins, with good blood pressure and diabetic control where appropriate. when carrying out interventions, an access sheath is used, peri-procedural heparin administered and lesions crossed using selective catheters and commonly hydrophilic guidewires. subintimal crossing of occlusions can be much simpler than trying to cross lesions luminally. balloon angioplasty and or stenting may be applied differently depending on the site and extent of the lesions. the evidence for drug-eluting technologies has also been growing with improved patency rates compared to standard balloon angioplasty. during the efrs meets russia session, radiographers have the opportunity to get information about the role and education of radiographers in the different european countries. the radiographer is a health-care team member who interacts with other professionals in the primary and secondary health-care environment to provide an optimum diagnostic or therapeutic outcome. radiographer education therefore requires that the curriculum covers a wide range of scientific, medical, pathological, sociological, ethical and technical subjects together with the development of appropriate clinical skills. the curriculum should also include the development of research and audit skills to ensure the constant improvement of service quality for the benefit of service users. the session will include a panel discussion about the role of the radiographer in image acquisition and processing. the tasks of the assistant to the radiologist are: filling of the protocol of research, survey of the patient, instructing the patient according to safety measures, positioning the patient, placement of coils of strengthening, beginning of magnetic and resonant research -the research is approved by the doctor, introduction of contrast substance (in the presence of the certificate of the procedural sister) and supervision over the patient during mr research. furthermore, the other tasks are briefing on patient safety, excluding introduction of the patient to metal objects on mr tomography, explaining the procedure of the study, informing about the duration of the study, wearing noise-cancelling headphones, warning about possible vibration and loud sounds, and providing a globular button to call the nurse. today coronary ct-angiography has become a well-established and proven diagnostic modality. quality of coronary and cardiac cta datasets has tremendous significance for correct diagnosis. a radiographer has a pivotal role in performance of coronary cta. coronary cta is one of the most challenging examinations for radiographers because even a small mistake at any stage of examination may ruin the whole study. before the scanning procedure, the radiographer performs a check for possible contraindications to contrast media injection (history of adverse reactions to contrast media and impairment of renal function are the most important ones). the radiographer checks the patient's heart rhythm and takes part in administration of betablockers for control of the heart rate. a detailed knowledge of different scanning modalities of ct-machine is a must. radiation exposure to the patient from coronary cta examinations has been one of the major public concerns. this is why the radiographer should be aware of different approaches to the performance of low-dose cta (prospective gating, tube current modulation, high-pitch scanning) according to patient body composition. the radiographer should have knowledge of when and how to use radiation dose control in an appropriate way. another big issue is injection protocols. selection of optimal bolus timing and iodine load results in highquality cta images. the radiographer has to know the basics of ct image reconstruction and interpretation in order to perform different types of reconstructions from the raw data according to the radiologist's requests and be able to recognise image artifacts. clinical examples of the radiographer's role for performance of coronary cta will be given. every country is famous for its architecture, history, literature, music, museums, etc. however, there are some distinctive features for russia. "russia is a riddle wrapped in a mystery inside an enigma." these words by the famous british statesman winston churchill aptly throws light on the pulsating art and culture of russia. the different aspects of russian art and culture find its best expression in the rich heritage. just feeling the nature and boundless expanses of the country can understand the mysterious russian soul, works of art and real masterpieces. cardiac mdct in children with congenital heart diseases v. bereznitskiy, k. serkova; moscow/ ru (vsber@mail.ru) in ct studies of children with congenital heart diseases, it is mandatory to keep the x-ray dose, amount of contrast agent and study time as low and as short as possible and simultaneously get the best diagnostic image quality. how can we reduce the x-ray dose? by minimising the volume coverage, reducing the voltage, minimising the effect of "overranging", use of x-ray protective equipment, use of tube current modulation technique, use of iterative reconstruction technique. how can we reduce the amount of contrast agent by volume? by covering of only necessary anatomic volume, minimising scanning time, use of adequate speed injection in ml/sec, which depends on catheter position and size, blood flow and anatomic structures. how can we reduce the amount of iodine concentration in the contrast agent? by lowering the voltage we may reduce the iodine concentration and get higher absorption ct values (hu). how can we reduce the time of cardiac ct studies? by preparing the study protocol ahead, preparing all necessary equipment in the ct room, warming up of the contrast agent before the study. what is the radiographer's role in cardiac ct studies? to take care along with the responsible radiologist the above-mentioned needs, to take care of adequate room and instrument temperature, to take care that only absolutely necessary people with adequate x-ray protection are in the study room, for performing the necessary image post-processing, archiving and distribution of studies. the purpose is to evaluate the quality of imaging in forced position of patients with anesthetic support. the role of laboratory technician in ct post processing. we analysed images of unconscious patients on artificial lung ventilation on -and -slice computer homographs ge and siemens and monitored them through the infusion. during investigation the patients were in forced positions, as a result they got artifacts from upper extremities on the abdominal cavity. we analysed patients -hands under the butt, patients -hands on the chest (abdomen), patients -arms along the body. according to the images the smallest number of artifacts was identified when the patient was on the table with hands under the butt. different variations of the patient's hands position and the problem of choice of this position will be offered for researching. the reconstruction the laboratory assistant can execute and also the results of tests will be presented. by order of the doctor the laboratory technician builds d and d reconstructions of fractured ribs, pelvis, facial skeleton, sagittal and coronary reconstructions of spine in case of its fracture. gastrointestinal stromal tumours (gist) are a rare disease that metastasises in up to % of patients with subsequent median progression-free survival (pfs) of around months. tumours are characterised by activating mutations in the kit or the pdgfra gene and treatment is mainly based on tyrosine kinase inhibitors designed to block mutated receptors. however, drug resistance is often based on mutations changing the conformity of the receptor, leaving little effective therapeutic options. to date, second line chemotherapy offers a median pfs of - months and external beam radiotherapy is limited by organs at risk close to the tumour. alternative approaches like endoradiotherapy or minimally-invasive ablation techniques are effective for local control but are inconsistently used and are not tailored to the individual patient's type of disease. to address these issues, the mitigate project proposes a closed-loop personalised treatment concept combining endoscopic-assisted tissue sampling, inline biotechnology and targeted molecular pet imaging probe development combined with minimally-invasive treatment monitored by new mr imaging techniques. a consistent value chain across european research institutes and smes will be established for mass spectrometry of tumours, linkage of radiochemical molecular imaging probes, design of new animal models and targeted therapeutic radiopharmaceuticals. this closed-loop platform will minimise fragmentation of treatment approaches by a coherent molecular-based multimodality concept, thus providing new treatment options. the mitigate platform can be expanded to further patient cohorts with oligometastatic diseases such as other sarcomas or renal cell carcinoma. gastrointestinal stromal tumours (gist) are characterised by highly specific genetic mutations. several specific targets are overexpressed in a majority of the tumours. on the other hand, secondary resistancies limit the usability of highly specific chemotherapeutics such as imatinib. instead of applying cascades of alternative tki inhibitors in order to find an efficient one, quantitative molecular imaging and targeted endoradiotherapy could be considered. for the detection of gist by imaging, ffluorodeoxyglucose (fdg)-pet is widely accepted to visualise the tumour burden. however, as fdg gives no molecular information of potential targets for treatment, new radiopharmaceuticals have to be developed to visualise and quantify other target-structures expressed by gist that would be able to be addressed. this molecular information can be used both for designing a conventional treatment or an advanced strategy: i.e. targeted endoradiopharmaceuticals. compared to conventional chemotherapy this method has the great advantage that not only tumour cells expressing the targeting vector are affected but also tumour cells within the range of the radiation of the decaying radiopharmaceutical. this method is used with great success in the case of neuroendocrine tumours using labeled octreotate derivatives (a small cyclic peptide binding to the somatostatin-receptor) and non-hodgkin's lymphoma applying y- labeled zevalin (a monoclonal antibody binding to the cd antigen). the success of these methods relies on the crossfire-effect, meaning that a certain margin of tissue surrounding the cell targeted by the specifically accumulating endoradiopharmaceuticals is destroyed as well, depending on the penetration range of the emitted radiation. thus, the development of new radiopharmaceuticals for the specific diagnosis and treatment of gist would strongly improve the outcome of the tumour patient. stereotactic radiofrequency ablation of liver tumours: does improved targeting increase tumour response? r. bale, g. widmann, p. schullian, m. haidu, w.r. jaschke; innsbruck/at (werner.jaschke@i-med.ac.at) the purpose is to describe stereotactic radiofrequency ablation (srfa) and to review its inital results in the treatment of patients with primary and secondary liver tumours. one retrospective review includes consecutive patients with srfa sessions for the treatment of hepatocellular carcinomas (hcc) and metastases ( ). in two other studies the outcome after srfa of intrahepatic cholangiocellular carcinomas (icc) ( ) and colorectal liver metastases (crlm) ( ) was evaluated. the overall technique effectiveness was . % with a local recurrence at year of . %. technique effectiveness was not significantly different for lesions< cm ( . %) and - cm ( %). after treatment of inoperable consecutive patients with iccs a median overall survival of months was achieved. a median os of months and os rates of %, % and % at , and years in patients with resectable crlm were achieved. tumour size did not affect os and dfs. rfa probes can be precisely planned, positioned and distributed by means of stereotaxy. especially in large liver tumours the local recurrence rate can be greatly reduced by precise stereotactic placement of multiple radiofrequency probes. these improved local control rates result in better long-term survival rates. author disclosure: r. bale: shareholder; coshareholder atlas aiming device. other; coinventor atlas aiming device. functional and molecular imaging in tumour therapy response assessment s. aime; turin/ it (silvio.aime@unito.it) in the mitigate project further development of currently used mri and ct techniques will be tackled in order to obtain functional and metabolic information which are mandatory to detect early response to the targeted radiopharmaceutical approach. new gd-based agents are under scrutiny in order to improve dce-mri procedures and attain more precise information on the tumour microvascularity level as well on the vessel permeability and the assessment of extracellular ph and mmp activity. the x-nuclei mri ( na sodium) is a non-invasive imaging technique, which enables the measurement of the tissue sodium concentration (tsc) in humans. the direct link of the tsc with the tissue integrity and viability provides a promising approach for monitoring tumour tissue, and could also help to assess cytoxicity and cell death by means of breakdown of the sodium-potassium-pump. however, na mri is challenging because of the low in vivo abundance, the fast transversal relaxation rate and the low gyromagnetic ratio of the na ions in human tissue. new mr measuring sequences for x-nuclei mri will be developed to establish a standardised tsc measurement method within the eu for better comparability. furthermore, the x-nuclei mr data will be reconstructed, scaled and fused with further imaging modalities. lung cancer is the leading cause of death related to cancer. most patients are inoperable as they present with advanced stage disease or even a localised tumour associated with poor general condition, limited cardiopulmonary function or a too high surgical risk. according to the stage of the disease, chemotherapy, radiotherapy and percutaneous ablation therapies are the current therapeutic options for inoperable patients. it is important that radiologists are familiar with the various response and complication imaging patterns related to each of those treatments. the timeline modifications after radiation therapy and percutaneous ablation and the diagnostic management of drug-induced lung disease will be reviewed. this presentation will summarise the current evidence and how to detect early recurrences after those treatments. learning objectives: . to learn about changes after radiotherapy. . to learn about sequela after percutaneous ablation of lung tumours. . to understand changes after chemotherapy of lung cancer. cardiovascular medicine owes much of its spectacular development to the parallel evolution of imaging techniques in the last thirty years. the complex contemporary techniques in interventional cardiology, electrophysiology, and cardiac surgery require advanced imaging modalities. in current times, a wide spectrum of imaging techniques -such as fluoroscopy, mri, non-contact mapping, echo techniques -is performed in organised cardiovascular labs while computed tomography and nuclear techniques are provided by the collaborative departments of radiology and nuclear medicine. it is indeed the collaborative spirit among specialists that bring about the results patients desire. cardiac magnetic resonance (cmr) is a very versatile imaging technique for the assessment of patients with left ventricular dysfunction and has become a central method for characterising the etiology of the dysfunction. indeed, wall thinning less than mm and aneurysmal motion are morphological signs of transmural necrosis. furthermore, a low dosage of dobutamine ( - microg/min) is used to detect functional reserve in the case of viable tissue. a further option offered by cmr is late contrast enhancement (le) imaging, which allows identifying the presence of fibrotic tissue as well as necrotic infarcted myocardium. the sensitivity and specificity of late hyperintensity is, respectively, . and . . similar results can be obtained with mtctetrofosmina g_spect. there is a relation between transmural extension of hyperenhancement and the recovery of contractile function after coronary revascularisation. the chance of recovery decreases progressively with the transmural extension of late hyperintensity, since the average value of the latter is ± % in the segments that recover and ± % in the segments that do not recover contractile function. cmr was also shown to be able to predict response to cardiac resynchronisation therapy differentiating between nonischemic and ischaemic cardiomyopathy le-cmr may allow to precisely delineate the presence and the location of fibrosis, avoiding the placement left ventricular leads in necrotic areas and in particular when the scar is located in the posterolateral area. at the beginning of the presentation, a short overview will be given on the relevance and prevalence of valvular heart diseases with special focus on europe and the data collected in the euroheart survey. also, the aetiologies of the various valve diseases will be briefly mentioned. in the second part, special attention will be given to aortic stenosis (as) and mitral regurgitation (mr), as these two entities are responsible for up to % of all valvular heart diseases. echocardiography is well accepted as the backbone examination of any valvular heart disease evaluation. echocardiographic criteria for severe as and mr are reviewed as well as their importance for the indication of valve repair or valve replacement. in the third part, we will focus on newer "cross-sectional" imaging technologies such as cardiac mr and ct. in particular, the strengths of cardiac mr in the assessment of regurgitant lesions will be demonstrated. in addition, the value of cardiac mr for the pre-interventional evaluation of congenital heart diseases will be discussed. similarly, the crucial role of cardiac ct in the workup for transaortic valve implantation (tavi) will be illustrated. finally, the yield of these novel techniques in the context of combined valvular and ischaemic heart disease will shortly be reviewed. learning objectives: . to better understand the role of cardiac mri in valvular heart disease. . to appreciate the added value of mri vs other imaging modailities. cardiac resynchronisation therapy (crt) and transcatheter valve heart (thv) interventions have been important therapeutic breakthroughs for heart failure patients and patients with valvular heart disease and contraindications for surgery. patient selection is crucial to optimise procedural outcomes and therapeutic efficacy. multimodality imaging plays a central role in patient selection and procedural strategy planning. assessment of left ventricular dyssynchrony, cardiac venous anatomy and extent and location of myocardial scar are key to identify heart failure patients who will respond to crt. stepwise use of non-invasive imaging modalities, including echocardiography, nuclear imaging, magnetic resonance imaging and multidetector row computed tomography (mdct), has been common practice to select patients for crt. recent technological advances have allowed integration or fusion of imaging modalities to create -dimensional models that provide relevant information. multimodality imaging is also crucial to optimise the results of thv interventions. detailed anatomical and geometrical evaluation of the mitral valve with current -dimensional imaging techniques has permitted better selection of patient candidates for transcatheter edge-to-edge mitral valve repair and accurate procedural guidance. for transcatheter aortic valve implantation, accurate measurement of the aortic annulus with -dimensional echocardiography or mdct allows us accurate selection of the prosthesis size to minimise the risk of complications, and evaluation of the procedural access (transarterial or transapical) with mdct permits accurate procedural strategy planning. the learning objectives of this session include: providing an overview of current imaging modalities to select patients for crt and thv interventions and how to use them in clinical practice. the inner layer of the anal canal consists of squamous and columnar epithelium with the transitional zone at the dentate line. the muscular component of the anal sphincter consists of an inner layer of circular smooth muscle (internal sphincter), extending downwards from the rectum, and an outer striated muscular layer extending downwards from the levator ani muscle, comprising the puborectalis muscle and the external sphincter. between these layers is the fat-containing intersphincteric space, including the continuation of smooth-muscle fibers of the longitudinal muscle of the rectum. outside the anal sphincter is the fat-containing ischioanal space. magnetic resonance imaging (mri) and endoscopic ultrasonography have become the mainstay for preoperative imaging of perianal fistulas. for complex tracts, mri seems preferable. mri can be performed using an endoluminal coil or a phased-array surface coil. a state-of-the-art imaging protocol should include t tse sequences in three orthogonal planes, with the axial and coronal sequences angulated at the anal canal. addition of a fat-saturated t tse sequence is recommended for optimal conspicuity of inflammatory changes and post-contrast t -weighted imaging can also be helpful. intersphincteric infection is the principal feature of perianal fistulas; this is generally not found in other conditions. veins can be mistaken for fistulas, but in contrast to fistulas, veins usually are thin-walled, tortuous, symmetric structures. a pilonidal sinus may resemble a fistula, but absence of extension to the intersphincteric space helps one to discriminate between them. haemorrhoids and anal tags may resemble small submucosal fluid collections, but are easily diagnosed at clinical examination. this lecture will describe the pathogenesis of fistula-in-ano, with a focus on cryptoglandular disease, so that the radiologist can understand how the various classifications of fistulas arise. the park's classification for fistula-inano will be described with reference to cryptoglandular disease and other aetiologies. the surgical questions that need to be answered by imaging will be presented, followed by a description of what the radiologists need to include in their report for it to be clinically useful. the role of anal ultrasound and mri for preoperative fistula imaging will be described, with explanation as to why the latter is fundamental to modern management of the disease. perianal fistulising disease develops in approximately half of the adult and paediatric patients with crohn's disease (cd), with a relevant impact on their quality of life. in patients with cd, particularly those with severe fistulising ileal or colo-rectal disease, complex ramified anal fistulas associated with abscesses (parks' classification type - or s.james hospital classification type - ) are more frequently observed than in other patients. perianal disease thus represents a severe complication of cd, which may change disease management, by requiring specific pharmacological and/or surgical treatments. a non-responsive disease eventually may lead to total proctectomy with ileostomy. mri represents the gold standard diagnostic modality, because it provides a comprehensive staging of both enteric and perianal disease, with high accuracy and without invasiveness. moreover, mri is the ideal tool for monitoring disease response to therapy, being able to detect the inflammatory activity of perianal fistulas with high accuracy. so far, several clinical indexes have been proposed to measure fistula's activity, including the perianal disease activity index (pdai). similarly, several mri classifications of fistula's activity, based either on t -weighted or t -weighted contrast-enhanced imaging, have been proposed, although a widely accepted imaging severity score is not available yet. several cases of complex perianal fistulising cd of increasing severity will be shown, with anatomical and clinical correlations, staging and activity description, particularly in patient follow-up and treatment monitoring. finally, differential diagnoses with other benign conditions which may affect the anal canal, including inflammatory infective diseases, hydradenitis and pilonidal disease will be discussed. ground glass opacity (ggo) is characterised on hrct by the presence of a hazy increase in lung opacity that does not cause obscuration of underlying bronchial and vascular margins. although a very common finding, it also constitutes a very nonspecific term since it can be seen in a variety of different intraalveolar and interstitial processes with different histology including inflammatory, infectious and neoplastic diseases that have a common physiologic mechanism: partial displacement of air. ground glass opacity may even be seen in normal processes such as poor ventilation in dependant lung areas and in expiration. moreover, ggo can represent either an ongoing, active and potentially treatable disease or an irreversible process. to interpret correctly this highly nonspecific but very significant finding, it is crucial to attempt to further classify the different large main entities in which this radiological finding appears. are there specific radiological and hrct findings that can help us differentiate ggo in autoimmune inflammatory conditions from infectious and neoplastic processes? are there associated findings other than ggo, such as nodules, reticulation or focal disease, and distribution of findings that can narrow the differential diagnosis? systematic evaluation of ggo and associated findings as well as integration with clinical information (acute, subacute or chronic symptoms) is essential in defining ggo subtypes to improve the radiological diagnosis. radiologists who regularly review high resolution ct (hrct) should be aware of the range of patterns and, more importantly, their potential pathological meaning. a pattern of ground-glass opacification is one of the more common hrct findings but, to the unwary, its interpretation can be problematic. an important underlying principle is that a ground-glass pattern may be caused by any process -physiological or pathological -which partially displaces air. physiological (i.e. non-disease-related) ground-glass opacification is perhaps most commonly seen in subjects who, for whatever reason (e.g. breathlessness, obesity), are unable to maintain or achieve a satisfactory inspiratory effort during scanning. a generally increased lung density (in contrast to adults) is also a feature in infants and young children simply because there are fewer alveoli in the developing lung. finally, it is worth noting that intravenous contrast administration (presumably because of a relative but temporary increase in capillary blood volume causing partial displacement of air) can unpredictably increase lung density. disease processes which lead to partial filling of the air spaces, thickening of the interstitium, partial collapsing of alveoli, and/or increased capillary blood volume will also manifest as a pattern of ground-glass opacification. in clinical practice, the recognised causes of ground-glass opacities on hrct include pulmonary oedema (cardiogenic or otherwise), infections (e.g. pneumocystis jiroveci pneumonia) and some of the idiopathic interstitial pneumonias (e.g. non-specific interstitial pneumonia and respiratory bronchiolitis associated interstitial lung disease). the presentation will review and revise the causes of physiological and disease-related ground-glass opacification on hrct. ground-glass opacity (ggo) is defined as increased attenuation of the lung parenchyma without obscuration of the pulmonary vascular markings on ct images. ggo may be the result of a variety of interstitial and alveolar infectious and noninfectious inflammatory diseases. as an imaging finding alone, ggo does not usually allow a specific diagnosis. ggo in inflammatory disorders is often present in the company of other interstitial or alveolar findings. however, the number of diseases that cause diffuse isolated ggo or ggo as the predominant finding is relatively small and can be prioritised with clinical information. the most common cause of diffuse isolated ggo in immunocompromised hosts are a variety of diffuse, opportunistic pneumonias, e.g. pneumocystis jiroveci pneumonia (pcp), cytomegalovirus pneumonia (cmv) or herpes simplex pneumonia (hsv), which constitute the first differential. chronic onset disorders in immunocompetent patients include cellular nonspecific interstitial pneumonia (nsip), subacute hypersensitivity pneumonitis (hp), organising pneumonia, air-space sarcoid, and drug-induced lung disease. in these disorders, ancillary findings such as an associated reticular pattern with traction bronchiectasis/bronchiolectasis (nsip), mediastinal lymphadenopathy (sarcoidosis), superimposed nodularity or cysts or may help to refine the diagnosis. in patients with collagen vascular disorders, e.g. scleroderma, ggo secondary to pulmonary involvement needs to be differentiated from drug-induced lung disease. this refresher course will put ggo in the context of outpatients versus inpatients, the acuity of clinical symptoms, e.g. fever, cough and dyspnoea, signs of massive systemic inflammation, and the clinical situation such as inhalational history, pneumotoxic drug administration, immunocompromise, or bone marrow suppression. in this course, we will review the dysplastic and neoplastic conditions that are associated with persistent ggo in the lung parenchyma. we will separate these conditions into those that are responsible for localised diseases such as single nodular ggo and those responsible for more extended diseases. nodular ggo can be separated into pure or mixed or part-solid nodules. pathology-radiology correlations show that nodular ggo are related to atypical adenomatous hyperplasia (aah), adenocarcinoma (adc) in situ (ais), minimally invasive adc (mia), and invasive adc according to the new iaslc/ats/ers lung adenocarcinoma classification. differential diagnosis includes exceptional metastases of angiosarcoma and melanoma as well as infection, inflammation and localised fibrosis. diffuse ggo related to neoplastic conditions is rare and may be due to lepidic adc (former advanced adc with bac component), diffuse large b-cell non-hodgkin's lymphoma, intravascular lymphomatosis (ivl) or mucosa-associated lymphoid tissue (malt) lymphoma. these neoplastic diseases should be differentiated from infectious and inflammatory causes of diffuse ggo. we will review the value of different morphological ct criteria to differentiate benign from malignant localised ggo, such as the size, the morphology (round, oval, flat), presence of mixed vs. pure ggo, and the multiplicity of nodular shadows. discussion will also include the changes that may occur within the nodule as well as the mean doubling time. the role of pet ct and transthoracic biopsy will be discussed. finally, we will present the current recommendations regarding the management of nodular ggo. it is the purpose of this lecture to briefly discuss ankle distortion-related lesions with emphasis on failed radiographic diagnosis, discuss their significance and management implications and define the diagnostic pathways in the acute and subacute stage. significant lesions are those with no return to sports activities after months; these have our major interest. in the acute setting of ankle distortion, the ottawa clinical decision rules are accepted to decide whether or not radiographic evaluation is needed; about % of radiographic examinations can be avoided. additional evaluation is restricted to patients with residual pain during reevaluation one week after trauma. assessment of fractures with the lauge hansen classification has a major advantage, as it defines the stability at the talocrural and distal tibiofibular joint. only in restricted cases, additional examinations may be needed to rule out instability. although radiographs easily detect displaced fractures, occult fractures may occur; also, grade ii-iii ligament lesions and peroneal tendon dislocation may go undetected. additional imaging evaluation should focus on the detection of significant lesions. significant lesions are talar fractures and complete calcaneofibular ligament tears. the latter is explained by the instability at the level of the subtalar joint with associated sinus tarsus syndrome. in case of residual local tenderness posterior and inferior to the lateral malleolus, the fibulocalcanear ligament and retinaculum peroneorum lesions are best evaluated with (dynamic) ultrasound. mri or ct is used to detect occult fractures in case of residual talocrural joint effusion with anterior talar tenderness during endorotation and plantar flexion. the ankle and foot can be affected by inflammation from a number of diseases. the main focus of this lecture will be inflammation secondary to infection and systemic inflammatory disorders. due to its function in locomotion and weightbearing, the foot is specifically susceptible to infections secondary to penetrative trauma including foreign bodies or to abnormal repetitive pressure. in addition, both seropositive and seronegative arthropathies can affect the foot. other unusual causes of inflammation include chronic recurrent multifocal osteomyelitis, osteoarthritis, mechanical disorders and sensory loss. this lecture will deal with the various patterns of inflammation in the context of pathogenesis and discuss the imaging features that aid in diagnosis. the importance of the clinical context in diagnosis will also be discussed. characterising tumours before deciding on the most appropriate treatment is a general rule in oncology. cystic tumours are now adequately graded based on bosniak's classification. however, this pre-therapeutic characterisation is not currently systematic in case of solid renal tumours, as it remains difficult in clinical practice due to the high prevalence of renal cell carcinomas (rcc) and the lack of reliable imaging criteria for recognition of benign versus malignant tumours. as a result, approximately % to % of surgically excised renal masses are actually benign. to avoid these unnecessary ablations, pretherapeutic image-guided biopsy has been proposed, but its use is still debated as it is invasive and time consuming. new validated imaging criteria, able to accurately differentiate the most common tumour types but also indolent vs more aggressive malignant lesions, would be useful to reduce the number of unnecessary biopsies or to consider the most appropriate treatment for a tumour or active surveillance. among these, mr imaging plays a major role based on chemical shift gradient echo (gre) sequences, signal intensity on t -weighted images, dynamic contrast-enhanced sequences, diffusionweighted sequences and late contrast-enhanced images. multiparametric mr imaging is now performed in clinical practice in most primary care centres. therefore, using different combinations of two or several parameters, it is now possible to distinguish certain renal tumours. a larger validation of all these combinations is still necessary to define those having a clinical significance for routine practice. targeted therapies such as vegf mab bevacizumab, vegf tyrosine kinase inhibitors (sunitinib, pazopanib, axitinib and sorafenib) and mtor inhibitors (temsirolimus and everolimus) have been approved and included in european guidelines. pre-therapeutic imaging prerequisites are mainly based on the natural history of mrcc. this justifies imaging through a thoracoabdominal ct scan. outside clinical symptoms, there is no need for bone imaging or brain ct scan; the latter nevertheless could be done because of influencing the therapeutic strategy. pet scan should not be done due to low sensitivity. the evolution of metastatic sites by comparison from previous imaging is useful to evaluate the natural history. outside clinical trials or research imput the strategy is to use the drug in an optimal way to increase pfs. so far, monitoring has to inform about change in recist criteria for cr, pr, sd or pd, and if pd is a real pd such as recist pd or a slowing pd. in conclusion, standard ct scan and recist are adapted to real life. nevertheless, more information on the mode of action of targeted drugs should be interesting for knowledge and research purpose, without any impact on the management of patients. additional imaging could be done with additional criteria than recist on ct scan, by vascular functional imaging and pet scan. breast mri is recognised as a useful tool for a number of clinical indications, but remains relatively challenging. recognising the importance of an evidencebased approach to the development of protocols will influence the further integration of this technique into everyday clinical practice in the management of breast cancer patients. there remain concerns regarding the potential of over-diagnosis from breast mri. the aim of this integrated rc is to inform the clinical practice with regard to the establishment of breast mri in specific clinical and imaging scenarios, namely, using mri for surveillance in high-risk patients, monitoring response to neo-adjuvant chemotherapy and developing protocols for the indeterminate imaging scenario of non-mass-like enhancement. the establishment of protocols to maximise the specificity and sensitivity of the technique of breast mri in such indeterminate clinical and imaging scenarios will be discussed. non-mass like enhancement is a frequent finding in breast mri. it relates to the fact that enhancement occurs in the normal-appearing fibroglandular tissue that surpasses that of the other parts of the parenchyma. there is no associated space-occupying lesion. in pre-contrast non-fat-suppressed or fatsuppressed t -and t -weighted images, there is usually no correlate observable. the differential diagnosis of non-mass-like enhancement is between benign nonspecific fibrocystic disease/adenosis, hormonal stimulation, and subclinical mastitis on one hand, vs dcis or (less likely) diffusely infiltrating (usually lobular) cancer on the other. key components of differential diagnosis is configuration of the enhancement (does it follow the orientation of the milk duct or not?) and symmetry (symmetric or asymmetric). less important criteria are internal enhancement (internal architecture) and enhancement kinetics. it is important to realise that enhancement kinetics can only be used to corroborate the suspicion of dcis -but they cannot be used to alleviate the indication to biopsy a finding which, based on configuration and asymmetry, is suspicious. management depends on the different constellation of clinical, mammographic, and mri findings. it usually includes short-term follow-up ( months) and, if stable/persistent, mr guided vacuum biopsy. assessment of the change in tumour burden is an important feature of the clinical evaluation of cancer therapeutics. tumour shrinkage and time to the development of disease progression are important end points in cancer clinical trials. however, these end points are useful only if based on widely accepted and readily applied standard criteria. criteria, known as recist, were published and are updated on a regular base. the revised recist includes a new imaging appendix and underlines the importance of moving from anatomic unidimensional assessment to either volumetric anatomical assessment or functional assessment with pet or mri. the goal of the lecture is to discuss the value of the different mr imaging techniques (e.g. mr spectroscopy, diffusion-weighted imaging, angiogenesis mapping, pet-mri), which evaluate response to treatment in breast cancer. participants will learn about particular imaging challenges of assessing response to neo-adjuvant chemotherapy. in addition, they will learn to understand clinical aspects of neo-adjuvant chemotherapy based on recist. currently, the esr has been using social media in many successful ways to improve the contacts among members and to boost our fast development as one of the most advanced scientific communities in the world. our session "the role of social media in radiology" presents the view of experts, acknowledged leaders of international it projects. it seems to be important to discuss the major implications of social media for radiology, the leading clinical discipline in information technology. davide caramella will clarify the relationship of social media to professional societies and especially to the esr, including their basic features. the "social media generation" has developed from schoolkids to students and, recently, to teachers as well. alexander sachs represents the young professional expert of elearning in radiology and will reflect the current user behaviour. osman ratib will share his view on how social networks enhance the communication between radiologists, nonradiologists and patients. critical aspects of the pros and cons of large communication scenarios are followed by some ideas of future developments. jürgen brandstätter will indicate the patient´s view. most patients see social network communications with their radiologist as useful for, e.g. appointment management or other non-sensitive communication. besides communicating personal health data, a wide area of potential useful other possibilities are at hand, like anonymised health data for reviewing purposes, second opinion or education of patients. the fast development of social media may induce hopes and fears; the four speakers of this session will present them in a panel discussion. the widespread use of social networks in all professional activities has attracted a great interest in the recent years. in medical applications, the main concerns include the possible consequences in terms of patients' confidentiality protection, perceived role of the physician, patient-physician relationship, and caregivers' distraction during professional activities. there are no doubts, however, that social networks are beneficial in enhancing the information flow between scientific societies and their professional members, without any interference at the point of care. social networks have proved to be extremely effective in updating members about relevant news concerning their areas of interests and in allowing them to be informed about the educational activities promoted by their scientific societies. this presentation focuses on the social network activities promoted by the esr via facebook, youtube, twitter and other blogs. impact of social media on the training of radiologists a. sachs; vienna/ at (alexander.sachs@meduniwien.ac.at) in modern times, social media have gained more and more important value in exchanging first experiences in radiology from resident to resident. social networks such as facebook, twitter, google plus and others are used to start discussion groups about cases and share the growing knowledge with different educational concepts in each hospital. growing e-learning modalities as moocs, applications for smartphones or tabs and web-based case series or learning platforms support the training of radiologist in social media. modern elearning platforms use social media as their first choice of sharing knowledge around the whole world about certain illnesses, cases or different decisions of therapy. though sharing information seems to be easier and shows several advantages than in former times, social media can also highlight new problems. this lecture focuses on user behaviour to improve learning, the pedagogic evidence for large group learning with networks and the importance of using networks to manage time. social media networks in communication between radiologists, nonradiologists and patients o. ratib; geneva/ch while social networks have gained unprecedented popularity in our daily environment, they have only limited utilisation in medical applications. the paradigm of communication within a given community for exchange and sharing of imaging data would certainly have its place in a medical environment where there is an increasing need for multidisciplinary collaborative work. the required security and confidentiality in management of sensitive patient data have often precluded the usage of existing public social networks. professional proprietary systems have emerged in a more restricted way with much less flexibility leading to limited use. the exchange of medical images adds a level of complexity due both to the size of the data and the need for appropriate browsing and visualisation tools. traditional pacs and teleradiology system offer such features, but in a very limited way, far from the desired convenience of social networking between groups of users. a prototype of such a system aimed essentially at the community of users that need to exchange anonymised medical images and data for academic and research purposes will be presented and discussed. the project nicknamed dicom sandbox is being tested and evaluated by some users in europe under the coordination of the esr subcommittee of ehealth and informatics. developed with open source software components, it allows using existing cloud-based storage services with additional layers of secure dicom file management and visualisation. it allows the community of users to share dicom data with all social networking and notification features beyond simple peer-to-peer exchange. interactions between patients and radiologists through social media j. brandstätter; wiener neudorf/ at (j.brandstaetter@codewerk.at) social networks have become integral parts of most citizen's use of the internet. especially, the younger generation uses social networks extensively; however the way those tools are used should be chosen carefully. it is one thing to use a social network for private interests, but a different one to use it as transport media for sensible data like personal health-care data. the sensitiveness of citizens regarding privacy has been increased recently by different events of misuse or fraud, especially accelerated by the recent privacy affairs caused by governmental agencies. though most patients see social network communications with their radiologist useful for, e.g. appointment management or other non-sensitive communication, personal medical reports or images shall not be shared across this media. besides communicating personal health data, a wide area of potential useful other possibilities are at hand (e.g. anonymised health data for reviewing purposes, second opinion, education of patients, …). future developments shall make use of social media where useful, but always with deep respect to the patient's privacy rights. apart from the historical, but ever present clinical expectation from the neuroradiologist is the answer to the most important question if the patient has a brain tumour or not. nowadays, due to the outstanding technological advances in imaging techniques during the last decades, the stakes are growing much higher and it is the neuroradiologist on whom lies the initial responsibility of answering a large number of questions that are of utmost importance for further brain tumour patient care and treatment. having the opportunity to provide the usual and generally basic information regarding tumour morphology and exact location and to narrow the differential diagnostic possibilities, neuroradiologic expertise now opens a wide spectrum of techniques, especially those derived from mri, such as mr spectroscopy, mr perfusion, dwi, dti, swi, etc. these provide us the unique possibility of not only obtaining and comparing images, but also of exploring multiparametric brain maps, allowing us to gain insight into the internal architecture of the tumour and the functional and molecular features of the tumorous tissue. this consequently defines the actual stand of neuroradiology, indicating the uprising clinical urge not only to provide the answers regarding the tumour type, grade and possibilities of the most appropriate and patient-individualised therapy modality, whether surgical or nonsurgical, but also to accurately assess the post-treatment tumour behaviour and status, by differentiating the true tumour progression from pseudoprogression, represented by inflammatory responses to the radio-and/or chemotherapeutical treatment, and to monitor other neurooncological response assessment criteria. a. differential diagnosis and pseudo-tumoural lesions h.r. jäger; london/uk (r.jager@ucl.ac.uk) conventional contrast-enhanced mr imaging gives an indication about the likely tumour type and histological grade, but advanced mr imaging methods, including perfusion-weighted (pwi) and diffusion-weighted (dwi) imaging, mr spectroscopy (mrs) and pet imaging provide additional information which helps to refine the diagnosis of intrinsic brain tumours. contrast enhancement can be a feature of low-grade (pilocytic astrocytoma and ganglioneuromas) as well as high-grade gliomas (who grade iii anaplastic gliomas and who grade iv glioblastomas). infiltrative low-grade (who grade ii) astrocytomas do not usually enhance, whereas who grade ii oligodendrogliomas can enhance. higher-grade glial tumours (who grade iii and iv) tend to have an elevated relative cerebral blood volume (rcbv) on pwi, a decreased adc on dwi and increased choline turnover on mrs and pet imaging. a raised rcbv can, however, also be seen in low-grade oligodendrogliomas, particularly in those with a p/ q chromosomal translocation, which is associated with a better response to chemotherapy. pwi and dwi are useful in the differentiation of glial neoplasms from cerebral lymphoma, which has an increasing incidence in the immuno-competent population. dwi and pwi are also very useful in the differentiation of enhancing pseudo-tumoural lesion such as cerebral abscesses, tumefactive demyelination, pseudoprogression and radiation necrosis. perfusion imaging plays an important role in the characterisation and management of brain tumours. low-grade brain tumours may transform into high-grade gliomas at some point, which is a transformation that is highly variable and difficult to predict in an individual patient. conventional contrastenhanced computed tomography (ct) and magnetic resonance (mr) imaging are found to be insufficient to depict this transformation and angiogenesis and therefore to detect malignancy. however, perfusion imaging provides additional information over conventional imaging in terms of tumour physiology and haemodynamics, providing important biomarkers for malignancy and prognosis. perfusion ct and mr perfusion techniques such as arteriel spin labelling and dynamic susceptibility-weighted perfusion imaging are more practical and widely used compared to nuclear medicine methods. these perfusion techniques should be considered and used in routine clinical workup of brain tumours to asses grading and prognosis. maximal safe resection, radiation therapy and temozolomide chemotherapy are the current standard of care for newly diagnosed high-grade gliomas. still, hgg have a poor survival rate. a contributing factor to the poor survival is the inability of currently available imaging techniques to accurately delineate the tumour, with the result that targeted focal treatment my not be effective. conventional imaging is not able to give an early assessment of the effectiveness of radiation and/or chemotherapy. in addition, conventional imaging has difficulties in differentiating pseudo-progression, which is a common phenomenon in conventional chemo-radiation therapy, from true progression. early identification of patients who suffer from tumour recurrence can be of great advantage: it provides the opportunity to adjust individuals more rapidly, sparing patients unnecessary morbidity and delay in the initiation of other, maybe more effective, treatment. in recent years, different functional imaging approaches such as perfusion mri, diffusion-weighted imaging and spectroscopy, have been complementarily used for imaging evaluation of treatment response. in this lecture, different advanced mr and ct imaging methods used to support differentiation between pseudo-progression and true tumour progression to assess treatment response will be discussed. in addition, a novel recently published promising technique, the parametric response mapping (prm), a novel voxel-wise analytical method of monitoring physiological and environmental changes in a tumour volume during treatment will be presented and compared to the traditional methods used. finally, the aim of the lecture is to consolidate the present knowledge and novel ideas in brain tumour imaging for assessment of pseudo-progression versus true tumour progression. learning objectives: . to understand the challenges and limitations of routine mri in monitoring brain tumour treatment. . to become familiar with the role of advanced imaging biomarkers for early assessment of treatment response. . to learn how to integrate routine and advance mri into clinical practice after tumour therapy. the purpose of this lecture is to describe the role of functional radiological imaging modality-ct and mr perfusion in the evaluation of head and neck tumors. conventional contrast-enhanced ct and/or mr imaging are the current standard techniques for the diagnosis and treatment evaluation of the head and neck tumors. however, this method is limited in its ability to depict the angiogenesis which is a hall-mark of tumor growth. perfusion imaging provides a rapid evaluation of tissue perfusion and can be easily implemented in every head and neck ct or mr protocol. the determination of tissue perfusion is based on examining the relationships between the arterial, tissue and potentially the venous enhancement after the introduction of a bolus of contrast material. the quantification of the perfusion values helps to outline the malignant tissue as well as to differentiate recurrent disease from nonspecific post-therapeutic changes and can be used as a therapeutic monitoring tool during and after tumor therapy. in recent years diffusion-weighted mri (dwi) gained increasing importance and also acceptance in head and neck radiology. although this functional technique is challenging due to air tissue interfaces, its ability to improve the diagnostic accuracy is widely accepted. dwi can be applied to detect lesions not only in adults, but also in children. it is helpful in lesion characterisation and has a great potential to differentiate recurrence from posttherapeutic changes. initial promising results to improve lymph node staging however are difficult to reproduce. image interpretation is performed qualitatively based on visual assessment of the high b-value images (b= - sec/mm ) and the corresponding apparent diffusion coefficient (adc) map. quantitative image analysis is based on the measurement of the underlying adc value. solid tumors including recurrences are bright on the high b-value images and dark on the corresponding adc map, whereas posttherapeutic changes are bight on both the high b-value images as well as the adc map. cystic and necrotic lesions are typically dark on the high b-value image and bright on the adc map. furthermore, malignant lesions tend to have a lower adc compared to benign and cystic lesions provided that no necrosis is present. therefore, image interpretation always has to be performed together with morphological images to avoid misinterpretation of functional images. pet/ct has established itself as a robust, rapid and reliable technique in head and neck oncology. it is mainly used to stage nodal disease, to detect distant metastases and synchronous tumours, to identify unknown primary tumours in patients with metastatic neck nodes, to assess treatment response and prognosis after chemoradiotherapy and for radiotherapy planning. mri with diffusion-weighted imaging (dwi) is routinely used for the assessment of submucosal tumour spread, to stage nodal disease, to monitor treatment response and to detect recurrent disease. the information provided by pet/ct and mri is often complementary and the recent implementation of hybrid mr/pet systems in clinical settings holds promise because it can combine morphologic, functional and molecular information. this lecture focuses on clinical applications of pet/ct and mr/pet in the head and neck. current evidence about the combined use of pet/ct and mri with dwi is discussed. the principles of mr/pet data fusion are summarised as well as current knowledge regarding the diagnostic performance of mr/pet in the head and neck. typical radiologic findings of tumour manifestations are reviewed with particular emphasis on the early detection of lesions, their appearance on different imaging modalities and the added value of hybrid imaging techniques. the variable appearance of functional phenomena mimicking disease as well as the potential pitfalls of image interpretation and how to avoid them are equally addressed. major emphasis will be put on how to report the findings in a comprehensive way. multi-energy and functional imaging ct has reached a robustness allowing the use of this new technology in clinical routine for a variety of different clinical questions. this presentation will discuss the basic principles and the strengths and limitations of the techniques. implementations of multi-energy methods for material characterisation and of ct methods for functional imaging will be discussed. contrary to normal single-energy ct systems, multi-energy ct scanners allow simultaneous scanning at two peak x-ray energies. when the attenuation is measured at two energies, their values are not exactly proportional to each other, which open new diagnostic possibilities. measurements at two spectra can be achieved using multiple kvp and/or filtration or with detectors with energy discrimination. these methods have different pros and cons such as sensitivity to subject motion and dose efficiency. to be able to acquire functional data such as perfusion, images are acquired dynamically following the injection of a contrast agent and physiological models are used to convert the measured contrast agent concentration to perfusion estimates. methods that acquire multiple images have the potential to increase the radiation dose to the patient, so ct protocols need to be optimised. in computed tomography, d images are reconstructed from a number of x-ray radiographs that were acquired at different angles. tomographic reconstruction relates to the generation of a d image based on these acquired radiographs. most tomographic reconstruction methods are based on a technique called filtered back projection (fbp) in which a sharpened version of the radiographs are back projected to generate the d image. while it has been the standard reconstruction method, mostly due to its speed and good quality if many radiographs are available, iterative reconstruction methods are emerging. the reason for that is that fbp suffers from important disadvantages. in this talk, the basic concepts of iterative reconstruction are explained and its virtues are detailed. the flexibility of iterative reconstruction methods is demonstrated for the field of x-ray computed tomography. finally an outlook is given with respect to future research on tomographic reconstruction. interventional radiology (ir) has been increasingly applied in the management of obstetric and gynaecological haemorrhage. national reviews of maternal deaths from post-partum haemorrhage have recognised that maternal deaths may be prevented by ir and that all obstetric units should have protocols and arrangements in place to ensure appropriate and timely referral to ir. the important role that irs play in the management of fibroids has also highlighted how these techniques can be applied to other gynaecological conditions which may result in haemorrhage. this session will start by describing which gynaecological disorders may result in haemorrhage and the technical aspects of treatment followed by the published evidence for embolisation. the session will then focus on obstetric haemorrhage, with an emphasis on prophylaxis and how women deemed at high risk for haemorrhage might be managed safely. the techniques used for prophylaxis of haemorrhage will be described in detail and the published data presented. the final presentation will concentrate on the technical aspects of embolisation when haemorrhage has occurred to ensure the best results by knowing the relevant anatomy and appropriate technique of embolisation. the published evidence of the results of embolisation in pph will be presented. these presentations will be followed by a panel discussion on how irs can reduce the radiation dose whilst simultaneously ensuring successful outcomes for their therapies, an important issue in a young and fertile group of women. gynaecologic massive bleeding related to benign and malignant causes is under the scope of all radiologists because of being diagnostic and also because of its implication in interventional radiology procedures. the causes are uterine fibroids (uf) and post-partum hemorrhage (pph). however, oncologic disease, arterio-venous abnormalities, or iatrogenic injuries are less commonly known to be eligible for embolisation procedures. usually, surgical homeostasis attempts or radical hysterectomy is preferred to embolisation procedures. despite the good clinical outcome for hysterectomy and the hazardous success rate of conservative treatment, both are unsatisfactory to patients. pelvic artery embolisation (pae) could dramatically change the patients' clinical issue. the purposes of this lecture are to: revise the pelvic arterial anatomy (possible arterial anastomosis or variation); outline the aetiology of non-obstetric massive menometrorrhagia; expose the typical clinical presenting features; describe the imaging appearances of the etiologies; and discuss patient section, procedure technique, pitfalls and complications. obstetric haemorrhage occurring mainly in the postpartum period is a significant cause of maternal morbidity and death. blood loss of over and ml after vaginal delivery or caesarean section, respectively, complicates % of deliveries. major blood loss of more than ml occurs following less than % of all deliveries. the causes include uterine atony, retained placenta products, placental abnormalities, uterine rupture, lower genital tract laceration, cervical ectopic pregnancy and coagulopathies. generally, treatment is based on administration of uterotonic drugs, vaginal packing, surgical ligation of uterine arteries and even hysterectomy is sometimes needed. transcatheter embolisation of uterine, pudendal, vaginal arteries and ovaries is considered to be superior and should be the first-line treatment for intractable obstetric haemorrhage where interventional radiology is available. angiography reveals extravasation of contrast agent in more than % of these patients. the most frequent extravasation is from vaginal artery, and then from pudendal and uterine arteries. depending on the extravasation location and haemodynamic stability of a patient, f catheters or coaxial microcatheter technique is utilised for catheterisation. gelatin foam, microparticles acrylic glue and microcoils are the most frequent embolic agents. the embolisation procedure usually does not require general anaesthesia and can be repeated if bleeding continues. primary success rate in bleeding control is reported from to %. the most commonly reported long-term side effects after embolisation were transient buttock numbness and urinary frequency. the transcatheter pelvic artery embolisation for obstetric intractable bleeding is a fertility-preserving alternative to hysterectomy. medical imaging has nowadays integrated the diagnostic armamentarium of anosmic patients regarding not only qualitative assessment of the olfactory tract, but also quantitative evaluation of olfactory bulb volumes which are known to closely correlate to the olfactory function. many clinical studies on various pathological conditions have evidenced the value of such measurements in the workup of olfactory dysfunction for both aetiologic and prognostic purposes. imaging workup also plays a role in the medico-legal evaluation of post-traumatic anosmia together with electrophysiological and clinical olfactory tests. technical improvements in fibre tracking (ft) using diffusion-tensor imaging (dti) and appropriate designs of olfactory stimulation at bold-based functional mri (fmri) are expected to allow insights into the neurophysiological processes and circuitry of olfaction in the very near future. imaging workup of the anosmic patients will be the cornerstone of this lecture. the relevance of the different imaging techniques will be detailed. beyond the workup of anosmia, a comprehensive overview of the most common lesions of the olfactory tract seen in clinical practice will be given. additional review of lesions observed at the anterior cranial fossa in the near vicinity of the olfactory tract will be done, which comprehensively includes all commonly observed developmental, traumatic, inflammatory and neoplastic conditions not arising from the olfactory tract. their potential impact on the olfactory function or on other sensory/neurological functions will be underlined. clues to clinical/radiological differential diagnoses of the most common conditions and radiological features of the anterior cranial fossa will be highlighted. the central skull base, the floor of the middle cranial fossa, has a complex anatomy and is pierced by a variety of foramina and canals providing crossroads for spread of disease between the extra-cranial head and neck and the intracranial compartment. disease spread into the intracranial compartment indicates a dismal prognosis, as often it becomes inoperable due to involvement of vital structures including cranial nerves, carotid artery and/or brain parenchyma. imaging plays a pivotal role in the assessment of these structures which are not amenable to clinical inspection and can dramatically change the patient's management. in this complex anatomical area, ct and mr have a complementary role in providing a comprehensive roadmap for treatment planning. of major importance is the pterygopalatine fossa, the cavernous sinuses and orbital apex. the former, lying between the pterygoid plates and the maxillary sinus, is a major crossroad between the intra-and extracranial compartments and should be carefully inspected. pathologies affecting the central skull base are varied and may originate from the skull base proper, from the middle cranial fossa or from the extracranial head and neck. by looking at the centre of the lesion, its tissue characteristics and pattern of growth, it is often possible to provide a useful differential diagnosis and, most importantly, to map the lesion's extent. here, we present a radiologist-friendly approach to central skull base pathology highlighting the most important features in the differential diagnosis and treatment planning. . the jugular foramen: the jugular foramen is an opening in the skull base. the radiologic evaluation requires high-quality imaging with ct and mr. angiography is reserved for preoperative embolisation. it is important to recognise the "pseudo lesions". the most common tumour of the jugular foramen is the paraganglioma. the second is the schwannoma of the lower cranial nerve, and the jugular foramen meningioma is the third most common. the differential diagnosis shall be discussed. . the cerebellopontine angle (cpa) and the internal auditory canal (iac): the iac is a bony conduit for several nerves and a vessel, the neurovascular bundle. the cpa is a cistern of the peripheral cerebral spinal fluid, and several anatomical structures pass through this. it is also the place of some frequent disease processes. most of the lesions in the cpa are benign tumours with order of frequency: vestibular schwannoma and meningioma. the third most common lesion is a benign cystic lesion: the epidermoid cyst. in the iac, you can encounter the same benign tumoural lesion as in the cpa, but also inflammatory lesions, viral lesions and malignant lesions. why is it important in your imaging protocol of the iac and cpa region to use gadolinium? the differential diagnosis of different lesions shall be discussed. learning objectives: . to learn about the imaging techniques and anatomy in the posterior cranial fossa. . to become familiar with the imaging findings of common posterior cranial fossa pathologies. . to learn how to differentiate between the lesions in the posterior cranial fossa. health care is characterised by several specific features making it different from traditional markets. two of the key features are: the impossibility of patients to make choices, due to asymmetry of knowledge between them and their health-care providers; the fact that patients create an agency relationship with health-care providers, delegating to them the decision about the care delivered. due to these characteristics and to the fact that patients are fragile when they need care, there is a natural tendency for patients to rely on healthcare professionals. it is in this complex socio-technical environment that radiographers must be aware of their roles and responsibilities and ensure professional autonomy and accountability; demonstrate an ethical and knowledgeable understanding of the profession; apply professional practice in securing, maintaining or improving health and well-being; develop knowledge, skills and competences that underpin their education and training, contributing to the wellbeing of the patient; understand that professional advancement arises out of evidence-based practice and is acquired through focused research. this demands for a focus on patient care and safety, based on high professional standards. ebp is the best way to achieve this desideratum, as it combines the best research evidence with clinical knowledge and expertise, addressing the patient in a holistic way. since the radiographer is the ultimate interface between patient and technology, it is crucial to create a real teamwork concept, using guidelines for the roles and responsibilities of each team member as the pathway to minimise practice error, maximising patient and staff safety. the use of ionising radiation in medical exposures is well documented across countries. recent studies indicate that a substantial fraction ( to %) of these procedures is unnecessary when taking into consideration patient clinical indication. defensive medicine, economic interest, poor patient clinical information, patient pressure and the lack of knowledge about other alternative procedures, taking into account the benefits and risks, are the principal causes of unnecessary radiological examinations. patients must be referred to a medical imaging department for an examination that should be justified according to clinically appropriate image criteria and informed of the potential benefits and risks. following justification, the optimisation of practice is essential to ensure the minimal exposure of radiation dose to the patient whilst diagnostic efficacy is maintained. the principal aim of optimisation is getting a narrower dose distribution, with lower mean and th percentile values of the diagnostic reference level. optimisation processes need to consider several factors including the type of examinations, body region, clinical information, available equipment technology and image processing tools. to implement this process, a multidisciplinary teamwork is essential where radiographers, being the pivot between patient and technology, have an essential role. to understand and apply optimisation procedures, radiographers should be aware of the international guidelines, standards and directives. all medical imaging procedures must be audited to analyse if the workflow processes (referral, justification, optimisation and radiation protection principles) are according to the recommendations to create a radiation protection safety culture. although we are approaching the year , a lot of clinical radiography is not based on best evidence. lot of clinical decision-making is based on, for example, traditional practices that we cannot argue as being the best possible ones. in this presentation, barriers to using research and other sources of evidence and facilitators of evidence-based (eb) radiography are described. the role radiographers have in developing eb guidelines and procedures may vary according to educational level and work description. developing eb guidelines is not the work of every radiographer, but obeying them is. the speaker gives some suggestions on what to do in a situation if there are no eb guidelines and procedures in ones' country or institution and no group that develops them. with the framework of "the new work order" and increasing implementation of new work processes, professionals are faced with new modes of collaboration requiring communicative skills as well as multiprofessional competencies between all the stakeholders across the hospital. some evidence about the consequences of ineffective communication in the field of radiography is presented. in addition to benefits associated with the procedure of clinical audit, uniform good quality protocols for examinations and uniform national/international criteria help to perform comparisons between radiology units. clinical audit also works as an educational tool and as a feedback tool for the staff on their performance. it also points out the need for corrective actions. initiatives from professional organisations are probably the most powerful engines for the construction of europe, and in many cases open the road for legal and political advances. many medical specialties felt that there was a need for the harmonisation and standardisation of medical training over europe. the esr has shared this opinion and has elaborated a unanimously appreciated training curriculum, which is constantly updated. establishing the ebr (european board of radiology), with the mission to organise a european diploma was the logical next step. today, examinations have already been organised and more that candidates from european countries and abroad have applied. the trainee who passes the examination proves his professional skills and has reached the objectives assigned in the curriculum. in this session, we will explain how esr organises the diploma. we will review, capitalising on our current experience, the main lessons learnt from the past editions, the keys for success and reasons for failure, as seen by the examiners. we will also learn about the "diploma adventure", from the point of view of a successful candidate. national radiology training programmes in europe differ to a large extent, regarding length of training, content, and the presence or absence of a national board examination for certification. thus, for cross-border radiologic activities, the level of training and expertise applying to radiologists is difficult to assess under these circumstances. there is an increasing number of medical subspecialties, which organise european diplomas. more than subspecialties (e.g. anaesthesiology, ophthalmology, urology, etc). organise european examinations, which are well received among the respective communities. growing numbers of residents in training successfully stand this test of knowledge and practical skills. recognition of european diplomas by national authorities is an issue, which will increase the level of acceptance. the present status of the recognition process in european countries will be summarised. case material for the diploma will test knowledge in general radiology at a standard to be expected at the end of training as outlined in the esr curriculum. all ten esr-recognised subspecialty areas of the curriculum will be tested. the written exam comprises two computer-based sections, a multiple response section, and a short case section. there will be multiple response questions. these questions comprise both multiple options format, a single stem with answer options, and short imaging studies where candidates are asked to either annotate the image from a drop-down menu, or select the radiological features displayed or differential diagnosis from the options given. a special scoring system has been developed to prevent guessing. the short case section comprises or case-based questions. you may practice using the self-assessment tests on the esr website which follow the same format as the written examination. for the oral cases, you must have a systematic method and perform under pressure, which takes practice. you may rehearse with experienced radiologists who feedback on your performance. you can break a radiology report into areas, observations, interpretation and conclusion. conclusions should take into account the clinical information. candidates often forget this under pressure, so ask for it to be repeated. your differential diagnosis should be logical and comprehensive. the commonest causes of an abnormality is a good topic to revise. suggest if further imaging tests are indicated and give an indication of urgency. each case is marked separately. as a well-known statement in the academic world of education, "assessment drives learning". with the help of carefully prepared and performed examinations, it is possible to emphasise and instill the training curriculum. due to different reasons, training of radiology in european countries is highly varied. like in our experience in turkey, a central examination system, accompanied by a neatly prepared training charter and curriculum, is a good starting point to solve the problem. we believe that a common european assessment system like edir will contribute a great deal to the harmonisation of radiological training and establishment of quality standard in every country. the need for harmonising the training is not unique to radiology. this is why in more than medical disciplines, european diploma examinations are now being organised. furthermore, in some disciplines like urology, annual and online "in-service assessment" of residents and practising urologists allows the participants to evaluate their current knowledge base against the current european standards, and also provides the trainers and directors knowledge about the teaching and learning process in education centres. although there are huge diversities among different european centres, the urgent need of harmonising radiology training and setting a standard of quality are felt by all radiologists in europe. establishing and institutionalising a common assessment system in european radiology appears to be the shortest way to reach this goal. this is why we should support "european diploma in radiology" by any means and work hard to promote its recognition throughout the continent. the majority of emergency ct studies reported by junior radiologists or general radiologists out-of-hours comprise brain scans. brain ct studies are often performed to detect acute life-threatening abnormalities, such as stroke, intraparenchymal or subarachnoid haemorrhage, cerebral edema, etc. misrecognition of these often subtle, but life-threatening abnormalities can lead to inappropriate patient management and worsen patient outcome. errors in interpretation can generally be categorised as either perceptual or cognitive in nature. perceptual errors are those in which the radiologist does not see the abnormality, resulting in a false-negative interpretation (e.g. basilar artery thrombosis, deep cerebral venous thrombosis, pres,…). cognitive errors, on the other hand, are those in which an abnormality is identified but the meaning or significance of the abnormality is not recognised. cognitive errors can result in false-positive interpretation if, for example, a normal anatomic variant is mistaken for a pathologic condition. while the more common normal variants and artefacts often do not present a problem to experienced clinicians and neuroradiologists, less experienced individuals should beware of these diagnostic hazards. to reduce false-negative and false-positive reporting, a checklist of the review areas (blind spots) to be verified on any brain ct scan will be offered and the most frequent normal variants will be discussed. pitfalls in brain imaging comprise perceptual or cognitive errors of interpretation of imaging findings. errors of perception refer to a missing of a pathology that is present on an image, while cognitive errors consist of a wrong interpretation of a seen structure or pathology. interpretation may be false negative or false positive. in addition, a wrong conclusion may be drawn resulting from missing, incomplete or false clinical information, or as a consequence of a lack of knowledge of differential diagnoses. perception errors are frequently the consequence of incomplete examination protocols where lesions are missed (for instance, acute ischaemic changes without the use of diffusion-weighted imaging) or signals, for instance, flow-related phenomena are misinterpreted. asymmetric positioning of the patient`s head may also lead to misinterpretation of side differences, especially in the temporal lobe. another source of perception errors might be reduced attention (especially at night shifts) and have been proved to occur in regions that are "potential blind spots", as the sulci, cavernous sinus, meckel cave, dural sinuses, brainstem, and skull base foramina. perceptual errors may be avoided by following a checklist when reading images. all sequences should be used for comparison of signal intensities to distinguish artefacts from pathology. another very important fact to avoid misinterpretation lies in a profound knowledge of morphologic and metabolic age-related changes of the brain and of anatomical normal variants (such as, for instance, accentuated virchow robin spaces in certain locations). cystic liver lesions can be classified based on their nature as benign and malignant. in the benign category are, among others, developmental and infectious/inflammatory cysts, while neoplastic cyst can be subdivided into primary and secondary. developmental cysts originate from abnormal ductal plate malformation and consist of hepatic (bile duct) cyst, bile duct hamartomas, caroli's disease and polycystic liver disease. infectious/inflammatory cysts include, among others, abscesses (pyogenic and amoebic) and hydatid cysts. primitive neoplastic cystic lesions are cystoadenoma and cystoadenocarcinoma. secondary lesions can originate mostly from mucinous tumours such as colon and ovary. the role of crosssectional imaging in the detection and characterisation of these entities will be discussed, with an emphasis on the differential diagnosis with ct and mr imaging. benign hepatocellular neoplasms are being recognised with increased frequency using cross-sectional imaging. one of the main goals is to be able to make a clear-cut differential diagnosis between focal nodular hyperplasia (fnh) and hepatocellular adenoma (hca) since patient management is substantially different. despite the sound knowledge acquired in the last few years about the morphological features of fnh using various cross-sectional imaging techniques, new players in the field have arisen such as diffusionweighted mr imaging (dwi) and use of hepatobiliary contrast agents. these new biomarkers offer a different view over fnh and allow a more accurate characterisation even in more atypical cases. concerning hca, current knowledge implies that the sub-types of this neoplasm should be known since, again, patient management differs and these patients are no longer seen as compulsory surgical candidates. these sub-types will be further discussed and the role of imaging for risk stratification (haemorrhage and malignant transformation) will be addressed. further, illustrative cases of combined fnh/hca cases will be demonstrated along with the main imaging clues for a successful differential diagnosis. imaging in the early postoperative period is complex. it is essential for radiologists to know the new anatomic arrangement after surgery and to understand the range of normal postoperative appearances. this latter aspect can be particularly difficult, because the radiological findings are affected by the type of operation performed (open vs. laparoscopic) and the complexity of the surgery (such as the presence of adhesions or haemorrhage) as well as the underlying comorbidity of the patient. patients may be considered in broad categories: haemodynamically unstable patients who may be bleeding; patients with distension or unopened bowels who may have obstruction or ileus; patients with sepsis in whom to search for an intraabdominal collection or leak; and patients who do not follow an expected recovery for which the cause is unclear. ct is the primary imaging technique, with ultrasound reserved predominantly for liver and renal transplants or assessment of perihepatic collections, and fluoroscopy for routine postoperative assessment of upper and lower gi anastomoses. ct protocols should be optimised to detect particular complications with positive luminal contrast for assessment of anastomotic leaks ( %), triple phase imaging for bleeding (without positive oral contrast) and delayed phase imaging to detect ureteric injury. since each operation has a specific range of expected complications, these should be considered when deciding on the protocol and in light of the patient's clinical status. excellent communication with the surgical team is required to make an accurate diagnosis and in particular where haemostatic compound or mesh for hernia repair was used. learning objectives: . to understand the best imaging options for investigating suspected postoperative complications. . to appreciate the normal appearances of the abdomen and pelvis after surgery, in particular with regard to free fluid, haematoma and free gas, and when to suspect complications. radiologists should be aware of the newer surgical techniques and expected post-operative alterations, to yield a correct interpretation of a post-surgery imaging examination, thus being able to differentiate a normal post-operative finding from a potential complication. in this setting, it is crucial to perform a technically adequate imaging examination, so that post-operative anatomical and functional findings may be evaluated. therefore, the aim of this lecture is to give an overview of the contribution of various imaging modalities in the diagnosis of late post-operative complications following gi tract surgery. it will include a mention of the technical issues that need to be considered to achieve better diagnostic accuracy, as well as a description and illustration of the main imaging findings of late post-operative complications. those include diseaserelated (recurrence for malignancy or inflammatory disease) and procedurerelated (anastomotic strictures, internal herniation, adhesions and intussusception, among others) complications. focus will be placed on crosssectional imaging techniques, which at present constitute the workhorse for detecting and characterising late post-operative complications after gi tract surgery. in this way, imaging has an obvious and pivotal role in planning therapy, since some late complications are usually treated in a conservative way while others require a surgical approach. lung biopsy of a suspected lung cancer remains a well-established technique for histopathologic examination in patients with suspected lung cancer. complications can nevertheless occur and therefore indication should be given after carefully balancing the benefits and drawbacks for a particular patient. the method should be clearly considered complementary to alternate methods of tissue sampling, fiberoptic endoscopic, mediastinoscopy or us-guided endoscopy, surgical biopsies and resection during a multidisciplinary discussion. several steps are needed in the preparation of the biopsy procedure, including informed consent, management of anticoagulation and anti-platelet medications, imaging assessment of the lesion and its environmental lung, and planing of the needle trajectory procedure. the choice of the guiding method and the most appropriate biopsy needle is still largely dependent on local skills and habits. ct-guided percutaneous biopsies using coaxial automated core biopsy needles offer many advantages. needle manipulation can help to reach difficult targets. participation of the patient is needed in terms of respiratory manoeuvres and breathhold. complications may occur such as pneumothoraces haemorrhage and air embolism. knowledge of the respective risk factors and the potential method of prevention or treatment by operators are essential. the therapeutic response of lung cancer can be objectively evaluated on the basis of changes in the tumoural size or depiction of metastases, such proposed in the recist criteria (response evaluation criteria in solid tumours). recent advances in cancer biology have triggered development of novel targeted therapies designed to disrupt specific biologic pathways. among them, antiangiogenic drugs represent a promising strategy for non-small cell lung carcinomas (nsclc). these agents are more cytostatic rather than cytotoxic, explaining the limitations of tumour response assessment based on morphological criteria. dynamic contrast-enhanced imaging techniques have the potential to quantify tumoural angiogenesis. in particular, dynamic contrastenhanced multidetector-row ct (dce-ct) represents a promising tool to provide non-invasive and repeatable assessment of the angiogenic process within non-small cell lung cancers (nsclc), offering the possibility to generate morphological and functional information from the same examination. dce-ct allows the calculation of regional tumour blood flow, blood volume, flowextraction product, and permeability-surface area product, over the entire tumoural volume, using mathematical models and dedicated softwares. dce-ct can depict early changes in lung cancer vascularity, before tumour shrinkage, that could help predict response to antiangiogenic drugs. becoming familiar with this technique enables the radiologist to integrate it into clinical practice and to assist the thoracic oncologist in the pre-therapeutic and follow-up evaluation of nsclc patients treated by antiangiogenic drugs. this new approach should improve patient's selection for targeted therapies. a- : it is now accepted that pet-ct is of value in the staging of lung cancer and reduces the number of unnecessary thoracotomies. its role has been further clarified by recent publications on its value in assessing mediastinal nodal involvement, tumour aggressiveness using either standardised uptake value or total glycolytic volume, and response to neoadjuvant chemotherapy. more recently, mri has been investigated as a tool to detect distant disease using diffusion-weighted imaging, and there are a number of trials that have compared both pet-ct and dwi mri retrospectively and prospectively. this presentation will summarise the current available data and the likely benefits of either imaging modality neurological deficits in children are an urgent condition that depends significantly on imaging for a prompt and accurate diagnosis because of the significant overlap present in clinical history, presentation and neurological examination. different imaging modalities, such as ultrasound, computed tomography (ct) or magnetic resonance imaging (mri), are utilised dependent on the age of the patient and neurological symptoms. the purpose of the present lecture is to discuss the causes and imaging appearance of acute neurological conditions in childhood, broadly classified into stroke, infection, inflammatory demyelination, metabolic disorder, cerebral neoplasm or neurotoxicity. imaging also plays an outstanding role in the management of paediatric oncology patients presenting with acute neurological symptoms related to disorders of blood cell counts, immunosuppression, neurotoxicity of therapy, or progression of the primary malignancy. a review of the main indications to perform a neuroimaging procedure in these children will be undertaken as well as a differential diagnosis based on representative cases selected from the daily routine in a paediatric tertiary hospital. practical algorithms with the preferential use of either ct or mri will be developed for each section. ct continues to be the first imaging modality in these patients in many centres, despite the accompanying radiation, because of the easy availability and no requirement of sedation. however, mr imaging is nowadays better for imaging these children owing to no radiation, the more completely provided information and the useful advanced techniques that can be used, such as diffusion imaging (di), spectroscopy, arterial spin labelling (asl), and susceptibility weighted imaging (swi). learning objectives: . to learn about the currently limited role of ct in the non-traumatic acute setting. . to become familiar with radioprotection strategies and protocols adapted to children. . to consolidate knowledge on the role of mri as the modality of choice for acute non-traumatic neurologically ill children, with an emphasis on newer techniques. . to become familiar with imaging findings and the main differential diagnosis of acute neurological conditions in children. b. imaging of acute chest pain and distress in children c.e. de lange; oslo/no (clange@ous-hf.no) acute chest pain in children is a common complaint in the emergency department, but patients rarely present with significant distress or lifethreatening symptoms requiring immediate care or resuscitation. the most frequently reported cause is benign musculoskeletal pain followed by respiratory and gastrointestinal causes, while cardiac causes are less frequent. a thorough clinical history and careful physical examination will determine, in most cases, the patients in need of further investigation to establish a diagnosis. in this regard, radiology plays an important role, especially in the emergency setting in patients with more serious associated symptoms like acute breathing difficulties, swallowing problems, fever or sepsis. when choosing the appropriate technique for investigation, the consequences of radiation exposure in children must be considered. plain radiography and fluoroscopy still remain the most important and frequently used tools to gain information on various acute chest/pulmonary problems. ultrasonography is the first choice for diagnosis/treatment of pleural effusions. multidetector computed tomography and magnetic resonance imaging are mainly used for investigating pulmonary/mediastinal masses and congenital abnormalities of the great vessels and the lungs. this lecture will discuss the choice of imaging technique and the urgency of radiological management depending on the symptoms and age of the patient. the imaging characteristics of the different causes of acute chest pain and/or distress in children will be reviewed, represented by the more common conditions involving the chest wall, respiratory tract, oesophagus and the heart, as well as less frequent causes such as tumours, manifestations of congenital malformations and nonaccidental trauma. outcome data from trauma series have demonstrated improved patient survival by the prompt diagnosis of a range of injuries and the recognition of life-threatening sequels, principally that of active arterial haemorrhage. widely used trauma scoring systems are applicable in the paediatric population, although the mechanisms and combination of injuries may differ from those encountered in adults. a ct diagnosis of active haemorrhage demands early operative or non-operative intervention with embolisation or use of alternative endovascular techniques including deployment of vascular stents. this principle is applicable to blunt or penetrating liver, splenic, renal or pelvic trauma. it is also applicable in some cases to severe mediastinal and limb vascular injury. important caveats are firstly the use of ct in an overall trauma service and avoidance of any inappropriate irradiation. secondly, in paediatric interventional practice, due regard needs to be given to the delivery of implantable devices that may have adverse sequels in later life. nevertheless, the demand for immediacy in intervention may outweigh any such consideration. this presentation will summarise the importance of imaging and intervention in both the early and delayed complications of trauma with an emphasis on abdominal and thoracic trauma. brachial plexus originates from the ventral branches of the cervical nerve roots from c to t . it is composed of roots, trunks, divisions, cords, and branches, topographically divided into supraclavicular (roots and trunks), retroclavicular (divisions), and infraclavicular sections (cords and branches). mri has the advantages of multiplanar imaging, high tissue contrast, and relative paucity of artefacts. the t -weighted sequences display topographic anatomy including muscles, blood vessels, and nerves stressed by tissue fat planes. the nerves appear as elongated fibres that are isointense to the scalene muscle, posteriorly and superiorly to the curvilinear flow void of the subclavian artery. the fat-suppressed pd and t -weighted and stir sequences detect signal alterations of the bp. general abnormal findings include: loss of fat planes around part or all bp components, nerve signal abnormalities with mild or marked hyperintensity on t -weighted images that can be associated with swelling, focal or extensive enhancement of the nerves after gad injection on t fat sat images. differences in signal intensity should be judged by visual inspection, which is susceptible to a subjective point of view; the comparison of both sides of bp has a relevant role in judging the presence of signal alterations, especially when they are smooth and/or focal. the pathology of brachial plexus can be divided into nontraumatic and traumatic brachial plexopathies. among nontraumatic brachial plexopathies, we find radiation fibrosis, metastatic breast cancer and primary or metastatic lung cancer. other pathologies are tumours and inflammatory disease or thoracic outlet disease. the peripheral nerves of the upper limb are affected by a number of entrapment and compression neuropathies. these syndromes involve the brachial plexus as well the musculocutaneous, axillary, subscapular, ulnar, radial and median nerves. clinical examination and electrophysiological studies are traditionally the mainstay of diagnostic workup. however, ultrasonography and magnetic resonance imaging (mri) may provide key information about the exact anatomic location of the lesion or may help to narrow the differential diagnosis. in certain patients with the diagnosis of a peripheral neuropathy, imaging using either ultrasonography or mri may help establish the cause of the condition and provide information crucial for conservative management or surgical planning. in addition, imaging is particularly valuable in complex cases with discrepant nerve function test results. a variety of peripheral neuropathies can be encountered in the lower limb. most are entrapment syndromes affecting many nerves, such as the sciatic, gluteal, femoral, lateral femoral cutaneous, obturator and pudendal around the hip, the peroneal and its branches and the saphenous at the knee, the superficial peroneal at the lateral leg, the tibial with its plantar and calcaneal branches at the ankle, the deep peroneal and the interdigital nerves in the foot. although clinical examination and nerve conduction studies are the mainstay of the diagnostic workup of peripheral neuropathies, ultrasound (us) and magnetic resonance (mr) imaging may provide key information about the exact anatomic location of a lesion and the nature of the constricting finding or may help narrow the differential diagnosis. in patients with peripheral neuropathies of the lower extremity, us and mr imaging may provide critical information for planning an adequate treatment strategy. although us and mr imaging have followed parallel paths for nerve imaging with little comparison of the two modalities, us seems to have some advantages over mr imaging, including higher spatial resolution, time effectiveness, the ability to explore long nerve segments in a single study and to examine tissues in both static and dynamic states. advances in diagnosis of acute stroke have been achieved by brain imaging. ct or mri distinguish ischaemia from haemorrhage and may identify acute clot (dense artery sign) or vessel wall pathology by "black blood mri". dwi provides evidence of early infarction. ct and mra enable identification of large vessel pathology as potential source of embolic or haemodynamic ischaemia. supplementary techniques are ct or mr perfusion. on mri perfusion, a mismatch between the area of restricted diffusion and perfusion (pwi) is a signature of the penumbra. the tissue of pwi restriction outside of the dwi abnormality represents "tissue at risk". similarly on ct perfusion, the region of reduced cerebral blood volume presumably represents irreversible infarction and the area of reduced cbf and extended mtt visible beyond the cerebral blood volume abnormality represents potentially reversible ischaemia. morphologic imaging and advanced standardised perfusion/penumbral stroke protocols aim at identifying lesions that are amenable to acute stroke therapy and exclude pathologies that mimic stroke but do not represent vascular disease. since iv tpa has become an approved therapy from , the number of acute stroke patients entitled for treatment has remained limited (~ ) despite extension of the time frame from to . h. dwi-flair mismatch and an individualised assessment of the ischaemic penumbra may serve in the identification of patients within the appropriate time frame. by selection of patients with advanced brain imaging and initiation of appropriate therapy, a further increase in good outcomes and reduction of the incidence of symptomatic haemorrhage may be achieved. in recent years, the role of imaging in the patient admitted with an acute neurologic deficit has changed significantly, due to the arrival of new treatments for acute stroke, aimed at re-establishing blood flow, reducing infarct size and protecting the brain at risk. the first goal is to differentiate haemorrhagic from ischaemic stroke and to rule out other stroke mimics. this can be achieved by performing nonenhanced ct scan of the brain. the next strategic imaging objectives include: demonstration of major blood vessel occlusion (e.g. by ct angiography) and identification of potentially salvageable brain tissue, the so-called "penumbra" (e.g. by ct perfusion). ct angiography is performed during rapid intravenous bolus injection of a high-concentration iodinated contrast agent. the fov should cover not only the intracranial arterial circulation, but also the arteries of the neck, to exclude dissection. ct perfusion is also achieved by bolus injection of contrast, followed by a series of fast images or volume acquisition. ct densities change over time and reflect the iodine concentration. perfusion images are processed to generate parametric maps, which reflect: regional cerebral blood flow (rcbf), blood volume (rcbv), mean transit time (mtt), and time to peak (ttp).the combination of ct angiography and ct perfusion provides a unique insight into the pathophysiology of the cerebral circulation. these techniques are now essential tools in the management of acute stroke and in selecting those patients who are potential candidates for advanced therapies such as thrombolysis or thrombectomy. learning objectives: . to become familiar with a comprehensive imaging protocol in patients with suspected stroke. . to understand the advantages and limitations of cta and perfusion in the initial work-up of stroke patients. . to recognise the different imaging patterns in stroke and their prognostic value. a- : b. stroke mimickers and pitfalls p. vilela; lisbon/pt (ferrovilela@sapo.pt) "stroke mimic" is classically used to describe nonvascular diseases that present with acute focal neurologic deficit corresponding to a consistent vascular distribution, which may resemble or may even be indistinguishable from stoke. it is estimated that up to % of stroke-like presentations are due to mimickers. there are several neurological and psychiatric disorders that can have such a clinical presentation, such as seizures and/or postictal status, the most frequent one. the other classical clinical stroke mimickers include: multiple sclerosis, migraine (specially hemiplegic migraine), metabolic disturbances (more commonly hypoglycaemia/hyperglycaemia), intracranial tumours or infections and the conversion reactions. brain imaging plays a key role in the diagnosis and management of acute stroke by differentiating ischaemic from haemorrhagic lesions, identifying the vessel occluded and estimating the viable brain tissue that is at risk for stroke. imaging is also important to exclude some of the aforementioned stroke mimics. the more comprehensive stroke imaging protocols, with ct perfusion/angiography and/or with mri, have reduced significantly the misdiagnosis of stroke. mri-dwi is the most sensitive and specific imaging modality for depicting ischaemic stroke. however, it is also essential to be aware that there are some pathological processes that can mimic stroke in imaging studies. these include some disorders that may present themselves with lesions associated with restricted diffusion, like transitory postictal brain abnormalities, migraine and encephalitis. the author reviews the most common clinical and imaging stroke mimics and highlights the importance of brain imaging in depicting these mimickers and avoiding the potential adverse effects of stroke therapy in these patients. learning objectives: . to learn the differential diagnosis of stroke. . to understand the role of ct and mri in the work-up of stroke and related disorders. . to recognise imaging patterns that may mimic stroke clinically and radiologically. imaging plays a central role in the management of stroke, which is an important health issue according to the number of patients involved and the severity of the disease. it helps to select patients who will benefit from a revascularisation therapy (iv thrombolysis or endovascular treatment) at the acute phase of stroke. if the value of perfusion/diffusion mri mismatch in the evaluation of penumbra is still a matter of debate, other imaging factors are associated with the clinical outcome including length of clot, flair positivity, and collateral circulation. if iv thrombolysis using rtpa is still the reference treatment, endovascular treatment is emerging since several years as a feasible and efficacious alternative singularly since the appearance of stent retrievers. recent neutral randomised trials comparing iv thrombolysis and endovascular treatment have shown the critical role of appropriate imaging in the selection of patients who can benefit from acute revascularisation as well as the importance of using the most efficacious endovascular devices. prevention of stroke is partially based on the treatment of cervical and intracranial stenosis. several randomised trials comparing carotid angioplasty and carotid endarterectomy were initially negative, but a recent meta-analysis showed that below the age of years both techniques were equivalent. the place and value of endovascular treatment of intracranial arterial stenosis is still controversial after the publication of the sammpris results. the management of thyroid nodules has been continuously evolving. i hope that during this session you will understand the important differences in the upto-date national and international guidelines on thyroid nodule management and understand the role of the radiologist in the multidisciplinary thyroid meetings. the features that are suggestive of benign, indeterminate and malignant nodules will be demonstrated. advances in both radiological and cytological techniques such as us elastography and braf mutation analysis that may help triage patients with thyroid nodules will be covered. the differing biopsy techniques (fine needle aspiration, non-aspiration (fna and fnnac) and trucut biopsy) and their roles will be highlighted. there will be time for an open question and answer discussion with all the speakers before the end of the session. the management of thyroid nodules and the guidelines of the various interested parties, surgeons, endocrinologists, nuclear medicine physicians, radiologists and ultrasound specialists, vary across the world, indeed between different countries within the eu, and are constantly evolving. i will discuss how the thyroid multidisciplinary meeting (mdt) works at our institution and the role of the radiologist in it. the current differing international guidelines on the management of thyroid nodules will be mentioned, highlighting their salient points and differences. the role of the differing imaging modalities used in the management of thyroid nodules will be discussed based on differing clinical scenarios. finally, the management of the common clinical scenario of the incidental thyroid nodule will also be discussed. learning objectives: . to understand the role of the radiologist as part of a multidisciplinary team. . to learn about current guidelines on the management of the thyroid nodule. . to understand the role of various imaging modalities in the patient with thyroid nodule. thyroid disease is ubiquitous and usually benign; therefore accurate imaging of the thyroid is a major challenge for radiology. significant advances in conventional ultrasonography allow superb visualisation and anatomic characterisation of thyroid pathology and the impact of broader bandwidths, higher frequencies, spatial compound imaging and novel signal processing techniques will be discussed in this session. the key b mode features of thyroid nodules are discussed with reference to relevant clinicoradiological guidelines, specific pitfalls and limitations. a significant number of nodules remain indeterminate after conventional assessment, and imaging advances that enable more accurate, non-invasive thyroid characterisation are highly attractive, potentially reducing unnecessary biopsy and surgery for a large number of patients. ultrasound elastography offers a potentially useful adjunct to conventional sonography in thyroid disease with a growing evidence base indicating that thyroid malignancies are typically stiffer than benign lesions and that a 'soft' cutoff value with a high negative predictive value is feasible. however, elastography studies have included a variety of different techniques, patient/nodule selection and assessment methods; therefore the current role of elastography will be discussed. fine needle biopsy of the thyroid nodule f. campoy-balbontín, m.c. jurado-gomez; sevilla/es (fcampoy @gmail.com) thyroid nodules are very common. the clinical importance of thyroid nodules rests with the need to exclude thyroid cancer, which occurs in - %. ultrasound (us) has been widely attempted to differentiate benign from malignant nodules and to guide fine needle biopsy (fnb). however, considerable overlap between benign and malignant characteristics has been found. nowadays, there are a number of different guidelines for the management of thyroid nodules. at our hospital, we have adopted the guideline proposed by the society of radiologist in ultrasound ( ). the different elements necessary to perform the fnb procedure are demonstrated; the transducer probe, the needles, the slides, the syringe. the way of managing these elements is shown by figures and videos, with different skills and performances to optimise the procedure and get the best sample. uscontrol fnb can be in parallel or perpendicular, both methods are demonstrated. thyroid fnb is usually non-aspirated, but sometimes it has to be undertaken with aspiration; when and how to change from one method to another is explained. with good technique, the insufficient cytological rate can be significantly reduced, with which the need for core biopsy diminishes. although the complication rate for core biopsy is low, fnb is safer and if performed correctly has a high diagnostic yield. core biopsy should be limited to those nodules with a second insufficient fnb cytological result, with us findings suspicious for malignancy. multimodality breast imaging is emerging as radiologists have access to new technologies coinciding with the refinement of operative techniques. one of the challenges for radiologist remains the correct preoperative staging, especially the metastatic involvement of axillary lymph nodes. multimodality imaging has new accurate solutions. the imaging follow-up of patients with sophisticated oncoplastic techniques is another challenge where multimodality breast imaging is the solution. coincident with this increasing contribution to the diagnostic process is the emerging role of the breast imager as a therapeutic clinician, making use of innovative image-guided procedures. in this integrated rc, experts will present a clinical update on these newer techniques and there will be an opportunity to discuss how the evolution of such techniques is changing the nature of the modern multidisciplinary team meeting. a. conventional, functional and interventional lymph node assessment r.m. pijnappel; utrecht/nl (r.m.pijnappel@umcutrecht.nl) metastatic involvement of axillary lymph nodes has been known to be one of the most important prognostic factors for women with breast cancer. the traditional approach to staging the axilla is either lymph node sampling procedures or sentinel node biopsy. the main diagnostic features of potentially malignant involvement of the axilla are abnormal lymph node morphology (shape and cortical thickness). there has been a concerted effort in recent years to find imaging techniques that might facilitate accurate axillary staging. so far, no imaging technique alone (ct, mri, scintigraphy and ultrasound) has been capable of differentiating between positive and negative lymph nodes of the axilla in breast cancer. recent techniques like gadofosveset-enhanced magnetic resonance imaging and high spatial resolution -t mri imaging appear promising; however ultrasound-guided sampling of suspicious lymph nodes by core or fna remains the standard of care in assessing the axilla prior to treatment planning. ultrasound-guided axillary lymph node sampling is an effective method of assessing the axilla. a recent meta-analysis shows that ultrasound can be expected to achieve sensitivity approaching % for detecting abnormal nodes in those that eventually prove to be nodal metastatic disease. the false-negative rate where biopsy is performed is around %. it is impossible to detect the sentinel node by ultrasound alone. therefore a new promising technique was introduced, injecting an ultrasound-contrast agent around the nipple. using this method, it is possible to detect the sentinel node in % and therefore lower the false-negative rate of us-guided biopsy with another %. oncoplastic breast procedures were introduced to fill the gap between comprehensive oncologic surgical treatment of breast cancer and the achievement of cosmetic results that fulfill patient expectations in both, body imaging and psychological well-being. due to its complexity and relevance for the patient, the decision of performing these procedures must be made as part of the multidisciplinary approach of breast cancer treatment. as a consequence, the role of breast radiologists has expanded beyond the anatomic region of the breast and the usual imaging techniques. basic knowledge of the different oncoplastic techniques is mandatory to understand the spectrum of findings from a multi-modality approach. implants and/or autologous reconstruction techniques (pedicle, free or perforator flaps, as well as lipofilling techniques) are widely applied. the role of the radiologist in the multidisciplinary team is twofold: assessment during the planning stage, and imaging evaluation at follow-up. the assessment during the planning stage includes the determination of the local extent of the disease that makes the choice of the appropriate surgical technique possible, and the imaging study of the donor site in those cases where autologous reconstruction is elected. imaging evaluation at follow-up comprises the recognition of changes and potential pitfalls after reconstruction, the identification of short/mid/long-term reconstruction complications, and the detection of recurrent/second carcinomas. controversial aspects will be reviewed, such as the probability of recurrence after oncoplastic surgery, the need to establish multimodality follow-up protocols and the interrelations between the autologous tissues and the mastectomy bed or remaining breast. the use of image guidance for surgical planning has only recently been accepted. the use of intraoperative ultrasound in women undergoing lumpectomy is associated with a higher rate of negative margins. the combination of image guidance and radiological intervention techniques also harbours the possibility of tumour treatment without surgery. most techniques make use of the placement of needles within the tumour. treatment is performed by heating, freezing or extracting the tumour tissue. currently, radiofrequency ablation under ultrasound guidance is being furthest evaluated. however, in rfa even after optical complete tumour ablation, residual vital tumour tissue is still found in many cases. this is mainly dependent on tumour size with poorer results ( - % success rates) in tumour over cm, and better results (~ % success rate) in smaller tumours. adequate tumour size estimation is thus of vital importance. currently, since remaining vital cells cannot be excluded, the technique is limited to use in patients who cannot undergo surgery due to poor health state. larger series in which rfa is combined with radiotherapy have not been reported. it is therefore not clear whether it is important to actually excise residual vital tumour. similar restrictions currently hold for cryotherapy, laser ablation and hifu. large vacuum-assisted needles and the breast lesion excision system can be used to remove the tumour through a minimal incision in the skin. however, margin evaluation is difficult. nevertheless, these techniques are already optional for the removal of high-risk lesions and can potentially be combined with (focused) radiotherapy. the müllerian ducts are paired embryologic structures that undergo fusion and resorption between the th - th weeks of gestation to give rise to the uterus, fallopian tubes, cervix, and upper two-thirds of the vagina. non-development, defective vertical or lateral fusion, or resorption failure of the müllerian ducts can result in formation of müllerian duct anomalies (mdas), whose reported prevalence ranges between . % and %- %. the classification revised by the american society for reproductive medicine in is the most widely accepted. obstructive mda can occur in infants as palpable pelvic mass, at menarche with cyclic pelvic pain, or pelvic mass, and primary amenorrhea. complications include hematocolpos, hematometra, hematosalpinx, endometriosis, pelvic adhesions, and obstruction of urinary tract. mdas are commonly associated with renal and other anomalies; thus, identification of both kidneys is important. accurate diagnosis of an mda is essential because of the high associated risk of infertility, endometriosis and miscarriage, and since the management approach varies depending on the type of malformation. hysterosalpingography (hsg) is routinely used in evaluation of infertility. because a key component of mdas characterisation is the external uterine fundal contour, hsg is limited for this purpose. ultrasonography (us) is initially performed to evaluate uterine anatomy and to assess for associated renal abnormalities. mri is reserved for complex or indeterminate cases to characterise the uterine anomaly and evaluate the possibility of a vaginal abnormality, or after a seemingly normal us when clinical opinion ensures its use, or to make decisions on management strategies and preoperative planning. this refresher course will focus on the radiologist's approach to using pet-ct within the context of the gynaecologic oncology multidisciplinary meeting. the current indications for using fdg-pet/ct will be discussed for cervix, endometrial and ovarian cancer as well as the potential use of fdg-pet/ct in rare gynaecologic cancers. the value of adding fdg-pet/ct to the patient management pathway will be presented alongside the potential pitfalls in interpretation as well as controversies. future developments, including potential new tracers, will be mentioned. cystic lesions account for the vast majority of ovarian masses and are detected incidentally in - %. their spectrum ranges from non-neoplastic cysts to benign tumours, e.g. cystadenomas and dermoids to the rare ovarian cancer. diagnostic criteria in us, ct and mri are based on the clinical background (age, menopausal status, medical history, and tumour markers) and the morphology of the ovarian mass. typical of a benign cystic lesion is its pure cystic structure or thin septations, fatty or haemorrhagic contents, and mild enhancement of solid components in a complex solid and cystic ovarian mass. thus, patients can be categorised into different risk groups. sonography has been established as the first-line imaging modality to assess the ovaries. recently, management guidelines have been adopted for cystic ovarian lesions. in these guidelines, also cystic adnexal incidentalomas are included. mri is most useful as a complementary technique in sonographically indeterminate masses. an algorithmic approach will render a specific diagnosis in the vast majority of cases. in complex cystic lesions, integration of dwi and dynamic contrast-mri allows differentiation of rare benign complex tumours, e.g. cystadenofibroma from ovarian cancer. pitfalls of cystic ovarian tumours include cystic fibroids, peritoneal cysts, and extraperitoneal cystic tumours. compared to us, both ct and mri are superior in assessing large cystic pelvic masses. criteria to differentiate between intra-and extraperioneal origin include displacement patterns and identification of the vascular pedicle. careful analysis of imaging and clinical findings usually allows differentiation of inflammatory tumours from ovarian cancer. learning objectives: . to learn about specific imaging algorithms of ovarian cystic tumours. . to understand certain imaging features that can differentiate ovarian from non-ovarian cystic tumours in the pelvis. . to become familiar with the pitfalls in imaging of ovarian cystic tumours and the lessons to be learned from them. the diagnostic methods available in patients with conductive hearing loss are: personal and family history, otoscopy, audiology, imaging, surgical inspection and counseling. the most important reasons for imaging are: atypical history, suspicion of congenital hearing loss, suspected otoscopic image, asymmetric bone conduction thresholds, profound mixed hearing loss and suspected tympanometry. ct can be used to detect otosclerosis, tympanosclerosis, posttraumatic ossicular lesions, superior semicircular canal dehiscence and cholesteatoma. mri can be used to exclude schwannoma, congenital cholesteatoma and residual and recurrent cholesteatoma after prior surgery. this lecture will illustrate the value of ct and mri in the evaluation of cholesteatoma patients as well as prior to first stage surgery and prior to second look surgery. different subtypes of surgery will be highlighted and illustrated. the growing importance of mr imaging and diffusion weighted (dw) imaging in particular will be illustrated in the evaluation of cholesteatoma patients. the role of echo-planar and non-echo-planar dw imaging will be discussed as well as the eventual use of delayed gadolinium-enhanced t weighted imaging. mr is the modality of choice in patients with congenital or acquired sensorineural hearing loss (snhl) and the complete auditory pathway from the cochlea to the auditory cortex must be studied in these patients. the labyrinth, internal auditory canal (iac) and cerebellopontine angle (cpa) are best studied using submillimetric heavily t w images, showing the intralabyrinthine fluid and nerves. but submillimetric gd-enhanced t w images or d-flair images remain more sensitive. the auditory pathway in the brainstem is best studied with a multi-echo sequence (m-ffe/medic/merge) or t w tse sequence and the auditory cortex is best studied on t w tse images. the clinical information provided by the otologist will direct the radiologist to a certain part of the auditory pathway or will let him use certain imaging techniques. for instance, congenital malformations in the labyrinth and iac must be excluded in case of congenital snhl, and in case of mixed hearing one will start with ct to exclude otosclerosis. the most frequent pathology in the labyrinth (labyrinthitis, intralabyrinthine schwannoma, congenital malformation, post-traumatic lesions), the iac and cpa (cochleovestibular schwannomas, meningiomas, epidermoid tumours and facial nerve neuritis) and central auditory pathway (ms, infarction, tumor and trauma) will be illustrated using clinical examples and the important "otologist-radiologist" team work will be stressed. for tumours that nearly always arise from the investing mucosa, like in the larynx and hypopharynx, it is endoscopy that directly maps the superficial extent and grades the functional impairment (arytenoid and vocal cord movement, pyriform sinus distensibility). in addition to white light, the recent use of narrow band imaging endoscopic technology, enhancing fine capillaries in the mucosal surface, enables the detection of neoangiogenesis caused by early squamous cell carcinoma. conversely, submucosal spread is the domain of cross-sectional imaging techniques. therefore, it is the integration of the two classes of data, along with the information about patient conditions, which permits the choice of the most proper treatment strategy. in early and advanced glottic cancer, treatment planning is modulated by information about deep neoplastic invasion into the paraglottic space, the cartilage or the suprasubglottis subsites. this information can be derived by discriminating the tumour tissue from intra-laryngeal muscles, fat spaces and the cortical rim of ossified cartilages. though mr shows a greater contrast resolution than ct, it is hampered by a significantly longer acquisition time. this means more artefacts caused by breathing and movement. nevertheless, mr has the potential to unravel the signals from submucosal tissues, separating tumour from oedema, muscles, fat and ossified cartilages. advanced laryngeal and hypopharyngeal cancers need to preliminary assess local (nodes) and distant (metastases) spread. ct-pet is the more accurate tool. the multidisciplinary approach to the processing of the whole frame of data is essential to offer the patient the best care. traditionally, x-ray ct scanners were equipped with a single or a few detector rows only, image reconstruction was assuming parallel slices, which was a good approximation for these fan-beam systems. about a decade ago the number of slices increased to or more and the parallel slice approximation was no longer valid. the cone-beam nature of these multi-slice ct (msct) scanners had to be taken into account by specific cone-beam reconstruction algorithms. while these msct systems -today they are simultaneously acquiring up to slices -are cone-beam ct systems in a general sense, the notion of cone-beam ct (cbct) is also associated with a specific kind of conebeam ct, namely those equipped with flat detectors, i.e. the non-diagnostic or non-clinical ct systems. msct, in contrast, is a cone-beam ct system for diagnostic use, i.e. a clinical ct system. this distinction between msct and cbct is useful, as there are decisive differences in application, performance, and in image reconstruction. these differences will be reviewed in the presentation, with a particular focus on why image quality in msct is so much better than in cbct. cone-beam (cb) imaging with flat detectors is performed on a variety of different imaging systems. the most important area is cb imaging using interventional c-arm systems. the minimally invasive procedures carried out on these systems benefit from the availability of high-resolution d images for intervention planning, guidance and outcome control. interventional cb imaging was first applied in neuroradiology using rotational angiography acquisitions. today, it is used for a variety of procedures in interventional radiology, cardiology and oncology based on angiographic and soft tissue protocols. one of the inherent advantages of this approach is the direct registration of the volume images into the interventional procedure. other application areas of cb imaging using different scanning systems are onboard imaging in radiation therapy or the integration of flat detector tomography and spect. this part of the course teaches the generation of d volume information from flat detector systems and its utilisation in different clinical applications. image acquisition protocols, scan modes, and system design parameters are explained. application-specific calibration and processing steps are introduced to show how cb imaging is tailored for specific clinical applications. examples are presented for angiographic and soft tissue volumetric imaging. medical applications utilising the tomographic images for diagnosis, intervention planning, guidance, or outcome control are discussed. in the last decade, three-dimensional dentomaxillofacial imaging through conebeam ct (cbct) technology has become widely available. dental cbct (digital volumetric tomography; dvt) equipment is compact and often affordable to dentists. the driver for dental cbct was implant dentistry, but its use has spread to other areas, including paediatric applications. radiation doses are variable. some systems offer a fixed, large, field of view and others fixed exposure factors, obstructing attempts at optimisation. typically, doses are at least an order of magnitude greater than for "conventional" imaging. image quality is also variable, which means that certain equipment may be unsuitable for some clinical applications. there is often scope for lower exposure factors to be used than those recommended by manufacturers. a key aspect of using cbct relates to justification. imaging in three dimensions may be perceived by dentists as inevitably superior, a view which is often implicitly encouraged by those selling equipment. the research on diagnostic efficacy is, however, limited. in , the european commission published "radiation protection : evidence-based guidelines on cone beam ct for dental and maxillofacial radiology". this provides a comprehensive set of recommendations, including referral criteria, a quality assurance programme and optimisation strategies. priorities for future research relate to exposures to the necessary image quality requirements for specific clinical applications, along with research on the impact on clinical outcomes of cbct-based treatments. it is clear that much work remains before the place of cbct in dentistry can be established. the role of nonvascular interventional radiology of thorax for both diagnosis and treatment has significantly increased in the last years. although these procedures are technically easy with highly successful results, thoracic nonvascular interventional procedures are not unfortunately routinely performed in all of the interventional units. the most commonly performed procedures generally under ct guidance are transthoracic biopsies of the lung, mediastinal lesions and pleura. the others include percutaneous drainage of thoracic collections such as pleural effusions, empyema and mediastinal collections. image-guided tumour ablation performed by either radiofrequency ablation (rfa) or microwave (mw) as a nonvascular thoracic intervention has become a serious treatment alternative in patients with lung tumours (either non-small cell lung cancer or lung metastasis) since the year . interventional radiologists are expected to understand the clinical indications of these procedures at the first step. in addition, the techniques of the procedures and possible risk of complications in their management methods should be learnt by interventional radiologists as well. this refresher course will help us to discuss the main indications, techniques and complication management of these procedures. a. lung biopsy t. sabharwal; london/uk (tarun. sabharwal@gstt.sthames.nhs.uk) lung biopsy is most commonly now performed under ct guidance. it has a high technical success rate. common complications include pneumothorax, bleeding, sepsis, pain and failure. air embolism is a rare complication. pet scan is a useful tool to guide for appropriate target. ultrasound is useful for biopsying pleural-based lesions. drainage of thoracic fluid collections is a relative emergency. we will review the different thoracic fluid collections that can be drained by radiologists: pleural (parapneumonic, empyema, and malignant effusions), mediastinal, chest wall, pulmonary (lung abscesses and infected tumours) and pericardial effusions. we will answer the following questions about the main thoracic fluid collections: how to diagnose, when and how to drain, which guidance (ultrasound or ct-fluoroscopy), and procedures to perform before and after the drainage. the choice of imaging to detect thoracic fluid collections and guide drainage depends on the availability of the modalities, the imaging characteristics, location of the collection, and the comfort and expertise of the operator with the specific modalities. we will also review the main complications of percutaneous drainage of thoracic fluid collections (pneumothorax, pain, drain dislodgement and drain blockage) and compare these complications with those related to large-bore chest catheters inserted by thoracic surgeons. the incidence of lung cancers continues to increase and primary lung cancer remains the leading cause of cancer-related deaths in both women and men. therapy of lung tumours includes resection, radiation therapy, chemotherapy, thermal ablation or a combination of these treatment modalities. image-guided percutaneous thermal ablation therapies are minimally invasive techniques established in the local treatment of hepatic, renal, or osseous tumours. among these techniques, radiofrequency ablation (rfa) has now attained consideration for therapy of small pulmonal tumours. other ablation techniques that have been used for treatment of lung tumours include cryoablation, laser (litt) and more recently microwave ablation (mwa) and irreversible electroporation (ire). ablative techniques may produce a complete and irreversible tumour tissue destruction through application of either hot or cold thermal energy, or through permeabilisation of the cell membrane while using ire. ct is currently the imaging modality that is most widely used for planning, monitoring the ablation's course and for assessment of treatment response. only patients with stage i and stage ii lung cancer and those with small metastases are potential candidates for ablation. the medical history and physical examination of the patient as well as recent imaging with ct should be evaluated to determine the indication for thermal ablation. percutaneous lung rfa is considered as a safe procedure with an overall morbidity rate from . % to . % and mortality rate from % to . %; it requires less costs and offers faster recovery, and reduced morbidity and mortality. sorafenib, a tyrosine kinase inhibitor, has shown clinical efficacy in patients with hepatocellular carcinoma (hcc) and is the standard of care for patients with advanced-stage hcc. nowadays, many targeted therapies are evaluated in hcc either as sole treatment or in combination with other treatments such as tumour ablation, chemo-embolisation, and surgical resection. therefore, there is a need to assess the efficacy of targeted therapy in hcc. recist is the reference method to evaluate treatment efficacy in solid tumours, but does not seem appropriate in evaluating targeted therapy as objective responses are seen in very few cases in patients treated with sorafenib or sunitinib. new criteria have been proposed to evaluate the treatment efficacy of nonsurgical treatments in patients with hcc. the most common ones are the choi criteria, the easl criteria, and the modified recist criteria. all these criteria mainly focus on internal tumour changes such as appearance of necrosis or disappearance ot tumour hypervascularity. many examples will be shown during the lecture. another approach is based on functional imaging and especially perfusion-related imaging. contrast-enhanced ultrasound, ct perfusion and dynamic contrast-enhanced mr imaging have the capability to assess perfusion changes in patients under treatment. the advantages and disadvantages of these modalities will be discussed. lastly, other functional tools that are not routinely used will be presented. the evaluation of treatment efficacy is a key issue with prognostic and patient survival implications. it is crucial to have objective and reproducible criteria for specific groups of patients. the goal of ablative therapies of hcc is to induce tumoural tissue destruction. complete response (cr) after initial chemical and thermal percutaneous ablation, defined as the absence of contrast enhancement of the treated tumour at ceus, dynamic ct or dynamic mr, has been reported to correlate to long-term survival. nevertheless, the clinical effectiveness of imaging techniques to assess initial treatment success differs according to tumour size. the success rate of rf has been demonstrated to be superior to pei in hccs > cm, and depends on the ability to ablate all viable tumour tissue including an adequate tumour-free margin all around the lesion of . to cm. thus, the effectiveness of rf directly depends on the tumour location and size. rf is considered an effective treatment in lesions cm and its effectiveness is progressively reduced along with tumour size and it is not effective in lesions > cm. ceus beyond month may confirm or detect residual tumour, deserving a final ablation procedure. ct and mr are more effective in the follow-up to confirm cr and detect local recurrence, or additional hcc lesions in the liver parenchyma. the presence of transient hyperaemic inflammatory changes in the periphery of the treated area is a common finding that should be considered to avoid overestimation of the recurrence rate. one of the major characteristics of medical imaging in the twenty-first century is the dramatic influx of novel technology. this impact of new technology and techniques is experienced in all imaging modalities. the continuous development and implementation of highly sophisticated medical products and devices is key to the evolution of medical imaging leading to the improvement of patient care in terms of quality and positive outcomes. this session will analyse state-of-the-art displays (monitors, smartphones, tablets) and their applications in modern imaging. the session will provide a brief overview of displays in the current imaging chain. it will then evaluate the various specifications and parameters associated with displays. the session will evaluate current qa standards of modern displays as well as the challenges surrounding such novel technologies. image quality can be described in terms of resolution and contrast. an image displayed on a monitor consists of differences in brightness. the display monitor is at the end of the image chain in radiology, which starts at the x-ray tube. there are several factors in this chain that have influence on the contrast displayed on the monitor. diagnostic image quality can be described as observed contrast, which is not only dependent on the displayed image, but is also influenced by ambient conditions. for the primary class displays, typical characteristics of display monitors; such as resolution, homogeneity, luminance, contrast, monochrome or color, must be appropriate for the radiologist to execute a reliable diagnosis. calibration of display monitors is also important. which parameters are significant and what is the effect of variation of these parameters. there are standards like dicom gsdf and technical standard from acr-aapm-siim. both within and outside the clinical environment, the use of smartphones and tablet computers is increasing. reported applications range from teaching and education to navigation in surgical procedures. interest in the use of smartphones and tablets for viewing radiological images has been growing. however, these portable displays can differ significantly from conventional radiological displays. in order to determine where and how smartphones and tablets can be used appropriately, it is important to understand these displays and the challenges associated with them. this presentation will outline the current and potential uses of smartphones and tablet computers in radiology and compare their performance with other radiological displays and standards. the possible limitations/benefits of smartphones and tablets as display devices for radiological images will be discussed. recent research in the field will be reviewed, with emphasis on studies of diagnostic efficacy. in modern clinical environment, diagnostic monitors have replaced glowboxes and films and have become an important part of the imaging chain. the required specifications and the quality of monitors largely depend on their purpose, beginning from quite simple monitors used for the preview of radiographic images placed on modality or in control room to monitors used by high-end diagnostic workstations. decision about the kind of monitor for certain workplace is also very important from the economic standpoint as there are large differences in their prices. besides monitor specifications, also ambient conditions and ergonometry in the reading rooms are also very important issues which need to be considered to ensure optimal environment for clinical image reading. some of good and bad examples will be given in the presentation. as with other radiological equipment, also diagnostic monitors need to be controlled to ensure their optimum performance. quality control begins with monitor acceptance testing and setting up measurement parameters which are to be followed. practically all monitor vendors include some qc software within their workstations which can, together with some independent measurements, form an efficient quality control programme. in the last steps, how to deliver all information regarding image quality and possible presets on the diagnostic monitor and how not to confuse the user are important. sitting an examination is always a source of anxiety. the edir exam is no exception. this workshop is dedicated to those who want to take the edir exam, or become examiners, and would like to learn more about its format and discover some tips and tricks. the edir organisers and examiners have decided to build an interactive, friendly and enjoyable session in order to teach the essentials. some will play the role of the examiners, some the role of the candidate. in order to simulate the candidate's experience, this session will have no safety net. some senior members will expose themselves to real difficult questions in general radiology. fortunately, we hope that the attendees will be able to help the "candidates" to succeed. hopefully, you will enjoy this session and get some very useful information for your edir exam. abdominal malignancies are an important health problem in mexico. like in many other middle-income countries, there has been an epidemiological transition with an overall increase in oncologic diseases. colorectal, gastric and liver carcinomas are some of the frequent abdominal malignancies. colorectal cancer is a disease that is curable if detected early and even preventable if precursor polypoid lesions are removed. imaging plays a critical role in staging at diagnosis. additionally, virtual colonoscopy is an accepted modality in cancer screening. high-resolution magnetic resonance imaging (mri) has become a pivotal modality in the pretreatment assessment of rectal carcinoma. computed tomography (ct) is an excellent modality in the preoperative staging of gastric cancer and follow-up after treatment. positron emission tomography (pet) combined with ct (pet/ct) is particularly helpful for gastric and colonic carcinoma staging. hepatocellular carcinoma (hcc) is also common. cirrhosis related to alcohol and hepatitis c infection are by far the commonest aetiologies. ultrasound (us) in conjunction with alpha-protein is the most widely used modality for screening purposes. ct and mr are confirmatory modalities. the advent of hepatospecific gadolinium contrast agents has been very helpful in the characterisation of focal lesions in cirrhotic patients. the use of multidetector ct (mdct) in pancreatic carcinoma for the detection of vascular and adjacent organ invasion is crucial in treatment planning. over the last few decades, there has been an important improvement in imaging techniques resulting in better quality images. imaging is critical not only for the diagnosis, but also for treatment planning and follow-up. learning objectives: . to learn about the imaging of common oncologic gastrointestinal diseases. . to understand the importance of imaging in liver and colon cancer. . to learn how imaging supports oncologic institutions. activity, ultrasound is readily available and gives detailed local information but is limited by the restricted field of view, communication of results to clinicians and comparison of examinations on time. computed tomography (ct) is fast, readily available and gives a detailed, reproducible overview, but radiation exposure and contrast resolution are limitations. magnetic resonance imaging combines a good, reproducible overview with high contrast resolution, dynamic information and no radiation exposure and is therefore preferable in many situations, but the longer examination times than for ct, availability and costs are limiting factors. for the diagnosis of stenoses, fistulas and abscesses, either technique can be used, although the unrestricted view of ct and mri favour these techniques in many situations. in acute situations, us and ct are more accessible than mri. in that setting us can be considered, but when the examination is inconclusive or the patient has clear inflammatory signs, ct is preferable. endoscopy is currently considered the reference standard for the evaluation of colonic pathologies, including colitis. it allows direct visualisation of the mucosa and in obtaining tissue sample. however, it has major limitations including the invasiveness of the technique, incomplete endoscopy and risk of perforation. endoscopy cannot, therefore, help to estimate the depth of involvement of transmural inflammation and extraluminal complications. by contrast, an evolving role for cross-sectional imaging in the evaluation of patients with colitis has been increasingly recognised, especially in the setting of crohn's disease (cd), since cross-sectional imaging has been demonstrated to have a high diagnostic accuracy not only for assessing the presence and extension of luminal disease, but also for evaluating cd-related acute or chronic complications. establishing the ultimate cause of colitis may sometimes be challenging and histology cannot be conclusive. however, cross-sectional imaging may provide additional information that is useful in the workup of colitis. the use of cross-sectional imaging has been increasing in the evaluation of inflammatory bowel disease. following their presentations on imaging protocols and features of small bowel disease and colitis, each speaker will present a case to illustrate the learning points covered in their lectures. the session will be moderated by the chairman and the audience will have full opportunity to ask questions of all the panel. multimodality imaging is essential in a wide variety of oncology situations. anatomic imaging, whether using us, ct or mri, is mandatory for tumour localisation. moreover, the evaluation of treatment response mostly relies on size assessment, whether uni-or bi-dimensional. with the advent of new targeted bio-therapies, functional imaging has progressively been integrated in the imaging strategies whether for better tumour characterisation or for optimal evaluation of treatment response. hence, assessment of molecular targets by pet is supplemented by the recent developments of diffusion mri, reflecting tissue architecture and cellularity, tissue perfusion, reflecting angiogenesis, and magnetisation properties of tissues. hcc is a primary liver tumour where the use of multimodal anatomic, functional and metabolic imaging appears of particular interest. according to easl and aasld recommendations, noninvasive diagnosis of hcc can be performed using dynamic contrast enhanced cross sectional imaging. liver mri provides optimal sensitivity and specificity for the detection of as small as cm large hcc. recent reports have suggested that the prognosis of hcc lesions could be anticipated based on the combined analysis of metabolic f -fdg pet ct, as well as with diffusion weighted imaging. the objective of this lecture will be to highlight the potential of combining both metabolic and multimodal cross sectional imaging in order to improve the management of patients with hcc. the (extra)ordinary night shift at the er k. petrovic; novi sad/rs (smakap@sbb.rs) besides the accuracy, working at the er requires maximal shortening of the diagnostics time, which has a significant influence on the patient's outcome. thus, it is the radiologist's duty to be familiar with the pathophysiological mechanism of the disorders, specific protocols, possibilities and limits of certain examinations, and also to be aware of all possible pearls and pitfalls, to make the correct diagnosis. pathology encountered at the er has an extremely wide range and requires expertise in all imaging modalities from head to toe. the more the radiologist is aware of all possible situations, the more is the diagnosis accurate, and information given to the clinician is more valuable. the aim of this presentation is to point out the possibility of encountering different pathological conditions in different body regions. moreover, it is important to be reminded that in radiology there are different modalities, each of which has its own indications and limits. this lecture reviews the selected series of cases from the er department of clinical center of vojvodina, pointing out the most common possible differential diagnosis and possible diagnostic mistakes, which often occur due to the lack of experience. learning objectives: . to point out the in-depth knowledge and experience in all imaging modalities and all body regions required for a radiologist to perform a routine work at the er. . to present a series of cases that are most and less often encountered at the er, discuss the possible differential diagnosis and mistakes which could potentially be made. diagnosis and management of pancreatic cystic lesions r.j. méndez; madrid/ es (ramiro.mendez@salud.madrid.org) pancreatic cystic lesions are frequently diagnosed in patients with clinically suspected pancreatic disease, but they are also increasingly detected on imaging studies performed due to other abdominal processes. the prevalence of pancreatic cysts increases with patient's age. most symptomatic cysts will be surgically resected, whereas asymptomatic lesions should be managed depending on the likelihood of causing harm to the patient. cystic lesions can be inflammatory or neoplastic. the incidence of pseudocysts is low without a history of pancreatitis. some pancreatic cystic neoplasms are malignant, but even benign lesions can become symptomatic depending on its size and location in the pancreas. the radiologist detects most of the pancreatic cystic lesions and should also play an important role in the clinical decision-making process. cyst size, morphology, calcifications, contrast enhancement, location in the pancreas, relation with pancreatic ducts, patient's age and gender are important data to classify the lesion. a specific radiological diagnosis is not possible in every patient, but in many cases this information is enough to decide on a conservative approach with imaging follow-up. if a more aggressive lesion is a concern, then endoscopic ultrasound and fluid analysis can help to better characterise some pancreatic cystic lesions. cyst puncture is only recommended if fluid analysis results will modify the patient's management. patient's age, status and preferences should also be taken into account. when follow-up is recommended, the preferred imaging technique and interval should be indicated. the chair will set the scene for the need for effective radiation protection in clinical radiology and highlight the role of clinical audit as a tool in achieving this. clinical audit is defined as a professionally led method of improving patient care through the systematic examination of systems, processes and outcomes against chosen and agreed standards. it can readily be carried out by individuals, groups or whole departments. if properly conducted, clinical audit can be an effective way of examining what we do to provide reassurance on performance, and to improve patient care. the clinical radiology audit committee (crac) of the royal college of radiologists (rcr) co-ordinates national radiology audit activity. it promotes and facilitates audit through nominated audit leads in each hospital, who act as a link between the rcr and their department. at least one national audit is carried out annually, with data collected via electronic submission and the anonymised results presented at an annual audit forum. individual departmental results are analysed using statistical process control (spc) methodology. this enables identification of departments underperforming against the national mean, and recommending corrective action, by redesigning the process being audited, or by identifying and eliminating specific root causes locally. the committee has developed a web-based tool for facilitating local audit, "auditlive", a fully searchable collection of templates which can be downloaded and adapted. fellows are also able to submit their own templates for publication hence sharing best practice. trainees are encouraged to participate in audit through audit poster competitions at national radiology scientific meetings. our experience leads us to believe that audit succeeds when relevant, locally owned and properly structured, and multi-professional, and the rcr model encourages this. models of external audit in the netherlands s. geers-van gemeren; utrecht/nl in the netherlands clinical audit is legally obligatory for healthcare professions in order to be able to practise since . clinical audit is a tool designed to improve the quality of patient care, experience and outcome through formal review of systems, pathways and outcome of care against defined standards, and the implementation of change based on the results. the quality of the provision of care by professionals is assessed by peers. in the fields of radiology, nuclear medicine and radiotherapy, different models of clinical audit are used. for radiotherapy a multidisciplinary audit has been used since . for nuclear medicine a multidisciplinary audit has been implemented since . for radiology the clinical audit for radiologists and for radiographers are separate. implementation of the multidisciplinary audits needs requirements and adjustments of the audit system. this process is complex and needs approval of the members of all involved societies. to support the clinical audit a web based tool adas (general digital audit system) is used. the development of professional standards is a prerequisite to start clinical audit. the use of adas in multidisciplinary audits is a requirement to be able to audit different professions and focus on the content and the quality of their contribution to patient care. clinical audit is a good tool to improve the quality of patient care. important are the professional standards, the culture of learning and willing to improve by the professionals. "every defect is a treasure." learning objectives: . to learn about the different dutch models of external clinical audit. . to comprehend the importance of professional standards, the culture of learning and willingness to improve. . to become familiar with the use of a digital audit system to support multidisciplinary clinical audit. external regulatory audit in finland r. seuri; helsinki/fi (raija.seuri@hus.fi) directive / /euratom states that the clinical audit of medical imaging should be carried out in accordance with national procedures. the finnish solution has been regulatory external audits every five years by radiological professionals with special training for audits. all radiological units have so far been audited at least twice, and the third time is performed on site in the unit. although the purpose is to audit the process of radiological practises compared to "good practise", special focuses are recommended by the finnish advisory committee for clinical audit, set by the national institute for health and welfare. at the beginning focus was on the organisation and documentation of the structure and processes of imaging practise like justification, optimisation and quality control, but also encouragement and guidance to self-assessment. later special focus has been on paediatric imaging and ct, and the third cycle will target deeper to ct practises. the auditing group includes at least a radiologist and a radiographer to audit a small unit, and a medical physicist if the unit has high-dose modalities like ct. during the audit the auditors work for an independent organisation. multi-professionality gives both insight and the possibility to contact all professionals in imaging practise. the focus of clinical audit is on quality improvement; it is a way to both give and get feed-back and education. it is not control or inspection, but encouragement and guidance to self evaluation and implementation of good practises. we often think of the scientific researcher as detached, objective, and dispassionate, nobly labouring without any expectation of reward. nothing could be further from the truth. scientists are as subject to ambition, competitiveness, envy and even guile as any person. lifting the veil on scientific discovery reveals to us the human dramas that underlie not only the coveting of recognition, but also great conflicts over priority and credit. nowhere are the stakes higher than for that pinnacle of scientific honour: the nobel prize. mri has had a notably tempestuous genesis -a cogent episode that has much to teach us. it involved an explosive clash of personalities; deceit and rampant self-interest; challenges to the basic concept of scientific behavior; legal suits and validation by the united states supreme court; and declamations of denunciation in the international press. it persisted as a year battle -a prize fight, a blood feud -between two protagonists: one whose seminal contribution established the biologic basis of mri, and the other whose flash of insight served as a cornerstone of diagnostic imaging. . metabolic disorders of the skeleton involve the mineralised components of the skeleton. they affect all bone components histologically, but involvement patterns may vary depending on the age of the patient (growing versus adult skeleton) as well as the type of bone (cortical versus trabecular bone). they can be depicted on radiographs and ct images, but remain occult on mr images because the bone marrow is spared in the vast majority of these disorders. mr imaging can help in the assessment of local complication such as fractures. . metabolic disorders of the bone marrow can affect either red (anemia…) or yellow marrow as well as the balance between these marrow types in the body. medical imaging plays a limited role in the assessment of these disorders, but marrow changes associated with these metabolic conditions must be recognised to avoid confusion with neoplastic conditions. in primary and secondary malignant tumours of solid organs, in most of the cases surgical resection is considered the curative treatment. however, this is possible only in about % of the cases with tumour-dependent recurrence rates of % and even more. the main components for adjuvant, neo-adjuvant and finally palliative therapy are the permanently growing number of chemoand antibody therapies. nevertheless, in many cases these therapies provide no definitive or long-lasting success, necessitating multimodality treatment concepts. in the meantime, local ablative techniques represent the main components of these concepts. three main minimally invasive tumour-ablative techniques can be differentiated: chemo-ablation (percutaneous alcohol injection, transarterial chemo-embolisation, chemotherapy, chemo-perfusion), thermo-ablation (radiofrequency-, microwave-, laser-ablation, high-intensified focused ultrasound, cryo-ablation) and radio-ablation (radio-embolisation, interstitial brachytherapy, percutaneous stereotactic radiation). these ablation techniques differ significantly among each other with respect to their mode of action and indications; nevertheless, their benefit is high tolerance and at the same time high therapeutic efficacy, which can easily be combined with other treatment modalities. the different minimally invasive techniques will be discussed together with specific short-and long-term results and complications. missed lung lesions are one of the most frequent causes of malpractice issues. chest radiography plays an important role in the detection and management of patients with lung cancer, chronic airways disease, pneumonia and interstitial lung disease. among all diagnostic tests, chest radiography is essential for confirming or excluding the diagnosis of most chest diseases. however, numerous lesions of a wide variety of disease processes affecting the thorax may be missed on a chest radiograph. the chest radiograph will also help narrow a differential diagnosis, help to direct additional diagnostic measures, and serve during follow-up. the diagnostic usefulness of the radiograph will be maximised by the integration of the radiological findings with the clinical features of the individual patient. ct has a tremendous spatial resolution that helps detect lesions in the chest and has proven to be more sensitive and specific than chest radiographs. however, missing lesions or misinterpreting lesions in ct of the chest is not uncommon. in this session, we will provide interactive cases of chest examinations (radiographs and ct) in which lesions have been missed and or misinterpreted, with a special focus on how correlation with mdct of missed lung lesions can help improve interpretation of plain chest radiographs. this session will explore the value of imaging for facilitating precision medicine, in which molecular data (including genomics, proteomics and metabolomics) is used to classify patients into subpopulations and tailor treatments to the specific molecular characteristics of their diseases. imaging already plays a limited role in precision medicine, primarily through the use of molecular imaging techniques (e.g. pet/ct, mri/pet and hyperpolarised mri) and theranostics (the combination of an imaging agent with a therapeutic entity). in the near future, the role of imaging in precision medicine will increase at a gradually accelerating pace through the development of new molecular imaging probes and theranostic agents and through progress in radiogenomics (the correlation of radiologic findings with genomic features). this session will discuss recent findings and methodologies in radiogenomics as well as the use of nanotechnology for designing novel molecular imaging probes and theranostics. in addition, as theranostics is often considered the essence of precision medicine, the session will provide an in-depth look at current and emerging theranostic strategies and their special benefits for treatment selection, assessment of dose distribution of targeted therapies, and treatment follow-up. radiogenomics and personalised (precision) medicine g.p. krestin; rotterdam/nl (g.p.krestin@erasmusmc.nl) "precision medicine" as well as related notions, such as personalised medicine, or stratification medicine, all revolve around the idea that the consideration of individual characteristics -molecular and otherwise -can improve medical research and practice. precision medicine is a multi-faceted approach to medicine that integrates molecular and clinical research with patient data and outcomes. individual assessment of the location and extent of an alteration is and always has been the basis of medical imaging, whether the 'alteration' is a disease, a malformation, or an injury. as such, medical imaging intrinsically enables "precision medicine". the addition of genomic data in the last twenty years allows new correlations to be made between cellular genomics and tissue-scale imaging. structural and functional imaging and the automated analysis of large amounts of image data have only recently reached a stage where they can be used on a large scale and in a population setting. identifying common genetic variants that contribute to explain variance in imaging phenotypes by a systematic analysis of the genome is based on genome-wide association studies (gwas). the power of gwa analyses has been recently demonstrated with the identification of susceptibility genes involved in a range of imaging phenotypes like coronary artery calcifications, intracranial volume, or size of the hippocampus. these developments highlight new etiological pathways and are expected to improve the understanding of the molecular basis of some diseases. correlation between genotype and imaging phenotypes may be relevant for further characterising the development of disease states. use of nanotechnology, imaging and therapy t. lammers; aachen/ de (tlammers@ukaachen.de) advances in nanotechnology and chemical engineering have led to the development of a significant number of novel materials for diagnosis and therapy. many different diagnostic and therapeutic nano-and micro-materials have been designed and evaluated over the years, including, e.g. gadoliniumcontaining dendrimers, uspio nanoparticles and microbubbles for functional and molecular imaging, and drug-loaded liposomes, polymers and micelles for temporally and spatially controlled drug delivery to tumors and to sites of inflammation. in the literature, such advanced nano-and micromaterials are generally claimed to be highly useful and broadly applicable. a critical reflection on their specific capabilities, however, as well as on their pharmacokinetic properties, biodegradability and toxicity is often lacking. in the present lecture, i will briefly introduce the rationale for using diagnostic and therapeutic nanomaterials. i will highlight several clinically relevant examples in which nano-and micromaterials hold potential for improving disease diagnosis and detail how combining diagnostic and therapeutic properties within a single 'nanomedicine' formulation can be used to individualise and improve (chemo-) therapeutic treatments. learning objectives: . to learn about the design and construction of nanoparticles for use in imaging and therapy. . to appreciate both the advantages and limitations of using nanoparticles as agents for both imaging and therapy. . to learn how nanotechnology enables multimodality imaging and therapeutic agents. theranostics w. weber; new york, ny/us precision medicine requires diagnostic tests that predict the effectiveness of specific therapeutic interventions for individual patients. this close interaction between therapeutics and diagnostics is expressed in the term "theranostics". a frequently used example for a theranostic is the staining of tumours for her expression prior to therapy with her antibodies, such as trastuzumab or pertuzumab. theranostic has also been practised since many years in nuclear medicine by using radioiodine scans to select patients for treatment with iodine- . a more recent example is the selection of patient for peptide receptor-targeted radiotherapy (prrt) by somatostatin receptor imaging. imaging is highly attractive for theranostics, because it allows investigators to study the spatial and temporal heterogeneity of target expression, whereas in vitro assays generally analyse a small part of the tumour at one point in time. several molecular imaging probes, such zr-trastuzumab or folate receptor targeting ligands, are in clinical development as in vivo companion diagnostics. imaging companion diagnostics can also be used to assess tissue pharmacokinetics and thereby help to determine the optimal dose and dose schedule of therapeutic agents. they can also identify unexpected interactions between two therapeutic agents. for example, studies with c-docetaxel have shown that bevacizumab can markedly decrease the intratumoral delivery of docetaxel. finally, imaging-based companion diagnostics can assess target inhibition, as demonstrated by the inhibition of uptake of the androgen receptor ligand f-fdht in metastatic prostate cancer treated with anti-androgens. imaging-based companion diagnostics are therefore expected to play an important role in establishing precision medicine. erus technique as well as the state-of-the-art mr imaging protocols tailored according to the presenting rectal tumor site, allowing trained radiologists to obtain all necessary information for appropriate treatment decision-making, will be described. normal cross-sectional appearances as well as morphological and signal changes encountered in pelvic structures/tissues that may be involved in primary rectal cancer will be illustrated. the influence of imaging findings on initial therapeutic approach and potential limitations of different imaging techniques will be discussed. the staging and categorisation of malignant lymph nodes in patients with rectal cancer is a topical issue and has resulted in some degree of confusion. much enthusiasm has been expended in determining whether mesorectal nodes are, or are not, involved in the primary disease process, as there is a perception that nodal disease is an important determinant of local recurrence. this incorrectly perceived association of nodal status and a high risk of pelvic recurrence have propagated the concept that this should be the primary indication for neoadjuvant therapy regardless of whether tme surgery is to be performed. furthermore, misinterpretation of involved local nodes results in over-treatment of patients, if firstly involved nodes alone are considered as a poor prognostic factor, and secondly the optimal treatment of involved nodes is pelvic radiotherapy plus a non-systemically acting but radiosensitising dose of chemotherapy within chemoradiotherapy (crt) schedules. in this lecture, the evidence for risk factors associated with nodal disease and validated risk factors for local recurrence will be reviewed. the evidence for both the optimal techniques and objective criteria for assessing lymph nodes with magnetic resonance imaging (mri) will be presented. the standard treatment for advanced rectal cancer is preoperative chemoradiotherapy (crt) followed by standard resection of the rectum and mesorectum. neoadjuvant crt allows downsizing and downstaging of the tumour, leading to improved resectability and local control. while the role of mri in rectal cancer treatment is recognised and mri is recommended as part of the standard staging workup, its role for restaging after preoperative treatment is more controversial. this lecture will provide an understanding of whether and how mri can assess treatment response in rectal cancer and how it may impact treatment decision. the attendees will learn about the difficulties in image interpretation and learn about potential new imaging techniques to improve its performance. primary tb typically presents with consolidation in the middle and lower lobes, and necrotic lymphadenopathy. fibrosis, tuberculomas and calcified nodes may result as sequelae. cavitation and tree-in-bud appearance involving the apical and posterior segments of the upper lobes and the superior segments of the lower lobes are the hallmarks of reactivation tb is typically seen in immunocompetent patients. in immunocompromised patients, primary tb findings are more commonly observed, as miliary or disseminated disease or atypical manifestations in case of severe immunosuppression. pleural effusion and tracheobronchial involvement may be observed. the "classical" appearance of non-tb mycobacteria (n tm ), less common and more indolent than tb, typically affects males more than years old with pre-existing pulmonary disease or underlying immunologic disorder. despite a great overlap in the radiologic appearances of both infections, the presence of cavities on sites other than the upper lobes should suggest an n tm infection. the "nonclassical" form related to mac infection that predominantly affects elderly women with no pre-existing pulmonary disease mainly consists in mild bronchiectasis and centrilobular nodules predominantly located in the lingula and middle lobe. a high rate of lymphadenopathy and disseminated disease are seen in immunocompromised patients. the radiologist has to ensure the diagnosis of active tb and mention scarring before starting specific treatments; to suggest n tm infections, immune reconstitution inflammatory syndrome with paradoxical worsening in haart treated hiv-infected patients as multi-drug resistant tb; to appreciate the extent of disease and follow-up; to diagnose the complications; to propose mri or pet scans in some situations. learning objectives: . to appreciate the imaging features of primary and post-primary infections in tb. . to learn about the similarities and differences between tb and non-tb mycobacterial infections. . to understand the radiologist's role in diagnosis. the appropriate investigational technique, frequently targeted differential diagnosis, and the special needs of immunocompromised patients need to be understood by the referring physician as well as by the radiologist. thus, an intensive interdisciplinary co-operation on a patient basis, as well as on a department basis is essential. early detection of a focus is the major goal in febrile neutropaenic patients. as pneumonia is the most common focus, chest imaging is a special radiological task. the sensitivity of chest x-ray, especially in the supine position, is known to be low. therefore, the very sensitive thinsection multislice-ct became the gold standard in neutropenic hosts and might be cost-effective in comparison to antibiotic treatment. the infiltrate needs to be localised, so that this information can be used as guidance for invasive procedures for further microbiological workup. furthermore, the radiological characterisation of infiltrates gives a first and rapid hint to differentiate between different sorts of infectious (e.g. typical bacterial, atypical bacterial, fungal) and non-infectious aetiologies. follow-up investigations need careful interpretation according to disease, recovery, and concomitant treatment. due to a high incidence of fungal infiltrates, interpretation of the follow-up of an infiltrate must use further parameters besides the lesion size. besides the lungs, also other organs systems such as brain, liver and paranasal sinuses need attention and are to be imaged with the appropriate technique. despite advances in diagnosis and treatment, new pulmonary infections have been diagnosed. streptococcus pneumoniae remains the main aetiological agent in outpatients with community-acquired pneumonia (cap). elderly patients or those with toxic habits and various comorbidities favour the development of severe cap. in addition, the development of nucleic acid amplification techniques has emphasised the role of concomitant bacterial and viral pneumonia in the outcome of cap in elderly patients. healthcareassociated pneumonia has been recently defined as a different infectious condition by the american thoracic society/infectious diseases society of america (ats/idsa). the main concern of this new disease is the risk of having an infection due to multidrug-resistant pathogens. with the advent of haart and increased long-term survival of hiv-positive patients, the range of pulmonary manifestations has also evolved. in patients with haematological malignancies or after hsc transplant, aspergillus is a common infection. actually, aspergillus spp. isolation from lrt samples in copd may indicate an increased diagnosis possibility of ipa. new emerging viruses such as human metapneumovirus (hmpv), sars-associated coronavirus, and avian influenza caused by the h n virus have been diagnosed. in , an outbreak of a novel swine-origin influenza a (h n ) virus was reported. the clinical diagnosis of new pulmonary infections as well as the presence of concomitant bacterial and viral infections has been significantly enhanced by improved laboratory methods. a systematic approach to the radiological evaluation of lung infections is essential and includes not only chest imaging pattern recognition, but also integration of available demographic, clinical and laboratory information. the paediatric central nervous system is a complex structure undergoing rapid development. as such, there is a rapid, continuous modification of what is "normal" in relation to age and the stage of development. knowledge of the normal patterns of brain development in the clinically relevant ages from to years is necessary to interpret neuroimaging findings correctly. knowledge of embryology and normal variants is also greatly helpful. mr imaging equipment and parameters need to be adjusted and optimised for paediatric studies. pitfalls often occur from the misunderstanding of normal conditions that are perceived as abnormal based on a comparison with the appearance of the normal brain in adults. this includes, for instance, the evaluation of the brain in the first - years of life during the course of the process of myelination. a summary of the most frequent conditions that may lead to misinterpretation of findings will be provided. a wide spectrum of anomalies of thoracic and abdominal organs may be encountered on radiologic evaluation. these anatomic variants and developmental anomalies can all pose a diagnostic challenge to the radiologist. familiarity with these anomalies, the imaging techniques available for their study, and their variable imaging manifestations is necessary for differentiating them from pathology. a basic understanding of the embryologic development and normal anatomy of thoracic and abdominal organs and vessels is also essential for identifying these anomalies. this review explores the wide variability in appearance of the normal thoracic and abdominal organs during imaging, stressing a thorough understanding of normal anatomy to recognise normal variants. the skeleton of a child is a developing system with a variety of changing normal appearances. imaging studies, especially plain films, are requested for many clinical reasons, and the radiologist is in the position to determine if an image is a normal finding or we are dealing with a lesion. the way the physis and epiphysis grow, ossify, and fuse constitutes a great source of physiologically bizarre appearances, which the radiologist must be familiar with. this talk will concentrate on the plain film diagnosis of some of the most common musculoskeletal variants. other imaging modalities will also be shown when appropriate for the case. irregularities, asymmetries, partial fusions, hypo-or hyper-dense bone areas, accessory bones, prominent normal structures, external artifacts, and potential fracture lines are the most often encountered pseudolesions. a defective radiological technique may also be potentially misleading. patient age, location of the supposed "abnormality" and lack of significant local symptoms are key factors. usually plain films, correlated with regional clinical findings, are the only imaging method that is required. however, in certain doubtful situations, ultrasound, ct, mri, bone scan, or even biopsy may be needed to reach the right diagnosis. unnecessary overuse of these imaging modalities, and the subsequent family anxiety that ensues from this overuse, should be avoided with careful analysis of the x-ray and clinical findings. the purpose of this lecture is to cover the clinical presentation, underlying pathological processes and essential mri features of relatively common conditions affecting the hip. as the hip is afflicted by different conditions according to age, this is how the various pathological entities will be presented. a simple imaging algorithm is presented showing the role of mri. the role of mr arthrography in the assessment of the dysplastic hip and femoroacetabular impingement is covered. a structured approach to mri reporting is outlined. (claudia.schueller-weidekamm@meduniwien.ac.at) mri of the hand requires high spatial resolution, perfect immobility, and homogeneous fat suppression. the hand can either be placed in the superman position, which often is uncomfortable for the patients, or both hands can be placed above the abdomen next to each other while the patient is in the supine position. standard sequences are axial pd, followed by coronal t tse, and t tse fs in the coronal and sagittal planes. additional d gradient echo sequences with fat saturation are recommended to assess ligaments and cartilage, as well as the triangular fibrocartilage complex (tfcc). in certain cases, mr arthrography with thin-slice t fs is helpful for further evaluation of the wrist ligaments. in inflammatory diseases, such as rheumatoid arthritis, static or dynamic t fs sequences are useful to assess tenosynovitis and synovitis. the most common injuries and inflammation of the hand and wrist are discussed with special emphasis on key findings for an accurate diagnosis. the awareness of advantages and drawbacks of other imaging modalities, such as conventional radiographs and ct, should be strengthened. the clinical impact of the radiological report is discussed to strengthen the importance of proper terminology for the description of pathological findings. the structure of the report should be clear and concise, and should allow an interaction and broad communication with clinicians. gastro-enteropancreatic neuroendocrine tumours (gep-net) are a heterogeneous group of cancers that differ in their biology and clinical presentation. diagnosis of these tumours has been improved by advances in pathology and classification and by the combined use of structural imaging and functional imaging modalities. multimodal imaging is increasingly recognised both in detecting and staging disease and also in characterising biological patterns of lesions that may be relevant to the selection and delivery of therapy. in this course, the complex nature of gep-net and the intrinsic uses and limitations of each diagnostic imaging modality will be underlined. insights to hybrid structural and molecular imaging techniques will be provided and discussed. a. tumour biology, pathogenesis and classification b. wiedenmann; berlin/ de (bertram.wiedenmann@charite.de) neuroendocrine tumour cells are characterised by the coexpression of neuronal and epithelial proteins and cellular organelles such as synaptic vesicles containing synaptophysin of neurons and intermediate filaments/cytokeratins of the epithelial cells. based on the presence of secretory vesicles and the continous, uncontrolled vesicular release of biogenic amines, neuropeptides and hormones, patients suffer in half of the cases of so called functional symptoms and syndromes. examples are the carcinoid syndrome (excessive release of serotonine) or the zollinger-ellison syndrome (excessive release of gastrin). activation or inhibition of certain g-protein coupled receptors (e.g. somatostatin receptors) or channel proteins (r-type calcium channels) can lead to the control of the hypersecretion or so called functionality of the affected patients. medical interference with signal transduction pathways involving tyrosine kinase receptors as such mtor and channel proteins can lead to an inhibition of cellular and tumour growth. these observations have led to the establishment of new therapies, especially for pancreatic nets using especially mtor and tyrosine kinase inhibitors. whereas the tumorigenesis is unknown in the case of sporadic nets, hereditary nets appear to develop via a menin mutation through the intermediate stage of hyplasia before they develop the full metastatic potential. based on the above given tumour biological and histopathological findings, a rather robust classification for nets has been developed by the european neuroendocrine tumor society (enets) using a tnm-classification together with a gradingsystem. furthermore, the formerly used terms such as apudoma, neurocrestoma, carcinoid, etc. have been largely replaced by the meanwhile generally accepted term neuroendocrine tumour. this presentation will focus on the pivotal role of nuclear medicine in the diagnosis and treatment of neuroendocrine tumours (nets). the metabolic and molecular imaging capabilities of both positron emission tomography (pet) and single photon emission tomography (spect) have made a great impact on the clinical management of patients with these tumours. a poster child of molecular imaging in oncology is scintigraphy of the somatostatin receptor (ssr). in-dtpa-octreotide has a substantial value in detection, diagnosis and staging of net and more particularly in gastroenteropancreatic nets. newer ssr-binding radiopharmaceuticals have been developed for pet, mainly with gallium- as radiolabel, with higher affinity and more advantageous pharmacokinetics. when used with high-resolution and rapidthroughput multimodal whole body imaging of modern pet/ct cameras, these tracers provide the current state-of-the art ssr imaging. we will also discuss the clinical value of metabolic tracers, such as [ ] -hydroxytryptophan) for amino acid metabolism imaging. the clinical merits and indications of these tracers will be explained. the continuously evolving quest to develop tracer for other receptor systems expressed on nets will be illustrated, e.g. bombesin, vip, cck and glucagon-like peptide receptor ligands. finally, the role of imaging as selection for metabolic and peptide receptor radionuclide therapy will be discussed. gastroenteropancreatic neuroendocrine tumours (gep-nets) are a heterogeneous group of neoplasms that arise from cells of the diffuse neuroendocrine system and may present with a wide spectrum of clinical presentations. their prognosis is mainly related to their biology, proliferation and differentiation. the main goals of imaging are the diagnosis and the staging of these tumours. the diagnostic challenge is very different in functional tumours where clinical presentation and laboratory parameters are of utmost importance and in nonfunctional tumours where imaging may show characteristic features such as hypervascularisation and calcifications. staging is also essential as locoregional involvement and distant metastases (such as liver metastases) may change the therapeutic approach and are major prognostic factors. multimodal workup included morphological imaging modalities with ct and mr imaging, and endoscopic ultrasound was the most useful and functional imaging. the latter includes somatostatin receptor scintigraphy, fdg pet and more recent functional tools such as pet using ga and f-dopa. imaging may also play a role in assessing prognosis in combination with tumour differentiation and tumour proliferation, obtained from pathologic examination. last, imaging is useful in evaluating tumour response after treatment. although surgery remains the only potentially curative therapy for patients with primary gep-nets, other available treatments include chemotherapy, interferon, somatostatin analogues, and targeted therapies. imaging criteria rely not only on changes in tumour size, but also on internal tumour changes. the purpose of this session is to bring the audience up to date with a novel mri method capable of measuring brain perfusion. this method is called arterial spin labelling (asl) and provides a complete non-invasive means to quantitatively assess cerebral blood flow (cbf). as with any mri technique, asl relies on proper setting of many technical parameters to provide an adequate image quality, with minimal influence from potential artefacts. a recent position paper, co-signed by members of the perfusion study group from the international society for magnetic resonance in medicine and the european cost-funded action on 'asl in dementia', has established a series of simple guidelines to help promote this technology in clinical practice. these guidelines will be provided within this session. the created cbf maps will then be analysed, and a simple description of the main features and clinical characteristics of these physiological images will be given to the audience. in particular, a proper difference in the meaning of cbf in several diseases will be highlighted, as it can be either causative, such as e.g. in stroke and cerebrovascular diseases, where a reduced cbf leads to a breakdown in tissue homeostasis, or consequential, as in e.g. dementia, in which a reduction of cbf is the mere reflection of impaired metabolism, combined or not with an underlying brain atrophy. following this session, the radiologist or clinician should be able to better appreciate asl-based sbf maps in several neurological conditions. perfusion is an important parameter to assess the status and liability of organs and tissue. typically, exogenous contrast agents are administered to measure this quantity. arterial spin labelling (asl) is capable of estimating perfusion without the use of exogenous contrast media by labelling inflowing blood magnetically. this labelling process can happen either in a short time over an extended region or over a longer time period, but in a localised area. these techniques are called pulsed asl (pasl) or continuous asl (casl), respectively. for quantification, a critical parameter is the time the labelled blood takes to flow from the region of labelling to the imaging region. this time is typically called bolus arrival time (bat) or arterial transit time (att). it is important to either reduce the influence of this transit time on measured signal intensity or directly estimate it. applying proper bio-physical models, the perfusion-weighted data can then be converted in absolute measures of perfusion. more sophisticated methods allow measuring of the main feeding artery of each imaging voxel (vascular territory mapping) or assessing other parameters beyond perfusion, allowing more detailed assessment of tissue status and function." the use of asl in cerebrovascular disease j. hendrikse; utrecht/nl (j.hendrikse@umcutrecht.nl) obvious applications of arterial spin labelling in clinical mr protocols are cerebral blood flow measurements in patients with acute or chronic cerebrovascular disease. in patients with acute stroke, the cerebral blood flow measurements may indicate the infarct core, with severely decreased perfusion and the infarct penumbra, with decreased perfusion but still viable brain tissue. in chronic cerebrovascular disease, arterial spin labelling cbf measurements show the regionally impaired haemodynamics distal to a carotid obstruction. with adequate collateral blood flow, these areas may be relatively small and with a failure of compensatory mechanism the cerebral blood flow may fall below a critical level. in acute stroke patients, asl mri may show compensatory hyperperfusion in stroke regions after the recanalisation of an occluded artery. other applications of arterial spin labelling are clinical mr protocols in children. in addition to cbf-weighted images, asl mri has also the ability to measure timing parameters: typically, the time it takes for the magnetically labelled arterial blood to flow from the arteries in the neck to the brain tissue, which may be delayed in patients with cerebrovascular disease. furthermore, asl mri has the ability to visualise the (collateral) perfusion territories of the brain feeding arteries in many clinical applications. in patients with cerebrovascular disease, a pitfall may be the absence of label in brain regions due to delayed (collateral) flow, which also may result in high asl signals in (collateral) arteries. learning objectives: . to appreciate the different roles of asl in cerebrovascular diseases. . to become familiar with the different types of calculated images obtained from multi-time points and selective pulses asl. . to become familiar with the limitations and pitfalls of asl. the use of asl in non-vascular brain disease m. smits; rotterdam/nl (marion.smits@erasmusmc.nl) arterial spin labelling (asl) is a non-invasive mri technique with which cerebral blood flow (cbf) can be measured quantitatively. although the first publications of asl mri date over years back, it is only now that asl is commercially available on mri systems from all major vendors and is making its way into clinical practice. the main areas of interest for current and future nonvascular clinical application of asl mri of the brain are dementia and neuro-oncology. asl is proposed as a diagnostic alternative to fluorodeoxy-dglucose (fdg)-pet in the workup of dementia patients. asl has several advantages over fdg-pet. crucially, it can easily be added to the routinely performed structural mri examination. feasibility studies show that asl provides reliable cbf maps in dementia. in patients with established alzheimer's disease and frontotemporal dementia, hypoperfusion patterns are seen that are similar to hypometabolism patterns with fdg-pet. current and future studies in this field will need to demonstrate the validity of asl in the diagnostic workup of the individual patient, early in the disease process. studies on asl in brain tumour imaging indicate a high correlation between areas of increased cbf as measured with asl, and increased cerebral blood volume as measured with dynamic susceptibility contrast-enhanced perfusion imaging. the major advantages of asl for brain tumour imaging are the fact that cbf measurements are not influenced by breakdown of the blood brain barrier, as well as its quantitative nature, facilitating multicentre and longitudinal studies. the analysis of a sinonasal tumour requires mri for differentiation between tumour and secretions or polyps, to assess the local extension and spread into adjacent compartments (skull base, intracranial, orbit, deep facial compartments) and to depict perineural spread. t , t and high-resolution postcontrast series preferably in three, but at least in two different planes, are needed. ct provides additional information of bony structures and serves as a road map for surgical navigation. a fascinating benign sinonasal tumour is inverted papilloma, which has a high recurrence rate if not removed in toto and may harbour carcinoma in < % of patients. ct may show the attachment of the tumour as an area of increased sclerosis, which directs the surgeon to plan the operation. in patients with recurrent inverted papilloma, providing information to the radiologist about its presumed localisation is important, the more so in patients suffering from polyposis. malignant tumours are uncommon and of a large histologic variety. about % arise in the maxillary sinus; % are squamous cell carcinomas. they are often large at diagnosis, because clinical symptoms of nasal obstruction or headache are non-specific. diagnosis is by biopsy. in view of the rapid development of advanced endoscopic techniques, preoperative imaging is extremely important to assess accurately tumour extension. the skull base and dura as well as the lamina papyracea should be scrutinised for tumour locations to foresee an additional cranioendoscopic approach to a standard endonasal endoscopic approach. finally, imaging may play a role in differentiating non-nasal disease, e.g. primary bone tumours, from mucosal disease. to discuss risk/benefit considerations in medical imaging from the perspective of patients and highlight some of the pre-requisites to ensure trust and confidence. this presentation will draw on the work of the european patients' forum on patient safety, quality of care, health literacy, and patient empowerment, to explore what are the key factors to consider in radiation risk analysis, from a patient's perspective, recognising that 'one size does not fit all'. it will examine what constitutes quality information in this environment, effective dialogue between the patient and the radiologist, and the interdisciplinary team, informed consent and transparency of data. it will also highlight some of the particular challenges regarding vulnerable patients, and those requiring on-going treatment due to chronic disease (s). the justification for medical procedures is based on the assumption that the benefit outweighs the risk. this presentation looks at the radiation risk factors from recent high-profile papers (pearce et al., ) and publications from international bodies such as beir and icrp. at lower radiation doses (< msv), quantifying, understanding and communicating radiation risk to staff, patients and referring clinicians presents a range of challenges. advances in health information systems will facilitate more precise dose risk relationships. there are a number of approaches to stochastic radiation risk assessment such as organ-/age-based assessment and effective dose equivalent assessment. at-risk groups, such as children and pregnant women, need special focus. eu directives demand special attention for high-dose interventional procedures and ct scans. these techniques, particularly if repeated, require further risk assessment regarding potential deterministic effects such as erythema, hair loss, and radiation-induced cataractogenesis. this paper looks at strategies in consenting, monitoring, and follow-up of such high-dose effects. the practical implications of the new occupational icrp eye dose limits for interventional practice are also examined. with the advent of higher field scanners in clinical practice and the construction of 'mri compatible' implanted devices, the list of the do's and don'ts while performing an mri examination changes constantly. in this presentation basic safety guidelines and rules will be explained regarding static magnetic field effects, time varying magnetic field effects, radiofrequency field effects and acoustic noise effects both with regard to the patient as well as the personnel using the equipment. due to the advances in medical technology the list of possible 'safe' and 'unsafe' items changes almost daily. therefore it is very important to have all the information about the patient's condition and implants prior to the mri procedure in order to asses possible contraindications in advance. while until a couple of years ago cardiac pacemakers and neurostimulators were contraindicated in the mri environment, the advent of 'mri compatible' pacemakers and other implanted devices introduces challenges in patient safety. in fact these devices are only safe in certain configurations and also in a lot of cases specific mri scan sequences and rf antennas are only allowed. following the european emf directive, where the mri part is derogated, the protection of staff working with em fields also became a topic of debate. what are the possible risks for staff working with mri magnets and how can one implement practical rules for the safe use of the mri equipment. the field of image-guided ablation has expended recently with new ablation techniques like micro-wave, irreversible electroporation, cryoablation. nevertheless, after each treatment, whatever the technique used, we will leave in place in the treated organ, a scar instead of the tumour. follow-up of these treated areas are done by radiologists using ct of mr or contrast enhanced ultrasound. standardisation of terms has been done in by an international committee presided by dr. goldberg. this allows reporting criteria identical from one center and from one country to another. furthermore, it allows a more homogeneous literature and evaluation of success. nevertheless, techniques are not all the same and the cellular and tissue damage in the tumour and around it in the healthy parenchyma are not identical and does not have the same evolution over time. thermal ablation is frequently used to treat liver, lung and bone tumoural lesions because of its safety, efficacy and tolerability. one issue is the lack of reliable imaging modality to assess treatment efficacy and to detect early relapse. several papers have demonstrated that fdg pet/ct is a useful tool to follow-up ablated liver tumour, detecting residual disease easily and earlier than conventional imaging. few reports evaluating the usefulness of fdg-pet/ct in the follow-up of ablated lung lesions are available, but prospective studies show promising results, with a high negative predictive value of this technique. very few data are available on bone lesions and further studies are needed to assess the role of fdg-pet/ct in the follow-up of these lesions. in general, the in vivo typical aspect of completely ablated lesion on fdg-pet/ct is a ring shape, diffuse, peripheral, homogeneous fdg uptake at the treated lesion; on the other hand, the presence of heterogeneous and focal uptake is more frequently related to disease relapse. suvmax (standardised uptake value) is not a reliable indicator. it is higher in case of disease relapse than in completely ablated lesions, but also in case of important inflammatory reaction. finally, the best time point to evaluate ablation efficacy still remains to be defined, but fdg-pet/ct should be performed at least months after treatment to avoid dubious or inconclusive findings due to inflammatory reaction. the aim of thermal ablation treatment is to generate an area of thermocoagulation whose diameter is larger or at least equivalent to that of the tumour. this necrotic scar usually shrinks with time, but most often very slowly. therefore, the criteria of response based on size measurement cannot be applied. the pattern of thermal ablation is similar whatever the thermo-ablation technique used. on ct imaging, thermal ablation areas are well circumscribed and oval shaped. the criterion commonly used to assess the efficacy is the absence of enhancement in the thermal ablation necrosis, which corresponds to tissue devoid of viable tumour. on mr imaging, the thermo-ablation areas are typically hyperintense on unenhanced t due to the presence of proteinaceous material, and hypointense on t , explained by the dehydrating effect of thermal damage. the residual tumour is typically round in shape and located at the periphery of the necrotic area or in contact with large vessels. mr imaging allows earlier detection of residual liver tumour than ct imaging. neurodegenerative diseases, cancer and heart disease perhaps summarise the major challenges to medicine in this century, a challenge in accurate diagnosis and also in treatment. recent technological advances in medical imaging technology mean that these challenges can be dealt with more efficiently. anatomy can be studied faster, safer and with higher spatial resolution and precision. in addition to anatomy, the study of function has become feasible; more sophisticated hardware and software are being used to get the required data to map out the functionality and understand how this relates to anatomy to offer a more comprehensive view of normal development and explain pathological conditions. at the same time, researchers and clinicians are urged to create a platform for reciprocal communication to facilitate translation of the research findings to a graspable clinical benefit for the patients. this translational platform will allow flagging the major clinical questions, inform current and future research experiments and at the same time help utilise recent research findings in the clinical setting. this session will review state-of-the-art mri techniques and document different approaches to translational imaging. it will also allow understanding the obstacles and remedies in implementing translational medicine. many neurological diseases are associated with progressively reduced cognitive function. recent evidence suggests that proficient cognitive function depends on an appropriate interaction between large-scale cognitive control networks in the brain. it is hypothesised that damage to white matter microstructure, as found in many neurological diseases, disrupts the integrated operation of these networks and results in impaired cognitive function. diffusion tensor imaging (dti) has been used to investigate alteration to white matter micro-structure and resting state fmri (rsfmri) has proven to be a useful technique to assess brain function in multiple cortical systems. however, the combined use of these techniques in the clinical setting has not yet taken hold. in this presentation, i will demonstrate the flexibility of these mri techniques in assessing brain structure and function and address their feasibility of use in a clinical setting. imaging in oncology is a growing field within radiology. different tomographic techniques are used either isolated or as multimodality-multivariable imaging, as there is an increasing need to combine morphological and functional information. different cutting-edge modalities, such as pet-ct, dw-mr, ce-mr and mr-spectroscopy, are standard in most clinical scenarios. new images have advantages providing excellent soft-tissue contrast and multidimensional functional, structural and morphological information. the development of new diagnostic imaging research areas, mainly in the field of oncology, cardiology and neuropsychiatry, will impact the way medicine is performed today. both clinical and experimental multimodality studies, in humans and animals, will have to demonstrate an efficient use of the imaging information provided by the modalities to affect the future of medical imaging. we will comment on the impact of continued technological developments in medical imaging on patients with cancer (diagnosis, staging and follow-up) and the challenges of imaging technologies from research into clinical reality. the recent advances and developments in measurements and biomarkers which have led to a greater understanding of cancer will be commented, together with the morphologic, metabolic and functional oncological imaging research and clinical practice. finally, the role of the radiographer in advanced oncological imaging techniques will be evaluated. when imaging the head and neck region with ct or mri, teeth are always present. we frequently encounter radiolucent or radiopaque lesions of the jaw on scans performed for other indications. familiarity with typical dental conditions is necessary to subject the patients to the right therapy. to correctly evaluate and describe those lesions, this special focus session on dental imaging gives the radiologist a tool to report dental lesions. the anatomy of panoramic and ct images will be reviewed in the first talk. technical details as well as pitfalls will be presented. in the second talk, the focus is on pre-and post-surgical imaging with ct where typical lesions of the jaw will be presented. an insight into imaging the teeth with mri will be given by the third speaker. the discussion on the impact of radiologists on dental images will complement this special focus session's theme. panoramic radiography produces a single image of the maxilla, mandible, teeth, temporomandibular joints and maxillary sinuses. during the exposure, the x-ray source and the detector rotate synchronously around the patient producing a curved surface tomography. this horseshoe-shaped zone of sharp image is called the focal trough/image layer. advantages of this technique are a good overview of lower facial hard tissues, the convenience of an extraoral examination, a low patient radiation dose, and low costs. disadvantages are limited width of the sharply imaged layer, variable magnification, and oblique projection, especially in the upper premolar region. patient positioning is most important for obtaining a detailed panoramic radiograph. in addition to patient position errors, patient movement during exposure and metal objects can cause artefacts. also, ghost images caused by structures located between the x-ray source and the rotation centre can hamper diagnostics. cbct is a radiographic imaging method that allows accurate d imaging of hard tissues. during a cbct scan, the scanner rotates around the patient's head ( °- °) obtaining multiple sequential planar projection images by a d detector. the scanning software collects the data which is processed to create a volumetric data set with isotopic voxels with varying fov. disadvantages of cbct imaging are poor soft tissue contrast and artefacts. in addition to normal panoramic and cbct anatomy, after this presentation the audience will be familiar with the panoramic and cbct techniques as well as common errors and pitfalls of these techniques. pre-surgical and post-surgical imaging with mdct and cone-beam ct a. gahleitner; vienna/at (andre.gahleitner@meduniwien.ac.at) multislice-ct and more recently cone-beam-ct have become an established method for anatomic imaging of the jaws prior to dental implant placement. commonly referred to as "dental-ct", these high-resolution imaging techniques have gained importance in diagnosing dental-associated diseases of the mandible and maxilla. especially in patients with inflammations, cysts, oro-antral fistulas, odontogenous sinusitis, impacted teeth and dental fractures, new indications have emerged. unfortunately, most radiologists have had little experience in this area and many of the dental-ct findings remain undescribed. hence, we will determine the ct appearance of frequent dentalrelated diseases of the jaws and demonstrate typical pre-and postoperative findings. this presentation reflects our experiences from years of performing dental-ct with . investigations, closely working together with dentists and oral surgeons. learning objectives: . to learn about the typical findings from pathological conditions of the jaw, which confront dentists and oral surgeons. . to understand these findings in cross-sectional imaging like multislice and cone-beam ct. . to learn about the usual treatments for these conditions in order to know how they are used in dental radiology. dental mri s. rohde; dortmund/ de (stefan.rohde@klinikumdo.de) this lecture will discuss the potential of dental mri in the field of inflammatory and neoplastic disease of the periodontal space. experimental and preliminary clinical data from high-field dental mri will be presented with a special focus on the visibility of critical anatomical structures on high-resolution sequences. the results will be compared to high-resolution cone-beam ct. based on representative cases, we will review the main causes of thoracic non-traumatic vascular emergencies (acute aortic syndrome, pulmonary thromboembolism and haemoptysis); mdct angiography has become the firstline imaging test for the diagnosis of these entities. as acute aortic disease is the most common fatal condition in patients with chest pain and prompt recognition and treatment are of paramount importance, we will review the spectrum of acute aortic pathology focusing on the distinctive findings of each entity (classic dissection, intramural haematoma and penetrating aortic ulcer) and upgrading the clues for their diagnosis. acute pulmonary embolism (pe) remains a common clinical challenge. mdct pulmonary angiography has become the first-line imaging study in the diagnosis of pe because of its speed, accuracy, low interobserver variability and ability to provide alternative diagnoses. we will review the role of mdct in the evaluation of acute thrombotic pe: findings of acute pe (including how to evaluate the severity of an episode of pe at ct pulmonary angiography) and some potential pitfalls. massive haemoptysis is a life-threatening condition that is associated with a high mortality rate. haemoptysis usually involves bleeding from the bronchial arteries or, less frequently, from nonbronchial systemic arteries. haemoptysis of pulmonary arterial origin is rare, estimated at less than % of haemoptysis cases. mdct angiography permits noninvasive, rapid, and accurate assessment of the cause and consequences of haemorrhage into the airways and helps guide subsequent management. acute respiratory failure can have multiple underlying causes including infection, fluid overload, immunological diseases or exacerbation of preexisting lung disease. since the clinical symptoms are nonspecific, imaging plays an important role. the first imaging method is mostly the chest radiograph, easy to access and to obtain, but non-diagnostic in many cases. (hr)ct offers more possibilities to define the differential diagnosis. the option of this interactive workshop will be to get familiar with the spectrum of diseases that can cause acute respiratory failure and learn about key findings in radiography as well as ct to reduce the differential diagnosis. the interaction between preexisting lung disease, clinical information (e.g. chemotherapy, rheumatoid arthritis, copd) and imaging findings will be discussed using clinical case studies. options and also limitations of imaging findings will be illustrated. the following scenarios will be taken into account: acute cardiac failure and various appearances of oedema; acute immunological-toxic disorders including druginduced lung disease and inhalational injuries; exacerbations of preexisting lung disease including fibrotic and obstructive lung disorders; severe infections causing respiratory failure and their complications. contrast-enhanced ultrasoud (ceus) and elastography are evolving us techniques that have already found their ways into clinical practice (ceus) or will do so in the next few years (elastography). ceus is performed with nd generation us contrast media, but these contrast media are not available worldwide. in many european countries, sonovue® (bracco, it) is the only available contrast, consisting of micro-bubbles less than the size of red blood cells. in contrast to ct and mr contrast media, these bubbles are strictly intravascular. for us imaging, low mechanical index us techniques are used to see the resonance of sound by these bubbles. ceus is excellent for the differential diagnosis of focal liver lesions based on vascularisation and specific contrast uptake (imaging the wash-in and wash-out of us contrast over time with excellent temporal resolution) and increases us sensitivity to liver metastases in colorectal cancer patients. however, ceus is only useful when there are excellent us conditions. in pancreatic us, ceus allows to differentiate adenocarcinoma from neuroendocrine tumours based on vascularisation (us contrast uptake). whereas elastography (strain elastography or shear wave elastography) is established for the diagnosis of liver fibrosis, there are no general recommendations for using these various techniques to measure the "hardness of a focal lesion" in focal liver and pancreas lesions. diffusion-weighted mr imaging (dw-mri) provides information on tissue cellularity, extracellular space tortuosity and integrity of cell membranes by measuring the motion of water molecules in tissues modified by flows (blood vessels, glandular ducts,.). and interaction with cellular components. integrated in conventional-mr acquisition protocol, dw-mri increases sensitivity for lesion detection. the apparent diffusion coefficient (adc) can be calculated using a mono-exponential relationship between signal attenuation and b-value. this fitting is influenced by microcapillary perfusion. a more sophisticated approach (intravoxel incoherent motion, ivim) would enable estimation of parameters that separately reflect tissue diffusivity and microcapillary perfusion. using ivim-analysis, the derived quantitative parameters describe tissue diffusivity, perfusion and perfusion fraction. by providing qualitative and quantitative information, dw-mri is applied in oncology to characterise malignancy, including lesion aggressiveness, and to monitor treatment response. perfusion imaging is a useful tool to achieve information concerning tissue vasculature, microvascular permeability and interstitial space characteristics. dynamic contrast-enhanced techniques (dce-ct, dce-mr) are based on the analysis of the contrast agent (tracer) biodistribution in tissues. quantitative parameters are obtained using pharmacokinetic models, as transfer constant ktrans, extracellular-extravascular space fraction ve, vascular tissue fraction vp and the rate constant kep. quantitative dw-mr and dce-mr parameters are increasingly used as imaging biomarkers to predict tumour response and/or to monitor the effects of therapy, especially when anticancer agents with novel models of action are used (anti-angiogenic, tyrosine kinase inhibitors and several others). therefore, these new imaging biomarkers may have a pivotal role in correctly evaluating tumour response and stratify and managing cancer patients. elderly and the young can all present special problems that require a greater depth of understanding to obtain a diagnostic study. this session will help you in your quest for reliable high-quality investigations for all. a. coronary cta in patients with severe arrhythmias and high heart rate c. loewe; vienna/ at (christian.loewe@meduniwien.ac.at) besides all advances in scanner technology, heart rate remains a critical issue for coronary cta, and motion artefacts due to cardiac function represents still the most frequent reason for limited diagnostic image quality in cardiac cta. thus, the target heart rate is defined depending on the scanner system used and ranged between below bpm and below bpm. however, in a number of patients heart rate control is not possible or not successful (i.e. children, emergencies, heart transplant recipients), whereas a relevant proportion of ctas are performed in patients with heart rates higher than the target frequency. during this presentation, the possibilities for heart rate control by beta blocker injection and beyond will be discussed and possible workflows will be presented. furthermore, examination strategies for patients with high heart rates will be presented including reverse dose modulation, high-pitch scanning, systolic scanning and more. finally, tools for reconstruction and assessment of patients scanned at higher heart rate will be introduced. different to high heart rates and even more critical with regard to image quality is arrhythmia. due to the complexity of cardiac synchronisation, a ct suite is not the place for cardiac resynchronisation, whereas the indication to cta has to be reevaluated depending on referring diagnosis and severity of arrhythmia. since there are patients undergoing cta because of arrhythmia including patients prior to ablation treatment, strategies for examination and image reconstruction in case of arrhythmic patients have to be established and will be presented. cardiac computed tomography (ct) has become a widely available diagnostic tool used in a range of heart conditions. the commonest application of this technique is in the evaluation for coronary artery patency (coronary ct angiography) in patients with chest pain. when coronary arteries are heavily calcified, or post-coronary angioplasty with stent implantation, diagnostic problems can occur. in these circumstances, the evaluation of the coronary arteries on ct is hampered by the occurrence of high-density artefacts caused by calcifications and stent struts. these artefacts may preclude the appropriate assessment of the coronary lumen. the presence of motion artefacts in the dataset or image noise in very large patients may exacerbate the problem. in this scenario, accurate patient selection and preparation remain key to ensure that the diagnostic yield of the cardiac ct study is good. optimisation of scan parameters (kv), contrast injection protocol and use of appropriate postprocessing techniques (e.g. dedicated convolution filters) play an important role in daily clinical practice. recent technical developments include dualenergy scan techniques and gemstone spectral detector systems that acquire simultaneously high and low kilovoltage datasets. this is done to achieve tissue differentiation. in principle, by using monochromatic image reconstruction, the effect of high-density artefacts may be decreased. using a similar principle, high-density structures can be subtracted from the image. the introduction of iterative reconstruction algorithms may play a role in that these algorithms are theoretically more accurate in the modeling of physical noise and tissue geometries. lack of movement artefacts is one of the major prerequisites for good image quality in cardiac mr. it is crucial to have the minimum possible image acquisition time. it is important to make both te and tr as short as possible. data acquisition should be synchronised with patient's ecg or pulse. special attention should be paid to good quality of ecg recordings (good contact of electrodes with the skin, electrodes positioning, using of dielectric pad). in patients with arrhythmia, prospective ecg synchronisation should be used instead or a retrospective one, or special protocols may be applied for arrhythmia correction. breathing artefacts are usually not a problem for cardiac mri, because most sequences are acquired during a single breath-hold. using ssfp and parallel imaging allows obtaining a complete set of cine mr images through the whole heart in - short breath-hold periods. the technique of realtime cardiac mr is a good way to perform successful examinations even in difficult patients, especially the ones with heart failure. other systemic mrartefacts (aliasing, chemical shift, magnetic susceptibility, off-resonance) should be recognised and diminished or eliminated by the operator. these artefacts are more prominent in case of t systems. late-enhancement studies with gd are very dependent on the correct selection of the ti time. phase-contrast mri requires venc calibration in cases of valve stenoses. to meet the challenges and the benefits of cardiac mri, one must balance the constraints of signal-and contrast-to-noise ratios, spatial and temporal resolution, scan time and image quality. scoliosis, a common spinal deformity in teenagers, especially girls, progresses during their growth until the end of puberty. therapeutic choices, which are either medical -with corset -or surgical, depend on this progression. follow-up is mainly clinical. however, radiographs are often indicated to give precise information: ap and lateral views of the spine in standing position remain the basis of this follow-up. obtaining a good image quality at all levels of the spine has been a technical challenge for a long time, and the question of radiation dose is also a main concern, as these radiographs require a high radiation dose. fortunately, radiographic techniques have greatly improved over the past few years: from the conventional or cm film to digital screens and now flat screens, we now obtain better quality images with less radiation. today, eos system using xenon chamber is the best to give good ap and lateral views. it allows d reconstructions with minimal radiation dose. on these radiographs, measures can be performed, essentially cobb's angle. it helps in evaluating progression of the curves and making surgical decisions. other imaging techniques are requested only in particular situations as in the presence of neurological symptoms or general disease such as neurofibromatosis, or in young children with malformative scoliosis and sometimes preoperatively. ct is best to study the vertebrae; it objectivates vertebral malformations (agenesis, hypoplasia, blocks). mr will be requested to study the cord, nervous roots, craniospinal junction and the soft tissues. collaboration between the radiologist and spinal surgeon is essential. the key elements in the diagnostic process, as for most bone lesions, are: the age of the patient, the type of bone and bone segment involved, the location within the bone, the presence of signs of aggressiveness (type of osteolysis, limits, presence and type of periosteal reaction). conventional x-rays should never be absent from the initial workup of a focal bone lesion in a child, as they provide essential features for differential diagnosis and, in most cases, eliminate the need for other more costly techniques. the need and priority for other imaging techniques, such as ct, mri and bone scintigraphy, are decided on a case-by-case basis and sometimes a combination of these techniques, which complement each other, is needed. it is the radiologist's responsibility to recommend histological analysis of a lesion via biopsy whenever the imaging aspect is not characteristic or indicates signs of possible malignancy. learning objectives: . to recognise the most common benign bone tumours and pseudo-tumours. . to understand the differences between benign bone tumours, pseudotumours and malignancies in children. . to understand imaging modalities that could help in the differential diagnosis of benign bone tumours and pseudo-tumours in children. a- : a.c. offiah; sheffield/uk (amaka.offiah@nhs.net) the nosology and classification of genetic skeletal disorders subdivides conditions into groups defined by molecular, biochemical and/or radiographic criteria. conditions are associated with mutations in at least one of different genes. some of these conditions are rare or even extremely rare (occurring in fewer than in , of the population). clearly, the general paediatric radiologist cannot be expected to correctly recognise and diagnose all of these conditions. the approach is to perform a set of radiographic images dependent on the patient's age/size and to develop a standard system for reviewing these images. the standard set of images for a patient over to years of age consists of ap and lateral skull, ap chest, ap pelvis, lateral thoracolumbar spine, ap one upper limb, ap one lower limb and dp left hand. variations on this routine dysplasia skeletal survey will be discussed and a standard system for interpreting the images will be presented using radiographs of the commoner skeletal dysplasias as examples. in the last few years, interest in body composition (bc) analysis, which is the quantification and characterisation of relative amounts of muscle, fat, bone, and other vital parts composing the human body, has grown rapidly for clinical, research and epidemiological purposes. studying body composition has gained great importance for the comprehension and decoding of a multitude of patho-physiological processes (e.g. obesity, diabetes and endocrine diseases and also gastrointestinal, renal, nervous, infectious diseases, etc). and physiological and para-physiological conditions as in athletes or growth and ageing processes. although the main imaging techniques, which include dualenergy x-ray absorptiometry (dexa), computed tomography (ct), and magnetic resonance imaging (mri), offer a differentiated and attractive analysis of bc, they still need to find a definite position in clinical practice. through 'programming' low birth weight is associated with increased rates of coronary heart disease, stroke, hypertension & non-insulin dependent diabetes. prediction of morbidity and mortality from body composition, particularly fat, stimulates the importance and application of accurate and precise methods for quantitative assessment of body composition; the gold standard for which is cadaver analysis, but other methods have to be implemented in vivo. body composition alters in many chronic diseases, starvation cases, metabolic syndromes, and senescence stages, and is a key component of health. several techniques are available which vary in simplicity and complexity of use. each make assumptions and may not measure body composition directly, but make predictions from other measurements made. skinfold thickness measurements assess regional fat and are quick and simple to perform at all ages. reproducibility is good, but less so in obesity. there is some limitation of reference data to express results as standard deviation scores (sds). body mass index (bmi; weight/height ) is widely used as an index of relative weight expressed as sds for gender, age and ethnicity. waist circumference (wc) is a measure of central fat, and can also be expressed as a ratio to hip circumference. bioelectric impedance analysis (bia) measures body impedance to a small electric current, which estimates total body water (tbw) from which can be derived fat free mass (ffm). tbw can also be measured by neutron activation. air displacement plethysmography (bod pod) is a new method for body composition assessment. learning objectives: . to understand normal body composition in children and adults. . to learn how body composition can be altered by disease. . to appreciate the clinical relevance of assessing body composition. . to understand the non-imaging methods available for measuring body composition, with their advantages and limitations. computed tomography: what does it measure and how? j. damilakis; iraklion/ gr (damilaki@med.uoc.gr) ct allows measurement of total body fat and enables differentiation of subcutaneous from visceral adipose tissue. body fat can be estimated using the conventional technique of manual planimetry. using planimetry, the user delineates manually the boundaries of subcutaneous and visceral fat in each ct image. however, this method is labour intensive, time-consuming, and, therefore, not easily applicable in routine clinical practice. another ct method used for the estimation of abdominal fat is the semiautomatic measurement of adipose tissue area. abdominal fat is assessed in a ct slice by using a fixed range of hounsfield units to define the area of adipose tissue. a limitation of this method is that the attenuation range of fat may vary among individuals. the stereological volume estimation method is based on the cavalieri's principle. according to this principle, the volume of an object can be measured by cutting it into equally spaced slices and measuring the area of the object on each slice. to measure body fat using stereology, a square grid of test points is randomly superimposed on each ct section. all points lying inside the fat tissue region are selected by the user and the software automatically calculates the total number of points hitting the fat. stereology provides the possibility for efficient fat volume assessment. however, research studies are needed to optimise the stereological estimation of fat and compare stereological measurements with those from other adipose tissue measurement ct techniques. learning objectives: . to appreciate the role of ct imaging in body composition analysis. . to learn how to measure visceral and subcutaneous adipose tissue using ct. . to understand the advantages and limitations of ct techniques (planimetry, thresholding, stereology) in evaluating adipose tissue. mri: current and future applications d.c. karampinos; munich/ de (dimitrios.karampinos@tum.de) mri has been emerging as an ionising radiation-free imaging modality to measure fat distribution in the human body and fat content in different organs. the present talk will first introduce mri methods to measure fat distribution, including the well-established t -weighted imaging and the emerging dixon imaging approaches. the challenges related to the data acquisition and image post-processing of the two imaging approaches in the study of fat distribution will be reviewed. examples will be shown from the current use of mri in investigating adipose tissue distribution alterations or differences in patients with metabolic disorders, including obesity and diabetes. quantitative mri methods enabling the measurement of fat content with high spatial resolution will be then presented, with a focus on water-fat separation methods. the technical challenges associated with the establishment of mri-based fat content, as an accurate and reproducible imaging biomarker will be discussed. the selection of pulse sequence parameters and image reconstruction algorithm in a state-of-the-art water-fat separation experiment will be explained. applications will be shown from the growing literature of mri-based fat quantification in abdominal organs (e.g. liver) and in skeletal muscles, aiming to show the great premise of quantitative water-fat mri in quantifying fat content with high spatial resolution in different body parts. at the end of the talk, the potential of quantitative water-fat mri will be discussed in the emerging application of measuring bone marrow fat content and its association with bone health and metabolic disorders. the key role of dual-energy x-ray absorptiometry (dxa) in the management of metabolic bone diseases is well known. the role of dxa in the study of body composition and in the clinical evaluation of disorders which directly or indirectly involve the whole metabolism as they may induce changes in body mass and fat percentage is less known or less understood. dxa has a range of clinical applications in this field, from assessing associations between adipose or lean mass and the risk of disease to understanding and measuring the effects of pathophysiological processes or therapeutic interventions, in both adult and paediatric human populations as well as in pre-clinical settings. dxa analyses body composition at the molecular level that is basically translated into a clinical model made up of fat mass, non-bone lean mass, and bone mineral content. dxa allows total and regional assessment of the three abovementioned compartments, usually by a whole body scan. since body composition is a hot topic today, manufacturers have steered the development of dxa technology and methodology towards this. new dxa machines have been designed to accommodate heavier and larger patients and to scan wider areas. new strategies, such as half-body assessment, permit accurate body scan and analysis of individuals exceeding scan field limits. although dxa is a projective imaging technique, new solutions have recently allowed the differential estimate of subcutaneous and intra-abdominal visceral fat. the transition to narrow fan-beam densitometers has led to faster scan times and better resolution; however, inter-or intra-device variation exists depending on several factors. in cancer patients, disease-free survival is a good indicator for tumour response, but for many common cancers, treatment of disseminated disease is often noncurative. the increased duration of survival is related to changes in tumour size after treatment. however, the anatomical determination of tumour response has some limitations, especially when non-cytotoxic targeted therapies are used. with these new treatments options, the lack of progression may be associated with a good improvement in outcome, even in the absence of major shrinkage of tumours. new imaging biomarkers are therefore needed to assess therapeutic response. molecular imaging is now playing a prominent role in the monitoring of cytostatic targeted therapies. pet-ct, dynamic contrast enhancement studies or diffusion-weighted imaging are the most promising ones. the aim of this session is to present the state of the art in tumour response assessment with regard to new therapeutic regimens. in early oncologic times, treatments of different malignancies were reported in different ways. c. gordon zubrod and others first articulated the model of multicentre clinical trials and argued for standards to be agreed for included and excluded subjects, the method of assigning treatment and in measuring response. nowadays, we have better knowledge of tumour biology; however, we continue using the classical response criteria (who and recist) and overall survival as a primary goal for effective treatment in most of the malignancies. in the last few years, different criteria for responses have been reported to evaluate the disease and a lot of discussions between authors have been reported. now, we can use the recist criteria v . , implement the percist criteria and also forget the immunotherapy criteria. furthermore in the last few years, different treatments such as vaccines, antiangiogenics and targeted therapies have increased our arsenal in the treatment of different malignancies such as kidney cancer, prostate cancer, breast cancer and so on. another problem for our patients is that those diseases have a long evolution after the first-line treatment. we have to be able to define in each disease the treatment line and type of treatment to determine which evaluation criteria are necessary and which is the objective of treatment, pfs or os. we have to be aware that if we are not able to define such topics, we may be losing active treatments. recist . are the criteria most often used in studies to evaluate response to treatment in solid tumors. on each follow-up examination, response is defined by a combination of unidimensional measurement of 'target lesions', qualitative evaluation of 'non-target' lesions, and presence/absence of 'new lesions'. ct and mri are the preferred modalities for recist evaluation, and evaluations must be performed using the same modality, in the same plane. we will review anatomic locations which should be avoided, and how to deal with intercurrent events resulting in the impossibility of measurement. cases when recist seems inadequate will be discussed, including evaluation of bone metastases, and focal therapy. finally, though these criteria were developed for drug trials, they may provide a frame for reading examinations and writing reports in routine practice. reproducible, objective and quantitative criteria help to define or in the obese patient. ct is especially helpful in those with suspected retroperitoneal pathology, in the investigation of immunocompromised patients and those with complex post-operative problems. ct guidance may be required to facilitate percutaneous abscess drainage, particularly for deep pelvic collections. in addition, ct plays a vital role as a 'problem-solver' when ultrasound has failed to fully answer the clinical question posed. this short presentation will utilise clinical studies to illustrate the benefits of ct in the investigation of the acute abdomen, both as the initial imaging modality and as a second line tool following ultrasound. learning objectives: . to understand the advantages of ct as a primary imaging modality for children with acute abdomen. . to learn about clinical scenarios in which ct is relevant. . to appreciate the use of ct as an adjunct to ultrasound. abdominal trauma: us is better v. miele; rome/it (vmiele@sirm.org) ultrasonography (us) is a reliable technique whose advantages are rapidity, portability and accuracy in depicting intraperitoneal fluid without interrupting resuscitation and without radiation exposure. in the haemodynamically unstable paediatric patients, it represents the first line together with the x-ray evaluation. us for trauma has become more standardised and is worldwide known with the acronym of fast (focused abdominal sonography for trauma) or e-fast (extended-fast) used in depicting also pleural and pericardial effusions and pneumothorax. nevertheless, many parenchymal injuries are not correctly visualised at baseline us and some traumatic solid organ lesions can occur without hemoperitoneum. in case of haemodynamically stable patients, who have suffered a low-energy trauma, the greater time available allows the use of specific us contrast agents, enabling a better identification of traumatic organ injuries. contrast-enhanced ultrasonography (ceus) has a greater sensibility and specificity in the identification of parenchymal traumatic lesions, both in the first evaluation and follow-up, and could avoid unnecessary radiation and iodinated contrast medium exposure. in case of haemodynamically stable paediatric patients, who have suffered a high-energy trauma, us is not recommended as first-line investigation, because ce-mdct should be performed first. only in the follow-up, ceus can be considered an alternative to ct. in conclusion, e-fast and ceus should be considered as a useful tool in the assessment and monitoring of paediatric trauma. this examination can be performed at the patient's bedside, representing a useful alternative to ct in the paediatric traumatised patients and in the follow-up of a known abdominal injury. learning objectives: . to understand the differences in the diagnostic paths of paediatric patients. . to learn about the diagnostic efficacy and limitations of ultrasonography. . to become familiar with the use of the contrast-enhanced ultrasonography (ceus). abdominal trauma: ct is better m. raissaki; iraklion/gr (mraissaki@yahoo.gr) ct has been considered a sensitive, specific, and accurate test in the identification and grading of injuries, especially in the severely injured child. it should be overemphasised that traumatised children differ from adults: haemodynamically stable children may actually be actively bleeding and rapidly deteriorate. conversely, children have smaller calibre vessels, stronger vasoconstriction, and stronger solid organ capsules; bleeding may stop spontaneously, organ rupture is more difficult and delayed rupture is rare. this is why few children will undergo laparotomy or trans-arterial embolisation. the goal of imaging is to clear the abdomen in multi-traumatised children, identify those that may rapidly deteriorate because of clinically silent active bleeding, increase the surgeon's confidence level and define short-and long-term medical management. due to children's increased radiosensitivity, all ct scans should be indicated based on appropriate early clinical evaluation, assessment of risk factors for abdominal injuries and evaluation of the closely monitored child. alara includes the availability of outside scans upon admission, avoiding non-contrast scans and multiple phases and applying age-and weight-dependent exposure parameters. ct should not be performed as follow-up unless there is clinical deterioration. ct has the advantage of rapidly identifying and delineating with high resolution solid organ, vascular, mesenteric, bowel injuries and pending oligaemic collapse (hypoperfusion complex or shock bowel). important fractures and thoracic injuries may be simultaneously revealed with ct. the objective documentation of intraabdominal injuries is extremely important in suspected child abuse. evaluation of mr imaging in a patient with an intramedullary lesion should focus on key features: a) the location of the lesion on the cross-sectional area of the cord, best evaluated on axial images, b) the length of the lesion evaluated on sagittal images, c) the presence of cavitation and cysts, d) signal intensity on t -wi, e) the presence of enhancement and enhancement type, and f) associated leptomeningeal enhancement. the knowledge of the presence or absence of the brain lesions is important information for narrowing the differential diagnosis. the clinical picture and the onset of symptoms will help the differentiation between the neoplastic and inflammatory and vascular lesions. in this lecture, the imaging characteristics and typical patterns of intramedullary lesions will be presented. a diagnostic algorithm, which includes imaging, clinics and csf analysis, will be discussed. a common clinico-radiological situation is the differentiation between spinal infection, degenerative changes and osteopaenia, and spinal tumour. in most cases, conventional ct and/or mri will allow a certain differentiation, and additional biopsies are mainly used to obtain tissue for bacteriological or histopathological classification. advanced mr techniques such as dwi may sometimes help in increasing diagnostic certainty, but are seldomly used in day-to-day practice. spinal infections typically present around the intervertebral disc, but may also present as isoloated spondylitis without disc involvement, and sometimes the infection quickly spreads to the epidural space. degenerative changes my sometimes mimic infection due to strong gadolinium enhancement. the main differential diagnosis of spinal tumorous processes is osteopaenic changes (oedema), and ct may be helpful in such cases, for example to demonstrate degenerative gas in the vertebral body. rare causes of spinal abnormalities such as atypical pathogens and rare tumours may cause diagnostic problems; often the fastest road to a diagnosis is biopsy in those cases. the correct clinical diagnostic approach to spine disease is mandatory in the selection of patients to be treated. the anatomy and the relationship between different structures must be known in detail to understand the source of the pain and so to treat it percutaneously. mr, ct, dynamic x-ray and nm bone scan in selected cases can be used to understand the reason for the pain. mr with t stir sequence or t fat supp technique is mandatory to show bone marrow oedema and to decide on which metamer to perform the treatment. ct is often necessary after mr in primary and secondary spine tumours. disk disease can be seen either on ct or mr. two major treatments must be considered: discogenic pain and vertebrogenic pain, and for this reason disk treatment and vertebral treatment. disk treatment includes many mini-invasive systems to use; however, no treatment has been shown to be superior to the others, with good clinical results in - % of the cases, even at long-term follow-up. vp and assisted techniques are available for the treatment of not within a few minutes following ablation, ct of the ablation zone will demonstrate an extensive area of ground glass opacity (ggo). a ggo of at least . mm peripheral to the tumour is predictive of complete ablation. as early as hours post-treatment, the entire ablated region usually appeared as a well-demarcated homogeneous dense opacity on ct that corresponded to necrotic tissue and its surrounding rim of granulation tissue. this zone of ablation is the "baseline post-ablation imaging" for follow-up. then, a relatively slow involution of the ablation zone will occur with various patterns, including nodular, fibrosis, disappearance, cavitation and atelectasis. morphologic features of local tumor progression are an increase in the overall size or a change in the shape of the ablation zone (even without enhancement). it is generally considered that an ablation volume that does not increase in size on subsequent imaging after the baseline post-ablation imaging is a complete ablation. the relatively slow decrease in size of the ablation zone renders ct morphologic evaluation responsible for late discovery of local tumour progression. pet/ct is able to discover incomplete ablation earlier than ct at a stage the disease remains small. patients who have very early evaluation with pet/ct are at risk of either false-positive result due to early inflammation process, or false-negative result due to early inflammation masking active tumor foci. or months after ablation can be a reasonable time for pet/ct. learning objectives: . to consolidate knowledge on the imaging aspects of successful ablation. . to become familiar with the main pitfalls of post-ablation imaging. . to learn about the imaging aspects of most common complications. a- : c. follow-up imaging of thermal ablative therapies for kidney tumours d.j. breen; southampton/uk (david.breen@uhs.nhs.uk) image-guided ablation of kidney tumours has been increasingly set to become the standard of care treatment for smaller (< cm) renal tumours, yet ablation remains a non-extirpative technique and is therefore paramount, in this curative setting, that imaging follow-up should reliably confirm complete tumour eradication. early on in radiofrequency ablation (rfa), control remained problematic and inadequate treatment was evidenced by residual marginal crescents of viable, enhancing disease. in the current era of more definitive ablation with multipolar techniques, cryo-and microwave ablation (mwa), this pattern of treatment failure should rarely, if ever, be encountered. typically following adequate ablation imaging should confirm a completely nonenhancing tumour and a related cortical ablation zone. whilst nonenhancement is an accepted surrogate of tumour non-viability, most practitioners look for additional collateral features such as the 'halo' sign, appearing as a soft tissue ring in the adjacent peri-renal fat, usually a sound marker of complete tumour eradication. follow-up data have shown that cryoablation (cra) can yield robust outcomes, but often incurs notable haemorrhagic change and a 'rind-like' feature around the ablation zone. cra also appears to induce faster involution of the treated tumour, whereas rfa and mwa can induce a persistent granulomatous mass which only very slowly involutes over a number of years. late local recurrence is increasingly rare at around - %, but can occur as nodules of enhancing disease as late as - years after the initial treatment. subtraction mr can be useful, but to date pet and perfusion techniques still lack resolution and specificity. multiple percutaneous image-guided therapies are currently available for thermal ablation of bone tumours. thermal sources for these treatment modalities include high-intensity ultrasound, laser, microwave, radiofrequency, and cryotherapy. the predictability of thermal ablation is adequate to limit collateral damage and complications, however, is limited by biologic and anatomic variability of tissue. clinical evaluation is essential in symptomatic tumours. close imaging follow-up with ct, mri, bone scan, and pet plays a vital role in the management of the post-thermal ablation patient and detection of complications. recurrences or regrowth can be considered for repeated thermal ablation if the lesion is discovered early, before the tumour geometry, location, or distribution become unfavourable. the imaging features could vary with the different ablation method. the radiologist reporting the follow-up imaging should be familiar with different ablation methods. mri with dynamic contrast enhanced imaging and subtraction allows to detect recurrences in hypervascular tumour. contrast enhancement on t -weighted mri imaging seems to be predictive of clinically unsuccessful ablation. on ct scan, bone reconstruction can be visualised but is a slow process, particularly in adults. pet scan is an excellent morphologic and metabolic image to follow-up the tumours. however, the inflammation produce after ablation can be misleading, particularly during the first three months. imaging follow-up plays an essential role in the management of the post-thermal ablation patient and detection of complications. interventional radiology (ir) is an evolution of radiology that treats many diseases, originally treated by traditional surgery. the clinical importance of ir has been demonstrated over the years by performing procedures that offer the benefit of therapeutic treatments, competitive from the point of view of a shorter hospitalisation time. indeed, thanks to ir, patients are treated in a less invasive manner, hospitalisation is limited and thus promotes the containment of social costs. to maintain standards clinical oversight needs to focus upon correct organisational, functional and technological appropriateness of practice. to achieve correct ir performance, it is necessary to guarantee that all the instrumental guides (fluoroscopy, ultrasound, computed tomography equipment) function optimally, the procedural equipment including guides/catheters/stents, etc. are chosen according to their technical features and their characteristics are appropriate for use, incorporating cost considerations. as the complexity and variety of interventional procedures grow, there is an increasing need to ensure the appropriate training of specialised ir staff. consideration of dedicated education and continued professional development options for radiographers working in ir is of priority. the italian association of interventional radiographers (aitri) is very important in sharing guidelines in a multidisciplinary environment to standardise and harmonise the knowledge and skills of the team in hybrid theatre and interventional suites. interventional radiology technology is rapidly expanding and, to maintain safe and efficient practice, careful consideration of current and potential future organisational needs and the training of staff within an ir suite require detailed consideration. the lecture will discuss where new and current knowledge about radiation risk and effects are coming from. a brief overview of the different sources of knowledge, including hiroshima and nagasaki life span study, will be given. the most important stakeholders involved in research and formulating guidelines for radiation protection, with special emphasis on the new main publication from the international committee on radiological protection (icrp), and the impact on radiographic practice will be discussed. new tissue weighting factors for breast glandule gives a significant higher risk for females today, especially in the pubertal age. on the other hand, they have the risk for hereditary effects significantly decreased. estimation of risk, both in general and in the individual, will be discussed. regarding staff protection, there is a new recommendation for annual dose limit for the eye lens. the previous annual dose limit was msv, and this is now recommended to be decreased to msv averaged over five years with no single year exceeding msv. the new recommendation can be a limiting factor in interventional radiology and cardiology, if sufficient protection is not used. learning objectives: . to understand the importance of radiation protection in interventional radiology for patients and staff. . to appreciate the latest recommendations for staff radiation protection in interventional radiology. . to appreciate the important role of the interventional radiographer in radiation protection. a- : the improvement of patient care and aims for the highest possible levels of service are to the forefront of the modern "interventional suite". role development experiences will be explored, considering need, effect and management of development. service demands, the need to extend those provided, the limited number of radiologists, financial constraints and the requirement for continuous professional development at state level provide much stimulus for professional radiographic role development. increased job satisfaction, reduced waiting lists and improved patient experience all provide largely positive results it appears. resistance from radiologists, multidisciplinary team members and radiographers themselves however, can provide unnecessary barriers to change. once abridged the blurring of professional lines and insecurity within multidisciplinary team members may also occur. various experiences would suggest that only by allowing ownership of change by all the clinical stakeholders involved, thus empowering them, leads to successful development. on examination clear guidelines and distinct protocols must be established, taking account of current workload, to create the ideal scenario for good multidisciplinary team ethos, where members have overlapping yet clearly defined roles. professional accountability, responsibility and an understanding of those role's are all key, but without correct training, including support and resources, no regime for role development can be achieved successfully. clinical audit not only ensures the delivery of high quality and effective care in line with best practice, whilst ensuring cost effectiveness, but also provides the confidence for all involved, especially the interventional patient. learning objectives: . to understand the factors influencing change in professional roles within interventional radiology. . to learn about the potential impact of enhanced professional roles and a multidisciplinary team approach on service delivery and patient outcomes. . to understand the need for clear protocols and guidelines along with appropriate training and audit of practice when implementing such changes. there have been many attempts to develop gene reporters for mri, however these give relatively modest image contrast that can be difficult to detect. i will describe in this talk a reporter that gives intense and positive contrast in mr images (up to ~ x increase in signal), which can also be used with radionuclide imaging, thus combining the sensitivity of radionuclide imaging with the spatial resolution of mri. the contrast obtained is directly related to the degree of gene expression and is readily reversible, thus allowing longitudinal studies of changes in expression. the transplantation of pancreatic islet into the liver is an excellent example of successful cell therapy. transplanted islet visualisation in vivo using a noninvasive imaging method, for example mri, is necessary to prove technical success. monitoring of transplanted islets in vivo and long-term tracking their fate using mri requires their labelling by a suitable contrast agent in vitro prior to transplantation. under encite project we successfully performed animal experiments, which proved therapy potential of labelled pancreatic islets. labelled islets implanted into the rat liver were viable and induced long-term normoglycemia in diabetic rats. mri proved their viability and even distribution in the host tissue. these results allowed performing a clinical study on a group of patients, which were transplanted by iron labelled pancreatic islets from cadaver donors. the successful pilot experiment enabled introducing of transplantation of native islets into routine clinical practice. search for better alternative sites, improved immunosuppression and alternative insulinproducing cells require multimodal and multifunctional molecular probes. currently we test polymer meshes as artificial transplant sites, effect of mesenchymal stem cells as a supportive net for beta cells, and novel cellular probes combing h, f labels and fluorescent ones. optical imaging in the clinic j. dijkstra; leiden/nl (j.dijkstra@lumc.nl) recently a lot of developments have been done in the field of optical imaging. new sensitive devices made it possible to use both visible and near infrared light as diagnostic tool and guidance tool. the advantage of near infrared is that the penetration depth in tissue is much better than for visible light, allowing to see deeper. by using techniques like augmented reality, the data from infrared, both anatomical and functional, can be presented to the operator in real-time. optical imaging is used e.g. as an evaluation tools for mammography where the optical spectral properties of the tumor cells is used to monitor the effectiveness of chemo treatment. the spectral properties of the breast are measured using a laser at different wavelengths and a camera to create tomographically a d volume. dedicated near infrared probes which bind to certain tissue types make it possible to look for e.g. remaining tumor tissue in resection margins during surgery. this techniques also allow to visualise structures which should be avoided during procedures like nerves. by adding multispectral imaging, the endogenous contrast can be used. different tissues have their own absorption spectrum which can be shown as additional information, for instance the ration hb/hbo . optical imaging also allows for acquiring images at near microscopic resolution real time in-vivo by using optical coherence tomography. this modality is being tested to provide information about the presence of certain cell types very fast where otherwise histology is needed. mesenchymal stem cells constructs for image-guided cell therapy in myocardial ischemia and digestive fistulas o. clément, e. blondiaux, g. rahmi, l. pidial, a. silva, f. gazeau, c. wilhelm, g. autret; paris/fr (olivier.clement@inserm.fr) regenerative medicine has recently emerged as a potential therapeutic tool. a number of preclinical and clinical trials have been conducted in many diseases ranging from diabetes to myocardial infarction and neuro-regenerative diseases that assess the feasibility and benefits of injecting stem cells. however, outcomes relating to graft survival remain generally unsatisfactory, whether the process of injection is direct, intravenous or catheter-guided. to overcome such issues, tissue engineering has potential to improve cell engraftment and therapeutic response including functional parameters. this work aimed to evaluate mesenchymal stem cell constructs for image-guided cell therapy in myocardial ischemia and digestive fistulas. we tried to options: . fibrin patches based on fibrinogen monomers polymerised with thrombin and seeded with cells. . constructs based on d multilayers of confluent cells sheets. tissue constructs were labelled with iron oxide particles and evaluated in a model a myocardial infarction for the fibrin patches or digestive fistula for the d constructs. mri at . was performed at various time points after treatments using a high resolution coil. fibrin patches could induce a therapeutic effect by increasing the left ventricular ejection fraction compared to sham. d constructs induced an increased number of fistula healing and enhanced micro-vasculature density compared to controls. mri of labelled stem cell constructs allowed a good evaluation of the models and showed increased therapeutic efficacy. the proposed paracrine mechanisms will be discussed. is cell imaging relevant for the clinic? lessons to be learned from preclinical research u. himmelreich; leuven/be (uwe.himmelreich@med.kuleuven.be) non-invasive imaging of therapeutic cells has become a popular field of research over the last decade. this interest was mainly based on the hope that the location, migration but also function of immune, stem and other cells can be visualised over time in individuals. the development of novel contrast agents and mechanisms for mri but also other imaging methods has resulted in exciting basic research findings. in particular, the application of relatively biotolerant iron oxide based nanoparticles has fostered the hope for direct translation into clinical research and general practice. however, pre-clinical research has also highlighted several limitations of nanoparticle based cell imaging by using mri including the generation of unspecific contrast, difficulties to quantitatively image engrafted cells, unambiguous contrast, adverse effects on cell biology, limitations for longitudinal follow-up or the lack of functional information. such shortcomings are traditionally overcome in preclinical research by combining mri with other imaging modalities like bioluminescence imaging or positron emission tomography. our research focuses on the optimisation of cell labeling strategies for robust, sensitive and potentially quantitative visualisation of stem and progenitor cells in therapy models in vivo to assess cell behavior after engraftment. the sensitivity, stability, toxicity and adverse effects on the cell biology by the labeling procedure were studied for iron oxide based particles. the potential of gdchelates and f labeled compounds for cell labeling has been assessed in vitro and in vivo. based on our preclinical research finding the potential of future applications in patients will be explored. cardiac ct is becoming the imaging modality of choice for an increasing number of clinical indications, not only to rule out coronary artery disease but also to evaluate cardiac morphology and function, and to determine patient outcome after coronary artery revascularisation. however, as with any other imaging tools, appropriate interpretation of cardiac ct examinations is required to assess the clinical value of this newly established diagnostic imaging modality. this process requires performance of thorough cardiac ct acquisition protocols, detailed knowledge of standard cardiac anatomic and physiologic terminology, as well as appropriate postprocessing, reading and reporting. in particular, radiologists need to recognise and be aware of the imaging findings that may confound and lead to interpretation errors. this lecture will summarise the practical aspects of postprocessing, reading and reporting of non-invasive cardiac ct examinations. the value and limitations of every available ct postprocessing technique including two-dimensional multiplanar reformations, curved multiplanar reformats, maximum intensity projection (mip) and volume rendered images will be explained. moreover, hints for improving reading results by recognising technical causes for various artefacts in cardiac ct will be elucidated and reading approaches to diminish false positives, false negatives and inaccuracies when assessing coronary artery stenosis will be suggested. cardiac magnetic resonance (cmr) is a complex imaging technique due to the intrinsic anatomical and technical peculiarities of the exam. these include the non-orthogonal cardiac orientation within the chest cavity requiring dedicated acquisition planes and the complex respiratory and cardiac motion to which the heart is subject and requiring a combination of ecg-gated and breath-hold sequences. potential additional anatomical pitfalls also include normal structures and variants like the moderator band, papillary muscles, and the presence of prominent crista terminalis or myocardial trabeculations, whose recognition is mandatory and may mimic in some cases a pathological condition. technical issues of cmr concern the continuous intracavitary inflow of protons and the associated "slow-flow" artifacts (limiting visualisation of endomyocardial border in some cases) pitfalls related to ecg gating, like inadequate synchronisation or the t-wave swell phenomenon; and finally a series of specific artifacts intrinsically related to the use of different pulse sequences that may interfere with image quality. an additional, more complex issue to consider is also the widespread diffusion of high-field magnets which have further enhanced those aspects. knowledge of the spectrum of those cmr peculiarities is mandatory to approaching and providing a correct diagnosis according to the main clinical request. the present lecture will review the most important anatomical and technical pitfalls of cmr examination and offer, when possible, practical solutions to overcome those limitations. shoulder imaging and intervention are becoming increasingly important in clinical practice. this session considers the indications, techniques, imaging findings and relative merits of diagnostic ultrasound and mri of the shoulder. the indications, techniques and results of us-guided interventional procedures are also considered. a panel discussion will deal with controversies in shoulder imaging such as the accuracy of us and mri in assessing rotator cuff tears, tendinosis, impingement and muscle atrophy, and the efficacy of us-guided interventions. audience participation in the discussion will be welcome. the shoulder is an anatomic area that is very commonly evaluated with musculoskeletal ultrasound. ultrasonography is widely recognised as a reliable means of assessing rotator cuff disease with accuracies reaching % for fullthickness tears and - % for partial-thickness tears. diagnostic accuracy depends mostly on the skills and experience of the examiner. a comprehensive ultrasound (us) examination requires, first of all, sound knowledge of the anatomy. a specific scanning protocol must be adopted in every us examination in patients with shoulder disease, because focal symptoms do not correlate with the location of the disease. the greatest importance of ultrasonography in rotator cuff assessment lies in its dynamic character. several dynamic manoeuvres can reveal pathologies such as subacromial impingement. last, but not least there are several scanning pitfalls such as anisotropy. anatomy key structures as well as the us technique and scanning protocol will be presented in this lecture. dynamic manoeuvres will be described and demonstrated with videos. scanning pitfalls will be emphasised. advantages and disadvantages of the us examination compared to other imaging modalities will be discussed. guidelines concerning the mr examination technique of the rotator cuff will be presented in this session. on intermediate-weighted mr images, tendinopathy and partial and complete tears of the rotator can be differentiated with high diagnostic accuracy. indications for mr arthrography, especially for the detection of small articular sided partial tears in athletes, will be presented as well. established classification systems for the description of rotator cuff tears will be discussed. besides characterisation of rotator cuff lesions, especially in view of therapeutic decision-making, recognition of the underlying pathomechanism is necessary. therefore, the role of imaging is to detect different structural findings that are suggestive of a possibly underlying impingement syndrome. in primary impingement syndromes imaging abnormalities of the rotator cuff, the overlying bursa and the coracohumeral arch represent the centre of imaging findings. primary extrinsic impingement is caused by structural abnormalities of the coracoacromial arch, whereas secondary extrinsic impingement is related to glenohumeral instability. types of internal impingement (posterosuperior and anterosuperior impingement) are secondary to rotator cuff and/or capsular dysfunction. posterosuperior impingement can be diagnosed on mr arthrograms by identification of the socalled "kissing lesion" pattern, with corresponding lesions of the undersurface of the rotator cuff, posterosuperior labrum, greater tuberosity and superior glenoid. imaging abnormalities of this condition will be discussed. the shoulder is one of the joints in the human body that is most subject to a number of pathologic conditions, both in young and in elderly subjects, such as subacromial-subdeltoid bursitis, calcific tendinopathy, and degenerative conditions. being inexpensive, readily available, and radiation-free, ultrasound is the imaging modality of choice to guide interventional procedures around the shoulder. thanks to its high resolution and multiplanar capabilities, ultrasound can be used to guide needles precisely in the tendons of the rotator cuff or within the joint space, both gleno-humeral and acromio-clavicular. this approach can be used to perform a number of different procedures. when dealing with bursitis, a needle can be guided within the subacromial bursa to aspirate fluid and to inject anti-inflammatory drugs. in case of calcific tendinopathy, one or two needles can be used to dissolve calcium deposit and drain it, providing patients prompt relief. in selected patients with overuse tendinopathy, ultrasound can be used to guide intratendinous injection of platelet-rich plasma that has been reported to be helpful in stimulating tendon healing. although minimally invasive, these procedures should be performed in an ultrasound ward with a high degree of sterility, as risk of infection can be concrete. multi-detector computed tomography (ct) offers new opportunities in the imaging of the gastrointestinal tract. its ability to cover a large volume in a very short scan time, and in a single breath-hold with thin collimation and isotropic voxels, allows the imaging of the entire oesophagus, stomach, and the whole chest and abdomen with high-quality multiplanar reformation and threedimensional reconstruction. preparation of the patients by fasting from solid food approximately hours prior the examination is important. proper distention of the oesophagus and stomach by oral administration of effervescent granules and water, and optimally timed administration of intravenous contrast material are required to detect and characterise the disease. preoperative staging of oesophageal and gastric carcinoma appears to be the main indication for mdct and may replace endoluminal ultrasound (eus) in the staging of advanced cancers. the use of various reconstruction techniques, including virtual gastroscopy (vg) using a volume-rendering (vr) technique, is promising for the detection of early gastric cancer. the application of the texture analysis technique to distinguish between the different types of gastric and esophageal tumors is still evolving. finally, the introduction of fdg pet, in combination with mdct, has resulted in further optimisation of the diagnostic workup of oesophageal cancer, as well as specific types of cases of gastric cancer. by providing morphologic and functional information in the same setting, this technique has come to be the modality of choice, when available. the diagnosis of oesophageal and gastric cancer is usually based on endoscopic findings accompanied by biopsy. however, staging is a matter for diagnostic imaging and is the major determinant of disease management. this should be discussed within a multidisciplinary forum (multidisciplinary team [mdt] meeting) in which the radiologist plays a crucial part. accurate stagingusually based on the tnm staging criteria -is essential and the radiologist's report should reflect this pivotal role. the tnm staging of oesophageal cancer and gastric cancer will be discussed in detail. the phases in staging is essentially a filtering process which seeks to initially exclude distant metastasis and/or advanced local disease, initially by optimally protocolled ct scanning, if ct shows advanced disease, treatment is palliative, but even under these circumstances imaging will help determine the method of palliation. conversely, if ct demonstrates localised disease, f fdg-pet scanning for oesophageal cancer and for selected cases of gastric cancer is indicated. if this, too, shows no nodal or distant metastasis, accurate t staging with eus will help determine whether the patient proceeds directly to surgery or undergoes neo-adjuvant chemo/radiotherapy prior to surgery, or in the case of oesophageal cancer may be suitable for emr. the role of staging laparoscopy in gastric cancer will also be discussed. in summary, the radiologist and nuclear medicine physician are crucial in determining treatment. their reports are lynch pins in the mdt discussion of patient management. it is therefore essential that the imaging report should optimally inform this discussion. learning objectives: . to learn about the latest tmn staging in oesophageal and gastric cancer. . to appreciate the imaging criteria for local, nodal and metastatic disease, and understand the accuracy of imaging staging. . to become familiar with the structure of a perfect imaging report. a- : c. assessment after treatment a.m. riddell; london/uk (angela. riddell@rmh.nhs.uk) it is now established that for the majority of patients with oesophageal and advanced gastric cancer, there is survival benefit from the use of neoadjuvant therapy. therefore, there is a requirement for imaging to accurately restage the tumour and to assess the response to neoadjuvant therapy, to provide prognostic information and to direct future management. restaging following therapy is challenging, as differentiating treatment-related fibrosis/oedema from viable tumour is problematic with both ct and endoscopic ultrasound. the t and n staging accuracy for both modalities falls following neoadjuvant therapy. inconsistencies in measurements due to alterations in the degree of gastric/oesophageal distension can also limit the accuracy of recist criteria to determine the response. functional imaging techniques such as pet-ct offer an improved method for assessing response. alterations in the standardised uptake value (suv) occur much earlier than changes in size; therefore a metabolic response can be detected sooner, allowing for more rapid alterations in treatment strategies. acute complications following oesophagogastrectomy generally occur within the thorax and are either related to a leak at the anastomosis/mediastinitis or respiratory complications such as pneumonia or a pleural effusion. intra-abdominal collections may develop following oesophagogastrectomy and gastrectomy. late complications following both procedures are often due to tumour recurrence: locoregional such as lymph node recurrence or at the anastomosis; metastatic spread such as haematogenous spread or via the peritoneum or pleura. currently, there is no consensus on the most appropriate timing or frequency of postoperative imaging. a. an overview of pulmonary artery hypertension n.j. screaton; cambridge/uk (nicholas.screaton@papworth.nhs.uk) pulmonary hypertension is defined by increased mean pulmonary arterial pressure > mmhg at rest or > mmhg during exercise. ph causes significant mortality and morbidity, but commonly presents with non-specific clinical signs and symptoms resulting in significant delay in accurate diagnosis and specific treatment. untreated ph is progressive with increased pulmonary vascular resistance leading to right ventricular failure and ultimately death. the current dana point classification of pulmonary hypertension is clinically based. it groups diseases with similar pathophysiological mechanisms and therapeutic approaches. groupings include conditions characterised by diffuse small vessel narrowing (group and group '), ph secondary to left sided cardiac disease (group ), chronic hypoxic pleuro-parenchymal disease (group ), chronic thrombo-embolic pulmonary hypertension cteph (group ), and a miscellaneous group of diseases with either unclear or multi-factorial aetiologies (group ). in the dana point classification, small vessel diseases are subdivided into group which primarily affect the pulmonary arterioles and group ' affecting the capillary/venous pulmonary circulation (pulmonary capillary haemangiomatosis and pulmonary veno-occlusive disease). the differentiation of group from group ' diseases is important since in group ' arteriolar dilatation treatments can cause life-threatening pulmonary oedema. group is synonymous with cteph with other causes of large vessel obstruction (vasculitis and pulmonary artery tumour) being considered as group disorders. recent advances include an increased understanding of molecular mechanisms underpinning pah, facilitating targeted therapy development, a rapidly expanding role of surgical pulmonary endarterectomy in proximal cteph, and recognition of imaging as a potential therapeutic end point. ct allows depicting pulmonary hypertension (ph) and helps identifying its cause, therefore playing a crucial role in the diagnostic workup. ct features of pulmonary arterial hypertension include dilatation of the pulmonary artery trunk, with a diameter greater than or equal to mm, a ratio to the aortic diameter greater than : and a segmental artery-to-bronchus ratio greater than : in at least three pulmonary lobes. on ecg-gated ct, right pulmonary artery distensibility shows the best diagnostic value with % sensitivity and % specificity for a cutoff value of . %. among the various causes of secondary ph, ct is especially useful for detecting signs of chronic thromboembolic pulmonary hypertension, including wall-adherent thrombi, bands, webs or chronic arterial occlusion, mosaic lung attenuation and systemic collateral supply. ct shows signs of pulmonary edema, such as thickening of the interlobular septa, centrilobular ground glass opacities, mediastinal lymph node enlargement and pleural effusion in ph caused by pulmonary veno-occlusive disease, left heart diseases or mediastinal fibrosis. signs of lung parenchyma diseases may be indentified on ct; ph is a late complication in patients with pulmonary fibrosis, sarcoidosis or chronic obstructive lung disease, but may affect systemic sclerosis patients with limited lung parenchyma involvement. congenital cardiac abnormalities with untreated right-to-left shunting resulting in eisenmenger syndrome, such as ventricular or atrial septal defect and patent ductus arteriosus are easily recognised on ct. conversely, signs of peripheral pulmonary arteriovenous shunting in portopulmonary hypertension and ph caused by hepatopulmonary syndrome are more difficult to assess. learning objectives: . to learn about the ct diagnosis of pulmonary artery hypertension. . to become familiar with the causes of pulmonary artery hypertension on ct. a- : c. mri in pulmonary artery hypertension j. biederer; heidelberg/ de (juergen.biederer@med.uni-heidelberg.de) for the assessment of pulmonary arterial hypertension (pah), the dedicated min mri protocol would comprise a free breathing and noncontrastenhanced examination, short t -w sequences, dynamic contrast-enhanced perfusion imaging, a high-resolution angiogram, a d breath-hold acquisition, dynamic steady-state free precession or gradient echo sequences of the heart and a study of myocardial late enhancement. the morphologic sequences show typical features of pah: right atrial/ventricular dilatation, enlargement of the pulmonary trunk/main pulmonary arteries and peripherally attenuated pulmonary vessels. incidental infiltrates, nodules or masses of the lung, mediastinum and chest wall would be covered. the first pass contrastenhanced perfusion imaging demonstrates an increased mean transit time/decreased pulmonary blood flow, but a relatively homogeneous lung perfusion (important to differentiate from cteph, where multiple segmental perfusion defects would be expected). the cardiac part shows right ventricular mass, wall thickness and functional changes correlating with elevation of pulmonary arterial pressure: distortion of the interventricular septum, area change of the pulmonary trunk, right ventricular volume/stroke volume as well as pathologic right/left ventricular end-diastolic volume indexes. late enhancement of the right ventricular wall would correlate with myocardial fibrosis. furthermore, optional experimental velocity-encoded sequences (ideally for multidirectional flow visualisation, " d flow") show a decreased pulmonary artery blood flow velocity, increased retrograde flow and inhomogeneous velocity profiles. in conclusion for the near future, given the availability of scanner time and appropriate experience of the team, thoracic mri is probably the most comprehensive and effective single examination for the diagnosis and follow-up of pah. in the era of organ-based radiology, the group of diseases known as multisystemic malignancies represents an obvious challenge to both radiologists and oncologists. the necessity to match the growing possibilities of different imaging modalities with widespread multisystemic pathology and clinical sufficiency resulted in upgrading well-known diagnostic algorithms. the precise knowledge of clinical staging systems and classification, and the pathologic and physiologic mechanisms of the disease pathways are important for planning imaging modalities and specific protocols. perfect imaging of multisystemic malignancies now includes not only traditional anatomic-based modalities, but also much more often different types of whole body scanning such as ct, mri, pet and their combination in spect/ct, pet/ct and now even pet/mri. new imaging modalities and growing possibilities of traditional imaging techniques obviously influence the current clinical guidelines for this disclosure: c. heussel: consultant boehringer ingelheim, grifols, novartis. a common language between radiologists and clinicians, so that the latter can make an informed treatment decision based on sound conclusions to become familiar with the conditions necessary to implement them to understand the limits of their application to learn useful lessons from these criteria for routine clinical practice chairman's introduction a. palko this requires a thorough knowledge of the relevant brain anatomy, choice of appropriate structural and molecular imaging modalities and interpretation of mri and pet/spect in the most prevalent disorders in a structured fashion the presentation has the objective of giving the audience a synthesised panorama of our country situated in north america, with more than million inhabitants and a large prehispanic history based on the aztec, toltec and maya cultures, and also of interesting facts related to the three centuries of colonial existence under the spain influence and dominium until the war of independence. after , mexico has never had an international war; the last was against the northern border country, the united states. also, we will give important data on how in the mexicans rebelled against a -year dictator, general porfirio diaz. the mexican revolution was a long and cruel war, but later opened the doors to democracy and a complex developmental era began that is still in process. some demographic and contributions to health, science and culture issues will be mentioned and also the works of mexican scientists, writers and philosophers who have been presented awards including the nobel prize. in relation to well-known mexican artists such as diego rivera and frida khalo, some facts of their works will be presented. interventional radiology in oncologic patients g. elizondo-riojas; monterrey/ mx (elizondoguillermo@hotmail.com) interventional radiology (ir) is becoming an increasingly prominent subspecialty in the care of oncologic patients. its role extends from initial diagnosis to minimally invasive treatment of the malignancy and its complications. image-guided biopsies are increasingly performed using minimally invasive techniques. also, an integral part of care of these patients is vascular access as a means of medication, chemotherapy or parenteral nutrition, and interventional radiologists can place required the devices with well-established safety and efficacy. ir also plays a substantial role in the therapy of oncologic patients, through local tumor treatments such as transarterial chemo-embolisation and locoregional control with radiofrequency/cryo ablation, as well as management of complications of malignancy such as pain, obstruction (biliary, ureteral, etc) ., venous thrombosis and drainage of thoracic and abdominal collections. in mexico, ir is a growing subspecialty, and more medical students nowadays want to be radiologists and eventually become interventional radiologists. this is a paradigm shift. more and more radiologist wants to be involved with patient management and to be more than just "observers" in the process of patient care. we have to be prepared to offer this opportunity to our residents; otherwise other specialties will "have to fill the empty space" that we have left. interventional oncology has all the advantages to fulfil this opportunity. it is our chance to contribute to the advancement of medical care. learning objectives: . to appreciate the role of interventional radiology in the management of oncologic patients. . to learn how interventional radiology changes the quality of life for patients with cancer. . to understand the impact of interventional radiology procedures in the outcome of some neoplastic diseases. interlude: origins and development of radiology in mexico m.e. stoopen-rometti; mexico/mx (mstoopen@clinicalomas.com.mx) mexican radiology started in , just a few months after the discovery of xrays. during the last few decades, as well as in other countries, there has been a great development both in public and private sectors, which will be described in this interlude. learning objectives: . to learn about the history of radiology in mexico. . to learn about the development of radiology in mexico. . to learn about the present and future of radiology in mexico. modern issues in oncologic ultrasound j. mexico/mx (jtanus @hotmail.com) advances in ultrasound (us) technology allow confident characterisation of masses. these include harmonic imaging, compound imaging, power doppler, faster frame rates, higher resolution transducers, three-dimensional ( d) us, us contrast agents and, more recently, elastography and fusion imaging. highfrequency transducers provide superb spatial and soft-tissue resolution, permitting substantially improved differentiation of subtle lesion, margin resolution, and lesion conspicuity in the background of normal tissue. elastography features such as size ratios, shape, homogeneity, and maximum lesion stiffness complement conventional us in the analysis of lesions. ultrasound contrast agents have overcome some of the limitations of doppler ultrasound techniques with demonstration of irregular branching central or penetrating vascularity within a solid mass raising suspicion of malignant neovascularity (neoangiogenesis). ultrasound contrast agents can provide important information in the assessment of lesions to be treated by locoregional therapies, which include ablation (feeding vessels), trans-arterial chemo/radio-embolisation, detecting viable tumour persistence following this treatment; facilitation of needle positioning in cases of poor lesion delineation, and assessment of local tumour progression. it facilitates needle positioning in cases of incomplete or poor lesion delineation on unenhanced ultrasound. us contrast agents are an important key during the evaluation of the immediate treatment effect of ablation and guidance for immediate re-treatment of residual tumour. learning objectives: . to understand the role of ultrasound in the management of oncology patients. . to learn how ultrasound is used in large oncology centers. . to learn about the modern concepts of ultrasound in oncology patients. the aim of this lecture is to give an overview of the techniques for imaging inflammatory bowel disease (ibd) of the small bowel and the colon with either ultrasound (us), multidetector row computed tomography (mdct) or with magnetic resonance imaging (mri) and compare the different modalities for its strength and weakness. optimal imaging of the bowel begins with the preparation phase. the small bowel has to be distended for a concise examination. this is mainly done orally, which is named enterography. a solution of . % mannitol seems to be the one preparation technique mostly used for small bowel distension. another technique is the enteroclysis, application of contrast after intubation of the small bowel. the comparative advatages and disatvantages of the two preparation methods will be discussed. this intraluminal contrast gives a neutral contrast in ct and a biphasic signal in mr. the colon can be prepared in a fashion similar to colonoscopy meaning total cleansing. another possibility is the so called fecal tagging whereas the stool will be contrasted with an additive to standardised food. therefore no cleansing is needed for preparation. imaging parameters will be discussed for mr and ct. the aim of imaging for the bowel should be to establish the following: ) presence, severity, and extent of disease; ) activity of the disease and ) extra-intestinal complications. us, mr and mdct have proven to be a good tool to evaluate the extent, the activity of the disease and the presence of extraluminal complications. pros and cons will be discussed when to use which technique. learning objectives: . to understand state-of-the-art mri, ct and us protocols for imaging ibd. . to appreciate the comparative advantages and disadvantages of enterography and enteroclysis protocols. . to learn about protocol modifications when evaluating the colon.a- : b. small bowel disease j. stoker; amsterdam/nl (j.stoker@amc.uva.nl) classification of small bowel crohn's disease is helpful for assessing disease activity and treatment monitoring. similar to clinically based classification, also imaging-based classification systems have been developed, of which some have been externally validated. important imaging features for determining disease activity include bowel wall thickness and vascularity/enhancement; at mri, also wall oedema plays a role. stenoses, fistulas and abscesses are important sequels. for assessment and monitoring of small bowel disease the breast imaging reporting and data system (bi-rads®) for mammography of the american college of radiology (acr®) consists of several components, a standardised lexicon of terms to be used during reporting, a -step coding system for the mammographic density as a surrogate parameter for the mammographic sensitivity, and a group of assessment categories ranging from to for structured communication regarding the recommended further management. the goal of bi-rads® is to improve the quality of breast imaging reporting and communication. in addition, by providing structured reports it facilitates regular quality assurance measures. the bi-rads® atlas for mammography is currently in its fourth edition and was released in . the upcoming th edition is expected soon and will be incorporated into the course as it becomes available. the breast imaging reporting and data system (bi-rads) was first developed by the american college of radiology for standardising the reporting of mammography. since its first publication in , new editions have also addressed breast ultrasound (us) and mr imaging examination. the new (fifth) edition will be published soon. on the form, this new version was designed to include a web-based format. substance includes updates in lexicon descriptors, e.g. masses, calcifications, associated features (now comprising surrounding tissue with stiffness assessment), and special cases. us descriptors will be reviewed in the lecture. of note, guidance on how to link bi-rads descriptors with management recommendations has been added in the report section. a new approach to outcome assessment (audit section) is being proposed for screening us. the appropriate use of descriptors is expected to increase the accuracy of imaging interpretation. for relevant patient management, us analysis is to be integrated with other available imaging, as well as with clinical data. learning objectives: . to learn about the bi-rads lexicon. . to understand the usefulness of bi-rads system. a- : c. mri k. pinker-domenig, p.a.t. baltzer; vienna/at (katja.pinker@meduniwien.ac.at) dynamic contrast-enhanced magnetic resonance imaging (dce-mri) of the breast is a well-established non-invasive imaging technique. it has clinical application in the screening of high-risk patients, diagnosis and staging of breast cancer, monitoring neoadjuvant chemotherapy and post-treatment follow-up. to standardise the reporting of dce-mri of the breast and minimise false-positive results without compromising sensitivity, the american college of radiology (acr) introduced the breast imaging-reporting and data system (bi-rads®) mri lexicon in . bi-rads relies on the combined analysis of morphological appearance and lesion enhancement kinetics. it is widely used for reporting dce-mri of the breast and is applicable at any given field strength. it aims to provide an up-date report on the bi-rads® lexicon and instill confidence in using bi-rads® descriptors. the bi-rads® system may be placed in a broader clinical context to highlight its value for standardised reporting of dce-mri of the breast. mr-guided focused ultrasound is a new therapeutic modality which can allow selective destruction and or heating of tissues in deep body areas under close image guidance control. these talks will introduce the field and allow you to understand the areas of current work and areas of future development in this rapidly expanding field. session objectives: . to become familiar with mr-guided focused ultrasound. . to understand the advantages of focused ultrasound. . to learn in which areas focused ultrasound is evolving successfully. description of technique c. moonen; utrecht/nl (c.moonen@umcutrecht.nl)high-intensity focused ultrasound (hifu) is the only clinically viable technology that can be used to achieve a local temperature increase deep inside the human body in a non-invasive way. mri guidance of the procedure allows in situ target definition and identification of nearby healthy tissue to be spared. in addition, mri can be used to provide continuous temperature mapping during hifu for spatial and temporal control of the heating procedure and prediction of the final lesion based on the received thermal dose. the primary purpose of the development of mr-guided hifu was to achieve safe non-invasive tissue ablation. the technique has been tested extensively and is now accepted in the clinic for ablation of uterine fibroids. mr-guided hifu for ablation shows conceptual similarities with radiation therapy. however, thermal damage generally shows threshold-like behaviour with necrosis above the critical thermal dose and full recovery below. mr-guided hifu is being clinically evaluated in the cancer field. this presentation will cover the basic technologies for treatment of stationary tissues, and some advances towards treatment of mobile abdominal organs. for state-of-the-art mr liver and pancreatic imaging, a field strength of at least . t is required. all non-blood pool gadolinium chelate-based contrast agents are suitable for dynamic liver and pancreatic mri. all gadolinium chelates should be routinely administered at a rate of - ml/s followed by a ml saline flush at - ml/s using a power injector. to obtain hepatobiliary phase imaging in addition to dynamic phase imaging, the use of liver-specific contrast agents is required. gd-eob provides the highest hepatocyte enhancement, but an overlap between delayed phase and hepatocyte phase has to be considered during dynamic evaluation. the hepatocyte phase can be considered adequate when contrast is detected in the intrahepatic bile ducts. hepatobiliary phase imaging benefits from a gradient echo high flip angle, depending on magnet field strength. in the absence of liver function impairment and biliary obstruction, contrast-enhanced mr cholangiography can be obtained with gd-eob at - minutes, and with gd-bopta at - minutes. when the differential diagnosis is primarily between solid benign lesion vs. metastasis, the use of a liver-specific ca is recommended, due to the ability to diagnose fnh confidently. the combined interpretation of dynamic and hepatobiliary phase improves diagnostic accuracy of mr imaging for the detection of hcc.hemangiomas and intrahepatic ccc result in relative hypointensity in the late vascular phase after gd-eob administration. when combined with t weighted mrcp, contrast-enhanced mrc allows morphologic and functional assessment of the biliary system. gastrointestinal stromal tumours (gist) are rare malignant tumours arising within the wall of the gut from the interstitial cells of cajal, which act as pacemaker cells controlling peristalsis. the crude annual incidence of clinically detected gists is approximately cases per million in europe. the median age at diagnosis is approximately years, and % of patients are older than years. however, a small number of cases do occur in younger people and children, and these are usually syndromic gists. gists can occur at any site of the gut from the oesophagus to rectum, although they can also arise in the extra-gastrointestinal abdominal and pelvic locations, so-called e-gists. the commonest location is the stomach ( %), followed by the small intestine ( %) and rectum ( %). diagnosis is by biopsy, with spindle cell or epithelioid morphology, and immunohistochemical staining for cd (the protein product of the kit gene) and/or dog- receptors. approximately, % of gists have mutations in the kit gene, % have mutations of the pdgfra gene, and the remaining % have no mutation (wild-type) or rare gene mutations. early stage disease is managed by surgery, followed by years of adjuvant imatinib (a tyrosine kinase inhibitor with activity against kit and pdgfra receptors) for cases at high risk of relapse. advanced metastatic disease is treated with imatinib, with a median duration of response of approximately years. at disease progression, second-line treatment is with sunitinib, with a median duration of response of approximately months. imaging plays a major role in the detection, characterisation and staging of gastrointestinal tumours (gists). imaging of gists depends on the mode of presentation and the local availability. endoscopic ultrasound and computed tomography (ct) are the most widely used imaging methods. gists have a spectrum of radiological appearances depending on tumour size and site of origin, but often show certain key radiological features. multiphase multidetector row ct is necessary to detect and stage gists and multiplanar imaging is important so as to define the likely organ of origin of the mass, which may be a challenging task. the clinical diagnosis of a gist is based mainly on imaging, as biopsy runs the risk of tumour rupture or seeding of the biopsy tract. in patients with an unresectable primary tumour or metastatic disease at presentation, biopsy confirmation is important before starting medical treatment. ct or/and mri are used to assess primary tumour extension, local invasion and the presence of metastases, with main sites of metastasis being the liver and the omentum. gastrointestinal stromal tumours (gists) are treated with targeted therapy regimes. these treatment strategies are based on the suppression of tumour vasculature using the tyrosine kinase inhibition pathway. drugs like imatinib and sunitinib exhibit specific changes in tumours and metastases that can be detected on cross-sectional imaging. these changes differ significantly from standard treatment effects of cytotoxic chemotherapy. while the latter leads to destruction of tumour cells and thereby to a reduction of tumour size, the former will cause a decrease in vascularity and thereby in attenuation and enhancement of lesions while the size may remain unchanged. radiologists have to be aware of these specific patterns of response to treatment. this presentation will include a review of the choi criteria which have been developed for the assessment of gist lesions under treatment. also, current imaging strategies focusing on time-resolved ct imaging (ct perfusion imaging) will be presented. the aim of this lecture is to provide a practical approach to response imaging in gist patients integrating both existing and novel strategies. radiological response evaluation using anatomical imaging was developed in the s in early phase ii clinical trials. potential new anti-cancer agents were assessed by measuring tumour size before and during therapy and a predetermined reduction in size constituted response. radiological response represents an objective surrogate for patient benefit and was the primary end point in early phase ii studies. if a pre-defined percentage of patients achieved the required response, then the agent proceeded to large phase ii and iii studies where clinical time to progression or progression-free survival comprised the primary end point. between and , there were extraordinary advances in cross-sectional imaging techniques which became widely available. different imaging techniques were introduced piecemeal with different co-operative groups adding different requirements, so meaningful comparisons from one trial to another could not be made. in , the recist criteria were introduced requiring specific imaging stipulations and a minimum baseline tumour size to unify the different criteria and enable meaningful comparisons from one study to another. further advances continue to be made regarding anatomical and functional imaging. not all anti-cancer agents are cytocidal and many studies now use time to progression or progression-free survival defined by radiological imaging as the primary end point. certain tumour types respond in a unique manner requiring the employment of specific response criteria in these tumour types to adequately demonstrate response. some of these tumour types and their specific response criteria will be discussed. learning objectives: . to learn about the role of radiological response evaluation in clinical trials. . to understand how radiological response evaluation has evolved and continues to evolve. . to understand which response criteria are utilised in specific tumour types. emerging biomarkers for response assessment: pros and cons m.c. roethke; heidelberg/ de (m.roethke@dkfz.de) non-invasive response assessment of new specific anti-cancer therapies is an emerging field of oncologic imaging. in the past few years, large efforts were undertaken to develop new functional biomarkers to enable an earlier diagnosis, improved risk stratification and treatment monitoring of oncological diseases. imaging biomarkers reflect changes in tumour biology, which can be differentiated into certain categories (e.g. cell density, tumour heterogeneity, iron concentration, elastic properties, or cellular receptors). in a first step, alternative qualitative and quantitative imaging biomarkers for the different modalities (mri, ct, pet) are elucidated. for magnetic resonance imaging, new techniques with potential for treatment response monitoring such as diffusion-weighted imaging, susceptibility weighted imaging, and elastography will be assessed. then, quantification of iodine uptake of contrast-enhanced ct as an imaging biomarker will be addressed. novel pet imaging strategies for therapy monitoring will be mentioned with focus on receptor targeting tracers (e.g. psma, dotatoc). furthermore, the role of pet-ct/mri is mentioned to facilitate functional techniques in oncological imaging with imaging biomarkers. the potential clinical use of prior introduced biomarkers is demonstrated for several cancer entities (e.g. hcc, prostate cancer, malign melanoma, multiple myeloma, glioblastoma). advantages and disadvantages of the illustrated imaging biomarkers are discussed during this part of the lecture. the goal is to image the right patient, at the right time, using the right test and with the right interpretation so that patients will be advised on the right therapy. ultimately, the aim is to maximise patient outcomes at an affordable cost. this session will cover the state of the art in ebr, cer, and hta and demonstrate how the results are used in imaging decisions. the application of evidence-based medicine to medical imaging was relatively delayed in comparison to other specialties. radiologists should be aware of the necessity to justify radiological examinations and imaging-based interventional procedures on the basis of the best available evidence. diagnostic tests can be evaluated with studies exploring their value in terms of: . technical performance; . diagnostic performance; . diagnostic impact; . therapeutic impact; . patient outcome; . societal impact. notably, this is a one-way logic chain. while improvement at the upper levels implies improvement at some of the lower levels, the vice versa is not always true (e.g., a better diagnostic performance does not always imply a therapeutic impact or a better patient outcome). moreover, different degrees of recommendations are based on different levels of evidence, with experts' opinion as the lowest level of evidence and meta-analyses of high-quality homogeneous studies and multicentre studies being the best level of evidence. the quality of studies needs to be evaluated in terms of internal and external validity, the former regarding study implementation (protocol violations, reference standard, measurements, and readers' independence), the latter regarding study planning (study design, subjects selection, methods, and statistical analysis). biases influencing the internal validity limit the intrinsic value of study results, while those influencing external validity limit the generalisability of study results to clinical practice. finally, high-quality research must be planned to build the evidence in favour of radiological procedures, especially for new technologies which tend to enter the market without any preliminary demonstration of efficacy. state-of-the-art methods in ebr, cer, and hta relevant to imaging u. siebert; hall i. tirol/at more and more, clinical guideline developers and reimbursement decision makers need to base their work and decisions on solid evidence. this presentation will introduce the key concepts and principles of evidence-based medicine (ebm), comparative effectiveness research (cer), and health technology assessment (hta) and their application to the field of radiology. in particular, it will be discussed which role observational studies, clinical trials, and decision-analytic modeling play in ebr, cer, and hta and when each of these study types is needed to assess imaging technologies. specific topics include the assessment of bias, optimising cutoffs and multiple test strategies, making causal inferences, explicitly weighing benefits, risks and costs, and considering ethical, legal and social implications (elsi). the excitement generated by the discovery of x-rays led to the early adoption of this technology in many hospitals around europe. over the last three decades, the explosion of new medical imaging technologies together with the recognition by clinicians of the value of these for their patients has meant that imaging budgets have increased exponentially. evidence based radiology (ebr) is a relatively new approach designed to inform clinicians of the most appropriate technique to use in a given clinical scenario. the comparative effectiveness research (cer) is used by healthcare systems to develop a strategic approach to rationalise the availability of imaging investigations. the health technology assessment (hta) funding approach is a mechanism to assess new and emerging imaging technologies in a systematic timely manner. the uk has a nationally funded healthcare system which is designed to deliver equitable care for the population free at the point of delivery. the challenge for the uk has been to ensure the highest quality service by delivering the most appropriate technology and care for patients in a timely manner. the national institute for clinical excellence (nice) is an independent body which gives guidance on new drugs and medical devices. this body requires robust scientific evidence on which to base their decisions. to create the evidence base, the imaging studies need to be of a certain standard to be included (consort, stard, etc). an example from oncologic imaging will be used to show how ebr influences daily practice. acute abdomen and abdominal trauma are both emergencies with potential fatal sequela when under/ misdiagnosed. imaging plays a crucial role in the diagnosis and management. us is the imaging technique of choice in most cases, as it is rapid, portable, lacks radiation and there is no need for sedation in young infants. us accuracy can be enhanced by iv contrast agents administration. however, limitations may occur in obese children, in deep structures, or because of gas filled bowel loops. on the other hand, ct provides excellent visualisation without limitations by obesity, gas, or deep lesions. however, there is always the radiation exposure risk of the radiosensitive paediatric patient, while sedation is required in non co-operative young children. the aim of this session is to understand "which" is the modality of choice and "why", for the most common paediatric abdominal emergencies. the acute abdomen: ct is the answer a. paterson; belfast/uk (anniezunz@gmail.com)abdominal pain is a common symptom in children, and whilst the majority will have a self-limiting condition, in some the pain may indicate an acute medical or surgical condition that requires prompt investigation and treatment. in the paediatric setting, the primary imaging modality for those with an acute abdomen is ultrasound. however, there are certain patient groups -often older children or adolescents -in whom ct plays an important role. it is well acknowledged that ct is non-operator dependent: an important factor for children presenting to emergency departments outside children's hospitals. the speed of a ct exam is valuable in the acute setting, as is the capability to obtain images without having to touch the tender abdomen of a distressed child. ct offers a global perspective of the abdomen, and image quality is not hindered by the presence of excessive bowel gas, an abnormal body habitus only porotic fragility fractures, but also of primary and secondary spine tumours such as traumatic fractures. a wide variety of lesions in and around the orbita can impair eye movement. ct and mr imaging is frequently used to confirm or exclude lesions in and around the orbit in patients with impaired eye movement. first of all, it is very important to know the exact clinical history of the patients. ct is excellent for confirming a mass; however mri is more sensitive and arrives often at a single most likely diagnosis. characteristic imaging features may help distinguish among lesions that have overlapping clinical presentations. this review focuses on some of the common orbital masses. in this lecture common benign and malignant lesions will be discussed. vascular lesions include capillary (infantile) haemangioma, cavernous haemangioma, and lymphangioma. benign tumours include optic nerve sheath meningioma, schwannoma, and neurofibroma. malignancies that are reviewed include: lymphoma, metastasis, rhabdomyosarcoma, and optic glioma. in addition, benign and malignant lesions affecting the eye movement from outside of the orbit (e.g. from the paranasal sinuses, nasopharynx and skull base) will be discussed. trigeminal neuralgia is a unique form of facial pain, defined by the international association for the study of pain as a sudden, unilateral, brief, stabbing, recurrent pain in the distribution of one or more trigeminal nerve branches, triggered by a specific event. additional diagnostic criteria of the international headache society include paroxysmal, stereotypic pain attacks and absence of associated neurological deficits. it is due to trigeminal nerve compression at the root entry zone, a transitional zone between central and peripheral myelination, where the myelin sheath is thinner and more prone to compression and electrical stimulation. the most common cause is vascular compression, by aberrant loops of the sca, aica, pica or vertebro-basilar dolichoectasia, leading to a neurovascular conflict. small size of the prepontine and cpa cisterns has been identified as a predisposing factor. occasionally, expansile lesions of the skull base or cns compress the root entry zone and lead to atypical trigeminal neuralgia. mr imaging is the modality of choice to evaluate these patients and requires specific tailored protocols to depict its causes, including d heavily t w images reconstructed in the three planes and an angiographic sequence for the depiction of neurovascular conflicts. as neurovascular contacts are quite common in the general population, strict imaging criteria for the diagnosis of nvc have emerged. the offending vessel needs to cross the nerve perpendicularly and deviate or indent its course at the rez. a pictorial review of the most common causes of trigeminal neuralgia and trigeminal neuropathy will be presented. learning objectives: . to understand the causes of trigeminal neuralgia and its clinical symptoms. . to learn about the relevant anatomy and appropriate imaging methods. . to become familiar with the relevant radiological images, differential diagnosis and limitations of the method. c. facing problems of the face: facial pain, tics and palsy b. verbist; leiden/nl (b.m.verbist@lumc.nl) facial impairments may be due to neuropathies of the trigeminal and facial nerve. this lecture will focus on the seventh cranial nerve. this nerve is a complex, mixed nerve with motor fibres, parasympathetic fibres, sensory fibres to the external auditory canal and special sensory (taste) fibres to the tongue. the most common presentation of facial nerve dysfunction is facial palsy. the paresis or paralysis of facial muscles may be caused by several conditions such as developmental abnormalities, infectious or inflammatory disease or tumoural lesions. other presentations of facial nerve dysfunction are facial tics or hemifacial spasm and pain. the indications for imaging, choice of imaging modality and possible imaging findings in case of facial palsy, facial tics and facial nerve-related pain will be discussed. in this presentation, the procedures used to create the standard will be reviewed and some of the most recent changes discussed. as a collaboration of professional societies and companies, integrating the healthcare enterprise (ihe, www.ihe.net) seeks to establish methods wherein health computer systems can communicate to achieve specific functional objectives. these involve development of methodologies to implement standards such as dicom, hl , etc. in this presentation, the procedures used to create the ihe profiles will be reviewed. patient dose tracking is rapidly growing in the usa as a large number of commercial products are available in response to user demand. these products leverage the work that has gone into the development of the dicom dose structured report and the proliferation of digital imaging systems. medical physicists are crucial team members as they are most capable of performing patient dose measurements and calculations. noteworthy is that the 'toolbox' of the medical physicist is expanding. informatics with patient dose tracking tools invariably includes familiarity at some detail with dicom structure and tags, dose structured reports (sr), sr readers, ris content and orders, modality work list broker content, modality (imaging) specific content as well as pacs, archive rules for storage/retrieval and emr. patient-specific information and the highly detailed specifics of the individual dose prescription are necessary for advanced estimates of information. a dose tracking system (a qa tool outside of the normal imaging device that uses content provided by dose sr and other information systems) usually strives to elevate the quality of the dose estimate, using informatics tools such as patient and organ models, dosimetry engines, and predictive statistics. general use cases for dose tracking will be presented including advanced dose estimations for individual patient exams and qa review for both ct and fluoroscopy. examples of tracking of prescriptions by patient, protocol/procedure and operator for determination of patient dose history, 'outliers', continuous improvement (using dmaic tools) or for meeting regulatory or accrediting bodies will be included. with the introduction of digital radiology, it is possible to have automatic systems to collect and archive patient dose data individually, in addition to demographic, geometric, and other procedural parameters, as part of the dicom header or through other dicom services. these automatic systems mean significant benefits for patient dosimetry and quality control. different approaches were used, depending on the availability and level of implementation of the dicom standard, including extracting the technical information from the headers, using the radiation dose structured reports (which contain accumulated dose over several irradiation events), analysing the mpps messages sent by the modalities to the radiology information system, and implementing optical character recognition techniques on saved screen images. before issuing a formal patient dose report, the medical physicists should verify and correct all patient dose data. all these approaches allow managing more information and provide better capacity to audit the full imaging procedure and to help with the optimisation. the current level of technology allows doing so at a reasonable cost and with a great benefit for the clinical practice. automatic detection of abnormal patient doses or mistakes in the technical parameters used and their prompt correction is possible. diagnostic reference levels will be effortlessly reviewed with such systems. some examples of pitfalls and possible optimisation actions will be presented. pathology. finally, the perfect assessment of clinical course of the disease and possible outcomes, the understanding of tumor response criteria and therapyinduced changes are significant for image interpretation in patients with multisystemic malignancies. multiple myeloma is a haematologic disorder characterised by the infiltration and proliferation of monoclonal plasma cells mainly in the bone marrow. the main symptoms are hypercalcaemia, renal impairment, cytopaenia/anaemia and bone disease -summarised as crab-criteria. symptomatic multiple myeloma is consistently preceded by asymptomatic premalignant stages called monoclonal gammopathy of undetermined significance and smoldering multiple myeloma. these stages also present with detectable monoclonal protein and/or monoclonal plasma cells in bone marrow, but do not show any end organ impairment. staging of multiple myeloma is based on the measurement of the monoclonal protein in serum and urine as well as the assessment of impairment of haematopoiesis, renal function and mineralised bone. in the last decade, the development of novel therapeutic agents has led to an increase in response rates and survival time of patients with multiple myeloma, which further stresses the value of response assessment by imaging. cross-sectional imaging like mri, ct and pet-ct is currently replacing conventional radiological surveys in the initial workup and follow-up of patients with monoclonal plasma cell diseases. recent studies demonstrate the added value of mri in improving initial staging by unravelling a diffuse infiltration of bone marrow by plasma cells, a focal pattern or a combination of both. also, pet-ct can detect response to therapy earlier than conventional response criteria. furthermore, recent studies revealed that a complete remission of myeloma confirmed by mri or pet-ct goes along with a better prognosis compared to a complete response based only on serological parameters. learning objectives: . to learn about the role of clinical staging systems and imaging in work-up and classification of plasma cell disorders with a focus on multiple myeloma and to learn about parameters of disease activity. . to understand the pathophysiologic mechanisms of multiple myeloma and to learn about the effects of abnormal plasma cells on bone remodeling cells. . to become familiar with response criteria and therapy-induced changes and to compare the significance of imaging and serological markers for response evaluation in multiple myeloma. . to learn about recent studies on imaging based response assessment and prognostic significance.a- : over the last years, there have been numerous efforts to classify lymphoid malignancies, culminating in the who classification introduced in . so it is clear that malignant lymphomas require a sophisticated diagnostic approach based on clinical features, morphology, immunophenotyping and genetic analysis. it is essential that such an approach underpins the clinical management of these diseases, many of which are amenable to cure. the same situation is present in radiology staging procedures -it has a multidisciplinary approach. a wide range of staging procedures can include all radiology methods from cxr and chest and abdominopelvic computed tomograph to whole body mri, scintigraphy and pet-ct scans. lesions of the regional lymph node system. distant spread of mm is thought to transpire intra-and extravascularly (along the external vessel lattices) supported by specific mechanisms of extravasation and protection of mm cells against the local immune system. to date, many imaging methods, such as ultrasound, computed tomography (ct), magnetic resonance imaging, and positron emission tomography/ct, are used in the diagnosis of mm and its metastases, whereas lymphoscintigraphy has become an important tool for workup of the lymph node drainage patterns. radiological challenges include improved staging and re-staging of multi-systemic mm. accordingly, current imaging guidelines and the role and applications of the different imaging modalities in advanced mm (stage iii / iv) are reviewed with regard to their usefulness in patient management. however, standardised imaging protocols and integration of functional information to morphological imaging are needed in the future to allow for improved detection and guidance of treatment in patients with mm. the original atlanta classification of acute pancreatitis established in is outdated. in , an international working group has modified the atlanta classification for acute pancreatitis to update the terminology and provide new morphologic classifications.the revised classification of acute pancreatitis identified two phases of the disease: early (first week) and late (after the first week). acute pancreatitis is subdivided into two types: interstitial oedematous pancreatitis and necrotising pancreatitis. if the diagnosis of acute pancreatitis is established by abdominal pain and by increases in the serum pancreatic enzyme activities, a contrast-enhanced ct is not usually required for diagnosis in the early phase. this revised classification introduces new terminology for pancreatic fluid collections. depending on the presence or absence of necrosis, acute collections in the first weeks are called acute necrotic collections or acute peripancreatic fluid collections. once an enhancing capsule develops, persistent acute peripancreatic fluid collections are referred to as pseudocysts and acute necrotic collections, as walled-off necroses. all can be sterile or infected. this classification of acute pancreatitis allows a consistent, worldwide classification and should avoid confusion in the terminology of pancreatic fluid collections. the role of diagnostic imaging in chronic and inflammatory pancreatitis and ipmns is to detect structural changes of the ducts and of pancreatic parenchyma, assess the functional integrity of the gland, detect associated complications, and assist in management. these goals are generally fully achieved using mdct and mr imaging. in this lecture, the advantages and limitations of each technique will be discussed and illustrated. key features allowing differential diagnosis of both entities will be underlined. autoimmune pancreatitis (aip) was first described in and represents a rare form of immune mediated chronic pancreatitis which is characterised by a marked infiltration of lymphocytes and plasma cells into pancreatic tissue. whilst the majority of cases present with diffuse gland involvement, approximately % of patients demonstrate either segmental or focal involvement of the pancreas. clinical presentation is very variable with patients describing a range of symptoms; severe pain however is uncommon. imaging plays a central role in the diagnosis and management of aip and knowledge of the radiological appearances, which can vary significantly due to the various degrees of fibrosis and inflammatory infiltrate, is critical. cardinal features include focal or diffuse pancreatic enlargement with the loss of normal lobular architecture. in addition, pancreatic duct involvement as demonstrated by single or multiple focal strictures with limited more proximal dilatation is common. whilst these appearances may suggest a diagnosis of aip correlation with clinical history, serology and histopathology is mandatory to accurately diagnose atypical cases. in contrast, paraduodenal pancreatitis is a specific and rare form of segmental chronic inflammation characterised by fibrous tissue formation in the "groove" area between the duodenum, head of pancreas and lower common bile duct. the pathology was first described in and has since been subdivided into pure, segmental and non-segmental forms. whilst the radiological diagnosis of both aip and paraduodenal pancreatitis remains challenging, the presentation will emphasise relevant imaging strategies as well as provide tips and tricks for accurate diagnosis. bone scintigraphy is often used in combination with ct and clinical information for staging and therapy response evaluation of bone metastases. magnetic resonance (mr) imaging is a technique that is known to be valuable both for detection of bone metastases and for evaluation of their response to treatment. integrated positron emission tomography with computed tomography (pet/ct) combines the functional data from pet with anatomic information of ct in a single examination. f-fluoride is a non-specific pet tracer that has recently shown very high sensitivity for bone metastases. for accurate response evaluation, it is important to recognise not only changes in bone metastases, but also the effects of treatment on unaffected, normal parts of the bone marrow. these latter therapy-related benign changes could otherwise be misinterpreted as disseminated disease or vice versa. despite the fact that the methods mentioned above, alone or in combination, have improved the assessment of bone metastases, they often remain non-specific. a specific diagnosis can in many cases only be achieved with a bone biopsy. this refresher course will give you an overview of the present imaging methods for detection and characterisation of bone lesions. indications for, and how to perform, ablation and cementoplasty of bone metastases will be presented. optimal algorithms for treatment follow-up of bone metastases and advantages and disadvantages with different imaging methods will be reviewed. also, future development of diagnostic and therapeutic methods will be included in the presentations, e.g. potential role of emerging pet imaging probes for assessing bone malignancies. author disclosure: h. ahlström: research/grant support; astrazeneca. a. diagnostic approach: the role of hybrid imaging k. herrmann; würzburg/ this presentation will include a short review of the epidemiology of primary and metastatic bone disease, its classification and staging definitions. then we discuss the role of radionuclide imaging in initial and subsequent treatment strategy considerations. another aim is to provide guidelines for the appropriate use and applications of diagnostic radionuclide approaches for the assessment of bone diseases. the focus of this presentation will be on the role of radionuclide imaging in metastatic prostate, breast and lung cancer in the context of other available diagnostic imaging approaches. the ability of hybrid imaging technologies to achieve improved diagnostic accuracy will be emphasised and when appropriate the potential role of emerging pet imaging probes for assessing bone malignancies discussed. if feasible, the availability and effectiveness of radionuclide-based therapeutic approaches for malignant bone diseases will be reviewed. skeletal metastases are associated with significant morbidity and have high impact on health costs. effective palliative treatments are available, but less than % of patients respond in terms of tumour markers, pain or quality of life and all treatments are associated with some toxicity. it is generally accepted that the current imaging techniques are inadequate for measuring treatment response in a clinically relevant time frame such that skeletal metastases are usually considered as non-measurable disease in clinical routine and trials. there is therefore a need for non-invasive, objective methods to evaluate treatment response of skeletal metastases at earlier time points to guide clinical care. in addition to imaging structural changes in bone (e.g. x-ray, ct), it is now possible to image a number of biological characteristics of bone metastases including tumour metabolism, tumour cellularity, and osteoblast and osteoclast activity. methods currently available, or being actively investigated, include m tc-mdp spect/ct, f-fluoride pet/ct, f-fdg pet/ct, c/ f-choline pet/ct, rgd-spect/pet and dw-mri. some of the tracer methodologies will potentially be applicable for and complementary to pet/mri. the timing of follow-up imaging after commencing treatment is still under investigation. it is likely that tumour-specific methodologies may reflect response/non-response earlier than bone-specific methods due to a prolonged flare in reactive bone in responding metastatic sites. learning objectives: . to understand the techniques and quantitative parameters used for treatment response evaluation. . to learn the optimal timing for follow-up imaging after treatment. . to become familiar with common pitfalls in the interpretation of posttreatment mri and pet. panel discussion: how to differentiate between bone metastases and chronic inflammatory or treatment-induced changes : structured reporting is an opportunity and a challenge at the same time. expert speakers of this session will present and discuss their views on the subject, contributing to the clear vision of the members of audience on this complicated subject, convincing us to take this technique as an opportunity to improve and standardise the quality of our reporting activities. even though structured reporting (sr) has been appreciated as one of the effective methods of electronic reporting, there are not that many real applications to facilitate utilisation of this technique in practice. why it is so?the radiologists want a flexible tool to create clear, concise reports in a reasonably short time. like all template-based reporting systems, the application must be tailored to preferences of multiple users in a radiology department. the report templates should also be flexible in terms of length to avoid inappropriately detailed reports. the final appearance of the report is critical for acceptance by clinicians. accordingly, the technical challenges of development of sr systems may be grouped as: "user interface", "database structure", and "output file/document" problems. flexibility to comply with different user preferences will lead to both user interface design and database structure challenges. one of the major technical challenges is the transformation of structured data to a final text to be acceptable and applicable for the referring physician. also, exporting of reports to dicom format using dicom-sr concepts is still a challenge. multi-media formats are becoming more and more popular specially in sr reports. effective communication of radiology results is critical to high-quality health care. to that end, the radiological society of north america (rsna) has developed a library with more than best-practice radiology reporting templates. the templates are freely available online (www.radreport.org) and have been accessed more than , times. the new ihe "management of radiology reporting templates" (mrrt) profile builds upon the web's hypertext markup language version (html ) to provide an international standard for describing and exchanging reporting templates. this presentation will describe the rsna report template library, introduce the international mrrt standard for report templates, and describe opportunities for esr members and affiliated societies to participate. the broad goals of this initiative are to improve the quality of radiology reports, increase the productivity of radiologists, promote the use of practice guidelines, and advance data-driven health care.learning objectives: . to explore a library of 'best practices' radiology reporting templates. . to become familiar with international standards for radiology reporting templates. . to understand how structured reporting will promote the use of practice guidelines and will advance data-driven health-care. structured reporting in europe: the esr initiative o. ratib; geneva/chthe rsna has initiated a new initiative called radreport with the aim of helping promote standard reporting and improve reporting practices by creating a library of clear and consistent report templates (http://reportingwiki.rsna.org/). this project also supported in part by the national institute of biomedical imaging and bioengineering (nibib) has already gained the participation of numerous countries around the world, contributing with reports in different languages. these report templates are "structured" in the sense that they incorporate reusable knowledge, or meaning, to the clinical reporting process. structured interpretation and reporting for detecting significant prostate cancer is crucial, as it allows comparing inter-observer interpretation variability, reduces this variability by stimulating discussion of the individual scores, enhances communication with the clinicians in a uniform way, facilitates quality assurance plus research, and in this way improves patient outcome. in this presentation, the pi-rads scoring system will be shown and discussed, and fast effective structured reporting using computer software will be presented. in a rapidly ageing society, dementia prevalences are sharply increasing. furthermore, knowledge about disease mechanisms is constantly evolving. a more nosologic approach in the workup of dementia is required to improve prognostication, patient management as well as select appropriate treatment. a. anatomy of the limbic system t.a. yousry; london/uk (t.yousry@ucl.ac.uk)the term "limbic" has been used in many different connotations. to understand the anatomy, we have to define the term first. the clearest definition stems from broca: "le grand lobe limbic". defined as such, the limbic lobe is composed of main structures: the limbic and the intralimbic gyri. . the limbic gyrus is composed of the subcallosoal gyrus anteriorly, followed in an arc by the cingulate gyrus, isthmus and parahippocampal gyrus. the latter is composed of parts: i) a posterior narrow segment, the superior surface of which is called subiculum, and ii) a more voluminous anterior segment, also known as the piriform lobe. the latter consists of the anterior part of the uncus and the entorhinal area. . the intralimbic gyrus arches within the limbic gyrus. it is divided into parts: i) anterior (prehippocampal rudiment); ii) superior (indusium griseum); and iii) inferior (hippocampus). the latter consists of lamina rolled inside each other: the cornu ammonis and the dentate gyrus, with the cornu ammonis consisting of neuronal fields (ca - ). to understand the function, we have to understand the connections that define this function. the interplay with the insula is of particular importance. in summary, we will review the mri characteristics of the components of the limbic lobe, their connections, and their function, using . t, t and . t high field imaging. at the end of this lecture, you will know definition (s) of the limbic lobe, its major subdivisions, connections and functions. structural neuroimaging is increasingly used in the diagnosis of neurodegenerative diseases. in a memory clinic setting, computed tomography (ct) and magnetic resonance imaging (mri) have become the most important paraclinical diagnostic tools. recent guidelines on the diagnosis and management of disorders associated with dementia state that neuroimaging should be performed at least once during the diagnostic workup. in the past, neuroimaging had been performed to exclude potentially treatable causes of dementia. however, this exclusionary approach of neuroimaging in the diagnosis of dementia has been replaced by an inclusionary approach driven by conclusive evidence that ct and mri can substantially support the clinical diagnosis by the demonstration of a distinct atrophy pattern and the assessment of vascular (co)morbidity. for these purposes, the use of visual rating scales allows a fast and reproducible assessment of global/regional cortical atrophy and vascular white matter pathology. more recently, new imaging markers such as cerebral microbleeds and superficial siderosis haven been identified and linked to alzheimer pathology. in addition, next to structural mri, advanced and quantitative mri methods have been introduced in the clinical setting. mri perfusion techniques such as arterial spin labelling (asl) demonstrated a diagnostic value in memory clinic patients, particularly in those showing no or inconclusive pathology on structural mri. de (horst.urbach@uniklinik-freiburg.de) cognitive decline is a clinical symptom in many neurodegenerative disorders. mri is typically performed in the initial diagnostic workup of these patients. as a structural imaging modality, mri is often unrevealing while several molecular imaging modalities show disease-associated alterations: f-fdg-pet shows reduced glucose metabolism in neocortical association cortices, mainly in the posterior cingulate, precuneus and temporoparietal regions. since glucose metabolism is normally higher in the posterior cingulate and precuneus, reduced glucose metabolism must be specifically sought for or highlighted by voxel-based analysis. dynamic imaging of swallowing from the mouth to the duodenum is the only clinical test providing a fast and accurate diagnostic overview of the upper gi function. swallowing disorders are divided into those with dysphagia that means problems during eating or drinking, with suspicion of aspiration as an important subgroup and those with sensations like the globus syndrome or noncardiac retrosternal pain. oropharyngeal dysphagia in patients with neuromuscular diseases or postoperative conditions can be evaluated precisely and within the same session as oesophageal motility disorders, stenoses or postoperative problems are detected and in a complementary fashion to endoscopy, ph monitoring and manometry. the exclusive ability of dynamic imaging of swallowing is to diagnose combined disorders of the pharynx and the oesophagus, to detect and localise subtle and multiple benign stenoses of the upper gi tract and to combine visualisation of pathophysiology and bolus transport as well. radiologic evaluation concentrates on functional units, which represent the visible "moving areas" of deglutition, where evident pathologic conditions can be found: ) oral cavity and tongue, ) soft palate, ) epiglottis, ) hyoid and larynx, ) pharyngeal constrictors, ) pharyngoesophageal segment, ) oesophagus and stomach. this lecture intends to explain the common causes of dysphagia, the approach to a tailored examination and the use of an advanced imaging technique. further, the basics of taking the swallowing history and the structure of reporting swallowing disorders along the seven functional units will be provided. hoarseness is defined as a rough or noisy quality of voice. the possible causes of hoarseness are manifold, ranging from benign diseases such as the common cold to malignant tumours. therefore, hoarseness as a symptom should always be taken seriously. evaluation of a patient with hoarseness by a head and neck specialist will always starts with a history and a physical examination including laryngoscopy. after these examinations, a diagnosis can be established in most patients without additional imaging. the aetiologies of hoarseness are: ) inflammation/infection, ) trauma, ) neoplasms, ) others (including medical conditions, e.g. hypothyroidism) and ) vocal cord paralysis. this presentation will focus on imaging of vocal cord paralysis. vocal cord paralysis should not be considered a diagnosis, but as a symptom of (possible) underlying disease. when vocal cord palsy is discovered, this is frequently a reason to perform cross-sectional imaging. the radiological workup needs to include the full course of the vagus nerve. moreover, reporting radiologists need to be able to recognise the radiological signs of vocal cord palsy in the absence of hoarseness, since many patients with cord palsy are asymptomatic (up to %). the anatomy of the vagus nerve and its laryngeal branches that innervate the intrinsic muscles of the larynx will be discussed. then the (expected) course of the vagus nerve and recurrent laryngeal nerve will be shown. finally, radiological signs of vocal cord palsy will be discussed using examples from daily practice. in contemporary medicine, endovascular techniques often replace conventional methods of treatment, including surgery, in the management of an increasing range of diseases. this requires development of specific methods assessing the effectiveness of treatment and able to detect complications that may be much different from those occurring in conventional therapy. this is first of all seen in the endovascular treatment of patients suffering from vascular lesions and neoplastic diseases. commonly, there is a high initial technical success of endovascular treatment, but the durability is not always satisfactory and needs to be further examined. endovascular treatment is bound to the risk of specific complications, often without clinical symptoms. therefore, there is a need to use imaging follow-up of these patients.interventional radiologists are aware of the importance of those issues and should play an important role in developing and deciding about the follow-up scheme and choice of the best imaging methods for these patients. besides indepth knowledge of the treatment, radiologists are also familiar with the possible complications and can offer an optimal, minimally invasive and cost effective diagnosis and treatment. the potential imaging methods for follow-up after angioplasty (pta) and/or stenting include doppler ultrasound, cta and mra. although excellent images can be obtained by cta and mra, the drawbacks of these studies for routine follow-up are obvious. (access to ct and mr equipment, cost, contrast medium, ionising radiation, etc). in the uk, the most common imaging method is duplex ultrasound. there is no established role for the use of ultrasound contrast agents. ultrasound is freely available in the majority of centres, is inexpensive and complication free. follow-up by ultrasound may be undertaken by radiologists, although more usually by technologists in vascular laboratories. in practice, few patients are followed up by any imaging study at all unless they develop symptoms. the main category of patients who undergo some form of imaging follow-up after pta/stenting are patients with surgical bypass grafts, who are usually routinely followed up whether they have undergone angioplasty/stenting or not. in view of the fact that this is a lecture on follow-up after intervention, procedural complications are excluded from the discussion. the complications of angioplasty and stenting are similar. the main early complications are restenosis or reocclusion. other early complications are related to the arterial puncture site and include haematoma, dissection, occlusion and pseudoaneurysms. the main late complications are restenosis and reocclusion. treatment of restenosis and reocclusion usually involves additional angioplasty or stents using conventional or drug-eluting balloons or stents. cutting balloons, atherectomy and cryotherapy have a controversial role based on limited evidence. imaging follow-up of oncologic patients after embolisation procedures j.i. bilbao; pamplona/es (jibilbao@unav.es)the term "embolisation" groups different procedures in which imaging guidance is fundamental for both performing the procedure and for the early detection of complications. it has been demonstrated by several studies that "tumoural response" is tightly associated with survival, thus it is of major interest to measure accurately how the tumour is modified by the treatment. the "world health organisation" -who -first published the objective criteria for the evaluation of response. these criteria were slightly modified in and named as "response evaluation criteria for solid tumors"-recist. accordingly, "complete response" (cr) corresponds to the disappearance of the tumour, "partial response" (pr) is defined when there is a decrease in the tumour size equal to or higher than % and "progressive disease" (pd) is applied when there is an increase equal to or higher than %. "stabilisation of the disease" (sd) corresponds to measurements in between > % (pr) and < % (pd). tumours (until five nodules in the same viscera), no matter if necrotic or viable, were evaluated with one measure (its largest diameter). a new version (" . recist) has introduced modifications, among which is the number of nodules ( instead of ) that needs to be evaluated. in some circumstances, when morphologic criteria (recist and who) fail to predict the outcome, then new functional criteria have been recently established. "mrecist" (which only measures the tumour that uptakes contrast) is an accurate classification for hcc. new methods "beyond recist" have been established for some specific treatments such as targeted therapies. in this session, the audience will have a comprehensive overview of the elastography, its principles and current state-of-the-art clinical applications. the session will deliver an overview of currently available methods of both ultrasound elastography (use) and magnetic resonance elastography (mre), their physical principles, technical and equipment requirements as well as the influence of various factors for obtained results. following this session, the audience will have insight into clinical applications of elastography in liver, prostate and brain diagnostics. the strengths and weaknesses of elastographic modalities will be compared and discussed under consideration of more established imaging modalities. the session will present potential developments of use and mre and possible future clinical applications. panel discussion will aim at defining the place of elastography in current and future diagnostic algorithms. the well-known sensitivity of the palpating hand for detecting lesions is related to the incredibly wide range of values of the shear modulus in the body, spanning over eight orders of magnitude. elastography was invented to exploit this high variability of constants by introducing the shear modulus into the image contrast of medical ultrasound or magnetic resonance imaging. today, both ultrasound elastography (use) and magnetic resonance elastography (mre) are in clinical use, predominantly for staging liver fibrosis or discriminating tumours in the breast, liver, and prostate. the talk reviews the physical principles, technical requirements and current methods of both use and mre. furthermore, the strengths and weaknesses of elastographic modalities are compared and discussed under consideration of more established imaging modalities. an outlook of elastography is given, highlighting the real-time feasibility of use and the sensitivity of mre to tissue pressure. suspicion of prostate cancer (pca) exists in the case of elevated psa serum values and/or suspicious findings on digital rectal examination (dre). systematic biopsy (sb) will be done to confirm or rule out pca. unfortunately, an elevation of psa serum values often is caused by benign changes, e.g. prostatitis or adenomyomatosis and not every cancer is palpable on dre. furthermore, sb may miss clinically significant disease in up to %. therefore, a more targeted approach would be desirable and imaging of pca is currently under strong effort. one possibility for visualisation of pca is the representation of tissue elasticity. usually, cancers have higher cell and vessel density than the normal surrounding tissue and therefore are associated with increased stiffness. in contrast to dre, where only the posterior parts of the prostate can be reached, rte does not have this problem, since all anatomical regions can be evaluated. furthermore, this noninvasive technique is time-and cost-effective and targeted biopsy or focal therapy of the prostate can be done under real-time conditions. another important issue is that rte can be performed by both urologists and radiologists. nevertheless, rte is of limited value in the detection of small cancer lesions and there may be problems in visualising pca with predominantly gleason pattern . the lack of data about inter-and intraobserver variability and of multicentre studies (now in process) are probably the reasons why rte has not been included in the guidelines of urological societies so far. cerebral tissue structure is altered in many neurodegenerative diseases, but also during physiological processes like maturation or ageing. structural changes directly affect the mechanical tissue properties. magnetic resonance elastography (mre) is an imaging technique capable of assessing biomechanical brain parenchymal properties non-invasively. viscoelasticity can be quantified by analysing the propagation of mechanically elicited shear waves in the investigated tissue. thus, mre could be a helpful tool to detect physiological or pathological processes influencing the cerebral tissue integrity. learning objectives: . to appreciate the advantages and limitations of a virtual palpation of the brain. . to become familiar with mechanical wave induction and detection in cerebral measurements. . to learn about current and potential clinical applications. . to learn about the relationship between microscopic and macroscopic, as well as focal and globally diffuse biomechanical brain parenchymal alterations. are based on the generation of shear waves inside the liver tissue with specific mr liver drivers and ultrasound probes. subsequently, phase images revealing the displacement of the waves will be investigated for healthy and pathological (alcoholic fibrosis) livers. moreover, the development of phantoms mimicking the stiffness of biological soft tissues (liver, muscle, …) will be also presented. the viscoelastic (elasticity and viscosity) properties of healthy and fibrotic livers were measured, and the relevance of these parameters, used as a liver diagnostic marker, was analysed. in parallel, an increase of the wavelength as a function of the stiffness was obtained for the developed set of phantoms. the characterisation of the elastic properties is an excellent marker to differentiate minor and major fibrosis. a summary of the advantages and disadvantages of us and mr elastography techniques will be presented. a- : the breast lesion excision system (bles) has evolved as a breast radiological technology over the last decade and is now in widespread use in europe and across the world. it was designed as a large biopsy device, but more recently due to its unique capability to obtain a single large breast tissue specimen in only a few seconds by utilising a radiofrequency cutting and cauterising wave, it has increasingly been explored in the therapeutic setting. it is easy to use under ultrasound or mammographic guidance with procedures taking a similar length of time to that of a vacuum biopsy, and with patient preparation and anaesthetic essentially identical. the technical aspects of performing these procedures will be detailed as well as its use specifically to perform excisional biopsies. this is limited by patient and lesional factors, all of which will be discussed in more detail. following a bles, the post-procedure appearances need to be considered so that follow-up imaging can be interpreted accurately. the risks and complications of this procedure are outlined as well as a discussion made of the latest papers in this field that may suggest future applications and developments. learning objectives: . to understand the mechanism of the bles technique. . to become familiar with the post-bles aspects of various types of imaging. during the past few years, it has been shown that there is not a single disease entity called "breast cancer". there are different subtypes that entail diverse recurrence risks. this is the first issue to take into account, and patients will be stratified accordingly before any follow-up is planned. imaging findings in a patient treated for breast cancer will depend on the type of treatment: breast conserving therapy (bct), mastectomy (and all the reconstructive techniques), radiotherapy and minimally invasive techniques. to differentiate between fat necrosis and other common post-treatment changes from relapse, it is important to know the timeline when all these changes take place and also schedule the follow-up imaging procedures accordingly. other important issues to take into account are the limitations and indications of the different modalities (mammography, ultrasound and mri). although ultrasound and mammography have traditionally been used in the follow-up of these patients, mri is being used more and more often due to its superior multiplanar capabilities and the functional information not supplied by the other techniques. blood clot formation in the veins is referred to as venous thrombosis (vt). vt is most common in the deep veins of the legs and pelvis. if the thrombus dislocates to the pulmonary arteries this is referred to as pulmonary embolism (pe). the combination of deep vein thrombosis (dvt) and pe is referred to as venous thromboembolism (vte). the diagnosis of dvt and vte is essential, as vte is potentially fatal. furthermore, undiagnosed, non-fatal dvt may result in negative long-term pathologies (e.g. post-thrombotic syndrome). major risk factors for the development of vte are thrombophilia, history of dvt, age > , surgery, obesity, long travel, cancer, immobility and pregnancy. in addition, underlying congenital abnormalities or compression syndromes (may-thurner syndrome) are also important to diagnose. diagnosis of vte is not always easy. primary diagnosis includes clinical (wells score) and lab testing (d-dimer). first line imaging testing is done by leg ultrasound (us). if pe is suspected ct is indicated immediately. ct of the pulmonary arteries (ctpa) may be combined with indirect ct venography (ctv). the question of when to combine ctpa and ctv still remains. a favourable approach is to add ctv in a negative ctpa. recently mr venography (mrv) is emerging as comprehensive imaging tool especially in patients with chronic dvt to assess the extent and underlying causes. in this respect imaging without radiation dose with high spatial delineation of vascular abnormalities facilitates intervention for thrombolysis or interventional therapy including recanalisation and stenting. alternatively, intravenous unfractionated heparin is used in situations when a quick reversal is necessary. b) non-medication: early mobilisation has been widely adopted to activate the muscle pump. if early mobilisation is not possible, compression stockings and/or pneumatic compression boots are applied to better empty the veins. . treatment: a) anticoagulation: the main goal of anticoagulation is to prevent progression and recurrence of dvt. typically, anticoagulation is started with lmh, followed by vitamin k antagonists (coumadin). the first dvt is generally treated for - months; recurrent dvt for months. b) compression therapy: compression stockings ameliorate pain and leg swelling of acute dvt. in addition, the development of a post-thrombotic syndrome (pts) should be reduced. c) thrombolysis: the main goal of thrombus removal is prevention of pts. in addition, thrombolysis is used for severe ilio-femoral dvt, especially with phlegmasia coerulea dolens. there are different ways of thrombolysis: systemic thrombolysis was abandoned because of high bleeding complications. catheter-based thrombolysis has shown to reduce the bleeding risk, but it is quite time and resource consuming. the latest development is pharmaco-mechanical catheter thrombus removal which combines thrombolytic drugs with a mechanical maceration. recent studies (cavent,torpedo) have shown a reduction of pts compared to anticoagulation. the use of inferior vena cava filters (ivcfs) is a controversial method for the prevention of pulmonary emboli. there are large variations in their usage; often with ten to one hundredfold differences in placement between different countries. ideally, ivcf usage is based on sensible protocols derived from clinical experience and trials. in practice, this is less frequently the case. indications, contraindications and questionable indications (mainly during venous thrombolysis) will be discussed. familiarity with ultrasound guidance will be stressed. the key technical steps in the insertion and removal of ivcfs will be discussed. the question that this refresher course is aimed to answer is whether novel it tools may actually help in improving quality and workflow efficiency in daily radiological practice. in fact, since the early installations of pacs, it tools have often been considered as mere productivity tools rather than enabling technologies for fostering quality in medical care. the three distinguished lecturers in this course will address the following topics: improving quality and efficiency of computerised order entry through decision support, improving quality and efficiency of reporting through structure and templates, and improving quality and efficiency of dose management through exchange between modalities and registries. they will cover all aspects of the radiological workflow: from the selection of the most appropriate diagnostic procedure, to the efficient reporting of diagnostic and non-diagnostic data (such as radiation dose information and contrast media information). they will demonstrate how newly adapted it tools may provide assistance throughout the radiological workflow, with potentially enormous gains in terms of patients' safety and total quality management. session objectives: . to appreciate the need for it tools to ensure quality control. . to understand how to collect data concerning radiation dose. a. improving the quality and efficiency of computerised order entry through decision support p. mildenberger; mainz/ de (peter.mildenberger@unimedizin-mainz.de) electronic communication of requests for radiological procedures is a logical and relevant extension to integrated information systems in health care. this communication of orders and the entry (oe) into ris improve the workflows. but, quality improvements require additional efforts to link order-entry-solutions with health knowledge for ordering the appropriate imaging procedure. these clinical decision support (cds) tools should be based on generally accepted and implemented criteria, e.g. evidence-based medicine. it is known that the acceptance of such systems, if successful and efficient implementations are given, is very good. it concepts for cds are well known and standards for classifications are available, but semantic interoperability is still a developing area. actually, clinical information systems provide different levels of integration of oe and cds. further developments could be an implementation of interoperability profiles and the representation of cds knowledge in webbased services of non-commercial organisations. b. improving quality and efficiency of reporting through structure and templates e. neri; pisa/it (emanueleneri @gmail.com)the report represents the final stage of the diagnostic imaging process, for which the radiologist is responsible. this process is driven by an accurate selection of the diagnostic tests, based on the clinical question. therefore, the report should be an expression of this path, depending on the question asked by the clinician. the structure of a radiology report for the same clinical problem and the same method of investigation varies from country to country and between different radiologists. this diversity can be a problem in the global world where a patient can have imaging tests from different places with different reporting languages, or when patient data is transmitted and shared between different centres. there is, therefore, the need to standardise the report as much as possible; finalising its structure and contents to a specific clinical problem, and possibly using a standard terminology. an attempt to solve this problem is in progress with the joint initiative on structured report esr-rsna (http://www.rsna.org/reporting_initiative.aspx), aimed at improving reporting practises by creating a library of clear and consistent report templates. the main expected benefits of structured reporting templates are report uniformity and improvement of communication between referring physicians. literature evidences that structured reporting can also quicken report turnaround, and reduce costs and lexical errors; thereby improving the quality and safety of radiological practise. the european directive on medical exposures requires the assessment and evaluation of patient doses, especially in procedures involving high doses to the patient. in the current draft of the new directive on basic safety standards, some requirements on patient dosimetry in diagnostic and interventional radiology have been reinforced: x-ray systems should provide dosimetric information with the capability of being transferred to the examination report (for all ct and interventional systems). diagnostic reference levels (drls) shall be reviewed regularly. these requirements will push the industry and the users to develop better strategies to evaluate patient doses, transfer these values to patient reports (contributing to the patient exposure tracking system) and also use available software to process these dosimetric data and perform some automatic analysis. this analysis should: a) include periodic calibration factors for patient dose quantities, b) include automatic detection of high dose values (especially relevant for interventional procedures), c) include statistical analysis to update drls and compare with the existing ones and d) suggest corrective actions to fulfil the quality assurance programmes and the clinical audit requirements. dicom radiation dose structured reports represent a significant advantage, but more efforts will be necessary for the automatic process of the relevant data contained in the report to verify that the radiological risk is acceptable and to suggest, if appropriate, corrective actions to improve clinical practice. without these last steps, patient dosimetry efforts and european regulations for radiation safety could only have a moderate impact. gastrointestinal tumors include a variety of lesions, with the most frequent being adenocarcinoma of the small and large intestine, small bowel lymphoma, neuroendocrine tumours (nets) and gastrointestinal stromal tumours (gists). according to histology, location and initial imaging staging, those lesions may require completely different therapies: surgery alone, adjuvant chemotherapy (cht), neoadjuvant cht followed by surgery or a combination of neoadjuvant chemoradiotherapy (crt) followed by surgery. after treatment, imaging follow-up is mandatory. the most common post-operative findings after small bowel or colonic resections will be presented, together with clues for early detection of recurrence. in those cases which underwent adjuvant cht, imaging findings and diagnostic criteria related to the use of either cytotoxic or cytostatic drugs will be shown, to facilitate the interpretation of radiologists in assessing response to therapy. finally, tissue changes following neoadjuvant crt will be discussed, particularly in rectal cancer. the possibilities of different imaging modalities in assessing either complete or partial response to therapy will be presented, with a critical analysis of different imaging findings. unlike infectious enteritis, in patients with crohn's disease (cd) the changes in clinical activity have poor correlation with changes in inflammatory lesions after medical treatment. mucosal healing (mh) and improvement in patient's symptomatology are usually considered the main objectives of medical treatment. however, improvement in clinical symptoms is not always associated with mucosal healing and the persistence of severe inflammatory lesions augurs a more aggressive disease course in terms of flare-ups, hospitalisation requirements and the need for surgery. endoscopy is the gold standard for the assessment of luminal lesions in cd, but given the good correlation shown between endoscopy and cross-sectional imaging in assessing the activity and severity, imaging is increasingly introduced as a tool to monitor medical treatment. there is some evidence indicating that crosssectional imaging can be considered a responsive and reliable tool as it detects meaningful changes in patients' status over time after therapeutic interventions. besides this, cross-sectional imaging is capable of monitoring the colon and the small bowel and penetrating lesions that cannot always be assessed by endoscopy. becoming familiar with the radiological changes during and after treatment will be key in the decision-making process. degeneration is routinely defined as a morbid change of cells, tissues and even organs. in the msk system degeneration occurs in bones, joints (synarthrosis and diarthrosis), muscles and tendons. primary degeneration implies ageing as well as overuse, based on mircrotrauma. the latter may be related to constitutional, professional or sports-related factors. a distinction between ageing and overuse is not possible with the use of histology and imaging. only the intensity of the changes, which may be inadequate in relation to the age of the patient, may give a hint. on the contrary, the term "secondary degeneration" should be used for clearly defined events or diseases, which finally will result in the degeneration of tissues. the causes are inflammation (ra, infection), metabolic disease (e.g. cppd) or trauma. other ways to classify degeneration of the msk system are related to the anatomy. accordingly, degeneration of the particular parts of the peripheral or axial skeleton, muscles and tendons has to be discussed. one has to have in mind that bones, cartilage, muscles and tendons form a complex unit. the single elements of these complex units jointly undergo degenerative deterioration, e.g. bone, cartilage, fibrocartilage and capsule are jointly involved in case of oa of the knee joint. the same holds true for the synchondroses of the spine. at the rotator cuff not only the tendons, but also the underlying bone and the muscle tissue are changed. (o.m.vandelden@amc.uva.nl) there are many different types of embolisation, but all share many basic principles. the specific approach, technique, materials and equipment used may differ depending upon many variables such as the type of vascular territory involved (venous, arterial, small vessels, large vessels), clinical setting (elective or emergent procedure), and type of underlying disease to be treated (e.g. tumor embolisation, acute haemorrhage, vascular malformation, arteriovenous fistula, etc). pre-procedural imaging and planning are essential for most embolisation procedures and intra-procedural navigation can be done with fluoroscopy, dsa, and new d-techniques. with proper imaging workup prior to embolisation procedure time, radiation dose and contrast load can be significantly reduced. embolisation materials can be roughly divided into liquid agents (alcohol, glue, polymers), particulate agents (pva, calibrate microspheres, drug-eluting beads) and coils (detachable, non-detachable) and plugs (amplatzer®-plugs). plugs and coils are deployed at the exact site of destination and usually easy and safe to use. particles and liquid agents reach their site of destination by flow guidance and can be more difficult and unpredictable in their use. complications include puncture-site complications (thrombosis, dissection, haematoma), systemic complications (contrastinduced nephropathy, allergic reactions) and specific embolisation-related complications (non-target organ embolisation, end-organ ischaemia, postembolisation syndrome). when used with expertise and proper experience, most types of embolisation have good results with acceptable complication rates. although there has been advancement in imaging techniques, several pitfalls in the assessment of diseases of the pancreas, small bowel and rectum remain. the differentiation and the correct characterisation of tumours and inflammatory disease in some cases may be difficult. also, atypical presentation of common tumours or uncommon tumours persists and is a challenge. problematic situations are constantly represented as intestinal bleeding and unexpected findings. in this session, we point out the procedure of the best imaging modality and protocols of challenging cases. a. pancreas c. triantopoulou; athens/gr (ctriantopoulou@gmail.com)pancreatic imaging and interpretation of focal lesions remains a challenging issue. despite the advances in imaging techniques and the dedicated protocols that are now in use, a possibility for pitfalls remains. these pitfalls are related either to the inability of the early recognition of a lesion, or to the wrong characterisation of a "mass". both pitfalls are of great importance, taking into account the lethal pancreatic cancer and the possible complications that may follow an unnecessary pancreatic surgery. there are many variants of the pancreatic parenchyma, the ducts or even vessels, and deep knowledge of the pancreatic anatomy and embryology is needed, to be able to recognise these variations in imaging. a pancreatic variant may not only be misinterpreted as a severe pancreatic disease (e.g. ectopic spleen vs neuroendocrine tumour), but may also be the underlying cause of pancreatic inflammatory lesions (e.g. ectopic pancreas on the duodenal wall causing groove pancreatitis). other pitfalls are related to the atypical presentation of a common lesion (e.g. isoattenuating pancreatic adenocarcinoma), the presence of uncommon tumours, diffuse or multifocal diseases, the co-existence of two different entities and the heterogeneous or overlapping appearance of cystic lesions. in any challenging case, a focused methodology should be applied and the diagnostic procedure based on predefined imaging parameters, taking also into consideration the clinical and laboratory findings. excluding pancreatic cancer should be the first goal and every attempt should be made to differentiate between surgical and non-surgical cases. endoscopy is the gold standard in small bowel diseases, but it is a challenging technique: the pillcam is a commonly used tool and multidetector ct is a diffuse investigation technique. ct enteroclysis/enterography is a worldwide tool in intestinal exploration. throughout the investigation of the small bowel, morphologic anomalies or embryonal development defects may be present (meckel's diverticulum, duplications of intestinal tracts). artefacts may be determined and there may be misunderstanding. mdct is the first tool in emergency diagnosis; imaging pitfalls are possible. unsuspected diseases may be revealed: we will see a case of gist in a patient affected by intestinal bleeding of an obscure origin. ct enteroclysis may find unknown or unsuspected diseases: correct technical parameters have to be respected, as artefacts may be derived from an improper acquisition technique, such as a limited distension or poor intravenous enhancement. in follow-up, mr is preferred to investigate the intestine, mainly in the young population. unexpected findings may be due to rare pathology: we met a case of endometriosis, with ambiguous presentations; patients affected by autoimmune pathologies (pyoderma gangrenosum or lupus erythematosus), with unknown inflammatory intestinal chronic diseases. in oncology, pet-ct imaging is the main diagnostic tool, but there are abdominal pitfalls that limit its effectiveness (intestinal hot spots, artefacts from peristalsis): the small bowel may frequently obstruct an easy diagnosis. in case of emergency, if the radiological diagnosis is not clear, the surgeon determines the management of the patient. in case of a defective study technique, a correct examination may be repeated. endoscopy or pillcam may help to detect mucosal lesions invisible at ct. mri plays a key role in the assessment of disease of the rectum and in particular for the staging (and restaging) of rectal cancer. in this session, the relevant mr anatomy of the rectum will be discussed. furthermore, the strengths and weaknesses of mri in the assessment of rectal cancer during primary staging and restaging after chemoradiotherapy will be highlighted using various rectal cancer cases. finally, we will discuss some rare tumours of the rectum (including gist and carcinoid). optimisation of ct and mr techniques has provided new challenges for imaging in the assessment of airway and lung diseases. phenotypic abnormalities which can be recognised on visual and quantitative evaluation of ct images in copd patients may improve the diagnostic accuracy, help optimise treatment and provide a framework for clinical trials. although expiratory ct helps assess air trapping due to small airway obstruction and excessive dynamic collapse of large airways, potential tricks in technique and interpretation of ct images must be known. owing to multiple and successive improvements over years, functional and morphologic evaluation of the lung using mri has become reality for clinical practice. already regarded as a favoured cross-sectional imaging in paediatric chest radiology, mri of the lung is gaining new indications also in lung diseases occurring in adults. the potential for high-resolution computed tomography (hrct) to uncover several morphological subtypes that come under the umbrella term chronic obstructive pulmonary disease (copd) is now more familiar to both radiologists and specialist respiratory physicians. a complete approach to the classification of copd would ideally assimilate several parameters through a combined visual-quantitative hrct analysis. the insight that some subjects given the label of copd have "pure" airways diseases or emphysema can be readily provided by a simple visual evaluation. the subtypes -centrilobular, panlobular, and paraseptal emphysema -can be reliably distinguished on hrct images. the visual assessment of bronchial abnormalities and accompanying smoking-related interstitial lung disease may also complete the phenotypic classification of copd. furthermore, it is now possible to objectively quantify the global extent of emphysema, gas-trapping, and bronchial metrics by two types of softwares which are now increasingly available on latest ct workstations. learning objectives: . to learn about the classification of copd. . to appreciate the role of hrct in the classification of copd. a- : this presentation will examine the role of expiratory ct in the diagnosis of small and large airways diseases. small airways disease or air trapping may be a feature of asthma, copd and hypersensitivity pneumonitis, and is typically characterised by a mosaic attenuation pattern on ct. tracheobronchomalacia and excessive dynamic airway collapse (edac) are large airways conditions that may be recognised by tracheal narrowing on inspiratory and/or expiratory ct. the typical clinical and ct manifestations of these diseases will be reviewed. additionally, a number of important caveats with regard to ct in small and large airways disease will be discussed: ) the comparative strengths and limitations of ct, bronchoscopy and lung function testing in making the diagnosis; ) the overlap in appearances that exists between diseased and healthy individuals; ) the variability in definitions of conditions such as tracheobronchomalacia. the optimal ct technique for imaging of airways disease, including the role of dynamic expiratory ct, will also be reviewed. for routine clinical applications, a standardised mri protocol has been widely implemented. it addresses the major challenges of mri of the lung, i.e. low proton density, susceptibility artefacts as well as respiratory and cardiac motion. beyond visualisation of lung morphology, which is done in an inspiratory breath-hold, functional imaging has become an integral part of the routine protocols: perfusion, blood flow, ventilation, respiratory motion, diffusion. for perfusion imaging, inspiratory or expiratory scans can be used, blood flow measurement should be performed during shallow breathing, and ventilation and diffusion are mainly assessed in inspiration. respiratory motion is best assessed by dynamic image acquisitions. continuous breathing can also be combined with triggering or navigators to improve image quality or derive functional maps. mri is recommended as the first-line cross-sectional imaging modality in paediatric chest radiology, including cystic fibrosis, complicated pneumonia, any pulmonary or cardiovascular anomaly, as well as the assessment of mediastinal masses in children and adults. mri is also challenging pet/ct in the staging of lung cancer (tnm) as well as ct and echocardiography in the assessment of pulmonary arterial hypertension. mrieven without contrast -is an alternative in the diagnosis of acute pulmonary embolism if iodinated contrast medium is contraindicated or in pregnant women. mri should also be used in complicated pneumonia, e.g. in immunocompromised patients as well as for the functional assessment of chronic obstructive pulmonary disease (copd) or severe asthma. the role of mri in interstitial lung disease stills needs to be determined. unlike the simple forms of cranisynostosis whose modalities and timing of surgical correction are well established, the management of faciocraniosynostoses requires a multispecialistic and repeated evaluation of the single patients. their evolution, in fact, depends on the specific genetic anomalies but also on the phenotype, which can vary in time, of their clinical expression which may lead to different degrees in severity of the associated functional disturbances (csf dynamics impairment, visual deficits, respiratory anomalies, etc). consequently these conditions may require several surgical steps the timing of which are dictated by the exact clinical diagnosis and the evaluation of the functional status at different ages. current management of faciocraniostenoses is thus based not only on the radiological studies but also on the functional assessment of the brain function (e.g. mri imaging studies, metabolic and cerebral blood circulation investigations, respiratory pathways volume evaluation, sleep recording). today's surgical multidisciplinary management may benefit a large variety of techniques which extend from free bone cranioplasty with intraoperative active fixed expansion to more dynamic and less invasive methods which exploit the physiological brain expansion in infants or the gradual cranial vault expansion mechanically stimulated by springs or distractors. in the present report, we will review the decision making process and the rationale on which, at the necker-enfants malades, we base the use of the currently available techniques for skull expansion and correction of cranial malformations according to the accurate dynamic radiological and functional evaluation at different stages of the disease. learning objectives: . to learn about the imaging patterns of faciocraniosynostoses. . to learn how and when to image. . to become familiar with associated brain anomalies. b. all about the paediatric pituitary gland m.i. argyropoulou; ioannina/ gr (margyrop@cc.uoi.gr) mr is the imaging modality of choice for the assessment of the pituitary gland (pg) and the hypothalamus. the normal adenohypophysis is bright during the first two months of life and appears isosignal to the brain parenchyma afterwards. the neurohypophysis is bright, provided that the child is well hydrated. the pg height decreases during the first year of life and then increases until puberty. adenohypophyseal deficiency has been associated with a small pituitary size, an ectopic neurohypophysis, a hypoplastic or absent pituitary stalk, hypothalamic gliomas, craniopharyngiomas and iron overload states. precocious puberty may be idiopathic, but it has also has been associated with hypothalamic hamartomas, craniopharyngiomas and hydrocephalus. diabetes insipidus may be secondary to histiocytosis x, germinomas and trauma causing pituitary stalk interruption. the hypothalamopituitary axis is evaluated by using sagittal and coronal t -weighted images without and with contrast administration. dynamic contrast enhancement may be useful in the evaluation of disorders responsible of diabetes insipidus. magnetisation transfer imaging may be useful in the evaluation of pituitary deficiencies or precocious puberty. familiarity with orbital and ocular anatomy is crucial to the understanding of disease processes of the orbit. lesions of the orbit may be divided into those which are intraocular and those which are extraocular. the underlying aetiology and geneses of many different lesions that can occur in the orbits vary depending on the location of the lesions and sometimes on additional nonorbital conditions. ct and mri play crucial roles in the evaluation of orbital pathology where often mri still is a complement to ct examination in the evaluation of orbital lesions familiarity with the radiologic appearance of common orbital lesions is important, as many of these lesions will not be seen on physical examination. after a very brief anatomic overview, most of this lecture will focus on the more common benign and malignant lesions as well as differential diagnosis involving the orbit and lachrymal gland in both the paediatric and adult population. the lecture will also present suggested imaging protocol and standard of care with respect to imaging. learning objectives: . to understand the embryology and imaging findings of the most common malformations. . to learn about space-occupying lesions and the differential diagnosis of tumours and inflammatory conditions. . to be aware of the role of conventional and advanced mr sequences in the diagnostic approach to lesions in the orbit. room e the hand and wrist injury to the wrist and hand is an important clinical problem. first, such injury is relatively common. second, the spectrum of abnormalities is complicated. the purpose of this presentation will be to learn more about the imaging appearances of soft tissue and osteoarticular injury of the wrist and hand using multiple imaging techniques. emphasis will be placed upon pathomechanics and characterisation of greater and lesser arc injury patterns of the wrist. the various posttraumatic instability patterns of the wrist will be also discussed. rheumatoid arthritis (ra), psoriatic arthritis (psa) and other inflammatory disease can be diagnosed and sometimes differentiated in the early stages of the disease on the basis of mri and/or pdus features of the hand and wrist. rheumatoid arthritis (ra) activity is closely correlated with inflammation. the synovial membrane is the principal site of inflammation in which the inflammatory process enhances capillary perfusion and permeability. doppler ultrasonography (dus), using the amount of colour pixels in the region of interest, and dynamic magnetic resonance imaging (de-mri) are both able to detect this inflammation in the wrist and hand. although these techniques are both capable of monitoring synovium inflammation modifications after ra treatment, pdus has become an essential tool for ra joint monitoring in routine practice in view of its sensitivity in the detection of synovitis, feasibility in outpatient clinics, and low cost. (ellopis@hospital-ribera.com) radiological study of the wrist and hand is challenging due to its complex anatomy with many small structures and the number of normal bone and soft tissue variants that might mimic injuries. moreover, many findings can be asymptomatic. their knowledge is important to avoid misdiagnosis. during this lecture we will also review the role of the different imaging modalities, such as plain films for wrist alignment and bone structures as well as the important role of us and mr in differentiating tumour from tumour-like conditions. we will become familiar with some specific radiological findings that allow us to make accurate diagnoses of soft tissue and bone lesions. learning objectives: . to learn more about the spectrum of intra and para-articular soft tissue tumours, and soft tissue tumour-like lesions. . to become familiar with us and mri findings of specific soft tissue lesions. room e oncologic imaging chairman's introduction c. pfannenberg; tübingen/ de (christina.pfannenberg@med.uni-tuebingen.de) with recent advances in cross-sectional imaging, the frequency of detecting "incidental findings" has markedly increased. incidental findings (=incidentaloma) are defined as unexpected, asymptomatic abnormalities detected by imaging performed for an unrelated reason. these incidentalomas have created a management dilemma for both radiologists and clinicians, particularly in the cancer patient in whom any mass warrants further evaluation. discovery of incidental findings often leads to a cascade of additional tests that is costly, provokes anxiety and exposes patients to the risk of unnecessary radiation and intervention. the workup of incidentalomas varies widely by physicians, and strategies for optimising patient management are only beginning to emerge. in this course, guidelines concerning a rational approach to some of the more common incidental abnormalities in cancer patients are presented. basic principles and tools for interpretation of incidental findings, common pitfalls and protocol issues regarding the differentiation of benign and malignant lesions as well as treatment-induced abnormalities will be addressed with a focus on the liver, lung and skeletal system. at the end of the session, the speakers will discuss the role of functional imaging techniques for characterisation of incidental lesions. session objectives: . to become familiar with basic principles and common pitfalls in interpretation of incidental findings in the lung, abdomen and skeletal system. . to learn how functional imaging (dwi, pet/ct, bs) can help in lesion characterisation. . to provide attendees with clear and practical messages for the management of the most common incidental findings in cancer patients. a. abdomen: common pitfalls and protocol issues a. ba-ssalamah; vienna/ at (ahmed.ba-ssalamah@meduniwien.ac.at) an incidentaloma is quite a frequent diagnosis in medicine, in general, and in radiology, in particular. by definition, an incidentaloma is an abnormality or a tumour found by coincidence without clinical symptoms or suspicion. these incidental findings have long posed challenges to physicians, and particularly to radiologists as well as health-care providers due to the resulting high costs. the scope and scale of these challenges have increased with the introduction of new technologies, in particular cross-sectional imaging, such as mdct and mri using sub-millimetre thin slices. incidentalomas still cause a management dilemma for clinicians, radiologists and even for the patients themselves. this dilemma is particularly pertinent to oncology patients. therefore, a precise knowledge of the broad spectrum of incidental findings is crucial. based on this knowledge, we can choose the appropriate radiologic examination that will provide a confident diagnosis. this way, needless uncertainty, for both the patient and the physician in charge, is avoided. furthermore, invasive procedures, such as biopsies, with the potential for complications, as well as cost-intensive follow-up examinations, can be reduced. furthermore, mri is usually used to detect the side effects of chemotherapy of the liver. simple steatosis is usually reversible, unless the liver receives a 'second hit' of damage from other causes leading to other manifestations, including chemotherapy-associated steatosis, sinusoidal obstructive syndrome, nodular regenerative hyperplasia, veno-occlusive disease, peliosis, pseudo-cirrhosis, and sclerosing cholangitis largely due to microvascular injury. finally, the effects of chemotherapy on peritoneal and mesenteric structures after performing intraperitoneal chemotherapy will be discussed. this presentation will discuss the complex topic of incidental findings in thoracic imaging of oncological patients. incidental findings will be presented with respect to their respective organs and anatomical regions. the presentation will emphasise the clinical relevancy of the findings as well as the specific of risk estimation in oncological patients. finally, the presentation will discuss the usefulness (or lack thereof) of current management guidelines for incidental findings, as designed for the general population. illustrative clinical scenarios will be discussed. radiographs and ct often detect incidental observations in bones, corresponding either to normal variants or benign conditions, which require additional imaging to rule out malignant conditions. mri most often provides nonambiguous explanation for these observations. beside this, mri, targeting either the whole body or only the axial skeleton, often including diffusionweighted (dwi) sequences, is increasingly used for bone tumour detection in many "osteophilic" cancers and haematologic malignancies, without need for contrast material injection and without irradiation, with unparallelled sensitivity to bone lesions. an important advantage and also a challenge for musculoskeletal radiologists are the all organ screening capabilities of dwi, demanding careful study of the huge information provided and knowledge extending far beyond bones in terms of organs and metastatic spread of different cancers. a second major advantage is its ability to detect lesion changes under therapy. however, benign lesions and non-neoplastic conditions, as well as artefacts may also lead to confusing observations on mri, and particularly on dwi. anatomical mr sequences as well as other imaging modalities are of utmost help to recognise these pitfalls. whole body mri including dwi sequences has to position itself among other diagnostic tools, bone scan, spect, and especially pet with its variety of tracers, in the currently evolving strategy of bone screening techniques, which will most likely vary according to the primary cancer. learning objectives: . to present most frequent x-ray and ct pseudo lesions and benign conditions and show how mri often enables straightforward interpretation of these abormalities. . to highlight the strengths of mri with diffusion weighted imaging (dwi) for malignant lesion detection and characterisation within bones, but also beyond bones. . to highlight the typical appearance of malignant lesions on projectional and cross-sectional imaging. . to learn to differentiate these lesions from normal marrow variations, stress lesions, bony pseudo-lesions and other benign conditions, and to become familiar with treatment induced changes within lesions and their environment. . to situate mri amongst other functional imaging techniques (pet, spect, ). colorectal cancer is the rd most commonly diagnosed cancer in the world with % of cases diagnosed in the developed world. with an estimated . million new cases clinically diagnosed and over , people killed worldwide by this disease on an annual basis, colorectal cancer is a true public health concern. survival of colorectal cancer is directly related to the extent of disease and specifically presence of liver metastases. imaging plays a key role in the initial staging of colorectal cancer and is the gold standard in evaluating extra colonic disease, primarily liver metastases. imaging is also widely used for therapy monitoring and staging. ct, mri, pet/ct and pet/mri are the key imaging modalities. in addition, tumour response therapy assessed with morphological and functional biomarkers is increasingly used by advanced gastrointestinal oncologic programs. furthermore, image-guided therapy is widely used for patients with unresectable lesions. liver colorectal metastases were the first liver metastases to be treated with image-guided ablation techniques. a gamut of ablative techniques exists ranging from transarterial embolisation, radiofrequency ablation, highly intensified focused ultrasound, brachitherapy etc. in short, diagnosing, characterising and finally assessing tumour response after neoadjuvant and image-guided therapy are all functions where imaging plays a pivotal role. this course is divided into three logical segments dealing with current treatment options, morphological and finally functional biomarkers and it is followed by a panel discussion which includes audience participation. a. current treatment options t.k. helmberger; munich/de (thomas.helmberger@klinikum-muenchen.de) hepatic metastases in colorectal cancer may occur in % to % of the cases. considering the general oncological (isolated hepatic tumour load; prognostic benefit), and technical (size, number, location of hepatic metastases; expected hepatic functional reserve) framework, surgical resection is still considered to be the method of choice -even if this statement never had been verified by rtcs. nevertheless, in clinical reality only - % of patients with liver metastases may qualify for resection. in consequence, the majority of patients need other or at least modified therapeutical pathways including adjuvant or neoadjuvant chemotherapy and more and more image-guided local ablative therapies. the latter encompass chemo-(transarterial chemoperfusion/-embolisation), thermo-(radiofrequency-, laser-, microwave ablation, high intensified focused ultrasound), and radio-ablative (radio embolisation, interstitial brachytherapy, etc). techniques. particularly, thermalablative techniques gained wide acceptance over the last years, since ample evidence could be presented showing that this method can be applied as primary and also complementary therapies in resectable and non-resectable metastatic disease. furthermore, recent data confirm that in multimodality therapy concepts, progression free survival and overall survival in patients with primarily unresectable and with unfavourable prognosis is comparable to surgery with -year survival rates more than %. minimally invasive, imageguided therapies will not replace surgical resection; however, these therapy modalities are eligible in a large number of cases and should be implemented consequently in multimodality treatment regimens according to the interdisciplinary consensus of oncologists, interventional radiologists, and surgeons. colorectal liver metastases are typically identified as low attenuation lesions on portal venous phase ct. planning of optimal therapy depends on accurate localisation and characterisation of all focal liver lesions and this is best achieved with mri, which should include diffusion-weighted imaging and use of hepatocyte-specific contrast medium. the typical mri signature of colorectal metastases includes low signal on t w, moderately increased signal on t w, irregular peripheral arterial phase enhancement with low signal on portal venous phase, restricted diffusion and absent hepatocytes. morphological tumour response can be assessed with either modality. size-based systems for assessing tumour response are widely applied, with recist . the most widely used at present. recist . includes several modifications that make it more user friendly than recist . . more advanced morphological criteria have been described for new targeted and molecular therapies, including overall attenuation, the tumour-liver interface and the appearance of the peripheral rim of enhancement. as hepatic surgeons become more aggressive in their approach to resection in patients with liver metastases, it is important to understand that disappearance or calcification of liver metastases after treatment does not necessarily equate to a complete pathological response. the timing of imaging is therefore critical in assisting the surgeon to remove all previously affected hepatic segments after chemotherapy. learning objectives: . to learn about the algorithm for detecting and characterising liver metastases. . to understand conventional imaging criteria for assessing tumour response. . to learn about the rationale for monitoring patients after radical and palliative treatments. conventional size measurement criteria remain the most widely used method to determine the response of colorectal liver metastases to treatment. however, tumour size reduction is assessed relatively late (e.g. weeks after treatment) and new targeted treatment may be effective without reducing tumour size. new functional imaging techniques can be applied to quantify different aspects of tumour biology and to develop response, and predictive and prognostic biomarkers. we discuss the use of diffusion-weighted mr imaging, dynamic contrast-enhanced mr imaging and fdg-pet imaging in the evaluation of treatment response in patients with colorectal liver metastases. digital breast tomosynthesis (dbt) is a promising technique for breast imaging based on a full-field digital mammography (ffdm) platform. the x-ray tube moves through a proscribed arc, and several low-dose projection images are acquired. images are reconstructed into a stack of mm slices. the radiation dose is about the same or slightly higher than for ffdm. the most important advantage of dbt is the elimination of superimposed tissue, which improves detection of lesions otherwise hidden by dense breast parenchyma and reduces the interpretation problems caused by overlapping tissue. dbt is suggested to improve sensitivity as well as specificity in women with dense breast. dbt is superior to ffdm in tumour size assessment and for mass visibility and cancer conspicuity. dbt is comparable to ffdm for evaluation of microcalcifications. dbt is superior for the detection of spiculated masses and architectural distortion. the potential to improve sensitivity and specificity is of interest for screening. an open question is whether dbt should be applied in one or two views. two-view dbt would mean a doubling of radiation dose, but a solution is the implementation of synthetic d images reconstructed from the d dataset of dbt. the synthesised images are created by summing and filtering the stack of reconstructed dbt slices. using synthetic d allows "combo mode" to be implemented in screening with the same radiation dose as for conventional d. results using dbt in breast cancer screening are very promising. different study design of published studies may explain the variations of results. magnetic resonance imaging of the breast provides a multitude of techniques for detection of breast cancer and differentiation of benign from malignant lesions. in the last few years, significant improvements of scanner hardware and equipment in terms of coils as well as sequence software have been achieved. to date, multiparametric quantitative measurement of perfusion, diffusion and tissue chemistry is possible at field strengths up to tesla. although higher field strengths and improved sequence protocols provide higher signal and allow faster imaging, specific technical issues have to be considered to avoid artefacts and pitfalls. this talk aims to demonstrate the possibilities and limitations of multiparametric and (ultra-)/high-field mri. furthermore, these new techniques are put into the broader clinical context to determine the potential value for breast lesion detection and differentiation. positron emission mammography is a recently developed imaging device using positron emission technology. after injection of a positron-emitting radiotracer, the radiation is detected by a dedicated high-resolution camera, providing high spatial resolution. commercially available systems include cameras where the breast is compressed and which display a d image similar in its layout to a mammogram and hanging breast devices where a d image similar in its layout to mri is produced. these devices have been compared to pet/ct and have shown higher spatial resolution, accuracy and sensitivity in detecting malignant breast lesions. the most widely studied tracer in pet/ct and in pem is fluorodeoxyglucose (fdg). fdg is a glucose analogue and has had a major impact on oncology imaging with pet/ct. breast carcinomas demonstrate increased glucose consumption and the intensity of the uptake has been correlated with prognosis, hormonal receptor and her status, ki and nodal involvement. current potential indications for pem are detection and characterisation of breast lesions, local staging in patients with known breast cancer and baseline assessment prior to neoadjuvant chemotherapy. future developments of pem will involve new tracers and fusion with other breast imaging modalities. fluorothymidine is a proliferation tracer that seems promising in early assessment of response to chemotherapy. fluoroestradiol has the potential to image oestrogen receptor status in vivo. the possibility of pem-guided biopsy is a very exciting development and has the potential to select lesions with the highest intensity of uptake. fusion with mri, us and mammography will increase the diagnostic accuracy. the presentation will focus on two frequent findings on mri with increasing incidence during ageing, notably "unspecific" hyperintense lesions on t /flair and cerebral mircobleeds (cmbs) on t * or swi images. clinicoradiologic studies suggest that these t /flair lesions are associated with increased risk of cognitive decline, stroke and death. the clinical relevance of these lesions probably depends on periventricular versus deep white matter location. radiologic-histopathologic studies correspondingly indicate that the degree of histopathologically confirmed demyelination also depends on the location of these t /flair lesions. cerebral mircobleeds (cmbs) are punctate hypointense lesions on t * or swi images. while multiple cmbs are associated with diseases such as cerebral amyloid angiopathy (caa), clinicoradiologic studies demonstrate increased incidence of sporadic cmbs in mild cognitive impairment (mci) and alzheimer dementia, indicating a degrading effect of cmbs on cognition. on the other hand, radiologic-histopathologic studies show that not all black spots on t * or swi correspond to cmbs. cmb mimics include micro-calcifications. the presentation will demonstrate typical manifestations of these "unspecific" t /flair lesions and cmbs during ageing and provide tips for the interpretation of these lesions during daily clinical routine. with the increasing use of mri, it has become more common to discover incidental brain findings. these findings may be non-specific or have some morphological characteristics and geographical distribution highly suggestive of a demyelinating disease. the term "radiologically isolated syndrome" (ris) was introduced by okuda in to describe those asymptomatic patients with radiographic abnormalities highly suggestive of multiple sclerosis (ms). sometimes, these lesions may even meet the mri criteria for dissemination in space, which are currently used to predict future development or conversion to ms in patients presenting a clinically isolated syndrome (cis). however, we must not forget that these radiological criteria should be applied only when the patient had experienced any clinical manifestations suggestive of a demyelinating disease. therefore, what happens in those patients in whom we found highly suggestive lesions but have never had symptoms? due to lack of knowledge about the natural history or evolution of this new syndrome, clinical and therapeutic management of these patients is not well established, nor is the risk of conversion to ms. recent data, however, indicate that the presence of gadolinium-enhancing cervical cord and cortical lesions significantly increases the risk of conversion to cis or ms. all these data have improved the characterisation of ris subjects and in our understanding of risk factors for initial symptom development. incidental findings on brain imaging are defined as previously undetected abnormalities of potential clinical relevance that are unexpectedly discovered and unrelated to the purpose of the imaging. incidental findings are increasingly detected in clinical practice, with screening, and in the research setting. data on the prevalence of these abnormalities are scarce, the clinical course of the findings is often unknown, and the management of such lesions is not clear. the prevalence of incidental findings can be expected to vary depending on the purpose of the imaging exams. with improvements in imaging technology (higher field scanners, new pulse sequences), the number of detected incidental findings will increase dramatically. another important point is the advent of imaging biomarkers. advanced techniques for postprocessing and analysis, such as automated segmentation of brain structures or voxel based morphometry, will lead to the discovery of imaging biomarkers. once the predictive value of these markers has been established, most mri studies of the brain, both in the clinical and research setting, will reveal information that might be relevant for the well-being of patients or participants. although still incidental, these findings can unfortunately no longer be considered unexpected. we will soon face large medical, ethical, and practical problems as a result of technical improvements. in this lecture, the most important incidental findings and their prevalence will be reported. the management of incidental findings in the clinical and research setting will be discussed. finally, recommendations for follow-up will be provided. the primary assessment of laryngeal cancer is provided by endoscopy, which is accurate in delineating both the superficial extent and functional impairment. imaging techniques are recommended to grade submucosal invasion, local and distant spread. in the last few decades, open and endolaryngeal surgical procedures as well highly sophisticated rt techniques have been developed to treat the tumour while preserving critical laryngeal functions. for example, early glottic tumours (tis-t ) can be treated by endoscopic laser excision or rt. the integration of information acquired by endoscopy and imaging is essential for proper treatment planning. the radiologist has to know that the site of origin (supraglottis vs glottis or subglottis) and local extent (superficial and submucosal) are the key tumour-related factors in planning the type of treatment. submucosal invasion has a variable impact depending on the location of the primary tumour. the key issues in glottic cancers include the invasion of: the posterior paraglottic space, crico-arytenoid joint, and anterior commissure and contralateral true vocal cord, and vertical spread towards supra and/or subglottis, thyroid or cricoid cartilage. the key issues in supraglottic cancers encompass the invasion of: base of the tongue, preepiglottic space, piriform sinus, vertical spread into glottis and subsequent cartilage invasion (observed exclusively in transglottic cancers). functionsparing surgical techniques -as supracricoid laryngectomies -can be applied in advanced cancers when sparing of the posterior commissure, the ipsilateral crico-arytenoid joint, the mucosa investing the upper cricoid and the outer perichondrium of the thyroid cartilage is demonstrated by endoscopic and imaging mapping. the detection of recurrent laryngeal carcinoma is often challenging. to better appraise the expected findings after initial surgery of laryngeal cancer, the classical partial laryngectomy and laser laryngeal surgery are briefly presented.(chemo)radiotherapy has become an important treatment modality for laryngeal carcinoma. the recurrence rate in t -t laryngeal carcinoma is reported to be between % and %. the difficulty in differentiation between radiation reaction (such as oedema, fibrosis and soft tissue and cartilage necrosis) and recurrent disease is discussed. a histologic study on wholeorgan sections of recurrent glottic carcinomas is also presented: recurrent disease presents with different tumour spread than does a primary carcinoma, resulting in difficulties in estimating the extent of tumour recurrence. currently, selected recurrences of early glottic carcinoma are, whenever possible, treated by larynx-preserving salvage surgery. in those cases, a precise evaluation of the recurrent tumour extent is mandatory for planning larynx-preserving salvage surgery. this is especially true in critical regions such as the preepiglottic space, infiltration into cartilage, contralateral tumour spread and subglottic tumour extension. the accuracy of crt-classification is relatively low: many patients with signs and symptoms suggesting tumour recurrence present with post-radiotherapy changes; small tumor foci, often localised in the subglottic region, are undetectable by imaging studies. tissue changes in the neck treated by surgery and/or radiotherapy (rt) make the detection of residual or recurrent tumour more difficult. clinical evaluation of the neck is also hampered by these changes. rt-induced fibrosis and postsurgical scar tissue make palpation of the neck very difficult. endoscopy is hampered by endolaryngeal oedema which can persist for many months post-rt. therefore, any (non-invasive) method helping in the detection of recurrence is welcome. patients at risk for local failure after rt can be successfully identified by a post-rt ct (or mr) study between to months after rt. the optimal time point to perform such a 'baseline study' seems to be about to months post-rt. patients with indeterminate findings are candidates for 'imaging surveillance'; i.e. follow-up imaging every to months up to a period of years after rt. however, ongoing studies suggest that metabolic imaging (fdg-pet) may detect local recurrences with a higher accuracy than 'conventional' anatomically based imaging techniques, such as ct and mr. ct and/or mr-findings in the treated neck are frequently inconclusive. at present, new techniques are available to detect recurrent cancer. pet-ct is widely applied in the post-treatment setting. also, advanced mr-techniques such as diffusion weighted imaging (dwi) and dynamic contrast-enhanced mr (dce-mr) can be applied. focusing on the larynx, the advantages of these techniques as well as the limitations will be shown using imaging examples from daily practice. during the last years, several hundred new radiotracers for pet imaging of cancer have been developed and tested preclinically. these tracers are based on proteins (e.g. antibodies and antibody fragments), peptides (e.g. g proteincoupled receptor ligands) or small molecules (e.g. radiolabelled protein kinase inhibitors or metabolic substrates). using these radiotracers, the expression and function of a variety of proteins can be studied in patients, including for example glutamine/glutamate metabolism, neutral amino acid transport, psma, grpr, sstr, cxcr , folate and alpha-v beta- integrin expression. some of these radiopharmaceuticals are potential companion diagnostics and may allow selection of patients for treatment with radiopharmaceuticals or targeted drug conjugates. preclinical and initial clinical data are promising for several new radiotracers, but the key challenge is the clinical validation and dissemination of these compounds. validation and dissemination have been hampered so far by regulatory hurdles as well as by the lack of standardised trial designs for the validation of imaging agents and the lack of accepted and appropriate end points to prove clinical utility. addressing these issues will be critical for the future clinical use of pet and other molecular imaging technologies. imaging targets in cancer range from simple size measurements to more specific biomarkers on functional, cellular, metabolic and molecular levels. as our understanding of basic tumour biology has advanced, techniques have been developed to exploit this information to produce increasingly specific molecular imaging tools. the biodistribution of these molecular imaging probes should be more specific in diagnosing and assessing cancer than the morphological information acquired using anatomical imaging alone. this lecture will discuss current and emerging functional and molecular imaging techniques using mri and their applications in oncology. functional measures of tumour blood flow and vascular permeability can be made using dynamic contrast-enhanced mri. diffusion-weighted imaging is a surrogate for the cellular content of the tumour and emerging methods can be used to probe features of the extracellular space such as tumour ph and stromal content. on the molecular level, cell surface expression of specific proteins and enzyme activity within the cell can be imaged; labelled probes have been developed which bind to these proteins and a new mr technique is being developed for assessing tumour glucose in a similar way to pet. hyperpolarisation methods are emerging to overcome the major limitation of mr: low sensitivity. one such approach is dynamic nuclear polarisation, which can probe carbon metabolism non-invasively in patients with cancer. functional and molecular imaging techniques with mri will increasingly be used in radiology in conjunction with anatomical imaging methods to improve diagnosis and prognosis, target biopsies, as well as predict and detect response to treatment. with mr-spectroscopy, diffusion-weighted imaging, pet-and spect-ct, as well as pet-mri, molecular imaging has already become part of clinical routine diagnosis. also, some contrast agents such as spio for mps-labelling and scavenger-receptor binding gadolinium chelates are clinically applied for liver and lymph node imaging. however, there are still a number of highly promising novel tools that are expected to emerge clinically in the near future. in this context, the first part of the talk will give an overview on how optical imaging basically works and which future clinical applications can be expected. in this context, raman spectroscopy, fluorescence optical reflectance imaging, fluorescence mediated tomography, photoacoustic imaging and cerenkov luminescence imaging will be addressed. the second part of the talk introduces molecular ultrasound imaging as a safe and preclinically wellevaluated method. besides the diagnostic use of molecular ultrasound contrast agents, which have been already evaluated in clinical trials, the potential of this method also for theranostic purposes will be highlighted. the assessment of the amount of arterial calcification with computed tomography is a standard method in the risk stratification of coronary heart disease. coronary calcium detection by ct has been shown to identify atherosclerotic plaque and to quantitatively assess coronary calcium. many studies have demonstrated the association between the degree of coronary calcium, the burden of atherosclerosis, and the risk for cardiovascular events associated with coronary calcium. the cac scoring can provide individual risk assessment and reclassify the low and particularly intermediate framingham risk cohort into lower-and higher-risk strata. the absence of cac is associated with a very low risk of future cardiovascular events, with modest incremental value of other diagnostic tests in this very low-risk group. the role of cac in the workup of symptomatic patients is under discussion and there is evidence that the absence of cac has a high negative predictive value for ruling out acute coronary syndrome. although cac measurement is highly standardised, some technical aspects have to be considered and all possibilities of dose reductions utilised. this presentation will show the technical and epidemiological fundamentals of cac scoring and discuss the clinical applications of the method. coronary cta has gained an important role in the evaluation of patients with chest pain, suspected of coronary artery disease (cad). in comparison to invasive coronary angiography, coronary cta with -multidetector ct has an excellent sensitivity for coronary stenosis. specificity for stenosis is less excellent, but has improved with newer ct generations. the strongest impact of coronary cta has been on the exclusion of stenosis in symptomatic patients at low-intermediate pre-test probability. in contrast to invasive angiography, coronary cta yields more information than just the severity of stenosis. coronary cta also allows determination of plaque types (calcified, non-calcified, partly calcified) and quantification of the atherosclerotic plaque burden. also, new developments point to the possibility to assess the haemodynamic significance of stenosis based on ct density measurements in the coronary arteries, or evaluation of myocardial perfusion. thus, coronary cta yields quantitative imaging biomarkers that could be used for risk stratification in the future. recent studies have shown that whether or not a patient has stenosis and plaque, as well as the type and burden of plaque, affects the risk of myocardial infarction and mortality. therefore, the impact of coronary cta imaging biomarkers reaches beyond the mere assessment of stenosis for symptomatic treatment and could potentially alter medical management of patients for improvement of long-term prognosis. a- : c. added value of carotid and peripheral artery imaging for risk assessment l. natale; rome/ it (lnatale@rm.unicatt.it) technical protocols optimisation of mra and cta of carotid and peripheral arteries is crucial for image quality and to complete the analysis of both lumen and vessel wall. furthermore, mra protocol needs to be integrated with dedicated pulse sequences in order to obtain vessel wall imaging that is already included in cta datasets. new ct and mr scanners allow this optimisation in terms of radiation exposure, contrast media dose reduction and spatial resolution. all these parameters will be discussed for both techniques. according to international guidelines, non-invasive imaging indications will be discussed, with particular attention to high risk population (e.g.: diabetic patients). some possible imaging biomarkers of plaque composition will be discussed. learning objectives: . to become familiar with optimal technical considerations for performing cta and mra of the carotid and peripheral arteries. . to understand clinical indications for carotid and peripheral cta and mra. . to discuss the role of cta and mra parameters including plaque imaging as biomarkers of cardiovascular disease. key: cord- -sz ieltb authors: solé, g; salort-campana, e; pereon, y; stojkovic, t; wahbi, k; cintas, p; adams, d; laforet, p; tiffreau, v; desguerre, i; pisella, li; molon, a; attarian, s title: guidance for the care of neuromuscular patients during the covid- pandemic outbreak from the french rare health care for neuromuscular diseases network date: - - journal: rev neurol (paris) doi: . /j.neurol. . . sha: doc_id: cord_uid: sz ieltb abstract in france, the epidemic phase of covid- caused by severe acute respiratory syndrome coronavirus (sars-cov- ) began in february and resulted in the implementation of emergency measures and a degradation in the organization of neuromuscular reference centers. in this special context, the french rare health care for neuromuscular diseases network (filnemus) has established guidance in an attempt to homogenize the management of neuromuscular (nm) patients within the french territory. hospitalization should be reserved for emergencies, the conduct of treatments that cannot be postponed, check-ups for which the diagnostic delay may result in a loss of survival chance, and cardiorespiratory assessments for which the delay could be detrimental to the patient. a national strategy was adopted during a period of to months concerning treatments usually administered in hospitalization. nm patients treated with steroid/ immunosuppressants for a dysimmune pathology should continue all of their treatments in the absence of any manifestations suggestive of covid- . a frequently asked questions (faq) sheet has been compiled and updated on the filnemus website. various support systems for self-rehabilitation and guided exercises have been also provided on the website. in the context of nm diseases, particular attention must be paid to two experimental covid- treatments, hydroxycholoroquine and azithromycin: risk of exacerbation of myasthenia gravis and qt prolongation in patients with pre-existing cardiac involvement. the unfavorable emergency context related to covid- may specially affect the potential for intensive care admission (icu) for people with nmd. in order to preserve the fairest medical decision, a multidisciplinary working group has listed the neuromuscular diseases with a good prognosis, usually eligible for resuscitation admission in icu and, for other nm conditions, the positive criteria suggesting a good prognosis. adaptation of the use of noninvasive ventilation (niv) make it possible to limit nebulization and continue using niv in ventilator-dependent patients. emergency measures and a degradation in the organization of neuromuscular reference centers. in this special context, the french rare health care for neuromuscular diseases network (filnemus) has established guidance in an attempt to homogenize the management of neuromuscular (nm) patients within the french territory. hospitalization should be reserved for emergencies, the conduct of treatments that cannot be postponed, check-ups for which the diagnostic delay may result in a loss of survival chance, and cardiorespiratory assessments for which the delay could be detrimental to the patient. a national strategy was adopted during a period of to months concerning treatments usually administered in hospitalization. nm patients treated with steroid/ immunosuppressants for a dysimmune pathology should continue all of their treatments in the absence of any manifestations suggestive of covid- . a frequently asked questions (faq) sheet has been compiled and updated on the filnemus website. various support systems for self-rehabilitation and guided exercises have been also provided on the website. in the context of nm diseases, particular attention must be paid to two experimental covid- treatments, hydroxycholoroquine and azithromycin: risk of exacerbation of myasthenia gravis and qt prolongation in patients with pre-existing cardiac involvement. the unfavorable emergency context related to covid- may specially affect the potential for intensive care admission (icu) for people with nmd. in order to preserve the fairest medical decision, a multidisciplinary working group has listed the neuromuscular diseases with a good prognosis, usually eligible for resuscitation admission in icu and, for other nm conditions, the positive criteria suggesting a good prognosis. adaptation of the use of noninvasive ventilation (niv) make it possible to limit nebulization and continue using niv in ventilator-dependent patients. keywords : covid- ; neuromuscular; treatment; management; guidelines medical practices worldwide have faced unique challenges in the context of the ongoing covid- outbreak. among the various existing medical disciplines, the pandemic has significantly changed the current practice in treating neuromuscular disorders. these diseases constitute a group of very heterogeneous conditions, most often of genetic or autoimmune origin, which affect both children and adults to a degree that varies widely from one individual to another. they include muscle disorders (e.g., muscular dystrophies, congenital myopathies, metabolic myopathies, inflammatory myopathies, and muscle channelopathies), diseases of the neuromuscular junction (e.g., either acquired or congenital myasthenic syndromes), peripheral nerve disorders (e.g., dysimmune neuropathies, familial amyloid neuropathies, and charcot-marie-tooth disease), and spinal muscular atrophies. in france, , - , patients are thought to suffer from neuromuscular diseases. a significant number of these patients display great disability and may have cardiac and/or respiratory impairments. of concern for this report, this number excludes those with amyotrophic lateral sclerosis; although also included under the umbrella of neuromuscular disorders, the herein proposed guidance will not cover this condition. in france, the epidemic phase of covid- caused by severe acute respiratory syndrome coronavirus (sars-cov- ) began in february and resulted in the implementation of emergency measures and a degradation in the organization of neuromuscular reference centers. the regional health agency for ile-de-france provided recommendations for covid- support in neurology [ ] ; the main challenge was to protect patients with neurological pathologies from contamination and to organize the continuation of necessary treatments in view of maintaining the continuity of care. the french rare health care for neuromuscular diseases network (filnemus) also announced guidance in an attempt to homogenize the management of neuromuscular patients in this context to limit the contamination of extremely fragile patients while avoiding the loss of survival chance linked to the interruption of essential treatment or follow-up. in the uncertainty expanding with the evolution of the epidemic, national measures have been proposed by filnemus to last for a period of months (as of the time of writing of this manuscript, from march to april ) to homogenize health care in france. however, it is difficult to establish specific guidelines concerning the heterogeneity of diseases and of patients being managed for the same disease. different scenarios considering regional specificities, particularly in terms of the severity of the epidemic, are then considered and will be the subject of subsequent guidance with the view of offering optimal care to our patients in accordance with our public health responsibilities. for neurological pathologies being assessed or requiring treatment in health care establishments, in cases where there is no emergency or risk to suspending treatment, one recommendation is to deprogram hospitals for a period of time. furthermore, to prepare to take care of patients suspected or confirmed to have covid- , suspected or confirmed covid- patients must be separated from non-covid- patients by ensuring reinforced hygiene rules and by applying barrier measures (among both patients and staff). conducting telephone interviews when the patient makes an appointment is important in eliminating signs of covid- (e.g., fever, chills, high or low respiratory signs, and body aches). if possible, surgical masks should be worn by all patients with comorbidities upon their arrival at the hospital. patients presenting for treatment of neuromuscular conditions should be placed in a non-covid- hospital sector/service, taking all necessary measures to avoid contamination. if a patient with a neuromuscular condition also shows symptoms of covid- or their test results are positive, advice from the neurologist concerning the unique measures to be applied should be considered. in the former case, the diagnosis of covid- should be confirmed by conducting polymerase chain reaction testing. if necessary, the patient should be referred to a covid- -specific health unit to protect the nursing staff at the hospital. patients with neuromuscular diseases may have risk factors for developing severe forms of covid- and receiving prolonged intensive care may worsen their functional prognosis. it is therefore essential to develop a preventive approach. this involves the supply of easily intelligible information to this patient population, the content of which must be updated as the knowledge progresses and widely disseminated. as patients demand information to keep themselves informed and safe and to homogenize the answers at the national level, a frequently asked questions (faq) sheet has been compiled from the questions most frequently asked of the secretariats at reference centers; the coordinator nurses; and the regional offices of the afm-telethon, french neuromuscular patient association. the main addressed topics pertain to the disease itself, its mode of transmission, the official national public health recommendations to prevent it, the behaviors to adopt in case symptoms appear, and its consequences specific to the neuromuscular patient (e.g., relating to the management of steroids and immunosuppressor treatments, medical appointments, rehabilitation, and ventilation). the constant evolution of both available knowledge and official instructions have made it necessary to continuously update the faq content. achieving the widest possible dissemination is necessary for this type of action to be effective. this faq sheet is therefore available on the filnemus website (www.filnemus.fr), and its dissemination is ensured by the neuromuscular reference centers and the afm-telethon in particular, thanks to the offering of backup and advice hotlines by the reference centers or the regional offices of the afm-telethon. in addition to fulfilling the mission of disseminating information, these hotlines offer a way to connect with patients and identify risky situations such as those involving the loss of human aid, isolation, disruption of care, or psychological distress. the reference center should therefore ensure that patients have received relevant information and adequate equipment. within the reference centers, these hotlines can be managed by paramedical staff working from home but also by residents redeployed from other medical units whose normal activities have been reduced. to reallocate human and material resources in the fight against covid- , nonurgent appointments should be postponed or, if appropriate, replaced by telemedicine [ , ] . teleconsultation is only possible by videoconferencing, and administrative steps have traditionally slowed down its development (decree no. - of october , , on telemedicine), but the rules have since been relaxed: when the patient does not have the necessary equipment to perform videoconferencing, telecare activities can be conducted by phone (decree no. - on march , ). a register of canceled appointments must be kept by the reference center to reschedule at a later date. acts such as electroneuromyography and muscle and nerve biopsies must be reserved for diagnostic emergencies such as in the case of vasculitis, guillain-barré syndrome, myasthenia gravis, or myositis. hospitalization should be reserved for emergencies, the conduct of treatments that cannot be postponed (poorly balanced condition, relapse), check-ups for which the diagnostic delay may result in a loss of survival chance, and cardiorespiratory assessments for which the delay could be detrimental to the patient. similar to with canceled appointments, a register of canceled hospitalizations must be kept by the centers for rescheduling to a later date. teleconsultations conducted by a doctor, a resident, or even a coordinator nurse will easily be able to verify that the cancelation of the hospitalization will not harm the patient. maintaining joint flexibility, muscle strength, and endurance is recommended in many neuromuscular diseases through regular in-house or office care by health professionals [ ] [ ] [ ] [ ] [ ] . in march , a decree regulating mobility to increase the resistance against the spread of the covid- led to the closure of private therapists' practices, including those of physiotherapists, speech therapists, and occupational therapists (decree no. - on march , ). a subsequent recommendation of the council of the order of physiotherapist called for "the maintenance of in-house physiotherapy of vulnerable patients for whom the cessation of care could lead to a major aggravation, noting that the usual management of many patients is severely disrupted. during the period of outbreak, the high council of public health recommends for the development of activities allowing the continuity of patient support when it is feasible at a distance (for example, by tele-education) [ ] . a working group of filnemus has since set up various support systems (e.g., illustrated sheets with links to online videos) for self-rehabilitation and exercises performed by caregivers or relatives. they are available on the filnemus website (www.filnemus.fr) and free of copyright and have been validated previously. classified by theme (e.g., according to pediatric or adult age, degree of motor impairment, and objectives), these exercises are deliberately simple and guided so that they can be performed by people who are not health professionals. it is suggested that these exercises be adapted to individual situations under the control of the referring doctor and in close collaboration with the usual therapists. as most of the neuromuscular reference centers and competence centers have maintained significant teleconsultation activity, patients and families are encouraged to contact these departments to receive individualized support. in the epidemic context, just prior to the containment period, a national strategy was adopted concerning treatments usually administered in hospitalization. this strategy was developed only for implementation during a period of to months and will need to be adopted further thereafter according to the evolution of the epidemic in the region. treatment with these enzyme replacement therapies, often administered during daily hospitalization, has been discontinued in most cases since the beginning of the epidemic to limit the risk of patients with pompe disease contracting covid- while in the hospital, especially since most patients with pompe disease have respiratory insufficiency related to diaphragmatic involvement. stopping enzyme replacement therapy over a period of to months is unlikely to lead to a significant worsening of the disease, although there are few data available in the medical literature with which to accurately estimate the risk of worsening the disease after a relatively short interruption of treatment. a swiss study of seven patients with pompe disease whose treatment was interrupted for economic reasons [ ] showed clear deteriorations of motor and respiratory functions and no complete recovery following the resumption of treatment [ ] . however, in this study, the duration of treatment interruption was greater than months in six of seven cases, and there was no clinically significant worsening in the remaining patient having the shortest duration of interruption of months. assuming that many of the daily in-patient units will remain closed for several weeks or months, the possibility of home infusions could be considered to limit the risk of contamination of patients in the hospital in the short term and to relieve the day hospital structures that will have to deal with an influx of patients during the course of the epidemic. when treatment is resumed, the evaluation of motor and respiratory functions should be performed, with pulmonary function and min walking test conducted to assess the impact of this suspension of infusions. the initiation of nusinersen represents a therapeutic emergency for children with type or type spinal muscular atrophy (sma). the indication should be maintained because of the functional and vital consequences of delaying treatment. for adolescents and adults with type sma and type sma, the therapeutic objective is to stabilize or slightly improve the functional state. therefore, for these patients, the initiation of treatment may be delayed. for patients already under treatment, nusinersen has a tissue half-life of more than days with an effect on alternative splicing present for several months [ ] . moreover, there appears to be a cumulative phenomenon as intrathecal concentrations of nusinersen dosed prior to injection increased on average from . ng/ml at days after the first injection to . ng/ml at months after the sixth injection [ ] . it is recommended to try as much as possible to continue intrathecal injections in patients with type sma and among o if the dose is delayed by months, the treating physician should entirely restart the treatment regimen and dose every months. it is recommended to interrupt the delivery of patisiran infusions in the hospital to avoid exposing these patients to the risk of covid- contamination in the hospital environment as these individuals are considered to be at high risk for serious complications (e.g., due to age of older than years and underlying cardiomyopathies) with a relay conducted by infusions performed at home. the time necessary to organize the relay and the interruption of one to two doses should not pose any particular long-term problem. a phase ii study showed that the injection of patisiran at . mg/kg reduced serum ttr very rapidly by more than % over a -week period [ ] . in phases ii and iii extension clinical trials (apollo), the interruption of one to two infusions of patisiran, authorized in the protocol, among several patients, did not have a negative impact on the final results [ ] . moreover, no anti-small interfering rna antibodies were observed in any of the treated patients. the treatment of dysimmune neuropathies (e.g., chronic polyradiculoneuropathy, lewis-sumner disease, and multifocal motor neuropathy with conduction blocks) most often involves the iterative administrations of either intravenous or subcutaneous immunoglobulins, performed in the hospital or at home, the benefit of which has been widely demonstrated [ ] . interruption of this therapy may result in the re-exacerbation of the symptoms of neuropathy; thus, home therapy should be organized. however, unfortunately, this arrangement is not always possible, given enhanced staff shortages, and is unsuitable for treatment initiation. switching to oral corticosteroids [ ] is not recommended during sars-cov- infection and may worsen the disease in dysimmune motor neuropathies [ ] . in myasthenia gravis, intravenous immunoglobulin is also used, either during an outbreak or recurrently [ ] . in the latter case, the recommendation for home therapy was also made, and the same is true in the context of dysimmune neuropathies unless the severity of the relapse warrants in-patient monitoring. the filnemus network recommends that patients treated with immunosuppressants for a dysimmune pathology should continue all of their treatments in the absence of any manifestations suggestive of covid- . it should be reminded that stopping treatment may lead to a relapse of the disease. particular attention should be paid to steroid therapy, since the abrupt interruption of corticosteroid therapy may be responsible for acute adrenal insufficiency. as the data in the literature are constantly evolving, these guidelines will be periodically reevaluated. there is no contraindication in the context of covid- to initiating immunosuppressant treatment (e.g., azathioprine, methotrexate and mycophenolate mofetil) to control a severe inflammatory pathology. this would, of course, be accompanied by a strict application of public health recommendations. for methotrexate more specifically, the switch from the injectable to the oral route can be discussed to prevent the patient from being contaminated by the home care nurse. ultimately, the decision depends on the reason for choosing the injectable form. if it is a reason of efficacy, then optimal disease control is necessary. conversely, if there is a problem of tolerance, it may be difficult to reverse the decision, and a dose-splitting trial may be warranted in this regard. as for biotherapies (e.g., rituximab and equivalents), it is justified to maintain them if they are effective and well-tolerated to avoid the potential occurrence of a relapse, in conjunction with strict application of public health recommendations. for the initiation of a biomedication, decisions will have to be made on a case-by-case basis depending on the pathology (e.g., anti-musk myasthenia gravis), its severity, the regional situation of the epidemic, and the informed consent of patients [ ] . in the case of covid- infection, steroids should not be stopped abruptly because of the risk of adrenal insufficiency. high-dose steroid therapy has been tested previously in respiratory syndromes such as sars or mers without worsening or even improving mortality rates j o u r n a l p r e -p r o o f [ , ] . currently, data about the effects of other treatments remain very sparse; nevertheless, the first results from the italian experience are demonstrative. out of a cohort of patients with chronic inflammatory rheumatic diseases treated by biotherapies or jak inhibitors, eight patients had a covid- infection either confirmed or strongly suspected [ ] . in all cases, the authors reported that they suspended the treatments during the infection and resumed them after a "transient" discontinuation. any discontinuation of immunosuppressive therapy should be discussed with the referral center following the patient. as in the experience of infectious events, particularly bacterial events under biotherapy, the resumption of immunosuppressant therapy should be discussed to weeks after the absence of any symptoms, i.e., a total cessation of around to weeks from the start of covid- infection. azathioprine cannot be crushed and then cannot be administered if the patient is tube-fed. in this case and if the decision to maintain immunosuppression is made, a switch to mycophenolate mofetil syrup can be an option to consider. finally, biotherapies such as tocilizumab are promising candidates for the treatment of the cytokine storm responsible for covid- acute respiratory distress syndrome [ ] . some patients have been tempted to stop their angiotensin-converting enzyme (ace) inhibitors or angiotensin ii receptor blockers (arbs), given the release of information (mostly transmitted on social media), suggesting that these drugs may increase both the risk and severity of covid- infection. this concern arose from the observation that the virus binds to ace to infect cells and the fact that ace levels are increased in patients treated with ace inhibitors and arbs. however, there are currently no data proving a causal relationship between ace activity and covid- -associated mortality [ ] . some findings from preclinical studies even suggest a possible protective role of arb in covid- associated lung injury [ ] . it has been well documented that the abrupt withdrawal of ace inhibitors or arbs in high risk patients, including those with cardiac dysfunction, may result in further clinical instability and adverse health outcomes. thus, patients who are at risk for, being evaluated for, or who have been diagnosed with covid- should continue with their usual cardiac treatments, including ace inhibitors and arbs [ ] . in the epidemic context, it was decided over a period of to months to discontinue inclusions in clinical research protocols. home delivery of products to those already enrolled was arranged with study sponsors, and follow-up visits were converted into teleconsultations. however, visits and treatments that are essential for urgent clinical care may concurrently still serve as research visits, in the appropriate circumstances. numerous therapeutic trials have been initiated in the context of covid- infections. as one example, a large randomized european study (discovery) evaluating four treatments for covid- -specifically, remdesivir, lopinavir in combination with ritonavir, ritonavir in combination or not with beta interferon, and hydroxychloroquine-was started in march (clinicaltrials.gov identifier no. nct ). although various treatments under review appear promising, their effectiveness still needs to be confirmed in larger populations. at this time, certain experimental treatments for covid- may be offered "compassionately," i.e., outside trial conditions. in the case of patients with neuromuscular disorders, the medication should only be taken after consultation with the patient's neuromuscular specialist. in the context of other neuromuscular diseases, particular attention must be paid to two experimental covid- treatments, hydroxycholoroquine and azithromycin [ ] . a retrospective study of patients with autoimmune myasthenia gravis showed a worsening of the disease after taking treatments such as azithromycin (odds ratio: . ), fluoroquinolone (odds ratio: . ), and beta-blockers (odds ratio: . ). these treatments are also contraindicated in congenital myasthenia gravis [ ] . however, if the patient is intubated and ventilated, these antibiotics can be used in the absence of alternative therapy. it should be kept in mind that the worsening or flare-up of myasthenia gravis usually occurs within days of the administration of the contraindicated antibiotic treatment, but flare-ups may occur later on up to days after the initiation of treatment [ ] . in the absence of a demonstrated benefit from hydroxychloroquine and given that an exacerbation of myasthenia gravis may be caused by this molecule, although reports are contradictory [ , ] , the filnemus network does not recommend their use in myasthenic patients with covid- infection at the time of writing. for other neuromuscular diseases (and, in particular, andersen's syndrome), great attention must be given to the fact that the primary cardiac effect of hydroxychloroquine is qt prolongation, which may lead to cardiac arrest secondary to cardiac arrhythmia. this risk is increased when hydroxychloroquine is combined with azithromycin, which has the same cardiac effects. the decision to initiate or continue with this treatment can only be made based on an individual benefit-risk assessment, considering i) corrected qt measurements and the occurrence of cardiac arrhythmia, ii) the effectiveness of the treatment on covid- infection, and iii) the presence of qt-modulating factors (e.g., ionic disturbances such as hypokalemia or qt-prolonging drugs). there is also an increased risk of conductive disorders and systolic left ventricular dysfunction, which have been mainly reported for long-term treatments. the covid- pandemic, unprecedented in terms of the number of patients affected and its severity, has prompted growing concerns about the capacity of the various health systems to cope with the resultant increased medical needs, particularly in terms of having adequate resuscitation beds. in france, the excess of patients in the intensive care unit (icu) has led to transfers of patients from the greater east region and paris to other regions in france or even other neighboring european countries. in france, the medical community-including, particularly, icu practitioners-has raised the possibility of having to make difficult choices and prioritize patients concerning access to resuscitation in an emergency. age and the presence of comorbidities appear to be the risk factors for developing severe covid- infection. recent papers also reported that the survival of patients with acute reparatory distress syndrome in association with covid- is lower than that in association with other conditions [ , ] . in the unfavorable emergency context related to covid- , the french society of anesthesiology and intensive care has drawn up recommendations for the process of decision making about admission to the icu [ ] . these recommendations recall that the context does not justify renouncing the decision making principles of treatment limitations and discontinuation usually adopted by icu practitioners. the goal is to preserve a medical decision based on deliberation while agreeing to allocate resources to those patients in whom interventions have the best chance of success. they recommend that the following five elements of decision making should be considered whenever possible: . anticipating decision making to escape the emergency and guarantee the necessary time for deliberation is available to mature a decision . collecting the patient's wishes directly, by relatives or through advance directives . maintaining collegiality with the reasoned opinion of at least one other doctor and conducting consultation with at least one member of the health care team . assessing the following aspects of the patient's state: a. the patient's previous condition as reflected by age, comorbidities, the fragility evaluated by the clinical fragility score [ ] , and the existence of a neurocognitive disorder b. current clinical severity as assessed by o requirements of more than l/min or respiratory distress, glasgow score of less than points, and systolic blood pressure of less than mmhg c. the kinetics of aggravation of the patient's previous and current conditions . transparency with regular and repeated evaluations of the response to the therapies used, justification and traceability of decisions in the medical file, and provision of information to relatives frailty is a recent geriatric concept that began to be discussed in the s in north america. the clinical frailty score, ranging from one to nine points, is an easy-to-use scale that includes various clinical items on cognition, mobility, physical fitness, and comorbidities. several studies to date have reported its usefulness in predicting the functional prognosis of patients in the icu [ , ] . neuromuscular disorders may be incurable, but they are not untreatable, and the implications of different treatment decisions vary significantly. the neuromuscular specialist must be available to play a role in ensuring the fair provision of intensive care to patients with neuromuscular disorders. in march , a filnemus multidisciplinary working group composed of neurologists, neuropediatricians, pneumologists, palliative care physicians, and icu practitioners met to discuss choosing decision making criteria for the admission of neuromuscular patients to the icu in the context of the covid- pandemic. the initial assessments of this meeting were as follows: . many neuromuscular patients could be considered at high risk of complications from covid- infection such as those with the presence of respiratory failure, cardiac involvment, long-term treatment with corticosteroids and/or immunosuppressive treatments, and comorbidities that may be associated with certain neuromuscular diseases (e.g., diabetes, obesity, and hypertension). . the clinical frailty score, used to assess the patient's previous condition, has never been validated in the context of neuromuscular diseases and could be a factor that overestimates a patient's prognostic severity. it is noted that some patients with neuromuscular diseases are not autonomous in daily life but have a social environment that effectively compensates for this lack of autonomy. as other procedures show a risk of generating aerosolization such as oxygen therapy, particularly at high flow rates, it has been recommended that noninvasive ventilation (niv) be avoided as much as possible to reduce the risk of contamination [ , ] . however, some patients with neuromuscular diseases use niv chronically. if a patient has to use niv, the use of a single circuit with a mask leak is contraindicated because of the aerosolization caused by the system. however, measures to adapt the circuit and the use of niv make it possible to limit aerosolization and continue using niv. before starting or stopping niv, the patient's mask must be in place, and personal protective equipment must be worn by caregivers [ ] . the mask should be sealed as tightly as possible, involving a full face mask, perhaps with a temporary lowering of the pressure if the leakage is too great, and an anti-bacterial filter should be used at the ventilator outlet on the inspiratory circuit and after the mask [ ] . oxygen therapy can be added to the niv if necessary. for patients with contraindications to resuscitation, we recommend that the local palliative care team be consulted. some neuromuscular patients have written advance directives, including whether or not they wish to be intubated in the event of respiratory distress. emergency medical teams are reminded of the importance of checking with the patient's family and friends or referring physicians beforehand, if possible, to find out whether any advance directives have been drawn up. the regional services of the afm-telethon in their emergency kit updated during the covid- period remind the patient of the importance of keeping these advance directives with them in the case of emergency. this research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. recommandation régionales covid the role of telehealth in the medical response to disasters advantages and limitations of teleneurology european cross-sectional survey of current care practices for duchenne muscular dystrophy reveals regional and age-dependent differences evidence-based guideline summary: evaluation, diagnosis, and management of congenital muscular dystrophy: report of the guideline 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quelques repères éthiques n a global clinical measure of fitness and frailty in elderly people long-term association between frailty and health-related quality of life among survivors of critical illness: a prospective multicenter cohort study clinical frailty scale score before icu admission is associated with mobility disability in septic patients receiving early rehabilitation staff safety during emergency airway management for covid- in hong kong exhaled air dispersion during highflow nasal cannula therapy versus cpap via different masks recommandations d'experts portant sur la prise en charge en réanimation des patients en période d'épidémie à sars-cov appareillages respiratoires de domicile d'un malade suspect ou porteur du de virus respiratoire the authors have no conflict of interest key: cord- -yzvag x authors: scolnick, barbara; zupec-kania, beth; calabrese, lori; aoki, chiye; hildebrandt, thomas title: remission from chronic anorexia nervosa with ketogenic diet and ketamine: case report date: - - journal: front psychiatry doi: . /fpsyt. . sha: doc_id: cord_uid: yzvag x background: chronic anorexia nervosa is a tragic disease with no known effective pharmacological or behavioral treatment. we report the case of a year-old woman who struggled with severe and enduring anorexia nervosa for years, and experienced a complete recovery following a novel treatment of adopting a ketogenic diet followed by ketamine infusions. her remission has persisted for over months. case presentation: at age . , the patient embarked on an effort to “eat healthy.” she quickly lost control of the dieting, developed associated compulsions and obsessions about food, body dissatisfaction, emotional lability, and lost nearly . kilograms ( pounds). she was hospitalized for weeks, and while she regained some weight, she did not attain full weight restoration. for years, she continued to eat in a restrictive manner, exercise compulsively, and have intermittent periods of alcohol dependence. nevertheless, she always hoped to get well, and at age , she began a novel treatment for anorexia nervosa. conclusions: this is the first report of a ketogenic diet used specifically for the treatment of anorexia nervosa, followed by a short series of titrated iv ketamine infusions leading to complete remission of severe and enduring anorexia nervosa, with weight restoration, and sustained cessation of cognitive and behavioral symptoms, for months. although these treatments were used sequentially the relationship between these modalities, and possible synergy, is unclear, and deserves further study. complete and sustained remission of chronic anorexia nervosa is quite rare, and the novel use of a ketogenic diet and iv ketamine treatment in this potentially lethal condition suggests avenues for further research, and hope for patients and their families. anorexia nervosa (an) is a severe disorder characterized by selfstarvation, hyperactivity, anxiety, body dissatisfaction, and emotional dysregulation that usually begins in early puberty, and affects females more frequently than males. when weight restoration is the only criteria measured, rates of % recovery are often noted, but when cognitive recovery is included, the results are more discouraging ( ) ( ) ( ) . severe and enduring anorexia nervosa refers to cases that have persisted for at least years, and are resistant to intervention. it is a tragic disorder with no consistently effective pharmacological or behavioral treatments. the mortality rate is estimated to be ten times higher than that of the general female population, due to medical complications of self-starvation, and suicide ( ) . we report a case of severe and chronic an treated successfully by adopting a ketogenic (kg) diet for months followed by a series of intravenous ketamine infusions. emerging data suggest that disturbances in lipid signaling may underlay some of the core pathology of anorexia nervosa ( ) ( ) ( ) and that chronic starvation may promote a type of metabolic hibernation in patients ( ) that requires normalization of lipid signals to resume premorbid metabolic and central nervous system functions. a kg diet is a high fat, low carbohydrate medical diet, that leads to increased fatty acid oxidation for cellular energy, which in turn results in increased ketone body production. ketones are produced in the liver whenever fat metabolism increases over carbohydrate metabolism; such as fasting, post-exercise, neonatal period, and kg diet, as well as during pathological states such as starvation or uncontrolled diabetes mellitus ( ) . ketones easily pass the blood brain barrier and become the brains' major energy source. this change in metabolic fuel from glucose to ketones leads to a myriad of changes in central nervous system neurotransmitters such as adenosine and gamma-aminobutyric acid (gaba), as well as neuropeptides such as leptin, adiponectin, and growth hormonereleasing peptides ( ) . as far as we know, this is the first publication describing the use of a kg diet for patients with an. in addition to dietary disturbances and potential metabolic disturbances, psychiatric symptoms such as anxiety, obsessivecompulsive disorder, depression, and addiction are frequently observed among individuals with an ( ) . ketamine has emerged as a novel treatment for treatment-resistant mood disorders, particularly those with suicidal ideation ( , ) . as far as we are aware, there is only one published study of ketamine infusions for an, and it was encouraging ( ) . we report the case of a year-old woman, with chronic severe an who had an excellent response to adopting a ketogenic diet and undergoing ketamine infusions. the patient was a years old single woman, diagnosed with an at age . , and intermittent alcohol dependence beginning at age . she was not in active psychiatric treatment, although she saw a supportive therapist episodically and attended alcoholic anonymous meetings at least once/month. she had been abstinent for months, and was eating with many restrictions-preferring to eat by herself and use a napkin rather than a plate, eating only ice cream for days at a time, and excessively using non-nutritive low calorie sweeteners. she exercised daily and compulsively, usually spending h at the gym. her weight had been stable at . kg ( lbs) for several years. recognizing she was living a very limited life, she decided to try a novel treatment, and worked closely with an internist who was knowledgeable about eating disorders, who is the first author. the patient was the product of a normal pregnancy and delivery and raised in an upper middle class home by parents who are both attorneys. her older sister was very concerned with her own appearance. family history was significant for a paternal grandmother who was obsessed with "being very slender" all her life, though was never given a psychiatric diagnosis. the patient's mother was diagnosed with an anxiety disorder and was prescribed citalopram. at an early age, the patient was identified as athletic, artistic, and excelled academically. her parents noted that she had "compulsive tendencies' such as "grinding erasers" and wanting her possessions to be lined up symmetrically, but this never reached the level of clinical concern. at age . , while at a sleep-away camp, she began a diet, with the aim of "eating healthier" with other girls in her bunk. when summer ended, she continued her diet. her parents slowly became aware of a change in her mood and behavior, from a happy child to a sullen and angry teenager. they initially attributed this to the "onset of adolescence" but when her weight loss became more obvious, she was evaluated by her pediatrician, and was referred to an outpatient eating disorder clinic, where she ate dinners/week. she also had weekly individual supportive therapy, and weekly meetings with a nutritionist. her parents also saw a therapist separately. her weights are summarized on table ; prior to illness she weighed . kg ( lbs); height . meters ( ' ") with a body mass index (bmi) of . . twelve months into the course of her illness, she had a grand mal seizure. at the time, her weight was . kg ( lbs) with bmi of . , and her treatment was changed to incorporate maudsley treatment in which the parents are actively taught to re-fed the child ( ) . she was resistant, and meals were rarely successful; after months of out patient treatment she was hospitalized for days followed by days of "partial hospitalization." on admission to the inpatient unit, her weight was . kg ( lbs.) with a bmi of . . her pulse was sitting, rising to standing, and her blood pressure was / sitting; and / standing. the remainder of the exam was normal as were her electrolytes, and kidney and renal function tests, and complete blood count, mri, eeg, and ekg. a bone density exam showed mild osteopenia of the hip and spine. she had had a normal menarche age , but had been amenorrheic for months. she denied binging, purging, laxative, or diuretic abuse and was given the diagnosis of anorexia nervosa restricting type. she was discharged to home after attaining a weight of . kg ( lbs.) with a bmi of . . she returned to high school, yet she never regained friendships she had prior to the hospitalization, and remained dismissive of her parents' efforts to supervise her eating. her weight generally hovered near . kg ( lbs.). she started college several times, and dropped out several times, but eventually graduated from an excellent university. over the next years, she had three month-long admissions to alcohol & drug rehabilitation programs. she worked as a recovery coach in several wilderness rehabilitation programs, and began graduate school. the only medications she was prescribed were lamotrigine for six months following the seizure, and lisexamfetamine dimesylate (vyvanse). at age , on physical exam, she appeared fit and well. her bp was / and pulse , without orthostatic changes, and her weight was . kg. ( lbs). her physical exam was normal, as was her complete blood count, electrolytes, liver and kidney function tests. she was coached by an experienced kg nutritionist on ways to prepare high fat, low carbohydrate meals and smoothies, and encouraged to eliminate nonnutritive sweeteners. the goal was to induce a stable degree of ketosis, following a liberal kg diet with a : to : ratio of fats: carbohydrates + protein in grams. while we anticipated it might be difficult for her to eat fatty foods, as it is known that individuals with an avoid high calorie foods ( ), she found it relatively easy. • "the whole time i was anorexic, i ate my safe foods, and there were not many: lots of splenda®, frozen yogurt, zucchini, eggplant and coffee. i only ate such a ridiculously limited amount of food, that the logistics of switching to keto were not that hard -when you think you want x, have y instead. if you have three x's and that's it, then have three y's, and for me the ketos were bacon, eggs, cheese avocado, medium chain triglyceride (mct) oil" initially, she varied between strictly following the kg diet and being lax, but gradually found she was gaining insights into the anorexic "voice", and it became easier to follow the diet and remain in ketosis. • "until now (kg), i ate sweetener with everything. i used to put splenda on broccoli." • "i now consider myself to have a sugar allergy. when i eat avocados or bacon and eggs, the "voice" is softer, if i eat sugar i feel euphoric, but the euphoria has feelings of panic." she measured breath acetone levels with a portable breath monitor, - times/week. breath acetone levels are scored qualitatively from to , and she was at or (mild-medium range) when she was on the kg diet. after months on the diet, she reported she was " - % better, but was still troubled by anorexic compulsions." she was referred for ketamine infusions. she underwent comprehensive evaluation, and met dsm-v criteria for anorexia nervosa, restricting type, and major depressive disorder, recurrent, moderately severe, with patient health questionnaire- (phq- ) of ( ) . she began treatment with racemic iv ketamine at dose of . mg/kg ( . mg), in cc . % normal saline infused over min in a private room with dimmed lights, sound machine, using an eye mask. pulse, blood pressure, respiration, o saturation, and cardiac waveform were monitored continuously throughout her infusion and showed expected variations in pulse and blood pressure which did not require intervention. dissociation was present, as evidenced by patient report of feeling "out of my body" and "seeing things in layers," and clinical observations. she displayed decreased verbal fluency and mild - beat end-gaze nystagmus during treatment, which resolved completely. she developed mild nausea following her first infusion. there were no other reported or observed side effects during treatment. all treatment-emergent side effects dissipated within min. within one hour of her first infusion, she felt the anorexic voice was weakening, and she had more ability to "be herself." phq- dropped to . she then had three more iv ketamine infusions over the next fourteen days, at doses titrated to . mg/kg, . mg/kg, and . mg/kg to achieve and maintain dissociation during infusion. each infusion was preceded by ondansetron g sublingual and she denied nausea during or after these infusions. her response was dramatic and occurred after the th infusion. • "i know this sounds ridiculous, but i am no longer anorexic. i had so many rules i didn't even know them. but they are gone. i can exercise because it feels good. it isn't that i have to. i can stop when i want to." notably, her phq- dropped to after her first treatment, and to following her third infusion. she has continued to feel free from the intrusive an obsessive thoughts, rigid an rules, and compulsive behaviors, and to explore a fuller life, and is now over months post ketamine infusion. she continues to eat a kg diet and her weight has inched up to . kilograms ( pounds), the weight when the disease took hold at age . . when she weighs herself now she notes: • "i really didn't know how i would feel getting on a scale and looking at my weight. now, i am so relieved. i think i do not care about the number because i can see myself now in the mirror, so the number on the scale is 'like' one source of information, but not the only one. i think pounds is fine and i love the way i look", following treatment, she sees a therapist weekly for supportive psychotherapy, although during the covid- pandemic visits have occurred by telemedicine. she checks her own weight every few weeks when she visits her cousin's apartment where there is a scale, and it has been stable at her premorbid weight of . kg ( lbs). "all these years, i was still in there watching, waiting, and hoping to escape. every single interaction now is a new freedom." she is very supportive of this publication and hopes this treatment will be studied to determine if it is effective for other patients who suffer, as she did. this is a striking case report of an unusual combination of a ketogenic diet and a short series of titrated ketamine infusions in a patient with severe chronic an of yearsmodalities that have a rational medical justification, but have never been used clinically for this disorder, or in this patient population. this resulted in a surprising and long lasting complete remission which has continued despite the stressors of living in new york city in the midst of the covid- pandemic. the strength of this case report is that it offers an innovative approach to chronic an, a disorder which is exceedingly resistant to treatment and associated with an increased risk of death. kg diets for an have been roundly dismissed by eating disorder experts, and with the exception of an early study in , ketamine has not been reported as effective in an. thus, it is critical to consider the context of how this treatment sequence evolved for this patient. the impetus for this treatment arose when the patient was presented with an etiological theory of an, known as adaptation to flee famine hypothesis, which frames the genesis of an as metabolic rather than psychological ( ) . this resonated deeply with the patient, as she often had felt she was battling invisible forces. seeing her symptoms as the result of distorted physiological signals and offering a metabolic solution was powerfully motivating. explaining that there was an animal model for an that replicated many of its symptoms, was also empowering, as it countered the narrative that she was somehow "choosing" this disorder in order to exert "control" over her life. these psycho-social constructs, which she had heard many times in rehabilitation centers, had never rung true for her, and had also burdened her with guilt for "causing her own illness." the adaptation to flee famine hypothesis posits that it would have been evolutionarily advantageous to a nomadic tribe if some members acted uniquely when presented with a state of food scarcity or famine. if these individuals could deny hunger, dismiss their obvious body inanition, act as if they were just fine, and engage in hyperactive running long distances, they might lead the tribe to better hunting grounds. these are precisely the behaviors seen in adolescents with an. the activity-based-anorexia rodent model involves housing a rodent in a cage with a running wheel, and decreasing the food supply slightly ( ) . some animals, often female and adolescent, will increase running and reduce eating drastically, thus replicating aspects of human an. the model requires both stimuli of decreased food supply plus unlimited access to a running wheel. advising the patient to adopt a kg diet was prompted by two factors. first, two studies employing an activity-based-anorexia model demonstrated that a kg diet rescued the animals from self-starvation ( ) ; and a high-fat diet (although not ketogenic) prevented the animals' self starvation ( ) . secondly, the kg diet has an impressive record of safety and efficacy for treating seizure disorders in children, and has been used continuously since the s ( ) . it is an emerging therapy for treatment of other neurological and psychiatric disorders such as parkinson's, early alzheimer's, and bipolar disorder ( ) . thus, since it is generally safe and effective for other neurological disorders, it might also prove effective for an, especially since an has been shown to be genetically linked with abnormalities in fat metabolism ( ) . there are known side effects of the kg diet which are occasionally observed in patients treated for seizures. these include weight loss, constipation, nephrolithiasis, and hypoglycemia. these effects are seen most often in children who are on multiple anti-seizure medications and are often physically compromised. fortunately, this patient did not experience any of these symptoms and her weight increased as she ate with more freedom. the patient was at a stable weight and the only medication was lisexamfetamine dimesylate (vyvanse). furthermore, a more rigid ketogenic diet of : fat: protein plus carbohydrate diet is often employed for patients with seizures, while the diet employed in this case was a more liberal diet of : or : which may have mitigated some of the possible side effects of the kg diet. it is unknown whether the positive results from the kg diet arm of the treatment were due to adopting a kg diet, or if simply adopting a high fat diet without the carbohydrate restriction required for ketosis would have been effective. we believe it was the ketogenic nature of the diet because the biochemical changes seen with ketosis are different from those seen with increased fat. a recent article testing a ketogenic diet in humans, and also transplanting the microbiome into mice, noted that the microbiome responds differently to a moderate fat diet, a high fat diet that is not ketogenic, and a high fat/low carbohydrate that is ketogenic ( ) . this is an area of active research. if the patient had been pleased with the results of the kg diet alone, the treatment would have stopped at that point. she reported the symptoms of an were " - % improved but she was still troubled with anorexic compulsions. thus the second "arm" of the treatment began-ketamine infusions. the addition of ketamine treatment in this case was also based on studies on the activity-based-anorexia model, plus one very interesting, and overlooked case series report from . experiments with the activity-based-anorexia model found that individual rodents vulnerability to self-starvation correlated with levels of n-methyl-d-aspartate (nmda) glutamine receptors in the dorsal hippocampus ( ) . since ketamine is a well known antagonist to nmda glutamine receptors, an elegant experiment examined whether injection of ketamine on day when the animal had started to self-starve and hyper-exercise could alter the behavior ( ) . as predicted, those treated with ketamine ate more, exercised less, and were resilient to the selfstarvation when they were re-exposed to the paradigm, compared to those treated with placebo. very similar reasoning was described for the rationale of a study from cambridge, england, published in in which mills et al. treated patients with chronic severe an with a series of ketamine infusions ( ) . significant prolonged improvement was reported in patients. some of the responses resembled the dramatic changes noted in this case report. it is difficult to determine the doses of ketamine administered in this report because the authors describe that infusions were delivered at mg/h for h using doses "similar to that used to produce analgesia" but exact doses were not stated. furthermore all patients in this series were prescribed an opiod blocker to "ensure they remained conscious". we approached the ketamine arm of the treatment cautiously because the patient had struggled with alcohol dependence, substance abuse is common in patients with an, and ketamine is a drug that is recreationally abused. a recent study, pooling data from clinical trials found no evidence of serious side effects from a single infusion of ketamine for clinical depression, and ketamine was not associated with increased abuse ( ) . many patients reported feeling "loopy" or "dissociative" during the infusion, but this passed rapidly. while this study is promising, racemic ketamine infusions for psychiatric disorders remains offlabel, and issues of optimal dose, duration, titration, and number of infusions needs further research. in an, these questions deserve further investigation and warrant controlled trials. this patient did indeed experience dissociation during her infusions, which she found was part of its therapeutic effect. although the efficacy of kg diet for seizure disorders, and ketamine infusion for severe treatment resistant depression has been clearly demonstrated, the mechanisms of actions of both agents are not well understood. it is notable that both ketamine and kg diet have been shown to intimately affect brain-derived neurotrophic factor (bdnf), gamma-aminobutyric acid (gaba), and n-methyl-d-aspartate (nmda) glutamate receptors which are the same molecules affected in the activitybased-anorexia model ( , ) . it is possible that the kg diet and iv ketamine act synergistically, with the kg diet "priming" the response to ketamine. this requires further study. there are several important limitations to this report and to the generalizability of the findings. most importantly, this is a single case report and further study is needed. secondly, standardized eating disorder rating scales were not used to monitor progress. this is because this is a report about a clinical experience with a patient used to monitoring her own eating and activity levels by journaling; it was not organized as a clinical trial. there are no eating disorder scales that have been validated for used with ketamine treatment. third, this treatment paradigm essentially involved three modalities, and not just two treatment arms: first the patients adoption and reconsideration of an as a disorder whose symptoms are predominately metabolically driven, which was an enormous paradigm shift for her; secondly adopting the kg diet and contextualizing ketosis as helpful for her brain rather than as a weight loss or weight control method for her body; and third iv ketamine infusions at a dose and titration schedule not previously reported. the fact that this sequential treatment resulted in complete and sustained remission of this patient's severe an thoughts and behaviors was unexpected. furthermore, her remission has persisted despite extreme stressors, social isolation, work restrictions, and treatment disruptions during the covid- pandemic in nyc. at his point it is not possible to state which modality was essential, or which had the most important therapeutic benefit, if both ketogenesis and ketamine are necessary and synergistic, or if the treatment would have been as effective if the kg diet were initiated with ketamine when ketamine infusions began instead of preceding them by several months. it is possible that ketamine infusions alone would have been effective. future studies are necessary to address these questions, and to address optimal kg diet ratios and optimization of ketamine dose, duration, and frequency. there remain many unanswered questions about the generalizability of these findings to other patients with an. yet, the medical plausibility of this treatment and the dire prognosis of chronic anorexia nervosa, suggest that both the kg diet and ketamine treatment warrant further study in this patient population towards the goals of restoring weight, normalizing cognitive and emotional functioning, and improving quality of life. it is hoped that this report will stimulate this research. the original contributions presented in the study are included in the article/supplementary material; further inquiries can be directed to the corresponding author. ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. the patient provided her written informed consent to participate in this study. written informed consent was obtained from the individual, for the publication of any potentially identifiable images or data included in this article. all authors contributed to the article and approved the submitted version. bs orchestrated the treatment and wrote the first draft of paper. bk coached the patient on the ketogenic die and edited the paper. lc performed a comprehensive evaluation of the patient, treated the patient with ketamine infusions, and edited the paper. ca performed the studies on activity-based-anorexia, kept the authors informed of her studies, and edited the paper. th was the primary medical provider years ago when the patient first became ill, continued to consult regarding her care over the years, and edited the paper. treatment outcome reporting in anorexia nervosa: time for a paradigm shift? recovery from anorexia nervosa and bulimia nervosa at -year follow up long-term outcome of anorexia nervosa: results from a large clinical longitudinal study severe and enduring anorexia nervosa in search of a new paradigm dysregulation of soluble epoxide hydrolase and lipidomic profiles in anorexia nervosa genome-wide association study identifies eight risk loci and implicates metabo-psychiatric origins for anorexia nervosa patients with anorexia nervosa demonstrate deficiencies of selected essential fatty acids, compensatory changes in nonessential fatty acids and decreased 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date: - - journal: principles of adult surgical critical care doi: . / - - - - _ sha: doc_id: cord_uid: kqx arn the progression of liver disease can cause several physiologic derangements that may precipitate hepatic failure and require admission to an intensive care unit. the underlying pathology may be acute, acute-on chronic, or chronic in nature. liver failure may manifest with a variety of clinical signs and symptoms that need prompt attention. the compromised synthetic and metabolic activity of the failing liver affects all organ systems, from neurologic to integumentary. supportive care and specific therapies should be instituted in order to improve outcome and minimize time of recovery. in this chapter we will discuss the definition, clinical manifestations, workup, and management of acute and chronic liver failure and the general principles of treatment of these patients. management of liver failure secondary to certain common etiologies will also be presented. finally, liver transplantation and alternative therapies will also be discussed. accepted theories that revolve around impaired detoxification of substances normally cleared by the liver. • ammonia • the metabolism of nitrogen-containing compounds in the gastrointestinal system results in the production of ammonia. in its normal state, the liver converts this neurotoxic product into glutamine and urea. impaired liver function results in elevated blood ammonia. astrocytes contain the enzyme glutamine synthetase in their endoplasmic reticulum as a means of handling excessive ammonia. accumulation of glutamine within the astrocytes results in cell swelling which leads to a series of events that result in a neuroinhibitory state [ ] . • false neurotransmitters • the failing liver results in the production of false neurotransmitters. these molecules may interfere with normal brain functioning and have a net inhibitory effect [ ] . • amino acid imbalance • patients with hepatic failure have decreased plasma levels of the branched-chain amino acids (bcaa) valine, leucine, and isoleucine while experiencing increased levels of aromatic amino acids (aaa) phenylalanine, tryptophan, and tyrosine. this is thought to be related to increased muscle catabolism and therefore increased bcaa metabolism as well as decreased breakdown of aaa by the compromised liver. the end result is an imbalance that leads to an increased influx of aaa in the brain which has an inhibitory effect in the nervous system [ ] . • gaba receptor • thought to be mediated by inflammatory cells, neurosteroids are produced by myelinated glial cells. this results in positive modulation of gaba receptors that in turn enhance the inhibitory tone [ ] . besides the astrocyte swelling that is seen with the accumulation of glutamine explained above, overall neurologic dysfunction results in loss of autoregulation of intracranial pressure as well as reduced cerebral blood flow. the result of these changes may result in further neurologic derangement and compromise [ ] . besides hepatic encephalopathy, patients with alf can also present with cerebral edema. there is an overlap with the clinical features that are seen with encephalopathy and include nausea, vomiting, headache, and agitation. in advanced cases which can progress to brain herniation, hypertension, bradycardia, changes in pupillary exam or reflexes, as well as respiratory depression can be seen [ ] . patients with alf may present with nonspecific respiratory symptoms including dyspnea on exertion, orthopnea, anxiety, and air hunger. the affecting processes involved are very broad and can range from a simple pleural effusion to acute respiratory distress syndrome (ards) [ ] . the spectrum of respiratory pathology that is seen can be grouped in to two major categories: infectious and noninfectious (table . ) . pulmonary edema can be of cardiogenic or noncardiogenic etiology. the prevalence of pulmonary edema appears to be higher in those patients with cerebral edema, suggesting the accumulation of osmotic substances within the lung parenchyma and outside the vasculature [ ] . molecular imbalance and injury to endothelial cells, accompanied by a decrease in oncotic pressure, may play a role in the development of this disease. hepatopulmonary syndrome can be seen in both alf and chronic liver failure. it is thought to arise from microscopic shunting from arteriovenous dilations that occur in the pulmonary vasculature [ ] . the precise mechanism is unknown; however, it is thought that the elevated levels of nitric oxide seen in patients with liver failure may mediate the abnormal vasodilation that occurs in the pulmonary parenchyma. the result is an overperfusion with maintenance of ventilation; a vq mismatch occurs that ultimately leads to hypoxemia [ ] . as part of the pathophysiology associated with alf, there is low systemic vascular resistance and a hyperdynamic circulation with elevated cardiac output. the pathophysiology is multifactorial but vasoactive substances are thought to mediate the process [ ] . while the underlying pathophysiology may differ, hemodynamic variables appear very similar to those seen in sepsis and septic shock. in the failing liver, there is an increase in splanchnic blood pooling that is associated with the increased resistance of flow through the liver. this results in increased shear stress in the splanchnic circulation that causes upregulation of endothelial nitric oxide synthase (enos) and ultimately nitric oxide (no) production [ , ] . there is further systemic vasodilation causing a low effective circulating volume and relative hypotension despite an overall elevated intravascular volume. the systemic baroreceptors are unloaded and there is a compensatory increase in cardiac output as well as activation of the renin-angiotensinaldosterone system (raas) that may ultimately affect the renal system ( fig. . ) [ ] . patients with alf usually present with varying degrees of coagulopathy. as the liver fails, there is decrease in the synthesis of factors involved in both coagulation and anticoagulation, specifically fibrinogen, prothrombin, protein c, protein s, and factors v, vii, viii, ix, x, and xi. the end result is an increased in prothrombin and activated partial thromboplastin times as well as elevation of inr [ ] . overt bleeding is not typically seen, as there is a decrease in both coagulation and anticoagulation factors. however, mucosal bleeding from the oropharynx or the gastrointestinal mucosa can be frequently seen. this is compounded by the underlying platelet dysfunction that can occur in patients with liver failure. right upper quadrant pain, gastrointestinal bleeding, ascites, nausea, and vomiting can be seen in patients with alf. these symptoms are nonspecific and can be multifactorial. patients with acute viral or autoimmune hepatitis may experience liver parenchyma inflammation as part of the normal response to infection. this leads to an increase in the overall volume of the liver. the liver capsule may be unable to accommodate acute volume changes, and stretching of it results in activation of pain receptors and right upper quadrant pain. discomfort in this area can also be related to direct trauma causing bleeding. abdominal distention may be associated with ascites. the neurohumoral alterations are seen with alf leading to excessive sodium retention and ultimately plasma volume expansion. this, combined with a decrease in the overall circulating proteins due to compromised liver function, leads to overflow of fluid into the peritoneal cavity [ ] . tense ascites can result in compromise of respiratory, renal, and cardiovascular function due to direct compression of the diaphragm and vasculature. as part of its normal physiologic function, the liver is responsible for gluconeogenesis as well as glycogen storage. as liver function worsens, these two key metabolic functions are compromised. in up to % of patients, hypoglycemia is seen and treatment is warranted [ ] . compromised flow through the liver secondary to fibrosis or intrinsic disease acute kidney injury can be present in - % of patients with alf [ , ] . the etiology can be variable: prerenal azotemia, drug toxicity, and acute tubular necrosis have all been implicated. hepatorenal syndrome, especially type , has also been associated with the progression of this disease. acute kidney injury can be divided into oliguric vs. anuric failure, with the latter making fluid management difficult in the critical care setting [ ] . accompanying this derangement we can also see electrolyte disturbances: hyperkalemia, hyperphosphatemia, hypophosphatemia, hypercalcemia, and hypomagnesaemia that can lead to secondary arrhythmias and mental status changes [ ] . lactic acidosis can be seen in patients with alf. the accumulation of tissue lactate is multifactorial. the effective blood pressure is usually lower in those patients with liver failure. this causes a generalized tissue hypoxia that leads to the production of lactate. the compromised liver is unable to uptake and process the lactate, leading to its accumulation [ ] [ ] [ ] . in addition, acute kidney injury can further contribute to the underlying acidosis due to failure of fixed acid clearance [ ] . kupffer cells can be found around the hepatic sinusoids. because of their location, they are constantly exposed to gut bacteria and endotoxins. they play a key role in clearing these pathogens and in maintaining normal homeostasis. in patients with liver failure, their function is impaired, and there is an increased susceptibility to develop gram-positive and gram-negative bacterial infections as well as possible fungal and viral infections [ ] . hepatic encephalopathy has been linked to an increased incidence of infection [ ] . although the mechanism behind this has not been clearly elucidated, it is thought that cns depression alters the immune system modulation. in alf, there is also a change in the production as well as clearance of different cytokines in patients with liver failure and compromised neutrophil function. these problems will lead to decreased bacterial opsonization and clearance. these alterations ultimately contribute to the immunologic impairment [ ] [ ] [ ] . up to three quarters of patients with alf will develop a bacterial infection. the organisms that are most commonly seen include gram-negative-bacteria, streptococcus, staphylococcus, and candida. they may develop a systemic inflammatory response syndrome (sirs) that will be undistinguishable from noninfectious conditions including necrotic hepatocytes from the failing liver [ ] [ ] [ ] . jaundice and pruritus are common complaints of patients with alf. although not specific to liver failure, the presence of both symptoms should raise suspicion of compromised excretion of bilirubin by hepatocyte failure. a normal by-product of the metabolism of heme, bilirubin is usually excreted in bile and urine. the liver is responsible for conjugating glucuronic acid with bilirubin in order to make a soluble compound. as a result, conjugated bilirubin passes into the colon and is eventually eliminated. in the failing liver, there is a severe compromise of the ability to metabolize and excrete bilirubin secondary to the undergoing cell necrosis. there is buildup of unconjugated bilirubin in the blood resulting in eventual deposition of these molecules in mucous membranes, skin, and conjunctiva, what is known as jaundice [ ] . because of the yellow color of the pigment, the physical appearance of the patient changes, directly correlating with bilirubin levels. besides bilirubin, there is also accumulation and deposition of bile acids in the skin. this has been associated with pruritus. other mechanisms that may explain this symptom include the endogenous opioids theory which proposes that the liver failure patient has elevated opioid levels secondary to decrease clearance and metabolism. these molecules activate the mu opioid receptor which may produce pruritus [ ] [ ] [ ] . as explained throughout this chapter, the management strategies for patients with alf are different from those of patients that have chronic liver failure with an acute decompensation. it is imperative to determine what form of failure the patient is experiencing. for those with alf, early recognition and transfer to a transplant center will improve outcomes and mortality. on initial presentation, a patient's mental status will be affected to different degrees; however it may deteriorate further. getting a thorough history during the first encounter is therefore important as it can elucidate the possible cause of the acute failure. the intensivist should review all medications that the patient ingested in the last days. specific questions about ingestion of acetaminophen should be asked. dietary intake should also be explored, playing close attention to any exposure to mushrooms. exact time of ingestion is key in order to determine treatment and further steps in management. social history should also be reviewed in detail. recent travel to viral hepatitis endemic areas as well as contact with other patients that have required hospital visits should be evaluated. focus on alcohol and drug use, sexual behaviors, and vaccination status can help determine the causative mechanism for the liver failure. past medical history plays a key role in determining if the patient has chronic liver disease or if they are experiencing an acute failure. a history of hepatitis, ascites, jaundice, asterixis, and gynecomastia and family history of a metabolic disorder favor chronic liver disease with an acute exacerbation. history of malignancy and lack of screening for colorectal cancer should also make the intensivist suspicious for metastatic malignancy. physical exam may disclose important findings that can elicit cause. an effort to identify the clinical manifestations described previously should be done. laboratory values that should be routinely obtained are listed in table . . when testing for hepatitis b, it is important to evaluate for immunity (hepatitis b surface antibody), infectivity (hepatitis b e antigen), and the presence of an acute infection (hepatitis b core antibody igm). although hepatitis c can cause alf, it is usually associated with chronic liver failure [ ] . bun and co can usually be lower than reference values in patients with alf. this is secondary to poor muscle mass as well as a respiratory alkalosis experienced by these patients. presentation with concomitant renal failure will alter most serum electrolytes. elevation of liver enzymes can be indicative of acute hepatitis and alf. however, values that are within reference range may be markers of poor prognosis as it may be reflective of decreased effective liver mass [ , ] . workup should be started on presentation, even if patient is going to be transferred to a liver center. early identification of the etiology and early treatment can significantly improve outcome. it can also identify those patients that will need liver transplantation in order to treat their disorder. if during the history and physical assessment a cause can be clearly identified, treatment should be started empirically. waiting for laboratory values can be detrimental and result in further deterioration of the patient. consultation with hepatology/gastroenterology, transplant surgery, and the intensivist should be done upon determination of liver failure of any cause. the development of alf has very different etiologies as well as presentations. as such, the management may differ from patient to patient. identification of the causative agent and treatment of it is important. however, supportive care in the intensive care unit is critical for ensuring a positive outcome. patients that have evidence of encephalopathy will require intensive care unit (icu) admission and management while those with no neurologic derangement can be followed on a regular ward with close monitoring. patients should have frequent checks of their coagulation parameters, arterial blood gases, complete blood counts, metabolic panels, serum aminotransferases, alkaline phosphatase, and bilirubin levels. derangements warrant further investigation. hemodynamic monitoring, precise fluid management, and monitoring for infections are all essential. the grade of hepatic encephalopathy guides the management and treatment of the neurologic system in alf. this is because intracranial hypertension (ich) and cerebral edema characterize the severity of patient presentation. those with mild forms (grades i and ii) very rarely develop these devastating complications while - % of patients with grade iii and - % of those with grade iv present with ich [ ] . for those patients with grades i and ii, frequent neurologic assessments should be performed to follow possible neurological progression. maintaining the patient in a quiet environment helps minimize agitation. sedation should be minimized; however, if needed minimal doses of short-acting benzodiazepines should be used [ ] . for patients who present with or develop grade iii and iv neurological symptoms, securing an airway should be the first treatment strategy followed by mechanical ventilation. for sedation, propofol should be used since there is evidence that it decreases cerebral blood flow and allows for frequent ongoing neurological assessment [ ] . intracranial pressure (icp) monitoring devices are used in some icus in patients with alf and grade iii or grade iv encephalopathy [ ] . the main reason for its use is the early identification of ich and subsequent treatment. also, not all patients present with cushing's trial of systemic hypertension, bradycardia, and irregular respirations. several trials have shown that icp monitoring can be performed safely and successfully be used to manage ich [ ] [ ] [ ] . however, no trial has demonstrated a survival benefit. bleeding has been associated with the placement of monitors; however, recent literature reports that there is a decrease prevalence of this particular complication. the incidence of bleeding after placement of icp monitor device has been less than % [ ] . ct scan of the brain should be considered in those patients with an acute mental status change and those with coagulopathy in order to rule out intracranial bleed. this imaging modality does not diagnose cerebral edema or ich in all patients, and therefore, it is not needed in every case of encephalopathy. patients at risk of encephalopathy should also have the head of their bed elevated at ° [ ] , minimize et suctioning, and minimize pain as these factors can lead to ich [ ] . for those patients with elevated ammonia levels (greater than ug/dl) and alf, administration of lactulose can lower the incidence of cerebral edema and decrease mortality [ ] . prior to prescribing this drug, the route of drug administration must be considered as the patient's ability to tolerate po intake may be compromised. other compounds studied include l-ornithine l-aspartate but have failed to demonstrate any survival improvement [ ] . phenytoin has been proposed as a possible prophylactic measure to prevent cerebral edema. an initial study that involved evaluation of brain at autopsy showed that patients who were treated with prophylactic phenytoin had a decrease in cerebral edema [ ] . follow-up trials were unable to replicate these results and more importantly, there was no survival improvement when this agent was used prophylactically [ ] . the administration of intravenous mannitol has been shown to transiently decrease cerebral edema and may be helpful in cases in which ich is < mmhg [ ] . a dose of . - g/kg may be beneficial and it may be repeated if serum osmolality is below mosm/l. the use of hypertonic saline has also been suggested. there is a lower incidence of ich in patients with alf that are treated with hypertonic if it is used to achieve a serum sodium level between and meq/l [ ] . use of hypertonic saline can be limited by renal failure. a newer treatment technique that has been proposed to prevent ich is hypothermia. it is thought to mediate this benefit by preventing hyperemia [ ] . concerns regarding the use of hypothermia in the treatment of alf include worsening coagulopathy and compromise of hepatocyte recovery [ ] . hyperventilation and use of corticosteroids have been proposed as a management option to reduce icp. the former may achieve this goal via vasoconstriction. however, trials suggest that although there is a delay in the onset of cerebral herniation, there is no reduction in the incidence of cerebral edema and no survival benefit [ ] . hyperventilation should only be used after all other resources have failed. while hypoxemia in patients with alf arises from many causes, it is treated with supplemental oxygen. if the patient has grade iii or iv hepatic encephalopathy, a definite airway should be established. during intubation, cis-atracurium is the agent of choice since it does not increase icp [ ] . pleural effusions can be observed and may or may not be contributing to hypoxemia or other respiratory problems. the use of diuretics should be carefully considered as these patients are usually in a very delicate hemodynamic state. overuse of diuretics can precipitate renal failure [ ] . hepatopulmonary syndrome (hps) has been traditionally resistant to medical therapies [ ] . oxygen supplementation for hypoxemia is recommended. transjugular intrahepatic portosystemic shunt (tips) has been reported to improve hps; however, it is not currently recommended as its outcomes are variable [ , ] . liver transplantation is the only therapy that has been shown to improve oxygenation and decrease oxygen requirement [ ] . the diagnosis of hps should prompt immediate referral to a transplant center. decreases in blood pressure lead to compromised renal and brain perfusion. it is imperative to be attentive to blood pressure and heart rate values in order to ensure adequate hemodynamics and, most importantly, adequate perfusion. patients with alf should be resuscitated initially with crystalloid before considering vasoactive agents. the generally accepted goal mean arterial pressure is mmhg [ ] . if after adequate volume resuscitation the patient is still hypotensive and not meeting blood pressure goals, vasopressors should be considered. norepinephrine should be initiated and titrated to effect [ ] . for resistant hypotension consideration to vasopressin should be given, although it should be used with caution as it has been associated with cerebral vasodilation and increased ich [ , ] . terlipressin has also been suggested as adjuvant treatment but it is currently not available in the united states [ ] . other causes of hypotension resistant to vasopressor therapy should also be entertained including adrenal failure and severe acidosis. during liver transplantation, ich and hemodynamics improve immediately after hepatectomy, probably secondary to removal of vasoactive cytokines. hepatectomy can improve these derangements for up to h [ ] . hepatectomy is currently recommended only as a last resort and when a liver graft in the process of being delivered to the transplant institution [ ] . despite the derangements of coagulation laboratories in patients with alf, their coagulation status remains in equilibrium and overall hemostasis. in the absence of bleeding, no correction of laboratory parameters should be performed [ ] . transfusion should be discouraged because treatment with ffp may precipitate pulmonary problems including hypoxia, and transfusion also prevents the use of inr as a marker of hepatocyte recovery [ ] . if an invasive procedure is planned or if there is evidence of significant bleeding, correction of coagulopathy should be done. ffp can be used for this purpose; however, careful volume management should also be achieved. the use of plasmapheresis and recombinant activated factor vii (rfviia) can help in the correction of coagulopathy. rfviia has been proposed as it effectively corrects derangements without volume overload [ ] . however, administration does carry the risk of myocardial infarction and portal vein thrombosis [ ] . alf has also been associated with vitamin k deficiency and it should be administered routinely in these patients [ ] . thrombocytopenia has also been reported in patients with alf. platelets should not be administered in the absence of bleeding. if the patient has platelet counts that are greater than , /mm , no prophylactic transfusion should be given [ ] . if an invasive procedure is planned, platelets between , /mm and , /mm have been proposed, and in those bleeding, the intensivist should consider transfusion if platelets drop below , /mm [ , ] . bleeding from intestinal mucosa is rare but has been reported in patients with alf. histamine- receptor blockers have been used in critically ill patients as prophylaxis of gastrointestinal (gi) bleeding with great success [ ] . also, proton pump inhibitors (ppi) have contributed to the reduced incidence of upper gi bleeding in patients with liver dysfunction [ ] . it is therefore recommended that alf patients are started on prophylaxis while in the icu. nutrition can be compromised in patients with alf; therefore, enteral feedings should be started early unless there are contraindications. there is no evidence that using branched-chain amino acid formulas has benefits over other enteral tube feeds [ ] . protein supplementation should not be restricted but rather limited to g per day in most patients. if gastrointestinal feeding is contraindicated, parenteral nutrition may be considered. there is also evidence that the risk of gi bleeding is reduced in patients that are on enteral feeding [ ] . hypoglycemia should be actively treated in patients with alf. the intensivist should consider adding dextrose to crystalloids in the form of d . if hypoglycemia is severe, central replacement with d concentration should be used. frequent glucose checks should be performed in order to assess the response to glucose administration. improvement and eventually weaning can be achieved in those patients that experience hepatocyte recovery. right upper quadrant pain can be treated with narcotics. judicious doses should be used as metabolism of medications can be compromised with the failing liver [ ] . the management of ascites will be discussed with chronic liver failure. close urine output monitoring is paramount in patients with alf. hemodynamic changes and alterations in the cardiovascular system make the kidneys susceptible to injury. insertion of a urinary catheter should be performed upon determination of hepatic failure. besides serum electrolytes, measurement of urinary sodium and creatinine is necessary. high or normal urine sodium may indicate the presence of acute tubular necrosis, while a low urine sodium may indicate prerenal azotemia or hepatorenal syndrome. several electrolyte derangements may occur and correction should be attempted. accumulation of lactate may result from tissue hypoxia and combined with renal failure may cause life-threatening acidosis. renal replacement therapy may be necessary in these patients. when indicated, continuous dialysis should be used as studies have shown that it provides cardiovascular as well as intracranial pressure stability when compared to intermittent dialysis [ ] . the development of an infection in a patient with alf has been associated with worsening encephalopathy and cerebral edema. also, the presence of bacterial or fungal infections may compromise any attempts at performing a liver transplantation. because of the impact that it has, prophylactic antimicrobials have been proposed as a prevention strategy for these patients [ ] . prophylactic antibiotics have been used and shown to decrease the incidence of infections in patients with alf. in a prospective control trial by rolando n et al., patients with fulminant liver failure were randomized to receive either selective parenteral and enteral antimicrobials vs. no treatment until clinically indicated. patients were included in this study. thirty-four percent of those patients randomized to receive prophylactic antibiotics developed an infection compared to % of those that were treated when clinically indicated (p < . ). however, this did not translate into a survival benefit [ ] . it is currently recommended that if no prophylactic antibiotics are used, periodic sputum, urine, and blood cultures are performed to determine if there are bacterial infections [ ] . the use of antifungals has also been studied [ ] . it is routine practice of the authors to use prophylactic enteric fluconazole in patients that are expected to be in the icu for more than days, given that there is a decrease in fungal infections in high-risk critically ill surgical patients [ ] . it is paramount to perform an infectious workup to any patient with liver failure that develops a change in mental status as it may be a change precipitated by infection. the most common cause of alf in the united states is acetaminophen (paracetamol) toxicity [ ] . over-the-counter availability and the fact that it can be found in combination with other medications make it the cause of voluntary or involuntary overdoses that compromise liver function and may result in fulminant liver failure. acetaminophen is usually taken orally and absorbed via the gastrointestinal system. its half-life is usually - h with one exception being extended release preparations in which it is increased to more than h. total doses should not exceed g per day. ingesting doses less than . g per day is unlikely to result in acute toxicity; however, it can vary depending on underlying liver function [ ] . the metabolism of acetaminophen is performed in the liver. most of the compound, approximately %, is conjugated with sulfate or glucuronide and excreted in the urine. five percent of the remaining medication is excreted unchanged in the urine. the remaining acetaminophen is subject to metabolism by the cytochrome p pathway. it is converted into n-acetyl-p-benzoquinoneimine (napqi), a highly reactive and toxic compound that is immediately conjugated with hepatic glutathione and excreted in the urine. when glutathione levels drop below % physiologic levels, napqi forms covalent bonds via cysteine groups with hepatic molecules and proteins, leading to irreversible hepatocyte damage. a decrease in glutathione levels, enhanced cytochrome p activity secondary to medication use, acetaminophen overdose, or decreased liver function from chronic disease make patients more susceptible to developing toxicity. the clinical presentation of acetaminophen toxicity can be divided into four different stages (table . ). stage i includes a series of nonspecific gi symptoms that start shortly after ingestion. no liver abnormality can be seen. during stage ii, there is usually transaminitis with a high ast/alt ratio. stage iii is characterized by the clinical evidence of liver failure and, in some patients, renal failure. mortality is higher at this stage. those patients that survive this stage progress to stage iv in which there is normalization of most of their lab derangements. because patients may not show symptoms up to h after ingestion, it is very important to obtain a detailed history. standard workup should be initiated as discussed previously. contacting poison control will help coordinate efforts to treat and eventually transfer patient to a liver center [ ] . in order to determine the severity of the poisoning, a serum acetaminophen concentration ( h post ingestion or later) should be plotted against time on the modified rumack-matthew nomogram (fig. . ) [ , ] . patients with acetaminophen levels below the treatment line can be discharged home after psychiatric and social evaluation. all other patients should be admitted to the intensive care unit [ ] . for those patients that ingested a single dose of acetaminophen of more than . g less than h prior to presentation, administration of activated charcoal should be considered. review of several small studies demonstrated that activated charcoal was the best available option to reduce absorption [ ] [ ] [ ] . also, there is a decreased risk of developing liver injury if charcoal is given prior to other forms of treatment [ ] . if patient has an unstable airway, charcoal should not be administered until the airway is controlled. the antidote of choice for acetaminophen toxicity is n-acetylcysteine (nac). the exact mechanism of action is unclear; however, it appears to restore glutathione levels [ , ] . indications for administration include a serum acetaminophen level above the treatment line, ingestion of more than . g, serum acetaminophen level > mcg/ml if time of ingestion is unknown, evidence of liver injury, and a history of acetaminophen ingestion regardless of time of ingestion [ ] [ ] [ ] . oral and iv administration of nac have been studied and both appear effective [ ] . the main factor determining the mode of treatment should be the mental status of the patient. if the patient is confused or has evidence of encephalopathy, oral administration should be avoided. if the oral protocol is used, a loading dose of mg/kg should be given followed by doses of mg/kg given every h. if iv nac is used, a loading dose of mg/kg is given over h. a second dose of mg/kg is then given over h and finally a third dose of mg/kg is given over h. an alternative to nac is hemodialysis. this method effectively removes acetaminophen [ ] . however, because of the effectiveness of nac, it should be reserved for cases in which the antidote is not available. acetaminophen toxicity is best managed in a multidisciplinary setting with assistance from hepatology and surgery teams. ingestion of poisonous mushrooms can lead to lethal emergencies including alf. amanita phalloides, amanita bisporigera, amanita verna, and other mushroom species may cause alf. these mushrooms do not express repulsive smells or tastes, and they can be found throughout midsummer in moist oak forests. alpha-amanitin is the amatoxin responsible for liver failure. after gastrointestinal absorption, enterohepatic circulation is responsible for transportation into the liver, where via active transport it concentrates in hepatocytes. the toxin will bind to rna polymerase and inhibit protein synthesis, ultimately leading to apoptosis [ ] . the clinical presentation of patients that ingest amatoxin includes an initial asymptomatic period of a few hours. this is followed by gastrointestinal symptoms that include abdominal pain, nausea, vomiting, and diarrhea that can be bloody. liver enzymes will be elevated and will continue to increase. one to two days after ingestion, the second phase of the presentation begins with an apparent recovery with continuing elevation of ast and alt. in severe poisonings, coagulopathy and possible dic and renal failure may ensue. the last phase includes alf and typically starts days after ingestion. hypoglycemia and multi-organ failure can be seen. workup of a patient with suspected amanita ingestion should proceed as indicated earlier in this chapter. detection of amatoxin can be performed in urine samples using enzyme-linked immunoassay (elisa); this test is not readily available in all institutions and awaiting results should not preclude supportive treatment [ ] . supportive treatment should be started immediately after presentation. in addition, an effort to minimize toxin absorption should be attempted. activated charcoal can bind amatoxin, and if given in repeated doses, it can reduce mortality significantly by increasing elimination via gastrointestinal tract [ ] . medications that can inhibit uptake of this toxin have also been described. these include penicillin g and silymarin. the former is given as a continuous infusion and has been show to decrease mortality [ , ] . the latter is a more potent inhibitor and is available in iv and po formats. silymarin has been shown to minimize damage to hepatocytes [ , , ] . nac has also been used in the treatment of amatoxin intoxication. mortality appears to improve with implementation of protocols very similar to those of acetaminophen toxicity [ , ] . wilson's disease poses a different presentation from frank alf. it normally occurs in the background of chronic liver disease that has been unrecognized. treatment varies when presentation of this disease is acute, and this will be the focus of this section. a genetically recessive disease, it is estimated that - % of alf cases are related to wilson's disease [ ] . the majority of copper that is ingested is transported into the liver where it is incorporated into enzymes and copper-binding proteins (ceruloplasmin). excess copper is combined with apometallothionein and excreted into bile. in wilson's disease, the incorporation into ceruloplasmin is compromised and copper is accumulated in the liver. as the disease progresses, other organs are affected. besides parkinsonian movements and tremors, kayser-fleischer rings, psychiatric alterations, and renal problems, wilson's disease will present with liver disease: cirrhosis, chronic failure without cirrhosis, and acute liver failure. laboratory workup should include serum ceruloplasmin, which is usually low, as well as serum copper level (above mcg/dl) [ ] . in patients with evidence of alf, low transaminases, low alkaline phosphatase, hypokalemia, glycosuria, hypophosphatemia, and renal tubular acidosis, the diagnosis of wilson's disease should be considered. in patients with acute failure, the aim should be to remove copper. hemodialysis and peritoneal dialysis can successfully achieve this goal [ ] . albumin dialysis and the molecular absorbent recirculating system (mars) device have also been used with promising results [ , ] . penicillamine, zinc, and other medications used for treatment of wilson's disease do not play a role in alf. the development of alf from viral hepatitis may occur after acute infection; ostapowicz et al. estimated that the etiology of % of those patients that were diagnosed with alf was viral hepatitis [ ] . most of the clinical deteriorations that are seen in patients with this etiology of disease are related to chronic liver infection. alf is more common with hepatitis b but it can also present in patients with hepatitis a, c, and e [ ] . presentation of viral hepatitis is described in four phases. phase is characterized by lack of symptoms but changes in laboratory studies that may be suggestive of viral hepatitis. phase marks the development of symptoms that include nausea, vomiting, abdominal pain, arthralgias, and possible fevers. the next phase includes clinical characteristics of alf including right upper quadrant pain, becoming icteric, and possible coagulopathy. the last phase, , leads to the normalization of laboratory values and resolution of symptoms. diagnosis of viral hepatitis relies on serum laboratories. hepatitis b has several important antigens and antibodies. hepatitis b surface antigen (hbsag) is usually found in patients with acute infection. a second antigen, associated with infectivity, is hepatitis b e antigen. the first antibody that can be detected in patients acutely infected and that indicates acute presentation of disease is igm anti-hbcag. resolution of acute infection and recovery results in igg antibodies against this antigen. finally, anti-hbsag appears in the serum several months after infection, indicating resolution. they will also be found in patients with hepatitis b vaccine. igg anti-hepatitis c virus has been used to diagnose exposure to this viral infection. it can usually be found in the serum several months after an acute infection and contrary to anti-hbsag, it does not confer immunity to hepatitis c. use of elisa and riba testing for diagnosis has fallen out of favor. hcv rna pcr assays were developed in order to detect the presence of the virus. it has been successful in not only establishing the diagnosis but also the presence of an acute infection. treatment of acute hepatitis a is limited to supportive care as there are no medications that improve outcome. hepatitis b treatment usually follows the same principles as most antiviral therapy is directed toward treatment of chronic disease. however, recent studies have suggested that acute hepatitis b may benefit from administration of lamivudine [ ] . finally, acute hepatitis c has been treated with ifn therapy with resolution of hcv rna after several months of treatment [ ] . low perfusion pressure to the liver may result in clinical manifestations of alf known as ischemic or hypoxic hepatitis. it is an uncommon cause of liver failure, with a prevalence of per , hospital admissions [ ] . this can be a direct consequence of global hypoperfusion, hemodynamic instability, direct vascular occlusion during surgical procedures, hepatic artery disease (occlusion, dissection, thrombosis) in patients with portal vein thrombosis, or hepatic sickle cell crisis [ ] . hepatocytes in zone become ischemic and eventually necrotic leading to liver insufficiency. prognosis of ischemic hepatitis is poor. raurich et al. described an in-hospital mortality of . % in all patients that were diagnosed with this disease process. in those patients with concomitant septic shock and those that experienced cardiac arrest, mortality rates were higher, at . % and . %, respectively. risk factors for mortality included an elevated inr, need for renal replacement therapy, and diagnosis of septic shock. non-survivors were more likely to be on vasopressors and to require mechanical ventilation [ ] . patients with hepatitis secondary to shock present with several symptoms related to their hemodynamic instability including altered mental status, respiratory distress, severe hypotension, and renal failure. patients with a history of cardiac compromise may present with nausea, vomiting, right upper quadrant pain, and malaise. up to % of patients with septic shock will also have ischemic hepatitis, presenting with fevers and severe hypotension [ ] . laboratory examination reveals elevated aminotransferase levels, usually above , iu/l. the ratio of serum alanine aminotransferase to ldh less than . suggests ischemic hepatitis [ ] . if hypoperfusion is chronic in nature, synthetic function may be preserved and coagulation studies may be normal; however, in acute cases, there is severe derangements that continue to progress with time. if ischemic hepatitis is suspected, a right upper quadrant ultrasound with doppler should be immediately performed as it may reveal the etiology of the insufficiency. there is no specific treatment for ischemic hepatitis. management is centered around restoring cardiac output and reestablishing hepatic perfusion. appropriate resuscitation is necessary. excessive fluid administration may lead to vascular congestion which can in turn compromise perfusion of hepatocytes and aggravate the presentation. judicious use of diuretics should be exercised as diuresis may exacerbate hypoperfusion and therefore liver failure. intensivists should rule out ischemic hepatitis in any patient that presents with septic shock and has elevated aminotransferases [ ] . prompt recognition of hypoperfusion state may lead to early intervention and possible better outcomes. continuous hepatic injury that persists for more than months is considered chronic liver disease (cld). the liver parenchyma suffers continuous inflammation and potential destruction. the hepatic insult does not only result in damage but also in attempts of repair. ultimately this leads to a broad spectrum of clinical manifestations including fibrosis, cirrhosis, and hepatocellular carcinoma. these changes are accompanied by alterations in serum liver function tests and can include physical exam finding suggestive of physiologic alterations. in the united states, the most common causes of cirrhosis leading to liver transplantation are alcoholic liver disease, chronic viral hepatitis, and nonalcoholic liver disease (table . ) [ ] . this last etiology has increased significantly in incidence. most patients are generally asymptomatic until decompensation occurs, making the calculation of prevalence difficult. approximately , deaths in where associated with cld [ ] . patients with cld may present with compensated or uncompensated hepatic failure. the former may be asymptomatic prior to evaluation, but patients usually report nonspecific symptoms such as weight change, fatigue, and lack of appetite. those patients with an acute decompensation may show signs of active bleeding, confusion, and skin changes. because of the broad spectrum of the disease, presentation will vary between different patients. due to similar underlying pathophysiology, symptoms and findings may be similar to those described previously during the acute liver failure presentation. patients with cld may present with varying degrees of hepatic encephalopathy. classification and underlying pathophysiology are similar to those described previously in the alf section. an acute exacerbation with an underlying chronic liver dysfunction can cause rapid progression from confusion to coma. shortness of breath, dyspnea, and other nonspecific respiratory symptoms may also be reported. as with acute dysfunction, the etiology may be of infectious, metabolic, or of cardiac etiology. hepatopulmonary syndrome can also play a role in underlying hypoxemia [ ] . the mechanisms that lead to the respiratory derangements in cld are similar to those described in acute liver compromise. figure . explains the molecular mechanism behind the underlying decreased effective perfusion pressure seen in patients with liver failure. as a result, patients will have a lower than baseline blood pressure, with some of them transitioning from hypertensive to normotensive. the cardiac output in patients with liver disease is usually high; however it is important to understand that myocardial cells are actually depressed from exposure to the changes in cytokines and other molecules. there is a slightly elevated heart rate that compensates for the depression and overall results in increase cardiac output, in a normal-sized man, often in the range of - l/min [ ] . patients with cld may present with anemia, leukopenia, thrombocytopenia, and coagulopathy [ ] . the pathophysiology behind anemia is multifactorial, and it may include episodes of gastrointestinal bleeding associated with portal hypertension and coagulopathy. there may also be nutritional deficiencies such as folate deficiency that can lead to compromised production of red cells and vitamin k deficiency that can lead to decreased production of coagulation factors [ ] . aplastic anemia, hypersplenism, and hemolysis may contribute to the anemia experienced by patients with chronic failure [ ] . thrombocytopenia is associated with portal hypertension: an enlarged spleen can sequester the majority of the circulating platelet mass and lead to a decrease platelet count. it has also been described that patients with liver disease have decreased levels of thrombopoietin that will also lead to thrombocytopenia [ ] . patients experiencing cld can present with abdominal distention and pain, anorexia, nausea, and vomiting. physical exam may also show ascites, hypogonadism, hypersplenism, and evidence of gastrointestinal (gi) bleeding such as hematemesis, hematochezia, and melena. gi bleeding can be the result of mucosal injury and thrombocytopenia or a more severe and life-threatening event such as variceal hemorrhage. an umbilical hernia may be seen when ascites becomes prominent. for those patients with cld, there are significant changes in the hemodynamics of the portal vein. the hepatic microcirculation, sinusoids, undergoes constriction secondary to architectural changes that compromise the lumen of these systems. furthermore, there is active contraction of myofibroblasts and active smooth muscle secondary to cytokine changes (increased levels of intrahepatic et- ) that cause even more restriction in the radius of these sinusoids [ , ] . these changes lead to an increase in portal pressure. a second factor that impacts the pressure of the portal vein is the increased in blood flow in the portal vein. as shown in fig. . , there is a splanchnic arteriolar vasodilation that leads to increase venous outflow and, therefore, increased flow that results in further increases of portal pressure and eventually portal hypertension (pht) [ ] . the elevated blood pressure and flow are partially relieved by decompressing the inflow into the portal vein into systemic collaterals. the esophageal submucosal veins are a preferred method of decompression and may result in esophageal varices. as flow increases so does the vessel radius [ ] . this ultimately leads to an increase in wall tension that may end up in rupture and variceal bleeding [ , ] . ascites is also closely related to pht. in fact, patients without evidence of pht do not develop ascites even in the presence of cirrhosis. the threshold for formation of ascites appears to be mmhg at the level of the portal vein [ ] . as a response to this increase in pressure, there is splanchnic vasodilation leading to a decrease in effective arterial blood volume that is mediated by several molecules including nitric oxide (no). there is subsequently an activation of the renin-angiotensin-aldosterone system that increases renal sodium retention and plasma expansion that ultimately leads to accumulation of fluid in the peritoneal cavity [ ] . the low levels of circulating protein secondary to liver compromise may also favor the formation of ascites. on physical exam, we can find evidence of pht by placing a stethoscope over the epigastrium. if there are collateral connections between the portal system and the umbilical vein, a murmur can be auscultated. this finding is known as cruveilhier-baumgarten murmur. dizziness, diaphoresis, and overall malaise may be reflective of underlying hypoglycemia. patients with cld undergoing an acute exacerbation may see decreased levels of circulating glucose with corresponding changes in neurologic exam. male and female patients with cld can report abnormalities related to infertility, impotence, and in the case of women chronic anovulation. physical exam may show evidence of testicular atrophy in men, while ultrasound and other imaging may show atrophic ovaries and uterus. there are several possible mechanisms that explain these findings. the increased levels of follicle-stimulating hormone (fsh) and luteinizing hormone (lh) observed in some patients suggest the primary dysfunction of the testicles or ovaries. an alternative mechanism suggests suppression of the hypothalamicpituitary function. the dysfunction may be secondary to decreased clearance of estrogen, testosterone, prolactin, and other substances [ , ] . male patients with cld may complain of loss of male pattern pubic hair, chest and axillary hair loss, and gynecomastia. this finding is thought to be related to an overall increase in estradiol: the adrenal glands produce and increase quantities of androstenedione that undergoes aromatization into estrone and eventually to estradiol [ ] . similar to patients with alf, patients with cld can present with renal pathology. these may manifest as decreased urine output, arrhythmias, generalized body edema, and overall malaise. most of the changes are associated with the underlying liver dysfunction. in hospitalized patients with cld, it is estimated that approximately % of them will develop hepatorenal syndrome (hrs). the pathophysiology of hrs follows the development of pht. as explained in fig. . , there is dilation of the splanchnic circulation, leading to a decrease in perfusion pressure. the response is cardiac compensation as well as activation of the renin-angiotensin-aldosterone system. there is also vasoconstriction mediated by the sympathetic nervous system. these changes ultimately lead to low renal perfusion and a significant decrease of the glomerular filtration rate [ ] . electrolyte abnormalities can accompany the changes that are seen on the renal system. hyperkalemia, hyperphosphatemia, and hyponatremia can be detected in serum electrolytes. symptoms may be variable and depend not only on severity of derangement but acuity. dizziness, weakness, and palpitations may be reflections of these abnormalities. cld leads to acquired immune deficiency and makes these patients prone to developing infections. the mechanism by which the immune response is compromised includes the deficiency of serum complement [ ] as well as the compromised activity and function of phagocytes such as macrophages, pmns, and kupffer cells [ , ] . certainly, the presence of fevers should make the intensivist suspicious for an infectious process and further investigation is warranted in order to determine additional symptoms that may guide further treatment. however, patients who present with decompensated liver failure may have an infection causing the decompensation. thus, suspicion for the presence of infection should be high, and the threshold for obtaining cultures is low in any patient with liver failure who is acutely ill. abdominal pain that worsens and fevers should raise the suspicion for spontaneous bacterial peritonitis (sbp) in those patients with evidence of ascites. up to % of these patients may develop sbp [ ] . patients with cirrhosis have an increased intestinal permeability as well as altered intestinal motility. this may lead to the bacterial overgrowth and infection of ascites [ ] . the most common organism seen is escherichia coli; however, other organisms have also been described [ ] . typically sbp is monomicrobial and a polymicrobial infection should prompt consideration of a perforated viscous. similar to alf, skin and urine color can change in patients with cld. the increase in bilirubin secondary to compromised liver function leads to the accumulation in the skin leading to jaundice as well as dark appearance of urine. these changes are usually undetectable if the serum bilirubin is less than mg/dl. another change that can be appreciated in the skin of patients with cld includes palmar erythema. it is thought to be the consequence of altered sex hormone metabolism which may lead to capillary vasodilation [ ] . careful examination of the skin can also reveal vascular lesions characterized by the presence of a central arteriole with surrounding smaller vessels. these are called spider angiomata and their appearance is related to an increase in estradiol levels. the number as well as size of these lesions is related to the severity of liver disease although they are not specific for it [ ] . as an additional route to decompress the portal vein during pht, the umbilical vein may open leading to shunting into abdominal wall veins. these vessels engorge significantly making them very easy to identify during physical exam. this finding is known as caput medusa. initial workup and management of patients with cld should begin with a thorough history. onset of symptoms and identification of disease progression helps determine the pathophysiologic manifestations of the disease. previous medical diagnosis including viral hepatitis should be assessed. a thorough review of all medications that the patient takes can help identify potential additional mechanisms of liver injury. hospitalizations and transfusions should be reviewed. social history including exposure to high-risk behaviors such as intravenous drug use and alcohol abuse should be performed. family history of liver disease and personal history of malignancy (including oncologic treatment and surveillance studies) also play a key role in the development of disease and should be explored. a complete physical exam should be performed and an attempt to determine if any of the clinical manifestation discussed previously are present. the exam should include neurologic, rectal, and skin exam. assessment of vital signs in order to identify possible hypotension, hypoxemia, as well as end-organ perfusion should be performed. there is no serologic test that can diagnose cld accurately. laboratory abnormalities that are identified could be related to alf or another etiology with some degree of liver dysfunction. besides serologic tests, evaluation of the degree of liver fibrosis and additional characteristics of cld can be investigated with radiologic studies. the initial serologic studies that are performed as well as initial management are similar to those described in table . in the alf section. in addition, studies from ascitic fluid should also be performed when it is desired to identify etiology of fluid and possibility of infection. after paracentesis with removal of ml of ascites in a sterile fashion, the intensivist should send the fluid for cell count, cytology, albumin, total protein, triglycerides, amylase, adenosine deaminase, as well as culture [ ] . this should be accompanied by a serum albumin in order to calculate the serum-ascites albumin gradient (saag). this is done by subtracting the albumin in the ascitic fluid from the serum value. based on such studies, the etiology of ascites can be determined (table . ) . imaging studies that are routinely used include ultrasonography (us), ct scan, and magnetic resonance imaging (mri). us can help identify morphologic changes such as nodularity. with doppler us, patterns of flow as well as possible occlusions can be identified. ct and mri are able to identify nodularity and changes in volume of liver mass (hypertrophy or atrophy) as well as assess the portal vasculature [ ] . evaluation of collateral circulation, varices, and tumors can also be performed. since us does not use contrast, this can be very helpful in those patients with renal compromise [ , ] . if after a thorough workup, the diagnosis of cld cannot safely be established, liver biopsy should be considered. identifying changes consistent with cld may be very beneficial as it may prevent delays in therapy and potential worsening of the patient [ ] [ ] [ ] . surgery and interventional radiology teams should be involved in order to determine the safest and least invasive method that can render a diagnosis. suspicious findings for cld should prompt consultation with hepatology/gastroenterology and transplant surgery in order to determine if the patient will benefit from additional therapies and workup including possible transplantation. evidence of encephalopathy, compromised ventilation, hypotension, hypoperfusion, active bleeding, sepsis, and sbp should prompt admission to the icu. consideration of additional hemodynamic monitors such as an arterial line and central access may be considered in every patient. a foley catheter should be placed in all patients with hemodynamic instability or with poor renal function but avoided in those with anuria to prevent a urinary tract infection. it is also helpful to classify the severity of liver disease. the child-turcotte pugh (ctp) classification divides patients into three groups based on serum labs and clinical presentation. it can help in determining possible surgical treatments or additional therapies [ , ] . this specific scoring system is presented in table . . another classification system that is used for the allocation of organs in the unites states is the model for end-stage liver disease (meld). it consists of a formula that will assign a score to a patient and that accurately predicts mortality within months. the formula is based on three laboratory values (bilirubin, inr, and creatinine) and it is modified by etiology. the formula is shown below [ ] : if the disease process is alcohol, is assigned to etiology. if the liver failure is secondary to a cholestatic process, is assigned instead. several factors can modify the calculated meld score for allocation purposes, and these include dialysis and the presence of hepatocellular carcinoma. the ctp and meld system have been compared in several studies in order to determine which provides a better answer to prognosis for patients. although some studies show superiorities of meld, others show no difference and good predictions with both systems [ ] [ ] [ ] [ ] . a systematic review, suggested that the meld was better for predicting -month mortality but otherwise the systems were similar [ ] . because of its use with united network for organ sharing (unos) lists for allocation of organs, meld has become more popular. hepatic encephalopathy (he) is a diagnosis of exclusion, and therefore, an effort to identify other etiologies of altered mental status should be performed. it is also necessary to determine the precipitating event leading to the neurologic derangement which includes bleeding, renal failure, electrolyte abnormalities, changes in diet, and changes in medication [ ] . treatment principles are similar to those described in the alf section. they should be based on supportive care, attempts to correct precipitating factors, minimizing gi nitrogen intake, and establishment of therapy. admission to an icu is important as patients with he need constant neurologic assessments for progression or resolution. for grade iii and grade iv he, establishment of definite airway should be the first step in management. laboratory studies are key in order to identify possible precipitating events. a decrease in nitrogen production as well as nitrogen delivery should be attempted with medication. the most common therapy used is lactulose, which reduces the absorption of ammonia. twenty-five milliliter should be given twice a day and should be titrated to achieve two soft bowel movements [ ] . rifaximin has also been used as an add-on therapy to lactulose. it is an antibiotic with activity against grampositive and gram-negative aerobes and anaerobes. the usual dose is mg three times a day. trials have shown benefit in the treatment of he when rifaximin is used in addition to lactulose [ ] . another antibiotic that has been use is neomycin. this alternative treatment has been used for the treatment of overt hepatic encephalopathy [ ] . however, because it has been associated with complications such as ototoxicity and nephrotoxicity, neomycin is used less commonly today [ ] . an assessment of nitrogen intake by assessing a patient's diet is also very important. if a patient's he is unresponsive to the therapies described above, oral branched-chain amino acids (bcaa) should be considered in an attempt to reduce the hepatically metabolized nitrogen load. a recent metaanalysis showed that bcaa-enriched formulations may be beneficial in some patients with he and cld [ ] . the daily protein intake should be . - . g/kg/day as severe restriction may be detrimental in the catabolic state of cld [ ] . the first step in management of a patient with cld and ascites should be sodium restriction to no more than , mg per day [ ] . this should also be accompanied by oral spironolactone and possibly furosemide in order to perform natriuresis while maintaining normokalemia. spironolactone inhibits sodium reabsorption in the distal tubule and collecting ducts but it can lead to gynecomastia and hyperkalemia. furosemide is a loop diuretic and inhibits the luminal na-k- cl symporter causing natriuresis and also hypokalemia when used alone. combination therapy has been used more effectively in achieving sustained results. if the serum sodium is less than mmol/l, fluid restriction to no more than . l per day should also be done [ ] . for those patients that are not responsive to diuretic therapy, serial paracenteses can be performed in order to relieve symptoms [ ] . in carefully selected patients, transjugular intrahepatic portosystemic shunt (tips) should be considered. trials have demonstrated that there is better control of ascites and overall survival with this procedure; however, there is worsening hepatic encephalopathy [ ] . referral to a transplant center should be done for patients with refractory ascites. tense ascites with respiratory compromise and abdominal discomfort can also be the initial presentation of patients with cld. prior to sodium restriction, paracentesis should be performed. for large volume (> l) removal, albumin replacement should be done [ ] . replacement of - g of albumin per l of fluid removed has been shown to improve survival [ ] . replacement after paracentesis has remained a controversial topic. in one study performed by gines et al., patients with tense ascites were randomized to receive albumin or no replacement. those that did not receive albumin had more changes in serum electrolytes, plasma renin, and creatinine but had no survival advantage [ ] . there has been no study up to date demonstrating decreased survival in patients without replacement when compared to albumin [ ] . in a meta-analysis by bernardi et al., , patients from trials were analyzed. albumin was shown to be superior to other plasma expanders, with an infusion between and g of albumin per liter removed [ ] . angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, aspirin, and nonsteroidal anti-inflammatory agents should be avoided in patients with cld and ascites: prostaglandin inhibition can severely affect renal hemodynamics as well as natriuresis. it is important to evaluate patients with ascites for ventral and umbilical hernias. for those patients with ascites, hernia repair should only be attempted after medical treatment of ascites. for those with refractory ascites, repair should be deferred until after liver transplantation. if the patient has an incarcerated or strangulated hernia, emergency repair is warranted, but special attention to the ascites postoperatively must be made. the diagnosis of spontaneous bacterial peritonitis (sbp) is established with studies sent from ascitic fluid revealing one of the following three findings: . leukocyte count of more than per mm . polymorphonuclear count of more than per mm the causative organism is usually a gram-negative enteric bacteria; if more than one organism is identified, secondary peritonitis should be considered. escherichia coli and klebsiella are responsible for more than % of the cases [ ] . therapy is tailored based on the most likely causative agent. if the patient has not been on empiric antibiotics prior to presentation, an intravenous third-generation cephalosporin should be started, preferably cefotaxime g every h. if the patient has been exposed prior to this medication, coverage should be based on hospital antibiogram [ ] . therapy should be started if there is a high suspicion for infection while cultures are pending. the recurrence rate of sbp can be as high as % and therefore prophylaxis is advocated. long-term antibiotic therapy, norfloxacin mg daily, is recommended [ ] . trimethoprim/sulfamethoxazole can be used as a secondline agent for those patients with sensitivities [ ] . the presence of esophageal varices in patients with cld warrants prophylactic therapy. the most effective medication has been propranolol that inhibits stimulation of the beta- venodilator receptors seen in varices. it should be started at low doses, mg orally twice a day, and titrated to reduction of pulse rate by %. if patients cannot take propranolol, isosorbide mononitrate can be used. if the patient is unable to tolerate medical therapy, esophagogastroduodenoscopy (egd) and variceal banding should be performed [ ] . three principles govern the management of an acute variceal bleed: stabilization and resuscitation, identification and treatment of bleeding, and prevention of recurrence. if a patient presents with evidence of gi bleeding, immediate type and cross should be performed, and if needed, transfusion of untyped and uncrossed blood should begin. waiting for laboratory values to show anemia may worsen the overall clinical condition of the patient. upper gi bleeding in a patient with presumed cld prompts urgent endoscopy to identify possible bleeding esophageal or gastric varices. if during endoscopy, no varices are seen, repeat evaluation should be done in years. if varices are identified but not bleeding, follow-up endoscopy should be done after year. if active bleeding is encountered and it appears to involve esophageal varices, an attempt at controlling the bleeding varices should be done. banding followed by sclerotherapy are the two most common methods of achieving control. if after appropriate attempts bleeding does not stop, a sengstaken-blakemore tube should be inserted. tips and surgical shunts should be considered if all previous methods fail. tips has shown improved outcomes [ ] ; however, it is associated with he [ ] . surgical shunts carry a high morbidity and should be considered a last resort. cld patients with gi bleeding are at risk of developing bacterial infections. some advocate the use of ceftriaxone for days while patients are gi bleeding [ , ] . if the patient stabilizes and tolerates oral intake, changing to norfloxacin is reasonable. the diagnostic criteria for hepatorenal syndrome (hrs) are shown in table . . hrs is a diagnosis of exclusion and it is important to rule out other etiologies including prerenal azotemia, intrinsic renal disease, and post renal failure. in order to diagnose hrs, all major criteria in table . must be met. minor criteria are not required; however, they provide supportive evidence that the pathophysiology is consistent with hrs. identification of precipitating event is also instrumental in the management of hrs as additional therapy can be instituted. when performing large volume (> l) paracentesis, it is recommended to replace volume with albumin (see ascites section above) as this procedure may lead to hrs. evaluation for possible sbp as well as workup for gi bleeding should be considered as they are well-established risk factors for the development of this syndrome. there are two manifestations of hrs: type i and type ii. the former shows a rapid decline in renal function with either an initial creatinine of greater than . mg/dl or a % reduction in the creatinine clearance. type ii usually leads to moderate renal failure that progresses slowly and is manifested as diuretic-resistant ascites [ ] . liver transplantation is the preferred treatment for patients with hrs. any patient with evidence of this syndrome should be referred to a liver transplantation center in order to be listed for transplantation [ ] . bridging with pharmacotherapy is necessary in most patients as there is rapid decompensation, especially in those with type i hrs. the basic principle behind the management of hrs is reversal of renal vasoconstriction and splanchnic vasodilation. dopamine, fenoldopam, and prostaglandins have been used in an attempt to cause direct renal vasodilation [ ] . results of several trials have not favored any of these agents as none have improved outcome [ ] [ ] [ ] . splanchnic vasoconstriction, in an attempt to reduce portal blood flow and decrease pressure, has been attempted with vasopressin, ornipressin, terlipressin, norepinephrine, and midodrine [ ] . ornipressin, with some promising results, resulted in an increase rate of ischemic events [ ] . terlipressin in combination with albumin has shown the most promising results, with improvements in renal function although its use has not been approved in the united states [ ] . norepinephrine and vasopressin have been used with improvement of renal function and successful bridging to transplantation [ ] . hemodialysis may be required in the treatment of these patients, especially those with type disease. those patients that are hospitalized in an icu should receive continuous dialysis rather than intermittent as it minimizes changes of abrupt hemodynamic changes and further compromise of these frail patients [ ] . patients with alf and cld may benefit from liver transplantation. this therapeutic option should be considered when medical therapy has failed and when there is progression of disease. referral to transplant center should occur once the patient has experienced ascites, variceal hemorrhage, hrs, and he. consultation with hepatology and transplant surgery teams ensures early consideration for transplantation. table . presents poor prognostic factors from the king's college criteria that may suggest that the need for transplantation is increased. prior to transplantation, a thorough evaluation is performed on patients regardless of etiology. this includes assessment of cardiac function, possible occult malignancy, identification of infection, contraindications to chronic steroid therapy, and appropriate social support. the rapidly progressive nature of alf designates that these patients are currently listed as status by the united network for organ sharing (unos) [ ] . approximately table . criteria for diagnosis of hepatorenal syndrome chronic or acute liver disease with advanced hepatic failure and portal hypertension low glomerular filtration rate serum creatinine > . mg/dl or h creatinine clearance < ml/min absence of shock, ongoing bacterial infection, and current or recent treatment with nephrotoxic drugs absence of gi fluid losses absence of renal fluid losses in response to diuretic therapy no sustained improvement in renal function after diuretic withdrawal and expansion of plasma volume with . l of plasma expander proteinuria < mg/day no obstructive uropathy, parenchymal renal disease, microhematuria minor criteria urine volume < ml/day urine sodium < meq/l urine osmolality greater than plasma osmolality urine rbcs < /high-power field serum sodium concentration < meq/l non-acetaminophen inr greater than . or three of the following five criteria: patient age of less than or greater than serum bilirubin of greater than μmol per liter time from onset of jaundice to the development of coma of greater than days inr greater than . drug toxicity, regardless of etiology of alf acetaminophen arterial ph < . inr greater than . creatinine greater than μmol per liter encephalopathy (grade iii or iv) % of patients with alf will undergo liver transplantation, % of them will improve with supportive care, and % will not survive their presentation; of those that have a liver transplant performed, the -year survival is approximately % [ ] . patients with failure secondary to viral hepatitis usually have better outcomes than those with drug reactions or metabolic causes. also, patients with alf have worst outcomes when compared with patients with cld. the -year survival for patients with cld that undergo liver transplantation is % [ ] . timing is not standard and is usually dependent on severity of meld. living donors have been used secondary to decrease in organ availability and it has been successful. this therapy has not been studied in patients with alf. liver replacement therapies (lrt), also known as liver dialysis, have been studied and used as a bridging therapy to transplant [ ] [ ] [ ] [ ] . several methods have been developed and they can be grouped into artificial and bioartificial devices. regardless of the mode of action, they attempt to clear toxins that are free and protein bound, as well as to regenerate or replace proteins that are affected by the liver failure process. among the artificial methods, the most studied is the molecular adsorbent recirculation system (mars). it effectively clears several toxic compounds and causes a dramatic improvement in serum laboratories and in some symptoms such as pruritus [ ] . unfortunately, this has not translated into clinical benefits [ ] . biologic methods include devices with porcine hepatocytes and with human hepatoblastoma cells [ , [ ] [ ] [ ] . their theoretical advantage is the production of proteins and compounds produced by a normal liver as well as detoxification functions. as opposed to artificial systems, technology is not readily available. the results from different trials have been promising, showing improvement in survival to transplantation and normalization of serum laboratories [ ] . an alternative to liver transplantation is hepatocyte transplantation. this consists of injecting human hepatocytes into the portal vein with an attempt to restore hepatic function [ ] . it has been principally used to correct errors of metabolism, and trials have shown improvement in encephalopathy and ammonia and serum laboratories in patients with alf that undergo this therapy [ ] . more 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acute-on-chronic liver failure: the relief trial pilot-controlled trial of the extracorporeal liver assist device in acute liver failure foreword: prospects of liver cell transplantation and liver-directed gene therapy treatment of the crigler-najjar syndrome type i with hepatocyte transplantation key: cord- - jzkdu authors: bickman, leonard title: improving mental health services: a -year journey from randomized experiments to artificial intelligence and precision mental health date: - - journal: adm policy ment health doi: . /s - - - sha: doc_id: cord_uid: jzkdu this conceptual paper describes the current state of mental health services, identifies critical problems, and suggests how to solve them. i focus on the potential contributions of artificial intelligence and precision mental health to improving mental health services. toward that end, i draw upon my own research, which has changed over the last half century, to highlight the need to transform the way we conduct mental health services research. i identify exemplars from the emerging literature on artificial intelligence and precision approaches to treatment in which there is an attempt to personalize or fit the treatment to the client in order to produce more effective interventions. in , i was writing my first graduate paper at columbia university on curing schizophrenia using sarnoff mednick's learning theory. i was not very modest even as a first-year graduate student! but i was puzzled as to how to develop and evaluate a cure. then, as now, the predominant research design was the randomized experiment or randomized clinical trial (rct). it was clear that simply describing, let alone manipulating, the relevant characteristics of this one disorder and promising treatments would require hundreds of variables. developing an effective treatment would take what seemed to me an incalculable number of randomized trials. how could we complete all the randomized experiments needed? how many different outcomes should we measure? how could we learn to improve treatment? how should we consider individual differences in these group comparisons? i am sure i was not insightful enough to think of all these questions back then, but i know i felt frustrated and stymied by our methodological approach to answering these questions. but i had to finish the paper, so i relegated these and similar questions to the list of universal imponderables such as why i exist. in fact, i became a committed experimentalist, and i dealt with the limitations of experiments by recognizing their restrictions and abiding by the principle "for determining causality, in many but not all circumstances, the randomized design is the worst form of design except all the others that have been tried " (bickman and reich , pp. - ) . for the much of my career, i was a committed proponent of the rct as the best approach to understanding causal relationships (bickman ) . however, as some of my writing indicates, it was a commitment with reservations. i did not see a plausible alternative or complement to rcts until recently, when i began to read about artificial intelligence (ai) and precision medicine in . the potential solution to my quandary did not crystallize until , when i collaborated with aaron lyons and miranda wolpert on a paper on what we called "precision mental health" (bickman et al. ) . with the development of ai and its application in precision medicine, i now believe that ai is another approach that we may be able to use to understand, predict, and influence human behavior. while not necessarily a substitute for rcts in efforts to improve mental health services, i believe that ai provides an exciting alternative to rcts or an adjunct to them. while i use precision medicine and precision mental health interchangeably, i will differentiate them later in this paper. toward that end, i focus much of this paper on the role of ai and precision medicine as a critical movement in the field with great potential to inform the next generation of research. before proposing such solutions, i first describe the challenges currently faced by mental health services, using examples drawn almost entirely from studies of children and youth, the area in which i have conducted most of my research. i describe five principal causes of this failure, which i attribute primarily, but not solely, to methodological limitations of rcts. lastly, i make the case for why i think ai and the parallel movement of precision medicine embody approaches that are needed to augment, but probably not replace, our current research and development efforts in the field of mental health services. i then discuss how ai and precision mental health can help inform the path forward, with a focus on similar problems manifested in mental health services for adults. these problems, i believe, make it clear that we need to consider alternatives to our predominant research approach to improving services. importantly, most of the research on ai and precision medicine i cite deals with adults, as there is little research in this area on children and youth. i am assuming that we can generalize from one literature to the other, but i anticipate that there many exceptions to this assumption. according to some estimates, more than half ( . %) of adults with a mental illness receive no treatment (mental health in america ) . less than half of adolescents with psychiatric disorders receive any kind of treatment (costello et al. ) . over % of youth with major depression do not receive any mental health treatment (mental health in america ). several other relevant facts when it comes to youth illustrate the problem of their access to services. hodgkinson et al. ( ) have documented that less than % of children in poverty receive needed services. these authors also showed that there is less access to services for minorities and rural families. when it comes to the educational system, mental health in america ( ) estimated that less than % of students have an individual education plan (iep), which students need to access school-supported services, even though studies have shown that a much larger percentage of students need those services. access is even more severely limited in in low-and middle-income countries (esponda et al. ). very few clients receive effective evidence-based quality mental health services that have been shown to be effective in laboratory-based research (garland et al. ; gyani et al. ). moreover, research shows that even when they do receive care that is labeled evidence-based, it is not implemented with sufficient fidelity to be considered evidence-based (park et al. ) . no matter how effective evidence-based treatments are in the laboratory, it is very clear that they lose much of their effectiveness when implemented in the real world (weisz et al. (weisz et al. , . research reviews demonstrate that services that are typically provided outside the laboratory lack substantial evidence of effectiveness. there are two factors that account for this lack of effectiveness. as noted above, evidencebased services are usually not implemented with sufficient fidelity to replicate the effectiveness found in the laboratory. more fundamentally, it is argued here that even evidencebased services may not be sufficiently effective as currently conceptualized. a review of published studies on school-based health centers found that while these services increased access, the review could not determine whether services were effective because the research was of such poor quality (bains and diallo ) . a meta-analysis of studies of mental health interventions implemented by school personnel found small to medium effect sizes, but only % of the services were provided by school counselors or mental health workers (sanchez et al. ) . a cochrane review concluded, "we do not know whether psychological therapy, antidepressant medication or a combination of the two is most effective to treat depressive disorders in children and adolescents" (cox et al. , p. ) . another meta-analysis of studies on school-based interventions delivered by teachers showed a small effect for internalizing behaviors but no effect on externalizing ones (franklin et al. a) . similarly, a meta-analysis of meta-analyses of universal prevention programs targeting school-age youth showed a great deal of variability with effect sizes from to . standard deviations depending on type of program and targeted outcome (tanner-smith et al. ) . a review of rcts found no compelling evidence to support any one psychosocial treatment over another for people with serious mental illnesses (hunt et al. ) . a systematic review and meta-analysis of conduct disorder interventions concluded that they have a small positive effect, but there was no evidence of any differential effectiveness by type of treatment (bakker et al. ) . fonagy and allison ( ) conclude, "the demand for a reboot of psychological therapies is unequivocal simply because of the disappointing lack of progress in the outcomes achieved by the best evidence-based interventions" (p. ). probably the most discouraging evidence was identified by weisz et al. ( ) on the basis of a review of rcts over a -year period. they found that the mean effect size for treatment did not improve significantly for anxiety and adhd and decreased significantly for depression and conduct problems. the authors conclude: in sum, there were strikingly few exceptions to the general pattern that treatment effects were either unchanged or declining across the decades for each of the target problems. one possible implication is that the research strategy used over the past decades, the treatment approaches investigated, or both, may not be ideal for generating incremental benefit over time. (p. ) there is a need-indeed, an urgent need-to change course, because our traditional approaches to services appear not to be working. however, we might be expecting too much from therapy. in an innovative approach to examining the effectiveness of psychotherapy for youth, jones et al. ( ) subjected rcts to a mathematical simulation model that estimated that even if therapy was perfectly implemented, the effect size would be a modest . . they concluded that improving the quality of existing psychotherapy will not result in much better outcomes. they also noted that ai may help us understand why some therapies are more effective than others. they suggested that the impact of therapy is limited because a plethora of other factors influence mental health, especially given that therapy typically lasts only one hour a week out of + waking hours. they also indicated that other factors that have not been included in typical therapies, such as individualizing or personalizing treatment, may increase the effectiveness of treatment. i am not alone in signaling concern about the state of mental health services. for example, other respected scholars in children's services research have also raised concerns about the quality and effectiveness of children's services. weisz and his colleagues (marchette and weisz ; ng and weisz ) described several factors that contribute to the problems identified above. these included a mismatch between empirically supported treatments and mental health care in the real world, the lack of personalized interventions, and the absence of transdiagnostic treatment approaches. it is important to acknowledge the pioneering work of sales and her colleagues, who identified the need and tested approaches to individualizing assessment and monitoring clients (alves et al. (alves et al. , elliott et al. ; alves , ; sales et al. sales et al. , . we need not only to appreciate the relevance of this work but also to integrate it with new artificial intelligence approaches described later in this paper. i am not concluding from such evidence that all mental health services are ineffective. this brief summary of the state of our services can be perceived in terms of a glass half full or half empty. in other words, there is good evidence that some services are effective under particular, but yet unspecified, conditions. however, i do not believe that the level of effectiveness is sufficient. moreover, we are not getting better at improving service effectiveness by following our traditional approach to program development, implementation, research, and program evaluation. while it is unlikely that the social and behavioral sciences will experience a major breakthrough in discovering how to "cure" mental illness, similar to those often found in the physical or biological sciences, i am arguing in this paper that we must increase our research efforts using alternative approaches to produce more effective services. a large part of this paper, therefore, is devoted to exploring what has been also called a precision approach to treatment in which there is an attempt to personalize treatment or fit treatment to the client in order to produce more effective interventions. in some of my earliest work in mental health, i identified the field's focus on system-level factors rather than on treatment effectiveness as one cause of the problems with mental health services. the most popular and well-funded approach to mental health services in the s and s, which continues even today, is called a system or continuum of care (bickman (bickman , bickman et al. b; bryant and bickman ) . this approach correctly recognized the problems with the practice of providing services that were limited to outpatient and hospitalization only, which was very common at that time. moreover, these traditional services did not recognize the importance of the role played by youth and families in the delivery of mental services. to remedy these important problems, advocates for children's mental health conceptualized that a system of care was needed, in which a key ingredient was a managed continuum of care with different levels or intensiveness of services to better meet the needs of children and youth (stroul and friedman ) . this continuum of care is a key component of a system of care. however, i believe that in actuality, these different levels of care simply represent different locations of treatment and restrictiveness (e.g., inpatient vs. outpatient care) and did not necessarily reflect a gradation of intensity of treatment. a system of care is not a specific type of program, but an approach or philosophy that combines a wide range of services and supports for these services with a set of guiding principles and core values. services and supports are supposed to be provided within these core values, which include the importance of services that are community-based, family-focused, youth-oriented, in the least restrictive environment, and culturally and linguistically proficient. system-level interventions focus on access and coordination of services and organizations and not on the effectiveness of the treatments that are provided. it appeared that the advocates of systems of care assumed that services were effective and that what was needed was to organize them better at the systems level. although proponents of systems of care indicated that they highly valued individualized treatment, especially in what were called wraparound services, there was no distinct and systematic way that individualization was operationalized or evaluated. moreover, there was not sufficient evidence that supported the assumption that wraparound services produced better clinical outcomes (bickman et al. ; stambaugh et al. ) . a key component of the system is providing different levels of care that include hospitalization, group homes, and outpatient services, but there is little evidence that clinicians can reliably assign children to what they consider the appropriate level of care (bickman et al. a ). my earliest effort in mental health services research was based on a chance encounter that led to the largest study ever conducted in the field of child and youth mental health services. i was asked by a friend to see if i could help a person whom i did not know to plan an evaluation of a new way to deliver services. this led to a project that cost about $ million to implement and evaluate. we evaluated a new system of care that was being implemented at fort bragg, a major u.s. army post in north carolina. we used a quasi-experimental design because the army would not allow us to conduct a rct; however, we were able to control for many variables by using two similar army posts as controls (bickman ; bickman et al. ) . the availability of sufficient resources allowed me to measure aspects of the program that were not commonly measured at that time, such as cost and family empowerment. with additional funding that i received from a competitive grant from the national institute of mental health (nimh) and additional follow-up funding from the army, we were able to do a cost-effectiveness analysis (foster and bickman ) , measure family outcomes (heflinger and bickman ) , and develop a new battery of mental health symptoms and functioning (bickman and athay ). in addition, we competed successfully for an additional nimh grant to evaluate another system of care in a civilian population using a rct (bickman et al. a, b) and a study of a wraparound services that was methodologically limited because of sponsor restrictions (bickman et al. ) . i concluded from this massive and concentrated effort that systems of care (including the continuum of care) were able to influence system-level variables, such as access, cost, and coordination, but that there was not sufficient evidence to support the conclusion that it produced better mental health outcomes for children or families or that it reduced costs per client . this conclusion was not accepted by the advocates for systems of care or the mental health provider community more generally. moreover, i became persona non grata among the proponents of systems of care. while the methodologists who were asked to critique on the fort bragg study saw it as an important but not flawless study (e.g., sechrest and walsh ; weisz et al. ) that should lead to new research (hoagwood ) , most advocates thought it to be a well-done evaluation but of very limited generalizability (behar ). it is important to note that the system of care approach, almost years later, remains the major child and youth program funded by the substance abuse and mental health services administration's (samhsa) center for mental health services (cmhs) to the tune of about a billion dollars in funding since the system of care program's inception in . there have been many evaluations funded as part of the samhsa program that show some positive results (e.g., holden et al. ), but, in my opinion, they are methodologically weak and, in some cases, not clearly independent. systems of care are still considered by samhsa's center for mental health services to be the premier child and adolescent program worthy of widespread diffusion and funding (substance abuse and mental health services administration ), regardless of what i believe is the weak scientific support. this large investment of capital should be considered a significant opportunity cost that has siphoned off funds and attention from more basic concerns such as effectiveness of services. sadly, based on my unsuccessful efforts to encourage change as a member of the cmhs national advisory council ( - ), i am not optimistic that there will be any modification of support for this program or shift of funding to more critical issues that are identified in this paper. in the following section, i consider some of the problems that have contributed to the current status of mental health services. my assessment of current services led me to categorize the previously described deficiencies into the five following related problem groups. the problems with the validity of diagnoses have existed for as long as we have had systems of diagnoses. while a diagnosis provides some basis for tying treatment to individual case characteristics, its major contribution is providing a payment system for reimbursement for services. research has shown that external factors such as insurance influence the diagnosis given, and the diagnosis located in electronic health records is influenced by commercial interests (perkins et al. ; taitsman et al. ) . other studies have demonstrated that the diagnosis of depression alone is not sufficient for treatment selection; additional information is required (iniesta et al. ). moreover, others have shown that diagnostic categories overlap and are not mutually exclusive (bickman et al. c) . in practice, medication is prescribed according to symptoms and not diagnosis (waszczuk et al. ) . in their thematic analysis of selected chapters of the diagnostic and statistical manual of mental disorders (dsm- ), allsopp et al. ( ) examined the heterogeneous nature of categories within the dsm- . they showed how this heterogeneity is expressed across diagnostic criteria, and explained its consequences for clinicians, clients, and the diagnostic model. the authors concluded that "a pragmatic approach to psychiatric assessment, allowing for recognition of individual experience, may therefore be a more effective way of understanding distress than maintaining commitment to a disingenuous categorical system" (p. ). moreover, in an interview, allsop stated: although diagnostic labels create the illusion of an explanation, they are scientifically meaningless and can create stigma and prejudice. i hope these findings will encourage mental health professionals to think beyond diagnoses and consider other explanations of mental distress, such as trauma and other adverse life experiences. (neuroscience news , para. ) finally, a putative solution to this muddle is nimh's research domain criteria initiative (rdoc) diagnostic guide. rdoc is not designed to be a replacement of current systems but serves as a research tool for guiding research on mental disorders systems. however, it has been criticized on several grounds. for example, heckers ( ) states, "it is not clear how the new domains of the rdoc matrix map on to the current dimensions of psychopathology" (p. ). moreover, there is limited evidence that rdoc has actually improved the development of treatments for children (e.g., clarkson et al. ) . as i will discuss later in the paper, rush and ibrahim ( ) , in their critical review of psychiatric diagnosis, predicted that ai, especially artificial neural networks, will change the nature of diagnosis to support precision medicine. if measures are going to be used in real world practice, then in addition to the classic and modern psychometric validity criteria, it must be possible to use measures sufficiently often to provide a fine-grained picture of change. if measures are used frequently, then they must be short so as not to take up clinical time (riemer et al. ) . moreover, since there is a low correlation among different respondents (de los reyes and ohannessian ), we need measures and data from different respondents including parents, clinicians, clients, and others (e.g., teachers). however, we are still lacking a systematic methodology for managing these different perspectives. since we are still unsure which constructs are important to measure, we need measures of several different constructs in order to pinpoint which ones we should administer on a regular basis. in addition to outcome measures, we need valid and reliable indicators of mediators and processes to test theories of treatment as well as to indicate short-term outcomes. we need measures that are sensitive to change to be valid measures of improvement. we need new types of measures that are more contextual, that occur outside of therapy sessions, and that are not just standardized questionnaires. we lack good measures of fidelity of implementation that capture in an efficient manner what clinicians actually do in therapy sessions. this information is required to provide critical feedback to clinicians. we also lack biomarkers of mental illness that can be used to develop and evaluate treatments that are often found in physical illnesses. this is a long and incomplete list of needs and meeting them will be difficult to accomplish without a concerted effort. there are some resources at the national institutes of health that are focused on measure development, such as patient-reported outcomes measurement system information (promis) (https ://www.healt hmeas ures.net/explo re-measu remen t-syste ms/promi s), but this program does not focus on mental health. thus, we depend upon the slow and uncoordinated piecemeal efforts of individual researchers to somehow fit measure development into their career paths. i know this intimately because when i started to be engaged with children's mental health services research, i found that the measures in use were too long, too expensive, and far from agile. this dissatisfaction led me down a long path to the development of a battery of measures called the peabody treatment progress battery riemer et al. ). this battery of brief measures was developed as part of ongoing research grants and not with any specific external support. for over a half century, i have been a committed experimentalist. i still am a big fan of experiments for some purposes (bickman ). the first independent study i conducted was my honors thesis at city college of new york in . my professor was a parapsychologist and personality psychologist, so the subject of my thesis was extrasensory perception (esp). my honors advisor had developed a theory of esp that predicted that those who were positive about esp, whom she called sheep, would be better at esp than the people who rejected esp, whom she called goats (schmeidler ) . although i did not realize it at the time, my experimentalist or action orientation was not satisfied with correlational findings that were the core of the personality approach. i designed an experiment in which i randomly assigned college students to hear a scripted talk from me supporting or debunking esp. i found very powerful results. the experimental manipulation changed people's perspective on the efficacy of esp, but i found no effect on actual esp scores. it was not until i finished my master's degree in experimental psychopathology at columbia university that i realized that i wanted to be an experimental social psychologist, and i became a graduate student at the city university of new york. however, i did not accept the predominant approach of social psychologists, which was laboratory experimentation. i was convinced that research needed to take place in the real world. although my dissertation was a laboratory study of helping behavior in an emergency , it was the last lab study i did that was not also paired with a field experiment (e.g. bickman and rosenbaum ) . one of my first published research studies as a graduate student was a widely cited field experiment (rct) that examined compliance to men in different uniforms in everyday settings (bickman a, b) . the first book i coedited, as a graduate student, was titled beyond the laboratory: field research in social psychology and was composed primarily of field experiments (bickman and henchy ) . almost all my early work as a social psychologist consisted of field experiments . i strongly supported the primacy of randomized designs in several textbooks i coauthored or coedited (alasuutari et al. ; bickman and rog ; bickman and rog ; hedrick et al. ) . while the fort bragg study i described above was a quasi-experiment (bickman ) , i was not happy that the funding agency, the u.s. army, did not permit me to use a rct for evaluating an important policy issue. as i was truly committed to using a rct to evaluate systems of care, i followed up this study with a conceptual replication in a civilian community using a rct (bickman et al. b ) that was funded by a nimh grant. while i have valued the rct and continue to do so, i have come to the conclusion that our experimental methods were developed for simpler problems. mental health research is more like weather forecasting with thousands of variables rather than like traditional experimentation, which is based on a century-old model for evaluating agricultural experiments with only a few variables (hall ) . we need alternatives to the traditional way of doing research, service development, and service delivery that recognize the complexity of disorders, heterogeneity of clients, and varied contexts of mental health services. the oversimplification of rcts has produced a blunt tool that has not served us well for swiftly improving our services. this is not to say that there has been no change in the last years. for example, the institute of education sciences, a more recent player the field of children's behavioral and mental health outcomes research, has released an informative monograph on the use of adaptive randomized trials that does demonstrate flexibility in describing how rcts can be implemented in innovative ways (nahum-shani and almirall ). the concerns about rcts are also apparent in other fields. for example, a special issue of social science and medicine focused on the limitations of rcts (deaton and cartwright ) . the contributors to this incisive issue indicated that a rct does not in practice equalize treatment and control groups. rcts do not deliver precise estimates of average treatment effects (ates) because a rct is typically just one trial, and precision depends on numerous trials. there is also an external validity problem; that is, it is difficult to generalize from rcts, especially those done in university laboratory settings. context is critical and theory confirmation/disconfirmation is important, for without generalizability, the findings are difficult to apply in the real world (bickman et al. ) . scaling up from a rigorous rct to a community-based treatment is now recognized as a significant problem in the relatively new fields of translational research and implementation sciences. in addition to scaling up, there is a major issue in scaling down to the individual client level. stratification and theory help, but they are still at the group level. the classic inferential approach also has problems with replication, clinical meaningfulness, accurate application to individuals, and p-value testing (dwyer et al. ) . the primary clinical problem with rcts is the emphasis on average treatment effects (ates) versus individual prediction. rcts emphasize postdiction, and ates lead to necessary oversimplification and a focus on group differences and not individuals. subramanian et al. ( ) gave two examples of the fallacy of averages: the first was a study to describe the "ideal woman," where they measured nine body dimensions and then averaged each one. a contest to identity the "average woman" got responses, but not a single woman matched the averages on all nine variables. in a second example, the u.s. air force in measured pilots on body dimensions to determine appropriate specifications for a cockpit. not a single pilot matched the averages on even as few as dimensions, even when their measurements fell within % of the mean value. as these examples show, the problem with using averages has been known for a long time, but we have tended to ignore this problem. we are disappointed when clinicians do not use our research findings when in fact our findings may not be very useful for clinicians because clinicians deal with individual clients and not some hypothetical average client. we can obtain significant differences in averages between groups, but the persons who actually benefit from therapy will vary widely to the extent to which they respond to the recommended treatments. thus, the usefulness of our results depends in part on the heterogeneity of the clients and the variability of the findings. the privileging of rcts also came with additional baggage. instead of trying to use generalizable samples of participants, the methodology favored the reduction of heterogeneity as a way to increase the probability of finding statistically significant results. this often resulted in the exclusion from studies of whole groups of people, such as women, children, people of color, and persons with more than one diagnosis. while discussions often included an acknowledgment of this limitation, little was done about these artificial limitations until inclusion of certain groups was required by federal funding agencies (national institutes of health, central resource for grants and funding information ) . the limitations of rcts are not a secret, but we tend to ignore these limitations (kent et al. ) . one attempt to solve the difficulty of translating average effect sizes by rcts to individualize predictions is called reference class forecasting. here, the investigator attempts to make predictions for individuals based on "similar" persons treated with alternative therapies. however, it is rarely the case that everyone in a clinical trial is influenced by the treatment in the same way. an attempt to reduce this heterogeneity of treatment effects (hte) by using conventional subgroup analysis with one variable at a time is rejected by kent et al. ( ) . they argue that this approach does not work. first, there are many variables on which participants can differ, and there is no way to produce the number of groups that represent these differences. for example, matching on just binary variables would produce over a million groups. moreover, one would have to start with an enormous sample to maintain adequate statistical power. the authors describe several technical reasons for not recommending this approach to dealing with the hte problem. they also suggested two other statistical approaches, risk modeling and treatment effect modeling, that may be useful, but more research on both is needed to support their use. kent et al. ( ) briefly discussed using observational or non-rct data, but they pointed out the typical problems of missing data and other data quality issues as well as the difficulty in making causal attributions. moreover, they reiterated their support for the rct as the "gold standard." although published in , their article mentioned machine learning only as a question for future research-a question that i address later in this paper. i will also present other statistical approaches to solving the limitations of rcts. there is another problem in depending upon rcts as the gold standard. nadin ( ) pointed out that failed reproducibility occurs almost exclusively in life sciences, in contrast to the physical sciences. i would add that the behavioral sciences have not been immune from criticisms about replicability. the open science collaboration ( ) systematically sampled results from three top-tier journals in psychology, and only % of the replication efforts yielded significant findings. this issue is far from resolved, and it is much more complex than simple replication (laraway et al. ) . nadin ( ) considered the issue of the replicability as evidence of an underlying false assumption about treating humans as if they were mechanistic physical objects and not reactive human beings. he noted that physics is nomothetic, while biology is idiographic, meaning that the former is the study of the formulation of universal laws and the latter deals with the study of individual cases or events. without accurate feedback, there is little learning (kluger and denisi ) . clinicians are in a low feedback occupation, and unlike carpenters or surgeons, they are unlikely to get direct accurate feedback on the effects of their activities. when carpenters cut something too short, they can quickly see that it no longer fits and have to start with a new piece, so they typically follow the maxim of measure twice, cut once. because clinicians in the real world of treatment do not get direct accurate feedback on client outcomes, especially after clients leave treatment, then they are unlikely to learn how to become more effective clinicians from practice alone. clinical practice is thus similar to an archer's trying to improve while practicing blindfolded (bickman ) . moreover, the services research field does not learn from treatment as usual in the real world, where most treatment occurs, because very few services collect outcome data, let alone try to tie these data to clinician actions (bickman b) . there are two critical requirements needed for learning. the first is the collection of fine-grained data that are contemporaneous with treatment. the second is the feedback of these data to the clinician or others so that they can learn from these data. learning can be accomplished with routine use of measures such as patient outcome measures (poms) and feedback through progress monitoring, measurementbased care (mbc), and measurement feedback systems (mfs). these measurement feedback concepts have repeatedly demonstrated their ability to improve outcomes in therapy across treatment type and patient populations (brattland et al. ; bickman et al. ; dyer et al. ; gibbons ; gondek et al. ; lambert et al. ) . despite this evidence base, most clinicians do not use these measurement feedback systems. for example, in one of the largest surveys of canadian psychologists, only % were using a progress monitoring measure (ionita et al. ) . a canadian psychological association task force (tasca et al. ) reinforced the need for psychologists to systematically monitor and evaluate their services using continuous monitoring and feedback. they stated that the association should encourage regulatory bodies to prioritize training in their continuing education and quality assurance requirements. moreover, lewis et al., in their review of measurement-based care ( ), presented a -point research agenda that captures much the ideas in the present paper: ( ) harmonize terminology and specify mbc's core components; ( ) develop criterion standard methods for monitoring fidelity and reporting quality of implementation; ( ) develop algorithms for mbc to guide psychotherapy; ( ) test putative mechanisms of change, particularly for psychotherapy; ( ) develop brief and psychometrically strong measures for use in combination; ( ) assess the critical timing of administration needed to optimize patient outcomes; ( ) streamline measurement feedback systems to include only key ingredients and enhance electronic health record interoperability; ( ) identify discrete strategies to support implementation; ( ) make evidence-based policy decisions; and ( ) align reimbursement structures. (p. ) it is not surprising that the measurement feedback approach has not yet produced dramatic effects, given how little we know about what data to collect, how often it should be collected, what feedback should be, and when and how it should be provided (bickman et al. ) . regardless, every time a client is treated, it is an opportunity to learn how to be more effective. by not collecting and analyzing information from usual care settings, we are missing a major opportunity to learn from ordinary services. the most successful model i know of using this real-world services approach is the treatment of childhood cancers in hospitals where most children enter a treatment rct (o'leary et al. ) . these authors note that in the past years, the survival rates for childhood cancer have climbed from % to almost %. they attribute this remarkable improvement to clinical research through pediatric cooperative groups. this level of cooperation is not easy to develop, and it is not frequently found in mental health services. most previous research shows differential outcomes among different types of therapies that are minor at most (wampold and imel ) . for example, weisz et al. ( ) report that in their meta-analysis, the effect of treatment type as a moderator was not statistically significant but there was a significant, but not clearly understood, treatment type by informant interaction effect. in addition, the evidence that therapists have a major influence on the outcomes of psychotherapy is still being hotly debated. the fact that the efficacy of therapists is far from a settled issue is troubling (anderson et al. ; goodyear et al. ; hill et al. ; king and bickman ) . also, current drug treatment choices in psychiatry are successful in only about % of the patients (bzdok and meyer-lindenberg ) and are as low as - % for antidepressants (dwyer et al. ) . while antidepressants are more effective than placebos, they have small effect sizes (perlis ) , and the choice of specific medicine is a matter of trial and error in many cases. it is relatively easy to distinguish one type of drug from another but not so for services, where even dosage in psychosocial treatments is hard to define. according to dwyer et al. ( ) , "currently, there are no objective, personalized methods to choose among multiple options when tailoring optimal psychotherapeutic and pharmacological treatment" (p. ). a recent summary concluded that after years and studies, it is unknown which patients benefit from interpersonal psychotherapy (ipt) versus another treatment (bernecker et al. ) . however, to provide a more definitive answer to the question about which treatments are more effective, we need head-to-head direct comparisons between different treatments and network meta-analytic approaches such as those used by dagnea et al. ( ) . the field of mental health is not alone in finding that many popular medications do not work with most of the people who take them. nexium, a common drug for treating heartburn, works with only person out of , while crestor, used to treat high cholesterol, works with only out of (schork ) . this poor alignment between what the patient needs, and the treatment provided is the primary basis for calling for a more precise medicine approach. this lack of precision leads to the application of treatments to people who cannot benefit from it, thus leading to overall poor effectiveness. in summary, a deep and growing body of work has led me to conclude that we need additional viable approaches to a rct when it comes to conducting services-related research. an absence of rigorous evaluation of treatments that are usually provided in the community contributes to a gap in our understanding why treatments are ineffective (bickman b) . poor use of measurement in routine care (bickman ) and the absence of measurement feedback systems and clinician training and supervision (garland et al. ) are rampant. there also a dire need for the application of more advanced analytics and data mining techniques in the mental health services area (bickman et al. ). these and other such challenges have in turn informed my current thinking about alternative or ancillary approaches for addressing the multitude of problems plaguing the field of mental health services. the five problems i have described above constitute significant obstacles to achieving accessibility, efficiency, and effectiveness in mental health services. nevertheless, there is a path forward that i believe can help us reach these goals. artificial intelligence promises to transform the way healthcare is delivered. the core of my recommendations in this paper rests on the revolutionary possibilities of artificial intelligence for improving mental healthcare through precision medicine that allows us to take into account the individual variability that exists with respect to genetic and other biological, environmental, and lifestyle characteristics. several others have similarly signaled a need for considering the use of personalized approaches to service delivery. for example, weisz and his colleagues (marchette and weisz ; ng and weisz ) called for more idiographic research and for studies tailoring strategies in usual care. kazdin ( ) focused on expanding mental health services through novel models of intervention delivery; called for task shifting among providers; advocated designing and implementing treatments that are more feasible, using disruptive technologies, for example, smartphones, social media such as twitter and facebook, and socially assistive robots; and emphasized social network interventions to connect with similar people. ai is currently used in areas ranging from prediction of weather patterns to manufacturing, logistic planning to determine efficient delivery routes, banking, and stock trading. ai is used in smartphones, cars, planes, and the digital assistants siri and alexa. in healthcare, decision support, testing and diagnosis, and self-care also use ai. ai can sort through large data sets and uncover relationships that humans cannot perceive. through learning that occurs with repeated, rapid use, ai surpasses the abilities of humans only in some areas. however, i would caution potential users that there are significant limitations associated with ai that are discussed later in this paper. rudin and carlson ( ) present a non-technical and well written review of how to utilize ai and of some of the problems that are typically encountered. ai is not one type of program or algorithm. machine learning (ml), a major type of ai, is the construction of algorithms that can learn from and make predictions based on data. it can be ( ) supervised, in which the outcome is known and labeled by humans and the algorithm learns to get that outcome; ( ) unsupervised, when the program learns from data to predict specific outcomes likely to come from the patterns identified; and ( ) reinforcement learning, in which ml is trial and error. in most cases, there is an extensive training data set that the algorithm "learns" from, followed by an independent validation sample that tests the validity of the algorithm. other variations of ai include random forest, decision trees, and the support vector machine (svm), a multivariate supervised learning technique that classifies individuals into groups (dwyer et al. ; shrivastava et al. ). the latter is most widely used in psychology and psychiatry. artificial neural networks (anns) or "neural networks" (nns) are learning algorithms that are conceptuality related to biological neural networks. this approach can have many hidden layers. deep learning is a special type of machine learning. it helps to build learning algorithms that can function conceptually in a way similar to the functioning of the human brain. large amounts of data are required to use deep learning. ibm's watson won jeopardy with deepqa algorithms designed for question answering. as exemplified by the term neural networks, algorithm developers appear to name their different approaches with reference to some biological process. genetic algorithms are based on the biological process of gene propagation and the methods of natural selection, and they try to mimic the process of natural evolution at the genotype level. it has been a widely used approach since the s. natural language processing (nlp) involves speech recognition, natural language understanding, and natural language generation. nlp may be especially useful in analyzing recordings of a therapy session or a therapist's notes. affective computing or sentiment analysis involves the emotion recognition, modeling, and expression of emotion by robots or chatbots. sentiment analysis can recognize and respond to human emotions. virtual reality and augmented reality are human-computer interfaces that allow a user to become immersed within and interact with computer-generated simulated environments. hinton ( ) , a major contributor to research on ai and health, described ai as the use of algorithms and software to approximate human cognition in the analysis of complex data without being explicitly programmed. the primary aim of health-related ai applications is to analyze relationships between prevention or treatment techniques and patient outcomes. ai programs have been developed and applied to practices such as diagnosis processes, treatment protocol development, drug development, personalized medicine, and patient monitoring and care. deep learning is best at modeling very complicated relationships between input and outputs and all their interactions, and it sometimes requires a very large number of cases-in the thousands or tens of thousands-to learn. however, there appears to be no consensus about how to determine, a priori, the number of cases needed, because the number is highly dependent on the nature of the problem and the characteristics of the data. ai is already widely used in medicine. for example, in ophthalmology, photos of the eyes of persons with diabetes were screened with % specificity and % sensitivity in detecting diabetes (gargeya and leng ) . one of the more prolific uses of ai is in the diagnosis of skin cancer. in a study that scanned , clinical images, the ai approach had accuracy similar to that of board-certified dermatologists (esteva et al. ) . cardiovascular risk prediction with ml is significantly improved over established methods of risk prediction (krittanawong et al. ; weng et al. ). however, a study by desai et al. ( ) found only limited improvements in predicting heart failure over traditional logistic regression. in cancer diagnostics, ai identified malignant tumors with % accuracy compared to % accuracy for human pathologists (liu et al. ). the ibm's watson ai platform took only min to analyze a genome of a patient with brain cancer and suggest a treatment plan, while human experts took h (wrzeszczynski et al. ) . ai has also been used to develop personalized immunotherapy for cancer treatment (kiyotani et al. ). rajpurkar et al. ( ) compared chest x-rays for signs of pneumonia using a state-of-the-art -layer convolutional neural network (cnn) program with a "swarm" of radiologists (groups connected by swarm algorithms) and found the latter to be significantly more accurate. in a direct comparison between radiologists on , interpretations and a stand-alone deep learning ai program designed to detect breast cancer in mammography, the ai program was as accurate as the radiologists (rodriguez-ruiz et al. ). as topol ( b) noted, ai is not always the winner in comparison with human experts. moreover, many of these applications have not been used in the real world, so we do not know how well ai will scale up in practice. topol describes other concerns with ai, many of which are discussed later in this paper. finally, many of the applications are visual, such as pictures of skin or scans, for which ai is particularly well suited. large banks of pictures often form the training and testing data for this approach. in mental health, visual data are not currently as relevant. however, there is starting to be some research on facial expressions in diagnosing mental illness. for example, abdullah and choudhury ( ) cite several studies that showed that patients with schizophrenia tend to show reduced facial expressivity or that facial features can be used to indicate mental health status. more generally, there is research showing how facial expressions can be used to indicate stress (mayo and heilig ) . visual data are ripe for exploration using ai. although an exhaustive review of the ai literature and its applications is well beyond the focus of this paper, rudin and carlson ( ) present a well-written, non-technical review of how to utilize ai and of some of the problems that are typically encountered. topol ( a) , in his book titled deep medicine: how artificial intelligence can make healthcare human again, includes a chapter on how to use of ai in mental health. topol ( b) also provides an excellent review of ai and its application to health and mental health in a briefer format. buskirk et al. ( ) and y. liu et al. ( ) provide well-written and relatively brief introductions to ml's basic concepts and methods and how they are evaluated. a more detailed introduction to deep learning and neural networks is provided by minar and naher ( ) . in most cases, i will use the generic term ai to refer to all types of ai unless the specific type of ai (e.g., ml for machine learning, dl for deep learning, and dnn for deep neural networks) is specified. precision medicine has been defined as the customization of healthcare, with medical decisions, treatments, practices, or products being tailored to the individual patient (love-koh et al. ) . typically, diagnostic testing is used for selecting the appropriate and best therapies based a person's genetic makeup or other analysis. in an idealized scenario, a person may be monitored with hundreds of inputs from various sources that use ai to make predictions. the hope is that precision medicine will replace annual doctor visits and their granular risk factors with individualized profiles and continuous longitudinal health monitoring (gambhir et al. ) . the aim of precision medicine, as stated by president barack obama when announcing his precision medicine initiative, is to find the long-sought goal of "delivering the right treatments, at the right time, every time to the right person" (kaiser ) . both ai and precision medicine can be considered revolutionary in the delivery of healthcare, since they enable us to move from one-size-fits-all diagnoses and treatment to individualized diagnoses and treatments that are based on vast amounts of data collected in healthcare settings. the use of ai and precision medicine to guide clinicians will change diagnoses and treatments in significant ways that will go beyond our dependence on the traditional rct. precision medicine should also be seen as evolutionary since even hippocrates advocated personalizing medicine (kohler ) . the importance of a precision medicine approach was recognized in the field of prevention science with a special issue of prevention science devoted to that topic (august and gewirtz ) . the articles in this special issue recognize the importance of identifying moderators of treatment that predict heterogeneous responses to treatment. describing moderators is a key feature of precision medicine. once these variables are discovered, it becomes possible to develop decision support systems that assist the provider (or even do the treatment assignment) in selecting the most appropriate treatment for each individual. this general approach has been tried using a sequential multiple assignment randomized trial (smart) in which participants are randomized two to three times at key decision points (august et al. ) . what i find notable about this special issue is the absence of any focus on ai. the articles were based on a conference in october , and apparently the relevance of ai had not yet influenced these very creative and thoughtful researchers at that point. precision medicine does not have an easy path to follow. x. liu et al. ( b) describe several challenges, including the following three. large parts of the human genome are not well enough known to support analyses; for example, almost % of our genetic code is unknown. it is also clear that a successful precision medicine approach depends on having access to large amounts of data at multiple levels, from the genetic to the behavioral. moreover, these data would have be placed into libraries that allow access for researchers. the u.s. federal government has a goal of establishing such a library with data on one million people through nih's all of us research program (https ://allof us.nih.gov/). recruitment of volunteers who would be willing to provide data and the "harmonization" of data from many different sources are major issues. x. liu et al. ( b) also point to ethical issues that confront precision medicine, such as informed consent, privacy, and predictions that someone may develop a disease. these issues are discussed later in this paper. chanfreau-coffinier et al. ( ) provided a helpful illustration of how precision medicine could be implemented. they convened a conference of veterans affairs stakeholders to develop a detailed logic model that can be used by an organization planning to introduce precision medicine. this model includes components typically found in logic models, such as inputs (clinical and information technology), big data (analytics, data sources), resources (workforce, funding) activities (research), outcomes (healthcare utilization), and impacts (access). the paper also includes challenges to implementing precision medicine (e.g., a poorly trained workforce) that apply to mental health. ai has the potential to unscramble traditional and new diagnostic categories based on analysis of biological/genetic and psychological data, and in addition, more data will likely be generated now that the potential for analysis has become so much greater. ai also has the potential to pinpoint those individuals who have the highest probability of benefiting from specific treatments and to provide early indicators of success or failure of treatment. research is currently being undertaken to provide feedback to clinicians at key decision points as an early warning of relapse. fernandes et al. ( ) describe what the authors call the domains related to precision psychiatry (see fig. ). these domains include many approaches and techniques, such as panomics, neuroimaging, cognition, and clinical characteristics, that form several domains including big data and molecular biosignature; the latter includes biomarkers. the authors include data from electronic health records, but i would also include data collected from treatment or therapy sessions as well as data collected outside of these sessions. these domains can be analyzed using biological and computational tools to produce a biosignature, a higher order domain that includes data from all the lower level techniques and approaches. this set of biomarkers in the biosignature should result in improved diagnosis, classification, and prognosis, as well as individualized interventions. the authors note that this bottom-up approach, from specific approaches to domains to the ultimate biosignature, can also be revised to a top-down approach, with the biosignature studied to better understand domains and its specific components. the bottom of the figure shows a paradigm shift where precision psychiatry contributes to different treatments being applied to persons with different diagnoses and endophenotypes, producing different prognoses. endophenotypes is a term used in genetic epidemiology to separate different behavioral another perspective on precision psychiatry is presented by bzdock and meyer-lindberg ( ). both models contain similar concepts. both start with a group of persons containing multiple traditional diagnoses. bzdock and meyer-lindberg recognize that these psychiatric diagnoses are often artificial dichotomies. machine learning is applied to diverse data from many sources and extracts hidden relationships. this produces different subgroups of endophenotypes. machine learning is also used to produce predictive models of the effects of different treatments instead of the more typical trial and error. further refinement of the predictive ml models results in better treatment selection and better prediction of the disease trajectory. an excellent overview of deep neural networks (dnns) in psychiatry and its applications is provided by durstewitz et al. ( ) . in addition to explaining how dnns work, they provide some suggestions on how dnns can be used in clinical practice with smartphones and large data sets. a major feature of deep neural networks is their ability to learn and adapt with experience. while dnns typically outperform ml, the authors state that they do not fully understand why this is the case. in mental health, dnns have been mostly used in diagnosis and predictions but not in designing personalized treatments. dnn's ability to integrate many different data sets (e.g., various neuroimaging data, movement patterns, social media, and genomics) should provide important insights on how to personalize treatments. regardless of the model used, eyre et al. ( ) remind us that consumers should not be left out of the development of precision psychiatry. in my conceptualization of precision medicine, precision mental health encompasses precision psychiatry and any other precision approach such as social work that focuses on mental health (bickman et al. ). there has not been much written about using a precision approach with psychosocial mental health services. possibly it is psychiatry's close relationship to general medicine and its roots in biology that make psychiatry more amenable to the precision science approach. in addition, the use of the precision construct is being applied in other fields, as exemplified by the special issue of the journal of school psychology devoted to precision education (cook et al. ) and precision public health (kee and taylor-robinson ) . however, in this paper i am primarily addressing the use of psychosocial treatment of mental health problems, which differs in important ways from psychiatric treatment. for example, precision psychosocial mental health treatment does not have a strong biological/medical perspective and does not focus almost exclusively on medication; instead, it emphasizes psychosocial interventions. psychosocial mental health services are also provided in hospital settings, but their primary use is in community-based services. these differences lead to different data sources for ai analyses. it is highly unlikely that electronic mental healthcare records found outside of hospital settings contain biological and genomic data (serretti ) . but hospital records are not likely to contain the detailed treatment process data that could possibly be found in community settings. the genomic and biological data offer new perspectives but may not be informative until we have a better understanding about the genomic basis of mental illness. in addition, the internet of things and smart healthcare connect wearable and home-based sensors that can be used to monitor movement, heart rate, ecg, emg, oxygen level, sleep, and blood glucose, through wi-fi, bluetooth, and related technologies. (sundaravadivel et al. ) . with wider use of very fast g internet service, there will be a major increase in the growth of the internet of things. i want to emphasize that applying precision medicine concepts to mental health services, especially psychotherapy, is a very difficult undertaking. the data requirements for psychosocial mental health treatment are more similar to meteorology or weather forecasting than to agriculture, which is considered the origin of the rct design. people's affect, cognition, and behavior are constantly changing just like the variables that affect weather. but unlike meteorology, which is mainly descriptive and not yet engaged in interventions, mental health services are interventions. thus, in addition to client data, we must identify the variables that are critical to the success of the intervention. we are beginning to grasp how difficult this task is as we develop greater understanding that the mere labeling of different forms of treatment by location (e.g., hospital or outpatient) or by generic type (e.g., cognitive behavior therapy) is not sufficiently informative. moreover, the emergence of implementation sciences has forced us to face the fact that a treatment manual describes only some aspects of the treatments as intended but does not describe the treatment that is actually delivered. nlp is a step in the right direction in trying to capture some aspects of treatment as actually delivered. data quality is the foundation upon which ai systems are built. while medical records are of higher technical quality than community-based data because they must adhere to national standards, i believe that the nascent interest in measurement-based care and measurement feedback systems in community settings bodes well for improved data systems in the future. moreover, although electronic hospitalbased data may be high quality from a technical viewpoint (validity, reliability) and be very large, they probably do not contain the data that are valuable for developing and evaluating mental health services. the development of electronic computer-based data collection and feedback systems will become more common as the growth in ai demands large amounts of good-quality treatment and finer grained longitudinal outcome data. there is a potential reciprocal relationship between the ai needs for large, high-quality data sets and the development of new measurement approaches and the electronic systems needed to collect such data (bickman a; bickman et al. a bickman et al. , . to accomplish this with sufficiently unbiased and valid data will be a challenge. ai can bypass many definitional problems by not using established diagnostic systems. ml can use a range of variables to describe the individual ml classifier systems (tandon and tandon ) . moreover, additional sources of data that help in classification are now feasible. for example, automated analysis of social media including tweets and facebook can detect depression, with accuracy measured by area under the curve (auc) ranging from . to . compared to clinical interviews with aucs of . (guntuku et al. ). as noted earlier, dnns have been shown to be superior to other machine learning approaches in general and specifically in identifying psychiatric stressors for suicide from social media (du et al. ). predictions of , adolescent suicides with ml showed high accuracy (auc > . ) and outperformed traditional logistic regression analyses ( . - . aucs) (tandon and tandon ) . saxe has published a pioneering proof of concept that has demonstrated that ml methods can be used to predict child posttraumatic stress (saxe et al. ) . ml was more accurate than humans in predicting social and occupational disability with persons in high-risk states of psychosis or with recent-onset depression (koutsouleris et al. a) . machine learning has also been used in predicting psychosis using everyday language (rezaii et al. ) . another application of ai to diagnosis is provided by kasthurirathne et al. ( ) . they demonstrated the ability to automate screening for , adult patients in need of advanced care for depression using structured and unstructured data sets covering acute and chronic conditions, patient demographics, behaviors, and past service use history. the use of many existing data elements is a key feature and thus does not depend on single screening instruments. the authors used this information to accurately predict the need for advanced care for depression using random forest classification ml. milne et al. ( ) recognized that in implementing online peer counseling, professionals need to participate and/or provide safety monitoring in using ai. however, cost and scalability issues appeared to be insurmountable barriers. what is needed is an automated triage system that would direct human moderators to cases that require the most urgent attention. the triage system milne et al. developed sent human moderators color-coded messages about their need to intervene. the algorithm supporting this triage system was based on supervised ml. the accuracy of the system was evaluated by comparing a test set of manually prioritized messages with the ones developed through the algorithm. they used several methods to judge accuracy, but their main one was an f-measure, or the harmonic mean of recall (i.e., sensitivity) and precision (i.e., positive predictive value). regression analysis indicated that the triage system made a significant and unique contribution to reducing the time taken to respond to some messages, after accounting for moderator and community activity. i can see the potential for this and similar ai approaches to deal with the typical service setting where some degree of supervision is required but even intermittent supervision is not feasible or possible. another use of ml as a classification tool is provided by pigoni et al. ( ) . in their review of treatment resistant depression, they found that ml could be used successfully to classify responders from non-responders. this suggested that stratification of patients might help in selecting the appropriate treatment, thus avoiding giving patients treatments that are unlikely to work with them. a more general systematic review and meta-analysis of the use of ml to predict depression are provided by lee et al. ( ) . the authors found qualitative and quantitative studies that qualified for inclusion in their review. while most of the studies were retrospective, they did find predictions with an average overall accuracy of . . kaur and sharma ( ) reviewed the literature on diagnosis of ten different psychological disorders and examined the different data mining and software approaches (ai) used in different publications. depending on the disorder and the software used, the accuracy ranged from to %. accuracy was defined differently depending on the study. only % of the articles exploring diagnosis of any health problem were found to be for psychological problems. this suggests that we need more studies on diagnosis and ai. a very informative synthesis and review are provided by low et al. ( ) . they screened studies and reviewed the that met the inclusion criterion: studies from the last years using speech to identify the presence or severity of disorders through ml methods. they concluded that ml could be predictive, but confidence in any conclusions was dampened by the general lack of cross-validation procedures. the article contains very useful information on how best to collect and analyze speech samples. another innovative approach using ml focused on wearable motion detector sensors, in which these devices were worn for s during a -s mood induction task (seeing a fake snake). these data were able to distinguish children with an internalizing disorder from controls with % accuracy (mcginnis et al. ) . this approach has potential for screening children for this disorder. a problem that seemingly has been ignored by most studies that deal with classification or diagnosis is the gold standard by which accuracy is judged. in most cases, the gold standard is human judgment, which is especially fallible when it comes to mental health diagnosis. we can clearly measure whether the ai approach is faster and less expensive than human judgment, but is the ultimate in ai accuracy matching human judgment with all its flaws? i believe that the endpoint that must also be measured is client clinical mental health improvement. a system that provides faster and less expensive diagnosis but does not lead to more precise treatment and better clinical outcomes will save us time and money, which are important, but they will not be the breakthrough for which we are looking. a solution to the problems described above will involve the integration of causal discovery methods with ai approaches. ai methods are capable of improving our capacity to predict outcomes. to enhance predictability, we will need to identify the factors in the predictive models that are causal. thus, there is the need to identify techniques that provide us with causal knowledge, which currently is based primarily on rcts. but, for real-world and ethical reasons, human etiological experiments can rarely be conducted. fortunately, there are newer ai methods that can be used to infer causes, which include well validated tests of conditional independencies based on the causal markov condition (pearl ; aliferis et al. ; saxe ) . these methods have been successfully used outside of psychiatry (sachs et al. ; ramsey et al. ; statnikov et al. ) and have, in the last five years, been applied in research on mental health, largely by the team of glenn saxe at new york university and constantin aliferis and sisi ma at university of minnesota. this group has reported causal models of ptsd in hospitalized injured children (saxe et al. (saxe et al. , , children seen in outpatient trauma centers (saxe et al. ) , maltreated children (morales et al. ) , adults seen in emergency rooms (galatzer-levy et al. ) , and police officers who were exposed to trauma (saxe et al. in press ). saxe ( ) recently described the promise of these methods for psychiatric diagnosis and personalized precision medicine. new measures need to be developed that cover multiple domains of mental health, are reported by different respondents (e.g., child, parent, clinician), and are very brief. cohen ( ) provides an excellent overview of what he calls ambulatory biobehavioral technologies in a special section of psychological assessment. he notes that the development of mobile devices can have a major impact on psychological assessment. he cautions, however, that while some of these approaches have been used for decades, they still have not progressed beyond the proof of concept phase for clinical and commercial applications. ecological momentary assessment (ema) is a relatively new approach to measurement development. ema is the collection of real-time data collected in naturalistic environments. this approach uses a wide range of smart watches, bands, garments, and patches with embedded sensors (gharani et al. ; pistorius ) . for example, using smartphones, researchers have identified gait features for estimating blood alcohol content level (gharani et al. ). other researchers have been able to map changes in emotional state ranging from sad to happy by using a movement sensor on smart watches (quiroz et al. ) . others have described real-time fluctuations in suicidal ideation and its risk factors, using an average of . assessments per day (kleiman et al. ) . social anxiety has been assessed from global positioning data obtained from smart watches by noting that socially anxious students were found to avoid public places and to spend more time at home than in leisure activities outside the home (boukhechba et al. ) . a review of studies using ema concluded that the compliance rate was moderate but not optimal and could be affected by study design (wen et al. ). this review is also a good source of descriptions of different approaches to using ema. another good summary that focused on ema in the treatment of psychotic disorders can be found in bell et al. ( ) . for ema use in depression and anxiety, schueller et al. ( ) is a good source. ema has been used to measure cardiorespiratory function, movement patterns, sweat analysis, tissue oxygenation, sleep, and emotional state (peake et al. ) . harari et al. ( ) present a catalog of behavior in more than aspects of daily living that can be used in studying physical movement, social interactions, and daily activities. these include walking, speaking, text messaging, and so on. these all can be collected from smartphones and serve as an alternative to traditional survey approaches. however, it is still not clear what higher-level constructs are measured using these approaches. a comprehensive and in-depth review of studies that have used speech to assess psychiatric disorders is provided by low et al. ( ) . they conclude that speech processing technology could assist in mental health assessments but believe that there are many obstacles to this use, including the need for longitudinal studies. another interesting application for children is the use of inexpensive screening for internalizing disorders. mcginnis et al. ( ) monitored the child's motion for s using a commercially available and inexpensive wearable sensor. using a supervised ml approach, they obtained an % accuracy ( % sensitivity, % specificity) compared to similar clinical threshold on parent-reported child symptoms that differentiate children with an internalizing diagnosis from controls without such a diagnosis. in a systematic review of ema use in major depression, colombo et al. ( ) evaluated studies that met their criteria for inclusion. these studies measured a wide variety of variables including self-reported symptoms, sleep patterns, social contacts, cortisol, heart rate, and affect. they point out many of the advantages of using emas such as realtime assessments, capturing the dynamic nature of change, improving generalizability, and providing information about context. they believe that the use of emas has resulted in novel insights about the nature of depression. they do note that there are few evaluations of these measures, and there is not much use in actual clinical practice. mohr et al. ( ) note that most of the research on ema has been carried out primarily by computer scientists and engineers using a very different research model than social and behavioral scientists. while computer scientists are mostly interested in exploratory proof of concepts approach (does it work at all?) using very small samples, social/behavioral scientists are more typically theory driven and investigate under what conditions the intervention will work. mental health care, apart from medication, is almost exclusively verbal. several approaches have been tried to capture the content of treatment sessions. my colleagues and i have tried by asking clinicians to use a brief checklist of topics discussed after each therapy session . although this technique produced some interesting findings such as the identification of topics that the clinician did not discuss but that were believed to be important by the youth or parent, it is clearly filtered by what the clinician recalls and is willing to check off as having been discussed. while recordings provide a richer source of information, coding recordings manually is too expensive and slow for the real world of service delivery. the content of therapy sessions, including notes kept by clinicians, is pretty much ignored by researchers because of the difficulty and cost of manually coding those sources. however, advances in natural language processing (nlp) are now being explored as a way of capturing aspects of the content of therapy sessions. for example, tanana et al. ( ) have shown how two types of nlp techniques can be used to study and code the use of motivational interviewing in taped sessions. carcone et al. ( ) also showed that they could accurately code motivational interviewing (mi) clinical encounter transcripts with sufficient accuracy. other researchers have used ai to analyze speech to distinguish between what they called high-and low-quality counselors (pérez-rosas et al. ). some colleagues and i have submitted a proposal to nimh to refine nlp tools that can be used to supervise clinicians implementing an evidence-based treatment using ai. as far as we know, using nlp to measure fidelity and provide feedback to clinicians has not been studied in a systematic way. while ai appears to be an attractive approach to new ways of analyzing data, it should be noted that, as always, the quality of the analysis is highly dependent on the quality of the data. jacobucci and grimm ( ) caution us that "in psychology specifically, the impact of machine learning has not been commensurate with what one would expect given the complexity of algorithms and their ability to capture nonlinear and interactive effects" (p. ). one observation made by these authors is that the apparent lack of progress in using ai may be caused by "throwing the same set of poorly measured variables that have been analyzed previously into machine learning algorithms" (p. ). they note that this is more than the generic garbage in, garbage out problem, but it is specifically related to measurement error, which can be measured relatively accurately. as described earlier, our privileging of rcts has contributed to a lack of focus on a precision approach to mental health services. this has resulted in the problem of ignoring the clinical need for predicting for an individual in contrast to establishing group difference, the approach favored by the experimentalist/ hypothesis testing tradition. ai offers an approach to the discovery of important relationships in mental health in addition to rcts that are based on singlesubject prediction accuracy and not null hypothesis testing (bzdok and karrer ) . saxe et al. ( ) have demonstrated the use of the complex-systems-causal network method to detect causal relationships among variables and bivariate relations in a psychiatric study using algorithms. a comprehensive review and meta-analysis of machine learning algorithms that predict outcomes of depression showed excellent accuracy ( . ) using multiple forms of data (lee et al. ) . it is interesting to note that none of the scholars commenting on the rct special issue in social science and medicine (deaton and cartwright ) specifically mentioned the use of ai as a potential solution to some of the problems of using average treatment effects (ates). kessler et al. ( a) noted that clinical trials do not tell us which treatments are more effective for which patients. they suggested that what they label as precision treatment rules (ptrs) be developed that are predictors of the relative treatment effectiveness of different treatments. the authors presented a comprehensive discussion on how to use ml to develop ptrs. they concluded that the sample sizes needed are much larger than usually those found in rcts; observational data, especially from electronic medical records (emrs) can be used to deal with the sample size issue; and statistical methods can be used to balance both observed and unobserved covariates using instrumental variables and discontinuity designs. they do note the difficulty in obtaining full baseline data from emrs and suggest several solutions for this problem, including supplemental data collection and links to other archival sources. they recommend the use of an ensemble ml approach that combines several algorithms. they are clear that their suggestions are exploratory and require verification, but they are more certain that if ml improves patient outcomes, it will be a substantial improvement. wu et al. ( ) collaborated with kessler on a proof of concept of a similar model called individualized treatment rules (itr). in a model simulation, they used a large sample (n = , ) with an ensemble ml method to identify the advantages of using ml algorithms to estimate the outcomes if a precision medicine approach was taken in prescribing medication for persons with first-onset schizophrenia. they found that the treatment success was estimated to be . % under itr compared to . % with the medication that was actually used. wu et al. see this as a first step that needs to be confirmed by pragmatic rcts. kessler et al. ( b) conducted a relatively small randomized study (n = ) in which soldiers seeking treatment were judged to be at risk for suicide. they were randomly assigned to two types of treatment but not on the basis of any a priori ptr. the data from that study were then analyzed using ml to produce ptrs. these data were then modeled in a simulation to see if the ptr would have produced better outcomes. the authors did find that the simulated ptr produced better effects. lenze et al. ( ) address the problems of rcts from a somewhat different perspective than i have presented here and suggest a potential solution that they call precision clinical trials (pcts). the authors propose that the problem with most existing rcts is that they measure only the fixed baseline characteristics that are not usually sensitive to detecting treatment responders. moreover, treatment is typically not dynamically adapting to the client during treatment, and measures are not administered with sufficient frequency. instead, the pcts would: ( ) first attempt to determine whether short-term responses to the intervention could determine who was a likely candidate for that specific treatment; ( ) initiate the treatment in an adaptive fashion that could vary over time, using stepped care or just-in-time adaptations that are responsive to the client's changing status, and frequently collect data possibly using multiple assignment randomized trial methods; and ( ) use frequent precision measurement, possibly using ecological momentary assessments described earlier. coincidently, they illustrate the application of pcts using repetitive transcranial magnetic stimulation (rtms), a form of brain stimulation therapy used to treat depression and anxiety that has been in use since . rtms will be described later in connection with what i call a third path for services and ai. it is disappointing that i could not find any examples of published research that used a rct to test whether an ai approach to an actual, not simulated, delivery of a mental health treatment produces better clinical outcomes than a competitive treatment or even treatment as usual. this is clearly an area requiring further rigorous empirical investigation. imel et al. ( ) provide an excellent overview on how ai and other technologies can be used for monitoring and feedback in psychotherapy in both training and supervision. imel et al. ( ) used ml to code and provide data to clinicians on metrics used to measure the quality of motivational interviewing (mi). a prior study (tanana et al. ) established that ml was able to code mi quality metrics with accuracy similar to human coders. they conducted a pilot study using standardized patients and -min speech segments that was designed to test the feasibility of providing feedback to clinicians on the quality of their mi intervention. the feedback was not in real-time but was provided after the session. they were able to establish that clinicians thought highly of the feedback they received. the authors anticipate that further developments in this technology will lead to its widespread use in supervision and in real-time feedback. it would seem that the next step is evaluating the enhanced ai feedback procedure in a real-world effectiveness study. another example of the use of nlp application is the use of a bot that was trained to assess and provide feedback on specific interviewing and counseling skills such as asking open-ended questions and providing feedback (tanana et al. ) . after training the bot on transcripts, non-therapists (using amazon mechanical turk recruits) were randomly assigned to either immediate feedback on a practice session with the bot or just encouragement on the use of those skills. the group provided the feedback were significantly more likely to use reflection even when feedback was removed. the authors consider this to be a proof of concept demonstration because of the many limitations (e.g., use of non-therapists). a plan for using nlp to monitor and provide feedback to clinicians on the implementation of an evidenced program is provided by berkel et al. ( ) . they provide excellent justification for using nlp to accomplish this goal, but unfortunately it is only a design at this point. rosenfeld et al. ( ) see ai making major contributions to improving the quality of treatment through efficient continuous monitoring of patients. until now, monitoring was limited to in-session contacts or manual contacts, an approach that is not practical or efficient. the almost universal availability of smartphones and other internet active devices (internet of things) makes collecting data from clients practical and efficient. these various data sources provide feedback to providers so that they can predict and prevent relapse and compliance with treatment, especially medication. the authors note that there is not a large body of research in this area, but early studies are positive. one concrete application of ai to providing feedback is described by ryan and his colleagues . their article only describes how such could be done; unfortunately, it is not an actual study but a suggestion on how to apply ai for feedback to physicians to improve their communications with patients. they note that routine assessment and feedback are not done manually because of the cost and time requirements. however, ai can automate these tasks by evaluating recordings. they suggest using already existing ai approaches that are in use by call centers to categorize and evaluate communication along the following dimensions: speaker ratio that indicates listening, overlapping talk that are interruptions, pauses longer than two seconds, speed, pitch, and tone. the content could also be evaluated along the dimensions of the use of plain language, clinical jargon, and shared decision making. ai could also explore other dimensions such as the meaning of words and phrases using nlp, turn taking, tone, and style. many technical difficulties would have to be overcome to assess many of these variables, but the field is making progress. an actual application of ml to feedback, but not in mental health, is provided by pardo et al. ( ) in a course for first-year engineering students. instructors developed in advance a set of feedback messages for levels of interaction with learning resources. for example, different feedback messages were provided depending on whether the student barely looked at video, watched a major portion, watched the whole video, or watched it several times. an ml algorithm selected the appropriate message to send the student through either email or the virtual learning environment. compared to earlier cohorts who did not receive the feedback, those who did were more satisfied with the course and had better performance on the midterm. i can see how such a protocol could be used in mental health services. an indication of the work that needs to be done in becoming more specific about feedback is a study conducted by hooke et al. ( ) . they provide feedback to patients with and without a trajectory showing expected progress and found that patients preferred the feedback with the expected change over time. they found that these patients preferred to have normative feedback with which they could compare their own ideographic progress. two systematic reviews that focused on implementing routine outcome measurement (rom) concluded that while rom has been shown to produce positive results, how to best implement rom remains to be determined by future research (gual-montolio et al. ; mackrill and sorensen ) . the authors of both reviews note several interesting points but focus on these two: how to integrate measurement into clinical practice and how organizations support staff in this effort. they highlight the importance of developing a culture of feedback in organizations. neither review includes any studies using ai. while they call for more research to move this field forward, i do not think there will be much change until either measurement feedback systems are required by funders or service delivery organizations are paid for providing such systems. probably the most advanced work in this area that includes ml is being done by lutz and his colleagues (lutz et al. ) . they have developed a measurement feedback system that includes the use of ml to make predictions and to provide clinicians with clinical decision support tools. they are able to predict dropouts and assign support tools to clinicians that are specific to the problems their clients are exhibiting, based on the data they have collected. lutz and his colleagues are currently evaluating the system to influence clinical outcomes in a prospective study. this comprehensive feedback system provided clinical support tools with recommendations based on identification of similar patients to the treatment group but not to the control group. they already have some very promising results using three different treatment strategies (w. lutz, personal communication, september , ) . almost all the research in this area has been on prediction and not in actually testing whether precision treatments are in fact better than standard treatments in improving mental health outcomes. even these predictive studies are on extant databases rather than data collected specially for use in ai algorithms. with a few exceptions to be discussed later, this is the state of the art. to establish the practical usefulness of ai, we need to move beyond prediction to show actual mental health improvements that have clinical and not just statistical significance. there are some scholars who are carefully considering how to improve methodology to achieve better predictions (e.g., garb and wood ) . in addition, zilcha-mano ( ) has a very thoughtful paper that describes traditional statistical and machine learning approaches to trying to answer the core question of what treatments work best for which patients, as well as the more general question about why psychotherapy works at all. nlp has been used to analyze unstructured or textual material for identifying suicidal ideation in a psychiatric research database. precision of % for identification of suicide ideation and % for suicide attempts has been found using nlp (fernandes et al. ) . a meta-analysis of studies of prediction of suicide using traditional methodologies found only slightly better than chance predictions and no improvement in accuracy in years (franklin et al. b ). recent ml decision support aids using large-scale biological and other data have been useful in predicting responses to different drugs for depression (dwyer et al. ). triantafyllidis and tsanas ( ) conducted a literature review of pragmatic evaluations of nonpharmacological applications of ml in real-life health interventions from january through november , following prisma guidelines. they found only eight articles that met their criteria from citations screened. three dealt with depression and the remainder with other health conditions. six of the eight produced significantly positive results, but only three were rcts. there has been little rigorous research to support ai in real-world contexts. accuracy of prediction is one of the putative advantages of ai. but the advantage of predicting outcomes is not as relevant if a client prematurely leaves treatment. thus, predicting premature termination is one of the key goals of an ai approach. in a pilot study to test whether ai could be beneficial in predicting premature termination, bohus et al. ( ) were not able to adequately predict dropouts using different ml approaches with responses to the borderline symptom list (bsl- ). however, they obtained some success when they combined the questionnaire data with personal diary questionnaires from patients, although they note that the sample is too small to draw any strong conclusions. this pilot study illustrates the importance of what data goes into the data set as well as our lack of knowledge of the data requirements we need to have confidence in as we select the appropriate data. duwe and kim ( ) compared statistical methods including ml approaches on their accuracy in predicting recidivism among , offenders. they found the newer ml algorithms generally performing modestly better. kessler et al. ( ) used data from u.s. army and department of defense administrative data systems to predict suicides of soldiers who were hospitalized for a psychiatric disorder (n = , ). within one year of hospitalization, ( . %) of the soldiers committed suicide. they used a statistical prediction rule based on ml that resulted in a high validity auc value of . . kessler and his colleagues have continued this important work, which was discussed earlier. another approach to prediction was taken by pearson et al. ( ) in predicting depression symptoms after an -week internet depression reduction program using participants. they used an elastic net and random forest ml ensemble (combination) and compared it to a simple linear autoregressive model. they found that the ensemble method predicted an additional % of the variance over the non-ml approach. the authors offer several good technical suggestions about how to avoid some common errors in using ml. moreover, the ml approach allowed them to identify specific module dosages that were related to outcomes that would be more difficult to determine using standard statistical approaches (e.g., detecting nonlinear relationships without having to specify them in advance). however, not all attempts to use ai are successful. pelham et al. ( ) compared logistic regression and five different ml approaches to typical sum-score approaches to identify boys in the fifth grade who would be repeatedly arrested. ml performed no better than simple logistic regression when appropriate cross-validation procedures were applied. the authors emphasize the importance of cross-validation in testing ml approaches. in contrast, a predictive study of people with first-episode psychosis used ai to successfully predict poor remission and recovery one year later based only on baseline data (leighton et al. ) . the model was cross validated on two independent samples. a comprehensive synthesis of the literature of studies that used ml or big data to address a mental health problem illustrated the wide variety of uses that currently exist; however, most dealt with detection and diagnosis (shatte et al. ) . a critical view of the way psychiatry is practiced for the treatment of depression and how ai can improve that practice is provided by tan et al. ( ) . they note that most depression is treated with an "educated-guess-and-check approach in which clinicians prescribe one of the numerous approved therapies for depression in a stepwise manner" (p. ). they posit that ai and especially deep learning have the ability to model the heterogeneity of outcomes and complexity of psychiatric disorders through the use large data sets. at this point, the authors have not provided any completed studies that have used ai, but two of the authors are shareholders in a medical technology company that is developing applications using deep learning in psychiatry. we are beginning to see commercial startups take an interest in mental health services even though the general health market is considerably bigger. entrepreneurially motivated research may be important for the future of ai growth in mental health services, with traditional federal research grants to support this important developmental work, including such mechanisms as the small business innovation research (sbir) program and the r and r nih funding mechanisms. one of the few studies that go beyond just prediction and actually attempt to develop a personalized treatment was conducted by fisher et al. ( ) . in a proof of concept study, the authors used fisher's modular model of cognitive-behavioral therapy (cbt) and algorithms to develop and implement person-by-person treatments for anxiety and mood disorders for adults. the participants were asked to complete surveys four times a day for about days. the average improvement was better than found in comparison benchmark studies. the authors state that this is the first study to use pre-therapy multivariate time series data to generate prospective treatment plans. rosenfeld et al. ( ) describe several treatment delivery approaches that utilize ai. woebot, for example, is a commercial product to provide cbt-based treatment using ai. the clients interact with woebot through instant messaging that is later reviewed by a psychologist. it has been shown to have short-term effectiveness in reducing phq- scores of college students who reported depression and anxiety symptoms. the authors are optimistic that approaches like the ones described will lead to more widely available and efficacious treatment modalities. applications of ml to addiction studies was the focus of a systematic review by mak et al. ( ) . they did an extensive search of the literature until december and could find only articles. none of the studies involved evaluating a treatment. i want to distinguish between the use of computer-assisted therapy, especially that provided through mobile apps, and the use of ai. in a review of these digital approaches to providing cbt for depression and anxiety, wright et al. ( ) point out while many of these apps have been shown to be better than no treatment, they usually do not use ai to personalize them. thus, they are less relevant to this paper and are not discussed in depth. ecological momentary interventions (emis) are treatments provided to patients between sessions during their everyday lives (i.e., in real time) and in natural settings ). these interventions extend some aspects of psychotherapy to patients' daily lives to encourage activities and skill building in diverse conditions. in the only systematic review available of emis, colombo et al. ( ) found only eight studies that used emis to treat major depression, with only four different interventions. the common factor of these four interventions is that they provide treatment in real-time and are not dependent on planned sessions with a clinician. the authors report that participants were generally satisfied with the interventions, but there was variability in compliance and dropout rates among the programs. with only two studies that tested for effectiveness with rcts, there is clearly a need for more rigorous evaluations. momentary reminders are typically used for behaviors such as medication adherence and management of symptoms. the more complex emis use algorithms to optimize and personalize systems. they also can use algorithms that changes the likelihood of the presentation of a particular intervention over time, based on past proximal outcomes. schueller et al. ( ) note that emis are becoming more popular as a result of technological advances. these authors suggest the use of micro-randomized trials (mrts) to evaluate them. an mrt uses a sequential factorial design that randomly assigns an intervention component to each person at multiple randomly chosen times. each person is thus randomized many times. this complex design represents the dynamic nature of these interventions and how their outcomes correspond to different contextual features. ai is often used to develop algorithms to optimize and personalize the mrt over time. one interesting algorithm, called a "bandit algorithm," changes the intervention presented based on a past proximal outcome. as an example, schueller et al. describe a hypothetical study to reduce anxiety through two different techniques-deep breathing and progressive muscle relaxation. the bandit algorithm may start the presentation of each technique with equal frequency but then shift more to the one that appears to be most successful for that individual. thus, each treatment (a combination of deep breathing and progressive muscle relaxation) would be different for each person. unlike rcts, this method does not use group-level outcomes of average effect sizes but uses individual-level data. in the future, we might have personal digital mental health "therapists" or assistants that can deliver individualized combinations of treatments based on algorithms developed with ai that are data driven. of course, this approach is best suited for these momentary interventions and would be difficult if not impossible to successfully apply to traditional treatment. i consider explicating the relationship between ai and causality to be a key factor in understanding whether ai is to be seen as replacing or as supplementing rcts. toward that end, i first consider whether observational data can replace rcts using ai. second, should a replacement not seem currently feasible, i explore ways to design studies that combine ai and rcts to evaluate whether the ai approach produces better outcomes than non-ai enhanced interventions. the journal prevention science devoted a special section of an issue to new approaches for making causal inferences from observational data (wiedermann et al. ). an example is the paper by shimizu ( ) that demonstrates the use of non-gaussian analysis tools to infer causation from observational data under certain assumptions. malinsky and danks ( ) provide an extended discussion of the use of causal discovery algorithms to learn causal structure from observational data. in a similar fashion, blöbaum et al. ( ) present a case for inferring causal direction between two variables by comparing the least-squares errors of prediction in both possible directions. using data that meet some assumptions, they provide an algorithm that requires only a regression in both causal directions and a comparison of the least-square errors. lechner's ( ) paper focuses on identifying the heterogeneity of treatment effects at the finest possible level or identifying what he calls groups of winners and losers who receive some treatment. hassani et al. ( ) hope to build a connection between researchers who use big data analysis and data mining techniques and those who are interested in causality analysis. they provide a guide that describes data mining applications in causality analysis. these include entity extractions, cluster analysis, association rule, and classification techniques. the authors also provide references to studies that use these techniques, key software, substantive areas in which they have been used, and the purpose of the applications. this is another bit of evidence that the issue of causality is being taken seriously and that some progress is being made. however, because of the newness of these publications, there is a lag in publications that are critical of these approaches; for example, d'amour ( ) provides a technical discussion about why some approaches will not work but also suggests that others may be potentially effective. clearly, caution is still warranted in drawing causal conclusion from observational data. chen ( ) provides a very interesting discussion of ai and causality but not from the perspective of the rct issue that i raise here but as a much broader but still relevant point of view. he advances the key question about whether ai technology should be adopted in the medical field. chen argues that there are two major deficits in ai, namely the causality deficit and the care deficit. the causality deficit refers to the inferior ability of ai to make accurate casual inferences, such as diagnosis, compared to humans. the care deficit is the comparative lack of ability of ai to care for a patient. both deficits are interesting, but the one most germane to this paper is the causality deficit. chen notes that ai represents statistical and not causal reasoning machines. he argues that ai is deficient compared to humans in causal reasoning, and, moreover, he doubts that there is a feasible way to deal with this lack of comparability in reasoning. he believes that ai is a model-blind approach in contrast to a human's more model-based approach to causal reasoning. thus, causation for chen is not an issue of experimental methodology (he never mentions rcts in his paper), but a characteristic associated with humans and not computers. chen does recognize that ai researchers are attempting to deal with the causality issue, for example, by briefly describing pearl's ( ) directed acyclic graphs and nonparametric structural equation models. but chen is skeptical that either the causality or care deficits will be overcome. he concludes that ai is best thought of as assisting humans in medical care and not replacing them. the relationship between ai and humans is a major concern of this paper. caliebe et al. ( ) see big data, and i would assume ai, as contributing to hypotheses generation that could then be tested in rcts. the critical issues they see are related to the quality and quantity of big data. they quote an institute of medicine (iom) report that refers to the use of big data and ai in medicine as "learning healthcare systems" and states that these systems will "transform the way evidence on clinical effectiveness is generated and used to improve health and health care" (institute of medicine , p. ). moreover, in , the iom suggested that alternative research methodologies will be needed. they do not acknowledge the conundrum that i have raised here; moreover, they do not see any need to consider changing any of our methodology or analyses. i have found many individual papers that describe how to solve the causality problem with ai (e.g., kuang et al. ; pearl ) . although these papers are complex, their mere existence gives me hope that this problem is being seriously considered. in addition to the statistical and validity issues in trying to replace rcts with observational data, there is the feasibility question. although the data studied in much of the research reported in this paper are in the medical domain and deal primarily with medications, the characteristics of these data have some important lessons for mental health services. bartlett et al. ( ) identified trials published in the top seven highest impact medical journals. they then determined whether the intervention, medical condition, inclusion and exclusion criteria, and primary end points could be routinely obtained from insurance claims and/or electronic health data (ehr) data. these data are recognized by the fda as what they term real-world evidence. they found that only % of the u.s.-based clinical trials published in highimpact journals in could be feasibly replicated through analysis of administrative claims or ehr data. the results suggest that potential for real-world evidence to replace clinical trials is very limited. at best, we can hope that they can complement trials. given the paucity of data collected in mental health settings, the odds are that such data are even less available. suggestions for improving the utility of real-world data for use in research are provided in an earlier article by some of these authors (dhruva et al. ). pearl ( ) posits causal information in terms of the types of questions that, in his three-level model, each level answers. his first level is association; the second, intervention; and the third, counterfactual. association is simply the statistical relationship or correlation. there is no causal information at this first level. the higher order levels can answer questions about the lower levels but not the other way around. counterfactuals are the control groups in rcts. they represent what would have happened if there had been no intervention. to pearl, this unidirectional hierarchy explains why ml, based on associations, cannot provide causal statements like rcts, which are based on counterfactuals. however, as noted earlier, pearl does present an approach using what he calls structural causal models to "extract" causal relationships from associations. pearl describes seven "talks" and accompanying tools that are accomplished in the framework provided by the structural causal models that are necessary to move from the lower levels to the counterfactual level to allow causal inferences. i would anticipate that there will be direct comparisons between this approach to causality and the randomized experiments like those done in program evaluation (bickman and reich ; boruch et al. ) . theory development or testing is usually not thought of as a strength of ai; instead, its lack of transparency, that is, the lack of explanatory power that would enable us to identify models/mechanisms that underlie outcomes, is seen as a major weakness. coutanche and hallion ( ) present a case for using feature ablation to test theories. this technique involves the removal or ablation of features from algorithms that have been thought to be theoretically meaningful and then seeing if there is a significant reduction in the predictive accuracy of the model. they have also studied whether the use of a different data set affects the predictive accuracy of a previously tested model in theoretically useful ways. they present a very useful hypothetical application of their approach to test theories using ai. it is clear that ai can be very useful in making predictions, but can it replace rcts? can ai perform the major function of rcts, that of determining causality? the dependence on rcts was one of the major limitations i saw as hindering the progress of mental health services research. while rcts have their flaws, they are still considered by most as the best method for determining causal relationships. is ai limited to being a precursor in identifying those variables that are good candidates for rcts because they have high predictive values? the core conceptual problem is that while it is possible to compare two different but theoretically equivalent groups, one receiving the experimental treatment and the other the control condition, it is not possible to compare the same individuals on both receiving and not receiving the experimental treatment. rcts produce average effect sizes, but the ultimate purpose of precision mental health is to predict individualized effects. how do we reconcile these two very different aims? one approach is to use ai to identify the most predictive variables and then test them in a randomized experiment. let us take a group of patients with the same disorder or problem. there may be several alternative treatments, but the most basic concept is to compare two conditions. in one condition, call it the traditional treatment condition in the rct, everyone in that condition gets the same treatment. it is not individualized. in the second condition, call it the ai condition, everyone gets a treatment that is based on prior ai research. the latter may differ among individuals in dosage, timing, type of treatment, and so on. the simplest is medication that differs in dosage. however, a more nuanced design is a yoked design used primarily in operant and classical conditioning research. there have been limitations associated with this design, but these problems apply to conditioning research and not the application considered here (church ) . to separate the effects of the individualization from the differences in treatment, i suggest using a yoked design. in this design, individuals who would be eligible to be treated with either the standard treatment or the ai-selected treatment would be yoked, that is, paired. which participant of the pair received which condition would be randomized. first, the eligible participants would be randomly divided into two groups. the individuals in the ai group would get a treatment that was precisely designed for each person in that group, while those in the yoked control group would not; instead, those in the control group would receive the treatment that had been designed for his or her partner in the ai group. in this way, each participant would receive the same treatment, but only the ai group participants would be receiving individualized treatment. if the ai approach is superior, we would expect those in the ai group to have a superior average treatment effect compared to the control group, who received a treatment matched not to their individual characteristics but to those in the ai group. we could also use an additional control group where the treatment is selected by a clinician. while this design would not easily identify which characteristics were responsible for its success, it would demonstrate whether individualized ai-based treatment was the causal factor. that is, we could learn that on the average, a precision approach is more effective than a traditional approach, but we would not be able to identify from this rct which particular combination of characteristics made it more effective. of note is that the statistical power of this design would depend on the differences among the participants at baseline. for example, if the individuals were identical on measured covariates, then they would get the same personalized treatment, which practically would produce no useful information. instead of yoking participants based on randomly assigning them as in the above example, we could yoke them on dissimilarity and then randomly assign each individual in the pair to ai-based treatment or a control condition that could be the same ai treatment or a clinician-assigned treatment. however, interesting this would be from a methodical point of view, i think this would also bring up ethical issues that are discussed next. of course, as with any rct, there are ethical issues to consider. in many rcts, the control group may receive standard treatment, which should not present any unusual ethical issues. however, in a yoked design, the control group participants will receive a treatment that was not selected for them on the basis of their characteristics. moreover, the yoked design would make the formulation of the informed consent document problematic because it would have to indicate that participants in the control group would receive a treatment designed for someone else. one principle that should be kept in mind is equipoise: there should be consensus among clinicians and researchers that the treatments, a priori, are equivalent. in a yoked design, we must be assured that none of individualized treatments would harm the yoked control group members, and moreover, that there is no uniform agreement that the individualized treatment would be better for the recipient. that is, the research is designed to answer a question about relative effectiveness for which we do not know the answer. almost all of the research previously cited in this paper has dealt with psychosocial interventions, along with some research on interventions with medications. clearly these are the two main approaches taken in providing services for mental health problems. however, in the last decade, a new approach to understanding mental illness has emerged from the field of psychoneuroimmunology. this relatively new field integrates research on psychology, neuroscience, and immunology to understand how these processes influence each other and, in turn, human health and behavior (slavich ). i want to explore this relatively new approach to understanding mental health because i believe that it is a potentially rich field in which to apply ai. slavich and irwin ( ) have combined diverse areas to show how stressors affect neural, physiologic, molecular, and genomic and epigenetic processes that mediate depression. they labeled this integrative theory the social signal transduction theory of depression. in a recent extension of this work, slavich ( ) proposed social safety theory, which describes how social-environmental stressors that degrade experiences of social safety-such as social isolation and rejection-affect neural, immunologic, and genomic processes that increase inflammation and damage health. a key aspect of this perspective is the role of inflammatory cytokines as key mediators of the inflammatory response (slavich ) . cytokines are the biological endpoint of immune system activity and are typically measured in biobehavioral studies of stress and health. cytokines promote the production of c-reactive protein, which is an inflammatory mediator like cytokines, but which also is a biomarker of inflammation that is assessed with a blood test. cytokines also interact with the central nervous system and produce what have been labeled "sickness behaviors," which include increased pain and threat sensitivity, anhedonia, fatigue, and social-behavioral withdrawal. while the relationship between inflammation and depression is well-established in adults, a systematic review and meta-analysis of studies with children and adolescents concluded that because of the small number of studies, more evidence was needed before drawing a similar conclusion for youth (d'acunto et al. ) . in contrast, a major longitudinal study of more than adults followed over years found that participants who had stable high c-reactive protein levels were more likely to report clinically significant late-life depression symptoms (sonsin-diaz et al. ) . chronic inflammation has been shown to be present in many psychiatric disorders including depression, schizophrenia, and ptsd, as well as in many other somatic and physical disease conditions (furman et al. ) . chronic inflammatory diseases have been shown to be a major cause of death. a typical inflammatory response occurs when a threat is present and then goes away when there is no longer a threat. however, when the threat is chronic and unresolved, systemic chronic inflammation can occur and is distinct from acute inflammation. chronic inflammation can cause significant damage to tissues and organs and break down the immune system tolerance. what is especially interesting from a behavioral health perspective is that inflammatory activity can apparently be initiated by any psychological stressor, real or imagined. thus, social and psychological stressors such as negative interpersonal relationships with friends and family, as well as physical stressors, can produce inflammation, which leads to increased risk of mental and physical health problems. this inflammatory response initially can have positive effects in that it can help increase survival in the short term, but it can also lead to a dysfunctional hypervigilance and anxiety that increases the risk of serious mental illness if chronic. the "cytokine storm" experienced by many covid- patients is an example of the damage an uncontrolled immune response can cause (konig et al. ). although we do not know a great deal about how this process operates, it is clear that there is a strong linkage between inflammatory responses and mental disorders such as depression. the role of the immune system in disease, especially brain inflammation related to brain microglial cells (i.e., neuroinflammation), is also receiving attention in the popular press (nakazawa ). psychoneuroimmunology research has explicated the linkage between the brain and the immune system, showing how stress affects the immune system, and how these interactions relate to mental illness. the relationships between these constructs suggest interventions that can be used to improve mental health. but much research remains to be done to identify specific processes and effective interventions. research will require multidisciplinary teams to produce personalized interventions guided by each patient's specific level of neuroinflammation and genetic profiles. this process will need to be monitored by continuous feedback that i believe will be made more feasible with the application of ai. at present, there are some existing interventions that appear to be aligned with this approach that are being explored. these include the following. three anti-inflammatory medications have been found to reduce depressive symptoms in well-designed rcts. these agents include celecoxib, usually used for treating excessive inflammation and pain, and etanercept and infliximab, which are used to treat rheumatoid arthritis, psoriasis, and other inflammatory conditions (slavich ) . however, there has not been a great deal of research in this area, so caution is warranted. a recent well-designed rct with depressed youth tested aspirin, rosuvastatin (a statin), and a placebo and found no significant differences in depression symptoms (berk et al. ). a meta-analysis explored the possible link between different types of psychosocial interventions, such as behavior therapy and cbt, and immune system function (shields et al. ) . the authors examined eight common psychosocial interventions, seven immune outcomes, and nine moderating factors in evaluating rcts. they found that psychosocial interventions were associated with a . % improvement in good immune system function and a . % decrease in detrimental immune function, on average. moreover, the effects lasted for at least months and were consistent across age, sex, and intervention duration. the authors concluded that psychosocial interventions are a feasible approach for influencing the immune system. repetitive transcranial magnetic stimulation (rtms) has been found to be an effective treatment for several mental illnesses, especially treatment-resistant depression (mutz et al. ; somani and kar ; voigt et al. ) . while the literature is not clear on how rtms produces its effect (noda et al. ; peng et al. ) , i was curious about its relationship to neuroinflammation. i could find little in the research literature that addressed the relationship between inflammation and rtms; therefore, i conducted an informal survey of rtms researchers who have published rtms research in peer-reviewed journals and asked them the following: i suspect that rtms is related to inflammation but the only published research that i could find on that relationship was two studies dealing with rats. are you aware of any other research on this relationship? in addition, do you know of anyone using ai to investigate rtms? i received replies from all but of the researchers. about half said they were aware of some research that linked rtms to inflammation and supplied citations. in contrast, only % were aware of any research on rtms and ai. the latter noted some research that used ai on eegs to predict rtms outcomes. a most informative response was from the author of a review article that dealt with several different nontraditional treatments including rtms on the hypothalamic-pituitary-adrenal (hpa) axis and immune function in the form of cytokine production in depression (perrin and parianti ) . the authors found relevant human studies ( studies using rtms) but were unable to conduct the metaanalysis because of significant methodological variability among studies. but they concluded that non-convulsive neurostimulation has the potential to impact abnormal endocrine and immune signaling in depression. moreover, given that there is more information available than on other neurostimulation techniques, the research suggests that rtms appears to reduce cytokines. finally, there is some support from animal models (rats) that rtms can have an anti-inflammatory effect on the brain and reduce depression and anxiety (tiana et al. ). moreover, four published studies showed that the efficacy of rtms for schizophrenics could be predicted koutsouleris et al. ( b) . three other studies were able to use ml and eeg to predict outcomes of rtms treatment for depression (bailey et al. ; hasanzadeh et al. ) . the existing literature indicates that metabolic activity and regional cerebral blood flow at the baseline can predict the response to rtms in depression (kar ) . as these baseline parameters are linked to inflammation, it is worth studying responses to rtms that predict inflammation. as noted by one of the respondents, "in summary, it is a relatively new field and there are no major multi-site machine learning studies in rtms response prediction" (n. koutsouleris, personal communication, march , ) . one of the significant limitations of measurement in mental health is the absence of robust biomarkers of inflammation. furman et al. ( ) caution us that "despite evidence linking sci [systemic chronic inflammation] with disease risk and mortality, there are presently no standard biomarkers for indicating the presence of health-damaging chronic inflammation" (p. ). however, some biomarkers that are currently being explored for inflammation may be of some help. for example, furman et al. ( ) are hopeful that a new approach using large numbers of inflammatory markers to identify predictors will produce useful information. a narrative review of inflammatory biomarkers for mood disorders was also cautious in drawing any conclusions from extant research because of "substantial complexities" (chang and chen ) . it is also worth noting the emerging area of research on gut-brain communication and the relationship between microbiome bacteria and quality of life and mental health (valles-colomer et al. ) . however, there is need for more research on the use of biomarkers. the area of inflammation and mental health offers an additional pathway to uncovering the causes of mental illness but also, most importantly for this paper, potential services interventions beyond traditional medications and psychosocial interventions. given the complexity, large number of variables from diverse data sets, and the emerging nature of this area, it appears that ai could be of great benefit in tying some potential biomarkers to effective interventions designed to produce better clinical outcomes. however, some caution is needed concerning the seemingly "hard data" provided by biomarkers. for example, elliot et al. ( ) found in a meta-analysis of experiments that one widely used biomarker, task-fmir, had poor overall reliability and poor test-retest reliability in two other large studies. they concluded that these measures were not suitable for brain biomarker research or research on individual differences. as noted in several places in this paper, ai is not without its problems and limitations. the next section of the paper discuses several of these problems. ai may force the treatment developer to make explicit choices that are ethically ambiguous. for example, automobile manufacturers designing fully autonomous driving capabilities now have to be explicit about whose lives to value more in avoiding a collision-the driver and his or her passengers or a pedestrian. should the car be programmed to avoid hitting a pedestrian, regardless of the circumstances, even if it results in the death of the driver? mental health services do not typically have such clear-cut conflicts, but the need to weigh the potential side effects of a drug against potential benefits suggests that ethical issues will confront uses of ai in mental health. some research has shown that inherent bias in original data sets has produced biased (racist) decisions (obermeyer et al. ; veale and binns ) . an unresolved question is who has the responsibility for determining the accuracy and quality of original data set (packin and lev-aretz ) . data scientists operating with data provided by others may not have sufficient understanding of the complexity of the data to be sensitive to its limitations. moreover, they may not consider it their responsibility to evaluate the accuracy of the data and attend to its limitations. librenza-garcia ( ) provides a comprehensive review of ethical issues in the use of large data sets with ai. the ethical issues in predicting major mental illness are discussed by lawrie et al. ( ) . they note that predictive algorithms are not sufficiently accurate at present, but they are progressing. the authors raise questions about whether people want to know their risk level for major psychiatric disorders, about individual and societal attitudes to such knowledge and the possible adverse effects of sharing such data, and about the possible impact of such information on early diagnosis and treatment. they urge conducting research in this area. related to the ethics issue but with more direct consequences to the health provider is the issue of legal responsibility in using an ai application. it is not clear what the legal liability is for interventions based on ai that go wrong. who is responsible for such outcomes-the person applying the ai, the developer of the algorithm, or both? price ( ) points out that providers typically do not have to be concerned about the legal liability of a negative outcome if they used standard care. thus, if there are negative outcomes of some treatment but that treatment was the standard of care, there is usually no legal liability. however, currently ai is probably not seen as the standard of care in most situations. while this will hopefully change as evidence of the effectiveness of ai applications develops, currently the healthcare provider is at greater risk of legal liability in using an ai application that is different from the standard of care. i have previously discussed the insufficient evidence for the effectiveness of many of the interventions used in mental health services. this lack of strong evidence has implications for the use of ai in mental health services. in an insightful article on using ai for individual-level treatment predictions, paulus and thompson ( ) make several key observations and suggestions that are very relevant to the current paper. the authors summarize several meta-analyses of the weak evidence of effectiveness of mental health interventions and come to conclusions similar to those i have already stated. they also identify similar factors i have focused on in accounting for the modest effect sizes found in mental health rcts. they point out that diagnostic categories are not useful if they are not aggregating homogenous populations. they suggest that what i call the diagnostic muddle may result from the nature of mental disorders themselves, for which there are many causes at many different levels, from the genetic to the environmental. thus, there is no simple explanatory model. paulus and thompson note that prediction studies rarely account for more than a very small percentage of the variance. they recommend conducting large, multisite pragmatic rcts that are clearly pre-defined with specific ml models and variables. predictive models generated by this research then need to be validated with independent samples. this is a demanding agenda, but i think it is necessary if we are going to advance mental health services with the help of ai. treatments are often considered black boxes that provide no understanding of how and why the treatment works (kelley et al. ; bickman b) . the problem of lack of transparency is compounded in the use of deep neural networks (samek et al. ) . at present we are not able to understand relationships between inputs and outcomes, because this ai technique does not adequately describe process. deep neural networks may contain many hidden layers and millions of parameters (de choudhury and kikkoman ). however, this problem is now being widely discussed, and new technologies are being developed to make ai more transparent (rauber et al. ; kuang et al. ). i do not believe it is possible to develop good theories of treatment effectiveness without this transparency. this is an important limitation of efforts to improve mental health services. but how important is this limitation? early in my program evaluation career, i wrote about the importance of program theory (bickman (bickman , . i argued that if individual studies were going to be conceptually useful, beyond local decisions such as program termination, then they must contribute to the broader goal of explaining why certain programs were effective and others not. this is in contrast to the worth and merit of a local program. a theory based evaluation of the program must add to our understanding of the theory underlying the program. while i still believe that generalizing to a broad theory of why certain interventions work is critical, at present it may be sufficient simply to increase the accuracy of our predictions, regardless of whether we understand why. as stephens-davidowitz ( ) argues, "in the prediction business, you just need to know that something works, not why" (p. ). however, turing award winner judea pearl argued in his paper theoretical impediments to machine learning with seven sparks from the causal revolution ( ) that human-level ai cannot emerge from model-blind learning machines that ignore causal relationships. one of the positive outcomes of the concern over transparency is the development of a subfield of ai that has been called explainable artificial intelligence (xai). adai and berrada ( ) present a very readable description of this movement and show that it has been a growing area since . they are optimistic that research in this area will go a long way toward solving the black box problem. large data sets are required for some ai techniques, especially deep neural networks. while such data sets may be common in consumer behavior, social media, and hospitalbased electronic health records, they are not common in community-based mental health services. the development and ownership of these data sets may be more important (and profitable) than ownership of specific ai applications. there is currently much turmoil over data ownership (mittelstadt ) . ownership issues are especially important in the mental health field given the sensitivity of the data. in addition to the size and quality of the data set, longitudinal data are necessary for prediction. collecting longitudinal data poses a particular problem for community-based services given the large treatment drop-out rate. in addition to the characteristics of the data, there is the need for competent data managers of large complex data sets. the data requirements for mental health applications are more demanding than those for health in general. first, mental health studies usually do not involve the large samples that are found in general health. for example, the wellknown physicians' health study of aspirin to prevent myocardial infarction (mi) utilized more than , doctors in a rct (steering committee of the physicians' health study research group ). they found a reduction in mi that was highly statistically significant: p < . . the trial was stopped because it was thought that this was conclusive evidence that aspirin should be adopted for general prevention. however, the effect size was extremely small: a risk difference of . % with r = . (sullivan and feinn ) . a study this size is not likely to occur in mental health. moreover, such small effects would not be considered important even if they could be detected. it is unlikely that very large clinical trials such as the aspirin study would ever be conducted in mental health. thus, it is probable that data will have to be obtained from service data. but mental health services usually do not collect sufficiently fine-grained data from clients. while i was an early and strong proponent of what i called a measurement feedback system for services (bickman a) , recent research shows that the collection of such data is rare in the real world. until services start collecting these data as part of their routine services, it is unlikely that ai will have much growth with the limited availability of relevant data. there is, of course, a chicken and egg problem. a major reason why services do not collect data is the limited usefulness of data in improving clinical care. while ai may offer the best possibility of increasing the usefulness of regularly collected data, such data will not be available until policy makers, funders, and providers deem it useful and are willing to devote financial resources to such data collection analysis. at present, there are no financial incentives for mental health providers to collect such data even if they improved services. moustafa et al. ( ) made the interesting observation that psychology is behind other fields in using big data. ai and big data are not considered core topics in psychology. the authors suggest several reasons for this, including that psychology is mostly theory-and hypothesis-driven rather than data-driven, and that studies use small sample sizes and a small number of variables that are typically categorical and thus are not as amenable to ai. moreover, most statistical packages used by psychologists are not well-equipped to analyze large data sets. however, the authors note that the method of clustering and thus differentiating among participants is used by psychologists and is in many ways similar to ai, especially deep neural networks, in trying to identify similar participants. using ml methods such as random forest algorithms, the investigator can identify variables that best explain differences among groups or clusters. instead of the typically few variables used by psychologists, ai can examine hundreds of variables. as a note of caution, rutledge et al. ( ) warn that "there is no silver bullet that can replace collecting enough data to generate stable and generalizable predictions" (p. ). while there are techniques that are often used in low sample size situations (e.g., the elastic net and tree-based ensembles), researchers need replications with independent samples if they are to have sufficient confidence in their findings. moreover, since big data are indeed big, they are easily misunderstood as automatically providing better results through smaller sampling errors. it is often not appreciated that the gain in precision drawn from larger samples may well be nullified by the introduction of additional population variance and biases. finding competent big data managers, data scientists, and programmers is a human resource problem. in my experience, ai scientists who are able and want to collaborate with mental health services researchers are rare. industry pays a lot more for these individuals than universities can afford. moreover, even within the health field, mental health is a very small component of the cost of services, so it is often ignored in this area. difficulty and resistance are encountered in the implementation of new technologies. clinicians are reluctant to adopt new approaches and to engage clients in new approaches and data collection procedures. community mental health services have been slow to successfully adopt new technologies (crutzen et al. ; lattie et al. ; yeager and benight ) . in their mixed methods study of community clinicians, crutzen et al. ( ) found there were concerns about privacy, the wide range of therapeutic techniques used, disruptions in trust and alliance, managing crises, and organizational issues such as billing and regulations contained in the privacy rule established by the health insurance portability and accountability act of (hipaa) that inhibited the use of new technologies. moreover, our current reimbursement policies do not support greater payment for better outcomes. thus, there is little or no financial incentive for hard-pressed community services to improve their services at their own expense. in fact, i would argue that there is a disincentive to improve outcomes since it results in increased costs (at least initially), organizational disruption and potentially a loss of clients if it takes less time and effort to successfully treat them. an interesting meta-issue has emerged from the widespread and ever-increasing investment in ai in healthcare. in a perceptive "viewpoint" published in jama, emanuel i would be happy to serve as a "matchmaker" for any ai programmers, data scientists (etc.), or behavioral scientists who are interested in collaborating on mental health projects. just contact me describing your background and interests and i will try to put together likeminded researchers. and wachter ( ), argue that the major challenge facing healthcare is not that of obtaining data and new analytics but the achievement of behavior change among both clinicians and patients. they point out the major failures of google and microsoft in not recognizing the problems in translating evidence into practice in connection with their large, web-based repositories for storage of health records, google health and microsoft healthvault, both of which have been discontinued. they indicate that the long delays in translation are due not primarily to data issues or lack of accurate predictions, but to the absence of behavioral changes needed for adoption of these practices. for example, the collection of longitudinal data has been problematic. another problem they note is that about half the people in the united states are nonadherent with medications. there is a huge gap between knowing what a problem is and actually solving it that "data gurus" seem to ignore. while this translation problem is evident in the sometimes narrow focus of ai promoters, it also represents an opportunity for the behavioral scientists engaged in ai research to marshal their skills and the knowledge gained from years of dealing with similar behavioral issues. the emergence of translational and implementation sciences, the latter more often led by behavioral scientists, can be of great service to the problems of applying ai to healthcare. the field of translational sciences has been developed and well-funded by the nih in recognition of the difficulty in using (i.e., translating) laboratory studies into practice. in , the budget for the clinical and translational science awards (ctsa) program was over a half billion dollars from to . however, as director of evaluation for vanderbilt's medical center's ctsa program for many years, i became very familiar with the difficulties in applying medical research in the real world. mental health is determined by multiple factors. it is unlikely that we will find a single vector such as a virus or a bacterium that causes mental illness. thus, data demands can include multiple systems with biological, psychological, sociological, economic, and environmental factors. within many of these domains, we do not have objective measures such as the lab tests found in medicine. subjective selfreports are prone to many biases, and many of the symptoms are not observable by observers. the lack of a strong theory of mental disorders also makes it difficult to intelligently focus on only a few variables. even with such apparently simple measures that include observations or recordings from multiple informants, we do not have a consensus on how to integrate them (bickman et al. a; martel et al. ). however, i would expect that research generated with ai will contribute not only to improved treatment but also to enhanced theories by including heterogeneous clients and many data sources. confidentiality and trust are key issues in mental health treatment. how will the introduction of ai affect the relationship between client and clinician? as noted earlier, there are problems, especially with deep learning, in interpreting the meaning of algorithmic solutions and predictions. our ability to explain the algorithms to clients is problematic. while many research projects outside of mental health show that combining ai with human judgment produces the best outcomes, this research is still in its infancy. a great deal has been written about ai in the context of medicine, but we need a reality check about the importance of ai in clinical practice. ben-israel et al. ( ) addressed the use of ai in a systematic review of the medical literature from to . the authors focused on human studies that addressed a problem in clinical medicine using one or more forms of ai. of the studies, only % were prospective. none of the studies included a power analysis, and half did not report attrition data. most were proof of concept studies. the authors concluded that their study showed that the use of ai in daily practice of clinical medicine is practically nonexistent. the authors acknowledge that use was defined by publication and that many applications of ai may be occurring without publication. regardless, this study suggests that there are many barriers that must be overcome before ai is more widely used. the self-help industry can provide perspective on digital apps, including some that use ai. it has been estimated that this sector was worth $ . billion in and is expected to be worth $ . billion in (la rosa ). part of that big dollar market is in digital mental health apps, although their precise monetary value is unknown. more to the point is that we know little about the effectiveness of digital apps in the marketplace (chandrashekar ) . moreover, many have warned that these unregulated and untested apps could be dangerous (wykes ) . in the united states, the publication of books is protected by the constitution, so there are no rules governing what can be published in the self-help sector. the market determines what gets accepted and used, regardless of effectiveness or negative side effects. but publication is limited by the cost of publishing and distribution. this is not the case for digital programs, where marginal costs of adding an additional user are negligible. unlike other mental health interventions, there are no licensing or ethical standards governing their use. there are no data being uniformly collected on their use and their effects. although there are u.s. government rules that can be applied to these apps (armontrout et al. ) , the law has many exceptions. the authors note that they could not find a single lawsuit related to software that diagnoses or treats a psychiatric condition. an interactive tool is provided by the federal trade commission to help judge which federal laws might apply in developing an app (https ://www.ftc.gov/tips-advic e/busin ess-cente r/guida nce/mobil e-healt h-apps-inter activ e-tool). it is clear that digital mental health apps will continue to grow. it is critical that services research and funding agencies do not overlook this development that might have potentially positive or negative effects. these are but a few of the many areas or ai needing additional research and potential limitations to be addressed. an excellent discussion of these and other relates issues regarding the potential hype common in the ai field is provided in the national academy of medicine's monograph on the use of ai in healthcare (matheny et al. ) . a thought-provoking paper by hagendorff and wezel ( ) classifies what ai can and cannot do. some of the authors' concerns, such as measurement, completeness and quality of the data, and problems with transparency of algorithms, have already been discussed, so i will describe those that i feel are most relevant to mental health services. the authors describe two methodological challenges, the first being that the data used in ai systems are not representative of reality because of the way they are collected and processed. this can lead to biases and problems with generalizability. second is the concern that supervised learning represents the past. thus, prediction can be based only on the past and not on expectations of change; thus, in some respects, change is inhibited. hagendorff and wezel ( ) also note several societal challenges. one such challenge they cite is that many software engineers who develop these algorithms do not have sufficient knowledge of the sociological, psychological, ethical, and political consequences of their software. they suggest this leads to misinterpretations and misunderstandings about how the software will operate in society. the authors also note the scarcity of competent programmers. i noted earlier that this is especially the case in academia and particularly in the behavioral sciences. the authors highlight that ai systems often produce hidden costs. this includes hardware to run the ai systems and, i would add, the disruptive nature of the intrusion of ai into a workflow. among the technological challenges discussed by hagendorff and wezel, i believe the authors' focus on the big differences between human thinking and intelligent machines is especially relevant to mental health. machines are in no way as complex as human brains; even ai's powerful neural networks, with more than a billion interconnections, represent only a tiny portion of the complexity of brain tissue. in order to obtain better convergence between machines and humans, hagendorff and wezel suggest that programmers follow the three suggestions made by lake et al. ( ) . first, programmers should move away from pattern recognition models, where most development started, to automated recognition of causal relationships. the second suggestion is to teach machines basic physical and psychological theories so that they have the appropriate background knowledge. the third suggestion is to teach machines to learn how to learn so that they can better deal with new situations. the comparison between ai and human thought is the only aspect of their paper where hagendorff and wezel mention causality issues. they note the challenge related to the inflexibility of many algorithms, especially the supervised ones, where simply changing one aspect would result in processing errors because that aspect was not in the training data. machines can be vastly superior to humans in some games where there are very specific inputs for achieving specific goals, but they cannot flexibly adapt to changes like humans. the authors suggest that promising technical solutions are being worked on to deal with this weakness in transferability. all these challenges will affect how well ai will work in mental health services. most problems will probably be solved, but the authors believe that some of these challenges will never be met, such as dealing with the differences between human and computer cognition, which means that ai will never fully grasp the context of mental health services. the machine's construction of a person may lead to a fragmented or distorted self-concept that conflicts with the person's own sense of identity, which seems critical to any analysis of the person's mental health or lack thereof. i do not have a sense of how serious this and the other challenges will be for us in the future, but it is clear that there is a lot more we need to learn. yet another set of concerns, specifically about the variation in ai called deep learning (dl), was enumerated by marcus ( ) , an expert in dl. in a controversial paper in which he identified limitations of dl, he noted that dl "may well be approaching a wall" (p. ) where progress will slow or cease. for example, he noted that dl is primarily a statistical approach for classifying data, using neural networks with multiple layers. dl "maps" the relationships between inputs and outputs. while children may need only a few trials to correctly identify a picture of a dog, dl may need thousands or even millions of labeled examples before making correct identifications without the labels. very large data sets are needed for dl. this is not the case for all ml techniques. i will not attempt to summarize the nine other limitations he sees with dl since many of them are noted elsewhere in this paper. he concludes that dl itself is not the problem; rather, the problem is that we do not fully understand the limitations of dl and what it does well. marcus warns against excessive hype and unrealistic expectations. i am taking this advice personally, and i am not expecting my tesla to be fully autonomous in as predicted by elon musk (woodyard ) . wolff ( ) provided an overview of how some of the problems of deep learning can be ameliorated. he responds to marcus using many of the subheadings in marcus's paper. he calls his framework the sp theory of intelligence, and its application is called the sp computer model (sp stands for simplicity and power). the theory was developed by wolff to integrate observations and concepts across several fields including ai, computing, mathematics, and human perception and cognition, using information compression to unify them. despite these and other concerns previously described, i do think that the advantages of ai for moving mental health services forward outweigh its disadvantages. however, this summary of advantages does not attempt to balance in length or number the disadvantages described above. i do not think it is necessary to repeat the already described numerous applications and potential applications of ai that can be used to improve health services. rather than repeating the numerous applications and potential applications of ai that can be used to improve health services, i highlight only a few key advantages. one of the main advantages is the way ai deals with data. it can handle large amounts of data from diverse sources. this includes structured (quantitative) and unstructured (text, pictures, sound) data in the same analyses. thus, it can integrate heterogeneous data from dissimilar sources. as noted earlier, the inclusion of non-traditional data such as those obtained from remote sensing (e.g., movement, facial expression, body temperature) will be responsible for a paradigm shift in what we consider relevant data. ai, if widely adopted, has the potential to have a major impact on employment. while most of the popular press coverage has been on the potential negative effects of eliminating many jobs, there also are potential positive effects. ai can reduce the costs of many tasks, thus increasing productivity. on the human side, it can streamline routine work and eliminate many boring aspects of work. it thus can free up workers to engage in the more complex and interesting aspects of many jobs. previous innovations have caused job dislocations. the classic loss of jobs in making buggy whips after the advent of automobiles is just one example. the inventions of the industrial age, such as steam engines, displaced many workers but also created many more new jobs. we know that many unskilled or semi-skilled jobs will be affected by ai in a major way. the elimination of cashiers with automated checkouts is now being implemented by amazon. in these stores, you scan your phone, and then ai and cameras take over. you just put products in your bag or cart and leave when you are finished. self-driving cars and trucks will greatly disrupt the transportation industry. we have weathered these disruptions in the past, but even the experts are unsure about how ai will influence jobs. probably the area in which there is the most positive potential in healthcare is when humans and machines collaborate in partnership. here, ai augments human tasks but keeps humans in the center. thus, physicians will no longer be separated by a laptop when speaking to a patient because ai will be able to record, take notes, and interpret the medical visit. we have documented the shortage of mental health workers and the immense gap between mental health needs and our ability to fill them. yes, we can train more clinicians, but our society seems unwilling to offer sufficient salaries to attract and keep such individuals. we have been experimenting with computers as therapists for more than years, but now we finally have the technological resources to develop and implement such approaches. we have started to use chatbots to extend services, but in the near future, ai may allow us to replace the human therapist under some conditions (hopp et al. ). in , the computer scientist and science fiction author vernor vinge developed the concept of a singularity in which artificial intelligence would lead to a world in which robots attain self-consciousness and are capable of what are now human cognitive activities (vinge ) . advocates and critics disagree on whether a singularity will be achieved and whether it would be a desirable development (braga and logan ) . braga and logan, editors of a special issue of information on the singularity and ai, conclude that although ai research is still in the early stage, the combination of human intelligence and ai will produce the best outcomes, but ai will never replace humans and we cannot fully depend on ai for the right answers. while these authors are well-informed, their crystal ball may not be clearer than anyone else's. the relevance of the singularity for healthcare lies in asking whether there will there be a time when ai-based computers are more effective and efficient than clinicians and will replace them. it is a question worth considering. i have presented a comprehensive, wide-ranging paper dealing with ai and mental health services. i have described major deficiencies of our current services, namely the lack of sufficient access, inadequate implementation, and low efficiency/effectiveness. i summarized how precision medicine and ai have contributed to improving healthcare in general and how these approaches are being applied in precision psychiatry and mental health. the paper then describes research that shows how ai has been or can be used to help solve the five problems i noted earlier. i then described the disadvantages and advantages of ai. in reviewing all this information, i believe there is one factor that i have not discussed sufficiently that clearly differentiates the way mental health services have been delivered and the way i expect they will be delivered in the future. i want to focus this last section of the paper on what i believe is the most important and significant change that can occur. this change is reflected in a simple question: is a human clinician necessary to deliver effective and efficient mental health services? i believe the answer to this question does not depend on the occurrence of the singularity but lies in the growth of ai research and its application to mental health services. i think there is widespread agreement that there are significant problems with diagnoses and the quality of our measures. moreover, most will probably agree that if ai can improve diagnoses and measures, then we should use utilize ai and let the results speak for themselves. the dependence on rcts will probably not be resolved by ai research, but ai can clearly help inform what should be tested in rcts. however, our current services overwhelmingly depend on human clinicians to deliver treatment. the problem with learning and feedback is that it requires clinicians to learn how to improve treatment over time with feedback. we are still uncertain about how well clinicians can learn from experience, training, and education (bacon ) . we also lack evidence of the best way to provide feedback to enhance that learning (bickman a; dyason et al. ). the problem of treatment precision is also currently tied to having the clinician deliver the treatment. while we can expect ai to deliver more precise information about treatment planning, we still depend on the clinician to interpret and deliver it with fidelity with some evidence-based model. a precision approach requires the clinician to systematically deliver treatment that is most appropriate to a specific client. we do not have good evidence that most clinicians can do that. i believe no other issue generates a bigger emotional response than the idea of the changing the role of the clinician. no other issue has the economic impact on services as the position of the clinician. i believe this issue is the most critical to the future of mental health services and will be most affected by ai. i note that in in writing an introduction to an extensive special issue of this journal called "therapist effects in mental health service outcome" (king ) , the authors of the introduction to that issue not did not note the potential role of ai in affecting clinicians (king and bickman ) . change is happening rapidly. mental health services are not alone in facing the issue of the role of humans, although human clinicians are probably more central to the provision of mental health services than other health services. a similar issue of the role of humans in the provision of services is being played out in surgery. surgery has been using robots for over years (bhandari et al. ), but the uptake has been slow for a variety of reasons. the next iteration of robot use is a move from using robots guided by surgeons to using robots assisted by ai and guided by surgeons. the use of ai may be seen as an intermediate step to fully autonomous ai-based robots not guided by surgeons. however, it is very clear that this progression is speculative and will take a long time to happen, if ever, given the consequences of errors. closer to our everyday experience is the similar path that the development of autonomous driving involves as we move toward the point at which a human driver is no longer needed. will mental health services follow a similar path? since we do not currently have a sufficient amount of research on using ai in treatment alone to inform us, we must look elsewhere for guidance. two bodies of literature are relevant. one deals with the use of computers and other technologies that do not include the use of ai at present, the second with self-help in which the participation of the clinician is minimal or totally absent. first, let us consider the existing literature that contrasts technology-based treatments with traditional face-to-face psychotherapy. then i will present some reviews of self-help research, followed by a description of the small amount of research using ai in treatment. a review of studies of internet-delivered cbt (icbt) to youth, using waitlist controls, supports the conclusion that cbt could be successfully adapted for internet-based treatment (vigerlan et al. ) . in a meta-analytic review of meta-analyses, containing studies of adult use of internet delivered via icbt, the authors concluded that icbt is as effective as face-to-face therapy (andersson et al. ) . hermes et al. ( ) include websites, software, mobile aps, and sensors as instances of what they call behavioral intervention technologies (bit). in their informative article, dealing primarily with implementation, they note that these technologies (they do not mention ai) can relate to a clinician in three ways: ( ) when intervention is delivered by the clinician and supported by bit, ( ) when bit provides the intervention with support from the clinician, or ( ) when intervention is fully automated with no role for the clinician. this schema clearly applies to the ai interventions and the role of clinicians as well. their conceptual model is helpful in understanding the parameters of implementation. they present a comprehensive plan for research to fill in the major gaps in the literature that addresses the question of comparative effectiveness of bit and traditional treatment. carlbring et al. ( ) conducted a systematic review and meta-analysis of eligible studies of ibct versus face-to-face cbt and reported that they produced equivalent outcomes, supporting the conclusions drawn by previous studies. it is also important to consider the issue of therapeutic alliance (ta) and its relationship to internet-based treatment. ta, to a large extent, is designed to capture the human aspect of the relationship between the clinician and the client. there are thousands of correlational studies that have established that ta is a predictor of treatment outcomes (flückiger et al. ) ; however, there are few studies of interventions that show a causal connection between ta and outcomes (e.g., hartley et al. ) . moreover, the very nature of ta as trait-like or state-like, which is central to causal assumptions, is being questioned and is subject to new research approaches (zilcha-mano ) as well as to questions about how it should be measured regardless of my doubts about the importance of ta, the fluckiger et al. ( ) meta-analysis found similar effect sizes (r = . ) for the alliance-outcome relationship in online interventions and in traditional face-to-face therapies. however, most of these studies were guided by a therapist, so the human factor was not totally absent. penedo et al. ( ) , in their study of a guided internet-based treatment, showed that it was important to align with the client's expectations and goals because these were related to outcomes, but no such relationship existed with the traditional third component of ta, bond with the supporting therapist, implying that ta might play a different role in internetbased treatments. i was trained as a social psychologist and was a graduate student of stanley milgram (of the famous obedience experiments), so i was curious about the research on the relationship between technological virtual agents and humans beyond the context of mental health treatment. several studies cited by schneeberger et al. ( ) showed that robots could get people to do tiring, shameful, or deviant tasks. the authors found that participants obeyed these virtual agents similarly to the way they responded to humans in a video-chat format. the participants did the same number of shameful tasks regardless of who or what was ordering them. moreover, doing the tasks produced the same level of shame and stress in the participant. they concluded that virtual agents and humans appear to have the same influence as human experimenters on participants. of course, there are many limitations associated with generalizing from this laboratory study, which was conducted with female college students in germany, but it does suggest that a great deal of research needs to be done on how humans relate to robots and virtual agents. miner et al. ( ) suggest that use of conversational ai in psychotherapy can be an asset for improving access to care, but there is limited research on efficacy and safety. can we learn about the role of the therapist from therapies that do not involve any therapist or technology? there is substantial research on self-help approaches from written material or what some call bibliotherapy. in general, research has supported the effectiveness of bibliotherapy before the advent of digital approaches. in , cuijpers et al. published a review of the literature that compared face-to face psychotherapy for depression and anxiety with guided selfhelp (i.e., with some therapist involvement) and concluded that they appeared comparable, but because there were so few studies in this comparison, this conclusion should be interpreted with caution. has the situation changed in the last decade? in a comprehensive review and meta-analysis almost years later, bennett et al. ( ) conducted a review and meta-analysis of studies. they concluded that self-help (both guided and unguided) had significant moderate to large effects on reducing symptoms of anxiety, depression, and disruptive behavior. however, there was also very high heterogeneity among the outcomes of these studies. compared to face-to-face therapy, self-help was better than no treatment but slightly worse than face-to-face treatments, guided therapy was better than unguided, and computerized treatment was better than bibliographic treatment. it is important to note that none of the studies were fully powered noninferiority trials, which would be a superior design. the authors concluded that their study showed potential near equivalence for self-help compared to faceto-face interventions, and their conclusions were consistent with several other reviews of self-help for mental health disorders in adults. the paper makes no mention of ai. cuijpers et al. ( ) conducted a network meta-analysis of trials of cbt addressing the question of whether format of delivery (individual, group, telephone-administered, guided self-help, or unguided self-help) influenced acceptability and effectiveness for these adult patients with acute depression. no statistically significant differences in effectiveness were found among these formats except that unguided self-help therapy was not more effective than care as usual but was more effective than a waitlist control group. the authors concluded that treatments using these different formats should be considered alternatives to therapist-delivered individual cbt. as in the previous publication, there was no mention of the use of ai, but cuijpers believes that few if any of the studies reviewed in his publication used ai (p. cuijpers, personal communication, march , ) . there is an emerging area of the use of ai in treatment that is informative. tuerk et al. ( ) , in a special section of current psychiatry reports focusing on psychiatry in a digital age, describe several approaches to using technology in evidence-based treatments. most relevant is their discussion of the use of ai in what has been called "conversational artificial intelligence" where there is a real-time interchange between a computer and a person. they note research that shows that this approach is low risk, high in consumer satisfaction, and high in self-disclosure. they suggest that there is a great deal of clinical potential in using ai in this manner. in a review of the literature from to on conversational agents used in the treatment of mental health problems, gaffney et al. ( ) found only qualifying studies out of an initial , with four being what they called full-scale rcts. they concluded that the use of conversational agents was limited but growing. all studies showed reduced psychological distress, with the five controlled studies showing a significant reduction compared to control groups. however, the three studies that used active controls did not show significant differences between the waitlist controls and use of a conversational agent, although all showed improvement. the authors concluded that the use of conversational agents in therapy looks promising, but not surprisingly, more research is needed. a similar conclusion on conversational agents was reached in another independent review (vaidyam et al. ) . i have little doubt that more research will be forthcoming in this emerging area. in summary, previous research using digital but not aipowered icbt, self-help (bibliotherapy), and ai-powered conversational agents suggests that effective treatment can be delivered without a human clinician under certain circumstances. i want to emphasize that these studies are suggestive but far from definitive. rather, they suggest that the role of the clinician is worth more exploration, but they do not establish the conclusion that we do not need clinicians to deliver services. we need to know a great deal more about how ai-supported therapy operates in different contexts. a survey of psychiatrists from countries asked about how technology will affect their future practice (doraiswamy et al. ) . only . % felt their jobs would become obsolete, and only a small minority ( %) felt that ai was likely to replace a human clinician in providing care. as much of the literature on the effects of ai on jobs suggests, those surveyed believed that ai would help in more routine tasks such as record keeping ( %) and synthesizing information, with about % believing their practices would be substantially changed. about % thought ai would have no influence or only minimal effect on their future work over the next years. another % thought their practices would be moderately changed by ai over the next years. more than three quarters ( %) thought it unlikely that technology would ever be able to provide care as well as or better than the average psychiatrist. only % of u.s.-based psychiatrists predicted that the potential benefits of future technologies or ai would outweigh the possible risks. some of the specific tasks that psychiatrists typically perform, including mental status examination, evaluation of dangerous behavior, and the development of a personalized treatment plan, were also felt to be tasks that a future technology would be unlikely to perform as well. i do not think many psychiatrists in this study are prepared for the major changes in their practices that are highly likely to occur in the next quarter century. in a thoughtful essay on the future of digital psychiatry, hariman et al. ( ) draw a number of conclusions. they predict major changes in practice, with treatment by an individual psychiatrist alone becoming rare. patients will receive treatment through their phones, participate in videoconferencing, and converse with chatbots. clinicians will receive daily updates on the patients through remote sensing devices and self-report. ai will be involved in both diagnosis and treatment and will integrate diverse sources of information. concerns over privacy and data security will increase. this is not the picture that the previously described survey of psychiatrists anticipated. brown et al. ( ) present the pros and cons of ai in an interesting debate format. on the pro side, the authors argue that while there are current limitations, the improvements in natural language processing (nlp) will lead to better clinical interviews. they point to research that shows people are more likely be honest with computers as a plus in obtaining more valid information from clients. they expect the ai "clinician" will be seen as competent and caring. they do note the danger that non-transparent ai will produce unintended negative side effects. those arguing against the use of ai clinicians acknowledge the technical superiority of ai to accomplish more routine tasks such as information gathering and tracking, but they point out the limitations even in the development of ai therapists. the lack of data needed to develop and test algorithms is critical. i have noted this in the discussion of the diagnostic muddle as a problem that ai can help solve, but these anti-ai authors argue that because psychiatrists disagree on diagnoses, there is no gold standard against which to measure the validity of ai models. this seems to be a rather unusual perspective from which to challenge change. they insightfully note that ai is different from human intelligence and does not perform well when presented with data that are different from training data. but the anti-ai authors acknowledge that more and better data may lead to improvement. brown et al. ( ) argue that common sense is something that ai cannot draw on; however, this seems to be a weak argument when common sense has been demonstrated to be inaccurate under many situations. they conclude with the statement that psychiatry "will always be about connecting with another human to help that individual" (p. ). this may be more wishful thinking than an accurate prediction about the future. those arguing the pro position state that the "the advance of ai psychiatry is inexorable" (p. ). on the other hand, the opponents of ai correctly point out that there is not yet sufficient evidence to draw a conclusion about the effectiveness of ai versus human clinicians. while there is disagreement about the potential advantages and disadvantages of ai, both sides agree that we need more and better research in this area. simon and yarborough ( ) present the case that ai should not be a major concern for mental health. they argue that ideally, our field would abandon the term artificial intelligence in regard to actual diagnosis and treatment of mental health conditions. using that term raises false hopes that machines will explain the mysteries of mental health and mental illness. it also raises false fears that all-knowing machines will displace human-centered mental health care. big data and advanced statistical methods have and will continue to yield useful tools for mental health care. but calling those tools artificially intelligent is neither necessary nor helpful. (p. ) the authors further take the position that despite the buildup around artificial intelligence, we need not fear the imminent arrival of "the singularity," that science fiction scenario of artificially intelligent computers linking together and ruling over all humanity. . . a scenario of autonomous machines selecting and delivering mental health treatments without human supervision or intervention remains in the realm of science fiction. (p. ) a more balanced approach to the role to the issue of replacement of clinicians by ai is presented by ahuja ( ) . after his review of the literature on medical specialists who may be replaced or more likely augmented by ai, his pithy take on this question is "or, it might come to pass that physicians who use ai might replace physicians who are unable to do so" (ahuja , p. ) . clearly, ai research will have to provide strong evidence of its effectiveness before ai will be accepted by some in the psychiatric community. there are several pressing questions about how mental health services should be delivered and about the future of mental health services. doubts about how much clinicians contribute to outcomes, our seeming inability to differentiate the effectiveness among clinicians except at the extremes, the lack of stability of employment of most community based clinicians, the poor track record on implementation of evidence-based programs, the cost of human services, the very limited availability of services especially where resources are inadequate-all lead to strong doubts about continuing the status quo of using clinicians as the primary way in which mental health services are delivered. in contrast, alternative approaches have many advantages. if scaled, ai therapists could be available to patients / and would not be bound to office hours. these ai therapists could represent any demographic or therapy style (e.g., directive) that the client preferred or that had been found to be more effective with a particular client. they can be specialists in any area for which there is sufficient research. in other words, not only can a personalized treatment plan be developed, but a personalized clinician (avatar) can be constructed for the best match with the client. of course, all these are putative advantages. as noted earlier, the application of ai is not without its risks and challenges, especially in putting together the interdisciplinary teams needed to accomplish this research. while i am optimistic about the potential contribution of ai to mental health services, it is just that-a potential. extensive research will be needed to learn whether these approaches produce positive outcomes when compared to traditional face-to face treatment, while also dealing with the ethical issues raised by ai applications. moreover, the quality of research needs significant improvement if we are going to have confidence in the findings. however, as exemplified by the rapid and uncontrolled growth of therapy apps, the world may not wait for rigorous supporting research before adopting a larger role for ai in mental health services. while my brief summaries of findings of ai in the medical literature are supportive of the application of ai, i do not want to give the impression that these positive findings are accepted uncritically. a deeper reading of many of these studies exposes methodological flaws that temper enthusiasm. for example, in reviewing comparisons between healthcare professionals and deep learning algorithms in classifying diseases of all types using medical imaging, x. liu et al. ( a) conclude that the ai models are equivalent to the accuracy of healthcare professionals. this review is the first to compare the diagnostic accuracy of deep learning models to health-care professionals; however, only a small number of the studies were direct comparisons. the authors also caution us by indicating what they labeled as the poor quality of many of the studies. the problems included low external validity (not done in a clinical practice setting), insufficient clarity in the reporting of results, lack of external validation, and lack of uniformity of metrics of diagnostic performance and deep learning terminology. however, the authors were encouraged by improvement in quality in the most recent studies analyzed. in commenting on the study, cook ( ) noted other limitations and concluded that it is premature to draw conclusions about the comparative accuracy of ai versus human physicians. if we are not more cautious, she warns that we will experience "inflated expectations on the gartner hype cycle" (p. e ). the latter refers to the examination of innovations and trends in ai. she cautions us to "stick to the facts, rather than risking a drop into the trough of disillusionment and a third major ai winter" (p. e ). many issues are raised in cook's paper, and the need to avoid the hype often found in the ai field is reiterated in the national academy of medicine's monograph on the use of ai in healthcare (matheny et al. ) . mental health services are changing. there are more than , mental health apps on the internet that are being used without much evidence of their effectiveness (marshall et al. ; bergin and davis ; gould et al. ) . the explosion of mental health apps is the leading edge of future autonomous interventions. however, there is pressure to bring some order to this chaos. probably the next innovation that will involve ai is its use in stepped therapy in which clients are typically triaged to low-intensity, low-cost care, monitored systematically, and stepped up to more intensive care if progress is not satisfactory . in this schema, the low-cost care could be ai-based apps with little risk to the client. if more confidence is gained in the safety and effectiveness of this type of protocol, the use of ai-based treatment would be expected to increase. the covid- pandemic will produce a major impact on mental health services. first, it is expected that the stresses caused by the pandemic will increase the demand for services (qiu et al. ; rajkumar ) . already poorly resourced mental health systems will not be able to meet this demand (Ćosić et al. ; ho et al. ; holmes et al. ) , especially in low resourced countries. however, the biggest change will be in the service delivery infrastructure. because of social distancing requirements, in-person delivery of therapy is being severely curtailed. while the major change at this time appears to be a shift to telemedicine (shore et al. ; van daele et al. ) , which is being adopted across almost all healthcare, there will need to be changes instituted in how clinicians are trained and supervised (zhou et al. ) . i have little doubt that ai will be adopted in order to increase efficiency and address the change in the service environment caused by the pandemic. in addition to changes initiated by the pandemic, there appear to be some changes in funding as a result of the protests concerning george floyd's killing. there is reconsideration of shifting some funding from police services to mental health and conflict reduction services to be delivered by personnel outside law enforcement (stockman and eligon ) . it will be difficult to meet this potential demand using the current infrastructure. the literature on ai and medicine is replete with warnings about the difficulties we face in integrating ai into our healthcare system. as a program evaluator, i appreciate the position paper describing the urgent need for well-designed and competently conducted evaluations of ai interventions as well as the guidelines provided by magrabi et al. ( ) . more suggestions for improving the quality of research on supervised machine learning can be found in the paper by cearns et al. ( ) . celi et al. ( ) describe the future in a very brief essay that is worth quoting: clinical practice should evolve as a hybrid enterprise with clinicians who know what to expect from, and how to work with, what is fundamentally a very sophisticated clinical support tool. working together, humans and machines can address many of the decisional fragilities intrinsic to current practice. the human-driven scientific method can be powerfully augmented by computational methods sifting through the necessarily large amounts of longitudinal patientand provider-generated data. (p. e ) however, research on ai, data science, and other technologies is in its infancy if not the embryonic stage of development. i am fully immersed in the struggle to implement several types of technologies in practice. changing the routine behavior of clinicians and clients is a major barrier to using new technologies, regardless of the effectiveness of these approaches. emanuel and wachter ( ) argue that the most important problem facing healthcare is not the absence of data or analytic approaches but turning predictions and findings into successful accomplishments through behavior change. alongside the investment in technology and analytics, we need to support the research and applications of psychologists, behavioral economists, and those working in the relatively new field of translational and implementation research. the emphasis on practical and implementable digital approaches requires a methodology that departs from the traditional efficacy approach, which does not focus on context and thus is difficult to translate to the real world. mohr et al. ( ) suggest a solution-based approach that focuses on three stages that they label create, trial and sustain. creation focuses on the initial stages of development, although not exclusively, and takes advantage of the unique characteristics of digital approaches that focus on engagement rather than trying to mimic traditional psychotherapy. trial must be dynamic because digital technologies rapidly change; rapid evaluations are required, such as continuous quality improvement strategies (bickman and noser ) . sustainability requires more from investigators and evaluators than publication of results; they must also produce sustainable implementation that no longer depends on a research project for support. we are currently in an ai summer in which there are important scientific breakthroughs and large investments in the application of ai (hagendorff and wezel ) . but ai has had several winters when enthusiasm for ai has waned and unreasonable expectations have cooled. we were confronted with the reality that ai could not accomplish everything that people thought it could and that investors and journalists had hyped. ai, at least in the near term, will not be the superintelligence that will destroy humanity or the ultimate solution that will solve all problems. enthusiasm for ai seems to run in cycles like the seasons. ai summers suffer from unrealistic expectations, but the winters bring an experience of disproportionate backlash and exaggerated disappointment. there was a severe winter in the late s, and another in the s and s (floridi ) . today, some are talking about another predictable winter (nield ; walch ; schuchmann ). floridi ( ) suggests that we can learn important principles from these cycles. first is whether ai is going to replace previous activities as the car did with the buggy, diversify activities as the car did with the bicycle, or complement and expand them as the plane did with the car. floridi asks how acceptable an ai that survives another winter will be. he suggests that we need to avoid oversimplification and think deeply about with we are doing with ai. in the june issue of the technology quarterly of the economist ( ), it is suggested that because ai's current summer is "warmer and brighter" than past ones because of widespread deployment of ai, "another fullblown winter is unlikely. but an autumnal breeze is picking up" (p. ). i have traced a path my career has taken from an almost exclusive focus on randomized experiments to consideration of the applications of ai. i have identified the main problems related to mental health services research's almost sole dependence on rct methodology. i have linked the problems with this methodology with the lack of satisfactory progress in developing sufficiently effective mental health services. the recent availability of ai and the value now being placed on precision medicine have produced the early stages of a revolution in healthcare that will determine how treatment will be developed and delivered. i anticipate that in the very near future, a first-year graduate student will be contemplating the same questions that i raised years ago, because they are still relevant, but this time he or she will realize that there are answers that were not available to me. acknowledgements this paper is part of a special issue of this journal titled "festschrift for leonard bickman: the future of children's mental health services." the issue includes a collection of original children's mental health services research articles, this article, three invited commentaries on this article, and a compilation of letters in which colleagues reflect on my career and on their experiences with me. the word festschrift is german and means a festival or celebration of the work of an author. there are many people to thank for their assistance in both the festschrift and this paper. first, i want to acknowledge my two colleagues and friends, nick ialongo and michael lindsey, who spontaneously originated the idea of a festschrift during a phone conversation with them. the folks at the johns hopkins bloomberg school of public health were great in supporting the daylong event held on may , . the many friends, family, former students and colleagues who traveled from around the country to attend and present made the event memorable. i am grateful to the committee that helped put this special issue together, which included marc atkins, catherine bradshaw, susan douglas, nick ialongo, kim hoagwood, and sonja schoenwald. this paper represents more than a yearlong effort for which many contributed including the scholars who provided email exchanges and ideas throughout the conceptualization and writing process. i thank the two editors of this special issue, sonja and catherine, who spent much of their valuable time on this project during a very difficult period. the manuscript was greatly improved through the efforts of my copy editor, diana axelsen. most of all i thank corinne bickman, who has been my partner in life for almost years and has managed this journal since its inception. without her support and love none of this would have been possible. funding no external funding was used in the preparation or writing of this article. conflict of interest from the editors: leonard bickman is editorin-chief of this journal and thus could have a conflict of interest in how this manuscript was managed. however, the guest editors of this special issue, entitled "festschrift for leonard bickman: the future of children's mental health services," managed the review process. three independent reviews of the manuscript were obtained and all recommended publication with some minor revisions, with which the editors concurred. while the reviewers were masked to the author, because of the nature of the manuscript is was not possible to mask the author for the reviewers. from the author: the author reported receipt of compensation related to the peabody 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alliance really therapeutic? revisiting this question in light of recent methodological advances major developments in methods addressing for whom psychotherapy may work and why key: cord- -z rc ubj authors: wilkins, pamela a. title: disorders of foals date: - - journal: equine internal medicine doi: . /b - - - / - sha: doc_id: cord_uid: z rc ubj nan before the s, intensive management of the compromised neonate was unusual and little was known regarding many of the problems of this special patient population. although some specific conditions had been described by astute clinician-researchers, most notably the "dummy" foal syndrome and respiratory distress syndrome caused by primary surfactant deficiency, little information regarding the diagnosis and management of conditions of the foal during the neonatal period was available, although at least one active group was investigating fetal and neonatal physiology of the horse in great britain. [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] when treatment of compromised foals was undertaken, the approach most commonly resembled treating them as small adults with little understanding of the different physiology of the equine neonate. the advent of improved management of reproductive efficiency of mares led naturally to increased interest in preservation of the conceptus to parturition and the foal thereafter. interested clinicians, taking their lessons from the field of human perinatology/neonatology and sometimes working hand-in-hand with their counterparts in the human field, pioneered investigations into these small patients and created the fields of equine perinatology and equine neonatal intensive care. [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] because of the foresight and energy of these early investigators, the field of veterinary perinatology/neonatology exploded in the s, leading to the creation of equine neonatal intensive care units throughout the united sates and the world. from these units information about the normal and abnormal physiology of foals, the medical conditions affecting them, and methods for treatment and management of these problems has been developed through observational, retrospective, and prospective studies. this veritable explosion of information over the last years has improved greatly the ability of all practitioners to provide appropriate care for these patients, whether in the field or at an equine neonatal intensive care unit. the ability not only to save the lives of these patients but also to treat them in such a manner as to allow them to fulfill their purposes, whether as pleasure animals or racing athletes, has improved almost exponentially from those early days. [ ] [ ] [ ] [ ] this chapter aims to provide the clinician with some of the most current information regarding the management of these patients, recognizing that much still remains unknown and that advances will continue to be made in this dynamic field. the reader is cautioned that much of this chapter is flavored by the experiences of the author and that variation in approach and treatment of specific problems exists between neonatal intensive care units (nicus) and between clinicians in the same nicu and that each year results in change. in some cases, information that is presented has been gleaned from human nicu studies, essentially using the critically ill infant as the experimental model. many of the problems of the newborn foal have their genesis in utero. identification of high-risk pregnancies is an important component of prenatal care of the foal, and some of the most commonly encountered problems of the dam resulting in abnormal foals include previous or concurrent disease, poor reproductive history, poor perineal or pelvic conformation, poor general health, poor nutritional condition, prolonged transport, history of previous abnormal foals, placental abnormalities, and twins. some of the more common causes of abortion can result in the birth of severely compromised foals of variable gestation lengths (box - ). these include pa m e l a a . wi l k i n s infectious causes such as equine herpesvirus (ehv) types (most commonly) and (rarely), equine infectious anemia, equine arteritis virus, bacterial and fungal placentitis, leptospirosis, equine ehrlichiosis, and gram-negative septicemia/endotoxemia. [ ] [ ] [ ] noninfectious causes of abortion include twinning and noninfectious placental abnormalities such as extensive endometrial fibrosis, body pregnancy, and abnormal length (long or short) of the umbilical cord. , to the equine neonatologist opportunities for intervention may appear limited, and in the case of many of the aforementioned causes of fetal loss, this is true. however, one can do much in an attempt to preserve the pregnancy and in effect treat the fetus. when one is faced with a threatened pregnancy, one has various ways of evaluating the fetus and its environment and may use many potential therapies. once one identifies a pregnancy as high risk, one should evaluate the fetus for viability. evaluation should include as thorough an evaluation as possible of the reproductive tract, placenta, and fetal fluids. prepartum disorders in the mare usually are readily recognizable, but disorders of the fetus and placenta can be more subtle and difficult to determine. the first step is to take a thorough history of the mare. of particular interest is any history of previous abnormal foals, but the history taking should include questions regarding transportation; establishment of an accurate breeding date (sometimes more difficult than one would suspect); any pertinent medical history including any diagnostic testing performed for this pregnancy such as culture, endometrial biopsy, and cytologic results; and any rectal and ultrasound examination results. additionally, one should obtain information regarding possible ingestion of endophyte-infected fescue or exposure to potential infectious causes of abortion. , a complete vaccination and deworming history is requisite, as is a complete history of any medications and supplements administered during pregnancy. after obtaining a history, one examines the mare per rectum. this examination should include palpation of the cervix, uterus, fetus, and all palpable abdominal contents. one should note any abnormalities. the cervix should be tight throughout gestation; the late gestation uterus will be large and distended with fluid and usually pulled craniad in the abdomen. palpation of the fetus frequently results in some fetal movement; however, one should interpret lack of movement with caution, for some normal fetuses do not respond. ultrasonographic evaluation of the uterus and conceptus per rectum can provide valuable information, particularly regarding placental thickness if placentitis is a concern. one may evaluate fetal fluids and estimate fetal size from the size of the eye later in gestation. in the author's hospital the practitioners choose not to perform vaginal examinations or speculum examinations because of an association between these examinations and the subsequent development of placentitis. unless placentitis is recognized with ultrasonograhic evaluation per rectum and culture is desirable, these types of examinations are generally not necessary. following examination per rectum, one performs transabdominal ultrasonographic evaluation of the uterus and conceptus. one can generate a biophysical profile of the fetus from this examination in the late-term fetus and readily determine viability. , one also readily can determine the presence or absence of twins in the late pregnant mare in this manner. one performs the sonogram through the acoustic window from the udder to the xiphoid ventrally and laterally to the skinfolds of the flank. imaging of the fetus usually requires a lowfrequency ( . -mhz) probe, whereas examination of the placenta and endometrium requires a higher-frequency ( . -mhz) probe. a complete description of this examination is beyond the scope of this chapter, but the reader will find several complete descriptions of the technique and normal values for specific gestation lengths within the relevant veterinary literature. the utility of this examination lies in its repeatability and low risk to the dam and fetus. sequential examinations over time allow the clinician to follow the pregnancy and to identify changes as they occur. a companion to transabdominal ultrasongraphy is evaluation of the fetal electrocardiogram (ecg). one can measure fetal ecgs continuously using telemetry or can obtain them using more conventional techniques several times throughout the day. , , one places electrodes on the skin of the mare in locations aimed at maximizing the magnitude of the fetal ecg. because the fetus frequently changes position, multiple sites may be needed in any -hour period. to begin, one places an electrode dorsally in the area of the sacral prominence with two electrodes placed bilaterally in a transverse plane in the region of the flank. the fetal ecg maximal amplitude is low, usually . to . mv, and can be lost in artifact or background noise, so one commonly must move electrodes to new positions to maximize the appearance of the fetal ecg. the normal fetal heart rate during the last months of gestation ranges from to beats/min, a fairly wide distribution. the range of heart rate of an individual fetus can be narrow, however. bradycardia in the fetus is an adaptation to in utero stress, most commonly thought to be hypoxia. by slowing the heart rate, the fetus prolongs exposure of fetal blood to maternal blood, increasing the time for equilibration of dissolved gas across the placenta and improving the oxygen content of the fetal blood. the fetus also has altered the distribution of its cardiac output in response to hypoxia, centralizing blood distribution. , tachycardia in the fetus can be associated with fetal movement, and brief periods of tachycardia should occur in the fetus in any -hour period. persistent tachycardia is a sign of fetal distress and represents more severe fetal compromise than bradycardia. the author has recognized dysrhythmias in the challenged fetus, most commonly as atrial fibrillation but also apparent runs of ventricular tachycardia. the ability to monitor the fetus in a high-risk pregnancy inevitably has led to questions of whether, how, and when to intervene. most equine neonatologists would agree that removal of the fetus from the uterus before its attainment of readiness for birth is not desirable. one of the difficulties in determining fetal preparedness for birth is that prediction of parturition is difficult in these mares. many of the parameters used in normal mares are unreliable in the high-risk pregnant mare. one must have an accurate history of any previous gestation length in terms of days for the specific mare in question to allow a more accurate estimate of her usual gestational length. evaluation of the usual mammary gland parameters, including size, the presence of "wax," and alteration of electrolyte concentrations, is not generally predictive in the high-risk mare, for in the author's experience many of these mares have changes predictive of parturition for weeks before actual parturition. , this circumstance may be related to the observation that many high-risk pregnant mares, particularly those with placentitis, are presented for a primary complaint of early onset lactation. although pulmonary system maturity in human beings can be assessed with some degree of accuracy using measurement of lecithin/sphingomyelin ratios, this measurement-along with sphingomyelin, cortisol, and creatinine concentrations in the amnionic fluid-has proved to be of no benefit in the horse. [ ] [ ] [ ] amniocentesis carries a high risk of abortion in the horse, even with ultrasound guidance, and is not a clinically useful technique at this time. currently, no clear-cut guidelines are available as to when to intervene, but the presence of persistent fetal tachycardia or prolonged absence of fetal movements, including breathing movements, as determined by transabdominal ultrasound evaluation, should initiate discussion regarding the appropriateness of induction of parturition or elective cesarean section. the goal of induction or cesarean section is to remove a pregnancy that is threatening the survival of the dam with no thought to fetal survival or to remove the fetus from a threatening environment to improve its likelihood for survival. preterm induction is ill advised if fetal survival is desirable because of the limited ability to treat severely immature neonates. timing of intervention in these circumstances remains an art, not a science. the approach to management of the high-risk pregnancy is dictated to some degree by the exact cause for concern, but for many mares therapy is similar. many high-risk mares have placentitis, primarily caused by ascending bacterial or fungal infections originating in the region of the cervix. these infections can cause in utero sepsis or compromise the fetus by local elucidation of inflammatory mediators or altered placental function. , premature udder development and vaginal discharge are common clinical signs. treatment consists of administration of broad-spectrum antimicrobial agents and nonsteroidal antiinflammatory drugs (table - ). in the author's clinic, trimethoprim-sulfonamide drugs have been the antimicrobial of choice based on unpublished studies performed at the facility demonstrating increased concentration of these agents in the fetal fluids compared with penicillin and gentamicin. however, if culture and sensitivity results are available, one should institute directed therapy. nonsteroidal antiinflammatory agents such as flunixin meglumine are useful to combat alterations in prostaglandin balance that may be associated with infection and inflammation. although the efficacy of these agents is best when administered before the development of clinical signs, to date no detrimental effects have been reported in the fetus or dam when chronically used at low doses in well-hydrated patients. tocolytic agents and agents that promote uterine quiescence have been used and include altrenogest, isoxuprine, and clenbuterol. [ ] [ ] [ ] [ ] [ ] altrenogest usually is administered, although its need in late gestation has been challenged. the efficacy of isoxuprine as a tocolytic in the horse is unproven, and bioavailability of orally administered isoxuprine appears to be highly variable. the long-term use of clenbuterol is inadvisable because of receptor population changes associated with chronic use and its unknown effects on the fetus at this time. clenbuterol may be indicated during management of dystocia in preparation for assisted delivery or cesarean section. the intravenous form of clenbuterol is not currently available in the united states. one can use three additional strategies in managing high-risk pregnancy patients. in mares with evidence of placental dysfunction, with or without signs of fetal distress, the author provides intranasal oxygen supplementation in the hope of improving oxygen delivery to the fetus. intranasal oxygen insufflation of to l/min to the mare significantly increases pao and percent oxygen saturation of hemoglobin. because of the placental vessel arrangement of the horse, improvement of these two arterial blood gas parameters should result in improved oxygen delivery to the fetus. blood gas transport is largely independent of diffusion distance in the equine placenta, particularly in late gestation, and depends more on blood flow. information from other species cannot be extrapolated to the equine placenta because of its diffuse epitheliochorial nature and the arrangement of the maternal and fetal blood vessels within the microcotyledons. , umbilical venous po is to mm hg in the horse fetus, compared with to mm hg in the sheep, whereas the maternal uterine vein to umbilical vein po difference is near . also unlike the sheep, the umbilical venous po values decrease to mm hg in response to maternal hypoxemia and increase in response to maternal hyperoxia. [ ] [ ] [ ] vitamin e (tocopherol) is administered orally to some high-risk mares as an antioxidant. administration of large doses of vitamin e before traumatic brain injury improves neurologic outcome in experimental models and has been examined as possible prophylaxis for human neonatal encephalopathy. [ ] [ ] [ ] extrapolation of that information to the compromised equine fetus suggests that increased antioxidant concentrations in the fetus may mitigate some of the consequences of uterine and birth hypoxia, but no evidence is available to date demonstrating that protection occurs or that vitamin e accumulates in the fetus in response to supplementation of the mare. finally, many high-risk mares are anorectic or held off feed because of their medical condition. these mares are at particularly great risk for fetal loss because of their lack of feed intake, which alters prostaglandin metabolism. therefore one should administer . % to % dextrose in . % saline or water ( % dextrose) intravenously at maintenance fluid rates to these patients. perhaps the most important aspect of managing high-risk pregnancy mares is frequent observation and development of a plan. one should observe mares at least hourly for evidence of early-stage labor and should put them under constant video surveillance if possible. depending on the primary problem, the team managing the mare should develop a plan for handling the parturition once labor begins and for fetal resuscitation following delivery. any equipment that might be needed should be readily available stallside, and a call sheet, listing contact numbers for all involved, should be posted on or near the stall. the plan should include a decision as to how to handle a complicated dystocia, should it occur, with permission for general anesthesia and cesarean section obtained before the event so that time is not wasted. an important question to be posed to the owner at the outset is which is most important to the owner, the mare or the foal, for the answer may dictate the direction of the decision tree once labor begins. early recognition of abnormalities is of utmost importance for successful management of critically ill foals. to recognize the abnormal, one must know the normal. immediately following birth, foals effect several important physiologic and behavioral changes. chief among these changes is the adaptation of the cardiovascular and respiratory systems to extrauterine life. the normal transition of the respiratory tract involves opening closed part ii disorders of specific body systems alveoli and absorption of fluid from the airway, accomplished by a combination of breathing efforts, expiration against a closed glottis (grunting), and a change in sodium flux across the respiratory membrane from net secretion to net absorption. [ ] [ ] [ ] [ ] [ ] the transition from fetal to neonatal circulatory patterns requires resolution of the pulmonary hypertension present in the fetus, normally shunting blood flow through the lower resistance ductus arteriosus in the fetal state, to direct cardiac output to the pulmonary vasculature for participation in gas exchange. this change is achieved by the opening of alveoli, decreasing airway resistance and providing radial support for pulmonary vessels, functional closure of the ductus arteriosus, and increasing the oxygen tension in the lung, reversing pulmonary vasoconstriction mediated by hypoxia. , pulmonary tree vasodilators (prostacyclin, nitric oxide [no] ) and vasoconstrictors (endothelin- , leukotrienes) play apparently well-coordinated, but as yet not fully elucidated, roles. in the normal newborn this change is smooth and rapid. these critical events are undermined by factors such as inadequate lung development, surfactant deficiency (primary or secondary), viral or bacterial infection, placental abnormalities, in utero hypoxia, and meconium aspiration. spontaneous breathing should begin in the neonate within minute of birth, many foals attempt to breathe as their thorax clears the pelvic canal. during the first hour of life, the respiratory rate of a healthy foal can be as high as breaths per minute but should decrease to to breaths per minute within a few hours. similarly, the heart rate of a healthy newborn foal has a regular rhythm and should be at least beats/min at the first minute. , one usually can auscultate a continuous murmur over the left side of the heart, although its loudness may vary with position. this murmur is thought to be associated with some shunting through the ductus arteriosus. one may auscultate variable systolic murmurs, thought to be flow murmurs, during the first week of life. one should investigate more thoroughly murmurs that persist beyond the first week of life in an otherwise healthy foal, along with any murmur associated with persistent hypoxia. auscultation of the thorax shortly after birth reveals a cacophony of sounds as airways open and fluid is cleared. end-expiratory crackles are consistently audible in the dependent lung during and following lateral recumbency. for a normal newborn foal to appear slightly cyanotic during this initial adaptation period is not unusual, but this should resolve within minutes of birth. the equine fetus, as do all fetuses, exists in a moderately hypoxic environment, but the equine fetus has a greater partial pressure of oxygen, around mm hg. because the fetus is well adapted to low oxygen tensions, cyanosis is rarely present in newborn foals once adaption occurs, even those with low oxygen tensions. although in many species the fetal blood oxygen affinity is greater than the maternal blood, in the equine fetus the oxygen affinity of its hemoglobin is only about mm hg greater than the maternal blood because of decreased levels of , -diphosphoglycerate compared with other species. the result is enhanced oxygen unloading in the equine fetus compared with others. , -diphosphoglycerate concentration increases after birth in the foal and reaches mature levels by to days of age. the major blood adaptation of the equine fetus to chronic hypoxia is an increase in packed cell volume of up to %, increasing the oxygen content of the blood as compensation for decreased oxygen delivery at the placenta. a larger than expected packed cell volume in any newborn foal should alert the clinician for possible sequelae from chronic hypoxia. the presence of significant cyanosis that persists should prompt the clinician to evaluate the foal thoroughly for cardiac anomalies resulting in significant right-to-left shunting or separated circulations, such as transposition of the great vessels. the chest wall of the foal is compliant, facilitating passage through the pelvic canal during parturition. this compliance requires that the foal actively participate in inspiration and expiration with several potential consequences. first, restriction of the thorax or the abdomen can result in impaired ventilation, which can occur easily when one restrains a foal and may result in spuriously abnormal arterial blood gas values (see the discussion on arterial blood gas evaluation, respiratory diseases associated with hypoxemia in the neonate). second, foals with primary pulmonary parenchymal disease resulting in poorly compliant lungs develop paradoxical chest wall motion, with the thorax moving inward during inspiration. [ ] [ ] [ ] [ ] the work of breathing can increase greatly, resulting in respiratory failure because of respiratory muscle fatigue. a foal that appears suddenly to improve a previously abnormal respiratory rate and pattern may in fact be in greater respiratory difficulty because of fatigue. one can observe a reduction in respiratory rate or abnormal breathing pattern in premature/dysmature foals or foals subjected to peripartum hypoxia/asphxia. although the genesis of these patterns is not understood fully, cheyne-stokes (lengthy periods of apnea interrupted by short breaths that wax and wane in depth), cluster (short periods of apnea interspersed with long periods of breathing), and biot's breathing (periods of apnea and breathing with no discernible pattern) may occur in these cases. foals attempting to maintain an adequate lung volume expire against a partially closed glottis, called valsalva's maneuver, producing an audible grunt. foals are normally nonresponsive while in the birth canal but should respond to stimulation immediately after birth. the lack of responsiveness while in the birth canal has lead to presumption of fetal death during dystocia. because of this, one should attempt other tests before determining that a foal is dead intrapartum. one possibly may detect pulses in the tongue, neck, or any presented limbs or palpate the thorax for a heartbeat. in the author's facility, nasotracheal intubation of the foal combined with measurement of co tensions in the exhaled gas aids practitioners in cases where they can reach the nose. nasotracheal intubation of foals under these circumstances actually can be performed readily with minimal practice. having long endotracheal tubes available of several different diameters ( to mm outer diameter) with an inflatable cuff is important. one can pass the tube blindly using a finger in one nostril for guidance and can check the position frequently by palpation of the throatlatch region. one inflates the cuff and begins manual ventilation with % oxygen or room air using an ambu-bag or equivalent. one can obtain continuous measurement of co tension using a capnograph or single-use disposable end-tidal co monitor attached to the ambu-bag or the nasotracheal tube. in a dead foal the end-tidal co measurement will be negligible after the first to breaths. one must ensure tube placement and seal integrity and allow for multiple breaths. some co will "wash out" with the first few breaths and can result in false hope initially. end-tidal co varies in living intrapartum foals, depending on cardiac output and ventilation frequency, but should be consistently greater than mm hg and is usually closer to mm hg. once one establishes manual ventilation of a living foal, one must continue ventilation until the foal is delivered satisfactorily. the author has resuscitated and maintained many foals successfully in this manner throughout induction of general anesthesia in the mare and cesarean section delivery of the foal. the nasotracheal tube also provides a convenient site for administration of intratracheal medications such as epinephrine used for extrauterine intrapartum resuscitation of the foal. the reader is cautioned that intratracheal epinephrine increases endtidal co measurements transiently, even in a dead foal, because of local actions on tissues. one should allow a washout period after intratracheal administration of epinephrine. the righting reflex is present as the foal exits the birth canal, as is the withdrawal reflex. cranial nerve responses are intact at birth, but the menace response may take as long as weeks to develop fully. one should not consider lack of a menace reflex diagnostic of visual deficits in the newborn foal. within an hour of birth the normal foal will demonstrate auditory orientation with unilateral pinna control. the normal pupillary angle is ventromedial in the newborn foal; this angle gradually becomes dorsomedial over the first month of life. foals should begin attempting to stand shortly after birth and should be able to achieve this on their own within hours of birth. the normal newborn foal has a suck reflex shortly after birth and should be searching for an udder even before it stands. the expectation is that a normal foal will be sucking from the dam unaided by hours post partum; many foals are overachievers and will be sucking well before this time. the normal foal may defecate shortly after standing but may not attempt defecation until after it first successfully sucks from the dam. urination varies more, with filly foals usually urinating before colt foals, but both usually do not urinate for several hours following birth, up to hours for some colts. for colt foals to fail to drop their penises when urinating over the first few days of life is not unusual. the gait of the newborn foal is hypermetric and the stance is base wide. extreme hypermetria of the forelimbs, usually bilateral but occasionally unilateral, has been observed in some foals and is associated with perinatal hypoxic/ischemic insults, but this gait abnormality usually resolves without specific therapy within a few days. spinal reflexes tend to be exaggerated, whereas the crossed extensor reflex may not be fully present until weeks of age. foals also exhibit an exaggerated response to external stimuli (noise, sudden visual changes, touch) for the first few weeks of life. foals are not bonded strongly to their mother for the first few weeks of life and will follow any large moving object, including other horses and human beings. orphan foals bond with surrogate mothers until they are several months of age; their primary motivation appears to be appetite. conversely, mares strongly bond with their foals shortly after parturition; the process begins once the chorioallantois ruptures and is driven more by olfaction and taste than by vision or hearing. interference with this process, by medical intervention or excessive owner manipulation of the foal, can disrupt normal bonding and result in foal rejection by the dam. most newborn foals make the transition to extrauterine life easily. however, for those in difficulty, recognition of the condition immediately and institution of appropriate resuscitation is of utmost importance. a modified apgar scoring system has been developed as a guide for initiating resuscitation and assessing probable level of fetal compromise (table - ). one also must at least perform a cursory physical examination before initiating resuscitation, for issues of humaneness are associated with with serious problems such as severe limb contracture, microophthalmia, and hydrocephalus, among others. the initial assessment begins during presentation of the fetus. although the following applies primarily to attending the birth of a foal from a high-risk pregnancy, one can perform quiet and rapid evaluation during any attended birth. the goal in a normal birth with a normal foal is to disturb the bonding process minimally. this goal also applies to high-risk parturitions, but some disruption of normal bonding is inevitable. the lead clinician should control tightly the number of persons attending, and the degree of activity surrounding, the birth. one should evaluate the strength and rate of any palpable peripheral pulse and should evaluate the apical pulse as soon as the chest clears the birth canal. bradycardia (pulse < beats/min) is expected during forceful contractions, and the pulse rate should increase rapidly once the chest clears the birth canal. persistent bradycardia is an indication for rapid intervention. the fetus is normally hypoxemic compared with the newborn foal, and this hypoxemia is largely responsible for the maintenance of fetal circulation by generation of pulmonary hypertension. the fetus responds to conditions producing more severe in utero hypoxia by strengthening the fetal circulatory pattern, and the neonate responds to hypoxia by reverting to the fetal circulatory pattern. during a normal parturition, mild asphyxia occurs and results in fetal responses that pave the way for a successful transition to extrauterine life. if more than mild transient asphyxia occurs, the fetus is stimulated to breathe in utero; this is known as primary asphyxia. if the initial breathing effort resulting from the primary asphyxia does not correct the asphyxia, a second gasping period occurs in several minutes, known as the secondary asphyxia response. if no improvement in asphyxia occurs during this period, the foal enters secondary apnea, a state that is irreversible except with resuscitation. therefore the first priority of neonatal resuscitation is establishing an airway and breathing pattern. one should assume that foals not spontaneously breathing are in secondary apnea and should clear the airway of membranes as soon as the nose is presented. if meconium staining is present, one should suction the airway before delivery of the foal is completed and before the foal breathes spontaneously. one should continue to the trachea if aspiration of the nasopharynx is productive. overzealous suctioning worsens bradycardia as it worsens hypoxia. one should stop suctioning once the foal begins breathing spontaneously, as hypoxia will worsen with continued suction. if the foal does not breathe or move spontaneously within seconds of birth, one should begin tactile stimulation. if tactile stimulation fails to result in spontaneous breathing, one immediately should intubate the foal and manually ventilate the foal using an ambu-bag or equivalent. one can use mouth-to-nose ventilation if nasotracheal tubes and an ambu-bag are not available. the goal of this therapy is to reverse fetal circulation, and hyperventilation with % oxygen is the best choice for this purpose. however, recent evidence suggests that no clinical disadvantages are apparent in using room air for ventilation of asphyxiated human neonates rather than % oxygen. , human infants resuscitated with room air recovered more quickly than those resuscitated with % oxygen in one study as assessed by apgar scores, time to the first cry, and the sustained pattern of breathing. in addition, neonates resuscitated with % oxygen exhibited biochemical findings reflecting prolonged oxidative stress, present even after weeks of postnatal life, which did not appear in the group resuscitated with room air. thus the current accepted recommendations for using % oxygen in the resuscitation of asphyxiated neonates needs further discussion and investigation. , almost % of foals requiring resuscitation respond to hyperventilation alone and require no additional therapy. one can initiate nasotracheal intubation while the foal is in the birth canal if the foal will not be delivered rapidly, such as with a difficult dystocia. this technique is "blind" and requires some practice but may be beneficial and lifesaving. once spontaneous breathing is present, one apgar score in the foal should provide humidified oxygen via nasal insufflation at to l/min. one should initiate cardiovascular support in the form of chest compression if the foal remains bradycardic despite ventilation and a nonperfusing rhythm is present. one should make sure the foal is on a hard surface in right lateral recumbency with the topline against a wall or other support. approximately % of foals are born with fractured ribs and an assessment for the presence of rib fractures is in order before initiating chest compressions. palpation of the ribs identifies many of these fractures, which usually are multiple and consecutive on one side of the thorax and located in a relatively straight line along the part of the rib with the greatest curvature dorsal to the costochondral junction. unfortunately, ribs to frequently are involved, and their location over the heart can make chest compression a potentially fatal exercise. auscultation over the ribs during breathing results in a recognizable click, identifying rib fractures that may have escaped detection by palpation. one should initiate drug therapy if a nonperfusing rhythm persists for more than to seconds in the face of chest compression. epinephrine is the first drug of choice (table - ) . practitioners pose various arguments regarding the best dose and the best frequency of administration for resuscitation. however, most of the data are acquired from human cardiac arrest studies and are not strictly applicable to the equine neonate because the genesis of the cardiovascular failure is different. , vasopressin is gaining attention as a cardiovascular resuscitation drug, and although the author has used this drug in resuscitation and as a pressor, experience is limited at this time. the author does not use atropine in bradycardic newborn foals because the bradycardia usually is caused by hypoxia, and if the hypoxia is not corrected, atropine can increase myocardial oxygen debt. the author also does not use doxapram because it does not reverse secondary apnea, the most common apnea in newborns. because birthing areas are generally cold, one should dry the foal and place it on dry bedding once resuscitation is complete. the fetus has some homeothermic mechanisms, but its size in relation to its mother and its position within her body means that it is in effect a poikilotherm. the body temperature of the foal generally reflects that of its environment, namely its mother, although the human fetal temperature directly measured at cesarean section, induction of labor, or during labor is approximately . °c higher than the mothers. , adaptation from poikilothermy to homeothermy normally takes place rapidly following birth. the fetus is capable of nonshivering thermogenesis, primarily through the oxidation of brown fat reserves, but this type of thermogenesis is inhibited in utero, probably by placental prostaglandin e and adenosine. , immediately after birth the foal must adapt to independent thermoregulation. local physical factors, including ambient temperature and humidity, act to induce cold stress, and the newborn must produce heat by metabolic activity. in response to the catecholamine surge associated with birth, uncoupling of oxidative phosphorylation occurs within mitochondria, releasing energy as heat. this nonshivering thermogenesis is impaired in newborns undergoing hypoxia or asphyxiation and in those that are ill at birth. infants born to mothers sedated with benzodiazepines are affected similarly, a consideration in the choice of sedative and preanesthetic medications in mares suffering dystocia or part ii disorders of specific body systems undergoing cesarean section. [ ] [ ] [ ] heat losses by convection, radiation, and evaporation are high in most areas where foals are delivered, resuscitated ,and managed, and one must take care to minimize cold stress in the newborn and the critically ill foal. supplementary heat, in the form of radiant heat lamps or warm air circulating blankets, may be required. one should use fluid therapy conservatively during postpartum resuscitation, for the neonate is not volume depleted unless excessive bleeding has occurred. some compromised newborn foals are actually hypervolemic. fluid therapy of the neonate is discussed in more detail later in this chapter. because the renal function of the equine neonate is substantially different from the adult, one cannot simply scale down fluid therapy from adult therapy. [ ] [ ] [ ] if intravenous fluids are required for resuscitation and blood loss is identified, administration of ml/kg of a non-glucose-containing polyionic isotonic fluid over minutes (about l for a -kg foal) once intravenous access is established can be effective. the author stresses non-glucose-containing polyionic intravenous fluids because hyperglycemia, but not hypoglycemia, immediately after fetal or neonatal asphyxia interfered with the recovery of brain cell membrane function and energy metabolism in neonatal piglets in one recent study. these findings suggest that post-hypoxic-ischemic hyperglycemia is not beneficial and might even be harmful in neonatal hypoxic-ischemic encephalopathy. indications for this shock bolus therapy include poor mentation, poorly palpable peripheral pulses, and the development of cold distal extremities, compatible with hemorrhagic shock. one should reassess the patient after the initial bolus and administer additional boluses as necessary. ideally, one should follow up on blood pressures and ecg readings and initiate appropriate pressor therapy if needed. again, these procedures are discussed in detail later in the chapter. one can administer glucose-containing fluids after resuscitation at a rate of to mg/kg/min (about ml/hr of % dextrose or ml/hr of % dextrose) to the average -kg foal, particularly in the obviously compromised foal. this therapy is indicated to help resolve metabolic acidosis, to support cardiac output because myocardial glycogen stores likely have been depleted, and to prevent postasphyxial hypoglycemia. under normal conditions, the fetal-to-maternal blood glucose concentration gradient is % to % in the horse, and glucose is the predominant source of energy during fetal development. , glucose transport across the placenta is facilitated by carrier receptors (glucose transporter [glut] receptors), and a direct relationship exists between maternal and fetal blood glucose concentration when maternal glucose is in the normal range. the glut receptors in the placenta are stereospecific, saturable, and energy independent. although the enzyme kinetics for glut isoform suggest that they are not saturable under conditions of euglycemia, equine maternal hyperglycemia results in increased fetal glucose concentration to a plateau point, likely caused by glut saturation. at term, the net umbilical uptake of glucose is to mg/kg/min, with most of the glucose being used by the brain and skeletal muscle. [ ] [ ] [ ] the fetus only develops gluconeogenesis under conditions of severe maternal starvation. a certain percentage of the delivered glucose is used to develop large glycogen stores in the fetal liver and cardiac muscle in preparation for birth, and at birth the foal liver produces glucose at a rate of to mg/ kg/min by using these stores. fetal glycogen stores also are built using the substrates lactate, pyruvate, and alanine; fetal uptake of lactate across the placenta is about half that of glucose. , the transition to gluconeogenesis, stimulated by increased circulating catecholamine concentration from birth and by stimulation of glucagon release at the time the umbilical cord breaks takes to hours in the normal foal, and glycogenolysis supplies needed glucose until feeding and glucose production are accomplished. in the challenged foal, glycogen stores may have been depleted and gluconeogenesis delayed, so provision of glucose at rates similar to what the liver would normally produce during this period is requisite. persistent pulmonary hypertension (pph) also is known as reversion to fetal circulation or persistent fetal circulation, and its genesis lies in the failure of the fetus to make the respiratory and cardiac transition to extrauterine life successfully or reversion of the newborn to fetal circulatory patterns in response to hypoxia or acidosis. differentiating this problem from other causes of hypoxemia in the newborn requires some investigation, and multiple serial arterial blood gas analyses are necessary to confirm suspicion of this problem (see the section on arterial blood gas analysis, respiratory diseases associated with hypoxemia in the neonate). however, one should suspect the condition in any neonate with hypercapnic hypoxemia that persists and worsens; these foals are in hypoxemic respiratory failure. the fetal circulatory pattern, with pulmonary hypertension and right-to-left shunting of blood through the patent foramen ovale and ductus arteriosus, is maintained in these cases. pulmonary vascular resistance falls at delivery to about % of fetal values, while pulmonary blood flow increases accordingly. early in the postnatal period these two changes balance each other, and mean pulmonary and systolic pressures remain increased for several hours. systolic pulmonary pressures can remain equivalent to systemic pressure for up to hours of age in human infants, although diastolic pulmonary pressures are well below systemic diastolic pressures by hour. mean pulmonary artery pressures fall gradually over the first hours. the direct effects of lung expansion and increasing alveolar oxygen tension probably provide the initial stimulus for pulmonary arteriolar dilation and partly result from direct physical effects, but vasoactive substances are released in response to physical forces associated with ventilation, for example prostacyclin. other vasoactive mediators thought to play a role in regulating pulmonary arteriolar tone include no, prostaglandins d and e , bradykinin, histamine, endothelin- , angiotensin ii, and atrial natriuretic peptide. the increase in alveolar and arterial oxygen tensions at birth is required for completion of resolution of pulmonary hypertension. much of this increase is thought to be mediated by no, evidence for this being the parallel increase during gestation of the pulmonary vasodilation response to hyperoxia and the increase in no synthesis. however, inhibition of no synthesis does not eliminate the initial decrease in pulmonary artery resistance occurring because of opening of the airways. when these mechanisms fail, one can recognize pph. right-to-left shunting within the lungs and through patent fetal conduits occurs and can result from many factors, including asphyxia and meconium aspiration, but in many cases the precipitating trigger is unknown. inappropriately decreased levels of vasodilators (no) and inappropriately increased levels of vasoconstrictors (endothelin- ) currently are being examined as potential mechanisms. chronic in utero hypoxia and acidosis may result in hypertrophy of the pulmonary arteriolar smooth muscle. in these cases, reversal of pph can be difficult and cannot be achieved rapidly. treatment of pph is twofold: abolishment of hypoxia and correction of the acidosis, for both abnormalities only bolster the fetal circulatory pattern. initial therapy is provision of oxygen intranasally at to l/min. some foals respond to this therapy and establish neonatal circulatory patterns within a few hours. failure to improve or worsening of hypoxemic respiratory failure following intranasal oxygen administration should prompt intubation and mechanical ventilation with % oxygen. this serves two purposes, one diagnostic and one therapeutic. ventilation with % oxygen may resolve pph and, if intrapulmonary shunt and altered ventilation-perfusion relationships are causing the hypoxic respiratory failure, arterial oxygen tension (pao ) should exceed mm hg under these conditions. failure to improve pao suggests pph or large right-to-left extrapulmonary shunt caused by congenital cardiac anomaly. the vasodilators prostacyclin and telazoline (an α-blocking vasodilator) cause pulmonary vasodilation in human infants with pph, but the effects on oxygenation vary and the sideeffects (tachycardia, severe systemic hypotension) are unacceptable. recognition of no as a potent dilator of pulmonary vessels has created a significant step forward in the treatment of these patients, for inhaled no dilates vessels in ventilated portions of the lung while having minimal effects on the systemic circulation. based on evidence presently available, use of inhaled no in an initial concentration of about ppm in the ventilatory gas seems reasonable for term and near-term foals with hypoxic respiratory failure and pph that fails to respond to mechanical ventilation using % oxygen alone. , the author has used this approach in the clinic, administering a range of to ppm no with success. hypoxic ischemic encephalopathy (hie), currently referred to as neonatal encephalopathy in the human literature, is one systemic manifestation of a broader syndrome of perinatal asphyxia syndrome (pas), and management of foals with signs consistent with a diagnosis of hie requires the clinician to examine other body systems fully and to provide therapy directed at treating other involved systems. although pas primarily manifests as hie, the gastrointestinal tract and kidneys frequently are affected by peripartum hypoxia/ischemia/ asphyxia, and one should expect complications associated with these systems. hypoxic ischemic encephalopathy also may affect the cardiovascular and respiratory systems, and one also may encounter endocrine disorders in these patients. hypoxic ischemic encephalopathy has been recognized as one of the most common diseases of the equine neonate for generations. , , in the past hie has been known as dummy foal syndrome and as neonatal maladjustment syndrome. the designation hie, although not perfect, attempts to describe the syndrome in terms of the suspected underlying pathophysiology. a wide spectrum of clinical signs is associated with hie and can range from mild depression with loss of the suck reflex to grand mal seizure activity. typically, affected foals are normal at birth but show signs of central nervous system abnormalities within a few hours after birth. some foals are obviously abnormal at birth, and some do not show signs until hours of age. hypoxic ischemic encephalopathy commonly is associated with adverse peripartum events, including dystocia and premature placental separation, but a fair number of foals have no known peripartum period of hypoxia, suggesting that these foals result from unrecognized in utero hypoxia (box - ). severe maternal illness also may result in foals born with pas. in human beings, ascending placental infection now is suspected of being a major contributor to neonatal encephalopathy in infants, and the incidence of neonatal encephalopathy increases with the presence of maternal fever, suggesting a role for maternal inflammatory mediators. the underlying pathophysiologic details of hie in the foal are unknown, and to date accurate experimental models of hie and pas in the foal have not been described. however, a great deal of attention has been paid to peripartum hypoxia/asphyxia by human counterparts because the effects of adverse peripartum events in the human neonate have far ranging implications for the affected human neonate and for society. therefore equine neonatologists have long looked to human studies and models of the human disease for understanding of the syndrome in the equine neonate. perinatal brain damage in the mature fetus usually results from severe uterine asphyxia caused by an acute reduction of uterine or umbilical circulation. the fetus responds to this challenge by activation of the sympathetic adrenergic nervous system, causing a redistribution of cardiac output that favors the central organs: brain, heart, and adrenal glands. , if the hypoxic insult continues, the fetus reaches a point beyond which it cannot maintain this centralization of circulation, cardiac output falls, and cerebral circulation diminishes. the loss of oxygen results in a substantial decrease in oxidative phosphorylation in the brain with concomitant decreased energy production. the na + /k + pump at the cell membrane cannot maintain the ionic gradients, and the membrane potential is lost in the brain cells. in the absence of the membrane potential, calcium flows down its large extracellular/intracellular concentration gradient through voltage-dependent ion channels into the cell. this calcium overload of the neuron leads to cell damage by activation of calcium-dependent proteases, lipases, and endonucleases. protein biosynthesis is halted. calcium also enters the cells by glutamate-regulated ion channels as glutamate, an excitatory neurotransmitter, is released from presynaptic vesicles following anoxic cellular depolarization. once the anoxic event is over, protein synthesis remains inhibited in specific areas of the brain and returns to normal in less vulnerable areas of the brain. loss of protein synthesis appears to be an early indicator of cell death caused by the primary hypoxic/anoxic event. a second wave of neuronal cell death occurs during the reperfusion phase and is thought to be similar to classically described postischemic reperfusion injury in that damage is caused by production of and release of oxygen radicals, synthesis of no, and inflammatory reactions. additionally, an imbalance between excitatory and inhibitory neurotransmitters occurs. part of the secondary cell death that occurs is thought to be caused by apoptosis, a type of programmed cell death termed cellular suicide. secondary cell death also is thought be caused by the neurotoxicity of glutamate and aspartate resulting again from increased intracellular calcium levels. , in human infants the distribution of lesions with hypoxic-ischemic brain damage following prenatal, perinatal, or postnatal asphyxia falls into distinct patterns depending on the type of hypoxia-ischemia rather than on postconceptual age at which the asphyxial event occurs. periventricular leukomalacia was associated with chronic hypoxia-ischemia, whereas the basal ganglia and thalamus were affected primarily in patients experiencing acute profound asphyxia, providing direct evidence that the nature of the event determines the severity and distribution of neurologic damage in human beings. these remarkably selective patterns of injury in children, with differential variability in the damage caused to regions anatomically located within millimeters of each other, resulted in the hypothesis that location within neurotransmitter-specific circuitry loops is important. this hypothesis has important implications in the design of neuroprotective strategies and therapies for neonates experiencing hypoxic-ischemic-asphyxial events. now the evidence is overwhelming that the excitotoxic cascade that evolves during hie extends over several days from the time of insult and is modifiable. , in brain injury, traumatic or hypoxic, the mechanisms underlying delayed tissue injury still are understood poorly. many believe that neurochemical changes, including excessive neurotransmitter release, are pivotal in the pathophysiology of secondary neuronal death. excitatory amino acid neurotransmitters and magnesium are known to play at least a minimal role in secondary cell death following brain injury; a fair body of literature regarding these factors has been generated over the last years. the activation of the n-methyl-d-aspartate (nmda) subtype of glutamate receptors is implicated in the pathophysiology of traumatic brain injury and is suspected to play a role in hie. [ ] [ ] [ ] mechanically injured neurons demonstrate a reduction of voltage-dependent mg + blockade of nmda current that can be restored partially by increasing extracellular mg + concentration or by pretreatment with calphostin c, a protein kinase c inhibitor. this finding suggested that administration of mg + to patients with brain injury could lead to improved outcome. subsequently, magnesium sulfate solution was shown to improve dramatically the immediate recovery of rats from hypoxia. however, although pretreatment with magnesium sulfate protected against hypoxic ischemic brain injury, postasphyxial treatment worsened brain damage in -day-old rats, suggesting an age-related response in the rat. delayed magnesium treatment of mature rats following severe traumatic axonal brain injury improved motor outcome when administered up to hours after injury, with early treatments providing the most benefit. maternal seizure in rats is associated with fetal histopathologic changes that are abolished by administration of magnesium sulfate to the mother, and magnesium sulfate has been demonstrated to protect the fetal brain from severe maternal hypoxia. clinical trials investigating the efficacy of magnesium treatment following hypoxia in infants are under way, with few reports currently in the medical literature. magnesium sulfate was used to treat nine infants after perinatal asphyxia in one study (no control group), and all children were neurologically normal at year of age. seizures did not occur in any of these children, nor were any adverse side effects noted. magnesium sulfate administration failed to delay the global impairment in energy metabolism after hypoxia ischemia, characteristic of severe brain damage, in newborn piglets; at hours after hypoxia ischemia, no difference could be found in the severity of injury in piglets treated with magnesium compared with piglets treated with placebo, suggesting magnesium may not be protective with severe acute injury. in developing countries, birth hypoxia frequently is associated with hie, and although this finding is attributed most frequently to inadequate obstetric care, poor nutrition also may play a role. red blood cell magnesium levels were measured in more than women in labor at a teaching hospital in south africa. fifty five of the women delivered infants with hie and had significantly lower levels of magnesium than controls; the infants with hie also had significantly lower magnesium levels than controls. the large majority ( of ) of the women giving birth to hie infants were from poor social circumstances, suggesting nutrition might play a role in some cases of hie, with maternal magnesium levels affecting outcome in the infants. the authors suggested an early pregnancy intervention study may help determine the role of magnesium in the pathogenesis of hie in human infants born to at-risk mothers. therapy for the various manifestations of hypoxiaischemia involves control of seizures, general cerebral support, correction of metabolic abnormalities, maintenance of normal arterial blood gas values, maintenance of tissue perfusion, maintenance of renal function, treatment of gastrointestinal dysfunction, prevention and recognition and early treatment of secondary infections, and general supportive care. control of seizures is important because cerebral oxygen consumption increases fivefold during seizures. one can use diazepam for emergency control of seizures (table - ). if diazepam does not stop seizures readily or one recognizes more than two seizures, then one should replace diazepam with phenobarbital given to effect. the half-life of phenobarbital can be long in the foal ( hours), and one should keep this in mind when monitoring neurologic function in these cases after phenobarbital administration (j.e. palmer, personal communication, ). earlystage, preseizure administration of phenobarbital has been advocated by some investigators for prevention of neonatal encephalopathy. however, one recent study in asphyxiated human infants demonstrated that early phenobarbital treatment was associated with a threefold increase in the incidence of subsequent seizures and consequently a trend toward increased mortality. seizures per se were associated with almost a twentyfold increase in mortality. their findings suggest that early phenobarbital administration may produce adverse rather than beneficial effects following asphyxia. because this was an observational study; the results need to be confirmed by appropriate randomized trials in similar clinical settings. if phenobarbital fails to control seizures, one may attempt phenytoin therapy. in cases of hie, one should avoid ketamine and xylazine because of their association with increased intracranial pressure. one must protect the foal from injury during a seizure and also ensure the patency of the airway to prevent the onset of negative pressure pulmonary edema or aspiration pneumonia. probably the most important therapeutic interventions are aimed at maintaining cerebral perfusion, which is achieved by careful titration of intravenous fluid support, neither too much nor too little (see fluid therapy in neonates) and judicious administration of inotropes and pressors to maintain adequate perfusion pressures (see pressor and inotrope therapy in neonates). cerebral interstitial edema is only truly present in the most severe cases , ; in most cases the lesion is intracellular edema and most of the classic agents used to treat cerebral interstitial edema (e.g., mannitol) are minimally effective treating cellular edema. occasionally the author uses thiamine supplementation in the intravenous fluids to support metabolic processes, specifically mitochondrial metabolism and membrane na + ,k + -atpases, involved in maintaining cellular fluid balance. , this therapy is rational and inexpensive but unproven in efficacy. only if cellular necrosis and vasogenic edema are present are drugs such as mannitol and dimethyl sulfoxide indicated, and again these cases are usually the most severely affected. in the author's clinic, practitioners rarely have used dimethyl sulfoxide in neonates for the last several years and have recognized no change in outcome by discontinuing its use. when the practitioners use intravenously administered dimethyl sulfoxide, they do so within the first hour after an acute asphyxial insult and use it primarily for its hydroxyl radical scavenging effects and its theoretical modulation of postischemic reperfusion injury. naloxone has been advocated for treating hie in human beings and in foals, [ ] [ ] [ ] perhaps based on a study suggesting that postasphyxia blood-brain barrier disruption was related causally to poor neurologic outcome in a lamb model of hie and that naloxone prevented disruption and neurologic dysfunction among those survivors with an intact blood-brain barrier. however, other studies have demonstrated that naloxone exacerbates hypoxic-ischemic brain injury in -day-old rats subjected to unilateral common carotid artery ligation and hypoxia. moreover, systemic acidosis and cellular edema were no different in naloxone-treated animals compared with animals treated with saline solution. the authors concluded that high doses of naloxone in fact may reduce the resistance of the fetus to hypoxic stress. the use of naloxone in human neonatal resuscitation remains controversial, for whether the contradictory effects are related to a reduction in acute neuronal swelling by osmotic effects or by a more direct receptor-mediated mechanism is currently unknown. naloxone is most effective in resuscitation of compromised human infants born to mothers addicted to drugs. some practitioners are using γ-aminobutyric acid adrenergic agonists to manage hie in foals, based on evidence showing neuroprotection when used in ischemia alone and combined with nmda antagonists. [ ] [ ] [ ] the author currently has no experience with these compounds and cannot comment regarding their efficacy in foals. regional hypothermia also is being investigated as a potential therapy for global hypoxia/ischemia; published data are consistent with the theory that cooling must be continued throughout the entire secondary phase of injury (about days) to be effective. experimentally, this approach has resulted in dramatic decreases in cellular edema and neuronal loss; its practical application remains to be demonstrated. despite a lack of consensus regarding the use of magnesium to treat infants with hie, the author has used magnesium sulfate infusion as part of the therapy for selected foals with hie for the past several years. the rationale is based primarily on the evidence demonstrating protection in some studies and a failure of any one study to demonstrate significant detrimental effects. the clinical impressions of the author to date suggest that the therapy is safe and may decrease the incidence of seizure in patients. the author administers magnesium sulfate as a constant rate infusion over hour after giving a loading dose. the author has continued the infusion for up to days without demonstrable negative effect beyond some possible trembling. given the current evidence, a -hour course of treatment may be effective and all that is necessary. postasphyxial treatment certainly may be beneficial in foals with hie, and maternal magnesium therapy may be beneficial in certain high-risk pregnancy patients. foals with pas often have a variety of metabolic problems including hypo-or hyperglycemia, hypo-or hypercalcemia, hypo-or hyperkalemia, hypo-or hyperchloremia, and varying degrees of metabolic acidosis. although one needs to address these problems, one should not forget the normal period of hypoglycemia that occurs postpartum and should not treat aggressively so as to avoid worsening the neurologic injury. foals suffering from pas also have frequent recurrent bouts of hypoxemia and occasional bouts of hypercapnia. intranasally administered oxygen is generally needed in these cases as a preventative therapy and as direct treatment, for the appearance of the abnormalities can be sporadic and unpredictable. additional respiratory support, particularly in those foals with centrally mediated hypoventilation and periods of apnea or abnormal breathing patterns, include caffeine (per os or per rectum) and positive pressure ventilation. caffeine is a central respiratory stimulant and has minimal side effects at the dosages used ( mg/kg loading dose; . mg/kg as needed). the author purchases whatever oral form of caffeine is available at the local convenience store or drug store and administers it dissolved in warm water per rectum. foals treated with caffeine have an increased level of arousal and are more reactive to the environment. adverse effects generally are limited to restlessness, hyperactivity, and mild to moderate tachycardia. mechanical ventilation of these patients can be rewarding and generally is required for less than hours. one must monitor and maintain blood ph within the normal range. metabolic alkalosis can develop in some of these foals and requires clinician tolerance of some degree of hypercapnia. ph is important in evaluation and consideration of alternatives for treatment. if the respiratory acidosis is not so severe as to affect the patient adversely (generally > mm hg), and the ph is within normal limits, the foal may tolerate hypercapnia. the goal is to normalize ph. foals with respiratory acidosis as compensation for metabolic alkalosis do not respond to caffeine. metabolic alkalosis in critically ill foals frequently is associated with electrolyte abnormalities, creating differences in strong ion balance. one handles this ph perturbation best by correcting the underlying electrolyte problem. maintaining tissue perfusion and oxygen delivery to tissues is a cornerstone of therapy for pas to avoid additional injury. one should maintain the oxygen-carrying capacity of the blood; some foals require transfusions to maintain a packed cell volume greater than %. adequate vascular volume is important, but one should take care to avoid fluid overload in the foal. early evidence of fluid overload is subtle accumulation of ventral edema between the front legs and over the distal limbs. fluid overload can result in cerebral edema, pulmonary edema, and edema of other tissues, including the gastrointestinal tract. this edema interferes with normal organ function and worsens the condition of the patient. one maintains perfusion by supporting cardiac output and blood pressure by judicious use of intravenous fluid support and inotrope/pressor support. the author does not target therapy to a specific systolic, mean, or diastolic pressure but monitors urine output, mentation, limb perfusion, gastrointestinal function, and respiratory function as indicators that perfusion is acceptable. for these patients to require pressor therapy is not unusual, but in some cases the hypoxic damage is sufficiently severe to blunt the response of the patient to the drugs. the kidney is a target for injury in patients with pph, and for renal compromise to play a significant role in the demise of these foals is not unusual. clinical signs of renal disease are generally referable to disruption of normal control of renal blood flow and tubular edema leading to tubular necrosis and renal failure. these foals have signs of fluid overload and generalized edema. one must balance urine output and fluid therapy in these cases to prevent additional organ dysfunction associated with edema. although evidence has accumulated that neither dopamine nor furosemide play a role in protecting the kidney or reversing acute renal failure, these agents can be useful in managing volume overload in these cases. [ ] [ ] [ ] the aim is not to drive oliguric renal failure into a highoutput condition but rather to enhance urine output. overzealous use of diuretics and pressors in these cases can result in diuresis requiring increased intravenous fluid support and can be counterproductive. the author's approach is more conservative. low doses of dopamine administered as a constant rate infusion of to µg/kg/min are usually effective in establishing diuresis by natriuresis. one should avoid large doses of dopamine (> µg/kg/min) because high doses can produce systemic and pulmonary vasoconstriction, potentially exacerbating pph. one can administer a bolus ( . to . mg/kg) or constant rate infusion ( . to . mg/kg/hr) of furosemide, but once furosemide diuresis is established, one must evaluate electrolyte concentrations and blood gas tensions frequently because potassium, chloride, and calcium losses can be considerable and because significant metabolic alkalosis can develop from strong ion imbalances. the author does not aim for urine production rates of ml/hr, as has been presented by other authors as a urine output goal for critically ill equine neonates. rather the author looks for urine output that is appropriate for fluid intake and does not attempt to drive urine output to an arbitrary goal by excessive fluid administration or pressor use. although the average urine output for a normal equine neonate is about ml/kg/hr (~ ml/hr for a -kg foal), these values were obtained from normal foals drinking a milk diet with a large free water component. [ ] [ ] [ ] the urine of normal newborn foals is dilute, reflecting the large free water load they incur by their diet. expecting critically ill foals to produce such large volumes of urine, particularly those on restricted diets or receiving total parenteral nutrition, is an exercise in futility, and manipulating fluid, pressor, or diuretic therapy in attempt to meet an artificial goal is inappropriate. fluid therapy in the critically ill neonate is discussed later in this chapter. one final caveat regarding renal dysfunction in pas is that one should perform therapeutic drug monitoring when it is available. many antimicrobial agents used to manage these cases, most notably the aminoglycosides, depend on renal clearance. aminoglycoside toxicity occurs in the equine neonate and exacerbates or complicates the management of renal failure originally resulting from primary hemodynamic causes. the author monitors aminoglycoside concentrations for -minute peak and -to -hour trough values in these cases and adjusts dosage and frequency of drug administration based on these results. the author considers a trough value of less than µg/dl as desirable for gentamicin and amikacin. foals with pas suffer from a variety of problems associated with abnormalities within the gastrointestinal tract. commonly they have ileus, recurrent excessive gastric reflux, and gas distention. these problems are exacerbated by constant feeding in the face of continued dysfunction and continued hypoxia. frequently, enteral feeding cannot meet their nutritional requirements, and partial or total parenteral nutrition is required. one must give special attention to passive transfer of immunity (see failure of passive transfer) and glucose homeostasis in these cases. although some practitioners use prokinetic agents as therapy for ileus in these cases, the author's approach is again more conservative. appearance of damage to the gastrointestinal tract can be subtle and lag behind other clinical abnormalities for days to weeks. low-grade colic, decreased gastrointestinal motility, decreased fecal output, and low weight gain are among the most common clinical signs of gastrointestinal dysfunction in these case, but more severe problems, including necrotizing enterocolitis and intussusception, have been associated with these cases. the return to enteral feeding must be slow in many of these cases. a currently debated topic is constant versus pulsed enteral feeding. [ ] [ ] [ ] the author uses pulsed feeding through an indwelling small-gauge feeding tube. in many foals these tubes stay in place for weeks and cause no problems as the foals are returned to their dams for sucking or are trained to drink from a bottle or bucket. foals with pas are also susceptible to secondary infection. treatment of recognized infection is covered under sepsis in this chapter. if infection is recognized in these patients after hospitalization, one should give attention to the likelihood of nosocomial infection and should direct antimicrobial therapy based on known nosocomial pathogens in the nicu and their susceptibility patterns until culture and sensitivity results become available. one should make repeat determinations of immunoglobulin g (igg) concentration; additional intravenous plasma therapy may be required. nosocomial infections are often rapidly overwhelming, and acute deterioration in the condition of a foal with pas should prompt a search for nosocomial infection. the prognosis for foals with pas is good to excellent when the condition is recognized early and aggressively treated in term foals. up to % of these neonates survive and go on to lead productive and useful athletic lives. [ ] [ ] [ ] [ ] the prognosis decreases with delayed or insufficient treatment and concurrent problems such as prematurity and sepsis. in human nicus the survival rates of low-gestationlength infants has increased dramatically since the s concurrent with improvements in obstetric and neonatal care. the now routine, well-validated use of antenatal steroid and artificial surfactant therapies has contributed greatly to the enhanced survival of this patient population, although the use of these particular therapies is not common or frequently indicated in the equine nicu. , however, with improved care, outcomes in the equine nicu population have improved also, with survival of premature patients in many nicus exceeding %. in the equine population, gestation length is much more flexible than in the human population; however, the definition of the term prematurity needs reexamination. traditionally, prematurity is defined as a preterm birth of less than days of gestation in the horse. given the variability of gestation length in the horse, ranging from days to more than days in some mares, a mare with a usual gestation length of days possibly could have a term foal at days, whereas a mare with a usual gestation length of days may have a premature foal at days, considered the normal gestation length. foals that are born postterm but are small are termed dysmature; a postmature foal is a postterm foal that has a normal axial skeletal size but is thin to emaciated. dysmature foals may have been classified in the past as small for gestational age and are thought to have suffered placental insufficiency, whereas postmature foals are usually normal foals that have been retained too long in utero, perhaps because of an abnormal signaling of readiness for birth, and have outgrown their somewhat aged placenta. postmature foals become more abnormal the longer they are maintained, also may suffer from placental insufficiency, and are represented best by the classic foal born to a mare ingesting endophyteinfested fescue. box - compares the characteristics of premature/dysmature foals with those of postmature foals. the causes of prematurity/dysmaturity/postmaturity include the causes of high-risk pregnancy presented in box - . additional causes include iatrogenic causes such as early elective induction of labor based on inaccurate breeding dates or misinterpretation of late-term colic or uterine bleeding as ineffective labor. most causes remain in the category of idiopathic, with no discernible precipitating factor. despite lack of an obvious cause, premature labor and delivery does not just happen, and even if undetermined, the cause may continue to affect the foal in the postparturient period. all body systems may be affected by prematurity, dysmaturity, and postmaturity, and thorough evaluation of all body systems is necessary. respiratory failure is common in these foals, although the cause usually is not surfactant deficiency. immaturity of the respiratory tract, poor control of respiratory vessel tone, and weak respiratory muscles combined with poorly compliant lungs and a greatly compliant chest wall contribute to respiratory failure in these cases. most require oxygen supplementation and positional support for optimal oxygenation and ventilation. one must extend effort to maintain these "floppy foals" in sternal recumbency. some foals may require mechanical ventilation. these foals also require cardiovascular support but are frequently unresponsive to commonly used pressors and inotropes: dopamine, dobutamine, epinephrine, and vasopressin. careful use of these drugs and judicious intravenous fluid therapy are necessary. the goal should not be one of achieving specific pressure values (e.g., mean arterial pressure of mm hg) but of adequate perfusion. renal function, reflected in low urine output, is frequently poor initially in these cases because of delay in making the transition from fetal to neonatal glomerular filtration rates. the delay can result from true failure of transition or from hypoxic/ischemic insult. one should approach fluid therapy cautiously in these cases; initial fluid restriction may be in order to avoid fluid overload. many premature/dysmature/postmature foals have suffered a hypoxic insult and have all of the disorders associated with pas, including hie. treatment is similar to that of term foals with these problems. these foals also are predisposed to secondary bacterial infection and must be examined frequently for signs consistent with early sepsis or nosocomial infection. the gastrointestinal system of these foals is not usually functionally mature, which may result from a primary lack of maturity or from hypoxia. dysmotility and varying degrees of necrotizing enterocolitis are common. one commonly encounters hyperglycemia and hypoglycemia. hyperglycemia generally is related to stress, increased levels of circulating catecholamines, and rapid progression to gluconeogenesis, whereas hypoglycemia is associated with diminished glycogen stores, inability to engage gluconeongenesis, sepsis, and hypoxic damage. immature endocrine function is present in many of these foals, particularly regarding the hypothalamic-pituitary-adrenal axis, and contributes to metabolic derangements. , one should delay enteral feeding when possible until the foal is stable regarding metabolic and cardiorespiratory parameters. on intiating enteral feeding, one should provide small volumes initially and slowly increase the volume over several days. one frequently encounters musculoskeletal problems, particularly in premature foals, that include significant flexor laxity and decreased muscle tone. postmature foals frequently are affected by flexure contracture deformities, most likely because of decreased intrauterine movement as they increase in size. premature foals frequently exhibit decreased cuboidal bone ossification that predisposes them to crush injury of the carpal and tarsal bones if weight bearing is not strictly controlled. physical therapy in the form of standing and exercise is indicated in the management of all these problems, but one should take care to ensure that the patient does not fatigue or stand in abnormal positions. bandaging of the limbs is contraindicated because this only increases laxity, although light bandages over the fetlock may be necessary to prevent injury to that area if flexor laxity is severe. the foals are predisposed to angular limb deformity and must be observed closely and frequently for this problem as they mature. the overall prognosis for premature/dysmature/ postmature foals remains good with intensive care and good attention to detail. many of these foals (up to %) survive and become productive athletes. complications associated with sepsis and musculoskeletal abnormalities are the most significant indicators of poor athletic outcome. the last years have seen an explosion of new therapeutic agents purportedly useful for treating sepsis. unfortunately, clinical trials investigating these new therapies have failed to demonstrate a positive effect, have shown negative results, or have resulted in diametrically opposed study results, one showing a benefit and another showing no benefit or a detrimental effect. on a positive note, the survival rate of foals being treated for sepsis has improved. work was done regarding foal diseases and their treatment in the s, but the field did not attract much serious attention until the s. since that time almost every major veterinary college and many large private referral practices have constructed nicus or their equivalent. next to hypoxic ischemic asphyxial syndromes, sepsis is the number one reason for presentation and treatment at these facilities. neonatal septicemia of the horse has been the subject of three international workshops, - and a perinatology lecture covering some aspect of neonatal sepsis has been presented at almost every large continuing education meeting attended by equine veterinarians. concensus criteria conferences in the early s defined sepsis and septic shock for human beings. , sepsis was defined as the systemic response to infection manifested by two or more of the following conditions as a result of infection: a) temperature > °c or < °; b) heart rate > beats/min; c) respiratory rate > breaths per minute or paco < torr; and d) white blood cell count > , cell/µl, < , cell/µl, or > % immature (band) forms. septic shock was defined as sepsis induced hypotension or the requirement for vasopressors/ionotropes to maintain blood pressure despite adequate fluid resuscitation along with the presence of perfusion abnormalities that may include lactic acidosis, oliguria, or acute alteration in mental status. these definitions are broadly acceptable and applicable to neonatal sepsis in foals, and many of the treatment modalities in human medicine have been applied in some manner to the equine neonatal patient. additional definitions that have come into vogue that are actually useful at times, include the following: sirs, the systemic inflammatory response system; mods, multiple organ system dysfuction; and mofs, multiple organ failure syndrome. (sirs is sick, mods is sicker, and mofs is dying.) the compensatory response syndrome (cars) ideally balances sirs and keeps it from becoming detrimental. if balance is achieved, recovery is possible. imbalance progresses to septic shock, mods, and mofs. in horses, mods is manifested most commonly as renal failure, hepatic failure, central nervous system dysfunction, and disseminated intravascular coagulation. managing the septic patient involves early recognition of all the potential alphabet combinations and supporting the patient or intervening in the face of multiple clinical consequences, termed chaos (cardiovacular compromise; homeostasis; apoptosis; organ dysfunction; suppression of the immune system). inflammatory mediators are involved in all these processes and can be beneficial or detrimental, depending on timing and opposing responses. neutrophils, platelets, lymphocytes, macrophages, and endothelial cells are involved, and the implicated inflammatory molecules grow daily in numbers. sepsis in the foal initially can be subtle, and the onset of clinical signs varies depending on the pathogen involved and the immune status of the foal. for the purposes here, the discussion is limited to bacterial sepsis, but the foal also is susceptible to viral and fungal sepsis, which can appear similar to bacterial sepsis. failure of passive transfer (fpt) of immunity can contribute to the development of sepsis in a foal at risk. , testing for and treating fpt has received attention in the veterinary literature. it remains true, however, that foals presented to nicus that have an ultimate diagnosis of sepsis have fpt. , the current recommendation is that foals have igg levels greater than or equal to mg/dl for passive transfer to be considered adequate. other risk factors for the development of sepsis include any adverse advents at the time of birth, maternal illness, or any abnormalities in the foal. although the umbilicus frequently is implicated as a major portal of entry for infectious organisms in the foal, the gastrointestinal tract may be the primary site of entry. other possible portals of entry include the respiratory tract and wounds. early signs of sepsis include depression, decreased suck reflex, increased recumbency, fever, hypothermia, weakness, dysphagia, failure to gain weight, increased respiratory rate, tachycardia, bradycardia, injected mucous membranes, decreased capillary refill time, shivering, lameness, aural petechia, and coronitis. if sepsis is recognized early, patients with sepsis may have a good outcome, depending on the pathogen involved. gram-negative sepsis remains the most commonly diagnosed, but increasingly gram-positive septicemia is being recognized. foals in intensive care units and at referral hospitals have an additional risk of nosocomial infection. an attempt to isolate the organim involved early in the course of the disease becomes important. if possible, one should obtain blood cultures, and if localizing signs are present, one should obtain samples as deemed appropriate. cultures should be aerobic and anaerobic. recently, work has been done evaluating real-time polymerase chain reaction technology in sepsis in the foal as a means of identifying causative organisms. , until one obtains antimicrobial sensitivity patterns for the pathogen involved, one should initiate broad-spectrum antimicrobial therapy (table - ). intravenously administered amikacin and penicillin are good first-line choices, but one should monitor renal function closely. other first-line antimicrobial choices might include high-dose ceftiofur sodium or ticarcillin/clavulanic acid. one should treat failure of passive transfer if present. one should provide intranasal oxygen insufflation at to l/min even if hypoxemia is not present to decrease the work of breathing and provide support for the increased oxygen demands associated with sepsis. should arterial blood gas analysis reveal significant hypoventilation, one may administer caffeine orally or per rectum to increase central respiratory drive. mechanical ventilation may be necessary in cases of severe respiratory involvement such as with acute lung injury or acute respiratory distress syndrome. if the foal is hypotensive, one may administer pressor agents or inotropes by constant rate infusion (table - ) . inotrope and pressor therapy generally is restricted to referral centers where these drugs can be given as constant rate infusions and blood pressure can be monitored closely. some practitioners use nonsteroidal antiinflammatory agents and, in specific circumstances, corticosteroids. use of these drugs should be judicious because they may have several negative consequences for the foal including renal failure and gastric/dunodenal ulceration. [ ] [ ] [ ] nursing care is one of the most important aspects of treating septic foals. foals should be kept warm and dry. they should be turned at -hour intervals if they are recumbent. feeding septic foals can be a challenge if gastrointestinal function is abnormal, and total parenteral nutrition may be needed. if at all possible, foals should be weighed daily and blood glucose levels monitored frequently. some foals become persistently hyperglycemic on small glucose infusion rates. these foals may benefit from constant rate low-dose insulin infusions (table - ) . recumbent foals must be examined frequently for decubital sore development, the appearance of corneal ulcers, and for heat and swelling associated with joints and physis. the prognosis for foals in the early stages of sepsis is fair to good. once the disease has progressed to septic shock the prognosis decreases, although short-term botulism is a neuromuscular disease of foals characterized by flaccid paralysis. although the disease is discussed in detail elsewhere in this text, the form most commonly observed in foals, the toxicoinfectious form, deserves some specific comments. the causative organism is clostridium botulinum, an anaerobic organism. although affected adults usually acquire the disease by ingestion of preformed toxin elucidated from the organism, in the foal less than months of age the organism can survive and multiply in the gastointestinal tract and produce necrotic foci within the liver, giving the foal constant exposure to newly formed toxin. the horse is exquisitely sensitive to the toxin, and only small quantities of toxin are required to produce clinical signs and death in affected animals. the ε-toxin of c. botulinum binds to the presynaptic membrane of motor neurons and prevents transmission of impulses by blocking the release of acetylcholine from the presynaptic vessicles. this block produces the clinical signs of muscle weakness, manifested in foals as trembling (shaker foals) or acute recumbency. pupillary dilation, dysphagia, tremors, recumbency, and terminal respiratory distress caused by respiratory muscle paralysis occur. foals can be found acutely dead. in endemic areas (the northeast and mid-atlantic regions of united states), for these foals to be evaluated first as having colic is not unusual. treatment aims to neutralize the toxin by administration of botulinum antitoxin and to provide antimicrobial treatment of the infection with penicillin, metronidazole, and/or oxytetracycline. , at a minimum, feeding of milk replacer via indwelling nasogastric tube at % of the body weight of the foal per day divided into every -hour meals is required. many of these foals require respiratory support (in the form of intranasal oxygen insufflation), because of respiratory muscle paralysis. respiratory acidosis is present on arterial blood gas analysis in most of these foals because of hypoventilation and lateral recumbency, but they can tolerate some degree of hypercapnia (paco ~ mm hg) if the ph is normal and oxygenation (pao > mm hg; percent oxygen saturation of hemoglobin, > %) is adequate. metabolic alkalosis can accompany the respiratory acidosis, but this is a compensatory change and resolves once gas exchange is normalized. some of these patients require mechanical ventilation, which may be lifesaving. one may discontinue mechanical ventilation as clinical signs resolve and the respiratory muscles gain strength. nursing care is important, and these foals should be turned every hours. they should be maintained in sternal recumbency if possible and kept warm and dry. with good nursing care, good nutritional support, and adequate respiratory support, the prognosis for these foals is good. the limiting factor in the prognosis for life is often financial. foals that recover from the acute stage of this disease eventually fully recover. botulism is an expensive disease to treat and is also an entirely preventable disease. , all pregnant mares in endemic areas should be vaccinated against c. botulinum. vaccination does not prevent all cases of botulism, particularly if the foal has failure of passive transfer or acquires the disease after maternal immunity wanes and before its own vaccination. nutritional muscular dystrophy or white muscle disease is a vitamin e/selenium-responsive muscle disease of horses of all ages probably caused by a dietary deficiency of selenium and vitamin e. the condition occurs most commonly in geographic areas with low selenium levels in the soil, generally the northeastern, northwestern, great lakes and mid-atlantic regions of the united states. two forms of the disease are described in foals: the fulminant form, in which the foal is found acutely dead, and the subacute form. in the fulminant form, death usually is attributed to myocardial lesions resulting in cardiovascular collapse. the subacute form is characterized by dysphagia and gait abnormalities primarily caused by stiffness of the muscles of locomotion. paralysis, if present, is not flaccid as in botulism. abnormal function of respiratory muscles may complicate the clinical situation. aspiration pneumonia may be present following problems associated with swallowing; the tongue and pharyngeal muscles frequently are affected in the early stages of disease. foals with severe disease may have widespread muscle necrosis leading to hyperkalemia, which can be severe and result in death of the foal. serum activities of the muscle enzymes creatine kinase and aspartate aminotransferase may be greatly increased. diagnosis is confirmed at necropsy or ante mortem by determination of decreased vitamin e, selenium, and glutathione peroxidase concentrations in the blood of the foal before supplementation. myoglobinuria and acute renal failure are not uncommon in these foals. treatment of foals with nutritional muscular dystrophy is primarily supportive. one should address all metabolic abnormalities. some foals require intranasal oxygen insufflation. affected foals are unable to suck effectively, and one should provide enteral (via an indwelling nasogastric tube) or parenteral nutritional support. because of the high likelihood of aspiration pneumonia, one should administer broad-spectrum antimicrobial therapy parenterally. the patient should be kept quiet and should be stimulated minimally. affected foals should receive parenteral (intramuscular) vitamin e and selenium supplementation. selenium is toxic in large doses. the prognosis for severely affected foals is guarded. for less severely affected foals the prognosis is good with appropriate treatment. the disease is preventable by ensuring that mares receive sufficient vitamin e and selenium while pregnant and by supplementing foals with parenteral injections of vitamin e and selenium at birth in endemic areas. a more complete discussion of the pathophysiology of this disease and the nutritional management is presented elsewhere in this text. primary liver disease is uncommon in the foal and occurs primarily as a sequela to sepsis. clinical signs of severe liver disease may include depression, ataxia, and seizures. in affected foals, increases in serum liver enzyme activities and concentrations of ammonia and bile acids frequently can be identified. the mechanism(s) underlying hepatoencephalopathy are not delineated clearly, although increased excitatory neurotransmitters, or compounds that mimic their activity, are implicated. hepatoencephalopathy is discussed in more detail elsewhere in this text. tyzzer's disease (clostridium piliformis infection) rarely causes primary liver disease in foals from to about days of age. this disease is almost uniformly fatal. the incubation period is short, and the mare is thought to be the carrier. [ ] [ ] [ ] [ ] [ ] clinical signs range from acute death to depression, fever, and pronounced icterus. the feces of affected foals may appear white to grey because of the lack of bile. clinicopathologic abnormalities include leukopenia, hyperfibrinogenemia, metabolic acidosis, and hypoglycemia. , liver lesions at postmortem are characterized microscopically by multiple foci of necrosis. one usually can demonstrate variable numbers of elongated, slender intracytoplasmic bacilli within hepatocytes bordering the necrotic foci. infiltration of the portal triads with inflammatory cells and biliary duct hyperplasia and degeneration are observable. the bacillus also occurs in association with myocardial lesions. lesions in the intestine are characterised by mucosal necrosis with inflammatory cell infiltration, increased mucus production, submucosal lymphoid hyperplasia, and submucosal hemorrhage. necrosis of lymphoid follicles, congestion, and hemorrhage can be present in the spleen and mesenteric lymph nodes. affected foals may have a profound metabolic acidosis that is unresponsive to treatment. the clinical course is short, and most affected foals die within a few hours of developing neurologic signs. primary liver disease has been reported in association with ferrous sulfate administration in a probiotic compound. the lesion was massive hepatocellular necrosis and liver failure. the product is no longer commercially available. portosystemic shunt is rare in the foal but has been reported in foals as young as months of age. [ ] [ ] [ ] most infectious causes of neurologic abnormalities in foals are associated with sepsis. although rarely reported, halicephalobus gingivalis (deletrix) infection has been reported in three foals; in one case the foal was weeks of age. , possibly transmission in these cases was transmammary; the dam in one case died year later with confirmed h. deletrix infestation of her udder. listeria monocytogenes has been reported as a cause of neurologic disease in foals. recently, sarcocystis neurona was identified as the causative agent of central nervous system disease in a foal, and equine herpes myeloencephalitis has been diagnosed in individual foals and in herd outbreaks involving foals. , neospora also was reported in one foal recently. rhodococcus equi abscesses can form in the central nervous system or cause neurologic signs associated with compression, as with vertebral body abscesses. [ ] [ ] [ ] cerebellar hypolasia, occipitoatlantoaxial malformation, and agenesis of the corpus callosum with cerebellar vermian hypoplasia have been reported in foals. [ ] [ ] [ ] [ ] [ ] [ ] ivermectin toxicity and moxidectin toxicity have been reported. , electrolyte abnormalities such as extreme hypo-or hypernatremia may result in neurologic manifestations of disease. , cervical stenotic myelopathy and degenerative myelopathy also have been reported in foals, although the age at onset is usually more than months. idiopathic epilepsy of arabian foals usually is associated with another infectious disease and is thought to be temporary and self-limiting. causes, diagnosis, and treatment of fpt of immunity are covered in detail elsewhere in this text. failure of passive transfer occurs when a foal fails to ingest a significant quantity of good-quality colostrum. failure of passive transfer may occur by several mechanisms: failure of the foal to suck from the dam for any reason and failure of the dam to produce sufficient quantity of quality colostrum. box - presents causes of fpt. several methods are available for measuring igg concentration in blood; the most reliable are enzyme-linked immunosorbent assay and single radial immunodiffusion technology-based tests. [ ] [ ] [ ] [ ] [ ] [ ] [ ] foals usually are tested at hours of age, but one may test the foal earlier if colostrum ingestion has occurred and a concern exists regarding the passive transfer of immunity status of the foal, recognizing that additional increases in igg concentration may occur with additional time. , the concentration of igg in the blood of the foal has been used as an indicator of the adequacy of passive transfer, but the actual blood concentration at which fpt is diagnosed has been challenged in recent years. [ ] [ ] [ ] foals with sepsis commonly have a serum igg concentration of less than mg/dl. , foals with fpt are more likely to die from sepsis. , , [ ] [ ] [ ] one should consider the igg concentration only as a marker for adequacy of colostral absorption. all the measured igg is unlikely to be directed against the specific pathogen affecting any particular neonate, and igg is not the only immune protection afforded the foal by colostrum. many factors that confer local and more general immunity to the newborn are present in colostrum; these include growth factors, cytokines, lactoferrins, cd , leukocytes, and other yet to be described proteins. [ ] [ ] [ ] [ ] [ ] by considering igg a marker of adequacy for passive transfer, similar to γ-glutamyltransferase in calves, the clinician can make choices for replacement that are more beneficial to the patient. after one identifies fpt in a foal, treatment depends on the current condition of the foal and its local environment. foals not presently ill and on well-managed farms with low population density and low prevalence of disease may not require treatment if their igg concentration is between and mg/dl. critically ill neonates with fpt in an equine nicu are by definition ill and in an environment with high disease prevalence. these patients require immediate treatment of fpt and frequent reassessment of their passive immunity status. critically ill foals often fail to demonstrate the expected increase in blood igg concentration based on grams of igg administered per kilogram of body mass compared with healthy, colostrum-deprived foals. , , sick foals also demonstrate a more rapid decline in igg concentration than do healthy foals because they use and catabolize available protein. one may treat foals with fpt by oral or intravenous administration of various products containing igg. one can attempt oral administration of additional colostrum or igg-containing products such as plasma, serum, or lyophilized colostrum in foals less than to hours of age. [ ] [ ] [ ] depending on the age of the foal and the maturity and function of the gastrointestinal tract, this treatment may be effective. many nicus and large breeding farms maintain colostrum banks for this purpose. one should administer plasma intravenously if the foal is not expected to absorb additional colostrum or if the enteral route is unavailable. commercially available hyperimmune plasma products designed for use in foals are available and can be stored frozen. plasma and banked colostrum should be stored in a non-frost-free freezer to minimize protein loss associated with freeze-thaw cycling. one should administer plasma through special tubing with an in-line filter and should monitor patients closely for transfusion reactions. one may use serum and concentrated igg products, but the practitioner should be aware that many of these products focus on igg retention and not on other factors associated with passive transfer of immunity. one should measure igg concentration after transfusion and provide additional plasma as necessary. administration of plasma to critically ill foals without fpt may be beneficial through provision of other factors present in the plasma. in these situations, fresh frozen plasma or fresh plasma may be best, particularly if transfusion of clotting proteins is desired. neonatal isoerythrolysis is a hemolytic syndrome in newborn foals caused by a blood group incompatibility between the foal and dam and is mediated by maternal antibodies against foal erythrocytes (alloantibodies) absorbed from the colostrum. the disease most often affects foals born to multiparous mares and should be suspected in foals less than days of age with clinical signs of icterus, weakness, and tachycardia. a primiparous mare can produce a foal with neonatal isoerythrolysis if she has received a prior sensitizing blood transfusion or has developed placental abnormalities in early gestation that allowed leakage of fetal red blood cells into her circulation. many are the causes of jaundice in newborn foals, including sepsis, meconium impaction, and liver failure, but these usually can be differentiated readily from neonatal isoerythrolysis by measuring the packed cell volume, which is usually less than % in foals with neonatal isoerythrolysis. foals with neonatal isoerythrolysis are born clinically normal then become depressed and weak and have a reduced suckle response within to hours of birth. the rapidity of onset and severity of disease are determined by the quantity and activity of absorbed alloantibodies. affected foals have tachycardia, tachypnea, and dyspnea. the oral mucosa is initially pale and then becomes icteric in foals that survive to hours. hemoglobinuria may occur. seizures caused by cerebral hypoxia are a preterminal event. the salient laboratory findings are anemia and hyperbilirubinemia. most of the increased bilirubin is unconjugated, although the absolute concentration of conjugated bilirubin generally is increased well above normal. urine may be red to brown and is positive for occult blood. the natural development of neonatal isoerythrolysis has several prerequisites. first, the foal must inherit from the sire and express an erythrocyte antigen (alloantigen) that is not possessed by the mare. blood group incompatibility between the foal and dam is not particularly uncommon, but most blood group factors are not strongly antigenic under the conditions of exposure through previous parturition or placental leakage. factor aa of the a system and factor qa of the q system are highly immunogenic, however, and nearly all cases of neonatal isoerythrolysis are caused by antibodies to these alloantigens. the exception is in the case of mule foals in which a specific donkey factor has been implicated. [ ] [ ] [ ] mares that are negative for aa or qa or both are considered to be at risk for producing a foal with neonatal isoerythrolysis. the risk involves approximately % and % of thoroughbred and standardbred mares, respectively. second, and perhaps most important, the mare must become sensitized to the incompatible alloantigen and produce antibodies to it. the mechanism for this is not known in many instances but generally is believed to result from transplacental hemorrhage during a previous pregnancy involving a foal with the same incompatible blood factor. sensitization via transplacental contamination with fetal erythrocytes earlier in the current pregnancy is possible, but an anamnestic response is generally necessary to induce a pathogenic quantity of alloantibodies. ten percent of thoroughbred mares and % of standardbred mares have antibodies to the ca blood group antigen without known exposure to erythrocytes. some common environmental antigen is postulated possibly to lead to production of anti-ca antibodies. data suggest that these natural antibodies may suppress an immune response to other blood group antigens because mares negative for aa that have anti-ca antibodies often do not produce antibodies to aa of the erythrocytes in their foals that also contain ca antigen. this antibodymediated immunosuppression is thought to result from the destruction of fetal cells before the dam mounts an immune response to other cell surface antigens. natural alloantibodies have not been associated with neonatal isoerythrolysis in horses. after the mare becomes sensitized to the erythrocytes of her foal, alloantibodies are concentrated in the colostrum during the last month of gestation. unlike the human neonate, which acquires alloantibodies in utero and thus is born with hemolytic disease, the foal is protected from these antibodies before birth by the complex epitheliochorial placentation of the mare. thus the final criterion for foal development of neonatal isoerythrolysis is ingestion in the first hours of life of colostrumcontaining alloantibodies specific for foal alloantigens. immunoglobulin-coated foal erythrocytes are removed prematurely from circulation by the mononuclear phagocyte system or are lysed intravascularly via complement. the rapidity of development and severity of clinical signs are determined by the amount of alloantibodies that was absorbed and their innate activity. alloantibodies against aa are potent hemolysins and generally are associated with a more severe clinical syndrome than antibodies against qa or other alloantigens. the highest alloantibody titers are likely to be produced by mares that were sensitized in a previous pregnancy and then subsequently reexposed to the same erythrocyte antigen during the last trimester of the current pregnancy. prior sensitization of a mare by blood transfusion or other exposure to equine blood products may predispose to neonatal isoerythrolysis. one can make a tentative diagnosis of neonatal isoerythrolysis in any foal that has lethargy, anemia, and icterus during the first days of life. blood loss anemia caused by birth trauma is attended by pallor. icterus caused by sepsis or liver dysfunction would not be associated with anemia. one must base the definitive diagnosis of neonatal isoerythrolysis on demonstration of alloantibodies in the serum or colostrum of the dam that are directed against foal erythrocytes. the most reliable serodiagnostic test for neonatal isoerythrolysis is the hemolytic cross-match using washed foal erythrocytes, mare serum, and an exogenous source of absorbed complement (usually from rabbits). although this test is impractical in a practice setting, a number of qualified laboratories routinely perform this diagnostic service. the direct antiglobulin test (coombs' test) may demonstrate the presence of antibodies on foal erythrocytes; however, false negatives occur frequently. most human or veterinary hematology laboratories can perform routine saline agglutination cross-match between mare serum and foal cells. because some equine alloantibodies act only as hemolysins, agglutination tests may be falsely negative. most field screening tests of colostrum have not proved to be reliable enough for practical use. if one recognizes neonatal isoerythrolysis when the foal is less than hours old, one must withhold the dam's milk and feed the foal an alternative source of milk during the first day of life. one can accomplish this by muzzling the foal and feeding it via nasogastric tube. the minimum necessary amount of milk is % of body mass every hours (e.g., a -kg foal should receive ml or pint of mare's milk or milk replacer every hours). the udder of the mare should be stripped regularly (at least every hours) and the milk discarded. in most instances, clinical signs are not apparent until after the foal is hours old, when colostral antibodies have been depleted or the absorptive capacity of the foal's intestine for immunoglobulin has diminished. withholding milk at this point is of minimal benefit. supportive care to ensure adequate warmth and hydration is paramount. the foal should not be stressed and exercise must be restricted. confining the mare and foal to a box stall is a best. intravenous fluids are indicated to promote and minimize the nephrotoxic effects of hemoglobin and to correct any fluid deficits and electrolyte and acid-base imbalances. antimicrobials may be necessary to prevent secondary infections. one should monitor foals carefully for the necessity of blood transfusion, although transfusion should be used only as a lifesaving measure. when the packed cell volume drops below %, blood transfusion is warranted to prevent life-threatening cerebral hypoxia. erythrocytes from the dam are perfect in terms of nonreactivity with the blood of the foal; however, the fluid portion of the blood of the mare has to be removed completely from the cells to prevent administration of additional harmful alloantibodies to the foal. one can pellet the erythrocytes of the dam from blood collected in acid-citrate-dextrose solution by centrifugation or gravity and then aseptically draw off the plasma by suction apparatus or syringe and replace it with sterile isotonic ( . %) saline. one thoroughly mixes the cells with the saline and then repeats the centrifugation or sedimentation, followed by aspiration and discarding of the saline. one should perform this washing process at least three times. one then can suspend the packed erythrocytes in an equal volume of isotonic saline for administration. erythrocyte washing by centrifugation is more desirable than gravity sedimentation because antibody removal is more complete and packed cell preparations can be prepared more quickly (each gravity sedimentation requires to hours). packed red blood cells are advantageous in overcoming the problem of volume overload. when equipment or conditions do not allow the safe use of dam erythrocytes, an alternative donor is necessary. because the alloantibodies absorbed by the foal generally are directed against aa or qa and because the latter are highly prevalent among most breeds of horses, a compatible blood donor is difficult to identify. the odds of finding a donor without aa or qa are higher in quarter horses, morgans, and standardbreds than in thoroughbreds and arabians. previously blood-typed individuals negative for aa and qa and free of alloantibodies are optimal. one should give to l of blood or to l of packed erythrocytes over to hours. these allogeneic cells have a short life span and represent a large burden to the neonatal mononuclear phagocyte system, which may cause increased susceptibility to infection. in addition, these cells sensitize the foal to future transfusion reactions. one must measure all potential harm against the benefit in each situation. if a mule foal is the patient, one should not use blood from a female previously bred to a donkey. in cases in which transfusion will be delayed, one cannot identify a compatible donor, or the packed cell volume is so low as to be life-threatening (hemoglobin < mg/dl), one may administer polymerized bovine hemoglobin products at a dose of to ml/kg. one may use dexamethasone ( . mg/kg) to treat peracute neonatal isoerythrolysis if the packed cell volume is less than % and transfusion may be delayed or is not fully compatible, but dexamethasone has detrimental effects on blood glucose regulation in the neonate, and because the antibody in question is of maternal origin, corticosteroid therapy in immunosuppressive doses probably is not indicated. intranasal oxygen insufflation ( to l/min) may be beneficial. most foals with neonatal isoerythrolysis have adequate passive transfer of immunity, but antimicrobial therapy is indicated to protect against secondary sepsis resulting from the compromised condition of the foal. supportive care and good nursing care, including keeping the foal warm and quiet are essential. one should expect the packed cell volume to decline again to days after transfusion. the prognosis for neonatal isoerythrolysis in foals depends on the quantity and activity of absorbed antibodies and is indirectly proportional to the rate of onset of signs. in peracute cases the foal may die before the problem is recognized, whereas foals with slowly progressive signs often live with appropriate supportive care. like most diseases, neonatal isoerythrolysis is much more effectively prevented than treated. any mare that has produced a foal with neonatal isoerythrolysis should be suspect for the production of another affected foal; thus one should provide all subsequent foals with an alternative colostrum source and discard the colostrum of the dam unless she is bred to a stallion with known blood type compatibility. mares negative for aa and qa alloantigens are most at risk of producing affected foals, thus they should be identified by blood-typing. subsequently, breeding of these mares may be restricted to aa-and qa-negative stallions, thus eliminating the possibility of producing an affected foal. in breeds with a high prevalence of aa or qa alloantigens (e.g., thoroughbreds and arabians), a stallion negative for these and suitable based on other criteria may be difficult to identify. if these "at risk" mares are bred as desired, their serum should be screened in the last month of pregnancy for the presence of erythrocyte alloantibodies. one must test mares with low or equivocal titers closer to the time of parturition. if one detects alloantibodies, the colostrum of the dam should be withheld and the foal then should be provided with an alternative colostrum source. maternal alloantibodies to ca do not appear to mediate neonatal isoerythrolysis in foals and actually may be preventive by removing potentially sensitizing cells from the circulation ; therefore one should not deprive foals of colostrum from mares possessing anti-ca antibodies, even when ca is present on their erythrocytes. rarely, the antigens de, ua, pa, and ab have been associated with neonatal isoerythrolysis in foals; however, to consider mares without these alloantigens to be at risk for neonatal isoerythrolysis is not practical. these syndromes recently have been recognized and described within the veterinary literature, although they have been recognized widely in human neonatology for many years. [ ] [ ] [ ] [ ] affected foals demonstrate these hematologic abnormalities within the first week of life, and the mechanism is similar to neonatal isoerythrolysis following ingestion of maternal antibody directed against the platelet or the neutrophil. in general, affected foals are healthy but may demonstrate bleeding tendencies if thrombocytopenia is severe or they may be more susceptible to sepsis. one confirms the diagnosis by appropriate testing for platelet-and neutrophil-associated antibody. one must rule out other causes of neonatal thrombocytopenia and neutropenia, particularly sepsis. foals born to the mare in the future seem likely to be at risk for developing similar problems, and one should treat future foals as one treats neonatal isoerythrolysis foals: prevent sucking from the dam and provide an alternate source of passive immunity in the form of banked colostrum or intravenous plasma. one should provide an alternative nutritional source, such as foal milk replacer, to the foal for the first hours of life and should muzzle the foal while it is in the company of its dam for that period of time. treatment is primarily supportive, but in the case of severe thrombocytopenia, transfusion of platelet-enriched fresh plasma may be indicated. granulocyte colony-stimulating factor has been used in foals with neutropenia, but substantial efficacy has yet to be demonstrated. broad-spectrum antimicrobial therapy may be prudent in cases of alloantibody-associated neutropenia. treatment with immunosuppressive doses of corticosteroids is probably unwarranted, given the increased risk of infection, because the antibody in question is of maternal origin. other specific diseases of the immune system of foals, severe combined immunodeficiency, selective igm deficiency, transient hypogammaglobulinemia, agammaglobulinemia, and other unclassified immunodeficincies are covered in detail elsewhere in this text. the neonate can experience respiratory distress immediately after birth because of several congenital respiratory tract or cardiac anomalies. chief among these causes are bilateral choanal atresia, stenotic nares, dorsal displacement of the soft palate caused by anatomic deformity or neurologic impairment, accessory or ectopic lung lobes, lung lobe hypertrophy, lung lobe dysplasia, cardiac anomalies with right-to-left shunting, and miscellaneous causes such as subepiglotic cysts and severe edema of the larynx. [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] one must evaluate and treat these situations immediately and should consider them true emergencies. one readily can recognize foals with airway occlusion by the lack of airflow through the nostrils despite obvious attempts to breathe and by respiratory stridor. these foals may demonstrate open-mouth breathing and their cheeks may puff outward when they exhale. one foal with congenital bilateral choanal atresia was recognized during extrauterine intrapartum resusucitation because of an inability to pass a nasotrancheal tube. one can establish an effective airway by orotracheal intubation in these cases under most circumstances, but some foals require an emergency tracheostomy. one diagnoses the underlying problem by endoscopy or radiography in most cases. treatment of choanal atresia and cystic structures is surgical, whereas severe laryngeal edema and laryngeal paralysis frequently respond to medical management. until the underlying problem is resolved in these cases, one should administer broad-spectrum antimicrobial therapy and feed the foal by intubation or total parenteral nutrition. one can give colostrum, but these foals frequently develop aspiration pneumonia if allowed to suck from their dams, so intravenously administered plasma also may be necessary to provide sufficient passive immunity. arterial blood gas determinations are the most sensitive indicator of respiratory function readily available to the clinician. the most readily available arteries for sampling are the metatarsal arteries and the brachial arteries. portable arterial/venous blood gas analyzers now are making arterial blood gas analysis more practical in the field, and the technique is no longer reserved for large referral practices. managing a critically ill equine neonate without knowledge of arterial blood gas parameters is veritably impossible. pulse oximetry is useful, but these monitors only measure oxygen saturation of hemoglobin. desaturation can occur rapidly in critically ill neonates. the utility of these monitors in the foal has yet to be demonstrated clearly, particularly in cases of poor peripheral perfusion. the most common abnormalities recognized with arterial blood gas analysis are hypoxemia with normo-or hypocapnia and hypoxemia with hypercapnia. hypoxemia is defined as decreased oxygen tension of the arterial blood (decrease pao ), and hypoxia is defined as decreased oxygen concentration at the level of the tissue, with or without hypoxemia. hypoxia results from hypoxemia, decreased perfusion of the tissue bed in question, or decreased oxygen-carrying capacity of the blood resulting from anemia or hemoglobin alteration. five primary means by which hypoxemia may develop are ( ) low concentration of oxygen in the inspired air such as in high altitude or in an error mixing ventilator gas; ( ) hypoventilation; ( ) ventilation/perfusion mismatch; ( ) diffusion limitation; and ( ) intrapulmonary or intracardiac right-to-left shunting of blood. hypoxemia is not an uncommon finding in neonates but must be evaluated in terms of the current age of the foal and its position. , [ ] [ ] [ ] [ ] one also must consider the difficulty encountered in obtaining the sample because severe struggling can affect the arterial blood gas results. table - presents normal arterial blood gas parameters for varying ages of foals. the normal foal has a small shunt fraction (~ %) that persists for the first few days of life and contributes slightly to a blunted response to breathing % oxygen compared with the adult. hypoxemia frequently occurs in foals with prematurity, pas, and sepsis, although other conditions also result in hypoxemia in the neonate. in the early stage of sepsis associated hypoxemia, paco may be within normal limits or decreased if the foal is hyperventilating for any reason. if the lung is involved significantly in the underlying pathologic condition, such as with severe pneumonia, acute lung injury, or acute respiratory distress syndrome, increased paco may well be present, representing respiratory failure. hypoxemia usually is treated with intranasal humidified oxygen insufflation at to l/min. hypercapnia is not a simple matter to treat. one must try to distinguish between acute and chronic hypercapnia. acute hypercapnia usually is accompanied by a dramatic decrease in blood ph of . ph units for each mm hg increase in paco . this acidemia can promote circulatory collapse, particularly in the concurrently hypoxemic and/or hypovolemic patient. the effects of more chronic co retention are less obvious because the time course allows for adaptation. the ph change is less, about . ph units per mm hg increase in paco , because it is balanced by enhanced renal absorption of bicarbonate by the proximal renal tubule. most foals with acute respiratory distress are in the acute stages of respiratory failure, but chronic adaptation begins to occur within to hours and is maximal in to days. one will note an increase in bicarbonate, particularly if the acidemia is primarily respiratory in origin. intravenous administration of sodium bicarbonate to correct respiratory acidosis/ acidemia should be done cautiously in these foals because co retention may only be increased. also, one should remember that meq of sodium is administered with each meq of bicarbonate and hypernatremia has been seen in foals treated exuberantly with sodium bicarbonate. foals with hypercapnia of several days' duration also may develop a blunted respiratory drive to increased co . in these foals, oxygen administration, although essential to treat hypoxemia, may further depress ventilation and further decrease ph. this effect is caused by a loss of hypoxic drive following oxygen therapy. one should consider these foals candidates for mechanical ventilation if the paco is greater than mm hg or is contributing to the poor condition of the foal, such as causing significant ph changes. if hypercapnia is caused by central depression of ventilation, as frequently occurs in foals with pas, one can administer caffeine ( mg/kg loading dose; then . mg/kg as needed) per rectum or orally in foals with normal gastrointestinal function. other clinicians may recommend continuous rate infusions of doxapram hydrochoride (dopram; mg/total dose at . mg/ kg/min) for these foals. if this therapy fails, one should consider mechanical ventilation. mechanical ventilation of foals with central respiratory depression is rewarding and may be necessary only for a few hours to days. a special category is the foal with botulism exhibiting respiratory failure caused by respiratory muscle paralysis. these foals do well with mechanical ventilation, although the duration of mechanical ventilation is more prolonged, frequently more than week. foals with primary metabolic alkalosis usually have compensatory respiratory acidosis. treatment of hypercapnia is not necessary in these cases because it is in response to the metabolic condition. these foals do not respond to caffeine, and they should not be ventilated mechanically if this is the only disorder present. in the neonate, bacterial pneumonia usually results from sepsis or aspiration during sucking. foals with sepsis can develop acute lung injury or acute respiratory distress syndrome as part of the systemic response to sepsis, and this is frequently a contributor to the demise of foals in septic shock. the best way to diagnose bacterial pneumonia is by cytologic examination and culture of a transtracheal aspirate, but blood culture may aid in early identification of the causative organism and allow for early institution of directed antimicrobial therapy. a second frequent cause of bacterial pneumonia in the neonate is aspiration caused by a poor suck reflex or dysphagia associated with pas, sepsis, or weakness. one must take care to ensure that aspiration is not iatrogenic in foals being bottle fed. auscultation over the trachea while the foal is sucking helps identify occult aspiration. one should suspect occult aspiration pneumonia in any critically ill neonate that is being bottle fed or is sucking on its own that has unexplained fever, fails to gain weight, or has a persistently increased fibrinogen level. older foals develop bacterial pneumonia, frequently following an earlier viral infection. bacterial pneumonia is discussed in depth elsewhere in this text, but a few comments specific to the foal are necessary. one should auscultate and percuss the thorax of the foal, but results may not correlate closely with the severity of disease. the most commonly isolated bacterial organism in foal pneumonia is streptococcus zooepidemicus, and one may isolate it alone or as a component of a mixed infection. [ ] [ ] [ ] transtracheal aspirate for culture and cytologic examination is recommended because mixed gram-positive and gram-negative infections are common, and antimicrobial susceptibility patterns can be unpredictable. one should split the obtained aspirate and submit samples for bacterial culture, virus isolation, and cytologic examination. additional diagnostics include radiography, ultrasonography, and serial determination of white blood cell counts (with differential) and blood fibrinogen concentrations. treatment includes administration of appropriate antimicrobial therapy. some foals may benefit from nebulization with saline or other local products. ascarid larval migration through the lung can mimic bacterial pneumonia. in these cases the foal may not respond to antimicrobial therapy and should be dewormed with ivermectin. deworming the mare within month of parturition and frequent deworming of the foal prevent ascarid migration pneumonia in most foals. a special category of bacterial pneumonia in foals is rhodococcus equi bronchopneumonia. this pneumonia of young foals was described first in . the organism originally was known as corynebacterium equi and is a gram-positive pleomorphic coccobacillus usually less than µm in diameter and µm in length. the organisms frequently are associated in l-and v-shaped clusters that have been termed chinese character formations. r. equi has an acid-fast staining characteristic under some growing circumstances because of the presence of mycolic acid in its cell wall, similar to mycobacterium and nocardia species. mycolic acid promotes granuloma formation. the organism is able to multiply in and destroy macrophages as it prevents phagosome lysosome fusion. , much attention has been paid to this organism in recent years, given its propensity to produce enzootic and epizootic outbreaks of disease. the organism is thought to be primarily an opportunistic pathogen, and it lives in the soil of most geographic areas. foals are affected most frequently between the ages of and months, when maternally derived immunity has begun to wane. the disease is insidious, and foals may have significant pulmonary involvement before developing noticeable clinical signs. phagocytosis of r. equi by equine macrophages is not associated with a functional respiratory burst and, at least in human beings, the l-arginine-no pathway is not required for intracellular killing of this organism. , optimal binding of r. equi to mouse macrophages in vitro requires complement and is mediated by mac- , a leukocyte complement receptor type (cr , cd b/ cd ). opsonisation of r. equi with specific antibody is associated with increased phagosome-lysosome fusion and enhanced killing of r. equi, suggesting that the mechanism of cellular entry is important. neutrophils from foals and adult horses are fully bactericidal, and killing of r. equi is enhanced considerably by specific opsonizing antibody. the ability of r. equi to induce disease in foals likely depends on host and microbial factors. knowledge of the virulence mechanisms of r. equi was speculative until the discovery of the virulence plasmid. as opposed to most environmental r. equi organisms, isolates from clinically affected foals typically contain -to -kb plasmids encoding an immunogenic virulence-associated protein (vapa) that is expressed on the bacterial surface in a temperature-regulated manner. plasmid-cured bacteria lose their ability to replicate and survive in macrophages and are cleared from the lungs within weeks of intrabronchial challenge without producing pneumonia. however, expression of vapa alone is not sufficient to restore the virulence phenotype. six other genes have approximately % overall amino acid identity with vapa, and the identification of multiple genes with considerable homology suggests these genes constitute a virulence-associated gene family in r. equi. other candidates for virulence factors include capsular polysaccharides and cholesterol oxidase, choline phosphohydrolase, and phospholipase c exoenzymes ("equi factors"), but their roles have not been defined clearly. the primary manifestation of disease caused by r. equi infection is severe bronchopneumonia with granuloma, abscess formation, or both. up to % of foals diagnosed with bronchopneumonia also have extrapulmonary sites of infection. as the pneumonia progresses, clinical signs may include decreased appetite, lethargy, fever, tachypnea, and increased effort of breathing characterized by nostril flaring and increased abdominal effort. cough and bilateral nasal discharge are inconsistent findings. a smaller percentage of affected foals may have a more devastating, subacute form. these foals may be found dead or have acute respiratory distress with a high fever and no previous history of clinical respiratory disease. hyperfibrinogenemia is the most consistent laboratory abnormality in foals with r. equi pneumonia. neutrophilic leukocytosis (> , cells/µl), with or without monocytosis, is common. thoracic radiography is a useful diagnostic aid, frequently revealing a prominent alveolar pattern with poorly defined regional consolidation and/or abscessation. ultrasonography is a helpful diagnostic tool when the disease involves peripheral lung tissue. although a number of serologic tests have been described, serologic diagnosis of r. equi infections is controversial and difficult because exposure of foals to this organism at a young age leads to production of antibody without necessarily producing clinical disease. , serologic tests may be more useful at the farm level to detect overall exposure than at the individual level. bacteriologic culture combined with cytologic examination of a tracheobronchial aspirate remains the most definitive method for accurate diagnosis of r. equi pneumonia. however, foals without clinical disease exposed to contaminated environments may have r. equi in their tracheae from inhalation of contaminated dust; therefore one should interpret culture results in the context of the overall case presentation. culture results in one study were as sensitive as polymerase chain reaction-based assays and offered the advantage of allowing in vitro antimicrobial susceptibility testing. however, polymerase chain reaction is likely to be a useful tool, and results from a second trial suggest the assay is more sensitive and specific than culture of tracheobronchial aspirates for diagnosis. the combination of erythromycin and rifampin has become the treatment of choice for r. equi infections in foals, and the combination reduces the likelihood of resistance to either drug. the recommended dosage regimen for rifampin is mg/kg every hours or mg/kg every hours orally. the recommended dose of estolate or ethylsuccinate esters of erythromycin is mg/kg every or hours orally. recently, azithromycin has been recommended for treatment of r. equi infection at a dosage of mg/kg orally every hours for to days and then every other day. alternatively, clarithromycin at . mg/kg every hours orally, in combination with rifampin, may be therapeutically effective. severely affected foals may require intranasal oxygen insufflation, intravenous fluid support, and nutritional support. treatment generally continues for to weeks until all clinical and laboratory evidence of infection is resolved. although well tolerated by most foals, erythromycin can result in soft feces. this diarrhea is generally self-limiting and does not require cessation of therapy, but one should monitor affected foals carefully. an idiosyncratic reaction characterized by severe hyperthermia and tachypnea has been described in foals treated with erythromycin during periods of hot weather. affected foals should be moved to a colder environment and treated with antipyretic drugs and alcohol baths if necessary. clostridium difficile enterocolitis has been reported in the dams of nursing foals treated with erythromycin given orally. the dam is exposed to active erythromycin by coprophagy or by drinking from a communal water source where the foal has "rinsed" its mouth. prevention of r. equi pneumonia on farms with recurrent problems is problematic. the most clearly demonstrated prophylactic measure to date has been the administration of plasma that is hyperimmune to r. equi to foals within the first week of life and then again when maternal immunity begins to wane at around days of age. [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] no effective vaccination protocols for the dam or foal have been described to date. farm management is important in preventing disease, and control measures include frequent manure removal, avoidance of overcrowded conditions, and planting of dusty or sandy soils. the prognosis for r. equi bronchopneumonia is fair to good in foals with the more chronic form of the disease. foals with acute respiratory distress have a more guarded prognosis, as do foals with sites of significant extrapulmonary infection. the long-term prognosis for survival for foals with r. equi bronchopneumonia is good, and many foals perform as expected as athletes. the most commonly identified causes of viral pneumonia in foals are equine herpesviruses and (ehv- and ehv- ), equine influenza, and equine arteritis virus (eva). equine herpesvirus is probably the most clinically important, but outbreaks of eva in neonates have occurred and are devastating. , [ ] [ ] [ ] [ ] [ ] [ ] adenovirus is reported sporadically and as a problem in arabian foals with severe combined immunodeficiency. [ ] [ ] [ ] in the neonate, infection with ehv- or eva is almost uniformly fatal and antemortem diagnosis is difficult, even once an outbreak on a particular farm is identified. several factors appear common to foals with ehv- , including icterus, leukopenia, neutropenia, and petechial hemorrhage, but these problems also are identified in foals with severe sepsis. , , the antiviral drug acyclovir ( to mg/kg orally or per rectum to times per day) has been used in cases of ehv- in neonates, with some evidence of efficacy in mildly affected foals or foals affected after birth. if viral pneumonia is a possibility, one should collect blood and tracheal aspirates at presentation for bacterial and virus isolation. the lungs of foals with ehv- or eva are noncompliant, and pulmonary edema may be present. mechanical ventilation of these cases may prolong life, but death is generally inevitable because of the magnitude of damage to the lungs. foals suspected of having ehv- or eva should be isolated because they may be shedding large quantities of virus and pose a threat to other neonates and pregnant mares. foals with eva generally are born to seronegative mares, and intravenous treatment with plasma with a high titer against eva may prove beneficial because passive immunity appears to have a large role in protection against this disease in neonates. , older foals and weanlings may be affected by herpesviruses. disease is usually mild, although a fatal pulmonary vasculotropic form of the disease has been described recently in young horses. , the clinical signs of disease are indistinguishable from influenza and include a dry cough, fever, and serous to mucopurulent nasal discharge, particularly if secondary bacterial infection occurs. rhinitis, pharyngitis, and tracheitis may be present. treatment of affected foals is primarily supportive. foals also may become infected with ehv- . the predominant clinical signs are fever and lymphoid hyperplasia with pharyngitis. , diagnosis is by virus isolation. rib fractures have been recognized in % to % of all neonatal foals and can be associated with respiratory distress. potential complications of rib fractures include fatal myocardial puncture, hemothorax, and pneumothorax. rib fractures frequently are found during physical examination by palpation of the ribs or by auscultation over the fracture sites. one can confirm the diagnosis by radiographic and ultrasonographic evaluation. often multiple ribs are affected on one side of the chest. specific treatment is generally unnecessary, but direct pressure on the thorax should be avoided in all cases. some specific patients may benefit from surgical stabilization of some fractures, particularly those fractures overlying the heart. pneumothorax can occur spontaneously or following excessive positive pressure ventilation or following tracheostomy surgery or trauma. any foal being ventilated mechanically that suddenly has respiratory distress and hypoxemia should be evaluated for pneumothorax. diagnosis is by auscultation and percussion of the thorax, but one can confirm the diagnosis with radiographic and ultrasonographic evaluation of the thorax. needle aspiration of air from the pleural space also confirms the diagnosis. treatment is required in cases in which clinical signs are moderate to severe or progressive and involves closed suction of the pleural space. subcutaneous emphysema can complicate treatment of this problem. idiopathic or transient tachypnea has been observed in clydesdale, thoroughbred, and arabian breed foals. in human infants, transient tachypnea can be related to delayed absorption of fluid from the lung, perhaps because of immature sodium channels. in foals, tachypnea generally occurs when conditions are warm and humid and is thought to result from immature or dysfunctional thermoregulatory mechanisms. clinical signs of increased respiratory rate and rectal temperature develop within a few days of birth and may persist for several weeks. treatment involves moving the foal to a cooler environment, body clipping, and provision of cool water or alcohol baths. these foals frequently are treated with broad-spectrum antimicrobial drugs until infectious pneumonia can be ruled out. a syndrome of bronchointerstitial pneumonia and acute respiratory distress has been described in older foals and appears to be a distinct entity from acute respiratory distress syndrome in neonatal foals in association with sepsis. the underlying cause has not been identified, but the genesis is probably multifactorial with several potential pathogens being implicated. affected foals have acute respiratory distress with significant tachypnea, dyspnea, nostril flare, and increased inspiratory and expiratory effort. auscultation reveals a cacophony of abnormal sounds including crackles and polyphonic wheezes in all lung fields. loud bronchial sounds are audible over central airways, and bronchovesicular sounds are lost peripherally. affected foals are cyanotic, febrile, and unwilling to move or eat. foals may be found acutely dead. laboratory abnormalities include leukocytosis, hyperfibrinogenemia, and hypoxemia with hypercapneic acidosis. foals can be dehydrated severely and have coagulation changes consistent with disseminated intravascular coagulation. hypoxic injury to other organs, primarily the kidneys and liver, can occur. chest radiographs reveal a prominent interstitial pattern overlying a bronchoalveolar pattern that is distributed diffusely throughout the lung. this syndrome is a respiratory emergency. treatment is broad-based and includes administration of oxygen, nonsteroidal antiinflammatory agents, broad-spectrum antimicrobial therapy, nebulization, judicious intravenous fluid therapy, nutritional support, and corticosteroid therapy. one must manage hyperthermia in the foal. corticosteroid therapy appears to have been lifesaving in most of the reported surviving foals. because this syndrome is associated with high environmental temperatures in some areas, prevention involves control of ambient temperatures, not transporting foals during hot weather, and keeping foals out of direct sun on hot days, particularly foals being treated with erythromycin for suspected or confirmed r. equi infection. uroperitoneum has been recognized as a syndrome in foals for more than years. , classically, affected foals are to hours old at the time clinical signs first are recognized. [ ] [ ] [ ] previous reports had a proportionately larger affected male than female population. , , the hypothesis was that colts were more at risk because their long, narrow, high-resistance urethra was less likely to allow bladder emptying, resulting in rupture of a full bladder during parturition when high pressures were applied focally or circumferentially around the bladder. more recent reports suggest that such extreme sex bias may have been an artifact of small case numbers in the early reports. rupture or disruption of any structure of the urinary tract can occur. the dorsal wall of the bladder has been reported to be a frequent disruption site, with the ventral wall less likely to be involved. the urachus appears to be the next most commonly affected structure. a few cases of ureteral and urethral defects have been reported. , sepsis does not appear to favor one site over the others. the pathophysiology of uroperitoneum is not yet understood fully. the high pressure exerted on a full bladder during parturition once was thought to be the main cause. full bladder and obstruction caused by a partial umbilical cord at parturition, strenuous exercise, and external trauma have been reported as causes. a few reports describe smooth and noninflamed edges of torn tissue, suggesting the possibility of congenital bladder wall defects. , , sepsis leading to urinary tract rupture and uroperitoneum may occur in foals hospitalized for a variety of unrelated problems. the onset of clinical signs of uroperitoneum may be insidious in these foals, and diagnosis may be less obvious. clinical signs associated with uroperitoneum in the neonatal foal typically include straining to urinate, dribbling urine, and a stretched-out stance. weakness, tachycardia, tachypnea, and not sucking well are also common. a distended abdomen may be evident, and one may feel a fluid wave on ballottement of the abdomen. occasionally, urine accumulates in the scrotum and should not be confused with hernia. foals also may show signs of sepsis, including fever, injected mucous membranes, diarrhea, and disease of other body systems. laboratory findings vary depending on the duration of the uroperitoneum and on the presence and severity of sepsis. classic findings include hyperkalemia, hyponatremia, and hypochloremia arising from equilibration of urine electrolytes and water with blood across the peritoneal membrane. [ ] [ ] [ ] the usual foal diet of milk, which is high in potassium and low in sodium, promotes the electrolyte abnormalities. foals that develop uroperitoneum while receiving intravenous fluids may not have classic electrolyte imbalances at the time clinical signs are recognized. increased serum creatinine concentration is often present, whereas blood urea nitrogen concentrations occasionally, but not consistently, are increased. [ ] [ ] [ ] metabolic acidosis and hypoxemia may be present. some patients also have serum hypoosmolality. one should test foals for failure of passive transfer. one of the most sensitive laboratory tests for uroperitoneum is the ratio of peritoneal to serum creatinine. a ratio greater than or equal to : is considered diagnostic of uroperitoneum. one should collect peritoneal fluid and test it for creatinine concentration, as well as for cytologic findings, culture, and sensitivity. cytologic evaluation of peritoneal fluid is necessary to identify concurrent peritonitis or other gastrointestinal compromise. one should perform an electrocardiogram on initial evaluation of a foal with suspected uroperitoneum because hyperkalemia may result in bradycardia, increased duration of the qrs complex, a shortened q-t interval, increased p-wave duration, prolonged p-r interval, or atrioventricular conduction disturbances. other possible cardiac sequelae to hyperkalemia include cardiac arrest, third-degree atrioventricular block, ventricular premature contractions, and ventricular fibrillation. , for any foal exhibiting signs of dypsnea, tachypnea, or hypoxemia, one should have thoracic radiographs taken before induction of anesthesia to rule out pleural effusion, pneumonia, or acute respiratory distress syndrome, which could complicate ventilation and oxygenation during anesthesia and the postoperative period. ultrasonography has become the tool of choice in the diagnosis of uroperitoneum and is a useful tool available to the practitioner. one can image free peritoneal fluid readily, and tears within the bladder are readily visible. the empty bladder with a significant defect, in a fluid-filled abdomen, will collapse on itself and often have a u shape. one also can visualize urachal and urethral lesions. six of eight foals in one study had urinary tract lesions identified sonographically, and all foals of another study underwent sonographic evaluation, and a significant correlation between ultrasonographic findings and location of the lesion at surgery existed. , initial treatment aims to stabilize the patient and correct any electrolyte and acid-base abnormalities and provide fluid volume replacement. one should use . % or . % saline with % dextrose until laboratory data are available. a potassium concentration of greater than . meq/l can be life threatening. one can manage hyperkalemia by peritoneal drainage to decrease whole-body potassium stores using teat cannulae, foley catheters, large-gauge ( or ) intravenous catheters, or human peritoneal dialysis catheters. fluid replacement at least should equal the amount of fluid removed from the abdomen to prevent acute hypotension caused by expansion of previously collapsed capillary beds. abdominal drainage also helps ventilation and decreases the work of breathing by decreasing pressure on the diaphragm. one may administer calcium gluconate, glucose, sodium bicarbonate, or insulin intravenously to decrease serum potassium concentrations. these maneuvers do not correct the whole-body potassium overload, however, and once therapy is discontinued, hyperkalemia can reappear until the urine is removed from the abdomen. one should correct hyponatremia slowly. because of the real possibility of concurrent sepsis, one should obtain blood cultures before preoperative administration of antimicrobials. broad-spectrum coverage (penicillin and amikacin or ceftiofur sodium) is recommended until culture results become available. one should perform therapeutic drug monitoring when using aminoglycoside therapy. however, the peak value may be depressed because of the increased volume of distribution represented by the volume of urine in the abdomen, so one should not make dose adjustment based on a low peak until obtaining a new peak after surgical correction of the uroperitoneum. one should treat foals with failure of passive transfer with adequate volumes of intravenously administered plasma. after one has addressed the metabolic abnormalities, one may consider surgical management. medical management using an indwelling foley catheter has been described. preoperative medical stabilization reduces anesthetic risk. safer inhalant agents such as isoflurane also have decreased risk. removal of the internal umbilical remnant at the time of surgery is usual. one should consider culturing any removed umbilical remnant and submitting the remnant for histopathologic evaluation. recurrence of urinary tract rupture can occur. sepsis, hypoxemia, pneumonia, peritonitis, and acute respiratory distress syndrome complicate the management of uroperitoneum. many affected foals are persistently oxygen dependent for several days following surgical correction, and one should perform serial arterial blood gas analyses before discontinuing intranasal oxygen supplementation. prognosis is associated closely with concurrent illness, especially septicemia. uncomplicated uroperitoneum from a defect in the bladder has a good prognosis. if the location of the lesion is other than the bladder, the prognosis is not as favorable. foals with septicemia have a much poorer prognosis. , acute renal failure most often occurs as a complication of prenatal asphyxial syndrome, sepsis, or aminoglycoside therapy. acute renal failure also has been reported following oxytetracycline administration in foals. the dose of oxytetracycline commonly used to treat flexural deformities in foals is approximately times the antimicrobial dose. many foals treated in this manner also have suffered some degree of perinatal asphxia, which also damages the kidney, because of prolonged parturition precipitated in part by the flexural deformity. evaluation of renal function in these foals before the administration of the first dose of oxytetracycline and continued monitoring of serum creatinine concentrations before administering subsequent doses of this nephrotoxic compound would seem reasonable. hemodialysis has been used as therapy in one of these cases, but prevention is important because these foals may fail to respond to usual therapy for oliguric renal failure and are euthanized. the most commonly reported congenital deformity of the kidney of the foal is renal hypoplasia and dysplasia, which may have a heritable component. , renal arteriovenous malformations have been reported also. ectopic ureters and fenestrated ureters have been described in the foal. [ ] [ ] [ ] congenital renal defects, among others, were reported in three weak, recumbent neonatal foals born to mares being treated for equine protozoal myeloencephalitis. mares received sulfadiazine or sulfamethoxazoletrimethoprim, pyrimethamine, folic acid, and vitamin e orally. the foals were anemic, leukopenic, azotemic, hyponatremic, and hyperkalemic. serum folate concentrations were lower than those reported in the literature for clinically normal brood mares. treatment was unsuccessful. necropsy revealed lobulated kidneys with thin cortices and a pale medulla. the authors postulated that oral administration of sulfonamides, , -diaminopyrimidines (pyrimethamine with or without trimethoprim), and folic acid to mares during pregnancy is related to congenital defects in newborn foals. the umbilicus serves as the conduit for nutrition and gas exchange between the dam and the fetal foal. the urine from the foal is expelled via this structure into the allantoic cavity. the author has recognized cases of in utero bladder distention in the fetus that were associated with multiple twists decreasing urine flow or focal stenosis creating the same effect. foals born with this condition did not have bladder rupture associated with parturition but did have other severe abnormalities that eventually resulted in their demise, primarily premature delivery with failure to adapt to extrauterine life (p.a. wilkins, j.e. palmer, and f.t. bain, unpublished data). at birth the umbilicus breaks, leaving a small external remnant and a large internal remnant. the umbilicus long has been regarded as the primary site of entry of pathogens into the neonate, although this has been challenged recently. treatment of the umbilicus after birth involves dipping it (preferably just the most distal component) with various caustic compounds. the most current recommendation is to treat the umbilicus with dilute chlorhexidine, povidone-iodine, or dilute iodine solutions for just a few times following birth. exhuberant treatment of the umbilical stump with caustic solutions can lead to scalding of the ventral abdomen and may promote patency of the urachus. the ultrasonographic appearance and measurements of the umbilical arteries, urachus, and umbilical vein of foals from hours to weeks of age have been described in detail. a . -mhz sector scanner transducer placed across the midline of the ventral portion of the abdominal wall of the foal works best because of the superficial location of these structures. the mean (± sd) diameter of the umbilical vein was . ± . cm immediately cranial to the umbilical stalk, . ± . cm midway between the umbilicus and liver, and . ± . cm at the liver. the urachus and umbilical arteries of normal foals have a mean total diameter of . ± . cm at the bladder apex. the umbilical arteries scanned along either side of the bladder have a mean diameter of . ± . cm. one can use these measurements and the ultrasonographic appearance of the internal umbilical structures from clinically normal foals as references to diagnose abnormalities of the umbilical structures in neonatal foals. , the most common abnormalities of these structures are focal abscess formation, hematoma, and urachal tear. herniae traditionally have been thought to develop from failure of closure at the umbilical stump after birth. however, the closure of the body wall defect at the umbilicus was studied in relation to the development of umbilical herniae in a large group of normal foals followed from birth until months of age or from birth until months of age. at birth, approximately half of these foals had a defect in the body wall at the umbilicus that was termed a palpable umbilical ring. in foals this defect disappeared within days, but in one foal the ring did not close and a hernial sac with abdominal contents was palpable. this foal was considered to be the only foal to have a truly congenital umbilical hernia. twelve foals developed an umbilical hernia between and weeks of age. the prevalence of umbilical herniae was much higher than in other studies, possibly because of the prospective nature of the study. based on this study, the large majority of umbilical herniae would appear not to result from failure of closure but rather to be acquired after birth. one should consider the palpable ring structure within the body wall at the umbilicus a variant of normal in the foal and should not call it a hernia until the foal is at least month of age. in one study of horses treated for umbilical herniae over a / -year period, only . % developed complications in association with umbilical defects. six horses had intestinal incarceration; the incarceration was reduced manually in horses before admission and resolved without treatment in others. the hernia was surgically reduced in horse. herniorrhaphy was performed on of the horses in which the incarceration did not require surgical reduction, and the fifth was managed conservatively. the study confirmed that complications of umbilical herniae are rare in horses; however, when they do develop, they may be one of various forms, some of which are insidious in onset. the primary differential diagnosis for an external swelling in the umbilical stump region is an external abdominal abscess, which will be firm, variably painful, warm, and nonreducible. ultrasonographic evaluation readily can confirm either possibility. one report describes a -day-old foal that died from intestinal strangulation caused by a remnant of vitelline vein that extended between the umbilicus and the portal vein. patent urachus frequently is recognized in the abnormal neonate, probably because of the increased recumbency and decreased movement of these patients. cauterization of a patent urachus is no longer recommended except in cases that persist for long periods of time (> month) after the foal becomes more active. surgical resection may provide relief in some foals, but most cases resolve without treatment if given enough time. foals with a patent urachus may posture and strain frequently to urinate, some of this may be associated with irritation or local infection of the urachus. one can alleviate this by administration of broad-spectrum antimicrobial therapy such that the drug has a high concentration in the urine (e.g., trimethoprim-sulfa drug combinations) and by oral administration of phenazopyridine hydrochloride (pyridium), a dye that anesthetizes the urinary tract epithelial surfaces (see table - ). this dye turns the urine orange and stains everything yellow-orange that it or the urine touches but can provide a great deal of relief to foals with this problem. the umbilicus has been considered the traditional point of entry of bacteria into the septic neonate, and septic foals have been referred to as having "navel ill" and "joint ill" in the past. although current thought suggests that the gastrointestinal tract may be the route of entry in most septic neonates, infection of the umbilicus-termed omphalitis, or omphalophlebitis if the vessels are involved-still occurs as a single focus of infection or along with more generalized infection. external signs, such as swelling, heat, pain, ventral edema, or purulent discharge may be present in some foals, but more usually external signs are minimal and one suspects infection because of infection in another site (e.g., an infected joint), fever, or otherwise unexplained increased blood fibrinogen concentration. one confirms the diagnosis by ultrasonographic evaluation of the internal umbilical remnant. any of the umbilical structures may be involved. a complete description of the evaluation is available within the relevant veterinary literature, but the examination is performed best with the foal standing using a . -mhz probe with a standoff. the usual finding is that the affected structure is larger than expected. a fluid-filled core and echogeneic shadows consistent with gas may be apparent in some cases. interpretation requires some experience, and the examiner should be familiar with variants of normal, such as gas shadows associated with a patent urachus and enlarged vessels caused by hematoma formation, so that treatment is not initiated inappropriately. two options for treatment are surgical and medical. medical treatment is preferable in cases in which the lesion is well localized and small and in foals with a medical condition that is not amenable to anesthesia and surgical intervention. one should institute broad-spectrum antimicrobial therapy, and one may need to continue therapy for to weeks. most affected foals respond to medical therapy. frequent reevaluation of the abnormality is necessary, every to days initially, and one should measure blood fibrinogen concentrations at reevaluation because they should stabilize and decrease with effective treatment. failure to respond to therapy within days to weeks suggests that an empiric change in the antimicrobial used may be necessary. in foals that are refractory to medical management or where the lesion is large, surgical excision of the entire umbilical remnant may be desirable. colic in the foal can be difficult to diagnose accurately because one cannot perform an examination per rectum. however, many diagnostic aids, most importantly ultrasonography, are available to help differentiate medical from surgical causes of abdominal discomfort in the foal. intestinal accidents of all types described in adult horses, with the possible exception of enteroliths, occur in foals. intussusception, volvulus, displacement, diaphragmatic hernia, and intra-and extraluminal obstruction have been reported in foals. abdominal ultrasonographic and radiographic evaluation greatly aids diagnosis. treatment is primarily surgical. foals with pas and intestinal dysmotility are at increased risk of intussusception and displacement, and miniature breed foals appear to be at increased risk for fecolith and enterolith formation. meconium retention or impaction is a common cause of abdominal discomfort in newborn foals. most foals defecate shortly after their first meal. the usual practice for most owners or veterinarians attending the birth of a foal is to administer an enema to aid this process. in the past, phosphate-based commercially available enemata (fleet) were used frequently, but if used excessively these types of enemata can create problems of their own, including rectal irritation and hyperphosphatemia. the best enema is warm soapy water made with a mild soap such as liquid ivory soap that can be administered through soft rubber tubing using gravity flow. foals with significant meconium retention become colicky within the first few hours of life as gas accumulates within their bowel. frequently, one can palpate the meconium through the abdominal wall. additional diagnostics can include abdominal ultrasonography and radiography, particularly if one must rule out other, more serious types of colic. these foals assume a classic stance with an arched back. one must differentiate this stance from the stance assumed by foals with uroperitoneum, which is more extended. foals with meconium retention have had simultaneous ruptured bladder, however, so the clinician must be sure to evaluate the foal fully for both problems. foals that do not respond rapidly to enema administration need additional treatment, which can include giving mineral oil ( to ounces) by nasogastric tube. one can treat persistent meconium retention resulting in significant abdominal distention by muzzling the foal to prevent further milk intake and administering intravenous fluids at an appropriate maintenance rate. if continuous rate infusion is possible, % to % dextrose is the preferred fluid to use to provide calories to the foal. one should not use dextrose as a bolus fluid. more aggressive treatment would include administration of retention enemata made using acetylcysteine, which serves as an irritant and increases secretion. extreme cases of meconium retention may require surgical intervention, but this is usually not necessary and most cases resolve with medical management alone within to hours. some foals require pain managment. one should avoid nonsteroidal antiinflammatory drugs in the neonate because of their effects on renal function and gastric mucosal blood flow (see gastric ulcers). many foals respond well to butorphanol administered intramuscularly at a dose of to mg to an average -kg foal. intranasal oxygen insufflation is beneficial in foals with significant abdominal distention. one should evaluate foals with meconium impaction/ retention for evidence of pas because intestinal dysmotility is common in pas. colostrum is a laxative, and these foals also may suffer from failure of passive transfer, with meconium retention resulting from the lack of adequate colostrum. these foals are also at risk of sepsis because the mucosal intestinal barrier probably has been disrupted and translocation of bacteria can occur. one should obtain blood cultures on these foals and should monitor them closely for signs of sepsis. atresia within the gastrointestinal system of the foal occurs infrequently, but clinical signs are characteristic. acute colic occurs within the first few hours and is accompanied by abdominal distention similar to meconium retention. three primary types of atresia are described in the foal: membrane atresia, cord atresia, and blind-end atresia. antemortem diagnosis of atresia, short of abdominal exploratory surgery, is aided by the lack of meconium staining of the rectum or any administered enema fluids. additional diagnostic tests may include administration of a barium enema for a radiographic study, colonoscopy, and abdominal ultrasonography. abdominocentesis is usually normal until bowel rupture is imminent or has occurred. one can make affected foals more comfortable by muzzling them to prevent further milk intake and by supplying them with fluids and nutrition intravenously. if one attempts surgical correction, one first should initiate broad-spectrum antimicrobial therapy and determine passive transfer status. frequently, these foals are hypoxemic because of the abdominal distention, and oxygen supplementation is desirable. solid white foals born to overo-overo matings of american paint horses may suffer from congential aganglionosis of the ileum, cecum, and colon. these foals present similarly to foals with meconium impaction or atresia in that colic develops shortly after birth and involves progressive abdominal distention with feeding. the inherited defect is in the endothelin receptor gene. [ ] [ ] [ ] [ ] no effective treatment exists, but the clinician should be aware that not all white foals of this mating are affected, and some simply may have meconium retention, so a short period of treatment may be warranted. necrotizing enterocolitis is considered the most common acquired gastrointestinal emergency of human infants. , the to infants that die every year from this disease in the united states and the large number of infants who develop short gut syndrome from this disease only represent the tip of the iceberg of the problems necrotizing enterocolitis causes. the widespread fear of necrotizing enterocolitis among neonatologists and pediatric surgeons has contributed in large part to the use of the intravenous route rather than the gastrointestinal tract for nourishing these infants for long periods. the pathogenesis of necrotizing enterocolitis is unknown but may result from a disturbance of the delicate balance among gastrointestinal perfusion, enteric organisms, and enteral feeding. risk factors for necrotizing enterocolitis in human infants include prematurity, hypoxic-ischemic insult, and formula or breast milk feedings. the clinical spectrum of necrotizing enterocolitis is multifactoral and ranges from temperature instability, apnea, lethargy, abdominal distention, bilious residuals, septic shock, disseminated intravascular coagulation, and death. medical management is usually adequate treatment for necrotizing enterocolitis. in the neonatal foal, necrotizing enterocolitis is probably one of the most underrecognized causes of gastrointestinal dysfunction and in the past has been attributed only to infection with anaerobic organisms including clostridium perfringens type c and c. difficile. although a specific form of enteritis is associated with intestinal infection by these organisms, most necrotizing enterocolitis is associated with prematurity or pas in the infant and the foal. one should suspect necrotizing enterocolitis in any foal that is having difficulty tolerating oral feeding, demonstrating signs of ileus, or having episodes of colic and in any foal with occult blood or frank blood in the stool. foals exhibiting any of these clinical signs should not be fed orally if possible and should receive parenteral nutrition until gastrointestinal function returns to near normal. the mucosal barrier of the intestine is unlikely to be fully intact, and these foals are at risk for sepsis from bacterial translocation. one should institute broadspectrum antimicrobial therapy in these foals and, if any evidence of coordinated gastrointestinal motility is apparent, should administer sucralfate orally as a protectant. gastric ulcer disease has been recognized in foals, and lesions vary in anatomic distribution, severity, and cause. in clinically normal neonatal foals (< days of age), gastric ulcers and mucosal desquamation have been documented. [ ] [ ] [ ] [ ] because of these reports and other early reports of death following ruptured clinically silent ulcers in neonatal foals, for years many clinicians felt it necessary to treat critically ill neonates with antiulcer medication prophylactically. [ ] [ ] [ ] recently, this paradigm has been challenged. the pathophysiology of gastric ulcer disease is described most reasonably as an imbalance in protective and aggressive factors. [ ] [ ] [ ] these protective factors are responsible for maintaining a healthy gastrointestinal tract by promoting adequate mucosal blood flow, adequate mucus and bicarbonate production, prostaglandin e production, epithelial growth factor production, gastric afferent innervation, epithelial cell restitution, and gastroduodenal motility. probably the most important factor is maintenance of mucosal blood flow. hypoxia, no, prostaglandins, and gastric afferent innervation influence mucosal blood flow. the aggressive factors include gastric acid, bile salts, pepsin, and enzymes. few specific causes have been found for gastric ulcer disease in foals. excessive administration of nonsteroidal antiinflammatory drugs can result in ulceration of the glandular and squamous epithelium because of an inhibition of prostaglandin production, which leads to a decrease in mucosal blood flow and an increase in acid production. nonsteroidal antiinflammatory drugs also can impair the healing of lesions and rarely are indicated in neonatal equine medicine. , in the critically ill neonate the suspected cause of gastric ulcers has shifted away from an excessive amount of intraluminal gastric acid toward gastric mucosal ischemia caused by hypoxia, low blood flow conditions, or both. perforating gastric ulcers are more likely a manifestation of necrotizing enterocolitis than of excessive gastric acid. shock, sepsis, or trauma can result in gastric mucosal ischemia, allowing for the disruption of epithelial cell integrity and permitting damage by aggressive factors or providing an environment suitable for the establishment of bacteria colonization. , impairment of mucosal blood flow also may result in reperfusion injury, allowing the formation of gastric ulcers. in the sick neonatal foal (< days of age) a wide variability in the intragastric ph has been documented depending on the type of disease, severity, and milk intake frequency and volume, suggesting that in the critically ill equine neonate, ulcer prophylaxis using histamine antagonists or proton pump inhibitors is not only unnecessary but unlikely to work. clinically significant gastric ulcers can occur in the squamous, glandular, or both portions of the stomach as a primary problem or resulting from another problem. clinical signs include diarrhea, abdominal pain, restlessness, rolling, lying in dorsal recumbency, excessive salivation, and bruxism. in the neonatal foal the only clinical signs present may be depression or partial anorexia until a more catastrophic event, such as perforation, occurs. some lesions in the gastric mucosa extend from the pylorus into the proximal duodenum and can result in stricture of the pylorus and proximal duodenum. these foals are usually older (> month of age) and have a greater volume of reflux. bruxism and ptyalism are also more prominent in these older foals. the most sensitive and specific method for diagnosing gastric ulcers is visualization by endoscopic examination. unfortunately, the use of gastric endoscopy has led to recognition of relative nonlesions and ulcers resulting from other problems and of clinically significant disease states. the clinician should not stop simply when ulceration of the stomach is recognized with endoscopy but should examine that patient fully for other potential sources of the clinical signs. other diagnostic tests may help in determining the severity of the ulcers, including fecal occult blood or gastric blood assessments, contrast radiography, abdominal ultrasound, and abdominocentesis. endoscopy of the foal stomach carries an additional risk of exacerbating colic in the short term, unless the examiner ensures that as much introduced air as possible is evacuated from the stomach at the end of the procedure. the presence of a brown gastric reflux fluid may indicate the presence of bleeding ulcers. blood in the feces of the neonate is more consistent with a diagnosis of necrotizing enterocolitis, which can be associated with gastric ulcers. contrast radiography is useful if one suspsects delayed gastric emptying or pyloric or duodenal stricture in older foals. if a stricture has occurred, one will note a delay in complete emptying of barium from the stomach (> hours). abdominal ultrasound may be useful to visualize free abdominal fluid and gastric or small intestinal distention if one suspects a perforation. one can visualize portions of the descending duodenum, and a thickened duodenum should increase the index of suspicion for duondenal stricture. abdominocentesis also may confirm perforation. traditional therapy for gastric ulceration includes mucosal adherents, histamine type receptor antagonists, proton pump inhibitors, and antacids. the most widely used mucosal adherent is sucralfate, which is a hydroxy aluminum salt of sucrose. the main therapeutic action of sucralfate is to bind to the negatively charged particles in the ulcer crater. , at a ph less than , sucralfate is converted to a sticky viscous gel, which adheres to the ulcer crater and remains adhered for hours, but at a higher ph, sucralfate remains in a suspension. sucralfate is still effective because it inhibits pepsin and buffers hydrogen ions. other important actions of sucralfate include stimulating production of prostaglandin e, which maintains mucosal blood flow; increasing bicarbonate secretion; stimulating mucous secretion; decreasing peptic activity; and binding epidermal growth factor. the histamine type receptor antagonists include cimetidine, ranitidine, and famotidine. these compounds block the interaction of histamine with the histamine type receptor on the parietal cell, resulting in inhibition of gastric acid secretion. clinically normal neonatal foals have a highly acidic gastric fluid that is influenced by sucking. intravenous and oral administration of ranitidine increases intragastric ph in normal foals but critically ill neonatal foals have a blunted response to ranitidine administration. , one possible conclusion reached from these studies is that in critically ill neonatal foals, gastric ulcers may not be caused by an increased intraluminal gastric acidity. the most commonly used proton pump inhibitor is omeprazole. this drug has not as yet been approved for use in foals under days of age. omeprazole inhibits the secretion of hydrogen ions at the parietal cell by irreversibly binding to the h + ,k + -atpase proton pump of the cell. most of the lesions in older foals were healed after daily administration of omeprazole for days according to one report. table - summarizes the therapeutic agents for treating gastric ulcers in foals. prophylactic treatment of critically ill neonates for gastric ulcers has been standard therapy for years because of the evidence of clinically silent ulcers. this approach may not be appropriate for several reasons. an increased incidence of nosocomial pneumonia and systemic sepsis is associated with high gastric ph in human patients in intensive care. [ ] [ ] [ ] patients in intensive care units treated prophylactically with histamine type receptor antagonists are more likely to develop pneumonia during ventilation therapy and gastric colonization with potentially pathogenic bacteria or yeast. , an acidic environment appears to protect against airway colonization by bacteria of intestinal origin and bacteria translocated across the gastrointestinal tract. pathogenesis of ulcers in the neonatal foal most likely does not involve increased intraluminal gastric acid but instead may be caused by decreased mucosal perfusion associated with shock, hypoxia, and hypoxic/ischemic insult to the gastric mucosa. a recent report revealed that gastric ulcer disease in equine nicu patients is independent of pharmacologic prophylaxis. in this study, despite decreased treatment, the incidence of gastric ulcers found in these foals at necropsy had decreased significantly. the decrease was attributed to overall improvement in management of these cases. similarly, in a human intensive care unit, the incidence of stress ulcers decreased independent of the use of prophylaxis. , early treatment of sepsis, sufficient oxygenation, improved monitoring, institution of enteral feedings, and improved nursing care may contribute to the reduction in gastric ulcers in the neonatal patient. use of histamine type receptor antagonist and proton pump inhibitors apparently may not be necessary; however, in some instances sucralfate may be useful. sucralfate reduced the rate of bacterial translocation in a rat model during hemorrhagic shock and also may prohibit the generation of acute gastric mucosal injury and progression to ulcer formation induced by ischemia-reperfusion. , in a human medical intensive care unit, airway colonization by new pathogens occurred more frequently in patients receiving agents that increased gastric ph than in those receiving sucralfate. , in the critically ill neonatal foal, risk factors for gastric ulceration have not been identified clearly, although foals treated routinely with nonsteroidal antiinflammatory drugs may be at increased risk for gastric lesions. prophylactic treatment for gastric ulcers in critically ill neonates may not be necessary, and one should consider carefully the pros and cons of their use before their administration. foal heat diarrhea is a mild, self-limiting form of diarrhea that occurs in foals between and days of age, about the time of the "foal heat" in the dam. the definitive cause of foal heat diarrhea has yet to be described, but the condition may be associated with dietary changes or changes in gastrointestinal function that occur around that time. this form of diarrhea is not caused by stongyloides westeri infestation as previously thought. foals with foal heat diarrhea are not systemically ill and should not require therapy. one should evaluate fully any foals with diarrhea at this time for other possible causes of diarrhea, particularly if they are unwell or exhibit anorexia or dehydration. viral diarrhea occurs most commonly in large groups of mares and foals that are housed together. rotavirus is an isolate from the feces of up to % of foals with diarrhea worldwide, alone or with another pathogen. , the virus infects and denudes the microvilli, resulting in increased secretion combined with decreased absorption. the virus interferes with disaccharidase function and alters the function of the intestinal sodium-glucose cotransport proteins. the initial clinical signs are anorexia and depression, with profuse watery diarrhea occurring shortly thereafter. severely affected foals may become significantly dehydrated and have electrolyte abnormalities, primarily hyponatremia and hypochloremia with metabolic acidosis. these foals generally require intravenous fluid support, whereas less severely affected foals may require only symptomatic therapy. definitive diagnosis is by detection of the virus in the feces of foals with diarrhea. however, none of the available tests are particularly sensitive, and the virus also may be found with other intestinal pathogens. recently, vaccination of pregnant mares has been suggested as a means of prevention, with preliminary results suggesting efficacy. , although a definitive role for adenovirus has not been established in the foal, adenovirus is a common co-isolate from foals with rotaviral diarrhea. a specific equine coronavirus recently has been identified from an immunocompetent foal with diarrhea, and a second report of cornavirus diarrhea was published recently. , one case report suggests a parvovirus caused diarrhea in the foal. treatment of viral diarrhea in foals is primarily supportive. intravenous fluid and parenteral nutritional support may be necessary in severe cases. very young foals may benefit from intravenous plasma administration and broad-spectrum antimicrobial coverage to limit bacterial translocation. one can administer sucralfate orally in these cases as a gastrointestinal protectant and to discourage bacterial translocation. foals with moderate to severe metabolic acidosis may benefit from sodium bicarbonate administration if their ventilatory function is normal. one administers sodium bicarbonate at half the calculated deficit ( . × standard base excess × body mass in kilograms) as an isotonic solution at the maintenance fluid rate. one should reevaluate sodium and bicarbonate (or standard base excess) concentrations regularly. nonspecific therapy of diarrhea is discussed elsewhere in this text. diarrhea is frequently the primary presenting complaint in foals with sepsis, so one should rule out this differential diagnosis in foals less than week of age. one should evaluate all neonatal foals with diarrhea for possible sepsis and should include a blood culture whenever possible. clostridium perfringens and c. difficile are recognized increasingly as serious pathogens of the foal. - foals with either pathogen generally have abdominal pain, dehydration, and profuse watery diarrhea. some foals may have red-tinged or frankly bloody feces, which carries a poorer prognosis. most foals with this type of diarrhea require intensive care or, at the minimum, intravenous fluid administration. outbreaks of this type of diarrhea on farms occasionally occur, and the suggestion is that the dam has a role in transmission of the bacteria. diagnosis is by recognition of the offending organism by gram stain of the feces, by bacterial isolation from the feces, and by detecting the presence of toxins associated with the organisms. specific treatment includes oral administration of metronidazole and broad-spectrum antimicrobial coverage as prophylaxis for bacterial translocation associated sepsis in younger foals. foals with severe blood loss in their feces may require transfusion of whole blood. salmonella spp., escherichia coli, bacteroides fragilis, and aeromonas hydrophila have been implicated in diarrhea in foals. salmonella generally is associated with septicemia in foals, and although some convincing evidence exists for a role for e. coli in foal diarrheal disease, the extent of e. coli as a pathogen of the gastrointestinal tract in foals has yet to be described fully. , [ ] [ ] [ ] [ ] proliferative enteropathy is a transmissible enteric disease caused by lawsonia intracellulare. , most foals have been weaned before the appearance of clinical signs of depression, rapid and significant weight loss, subcutaneous edema, diarrhea, and colic. poor body condition with a rough hair coat and a pot-bellied appearance are common in affected foals. clinicopathologic abnormalities included hypoproteinemia, leukocytosis, anemia, and increased serum creatine kinase concentration. postmortem reveals characteristic intracellular bacteria within the apical cytoplasm of proliferating crypt epithelial cells of the intestinal mucosa. antemortem diagnosis of equine proliferative enteropathy is based on clinical signs, hypoproteinemia, and the exclusion of other common enteric pathogens. fecal polymerase chain reaction analysis may be positive for the presence of l. intracellulare, and affected foals develop antibodies against l. intracellulare. treatment with erythromycin estolate alone or combined with rifampin for a minimum of days is recommended with additional symptomatic treatment when indicated. cryptosporidium spp. cause gastroenteritis and diarrhea in many animal species and are not host-specific. cryptosporidium has been implicated as the casual agent of diarrhea in foals, but the organism is isolated from the feces of diarrheic foals and normal foals with the same frequency and concentration, making a clear role for the organism difficult to elucidate. - diarrhea caused by cryptosporidium in other species and that described for foals is generally self-limiting, with a clinical course of between to days. immunosuppressed patients, including foals compromised by concurrent disease, are thought to be at increased risk for complications resulting from infection with this organism. , treatment is symptomatic. cryptosporidiosis is a disease with zoonotic potential, and one should take appropriate precautions, including use of gloves and frequent hand washing, if organisms are identified in the feces of any patients so as to prevent spread to other patients and personnel. eimeria leukarti, trichomonas equi, and giardia equi have been identified in the feces of normal horses and horses with diarrhea. transmission studies have failed to produce reliable clinical signs, and the prevalence and significance of these organisms in the genesis of foal diarrhea remain unknown. strongyloides westeri is a common parasitic infection of foals. , transmission is transmammary, and patent infection is recognizable in the foal by to days of age. this nematode previously was associated anecdotally with foal heat diarrhea, but the association has not been demonstrated clearly. the diarrhea is generally mild and is treated effectively by deworming with benzimidazole or ivermectin anthelmintics. strongylus vulgaris fourth-stage larvae cause diarrhea in young foals during migration through the arterioles of the cecum and descending colon. clinical signs may resemble thromboembolic colic. the prepatent period is about months, and diagnosis is based on clinical examination, clinicopathologic changes, and farm deworming history. patients with diarrhea associated with this parasite may have peripheral leukocytosis, neutrophilia, eosinophilia, and hypoproteinemia. appropriate deworming with ivermectin (label dose), fenbendazole ( mg/kg/day orally for days), or thiabendazole ( mg/kg/day orally for days) is recommended, with the last two drug dosages being larger than the label dose. cyathostomiasis, or diarrhea resulting from the sudden emergence of encysted cyathostome larvae, is an unusual cause of diarrhea in the foal. the clinician managing critically ill neonates must recognize that intravenous fluid therapy simply cannot be scaled down from adult management approaches. fluid management of the ill neonate, particularly over the first few days of life, must take into consideration that the neonate is undergoing a large transition from the fetal to the neonatal state and that important physiologic changes are taking place. these transitions include shifts in renal handling of free water and sodium and increased insensible losses because of evaporation from the body surface area and the respiratory tract. the newborn kidney has a limited ability to excrete excess free water and sodium, and the barrier between the vascular and interstitial space is more porous than that of adults. water and sodium overload, particularly in the first few days of life, can have disastrous long-term consequences for the neonate. , in the equine neonate, excess fluid administration frequently manifests as generalized edema formation and excessive weight gain, frequently equivalent to the volume of excess fluid administered intravenously. in cases in which antidiuretic hormone secretion is inappropriate, as in some foals with pas, generalized edema may not form, but the excess free water is maintained in the vascular space. this syndrome of inappropriate antidiuretic hormone secretion is recognized in the foal that gains excessive weight not manifested as edema generally, with decreased urine output and electrolyte abnormalities such as hyponatremia and hypochloremia. the foal manifests neurologic abnormalities associated with hyponatremia. the serum creatinine concentration varies in these cases, but urine always is concentrated compared with the normally dilute, copious amounts of urine produced by foals more than hours of age on a milk diet. if measured, serum osmolarity is less than urine osmolarity. the treatment for this disorder is fluid restriction until weight loss occurs, electrolyte abnormalities normalize, and urine concentration decreases. if the clinician is unaware of this differential diagnosis, the neonate can be assumed mistakenly to be in renal failure, and the condition can be exacerbated by excessive intravenous fluid administration in an attempt to produce diuresis. the problem of appropriate fluid management in critically ill neonates has been recognized by medical physicians for years and has resulted in changes in fluid management of these patients. the approach taken has been one of fluid restriction, in particular sodium restriction but also free water restriction, and has resulted in improved outcome and fewer complications, such as patent ductus arteriosus and necrotizing enterocolitis. , the calculations used for maintenance intravenous fluid support in these patients takes into consideration the ratio of surface area to volume and partially compensates for insensible water losses. maintenance fluids are provided as % dextrose to limit sodium overload and provide sufficient free water to restore intracellular and interstitial requirements. the calculation for maintenance fluid administration is as follows: first kg body mass ml/kg/day second kg body mass ml/kg/day all additional kilograms of body mass ml/kg/day as an example, the average -kg foal would receive ml/day for the first kg of body mass, ml/day for the next kg of body mass, and ml/day for the remaining kg of body mass for a total of ml/day. this translates to an hourly fluid rate of about ml/hr. one should adjust the fluid and sodium requirements for ongoing losses exceeding the maintenance requirements. these losses can take the form of diarrheal losses and excessive urine output, such as those with glucose diuresis and renal damage resulting in an increased fractional excretion of sodium. the normal fractional excretion of sodium in neonatal foals is less than that of adult horses, usually less than % (j.e. palmer, unpublished data). in the critically ill foal the sodium requirement can be met with as little as meq of sodium per day, about that administered in a single liter of normal equine plasma. one can address sodium deficits by separate infusion of sodium-containing fluids, although this may not be necessary if one considers the sodium being administered in other forms, including drugs administered as sodium salts and any constant rate infusions (pressors, inotropes, etc.) that are being provided as solutions made with . % sodium chloride. the author has used this approach to fluid therapy in her nicu for the last few years and believes that the percentage of foals suffering from generalized edema and related problems has decreased. if one takes this approach to fluid therapy, one should take the weight of the patient once daily, or even twice daily, and monitor the fluid intake and output as closely as practical. one should evaluate any larger than anticipated weight gains or losses. one should not expect urine output to approach the reported normal of ml/hr for a -kg foal because the free water administered is limited, unless the patient is experiencing diuresis (glucosuria, resolution of the syndrome of inappropriate antidiuretic hormone secretion, resolution of previous edematous state, renal disease). one should obtain the urine specific gravity several times daily and should determine fractional excretion of sodium at regular intervals. if the volume of urine produced by the patient is measured accurately, one can determine sodium losses accurately and can obtain creatinine clearance values. one should obtain blood pressure measurements at regular intervals throughout the day because hypotension can be a problem in these patients, particularly in septic foals and foals suffering from pas, and one may need to increase fluid therapy to maintain adequate vascular volume. patients with hypotension may need inotrope and pressor support. inotrope and pressor therapy generally is restricted to referral centers where these drugs can be administered as constant rate infusions and blood pressure can be monitored closely. blood pressure can be monitored directly or indirectly by the use of cuffs placed on the base of the tail. both techniques have advantages and disadvantages. although direct blood pressure measurements are considered the gold standard and are generally more accurate, the difficulty in placing and maintaining arterial catheters and lines in these patients severely restricts the utility of this method. indirect techniques can be inaccurate and are affected by cuff size and placement. however, indirect techniques are easier to use in the nicu and can be useful if trained staff are using the equipment. in the author's nicu, once practitioners identify the appropriate cuff size, they dedicate that cuff to that patient for the duration of the hospitalization to decrease variability caused by using different cuffs. one should monitor the blood pressure of all recumbent patients at regular intervals, and trends upward or downward should prompt the clinician to make necessary adjustments. foals suffering from pas and sepsis are the patients most at risk for significant hypotension and perfusion abnormalities. perfusion is maintained by supporting cardiac output and blood pressure with judicious use of intravenous fluid support and inotrope/pressor support. the author does not aim for any specific target systolic, mean, or diastolic pressure. instead the author monitors urine output, mentation, limb perfusion, gastrointestinal function, and respiratory function as indicators that perfusion is acceptable. for nicu patients to require inotrope and pressor therapy is not unusual, but in some cases hypoxic and septic damage is sufficiently severe to blunt the response of the patient to the drugs. one must approach each patient as an individual, and no single inotrope/pressor protocol will suffice for all patients. dobutamine is a β-adrenergic inotrope that is frequently used as first choice therapy in nicu patients. its effects are β at the lower dose range. neonates have a limited ability to increase stroke volume in an effort to maintain cardiac output, and one may observe tachycardia in these patients as heart rate increases to maintain cardiac output and vascular pressure. dobutamine is useful after patients are volume replete for support of cardiac output. the dose range is between to µg/kg/min provided as a constant rate infusion. dopamine has dopaminergic activity at low doses, β and β activity at moderate doses, and α activity at high doses. dopamine causes norepinephrine release, which has lead to the suggestion that this is its major mode of action at higher doses. at doses greater than µg/kg/min, intrapulmonary shunting, pulmonary venous vasoconstriction, and reduced splanchic perfusion may occur. dopamine also produces natriuresis at lower doses through a direct effect on renal tubules. for these reasons, dopamine has fallen out of favor at some referral institutions. norepinephrine has α and β activity but variable β activity, resulting in potent vasopressor effects; it has inotropic and chronotropic effects, but its chronotropic effect usually is blunted by vagal reflexes slowing the heart rate induced by the increase in blood pressure. in many critical care units, norepinephrine has become a pressor of choice and frequently is used along with dobutamine. evidence suggests that splanchic perfusion is maintained better with norepinephrine than with some other pressors. the dose range is . to . µg/kg/min, although larger doses have been used when necessary in certain patients. epinephrine has α , α , β , and β activity; β activity predominates and results in increased cardiac output and decreased peripheral resistance at low doses. epinephrine has been associated with hyperglycemia, hypokalemia, lipolysis, increased lactate concentration, and increased platelet aggregation. the effect on renal function is controversial. use of epinephrine usually is limited to those patients not responding to other pressors. vasopressin (antidiuretic hormone) is a pressor gaining a great deal of attention in the critical care literature. vasopressin appears to be depleted from the neurohypophysis in septic shock, and short-term administration of vasopressin spares conventional vasopressor use, in addition to improving some measures of renal function. low-dose vasopressin infusion increases mean arterial pressure, systemic vascular resistance, and urine output in patients with vasodilatory septic shock that are hyporesponsive to catecholamines. these data indicate that low-dose vasopressin infusions may be useful in treating hypotension in patients with septic shock. the author has been using low-dose vasopressin in patients in her nicu for the past few years and has the clinical impression that blood pressure is defended more readily using this agent in concert with other management strategies. the author commonly uses low-dose vasopressin constant rate infusion with dobutamine constant rate infusion as the initial inotrope/pressor therapy in cases requiring pressure defense, although no prospective studies are yet available regarding this drug in veterinary medicine. for quality health care for animals, advances in medical science, and in some breeds the increasing value of the juvenile equine athlete. equine veterinarians that encounter pediatric orthopedic problems are only beginning to get the information needed to make appropriate treatment decisions. the equine neonate has specific differences in structure and physiology from adults that one must consider when designing an optimal therapeutic or management strategy. few investigations have focused on the equine neonatal musculoskeletal system, - but a large body of clinical information exists, and one can make cautious extrapolations from work in other species. neonatal equine bones have accelerated modeling and remodeling processes that result in accelerated fracture healing and an increased susceptibility to deformation caused by excessive loading. contralateral limb varus deformities of the growth centers (most commonly distal radius and metacarpus/ metatarsus) are common in overloaded limbs. the increased plasticity of the skeletal structure also is mirrored in the soft tissue support system, for these units become flaccid within weeks of immobilization. this laxity is important, because it further compromises the use of the fractured limb and can last as long as the coaptation was in place. additional divergences from adult physiology include musculoskeletal immaturity (generalized or focal) and immune system differences. finally, foals are lighter and can tolerate and will assume recumbency more readily than adults. the net results of these differences are that one must consider the use of external coaptation carefully, fractures heal quickly, one must consider damage to the contralateral limb from overstress, reducing weight bearing is possible, and infection is always lurking. stresses can affect the musculoskeletal system of the foal at any time, including in utero. although rare, reports describe in utero fractures (k. sprayberry, personal communication, ) that result in foal locomotor problems and even maternal uterine damage from sharp bone ends. the cause is presumably from vigorous muscular activity of the foal, but one cannot rule out direct trauma. the fractures result in foal lameness and can increase the likelihood of dystocia and caused colic in one mare when the broken bones damaged the uterus. treatment depends on how long the fracture has been present and on the fracture location and configuration, but if the fracture is repairable, internal fixation probably is necessary. fractures occurring during foaling result from aggressive obstetric manipulation (mandibles) or the advances in medical care of equine neonates in the last years have resulted in the survival of many foals that previously would have died from sepsis, asphyxia, and prematurity; and the successful management of their musculoskeletal system can be a major challenge. major factors adding to the challenge are the immaturity of components of the musculoskeletal system and the demands placed on them by a growing and active foal. additional pressures to treat orthopedic conditions in foals have come from an overall increase in the demand chest compression. one should stabilize unstable mandibular fractures. appendicular fractures usually do not occur during parturition because of the robust character of the bones of the foal. after birth, foals are susceptible to external trauma from many sources. the dilemma is that younger foals with fractures are more likely to heal but also are more likely to develop contralateral limb problems because of excessive weight bearing and affected limb flexor tendon laxity if the limb is immobilized fully. as a result, internal fixation is often the best choice for neonatal fractures to keep the fractured limb in use. proximal sesamoid bone fractures result from hyperextension of the fetlock joint. foals are lame after the fracture, but the lameness can be mild and often diminishes quickly. soft tissue swelling occurs over the sesamoids. fractures are usually simple, can occur uniaxially or biaxially, and can be apical, midbody, or basilar. fractures can occur in any joint and can affect multiple sesamoids in one foal. however, they most commonly are single forelimb fractures and in thoroughbreds are most frequent in the left front medial proximal sesamoid (j.p. morehead, personal communication, ). of particular interest to neonatologists is that proximal sesamoids fractures often occur in recovered neonatal patients that are allowed too much exercise too soon. foals from the nicu need a gradual introduction to pasture turnout to allow their musculoskeletal system to adjust. mares are often in need of turnout, but in the interest of their foals, they must wait. treatment of proximal sesamoid fractures in foals is stall confinement with support bandaging. healing occurs, albeit with some distortion of the shape of the sesamoid. severely displaced fragments result in large and misshapen sesamoids, and surgery may be considered for these foals, because restriction of fetlock flexion can occur after conservative therapy. third phalangeal fractures are also common in foals. these foals have a lameness that worsens with hoof compression. hoof abscesses are uncommon in young foals but should be considered. most commonly, radiographs reveal nonarticular small fractures on the wings on the third phalanx. the fractures are associated with hard ground and exercise. the fractures heal with stall confinement, and unlike adults, leave no discernable radiographic fibrous union. avulsion fractures of the proximal insertion of the peroneus tertius and the origin of the long digital extensor tendon have been reported. , both soft tissue structures attach to the extensor fossa of the distal femur. the two affected foals had lameness of a hindlimb associated with swelling, pain, and crepitation. radiographs revealed multiple avulsion fractures of the extensor fossa. because of the intraarticular fragments in the femoropatellar joint, and the fear of later degenerative joint disease, fragments were removed arthroscopically. both foals were juveniles at last follow-up; one foal was considered normal, and one had a mild residual lameness. tendon and ligament damage is uncommon in neonates probably because of their low body weight. extensor tendon damage following flexural deformities is the most common tendon problem and is discussed in congential flexural deformities of foals. gastrocnemius ruptures are one of the most devastating problems and have occurred after forced extraction because of a breech presentation, severe flexor tendon laxity, and tarsal contracture. loss of gastrocnemius function usually results in a non-weight-bearing limb, although an intact superficial digital flexor tendon may make some weight bearing possible. complete loss of support is difficult to treat successfully. coaptation of the limb is logical but difficult to obtain. schroeder-thomas splints have been used but are difficult to manage. tube casts also are used but must be changed frequently, and cast sores are inevitable (l.r. bramlage, personal communication, ) . the prognosis for athletic function is guarded. treatment for ligamentous injuries is usually some form of coaptation, although surgical repairs have been performed when coaptation was unworkable. coaptation in proper limb alignment allows the ligaments to heal and should be used if the injury will destabilize a joint and cause damage to growing epiphyses or cuboidal bones. one can achieve coaptation with casts or splints under a bandage. casts are initially a greater expense, and cast sores and their resulting white hairs are a risk, but the rigid immobilization and the lack of the requirement for daily adjustment makes them preferable. important to musculotendinous health is some measure of weight bearing to avoid laxity after coaptation removal, which one can achieve by using tube casts and splints that allow weight bearing. following coaptation, bandaging and a gradual return to exercise are recommended for ligamentous injuries. patellar luxation can affect foals in one or both hindlimbs, and the luxation can vary from a laxity in the medial attachments to complete luxations that cannot be replaced in the patellar groove of the distal femur. , medial luxations have not been reported. clinical signs vary from a slight discontinuous motion during stifle flexion to an inability to stand. many foals have a crouching stance on the affected limb because of an inability to extend the stifle. the pathophysiology of patellar luxations is unknown. congenital bilateral luxations are common in miniature horse foals and are believed to be genetic. luxations are rarer in other breeds and are occasionally traumatic. the affected limbs are usually not grossly abnormal except for effusion of the femoropatellar joint and the luxation. a shallow trochlear groove has been reported to be a cause of patellar luxation, but objective evidence is lacking. one should evaluate foals for the ability to stand. once the appropriate supportive care is provided, if a foal cannot stand, euthanasia is recommended. most bilateral luxations in horses fit in this category. however, miniature horse foals often can stand sufficiently to nurse despite bilateral luxations, and one may consider treatment. treatment consists of replacing and stabilizing the patella and sometimes surgically deepening the patellar groove. delaying surgical repair until the foal is approximately days old is recommended to avoid neonatal problems, allow the musculoskeletal system to mature, and provide good anchors for suture. some surgeons worry that delay may cause further femoropatellar developmental abnormalities, but in a small number of cases, this has not been an issue. the prognosis for miniature horse foals appears to be good because of their low body weights and modest performance expectations. too few reports about the correction of unilateral luxations in light horses exist to make a definitive statement about prognosis except that success and failure have been experienced. , congenital flexural deformities in foals can be classified as severe (rarely correctable), moderate (correctable with therapy), or mild (self-correctable). examples of severe flexural deformities include arthrogryposis (deformities of multiple limbs and often the head and neck), severe carpal deformities (flexor angle of the carpus less than degrees), and tarsal contractures (rare). extraordinary methods have been used to correct severe deformities but are often unsuccessful. mild flexural deformities are those that result in an upright conformation to the limb, but the foal can bear weight on the limb and load the flexor structures. these foals require no specific treatment and will self-correct with controlled exercise. moderate flexural deformities are those that make bearing weight on the limb and loading the flexor structures and ligaments difficult for the foal. when these deformities occur bilaterally (most common), the foals cannot rise to suckle or does so with great difficulty, and the lack of weight bearing worsens the flexural deformity. examples of moderate flexural deformities include carpal and forelimb fetlock flexural deformities that usually occur together, hindlimb fetlock flexural deformities with coronopedal flexion or hyperextension, and the uncommon coronopedal flexural deformity alone. treatment of moderate flexural deformities aims to place the solar surface of the foot on the ground so that the weight of the foal can stretch the flexor structures. splints are useful for restoring the limb to normal orientation but require attention to detail because the splints often exert an extreme amount of tension on the soft tissues, and the skin of the foal is thin. pressure sores are easy to create and at a minimum result in an extended convalescence. the first step in splint application is to apply a separate heavy bandage to the limb, which should be reapplied as necessary because the bandage can slip and cause focal constriction. commercial gauze over cotton bandage material works better than sheet cotton as a bandage. the splint is made of polyvinyl chloride pipe cut in half or thirds. using % of the diameter of the pipe results in less splint rotation but is bulkier and leaves more splint exposed to cause trauma. one cuts off the corners of the splint and pads the ends with gauze or roll cotton covered with tape. palmar or plantar placement of the splint is preferable, but severe deformities may require initial dorsal placement. as the limb straightens, one can bend the splint to tape the fetlock into the bend to extend it. one can tape the splint tightly to the limb over the bandage with nonelastic (white or duct) tape. this procedure requires at least two persons, one to extend the limb firmly and hold the limb and one to tape. one should leave the splint on for to hours and then remove it for to hours. one can reapply splints as necessary. in addition to splints, some medications are of value for treating flexural deformities. oxytetracycline ( to mg/kg) given intravenously appears to relax the soft tissues. the mechanism of action is unknown, and the drug is most efficacious when given in the first days of life. this dose is high but appears to be safe for healthy foals and can be repeated at -hour intervals. foals should be normovolemic during tetracycline administration. one should use the drug with caution in foals with renal impairment. foals should be urinating and have reasonable urinary parameters (serum urea nitrogen, creatinine, and urinalysis) before tetracycline use. diarrhea is an uncommon sequela to tetracycline use. one should monitor the unaffected limbs closely because all limbs experience a relaxation of the palmar/plantar support. , discontinuation of tetracycline therapy before affected limbs are normal but after they can bear weight is common because of worsening laxity in the "normal" limbs. one also can use phenylbutazone ( mg/kg) for a short time when the splints are used. some analgesia appears to help the foals use the limbs and stretch the soft tissues. one should not use phenylbutazone for long periods of time because of the potential of inducing gastric ulcers. surgical treatment of congenital flexural deformities rarely is indicated. severely affected foals rarely respond favorably to surgery, and mildly affected foals do not need it. surgery is most appropriate for foals with moderate flexural deformities that are neglected or have not responded to splinting and tetracycline. the most common surgical therapy performed for congenital flexural deformities is the inferior check ligament desmotomy for fetlock or coronopedal flexural deformities. ruptures of the extensor tendons commonly occur with congenital flexural deformities and result from the foal overloading the extensor tendons. no specific therapy for the ruptures is necessary. if the rupture is extensive, it can interfere with the ability to extend the fetlock and to place the foot flat. these foals then tend to knuckle over, even after correction of the flexural deformity. a firm fetlock bandage extends the digit and assists in foot placement until the extensor tendons heal. foals commonly are born with hyperextension deformities of the fetlock of varying degrees of severity. all but the worst deformities self-correct as muscle tone improves. a deeply bedded stall is all that is usually necessary to protect the soft tissues, but one can apply a light bandage to the coronary band and pastern if trauma is a problem. severe deformities are more problematic but rare, so therapeutic recommendations are not available. hyperextension of the carpus occasionally occurs and usually is treated conservatively. however, a tube cast to align the limb may be necessary to protect the dorsal surface of developing carpal bones. neonatal foals exhibit three categories of forelimb conformational deviations: angulation, rotation, and carpal offset. angular deviations most commonly are centered in the metaphysis and epiphysis, but their location is described by the closest joint, usually the carpus and fetlock. when the deviation of the distal limb is lateral to the long axis, the deviation is valgus, and when the deviation is medial, the deviation is varus. more than one joint can be affected, and although rare in neonates, valgus and varus can occur in different joints in one limb. rotational deformities appear to originate most commonly in the diaphysis or metaphysis of the radius or the metacarpus. in neonates the direction of rotation of the distal limb at both sites is almost exclusively outward. associated angular and rotational deviations occur. in neonates, limb deviations occur in foals with narrower chests and less developed pectoral muscles than in straight foals, and they appear to have an initial greater overall weakness in the musculoskeletal system because it first interacts with gravity, body mass, and ground reaction forces. however, after the first few days of life, the asymmetric loading of the growth centers does affect limb deviations. angulation results from a compressive load that is asymmetric in a frontal plane but is uniform in the sagittal plane, and rotation occurs when the compressive load is asymmetric in both planes and the limb develops around an overloaded axis point. considered this way, valgus and outward rotation deviations in young foals are coupled, as are varus and inward rotation in older foals. the loading asymmetry for valgus/outward rotation foals is accentuated as foals assume a base-wide posture that is more stable side-to-side but promotes a lateralization of the limb load. the specific effects of intermittent versus static loads, strain magnitude versus strain rate, and shear and hydrostatic stress on growing bones is only beginning to be understood. however, clinical experience supports the general observation that excessive cartilage compression is deleterious to bone growth. offset carpal conformation describes a joint that appears to deviate outwardly and then inwardly, all within the carpus. the deformity is thought to be centered at the radiocarpal joint, but the specific structural cause of offset has not been determined. this conformation is more common in older foals but occasionally occurs in neonates. the deviation is particularly common when incomplete ossification of the carpal bones is present. the causes of conformational deviations are a matter of some debate. as always, the major factors are genetics or environment. genetic influences include the assortment of alleles that controls bone form and growth and the assortment that modulates bone remodeling. many in the horse industry believe that genetics is a strong determiner of limb conformation. environmental influences are many and include the intrauterine environment, the postnatal limb load, nutrition, and bad luck. suffice to say, the situation is complex, but one must consider biologic and mechanicobiologic influences when evaluating the growth of long bones. several factors may contribute to the common occurrence of deviations in the carpus. first, the carpus is in the middle of the limb and is subject to the greatest bending forces. second, the carpal anatomy is complex and perhaps is not understood completely. the carpus has seven cuboidal bones, two long bones, and two epiphyses (distal radial and lateral styloid); and cartilage surrounds all. the ligamentous support includes collateral ligaments, innumerable intracarpal ligaments, and a palmar carpal soft tissue ligament. the distal radial physis is not flat transversely, but undulates in the frontal and sagittal planes. a separate center of ossification for the lateral styloid process is found at its palmar-lateral aspect. because of this separate center of ossification, more cartilage and less bone are in the lateral aspect of the distal radial growth center, suggesting it may be more susceptible to growth alterations from load. less common conformation deformities in young foals include hindlimb deformities, windswept conformation, diaphyseal deviations (usually of the metacarpus/ metatarsus), gross congenital malformations such as agenesis and polydactyly, and acquired varus deformities of the carpus and fetlock. hindlimb conformational deviations can manifest as tarsal and fetlock angular deformities and external limb rotation, usually centered above the tarsus. windswept foals have limbs (usually both forelimb or both hindlimbs) that are curved in the same direction in the frontal plane. diaphyseal deviations, agenesis, and polydactyly are rare and have various presentations. acquired varus deformities are caused by excessive loading, which appears to be focused medially on the growth plates. one should evaluate the limbs to determine the location, extent, and potential cause of the deviation. evaluation consists of observation and then palpation for heat, swelling, or ligament laxity. ligamentous laxity of the medial carpal ligaments is an important cause of carpal valgus and should be evaluated carefully. lameness is not a characteristic of uncomplicated angular limb deformities and suggests further evaluations are necessary. radiography is indicated for foals with severe deviations (all tarsal valgus), ligamentous laxity, lameness, or joint effusions. ultrasonography may be valuable for selected soft tissue evaluations. conservative therapy is by far the most commonly used therapy in foals less than days of age. mild to moderate carpal valgus and external rotation of the carpus and fetlock are common and normal in neonates, particularly light breed horses. most congenital limb deviations improve with age, if the developing musculoskeletal system is protected from overuse and abnormal loads. approximately % of thoroughbred foals with congenital carpal valgus self-correct. those foals that do not most often have abnormal bone (incomplete ossification) with normal stress or normal bone with abnormal stress (ligamentous laxity or contralateral limb lameness). correction continues for several months, and on average, foals reach their straightest conformation (regarding angulation) at approximately months of age (e.m. santschi, unpublished data). determination of the appropriate treatment for foals with angular limb deformities is based on the age of the foal, the severity and location of the deviation, and its causes. one must evaluate the entire foal and the affected limb. if the carpal collateral ligaments have no laxity and carpal incomplete ossification is not suspected, one may use an exercise program such as in table - , assuming that the foal has no contradicting additional problems. exercise is essential for the robust development of almost every body system for neonates, and fresh air and good ventilation reduce the occurrence of respiratory disease. appropriate limb loading along with growth and maturity is what straightens limbs, but excessive amounts of loading can be deleterious. for example, one should use exercise cautiously in foals with very asymmetric deviations. when one limb is much more deviated than the other, it appears to be loaded excessively and compromised more than if both limbs were affected similarly. and finally, limb deviations are additive. foals with external rotation and carpal valgus improve more slowly than those with one type of deviation. incomplete ossification of cuboidal bones and focal ligamentous laxity are complicating matters of great potential impact on adult conformation. they generally manifest as a moderate to severe limb deviation. physical examination indicates laxity because angular limb deviations are reducible. radiographs are the best way to evaluate the extent of carpal bone ossification. incomplete ossification of the cuboidal bones can be focal or widespread. focal immaturity is not common but can result in severe angulation. generalized immaturity is more frequent and initially often manifests as an offset conformation with valgus angulation. when the foal becomes heavier, assumes a base-wide stance, and is allowed exercise, crushing of the bones of the lateral carpus (usually the lateral styloid process of the radius, the ulnar, the fourth and the intermediate facet of the third carpal bone) results in a permanent intracarpal valgus deviation. the same result occurs when significant medial carpal ligament laxity goes untreated. in the forelimb, foals with collateral ligamentous laxity and moderate to severely immature cuboidal bones should have external coaptation placed on the affected limb to maintain axial orientation. tube casts that allow weight bearing on the digit are preferred to splints. ligamentous laxity in the carpus usually responds to tube casting for to days followed by bandaging and cautious exercise. the duration of similar coaptation necessary for immature carpal bones depends on the degree of immaturity and the speed with which the bones mature. because casts cannot be left on neonatal limbs for more than to days because of their fast growth, more than one cast may be necessary. treatment of tarsal valgus and rotational deformities is much less common than in the forelimbs because deviations are less common than in the forelimb, because some breeds prefer an outward position to the hindlimb, and perhaps because owners recognize it less frequently. hindlimbs generally are unaffected by ligamentous laxity, but tarsal incomplete ossification is common and often is associated with tarsal valgus. treatment of tarsal incomplete ossification is important because tarsal crushing results in an unfavorable prognosis for athletic performance. , hindlimbs require a slightly different approach to coaptation than forelimbs because of their anatomy. foals can rise to stand if their forelimbs are fixed in extension but cannot do so if their hindlimbs are extended. the multiple bony protuberances of the hock make cast sores more likely than in the forelimb, so casts are problematic. gutter splints are not useful because of the angle of the hock. severely limiting exercise is part of allowing the tarsus to mature without cartilage crushing, but foals cannot always be recumbent. extra small articulated anterior cruciate ligament splints for human beings (playmaker wraparound, dj orthopedics, vista, california) have given the best results. for small foals, a padded bandage is necessary under the splint, which is reversed to conform to the angle of the hock. the splints allow enough flexion in the hock for the foal to rise but appear sufficient when combined with stall rest to protect the cartilage from crushing. splints are left on the hocks until the cuboidal bones have ossified as shown by radiography. fetlock conformational deviations in neonates that are treated best conservatively are rare. outward rotation is the most common deviation but is thought to have minimal effect on the performance and improves with maturity. the only therapy used is to rasp the toe square to promote central breakover. severe outward rotation can promote a fetlock valgus conformation, so one can use a medial hoof wall extension of epoxy to bring the limb load medially. the most commonly treated fetlock deviations are inward but usually occur in foals older than days. however, if the deviation is noticed in neonates, one can use small lateral hoof wall extensions that generally are made of epoxy with fiberglass cloth embedded to prevent chipping. windswept foals are born with multiple deviations. evaluating the foal as a whole is best rather than focusing on individual joints. most of these foals become straight over time with conservative therapy. no surgical procedures are commonly accepted for direct treatment of rotational or carpal offset deviations, so angular deviations are described. surgical procedures to correct carpal and fetlock valgus include periosteal transection and elevation and transphyseal bridging. periosteal elevation is thought to accelerate growth on the concave side of the metaphysis, and transphyseal bridging is used to restrict the growth on the convex side of the physis. studies indicate an approximately % improvement of carpal valgus foals after periosteal transection and elevation, but unfortunately they do not compare foals that had surgery with controls that did not. , recently, some have suggested that most of the correction was unrelated to the surgery, and one experimental study supports that conclusion. as a result, at this time making firm recommendations about the indications for periosteal transection and elevation is difficult. however, periosteal transection and elevation has a low likelihood of complications and may be effective. the procedure is inexpensive and can be done in the field and therefore may be an option for clients with foals with carpal valgus in which a transphyseal bridging is undesirable or unnecessary. one indication is the very young foal born with a notably asymmetric epiphysis that results in a severe carpal valgus. this distal radial appearance is not particularly common, but the lack of ossification in the epiphysis can make a firm hold with a transphyseal bridging difficult to achieve. however, one can use distolateral radial periosteal elevation at an early age in an attempt to accelerate correction of the valgus and protect developing carpal bones. often a degree of anxiety exists about correction of fetlock angulations because of the much shorter time period for physeal growth. most fetlocks are in their final conformation by days of age, so correction is best accomplished with earlier treatment, usually by weeks of age. one can perform periosteal elevation on the medial (for varus deviations) or lateral (for valgus deviations) aspect of the distal metacarpus/metatarsus. the definitive treatment of limb angulation at a growth plate is transphyseal bridging. one should consider using the procedure at about weeks of age for all moderate to severe fetlock deviations, at about weeks for severe carpal deviations, and to weeks for mild fetlock deviations, moderate carpal deviations, and any worsening angular deformities. one must perform bridge removal when the limb straightens to prevent overcorrection. diaphyseal deviations are rare but can occur in varying degrees of severity. if the foal can bear weight on the limb, a conservative approach is indicated. one can consider periosteal elevation of the length of the concave surface of the long bone. if the foal cannot bear weight on the limb because of the severity of deviation, euthanasia is probably the best option. however, a revision osteotomy and internal fixation may be appropriate for selected foals. polydactyly is also rare and sometimes can be corrected surgically. the outcome is based on the degree of articular involvement. bacteria may invade the foal musculoskeletal system and cause orthopedic infection after delivery by the circulation, by direct extension from another system, or by direct inoculation. hematogenous delivery is by far the most common and results in infection of synovial structures (joints, tendon sheaths, bursae) and bone. extension from another site without hematogenous delivery is rare. direct inoculation almost exclusively results from traumatic rather than surgical wounds. much is still to be learned about the pathophysiology of orthopedic infection, including the source of the infecting bacteria. the umbilicus commonly is accepted as a possible source of bacteria, but many believe that the gastrointestinal and respiratory tracts are at least equally responsible. associated conditions in foals with septic arthritis include failure of passive transfer, pneumonia, and enteritis. the classification of orthopedic sepsis in foals into infection of bones and joints is probably irrelevant because most foals with septic arthritis also have infectious osteitis or osteomyelitis. , septic arthritis is more readily recognizable because the reactivity of the synovium to the bacteria causes joint effusion and lameness and because early radiographic signs of bone infection in foals are equivocal. also unclear are the reasons for the apparent site predilection for orthopedic infection in foals. the femoropatellar joint and the tarsocrural joint are affected most frequently, followed by the carpal and fetlock joints, and finally an assortment of miscellaneous joints such as the elbow, shoulder, and hip. the common association of osteomyelitis of the distal femoral, tibial, and metacarpal/metatarsal physes with a newly recognized septic arthritis suggests that the infection in that area started at the growth center (epiphysis, physis, or metaphysis). the localization of the apparent initial site of infection to the growth center has been suggested to result from "looping" metaphyseal vessels with sluggish blood flow that allow pathogens more time to escape the circulation. , however, transmission electron microscopy indicates that osteogenic cells and the vascular endothelium are a continuous network in developing embryos, indicating that the relationship between circulation and bone is more intimate than previously suspected. a possible association between osteomyelitis and thickened or traumatized cartilage exists. focal osteomyelitis lesions occur commonly at the bone cartilage junction , and particularly in areas where cartilage is attached at an angle to the long axis or where thickened. an association also exists between incomplete ossification of the central and third tarsal bones and osteomyelitis. trauma to the metaphysis is a known predisposing cause of osteomyelitis in young bacteremic rabbits. a trend exists for foals with more than one joint affected to be affected bilaterally in the same joint, rather than in random joints. this trend suggests that a "window" exists when a joint may be more susceptible to infection and that trauma to the developing cartilage may be a contributing factor. in neonates, cartilage is vascular, and possibly small traumatic cartilage lesions with associated hemorrhage and exposure of bacterial binding sites might be the inciting cause for the location of infection. the pathogens most commonly associated with septic arthritis in young foals are also those that frequently are implicated in neonatal sepsis. the most commonly isolated gram-negative organisms are escherichia coli and other enterobacteriaceae, actinobacillus equuli, and salmonella spp. frequently isolated gram-positive organisms include streptococcus spp., staphylococcus spp., and rhodococcus equi. anaerobic bacteria and fungi are rare but should be considered in refractory cases. the diagnosis of orthopedic sepsis can be challenging. the most common clinical sign is lameness, followed by swelling around a joint or metaphysis. joint effusion alone may cause the swelling, but edema is also common, especially if metaphyseal osteomyelitis is present. but effusion and edema can be difficult to detect because of the tissue surrounding the focus of infection in the shoulder, elbow, hip, and coffin joints. one should evaluate lame foals carefully by palpation to localize pain and swelling. if one can find no pain or swelling, one should obtain a complete blood count and fibrinogen level. although a complete blood count is not always abnormal in foals with septic arthritis, abnormalities should raise the index of suspicion of infection. elevations in fibrinogen are fairly common in septic arthritis, and fibrinogen almost always is elevated if the infection involves bone. if hematologic values are normal, the lameness could be caused by trauma, but the foal should be monitored closely for improvement, and closer evaluation is indicated if improvement is not rapid. an arthrocentesis is the diagnostic test of choice for confirmation of septic arthritis. one should perform joint puncture in a sterile fashion, and sedation is indicated to get an atraumatic tap. short-term anesthesia is preferable when joints have effusion because one may perform joint lavage at the same time. normal joint fluid should be clear to slightly yellow, should be viscous, and should contain less than nucleated cells per deciliter. the cell ratio should be roughly : polymorphonuclear and mononuclear. the total protein content should be less than . mg/dl. one should consider joints to be infected if the nucleated cell count is greater than , cells/dl. for joints falling between and , cells/dl, if the polymorphonuclear cell count is > %, one should consider the joints infected. cytologists are often reluctant to diagnose infection when nuclear degeneration or bacteria are not visible. this is overly conservative and results in delay in treating infections because bacteria and nuclear degeneration are rare in early cases of joint infection. out of an abundance of caution, one should treat lame foals with suspicious joints as infected unless they are clearly normal. one should always culture joint fluid in an attempt to identify the offending organisms, but because of difficulties in culturing pathogens from joint fluid samples, absence of growth does not mean absence of infection. one obtains the best culture results if the foal has not been treated with antimicrobial agents beforehand. one should obtain as much joint fluid as possible for culture and should incubate it overnight in blood culture media before plate inoculation. as always in potentially septic foals, blood culture may assist in the isolation of the organism. other orthopedic infections that do not involve the joint may be more difficult to detect. often these are not apparent until infection breeches the joint and causes lameness. however, astute caretakers may notice early clinical signs such as mild lameness, fever, or edema centered at a growth center. radiography and advanced imaging modalities such as magnetic resonance imaging are the best diagnostic tools for the localization of areas of osteitis and osteomyelitis. one should examine the area of concern carefully, giving particular attention to the growth centers and subchondral bone. interpretation of radiographs may be difficult because these areas are complex and normally have irregular bone margins in the growing foal. if a normal contralateral joint is available, comparison radiographs may be useful. because of the high metabolic turnover in growing foal bone, changes occur faster than with adults, so radiographs at the earliest sign of potential infection of bone and joint are recommended. if evidence of osteolysis is clear, aspiration of the area may yield material for culture. the goals of treatment are to eliminate infection immediately and then resolve inflammation. bacteria and products of inflammation elicited by infection are responsible for destruction of bone and cartilage. the ultimate aim of treatment is to protect the structures critical to athletic performance such as subchondral bone and cartilage in weight-bearing areas. advances in the treatment of sepsis have resulted in hospital discharge rates of % for foals with septic arthritis, but their rate of high performers is %, indicating a need for improvement. equine veterinarians cannot replace what has been destroyed, so early identification and aggressive therapies are presently the best methods to improve performance rates. one achieves the goals of treatment by physical removal of bacteria, products of inflammation, and debris and by medications to kill the bacteria and reduce inflammation. one should optimize the physiology and general health of the foal to assist this process; one should include other treatments and supportive therapies for septic foals, especially treatment of failure of passive transfer, in the therapeutic plan. intravenous administration of antimicrobials (see chapter ) is the cornerstone of treatment of orthopedic infection, and if the drug is administered early in the course of infection and bacteria are susceptible, intravenous administration may be sufficient to eliminate the organisms. however, treatment of many foals does not begin until disease is advanced. if treatment begins after bacteria have had a chance to establish themselves, one should bring all appropriate methods to bear to end the infection. additional therapies for septic arthritis include joint lavage, arthrotomy (for drainage), , debridement (arthroscopically or arthrotomy), intraarticular administration of antimicrobials, intravenous regional perfusion, and antimicrobial beads. , one can use any sterile isotonic solution to flush a joint, and additives do not appear to give significant additional benefit. if radiographs do not indicate osteomyelitis, lavage, intraarticular antibiotics, and if possible, regional perfusion are recommended. if osteitis or osteomyelitis is present, debridement is indicated arthroscopically or via arthrotomy (one should culture the debris if the pathogen is unknown). if the joint is closed, one may use antibiotics intraarticularly. if the joint is left open to drain, regional perfusion is useful. antimicrobial beads theoretically are best to use if the wound is closed, but they appear to give benefit even if the wound is open under a bandage. because of concerns about the use of beads in a joint, beads often are used in tissue defects and the surrounding tissues. the major goal is to remove material that is compromising healthy tissues and to obtain high concentrations of antimicrobials in infected tissues. high antimicrobial concentrations are necessary because adhered bacteria are difficult to kill and may require many times the in vitro bacterial minimum inhibitory concentration. intraarticular administration of antimicrobials has been used for many years and has great value. regional perfusion of diluted antimicrobials recently has come into use and may be administered intraosseously or intravenously. intravenous perfusion is preferable because no special equipment is needed, but intraosseous perfusion may be valuable where intravenous access is impossible. the concept behind both procedures is to fill the venous vasculature in the area of the infection with antimicrobials diluted by a sterile balanced electrolyte solution. one isolates the anatomic area of interest using one or two tourniquets. the perfusate diffuses into all tissues and achieves much higher concentrations than are possible using intravenous therapy. this technique has shown excellent results as an adjunct therapy for orthopedic infection. for foals, to ml total of perfusate containing mg amikacin is useful for most single joint sites. amikacin has given consistently good results without complication and is a good choice based on its concentration-dependent activity. one may use a higher volume for the stifle, but the thigh musculature makes an effective tourniquet difficult to achieve. because of concerns that perfusion might dislodge bacteria and renew systemic sepsis, high concentrations of systemic antimicrobials are recommended at the time of the perfusion. if joint lavage and intraarticular administration of antimicrobials are not sufficient to resolve infection, one may perform arthrotomy to assist the joint to drain. passive and active drains add foreign material and so are not useful. maintaining the joint under a sterile bandage is critical and can be difficult to do in proximal joints such as the stifle and elbow. tie-over bandages can be useful in this application. the best measure of success is the resolution of lameness and local inflammation. radiographs may be helpful, but the most common sign of success is a failure of the infection to progress, rather than radiographic healing. one should continue intravenously administered antimicrobials for at least week after the resolution of lameness. if an appropriate drug is available, one should give foals antimicrobials orally for at least weeks more. a total of at least weeks of antimicrobials is recommended for most foals with orthopedic infection. treatment failures usually result from an inability to kill bacteria adhered to isolated tissue (usually dead bone). sometimes this failure is caused by incomplete debridement or an inability to access a known site of infection, but more frequently it is because infection has flourished in an unknown site. for this reason, multiple imaging modalities (radiographs, ultrasound, computed tomography, and magnetic resonance imaging) used multiple times are 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arthritis/tenosynovitis regional intravenous perfusion of the distal limbs of horses with amikacin sulfate treatment of sepsis in the small tarsal joints of horses with gentamicin-impregnated polymethylmethacrylate beads use of antibioticimpregnated polymethyl-methacrylate in horses with open or infected fractures or joints: cases ( - ) the effect of implanting gentamicin-impregnated polymethylmethacrylate beads in the tarsocrural joint of the horse regional perfusion of the equine carpus for antibiotic delivery how to perform equine digital intravascular perfusion surgical management of rhodococcus equi metaphysitis in a foal intraosseous regional perfusion for treatment of septic physitis in a -week-old foal key: cord- - bwhaga authors: aydogdu, ugur; coskun, alparslan; atas, ahmet duran; basbug, onur; agaoglu, zahid tevfik title: the determination of treatment effect of chitosan oligosaccharide in lambs with experimentally cryptosporidiosis date: - - journal: small ruminant research doi: . /j.smallrumres. . . sha: doc_id: cord_uid: bwhaga abstract in this study, it was aimed to investigate the efficacy of chitosan oligosaccharide administrations in different doses of experimental infected lambs with cryptosporidium parvum. male lambs were used in the study and the lambs were divided into groups with lambs in each group. groups , and , twice a day, were administered chitosan oligosaccharide at a dose of , , and mg/kg for days, respectively, with milk replacer. in group , lambs with cryptosporidiosis were subjected to normal feeding as control without drug administration. clinical examinations of lambs were made before treatment (day ) and on days , , and after treatment and ml of blood was collected from vena jugularis for blood analysis of all lambs. weight changes of lambs were recorded at , , , and days. stool specimens were collected pre-treatment (day ) and on days , , , , and post-treatment to determine oocyst excretion of lambs with cryptosporidiosis. lambs with a mean oocyte counts > after stool examination were included to the treatment. changes in clinical hematology, blood gases and biochemical parameters were observed during the course of treatment, but these changes were limited. weight loss was observed at th day according to th day the lambs with experimental cryptosporidiosis but gradually weight increase was observed at th and st days and these changes were similar in all groups. oocyst excretion decreased in all groups during treatment. according to th day, there was a significant (p < . ) decrease in oocyte excretions in the third day in group and , and in day in the group and . significant changes (p < . ) were observed in oocyst excretions on the third and fifth days among the groups. as a result, in lambs with experimental cryptosporidiosis, chitosan oligosaccharide improved in clinical signs and stool character shorter than the positive control group and the administration of chitosan oligosaccharide at doses of , and mg/kg for days significantly reduced oocyst excretion but not enough to remove cryptosporidiosis completely. infection caused by cryptosporidium parvum is common among young ruminants and is seen in various mammalians including humans. the disease has a high prevalence across the world and is among the important causes of diarrhea in neonatal farm animals (scott, ; paraud and chartier, ; constable et al., ) . c. parvum is one of the primary causes of diarrhea seen in young lambs and goats. diarrhea can develop as a result of c. parvum infection alone; however, it mostly develops due to mixed infection. infection can occur as a severe diarrhea outbreak which can cause high mortality in lambs aged - days (zorana et al., ; goma et al., ; paraud and chartier, ; constable et al., ) . there is no specific treatment for cryptosporidiosis. it has been reported that paromomycin, lasalocid, halofuginone lactate, sulfoxinoxalin, azithromycin and toltrazuril have partial or demonstrable effect against in neonatal ruminants with cryptosporidiosis (viu et al., ; wright and coop, ; giadinis et al., ; navarre et al., ; yagci et al., ; aydogdu et al., ) . chitosan is a natural polysaccharide produced by deacetylation of chitin. it is non-toxic, biocompatible and biodegradable (huang et al., ; zhao et al., ) . chitin is the main component of crustaceans (crab, shrimp, etc.) and is also found in skeletons of insects and cell walls of fungi. there are many derivatives of chitin and the most important one is chitosan (kumar, ) . chitosan and chitosan oligosaccharide (cos) have important uses in the medical field, such as controlled drug release, artificial blood vessels, antidiabetic, antibacterial, antifungal and hemostatic effect (baldrick, ; xia et al., ; muanprasat and chatsudthipong, ) . in a study on the treatment of calves with diarrhea, oral chitosan oligosaccharide administration has been reported to be successful in treatment (alam et al., ) . in studies conducted, chitosan has been reported to inhibit the in vitro development of c. parvum (luzardo Álvarez et al., ; adjou et al., ; mammeri et al., ) . there is no study found in which the efficacy of chitosan oligosaccharide in the treatment of cryptosporidiosis in neonatal ruminants has been determined. according to this information, this study is the first to determine the efficacy of chitosan oligosaccharide in the treatment of cryptosporidiosis in lambs. considering that chitosan inhibits the development of c. parvum in in vitro studies, we hypothesized that oral chitosan administration may be used in the treatment of lambs with experimentally cryptosporidiosis. the aim of this study was to determine the treatment efficacy of oral chitosan oligosaccharide in lambs with experimental cryptosporidiosis. ethics committee approval of the project was taken from sivas cumhuriyet university animal experiments local ethics committee ( . . / ). the study was conducted between - . experimental procedure was started simultaneously in all groups. in our study, a total of male lambs younger than days of age, lambs in every groups, were used. stool specimens of lambs were collected and tested using rapid pen-side test (bio-x diagnostics s.a. belgium) in terms of cryptosporidium parvum, rotavirus, escherichia (e) coli and clostridium perfringens. stained stool samples were also examined for cryptosporidium detection. positive ones were excluded from the study. to prevent contact between lambs, each was housed separately in individual compartments. c. parvum oocysts needed for the formation of infection were obtained from rectal stool samples taken from naturally infected calves with diarrhea. stool samples of the calves were examined using a rapid pen-side test (bio-x diagnostics s.a. belgium) in terms of the presence of rotavirus, coronavirus and e. coli and negative ones were used. the oocysts required for infection formation were obtained as reported in a study conducted on goat kids (koudela and jiri, ) . for the formation of infection in lambs, ml distilled water containing c. parvum oocysts were given using an intraorally catheter (nasogastric catheter ch, mm, bicakcilar co. ltd., istanbul, turkey). the development of the infection was monitored through the collection of rectal stool samples daily and microscopic examination of the stained preparations. the stained preparations from stool samples was made according to koudela and jiri ( ) . lambs with an average of > oocysts in stained stool preparations were considered to be infected, and treatment was initiated. when infection developed the following treatment protocols were applied to groups, each including lambs. oocyst shedding started in the lambs on the th and th days, and it had reached to peak level between on day and . as a treatment procedure, doses of , and mg/kg chitosan oligosaccharide were given to the lambs in st, nd, and rd groups at intervals of h. no drug was given to the infected lambs in the th group and they were fed normally for positive control. considering dehydration degree and blood gas analysis findings, required fluid treatments were given to the lambs in which diarrhea caused dehydration developed (oral fluid treatment was applied to the lambs with mild or moderate dehydration and metabolic acidosis (ph = . - . ), intravenous ml/kg/hour isotonic sodium bicarbonate was applied to the lambs with severe dehydration and metabolic acidosis (ph < . ), % dextrose was applied in case of hypoglycemia). during the study, lambs were fed with lamb food (optimilk, optima, kirklareli, turkey) at an amount of - % of their body weight at a proper temperature in two meals. in addition, adlibitum water was provided to lambs. in the study, water-soluble ( %) chitosan oligosaccharide with a deacetylation degree > % and a molecular weight < daltons was used as the treatment material (glycobio company, dalian, china). routine clinical examinations of the lambs (body temperature, heart frequency, respiratory rate, capillary refill time, assessment of dehydration degree) were conducted before the treatment (day ) and on st, rd, th and th days of the treatment. during the treatment, lambs were examined daily clinically and in terms of the stool analysis. . . collection of blood samples and analyses ml of blood samples were collected from lambs before the treatment (day ) and on st, rd, th and th days during treatment for blood gas analysis, hematological analyses (into k edta tubes) and biochemical analyses (into ml anticoagulant free gel tubes). blood hydrogen ion concentration (ph), partial carbon dioxide pressure (pco ), partial oxygen pressure (po ), bicarbonate (hco − ), total carbon dioxide (tco ), base excess (be), oxygen saturation (o sat), glucose and lactate levels were measured using blood gas analyzer (epoc, canada) immediately after blood sample collection without adding anticoagulant agents. using blood samples collected in k edta tubes, white blood cell (wbc), red blood cell (rbc), hemoglobin (hgb), hematocrit (hct), mean corpuscular volume (mcv), mean cell hemoglobin concentration (mchc), red cell distribution width (rdw) and platelet (plt) values were determined by automatic cell counter (bc- vet, mindray, china). hematological analyses were conducted within min after blood collection. the tubes without anticoagulant were kept at room temperature for clotting and centrifuged at rpm for min to obtain serum. serum samples were stored at - °c until the analysis. urea, creatinine, total protein, albumin, aspartate aminotransferase (ast), gamma-glutamyltransferase (ggt) and alkaline phosphatase (alp) levels in serum samples were determined using autoanalyzer (bs , mindray, china). stool samples of lambs were collected from the rectum into sterile stool container before the treatment (day ) and on the st, rd, th, th and st days of the treatment. stool samples were evaluated in terms of physical [normal(solid), loose and formless, semi-fluid, watery] and oocysts. the presence of c. parvum oocysts in stools was determined using kinyoun acid-fast staining method (korkmaz and ok, ) . stained preparations were examined using immersion oil at x magnification in the light microscope. the concentration of c. parvum oocysts in the stool was averaged by counting the oocysts in different microscope fields in each preparation, and semi-quantitative scoring was made as follows; the absence of oocysts ( ), oocyst < ( ) oocysts between - ( ), oocysts > ( ). lambs with a mean number of oocysts > were included in the study (koudela and jiri, ) . examination of stool samples were made by the same personnel. lambs were weighed using a digital scale before treatment (day ) and on post-treatment th, th and st days and weight changes were recorded. the data were expressed as mean and standard error of the mean (sem). kolmogorov-smirnov test was used for normality. one-way anova and tukey multiple range tests were used to evaluate differences between each treatment group during the experiment and significance levels of variation. the statistical significance level was accepted to be p < . . the spss software program (version . , spss inc., chicago, il, usa) was used for statistical analysis. after oral administration of oocysts, as of rd day, it was observed that there were changes in the characteristics of stool, that there was a decrease in the stool consistency and that oocyst excretion started with the presence of mucus. after oral administration of oocysts in lambs, as of th- th days, diarrhea ranging from the pasty to liquid in consistency containing a high number of oocysts was observed and lambs that were suitable to the experimental procedure were taken to treatment protocols. infection occurred in all lambs in groups, and experimental procedure was applied to all lambs (n = ). stools with mucus were observed in , , and lambs in groups , , , and , respectively. when intense oocysts began to be excreted, stools were in yellowgreenish color and sometimes brown color and had a condensed mucus appearance. there was no blood observed in stools. there was no death in groups - for days; however, lamb in group died on the rd day and lamb on the th day. both lambs died in the th group had condensed mucus and liquid diarrhea and dehydration were observed in these lambs. inappetence, abdominal distension, severe diarrhea and hypoglycemia were observed on the last day in the dead lamb. the lambs did not respond to fluid treatment applications and died. lambs that developed cryptosporidiosis generally had a dynamic appearance, normal mucosa, and good sucking reflex. however, depression, reluctance to stand up, dehydration (max. % level), prolonged capillary refill time ( s) and a decrease in sucking reflex were observed in some lambs. dehydration occurred only in of lambs in a maximum level of %. changes in the body temperature, heart and respiratory frequencies of lambs are presented in table . the body temperature of the lambs was observed to range from . to . ᵒc. there was a significant difference (p < . ) observed on day between the groups in terms of body temperature and no significant difference was found for the other days. moreover, the body temperature of lambs decreased in all groups compared to day and this decrease was statistically significant except for the th group (p < . ). a significant difference was found on the st day between the groups in terms of respiratory frequency (p < . ). changes in the oocyst excretion of the lambs before the treatment (day ) and on post-treatment st, rd, th, th, th and st days are given in table . it was found that oocyst excretion in group and significantly decreased from the rd day compared to day (p < . ). on the other hand, it was found that oocyst excretion in group and significantly decreased from the th day compared to day (p < . ). as between groups, a significant decrease was observed in group on the rd day and in group on the th day compared to group (p < . ). body weight measurements of lambs were performed before the treatment (day ) and on post-treatment th, th and st days. the changes in the body weight of the lambs by days are given in table . it was found that lambs in all groups had weight loss on the th day and that there was a gradual increase in the weight on th and st days. there was no significant difference observed between groups in terms of weight changes of lambs. when the in-group differences between the days were examined, significant differences were found in the groups except for the third group (p < . ). the blood gas analysis results of the lambs before and during treatment by days are given in table . in all groups, the mean blood ph was within the normal range ( . - . ) during the treatment. ingroups, there was no statistically significant change in blood ph between the days; however, there was a statistically significant difference between the groups on the th and th days (p < . ). metabolic acidosis was observed in cases in the group on day and ; case in the group on day ; cases in the group on day and ; cases in the group on day and . while pco levels were similar between groups, increases and decreases were observed in-groups between the days. however, these increases and decreases were statistically significant only in st and nd groups (p < . ). blood po and o sat levels did not show significant change between groups and in-groups between days. the lactate level of group was significantly higher than the other groups on day and the lactate level of group was significantly higher than those of group and group on the second day. there were increases and decreases in lactate level in-group between days and a statistically significant difference was observed in st and th groups (p < . ). there were increases and decreases in hco , be and tco levels of lambs during the treatment. however, these changes were not significant to affect ph. the difference in hco , be and tco levels in-group between days was significant (p < . ) only in the nd group. there were significant differences determined between the groups in terms of hco , be and tco levels on th and th days (p < . ). changes in the hematological parameters of the lambs by days before and during the treatment are given in table . although there were increases and decreases in hematological parameters in-group between days, there was no statistically significant difference found. there was significant (p < . ) difference in wbc levels on the st day between the groups and there was no significant difference found on the other days. there was a similarity between the groups in terms of rbc, hgb, hct, mchc and plt levels. in addition, between the groups, mcv levels were different at a statistically significant level on th, st and rd days and rdw levels on the st day (p < . ). changes in the biochemical parameters of the lambs by days before and during the treatment are given in table . while ast levels of the lambs increased during the treatment compared to pre-treatment (day ), alp, tp and ggt levels decreased. however, only changes in ast and alp activities of the st group and the change in total protein level of the nd group were statistically significant (p < . ). while there were increases and decreases in urea and creatinine levels of the groups by days, changes in the creatinine levels only in the st and nd groups were significant (p < . ). when the glucose levels of the groups were examined by days, glucose levels of the st, nd and th groups decreased on the nd day compared to day and increased in the following days. the glucose level of the rd group decreased on the st and rd days compared to day and increased gradually in the following days. statistical significance was determined only in the st group (p < . ). significant differences (p < . ) between the groups were determined only in tp and creatinine levels on the th day. a major problem about cryptosporidiosis is the lack of an effective tool for the prevention and treatment of this disease. more than substances have been tested to treat cryptosporidiosis (dinler and ulutas, ). some have shown promising effects; however, none of them have been reported to control clinical findings consistently or eliminate the infection completely. on the other hand, the use of certain drugs may reduce the oocyst excretion and thus probably the environmental pathogen level, the subsequent exposure, and infection of susceptible hosts (shahiduzzaman and daugschies, ) . it has been reported that paromomycin, halofuginone lactate, lasalocid, and sulfaquinoxaline have partial or demonstrable effect against cryptosporidium in infected neonatal ruminants (wright and coop, ; aydogdu et al., ) . however, knowledge about the treatment of cryptosporidiosis in sheep is limited. halofuginone exhibits -fold toxicity of the recommended doses of lactate, and its use is contraindicated in severely dehydrated or inappetent animals (wright and coop, ) . in addition, many drugs such as paromomycin, azithromycin, and sulfaquinoxaline that have been determined to reduce oocyst excretion in cryptosporidiosis have a risk to leave antibiotic residues. in recent years, serious concerns about antibiotic residues have emerged worldwide. in recent years, there have been studies carried out about the effects of chitosan and its derivatives on the underlying mechanism of antimicrobial activity of chitosan microparticles in the medical field and on the treatment of infectious diseases (jeon et al., ) . kim et al. ( ) reported that oral chitosan oligosaccharide applications at doses of , and mg/kg/day did not cause any side effects different letters in the same rows (a, b) and columns (a, b) are statistically significant (p < . ). group : mg/kg cos, group : mg/kg cos, group : mg/kg cos at intervals of h, group : no drug was given to the infected lambs. . ± . a . ± . a . ± . a,a . ± . a,b . ± . c . ± . d . ± . d different letters in the same rows (a, b, c, d, e) and columns (a, b) are statistically significant (p < . ). group : mg/kg cos, group : mg/kg cos, group : mg/kg cos at intervals of h, group : no drug was given to the infected lambs. in rats. in a study conducted, protective activity of chitosan oligosaccharide has been determined in mice in which colitis was formed experimentally (yousef et al., ) . chung et al. ( ) , found that oral administering of chitosan oligosaccharide with a low molecular weight reduced the allergic inflammation in mice in which experimental asthma model was formed. abdel-latif et al. ( ) reported that it had "anticoccidial" effects on eimeria papillata-infected mice. in the same study, it has been reported that both excreted oocysts and developmental stage parasites were reduced and chitosan had anti-inflammatory activity (abdel-latif et al., ) . in a study, oral chitosan oligosaccharide administering in the treatment of diarrheal calves has been reported to be very successful (alam et al., ) . in addition, chitosan has been used to create excipients in a microparticle system and it has been reported that it might play a role as a physical barrier against cryptosporidium parvum (blanco-garcía et al., ) . in the studies conducted, it has been reported to inhibit the in vitro development of c. parvum (luzardo Álvarez et al., ; adjou et al., ; mammeri et al., ) . in addition, mammeri et al. ( ) reported that chitosan nag and chitosan mix demonstrated in vivo anticryptosporidial properties in cd- mice, a highly sensitive animal model against c. parvum infection. therefore, it has been stated that both of these compounds have a promising potential in therapeutic and preventive applications against c. parvum infection. in this study, oocyst excretion decreased significantly (p < . ) in the st and nd groups by the rd day compared to pre-treatment and in the rd and th groups by the th day. as between groups, a significant decrease was observed in group on the rd day and in group on the th day compared to group (p < . ). although stool characteristics became normal on the th and st days, it was observed that oocyst excretion still continued in the lambs. while all the lambs in the positive control group had oocyst excretion at the level of + on the th and st days, this level was found to be lower in treatment groups compared to the positive control group. however, there was no statistical difference found. these results showed that chitosan oligosaccharide significantly reduced oocyst excretion compared to the positive control group; however, it was not efficacious to eliminate cryptosporidiosis completely. according to the findings of this study, the use of chitosan oligosaccharide to be used in the treatment of experimental cryptosporidiosis at doses of and/or mg/kg was found to provide an earlier reduction in oocyst excretion compared to mg/kg dose. the use of higher doses had no negative effect; however, it increases the costs and does not show more positive affects compared to lower doses. considering this, a dose of mg/kg was thought to be the most appropriate dose. the results indicated that low dose of chitosan oligosaccharide was better to reduce oocyst excretion and improve clinical findings in lambs with cryptosporidiosis. studies ph: concentration of hydrogen ions, pco : partial pressure of carbon dioxide, po : partial pressure of oxygen, hco − : bicarbonate, tco ; total amount of carbon dioxide, be: base excess, o sat: oxygen saturation. different letters in the same rows (a, b) and columns (a, b) are statistically significant (p < . ). group : mg/kg cos, group : mg/kg cos, group : mg/kg cos at intervals of h, group : no drug was given to the infected lambs. (mammeri et al., ) on the exact mechanism of action of chitosan continue. it has been reported that it is possible for chitosan to cause effects on the production of trophozoites and oocysts via various mechanisms (direct effects on parasitic viability and/or infectivity and/or parasitic growth in intestines and/or oocyst formation) (mammeri et al., ) . however, further studies are required to determine the exact mechanism of action. the limitations of this study are the absence of a negative control group without infection and treatment and the absence of groups treated with cos without cryptosporidiosis infection. generally, if there is no mix infection, the clinical findings in cryptosporidiosis are not severe and are transient and mild levels. in mix infections, clinical findings are more severe and mortality rates are higher. morbidity rates are high and mortality is low in cryptosporidiosis infections alone (constable et al., ) . in this study, it was observed that the changes in the clinical findings were not severe in all groups; however, there were some individual differences. the characteristics of diarrhea improved day by day in the treatment groups and in the positive control group. in the treatment groups (g - ), stools became normal or pasty in consistency on the th day, while there was still diarrhea in liquid level in cases in the positive control group on the th day. these results showed that chitosan oligosaccharide provided faster recovery in clinical findings and stool characteristics in lambs with cryptosporidiosis compared to the positive control group. the most important clinical finding in cryptosporidiosis is diarrhea in varying levels. endogenous forms of cryptosporidium lead to loss of mature enterocytes, shortening, and fusion of villus. they disrupt the microvilli boundary which causes the elongation of crypts caused by increased cell division and edema. this causes the loss of membranebound digestive enzymes, reduces intestinal absorption capacity and reduces intake of liquids, electrolytes, and nutrients from the intestinal lumen (foster and smith, ; constable et al., ) . in this study, it was found that although some significant in-group and/or intragroup changes were observed in blood gases, hematological and biochemical parameters in both treatment groups and in the positive control group, these changes remained limited and progressed generally within the reference limits. metabolic acidosis was observed in cases in the group on day and ; case in the group on day ; cases in the group on day and ; cases in the group on day and . however, it was determined that metabolic acidosis was at moderate and severe levels in only st and th groups in case in each. in other cases, the severity of metabolic acidosis remained mild. these results show that experimentally developed cryptosporidiosis alone in lambs leads to changes in blood gases and hematological and biochemical parameters; however, these changes were not at a level to disrupt the general condition. in conclusion, it was found that experimental cryptosporidiosis can be formed successfully through the oral inoculation of the solution containing oocysts in lambs aged < days, that oral administering of chitosan oligosaccharide in lambs at doses of , and mg/ kg had no side effect, that chitosan oligosaccharide provided faster recovery in clinical findings and stool characteristics in lambs in which cryptosporidiosis was formed experimentally compared to positive control group and that administering of chitosan oligosaccharide at doses of , , mg/kg for days significantly decreased oocyst excretion; however, it was not efficient enough to completely eliminate cryptosporidiosis. in this study, the appropriate chitosan oligosaccharide dose to treat cryptosporidiosis in lambs was observed to be - mg/kg, whereas new studies on this subject are required. we think that this study will provide a basic knowledge for further studies on the use of 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goat kids in serbia this project supported by the scientific and technological research council of turkey (project number: o ). ast: aspartate aminotransferase, alp: alkaline phosphatase, ggt: gamma-glutamyltransferase, tp: total protein. different letters in the same rows (a, b) and columns (a, b) are statistically significant (p < . ). group : mg/kg cos, group : mg/kg cos, group : mg/kg cos at intervals of h, group : no drug was given to the infected lambs. key: cord- - rblzyry authors: hill, andrew; wang, junzheng; levi, jacob; heath, katie; fortunak, joseph title: minimum costs to manufacture new treatments for covid- date: - - journal: nan doi: nan sha: doc_id: cord_uid: rblzyry introduction: ‘repurposing’ existing drugs to treat covid- is vital to reducing mortality and controlling the pandemic. several promising drugs have been identified and are in various stages of clinical trials globally. if efficacy of these drugs is demonstrated, rapid, mass availability at an affordable cost would be essential to ensuring equity and access especially amongst low- and middle-income economies. methods: minimum costs of production were estimated from the costs of active pharmaceutical ingredients using established methodology, which had good predictive accuracy for medicines for hepatitis c and hiv amongst others. data were extracted from global export shipment records or analysis of the route of chemical synthesis. the estimated costs were compared with list prices from a range of countries where pricing data were available. results: minimum estimated costs of production were us $ . /day for remdesivir, $ . /day for favipiravir, $ . /day for hydroxychloroquine, $ . /day for chloroquine, $ . /day for azithromycin, $ . /day for lopinavir/ritonavir, $ . /day for sofosbuvir/daclatasvir and $ . /day for pirfenidone. costs of production ranged between $ . and $ per treatment course ( – days). current prices of these drugs were far higher than the costs of production, particularly in the us. conclusions: should repurposed drugs demonstrate efficacy against covid- , they could be manufactured profitably at very low costs, for much less than current list prices. estimations for the minimum production costs can strengthen price negotiations and help ensure affordable access to vital treatment for covid- at low prices globally. introduction as the sars-cov pandemic continues to grow, researchers worldwide are urgently looking for new treatments to prevent new infections, cure those already infected or lessen the severity of disease. an effective vaccine may not be widely available until late , even if trials are successful [ ] . there are clinical trials in progress to 'repurpose' drugs, normally indicated for other diseases, to treat covid- [ , ] . the shortened development timeline and reduced costs to this approach [ ] of using already existing compounds is particularly advantageous compared with new drug discovery in a pandemic situation, where time is of the essence. antiviral drugs include nucleotide analogue remdesivir, which was previously used experimentally but unsuccessfully against ebola [ ] [ ] [ ] [ ] , favipiravir, used to treat influenza [ ] , the hiv protease inhibitor lopinavir/ritonavir (lpv/r) [ , ] , the antimalarials chloroquine and hydroxychloroquine [ ] [ ] [ ] , and the directacting antivirals sofosbuvir and daclatasvir [ ] , which are all potential candidates. additionally, treatments to improve lung function and reduce inflammation, such as pirfenidone [ , ] and tocilizumab [ , ] , are being evaluated in clinical trials. most of the clinical trials reported so far are small pilot studies, often non-randomised, making interpretation of current evidence difficult. however, results from randomised trials of these repurposed treatments should become available from may onwards. if favourable results are shown from these new trials, there is the potential to rapidly upscale production of the most promising drugs. the safety profiles of these drugs have already been established from clinical trials for other diseases, so they could be rapidly deployed to treat covid- before vaccines become available. low-and middle-income countries will need access to these treatments at minimum prices to ensure all those in need can be treated. even in high-income countries, the burden of disease could be so great that access to drugs at minimum costs could also be necessary. the hiv epidemic has been controlled by mass treatment with antiretroviral drugs worldwide, at very low unit costs. large donor organisations such as the global fund for aids, tb and malaria (gfatm) and the president's emergency plan for aids relief (pepfar) order drugs to treat > million people with hiv, at prices close to the cost of production [ , ] . this system allows low-and middle-income countries to access high-quality drugs at affordable prices. the minimum costs of drug production can be estimated by calculating the cost of active pharmaceutical ingredients (api), which is combined with costs of excipients, formulation, packaging and a profit margin, to estimate the price of 'final finished product' (ffp) -the drug ready for use. there are established methods for these calculations, which have reliably predicted the minimum costs of drugs to cure hepatitis c [ , ] and other diseases [ , ] . the purpose of this analysis was to apply the same calculations to the new candidate treatments for covid- . the leading candidate drugs to treat covid- were selected based on recent reviews and analysis of ongoing clinical trials [ , , [ ] [ ] [ ] , [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] . the treatments selected were remdesivir, favipiravir, lopinavir/ritonavir, hydroxychloroquine, chloroquine, azithromycin, pirfenidone, tocilizumab and sofosbuvir/daclatasvir. all are currently being evaluated in randomised trials, with results expected between may and september . the methods used to estimate minimum costs of production have been described previously [ , ] . briefly, we analysed the costs of exports of api from india using the online tracking database panjiva [ ] , which shows details of all shipments of api with quantities and costs per kilogram. we used all available costing data for each drug api found on panjiva, excluding shipments < kg in size, alongside the lowest and highest % of results based on prices per kg. a % api loss during tableting process was factored into our calculations, and a conversion cost of us $ . per tablet was used. a multiplier based on api mass was applied to account for the price of excipients, which are additional substances needed to convert api into fpp. our estimated api costs presume that production is carried out by a generic provider of apis, where associated costs of capital investment, overhead and labour are not as high as for production by originator companies. this method was applied to small-molecule drugs only. in addition, the drug remdesivir, which is administered by iv infusion, was considered separately when estimating formulation costs. a profit margin of % and indian taxation of % on profit was added. these results were cross-checked with a second api database, pharmacompass [ ] , which displayed records up to only. panjiva was selected to provide real time, up-to-date shipment and cost data. the estimates assume a volume of kg of api for each compound. three drugs did not have available data on api production: remdesivir and favipiravir and tocilizumab. for the first two, api production costs were estimated based on published routes of chemical synthesis [ , , , ] . since remdesivir is administered by iv infusion, the costs of production were adjusted to include the cost of injections, according to an established method used for the world health organization (who) essential medicines list [ ] . it was not possible to track the cost of api for the monoclonal antibody tocilizumab; therefore, we tracked list prices in a range of countries, in particular developing economies as a proxy for minimum costs. the costs of regulatory filings and approvals are often significant add-ons to the initial use of drugs in any specific country. all drugs analysed in this study, except for remdesivir have been approved for treatment for some indications in all countries, but few are approved for treatment of covid- . remdesivir is an investigational drug without any prior regulatory approvals, but it has a known favourable safety profile after clinical trials against ebola. favipiravir has been approved for the treatment of influenza in japan since [ ] , and in china since march . it has also been approved for investigational use (china and italy) against covid- in march . we have not included the cost or timing associated with regulatory approvals for the use of these drugs. we are assuming in our analysis that the who and other influential regulatory agencies will cooperate to define a pathway for use of these drugs which does not include additional financial outlays or filing for marketing approvals. the minimum costs of production were then compared with published list prices for each drug in a range of countries -usa, uk, france, sweden, south africa, india, bangladesh, malaysia, brazil, turkey, pakistan, egypt and china [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] -to give a representative sample of prices in countries with different levels of economic development. for consistency, we selected a single data source per country to be used for all searches of drug prices within that country, based on the organisation of data and perceived reliability. not all drugs analysed in this study were available in our selected countries, and in some countries, online pharmacy sites were used because national databases were not available. where several prices were available in the same database, the lowest price was selected. available clinical trial data for each drug were collected from literature searches, clinicaltrials.gov and the chinese clinical trials registry. results from pilot studies were included, together with the planned clinical trial programmes and expected completion dates. the predicted costs of production, and the highest/lowest available list prices of all drugs analysed are shown in table , and chemical structures for all drugs are shown in figure . remdesivir remdesivir (formerly gs- ) has been evaluated for treatment of sars and ebola [ , ] . there are five randomised trials of remdesivir for sars-cov , with first results expected at the end of april . there is a -day course of treatment under evaluation. the dose of remdesivir is mg on the first day with mg per day thereafter. remdesivir is administered by iv infusion. one metric ton of remdesivir is sufficient api to manufacture , courses of treatment, without allowance for any losses during formulation. based on analysis of the published second-generation route of chemical synthesis and assumed overheads such as occupancy rate per hour and labour of an india-based generic producer, the cost of api was estimated to be $ /kg [ , ] for -kg batches produced without capital investment in dedicated remdesivir production facilities. the -day course of treatment would therefore cost $ . per person. after adjustment for the cost of formulation (and % losses projected during formulation), cost of vials, profit margin and tax, the estimated cost per treatment would be approximately $ per person as shown in figure a . daily cost is estimated to be $ . . as an iv infusion, there would be an additional cost for saline, estimated at $ per infusion [ ] , equipment such as syringe, sterile water for reconstitution and iv lines, as well as staff-time cost associated with the healthcare professional administrating the infusion. these additional non-drug components are likely to be more expensive than the estimated cost of the drug itself and are not included in our cost estimate. the main randomised trial of favipiravir evaluated up to days of treatment, vs another influenza drug, umifenovir, in patients. after days of treatment, the clinical recovery rate was % for favipiravir vs % for umifenovir (p< . ). recovery from fever was also faster for people treated with favipiravir (p< . ), but there was no difference between arms in auxiliary oxygen therapy or non-invasive mechanical ventilation rates [ ] . a second, non-randomised study in china evaluated days of treatment with either favipiravir or lpv/r. the median time to virus clearance was significantly shorter in the favipiravir group ( days) vs the lpv/r group ( days, p< . ) [ ] . favipiravir is dosed mg twice daily. a metric ton of favipiravir, therefore, would provide approximately , courses of treatment. the cost of api was estimated at about $ /kg, based [ , ] . this is a simple molecule to synthesise: several very basic steps involved are more akin to processes for manufacturing fine chemicals rather than pharmaceuticals. the structure is a -fluoro substituted -hydroxypyrazine- -carboxamide. based on a -day course of treatment, the cost of the api would be $ . . after adjustment for loss, formulation, packaging and profit margins, the estimated cost of production is $ per -day treatment cost (figure b ), or $ . per day. in late february , favipiravir was launched for sale in china for $ per treatment course, in an announcement by the shandong provincial public resource trading centre [ ] . the standard dose of lpv/r is / mg twice daily. lpv/r has been evaluated in two published studies of sars-cov infection [ ] . in these studies, there has been no difference in measures of efficacy between lpv/r (given for days) and control treatment. a systematic review by the who showed no clear evidence for the efficacy of lpv/r. however, there were very few clinical trials available for this evaluation at the time of the review [ ] . it is not clear whether this hiv protease inhibitor will work in the earlier stage of sars-cov infection, or if used in combination with other drugs. results from other clinical trials are expected between june and august . the estimated cost of production is $ . per treatment course, based on api cost of $ /kg for lopinavir and $ /kg for ritonavir. after adjustment for loss, formulation, packaging and profit margins, the estimated cost of production of the combined drug is $ per -day course, or $ . per day. searches in selected national databases and online pharmacies yielded a range of list prices between $ in the us, to $ in south africa per -day dose, as shown in figure a . additionally, lpv/r is also available through the global fund for a range of low-and middle-income countries, with a median cost of $ per -day course [ ] . in vitro, hydroxychloroquine is predicted to show superior activity against covid- compared with chloroquine [ ] . in a recent parallel-group, a randomised chinese study in wuhan of patients found treatment with hydroxychloroquine mg per day led to faster symptomatic improvement times in the treatment arm (n = ) after days in terms of temperature normalisation and cough remission, and a greater proportion of patients ( . % vs . %) with improved pneumonia [ ] . similarly, another chinese randomised trial in shanghai [ ] of patients also used mg per day in the treatment arm but found no statistically significant difference in clinical findings, symptomatic improvements or radiological improvements between the arms by day . the authors also highlighted the need for much larger, better powered trials to reach reliable conclusions. journal of virus eradication ; : - minimum costs to manufacture new treatments for covid- different dosing protocols are being used for hydroxychloroquine, including mg daily in the small, open-label, non-randomised french study by gautret et al. (n = ) that has suggested improved efficacy for hydroxychloroquine [ ] . for our analysis, we have therefore chosen mg daily, which was the most commonly used dosage. this is also the upper recommended dose by the british national formulary for existing indications [ ] . api cost-per-kilogram of hydroxychloroquine is $ /kg, with a -day dose-equivalent of api costing $ . . after adjustment for the cost of formulation, packaging and profit margin, the final cost would be $ per -day treatment course ($ . per day). globally, list prices range between $ per -day course in china and only $ per -day course in india ( figure b ). for chloroquine, the cost of api is $ /kg from panjiva data. a -day course equivalent of api would therefore cost $ . based on the equivalent dose of mg per day of chloroquine base. after adjustment for the cost of loss, formulation, packaging and profit margin, the final cost would be $ . per -day treatment course of chloroquine, equivalent to $ . per day. available list prices vary from $ in the us, to $ . per -day course in bangladesh, which is less than our estimated generic treatment cost. it is worth noting that the us price for chloroquine may be considered an outlier, given the next most expensive list price, found in the uk, was only $ per -day course (figure c ). azithromycin this macrolide antibiotic has been used as an adjunctive treatment for six patients in the small french pilot study of hydroxychloroquine by gautret et al. to prevent bacterial superinfection, with all six patients virologically cured by day six [ ] . however, this finding is contradicted by a small, open-label study (n = ) in paris by molina et al. [ ] , who found no strong viral clearance effect associated with hydroxychloroquine/azithromycin combination therapy. the cost of api derived from panjiva shipment data for azithromycin is $ /kg. a -day course equivalent of api at a dose of mg per day would therefore cost $ . . after adjustment for the cost of loss, formulation, packaging and profit margin, the final cost would be $ . per day or $ . per -day treatment course. list prices for azithromycin range between $ per -day course in the us, and $ per -day course in india and bangladesh (figure d ). sofosbuvir/daclatasvir combination treatment with sofosbuvir/daclatasvir, direct-acting antivirals normally used to treat hepatitis c, is being evaluated in iran for covid- patients with moderate to severe symptoms [ ] . the dosage of sofosbuvir/daclatasvir is / mg daily. api per kilogram was $ for sofosbuvir and $ for daclatasvir. fourteen-day dose-equivalent of api for the combined drug therefore costs $ . . after adjusting for the cost of loss, formulation, packaging and profit margin, the final cost would be $ per -day treatment course, or $ . per day. the cost of sofosbuvir/daclatasvir api has been falling significantly in recent years; earlier estimates in for a -week course of treatment were $ per patient, or $ per days [ ] and in , $ per -week course, or $ . per days [ ] . therefore, our new estimates represent a . -fold reduction in the minimum cost of production since . globally, -day course list prices range between $ , in the us and $ in india, or $ in neighbouring pakistan, as shown in figure e [ ] . there is a randomised trial of pirfenidone vs placebo in progress [ ] . there are patients with severe or critical sars-cov infection being evaluated in this clinical trial, with results expected in may . the dose being evaluated is mg three times daily for weeks. the cost of api from the panjiva database was $ /kg, representing a -week api cost of $ . after adjustment for costs of loss, formulation, packaging and profit margins, the minimum cost of treatment would be $ per person, or $ . per day. there is again a large variation between individual countries' list prices. pirfenidone is available in the us for $ for a -week course, but only $ in bangladesh and $ in india for a generic version (figure f) . however, even at $ per month, this is still higher than our api cost-based estimate. there are several large clinical trials of this monoclonal antibody in progress, for patients with late-stage disease [ , ] . as an iv infusion, doses are based on bodyweight ( mg/kg) with a maximum single dose of mg every hours. we therefore made the assumption of average bodyweight being kg, with a single dose of mg. no api data were available for tocilizumab; therefore, we were unable to estimate the minimum cost of production. list prices per mg single dose varied from $ in the us to $ in pakistan (figure g ). across several developing economies with available list prices -india, bangladesh, turkey, south africa, egypt and pakistan -the median was $ per dose. several tocilizumab biosimilars are currently under development [ , ] ; however, none has yet been approved and launched. the general experience so far of biosimilars has been that they offer health care systems the potential to lower costs significantly [ ] , with the uk alone expected to save up to gbp -gbp million per year through increased uptake of better-value biological medicines [ ] . this analysis shows that drugs to treat covid- could be manufactured for very low prices, between $ and $ per course. many of these drugs are already available as generics, at prices close to the cost of manufacture, in low-and middle-income countries. we do not yet know which of these drugs will show significant benefits. however, if promising results emerge from pivotal clinical trials, there is the potential to upscale generic production and provide treatment for millions of people at very low unit prices. there is an established mechanism to do this: donor organisations such as gfatm and pepfar already provide mass treatment of hiv, tb and malaria worldwide at prices close to the costs of production. the drugs in this analysis were not designed against the sars-cov virus; they were developed to treat other viruses or diseases. some, such as chloroquine, were developed in the s. most of the clinical trials of treatments have been funded by national health authorities and donor agencies rather than pharmaceutical companies. patients with covid- have risked their own health in these clinical trials, often with no clear benefits. companies should be encouraged to continue their research, with costs of clinical trials supported by public funding. since the start of the pandemic, the money spent by pharmaceutical companies on research and development of these drugs will be minimal, relative to funding from national health authorities. where pharmaceutical companies have donated drugs for clinical trials, there are already tax rebate systems in place that will recover the costs of the donated drugs. for mass production of these drugs, our analysis assumed a profit margin of % to companies manufacturing the drugs. this is similar to the pricing structure for hiv, tb and malaria, where generic drug companies still earn acceptable profits while mass producing these drugs at prices close to production costs. large-volume orders are needed to incentivise generic companies to manufacture drugs at low prices. other mechanisms exist to optimise drug manufacture. with pooled procurement, a set of countries can order drug supplies together, to take advantage of economies of scale. there can be volume-price guarantees to procure large amounts of drugs at fixed prices for a set number of years. prequalification of key companies by the who can be recognised by any country as an indicator of drug quality, including adherence to good manufacturing practice and the stability, or viability of the drug over its stated shelf life, alongside the bioequivalence of generic drugs vs the original branded versions. additionally, the costs of treatment may be higher if combinations of two or three drugs are needed. other infectious diseases such as hiv, hepatitis c or tb are best treated with two/threedrug combination treatments. drugs which have not shown efficacy against covid- as monotherapy should not necessarily be discarded: they might still contribute to the efficacy of two-or three-drug combination treatments. drugs that are not curative but lessen disease severity are also needed. these treatments could lessen the burden on healthcare systems, which could otherwise be overwhelmed by a lack of ventilators or other supportive services. when these drugs are repurposed to treat covid- , we will need to ensure a constant supply of drugs for the original indications, for example, pirfenidone for people with pulmonary fibrosis, or hydroxychloroquine for people with rheumatoid arthritis and systemic lupus erythematosus. the costs of these treatments will be higher if used for longerterm prevention, for example, in healthcare workers. randomised trials of chloroquine and hydroxychloroquine for prevention of sars-cov infection are in progress [ , ] and other candidate drugs could emerge for use as prophylactics. we highlight four limitations of our study, for consideration in future work. first, this analysis does not include all candidate drugs for covid- . there are drugs at earlier stages of development; a wide range of candidate drugs have been identified by machine learning models [ ] . these drugs may need further in vitro testing before being introduced into human studies. second, treatments like lpv/r and sofosbuvir/daclatasvir have only a small chance of showing significant benefits to patients in ongoing trials, given current evidence. third, for newer drugs such as remdesivir, favipiravir and pirfenidone, costs of production could continue to fall over time through economies of scale. this trend has been seen for drugs to treat hiv and hepatitis c. the cost of api for the hepatitis c drug daclatasvir fell by % in the years after initial launch, as more generic companies upscaled synthesis of the api with greater competition in the market. fourth, many drugs may have been given discounts from the list prices that we have identified for comparison in this analysis following in-country negotiations. even so, list prices can be over -fold higher than the predicted costs of production in some cases. we propose four main recommendations to ensure that any patient with covid- , in any country, can access the drugs they need: . treatments showing efficacy in well-powered clinical trials should be made available worldwide at prices close to the cost of manufacture. all the treatments being evaluated in clinical trials are very cheap to manufacture. clearly, the mass production of these drugs will need to be economically sustainable. treatments for hiv, tb and malaria are distributed worldwide by gfatm and pepfar, to treat millions of people at prices close the cost of manufacture. the prices paid allow generic companies to make acceptable profits. we should adopt a similar model of drug distribution for covid- . . there should be parallel manufacture by at least three different companies for each product, sourcing their api from different countries. in the early stages of the sars-cov epidemic, api production in china was severely disrupted because of quarantine of key workers and delays in transporting key raw materials between factories [ ] . india has suspended export of several key drugs because of anticipated local shortages. production of drugs in a range of countries will protect us from disruption or shortages in individual countries. . there should be no intellectual property barriers preventing mass production of these treatments worldwide. we need open 'technology transfer' so that the methods used to manufacture the key drugs can be shared with any country deciding to produce the drugs locally. . results and databases from all covid- clinical trials should be fully accessible so others can learn from them. to speed up access to these drugs, countries could rely on recognition of the review and approval of key treatments by regulatory authorities in the us or europe, or other stringent regulatory authorities. there may not be time for the normal times of regulatory review by all individual countries. in summary, repurposed drugs may be our only option to treat covid- for the next - months, until effective vaccines can be developed and manufactured at scale. if repurposed drugs do show efficacy against covid- , they could be manufactured at very low unit prices, in the range of $ to $ per treatment course. the system of mass production and distribution of drugs to treat hiv, tb and malaria via gfatm and pepfar could act as a blueprint for the treatment of sars-cov , to ensure access to effective 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rheumatology: reshaping the healthcare environment commissioning framework for biological medicines (including biosimilar medicines indian pharma threatened by covid- shutdowns in china acknowledgements conflicts of interest ah received a consultancy payment from merck for a clinical trial review that is not connected with this project.funding ah received funding from the international treatment preparedness coalition (itpc) as part of the unitaid-supported project 'affordable medicines for developing countries'. journal of virus eradication ; : - minimum costs to manufacture new treatments for covid- key: cord- -e o ml authors: du, jiang; fan, ni; zhao, min; hao, wei; liu, tieqiao; lu, lin; shi, jie; jiang, haifeng; zhong, na; lan, xiaochang; xu, shichao; chen, hongxian; xiang, xiaojun; wang, xuyi; sun, hongqiang; li, bing; ning, yu-ping; li, jing; guo, wanjun; niu, yajuan; sheng, lixia; li, yi; liu, xuebin; zhou, xuhui; qian, mincai; zhou, wenhua; zhang, ruiling; hu, hongxing; xia, yan; su, zhonghua; zhang, ruimin; yang, mei; liu, fen; yuan, wei title: expert consensus on the prevention and treatment of substance use and addictive behaviour-related disorders during the covid- pandemic date: - - journal: gen psychiatr doi: . /gpsych- - sha: doc_id: cord_uid: e o ml nan in early , the covid- outbreak complicated the diagnosis, treatment and rehabilitation of patients with substance use disorders and increased the risks of substance abuse and addictive behaviours, such as online gaming disorders, in the general public. substance use disorder is a chronic recurrent brain disease characterised by strong cravings, high recurrence rates, and a high proportion of comorbidity of mental and physical disorders. therefore, regular long-term therapeutic interventions are critical to preventing drug relapses while maintaining withdrawal. covid- severely affects normal medical diagnoses, treatments and managements of patients with substance use disorder coupled with addiction-related behaviour. it also adversely impacts the mental state of the general public in several ways and leads to broader symptoms, including anxiety, tension and insomnia, that may increase the risk of alcohol abuse, sedative and hypnotic drug abuse, and other addictive behaviours. the state council's comprehensive team for joint prevention and control of covid- released a series of documents to address the importance of focusing on the prevention and control of both imported cases and internal transmission in particularly vulnerable places, such as supervision sites, pension facilities, welfare homes and mental health institutions. it is also of utmost importance to ensure the continuous, regular and effective treatment of existing patients with addiction problems, reduce the risk of drug relapse and prevent new cases of addiction during the pandemic. to this end, the chinese association of drug abuse prevention and treatment, the academic group of drug dependence of the chinese society of psychiatry, the academic group of addiction of the chinese society of psychosomatic medicine, and the specialty committee of addiction medicine of the chinese psychiatrist association jointly published an expert consensus to inform the public with proper guidance to prevent addiction and provide professional diagnoses, treatment and management of these addictions. since these issues are faced by various groups of people, we addressed these problems based on different populations. practical difficulties faced by the general population and patients with addiction problems during the pandemic covid- has caused a serious and comprehensive impact on the public. the dual stress fomented by 'confronting a pandemic' and 'isolation at home' negatively impacts mental health to various degrees. those affected often manifest symptoms such as tension, worry, fear, depression and distress. if not properly vented, these emotional problems can increase the risk of substance abuse and gaming disorders. studies have shown that when stressed, abstinent patients with substance use disorder are more likely to have negative emotions and are preconditioned to return to previous behavioural patterns as a coping mechanism. for example, they relieve anxiety, depression or insomnia through excessive use of tobacco, alcohol or even drugs, all of which lead to relapses or exacerbations of existing conditions. [ ] [ ] [ ] for current patients with addiction problems, the amount and frequency of substance use are amplified when they encounter stressful situations. therefore, the occurrence, development, addiction relapse and the state of stress may mutually influence and aggravate each other during the pandemic. this in turn increases the aggregated risk. in addition to mutual influences, daily medical treatments for patients with addiction problems are also affected to varying degrees based on restrictive isolation policies and delivery inconveniences during a pandemic. for instance, patients who require methadone maintenance therapy may not be able to receive methadone in a timely manner, and this may increase the risk of psychobehavioural problems and potential relapse. addiction problems and prevention advice that the general public should focus on during the pandemic the covid- pandemic is a serious public crisis that has interactive susceptibility with addictive behaviours. stressful circumstances can increase the risk of addictive behaviour; therefore, it is important to prevent the occurrence of substance use and other addictive behaviours during difficult situations, such as this pandemic. as mentioned, during the pandemicespecially during long periods of isolation-several kinds of stress may lead to negative emotions and related maladaptive coping styles. among the types of addictive substances and behaviours that warrant special attention are abuse of alcohol or sedative hypnotics and compulsive internet gaming. as a central nervous system depressant, alcohol is widely used by the general public. in addition to social drinking, many individuals imbibe as a form of self-treatment, such as relief for anxiety or depression, or to help them sleep. however, long-term excessive drinking often leads to alcohol abuse or dependence and can cause a series of physical and mental health problems. during any pandemic, there is an increased risk of fomenting disturbing feelings or aggravating existing negative emotions in patients with addiction problems as well as in the general public. some will attempt to confront their problems by drinking. this in turn increases the risk of alcohol abuse or eventual addiction. in addition, if alcohol-dependent patients suddenly stop drinking, they may experience severe withdrawal symptoms which could be lifethreatening, such as delirium tremens, epileptic seizures and electrolyte imbalance. therefore, at-risk persons should avoid drinking as a means to cope with emotional problems or insomnia, and patients with alcohol dependence must be encouraged to remain abstinent when isolated at home. there are many types of sedative and hypnotic drugs, most of which include antianxiety remedies that can mitigate negative emotions caused by tension, anxiety and fear. sedative hypnotics offer mild and generally positive sedative effects when taken in small dosages. larger dosages tend to induce sleep. as a pandemic spreads, the number of individuals with anxiety and insomnia likewise increases gradually, as do the risks and potential addictions. some also use sedatives and hypnotic drugs combined with alcohol to accentuate the effects, and this often results in more serious negative consequences. therefore, the preferred recommendations for relieving anxiety and insomnia are non-pharmaceutical therapies such as relaxation practices, t'ai chi and yoga. if pharmacotherapy is necessary for acute cases, sedative and hypnotic drugs should only be used under the guidance of professional doctors rather than self-administration. gaming disorder is primarily found in adolescents, while excessive internet use is seen in all ages. with the popularity of the internet and smartphones, there are increased risks of addiction to internet games, short videos, online graphic novels and comics, and even internet gambling, online pornography and other disruptive content. for teenagers, the influencing factors generally include changes to their daily routines and home studies during the pandemic period. some of the most prevalent characteristics of adolescents are impulsiveness and curiosity. for young and middle-aged adults, the main factors are disruptive changes to their living and working spaces, as well as interruptions to their daily social activities. the elderly are adversely affected by changes to their daily rhythm. interventions to prevent internet and gaming addictions should be tailored to the specific characteristics of each age group, including regular rest and alternative forms of enriching one's daily life by developing healthy interests and hobbies. during the covid- pandemic, related work can be conducted in accordance with the different risk levels. the general public should plan their lives, maintain healthy lifestyles and conform to proper daily routines during isolation periods. regular sleeping and eating combined with moderate exercise provide individuals with sufficient energy to manage the daily requirements of work and life. maintain communication with friends and distant family members through email, telephone and social apps such as wechat. those who are physically and mentally capable should make full use of available resources to learn simple, practical and evidence-based self-adjustment methods (eg, muscle relaxation training, mindfulness, negative emotion recognition and coping mechanisms). harmful coping strategies should be avoided, such as reliance on tobacco, alcohol or other addictive substances. parents can also use digital management software to restrict their children's phone usage to reduce the potential risks of communicating with anonymous or aggressive persons. expanding public knowledge on addiction is an important way to prevent addictive behaviours. professionals should make use of various media, including published articles, animation, audio and broadcasts, to enhance the accessibility of informative content for different groups. groups with higher risks of addiction include persons with sleep disorders, smokers, drinkers, adolescents, individuals who are particularly susceptible to stress or have specific personality characteristics (eg, impulsiveness, curiosity), people who to date have abstained from addictive behaviours, patients with mental diseases and so on. according to the changes to addictive behaviours after previous public health or other major stress events, training related to adaptive coping skills should be available for high-risk groups. this includes maintaining healthy lifestyles, stress management, coping to a reasonable degree with negative emotions and seeking psychological assistance, all of which can serve to identify additional risk factors as early as possible and prevent addiction through further intervention. psychological intervention hotlines and outpatient services that screen for addictive behaviours should be widely available to improve early detection and intervention. in addition to the aforementioned high-risk groups, visitors should also be asked about the following problematic characteristics that may manifest during a pandemic: whether their dosages and frequency of substance use have increased compared with previous events; whether they have been able to quit again; whether they now rely on any addictive substances to relieve negative emotions; and general psychiatry whether they experienced withdrawal symptoms after reducing or quitting substance use. patients who are known to have elevated risk or have the aforementioned characteristics should accept brief interventions or agree to further professional evaluations. those who are diagnosed with substance use disorder should be transferred to specialised treatment institutions that provide addiction medicine to receive timely treatment. advice for patients with addiction problems and their families or guardians family support plays an important role in preventing relapses of patients with addiction problems. family members can reduce patient cravings and prevent regression by stabilising family relationships while helping them reduce negative emotions and cope with high-risk factors. patients with addiction problems and their families should pay special attention to all of the followings: understand and pay close attention to emotions patients and their families can learn to understand their emotional states using appropriate psychometric assessment tools. furthermore, they can also receive training to adjust and relieve negative emotions through mindfulness, meditation, relaxation training and other methods. patients and their families should realise that mild tension and anxiety during stressful situations are considered normal reactions that in turn can help them remain alert and mitigate their nervousness. once uncontrolled negative emotions begin to have a significant impact on daily life and work, patients should request an online consultation or visit a professional institution for appropriate treatment. build one's own social support system talking with others can effectively help individuals relieve tension and anxiety. therefore, the family members of patients with addiction problems can establish their own social support systems. family members and close friends should communicate more frequently and adopt methods of 'healing in groups' to help each other solve problems encountered during a pandemic. if this method does not effectively solve the problem and bouts of severe insomnia, depression or anxiety continue to occur, the best advice is to request a phone consultation with a mental health institution. if necessary in severe cases, the person should visit a psychiatric emergency department to receive appropriate treatment. proper management of addictive substances: strengthening observation and support for patients during a pandemic, negative emotions may increase substance abuse. family members should carefully monitor all addictive substances at home, including alcohol and sedative hypnotics. for patients with drug addiction, family members should control all finances to ensure that the patient is unable to acquire drugs. after using addictive substances, patients with addiction problems often change their diets, sleep patterns and daily routines. therefore, these often serve as indirect indicators that the patient has suffered a relapse simply by observing changes in their daily life. proper responses to withdrawal symptoms and relapses patients who are currently using addictive substances, those who have been using alcohol and sedative hypnotics for a long time, or patients who are receiving drug maintenance therapy may experience withdrawal symptoms as a result of the pandemic's impact. when this occurs, they should seek immediate help from professional institutions. when a patient relapses for the first time, family members should stabilise their emotions and avoid casting excessive blame on the patient. at the appropriate time, they can analyse the causes and discuss countermeasures together with the patient to avoid further recurrences. if the patient has had repeated relapses, they should be observed closely, advised patiently and escorted to a medical institution for treatment as soon as possible once the pandemic is under control or when the conditions are considered safe enough to visit public facilities. if the relapse has resulted in a physical or psychiatric emergency, the patient should be taken to a professional medical institution for emergency treatment. actively acquire knowledge related to covid- and strengthen self-protection patients and families can acquire scientific knowledge, learn the protective measures for covid- from official media sources, and control the quality of information to avoid negative effects caused by false or excessive information. at the same time, social resources, including community portals, media outlets and hotlines, can be used to alleviate negative emotions and concerns. suggestions for rehabilitation treatment centres at present, china's intervention institutions for drug use and addiction include primarily compulsory isolation drug rehabilitation institutions, voluntary rehabilitation facilities, methadone maintenance treatment clinics and community treatment centres. during a pandemic, these institutions should take preventive measures against covid- while ensuring the continuity of treatment and rehabilitation to the greatest possible extent. in response to practical difficulties, the various types of institutions should offer corresponding solutions whenever possible. isolation and detoxification agencies of the public security and judicial systems are all stringently managed. limitations to rehabilitation activities, family visits, communication and related problems may cause patients to experience emotional stress with corresponding physical symptoms during a pandemic. in severe cases, negative effects, self-injury or even psychotic symptoms may occur. at the same time, appropriate site management and services may be hindered. possible actions to address these circumstances include the following: patients can be sent outdoors (playground) or to a rehabilitation treatment room in groups, subject to safety regulations through reasonable planning and organisation, participant activity spaces can be amplified based on the premise that closed isolation may have been a root cause of their negative behaviour. in these spaces, appropriate recreation can be offered, such as yoga, mindfulness exercises, aerobics, t'ai chi, baduanjin and other sports that have been found to reduce anxiety, irritability and stress. for these rehabilitation activities, individuals should maintain social distancing of more than metre, wear masks and pay attention to disinfection and ventilation in the activity areas. posters, missionary videos and health education lectures can be used to educate patients about covid- in a venue. this can help improve patients' ability to identify diseases, understand prevention and control techniques, and reduce the risk of negative emotions caused by inadequate knowledge or misunderstanding. if possible, the venue should provide family telephones to allow patients to communicate via telephone or video so they are kept abreast of their situation and receive care and encouragement from family members, thereby alleviating potential negative emotions. receive help from specialist agencies when necessary most psychological problems suffered by patients can be resolved by using online consultation services provided by various medical institutions or other social services. however, for patients with more severe emotional disorders or persistent hallucinations, impulsive violence or other detrimental behaviours, appropriate medical treatment should be sought based on the evaluation of a professional physician. commonly used medications include benzodiazepines, antidepressants, mood stabilisers or antipsychotics. methadone maintenance treatment facilities for patients receiving methadone maintenance treatment, the dual effects of opioid addiction and pandemic stress may leave patients more prone to mental and psychological distress. in addition, certain circumstances will make treatment of such patients difficult, including isolation management, fear of being infected when going out to take medication, conscious avoidance of treatment and complications of the medication process under pandemic conditions. open management and treatment in the community may also increase the risk of relapse. possible actions to address these issues include the followings: provide a safer medical environment and alleviate patient concerns about infection during daily medication methadone maintenance treatment sites should manage the environment of the entire facility, maintain clean and ventilated spaces, disinfect regularly, and ensure that all medical personnel adhere to personal protective measures. patients should be assisted when taking medicine in groups at clinics, and long line-ups should be avoided. patients receiving medication should be required to wear a mask and cooperate during body temperature measurements. they should be questioned about any related clinical symptoms and their epidemiological history, such as cough, shortness of breath, fatigue, diarrhoea and so on. those with any abnormalities should be reported to the appropriate departments for further treatment. pay more attention to the education and prevention of covid- and screening evaluations to reduce the risk of cross-infection, remote networks and psychological interventions by telephone can be implemented. if a patient's mental and behavioural problems have affected regular daily life and social functioning, the patient should be referred to a mental health institution for further diagnosis and treatment in a timely manner subject to local safety measures. maintain the stability of the treatment plan and prevent additional substance addiction during a pandemic, care should be taken before avoiding or adjusting any methadone dose to prevent withdrawal symptoms or fluctuating conditions that increase the difficulty of treatment. combined with local methadone maintenance treatment policies and outpatient management regulations, to ensure safety, patients in stable condition with good compliance records can be considered for methadone take-home services or provided with alternative treatments such as suboxone to minimise risks of cross-infection. voluntary detoxification is an important part of our drug rehabilitation system. at present, the domestic voluntary drug treatment institutions encompass primarily the addiction specialty departments of psychiatric hospitals and independent drug treatment hospitals. in addition to providing diagnoses and treatment services for drug dependence and related disorders, they also conduct outpatient and inpatient treatment of issues related to substance addiction, including alcohol and sedative hypnotics and behavioural addiction. during this covid- pandemic, the normal diagnoses and treatment of patients with substance and behavioural dependence throughout the community are inevitably affected. the goal should be to establish sound coordination mechanisms with public security agencies, comprehensive medical institutions, community drug treatment and rehabilitation agencies, drug maintenance and treatment agencies, and other addiction-related units. also important is the fortification of contacts and liaisons with consultants. given the actual situation in any local area, it is necessary to refine the work content and procedures to further general psychiatry ensure that persons with substance abuse and behavioural problems can receive prompt medical treatment, timely referrals and hospitalisation when necessary. strengthen publicity and expand the coverage of treatment and prevention of addictive diseases voluntary detoxification agencies should not only ensure routine diagnoses and treatment but also assume the responsibility of preventing addictive behaviours caused by serious public health events. measures like science popularisation and professional training to assist the general population's ability to improve selfscreening for substance abuse and behavioural problems also benefit the community medical institutions and non-addiction-related professional medical personnel in their attempts to identify addiction-related disorders and to expand the coverage of prevention and treatment services. the screening of addictive substance use, prevention and education for clinic patients, as well as the timely identification, diagnosis and treatment of related mental and behavioural problems may all occur under stressful conditions. follow-up sessions can be conducted through appropriate communication channels (eg, phone, email, wechat and so on). strengthen internal management to ensure treatment effectiveness it is necessary to improve the management of facilities and all hospitalised patients, to adopt appropriate measures to isolate and prevent infection from spreading among both the hospital staff and patients, and to eliminate the introduction of possible sources of out-of-hospital external infections. also important is the dissemination of related medical knowledge and the provision of pharmaceutical and/or psychological interventions to treat mental and psychological problems such as stress, negative feelings and insomnia. also, the optimisation of outpatient appointment schedules would enable patients to visit doctors in an orderly manner and prevent infection risks caused by too many persons gathering in confined spaces. telemedicine services can also be provided to discharged patients by telephone, online consultation and other methods to enhance continuous service quality. management of comorbid covid- and/or other diseases in patients with addiction problems patients with addiction problems often suffer from several physical and mental illnesses. this substantially increases the difficulty of treatment once a patient contracts covid- . the treatment of comorbid physical and mental illnesses often requires the deployment of alternative addiction treatments. suspected or actual covid- infection in patients with addiction problems patients with addiction problems who are either suspected of being infected or are infected with covid- should be isolated immediately for a predetermined period. isolation, treatment and recovery management should be provided in accordance with the stipulated requirements for suspected or infected patients. special attention should be paid when asking patients about previous and current substance abuse, withdrawal symptoms previously experienced, and other physical diseases. addiction professionals should be invited to join treatment groups, thereby allowing general physicians and these specialists to jointly formulate the most appropriate treatment plans. when controlling physical diseases, medical teams should treat the symptoms generated by withdrawal from addictive substances. patients suffering from the dual effects of covid- and withdrawal may complicate the disease and increase the difficulty of treatment. therefore, the patient's vital signs should be closely monitored and variances should be treated promptly. psychosocial interventions should also be provided during treatment. other comorbid physical or mental diseases in patients with addiction problems often that patients with addiction problems have other comorbid physical or mental diseases. reports show that about %- % of patients with addiction problems suffer from other mental illnesses, and %- % of patients with other mental illnesses also suffer from substance use disorders. also, long-term use of psychoactive substances may lead to malnutrition, low immune function and a higher risk of contracting other physical diseases. practical difficulties during this pandemic have inconvenienced patients from receiving timely medical treatment, and this in turn may lead to increased risk of addictive substance use. therefore, more attention should be paid to the physical and mental conditions of patients with comorbid conditions. if treatments not involving drugs are ineffective in coping with negative emotions and/or exacerbations of physical illnesses, patients should be instructed to seek professional treatment as soon as possible. in sum, according to the theory of stress-facilitated addictive behaviours when coupled with environmental and other restrictions, the prevalence of patients with addiction-related disorders may increase during a pandemic, while existing patients may exacerbate their poor condition or even relapse, thus posing greater challenges for the healthcare personnel. this article provides a summary of the common addictive behaviour problems that may occur or worsen among the general population and patients with addiction problems during a pandemic and proposes possible intervention methods. we hope to use this research as a foundation to further explore a set of effective prevention and treatment methods for addiction that are bound to be necessary during future major public health crises in order to prepare and benefit the general population. general psychiatry epub ahead of print covid- pneumonia joint prevention and control mechanism group of the state council. the notice on strengthening management and treatment of severe mental disorders during the period of covid- pneumonia a nationwide survey of psychological distress among chinese people in the covid- epidemic: implications and policy recommendations increased use of cigarettes, alcohol, and marijuana among manhattan, new york, residents after the september th terrorist attacks hospitalizations for substance abuse disorders before and after hurricane katrina: spatial clustering and area-level predictors, new orleans feasibility of studying a brief intervention to help chinese villagers with problem alcohol use after an earthquake problematic internet usage and immune function pathological preoccupation with video games new coronavirus handbook for public psychological protection drug-induced stress responses and addiction risk and relapse alcohol disrupts sleep homeostasis psychoneuroimmunology-developments in stress research -ncov epidemic: address mental health care to empower society du received her doctor's degree from shanghai jiao tong university school of medicine. she is currently the director of drug abuse treatment center at shanghai mental health center open access this is an open access article distributed in accordance with the creative commons attribution non commercial (cc by-nc . ) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. see: http:// creativecommons. org/ licenses/ by-nc/ . /. key: cord- -vcm v ix authors: pollmann, michael title: causal inference for spatial treatments date: - - journal: nan doi: nan sha: doc_id: cord_uid: vcm v ix i propose a framework, estimators, and inference procedures for the analysis of causal effects in a setting with spatial treatments. many events and policies (treatments), such as opening of businesses, building of hospitals, and sources of pollution, occur at specific spatial locations, with researchers interested in their effects on nearby individuals or businesses (outcome units). however, the existing treatment effects literature primarily considers treatments that could be assigned directly at the level of the outcome units, potentially with spillover effects. i approach the spatial treatment setting from a similar experimental perspective: what ideal experiment would we design to estimate the causal effects of spatial treatments? this perspective motivates a comparison between individuals near realized treatment locations and individuals near unrealized candidate locations, which is distinct from current empirical practice. furthermore, i show how to find such candidate locations and apply the proposed methods with observational data. i apply the proposed methods to study the causal effects of grocery stores on foot traffic to nearby businesses during covid- lockdowns. how can we do causal inference with spatial treatments? in the setting of this paper, a spatial treatment, such as the opening of a "million dollar plant" (greenstone and moretti, ; greenstone et al., ) occurs at a geographic location, and the outcome of interest, such as earnings, is measured for separate individuals who are located nearby. this distinction between units of treatment assignment and outcome units has received little attention in theoretical work in causal inference. in the absence of guidance from theoretical work, most recent empirical studies using highly-detailed location data rely on adaptations of the familiar difference-in-differences method. unfortunately, these adaptations to the spatial treatment setting implicitly either rely heavily on functional form assumptions or on partly incongruent nonparametric assumptions to identify causal effects. this is in stark contrast to settings with individual-level treatments, where many researchers prefer causal inference based on quasi-experimental methods with simpler, more transparent assumptions, that obtain credibility by emulating an "ideal experiment" the researcher wished to have run. in this paper, i propose (quasi-) experimental methods for spatial treatments that are motivated by an ideal experiment where the spatial locations of treatments are random. these methods are based on a simple insight: suppose the ideal experiment randomly chooses some locations from a larger set of candidate locations. then quasi-experimental methods should compare individuals near locations that are chosen to individuals near locations that were not chosen for treatment. for a formal characterization of estimands and estimators, i extend the potential outcomes framework for individual-level treatments to allow treatments to be randomized across space and to directly affect nearby individuals. within this framework, i derive finite sample design-based standard errors similar to those of neyman ( neyman ( , for randomized experiments with individual-level treatment assignment for a fixed population. in the "million dollar plant" example, my proposals using micro location data are analogous to the approach greenstone and moretti ( ) take with aggregate data, while most current empirical work takes a conceptually distinct approach. suppose we want to estimate the average effect of a million dollar plant on individuals who are, say, mile away. the method employed by most recent empirical work compares individuals on an "inner ring" around the million dollar plant with radius mile to individuals on an "outer ring," who are, say, miles away from the same million dollar plant. since many observable and unobservable characteristics correlate with distance from any one point in space (lee and ogburn, ; kelly, ) , this comparison of inner and outer ring is often unattractive: if treatment always occurs in the city center, the inner ring, or treated, individuals are urban individuals, while the outer ring, or control, individuals are suburban and rural individuals. researchers attempt to ameliorate this issue by adding a pre vs. post comparison in a difference-in-differences approach, where outcomes for urban and suburban individuals are allowed to be on different levels, but must evolve along parallel trends. in contrast, greenstone and moretti ( ) take a different approach with data aggregated at the county level. they compare counties that "won" the bidding war for a million dollar plant to "runners-up" counties that were also very seriously considered as locations for million dollar plants, but ultimately "lost" (greenstone and moretti, ) . in short, the methods i propose compare individuals who are mile away from the million dollar plants to individuals who are mile away from locations that would have been chosen for the plants in the losing counties. since these counterfactual locations are rarely known in observational studies, i show how to find suitable candidate locations in practice. with micro location data, the methods then estimate the same detailed estimands targeted by the difference-in-differences approach. they have an attractive quasi-experimental interpretation and are valid by design if the choice of treatment location is as good as random within a set of plausible candidate locations. the difference-in-differences approach of current empirical practice relies on either partly incongruent nonparametric or functional form assumptions that are not guaranteed to be satisfied even in a true randomized experiment. the comparison of individuals on an inner ring to those on an outer ring inherently makes two assumptions: first, the treatment must not affect individuals on the outer ring directly. this is most easily achieved by choosing an outer ring with large radius, such that these "control" individuals are far away. second, the individuals on inner and outer rings must be comparable. this is most easily achieved by choosing an outer ring close to the inner ring, in conflict with the first assumption. even when the differences in levels between inner and outer ring are differenced out with individual fixed effects in panel data, the parallel trends assumption is particularly strong in spatial treatment settings. suppose, for instance, that treatment only occurs in city centers. then the assumption may require individuals living in downtown areas to be on parallel trends to those on the outskirts of the city. furthermore, researchers typically estimate the effect not just at one distance but at multiple distances, typically using the same outer ring control group. this effectively requires that individuals at all distances up to the outer ring are on the same parallel trend, with additively separable time fixed effects. these assumptions are not just approximations to make finite sample analysis feasible where asymptotically an analogous nonparametric specification identifies treatment effects: identification in this approach rests upon the functional form assumptions even asymptotically, and even with experimental data. instead, i recommend estimators that are formally valid under the quasi-experimental variation in treatment location sometimes used to informally justify the assumptions of the difference-in-differences approach. the difference-in-differences approach generally yields the most credible estimates if the treatment is known not to have an effect past a short, known, distance. then individuals on the outer ring are likely to be comparable. sometimes, these comparisons are then justified by the fact that the exact location of the treatment was as good as random. for instance, (linden and rockoff, , p. ) , referencing bayer et al. ( ) , argue that for their treatment, sex offenders moving into neighborhoods, "the nature of the search for housing is also a largely random process at the local level. individuals may choose neighborhoods with specific characteristics, but, within a fraction of a mile, the exact locations available at the time individuals seek to move into a neighborhood are arguably exogenous." the estimators proposed in this paper allow researchers to make use of such credible identifying variation directly, rather than relying on an ultimately arbitrary outer ring. i demonstrate the quasi-experimental methods i propose in an application studying the causal effects of grocery stores on foot-traffic to nearby restaurants during covid- lockdowns in april of . in this application, i observe the exact spatial locations of grocery stores as well as other businesses in the san francisco bay area. i show how to find "control" neighborhoods that are similar to neighborhoods of actual grocery stores except for the absence of one marginal grocery store. the outcome of interest, foot-traffic to restaurants, is measured as the number of customers whose smarthphone location is shared with safegraph. i find that restaurants at distances of less than . miles from a grocery store have substantially more weekly customers than restaurants near counterfactual grocery store locations in comparable neighborhoods lacking the marginal grocery store. this suggests a positive externality of grocery stores on nearby businesses, akin to anchor stores in shopping malls, at least when customer mobility is reduced as during the covid- pandemic. while i argue in favor of a design-based, quasi-experimental approach in this paper, the difference-in-differences approach has its own advantages, such that both approaches are complementary. specifically, the comparison with an "outer ring" effectively removes time-specific noise that is shared within a larger region but distinct across regions. in contrast, the methods proposed in this paper focus mostly on eliminating confounding due to differences in the spatial neighborhoods, such as population density, of treated and control individuals. whether spatial variation, temporal variation, or functional form assumptions yield the most credible estimates of causal effects depends on the particular empirical setting. researchers may find studies particularly credible if several distinct identification strategies lead to similar conclusions. doubly-robust estimators (e.g. robins and rotnitzky, ; belloni et al., ) , which model both the outcome (conditional expectation) and assignment process (propensity score), may offer an attractive bridge between approaches. the framework developed in this paper allows me to extend the proposed methods to settings where multiple treatment locations are close to one another, as in the application to foot-traffic caused by grocery stores, which are often near other grocery stores. the existing difference-in-differences approach, in contrast, is not applicable when treatment locations are too close to one another. in the framework of this paper, i can allow for such interference between spatial treatments and illustrate the complications it causes. in recent work, zigler and papadogeorgou ( ) and aronow et al. ( ) specifically study such interference in a spatial treatment setting. they derive average effect estimands that are identified despite interference. in the present paper, i instead define the estimands of interest based on an ideal experiment that rules out interference by design. in extensions that complement the work by zigler and papadogeorgou ( ) and aronow et al. ( ) , i then discuss assumptions under which these estimands are identified even when there is interference. in addition, i demonstrate how to find additional candidate treatment locations, where treatment could have occurred but did not, with observational data, increasing the number of settings the proposed methods can be applied to. furthermore, i view the framework developed in this paper as particularly helpful for deriving standard errors of estimators of the effects of spatial treatments. by providing formulas for finite sample design-based standard errors, i sidestep the often difficult decisions regarding clustering and "spatially correlated errors" (e.g. conley, ) that arise in practice for virtually any application using spatial relationships between observations. aronow et al. ( ) also provide some design-based standard errors, but focus on asymptotic normality and sampling-based variances in the style of conley ( ) for the estimator most similar to the ones proposed in this paper. the results in their work therefore complement those in this paper. the interpretation of the standard errors i propose is simple: they reflect the variation in the estimator that arises from randomizing treatment locations, holding the individuals in the sample fixed. this is the same variation that is needed for internal validity of the causal effect estimates (abadie et al., ) . in the baseline setting, the variance estimators i derive are similar to clustering at the level of treatment assignment (abadie et al., ) . the approach i take in this paper, generalizes straightforwardly to settings with a contiguous region or multiple treatments close to one another. clustering, in contrast, is based on sharp, sometimes arbitrary, boundaries and the absence of interference between clusters. finally, the framework highlights nuances in interpretation that have received little attention in the literature thus far. most recent empirical work estimates the effects of spatial treatments at multiple distances. however, the average effects at different distances are not generally comparable. since some individuals are often more likely -before realization of treatment assignment -to be close to treatment locations, their treatment effects typically get more weight in average effect estimands at shorter distances, and less weight in average effect estimands at longer distances. in other words, we cannot generally interpret effect-by-distance curves or the change in effect between distances as average within-individual effects. even the aggregate weight placed on individuals near any one treatment location varies with distance. both of these effects can lead to estimates of average treatment effects that increase in distance, even though individual-level treatment effects are decreasing in distance for every individual. the framework in this paper allows me to characterize estimators with alternative weights on individuals to mitigate such issues. in addition, in this framework i can show how to aggregate individual-level treatment effects to estimate the aggregate effects of treatment at a location on all nearby individuals. the framework and methods discussed in this paper may also prove useful for causal inference questions not directly related to spatial treatments. first, other non-spatial settings also feature "treatments" that are not directly assigned to individuals but affect them based on some measure of distance. in this paper, i briefly discuss bartik ( ) -, or shift-share, instruments, where for instance industry-level shocks affect all cities depending on industry composition. the perspective taken in this paper resembles that of borusyak and hull ( ) , with non-random distances from candidate treatment locations but random variation in which candidate locations are realized. second, i develop an approach to finding suitable unrealized candidate locations in observational data based on flexible machine learning methods. this approach may extend to other settings with dependency between observations where it is sometimes challenging to find (good) control observations, such as event studies and other time series settings. third, separating treatment assignment and outcome individuals in this framework further clarifies distinctions between design-based and sampling-based inference (abadie et al., ) . while design-based inference captures variation in treatment locations, sampling-based inference can reflect sampling of individuals at fixed locations, within fixed regions (infill asymptotics (cressie, ) in the spatial statistics literature), of a growing contiguous space (expanding domain asymptotics (cressie, ) ), or of independent regions (clustering). the present paper focuses on design-based inference specifically; in-depth comparisons of different modes of inference are beyond its scope. my current analysis is limited in at least three important ways. first, i assume that outcome individuals have fixed locations. this is problematic if individuals move, or migrate, strategically in response to the treatment. second, the framework is not directly applicable to settings where we are interested in the causal effects of spatially correlated characteristics of places, such as in the literature on social mobility (e.g. chetty et al., ) . instead, the present paper focuses on treatments that occur at discrete locations in space. while the ideal experiment of randomizing treatment locations also creates a spatially correlated covariate of interest (distance from treatment), the randomization distribution it induces is much simpler to characterize. third, alternative estimators that are more robust or more efficient in certain settings may exist. while i attempt to offer theory and estimators for a variety of spatial treatment settings, the primary focus of this paper lies in developing a coherent conceptual framework that allows me to characterize, discuss, and exploit the ideal experiment with spatial treatments. in particular, the present paper provides no formal justification for the use of methods from the literature on sample splitting and double robustness (e.g. chernozhukov et al., ) . the need to consider many relative spatial locations for finding suitable unrealized candidate locations makes this a high-dimensional estimation problem in observational settings, suggesting the importance of methods and insights from that literature. the remainder of this paper is organized as follows. the final part of the introduction highlights the wide range of empirical applications for which this work is relevant, as well as connections to the theoretical literature. section develops a potential outcomes framework for spatial treatments. section contains the main results on identification, estimation, and inference under the ideal experiment. section discusses how to extend these results to additional settings of empirical relevance. section shifts the focus from experimental to observational data, proposing assumptions and methods that allow researchers to emulate the ideal experiment. section shows how to apply these methods in practice. in the conclusion, i discuss limitations of the present paper and fruitful directions for future research on causal inference for spatial treatments. empirical relevance the methods i propose are relevant for a diverse range of questions from many applied fields in economics and other social sciences. recent studies estimating the effects of spatial treatments using individual-level outcome and location data include stock ( stock ( , ; linden and rockoff ( ) ; currie et al. ( ) ; aliprantis and hartley ( ) ; sandler ( ); diamond and mcquade ( ) ; chalfin et al. ( ) ; rossin-slater et al. ( ) . notably, dell and olken ( ) explicitly consider counterfactual treatment locations in a quasi-experimental setting, as well as the permutation distribution based on counterfactual assignments. much more existing empirical work studying spatial treatments is limited to aggregated outcome data. if micro location data had been available for these studies at the time, researchers would likely have asked questions that can be answered using the methods i propose in this paper. experimental and observational studies of spatial treatments in economics using aggregate data fitting into the framework of this paper include duflo ( ) ; miguel and kremer ( ) ; cohen and dupas ( ) in development economics, greenstone et al. ( ); feyrer et al. ( ) public and labor economics, (jia, ) in industrial organization, and environmental economics (keiser and shapiro, ) . furthermore, a recent literature has documented large geographic variation in a diverse range of outcomes (for instance chetty et al., ; chetty and hendren, ; finkelstein et al., finkelstein et al., , bilal, ) . many potential sources or causes of this inequality, as well as many potential remedies such as place-based policies, involve spatial treatments. related theoretical literature this paper sits at the intersection of the literatures on causal inference, spatial statistics and econometrics. a small number of recent theoretical papers has similarly studied spatial treatments, albeit with a different focus. most closely related zigler and papadogeorgou ( ) , aronow et al. ( ), and imai et al. ( ) focus on settings with interference between treatment locations and show that only some average treatment effects are identified without additional semiparametric assumptions. in contrast, i define estimands of interest in a setting without interference, and discuss application-specific assumptions to retain identification of these estimands under interference. furthermore, i discuss a broader range of estimands and estimators, in particular for observational data where unrealized candidate treatment locations are rarely known. the simpler baseline setting also highlights interpretation and weighting issues that are obscured in the presence of interference. papadogeorgou et al. ( ) take a conceptually different approach. they develop a framework based on spatial point patterns (cf. cressie, ) rather than fixed units of observation to answer a distinct question. for them, the locations of outcome units vary with the treatment assignment, and the number of outcome units is the object of interest. instead of contrasting different treatment assignments to define effects, their estimand contrasts entire assignment mechanisms (stochastic interventions, muñoz and van der laan, ) . mcintosh ( ) proposes an estimator for settings where individuals known to be unaffected by the treatment exist as a natural group group. pouliot ( ) also studies a setting where the locations of outcomes and covariates are spatially misaligned, but not in the context of spatial treatments and causal inference. within the causal inference literature, the setting of this paper most closely relates to work on interference and networks. some work in causal inference explicitly considers spatially correlated treatments (delgado and florax, ; druckenmiller and hsiang, ) , but is not directly applicable to the patterns generated by spatial treatments. the literature on interference is concerned with spillover, or indirect, effects of treatments assigned to individuals in violation of the stable unit treatment value assumption (rosenbaum, ; hudgens and halloran, ; tchetgen tchetgen and vanderweele, ; aronow and samii, ; vazquez-bare, ; sävje et al., ; sävje, ; basse et al., ) . treatment effects in network settings typically originate from individual-level treatment assignment and propagate through the network (e.g. basse et al., ). in contrast to the interference and networks literatures, the present paper is concerned with a setting where the units of treatment are separate from outcome units. while the effect "spills over" to the outcome units, there is no interference between different treatment units if they are few and far apart, as in the baseline setting of this paper. consequently, the estimands and estimators of interest in spatial treatment settings generally differ from those in interference and network settings. for spatial treatment settings with interference, the spatial relationships between observations allow me to make semiparametric functional form assumptions to limit interference; see section . for details. similar assumptions may sometimes also be plausible if treatments are directly assigned to individuals but have spillover effects on other individuals. the design-based finite sample inference developed in this paper complements samplingbased large sample asymptotic theory developed in the spatial statistics and econometrics literature. conley ( ) proposed standard errors taking into account cross-sectional (spatial) dependence in a gmm framework; see also case ( ) ; lahiri et al. ( ) ; lee ( ) ; andrews ( ) ; kelejian and prucha ( ) ; bester et al. ( ); lahiri and robinson ( ) ; kuersteiner and prucha ( ) and references therein for alternative results. spatial proximity is also commonly used to motivate cross-sectional dependence in the literature on clustered sampling (moulton, (moulton, , moulton and randolph, ; hansen, ; donald and lang, ; barrios et al., ; cameron and miller, ; abadie et al., ) . the spatial statistics and econometrics literature is primarily concerned with descriptive estimands, modeling the spatial correlations existing in outcome data even in the absence of spatial treatments. textbook treatments of such models in spatial statistics and econometrics include cressie ( ) ; cressie and wikle ( ); anselin ( ) ; anselin et al. ( ) ; anselin and rey ( ) ; lesage and pace ( ) ; arbia ( ) . since treatment assignment (or distance from treatment) does not vary within location, "increasing domain asymptotics" (cressie, ) (asymptotics in the number or size of regions or clusters) are likely needed for consistency of causal effect estimates. spatial treatment applications, however, typically feature a large number of individuals near a smaller number of treatment locations, such that alternative "infill asymptotics" (cressie, ) may offer better approximations. the primary contribution of this paper to this literature is a focus on the estimation of causal effects and design-based in-sample inference, rather than descriptive estimands and sampling-based inference. this paper also connects to the literature on estimation of treatment effects under unconfoundedness and doubly-robust estimation. specifically, i propose a formal notion of unconfoundedness (cf. rosenbaum and rubin, ; imbens and rubin, ) that is appropriate for spatial treatments. with individuals and treatment locations distributed across space, a large number of covariates, such as population density or average income at different distances, are predictive of both outcomes and treatment assignment probabilities. doublyrobust estimators are particularly promising in observational settings with spatial treatments: they have attractive consistency and efficiency properties based on the combination of outcome and treatment (propensity score) modeling. recent work has adapted these estimators to high-dimensional settings (belloni et al., (belloni et al., , farrell, ; chernozhukov et al., ; . initial results suggest that such estimators may also perform well in spatial treatment settings. finally, this paper contributes to the recent literature illustrating creative uses of modern machine learning methods for economic analyses (see mullainathan and spiess, ; glaeser et al., ; athey, ; gentzkow et al., ; , for recent reviews). i propose a method for finding unrealized candidate treatment locations based on an adversarial task: finding unrealized locations that are indistinguishable (to the algorithm) from realized treatment locations. most closely related, use generative adversarial networks (goodfellow et al., ) to create samples for simulation studies. kaji et al. ( ) similarly propose "adversarial estimation" to estimate structural models using generative adversarial networks. in each of these applications, the aim is to generate synthetic samples which look indistinguishable from the real data. in the application of this paper, only the unrealized candidate treatment locations are synthetic, while the outcome and covariate data around it are real. in this paper, i argue in favor of convolutional neural networks in particular, based on the similarity between spatial data and image data, which sparked more recent developments in this method (krizhevsky et al., ) . relative spatial positions are similar to relative positions of pixels, and different covariates at each location correspond to the different color channels of images. for economic applications using satellite data (see donaldson and storeygard, , for a review), convolutional neural networks have also shown promise (e.g. jean et al., ; engstrom et al., ) . convolutional neural networks are particularly attractive for spatial settings because they build on relevant economic intuition for regularization: while the geographic space might be large and high-dimensional, the immediate spatial neighborhood often matters the most, and relative distances matter similarly at different absolute locations. through careful design decisions, the methods i propose for the spatial treatment setting retain some interpretability in addition to the good performance commonly associated with "black box" machine learning algorithms. in this section, i propose an extension of the potential outcomes notation (cf. imbens and rubin, ) that treats the level of treatment assignment as conceptually distinct from the level at which we measure outcomes. this distinction separates the intervention that is the cause of the effect from the individuals for whom the effect is measured. it allows me to formally characterize estimands of interest, and to derive estimators and their properties in the following sections. with spatial treatments, potential outcomes of individuals are functions not of an individual-level binary or continuous treatment, but of a set of candidate treatment locations. we are interested in the effects of spatial treatments. let s denote the set of candidate treatment locations, shown as triangles in figure . th set of candidate treatment locations is assumed to be finite; in the example of figure just two locations in the region shown. this reflects an inherent scarcity that is common to most applications: only a small number of locations are ultimately realized, and most locations are infeasible, unsuitable, implausible, or unlikely for the treatment. in spatial settings, the candidate locations are typically given by latitude and longitude or other (relative) coordinates, such that s ⊂ r . throughout this paper, the set s is finite, as virtually any practical application will be based on some discretized, or rounded, locations. one can, however, take s as defining a finely spaced grid over r . this is convenient to figure : illustration of the setup. while typically only relative locations matter, locations are often given by their "gps coordinates" as latitude and longitude. in the figure, the candidate treatment locations at which the treatment may occur are given by triangles. the small circles indicate the locations of individuals. the researcher typically estimates the treatment effects, caused by treatment at one of the candidate locations and experienced by the individuals, conditional on distance from treatment. when the (weighted) euclidean distance function is used, individuals within a narrow distance bin from a candidate location are located on a ring, here displayed as an area shaded gray. if driving time is used instead to measure distance, individuals at a given distance need not be located on a circular ring. the figure shows data from a single region. in the baseline setting of this paper, the researcher has data from multiple such regions, with treatment realized only in some of them. if treatment is realized at multiple (both) candidate locations (triangles) within the same region, there is potential interference between them, complicating estimation and inference. in the baseline setting, the probability of treatment at locations and in regions describes a two-stage process. in the first stage, a fixed number of regions are chosen randomly for treatment somewhere in the region. in the second stage, a single candidate location in each chosen region is chosen randomly to receive treatment. conceptualize situations where treatment could be realized anywhere with some positive probability. the random variable ⊂ s denotes the set of the realized treatment locations. we measure the outcome of interest for units indexed by . for the remainder of this paper, i will refer to these outcome units as individuals, but in some settings may be a business, census tract, or similar, typically small, unit with fixed geographic location. denote the set of all individuals by i. individual has spatial location, or residence, , shown as small circles in figure . throughout this paper, i assume that the locations of individuals are fixed; there is no migration. in some applications, corresponds to, for instance, the workplace of individual rather than their residence. the location of is in the same space as the candidate treatment locations, such that typically ∈ r are latitude and longitude. define potential outcomes for each individual ∈ i potential outcomes: as the outcome for individual if treatment is realized in locations ⊂ s. to simplify notation, and consistent with standard potential outcomes notation, let the potential outcome of individual in the absence of any realized treatment be ( ) ≡ (∅). the treatment effects of primary interest contrast some treatment vector ⊂ s with the absence of realized treatments, ′ = ∅. specifically, i define the effect of on an individual ∈ i as treatment effects: oftentimes, the treatment vector of interest, , is a singleton, = { } for a single candidate location ∈ s. with slight abuse of notation, define treatment effects: i define meaningful average treatment effects in section . these average treatment effects average across both individuals and treatment vectors . distances distances between treatment locations and individuals are central to defining interesting average treatment effects in section . for instance, the researcher may estimate the average effect of a treatment at a distance of mile. in figure , the areas shaded gray highlight all locations approximately mile away from any candidate treatment location. the distance between treatment location ∈ s and individual ∈ i is given by a distance function distance function: ( , ) ≥ importantly, the distance between two locations must be observable (to the researcher) and must not be affected by treatment assignment, ruling out migration in response to the treatment. the distance function is used for two purposes. first, to estimate heterogeneous average treatment effects by distance from treatment. second, to assume distances at which treatments have no effect to limit interference and to thereby aid in estimation and inference. when locations are given as cartesian coordinates, we can use the euclidean distance in r : euclidean distance: when locations are given by latitude and longitude, the great circle distance is more accurate than a euclidean distance with fixed weights on latitude and longitude. for some applications in social sciences, driving distances are arguably more relevant. suppose the spatial treatment corresponds to an employer opening a new location. then an individual's access to the treatment, and hence treatment effect, likely depends on driving time rather than straight line distance. however, computing driving times between many locations may be computationally and financially expensive. when using straight line distances instead, some interpretability, but not validity, is lost. we can also study the effects of state-wide policies and other clustered assignments in this framework. in this setting, each candidate treatment location ∈ s corresponds to one cluster, or state. the appropriate distance function for this setting is in the simplest case of state-wide policies, we use this distance function to estimate the treatment effect at a distance of . this corresponds to estimating the treatment effect of the policy by comparing individuals in treated states to individuals in untreated states. we can generalize the cluster membership function to be smooth in distance to a treated state: for individuals in treated states, this distance is . for individuals in untreated states, the distance is smallest if they are most exposed to treated states. exposure may measure, for instance, distance to the state border, shared media markets, number or cost of flights between airports, or the relevance of the industries of treated state to 's occupation. regions in many applications, it is convenient to group individuals and treatment locations into regions. for instance, in a sample of data from different cities, individuals and treatment locations of each city may form a separate region. when regions are not directly coded in the data, one can sometimes define regions based on geographic proximity such that treatment locations only have effects within their own regions. that is, no individual is close enough to candidate treatment locations from two or more distinct regions to be affected by both of them. figure shows data from one such region. in the baseline setting of this paper, the researcher has access to data from multiple such regions, but this requirement is relaxed in section . . throughout, i denote regions by subscripts = , . . . , . let s ⊂ s be the set of candidate treatment locations within region . the set of realized treatment locations within region is . if treatment is realized within region , ̸ = ∅, let = , and otherwise, = ∅, let = . if = , i say that region "is treated" or "is a treated region." analogously, if = , i say that region "is a control region." let i ⊂ i be the set of individuals with residence in region . the region where individual resides is given by ( ), such that ∈ i ( ) . interference the notation in this paper can be seen as an extension of the notation of the literature on interference (cf. aronow and samii, ) . consider first a setting with individual-level treatments. let be the treatment assigned to an individual = , . . . , , and ∈ { , } be the vector stacking all of the . in the absence of interference, that is, under the stable unit treatment value assumption (cf. imbens and rubin, ) , the observed outcome of individual is = ( ). with interference, the outcome of individual may depend not only on her own treatment assignment, but also on the treatment assignment of other individuals. that is, the potential outcomes of are function a function of the entire rather than only her own , and her observed outcome is = ( ). notationally, spatial treatments generalize this setting by allowing to have a dimension other than , the number of individuals. for the closest analogy, enumerate the candidate treatment locations by = , , . . . , where is the finite number of candidate treatment locations. the random variable of realized treatment locations takes on values ∈ { , } , such that ≡ whenever the kℎ candidate location is treated, and ≡ otherwise. the realized outcome for individual is then = ( ), where is rather than dimensional. consider the example given in figure . some individuals are at a distance of mile from both treatment locations. if the treatment has an effect at that distance, the treatment states of both candidate locations jointly determine the observed outcome. the two candidate locations can interfere because conditional on the treatment state of just one of them, the outcome for some individuals still varies depending on the treatment state of the other candidate location. the literature on interference is typically interested in answering (at least) one of two questions. first, what is the effect of changing 's treatment status, holding the treatment status of 's neighbors fixed? second, what is the effect of changing the treatment status of 's neighbors, holding the treatment status of fixed? with spatial treatments, neither of these questions is of primary interest. if is mile away from a realized treatment location, then a neighbor of , say ′ , is also approximately mile away from the same realized treatment location. a counterfactual where is mile away from a realized treatment location, while her neighbor ′ is not, is typically not feasible or relevant in practice. the treatment does not spill over from to ′ , it affects both of them directly, such that decompositions into direct and indirect effects (cf. hudgens and halloran, ) are not well defined. interference in the spatial treatment setting refers to multiple treatment locations affecting the same individual, rather than the treatment or effect of one individual spilling over to another individual. formally, a treatment location affects an individual if for some set of treatment locations ⊂ s, the outcome of changes when is included or excluded: . two treatment locations , ′ ∈ s interfere with one another if there is an individual affected by treatment at both locations, that is in spatial treatment settings, it is often natural to assume that treatment locations that are far away from an individual do not affect her. formally, assume that whenever ( , ) > max for some sufficiently large distance max , ( ∪ { }) = ( ∖ { }) for all ⊂ s. assumption formally states that there is no interference across regions. assumption (no interference across regions). individuals in region are unaffected by treatment locations in regions ′ ̸ = . that is, for ∈ i and ⊂ s, regions are sufficiently far apart that individuals in one region are unaffected by treatment locations in another region. the results in this paper, however, fundamentally rely on the absence of interference between treatment locations that are far apart, not on separate regions. section . discusses a setting where all data available to the researcher comes from a single large contiguous region. if the region is sufficiently large and realized treatment locations are sufficiently scarce, it is still possible to estimate causal effects without strong additional assumptions. the separate region framework, however, helps clarify key concepts by simplifying estimators, and it is applicable to a large number of empirical studies. the assumption that treatment locations only affect individuals within the same region is similar in spirit to assumptions that interference or spillovers are limited to family members, classrooms, or other subgroups in settings with individual-level treatments (e.g. vazquez-bare, ). the assignment mechanism (imbens and rubin, ) determines the probabilities with which treatment is realized at each of the candidate treatment locations. the marginal probability that treatment is realized at a location ∈ s is given by pr( ∈ ). in the main part of the paper, i consider a two-stage assignment mechanism that imposes structure on pr( ∈ ) as well as on the conditional probabilities pr( ∈ | ′ ∈ ) and pr( ∈ | ′ ̸ ∈ ). in the first stage, either a fixed number of regions is chosen to receive treatment, or assignment is through independent bernoulli trials (coin flips). in the second stage, a single location receives treatment in each treated region. i discuss methods for some observational settings that deviate from this assignment mechanism in sections . . suppose the randomization of treatments across regions takes the form a completely randomized experiment with a fixed number of treated regions. assumption formalizes this design together with an assumption that each region is equally likely to be treated. define ≡ pr( = ) for = , . . . , to be the probability that a region receives treatment. note that the completely randomized design differs from experiments that are paired or stratified at the region-level. results for stratified experiments are generally similar and can be obtained by substituting the appropriate covariances of treatment indicators in the proofs. estimating the variance of estimators under paired designs is often difficult (e.g. bai et al., , for individual-level treatment assignment), but does not contribute conceptually to our understanding of the spatial treatment setting. assumption (completely randomized experiment). regions are chosen for treatment according to a completely randomized design (e.g. imbens and rubin, , ch. . ) where each region has equal marginal probability of receiving treatment somewhere, = for all regions . that is, all assignment vectors ∈ { , } with ∑︀ = ≡ are equally likely, and assignments with ∑︀ ̸ = have zero probability: as an alternative to completely randomized designs with fixed probability of treatment, i also consider designs where treatment is decided by independent coin flip for each region, potentially with different probabilities. assumption below formalizes this assumption. assumption (bernoulli trial). regions are chosen for treatment according to a bernoulli trial (e.g. imbens and rubin, , ch. . ) where region has marginal probability of receiving treatment somewhere and assignment is independent across regions. that is, the probability of assignment ∈ { , } is such that the number of treated regions varies. in the main part of the paper, i consider a setting with exactly one treated location in each treated region. this restriction of the assignment mechanism rules out interference by design under the minimal assumption that treatments have no effects across regions. for each candidate treatment location in a region, ∈ s , define the probability of treatment conditional on the region receiving treatment as ( ) ≡ pr( ∈ | = ). then, by the definition of conditional probabilities, pr( ∈ ) = pr( ∈ | = ) pr( = ) = ( ) . the notational distinction between treatment of regions and treatment of particular locations within regions is motivated by an asymmetry in which potential outcomes are observed: in control regions, the control potential outcomes are observed for all individuals near each (unrealized) candidate treatment location. in treated regions, in contrast, only the treated potential outcomes corresponding to one particular treatment location are observed for all individuals. this asymmetry is apparent in the estimators and variances throughout section . individual-level effects express the average effects of treatment locations on individuals. the most intuitive estimator of the average effect of a spatial treatment on nearby individuals takes the simple average of individuals near realized treatment and subtracts from it the average outcome of properly chosen control individuals. in this section, i first show who the proper control individuals are under the ideal experiment of random variation in treatment locations. then i present properties of this estimator and discuss its interpretation as the average treatment effect on the treated. the average of individuals who are treated at a distance ± ℎ from a treated location is where ( ) = if and only if individual is in a region ( ) that is treated. the indicator function equals if and only if the distance between individual and the realized treatment location in her region, ( ) , is within the distance bin of distances between − ℎ and + ℎ. for instance, to estimate the average outcome for individuals who are between and miles from treatment, calculate¯( . ) with ℎ = . . the choice of control individuals to compare this average of treated individuals to is less obvious. recent empirical studies compare the treated to controls on an outer ring; that is, to individuals ′ in treated regions ( ( ′ ) = ) who are farther away from treatment. effectively, this estimates the treatment effect at distance as¯( ) −¯( ′ ) where ′ ≪ . in analogy to individual-level randomized experiments, one might also consider taking the simple average of individuals in control regions, ∑︀ ( − ( ) ) / ∑︀ ( − ( ) . while either of these strategies is valid under further assumptions or in particular settings, below i argue in favor of a different strategy that is justified by the experimental design. one particular choice of (weighted) control average is, however, justified by the experimental design of the ideal experiment considered in this paper: most importantly, the estimator¯( ) only averages over individuals who are at approximately distance from some candidate location ∈ s ( ) . the remaining weighting is similar to inverse probability weighting estimators of the average effect of the treatment on the treated (att) in settings with individual-level treatments (cf. imbens, ) . to see that the control average¯( ) provides the appropriate counterfactual for the simple average of the treated ( ), consider the expected value of the terms in the numerator of the latter. it is straightforward to show that see appendix a. for the details. the difference between the expression above and the terms of the estimator¯( ) is that the latter can only average over individuals in control regions, with ( ) = , requiring the additional inverse probability weight ( ) in¯( ). the estimator¯( ) therefore aligns, in expectation, the weights placed on each control potential outcome ( ) with those placed on the corresponding treated potential outcome ( ) bȳ ( ). consequently, the estimator^( estimates a weighted average of the differences ( ) − ( ), which are the individual-level treatment effects ( ) defined in section above. the particular inverse probability weights make^( ) an estimate of the average treatment effect on the treated at a distance of ± ℎ. theorem states approximate finite sample properties of this estimator. (i) unbiasedness for the att: is the average potential outcome of individuals at distance from location corresponding to treatment at location ,˜( ) averages the˜( , ) within region , with weights proportional to the probability of treatment at location .˜( ) is the analogous withinregion average potential outcome for the same individuals but in the absence of treatment. ( ) and˜( ) similarly average the within-region averages across regions. the number of individuals at distance from location is ( , ),¯( ) when averaged within region , while¯( ) is the expected number of individuals at distance from realized treatment across regions. the theorem is a special case of theorem below with weight remark . the approximation in theorem arises because the denominators of the estimator ( ) are stochastic. the proof proceeds by deriving the finite sample properties of an infeasible demeaned estimator˜( ) with non-stochastic denominators that satisfies^( )−˜( ) = ( − ), where is the number of regions; details are given in the appendix. even with relatively few regions, the approximation is likely to perform well in practice. similar issues arise with individual-level treatments if treatment is decided by successive coin flips, rather than by fixing the number of treated. in spatial treatment settings, however, it is rarely feasible to hold the number of individuals near treatment fixed when randomizing the assignment of treatment locations. when all candidate locations have equal numbers of individuals in the distance bin, the approximations in the theorem above hold with equality. remark . the expected value given by theorem is also relevant for other estimators usinḡ ( ) as the mean of the treated but relying on a different control comparison group and auxiliary assumptions to justify the comparison. when researchers argue that randomization in the spatial locations for treatments allows them to estimate the treatment effect usinḡ ( ) (or close analogs), they therefore implicitly estimate the average treatment effect on the treated. i believe there is value in making the estimation target explicit: as i argue in section . . below, the att as defined above does not necessarily allow the most meaningful comparisons of the effects at different distances. remark . the control average¯( ) used by the proposed estimator^( ) simplifies to the simple average over all individuals in control regions, if each individual is equally likely to be distance from realized treatment. this typically requires that treatment can be realized at any location within a region with equal probability ( ( ) is constant within ), and the probability that a region is selected for treatment ( ) must be proportional to its area. then the unconditional treatment probability ( ) is constant for all locations , not just for a small, finite, set of candidate locations. figure illustrates and contrasts this with the more common setting where only a small number of candidate locations have positive probability of receiving treatment. remark . the variance given in the theorem is the design-based variance (abadie et al., ) of the estimator. it expresses the variation in the estimate arising from assigning treatment randomly to one candidate location in a fixed number of randomly chosen regions. the individuals whose outcomes are measured are held fixed across these repeated samples; the only difference between samples lies in which potential outcome is observed for each individual. the thought experiment behind the variance above is therefore similar to performing a permutation, or placebo, test. aronow et al. ( ) also suggest permutation tests as an alternative basis for inference in the spatial treatment setting. remark . the first three terms in the variance expression are similar to the variance of the difference in means estimator in a completely randomized experiment with individual-level treatments (cf. imbens and rubin, , ch. ). in the ideal spatial experiment considered in this section, treatment is randomized similar to a completely randomized experiment across regions with outcomes aggregated within regions (and distance bins).˜( ) ( ) is the variance of aggregated treated potential outcomes,˜( ) ( ) is the variance of aggregated control potential outcomes, and ( ) ( ) resembles a variance of treatment effects, such that˜( ) ( ) +˜( ) ( ) − ( ) ( ) resembles the variance of the difference in means under repeated sampling of fixed individuals but varying treatment assignment, the framework of this paper. remark . there is a distinct asymmetry between treated and control outcomes in the expressions for the variance: there are two terms capturing different variances of treated potential outcomes, but only one variance of control potential outcomes. in a treated region, ( ) only averages over potential outcomes corresponding to the realized treatment location, but not those of other, unrealized, candidate treatment locations. the variance of this estimator therefore depends both on how treated potential outcomes vary across regions and within region across candidate locations. if most of the variance is across regions, the final term, −˜( ) is large (negative), reducing the overall variance of the estimator that is due to the variance of treated potential outcomes,˜( ) ( ). since most of the variance is across regions, little is lost by only observing outcomes corresponding to one treatment location in regions with treatment. in a control region, in contrast, we observe the control potential outcomes ( ) that are the counterfactual to all candidate treatment locations s ( ) in the region.¯( ) therefore averages over potential outcomes for all candidate locations within each region, and˜( ) ( ) is the variance of such averages of ( ) within region, across candidate locations. remark . the last two terms in the variance expression arise due to the two-stage randomization in the ideal experiment. after randomizing between regions, the ideal experiment also randomizes between the candidate treatment locations within each treated region. when each region only has a single candidate treatment location, the variance can be simplified to only use the first three terms (scaled), as there is no second stage randomization in that case. estimation of variance without further assumptions, one can only estimate the first two terms of the variance,˜( ) ( ) and˜( ) ( ), to form a conservative estimator of the approximate finite sample variance of^( ). if there is a single candidate treatment location per region, the fifth term can be combined and estimated along with the first (and second) term. the third and fourth term are (approximately) variances of treatment effects, which are unidentified. however, the third term is larger in absolute value than the fourth term (see appendix a. . ), such that − ( ) ( ) + ( ) ≤ . intuitively, ( ) ( ) is approximately the unconditional variance of treatment effects, while ( ) is the variance of the conditional expectation (conditional on region) of treatment effects. by the law of total variance, the difference is expectation of the conditional variance, which is necessarily non-negative. hence, dropping both terms yields a conservative estimate of the variance. if there are multiple candidate treatment locations per region, one can still estimate the fifth term under semiparametric assumption on potential outcomes, such as constant treatment effects. specifically, note that the fifth term consists of the variance of regionaverage potential outcomes, ≈ var( (¯( , )| ∈ s )). one can readily estimate the variance of ≈ var( (¯( , ))), as in the estimation of ≈˜( ) ( ). one can also estimate both types of variances for control potential outcomes because in control regions, the relevant control potential outcome for individuals at distance from any candidate treatment location are observed. if treatment effects are constant, one can estimate¯by scaling^¯( ) by the ratio of the average within region variance to the across region variance of average control potential outcomes. the estimand ( ) is not generally appropriate when the researcher is interested in how the effect of the treatment changes with distance from treatment. as an alternative, i propose the estimand − ( ) with a more attractive interpretation when comparing effects at the figures show regions with individuals (small circles) and candidate treatment locations (triangles), highlighting areas that are distance away from a candidate treatment location in gray. suppose each candidate treatment location is equally likely to be realized. in panel a, all individuals who are distance away from a candidate treatment location receive equal weight in the estimand ( ). in estimation, if the region is in the control group, we take the simple average of outcomes of the highlighted individuals. in panel b, some individuals are distance away from both candidate treatment locations, so these individuals receive greater weight in the estimand ( ). in estimation, if the region is in the control group, we take the average of outcomes of the highlighted individuals, but individuals who are located in both gray rings receive twice the weight. in panel c, candidate treatment locations are everywhere (for illustration, only candidate treatment locations along a grid are displayed). if we assume that candidate treatment locations extend past the boundaries of the region, then all individuals in the region receive equal weight in the estimand ( ). in estimation, if the region is in the control group, we take the simple average of outcomes of all individuals. distance from treatment different distances. additional, one can interpret − ( ) as the expected average effect at distance of a new treatment location. figure illustrates the problem of interpreting the difference between the estimands ( ) and ( ′ ) as the pattern of treatment effects across distance from treatment . suppose the researcher is interested in comparing the average treatment effect at a short distance = short and long distance ′ = long . suppose further that there are two types of candidate treatment locations, each type equally likely to be realized. the first type of candidate treatment locations has many individuals located at the short distance and few individuals at the long distance. these first candidate locations all have relatively small treatment effect at both distances, but decreasing in distance from treatment. the second type of candidate treatment locations has few individuals located at the short distance, and many individuals at the long distance. these second candidate locations all have relatively large treatment effect at both distances, but also decreasing in distance from treatment. in the example in figure , the estimand ( ) is increasing in distance even though the treatment effect of any single treatment location is decreasing in distance from treatment. the estimand ( short ) places most weight on the first type of candidate locations because most individuals at the short distance from treatment are near this type of location. in contrast, the estimand (long) places most weight on the second type of candidate locations. hence, (long) > (short). this inequality states that the average treatment effect at a long distance for the average individual at the long distance from a candidate treatment location is larger than the average effect at a short distance for the average individual at the short distance from candidate treatment locations. it does not imply that the average effect of any single treatment is increasing in distance from treatment. instead, the average individual at a long distance may simply be both a different type of individual (in terms of observables and unobservables) and also be exposed to a different treatment location on average. an alternative estimand, − ( ) defined below and also shown in figure , avoids such issues in interpretation by placing the same aggregate weight on each candidate treatment location irrespective of the distance . the estimand − ( ) first separately averages the potential outcomes of nearby individuals for each candidate treatment location. these averages are then averaged again, with weights proportional only to the probability of treatment at the location. in contrast, the estimand ( ) uses weights proportional to the product of the treatment probability and the number of individuals near the treatment location. formally, where¯( , ) is the average effect of a given candidate location on individuals at distance ± ℎ from it. these average effects are then averaged with weights ( ), which do not depend on distance from treatment. hence, the weight placed on the average effect of a given location does not depend on the distance from treatment. to also non-parametrically control for observable differences in pre-treatment variables , one can estimate − ( ) separately using only individuals with covariate values falling into groups defined by . the comparison of − ( ) and − ( ′ ) then compares individuals with the same average exposure to the different candidate locations and similar individual characteristics . holding the aggregate weight per treatment location constant across distance from treatment is attractive when the treatment effects are expected to be heterogeneous by region or location. such heterogeneity is particularly plausible in many spatial treatment settings: oftentimes, the exact implementation of the treatment differs substantially from location to location. for instance, the million dollar plants in the study of greenstone and moretti ( ) are each operated by distinct companies which may differ in their labor demand and wage setting. hence, heterogeneous treatment effects arise not only due to differences between individuals, but also due to differences in the implementation of the treatments. since spatial treatments are often larger, rarer, and more complex, their implementation tends to vary more than, say, the administration of a drug in medical trials to different patients, or the content of a job training program across training sites or cohorts. additionally, the estimand − ( ) has an attractive interpretation as the expected effect at distance of a new treatment location. consider the following hierarchical model. first, when treatment is realized at location , its average effect at distance is drawn as ( ) ∼ . second, the individual-level effect of location on individual is given by where ( ) is a mean zero individual-specific component. then, as the width of the distance bin, ℎ, goes to , the estimand − ( ) approaches the mean of the distribution . hence, one can interpret − ( ) as the expected average individual-level treatment effect of a new treatment location drawn in the same way as existing realized treatment locations. i propose the following estimator to estimate − ( ): theorem gives the approximate properties of the finite sample distribution of − ( ). under assumptions (no interference across regions) and (completely randomized design), the estimator^− ( ) has an approximate finite sample distribution over the assignment distribution with (ii) and variance as given by theorem with the theorem is a special case of theorem below with weight as specified above. remark . the estimator here is exactly unbiased because under a completely randomized design, the sum of weights is constant across assignment realizations. this is different from theorem above, where the number of treated individuals varies. here, treated individuals are averaged by candidate treatment location, and the number of treated locations is constant across assignment realizations by assumption . more generally, the same ideas allow estimation of any weighted average of individual-level treatment effects that places non-zero weights only on the effects of candidate treatment locations with positive probability of realization. write these estimands of individual-level average effects of the spatial treatment on individuals at a distance from treatment as: where ( ) is the effect of treatment at location on individual , and ( , ) are weights specified by the researcher. the estimand here therefore can be any weighted average of the effect of single treatments on individuals with weights as specified by the researcher. for the average effect of the treatment at distance , weights ( , ) are non-zero only when location and individual are (approximately) distance apart. while i define the att estimands ( ) and − ( ) for distance bins ± ℎ above by using the rectangular, or uniform, kernel function {| ( , ) − | ≤ ℎ}, the weights ( , ) can generally use any kernel function in place of distance bins to estimate the effects at distance . the average effect of the treatment on the treated estimands in equations (i) and are special case of . for att the estimand corresponding to^( ), choose weights for att the estimand corresponding to^− ( ), choose weights i propose an inverse probability weighting estimator (cf. imbens, ) to estimate the weighted average treatment effect in equation above. in short, the estimator is the difference between weighted average outcomes of individuals near realized treatment locations and weighted average outcomes of individuals in regions without treatments. the weights here need to account for two aspects: first, the researcher specifies the desired weights ( , ) in the estimand. second, individuals near locations with high treatment probability are relatively more likely, across samples of repeated treatment assignment, to appear in the sum of "treated" individuals than in the sum of "control" individuals due to the experimental design. the estimator cancels out the probability weighting induced by averaging over individuals (not) near realized treatment for the treated (control) average. to estimate the average effect of the treatment on the treated, the treatment probabilities ( ) ( ) ( ) can be included in the weights ( , ). the proposed estimator for the weighted average treatment effect in iŝ the weights ( , ) are fixed and specified by the researcher. the weights ( ) and , in contrast, are stochastic due to their dependence on the treatment assignment random variables and . specifically, ( ) = unless treatment is realized at location , in which case it is equal to the inverse of the probability of this event. similarly, = unless there is no treatment in the region of individual , in which case it is equal to the inverse of the probability of no treatment in the region. consequently, the stochastic weights are equal to in expectation. the estimator divides each term by the sum of realized weights, ( ) ( , ) and ( , ), such that it is the difference between a convex combination of treated outcomes and a convex combination of control outcomes. theorem gives the approximate finite sample properties of the estimator^( ). under assumption proof: see appendix a. . remark . the variance in theorem can be estimated analogously to that of theorem , also see appendix a. . . remark . the approximate finite sample variance is smaller under bernoulli trials than under a completely randomized design. this is due to the nature of the approximation, which does not penalize the variance as heavily when for instance few treated regions are available under an imbalanced assignment. in practice, the difference between both designs is negligible due to the factor − in the denominator of , such that √ → and there is no difference between the two designs under standard asymptotics in the number of regions. the aggregate effects of a single treatment on all affected individuals is of importance for cost-benefit and welfare analysis. in this section, i propose estimators of aggregate effects that build on estimators of individual-level effects. in experiments with spatial treatments, there are two units of observation: outcome individuals and spatial treatments. the individual-level treatment effects of the previous section are average effects per outcome individual. the aggregate treatment effects of this section are average effects per spatial treatment. suppose the researcher is interested in the aggregate effect that a single treatment location has on all affected individuals. define the estimand where, as before, ( ) = ( ) − ( ) is the effect of treatment location on individual . the aggregate treatment effect sums these effects across individuals and averages them across candidate treatment locations , with weights ( ). in this section, i focus on the average aggregate treatment effect on the treated, , with weights ( ) ≡ pr( = | = ) pr( = ) these weights place larger weight on the effects of treatment locations that are more likely to be realized. the estimand therefore answers the question: what is the expected aggregate effect of a treatment location under the observed policy of assigning treatments to locations? one can estimate the aggregate effect by aggregating outcomes at the region-level: . this is the propensity score weighting estimator of an average treatment effect on the treated, where the outcome variable of interest is the sum over the outcomes of all individuals in a region. when there is a single candidate treatment location per region, standard results from the literature on experiments with individual-level treatments apply (cf. imbens, ) , with regions taking the role of individuals. estimators based on region-aggregate outcomes are likely to have very large variance. each region-aggregate outcome is the sum of outcomes of individuals in the region. if there is substantial variance in the number of individuals per region and outcomes are positive, the aggregate outcome of regions with many individuals can be substantially larger than the aggregate outcome of smaller regions. for instance, suppose that the number of individuals per region is poisson distributed with mean , and individual-level outcomes are i.i.d. within and across regions, with mean and variance . then region-aggregate outcomes have variance · ( + ) by the law of total variance. hence, aggregate potential outcomes have large variance, which leads to large variance of the estimator (cf. imbens, ) . variation in region sizes generates a large variance of the region-aggregate estimator , in two ways. first, if there is variance in the number of individuals per region, then in finite samples, some treatment assignments will be such that there are more individuals in treated regions than in control regions. suppose outcomes are positive and constant, for instance all individuals have the exact same value for the outcome. then the treatment effect estimate^, in such a sample is positive and sensitive to the scale of the outcome value. hence, the estimator^, can have large variance even when there is no variance in potential outcomes. second, variation in region sizes increases the variance in a sampling-ofregions thought experiment. even if the average individual-level treatment effect was known, needing to estimate the number of times the effect is realized on average per region can create substantial variance. the design-based variances considered in this paper condition on the individuals in the sample. with known number of individuals and known individual-level average treatment effect, it is possible to form an estimator of aggregate treatment effects with a design-based variance equal to zero, in contrast to the variance results for the estimator , above. i therefore recommend an estimator of average aggregate effects that reduces the variance by building on the estimator of the average individual-level effect at a distance . let where¯( ) is the average number of individuals at distance from candidate treatment locations: using the same distance bins (uniform kernel and bandwidth equal to bin width) for botĥ ( ) and¯( ). the set of distances d contains the midpoints of the bins that partition the full space into distance bins. for instance, if one uses distance bins [ , ], ( , ], . . . , ( , ] for a treatment that is known not to have effects past a distance of miles, then d = { . , . , . . . , . }. the theoretical properties of the estimator^, follow from those of^( ) in theorem above. theorem . under the ideal experiment, the estimator^, has an approximate finite sample distribution over the assignment distribution with remark . for approximate unbiasedness, the estimator^, must be based on^( ), not^− ( ). intuitively, when "integrating" the effect^( ) against the number of individuals at this distance, one needs to ensure that^( ) is an unbiased estimate of the effect for these particular¯( ) individuals. remark . the variance follows from theorem and theorem . the covariances can be derived analogously. since^, is a sum, its variance is a sum of the covariances of the terms. in the design-based perspective, the analysis is conditional on the individuals in the sample. hence, the number of individuals in each bin,¯( ), is fixed. the estimators^( ) for distances ∈ d are therefore the only stochastic components. remark . the optimal choice of distance bins (and bandwidths) remains an open question. if individuals are spread uniformly across space, equal-width rings with larger radii have larger area and hence contain more individuals. more generally, in densely populated areas, smaller bins may be preferable, and under suitable sequences of populations (infill asymptotics or growing number of regions), it may be possible to allow ℎ → and |d| → ∞. generally, in the formula above, additional distance bins decrease the (squared) weights¯( ) at the cost of increasing variances var i discuss issues in imposing parametric assumptions on the decay of treatment effects over distance from treatment and estimation by least squares regression. first, i show how to impose a parametric model on the individual-level effects at different distances. second, i show how to estimate aggregate effects based on such a model. most simple linear parametric models for the decay of average treatment effects over distance from treatment take the form ( ) = ∑︁˜( ) where˜are known functions of distance, and are coefficients to be estimated. in many settings, one needs to impose a distance after which the treatment has no effect, even within region, to obtain reasonable estimates from parametric models. assumption below formalizes this assumption. assumption . the treatment has no effect after a distance max if, for any individual ∈ i, set of treatment locations ⊂ s, and location ∈ such that ( , ) > max , without such a restriction, any simple functional form for˜will typically offer a poor approximation for at least some distances from treatment. one can improve the approximation to the treatment effect at short distances by using functions that only fit the treatment effect pattern up to the maximum distance max : relatively simple functions may well approximate the average treatment effects at distances ∈ ( , max ). this imposes contextual knowledge that average treatment effects are negligible at large distances from treatment. it also resembles a "bet on sparsity" (hastie et al., ) : if treatment effects really are negligible at distances longer than max , the estimators proposed below will likely perform well. if treatment effects are not negligible even at long distances, then no (parametric) estimator will perform well. for instance, one can impose a linear functional form on the treatment effect decay by choosing = , = . the coefficient then estimates the rate of decay. a quadratic functional form is imposed by = , = , = . in principle, the analysis in this section can be extended also to functional forms that are non-linear in the parameters, such as an exponential decay of treatment effects with unknown rate of decay, ( ) = exp( (− )). to estimate the parameters , suppose initially that there is only a single candidate treatment location in each region. this allows the definition of the distance of individual from the candidate treatment location uniquely as , irrespective of realized treatment. then estimate the weighted linear regression with weights reflecting those in section . . depending on the estimand, such as ( ) or − ( ) for different versions of the average effect of the treatment on the treated. the function ℎ models the average control potential outcomes at each distance from candidate treatment locations. for semiparametric estimation, specify the treatment effect decay ( ) parametrically, and estimate ℎ nonparametrically, as a partially linear model (e.g. robinson, ) . in this paper, i instead focus on parametric linear estimation, which imposes known parametric functions and ℎ and estimates their coefficients: the same caveat about setting a maximum distance applies also to ℎ. since there is no interest in effects at distances larger than max , the constant captures the mean outcome for individuals at such larger distances. in practice, one typically not only want to impose a zero treatment effect after distance max (assumption ), but a treatment effect that tends to zero continuously at max . to this end, estimate the linear regression with transformed covariates figure illustrates what it means to impose this restriction. in panel (a), without the restriction, the estimated treatment effect will jump to discontinuously at max . imposing the restriction in panel (b), the estimated treatment effect is continuous also at max . the restriction generally reduces the variance of the estimator, in particular for estimating aggregate effects, as discussed below. in practice, most functional forms for imply not just a zero effect after distance max , but also a non-zero effect at distances slightly shorter than max . the figure shows a scatter plot of outcomes against distance from treatment. both regression estimators use a quadratic in distance that is set to at a distance of max . the restricted estimator further restricts the regression coefficients such that function is continuous at max . the same parametric functional form can be imposed to estimate the average aggregate effects of the treatment. under the parametric model, the average aggregate treatment effect on the treated is solving for plugging this into the regression specification above, obtain the one-step regression specification where the coefficient on the first (transformed) covariate is the estimate of the average aggregate treatment effect. the transformed covariates are readily computed by realizing they are equal to the original covariates multiplied or shifted by average covariates. the average here is taken across all regions, both treated and untreated, such that this estimates has similarly attractive properties as the nonparametric estimator^, above, in leveraging that the number of individuals near candidate treatment locations are available irrespective of assignment. when there is more than one candidate treatment location per region, augment the regression approach as follows. the variable is not uniquely defined, since there are multiple "distances from candidate treatment locations" for individuals. suppose individual in a control region ( ( ) = ) is mile away from one candidate treatment location and miles away from a different candidate treatment location. then should be used to estimate the control mean ℎ( ) for the two distances = and = . one can therefore duplicate observation . specifically, if individual is in a region with |s ( ) | candidate treatment locations, then include |s ( ) | times in the regression. each version of uses the corresponding to a different candidate treatment location. this ensures ( | = , = ) = and hence results in consistent linear regression estimates. the framework and estimators proposed in the previous sections can readily be adapted to variations in the setting that are of empirical relevance, such as panel data and settings with interference. panel data can serve two distinct purposes in settings with spatial treatments. first, one can use pre-treatment outcomes to reduce the variance of treatment effect estimators. second, with panel data one can base identification of causal effects on a "parallel trends" assumption that is familiar from difference-in-differences methods. i show that existing empirical work relies on a version of this assumption that is not justified by the ideal experiment, discussed in section above, or other (quasi-) random variation in the location of spatial treatments. reducing variance under the ideal experiment, the nonparametric estimators proposed above are (approximately) unbiased, but may have large variance. the variance may be particularly large if potential outcomes of individuals in different regions are on substantially different levels. then, for some treatment assignment realizations, treatment is predominantly realized in the regions with large potential outcomes, such that the estimate ex-post overstates the true average treatment effect. symmetrically, under the inverse of this assignment, treatment is predominantly realized in the regions with small potential outcomes, and the estimate understates the true effect. ex-ante (on average across treatment assignments) the estimator is unbiased. the large differences between estimates for different treatment assignments imply, however, a large design-based variance of the estimator. if the researcher has a pre-treatment outcome for each individual, she can difference out the different levels of the potential outcomes in different regions. to implement this, simply take the difference between post-treatment and pre-treatment outcome for each individual, − pre , and then use the same estimators as before. this does not substantively affect the approximate unbiasedness of the nonparametric estimators. denote, for instance, the estimator^( ) with differenced outcomes as^d iff ( ). it follows immediately that where the pre-treatment outcomes, pre , are fixed across treatment assignments. the treated and control weights, ( ( ) , ( ) , ) and ( ( ) , ) mirror the weights in¯( ) and¯( ), respectively. hence, they are (approximately) equal in expectation by the arguments for unbiasedness of^( ) itself (appendix a. . ). hence, the second term is equal to zero in expectation. subtracting the pre-treatment outcomes from the potential outcomes within the estimand ( ) does not change the estimand at all because the pre-treatment outcomes cancel between the treated potential outcome and the control potential outcome. for the regression estimators, one can alternatively use pre-and post-outcomes as separate observations and include individual fixed effects in the regression for a similar effect. differencing out the levels of the potential outcomes greatly reduces the variance of the estimator if the temporal persistence in potential outcomes is large. this is most easily seen in the case with one candidate treatment location per region. then subtracting the pre-treatment outcomes affects the marginal variances¯( ) ( ) and¯( ) ( ). i recommend using the same formula for the variance estimator as before, but applied to the differenced outcomes, to obtain an estimate of the variance of^d iff ( ). loosely speaking, the variance of^d iff ( ) is smaller if the differenced outcomes have smaller marginal variance: var( ( ) − pre ) < var( ( )) and var( ( ) − pre ) < var( ( )). hence, using the differenced outcomes is likely to reduce the variance if the coefficients in (population) regressions of post-treatment potential outcomes on pre-treatment outcomes is at least . . one can also incorporate multiple pre-periods into this approach for variance reduction. relying on randomized treatment assignment for identification, additional pre-periods can be useful for differencing out the levels of the potential outcomes more precisely. specifically, if there are period specific unobservable components affecting outcomes, averaging over outcomes from multiple pre-periods may provide a more precise estimate of the level of control potential outcomes in the post-period. since the target of estimation is the postperiod effect, however, it is attractive to give greater weight to pre-periods that are closer in time to the post-period. intuitively, the goal is to use the pre-period outcomes to make a one-step-ahead forecast of post ( ). small adjustments have to be made if the pre-period data is for different individuals than those observed in the post-period. since the individuals are distinct, there is no single pre for a post-period individual . instead, the goal is to deterministically construct an estimate^p re based on pre-period outcomes of individuals with locations near the location of , . one can then use the same estimators as before with the transformed outcomes −^p re . if the construction of^p re does not depend on treatment assignment and post-period outcomes, formal results, such as theorem , continue to hold for the differenced outcomes. averaging over pre-period outcomes for different individuals estimates the expected outcome conditional on location. however, it fails to remove individual-specific fixed effects that are not correlated with the location of the individual. intuitively, the loss due to only having pre-period outcomes for different individuals is greater if individual-specific components are large and individual-time specific "noise" is small. in practice, pre-period outcomes for different individuals remain useful as long as neighbors' outcomes are sufficiently predictive of own outcomes, and neighborhood-level outcomes are sufficiently stable across time. identification based on parallel trends one can alternatively use the panel structure of the data to rely on a "parallel trends" assumption for identification of causal effects in a difference-in-differences approach. in practice, such an approach uses the same estimators as proposed for variance reduction. under the ideal experiment, treatment assignment is independent both of the post-period potential outcomes and of trends between the pre-period and the post-period, conditional on the known randomization probabilities. hence, the experimental setting allows the use of the pre-period data but does not require it, as discussed before. in observational settings, discussed in section , using pre-period data augments the assumption underlying identification. whether treatment assignment is more plausibly conditionally independent of levels or of trends depends on the setting. existing empirical work oftentimes uses panel data without control regions in which no treatment occurred (for instance linden and rockoff, ; currie et al., ; diamond and mcquade, ) . instead, these papers compare individuals near a treated location to individuals farther away from the same treated locations. these farther-away individuals are the control group in a difference-in-difference setup. figure illustrates which individuals these estimators are based on. when estimating the treatment effect ( ) at distance , individuals in an "inner ring" at radius from realized treatment constitute the treatment group. individuals who are substantially farther away in an "outer ring" around the same realized treatment location constitute the control group. typically, the same outer ring individuals serve as control units irrespective of the distance at which the treatment effect is estimated. in a difference-in-differences setup, estimators used in much existing empirical work hence rely on a different parallel trends assumption. specifically, individuals on the inner ring need to be on the same trend as individuals on the outer ring. for each distance for which the researcher estimates an effect, she obtains a different set of inner ring individuals. when the effect at each distance is estimated using the same outer ring individuals, she therefore needs to assume that individuals at any distance from treatment (up to the farther distance) are on parallel trends. effectively, this is the semi-parametric functional form assumption that control potential outcomes in all neighborhoods within a region share the same additively separable time-specific component. for these existing estimator, one additionally needs to assume that the farther-way individuals are unaffected by the treatment. if individuals on the outer ring were directly affected, their outcomes in the post-period would not generally reflect the control potential outcomes of individuals on inner rings even when the parallel trend assumption holds. researchers therefore typically restrict the control group to individuals who are substantially farther away from treatment than the treated individuals. however, this assumption is partly incongruent with the parallel trends assumption: the farther the control individuals are figure : existing estimators focus only on regions that received treatment. in this figure, the realized treatment location is shown as filled-in triangle. the treatment group consists of individuals in an "inner ring" at a given distance of interest from treatment, here displayed as small filled-in circles. the control group consists of individuals in an "outer ring" who are farther away from realized treatment, here displayed as hollow squares. existing estimators use pre-and post-treatment data for both groups in a difference-in-differences setup. typically, when researchers estimate the effect at multiple distances, the same control group is used for all distances. panel a shows the estimator^( short ) for a short distance short . panel b shows the estimator^( med ) for a medium distance med . away from treatment, the less likely the parallel trends assumption is to hold. the choice of distance for the outer ring needs to carefully balance these two competing assumptions. as with other difference-in-differences estimators, demonstrating an absence of pre-trends can strengthen the credibility of the parallel trends assumption. for inner vs. outer ring estimators, researchers need to argue that the absence of pre-trends suggests parallel trends even into the post-treatment period based on randomness of timing, not randomness of treatment locations. when treatment effects at multiple distances are estimated, control potential outcomes at each distance from treatment must be on parallel trends with one another and with the outer ring control individuals. for instance, (diamond and mcquade, , figures , , ) illustrate the absence of pre-trends in plots of three-dimensional data (time since treatment, geographic distance from treatment, outcome). in contrast to the more familiar two-dimensional plots from non-spatial settings, it is unfortunately challenging to include standard errors in such figures. it is therefore oftentimes difficult to accurately assess the magnitude and sometimes even direction of possible pre-trends visually. i therefore recommend formal sensitivity analysis and estimation of the partially identified set of treatment effects under small violations of the parallel trends assumption. recent theoretical work has proposed promising approaches to this problem for non-spatial settings that likely extend to the setting of spatial treatments (for instance manski and pepper, ; freyaldenhoven et al., ; rambachan and roth, ) . in settings with panel data, existing estimators and the estimators proposed in this paper both compare individuals near realized treatment to individuals farther away. for existing estimators, far-away individuals are in an outer ring around the realized treatment locations. for the estimators proposed in this paper, far-away individuals are in other, untreated, regions, near candidate treatment locations that appear similar to real treatment locations. however, the assumption for estimators using individuals on an outer ring as a control group is not generally justified by an ideal experiment of randomizing treatment locations. suppose the researcher is interested in the effect of the treatment at some distance . if individuals on the outer ring were the proper control individuals under an ideal experiment, then for each individual on the outer ring, there must be at least one candidate treatment location at distance from the individual. similarly, there must be candidate treatment locations such that individuals who are at distance from the realized treatment would be in the outer ring relative to these locations. this suggests that candidate treatment locations are everywhere and realized with equal probability, as in panel (c) of figure . this assumption is, in general, testable and typically violated in treatments that are of interest to social scientist; an example is given below. hence, these estimators are generally based on functional form assumptions such as additive separability of time-specific effects, rather than on an ideal experiment that involves randomized treatment locations. a first example illustrates when existing estimators based on an outer ring are relatively more attractive. suppose the researcher is interested in the effect of a spatial treatment at a distance of . miles, and knows that individuals at a distance of . miles are unaffected by it. in this setting, individuals at either distance from treatment are likely similar. they live in the same neighborhood and experience the same conditions except for exposure to treatment. the parallel trends assumptions between inner and outer ring individuals is plausible. instead, one should primarily focus on supporting the argument that the treatment has no effect after a distance of . miles. a second example illustrates when the estimators proposed in this paper based on untreated regions are relatively more attractive. suppose the researcher is interested in the effect of a spatial treatment that is typically realized in the city center. she is only willing to assume that the treatment has no effect after a distance of more than miles. then a comparison of individuals close to the treatment to individuals farther than miles from treatment may compare individuals who live close to the city center to individuals living in suburban neighborhoods. the parallel trends assumption between these individuals is less plausible. since treatment is typically realized in city centers, simple tests are likely to reject pr(treatment at | in rural area). instead, it may be more attractive to compare the individuals near treatment to individuals who live close to the city center of other, untreated, cities. with panel data, one can then assume that the inner city neighborhoods of treated and untreated cities are on parallel trends. if one can argue that the location of the treatment was chosen (quasi-) randomly from a set of candidate treatment locations across multiple cities, the assumption is satisfied by design. the estimators proposed in this paper allow this information to be used directly for identification and estimation of causal effects. in this section, i discuss two assumptions on how realized treatment locations that are close to one another interfere. under either of these assumptions, average treatment effects very similar to those in section are identified and readily estimated. the two assumptions i focus on in this section are: (i) treatment locations have additively separable effects; and (ii) only the nearest realized treatment location matters. additively separable treatment effects are an appropriate specification if the effect of each treatment is independent of the realization of other treatments. for instance, the effects of toxic waste plants (cf. currie et al., ) or air-polluting power plants (cf. zigler and papadogeorgou, ) on exposure to pollution are likely approximately additive. typically, only the nearest realized treatment location matters if individuals only access, or visit, a single realized treatment location. for instance, if a developing country quasi-randomly chooses locations to construct new schools (cf. duflo, ) , it may be plausible to assume that only the nearest school matters to an individual. for the effects of infrastructure projects, such as additional bus or subway stops, on commute times and real estate prices (cf. gupta et al., ) , the appropriate assumption may depend on the type of stops that are added. an additive effects specification for bus or subway stops may be a good approximation if each stop gives access to a different transit line. a specification where only the nearest stop matters may be more appropriate for stops of the same line. in contrast, if the treatments interact in some way leading to diminishing or increasing returns in the number of nearby treatment locations, different parametric assumptions on the functional form of these returns may be necessary. this section serves as an example for how to incorporate such assumptions on interference into the analysis of causal effects. i focus one two settings: a first setting where if a region is treated, a fixed number of candidate locations in the region are realized (completely randomized design within region), and data from untreated regions are available. a second setting where treatment assignment to candidate locations is independent (bernoulli trials), but all data come from a single (contiguous) region. suppose that if region receives treatment, exactly˜of the |s | candidate treatment locations are realized, each with equal marginal probability. assuming a completely randomized experiment between the candidate treatment locations within a region greatly simplifies the formulas in this section without mechanically resolving key conceptual issues. in practice, it is sometimes more plausible to assume that the assignment mechanism guarantees some minimum distance between realized treatment locations. it may be possible to obtain analogous results for such more complicated assignment mechanisms. continue to consider a setting with some regions with no realized treatment location. the presence of regions without realized treatment locations is a crucial simplification because it allows identification of control potential outcomes. within this setting, one can see how the assumptions on treatment effects limit interference and allow estimation average treatment effects similar to those in section . to give an example, suppose a company operating chain stores (quasi-) randomly chooses which cities to enter, and opens multiple stores in chosen cities. then there are multiple realized treatment locations close to one another (in the same city), but also control regions with (unrealized) candidate treatment locations. i discuss a settings without untreated regions further below. even in settings with control regions, one needs to make an assumption on interference to identify and estimate the treatment effects as defined in section . . . suppose one makes no such assumption. if some treated regions have multiple, for instance two, realized treatment figure : an example of a region with three candidate treatment locations (panel a): (blue), (red), (yellow). suppose exactly two of these treatment locations are realized whenever the region is treated, such that there is interference. under the assumption that only the nearest realized treatment location matters, panel b illustrates the locations for which we can estimate effects for individuals in each area. for individuals in the orange area, we can estimate the effects of the red and yellow locations. for individuals in the green area, we can estimate the effects of the blue and yellow locations. for individuals in the purple area, we can estimate the effects of the blue and read locations. locations, then it is impossible to identify the average (across all candidate locations) causal effect of implementing one treatment location. but even the effect of implementing multiple treatment locations at once is difficult to estimate in the detail of interest. presumably, one would be interested in the average effect of implementing two treatment locations at distance and , respectively. a non-parametric estimate of this effect is likely based on very few individuals, since few treated individuals are at distance from one treatment and at distance from another treatment. for a given pair of realized treatment locations, there are at most two locations where circles around them with radii and intersect. limiting estimation to only individuals residing close to such intersection points is therefore oftentimes impractical. it implies a dramatic reduction in sample size relative to estimating the effect of a single treatment at a given distance, based on all individuals around this distance ring. if there are more than two realized treatment locations, or treated regions vary in the number of realized treatment locations, this estimation issue worsens. a simple example, illustrated by figure a, helps to build intuition for the estimators proposed below. suppose the researcher has data from multiple regions . each region has three candidate treatment locations; , , , , and , . if region receives treatment, the assignment mechanism randomly chooses exactly two of the three candidate locations to be realized. hence, each candidate location has marginal conditional probability of / of being realized. the set of realized treatment locations in region , , satisfies ∈ i present and discuss two assumptions on interference and how to estimate effects under them in turn. assumption (additive separability of treatment effects). let ⊂ s be an arbitrary subset of the candidate treatment locations, and let ∈ be an arbitrary location in this subset. the effects of spatial treatments are additively separable if, for all individuals ∈ i, ( ) = ( ∖ ) + ( ). assumption formally states that the effects of all treatment locations are additively separable. intuitively, the assumption requires that there are no diminishing (or increasing) returns to having additional treatment locations nearby. under assumption , one can still identify the average treatment effects defined in section . these estimands are weighted averages of individual-level treatment effects ( ) of individual and candidate treatment location which are distance apart. for exposition, i focus on the example with three candidate treatment locations, two of which are realized in treated regions. under the additive separability, assumption , the potential outcomes satisfy hence the treatment effect of interest is where each of the potential outcomes has positive probability of realization. one can therefore estimate ( ) aŝ additive ( , ) = each term in the sum is an unbiased estimator of the the corresponding potential outcome, such that (^a dditive ( , )) = ( , ). one can then average such estimators to estimate, for instance, the att estimand, ( ). see appendix a. for a generalization. assumption (only nearest realized treatment location matters). let ⊂ s be an arbitrary subset of the candidate treatment locations, and ∈ i an arbitrary individual. only the nearest realized treatment location matters if whenever ∈ satisfies ( , ) ≤ ( ′ , ) for all ′ ∈ , we have, for ′ ∈ ∖ { }, assumption states that if ′ ∈ is not the nearest realized location to individual , it does not affect her. the assumption also implies that if individual is at equal distance to two treatment locations and , then both have the same effect on her: under assumption , only some of the average treatment effects of section are nonparametrically identified in general. specifically, it is impossible to identify the effect of a candidate treatment location on an individual if the treatment location is never the nearest realized location for the individual. consider the example of three candidate locations with two realized locations. the effect of location , is unidentified for individuals nearer to both locations , and , . panel b of figure highlights areas in which each candidate treatment location is nearest with positive probability before realization of treatment assignment. generally, the estimand ( ) from section is identified nonparametrically under assumption if it only places weight on individual level effects ( ) if is the nearest realized location to individual with positive probability. formally, write this as where the probability is taken over draws from the assignment distribution of for fixed , , , and . in the example illustrated in figure , one can estimate ( , ) for individuals in the purple and green shaded areas. under assumption , the potential outcomes satisfy an unbiased estimator of ( , ) iŝ one can then average estimates^n earest ( ) across individuals and locations to estimate average treatment effects similar to those in section . however, the estimator^n earest ( , ) is undefined for individuals in the orange shaded area (last line of the definition). since location , is never the nearest realized treatment location for these individuals, it is impossible to estimate its effect on individuals in that area. that is, only average treatment effects that place weight ( , , ) = on individuals in the orange area are identified nonparametrically. see appendix a. for examples of identified estimands and the general setting. suppose the researcher has data on a single contiguous region with individuals , outcomes and candidate treatment locations s. the realized treatment locations are ⊆ s, with assignment to locations , ′ ∈ s independent when ̸ = ′ . assumption formalizes this assumption, which is a straightforward extension of assumption above. assumption (independent treatment assignment -single region). assignment of treatment to locations is independent: for ∈ s,˜⊆ s with ̸ ∈˜⊆ s, as before, the researcher is interested in the weighted average treatment effect with known weights ( , ), for instance for a distance-bin estimator of the average effect of the treatment on the treated. to estimate the average this average treatment effect, consider the estimator which is the difference in average outcomes for individuals near realized candidate locations, remark . while all treatment probabilities are known to the experimenter in experimental analyses, they typically need to be estimated in observational studies. to this end, first note that one can generally write, for any potential assignment ∈ s , second, pr( ⊂ ) pr( = ) cancels between numerator and denominator. hence, to estimate pr( ∈ | ⊂ ) in practice, it is convenient to parameterize this conditional probability and estimate where ( ) are other (spatial) covariates specific to treatment location (and its neighborhood). the framework, estimators, and analysis of this paper are applicable more generally to settings where treatment assignment is separate from the units of observation, and the effect of treatment is moderated by some observable, not necessarily geographic, distance from treatment. i give two examples in this section: firm entry in markets with differentiated products, and shift-share designs based on randomness of the shifts. for the first example, suppose the researcher is interested in the effects of firm entry on competition in markets with differentiated products. she has data for several markets on prices charged by firms ∈ i for products with horizontal or vertical locations in characteristics space. in some markets, a new firm enters with a product with characteristics . here, the estimand ( ) measures the average effect an entrant has on the price of a product at distance in characteristics space. for short distances , it captures competitive effects or deterrence behavior by firms selling products very similar to the product of the entrant. for longer distances , it captures ripple effects that arise if in equilibrium firms with more different products react to the price changes of firms with products similar to the entrant's. these estimands are therefore informative about the nature of competition. firm entry, however, is not generally random. theoretical models of competition and profits may therefore help to determine the probability of firm entry at any given point in characteristics space, conditional on the locations of existing competitors in characteristic space. for instance, expected profits of the entrant may come from a structural model based on distance to competitors in characteristics space (cf. hotelling, ) , perhaps calibrated to pre-treatment data. intuitively, validity of the estimator then requires that firm entry is random conditional on the expected profitability in the model. the structural model provides a baseline to enhance the credibility of the quasi-experimental analysis, but does not directly restrict the estimated pattern of competition. for a second example, suppose the researcher is interested in the causal effects of exogenous shocks to individual industries on employment outcomes in cities based on their industry mixes (cf. autor et al., ) . the framework of this paper is useful in this setting if the claims of causal identification are based on randomness in which industries are shocked, rather than on randomness in industry composition. importantly, the analysis in this paper reflects that cities with similar industry mixes are shocked similarly, in a way that is difficult to capture accurately with existing clustered standard errors. adao et al. ( ) and borusyak et al. ( ) develop alternative approaches based on the same idea, and show how it relates to bartik ( ) and shift-share instruments more generally. a benefit of the framework of this paper is that its results are not specific to linear (or other) functional form and that it allows for very transparent estimation of aggregate effects. the setting fits into the framework of this paper as follows. data are available for time periods = , . . . , . in some time periods, a single industry ∈ s = { , . . . , } receives an exogenous shock, potentially with different industries shocked in different time periods. assume that the time periods are chosen such that the shock only affects outcomes within the same time period. define the indicator = if an industry in period is shocked, and = otherwise. the researcher observes employment outcomes for cities ∈ i in time period . city has industry shares ∈ r , satisfying , ∈ [ , ] and ∑︀ = , = . here, the distance function captures exposure to the shock. city is heavily exposed to shocks of sector if industry has large share , , such that the "distance" ( , ) = − , is small between industry and city . the estimands ( ) and measure the effects of the exogenous industry shocks. for = , the estimand ( ) measures the average effect of shocking an industry on employment in cities with employment only in the shocked industry. for = . , the estimand measures the average effect of the exogenous shock on cities with % of their employment in the shocked industry. the estimand measures the aggregate effect of the exogenous shock across all cities, averaged across shocks to different sectors. the estimators and inference procedures of section are valid if it is random in which time periods and sectors an exogenous shock occurs. in principle, one can augment the variance calculations to allow, for instance, dependence structure in the shocked industry across time periods. the results in section . are relevant for settings where shocks occur to multiple industries in the same time period. while the previous sections presumed that the researcher designed the experiment for assignment of the spatial treatment, much empirical work relies on observational data. the primary challenge to observational studies in this setting is that researchers typically do not observe the exact locations of unrealized candidate treatment locations. to emulate the analysis of the ideal experiment with observational data, researchers need to estimate candidate treatment locations and their treatment probabilities. estimation is then based on an unconfoundedness assumption stating that among individuals near candidate treatment locations, whether their treatment location is realized is as good as random, conditional on characteristics of the individuals and the neighborhood of the candidate treatment location. suppose that there are multiple regions = , . . . , , defined such that any treatment location only affects individuals within the same region. define the location-specific treatment indicator ( ) to equal if location in region is treated, and − if the location is no treated: where = if treatment occurs somewhere in region , and is the realized treatment location in region as in section . in treatment effect settings with individual-level randomized experiments, unconfoundedness is often written as ⊥ ⊥ ( ), ( ) | = which is equivalent to an assumption on densities i similarly define unconfoundedness of spatial treatments at distance from location as here, = means that the sets of individual covariates are the same up to permutation. in practice, it is rarely feasible to find two candidate locations with equal number of individuals and equal covariates. instead, one can assume that treatment is unconfounded conditional on, for instance, average characteristics of individuals in the neighborhoods of candidate locations. such an assumption greatly simplifies estimation in practice. alternatively, one can make an individual-level unconfoundedness assumption for spatial treatments as a conditional mean equality, where, for the control potential outcome, there is no conditioning on distance from candidate treatment locations. in other words, individuals with the same covariates , potentially including neighborhood characteristics of , in control regions offer a valid comparison for the individuals treated at distance . such an assumption simplifies estimation, but is not justified by experimental design or arguments that the location of the treatment is as good as random. in this section, i outline a general strategy for finding unrealized candidate treatment locations with observational data. these counterfactual locations for the treatment are necessary for the quasi-experimental methods i propose in this paper. consider first the example of linden and rockoff ( ) given in the introduction, where the choice of candidate locations is relatively straightforward. they argue that the exact houses where sex offenders move in are as good as random due to random availability of houses within neighborhoods. here, the candidate treatment locations are houses in these neighborhoods. hence, the candidate locations are known, but their probabilities of treatment need to be estimated. see section . for propensity score estimation. when there are no (or insufficiently many) known unrealized candidate locations, however, the problem of choosing candidate locations from continuous space is hard. in principle, one could imagine estimating the probability of treatment at any location in a region conditional on all the features of the region. this is akin to estimating the spatial distribution of treatment locations ∼ ( ), where are the characteristics of region , potentially relative locations of all individuals in the region as well as moments of their covariates. one could then use the estimated^to inform the treatment probabilities at each point in the region as inputs in the estimators proposed in this paper. in practice, it is typically sufficient to find a finite number of candidate treatment locations that offer a plausible counterfactual to the realized treatment locations. computationally, it is often infeasible to use a continuous distribution , since the weight of each individual when estimating effects at distance would depend on the integral of^along a ring with radius around her location, . instead, i recommend finding a finite number of candidate locations. the average across these finitely many candidate locations approximates the strategy based on the complete distribution . i propose taking draws ∼^( ) to obtain candidate treatment locations. perhaps surprisingly, recent machine learning methods achieve good results at this task, despite the difficulty of estimating itself. specifically, i recommend a formulation similar to generative adversarial networks (goodfellow et al., ) ; see liang ( ) and singh et al. ( ) on the relationship between generative adversarial networks and density estimation. most closely related to this paper, use generative adversarial networks to draw artificial observations from the distribution that generated the (real) sample, for use in monte carlo simulations. generative adversarial methods for drawing ∼ ( ) are based on iteration between two steps. first, a generator generates draws˜∼˜( ), where˜is an implicit estimate of the density maintained by the generator in the current iteration. second, a discriminator receives as input either counterfactual locations proposed by the generator,˜| , or real treatment locations, | , and guesses whether its input is real. both the generator and the discriminator are highly flexible parametric models for their given tasks. the discriminator is trained by taking (stochastic) gradient descent steps in the direction that improves discrimination between real and counterfactual locations. the generator is trained by taking (stochastic) gradient descent steps in the direction that leads to fooling the discriminator into classifying counterfactual locations as real. effectively, the output of such models are counterfactual candidate treatment locations | that are indistinguishable (to the discriminator) from real treatment locations | . with a sufficiently flexible discriminator, the process is therefore similar to matching. if a proposed candidate location˜is noticeably different from all real treatment locations , a flexible discriminator will learn to reject˜. in contrast, synthetic control-type methods (abadie et al., ) would average multiple candidate locations, for instance˜and˜, to create a synthetic counterfactual for a real treatment location . if˜and˜individually differ from all real treatment locations , the discriminator will reject them despite their average resembling . the goal therefore is to find "false positives:" occasions when the classifier suspects a missing realized location even though there is no such missing realized location. typical classifier networks do not directly make binary predictions, but give a continuous activation score that indicates how likely each location (or the "no missing location" category, see below) is. in practice, i recommend looking for high activation scores for a particular location and low activation score for "no missing location." alternatively, one can look directly for activation scores resembling the activation scores of real treatment locations. such locations are likely to be decent matches for the real treatment locations, since they must share features of realized locations in order to achieve high activation scores. in the remainder of this section, i discuss how to tune generic machine learning methods to find suitable candidate treatment locations in social science applications. i recommend four high-level implementation decisions in adapting these methods. first, discretization of geographic space into a fine grid for tractability. second, convolutional neural networks capture the idea that spatial neighborhoods matter in a parsimonious way. third, incorporating the adversarial task of the discriminator into a classification task for the generator greatly simplifies training. fourth, data augmentation (rotation, mirroring, shifting) for settings where absolute locations and orientation are irrelevant. discretization to tractably summarize the relative spatial locations of individuals and treatment locations, i recommend discretizing geographic space into a fine grid. discretization provides an approximation that is particularly tractable for the convolutional neural networks recommended below. in principle, future improvements to, for instance, capsule neural networks (hinton et al., ) or other novel methods, may replace this as the preferred architecture and eliminate the need for discretization. for each grid cell, one can include a count of individuals with residence in the cell, potentially separately for individuals with different values of covariates, as well as average covariate values of the individuals in the cell or other moments of their covariates. if the grid is very fine, this discretization retains almost all meaningful information about relative locations. for instance, in the application of this paper, each grid cell has size . mi × . mi (approximately m × m). the discretized grid creates a three-dimensional array: the first two dimensions determine spatial location, and the third dimension enumerates the different covariates that are summarized. rather than taking the spatial dimensions to be entire regions, i recommend using square cutouts of regions such that the probability of treatment in the center of the cutout is only affected by individuals and covariates within the cutout. convolutional neural networks convolutional neural networks (cf. krizhevsky et al., ) have been particularly successful at image recognition tasks. in image recognition tasks, the input is a d array: a d grid of pixels, with multiple layers corresponding to the rgb color channels. for spatial treatments, the input also is a d array: the d spatial grid with layers corresponding to different covariates as described above. convolutional steps in neural networks generally retain the shape of the d grid, but the value of each neuron is a function of the covariates (or neurons) of the previous step not just at the same grid cell, but also the covariates (or neurons) at neighboring grid cells. figure illustrates this aspect of the convolution operation. however, the particular way in which the neighborhood of a grid cell is averaged is the same for any point in the grid. this makes convolutional layers substantially more parsimonious than fully connected layers, and allows the neural network to capture neighborhood patterns appearing in different parts of a region in a unified way. in particular, i recommend using at least two convolutions with reasonably large spatial reach. consider the application in this paper, where grocery stores are spatial treatments and restaurants are individuals with foot-traffic to the restaurants as the outcome. the first convolution allows each grid cell to see what other cells are around it. in the example, the output of the first convolution for a particular grid cell may be: "there are grocery stores nearby, competing restaurants very close, and restaurants within walking distance." the second convolution then uses the information on such neighborhoods to determine whether treatment is likely in a grid cell: "if there are many grid cells nearby (in all directions) containing restaurants or grocery stores facing much competition, this location is probably in center of a shopping area and reasonably likely to contain another grocery store." intuitively, the first convolution may measure what is important to the restaurants, while the second figure : convolutions in a neural network allow the prediction of a candidate location in a grid cell to depend on the characteristics of neighboring grid cells (up to a user-specified distance). these models remain parsimonious by requiring the same "neighborhood scan" to be performed for each grid cell. convolution translates how that is important for the treatment location choice, mirroring the unconfoundedness assumption (equation ) of the previous section. adversarial classification generative adversarial networks are oftentimes difficult to train despite recent advances such as networks with wasserstein-type criterion function . the difficulty arises because the training of generator and discriminator needs to be sufficiently balanced such that both improve. in contrast, convolutional neural networks for image classification are much easier to train. i therefore recommend to set up the problem of finding candidate treatment locations as a classification task. specifically, the convolutional neural network takes a given input array and "classifies" it into, say, categories, where each category corresponds to a grid cell and signifies that there should be an additional treatment location at that point in the grid. to retain the adversarial nature of the task, train the classification on three sets of data: first, regions with at least one real treatment location, but with one treatment location removed. the correct classification of such region data is into the category corresponding to the grid cell from which the treatment location was removed. second, regions with at least one real treatment location, but without any treatment location removed. the correct classification of such region data is into a specially added category signifying no missing treatment location. third, regions without treatment locations. these are also classified as not missing any treatment location. the neural network then balances two tasks: a generative task of picking the correct location if a treatment location is missing, and a discriminatory task of deciding whether a treatment location is missing at all. this structure retains the attractive interpretation of generative adversarial networks, but is substantially easier to train. technically, it resembles denoising autoencoders (cf. vincent et al., ) . data augmentation data augmentation serves two closely related purposes. first, rotating, mirroring, and shifting regions, while maintaining relative distances, produces additional, albeit dependent, observations. this is helpful since training neural networks requires large numbers of training samples. second, these transformations effectively regularize the parameters of the estimated model. one can choose transformation that induce equivariance to rotation, mirroring, and shifts as appropriate for the particular setting. for instance, in many applications in the social sciences, north-south and east-west orientation is irrelevant on a small scale; only the relative distances matter. in particular, suppose an individual who visits a business to the north of her home because it is on the way to work in the north. if the whole space was rotated, the individual equally visits the same business now to the west as it is still on the way to work, now also rotated to be to the west of her home. in image classification, the use of similar data augmentation is common and often associated with greater generalizability of the learned models. shifting the entire grid has two further desirable effects: first, if one imposes a continuous shift of relative coordinates in combination with a fixed grid, the exact discretization becomes less relevant. the average (across draws from the shift distribution) distance in grid cells between two observations becomes directly proportional to their actual distance. second, the location of an observation within a grid cell is no longer fixed. this is attractive because the classification is not actually informative of whether the candidate treatment location is at the center or towards the edge of a grid cell. with a continuous shift of the observations, the center of the grid cell points to different absolute locations depending on the shift. one can then average over several realizations of the shift to reduce the influence of the particular translation of grid cell to absolute location. there are at least two notable alternatives or complements to data augmentation in the machine learning literature. first, spatial transformer networks (jaderberg et al., ) attempt to estimate a rotation or other transformation that makes the subsequent classification task as easy as possible. second, some recent work considers imposing the desired in-and equivariance properties on the convolution kernel. similarly, penalization of deviations from in-or equivariance serves as a less strict regularization of the model parameters. ultimately, current implementations of these methods are less computationally efficient than data augmentation and standard convolutional neural networks. furthermore, simulation evidence suggests that data augmentation achieves the first order gains implied by these properties. one can also inspect the models to assess the implied degree of invariance, and consider averaging parameters as implied by invariance. suppose candidate treatment locations s are known (in all regions), for instance as output of the convolutional neural network classification tast described in the previous section. the remaining challenge in implementing the methods proposed in this paper is the estimation of the "propensity score" pr( ∈ ). i briefly sketch propensity score estimation in two canonical settings: a fixed number of realized treatment locations per treated region (often just one realized location), and independent bernoulli trials determining realization of treatment at candidate locations. fixed number of realized treatment locations suppose there are a fixed number of realized treatment locations per treated region. then the problem of propensity score estimation resembles discrete choice modeling: there are |s | discrete alternatives in region , a fixed number of which is realized. see, for instance, greene ( ) for an overview of estimation methods. when treatment assignment is independent across locations, propensity score estimation for spatial treatments is similar to propensity score estimation for individual-level treatments. logistic regression is a simple option. each candidate treatment location ∈ s is a separate observation. with logistic regression, regress the indicator { ∈ } on covariates ( ) that describe the neighborhood of candidate location as well as (moments of) the characteristics of individuals near location , ( ) : ( , )= for all distances of interest . adjusting for the true propensity score is likely sufficient for unconfoundedness in equation , similar to the setting with individual-level treatments (cf. rosenbaum and rubin, ) . using estimated propensity scores in observational studies, the propensity score is typically estimated by the methods above rather than known. even when the propensity score is known, there may be benefits from using estimated propensity scores for parts of the analysis as in experiments with individual-level treatments (cf. hahn, ; hirano et al., ; frölich, b) . when estimated propensity scores are close to or , the inverse propensity score weighting estimators proposed in this paper may perform poorly (cf. frölich, a; busso et al., ) because small estimation errors in the propensity scores have large effects on the weights when denominators are close to zero. to reduce the effect of estimation error from this first-stage estimation, i also use cross-fitting and a doubly-robust moment condition (e.g. chernozhukov et al., ) in the application of this paper. while existing results assuming i.i.d. data are not directly applicable to the spatial treatment setting, doubly-robust moments likely still substantively reduce the effect of error due to propensity score (and outcome model) estimation. treatments, restaurants are the (outcome) individuals, and foot-traffic (the number of customers) is the outcome of interest. i argue that the inner ring vs. outer ring comparison used in many recent empirical studies is unattractive in this setting: its identifying assumption is not credible, and it requires discarding the majority of the sample for practical reasons. i show how to implement the methods proposed in this paper, and argue that the control groups these methods are based on are preferable to outer ring control groups. the average treatment effect of interest is identified by an ideal experiment where some grocery store locations are randomly closed during covid- lockdowns. specifically, take a restaurant near a grocery store at location . what is the difference between the number of customers of restaurant during the covid- lockdown when there is a grocery store at location , and the number of customers of restaurant if there was no grocery store at location , holding fixed the locations of all other businesses and grocery stores. in the notation of this paper, if are the locations of other grocery stores, the treatment effect of interest is ( ) = ( ∪ { }) − ( ). this effect is distinct from fixing a spatial location near a grocery store, and considering the difference in the outcome (during covid- ) of the business that exists at this point in space when there is a grocery store nearby, and the outcome (also during covid- ) of the, possibly different, business that would have been at the same location, had there never been a grocery store nearby. grocery stores may have causal effects on the number of customers to nearby restaurants if they draw customers into the shopping and business area. in particular during the first few weeks of the covid- lockdowns, when individual mobility was greatly reduced, getting groceries may have been one of the few trips still made. if grocery store customers are more likely to stop by coffee shops or restaurants for pick-up orders right before or after getting groceries, restaurants and similar businesses may receive more foot-traffic if there is a grocery store nearby. large department stores serving as "anchor stores" of shopping malls may play a similar role in normal times. relatedly, jia ( ) studies the effects of new wal-mart stores on existing businesses. study the effect of restaurant closings on nearby restaurants. the effects of grocery stores on nearby restaurants are informative about several questions. do grocery stores have (positive) externalities on other businesses? if so, should mall operators subsidize grocery stores through lower rent such that they internalize these externalities, to support other businesses in the mall? in the context of pandemics, are grocery stores likely choke points leading to bunching of customers at nearby restaurants instead of spreading out across all restaurants, increasing the risk of infections? alternatively, grocery stores may resolve a coordination problem: suppose that the overall reduced number of restaurant customers is insufficient to operate restaurants profitably or with reduced loss when spread across all restaurants. grocery stores may then help to resolve a coordination problem between restaurants, by focusing potential restaurant customers on the nearby restaurants. i use safegraph data on the number of customers of each business in the week starting april , . i restrict the sample to businesses in the area between san francisco and san jose in the san francisco bay area, as highlighted in figure . restricting to businesses with the outcome of interest is the inverse hyperbolic sine of visits to restaurants, with visits as measured by safegraph. to interpret the percentage point effect on the number of safegraphtracked customers as the overall effect, assume that safegraph's sample selection is orthogonal to the presence and absence of grocery stores. otherwise, the estimates retain internal validity as the effects on the number of safegraph-tracked customers to these restaurants. the inverse hyperbolic sine allows for zero visits, and effects on it can be transformed into elasticity estimates similar to log( ) or log( + ) specifications (see bellemare and wichman, , for a discussion). businesses with fewer customers may also be open. however, grocery stores with few if any customers tracked by safegraph are unlikely to have effects on the number of safegraph-tracked customers to nearby restaurants. safegraph ( ) describes the algorithm used for attributing visits to businesses. generally, pick-up orders as well as outside dining are likely picked up by the algorithm as long as a customer's smartphone sends location data at the point of interest for more than one minute. for errors in attribution to matter in the application of this paper, they need to correlate with the presence or absence of nearby grocery stores. the inverse hyperbolic sine is defined as arcsinh( ) ≡ ln( + √︀ + ). hence arcsinh( ) = , arcsinh( ) ≈ . , arcsinh( ) = . , and arcsinh( ) ≈ ln( ) + . if ≥ . figure : the comparison of businesses on an inner vs. outer ring around a particular grocery. the grocery store is marked by an orange triangle in the center of the figure. other businesses are small blue circles. businesses on the gray inner ring, at a distance of . ± . miles, are primarily in strip malls, while businesses on the gray outer ring, at a distance of . ± . miles, are away from these main shopping areas. figure illustrates why comparisons between observations on an inner ring and observations on an outer ring around a strategically chosen location are often not attractive. here, businesses (blue circles) on the inner ring are at a distance of . ± . miles from the grocery store (orange triangle), while businesses on the outer ring are at a distance of . ± . miles from the same grocery store. while inner ring businesses are part of the same strip mall, outer ring businesses are outside of the primary shopping areas. interpreting differences in outcomes for these two groups of businesses as causal effects requires assuming that outer ring businesses are unaffected by treatment and have similar outcomes as inner ring businesses in the absence of treatment. generally, distance from treatment often correlates with many other variables (kelly, ) . with small numbers of grocery stores (see below), the mode of average treatment effect estimates may not be close to the true average effect, even if the locations of grocery stores were random. this arises due to spatial correlations in outcomes even in the absence of treatments (cf. lee and ogburn, , in a network setting). while panel data can in principle relax one of the underlying assumptions, the common (visual) test for the absence of pre-trends carries little information about the validity of the identifying assumption in this setting. with panel data, the assumption of comparability of inner and outer ring businesses is relaxed slightly to an assumption of parallel trends. businesses on inner and outer rings are allowed to have different average levels of customers, but trends in the inverse hyperbolic sine of the number of customers must be parallel. however, even if panel data suggested that trends between inner and outer ring businesses were indeed parallel pre covid- , one may question whether this is informative about changes in (potential) outcomes during covid- lockdowns. given the dramatic decrease in customers for all businesses, it is questionable that this decrease would have occurred in parallel with only an additive shift (in the inverse hyperbolic sine) for inner and outer ring businesses in the absence of treatment. additionally, the estimand of a difference in differences estimator in this setting is the additional effect of grocery stores on nearby businesses during covid- on top of any effects that may have already existed pre covid- . even if the parallel trends assumption was credible, this estimand differs from the estimand of interest described above. the difference in differences estimand can be negative even though the effect of grocery stores on nearby businesses is positive during covid- if the effect of grocery stores pre covid- was also positive but larger in magnitude, for instance due to overall difference in the scale of the number of customers. finally, in most instances, businesses on the outer ring around a grocery store are not actually far away from grocery stores ("untreated"), as illustrated by panel (a) of figure . here, some of the businesses on the outer ring centered around the grocery store in the center of the figure are very close to a second grocery store to the north. applying the inner vs. outer ring estimator in this setting therefore requires restricting the sample to the neighborhoods of the few grocery stores that are sufficiently far away from other grocery stores. specifically, to guarantee the absence of interfering grocery stores for an outer ring "no effect" distance of . miles, only grocery stores with no other grocery store within × . miles can be used. panel (b) of figure shows the locations of the remaining grocery stores. compared to figure , these grocery stores are in more remote, less (sub-) urban neighborhoods. while the average treatment effect of grocery stores in such locations may continue to be of interest, it is plausibly distinct from the treatment effect in areas with higher population or business density. figure shows the comparison of means resulting from the inner vs. outer ring estimation. the average outcome of any distance to treatment (blue curve) is differenced with the average outcome of the outer ring (horizontal gray line), here chosen to be businesses between . and . miles from real grocery store locations. using grocery store fixed effects improves upon these estimates slightly by allowing the weights on the outer ring of each grocery store to vary by distance from treatment. intuitively, if % of all inner ring businesses are at distance from grocery store a, then the outer ring businesses around grocery store a should receive % of the aggregate weight of all outer ring businesses for estimating the effect at distance . if the fraction of inner ring businesses that are near grocery store a is different at distance , then also the businesses on the outer ring of grocery store a should on aggregate receive the different weight. estimates from this fixed effect specification are shown in row of table . for row , the aggregate weight for businesses near each grocery store are constant at / (weighting each of the grocery store locations equally), irrespective of the number of businesses near each grocery store, resembling the weighting of the estimand att-eq ( ) and facilitating a comparison of the effect at different distances from treatment. note that, for the inner ring vs. outer ring estimation, i cannot estimate the effect at a distance of larger than . miles because i have to assume that there was no treatment effect at that distance to be able to define an outer ring that is not near any grocery store. the spatial experiment estimator based on the ideas proposed in this paper, also shown in table , suggests that there indeed likely is no treatment effect past that distance. however, : panel (a) shows an example of a grocery store (triangle in the center) with a second "interfering" grocery store (triangle towards the top) nearby. some businesses on the outer ring are close to (treated by) this second grocery store and therefore not a valid control group. panel (b) shows that restricting the sample to the (out of ) grocery stores without interference leads to a sample selected heavily towards less business-dense areas compared to the overall sample shown in figure . the inner ring vs. outer ring estimator additionally requires that the average outcome at those longer distances is informative about the average outcome at shorter distances. as argued above, figure suggests this assumption is not a particularly good approximation. this application is covered by the framework of section . for a single contiguous region with independent treatment assignment. the key idea behind identification for the proposed methods is that the location of a grocery store is as good as random between candidate locations with similar numbers and industries of nearby businesses. figure shows an example of an ideal comparison where the only difference between the (parts of the) regions is the absence of the bottom-most grocery store, and all other relative distances are the same. the approach i propose for observational data proceeds in two steps: first, it finds good "matches" for each grocery store; that is, locations without a grocery store that are similar in terms of the number, types, and relative locations of other businesses and grocery stores. second, assume the matched data resemble the ideal experiment of randomizing grocery stores between the real and counterfactual candidate treatment locations. i recommend inverse propensity score weighting estimators based on the results of sections and . . conceptually similar combinations of matching or stratification and propensity score weighting or regression adjustments have been advocated for by abadie and imbens ( ) , (imbens and rubin, , ch. ) , and kellogg et al. ( ) , among others. the grocery store location prediction following section . discretizes the south bay region into a fine grid and aggregates characteristics of businesses in each grid cell. figure illustrates the discretization for the surroundings of an example grocery store, see panel (a). for each grid cell, record the number of grocery stores as in panel (b) . other characteristics of each grid cell, for instance the number of businesses by industry are recorded in similar grids as in panel (c). figure : the propensity score model can still distinguish between some of the false positives / counterfactual locations and real grocery store location, resulting in many candidate locations with low propensity score. after a propensity score matching step and re-estimation of the propensity score, overlap is better. real and counterfactual grocery store locations have similar (estimated) propensity score. based on this discretization, i use the method as described in section . to find counterfactual candidate grocery store locations that are indistinguishable from the real grocery store locations. since the method can find a very large number of counterfactual grocery store locations, i use propensity score matching to narrow the sample down to a smaller but more balanced sample of real and counterfactual grocery store locations. panel (a) of figure shows the limited overlap in propensity scores before this second matching step, while panel (b) shows good overlap for the final set of candidate locations. to estimate propensity scores in this setting, i assume that grocery store openings are independent decisions at each location, assumption . in practice, this assumption is primarily relevant at the margin of opening (or closing) additional grocery stores relative to the existing grocery stores. since there are neighborhoods similar in other businesses but differing in the number of grocery stores, this assumption may offer a reasonable approximation. the inverse probability weighted real and counterfactual grocery store locations are similar in everything except their exposure to real grocery stores, which differs by one additional grocery store. figure shows that the exposure to treatment is as intended: the number of grocery stores at distance between . and . miles from a business is the same between businesses at any distance from real and counterfactual grocery store locations, except businesses at that distance from a candidate grocery store location. businesses at distance from a real grocery store have exactly one additional real grocery store at distance on average, compared to businesses at distance from counterfactual grocery store locations. furthermore, the composition of nearby businesses is similar between real and counterfactual grocery store locations at any distance. figure shows that the fraction of restaurants among businesses at distance from counterfactual grocery store locations is comparable to the fraction of restaurants among businesses at distance from real grocery store locations. this lends credibility to the treatment effect estimates below. treated and control businesses are alike, except for a single additional grocery at the intended distance. distance from potential grocery store location in miles share of businesses that are restaurants realized false true figure : the composition of businesses near real and counterfactual grocery store locations is similar. it is encouraging that counterfactual grocery store locations mimic the business composition pattern across distance of real grocery store locations. since the fraction of restaurants decreases meaningfully from short distances to longer distances, inner vs. outer ring comparisons of all businesses would compare businesses in different industries. inner ring vs. outer ring comparisons of restaurants would compare restaurants in different (business) neighborhoods. figure : weighted mean of inverse hyperbolic sine of visits for businesses near real grocery store locations (blue line) and for businesses near counterfactual grocery store locations (red line). the difference between the two lines at a given distance is the estimate of the average treatment effect at that distance. panel (a) includes all businesses, while panel (b) restricts the sample to restaurants. there is a substantial estimated treatment effect at very short distances of up to . miles, and no meaningful difference between treated and control businesses at larger distances. given candidate treatment locations and propensity scores, i estimate treatment effects with the estimators of section . . to interpret the estimated effect as the average effect of opening single grocery stores, rather than the marginal of adding a grocery store to existing exposure, one can make the additivity assumption . additivity may be plausible if each additional grocery store brings new customers into an area. during covid- , customers may reduce the number of different grocery stores they shop at to limit their exposure. furthermore, there is differentiation in the grocery store market: the customers at discount grocery outlets may be distinct from the customers at whole foods. figure shows the average outcome of all businesses (panel a) and restricted to restaurants (panel b) by distance from candidate treatment location, contrasting real grocery store locations (blue line) and counterfactual grocery store locations (red line). at very short distances, businesses (including restaurants) on average have more customers if a (real) grocery store is nearby. if the grocery store is . or more miles away, it has no more effect on the businesses. table shows the spatial experiment estimator, which is the same as the difference between the curves at each distance for restaurants (corresponding to panel b of figure ). i also report estimates for the alternative estimator^a tt-eq ( ), which holds the aggregate weight placed on each grocery store constant across distances. i recommend this estimator for comparisons of effects across distances. since the grocery stores causing the effects are heterogeneous in their numbers of customers, their effects on foot-traffic to nearby restaurants is likely to be heterogeneous as well. i also estimate the att using a doubly-robust moment (e.g. chernozhukov et al., ) . the natural extension of the att-moment to the spatial treatment setting with interference table : estimated effects on the inverse hyperbolic sine of number of visits to restaurants using different estimators. the first panel uses the inner vs. outer ring comparison. the second panel uses the inverse probability weighting estimators for spatial experiments proposed in this paper. the third and final panel uses a doubly-robust version of the spatial experiment estimator. for each method, i implement to estimators: the average effect of the treatment on the treated (^( )), and the equal weighted att estimator (^a tt-eq ( )) that has a more attractive interpretation for comparing the effect at different distances. standard errors for the inner vs. outer ring estimators are clustered by grocery store. standard errors for the spatial experiment estimators will be reported in future version. note that the inner ring vs. outer ring comparison uses substantially fewer treatment locations because it requires restricting the sample to isolated grocery stores. where ( ( ) ) averages over all combinations of candidate grocery store locations and individuals satisfying ( , ) ≈ . { ∈ } plays the role of the "treatment indicator." the function ( , ) gives the expected outcome (inverse hyperbolic sine of number of visits) for a business with covariates , including neighborhood characteristics, when there are grocery stores at locations . for a business near a real grocery store, the conditional mean function is evaluated in the absence of the nearby grocery store , ∖ { }, with the parameter of interest, ( ), capturing the difference between actual outcome and expected outcome in the absence of the nearby grocery store. for businesses near an unrealized candidate location , the conditional mean function is evaluated at the background treatment exposure level . the propensity score ( ) gives the probability that there is a real grocery store at candidate location , conditional on characteristics of the neighborhood of . this moment function satisfies the neyman orthogonality condition of chernozhukov et al. ( ) . relative to the spatial experiment estimator, which treats the propensity score as known, this estimator has the advantage of reducing the impact of small errors in the estimated propensity score through orthogonalization. overall, the inverse propensity score weighting estimator and the doubly-robust estimator yield similar results as shown in table above. grocery stores have an economically large positive effect during covid- lockdowns only at short distances of less than . miles. intuitively, grocery store customers do visit nearby restaurants and coffee shops, but are unlikely to walk for more than a couple of minutes from the grocery store location. for instance, at the (control) average inverse hyperbolic sine of visits of approximately . , an increase of . points implies a % increase in the number of customers. the aim of this paper is to argue that leveraging quasi-random variation in the location of spatial treatments is both conceptually attractive and feasible in many settings in practice. i propose a framework and experimental approach for estimating the effects of spatial treatments. this approach uses random variation in the realized locations of the spatial treatments for causal identification. i argue that an alternative estimator commonly used in practice is not justified by the same random variation, but instead identifies causal effects only under sometimes questionable functional form assumptions. to operationalize the (quasi-) experimental approach with observational data, i propose a machine learning method to find counterfactual locations where the treatment could have occurred but did not. the proposed method specifically leverages that neighborhood characteristics are predictive of both the location of treatments and the outcomes of individuals. convolutional neural networks learn this rich spatial dependence structure encoding relevant institutional features from the data. i incorporate the appealing properties of generative adversarial networks in a classification problem that leads to much simpler training in practice, similar to denoising autoencoders. i illustrate the proposed methods in an application studying the causal effects of grocery stores on foot-traffic to nearby restaurants during covid- lockdowns. several key questions remain for future research. in some settings, the spatial treatment is endogenous, but geographic characteristics which are continuous in space are available as plausibly exogenous instruments (cf. feyrer et al., feyrer et al., , james and smith, ) . it is unclear how to construct powerful instruments from such geographic characteristics and incorporate them in the causal framework of this paper. in this paper, i also assume that there is no migration response to the treatment. to allow for migration, one could either focus on outcomes at fixed geographic locations instead of outcomes of fixed individuals or embrace a local average treatment effect (angrist et al., ) with a large number of compliance types if individuals move to different distances from treatment. the analysis in this paper is focused on estimating (potentially weighted) average treatment effects. in practice, decision makers may often be more interested in the optimal location for the spatial treatment. here, consider the expectation of the term in the numerator corresponding to individual , the first step uses that the realized outcome is the potential outcome corresponding to the realized treatment. the second step rewrites the potential outcome and distance bin indicator function in terms of non-stochastic candidate locations by summing over all possible treatment locations in the region, ∑︀ ∈s ( ) { = ( ) }. the third step moves the expectation into the summation, and the non-stochastic distance bin indicator function and potential outcome out. the final step resolves the expectation in terms of the probabilities determined by the experimental design, defined in section . the general estimator of interest in the setting without interference can be written aŝ where index denotes regions, = if region is treated at some location, and is the single treatment location chosen in region (if any). the weight function ( , ) is chosen by the user to weight individuals and treatment locations as desired and primarily place weight on pairs that are distance apart. for instance, for the att estimator with distance bin, choose ( , ) = ( ) { ( , ) ≤ ℎ}. the probabilities of treatment in regions and locations are given by ≡ pr( = ) and ( ) ≡ pr( = { }| = ). the first term averages over individuals at distance from a realized treatment location. the second term averages over individuals at distance from unrealized candidate treatment locations. the estimator estimates the weighted average treatment effect: with user-specified weights . the experiment considered here is a completely randomized experiment at the region level, where a fixed number of regions receive treatment at exactly one location each, and treatment in a region is assumed to have no effect on outcomes in other regions -regions are "far apart." the estimator^( ) is hard to analyze (in finite samples) because the denominators are random. this arises because, depending on treatment assignment, there may be more or fewer individuals near realized / unrealized locations. the same problem exists in standard randomized experiments when the treatment is randomized by an independent coin flip for each individual, such that the number of treated varies from assignment to assignment. in that setting, we can instead analyze the experiment with number of treated fixed at the value observed in the realized sample. conditioning on the number of realized treatment locations is not sufficient in the spatial setting because the number of individuals would still vary since some locations have more individuals near them than other locations. conditioning on the number of individuals restricts the assignment distribution asymmetrically -inverting an assignment generally changes the number of individuals near treatment -such that standard estimators are no longer unbiased by design. the theoretical analysis of^( ) therefore relies on an approximate estimator that fixes the denominators (at their expected values), and centers the numerators in a way that minimizes the difference between^( ) and its approximation. the approximate estimator is where ( ) and ( ) are average potential outcomes: here, i show that the estimators^( ) and˜( ) are very close in large enough samples. this motivates the use of exact finite sample results for the mean and variance of the infeasible estimator˜( ) for inference with the feasible estimator^( ). the analysis uses the mean value theorem to derive the difference^( ) −˜( ) and argues that this difference is small in large enough samples. as a practical matter, a sample is large enough if the number of individuals near treatment and control are close to their expected values. the approximation of^( ) by˜( ) is particular close when also the average outcomes are close to their expected values. to simplify notation, define the following shorthands: where˜, ( ) and˜, ( ) replicate^, ( ) and^, ( ) but with expected values rather than sample averages in the denominators. the sample average denominators are^, ( ) and , ( ) (scaled such that they converge under suitable conditions when grows), and the expected value of the denominators is ( ) (similarly scaled). without loss of generality, i fix the distance and weighting of interest and suppress the dependence on and in the following derivations for ease of presentation. the feasible estimator written in terms of the shorthand notation iŝ where˙is some convex combination of^and . it is straightforward to see thatΔ( , , , ) = . hence the left-hand-side of the equality above is justΔ(^,^,˜,˜), such that the right-hand-side is an expression for^−˜. hencê each of the four terms is a product with each factor close to zero under appropriate asymptotics. for instance, with independent regions and bounded outcomes and number of individuals per region, one can get √ (^− ) → . that is, the difference between the estimators^( ) and˜( ) is negligible under standard asymptotic frameworks. since the difference between estimators is very small for large samples, exact finite sample results for ( ) likely provide decent approximations for^( ) in smaller samples. consider the expected value of the estimator˜( ). to show: (˜( )) = ( ). since ( ) is the first term of˜( ), i proceed by showing that (˜( ) − ( )) = . since the denominators are non-stochastic, it suffices to show that the expectations of the numerators are equal to zero. the "first term" and "second term" designations below therefore refer to the first and second term of˜( ) − ( ). the expectation of the numerator of the first term is: the first equality rewrites the observed outcome = ( ( ) ) in terms of potential outcome ( ) = ( ) for = . the second equality moves all non-stochastic terms out of the expectation. the third equality rewrites the expectation of indicators as probabilities. the fourth equality distributes the difference ( ) − , ( ) and replaces , ( ) by its definition. for the second term, the factor multiplying the ratio cancels with the denominator, and the numerator is equal to the first term, such that the difference is equal to zero. analogously, the expectation of the numerator of the second term is: hence (˜( )) = ( ). the approximate estimator˜( ) in equation is the sum of three terms. since the first term, ( ) is fixed, the variance only depends on the last two terms. for the third equality, distribute out the − term of −( − ( ∑︀ ( ))) . . ., which is non-stochastic and hence does not contribute to the variance, such that only +( ∑︀ ( )) . . . remains of the second term. the fourth and final equality above distributes out the ( ) of the second term and then combines the first and second term by factoring out ( ). for ease of notation, definē the only stochastic terms left are the ( ); they represent the design-based variation that is due to random treatment assignment. the average¯+ , ( , ) consists only of a sum of potential outcomes, which are non-stochastic in the design-based perspective, in the numerator and the expected number of individuals near treatment, which is also non-stochastic, in the denominator. the where pr( ′ = | = ) is determined by the completely randomized design. let be the (fixed) number of treated regions in a completely randomized design. then pr( ′ = | = ) = − − since, under assumption , if region receives treatment, − of the remaining − regions receive treatment, each with equal probability. so )︂ the first equality combines the added term with the first summation and the subtracted term with the second summation. the second equality simplifies the factor of the first term, factors the second term into and ′ , and notices that both summations are the same, yielding the square in the second term. here, the third summation is "missing" the terms where = ′ . adding and subtracting by combining the added = ′ term into the second term and the subtracted = ′ term into the third term. note that dropping the (unidentified) variances of treatment effects (terms four and five) unambiguously leads to a conservative estimator of the variance. the absolute value of the factor in the fourth term, , is larger than the factor in the fifth term, − , and the numerator of the ratio in the fourth term is larger than the numerator of the ratio in the fifth term by jensen's inequality (while the denominators are identical). hence the absolute value of the fourth term is larger than the fifth terms, such that dropping both terms increases the expression, leading to a conservative estimator of the variance. to estimate the first term, takê to estimate the second term, takê { ̸ ∈ } pr( = ) pr( ̸ ∈ | = ) the estimator^a dditive ( ) here 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effects based on stochastic interventions on the application of probability theory to agricultural experiments. essay on principles. section on the application of probability theory to agricultural experiments. essay on principles. section causal inference with spatio-temporal data: estimating the effects of airstrikes on insurgent violence in iraq spatial econometrics for misaligned data an honest approach to parallel trends semiparametric efficiency in multivariate regression models with missing data root-n-consistent semiparametric regression interference between units in randomized experiments the central role of the propensity score in observational studies for causal effects local exposure to school shootings and youth antidepressant use determining point-of-interest visits from location data: a technical guide to visit attribution externalities of public housing: the effect of public housing demolitions on local crime causal inference with misspecified exposure mappings average treatment effects in the presence of unknown interference nonparametric density estimation under adversarial losses nonparametric policy analysis nonparametric policy analysis: an application to estimating hazardous waste cleanup benefits on causal inference in the presence of interference identification and estimation of spillover effects in randomized experiments extracting and composing robust features with denoising autoencoders bipartite causal inference with interference the average of treated individuals at distance ± ℎ from realized treatment locations isthe term inside the square equals zero:the first equality substitutes the definition of¯+ , ( , ). the second equality splits the ratio into two separate sums, one of treated, the other of control potential outcomes. for the first term, the third equality factors out = , which is constant across regions by assumption , and cancels ( ) ( ) . for the second term, the third equality factors out − = − , which is constant across regions by assumption , and notes that the sum of conditional probabilities is equal to in each region, ∑︀ ( ) = . both terms are equal to zero by the definitions of , ( ) and , ( ).hence, under assumption (completely randomized experiment), equation becomes var (︂˜()︂ where = = by assumption .bernoulli trial under assumption (bernoulli trial), equation becomesto treat the variances under assumptions and jointly, define both under assumption and under assumption , the variance of˜( ) depends on squares of (sums of) the potential outcome sums¯+ , ( , ).consider the first square of potential outcomes above. by applying the binomial theorem twice, rewrite the squared sum of potential outcomes as the difference between estimable marginal variances and an inestimable (approximate) treatment effect variance. by dropping the inestimable variance of treatment effects, one obtains a conservative estimate of the variance.since ( + ) = + + and ( − ) = − + , ( + ) = + − ( − ) . similarly for the second square of potential outcomes above:substituting these expressions into equation , the variance in equation consists of five terms. the first and third terms resemble a variance of outcomes of treated individuals. the second term resembles a variance of outcomes of control individuals. the fourth and fifth terms resemble variances of treatment effects. it is only possible to identify the effect of a candidate treatment location on individual , ( ), if is the closest realized treatment location to with positive probability. one can take^,the estimator^n earest ( ) is equal to if the region of individual is treated but location is not the closest realized treatment location to . this happens both when is not realized itself, and when another realized treatment location ′ is closer to . if is the closest realized location to ,^n earest ( ) is equal to the outcome of scaled by the inverse of the probability of this event. if the region is not treated,^n earest ( ) is equal to the outcome of scaled by the inverse of the probability of region not being treated. clearly,^n earest ( ) is an unbiased inverse probability weighting estimator of ( ) ≡ ( ) − ( ) under the assumption that only the nearest realized treatment matters. key: cord- -f o owg authors: navarre, christine b.; pugh, d.g. title: diseases of the gastrointestinal system date: - - journal: sheep & goat medicine doi: . /b - - - / - sha: doc_id: cord_uid: f o owg nan the gastrointestinal system is, arguably, more prone to disease than any other part of the sheep or goat. gastrointestinal parasitism alone is the most significant cause of production and animal losses in much of north america. , there is no substitute for a thorough physical examination when trying to determine the affected body systems of a sick animal; this is especially true in diseases of the gastrointestinal system. a complete physical examination should include palpation for body condition, assessment of abdominal shape and rumen motility, observation of the consistency of the stool, and evaluation for the presence of bloat. however, because rectal palpation cannot be performed in sheep and goats, diagnosis of disease in a particular segment of the gastrointestinal system can be difficult. therefore, the clinician may have to perform ancillary diagnostic procedures to characterize gastrointestinal diseases properly. clinicopathologic data consisting of a complete blood count (cbc), serum biochemical evaluation (sbe), and urinalysis can be helpful in differentiating gastrointestinal diseases, developing a prognosis and plan for treatment, and monitoring treatment. a cbc rarely identifies a specific disease, but it can be helpful in evaluating the severity of dehydration, anemia, and hypoproteinemia. the clinician must take care to interpret the packed cell volume (pcv) and total protein in light of the hydration status of the animal as noted on physical examination. an anemic or dehydrated hypoproteinemic animal may have normal pcv and total protein values. both the cbc and sbe can be helpful in characterizing the presence and severity of an inflammatory disease process. changes in the total and differential white blood cell count indicate acute or chronic inflammation; increases in globulins or fibrinogen suggest a chronic inflammatory disease. low protein levels, especially albumin, can point to chronic blood loss from intestinal parasitism or infiltrative bowel disease. liver disease should be suspected if liver enzymes or bilirubin are elevated. however, liver enzymes can be normal in chronic liver disease. also, albumin levels rarely drop in ruminants with liver disease, as they do in other species. changes in electrolytes can occur with gastrointestinal disease, especially if the animals are anorexic. electrolyte measurements also are helpful in formulating a treatment plan. hypochloremia and metabolic alkalosis occasionally occur in abomasal disease. a mild hypocalcemia may be encountered in some small ruminants with gastrointestinal atony. because many animals with gastrointestinal disease are dehydrated and therefore azotemic and possibly hypoproteinemic, urinalysis is helpful to eliminate urinary disease as a cause of these pathologies. normal ranges for clinicopathologic values are included in this textbook (see appendix iii) and also have been published in several other textbooks. [ ] [ ] [ ] [ ] however, clinicians would do well to learn the normal values, especially serum biochemistry values, established by the laboratory most commonly used for analysis. analysis of rumen fluid can help differentiate diseases of the forestomachs. an appropriately sized orogastric tube can be passed through the oral cavity for fluid collection (figure - ) . the clinician must properly restrain the animal, using a mouth speculum (figure - ) to prevent tube chewing. if the tube is chewed, its roughened surface may damage the esophagus; parts of a broken tube can be swallowed. rumen fluid also can be collected using percutaneous rumenocentesis , [ ] [ ] [ ] [ ] [ ] (figure the clinician then aspirates fluid with a syringe. local anesthesia and sedation of the animal may be necessary. this technique avoids the saliva contamination that can occur during collection with an orogastric tube, and it appears to be less stressful. rumenocentesis presents a slight risk of peritonitis, but this risk can be minimized with proper restraint. percutaneous rumenocentesis should not be performed on pregnant females. after the fluid is collected, it can be analyzed for color, odor, ph, protozoal species and motility, methylene blue reduction time (mbr), gram's staining characteristics, and chloride levels. normal values are listed in table - . anorexia may cause the fluid to appear darker, the ph to increase, and the number and motility of protozoa to decrease. a gray color, low ph, and dead or no protozoa are seen in rumen acidosis from grain overload. the mbr is prolonged with any type of indigestion. large numbers of gram-positive rods (lactobacillus species) also may be seen in rumen acidosis. elevated rumen chloride indicates an abomasal or proximal small intestinal obstruction (either functional or mechanical). the most important reason for examining feces in sheep and goats is to determine the presence and relative number of nematode parasites infesting an animal or flock. the quantitative technique for determining eggs per gram of feces (epg) is shown in box - . fecal epg values of more than to indicate serious infestation and the need for intervention. fecal occult blood testing and acid-fast staining of fecal smears also can be performed. fecal occult blood tests can detect microscopic amounts of blood in the feces. however, they cannot indicate which part of the gastrointestinal tract is bleeding. acid-fast stains of fecal smears that reveal clumps of acid-fast rods usually indicate infection with mycobacterium paratuberculosis ( johne's disease). generally, individual acid-fast rods found on fecal examination are nonpathogenic. abdominocentesis is useful in discerning the causes of fluid distention in the abdomen. two methods can be used. the first technique involves tapping the lowest point of the abdomen slightly to the right of midline; it is useful in ruling out a ruptured bladder as the cause of general ascites (figure - ) . , the clinician should take care to avoid the prepuce in males. the second technique is useful if peritonitis is suspected. because localized peritonitis is more common than generalized peritonitis, four sites are tapped. the two cranial sites are slightly caudal to the xyphoid and medial to the milk veins on the left and right sides. the two caudal sites are slightly cranial to the mammary gland and to the left and right of midline. for either technique, manual restraint with sedation is recommended; the use of real-time ultrasonography may help locate fluid pockets. a -gauge needle or teat cannula can be used for fluid collection. the clinician should prepare the site using sterile technique and provide local anesthesia when employing a teat cannula. fluid should be collected in a small ethylenediamine tetra-acetic acid (edta) tube for analysis and a sterile tube for culture. abdominal fluid can be difficult to obtain because of the small amounts normally present in both sheep and goats. the clinician should minimize the ratio of edta to fluid because edta can falsely elevate protein levels. using edta tubes made for small animals or shaking excess edta out of large tubes resolves this problem. normal culture values are similar to those for cattle (clear, colorless to slightly yellow, to g/dl protein, less than , cells). cytologic examination . weigh g of feces and thoroughly mix with ml of water. this is the preferred method. however, if a gram scale is not available, feces can be added to the ml of water until the water level indicates ml. this approximates g of feces. . remove ml of well-mixed fecal-water suspension, add to ml of sheather's solution,* and mix well. is needed to characterize the cell population and assess for the presence of phagocytized bacteria. radiography of the abdomen can be performed in small ruminants using small animal techniques. in adults, the rumen normally fills the entire abdomen. radiography can detect gas distention of the small intestine, abdominal fluid, and foreign bodies. , contrast techniques are useful for diagnosing atresia of the rectum or colon. unlike in other small animals, contrast techniques are not practical for characterizing small intestinal problems in sheep and goats because the rumen dilutes and slows passage of the contrast media. ultrasonography ultrasonography can be used to provide better characterization of abdominal distention, internal and external abdominal masses, and gross lesions of the liver. ascites may be differentiated from fluid in the intestinal tract, and gas distention of the intestines can be differentiated from fluid distention. normal ultrasonographic examination of the liver in sheep has been described. the liver can be viewed on the right side from the seventh or eighth rib caudally to the thirteenth rib ( . ultrasonography can be used to perform biopsies of organs or masses and to locate pockets of fluid. laparoscopy is more commonly used as a reproductive tool, but it also can be used diagnostically as an alternative to exploratory laparotomy in small ruminants. , general anesthesia is recommended. the technique for laparoscopic exploration of the abdomen used for cattle can be modified for use in sheep and goats. the clinician inserts a cannula in the caudal abdomen and carefully inflates the abdomen with carbon dioxide (co ). with the animal restrained in dorsal recumbency and either sedated or anesthetized, the clinician places the cannula in the inguinal area as described for laparoscopic insemination in chapter . entrance on the right side allows visualization of most of the abdominal organs. the clinician should avoid the rumen when introducing the laparoscope into the abdomen. this procedure may be enhanced by lowering the head or rear of the animal, allowing better visualization of the entire abdomen. animals should be properly ventilated during this procedure because inflation of the abdomen and lowering of the head can put pressure on the diaphragm. exploratory laparotomy can be a valuable diagnostic tool in evaluating gastrointestinal diseases when other tests indicate abdominal disease. in some cases, therapeutic surgical techniques can be performed at the same time. the technique of exploratory laparotomy used in cattle can be adopted for sheep and goats as long as the clinician keeps in mind that these animals are more likely to lie down during surgery and standing surgery should only rarely be attempted. small ruminants should be heavily sedated or placed under general anesthesia during this procedure. they may show signs of postoperative pain, anorexia, and depression and should be treated accordingly with a nonsteroidal antiinflammatory drug (nsaid) (flunixin meglumine . to . mg/kg intravenously [iv] ). the decision to use perioperative and postoperative antimicrobial agents should be based on the conditions under which the surgery is performed and the diagnosis made at surgery. sheep the area should be clipped, but in goats alcohol can be applied to the overlying hair and skin. if the area is clipped, the clinician should apply a bland coupling material (e.g., methyl cellulose, vegetable oil) between the skin and the transducer. liver biopsy in sheep and goats is performed using the same technique and instruments as in cattle. however, sedation and ultrasound guidance are recommended. the biopsy can be performed in the ninth to tenth intercostal space slightly above an imaginary line from the tuber coxae to the point of the elbow (figure - ) . the site should be surgically prepared, and a local anesthetic ( % lidocaine hydrochloride) infused subcutaneously. a small scalpel blade is used to make a stab incision through the skin. a -gauge, . -cm liver biopsy instrument is inserted through the incision and the intercostal muscles and into the liver. the biopsy instrument should be directed toward the opposite elbow in most cases, but the use of real-time ultrasonography can help determine the direction and depth needed ( to cm). the clinician should avoid the vessels along the caudal border of the ribs. on reaching the liver, the clinician will note a slight increase in resistance. samples can be submitted for culture (in a sterile plastic or glass vial or tube), histopathology (in formalin at a Ϻ ratio of formalin to tissue); and/or mineral analysis (in a plastic tube). when performing a liver biopsy for mineral analysis, the clinician should rinse the biopsy site with distilled and deionized water after sterile preparation to minimize sample contamination. samples for mineral analysis should not be placed in formalin. the skin incision can be sutured, and aseptically prepared, the surgeon makes a stab incision in the skin and introduces a -gauge biopsy needle. bloat is less common in small ruminants than in cattle, with goats having the condition less commonly than sheep. bloat is the accumulation of either free gas or froth in the rumen, which causes rumen distention. the causes of bloat can be divided into three categories , : . frothy bloat-caused by diets that promote the formation of stable froth . free gas bloat-caused by diets that promote excessive free gas production . free gas bloat-caused by failure to eructate pathogenesis. frothy bloat is usually associated with the ingestion of legume forages or hay (particularly alfalfa) and with grazing on lush cereal grain pastures, but it also may occur with high-grain diets. in the case of frothy bloat from a finely ground diet (usually corn), mucoprotein released from rumen protozoa stabilizes the foam at a low ph. in legume-associated frothy bloat, plant chloroplasts released into the rumen trap gas bubbles. regardless of the form of frothy bloat, the small bubbles fill much of the rumen, preventing clearance of the rumen's cardia and resulting in a cessation of eructation. free gas bloat also occurs with grain diets, especially if the animals are not adapted to the diet. failure to eructate has a variety of causes. physical obstructions of the esophagus such as choke or swollen mediastinal lymph nodes can cause free gas bloat. any disease of the rumen wall can interfere with rumen contractions and eructation. hypocalcemia, endotoxemia, pain, peritonitis, and some pharmaceutical agents (especially xylazine) can all interfere with rumen function and eructation. , , , clinical signs. clinical signs of frothy bloat and free gas bloat from either food intake or physical obstruction of the esophagus are usually more severe and immediately life-threatening than bloat seen from rumen wall diseases and systemic influences. abdominal enlargement occurs, particularly in the dorsal left paralumbar fossa. this may be subtle in sheep or angora goats with full fleece. signs of colic and anxiety are common. the rumen may be either hypomotile or hypermotile. respiratory distress is evident, with some animals breathing through their mouths; death can ensue if the bloat is not treated. this condition is a medical emergency, and therefore diagnosis and treatment should occur almost simultaneously. if the animal is not in immediate danger of dying, an orogastric tube can be passed. most cases of free gas bloat are relieved with passage of the tube. a clinician should then take a thorough history and perform a complete physical examination to find the cause of the bloat. if the bloat is not relieved with an orogastric tube, the tube should be removed and examined for evidence of froth. frothy bloat can be treated with poloxalene ( mg/kg) or dioctyl sodium sulfosuccinate (dss) ( cc [ oz]) delivered by orogastric tube. the froth encountered in frothy bloat caused by the ingestion of finely ground grain has a ph of less than . . if frothy bloat occurs while animals are being fed concentrates, mineral oil ( ml) may work better. peanut oil ( to mg/kg), vegetable oil ( to ml), and hand soap ( ml) also have been recommended in emergency situations. if the animal is in severe respiratory distress, the clinician should insert a trocar or large needle into the rumen at the paralumbar fossa. if gas does not escape, or froth is seen coming out of the trocar, an emergency rumenotomy should be performed (see the rumenotomy section of this chapter). if several cases of bloat are encountered in a group of pastured animals, the entire group should be removed from the pasture and reintroduced slowly after gradual acclimation. if only one or two cases of bloat are encountered, the healthy animals can remain on the offending pasture, but grazing should be limited to ensure gradual acclimation. prevention. prevention of frothy bloat involves limiting access to offending pastures or feedstuffs; providing supplemental feed and providing poloxalene in mineral supplements; and adding ionophores to the ration or supplement. when grazing or consuming legumes as "greenchop," animals should be introduced to the feed or pasture slowly, preferably over to weeks. animals should be closely monitored after a frost and during the rapid growth phase of plants because legumes, particularly alfalfa, may be more likely to cause bloat at this time. certain varieties of legumes that are designed for intensive grazing systems (e.g., alfagraze) should be planted and managed in a manner that decreases the incidence of bloat (limited or creep grazing). feeding dry, stemmy hay for to hours before allowing access to the legume pasture also may help minimize bloat. grass-legume pastures in which legumes are limited to less than % of the forage are safer but can still pose a problem for animals that are selective grazers. grazing legumes with high leaf tannin concentrations (e.g., arrowleaf clover, kudzu) is usually safer because tannins help break down rumen foam. the inclusion of poloxalene ( to mg/kg daily) in the feed or mineral supplement is useful in preventing frothy bloat. if poloxalene supplements are used, keepers should feed them for to weeks before moving animals onto a problem pasture. free gas bloat from concentrate feeds can be controlled by slow introduction to these feeds to allow for rumen adaptation and by the inclusion of ionophores in the diet. monensin ( mg/head/day in ewes, mg/kg/day in goats) and lasalocid ( . to mg/kg/day in sheep and goats) both decrease the formation of free ruminal gas. by enhancing propionic acid formation, these drugs not only reduce the amount of methane produced in the rumen, they also improve the efficiency of nutrient assimilation from feedstuffs. bloat in lambs and kids can have the same causes as in adults but also can be caused by improper milk feeding. overfeeding, feeding of large infrequent meals, and feeding spoiled or cold milk have all been associated with bloat in lambs and kids. rapid overdistention of the abomasum and improper chemical or physical composition of milk replacers inhibit rumen motility, leading to bloat. even though the feeding of cold milk has been associated with bloat, the practice can be used effectively in orphan feeding programs. lambs and kids tend to limit their intake of cold milk after they have become accustomed to cold milk in a free-choice feeding system. milk is usually placed in the rumen when animals are tube-fed; this may result in milk spoilage. , simple indigestion is a mild form of upset of the reticulorumen caused by a change in feeding routine. it can be caused by an alteration in the type of feed or in the amount of feed offered. the most common causes of simple indigestion are the addition of grain to the diet, an increase in the amount of grain fed, and an increase in the energy density of the diet. examples of such dietary changes are replacing oats with corn or changing from whole to ground corn. if the changes are drastic, rumen acidosis can occur (see the following section). other common causes are changes in hay or pasture, consumption of moldy hay, and ingestion of weeds and toxic plants after overgrazing or droughts. clinical signs include mild anorexia that lasts for to days. mild diarrhea and bloat also may occur. rumen fluid ph can be unchanged, increased, or decreased depending on the inciting cause. most animals improve with no treatment. pathogenesis. rumen acidosis is caused by the rapid rumen fermentation of highly digestible carbohydrates that are ingested in excessive amounts. although corn is commonly implicated, other cereal grains (oats, wheat, barley) may be involved, particularly if they are finely ground. the smaller the particle size, the more quickly rumen bacteria are able to ferment the carbohydrates contained in the feed. the common name of this condition is "grain overload," but breads, candy, apples and other fruits, beets, and potatoes also can cause this condi-tion. rumen acidosis usually occurs in animals that have been fed predominantly forage-based rations and are suddenly given access to large amounts of highly fermentable concentrates or concentrated forms of energy. it also can occur in animals that have been receiving concentrates previously, if the amount is suddenly and drastically increased; if access is denied for a time, then suddenly returned (e.g., during weather changes and alterations in water availability); or if ration mixing errors occur (e.g., leaving out monensin and rumen buffers) as highly digestible carbohydrates are fermented, rumen ph drops. lactobacillus species, which are lactic acid producers, proliferate in the acidic rumen environment and further lower rumen ph. as the rumen ph drops, rumen protozoa and many of the lactate users begin to die. lactic acid production causes the osmotic pressure in the rumen to increase. fluid is drawn from the systemic circulation into the rumen, resulting in dehydration and possibly hypovolemic shock. lactate concentrations increase in the blood and may cause systemic lactic acidosis. the lactic acid in the rumen also is toxic to the rumen epithelium. damage to the epithelium can result in leakage of bacteria and toxins into the portal and systemic circulation. chronic sequelae to rumen acidosis include fungal rumenitis and occasionally liver abscesses. , liver abscesses are less commonly encountered in sheep and goats than in cattle. laminitis also can occur, but may be more of a problem in sheep than in goats. the severity of the disease depends on the composition of the feed, particle size, amount of feed consumed, and the period of adaptation to the diet. clinical signs. clinical signs vary with the amount and type of feed ingested and the time since ingestion. signs first appear to hours after ingestion of the offending feed; they vary from anorexia, depression, and weakness to a down animal suffering from severe circulatory shock. dehydration is usually severe and evidence of toxemia is present (e.g., injected mucous membranes, increased scleral injection). colic, bilateral ventral abdominal distention, rumen stasis, and a "splashy" feel to the rumen also may be present. diarrhea can develop, adding to dehydration. , , the diarrhea can range from a pastelike feces to very watery droppings with foam and occasionally pieces of grain easily recognized. dehydration, lactic acidosis, and toxemia result in neurologic signs, including ataxia, head pressing, opisthotonos, and seizures. the body temperature is initially elevated but may drop as the condition worsens or the animal becomes toxic. some animals develop polioencephalomalacia and appear blind. diagnosis. the rumen fluid ph may fall below . . the fluid itself is milky gray and particles of the inciting feed may be noticed. protozoa are usually reduced in number or absent, and large gram-positive rods (lactobacillus species) may be seen on gram's stain. clinicopathology is consistent with dehydration (increased pcv and total protein, prerenal azotemia) and metabolic acidosis. liver enzymes (gamma-glutamyl transpeptidase [ggt], aspartate aminotransferase [ast], lactate dehydrogenase [ldh]) may be elevated on serum biochemical analysis. , the leukogram can vary from normal to a degenerative left shift, depending on the severity of the case. urinalysis reveals an increased specific gravity. treatment. treatment is aimed at correcting cardiovascular shock, dehydration, acidosis, and toxemia and removing or neutralizing the offending feedstuffs. iv fluids containing % sodium bicarbonate should be administered. , oral fluids are contraindicated because they cannot be absorbed and may increase the rumen distention and discomfort of the animal. nsaids are indicated for toxemia (flunixin meglumine, . to . mg/kg iv). , oral administration of magnesium hydroxide and magnesium oxide ( g/kg) may neutralize the acidic ph and is sufficient in mild cases. however, if much of the feed is still in the rumen, these two alkalinizing agents will only work temporarily. oral antibiotics have been recommended to kill rumen microflora and stop fermentation. however, the authors of this chapter feel they are contraindicated because the gram-negative anaerobes that need to flourish to reestablish normal rumen microflora are susceptible to most antimicrobials effective against lactobacillus species. removing the substrate for the lactobacillus species is more effective. because orogastric tubes with large enough bores to reflux feedstuffs are too large for sheep and goats, rumenotomy is indicated in severe cases to remove the feed (see the section on rumenotomy in this chapter). after the rumen ph is cor-rected, transfaunation of the rumen microflora with about qt of rumen fluid from a small ruminant is beneficial (box - ). thiamine supplementation (vitamin b , mg/lb subcutaneously [sc] three times a day [tid] to four times a day [qid]) is indicated until rumen function returns. in certain instances, calcium may be indicated and can be included in the iv fluids (calcium gluconate). the clinician should avoid mixing calcium salts and sodium bicarbonate. bacterial leakage into the rumen wall, liver, and systemic circulation makes antimicrobial therapy necessary. the systemic antimicrobial agent of choice is penicillin (procaine penicillin g, , iu/kg im bid) because anaerobes are the most likely offending organisms. if treated aggressively, the prognosis for immediate survival is good. feed (grass hay only) and water should be limited until rumen contractions return to prevent overdistention of the rumen. the chronic sequelae discussed previously influence long-term survival. prevention. prevention involves introducing concentrate feeds slowly to allow rumen microflora adaptation. dietary change from a lower to a higher fermentable energy concentration should occur slowly and preferably over a -to -week period. in the case of animals being fed high-grain rations (e.g., club lambs, feedlot lambs, dairy goats), buffering agents can be added to the diet. rumen buffers may improve milk production, increase feed intake, and increase rate of gain. the crude fiber content should comprise a minimum of % of the diet's total digestible nutrients (tdn). for example, the tdn is %, the minimum acceptable crude fiber is %. crude fiber levels lower than this can be fed for short periods if the rumen is properly adapted, but problems may nevertheless occur. sodium bicarbonate is probably the most commonly used buffer; it can be offered free choice or included in the diet as % of dry matter intake. calcium carbonate or limestone (which both have low can be collected through a weighted orogastric tube. alternatively, fluid can be collected from any normal ruminant at slaughter. handling rumen contents collected from a fistulated cow or at slaughter can be strained through gauze or cheesecloth to separate the fluid from the fibrous contents. fluid collected through a weighted tube should be ready for storage. rumen fluid should ideally be administered immediately. however, it can be stored for to hours. the surface of the fluid should be covered with a layer of mineral oil to maintain an anaerobic environment and stored at refrigerator temperature. caution: do not store rumen fluid in a closed container because it may explode. rumen solubility) and magnesium oxide (which has poor palatability) also can be included in the feed. magnesium oxide should be limited to . % to . % of the dry matter intake. pathogenesis. reticulitis and rumenitis can result from chemical or mechanical damage to the mucosal lining of the reticulorumen. the most common cause of chemical damage is rumen acidosis. however, ingestion of caustic toxins also can damage the mucosa. mechanical damage can occur from ingested foreign bodies or the formation of rumen bezoars. in cattle, some viruses such as the ones that cause bovine virus diarrhea and infectious bovine rhinotracheitis can infect the rumen wall. similar viruses have yet to be identified in sheep and goats. after the mucosa has been damaged, secondary infection by bacteria or fungi can occur. previous treatment with oral antibiotics may predispose to fungal infections of the rumen wall, especially if the mucosa is already damaged. actinobacillosis, actinomycosis, and tuberculosis rarely affect the rumen wall. tumors of the rumen wall also have been reported. , not all of these causes of reticulitis and rumenitis have been reported in sheep and goats, but all are potential problems. clinical signs. the clinical signs of these diseases are vague. anorexia and forestomach hypomotility may be the only clinical signs. confirming a diagnosis also may prove difficult. samples of rumen fluid may only show changes associated with anorexia (alkaline ph, decreased numbers and motility of protozoa, prolonged mbr time; see table - for normal values). occasionally fungal organisms may be seen on diff quik stained slides of rumen fluid. in these cases a diagnosis of fungal rumenitis should be made. an exploratory laparotomy and rumenotomy may be required to diagnose foreign bodies or masses. rumen parakeratosis is characterized by dark, thickened, and clumped rumen papillae. it is seen mainly in feedlot lambs that consume finely ground or pelleted rations. the parakeratotic rumen papillae are fragile and predisposed to damage, which can increase the chances of rumenitis. treatment and prevention. treatment depends on the inciting cause. dietary changes should be made to decrease energy density and increase fiber intake. mild rumenitis may improve with time and supportive care (transfaunation, fluid support, high-quality feed). fungal rumenitis can be treated with thiabendazole ( mg/kg orally). severe changes may lead to scarring and permanent impairment of rumen function. traumatic reticuloperitonitis is not as common in small ruminants as in cattle, but it has been reported. goats are affected more commonly than sheep. this is probably because of the dietary habits of small ruminants; they tend to be selective grazers and do not "vacuum" the ground as cattle do. offending foreign bodies that cause traumatic reticuloperitonitis include pieces of wire and needles. , the clinical signs are identical to those in cattle and may include anorexia, depression, colic, signs of heart failure, and evidence of draining tracts from the chest cavity. treatment is usually difficult. rumen impaction can occur after dehydration, blockage of the omasal orifice by a foreign body, sand ingestion, or consumption of diets high in fiber and low in digestibility. clinical signs are nonspecific, but the firm rumen can usually be palpated in the left flank. the feces may be scant and dry. oral fluids containing magnesium sulfate ( g) may loosen impactions, but a rumenotomy is required in severe cases. to reduce rumen fill, sheep or goats should ideally have feed withheld for hours before rumenotomy. however, this is usually impossible because in most cases rumenotomy is an emergency procedure. the perioperative administration of antimicrobial agents is essential because even with meticulous technique some contamination of the incision site and possibly the peritoneal cavity is inevitable. because the rumen microflora is predominantly composed of anaerobic bacteria, penicillin ( , iu/kg) is the antimicrobial agent of choice and should be administered to hours before surgery. if the rumenotomy is being performed in an emergency situation, penicillin salts (potassium or sodium) that can be given iv provide therapeutic concentrations more rapidly than procaine penicillin. nsaids (flunixin meglumine, . to . mg/kg iv) also are recommended before surgery. if necessary, treatment of cardiovascular shock and dehydration with iv fluids also should begin before surgery and continue until the animal is rehydrated and in stable condition (see appendix ii). general anesthesia is recommended, but heavy sedation and local anesthetic infiltration of the incision site can be efficiently used (see chapter ) . the clinician should clip and surgically prepare a square area from cm in front of the last rib to the tuber coxae, and from the dorsal midline to the lower abdomen, encompassing the entire left paralumbar fossa. the surgeon makes a skin incision approximately cm longer than the width of the hand cm caudal and parallel to the last rib. the incision is continued through the muscle layers into the abdomen. because the abdominal wall is relatively thin, the surgeon should take care not to enter the rumen or bowel. the surgeon grasps the rumen wall and pulls it through the incision; suturing it to the skin with a simple continuous circular pattern around the entire incision. this forms a seal that minimizes rumen content contamination of the deep layers of the incision and peritoneal cavity. the rumen wall is then incised inside the circle of sutures. the incision in the rumen wall should be large enough for the surgeon to put his or her hand inside the rumen without traumatizing the rumen wall. after the rumen has been explored and emptied and the primary reason for doing the procedure has been completed, the surgeon closes the rumen wall in a continuous inverting pattern (cushing, lembert, or guard's rumen stitch) with absorbable suture ( catgut). the area should be rinsed with copious amounts of sterile isotonic fluids, and a new set of sterile instruments, sterile gloves, and surgical attire should be used for the remainder of the surgery. the surgeon then removes the suture securing the rumen to the skin and rinses the area again before performing routine closure of the abdominal muscles and subcutaneous layers with absorbable suture ( catgut) in simple continuous patterns, taking care to close dead space between layers. the skin is closed with a continuous pattern (ford interlocking) using a nonabsorbable suture material. the sheep or goat should be observed closely by the clinician for signs of complications, including peritonitis, incisional dehiscence, incisional hematoma, abscess, and hernia formation. penicillin therapy (procaine penicillin g, , iu/kg bid) should continue for at least days. the skin sutures can be removed to days after surgery. abomasitis and abomasal ulcers in adult sheep and goats are associated with rumen acidosis or chronic rumenitis but also can be caused by infections. [ ] [ ] [ ] [ ] finely ground feeds, pelleted rations, systemic stress, and feeding lush forages have all been implicated. anecdotal associations with mineral deficiency (copper) have gone unproved. clinical signs and diagnosis. this disease often goes unnoticed in mild cases, and the most common signs are anorexia and colic. no definitive antemortem diagnostic tests are available. fecal occult blood is often absent. occasionally dark stool, altered appetite (wood chewing), and bruxism are seen. therefore other causes of colic should be eliminated. diagnosis is based on clinical signs. effective therapy can be difficult. oral medications such as coating agents must first pass through the rumen, and therefore arrive at the abomasum diluted. iv (not oral) ranitidine ( mg/kg once a day [sid]) may be beneficial. herd problems of rumen acidosis may be addressed with buffers in the feed. a syndrome of abomasal hemorrhage, bloat, and ulceration is seen in lambs and kids to weeks of age. sarcina-like bacteria, clostridium falax, clostridium sordelli, and clostridium septicum have been isolated from many of these cases. [ ] [ ] [ ] [ ] c. septicum infections of the abomasum are commonly called braxy. the feeding of milk replacer free choice, iron deficiency, and bezoars have been implicated as predisposing factors. , clinical signs. the signs of this syndrome are severe, acute abdominal distention; colic; and death. [ ] [ ] [ ] [ ] diagnosis and treatment. the diagnosis of this condition is by postmortem examination. treatment in suspected antemortem cases is unsuccessful. prevention. adding formalin to milk replacers and vaccinating for clostridial diseases may decrease the occurrence of this disease. , lambs or kids on problem farms can be vaccinated for clostridium species during the first week of life with multivalent bacterins. similar to rumen impaction, abomasal impaction usually occurs when poor-quality roughage is fed, but it also can be seen with foreign body obstruction of the pylorus. , , goats appear to be more commonly affected than sheep, and boer goats are more commonly affected than angora goats. pregnant animals may be more prone to this condition. clinical signs and diagnosis. affected animals are usually anorexic. they have mild distention of the ventral abdomen, and in some cases the firm abomasum can be palpated through the abdominal wall on the right side. weight loss may be apparent. clinicopathologic evaluation may be normal, or mild hypochloremic metabolic alkalosis may be present, with elevated rumen chloride concentrations (more than meq/l). treatment. diet changes and mineral oil by mouth (po) are the most commonly employed treatments. abomasotomy can be attempted, but it has rarely been reported in small ruminants and does not usually improve the animals' long-term prognosis. when attempting abomasotomy, the clinician should perform the procedure with the animal in dorsal recumbency and under general anesthesia. the abomasum can best be visualized through an incision parallel and to the right of midline, caudal to the xyphoid process. the prognosis is poor. prevention. dietary manipulation to improve feed or forage quality is the best mode of prevention. abomasal emptying defect is a disease that presents similarly to abomasal impaction but is recognized only in suffolk sheep. the underlying cause is unknown. unlike abomasal impaction, this disease is associated with concentrate feeding and often occurs around lambing time. the clinical signs are chronic weight loss, abdominal distention, and anorexia. clinical pathology and rumen chloride levels are the same as described for abomasal impaction. on necropsy the abomasum is greatly distended, and the contents may be liquid or dry. treatment with laxatives, cathartics, motility modifiers, and abomasotomy has been mostly unsuccessful. [ ] [ ] [ ] azalea, laurel, and rhododendron toxicity members of the azalea, laurel, and rhododendron plant group produce andromedotoxins that alter sodium metabolism, resulting in prolonged nerve depolarization. these plants are cardiotoxic, but affected animals generally exhibit acute gastrointestinal upset. these evergreen shrubs produce thick, dark green leaves. they also have five-lobed, white to pink, saucer-shaped flowers that bloom around july. some of these plants are grown as ornamental shrubbery around homes, whereas others grow wild along streams, cliffs, and rocky slopes. they can be short or tall (as large as m) and can form thickets. all parts of these plants are toxic. clinical signs. animals browsing a new area, those fed clippings from trimmed azalea hedges, and underfed, hungry animals given access to these plants are likely candidates for intoxication. animals that ingest as few as two or three leaves may show signs of salivation, grinding teeth, nasal discharge, colic, epiphora, and acute digestive upset within hours of ingestion. as the intoxication progresses, animals become depressed and exhibit projectile vomiting, frequent defecation, and a slowed pulse. terminally intoxicated animals become paralyzed and comatose. some sheep and goats develop aspiration pneumonia secondary to intoxication. diagnosis. the diagnosis of this condition is usually based on clinical signs coupled with a history of ingestion of one of these plants and/or the discovery of these plants in the gastrointestinal tract. treatment. intoxicated animals may recover in to days without any therapy if the offending plants are removed from the diet. however, the administration of charcoal ( to g/kg po), atropine ( . to . mg/kg iv), other antiarrhythmic drugs, and iv fluids all may be indicated. to manage the aspiration pneumonia, the administration of antibiotics (penicillin , units/kg bid im) and oral magnesium hydroxide also may be beneficial. obviously, any existing dehydration should be corrected (see appendix ii). mountainous or hilly areas should be fenced. feeding shrubbery clippings is discouraged. diarrhea in lambs and kids is a complex, multifactorial disease involving the animal, the environment, nutrition, and infectious agents. decades of research have been devoted to the study of the pathophysiology of infectious diarrhea of calves; the pathology in lambs and kids is quite similar. despite improvements in management practices and prevention and treatment strategies, diarrhea is still the most common and costly disease affecting neonatal ruminants. [ ] [ ] [ ] [ ] some general preventive measures (e.g., improved sanitation) decrease disease no matter the cause. however, specific control measures such as vaccination require the definition of a specific cause of diarrhea. table - lists the agents most likely to cause diarrhea in lambs and kids, tissues or other samples required for diagnosis, and commonly employed test methods. the color and consistency of the feces and any gross lesions can appear similar no matter the cause. therefore laboratory identification of infectious agents and tissue histopathology are key to establishing a diagnosis. because autolysis and secondary bacterial invasion of the gut begins within minutes of death, necropsy samples taken immediately from euthanized lambs and kids yield the most reliable diagnostic material. mixed infections with two or more pathogens are common, and pathogens that are a problem on a farm change from year to year. , , in some cases an underlying nutritional deficiency or excess may occur concurrently with an infectious agent. therefore the clinician should be careful to take a variety of samples to ensure that all pathogens and predisposing factors involved are recognized; continued reevaluation of the causes of diarrhea is crucial. examination of several cases, with a focus on those in the acute phases, is important. although examination of antemortem fecal samples can be diagnostic, laboratory testing of tissue samples may yield better results. treatment and preventive measures specific to a particular disease are discussed with that disease in the following paragraphs. general supportive treatment and control measures are covered at the end of this section. four major pathogens cause diarrhea in lambs and kids during the first month of life: enterotoxigenic escherichia coli (etec), rotavirus, cryptosporidium species, and salmonella species. the relative prevalence of these infectious agents varies greatly among studies. this variance most likely results from differences in location, season, diagnostic techniques, and the occurrence of mixed infections. other, less common causes of diarrhea in neonates are giardia infections and nutritional diarrhea. pathogenesis. etec employs two virulence factors to cause disease. the first is the ability to attach and colonize the intestinal villi, which is accomplished via fimbria or pili. the most important fimbria in lambs are k and f . , the fimbrial antigens can be recognized from samples sent to most diagnostic laboratories and are im- portant in diagnosing this agent as a cause of diarrhea. after the organism attaches to the villi, it produces the second virulence factor, enterotoxin. enterotoxin interferes with the normal physiology of the gut, with resultant diarrhea. calves have an age-associated resistance, most likely related to the blocking of fimbrial attachment to the gut, so etec occurs mainly in calves less than a week old. , the mode of infection is fecal-oral. clinical signs. etec is seen in lambs and kids less than days of age but is most common at to days of age, so age-related resistance also may occur in these animals. , it usually presents as an outbreak in lambs and kids between and hours of age. because etec causes a "secretory" diarrhea, bicarbonate loss in the diarrhea leads to severe acidosis, with lambs and kids quickly becoming dehydrated and recumbent. however, many infected animals die before developing diarrhea. affected neonates are depressed, stop nursing, and may show excessive salivation. fluid sequestration in the abomasum causes a "splashing" sound on movement.this condition results in high mortality if animals are not treated promptly. diagnosis. fecal culture and serotyping for the k and f fimbrial antigens are the basis for diagnosis. because many nonpathogenic e. coli are normal gut inhabitants, simply culturing this organism is usually insignificant. occasionally the bacteria do not express the fimbrial antigens in culture, so etec cannot be ruled out if the culture is negative for k and f . histologic evidence of colonization of the small intestine can support a diagnosis. treatment. supportive care consisting of fluid therapy with either oral, iv, or sc administration of a polyionic solution is the mainstay of therapy. the use of oral antimicrobial agents is controversial. although antibiotics may kill the etec, they also may interfere with normal gut flora. if fluid support is provided, the diarrhea usually subsides without antibiotic treatment. still, oral neomycin ( to mg/kg bid) or trimethoprim sulfa ( mg/kg po) and systemic ampicillin ( to mg/kg im bid) or amoxicillin ( to mg/kg im tid) may be beneficial. nsaids are indicated to decrease inflammation of the gut and provide some analgesia. the use of flunixin meglumine ( to mg/kg im) has been shown to decrease fecal output in etec infections in calves and appears to be beneficial in lambs. prevention. it is recommended that clinicians vaccinate ewes and does with bovine etec vaccine before they give birth to increase passive immunity. , , monoclonal and polyclonal antibody products for calves may be beneficial during an outbreak if it can be given to lambs or kids within the first hours of life. the use of neomycin ( to mg/kg po bid) in lambs that appear normal may help stop the progression of an outbreak. shearing ewes prepartum to minimize fecal ingestion by neonates and ensuring that newborns ingest adequate colostrum both help decrease the incidence of this disease. making sure that ewes and does give birth at a . to . body condition score increases the chance of adequate colostrum manufacture by the dam. pathogenesis. lambs and kids are infected with group b rotaviruses, whereas most other animals and human beings are infected with group a rotaviruses. rotaviruses infect villus tip cells of the small intestine, which results in villus atrophy and malabsorptive diarrhea. clinical signs. rotavirus generally causes diarrhea in lambs and kids to days old, but older animals also can be affected. young animals can become very depressed and dehydrated. , , , diagnosis. detection of the organism by electron microscopy of fecal or colonic samples or by immunologic techniques on feces or tissue sections is the basis of diagnosis. , because these organisms are sloughed with the villus tip cells they infect, and viral antigens are complexed with the lambs' and kids' antibodies, tissue samples from acutely infected animals are best. rotavirus has been detected in animals without diarrhea, so other causes of diarrhea should be investigated as well. , treatment and prevention. rotavirus is treated with supportive care. prevention by vaccination of ewes and does with bovine rotavirus vaccines before they give birth is recommended to increase passive immunity. clinical signs. cryptosporidia can cause diarrhea in lambs and kids to days of age. , , affected animals are often active, alert, and nursing. the diarrhea is usually very liquid and yellow. diarrhea can vary from mild and self-limiting to severe, especially with mixed infections. , , , relapses are quite common, and this organism usually occurs as a component of mixed infections. diagnosis. acid-fast staining of air-dried fecal smears is a quick and easy method of diagnosis. examination under ϫ to ϫ magnification reveals round protozoa that have taken up the red color of the carbol fuchsin portions of the stain on a green background (figure - ). although they can be diagnosed by fecal flotation, their very small size ( - mm) makes this method difficult and subject to false negative results. , both immunologic and polymerase chain reaction (pcr) techniques have been developed to improve detection limits. , cryptosporidia also can be identified with histology. cryptosporidiosis is a zoonotic disease, and people can easily become infected from handling infected animals or feces. prevention. no consistently effective treatment for cryptosporidiosis in ruminants has been identified. anecdotal reports suggest that decoquinate and monensin sodium may be useful in control of cryptosporosis. decoquinate ( . mg/kg po) may be very useful in prevention of cryptospirosis in goats and possibly kids. during an outbreak affected animals should be isolated from the rest of the flock. no new animals should be added to a pen in which the disease has been diagnosed. keepers should depopulate pens in which the disease has been diagnosed and attempt to clean the environment. cryptosporidiosis can be particularly difficult to control because of the organisms' persistence in the environment and resistance to most chemical disinfectants. however, ammonia ( % to %) and formalin ( %) seem to be most effective. , feeders should be constructed to minimize fecal contamination. studies are currently underway to develop a vaccine for cryptosporidiosis in cattle. early results are favorable, and this may prove the best way to control the disease in the future. this is potentially a zoonotic disease, and therefore clinicians and keepers should exercise great caution when handling affected animals. pathogenesis. the bacterial genus salmonella has thousands of serotypes, and all can potentially cause diarrhea in animals. salmonella can cause diarrhea in lambs and kids of any age. , the microbes produce enterotoxins, are invasive, and cause severe inflammatory disease and necrosis of the lining of the small and large intestines. clinical signs. animals less than week old are more likely to die acutely without clinical signs, whereas animals older than week are more likely to have diarrhea. , , an acute onset of fever, depression, tenesmus, and shock is occasionally observed. salmonella-induced diarrhea is more likely to contain blood. this also is a zoonotic disease that warrants protective measures. a diagnosis of this condition is based on culture of the organism in feces or tissues and histologic examination of the small and large intestine. more sensitive pcr techniques for identifying salmonella species in feces are being developed. the diarrhea may occa-sionally contain fibrin, but many animals die before this is observed. clinicians may note leukopenia or leukocytosis in the cbc results. treatment. therapy for salmonella-induced diarrhea involves supportive care and possibly parenteral antimicrobial therapy. the use of antimicrobial agents is controversial and probably does not influence the gastrointestinal infection. however, because this is an invasive organism, parenteral use of antimicrobial agents may be beneficial in preventing septicemia. antimicrobial susceptibility patterns are difficult to predict for salmonella species, so antimicrobial therapy should be based on culture and sensitivity results. ceftiofur sodium ( . to . mg/kg im bid) or trimethoprim sulfadiazine ( mg/kg sc sid) can be administered until antimicrobial sensitivity results are known. prevention. latent carriers of salmonella can potentially shed organisms to other animals, particularly when they are stressed. newly introduced animals should be isolated for month, and fecal culture should be considered. bleach is an effective disinfectant to use during an outbreak. identification of carrier animals by fecal culture is recommended for herd problems. vaccine efficacy is questionable, and to date its effects have not been thoroughly evaluated in sheep and goats. giardia: giardia-induced diarrhea is more commonly seen in but not limited to -to -week-old lambs and kids. , the diarrhea is usually transient, but infected animals can continue to shed cysts for many weeks, even when they are clinically normal. , , therefore simply finding the agent in feces does not mean it is the cause of diarrhea, especially in older animals. however, these animals may be a source of infection for other animals and possibly humans. , iodine-stained wet mounts of feces or tissue is the classic method of diagnosing giardiasis, but more sensitive immunologic techniques are now available. , infected animals can be treated effectively with fenbendazole ( to mg/kg bid for days or sid for days). giardia has historically been treated with metronidazole ( mg/kg po sid for days). however, use of this drug class in food animals is currently illegal in the united states.this is potentially a zoonotic condition. infectious agents are not the only cause of diarrhea in neonates. nutritional problems can result in diarrhea, but these causes are overshadowed in the literature because the resulting diarrhea is usually mild and subsides without treatment. nutritional diarrhea is most common in orphaned animals as a result of keepers offering poorquality milk replacers, making mixing errors, or feeding large amounts infrequently (see chapter ) . diarrhea re- sulting from consumption of lush pasture or high-energy rations is a common occurrence. in most cases such diarrhea is self-limiting. the incidence of this form of gastric upset can be minimized by a slow introduction (over to weeks) to energy-dense diets. calves with infectious diarrhea that develop maldigestion or malabsorption can have secondary nutritional diarrhea from an inability to digest carbohydrates (lactose, xylose). , this has been reported in goats, and also is probably a cause of diarrhea in lambs. diarrhea resulting from primary lactose deficiency also has been reported in calves. calves on poor-quality milk replacers can develop an overgrowth of normal enteric e. coli, resulting in diarrhea. if lactose intolerance is suspected, decreasing the amount of lactose fed and using commercially available lactose enzymes may alleviate signs. the most common cause of diarrhea in older lambs and kids is nematode infestation. this condition is discussed later in this chapter in the section on causes of adult diarrhea. other major causes of diarrhea in older lambs and kids are c. perfringens and coccidiosis. c. perfringens types a, b, c, and d can all cause diarrhea in lambs and kids, but type d is the most common agent. , , pathogenesis. the disease occurs in peracute, acute, and chronic forms and is commonly called enterotoxemia or overeating disease. in the case of type c infection, a beta-toxin can cause acute hemorrhagic enteritis. type c infection is seen mostly in lambs or kids younger than weeks of age. an epsilon-toxin is responsible for pathology in type d infections. enterotoxemia is usually seen in rapidly growing feedlot lambs on high concentrate rations. it also is associated with other feeding changes, including changes in type of pasture. however, it occasionally occurs with no reported dietary changes, particularly in goats. , , this disease usually occurs in the fastest-growing and most well-conditioned animals. it can occur in vaccinated herds (again, more commonly in goats) so it should not be ruled out if a history of previous vaccination is present. clinical signs. the peracute form of clostridial infection is characterized by the rapid onset of severe depression; abdominal pain; profuse, bloody diarrhea; and neurologic signs. death occurs within hours of the onset of signs. sudden death may occur without signs of diarrhea. the onset of neurologic signs followed by sudden death is more common in sheep, whereas goats are more likely to show signs of diarrhea before death. similar but less severe signs are seen in the acute form of the disease. the chronic form occurs more commonly in goats. , diagnosis. antemortem diagnosis is based on clinical signs. at necropsy, c. perfringens can be cultured from intestinal tissue samples. however, the significance of a positive culture can be difficult to interpret because these organisms can be present in the gut normally and then proliferate after death. histologic examination of sections of the gut can be helpful. identification of the toxins (namely the epsilon-toxin) in intestinal contents is required for a definitive diagnosis. , because the toxin degrades within several hours of death, not finding the toxin does not preclude enterotoxemia as a diagnosis. treatment. treatment is rarely effective but consists mainly of aggressive supportive care. c. perfringens type d antitoxins ( to ml sc) can be administered to animals during an outbreak of enterotoxemia if clinical signs are noted before death. the antitoxin may be more effectively used as a preventive in the face of an outbreak. during an outbreak any animals that have not been vaccinated should be given the antitoxin and vaccinated with the toxoid simultaneously; those previously vaccinated should receive a booster vaccination. prevention. routine vaccination should start at to weeks of age and be followed by a booster to weeks later. however, on farms where the disease has become endemic, lambs or kids can be vaccinated and given antitoxin during the first week of life. yearly vaccination, preferably a few weeks before the ewes and dams give birth increases colostral immunity in neonates and improves prevention programs. goats may not respond as well to vaccination as sheep, so biannual or triannual vaccination is recommended, especially in problem herds. , vaccination with only c. perfringens types c and d and tetanus is superior to the use of more polyvalent clostridial vaccines. reducing the energy density of the diet and avoiding sudden dietary changes or alterations of the feeding routine are crucial to prevention. reducing internal parasites, particularly tapeworms, may further reduce the incidence of these disorders. pathogenesis. coccidiosis is a protozoan parasitic disease that is a common cause of diarrhea in lambs and kids. it also may cause subclinical production losses. clinical disease is often seen when some form of stress (e.g., dietary change, weather changes, parturition, weaning) is occurring on the farm or in the flock. eimeria species cause the disease in sheep and goats; each is infested with its own host-specific species. unlike cryptosporidium, which can be shed in feces in the infective stage, coccidia must sporulate outside the host to become infective. sporulation occurs under moderate temperatures and high moisture conditions. the nonsporulated and sporulated oocysts can survive a wide range of temperatures and may survive for years under certain conditions. clinical signs. lambs and kids are most susceptible to the problem at approximately to months of age, although younger animals may become infected. clinical disease is common after the stress of weaning, feed changes, or shipping. crowded conditions result in excessive manure and urine contamination, which is ideal for the buildup and sporulation of the oocysts. under these conditions, animals may be exposed to high numbers of infective organisms and develop diarrhea.the diarrhea in lambs and kids is usually not bloody, but it can contain blood or mucus and be very watery. anorexia, dehydration, weakness, rough hair coat, and death all may occur. weight loss is common, and constant straining can result in rectal prolapse. in severe cases the disease becomes protracted because of necrosis of the mucosal lining. even if these animals are treated appropriately, the diarrhea continues until the intestinal mucosa heals, which can take several days to weeks. permanent scarring can result in chronic poor development, even if the diarrhea subsides. , [ ] [ ] [ ] diagnosis. acute coccidiosis can be easily diagnosed from a direct smear or flotation of feces (figure - ) . in the chronic stages, most of the organisms have been shed and very low numbers are seen on fecal examination. because normal animals can shed small numbers of pathogenic species or large numbers of nonpathogenic species, interpretation of fecal examinations in the chronic stages of coccidiosis or in animals with diarrhea from other causes can be difficult. [ ] [ ] [ ] in these cases the clinician should rule out other diseases before making a diagnosis of coccidiosis. blood analysis may show both anemia and hypoproteinemia. treatment. treatment of affected animals with clinical signs includes supportive care and administration of coccidiostats. all animals in the group should be treated during an outbreak. the use of coccidiostats has little effect on the existing infection, but it does prevent the spread of the disease from continued exposure to infective organisms. many coccidiostats inhibit coccidia development and prevent disease if given prophylactically. they are of little value if they are given after the onset of clinical disease. sulfa drugs appear to be clinically beneficial, but they may simply decrease secondary or concurrent bacteria-induced diarrhea. because coccidia develop some resistance to coccidiostats, these drugs should be administered only before stressful events (e.g., shipping, weaning, parturition). the drugs listed in table - and trimethoprim sulfa ( mg/kg orally sid for days) are approved for use in the united states. , prevention. control involves improved sanitation and possibly the use of coccidiostats. preventing overcrowding decreases the buildup of manure and infective oocysts. exposure to sunlight and desiccation are two of the most effective means of killing the organisms. minimizing stress and optimizing nutritional intake also are important. coccidiostats available in the united states are shown in table - and appendix i. to avoid toxicity in growing animals, the clinician or keeper must carefully adjust dosages to the changing levels of feed intake as animals grow. all agents except amprolium should be fed for at least weeks. , this allows exposure and subsequent development of immunity to occur while preventing the detrimental effects of clinical disease. however, coccidia can become resistant to coccidiostats; fecal samples should be periodically evaluated after prolonged use of a particular product. anecdotal reports suggest amprolium resistance may occur on some farms. moreover, if amprolium is offered with a creep feed rich in thiamine, its ability to act as a thiamine antagonist may be compromised. year-round use of coccidiostats increases the potential for resistance. therefore they should be fed only during times of expected risk. the inclusion of lasalocid ( kg of % premix) or decoquinate ( kg of % premix) in kg of trace mineralized salt fed as the only source of salt for days prepartum can reduce the number of oocysts shed in ewe or dam feces. this practice can reduce the coccidia contamination of pasture and thereby remove a source of infection for kids and lambs. the benefits of administering lasalocid and monensin beyond coccidia control include increased feed efficiency, enhanced growth rate, and decreased incidence of free gas bloat. however, if coccidiostats are included in either mineral or feed supplements, inconsistent or depressed intake may result in subtherapeutic drug dosing. lambs are resistant to infection in the first few weeks of life. exposure to the protozoa during this time confers immunity and resistance to later infections. , adenovirus, caprine herpesvirus, coronavirus, campylobacter jejuni, yersinia species, and strongyloides papillosus can cause diarrhea in lambs and kids of various ages. , , enterohemorrhagic e. coli (ehec) and enteropathogenic e. coli (epec) also have been isolated in the feces of kids with diarrhea. , these e. coli types are k and f -negative. culture and serotyping of these organisms from feces and tissue samples with typical histopathologic lesions is diagnostic. although etec is not zoonotic, ehec and epec can potentially affect humans. although some causes of diarrhea have specific treatments, many animals need to be treated for dehydration and metabolic acidosis regardless of the inciting cause. animals with only mild diarrhea, especially mild nutritional diarrhea, may not require therapy unless they become dehydrated. if kids or lambs become less than % dehydrated and are only mildly depressed but still willing to nurse, they can be treated with oral electrolytes designed for calves. fluids can be administered by bottle or by tube if the animal will not nurse. the keeper or clinician should carefully adjust the amount of fluids for lambs and kids ( to ml, or to oz, as opposed to l in a calf ). because most electrolyte solutions designed for calves contain glucose, after they have been mixed they should be refrigerated and any leftovers discarded within hours. iv fluids may be needed to treat more severe dehydration. if the lamb or kid is too weak to stand, iv fluids are indicated. isotonic fluids containing electrolytes should be given to replenish losses. glucose can be added to fluids to make a % to . % solution. sodium bicarbonate also may be administered, especially if the dehydration is severe. a rule of thumb is to give one fourth of the calculated fluid need (see appendix ii) as isotonic bicarbonate ( . %). extra potassium ( to meq/l) can be added to fluids because most animals are severely dehydrated from diarrhea and depleted in potassium, even though their blood potassium levels may be elevated. if extra potassium is added, acidosis must be corrected concurrently. after correcting the dehydration, the keeper or clinician can offer oral electrolyte-enriched fluids to replace ongoing losses caused by continued diarrhea. removing milk or milk replacer from the diet is not recommended. young animals need nutrients, and even high-energy, glucose-containing electrolyte solutions are no substitute for milk. animals should continue to receive milk replacer in normal amounts or be allowed to nurse; they can be supplemented with oral electrolytes if necessary. animals being hand fed should be offered small amounts frequently to help minimize problems. electrolytes should never be mixed with milk, but should instead be given in separate feedings. if lactose deficiency is suspected, lactase drops or capsules (available in health food stores) can be added to milk or milk replacer. nsaids (flunixin meglumine, . to . mg/kg iv; ketoprofen, . to . mg/kg iv) are beneficial, especially if toxemia is involved, as in etec, enterotoxemia, and salmonellosis. it is the authors' opinion that antimicrobial agents should be reserved for proven outbreaks of salmonellosis and for animals with other causes of diarrhea that do not respond to fluid therapy and nsaids; these drugs should only be administered parenterally. the use of oral coating agents and antacids is popular, but it has not been shown to be beneficial and is not therapeutically logical in light of the pathogenesis of these diseases. probiotics may be beneficial in reestablishing the normal flora of the small intestine. the authors' rule of thumb is that nothing should be given orally except milk, oral electrolytes, and probiotics. ensuring adequate intake of high-quality colostrum and minimizing stress are important for prevention of all neonatal diseases. a normal lamb or kid will stand and nurse within minutes to hour of birth. the ingestion of colostrum within to hours is essential in preventing hypothermia and hypoglycemia and decreasing the incidence of various diseases. lambs or kids born as twins or triplets, weak or injured neonates, those born during severe weather, those born from a dam with dystocia, and those delivered by cesarean section are all candidates for colostrum supplementation. if supplemental colostrum is provided, it should be good-quality colostrum from females that have tested negative for johne's disease, ovine progressive pneumonia (opp), and caprine arthritis-encephalitis (cae). mixing colostrum from several cows decreases the incidence of the "cow colostrum-associated" hemolytic disease sometimes seen in lambs. if the lamb or kid is unable to nurse, it should be tube fed ml/kg of colostrum. the veterinarian or animal handler can sit comfortably holding the lamb or kid in sternal recumbency in the lap. a to french soft feeding tube is then lubricated, inserted into the side of the mouth, and passed slowly. if the tube is placed in the trachea, the lamb or kid will become uncomfortable and may shake and cough. the tube may be palpated on the left side of the throat. after the tube has been slowly passed to the thoracic inlet, colostrum can be administered by gravity flow (see chapter ) . prepartum shearing of the dam may decrease the ingestion of feces by lambs. good sanitation of lambing and kidding areas is paramount in management programs that stress prevention. the presence of organic matter interferes with the effectiveness of many disinfectants, so removal and proper disposal of feces, carcasses, and placentas are essential. when disposing of waste material containing either cryptosporidium or giardia, the keeper should be careful to avoid contaminating water sources. infected animals should be isolated to prevent spread of the infection throughout the flock. in general, infected animals should remain in the environment where the infection was first diagnosed, because it is already contaminated. removing pregnant ewes or dams to a clean area before lambing or kidding helps minimize the continued spread of disease. if possible, lambs and kids already born but not showing clinical signs should be removed to a third area. if "safe" pastures are maintained for internal nematode control, they are ideal for use in an emergency situation to control these diseases. although some animals may appear normal, they may be incubating and possibly shedding the infective agents of a disease. if such animals are moved with pregnant females, they can be a source of contamination in a clean area. if healthy lambs and kids cannot be moved to a third, relatively safe area, they should be left with the clinically infected animals because they have already been exposed. . schultheiss p: diarrheal disease in calves, large anim vet ( ) the differential diagnosis list for acute and chronic diarrhea in small ruminants is very long. the most common cause of diarrhea in adult sheep and goats is parasitism; another major cause is johne's disease. both of these diseases are discussed in the following sections. other causes of acute diarrhea include rumen acidosis, peritonitis, endotoxemia, and ingestion of toxins. the list of toxins that cause diarrhea also is very long, and often the diarrhea is not the primary clinical sign. some of the more common toxins that produce diarrhea are arsenic, toxic amounts of salt, levamisole, copper, oak, selenium, and pyrrolizidine alkaloids. salmonella species and chronic enterotoxemia can cause diarrhea in adult animals. coccidiosis can occur in adults under severe stress or in animals that possess limited immunity because of lack of exposure. hepatic and renal disease and copper deficiency are sometimes accompanied by chronic diarrhea, but weight loss is a more common sign in adults. etiology and pathogenesis. sheep and goats are infested with many of the same gastrointestinal nematode parasites as cattle, but these parasites tend to either be species-specific or have some amount of host specificity. sheep and goats are susceptible to the same nematodes and tend to share resistance to those that infect cattle and horses. the major gastrointestinal nematodes that parasitize pastured sheep and goats are haemonchus, ostertagia, trichostrongylus, cooperia, nematodirus, oesophagostomum, and bunostomum species. the acronym hotc comes from the first letter of each of the first four genera of parasites listed. the specific parasites that produce disease vary from flock to flock. climate usually determines which parasites are of clinical significance on a farm, and the weather determines when the parasites will be transmitted and infective. in much of the united states, haemonchus is the most significant parasite with respect to both clinical disease and anthelmintic resistance. most of these parasites affect the abomasum or small intestine of young, recently weaned animals and occasionally adult animals. sheep (and, to a lesser extent, goats) that are older than months may be less susceptible. overcrowding and overgrazing with concurrent pasture mismanagement and malnutrition usually increase susceptibility to these parasites. inadequate nutrient or protein intake may result in greater susceptibility. the life cycle appears to be similar in most of these parasite species. adults lay eggs that are passed in the feces; except for nematodirus species, the eggs hatch under favorable environmental conditions. the larvae go through several free-living developmental stages becoming infective. when the infective larvae are ingested by the host, the parasite completes its life cycle as an adult. trichuris eggs are the infective stage and can survive for extended periods in dry lots or barns. however, trichuris is associated with minimal pathology. during dry environmental conditions, fecal pellets tend to trap the nematode larvae, whereas in wet conditions, larvae are released onto the pasture. therefore drought conditions followed by rain can result in devastatingly high rates of pasture contamination as larvae that have remained in fecal pellets are released. very high environmental temperatures result in shorter survivability of some stages of infective larvae. most of the larvae have adapted the ability to over-winter, but can survive only for short periods outside the host during spring. nematodirus is an exception in that the developmental stages leading to infective larvae occur while the microbe is still encapsulated in the egg. however, compared with other species of parasite, nematodirus is of minor importance. nematodirus battus may pose a threat to young, newly weaned and therefore immunologically naive grazing lambs. the hookworm bunostomum also is different, as it may infect the host by either oral ingestion or percutaneous penetration. with the exception of the small intestinal parasite strongyloides, lambs or kids fed indoors or in dry pens tend to be free of parasites. clinical signs. all intestinal nematode infections produce similar signs, although infection with the more rarely encountered bunostomum may perhaps result in more profound anemia. if they infest the animal in sufficient numbers, all nematodes may cause poor growth, decreased feed conversion, decreased milk production, weight loss, diarrhea, anemia, ventral edema (bottle jaw), midline edema, and death. again, all these parasites can potentially result in disease, but haemonchus is the most devastating, particularly in more temperate regions. diagnosis. antemortem diagnosis of nematode infestation is made by examining the feces for nematode eggs. although a direct fecal smear can be examined, the mere presence of parasite eggs is not helpful in determining the parasite load of an animal or animals. quantifying of the epg of feces is the best way of estimating parasite loads. the quantitative mcmaster's technique for determining the epg of feces is shown in box - . common nematode eggs are shown in figure - . treatment and control program. after taking a thorough history of the previous parasite control program used on a farm and determining its effectiveness, the clinician can design and implement a new control program. , however, before deciding to implement a deworming program, the clinician should decide which parasites are in need of control and whether control of these parasites is cost effective in a particular flock. whenever possible, a dewormer that can reduce epg counts on the farm by % should be identified and used for at least a year. of all the parasite prevention programs, strategic deworming or a combination of strategic and tactical programs appear to produce the best results. , , strategic deworming is used when most of the parasites are inside the animals and not on the pasture. in northern climates, strategic deworming can best be carried out during the winter, when the nematode parasites are in a hypobiotic state. when environmental conditions are inhospitable for the survival of the infective larvae, some of the most pathogenic nematodes (e.g., haemonchus) may become hypobiotic; that is, they assume a state of arrested development. they may then mature to the adult stage when environmental conditions become conducive for the survival of their eggs or larvae. preventing or decreasing the numbers of maturing adults by killing the larvae before the periparturient rise in parasite egg production and pasture contamination is an excellent management tool. , , unfortunately, in warmer, more temperate to subtropical environments, this method is less effective because larvae can survive the environment for longer periods. the addition of a protein supplement overlapping the expected periparturient rise has been shown to decrease the number of parasite eggs shed around the time of parturition. however, the cost of the protein supplement may outweigh its benefits. a strategic program entails the use of an anthelmintic agent that is capable of killing encysted larvae. animals are then moved to parasite-free or safe pastures-areas in which the level of parasite contamination is too low to result in infection of grazing animals. examples of safe pastures include pastures where sheep or goats have not grazed for to months in the spring or fall, respectively (and depending on the climate); pastures used for hay production; new pastures (i.e., those used for corn, cotton, or other crops); and pastures grazed by horses or cattle. the use of safe pastures is paramount in any de-worming program. rotating pastures after less than months during the warm part of the year or less than months during cooler months is ineffective. however, if pastures are tilled and replanted, by the time new grazeable forage is available, infective parasite larvae will be dead or significantly decreased. an alternative to pasture rotation is to perform an initial strategic deworming before lambing or kidding and follow it with two to four more dewormings at week intervals throughout the lambing and kidding period. [ ] [ ] [ ] treating lambs or kids at weaning and moving them to a safe pasture is a form of strategic deworming. in lambs or kids to be sold at an early age, the administration of a single anthelmintic treatment followed by a move to a safe pasture may be all that is required. a "double treat and move" system is required for lambs kept for to weeks after weaning, particularly during the summer. , this form of strategic deworming requires two treatments to weeks apart as well as two safe pastures. in northern climates where animals are moved to a dry lot or barn for the winter, a strategic anthelmintic administration as animals are moved off pasture can help reduce the parasite burden through the winter. if this deworming is followed by minimal or no exposure to grazing areas and another dewormer is administered before the spring rise in fecal egg counts, the total parasite burden on spring pasture can be drastically reduced, effectively controlling parasites until summer or fall. tactical deworming programs are used to remove parasites from their hosts before they enter their reproductive phase and can contaminate the pasture. an example of tactical deworming is treating animals to days after a rain, particularly if the rain has followed a drought. parasite transmission is worse in most flocks during this time as pastures become heavily contaminated. mcmaster's counts of more than epg in the spring or more than epg in the fall warrant tactical deworming. , , opportunistic deworming and salvage deworming are usually less effective in long-term flock management. many times salvage deworming programs are used to save the lives of heavily parasitized animals. if animals are dewormed only after showing signs of parasitism (e.g., bottle jaw, anemia), animal and flock productivity have already been depressed. deworming during handling for other procedures (e.g., castration, vaccination, shearing) is an example of an opportunistic program. it is convenient but is not conducive to long-term flock health. flock work should be scheduled around parasite management programs, not vice versa. , suppressive deworming programs entail the use of anthelmintics at regular intervals, usually every to weeks. suppressive programs are labor-intensive, tend to be very expensive, fail to identify animals with superior immunity to parasites, and ultimately result in anthelmintic resistance despite initial effectiveness. , as a general rule, the more frequently deworming occurs, the more quickly resistance is attained to anthelmintics. after deworming, only resistant parasites remain to infect the animal and they are able to reproduce freely, resulting in proliferation of resistant strains. , using drugs that remain in tissues at inappropriately low concentrations and treating and retaining immunocompromised animals encourage the development of anthelmintic resistance. practices that ensure adequate dosages, proper treatment techniques, and appropriate types of anthelmintics should be emphasized. , the clinician should do everything in his or her power to minimize the incidence of anthelmintic resistance, both through their own actions and by counseling owners in proper use of deworming drugs. the product development market for anthelmintics is the cattle industry. the small sheep and goat markets simply use drugs made available for cattle. because most available anthelmintics are highly effective in controlling parasites, anthelmintic resistance in sheep and goats must be avoided. the anthelmintics that have been used previously on a flock, the route of administration (e.g., po, sc, im, pour-on), and the length of use should be determined. few dewormers are approved for use in sheep and goats, but many approved for use in cattle and horses may be effective. , if sheep graze with goats that harbor anthelmintic-resistant parasites, the sheep also may become infected. however, if sheep are allowed to graze while the goats browse and the two groups rarely mingle, less parasite movement will occur between these species. resistance to macrolides (e.g., ivermectin, doramectin, moxidectin) does occur. resistant worms are generally not very tolerant of cold temperatures and therefore resistance to this drug class in northern environments is not as large a problem as it is in more temperate or subtropical zones. although moxidectin is not approved for use in sheep and goats in the united states, it has been shown to be effective in cases where ivermectin resistance is encountered. still, this drug should be avoided until all other anthelmintics have failed. craig , has suggested that clinicians refrain from injecting or using pour-on macrolide preparations designed for cattle in small ruminants. this practice may enhance the development of resistant strains of some internal parasites because of inappropriately low drug absorption (with pour-on use) or long-term subtherapeutic levels (with injection). if resistance to tetrahydropyrimidines (e.g., morantel, pyrantel) occurs in a flock, levamisole also may be ineffective. morantel and levamisole resistance in parasites appears to be sex-linked. therefore if animals are not exposed to these drugs for several years, reversion to susceptibility can occur. , if resistance to one of the benzimidazole dewormers has been documented in a flock, some resistance to all members of that class is likely. benzimidazole-resistant haemonchus species appear to be more virulent, produce more eggs, cause greater environmental contamination, and survive in the environment as free-living larvae for longer periods. benzimidazole-resistant parasites apparently do not revert to susceptible forms, even over long periods. therefore the clinician or keeper should exercise caution to minimize resistance. benzimidazole efficacy can be improved by increasing dosages, dividing dosages into two treatments administered at -hour intervals, and instituting pretreatment fasting. if resistance to numerous classes of anthelmintics occurs on a farm, combining two of the resistant classes of dewormers (fenbendazole and levamisole) has proven effective. when using combined dewormers, the clinician should administer the full therapeutic dosage of each. anthelmintics are metabolized at different rates by sheep and goats. goats may require larger dosages of some dewormers than sheep. craig has suggested that if no dose rate is known for a particular anthelmintic for sheep or goats, the animals should be treated at twice the suggested cow dosage. pour-on anthelmintics designed for cattle tend to be of limited value when used topically on either goats or sheep. table - . to maximize a parasite control program, anthelmintics that appear effective should be used for only year before a new class of deworming drug is used. more frequent rotation (after less than year) of anthelmintic agents hastens resistance and should be avoided whenever possible. whenever a flock is dewormed, animals should be treated based on the heaviest animal in the group and not on the group's average weight. underdosing can hasten the formation of parasitic resistance and therefore should be avoided. holding the sheep or goats in a dry lot overnight or feeding only dry hay for to hours before and hours after deworming appears to improve the efficacy of some orally administered anthelmintic agents (benzimidazole). limiting feed intake before deworming slows the rate of passage of ingesta through the bowel, enhancing drug effectiveness. , , feed should never be withheld from sick or debilitated animals or late-term females. , , most dewormers may effectively control adult or larval parasites but are ineffective against eggs. therefore animals should be kept on a dry lot for as long as days after deworming, then moved to a safe pasture. use of this procedure minimizes parasite egg contamination of the new pasture because most of the egg-contaminated feces is voided within hours of deworming. if more than one dosage appears on the drug label, the larvacidal dose should be used (fenbendazole at mg/kg rather than mg/kg). anthelmintic effectiveness can be determined by comparing a mcmaster's fecal epg on the day of deworming with one taken to days later. if less than a % drop in epg is found, anthelmintic resistance exists and the animals should be switched to another class of dewormer. although it is a controversial method, the authors have used this technique to identify anthelmintic effectiveness for many years and on many farms and ranches. , the authors randomly collect feces from % to % (or a minimum of animals) of the sheep or goats on the farm. a composite sample is prepared by combining equal amounts of stool from all animals. craig has suggested that combining stool samples from many animals alters the accuracy of the tests because great individual variation in fecal egg counts occurs among animals. composite egg counts more accurately reflect parasite burdens in groups of young animals, and individual fecal examinations are more accurate in adults. , still, the authors prefer to use composite samples unless obvious differences in stool character or body condition score exist among the sampled animals. anthelmintic resistance can be minimized by using drugs that reduce fecal egg counts by %. pre-and postdeworming changes in epg should be evaluated yearly or whenever resistance is suspected. in vitro methods of assessing flock parasite resistance also are available at some diagnostic laboratories. in most in vitro tests, larvae are hatched from collected feces and the sensitivity of different anthelmintics is determined by larval exposure. these tests are very accurate but tend to be quite expensive. the most effective method to prevent anthelmintic resistance is to not use deworming drugs at all. one of the most overlooked management procedures is the identification and selection of parasite-resistant sheep and goats. some breeds or familial lines within breeds have excellent parasite resistance (e.g., gulf coast native and barbados sheep, some strains of spanish, pygmy, and tennessee myotonic-fainting goats). one study comparing boercrossed goats with non-boer crosses found that the boer crosses had significantly more parasite infestations. only a small number of flock members contribute the greatest amount of environmental parasite contamination because susceptible animals shed the most eggs in their feces. animals with the lowest epg in a flock may be those that possess the most parasite resistance. salvage deworming programs should generally be avoided, but they may be used as aggressive selection criteria. that is, animals that do well with little or no deworming, particularly those grazing heavily contaminated pastures, should be identified and retained in the breeding flock. those that become infected should be dewormed to salvage them or save their lives and then sold when possible. proper record keeping and identification of all animals is paramount in selecting for parasite resistance. , this aggressive approach can yield excellent results if it is carefully implemented, but devastating losses can occur if it is poorly managed. when introducing new animals to a flock, keepers should have biosecurity programs in place to limit the introduction of new or potentially anthelmintic-resistant parasites. new flock additions should be kept in a dry lot for weeks and dewormed at least twice with two different classes of dewormers during this period. the effectiveness of the anthelmintic agent used should be deter-mined by fecal examination before the animal is allowed contact with the rest of the flock. other nontraditional chemical methods of parasite control are used by some owners. some appear to be worthless (e.g., diatomaceous earth), but others (e.g., nematophagous fungi, herbal dewormers) may prove effective in some situations. pathogenesis. the most common gastrointestinal tapeworm of sheep and goats seen in north america belongs to the genus moniezia. cestodes (tapeworms) are usually of more concern to owners than clinicians, who generally consider them only incidental low-grade pathogens, particularly in adult animals. still, several to -foot-long tapeworms can compete with the host for nutrients, hinder normal gut motility, and excrete some toxic wastes into the host's gastrointestinal tract. mature tapeworm eggs are passed in the feces individually or protected in proglottides, which are usually visible to the owner. the eggs embryonate and infect a mite, a small pasture-living arthropod that serves as the intermediate host. a sheep or goat ingests the mite while grazing, allowing the tapeworm to complete its life cycle. clinical signs. tapeworms may rarely cause disease in lambs and kids less than months of age. anecdotal reports suggest a cause-effect relationship between heavy tapeworm infestation and an increased incidence of c. perfringens enteritis, digestive disturbances (e.g., diarrhea, constipation), poor condition, and anemia. ulceration at the site of attachment may be seen on necropsy. rarely species of trypanosoma, the fringed tapeworm, may cause liver condemnation. a presumptive diagnosis can be made by finding proglottides in the stool, eggs on direct smears, or eggs on fecal flotations (see figure - ).treatment with albendazole ( mg/kg), fenbendazole ( to mg/kg), or praziquantel ( to mg/kg) may be effective either with a single treatment or with daily therapy (e.g., fenbendazole daily for to days). because of the free-living nature of the arthropod intermediate host, animals are readily reinfected after treatment, which may give rise to the false assumption that the therapy was ineffective. again, tapeworm infestation may result in disease, but often it is easier to blame the tapeworm segment seen in the stool as a cause of disease than to implicate the unseen thousands of hotc complex parasites in the abomasum and small intestine of the animal. , johne's disease johne's disease (also called paratuberculosis) is a chronic wasting and diarrheal disease caused by the bacteria my-cobacterium avium subspecies paratuberculosis. transmission of the organism is primarily by the fecal-oral route. young animals are more susceptible to infection than adults. it can be transmitted through milk and placenta. pathogenesis. bacterial shedding in feces and milk and transplacental transmission is more common in animals showing clinical signs. [ ] [ ] [ ] therefore the offspring of infected animals and especially the offspring of animals showing clinical signs are most likely to acquire the infection. after an animal is exposed, it will either clear the organism or develop a chronic, persistent infection. the infection is most commonly isolated to the ileal regions of the small intestine, where it causes granulomatous thickening of the intestine and subsequent malabsorptive diarrhea. infected animals may be asymptomatic for years. clinical signs. morbidity rates are low (approximately %), but for every animal with clinical signs, several exist in the subclinical state, and may be a source of both horizontal and vertical transmission. both sheep and goats appear to remain asymptomatic until to years of age. the most consistent clinical sign in sheep and goats is chronic weight loss. chronic diarrhea occurs in approximately % of cases. signs may appear with or be exacerbated by stress, especially after parturition. , hypoproteinemia and chronic mild anemia are the only consistent clinicopathologic findings. because of their low protein levels, infected animals can develop submandibular edema. diagnosis is by culture of the organism from feces. unfortunately, this testing takes between and weeks, but it can detect % to % of clinically infected goats. sheep strains of johne's disease and some goat variant strains seem to be more difficult to culture in media used to identify cattle strains of the disease.therefore fecal culture in sheep and goats appears to be of limited benefit. , a relatively inexpensive and easily performed method of identifying approximately % of all clinically infected animals is acid-fast staining of fecal smears. , a pcr test of feces also is available, but its sensitivity is lower than that of fecal culture. good diagnostic results can be obtained with serologic testing for antibodies (e.g., agar gel immunodiffusion [agid], enzyme-linked immunospecific assay [elisa], complement fixation) in animals showing clinical signs. the specificity of all the serologic tests is greater than % in sheep and goats with signs of clinical disease, although the sensitivity is not as high. [ ] [ ] [ ] therefore a positive serologic test in an animal showing clinical signs indicates that the animal has johne's disease. however, the disease cannot be ruled out with a negative test. sheep and goats appear to respond differently in regard to the formation of antibodies. sheep tend to develop antibodies in the later stages of the disease, whereas antibodies may be detected much earlier in the goat. the agid test appears to be the best serologic test currently available. , the elisa and complement fixation tests can cross-react with corynebacterium pseudotuberculosis, making them of limited value in flocks with caseous lymphadenitis infections. , necropsy diagnosis is based on the finding of thickened, corrugated intestines, especially in the area of the ileum. acid-fast staining of impression smears (taken from the ileum and ileocecal lymph nodes) can help yield a quick diagnosis. the staining of numerous clumps of acid-fast rods is highly suggestive of johne's disease. prevention. johne's disease has no effective treatment, so prevention and control are imperative. however, preventing the introduction of johne's disease into a herd can be difficult. because animals with subclinical infection may not shed the organism or may shed only small quantities of it, fecal culture is helpful only if a positive culture is obtained. the sensitivity of serologic tests of animals with subclinical disease is low and variable among flocks. , negative test results in subclinically infected animals are common. however, the specificity of serologic tests remains high, and therefore a positive test is a valid reason to not purchase an animal. because johne's disease also occurs in cattle, supplemental colostrum supplies should come only from dairy herds with no history of johne's disease. after johne's disease is diagnosed in a herd, several control measures can be taken. sanitation is important because the organism is highly resistant in the environment (able to survive more than year under most conditions). reduced stocking rates, frequent cleaning of pens, and use of automatic waterers decrease fecal transmission. keepers should cull the offspring of infected animals. culling animals based on the results of agid tests or fecal culture of the flock is recommended. animals should be tested at least once a year. more frequent testing as resources allow speeds the identification of infected animals. a vaccine for cattle is only available in some locales and clinicians or keepers may require official permission to use it. vaccine use does not eliminate infection, but it can decrease herd prevalence, delay the onset of clinical signs, and decrease cross-transmission by infective bacterial shedding in the feces. any cause of intestinal obstruction that occurs in other ruminants may occur in sheep and goats. most of these diseases produce abdominal discomfort and occasionally abdominal distention. diagnosis can be difficult because rectal palpation cannot be performed on small ruminants. abdominal radiographs and ultrasonography may help differentiate these diseases, but exploratory surgery may be required to obtain a definitive diagnosis and select appropriate treatment. intussusception is more common in young animals, but it can occur in adults. it occurs when one segment of the intestine telescopes into an adjacent segment. any portion of the intestine can intussuscept, but the ileum and ileocecal junction are the most common areas involved. when intussusception occurs, the lumen of the intestine narrows to the point of obstruction. the initiating cause is not always known. , it is associated with an intestinal mass in adults and enteritis in young animals. oesophagostomum infestations have been implicated as a cause in sheep. clinical signs. the initial complaint is colic (manifested as kicking at the abdomen, repeated rising and lying down, and vocalization) followed by low-grade pain. true colic signs are variable in lambs and kids. in some cases, after the initial colic episode subsides, animals show no evidence of pain until the abdomen becomes distended. the time between the initial intussusception and abdominal distention depends on where the blockage occurs. intussusception of the ileal area may take several days to cause bilaterally symmetric abdominal distention. fecal output is scant, and what little there is may be dark or tarry, or may contain mucus. dehydration becomes evident, hypochloremic metabolic alkalosis may develop and rumen chloride levels may increase with obstructions of the duodenum. diagnosis. abdominocentesis may yield fluid compatible with a transudate (increased protein concentration and leukocyte numbers). radiography and ultrasonography reveal fluid-distended intestinal loops. occasionally the intussusception itself can be visualized with ultrasonography or palpable through the abdominal wall. if the disease is not treated, intestinal rupture and peritonitis can occur. treatment. surgical correction is required. if the intussusception is corrected early, the prognosis is good in the absence of peritonitis. fluid support is needed to correct dehydration and metabolic abnormalities. fluids should be administered iv until rumen function returns. ringer's solution with added calcium (approximately ml calcium borogluconate per liter) and potassium ( to meq/l) is a good choice for fluid therapy. ingested foreign bodies or bezoars can obstruct portions of the intestines. , the signs are similar to those of obstruction caused by intussusception and depend on the part of the intestine that is blocked. in some cases the obstructing body can be seen with radiography or ultrasonography. surgical removal is required for treatment. cecal volvulus and torsion of the root of the mesentery occur sporadically in sheep and goats. , extreme abdominal pain, rapid abdominal distention, and circulatory collapse are typical signs. immediate surgical correction and circulatory support are needed. atresia of the colon, rectum, and anus can all occur as congenital problems. the clinical sign of progressive abdominal distention usually is noted in the first week of life. atresia of the anus can be diagnosed on physical examination, but atresia of the colon and rectum may require contrast radiography for a definitive diagnosis. surgical establishment of anal patency can be performed for atresia ani. a permanent colostomy may be required for atresia of the colon and rectum. atresia of the anus and rectum are considered heritable in cattle. in the authors' experience, atresia ani is more common in sheep than in goats. if surgical correction of atresia ani is attempted, the animal should be neutered or kept out of the breeding program because of the potential genetic basis for this condition. occasionally a slight bulge in the skin may occur where the anus should be located, especially in male lambs. ultrasonography can be used to locate a fecesfilled rectum. for surgical correction, the clinician should locate the area where the anus should be, prepare it with sterile technique, and infiltrate it with a local anesthetic. the surgeon then makes a circumferential incision to remove the overlying skin covering the rectum. an alternative is to make an x-shaped incision into the rectum. treated animals should be given mineral oil, dss, or stool softeners as needed. ileus of the small intestine is a pseudo-obstruction that occurs when there is an absence of intestinal motility. the animal's failure to pass ingesta leads to signs similar to intussusception. the cause of ileus is usually unclear, but it often occurs secondary to systemic diseases. the same elements that cause rumen stasis may potentially result in intestinal stasis and ileus. symptomatic treatment with nsaids for pain and inflammation and fluids for dehydration is usually curative. however, if signs persist, surgical exploration is indicated to rule out true obstructive diseases. pathogenesis. infection of the peritoneal lining of the abdominal cavity may lead to septic peritonitis. common causes include uterine tears; rupture of the rumen or abomasum secondary to rumenitis, abomasitis, or abomasal ulcers; trocarization of the rumen for bloat; and rupture of the intestine secondary to obstruction. clinical signs. signs depend on the severity of the condition. abdominal discomfort and distention, dehydration, injected mucous membranes, depression, and death can all occur in cases of peritonitis. the presence of a fever is variable, both heart rate and respiration rate are usually elevated, and respiratory effort may be guarded. animals may be febrile early, but have a normal to low body temperature as the condition progresses. abdominal ultrasound can be useful in locating pockets of fluid for abdominocentesis, which usually yields fluid with increased protein concentration and leukocyte numbers. on occasion, intracellular bacteria are observed on cytologic examination. the presence of extracellular bacteria is not diagnostic because accidental enterocentesis can occur. culture of abdominal fluid and subsequent antimicrobial sensitivity tests are indicated for the implementation of proper treatment. the causative organisms vary depending on the source of the bacteria. rumen bacteria are typically gram-negative anaerobes, and e. coli and other enteric bacteria are common if the intestine is the source of infection. exploratory surgery may be required to diagnose a gastrointestinal rupture. the cbc can be normal but often shows an inflammatory leukogram and, in severe cases, a degenerative left shift. treatment. treatment includes the prescription of appropriate antimicrobial agents, the administration of nsaids for pain and endotoxemia, and fluid support for dehydration. the prognosis is guarded, especially if an intestinal rupture has occurred. pathogenesis, clinical signs, and diagnosis. rectal prolapse is more common in sheep than in goats. this evagination of the rectal mucosa and rectal structures (and possibly the descending colon) is usually associated with excessive straining. straining is seen in lambs with diarrhea caused by coccidiosis, salmonella, or dietary imbalances, in ewes or ewe lambs with vaginal prolapse, in males with urolithiasis, and in animals grazing lush forage (particularly legumes such as alfalfa and clover). it also can occur secondary to chronic coughing, short tail docking, and the use of growth implants. [ ] [ ] [ ] rabies also can cause chronic straining and rectal prolapse. [ ] [ ] [ ] [ ] [ ] regardless of the cause, after the rectal mucosa becomes everted and exposed, irritation of the mucosa causes further straining, which exacerbates the problem. venous drainage of the prolapse may be compromised, but the arterial supply usually remains intact and contributes to the swelling. rectal prolapses are graded as type i to iv, based on the portion of rectum and distal colon that is everted. a description of these grades in shown in table - . treatment. correction may be cost prohibitive for feedlot lambs, and immediate slaughter is recommended. in more valuable animals, very mild, early cases can be treated with frequent application of hemorrhoidal ointment designed for humans and manual replacement of the prolapsed mucosa into the anus. the authors try to avoid applying purse-string sutures in the anus because they tend to serve as a nidus and result in further straining. however, if less aggressive therapies do not relieve the problem in hours, a purse-string suture may become necessary, particularly in type i and ii prolapse. in all cases and modes of treatment, restricting feed for to hours and administering mineral oil is recommended. dusty feedstuffs (concentrates, pellets, hay) should be avoided because they may contribute to coughing, which exacerbates this condition. adding molasses to feeds and lightly wetting hay may help reduce problems with dust. purse-string suture is easily performed. the prolapsed tissue and perineal area are washed with mild soap and lubricated with petroleum jelly or hemorrhoidal ointment before the prolapse is replaced. , after replacing the prolapsed mucosa, the clinician inserts a tubular object (syringe case, wooden dowel, gloved finger) into the rectum. he or she then places a purse-string suture of nonabsorbable suture material ( - nylon) in the skin around the anus, tightens it around the tubular object, and ties it off. the suture should be placed around the anus using a cutting needle, and entering and exiting at the o'clock position. tying the knot above the anus ensures that less fecal soiling of the suture will occur. the clinician should tie the suture in a bow knot to allow easy identification over the next few days and then remove the tubular object. the suture should be tight enough to prevent prolapse but loose enough to allow feces to pass. the clinician should regularly reevaluate the animal and if possible loosen the purse-string suture at -hour intervals until no tension exists. after a full day of no tension, the suture can be removed. if animals continue to strain, an epidural anesthetic can be administered. petroleum jelly and hemorrhoid gels should be placed on the anus daily. , the injection of counterirritants around the rectum ( ml or less of lugol's iodine) either alone or in conjunction with anal purse-string suturing is a quick and inexpensive treatment. , , the clinician inserts an -gauge needle ( cm) deeply into the skin around the anus at , , and o'clock. an injection at the o'clock position should be avoided because swelling around the urethra can result in obstruction. for more severe cases, submucosal resection or rectal amputation of tissue may be necessary. , rectal amputation can be performed with a prolapse ring or suture technique. prolapse ring usage is a salvage technique. the clinician inserts the prolapse ring into the rectum and places an elastrator band or suture around the area to be amputated to induce vascular compromise and necrosis of tissue. if a ligature is used, it should be tightened to allow purchase on the tube or ring. a fibrosis is induced just proximal to the band or suture, and mucosa subsequently grow across the areas. strictures, peritonitis, and abscesses are possible complications, but this technique may be useful as a field procedure. submucosal resection can be performed under epidural analgesia after the prolapse and the perineal area have been surgically prepared. the clinician places two spinal needles ( to cm) at -degree angles to each other to mm distal to the anal sphincter and through the entire prolapse. a circular incision is made to mm distal to the spinal needles through the mucosa and around the outside of the anus. another circular incision is made just distal to the caudal extent of the prolapse into the point where the mucosa reflects on itself on the innerside of the prolapse. the clinician connects these two incisions with a longitudinal incision parallel to the prolapse and dissects the mucosa between the circumferential incisions. the mucosal edges are then sutured with a simple interrupted pattern using a suitable absorbable suture material. after completely suturing the mucosal surfaces, the clinician removes the two spinal needles and places a purse-string suture in the anal sphincter. placement of the suture and follow-up care are the same as described for the purse-string suture technique. submucosal resection decreases the incidence of both peritonitis and stricture formation compared with other surgical techniques, but it is expensive. in all of these techniques, a caudal epidural anesthetic ( % lidocaine, . ml per kg) is recommended to decrease straining and ease pain from the procedures. , a xylazine epidural ( . to . mg/kg as sufficient [qs] to ml with % lidocaine) may give longer relief (approximately to hours) from straining than lidocaine. an alcohol epidural also may prevent straining for extended periods. either isopropyl alcohol or ethanol can be used to demyelinate the motor and sensory nerves. this type type i small, circular amount of submucosal swelling good prognosis if there is no damage to mucosa; protrudes through anus; probing reveals a pocket purse-string suture, iodine injection, submucosal or fornix just inside anus resection type ii slightly more circular submucosal and mucosal good prognosis if treated quickly and no mucosal swelling, possibly containing retroperitoneal rectal damage; purse-string suture, iodine injection, tissue from anus; probing reveals a pocket just submucosal resection, rectal amputation inside anus type iii complete prolapse containing part of the if there is vascular injury to the descending colon, retroperitoneal structures of the rectum and the prognosis is guarded to poor; submucosal descending colon; probing reveals a fornix just resection or rectal amputation are the methods of inside anus; the affected portion of the descending choice colon does not prolapse through the anus type iv the descending colon appears as a tube, and has if there is vascular injury to the descending colon, intussuscepted through the rectum and anus; prognosis is poor; abdominal exploration may unlike the previous types, in this case a probe be required to determine the extent of damage to or finger can be inserted into the prolapse through the descending colon the anal sphincter for a distance of to cm of anesthesia can be permanent and therefore should be used only for animals intended for slaughter. because of the potential for some loss of sciatic nerve function, the clinician should perform a test injection of a local anesthetic ( % lidocaine) before using alcohol. if the epidural appears effective and no ataxia or muscle weakness of the rear limbs occurs, the clinician can inject a mixture of equal parts of lidocaine and alcohol into the sites where the test epidural was performed. possible problems with alcohol epidural anesthesia include injection site necrosis, sciatic nerve dysfunction, and the inability to void feces. regardless of the type of epidural used, the clinician clips, washes, and dries the area before placing a small needle ( -to -gauge [ . cm]) in the most cranial yet moveable intracaudal vertebral space-usually c to c or c to c . the needle is placed on the dorsal midline, with the needle degrees to the skin and the hub moved slightly caudal, and then slowly advanced. liver abscesses usually occur as a result of chronic rumenitis in cattle, but they are rare in sheep and goats. they can occur in feedlot lambs and kids and other animals fed rations high in grain. in lambs and kids, septicemia or extension of an umbilical vein infection can cause liver abscesses. in most cases, however, liver abscesses are an incidental finding. weight loss, anorexia, depression, and decreased production (growth, milk) may occur. in adults, corynebacterium pseudotuberculosis is the most common cause. actinomyces pyogenes and fusobacterium necrophorum also are cultured from abscesses. [ ] [ ] [ ] liver enzymes may or may not be elevated. diagnostic ultrasonography of the liver may help detect abscesses, especially if they are numerous and widespread. however, no specific treatment or control measure is available. many of the preventive protocols used for feeder cattle apply to the control of abscesses in sheep and goats. these include slowly introducing concentrates into the diet, offering long-stemmed hay free choice, and including rumen buffers (alkalinizing agents) and antimicrobial agents in the feed. pathogenesis. fatty liver occurs in conjunction with pregnancy toxemia in ewes and does during the last month of gestation. it is most common in thin or obese ewes or does with a single large fetus, twins, or triplets. during late gestation, particularly in obese females, the abdominal space is filled with accumulated fat and an ever-expanding uterus. because of the lack of rumen space, these females have difficulty consuming enough feedstuffs to satisfy energy requirements. in most management systems, late gestation occurs during the winter months, when less pasture is available and poorer-quality feedstuffs are offered. energy requirements for ewes and does carrying twins or triplets is greatly increased during the final months of gestation because % to % of fetal growth occurs during this time. ewes with twins require % more energy, and those with triplets need % to % more dietary energy. pregnancy toxemia also occurs in association with anorexia caused by other diseases (foot rot, opp, cae) or sudden stresses (feed or weather changes, predator attacks, hauling). whatever the initiating cause, a period of anorexia and lack of sufficient energy intake result in a negative energy balance. these animals begin to mobilize body stores of fat and transport them to the liver. in the liver, fat is catabolized to glycerol and free fatty acids (ffas). ffas can be used in the citric acid cycle (krebs cycle) as an energy source, but not in the direct formation of glucose. anorexic animals have less ruminal substrate available for production of the glucose precursor propionic acid. however, oxaloacetate, which is an integral part of the citric acid cycle, is removed from the cycle and converted into glucose. depletion of oxaloacetate inhibits the normal citric acid cycle's function, inhibiting the use of ffas. as the pool of ffas increases, they are converted to ketone bodies or repackaged into lipoproteins. because ruminants are not efficient at transporting lipoproteins out of the liver and back to the adipose stores, the lipoproteins overwhelm the liver's ability to handle this massive buildup, resulting in a fatty liver. because less substrate is available for glucose formation, more oxaloacetate is "cannibalized" from the citric acid cycle, further inhibiting the body's ability to use ffas. this in turn causes the continued accumulation of ketone bodies. hypoglycemia, hy-perketonemia, and potentially uremia and death can occur. clinical signs. animals suffering from fatty liver or pregnancy toxemia become anorexic and depressed, display altered behavior, and become recumbent. some are constipated, grind their teeth, have a ketone smell to their breath, and suffer from dystocia. neurologic signs include blindness, circling, incoordination, star-gazing, tremors, and convulsions. , death can occur if the condition is left untreated. in the case of in-utero fetal death, maternal septicemia-endotoxemia and death are common sequelae. diagnosis. diagnosis is based on clinical signs, the presence of multiple fetuses, and typical clinicopathologic findings. cbc results may be normal or show an eosinophilia, neutropenia, and lymphocytosis. these animals may or may not be hypoglycemic, but ketoacidosis, hypocalcemia, and hypokalemia are common. , liver enzymes are usually within normal limits but occasionally may be increased. azotemia, both from dehydration and secondary renal disease, is a common finding, and a fatal uremia may occur. blood concentrations of ß-hydroxybutyric acid greater than mmol/l are consistent with pregnancy toxemia. urinalysis will be positive for both ketones and protein. urine is collected from sheep by holding the nares and from does by frightening them and then allowing them a perceived escape when they stop, squat, and void. although not commonly performed, liver biopsy can help determine the extent of fatty infiltration. this syndrome must be differentiated from hypocalcemia, hypomagnesemia, polioencephalomalacia, encephalitis, lead toxicity, and cerebral abscesses. treatment. very early cases (before the animal exhibits recumbency) may be treated with oral or iv glucose. a balanced electrolyte solution with extra calcium ( ml of a % calcium borogluconate per liter), potassium ( to meq/l), and % dextrose is needed. in some cases, sodium bicarbonate is valuable in treating acidosis (see appendix ii). energy intake must be increased, and propylene glycol can be administered ( to ml every hours) as a glucose precursor. rumen transfaunation and supplementation with vitamin b complex (including vitamin b , biotin, niacin, and thiamine) also are recommended. after females become recumbent, treatment must be very aggressive. removal of the fetuses is crucial in these cases. chemically inducing parturition (by administering . to mg of prostaglandin f a or . mg/ kg of cloprostenol in does and to mg of dexamethasone in ewes) and giving the ewe or doe medical support (fluids, b vitamins, glucose) while waiting is a useful protocol in some cases. unfortunately, during the time before parturition, endotoxemia from dead fetuses further compromises the female. for this reason, the authors recommend immediate cesarean section on depressed moribund animals (see chapters and ) . the owner should be forewarned of the poor prognosis for animals already in a moribund state. fluid support during and after surgery is crucial. regardless of the therapeutic plan, the animal should be offered a palatable, energy-rich, highly digestible feedstuff. the keeper and clinician should take care to minimize the risk of a confounding disease during convalescence (e.g., lactic acidosis, polioencephalomalacia). prevention. fatty liver and pregnancy toxemia can be prevented through proper nutrition. maintaining animals in proper body condition throughout the year and making sure energy and protein levels are adequate in late gestation (see chapter ) are two key preventive measures. , the owner/manager should be taught to assess body condition in individual animals and should maintain emergency stores of feed in case of severe weather or natural disasters. the requirement for energy may be one and a half to two times maintenance for single fetuses and two to three times maintenance for multiple fetuses. prevention of concurrent disease that may further increase energy demands or cause anorexia (e.g., intestinal parasitism, foot rot) is crucial. the keeper should take care to increase the grain portion of the diet slowly because anorexia from rumen upset can lead to this disease. ewes should be offered . to kg of a cereal grain (corn, oats, barley, or a combination) every day during the final months of gestation; does can be offered ⁄ to kg of grain. keepers should maintain ewes and does at a body condition score of . to (see chapter ) throughout gestation and evaluate the animals' energy every to weeks. ultrasonography can help identify females with multiple fetuses. these animals should be separated into groups and fed accordingly. ultrasonographic determination of fetal numbers is best accomplished between days and after breeding with a . mhz transducer; a mhz transducer produces better results between days to . either type of transducer may be of value and these windows of time may be expanded by the ability of the operator (see chapter ) . determination of fetal numbers may be enhanced by shearing the hair or fiber in front of the udder, applying a coupling substance to the skin, and viewing as much of the abdomen as possible, building a mental image of its structures and the number of fetuses while systematically moving from one side of the posterior abdomen to the other. keepers and clinicians should ensure that ewes are healthy and free of chronic diseases (e.g., opp, cae, foot rot, chronic parasitism) and that a good-quality trace mineral salt mixture is available free choice. the addition of lasalocid ( . to mg/kg/day) or monensin ( mg/kg/day) to the feed or mineral mixture enhances the formation of the glucose precursor propionic acid and improves the efficiency of feed use. however, monensin should be used with caution because toxicity may occur; the agent should comprise no more than ppm of the complete diet. the inclusion of niacin ( g/head/day) in a feed supplement or mineral mixture helps prevent pregnancy toxemia. supplementation with lasalocid, monensin, or niacin should begin to weeks before the females give birth. shearing in the last trimester also is recommended in ewes. many sheep producers routinely clip the wool around the vulva. if complete body shearing is performed, the incidence of fatty liver or pregnancy toxemia may be decreased. sheared sheep require less energy to walk and graze. sheared ewes also tend to shiver on cold days, exercising the enzyme systems that promote the more efficient use of ffas as energy substrate. these ewes tend to seek shelter during cold weather, which may decrease lamb losses resulting from hypothermia. obviously, if ewes are to be shorn, keepers should make adequate shelter available. keepers should avoid hauling or moving females during late gestation. proper predator control measures should be maintained. good hoof care programs should be in place on farms or ranches where grazing is the predominant form of nutrient intake. sheep and goats should have their teeth checked to ensure good dentition before the breeding season. animals with poor teeth should be culled. measuring serum b-hydroxybutyric acid concentrations is useful in assessing energy status in ewes. values of . to . mmol/l suggest a negative energy balance. keepers should take steps to correct the problem by feeding better-quality, more digestible feedstuffs. white liver disease is a form of fatty liver disease reported only in angora and angora-cross goats and sheep. it is associated with cobalt deficiency. pathogenesis. cobalt is needed by rumen microflora to produce cyanocobalamin, or vitamin b , which is a coenzyme for methylmalonyl-coa mutase. in turn, this enzyme is needed to convert propionate to glucose through the krebs cycle. cobalt deficiency leads to the accumulation of methylmalonyl-coa, or methylmalonic acid, which is converted to branched chain fatty acids that accumulate in the liver. , high-grain diets that are fermented to propionate coupled with deficient or marginal cobalt intake may predispose to this condition. , white liver disease has not been reported in the united states, but ill thrift from cobalt deficiency has been observed. it is therefore possible that the disease goes unrecognized. clinical signs. signs are most commonly seen in young animals, and include ill thrift, anorexia, and diar-rhea; sheep may exhibit photosensitization. clinicopathologic findings include a macrocytic, normochromic anemia and hypoproteinemia. , diagnosis. abnormal serum or liver concentrations of vitamin b or liver cobalt are the basis of diagnosis. liver cobalt concentrations on a dry matter basis of . Ϯ . ppm were reported in goats with white liver disease, compared with . Ϯ . ppm in controls. treatment and prevention. sheep can be treated with oral cobalt ( mg/head/day) or vitamin b injections. the condition can be prevented by including cobalt in the ration by feeding a good-quality trace mineral salt. both fasciola hepatica and fascioloides magna can infest sheep and goats. the disease occurs along the gulf coast and in the pacific northwest and great lakes areas. clinical signs. f. hepatica infestation usually causes acute disease in sheep and goats but can present as a chronic condition. chronic disease is the result of the mature flukes in the bile ducts and is manifested in depressed growth and milk production. acute disease occurs when large numbers of immature flukes migrate at once, particularly in animals with limited immunity to flukes. signs include anorexia, depression, weakness, dyspnea, anemia, ascites, colic-like signs, dry feces, and sudden death. the clinical signs are identical to those of nematode infestations (i.e., chronic weight loss, ill thrift, diarrhea, anemia, hypoproteinemia). similar but more severe signs occur with f. magna infection, which is usually fatal. , , diagnosis. antemortem diagnosis of fluke infestation can be difficult. finding eggs in feces is diagnostic for f. hepatica. eggs are only produced by adults and not in great numbers, so a negative fecal test cannot preclude acute or chronic fascioliasis. fluke eggs do not float in routine fecal flotation methods used for nematode diagnosis; a sedimentation technique should be used for suspected fluke infestations. to perform a sedimentation test, the clinician mixes to g of feces with ml of tap water and strains the mixture through a tea strainer into a beaker. the sediment can be examined minutes later under a dissecting microscope. eggs are light yellow to golden and have an operculum at one end (see figure - ). f. magna does not mature, so eggs are not produced and fecal examination is of no value. most fluke infestations are discovered by finding the flukes at necropsy or slaughter. an elisa test may be available in the future. , , cbcs of affected animals may indicate eosinophilia and anemia. increased liver enzymes and hypoalbuminemia also are occasional findings. because antemortem diagnosis is difficult, the clinician should institute fluke treatment after ruling out other differential diagnoses if the possibility of fascioliasis exists. if fascioliasis is diagnosed at necropsy, the remaining animals in the herd should be treated. because flukicides available in the united states are highly effective only against mature flukes, the timing of treatment is important. in the southern portions of north america the snails are ingested in the spring and the flukes migrate in the summer and mature in the fall. in cooler, northern climates, snails may remain active during summer, so flukes can mature in the fall and into the winter. clinicians should begin treatment in the southern united states in the late summer or early fall. a single treatment in late winter or early spring is commonly used in the northern climates of north america. albendazole ( - mg/kg orally) and clorsulon ( mg/kg orally, mg/kg sc) are very effective against adult f. hepatica. , , clorsulon has no efficacy against nematode parasites but is highly efficacious against both adult and late-stage immature flukes. albendazole ( mg/kg orally) is somewhat useful in controlling f. magna at weeks after infestation, and clorsulon is effective only at very high dosages. [ ] [ ] [ ] unfortunately, neither agent can kill % of f. magna, and only a few remaining flukes can be fatal. control of fluke infestations is difficult, although timely treatment of animals can decrease infec-tions in successive years. decreasing exposure is the key to control. eliminating the snail is impractical, but fencing off low-lying areas may prevent ingestion. depending on local fluke life cycles, keepers should avoid grazing animals on areas with high fluke populations during peak infection times. areas where water stands or flows over grazing pastures, streams, and irrigation ditches (particularly those with clay soil) are high-risk zones. cysticercus tenuicollis is the larval stage of the dog tapeworm taenia hydatigena, of which sheep and goats are intermediate hosts. the larval stage migrates through the liver, then attaches to the liver or other abdominal organs and causes black, winding tracts and cysts in the liver. acute disease occurs only with large numbers of cysticerci and is characterized by depression and weakness resulting from liver damage. the chronic cystic stage is usually asymptomatic. no treatment is available and control is problematic because it requires treating infestation in dogs and preventing contact with dogs. , , pathogenesis. copper (cu) toxicosis is more common in sheep than in goats. goats appear closer to cattle than sheep in their ability to store and handle cu and resist toxicosis. toxicity results from chronic accumulation in the liver from the ingestion of excess cu in relation to molybdenum (mo) or sulfate in the diet. in sheep, a cuto-mo ratio greater than Ϻ leads to the accumulation of excess cu. the most common sources of excess cu in sheep and goats are trace mineral mixtures and feeds formulated for cattle or horses. clinical signs are often absent during the chronic accumulation phase. acute disease is seen when cu is suddenly released from the liver in large amounts. stress usually precipitates this acute phase. acute release and subsequent high blood cu concentrations cause an acute hemolytic crisis, resulting in anemia, hemoglobinuria, and acute renal failure. existing hepatic disease (such as that caused by liver flukes) may predispose animals to this condition. some breeds seem to be prone to cu absorption and storage problems (merino sheep), whereas others tend to be more resistant and prone to deficiency (pygmy goats) (see chapters and ). clinical signs. anorexia, depression, diarrhea, and weakness are all signs of cu toxicity. many affected animals are found dead with hemolysis and icterus. signs of abdominal pain and diarrhea are sometimes present. port wine-colored urine is evidence of hemoglobinuria. hemoglobinemia produces icterus of the mucosal membranes and fever. diagnosis. on clinicopathologic examination, anemia, hemoglobinemia, hyperbilirubinemia, increased liver enzymes, and azotemia are present. urinalysis reveals hemoglobinuria and isosthenuria. the combination of azotemia and isosthenuria indicates acute renal failure. definitive diagnosis of acute disease requires measurement of cu concentrations in serum. normal blood cu concentrations are approximately to mg/dl in sheep and goats. , , these concentrations increase to -fold with an acute hemolytic crisis. on necropsy, kidney cu concentrations are the most diagnostic because liver concentrations may be normal from release into the bloodstream. generally kidney concentrations greater than ppm and liver concentrations greater than ppm on a dry matter basis are diagnostic. , if tissue copper is reported in wet weight, the conversion to dry tissue weight can be estimated by multiplying the tissue concentration by a factor of . treatment. treatment of acutely affected animals is often futile. it consists of supportive therapy for the acute renal failure and anemia and attempts to lower liver cu stores. fluid therapy for the acute renal failure (see appendix ii) is of therapeutic value, and a blood transfusion may be needed if the pcv drops precipitously. ammonium tetrathiomolybdate ( . mg/kg iv or . mg/kg sc on alternate days for three treatments) is the most economical agent for treatment for acute cases. in valuable animals, d-penicillamine ( to mg/kg bid or mg/kg sid po for days) increases urinary cu excretion. trientine is used in human beings, but has shown variable results in sheep. treatment of the remainder of the flock should include the administration of ammonium molybdate ( to mg/head/day po) and sodium thiosulfate ( to mg/head/day po) for weeks. stress should be minimized, so keepers and clinicians should delay routine maintenance procedures such as deworming and hoof trimming until after treatment. the offending source of cu should be eliminated. prevention. avoiding high dietary cu (more than ppm), a high cu-to-mo ratio (greater than Ϻ ) in the feed, cu-containing foot baths, and other sources of cu is crucial. including supplemental mo in the diet to lower the cu-to-mo ratio to Ϻ to Ϻ is beneficial. this requires to ppm of mo in many instances. often too much emphasis is placed on the trace mineral component of the diet. the clinician should be aware that even if no cu is added to the trace mineral mixture and the element does not appear on the product label, the mineral mixture may still contain cu. many components of mineral mixes are contaminated with cu (zinc sulfate may contain ppm of cu, dicalcium phosphate may contain more than ppm of cu). therefore the clinician needs to perform a dietary analysis to find and correct the problem. pathogenesis. the liver is vulnerable to toxic insult because one of its major functions is detoxification. the most common plants that are gastrointestinal and liver toxins are shown in table - . clinical signs depend on the cause. acute, severe toxicity is more common with chemical toxicosis, whereas plant toxins usually cause chronic disease. a thorough history is important and in many cases inspection of the animals' environment is required. clinical signs. the clinical signs of toxic hepatitis can be vague. animals may only show anorexia and depression. icterus is more common with hemolytic diseases and is not always seen with liver disease. photosensitivity is a common clinical feature in ruminants and hepatoencephalopathy also can occur. clinicopathologic data are more helpful in diagnosing acute toxicity. serum ast and ldh levels can increase with hepatocellular necrosis but are not liverspecific, so muscle injury and disease must be ruled out. these enzymes also increase if serum is not separated from a blood clot in a timely fashion. increased levels of alkaline phosphatase (ap) and ggt indicate biliary stasis. ap also is not liver-specific, but increased serum levels of ggt are very specific for liver disease. ggt also increases in some hepatocellular diseases, so testing for its normal concentrations is important. unfortunately, all of these enzymes can be normal with liver disease, especially if it is chronic. hyperbilirubinemia, hypoglycemia, low blood urea nitrogen (bun), and hypoalbuminemia are not always evident as classically taught. if hepatoencephalopathy is suspected, blood ammonia concentrations may be elevated. blood ammonia analysis may be impractical in the field because the blood should be kept on ice, and the test should be performed within minutes of collection. to enhance the accuracy of blood ammonia analysis, the clinician should collect blood from a normal control animal for comparison. ammonia concentrations three times those of the control animal are diagnostic. liver biopsy remains the most valuable tool in diagnosing liver disease. although clotting dysfunction may occur in liver disease, it is an uncommon complication in ruminants and should not discourage the clinician from performing a liver biopsy. treatment. if the intoxication is caught in the acute stage, activated charcoal ( g per adult animal) can be given. supportive care, especially fluid support with dextrose solutions, is the mainstay of therapy. low-protein diets may suppress ammonia production temporarily, but they can be detrimental over time depending on the production status of the animal. if photosensitization occurs, animals should be housed indoors if possible, and broad-spectrum (systemic or topical) antibiotics may be necessary to control secondary bacterial dermatitis. corticosteroids (dexamethasone . to mg/kg iv or im) may be indicated in early cases of photosensitization to decrease inflammation. neurologic signs can be controlled with phenobarbital (initial dose: to mg/kg iv diluted in saline and administered over minutes; subsequent doses: to mg/kg iv diluted in saline, as needed up to tid). diazepam (valium) is contraindicated in hepatoencephalopathy because it may worsen signs. congenital hyperbilirubinemia, or black liver disease, occurs in mutant corriedale sheep (dublin-johnson syn-drome). this is a genetically recessive condition. it is characterized by an abnormality in the excretion of conjugated bilirubin and phylloerythrin and is often seen in animals consuming green forage. clinical signs include anorexia, photodermatitis, and icterus. liver biopsy of affected animals reveals dark to black granules in otherwise normal hepatocytes. the syndrome first manifests itself in lambs around months of age. a similar condition occurs in southdown lambs around months of age (gilbert's syndrome). this too is a recessive condition that causes decreased hepatic uptake of phylloerythrin and bilirubin, with concurrent renal failure. signs include icterus, photodermatitis, and ulceration around the ears and mouth. a liver biopsy reveals normal hepatic tissue. in both of these conditions, animals should be kept out of sunlight and fed minimal various tumors of the liver, including fibrosarcoma, lymphosarcoma, and cholangiocellular carcinoma, have been reported. , the use of ultrasonography and ultrasound-guided liver biopsy may aid in diagnosis. the umbilicus is an opening in the ventral abdominal wall that allows passage of the umbilical vessels and allantoic stalks. this opening should close within a few day of birth. the failure of this opening to close properly is termed umbilical hernia. the hernial sac has an inner peritoneal layer and an outer layer of skin. these hernias are probably of genetic origin but may occur as sequelae to umbilical remnant infection. the opening in the abdominal wall is perceived as a ring on palpation. if the clinician can insert more than one finger into the hernial ring or if the hernia persists for more than to weeks, surgical intervention is indicated. penning. clamps or rubber bands may be of value for closing small hernias (those less than cm in diameter). the clinician should either lightly sedate the animal or infiltrate the skin around the hernia with a local anesthetic ( % lidocaine). the animal should be placed on its back and held by a technician-helper. any viscera prolapsing into the hernial sac should be replaced into the abdomen. the clinician then inserts two metal pins (baby diaper pins can be used) through the skin and on opposite sides of the hernial ring, just on the edge of the linea alba. the pins should be placed deep enough to sit next to the abdominal wall. slight tension is placed on the skin in the center of the umbilical sac, pulling it away from the abdomen. when the clinician is confident that all viscera have been cleared from the hernial sac, he or she places an elastrator band between the pins and the abdominal wall. this results in ischemic necrosis of the skin. the skin will slough and the abdominal defect will heal in to days. lambs should be given tetanus prophylaxis. this procedure and other clamping techniques are useful in females and some males. however, urine scalding of the skin may occur in some males. clinicians should closely monitor animals that have undergone clamping. surgical resection. in cases in which the hernial ring is larger than cm, surgical intervention should be carried out. animals can be sedated and then infiltrated with a local anesthetic or placed under general anesthesia. the area around the hernia is clipped and surgically prepared. the clinician opens the hernial sac and introduces a finger into the abdomen to ensure that no viscera have adhered to the inner lining of the ring and that no enlarged or infected umbilical remnants are present. he or she then carefully excises the ring and closes the defect in the abdominal wall. this closure can be made by simply opposing the abdominal wall with a horizontal mattress pattern stitch (absorbable suture). an alternate closure of the abdominal wall is to suture the peritoneal lining in a separate pattern and close the abdominal wall defect so one side of the defect is pulled to overlap the other side. the upper free edge is sutured to the opposite wall with a near-far-far-near pattern. the authors choose not to employ surgical techniques that slow this procedure. the subcutaneous tissue can be closed with simple interrupted pattern using absorbable suture and the skin should be closed with whatever pattern the clinician prefers. animals should be given tetanus prophylaxis and antibiotics. they should be closely monitored for signs of sepsis and surgical failure. exercise should be limited for to days after surgery. infections of the umbilical arteries (omphaloarteritis) and veins (omphalophlebitis) and urachal disease can occur because of failure or partial failure of passive transfer of colostral antibodies and subsequent sepsis. contamination of the umbilicus, retracting of these structures after stretching and breaking, and chemical damage (from strong tincture of iodine) to the amniotic remnants are other possible causes. , , dipping the umbilicus with iodine or iodine-chloriodine substances is a common practice. aggressive use of these chemicals may precipitate serious inflammation of the cord. excessive torsion of the umbilical cord, distention of the proximal urachus, and some genetic factors may all be associated with patent urachus, which also may occur as a sequela to omphaloarteritis or omphalophlebitis. clinical signs and diagnosis. the clinical signs include umbilical swelling, pain, and occasionally drainage or discharge of the umbilical stump. palpation and transabdominal ultrasonographic evaluation reveal an enlarged cord-like structure ascending from the umbilicus cranially (umbilical vein) or caudally (urachus or um-bilical artery). ultrasonographic evaluation may indicate an abscess or thickened tissue. patent urachus is associated with dermatitis, urine scalding of the ventral abdomen, and urine dribbling. if the urachus becomes infected it may leak urine intraperitoneally or subcutaneously. both of these developments may be identified with abdominal palpation, ballottement, ultrasonographic evaluation, and, when indicated, paracentesis. the cbc may indicate neutrophilia. blood culture is indicated if sepsis occurs simultaneously. occasionally infection of the internal structures may occur with no outward umbilical swelling. deep abdominal palpation and/or the use of real-time ultrasound are necessary to attain a diagnosis. animals with umbilical infections also may have signs of septicemia, anorexia, depression, joint distention, and fever. treatment. if a patent urachus occurs without inflammation of the associated tissues, it can be cauterized daily with iodine or silver nitrate. however, if it remains patent for more than days, it should be surgically closed. the animal should be placed under general anesthesia (see chapter ) . the area around the umbilicus should be clipped and surgically prepared, and the animal should be placed on a broad-spectrum antimicrobial agent to hours before surgery. the clinician opens the abdomen lateral to the umbilicus and digitally explores the adjacent area for adhesion formation. the urachus should be identified and followed to the urinary bladder. after this, the clinician should amputate the urachal attachment to the bladder and close the bladder with a double-layered inverting pattern (cushing). the abdominal wall, subcutaneous tissue, and skin are closed as described for umbilical hernia repair. on occasion some cases of omphalophlebitis-omphaloarteritis can be treated medically. prolonged antibiotic therapy with a broad-spectrum antimicrobial agent (ceftiofur . mg/kg sid or oxytetracycline mg/kg sc every hours) may be attempted. however, if medical therapy is ineffective, the infected umbilical remnants should be marsupialized or excised. the authors prefer more aggressive, surgical removal of the umbilical rem-nants. as with urachal surgery, the abdomen should be opened lateral to the umbilicus. depending on the severity of infection and the amount of tissue involved, the clinician may need to perform extensive dissection of necrotic tissue and possibly intestinal resection. if the infection of the umbilical vein extends to and involves the liver, marsupialization of the umbilical vein is an effective method of therapy. , the clinician can pull the vein to the most cranial portion of the abdominal incision and suture it to the muscle layers and skin before closing the abdomen as described for umbilical hernia repair. however, a preferable method is to close the abdominal wall, pull the transected umbilical vein through, and suture it to a separate stab incision. this may help minimize the incidence of abdominal wall herniation. only monofilament, absorbable, non-gut suture material should be used. the venous stump should be flushed daily with antiseptic solution ( % chlorhexidine, . % povidone iodine), and the animal should be maintained on antibiotics for more than days. the venous stump usually closes within a month. prevention. umbilical infections can be prevented or drastically reduced by ensuring adequate intake of goodquality colostrum. lambs and kids also should be only minimally stressed (particularly during the first to days of life) to enhance colostral absorption. in some management scenarios, proper dipping of the navel with non-caustic materials also helps reduce the incidence of this disease. indigestion in ruminants bloat or ruminal tympany diseases of the goat on the effect of xylazine on forestomach motility in sheep anorexia during febrile conditions in dwarf goats: the effect of diazepam, flurbiprofen and naloxone bloat in kids experimentally induced lactic acidosis in nubian goats: clinical, biochemical, and pathological investigations diagnosis of enteric disease in small ruminants ruminal lactic acidosis in sheep and goats biochemical alterations in serum and cerebrospinal fluid in experimental acidosis in goats commonly encountered diseases of goats generalized aspergillosis in dairy sheep rumen papillomas in sheep effect of monensin on development of ruminal parakeratosis in fattening lambs, zentralblatt fur veterinarmedizin lactic acidosis foreign body syndrome in goats-a report of five cases traumatic gastritis in sheep and goats goat medicine references . sherman dm: causes of kid morbidity and mortality: an overview, proceedings of the fourth international conference on goats enteric infections in young goats and their control enteritis and diarrhea goat medicine infectious gastrointestinal diseases of young goats occurrence of cryptosporidia, rotaviruses, coronavirus-like particles and k ϩ escherichia coli in goat kids and lambs jensen and swift's diseases of sheep escherichia coli in domestic animals and humans development of resistance with host age to adhesion of k ϩ escherichia coli to isolated intestinal epithelial cells references . smith bp: alterations in alimentary and hepatic function control programs for gastrointestinal nematodes in sheep and goats epidemiology of internal parasites: effects of climate and host reproductive cycles on parasite survival anthelmintic resistance: the selection and successful breeding of superior parasites control and prevention of specific diseases of sheep and goats herd rp: control of periparturient rise in worm egg counts of lambing ewes production medicine and health programs for goats the effects of dietary protein on establishment and maturation of nematode populations in adult sheep nematode infections-cattle, sheep, goats, swine parasites affecting goats in the southeast, proceedings of goat production and marketing opportunities in the south grazing management strategies for the control of parasitic diseases in intensive sheep production systems goat medicine helminth parasites of the gastrointestinal tract. nematode infections in cattle, sheep, goats, and swine parasite control programs in sheep and goats epidemiology and control of trematodes in small ruminants use of anthelmintic combinations against multiple resistant haemonchus contortus in angora goats preliminary investigation of anthelmintic efficacy against gi nematodes of goats and susceptibility of goat kids to gastrointestinal nematode infection johne's disease in sheep and goats paratuberculosis in small ruminants, proceedings of the small ruminants for the mixed animal practitioner, western veterinary conference paratuberculosis in small ruminants, deer, and south american camelids comparison of the absorbed elisa and agar gel immunodiffusion test with clinicopathologic findings in ovine clinical paratuberculosis paratuberculosis in a large goat herd serodiagnosis of paratuberculosis in sheep by use of agar gel immunodiffusion corynebacterium pseudotuberculosis infection in sheep and the complement fixation test for paratuberculosis obstructive intestinal diseases intussusception in goats goat medicine duodenal obstruction by a phytobezoar in a goat general surgical techniques for small ruminants: part ii, proceedings of the small ruminants for the mixed animal practitioner, western veterinary conference rectal prolapse in ruminants and horses jensen and swift's diseases of sheep rectal prolapse in food animals. part : cause and conservative management rectal prolapse in food animals. part ii: surgical options, comp cont ed pract vet : , . references . fetcher a: liver diseases of sheep and goats goat medicine a retrospective study of hepatic abscesses in goats: pathological and microbiological findings hepatic lipidosis jensen and swift's diseases of sheep hepatic lipidosis associated with cobalt deficiency in omani goats epidemiology of internal parasites: effects of climate and host reproductive cycle on parasite survival epidemiology and control of trematodes in small ruminants efficacy and safety of albendazole against experimentally induced fasciola hepatica infections in goats efficacy of an injectable ivermectin/clorsulon combination against fasciola hepatica in sheep albendazole treatment of experimentally induced fascioloides magna infection in goats efficacy of clorsulon against fascioloides magna infection in sheep evaluation of clorsulon against fascioloides magna in cattle and sheep clinical biochemistry of domestic animals metals and other inorganic compounds interpreting a bovine serum chemistry profile: part i large animal internal medicine large animal internal medicine neonatal conditions, with emphasis on equine neonate umbilical hernia, umbilical abscess, and auricle fistula general surgical techniques for small ruminants: part ii, proceedings of the small ruminants for the mixed animal practitioner, western veterinary conference key: cord- -cd adns authors: thachil, jecko; owusu-ofori, shirley; bates, imelda title: haematological diseases in the tropics date: - - journal: manson's tropical infectious diseases doi: . /b - - - - . - sha: doc_id: cord_uid: cd adns nan haematological disorders are common in low-income countries. they make a substantial contribution to morbidity and mortality of individuals in these regions and have a negative impact on the growth and development of under-resourced nations. genetic red cells abnormalities are common in lowincome countries because they provide protection against malaria and they often co-exist with other causes of anaemia such as malnutrition and chronic illnesses. there is a close association between haematological abnormalities and infections which are a major cause of illness and death in these populations. morphological abnormalities of blood can often provide clues about the underlying diagnosis and blood film examination is particularly important where diagnostic facilities are limited. abnormal blood counts can manifest as various combinations of alterations of numbers of red cells, white cells or platelets. this section will outline some of the most common causes of abnormal blood counts likely to be encountered in clinical practice in low-income countries. anaemia is one of the most common causes of morbidity in the world and its impact is reflected in several of the health-related millennium development goals. although anaemia by itself is not a diagnosis, it suggests that there is an underlying disease state which needs to be recognized and treated. it is also a useful indicator of the general health of the population. the causes of anaemia may be identified systematically by considering the life cycle of the red cells (figure . ). nutrients necessary for red cell production are absorbed from the gastrointestinal tract and carried through the portal vein to the liver and ultimately reach the bone marrow where erythropoiesis occurs. this process is regulated by erythropoietin, a hormone released from the kidneys mainly in response to hypoxia. mature • africa and asia have more than % of the world's anaemic populations and anaemia burden is highest among children and women of reproductive age. • the accurate diagnosis of anaemia has been neglected; clinical assessment of anaemia is unreliable unless the anaemia is severe. • in low-income countries, anaemia in an individual is often due to multiple interdependent factors. removing or treating a single factor may not resolve the anaemia. • early diagnosis of sickle cell disease and rapid access to a specialist centre for emergencies such as severe pain crises, strokes and acute chest syndrome, can help to prevent permanent long-term complications. • beta-thalassaemia major is fatal in the first few years of life unless regular blood transfusions are given; unless they are accompanied by iron chelation, these transfusions will eventually cause death due to irreversible organ damage from iron overload. • malarial anaemia is a particular problem for children and pregnant women and severe anaemia can be caused by p. falciparum and p. vivax. malarial anaemia can be reduced with chemoprophylaxis and intermittent treatment, and by anti-mosquito measures such as insecticidetreated bed nets and vector control. • anaemia occurs in % of hiv-infected patients and is an independent risk factor for death. prompt treatment of factors associated with anaemia, such as infections and poor nutrition, and commencement of antiretroviral treatment will reduce deaths. • blood shortages are common in tropical countries. to increase the availability of blood, transfusions should be prescribed in accordance with guidelines and efforts made to encourage blood donors to donate regularly as repeat donors are the safest type of donor. reaction' , characterized by circulating myelocytes and metamyelocytes, can be mistaken for leukaemia but, unlike leukaemia, there is an orderly maturation and proliferation of neutrophils. leukaemoid reactions have also been described in patients with tuberculosis, juvenile rheumatoid arthritis and dermatitis herpetiformis. , decreased margination of neutrophils with egress of cells into the circulation can occur with exercise, adrenaline (epinephrine) injection, emotional stress and postoperatively or in response to drugs (e.g. steroids, β-agonists). other drugs, such as lithium and tetracycline, produce neutrophilia through increased production. neutrophilia is also a feature of bone marrow proliferation which occurs in myeloproliferative neoplasms, particularly chronic myeloid leukemia and myelofibrosis. teardrop cells and nucleated red blood cells are features of myelofibrosis on the blood film; basophilia and eosinophilia are common with chronic myeloid leukaemia. molecular testing for the jak- mutation or bcr-abl fusion gene can also help to differentiate between myeloproliferative neoplasms. rebound neutrophilia can occur following treatment of megaloblastic anaemia or after recovery from neutropenia induced by drugs. acute haemorrhage can cause neutrophilia, especially if bleeding occurs into the peritoneal cavity, pleural space, joints or adjacent to the dura. this is possibly due to the release of adrenaline and chemokines in response to local inflammation. the presence of neutrophilia can be useful in raising suspicions about the onset of complications in infections that are not primarily associated with neutrophilia. examples include meningitis in tuberculosis, orchitis in mumps, bowel perforation in typhoid fever and superadded bacterial infection in measles. the absence of neutrophilia can be helpful in differentiating typhoid and paratyphoid fever from pyogenic infections. neutropenia is defined as an absolute neutrophil count < . × /l. it is usually classified into severe (< . × /l), moderate red cells are released into the circulation from the bone marrow and percolate through the tissues and organs. anaemia can result from defects in any of these stages. inadequate production of red cells in the bone marrow can be due to lack of nutrients (e.g. iron, b , folate, vitamin a, copper or zinc), abnormal haemoglobin synthesis (i.e. haemoglobinopathies) or ineffective erythropoeisis from myelodysplasia or infections. red cells can be lost from the body (e.g. gastrointestinal bleeding) or removed prematurely if they are abnormal or the spleen is enlarged (i.e. haemolysis). kidney disease can result in decreased erythropoietin. anaemia of chronic disease (or 'anaemia of inflammation') is due to an inadequate response to erythropoieitin or to increased cytokine-induced hepcidin release in inflammatory states which interferes with iron absorption or iron utilization. diagnostic algorithms to determine the cause of anaemia are usually based on a combination of the mean cell volume of the red cells, the reticulocyte count and blood film appearance (figures . , . ). this approach is based on the availability of a haematology analyser and an experienced microscopist. several conditions which cause anaemia may co-exist in the same individual (e.g. intestinal parasites, malaria and sickle cell disease) and hence a thorough investigation is crucial to identify all potential causes of anaemia. neutrophils released from the marrow after maturation can either enter the 'circulating pool' or they can remain in the 'marginal pool' where they are loosely attached to the blood vessel wall. cells in the marginal pool are not sampled when blood is taken for a full blood count. neutrophilia can therefore result from increased bone marrow synthesis and also from decreased margination which increases the circulating pool. there are many causes of neutrophilia (box . ) but the commonest is bacterial infection in which there is increased bone marrow production of neutrophils and release of neutrophil precursors into the peripheral blood. this 'leukaemoid ( . - . × /l) or mild ( . - . × /l). the propensity to develop infections is related to the degree and duration of neutropenia, with higher risk associated with counts below . × /l. africans, african americans, yemenite jews, palestinians and saudi arabians generally have slightly lower neutrophil counts compared with other races. this is thought to be due to an increase in the bone marrow storage pool as ethnic neutropenia is associated with good neutrophil responses to infections. neutropenia can be due to impaired or ineffective (intramedullary death of neutrophil precursors despite normal bone marrow production) synthesis by the bone marrow (e.g. myelodysplasia, megaloblastic anaemia, treatment with phenytoin or methotrexate); a shift from the circulating pool to marginated pool (pseudoneutropenia) and increased peripheral destruction (e.g. secondary to antibodies against the neutrophils or increased reticulo-endothelial activity in sepsis or haemophagocytic syndrome) (box . ). increased consumption of neutrophils can result from increased attachment of cells to endothelium or other leukocytes in inflammatory states. neutropenia is often the result of a combination of several of these mechanisms. infants of hypertensive mothers may have moderate to severe neutropenia, which can last for several days. this is probably related to bone marrow suppression. moderate to severe neutropenia can also occur in newborn infants as a result of the transfer of maternal igg anti-neutrophil antibodies in a manner similar to rhesus haemolytic disease of the newborn. although neutropenia has been described with typhoid fever, minimum neutrophil count seldom falls below . × /l and the box neutropenia may not develop until after the first week of illness. infectious hepatitis and yellow fever can both cause neutropenia. overwhelming infections can lead to a failure of bone marrow production of neutrophils, especially in undernourished individuals and alcoholics. individuals with severe neutropenia can develop lifethreatening septicaemia, often from endogenous flora (e.g. oral cavity), and stringent measures should be taken to avoid situations which may predispose these individuals to infections. they may need prophylactic antimicrobials and should have rapid access to medical care. fungal infections are less common than bacterial infections in neutropenic individuals, and viral or parasitic infections rarely occur with isolated neutropenia. granulocyte colony stimulating factor (gcsf) injections can be helpful in raising the neutrophil count in patients with complicating infections since it stimulates the release of neutrophils from the marrow, but gcsf is only useful if there is some bone marrow reserve. patients with some congenital or immune forms of neutropenia can tolerate persistently low counts without any increase in the incidence of infections. monocytosis occurs in chronic infections and inflammatory conditions. protozoan infections such as typhus, trypanosomiasis and kala-azar may be associated with monocytosis. chronic and juvenile myelomonocytic leukaemias are malignant disorders in which monocytosis may be severe; acute monocytic leukaemias may present with mild to moderate monocytosis. monocytosis, and particularly a monocyte : lymphocyte ratio greater than . - . , may indicate active progression of tuberculosis and an unfavourable prognosis. the normal ratio of . or less is restored when the healing process is complete. a decreased absolute monocyte count occurs in bone marrow failure states such as aplastic anaemia or after chemotherapy. low monocyte counts can occur with overwhelming sepsis and with splenomegaly. monocytopenia is a characteristic feature of hairy cell leukaemia and is considered to be a diagnostic hallmark of this disease. peripheral blood contains only around % of the total body lymphocyte population since these represent the cells present in the blood during their transit into secondary lymphoid organs. wide variations exist in lymphocyte counts between individuals especially in childhood. lymphocyte counts exhibit a diurnal pattern; peaking at night with a nadir in the morning. lymphocytosis is characteristic of infectious mononucleosis and many atypical and large lymphocytes can be seen in the peripheral blood film. these atypical cells can also occur in cytomegalovirus infection and infectious hepatitis. absolute lymphocytosis can occur with chronic infections such as brucellosis and in the recovery stages of tuberculosis. lymphocytosis is unusual in bacterial infections except in the case of pertussis. heavy smoking is also an often overlooked cause of lymphocytosis and is probably one of the commonest reasons for a mild to moderate increase in the lymphocyte count. malignant bone marrow disorders, predominantly acute lymphoblastic and chronic lymphocytic leukaemia and non-hodgkin's lymphomas, can cause lymphocytosis. these lymphocytes may have characteristic morphological changes identifiable in the blood film (e.g. smear cells with chronic lymphocytic leukaemia) and the correct diagnosis can be confirmed by immunophenotyping for specific combinations of cell markers. lymphopenia is due to decreased production, redistribution or increased rate of death of lymphocytes. decreased production usually results from cytotoxic drugs and radiotherapy, while increased lymphocyte death can occur in infections such as influenza and hiv. occasionally, an isolated low lymphocyte count in the context of an otherwise normal full blood count can be a clue to the diagnosis of hiv. this reflects the destruction of cd + t cells by the virus although an expansion of cd + t cells may raise the total lymphocyte count to normal levels. redistribution rather than depletion of total body lymphocyte numbers occurs with steroid treatment or with endogenous secretion of corticosteroids during acute illnesses due to the retention of lymphocytes in secondary lymphoid organs. eosinophilia eosinophils are involved in innate immunity and hypersensitivity. their number in the circulation is relatively small compared to other leukocytes because they predominantly reside in tissues such as the gut, skin and lungs which are entry points for allergens and infections. the commonest causes of eosinophilia are helminthic infections, atopy and allergic diseases, and adverse drug reactions. less common causes are classified under the umbrella term of hypereosinophilic syndromes (table . ). since parasitic infections are likely to be the commonest cause of eosinophilia in the tropics and in returning travellers, an extensive search for such infections should be undertaken in patients with persistent eosinophilia; initial investigations should be determined by the patient's history of geographical exposure (figure . ) . [ ] [ ] [ ] the absolute number of eosinophils in the peripheral blood may not correlate with their tissue distribution or with their potential to cause tissue damage from their granule release. this is because the degree of eosinophilia depends on the extent of tissue invasion and is therefore modest with tapeworms and roundworms resident in the bowel but much higher where invasion occurs, for example with, toxocara canis or filaria. schistosomiasis almost always causes eosinophilia. strongyloides stercoralis has the capacity to remain in the host for decades after initial infection and causes varying degrees of eosinophilia, with or without other symptoms. steroid treatment, which may be necessary in cases of eosinophilic tissue damage, can exacerbate clinical problems in patients with strongyloides infection so this parasitic infestation should be excluded before starting steroids for hypereosinophilia. mild to moderate eosinophilia is common in asthma although a very high count should prompt a search for churg-strauss syndrome or allergic bronchopulmonary aspergillosis. most drugs including penicillins can cause eosinophilia but the diagnosis can only be made by noting recovery when the drug is discontinued. eosinophilia can be a feature of hodgkin's lymphoma. it signifies a more favourable prognosis and may precede the original diagnosis of lymphoma or relapses. in immunocompromised patients, such as those with hiv infection, the finding of eosinophilia may be crucial since the success of antiretroviral treatment may depend on concomitant eradication of parasites. thrombocytopenia is often discovered incidentally in patients during full blood count estimation. a platelet count above - × /l is usually not associated with any symptoms such as bleeding. if clinically evident haemorrhage does occur at counts above this level, other conditions such as coagulation defects, vascular problems or rarely platelet dysfunction should be suspected. although the prime role of platelets is in haemostasis, several other important roles have been recognized in recent years including wound repair, tissue healing, antimicrobicidal properties, lymphangiogenesis, tumour metastasization and maintenance of blood vessel integrity. congenital platelet disorders are often part of a syndrome. patients with wiskott-aldrich syndrome have small platelets in association with eczema and recurrent infections. other congenital platelet disorders, such as myh -related disorders, can present with deafness or cataracts while skeletal deformities and oculocutaneous albinism are common in other syndromic presentations. blood film morphology can provide important clues about the causes of thrombocytopenia (figure . ). fragmented red cells (schistocytes) increase the possibility of microangiopathic haemolytic anaemia, where an altered vessel wall and fibrin formation in the blood vessels shred the erythrocytes and consume platelets. thrombotic thrombocytopenia purpura, haemolytic uremic syndrome and disseminated intravascular coagulation can all present with thrombocytopenia. dysplastic red or white cells should raise the suspicion of myelodysplasia which can be confirmed by bone marrow examination and cytogenetic analysis. it is important to exclude in vitro platelet agglutination as a cause for apparent thrombocytopenia. this can be an anticoagulant (edta)-dependent phenomenon so a repeat sample should be examined using citrate anticoagulant. rarely, platelet satellitism where the platelets clump round the neutrophils, can cause artefactual thrombocytopenia. anaemia affects nearly two billion people globally with a much higher prevalence in developing countries compared with more wealthy nations ( % vs %). the continents of africa (highest prevalence) and asia (greatest absolute burden) account for more than % of the anaemic population. anaemia burden is highest among children and women of reproductive age. anaemia contributes to more than maternal deaths and perinatal deaths globally per year. who have defined anaemia according to various haemoglobin concentrations (table . ) but the appropriateness of these thresholds has been questioned because there are wide variations in haemoglobin concentration among people of different races. the prevalence of anaemia can be a useful indicator of public health status of a nation because: • the prevalence of anaemia is objective and quantifiable • anaemia is a major complication of several infections, including malaria, hiv, tuberculosis, and the neglected tropical diseases, which are among the commonest problems in most tropical countries • the incidence of anaemia changes in a predictable fashion with alterations in disease burden • the prevalence of anaemia can be used to assess whether an intervention has reached the poorest communities. haemoglobin concentration of < g/l has been recommended for disease surveillance in high-prevalence countries where changes in haemoglobin are used for monitoring the impact of interventions. anaemia in tropical countries (box . ) is often due to infections but chronic health problems, such as diabetes and chronic respiratory disease, and cancer and related complications are increasing as causes partly due to lifestyle changes. the body to compensate for the drop in haemoglobin content. for this reason the haemoglobin level can drop to extremely low levels before symptoms develop. anaemia presents with symptoms such as exertional breathlessness, palpitations and in some cases, syncopal attacks. patients with chronic anaemia may also have a multitude of nonspecific symptoms including poor concentration, decreased work performance and easy exhaustion (table . ). a thorough history and clinical examination may provide clues about the cause of anaemia but further investigations are often necessary to confirm the diagnosis and guide treatment. however, in many resource-poor settings, access to routine biochemical and haematological testing is scarce, so much reliance is placed on clinical examination. the international guidelines for the integrated management of childhood illness recommend that a diagnosis of anaemia in sick children is based on the assessment of palmar pallor. for pregnant women, symptoms of fatigue and dyspnoea, combined with signs of conjunctival and palmar pallor, and increased respiratory rate suggest anaemia. however, making a diagnosis of anaemia based on clinical assessment alone is unreliable unless the anaemia is severe. no specific anatomical site is particularly accurate for the prediction of anaemia though sensitivity may be increased by using multiple sites. most central laboratories in low-income countries have automated haematology analysers and several manual methods exist for assessment of haemoglobin concentration, which are suitable for rural areas where there is no mains electricity (e.g. haemoglobin colour scale; hemocue technique). [ ] [ ] [ ] haemoglobin colour scale principle. the colour of a finger-prick blood sample, soaked into special chromatography paper, is compared with the clinical symptoms and signs of anaemia vary and depend on the cause and the speed of onset. a rapid drop in haemoglobin is much more likely to cause symptoms of anaemia than chronic anaemia. slowly developing anaemia allows time for in many cases, there will be more than one of these conditions coexisting in the same individual. an adequate response to the treatment of anaemia requires management of all the contributory factors. intrauterine growth. thus, low birth weight and prematurity are both associated with iron depletion in the postnatal period. several interventions have been suggested to improve infantile iron deficiency, including: [ ] [ ] [ ] • delayed cord clamping at delivery; the short delay of - minutes allows a small but important amount of blood to continue to flow to the foetus from the placenta • improvement of infant feeding practices • prevention and treatment of infectious diseases • interventions to prevent low birth weight, such as maternal nutritional supplementation, the control of infections and chronic health problems in pregnancy. anaemia in young children can be due to increased nutrition requirements during periods of rapid growth; these requirements may be up to times higher per kilogram of body weight than that of an adult male. in addition, infant and toddler diets often lack bio-available iron. a case-control study of preschool children in malawi with severe anaemia (haemoglobin concentration, < g/l) identified bacteraemia, malaria, hookworm, hiv infections and deficiencies of vitamins a and b as the commonest causes of anaemia. lack of folate and iron were uncommon. in low-income countries multiple interdependent causes of anaemia often operate in one individual so rectifying a single factor is unlikely to make a big impact on resolving anaemia. interventions which are useful in preventing anaemia in younger children include micronutrient supplementation (food fortification), de-worming, prevention and treatment of infectious diseases, school nutrition programmes and community-based nutrition promotion. who defines anaemia of pregnancy as a haemoglobin level less than g/l, or haematocrit less than %, at any time during pregnancy. about one-fifth of maternal mortality is attributable to anaemia in pregnancy and anaemia affects nearly half of all pregnant women worldwide. maternal anaemia is associated with many factors that might also be causally associated with mortality including poverty, infections and inadequate health-seeking behaviour. globally, the most important cause of anaemia in pregnancy is iron deficiency although hookworm, malaria, hiv infection, and deficiencies in folate and other micronutrients may contribute. pregnancy-associated complications, including septicaemia, pre-eclampsia and other obstetric problems can precipitate anaemia. it is important to note that a diagnosis of iron deficiency in pregnancy which relies on ferritin measurements may be misleading because of high-quality digital examples of known haemoglobin concentration. the colours are represented in g/l increments from g/l to g/l. this method is inexpensive, does not depend on skilled scientists, is durable in dusty, hot, dry and humid conditions and is probably better than clinical diagnosis for detecting mild and moderate degrees of anaemia. the disadvantages are that it requires specific chromatography paper and good natural light and it cannot detect changes in haemoglobin less than g/l. this is a small battery-or mains-operated machine, which uses a drop of blood in a plastic cuvette to produce a direct read-out of haemoglobin in a few seconds. it is simple to use, produces accurate and consistent results to one decimal place and it has an in-built quality-checking mechanism. the hemocue hb- has been specifically designed for tropical conditions and operates in temperatures up to °c, in dusty and humid conditions. however the recurrent costs associated with disposable plastic cuvettes mean there is little opportunity for cost-saving with high-volume workloads. the iron status of an infant is directly proportional to its body mass and blood volume, both of which are reflections of the major cause of anaemia in most of these cases is iron deficiency. some of the effects have been described in individuals with iron deficiency without obvious features of anaemia. there are three intervention strategies recommended by who to prevent anaemia in pregnancy: . weekly iron and folic acid supplementation in women of reproductive age . daily iron and folic acid supplementation during pregnancy . presumptive treatment of hookworm infection during pregnancy in areas where hookworm infection is known to be endemic. several factors may interfere with the efficacy of these interventions. under-participation in antenatal care may be common due to factors such as geographic distance, low motivation and poor interpersonal skills of health staff, poor quality of supplies and facilities, insufficient supply of iron and folic acid pills and womens' poor understanding about the daily use of supplements, especially in the face of common side effects. in sub-saharan africa, the acute shortage and high turnover of health workers, and lack of time have also been shown to contribute to ineffective antenatal measures for reducing anaemia. interestingly, a study from bangladesh showed that the first pills (whether taken on a daily basis or less frequently) yielded most of the benefit for raising haemoglobin levels, which suggests that currently recommended doses may be higher than necessary to achieve optimal outcomes, except when anaemia is very severe. the global burden of iron deficiency has been estimated from anaemia prevalence surveys, which include many different causes of anaemia so data may be unreliable as they are often not based on proven cases of iron deficiency. who estimates that globally % of women and % of pre-school children are affected by iron-deficiency anaemia, making it number of selected risk factors for preventable death and disability worldwide. iron deficiency begins in childhood, worsens during adolescence in girls and is aggravated during pregnancy. poor iron stores at birth, low iron content of breast milk and low dietary iron intake throughout infancy and childhood result in high prevalence of anaemia in childhood. anaemia is exacerbated by increased requirements during adolescence and iron loss from menstruation and is often compounded by the lack of adequate nutrition. the situation is worsened by pregnancy when iron requirement is approximately two times higher than in a nonpregnant state. iron deficiency should not be considered a diagnosis but a secondary outcome due to an underlying medical condition. although it may be a physiological response to rapid growth or increased requirements during childhood and pregnancy, it still requires treatment due to potential deleterious consequences. many of the chronic effects of iron deficiency may develop before the clinical and laboratory evidence of anaemia becomes apparent. the biochemical evidence for iron deficiency occurs in several steps. initially, iron stores in the bone marrow are depleted as reflected by a decreased serum ferritin. the total iron-binding capacity then starts to rise, while the serum iron saturation begins to fall before microcytosis and a drop in haemoglobin ensue. there have been attempts to identify this early iron deficiency before anaemia develops in order to improve neurological and psychomotor functions in children and work performance in adults through widespread iron supplementation. however, there are concerns that iron excess may promote infections, especially in malarious areas. a range of laboratory investigations are usually necessary if iron deficiency is suspected (table . ) - because once the diagnosis is confirmed, a search for the precise cause is necessary. a systematic approach to the investigation of iron deficiency (see below) is required based on an understanding of alterations in the iron absorption and transport cycle. • deficient intake (cow's milk has poor iron content and can cause gut blood loss in some infants) • rare defects of haem biosynthesis and iron transport. iron-deficient individuals may have no symptoms. excessive fatigue and other nonspecific signs of anaemia become more pronounced as anaemia develops. consumption of unusual 'foods' such as ice and paint or 'pica' only occurs in a minority of individuals. physical examination may reveal stomatitis, glossitis, koilonychia (spoon-shaped nails) and hair loss. oesophageal webs have been described in the plummer-vinson syndrome but are rare and may respond to iron replacement. since iron is important in neuromuscular development, several features of anaemia described in table . may be related to iron deficiency. treatment of iron deficiency is with dietary modifications and oral or parenteral iron. blood transfusions should be reserved for those with severe symptoms especially if the anaemia developed rapidly. haemoglobin levels alone should not be considered as a criterion for transfusion since very low levels (e.g. - g/l) may be appropriately treated with oral iron if anaemia has developed slowly. intravenous iron should only be considered in cases of poor response or intolerance to oral iron. cereals, poultry and green leafy vegetables, contain non-haem iron, which is often poorly absorbed. if dietary history suggests a deficiency, diet with foods rich in haem iron, such as red meat or liver should be recommended if social and religious customs and financial status allow, ideally with a drink containing vitamin c to facilitate iron absorption. absorption is also facilitated by taking supplements on an empty stomach although side effects of dyspepsia may not always allow this strategy. heavy tea intake can interfere with iron absorption and should be avoided. multivitamin or dietary supplements containing calcium, zinc or copper can also interfere with iron absorption. absorption may be delayed by tetracyclines, milk and soft drinks. since acid is necessary for iron absorption, antacids may account for a poor response to oral iron. iron is usually prescribed as a daily dose of - mg of elemental iron, commonly ferrous sulphate, tablet three times daily. the dose in children is - mg/kg per day split into divided doses. assuming good compliance and absorption, this should result in an increase in haemoglobin within weeks. once the haemoglobin is normalized, iron should be continued for months to replenish the iron stores. the major problem with oral iron is upper gastrointestinal side-effects, which can be dose-dependent. a reduction in the dose or change in the formulation to gluconate or fumarate or even liquid forms, may be successful. liquid iron preparations may stain the teeth and should therefore be taken through a straw. oral iron can also cause constipation or diarrhoea which is not dose-dependent. parenteral iron is best given intravenously because intramuscular iron is painful and has been associated with development of soft tissue sarcomas. high-molecular-weight iron dextran carries a low but significant risk of anaphylaxis, but the newer formulations including low-molecular-weight iron dextran, iron sucrose, ferumoxytol and iron gluconate have minimal risks. vitamin b or cobalamin deficiency is a well-recognized cause of macrocytic anaemia (box . ). although some microorganisms can synthesize cobalamin, humans need to obtain this essential vitamin from foods, mainly meat, poultry and dairy products. vitamin b is an essential co-factor in dna synthesis, serving as a co-factor in two key biochemical processes involving methylmalonic acid and homocysteine as precursors. consequently vitamin b deficiency can interfere with dna synthesis. clinical manifestations include haematological (megaloblastic anaemia and pancytopenia), and neuropsychiatric disorders (paraesthesia, peripheral neuropathy, psychosis and dementia) and an increased risk of cardiovascular disease because of hyperhomocystinaemia. [ ] [ ] [ ] a systematic approach to the investigation of vitamin b deficiency requires an understanding of the absorption cycle. ingested vitamin b is broken down in the acidic environment of the stomach. it binds to r-binders in gastric secretions and saliva which stabilize the vitamin b . in the alkaline environment of the small intestine, vitamin b is released from r-binders to bind to intrinsic factor, synthesized in the gastric parietal cells. this vitamin b -intrinsic factor complex is absorbed from the terminal ileum. recently, an alternative absorption system independent of intrinsic factor and the terminal ileum has been postulated which provides a rationale for mean cell volume useful as a diagnostic clue but not confirmatory can also be low in thalassaemia, sideroblastic anaemia and rarely lead poisoning can be falsely normal in the presence of iron deficiency in older people or with coexistent megaloblastic anaemia anaemia of chronic disease can occasionally cause microcytosis serum ferritin the most useful laboratory measure of iron status low value is diagnostic in the presence of anaemia very high values (> µg/l) usually exclude iron deficiency' being an acute-phase protein, it increases in inflammatory conditions, and certain malignancies, making it unreliable also increased in tissue damage especially of the liver levels are falsely decreased in vitamin c deficiency and hypothyroidism erythrocyte zinc protoporphyrin an intermediate in haem biosynthesis and elevated concentrations indicate interrupted haem synthesis due to iron deficiency when zinc is incorporated in place of iron can be measured on a drop of blood with a portable haematofluorometer small sample size makes it very useful as a screening test in field surveys, particularly in children, and pregnant women where inflammatory states may not co-exist red cells should be washed before measurement (serum bilirubin and fluorescent compounds like some drugs can give falsely high values) although not often done lead poisoning can give falsely high values rarely acute myeloid leukaemia and sideroblastic anaemia give slightly high values useful in that it is not increased in thalassaemias who recommends normal level > µmol/mol haem iron studies serum iron concentration represents the iron entering and leaving the circulation. its range varies widely with age, circadian rhythm, infections and iron ingestion total iron binding capacity measures iron bound to transferrin. raised levels are suggestive of iron deficiency transferrin saturation is the ratio of serum iron and the tibc expressed as a percentage -it is probably more useful in detecting iron overload rather than low levels. sensitive indicator that falls within days of onset of iron-deficiency reduced levels shown to be predictor of iron deficiency especially in the setting of renal insufficiency false normal values can occur when mcv is increased or in thalassaemia serum transferrin receptor it is not increased in inflammatory conditions may be upregulated by increased erythropoiesis (haemolytic diseases) giving falsely high values -serum transferrin receptor to ferritin ratio has been suggested in these cases bone marrow examination with special iron staining (perl's) absence of stainable iron in a sample that contains particles can establish the diagnosis without other laboratory tests a simultaneous control specimen containing stainable iron should also be assessed useful in differentiating from anaemia of chronic disorders or α-thalassaemia or milder forms of thalassaemia can help in identifying the sideroblastic anaemias (ring sideroblasts with perls stain), and some forms of congenital dyserythropoietic anaemia which can also cause microcytosis. an improvement in haemoglobin and clinical symptoms with iron replacement is probably the simplest way to diagnose iron deficiency. peripheral smear may help by demonstrating pencil cells, anisopoikilocytosis and high platelet number in cases of blood loss. the treatment of vitamin b deficiency can be by the oral or parenteral route. increasing evidence suggests that oral supplementation may be adequate even in the presence of malabsorption or pernicious anaemia. , the recommended initial oral replacement dosage is - mg but higher doses may be needed for malabsorption or pernicious anaemia. for patients with severe anaemia and/or neurological disease, daily or alternate day intramuscular injections should be initiated for the first - weeks before reverting to the maintenance threemonthly dose. reticulocytosis is an early marker of response to treatment and is noticeable within - weeks. folic acid deficiency causes similar haematological manifestations to vitamin b deficiency though neuropsychiatric manifestations are less common. the ability of nerve tissue to concentrate folate to levels five times greater than those in the plasma has been suggested as a reason for the absence of neuropathy in folate deficiency. folic acid deficiency is associated with fetal neural tube defects, and possibly with an increase in atherosclerosis and arteriovenous thrombosis, dementia and colonic cancer. dietary folic acid is present in the form of polyglutamates, which are converted to folate monoglutamates by the enzyme folate conjugase in the intestinal brush border, prior to absorption. the monoglutamates function as a carbon transporter and are essential for dna biosynthesis. folate is found in green vegetables and fruits and deficiency can result from decreased intake, impaired absorption and increased utilization, although the commonest cause is dietary insufficiency. in some wealthy countries, cereals have been fortified with folic acid to successfully prevent vitamin deficiency. however folate deficiency continues to be a problem in less wealthy countries and particularly among children and pregnant women. , exclusive feeding of goat's milk to infants can lead to folate deficiency. other causes include alcoholism, excessive cooking of vegetables, and malabsorption (e.g. abnormalities of the small bowel). increased demand for folic acid occurs in pregnancy because the growing foetus has a high avidity for folate. for this reason, folate supplementation has been widely recognized as an essential part of routine antenatal care to reduce the risks of neural tube defects. high folate utilization also occurs in haemolytic anaemias such as sickle cell disease due to high red cell turnover and exfoliative dermatitis. several drugs, including sulfasalazine, trimethoprim, methotrexate, pyrimethamine and phenytoin, can also interfere with folate metabolism. folate-deficient individuals develop a macrocytic anaemia with peripheral blood and bone marrow findings similar to that found in vitamin b deficiency. diagnosis of folate deficiency is confirmed by the presence of low serum folate. red cell folate levels decrease more slowly than serum levels during the -day turnover of the red cells. red cell folate levels may be a better indicator of tissue folate levels than serum folate, although red cell folate can be more expensive and falsely low in vitamin b deficiency. , treatment of folate deficiency is with oral folate ( mg daily) which is sufficient even in malabsorptive states. it is crucial that any co-existing vitamin b deficiency is ruled out before initiating folic acid therapy, otherwise the neurological manifestations of b deficiency may deteriorate rapidly. it is also important increasingly popular oral replacement therapies. once absorbed, vitamin b binds to transcobalamin ii to be transported around the body. the diagnosis of vitamin b deficiency is based on the measurement of serum vitamin levels in a patient with clinical evidence of deficiency. a note of caution is that folic acid deficiency can cause falsely low serum vitamin b levels. diagnostic clues for vitamin b deficiency include marked macrocytosis (often > fl), neutrophil nuclear hypersegmentation and oval macrocytes in the peripheral blood film. blood tests may demonstrate increased lactate dehydrogenase and low haptoglobin levels due to haemolysis within the bone marrow. the cause of the macrocytosis can be confirmed by bone marrow examination which reveals a megaloblastic picture. although macrocytic anaemia is a typical feature of vitamin b deficiency, it can be absent in older individuals who may only have neuropsychiatric features. measurements of methylmalonic acid and homocysteine levels, two markers which are very sensitive for detecting b deficiency, have shown that vitamin b deficiency can occur with normal haemoglobin levels and without macrocytosis. pernicious anaemia is probably the commonest cause of vitamin b deficiency. the presence of parietal cell or intrinsic factor antibodies supports a diagnosis of pernicious anaemia. [ ] [ ] [ ] [ ] schilling tests are rarely performed because of the unavailability of the radio-labelled vitamin b and the difficulty in interpreting the results in the presence of renal insufficiency. • pernicious anaemia (begins after ), increased risk of gastric carcinoma and carcinoid tumours • rare congenital disorders, e.g. imerslund-grasbeck syndrome. the neglected tropical diseases are a group of infections which are endemic in developing countries. several of these neglected tropical diseases cause anaemia and many can be managed using inexpensive interventions to treat the underlying parasitic infections. the mechanisms of anaemia in these conditions are predominantly blood loss from the gastrointestinal or genitourinary tracts but also poor nutrition, bone marrow suppression, inflammation, hypersplenism and haemolysis. anaemia is a common consequence of infections with soiltransmitted helminths or schistosoma with a strong correlation between haemoglobin level and worm load or faecal egg count. even mild infections can lead to anaemia. polyparasitism (i.e. infection with several parasites simultaneously) can be responsible for unresponsiveness of the anaemia to eradication of one organism. treatment of communities at high risk of soiltransmitted helminths improves growth and iron stores in children and reduces anaemia in pregnant women. the treatment of anaemia due to neglected tropical diseases depends on eradication of the parasite with drugs such as albendazole and praziquantel though anaemia resolution may be less successful if it is due to trichuriasis. - the addition of iron to anthelmintic treatment has met with variable success rates probably because there is associated anaemia related to inflammation. however it is still generally recommended that iron supplementation should be included with anthelmintic therapy in treatment programmes for neglected tropical diseases. [ ] [ ] [ ] introduction haemoglobin s (hbs) has a prevalence of - % in many parts of africa and also some areas in the middle east ( figure . ). hbs tends to be common among ethnic groups that have traditionally had high exposure to plasmodium falciparum malaria. in sub-saharan africa approximately infants are born with sickle cell disease each year, mostly with hbss. sickle cell disease (scd) is an autosomal recessive disorder characterized by production of an abnormal haemoglobin, sickle haemoglobin. sickle haemoglobin (hbs) arises from a mutation in codon of the β-globin gene resulting in replacement of the normal glutamic acid residue by a valine. scd is most commonly caused by the co-inheritance of two sickle cell genes (homozygous hb ss disease) but patients who are heterozygous for hbs and for another haemoglobin mutation such as hbc (haemoglobin sc disease) or β-thalassaemia (sβ and sβ + ) can also present with features of scd. ss disease and sβ disease are more severe than sc disease and sβ + disease (box . ). scd can affect multiple organs and its clinical course is punctuated by episodes of acute illness on a background of progressive organ damage, especially of the central nervous system and the lungs. the first description of scd was in in an anaemic grenadian dental student and over the next years it was that the underlying cause of folate deficiency is identified and treated. vitamin a is important in erythropoiesis, iron metabolism (enhances iron absorption and its release from stores to the bone marrow) and for decreasing the risk of infections. vitamin a deficiency is a major public health problem in lowincome countries, with an estimated million preschool children affected. pregnant women and women of childbearing age also constitute high-risk groups for vitamin a deficiency. vitamin a given to thai school children with conjunctival xerosis led to a significant increase in haemoglobin level and in anaemic school children in tanzania, vitamin a supplementation produced a marked increase in haemoglobin which was enhanced by co-administration of iron. vitamin a can also improve anaemia in pregnant women, depending on the local prevalence of deficiency [ ] [ ] [ ] [ ] though the response may be suboptimal in pregnant women infected with hiv. copper is a trace element necessary for normal haematopoiesis and myelopoiesis. anaemia in copper deficiency is due to decreased activity of the copper-dependent enzymes, hephaestin, ceruloplasmin and cytochrome c oxidase. these are important in ferrous-ferric iron conversions and their decrease leads to abnormalities in iron absorption and its incorporation into the haemoglobin molecule. acquired copper deficiency occurs with malnutrition and gastrointestinal malabsorption syndromes. coeliac disease, cystic fibrosis and individuals who have had gastrectomy or surgery resulting in 'short bowel' are also at risk. copper deficiency has also been described in persons ingesting excessive amounts of zinc-containing supplements and those who have swallowed zinc-containing coins. , anaemia related to copper deficiency is normocytic or macrocytic and can be associated with neutropenia; thrombocytopenia is rare. bone marrow findings are characteristic with cytoplasmic vacuolization of both erythroid and myeloid precursor cells with ringed sideroblasts and an unusual finding of iron granules in plasma cells. these findings may be misdiagnosed as myelodysplastic neoplasm. measurement of serum copper levels is helpful in confirming the diagnosis although the test is fairly insensitive. since almost complete haematological recovery can occur with copper replacement, this may be a useful diagnostic test. oral copper supplements can be started with mg of elemental copper a day slowly decreasing over the next few weeks to mg until a good response is noted. although low zinc levels do not cause anaemia they have been linked to growth retardation, heightened susceptibility to infection and male hypogonadism in relation to sickle cell disease. zinc deficiency has been described in nearly half of children and % of adults with sickle cell disease possibly due to increased loss of zinc in the urine and high cell turnover with decreased dietary intake. in contrast zinc excess can cause anaemia through interference with copper absorption by sequestering it in the gut lumen. for this reason, zinc compounds have been used to treat wilson's disease which is characterized by copper excess. however repeated sickling and unsickling eventually causes irreversible changes, so early management to avoid repeated crises is important to prevent disease progression. polymerization, and therefore the clinical features of scd, are influenced by three main factors ; hypoxia, the intracellular hbs concentration and the co-existence of other genetic haemoglobin abnormalities (e.g. α-thalassaemia or hereditary persistence of fetal haemoglobin-haemoglobin f). sickled red cells lead to vaso-occlusion and haemolysis due to the entrapment of sickled erythrocytes in the microvasculature and upregulation of adhesion receptors. , , white blood cells contribute to this process by providing an inflammatory discovered hypoxia led to red cell sickling scd arises from the tendency of hbs to polymerize in hypoxic states. this phenomenon occurs where there is deoxygenation and is due to the binding between β and β chains of two haemoglobin molecules, a property unique to haemoglobin variants that have the glu- -val substitution. the polymerized haemoglobin fills the erythrocyte and deforms its architecture and flexibility to form a sickle shape. this alteration in the structure promotes cellular dehydration, , , upon reoxygenation, the polymers dissolve thus reversing the sickling process. exposure to cold, fever, menstruation, alcohol intake and dehydration can precipitate pain crises. unlike acute pain crises, chronic pain in scd usually has an identifiable basis such as femoral head necrosis, osteoarthritis or chronic skin ulcers. sickle erythrocytes have an average life span of days and anaemia can be due to several causes (box . ). red cell haemolysis causes anaemia and gall stones and can cause fatigue out of proportion to the anaemia. , there are suggestions that patients with low haemoglobin concentrations and high haemolytic rates are more likely to develop vascular problems compared with those with higher haemoglobin concentrations. splenic sequestration with a sudden rapid drop in haemoglobin occurs in those who have not yet developed autosplenectomy so it can occur in young children with hbss and adults with hbsc disease or sickle cell-β + -thalassaemia. treatment may require blood transfusion and in rare cases, sequestration can be fatal. splenectomy may be needed for recurrent severe sequestration. parents can be taught to feel their infant's abdomen for an enlarging spleen and report to hospital if there is a sudden increase in spleen size. red cell aplasia can develop due to secondary parvovirus infection which has a predilection for erythroid progenitors. alloimmunization is common in scd patients who have had frequent transfusions so, if possible, extended red cell phenotyping should be undertaken. hyperhaemolytic crisis is suspected when there is sudden exacerbation of anaemia with increased reticulocytosis and bilirubin level. infectious complications of scd are a major cause of morbidity and mortality, even with adequate vaccination and prophylactic antibiotic regimens. this propensity to infection is related to impaired splenic function although tissue ischaemia, especially in the lungs and renal system, can contribute. hyposplenism is demonstrable in the peripheral blood film by the presence of howell-jolly bodies. most children with scd have undergone autosplenectomy by the age of years and therefore have increased risk of infection from encapsulated microorganisms. typical infectious complications include pneumococcal sepsis, neisseria meningitis, osteomyelitis caused by salmonella species, urinary tract infections and pyelonephritis due to escherichia coli. anatomical abnormalities such as renal papillary necrosis can predispose to urinary complications which may require long-term antibiotics. acute chest syndrome (acs) is defined as a new pulmonary infiltrate on the chest radiograph combined with one or more environment. activation of platelets and the coagulation system also contribute to the vaso-occlusion in scd. [ ] [ ] [ ] [ ] [ ] infants with scd are protected during the first few months of life by the high levels of haemoglobin f in the red cells. anaemia usually develops by months. at all ages, chronic haemolysis of abnormal red cells means that scd is associated with steady state haemoglobin levels of - g/l. although any organ can be affected by scd and complications can occur at any age, certain features tend to predominate in different age groups (box . ). pain is the hallmark of scd and four different patterns of pain have been described with scd each with different underlying mechanisms: • vaso-occlusive (acute and intermittent) • pain from bone and tissue necrosis (chronic) • neuroplasticity (chronic, neuropathic) -functional brain changes • opioid-induced hyperalgesia (acute or chronic). painful crises often start in young children as dactylitis or handfoot syndrome, in which painful swelling of the hands and feet results from the inflammation of metacarpal and metatarsal periosteum. these crises are the result of vaso-occlusion of the bone marrow causing bone infarction and release of mediators that activate pain receptors. the number, severity and frequency of painful episodes vary widely in individuals. half may never have any episodes whereas about % may need hospital admission up to times a year. more than three pain episodes requiring hospitalization per year is associated with increased mortality among patients over years old. in under-resourced settings, hospital visits underestimate the frequency of pain box manifestations such as fever, cough, sputum production, tachypnoea, dyspnoea or new-onset hypoxia. acs is the most common cause of death in scd patients and a frequent cause of hospitalization, second only to painful crisis. mortality in patients with acs in a wealthy country setting is % in children and . % in adults. the peak incidence for acs is - years of age and gradually declines to . per patient-years in subjects older than years. , fever and cough are more common in children with acs and chest pain and dyspnoea are more common in adults. acs is often preceded by febrile pulmonary infection in children and by vaso-occlusive pain crisis and lung infarction in adults. it is important to note that although tachypnoea, wheezing and features of chest infection may be identified, a third of the patients may have a normal physical examination. more than one-third of patients with acs are hypoxaemic (oxygen saturation < %). chest radiography is essential although infiltrates may lag behind clinical symptoms by up to days. repeat chest x-rays are recommended if there is a strong clinical suspicion of acs. bilateral infiltrates or involvement of multiple lobes may predict a poorer prognosis. risk factors for acs (box . ) include fat embolus which can be confirmed by finding stainable fat in pulmonary macrophages. chronic complications such as pulmonary hypertension occur in as many as % of patients and do not appear to be associated with prior episodes of acs. high serum phospholipase a , and the surrogate marker c-reactive protein, have been noted in patients admitted with vaso-occlusive crisis - hours before the development of acs. , stroke neurological complications occur in at least % of patients with scd and scd is one of the most common causes of stroke in children. , in scd, the risk of having a first stroke is % by the age of , % by age years and % by age years. both thrombotic and haemorrhagic strokes occur, although the former is more common in children and those over years of age, whereas the latter is more common between the ages of and years. this age-specific pattern may be related to the higher cerebral flow rates in early childhood. although the prevalence of clinically overt stroke is of the order of %, clinically silent infarction, detectable by magnetic resonance scans, affect nearly double this number by the age of . silent infarcts are associated with cognitive impairment and the majority of these children require lifelong specialist care. cerebral thrombosis, which accounts for - % of all strokes in scd, results from large-vessel occlusion whereas silent infarcts are the result of microvascular occlusion or thrombosis or hypoxia secondary to large-vessel disease. in a third of scd patients, major-vessel stenosis is accompanied by collateral vessels that appear as 'puffs of smoke' (moyamoya) on angiography. risk factors for ischaemic strokes in scd include increased cerebral blood flow velocity, previous silent infarcts, nocturnal hypoxaemia, severe anaemia, acute chest syndrome and elevated systolic blood pressure. an elevated leukocyte count is a risk factor for haemorrhagic stroke. [ ] [ ] [ ] [ ] diagnosis often the family history and clinical findings clearly point towards a diagnosis of scd and during an acute crisis, abundant sickled red cells can be seen on a blood film. white cell counts are higher than normal in scd disease, particularly in patients under age years. the presence of sickle haemoglobin in different sickle syndromes (e.g. hbas, hbss, hbsc) ( table . ) can be confirmed by a simple sickle slide or solubility test. haemoglobin electrophoresis will distinguish between many of these variants but high-performance liquid chromatography and iso-electric focusing are preferred for a definitive diagnosis. haemoglobin mass spectrometry and dna analysis are being increasingly used. antenatal screening is available to women in some countries to help to identify couples who are at risk of having a baby with scd. community acceptance of reproductive genetic services however depends on the effectiveness of education and counselling. the use of prophylactic penicillin and the provision of comprehensive medical care during the first years of life have reduced mortality related to scd from % to less than %. management (box . ) individuals with scd are best managed by a multidisciplinary team as they may require a variety of specialist inputs including haematology, ophthalmology, nephrology, obstetrics, orthopaedics and physiotherapy. the cornerstones of scd therapy are disease modification and prompt and effective management of crises. severe pain crises generally require intravenous fluids and adequate, often opiate, analgesia (box . ), while disease modification is based on interventions to increase hbf levels. in steady state it is usual practice to give sickle cell patients folate supplements ( - mg/day) because their high rates of haemopoiesis put them at risk of deficiency. scd is associated with functional asplenia so patients should also receive prophylactic oral penicillin ( mg twice a day) and vaccinations against encapsulated organisms. hydroxycarbamide is the main agent used to increase hbf (box . ) and is associated with significant reductions in acute pain crises, hospitalization rate, time to first and second pain crises, episodes of acute chest syndrome, and the need for transfusions and the number of units transfused. other beneficial effects of hydroxycarbamide, which are independent of the increase in hbf, include reduced neutrophil count, increased cellular water content, decreased hbs concentration, changing expression of adhesion molecules and nitric oxide generation. hydroxycarbamide may also be an alternative to frequent blood transfusions for the prevention of recurrent stroke in children as it can lower transcranial doppler velocities. , under-use of this cheap, effective drug is related to concerns about leukaemogenicity but this has not been shown to be a problem when used for a non-malignant condition like scd. the two main approaches to transfusion in scd are simple top-up transfusion and exchange transfusion. target haemoglobin level in scd therapy is g/l or a haematocrit of %; higher target levels are associated with hyperviscosity and box . management of complications of sickle cell disease • inability to maximally concentrate urine (hyposthenuria) in response to water deprivation is an early finding • renal tubular acidosis • increased urinary tract infections • glomerular hyperfiltration, increased creatinine secretion, and a very low serum creatinine are characteristic of young patients with sickle cell anaemia, so renal dysfunction can be present even with normal serum creatinine values • microalbuminuria is common in childhood and up to % of adults develop nephrotic-range protein loss • gross haematuria can develop due to microthrombin in renal vessels, renal medullary carcinoma, and nocturnal enuresis • treatment is based on the early use of hydroxycarbamide and angiotensin-converting enzyme inhibitors in children with clinically significant albuminuria. • noted in up to % of scd cases • no relationship to acute chest syndrome (different pathophysiology) • mortality risk with even mild pulmonary hypertension is high • regular blood transfusions and long-term anticoagulation have been tried • hydroxycarbamide may decrease the risk • prostacycline analogues (epoprostenol, and iloprost), endothelin- receptor antagonists (bosentan), phosphodiesterase inhibitors (including sildenafil), and calcium channel blockers are being evaluated. • brief but recurrent (stuttering); may occasionally last for many hours and can lead to impotence • usually ischaemic, or low-flow, priapism • patients should be educated to seek medical attention if more than hours duration • detumescence within hours is necessary to retain potency • intravenous hydration and analgesia initially with consideration for α-adrenergic agonists (etilefrine or phenylephrine) • penile aspiration and irrigation with saline and α-adrenergic agents or shunting may be required in severe cases in combination with an exchange transfusion. • assess pain intensity • choose the analgesic, dosage, and route of administration • paracetamol and hydration should be considered in all patients • oral, sustained-release morphine is as good as intravenous morphine infusion in children and young adults • manage mild pain with rest, hydration, and weak opioids (such as codeine). admit patients in whom pain that does not subside promptly or require opioid treatment; fever, pallor, or signs of respiratory compromise; a low likelihood of receiving appropriate care at home • pain management should be individualized and dosing should take into account prior pain management and use of opioids • the pain pathway should be targeted at different points with different agents, avoiding toxicity with any one class • always look for a cause, e.g. infection, dehydration, etc. • education about avoiding exposure to precipitants • be empathetic, reassuring, and supportive • benzodiazepines may be helpful to reduce anxiety • re-examine the patient often to ensure adequate pain relief, to assess sedation and respiratory rate (to avoid opioid overdose). in assessing patient responses to conventional doses of analgesia, it must be remembered that those with sickle cell disease metabolize narcotics rapidly • re-search for evidence of any complications such as acute chest syndrome or anaemia • always look for a cause, e.g. infection. of multi-organ failure. both simple transfusion and exchange transfusions have been used and neither appears to be superior. a short course of steroids may attenuate acs but it may also increase the risk of re-hospitalization. bronchodilators may help patients with wheezing but inhaled nitric oxide has not shown any clear benefits. since coagulation activation is important in the pathophysiology of acute chest syndrome, treatment with low-molecular-weight heparin may reduce clinical complications. transcranial doppler measurement of cerebral blood flow has been a major step forwards in identifying individuals with an increased risk of ischaemic stroke. a value more than cm/ second imparts a % risk of stroke within the next years. regular blood transfusions can reduce the incidence of stroke in children. due to a high recurrence of stroke ( %) on stopping transfusions, continuation of transfusions should be guided by transcranial doppler measurements. , once a stroke has developed, the best therapeutic strategy is exchange transfusion which probably needs to be done monthly. , neurosurgical re-vascularization should be considered for moyamoya-like syndromes when new strokes occur despite transfusion. haemoglobin sc results from the co-inheritance of hbs and hbc and has its highest prevalence in west africa. clinical features and disease management are similar to those of hbss disease but splenomegaly, splenic infarcts and splenic sequestration may occur into adulthood. proliferative retinopathy necessitates regular ophthalmic review in those aged over years. compared with hbss, anaemia is less marked in hb sc ( - g/l) and there are fewer sickle cells and more target cells on the blood film. the diagnosis can be confirmed by haemoglobin electrophoresis, hplc or iso-electric focussing. worsening of complications. in exchange transfusion, the aim is to achieve an hbs% of < %. complications of transfusion in scd include alloimmunization, delayed haemolytic transfusion reactions and iron overload. the high rates of red cell antibody formation ( %) noted in wealthy countries are due to minor blood group incompatibilities between the recipient and the blood donor who is often of a different ethnicity. leukocyte reduction of transfused blood, routine abo, rh and kell matching for all patients and extended phenotype matching for those with alloantibodies may be useful for reducing transfusion reactions. treatment for acs is predominantly supportive and includes adequate pain relief, antibiotics (e.g. a macrolide with a cephalosporin), continuous pulse oximetry and delivery of supplemental oxygen to patients with hypoxaemia. incentive spirometry can prevent atelectasis and infiltrates and blood transfusion is indicated when a patient develops respiratory distress, a clinically significant fall in the haematocrit or signs the following predict a more severe clinical course and are additional reasons to consider offering hydroxyurea: hb < g/l, wbc > × /l, hbf < % and renal insufficiency due to scd. • start at - mg/kg per day (to the nearest mg/day) • if no or poor response, increase dose by increments of mg/ kg per day every weeks (max: mg/kg per day). most good responses require about - g/day in adults • monitor fbc, hbf%, and reticulocytes every or weeks initially, then every weeks when on a stable dose • monitor biochemistry profile (hydroxyurea has renal excretion and hepatic toxicity). • less pain • persistent increase in hbf (usually measured every - weeks) or mean cell volume • persistent increase in haematocrit if severely anaemic • decrease in ldh • acceptable toxicity. improvement in symptoms and blood parameters may take - months of therapy, but can be seen after approximately weeks. if the reticulocyte count is less than expected for the degree of anaemia, erythropoietin deficiency should be considered. • aim in all cases to reduce hbs level to < % • exchange transfusions may be considered in cases of stroke, acute chest syndrome not responding to top-up transfusion and major surgeries • target haemoglobin concentration of g/l may be considered in cases of organ failure and surgery. individuals with sickle cell trait (hb as) have -fold protection against severe malaria compared to individuals with normal haemoglobin (hbaa) probably due to both innate and immune-mediated mechanisms. individuals with sickle cell trait (hbas) are generally asymptomatic and they have a normal haemoglobin and normal life expectancy. uncommonly, complications such as poor perfusion of the renal papillae and increased bacteruria may occur. the blood film is generally normal and the diagnosis can be confirmed by haemoglobin electrophoresis, hplc or iso-electric focusing. the original descriptions of thalassaemia originated from areas round the mediterranean and the term derives from the greek thalassos (sea) and haima (blood). [ ] [ ] [ ] epidemiology thalassaemia is one of the most common single gene disorders and approximately - % of the global population are carriers. α + -thalassaemia occurs throughout the tropics, whereas α thalassaemia, which is responsible for haemoglobin bart's hydrops fetalis, is concentrated predominantly in south-east asia and to a lesser extent around the mediterranean. , β-thalassaemia is common in the mediterranean countries, parts of africa, throughout the middle east, the indian subcontinent and south-east asia. haemoglobin e prevalence is highest in cambodia, laos and thailand and can reach - % with lower prevalence rates in indonesia, malaysia, singapore and vietnam. β-thalassaemia β-thalassaemia is an inherited quantitative deficiency of β-globin chains which are required to make normal adult haemoglobin. more than mutations have been associated with the development of β-thalassaemia (a complete list is available at the globin gene server website, at: http://globin.cse. psu.edu) and they affect protein synthesis , leading to reduced (designated β + ) or absent (designated β ) production of the β-globin chains. the clinical severity of thalassaemia can be lessened by co-existing haemoglobin abnormalities such as the co-inheritance of α-thalassaemia and increased production of haemoglobin f. , α-thalassaemia normal α-globin synthesis is regulated by duplicate α-globin genes on chromosome . the genotype is usually represented as αα/αα and α-thalassaemia usually results from deletion of one or both α-genes. occasionally point mutations in critical regions of the α-genes may cause non-deletional α-thalassaemia (α t ). mutations can completely abolish expression of the αgenes (i.e. α -thalassaemia) or partially down-regulate expression (α + -thalassaemia). both α and α + thalassaemias can occur in the heterozygous or homozygous state or as a compound α /α + heterozygote form (table . ). underproduction of α-globin chains due to three or four gene deletions gives rise to excess γ (fetal) or β (adult) globin chains which form tetramers, called hb bart's (fetal) or hbh (adult). rare forms of α-thalassaemia occur in association with other conditions such as mental retardation and myelodysplastic/ leukaemia syndrome. , pathophysiology β-thalassaemia (figure . ) thalassaemias , , cause an imbalance of αand β-globin chain synthesis. in homozygous β-thalassaemia, excess α-chains precipitate in the red cell precursors and up to % of cells are destroyed in the bone marrow resulting in ineffective erythropoiesis and a shortened red cell survival. the red cells released from the bone marrow contain abnormal α-chains and these inclusions promote destruction of the cells by the spleen leading to clinical symptoms and signs of haemolysis. in heterozygotes, the α-chain excess and the degree of inadequate erythropoiesis is much less than in homozygous β-thalassaemia. hbf production normally tails off within a few months of birth but in β-thalassaemia hbf production can continue into adulthood. the effect of increased hbf production is to prevent precipitation of the excess globin chains and consequent ineffective erythropoiesis. however hbf has a high oxygen affinity, which can lead to increased erythropoietin production and thus, increased bone marrow expansion. the pathophysiology of α-thalassaemia, and hence the clinical manifestations, is quite different from β-thalassaemia. the excess non-α-globin chains form soluble tetramers rather than precipitates so there is only minimal ineffective erythropoiesis. the only clinical abnormality in those with hbh may be splenomegaly secondary to increased work load from destruction of red cells containing inclusions. rarely anaemia may be severe enough to require blood transfusions. classification of α-thalassaemia divide β-thalassaemia into thalassaemia major (transfusiondependent), thalassaemia intermedia (able to maintain adequate haemoglobin without transfusions or requiring less than units/year) and thalassaemia minor (asymptomatic). infants with β-thalassaemia are protected from severe anaemia by the presence of haemoglobin f and are usually asymptomatic. clinical manifestations of thalassaemia major depend on whether adequate blood transfusions are available and the stringency with which iron chelation is undertaken. untreated patients with thalassaemia major will die in late infancy or early childhood from the effects of severe anaemia. those who receive sporadic transfusions may survive longer but suffer from the secondary effects of anaemia, bony deformities and growth retardation. the clinical features of β-thalassaemia major are divided into those resulting from anaemia, bony changes and iron overload. anaemia from defective erythropoeisis, decreased red cell survival and increased haemolysis in thalassaemia major leads to cardiac decompensation, failure to thrive and growth retardation in children. splenomegaly, from the increased work load of culling red cells with inclusion bodies, can cause dilutional anaemia and a further drop in haemoglobin. compensatory extra-medullary haematopoiesis can lead to hepatomegaly and occasionally vertebral compression and neurological defects. haemolysis from increased red cell destruction is associated with gall stones in up to % of individuals with β-thalassaemia. another consequence of accelerated haemolysis is the increased incidence of thromboembolism ( % in thalassaemia major and % with intermedia) from the exposure of negatively charged phospholipids on the red cell membrane and the generation of red cell and platelet microparticles. splenectomy with postoperative thrombocytosis is a risk factor for thrombosis especially if combined with endothelial oxidative stress from iron overload, or procoagulant co-morbid conditions such as diabetes mellitus, hormone therapy, thrombophilic mutations and atrial fibrillation. folate deficiency, hyperuricaemia and occasionally gout have been observed in thalassaemia major due to the high turnover of red cells. the enhanced erythropoietic drive from anaemia in thalassaemia can lead to increased marrow expansion with in homozygous β-thalassemia, β-globin synthesis is markedly reduced or absent. the excess α-chains cannot form a tetramer but form a precipitate in the red cell precursors leading to intra-medullary destruction of these cells. this destructive process of the red cell membrane occurs from the formation of α-chain hemichromes (shown as red cell inclusions) and degradation products of the excess α-chains. the red cells which may be released from the bone marrow are destroyed by the spleen leading to clinical symptoms and signs of haemolysis. since only the β-chain is affected in these individuals, the synthesis of hbf and hba continues unabated. these haemoglobins have very high oxygen affinity, which can lead to increased erythropoietin production and thus, increased bone marrow expansion splenomegaly, which may be massive, and growth retardation in children. bony changes are unusual. other complications include infections, leg ulcers, gall stones and acute haemolysis in response to drugs and infections. the severity of the clinical features is related to the molecular basis with non-deletional types of hbh disease more severely affected. haemoglobin bart's (−/−) occurs almost exclusively in asians, especially chinese, cambodian and thai populations. an infant with hb bart's hydrops fetalis syndrome has pallor and gross oedema with signs of cardiac failure, marked hepatosplenomegaly and skeletal and cardiovascular deformities. there is often gross hypertrophy of the placenta. many of the clinical manifestations of this condition can be explained by the characteristic bossing of the skull and overgrowth of maxillary region, radiologically noted as 'hair on end' or 'sun-ray' appearance. metatarsal and metacarpal bones are the first to expand so measurement of the metacarpal bones has been considered a good indicator for initiation of transfusion therapy. other skeletal deformities include shortening of long bones due to early epiphyseal fusion and overgrowth of the maxilla causing dental malocclusion. the marrow expansion can also lead to pathological fractures, early bone thinning and osteoporosis , while ineffective drainage of the sinuses and middle ear from skull bone overgrowth can cause chronic sinus and ear infections. growth retardation is primarily the result of anaemia with contributions from iron overload, hypersplenism, deficiencies of thyroid and growth hormone, hypogonadism, zinc deficiency, chronic liver disease, malnutrition and psychosocial stress. patients with β-thalassaemia have increased iron absorption mediated by reduced hepcidin and those who receive regular transfusions may also develop transfusion siderosis if they are inadequately chelated. the iron is deposited in the parenchymal tissues with a variety of clinical consequences (box . ), [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] a process which may be modulated by variants in the haemochromatosis (hfe) gene. thalassaemia intermedia is characterized by haemoglobin concentrations of - g/l and children usually present at around - years of age with symptoms of anaemia, jaundice and hepatosplenomegaly. there may also be skeletal changes such as expansion of the facial bones and obliteration of the maxillary sinuses. several molecular factors including: (a) coinheritance of α-thalassaemia; (b) hereditary persistence of haemoglobin f; (c) δβ-thalassaemia and (d) the specific gγxmn polymorphism contribute to the 'conversion' of thalassaemia from major to intermedia type. in contrast to patients with thalassaemia major, iron loading in thalassaemia intermedia occurs mainly as a result of increased intestinal iron absorption rather than transfusion therapy. ineffective erythropoiesis with resultant chronic anaemia and hypoxia can suppress hepcidin, the regulator of iron metabolism, leading to increased iron absorption. the excess iron tends to accumulate in the liver rather than the heart. other clinical complications in thalassaemia intermedia include gallstones, extramedullary haemopoiesis leg ulcers, thromboembolic events and pulmonary hypertension, which is the major cause of heart failure in these individuals. although individuals with thalassaemia intermedia do not usually need regular blood transfusions, there is some evidence that complications, particularly later in life, may be less common in regularly transfused patients. α-thalassaemias , carriers of α-thalassaemia (traits, with loss of or α genes) are usually asymptomatic and may only be detected through a routine blood count which shows mild to moderate microcytic, hypochromic anaemia. antenatal counselling may be indicated if the mother has αα/− as there is a possibility that the fetus may be at risk of having haemoglobin bart's. haemoglobin h disease occurs mainly in asians and occasionally in the mediterranean population. it is the result of deletion of three α genes (α−/−) and can produce anaemia varying from - g/l. there is usually associated • hypogonadism is the most frequent complication in patients with prevalence over % in both males and females. it is usually hypogonadotrophic suggesting iron damage to the anterior pituitary or hypothalamus. the features range from total absence of sexual development to delayed puberty. in females with normal menstrual function, fertility is normal with the ovarian function preserved in most although secondary amenorrhoea can develop. damage of the ovaries is rare and is more likely to appear in older women (around ) because of high vascular activity on the ovaries at this age. secondary hypogonadism is common ( %) in older men. serum ferritin > ng/ml is a risk factor. • hypothyroidism is the second most common endocrine disorder (about %) although many of them may have the subclinical variety. most commonly hypothyroidism is of the primary type with secondary, central hypothyroidism increasingly being diagnosed in recent years. • the prevalence of diabetes mellitus is around % with the mean age of diagnosis being years. impaired glucose tolerance occurs first with microvascular damage like retinal changes being less common than the conventional form. erythroid precursor destruction. osmotic fragility is reduced, sometimes strikingly so since in some cases the red blood cells do not haemolyse even in distilled water. for this reason, if sophisticated tests are not available, osmotic fragility can be used as a screening test for thalassaemia trait. serum zinc levels may be low and this may be related to abnormal growth. vitamin c levels may also be low due to its increased conversion to oxalic acid in the presence of iron overload. care may be needed if folic acid is commenced on a background of bone marrow failure due to folate deficiency as it may precipitate painful erythropoietic crises. management a comprehensive management plan for patients with thalassaemia may involve transfusion therapy, iron chelation, splenectomy, prevention or early treatment of complications and stem cell transplant. the mainstay of treatment for the severe forms of thalassaemia is blood transfusion with the aim of reducing anaemia and erythropoietic drive. however, in many low-income settings blood supplies are inadequate and many thalassaemic patients are chronically under-transfused (table . ). transfusion frequency should be guided by clinical symptoms and signs such as poor growth and facial or other bone abnormalities, and should take into account any potential disease-modifying comorbidities. although the decision to transfuse should not be based purely on haemoglobin levels, a value of < g/l is often used as a trigger for regular transfusions. to prevent alloimmunization, extended red cell antigen typing for c, e and kell in addition to abo and rh(d) typing should be carried out prior to the first transfusion, and before each transfusion, full cross-match and screening for new antibodies should be undertaken. the risk of alloimmunization appears to be greater in patients who begin transfusion therapy after the first few years of life. development of alloantibodies and autoantibodies may result in increased transfusion requirements or haemolysis. use of leukodepletion techniques can result in less alloimmunization and fewer febrile transfusion reactions. since storage of red cells in anticoagulant solutions may decrease their efficacy, the use of blood that has been stored for less than - days may be beneficial for patients who require frequent transfusions. the use of st-degree relatives as blood donors should be discouraged, especially if the patient is a candidate for stem cell transplant. patients with thalassaemia major need lifelong regular blood transfusions, ml/kg per month or - units of blood every - weeks, to maintain the pre-transfusion haemoglobin level above - g/l. the clinical benefits of this regular transfusion programme include normal growth, suppression of erythropoiesis and bone marrow expansion, reduced hepatosplenomegaly and an overall sense of wellbeing, which allows normal age-appropriate activities. a higher target pretransfusion haemoglobin level of - g/l may be necessary for patients with heart disease or other medical conditions and for those patients who do not achieve adequate suppression of bone marrow activity at the lower haemoglobin level. shorter intervals between transfusions may reduce overall blood requirements but need to be balanced against the patient's work or school schedule and other lifestyle issues. iron chelation therapy , has improved survival rates for thalassaemic patients, and prevented hepatic fibrosis and ironinduced cardiac disease; most patients who are compliant with chelation therapy have normal growth and sexual development. iron chelators (box . ) are usually initiated in children over years who have received units of blood and/or have a steady-state serum ferritin level above ng/ml on at least two occasions. this level of iron overload typically occurs after - years of transfusions. desferrioxamine is started at - mg/kg per day in these children initially, to avoid toxicity due to over chelation. marked splenomegaly, often treated with splenectomy, was common in thalassaemia patients before the advent of regular transfusion programmes. severe haemolysis in thalassaemia is related to a hyperactive spleen, which aggravates anaemia and can increase transfusion requirements. although early the initiation of regular transfusion therapy for severe thalassaemia usually occurs in the first years of life. some patients with thalassaemia intermedia who only need sporadic transfusions in the first two decades of life may later need regular transfusions because of a falling haemoglobin level or the development of serious complications. haemoglobin should be monitored to assess the rate of fall in the haemoglobin level between transfusions and this can be used to indicate the frequency of transfusions. exchange transfusions have been tried as a way of reducing iron loading and are associated with a reduction in blood requirements by about one-third. (table . since each unit of red cells can contain up to mg of iron, cumulative iron burden is an inevitable consequence of a longterm transfusion programme. in addition there is increased iron absorption from the gut ( . - . mg/kg per day) as a response to severe anaemia and down-regulation of hepcidin. transfusion therapy can avert splenomegaly, hypersplenism still can develop, usually in children between and years of age. in these individuals, splenectomy can limit the complications from extramedullary hematopoiesis. splenectomy should be considered when the annual transfusion requirement reaches - ml red blood cells/kg per year and usually results in a halving of the transfusion requirements. splenectomy complications include opportunistic infections with encapsulated organisms. patients should therefore receive appropriate vaccinations preoperatively and should be advised to seek medical advice at the first sign of infection. it is advisable to delay splenectomy until patients are at least years old because of the increased risk of overwhelming sepsis below this age. thalassaemia patients can develop thromboembolic complications and pulmonary hypertension after splenectomy so partial splenectomy and splenic embolization have been attempted to minimize these complications but have not been studied in large trials. iron overload can occur in any organ in thalassaemia patients but particularly affects the heart, liver, the endocrine system, the bone and occasionally the pancreas and lungs. iron overload needs to be detected early and treated to prevent long-term damage. annual assessment of the iron loading of the liver and heart can be achieved using non-invasive methods such as magnetic resonance scanning to detect early changes. children should have regular growth and endocrine assessments and appropriate investigations should be carried out if there are any signs of developmental delay or hormonal deficiencies. osteoporosis is increasingly being recognized and should be prevented by ensuring adequate dietary calcium intake and sun exposure. vitamin supplementation with folic acid, zinc, vitamin e and vitamin c may be useful although the combination of vitamin c and desferrioxamine carries a risk of cardiac toxicity. allogeneic stem cell transplant , is currently the only means of curing thalassaemia. the outcome in carefully selected patients, measured by overall event-free survival, is around % with a transplant-related mortality of %. hepatomegaly, liver fibrosis, and inadequate iron chelation therapy predict a poor outcome. the best results from transplant have been obtained with hla-matched siblings. umbilical cord blood is a useful source of stem cells for young children. other potential treatment options for thalassaemia are outlined in box . . [ ] [ ] [ ] [ ] prevention of severe thalassaemia births by prenatal diagnosis and termination of pregnancies has been successful in countries with a high prevalence of thalassaemia. early identification of couples at risk and culturally sensitive genetic counselling facilitate decision-making for termination or continuation of pregnancy. the mean corpuscular haemoglobin (mch) is used to screen for the presence of thalassaemia using a cut-off of less than pg. rarely, silent β-thalassaemia mutation may present with an mcv over pg and should be considered in those with a positive family history. at-risk couples should be referred for detailed counselling on the options for prenatal diagnosis. these include chorionic villous sampling or amniocentesis, which are used to obtain fetal dna samples for genetic analysis. polymerase chain reactions and precise hybridization assays to detect single point mutations using very small dna samples have also been developed. a less invasive and less risky option is to isolate fetal dna circulating in the maternal blood for genetic analysis. pre-implantation genetic diagnosis is a newer technique where dna from the blastomere is used for genetic diagnosis. ultrasound can be used from the nd trimester for fetuses suspected of having α-thalassaemia to detect signs of hydrops fetalis and enlarged placenta (figure . ) . • hydroxyurea -helpful in some patients with β-thalassaemia intermedia, but not as effective in thalassaemia major • histone deacetylase inhibitors -derivatives of butyric acid; intermittent pulses with hydroxycarbamide has been tried • kit ligand • decitabine • knockdown of bcl a (regulator of γ-globin expression) • erythropoietin. • vitamins c and e • fermented papaya preparations. • successful in β-thalassaemia animal models using a retroviral vector transferring the human β-globin gene sequence and its promoter region into mice stem cells • β-globin gene transfer into progenitor hematopoietic cells of humans is also being studied • other molecular approaches being tried include using different mutations of stop codons and aberrant splicing. partner testing in all cases β-thalassaemia trait protecting red cells. red cells lack any other source of nadph and are solely dependent on the pentose phosphate pathway so g pd deficiency leaves these cells with no defence against oxidative damage. oxidative damage results in denatured haemoglobin aggregates which form heinz bodies (denatured haemoglobin precipitates). these damaged cells bind to the membrane cytoskeleton resulting in decreased cellular deformability, and are also destroyed in the spleen, resulting in haemolysis. the level of enzyme activity is higher in young erythrocytes than in more mature cells so older cells are more susceptible to haemolysis. the global distribution of g pd deficiency mirrors that of malaria, and where malaria has historically been prevalent, and it provides a degree of protection against malaria. • class iv -normal ( - % enzyme activity) • class v -increased activity (> % enzyme activity). g pd enzyme variants can be distinguished by their electrophoretic mobility. g pd b, the wild-type enzyme, and g pd a + , a common variant in populations of african descent, demonstrate normal enzyme activity and are not associated with haemolysis. g pd a − is the most common variant associated with mild to moderate haemolysis with approximately - % hb e is caused by a substitution of glutamic acid by lysine at codon of the β-globin gene. this causes reduced synthesis of the β-e chain and leads to a thalassaemia phenotype. hb e β-thalassaemia affects at least a million people worldwide and is an important health problem particularly in the indian subcontinent and south-east asia. in some areas, it has replaced β-thalassaemia as the most common thalassaemia disorder. the frequency of hbe reaches % in many regions of thailand, laos and cambodia with estimates of at least new cases of hbe β-thalassaemia expected in the next few decades in thailand alone. the natural history of hbe thalassaemia is highly variable; some patients are asymptomatic (e.g. heterozygotes, hbe - % or homozygotes hbe, - %) while others (e.g. hbe with β-thalassaemia) may be transfusiondependent. pathophysiology glucose- -phosphate dehydrogenase (g pd) deficiency was originally recognized through its association with haemolysis related to eating fava beans ('favism') and primaquine ingestion. g pd deficiency is the most common enzyme defect in humans and is present in about million people worldwide (figure . ). , it is an x-linked, hereditary defect caused by mutations in the g pd gene. g pd is an enzyme that catalyses the first reaction in the pentose phosphate pathway, to produce nadph, which is an important antioxidant used to preserve the reduced form of glutathione. , reduced glutathione acts as a scavenger for oxidative metabolites thereby < . % . - . % - . % - . % - . % - % of africans carrying this variant. g pd mediterranean, present in all countries surrounding the mediterranean sea, middle east, india and indonesia, has the same electrophoretic mobility as g pd b but the enzyme synthesis and catalytic activity are reduced. in several populations, g pd a − and g pd mediterranean co-exist. the clinical manifestations of g pd deficiency can be classified into: (i) asymptomatic; (ii) acute haemolytic anaemia; (iii) favism; (iv) neonatal jaundice; and (v) chronic non-spherocytic haemolytic anaemia. acute haemolytic anaemia in g pd deficiency can be secondary to infection (e.g. pneumonia, hepatitis a and b, and typhoid fever) or oxidant drugs, or may be precipitated by diabetic ketoacidosis, myocardial infarction and strenuous physical exercise. , a list of the drugs which may cause haemolysis in g pd-deficient individuals (table . ) can be obtained from: http://www.g pd.org/favism/english/index.mv. a drug which is deemed to be safe for some g pd-deficient individuals may cause haemolysis in others due to the heterogeneity of the underlying genetic variants. haemolysis typically occurs within - days after commencing the drug and can produce intense haemoglobinuria. fortunately, the disorder is self-limiting and most patients do not develop renal impairment or anaemia requiring transfusion. the spontaneous recovery reflects replacement of the older, enzyme-deficient red cells by younger reticulocytes which can withstand oxidative injury. if the precipitating cause has been removed the haemoglobin begins to recover after - days. acute renal failure due to acute tubular necrosis and tubular obstruction by haemoglobin casts can develop as a complication of haemolysis in g pd deficiency. this occurs more often in adults than children and may require haemodialysis. this occurs predominantly in boys aged - years in mediterranean countries, but it has also been observed in the middle east, asia and north africa. both intravascular and extravascular haemolysis, occasionally severe enough to cause renal impairment, can occur after eating fresh or cooked fava beans, and favism has been reported in breastfed babies of mothers who have eaten fava beans. divicine and isouramil have been implicated as the toxic components of fava beans. neonatal jaundice this occurs in one-third of male babies in areas where g pd deficiency is common and is likely due to g pd deficiency. it presents - days after birth and can lead to kernicterus. , maternal exposure to oxidant drugs, and even naphthalenecamphor mothballs, can precipitate haemolysis in affected babies. breast-feeding mothers should therefore be warned to avoid offending drugs, umbilical potions containing fava, triple dye or menthol, and should not apply henna to the skin or use clothes that have been stored in naphthalene. premature infants and babies who have co-inherited the mutation for gilbert's syndrome are at particular risk. phototherapy and exchange transfusion therapy may be required to reduce the level of unconjugated bilirubin. the diagnosis may be easily missed so assessment of g pd status should be undertaken for any jaundiced infant whose family history or ethnic or geographic origin suggest the likelihood of g pd deficiency, and in infants who respond poorly to phototherapy. this is an unusual manifestation of g pd deficiency and usually presents in childhood. , there may be a history of severe neonatal jaundice, episodic or worsening anaemia which requires blood transfusions, and complications from gallstones. although these individuals usually have a well-compensated anaemia, and require transfusions only for exacerbations, rarely some may become transfusion-dependent. antioxidants such as vitamin e and selenium may be of benefit in some cases. the haemolysis does not resolve following splenectomy. folic acid supplementation is necessary to support the increased compensatory erythropoiesis. the diagnosis of g pd deficiency is usually suspected when neonatal jaundice occurs in an area where g pd deficiency is drugs which may cause haemolysis in g pd-deficient individuals common or when an episode of non-immune haemolytic anaemia occurs in association with an infection or drug. the appearance of the red cells on the blood film is characteristic because denatured haemoglobin concentrates in one area within the cell creating 'helmet' or 'bite' cells. denatured haemoglobin precipitates in peripheral red blood cells as heinz bodies which can be detected by staining with methyl violet. definitive diagnosis of g pd deficiency is by quantitative spectrophotometric analysis of the rate of nadph production. point of care tests for g pd deficiency are being developed but have not yet been validated for routine use. measuring enzyme activity during an episode of acute haemolysis is not helpful since reticulocytosis, which is a feature of acute haemolysis, produces a false-negative result because of the high enzyme levels in younger erythrocytes. , management the most effective management strategy for g pd deficiency is to prevent haemolysis by avoiding triggering agents like infections, drugs and fava beans. for the milder variants (e.g. class iii and iv), drugs known to trigger haemolysis may be given to individuals with g pd deficiency if the benefits outweigh the risks and the blood count is closely monitored (e.g. use of low-dose primaquine for individuals with g pd avariant). screening programmes have been established in some mediterranean and other populations where g pd deficiency is prevalent. haematological complications of malaria (see chapter ) the pathophysiology of anaemia in malaria is multi-factorial and influenced by the age of the individual and their antimalarial immune status. anaemia mechanisms in malaria involve: • haemolysis with increased red cell destruction of both infected and bystander erythrocytes • dyserythropoiesis • hypersplenism • haemolysis • co-existent conditions which can cause anaemia. haemolysis is more common in non-immune individuals with acute malaria, whereas dyserythropoiesis is the predominant mechanism for anaemia in recurrent falciparum malaria. , haemolysis is the result of red cell phagocytosis by the reticuloendothelial system and is triggered by damage to the red cell membranes and exposure of abnormal surface antigens on their surface. [ ] [ ] [ ] [ ] ten uninfected red cells are removed from the circulation for each infected red cell destroyed, possibly related to loss of red cell complement regulatory proteins and increased levels of circulating immune complexes. this may partly explain the persistent or worsening anaemia following parasite clearance and the poor correlation between parasitaemia and the severity of anaemia noted in some studies. an increased incidence of anaemia has been noted in malaria vaccine trials possibly due to enhanced clearance of uninfected red blood cells. decreased erythropoeisis with abnormalities in red cell precursors and reticulocytopenia is found consistently on examination of bone marrow from malaria-infected patients. the decreased erythropoiesis is due to many factors including low levels of tnf-α, high levels of interleukin- , abnormalities of erythropoietin, a decrease in burst colony forming units, cytokine-induced suppression of red cell production and the inhibitory effect of the malarial pigment haemozoin. [ ] [ ] [ ] [ ] epidemiology malaria-related anaemia is most commonly seen in children and pregnant women. the prevalence of malarial anaemia in sub-saharan africa in children is - % and in pregnant women it is - %. the highest prevalence is in infants and children less than years of age. infants may acquire malaria through the placenta. , individuals living in malarious areas may have multiple reasons for anaemia such as bacteraemia, hookworm infections and vitamin a deficiency making it difficult to assign anaemia solely to malaria. however, animal studies and the fact that anaemia improves with anti-malarial treatment suggest a direct relationship between malaria infection and anaemia. , for example, in tanzanian children about % of anaemic episodes were thought to be caused by malaria. who defines severe anaemia attributable to malaria as: (i) haemoglobin concentration < g/l or haematocrit < %; (ii) parasitaemia with > parasites/µl of blood and (iii) normocytic blood film (to exclude other common causes of anaemia). however, aspects of this definition have been criticized because blood films are not examined routinely and parasite density varies with endemicity and age. although traditionally it is p. falciparum that has been associated with the most severe malaria-related anaemia, p. vivax is also a major risk factor for severe anaemia especially in young children or those with chronic and recurrent infections. p. vivax anaemia is associated with recurrent bouts of haemolysis of predominantly uninfected erythrocytes with increased fragility. symptoms of malarial anaemia can vary from negligible to profound depending on the degree of anaemia and the rapidity of onset. splenomegaly is a common feature of malarial anaemia because of the role of the spleen in the removal of both infected and uninfected red cells. blackwater fever, characterized by intense intravascular haemolysis with haemoglobinuria and occasionally renal failure in a patient with malaria, may be related to underlying glucose- -phosphate deficiency. , factors such as poor nutrition, deficiencies of vitamins and micronutrients, bacteraemia, and hookworm or hiv infection may co-exist with malaria and contribute to anaemia so nonmalarial causes of anaemia should be considered in patients whose anaemia does not respond to malaria treatment. the management of severe malarial anaemia involves supportive care and treatment of the malaria and any other underlying conditions. recovery from malaria-associated anaemia can be slow, taking weeks or even longer if there are episodes of re-infection. in children, blood transfusion is usually reserved for those with haemoglobin levels of less than g/l (< g/l if there are complications such as respiratory distress ). there of parasitized red cells and the release of von willebrand factor multimers which cause widespread platelet aggregation leading to thrombocytopenia , , platelet synthesis by the bone marrow is relatively well maintained during infection , but antiplatelet antibodies, immune complexes and splenomegaly all contribute to thrombocytopenia. thrombocytopenia occurs in - % of individuals infected with malaria irrespective of the species of plasmodium. , thrombocytopenia in febrile patients in an endemic area increases the probability of malaria by a factor of and in individuals returning from tropical countries with a fever, thrombocytopenia is highly specific for malaria infection. profound thrombocytopenia is unusual and malaria-associated thrombocytopenia is rarely associated with haemorrhagic manifestations. the clinical consequences of platelet aggregation and endothelial binding are primarily microvascular ischaemia. this may manifest as renal impairment, cerebral ischaemia, and occlusion of retinal vasculature or even in some cases, skin necrosis. bleeding is unlikely, although in severe thrombocytopenia, petechiae or purpura may develop which denotes extravasation of red cells into the subcutaneous tissue. continued platelet activation and consumption can exacerbate bleeding and decreased circulating platelets are associated with increased vascular leakage and the development of oedema. platelet transfusions are rarely required because the platelet count generally rises rapidly on treating the underlying malaria. coagulopathy is a disturbance of the whole coagulation system involving not just coagulation factors but platelets, anticoagulant factors, fibrinolytic system and, in the case of malaria, the parasitized red cells and the vascular endothelium. parasitized red cells induce expression of tissue factor on endothelial cells and monocytes, release of microparticles, cytokine release and platelet clumping, all of which initiate blood coagulation and tilt the balance towards the pro-coagulant state ( figure . ) . , [ ] [ ] [ ] [ ] [ ] [ ] anticoagulant factors are severely depleted in malaria. protein c and antithrombin levels are inversely correlated with severity of falciparum malaria and return to normal with treatment of the malaria. have been some concerns about a possible increased risk of infection associated with iron supplementation for children in malarious areas , but current recommendations advocate that where iron deficiency and malaria are common, iron supplements should not be withheld and appropriate anti-malarial treatment or prevention should also be offered. the best way to prevent malarial anaemia is to prevent malaria infection by avoiding mosquito bites (e.g. through the use of bed nets) or through chemoprophylaxis. malaria chemoprophylaxis during infancy can reduce both malaria and anaemia. children who have been hospitalized with severe malarial anaemia may benefit from intermittent preventive malarial therapy after discharge to prevent recurrence of anaemia. daily co-trimoxazole prophylaxis which is used for hiv-infected individuals has been shown to reduce malaria parasitaemia and anaemia. the normal platelet life span of - days is reduced to less than days in malaria infection. several factors are responsible for thrombocytopenia in malaria infection, the most common being increased platelet activation and aggregation ( figure . ). platelet activation is by parasitized red cells which express surface tissue factor and initiate coagulation and platelet aggregation. the resultant activated endothelium binds platelets and sequesters them in vascular beds including in the cerebral vasculature. , these platelets facilitate the adhesion and to % after a year. , although transfusions may be required in severe life-threatening cases of anaemia, aggressive transfusion therapy has been associated with fatal pulmonary emboli due to accelerated haemolysis and disseminated intravascular coagulation. in those who do not respond to art, erythropoietin may be considered since reduced responsiveness to this hormone and antierythropoietin antibodies have been noted in hiv patients. erythropoietin is particularly useful in individuals whose erythropoietin levels are less than iu/l because in addition to increasing the haemoglobin it can also improve the quality of life. erythropoietin may take several weeks to achieve full effect and patients should be replete in haematinics. erythropoietin can very rarely be associated with thrombosis or pure red cell aplasia. thrombocytopenia is a common finding in hiv-infected patients and it may be the initial manifestation of hiv infection in as many as % of patients. data from wealthy countries demonstrate platelet counts less than × /l in % of patients, and less than × /l in . %. overall the -year coagulopathy in malaria infection is unusual, occurring in less than % of cases. it appears to be most common in adults with cerebral malaria who may present with gastrointestinal bleeding or with microvascular ischaemia in the brain, kidneys, retina and occasionally, the dermal vasculature. prolongation of prothrombin time and activated partial thromboplastin time only occur in - % of patients with p. falciparum infection and coagulopathy does not appear to be a feature of p. vivax infection. since coagulation factors need to be depleted to less than % of normal to prolong the clotting times, these tests can be normal despite active coagulopathy. management of coagulopathy aims to restore the balance between pro-and anticoagulant processes. this is complex and requires input from a coagulation specialist and ideally, access to plasma, heparin and factor concentrates and a well-equipped coagulation laboratory. anaemia anaemia is very common in hiv-infected individuals occurring in up to % at initial presentation and about % at some stage during their disease. thirty-seven percent of patients with clinical aids have a -year incidence of anaemia (haemoglobin < g/l) and high rates of anaemia persist despite combination anti retroviral treatment (art). anaemia is directly related to mortality in hiv infection and is independent of other risk factors including cd count. there are multiple reasons for anaemia in hiv-infected patients (box . ), which often co-exist in individual patients. bone marrow infection by mycobacteria species, histoplasma, cryptococcus and penicillium marneffei can all decrease red cell production and can be detected by bone marrow examination and cultures. parvovirus has a predilection for the erythroid progenitor cells and can cause severe anaemia in hiv-infected patients. serological tests for parvovirus are unhelpful in hivinfected patients and viral polymerase chain reaction is needed to confirm the diagnosis. the likelihood of parvovirusinduced anaemia increases with the severity of anaemia and has been found in % of individuals with hiv and haemoglobin less than g/l. haemophagocytosis occurs in hiv infections and may be secondary to co-infection with mycobacteria, cytomegalovirus, epstein-barr or other herpesviruses. poor nutrition due to socioeconomic reasons, hiv-related anorexia, malabsorption from conditions affecting the gastrointestinal tract, and achlorhydria may contribute to anaemia. haemolytic anaemia occurs secondary to drugs or concomitant glucose- phosphate dehydrogenase deficiency and because reticulocytopenia is common in those with hiv infection, reticulocyte counts cannot be used to exclude haemolysis. although the direct coombs test may be positive in patients with hiv infection, autoimmune haemolysis is not a common cause of anaemia. a reduction in red cell precursors has also been noted in children in africa with severe anaemia. treatment of hiv-related anaemia should focus on starting art and eliminating any other factors, such as infections or vitamin deficiencies, which may contribute to the anaemia. in wealthy countries art has been shown to reduce anaemia prevalence from % to % within months of starting treatment, non-hodgkin's lymphoma (nhl) was noted to be associated with hiv infection early in the epidemic and is an aidsdefining illness. the incidence of nhl is up to times greater in hiv-infected adults than in those who are not infected, and it is responsible for nearly one-sixth of the deaths attributable to aids. since the introduction of haart, the incidence of all types of nhl has decreased by approximately - % , and the outcome of hiv-infected patients with lymphoma has improved. in the setting of clinical trials, the % -year survival rate is comparable to those without hiv infection. the incidence of hodgkin's lymphoma has increased in the post-haart era, possibly due to immune reconstitution and increased cd cells. , evidence of epstein-barr virus (ebv) infection can be found in virtually all cases of hodgkin's disease. hiv-related lymphomas (box . ) (see also lymphomas, below), are broadly divided into systemic lymphomas ( %) and primary central nervous system lymphomas. the incidence of highly aggressive lymphomas, either burkitt's lymphoma (approx. %) or diffuse large b-cell lymphoma (approx. %), is much higher in hiv-infected patients than in those without infection. although t-cell lymphomas are uncommon in hiv disease ( %), there has been an increase in recent years. the incidence of primary central nervous system lymphoma in hiv-affected individuals is - % and it is times more common than in the general population. the pathogenesis of nhl in hiv infection is related to the inadequate host immune responses to viruses with oncogenic potential, predominantly ebv and human herpesvirus (hhv )/kaposi's sarcoma-associated herpesvirus. this allows unregulated lymphoid growth and an accumulation of genetic abnormalities in b cells. markers of b-cell activation such as serum immunoglobulins and free light chains, and cd cell count have been suggested as predictive markers for the development of nhl in hiv infection. , extranodal and leptomeningeal involvement, and b-symptoms occur in the majority of hiv-infected patients with nhl and the bone marrow is commonly involved. the most common extranodal site to be involved is the incidence of moderate thrombocytopenia (< × /l) is . %, though this is higher in those with clinical aids ( . %). , thrombocytopenia is more common in those who abuse drugs, have opportunistic infections and malignant disorders of the bone marrow (e.g. lymphoma), and it may also be a side-effect of therapeutic drugs. the most common cause of thrombocytopenia in hiv infection is immune thrombocytopenia which may be associated with hepatitis c co-infection, and produces decreased platelet survival, particularly at cd counts below /µl. the anti-platelet antibodies, immune complexes and cross-reacting antibodies to hiv envelope proteins and platelets, which occur in hiv-associated thrombocytopenia , may also contribute to generation of reactive oxygen species. platelet production can also be affected in hiv infection and may explain the high levels of thrombopoietin that have been documented in hivrelated thrombocytopenia. some cases of hiv-related thrombocytopenia may undergo spontaneous remission so treatment of thrombocytopenia is usually only initiated if it is associated with bleeding, which is unusual. the first line of treatment involves antiretroviral therapy with the aim of achieving undetectable plasma hiv viraemia. , any drugs that may be associated with causing thrombocytopenia should be withdrawn and opportunistic infections or secondary malignancies treated. the treatment of immune thrombocytopenia is the same as in non-hiv cases and options include a short course of steroids, intravenous immunoglobulin (short-lived response), anti-d, interferon-α or splenectomy. although there are multiple causes of thrombocytopenia in hiv-positive individuals, one of the most devastating is the thrombotic microangiopathy of thrombotic thrombocytopenic purpura (ttp). this is because the combination of haemolytic anaemia and microthrombi has a very poor prognosis. symptoms are nonspecific and may include fever, headache, bleeding and changes in consciousness. if ttp is suspected, an urgent blood film should be requested and the combination of thrombocytopenia with red cell fragmentation is highly suggestive of ttp. ttp associated with hiv infection was more frequent before the introduction of art and is more common if adherence to treatment is poor or resistance to therapy has developed. ttp is thought to be due to endothelial damage, but unlike the situation in non-hiv-infected individuals, low levels of adamts- are not a useful predictor of outcome. treatment of ttp involves plasma exchange, and although refractoriness may occur, this can be corrected by art in some cases. if art is administered in these cases it is important to maintain adherence throughout the period of plasma exchange. if apheresis facilities are limited, plasma infusions alone ( ml/ kg per day) may also produce a response. art should also be administered immediately after plasma exchange to minimize drug removal. patients with a viral load of less than copies/ml generally require fewer plasma exchanges for remission than those with a higher load. survival of patients with hiv-associated ttp in the pre-art era was rarely longer than years, even with plasma exchange and steroid treatment, but for patients who are compliant with art the mortality is around %. which immediately limits the amount of blood loss. exposure of the subendothelial space releases factors such as von willebrand factor multimers which bind to platelets and initiate platelet adhesion to the endothelium. the adherent platelets release their granules and attract more platelets, which in combination with fibrinogen, form an aggregate. the activated platelets also attract coagulation factors thereby promoting the clotting process. the critical parts of clot formation are the conversion of prothrombin to thrombin and the thrombinfacilitated conversion of fibrinogen to fibrin (figure . ) . haemostatic control mechanisms operate throughout the clotting process to prevent excessive clot formation and involve proteins c and s, and anti-thrombin and antifibrinolytic systems. any alteration in these regulatory pathways can lead to either bleeding or thrombotic complications. bleeding can result from: • inadequate vasoconstriction, due to vascular problems which can be acquired (e.g. viral haemorrhagic fevers or immune vasculitis) or congenital (e.g. collagen vascular disorders) • qualitative or quantitative abnormality of von willebrand factor causing von willebrand's disease • decreased number or function of platelets which can be either acquired (e.g. aspirin, nsaids) or congenital (e.g. platelet function defects) • qualitative (e.g. caused by inhibitors to coagulation factors, commonly factor viii) or quantitative (e.g. haemophilia) abnormality of coagulation factors • increased fibrinolysis (e.g. viral haemorrhagic fevers, snake bites). acquired bleeding disorders are commonly caused by vitamin k deficiency, disseminated intravascular coagulation (dic) or platelet disorders (box . ) but may sometimes be due to acquired inhibitors of coagulation factors. the initial laboratory tests in a patient with excessive bleeding should therefore include a platelet count, clotting screen (prothrombin time (pt) and activated partial thromboplastin time (aptt)), and gastrointestinal tract, often the stomach or the perianal region. hepatic involvement, seen in a quarter of cases, is associated with a particularly poor prognosis. cns disease may be asymptomatic so diagnostic lumbar puncture may be required. hiv-related lymphomas frequently present with poor prognostic features such as elevated serum lactate dehydrogenase levels. , older age, lowest nadir cd cell counts prior to nhl diagnosis, developing nhl while on art, and cumulative hiv viraemia are also poor prognostic features. a formal prognostic scoring system has been developed which takes into account the cd count (< cells/µl). some types of hiv-related lymphoma are associated with characteristic clinical and laboratory features. primary effusion lymphoma is an aggressive lymphoma characterized by effusions in serosal cavities in the absence of any other tumour masses. , it is strongly associated with hhv infection and the virus can be identified in the nuclei of the malignant cells. plasmablastic lymphoma mainly affects the oral cavity and the mucosa of the jaw and is typically associated with epstein-barr virus. histological examination of biopsied tissue is necessary to confirm the diagnosis and type of lymphoma. diagnostic difficulties may arise because hiv-related hyperplasia in lymph node biopsies may be confused with lymphoma, the histological appearance of hiv-related lymphomas may be different from those of non-infected individuals and many opportunistic pathogens may mimic the appearances of nhl, or co-exist with it, and will need to be identified or excluded before making a diagnosis of lymphoma. prior to the widespread use of art, conventional lymphoma chemotherapy resulted in considerable toxicity, increased opportunistic infections and high mortality. art has facilitated the use of conventional doses of chemotherapy in conjunction with haematopoietic growth factor support. this has markedly improved the outcome of patients with hiv-related lymphomas who now have overall response rates of %. the concomitant use of art and chemotherapy is therefore recommended, especially in those with cd counts of less than /µl. anti-cd antibody is now included in treatment regimens for nhl, and studies that include patients with hivrelated lymphomas all report favourable outcomes. , some antiretroviral agents such as zidovudine are best avoided in combination with chemotherapy, because it adds to the myelosuppression of chemotherapy. didanosine may worsen the peripheral neuropathy caused by taxanes and vinca alkaloids. hiv-infected patients undergoing chemotherapy should receive adequate anti-infective prophylaxis due to the high risk of opportunistic infections such as pneumocystis, herpes simplex and zoster and candida. consolidation chemotherapy and stem cell transplant have been used successfully in relapsed hivrelated lymphomas. haemostasis is maintained by interactions between vessel walls, platelets and a balance between pro-and anticoagulant factors. although the process of haemostasis is usually considered to occur in a stepwise fashion, in vivo the steps happen virtually simultaneously. activation of the lining of the endothelium by trauma, cancer cells or cytokines triggers vasoconstriction, the tests for each pathway is given with arrows corresponding to each box complications, malignancies and infections and is a serious condition with a high mortality. patients present with spontaneous bruising or excessive bleeding from minor wounds such as venepuncture sites, and they may also have signs of complications such as renal failure, acute respiratory distress syndrome and microangiopathic haemolytic anaemia. dic is associated with a combination of depleted clotting factors (i.e. prolonged pt and aptt), a falling platelet count, red cell fragments on the blood film, raised d-dimers or fibrin degradation products, and reduced fibrinogen levels. management of disseminated intravascular coagulation includes treating or removing the underlying cause, and correcting the haemostatic abnormalities with combinations of platelets, cryoprecipitate and fresh frozen plasma. although bleeding due to thrombocytopenia is unusual unless the platelet counts falls below - × /l, bleeding may occur with a normal platelet count and normal clotting screening tests (i.e. pt and aptt) if platelet functions are impaired (e.g. myelodysplastic syndromes). platelet transfusions are generally not required unless there is active bleeding or prior to surgery. idiopathic thrombocytopenic purpura. idiopathic thrombocytopenic purpura is due to immune destruction of platelets. it is usually primary but can be associated with conditions such as lymphomas and infections including hiv. it may present incidentally or with petechiae, bruising or bleeding from the nose or gums, especially if the platelet count is less than × fibrinogen levels, which may be helpful in cases of excessive fibrinolysis (table . ). a difficult venepuncture can cause in vitro activation of the clotting system resulting in a shortened pt or aptt. similar findings may occur in chronic dic due to in vivo activation. the pt and aptt are not necessarily good predictors of the bleeding risk because some clotting disorders associated with thrombosis (e.g. anti-phospholipid antibodies) can prolong the aptt. a shortened aptt can be associated with marked elevation of factor viii levels (e.g. pregnancy) and may be a predictor of deep vein thrombosis. a prolonged thrombin time is caused by quantitative or qualitative fibrinogen deficiency, heparin and fibrin degradation products. reptilase time is helpful to distinguish between fibrinogen abnormalities (prolonged reptilase time) and heparin therapy (normal reptilase time). deficiency of vitamin k can be due to poor diet, small bowel disease or bile flow obstruction. clotting factors (ii, vii, ix and x) are dependent on vitamin k which is a fat-soluble vitamin. vitamin k deficiency therefore causes prolongation of the pt and aptt. in newborn infants, vitamin-k-dependent clotting factors can drop precipitously within a couple of days of birth. this causes haemorrhagic disease of the newborn which particularly affects infants that are premature, exclusively breast fed or have been exposed to drugs for tuberculosis, convulsions or anticoagulation in utero. these babies develop bleeding into the skin and gut, or bleeding from the umbilical stump or circumcision. vitamin k deficiency will respond to intravenous vitamin k ( mg/day for days orally or by intravenous injection) and in severe bleeding the clotting abnormality can be treated with fresh frozen plasma. haemorrhagic disease of the newborn can be prevented with mg of intramuscular vitamin k given at delivery. disseminated intravascular coagulation (dic) is characterized by activation of haemostasis with widespread fibrin formation, activation of fibrinolysis and consumption of platelets and clotting factors. it may be precipitated by tissue injury, obstetric desmopressin (ddavp) is a relatively inexpensive drug that increases fviii levels and vwf activity within minutes of administration. it is useful in mild haemophilia and mild von willebrand's disease. the major side effects are headaches and hyponatraemia so fluid intake should be restricted to . l/ day. tranexamic acid mouthwashes may be helpful for oral mucosal bleeding. danazol can increase both factor viii and ix levels within - days and has therefore been recommended for patients with recurrent haemarthrosis or with central nervous system bleeding which both carry a high risk of recurrence. most thromboembolic episodes are single events and may be associated with precipitating events or underlying risk factors. thrombophilia is the clinical state of hypercoagulability and should be suspected in patients who have a strong family history of thrombosis, or who have recurrent or unusual thromboses. increasing affluence and consequent lifestyle changes mean that the prevalence of thromboembolism is rising in some low-and middle-income countries. risk factors such as sedentary work, obesity, excessive alcohol intake, smoking and additional cardiovascular risk factors are compounded by other /l. spontaneous recovery occurs less commonly in adults than in children. it is important to exclude other causes of thrombocytopenia such as drugs, dic or sepsis. the diagnosis can be suspected from a bone marrow examination which shows increased numbers of platelet precursors. treatment with prednisolone ( . - . mg/kg) is usually only necessary if there is bleeding or excessive bruising and the dose should be reduced slowly once the platelet count improves. second-line treatments include immunosuppressive agents and danazol. splenectomy may also be beneficial but carries an increased risk of infection. platelet transfusions or intravenous gammaglobulin can temporarily increase the platelet count in an emergency or prior to surgical procedures. inherited bleeding disorders can be classified broadly into coagulation factor deficiencies (e.g. factor viii and factor ix deficiencies), von willebrand's disease and platelet disorders. the frequency of genes for inherited bleeding disorders is the same throughout the world. haemophilia a has a prevalence of about / , von willebrand's disease of > / and haemophilia b of < . / . these conditions occur more frequently among populations where consanguineous marriage is common and where prenatal diagnostic facilities are unavailable. in general, individuals with inherited coagulation factor deficiencies present with soft tissue bleeds such as haemarthroses or intramuscular bleeds. those with platelet disorders or von willebrand's disease tend to present with mucosal bleeds, however severe (type iii) von willebrand's disease can present with severe soft tissue bleeds. many of these conditions are diagnosed following excessive and uncontrolled bleeding after trauma or surgical procedures. menorrhagia and delayed severe postpartum haemorrhage may be presenting features of bleeding disorders, particularly von willebrand's disease or hypothyroidism, which can cause decreased synthesis of von willebrand factor. some inherited platelet function disorders are associated with characteristic syndromes (e.g. oculocutaneous albinism or skeletal defects) which may provide a clue to the diagnosis. early recognition of symptoms by clinicians, teachers and the public is important so that early treatment can be established. patients with inherited bleeding disorders are usually managed with blood products (box . ) or chemotherapy designed to reduce bleeding and associated complications. , , , clotting factor concentrates may be imported or produced locally by fractionation of plasma and are included in the who list of essential medicines. , one international unit (iu) of fviii clotting factor concentrate per capita is recommended as the minimum requirement for countries wishing to achieve optimal survival for their haemophilia population but only about % of the estimated people in the world with haemophilia receive adequate treatment. management of patients with bleeding disorders relies on a wellequipped and quality assessed laboratory for accurate diagnosis and monitoring of treatment and access to plasma and components for replacement therapy. appropriate support services such as physiotherapy, orthopaedics and counselling should also be available. in many countries inherited bleeding disorders are associated with stigma, which is particularly directed against the mothers of affected children, acute and chronic leukaemias are usually associated with a high white cell count but acute leukaemias can present with normal or even sub-normal white cell counts. morphology of peripheral blood and bone marrow specimens is crucial to confirm the diagnosis. this is particularly important in the case of acute leukaemia in children which may be mistaken for an acute viral infection. staining methods including sudan black b, myeloperoxidase and nonspecific esterase are important to distinguish between the different subtypes of acute myeloid and lymphoid leukaemias and therefore to guide treatment. acute myeloid leukaemia (aml). prevalence of this increases with age and the success rate with chemotherapy protocols is not high even in the most sophisticated centres. neutropenia and myelosuppression requiring intensive blood component support occur during chemotherapy and bone marrow transplantation offers the best option for cure for patients who relapse. management of aml is therefore complex and expensive. hydroxycarbamide or subcutaneous cytarabine may be used as a palliative treatment. acute promyelocytic leukaemia (aml subtype m ). this must be distinguished from other types of acute myeloid leukaemia because it has a high cure rate with early treatment. it predominantly affects young adults and it has a high incidence in certain ethnic groups especially those of latin american descent. a treatment protocol which includes all-transretinoic acid with combination chemotherapy has been developed which is feasible in low-income countries. , another regimen based on intravenous arsenic trioxide has been developed in india, , which has an % response rate with good diseasefree and overall survival. conditions that are associated with thrombosis such as hiv infection, and chronic infections including tuberculosis , and helminth-induced eosinophilic myocarditis. african americans are more likely to be diagnosed with pulmonary embolism rather than deep-vein thrombosis compared to other racial groups and african patients with thrombosis tend to be younger than those reported in literature with higher mortality rates (around %) possibly due to late presentation and poor access to health facilities. asian populations - seem to have a lower prevalence of symptomatic venous thrombosis compared to african americans. very little is known about the prevalence of prothrombotic factors such as mutations of the prothrombin gene or deficiencies of antithrombin, protein c and protein s in tropical countries, although high rates of factor v leiden, a risk factor for venous thrombosis, have been described in tunisia. , lupus anticoagulant and anti-phospholipid syndrome, which are associated with increased thrombosis risk, are increased in afro-caribbean populations, especially in the presence of hiv, and have also been described in nigerian women with pre-eclampsia. , the management of venous thrombosis is initially with heparin and then with warfarin for - months. compliance may be difficult in low-resource settings because of the requirement for regular monitoring of warfarin. it is therefore important to try to prevent thromboses by removing any underlying risk factors and by treating individuals at risk of thrombosis with a short course of prophylactic heparin to cover procedures known to be associated with thrombosis risk. this can present as venous or arterial thromboembolism and it may be inherited (e.g. deficiencies of thrombin, protein s or protein c) or acquired (e.g. antiphospholipids). the patient's personal and family history, and the results of clinical and imaging examinations to confirm thrombosis, may suggest the diagnosis. the laboratory tests needed to determine the cause and classify the type of thrombophilia, and their interpretation, are complex, so patients with recurrent or unusual thromboses should be referred to a specialist centre. haematological malignancies are predominantly leukaemias, lymphomas and myelomas. some of the general approaches for managing these conditions in low-income countries are outlined in box . but definitive treatment should be undertaken by a specialist haematology unit. leukaemias can be broadly classified as acute or chronic, and lymphoid or myeloid. the presenting symptoms and signs are related to the disturbed blood cell production from the bone marrow due to the effects of the malignant cell clone (box . ) . acute leukaemias are characterized by rapid progression and poor prognosis if left untreated whereas chronic leukaemias generally follow a much slower course. • mobilization of the community (especially parents and families) to raise awareness among local councils and government bodies about the treatability of the cancers and benefits from curing them • find an external partner unit locally, nationally or internationally which is already well-established and willing to help but will not dictate terms • improvement of supportive care facilities, especially protection from those with infectious diseases • development of a safe and reliable blood transfusion service • provision of subsidized travel, and satellite clinics to lessen the burden • development of appropriate protocols for each disease entity which is locally practicable with minimum cost and maximum efficacy • development of medical, nursing and paramedical expertise in the diseases to be treated -initially by offering visiting fellowships and in the long term for the trained individuals to arrange regional and local teaching programmes • formation of a cooperative group bringing together all the professionals involved in the speciality within a country or region to share expertise and develop training programmes. acute lymphoblastic leukaemia (all). this is the most common type of leukaemia in children. it has a good prognosis when treated with modern chemotherapy protocols with cure rates in the best centres exceeding %. in low-income countries, cure rates are much lower at around % primarily because of failure to complete therapy and deaths caused by treatment. considerable improvements in all outcomes have been achieved by twinning institutions in developing countries with specialist centres elsewhere in the country or internationally. measures that may improve outcomes focus on preventing abandonment of therapy (e.g. providing funding for transport, satellite clinics and support groups) and prompt treatment of infection. treatment in a dedicated paediatric oncology unit using a comprehensive multidisciplinary team approach and protocol-based therapy, is also associated with improved outcomes in resource-poor settings. chronic myeloid leukaemia (cml). management has been revolutionized by tyrosine kinase inhibitors (e.g. imatinib) which can produce complete remission in over % of cases. once the diagnosis of cml is established, hydroxycarbamide can be used to reduce the white cell count, followed by treatment with a tyrosine kinase inhibitor. manufacturers will provide the drug free of charge to patients in low-income countries with confirmed cml and generic forms of tyrosine kinase inhibitors are now becoming available. chronic lymphocytic leukaemia (cll). this occurs predominantly in older people and usually presents with lymphadenopathy and recurrent infections. treatment is with chlorambucil and prednisolone although aggressive forms require combination therapy with rituximab, fludarabine and cyclophosphamide. treatment is generally not curative but the disease may be indolent and drugs may only be required if the patient has symptoms or if there is a risk of hyperviscosity from a very high lymphocyte count. approximately cases of non-hodgkin lymphoma (nhl) occur in the equatorial belt of africa each year (table . ). there are marked geographical variations in prevalence but up to % are thought to be related to hiv infection. burkitt's lymphoma, a b-cell nhl, was originally described in children from africa and has an estimated incidence of - per million. lymphomas are broadly classified into hodgkin's lymphoma and nhl; nhl are divided into b-cell, t-cell and nk-cell, and immunodeficiency-associated types. the clinical presentation of lymphomas is characterized by enlargement of the lymphoid organs and subsequent compression of the adjacent structures, infiltration of organs by the malignant lymphoid cells and a dysfunctional immunological system which can manifest as immunosuppression or excessive but dysregulated immune activation associated with, for example, autoimmune conditions. the diagnosis and management of the various types of lymphomas are complicated and should be undertaken in a specialist box . clinical features of leukaemias • fatigue and cardiac symptoms from anaemia • bleeding from thrombocytopenia • increased risk of infections despite a higher number but dysfunctional white cells • lymphadenopathy and hepatosplenomegaly occur with all although lymphadenopathy may be observed in the monocytic variety of aml • blindness due to hyperviscosity from hyperleukocytosis • tumour lysis syndrome due to spontaneous cell lysis presents as renal failure • pustules or pyogenic infections of the skin from minor wounds • bleeding gums are a characteristic feature of acute monocytic leukaemia • disseminated intravascular coagulation can occur with acute promyelocytic leukaemia • gout can arise from breakdown of the excess white cells and release of uric acid • oral aphthous ulceration is seen with severe neutropenia in both aml and all • granulocytic sarcoma or chloroma represent extramedullary deposits of leukaemic cells in any organ but mainly the skin. this may occur in the absence of peripheral blood involvement and is more common with chromosomal translocation ( ; ) of aml • central nervous system manifestations due to sludging of the cerebral circulation by the malignant cells or increased intracranial pressure due to ventricular blockade can occur. monocytic myeloid leukaemia can also involve the meninges • intracranial haemorrhage can occur in all with very high white cell counts (> × /l) • bone pain and arthralgia can be a presenting feature of all in children in more than a quarter. these children may present with a limp or unwillingness to walk due to marrow infiltration by leukaemic cells. rarely, they may have normal blood counts delaying the diagnosis of all • anterior mediastinal mass (thymus enlargement) can also occur in children and young adults with all which may present as superior venocaval obstruction • painless enlargement of scrotum is a sign of testicular leukaemia or hydrocele from lymphatic obstruction. priapism can result from hyperleukocytosis rarely. • most often asymptomatic and usually suspected on blood counts • the chronicity of cml or cll tends to cause gradual-onset symptoms since the patients get adjusted to the slowly developing anaemia • abdominal discomfort and early satiety are a feature of cml due to excessive splenomegaly compressing the stomach and reducing the luminal volume • sternal tenderness may be noted in cml • hyperleukocytosis in cml can occur more often than with aml or all due to the gradual increase in white cells. this can cause symptoms like hyperuricaemia and gout, tinnitus, priapism or central nervous system disturbances • left shoulder tip pain can arise from splenic infarction from the massive splenomegaly in cml • cml can rarely present with features of thyrotoxicosis (heat intolerance, weight loss and excessive sweating) due to hyper-metabolism • cll is often associated with lymphadenopathy and rarely with mild to moderate splenomegaly. all, acute lymphoid leukaemia; aml, acute myeloid leukaemia; cll, chronic lymphocytic leukaemia; cml, chronic myeloid leukaemia. centre. diagnosis depends on clinical history and examination, radiological investigations to document the extent of disease, and morphology, immunohistochemistry and molecular studies on tissue samples to confirm the lymphoma subtype. guidance on the diagnosis and treatment of lymphoma in settings where resources are limited includes recommendations about panels of immunostains and chemotherapy regimens that minimize the need for supportive care. tele-pathology, which involves transmitting histological images via the internet to experts overseas, may be helpful in certain circumstances though it is dependent on the quality of the histology preparations and the images of appropriate diagnostic regions in the sample. treatment regimens for lymphomas differ according to the subtype but may involve chemotherapy and radiotherapy. high remission rates can be achieved in burkitt's lymphoma with a combination of cyclophosphamide, vincristine and methotrexate and progressive disease can be managed with ifosfamide, mesna and cytosine arabinoside. , adult t-cell leukaemia-lymphoma (atll) adult t-cell leukaemia-lymphoma (atll) is an uncommon lymphoid malignancy which occurs in patients infected with human t-lymphotropic virus type i (htlv-i). htlv- is endemic in the caribbean, western africa, peru and southern japan. less than % of those infected with htlv-i develop atll and up to years can elapse between the primary infection and the development of atll suggesting additional factors are needed for malignant transformation. atll presents acutely in approximately % of cases, although chronic forms have also been described. the clinical presentation is with generalized lymphadenopathy in most cases and hepatosplenomegaly in over half. atll is associated with a high risk of hypercalcaemia which occurs in more than two-thirds of patients during the course of their disease and may be associated with central nervous system disturbances and renal impairment. lytic bone lesions occur as a para-neoplastic types of lymphomas identified from selected countries in sub-saharan africa phenomenon due to production of parathormone-like peptides. as with other t-cell disorders, atll can involve the skin, producing, e.g. erythrodermic plaques. the diagnosis of atll can be suspected from a high peripheral blood white blood cell count in combination with hypercalcaemia and characteristic lymphocytes with convoluted and hyperlobulated nuclei. the diagnosis is confirmed by histological examination of a tissue (lymph node or bone marrow), immunophenotyping for specific cell markers and proof of htlv infection, usually by serological methods. management of atll is primarily with combination chemotherapy with intrathecal prophylaxis. , a combination of zidovudine and interferon, as agents against htlv, has also been tried with some success. hypercalcaemia and opportunistic infections should be sought and treated early in these patients. the high white cell count is associated with a significant risk of tumour lysis syndrome and should be prevented by adequate hydration and the judicious use of allopurinol and other urate-reducing agents. myeloma is a monoclonal proliferation of plasma cells and it particularly affects older people. myeloma appears to be less common in asian countries than elsewhere, although during the last years, an almost four-fold increase in incidence of myeloma has occurred in taiwan. in the united states, the incidence of multiple myeloma in the black population is twice that of the white population. the abundant plasma cells infiltrate the bone marrow and interfere with normal haematopoiesis. this leads to anaemia, which is a presenting feature in % of individuals. bony infiltration by the malignant plasma cells can produce osteoporosis, lytic lesions and pathological fractures in % of patients with myeloma. involvement of the bones can lead to hypercalcaemia, which may be a presenting feature, and vertebral fracture leading to spinal cord compression. the malignant plasma cells produce a paraprotein which can cause renal impairment in - % and hyperviscosity may ensue in % of patients if the paraprotein production is not controlled. patients with myeloma may need a variety of supportive interventions including management of anaemia, renal failure, hypercalcaemia, hyperviscosity, infections and bone pains. specific anti-myeloma treatment should be managed within a specialist unit and has undergone a radical change in the last decade with the use of thalidomide and its newer formulations, and the more expensive, proteasome inhibitors (e.g. bortzomib). thalidomide is relatively safe and effective although somnolence and constipation can sometimes be troublesome. there is a risk of thrombosis with thalidomide especially at the initiation of therapy, and prophylaxis with heparin, warfarin or antiplatelet agents, depending on an assessment of the risk, may be warranted. melphalan may also be useful, particularly if resources are limited and there is no specialist centre. however it is myelosuppressive, so regular monitoring of the blood count is essential. maintaining an adequate blood supply is a major challenge for low-income countries. only % of the global blood supply is donated in the poorest countries where % of the world's population lives. blood transfusion is a vital component of every country's health service. it can be a life-saving intervention for illnesses such as severe acute anaemia, but mistakes in the transfusion process can be life-threatening, either immediately or years later through transmission of infectious agents. clinicians need to understand how blood is acquired and its risks and benefits, and to use it appropriately. governments and transfusion services need to put measures in place to ensure that blood is safe for transfusion and that it reaches those who need it in a timely manner. only % of member states meet all the world health organization's (who) recommendations for a national quality blood transfusion system. at the national level the transfusion service should have a director, an advisory committee and clear transfusion policies and strategies (table . ). who recommend standardization of blood collection, testing and distribution. although centralization of these services may offer the best guarantee of quality, it is often not practical in countries with poorly developed communications and transport infrastructure. two systems, centralized and hospital-based, exist in lowincome countries for managing blood supply. in the centralized system, voluntary blood donors are recruited, screened and bled by regional centres and the blood collected is distributed to peripheral hospitals. hospital-based systems are the predominant source of blood across sub-saharan africa. hospital-based systems obtain blood predominantly from relatives of patients, and blood is screened and used within the local vicinity. blood from the centralized system costs at least three times as much per unit as that from a hospital-based system. although centralized systems can save costs through batching and bulk purchasing, the quality assurance processes and donor recruitment components are expensive and difficult to maintain without dependence on external funds. in hospital-based transfusion services, testing quality is variable and the families of patients bear the cost of finding blood donors. the vast majority of blood in low-income countries is transfused as whole blood. in high-income countries it is standard practice to optimize the use of each donation of blood by separating it into individual components but whether this approach is cost-effective in low-income countries, where indications for transfusion are different, is not known. these components, which may include plasma, platelets and cryoprecipitate, are prepared by centrifugation using a closed, sterile system and each component has different storage requirements. plasma and cryoprecipitate are kept frozen, red cells are stored at - °c, and platelets at - °c with constant agitation. recent evidence suggests that warm, fresh, whole blood may be better than component therapy for resuscitation of acidotic, hypothermic and coagulopathic trauma patients and for patients needing massive transfusions. many infections can be transmitted through blood transfusions and transfusion of infected blood causes morbidity and mortality in the recipients, and has an economic and emotional impact on their families and communities. those who become infected through blood transfusion are infectious to others and contribute to the spread of disease thereby increasing the burden on health services and reducing productive labour. strategies for recruiting blood donors have to provide blood for all who need it in a timely manner while ensuring that the blood is as safe as possible. the safest type of blood donor is one who donates regularly (i.e. repeat donors). who states that the safest source of blood is altruistic, voluntary, unpaid donors. only % of who member states report having at least % of their blood supply from voluntary donors, and low-income countries have not been able to increase the recruitment of voluntary donors for several years. recent evidence from sub-saharan africa indicates that the focus on voluntary donors may be misplaced since first-time voluntary donors have a similar prevalence of transfusion-transmitted infections as family replacement donors. in order to limit blood shortage and maintain constant blood supply in poorer countries, both voluntary and replacement donors should be accepted and encouraged to donate regularly. mechanisms to convert family replacement donors into repeating voluntary donors have the potential to significantly increase blood donations in africa. political will and open-mindedness about ways to improve the supply and safety of blood are essential to promote more evidence-based approaches to blood transfusion practice in poorer countries. supporting strategy in wealthy countries, the majority of transfusions are carried out electively. by contrast, in poorer countries, and particularly those where the malaria transmission rate is high, most transfusions are given for life-threatening emergencies. in low-income countries, - % of transfusions are administered to children, predominantly for malaria-related anaemia, and pregnant women. transfusion can significantly reduce the mortality of children with severe anaemia within the first days of hospital admission and successful malaria control can reduce paediatric transfusion requirements. in sub-saharan africa, % of in-hospital maternal deaths from severe bleeding were due to lack of blood for transfusion. other specialities which are significant users of blood are surgery, trauma, emergency medicine and general medicine. in low-income countries the most effective way to avoid transfusions is to reduce the prevalence of anaemia. more studies on the efficacy and cost of combinations of interventions including insecticide-treated bed nets, nutritional supplements and anthelmintic drugs to prevent anaemia are needed. when resources are very limited, governments may need to make some difficult decisions in order to achieve an equitable balance between investing in a transfusion service and public health measures to reduce anaemia. whether a patient needs a blood transfusion or not is ultimately a clinical decision. emergency transfusions can be lifesaving for patients in whom anaemia has developed too quickly to allow physiological compensation, as in severe malariarelated anaemia in children, and sudden, severe obstetric bleeding. in contrast, if the anaemia has developed slowly, for example due to hookworm infestation or nutritional deficiency, patients can generally be managed conservatively by treating the cause of the anaemia and prescribing haematinic replacements. iron supplements should be continued for at least months after the haemoglobin has returned to normal, so that body stores can be replenished. clinical guidelines. it is possible to avoid unnecessary transfusions by adhering to clinical transfusion guidelines. most institutions have developed guidelines to help clinicians make rational decisions about the use of blood transfusions (box . ) , and strict enforcement of transfusion protocols can significantly reduce avoidable transfusions. the principles underlying most transfusion guidelines are similar and combine a clinical assessment of oxygenation, with haemoglobin measurement being used as a surrogate measure for intracellular oxygen concentration. increasingly, transfusion guidelines are making use of evidence which shows that adequate oxygen delivery to the tissues can be achieved at haemoglobin levels that are significantly lower than the normal range. implementation of transfusion guidelines is particularly difficult if clinicians do not have access to reliable haemoglobin high-risk donors, such as commercial sex workers and their contacts, intravenous drug abusers, or those with an itinerant lifestyle such as traders, drivers and military personnel, should be deterred from donating. even in areas where hiv infection rates in the general population are high, donor deferral can be effective in excluding hiv-infected donors. the whole donation process, including tests for hiv and other infections, should be explained to the donor before blood is collected and donors should have the option of knowing the results and receiving counselling. it is imperative that complete confidentiality is maintained throughout all procedures. infections with organisms such as hiv, hepatitis viruses, cytomegalovirus, syphilis, lyme borreliosis, malaria, babesiosis, american trypanosomiasis (chagas disease) and toxoplasmosis can all be acquired through blood transfusions. some - % of hiv infections worldwide are thought to have been transmitted through the transfusion of infected blood and blood products. there have also been reports of transmission of variant creutzfeldt-jakob disease through blood transfusion and there is a theoretical risk of transmission of severe acute respiratory syndrome (sars). , who recommends that all donated blood should be screened for hiv, hepatitis b and syphilis and, where feasible and appropriate, for hepatitis c, malaria and chagas disease. malaria can be transmitted by blood transfusion and, depending on the local infection prevalence, - % of blood donors in africa screen positive for malaria. however, there is very little evidence to suggest that these donors transmit malaria to transfusion recipients. although who recommends screening donors in endemic areas for malaria, none of the screening methods that would be practical for transfusion services are sufficiently sensitive. furthermore, in some countries with high malaria transmission, exclusion of parasitaemic donors could result in deferral rates exceeding % which would have a major impact on blood supply. there is no evidence to support the widespread practice of routine treatment of transfusion recipients for malaria. fresh blood is potentially infectious for syphilis, but storage at °c for more than days can inactivate treponema pallidum. the high demand for blood in low-income countries means that blood is generally not stored for long enough to inactivate t. pallidum and syphilis seroconversion associated with transfusion has been reported from africa. globally, the prevalence of hepatitis c, htlv- and - and chagas disease is variable and the decision to introduce donor screening for these infections should be based on local assessments of the risks, benefits, feasibility and costs. blood should not be separated into components if the residual risk of infection is high, as this will increase the number of potentially infected recipients. a unit of blood is usually stored until screening tests for infections have been completed. this means that potentially infected blood may be mixed up with units that have already been screened, and costly blood collection bags are wasted. screening potential donors before venesecting a unit of blood may therefore be a more cost-effective way of ensuring safe blood. tests for screening blood donors need to be highly sensitive, and infected blood should be rejected. before informing the donor of the outcome, all positive results should be confirmed using a test with a high degree of specificity. where blood or that the blood may become infected with bacteria during the process. intraoperative blood salvage. this involves collecting blood lost during the operation and reinfusing it into the patient either during or after surgery. although this technique is practical and safe, and reduces the need for donor blood by - %, it requires specialized equipment and training, and may be more expensive than routinely donated blood. other measures. normal saline or intravenous replacement fluids can be used judiciously in acute blood loss, and in certain circumstances may be as effective as whole blood, red cells or plasma. erythropoietin, which stimulates endogenous red cell production is well-established for use in chronic anaemias such as those due to renal failure, cancer and hiv infection but its delayed action makes it unsuitable for use in acute anaemias. synthetic oxygen carriers, such as perfluorocarbons, are not yet routinely available. in low-income countries, the recommended haemoglobin threshold for transfusions is often well below that which would be accepted in more wealthy countries. randomized controlled studies in wealthy countries indicate that for most adults and children undergoing critical care, a haemoglobin threshold of g/l for transfusion is safe whereas paediatric blood transfusion protocols in sub-saharan africa often recommend transfusions for stable children only when the haemoglobin level is less than g/l. complications such as cardiac failure or infection may necessitate transfusion at a higher haemoglobin level. transfusion should be combined with adequate haematinic replacements and underlying conditions should be treated. early evidence suggests that intermittent preventive treatment with anti-malarials may reduce the high hospital readmission rates experienced by children post-transfusion. complications can occur immediately during transfusion, within a few hours of its completion, or be delayed for many years, as in the case of viral infections (box . ). measurements. when they doubt the haemoglobin result, clinicians rely entirely on clinical judgement to guide transfusion practice which can lead to significant numbers of inappropriate transfusions. a lack of investment in the quality of a critical test, such as haemoglobin measurement, can waste significant resources downstream in the transfusion process, and unnecessarily expose recipients to the risk of transfusion-related infections. minimizing surgical blood loss. where blood is in short supply, it is particularly important to ensure that the best anaesthetic and surgical techniques are used, to minimize blood loss during surgery. drugs which improve haemostasis or reduce fibrinolysis, such as aprotinin and cyklokapron, and fibrin sealants, can be effective in reducing perioperative blood loss. these drugs can therefore reduce the need for blood transfusion but they may be too expensive for use in low-income countries. a cost-effectiveness study of surgical bleeding in four sub-saharan countries indicates that the antifibrinolytic, tranexamic acid, could save lives in countries with blood shortages, reduce healthcare costs and prevent transmission of infections. preoperative autologous blood deposit. patients undergoing planned surgery who are likely to require a blood transfusion can have units of their own blood removed and stored in case they have significant intraoperative blood loss and need a transfusion. this process, known as preoperative autologous donation, can reduce the need for allogeneic transfusions by - % but it requires careful organization: the surgeon needs to predict how much blood will be required, the patient has to be fit enough to withstand removal of one or more units of blood over the weeks preceding the surgery and the surgery must take place within the shelf-life of the blood. as the blood has to be stored in the blood bank there is still a risk that the patient may receive blood which is not their own box . prescribing blood: a checklist for clinicians always ask yourself the following questions before prescribing blood or blood products for a patient: . what improvement in the patient's clinical condition am i aiming to achieve? . can i minimize blood loss to reduce this patient's need for transfusion? . are there any other treatments i should give before making the decision to transfuse, such as intravenous replacement fluids or oxygen? . what are the specific clinical or laboratory indications for transfusion in this patient? . what are the risks of transmitting hiv, hepatitis, syphilis or other infectious agents through the blood products that are available for this patient? bacterial contamination and should be investigated and managed accordingly. allergic reactions are due to infusion of plasma proteins and manifestations include erythema, rash, pruritus, bronchospasm and anaphylaxis. the transfusion should be stopped and the patient treated with antihistamines. if the reaction is mild and the symptoms and signs completely disappear, the transfusion can be restarted. if this type of mild reaction occurs repeatedly with more than one unit of blood, the red cells can be washed before transfusion. this should only be done if absolutely necessary, as it carries the risk of introducing potentially fatal bacterial infection. severe allergic reactions with evidence of systemic toxicity should be managed as acute anaphylaxis. blood should always be transfused slowly to avoid overloading the circulation, unless the patient has active and severe bleeding. fluid overload may be a particular problem when paediatric blood bags are not available, as children may be over-transfused due to miscalculation of the required volume, lack of accurate infusion devices or inadvertent administration of an adult-sized unit of blood. four units of blood contain the equivalent amount of iron stored in bone marrow (approx. g). repeated transfusions for chronic haemolytic anaemia, as in thalassaemia major and sickle cell disease, lead to iron deposition in parenchymal cells. eventually failure of the heart, liver and other organs supersedes. adequate doses of iron chelators, such as injectable desferrioxamine or oral deferiprone, are able to maintain acceptable iron balance in patients with chronic anaemia who need regular transfusions. it is not usually necessary to warm blood unless large quantities are transfused rapidly. this may lower the temperature of the sino-atrial node to below °c at which point ventricular fibrillation can occur. if blood needs to be warmed, an electric blood warmer specifically designed for the purpose should be used. this keeps the temperature below °c and avoids the haemolysis associated with overheating blood. graft-versus-host disease occurs when donor lymphocytes engraft in an immune-suppressed recipient. the lymphocytes recognize the recipient's bone marrow as foreign and induce aplasia. graft-versus-host disease is almost universally fatal and can be prevented by irradiating the donor blood, which inactivates the donor lymphocytes. transfusion of blood into a recipient who possesses antibodies to the donor's red cells can cause an acute, and occasionally fatal, intravascular haemolysis. this could occur, e.g. if group a cells are transfused into a group o recipient who has naturally occurring antibodies to group a cells. the profound haemolysis induces renal vasoconstriction and acute tubular necrosis. treatment involves stopping the transfusion, cardiorespiratory support and inducing a brisk diuresis. in addition to abnormalities indicating renal failure, laboratory findings include haemoglobinuria and haemoglobinaemia. proof of the diagnosis involves rechecking the whole transfusion process including all documentation stages, regrouping the donor and the recipient, and screening for antibodies on red cells with a direct antiglobulin test. these tests are usually available in any hospital laboratory capable of providing a transfusion service. delayed haemolysis has a similar physiological basis to acute intravascular haemolysis but it tends to be less severe, it occurs - days after the transfusion and it is less likely to present as a clinical emergency. limited data from sub-saharan africa show rates of bacterial contamination in donated blood of around % , but the clinical consequences for transfusion recipients are unknown. bacteria can enter the blood bag during venesection or if the bag is breached, e.g. when reducing the volume for a paediatric recipient or during component preparation. gram-negative bacteria, including pseudomonas and yersinia, grow optimally at °c and infected blood may not necessarily appear abnormal to the naked eye. reactions following infusion of infected blood are often due to endotoxins and may occur several hours after the transfusion has finished. although these reactions are rare, they can be severe and fatal. if bacterial contamination is suspected, the transfusion should be stopped and samples from the patient and the blood bag sent to the laboratory for culture. cardiorespiratory support may be needed and broad-spectrum antibiotics should be started immediately and continued until culture results are available. non-haemolytic febrile reactions are episodes of fever and chills associated with transfusion and for which no other cause can be found. they are due to the recipient's antibodies reacting against antigens present on the donor's white cells or platelets. these reactions are most common in patients who have had transfusions in the past and have therefore been exposed to allo-antigens. mild febrile reactions usually respond to simple antipyretics such as paracetamol. more 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contribution of ineffective blood transfusion services press release who/ . . whd/ information sheet for clinicians development and evaluation of a new paediatric blood transfusion protocol for africa electrocardiographic st-segment changes during acute, severe isovolemic hemodilution in humans use of clinical judgement to guide administration of blood transfusions in malawi giving tranexamic acid to reduce surgical bleeding in sub-saharan africa: an economic evaluation autologous transfusion techniques: a systematic review of their efficacy intraoperative autologous blood management artificial o carriers: status in red blood cell transfusions in acute paediatrics survival and haematological recovery of children with severe malaria transfused in accordance to who guidelines in kilifi intermittent preventive therapy for malaria with monthly artemether-lumefantrine for the post-discharge management of severe anaemia in children aged - months in southern malawi: a multicentre, randomised, placebocontrolled trial bacterial contamination of pediatric whole blood transfusions in a kenyan hospital bacterial contamination of blood and blood components in three major blood transfusion centres in accra, ghana access the complete references online at www.expertconsult.com key: cord- - e i m b authors: potsic, william p.; wetmore, ralph f. title: otolaryngologic disorders date: - - journal: pediatric surgery doi: . /b - - - - . - sha: doc_id: cord_uid: e i m b nan the ear is divided into three anatomic and functional areas: the external ear, the middle ear, and the inner ear. the external ear consists of the auricle, external auditory canal, and the lateral surface of the tympanic membrane. the auricle is a complex fibroelastic skeleton that is covered by skin and subcutaneous tissue that directs sound into the external ear canal. the external auditory canal is oval with the long axis in the superior to inferior direction. in neonates, the external canal is almost entirely supported by soft, collapsible cartilage. as the temporal bone grows over several years, the bony portion of the canal enlarges to comprise the inner one third, leaving the outer two thirds supported by firm cartilage. hair and cerumen glands are present in the outer two thirds of the external canal. the ear canal is lined by skin that is continuous with the lateral surface of the tympanic membrane, and it is innervated by cranial nerves v, vii, and x and cervical nerve iii. the tympanic membrane separates the external ear canal from the middle ear. it has three layers: an outer layer of skin; a middle layer of fibrous tissue that is attached to the malleus, the most lateral middle ear ossicle; and an inner layer of mucosa that is continuous with the mucosa lining the middle ear. the fibrous layer is also attached to a thick fibrous annulus that anchors it to the temporal bone. the middle ear is an air-filled space within the temporal bone of the skull that is lined by ciliated, columnar respiratory epithelium. the middle ear communicates with the mastoid air cell system posteriorly and is lined by the same mucosa. it also communicates with the nasopharynx anteriorly through the eustachian tube. the mucociliary transport system of the middle ear moves mucus and debris into the nasopharynx, where it is swallowed. secretory cells are not evenly distributed throughout the middle ear and mastoid complex and are more numerous anteriorly near the eustachian tube. three ossicles are present in the middle ear-the malleus, incus, and stapes-that transmit sound from the vibrating tympanic membrane to the stapes footplate. stapes movement creates a fluid wave in the inner ear that travels to the round window membrane and is dissipated by reciprocal motion to the stapes. there are two striated muscles in the middle ear. the tensor tympani muscle lies along the side of the eustachian tube, and its tendon attaches to the medial surface of the malleus. the stapedius muscle lies along the vertical portion of the facial nerve in the posterosuperior part of the middle ear. its tendon attaches to the head of the stapes. these muscles stiffen the ossicular chain in the presence of sustained loud noise. the facial nerve traverses the middle ear with its horizontal portion lying superior to the stapes. posterior to the stapes, the facial nerve turns inferiorly in a vertical fashion to exit the stylomastoid foramen deep to the tip of the mastoid. the chorda tympani nerve is a branch of the facial nerve that innervates taste to the anterior two thirds of the tongue. it exits the facial nerve in the vertical segment and passes under the posterosuperior surface of the tympanic membrane, crossing the middle ear lateral to the long process of the incus and medial to the malleus. the facial nerve lies within a protective bony canal throughout its course in the middle ear. however, the bony canal may be absent (in the horizontal portion) in as many as % of patients. cranial nerve ix supplies sensation to the floor of the middle ear. the inner ear consists of the cochlea, semicircular canals, and vestibule. the cochlea is a coiled fluid-filled tube consisting of / turns surrounded by dense bone. it contains the membranes that support the organ of corti and has hair cells that detect the fluid wave from vibration of the stapes footplate. the hair cells create the neural impulses that are transmitted from the auditory nerve (cranial nerve viii) to the brain, providing the sensation of hearing. the three paired semicircular canals (horizontal, superior, and inferior) are also fluid-filled tubes surrounded by dense bone. the semicircular canals each have a hair cell-containing structure (the ampulla) that detects motion. the utricle and saccule of the vestibule also have hair cell structures that detect acceleration. the external ear develops during the sixth week of gestation and is completely developed by the th week. six hillocks fuse to form the basic units of the pinna. defects in the fusion of the hillocks lead to preauricular tags and sinuses. the external auditory canal develops from the first pharyngeal cleft. a solid epithelial plug forms during the beginning of the third month of gestation and canalizes in the seventh month to form the external auditory canal. the middle ear canal develops from the first pharyngeal pouch. the ossicles develop from the first and second pharyngeal arches. the inner ear arises from neuroectodermal tissue within the otic placode that forms the otic pit. any combination of anomalies may occur. abnormalities of the development of the ear may create anomalies of the pinna, external auditory canal, middle ear structures, and inner ear. one of the anomalies that involves the external and middle ear is aural atresia (absence of the external auditory canal). absence of the external canal may occur with a deformed or normal external ear. the ossicles may be deformed and are usually fused to each other as well as the bony plate representing the undeveloped tympanic membrane. the facial nerve may also be altered in its course through the temporal bone. reconstruction of the atretic canal, removal of the bony tympanic plate, release of the fused ossicles, and reconstruction of a new eardrum is a complex surgical procedure that may improve hearing. rarely there is incomplete development of the inner ear structures. the most common of these is dysplasia of the cochlea, and it may vary in severity. dysplasia causes sensorineural hearing loss. , the examination of the ear should always start with inspection of the outer ear and surrounding structures. deformities of the outer ear structure may suggest the presence of other anomalies, such as a first branchial cleft sinus. a first branchial cleft sinus usually presents below the ear lobe near the angle of the jaw. the sinus tract may connect to the ear canal or, rarely, the middle ear. the external auditory canal and tympanic membrane are best examined with a hand-held otoscope with a bright fiberoptic light source. the largest speculum that comfortably fits in the external canal should be used to maximize visualization and minimize pain. a very small speculum may be inserted deeply, but it might lacerate the ear canal as well as limit visibility of the tympanic membrane. the otoscope permits visualization of the ear canal and tympanic membrane. a translucent tympanic membrane will also permit visualization of the contents of the middle ear. cerumen may be encountered in the ear canal that obstructs the view of the tympanic membrane. removal of cerumen may be performed by using an operating otoscope head and an ear curet. however, the use of a headlight such as the lumiview (welch allyn, skaneateles, ny) or operating microscope permits the use of both hands and superior visualization. care should be taken to secure the child to prevent sudden movement, and the ear curet should be used gently to avoid causing pain and a laceration of the ear canal. examination of a child with an apparent or suspected ear condition often requires objective assessment of hearing by audiometry. current technology and expertise makes it possible to test a child at any age. behavioral audiometry can usually be accurately performed for a child who is older than months of age by sound-field testing. older children are presented with a tone through insert earphones and a range of frequencies between and hz for ear-specific testing. the hearing thresholds are recorded at each presented frequency; and this represents the air conduction threshold. the sound has to traverse the ear canal, tympanic membrane, and middle ear. the inner ear must respond by creating electrical impulses that are transmitted to the brain. normal thresholds are less than db for children. bone conduction thresholds test the sensorineural component of hearing. a bone oscillator is used to test a range of frequencies by vibrating the skull, which stimulates the inner ear, directly bypassing the external and middle ear. normally, air conduction thresholds require less energy than bone conduction thresholds. if bone conduction thresholds require less sound intensity than air conduction to be heard, the child has a conductive hearing loss. if air conduction and bone conduction thresholds are elevated but the same, the child has a sensorineural hearing loss. most sensorineural hearing loss in children is a result of hair cell dysfunction in the organ of corti. hearing loss may be conductive, sensorineural, or mixed. electrophysical tests such as brainstem auditory evoked response and sound emission tests that measure the intrinsic sounds from the inner ear (otoacoustic emissions) may be employed in young infants and children who cannot participate in behavioral audiometry. a mechanical test of tympanic membrane compliance (tympanometry) may also be used for audiometric assessment. all of these tools are employed by pediatric audiologists. for purposes of describing hearing loss, a threshold between and db is considered mild, to db is moderate, to db is moderately severe, to db is severe, and greater than db is profound. four of children are born with a hearing loss, and of those children is born with a severe to profound hearing loss. conductive hearing loss may be corrected with otologic surgery. hearing aids and fm systems may be helpful to children with both conductive and sensorineural hearing loss. assistance may be needed through auditory training, speech language therapy, and education to maximally develop communication skills. when a child has a sensorineural hearing loss that is too severe to be helped with hearing aids, a cochlear implant may be considered. a cochlear implant is an electrical device that is implanted under the scalp behind the ear. its processor converts sound to electrical impulses. a cable travels through the mastoid and facial recess to reach the middle ear, and the electrode array is inserted into the scala tympani of the cochlea through an opening that is made in the cochlea. cochlear implants stimulate the neural elements of the cochlea directly and bypass the hair cells. because the vast majority of sensorineural hearing loss in children is due to hair cell dysfunction, nearly all children get sound perception from a cochlear implant. rare conditions such as an absent auditory nerve or an absent cochlea preclude the use of a cochlear implant. a multidisciplinary evaluation by a cochlear implant team is required to evaluate a child and determine family expectations before performing a cochlear implant. a temporal bone computed tomographic (ct) scan and/or magnetic resonance imaging (mri) is performed to assess the cochlea and auditory nerves. children who are born deaf and are younger than the age of years, as well as children who have already developed communication skills, language, and speech before losing their hearing, derive the greatest benefit from cochlear implants. cochlear implantation is approved for children months of age or older by the u.s. food and drug administration. after a cochlear implant is performed, considerable auditory oral training is required to maximize a child's benefit to develop skills of audition, speech, and language. a child who has been deaf and without sound perception for several years is expected to benefit to a lesser degree. otitis media with effusion is the most common chronic condition of the ear during childhood. all children are born with small eustachian tubes that may at times be unable to clear mucus that is secreted in the mastoid and middle ear. fluid may develop in the middle ear during an upper respiratory infection. it usually clears within a few weeks as the upper respiratory tract infection resolves. children with craniofacial anomalies such as cleft palate and down syndrome are also prone to middle ear effusions; there is no medication that is consistently effective in resolving such effusions. persistent effusion may cause a conductive hearing loss in the range of to db. a middle ear effusion may also function as a culture medium and predispose children to recurrent acute suppurative otitis media (asom). when fluid persists in the middle ear for to months, causing a hearing loss or is associated with asom, myringotomy and tympanostomy tube placement is helpful to resolve the hearing loss and reduce the frequency and severity of infection. myringotomy and placement of a tube is performed under general anesthesia using an operating microscope. a small incision is made in any quadrant of the tympanic membrane except the posterosuperior quadrant, where there would be risk of injuring the ossicles. the mucus is suctioned from the ear, and a silastic tube is placed in the myringotomy to provide prolonged ventilation of the middle ear. the tube will usually be extruded and the tympanostomy will heal in months to year. when the ear is no longer ventilated by a tube, the eustachian tube must ventilate the middle ear. if fluid recurs and persists, a repeat procedure may be needed. most children outgrow this problem as their eustachian tube grows. occasionally, adenoid tissue in the nasopharynx may contribute to the persistence of middle ear effusion and may also be removed at the time that a tube is placed. children who have had multiple sets of tubes are candidates for adenoidectomy. acute suppurative otitis media is the most common infection of childhood except for acute upper respiratory tract infections. it is the most common condition for which children seek medical care from their primary care physician. usual pathogens causing asom include streptococcus pneumoniae, haemophilus influenzae, and moraxella catarrhalis. acute suppurative otitis media usually causes severe deep ear pain, fever, and a conductive hearing loss in the affected ear. the purulence in the middle ear is also present in the mastoid air cells because they are connected. asom is treated with broad-spectrum oral antibiotics; however, there is growing concern that indiscriminant use of antibiotics may result in antibiotic resistance. for this reason, accurate diagnosis by otoscopy should be made before initiating a course of antibiotics. occasionally, asom does not respond as expected to standard antibiotic therapy. when this occurs, culture and sensitivity testing can be obtained by tympanocentesis. after sterilizing the ear canal with alcohol, a -gauge spinal needle can be placed through the posterior or anterior inferior quadrant of the tympanic membrane and fluid can be aspirated with a small syringe. complications of asom are uncommon if appropriate antibiotic therapy is used. the conductive hearing loss resolves as the middle ear effusion clears. however, infection may necrose the tympanic membrane, causing a spontaneous perforation. small perforations usually heal in less than days, but larger perforations may persist, cause a conductive hearing loss, and require a tympanoplasty for closure. the ossicular chain may also be disrupted by necrosis of the long process of the incus requiring ossicular reconstruction to restore hearing. acute coalescent mastoiditis occurs when infection erodes the bony mastoid cortex and destroys bony septa within the mastoid. a subperiosteal abscess may also be present. there is usually postauricular erythema and edema over the mastoid area. the auricle is displaced laterally and forward ( fig. - ). otoscopy reveals forward displacement of the posterior superior skin of the ear canal. in addition to antibiotics, treatment should include a wide field myringotomy from the anterior inferior quadrant to the posterior inferior quadrant, a tympanostomy tube placement for middle ear drainage, and a postauricular mastoidectomy to drain the subperiosteal abscess and the mastoid. facial nerve paralysis may occur from inflammation of that portion of the facial nerve that is exposed in the otolaryngologic disorders middle ear during asom. treatment with parenteral antibiotics, ototopical antibiotic drops applied in the ear canal, and a wide field myringotomy and tympanostomy tube placement almost always result in complete recovery of facial function. facial nerve recovery may take a few weeks to several months. intracranial complications of asom may include meningitis, epidural abscess, brain abscess, otitic hydrocephalus, and lateral sinus thrombosis. meningitis is the most common intracranial complication of asom and may be associated with profound sensorineural hearing loss and loss of vestibular function. treatment of the intracranial complications of asom is focused on appropriate treatment of the intracranial process, in addition to a wide field myringotomy and tympanostomy tube placement in the affected ear. chronic otitis media is a descriptive term that refers to a persistent perforation of the tympanic membrane or the presence of a cholesteatoma of the middle ear. a cholesteatoma is a squamous epithelial-lined cyst that may be congenital or acquired. congenital cholesteatomas are caused by epithelial rests that persist in the middle ear during temporal bone development. they present behind an intact tympanic membrane and appear as a white, smooth mass in the middle ear. they expand over time and are filled with squamous debris and may erode the ossicular chain and extend into the mastoid. acquired cholesteatoma develops from skin entering the middle ear after a tympanic membrane perforation or a retraction pocket from eustachian tube dysfunction. cholesteatomas are usually painless, cause a conductive hearing loss, and, in acquired cases, often present as otorrhea. the otorrhea should be treated with ototopical antibiotic eardrops, but the only treatment of cholesteatomas is complete surgical excision by tympanomastoid surgery and ossicular reconstruction. [pp - ] the potential complications of cholesteatomas are the same as those for asom. objects stuck deeply into the ear canal such as a cottontipped applicator may perforate the tympanic membrane. this usually causes acute pain, bleeding, and a conductive hearing loss. if the ossicular chain is not disrupted, the vast majority of these perforations will heal spontaneously in about weeks. if the tympanic membrane is perforated and the middle ear is contaminated with water, oral antibiotics should be given. lacerations of the auricle should be cleaned to prevent tattooing and repaired by careful approximation of the skin and soft tissue to restore the contours of the ear. the cartilage itself does not usually need to be sutured. partially or totally avulsed tissue should be replaced. if necrosis of tissue occurs, it can be débrided as needed. in severe injuries of the auricle, oral antibiotic treatment is helpful to prevent chondritis and loss of the cartilage framework. blunt trauma to the ear is commonly seen in wrestlers, in children with poor neuromuscular tone, or in children with self-injurious behaviors. blood or serum collects between the periosteum and the auricular cartilage. if the cartilage is fractured, the collection may occur on both sides of the ear. evacuation of the collection is required to restore the contours of the ear, prevent infection, and prevent scarring with formation of a "cauliflower ear." aspiration of the fluid and placement of a mastoid dressing for compression may be tried but is most often unsuccessful. incision and drainage provides for complete evacuation of the blood or serum. cotton dental rolls placed in each side of the auricle and held in place with bolster mattress sutures is the most effective management. the dental rolls should be left in place for to days while the patient also continues with a course of oral antibiotics. no outer dressing is required. [pp - ] blunt head trauma may disrupt the inner ear membranes causing sensorineural hearing loss and vertigo. no treatment is required, and the injury and symptoms may resolve spontaneously, but the sensorineural hearing loss may persist. severe head trauma may cause fracture of the temporal bone of the skull. temporal bone fractures can be classified as longitudinal, transverse, or mixed ( fig. - ) but are often complex and do not neatly fit into one category or another. a high-resolution, thin section ct scan of the temporal bone will define the extent of the fracture. the middle ear and mastoid are filled with blood when a fracture is present. the blood causes a conductive hearing loss that resolves when the ear clears. otoscopic evaluation of a child with a temporal bone fracture may reveal a laceration of the ear canal and tympanic membrane. blood is usually present in the ear canal, and the tympanic membrane appears to be dark blue because the middle ear is filled with blood. there is often ecchymosis of the mastoid area (battle's sign). it is important during evaluation of a skull and temporal bone fracture to note and record the function of the facial nerve if the patient is not unconscious. facial nerve paralysis may be immediate or delayed in onset. delayed facial nerve paralysis has a good prognosis for spontaneous recovery. immediate facial paralysis may indicate disruption of the nerve or compression by bone fragments. immediate facial nerve paralysis requires exploration and repair once the patient is stable and sufficiently recovered from any associated trauma. the facial nerve should be decompressed in the mastoid, middle ear, and middle cranial fossa. bone chips impinging on the nerve should be removed, and the nerve should be sutured or grafted if needed. all patients with temporal bone fractures should have an audiogram once their condition has stabilized. if the fracture disarticulates the ossicles, a conductive hearing loss will persist after the blood has cleared from the middle ear and mastoid. fractures of the temporal bone may transverse the cochlea and vestibular apparatus. these fractures usually cause a severe sensorineural hearing loss and loss of vestibular function on the affected side. a concussive injury of the cochlea may also simultaneously be present in the opposite ear in severe head trauma. temporal bone fractures may permit leakage of cerebrospinal fluid (csf) into the middle ear and mastoid. csf may also drain through the lacerated tympanic membrane, causing csf otorrhea. these leaks usually stop spontaneously, but persistent csf otorrhea may require a lumbar drain to reduce the pressure and permit healing. rarely, tympanomastoid exploration is required to close the leak. persistent csf leaks in the ear are associated with meningitis. benign and malignant tumors of the ear are rare. glomus tympanicum tumors and neuromas of the facial nerve may present in the middle ear. also, eosinophilic granuloma and rhabdomyosarcoma may involve the structures of the temporal bone. , the nose can be divided into three anatomic sections. the bony vault is the immobile portion of the nose. it consists of the paired nasal bones, the frontal process of the maxillary bone, and the nasal process of the frontal bone. the cartilaginous vault is supported by the upper lateral cartilages and the cartilaginous nasal septum. the nasal lobule is supported by the lower lateral cartilages and the cartilaginous septum. the nasal septum is formed by the quadrilateral cartilage anteriorly. the posterior septum is composed of bone from the vomer, perpendicular plate of the ethmoid, nasal crest of the maxillary bone, and palatine bone. both the internal and external carotid artery systems supply blood to the nose. the roof and lateral wall of the internal nasal cavity are supplied by the anterior and posterior ethmoidal arteries, sphenopalatine artery, and greater palatine artery. the septum is supplied by the anterior and posterior ethmoidal arteries, palatine artery, and the superior labial artery. the convergence of these vessels in the anterior segment of the nose is referred to as kiesselbach's plexus or little's area. venous drainage is accomplished mainly by the ophthalmic, anterior facial, and sphenopalatine veins. the olfactory bulb is positioned high in the roof of the nasal cavity and is responsible for the sense of smell. sensory information is transported by nerves that penetrate the cribriform plate and traverse cranial nerve i (the olfactory nerve) to the brain. smell is also an important component of what is perceived as taste. bony projections, turbinates, form the lateral nasal wall and significantly increase the surface area of the nose, allowing for more efficient humidification and warming of the air to °c. three turbinates are usually present (i.e., inferior, middle, and superior). a supreme turbinate, which is essentially a flap of mucosa, is occasionally present. the turbinates contribute to the turbulent airflow that creates approximately % of the total airflow resistance to the lungs. cleaning of air is accomplished through the nasal hairs (vibrissae) and the mucosal surface. anteriorly, the nose is lined with stratified squamous epithelium, which changes to respiratory epithelium immediately anterior to the turbinates. trapped debris is transported in a posterior direction into the nasopharynx by a mucociliary transport mechanism. speech is affected by nasal anatomy and pathologic conditions. hyponasality from nasal obstruction or hypernasality from an excessive air leak can affect voice quality and intelligibility of speech. the nose serves as a drainage port for the paranasal sinuses. the meati are spaces between the lateral aspect of the nasal turbinates and the medial aspects of the lateral nasal wall. each meatus is named for the turbinate that surrounds it. the maxillary, frontal, and anterior ethmoidal sinuses drain into the middle meatus. the posterior ethmoidal sinuses drain into the superior meatus. the sphenoidal sinus drains into an area known as the sphenoethmoidal recess that is located posterior and superior to the superior turbinate. the nasolacrimal duct drains into the inferior meatus. the nasal cavities develop from the nasal pits in the -week embryo. these pits deepen and move medially to form the nasal cavity. the oronasal membrane that separates the nose from the mouth resolves in the seventh week to permit communication between the nose and nasopharynx. the paranasal sinuses develop from an outpouching of the lateral nasal walls during the third and fourth months of development. the maxillary and ethmoidal sinuses are present at birth. the frontal and sphenoidal sinuses begin to develop several years after birth. the frontal sinus begins to develop at years of age but is not fully aerated until adulthood. viral rhinosinusitis (the common cold) accounts for the majority of nose and sinus infections. it is caused by many strains of viruses and is a self-limited infection. symptoms of fever, nasal congestion, headache, and clear rhinorrhea usually resolve over to days. treatment is symptomatic. acute bacterial rhinosinusitis may often follow an acute viral upper respiratory tract infection. the most common bacteria causing rhinosinusitis are streptococcus pneumoniae, haemophilus influenzae, and moraxella catarrhalis. acute rhinosinusitis causes malaise, headache, and nasal congestion. there may also be pain localized to the sinus region or pain on palpation over the maxillary or frontal sinuses. chronic sinus infection may persist after the acute phase and symptoms often last longer than days. the "gold standard" for diagnosing sinusitis is a ct of the sinuses, but a thorough history and nasal examination is usually sufficient to diagnose acute rhinosinusitis. the nasal cavity can be visualized by using a large speculum on an otoscopic head. the posterior nasal cavity can be visualized with either a straight rod endoscope or a flexible fiberoptic nasopharyngoscope. the treatment of rhinosinusitis includes oral antibiotics, short-term use of topical nasal decongestants (e.g., oxymethazoline), and saline nasal sprays. topical nasal corticosteroid sprays may be helpful for the treatment of chronic sinusitis. chronic sinusitis in a child may be exacerbated by gastroesophageal reflux disease, immunodeficiencies, mucociliary dysfunction, and, more commonly, upper respiratory allergy. these predisposing conditions should be managed while treating the sinus infection. if the signs and symptoms of chronic sinus infection persist, a sinus ct is required to evaluate the condition of the sinus mucosa and the drainage pathways. endoscopic sinus surgery may be necessary to open the involved sinuses to provide drainage. chronic inflammation of the nasal and sinus mucosa may lead to nasal and sinus polyp formation that chronically obstructs the nose and sinuses. antrochoanal polyps are large polyps that originate from the walls of the maxillary sinus and extend through the nasal cavity into the nasopharynx. nasal polyps may be removed endoscopically, but a large antrochoanal polyp may require removal through an open maxillary sinus procedure. nasal polyps in a child should always prompt an evaluation for cystic fibrosis. the sinuses surround the orbit so a common complication of acute rhinosinusitis in children is orbital cellulitis with erythema and edema of the eyelids. chemosis (edema of the ocular conjunctiva) is usually absent. however, if a periorbital subperiosteal abscess forms adjacent to an infected sinus, there may be proptosis, chemosis, ophthalmoplegia, and loss of vision. infection in the ethmoidal sinuses most commonly results in this complication. subperiosteal periorbital abscess is demonstrated best by sinus ct. initial treatment should include intravenous antibiotics. endoscopic or external drainage may be required in some cases. intracranial complications of sinusitis include cerebritis, cavernous sinus thrombosis, as well as epidural, subdural, and brain abscess. treatment of intracranial complications or impending intracranial complications requires surgical drainage of the involved sinus and concurrent treatment of the intracranial lesion by a neurosurgeon. fungal sinusitis may occur in immunocompromised children, specifically severe diabetics, children undergoing chemotherapy, and bone marrow transplant recipients. the treatment of fungal sinusitis involves surgical drainage and intravenous antifungal agents. however, a chronic form of fungal sinusitis is allergic fungal sinusitis. these patients usually have other signs of allergy, such as asthma. the treatment of this condition is corticosteroids and débridement of the involved sinuses. the diagnosis is made by sinus ct findings and the presence of eosinophils as well as fungi in the sinus secretions that are removed at the time of surgery. congenital stenosis of the anterior bony aperture causes partial nasal obstruction that may be severe enough to cause difficulty feeding, respiratory distress, and failure to thrive. anterior rhinoscopy demonstrates a very constricted nasal opening bilaterally. ct of the nose shows marked narrowing of the pyriform aperture. neonates are obligate nasal breathers, and severe stenosis must be surgically corrected. because the stenotic segment is very anterior and the remainder of the nasal cavity is normal, removal of the constricting bone with drills is done through a sublabial approach. the nasal openings are stented with . -mm endotracheal tube stents that are sutured in place and removed after a few days. choanal atresia may be unilateral or bilateral. the obstructing tissue is usually a bony plate, but a few cases will have only membranous atresia. unilateral choanal atresia presents as chronic unilateral rhinorrhea. there is no significant respiratory distress. because neonates are obligate nose breathers, bilateral choanal atresia is associated with severe respiratory distress, difficulty feeding, and failure to thrive. the diagnosis is suspected if catheters cannot be passed through the nose and into the pharynx. the obstruction may be visualized with a narrow flexible nasopharyngoscope after the nasal cavity has been suctioned of mucus and the nasal mucosa has been constricted with a nasal decongestant (e.g., oxymetazoline). the diagnosis is best made with ct of the nasal cavity. ct will demonstrate the atresia, define the tissue (bony or membranous), and show the configuration of the entire nasal cavity. choanal atresia may be successfully treated by removing the obstructing tissue transnasally. curets, bone punches, and drills may all be effective to remove the atresia plate. however, when the bony plate is very thick and there is an extremely narrow posterior nasal cavity, a transpalatal repair is more direct. a transpalatal repair provides better access for more effective removal of the bony plate and posterior septum ( fig. - ). stents fashioned from endotracheal tubes are placed and secured with sutures to the septum. they are removed in several weeks. the stents must be moistened with saline and suctioned several times daily to prevent mucus plugging and acute respiratory distress. transpalatal repair of choanal atresia has a lower incidence of restenosis. [pp - ] nasal dermoid cysts or sinuses present in the midline of the nasal dorsum ( fig. - ). they usually appear as a round bump or a pit with hair present in the pit ( fig. - ). they also may become infected. nasal dermoid sinuses may extend through the nasal bones into the nasofrontal area and have an intracranial component. both ct and mri may be necessary to demonstrate the extent of the dermoid. surgical removal is required to prevent infection and recurrence. this may be done between ages and years if prior infection has not occurred. dermoids confined to the nose are resected completely using a midline incision with an ellipse around the sinus tract. otolaryngologic disorders the tract is followed to its termination, and the nasal bones may need to be separated to reach the end of the tract. [pp - ] if an intracranial component is present, a combined craniotomy and nasal approach with a neurosurgeon is recommended. a nasal glioma presents as an intranasal mass and may be confused with a nasal polyp. the mass contains dysplastic brain tissue and may have an intracranial connection. ct and mri are important to define the extent of the glioma and intracranial component as well as to plan the surgical approach. an encephalocele presents as a soft compressible mass and may also be confused with a nasal polyp. intranasal encephaloceles extend through a defect in the skull at the cribriform plate. ct and mri define the extent of the encephalocele and are necessary to design the surgical approach. surgical removal often includes a frontal craniotomy. nasal encephaloceles may be associated with csf rhinorrhea and meningitis. an infant may be born with the soft nasal bones and the septum deviated to one side either as a result of a difficult delivery or from persistent intrauterine compression of the nose. the nasal structures can most often be returned to the midline with digital manipulation. if the nasal deformity is partially reduced, the nose usually straightens with growth during the first year to months of age. nasal bone and nasal septal fractures in older children usually occur from a blow to the face during sports. there is usually a brief period of epistaxis and deviation of the nasal dorsum to one side. swelling occurs rapidly, and the degree of the cosmetic deformity or the need for fracture reduction may not be easily determined. at the fourth to sixth day after injury, the edema subsides and the need for reduction can be determined. nasal bone radiographs are of little help in making this judgment, so the need for nasal fracture reduction is usually based solely on clinical examination. effective nasal fracture reduction may be done up to weeks after the injury. closed reduction under general anesthesia is the method of choice. oral antibiotics prevent infection and are essential if nasal packing is used to support the nasal bone. although nasal fracture reduction is not urgent, a septal hematoma from a fractured septum should be excluded by the initial physician seeing the child. a septal hematoma that remains untreated may cause cartilage necrosis and loss of nasal support, with a resulting saddle-nose deformity. treatment of a septal hematoma is with incision and evacuation of the clot. the mucoperichondral flap should then be sutured in place by bolster sutures through the septum. a small rubber band drain should remain in place for to hours, and antibiotics should be given. epistaxis in children usually occurs in little's area of the anterior septum and frequently results from digital trauma (nose picking). the bleeding usually stops with pressure by squeezing the nasal ala. infrequently, cauterization of the vessels under general anesthesia is needed. children may be observed inserting a foreign body into their nose, or they may inform their parents of the event. most children, however, present with a foul-smelling unilateral purulent nasal discharge and deny putting anything into their nose. most nasal foreign bodies are painless and do no harm to the nose except cause a foul nasal discharge. disc batteries, on the other hand, cause very rapid alkali burns of the nasal cavity and pain. batteries must be removed from the nose quickly because the chemical burn occurs in minutes to hours. if extensive tissue necrosis occurs, it may cause a nasal stenosis. removal of a nasal foreign body is aided by decongesting the nasal mucosa and using a headlamp to visualize the foreign body. a variety of forceps or hooks may be used. if the object is deep in the nose, the removal is best performed under general anesthesia. the endotracheal tube prevents aspiration of the object into the tracheobronchial tree if it is pushed back into the nasopharynx. one must remember that multiple foreign bodies may be present. nasal lacerations should be closed with care to match edges and restore the contours of the nose. standard wound closure technique is employed. the nasal mucosa does not need to be sutured unless a large flap is displaced. rhabdomyosarcoma, lymphoma, squamous cell carcinoma, and esthesioneuroblastoma may occur in the nose and sinuses of children. fortunately, these malignant tumors are very rare in children. the treatment of children with malignant tumors of the nose and sinuses usually involves a multidisciplinary, multimodal approach. juvenile nasopharyngeal angiofibroma is a benign tumor of adolescent males that originates from the lateral wall of the nose and nasopharynx. the tumor may completely obstruct the nose and fill the nasopharynx. this type of angiofibroma may also extend intracranially through the base of the skull. patients with these tumors present with nasal obstruction, recurrent epistaxis, and rhinorrhea. the tumor may be seen with a flexible fiberoptic nasopharyngoscope or a rod lens telescope after decongesting the nasal mucosa. it appears as a smooth reddish mass. biopsy of the mass should be avoided because of the potential for severe bleeding. ct and mri define the extent and location of the tumor. mr angiography helps to delineate the blood supply, which may originate from both the internal and external carotid arteries. contrast angiography may be reserved for presurgical planning and embolization of the copious blood supply that is often present. the treatment of juvenile nasopharyngeal angiofibroma is complete surgical resection after preoperative embolization. depending on the material used, the embolization may be effective for days to weeks. a variety of surgical approaches may be used, including endoscopic resection of small tumors. extensive tumors may require a combined midfacial and craniotomy approach. some authors have proposed radiation therapy as the primary treatment of juvenile nasopharyngeal angiofibroma, but many surgeons are concerned about the long-term effects of radiation in children, including the induction of malignant tumors. the boundaries of the oral cavity include the lips anteriorly, the cheeks laterally, and the palate superiorly. the posterior boundary is a plane that extends from the soft palate to the junction of the anterior two thirds and posterior one third of the tongue. the oral cavity is composed of the vestibule, the space between the lips and cheeks and alveolar ridges, and the oral cavity proper. the vestibule and oral cavity proper are separated by the alveolar ridge and teeth. the vestibule is divided in the midline by the labial frenula of the upper and lower lips. the alveolar ridge is contiguous superiorly with the hard palate. the parotid ducts (stensen's ducts) enter the vestibule opposite the second maxillary molars. the submandibular ducts (wharton's ducts) enter the floor of mouth near the lingual frenulum. the palate is formed by a fusion of the primary palate anteriorly and medial growth of the palatal processes that form the secondary palate. the hard palate divides the nasal and oral cavities and is formed by the premaxilla and the horizontal plates of the palatine bones. the soft palate is formed by a muscular aponeurosis of the tensor veli palatini tendon. five muscles insert into this aponeurosis and include the tensor veli palatini, levator veli palatini, palatoglossus, palatopharyngeus, and the musculus uvulae. defects in formation of the hard and/or soft palate result in clefting. the sensory and motor innervation of the palate is through the trigeminal nerve and pharyngeal plexus. the circumvallate papillae divide the tongue into the anterior two thirds that lies in the oral cavity and the posterior one third lying in the oropharynx. the innervation and vascular supply to the two major divisions of the tongue reflect their differences in origin-the anterior two thirds of the tongue being a first branchial arch derivative (trigeminal) whereas the posterior one third being a combination of third and fourth arch derivatives (pharyngeal plexus). the hypoglossal nerve supplies motor innervation to the intrinsic musculature. in addition to the intrinsic tongue musculature, the action of four extrinsic muscles combine to provide mobility. the genioglossus protrudes and depresses, the hyoglossus retracts and depresses, the styloglossus retracts, and the palatoglossus elevates. in addition to the circumvallate papilla, other taste buds on the tongue surface include conical, filiform, fungiform, and foliate papillae. the pharynx is a fibromuscular tube that extends from the skull base to the level of the cricoid cartilage of the larynx and can be divided into three levels. the nasopharynx extends from the skull base to the level of the soft palate, the oropharynx extends from the soft palate to the tongue base, and the hypopharynx extends from the tongue base to the cricoid cartilage. three muscular constrictors combine to form the muscular portion of the pharynx: superior, middle, and inferior constrictors. passavant's ridge is a muscular segment of the superior constrictor that is involved in velopharyngeal closure. lower fibers of the inferior constrictor help to form the upper esophageal sphincter. the motor and sensory innervation of the pharynx is from the glossopharyngeal and vagus nerves via the pharyngeal plexus. a collection of lymphoid tissue within the pharynx forms waldeyer's ring that includes the palatine tonsils, the adenoid (pharyngeal tonsil), and lymphoid follicles lining the lateral and posterior pharyngeal walls. in addition to the acute onset of sore throat, viral pharyngitis typically presents with fever and malaise. signs include erythema of the pharynx and cervical lymphadenopathy. depending on the viral agent, associated symptoms of nasal obstruction and rhinorrhea may also be present. rhinovirus, coronavirus, parainfluenza virus, respiratory syncytial virus, adenovirus, and influenza virus are agents responsible for viral pharyngitis. primary herpetic gingivostomatitis, caused by herpes simplex types or , presents as fever, adenopathy, and vesicles and ulcers on the lips, tongue, buccal mucosa, soft palate, and pharyngeal mucosa. herpangina and hand-foot-and-mouth disease are viral infections that involve the oropharynx. epstein-barr virus (ebv) infection (infectious mononucleosis) presents as acute pharyngotonsillitis, fever, generalized adenopathy, malaise, and splenomegaly. although ebv infection is suspected by the appearance of % or more atypical lymphocytes on a complete blood cell count and the presence of a positive monospot test, the definitive diagnosis is confirmed by elevated titers of ebv. group a β-hemolytic streptococcus (gabhs, i.e., s. pyogenes) commonly infects the pharynx. in addition to sore throat, associated symptoms include fever, headache, and abdominal pain. associated signs include pharyngeal erythema, halitosis, tonsillar exudates, and tender adenopathy. diagnosis may be confirmed initially with a rapid streptococcal antigen test. because rapid antigen testing is more sensitive than formal plating on blood agar, a negative test does not need confirmation, but positive rapid streptococcal tests should be confirmed with formal plating. other bacterial pathogens that cause acute pharyngitis include haemophilus influenzae and groups c and g β-hemolytic streptococci. occasionally, concurrent infection with penicillin-resistant staphylococcus aureus may interfere with treatment of a gabhs infection. although many cases of gabhs infections respond to treatment with penicillin v or amoxicillin, emerging resistance to oropharyngeal pathogens mandates treatment of recalcitrant cases with an antibiotic having known effectiveness against β-lactamase-producing organisms. in cases in which a lack of compliance is suspected, intramuscular benzathine penicillin or ceftriaxone may be used. acute pharyngitis may also be associated with acute bacterial infections of the nose, nasopharynx, and sinuses. these infections may be caused by a variety of viral and bacterial pathogens; and in addition to sore throat, symptoms include fever, mucopurulent nasal drainage, nasal obstruction, and facial pain. recurrent infection of the pharynx may be either viral or bacterial. gabhs are the most worrisome bacterial organisms because recurrent infection may lead to complications such as scarlet fever, acute rheumatic fever, septic arthritis, and acute glomerulonephritis. in addition to a history of multiple positive cultures for s. pyogenes, elevated antistreptolysin-o (aso) titers may identify patients with chronic infection who are at risk for developing complications. some asymptomatic children may be chronic carriers of gabhs, and elevated aso titers may not be a reliable indicator for distinguishing between an active infection and the carrier state. treatment of recurrent streptococcal infection or the child who is a carrier should include a trial course of an antibiotic shown to reduce carriage (e.g., clindamycin, vancomycin, or rifampin). children with recurrent pharyngotonsillitis unresponsive to medical therapy or those who suffer a complication should be considered for surgical management. whereas treatment of each child should be individualized, suggested guidelines for surgical candidates include seven infections in year, five or more infections per year for years, or three or more infections per year for years. other factors to be considered in employing a surgical option include severity of infection, response to antibiotic therapy, loss of time from school, and need for hospitalization. the pharynx and specifically the tonsils may be the target of chronic infection. affected children complain of chronic throat pain, halitosis, and production of white particles or tonsilliths. signs include erythema of the tonsils, cryptic debris, and chronically enlarged cervical adenopathy. a variety of viral and bacterial agents can be blamed for chronic infection of the pharynx. cultures may or may not be positive in these patients, because surface cultures may be negative while core tissue is positive. antibiotic therapy directed at anaerobes or s. aureus may be helpful in resistant cases. children with infections unresponsive to medical management are candidates for tonsillectomy. localized extension of tonsillar infection may result in peritonsillar cellulitis. the same pathogens that cause acute pharyngotonsillitis are responsible for peritonsillar cellulitis. in addition to severe sore throat, symptoms and signs include drooling, trismus, muffled voice, ipsilateral referred otalgia, and tender lymphadenopathy. the affected tonsil is usually displaced in a medial and inferior position. peritonsillar cellulitis may progress to frank abscess formation (quinsy). early cases of peritonsillar cellulitis may respond to oral antibiotics, such as the penicillins, cephalosporins, erythromycins, or clindamycin. unresponsive cases of cellulitis or abscess should be treated with intravenous antibiotics. in children with suspected abscess formation, a variety of surgical drainage procedures can be performed. needle aspiration or incision and drainage have been shown to be equally effective. in persistent cases or in those children who will require general anesthesia for drainage, consideration should be given to performing a tonsillectomy (quinsy tonsillectomy). signs and symptoms of deep neck space (retropharyngeal/ parapharyngeal) infections that involve the pharynx typically present as fever, drooling, irritability, decreased oral intake, torticollis, and/or trismus. often there is a history of a preceding viral illness. stridor or symptoms of upper airway obstruction may be seen in half of patients. a neck mass or enlarged cervical nodes may be present depending on the location of the infection. usual pathogens include coagulase-positive staphylococci and gabhs. anaerobic bacteria have been found in as many as % of cases. complications of deep neck space infections include airway obstruction, bacteremia, rupture of the abscess into the pharynx with aspiration, mediastinal extension of infection, jugular thrombosis, and carotid artery rupture. in suspected cases, the diagnosis of a retropharyngeal/parapharyngeal space infection is confirmed with either contrast medium-enhanced ct or mri. widening of the retropharynx on a lateral neck radiograph suggests a retropharyngeal infection. while ultrasound can detect the presence of an abscess cavity, ct or mri are most helpful in demonstrating the extent of infection and the location of surrounding structures of importance, specifically the great vessels. contrast medium-enhanced ct is particularly useful in distinguishing a phlegmon (cellulitis) from cases of frank suppuration. demonstration of a hypodense region with surrounding rim enhancement has been shown to correlate with an abscess in % of cases (fig. - ) . the initial management of a deep neck infection should begin with intravenous antibiotics, including oxacillin, clindamycin, cefazolin, β-lactamase penicillins, or a combination thereof. surgical drainage should be reserved for those children who fail to show clinical improvement or progress to frank abscess formation on ct. the usual approach to surgical drainage is intraoral if the abscess points medial to the great vessels or extraoral if the infection points lateral to the great vessels. complications of deep neck infections should be treated aggressively. mediastinal spread requires prompt surgical drainage in most cases. an infected jugular thrombosis (lemierre's syndrome) can be a source of metastatic spread of infection as septic emboli. signs and symptoms include spiking chills and fever (picket-fence fevers) and a neck mass in spite of appropriate antibiotic therapy. ligature or excision of the infected thrombus may be required to eradicate the infection. in the past decade, the impact of sleep-disordered breathing (sdb) on the health of children has been well described, beginning with the report of normative sleep data by marcus and colleagues. children appear to have briefer but more frequent episodes of partial (hypopnea) and complete (apnea) obstruction. because an apnea of less than seconds may represent several missed breaths in a child, an apnea of any duration is abnormal. in most cases the site of obstruction during sleep is in the pharynx. in contrast to adults with this disorder in whom the pharyngeal impingement is due to adipose tissue surrounding the pharyngeal musculature, the major cause of airway obstruction in children results from adenotonsillar hypertrophy. the apnea index represents the number of apneas in an hour, with a normal value being less than in children. because most children have an increased frequency of partial obstructions compared with adults, a measure of hypopneas may be more significant. a hypopnea is variably described as a reduction in airflow or respiratory otolaryngologic disorders effort or oxygen desaturation or combination thereof. respiratory disturbance index is a measure of both apneas and hypopneas in an hour and may be a better reflection of sdb in children. a respiratory disturbance index greater than is abnormal. upper airway resistance syndrome represents obstructed breathing with normal respiratory indices but with sleep fragmentation and electroencephalographic arousals that indicate disordered sleep. the major group at risk for sdb includes children with adenotonsillar hypertrophy secondary to lymphoid hyperplasia (figs. - and - ). whereas the age of affected children ranges from years through adolescence, the prevalence mirrors the age of greatest lymphoid hyperplasia, to years, the age the tonsils and adenoids are largest in size. other at-risk groups include syndromic children with down syndrome, children with craniofacial disorders, and patients with cleft palate or storage diseases (hunter's, hurler's syndromes). adverse effects of obstructive sleep apnea on children include poor school performance, failure to thrive, facial and dental maldevelopment, and, rarely, severe cardiac impairment, including systemic hypertension, cardiac arrhythmias, and cor pulmonale. daytime symptoms include noisy mouth-breathing, nasal obstruction and congestion, hyponasal speech, and dyspnea on exertion. in contrast to adults, hypersomnolence is uncommon in children because of the lower incidence of gas exchange abnormalities, specifically hypercarbia. children may complain of headaches, seem irritable, and perform poorly in school. nighttime symptoms are more obvious and include snoring, gasping and choking respirations, apnea, coughing, and a variety of other behaviors including sleepwalking, sleeptalking, rocking, head banging, and bruxism. enuresis may appear in children with airway obstruction and then resolve after surgical treatment. in addition to enlarged tonsils, signs include the presence of a posterior pharyngeal flap in cleft palate patients, a craniofacial disorder, adenoid facies, and, rarely, evidence of right-sided heart failure. the diagnosis of sdb is suggested by history and physical examination. confirmation of obstruction and apnea may be made with overnight pulse oximetry and video or audio monitoring of sleep. the "gold standard" in the diagnosis of obstructive sleep apnea remains formal polysomnography, including measures of nasal and oral airflow, chest wall movements, electrocardiography, extraocular muscle movements, and gastric ph monitoring in selected cases. depending on the suspected site of obstruction, adjuvant studies such as a lateral neck radiograph, mri of the head and neck, and flexible upper airway endoscopy might be helpful. the nonsurgical management of sdb consists of weight loss in obese patients and treatment of underlying allergies and gastroesophageal reflux. nasal and dental appliances to maintain airway patency that may be useful in adults are usually poorly tolerated in children. nasal continuous positive airway pressure, the mainstay of treatment in adults, is tolerated in many children and should be considered as a treatment option, especially in patients in whom other therapies have been exhausted or proven ineffective. the initial surgical treatment for most children with sdb remains a tonsillectomy and adenoidectomy, a therapy that is usually curative. in patients with documented sleep apnea or a sleep disorder, both procedures should be utilized even if the tonsils appear small. tonsillectomy and adenoidectomy techniques that have been standard for decades have been supplanted in some institutions by new technology including use of coblation, harmonic scalpel, and the microdebrider. efficacy of these newer techniques over established methods remains unproven. complications after tonsillectomy and adenoidectomy usually consist of respiratory compromise and acute or delayed bleeding. since the advent of modern pediatric anesthesia, respiratory complications such as aspiration with resultant pneumonia and lung abscess are rare. humidification, corticosteroids, and antibiotics have all been shown to improve the postoperative course after tonsil and adenoid surgery. young children are most vulnerable to complications, and in most institutions children younger than years of age are observed overnight for signs of dehydration and respiratory compromise. adjuvant surgery in the management of sdb includes craniofacial repair or posterior flap revision surgery in appropriate patients. midface, mandibular, and hyoid advancement have proved useful in selected patients, along with nasal surgery such as septoplasty, partial inferior turbinectomy, or nasal polypectomy. tracheostomy remains the treatment of last resort in patients who fail to respond to other forms of therapy. ankyloglossia or tongue-tie is a common congenital disorder involving the lingual frenulum ( fig. - ). neonates with diminished tongue mobility due to a foreshortened frenulum may have problems in sucking and feeding. because the frenulum is thin and relatively avascular in neonates and young infants, it can often be incised as an office procedure. in older children the greatest effect of ankyloglossia is on speech. because the tip of the tongue curls under on extrusion and has limited lateral and superior movement, speech articulation may be affected. surgical treatment in these patients may require a short general anesthetic as the frenulum is thicker and more vascular, requiring surgical correction that includes either simple division with or without a z-plasty repair. macroglossia is uncommon. generalized macroglossia, as seen in association with omphalocele, visceromegaly, and adrenal and renal disorders (beckwith-wiedemann syndrome), with glycogen storage diseases (hunter's and hurler's syndromes) or hypothyroidism, is rare. relative macroglossia can be seen normally on occasion but is most common in down syndrome. the most serious complication of this condition is airway obstruction. in infants, macroglossia should be distinguished from focal enlargement of the tongue seen in patients with a lymphatic malformation or hemangioma. glossoptosis, posterior displacement of a normal-sized tongue, is seen in association with cleft palate and micrognathia in infants afflicted with the pierre robin sequence. infants with airway obstruction secondary to an enlarged or displaced tongue may require a tracheostomy. macroglossia in older children that affects cosmesis, interferes with speech, or causes drooling may be treated with a variety of tongue reduction techniques. epulis is a congenital granular cell tumor that typically presents as a soft, pink submucosal mass on the anterior alveolar ridge of the maxilla (fig. - ) . females are otolaryngologic disorders more commonly affected, and symptoms are usually confined to feeding problems. surgical excision is curative. ranula is a pseudocyst located in the floor of the mouth that may occur congenitally or result from intraoral trauma (fig. - ) . large ranulas may extend through the mylohyoid musculature and present in the neck as a "plunging ranula." treatment of ranulas is by excision or marsupialization of the pseudocyst, often in conjunction with excision of the sublingual gland. mucoceles are also pseudocysts of minor salivary gland origin and frequently rupture spontaneously. recurrent or symptomatic mucoceles respond to surgical excision. hemangioma is a proliferative endothelial lesion found commonly in the head and neck. their growth characteristics include enlargement during the first year of life, followed by spontaneous resolution. surgical excision or treatment with corticosteroids may be necessary in lesions that cause ulceration and bleeding, airway obstruction, cardiovascular compromise, or platelettrapping coagulopathy (kasabach-merritt syndrome). vascular malformations, including venous, arterial, or arteriovenous malformations, rarely occur in the oral cavity and pharynx and necessitate intervention only if they cause pain, bleeding, ulceration, or heart failure. management of complicated cases is by surgical excision or sclerotherapy for low-flow lesions (venous) and angiographic embolization for high-flow lesions. lymphatic malformation, formerly known as lymphangioma or cystic hygroma, is congenital and usually presents before years of age. histologically, lymphatic malformations consist of multiple dilated lymphatic channels or may contain either capillary or venous elements (venolymphatic malformations). lymphatic malformations can occur anywhere in the neck and may cause extensive cosmetic deformity and functional problems in cases with involvement of the tongue, floor of mouth, mandible, or larynx. surgical resection of lymphatic malformations may be fraught with difficulty because they lack a capsule and are infiltrative. during surgical excision, care should be taken to avoid damaging nearby vital structures, and debulking is an acceptable option to total radical excision in many cases. postoperative suction drains can be helpful in preventing the recurrence of lymphatic drainage under skin flaps. carbon dioxide laser therapy has been employed in superficial lymphatic malformations of the tongue, and sclerotherapy of large cystic lesions may be an option. foregut cysts are true cysts, lined with respiratory epithelium, that present in the floor of mouth and should be distinguished from dermoid cysts, lined with stratified squamous epithelium and skin appendages, which may also be found in this location. a thyroglossal duct cyst may rarely present in the base of the tongue. likewise, aberrant thyroid tissue, lingual thyroid, presents as a purple mass in the tongue base. thyroid tissue in this location is usually hypofunctioning, and affected children require thyroid supplementation. other aberrant rests of tissue, choristomas, consist of gastric, enteric, or neural tissue of normal histology in an abnormal location. second branchial cleft derivatives will rarely present as a cystic mass near the superior pole of the tonsil. their extent and associated tracts can be demonstrated on mri. tornwaldt's cyst is a blind pouch in the nasopharynx that represents a persistence of an embryonic connection between the primitive notochord and the pharynx. other benign nasopharyngeal masses include nasopharyngeal teratomas, dermoid lesions (hairy polyp), and nasopharyngeal encephaloceles. most of these lesions are best evaluated by ct and/or mri to determine their extent and the presence of an intracranial connection. surgical excision is curative in most cases. squamous papillomas are benign slow-growing lesions typically found on the soft palate, uvula, and tonsillar pillars and are the result of infection with serotypes , , or of the human papillomavirus (hpv). because of concern that these lesions could spread to the larynx or trachea, complete surgical excision is usually recommended. pleomorphic adenoma (mixed tumor) is a benign neoplasm of minor salivary glands with a predilection for the palate, although it may also be found in the lip and buccal mucosa. treatment is with surgical excision. rhabdomyosarcoma, the most frequent soft tissue malignancy of childhood, typically occurs in the -to -year age group and is derived from embryonic skeletal muscle. , in the oral cavity and oropharynx it presents as a rapidly growing mass in the tongue, palate, and uvula or cheek. these tumors metastasize early to local nodes, lung, and bone. surgical therapy is limited to biopsy, excision of small lesions, or surgical salvage of treatment failures. the usual therapy includes a combination of chemotherapy and radiation therapy. lymphoma of the oral cavity and oropharynx typically involves the lymphoid tissue of waldeyer's ring and presents as a mass of the tonsil or in the nasopharynx. the diagnosis may be suspected by evidence of involved adenopathy in the neck but is confirmed by surgical biopsy. treatment is with a combination of chemotherapy and radiation therapy. other rare malignant neoplasms of the oral cavity and pharynx include malignant salivary gland tumors (mucoepidermoid carcinoma) and epidermoid or squamous cell carcinoma. this latter tumor has been reported in organ transplant patients and adolescents who use snuff or chewing tobacco. treatment is usually surgical depending on the site and extent of involvement. with the exception of the hyoid bone, the major structural framework of the larynx consists of cartilage and soft tissue. the hyoid bone lies superior to the larynx and is attached to it by the thyrohyoid membrane and strap muscles. the hyoid bone is derived from the second and third branchial arches. the cartilaginous structures of the larynx are composed of hyaline cartilage, with the exception of the epiglottis, which is composed of elastic cartilage. the cartilaginous structures of the larynx develop from the fourth, fifth, and sixth branchial arches. there are nine laryngeal cartilages, three that are single (thyroid, cricoid, and epiglottis) and six that are paired (arytenoid, cuneiform, and corniculate). the thyroid cartilage consists of two quadrilateral cartilages that form the anterior framework of the larynx. the cricoid cartilage is the only complete cartilaginous structure in the airway and provides posterior stability and a base of support for the cricoarytenoid and cricothyroid joints. the cricothyroid muscles are paired extrinsic laryngeal muscles that serve to tilt the larynx down and forward, tensing the vocal folds. paired intrinsic muscles-the thyroarytenoid, thyroepiglottic, and aryepiglottic muscles-act as a sphincter to close the larynx. the vocalis muscle comprises the internal fibers of the thyroarytenoid muscle and attaches to the vocal ligament. action of this muscle serves to regulate the pitch of the vocal ligament. the other set of paired muscles includes the posterior cricoarytenoid, lateral cricoarytenoid, and interarytenoid muscles. the posterior cricoarytenoid muscles serve to abduct the vocal folds, whereas the cricoarytenoid and interarytenoid muscles adduct the vocal folds. the quadrangular membrane is a connective tissue covering of the superior larynx that ends in a free margin along the vestibular ligament of the false cord. the conus elasticus is a membrane of elastic tissue that extends superiorly from the cricoid cartilage to form the paired vocal ligaments, the supporting structures of the vocal folds. the blood supply of the larynx arises from the superior and inferior laryngeal arteries. the former is a branch of the superior thyroid artery, whereas the latter is a branch from the thyrocervical trunk. the intrinsic muscles of the larynx are innervated by the recurrent laryngeal nerve, which also supplies sensory branches to the inferior larynx. the superior laryngeal nerve has two branches: the external branch innervates the cricothyroid muscle, while the internal branch supplies sensation to the superior larynx. the larynx has multiple functions within the upper airway. during respiration, it regulates airflow by opening during inspiration. the posterior cricoarytenoid muscle contracts with each inspiration to abduct the cords just before activation of the diaphragm. the protective function of the larynx produces two reflexes: cough and closure. cough is important to expel mucus and foreign objects. the closure reflex serves to prevent aspiration of foreign matter. in addition to closure, the larynx elevates during swallowing. both closure and elevation occur simultaneously along with relaxation of the cricopharyngeus muscle during the swallow of a bolus. finally, the larynx plays an important role in speech production by generating sound. vibration of the mucosa covering the vocalis structures produces sound whose pitch and register is altered by changes in tension, length, and mass of the underlying vocalis muscle and ligament. the larynx of an infant sits much higher than that of an adult. the cricoid is located at the level of c , whereas the tip of the epiglottis is at c . the close approximation of the epiglottis to the soft palate makes the infant an obligate nose breather. by years of age, the larynx has descended to the level of c and reaches the adult level of c to c by puberty. the glottis of the newborn is mm in the anteroposterior dimension and mm in the lateral dimension. the narrowest area of the infant airway, the subglottis, is approximately mm in diameter. symptoms of acute airway obstruction include dyspnea, cough, vocal changes, dysphagia, and sore throat. dyspnea and rapid or labored breathing are indications of inadequate ventilation and may be triggered by changes in pco and po . a stimulus anywhere in the airway may produce cough. it is difficult to localize the site of the stimulus from the quality of the cough. changes in the child's vocal character such as hoarseness or a muffled or weak cry may help in localizing the area of obstruction. dysphagia for solids and/or liquids is often associated with airway obstruction. depending on the cause of airway obstruction, affected patients may complain of sore throat. the child's overall appearance is the first sign to be assessed in airway obstruction, because airway status often dictates how quickly further evaluation and intervention need to be performed. the level of consciousness should be determined because the unconscious or obtunded patient may need immediate airway management. along with cyanosis in a patient without cyanotic heart disease, the presence of anxiety, restlessness, and diaphoresis are all ominous signs of impending airway compromise. other symptoms of airway obstruction include tachypnea and substernal retractions. the child with airway obstruction is often tachycardic. the presence of bradycardia is a otolaryngologic disorders late indicator of severe hypoxia. the presence of a muffled cry often suggests obstruction at the level of the pharynx, whereas a barking cough is associated with laryngeal inflammation and edema. stertor is a snorting sound whose origin is often in the pharynx. stridor is noise produced by turbulent airflow in the laryngeal or tracheal airway. inspiratory stridor suggests turbulence at or above the glottis. expiratory stridor results from turbulent airflow in the distal trachea or bronchi. biphasic stridor suggests a tracheal source. the degree and loudness of the sound is not always indicative of the severity of obstruction, because stridor can become softer just before complete obstruction. other important signs of airway obstruction include drooling and use of accessory respiratory muscles. in addition to determination of the child's physical status, assessment of the degree of airway obstruction should include an evaluation of the ventilatory status. pulse oximetry provides an immediate record of arterial oxygenation while transcutaneous monitoring of co is a good indicator of ventilation. the lateral neck radiograph remains the best study for the initial evaluation of a child with airway obstruction because it demonstrates the anatomy from the tip of the nose to the thoracic inlet. the anteroposterior view of the neck is also helpful, specifically in defining areas of narrowing, such as a steeple sign associated with subglottic edema. a chest radiograph is also important in the initial assessment to identify foreign bodies or other conditions such as unilateral emphysema, atelectasis, or pneumonia that may account for the child's respiratory compromise. if time permits, a barium swallow or airway fluoroscopy may provide additional information. additional airway evaluation may include a brief flexible endoscopic examination. the nose is first sprayed with a combination of % lidocaine and oxymetazoline, and the child is gently restrained. the airway can be examined from the nares to the glottis. attempts to pass a flexible scope through the glottis in a child with airway obstruction should be avoided. likewise, flexible endoscopy should be avoided in a child with supraglottitis because of the possibility of precipitating complete obstruction. children with suspected airway pathology distal to the glottis or those in whom the possibility that flexible endoscopy could compromise the airway should undergo any airway examination in the operating room where rigid endoscopes and other airway equipment is immediately available to secure the airway if necessary. nonsurgical intervention in the child with acute airway obstruction may begin with just observation alone in a high surveillance unit. humidified oxygen administered by face mask will improve po and clearance of secretions. racemic epinephrine administered by nebulizer acts to reduce mucosal edema and is useful in conditions such as laryngotracheobronchitis (infectious croup). because its length of action lasts to minutes, treated patients should be observed for signs of rebound for to hours after administration. corticosteroids have been shown to have value in the management of postintubation croup, adenotonsillar hypertrophy that results from ebv infection, allergic edema, and spasmodic croup. use of corticosteroids in infectious croup and in infants with a subglottic hemangioma remains controversial. , other adjuvant therapies include antibiotics and inhalation of helium/oxygen mixture (heliox). although viral agents are often responsible for inflammation in the larynx and trachea, bacterial superinfection is also common. because of the prevalence of penicillin-resistant organisms, broad-spectrum antibiotics, including a higher-generation cephalosporin, penicillinase-resistant penicillin, or β-lactamase penicillin, are useful in preventing or eradicating infection. heliox is a mixture of gas in which helium is used to replace nitrogen. the advantage of the helium-oxygen mixture is that its low density reduces air turbulence and gas resistance, allowing improved delivery of oxygen in patients with airway obstruction. nonsurgical airway management may include use of nasal or oral airways, endotracheal intubation, and, rarely, transtracheal ventilation. nasal airways of rubber or other synthetic material can be easily inserted into the nose of most children after adequate lubrication with a water-soluble lubricant. their best use is in cases where the pharynx is the site of obstruction. oral airways are not as readily tolerated by children and only serve as a brief solution to an airway problem. during the s, endotracheal intubation with polyvinyl chloride tubes revolutionized the management of supraglottitis, and even today intubation remains the mainstay of initial airway therapy in most children with severe airway obstruction. the size of the endotracheal tube used correlates with the age of the child. the subglottis, the narrowest part of the infant airway, typically admits a . -or . -mm inner diameter tube. the tube used in children older than a year can be roughly estimated by using the following formula: tube size = ( + age in years) ÷ . once the airway has been established, the tube should be carefully secured and the child appropriately sedated and/or restrained if necessary to avoid accidental self-extubation. another method of airway management should be considered in children with an unstable cervical spine or in whom oral or neck trauma makes visualization difficult. transtracheal ventilation, insertion of a -gauge needle through the cricothyroid membrane for the delivery of oxygen, should be reserved for emergencies and used only until a more stable airway can be obtained. the surgical management of the child with acute airway obstruction should begin with endoscopy. the larynx can be visualized with one of a variety of pediatric laryngoscopes and the airway secured with a rigid pediatric ventilating bronchoscope of appropriate size. once the airway is secured, a more stable form of airway management can be utilized. rarely, in a child with acute airway obstruction, an airway cannot be established, and a cricothyrotomy may need to be performed. as in adults, this procedure avoids some of the risks of bleeding and pneumothorax inherent in a formal emergency tracheostomy. a small endotracheal or tracheostomy tube can be inserted through the incision in the cricothyroid membrane, but conversion should be made to a more stable airway as soon as possible. tracheostomy remains the preferred airway in cases of acute obstruction in which a translaryngeal approach is unsuccessful or must be avoided. the emergent tracheostomy should be avoided if at all possible to lessen complications of bleeding, pneumothorax, pneumomediastinum, subcutaneous emphysema, or damage to surrounding structures. the incidence of these complications can be reduced by careful attention to surgical technique, good lighting, and adequate assistance. laryngomalacia is the most common cause of newborn stridor and is caused by prolapse of the supraglottic structures (arytenoid cartilages, aryepiglottic folds) during inspiration ( fig. - ). symptoms typically appear at birth or soon thereafter and include inspiratory stridor, feeding difficulties, and, rarely, apnea or signs of severe airway obstruction. gastroesophageal reflux disease tends to worsen symptoms of laryngomalacia. the diagnosis is confirmed by flexible endoscopy of the larynx, and other airway pathology can be excluded with lateral neck, chest, and barium swallow radiography. in most cases, laryngomalacia is self-limited and resolves by months of age. changes in positioning and feeding, treatment of reflux, and, in some neonates, use of monitoring may be necessary. in severe cases, surgical intervention with either a supraglottoplasy (surgical division of the aryepiglottic folds) or a tracheostomy may be necessary. tracheobronchomalacia is defined as collapse of the tracheobronchial airway. it may be congenital or acquired (from long-standing intubation and infection) and may be segmental or involve the entire tracheobronchial tree. depending on the extent and location, symptoms include low-pitched biphasic stridor and signs of respiratory compromise. the diagnosis is usually made with endoscopy, although fluoroscopy of the airway may often demonstrate it. treatment ranges from observation in most cases to airway management with a tracheostomy tube and positive-pressure ventilation in severe cases. vocal fold paralysis is the second most common congenital laryngeal anomaly (after laryngomalacia) and may be unilateral or bilateral. congenital vocal fold paralysis may be caused by neurologic abnormalities (hydrocephalus, arnold-chiari malformation), birth trauma, or rarely in association with neoplasms of the larynx or neck. neonates with bilateral involvement typically present with highpitched inspiratory or biphasic stridor but a good cry. respiratory compromise and feeding difficulties may accompany the stridor. in infants with unilateral involvement, the airway may be adequate although a few infants will show evidence of compromise, especially during feeding. the cry is often hoarse or breathy. acquired vocal fold paralysis may result from trauma or from neoplasms of the chest or neck or may be iatrogenic, typically after surgery of the neck or arch of the aorta. the diagnosis of unilateral or bilateral vocal fold paralysis is confirmed with endoscopy. additional studies in the evaluation of patients with vocal fold paralysis include lateral neck and chest radiography, barium swallow, and ct or mri of the head and neck. most cases of unilateral involvement can be observed, but infants with bilateral vocal fold paralysis often require a tracheostomy. in addition, infants with associated feeding difficulties may necessitate a gastrostomy. in older children (> or years of age) a more permanent solution such as a cordotomy or arytenoidectomy can be considered to improve the glottic airway. congenital subglottic stenosis is the third most common congenital laryngeal anomaly and is defined as a neonatal larynx that fails to admit a . -mm endotracheal tube without a history of prior instrumentation or intubation ( fig. - ). the underlying abnormality is a cricoid cartilage that is either small or deformed. infants with congenital subglottic stenosis present with inspiratory or biphasic stridor, barking cough, and other symptoms of airway obstruction. the diagnosis is often suggested by narrowing of the subglottis on a lateral neck radiograph and confirmed by endoscopy. treatment depends on the severity of symptoms and ranges from observation to laryngeal reconstruction to tracheostomy. a child with a subglottic hemangioma presents with the onset of progressive stridor during the first few months of life (fig - ) . hemangiomas are proliferative endothelial lesions that can form in the submucosa of the posterior subglottis. occasionally, they may involve the subglottis in a circumferential pattern. associated cutaneous hemangiomas may be found in approximately % of patients. symptoms are dependent on the amount of airway compromise and include biphasic stridor, barking cough, difficulty feeding, and other symptoms and signs of airway obstruction. the diagnosis may be suggested on a lateral neck radiograph but is confirmed with endoscopy. nonsurgical management of infants with a subglottic hemangioma includes observation or treatment with systemic corticosteroids. surgical therapy includes laser excision, open excision through a laryngofissure, or a tracheostomy. a laryngocele is an air-filled dilatation of the saccule of the larynx that communicates with the laryngeal airway. it may present internally into the posterior superior false cord region or externally through the thyrohyoid membrane. a saccular cyst is fluid filled and protrudes between the true and false vocal folds. the diagnosis of this lesion is confirmed endoscopically, and ct of the larynx is helpful in assessing its extent and if it is fluid or air filled. treatment is with endoscopic marsupialization or excision through a laryngofissure. laryngotracheobronchitis (viral croup) is an inflammation of the subglottic airway caused by a variety of parainfluenza and influenza viral agents. the infection may involve the entire glottis and extend into the trachea and bronchi. affected children fall typically into the -to -year age group; males are more commonly affected than females. symptoms and signs of viral croup include biphasic stridor, barking cough, and hoarseness, often in association with a prodromal viral upper respiratory tract infection. the diagnosis of croup is made clinically, but endoscopic examination may help to exclude other pathologic processes. care should be taken not to instrument the subglottis, causing more swelling and inflammation and precipitating acute obstruction. lateral neck radiography demonstrates subglottic narrowing, whereas anteroposterior neck films show a "steeple sign," the result of subglottic edema. treatment of viral croup is typically supportive with humidification. use of corticosteroids remains controversial. treatment with nebulized racemic epinephrine in the emergency department or hospital setting often relieves symptoms; however, rebound of signs may occur several hours later and children should be monitored accordingly. severely affected children may require intubation for respiratory failure. a smaller than normal tube should be employed. in rare cases, a tracheostomy may be required if the inflammation fails to resolve. a child younger than year of age with recurrent bouts of "croup" should be suspected of having either congenital subglottic stenosis or a hemangioma. spasmodic croup is the recurrence of croup-like symptoms in a child who is otherwise well. fever is rarely present, and the attacks frequently occur at night. gastroesophageal reflux disease has been suggested as a possible inciting process. treatment of spasmodic croup is usually observant, although corticosteroids or reflux medications may prove beneficial. supraglottitis (epiglottitis) is an infectious disease that involves the supraglottic larynx. in children the typical pathogen is type b haemophilus influenzae (hib). other pathogens have been implicated in adolescent and adult cases. the incidence of supraglottitis in children has diminished markedly since the introduction of the conjugated hib vaccine in the early s. affected children are somewhat older than those seen with croup-in the -to -year age group. symptoms and signs have a rapid onset, progress quickly to frank airway obstruction, and include stridor, dysphagia, fever, muffled voice, and signs of systemic toxicity. affected children frequently sit and assume the "sniffing" position in an attempt to maximize their airway. intraoral or endoscopic examination should be avoided in suspected patients because of concern for precipitating complete obstruction. lateral neck radiography demonstrates a classic "thumbprinting" of the epiglottis but should only be obtained if facilities are present in close proximity to secure the airway. prompt airway management is essential in children with supraglottitis. the child's airway should be secured in either the emergency department or operating room with team members who include a pediatrician, anesthesiologist, critical care physician, otolaryngologist, or pediatric surgeon or others familiar with the pediatric airway. after inducing the child with general anesthesia, the airway should be intubated. examination of the supraglottis may be made, and cultures of the larynx and blood are obtained. equipment to perform a tracheostomy should be readily available. the child should remain intubated for to hours and should be supported with intravenous fluids and antibiotics that treat antibioticresistant haemophilus (third-generation cephalosporins, chloramphenicol). bacterial tracheitis (membranous croup) often occurs as a complication of another infection, such as measles, varicella, or other viral agents. the most common organisms include s. aureus, gabhs, m. catarrhalis, or h. influenzae. it can occur in any age child and present with stridor, barking cough, and low-grade fever. symptoms and signs then progress to include high fever and increasing obstruction and toxicity. the diagnosis may be suspected by diffuse narrowing of the tracheal air shadow on chest radiograph but is confirmed by endoscopic examination in the operating room. purulent debris and crusts can be removed at this time. cultures of secretions and crusts may be helpful in guiding intravenous antibiotic therapy that should be aimed initially at the usual pathogens. the airway should be secured with an endotracheal tube or, rarely, a tracheostomy. repeat endoscopic examination of the airway may be warranted to continue débridement and to determine the feasibility of extubation. the chronic management of subglottic stenosis and other prolonged airway disorders is discussed in chapter . recurrent respiratory papillomatosis is the most common benign neoplasm of the larynx in children. squamous papillomas involve the larynx and occasionally the trachea and lower respiratory tract as exophytic lesions. because of its recurrent nature, recurrent respiratory papillomatosis causes morbidity and, rarely, mortality due to malignant degeneration. patients may be almost any age, but the disease is more aggressive in children. human papillomavirus subtypes , , , and have all been identified within papilloma tissue. the first two subtypes have been associated with genital warts, whereas the latter two have been associated with cervical and laryngeal cancers. the exact mechanism of human papillomavirus infection in the larynx remains unknown. transmission of virus to the child from a mother with genital warts is suspected in many cases, but there is no concrete evidence to support this route of infection. children afflicted with recurrent respiratory papillomatosis present initially with hoarseness but may also have symptoms and signs of airway obstruction, including stridor. lateral neck radiography may suggest laryngeal involvement, but the diagnosis is confirmed by direct laryngoscopy and biopsy (fig. - ). in addition to the trachea and bronchi, squamous papillomas may also be found in the oral cavity. surgical excision is the mainstay of therapy in patients with recurrent respiratory papillomatosis. in the past, papillomas were excised using the carbon dioxide laser. more recently, the laryngeal microdebrider has become the preferred method of excision in many centers. in aggressive cases with swift recurrence and accompanying airway obstruction, tracheostomy may be necessary for airway management, although tracheostomy has been implicated in the spread of disease to the trachea and lower respiratory tract. medical adjuvant therapy that has been employed with mixed results includes interferon, photodynamic therapy with dihematoporphyrin ether, indole- -carbinol, or antiviral agents such as cidofovir. other benign laryngeal neoplasms are rare and include connective tissue tumors such as chondromas or fibromas, neurogenic tumors such as neurofibromas, or granular cell tumors and other cell types such as hamartomas or fibrous histiocytomas. malignant tumors of the larynx are also rare and include squamous cell carcinoma and a variety of epithelial and connective tissue malignancies such as spindle cell carcinoma, rhabdomyosarcoma, mucoepidermoid carcinoma, and chondrosarcoma. metastatic tumors and lymphoma may also rarely involve the larynx in children. diagnosis is suspected by the sudden appearance of stridor, hoarseness, and airway obstruction and confirmed by biopsy. treatment is dependent on cell type and may include surgical excision, radiation therapy, and/or chemotherapy. the surgical anatomy and embryology of the neck is discussed in chapter . the initial examination of a disease or disorder of the neck begins with a thorough history. a detailed history can often serve to focus the differential diagnosis of a neck disorder. the age of the child is an important otolaryngologic disorders first consideration. the appearance of a neck mass in an infant often suggests a congenital disorder, whereas the sudden appearance of a mass in an adolescent might suggest a malignant process. inflammatory diseases of the neck may occur in any age group but typically mirror the incidence of upper respiratory tract infections in children. growth and temporal relationships are often important clues to a diagnosis. neck masses that grow rapidly suggest either an inflammatory or malignant process, whereas slow-growing masses are typically benign. a history of systemic infection elsewhere in the body or recent travel or exposure to farm animals often points to an infectious origin. a history of trauma to the neck may explain the sudden appearance of a neck mass. likewise, changes in the size of a neck mass with eating may suggest a salivary gland origin. vascular lesions enlarge with straining or crying. finally, systemic symptoms of fever, weight loss, night sweats, or fatigue in association with the sudden development of a neck mass may indicate a malignant process. the physical examination of a child with a neck mass should begin with a comprehensive examination of the entire head and neck. because the vascular, neural, and lymphatic patterns of the head drain into the neck, the source of neck disorders may be found in the head. depending on the differential diagnosis, a physical examination of the entire body, including an assessment of lymph nodes in the groin and axillae and the presence of an enlarged spleen or liver, is essential. palpable lymph nodes in the neck of children are a common finding, but lymph nodes larger than cm fall outside the range of normal hyperplastic nodes and should be either monitored or investigated. the sudden appearance of large nodes in either the posterior cervical or supraclavicular regions may suggest a malignancy. the consistency of a neck mass is also important in narrowing the differential diagnosis. hard masses tend to be associated with either infection or malignancy. fixation of a neck mass to skin or nearby structures is also suggestive of a malignancy. cysts or abscesses tend to have a characteristic feel on palpation. depending on the differential diagnosis after a history and physical examination, radiologic studies may be useful. a lateral neck radiograph may demonstrate an abnormality of the nasopharynx, retropharynx, or cervical spine. likewise, a chest radiograph may identify a malignancy, sarcoidosis, or tuberculosis. infection or a neoplastic process in the sinuses may appear on a sinus series. ct and mri are useful in the evaluation of a neck mass. demonstration of hypodensity on ct suggests an inflammatory or necrotic process. ring enhancement of a hypodense region on a contrast ct scan is indicative of an abscess. mri is excellent for distinguishing fine detail within soft tissue and in the evaluation of vascular lesions of the neck. finally, ultrasound is helpful in distinguishing solid and cystic masses. use of ultrasound preoperatively in patients with a thyroglossal duct cyst is also a simple and economic way to assess the presence of normal thyroid tissue when it is not easily felt. ultrasound and thyroid scanning should be employed in the assessment of any thyroid mass. selected laboratory studies may be helpful in the evaluation of a child with a neck disorder. a complete blood cell count with differential may identify patients with either a malignancy or systemic infection. serologic testing for ebv or cytomegalovirus infection, toxoplasmosis, or cat-scratch disease may be diagnostic. thyroid function testing is essential in any child with a suspected thyroid disorder. finally, collection of urine for catecholamine metabolites (vanillylmandelic acid) may assist in the diagnosis of neuroblastoma. if the diagnosis remains in doubt at this point, incisional or excisional biopsy may be indicated. biopsy provides material for pathologic examination, culture, and other more sophisticated testing if necessary. fine-needle aspiration of a neck mass in children for suspected malignancy is not as reliable as in adults. congenital sinuses and cysts are discussed in chapter . viral adenitis is the most common infectious disorder to involve the neck in children. enlarged or hyperplastic lymph nodes are frequently the result of viral upper respiratory tract illnesses. common pathogens include rhinovirus, adenovirus, and enterovirus, but measles, mumps, rubella, varicella, ebv, and cytomegalovirus may also cause lymphadenopathy. the diagnosis is often suspected by other findings in the history or physical examination and can be confirmed by serologic testing. acute human immunodeficiency virus infection may present, as do other viral syndromes, with fever, headache, malaise, gastrointestinal symptoms, and a neck mass. the usual source of bacterial cervical adenitis is the pharynx. causative organisms are often streptococcal or staphylococcal species. patients present with systemic symptoms of fever and malaise in addition to a neck mass that is diffusely swollen, erythematous, and tender. in contrast to viral adenitis, which is frequently bilateral, bacterial infections of the neck are usually unilateral. ct with contrast medium enhancement may be helpful in the evaluation of large infectious neck masses that may contain an abscess cavity. needle aspiration of suspected infectious masses may provide material for culture and decompress the mass. broad-spectrum antibiotic therapy, administered either orally or intravenously, may be curative, although surgical drainage is usually necessary in extensive cases. cat-scratch disease is caused by bartonella henselae infection. the clinical picture includes the sudden appearance of unilateral lymphadenopathy after a scratch from a cat. fever and malaise may be accompanying symptoms in many cases. serologic testing for antibodies to bartonella is diagnostic. cat-scratch disease is usually self-limited, although some benefit has been described with the use of erythromycins and other antibiotics. in the past most mycobacterial infections have been caused by atypical organisms such as mycobacterium avium-intracellulare, m. scrofulaceum, m. bovis, or m. kansasii. in the past decade or so, mycobacterial tuberculosis has made a resurgence as the pathogen responsible for a neck infection. atypical mycobacterial infections present as nontender nodes in the preauricular, intraparotid, or posterior triangle regions. the skin overlying the node typically assumes a violet color, and systemic symptoms are rare. a chest radiograph should be obtained if m. tuberculosis is suspected. the diagnosis is made by obtaining material for acid-fast stain and culture with needle aspiration, surgical drainage, or excision of involved nodes. surgical curettage or total excision is curative for atypical lesions. tuberculosis should be treated with appropriate antituberculin chemotherapy. rarely, the neck may be involved with infections such as tularemia, brucellosis, actinomycosis, plague, histoplasmosis, or toxoplasmosis. inflammatory disorders that may affect the neck include kawasaki syndrome, sarcoidosis, sinus histiocytosis (rosai-dorfman disease), kikuchi-fujimoto disease, and pfapa syndrome (periodic recurrent fever). thyroid malignancies are not uncommon in the adolescent age group, with % of thyroid carcinomas occurring in patients younger than years of age. welldifferentiated tumors, usually papillary carcinoma, make up the majority of tumors. follicular, mixed, and medullary tumors occur less commonly. most patients present with a painless midline neck mass. on presentation, cervical adenopathy can be palpated in a majority of patients, a finding that reflects the high incidence of papillary disease that metastasizes via the lymphatics. other important symptoms and signs include a rapid rate of growth, pain, hoarseness, and dysphagia. children who have received prior radiation are at greater risk of thyroid malignancy. the occurrence of thyroid malignancy may be associated with iodine deficiency, hashimoto's thyroiditis, and graves' disease. , preoperative assessment should include thyroid nucleotide scanning to distinguish between cold (hypofunctioning) and hot (hyperfunctioning) nodules. up to a third of cold nodules can be malignant, whereas hot nodules are rarely malignant. ultrasonography can distinguish between solid and cystic lesions, and fine-needle aspiration is an alternative to surgical biopsy for diagnosis. surgical management includes near-total or total thyroidectomy, neck dissection if indicated, and postoperative i ablation. lymphoma is a common pediatric malignancy and can present in the neck as painless lymphadenopathy. hodgkin's disease occurs most often in late adolescence and has four histologic subtypes: lymphocyte predominance, nodular sclerosing, mixed cellularity, and lymphocyte depletion. lymphocyte predominance and nodular sclerosing types make up most cases. staging of hodgkin's disease depends on the amount and location of nodal involvement and the presence or absence of systemic or b symptoms (fever, night sweats, weight loss). treatment is with multiple-agent chemotherapy and localized radiation therapy. non-hodgkin's lymphoma can be divided into low-, intermediate-, or high-grade subtypes. high-grade tumors may be further divided into large cell, lymphoblastic, and small cell types. staging of non-hodgkin's lymphoma is by location and extent. treatment is with multiple-agent chemotherapy. langerhans' cell histiocytosis (previously histiocytosis x) includes the disease entities known as eosinophilic granuloma, hand-schüller-christian syndrome, and letterer-siwe disease. the exact nature of this entity remains an enigma: it may represent a neoplasm or a hyperimmune response. symptoms and signs include lymphadenopathy, rashes, otorrhea, oral lesions, and hepatosplenomegaly. diagnosis is dependent on the identification of langerhan's cells on pathologic specimens. treatment ranges from curettage or excision to intralesional or systemic corticosteroids to chemotherapy and radiation therapy. two major categories of neural tumors may be found in the neck. neurofibromatosis is a benign disorder that in some forms (plexiform) may infiltrate surrounding tissues. for this reason, ct and/or mri are vital in the preoperative evaluation of these lesions. surgical resection is the mainstay of treatment. neuroblastoma is a malignancy that develops from neural crest cells and may present as a solitary tumor or as lymphadenopathy. clinical staging determines the mode of therapy that includes surgery, chemotherapy, and radiation therapy. rhabdomyosarcoma rarely presents as a primary tumor in the neck, more often being found as a primary tumor in the orbit, temporal bone, or nasopharynx. the diagnosis is made by biopsy, and patients are staged according to involvement. treatment includes surgery, chemotherapy, and radiation therapy. malignancies of almost any type and location in the body can metastasize to the neck. the most common are thyroid malignancies. in adolescents, carcinomas, especially those arising in the nasopharynx, may spread to the neck lymphatics. anatomy and embryology of the paranasal sinuses otitis media and eustachian tube dysfunction cancer of the thyroid in youth pediatric malignancies neoplasms of the ear and temporal bone congenital malformations of the temporal bone head and neck langerhans' cell histiocytosis otolaryngologic disorders lymphomas of the head and neck thyroid tumors in children corticosteroids in airway management allergic fungal sinusitis: pathophysiology, epidemiology and diagnosis solitary thyroid nodules in children and adolescents glomus tympanicum in infancy grading system for the selection of patients with congenital aural atresia an evidence-based review of the treatment of peritonsillar abscess steroid treatment of laryngotracheitis: a meta-analysis of the evidence from randomized trials childhood epiglottitis in recent years is fetal cellular rhabdomyoma an entity or a differentiated rhabdomyosarcoma? a study of patients with rhabdomyoma of the tongue and sarcoma of the tongue enrolled in the intergroup rhabdomyosarcoma studies i, ii and iii squamous cell carcinoma of the tongue in a nine-year renal transplant survivor: a case report with a discussion of the risk of development of epithelial carcinoma in renal transplant survivors normal polysomnographic values for children and adolescents current knowledge of bartonella species thyroid carcinoma in children and adolescents pediatric audiology efficacy of tonsillectomy for recurrent throat infection in severely affected children: results of parallel randomized and nonrandomized clinical trials first-line treatment of otitis media structure and function of the temporal bone surgical pediatric otolaryngology influence of penicillin-producing staphylococci and the eradication of group a streptococci from the upper respiratory tract by penicillin treatments angiofibroma: changes in staging and treatment regional and intracranial complications of sinuses pediatric neck masses: guidelines for evaluation computed tomography in the evaluation of pediatric neck infections pediatric cochlear implantation key: cord- - ukn xbr authors: di girolamo, nicola; selleri, paolo title: medical and surgical emergencies in ferrets date: - - journal: vet clin north am exot anim pract doi: . /j.cvex. . . sha: doc_id: cord_uid: ukn xbr in the last few years, significant improvement in diagnosis and treatment of ferret emergencies has occurred. scientific advances demonstrated the need of specific practices when dealing with emergencies in ferrets. the risk of overdiagnosis of hypoglycemia with human portable blood glucose meters is a clear example. the purpose of this article is to describe the current approach to common medical and surgical emergencies in ferrets. seizures commonly occur in ferrets and may be consequent to a wide variety of causes. however, true spontaneous epileptic seizures have never been described in ferrets, and seizures are usually reactive, that is, caused by metabolic or toxic conditions. hypoglycemia is considered the most common condition causing seizures in ferrets; however, other conditions, including electrolyte disorders, intoxication, hepatic encephalopathy, hypothyroidism, uremic encephalopathy, hypoxia, and hyperglycemia, may also be the cause. hypoglycemia hypoglycemic seizures are an extremely common emergency presentation in ferrets. typically, hypoglycemia in ferrets is the consequence of hyperinsulinemia caused by pancreatic b-cell tumors (ie, insulinomas). [ ] [ ] [ ] other causes that should be included in the differentials for hypoglycemia include anorexia, liver disorders, and hypoadrenocorticism. ferrets with severe hypoglycemic crises are usually stuporous and may present with opisthotonus (video ) and nystagmus (video ). often the crises are accompanied by vocalizations (video ). diagnosis of hypoglycemia is based on detection of a blood glucose level lower than to mg/dl. , although tempting for its easiness, diagnosis of hypoglycemia should never be based only on the use of portable blood glucose meters (pbgm). pbgm for use in humans unpredictably underestimate blood glucose in ferrets and have specificity for diagnosis of hypoglycemia in ferrets of %, which means that half of the ferrets in which the pbgm detect hypoglycemia are actually normoglycemic (false positives). pbgm developed for canine and feline patients (alphatrak, abbott, abbott park, il) provide results that are more in agreement with laboratory analyzers. however, given the clinical importance of the diagnosis, these methods should be mainly used for screening and monitoring instead of for diagnosing. instead, the diagnosis on presentation should be based on a hexokinase-based laboratory analyzer whenever possible. an empirical approach to the ferret presented with suspected hypoglycemic seizures is as follows: placement of an intravenous (iv) catheter preferably in the cephalic vein (fig. ) under manual restraint. alternatively, catheterize the saphenous or jugular vein (fig. ) . intraosseous catheterization should be avoided, because with proper technique, iv catheterization is almost always feasible. collect an adequate amount of blood from the catheter itself in a lithiumheparin-coated tube. alternatively, obtain a blood sample to be placed in the collection tube under manual restraint (figs. and ). immediate measurement of glucose with a point-of-care device that uses the hexokinase method (eg, vetscan vs , abaxis, darmstadt, germany). ideally, concurrently measure other electrolytes, including ionized calcium. if hypoglycemia is confirmed, slow administration of a bolus of % glucose solution or % dextrose solution ( - ml) followed by constant-rate infusion (cri) of % glucose ( ml/kg/h). notice that there is potential risk of phlebitis by using high osmotic solutions. if the seizures persist, a second bolus of glucose/dextrose solution and administration of diazepam (rectally or iv, . mg/kg; cri, . - . mg/kg/h) or midazolam (rectally or iv, . mg/kg; cri, . mg/kg/h) may be administered. if available, a cri of glucagon may be administered at a rate of ng/kg/min ( . ng/lb/min). serial monitoring (ie, every - hours) of glucose concentration with a hexokinase method. after management of hypoglycemic crisis and stabilization of the ferret, ultrasound of the pancreas assists in the identification of neoplasia (fig. ) . surgery, especially when partial pancreatectomy is performed, has a good prognosis (fig. ) . however, recurrences do occur, and in such cases, medical treatment may palliate the symptoms. medical treatment for long-term management of insulinomic ferrets may include corticosteroids, diazoxide, and octreotide, among other drugs. a less common cause of seizures in ferrets is severe hypocalcemia. for the diagnosis, complete blood work, including ionized calcium, is indicated. although no proper reference ranges for ionized calcium in ferrets are established, values higher than . mmol/l may be considered normal based on dogs' and cats' reference ranges (reference needed and unpublished data). currently, there are point-of-care devices that evaluate ionized calcium along with the other electrolytes requiring only . mls of whole blood (eg, cg cartridge, i-stat, abaxis, darmstadt, germany); however, their validity in ferrets has not been assessed. differential diagnoses for hypocalcemia should include hypoparathyroidism, pseudohypoparathyroidism, hypomagnesemia, renal failure, acute pancreatitis, hypoalbuminemia, puerperal tetany, ethylene glycol intoxication, intestinal malabsorption, nutritional secondary hyperparathyroidism, and tumor lysis syndrome. , among these causes, primary hypoparathyroidism has been recently diagnosed in ferrets and pseudohypoparathyroidism in another ferret. [ ] [ ] [ ] diagnosis of these conditions is based on a combination of low-serum ionized calcium concentration, high-serum phosphorus concentration, and appropriate renal function (based on serum chemistry values of serum urea nitrogen and creatinine) in the face of low parathyroid hormone (pth) concentrations (hypoparathyroidism) or high pth concentrations (pseudohypoparathyroidism). emergency treatment of hypocalcemic seizures is managed by cri administration of calcium gluconate at to mg/kg/h, with continuous ecg monitoring controlling for bradycardia, ventricular premature complexes/contractions, or shortening of the qt interval (fig. ) . , in case of spontaneous primary hypoparathyroidism, long-term maintenance therapy with dihydrotachysterol (orally, - mg/kg/d) and calcium monitoring is indicated to control clinical signs. other disorders that occasionally cause central neurologic signs and seizures in ferrets include brain tumors, intoxication, and infectious diseases (viral, fungal, and protozoan infections), including distemper, rabies, aleutian disease, systemic coronavirus, cryptococcus, and toxoplasma gondii infection (fig. ). , - anemia in ferrets should be worked up as in other domestic animals. a preliminary diagnosis of anemia is formulated based on clinical features (fig. ) and hematology (hematocrit < %). most causes of anemia in other animals also occur in ferrets, including immune-mediated forms. typical causes of anemia in ferrets are lymphoma and hyperestrogenism. hyperestrogenism may be secondary to prolonged estrus in female ferrets (either intact or neutered with ovarian remnant), adrenal disorders, or, rarely, estrogenproducing tumors (fig. ) . [ ] [ ] [ ] [ ] [ ] the mechanism behind anemia in intact female ferrets is from the lack of spontaneous ovulation. in the absence of copulation, ovulation does not occur, and the maintained production of estrogens by the follicles may result in bone marrow aplasia, with consequent pancytopenia. , clinical signs of hyperestrogenism in female ferrets include swelling of the vulva, alopecia, and pruritus, among others ( fig. ) . in male ferrets, gynecomastia and dysuria as a consequence of prostatic cysts are occasionally observed during hyperestrogenism. emergency treatment includes ( ) stabilization of the ferret and ( ) removal of the source of endogenous estrogen production. transfusions are anecdotally indicated for hematocrit values lower than %. ferrets do not have clinically significant blood groups ; therefore, any healthy adult male ferret is an appropriate donor. as a clinical guide, avoid sampling more than % of the ferret body weight (ie, in a . -kg ferret, ml of blood). some investigators suggest drawing blood with cardiac puncture to permit a rapid, clot-free collection. however, in the author's clinical experience, transfusion is safely performed even with blood samples obtained from the cranial vena cava with a -g needle and use of a -mm clot filter (fig. ) . rate of administration of blood for the recipient depends on the underlying disorder (ie, acute vs chronic loss) and ranges from minutes to a maximum of hours. ferret blood stored using citrate-phosphate-dextroseadenine should not be used for transfusion after days of storage at c. hyperestrogenism from persistent-estrus currently, gonadectomy in ferrets is discouraged given the consequent increase in risk of developing adrenal disease. therefore, alternative medical treatments should be elected. in ferrets, ovulation may be induced with the following , , : human chorionic gonadotropin ( iu) medroxyprogesterone ( mg) proligestone ( mg) gonadotropin-releasing hormone (gnrh; mg/kg) long-term depot gnrh agonists ( . mg deslorelin acetate [suprelorin, virbac]) hyperestrogenism from adrenal hyperplasia or neoplasia current therapies for adrenal disease in ferrets include medical and/or surgical treatment. the gnrh agonist, deslorelin acetate, . -mg dose proved to be an interesting alternative to surgical adrenalectomy. however, in ferrets that do not respond to medical treatment (ie, persistence of symptoms, evidence of increase in size of the adrenal gland ) (fig. ) , surgery is indicated (fig. ). percutaneous ultrasound-guided alcoholization of the adrenal gland may be a palliative alternative (fig. ). hyperestrogenism from estrogen-producing tumors the treatment of choice depends on type of tumor, location, and so on. ideally, as soon as the ferret is stabilized, prompt surgical removal is indicated to discontinue estrogen production. because of their curious nature and strong jaws that allow them to open pill vials and sealed containers, ferrets are prone to toxin exposure. because of their small size, even small ingestions of a toxicant can lead to a large exposure on a milligram per kilogram basis. furthermore, intoxication in ferrets may occur as a consequence of inherited defects, as in the case of copper toxicosis. the treatment of toxicity in ferrets should be approached the same as in any other species. general treatments should be started and, when available, specific therapy for a toxicant should be instituted. if there is substantial evidence of recent intoxication (ie, within hours), when indicated, emesis can be achieved with oral administration of % hydrogen peroxide ( . ml/kg), syrup of ipecac ( . - ml/kg, orally), or apomorphine ( . mg/kg, iv, subcutaneously, or intramuscularly [im]). , emesis should not be induced for ingestion of corrosives such as alkalis, acids, cationic detergents, and petroleum distillates. finally, if the animal is already symptomatic (eg, vomiting, depressed, seizuring), induction of emesis is not indicated. a single tablet of common size ibuprofen ( mg) could be fatal to an average-sized ferret. common presenting complaints include the following neurologic signs ( . % of ferrets with presumed toxicosis): depression, coma, ataxia, recumbency, tremors, and weakness gastrointestinal (gi) signs ( . %): anorexia, vomiting, retching or gagging, diarrhea, and melena renal signs: polydipsia, polyuria, dysuria, renal failure other findings: shallow breathing, metabolic acidosis, dehydration, and hypothermia. treatment for ibuprofen toxicosis in the ferret includes stabilization, gi decontamination, fluid diuresis, gi protection, and supportive care. the ingestion of ibuprofen has an unfavorable prognosis unless the animal is decontaminated early and given aggressive treatment. however, in a retrospective study of suspect ibuprofen toxicosis, death was reported in only % of cases ( / cases). anticoagulant rodenticides interfere with the liver's production of clotting factors ii, vii, ix, and x. signs of hemorrhage are not evident right after intoxication, typically taking to days after ingestion to occur. hemorrhages may occur anywhere, including thorax, abdomen, subcutis, and central nervous system (fig. ) . emergency treatment should be aimed at stopping hemorrhage, correcting anemia, and supplementing vitamin k . although there is a lack of clinical research data on ferrets, vitamin k is empirically indicated at a dose of mg/kg divided every to hours. oral vitamin k should be given with a fatty meal because bile acids are needed for its absorption, while injections are generally discouraged for the risk of anaphylactic reactions. plasma or whole blood may be given in symptomatic ferrets to provide clotting factors. in case of anemia, whole blood transfusions are indicated. course of treatment depends on the rodenticide (around - weeks) during which coagulation parameters should be monitored (table ) . , ferrets presented with an acute onset of abdominal pain should be closely evaluated, because the underlying cause of acute abdomen in the ferret may be minor and transient or an immediately life-threatening process. acute abdomen may result from specific injury or disease of the peritoneal or retroperitoneal structures, diaphragm, or body wall constituents, with pain from the spine also frequently referred as abdominal pain. gi foreign bodies are particularly common in ferrets, especially in young individuals. ferrets seem to be attracted to plastic and latex objects. vomiting and/or diarrhea are frequent presenting complaints. occasionally, gastric dilatation-volvulus may occur. radiography and ultrasonography are usually sufficient for diagnosis (fig. a) , although in some instances, other diagnostic techniques are required (fig. b) . obstructing intestinal foreign bodies should be considered a surgical emergency, and exploratory laparotomy should be performed as soon as the ferret is able to withstand general anesthesia (fig. ) . intestinal perforation may occur as a consequence of gi foreign bodies or neoplasia of the intestinal tract and should be considered a surgical emergency. treatment consists of stabilization of the patient and resection of the affected tract of the intestine (fig. ) . in cases of perforating foreign bodies, excision of a small area of intestine around the perforation (after foreign body removal) may be a valid alternative to end-to-end anastomosis. in the author's experience, the prognosis is generally guarded. biliary disorders are increasingly being diagnosed in ferrets. , ferrets with biliary disorders may present with discolored (acholic) feces (fig. ) , icteric mucus membranes, vomiting, anorexia, and lethargy. alanine aminotransferase (alt) and total bilirubin are usually elevated (reference ranges, alt: - u/l; total bilirubin: . - . ). ultrasonography of the gallbladder may identify surgical emergencies (ie, obstruction and rupture; fig. a ). usually requires immediate surgical treatment, with removal of the cholelith (fig. b) . depending on the severity of the disorder, it may be appropriate to attempt medical treatment, such as antibiotics, gastroprotectants, and ursodeoxycholic acid (fig. a, b) . in severe cases, cholecystectomy is indicated (fig. c) . rupture of the gallbladder requires immediate surgical treatment, consisting of cholecystectomy and peritoneal lavage (fig. ) . conditions requiring immediate surgical treatment include splenic torsion and rupture. both are quite uncommon in ferrets. splenomegaly is a more common condition but usually does not require emergency treatment. however, in some cases, generalized splenomegaly (hypersplenism) or large splenic masses may result in weakness, lethargy, anorexia, and even vomiting from mechanical compression of the stomach (fig. a) . in these cases, splenectomy may resolve the symptoms (fig. b) . , histology should always be performed on the removed spleen for diagnosis of subtle lymphomas. intervertebral disk prolapse in ferrets generally occurs at the level of the lumbar vertebrae and results in ambulatory deficits of the hind limbs (video ). , vertebral trauma can lead to a similar clinical presentation. such alteration should not be confused with the common hind limb weakness that affects ferrets in a variety of conditions, including hypoglycemia and congestive heart failure (chf), or with paresis related to neuromuscular disease, as in a course of myasthenia gravis or disseminated idiopathic myositis. , a preliminary indication during emergency consultation may be provided by radiographs of the lumbar vertebrae. definitive diagnosis requires myelography, computed tomography (ct), or mri, although the latter techniques are preferred. treatment options include hemilaminectomy and/or conservative physiotherapy, hydrotherapy, and low-level laser therapy. , , in ferrets, acute kidney injury (aki) (acute renal failure) may result from prostatic disease, urolithiasis, ureteral obstruction (stenotic and retrocaval ureters), toxic exposure, and infectious disease (fig. ) . , - initial laboratory evaluation should include a complete blood count, serum biochemistry profile, assessment of acid-base status, urinalysis, and urine culture. hyperkalemia occurs primarily in oliguric or anuric ferrets. radiography and ultrasonography may serve as a diagnostic imaging step to aid in the assessment of a ferret with suspected aki (fig. ) . ct and excretory urography may be required to characterize some disorders (fig. ) , for example, focal dilation of the ureters (fig. ) . the primary treatment should be aimed at the underlying cause of aki (eg, ureteral bypass, antidotes for toxins); however, correction and maintenance of the animal's hydration, acid-base, and electrolyte status are the mainstays of management for aki. urethral obstruction is a condition that requires immediate care and may be secondary to prostate enlargement (frequently secondary to adrenal disease), urethrolithiasis, and urethral masses. in male ferrets, even small uroliths may cause a life-threatening postrenal obstruction because of the narrow diameter of the urethra and the os penis. the urethrolith may be dislodged by means of urethral catheterization and retrograde urohydropulsion to the bladder (fig. ) . if retrograde urohydropulsion is unsuccessful, perineal urethrostomy or temporary tube cystostomy permits urine voidance (fig. ) . temporary tube cystostomy may be performed as follows : during laparotomy, a cystostomy tube ( -or -french foley catheter) is passed in a paramedian incision in the ventral body wall. a foley catheter is passed into the urinary bladder, inflated, and fixated with a purse-string suture. the bladder is tacked to the body wall with simple interrupted sutures. the abdomen is closed routinely, and the skin around the exiting foley catheter is closed with a purse-string suture. a finger-trap connected to the purse-string suture is placed around the foley catheter. diabetic ketoacidosis is a severe, life-threatening complication of diabetes mellitus, characterized by the biochemical triad of hyperglycemia, acidosis, and ketosis. as compared with dogs and cats, ferrets rarely suffer diabetes mellitus. diabetes after which switching to long-acting insulin (insulin glargine) for maintenance glycemic control ( . u, subcutaneously, every hours). cardiac disease in ferrets is far more common than previously thought, and chf is a common emergency condition in ferrets requiring immediate care. ferrets with chf may present to the emergency department with cough, respiratory distress, syncope, ascites, and/or generalized or hind limb weakness. the ferret may acquire an orthopneic position while breathing (fig. ) . after evaluation of heart rate, rhythm, murmurs, pulse, capillary refill time, and thoracic percussion for fluid presence, radiographs should be obtained. assessment of the vertebral heart scale (vhs) is a rapid, but limited technique that may assist the nonexpert radiologist in evaluating the cardiac silhouette (right lateral vhs reference interval: . - . vertebrae; fig. ). thoracic ultrasonography and ecg are typically needed to make a definitive diagnosis. depending on the cause of chf, different emergency treatments should be planned: oxygen, provided both via flow-by ( - l/min) and in an oxygen cage, should be administered to hypoxic ferrets. suspected pulmonary edema is empirically treated with an initial im administration of furosemide at mg/kg, followed by recheck radiographs at to hours, and decreased to or mg/kg, once or twice a day (fig. ) . in ferrets presenting with significant pleural effusion (fig. ) , thoracentesis should be performed immediately for diagnostic and therapeutic purposes ( fig. ; video ) . effusion of cardiac origin should be differentiated from chylothorax and pyothorax (eg, pseudomonas luteola and nocardia sp infection). , chylous effusion may have a "milky" appearance ( fig. ) or may be transparent; therefore, visual assessment may not be diagnostic. a high effusion:serum triglyceride ratio ( - : ) is suggestive of chylothorax. in dubious cases, the presence of chylomicrons in the lipoprotein electrophoresis from the effusion is diagnostic. lymphangiography permits evaluation of the thoracic duct (see fig. ). valve incompetence is the most common cause of cardiac disease in ferrets. dilated, hypertrophic, and restrictive cardiomyopathies are less common, but often associated with chf. in the author's experience, the use of an electronic stethoscope may simplify auscultation of ferrets and usually permits the identification of murmurs (fig. a) . valvular disorders are diagnosed by doppler echocardiography and should be treated as in other small animals. empirically, the author uses pimobendan ( . - . mg/kg, twice a day) and benazepril ( . mg/kg, once a day). chronic diuretic use of furosemide, at the lowest dose to control signs of chf, is needed. atrioventricular block is common in ferrets, and third-degree atrioventricular block often results in chf. in most ferrets, ecg may be performed without need of chemical restraint. the ferret may be maintained in a vertical, "hanging" position ( fig. b) , or manually restrained in the lateral position. administration of commercial malt paste may simplify restraint of uncooperative individuals. the ecg is interpreted as in other domestic animals (fig. ) , and values of healthy individuals are detailed elsewhere. treatment options include medical therapy with sympathicomimetic medications (isoproterenol, metaproterenol) or cardiac pacing. both epicardial and intracardial pacing have been successfully performed in ferrets. , filariosis caval syndrome caused by adult heartworms may occur in ferrets living in areas endemic of the disease. accuracy of snap elisa (enzyme-linked immunosorbent assay) -based antigen tests is unclear in ferrets, and it is suspected those tests may give false negative results. diagnosis is based on evidence of adult worms in the heart and cranial vena cava by ultrasonography. in a ferret, heartworms had been transvenously extracted. the jugular vein is dissected; a basket endoscopic retrieval device is inserted into the vein and advanced into the cranial vena cava with fluoroscopic guidance, and heartworms are extracted. medical adulticide therapy using melarsomine in ferrets causes anaphylaxis in approximately half of the cases. prednisone at a dosage of mg/kg may be used to mitigate clinical symptoms. preventative medication is mandatory in endemic areas. congenital heart disorders are increasingly being diagnosed in ferrets (fig. ) . currently, ventricular septal defect, atrial septal defect, and tetralogy of fallot are described in ferrets. , , often the ferrets are asymptomatic until adulthood, when, as a consequence of severe heart remodeling, they develop chf. , treatment is symptomatic, because surgical correction of congenital heart disorders in ferrets has never been reported. systemic hypertension may be associated with chf and renal disease, and blood pressure should be closely monitored in ferrets with cardiac disorders (fig. , video ). the practitioner needs to be aware that noninvasive blood pressure measurement (with manual sphygmomanometer and doppler probe) underestimates blood pressure in ferrets. however, it remains an affordable technique for blood pressure monitoring. as a rule of thumb, mm hg may be added after doppler measurement (based on published data, mean difference: À mm hg, % confidence interval approximately to mm hg). systemic hypertension in ferrets may be secondary to causes similar to other domestic carnivores, including aldosterone-secreting adrenal tumors. in cases of hyperaldosteronism, administration of spironolactone and amlodipine mitigates the hypertension. uncontrolled hypertension may result in dissecting aortic aneurism and sudden death (fig. ) . given the curious nature of ferrets, they tend to escape their enclosures and suffer accidents, including falling from windows or balconies, electrocution, washing machine-related injuries, and so on. fractures in ferrets should be managed in a similar fashion as in other small animals. spinal and pelvic fractures occasionally occur as a consequence of falling, and standard orthopedic treatment should be considered. in general, standard diagnostic and therapeutic principles developed in small animal emergency medicine should be used in case of trauma. dr tommaso collarile is kindly acknowledged for suggestions, images, and assistance for some of the cases described in this article. dr annalisa nicoletti, dr ulrich zeyen, and dr paolo fonti are kindly acknowledged for assistance regarding diagnostic imaging interpretation. approach to the acute abdomen neurological diseases of ferrets metabolic and toxic causes of canine seizure disorders: a retrospective study of cases diagnosis and treatment of insulinsecreting pancreatic islet cell tumors in ferrets pancreatic beta cell tumor in ferrets: cases ( - 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) echocardiographic and electrocardiographic findings in client-owned ferrets: cases radiographic measurement of cardiac size in normal ferrets pyogranulomatous pleuropneumonia and mediastinitis in ferrets (mustela putorius furo) associated with pseudomonas luteola infection successful treatment of a suspected nocardia-related pyothorax in two ferrets the lipoprotein profile of chylous and nonchylous pleural effusions fluid accumulation disorders ventricular septal defect in a ferret (mustela putorius furo) echocardiographic and electrocardiographic examination of clinically healthy, conscious ferrets pacemaker implantation in a ferret (mustela putorius furo) with third-degree atrioventricular block proceedings of the annual conference of the association of exotic mammal veterinarians transvenous heartworm extraction in a ferret with caval syndrome clinical observations in ferrets with naturally occurring heartworm disease and preliminary evaluation of treatment with ivermectin with and without melarsomine tetralogy of fallot in a young ferret (mustela putorius furo) atrial septal defect in a ferret (mustela putorius furo) high-grade aortic insufficiency secondary to hypertension in a ferret with elevated serum aldosterone evaluation of noninvasive monitoring techniques in domestic ferrets (mustela putorius furo) primary hyperaldosteronism in a domestic ferret with an adrenocortical adenoma orthopedic pelvic fracture repair in a ferret (mustela putorius furo) multi-systemic trauma in a ferret supplementary data related to this article can be found online at http://dx.doi.org/ . /j.cvex. . . . key: cord- -ruqednj authors: lin, dong d.; meghal, trishala; murthy, pooja; mo, lan; d’silva, ashley; huang, yiwu; xu, yiqing title: chemotherapy treatment modifications during the covid- outbreak at a community cancer center in new york city date: - - journal: jco glob oncol doi: . /go. . sha: doc_id: cord_uid: ruqednj purpose: as a result of their immunocompromised status associated with disease and treatment, patients with cancer face a profound threat for higher rates of complications and mortality if they contract the coronavirus disease infection. medical oncology communities have developed treatment modifications to balance the risk of contracting the virus with the benefit of improving cancer-related outcomes. methods: we systemically examined our community cancer center database to display patterns of change and to unveil factors that have been considered with each decision. we studied a cohort of patients receiving treatment and found that patients ( . %) had treatment modifications. results: the incidence of treatment modification was observed in patients undergoing adjuvant and neoadjuvant ( . %), palliative ( . %), or injectable endocrine or bone-modulating only ( . %) treatments. modifications were applied to regimens with myelosuppressive ( . %), immunosuppressive ( . %), and immunomodulating ( . %) potentials. these modifications also affected intravenous ( . %) and subcutaneous injectable treatments ( . %) more than oral treatments ( . %). treatment modifications in patients ( . %) were recommended by providers, and ( . %) were initiated by patients. the most common strategy of modification was to skip or postpone a scheduled treatment ( %). among treatment with no modifications, treatment regimens were maintained in patients who tolerated treatment well ( . %), in treatments with curative intent ( %), and in symptomatic patients who required treatment ( %). conclusion: our observation and analysis suggested that the primary goal of treatment modification was to decrease potential exposure. the pattern also reflected the negative impact of the pandemic on health care providers who initiated these changes. providers have to consider individualized recommendations incorporating multiple factors, such as tolerance, potential toxicity, treatment nature and route, and disease severity. the unprecedented coronavirus disease (covid- ) pandemic has presented a public health challenge globally. since the first confirmed case reported in new york city on march , , there have been more than , confirmed cases and , deaths by may , . initial retrospective studies from china reported higher complication and mortality rates in patients with cancer compared with the general population owing to their immunocompromised status induced by the disease and/or treatment. [ ] [ ] [ ] [ ] [ ] in an early italian case-fatality study, approximately % of patients who died of covid- had active cancer. since the start of the outbreak, the oncology community has faced a tremendous responsibility to make a correct recommendation for each individual patient receiving treatment. oncologists had to consider the benefits of continuing or initiating cancer treatment, with many of these being myelosuppressive or immunosuppressive in nature, or both, against the risk of patients contracting the virus and developing severe complications. in addition, a pause order was issued in new york state on march , , and social distancing required the cancer center to reduce its occupancy even for patients receiving chemotherapy. medical societies have published some timely guidelines that mainly discussed the sequence of multimodality treatments, whereas chemotherapy treatment decisions for individual patients were left to individual providers. [ ] [ ] [ ] the covid- cases started to increase exponentially in new york city in early march, and we witnessed the fear and its impact on both patients with cancer and providers, who started to make recommendations on chemotherapy regimen modifications. author affiliations and support information (if applicable) appear at the end of this article. accepted on july , and published at ascopubs.org/journal/ go on august , : doi https://doi. org/ . / go. . in this study, we aimed to examine the prevalence and characteristics of the treatment modifications carried out in our community cancer center. we were interested in uncovering the factors that lead to the decision, and we analyzed the influence of such variables as patients' disease status, treatment purpose, treatment regimen natures, and preferences of the providers or patients in the practice of treatment modification. we have established a prospective registry to observe the treatment patterns of patients with cancer undergoing treatment who may or may not have had a confirmed diagnosis of covid- during the pandemic at the maimonides cancer center. the project was approved by the institutional review board. consecutive patients whose names were present on the cancer center daily chemotherapy schedule between march , , and april , , were compiled after removing redundant entries. patients who belonged to the selected six of medical oncology attending physicians in the cancer center were enrolled in this study. eligible patients should be receiving active treatment. those patients who only received transfusion of blood products or who needed mediport maintenance flushes were not eligible. patients who were on active treatment of benign hematologic conditions were eligible, whereas patients who had suspicious or confirmed diagnosis of covid- infection were excluded. patient demographics were extracted from electronic medical records. the senior author (y.x.) interviewed each of the five medical oncologists to gather the following information on every patient: cancer type; nature of treatment and status of disease: metastatic, adjuvant or primary treatment; treatment regimen; modification(s) made; who-provider or patient-initiated the modifications; and the reason for not offering modifications, if applicable. data were verified from the electronic medical records. myelosuppressive regimens included all routine chemotherapy drugs. nonmyelosuppressive regimens included drugs without myelosuppressive potential, mainly antibodies, such as trastuzumab, bevacizumab, or oral targeted therapies, such as osimertinib. immunosuppressive drugs included rituximab, lenalidomide, high-dose corticosteroids, and daratumumab. immune-modulating agents included the immune checkpoint inhibitors that target programmed death or programmed death ligand , such as pembrolizumab, nivolumab, atezolizumab, and durvalumab. endocrine therapy included luteinizing hormone-releasing hormone agonists, fulvestrant, tamoxifen, and aromatase inhibitors. bone-modulatory therapies included zoledronic acid and denosumab. benign hematology treatments included intravenous iron replacement, erythropoietin, and romiplostim. we initially identified patients on the chemotherapy schedule, of which were excluded as a result of a covid- diagnosis. this study is composed of patients; males and females. median age was years (range, - years). the patient population represented multiethnic groups, with the majority being asian chinese (n = ; %), followed by african americans (n = ; . %), and whites (n = ; . %). two hundred forty-six patients were receiving chemotherapy, which included patients in the face of the coronavirus pandemic at a community cancer center in new york city, we wanted to know how often chemotherapy schedules were modified and what the key factors were that influenced the decision-making process. knowledge generated treatment modifications were made in % of patients in all treatment categories, including both myelosuppressive and nonmyelosuppressive regimens. these modifications affected intravenous and subcutaneous injectable treatments more than oral treatments. health care providers recommended changes in . % of cases, frequently using a strategy of skipping or postponing a scheduled treatment ( %). among patients who maintained treatment intensity, % of them tolerated treatment well, % had treatments with curative intent, and % of them were symptomatic and required treatment. the decision to modify chemotherapy regimens should take into consideration both the benefit and risk of treatment versus the potential of increased exposure to covid- infection. reducing treatment frequency can reduce exposure and, in turn, morbidity and mortality. ( . %) receiving adjuvant or neoadjuvant chemotherapy (with or without endocrine therapy), patients ( . %) receiving palliative treatment of metastatic disease (with or without bone-modulating therapy), patients ( . %) receiving only endocrine therapy or bone-modulating therapy, and patients receiving treatment of nonmalignant purpose ( table ) . the most common cancer type was breast cancer (n = ; . %), followed by gi (n = ; . %) and gynecologic (n = ; . %) cancers. altogether, the treatments of patients ( . %) were modified, or . % of the regimens ( of regimens). of note, chemotherapy drugs and a targeted oral drug may comprise the regimen of some patients, and the changes may be counted separately in different regimen categories. median age of patients receiving treatment modification was years, which reflected an older distribution compared with patients who did not have any modification (age years). the majority of those treatment changes fell into the category of palliative. treatment modifications occurred in all categories divided on the basis of the goals and nature of the treatments (fig ) manifesting in . % of the adjuvant and neoadjuvant settings, . % of the palliative setting, and . % of the injectable endocrine or bonemodulating only treatments. divided by route of administration, these modifications affected intravenous treatments ( . %) and subcutaneous injectable treatments ( . %) more than oral treatments ( . %; fig ) . upon breaking down the treatment regimens according to the potential adverse effects (fig ) , modifications were recommended for patients taking intravenous myelosuppressive therapies ( . %), intravenous nonmyelosuppressive regimens ( . %), and immunomodulating and myelosuppressive combination therapies ( . %). treatments in the following categories showed a higher chance of needing modification: immunosuppressive ( . %) and immunomodulating single agent ( . %). conversely, oral myelosuppressive treatments ( . %) and oral nonmyelosuppressive treatments ( %) were less likely to be modified (fig ) . we further analyzed the patterns of changes within each cancer type and individual regimens, and a detailed list of all regimens is provided in the data supplement. data comparing curative with palliative treatment in several selected cancer types are listed in table . consistently in breast, gi, and gynecologic cancers, treatment modifications were only offered to . % of patients receiving curative treatments, whereas it was offered to more than % of patients in palliative treatment cases. in the small subset of patients who were treated for multiple myeloma (n = ), nine patients had treatment change ( %), and most of the drugs used for this cancer treatment belonged to the category of immunosuppressive drugs (data supplement). seven types of modification strategies were documented (fig ) , the most common being to postpone or skip an upcoming treatment (n = ; . %), followed by a change in treatment intervals (n = ; . %). four common changes in the latter category were recorded (data not shown) as follows: prolongation of luteinizing hormonereleasing hormone antagonists interval from every month to every months; change of weekly paclitaxel to every weeks; change of weekly gemcitabine and protein-bound paclitaxel used for pancreatic cancer to every weeks; and increased treatment interval of single-agent checkpoint inhibitor immunotherapy programmed death ligand inhibitory agents. for patients, it was recommended that treatment be held for an unlimited time. among this group, median age of patients was . years (range, - years). a strategy of dose reduction was occasionally applied, particularly for three patients taking oral poly (adpribose) polymerase inhibitors, which are known for their myelosuppressive potential. in situations involving surgery as part of the multimodality treatment, six patients had a delay of surgery after the completion of neoadjuvant treatments and were started on hormonal treatment, which was meant to be taken in an adjuvant setting (prepone treatment group). whereas all of the treatment changes were agreed upon by both providers and patients, the changes in patients ( . %) were recommended by providers and ( . %) were initiated by patients. median age of the patients in those two groups was and years, respectively, which does not represent a major difference. each health care provider seemed to have a favorable preference in modification strategies, manifested by some by the predominant use of postponing or skipping a cycle of treatment, and by others in favor of increasing intervals (data not shown). reasons were also explored for those cases in which treatment regimens were maintained (fig ) . the most common reason for not changing treatment occurred in patients who have tolerated the treatment well, even in the palliative treatment setting (n = ; . %). treatment of symptomatic patients who required palliation from treatment was observed in patients ( . %). early studies from china indicated that patients with cancer were more likely to have intensive care unit admissions and undergo intubation after contracting covid- infection. , this observation alerted health care providers involved in the care of patients with cancer to exam their practice and recommend individualized cancer treatment during the covid- pandemic. new york city, as an epicenter, started to have an exponential surge of cases in early march . at the time, the covid- clinical oncology frequently asked questions published on march , , on the asco web site stated that there was no evidence to support changing or holding chemotherapy or immunotherapy in patients with cancer or in bone marrow transplantation/stem-cell transplantation, and withholding critical anticancer or immunosuppressive therapy was not recommended. conversely, the guideline published by the american society for breast surgeons recommended maintaining the treatment plan in patients undergoing curative treatment, as well as in the case of first-line treatment of metastatic disease where patients derive the most benefit. nevertheless, in practice, treatment modifications were made widely among the medical oncology community. in this study, we aimed to examine the prevalence and factors influencing the decision-making process that led to individualized treatment modifications. we found that treatment modifications were made in more than one half of all patients and in almost all treatment categories, including those of curative and palliative intent. despite curative intent and contradicting guidelines, treatment modifications were offered to % to % of patients taking adjuvant or neoadjuvant treatments. although it is not surprising that treatment modifications were commonly observed in those regimens that may have a negative impact on covid- complications, such as myelosuppressive, immunosuppressive, or immunomodulating treatments, it is surprising to find treatment changes in those with nonmyelosuppressive potential, such as injectable endocrine and bone-modulating treatments. with a close examination of this pattern of treatment modifications, along with data on increased rates of modifications in intravenous and injectable treatments compared with oral treatments, our data show that the primary intention behind modifying treatments was to minimize possible covid- exposure, followed by a secondary goal of reducing treatment-induced toxicities. the results of the study also provide a glimpse of the negative impact of the pandemic on the decision-making processes of health care providers. we designed the study enrollment period to be weeks between march and april , , which reflected a time span when the cumulating cases of covid- were increasing exponentially but had not reached their peak. however, despite being early in the pandemic, as many as % of treatment modifications were already planned, with a majority recommended by physicians. different providers also had their predominant treatment modification strategies. among them, a simple solution of skipping or postponing a scheduled treatment seemed to be a temporary decision, likely reflecting a day-byday stress level on the providers from the public health crisis. despite the concern of increased morbidity and mortality from covid- infection in patients with cancer, approximately . % of patients continued prescribed treatments without modifications. for patients receiving palliative treatment for metastatic disease, . % (n = ) continued planned treatment. the american society for breast surgeons guideline also recommended that first-line treatment of metastatic disease be continued as it is likely to improve disease outcome. , in the mind of our providers, continuing treatment in the palliative setting was offered to those who were tolerating treatment well and who were symptomatic. continuing treatment in those tolerating it well may have implied a perceivable diminished chance of severe myelosuppressive or immunosuppressive toxicities affecting the consequence of covid- infection. treatment in those who were symptomatic clearly indicated prioritizing and weighing the overall benefits more than the risks in the patient's disease condition. age and comorbidities have also been identified as the most important negative factors for poor outcome from covid- infection. , in our study, the median age of those whose treatment was recommended to be changed was older, indicating that age is an important factor in decision making. in contrast, we did not see a difference in the median age of patients who received treatment modification initiated by providers or by themselves. there were also no differences in the median age of patients who were offered an unlimited break from treatment. this study provides a real-world snapshot of the response to the covid- threat in a medical oncology community located within a hard-hit area of the pandemic. the advantage of this study is its unbiased patient selection of consecutive patients, which accounts for those who did or did not receive modifications to their treatments. there are also multiple shortcomings of this study. first, there was a disproportionately low representation of certain disease groups, such as hematologic malignancies, lung, and genitourinary cancers, in which decision making may have been different. there was also an underrepresentation of patients taking oral treatments, which can be myelosuppressive/nonmyelosuppressive targeted therapies or hormonal treatments, as they would not appear on the chemotherapy schedule. the selection criteria did not capture newly diagnosed patients who did not start treatment, and no additional information on the decisionmaking process can thus be obtained. finally, our study did not follow up on the potential detrimental effects and clinical outcomes of patients who had treatment modifications. overall, our study revealed that as many as . % of all patients and approximately % of patients taking curative treatments received treatment modifications in the midst of the covid- pandemic in our community cancer center. the pattern of modification was best explained by a primary goal of decreasing potential exposure. it also reflected the negative impact of the pandemic on health care providers, who struggled to make right recommendations on an individualized basis incorporating multiple factors, such as tolerance, potential toxicity, nature of the treatment, severity of disease, and route of treatment. open payments is a public database containing information reported by companies about payments made to us-licensed physicians (open payments). yiqing xu administrative support: ashley d'silva provision of study materials or patients: trishala meghal, pooja murthy, lan mo, yiwu huang collection and assembly of data new york state department of health: nysdoh covid- tracker cancer patients in sars-cov- infection: a nationwide analysis in china risk of covid- for patients with cancer characteristics of and important lessons from the coronavirus disease (covid- ) outbreak in china: summary of a report of cases from the chinese center for disease control and prevention sars-cov- transmission in patients with cancer at a tertiary care hospital in wuhan, china report of the who-china joint mission on coronavirus disease case-fatality rate and characteristics of patients dying in relation to covid- in italy cancer guidelines during the covid- pandemic covid- clinical oncology: frequently asked questions (faqs) american college of surgeons: recommendations for prioritization, treatment and triage of breast cancer patients during the covid- pandemic: executive summary recommendations for prioritization, treatment, and triage of breast cancer patients during the covid- pandemic. the covid- pandemic breast cancer consortium the risk of death in novel coronavirus disease the following represents disclosure information provided by authors of this manuscript. all relationships are considered compensated unless otherwise noted. relationships are self-held unless noted. i = immediate family member, inst = my institution. relationships may not relate to the subject matter of this manuscript. for more information about asco's conflict of interest policy, please refer to www.asco.org/rwc or ascopubs. org/go/site/misc/authors.html. key: cord- -h xuhm c authors: schleider, jessica l.; dobias, mallory l.; mullarkey, michael c.; ollendick, thomas title: retiring, rethinking, and reconstructing the norm of once-weekly psychotherapy date: - - journal: adm policy ment health doi: . /s - - - sha: doc_id: cord_uid: h xuhm c nan quality assessment ensuring reliance of evidence-based approaches-remains the practical default. given limited accessibility of, and significant dropout from, weekly outpatient therapy (suggesting that many are unable to access treatment as it is routinely provided), and the established efficacy of alternative treatment formats (suggesting that treatment may be redesigned to improve accessibility without sacrificing clinical utility), we assert that it is our field's ethical obligation to retire and rebuild the longstanding "default" to once-weekly outpatient services. to be clear, we do not endorse eliminating weekly psychotherapy as an option for patients; many once-weekly, evidence-based treatments, if delivered as intended, may benefit patients greatly. however, repositioning evidencebased weekly therapy as one of many treatment options, and improving the availability of additional, diverse evidencebased service types, may strengthen the accessibility, flexibility, and potentially the effectiveness of mental health treatment overall. psychotherapies need not be delivered in a once-weekly format to effect clinical improvement. one intensive outpatient treatment, involving four consecutive days of exposure and response prevention treatment, has substantially reduced ocd symptoms for adults up to years later (hansen et al. ; kvale et al. ) and adolescents up to months later (riise et al. (riise et al. , . other trials indicate that an -day, -h treatment involving cognitive-behavioral techniquesincluding interoceptive exposures and psycho-educationcan reduce symptoms of specific phobia, social phobia, in the present article, we focus our discussion on outpatient mental health services, given the numerous structural and practical differences between inpatient and outpatient mental health treatment options for individuals. as such, our discussion is centered on outpatient psychotherapy options, which collectively represent the majority of mental health services that individuals receive in their lifetimes. and gad (gallo et al. ) . written-exposure therapy, an exposure-based treatment involving recalling, processing, and making meaning of past traumatic experiences via timed sessions of expressive personal writing, has produced clinically-significant reductions in ptsd after just - h of intervention-and is non-inferior, and carries lower dropoutrates ( % vs. %) than lengthier, evidence-based alternatives (e.g., cognitive processing therapy; thompson-hollands et al. ) . clearly, cookie-cutter treatment formats are unnecessary for meaningful therapeutic change. indeed, large-scale trials and systematic reviews of treatments for anxiety disorders, depression, and behavior problems indicate that non-weekly interventions-from self-guided supports to brief, one-session treatments to concentrated, week-long interventions-can yield benefits approximately equivalent to once-weekly evidence-based psychotherapy, both for youths and adults (beevers et al. ; Öst and ollendick ; stoll et al. ; thompson-hollands et al. ) . breaking away from traditional delivery models may even carry advantages over once-weekly options. a metaregression including psychotherapy trials found session frequency-rather than number of sessions or duration of therapy-was strongly associated with treatment efficacy for depression (cuijpers et al. ) . controlling for total number of sessions, treatment effect size was notably higher among twice-weekly treatments, versus once-weekly treatments (increase of g = . ). higher session frequency in the first months of treatment is associated with faster improvement and recovery (tiemens et al. ) . further, patients randomized to receive twice-weekly sessions experienced greater depression reductions than those offered onceweekly therapy (bruijniks et al. ) . thus, defaulting to once-weekly treatment may fail to optimize patients' clinical progress. brief, evidence-based treatments, including some lasting just a few hours or a few days, can benefit many populations and problem types. meta-analytic evidence suggests a single session intervention (ssi) can significantly improve anxiety, conduct problems, and substance use in youth (schleider and weisz ), and recent trials indicate that ssis can reduce youth depression (schleider and weisz ; schleider et al. ) . evidence across studies indicates interventions lasting < min can have similar effects on young adults' problem drinking, versus multi-session interventions (tanner-smith and lipsey ). single-session, walk-in therapy is associated with symptom improvement in adults ages - and can reduce clinic wait-list length (harper-jaques and foucault ). still, even if patients can benefit from brief treatments, wouldn't more treatment be better? some correlational work suggests receiving more sessions relates to greater symptom improvement (hansen et al. ) , but this evidence is mixed (king ) . indeed, correlational analyses cannot establish whether more treatment causes greater improvement. rcts where patients are randomized to receive more versus fewer sessions for specific phobia (Öst et al. ) , panic disorder (roberge et al. ) , insomnia (edinger et al. ), ptsd (deblinger et al. ) , and substance abuse (covi et al. ) consistently find no evidence for longer treatments' clinical superiority. the assumption that "more treatment is better" is unsupported by gold-standard evidence. "personalized" treatment refers to therapies that are tailored to an individual's specific presenting needs. a course of treatment may be "personalized" in multiple ways, including through matching individuals with particular therapies most likely to benefit them based on pre-treatment characteristics (e.g., symptom severity), or altering the course of treatment based on changing needs, problems, or preferences as therapy progresses. one concern around brief treatments and ssis is that their brevity might preclude personalization to individual patients' needs. this concern is misguided for at least two reasons. first, many brief treatments are "problem-agnostic" by necessity (e.g., walk-in single session therapy): they are inherently designed to adapt to the patient's presenting problem as they understand it-not to a particular clinical diagnosis, which many therapy protocols are designed to target (harper-jaques and foucault ; schleider et al. a, b) . thus, many brief treatments may be easier to personalize than traditional, manualized treatments centering diagnostic-criteria. second, psychotherapy may be personalized not just during the treatment, but prior to treatment, as well. indeed, many treatment personalization attempts have involved "matching" particular patients with best-fit interventions before services begin (cohen and derubeis ) . this personalization approach may be especially important with respect to the effectiveness and accessibility of mental health services, as patients routinely see + outpatient providers before accessing treatment they perceive as helpful (harris et al. ) . given sufficiently-large samples, artificial intelligence could help identify precision treatment "rules" indicating which treatment is most likely to benefit particular patients (bickman ) . most traditional rcts have too few participants to reliably identify precision treatment rules (kessler et al. ) , but online ssi research may overcome this obstacle. in the previous year, our group has recruited over youths for an open-label trial of ssis ; participants for an online rct testing an ssi targeting parents experiencing anxiety (nlm, nct ); and > adolescents for another online ssi rct (nlm, nct ). large datasets aggregated across affordable, online ssi trials could be leveraged to develop precision-treatment "rules" with great statistical precision, and at a long-impossible rate, thus rapidly forwarding efforts to reduce psychopathology's public health burden (kazdin ). clearly, diverse cost-and time-efficient treatment structures-not just once-weekly psychotherapy-can yield meaningful clinical benefits for youths and adults. treatment utilization patterns suggest that many clients cannot consistently access or complete weekly treatment involving months-long commitments; likewise, it is unrealistic to think this model would be preferable to individuals seeking high-quality care. however, major structural changes to our mental healthcare ecosystem are needed to broaden access to and awareness of diverse treatments. we offer the following recommendations as first-steps. therapists should be trained to deliver treatment in varying formats and structures, and once weekly therapy should be identified as just one of many evidence-based treatment approaches. this will require a major revolution in training programs in clinical psychology and allied disciplines. indeed, it may involve overhauling how we are willing to define "treatment" for psychological distress, and acknowledging that "treatment" can occur in a wide variety of settings, with or without a trained provider present, over an hour or many months, and within or beyond brick-andmortar clinic. this expanded understanding of "treatment" may create new roles and opportunities for mental healthcare providers, including flexible utilization of widely-varying forms of therapeutic client supports both in and out of traditional "sessions." it will also require sustained commitment to questioning longstanding assumptions about when, where, and how clinical progress may be achieved. the vast majority of treatment trials focus on weekly therapy sessions. however, a robust and growing body of literature has revealed that other brief, intensive and concentrated approaches can work equally well. it will be important that we personalize these approaches and determine for whom they are most effective. insurance companies must provide flexible structures for supporting non-weekly psychotherapy-for instance, reimbursing by time spent in treatment regardless of frequency, intensity, or duration. it is most cost-effective to cover treatment that is efficient and that "works." there must be flexibility such that, if weekly therapy is needed for certain people-which it naturally will be-that will be coverable, too. the key is making therapy sufficiently accessible and flexible to meet all individuals' clinical needs. just as with any mental health treatment, it is critically important to ensure that brief treatments and ssis are monitored for quality-including their adherence to evidence-based models and practices. without ensuring high-quality treatment content, diversifying the structure of available interventions will fail to reduce mental illness on a large scale. brief, digital and self-help interventions are relatively straightforward to monitor for quality, as they are often standardized by design; quality assessment of therapist-delivered brief interventions must be supported via continued promotion of measurement-based approaches to treatment across disciplines (see bickman ; garland et al. , for further discussion on this topic). in sum, we do not endorse abandoning weekly therapy; rather we submit that it cannot ethically remain the "norm" or the sole format for the delivery of evidence-based treatments. evidence supports the use of brief, intensive and concentrated treatments; they can be more efficient than longer treatments, more cost-effective, and more accessible (ollendick et al. a; . to some extent, psychological treatment provision is already being overhauled by the covid- pandemic, including rapid normalization and expansion of telehealth and digital interventions. this moment presents a prime opportunity for our field to reconsider how psychological services can and should be structured-both regarding session frequency and what a "session" looks like, and deployment of brief, concentrated therapies without sacrificing personalization potential. doing so could create more accessible, ethical, and effective treatment options for clients. when is psychotherapy brief? considering sociodemographic factors, problem complexity, and problem type in u.s. adolescents effectiveness of an internet intervention (deprexis) for depression in a united states adult sample: a parallel-group pragmatic randomized controlled trial a continuum of care: more is not always better improving mental health services: a -year 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changing practices in children's mental health services. administration and policy in mental health and mental health services research the bergen -day treatment for ocd: four years followup of concentrated erp in a clinical mental health setting the psychotherapy dose-response effect and its implications for treatment delivery services walk-in single-session therapy: client satisfaction and clinical outcomes findings from world mental health surveys of the perceived helpfulness of treatment for patients with major depressive disorder annual research review: expanding mental health services through novel models of intervention delivery machine learning methods for developing precision treatment rules with observational data duration of psychotherapy has little association with outcome successfully treating patients with obsessive compulsive disorder in eight days: the bergen -day treatment engaging families in child mental health services innovations in the psychosocial treatment of youth with anxiety disorders: implications for a stepped care approach. evidence-based mental health have phobias, will travel: addressing one barrier to the delivery of an evidence-based treatment one versus five sessions of exposure in the treatment of flying phobia brief, intensive and concentrated cognitive behavioral treatments for anxiety disorders in children: a systematic review and meta-analysis concentrated exposure and response prevention for adolescents with obsessive-compulsive disorder: a replication study concentrated exposure and response prevention for adolescents with obsessive-compulsive disorder: an effectiveness study cognitive-behavioral treatment for panic disorder with agoraphobia a randomized, controlled trial and cost-effectiveness analysis randomized trial of a single-session growth mind-set intervention for rural adolescents' internalizing and externalizing problems future directions in single-session youth mental health interventions acceptability and utility of an open-access, online single-session intervention platform for adolescent mental health little treatments, promising effects? meta-analysis of single-session interventions for youth psychiatric problems a single-session growth mindset intervention for adolescent anxiety and depression: nine-month outcomes of a randomized trial brief, non-pharmacological, interventions for pediatric anxiety: meta-analysis and evidence base status brief alcohol interventions for adolescents and young adults: a systematic review and meta-analysis brief novel therapies for ptsd: written exposure therapy lower versus higher frequency of sessions in starting outpatient mental health care and the risk of a chronic course; a naturalistic cohort study what five decades of research tells us about the effects of youth psychological therapy: a multilevel meta-analysis and implications for science and practice conflict of interest jls receives grant and research support from the national institutes of health (dp od ), the klingenstein third generation foundation, the american psychological foundation, the national science foundation, and limbix, inc. mld receives research funding from the psi chi honor society. jls, mld, and mcm have co-written a forthcoming therapeutic workbook for adolescents, to be published by new harbinger publications. jls is under contract with oxford university press to co-edit a book on low-intensity youth mental health interventions. jls serves on the scientific advisory board for walden wise. the authors report no other financial conflicts. key: cord- -r p helx authors: aggarwal, sadhna; verma, sumit singh; aggarwal, sumit; gupta, subash chandra title: drug repurposing for breast cancer therapy: old weapon for new battle date: - - journal: semin cancer biol doi: . /j.semcancer. . . sha: doc_id: cord_uid: r p helx abstract despite tremendous resources being invested in prevention and treatment, breast cancer remains a leading cause of cancer deaths in women globally. the available treatment modalities are very costly and produces severe side effects. drug repurposing that relate to new uses for old drugs has emerged as a novel approach for drug development. repositioning of old, clinically approved, off patent non-cancer drugs with known targets, into newer indication is like using old weapons for new battle. the advances in genomics, proteomics and information computational biology has facilitated the process of drug repurposing. repositioning approach not only fastens the process of drug development but also offers more effective, cheaper, safer drugs with lesser/known side effects. during the last decade, drugs such as alkylating agents, anthracyclins, antimetabolite, cdk / inhibitor, aromatase inhibitor, mtor inhibitor and mitotic inhibitors has been repositioned for breast cancer treatment. the repositioned drugs have been successfully used for the treatment of most aggressive triple negative breast cancer. the literature review suggest that serendipity plays a major role in the drug development. this article describes the comprehensive overview of the current scenario of drug repurposing for the breast cancer treatment. the strategies as well as several examples of repurposed drugs are provided. the challenges associated with drug repurposing are discussed. breast cancer, one of the most common cancer in women, is globally diagnosed by physical examination, breast scan and tissue biopsies. a total of . million new cases of breast cancer were identified in , of which ∼ , cases died. this accounted for approximately % of all cancer deaths among women globally [ ] . in , the highest numbers of breast cancer cases were reported from asia ( , , ) followed by europe ( , , ) , north america ( , , ) , latin america and caribbean ( , ), africa ( , , ) and oceania ( , ) [ ] . although very common in women, breast cancer rarely occurs in men [ ] . a vast heterogeneity in breast cancer molecular profiling has been reported [ ] . based on the er/pr and her expression, breast cancer can be of types: (i) er/pr+, her +; (ii) er/ pr−, her +; (iii) er/pr+, her −; and (iv) er/pr−, her − [ ] . the most aggressive breast cancer is er/pr−, her − (also called triple negative breast cancer, tnbc) because no receptor is present on these tumors. it is estimated that % of the breast cancers are hormone receptor positive ( %) and can be treated with corresponding therapies [ , ] . in addition to hormone receptors, other biomarkers used for clinical, pathological and molecular characterization of breast cancer include ki , p , ca , cea, brca /brca etc. [ ] . these molecular biomarkers in breast cancer are used for diagnosis, staging and grading, therapeutic intervention, prognosis as well as clinical management of recurrent and metastatic cases [ ] . are given as neoadjuvant therapy and only trastuzumab is continued post-surgery [ , ] . surgery is mostly followed by chemotherapy or radiotherapy to further destroy the remnant micrometastatic cancer cells that have escaped the breast or lymph nodes, to decrease the chances of recurrence and to increase the overall patient survival [ , ] . the adjuvant (additional) therapies i.e. hormone or targeted therapy are provided to breast cancer patients depending on the expression of hormone receptor or target protein, respectively [ ] . the er/pr + breast cancer patients are given tamoxifen and aromatase inhibitor together or alternatively after the surgical resection [ , ] . likewise, trastuzumab (herceptin) is mostly recommended to the her + breast cancer patients [ ] . tnbc patients are difficult to treat, with unfavorable prognosis and are generally administered with the standard chemotherapy along with the parp inhibitors or the dnatargeting platinum drug (carboplatin) [ , ] . another strategy is based on the holistic approach of patient recovery i.e. complementary and alternative medicine. in the holistic approach, the patients are advised for several life style changes like exercise, yoga, meditation, acupuncture and/or ayurvedic treatments in addition to the standard therapies [ ] . the united states fda has approved a number of drugs for the breast cancer therapy (table ) . however, these drugs are very costly and produce numerous side effects [ , ] . the common reported side effects in patients include fatigue, headaches, pain, numbness, dental issues, lymphedema, musculoskeletal symptoms, heart problems, blood clots, menstrual and menopausal symptoms, infertility, bone loss, and memory loss. these side effects are hard to be tolerated by the patients who are already weakened by the disease. eventually these also affect the decision for further choice of treatment and impair the quality of life. this necessitates the development of novel drugs for breast cancer therapy. we have previously reviewed the overall process involved in cancer drug development [ , ] . the drug development for breast cancer like other cancer types is a multi-step process involving the designing, synthesis, characterization, testing for efficacy and toxicities, and approval. overall, the process is lengthy, involving huge investment of money. it is estimated that the development of a new drug usually requires - years of time and approximately - billion dollars. on the top of all this, nearly % of the drugs fail during the clinical trial stage due to unexpected lack of appropriate efficacy, unacceptable side effects or regulatory norms [ , ] . therefore, the approaches to expedite the drug development process are required. one approach might be finding new uses for old clinically approved drugs (drug repositioning). the drug repositioning (aka drug repurposing, drug reprofiling, drug re-tasking, drug redesigning, drug resorting, drug reindication, indication switching, therapeutic switching) can be defined as exploring the new uses for an old clinically approved drug, with reduced risk, time and cost. drug repositioning circumvents the usual route of substantially higher rates, slow pace and side effects etc. [ ] [ ] [ ] . it is becoming an attractive concept for pharmaceutical industries. it is estimated that the repositioning for drug development requires much lesser time ( - years) and money ($ . billion) with at least known and approved side effects; and higher probability of success [ , [ ] [ ] [ ] [ ] . repositioning of old drugs offer rapid transition from bench to bedside as already approved by fda and other regulatory norms, passed through the clinical trials and are approved for human use. these drugs have well defined pharmacodynamics, pharmacokinetics, dose, side effects, metabolic profiles and targeted molecular pathway etc [ , ] . here, the clinical development can directly start from the phase ii trial to assess the efficacy for new indication/disease target. the successful example of drug repositioning includes sildenafil (viagra) and thalidomide. viagra was originally launched for hypertension and angina pectoris patients by pfizer ( ) . however, the patients developed penile erections as side effects in phase i clinical trial. the drug was later developed for erectile dysfunctions. in , the total sale of viagra was . billion dollars [ ] . similarly, the sedative thalidomide was serendipitously repurposed for erythema nodosum leprosum (enl) in and for multiple myeloma and other cancers in [ ] [ ] [ ] [ ] . recent advances in genomics, proteomics, transcriptomics and metabolomics have provided vast and deep knowledge about the molecular and metabolic alterations that occurs in cancers. the fundamentals of drug repurposing through the integration of system biology and bioinformatics depends on basic concepts i.e. activity based and in silico drug discovery [ ] . activity based drug repurposing is the experimental approach where the drug candidate is evaluated for the anticancer activity directly. the drug that is structurally similar would tend to have similar target, shared biological activity and indications [ ] . in the two diseases where same metabolic pathway or signaling is affected, then the drugs that target the specific pathway can be used in both of the diseases irrespective of their structural dissimilarity [ , ] . the drug that shows strong efficiency for any off-target (side effect) in one disease can be explored further i.e. the off-target binding and effect can be used as the novel indication of that drug in some other disease [ ] [ ] [ ] . in silico drug repurposing approach is based on the association and/or overlaps in the disease-gene-drug paradigm. the large data about drug-disease, gene expression (microarrays) or protein-protein interactions or gene-protein interactions or signaling pathway mapping, signature matching, genome-wide association studies (gwas) can be used for providing drug-disease gene association networking by the systematic integration and coordination of computation and bioinformatics, modeling (such as docking for structural modeling), experimentation, statistics, machine learning etc. [ ] [ ] [ ] [ ] . the various data resources are available that can be used for bio-informatics based exploration followed by experimental validation for any drug repurposing possibilities in any disease. the similar gene expression profile for drug phenotype in patients with different diseases as mapped by connectivity map (cmap), library integrated network based cellular signatures (lincs), expression signatures may have similar therapeutic applications [ ] [ ] [ ] . other important public data resources that are used for network-based drug repositioning includes gene set enrichment analysis (gsea) for drug-drug similarity network [ ] ; drugbank [ ] , online mendelian inheritance in men (omim) [ ] and geo [ ] for predicting drug-disease network; kegg [ ] , string [ ] , biogrid [ ] , happi [ ] and reactome [ ] for pathway and/or proteinprotein interactions; stitch drug-gene/protein database [ , ] , ttd therapeutic target database [ ] , sfinx for drug-drug interactions [ ] ; and sider for drug side effects [ ] . also, the recently reported 'drug repurposing from control system theory (decost)' is a comprehensive platform for drug repurposing that encompasses various limitations in the previous databases like variation in number of copies of gene of interest, mutations, lack of reference for normal range of gene expression etc. in different diseases [ ] . vigorously exploited 'network-based approach' by integrating the mentioned resources for identifying potential target, pathway and drug has been reported as the most potential way for drug repositioning [ ] . in the following section, we discuss the clinically approved drugs that were originally used for diseases other than breast cancer. however, these drugs are now being used or explored for breast cancer therapy. the clinically approved repositioned drugs for breast cancer are grouped based on their mode of action (table ). these drugs are diverse in terms of their chemical structures (fig. ) . abbreviations: cdk: cyclin-dependent kinase; erd: er down-regulator; lhrh: luteinizing hormone-releasing hormone; serd: selective estrogen receptor degrader; serm: selective estrogen receptor modulator; er: estrogen receptor; pr: progesterone receptor, her: human epidermal growth factor receptor. these are dna damaging agent that alkylate the guanine base thereby rendering them unable to bind to complementary strand. this leads to inhibition of dna replication and cancer cell growth. the alkylating agents affect all phases of cell cycle. cyclophosphamide is a known immuno-modulator that inhibits the suppressive regulatory t cells and enhances the effector t cells in tumor microenvironment. it shows the biphasic effect i.e. at low doses it imparts the immuno-suppressive function and at higher doses it functions as an alkylating agent leading to the death of tumour as well as the lymphoid cells [ , ] . usually mg/m² cyclophosphamide is intravenously (iv) administered to breast cancer patients in combination with other chemotherapeutics (docetaxel, paclitaxel, doxorubicin). the recommended regimens for robustly healthy breast cancer patients include cycles of cyclophosphamide, methotrexate and -fluorouracil (cmf) or cycles of adriamycin and cyclophosphamide (ac) [ , ] . thiotepa is a derivative of n,n',n"-triethylenephosphoramide (tepa) that was launched ( ) as immunosuppressive drug for transplantation in hematological diseases [ ] . subsequently, the drug was recommended for solid tumors in [ ] and for breast cancer ( . to . mg/kg iv repeated every - weeks) in [ ] . thiotepa in combination with vinblastine, adriamycin, and halotestin (vath) was effective in patients with relapse after adjuvant therapy and in metastatic breast cancer patients [ ] . anthracyclins are antibiotics that intercalates between the adjacent base pairs of dna in such a manner that it forms anthracyclin-dna-topoisomeraseii ternary complex. the ternary complex disrupts the resealing activity of enzyme leading to inhibition of dna and rna synthesis in highly replicating cancer cells [ , ] . some of the common anthracyclins are doxorubicin, daunorubicin, epirubicin and idarubicin. these are generally extracted from streptomyces bacterium. approved for medical use in , doxorubicin ( -hydroxylated version of daunorubicin) [ ] was originally extracted from streptomyces peucetius [ ] . there was a long lapse of years between first clinical usages of anthracyclins to their proven relevance in breast cancer treatment. however, once established the chemotherapeutic regimens that contained doxorubicin [usual dose: - mg/m² intravenously (iv) every days] were used regularly with dose-intense and dosedense schedules. some of the regimens containing doxorubicin are ac (adriamycin, cyclophosphamide), tac (taxotere, ac) and fac ( fluorouracil, ac) [ ] . unlike doxil (the pegylated form of doxorubucin), myocet is the non-pegylated liposomal version of doxorubicin that is approved for treatment of metastatic breast cancer in combination with cyclophosphamide in europe and canada [ ] . antimetabolites are the chemo-drugs that interfere with the metabolic pathways in the cancer cells primarily by acting as structural analogues to important cellular metabolites. -flourouracil ( -fu) is a pyrimidine antimetabolite, an uracil analogue that inhibits the activity of thymidylate synthetase by converting -fu to fdump and futp, instead of uracil to thymidine conversion. therefore, -fu not only inhibits the dna synthesis in the cell but also inhibits rna synthesis due to fdutp incorporation in rna; leading to highly toxic effects on the growth of rapidly multiplying cells like cancer cells. klein and colleagues introduced -fu for medical use in for the treatment of self-healing, squamous cell tumors of skin i.e. keratoacanthomas (kas) [ ] . -fu was subsequently used for other cancer types including breast cancer [ ] . general drug dosage of -fu is mg/m or mg/m iv on day and day of every -day cycle (six cycles in total). lokich et al ( ) first introduced the infusion of -fu in combination with methotrexate (m) for breast cancer [ ] . since then various regimes of combination therapy containing -fu (f) with other drugs like doxorubicin (a), cisplatin (c), cyclophosphamide (cx) and epirubicin (e) (ecf, cmf, caf) have been continuously used for treating metastatic breast cancer [ ] . the other combinations such as -fu with paclitaxel in [ ] and high dose -fu/paclitaxel with doxorubicin [ ] were found successful for breast cancer treatment. methotrexate is a folate/folic acid antagonist that binds to the dihydrofolate reductase (dhfr) enzyme and inhibits the synthesis of building blocks of dna and rna itself. folic acid is converted to dihydrofolate by dhfr, which is then reduced to tetrahydrofolate (thdf) for further action by thymidine synthetase. methotrexate binding to dhfr decreases the synthesis of purines and pyrimidines in the cells that inhibits the cell cycle progression in s-phase. methotrexate was discovered in s as a substitute to folic acid, because the cases with decreased leukemic cell count (acute lymphoblastic leukemia) due to dietary deficiency of folic acid were being presented in clinics [ , ] . methotrexate was first shown to remit breast cancer in by jane c wright [ ] . in s and s, methotrexate was being used as single cytotoxic agent for advanced breast cancer treatment [ ] . however, gianni and bonadonna group ( ) showed the first treatment with cycles of cmf combination in mastectomised women with advanced cancer and positive lymph nodes and reported only . % treatment failure with acceptable toxicity [ , ] . in fact, cmf regimen was the first ever schedule for breast cancer treatment. further, cmf was found to be equally effective even at cycles. immunosuppressive activity of methotrexate has been explored for its clinical use in autoimmune diseases like rheumatoid arthritis [ ] . general dosage of cmf regimen is defined as - cycles of cyclophosphamide ( mg/m ); methotrexate ( mg/m ), and fluorouracil ( mg/m ) at -day intervals. capecitabine, a pro-drug for -fu, is another pyrimidine antimetabolite. the conversion of capecitabine to -fu requires the three systematic enzymatic reaction cascades through intestine, liver and tumour cells. the enzyme that catalyzes the last step of conversion is highly expressed in tumour cells as compared to the normal cells. therefore, the tumour selective conversion of capecitabine to -fu prevents the systemic exposure of body to -fu [ ] . also, capecitabine is easier to administer and safer than -fu with better efficacy. the capecitabine was first used against colon cancer in [ ] . capecitabine ( mg/m given orally twice daily for days followed by a -day rest period in a -day cycle for cycles) is generally used to treat paclitaxel or docetaxel resistant advanced and metastatic breast cancers [ ] . it is used either alone or in combination with cabazitaxel [ ] , vinorelbine [ ] or ixabepilone [ ] . gemcitabine is a pro-drug that gets tri-phosphorylated inside the cell (dfdctp) by sequential enzyme catalyzed reactions. this dfdctp masquerades as an analogue of cytidine and gets incorporated in the newly synthesized dna generating irreparable error that inhibits dna replication leading to cell death [ , ] . gemcitabine was primarily manufactured in by larry hertel's group at eli lilly and company to be used as an anti-viral drug against enteroviruses [coxsackievirus b (cvb )]. the drug was also used against cvb , ev , human rhinoviruses (hrvs), human immunodeficiency virus (hiv), hepatitis c virus (hcv), poliovirus, influenza virus, zikv and mers-cov [ , ] . it was then pre-clinically tested for its anti-tumour attribute. the drug was approved by fda for pancreatic cancer in [ ] and for non-small lung cancer in [ ] . finally, gemcitabine was approved for metastatic breast cancer in in combination with paclitaxel [ , ] . after anthracycline-containing adjuvant chemotherapy failure, gemcitabine ( mg/m² iv infusion over min on days and of each -day cycle) and paclitaxel ( mg/m² on day as a h infusion before gemcitabine) combination is used as the first-line of treatment against metastatic cancer. other combinations such as gemcitabine/vinorelbine (gemvin), gemcitabine/cisplatin (gemcis), gemcitabine/capecitabine (gemcap) have also shown increased response rate and overall survival in pretreated metastatic breast cancer patients [ ] . palbociclib is a cdk / inhibitor that halts the progression of cells from g -to s-phase. palbociclib ( mg, -day cycle with aromatase inhibitor) is used as the targeted therapy against er + /her − advanced and metastatic breast cancer in conjunction with hormone therapy. the open label paloma (palbociclib: ongoing trials in the management of breast cancer) clinical trials were designed recently with either aromatase inhibitor (letrozole) (paloma- or paloma- trials) [ , ] or fulvestrant hormone therapies (paloma- trails) [ ] . an improvement in the overall survival of metastatic breast cancer patients was reported in paloma- phase iii clinical trials. inhibiting cdk / activity delays the resistant to hormone therapy and significantly improves the progression free survival (pfs) of patients [ , ] . the hormonal therapy or endocrine therapy is usually given for - years. this therapy either directly targets the hormone (estrogen and/or progesterone) production or negatively regulates the functional effects in hormone sensitive breast cancer patients (er + and/or pr + ). selective estrogen receptor modules (serms) serve as anti-estrogens by binding to the hormone receptors as antagonists. the widely used serms that have been repositioned as breast cancer drugs are tamoxifen ( ), toremifene ( ) and raloxifene ( ) . tamoxifen is the oldest serm that has been in use for more than years for early stage breast cancer treatments in pre-and post-menopausal women. toremifene and raloxifene are equally effective but safer alternatives of tamoxifen that are used in only post-menopausal women with advanced breast cancer [ , ] . multiple outcomes raloxifene evaluation (more) clinical trial was an osteoporosis treatment trial in postmenopausal women, with secondary objective of evaluating the effects on breast cancer risk reduction. more lead to the designing of further clinical trials such as continuing outcomes relevant to evista® (core), raloxifene use for the heart (ruth), and study of tamoxifen and raloxifene (star) [ ] . aromatase inhibitor hormone therapy is administered only in postmenopausal women to treat er + early and/or late stage breast cancer [ ] . it acts on the aromatase enzyme that still produces estrogen hormone in fat tissue of post-menopausal women or women without active ovaries. thus, the aromatase inhibitor reduces the amount of estrogen in post-menopausal women with breast cancer that would otherwise feed the breast cancer cells for further growth. the aromatase inhibitors (anastrazole, exemestane and letrozole) were initially used for ovary stimulation and induction of ovulation in infertile females or polycystic ovary syndrome. aromatase inhibitors can be used as neoadjuvant or adjuvant therapy, mostly alone or in combination, which were introduced as an alternate to tamoxifen in postmenopausal patients [ ] . selective estrogen receptor degrader (serd) such as fulvestrant, are pure anti-estrogens that blocks estrogen receptor and degrades the receptor without any agonist effect [ ] . fulvestrant was first used in as a 'serd hormone therapy' against hr + her − advanced and metastatic breast cancer in post-menopausal women that were resistant to other hormone therapy [ ] . it is used in combination with cdk / inhibitors like palbociclib (paloma- ) and ribociclib (monaleesa- ) and anti-pi k/akt/mtor pathway drugs such as pictilisib (fergi) and buparlisib (belle- and belle- ) [ ] . luteinizing hormone releasing hormone (lhrh) analogs interfere with the signaling mechanism that activates the estrogen synthesis in ovaries causing temporary menopause. in , goserelin was used for the assisted reproduction and prostate cancer treatment. goserelin was then approved for the treatment of pre-menopausal women with hormone sensitive breast cancers in . it is used alone or in combination with other hormone therapies [ ] . goserelin is currently under phase ii clinical trial as an additional drug into the standard neoadjuvant therapy for tnbc patients. the goserelin phase ii trial is expected to complete by [ ] . everolimus is an mtor kinase inhibitor that inhibits the pi k/akt/ mtor signaling pathway. everolimus was originally approved for renal cancer in , as immunosuppressant during renal transplants in and for pancreatic cancer in . a phase iii clinical trial 'breast cancer trial of oral everolimus- (bolero- )' that included everolimus in combination with exemestane was successfully completed in leading to the approval of everolimus by us fda for the treatment of hr + , her − advanced metastatic cancers that are resistant to letrozole or anastrazole [ , ] . mitotic inhibitors terminate the cell division or mitosis by disrupting the microtubule dynamics. this leads to g /m phase cell cycle arrest or inhibition of spindle formation. some of the common examples of mitotic inhibitor include docetaxel, paclitaxel and vinblastine. while docetaxel and paclitaxel induces g /m cell cycle arrest, vinblastine is known to inhibit spindle formation. docetaxel and paclitaxel are used as neoadjuvant or adjuvant therapy as single agent or in combination with other chemotherapeutic agents for the treatment of early, advanced and metastatic breast cancer in pre-and postmenopausal women. paclitaxel was isolated from pacific yew in . it was used as drug for arterial restenosis. docetaxel and paclitaxel were initially used as therapeutics in prostate and ovarian cancer ( ) respectively. thereafter, docetaxel ( mg/m² iv h after doxorubicin and cyclophosphamide weeks x cycles) and paclitaxel ( mg/m² iv over h weeks times with doxorubicincontaining regimen) were repositioned as chemotherapy adjunct in breast cancer treatment regimen [ ] [ ] [ ] . taxanes are now used as the part of standard chemotherapy in metastatic breast cancer. numerous combinatorial chemotherapy containing taxanes are used in routine practice for treating breast cancer by clinicians around the globe [ ] . vinblastine is a naturally occurring vinca alkaloid found in white flowered periwinkle, vinca rosea. this was discovered by robert noble and charles t beer in . the discovery of vinblastine is a beautiful example of serendipity in drug development. the group rather aimed to evaluate the anti-diabetic effect of extract in rats and observed pseudomonas mediated septicemia that was accompanied with the rapid wbc fall and granulocytopenia. further study in this direction showed peripheral granulocytopenia and leukopenia in vinca rosea extract treated rats. finally, they reported carcinostatic activity of vinca rosea extract/vinblastine in rats with transplantable mammary adenocarcinoma and sarcoma [ , ] . vinblastine was approved for lymphoma in . also, since s, vinblastine ( - mg/mm iv once weekly or every other week) in combination with mitomycin or mvp (mitomycin c, vinblastine and cisplatin) has been used as chemotherapy against advanced and metastatic breast cancer [ , ] . with a drastic increase in the number of new cases, the cost of the cancer treatment is rising even at a higher speed. this is because the disease demands molecular dissection at gene and protein level to find newer strategies, appropriate targets and corresponding drugs. this requires a lot of time and the use of high-end techniques by pharmaceutical companies thereby increasing the overall financial investments and eventually the cost of the drug [ ] . the antibody-based immunotherapies or cell-based cart therapy, dc vaccine, act types of drug treatment might prove promising. however, these therapies are unaffordable by most patients in developed as well as developing countries. this necessitates the development of drugs with higher efficacy, lower side effects and practically lower cost. one of the smart ways is to repurpose an old, existing and approved drug for a newer indication. the advantage of this approach is that the approved drugs have existing information about molecular targets, off-targets, modes of action, safety level and side effects. this would not only save a lot of time that is otherwise required for discovery, designing, clinical trials and approvals of a new drug but also reduce the overall cost of anticancer drug. this will cut the cost involved in preclinical development and phase i trial. further, the old drugs would be off-patent and hence cheaper than the initial costs. in this article, we discussed in detail the advantages of drug repurposing for breast cancer treatment. we provided several drugs that have been successfully repurposed for breast cancer treatment. the triple negative breast cancer (tnbc) is highly heterogeneous, aggressive and complex form of breast cancer without expression of er, pr, or her receptors. tnbc is untreatable with regular hormone therapy. however, the combination of chemotherapies and the drug repositioning approach has offered promising outcomes by preclinical studies. flunarizine, a n-ras inhibitor, has been approved for migraine or vertigo. flunarizine has also shown promise in tnbc mouse models by inducing autophagy [ ] . a recent publication showed that the combination of metformin and hemin, used for type diabetes or porphyria respectively, could inhibit the growth of breast cancer cells. bioinformatics tools revealed that the bach expression is significantly elevated in tnbc and the hemin sensitizes the tnbc to metforminmediated degradation of bach [ ] . the completion of repurposing drug in oncology (redo) project has provided evidence for the new uses of drugs for breast cancer. originally these were discovered for indications other than breast cancer [ ] . these drugs include mebendazole (anti-helminthic), cimitedine (anti-acid), nitroglycerins (heart attack preventing), itraconazole (anti-fungal), and diclofenac (anti-inflammatory). other drugs such as l-nmma (tilarginine acetate, a nitric oxide synthase inhibitor) [ ] , pro-viral integration moloney virus kinase (pim)- inhibitors (olaparib) [ ] , l-asparginase [ ] , and fenofibrate [ ] are being repurposed for breast cancer. these drugs were originally used in patients with cardiogenic shock, against viral infection, leukemia, helminthic infection, and in patients with high serum cholesterol and triglycerides, respectively. implementation of network pharmacology in examining the potential of natural herbs i.e. ayurvedic formulations and traditional chinese medicines (tcm) are also clinching the attention of researchers for anticancer drug repositioning. these are based on multi-targeted synergistic drug approach instead of one target-one drug approach and thus appear to be promising for breast cancer therapy. the integration of super-computation, simulations, network pharmacology and bioinformatics can detect the target and efficacy of herbs. triphala is the mixture of at least ayurvedic formulations meant for the treatment of many diseases. the bioactive-target-pathwaycancer type networking revealed the link of triphala with cancer types including breast cancer through bioactive and targets. this information can be explored further for either bioactive-or target-based drug repositioning and/or new drug development. however, some challenges and concerns associated with drug repurposing for breast cancer therapy require thorough consideration. the breast tumor heterogeneity, poorly defined molecular signatures, and poorly identified drug dosage provides a roadblock to the drug repurposing. moreover, the current strategies often ignore tumor grade. it is crucial to search the new therapeutic strategies for certain very stringent and hard to treat molecular subgroups of breast cancers such as basal subtype, tnbc, mbc and tumors resistant to standard treatment therapy. the molecular alterations in tnbc, mbc, and resistant tumor types should also be thoroughly investigated. aforementioned bach inhibition by targeting the energy generating mechanism of rapidly growing cells is indeed the novel approach against otherwise resistant-breast cancer. understanding and targeting the tumour microenvironment instead of tumor itself appears more promising in detailing the heterogeneity in breast cancer patients. the overlapping area that consists of tumour and normal cells in tumor microenvironment should be thoroughly characterized at the molecular level [ , ] . identifying the molecular basis of super-responders and non-responders also holds valuable insight for deeper exploration [ ] . another area that needs attention while strategizing drug repositioning for breast cancer is personalized medicine i.e. to extend the repositioning strategy to treat upto single patient design, as the patients under same molecular subgroup often presents further variations leading to unexpected response. structurally similar drugs may, at times, target functionally dissimilar protein hence pathway driven repurposing strategy is better for multi-targeted diseases like cancer. the orphan drugs generally have short or no patent and thus repurposing them is associated with lower cost. repurposing the off-patent drugs eventually blocks the patenting rights on repurposed drug and hence future investors [ ] . inclusion and exclusion criteria for the selection of trial group for repurposed drug is very crucial as different physiological responses are anticipated in comparison to the original group. for example, the pregnant women (first trimester) with cancer are excluded for thalidomide treatment due to risk of amelia and phocomelia [ ] . drug companies that expand the repositioning in similar therapeutic areas, such as reusing ovarian cancer drug as breast cancer drug, had success rate of % in comparison to % success rate when explored in different area [ ] . a comprehensive, large-scale data mining and research is required before jumping on to actual repurposing procedure in order to save the time and finances because smallest of errors in computation or simulations can mislead the entire study. faultless selection of most relevant pharmacological target using most appropriate database (tcga and metabric) for data mining and accurate repurposing strategy is indispensable for the successful drug repositioning for breast cancer. repurposed drugs mainly include the phase iii clinical trial, which still is the most challenging phase due to the longest duration, huge investments and inclusion of largest number of patients as compared to the phase i and phase ii clinical trials. the repurposed drug for breast cancers usually does not work in monotherapy but as poly-pharmacology/combinations. the parp inhibitors are synthetic lethal with brac mutation [ ] . hence, initially proving the repurposed drug efficacy as single drug agent becomes difficult. the toxicity of repurposed drug in pretreated patients or in combination therapy is unknown. for example, valproate-doxorubicin treatment caused toxicityinduced death of two patients in a group of cancer patients [ ] . the overall success rate of development of new drugs ( %) and repositioning of drugs does not vary much as the ultimate efficacy remains same [ ] . also, the repositioned drug anyhow requires clinical re-assessment for optimizing its efficacy and cytotoxicity if the route of administration or drug dosage is different from the older indication; thereby increasing the overall cost of repositioning scheme. nonetheless, the animal model used for drug testing does not represent the exact patient phenotype and hence is less predictive of efficacy in real [ ] . despite many benefits of drug repositioning, much attention is required to lower the drug dosage and toxicity without mitigating efficacy and resolve above discussed limitations for cost effective and more efficient drug development. in this article, we have comprehensively explained the current scenario of repurposed drugs for breast cancer. we have discussed in detail the need and strategies of drug repositioning in breast cancer and several classical examples of drugs that have been repositioned as breast cancer chemotherapy. the futuristic potential of non-cancer drugs that are under investigations for breast cancer as well as the challenges and bottlenecks of drug repositioning were also discussed. we thus conclude that comprehensive approach of selecting the most appropriate gene-protein-pathway-target-drug modeling via integration of system 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computational approaches for colorectal cancer this work was supported in part by funds from the science and engineering research board (ecr/ / ), and university grants commission [ - / (bsr)] to scg. ssv was supported by a fellowship from dbt new delhi (dbt/ /bhu/ ). key: cord- -kdeynhzq authors: opgenorth, julie; sordillo, lorraine m.; lock, adam l.; gandy, jeff c.; vandehaar, michael j. title: colostrum supplementation with n- fatty acids alters plasma polyunsaturated fatty acids and inflammatory mediators in newborn calves date: - - journal: j dairy sci doi: . /jds. - sha: doc_id: cord_uid: kdeynhzq calves may experience increased oxidative stress at birth through activation of metabolic and respiratory processes. reducing oxidative stress may enhance calf viability in early life. our objective was to determine the dose response to fish and flaxseed oil when supplemented in colostrum on concentrations of plasma fatty acid (fa), fa metabolites, and index of oxidative stress during the critical first week of life in calves to understand how supplementing n- fa may decrease oxidative stress. we hypothesized that n- fa supplemented in colostrum in a linear dose-dependent fashion would associate with increased plasma n- fa concentrations and decreased oxidative stress. twenty-four male and female holstein calves were randomly assigned to receive , , , or ml of a : fish to flaxseed oil supplement in colostrum. all calves received . l of previously frozen colostrum (≥ % brix) with their respective treatment within h after birth. blood was sampled before first feeding after birth and on d , , , , and d of age to assess oxidant status and plasma free pufa, phospholipid fa, and oxylipid concentrations. health indicators were observed daily. indicators of general health and growth were unaffected by treatment. supplemented calves exhibited greater concentrations of n- fa in plasma as free and phospholipid fa and some n- and n- fa-derived oxylipids in the first week of life in a linear fashion with increasing supplemental dose. fish and flaxseed oil treatments did not alter oxidant status but overall decreased isoprostane concentrations in plasma, indicating oxidative stress was decreased. together, these responses indicate that the fish and flaxseed oil supplement was antiinflammatory. in conclusion, supplementing colostrum with , , and ml of a : mixture of fish and flaxseed oil linearly increased plasma concentrations of n- fa and metabolites and decreased biomarkers of oxidative stress, but did not alter oxidant status or affect health or growth. our findings suggest neonatal calves may benefit from n- fa supplementation in colostrum to encourage a greater antiinflammatory state. parturition and the associated physiological changes that accompany it are stressful to the dam and calf (ling et al., ) , contributing to an increased risk of immune dysfunction and oxidative stress. though acute inflammation aids normal parturition (hansen et al., ) , unresolved inflammation and oxidative stress can lead to increased disease incidence in the cow (bradford et al., ) and decreased calf vitality (abuelo et al., ) . oxidative stress occurs in the neonate just after birth as oxygen concentrations entering tissues increase rapidly, resulting in production of reactive oxygen and nitrogen species (rons; frank and sosenko, ) . the overproduction of rons and associated free radicals may prove toxic to newborn tissues if antioxidant defense mechanisms are overwhelmed (buonocore et al., ) . additionally, dystocia can decrease neonatal plasma concentrations of vitamins with antioxidant properties such as vitamins a and c and β-carotene, along with a concurrent increase in cortisol (civelek et al., ) . these changes further affect the balance between free radical production and the capacity of antioxidants to mitigate them. supplementation of calves with fish or flaxseed oils, both of which are enriched for n- fatty acids (fa), seems to improve health and growth of milk-fed calves (ballou and depeters, ; hill et al., ; karcher et al., ) . ballou and depeters ( ) found that fish oil reduces signs of disease and the acute phase response during an endotoxemic challenge. karcher et al. ( ) compared fish and flaxseed oils and found both oils decrease inflammatory cytokine gene expression, but flaxseed oil enhances feed efficiency in early life and reduces fever after vaccination. hill et al. ( ) fed a diversified fat supplement containing flaxseed oil to improve feed efficiency and decrease disease incidence. in each of these studies, calves received their n- fa supplement as part of their milk replacer feeding program, starting several days after birth. however, the best time to supplement n- fa might be at birth when oxidative stress is likely to occur. compared with milk at mo after parturition, colostrum collected within the first h has more fat ( . vs. . %) with a smaller n - : n - fa ratio ( vs. ; contarini et al., ) . provision of n- fa to cows before calving does little to increase n- fa concentrations in blood of calves (moallem and zachut, ) . thus, supplementation of n- fa in colostrum might be a reasonable approach. we recently found that supplementing calves with a ml of : mixture of fish: flaxseed oil along with mg of α-tocopherol in colostrum decreased oxidant status index (osi) during the first week of life . oxidant status is the ratio of the concentrations of rons to antioxidants, so a decreased oxidant status indicates that supplemented calves had less oxidative stress. our supplement contained n- fa and α-tocopherol, which both have antioxidant properties, so whether the benefit of our treatment was due to n- fa-enriched oils, α-tocopherol, or both was not known. because calves on both treatments received α-tocopherol, albeit in different dosages, we postulated that the major benefit was from the fish and flax oils. in the current study, we supplemented calves with n- fa without additional α-tocopherol. in addition, to examine possible mechanisms, we measured blood concentrations of inflammatory markers and oxylipids. oxylipids, which are produced from enzymatic oxidation of n- fa, promote resolution of inflammation and repair of oxidative tissue damage (raphael and sordillo, ) . therefore, the objective of our current study was to determine effects of doses of a : blend of fish and flaxseed oils (without extra α-tocopherol) on plasma fa composition and osi, on the concentration of several oxylipids and inflammatory markers in blood, and on health and growth. we hypothesized that an n- fa supplement would increase plasma n- fa concentrations in a linear, dose-dependent manner, leading to an increase in the biosynthesis of antiinflammatory n- fa-derived oxylipids and decreased oxidative stress. the study was conducted from june to july of at the michigan state university (msu) dairy teaching and research center (east lansing) and was ap-proved by the msu animal care and use committee (approval no. / - - ). calves were born between june and july and housed in outdoor hutches under shade. throughout the course of the study, outside temperature averaged °c and the minimum and maximum temperatures were °c and °c, respectively. twenty-four holstein ( male, female) calves were assigned to of treatment groups in a randomized block design by sex. treatments followed a pattern of varying amounts of a : mixture of fish: flaxseed oil, which also included polysorbate- at . ml/ml of oils to emulsify the oils and enhance absorption. treatments were assigned as follows: ( ) control: no supplement in colostrum (con), ( ) ml of : fish: flaxseed oil blend in colostrum (ff ), ( ) ml of : fish: flaxseed oil blend in colostrum (ff ), and ( ) ml of : fish: flaxseed oil blend in colostrum (ff ). colostrum from cows in the msu herd was frozen in pouches of . l for later use if it scored ≥ % on the brix scale (indicating ≥ g/l immunoglobulins: bielmann et al., ) . each calf received a randomly assigned pouch. the pouches were thawed and sampled for immunoglobulin concentration. the supplement for treatment calves was then added to . l of colostrum, but control calves did not receive any supplement. calves were fed colostrum within h after birth (average was . h); if a calf did not consume by suckling, the colostrum was delivered by intragastric tube. after birth, all calves were removed from the dam immediately and received a bovine rotavirus and coronavirus vaccine and intramuscular supplements of ml of vitamin a and d vetone, equivalent to kiu of vitamin a and kiu of vitamin d (mwi animal health, boise, id) and ml bo-se (merck animal health, madison, nj), which contains mg of α-tocopherol and mg of selenium per ml. a second colostrum feeding of . l was given to h after birth, but no supplement was added to the second feeding for any calves. calves were housed outside after their first day of life in individual calf hutches bedded with sand and were isolated to prevent physical contact with other calves. they were provided with ad libitum access to water and calf starter grain (ampli-calf as starter p r , % protein; land o'lakes, arden hills, mn) and fed daily with milk replacer (cow's match warmfront milk replacer, % protein and % fat; land o'lakes) at approximately , , and h. each liter of milk replacer contained % solids. milk replacer was given times per day at , , and h. age to wk calves received . l at the morning and opgenorth et al.: colostrum supplementation and oxylipid profiles afternoon feeding and . l in the evening. calves to wk of age received . l at the morning and afternoon feeding and . l in the evening. at to wk, calves received . l in the morning only. health was scored for wk after birth. medication, milk replacer refusal feedings, and disease incidence were recorded throughout the preweaning period. we measured bw with a calibrated calf cart scale (digi-star, fort atkinson, wi) and wither height and heart girth at birth, wk of age, and weaning. health was assessed daily for wk after birth by trained researchers blind to treatment before the am milk feeding. health scores for feces, eyes, nose, and ears were based on methods by mcguirk, university of wisconsin, on a to scale where scoring was described as fecal: = normal to = watery, discolored, or bloody; eyes: = no discharge to = excessive discharge; nose: = normal discharge to = excessive discharge; ear: = normal ear alertness to = tilted head or blatant ear droop (university of wisconsin madison, ). twenty microliters of an antioxidant-reducing agent of % methanol, % ethanol, and % water with . mm of butylated hydroxytoluene, . mm edta, . mm triphenylphosphine, and . mm indomethacin, as described in kuhn et al. ( ) , was added to µl of thawed colostrum. samples underwent lipid hydrolysis via the addition of µl of koh and incubating for min at °c. once samples cooled to room temperature, they were centrifuged at , × g for min at °c. the hcl at m was added to the removed supernatant in increments of µl until the supernatant ph was decreased to or less. a mixture of internal standards of µl was added to each sample mixture as well, consisting of . µm (s)-hydroxyeicosatetraenoic-d , . µm ( )-epoxyeicosatrienoic acid-d , . µm prostaglandin e -d , and . µm , -dihydroxyeicosatrienoic acid-d . samples underwent solid-phase extraction with oasis hlb cc lp extraction columns (waters, milford, ma) via a biotage extrahera (biotage, charlotte, nc), further described in putman et al. ( ) . samples were then dried in a savant speedvac (thermo fisher scientific, waltham, ma) and reconstituted in . : methanol: hplc water. after filtration, samples were placed in glass vials with inserts and stored at − °c until liquid chromatography/ms analysis. blood was collected from the jugular vein of calves on d (before first colostrum feeding), ( ± h), ( ± h), (± d), (± d), and (± d) after birth. analysis of d samples were used as a covariate in the statistical model, but if not significant, were not included in results. serum was harvested to determine serum total protein using a digital brix refractometer and was sent to saskatoon colostrum company for analysis of immunoglobulins (saskatoon, sk, canada). serum was harvested and immediately flash frozen in liquid nitrogen and placed in dry ice during transit to a − °c freezer for later analysis of osi. plasma was harvested immediately and stored at − °c until analysis of fa phospholipid profiles. another aliquot of plasma was immediately flash frozen with liquid nitrogen and stored at − °c for future analysis of oxylipid and free pufa concentrations. the concentrations of rons and of antioxidants in serum were measured in the same sample concurrently to calculate osi. the rons were measured using the cell biolabs inc. oxiselect in vitro ros/rns assay kit (cell biolabs inc., san diego, ca). free radicals in samples convert a dichlorodihydrofluorescein fluorogenic probe to ', '-dichlorodihydrofluorescein to detect fluorescence intensity to quantify total free radical concentration as described previously (putman et al., ) . antioxidant potential (aop) of the same samples was quantified through the units of trolox equivalence, a synthetic analog of α-tocopherol, where values of aop were compared with a photometric plate reader. , '-azino-bis- -ethylbenzothiazoline- -sulfonic acid was used as a radical cation to be reduced by antioxidants as described previously (putman et al., ) . the reduction potential of each sample, compared as trolox equivalence, was compared by a photometric plate reader. this decolorization assay is further described in re et al. ( ) . sample preparation. extraction and analysis of plasma for analysis of free pufa, oxylipid, and isoprostane concentrations followed methods modified from mavangira et al. ( ) . in brief, ml of plasma was thawed on ice and ml % formic acid and µl/ ml of an antioxidant-reducing agent to protect samples from lipid peroxidation during processing (o'donnell et al., ) was added to plasma. the antioxidantreducing agent was % methanol, % ethanol, and % water with . mm butylated hydroxytoluene, . mm edta, . mm triphenylphosphine, and . mm indomethacin, as described in kuhn et al. ( ) . a mixture of internal standards of µl was added to each sample mixture as well, consisting of . µm (s)-hydroxyeicosatetraenoic acid-d , . µm (s)-hydroxyeicosatetraenoic acid-d , . µm ( )-epoxyeicosatrienoic acid-d , . µm prostaglandin e -d , and . µm , -dihydroxyeicosatrienoic acid-d . waters oasis prime hlb cc solid-phase extraction columns were used for solid phase extraction performed by biotage extrahera (biotage). after samples were loaded onto columns and excess infranatant was discarded with nitrogen, columns were washed with ml of % methanol and then . ml of : acetonitrile: methanol eluted samples. leftover solvents were evaporated with a savant speedvac. a mixture of . : methanol: hplc water brought the fa back into solution before filtering and dispensing into glass chromatography vials with inserts. quantification of oxylipids. in short, the quantification of metabolites was accomplished on a waters xevo-tq-s tandem quadrupole mass spectrometer using multiple reaction monitoring. chromatography separation was performed with an ascentis express c hplc column (sigma-aldrich, st. louis, mo), held at °c and autosampler held at °c. mobile phase bottle a was water containing . % formic acid and mobile phase bottle b was acetonitrile; the flow rate was . ml/min. liquid chromatography separation took min per sample with linear gradient steps programmed as follows (a: b ratio): time to . min ( : ), to ( : ) at . min; to ( : ) at . min; to ( : ) at . min; . min held at ( : ) until min . ; then return to ( : ) at . min, and held at this condition until . min. all oxylipids were detected using electrospray ionization in negative-ion mode. cone voltages and collision voltages were optimized for each analyte using waters quanoptimize software and data analysis was carried out with waters masslynx software. quantification of isoprostanes. quantification of isoprostanes was accomplished with a waters xevo tq-s tandem quadrupole mass spectrometer using multiple reaction monitoring. chromatography separation was performed with a waters acquity uplc utilizing a beh c . µm ( . × mm) column, held at °c, and autosampler held at °c. mobile phase bottle a was . % acetic acid and mobile phase bottle b was acetonitrile, mobile phase bottle c was methanol, and the flow rate was . ml/min. the gradient initial phase a:b, : to min changing to a:b:c, : : , to min changing to a:b:c, : : , to . changing back to initial phase and holding until min. all oxylipids were detected using electrospray ionization in negative-ion mode. cone voltages and collision voltages were optimized for each analyte using waters quanoptimize software and data analysis was carried out with waters masslynx software. quantification of free polyunsaturated fatty acids. briefly, reverse-phase liquid chromatography/ ms on a waters acquity uplc employing a beh c . µm ( . × mm) column with a flow rate of . ml/min at °c was utilized. the quadrupole ms was in electrospray negative ionization mode and voltage was − kv with the turbo ion spray source temperature at °c. the gradient mobile phase was programmed in the following manner (a/b/d ratio): time to . min ( / / ), to ( / / ) at . min, to ( / / ) at . min, to ( / / ) at . min, and held until . min, then return to ( / / ) at . min, and held at this condition until . min. in this gradient mobile phase a = acetonitrile, b = methanol, and d = . % formic acid. fatty acids were quantified by matching mass- and retention time with corresponding deuterated internal standard abundance and calibrated to a linear -point standard curve (r > . ) using waters empower software. phospholipids were analyzed using methods adapted from folch et al. ( ) and kramer et al. ( ) . in brief, total lipids were extracted from an aliquot of ml of plasma by shaking samples in ml of methanol and ml of chloroform. a solution of % sodium chloride in water was then added. the chloroform layer with lipids was filtered out, dried, and weighed for total lipid content. next, the phospholipid fractions were isolated using solid phase extraction. columns were initially washed with . ml of : acetone: water and eluted with ml of hexane before loading lipid samples dissolved in . ml of hexane: methyl tertbutyl ether: acetic acid ( : : . ). cholesterol esters were first eluted with ml of hexane, and free fa eluted with ml of hexane: chloroform: ethyl acetate ( : : ). columns were washed with ml of : chloroform: isopropanol. next, the triglyceride fraction was collected via ml of chloroform: methanol: acetic acid ( : : ), and phospholipids eluted via ml of methanol: chloroform: water ( : : ). the phospholipid fraction was then washed with ml of % sodium chloride in water and phospholipids in the chloroform layer were collected. only the phospholipid fraction was analyzed in the interest of relevance to experiment objectives. after phospholipid content was calculated, . ml of the internal standard, c : -heptadecenoic acid in toluene, was added. phospholipids were then methylated into fame as previously described (lock et al., ) . hexane reconstituted fame in solvent to produce a % solution for glc analysis with a gc- plus gas chromatograph (shimadzu, kyoto, japan). conditions for glc analysis are further described in lock et al., ( ) . plasma phospholipid fa concentrations were calculated as a percentage of total phospholipids recovered from plasma in g/ g. all values were calculated with average response factor of from external standards. due to sample number constraints per analysis, samples collected d , , , and were analyzed separately from d and and were run consistently with randomized blocks. data were analyzed using sas version . (sas institute inc., cary, nc) with a mixed procedure. fixed effects were sex, treatment, and day. random effects were block within sex and calf within block, sex, and treatment. contrast coefficients were assigned for each treatment to test linear, quadratic, and cubic effects as follows: linear − , − , , and ; quadratic , − , − , and ; cubic − , , − , and for con, ff , ff , and ff , respectively. when analyzing statistics for bw and adg up to weaning, the variable week replaced day. average daily gain for the first wk of life, health scores, and d , , , and of blood variables were analyzed with the mixed model. blood variables from d were included in figures but not in statistical analysis, as we expected most variables to return to baseline by d . all p-values or data expressed in tables are results from analyzing d , , , and after birth only. after birth and before the first colostrum feeding, blood was sampled and analyzed to use as a potential covariate in the model. if the covariate was not significant and did not correlate with day, it was not included in the model. assays were conducted by block. the order on the well plate of the rons concentration assay significantly affected resulting values, and therefore, was included in the model for osi analysis as order within block. effect of block was confounded with order. treatment was not confounded with order, as treatments were random with respect to order of wells. preweaning adg, general health observations, colostrum immunoglobulin count, and brix measures were analyzed with the general linear model anova procedure. normality was assumed if a variable's general linear model procedure's bartlett homogeneity of variance test indicated p > . . data were log-transformed if p ≤ . and transformed least squares means were backtransformed from the model for interpretation in tables and figures. differences were considered significant if p ≤ . and a tendency if . < p ≤ . . differences were considered significant if interaction p ≤ . and a tendency if . < p ≤ . . during the first wk of life, calves were treated for diarrhea. calves typically showed initial symptoms of diarrhea to d after birth. across treatment groups, the average number of medication doses for diarrhea per calf was . during the first wk of life, and differences between treatments were not significant (p = . ). if a calf did not complete a meal of milk replacer, it was recorded as one refusal. the average number of refusals per calf was . during the first wk and was similar across treatment groups (p = . ). one calf died at d of age, presumably from heat stress; all available data for this calf were included in the data set. average health scores over the first wk of life were . , . , . , and . for fecal, eye, nasal, and ear scores, respectively, and were not altered by treatments (p > . ). despite the fact that calves were given treatments by farm staff blinded to treatment, the time of feeding first colostrum was . , . , . , and . h for the con, ff , ff , and ff groups, respectively, and the overall treatment effect was significant (p = . ). however, the concentrations of immunoglobulins and total protein in serum in calves in the first week were not altered by treatment and were > and ≥ g/l, respectively, indicating all calves received colostrum of acceptable quality in a timely fashion for antibody absorption in the bloodstream (calloway et al., ; godden, ) . treatment did not alter serum total protein (mean of g/l) or immunoglobulin concentration (mean of g/l) during the first week of life (p > . for overall treatment effect for both variables). mean colostrum n - : n - fa ratios before addition of supplements for con, ff , ff , and ff were . , . , . , and . , respectively, and did not differ across treatment groups. treatment did not alter growth rates in the first wk of life or during the preweaning period (p > . ). average wither height, heart girth, and bw gain during the first wk were . cm/d, . cm/d, and . kg/d and were not altered by treatment (p > . ). treatment also did not alter bw gain through the entire preweaning period ( . , . , . , and . kg/d for con, ff , ff , and ff , respectively; p = . ). fish and flaxseed oil (ff) treatments increased free concentrations of the n- fa α-linolenic acid (ala), eicosapentaenoic acid (epa), docosahexaenoic acid (dha), and docosapentaenoic acid in plasma on d , , , and after birth in a linear fashion (table , p < . ). this corresponded well with the fa found in fish and flaxseed oil. dha was significantly increased in plasma free pufa concentrations with ff treatments where con, ff , ff , and ff averaged , , , and nm dha (p < . ) during the first week after supplementation. likewise, epa also increased with increasing ff supplement volume ( . , . , . , and . nm, respectively; p < . ). the ala significantly differed in concentration among con and ff treatment calves during the first week of life ( , , , and nm, respectively; p < . ) as well. all primary n- fa concentrations were linearly increased by ff treatments (p ≤ . ) on d , , and after birth. by d after birth, concentrations either returned to normal or tended to be elevated (p ≥ . ) with ff, and by d , n- fa concentrations all returned to baseline (figure ) . linoleic acid constitutes % of flaxseed oil and is a precursor to arachidonic acid (ara). plasma concentrations of free linoleic acid averaged ~ , nm in calves given ff treatments, compared with , nm for con, but these were not different. additionally, treatments did not alter concentrations of free ara in plasma (mean nm, p = . for treatments). the concentration of n- fa remained constant for all calves, whereas primary n- fa linearly increased in ff treatments. thus, during the first week of life, the ratio of free n - : n - fa in plasma was decreased with ff in a linear fashion (p = . ; , , , and for con, ff , ff , and ff , respectively). the linear trend of increased free n- fa and decreased free n - : n - fa ratio was also associated with similar changes in the plasma phospholipid fa fraction (supplemental table s , https: / / doi .org/ . / jds . - ). as expected, supplementing ff increased (p < . ) the concentrations of ala, epa, and dha in the first week of life ( figure ; table ). the dha increased linearly (p < . ) with increasing ff dose, whereas ala and epa increased quadratically (p < . and p = . , respectively). treatment did not alter the content of linoleic acid and ara in phospholipids (both p > . ), but linoleic acid had a quadratic effect (p = . ). the content of total n- fa and total pufa in phospholipids increased with ff supplementation in linear and quadratic fashions (p = . ). however, the concentration of total n- fa did not change with treatments, although a quadratic upward trend was observed (p = . ). the ratio of n- to n- fa in plasma phospholipid decreased as calves were fed more ff ( . , . , . , and . ) in a linear fashion (p < . ). the ff treatments linearly decreased monounsaturated plasma phospholipid fa and quadratically altered sfa (p = . , p = . , respectively). for all phospholipid pufa that were altered by treatment, the concentration in phospholipids decreased over time in calves fed ff treatments (p ≤ . for day; figure ). treatments (n = ): con = control, no supplement added to colostrum; ff = ml of a : ratio fish and flaxseed oil blend added to colostrum; ff = ml of a : ratio fish and flaxseed oil blend added to colostrum; ff = ml of a : ratio fish and flaxseed oil blend added to colostrum. l = linear polynomial contrast. q = quadratic polynomial contrast. c = cubic polynomial contrast. overall p-value = treatment effect p-value. average concentrations of oxylipids and isoprostanes for each treatment during wk are reported in supplemental tables s and s , respectively (https: / / doi .org/ . / jds . - ). concentrations of oxylipids and isoprostane in plasma were altered by ff treatments (figure ). calves given ff treatments had linearly increased (p < . ) epa-derived , -dihydroxy-eicosatetraenoic acid ( , -dihete) and quadratically increased , -dihete (p = . ) and , -dihete (p = . ) with supplement dose. the ff treatments increased dha-derived , -dihydroxy-docosapentaenoic acid ( , -dihdpa) by , , and % of con, respectively (p = . in quadratic fashion). the n- -derived leukotriene b (ltb ) increased with ff treatments , , and % of con (p = . in quadratic fashion), and -iso-prostaglandin-a decreased by , , and % of con (p = . overall and p = . cubic). the , and total n - : total n- fa ratio (d) predicted from the model. the ala, epa, and dha are backtransformed for interpretation with adjusted se. during wk , fish and flaxseed oil treatments increased ala, epa, and dha and decreased the n - : n - fa ratio (p < . ). treatments (n = ): con = control, no supplement added to colostrum; ff = ml of a : ratio fish and flaxseed oil blend added to colostrum; ff = ml of a : ratio fish and flaxseed oil blend added to colostrum; ff = ml of a : ratio fish and flaxseed oil blend added to colostrum. , -lipoxin a (lxa ) increased (p = . in linear fashion) with ff treatments by , , and % of con. three enzymatic complexes produce the n- and n- fa-derived oxylipids analyzed in this experiment. oxylipids produced from cytochrome p epoxygenase (cyp) and lipoxygenase (lox) were primarily affected by supplementation. no oxylipids analyzed that derived from cyclooxygenase (cox) pathways were altered in concentration by ff treatments. the ff treatment did not decrease osi during the first week of life (p = . ). the rons concentrations and aop remained constant across treatment groups (p = . and p = . , respectively). least squares means of indicators of oxidative stress, including -isoprostaglandin-a , are shown as treatment by sampling day in figure . increasing doses of , , and ml of : fish: flaxseed oil blend supplemented in colostrum did not affect health or growth in calves, decreased phospholipid n- fa: n - fa profile, increased free and phospholipid n- fa concentrations, and increased several oxylipids deriving from n- fa during the first week of life. though osi was unaltered by ff treatments, concentrations of an n- fa-derived isoprostane, -iso-pga , were reduced, indicating oxidative stress was decreased in ff calves the first week of life. our previous experiment, which supplemented ml of a : ratio fish: flaxseed oil blend with an additional mg of α-tocopherol , observed increased free ala, epa, and dha in plasma similar to the current study. we also analyzed phospholipid fa content, which is of particular interest because, once incorporated in phospholipid membranes, phospholipid pufa and esterified forms cleaved by phospholipase a become available for enzymatic oxidation. oxylipids become products of oxidation and are able to mediate inflammation and oxidative stress (raphael and sordillo, ) . with an increase in the n- fa in plasma phospholipids of ff calves, we observed an increase in some n- fa-derived oxylipid concentrations. raphael et al. ( ) proposed that manipulation of oxylipids may be feasible via dietary pufa, and we found that with one n- fa supplementation, several oxylipid concentrations were altered. though we observed oxylipids in plasma, contreras et al. ( ) similarly found that increasing n- fa in the phospholipid profile of endothelial cells leads to increased beneficial n- fa-derived oxylipid concentrations. they also observed a decrease in reactive oxygen species (contreras et al., ) , though we did not find a corresponding rons decrease in plasma in our experiment. oxylipids are products of pufa substrates of enzymes such as lox, cox, and cyp. these are cell signaling molecules able to mediate inflammation and its resolution through a variety of mechanisms. oxylipids that increased in concentration by ff , ff , and ff were primarily end products of metabolism of epa and dha. the , , and , , -dihdpa from dha increased linearly with increased n- fa supplementation. of the aforementioned oxylipids, all are end products of cyp enzymatic activity. the n- fa are more favorable substrates to lox and cyp enzymes when compared with n- fa substrates (zhang et al., ) , but cox favors n- fa (wada et al., ) . this may explain why no oxylipids formed from cox pathways were altered by increasing n- fa supplementation. dietary supplementation of linoleic acid causes an observed increase in cox activity (marchix et al., ) , and dha decreases cox expression (massaro opgenorth et al.: colostrum supplementation and oxylipid profiles figure . fish and flaxseed oil treatments depicted as a lsm percentage of control (con) ± sem for n- fatty acid (fa)-derived oxylipids (a) and n- fa-derived oxylipids (b) that differed from con concentrations during the first week of age. oxylipids were dihydroxy-eicosatetraenoic acid (dihete), dihydroxy-docosapentaenoic acid (dihdpa), lipoxin (lx), and leukotriene (lt). overall treatment p-values were as follows: , -dihete: p < . ; , -dihete: p < . ; , -dihete: p = . ; , -dihdpa: p = . ; , -lxa : p = . ; ltb : p = . . treatments (n = ): con = no supplement added to colostrum; ff = ml of a : ratio fish and flaxseed oil blend added to colostrum; ff = ml of a : ratio fish and flaxseed oil blend added to colostrum; ff = ml of a : ratio fish and flaxseed oil blend added to colostrum. et al., ) . though we did not analyze gene expression, it is possible ff treatments may decrease cox expression due to an increase in dha concentrations and a decrease in the ratio n - : n - fa. many painrelieving drugs such as aspirin or meloxicam function to inhibit cox activity (brune and patrignani, ) , which is the very reason they are considered antiinflammatory. the only cox-produced oxylipid that linearly decreased with increasing ff supplementation was thromboxane- , which has proinflammatory functions, though no overall difference (p = . ) in concentration among treatments was observed. thus, further analysis of cox gene expression may be warranted to provide further evidence of the antiinflammatory effects of ff treatments in neonatal calves. the oxylipids ltb and lxa also increased with ff supplementation. interestingly, ara, the source of these oxylipids, did not increase as plasma free pufa the rons, osi, and -iso-pga means are back-transformed from the model for interpretation with adjusted se. the fish and flaxseed oil treatments did not alter rons, aop, or osi, but did decrease -iso-pga (p = . ) during the first week of age. treatments (n = ): con = control, no supplement added to colostrum; ff = ml of a : ratio fish and flaxseed oil blend added to colostrum; ff = ml of a : ratio fish and flaxseed oil blend added to colostrum; ff = ml of a : ratio fish and flaxseed oil blend added to colostrum. rfu = relative fluorescent units; te = trolox equivalents; au = arbitrary units. or phospholipid pufa in ff-supplemented calves compared with con. the lxa is antiinflammatory and ltb has some known proinflammatory functions. the lxa functions to enhance epithelial cell wound healing in rodents (gronert et al., ) and initiate remodeling of phospholipids in humans (nigam et al., ) among many more actions (gabbs et al., ) . contrastingly, ltb helps instigate neutrophil chemotaxis in bovines (heidel et al., ) . our study is perhaps the first to describe oxylipid and isoprostane concentrations during the first week of life of any neonate mammalian species. oxylipid concentrations differ among cows in varying stages of lactation, and concentrations are not always necessarily indicative of physiological changes (kuhn et al., ; putman et al., ) . though calf oxylipid concentrations were found to be much smaller than adult cows (nm vs. µm), the periparturient stage of the dairy cow can yield some interesting parallels to neonatal calves. kuhn et al. ( ) suggested lxa is preferentially produced in periparturient cows, perhaps as a mechanism to reduce the systemic inflammatory state observed after parturition. we found supplementing calves with n- fa in their first meal tended to increase lxa concentrations, which is curious considering lxa is derived from ara. supplementation with n- fa in rainbow trout and female rats decreases lxa and other ara-derived lipoxygenase products (ashton et al., ; poulsen et al., ) , which was consistent with the idea that ara and n- fa compete for lipoxygenase binding (schmitz and ecker, ) . however, calves receive a greater n - : n - fa ratio in the diet, and supplementing n- fa in a short period of time in the current study is likely not enough to alter n- fa phospholipid content, and thus their oxylipid products, in all tissues. nevertheless, lxa concentrations tended to increase with increasing n- fa supplementation, indicating preferential production of this metabolite similar to what has been observed in periparturient cows (kuhn et al., ) during a time when reducing systemic inflammation is a key homeostatic goal. differing from oxylipids, isoprostanes are direct biomarkers of oxidative stress because their production results from rons-induced peroxidation and damage to the phospholipid membrane and thus cellular components (montuschi et al., ) . a decrease in isoprostane concentration indicates reduced lipid peroxidation and thus oxidative damage that compromises normal cellular functions (van 't erve, ). alternatively, osi, the concentration of rons to aop, is considered a measure of redox balance (kuhn et al., ) ; therefore, we speculate ff treatments decreased oxidative stress due to decreased -iso-pga in plasma, even though osi remained unchanged. some evidence suggests neonate immune processes gravitate toward a proinflammatory state at birth (braekke et al., ; boro et al., ) . the placenta favors prooxidant isoprostanes derived from n- fa pathways; in humans, -iso-prostaglandin-f α , a prominent and well-studied isoprostane known to indicate increased free radical concentrations, is highly concentrated in the umbilical vein (braekke et al., ) . placental production of this biomarker of oxidative stress may be regulated by hormones, though explanations as to why this phenomenon occurs are still unclear (hermenegildo et al., ) . the placenta may require a certain degree of inflammation to detach normally (boro et al., ) , and inflammation plays important and necessary roles in the calving process (bradford et al., ) . however, oxidative stress can affect calves well beyond the acute response at birth (abuelo et al., ) , and the additional supplementation of antioxidant and antiinflammatory nutrients after birth may be beneficial for resolving these pathways quickly to avoid decreased calf viability and a disadvantaged immune system. a : fish: flaxseed oil supplement in colostrum at , , and ml linearly increased plasma concentrations of n- fa 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growth and immunity in milk-fed calves comparison of supplementation of n- fatty acids from fish and flax oil on cytokine gene expression and growth of milk-fed holstein calves evaluating acid and base catalysts in the methylation of milk and rumen fatty acids with special emphasis on conjugated dienes and total trans fatty acids differences in the oxylipid profiles of bovine milk and plasma at different stages of lactation production of -f-isoprostane as an assessment of oxidative stress in dairy cows at different stages of lactation maternal late-gestation metabolic stress is associated with changes in immune and metabolic responses of dairy calves feeding a c : -enriched fat supplement increased the yield of milk fat and improved conversion of feed to milk excessive dietary linoleic acid induces proinflammatory markers in rats the omega- fatty acid docosahexaenoate attenuates endothelial cyclooxygenase- induction through both nadp(h) oxidase and pkc inhibition polyunsaturated fatty acids influence differential biosynthesis of oxylipids and other lipid mediators during bovine coliform mastitis the effects of supplementation of various n- fatty acids to late-pregnant dairy cows on plasma fatty acid composition of the newborn calves isoprostanes: markers and mediators of oxidative stress lipoxin a and lipoxin b stimulate the release but not the oxygenation of arachidonic acid in human neutrophils: dissociation between lipid remodeling and adhesion eicosanoids: generation and detection in mammalian cells colostrum supplementation with n- fatty acids and α-tocopherol alters plasma polyunsaturated fatty acid profile and decreases an indicator of oxidative stress in newborn calves identification of inflammatory and proresolving lipid mediators in bone marrow and their lipidomic profiles with ovariectomy and omega- intake oxylipid profiles of dairy cattle vary throughout the transition into early mammary gland involution changes in biomarkers of nutrient metabolism, inflammation, and oxidative stress in dairy cows during the transition into the early dry period association between polyunsaturated fatty acid-derived oxylipid biosynthesis and leukocyte inflammatory marker expression in periparturient dairy cows dietary polyunsaturated fatty acids and inflammation: the role of phospholipid biosynthesis antioxidant activity applying an improved abts radical cation decolorization assay. free radic strategies to decrease oxidative stress biomarker levels in human medical conditions: a meta-analysis on -iso-prostaglandin f α enzymes and receptors of prostaglandin pathways with arachidonic acid-derived versus eicosapentaenoic acid-derived substrates and products stabilized epoxygenated fatty acids regulate inflammation, pain, angiogenesis and cancer sordillo https: / / orcid vandehaar https: / / orcid colostrum supplementation and oxylipid profiles this project was supported by the michigan alliance for animal agriculture (#aa - ), michigan milk producers association, and michigan state university agbioresearch. the authors appreciate lynn worden and the saskatoon colostrum company (saskatoon, sk, canada) for their contributions to sample analysis key: cord- -twsy oq authors: nan title: siu abstracts date: - - journal: world j urol doi: . /s - - - sha: doc_id: cord_uid: twsy oq nan introduction and objective: th e bladder is generally considered an organ for voiding and storage of urine, with the urothelium serving as an impermeable barrier. recent discovery of aquaporins in the bladder urothelium in rodents and later on also in human challenges this notion of impermeability. upregulation of aquaporins in response to dehydration or bladder outlet obstruction and downregulation following transitional cell carcinoma has been shown. th is emphasize the need to better understand the function and distribution of aquaporins, as well as their role in bladder diseases. th e present study aims at establishing basic knowledge about the expression of aquaporin (aqp ) in the porcine bladder, related to gender and gestational age. th ree pregnant sows at , or days of gestation were sacrifi ced. fetuses were removed and necropsied. th e bladder was rapidly removed and whole wall tissue samples from the bladder dome was snap frozen in liquid nitrogen and stored at - c. genetic gender determination was performed and fetuses with uncertain gender determination were excluded. aquaporin mrna expression was analyzed using qpcr and β-actin was used as the reference housekeeping gene. results were compared using two-way anova. results: a total of samples were analyzed. gestational age was either (n= ), (n= ) or days (n= ). aquaporin was expressed in all samples. aqp mrna expression was increased in the fetal porcine bladder with increasing gestational age (p< . ). however, there was no signifi cant diff erence in aqp mrna expression between genders (p= . ). conclusion: expression of aqp in fetal porcine bladder is demonstrated with increasing expression during gestation. to our knowledge aquaporins in the porcine bladder tissue have not previously been studied. th is exciting new discovery contributes to the ongoing discussion on reviewing the dogma that the lower urinary tract has an impermeable barrier function. improved contractility of the long term bladder outlet obstruction induced bladder underactivity using growth factor expressing mesenchymal stem cells introduction and objective: as the underactive bladder is diffi cult to manage, a new method of increasing bladder contractility in patients with underactive bladder is desired. mesenchymal stem cells (mscs) can serve as vehicles for the gene, proliferate and differentiate into bladder smooth muscle cells to repopulate damaged bladder. th e other is that the exogenous hepatocyte growth factor (hgf) gene can provide complementary functions as angiogenesis and inhibition of fi brosis. th is study was performed to examine the recovery of the decreased bladder contractility in the long term bladder outlet obstruction (boo) models of rats using transplantation of hgf expressing human mscs (hgf-hmscs) into the bladder wall. introduction and objective: suddenly dropping to low environmental temperature, cold stress exacerbates lower urinary tract symptoms (luts) such as urinary frequency and urgency. th is study determined if transient receptor potential ankyrin (trpa ) channels could mediate the cold-stress induced detrusor overactivity in rats. materials and methods: twenty-four female -weeks sprague dawley (sd) rats were used. th is th congress of the sociÉtÉ internationale d'urologie -siu abstract book study used hc (tocris bioscience) as trpa channel antagonist. th ree days prior to cystometric investigations, polyethylene catheters were inserted into the bladder and abdominal cavity. cystometric investigations of the unanesthetized rats were performed at room temperature (rt, ± °c) for min. following, the rats were intraperitoneally injected with vehicle, . -(low dose), or . -(high dose) mg/kg hc (n= , in each). aft er min, the treated rats were exposed to low temperature (lt, ± °c) for min. during the cystometric investigations, the micturition parameters were recorded. introduction and objective: hypoxia-inducible factors (hif , hif and hif ) play a critical role in cellular and systemic responses to hypoxia by inducing a range of diverse genes involved in cell survival, they have also been implicated in development of renal cell carcinoma. we aimed to assess the eff ect of zinc and cobalt on hypoxia-inducible factor expression in immortalized human kidney cells. to cells in mcl). esr at the observed patient aft er the seventh transfusion decreased from initial mm/ hour to mm/hour. aft er the fourth transfusion of mononuclear fraction of peripheral blood at the patient the increase in the content of the total testosterone that allowed to reduce a dose of % of dermal gel of testosterone from . ml per day to . ml per day was observed. aft er the seventh transfusion of mononuclear fraction of peripheral blood because of normalization of production of testosterone the restored number of own leydig's cells an androgen -replacement therapy was cancelled. introduction and objective: ketamine use as a recreational drug is on a rapid increase in young people. many reports have shown that long-term ketamine abuse is liable to lead to lower urinary tract symptoms that resemble interstitial cystitis (ic). ic is a disease characterised by severe and chronic pelvic pain with frequency, urinary urgency, and nocturia in the absence of bacterial infection or other diseases. th is study evaluated the therapeutic eff ect of human umbilical cord blood derived mesenchymal stem cells (ucb-mscs) in a ketamine induced cystitis (kc) rat model. for kc rat models -weekold, female sprague-dawley rats were used. sham treatment (n= ) rats were assigned to the control group. th e rats in the kc group (n= ) and kc+m-scs group (n= ) were intravenously injected with ketamine at a dose of mg/kg for days a week over a duration of weeks. aft er one week, x ucb-mscs were directly injected into the submucosal layer of the anterior wall and dome of the bladder in kc+mscs group. th e cystometric parameters and immunohistochemical results (toluidine-blue, masson trichrome, tunel staining) were measured at one week following the intervention. results: most rats in the kc group exhibited irregular voiding frequency and decreased inter-contraction interval in comparison with the control group ( . ± . vs. . ± . seconds, respectively; p< . ). th e kc+mscs group demonstrated improvement in most voiding parameters to normal levels within week. a single injection of ucb-mscs signifi cantly increased the inter-contraction interval ( . ± . , p< . ) ( figure ). in immunohistochemical analysis, the bladders in kc group were characterized by mast cell infi ltration in toluidine-blue staining, fibrosis in masson trichrome staining and apoptosis in tunel staining which were signifi cantly ameliorated in the bladders in the kc+mscs group ( figure ). conclusion: th e injection of ucb-mscs restored the damaged bladder and associated pathologies including mast cell infi ltration, fi brosis and apoptosis in the kc rat model. stem cell therapy could be valuable treatment option for painful bladder conditions such as ketamine induced interstitial cystitis. mp- . , figure . introduction and objective: currently no markers are available to predict intravesical bacillus calmette-guerin (bcg) response. among the various markers under study survivin has good sensitivity in detecting bladder cancer cases and there has been very limited number of studies regarding survivin as a prognostic marker and predictive marker. prospective evaluation of urinary survivin levels as a potential prognostic and predictive biomarker in non-muscle invasive bladder cancer cases on intravesical bcg therapy was planned in this study. from august to august a total intermediate and high risk group patients of nmibc age ranging from to yrs (mean ) planned for intravesical bcg instillation were enrolled. recurrence and progression score were calculated by using eortc genitourinary scoring system and risk table. patient's urinary samples were taken, pre and post [ (t ), (t ) and weeks (t )], intravesical bcg instillation. urinary survivin expression was studied by elisa technique. results: out of patients, ( . %) had complete remission at months th e mean survivin levels in remission group (group i) was . +/- . which was signifi cantly less than those in recurrence group (group ii) mean . +/- . . pre and post bcg, there was a signifi cant decrease in the urinary survivin levels in group i when compared to group ii where there was a signifi cant rise in pre and post bcg urinary survivin levels (p value< . ). conclusion: low pre bcg urinary survivin level can be used as a useful predictive marker for achieving complete remission in nmibc patients with on intravesical bcg immunotherapy. also pre and post bcg urinary survivin levels act as a useful prognostic marker and can be used as an adjunct to cystoscopy. introduction and objective: th e natural resistance-associated macrophage protein (nramp ) gene modulates macrophage activation in a myriad of infectious and autoimmune diseases. its single nucleotide polymorphisms (snps) have been identifi ed to infl uence susceptibility to tuberculosis and response to bcg therapy in murine models. in this study, we evaluate the predictive role of nramp snps in the oncological outcomes of asian patients receiving intravesical regimes of bcg for nmibc. a total of nmibc patients who underwent post-transurethral resection intravesical regimes of bcg ( mg or mg) or bcg ( mg) with interferon alfa from to and deemed intermediate to high risk by the european organisation for research and treatment of cancer risk tables, were prospectively recruited. from these patients and a group of healthy controls, peripheral blood samples were stored and genomic dna purifi ed. a total of nramp snps were evaluated using high resolution melt analysis. th e corresponding results were verifi ed by dna sequence analysis. kaplan-meier and cox regression methods were used to analyze the data. introduction and objective: microscopic hematuria can indicate presence of underlying urological conditions. aua guidelines recommend evaluation algorithms for microscopic hematuria. population-based studies have focused on risk pools such as heavy smokers and elderly men. we evaluated whether men interested in self-managing their lower urinary tract symptoms (luts) with an over-the-counter (otc) product should be screened for microscopic hematuria to detect undiagnosed signifi cant conditions (including urothelial malignancy) causing hematuria. materials and methods: urine dipstick testing was conducted in men who preferred to self-manage luts using an otc product. urologic assessment was conducted by a urologist to determine conditions causing/contributing to the urinary symptoms for: men < years; and men ≥ years who had traces of glucose, leukocyte, and/or blood in urine; or had an aua symptom index score ≥ . men experiencing complete urinary retention, dysuria, extreme thirst, gross hematuria, or urethral discharge ("do not use" symptoms in this study) were also assessed. men ≥ years of age who did not meet any of these criteria did not undergo urologic assessment. introduction and objective: th is fi rst experience, pilot study, was aimed to evaluate the outcome of en-bloc bladder tumor resection using the plasma-button electrode in cases of papillary non-muscle invasive bladder tumors (nmibt) from the perspectives of surgical safety and effi cacy, perioperative morbidity, histological assessment and short-term oncologic outcome. a total of patients previously diagnosed by abdominal ultrasound, contrast ct and fl exible cystoscopy with papillary bladder tumors over cm in diameter were included in the trial. th e exclusion criteria consisted in solid sessile tumors, lesions located in bladder neck area and tumors involving the ureteral orifi ce. en-bloc tumor resection using the plasma-button approach was applied in all enrolled cases. th e tumor base was subsequently biopsied by standard single-wire loop resection and followed by plasma-button coagulation. th e fi rst follow-up cystoscopy was completed at months. results: all procedures were successfully performed leading to visually complete tumor ablation. th e mean tumor diameter was . cm (range between and cm). no obturator nerve refl ex adverse events or cases of bladder wall perforation were encountered. no signifi cant postoperative hematuria and re-intervention requirements were encountered in this series. th e mean catheterization period was . days (range to . days) and the mean hospital stay was . days (range to days). th e pathological analysis confi rmed the presence of detrusor muscle in the resected biopsy specimens for all enrolled patients, thus enabling for a reliable tumor staging to be established (all nmibt histology diagnosed patients). a single case of other site residual lesion was found during the fi rst evaluation cystoscopy, while no orthotopic recurrences were described. to reduce the overdiagnosis and overtreatment of insignifi cant tumors there is an urgent need for a specifi c test to detect clinically signifi cant prostate cancer (pca). using gene expression profi ling specifi c pca-biomarkers were identifi ed. eight promising biomarkers were selected and the diagnostic accuracy was tested in urine of an intent-to-treat cohort. th e aim of this study was to clinically validate the four-gene biomarker panel (hoxc , dlx , tdrd and hoxc ) using an independent prospective multicenter study cohort. in two independent prospective, multicenter studies (cohort : n= en cohort : n= ) urine was collected aft er digital rectal examination (dre) from men undergoing prostate biopsies based on an elevated serum psa level (≥ . ng/ ml) and/or suspicious dre. klk , hoxc , hoxc , tdrd and dlx mrna levels were measured using rt-qpcr. th e assay was validated according to miqe criteria, hence the test is a standardized laboratory developed test (ldt). results from cohort were used to develop models with (combinations of) the four genes based on the comparative ct method. th e chosen model was validated in cohort , i.e. a fully independent validation cohort. results: pca was identifi ed in % ( / ) and % ( / ) of men from the studies respectively. th e model with the combination of hoxc /dlx resulted in the highest average auc ( . ) and specifi city ( %) at ≈ % sensitivity, based on cohort . furthermore, hoxc and dlx were signifi cant in the logistic regression, in % and % respectively. th is model was independently validated for the diagnosis of pca with gleason score ≥ in prostate biopsies. using roc curve analysis hoxc /dlx outperformed pca in both cohorts (cohort auc= . vs. . ; cohort auc= . vs. . ). adding serum psa to the hoxc /dlx model resulted in an auc of . and . , respectively. th is study showed the promising results of a new urine test for the early diagnosis of clini-cally signifi cant pca using a model which combines hoxc with dlx . th ese results demonstrate that this model could be used to assess the risk of pca with gleason score ≥ and therefore could reduce the amount of unnecessary prostate biopsies. introduction and objective: curcumin contains mul-introduction and objective: a family history of prostate cancer is a well-recognized high risk factor for this disease. various models for an inherited risk for prostate cancer have been described, but to date traditional linkage and association studies have only identifi ed a small number of rare tumor suppressor genes and snps involved in prostate cancer risk and development. we performed whole exome sequencing on multiple participants (n= ) with prostate cancer from families with a signifi cant history of prostate cancer to potentially identify new prostate cancer susceptibility variants. exome variants were fi ltered against a range of parameters with a subset of variants chosen for validation by sanger sequencing and segregation analysis within their respective families. each prostate cancer participant met the following criteria for inclusion if: (i) they had a verifi ed diagnosis of prostate cancer, (ii) there were multiple cases of prostate cancers in the family, iii) pathology, diagnostic and treatment notes were available, and (iv) they were classifi ed as brcax mutation status. results: essential splice site, missense and stop lost variants were fi ltered against a recently published candidate gene list, leaving shared truncating variants and shared missense variants to be genotyped through all prostate aff ected (n= ) and unaff ected male participants (n= ). th ree missense variants demonstrated complete segregation and one missense variant demonstrated partial segregation with the prostate cancers. th ree truncating variants demonstrated complete segregation and three truncation mutations demonstrated partial segregation with prostate cancer. no segregating variants between the three families were shared. conclusion: ten truncating or missense variants showed either complete or partial segregation in our three familial prostate cancer families. of interest, we detected a cyp a and parp variant in our multicase prostate cancer families. th ese two variants have previously been reported to occur in other familial associated prostate cancer families, thereby, potentially adding to the evidence that these two variants may have a role in the risk and development of prostate cancer. another eight novel variants were detected that segregated with disease and warrants further investigation. th congress of the sociÉtÉ internationale d'urologie -siu abstract book were recorded. patients with diabetes, hypertension or known cardiovascular disease were excluded. introduction and objective: traditional methods of prostate cancer diagnosis in males with an elevated or rising psa have relied on outpatient trus biopsy using local anaesthetic and taking between - biopsies. trus biopsy is painful, associated with rectal bleeding in %, uti in % and urosepsis in up to % of patients. it is also has a poor sensitivity (< %) low accuracy rates of < % and a poor specifi city of < %. from we changed to template guided prostatic biopsy (tgpb) carried out transperineally under a general anaesthetic. to date we have carried out tgpb in patients with a positive biopsy rate of % (accuracy of %; and specifi city of %). th e procedure is painless, utis occurred in %, no sepsis and no rectal bleeding. because of the large numbers of biopsies taken % of patients had transient retention. in patients who had a previous -ve trus biopsy % had a subsequent +ve tgbp and patients having tgbp on the fi rst occasion for an elevated psa ( . - ) % had a positive biopsy. results: with the advent of tesla mri and mri fusion technology we have now progressed to mri fusion biopsy using real time ultrasound imaging and fusing the abnormal mri image to perform the biopsy (biojet fusion, global prostate solutions) . th is allows for even greater accuracy of the biopsy without taking large numbers of samples. to date we have achieved a +ve biopsy rate of % with an accuracy of > % (in patients). to date there have been no cases of uti, sepsis or retention. to determine the suitability of circulating tumour cells (ctcs) as prognosticating indicator and biomarker for delivery of precision medicine. patients were recruited and screened (n= ) as a part of admet (androgen deprivation th erapy and adjuvant metformin) trial. five millilitres of whole blood was collected from patients for ctc enrichment, enumeration and propagation. enrichment was performed using cd negative selection kit (rosettesep™). ctcs were identifi ed using immunofl uorescence imaging with antibodies against prostate specifi c antigen, cytokeratin, cd and nucleus. cells were propagated in customized stem cell solution with hypoxic conditions. results: at screening, of patients demonstrated circulating tumour cells with the mean number of (range - , ± ) . in all of the enriched samples, cells could be propagated temporarily with the peak population being reached at . weeks. cells were cultured in both d and d conditions and temporary organoids could be developed from of patients. polymerase chain reaction and immunofl uorescence imaging at weeks aft er culturing demonstrated characteristics consistent with prostate cancer cells. conclusions: circulating tumour cell technology remains a viable option as a means of providing biomarker information and tumour activity indicator in delivering precision medicine. firstly, enumeration can be used to help determine the response to a treatment. secondly, temporary culture and progression into development of organoids may be used to allow for downstream analysis and therapeutic decision. transcriptionally-targeted retroviral replicating vectors: a novel strategy for gene therapy of prostate cancer introduction and objective: while hematospermia is mainly associated with genitourinary infl ammatory disorders, there are very few studies for prostatitis associated hematospermia (pah) via robust prostatitis evaluation methods. for this reason, we evaluated the incidence of pah with systematic evaluation methods for prostatitis. we evaluated hematospermia patients from a single hospital over fi ve years. we classifi ed the patients into pah versus he-matospermia without evidences of prostatitis (hwp) by using a nih-cpsi (chronic prostatitis symptom index) questionnaire and expressed prostatic secretion studies. th congress of the sociÉtÉ internationale d'urologie -siu abstract book cant diff erence in patient's the quality of life impact (table ) . introduction and objective: chronic prostatitis/ chronic pelvic pain syndrome is a chronic pain disease with high prevalence rates and substantial health care costs. chronic prostatitis syndrome is a common urological condition that many clinicians fi nd diffi cult to diagnose and treat eff ectively. th e signifi cance and diagnostic value of semen analysis in bacterial prostatitis has been extensively debated and remains controversial. our objective was to investigate the diagnostic accuracy of semen and urine culture in the diagnosis and treatment outcome of bacterial prostatitis. th e present study is based on a retrospective analysis of a database of over patients (age range - years) who met the consensus criteria for bacterial prostatitis, % of whom had dysuria, % perineal discomfort, % had obstructive luts, % infertility of unknown etiology, % erectile dysfunction and % recurrent infection of the partner. segmented urine cultures and semen culture, were performed in all patients. treatment were started as per the culture report and culture negative patients were treated empirically with quinolones group of antibiotics. patients were followed-up for year to rule out disease recurrence. results: of the patients, had positive semen culture and had positive urine culture; had negative culture for both semen and urine. of the positive cultures % of the bacteria was gram-negative microorganisms (escherichia coli was the commonest specimen isolated) and % had signifi cant positive cultures for gram-positive microorganisms. patients with positive semen culture had % response to antibiotics and full recovery was noted from the symptoms prospective aft er the full course of the antibiotic and recurrence of the disease were noted in % of the patient aft er year follow-up. patients with urine positive cultures, % had response to antibiotic, but % recurrence were noted in year. patients with negative cultures, % had symptomatic relieve but all of them had recurrence in year follow-up. conclusions: th e diagnosis of chronic prostatitis is diffi cult due to the absence of typical clinical symptoms and specifi c ultrasonographic signs. our data support the usefulness of semen analysis in the diagnostic work-up of prostatitis patients. semen culture positive patient responded well to medications and recurrence rate was very minimal compared to urine positive and culture negative patients. in our clinical work-up, semenculture are considered the only tests necessary to diagnose bacterial prostatitis and also guide us through the treatment. (rc) has been shown to be a predictor of poor outcomes in patients with bladder cancer. change in muscle volume during neoadjuvant chemotherapy (nac) administration has not been well studied. our objective was to assess for psoas muscle volume (pmv) change during the period of nac therapy and to assess if such a change was a predictor of pathologic response or survival. mp- . , figure . introduction and objective: alternative approach to the radical cystectomy for muscle-invasive bladder cancer is radical transurethral resection (tur), followed by chemotherapy/ radiotherapy. objectives: primary end points of the study were os (overall survival) and dss (disease-specifi c survival). secondary endpoint -oos survival aft er salvage cystectomy. materials and methods: sixty eight patients with t bladder cancer were treated by 'complete' tur fol-lowed by chemotherapy / radiotherapy. th e follow-up ended in june . all patients were subjected to "safety" resection. patients who had no tumor (t ), or had non-muscle-invasive (t ) tumor were given the option of follow-up with cystoscopy and adjuvant therapy or immediate cystectomy. mostly elder patients are candidates for bladder sparing. th ose with invasive tumor on the safety resection were subjected to cystectomy- patients (control group). we used spss : xi-square and kaplan-meier for statistical processing. results: five years overall survival (os) in the bladder spared group was % (n- ), and % of the cystectomy group (n- ) -p= . . th e disease specifi c survival (dss) was % and % for the bladder spared and cystectomy group respectively (p= . ). th irty four percent ( patients) with preserved bladder developed recurrent tumors. a repeated tur was conducted. fift een percent ( ) of them were with invasive tumor and the action taken was cystectomy. fift y percent ( ) of the salvage cystectomy group and % of the immediate cystectomy group survived years. of the preserved bladder patients, ( %) necessitated dj stenting and ( %) pns. pns in the cystectomy group were ( %). haematuria occurred in patients with preserved bladder and in of the cystectomy group. th e statistical diff erence between both groups according to complications is p = . . infl ammatory conditions were more common in the bladder sparing technique- orchiepididymitis, urosepsis, pyelonephritis, compared to urosepsis and pyelonephritis in the cystectomy group. conclusion: bladder conservation and radical cystectomy for muscle-invasive bladder cancer appear comparable regarding the dss until the th year. cystectomy continues to be standard of care. radical tur is successful bladder-sparing strategy in selected patients with no residual tumor on retur and lower life expectancy. introduction and objective: bladder cancer occurs commonly in the elderly patients. in some circumstance, uremic patients developed bladder cancer. we considered patients who are aged more than years old, end stage renal disease (esrd) or poor performance status (eastern cooperative oncology group, ecog >= ) as fragile patients for operation. we conducted this study to assess radical cystectomy (rc) outcomes and chemotherapy use including neoadjuvant and/or adjuvant chemotherapy in the fragile patients in routine practice. all patients undergoing rc for bladder urothelial cancer in china medical university hospital from to were enrolled. patients' basic characters, surgical and pathology reports and treatment records were retrospectively collected. patients were stratifi ed into fragile and non-fragile group. pearson's chi-square test and student t-test were used to assess parameters of these two groups. results: we identifi ed patients. th ere were patients aged more than years old, patient are uremic status and patients were performance ecog: . total patients were stratifi ed into fragile group. th e sex and pathological staging were no diff erence in these two groups. major perioperative complications defi ned as clavien-dino grade or more were . % in fragile group and only . % in non-fragile group (p= . ). chemotherapy use rate was . % and . % in fragile and non-fragile groups (p= . ). th e -day morbidity rate of non-fragile and fragile group was . % and . %, respectively. th e day morbidity was no signifi cant between these two groups ( . % of non-fragile and . % of fragile groups). in fragile group, -day mortality rate was . % and -day mortality rate was . %. th ere was no -day mortality in non-fragile group. half the patients died within months in fragile patients and fi ft y percent of patients lived aft er years in non-fragile patients. conclusions: fragile patients received radical cystectomy had higher perioperative major complications rate and higher -day mortality rate. we off ered complications and morbidity rate in these patients who received radical cystectomy. in elderly, esrd or ecog>= patients, we need more cautious care to decrease complication and morbidity rate. introduction and objective: primary management of muscle invasive bladder cancer (mibc) is cystectomy (cx). all traumas, including major surgery like cx, induce a stress response (sr), which plays an important role controlling the human immune system. a widely used parameter for systemic surgical sr is measurement of serum levels of c-reactive protein (crp). th is prospective study aims to compare the introduction and objective: several prognostic models predicting survival of patients with metastatic urothelial carcinoma (uc) have been developed, however, of them, the fi rst model by bajorin in is still the most representative and widely-used. th e aim of this study was to validate three major prognostic models constructed based on phase and trials, by using a cohort of real-world patients. we reviewed patients with metastatic uc who received fi rst-line chemotherapy at our fi ve affi liate institutions between and . using this multi-institutional cohort, we validated the following models: the "bajorin model", a model consisting of visceral metastasis and performance status (j clin oncol ; : ) ; the "apolo model", a nomogram including visceral metastasis, performance status, albumin and hemoglobin (j natl cancer inst ; : ) ; and the "galsky model", a nomogram including leukocyte count, number of sites of visceral metastases, site of primary tumor, performance status and lymph node metastasis (cancer ; : ) . cox proportional hazards regression model was used for multivariate analysis. harrell's c-index was calculated for each model. conclusion: all models were demonstrated to have high external validities in real-world patients, and of them, the "apolo model" achieved the highest c-index in the present population. further studies with larger populations are needed for establishment of the next standard model. the impact of female gender on bladder cancer specifi c death risk after radical cystectomy: a meta-analysis of patients liu s, yang t, na r, jiang h, ding q introduction and objective: bladder cancer was one of the most commonly diagnosed cancers in the world. up till now, there has been no study summarizing current studies on gender disparity and bladder cancer outcomes aft er radical cystectomy. to perform a fi rst meta-analysis on the association between female gender and cancer-specifi c death risk aft er radical cystectomy. a comprehensive literature search of the medline and embase databases was conducted for relevant studies published till november, th . th e primary goal of our study was to investigate the impact of gender disparity on cancer-specifi c death risk aft er radical cystectomy in urothelial bladder carcinoma population. th e meta-analysis was performed by estimating the odds ratios (or) and confi dence intervals (ci) through a random eff ect approach. results: a total of studies were included in the meta-analysis with a total population of patients. th e baseline characteristics of the studies were described in table . female gender was associated with a worse survival (pooled or: . , % confi dence interval . - . ) compared with male gender aft er radical cystectomy. signifi cant (q= . , p= . ) statistical between-study heterogeneity was present, with . % of variance secondary to between-study diff erences (i : . %). sub-group analysis found the correlation was signifi cant in north american, european studies (or: . , % ci . - . and or: . , % ci . - . , respectively) and studies from larger size of samples (or: . , % ci . - . ). we also found studies adjusted for the key elements (t stage, n stage and grade) obtained positive correlation (or: . , % ci . - . ). introduction and objective: pathologic response after neoadjuvant chemotherapy for muscle invasive bladder cancer is used widely as a surrogate endpoint for overall survival. controversy persists, however, whether the absence of residual cancer (pt ) or the presence of only non-muscle invasive residual cancer (pt , ptis, pta) is the optimal surrogate endpoint. we aimed to assess survival dependent on these pathologic responses in a large multicenter patient cohort. we retrospectively reviewed records of patients with urothelial cancer who received neoadjuvant chemotherapy and underwent cystectomy at contributing institutions from - . patients with ct - an m and eventual pn disease were selected for this analysis. estimated os was compared between pt and pt /pta/ptis patients. a multivariable cox proportional hazards regression model for overall mortality was generated to evaluate hazard ratios (hrs) for variables of interest (age, gender, number of cycles and type of chemotherapy regimen, surgical margin, and pt vs. pt /pta/ptis). conclusions: pt /pta/ptisn and pt n stage on the fi nal cystectomy specimen are strong predictors of survival in patients receiving nac and rc. we did not discern a statistically signifi cant diff erence in os when comparing these two endpoints. signifi cance of computer materials and methods: fift y patients were included in our study, of them presented with haematuria and a recent diagnosis of bladder carcinoma, and patients with a history of previous transurethral resection of superfi cial bladder cancer in their follow up period. th ey ranged in age years to years with a mean of . ; while male to female ratio was . : . th e main steps to perform virtual cyctoscopy incorporate proper bladder distention with air aft er draining the residual urine through foley's catheter and scanning the patient in both supine and prone positions. an excellent overview of the bladder masses was obtained in all cases and the results of virtual cyctoscopy and conventional one were comparable with excellent sensitivity rates of virtual cyctoscopy in detection, localization and morphology description of the bladder lesions at variable sizes. results: for detection of all lesions (n= ), virtual cyctoscopy alone showed sensitivity: . %, specifi ty: . % with two false positive and one false negative in comparison to conventional cyctoscopy which detected lesion while in axial ct alone the sensitivity: . %, specifi ty: % with false negative fi ndings. conclusion: ct virtual cystoscopy is a promising technique for use in bladder tumor detection of lesions larger than mm. optimal evaluation requires adequate bladder distention with the patient in both supine and prone positions and interpretation of both transverse and virtual images. is an evolving technique aiming to improve upon the diagnostic sensitivity of prostate biopsy for the diagnosis and local staging of prostate cancer (pca). diff erences in interpretation, expertise and application of mpmri may be responsible for the range of reported results. th is retrospective study aims to evaluate the diagnostic accuracy of mpmri in a cohort of patients from melbourne, australia, as compared to the gold standard of radical prostatectomy (rp). th is retrospective study was conducted in through the electronic patient records of a tertiary hospital and several private urology practices in melbourne, australia. patients having undergone rp had their records assessed for the presence of a pre-operative mri performed aft er st january which was then evaluated against the reference standard of a radical prostatectomy wholemount specimen. mri sequences typically included t weighted imaging, diff usion weighted imaging and dynamic contrast enhancement at t. mri reports were evaluated using the prostate imaging-reporting and data system (pi-rads) system. in our cohort the sensitivity and specifi city of mpmri for prostate cancer (pca) detection was found to be approximately - % and - % respectively. th e area under the curve for determining local stage was approximately . . conclusion: mpmri may have a useful role as an adjunct for prostate cancer diagnosis and directing management toward improving patient outcomes. staging information may be less reliable. a randomized prospective trial to assess the outcomes of mri/trus-guided prostate biopsy and traditional -core trus-guided prostate biopsy baco e , rud e , eri l , moen g , vlatkovic l , svindland a , eggesbø h , ukimura o introduction and objective: th e outcomes of magnetic resonance imaging (mri) and -dimensional transrectal ultrasound ( d-trus)-image-fusion-guided prostate targeted biopsy (mri-group) has not yet been compared with traditional -core trus-guided prostate biopsy (control-group) in a randomized control trial (rct) . th e aim of this study was to compare the prostate cancer (pca) detection rates (cdrs) and histopathological outcomes in the two groups. th is prospective rct included prostate biopsy (pb) naïve patients with suspicion for pca, where were randomized to mri-group and to control-group from / to / . in the mri-group, two tb of mri suspicious regions was followed by -core systematic random biopsy (rb). in the control-group, two tb towards palpable and/or trus-visible suspicious regions and -core systematic rb were performed. clinically signifi cant pca (cspca) on biopsy was defi ned as maximum cancer core length (mccl) ≥ mm of gleason score (gs) or any mccl of gs ≥ according to start criteria. cdr of all pca and cspca, and histopathological fi ndings were compared between the two groups. results: in the mri-and control-group cdrs were / ( %) and / ( %), (p= . ). cspca were detected in / ( %) in and / ( %) in control-group, (p= . ). tb (median cores/ patient) detected cspca in / ( %) in mri-and / ( %) in control-group (p= . ), respectively. concordance of gs on biopsy and radical prostatectomy specimen was / ( %, k = . ) in mri-and / ( %, k = . ) in the control-group (p< . ). upgrading of gs biopsy vs. gs-rp specimen was % in mri-group and % in control-group (p< . ). since the present study had a restricted cohort size, this may limit the generalizability of the results. no signifi cant diff erence in cdrs was found between the two groups. pca diagnosis can be achieved with few mri/trus-fusion guided prostate biopsy. gleason score on targeted biopsy was more accurate in the mri-group. introduction and objective: infection is a complication of trus prostate biopsy, despite the use of antibiotic prophylaxis. worryingly the rate of infectious complications following trus biopsy has been shown to be increasing. we aimed to determine the rate, severity, risk factors and microbiology resistance patterns associated with trus biopsy sepsis. as well the standard patterns of care surrounding trus prostate biopsy. a retrospective case-control study was conducted. using electronic coding all patients who presented to cabrini hospital with sepsis following a trus biopsy from to were identifi ed. validated cases were matched to controls in a ratio of : . eligible controls were required to have undergone a trus biopsy at the same surgical institution as the case and in the closest period of time. demographic, procedural and patient related data-points were recorded for all patients using hospital and urologist records. univariate logistic regression models were constructed and used to determine risk factors associated with infection. results: seventy-one cases developed sepsis following trus biopsy and were matched to controls. th e average rate of sepsis over the -year study period was . %. a sofa score ≥ was identifi ed in % of cases. we found a high prevalence of antibiotic resistant e. coli, with % of blood culture isolates classifi ed as multidrug resistant organisms. eight diff erent prophylactic antibiotic regimens were identifi ed. statistically signifi cant risk factors included previous antibiotic use and prior international travel within the six months prior to biopsy. th e addition of a penicillin antibiotic to standard fl uoroquinolone antibiotic prophylaxis was protective. conclusions: trus biopsy is an elective procedure and as such needs to be associated with minimal morbidity. th e patterns of care surrounding periprocedural variables for trus biopsies were non-uniform and diverse. a wide variety of diff erent prophylaxis regimens and bowel preparation routines were recorded. patients with risk factors for sepsis may represent a better target population for intervention with alternative preventative strategies. alternative preventative options include augmented prophylaxis, tailored prophylaxis or the tp biopsy approach either as a fi rst line biopsy modality or based on epidemiological risk factors. psa level) and pathological data was collected for all patients undergoing fi rst-time prostate biopsy with at least months follow-up, at music practices. from this overall cohort we identifi ed all patients whose pathology revealed multi-focal hgpin and/or asap (pre-malignant pathology) . for this subgroup, we examined the frequency of repeat biopsy across music practices and cancer detection outcomes. introduction and objective: nowadays overtreatment is recognisable challenge in pca management. overdiagnosis is possible reason for further overtreat-ment. we hypothesised that repeated prostate biopsies could not only help to cure but also harm patients with pca. consecutive patients who underwent biopsy for suspicious pca following at least one rebiopsy at single tertiary medical centre in - were included. age, initial and subsequent psa, drv, histology and biopsy features were recorded along with characteristics of subsequently diagnosed pca and chosen treatment approach. descriptive statistical methods were used for further analysis. results: basic characteristics were (mean±sd or frequency): age at initial biopsy ( . ± . years), time between initial/fi nal biopsy ( . ± . months), initial/ fi nal psa ( . ± . and . ± . ng/ml), drv (normal/suspicious . %/ . %), and number of initial/fi nal biopsy cores ( . ± . and . ± . ). initial/ fi nal histology was bph in ( . %)/ ( . %), infl ammation in ( . %)/ ( . %) and premalignant lesions in ( . %)/ ( . %) cases. finally, ( . %) pca were diagnosed ( by biopsy, by turp) performing biopsies aft er all. mean number of biopsies per patient was . in total and . to reach cancer positive histology; turp was performed in ( . %) patients. in ( . %) patients ≤ biopsy cores were cancer positive and in ( . %) patients gleason score was ≤ . gleason score ≥ was found in ( . %) cases. treatment with curative intention was held in cases (rrp , external radiotherapy ), no treatment (as/ww) in and hormonal therapy in patients. fourteen patients with minimal low grade cancer (≤ positive cores, gleason score ≤ ) underwent rrp ( % of all surgery cases). conclusion: repeated biopsy is important approach in pca diagnosis. however, based on our results we cannot exclude the risk of overdiagnosis and subsequent overtreatment with signifi cant impact on patients' quality of life, including radical surgery for low risk disease and early hormonal therapy in non-metastatic low-intermediate risk disease. th e study is retrospective, but potential bias became the advantage, since we could exclude prospective "self-control" within treatment decision making process. (siemens, munich, germany) and images were interpreted visually to evaluate uptake in biopsy districts of prostate gland. th e lesions suspicious for pca were submitted to additional targeted biopsies. introduction and objective: multiparametric mri (mpmri) and mri/trus-fusion-guided biopsy (tb) are advocated to detect index lesions and signifi cant prostate cancer (pc) within the prostate more exactly than systematic biopsies (sb) . th e aim of this study was to evaluate the detection accuracy of tumor foci by mp-mri and tb on radical prostatectomy (rp) specimen. we selected consecutive patients who were treated with rp for localized pc diagnosed by tb and/or transperineal saturation sb. on mpmri, all lesions were scored according to pirads. all lesions with pirads≥ underwent tb. on rp specimen, index lesion was defi ned as highest gleason score (gs) or highest tumor volume (tv). gs= + and tv≥ . ml or gs≥ + and tv≥ . ml were considered signifi cant. we performed spearmans correlation coeffi cient between mpmri and rp specimen and fisher's test between mpmri, tb and sb. introduction and objective: prostate biopsy is evolving to pre-biopsy multi-parametric mri (mp-mri), followed by systematic biopsy (sb) ± targeted biopsy (tb). mp-mri combined with trus-guided tb may increase detection rates of prostate cancer (pca), especially clinically signifi cant pca (cspca). however, few studies compare the detection rate of sb versus tb in the same cohort of men, as recommended by the standards of reporting for mri-targeted biopsy studies (start) consensus panel. th is study compares the diagnostic yield of sb and tb in a single cohort. th irty-three patients had a pre-biopsy mp-mri that identifi ed a target lesion. each patient then had a trus-guided sb and tb. th e cognitive fusion technique was used to perform the tb. results: among the patients, mean age was years; mean psa was . ng/ml. th e positivity rate for pca was % (n= ) for both sb and tb. th e positivity rate for cspca was % (n= ) for sb and % (n= ) for tb (p= . ). sb underdiagnosed cases ( %) of cspca that were detected through tb; tb underdiagnosed cases ( %) of cspca (p= . ) . th e positivity rate for sb and tb combined was % (n= ) for cspca (p= . ). conclusion: detection rates for pca using sb and tb were equal, but sb had a higher detection rate for cspca. combining tb with sb increased the rate of detection for cspca by %. tb alone was % more introduction and objective: active surveillance (as) has gained popularity with the intention of avoiding or postponing interventions in subjects with pca of low biological potential. unfortunately, several inclusion criteria have been proposed but many doubts still persist about their performance in predicting favorable disease. we aimed to assess the added value of biopsy factors, like maximum cancer length in a core (mcl), cumulative cancer length (ccl), cumulative length of positive cores (clpc), and percentage of cancer involvement in positive cores (cipc), to the prias criteria in patients who underwent radical prostatectomy (rp) but eligible for active surveillance (as). from january to december , consecutive subjects underwent rp. we identifi ed ( . %) patients who were eligible for as based on prias criteria: clinical stage t c or t , psa level of ≤ ng/ml, gleason score ≤ , psa-d of < . ng/ml and one or two positive biopsy cores. we calculated the diagnostic accuracy of biopsy factors in determining pathological confi rmed unfavorable disease. decision curve analysis (dca) were performed. explored, we examine the feasibility of monitoring low volume gleason sum (gs) + disease compared to gs + disease. introduction and objective: th e selection of prostate cancer patients for active surveillance (as) is based on the criteria for low risk according to protocols such as the national comprehensive cancer network (nccn) or european association of urology (eau) guidelines. we aim to compare pathological upgrading and upstaging rates between prostate cancer patients who met the above guidelines but underwent radical prostatectomy. we also aim to refi ne the selection criteria for our local population. a total of men were treated with rp at our tertiary center from to . seventy-three patients met the nccn criteria for active surveillance: ct -t a, prostate-specifi c antigen (psa) less than ng/ml, and biopsy gleason sum to . th irty-fi ve met the eau guidelines, which had additional criteria of: or less biopsy cores positive and % or less ca detected per core. results: of the patients who met the nccn criteria, ( . %) showed pathological upgrading (gleason > ) while ( . %) were upstaged (pt ). upgrading and upstaging fi gures for the patients meeting the eau guidelines were ( . %) and ( . %) respectively. analyzing the patients who met the nccn criteria, those who had % or more of the number of biopsy cores positive for prostate cancer had a far greater upgrading rate of . %, which was more than the . % (p = . ) seen in the other patients. psa density or percentage of individual core did not show any statistical diff erence in upgrading or upstaging. conclusion: a lower percentage of upgrading was seen in patients meeting the eau. upstaging fi gures were relatively the same. when counseling patients for active surveillance using the nccn criteria for low risk, we should exercise strong caution in patients with % or more of the number of biopsy cores positive for prostate cancer. biochemical recurrence rates in active surveillance candidates and the role of improving gleason grading introduction and objective: to evaluate prospectively the role of prostate-specifi c antigen (psa) density to predict gleason score upgrade in prostate cancer patients eligible for active surveillance (t /t , biopsy gleason score ≤ and psa ≤ ng/ml and ≤ positive biopsy cores). between january and november , among the patients who underwent more than core trans-rectal ultrasound guided biopsy, patients eligible for active surveillance under-went radical prostatectomy. using the modifi ed gleason criteria, tumor grade of the surgical specimens was examined and compared to the biopsy results. results: a tumor upgrade was noticed in ( . %) patients. extra-capsular disease and positive surgical margin was found in ( . %) and ( . %) patients, respectively. a statistical signifi cant correlation between the psa density and postoperative upgrade was found (p= . ); this is in contrast to the other studied parameters which failed to reach signifi cance, including psa, prostate volume, number of biopsy cores and number of positive cores. tumor upgrade was also highly associated with extra-capsular cancer extension (p= . ). th e estimated optimal cutoff value of psa density was . ng/ml , obtained by roc analysis (area under the curve . , p= . , % ci . - . ). conclusions: psa density represents a strong predictor for gleason score upgrade aft er radical prostatectomy in patients eligible for active surveillance. since tumor upgrade increases the potential for postoperative pathological adverse fi ndings and prognosis, psa density should be considered when treating and consulting patients eligible for active surveillance. surgical outcomes of south australian patients who have discontinued active surveillance plagakis s , o'callaghan m , , , moretti k , , foreman d , introduction and objective: active surveillance (as) is a recognized management pathway for patients with low risk prostate cancer (pca). diff ering protocols exist to identify suitable patients and manage their follow up. our study compares surgical pathology outcomes between patients who were initiated on, but discontinued, as and underwent radical prostatectomy (rp) with patients who received surgery immediately at the time of diagnosis. we also explore predictors of as discontinuation. our cohort comprised men diagnosed with pca from the south australian prostate cancer clinical outcomes collaborative database between - , aged - years, gleason score ≤ and psa ≤ . patients were stratifi ed into an immediate treatment group and an as group. to assess if as derivation rules aff ected outcomes, patients were sub-categorised according to enrolment criteria of university of toronto, prias and royal marsden protocols (with psa and gleason adjustment accordingly). all patients had a minimum of two years follow up. chi squared, logistic regression and cox proportional hazards modelling were used to compare outcomes between groups. results: forty-three ( %) patients in the as group underwent rp, compared with in the immediate treatment group. extra capsular extension and upgrading of histology at rp were more common in those managed by as compared to those receiving im-mediate surgery. th ese associations were supported by sensitivity analysis using prias and toronto criteria but not royal marsden selection criteria. as trended to being associated with unfavourable surgical pathology in multi-variable analysis, but this was only statistically signifi cant for prias ), p= . ). in all patients managed by as, sensitivity analysis suggested that the percentage of core positive at diagnosis is a signifi cant predictor of as discontinuation in those meeting the university of toronto selection criteria (hr . ( . - . ), p= . ). to determine if prias has increased rates of active surveillance (as) for patients with low-risk prostate cancer (pca). secondly, to determine whether urologists are operating on greater proportions of high-grade pca as a result of increasing as and what eff ect this has on surgical practice. prospective data was collected on patients from - (cohorts - , - ) who underwent trus biopsy by a urologist in geelong (n= ). positive trus biopsies (n= ) in both the pre and post prias cohorts were assessed to see if they met prias eligibility and whether they received as or active treatment (at). at patients were risk stratifi ed by gleason score and d' amico risk. data on post-prostatectomy staging, margin status and nerve-sparing techniques were collected. chi-squared test were used to calculate statistical signifi cance between cohorts. results: as increased between cohorts ( %, %, p= . ). before prias % ( / ) of patients eligible for as by prias criteria opted to undergo as compared with % ( / ) aft er the introduction of prias (p=< . ). th e relative proportion of high-grade pca (gleason score ≥ and d' amico high-risk) undergoing at increased from to % (p= . ) and to % (p= . introduction and objective: renal trauma is predominantly managed conservatively. trauma nephrectomy is reserved for patients who fail conservative or alternative management options. nephron sparing surgery is the cornerstone of renal preservation. our objective was to review the management of renal trauma at three tertiary facilities in queensland over a year period and compare these outcomes with current literature. a retrospective analysis was performed to fi nd the total number of renal traumas presenting to the princess alexandra hospital, royal brisbane and women's hospital and gold coast hospital, in queensland, australia. renal trauma patients were identifi ed using icd- codes (s . - ) and operative databases. patients requiring angioembolisation were obtained from radiological databases. we accessed the number of conservatively managed patients, trauma nephrectomies and angioembolisations for renal trauma. results: a total of renal traumas were identifi ed from june to june . six hundred and sixteen injuries were managed conservatively. th irty-three patients warranted acute exploration due to haemodynamic instability and resulted in nephrectomy in all cases. a trauma or general surgeon was the primary operator. fift een patients underwent angioembolisation for blunt renal trauma and patients for penetrating injuries. two patients proceeded to delayed nephrectomy for ongoing bleeding and for a ureteric stricture requiring nephrectomy aft er failed auto transplantation. th ese were performed by an urologist. th ere were further devascularised atrophic kidneys. seventeen of renal units were spared and of patients remained with functioning kidneys. all treated patients with angioembolisation were followed up with either mag renogram or ct triple phase and had functional kidneys at . years. conclusion: renal trauma is managed conservatively in most cases, consistent with the current literature. angioembolisation is an eff ective management option in selected patients with renal trauma. th is may prevent the need for trauma nephrectomy. in our cohort, patients requiring a trauma nephrectomy had predominantly grade iv and v injuries. general or trauma surgeons performed trauma nephrectomies in the acute setting of haemodynamic instability with rapid transfer to theatre. delayed nephrectomies were performed primarily by urologists in this cohort. introduction and objective: to review the contemporary management of traumatic extra-peritoneal bladder ruptures at an australian level one trauma centre. patients presenting with bladder injuries from july through to june were identifi ed using the traumanet database. th is was cross-linked with medical records and only patients with extra-peritoneal bladder rupture were included in the study. clinico-pathological data were collected from the database, medical records and health information services coding data. results: over the twelve-year study period, multi-trauma patients sustained an extra-peritoneal bladder rupture. of these patients, . % had a concurrent pelvic fracture and . % had co-existing intra-abdominal injury. a total of patients underwent operative repair for the bladder rupture and patients were managed conservatively with catheter drainage. of the patients managed operatively, % of cases were done at the time of another general surgical or orthopaedic operation and only two cases were done as a stand-alone repair. conclusion: extra-peritoneal bladder ruptures can be managed both conservatively and with operative repair. if operative repair is performed, it is usually done at the time of another operation for concomitant injury. management outcomes of major renal injuries following blunt trauma: changing concepts over years results: a total of / ( . %) of group i, and / ( . %) of group ii were treated non-operatively. diagnosis and grading in group i depended mainly on u/s, ivp and in some cases ct scan, while u/s and enhanced ct scan were mainly used for most of the group ii cases. in the total cohort, grade iii, iv and v renal injury were seen in ( . %), ( . %) and ( . %) patients respectively. open exploration was followed in ( . %) and ( . %) patients of group i and ii, with an overall exploration rate in / ( . %) of grade iv and v injury. th e incidence of nephrectomy have decreased from cases ( . %) in group i to cases ( %) only in group ii ( / kidneys were pathologic). double-j stenting and percutaneous drainage of urinoma was done in and cases, and chest-tube drainage to one patient with traumatic urinothorax in the conservatively managed group. outcomes were excellent, however in the non-operatively managed (grade iv-v) cases, / ( . %) normotensive patients had a non-functioning kidney within one year of follow up. conclusion: non-surgical management of high grade blunt renal injury can be safely undertaken and also recommended unless the patient is haemodynamically unstable. accurate grading is sometimes imprecise in multi-trauma patients, where instability is not always due to renal injury. drainage of extravasation is necessary to reduce morbidity. abdominal exploration does not mandate concomitant renal exploration, which is indicated in selected instances, otherwise it is an aggressive decision with a triple incidence nephrectomy rate. management of grade iv renal trauma: a revision of the aast renal injury grading scale is mandatory chiron p , hornez e , , boddaert g , dusaud m , bayoud y , molimard b , desfemmes f , durand x introduction and objective: th e aast (american association for the surgery of trauma) injury grading scale for renal trauma is currently the most important variable predicting the need for kidney repair or removal, for morbidity and mortality aft er blunt or penetrating injuries of the kidney. th e revision included the renal pelvis, the uretero pelvic junction and the segmental vascular injuries as grade iv, limiting grade v to severe hilar injuries. however, this revision does not permit the identifi cation of the group of patients who will require surgery because of hemodynamic instability due to grade iv renal injuries. th is study aims to propose an add-on for the grade iv of aast renal injury scale, in order to improve the management of these patients. we searched the following electronic databases: medline and scopus database. searches were not restricted by date, language or publication status. searches were last conducted in september . paediatric studies were excluded. results: seventy-one articles were found, were pertinent, including directly related to the topic. th ree risk factors were identifi ed to be associated with surgery for hemodynamic instability: peri-renal hematoma > . cm, intravascular contrast extravasation, medial renal laceration. presence of two or more of these criteria has been validated by others studies to predict the need for intervention. patients with > % devascularized fragments also present a poor prognosis and should be treated more aggressively. conclusion: th ese data should be incorporated into a future reassessment of the classifi cation, in order to better determine the need and time for surgery in grade iv renal traumas, generally leading to a nephrectomy. single panurethral reconstruction can be a surgical challenge. techniques include staged urethroplasty, augmented anastomosis with buccal mucosa graft (bmg) onlay via penile and/or transperineal, skin fl aps, or combinations of these. we report our experience of single stage modifi ed transperineal urethroplasty using a dorsal bmg in treatment of panurethral stricture. aft er obtaining irb approval, we performed a retrospective review of our urethral stricture database and identifi ed patients having undergone single stage transperineal urethroplasty using dorsal bmg as treatment of pan-anterior urethral stricture. patient characteristics, operative, and post-operative outcomes were studied. failure was defi ned as a need to any intervention during the follow-up period. results: th irteen patients underwent complete anterior urethra dorsal urethrotomy with dorsal bmg onlay between september and january . mean age was . years (sd: +/- . ). urethral stricture etiology was lichen sclerosis in patients ( . %), idiopathic in ( . %), hypospadias in ( . %) and infection in ( . %). previous treatments of dilatation and dviu were noted in patients ( . %) and previous urethroplasty in ( . %). mean operative time was . minutes (sd: +/- . ). mean estimated blood loss was . cc (sd: +/- . ). th ere were no intraoperative complications. early postoperative complications were buccal donor site bleed in patients ( . %) one treated with digital compression and other with hemostatic stitch, one patient ( . %) presented a perineal abscess and secondary urethroperineal fi stula. late complications was observed in patients who had postoperatory dribbling ( %). at mean follow up of . +/- . months, had recurrence ( . %) requiring dviu without new recurrence aft er a mean follow-up of . months (range - ) and one had meatal stenosis treated with dilatation ( . %) without recurrence aft er . month of follow-up. conclusion: in this small cohort, reconstruction of panurethral strictures may be safely and eff ective-introduction and objective: we present a novel technique for reconstruction of bulbo-membranous urethral strictures aft er surgery for bph with external sphincter sparing to preserve continence. anatomical studies have shown that the rhabdosphincter is separated from the membranous urethra by a sheath of connective tissue. by meticulous dissection of this sheath we separated the muscle from the urethral wall preserving the sphincteric function. patients with bulbo-membranous strictures aft er turp or open prostatectomy (op) who failed dilation and/or internal urethrotomy were reconstructed with a bulbo-prostatic anastomosis with preservation of the fi bers of the external sphincter. th e bulbo-membranous junction is approached dorsally, the inter-crural space is opened on the midline and the bulb is mobilized only from one side, without detachment from the perineal body. th e bulbo-membranous junction and membranous urethra are exposed and secured with vessel loops. th e membranous urethra sheath is opened circumferentially, carefully refl ecting the circular muscle fibers until exposure of the urethral wall. gentle blunt proximal dissection allows separating the muscle away from the urethra up to the prostatic apex, where healthy urethra is found to perform the anastomosis. results: from january to march we operated patients ( aft er turp and aft er op). all had membranous or bulbo-membranous strictures; bladder neck contractions were excluded. mean age was years ( - ). fourteen patients have been treated with either dilation and/or dviu; seven were with a suprapubic tube. mean length of stricture was cm ( - . ) , mean time from surgery to reconstruction was months ( - ) and mean follow-up was months ( - ) . two patients were not evaluable due to insuffi cient follow up. of the remaining , twelve were completely dry or using one security pad ( . % success). th ere were two clavien complications (both scrotal hematomas) and no stricture recurrence. conclusion: excision and bulbo-prostatic anastomosis with sphincter sparing for strictures aft er surgery for bph is feasible and safe. our technique allows preserving continence in most patients. to our knowledge this technique has not been described before. a larger series and reproduction in other centers will help to validate its therapeutic role. introduction and objective: panurethral strictures are complex and extensive strictures that involve the penile and bulbar urethra. management of these patients is challenging. in the last two decades, oral mucosal graft s have gained widespread popularity as the most versatile substitute tissue for urethral reconstruction. th e aim of this paper to present the shortterm outcome of our experience in the use of oral mucosal graft s in one-stage urethroplasty in patients with panurethral strictures. materials and methods: between april and october , men were evaluated and had one-stage oral mucosa urethroplasty for panurethral strictures. results: th ere were patients age range of - years with a mean of . years. aetiological factors identifi ed were poorly treated urethritis ( . %), post-urethral catheterization ( %) and lichen sclerosis ( . %). th e commonest cause of catheter-associated panurethral strictures was part of intra-operative patient monitoring in ( %), following spinal cord injury ( %). preliminary suprapubic cystostomy was done in patients ( . %). graft length ranged from - cm with a mean of . cm. oral mucosa donor sites were buccal in ( . %), labial ( . %), combined buccal and labial ( . %) and ( . %) for combined buccal/lingual and buccal/labial/penile skin fl ap respectively. twenty eight patients ( . %) had satisfactory voiding on removal of the urethral catheter and subsequent follow-up whereas patients ( . %) experienced diffi culty. of these , one patient had bladder outlet obstruction due to benign prostatic hyperplasia which was the reason for previous repeated urethral catheterization that had resulted in the stricture. oral mucosa donor site complications were present in patients ( . %) and consisted mainly pain and numbness in the mouth. duration of follow-up ranged from - months and there was no mortality among the patients. conclusion: panurethral strictures are common in our practice mainly resulting as complication of prolonged urethral catheterization. urethral reconstruction by one-stage oral mucosa graft urethroplasty is feasible, has good outcome though it may be associated with minor donor site complications. larger number of patients and longer-term follow-up are needed to assess durability of the procedure. missed and delayed ureteral injuries in hasan sadikin hospital, bandung, indonesia introduction and objective: to review our experience with delayed and missed traumatic ureteral injuries. materials and methods: genitourinary trauma database was retrospectively reviewed from - . variables such as time to diagnosis, imaging modalitites, location of missed or delay injuries, management, duration of operation, length of stay and complications were noted. introduction and objective: traumatic urethral stricture as the result of straddle injury or pelvic fracture urethral injury (pfui) is associated with long term morbidity and reduce the quality of life. most patients will end with long life urethral dilatation even aft er endoscopic treatment. anastomotic urethroplasty at present is the answer of defi nitive treatment. general principles of urethroplasty are to defi ne healthy urethra above and below the site of surrounding fi brosis and to perform a spatulated end-to-end anastomosis. prior to the year of , most urethral stricture cases including traumatic anterior and posterior urethral stricture was managed mostly with direct vision internal urethrotomy (dviu) in our institution. we present our experience with transperineal anastomotic urethroplasty. to our knowledge this is the fi rst indonesian local centre report of the changing defi nitive treatment of traumatic urethral stricture in a series of patients. we retrospectively reviewed traumatic urethral stricture due to straddle injury and pfui that had been treated with urethral reconstructive surgery by transperineal anastomotic urethroplasty approach. th e data cases from january -december were analyzed; which were the age of patients, location, length of gap, previous operations, and treatments. th e clinical outcome was evaluated with urofl owmetry aft er , , , and months aft er the surgery. results: a total of patients came with traumatic urethral stricture to hasan sadikin hospital during , which consist of patients with pfui and patients with traumatic anterior urethral stricture due to straddle injury. th e median age was . and . for pfui and straddle injury, respectively. twenty four percent of pfui patients had distraction length > cm and % had distraction length < cm. meanwhile, % of straddle injuries had stricture length < cm and % had distraction length > cm. in order to achieve tension free of anastomotic urethroplasty, % of pfui patients underwent crural separation, % patients underwent inferior pubectomy and only one patient for supracrural re-routing. sixteen percent of patient of pfui are redo case urethroplasty. success rate aft er transperineal anastomotic urethroplasty of pfui cases was %, % for redo case pfui and % for straddle injury cases. mean q max rates at , , , and months aft er catheter removal of pfui patients was , , , and ml/s whereas for straddle injury patients was , , , and . conclusions: in short term follow up, transperineal anastomotic urethroplasty achieved a signifi cant good result for traumatic urethral stricture treatment at our institution. recurrence after urethroplasty in a tertiary care centre in sub-saharan africa: an analysis of preoperative factors introduction and objective: urethral strictures disease remains very common in sub-saharan africa but despite this, there are no available reconstructive urology trainings / fellowships outside the formal urology residency programmes of the region. we reviewed the outcomes of urethroplasties at a tertiary urology centre in nigeria, sub-saharan africa which typically off ers general urology service. preoperative independent predictors of recurrence post-urethroplasty were determined. th e records of a total of men who had urethroplasty for proven anterior urethral stricture disease between february and january were retrospectively analyzed. age, social status, aetiology of strictures, stricture location, length of strictures and type of urethroplasty were assessed. appropriate inferential statistics were performed to determine independent predictors of stricture recurrence. results: mean patient age was years (range to ) and majority of the patients were of low income status ( . %). iatrogenic strictures due to urethral instrumentations and catheterization ( . %) and post infl ammatory strictures ( . %) were more common. isolated penile and long segment peno-bulbar strictures accounted for over two-thirds of all patients ( . %). mean stricture length was . cm (range to cm). most patients had quartey's urethroplasty ( . %), others had buccal mucosal graft ( . %), orandi ( . %) and anastomotic bulbar urethroplasty ( . %). for a mean follow up of . ± months, the overall recurrence rate was . % with mean time to recurrence of . months. of the evaluated preoperative factors (age, p= . ; social status, p= . ; aetiology, p= . ; stricture location, p= . ; type of urethroplasty, p= . ; stric-ture length, p= . ), only stricture length (p= . ) was a signifi cant predictor of recurrence. roc analysis was done and stricture length > cm signifi cantly predicted recurrence (auc of . , p= . ). conclusion: stricture length > cm are a signifi cant cause of recurrence following urethroplasty in the setting of prevalent general urology practice in sub-saharan africa. th e introduction of formal reconstructive urology fellowship or training may help improve skills and outcomes. introduction and objective: males with hypospadias are likely at increased risk for future urologic complications as adults. however, it is unclear how childhood surgery modifi es this risk. th e purpose of this study is to describe the spectrum of adult presentations with hypospadias-related complications and examine the eff ect of childhood surgery on these complications. a retrospective chart review over a year period, from august -december , demonstrated adult patients who presented to an adult reconstructive urologist with urologic complications related to hypospadias. patients were divided into two groups: those with no prior hypospadias surgery (group , n= ) and those who underwent surgical correction as a child (group , n= ). charts were reviewed for age at presentation, initial complaints, history of repair, and surgical intervention required. results: overall, the mean age at presentation was . years old. meatal location was not statistically diff erent between groups and , respectively: glans ( . % vs. . %), subcoronal ( . % vs. . %), coronal ( . % vs. . %), distal penile ( . % vs. . %), midshaft ( . % vs. . %), and penoscrotal ( . % vs. . %). overall, luts ( . %) was the most common presenting complaint, followed by spraying ( . %), urethrocutaneous fi stula ( . %), recurrent uti's ( . %), and chordee ( %). comparison demonstrated group patients were more likely to present with luts ( . % vs. . %, p= . ) and recurrent uti's ( . % vs. %, p= . ). contrastingly, group patients presented more commonly with cosmetic dissatisfaction ( . % vs. . %, p= . ). urethral stricture disease was demonstrated in more patients who had previous hypospadias repair, than those who had not ( . % vs. . % p= . ). of these, strictures were signifi cantly longer in the previous surgery group ( . cm vs. . cm, p= . ). surgical intervention was required in . % of group and . % of group (p= . ). conclusion: correction of hypospadias as a child likely increases the future risk of urethral stricture, recurrent uti's, and subsequent luts, but improves patient satisfaction with cosmesis. follow-up of hypospadias repair patients should extend into adulthood, as a signifi cant portion of adult presentations ultimately require surgical intervention. introduction and objective: during male to female gender confi rming surgery with vaginoplasty, a space is created for the neovagina within the potential space between the prostate anteriorly, and denonvillier's fascia and rectum posteriorly. entry to this plane is challenging, and to date, the only surgical approaches to this space describe blunt and sharp dissection along the ventral surface of the urethra. th e likely trauma to perirectal vasculature muscle-laden connective associated with this approach may account for the observed recto-vaginal fi stula rate associated with vaginoplasty. we describe an alternative, never before published approach using a male urethral sound upon the apex of the prostate to enter this plane with sharp dissection in a reliable and effi cient fashion. we describe our surgical technique, wherein we use a male urethral sound during the dissection to help expose denonvillier's fascia over the apex of the prostate. we dissected a block of tissue containing prostate, denonvillier's fascia and rectum from human cadavers, to describe (using ihc) the location and relative abundance of blood vessels (factor viii ab.), nerves (nf & s- ab.), and connective tissue (h&e and masson's trichrome), to support the sharp surgical approach we describe over the traditional approach to this plane. we describe clinical outcomes and the recto-neovaginal fi stula rate utilizing this approach in our institutions. results: immunohistochemistry results showed that the sharp dissection we describe is associated with incision through signifi cantly fewer blood vessels and sensory-motor nerves as compared to the traditional surgical approach. use of the sharp dissection we describe resulted in, at our institutions, a signifi cant decrease in recto-neovaginal fi stula in the peri-operative period. conclusion: th e surgical technique we describe for dissection of the plane between prostate and denonvillier's fascia during vaginoplasty is well supported by the anatomic studies we performed, and, is associated with lower morbidity. th is surgical approach and technique is also likely useful for gaining access to this same plane for repair of recto-vesical and recto-urethral fi stulas. introduction and objective: mitrofi noff procedure is commonly employed as bladder draining tool in patients who are unable to do clean intermittent self-catheterization through native urethera. it preserves renal function in small capacity and high pressure bladders and to improve quality of life. here we want to share our single centre experience of patients undergoing mitroffi noff procedure. a retrospective study of patients who underwent mitrofi noff procedure from january till december with a median age of (range = to ). twenty eight patients were males while female. indications for catheterizable stoma formation included neurogenic bladder in patients, small bladder in , bladder tumor in , uretheral stricture in one and interstitial cystitis in one patient. median follow-up was month to years. stoma was made from appendix in cases, from tapered ileum in cases and from ureter in cases. stoma location was lower right quadrant in cases, left lower quadrant in cases and at umbilicus in cases. augmentation accompanied by mitrofanoff was done in patients while mitrofanoff alone was done in patients. augmentation was done by using ileum in patients and cecum in one and illeocecum in one patient. data was entered from chart review and analyzed on spss. sixteen patients were analyzed in terms of complications and stoma revision. results: post-operative complications included uti in ( . %) patients, stones formed in ( . %), fistula was seen in ( . %) patient (augmentation cystoplasty + mitrofanoff ), stoma stenosis seen in ( . %), stoma revision done in ( . %). one female ( . %) patient had dribbling urine through urethera (incontinence), she underwent bladder neck closure. metabolic complications were not seen based on serum electrolytes follow-up records. we concluded that aft er mitrofanoff procedure renal function was preserved in most of the patients while no metabolic complications were seen in patients aft er undergoing mitrofanoff +bladder augmentation. stone risk was . % which was not very high. quality of patients was improved aft er mitrofanoff procedure. results: sesfm has higher porosity and larger pore size compared with bam (p< . ). at weeks, the presence of vesical calculus was evident in / rabbits. histological analysis showed that sesfm and bam promoted similar degree of urothelium regeneration (p> . ), and sesfm promoted a higher degree of smooth muscle and vessel regeneration compared to bam at each time point (p< . ). in addition, muscle strips supported by sesfm displayed higher contractile responses to carbachol, kcl, and phenylephrine compared with bam. at weeks, both matrices elicited similar mild acute and chronic infl ammatory reactions. conclusion: our results demonstrated that sesfm has greater ability to promote bladder tissue regeneration with structural and functional properties compared to bam, and with similar biocompatibility. introduction and objective: ureteral access sheaths (uas) can aid ureteroscopy by facilitating multiple passes of the ureteroscope, maximizing irrigation drainage, and reducing intra-renal pressures. however insertion of the access sheath may induce ureteral ischemia, cause iatrogenic ureteric injury, and could ultimately lead to ureteric stricture. in this study, we aim to evaluate the stricture rate following ureteroscopy both with and without the use of uas. we performed a retrospective chart review of consecutive ureteroscopies performed at our center (a tertiary referral center for endourology) between april and april to treat ureteric and renal calculi. th e primary outcome was the development of new hydronephrosis three months following successful ureteroscopy, not due to an obstructing stone. patients without follow-up renal ultrasound (us) or ct scan months post-ureteroscopy were excluded. data on age, sex, size of the stone, location of the stone, stone density, stone-free rate (sfr), time of the procedure, pre-op stenting, postop stenting, use of the uas, size of the uas, length of the uas, stone analysis, and imaging details were recorded. baseline and outcome variables were compared with anova and chi-square analysis where appropriate using spss statistical soft ware. results: a total of patients were eligible. a uas was used in ( . %) patients; ( . %) for renal stones and for proximal ureteric stones. th ere was no signifi cant diff erence in baseline or demographic data. none of the patients developed new hydronephrosis or developed a ureteric stricture, and none required endoureterotomy. conclusions: uas use during ureteroscopy for renal and ureteric stones is both safe and eff ective. even with routine use of . f and f uas, ureteric stricture rates are very low (zero in this series), suggesting that signifi cant ureteric injury is rare with proper technique and case selection. to evaluate the value of fl exible ureteroscopy for the treatment of the upper urinary tract calculi in children. a total of children, males and females, were identifi ed in this study. th e median age was . years, range months to years. among them, patients had the upper ureteral calculi ( with calculi in situ, with middle/fi stal ureteral calculi shift ing to upper ureteral aft er rigid ureteroscopic lithotripsy) and had renal calculi. ipsilateral mild to moderate hydronephrosis was found in all of the cases. four children had melamine-induced stones ( with upper ureteral calculi and with renal calculi). th e calculi were found on left side in cases, on right side in , and on both sides in (upper ureteral calculi). th e median stone size was . (range . to . ) cm. retrograde fl exible ureteroscopy and anterograde fl exible ureteroscopy in mini-percutaneous nephrolithotomy was performed. results: twenty eight cases were performed retrograde fl exible ureteroscopic procedure. one case was conversed to mini-percutaneous nephrolithotomy because the fl exible ureteroscope could not be inserted into the upper ureter. th e fl exible ureteral access sheath was failed to insert into the upper ureter in cases, and the fl exible ureteroscope was inserted into ureter directly. th e successful rate of stone search was % in cases. th irty cases were successfully performed in one stage. th e stones were successfully fragmented aft er two stages in two cases. th e success rate of stone fragmentation was . % with the holmium laser lithotripsy in one stage. th ree anterograde fl exible ureteroscopy with mini-percutaneous nephrolithotomy were successfully performed, and the stones were successfully found and fragmented aft er a single holmium laser lithotripsy. th e median operative time was (range to ) mins. th ere was no major perioperative complication. th e patients were discharged from hospital aft er a median of . days (range to ). double-j stent was removed aft er to weeks when no residual stones more than . mm in size were found. no recurred stones, no urethra stricture, no ureter stricture, no urinary incontinence and no vesicoureteral refl ux were found during the to -months follow-up. conclusion: flexible ureteroscopy is a safe and feasible method for the treatment of the upper urinary tract calculi in children. it is suitable for the stones in the pelvis and calyceal where the rigid ureteroscopy could not reach. introduction and objective: laparoscopic ureterolithotomy is an alternative to open ureterolithotomy for the primary treatment of large, impacted, proximal or mid ureteral stone. transperitoneal and retroperitoneal approaches are the basic techniques and each has its own advantages and disadvantages. th e aim of this study is to compare retroperitoneal versus transperitoneal laparoscopic ureterolithotomy in eff ectivity, pain scale and early complications. in this prospective comparison study from january to december , patients with proximal and mid ureteral stones underwent retroperitoneal laparoscopic ureterolithotomy or transperitoneal laparoscopic ureterolithotomy. th e randomization occurred on consecutive sampling on a : basis. groups and consisted of patients who underwent retroperitoneal laparoscopic ureterolithotomy and transperitoneal laparoscopic ureterolithotomy, respectively. demographic and clinical variable, operative time, length of stay, ureteral suturing, pain scale according to visual analog scale (vas) and early complications data were collected and analyzed. statistical analysis was performed with spss® version . using student t-test and mann-whitney u tests with p value< . considered statistically signifi cant. results: vas on day between the groups was statistically signifi cant, and was higher in group (p< . ). according to the clavien-dindo classification of surgical complication all the patients were in grade classifi cation. th e diff erences in operative time, length of stay, ureteral suturing, visual pain analog score on day , and early complications between the groups were not statistically signifi cant. ionising radiation is commonly used in urological practice in the form of fl ouroscopy. to date there is a relative dearth of information regarding patient exposure during the urological procedures and the subsequent risk of development of a lethal malignancy due to the radiation exposure. objectives: to determine the radiation exposure for a patient for the most commonly performed urological procedures and determine the lifetime additional risk of fatal cancer per procedure. data was collected prospectively in two institutions on endoscopic urological operations. procedures were classifi ed as retro-graphic, semi-rigid ureteroscopic (urs) and fl exible ureterorenscopic (furs). data collected included procure type and diffi culty, dose are product [dap (gy*cm )]). th e eff ective dose (ed) as measured in millisievert was determined from the dap by using the monte carlo calculation. results: a total of consecutive operations from two institutions were assessed. th e mean ed for all procedures in this study was . msev, irq ( . - . ). th e maximum ed was . msev. th e radiation exposure for all procedures was relatively small, for diagnostic retrographic procedures the median ed was . msev. for retrograde procedures that involved a stent insertion the median ed was . msev. th e median ed for all ureteroscopic surgeries was . msev, and the median ed for all furs procedures is . . th e fi ndings of this study are reassuring. endoscopic urological procedures appear to expose patients to relatively small radiation compared to other procedures requiring fl uoroscopy and a very low lifetime additional risk of fatal cancer per procedure. five during the follow no local recurrence was noted and two patients presented with distant metastasis. th e actual -year overall and cancer specifi c survival was . % and . %, respectively. on multivariable cox regression analysis, acci was the only factor associated with increased risk of overall mortality (hr . ; % ci ( . - . )). conclusion: rpn achieves excellent long-term oncological outcomes. age and comorbidities are associated with increased risk of overall mortality. to our knowledge, this is the fi rst series of long-term follow up aft er rpn reported to date. introduction and objective: partial nephrectomy provides equivalent oncologic and superior functional outcome compared with radical nephrectomy over the short and long term. with the development of laparoscopic techniques and increasing laparoscopic surgical experiences, laparoscopic partial nephrectomy (lpn) has become an acceptable alternative to radical nephrectomy for expert laparoscopic urologists to treat small renal mass. it was reported that using barbed suture can reduce warm ischemia time during lpn. we designed a single blind randomized controlled trial to fi nd whether the barbed suture can materials and methods: from july to march , forty-six patients with renal score less than were enrolled for this study. patients were randomized into two groups: control and v-loc group. all patients were evaluated before surgery including performance status, asa score, liver and renal function, abdominal ct, lung function, and cardiac function etc. during the surgeries, standard ports were placed. aft er the renal artery was clamped by bulldog, tumor resection was performed using a cold scissor. th en the inner layer deep vessels and collecting system, and outer layer were sutured with v-loctm respectively in v-loc group. in control group, inner layer was sutured with - absorbable sutures, and the outer layer renal parenchyma was sutured with absorbable sutures. operative characteristics and complications were compared between groups. results: laparoscopic partial nephrectomy was successfully completed in all forty-six patients without open conversion. control and v-loc groups were equivalent in demographic and tumor characteristics. no signifi cant diff erence was seen between control and v-loc groups in operative time ( vs. min, p = . ), estimated blood loss ( vs. , p = . ), warm ischemia time ( vs. min, p = . ), and complication rate ( % vs. . %, p = . ). conclusion: lpn with v-loc sutures for renorrhaphy is safe and feasible. however, using v-loc suture for renorrhaphy doesn't show any superiority in patients with low and moderate complexity renal tumors in our randomized control trial. small th e local recurrence free survival was signifi cantly better in the combined us/ct-guided group than in the us-guided group (p= . ). recurrences were found in % with us/ct-group and in % in usgroup. th e overall complication rate was similar (us/ ct % versus us %) in both groups. th e mean percentage decrease in the estimated glomerular fi ltration rate (egfr) aft er the treatment was . ± . % with us/ct, compared to . ± . % mean decrease in egfr aft er treatment in the us-guided group (p= . ). conclusion: th e use of combined us/ct-guidance when performing renal rfa resulted in superior primary and short term outcome compared to the use of us-guidance alone in patients treated at the same institution. increased experience with rfa treatment probably also contributed to the results. introduction and objective: to present our initial experience in female patients undergoing transvaginal notes-assisted laparoscopic partial nephrectomy (pn). between august and january , a prospective analysis of the initial ten patients who underwent transvaginal notes-assisted pn was entered into an institutional review board (irb)-approved database. th e procedure was performed using two umbilical trocars and one trocar through the vaginal wall. th e main renal artery clamping, segmental renal artery clamping and unclamped pn were performed depending on the circumstances of the tumour. some perioperative parameters including operative time, warm ischemic time, blood loss, and perioperative complications were recorded. sexual function was assessed with the female sexual function index (fsfi) questionnaire before and aft er surgery. th e cosmetic results were investigated by administering patient scar assessment questionnaire and scoring system (psaq). results: nine transvaginal notes-assisted pns were completed successfully. one patient with a right anterior upper-pole tumor was converted to radical nephrectomy because of persistent bleeding from the parenchymal defect. th e median (range) operating time was ( - ) mins and the median (range) estimated blood loss was ( - ) ml. th e median (range) warm ischaemia time (wit) was ( - ) mins. th e median (range) postoperative hospital stay was ( - ) days. all surgical margins were negative. eight patients completed the fsfi questionnaire, and analysis did not show diff erences in fsfi scores before and aft er surgery. th e better cosmesis results were confi rmed by the psaq score. transvaginal notes-assisted pn is a safe and feasible surgical procedure in the treatment of small renal mass with excellent cosmesis results. more prospective studies with long follow-up are needed to investigate the oncologic safety. introduction and objective: to analyze the complications of urologic transvaginal natural orifi ce transluminal endoscopic surgery (tv-notes), and to explore eff ective measures for its prevention and management. materials and methods: from may to february , a total of cases underwent tv-notes in our institute. intraoperative and postoperative complications were graded according to satava and clavien-dindo grade classifi cations system. th e major complications and their treatments were most importantly analyzed. results: among the tv-notes procedures, case conversion to open surgery and one case conversion to suprapubic-assisted laparoendoscopic single-site surgery (sa-less). th irty-one ( . %) patients had intraoperative complications, the minor and major was ( . %) and ( . %), respectively. th e intraoperative complications include cases of pneumoderm, cases of skin ecchymosis, cases of pleural damage, cases of liver injury, case of adrenal central vein injury, cases of spleen injury, cases of inferior vena cava injury, cases of renal veins injury, case of right iliac vein injury, case of bladder injury, case of renal collecting system injury, cases of colon injury, case of rectum injury. th e proportion of patients incurring minor and major postoperative complications undergoing tv-notes was . % (n = ) and . % (n = ), respectively. th e postoperative complications include case of adrenal crisis, cases of incision infection, cases of postoperative fever, cases of postoperative bleeding, case of the right external iliac artery thrombosis and case of urinary leakage. no intraoperative and postoperative deaths occurred. conclusion: tv-notes operation is safe and feasible surgical technique in urology, and does not increase the incidence of complications. but there is a potential risk of major complications occurring, which should be paid more attention to prevent. introduction and objective: knotless barbed suture, a relatively innovative type of suture, can eliminate knot tying, speed the placement of the sutures, and create the possibility of improved scar cosmoses. th e minimally invasive radical prostatectomy (mirp), as one of the earliest surgeries that adopted this advanced technique, was reported about diverse eff ects on the patients and the surgeons. our objective is to present the available evidence about the effi cacy and safety of barbed sutures in minimally invasive radical prostatectomy. we searched pubmed, em-base, and cochrane library for published studies and clinicaltrials.gov for additional information to identify randomized controlled trials (rcts) and cohort studies addressing the application of barbed and conventional sutures in mirp (until feb. ) . quality assessment was performed according to cochrane recommendations. th e data were analyzed using review manager (version . ), and sensitivity analysis was performed by sequentially omitting each study. hemi-pelvises, . % had the periprostatic plexus (ppp) as the largest vein of the dvc. th is was followed by the obturator vein (ov) ( . %), which originates from the lateral part of the plexus and runs laterally. next was the internal pudendal vein (ipv) ( . %), which originates lateral to the posterior part and runs postero-laterally. in the rp group, the dvc bunching stump was an average of . mm from the origin of the cavernous vein. no complications occurred while performing examinations. conclusion: d-ct pelvic venography depicted the dvc and its related veins in all cases. venous systems making up the dvc diff ered among patients. in . %, the main venous system was the ppp, which can be controlled by conventional dvc ligation technique. however, in the remaining % of hemi-pelvises, the ipv and the ov were the main venous systems. th ese will need wider ligation because of existing outside and to the back of pathways. we believe that a better understanding of dvc will lead to refi ned rp. introduction and objective: bladder pheochromocytoma and carcinoid tumors are rare neuroendocrine tumors of the bladder. presenting a series of cases of these rare bladder tumors which were managed laparoscopically. materials and methods: case was a years lady who presented with symptom of giddiness following micturition. ultrasound revealed a . cm bladder mass at the bladder base. twenty four hour urinary biochemical evaluation and mibg scan did not reveal any abnormalities. cystoscopy revealed a submucosal sessile mass above the trigone. on cystoscopic bladder distension a spike in blood pressure ( / ) was noticed which fell rapidly on emptying. patient underwent laparoscopic partial cystectomy aft er weeks of alpha blockade with phenoxybenzamine. case was a years old gentleman who presented with episodes of severe headache following micturition. despite antihypertensives his blood pressures were not under control. ultrasound revealed a cm bladder mass in the left lateral wall encroaching close to the left ureteric orifi ce. twenty four hour urinary biochemistry and mibg scan was suggestive of bladder pheochromocytoma. aft er weeks of alpha blockade he underwent cystoscopy followed by laparoscopic partial cystectomy with left ureteric reimplantation. case was a years old gentleman a hypertensive who underwent an attempted turbt and subsequent hypertensive crisis and bleeding for a bladder mass in a peripheral hospital. he was stabilized and referred to our center for further management. ultrasound revealed a cm anterior wall mass. twenty four hour urinary biochemistry and mibg scan was suggestive of bladder pheochromocytoma. aft er weeks of alpha blockade he underwent laparoscopic partial cystectomy. mri has shown to be accurate in diagnosing index tumours in prostate cancer. a variety of focal therapies has been explored in treating these lesions. th is study aims to compare the detection rate, grade and location of non-index lesions found in radical prostatectomy specimens with their initial mpmri. a prospective database of all men undergoing mpmri for suspicion of prostate cancer in our group practice was kept. ethics approval was obtained from epworth healthcare. of these men, all who had a -d summary diagram including pirads score for each mpmri and who then underwent radical prostatectomy were assessed. volumetric studies were performed for all prostatectomy specimens and compared to each corresponding mpmri -d summary diagram. analysis of non-index lesions was performed. conclusion: a signifi cant amount of patients who underwent radical prostatectomy in treatment for prostate cancer were identifi ed to have non-index tumours in their volumetric analysis. in our cohort of patients, the majority of low grade disease was undiagnosed on mpmri. however, a signifi cant amount of moderate grade non-index tumours were also missed on initial mpmri. th is questions the safety and appropriateness of focal therapy. ongoing research is warranted and we will continue to report our prospective mp-mri database as our experience with this modality grows. eligibility for active surveillance of prostate cancer and functional outcomes after prostatectomy shepherd a , , o'callaghan m , , introduction and objective: we aimed to compare the outcomes following radical prostatectomy (rp) of active surveillance (as) and non-as candidates. we hypothesised that as eligibility at diagnosis would be associated with favourable pathological, surgical and also functional outcomes. using a prospectively maintained database, all patients with a primary treatment of rp conducted prior to were identifi ed, including those who were initially eligible for as. men defi ned as eligible for as were those: diagnosed between and years of age; with gleason score ≤ ; psa ≤ ; clinical stage ≤ a; and with percentage of positive cores ≤ %. we compared the histopathological and functional outcomes of the two groups. results: of patients with a primary treatment of rp, met the criteria for as. pre-operative tumour characteristics of the patients meeting criteria for as were favourable compared with those ineligible (lower psas and less cancer in the biopsies; p< . ). functionally, the groups had similar pre-operative continence ( % vs. %) and potency rates ( % vs. %). histologic characteristics of the prostate specimen in patients qualifying for as were more favourable, with lower rates of positive surgical margins and extracapsular extension observed in this group (p< . ). following rp, at -, -and -month follow-up, there were no signifi cant diff erences in the proportion of men who were continent between as and non-as candidate groups ( months: % vs. %; months: % vs. %; months: % vs. %; p> . ). similarly, no signifi cant diff erences between groups were observed in the proportion of men who were potent at -and -month follow-up ( months: % vs. %; months: % vs. %; p> . ). aft er -month follow-up, however, potency appeared to be higher for the as candidates ( % vs. %; p= . ). were assessed pre-implant as well as at , , and months aft er seed implantation, and every months thereaft er. we evaluated clinical factors, including prostate volume (pv), neoadjuvant combined androgen blockade (cad), radiation dose to % of the prostate volume (d ), and to % of the urethral volume (ud ) to predict urinary disorders aft er brachytherapy using multivariate analysis. results: th e mean pre-implant ipss was . , with the greatest mean score of . at month aft er seed implantation. at , , , , and months, the mean ipss had decreased to . , . , . , . , . and, . respectively. th e mean pre-implant prostate volume (pv) was . g, followed by . g at months and . g at months aft er brachytherapy. in cases with pv more than g, d more than gy, and ud more than gy, ipss levels were signifi cantly high-er even years aft er treatment. on multivariate analysis, d more than gy (p< . ) and ud more than gy (p= . ) were independent predictors for ipss increases of more than points at years aft er brachytherapy. only d was an independent predictor at (p< . ) and years (p= . ) aft er brachytherapy. introduction and objective: metformin has been shown to be protective in prostate cancer (pc). we aimed to assess the eff ects of metformin on pc outcomes in men treated with external beam radiotherapy (ebrt) and/or androgen deprivation th erapy (adt). we also aimed to investigate the eff ects of metformin on the above outcome measures in type diabetic men with pc. th e outcome measures of time to biochemical failure (bf), metastasis, pc specifi c mortality and overall mortality were analysed in men on metformin using a competing risk model and a cox proportional regression model. a total of eligible cases, of whom were on metformin, were identifi ed with a median follow-up of . months. th ere were no diff erences in age, initial psa, gleason scores, t stage, d' amico risk or duration of adt between men who were on metformin and those not on metformin. treatment with metformin did not result in any apparent improvement in time to bf, time to metastases or overall survival but there was an increase of . fold in pc-specifi c deaths (p< . ) in men on metformin and adt when adjusted for cancer risk and co-morbidities. on a subgroup analysis of the men with type diabetes, similar fi ndings were seen with metformin being associated with a . fold increase in pc-specifi c deaths (p < . ). th ese adverse eff ects were lost in men on metformin and statins. conclusions: th e use of metformin did not improve time to metastases, time to bf or overall survival in men undergoing ebrt +/-adt for pc with curative intent. however, in type diabetic men on high doses of metformin there was an increased risk of pc-specifi c mortality. further studies are needed to investigate these fi ndings. th e objective of this study is to assess ire eff ects in prostate tissue and to correlate ire treatment planning with the d-histopathology of radical prostatectomy (rp) specimens that essential structures will be spared. sixteen patients, scheduled for rp, ire procedures were performed weeks before rp. ablation was performed according to two protocols: focal or extended ablation. th e electrode probes were inserted transperineally under ultrasound guidance. th e locations of the electrodes were used as input for the plannings soft ware. following rp, the specimens were processed into whole-mount sections, were histopathologically (pa) assessed and ablation zones were delineated. th e volumes of tissue alteration were determined by adding the delineated areas. th e planned and pa ablation volumes were compared using the pearson correlation coeffi cient. results: th e d volumes of the ablation zones follow the planned lesions volumes with a pearson correlation index r= . with a slope of . ( figure ). th e focally planned ablations results in a volumetric smaller histopathological ablation zone than predicted whereas the extended ablations result in volumetric larger ablation. pa showed sharply demarcated fi brotic and necrotic areas with mild infl ammation. th e urethra was aff ected by the ire treatment in nine mp- . , figure . correlation of ablation volumes t -weighted mri and ceus with h&e pathology (pa) mp- . , figure . scatterplot of planned ablation zone volumes compared with volumes in histopathology patients were observed throughout the neurovascular bundle in thirteen prostates and extended beyond the prostatic capsule in twelve cases. conclusion: ) ire in prostates results in sharply demarcated lesions with fi brotic and necrotic features, but may damage essential structures as urethra, capsule and nerves. ) th e actual ablation zones on d-histopathology follow reasonably the planned ablation zones. ) focal ablation protocols lead to a smaller ablation zone than extended ablation protocols. therapeutic all patients treated at our institution with primary pca t - , n , m were included provided they did not present with a long history of adt. patients were stratifi ed into groups according to their psa nadir occurring between - weeks following hifu. group a (n= : nadir < . ng/ml), group b (n= : nadir > . - ng/ml ng/ml), group c (n= : nadir > ng/ml). th e primary endpoint of our analysis was the onset of any salvage therapy other than hifu. repeat hifu can be performed without undue additional morbidity and is standardly not considered as salvage therapy but rather an adjuvant to the index hifu. multivariate analysis was performed to determine what predicts onset of salvage therapy. results: at inclusion: . % of patients were t and . % were t . outcomes are summarized in table . conclusion: group a (nadir < . ) showed % salvage treatment free survival without adt; preoperative high gleason, high initial psa and "no turp" were negative predictive factors for outcome; % of the patients had nd hifu treatments in follow-up; in case of salvage therapy most patients opted for adt. metastasis-free survival of % at and % at years excludes turp in pca as potential metastasis-inducing factor. combined "turp and hifu" showed its oncological effi cacy, postponing / avoiding classical salvage therapies (rad/adt) and their potential side eff ects. laparoscopic radical prostatectomy (lrp): changing trends in practice introduction and objective: we audited our lrp outcomes in order to evaluate outcomes and how our practice has evolved over the years. we evaluate pathological and margin status outcomes and determine whether there has been a shift towards treatment of higher risk disease and the impact of this practice on margin status. a total of patients underwent lrp performed by one surgeon at our institution from june to september . we divided the cohort into early period from - (group , n= ) and - (group , n= ). results: mean age was yrs. mean preoperative psa ( . ) and gleason score (gs, ) did not diff er between groups. however, preoperative stage ≥t c increased from ( %) to ( %) for groups and respectively. postoperatively, diagnosis of gs ≥ increased from ( %) in group to ( %) in group . similarly, % of group was staged as pt compared to % of group . th ere were more extracapsular extension in group ( %) compared to group ( %). overall positive surgical margin (psm) rate was % (group , % vs. group , %). when stratifi ed according to pathological stage, psm was identifi ed in more men with pt ( %) compared to pt ( %). th e commonest site of psm was at the apex. seminal vesicle invasion rate was similar ( %). results: mean operation time and length of hospital stay for rarp and lrp were . ± . min and . ± . min, and . ± . days and . ± . days, respectively (p = . and p = . ). aft er cases, the mean operation time for rarp was similar to lrp (less than h). positive surgical margins in localized cancer were seen in . % and . % of cases in rarp an lrp, respectively (p = . ). at postoperative months, sexual intercourse was reported in % and %, and pad-free continence in % and % in patients with rarp and lrp, respectively (p = . and p = . ). conclusion: previous large-volume experience of lrps may shorten the learning curve for rarp in terms of oncological outcome. additionally, previous experience with laparoscopy may improve the functional outcomes of rarp. introduction and objective: signifi cant prostate cancer is increasingly diagnosed in younger men. th is patient group has high expectations regarding oncological and functional outcomes at robotic radical prostatectomy (rarp). we reviewed a prospective database ( rarps) at a single tertiary referral centre and obtained erectile dysfunction rates/treatment and continence pre-and post-operatively, positive margins, metastases and death. median follow-up was years. male sprague-dawley rat aged weeks were used. a total of rats were divided into two groups. one group was used as a control and other group received intramuscular injections of testosterone propionate ( mg/kg) plus β-estradiol ( . mg/kg) for weeks to induce bph. th e prostate and genitourinary organ weights, histopathologic change and serum hormones were evaluated. we compared the eff ects of ldd ( mg/kg) with tamsulosin ( μg/kg) in intraurethral pressure responses induced by es of the hypogastric nerves. we performed western blotting for alpha a and d receptor of adrenergic nerve. results: bph-induced rats showed signifi cantly increased absolute prostate weight and prostatic index (prostate weight/body weight x ), increased testosterone, free testosterone and estradiol levels in the serum. histomorphology also showed that epithelial cell layers in the prostates of bph-induced rats were larger than control groups. ldd and tamsulosin signifi cantly inhibited the intraurethral pressure elevation induced by es of the hypogastric nerves. alpha d and alpha a adrenergic receptors in bph rat model were expressed more than control. ldd decreased expression of alpha d adrenergic receptor than control. conclusions: th is study suggested that ldd could be an alternative medicine to treat bph inducing lower urinary tract symptoms. does according to recent studies, atherosclerosis has a key role in the pathogenesis of bph. th erefore, we evaluate the correlation between prostate volume and intima-media thickness (imt) of carotid artery in diabetic bph. from january to august , patients with dm were analyzed, retrospectively. baseline characteristics and diabetic profi le were collected. mean intima-media thicknesses (imt) were collected using carotid doppler ultrasound. and prostate volume (pv) was measured by transrectal ultrasound. two groups were analyzed using lineal regression analysis. results: th e patients were classifi ed into group (n= , . %) and into group (n= , . %) based on the presence of bph. th ere were statistically signifi cant diff erences on bmi, waist circumference and hba c between the two groups (table ) . th ere is a signifi cant correlations between imt and pv and imt and transition zone (tz) (p= . , p= . , figure ). porting symptoms listed on the otc label as reasons for not using the product; traces of glucose, leukocyte, and/or blood in their urine; or an aua-si score ≥ . conclusion: pvp has demonstrated acceptable complication rates compared to traditional turp in treating bph in a cohort of men having a greater frequency of comorbidities and in those having to remain on oral anticoagulation. th is makes pvp an attractive alternative to turp in such men particularly if symptomatic relief and re-treatment rate in the longer term is demonstrated to be equivalent. prospective study of high-risk patients undergoing photovaporisation of prostate (pvp) without cessation of oral anticoagulants ow d , papa n , sengupta s , , lawrentschuk n , , , bolton d introduction and objective: greenlight laser photovaporisation of the prostate (pvp) is suggested to be safe to perform on high risk patients requiring surgical intervention in the management of benign prostatic hyperplasia (bph), where cessation of oral anticoagulation is not possible due to medical comorbidities. we prospectively evaluated the outcomes of patients who underwent pvp with ongoing oral anticoagulant therapy. materials and methods: between january and december , patients with ongoing oral anticoagulant therapy were treated with pvp. types of oral anticoagulants were recorded and perioperative outcomes were collected. th ese metrics included transfusion rate, duration of hospital stay and laser treatment variables. ninety-day readmissions also were recorded as were complications of treatment. results: sixty-two patients were treated by greenlight laser pvp while taking oral anticoagulants. out of this total, patients ( . %) were on warfarin while ( . %) had ongoing clopidogrel. th e remaining were either taking one or a combination of other (non-asprin) oral anticoagulants. nine out of ( . %) patients required readmission post pvp, and all of these readmissions were for management of complications related to haematuria. five of this group of patients ( . % of total cohort) had undergone pvp without cessation of warfarin, while of patients ( . % of total cohort) had undergone treatment without cessation of clopidogrel. th ree patients ( . %) required blood transfusion. conclusions: despite continuation of oral anticoagulants in these high risk patients, the readmission rate is low and transfusion rate is similar to what has previously been reported for conventional turp in patients without anticoagulation. greenlight laser pvp is a viable option for surgical management of bph in patients for whom cessation of oral anticoagulant therapy is contraindicated. introduction and objective: cystinuria is a rare, chronic condition characterised by recurrent urolithiasis. th e condition is due to a variety of genetic mutations in an amino acid transporter and accounts for between . - percent of urinary tract stones. cystine urolithiasis may be treated by preventative medical therapy or therapeutic urological intervention. it is the authors' experience that patients tend to shy away from long-term medical treatment, possibly due to a perceived lack of effi cacy or poorly tolerated side-eff ects. as with all chronic conditions, quality of life for cystinuric patients is expected to be diminished. sub-optimal medical therapy and the need for repeated urological intervention is expected to have a further impact on quality of life. th e authors seek to describe the natural history and quality of life in patients with cystine urolithiasis. th is in turn allows further improvements to the standard-of-care off ered to such patients. a cohort study was carried out involving participants recruited from a single surgeon's case mix. participants suff ering from cystinuria and related urolithiasis were invited to complete a questionnaire involving demographic information, use of medical treatment, surgical interventions and the sf- quality of life survey. attitudes towards the use of current and potential future medical treatments were also explored. results: fourteen participants completed the survey. th e sf- survey showed lower quality of life than the general public in of domains. th e mean interventional rate in patients with cystinuria was . procedures per patient. most patients reported previ-ous use of d-penicillamine and urinary alkalinisation medications, with most ceasing due to side-eff ects or lack of perceived effi cacy. conclusion: cystinuria is associated with a high rate of surgical intervention and lower quality of life than the general public. individuals with this condition report that medical management is either ineff ective or poorly tolerated. th ere is a need for further improvements in medical management of cystinuria, to reduce the rate of operative intervention. recommendations to guide clinical practice, based on patients' experience of cystinuria management can be made. dipstick results: a total patients were retrospectively reviewed for the ph results. th e mean diff erence in ph between spot urine value and the -hr collection values was . ± . ph. higher ph was associated with lower accuracy (p < . ). th e accuracy of spot urine samples to predict -hour ph values of < . was . %, . % for . to . and % for > . . samples taken more than days apart had only % the accuracy of more recent samples (p < . ). th e overall accuracy is lower than % (p < . ). infl uence of diurnal variation was not signifi cant (p = . ). conclusions: spot urine ph by dipstick is not an accurate method for evaluation of the patients with urolithiasis. patients with alkaline urine are more prone to error with reliance on spot urine ph. relationship is the fi rst lithotripter on the market with a unique design that allows for a dual focus system with the option of either a narrow or wide focal zone. ex vivo data on the slk-f lithotripter shows that the disintegration capacity and the renal vascular injury are independent of the focal diameter of the sw generator at the same peak positive pressure and disintegration power. th e objective of this study is to compare the single-treatment success rates of narrow and wide focal zones for the shock wave lithotripsy of renal stones. a total of patients with previously untreated radio-opaque solitary stone located within the renal collecting system, measuring at least mm, were randomized to receive narrow or wide focus lithotripsy while maintaining a constant overall energy level. patients were followed with kub x-rays and renal ultrasound at and weeks post lithotripsy to assess stone area and stone free status. urinary markers indicating the degree of renal cellular damage (microalbulin and beta microglobulin) were measured pre and post swl, hours post swl and days post-treatment. primary outcome was success rate, defi ned as stone-free or adequate fragmentation (sand and asymptomatic fragments <= mm) at months post-treatment. mp- . , figure . introduction and objective: despite being uncommon, infantile kidney stone remains a major health problem due to its higher recurrence rate and morbidity. th e parents usually notice that their infants have recurrent fever and failure to thrive of unknown origin. th ose patients comprise a big challenge for the urologist in management. th erefore, this study aimed to evaluate the outcome of shockwave lithotripsy (swl) in management of renal stones in infants. a retrospective analysis of prospectively collected data performed between january and december for infants underwent swl for single radio-opaque renal stones ≤ mm at a single stone center. swl was performed with dorneir s lithotripter with a maximum of shocks per session. a single session was indicated for each infant, but a second session was performed when satisfactory disintegration was not achieved. follow-up based on urinalysis, urine culture and sensitivity, plain x-ray kidney ureter bladder (kub) and abdominal ultrasonography (us) was carried out weeks post swl and monthly for successive months. multislice computed tomography (msct) was performed -months post-swl to confi rm the stone-free status. results: a total of infants, less than months of age were enrolled in this research. swl success was defi ned as absence of any residual fragments on msct months aft er the last session. stone free rate was . % aft er the fi rst swl session and reached % aft er the second session. rate of retreatment with second session of swl was . %. urinary tract infection (uti) was detected in . %, transient renal obstruction with low grade fever in . % of infants and no major complication had been recorded. conclusion: th e new generation of swl technology with a precise focal area seems to be safe and eff ective in management of kidney calculi in infants. stone introduction and objective: th e incidence of abdominal discomfort is frequent during pregnancy, but renal colic is infrequent. one of the main causes of renal colic during pregnancy is urolithiasis. managements of urolithiasis during pregnancy are hydration, antibiotics, ureteral stent insertion, percutaneous nephrostomy, and ureteroscopic stone removal. in this study, we assessed the reliability and stability of ureteral stent insertion to pregnant patients with renal colic. results: th e overall mean patient age ( years), male to female ratio ( . : ) and mean asa score ( . ) did not vary signifi cantly between years. admissions for elective renal stone procedures, adjusted for population, increased % over the study period. th is growth was entirely in the last years, corresponding with a -fold increase in the use of pyeloscopy (from to cases per year). from the fi rst to last year, there was a % reduction in eswl (from to cases per year) and a % increase in pcnl (from to cases per year). nephrolithotomy ranged from to cases per year. th ere has been an increase in the proportion of associated ureteric stent insertions from % to %. th e proportion of day-only admissions has decreased from % to %. th e average government assigned cost per admission has increased %. conclusion: victorian public hospitals have seen a rapid expansion in the use of pyeloscopy and laser for treatment of renal stones. th is corresponds with a signifi cant increase in admissions for elective renal stone treatment, relatively fewer day-case admissions, higher treatment costs and more associated stent isertions. introduction and objective: th is retrospective study assessed the semirigid ureteroscopy approach coupled with ballistic or ho:yag laser lithotripsy for the treatment of proximal ureteral stones. patients with a single lower calyceal stone with an evidence of a ct diameter between and cm were enrolled in this multicentric study. exclusion criteria were the presence of coagulation impairments, age less than or more than , presence of acute infection, presence of cardiovascular or pulmonary comorbidities. patients were randomized into three groups: group a: patients treated with swl; group b: patients treated with rirs; group c: patients treated with pcnl. patients were controlled with abdomen x-ray and ct scan aft er months. a negative x-ray or an asymptomatic patient with stone fragments less than mm big and a negative urinary colture were the criteria to assess the stone-free status. a statistical analysis was carried out to assess patients' data, success and complications rates, re-treatment rate and need for auxiliary treatment. radiotherapy is an eff ective and common treatment for the prostate cancer. however, there is still an historic deep rooted fear of its use due to the existence of late genitourinary toxicities such as the radiation cystitis. nowadays these toxicities may pose less of a threat due to the use of newer radiotherapy techniques and the reduction of radiation doses applied to the tissues adjacent to the tumor. th e objective of our study is to fi nd predictive factors and determine the cumulative incidence of overall and severe radiation cystitis. conclusion: radiation cystitis is a feared complication of the use of radiation therapy in prostate cancer which occurs infrequently, and the severe cases requiring hospitalization are very rare. th e characteristics of the tumor, purpose of radiotherapy used or radiation dose applied do not seem to infl uence the incidence of radiation cystitis. introduction and objective: th e aim of the study was to assess prognostic factors of biochemical and radiological disease progression (dp) in subgroup of lymph node (ln) positive prostate cancer (pc) pts. evaluation of detection rate of ga-psma pet/ct for biochemical recurrence after radical prostatectomy introduction and objective: prostate specifi c membrane antigen (psma) is overexpressed in more than % of all prostate cancers (pca). since the introduction of pet-imaging with gallium-labelled psma, this method is regarded as a signifi cant step forward in the diagnosis for recurrent pca. from the patients that were scanned for detection of recurrent pca aft er radical prostatectomy between august and december , were evaluable for retrospective analysis. patients underwent pet/ct aft er injection with the ga-hbed-psma. th e potential infl uence of psa-level, primary gleason score (gsc) and psa-doubling time (psa-dt) on the detection rate were evaluated. results: a total of ( %) patients had pathological fi ndings on the ga-psma pet/ct, with an average psa-level of . ng/ml (range . - ng/ ml). detection rates were %, %, % and % for psa-levels < . , . - , > - . and > . respectively. if recurrent pca was detected, oligometastatic disease ( metastasis or less) was most commonly seen ( %). th e detection effi cacy was signifi cantly infl uenced (p< . ) by higher gsc ( % and %, for gsc ≤ and ≥ respectively). for the patients that were evaluated for the infl uence of psa-dt on detection rate, no signifi cant diff erence was found (p= . ) for psa-dt < months and ≥ months (detection rate % and % respectively). conclusion: ga-psma pet/ct has a high detection rate compared to prior studies of conventional imaging modalities, especially in lower range psa-levels. further research is needed to determine to assess whether localization of small volume disease on ga-psma pet/ct can improve diagnostic algorithms and outcomes in patients with recurrent pca. introduction and objective: to assess long-term results of salvage pelvic lymph node dissection (plnd) in prostate cancer (pc) patients (pts) with biochemical recurrence aft er primary local treatment and confi rmed solitary lymph node (ln) metastases. results: a total of , abstracts were screened, full-text papers were considered, and articles were included ( rct, comparative studies, and case series). th is abstract focuses on the comparative studies. primary therapy was prostatectomy in , radiation therapy in , and studies included both therapies. diff erent defi nitions of recurrence were applied among mostly retrospective studies and the adt strategy oft en not specifi ed. factors associated with unfavorable outcomes (overall, pc-specifi c, or metastasis-free survival) included higher age, higher psa nadir, higher gleason score, higher psa-dt, and early start of adt at recurrence. contradictory results were reported on the role of the length of adt aft er ebrt, partly explained by a selection of high risk cases. most patients with disease relapse aft er primary therapy seem not to benefi t from adt while side eff ects are known to be harmful. selected highrisk patients (short psa doubling time, high gleason score) however may have benefi t, and early start of adt may be preferable in this group. an intermittent adt strategy in this setting may be feasible. a rct is indicated, although diffi cult to perform. a personalized approach is warranted, taking disease characteristics, side eff ects, and quality of life into account. adt may only be given in patients with pc recurrence who have high risk characteristics. introduction and objective: locally radio-recurrent prostate cancer (rr-pca) can off er a chance of cure albeit with potential morbidities. current salvage treatment options include radical surgery and minimally-invasive ablative modalities such as hifu and cryosurgery (s-cryo). current data suggests that s-cryo can achieve disease-free survival (dfs) rates up to % at years. however, the majority of data is based on retrospective analysis with mid-term follow-up and there is still paucity of data on longterm outcomes. th e aim of this study was to analyze morbidity and oncological outcomes, with median follow-up years, of s-cryo on rr-pca patients at an academic center. figure ). adverse events were similar between the treatment arms. figure . th ese analyses demonstrates that, during the fi rst year of treatment, men treated with degarelix had a reduced risk of disease-related adverse events. th ere was also a lower risk of death, likely due to the higher incidence of cv events in lhrh agonist patients. introduction and objective: androgen-deprivation therapy (adt) appears to increase cardiovascular (cv) morbidity and mortality in men with prostate cancer, particularly in those with a history of cv disease (cvd). however, the risk is lower with the gonadotropin-releasing hormone (gnrh) antagonist, degarelix, compared with lhrh agonists. here we evaluate regional diff erences in baseline cv status in men with prostate cancer treated with degarelix or lhrh agonists and their subsequent risk of cv events. th is was a pooled analysis of data from three phase studies with a duration > months. individual patient level data on baseline cv status and subsequent cv events over year were summarized by geographic region (usa/canada vs. europe). cv event data were compared using cumulative incidence functions (with all-cause mortality as the competing risk) and cox regression analyses. canada had more severe disease and a higher cv risk (p< . ) ( table ). in men with baseline cvd, cumulative incidence ( % ci) of a cv event was . ( . - . ) in usa/canada vs. . ( . - . ) in europe (p= . ). at baseline, cv status was similar in the degarelix and lhrh agonist groups (table ) . however, in those with baseline cvd, degarelix was associated with a lower risk of subsequent cv events vs. lhrh agonists in both regions (hazard ratio [ % ci]: . [ . - . ]; p= . ). conclusions: men in the usa/canada with prostate cancer and cvd and who were treated with adt were more likely to experience a cv event than their counterparts in europe. th is likely refl ects the greater severity of baseline cvd and higher cv risk in these patients. degarelix reduced the risk of cv events compared with lhrh agonists in both regions. introduction and objective: androgendeprivation therapy (adt) decreases bone mineral density and may increase skeletal complications in metastatic prostate cancer. however, lhrh agonists and gnrh antagonists have diff erential eff ects on follicle-stimulating hormone (fsh), which regulates bone resorption. th e current analysis compared the eff ect of lhrh agonists and the gnrh antagonist, degarelix, on serum alkaline phosphatase (salp), a marker of bone turnover, and the incidence of skeletal adverse events (aes). conclusions: degarelix suppressed s-alp more quickly and for longer than lhrh agonists. it also reduced bone pain and was associated with a lower incidence of fractures. collectively, these data indicate that degarelix provides better control of skeletal disease in men with metastatic prostate cancer, an eff ect that may be mediated by its diff erential eff ect on fsh. prognostic introduction and objective: testosterone (t) regulates nitric oxide synthase and is necessary to achieve an optimum response to pde inhibitors for erectile dysfunction. recently, tadalafi l was found to be eff ective for treating lower urinary tract symptoms (luts) secondary to benign prostatic hyperplasia (bph). we studied the relative importance of the t level in patients with luts and determined whether the t level predicts the response to tadalafi l mg once daily for luts/bph. aft er a -week washout period, men older than years without (n= , t level ≥ ng/dl) and with (n= , t level < ng/dl) hypogonadism were given tadalafi l mg once daily for weeks. we assessed its impact and the severity of luts/bph using the international prostate symptom score (ipss) and bph impact index (bii) and ipss quality-of-life (ipss-qol) subscores. safety was assessed using treatment-emergent adverse events. introduction and objective: diabetes has been reported as a major cause in patients who complain of erectile dysfunction and is frequent in the comorbidity of severe erectile dysfunction. also, patients with diabetes are oft en poor response to treatment for erectile dysfunction. in such patients, according to the mirodenafi l (mvix ) use of the odf (oral decomposition fi lm) mg and mg was to compare the therapeutic eff ects of the treatment period. of the patients with erectile dysfunction were enrolled in a patient with diabetes. and the patients were classifi ed into two groups by randomized double blind controlled trial. th e fi rst group was to take the mirodenafi l odf mg once a daily and the second group was to take a mg at least twice one week, depending on the need to have sexual intercourse. international index of erectile function- (iief- ), international prostate symptom score(ipss) were examined for each time of initial visit, weeks, weeks, weeks. th e questionnaire items of two groups were analyzed at each time point. total of patients were included in the study. th e patients who were taking once a daily were and the patients taking when needed were . th ere was no signifi cant diff erence between age, iief- score, and ipss of each groups on initial visit. ipss score and quality of life score was lowered gradually all aspects in the two groups. iief- score was a tendency to increase in all categories. in comparing the two groups at weeks, once a day group showed a signifi cantly higher score than the group taking when needed for the questionnaire of erection confi dence, erection times, iief- total score(p< . ). th ere was no diff erence between two groups at weeks, weeks. in addition, this study showed the similar therapeutic eff ect between the two groups at end point of continued treatment during the weeks. conclusion: aft er daily dose method weeks, at least twice weekly dosing method and daily dose method is determined to exhibit the same eff ect. th erefore, we think that it is possible to change the intermittent dosing from daily regimen aft er two months. introduction introduction and objective: phosphodiesterase inhibitors (pde i) are the established fi rst line therapy for most cases of erectile dysfunction(ed). it is estimated that - % of ed patients may drop out and discontinue the usage of these drugs. th is study aims to evaluate the patient perspective of discontinuation of on-demand tadalafi l mgm and switching to daily tadalafi l mgm for ed. th e study comprises men with median age years suff ering from ed of average . years duration. co-morbidities included: hypertension ( %), diabetes ( %), dyslipidemia ( %) and smoking ( %). th e primary indication for usage of on-demand tadalafi l mgm was ed. all the patients had used mgm tadalafi l on demand on more than occasions over the last months. results: th irty-eight out of men opted to discontinue on-demand mgm tadalafi l and switch to daily dose mgm tadalafi l. a detailed interview was conducted to identify the reasons for this switch over. th e salient factors were: ) unsatisfactory clinical response to on-demand dose ( %), ) adverse eff ects with on-demand dose ( %), ) concomitant improvement in luts ( %), ) economic factors-daily dose therapy is cheaper than on-demand ( %), ) freedom of spontaneous sexual activity with daily dose ( %), ) patient perception of daily dose as a long-term cure for ed ( %), ) combination of above factors ( %). overall % of patients planned to continue daily dose tadalafi l mgm. conclusion: daily dose tadalafi l mgm appears to be preferred by patients over on-demand mgm tadalafi l for ed treatment. and plateaued aft er two years. in % of men, iief-ef improved by category, in % by and in % by categories. five men remained within the same category despite slight improvements in score, man's score dropped from to changing from "no ed" to "mild ed". fift y six percent men achieved normal erectile function. conclusions: improvements in erectile function were clinically meaningful and signifi cant during the fi rst to years of t therapy and sustained during the full treatment duration. th ey were independent of obesity class. it may be necessary to continue t therapy for to years before an optimal response is achieved. hypogonadal conclusion: all changes were clinically meaningful and sustained for the full observation period, despite the fact that patients' age increased by years. t therapy seems to be highly eff ective in hypogonadal men with t dm, improving both erectile function and glycemic control. needle-free delivery of intracavernosal injections: proof of concept introduction and objective: intracavernosal injection is a well-established second line therapy for the treatment of erectile dysfunction (ed) and has shown very high success rates. despite this, intracavernosal injection is not a therapy suited to all patients for a number of reasons including needle phobia (trypanophobia), pain, and anxiety with self-needling. th e development of needle-free injectable devices has been heralded as a promising advance in the administration of certain vaccines and parenteral medications. initial research into the use of these devices in the delivery of intracavernosal injections however showed inferiority to needle-tipped injectors in terms of efficacy and pain scores. th e use of needle-free injection devices is not currently recognised for the administration of intracavernosal injections. it was the aim of our study to investigate the ability of contemporary needle-free injection devices to successfully deliver intracavernosal injections. two diff erent needle-free injection devices were used to inject . mls of methylene-blue solution into the corporal bodies of a number of australian brangus bullock penises; the bioject®ze-tajet™(spring-loaded fi ring system) and biojector® (pressurized co fi ring system) were used. both products are produced by bioject medical technologies inc., california, usa. all the available syringe depths were used for each device, and compared with the injection of the same volume of methylene-blue with an insulin syringe as a control. following injection, a cross-section of the penis was taken, and the depth of penetration observed macroscopically. results: despite the comparatively thicker and denser tunica albuginia of the bullock penis, the pressurized co device successfully delivered the solution into the corporal body, through the tunica. none of the syringes from the spring-loaded device penetrated the tunica. we have shown that contemporary needle-free injectable devices can in theory be used to administer intracavernosal injections successfully. th e bullock penis model may not be the ideal model for the human penis but we are currently in the process of performing human cadaveric experiments with these devices. needle-free injection devices may be very useful in the administration of intracavernosal injections in the future and extend the use of these therapies to a wider population of patients. penile linear shock wave therapy for poor responders to prior erectile dysfunction therapy ( ), ici with alprostadil ( ), vcd ( ) and muse ( ) . all these patients opted to discontinue these regimen due to unsatisfactory erectile improvement or side eff ects. th ese patients were treated with lswt by renova device with four weekly outpatient sessions without any analgesia or preparation. lswt was applied to four anatomical sites (right, left crura, and right, left corpus cavernosum) at shocks per minute, total shocks per session. patients were followed up at and months aft er the last session. results: at one month follow up statistically significant improvement in iief was recorded in patients ( %) from mean score of . at baseline to . .th e improvement was maintained at months .no side eff ect was noted. overall % patients expressed satisfaction with lswt irrespective of the clinical outcome. conclusion: lswt appears to be a safe and eff ective noninvasive, offi ce based therapy in the management of diffi cult to treat poor responders to prior treatment of ed. introduction and objective: hypogonadism and sexual dysfunction are common clinical presentation in male liver transplant candidate. th e aim of the study was to evaluate the eff ects of living donor liver transplantation (ldlt) on testosterone, sex hormone-binding globulin (shbg), free androgen index (fai) and erectile function in ldlt recipient. introduction and objective: penile size has been a source of major concern and anxiety to the male population since several years. diff erent methods for increasing penile size have been described in the literature, such as, pubopelvic liposuction, lipectomy, suspensory ligament dissection, z-plasty, v-yplasty and injections. combining some of these techniques may be more eff ective to improve the length of the penis. in this study, patients were underwent the combination of z-plasty and suprapubic lipectomy for increasing penile size. between and , patients who complained decreased penile size were underwent surgery. z plasty and suprapubic lipectomy were performed to each patient. informed consent was provided by all participants. th e outcomes were assessed based on the preoperative and postoperative penile length in the fl accid state at maximal stretch and patient-partner satisfaction. th e paired student t test was used for statistical analysis. results: median age of the patients was . ( - ) years. th e etiologies were congenital micropenis in ( %), concealed penis in ( %), previous penile surgery in ( %) and epispadias in ( %) patient. mean preoperative and postoperative penile lengths were . cm ( - cm) and . cm ( . - cm) respectively. th e mean increase in stretched penile length was . ± . cm (minimum . cm, maximum cm) (p< . ). th e patient and partner satisfaction rates were . % ( / ) and . % ( / ) respectively. only one postoperative complication was detected. th is was a wound infection at suprapubic incision site. conclusions: based on our results, the combining of the penoscrotal z-plasty and suprapubic lipectomy is a safety, eff ective and satisfactory procedure for lengthening of the penis in selected cases. corporal lengthening with infl atable penile implants : - ( ) ). recently, we have developed a new technique that combines key aspects of these approaches to create a minimally invasive, no-touch ("mint") technique for penile prosthesis insertion. we theorized that the mint technique would take advantage of the benefi ts that each of these established approaches off ered and therefore our aims were to assess feasibility, safety, post-operative hematoma and infection rate and percentage of patients cycling the prosthesis by weeks. th e principles of the mint technique involve a small infrapubic incision approach combined with a no-touch technique facilitated by using standard surgical drapes ( x clear non-adhesive drape and x ioban® drape) and an alexis® wound retractor. we present results for our fi rst consecutive patients undergoing primary prosthesis implantation from may -july with at least months follow-up. patients having revision surgery, or with complex surgery necessitating > incision were excluded. data was collected using a prospective database. results: average age (±sd) was . (± . ) years. median follow-up was . months. patients had one or more of the following etiologies for erectile dysfunction: vascular disease (n= ), post-radical prostatectomy (n= ), diabetes (n= ), peyronies disease (n= ), venous leak (n= ) and priapism fi brosis (n= ). seventy percent had used intracavernosal injections. implant used: coloplast titan (n= ), american medical systems (lgx; n = ), (cx; n = ). th e average (±sd) cylinder and rear tip extender length was . (± . ) and . (± . ) cms respectively. all operations were completed successfully and there were no peri-operative complications necessitating intervention or re-operation. th ere were post-operative hematomas (treated conservatively). sixty-fi ve percent could cycle prosthesis by weeks. th ere were no post-operative infections. conclusion: th e mint technique for penile implant surgery is a safe and feasible procedure with a zero infection rate in our fi rst patients. effi cacy and safety of botulinum th e initial number of patients to be recruited were twenty-six, but actual patient enrolment was eleven (six control and fi ve botulinum toxin a). all of the patients had a history of vulvar pain for more than six months despite proper medical treatments. patients were randomly assigned to two groups: control -saline injection, toxin -botulinum toxin a (meditoxin® injection, meditox, inc., korea). in both groups, areas of pain were mapped on the vestibule and injections were performed at fi ve sites to cover the entire painful area. th e dosage of each injection was - ml with a maximum cumulative total of ml. at baseline, two, four, and eight weeks aft er the injection, visual analogue scale (vas) and sf- questionnaires were scored. data was analyzed and p value was considered to be signifi cant at < . according to the mann-whitney test. results: th e mean age of patients was . ( - ) years old in the control group and . ( - ) years old in the toxin group. aft er breaking of the blinding, two of the toxin group had iu of botulinum injection, and the others had iu injections. two patients from the control group dropped out because of aggravated pain. th eir vas were and respectively at their drop-out point (baseline and , respectively). at week eight, vas was signifi cantly decreased in toxin group when compared with baseline (table ) . th ere were no drug related adverse reactions. introduction and objective: congenital anomalies of uro-genital system have increased globally as a consequence of higher maternal age at pregnancy and developments in assisted reproductive techniques in the last few decades. aim of the study was to determine the incidence of apparent congenital uro-genital anomalies in north indian newborns and factors associated with them. a prospective study was conducted to collect data of all newborns delivered at our institute between september and august . th e predetermined format included newborn's birth weight and gestational age, maternal age, parity and infertility treatment if any. newborns weighing less than gm or born before weeks of gestation were excluded from the study. results: th ere were , deliveries with , males and females. a total of apparent uro-genital congenital anomalies were recorded with an incidence of . per newborns. th e most common anomaly was cryptorchidism found in newborns, amongst others hypospadias was noted in , ambiguous genitalia in , congenital hernia/hydrocele in , exstrophy-epispadias complex in and prune belly syndrome in newborn. newborns weighing less than , grams had a higher proportion of anomalies ( . %) in comparison to those weighing over , grams having . % (p = . ). maternal age (> yrs), parity (> ) and infertility treatment were recorded in . %, . % and . % respectively and all were independently associated with increased risk of uro-genital anomalies (p= . ). conclusions: incidence of apparent congenital uro-genital anomalies was . %. infertility treatment, parity (> ) and maternal age (> years) were independently associated with increased risk of congenital uro-genital anomalies. comparison conclusions: double-breasting spongioplasty is very good method to decrease complications in hypospadias repair, so it is recommended an as interposing tissue in tipu. advantages of the double breasting spongioplasty are that avoiding of suture line and adding two layers of spongiosum over neourethra decreases the chances of urethral fi stula and gives cylindrical shape to neo-urethra. use stretched penile length (spl) is the standard measurement used in reconstructive penile surgery (rps), but is associated with high inter-rater variability, and is seldom reported. furthermore, ruler-based measurements require that all measurements be made intraoperatively; post-hoc measurements are diffi cult to impossible. we used a novel smartphone application to assess the correlation of post-op digital-photo based length measurements to intra-operative ruler measurements. th congress of the sociÉtÉ internationale d'urologie -siu abstract book materials and methods: intra-operative spl was measured in a consecutive series of pediatric patients undergoing rps who agreed to participate in this study. spl was measured intra-operatively (spl-io), and a picture was taken, with the ruler and from a true lateral view, as proof. a second digital picture was taken at the same time, with a reference object (obj) (object whose dimensions are known and constant). post-op, spl was later measured using the medmeasure! app for iphone and ios android, using the picture with obj, by two diff erent surgeons blinded to intra-op measurements. th e three diff erent measurements (intra-op spl (spl-io), and post-op using the app (spl-s -spl-s ) were then compared to assess overall correlation and correlation to ruler measurements using spss . statistical soft ware package. results: twenty consecutive patients underwent surgery for hypospadias (n= ), buried penis (n= ), epispadias (n= ) and circumcision accident (n= ). median age at surgery was months [ - ]. median penile spl-io was . cm [ . - . ]. when ruler-based measurements (spl-io) and app-photo based measurements were treated as independent measurements (students t test), there was no statistical diff erence between any of the three groups (p . - . ). even with spl-io measurements were treated as the gold standard, by bland-altman limits of agreement analysis, the correlation factor of spl-ip to spl-s & spl-s was > %. conclusions: when compared with intraoperative measurements, digital measurements using medmeasure! are reliable and precise, provided that the picture is taken from a true anterior-posterior or lateral view. because measurements are made based on captured images, a limitless number of length measurements (within the same plane as the reference object) can be made post-hoc. use of digital photography and this smartphone app has the potential to aid in surgical planning, improve documentation, and, facilitate clinical research. aseel's technique for distal penile and coronal hypospadius repair (simple, easy with less complications) introduction and objective: th is technique is modification of the old operation of arab that makes it very simple, easy to learn and even in cases of failure there will be no problem of redoing it or other operation because of the minimal tissue dissection. th is technique was applied in patients. first a transverse ventral incision is done parallel to the circumcision incision and cm proximal to the urethral meatus, figure ( ) . th en proximal and distal skin dissection is done, figure ( ). a longitudinal incision across the urethra plate extending through the meatus is done, figure ( ) and closed transversely that leads to urethral advancement, figure ( ). th en aided by skin hooks the distal skin edge is pulled downwards to create a roof for the advanced urethra, figure ( ) followed by closure of the skin incision, no catheter or stent is left , figure ( ). th is is a -minute operation and the patient is discharged as a day case. results: th irty-eight patients passed without complications and had loss of the skin stitches either partial in cases or complete in cases that were repaired by reapplication of the stitches, no meatal stenosis or fi stula were reported. th is is a very easy technique that can be applied as an outpatient or day case, and done in minutes, with no catheter or stent per urethra left or complications such as urethral meatus stenosis or fi stula formation. th e remained boys ( ) underwent transinguinal laparoscopy during ipsilateral herniorrhaphy. all data were collected prospectively. results: th e incidence of cppv confi rmed by transinguinal laparoscopy was . % ( / ). th e width of hernia sac and mother's age at birth were signifi cant risk factors in the univariate analysis. however, in the multivariate analysis the width of hernia (> cm) sac was only an independent risk factor for cppv (odds ratio . ; p= . ). th e laterality, type of hernia, age, preterm, low birth weight, twin, blood type, father's and mother's age at birth, and the type of delivery were insignifi cant. in this study the width of hernia sac was the independent risk factor for cppv. th is result suggests that the transinguinal laparoscopic examination is benefi cial for the detection of cppv in boys with this risk factor. however, it should be considered in the clinical practice that the one-third of boys with cppv has a narrowed width of hernia sac (< cm). low introduction and objective: traditionally bladder exstrophy complex is managed by staged repair, however now there is trend towards single stage repair. to achieve a satisfactory level of continence, secure abdominal wall closure and preservation of renal functions in patients with bladder exstrophy remains an elusive goal. objective of the study was to assess continence and functional outcome of single stage repair pediatric and adults. materials and methods: th irteen patients, boys and girls with classic bladder exstrophy were treated from to . aft er proper evaluation patients under went complete primary repair of exstrophy repair (ureteric re-implantation, bladder closure with or without cystoplasty, iliac osteotomy, neck reconstruction and epispadias repair). bladder and urethral plate was mobilized as single unit and bladder closure was done to create an adequate capacity bladder. epispadias repair was done by separating the two corpora; tubularization of urethral plate and ventral transposition of neo-urethra to create an orthotopic neomeatus. th en bilateral anterior iliac osteotomies were performed and external fi xators were applied to approximate the pubic symphysis which helps in sphincteroplasty. bladder neck was reconstructed using young dees technique and placed deep within the pelvis; sphincteroplasty was done followed by abdominal wall closure. voiding cysto-urethrography was obtained at months and at one year. continence was defi ned as dry intervals of hours or more. patients were followed-up at , , , months and annually. results: age of patients varied from days to years (mean . years). pre-operative symphyseal gap varied between - cm and post operatively the average diastasis was . cm with the range of cm to cm. in a follow-up period was months to years, patients had good results ( girl and boys) minor supra-pubic leak was present in patients which was managed conservatively, all being able to hold urine for - hours with no leaking at night. colo-cystoplasty was needed in cases with small bladder plate. overall continence rate was . % in single stage. two male incontinent patients were continent aft er second surgery. conclusions: single stage complete bladder exstrophy repair is safe and viable option for both pediatric and adult cases. augmentation enterocystoplasty is required in small bladder capacity cases. anterior iliac osteotomy with approximation of pubic symphysis improves continence and allows tension free closure of abdominal wall and sphincter. long wilms tumor (wt) represents approximately six to seven percent of all pediatric cancers and accounts for more than percent of all tumors of the kidney in the pediatric age group. recently some centers have explored the role of nephron sparing procedures in children with unilateral wilms tumors because of the concern about late occurrence of renal dysfunction aft er unilateral nephrectomy. we assessed the long-term renal functional outcome aft er parenchymal-sparing procedure for non-syndromic unilateral wilms tumor at our center. we retrospectively reviewed the records of all children with unilateral wilms tumor who had undergone nephron sparing surgery at our center. patient's long-term renal function, tumor recurrence, and survival, were determined from a review of each patient's medical record. results: a total of eight patients underwent partial nephrectomy (pn) and the remaining three with polar tumors underwent hemi-nephrectomy (hn) following chemotherapy. smaller tumor volumes were associated with not only preservation of renal function but also increase in egfr during the follow-up period. th e median preoperative egfr was ± . and median egfr at the last follow-up was . ± . . in properly selected children with non-syndromic unilateral wilms tumor, nephron sparing surgery provides excellent renal function preservation. introduction introduction and objective: hyperbaric oxygen (hbo) therapy, which increases the amount of oxygen dissolved in the blood and that carried to tissues, is used in the treatment of several disorders. hbo therapy may be a useful adjunctive treatment in the management of some of challenging conditions encountered in pediatric urology practice. in this paper, we report our experience on the use of hbo therapy in children with urologic problems. we reviewed our department's records to identify pediatric patients who received hbo therapy between and . all patients were evaluated at the department of underwater and hyperbaric medicine and informed consent was obtained from the patient or his parents. total number of hbo sessions was determined based on patient's clinical response to hbo therapy. results: eleven patients received hbo therapy during the study period. all of them were male. th e mean age was . ± . ( - years) . indications of hbo therapy were necrosis aft er hypospadias and epispadias repair, penile glans necrosis, circumcision caused penile skin necrosis, sickle cell crisis induced priapism, and testicular torsion. th e average number of hbo sessions was . ± . ( - ). nine patients ( %) healed aft er hbo therapy, but ( %) patients did not (table ) . . th e essential parameters of kegel exercise are duration of contraction and active relaxation, and, frequency of exercises. to date, exercise duration times could only be captured during in-clinic biofeedback. we hypothesized that a smartphone-based app that provides users biofeedback -and reports mean duration of contraction and relaxation, could help return to continence aft er rp. we designed/made a working prototype of such an app, and validated it. our novel app (ios) was programmed to allow users to record the duration of kegel active pfm contraction and relaxation. it also allows users to record urinary frequency, urgency, voiding, and leakage events, and number of pads used-on a daily basis. it contains a -q visual analog scale questionnaire that queries satisfaction (urinary, sexual, erectile), pain control, depression, sleep quality, and quality of life. data from the app can be "pushed" automatically by the user to a queryable custom database on a hipaa-secure server (ucsf). we provided the app to non-medical colleagues ( women/ men age - ) for evaluation. all completed mock kegel exercises using the app to measure contraction/relaxation duration, which were timed using a stopwatch. measured times were compared to duration times recorded in our database for each user. a -point likert scale was used to query the following items: ) user reported ease of use; ) privacy related anxiety related to use of such an app to submit study data wirelessly; and ) perceived usefulness of the app to improve kegel performance. results: th e pfm contraction and relaxation times recorded by the app within the wireless database disagreed with stop-watch measured duration times by mean +/-< second for all subjects. mean likert scores: . "overall ease of use" score = . (sd . ), "privacy related anxiety" score = . (sd . ), and "usefulness"= . (sd . ). conclusions: our novel smartphone app appears to allow users to accurately record key kegel exercise parameters: duration and progress. th e platform also allows collection of key patient data during daily life. a randomized controlled clinical study is warranted to further assess clinical utility, and, possible means to further enhance utility and research. safety and effi cacy of reduced dose of botulinum toxin-a for patients with detrusor overactivity place j, vyas l, watcyn-jones t, lupton b, miah s, darrad j, kumar v introduction and objective: th is prospective study was carried out to look at the response of a lower dose of botulinum toxin-a for treatment of symptoms of oab, its tolerability and side-eff ects. materials and methods: following due counselling and consenting, all newly diagnosed patients with confi rmed detrusor overactivity on uds (n= , with a mean age of . years (range= - )) were given iu of trigone-sparing, intra-detrusor botulinum toxin-a. of the total of patients, ( . %) were males and ( . %) were females. of this cohort, . % stopped anticholinergic medications because of lack of benefi t. th e rest ( . %) could not tolerate the side eff ects. th e procedure was performed in outpatient department using a fl exible cystoscope under local anaesthetic. th ese patients fi lled up a pre-treatment iciq-sf for oab as well as ui and follow-up scores at week , and . th e per-procedural pain score and follow-up urinary residual volumes were recorded. results: two ( . %) patients did not respond to the treatment at all. in the responders, average scores from the iciq-sf questionnaire fell from the pre-treatment level of . ( - ) to . ( - ) at week , . ( - ) at week and . ( - ) at week (p< . ). th e urgency incontinence scores fell from an average pre-treatment level of . ( - ) to . ( - ) at week follow-up. th e average daytime urinary frequency scores fell from . to . and nocturia scores fell from . to . . five patients went into urinary retention following intra-detrusor botulinum toxin-a injections. in the rest of the cohort, post void residuals remained largely unchanged with pre-procedure fi gure of . mls ( - ) to . mls ( - ) (p=ns). average pain score was . ( - ) on a scale of to . no symptomatic uti was found in post procedural patients. conclusions: th ese results albeit with a small number of cases, have suggested a signifi cant clinical response in over % patients with proven detrusor overactivity with a reduced dose of intra-detrusor botulinum toxin-a injections, thereby maintaining the clinical eff ectiveness of the drug and at the same time reducing the cost of delivery with possibly reduced incidence of urinary retention. prior to the initiation of intravesical onabotulinumtoxina treatment, all patients had an assessment of mid-stream urine for culture and sensitivity, renal tract ultrasound scan, subjective and objective assessments of symptoms (including iciq-ui and iciq-oab questionnaires) and conventional urodynamic study. all patients had proven overactive bladder. onabotulinumtoxina effi cacy and durability was assessed by subjective and objective assessments of symptoms. results: duration of effi cacy of onabotulinumtoxi-na injections is well maintained in the idoa group in comparison with noab group. th ese trends are shown in figure . four injections out of administered in total to the idoa group were unsuccessful ( . %) and brought no relief of symptoms to the patient. th ere were no unsuccessful treatments in the ndoa group ( / total injections administered). results: from the general practitioner's records, none of the non-traceable patients were on botulinum toxin-a treatment elsewhere. of the total number of traceable patients (n= ), ( %) stayed on mirabegron alone. of these % were satisfi ed ( / ). as a whole . % ( / ) were satisfi ed and continued with mirabegron only. one patient moved to combined mirabegron with an anticholinergic. of the patients on mirabegron iciq-sf scores fell from . ( - ) to . ( - ) at months. eighteen of ( %) patients progressed requiring botulinum toxin a treatment. side-eff ects included-palpitations ( ), vomiting ( ), rashes ( ), lethargy ( ) and yellow urine ( ) . th is study showed that % of patient with refractory oab symptoms awaiting fi rst or subsequent treatment with intra-detrusor botulinum toxin a injections will respond to mirabegron and % of these responders ( . % of total) are able to come off botulinum toxin a at months, reducing the burden of the waiting list; with a cost reduction mirabegron= £ vs cost of botulinum toxin a= £ /year/patient. th is is a small study but provides a medium-term option for patients on long waiting list for botulinum toxin a thereby helping to limit use of botulinum toxin-a for patients with detrusor overactivity. introduction and objective: patients that fail to achieve symptom improvements with sacral neuromodulation (snm) may benefi t from increased aff erent stimulation via tined lead placement at the pudendal nerve. we evaluated −year outcomes of chronic pudendal neuromodulation (cpn) in patients that had failed sacral neuromodulation (snm). adults enrolled in our prospective observational neuromodulation study that had a pudendal lead placed were evaluated. medical records were reviewed. outcomes were measured at , , and months with interstitial cystitis symptom/problem indices (icsi−pi), overactive bladder questionnaire (oabq) symptom severity (ss) and quality of life (qol), voiding diaries, and global response assessments (gra analysis of voiding dysfunction after transobturator tape procedure for stress urinary incontinence introduction and objective: voiding dysfunction is common complication of midurethral sling surgery (mus) for stress urinary incontinence. however, the defi nition of post-mus voiding dysfunction is inconsistent in the literature. subjective feeling of slow stream, signifi cant postvoid residual (pvr), additional procedure for bladder emptying, or objective fl ow rates can be a yardstick of voiding dysfunction. in this study we retrospectively investigated the risk factors for post transobturator tape procedure (tot) voiding dysfunction applying various defi nitions in one cohort. four hundred fi ft een patients were evaluated who underwent tot. preoperative urodynamic study were performed and urofl owmetry and international prostate symptom score questionnaire were investigated pre and post-operatively. several postoperatively parameters representing voiding dysfunction were adopted for analysis. acute urinary retention requiring catheterization (aur), subjective feeling of voiding diffi culty during follow-up (vd), and signifi cant postoperative pvr greater than ml or more than % of voided volume (pvr) were adopted for categorization of the defi nition of voiding dysfunction. results: sixteen patients ( . %) required catheterization, ( . %) experienced post-operative voiding diffi culty, ( . %) and ( . %) showed low fl ow rate and signifi cant pvr. in the aur and vd category, concomitant co-operation and general anesthesia were signifi cant parameters, especially anteroposterior repair of vagina. older and menopaused patients complained subjective voiding diffi culty. th e patients in vd category showed lower fl ow rates and larger pvrs. patients in pvr category had old age and low preoperative fl ow rates. th e patients with vd tend to be prescribed alpha blocker during postoperative follow-up period. th ere were no signifi cant urodynamic parameters attributing for various voiding dysfunction categories. with logistic regression analysis aur, vd and pvr category had concomitant co-operation and preoperative retention history as risk factors. conclusion: several factors including preoperative voiding symptoms and intraoperative parameters such as co-operation may aff ect postoperative voiding dysfunction. th e diversity in clinical presentation underscores the importance of a high clinical suspicion with an appropriate diagnostic evaluation. subjective and objective voiding dysfunction should be evaluated aft er midurethral sling operation. introduction and objective: some have hypothesized that patients with lower functional bladder capacity (fbc) experience less improvement in symptoms after staged neuromodulation procedures. th erefore, we evaluated the impact of baseline fbc on generator implant rate and symptom changes. adults enrolled in our prospective observational neuromodulation study were evaluated. functional bladder capacity (fbc) was defi ned as average volume per void on day voiding diary. data were collected from medical records, and validated interstitial cystitis symptom/problem indices (icsi−pi) and overactive bladder questionnaire (oabq) symptom severity and health related quality of life (hrqol) domains, and examined with descriptive statistics, wilcoxon rank sum tests, logistic regression, and spearman correlation coeffi cients. results: of patients (mean age . ± . years; % female), most had urinary urgency/frequency with or without urge incontinence ( %) and a sacral lead placed ( %); % had the lead placed at the pudendal nerve. mean fbc at baseline was . ± . ml. among the , ( %) had ≥ % improvement in overall symptoms aft er lead placement with subsequent generator implant. baseline fbc was similar between implanted/not implanted patients (p= . ), however implanted patients had a median . % increase in fbc aft er lead placement compared to explanted patients whose fbc decreased by median . % (p= . ). logistic regression identifi ed a strong relationship between percent change in fbc aft er lead placement and generator implant (p= . ) but there was no relationship between baseline fbc (ml) and subsequent generator implant. at months, a lower pre-implant fbc weakly predicted a greater improvement in oab-q hrqol from baseline (p= . ; r = - . ). fbc (ml) at baseline, or percent change in fbc aft er lead placement, had no relationship with achieving at least % improvement in icsi−pi or oab−q symptom severity scores at months. conclusions: lower baseline fbc should not be a contraindication to neuromodulation since there was no impact on outcomes. improved fbc aft er lead placement may have contributed to overall improvements in symptoms leading to generator implant. improvement in fbc was equal to or greater than that seen in medical treatment trials for oab. introduction and objective: to present our preliminary experience with the sars (sacral anterior root stimulator) in spinal cord-injury patients with hyperactive bladder at our center. th e sars is an implantable electronic device that allows patients with spinal cord injury to assume voluntary control of micturition, defecation and erectile function. it involves a s -s dorsal (sensitive) rhizotomy and placement of electrodes around those roots, which are connected to a subcutaneous receiver antenna. by transcutaneous radiofrequency stimulation of that antenna the patient can selectively use stimulation programs to activate the diff erent functions: program for micturition, program for defecation and program for erection. results: between january and november nine sars implants (eight men and one woman) were performed in patients with spinal cord injury-related overactive bladder refractory to standard conservative treatment. average age was years and mean follow-up was months (range - ). bladder function: eight of the nine patients exhibit an increase of the bladder capacity and use the device - times daily, voiding - cc with ≤ cc residual urine. one of these patients showed de-novo postoperative stress incontinence due to sphincter incompetence that was solved with placement of a suburethral sling. th e ninth case had a poor compliance and low capacity bladder; despite sars, he failed to increase capacity and persisted incontinent so aft er months he underwent a continent urinary reservoir. voiding objectives were therefore achieved in / patients ( % success). defecation: all patients use the device once a day. erectile function: of the eight male patients, seven achieved erection with sars. however, this erection was not always reliable for intercourse; patients associate sildenafi l and eventually requested a penile prosthesis implantation. complications: th ere were no postoperative complications or failure of the internal components. one patient showed a transient s neurapraxia, which resolved spontaneously aft er months. conclusion: in selected spinal cord injury patients, sars is an excellent option for urinary and defecatory control, being also useful for erectile function in some of them. how to determine the complication rate of urolastic (vinyl dimethyl polydimethylsiloxane, pdms), a bulking agent for female stress urinary incontinence. twenty-eight females with stress urinary incontinence were treated with pdms. th e group mainly consisted of secondary patients (n= ), with extensive comorbidity. six patients had one previous surgical procedure for sui; nine underwent two procedures and ten received three or more interventions. an amount of . - . ml of pdms was injected at - positions paraurethrally at the midurethra. procedures were performed on the outpatient department, with local anaesthesia. th e clavien dindo score was determined aft er months, to assess the severity of the complications encountered. results: aft er six months, % ( / ) of the patients reported a % improvement, % ( / ) a - % improvement and % ( / ) a - % improvement, % ( / ) reported % improvement and % ( / ) was % improved. six patients ( %) had no improvement aft er six months, four of which had also not shown initial improvement. in one patient the implants were removed during surgery, so no follow-up was available. of twenty-eight patients treated, % ( / ) had no complications. in % ( / ) complications were seen, which were classifi ed following the clavien dindo-classifi cation. a score of i was appointed to % ( / ) of the patients. reasons were: implant-exposure, minor pain, anti-emetics use or de novo retention. th ree patients had a score of ii, because of more severe complaints of pain or urge. th ey were treated pharmacologically. in % ( / ) one or more implants were removed, mostly due to exposure, erosion or pain. removal under local anaesthesia was performed in % ( / ) of the patients and this resulted in a iiia-score. th ree patients ( %) had a iiib-score, which meant the implant(s) were removed under general anaesthesia. in the fi rst twenty-eight diffi cult to treat patients receiving pdms, in ten cases a clavien dindo grade ii-iiib is scored, mainly because of surgical removal of implants. in spite of the seemingly high complication rate, this remains a useful therapeutical option for female stress urinary incontinence. magnetic stimulation for stress urinary incontinence: a randomized, double-blind, sham-controlled trial introduction and objective: we conducted a multicenter, randomized, double-blind, sham-controlled trial to evaluate the effi cacy of magnetic stimulation (ms) for stress urinary incontinence (sui). a total of sui subjects were randomized : to active or sham ms for eight weeks (twice weekly). th e primary criterion for response was a reduction of points or more in the international consultation on incontinence questionnaire for urinary incontinence-short form (iciq-ui sf). th e secondary outcomes included objective (leakage of less than gram on -hour pad test) and subjective cure (a 'never' response to 'how oft en do you leak urine?), incontinence diary, pelvic fl oor muscle strength, urofl owmetry, patient global impression of improvement (pgi-i) and international consultation on incontinence questionnaire-lower urinary tract symptoms quality of life (iciq-lutsqol). results: using the primary criterion, ( . %) of subjects were treatment responders in the active group compared to ( . %) of subjects in the sham group (relative risk (rr) . , % ci . - . , p< . ). based on objective cure, ( . %) subjects in the active group were dry versus ( . %) subjects in the sham group (rr . , % ci . - . , p< . ). nineteen ( . %) in the active group and ( %) subjects in the sham group perceived themselves as dry (rr . , % ci . - . , p< . ). th e active group had greater reductions (p< . ) in incontinence frequency than the sham group. changes in pelvic fl oor muscle strength and urofl owmetry parameters were not statistically signifi cant between groups (p> . ). th irty-nine ( %) subjects in the active group reported signifi cant benefi ts (much/very much better) for pgi-i rating compared to ( . %) subjects in the sham group (p< . ). all item scores in iciq-lutsqol were not statistically diff erent (p> . ) except 'eff ect on friends' , 'smell' , feeling of embarrassment' and 'overall impact' in the active group. of all evaluable subjects, ( . %) of subjects in the active group and ( . %) of subjects in the sham group experienced adverse events (p= . ). conclusions: modifi ed tvt abbrevo is a simple, safe and eff ective procedure with comparable short-midterm cure rates to standard tvt abbrevo. th e modifi cations of avoiding the tunnelling device and groin exit helped to minimize the groin pain and analgesic requirements. evaluation of standard practice for artifi cial urinary sphincter implantation auckland dhb, auckland, new zealand; ucd medical center, sacramento, usa introduction and objective: th e artifi cial urinary sphincter (aus) has been available since and over this time it has established itself as the gold standard in management of post prostatectomy incontinence. th e successes, failures and diffi culties are well documented, however little is published regarding the standard implantation practice of the aus. our objective was to review the standard practice for implantation of the aus within a group of high volume implanters. aft er obtaining institutional review board ethical approval a web-based questionnaire was designed using survey monkey soft ware. an email was sent to the current members of the society of genitourinary reconstructive surgeons (gurs) explaining the aims of the confi dential questionnaire with a web link to the aforementioned questionnaire. all results were collected via survey monkey and were then analyzed. results: one hundred and twenty gurs members were contacted by email, members replied. th is group averaged aus placements a year (range to ). pre-operative assessment utilized routinely included pad weights in . %, pad numbers in . % and urodynamic studies in % of participants. additionally % of participants surveyed would routinely perform a cystoscopy in the pre-operative assessment ninety four percent of those surveyed used greater than one pre-operative antibiotic; most commonly gentamicin with either vancomycin or cefazolin. th e antibiotic most commonly utilized alone was levofl oxacin. post-operatively % continue antibiotics anywhere between hours and month, with % continuing intravenous antibiotics for a minimum of days. intra-operatively % have aus componentry prepared on a separate set up stand. th e single cuff aus, size . and . cm cuff were the most commonly placed cuff s, with the - cm reservoirs. radio-opaque contrast is used by % of participants in the aus reservoir. only % of participants would recommend a medical alert bracelet in the post-operative period, and % encourage pump traction. conclusion: despite a uniform technique recommended for the implantation of the aus by american medical systems in order to improve success and decrease complications, there is great heterogeneity in pre-operative assessment, surgical placement and post-operative management of the aus in a cohort of high volume implanters. patients presenting to a multi-disciplinary stone clinic were administered a survey. th ey were asked to elect a treatment modality from shock wave lithotripsy (swl), ureteroscopy (urs) or percutaneous nephrolithotomy (pcnl) for a hypothetical mm kidney stone. th e success rates ( % swl, % urs and % pcnl), morbidity and the risks associated with each treatment options were explained. patients were also to elect whether personal or doctors' decision of treatment is most preferred and the most important variable in deciding a choice of treatment modality. results: of the respondents with mean age . ± . , female/male ratio was : ( figure ). majority of the subjects ( %) elected urs as their treatment choice (table ) . previous experience with urs (p= . ) and pcnl (p= . ) impacted the choice of urs. th e respondents were equally distributed in their primary concern being success rate ( %) versus risks ( %) associated with the procedure of choice (p= . ). age and gender has no infl uence on treatment choice (p= . and p= . ) and on whether the primary concern is success or risk (p= . and p= . respectively). majority ( %) of the surveyed population would prefer the physician recommend the appropriate treatment. conclusion: th ough patients prefer the physician to recommend the appropriate treatment for a medium-sized renal stone, it is important for the physician to consider the patient's priorities of minimizing risk versus maximizing success. as such, majority of patients selected ureteroscopy as a procedure with a balance of moderate risk and moderate success. solo introduction and objective: sonography has been brought in percutaneous nephrolithotripsy (pcnl) as an adjunct to x-ray to restrict radiation exposure. th is study was designed to respond this question that "is sonography proper enough to supersede x-ray in pcnl under spinal anesthesia?" moreover, we investigated possible predictors of success. tract infection were excluded from study. th e intraand post-operative surgical outcomes were evaluated. results: th e mean age of the patients was . ± . years. mean stone size was . ± . cm. mean access and operative time were . ± . and ± . minutes respectively. superior calyx was selected for access in % of patients. th e patients were categorized in following groups; history of more than one section previously open stone surgery ( %), horseshoe kidney ( %), major lumbosacral deformity ( %), failed standard pcnl ( %), children under years old ( %), pregnancy ( %). th e primary complete stone free rate was %, and aft er ancillary procedures (urs, swl), raised to %. th e mean hemoglobin drop was . ± . gr/dl. transfusion needs in patients. signifi cant prolonged or delay hemorrhage was not shown in any cases. pneumothorax was detected in one patient that managed with chest tube insertion. visceral or solid abdominal organ injury was not occurred. conclusion: with some attention, the outcomes of ultrasonography-guided pcnl for challenging renal stones are comparable with standard fl uoroscopic approach, and in some situation, fl ank position contain benefi ts rather than standard prone position. study of ten cases of p.c.n.l in "previously operated kidney stone with incisional hernia" conclusions: p.c.n.l in incision hernia patient is a safe procedure with excellent results. c.t. urogram is necessary tool for puncture. st puncture in virgin fi eld (out of incisional hernia site) and avoiding colonic gas shadow on fl uoroscopy is key point. bowel injury is the concern -which should be taken care during puncture. daycare pcnl: now a reality! introduction and objective: pcnl as a therapy for renal stones is an established modality. th e use of holmium laser has led to miniaturisation of instruments and sheaths and has thus made the procedure less morbid. a stage has come for the patient to now leave hospital on the same day of the procedure. materials and methods: all cases were done under spinal anaesthesia and prone position. aft er placing a retrograde ureteric catheter, pcs was accessed through the appropriate calyx, and a french sheath with suction capability was used. holmium laser was the energy used. aft er fragmentation, clearance was achieved by a combination of suction and retrograde wash and confi rmed radiologically and visually. clots were fl ushed out through the sheath which was then removed having retained the guide wire. finger pressure on the puncture site achieved haemostasis. th e guide wire and the retrograde catheter were fi nally removed. no urethral catheter was kept. a total tubeless procedure in the real sense. all patients were counselled about haematuria and pain. results: from january to march , a total of cases are included comprising renal and upper ureteric stones. stone size ranged from . to . cms. age ranged from to yrs. th e m/f ratio was : . operative time ranged from to mins. th ere was no signifi cant blood loss. all patients received dose of a parenteral analgesic hrs post procedure, were ambulant hours postopt and were allowed oral liquids. patient had leak at puncture site lasting for hours .all had haematuria which cleared completely within to hours. all were off ered discharge on the same day without any major event. one patient had clot retention on the th po day requiring clot evacuation. conclusion: pcnl as a day care procedure has been achieved by the above described method. patient acceptance is fair though most showed apprehension of going home the same day aft er a major procedure. whether it can be accepted universally remains to be seen. initial experience in ultraminiperc we have reviewed our initial experience of ultra-miniperc-ump in patients. between june and march , total patients underwent ultra-miniperc. puncture and dilatation were done under fl uoroscopy in prone position. we used and fr ump amplatz. stones were fragmented by holmium laser and removed by whirlpool eff ect. post-operative stone-free status was confi rmed by ultrasonography and x-ray aft er week. results: mean patient age was years ( to years) and male to female ratio was . : . in % the procedure was bilateral simultaneous and in % in solitary kidney. stone locations were lower calyx ( %); upper calyx ( %), middle calyx ( %), renal pelvis ( %), upper ureter ( %) and rest were at multiple sites. calyx punctures were lower ( %), upper ( %), middle ( %) and multiple in rest. eight punctures were supracostal. mean operative time from puncture to amplatz removal was minutes (range to minutes). signifi cant bleeding (hb drop more than . gm/dl) was in %. all were managed conservatively without transfusion. dj stents were kept in patients. nephrostomy-tube was not kept in any patient. eleven percent of patients had minor complications like pleural eff usion ( %), uti-fever ( %), and mild hematuria ( %). all were managed conservatively. one patient required conversion to miniperc- fr track due to intraoperative poor vision. mean hospital stay was days ( - days). th ree patients required readmission for fever or clot colic. stone-free rate was %. eight percent had small fragments that were treated by oral hydrotherapy. two patients were treated by eswl. introduction and objective: a prospective randomized controlled study was executed to compare minipercutaneous nephrolithotomy (miniperc) and retrograde intrarenal surgery (rirs) in the management of renal stones larger than mm in a single session. between june and february , patients presenting with renal stones > mm were randomized to a miniperc or a rirs group in a ratio of : . randomization was performed by a biostatistician and opened to the surgeon at the time of the patient's admission on the day before surgery. patient and stone characteristics, perioperative outcomes, and complications were compared between the two groups. th e primary end point was "stonefree", which was defi ned as no residual stone or stones < mm on computed tomography within months postoperatively. results: th irty-fi ve patients (miniperc) and (rirs) were included in the fi nal analysis. th ere were no statistically signifi cant diff erences in stone size ( . ± . versus . ± . mm, p= . ) and stone number ( . ± . versus . ± . , p= . ) between the miniperc and rirs groups. laterality, mean hounsfi eld units, stone location, presence of staghorn stone, and stone composition were similar between the both groups (p> . ). miniperc and rirs had stone free rates of . % and . %, respectively (p= . ). operation time ( . ± . versus . ± . minutes, p= . ), hemoglobin drop ( . ± . versus . ± . g/dl, p= . ), and hospital stay ( . ± . versus . ± . days, p= . ) were similar between the two groups. pain visual analogue score at hour postoperatively ( . ± . versus . ± . , p= . ) and analgesic requirement ( . % versus . %, p= . ) were lower in the miniperc group. two patients in the miniperc group and in the rirs group had minor pelvic or ureter perforation. one patient in each of both groups had hypertension and urinary tract infection. miniperc and rirs are safe and feasible surgical options for managing renal stones larger than mm. rirs had a little higher stone free rates, but more immediate postoperative pain and higher analgesic requirement compared with miniperc. colonic perforation during percutaneous nephrolithotomy darabi mahboub m, aslzare m, shakiba b introduction and objective: percutaneous nephrolithotomy (pcnl) is the treatment of choice for large, extracorporeal lithotripsy failure stones and those in the inferior calyx. despite the development of new techniques and the increasing experience in recent decades, complications may still occur. colonic perforation is one of the most dangerous and rare complications of pcnl, which may lead to peritonitis and sepsis. we present our -year experience on the diagnosis and management of colonic perforation during pcnl. we retrospectively reviewed the data of pcnl procedures performed between may and august . preoperative and operative factors, such as age, sex, history of previous ipsilateral stone intervention, stone side, stone location, site of skin puncture and punctured calyx, were reviewed in patients with colonic injury. results: colonic perforation was found in patients ( males and females) and the mean age was . ± . years (range: to ). all injuries were retroperitoneal. th e left side was aff ected in patients and the right side was injured in cases. conservative management was the treatment planned for all patients. it included withdrawal of the nephrostomy tube outside the kidney to the colon as a percutaneous colostomy, insertion of a double-j ureteral stent, intravenous broad-spectrum antibiotics, bowel rest and total parenteral nutrition. under this conservative management, complete healing of the colon was achieved in all patients. early diagnosis and conservative management of colonic perforation can minimize patient morbidity and mortality and result in excellent healing of the fi stulous tract without any serious complications. colon materials and methods: during ten years, pnl procedures performed in our center. extraperitoneal colonic perforation complicated procedures. all cases were managed without any tube in the colon. we took a retroperitoneal drain through pnl tract and a double-j stent inserted in all cases. we reported the results of our cases that managed without colostomy tube. results: male to female ratio was / . th e diagnosis was established aft er nephrostomy tract dilation and nephroscope insertion before lithotripsy in two cases and in other cases, at the end of nephrolithotomy during amplatz sheath removal. conservative treatment was successful in all cases. mean hospital stay was / days. th ere wasn't any fever or other major complication. conclusions: it seems that management of retroperitoneal colonic perforation when diagnosed intraoperatively during tubeless pnl without colostomy tube is safe and eff ective. does intercostals nerve block and peritubal nerve block with bupivacaine reduce post-operative pain after percutaneous nephrolithomy? introduction and objective: to fi nd the most eff ective post-operative analgesia method aft er percutaneous nephrolithotomy (pcnl). in a prospective, -months duration study all patients undergoing pcnl (tubeless or with -f nephrostomy) were divided into groups. group (pcnl in fi rst- -months) had no intervention; group (pcnl between and months) received intercostal block (icb) with . % bupivacaine; group (pcnl in last -months of study) had peritubal track infi ltration (pti) with . % bupivacaine at end of procedure. visual analog pain scores and rescue analgesia requirements at , , and hours in the arms were compared. results: see table . conclusions: peritubular tract infi ltration with bupivacaine established its superiority over both intercostal block and standard pcnl for post-operative analgesia and rescue analgesic requirements. the post-operative fever was defi ned as body temperature above . within hospital stay. relationship between clinical factors and sirs or post-operation fever was assessed using logistic regression analysis. results: a total of male ( . %) and female ( . %) were enrolled in our study (table ) . forty-fi ve cases ( . %) developed sirs and fever was observed in cases ( . %). shock was observed in ( . %) cases. in univariate analysis, stone size (p = . ) and urine wbc (p = . ) were found to be the predictors of sirs. in multivariate logistic analysis, stone size (or= . , p= . ) and urine wbc (or= . , p= . ) were signifi cantly related to the development of sirs (table ). in univariate analysis, post-operative fever was found to be associated with the location of stones (p= . ), stone size (p= . ), urine wbc (p< . ) and albumin (p= . ). by multivariate logistic regression analysis, only stone size (or= . , p= . ), urine wbc (or= . , p= . ) and serum albumin (or= . , p= . ) were associated with post-operative fever (table ) . conclusion: patients with larger stone size and urinary tract infection before surgery might have higher risk of developing sirs and fever, while a normal serum albumin was found to be the protective factors of fever development. introduction and objective: perioperative hemorrhage owing to high vascularity in bph is the fearsome complication of turp that leads to clot retention, reoperation and oft en requiring blood transfusion. finasteride, a type α-reductase inhibitor, by interacting with vascular endothelial growth factor (vegf), reduces prostatic angiogenesis. microvessel density (mvd) is a histological measurement of angiogenesis and thus a marker of bleeding. we aim to determine the eff ect of two weeks preoperative fi nasteride therapy in reducing prostate vascularity in terms of mean microvessel density (mvd) and expression of vegf in prostate urothelium among patients of bph by comparing with controls. trial has been conducted in department of urology at shifa international hospital islamabad from jan to jan . total patients of benign prostatic hyperplasia (bph) planned for transurethral resection of prostate (turp) having prostate sized of more than grams on trans-abdominal ultrasonography were randomized into two groups each group having patients. th e finasteride group (group a) was prescribed oral mg of fi nasteride daily for weeks before surgery. th e control group (group b) didn't receive any drug. aft er weeks, turp was performed and prostate chips were sent for histopathological determination of mvd and expression of vegf. results: mean age . ± . years, ranging from minimum of years to years. th e mean prostate gland size was comparable in both groups ( ± . grams vs. . ± . grams). mean mvd in fi nasteride group was . ± . whereas in control group mean mvd was . ± . . when compared the mean mvd in both group, the mean mvd was signifi cantly low in fi nasteride group as compared to control group with a p= < . . similarly mean expression of vegf was % in fi nasteride group compared to % in control group. th is expression of vegf was also signifi cantly lower in fi nasteride group as compared to control group (p= . ). also mean mvd was clearly correlated with size of prostate gland and the correlation was found statistically signifi cant on pearson correlation test ( -tailed) with p= . . conclusion: finasteride reduces microvessel density and hence prostate vascularity with only week therapy and the mean mvd is clearly correlated with size of prostate. characteristics -alpha reductase inhibitor induced prostate volume reductions yun j , yang h , kim d , jeon y , lee c introduction and objective: benign prostatic hyperplasia develops in the transition zone of the prostate and α-reductase inhibitors ( -aris) reduce prostate volume. we investigated whether oral treatment with the -aris dutasteride and fi nasteride more significantly aff ected volume reduction in the transition zone or in the entire prostate. total prostate and transition zone volumes (tpv and tzv) were measured at baseline using a transrectal ultrasound (trus) and then at yr aft er the commencement of dutasteride ( . mg) or fi nasteride ( . mg). th e ratio of tpv to tzv was used to determine the transition zone index (tzi). volume reduction (%) was calculated as the ratio of volume reduction to baseline prostate volume. additionally, serum prostate specifi c antigen (psa) concentrations were measured at baseline and then at yr aft er the -ari were commenced. results: all of the patients (mean age, . yr ± . ; range, - yr) with clinical lower urinary tract symptoms suggestive of benign prostatic hyperplasia and who were -ari naïve were prescribed dutasteride ( . mg, . %, / ) or fi nasteride ( . mg, . %, / ) for more than yr ( . ± . mos). at baseline, the mean tpv, tzv, and tzi values were . ± . cm , . ± . cm , and . ± . , respectively. at yr aft er the commencement of the -ari, the mean tpv, tzv, and tzi were . ± . cm , . ± . cm , and . ± . , respectively. th e tzi value is not signifi cantly diff erent at yr compared with baseline (p > . ), while the tpv and tzv reductions are . ± . % and . ± . %, respectively; there is no signifi cant diff erence between the tpv and tzv volume reductions (p> . ). conclusion: th ese results show that prostate volume reduction induced by -aris occurs in the entire prostate universally, rather than in the transition zone specifi cally. russo g, favilla v, privitera s, castelli t, fragalà e, cimino s, morgia g introduction and objective: combination therapy with of -alpha reductase inhibitors ( -ari) and alpha-blockers (ab) is the gold standard for the treatment of moderate-severe secondary to benign prostatic hyperplasia (bph). several clinical trials have already analyzed the overall impact of the medical treatment of luts/bph on sexual sphere, but any one investigated the overall impact on erectile dysfunction (ed) and libido alterations (la). th e aim of this this systematic review and meta-analysis was to evaluate the impact of combination therapy on ed and la from randomized clinical trial (rct). we performed a search of the cochrane central register of controlled trials, pubmed, embase, cochrane database of systematic review, and web of science, until december . we conducted a meta-analysis to determine the impact of combination therapy ( ari + ab) in determining the onset of ed or la. a p value < . was used to denote the presence of heterogeneity. of the studies reviewed, only fi ve rct were included, involving participants. th e overall prevalence of erectile dysfunction was of . %, . % and . % in patients treated with combination therapy, ari and ab respectively. th e overall prevalence of altered libido was of . %, . % and . % in patients treated with combination therapy, ari and ab respectively. combination therapy ari + ab was found to be associated with increased risk of ed (or = . ; p < . ) and la (or = : ; p = . ) compared to monotherapy with ab. th e combination therapy was found to increase the risk of ed (or = . ; p = . ) compared to monotherapy with ari, but not the risk of la (or = : ; p = . ). analyzing the individual monotherapies, therapy with alpha-blockers signifi cantly reduces the risk of ed (or = . ; p < . ) and la (or = . ; p = . ) compared to treatment with ari. conclusions: combination therapy ari + ab is associated with a higher risk of ed. in addition, ari monotherapy has the same risk of the combination of having la. th ese results could be taken into account during the counseling therapy in patients with luts/ bph. mladenov b, mariyanovski v introduction and objective: bph bleeding is one of the common causes of gross hematuria in older men. -alpha reductase inhibitor ( ari) treatment has been showed to reduce prostate tissue microvascularity and to prevent bph-associated hematuria. alpha-blockers are oft en prescribed, where their eff ect on hematuria is not well evaluated. th e aim of this study was to investigate the impact and effi cacy of the current used drugs for bph for treatment and prevention of bph-caused hematuria. a total of men with median age of were enrolled for a period of years. all were presented with bph-caused macrospopic hematuria, diagnosed according to an adopted investigation protocol. detailed history was obtained, including usage of alpha-blockers and/or -ari prior to the hematuria episode. patients were released or immediately hospitalized and catheterized according to their status. all patients were followed up for year for recurrent bleeding and were divided into groups -with an alpha-blocker, -ari, or without therapy. in this study patients were sent home and treated conservatively, other with severe bleeding and/or clot retention necessitated catheterization and hospitalization. from patients ( %) were taking alpha-blockers, ( %) -ari, and ( %) had no medications for the bph prior to the hematuria. patients were followed up for recurrent bleeding for year in medication groups. were given alpha-blockers, - -ari and were released without medication for the bph. within year bph-bleeding occur respectively in , , and cases. th ere was a statistically signifi cant diff erence between the group with -ari therapy and the group without therapy (p= . ). no statistically signifi cant diff erence (p= . ) was found between the groups with an alpha-blocker and without therapy. in all cases with medication the hematuria episodes were lighter according to blood loss and/or hospital stay (in days) than the initial one. conclusions: according to our study, bph-associated hematuria can be eff ectively controlled and reduced with ari. although as per our data alpha-blockers have a positive eff ect on the intensity of the recurrent hematuria, much more signifi cant results in treating and controlling bph-bleeding are shown with -ari. effi overactive bladder syndrome (oab) is a common condition with a negative impact on quality of life. botulinum toxin is commonly used. despite the favorable outcomes seen using botulinum toxin a, the method of injection and side eff ects still need to be solved. our aim is to use botulinium toxin with simple method and check its safety and effi cacy. a total of patients with refractory oab were included in this study. inclusion criteria was refractory non neurogenic oab not responding to conservative management for at least months. aft er written consent, patients were randomly divided into two groups. group a ( patients) received botulinium toxin a unit intravesical instillation diluted in cc normal saline, group b ( patients) received placebo in the form of cc normal saline by the same method. patients were evaluated initially by history, physical examination, overactive bladder symptom score (oabss), quality of life symptom score (qolss), urine analysis, routine laboratory investigations, kub, pelviabdominal ultrasound and urodynamics. patients were followed up at one, and two month post instillation for effi cacy and safety by oabss, qol score, side eff ects and postvoid residual urine. introduction and objective: th e authors evaluate the safety and effi cacy of the prostatic urethral lift when performed in conjunction with a second procedure. in this retrospective study, patients underwent the prostatic urethral lift between january and november . sixteen patients received the prostatic urethral lift as a single procedure and the mean patient age for this group was years (range to ). in the remaining patients, a second procedure was performed in conjunction with the prostatic urethral lift . th ese procedures were: th ulium laser enucleation of the middle lobe, optical urethrotomy and bladder neck incision. results: in patients who were treated with the prostatic urethral lift as a single procedure the mean international prostate symptom score was . (range to ) and mean maximum urine fl ow rate was . mls- (range to ). th e average prostate volume was cc (range to ) and mean quality of life rating was . points (range to ). at months aft er the procedure, the mean international prostate symptom score improved by . points ( %), mean maximum urine fl ow rate by . mls- ( %) and mean quality of life rating by . ( %). th e improvements achieved in the combined procedures were greater than the patients who underwent the prostatic urethral lift as a single procedure. th ere was one case ( %) of postoperative moderate pelvic pain which was managed conservatively with a nonsteroidal anti-infl ammatory drug. a urinary tract infection occurred in one case ( %) and resolved aft er treatment with an antibiotic. th ere were no complications in the combined procedure cases. no patients reported any decline in erectile function, retrograde ejaculation or dysejaculation. conclusion: th e prostatic urethral lift is a safe and eff ective treatment for lower urinary tract symptoms secondary to benign prostatic hyperplasia while preserving sexual function. in carefully selected patients, the performing the prostatic urethral lift in conjunction with a second procedure may achieve superior results with no major complications. evaluation . we sought to evaluate the effi cien-cy, safety and outcome parameters between green-light pvp and vit. data of xps cases were retrospectively collected from experienced surgeons at high volume greenlight xps centers. preoperative, operative and post-operative parameters were collected and compared between groups. pvp was defi ned as pure vaporization only while vit included techniques to incise into adenoma and allow tissue resection and removal. results: as summarized in table , men undergoing vit (n= ) had larger prostate size, higher ipss∕qol and retention preoperatively than those undergoing pvp (n= ). while vit allowed greater delivery of energy ( . vs. . kj∕g), operative time was longer and had greater need for > fi bres. th ere were no diff erences in intra and post-operative adverse events. while no diff erences were observed in ipss∕qol at months post-operatively, more favorable qmax and pvr were observed at months, along with greater psa reduction, in the vit group. preoperative patient characteristics introduction and objective: to prospectively evaluate at two years, the quality of life (qol) and satisfaction of subjects randomized to either gl-xps or turp for luts/bpo. a total of patients at sites in european countries who were candidates for surgical relief of bpo were randomised : to undergo gl-xps or turp. subjects had ipss scores > and prostate volumes < mls. multiple self-administered patient questionnaires were assessed from baseline to years via: ) a general health status eq- d- l questionnaire (index score and visual scale); ) physical and mental health (sf- physical health and sf- mental health scores); ) erectile function and ejaculatory status (iief- questionnaire); ) urinary continence via oabq-sf symptoms, oabq-sf health and iciq-ui sf; ) overall satisfaction: willingness to undergo the procedure gain or ) recommend to a friend. table and subject satisfaction at years is shown in figure . conclusions: th ere is a statistically similar improvement in qol with gl-xps and turp at years. erectile function is not aff ected by gl-xps or turp and both result in a % risk of retrograde ejaculation at years. functional introduction and objective: technology for photoselective vaporisation of the prostate (pvp) has evolved in recent years. we report our early experience of pvp with the greenlight™ -w xps and assess our institutional learning curve for this technique. we performed a retrospectively analysis of our fi rst patients undergoing pvp using the greenlight™ -w xps over a twoyear period. data was collected on demographics, prostate volume, length of stay, time to trial of void, and complications. complications were graded according to the clavien classifi cation system. th e operative learning curve was analysed via various intra-operative lasering variables including the total delivered energy, total vapourisation time (vt), and vapourisation time/operation time (vt/ot). th e study population was divided into three consecutive equal groups and the three groups were compared. results: mean age was . mean length of stay was . days. mean prostate volume was cc. twenty-fi ve percent were on some form of anticoagulation. twenty-one percent were in-dwelling catheter-dependent preoperatively. th e median duration to removal of in-dwelling catheter was day. seventy-six percent had a successful trial of void on day . th e overall complication rate was %, the vast majority of which were clavien grade i or ii. th ere were no statistically signifi cant diff erences between the groups in terms of age or prostate size. over time, there was a statistically signifi cant decrease in ot and increase in vt/ot but no diff erences in complication rates, time to trial of void or length of stay as experience increased. conclusion: greenlight laser pvp using the -w xps is a safe and effi cient treatment option for benign prostatic hyperplasia, with minimal bleeding and low complication rates. our data suggests that a learning curve exists for this procedure in terms of intra-operative lasering variables with no statistically signifi cant increase in post-operative complications or length of hospital stay during this period. tillou x, le gal s, chahwan c, oitchayomi a, doerfl er a introduction and objective: to compare results of pvp (photoselective vaporisation of the prostate) in elderly patients to those observed in younger male patients taking into account the presence of an indwelling bladder catheter. we performed a review of our prospectively maintained database between december and march . a total of patients were operated for luts related to hbp. th ree groups were fi rst established to compare results of pvp in elderly male patients. we then analyzed the impact of an indwelling bladder catheter by comparing two groups of patients under and above year-old. results: th ere were no diff erences between groups for bmi, neurological disorder or hypertension history, aspirin treatment, ipss, qol and preoperative pvr (post void residual). patients above years old had statistically more heart diseases (p= . ) and had more anticoagulant treatments (p= . ). prostate volume increased with aging (p= . ), which resulted in an increased procedure time (p= . ) and an increased amount of energy delivered (p= . ). for postoperative outcomes, there were no diff erences between groups for bladder catheter removal time, ipss, qol, pvr, and surgical complications. postoperative qmax was statistically lower for patients above years old (p= . ) but with a decreased diff erence compared to preoperative measurements (p= . ). in the group without an indwelling catheter, postoperative catheter time was signifi cantly longer in patients over years (p= . ) with a greater pvr (p= . ). urofl owmetry and ipss voiding were signifi cantly improved in both groups without diff erences. th ere was no diff erence for early or late postoperative complications. for patients with an indwelling catheter, for all parameters studied, no statistically signifi cant diff erences were found except higher post-operative pvr in patients older than year-old. conclusions: pvp is an effi cient and safe procedure in elderly male patients despite more heart diseases and anticoagulant treatments. with or without a previous indwelling bladder catheter, functional outcomes were identical whatever age. introduction and objective: th e procedure of holep has steep learning curve and more than cases are needed for overcoming the curve. th e objective of our study is for identifying the detailed steps in improving skills during learning curve. total patients who underwent holep in single center were included in the study. th e operation was performed by surgeons who were experienced tur-p more than cases. patients were divided into groups. groups were initial cases (group ), mid cases (group ), and later cases (group ) in each surgeons. th e enucleation time, morcellation time, the amount of energy use, diff erential count of hemoglobin between pre-and post-operation, post-operative urofl owmetry parameter were compared between each group. especially, enucleation time was divided into diff erent steps, which was action time that was actual use of laser energy or dissecting prostate tissue using cystoscopy and identifi cation time was time for identifying anatomical structure without any procedure. results: mean ages was . years old and mean bmi was . kg/m . mean psa was . ng/ml and mean prostate volume was . cc. th ere were no signifi cant diff erences in baseline characteristics in preoperative data. aft er cases (group ), there was less use of laser energy, less time consuming for morcellation and identifi cation compared to group . identifi cation time was signifi cantly improved than group and more shortening feature as cases added but had no signifi cant diff erence. aft er cases (in groups ), there was more signifi cant diff erence in all operative parameter. especially morcellation time was signifi cantly improved aft er cases. th ere was no signifi cant diff erence in post-operative urofl owmetric parameters. conclusion: in initial experience, it seemed to be overcoming one step about identifying surgical anatomy in learning curve aft er cases. especially, cases were optimal cases for overcoming learning curve for morcellation. aft er cases, we did not overcome the learning curve but all operative parameter was improved. transrectal ultrasound as an intraoperative tool in the identifi cation of the plane of dissection during holep procedure introduction and objective: holmium laser enuclation of the prostate (holep) has been named since as the potential gold standard of treatment for bladder outlet obstruction as a consequence of benign prostatic hiperplasia. one of the most important steps during procedure is to identify the plane of dissection between the adenoma and periferic zone. in this study we demonstrated the utility of transrectal ultrasound in the identifi cation of this surgical plane during ho-lep for novel surgeons. materials and methods: previews informed concerned, we preform transrectal ultrasound during holep of patients, using the proved of the flex focus ultrasound system of bk medical, obtaining images of the prostate as a method to simplify the identifi cation of the surgical plane. we preformed holep as a standard method with storz endoscopic instruments using fr resectoscope with a kunts element and with the watts holium laser power suite from lumenis, we obtained images of the fi ve patients in real time with axial and sagital planes simultaneously, clearly helping the surgeon to identify the surgical dissection plane between the adenoma and the peripherical zone. conclusions: transrectal ultrasound could be a useful tool during the training of novel surgeons in holep technique. introduction and objective: th e aristolochia family of herbaceous plants has been used worldwide for traditional medicinal purposes for more than two centuries. th ese plants contain aristolochic acid (aa), a powerful nephrotoxin and human carcinogen, which, in susceptible individuals, causes chronic kidney disease and/or upper urinary tract urothelial carcinoma (utuc). bioactivation of aa yields a reactive intermediate that binds covalently with dna to form aristolactam (al)-dna adducts. in the urothelium, these adducts give rise to a unique mutational signature. as there are several reports of renal dysfunction in japan associated with the use of aa-containing chinese herbs, we hypothesize that a fraction of utuc cases in this country may result from past use of aristolochia herbs. patients with histologically confi rmed utuc who underwent nephroureterectomy in kyushu university aft er august were eligible for this study. informed consent was provided by each participant prior to surgery. surgical specimens of tumor and renal cortex were snap-frozen following nephroureterectomy. dna was isolated from renal cortex and analyzed for the presence of al-dna adducts using either mass spectrometry or a p-postlabelling method. dna isolated from matched tumor samples was subjected to mutational analysis of the tumor suppressor gene tp . results: th irty three utuc patients were enrolled in this study between august and march , males and females, with a mean age of years. al-dna adducts were detected in of renal cortex samples ( . %) analyzed; adduct levels were . and . per deoxynucelotides. sequencing analysis of tp in tumor dna revealed the absence of the unique mutational signature associated with aa. conclusion: aa exposure was confi rmed in two utuc patients; however, in these two cases, the mutational profi le of tp in tumor dna was not consistent with aa-induced carcinogenesis. further accrual and analysis of utuc cases are needed to estimate the prevalence of aa exposure in japan, to evaluate the role of aa exposure to utuc in this country, and to confi rm the public health implications of these fi ndings. preoperative introduction and objective: our aims are to assess the association between upper urinary tract urothelial carcinoma (uutuc) development and the polymorphisms in the aurora kinase a (aurka) phe ile (rs ) and survivin rs c>t genes. a total of patients with uutuc and hospital controls with bladder stones were recruited in this study. clinical records, demographic data, and possible confounding factors were collected using a standardized questionnaire. genotyping was determined using a real-time polymerase chain reaction using taqman probe. results: signifi cantly more controls than patients with uutuc drank alcohol and tea, but there were no diff erences in the frequencies of cigarette smokers and coff ee drinkers. aurka phe ile gene polymorphisms, but not survivin rs c>t gene polymorphisms, were associated with uutuc development (χ test and multivariate logistic regression) (χ = . , p= . ; crude or= . , % ci= . - . ; adjusted or= . , % ci = . - . ). stratifi cation analysis and multivariate logistic regression analysis showed that only the association between aurka phe ile gene polymorphisms and uutuc development were diff erentiated between those with and without the habits of smoking, tea drinking, or coff ee drinking. conclusion: our major fi ndings supported that aur-ka phe ile gene polymorphisms, but not survivin rs c>t gene polymorphisms, increase genetic susceptibility to uutuc. metastatic and has thereaft er stabilized around %. th ere was a regional variation in the proportion of patients who underwent cn between % and %. th e relative survival at fi ve years was % aft er cn compared to % in patients who did not undergo cn (p< . ). th e median age of the m patients who underwent cn was years compared to years in patients who did not undergo cn. tumor recurrence, aft er initial treatment with curative intention in primary m patients, was % aft er fi ve years. th e location of the metastases were: lung %, bone %, lymph nodes %, liver %, adrenal % and brain metastases in % of the patients. th irteen percent of the patients suff ered local recurrence in the renal fossa aft er nephrectomy. th e most common treatment for patients with a recurrence was oncological medical treatment ( %). metastasectomy was performed in % of the patients with recurrence and in % of the patients the surgery had a curative intention. conclusions: th e incidence of metastases in renal cell carcinoma in sweden is decreasing and is lower than in historical materials. th e patients with synchronous metastases who undergo cn have a signifi cantly better survival than patients who do not undergo cn, but constitute a highly selected group. recurrence after initial treatment with curative intention is treated surgically in % and oncologically in %. immediate introduction and objective: pretreatment characterization of renal masses (rm) remain suboptimal with overtreatment being a signifi cant concern. we examined the ability of preoperative clinical characteristics to predict histological features of rms. in the global renal mass study conducted by the clinical research offi ce of endourology society (croes), data were collected for consecutive patients with renal masses who underwent surgery for clinical stage i renal mass between - . based on surgical histology, tumors were categorized as benign, low aggressiveness cancer, and high aggressiveness cancer. we assessed the ability of clinical (patient gender, age, smoking history, bmi), laboratory (preoperative hemoglobin and c-reactive protein) and radiographic (tumor diameter, location, exophytic rate and enhancement) characteristics to discriminate between benign and cancer (low + high aggressiveness) and between highly aggressive tumors and others (benign + low aggressiveness cancer). multivariate logistic regression was used to estimate the probability of the histological group by clinical and radiographic features in the entire cohort and a sub group of ct a tumor. th e performance of the models was consequently studied by calibration, nagelkerke's r , and discrimination (roc area under the curve). results: th e study cohort included patients with clinical stage i renal mass of which ( %) had ct a mass. benign lesions were found in ( . %), low aggressiveness tumors in ( %) and high aggressiveness tumors in ( . %). male gender, smoking history, increased tumor size, and lower exophytic rate were associated with malignancy and high aggressiveness features (all p-values < . ). models developed based on these characteristics had the ability to discriminate benign from malignant (bootstrap corrected c-index of . ) and high aggressiveness tumors from benign and low aggressiveness tumors (bootstrap corrected c-index of . ). similar results were achieved in the ct a subgroup. th e c-index of tumor diameter as a single predictor of malignancy and high aggressiveness tumors in the entire cohort was . and . , respectively. conclusions: although older age, male gender, smoking history, increased tumor diameter and reduced exophytic rate are associated with malignancy and high aggressiveness of renal mass, models incorporating these characteristics have modest discriminating power, slightly better than the predictive ability of tumor size alone in clinical stage i tumors. could surgery be prevented in the management of small renal masses? introduction and objective: th e diagnosis, characterization and management of small renal masses (srms) remains an important clinical issue. a proportion of srms may be benign or have low malignant potential. th ese lesions could arguably be managed non-operatively. strategies such as renal mass biopsy may be valuable in reducing the rate of unnecessary surgery. we evaluated a large contemporary surgical series of resected srms in a tertiary center with a very low biopsy rate to determine the number of procedures that could have been prevented for benign and low malignant potential lesions. conclusion: sbrt is a safe and effi cacious modality and appears to be well-tolerated at the dose fractionation we have used, and its use correlates with improved survival in this cohort of patients with rcc. cyberknife can deliver complex treatment plans to multiple lesions while minimizing irradiation to the surrounding healthy tissue, thereby decreasing the risk of complications. cyberknife has the potential to be an excellent treatment modality for renal cancer patients with renal cell carcinomas or patients with bilateral renal cell carcinoma who refuse surgery or are medically inoperable. introduction and objective: th e introduction of the robotic surgical systems has changed the way both surgeons and patients view urological surgical procedures. we tested the same theoretical and tangible benefi ts for partial nephrectomy with tele-lap alf-x system. we review our technique of robot-assisted laparoscopic partial nephrectomy performed using a new robotic telesurgical device (alf-x) on swine large white/landrace model. we set up an operating theatre to test alf-x on partial nephrectomy procedure to be performed on swine large white/landrace in total anesthesia. th e console incorporates the following main components: an ergonomic seat, the laparoscopic teleoperation master (ltm) with haptic handles, a d-hd monitor, an eye-tracking system (ets), a keyboard and a touchpad, and one foot pedal. th e ets is an infrared-based eye tracking system that detects which point the surgeon is looking at. th ere was one surgeon placed at computer-console and one surgeon placed at the surgical table. a random decision on the kidney to be tested is performed before the operation. once the trocars are placed and the kidney isolated a period of warm ischemia is due to perform the partial nephrectomy on the lower or upper pole (random choice). th e haptic sensation can be used for palpation, pushing or pulling to estimate elasticity and consistency of tissues and controlling the tensility of the sutures when tying. low-cost disposable or reusable instruments were used. results: to date, we performed partial nephrectomy with alf-x robot on swine large white/landrace (pigs) models. th ree robot's arms were used. five partial nephrectomies were on the right kidney, while were on the left one. th e mean surgical time was . minutes (range - min). th e mean warm ischemia time was . min (range . - min). th e mean blood loss was . ml (range - ml). conclusions: according to these experimental experiences on pig models, we may assume that robot-assisted laparoscopic partial nephrectomy, using tele-lap alf-x system, is safe, feasible and reproducible procedure. moreover it off ers a good perception when instruments touch each other avoiding collision between robotic arms. we believe that robot-assisted tele surgery approach could be reasonable an innovative contribution in the near future also in humans. it also off ers a reduction of costs per intervention. preoperative chronic kidney disease to reduce the eff ects of selection bias and potential confounding factors, patients in non-ckd group were selected by propensity score matching. results: th e median age of all patients was . years (range, - years) and the median follow-up was . months (range, - months). comparisons of the propensity score-matched cohorts showed that t and n stages were more advanced and the tumor size was larger in the ckd than in the non-ckd group (p < . each). kaplan-meier analyses showed that recurrence-free survival (rfs), cancer-specifi c survival (css), and overall survival (os) were signifi cantly lower in the ckd group (p < . each). multivariate regression analysis showed that preoperative ckd status was an independent predictor of css and os in patients with rcc (p < . each). conclusion: preoperative ckd may be associated with more aggressive features and poorer prognosis in patients with rcc. rcc patients with preoperative ckd should be followed up frequently and carefully aft er nephrectomy. . ) were independent prognostic factors. bone-modifying agents (zoledronic acid and denosumab) were not associated with os. th e median os of patients receiving molecular-targeted therapy aft er diagnosis of bone metastasis was signifi cantly better than that of those who did not receive targeted therapy ( . vs. . months, p= . ). our study suggests that molecular-targeted therapy prolongs survival of rcc patients with bone metastasis. th us, molecular-targeted therapy, nephrectomy and surgery for bone metastasis should be considered for these patients. introduction and objective: ureteric stenting for urinary tract obstruction secondary to malignancy may off er a survival benefi t and buy time for oncological management. since the introduction of the ureteral stent symptom questionnaire (ussq), studies have revealed that up to % of patients with ureteric stents for benign conditions experience stent related symptoms that interfere with daily activities and reduce quality of life. our aim was to evaluate stent symptoms in patients with malignant obstruction and their impact on health related quality of life. patients with indwelling ureteric stents for malignant obstruction were identifi ed from the departmental stent register during a march to june . telephone interviews and face to face interviews at the time of stent change were conducted using the validated ussq. results were analysed according to the questionnaire scoring system. results: twenty patients with a mean age of years completed the ussq. of these patients - % reported bothersome urinary symptoms that included storage symptoms, incontinence and haematuria. fifty percent of patients experienced stent related pain in the fl ank ( / ), suprapubic ( / ) and groin area ( / ). fift y percent of these patients required regular analgesia and - % experienced pain interfered with activities and daily life. seventy percent of patients experienced diffi culty in performing physical activities, with a negative impact on social life. one out of patients reported sexual dysfunction. eighty fi ve percent experienced urinary tract infection (uti) with % having a uti most or all of the time and % requiring admission to hospital. mortality within one year of stent insertion was %. conclusion: ureteric stents are associated with signifi cant debilitating symptoms and reduced quality of life in patients with malignant obstruction. th is has signifi cant implications for management of cancer patients and patient counselling. ureteric stenting can prevent death from malignant obstruction, but may result in prolonged suff ering due to stent symptoms without benefi t in overall survival. introduction and objective: management pheochromocytoma laparoscopic was initially controversial because of the possibility of adrenergic discharge with the generation of the pneumoperitoneum. th e work of a proper medical preparation and anesthetic precise control obvious that circumstance and allows more precise surgery and a better image as it gives the laparoscopy to get with much less aggressive surgical removal. our goal is to present the preparation and the key points in its approach. we present -year-old male with recent diagnosis prostate cancer and high pressure treated with drugs. discovery of left adrenal mass of cm. in ct and mri and scintography with mibg suggestive focus of pheochromocytoma in the adrenal gland. twenty-four-hours urine: total catecholamines: . ug/ ( - ) adrenaline: . ug/ hours ( d- ); normetanephrines ug/ ( - ), metanephrines: ug/ ( - ). vanilvandelico . ug/ ( - ). preparing medical / anaesthetic consisted: entry days before surgery and control alpha-blockers with doxazosin every hours. treatment with beta-blockers with propranolol. expansion of intravascular volume with intravenous fl uid therapy hours before surgery. and control of blood glucose levels. intraoperatively crisis were treated with nitroprusiate. results: aft er adrenalectomy laparoscopic left with a length of minutes and adequate control pressure intraoperative the pathology diagnosis was of pheochromocytoma. postoperative attended without incident (clavien i) and went out hospital to the hours. th e presence a pheochromocytoma should not be a contraindication to laparoscopic approach of the adrenal gland in services experienced laparoscopic, and must be an exhaustive control of anesthetic, as well as a careful dissection of the gland trying to avoid excessive manipulation of the same. robotic assisted "davinci" adrenalectomy al-ansari a, younes n, al-rumaihi k, al-jalham k, gul t, badawi a, kamkoum h introduction and objective: adrenal mass could be challenging, especially when it is large in size or cystic, adrenal had short and variable vasculature, in addition to functional adenoma, adrenal surgery require minimal handling. robotic assisted adrenalectomy (ra) had been proven to be safe and eff ective. objectives: to describe robotic adrenalectomy (ra), to ensure a safe and eff ective removal of complex adrenal mass. we reviewed the record of consecutive patients who underwent ra performed by a single surgeon, between january and january , fi ve were right and fi ve were left , were solid and were cystic, none were functional adenoma patients position and port placement were similar to renal surgery, aft er control of the renal vein the gland was dissected, small arteries were clipped and the gland were removed. results: patients were females and males, age range between to years mean tumor size was . cm range ( . - cm), mean hospital stay was days, no perioperative complications, all masses were intact, one postoperative addisonian crisis pathology was benign cyst, adenoma, ganglionuroma, neuroendocine, adrenal hyperplasia, adrenocortical neoplasm of low malignant potential. conclusion: robotic adrenalectomy is safe and feasible in the management of complex adrenal mass. robotic materials and methods: th e girl was in a good general health and came walking to our out-patients department. she was admitted and her investigations reviewed. she had a right renal mass with cavo-atrial extension with an isolated embolus in the pulmonary artery. she was planned for a complete excision under cardio-pulmonary bypass with deep hypothermic circulatory arrest. under general anaesthesia, aft er establishing complete monitoring, she was opened by long midline laparotomy and mid-sternotomy. mid-sternotomy extension was done up-front in-view of the pulmonary embolus. an incision was made in the posterior peritoneum medial to the inferior mesenteric vein. th e right renal artery was dissected posterior to the left renal vein, ligated and divided. suddenly her end tidal carbon-di-oxide fell. th e video demonstrates the trans-esophageal echo-cardiography confi rming fragmentation of the cavo-atrial thrombus and its migration into the right ventricle and main pulmonary artery. th e patient was immediately put on cardio-pulmonary bypass. initially the venous return was low. she was rapidly cooled to degrees centigrade and aorta cross clamped just above the diaphragm. arterial infl ow was reduced to litre per minute to main blood fl ow to the brain. th e video demonstrates opening, clearing and repairing of the right atrium, right ventricle and main pulmonary artery in a step by step approach. th e branches of the pulmonary artery were cleared with fogarty's catheter. right radical nephrectomy was completed and ivc cleared and repaired. th e total circulatory arrest time was minutes. she was slowly re-warmed and taken off cardio-pulmonary bypass. results: her post-op recovery was uneventful. th e fi nal histo-pathology report showed a primitive neuro-ectodermal tumor. she received adjuvant chemotherapy for cycles and is well at months of follow-up. in an appropriate case pulmonary artery embolectomy along with excision of cavo-atrial tumor thrombus is acceptable in experienced centers. an up-front mid-sternotomy should be contemplated in patients where the risk of embolisation of tumor thrombus is high. a total of consecutive patients who underwent a turbts were identifi ed from january to february by a single surgeon at our institution. we excluded patients as they had a known history of bladder cancer that previously underwent treatment. via rigid cystoscopy, tumors were resected en bloc using a polypectomy snare with electro-cautery and retrieved transurethrally. following turbts, the base of the tumor was either biopsied and fulgurize or a formal turbt was performed. results: nineteen consecutive patients (median age , range - ) underwent an initial turbts for the initial staging and management of bladder tumor. median number of tumors found was (range - ). median tumor size was cm (range cm- cm). median follow-up was months (range - months). tumors sites were: posterior wall, trigone, lateral wall, anterior wall. immediate aft er snaring of the tumor, patients underwent biopsy and fulguration while underwent a turbt in the same operative setting. patient from the turbt group experienced an obturator refl ex. muscle was visualized on of pathology specimens. patients required subsequent redo procedure to obtain muscle for tissue diagnosis and staging. recurrence occurred in patients (median . months, range . - months). conclusion: turbts is a feasible technique for pedunculated bladder tumors. it provides a bloodless fi eld with maximal visibility for the surgeon and may be an adjunct in turbt. dilep-diode laser ( nm technical aspects for overcoming the holep learning curve omori y, matsumoto s, matsumoto s introduction and objective: holep is an excellent surgical procedure and alternative to turp and open prostatectomy for bladder outlet obstruction due to benign prostatic hyperplasia. it has been widely accepted and performed, for its safety and eff ectiveness. however, it may not be considered an option for the majority of worldwide urologists, because of its steep learning curve. our objective is to help beginners and operators who are interested in learning holep to get familiarized with it, and feel confi dent about opting for this procedure. in this video we demonstrate a case of holep using watt holmium laser in a -year-old male with ml prostate. th e operative fl ow is described as follow: ) downward dissection of the left lobe and longitudinal incision; ) downward dissection of the right lobe and longitudinal incision; ) enucleation of the medium lobe; ) lateral side dissection of the both lobes; ) o' clock incision and bladder neck ablation at between and o' clock ) diagonal longitudinal incision of apical lobes; ) enucleation of the both lobes; ) hemostasis; ) morcellation. results: in this video operative time was min (enucleation time: min) and resected tissue weight was g. our procedure has some modifi cations compared to the surgical technique from original procedure of gilling, separating lobes and dissecting in a retrograde fashion. conclusion: holep is a safe and eff ective surgical procedure. we hope our procedure will become the reference for beginners and urologists who are wishing to master it, but are worried about methods and complications. and also we hope holep will become the new gold standard for the treatment of benign prostatic hyperplasia. to obliterate the circular fi bers of bladder neck to the level of proximal urethra, carefully avoiding the external striated sphincter. laser power is reduced to w to prior to vaporization of any pseudomembranous trigonitis, which is commonly found in pbno or recurrent cystitis cases. results: laser vaporization is successful in relieving voiding diffi culties. th is procedure opens the bladder neck and allows for optimal post-operative urine fl ow. th e patient had improvement in both objective and subjective voiding functions immediately aft er treatment. during -months follow-up urofl owmetry, the maximum fl ow rate increased from to ml/s. th e postvoid residual urine decreased from ml to less than ml. conclusion: primary bladder neck obstruction in female can be eff ectively and safely treated with laser photoselective vaporization of the bladder neck. bilateral retroperitoneal laparoscopic nephrectomy using mm instruments introduction and objective: laparoscopy has become the standard nephrectomy approach. it has been shown that th e retroperitoneal approach is comparable to the transperitoneal approach when it comes to safety and results, even more, it can present advantages in selected patients, as in patients with prior abdominal surgery. th e use of mm instruments is gaining acceptance as a safe way to improve aesthetic results and minimize abdominal wall trauma while maintaining the principles of standard laparoscopy. we present the case of a -year-old woman with a history of radical hysterectomy and radiotherapy, aft er which she presents: ) bilateral ureteral obstruction that produces terminal renal insuffi ciency, and, ) vesico-vaginal fi stula, refractory to conservative treatment. th e decision is made to perform a bilateral retroperitoneal laparoscopic radical nephrectomy as a defi nitive treatment of the vaginal fi stula and as preparation for the kidney transplant. results: th e right nephrectomy is performed fi rst. classic retroperitoneal technique is used, using mm trocars (with an mm trocar to create the retroperitoneal space). on the left side, a previously produced nephrostomy catheter tract is used to insert a mm trocar. no relevant intraoperatory complications were observed. preoperative haemoglobin was g/l and the postoperative was g/l aft er transfusion of one bag of packed red blood cells. th e only postoperative complication was the infection of the mm left side trocar tract (where the previous nephrostomy catheter was placed). th e total hospital stay was days. th e pathological anatomy for both kidneys was: chronic pyelonephritis with extended interstitial fi brosis and tubular atrophy. conclusions: retroperitoneal laparoscopic nephrectomy is an effi cient and safe approach, comparable to transperitoneal laparoscopic nephrectomy, and even superior to this one in patients with previous abdominal surgery. th e use of mm instruments (in this case in a combined fashion), allows performing the surgery in a safe way, with superior aesthetic results. pure aft er complete mobilization of the renal artery three hem-o-lok clips were applied and the artery was transected. th e ivc was isolated upwards as far as possible, and intraoperative laparoscopic ultrasound was employed to identify the extent of the thrombus. aft er the inferior vena cava ivc was blocked using tourniquet loops above and below the thrombus and the contralateral renal vein was blocked, the ivc was opened and the tumor thrombus was extracted entirely. th e ivc was stitched with a running - polypropylene suture. th e specimen was extracted in an endoscopic extraction bag through a gibson incision. results: from february to june , fi ve patients underwent pure conventional retroperitoneal laparoscopic nephrectomy and tumor thrombectomy. th e mean patient age was yr ( - yr). th e mean operative time was min ( - min), and the mean estimated blood loss was ml ( - ml). th e mean length of tumor thrombus was . cm ( - cm). with a mean follow-up of . mo ( - mo), one patient was identifi ed lung metastasis four months postoperatively. introduction and objective: partial nephrectomy provides equivalent oncologic and superior functional outcome compared with radical nephrectomy over the short-and long-term. with the development of laparoscopic techniques and increasing laparoscopic surgical experiences, laparoscopic partial nephrectomy has become an acceptable alternative to radical nephrectomy for expert laparoscopic urologists to treat small renal mass. however, higher complexity tumors are associated with more resection of normal tissue, a longer warm ischemia time, and postoperative morbidity, especially entirely endophytic hilar tumor. in order to reduce normal tissue resected during laparoscopic partial nephrectomy for entirely endophytic hilar tumor, we develop a novel technique to deal with the higher complexity tumors. subject is a -year-old female with t a clear cell carcinoma with a diameter of . cm. th e tumor is entirely endophytic hilar tumor. renal nephrometry score is . she underwent laparoscopic partial nephrectomy in retroperitoneal approach. standard ports were placed. th e surgeon opened gerota's fascia and dissects along the renal capsule mobilizing the kidney from within gerota's fascia. th e resection line was marked using the laparoscopic ultrasound probe. aft er the renal artery was clamped by bulldog, tumor enucleation was performed using a cold scissor. one incision above the tumor was made, and careful dissection was performed to approach the tumor. th e tumor was completely mobilized outside its margin. th en the inner layer renal parenchyma and collecting system was sutured with - absorbable sutures and the outer layer renal parenchyma was sutured with absorbable suture. results: th e procedure was successfully accomplished without open conversion and transfusion. th e operative time was min, and the estimated blood loss was ml. th e warm ischemia time was min. histology revealed that the tumor was chromophobe renal cell carcinoma, and the surgical margin was negative. conclusion: laparoscopic partial nephrectomy for entirely endophytic tumor is challenging. tumor enucleation with one resection line can reserve more normal renal tissue during the procedure. more cases are needed to evaluate the effi ciency of the technique. introduction and objective: laparoscopic adrenalectomy by posterior approach carries high recovery and shorter operative time. children with metastatic high risk neuroblastoma arising from the suprarenal gland should undergo local surgical excision of the primary tumor before further intensifi cation of chemotherapy and possible bone marrow transplantation. herein, we report a video of left laparoscopic adrenalectomy showing the diff erent steps of the procedure. th congress of the sociÉtÉ internationale d'urologie -siu abstract book materials and methods: a . -year-old boy with left metastatic suprarenal neuroblastoma, received chemotherapy according to high risk european protocol. child positioned in prone position, fi rst trocar at the tip of the last rib by open introduction, two mm trocars one in costovertebral angle and the other is lateral. balloon development of the space, gerota fascia opened, the upper pole of kidney identifi ed, mass dissected, suprarenal vein is clipped during dissection, extraction in bag. results: oral feeding is begun aft er hours, discharge from hospital in the second day postoperatively, rapid convalescence, rapid resumption of chemotherapy. conclusion: laparoscopic adrenalectomy using posterior approach gives direct access to the adrenal gland, no peritoneal violation, rapid intestinal movement recovery, short hospital stay and rapid recovery. all advantages that might facilitate the early start of adjuvant chemotherapy in children with neuroblastoma, however, oncological outcome should be proven by long-term follow-up, larger number of patients, and good selection of small tumor facilitates surgical extirpation. introduction and objective: robotic multiplex partial nephrectomy (rmxpnx) is minimally invasive partial nephrectomy for three or more tumors in a single kidney. rmxpnx has been previously shown feasible with excellent preservation of renal function. we present our technique of off -clamp robotic transperitoneal multiplex partial nephrectomy in the treatment of multifocal and hereditary renal tumors. a prospectively maintained database was retrospectively queried to identify all patients who underwent rmxpnx from to . rmxpnx is defi ned a resection of or more masses from a single kidney. patients underwent rmxpnx when the largest tumor reached cm in size. tumors were excised using enucleation techniques. from the data of eligible patients, a representative patient was identifi ed and surgical video was edited to demonstrate the important aspects of the surgical technique. results: th e patient is a -year-old white male with von hippel lindau diagnosed with bilateral multifocal renal tumors with several tumors > cm in size. he underwent bilateral robotic multiplex partial nephrectomy separated by weeks with no operative complications. th irty fi ve tumors were excised from the right kidney. fift y two lesions were then resected from the left kidney. his preoperative creatinine was . and at year postop from bilateral multiplex partial nephrectomies his creatinine is . . in the hands of an experienced surgeon, off -clamp robotic transperitoneal multiplex partial nephrectomy is feasible, safe and eff ective in the treatment of multifocal and hereditary renal tumors. th is technique provides exceptional renal functional preservation and decreases technical diffi culty of reoperation. louie-johnsun m introduction and objective: th e advantages of minimally invasive laparoscopic surgery are well documented. as there are few urological emergencies suitable for a laparoscopic approach, the increased use of robotic surgery for elective procedures that can be performed equally as well laparoscopically threatens the acquisition of skills that can be transferred from these elective procedures (e.g. laparoscopic radical prostatectomy, pyeloplasty and partial nephrectomy) to emergency cases. in emergency situations, a robotic approach may not be feasible or practical. we highlight this with three recent cases. materials and methods/results: a video presentation of three of our recent urological emergency cases managed successfully laparoscopically which includes: ( ) a -year-old girl with neurogenic bladder presenting with urinary peritonitis aft er spontaneous rupture of an augmentation cystoplasty: laparoscopic adhesolysis and repair of perforated augmented bladder. ( ) an -year-old woman with intraoperative mid ureteric injury during laparoscopic right hemicolectomy: laparoscopic ureteroureterostomy and insertion of ureteric stent. ( ) a -year-old woman with ureterovaginal fi stula post laparoscopic hysterectomy: laparoscopic ureteric reimplantation with psoas hitch and insertion of stent. conclusion: despite the increasing use of robotic surgery in urology we encourage the continued training and dissemination of advanced laparoscopic skills in the elective setting to allow for the advantages of laparoscopy to be transferred to the less common urological emergency setting. robotic ureteric catheter placement; ) port placement with patient in lateral position; ) bowel mobilization; ) localization of lower calyx by intra-operative ultra sound probe; ) lower segmental nephrectomy; ) anastomosis (ureterocalicostomy) with - v-lock sutures over a pre placed f ureteric catheter and drain placement; ) changing of ureteric catheter to dj-stent on rd day post-operatively. results: th e procedure was completed successfully without any intra operative complications in all the cases. mean operative time was ± minutes and analgesic requirement of ± milligram of tramadol. none of the patients required blood transfusion. urethral catheter was removed on th and drain on th post-operative day and stent aft er weeks. one patient had clavien grade (pyrexia) complication. conclusions: robot-assisted laparoscopic ureterocalicostomy for secondary upjo is safe and feasible in expert hands. apart from the short recovery times, early mobilization, decreased analgesic requirements; robotic approach provides the added advantage of technical ease and precision of suturing. laparoscopic dismembered pyeloplasty for upjo in pelvic ectopic kidney apollo bgs hospital, mysore, india introduction and objective: renal ectopia is a rare anomaly and may be associated with pelvic ureteric junction obstruction (pujo). we report such a case with an ectopic pelvic kidney (l-type) with pujo and its successful laparoscopic management. th rough this report we emphasize the importance of adequate preoperative imaging and intraoperative details to avoid mishaps. a -year-old male was admitted with complaints of right-side lower abdominal pain of a dull aching type lasting months. ultrasonography revealed left pelvic kidney. th ese fi ndings were confi rmed with an intravenous pyelogram, which showed the left kidney low lying in the pelvic region with features of hydronephrosis and upjo. ct angiography revealed no crossing vessel as the cause of pujo. results: th e patient was taken up for transperitoneal laparoscopic pyeloplasty under general anesthesia. aft er creation of the pneumoperitoneum and with the ports in place, dissection was started and the dilated pelvis could be visualized through the peritoneal window. th e peritoneum was incised and the dilated pelvis on the left side was reached. aft er further dissection, the classic anderson-hynes dismembered laparoscopic pyeloplasty was done by using - vicryl. minimal excision of the redundant pelvis was required and because the kidney was not mobilized, nephropexy was not required. care was taken to avoid injury to the right ureter, which was coursing in close proximity to the left renal pelvis. preoperatively placed stent was retained and repositioned during the pyeloplasty. estimated blood loss during the procedure was around ml, and the procedure was completed in minutes without any intraoperative complications. th e patient could tolerate oral feeding on the evening of the same day. conclusion: th e upjo in ectopic pelvic kidneys presents a large spectrum of presentation. th e laparoscopic approach provides good surgical exposure, and operative times are compared to those of laparoscopic procedure in anatomically normal kidneys. laparoscopic we present laparoscopic radical cystectomy (lrc) and intracorporeal orthotopic ileal neobladder with two isoperistaltic aff erent limbs. a -year-old male patient with recurrent urothelial bladder carcinoma. ct demonstrates bulky bladder tumor in right lateral wall. lrc and intracorporeal urinary diversion were performed. six trocars were used in the procedure. aft er lrc and extended pelvic lymph node dissection were accomplished, a cm ileal segment cm proximal to the ileocecum was harvested, of which a cm proximal ileal segment was moved to anastomose with the end of the harvested segment which was right isoperistaltic aff erent limb. th en cm ileal segment was detubularisated leaving cm intact proximal ileum for left isoperistaltic aff erent limb. th e harvested ileal segment was symmetrically folded with identical limb lengths. th e posterior wall of the neobladder was sutured, and ileoureteral stents were delivered into the two isoperistaltic limbs and passed up the ureter and coiled into the renal pelvis, and one foley catheter was delivered into the neobladder at the same time. bilateral ureteroileal anastomoses were performed in a continuous manner respectively. th e anterior wall of the neobladder was closed and the posterior urethra was anastomosed with the neobladder. we have performed cases with this technique. all procedures were completed without open conversion. th e mean operative time was min with a blood loss of ml. th e construction time of the neobladder was min. th e time to orally allow was postoperative day in all. th e mean hospital stay was d. foley catheter and dj stents were removed on postoperative day . no major complication was occurred. conclusion: laparoscopic radical cystectomy and intracorporeal orthotopic ileal neobladder with two isoperistaltic limbs were a safe and feasible for experienced laparoscopic surgeons. however, more cases and long follow-up were required to evaluate the function of the novel neobladder. all in this video, we wanted to share our robotics augmentation ileosistoplasty experience in -year-old male patient with a diagnosis of neurogenic bladder. an -year-old male patient treated with clean intermittent catheterization and anti-cholinergic therapy for neurogenic bladder. bladder capacity was detected cc, the irregularities in the bladder contour and left grade vur was detected in control video urodynamics. so we decided to implement robotic augmentation ileocystoplasty to the patients. results: th e transperitoneal approach is performed by using veress needle to access the peritoneal cavity. th e abdomen was insuffl ated using co and trocars placed under direct vision ( of camera port ( mm), of da vinci ports ( mm) was placed and of mm and of mm assistant ports were placed). a cm segment of ileum with mesentery was incised with about cm proximal from the ileocecal valve and this segment was suspended. intestinal anastomosis was performed with - vicril and - monocril sutures and created a u-shaped ileal pouch. th e bladder was released from the surrounding tissue. about cm, longitudinal incision was made to the bladder. a single-j catheters were placed to the left ureter and bladder for the left ureteral catheter and cystostomy. th e bowel prepared for bladder augmentation and it was sutured with . pds with wate tight anastomosis. operation was terminated by placing the drainage catheter. introduction and objective: although their numerous indications make double-j stents frequently preferred in the armamentarium of the urological practice, serious complications can arise, if they are not used correctly. in endourological surgeries, due to type and stuff of material the breakage or fracture risk of the equipment is more. th ere are various types of surgical procedures for the removal of the foreign bodies. shock wave lithotomy (swl) and ureteroscopy (urs) are the fi rst step in the removal encrusted ureteral stent. th is report presents a case of successful forgotten ureteral stent removal by means of fl exible ureterorenoscope (furs) and fl uoroscopic imaging. a -year-old male patient was admitted to our clinic with the complaint of recurrent urinary tract infection. in his medical history he said that he had an open kidney stone surgery in and aft er months d-j catheter removal had been performed. aft er radiologic imaging it is determined that there are two d-j catheter pieces in the right kidney collecting system. furs and removal of foreign body was performed successfully. postoperative fi rst day patient discharged with no complication. results: various materials and coatings have been developed to avoid ureteral stent complications such as encrustation and infections. th e incidence of encrustation increases with the duration that the stent remains in place. th ere are numerous types of removal techniques for foreign body removal, however furs seems to be the better one with the minimal postoperative rates. our technique was performed easily and in a short surgery time. conclusion: flexible urs modifi ed with fl uoroscopy has particular advantages for treating encrusted ureteral stents. th is procedure is least invasive and is thus considered to be most suitable surgery for encrusted ureteral stents or foreign body materials in the kidney. results: we outline strategies to prevent diffi culties with urethro-ileal anastomosis during rarc iucd neobladder formation. furthermore we off er some key technical points that can be benefi cial in overcoming challenging urethro-ileal anastomosis. conclusions: due to the technically complex nature of rarc icud neobladder formation, the awareness of potential pitfalls during each step of the process is essential. issues and solutions discussed in this video provide a valuable resource for clinicians performing this procedure. robotic in this video we present a patient presenting with concomitant renal neoplasm and a large calculus in the renal pelvis that what was managed with robotic pyelolithotomy at the time of partial nephrectomy. results: aft er exposure of kidney the ureter was identifi ed. th e renal pelvis was exposed and pyelolithotomy was performed. aft er this hilum was clamped and partial nephrectomy and renorrhaphy followed. th e warm ischemia time was minutes. th e procedure was completed without any complications. patient was discharged on the second postoperative day. conclusions: although uncommon, the presence of concomitant stone and renal neoplasm can make the decision of optimal patient care more challenging. using robotic platform simultaneous management of both conditions can be accomplished in appropriately selected cases. single introduction and objective: female epispadias is a rare congenital anomaly and is classifi ed, into vestibular, subsymphyseal, and retro-symphyseal. historically treatment consists of staged repairs with urethral and vulvar reconstruction in fi rst stage followed by bladder neck reconstruction at a later age. in addition, staged procedures require multiple sessions of surgery and anesthesia, and are associated with relatively higher morbidity. recently single stage perineal urethroplasty has been used for epispadias repair. objective of the study is to evaluate the results of single-stage perineal urethroplasty with double breasting of the urethra and bladder neck and sphincteroplasty in female epispadias. we treated patients with severe female epispadias since to . age varied from to years (mean years). perineal urethroplasty with double breasting, sphincteroplasty, and genitoplasty was done in cases. th e urethral plate and bladder neck was mobilized from the surrounding tissue till bladder neck. a urethral mucosal strip of about to mm was denuded from the bladder neck to the end of urethral plate on one lateral edge, and tubularized over a f catheter. urethroplasty was done with double breasting of the urethral muscle margins starting from inside the bladder neck downward to the neo-meatus with corporoplasty, sphincteroplasty, and genital reconstruction. results: all patients were satisfi ed and happy about cosmesis. of the patients, were fully continent with a dry interval of to hours, one of them had occasional night wetting was put on anticholinergic. one was partially continent with dry interval of hours required anticholinergic. conclusions: perineal urethroplasty with double breasting of urethra, from inside the bladder neck to the neomeatus, resulted in continence in most cases because it increased the urethral and bladder neck resistance, as well as bladder capacity, all were important factors in continence. we advocate this procedure as a fi rst choice in all patients with female epispadias, because it is simple, safe, and eff ective for continence. single we had partial penile disassembly to have the advantage of both technique. so objective of the study was to evaluate the functional and cosmetic outcome of single stage partial penile disassembly repair in isolated male epispadias. a retrospective analysis of cases of primary epispadias repair, performed during july to july at our institution. patients were classifi ed on the basis of type of epispadias, urinary incontinence, presence/degree of chordee and penile rotation. exstrophy epispadias complex and secondary repair were excluded. surgical technique: penile de-gloving with mobilization of urethral plate from ventral to dorsal aspect with preservation of blood supply at both ends, distally up to the level of midglans and proximally up to pubic symphysis with division of penopubic ligament to lengthen the penis and position the urethra ventrally. tubularization of urethral plate followed by spongioplasty, corporoplasty with medial rotation of corporeal bodies (without any corporotomy) and glanuloplasty with meatoplasty to bring the meatus ventrally. skin cover with rotation of ventral fl aps and z-plasty when required. results: age of the patients varied from months to years with a mean of years. forty patients ( %) had excellent cosmetic outcome while three patients ( %) had minimal residual chordee/torque but didn't require any surgery in a follow-up to - years. all seven partially incontinent patients in the study group achieved continence aft er surgery. none of the patients developed complications like fi stula or stricture. all the patients in the post pubertal group reported normal erections and successful ejaculations aft er the surgery. post-operative follow-up ranged from - years with a mean of years. conclusions: th e technique incorporates all the benefi ts of cantwell ransley repair, needs less extensive dissection than total penile disassembly. both functional and cosmetic results are good with low complication rate. spongioplasty reconstructs near normal urethra and corporoplasty with spongioplasty also helps in prevention of urethral fi stula. introduction and objective: to introduce a unique technique, single port laparoscopic assisted extraperitoneal closure of patent processus vaginalis using j shaped bended spinal needle. materials and methods: a . -mm -degree laparoscope was inserted through an umbilical incision. th e scope could view both inguinal ring. j shaped bended g spinal needle was inserted just mm lateral to the internal inguinal ring. th e needle was introduced to the extraperitoneal space over the vas deferens and spermatic vessels, injecting of saline for the preperitoneal hydrodilation. a - polyester suture was threaded through an g spinal needle. same - polyester suture was threaded through a g spinal needle from the tip. along the guidance of the suture and g needle, j shaped bended g spinal needle was reintroduced to extraperitoneal space. g spinal needle traveled through the upper margin of internal ring, g needle tip was pulled out of the initial g needle punctured opening. - polyester suture was pulled outside from the g needle tip and then g needle is also withdrawn. aft er all these procedure, internal inguinal ring was completely encircled and tied extracorporeally. th e knot was buried in the subcutaneous area within the punctured needle hole. results: sixteen children underwent laparoscopic transcutaneous extraperitoneal (lte) repair of hydrocele by using j shaped bended spinal needle. all patients were discharged on the same day aft er surgery without any complication. during a mean follow-up period of months (range - mo), no recurrence has been observed except fi rst cases. th is lte technique is simple, fast, safe and cosmetic procedure for pediatric hydrocele. robot assisted laparoscopic ureteral reimplantation for girl and boy patients: differences and similarities introduction and objective: nowadays robot assisted laparoscopic extravesical ureteral reimplantation is getting famous and in the literature is being an alternative for gold standard open surgery. in our clinic we have performed ralur procedures in our clinic for vesicoureteral refl ux and ureterovesical stricture and with this video-abstract we would like to share our experience on ralur in girl and boy patients; diff erences and similarities of procedure. we have performed ral-ur cases in our clinic between july -april for pediatric and adult patients. technique: all procedures have been performed under general anesthesia. nasogastric tube and urethral catheter placed to all patients. for all procedures -port confi guration is used: two robotic mm trocar, one mm camera trocar and one mm (including mm cover) assistant trocar. following docking robotic working arms of robot is placed. in all procedures one monopolar curved scissors, one needle holder and one maryland bipolar forceps is used as the working arms. all procedures performed transperitoneally and extravesically. in the working area of the procedure girls have more structures compared to boys. uterus, fallopian tubes and ovaries are the risky structures for girls while the vas deferens in boys. as seen in the video fallopian tubes, uterus and vas deferens are extraperitoneal organs, but ovary is intraperitoneal organ. we create a peritoneal window to reach the retroperioneal space and to dissect the ureter. dissecting the ureter we have been very careful not to harm vas deferens in boys and fallopian tubes in girls. protecting this structures we open one peritoneal window in boys and two windows in girls to fi nd and to work with the distal part of the ureter. vessel tape is used to hang the ureters. th e bladder is elevated with a - straight needle vicryl suture through the abdominal wall. aft er that the ureter was clipped with a hemoloc clip and sutured with a - vicryl suture in watertight fashion (if necessary). aft er suturing the distal ureter tailoring for the dilated distal rest ureter is performed (if necessary). following detrusorotomy, mucosa is cut for the anastomosis (if necessary). before the ureterovesical anastomosis f nelaton or a dj catheter was placed inside the ureter (if necessary). ureterovesical anastomosis is made with a - monocryl suture (if necessary). in the cases that ureter and mucosa are not cut, realignment suture is used. detrusorraphy is performed by a - barbed suture. following detrusorraphy we repaired the parietal peritoneum to close the peritoneal window one line and two lines in boys and girls, respectively. results: ralur procedure has been used successfully in girls and boys by considering the anatomical differences. bleeding was minimal in all patients. all patients discharged at the nd or rd postoperative days. conclusion: while using ralur procedures in pediatric patients, surgeon must be aware of the anatomy. mistakes during the procedure may damage the reproductive system components. performing this procedure in children, compared in adult patients, there are diffi culties due to the small size of the abdominal cavity. with the appropriate trocar placement this problem can be solved. robot assisted laparoscopic left ureteral reimplantation for ureterovesical stricture introduction and objective: extravesical robot-assisted laparoscopic ureteral reimplantation (ralur) for vesicoureteral refl ux (vur), ureterovesical strictures (uvs) and ureteral pathologies are alternative to the gold standard open repair in the literature. with this video presentation we want to share our initial experience with robot-assisted laparoscopic extravesical ureteral reimplantation using the ureteral advancement technique for a -year-old boy patient who is the youngest patient received this intervention in turkey. we have performed ral-ur procedure for adult and pediatric patients in our clinic. th is patient explained in the video was a -yearold boy who has had recurrent infections due to this condition. when the patient applied to our clinic he had already grade left ureterohydronephrosis. we performed left sided ralur procedure for this patient. technique: th e davinci si system was used via a transperitoneal approach. we used a port confi guration for the procedure; one -mm trochar for optic, two -mm trochars for robotic working arms and one -mm trochar for assistance. th e patient was placed in a modifi ed trendelenburg (approximately °) position. aft er docking the robotic arms, the ureter is identifi ed closed to the vas deferens. th e ureter is dissected distal to the vas and tented up with a tape. th e bladder is elevated with a - straight needle vicryl suture through the abdominal wall. a cm detrusorotomy is performed". aft er that left ureter was clipped with a hemoloc clip and sutured with a - vicryl suture in watertight fashion. aft er suturing the distal ureter tailoring for the dilated distal rest ureter is performed. before the ureterovesical anastomosis f nelaton catheter is placed thorough urethra and bladder inside the left tailored ureter. following this application nelaton catheter is binded to the urethral catheter. ureterovesical anastomosis is made with a - monocryl suture. detrusorraphy is performed by a - barbed suture. following detrusorraphy we repaired the parietal peritoneum and fi nished the procedure. foley catheter, nelaton catheter and drain are left at the end of the procedure. rectourethral fi stula is a morbid complication that can occur post trauma, radical prostatectomy, radiation, or pelvic surgery. th e management of these cases can be challenging and might require multiple procedures to achieve cure. th e use of omentum fl ap between the rectum and the urethra is recommended for its potential benefi ts in prevention of fi stula recurrence. we aim to illustrate the feasibility and safety of a new laparoscopic surgical technique for interposition of omentum in patients with complex pelvic fractures urethral injury (pfui) and rectourethral fi stula (ruf). we performed prospective case series of patients with pfui and ruf from september till october . th e initial approach is perineal with continued dissection until urethral transaction. laparoscopic team mobilises omentum and enters retroperitoneum lateral to bladder. a tvt needle is passed from perineum hugging the posterior wall of pubic symphysis and enters peritoneal cavity. th is tract is dilated and omentum transposed in to perineum. th is omentum is used as interposition between urethral anastomosis and rectum. th e clinical outcome was considered a failure when any instrumentation was needed or the recurrence of ruf. th congress of the sociÉtÉ internationale d'urologie -siu abstract book results: median age is years (range - ). all patients had complex pfui with ruf. th ey all had an attempt of perineal anastomotic urethroplasty with ruf repair that failed outside our center and were referred to us subsequently. all the patients had supra pubic catheters and of the three patients were passing urine through the rectum and the urethral meatus. one of the patients had a loop colostomy that was closed during the fi rst failed surgery. no intra-operative or post-operative complications occurred. patients were discharged home on post-operative day . all patients had the urethral catheter removed aft er weeks. th ree-month follow-up shows no fi stula recurrence with good urine fl ow. conclusion: using our new technique of laparoscopic omentoplasty for interposition of omentum in patients with ruf post pfui is a viable and safe option. th is allows us to perform a perineal surgery with the benefi t of omental interposition using a minimally invasive technique. further studies with larger number of patients as well as longer follow-up would be needed. introduction and objective: to test the hypothesis that a new surgical technique using elaborated perineal anastomotic urethroplasty combined with laparoscopic omentoplasty for patients with complex and prior failed pelvic fracture urethral defect repair was feasible, safe, and eff ective. we performed a prospective, observational, stage a study to observe treatment outcomes of combined perineal and laparoscopic approach for urethroplasty in patients with pelvic fracture urethral defect at a single center in pune, india, between january and february . complex and redo patients with pelvic fracture urethral defect occurring aft er pelvic fracture urethral injury were included in the study. anterior urethral strictures were excluded. th e primary study outcome was the success rate of the surgical technique, and the secondary outcome was to evaluate feasibility and safety of the procedure. th e clinical outcome was considered a failure when any postoperative instrumentation was needed. results: fift een male patients with a median age of years were included in the study. seven patients were adolescents ( - years) and patients ( . %) were adults ( - years). th e mean number of prior urethroplasties was . (range, - ). all patients underwent elaborated bulbomembranous anastomosis using a perineal approach with inferior pubectomy combined with laparoscopic mobilization of the omentum into the perineum to envelope the anastomosis and to fi ll the perineal dead space. of patients, ( . %) were successful and ( . %) failed. one adolescent boy years old developed a recurrent stricture months aft er the procedure and was managed using internal urethrotomy. median follow-up was months (range, - months). conclusion: combining a laparoscopic omentoplasty to a membranobulbar anastomosis for complex and redo pelvic fracture urethral injury is successful, feasible, safe, and with minimal additional morbidity to the patient. th e technique has the advantage of a perineal incision and the ability to use the omentum to support the anastomosis. dorsal results: buccal mucosal graft urethroplasty was done in all the patients with the graft being harvested from the buccal mucosa of the oral cavity. postoperative evaluation was done with voiding cystourethrogram at the time of catheter removal during the th postoperative week. mean peak urinary fl ow rate increased from . ml/sec to . ml/sec with normal fl ow curve stabilised at months to a mean of . ml/sec. patients were followed at , , and months in the fi rst year and then monthly thereaft er with urofl owmetry and ultrasonogram. mean follow-up period is around months. two patients required urethral dilatation for recurrence of symptoms. none of the patients developed stress urinary incontinence during follow-up. conclusions: female urethral stricture disease is under diagnosed and bmg urethroplasty is underutilised. our study adds to the limited evidence base, that bmg urethroplasty can be done safely with good results in females. a introduction and objective: ureteral fi stula's treatment oft en includes long and complex surgical and endoscopic therapies and represent a challenge for the urologist oft en with disappointing results. uventa® stent placement could represent a new option of conservative treatment for ureteral fi stulas. materials and methods: uventa® self-expanding ureteral stent are able to restore urinary fl ow in ureteral stenosis and to facilitate the closure of ureteral fi stulas thanks to its triple layer structure made of two layers of metal mesh with interposed a ptfe membrane. uventa® stents are available in diff erent lengths and diameters, and allow the coaxial overlap of the ends of multiple stents, providing a lumen of large caliber able to ensure the proper urinary fl ow and the possibility of further endoscopic procedures. we show the case of -year-old man that in september , undergone to pelvic surgery for an adenocarcinoma of the sigma in advanced stage. th e postoperative period revealed a urinary leakage, dealt initially in conservative way by the general surgeon. due to unsatisfactory results, the patient was then evaluated by the urologist and subjected to bilateral ascending pyelography highlighting the presence of a high fl ow left ureteral fi stula in pelvic tract; he case was managed immediately with bilateral ureteral stenting prior to placement of a uventa® stent. th e subsequent step was a retrograde pyelography through the left stent, used to identify the site of the ureteral fi stula. aft er hydrophilic guidewire positioning and mono-j stent removal, the delivery system of the uventa® stent is advanced coaxially to the guidewire under radiologia control. once reached the desired position the stent is released from its delivery system whit pull-back technique playing a uventa® stent fr x cm allowing its simultaneous self-expansion. th e next ureteroscopic control has shown the need to placement of an additional uventa® stent to complete fi stula's coverage. following the insertion of a hydrophilic nitinol guidewire a new uventa® stent fr x cm has been positioned further in order that the ends of the two stent's overlap for a length of at least cm. results: intraoperative retrograde pyelography showed that the stent have eff ectively excluded the fi stula. th e absence of contrast medium leakage was also documented by retrograde cystography performed after days from stents positioning. conclusions: in our experience, the application of uventa® stent has proven to be an eff ective option in the conservative treatment of minimally invasive ureteral fi stulas. robotic we performed fi ve robotic ureteroplasties using a buccal mucosal onlay between september and march . th e graft was procured by our otolaryngology colleague (jcl). th e graft onlay was performed using - pds suture and stent was placed robotically. stent was left in place for - weeks, and imaging repeated aft er removal. results: table describes each case and the outcomes observed. th e three patients who have undergone stent removal and reimaging had complete success and resolution of obstruction. th ere were post-operative complications, and none were higher than grade iii (table ) . table shows the demographic and perioperative variables of the patients undergoing this procedure. conclusion: our technique of robotic buccal mucosal ureteroplasty is safe and eff ective. we believe this is a relatively simple technique which is easily replicated. long-term data will be important to prove the validity of this procedure. primary endoscopic realignment of rupture urethra introduction and objective: pelvic fracture urethral injury (pfui) is more common in india and subcontinent. th ere is no consensus on the initial management of this injury. th ere are two schools of thoughts in all cases of suspected or confi rmed urethral rupture: a) initial supra-pubic catheterization (spc) followed by urethral reconstruction of inevitable stricture; and b) realignment of urethra. we demonstrate method of primary endoscopic realignment of rupture urethra and review the literature comparing these two procedures. a /m-presented with retention of urine and bleeding per urethra. he had sustained pelvic trauma when he was crushed between a tank and a wall. aft er initial resuscitation he had x ray pelvis, ct abdomen, rgu. he then underwent spc under ultrasound guidance. on th day aft er spc he underwent primary endoscopic realignment of the rupture urethra. we have shown a technique and reviewed the relevant literature emphasizing advantages of realignment. results: we used a two endoscopes technique one each from the spc route and per-urethral route. intra-operative contrast study was done to see extent of injury and also to see possible patency and continuity of the urethra. additionally methylene blue study was also done. a ptfe guide wire (gw) was passed from below. at the fi rst site of the gw from above it was apparent that further manoeuvers such as "going for light" would not be required. th e gw was carefully pulled in suprapubically. a silicon foley catheter ( f) was gently passed perurethrally over it. th e position of catheter was confi rmed suprapubically. patient had no major or minor complication. catheter was placed in for weeks and removed. post catheter removal patient voided well. th ese results correlated well with other studies in the literature. conclusion: ) technically not a challenging procedure. ) low risk and low complication rate. ) one failure of procedure does not preclude further attempts. ) adequate experience and instrumentation are essential. ) level evidence in favor of this approach over spc alone and further urethroplasty. neourethra with penile skin flap after total amputation of the penis kulkarni s, joshi p, batra v, sharour w, hunter c, surana s, kulkarni j introduction and objective: urethral carcinoma is a rare oncological entity. th e standard treatment for invasive urethral squamous cell carcinoma is radical penectomy, prostatectomy, cystectomy and ileal conduit. in our technique, we describe a palliative surgery that avoids the ileal diversion and perineal urethrostomy through the use of dorsal penile skin tubularization. th is video represents a detailed, step-by-step technique for retro auricular graft harvesting that we have found facilitates resident and general urologist teaching. ears were prepped and draped. th e grafted was areas were marked bilaterally. diluted lidocaine with epinephrine was injected subcutaneously. th e graft was harvested using sharp scissors. donor site was closed in two layers with minimal aesthetic changes. conclusions: our technique to harvest retroauricular graft is a simple and reproducible. it is useful in patients with lack of bmg. th is step-by-step video could be a useful resource for residents and general urologist who wish to learn an alternative graft . hand combined antegrade and retrograde intraureteric surgery in re-implanted ureter introduction and objective: we review a case of re-implanted ureter complicated with stricture and stone impaction. a -year-old gentleman was following the urology department at hmc. between the year until he was managed by the same urology team for his multiple urological complaints. diff erent open and endourological approaches were conducted. at the year of , this gentleman was complaining of colicky pain due to a cm impacted stone in the left lower ureter, sessions of eswl failed to break it. ivu showed left ureteric stricture, cystoscopy with trial of ureteroscopy was unsuccessful because the left ureteric orifi ce couldn't be identifi ed, so left percutaneous nephrostomy access inserted and followed by antegrade fl exible ureteroscopy, small opening found at the lower part of mid ureter and opened widely by laser, then followed by antegrade double j stenting. retrograde rigid ureteroscopy french identifi ed the stone at mid ureter in a later session and fragmented by laser. a double j stent was reinserted and removed later with smooth recovery. results: management of stones, in the male urethra, is a challenge, more so in a reconstructed urethra. th e dilemma always is whether it is worth incising an otherwise normal or reconstructed urethra, to extract a calculus, especially in this minimally invasive era. th e point to note is the 'painting' technique used to powder the stone, rather than fragmenting the stone into large fragments, which are then diffi cult to remove. high frequency and low energy laser setting is the order of the day. conclusion: laser lithotripsy using a high frequency low energy setting, is a good option for urethral calculi in a reconstructed urethra. retrograd introduction and objective: uretery duplication is a most common congenital anomaly of upper urinary system. th e incidence of it, in autopsy and intravenous pyelography (ivp) series, is . % and - % respectively. it is two-fold more frequent in women than men. retrograde intrarenal surgery (rirs) is a new technology in stone surgery with the fl exibility and most eff ective visualing. in patients who suff er from kidney or uretery with ureter duplication, rirs become the best surgery choice with its advantages. in this case, we present a patient who have the symptoms of kidney stone and ureter duplication. a -year-old male patient applied our clinic with the left fl ank pain. in his intravenous pyelography (ivp) and computerized tomography, it was clearly seen left ureter duplication of which both ureteropelvic junction and duplicated ureters obstructed by two kidney stones. other laboratory tests were normal. rirs surgery was performed the patient successfully. postoperative fi rst day patient was discharged without any complication. results: ureter duplication is a rare congenital anomaly of upper urinary system but the rarest thing is that the obstruction of both duplicated ureters with upj by kidney stones. in our case this kind of case successfully treated by rirs. in this surgery a new technique of access sheet entering for rirs was applied. to our knowledge it is the fi rst case in literature. surgical procedures in patients with urinary tract abnormalities are more diffi cult than the normal anatomy. th e development of new technologies is changing approach to such cases. rirs fi eld of use is gradually increasing in urologic practice. rirs in is a preferable method in duplicated ureter with stone formation. a introduction and objective: nephron-sparing surgery is now the standard of management of small renal mass and is increasingly performed for larger and more challenging lesions. th e aim of this study is to report our experience with robotic partial nephrectomy (rpn) and lapascopic partial nephrectomy (lpn) in patient's surgical outcome (blood loss, wit los renal function, complication). ( )) aml (rpn ( ) lpn ( )), oncocytoma (rpn ( ) lpn ( )) and simple cyst (lpn ( )). th e positive surgical margin rate were both % in rpn and lpn group. th e decline in glomerular fi ltration rate at the last available follow-up was similar in both groups. laparoscopy training at home guijarro a, ascencios j, morales s, huertas j, fernández b, navarro f, paniagua p introduction and objective: th e increasing use of laparoscopic surgery makes training fundamental to acquisition of the basics techniques of endourology. unfortunately, laparoscopic fi eld requires high ability and a long learning curve so it's needed simulators to practice. traditional pelvitrainers improve the laparoscopic skills of a trainee but don't simulate the real conditions of the human body. we present a homemade training surgical model that may help to achieve the skills needed and simulates the abdominal space. it is called simulated environment for laparoscopic training (selt). we have developed a laparoscopic training system based in a simulated environment. we modifi ed a dummy who represents a human trunk, this model it easy to fi nd in hardware stores. th en, we performed several orifi ces in order to place traditional laparoscopic ports in pelvic surgery disposition and two additional for our camera. inside the dummy we placed three screws and developed another hole for attaching a cork panel. also, we used a wardrobe fl ashlight as lighting system. as optical system we have used a inch tablet or a photographic camera linked to the tv. finally, for reproducing a vesicourethral model we use two balloons in order to create an anastomosis between them. final price for the selt model, excluding optical system and disposables (we used discarded ports) was euros, what is signifi cantly lower than the commercial pelvitrainers. time needed for installing all the devices is about minutes. results: th e level of simulation is high, it is more realistic, being harder and diffi cult than "traditional" pelvitrainers. th e degree of movements is limited by the real placement of the ports, distance until exercise is similar and we have to be able to work without results: nine patients underwent tmc left pyeloplasty. th ere were female and male patients with age ranging from - years .operating time ranged from - minutes with mean of minutes. per-operative blood loss was minimal ranging from - ml. return of bowel movement was within - days. all patients were discharged within days and drain removed with - days. two patients were discharged on nd day but drain was removed on rd day in outdoor. follow-up of patients showed improvement in their pain status and ivu showed no re-stricture or stenosis. our last patient is yet to come for the fi rst follow-up. conclusion: tranmesocolic approach for left puj obstruction is feasible and seems to have low morbidity with shorter hospital stay. comparison with colon-refl ecting pyeloplasty and larger number of cases are needed for better statistical evaluation. transperitoneal conclusion: th e overall cdr ( %) for our cohort was comparable to results from mri in-gantry biopsy. in volumes > cm , the cdr was % which was signifi cantly higher than that achieved by historical trus controls. th is study reinforces the benefi t of fusion biopsy in prostates in all volumes, but this utility is further enhanced in large volume glands without the potential toxicity associated with increased number of biopsies. fusion mim-transperineal fusion biopsy has the greatest impact in the biopsy naive population results: during the above mentioned period patients underwent radical prostatectomy. in ( . %) cases erp was preceded by mpmri and psm was detected in of them ( . %). in the majority of patients ( / ; . %) with positive margins pca was locally advanced or gleason score was greater than . th e margin was focal in ( . %) cases. th e most frequent location of psm was the prostate apex. it occurred in patients ( . %) and in of them the right side was involved. in ( . %) patients psm was detected in a location in which mpmri did not reveal the presence of pca. in of them, cancer invaded periprostatic tissues. macroscopic evaluation of the specimen performed directly aft er the erp indicated the possibility of psm presence only in patients but in both cases histological evaluation of the prostate specimen revealed extensive psm. the peri-prostate fat seen on mri. prostate volume was calculated using (height x width x length x π)/ . peri-prostatic fat density was then calculated using peri-prostatic fat volume/ (peri-prostatic fat volume + prostate volume). peri-prostatic fat ratio was calculated using (peri-prostatic fat volume / prostate volume). intervention includes cryoablation, brachytherapy, prostatectomy, external beam radiation with or without androgen deprivation therapy. results: a higher periprostatic fat density is signifi cantly associated with a higher gleason score, p= . , odds ratio . . a higher periprostatic fat ratio is also associated with a higher gleason score, p= . odds ratio . .patients with a higher prostate fat density (p= . , odds ratio . ) and higher peri-prostatic fat ratio (p= . , odds ratio . ) was also more likely to undergo intervention for prostate cancer (table ). psa has no correlation between periprostatic fat and periprostatic fat ratio. a higher prostate fat density and fat ratio is signifi cantly associated with a higher gleason score and a higher likelihood of patient undergoing an intervention for prostate cancer. peri-prostatic fat density and fat ratio may be an important risk factor in diagnosing patients higher grade prostate cancer. laparoscopic . th e mean urinary ph among the diabetics was . ± . and among the non-diabetics was . ± . , which was signifi cantly lower (p< . ). conclusions: th ere is a strong association between type diabetes and uric acid stone formation. th ere is also a strong association between diabetes mellitus, bmi, and also with lower urinary ph. the most patients ( %) were discharged on good condition while one patient died post-operatively. majority of patients ( %) stayed in the ward more than days post operation, the long-term post-operative outcome is yet to be assessed. conclusion: usd in our local setting seem to aff ect people of low social economic status whose daily activities in the fi elds, livestock keeping etc. mean survival; therefore longer stay in the hospital has a detrimental economic impact. outdated diagnostic, treatment equipment and technology lead to prolonged hospital stay. th ere is a need therefore for administrators and urologists in tanzania to improve quality of management of usd by acquiring aff ordable equipment and technologies. percutaneous nephrolithotomy in an ambulatory setting introduction and objective: percutaneous nephrolithotomy (pcnl) is the gold standard for the surgical management of large renal stones. various modifi cations have been done over a period of time to bring down the morbidity of this procedure. ambulatory pcnl (a-pcnl) aims at short hospital stay which is less than hours with faster recovery aft er pcnl. th is study aimed at exploring the feasibility and safety of short stay ambulatory pcnl. : th e number of pcnl procedure done at our institute annually ranges between - . hence, carefully selected patients with single renal calculus, size< cm, bmi < kg/m , favorable anatomy, no medical co-morbidities and moreover patients staying within a radius of km to the hospital with a supportive well informed family were given the option of a-pcnl. a total of patients underwent a-pcnl from april to june . all patients underwent totally tubeless pcnl with single puncture, amplatz size < f, minimal saline irrigation and puncture site infi ltration with . % bupivacaine. postoperatively narcotic analgesics were given; catheter was removed in the post-operative ward and patient was discharged within hrs. patients were explained regarding the complications of the procedure and need for homecare management. results: ten out of patients had insignifi cant post-operative period. one patient returned aft er hrs with loin pain which was evaluated and managed with injectable nsaid. another patient had hematuria which resolved aft er hours with conservative management. introduction and objective: chronic kidney disease (ckd) is associated with increased cardiovascular (cv) disease, independent of other risk factors. it is unclear whether anaemia develops in the setting of nephrectomy induced ckd, and whether it leads to an increased risk of cv morbidity. we assessed the impact nephrectomy has on renal function and evaluated our cohort for the presence of anaemia in relation to ckd stage and cardiac specifi c morbidity. pre-operative, post-operative, and yearly creatinine, hb and hct (up to years) was collected from nephrectomy patients between and . th e cohort was stratifi ed by cardiac risk factors and the prevalence of anaemia was stratifi ed by each ckd stage. we collected all-cause mortality and cv morbidity and mortality data. statistical tests were two-sided. where data was non-normally distributed median values and non-parametric tests were used. results: th e eff ect of nephrectomy on renal function is immediate (pre-operative vs. post-operative cr: p= . ) but not progressive (post-operative vs. -year cr: p= . ). elderly patients, patients with ≥ risk factors, bmi≥ or hypertension had signifi cantly higher post-operative cr (p= . ; p= . ; p= . ; p= . ). advanced age and mild ckd were important risk factors for ckd stage progression. th e prevalence of anaemia increased as ckd stage increased. at one year, the prevalence of anaemia was highest in ckd- patients ( . %), compared to ckd- ( . %) and ckd- ( . %) patients. fift een percent of patients experienced a new cv event; % of these patients were anaemic. conclusion: nephrectomy leads to immediate renal function deterioration but with no progression over time. th e clinical impact of nephrectomy is especially important in elderly patients and in patients with mild pre-operative renal impairment. th e prevalence of anaemia is more common in patients who have a higher ckd stage aft er nephrectomy, and may be a key risk factor for cv morbidity in nephrectomy patients. we believe that it is important to be able to predict who will progress to clinically signifi cant ckd, in order to optimise comorbidities and aggressively treat complications of ckd, such as anaemia. renal results: urological complication were observed in . % of all transplants. in an early phase we found that . % of patients showed problems related to the ureterovesical suture (loosening of the suture or attaching the double-j stent in the suture). suspicion of leakage with the formation of a urinoma was noted in . % of cases. more frequent were the late urological complications: hydronephrosis was seen in . % of cases. when further analyzing this group we discovered a distal ureteral stenosis in . % of all transplants. persistent hydronephrosis was resolved by reimplantation ( . %), permanent nephrostomy ( . %) or placement of a double-j stent ( . %). a large group of late complications consisted of infectious pathology. th us . % suff ered from complicated urinary tract infections which slightly more than a quarter of this population presenting with hydronephrosis. recurrent urinary tract infections without complications were found in . % of transplanted patients. conclusion: currently, the urological team mainly plays a role in the pre-and post-operative phase of renal transplantation. given the signifi cant compli-cations associated with the ureterimplantation performed during kidney transplantation, we advocate a place for the urologist in the perioperative phase as well. since the majority of the complications could be related to refl ux pathology, we propose a ureterimplantation with anti-refl ux mechanism. and october , patients were prospectively randomised into two groups. all patients presented with a simple renal cyst underwent ultrasonographic aspiration and injection of a sclerosing agent. in group , patients had the cyst injected with eo, and in group , were treated with ae. one injection was used in cysts of < ml and two injections were used in larger cysts. complete and partial success were defi ned as complete cyst ablation or a > % reduction in cyst volume with symptomatic relief, respectively. patients were followed up using semi-annual ultrasonography and computed tomography for years. results: sclerotherapy was technically successful in all patients. th ere was no signifi cant diff erence in cyst volume between the groups. aft er years of follow-up there was complete symptomatic relief in both groups, and the overall radiological success rate was % of both groups, at % complete and % partial in group , and % complete and % partial in group . th e frequency of transient complications in the form of microscopic haematuria was % and %, and of low-grade fever was % and % in groups and , respectively. a composite outcome parameter, known as "trifecta", has been recently proposed as measure of the surgical quality for partial nephrectomy (pn) procedures. we aim to validate the value of "trifecta" as a predictor of operated kidney functional preservation in a multi-institutional cohort of patients undergoing minimally invasive pn. we retrospectively reviewed records of consecutive cases of minimally invasive (laparoscopic and robotic) pn performed for ct renal masses in centres from usa and europe from to . inclusion criteria consisted of availability of a renal scan obtained within two weeks prior to surgery and follow-up renal scan - months aft er the surgery. trifecta was defi ned as a combination of negative surgical margin, zero perioperative complications and warm ischemia of less than minutes. th e primary endpoint of the study was to compare the degree of ipsilateral renal function preservation in relation to achievement of trifecta. renal function preservation was defi ned as a proportion of post-operative to pre-operative split renal function assessed by mag renal scan. a multivariable linear regression model was used to determine the independent value of several factors (surgical modality, charlson comorbidity score, achievement of trifecta, r.e.n.a.l score) to predict ipsilateral split function preservation. th e logic was that pnet is chemo-responsive and remaining are not. results: a total of patients were identifi ed. th e various histo-pathologies are shown in table . group had and group had patients. mean age in group was . yrs ( - yrs) with ( %) males and ( %) females. tumor was right-sided in ( %) and left -sided in ( %) cases. th e mean tumor size was . ( - ) cm. necrosis was noted in ( %). level of thrombus was level i in , level ii in , level iii in and level iv in . mean age in group was . yrs ( - yrs) with ( %) males and ( %) females. tumor was right-sided in ( . %) and left -sided in ( . %) cases. th e mean tumor size was . ( - ) cm. necrosis was noted in ( %). level of thrombus was level i in , level ii in , level iii in and level iv in . one of these was diagnosed pre-operatively by a biopsy and had received chemotherapy with partial tumor shrinkage. remaining received adjuvant chemotherapy. of relevance is that the youngest patient in group was years whereas the oldest patient in group was years. in patients with renal tumors and venous thrombus who are younger than years, pre-operative biopsy should be contemplated. in patients with a diagnosis of pnet, neo-adjuvant chemotherapy can be studied. introduction and objective: th e use of nephrectomy in emergency is increasingly rare due to the improved critical care urinary sepsis and development of radio-embolization. few series have been reported on this subject. th e aim of our study was to evaluate current indications, morbidity and mortality and results of nephrectomies performed in our hospital in emergency. a single-center retrospective study was conducted from january to december . twenty patients were operated in emergency from total nephrectomy. results: nine women and men with a mean age . ( . to . ) were treated for sepsis on emphysematous pyelonephritis or renal abscess, trauma with haemorrhagic shock, acute bleeding on renal tumours with haemorrhagic shock. one patient required critical care for multiple organ failure. th e time between the initial care and surgery was . days ( . - ). ten patients were referred to the emergency room by their physician and by a peripheral hospital. all these nephrectomies concerned native kidneys ( left kidneys). surgical approach was a lumbotomy for patients and a median laparotomy for patients. one patient died of multiple organ failure following urinary sepsis. one patient required dialysis following nephrectomy. th e mean follow-up aft er surgery was . months ( . to . ). conclusion: th e nephrectomy in emergency remains anecdotal. uncontrolled urinary sepsis were the main indications. th e identifi cation of populations at risk of progression to septic shock is essential for faster and reduced mortality in sepsis care. experiences of adrenalectomy for the incidentally discovered adrenal masses introduction and objective: a diagnosis of urinary tract obstruction (upjo) results in a functionally signifi cant impairment of the urinary transport from the renal pelvis to the ureter. options for the surgical management of upjo include ureteral stent placement, balloon dilation (antegrade, retrograde or cutting balloon), endopyelotomy, and open or laparoscopic pyeloplasty. however, in some cases, surgery is not eff ective, or too invasive for a particular patient. we herein report ten cases of treatment using bethanecol chloride. we retrospectively reviewed the record of patients, men and women, aged - years (mean . ) whose diagnosis was upjo ( cases of hydronephrosis on the left , on the right). th e chief complaints were back pain ( cases) and urinary tract infection ( cases). one patient had no complaint. all patients took mg of bethanecol chloride times a day for two weeks. aft er two weeks, kidney condition was evaluated using ultrasonography. results: five cases of hydronephrosis decreased or disappeared. five cases showed no improvement. among the latter, one had pyelonephritis, two had received laparoscopic pyeloplasty (one of whom had a non-functioning kidney and a pyelonephritis), and another had a non-functioning kidney. guzman martinez-valls p, sanchez rodriguez c, doñate iñiguez g, maluff torres a, honrubia vilchez b introduction and objective: we present man -yearold, hypertensive, diagnosed incidentally of intrathoracic renal ectopia during a constitutional syndrome study. intrathoracic renal ectopia is a very rare fi nd, with an incidence of less than of every , , which mainly aff ects left kidney since the liver protects the right diaphragm from pressure changes. a literature review of incidence, source, clinic, diagnostic and treatment of this type of renal ectopia occurs and we present the case diagnosed in our service. : chest x-ray shows a mass back in mediastinum so it was decided to ask for tomography computer (ct) that shows a hernia left postero-lateral difragmatic with promotion to the thoracic cavity of upper pole and half of the left kidney. since the patient is asymptomatic and the hernia is extrapleural does not need repairing surgical treatment. annual checks will be. intrathoracic renal ectopia is a very uncommon, usually asymptomatic, fi nding oft en diagnosed incidentally and which does not usually require treatment. surgical ( ), non-clamp zero ischemia ( ). th e average blood loss was ml (range ml - ml) and patients ( %) required blood transfusion. postoperatively patients ( %) had surgical complications: severe haemorrhage requiring emergency completion nephrectomy ( ), post-operative urinoma formation requiring ureteric stenting ( ), pneumothorax requiring tube thoracostomy ( ) . early day mortality occurred in one patient with pre-existing stage chronic kidney disease who died of acute on chronic renal failure. th e r.e.n.a.l. score of those with and without surgical complications was . and . respectively. th e complication rate of low (score - ), intermediate (score - ), and high (score - ) r.e.n.a.l. category was . %, . % and % respectively. statistically, blood loss, transfusion rate and surgical complication rate were not signifi cantly associated with medical co-morbidity, r.e.n.a.l. score or mode of ischemia, although more complex mass apparently resulted in more surgical complications. our study suggested that partial nephrectomy is a safe operation with acceptable bleeding risk and low complication rate. further larger scale study is needed to analyze the correlation of complications with renal mass complexity. introduction and objective: th e sound of running water has been eff ectively used for toilet training during the toddler period. however the eff ect of the sound of running water (srw) on voiding function for adult male with lower urinary tract symptoms (luts) has not been evaluated yet. to determine the eff ect of the srw on urination of male patients with luts, multiple voiding parameters of urofl owmetry with postvoid residual urine (pvr) were assessed according to the presence of the srw played by mobile application. a statistically pre-calculated numbers of consecutive male patients with luts were prospectively enrolled between march and april , excluding patients with hearing impairment, disability for movement, neurologic disease, urology deformity, and recent history of urinary tract infection or urethral stricture. urofl owmetry with pvr measured by bladder scan were randomly performed once a week for two consecutive weeks with and without srw in a completely sealed room away from exterior noise aft er pre-checking bladder volume scanned to be more than cc. th e srw was played with river water sound among relax melodies recorded in the smart-mobile application. results: th e mean age of enrolled patients and their mean ipss were . ± . years (range: - ) and . ± . . all patients have not been prescribed any medications including alpha-blocker or anti-muscarinic agents in the last three months. a signifi cant increase in mean peak fl ow rate (pfr) with srw was detected in comparison with pfr without srw ( . ml/s vs. . ml/s, p = . ). however, there were no diff erences in other urofl owmetric parameters including pvr. materials and methods: over a two-year period, men underwent lumbar spinal fusion by a single neurosurgeon. we excluded men with previous prostate or urethral surgery, a history of urinary retention, men taking alpha-blockers or fi ve alpha-reductase inhibitors, and men with prolonged hospital stay, leaving men evaluable. all men left the operating room with a foley catheter in place and were given a void trial on the day of anticipated discharge. twenty-three men were unable to void aft er eight hours and had their foley catheters replaced; they were discharged next day with an appointment for urologic follow-up. th ese men were compared to successful voiders with respect to comorbid medical conditions, age, surgical placement of hardware, operative time, lumbar level, multiple level fusion, and surgical approach. results: using multivariable analysis, successful postoperative voiders were compared with men who failed the initial voiding trial. only insulin-dependent diabetes mellitus (p-value less than . ) and multiple lumbar level surgery (p-value less than . ) were predictive of initial postoperative failure of voiding trial. conclusion: men scheduled to undergo lumbar fusion who have insulin-dependent diabetes or who will require multiple level intervention may benefi t from preoperative initiation of alpha blockade at the time of scheduling, as well as an inpatient postoperative urologic consultation. introduction and objective: heart rate variability (hrv) is a tool to measure autonomic nervous function, however there is no evidence that it is able to defi ne sympathetic hyperactivity in men with luts. we suppose that luts is diff erent between sympathetic hyperactive and hypoactive patients. th erefore we measured their hrv, divided luts patients into two groups, sympathetic hyperactive group and sympathetic hypoactive group according to the lf/hf ratio, and then compared their clinical situations. a total of symptomatic luts patients (ipss> ) and healthy volunteers were enrolled. all subjects had no disease which can aff ect autonomic nervous system, such as diabetes, hypertension and so on. electrocardiographic signals were obtained from subjects in resting state and calculated the hrv indices with spectral analyses. we divided luts patients into two groups by lf/hf ratio . which was mean value in healthy volunteer and compared the diff erence of clinical characteristics, ipss, psa and trus results. th e parameters were compared by independent sample t-test using spss version . results: th ere was no diff erence in age, serum psa and volume of prostate. th e comparative results of pa-rameters of hrv between groups (mean ± standard error) are in the table . conclusions: as most investigators believe that lf and hf represent sympathetic and parasympathetic nervous system activity, respectively, our results may suggest that luts patients with relatively sympathetic hypoactivity suff er from nocturia more than those with sympathetic hyperactivity. we suggest that the imbalance of the autonomic nervous system activity may be a factor that evokes varieties of symptoms in men with luts. introduction and objective: women presenting with urogenital pain oft en have lower urinary tract symptoms (luts). pelvic fl oor dysfunction and hypertonicity is thought to contribute to these symptoms. physical therapy and myofascial release are eff ective for both conditions, suggesting a common underlying pathophysiology. we aim to investigate the association among pelvic fl oor tone, luts, and pelvic organ distress. th ere was a tendency of lower hemoblobin decrease in ari group, however, this results was not statistically signifi cant. th ere were also no significant diff erences in improvement of ipss, qol and urodynamic fi ndings between the two groups. conclusion: preoperative use of ari does not compromise, but rather increase the effi ciency of surgery. th e use of ari is not a contraindication to th ulium laser vapoenucleation. age-specifi c relationships between lower urinary tract symptoms and late-onset hypogonadism symptoms in the japanese general population introduction and objective: aging is known to aff ect sexual, psychological and physiological functions including lower urinary tract symptoms (luts). recent data suggested that severity of luts was associated with that of late-onset hypogonadism (loh) in elderly men. however, information on the association in young adults is limited. in this study, we evaluated the relationship between luts and loh symptoms in young and middle-aged adults. results: th e mean ages of the patient and control groups were . ± . years and . ± . years, respectively (p= . ). th e mean ifsf-total and all of the ifsf sub scales (except pain) in the patient group were signifi cantly lower than those of the control group. th e mean udi- score of the patients was signifi cantly higher than the controls (p= . ). th e mean iiq- scores of the patients was higher than controls, however this increase was not statistically signifi cant (p= . ). introduction and objective: sav is one of the core components of hippo pathway, and this pathway plays a role for cell proliferation, apoptosis and migration through regulation of yes-associated protein (yap ). yap is known as an oncogenic protein in many human cancers, but only a few studies demonstrated that yap acts as an oncogene in renal cell carcinoma (rcc). in our previous study, we identifi ed sav was downregulated in high grade clear cell renal cell carcinoma (ccrcc) cases compared with low grade ccrcc cases and re-expression of sav inhibited rcc cell proliferation in vitro. to evaluate a role of sav in vivo, we created a murine xenograft model of human rcc. a total of -o cells with stable sav re-expression (sav - ) and control cells (control) were subcutaneously injected into the fl anks of mice, respectively. th ese two cell lines were also injected into subrenal capsule. tumor size, histological appearance and proliferation rate were evaluated. furthermore, transcriptome analysis was performed using a whole-genome microarray, in order to identify functional pathway by ingenuity pathway analysis (ipa) soft ware. to explore whether the identifi ed pathway was involved in hippo signaling pathway, western blotting was performed using antibodies against downstream proteins. in addition, the luciferase reporter assay was performed to explore whether the promoter activity is regulated by hippo signaling. results: tumors injected with sav - showed a decrease of tumor size and growth rate, compared with those of control. by immunohistochemical analysis, it was shown that re-expression of sav caused yap to localize in the cytoplasm. pathway analysis revealed that tgfβ signaling was found to be inhibited in tumors with sav - . in sav re-expression cells, protein levels of tgfβ were lower than those in control cells. when yap and tead were introduced, reporter activity of tgfβ promoter was increased. attached to a linear motion stage with a stepper motor. shaft buckling was determined by measuring the peak force to compress a cm section of the shaft a distance of cm. lubricity was measured by extracting each wire through simulated tissue at a constant speed, measuring average force over a second period. tip fl exibility was determined by isolating the distal cm portion of each guidewire and measuring the peak force required to compress a distance . cm while securing the tip in a small hole in a wooden block. perforation force was evaluated by stabilizing each wire in the dilator of a ureteral access sheath and measuring peak force required to perforate aluminum foil. up. , table . th e results showed that kh- protected tm cells against h o -induced oxdidative stress in a dose-dependent manner. it improved signifi cantly both the decline of semen parameters and decrease of testicular weight of androgen-defi cient rats at a dose of mg/kg. also it inhibited the activities of aromatase with and then increase the serum testosterone levels. conclusion: th ese results suggested that the aromatase inhibitory activity of kh- may contribute to the improvement of serum testosterone levels in androgen-defi cient male rats. introduction and objective: although several theories have been suggested, the pathophysiology of interstitial cystitis/bladder pain syndrome (ic/bps) is unclear. disruption of the bladder epithelial barrier is an important pathophysiologic theory of ic/bps, and uroplakin is known to have an important role in the bladder epithelial barrier. th e change in expression of uroplakin subtypes in the bladder could be related to ic/bps. we investigated the change in expression of uroplakin ib and iii in the bladders of patients with ulcerative ic/bps. bladder tissue samples were obtained from patients with ulcerative ic/bps who were treated with augmentation ileocystoplasty. samples for the control were obtained from normal bladder tissue apart from the malignant lesions of patients with bladder cancer who needed radical cystectomy. a voiding diary, the pain visual analogue scale (vas), and the o'leary-sant interstitial cystitis symptom index (icsi), and problem index (icpi) were used to assess patients with ic/bps before operation. expressions of uroplakin ib and iii were compared between the ulcerative ic/bps and control groups by immunofl uorescence staining and western blotting. results: in total, patients with ic/bps (mean age . ± . years, women and men) were evaluated. th e mean symptom duration was . ± . years. preoperative voiding frequency, nocturia, and functional bladder capacity documented in the voiding diary were . ± . , . ± . , and . ± . ml (mean ± sd), respectively. pain vas score, icsi, and icpi were . ± . , . ± . , and . ± . (mean ± sd), respectively. th e mean anesthetic bladder capacity was . ± . ml. immunofl uorescence staining showed that uroplakin ib and iii were localized in the urothelium. in western blot analysis, immunoreactive bands indicating expression of uroplakin iii were signifi cantly increased in the ic/bps group compared with the control group. however, uroplakin ib expression was not diff erent between the ic/bps and control groups. green fl uorescence protein cassette, and the infectivity of kshv was assessed using fl ow cytometry. to investigate viral replication, the levels of expression of representative kshv latent and lytic proteins were analyzed by immunofl uorescence assay. in addition, cell cycle and proliferation following kshv infection was analyzed. finally, cdna microarray was performed to identify gene changes by infection of kshv in bc. results: four bc cell lines, except rt , showed levels of infection similar to or higher than those of hu-vecs. infectivity of kshv in tccsup and huvec cells was similar, but t , , and ht- cells showed signifi cantly higher infectivity than huvec. our tested kshv-infected bc cells were latently infected by kshv. interestingly, a subset of kshv-infected bc cells showed higher brdu incorporation and proliferation rate than non-infected cells. furthermore, in soft agar colony formation assay, the numbers and sizes of colonies of kshv-infected cells were signifi cantly greater and larger, respectively, than non-infected cells. cdna microarray analysis showed that many proliferation and cancer development-related genes were simultaneously up-regulated in kshv-infected cells. introduction and objective: bladder cancer (bca) is the second common genitourinary tumor, and especially muscle-invasive bca (mibc) is poor prognosis. th erefore, it is important to clarify the mechanism of invasion in mibc is useful for the strategy of appropriate treatment. previously, we have showed hgf-met signaling is correlated with invasion in bca cells. here, we investigate the eff ects of met inhibitor, cabozantinib (xl ), in bca cells to investigate the significance of met upregulation in rt , , j , t , um-uc- cells, we conducted western blot analysis. next, we examined eff ect of cabozantinib on proliferation and invasion abilities using mtt and matrigel invasion assays. invasion assays were performed by the xcelligence system. moreover, to investigate biological function of hgf-met signaling, we analyzed gene expression profi le and real time pcr of cells which cultivated with or without hgf stimulation. . th e mechanical properties of scaff olds were measured to compare tensile strength between two types. for in vitro cell study, scaff olds were seeded with human fi broblast cell at x cells and were cultured for up to weeks. th e ability of these scaffolds to support fi broblast cell growth was also investigated in vitro. results: d strand-deposited scaff olds were characterized by sem images and porosity measurement. sem images showed the surface morphology of pcl scaff olds. th e young's modulus of °pcl was . ± . mpa, and °pcl was . ± . mpa, respectively. human fi broblast cells covered well the surface of the scaff olds. immunofl uorescent staining of α-er-tr on fi broblast cells/scaff olds confi rmed that the cells remained viable and proliferated throughout the time course of the culture. th is is a preliminary study to investigate the possibility of using d bioprinting technique for tissue engineered tunica albuginea. introduction and objective: aft er - years at people the decrease in a pool of pluripotent stem cells resulting in insuffi ciency of replenishment of cellular structure of cambial zones and, as a result, to incomplete replacement of the perishing old cells is observed. in reply surrounding epithelial and endothelial cells, and also the macrophages, attracted with death of old cells, stimulate cells division of growth zones by the cellular growth factors (pechersky a.v. et al., ) . to patients aged from till years with a cancer of a kidney, bladder, prostate gland of a stage of t -t the chemotherapy or target therapy was carried out. to patients of - years for restoration of regeneration it was carried out from to transfusions of mononuclear fraction of peripheral blood, same-gender and blood types with recipients. results: in month aft er carrying out chemotherapy or target therapy aft er development of a leukopenia in patients the level of the basic fi broblast growth factor (bfgf) increased on average by . times, at patients from them the increase in level of the human vascular-endothelial growth factor (human vegf-a) on average by . times was observed, the rd of them had an increase in the human epidermal growth factor (human egf) on average by . times. in - months aft er the last transfusion of mononuclear fraction of peripheral blood the maintenance of hemopoietic cells predecessors of cd + in peripheral blood increased on average by . times (at patients with to - cells in mcl). at patients the level of the basic fi broblast growth factor (bfgf) decreased on average by . times, at patients from them reduction of level of the human vascular-endothelial growth factor (human vegf-a) on average by . times was observed, the rd of them had a reduction an human epidermal growth factor (human egf) on average by . times. decrease in levels of cellular growth factors naturally brought at all patients in a buccal epithelium to decrease in an expression of p on average by . times, at the rd of them to decrease in an expression of bcl- on average by . times. excess stimulation of mitotic activity at people years are more senior it is possible to lower to normal level by means of restoration of number of a pool of pluripotent stem cells by transfusion of mononuclear fraction of the peripheral blood from young donors of - years of one with the recipient blood types and a sex. mashhadi r to compare the expression rate of sex steroid hormone receptors of estrogen (er), progesterone (pr) and androgen (ar) in normal urothelium and urothelial bladder cancer (ubc) and to evaluate the possible associations of these receptors expression with cancer progression and patient's survival. we evaluated the clinical data and tumor specimens of patients with patho-logically confi rmed primary ubc with normal healthy controls. both patients and controls selected from list of subjects who have been referred to sina urology clinic, and had a minimum of one year follow-up duration. data collected from medical cords. for evaluation of expression, immunohistochemistry was performed on paraffi n-embedded tissue sections using a monoclonal antibody for androgen, estrogen and progesterone receptors. presence of at least % positive cells defi ned as positive expression. results: none of the control subjects showed ar expression, while % of the patients were ar-positive. er/pr expressions were observed in . %/ and . % of the cases and in . % and . % of the controls, respectively. a statistically signifi cant correlation was found between ar expression and tumor stage and grade (p < . ). ar-positive patients showed a signifi cantly poorer prognosis than ar-negative cases (log-rank test, p = . , hazard ratio = . ; % confidence interval: . - . ). conclusion: ar expression was signifi cantly associated with higher grade and poorly diff erentiated tumors with unfavorable outcome. ar expression test might be useful as a diagnostic tool for determining the malignancy and outcome of ubc patients. park s, park w, yoon s introduction and objective: previous researchers consider interaction roles of ampk and ros as a regulator of cancer cell apoptosis and cancer invasiveness in hypoxia and oxidative stress. th e aim of this study was to fi nd out the other aspect of invasion and cell death mechanisms as a new treatment option in urothelial cancer. we performed western blot analysis to determine association between ampk regulator (compound c, aicar) and ros scavenger (nac and tempol) as cytotoxic eff ectors. using gelatin zymography to measure mmp- , activity, we evaluated the cancer invasion. pathway activation analysis was also determined by western blot. cell survival was investigated by mtt analysis. results: ros scavenger like nac and tempol treated cells showed no change of expressions of phospho-ampk. aicar, compound c and tempol treated cells showed no change of mmp- and mmp- expressions. however, nac treated cells showed decreased expressions of mmp- and mmp- . ai-car and compound c treated cells with or without added nac and tempol showed no change of mtor and phospho-mtor expressions. aicar treated cells only showed decreased expression of phospho-p s k. compound c and tempol treated cells did not showed statistically any change in cell counts. however, aicar and nac treated with or without added compound c and tempol showed increased cell death signifi cantly. conclusions: activator of ampk and ros scavenger like nac decrease t invasion activity and increase t cell death. so, we demonstrate that the cytotoxic mechanism of bladder cancer remains to be further investigated. epigenetic bladder cancer is still one of common human malignancies which some environmental agents play important role in the process of carcinogenesis, such as aromatic amines or chronic arsenism, and easy to be recurrent and progressive despite of therapy. it is continuing to search some novel genetic or epigenetic biomarkers and to investigate their signifi cance in bladder urothelial carcinoma. doc- /dab (diff erentially expressed in ovarian carcinoma- /disabled- ) interacting protein (dab ip), a novel family of ras gtpase-activating protein family, is a potent tumor suppressor gene. th e objectives of this study are to explore the prognostic values of dab ip expression and the possible regulatory mechanism in superfi cial bladder cancer. with irb consent and patient permit, eight human urothelial cancer cell lines and superfi cial bladder cancer tissues were available for exploring dab ip expression using western blotting and immunohistochemical staining, respectively. th e prognostic signifi cance of dab ip expression in term of recurrence and progression were analyzed with log-rank test. aft er treated with demethylizing agents trichostatin a (tsa) and -aza ' deoxycytidine (aza) separately and together, urothelial carcinoma cell lines were then tested with dab ip mrna expression using quantitative rtpcr. data mining was also done using published mrna diff erential array (dataset gse ). th irty patients with non-muscle invasive bladder cancer and agematched healthy controls were included in the study. peripheral blood samples were obtained from the patients before transurethral resection of bladder tumor (turbt), twenty days aft er the operation (fi rst control) and at the end of intravesical immunotherapy (second control). vegf- , mmp- , es and tsp- were measured by enzyme-linked immunosorbent assay (elisa). th e mean marker levels of the patients and controls were statistically compared. th e mean marker levels of the patients before turbt, in the fi rst and second control were also compared. results: th e mean age of the patients ( females and males) and controls ( females and males) were found to be . ± . and . ± . , respectively (p= . ). although the mean vegf and mmp levels in the patients before turbt were signifi cantly higher than the controls (p< . and p< . , respectively), there were no diff erences between the mean es and tps- levels (p= . and p= . , respectively). th e wegf- and mmp- levels signifi cantly decreased aft er turbt (p< . and p< . , respectively). th ese reductions continued aft er intravesical immunotherapy, but these diff erences between fi rst and second control were statistically insignifi cant. th is study showed that elevated angionenic factors in the patients with bladder cancer decreased aft er the treatment. we think that vegf and mmp may be used for the follow-up and therapy of non-muscle invasive bladder cancer. prognostic results: nitrose oxide level and bfgf expression were signifi cally elevated in patients with urothelial carcinoma associated with chronic bladder infection, normal urothelium showed low levels of no and low expression of bfgf. conclusion: th e association of elevated levels of nitrose oxide and over-expression of bfgf indicated that the angiogenic peptide bfgf had been modulated by nitrose oxide. th ese results would indicate an anti-angiogenisis target therapy in urothelial carcinoma associated with chronic bladder infection. the relationships between increase of serum creatinine and recurrence of nonmuscle invasive bladder cancer after transurethral resection of bladder tumor introduction and objective: while impaired renal function had a negative impact on the prognosis of invasive bladder cancer by infl uencing stage of tumor and selection of treatment modality, the relationships between the change of renal function and prognosis of non-muscle invasive bladder cancer (nmibc) have not yet been studied. preliminarily, we investigated the impact of increased serum creatinine and recurrence of nmibc. a total of patients who underwent transurethral resection of bladder tumor (turbt) with minimum follow-up of months were divided into two groups based on with (n= ) or without recurrence (n= ). th e changes of serum creatinine from the preoperative baseline to the time of recurrence were evaluated (Δ creatinine). for subjects without recurrence, serum creatinine was measured at months aft er turbt. th e impact of variables including characteristics of host (age, sex, past medical history, bmi, and smoking history), tumor (location, size, and grade), and laboratory data on recurrence of nmibc were then analyzed. tsai y , jou y , tsai y , liu b , lin h , wei c , chen s , tsai h , tzai t introduction and objective: bladder cancer is a common human malignancy and exhibits a life-long risk of disease recurrence and progression. it is continuing to search some simple, innovative biomarker to monitor the disease status in order to diminish the suff ering during cystoscopic follow-up. th e metabolite of tryptophan aft er indoleamine , -dioxygenase (ido) digestion, -hydroxyanthranilic acid ( -haa) is conventionally thought to be a potential biomarker for bladder cancer occurrence. th e aim to study is to investigate the diagnostic potential of an integrated a -haa-based biosensor for urothelial carcinoma of the upper tract and urinary bladder. human urothelial cancer cell lines and human urothelial carcinoma tissues as well as adjacent benign tissues were available for exploring ido expression, including western blotting and immunohistochemical staining. patients who received urological surgery were enrolled for urine -haa testing using an integrating biosensor for -haa. some of urine specimens were investigated with high performance liquid chromatography (hplc) assay. results: from western blotting assays, eight human urothelial carcinoma cell lines exhibited more ido expression than the immortalized cell sv-huc. both of urothelial carcinoma of urinary bladder and upper urinary tract exhibited more ido immunoreactivity than those of the adjacent benign bladder, ureteral or cortical tissues (chi-square test, p= . ). th ere is a moderate correlation for urine -haa measurement based on between hplc and the biosensor assays (r = . , p= . ). besides, the -haa content within the cultured media of tccsup and bftc measured with biosensors signifi cantly increased with incubation time (p < . ). finally, patients with urothelial carcinoma of bladder and upper tract have higher urine -haa levels than those without recurrence or benign urological disease, such as bph, or hernia (unpaired t-test, p= . ), except for urolithiasis. conclusion: th e integrated biosensor exhibited a modest accuracy in urine -haa detection. both of urothelial carcinoma of urinary bladder and upper tract exhibited higher ido expression and its metabolite -haa in urine. how a cancer spreads: public awareness of genitourinary cancer introduction and objective: patients' perceptions of disease can aff ect the diagnosis and treatment of the disease. it is diffi cult to give a defi nite answer to the questions; "can genitourinary cancers be spread around during coitus or in public bathtub?". doctors know that there is no evidence that cancers can be spread in this way, however many people don't know that. th e objective of this study was to investigate the public awareness of genitourinary cancer. one hundred and forty nine patients who have visited outpatient department of urology completed a self-administered questionnaire from june to july . th e questionnaires included epidemiologic information about age, gender, residential area, level of education and yearly income and the questions whether prostate cancer and bladder tumor could spread out during coitus or bathing. returned responses to questions were analyzed. results: a total of of ( %) patients completed the questionnaires. mean age was years, and ( %) men and ( %) women were included. th e residential area were metropolitan in ( %), urban in ( %), and suburban in ( %), respectively. th e level of education were middle school graduates in ( %), high school graduates in ( %), and college graduates in ( %), respectively. th e yearly incomes were under , dollars in ( %), , ~ , in ( %), and over , in ( %), respectively. seventeen ( %) and ( %) patients answered that they thought that bladder tumor could spread during coitus and bathing, respectively. likewise ( %) and ( %) patients answered that they believed that prostate cancer could spread during coitus and bathing, respectively. moreover, young patients (< years) reported that they have the opinions that coitus spreads prostate cancer ( %) and bladder tumor ( %). of college graduates, % and % reported that they thought coitus spreads prostate cancer and bladder tumor, respectively. conclusion: a signifi cant proportion of patients believed that prostate cancer and bladder tumor could spread during coitus. furthermore, even young and highly educated people also tended to have this misbelief. protoporphyrin we evaluated the feasibility of photodynamic diagnosis of bladder cancer by spectrophotometric analysis of voided urine samples aft er extracorporeal treatment with -aminolevulinic acid (ala). further, we investigate the protein that plays a key role in increased accumulation of protoporphyrin ix in bladder cancer cells. sixty-one patients with bladder cancer, confi rmed histologically aft er the transurethral resection of a bladder tumor, were recruited as the bladder cancer group, and outpatients without history of urothelial carcinoma were recruited as the control group. half of the voided urine sample was incubated with ala, and the rest was incubated without treatment. intensity of the samples at the excitation wavelength of nm was measured using a spectrophotometer. th e diff erence between the intensity of the ala-treated and ala-untreated samples at nm was calculated for photodynamic diagnosis of bladder cancer. immunohistochemistry was used to estimate the expression of peptide transporter , hydroxymethylbilane synthase, ferrochelatase, atp-binding cassette , and heme oxygenase- in samples from patients who underwent transurethral resection of bladder tumors. th e correlation between the expression of each protein in cells from resected bladder specimens and accumulated protoporphyrin ix in bladder cancer cells in voided urine was evaluated using pearson's correlation analysis. results: th e area under the curve was . . sensitivity and specifi city of the method were % and % respectively. th e expression of peptide transporter (p < . , r = . ), heme oxygenase- (p < . , r = . ), and ferrochelatase (p < . , r = . ) was correlated with the accumulation of protoporphyrin ix in bladder cancer cells in voided urine. we demonstrated that protoporphyrin ix levels in urinary cells treated with ala could be quantitatively detected by spectrophotometer in patients with bladder cancer. th e expression of ferrochelatase plays a key role in the accumulation of protoporphyrin ix in photodynamic diagnosis of bladder cancer. assessment of visual inspection as a tool to determine pelvic drain fluid type following radical cystectomy crozier j, papa n, lawrentschuk n introduction and objective: following radical cystectomy, patients generally spend a period of days under observation on a urology ward. during that time, staff closely monitor pelvic drain output to assess for the possibility of a urine leak. we aim to investigate the ability of medical and nursing staff to correctly identify pelvic drain fl uid type using visual inspection alone. investigators collected a series of de-identifi ed images showing pelvic drain fl uid in patients post radical cystectomy. th e fl uid type in each image was confi rmed by measuring creatinine level. investigators then attended a victorian public hospital urology meeting and a victorian gp conference. attendees were invited to participate in a study. present staff included consultant urologists, urology registrars, urology residents, urology nurses, medical oncologists, radiation oncologists, general practitioners and medical students. participants were then provided with a survey. th ey were asked to indicate their level of experience working on a urology ward, the number of years since graduation from their primary medical or nursing degree. participants were then shown the series of pelvic drain fl uid images on a project. th ey were asked to correctly identifying the fl uid type in each image. using the survey, participants had the option of choosing either urine or peritoneal fl uid. results: all groups poorly identifi ed fl uid type. no individual staff group was signifi cantly better at identifying fl uid type. level of experience on a urology ward and years since graduation do not infl uence ability to determine fl uid type. conclusion: visual inspection of pelvic drain fl uid is a poor determinant of fl uid type. chang y, hsiao p, chen g, lee s, huang c, wu h, yang c, chang c introduction and objective: muscle invasive bladder urothelial cell carcinoma occasionally mixed with squamous diff erentiation. we conducted this study to investigate the incidence and treatment outcome of bladder urothelial cell carcinoma with squamous component. we enrolled patients muscle invasion bladder cancer who received radical cystectomy with bilateral pelvic lymph node dissection during to . patients' characteristics, chemotherapy record, and pathological report were retrospectively reviewed. th e following endpoints were assessed: overall survival (os) and recurrence-free survival (rfs). response of neoadjuvant chemotherapy subgroup was also analyzed. all survival data were analyzed by the kaplan-meier method using a log-rank test and multivariate analysis was carried out using a cox proportional hazards regression model. results: it was very clear that more than one third of these cases coming from the south of saudi arabia ( . %). th e bilharzia infestation found in ( . %) of the cases most of them are the southern patients. th e t staging turn to be high in most of our cases ( . % are t b). squamous cells carcinomas was also a striking feature of our result and found in ( . %). lymph node involvement found in one fourth of these cases ( . %). a total of ( . %) had local or lymph node recurrence and ( . %) got distant metastasis. around % ( cases) of our result showing that these cases having high grade and around % ( cases) had a hydronephrosis upon presentation. bladder cancer as a cause of death because of its advancement or recurrence account for ( . %) of deaths happened in these cases. th e survival of these cases severely aff ected by the fact that cases ( . %) could not know there survival status because they stop to show up in our institute for follow-up in spite the fact that there are some of them followed for more than years. arabia showing that the bilharzia infestation is quit high especially in the south and the squamous cell cancer is not as low as we expected. finding of hydronephrosis, lymph node involvement, high t and high recurrence in high percentage of our cases indicating that the bladder cancer aggressiveness behavior is not changing over years. introduction and objective: th is is an observational retrospective study utilising long-term patient follow-up for years (ys). to determine the survival and quality of life in women with age range - years, who had been treated for carcinoma of the bladder with radical cystectomy with preservation of genital organs. materials and methods: study included women patients with invasive urothelial carcinoma of the bladder treated with genital sparring radical cystectomy during the period from to . th ey had orthotopic ileal neobladder. follow-up included recurrence-free survival, metastases-free survival, overall survival, continence, and sexual function. results: overall survival up to - ys was in / women ( . %). survivors up to ys were in / ( . %). survival from to ys was in / patients ( . %). tumours stage of t were / patients, t were / patients, and t a were / patients. tumour grade was g in / , g in / , and g in / . age range of - ys were patients, range of - ys was patients, range of - ys was patients. continence was good in / patients; three patients / needed cic. sexual function tested by fsfi over< - was ( . %). conclusion: th e study provide evidence of safety and effi cacy of radical cystectomy with sparing of genital organs in women aged to with low grade, low stage invasive urothelial carcinoma of the bladder. oncological outcome for - years was good; continence and sexual function were very good. th is procedure should be considered when surgical approach appears to be feasible. tan w, sherer b, nehra a, deane l introduction and objective: radical cystectomy for bladder cancer has been the surgical gold standard for decades. increasingly, experience with robotic assisted techniques has become more common in select centers. in the majority of instances, the urinary diversion has been performed extracorporeally and with the use of stents. herein, we report our center's initial experience with robotic radical cystectomy and stentless totally intracorporeal urinary diversion. a retrospective review of the medical records of all patients undergoing robotic cystectomy and intracorporeal diversion was conducted at rumc from - . specifi cally, attention was focused on perioperative parameters. results: a total of patients were identifi ed (male= , female= ) in the sample. four patients underwent intracorporeal ileal conduit reconstruction and one patient underwent totally intracorporeal ileal neobladder reconstruction. no patients received a pre op bowel preparation, post op pca or epidural and all were allowed oral intake early. no patient received a transfusion for operative blood loss. one patient was readmitted for dehydration. see table for details. conclusion: robotic assisted radical cystectomy with stentless intracorporeal diversion is safe and feasible. eliminating bowel preparation, pca and epidural, and incorporating early refeeding and ambulation may result in a shortened length of stay. a rigorous post-operative plan to optimize return of bowel function, permit rapid reintroduction of diet without restrictions and facilitate early ambulation is critical in improving outcomes for this patient population. computed up. , table . and hypermethylation of these two gene promoters. in order to investigate clinical usefulness for noninvasive bladder cancer detection, we further analyzed the methylation status in urine samples of bladder cancer patients. methylation of the tested genes in urine sediment dna was detected in the majority of cases that were hypermethylated in tumor samples ( . %) and the frequencies were . % . % and . % for apc, rarβ and survivin, respectively. our results indicate that methylation of apc, rarβ and survivin gene promoters is a common fi nding in patients with bladder carcinoma. th e ability to detect methylation not only in bladder tissue, but also in urine sediments, suggests that methylation markers are promising tools for noninvasive detection of bladder cancer. usefulness of the all cases were followed for over year. th e procedure is ) point marking; ) circular incision; ) level incision; and ) specimen retrieval using a needle electrode in accordance with the ukai's method. we investigated pathological fi ndings (margin situation), operation time, complications and recurrence. results: it is possible to diagnose the precise pathological fi ndings by turbo. we judged the width and depth ew in sequential section. th ere were few complications during and aft er the operation. operation time of turbo ( - min) was longer than conventional turbt. urethral catheter holding period and hospitalization period aft er turbo was the same as turbt. turbo is a relatively safe procedure even for beginners. twenty cases had a recurrence in cases. eleven cases had a recurrence in under year, but the same place recurrence was cases. th ere were few cases of same place recurrence in under year among margin-negative cases. th erefore we judged that ew-negative cases had no residual cancers. conclusion: turbo is a safe and useful procedure that provides precise pathological fi ndings with minimal complications. second tur is not necessary for turbo. turbo has a possibility to be gold standard of the treatment for non-muscle invasive bladder cancer (nmibc). the risks of bladder-preserving bacillus calmette-guérin therapy in high-grade non-muscle-invasive bladder cancer continuous physical activity has many eff ects on human body. it doesn't only strengthen the skeleton or muscles; it also affects cardiovascular system, nervous system and etc. in this research we wanted to fi gure out if continuous physical activity (cpa) eff ects the lower urinary tract symptoms in retired military offi cers or not. th is is a retrospective study. retired offi cers attending to urology clinic for annual prostate control and not using any drugs for prostate were enrolled in this study. aft er the patients' permission were taken for the study they were asked for cpa or not and their international prostate symptom scale (ipss) answers were compared. results: th ere were patients in cpa group and patients in non-cpa group. th e mean age is ( - ) in cpa group and . ( - ) in non-cpa group. answers of questions in ipss: incomplete emptying (p= . ), frequency (p= . ), urgency (p= . ), and straining (p= . ) were detected statistically rare in cpa group (table ) . although they were not statistically signifi cant, intermittency (p= . ), weak stream (p= . ) and nocturia (p= . ) were rare in cpa group too (table ) . in order to maintain a better lower urinary tract function, elderly men should continue their physical activity aft er retirement. conclusions: th e number of nocturia episodes was signifi cantly and linearly correlated with ipss total score, voiding, storage, qol and nih-cpsi voiding scores. however, other risk factors, including bmi, body fat percentage, blood pressure, bun, creatinine, lipid panel, ck, t , free t , prostate-specifi c antigen, serum testosterone levels, urine fl ow (assessed using urofl owmetry) and prostate size (assessed using transrectal ultrasound and digital rectal examinations) were not associated with the number of nocturia episodes, despite an a priori assumption that they all infl uence nocturia risk. risk results: symptom prevalence increased to . %, and the mean international prostate symptom score increased by . points during years. aft er adjusting for confounders, smoking history of ≥ pack-years was an independent risk factor for symptom deterioration and storage sub-symptoms, compared with non-smokers ( . and . odds, respectively). physical activity had a protective eff ect for voiding sub-symptoms. high daily protein intake exacerbated the storage symptoms. however, alcohol intake was not associated with symptom deterioration. conclusions: th e symptom prevalence among elderly men living in a suburban area increased to . %, and the international prostate symptom score increased by . points during years. smoking history, physical activity, and protein intake were associated with symptom deterioration. however, there was no signifi cant association with alcohol intake and symptom deterioration. russo g, castelli t, urzì d, privitera s, fragalà e, favilla v, cimino s, morgia g introduction and objective: a signifi cant amount of epidemiological evidences have underlined an emerging link between mets, benign prostatic enlargement (bpe) secondary to benign prostatic hyperplasia (bph) and related lower urinary tract symptoms (luts). we aimed to assess the connections between lower urinary tract symptoms (luts) related to benign prostatic enlargement (bpe) and metabolic syndrome (mets) with its components. is increased prostatic urethral angle related to lower urinary symptoms in male without prostatic obstruction? introduction and objective: th e prostatic urethra is a bent tube, and the clinical signifi cance of the prostatic urethral angle (pua) was recently reported. we investigated the statistical signifi cance of an increased pua on the international prostate symptom score (ipss), with luts/bph. a prospective analysis was made of patients ( . ± . years) with luts and/or bph. patient underwent an evaluation including the ipss, psa, transrectal ultrasonography, urofl owmetry, and measurement of post-void residual. pua were measured by cystourethroscopy ( figure ). in order to minimize the eff ect of prostate, patients with prostatic obstruction under cystourethroscopy were excluded. th e minimum pua degree of symptoms change was constructed as a predictor of the eff ect of medication. all patients received tamsulosin . mg during the fi rst weeks and . mg during the next weeks. results: th e psa, prostate volume and pua were . ± . ng/ml, . ± . ml and . ± . °, respectively. th e area under the roc curve was . at the degrees with a sensitivity of . % and a specifi city of . %. comparing a higher pua (over degree, group a) with a lower pua (under degree, group b), patient with a higher pua had a longer luts period (p= . ), an improvement of symptoms aft er medication (p= . ) and an increase of average fl ow rate (p= . ). however, there was no signifi cant diff erence in age, psa, post-voided volume between the two groups. conclusion: pua showed signifi cantly correlated with the improvement of ipss, the eff ect of medication, and urofl owmetry. our fi ndings suggest that pua under cystourethroscopy may be one method to assess the presence of luts in men and help in the treatment of individuals by better predicting their likely classifi cation from ipss, urofl owmetry, and prostate volume. however, further studies are needed to explore the mechanisms and the eff ects of pua under cystourethroscopy. introduction and objective: th e prevalence of lower urinary tract symptoms increased with age. it is known that irritable bladder symptoms such as urinary frequency, urgency, nocturia increased with age in many studies. recently it was reported that vascular calcifi cation was one of the cause of lower urinary tract symptoms. we studied to evaluate the association between lower urinary tract symptoms of vascular calcifi cation in the abdominal ct using by agar score. th e records were obtained from a retrospective database who underwent abdominal ct due abdominal pain, hematuria. sex, age, height, weight, prostatic size, calcifi cation of aorta and internal iliac artery, amount of subcutaneous fat and visceral fat in the umbilicus level, international prostate symptom score, overactive symptoms score and urofl owmetry were assessed. calcifi cation of aorta was estimated from renal artery bifurcation to iliac artery bifurcation level. and internal iliac artery calcifi cation was calculated from bifurcation of iliac artery to bladder. we scanned each subject of . cm interval on the ct scan. th e calcifi cation of blood vessels was measured as agar score using abdominal ct aft er our explaining about each contents of nih-cp-si and iief- , the paper was checked by volunteers in person, and then we collected it. th e subjects were limited to - s korean male. we analyzed the collected questionnaires, and considered men who have perineal and/or ejaculatory pain or discomfort and a total nih-cpsi pain score of ≥ as having prostatitis-like symptoms, and categorized to four groups by iief- score, mild ( - ), mild-moderate ( - ), moderate ( - ), severe ( - ). results: an average age of volunteers was years old ( - ). th e iief- category was divided to fi ve groups. among total volunteers, persons were chronic prostatitis like symptom patients ( . %), and whose nih-cpsi average of pain score, voiding score, quality of life score and total score were . ± . , . ± . , . ± . , and . ± . , respective-up. , figure . ly. th ere were a little correlations among pain score, voiding score, quality life score, but not signifi cant. an average of total iief- scores in chronic prostatitis like symptom patients was . ± . , it was signifi cantly lower than absent group. th ere were all negative correlations of between iief- and pain score (t=- . , r = . , p= . ), voiding score (t=- . , r = . , p= . ), qol score (t=- . , r = . , p= . ), and total score (t=- . , r = . , p= . ). conclusion: th e higher total nih-cpsi score, especially pain score plays a larger role, adversely aff ects erectile function of chronic prostatitis like symptom patients in - s korean male. a antimuscarinic agent is the mainstay of treatment, but it have side eff ects such as dry mouth, constipation. th ese eff ects resulted in cessation of medication in many cases. th e authors therefore assessed the impact of side eff ects on health-related quality of life (hr-qol) through an analysis of questionnaires. th is study was designed to investigate the patients' satisfaction by quality weight (utility weight) of health status as aff ected by the side eff ects of oab medications in tertiary hospitals in korea. patients who had oab symptoms lasting longer than months and side eff ects aft er any antimuscarinic treatment fi lled in the eq- d. th e questionnaire and vas score for two diff erent health statuses, presence or absence of side eff ects, were analyzed. quality weight was calculated using the score of ed- d health status. results: one hundred patients were enrolled. th e most prevalent side eff ect was dry mouth ( %), followed by constipation ( %). twenty-eight percent of the patients had dry mouth and constipation concurrently. most of the patients with side eff ects tried to overcome these side eff ects ( %), but % desired a change in medication, and % stopped medication altogether. fift y-fi ve patients replied that they consider side eff ects to be an important factor in deciding on the continuation of medication. th e quality weight of eq- d without side eff ects was . , while the quality weight with side eff ects was . (p= . ). th e vas score was in patient without side eff ects and in those with side eff ects, supporting the results of quality weight assessment. th e same trend was observed when stratifi ed according to age and sex. as for the overall distribution of ed- d, the patients with side eff ects were less healthy in terms of daily life, pain/discomfort, and anxiety/depression. introduction and objective: treatment of men with large prostates is challenging with greater risk of complication and retreatment. while photo-vaporization (pvp) has been well described for greenlight w-xps, vapor resection techniques have been described to help improve tissue resection, including vapour-incision techniques (vit). we sought to evaluate the effi ciency, safety and outcome parameters between greenlight pvp and vit specifi cally for men with prostate volumes > . among xps cases retrospectively collected from experienced surgeons at high-volume greenlight xps centers, had large prostates. preoperative, operative and post-operative parameters were collected and compared between groups. results: as summarized in table , men undergoing vit (n= ) had comparable preoperative parameters to those undergoing pvp (n= ). while vit allowed greater delivery of energy ( . vs . kj/g), operative time was longer and there was greater need for > fi bres. th ere were no diff erences in intra-and day post-operative adverse events. both vit and pvp demonstrated comparable marked improvements in ipss/qol at months post-operatively. however, despite greater urinary retention and pvr preoperatively, men with vit demonstrated signifi cantly lower post-operative pvr and greater qmax at moths. no signifi cant diff erence in retreatment rates was noted between vit and pvp follow-up. conclusions: both greenlight pvp and vit techniques can be safely used to treat men with large prostates. both techniques off er signifi cant and durable relief of symptom relief with comparable complication rates at years. longer follow-up is necessary to assess durability. open within two years, one-hundred patients were prospectively randomized into two equal groups. all patients underwent tvp whereas rb was used in group- . rb is a balloon fi xed to -way foley catheter tip by blaster strip making it air tight. we placed it in the rectum opposing prostate and infl ate (pressure controlled) for min. hemoglobin (hg) levels have been assessed pre-and postoperation. blood transfusion, amount of saline for irrigation, catheter duration, hospital stay, and rectal complain were recorded. follow-up was and -mo, postoperatively. results: enucleated adenoma weight was gm in g- and gm in g- . th ere is signifi cant diff erence between both group for hg-loss within fi rst h post-operative and total hg-loss . gm in g- and . gm in g- (p, . ) and . gm vs. gm (p, . ) respectively. also there is signifi cant diff erence between both group in relation to the saline/l for irrigation ( . vs. . l), catheter duration ( . vs. . day), and hospital stay ( . vs. . day), with favorable results to the rb group. blood transfusion was in g- and one in g- . th ere is no rectal complain. conclusion: rb infl ation post-tvp is simple and safe procedure without operative technique, reduces post-operative blood loss, blood transfusion incidence, saline for irrigation, and shortens the catheterization period and hospital stay, without rectal complication. conclusion: th ough this was not a head-to-head study and there were a number of dissimilarities in the study design, we demonstrated a non-inferiority of our study and a signifi cantly shorter median length of catheterization, time until stable health, and hospitalization relative to the goliath study. introduction and objective: th ulium laser enucleation of the prostate (th ulep) has been introduced as a minimally invasive treatment for benign prostatic obstruction (bpo). th e aim of the study is to assess what are the intraoperative key points and possible complications of the morcellation procedure aft er th ulep. to assess whether this events have any eff ect on hospitalization length. a cooperation between the university of milan and moscow was settled. prospective study that analyzes events that prolonged the morcellation process aft er completing thullium laser enucleation procedure in a group of consecutive patients was performed. events related to the morcellation procedure were recorded. patients' hospitalization length were evaluated aft er discharge only considering patients that were not re-admitted because of a surgical related issue. statistical analysis was performed by the student t and chi-square test and logistic regression analysis. for all statistical comparisons signifi cance was considered at p< . . results: mean age was . years. five groups of reasons for prolonged morcellation were recorded. bladder suction with wall damage, bleeding due to "ex vacuo" fast empting, suction problem, morcellation impairment and prolonged morcellation time due to enlarged prostate. each group of issues was related to a signifi cant prolonged operative time (p< . ). th e table shows the key points rate and their correlation with a prolonged hospital stay. a statistical significance between the event and the prolonged hospital stay found only for bladder suction. conclusions: issues related to the morcellation procedure aft er laser enucleation of the prostate (th ulep) causes prolonged hospitalization length only in the case of bladder suction. other events, even if related to a slower operative time, do not mean a prolonged hospitalization. suprapubic cystostomy makes turp more effective and safer introduction and objective: a recent survey found turp the commonest performed procedure in bph, despite the rising popularity of laser prostatectomy. th e reasons for popularity in laser are ease of performance, lesser complications, and good results. it is the complications factor that makes it look attractive. th e onus is therefore to make turp safer. th is is more applicable in india, where the cost of laser excludes - % of patients. numerous innovative procedures have been tried to make turp safer. continuous outfl ow has been described as innovation, the means to achieve it not described. introduction and objective: prophylactic peri-vesical drain placement during suprapubic prostatectomy remains a widespread surgical practice. however the surgical technique of suprapubic prostatectomy has signifi cantly improved and as such the contemporary role of prophylactic surgical drains needs reevaluation. it has been traditionally assumed that prophylactic drains helps prevent fl uid collection (blood, serum, urine) which if not drained can lead to surgical wound complications. th is paper investigates the incidence of surgical wound complications aft er a series of suprapubic prostatectomy done without placement of surgical drains but in the context of modifi cations to the surgical technique. prostatic hyperplasia (bph) were operated upon between and -all using a modifi ed suprapubic prostatectomy technique that includes meticulous dissection, hemostatic suturing that covers the main areas of anatomic distribution of the urethral arterial branches of the inferior vesical artery, non-placement of drains and suprapubic catheter, and also routine irrigation of the surgical wound with normal saline among other modifi cations. pre-and post-operative blood hemoglobin levels, prostate specimen weights and presence of surgical wound complications if any were recorded. th e main outcome measure was to determine the presence of early surgical wound complication defi ned as clinical evidence of hematoma/ seroma, infection, drainage or wound dehiscence. results: th e mean age of the patients was . (range of to years). th e mean prostate weight was . gm-(range of to gm). th e mean hemoglobin diff erence was . mg/dl (range of . mg/dl to . mg/dl). on a minimum days observation of the surgical wounds, there was only one case of superficial wound infection ( . %) that healed with wound dressing. th ere was no mortality and none of the patients received blood transfusion. in the context of an improved surgical technique, suprapubic prostatectomy for bph can be safely performed without the placement of prophylactic peri-vesical drain. non-placement of prophylactic surgical drains in this series was not associated with increased wound complication rate. effects of detrusor underactivity conclusions: according to detrusor activity, there were not diff erent in diff erences between preoperative or postoperative ipss. abnormal detrusor contractility (esp. dua) cannot be a contraindication for tur-p, and turp should be a defi nite therapeutic option in abnormal detrusor activity. geavlete p, dragutescu m, multescu r, georgescu d, geavlete p introduction and objective: th is long-term retrospective study aimed to analyze the re-intervention necessities aft er bipolar plasma vaporization of the prostate (bpvp) in patients with medium sized benign prostatic hyperplasia (bph). materials and methods: th ere were followed patients who underwent bpvp for prostates sized between and ml. th e re-intervention rates were analyzed during a follow-up period of at least months. results: additional interventions consisted of immediate reoperation for secondary hematuria, endoscopic re-intervention for urethral stricture or blad-der neck sclerosis and transurethral resection of the prostate (turp) for residual bph bulk. endoscopic hemostasis during hospitalization was required in cases ( . %) and in discharged patients in other cases ( . %). during the follow-up period, patients ( . %) with bladder neck sclerosis underwent the plasma vaporization approach. urethral stricture was diagnosed in patients ( . %), of them receiving internal optical urethrotomy while urethroplasty was performed in cases. residual adenoma was present in patients ( . %), thus requiring and secondary turp. conclusion: bpvp is a valuable endoscopic treatment alternative for medium size bph cases with higher effi ciency and a satisfactory rate of reoperation. diode laser nm for the treatment of bph: long-term comparison of the enucleation vs. vaporization introduction and objective: to report -years follow-up results of clinical trial comparing diode laser enucleation of the prostate (dilep) with diode laser vaporisation of the prostate (dlvap). a total of consecutive patients were included in the prospective study who had received laser treatment for bph. patients were assigned to two groups based on the type of procedure: to dilep group and to dlvap group. patients with a history of neurogenic bladder dysfunction, chronic prostatitis or bladder cancer were excluded from evaluation. standard follow-up examinations were performed in both study groups in predefi ned time points (in the perioperative period, at month and month , and month , and then every year). primary endpoints included: lower urinary tract symptoms (luts) as measured by the international prostate symptom score (ipss), urinary fl ow rates and post-void residual urinary volume. complications were assessed. an additional endpoint was to review video records to precisely determine the timeframes for individual surgical procedures and to plot the learning curve. results: all the remaining patients had undergone the -year follow-up assessment. measurements were performed at , , , , , , and months. th ere were no statistically signifi cant differences in baseline characteristics between the two groups. no signifi cant intraoperative and early postoperative bleeding was observed. hospital stay aft er surgical intervention covered day that was equal to average time of urethral catheter indwelling. th e improvement rates, calculated based on the ipss scores at years aft er surgery, were . % and . % in the dilep and dlvap group, respectively. th e results indicate signifi cant decrease in severity of luts. th e sustained treatment eff ect was in favor of dilep intervention group. also treatment effi cacy was better in the dilep group compared to the dvlap group, as regards the maximum urinary fl ow rate (qmax). th e diff erence was statistically signifi cant. conclusions: diode laser enucleation and vaporisation of the prostate are low-risk minimally-invasive treatment option of treatment of patients with bph. both methods may be safely performed even in high risk and patients on ongoing oral anticoagulation. treatment eff ects are better and more sustained with laser enucleation than with laser vaporization of the prostate. dilep is a true endourological alternative to turp. changes in urination according to the sound of running water using a mobile phone application introduction and objective: th e sound of running water (srw) has been eff ectively used for toilet training during toddlerhood. however, the eff ect of srw on voiding functions in adult males with lower urinary tract symptoms (luts) has not been evaluated. to determine the eff ect of srw on urination in male patients with luts, multiple voiding parameters of urofl owmetry with postvoid residual urine (pvr) were assessed according to the presence of srw played by a mobile application. eighteen consecutive male patients with luts were prospectively enrolled between march and april . urofl owmetry with pvr measured by a bladder scan was randomly performed once weekly for two consecutive weeks with and without srw in a completely sealed room aft er pre-checked bladder volume was scanned to be more than cc. srw was played with river water sounds amongst relaxed melodies from a smartphone mobile application. results: th e mean age of enrolled patients and their mean international prostate symptom score (ipss) were . ± . years (range: - ) and . ± . , respectively. all patients had not been prescribed any medications, including alpha-blockers or anti-muscarinic agents, in the last months. th ere was a signifi cant increase in mean peak fl ow rate (pfr) with srw in comparison to without srw ( . ml/s vs. . ml/s, respectively, p = . ). however, there were no diff erences in other urofl owmetric parameters, including pvr. th e study showed that srw from a mobile phone application may be helpful in facilitating voiding functions by increasing pfr in male luts patients. th is study aims to analyse how bladder outlet obstruction index (booi) and bladder contractility index (bci) aff ect surgical outcome for bph patients who were treated homium laser enucleation of the prostate (holep). we classifi ed the patients, who were treated holep and observed more than months, into group i (booi≥ and bci≥ , n= ), group ii (booi≥ and bci< , n= ), group iii ( <booi< and bci≥ , n= ) and group iv ( <booi< and bci< , n= ) based on urodynamic study result. patient's characteristics including volume of prostate, psa, ipss, maximum urinary fl ow rate and residual urine volume compared in each group. and we also compared ipss, maximum urinary fl ow rate, residual urine volume before and months aft er surgery. results: th ere was no signifi cant diff erence comparing age, psa, ipss, maximum urinary fl ow rate and residual urine volume among each group. th e prostate volume, ranked in ascending order of group, are as follows: . ± . ml, . ± . ml, . ± . ml and . ± . ml, it had signifi cantly disparity between group i and iii (p= . ), group i and iv (p= . ), and group ii and iv p= . ). using repeated measure anova, we found that ipss, maximum urinary fl ow rate and residual urine volume were signifi cantly improved within group in each group aft er surgery except ipss storage subscore between group ii and group iii and residual urine volume. and the degree of improvement among each group was not diff erent (table ) . th e incidence of aur ( . %) and bph-related surgery ( . %) were low in ct group. in comparison of baseline age, psa, and pv according to switch of medical therapy, baseline pv was signifi cant diff erence in both groups, respectively (p= . , p= . ). conclusion: th ere was more mt than ct in initial treatment. however, there was more switch of medical treatment type in initial mt in real-world clinical practice over -year follow-up. th e incidence of bph progression events was high in initial mt group. th e initial use of ct is recommended in patients with luts and bph. relationship between bladder wall thickness and lower urinary board the antarctic research vessel "shirase" on their way home and approximately two months aft er returning to japan. we analyzed the data of members of the winter party who had responded to the questionnaires more than times before departure and during their stays in antarctica. results: compared to before departure, the mean scores for all of the questionnaires decreased during their stays in antarctica, from . to . points for ipss, from . to . points for oabss, and from . to . points for psqi, but the mean volume voided per micturition increased from to ml. in regard to the amount of change in ipss scores over the same period, a signifi cant diff erence was noted between members with a pre-departure score ≥ points and members with a pre-departure score < points (- . vs. . , p = . ). th is study is the fi rst to report the urinary status of people in a polar environment investigated with questionnaires and voiding logs. we initiated this study under the assumption that one's urinary status would deteriorate in a polar environment, but our fi ndings indicated that urination and sleep tend to improve in antarctica. management of male luts: a southeast asia regional survey on practice patterns and perspectives results: responses were obtained from urologists from centres with size ranging from to patients per week. referral patterns diff er across the region -in hong kong, singapore and malaysia, patients prefer or are required to consult a general practitioner before seeking urologist care. common investigations that respondents proposed included urofl owmetry ± post-void residual volume measurement ( %), psa ( %), urinalysis ( %), voiding diary ( %), physical examination ( %) and trus-biopsy ( %). however, only urinalysis and symptom scores are essential investigations recommended consistently in major international guidelines. whether urofl owmetry should become an essential investigation in sea remains debatable. luts secondary to bph/bpo ( %) and oab ( %) were the two most common diagnoses for the case scenario, and correspondingly, alpha-blocker ( %) and antimuscarinics ( %) were the two predominant treatments suggested by respondents. nocturnal polyuria is a common cause of nocturia especially amongst elderly, yet relatively few urologists ( %) considered this condition as a main diagnosis. respondents felt that there was a paucity of large-scale epidemiology studies on luts in sea, and on the natural history of the disease. more education on the proper evaluation and diagnosis of luts is needed for both gps and urologists in the region. results from this sea survey revealed variations in urologists' practice patterns and guideline recommendations, and pointed to the needs for further research and education in luts. female urethral prolapse: bhalla v , attri a , bhalla s introduction and objective: urethral prolapse means the protrusion of the distal urethra through the external urethral meatus. female urethral prolapse is a rare condition that has bimodal distribution aff ecting postmenopausal women and prepubertal girls. female urethra has two layers of smooth muscles inner longitudinal layer and outer circular which remain adherent to each other by strong connective tissue. separation of these two layers with episodic increase in intra-abdominal pressure leads to complete urethral prolapse. birth trauma during prolonged vaginal delivery, perineal tears, debility, malnutrition and periurethral bulking agent injections have been implicated in postmenopausal group. we present two postmenopausal female patients of urethral prolapse having similar clinical presentation aged years and years respectively. th ey presented with symptoms of blood spotting of undergarments and voiding diffi culty with dysuria of acute onset. on physical examination a doughnut-shaped erythematous infl amed mass was seen protruding from external urethral opening. th e evaluated parameters included pop-q grade, international prostatic symptom score (ipss), overactive bladder questionnaire (oab-q), international consultation on incontinence questionnaires short form (iciq-sf), maximum fl ow rate (q-max), and residual urine volume (ru). we evaluated them before and , , year aft er surgery. results: pop-q grade before surgery tended to be high in elderly group without signifi cance. anatomical cure at year aft er surgery (%) of non-elderly and elderly was and %, respectively. a tendency to having poor scores was observed in elderly group concerning preoperative ipss, iciq-sf and oabss; however they did not attain signifi cance. th ese three parameters improved in both groups aft er surgery; however, the percent improvement was signifi cantly poor in elderly group. th e maximum fl ow rate before surgery was signifi cantly low in elderly group and was still low aft er surgery. th e residual urine volume did not show signifi cant diff erence in each group before and aft er surgery. in the observation period of year, de novo oab and mesh extrusion were observed in elderly group with a signifi cant frequency. conclusions: th ough the anatomical cure was not age specifi c, age apparently aff ected on the outcome of tvm especially in the percent improvement of luts. autologous materials and methods: ten women with sever and complicated stress urinary incontinence secondary to the bladder neck and urethral trauma or congenital epispadias (with or without extrophy) underwent transurethral injection of autologous muscle derived cells. a second injection was performed according to the assessment of patients, months aft er the fi rst treatment session. all patients were followed at one week, , and months aft er injection by physical examination (cough stress tests), one hour pad test and iiq- score. multi-channel urodynamic study and maximal urethral closure profi lometry (mucp) was performed before and months aft er the last treatment session. cough stress test, one hour pad test and urofl owmetry were repeated at months aft er the last injection. in each visit the severity and incidence of complications was recorded. results: all patients completed the study and were followed for months. th ree patients were cured; four and three of patients were improved and failed to the treatment respectively. th ere were no major adverse events related to the treatment. conclusions: according to our clinical results, in a limited number of female patients, muscle derived cell therapy is a minimally invasive and safe procedure in the treatment of patients with severe and complicated sui. th e cure rate is not high, though it may be considered as an option beside other treatment modality. are we evaluated the eff ect of patient position and bladder fi lling status on the q-tip angle for urethral hypermobility. we measured the q-tip angle in the supine position and at a ° angle in a reclining position in patients during bladder emptying and then repeated the measurements while fi lling the bladder, usually - ml. we defi ned urethral hypermobility as the urethral angle straining or coughing minus that at rest > °. results: all female patients (mean age, ± years; range, - ) who complained of urinary incontinence were assessed using the q-tip angle. th e pelvic organ prolapse quantifi cation stages of all patients were ≤ stage . mean q-tip angle with an empty bladder was . ± . ° in the supine position and . ± . ° in the ° reclining position (p = . ). mean q-tip angle during the fi lling bladder state was . ± . ° in the supine position and . ± . ° in the ° reclining position (p = . ). th e urethral hypermobility rate during the bladder emptying state was . % ( / ) in the supine position and . % ( / ) in the ° reclining position. th e relative positive ratio of the reclining to the supine position is . . th e urethral hypermobility rate during the bladder fi lling state was . % ( / ) in the supine position and . % ( / ) in the ° reclining position. th e positive rate was higher in the ° reclining position during bladder emptying than that in the other position during bladder fi lling. conclusion: th e outcome of the q-tip angle measurement and the rate of urethral hypermobility changed in relation to patient position. th e reclining position during bladder emptying increased the q-tip angle, resulting in positive urethral hypermobility. rotational th ere was no mortality from the surgical procedure, whereas pain and catheter blockage was main complication. all patients were followed at , , and weeks respectively. our success rate was %. vesicovaginal fi stula is the most common urogenital fi stula. obstructed labor and its complications are still the leading cause of its development, whereas iatrogenic fi stula is also up-coming warning for all health care professional. the effi cacy of combination therapy of alpha blocker with anticholinergic in adult women with overactive bladder introduction and objective: overactive bladder (oab) is associated with symptoms including urgency, with or without urge incontinence, usually with frequency and nocturia. anticholinergics are mainly used for the treatment of patients with oab, especially women. other than anticholinergics, alpha blockers have been shown in several clinical reports to be useful in treating detrusor overactivity caused by neurological diseases. th e aim of the study is to evaluate the effi cacy of alpha blocker in combination with anticholinergics to treat women suff ering from oab. th is prospective study enrolled female patients with oab. patients have been randomised into two groups. th e interventions for the -week treatment period included solifenacin daily for the group and combination of both solifenacin and tamsulosin daily for the group . at baseline and weeks aft er treatment, patients completed a -day bladder diary, international prostate symptom score (ipss), quality of life (qol) index, overactive bladder symptom score (oabss), maximum fl ow rate (qmax) and postvoid residual urine volume (pvr). results: a total of women were randomised and completed this study (group ; , group ; ). statistically signifi cant improvements in terms of urgency and frequency were observed in both groups at weeks aft er treatment as compared with baseline (p< . and < . ), while no inter-group diff erence was observed between the two groups. although group showed improvement of ipss voiding subscore, qol and qmax than group but not statistically signifi cant (p= . , p= . , p= . ) . no signifi cant diff erence was observed in terms of toxic events between the two groups. conclusion: th e combination of alpha blocker and anticholinergic for weeks was noninferior to anticholinergic alone in effi cacy, and there was no evidence of benefi t of alpha blocker in treating female oab. further studies are needed to assess the role of combined therapy of alpha blocker and anticholinergic in the treatment of female oab. conclusion: advancement of cystoscopy will continue undoubtedly. th is report emphasizes the key people whom contributions will always be a corner stone in the fi eld of urology. "gleason" in a nutshell unusual urogenital disorders introduction and objective: to present some aspects of unusual urogenital disorders, congenital malformations, and syndromes, sometimes occurring in eminent personalities or having been described by famous scientists. th e review of historical sources and biographies of famous suff erers and the study of modern medical literature about all these rare urogenital diseases. results: penile deformities such as hypospadias (the most known representative was henry ii of france - , suff ering also from chordee) and the rare epispadias (respectively the most known was the byzantine emperor heraclius, - ) were recorded by historians because of the infertility consequences or the bizarre urination habits (heraclius needed protective measures to avoid getting wet). historians also were attracted by spectacular and dramatic urological emergencies, such as fournier gangrene, known by the case of the prominent suff erer herod. referring to famous researchers, françois gigot de la peyronie ( - ), founder of the royal academy of surgery of france, described the homonymous disorder ( ), consisting of penile deformity due to induration of the corpora cavernosa of the penis. th e above disease, called also induratio penis plastica (ipp) is one of the extraordinary urogenital problems together with the strongly psychologically and non-physically induced syndromes koro (genital retraction syndrome) and castration anxiety (the latter described by freud). belief that genitals have disappear and fear of damage or loss of the penis characterize them both. much of the research has been done on the two above topics, although still relevant today. conclusions: unusual urological disorders are broadly known when happening on famous personalities or when described by famous physicians or when attract the common opinion as extraordinary events (called mirabilia by historians). koutsiaris e , drettas p , oikonomou a , poulakou-rebelakou e , rempelakos a introduction and objective: th e loss of a testis represents a psychologically traumatic experience in males of any age. testicular loss is commonly the result of torsion, trauma, infection or malignancy. th e patients who experience orchiectomy request the implantation of an artifi cial testis for psychological or cosmetic reasons. testicular prostheses are one of the most commonly implanted devices and we present the evolution of these devices. review of the medical literature regarding the history of testicular prostheses and the various materials that have been used during the decades. results: th e fi rst testicular prosthesis was an alloy of molybdenium, cobalt and chromium and was used in . during the s, other materials were used such as plexiglass and polyethylene without much success. it was then suggested by the scientifi c community that the ideal testicular prosthesis should not produce any infl ammatory reaction and that should be also made by a proven non carcinogen material. it was also suggested that the material of the prosthesis should also resist mechanical press and take and hold the desired form. as a result, solid silicone rubber prostheses were introduced and used in the s. th e demand for more natural feeling implants lead to gel fi lled silicone devices appearing in . in , fi rmer silicone coated prosthesis became the "gold" standard. in the us in , the food and drug administration (fda) halted the use of gel fi lled breast implants due to the risks of autoimmune disorders and the possibility of tumor development. as a consequence, in there was a voluntary withdrawal of silicone gel fi lled testicular prostheses and replacement with saline fi lled prostheses. nowadays both silicone and saline fi lled testicular implants are used worldwide which are safe and eff ective. conclusions: testicular prostheses reduce the psychological impact that results from loss or absence of a testicle and should be off ered to male patients of any age. introduction and objective: we investigated population-based management trends of urinary stone disease in the use of extracorporeal shock wave lithotripsy, ureteroscopy and percutaneous nephrolithotomy during the recent years in a korean population. we conducted this retrospective study by reviewing the medical records of patients diagnosed with acute ureteric colic in the emergency room and in the urology outpatient from january to december . nine hundred patients were diagnosed with ureteric stone and all of them underwent ultrasound as the primary imaging modality. sensitivity, specifi city, positive and negative predictive value in determining the size, position of the stone in the ureter by ultrasound has been documented. results: out of patients, there were males ( %) and females ( %). age range was - years. our study found that color doppler ultrasound with twinkling sign, diagnosis was made with confi dence in cases ( . %). sixty-fi ve patients who failed the ultrasound, the stones were confi rmed by helical ct, failure to detect the stone was mainly due to poor visualization (due to bowel gases and obesity) and smaller size of stone. right side stones were seen in ( . %) patients while left side stones were seen in ( . %). stones were detected bilaterally in cases ( . %). th e range of stones size was - . mm. th ere were ( . %), ( . %) and ( . %) upper, middle and lower ureteral stones. conclusion: th ere is no doubt that spiral ct is superior in the demonstrating of ureteral calculi. th e present study emphasized that utilization of color doppler ultrasound with twinkling in trained hands can provide an excellent alternative modality with high sensitivity and specifi city in diagnosis of acute ureteric colic and with confi dence can be used as fi rst imaging modality, hence we could avoid high cost, higher radiation dose and high workload. contemporary imaging practice patterns following ureteroscopy for stone disease cleveland clinic, cleveland, usa introduction and objective: routine imaging following ureteroscopy for treatment of renal/ureteral calculi continues to be a topic of debate. however, with the increasing focus on healthcare costs and quality, judicious use of diagnostic imaging to optimize outcomes while minimizing resource utilization is a priority. we sought to identify post-ureteroscopy imaging practices amongst experienced urologists. a redcap questionnaire was sent to urologists in north america. th e questionnaire surveyed demographic data, clinical volume, and imaging preferences post-ureteroscopy. additionally, we surveyed the extent to which stone, anatomic, and procedure-related factors infl uenced these preferences. th e likelihood of altering clinical practice and the desire for specifi c imaging guidelines were also assessed. th e interquartile range (iqr) was utilized as a measure of median consensus, with a lower iqr denoting increased agreement. results: th ree hundred twenty two urologists completed the questionnaire. th e mean number of years in practice was ± ; % of respondents performed more than ureteroscopic stone procedures monthly. routine postoperative imaging was obtained by % of participants as follows: us ( %), kub ( %), ct ( %), ivp ( %), and kub + us ( %). urologists who did not routinely image patients were more concerned about cost ( % vs. %, p= < . ), radiation exposure ( % vs. %, p= < . ), and diagnostic inaccuracy of us ( % vs. %, p= < . ). th ese urologists were also less likely to have completed an endourology fellowship ( % vs. %, p= < . ). th e most compelling predictors of obtaining postoperative imaging were post-op pain and fever (median , iqr ), residual stones (median , iqr ), ureteral perforation (median , iqr ), and presence of a solitary kidney (median . , iqr ). conclusions: currently, about % of urologists who regularly perform ureteroscopic stone procedures obtain post-op imaging. imaging preferences were guided by the presence of residual fragments, ureteral perforation, solitary kidney, and postoperative pain or fever. introduction and objective: ct scans expose patients to ionizing radiation which is associated with risks of secondary malignancy. we sought to evaluate the performance of reduced dose ct scans in patients evaluated for renal colic in the emergency room. up. , figure . introduction and objective: intraoperative exposure to ionizing radiation is a growing concern for the safety of both patient and or staff . eff orts to reduce the amount of radiation during ureteroscopic procedures oft en result in decreased image quality. lessray™ is a device used to digitally enhance images obtained from a c-arm using a low-dose pulse setting allowing for reduction in radiation dose while maintaining image quality. a randomized prospective trial of patients was performed comparing ureteroscopic cases for unilateral obstructing ureteral stones using standard fl uoroscopy compared to lessray™. patient demographics, stone parameters, and operative characteristics were recorded in addition to total radiation dose, total fl uoroscopy time and images obtained ( (table ) . a statistically signifi cant reduction in radiation exposure to the surgeon was also noted (p = . ). image quality was not compromised and no conversion from less-ray™ to standard fl uoroscopy was needed in any case. a nearly threefold reduction in patient radiation exposure was achieved using the lessray™ digital enhancement device compared to standard fl uoroscopy. th is novel technology has not previously been used in urologic surgery and off ers a promising alternative to standard fl uoroscopy while ameliorating risks to both the patient and surgeon. bilateral results: in the cases of cn patients, accepted retroperitoneal laparoscopic cyst unroofi ng, accepted retroperitoneal laparoscopic partial nephrectomy, patient with a preoperative diagnosis of cystic renal cell carcinoma, the maximum diameter of cm and located in the center of the kidney got retroperitoneal laparoscopic radical nephrectomy. one patient recurred yrs later aft er retroperitoneal laparoscopic cyst unroofi ng, and underwent open partial nephrectomy at last. six mestk patients underwent retroperitoneal laparoscopic radical nephrectomy and accepted retroperitoneal laparoscopic partial nephrectomy. twelve cases were followed up for months to years, no recurrence. conclusion: cn and mestk are rare benign tumors of the kidney. preoperative misdiagnosis is high. multi-cystic lesions with no mural nodules should take cn/mestk into consideration, especially when the lesions convex to the pelvis, should be highly suspected for cn diagnosis, and to assess the possibility of partial nephrectomy. cyst unroofi ng for cn has recurrence risk. the value of -t multiparametric mri for detecting prostate cancer of t stage introduction and objective: th e objective of this study was to prospectively determine the value of -t multiparametric (mp) mri with pelvic -phased array coil for prostate cancer of t stage. december , patients underwent -t mpm-ri with pelvic -phased array coil, transrectal ultrasound-guided biopsy and radical prostatectomy for adenocarcinoma. mr images were evaluated by three experienced radiologists with regard to extracapsular extension and seminal vesicle involvement and compared with whole-mount histopathological sections as a gold standard. we estimated the sensitivity, specifi city, positive, and negative predictive value and overall accuracy of mpmri for t disease. introduction and objective: prostate cancer (pca) imaging has undergone a revolution in the past fi ve years with the rise of multiparametric magnetic resonance imaging (mri) for cancer detection and the evolution of positron emission tomography-computed tomography (pet-ct) for staging. initially, choline pet-ct was considered the new standard for detecting metastatic disease where biochemical recurrence (bcr) occurs aft er primary treatment, but a newer agent based on prostate-specifi c membrane antigen (psma) has emerged. despite the reported promising results with this novel imaging modality few reports correlating psma pet-ct with pca histology have been documented. we present the case of a fi t year old gentleman, where psma pet-ct was used to accurately detect pca pelvic lymph node (ln) metastasis in the setting of bcr following primary radiation treatment. results: th e positive psma pet result was confi rmed with histological examination of the involved pelvic lns following robotic-assisted laparoscopic pelvic ln dissection (plnd). larger studies are required to document accurately the role of psma pet-ct but it is likely it will usher in a new era of surgical and even radiation treatment of oligometastatic disease, aiming for cure or prolonged deferring of systemic treatment. introduction and objective: imaged guided radiotherapy has been shown to improve the outcome of pelvic radiotherapy, notably with prostate gold seed fi ducials. lipiodol has been utilized for radiotherapy bladder fi ducials, but can be technically diffi cult to inject as discrete fi ducial markers, particularly in the post-prostatectomy setting. th e objective is to investigate contrast agent/tissue glue mixtures as radiotherapy bladder fi ducials with respect to deliverability and visualisation for radiotherapy verifi cation. two radiopaque contrast agents, lipiodol and urograffi n were investigated. th ese were mixed with a three tissue glues: histoac-ryl™, tisseel™ and glubran™. to simulate the clinical procedure, the mixtures were injected ex-vivo into the submucosa of fl uid fi lled pigs' bladders using a cystoscope and williams needle. th e aim was to produce a small, medium and large fi ducial. th e bladders were transferred to a pigs' pelvis to provide realistic tissue densities for radiotherapy imaging. visualisation of the pelvis was performed in accordance with radiotherapy procedures. th e initial imaging was done on a radiotherapy ct simulator. radiotherapy verifi cation was performed by radiation therapists using widely accepted protocols including cone beam ct (cbct) and kilovoltage (kv) & megavoltage (mv) d planar images. results: delivery: urograffi n glue mixtures were diffi cult to deliver as it polymerized rapidly in the catheter. consequently it was only possible to produce a single fi ducial. th e lipiodol glue combinations were all deliverable. visibility: th e urograffi n glue combinations were only able to produce a single fi ducial that was visible on ct and cbct but were not visible with kv or mv verifi cation. all of the lipiodol glue combinations produced multiple fi ducials that could be satisfactorily visualised on ct and cbct. lipiodol with either hystoacryl or glubran produced visible fi ducials on kv imaging, however the lipiodol tisseel combinations could not be seen. no combination produced suffi cient contrast with mv planar imaging. introduction and objective: th e fl exible urethrocystoscopy is a procedure that is performed routinely in urology for monitoring bladder tumors and diagnosis in patients with lower urinary tract symptoms and hematuria. th e aim of this study is to analyze whether the use or not of antibiotic prophylaxis is indicated in this outpatient procedure. prospective nonrandomized observational study in which patients were divided into two groups: -group : patients with prophylaxis with ciprofl oxacin mg h before urethrocystoscopy; -group : patients without antibiotic prophylaxis. prior to inclusion in the study absence of urinary tract infection is checked by urine culture obtained three days before the procedure. indication of cystoscopy, cystoscopy results, presence of comorbidities, urine culture aft er days, urinary symptoms over the next seven days were analyzed. statistical analysis with spss . with signifi cance diff erences p≤ . . results: th e mean age of patients in group was . ± . years versus . ± . years in group (p= . ). no diff erences in the percentage of men / women included among the groups. fourteen percent of patients in group had bacteriuria compared with % in group , no signifi cant diff erence. in the multivariate analysis, it appears that neither age, diabetes, smoking, lower urinary tract symptoms or immunosuppression were associated with the onset of bacteriuria between groups. conclusion: th e use of ciprofl oxacin prophylaxis in fl exible cystoscopy is not indicated in our health area, because does not diminish the presence of urinary tract infection or bacteriuria. minimal inhibitory concentrations for a novel anti-bacterial peptide eluting urethral catheter introduction and objective: catheter associated urinary tract infection is a serious prevalent medical problem. several strategies have been developed to suppress the seemingly inevitable ascent of foreign pathogens through the urethra. th e primary strategy has been to coat the surface of the catheter with repellant agents, such as silver alloy hydrogels or anti-biotics. anti-bacterial peptides, such as human beta defensing (hbd- ) or cathelicidine are naturally produced peptides from the urothelium, acting to inhibit bacterial attachment and infi ltration as part of the innate immunity of the host. we have recently been able to engineer anti-bacterial peptide elution through gelatin coated catheters. th is study investigates the effi cacy of this strategy in deterring common uti pathogens. materials and methods: e. coli and p. aeruginosa, bacteria commonly associated with uti, were inoculated in tryptic soy broth, and then were aliquoted into each well of plates. anti-bacterial peptides, either recombinant hbd- or cathelicidine, were diluted and added to each well at increasing concentrations, where microorganisms were exposed for hours or for the indicated times following antimicrobial challenge and determination of the planktonic mics. bacteria were then enumerated by serial dilution plating. time-kill studies were performed. bactericidal activities of the antimicrobial agents were defi ned as a log decrease in the cfu/ml over hours relative to cell counts in the starting inoculum. results: th e standard inoculant of e. coli and p. aeruginosa commonly required an mic of μg/ml hbd- , and μg/ml for cathelicidine. time kill studies estimated bactericidal eff ect for hbd- on e. coli and p. aeruginosa both at hours, while for cathelicidine it was and hours, respectively. conclusion: th e current study demonstrates the efficacy and feasibility of a controlled release elution of anti-bacterial peptides, hbd- and cathelicidine, in inhibiting growth of common uti pathogens. the conclusion: co-infections of ng with ct appear less frequently. and mpcr method is rapid and accurate for identifi cation of stp. th e mpcr should be conducted in advance prior to antibiotic treatment as well as it will be better to give suitable antibiotics rather than empirical combination antibiotics for ng with ct in patient with urethritis. introduction and objective: th e prevalence of multi-drug resistant extended-spectrum beta-lactamase-producing (esbl) bacteria in normal gut fl ora in the australian community is increasing. current prophylactic antibiotic regimes for trans-rectal ultrasound (trus) prostate biopsies do not have activity against esbl organisms leaving some men at risk of esbl sepsis. our objective is to determine the prevalence of esbl in gut fl ora in northern tasmanian men and to identify risk factors for colonisation. patients were recruited into two groups. group were volunteers from the urology pre-operative clinic or the general community. group were men undergoing trus prostate biopsies. all patients were assessed via an enrolment questionnaire for the presence of known esbl risk factors. further procedural data were collected for those who had trus biopsies. all patients were assessed for esbl via a faecal culture, prior to any antibiotic prophylaxis. fisher's two-tailed test was used for comparative analysis. patients with ic/pbs were assessed with the o'leary-sant interstitial cystitis index score and global response assessment questionnaire prior to commencing treatment. assessment with these questionnaires was performed aft er treatments ( weeks) and again aft er treatments ( weeks). assessment end points were pain, urgency, symptom score and problem score. results: data was collected on patients, female and male. six patients had failed rimso- dimethyl sulphoxide (dmso) % w/w treatment prior. at baseline the mean pain score was . , urgency score . , symptom score . and problem score . . aft er weeks the mean pain score fell to . , urgency score to . , symptom score to . and problem score to . . at weeks the global response to treatment was %. nocturia was the fi rst symptom to improve with urgency and pain following. no side eff ects were noted no was reported during instillation and all patients tolerated the treatments. conclusion: ic is a diffi cult disease to treat. it requires a multimodal approach. we found that intravesical chondroitin sulphate reduced pain, urgency and o'leary-sant symptom and problem scores in patients with ic/pbs. all patients tolerated the treatment and no side eff ects were reported. introduction and objective: extended spectrum beta-lactamase (esbl) producing enterobacteriaceae are an increasing concern in an era of antibiotic resistance as they cause infections ranging from community acquired urinary tract infection (uti) to life threatening sepsis. we retrospectively reviewed the incidence and antibiotic susceptibility profi le of all esbl producing enterobacteriaceae at a university hospital in the united kingdom. patient gender, age and catheter specimen were assessed as risk factors. patient age, gender and specimen type were recorded in the database. urine samples received from outside our institution (including community isolates) were excluded from the analysis. urine was processed by calibrated loop sampling on to chromogenic clear media (oxoid ltd, basingstoke, uk). a positive culture was defi ned as ≥ cfu/ml except for samples from children and pregnant women where a cut-off value of > cfu/ml was used. susceptibility testing was performed by bsac (british society of antimicrobial chemotherapy) disc diff usion testing and reported for ampicillin, co-amoxiclav, piperacillin-tazobactam, carbapenems (ertapenem, meropenem), nitrofurantoin, pivmecillinam, trimethoprim, cephalexin, fosfomycin, third generation cephalosporins (ceft riaxone, ceft azidime) quinolones (norfl oxacin or ciprofl oxacin), aminoglycosides (gentamicin, amikacin) and others. cultures of more than two organisms (heavy mixed growth) were considered contamination and excluded. other exclusion criteria included missing data such as gender, age or susceptibility results, age < years old or an unusual specimen type such as an ileal conduit, nephrostomy, prostatic secretion, bag specimen or a suprapubic aspirate. results: our initial database included , samples which was reduced to , samples from , unique patients aft er exclusion criteria were applied. causative organisms were found to predominantly be e. coli, enterococcus, klebsiella, pseudomonas and proteus species. th e proportion of causative organisms was largely stable across the ten year period. antibiotic resistance was demonstrated to have increased, particularly across fi rst line agents. male gender and catheter use were associated with multi-resistance. in the modern era of antibiotic resistance we demonstrate that antibiotic resistance in hospital urinary tract infections is increasing. our results may be used to guide empirical treatment of hospital urinary tract infection. chronic pyelonephritis is a risk factor for renal dysfunction after urinary diversion in bladder cancer uehara s , , murao w , otsuki h , shimizu t , yoshioka t , , fujio k okayama university, okayama, japan; abiko toho hospital, abiko, japan introduction and objective: several reports showed that acute pyelonephritis is a risk factor for renal dysfunction in bladder cancer aft er urinary diversion, but the impact of chronic pyelonephritis fer renal dysfunction was unclear. materials and methods: from to , patients underwent radical cystectomy in our institute. among those patients, who showed hydronephrosis (more than grade ) or did not have enough data were excluded in this retrospective study. finally patients were enrolled. th e urinary diversions were divided into types: ileal neobladder (ib), ileal conduit (ic), ureterocutaneostomy without stent (uc) and ureterocutaneostomy with stent (ucws). ureteral stents were indwelled because of the ureteral stenosis aft er ureterocutaneostomy. because the cases of ucws generally showed pyuria and bacteriuria, ucws was determined as the chronic pyelonephritis model, and the estimated serum creatinine-based glomerular fi ltration rate (egfr) was calculated and compared with other urinary diversion. results: median follow-up period was . months (range - months) and median egfr was . ml/ min/ . m before surgery and . ml/min/ . m at the last follow-up. th e median decrease of egfr during the period between pre-surgery and the last follow-up in ib, ic, uc and ucws was . , . , . and . ml/min/ . m respectively. renal function was signifi cantly impaired in ucws cases than other urinay diversion. conclusion: chronic pyelonephritis may be a risk factor for renal dysfunction aft er urinary diversion. to avoid the renal dysfunction, ureteral stents should not be indwelled permanently. comparison of antibiotic susceptibility of escherichia coli between community-acquired and post-biopsy acute prostatitis introduction and objective: th e etiology of acute prostatitis aft er transrectal-ultrasound-guided-prostate-biopsy (pbx-ap) seems to be diff erent from that of community-acquired acute prostatitis (ca-ap). recent studies suggested that pbx-ap should be considered a separate category of prostatitis, distinct from spontaneous acute prostatitis. th us, we aimed to compare antibiotic susceptibility of escherichia coli between ca-ap and pbx-ap. of , patients who underwent transrectal-ultrasound-guided-prostate-biopsy, a total of patients had pbx-ap. in among these, escherichia coli was isolated on urine or blood culture. in of the patients with ca-ap, escherichia coli was identifi ed on urine or blood culture test. th us, a total of patients with ca-ap (n = ) or pbx-ap (n = ) caused by escherichia coli were included in this retrospective study. we compared demographic variables, data on clinical laboratory tests or transrectal ultrasound and antibiotic sensitivity data between the two types of prostatitis. results: in comparison to the ca-ap group, the pbx-ap group showed signifi cantly higher incidence of bacteremia and lower count of white blood cell. th ere was no signifi cant diff erence between the two, regarding to other clinical or laboratory parameters including age, body mass index, serum psa, prostate volume and percentage of patients with ebsl-positive escherichia coli. th e percentages of patients with quinolone-resistant escherichia coli in the ca-ap and pbx-ap groups were . % and . %, respectively, while those with nd or rd cephalosporin-resistant escherichia coli were . % - . % and . % - . %, respectively (table ). in both groups, the percentage of patients with amikacin-resistant escherichia coli were . %. our data suggest that a combination therapy of cephalosporin and amikacin can be recommended for treatment of pbx-ap while quinolone alone may be a feasible treatment option for ca-ap. the effectiveness of prostatic massage in treating chronic prostatitis (cp) tanabalan c, panah a, kabir m, masood j, pati j, nargund v introduction and objective: we review the eff ectiveness of prostatic massage under general anaesthesia (ga) for persistent symptoms aft er failure of antibiotic therapy. th e mainstay of treating cp is empirical antibacterial therapy with varying results. prostatic massage has been used to treat cp with mixed results. retrospective study of patients that were seen in urology outpatient clinics from june to july with symptoms of chronic prostatitis. all patients had a full clinical evaluation and urinary samples were sent for culture/microscopy on their visit. patients were treated initially with a course of -aminoquinolone and doxycycline in combination with lifestyle advice. if initial antibiotic therapy failed and no abnormal results detected in the work-up, a prostatic massage was off ered. th is involved a rigid cystoscopy followed by a -minute prostatic massage under anaesthesia. post-operatively patients received a further course of antibiotics. patients were followed up aft er the procedure and were assessed for improvement in symptoms. a total of patients ( %) commented on an improvement in some or all of their cp symptoms for a mean length of time of . (range . to . weeks). mean psa was . (range . to . ). one bladder tumour and one urethral stricture were detected on cystoscopy with one prostate cancer following prostate biopsies. if voiding urinary symptoms present men were given an alpha-blocker, there was no signifi cant improvement in pain symptoms post-operatively between the two groups (p= . ). th ere were no adverse eff ects from having the procedure with no complications noted. prostatic massage under ga is a safe and eff ective therapy in the treatment of refractory cp in select patients. th e issues of long-term surveillance and assessment of response to treatment remains a challenge. th ere seems little role for alpha-blockers, psa testing and mri prostate in the management of cp. oral antibiotic therapy and lifestyle modifi cations should remain as a fi rst-line treatment option. th e eff ect of stress, lifestyle and ethnicity has not been demonstrated in this study and further research will need to be undertaken. intravesical hyaluronic acid and chondroitin sulfate therapy for interstitial cystitis and painful bladder syndrome shin b, hwang e, chung h, kim s, jung s, kang t, park k, kwon d introduction and objective: damage to the urothelial glycosaminoglycan (gag) barrier layer may underlie the pathogenesis of several chronic bladder pathologies, including interstitial cystitis/painful bladder syndrome (ic/pbs). th is study evaluated the eff ect of intravesical hyaluronic acid (ha) in ic/pbs. twenty patients received intravesical ha mg and chondroitin sulfate (cs) g (ialuril®) in ml saline solutions once weekly for weeks, once every weeks for the next month, then once every month for the next months. results: a signifi cant improvement in urinary symptoms was evident on voiding diaries (number of voids and mean void volume; p= . and . , respectively). th e interstitial cystitis symptom index and interstitial cystitis problem index resulted in a significant improvement in both scores (p= . and . , respectively). th e storage symptom score (ipps) decreased from . to . (p= . ). th e quality of life to urinary symptom reduced from . to . (p= . ). th ere was no statistical signifi cant change in the voiding symptom score of ipps aft er ialuril instillation (p= . ). conclusions: th is promising experience seems to offer an additional therapeutic option in patients with refractory ic/pbs. prevention of surgical site infection: new approach alexander e , , hulda t , edna d introduction and objective: until the middle of the th century, when ignaz semmelweis and joseph lister became the pioneers of infection control by introducing antiseptic surgery, most wounds became infected. in cases of deep or extensive infection this resulted in a mortality rate of - %. most surgical site infections (ssi) are superfi cial, but even so they contribute greatly to the morbidity and mortality associated with surgery. th e aim of this study is to fi nd out rate of surgical site infection by single change of wound dressing. th e study is prospective in two hospitals (ba regional hospital, tophill hospital in kumasi). surgically clean cases are selected for operation. wounds are not opened till the seventh day or when soaked. window is left for wound inspection. results: results are shown in table . table , patients with diff erent surgical conditions were operated. average post-surgery change of dressing was days. ssi= / ( . %). single post-surgery change of dressing is eff ective ssi prevention method. effects of semen cuscutae on the fertilization ability in varicocele-induced rat introduction and objective: th ere is no specifi c medication to improve the sperm motility and count yet. th is study aimed to evaluate the favorable eff ects of purifi ed fl avonoid, semen cuscutae extract (sce) against oxidative stress injuries and other homeostatic imbalances in reproductive organs in adolescent rat with varicocele and to develop the new herbal medication to treat the male fertility. materials and methods: seventy-two rats were divided into groups: control (ctr) + hydroxypropyl-methyl cellulose (hpmc) (ctr + hpmc), ctr + mg/kg sce and ctr + mg/kg sce, varicocele (vc) + hpmc, vc + mg/kg sce and vc + mg/kg sce. in ctr group, they were started with medication for days from weeks aft er environmental stabilization. for the vc groups, they were given medications for days aft er weeks of operation. blood was collected before sacrifi ce for the testosterone test. sperm motility, daily sperm production (dsp), sperm count, and sperm transit time were calculated. th e seminiferous tubules were graded according to johnsen scoring. th e mrna expression of glutathione peroxidase (gpx ) and . nmol/mg protein, respectively) than vc group ( . ± . u/mg protein and . ± . nmol/mg protein, respectively). also, the testosterone, johnsen score were signifi cantly increased in the dose of mg/kg sce group than other groups. th ese results suggest that purifi ed fl avonoid semen cuscutae extract could be an alternative medicine for the infertility patients by inhibition of oxidative stress by favorable mechanisms. the relationship between pregnancy rate and semen quality improvement after varicocelectomy varicocele is the most common cause of male infertility and is generally correctable via surgery. in some reports, pregnancy rates were improved aft er varicocelectomy in male patients with poor semen quality. th e aim of this study was to determine the relationship between semen improvement and pregnancy rate. patients who underwent microsurgical varicocelectomy from jan. to jun. were enrolled. all patients had history of infertility (> year) and confi rmed varicocele on physical examination. th e abnormality of semen analysis results was based on who guidelines. varicocelectomy was performed in patients with poor semen quality in a series of two semen analysis where the female partner was normal in spontaneous pregnancy, as evaluated gynecologically. microsurgical varicocelectomy was performed by single surgeon. follow-up semen analysis was performed months aft er operation. improvement in semen quality was defi ned as > % improvement in total motile sperm compared with pre-operation semen analysis. pregnancy rate, method of pregnancy, and time to pregnancy were investigated. results: a total of male patients were included in this study, ( . %) in the improvement group (ig) and ( . %) in the non-improvement (nig). th e pregnancy rate was % ( / ) in the ig group and % ( / ) in the nig group; there was no significant diff erence between groups. pregnancy methods between the two groups were similar (table ) . introduction and objective: to review the learning curve, complications and outcomes of the fi rst cases of microsurgical vasectomy reversal performed in a developing country. th e fi rst dedicated service in male infertility microsurgery in south africa was established in . between january and december , a total of patients underwent microsurgical vasectomy reversal by a single surgeon (amir d zarrabi). mean patient age was years (range to ), mean age at vasectomy years (range to ), mean number of children for the male partner . and mean age of the female partner years (range to ). th e mean time interval between vasectomy and reversal was . years (range . to . ). five patients had previous failed vasectomy reversals and in patients the indication for reversal was post-vasectomy pain syndrome. a total of % of patients travelled from other countries for their surgery. results: mean surgical time per testicular unit was . minutes (range to ) and total operative time minutes (range to ). sperm motility (intra-operative light microscopy) was good in . %, average in . % and poor in . %. vasovasostomy was required in . % of testicular units and vaso-epididymostomy in . %. in patients sperm was harvested at the time of reversal for cryopreservation. complications occurred in % of patients and were managed conservatively in all but , who required an additional surgical procedure. for patients with adequate follow-up the overall surgical success rate was %. mean post-operative sperm count was . million. nine pregnancies and live births have been recorded during the limited follow-up. comparing the fi rst cases with the last cases revealed no signifi cant diff erences in surgical time, complications or patency rates. th e mean post-operative sperm count was % higher for the last cases. although microsurgical vasectomy reversal is technically demanding and requires specialized equipment and instruments, it can be successfully implemented in a developing country. infl uence of unilateral iatrogenic torsin on contralateral testis in rat, prepubertal and postpubertal introduction and objective: th e present study was conducted to investigate the infl uence of hemicastration and age at hemicastration on the subsequent contralateral testis. sixty-four wistar-derived male rats divided randomly in groups. group named immature intervention, group immature control, group mature intervention and group mature control. in group , rats hemicastrated at days of age (prepubertal). in group , sham surgery (midscrotal incision) was done at same age. in group , rats hemicastrated at days of age (postpubertal) and in group sham surgery was done at same age. twenty days aft er fi rst surgery, in intervention groups contralateral orchiectomy was done and in control groups random orchiectomy (left or right) was done. blood sampling for evaluation of serum testosterone was performed just before second surgery. results: testis weight and the mean testicular weight per g of body weight was greater in hemicastrated rats. th ese parameters was greater in prepubertal group than postpubertal hemicastrated rats. th ere was no appreciable diff erence in serum testosterone levels in groups. our research demonstrated that hemicastration resulted in compensatory hypertrophy of the remaining testis and it decreased as the animals aged. hemicastration does not lead to reduction in serum testosterone levels and remaining testis can retrieve a normal serum testosterone level. role of antibiotic in the treatment of semen hyperviscosity: a single institution study introduction and objective: th e prevalence of semen hyperviscosity is estimated to be between - % and can lead to male factor infertility both in vivo and in vitro. semen is composed of fl uids secreted by the male accessory glands, which contain proteins essential to the coagulation and liquefaction of semen. hypofunction of the prostate or seminal vesicles causes' abnormal viscosity of seminal fl uid. hyperviscosity can impair normal sperm movement in the female reproductive tract, and can lead to decreased sperm count. multiple factors have been predicated which result in the development of semen hyperviscosity, of this infection is considered to be one of the main contributor. aim of the study was to predict the eff ect of antibiotic in the treatment of hyperviscosity. th is is a single institution study, patients (age range - years) were recruited who were diagnosed with semen hyperviscosity (failure to liquefy aft er min). medical, sexual, and family history were documented. all the patients semen were kept for culture and they all got levofl oxacin for days and patient who had positive culture were changed to appropriate antibiotics. all the patients underwent repeat semen analysis aft er weeks. results: seventy seven percent patient had previous history of prostatitis, % patient had past history of sexual transmitted diseases. seventy fi ve percent patient are suff ering from infertility, of this % patient had a family history. th irty seven percent patients had positive culture and of this only % patient had liquefaction post treatment. culture negative patients, % patient had liquefaction post treatment. conclusions: semen hyperviscosity is associated with infertility and exact cause is considered to be multifactorial, of this infection is considered to be the main factor. in our study we did found that most of the patients has infection but antibiotic treatment even for culture positive patients showed minimal eff ect. treatment with antibiotic along to treat hyperviscosity cannot be considered curative since in our study the eff ect was only %. further research is needed to better understand the contributors to semen hyperviscosity and the treatments that can be used for infertile males with hyperviscous semen. modifi ed microsurgical subinguinal varicocelectomy: bundle ligation technique hong y, lee s, choi k, park d, hong j introduction and objective: microsurgical varicocelectomy has become the gold standard because of low recurrence and postoperative complication rate. during the procedure, isvs should be carefully dissected, cut and suture-ligated one by one. however, it is not easy to divide all isvs in a horizontal line, which can result in some uncertainty whether every single isv was divided or the same vein was unnecessarily divided multiple times. th erefore, we have developed a modifi ed technique, so called bundle ligation technique (blt), to make the procedure more reliable and simpler. a total of cases of microsurgical subinguinal varicocelectomy performed from to were grouped as conventional varicocelectomy (cv, n= , age: ± . ) and blt (n= , age: ± . ). mean follow-up time was . ± . months. blt is a simpler procedure because isvs are ligated as a whole, however, it is possible only aft er dissecting and securing the testicular artery fi rst. we compared operation time, resolution of palpable varicocele or pain, recurrence rate and complications. results: mean operation time was . ± . in cv group and . ± . in blt group (p= . ). resolution rates months aft er surgery were . % (cv) and . % (blt) in each group. recurrence aft er surgery during the mean follow-up time was . % (cv) and . % (blt). th e aim of the study is to evaluate the eff ect of hbo on the level of sperm dnaf and on the content of reactive oxygen species (ros) in semen. th e study included men with idiopathic infertility, the level of sperm dnaf was above % and the content of ros in the sperm was above . mv/sec. in the main group (n= ) sessions of hbo were performed and in vitro fertilization (ivf) was carried out months later. in the control group (n= ) ivf was performed without preceding hbo. th e age of patients ranged from to years (median - . years). sperm dnaf was determined by tunel, the level of ros in semen was studied by chemiluminescence. th e assessment was made at the time of entry into the study and aft er months (in the main group - months aft er hbo). in the main group, average sperm dnaf aft er hbo decreased from . ± . % to . ± . % (p< . ), the median level of ros in semen decreased from . mv/sec to . mv/sec (p< . ), whereas in the control group of patients these fi gures have remained almost at the same level - . ± . % and . ± . % (p> . ), . mv/sec and . mv/sec (p> . ). pregnancy resulting from ivf occurred in . % ( / ) of the cases in the study group and in . % ( / ) -in the control group (p< . ). conclusion: hbo is an eff ective method to reduce the number of sperm with dnaf, which can potentially lead to an increased fertility in patients with idiopathic male infertility. to evaluate the natural history and growth kinetics between sporadic clear cell renal cell carcinoma (ccrcc) and ccrcc in von hippel-lindau disease (vhl). we reviewed patients with sporadic ccrccs and patients with vhl ccrccs all confi rmed by delayed surgery aft er at least months active surveillance. th e growth rate was calculated. th e growth kinetics between sporadic and vhl ccrcc were compared. th e initial tumor diameter and pathological grade were reviewed, and their correlation with the growth rate were analyzed. results: th e mean growth rate of sporadic ccrcc was . cm/yr (range, - . cm/yr). th e mean growth rate of vhl ccrcc was . cm/yr (range, . - . cm/yr). th e growth rate of vhl ccrcc was lower than that of sporadic ccrcc (p= . ). for vhl ccrcc, the initial tumor diameter aff ect the growth rate (r= . , p< . ), while the pathological grade not (p= . ). for sporadic ccrcc, the pathological grade aff ect the growth rate (p< . ), while the initial tumor diameter not (r=- . , p= . ). conclusion: th e growth kinetics of vhl ccrcc is more indolent than that of sporadic ccrcc. for ccrcc with aggressive growth kinetics, its growth rate might correlates with the pathological grade, for those with slow growth kinetics, the growth rate might correlates with the initial tumor diameter. effects of trpm silencing on the proliferation, migration, and invasiveness of renal cell carcinoma (rcc) cells proliferation, migration, and invasiveness of human rcc following trpm knockdown. we constructed sirna sequences targeting the trpm gene and then transfected them into rcc cells mediated by liposome. th e potency of nm trpm sirnas was detected trpm mrna measurement by rt-pcr. th e eff ect of trpm sirna on cell viability was determined by wst- assay. cell motility and invasiveness were evaluated by wound healing assays and a matrigel migration and invasion assay. transfected rcc cells were cultured in eagle's minimum essential media supplemented with % fetal bovine serum. all measurements were done hours aft er trpm blocking. results: trpm sirna weakly inhibited the gene transcription of trpm . it was for nothing in the proliferation of human rcc cells. compared with vehicle control, the migration and invasion of human rcc cells were suppressed signifi cantly by trpm sirna until aft er hours. in addition, although protein levels of mmp- were not changed signifi cantly, we found that the protein levels of matrix metalloproteinase (mmp)- were diminished markedly by trpm sirna. th ese results suggest that trpm may have a role in the rcc progression including migration and invasion through upregulation of mmp . role of tnf-and cd in resistance to sunitinib treatment in clear cell renal cell carcinomas introduction and objective: tumor necrosis factor-α (tnf-α) was originally reported as a cytokine to induce apoptotic cell death and cachexia. recent studies have indicated that tnf-α also enhances tumor progression by inducing epithelial-mesenchymal transition (emt). tnf-α is also known as a modulator of cd expression, which belongs to cancer stem cell marker in several cancers. in this study we clarifi ed the signifi cance of tnf-α as well as cd in clear cell renal cell carcinomas (ccrccs). protein expression of tnf-α and cd was examined by immunohistochemistry in primary ccrccs, untreated metastatic ccrccs, and metastatic ccrccs treated with sunitinib, and its association with the clinicopathological parameters and prognosis was analyzed. involvement of tnf-α in emt and induction of cd was analyzed by comparing expression of emt-related genes and cd , and migration and invasion in cultured ccrcc cell lines. results: tnf-α and cd were predominantly expressed in carcinoma cells of high-grade ccrccs with positive correlations with primary tumor stage and distant metastasis. th ere was a positive correlation between tnf-α and cd expression, and elevated expression of tnf-α and cd was a poor predictor of prognosis. tnf-α enhanced migration and invasion of ccrcc cells together with down-regulation of e-cadherin expression and up-regulation of matrix metalloproteinase and cd expression. tnf-α also up-regulated the expression of tnf-α itself in ccrcc cells. twenty-fi ve patients were treated with sunitinib for metastasis, and the patients with cd -high tumors showed a shorter time to treatment failure compared to those with cd -low tumors. furthermore, residual carcinoma cells in the sunitinib-treated metastatic ccrccs were strongly positive for cd , and the cd expression was signifi cantly higher in tumors from the sunitinib-treated patients than in those from untreated ones. conclusions: tnf-α seemed to play an important role in progression of ccrccs by inducing emt, and suggested that tnf-α-induced cd might be involved in the resistance to sunitinib treatment. although further experimental studies on the relations between cd expression and cancer stem cells in ccrccs are needed, our data suggest that therapy targeting tnf-α and/or cd may provide a clue for improving the prognosis of patients with sunitinib-resistant ccrcc. introduction and objective: th e aim of this study was to investigate the relationship between the immunohistochemical expression of hypoxia-inducible factor- α (hif- α) with histological parameters such as tumor size; presence of tumor necrosis and hemorrhage; nuclear grade and pathological stage in patients with clear cell renal cell carcinoma (ccrcc). specimens from cases of rcc patients treated with radical prostatectomy were formalin-fi xed, paraffi n embedded, and stained with h&e. additional sections from each case were stained for hif- α. hif- α immunohistochemical expression was estimated as negative ( ), weak positive (+ ), moderate positive (+ ), and intense positive (+ ). th e statistical package "in stat " was used for data processing. results: immunohistochemical expression of hif- α in crcc was signifi cantly higher than in normal kidney tissue at statistically signifi cant level (hif- α: x -test = . , p= . ). a positive non-signifi cant correlation was found between hif- α and the tumor nuclear grade (r= . , p= . ); between hif- α and presence of hemorrhage (r= . , p= . ); whereas, a negative non-signifi cant correlation of a very weak scale was observed comparing hif- α and tumor size (r = - . , p= . ); hif- α and pathological stage (r=- . , p= . ), as well as hif- α and tumor necrosis (r=- . , p= . ). conclusion: our data showed heterogeneity in angiogenic activity, which might have an impact on biological behavior and anti-angiogenic, anti-vegf therapy of ccrcc patients. th is study suggests that there should be taken more than one tissue biomarkers into the consideration in predicting the biological behavior of ccrcc. introduction and objective: clear cell renal carcinoma (ccrcc) is the most frequent rcc subtype and is characterized by high mortality of %, due to late diagnosis and distant metastases found in % of rcc patients. although the involvement of vhl (von hippel-lindau), hif a (hypoxia-inducible factor -alpha) and vegf-a (vascular endothelial growth factor a) genes in development and progression of ccrcc is widely analyzed, our objective was to perform the common study of those factors in clinical samples of matched tumor-normal kidney biopsies of ccrcc cases. materials and methods: vhl, hif a and vegf-a mrna levels in samples were assessed by quantitative polymerase chain reaction (qpcr); rna was extracted from matched tumor-normal (t, c) kidney samples of ccrcc patients (mean age . ± . , median age ); ccrcc cases were characterized by local or distant metastasis; sunitinib was administrated to patients. vhl, hif α and vegf-a proteins were localized in matched tumor-kidney tissue of patients with the use of immunohistochemistry (ihc). molecular data was statistically calculated with clinical and follow-up data. introduction and objective: to identify tissue biomarker that are predictive of the therapeutic eff ect of sunitinib in treatment of metastatic clear cell renal cell carcinoma (mcrcc). our study included patients with mcrcc; these were selected from patients who received sunitinib in our hospital between the years - according to inclusion criteria of the study. patients were stratifi ed into two groups based on their response to sunitinib treatment; non-responders (progression), and responders (stable disease, regression). th e eff ect of treatment was measured by comparing imaging studies performed before the initiation of treatment with those done between rd and th months of treatment. histological samples of tumour tissue and healthy renal parenchyma, acquired during surgery of the primary tumour, were examined with immunohistochemistry to detect tissue biomarkers (mtor, p , vegf, hif , hif , caix). th e comparison between the two groups of patients was based on comparing the average levels of biomarker expression in both tumour tissue, as well as in healthy renal parenchyma. results were evaluated using student's t-test. results: when considering the results of the group of responders, statistically signifi cant diff erences in marker expression in tumour tissue versus healthy parenchyma were found for mtor ( %/ . %;p= . ), p ( %/ . %;p= . ), vegf ( . %/ %;p= . ) and caix ( %/ . %;p= . ). as for the group without response (non-responders), a statistically signifi cant diff erence was also evident in p a vegf expression in tumour versus healthy tissue ( %/ . %;p= . resp. . %/ %;p= . ). in the responders, a further signifi cant diff erence was found in the frequency of high expression (more than %) between tumour tissue and healthy parenchyma in vegf ( %/ %;p= . ) and caix ( %/ %;p= . ). caix shows high levels of expression in the tumour tissue, in both of the evaluated groups. when comparing the expression levels in the same type of tissue, between the group of responders and non-responders, no signifi cant diff erence in any biomarker was found. conclusion: a signifi cantly higher expression of vegf in crcc in comparison to healthy parenchyma, can predict a better response to sunitinib. on the other hand, the high expression of vegf in healthy renal parenchyma can predict worse response to treatment. the impact of preoperative retrograde pyelography before radical nephroureterectomy for upper urinary tract urothelial carcinoma on intravesical tumor recurrence song p , ko y , choi j , moon k , jung h , kim t introduction and objective: despite its diagnostic role in identifi cation of upper urinary tract urothelial carcinoma (uut-uc), approach to ipsilateral ureteral potentially aggravates spread of tumor, as reported in preoperative ureteroscopy before nephroureterectomy. we thus assessed the impact of preoperative retrograde pyelography (rgp) on intravesical recurrence aft er radical nephroureterectomy for uut-uc. of a total of patients who underwent nephroureterectomy for uut-uc from january to june in our institution, patients who did not undergo preoperative ureteroscopy were selectively enrolled. computed tomography and urine cytology as a basic diagnostic modality were performed in all subjects. th e impact of preoperative rgp and the other variables (age, sex, operating time, clinicopathological factors, and hematological factors) on intravesical recurrence were analyzed by multivariate cox regression model. during a mean follow-up period of . months, ( . %) patients had intravesical recurrence aft er rnu, and subjects ( . %) underwent preoperative rgp. th e mean duration from preoperative rgp to rnu was . ± . days and mean interval of intravesical recurrence was . ± . months. multivariable analysis showed that rgp and pathologic stage over t were independent factors for intravesical tumor recurrence (p= . and p= . , respectively, table ). regarding the duration from preoperative rgp to rnu, no signifi cant diff erence was observed between the recurrence group and the non-recurrence group (p> . ). as with preoperative ureteroscopy, our data demonstrated that preoperative rgp is an independent factor associated with intravesical recurrence of uut-uc aft er rnu. introduction and objective: axitinib which is tyrosine kinase inhibitor is standard nd-line treatment for metastatic renal cell carcinoma (mrcc). th e neutrophil-to-lymphocyte ratio (nlr), an index of systemic infl ammation, is associated with outcome in several cancer types. to assess the relation of pretreatment nlr with progression-free survival (pfs) and overall survival (os) of patients treated with axitinib. twenty-two patients with mrcc were treated with axitinib between october and january . patients were stratifi ed in two groups with nlr > (group a: n= ) vs. < (group b: n= ). pfs and os were estimated using kaplan-meier method. results: median os and pfs were . and . months, respectively. median os was . and . months in group a and group b, respectively (p= . ). median pfs was . and . months in group a and group b, respectively (p< . ). multivariate analysis showed that nlr > was an independent predictor of os (hr . . ; p= . ). in patients with mrcc treated with axitinib, pretreatment nlr might be an independent predictor for the outcome. th e aim of this study was to evaluate whether preoperative neutrophil-to-lymphocyte ratio (nlr) predict the prognosis in patients with upper urinary tract urothelial carcinoma (uu-tuc). a cohort of patients diagnosed with uutuc from to at tokyo metropolitan tama medical center was enrolled in this retrospective study. log-rank test and cox proportional hazards regression models were used for univariate and multivariate analyses. results: on univariate analysis, pathologic t stage, grade, lymphovascular invasion, c-reactive protein (crp) level, and nlr were signifi cantly associated with recurrence-free survival (rfs) and cancer-specifi c survival (css). th e rfs rates for an nlr < . and for one ≥ . at years were . % and . %, respectively. th e css rates for an nlr < . and for one ≥ . at years were . % and . %, respectively. th e multivariate cox proportional hazards regression models showed that the nlr could be an independent predictor for rfs and css. based on the results of multivariate analysis, the scoring model was developed. rfs and css rates at years were as follows: risk factor, . % and . %, respectively; risk factor, . % and . %, respectively; risk factors, . % and . %, respectively; risk factors, . % and . %, respectively; and risk factors, . % and . %, respectively. conclusion: th e preoperative nlr is an independent prognostic predictor. th e model based on the nlr and pathologic factors can be useful in clinical practice. clinicopathological outcome of small cell carcinoma of upper urinary tract: one starting point, diverging paths lu k, wang h, lin v, yu t introduction and objective: primary small cell carcinoma of upper urinary tract (uut-scc) is an extremely rare disease entity with distinct histological and biological behavior, representing less than . % of urinary tract tumor. th e rarity of these neoplasms poses a diagnostic and therapeutic challenge. little is known about uut-scc and the current knowledge of this disease is based on case reports or small series. our aim of study was to characterize the patients with uut-scc and to evaluate patient outcomes with the available treatment modalities. th is was a single-institute retrospective observational cohort study of patients with small cell carcinoma of upper urinary tract followed at e-da hospital, kaohsiung city, taiwan be-tween january , and october , . patient and tumor data were analyzed using descriptive statistical methods. results: six patients with primary uut-scc were identifi ed, consisting of arising from renal pelvis and from upper ureter. th e median age at diagnosis was years with male-to-female ration of : . th e most common presenting symptoms were painless gross hematuria, followed by fl ank pain. th e morphological appearance of the tumor cells and their immunohistochemical reactivity for neuroendocrine markers and cytokeratin helped establish the diagnosis. in of cases, scc coexisted with urothelial carcinoma. surgery was standard treatment given to all patients. of all cases, of patients received chemotherapy, including one receiving neoadjuvant chemotherapy and administering adjuvant chemotherapy. overall median survival was months. conclusion: primary small cell carcinoma of the upper urinary tract is characterized by an aggressive clinical course with early metastatic spread and relatively short overall survival. although high response rate to cytotoxic chemotherapy, its duration of response is limited and the prognosis remains dismal. as there is no standard of care for patients with uut-scc, further eff orts should be directed at its early detection and made to develop more eff ective therapeutic approach for this high-risk lethal disease. prognostic introduction and objective: th e aim of this study was to evaluate the impact of body mass index (bmi) on survival in patients with non-metastatic renal cell carcinoma (rcc) treated with radical or partial nephrectomy. between june and july , patients with rcc underwent radical or partial nephrectomy at two hospitals. among these patients, patients with lymph node or distant metastasis were excluded. th us, the medical records of the remaining patients ( men and women, mean age of . years) were retrospectively reviewed. th e median follow-up duration was months (range to months). th e patients were classifi ed into groups according to their bmi based on the asia-pacifi c criteria for obesity: normal ( . to < kg/m ), overweight ( to < kg/m ), and obese (≥ kg/ m ). th e prognostic signifi cance of various clinicopathological variables including bmi was analyzed using univariate and multivariate analysis. results: of the total patients, patients ( . %) were categorized as normal, ( . %) as overweight, and ( . %) as obese. forty-six patients ( . %) developed local recurrence or distant metastasis and patients ( . %) died of disease during the follow-up period. in the univariate analysis, bmi, tumor size, t stage, fuhrman's nuclear grade, coag-ulative tumor necrosis, and lymphovascular invasion were signifi cant predictors of recurrence-free survival. also, bmi, tumor size, t stage, fuhrman's nuclear grade, and lymphovascular invasion were signifi cant predictors of cancer-specifi c survival. in the multivariate analysis, bmi (p= . ), tumor size (p= . ), t stage (p< . ), fuhrman's nuclear grade (p= . ), and lymphovascular invasion (p= . ) were independent predictors of recurrence-free survival. also, bmi (p= . ), tumor size (p= . ), t stage (p= . ), and lymphovascular invasion (p= . ) were independent predictors of cancer-specifi c survival. our results suggest that bmi is an independent prognostic factor for recurrence-free and cancer-specifi c survival in patients with non-metastatic rcc treated with radical or partial nephrectomy. th ese fi ndings indicate that bmi could be an eff ective tool for predicting recurrence or survival in patients undergoing nephrectomy for non-metastatic rcc. phase i/ii study of multipeptide-based cancer vaccine ima after single-dose cyclophosphamide in japanese patients with advanced renal cell cancer hongo f , ueda t , nakamura t , naya y , okihara k , tamada s , schoor o , singh-jasuja h , nakatani t , miki t introduction and objective: ima is the fi rst therapeutic vaccine for renal cell cancer (rcc) consisting of multiple tumor-associated peptides (tumaps) confi rmed to be naturally presented in human cancer tissue. objective was to assess the safety and tolerability of ima vaccination. in this phase i/ii study in japan, we treated a total of japanese patients with advanced rcc with human leukocyte antigen a (hla-a)* + subjects in - . each of the vaccinations consisted of an i.d. injection of gm-csf ( μg) followed within - minutes by an i.d. injection of ima ( μg of each peptide). th e vaccine therapy was a monotherapy, i.e. no other anti-tumor therapies were concomitantly administered during the study course. no treatment with either anti-cancer agents or immunosuppressants was allowed within weeks before entering the trial. patients were to receive vaccinations in the fi rst weeks of treatment (induction period) followed by further vaccinations at weeks intervals for up to weeks (maintenance period). th e primary endpoint was safety and tolerability. th e secondary endpoints were pfs, os, immunogenicity. results: no treatment-related serious adverse events (saes) or deaths were observed during the study period. at follow-up at months, all cases were assessed for treatment response. ten percent of patients had partial response (pr), % with stable disease (sd), % of patients had progressive disease (pd). median pfs was . months and median os was . months. among all patients analyzed for t-cell response, fi ve showed vaccine-induced (vi) t-cell responses against at least one hla class i-restricted tumap and two patients with responses to multiple tumaps. interestingly, two of the immune responders were of hla-a* phenotype, a hla suballele rarely occurring in europe and us but common in japan. we evaluate the patients who underwent robot-assisted laparoscopic partial nephrectomy (ralpn), laparoscopic partial nephrectomy (lapn), or open partial nephrectomy (opn) in terms of perioperative outcomes. all patients with ct a renal masses who underwent ralpn (n= ), lapn (n= ), or opn (n= ) between november and may at our institute were compared in terms of perioperative outcomes, including the mean operative time, ischemia time, estimated blood loss, change in the estimated glomerular fi ltration rate (egfr), surgical margins, and complications. intraoperative and early postoperative data were collected retrospectively. conclusion: ralpn was signifi cantly associated with shorter ischemia time. any methods of partial nephrectomy preserved renal function at three months postoperatively and showed good oncological outcomes. laparoscopic nephrectomy: does patient obesity affect outcome? introduction and objective: th e prevalence of obesity worldwide is increasing, up to % of men and % of women are now obese. th ere are various means to assess obesity, waist circumference (wc) has emerged as a superior determinant of obesity and then body mass index (bmi). th is study evaluates wc on the outcome of laparoscopic nephrectomy. data was obtained on consecutive patients. a wc of > cm for women and > cm for men is considered obese. data collected includes age, gender, asa score, wc, anaesthetic duration, operative approach, surgery duration, blood loss, renal function, complication rate and duration of hospital stay. overall, patients underwent laparoscopic nephrectomy, were male and female. seventy three ( . %) patients had wc above normal for their gender. mean anaesthetic duration was longer in obese patients . minutes vs. . minutes, (p= . ). operative duration in obese patients was also longer, . minutes vs. . minutes, (p= . ). th ere was no diff erence between groups for conversion, number of ports, intra-operative complications, blood loss, or post-operative complications. however, obese patients had a longer in-patient stay; . days versus . days. conclusion: laparoscopic nephrectomy is safe in obese patients. however, obese patients should be warned that their obesity may be associated with increased anaesthetic and surgical ties and prolonged recovery. the long-term oncologic results of radiofrequency ablation for small renal tumors sung g , bae y , kim s introduction and objective: th e aim of this study was to retrospectively evaluate the long-term oncologic results of radiofrequency ablation (rfa) of small renal masses (srms). : th e patients who had been followed over years aft er percutaneous or laparoscopic rfa for small renal mass were included in this study. a total of patients and renal tumors were included. th e follow-up study included physical examination, chest radiography, creatinine, and contrast-enhanced ct or mri. recurrence was defi ned as contrast enhancement aft er months or lesion growth at subsequent imaging or viable cancer cells on follow-up biopsy. results: th e mean tumor size was . cm and the mean follow-up period was . months. technical success was achieved in / renal tumors ( . %). repeated rfa was necessary in tumors due to incomplete ablation. th e overall complication (oc) occurred in . % of which the low-grade complications accounted for . % of oc. a relevant deterioration of renal function aft er rfa was very rare. th e -year local recurrence-free survival rates, cancer-specific survival rates, and overall survival rates are %, . %, and . % respectively. conclusion: rfa is considered useful treatment for selected patients with srms and also for nephron-sparing. our long-term follow-up results suggest excellent therapeutic outcome with rfa, while achieving eff ective local tumor control. introduction and objective: endoscopic approach of the terminal ureter was proposed as a complementary fi rst step in nephroureterectomy with perimetal cystectomy in order to obviate the low abdominal incision. we aimed to establish the value of a novel method of endoscopic distal ureteral management: pluck technique using bipolar plasma vaporization. during the last years, we performed nephroureterectomy involving plasma-button uretreal desinsertion by bipolar vaporization in upper urinary tract transitional cell carcinoma (uuttcc) cases (pta - cases; pt - cases; pt - cases; pt - cases). th e tumor was pyelocaliceal in cases, ureteral in cases and both ureteral and pyelocaliceal in cases. th e follow-up protocol included cystoscopy with urinary cytology, abdominal ultrasound and ct. th e mean follow-up period was months (range to months). results: all procedures were successfully completed. th e mean duration of the endoscopic procedure was minutes. in cases, aft er the completion of the nephroureterectomy, endoscopic haemostasis of the desinsetion area and margins was necessary. th e postoperative complications' rate was . %: cases of hematuria, one imposing endoscopic approach and another treated conservatively. during the follow-up period, patients presented bladder recurrences, had renal fossa tumor and had secondary lymphnode invasion. th e disease-specifi c mortality rate was %. conclusion: th e endoscopic detachment of the terminal ureter using bipolar plasma vaporization as part of one-step nephroureterectomy is a safe and eff ective method. mid-term evaluation demonstrated good oncologic outcomes. th congress of the sociÉtÉ internationale d'urologie -siu abstract book introduction and objective: we thought that combining open and laparoscopic surgery for partial nephrectomy would be less invasive than open method, easier and expend shorter time to clamp renal artery than pure laparoscopic approach. and combining approach would lead to introduce pure laparoscopic approach safely from open method. we reviewed the records of patients with renal mass treated with partial nephrectomy from to at our hospital. a total of patients underwent partial nephrectomy. of these, patients underwent pure laparoscopic procedures. seventy-seven patients underwent combining method, and two patients of these with solitary kidney and one patient with chronic nephritis were excluded. we compared these two groups in terms of perioperative outcomes, including the mean operative time, ischemic time, change in the glomerulofi ltration rate (egfr), and adverse events. conclusion: th is nonrandomized, comparative study suggests that pure laparoscopic approach had longer cold ischemic time but lower postoperative egfr change. complication rates were almost equivalent for both approaches. th erefore, we might shift safely to pure laparoscopic approach through the combined approach in the way of partial nephrectomy. nephron th irty-four ( . %) had bilateral suspected malignant tumors and were used as material for this study. twenty-fi ve were men and were women. results: eighteen patients ( %) had the same type of tumor in both kidneys. ten of them had clear cell carcinoma and had papillary renal cell cancer. four patients had bilateral oncocytomas. in patients ( %) the lesions diff ered between the kidneys (table ). in all patients only one kidney was operated on one occasion. in two patients treated with radical nephrectomy (rn) over years ago for renal cancer the subtype of the fi rst tumor was unknown. ten patients were treated with nss -nss, with rn -nss, with nss -rn, with nss -observation and with nss -radiofrequency ablation. two of the patients had von hippel-lindaus disease and one had birt-hogg-dubé syndrome. conclusion: bilateral renal masses were found in % of the patients in a material of patients treated with nss. over % of them had the same type of tumor on both sides but % of these were benign. th e combination of diff erent malignant and benign lesions occurred in %. th ese fi ndings are strong arguments for tumor biopsy before surgery is decided. preoperative oita red cross hospital, oita, japan introduction and objective: approximately % to % of patients who underwent total nephroureterectomy for upper urinary tract (uut) urothelial carcinoma (uc) developed recurrence in the bladder during the follow-up period. last year, we presented a risk factor for intravesical recurrence aft er laparoscopic radical nephroureterectomy (lrnu) in patients with uut-uc in siu congress. th is time, we will report the result of analysis of a multi-center study. a total of patients with uut-uc received lrnu between january and december in oita university hospital and affi liated institutions that were enrolled in this study. patients with concomitant bladder cancer or a history of bladder cancer were excluded from this study. postoperative cystoscopy and urine cytology were performed every months for to years, and postoperative intravesical recurrence was evaluated pathologically. th e signifi cance of each variable was analyzed univariately by log-rank test. multivariate analyses by cox proportion hazards regression model was used to estimate simultaneous eff ects of multiple risk factors. statistical signifi cance was defi ned as a p value of < . . results: median follow-up aft er lrnu was months (range - ). of the patients, postoperative intravesical recurrences were shown in / ( %). average time to fi rst intravesical recurrence was . months. in univariate analysis, there were two signifi cant risk factors of intravesical recurrences. one was for patients who did not receive postoperative adjuvant chemotherapy (p= . ). th e other was for patients with preoperative positive urine cytology indicating class iv and v (p= . ). multivarite analysis revealed that preoperative positive urine cytology indicating class iv and class v was a signifi cant risk factor for intravesical recurrence (hr . % ci . - . p= . ). in this multi-center retrospective study, preoperative positive urine cytology was a significant risk factor for intravesical recurrence. th erefore, adjuvant chemotherapy such as intravesical instillation therapy can be eff ective to prevent intravesical recurrence in patients with preoperative positive urine cytology. retroperitoneal laparoscopic nephron-sparing surgery for complicated renal cysts introduction and objective: to evaluate the feasibility, effi cacy and safety of laparoscopic partial nephrectomy for complex renal cystic lesions. a retrospective cohort study on clinical data of patients with complex renal cystic lesions treated by laparoscopic partial nephrectomy from may to april in peking university th ird hospital. according to the bosniak classifi cation, cases were lesions of grade iif, were grade iii, and were grade iv. th e mean diameter of cystic lesions was ( . ± . ) cm, and lesions were larger than . cm. results: all procedures were performed through retroperitoneal approach and successful. th e mean operative time was ( . ± . ) min, ranged from min to min, and the mean renal warm ischemia time was ( . ± . ) min, ranged from min to min. blood loss in operations was from ml to ml, and the mean was ( . ± . ) ml. th e postoperative hospital stay was ~ days, and the mean was ( . ± . ) day. postoperative pathological results included simple renal cysts ( . %), cases of adult cystic nephroma ( . %), mixed epithelial and stromal tumor ( . %), cases of renal cell carcinoma with cystic change ( . %), and multilocular cystic renal cell carcinoma ( . %). th e results showed . % of cystic lesions of grade iif, . % of grade iii and . % of grade iv were malignant. in the follow-up ranged from to months (median months), there was no case of recurrence. conclusion: th e diff erentiation between benign and malignant renal cystic lesions before surgery remains diffi cult. according to the bosniak classifi cation, radiological diagnostic fi ndings are standard but still limit to the accuracy to determine the dignity of pathological entity. laparoscopic partial nephrectomy is feasible to treat complex renal cystic lesions, and is a safe and eff ective minimally invasive option. introduction and objective: th e aim of the study was to evaluate the value of metastasectomy in patients with metastatic renal cell carcinoma (mrcc) in the targeted therapy era. we reviewed the medical records of patients who presented with mrcc and received no systemic therapy before enrollment. of them, underwent complete metastasectomy followed by targeted therapy (complete metastasectomy group), underwent partial metastasectomy followed by targeted therapy (partial metastasectomy group), and treated with targeted therapy alone (non-metastasectomy group). we estimated progression-free and overall survival using kaplan-meier curves. a cox proportional hazards regression model was used to estimate the prognostic signifi cance of metastasectomy. results: clinicopathological variables did not diff er among the groups except for history of nephrectomy, bone metastasis, number of metastatic sites, and time from diagnosis to treatment. th e median progression-free survival was . , . , and . months in the complete, partial, and non-metastasectomy groups (p = . ). karnofsky performance status (hr . , p < . ), cell type (hr . , p = . ), sarcomatoid or rhabdoid features (hr . , p < . ), retroperitoneal lymphadenopathy (hr . , p < . ), number of metastatic sites (hr . , p = . ), lactate dehydrogenase (hr . , p = . ), and time from diagnosis to treatment (hr . , p = . ) were independent predictors of progression-free survival. th e median overall survival was . , . , and . months in the complete, partial, and non-metastasectomy groups (p < . ). complete metastasectomy (hr . , p = . ) was an independent predictor of overall survival, along with age (hr . , p = . ), karnofsky performance status (hr . , p < . ), sarcomatoid or rhabdoid features (hr . , p = . ), bone metastasis (hr . , p = . ), retroperitoneal lymphadenopathy (hr . , p < . ), number of metastatic sites (hr . , p = . ), hemoglobin (hr . , p = . ), neutrophil (hr . , p = . ), corrected calcium (hr . , p = . ), and time from diagnosis to treatment (hr . , p = . ). conclusion: complete metastasectomy performed before targeted therapy signifi cantly increased overall survival in patients with mrcc. if surgically resectable, aggressive metastasectomy should be considered. guideline results: prominent international guidelines and strategies varied signifi cantly in relation to follow-up practice. th e mode and frequency of radiological imaging was signifi cantly diff erent across the guidelines for low and intermediate risk disease. although there is currently no consensus within the literature regarding surveillance protocols, various guidelines and strategies have been developed using both patient and tumour characteristics. th is information raises questions regarding the follow-up practice in australia due to both the lack of guidelines and the fi nancial. introduction and objective: nephrectomy is the cornerstone therapy for renal cell carcinoma (rcc) and its continued refi nement through research may enhance patient outcomes. medical registries are used domestically and internationally to aid research, assess trends and help guide future practice of many medical disciplines. th ere is currently no national australian nephrectomy registry. th is review aimed to explore possible defi ciencies within the australian rcc nephrectomy fi eld and through assessment of literature from established registries, determine if a national nephrectomy registry is appropriate and justifi ed to address these issues. a pubmed search identifi ed records pertaining to rcc nephrectomy in australia. a similar search identifi ed records relating to established nephrectomy registries internationally as well as other surgical registries of clinical importance. th ese records were reviewed to address the stated aims of this article. results: australian rcc nephrectomy fi eld lacks population-based data: resulting key issues identifi ed ) diffi culty benchmarking individual and institutional outcomes; ) small sample sizes and reduced power of studies; ) assessment of regional and nationwide outcome trends: diffi cult to achieve and oft en done years in retrospect with no ongoing monitoring; ) care centralisation debate: can small volume centres provide comparable outcomes to high volume centres? ) best practice guidelines: patterns of adherence to existing protocols is uncertain; and ) limited platform for large scale prospective studies -restricting potential research. review of established international registries demonstrated the registry model can eff ectively address issues comparable to those identifi ed in the australian literature. a centrally held, de-identifi ed national nephrectomy registry could provide a means of ad-dressing defi ciencies identifi ed in the australian rcc nephrectomy fi eld. th e model is supported by evidence from comparable international examples and will provide population-based data needed for studies at the institutional, regional and national level. th e development of a confi dential and non-threatening escalation policy to be implemented should trends in the data emerge is a future possibility. scope exists for possible integration with current or future registries/ databases to develop a more encompassing urological, cancer or surgical registry. need remains for continued exploration of the feasibility and practicalities of initiating such a registry. new technologies of identifi cation of renal artery in retroperitoneal laparoscopic renal surgery hao y, xiao c, liu y, ma l introduction and objective: th e objective of this study was to evaluate the feasibility of a new method to identify renal vessels during retroperitoneal laparoscopic nephrectomy. a total of patients underwent transperitoneal radical laparoscopic nephrectomies from january to august . in the fi rst consecutive patients (group ) we located renal artery with the standard technique; in the last consecutive patients (group ) the medial arcuate ligament (mal)-psoas muscle fat complex was used as an anatomic landmark to identify renal vessels. comparative analysis was carried out between the two groups, including mean hilar exposure time, mean blood loss, duration of hospital stay, conversion rate and complication rate. no diff erences were noted in gender, age, mean body mass index, tumor side and size of the lesions in the two groups (p> . ). mean hilar exposure times were . ± . minutes in group versus . ± . minutes in group (p< . ). mean blood loss was . ± . ml in group versus . ± . ml in group (p< . ). no signifi cant diff erences were detected regarding duration of hospital stay, complication rate and conversion rate between the two groups (p > . ). no complications and no recurrence of disease at ct evaluation were recorded neither in group nor in group . conclusion: radical laparoscopic nephrectomy in use of the mal-psoas muscle fat complex as an anatomic landmark is technically feasible and safe. in conclusion, the mal-psoas muscle fat complex can serve as an objective and belt-and-braces anatomic landmark for the identifi cation of the renal vessels in retroperitoneal laparoscopies. kalpinskiy a, alekseev b, kaprin a, nyushko k, vorobyev n, vokach d introduction and objective: th e aim of our study is to evaluate the results of percutaneous radiofrequency ablation (rfa) of renal tumors in elderly patients with severe comorbidities and a high risk of surgical intervention. th e aim of this study was to evaluate the expression of cd and microvessel density (mvd) in clear cell renal cell carcinoma (ccrcc) as well as the relationship between mvd and possible prognostic markers like tumor size, degree of tumor necrosis and degree of tumor hemorrhage. expression of cd was detected in patients with ccrcc and cases with benign kidney tissue using immunohistochemical staining. th e mvd was studied by weidner's method. results: th e expression of cd in the clear cell renal cell carcinoma (ccrcc) ( . (ds± . ), varied from to .) were signifi cantly higher than the expression of cd in the benign kidney tissue, as the control group, was . (ds± . ) (u= , p< . ). th e mvd values marked by cd were negatively correlated with degree of tumor necrosis (r=- . , p= . ), tumor size (r=- . , p= . ), but no association was found between mvd values and degree of tumor hemorrhage (r=- . , p= . ) in crcc. our results show that mvd in crcc were signifi cantly higher than mvd in the benign kidney tissue. th ere was a negative non signifi cant correlation between the mvd and presence of tumor necrosis as well as between mvd and tumor size. on the other hand, there was no correlation between mvd and degree of tumor hemorrhage in ccrcc. conclusion: expression of hif- α and vegf in crcc was signifi cantly higher than in normal kidney tissue. th e expression of hif- α and vegf may be responsible for angiogenesis in ccrcc, however these angiogenic factors play an important role in the prognosis of ccrcc patients. transvaginal hybrid notes nephrectomy in a low resource setting firaza p, lorenzo e, bardelosa j, reyes e, patron n introduction and objective: hybrid notes decreases the invasiveness of conventional laparoscopic surgery and overcomes the limitation of pure notes especially in the absence of angulated instruments. th e patients are , and -year-old females with complaints of recurrent fl ank pain and urinary tract infection due to an obstructed non-functioning kidney. materials and methods: materials used include standard laparoscopic instrumentations and a endoscope. under general anesthesia the patient was placed in a lithotomy position with the aff ected side up at degrees. veress needle was initially inserted thru the umbilicus and was later replaced with a mm laparoscopic port with additional mm port also inserted at the aff ected lower quadrant site. pa-tient was then positioned in a steep trendelenberg and mm port was inserted thru the posterior vaginal wall under direct vision from the abdominal cavity that was later used for the endoscope. nephrectomy proceeded despite noted severe adhesions and the kidney was placed in the specimen retrieval bag. th e vaginal port site was enlarged to cm for extraction of the specimen. th e vaginal wound was repaired using running - absorbable sutures. results: th ree cases of transvaginal hybrid notes nephrectomy were successfully completed. th e median operative time was minutes (range: - ). th e mean estimated blood loss was ml for the three cases. median renal dimensions (cm) were as follows: craniocaudal . (range: . - ), laterolateral . (range: - . ), and anteroposterior . (range: . - . ). th e patient resumed regular diet as early as day post operatively. drain was removed prior to discharge. th e mean date of discharge was rd day post-operatively. th ere were no noted surgical complications according to clavien-dindo grading system. conclusion: hybrid notes transvaginal nephrectomy is a feasible and reproducible procedure in selected patients regardless of laterality for better cosmesis, reduced post-operative pain and early recovery. however, the view was challenging because it was from the pelvis. th e left side procedure proved to be more diffi cult due to the gonadal vein obstructing the view, which is usually larger in young females. introduction and objective: to summarize our clinical experiences of laparoendoscopic single-site surgery (less) in urology. results: all procedure underwent successfully using single trocar x cone (storz) without any major complications. early recovery with minimal scar is the hallmark of less surgery. duration of time ( - mns), blood loss ( - ml), mobilization ( - hrs), hospital stay ( - days). no intraoperative complication without any conversion to other surgery (multi port laparoscopic surgery) and uneventful post-operative period was the fi nal outcome. introduction and objective: th e use of fl exible cystoscopy to study bladder is usually perform in urology departments using diff erent types of lubricant to reduce pain. th e objective is to compare the use of lubricant gel with lidocaine versus lubricant gel without anesthetic in fl exible cystoscopy in terms of pain and tolerability. materials and methods: seventy two patients are divided in two groups in this observational not randomized study. group : patients with lidocaine gel % and group : patients with lubricant gel without anesthetic. th e main variables analyzed are score in visual analogue scale (vas) and score in spanish pain questionnaire (spq). t-student test and chi-square test are used to compare diff erences using spss program and signifi cant statistical diff erences is considered p≤ . . results: mean age of patients in group is . ± . years and . ± . years in group (p= . ). th e distribution according to sex was men: women in group and men: women in group (p= . ). th e main pain score in vas was . ± . in group versus . ± . in group (p= . ). in the spq, the current intensity value was . ± . in group versus . ± . in group (p= . ), and the total intensity value was . ± . in group versus . ± . in group (p= . ). th e cost of gel with lidocaine is . euro and gel without anaesthetic . euro. conclusion: th e use of lidocaine gel do not produce benefi t in the fl exible cystoscopy and expensive the procedure. new laparoscopic surgery using water filled laparo-endoscopic surgery systems introduction and objective: urologist usual operated under water fi lled condition, such as transurethral surgery, percutaneous renal surgery. however, laparoscopic surgery was done under co . water fi lled condition has several merits. water pressure is suppressing venous bleeding and prevent from co embolism in venous injury condition. to keep water temperature as same as body temperature was useful to avoid low body temperature. simultaneous observation of ultrasound image from the surface of the body and laparoscopic view is possible during surgery. th us we conduct to develop the water fi lled laparo-endoscopic surgery systems (wafles). first problem is dispersion of blood aft er bleeding. it interrupts the laparoscopic view. we solved this problem to control the fl ow of irrigation, aff ording the continuous observation of bleeding point and it is easy to control the bleeding by vessel sealing system or coagulation. second problem is managing fl oating organs such as intestine or nets. th ese are disturbed the operating view and space. to keep the operating space, we use sheath and single port devices. however, obtaining wide view was still hard in the water because fl oating organs disturb the fi eld. to solve this problem, we use -d tracking navigation system. results: using young male pig, we performed partial nephrectomy and radical cystectomy using this new system. wafles is now developing. we will be present the update of this research soon. comparison of safety, effi cacy and cosmetic outcomes between standard laparoscopic live donor nephrectomy and mini-laparoscopic donor nephrectomy: a randomized clinical trial introduction and objective: th is study was conducted to compare safety, effi cacy and cosmetic outcome between standard laparoscopic live donor nephrectomy (sldn) and mini-laparoscopic donor nephrectomy (mldn) in a randomized clinical trial. from march to june , consecutive kidney donors were randomly assigned to two equal groups for laparoscopic donor nephrectomy. from march to june , consecutive kidney donors were randomly assigned to two equal groups for laparoscopic donor nephrectomy. mldn: six to eight centimeters pfannenstiel incision was made slightly above pubis symphysis and millimeters trocar was fi xed through exposed fascia using open technique. five mm port was placed under direct vision at the umbilicus for camera insertion and two . mm ports were placed in subxiphoid and paraumbilical area. sldn: ten mm port was placed at umbilicus using open access technique for camera insertion. five mm trocar for grasping and mm trocar for vascular clipping were placed at subxiphoid and paraumbilical areas under direct vision, respectively. th e second mm trocar was placed in suprapubic area. cosmetic appearance was assessed three months aft er surgery by using the modifi ed patient scar assessment questionnaire (psaq). conclusion: our experience in this study revealed that peri and postoperative fi ndings were comparable between sldn and mldn but mldn has signifi cant better cosmetic appearance than standard laparoscopic approach. qiu m, ma l, lu j introduction and objective: to report our experience and outcomes with retroperitoneal laparoscopic anderson-hynes dismembered pyeloplasty for the repair of ureteropelvic junction obstruction (upjo). we performed retroperitoneal laparoscopic anderson-hynes dismembered pyeloplasty between june and december . ureter was found in the lower pole of the kidney psoas front, then ureteropelvic junction stenosis was dissociated. ureter was cut at about cm distal ureter beyond the part of stenosis, then stenosis was resected. posterior wall was continuous sutured, and double j tube was antegrade placed. at last, anterior wall was continuous sutured. patient characteristics and perioperative outcomes were analyzed. perioperative parameters including operative time, estimated blood loss, postoperative length of hospital stay, and complication. results: th e procedure was successfully accomplished in all patients, and no patient required conversion to open surgery. th e mean operation time was . min ( - min), mean estimated blood loss was ml ( - ml), mean postoperative length of hospital stay was . d ( - d), and mean time of keep drainage tube was . d ( - d) . patients were followed up for ~ months (average . months). eighteen cases were followed up in years, and an- renal cyst ( ) other patients were followed up for - years. th e total remission rate was . %. conclusion: retroperitoneal laparoscopic dismembered pyeloplasty is a safe and effi cacious procedure for upjo in a long time follow-up. positioning-related complications of robot-assisted radical prostatectomy (rarp) in a steep trendelenberg position with physique fixation appliance by the negative pressure takeda h, nakano y, narita h introduction and objective: because of recent advances in minimally invasive surgical techniques, robot-assisted radical prostatectomy (rarp) has become the primary treatment option in prostate cancer. rarp, however, necessitates patients to be placed in a steep trendelenberg position, which presents multiple opportunities for complications relating to the positioning of the patient. our study aims to study the prevalence and demographic predictors of these positioning complications. we included patients who underwent rp from to using data extracted from our hospital database. all patients (n= ) had trendelenberg position with physique fi xation appliance by the negative pressure, hug-u-vac and film dressings. positioning complications (skin, eye, nerve, compartment syndrome/rhabdomyolysis) were identifi ed using patient-level diagnosis and procedural international classifi cation of disease, th edition, clinical modifi cation codes. we analyzed body pressure by portable interface pressure sensor. results: positioning complications occurred in . % of cases with shoulder complications contributing the most to this frequency. rubefaction occurred in cases, without bedsore. having positioning complications not increased a patient's odds of having increased age, bmi, operation time, body pressure, insignifi cantly. conclusion: th e steep trendelenberg position used in rarp was not shown to be associated with patient positioning-related complications in this sample. physique fi xation appliance by the negative pressure is safety and useful. evaluation of nasogastric tube (ngt) suction for evacuation of large bladder blood clot introduction and objective: blood clot formation in the urinary bladder can be caused by many etiologies such as postoperative bleeding, tumor bleeding, radiation cystitis and etc. acute urinary retention may disclose and a large three way catheter with irrigation is placed conventionally to prevent further formation of blood clot and manually remove the blood clot. when this failed an endoscopic procedure takes place to con-trol the bleeding and to relief the bladder. urologists may fi nd it diffi cult to remove a large, thick and bulky clot using ellik evacuator. here we introduce using nasogastric tube as an alternative to procure a safe and effi cient way to remove these bothersome clots. aim: to introduce a novel method to successfully remove large, troublesome blood clots during cystoscopy. we prospectively perform blood clot evacuation on patients within month (september -february ) in hasan sadikin hospital. th e patient, preoperatively have at least ½ of bladder volume with blood clot using ultrasonography. a fr ngt inserted into the bladder through the resectoscope sheath fr and connected to suction unit with a mmhg negative pressure. a calibration of the ngt tip does not exceed more than cm from the cystoscopy beak was made. backward and forward movement was set in motion during the procedure to facilitate blood clot removal. cystoscopy evaluation was performed in the end of the procedure to evaluate any complication. a total cystoscopy time, ngt suction time, and the volume of blood clot were documented. results: a total patients was all successfully managed with this method without any complications such as bladder laceration/perforation. th e mean age was years old with male predominance. most common etiologies of blood clots retention were postoperative bleeding ( %). th e average time for clot removal time was ( - ) minutes. th e average volume of blood clots removed was grams. conclusion: evacuation using ngt suction is eff ective, safe and an effi cient way to remove of large bothersome clot. learning curve assessment of robot-assisted radical prostatectomy in the oncological and functional outcomes takeda h, nakano y, narita h introduction and objective: th is study aims to compare the oncological, safety and functional outcomes between fi rst-step rarp and second-step rarp. th e study was conducted on a total of patients having undergone robot-assisted radical prostatectomy from to . th e fi rst patients (group ) were compared with the second (group ) to evaluate the learning curve eff ects. results: both groups were similar with respect to age, prostate-specifi c antigen level, body mass index, gleason score, and distribution of the clinical stage. th e operative time was minutes for group , and minutes for group (p= . ). individual times of various stages of the procedure (dissection of the seminal vesicles, entering the extraperitoneal space and dissection of the endopelvic fascia, incision of the bladder neck, division of the prostatic pedicles and preservation of the neurovascular bundle, and urethrovesical anastomosis) decreased signifi cantly over time. estimated blood loss was ml for group , ml for group . th e length of stay was . days for group , . days for group . positive surgical margin rates were % for group , % for group . while one patient in group had biochemical recur-rence, no patient in group had biochemical recurrence. continence rates at months were . %, and . % in groups and . conclusion: surgical, oncologic, and functional outcomes of rarp improve with increasing experience. outcomes similar to the published series by high-volume centers could be achieved aft er to rarp cases. possibility of d modeling and intraoperative navigation during procedures in the retroperitoneal space introduction and objective: application of d modeling allows you to get more information about the spatial imaging of the disease. intraoperative navigation in the retroperitoneal space is an innovative minimally invasive procedure, the surgeon improves orientation in retroperitoneal space. we present the method of intraoperative navigation based on virtual simulation during videoendoscopic partial nephrectomy for kidney's tumors. special computer program has been developed, that created three-dimensional image of operative space on the basis of preoperational tomographic data of a concrete patient. we used hardware-soft ware complex (hsc) for virtual modeling of the surgery zone. th e complex consists of a pc, original soft ware and mechanical d digitizer. th e hsc allowing to form virtual d model of a patient according to the results of tomography examination. th e original method of matching the system of coordinates of a virtual model with the patient was off ered. th e procedure was conducted under the conditions warm ischemia, aft er mobilization of the kidney, partial nephrectomy was performed by observing the image of d organ model agreed with the video image of the kidney tumor. th e method was originally performed for the patients with small renal tumors, who needed in surgical treatment, their average age was . (in the range from to ) years, men - ( . %), women - ( . %). size of the tumors were . ( . - . ) cm, they were located in the lower poles of the kidneys. average time of an operation performed with the use of the computerized choice of the surgical approach was . ( - ) minutes. warm ischemia time was . ( - min). th ere were no complications during the operation and in the post-operative period. th ere were no cases of positive surgical margins. conclusions: usage of the introduced computer program allows the surgeon to determine compliance with the contours of the d models of the body shown in the video monitor. th e technique provides additional possibilities for the surgeon in selecting borders in partial nephrectomy. th is method is particularly perspective for teaching beginner surgeons, it can help them acquire skills in minimally invasive surgery. possible impact of continuous drainage after minimally invasive partial nephrectomy introduction and objective: postoperative management of partial nephrectomy without drain placement is common, but the specifi c eff ects on patients are unclear. we investigated the impact of no drain placement aft er minimally invasive partial nephrectomy (mipn). we retrospectively studied consecutive patients who underwent laparoscopic and robotic partial nephrectomy at a single academic center. th e study group included evaluable patients without drain placement. th e quantity of postoperative fl uid collection in the perirenal space was calculated using computed tomography. th e pre-and postoperative serum concentrations of total protein and albumin, in addition to neutrophils, lymphocytes, monocytes numbers and c-reactive protein (crp) levels in the blood were compared. results: drain was placed in ( . %) patients who underwent mipn. th e remaining ( . %) patients were not provided with drain placement. although the average total quantity of fl uid discharged from the drain was ml, the average fl uid remaining in the perirenal space was not signifi cantly diff erent with or without drain placement ( . ml vs. . ml, p= . ). decrease in serum total protein and albumin with drain placement was signifi cantly greater than without drain placement (total protein; . % vs. . % p< . and albumin; . % vs. % p= . ). no drain placement also caused markedly greater decreases in lymphocytes and monocytes than drain placement, while neutrophils and crp were not different. a mipn population was necessary by design, which may limit the ability to generalize these results. conclusion: analysis of the quantity of fl uid collection showed little need for routine drain placement. no drain aft er mipn prevents serum protein loss and might aff ect wound-healing immune responses. initial experiences of laparoscopic radical cystectomy introduction and objective: simultaneous treatment of bilateral lesions is an interesting application of laparoscopy. our goal was to present our experience with simultaneous bilateral laparoscopic pyeloplasty using three midline ports in two adult patients. two adult patients (one male and one female) underwent bilateral laparoscopic dismembered pyeloplasty in one session. one of the patients had horseshoe kidneys. a -mm trocar was placed through the umbilicus, and two -mm trocars were placed midline - cm superior and inferior to the umbilicus. results: intra-and postoperative periods were uneventful. operation time was and minutes in the fi rst and second patient, respectively. obstruction was relieved in both patients bilaterally on a -month follow-up. conclusions: simultaneous bilateral laparoscopic pyeloplasty using three midline ports is safe and feasible in adult patients with bilateral ureteropelvic junction obstruction. introduction and objective: radical cystectomy is considered to be the most eff ective treatment for patients with muscle-invasive bladder cancer. most urinary diversions are performed extracorporeally because of complex procedure time consuming. however, with the development of minimally invasive radical cystectomy techniques, increasing attention has been focused on intracorporeal urinary diversions, including both ileal conduit and orthotopic neobladder. we reviewed cases of laparoscopic radical cystectomy with intracorporeal ileal conduit in our medical center. ten patients with bladder cancer who underwent laparoscopic radical cystectomy and intracorporeal ileal conduit were retrospectively reviewed. with the cystoprostatectomy and lymphadenectomy completed, a - cm segment of ileum was identifi ed cm from the ileocecal junction. division of the isolated segment of bowel and the mesentery was performed using the endo-gia stapler. ileo-ileal continuity was reestablished by creating a generous side-to-side anastomosis with endo-gia stapler. th e left ureter was passed to the right side of the abdomen. aft er placement of single-j stent, the ureters were spatulated and the ureteroileal anastomis was performed with a running suture. results: laparoscopic radical cystectomy and intracorporeal ileal conduit were performed successfully in all ten patients from jan to dec . th e mean operating time was min ( - min), and the mean ileal conduit construction time was min ( - min). th e mean blood loss was ml ( - ml), and no patient received transfusion. th e time to orally allow was postoperative day ( - ). th e mean hospital stay was d. no major complication occurred. results: all the procedures were successfully completed without additional trocars except for one patient who was immediately converted to suprapubic-assisted laparoendoscopic single-site surgery (sa-less) nephrectomy for rectal injury during the placement of the zou-port. in our initial cases, tri-port was used. in the subsequent procedures, zou-port was used. th ere were no other intraoperative complications occurred. postoperative complications included a right external iliac artery thrombosis in one patient who underwent pure transvaginal notes simple nephrectomy. th e mean operative time was (range to ) mins and the mean estimated blood loss was (range to ) ml for pure transvaginal notes renal cyst decortication. th e mean operative time was (range to ) mins and the mean estimated blood loss was (range to ) ml for pure transvaginal notes nephrectomy. th e mean visual analog scale (vas) pain score was . (range - ) on postoperative day . th e mean time for ambulation was . (range - ) d. th e mean time for oral feeding was . (range ~ ) d. th e mean postoperative hospitalization stay was . (range ~ ) d. during the to -month follow-up period, all the patients were in good condition. th e posterior colpotomy incision healed well. th ere was no scar on the abdominal wall. th ere was no retrograde infection of pelvic and abdominal cavity, umbilical hernia, or uterine prolapse. conclusion: th e application of zou-port in pure notes transvaginal eff ectively reduces the diffi culty of operation and avoids the abdominal and pelvic organ injury, which is worthy of clinical application. lower ureter stricture. all the cases presented only one abdominal scar before surgery, including cases with the history of caesarean section, cases with the history of birth control surgery, cases with the history of appendectomy, cases with the history of inguinal hernia repair, cases with the history of ureterolithotomy, one case with the history of bladder lithotomy, and cases with the history of laparotomy surgery. th e mean length of scar is . ( . to . ) cm. under general anesthesia, the patients were positioned in lithotomy with aff ected side elevated at °. two trocars ( mm or mm) were introduced into abdominal cavity from the incisions at the right and left medial margin of umbilicus. a -or -mm trocar was inserted into the abdominal cavity through the abdominal scar under the direct vision. our technique for the transabdominal scar-assisted u-less is similar to that of standard laparoscopy, using conventional operating apparatus placed in the umbilical trocars, under direct vision achieved by a fl exible-tip ° laparoscope placed through the trocar at the abdominal scar. th e specimen was placed inside a homemade bag and removed under direct vision through an extended incision at the abdominal scar. to explore the application of three-dimensional ( d) laparoscopic technique in hybrid transvaginal notes nephrectomy. a total of female patients underwent hybrid transvaginal notes nephrectomy using d laparoscopy system. th ose included cases of hydronephrosis, cases of renal empyema, and cases of renal atrophy. th e median age was (range to ) years, and body mass index was . ( . ~ . ) kg/m . all patients were with unilateral disease and normal contralateral kidney. th e perioperative data including operative time, estimated blood loss, and surgical outcome were analyzed. results: th e procedures were successfully completed. th e median operative time was ( to ) mins. th e median estimated blood loss was ( to ) ml. th e patients were recover ambulation on postoperative day to , and tolerated diet on postoperative day to . th e patients were discharged on postoperative day to . th ere were no intraoperative or postoperative complications. during the -to -month follow-up period, all the patients were in good condition. th e posterior colpotomy incision healed up well. th ere were two hidden umbilicus scars. and p= . , respectively). mean incision length was shorter ( . vs. . cm, p< . ) and the scar satisfaction score was higher ( . vs. . , p= . ) in ldn with fl ank incision group. th e postoperative pain scores were higher (p= . ) in ldn with fl ank incision group but analgesic requirements were similar in both groups (p= . ). conclusion: ldn with fl ank incision had cosmetic satisfaction and comparable graft function, although challenging to the surgeon with longer warm ischemia time and higher postoperative pain. the effect of caudal block on postoperative analgesia in robotic assisted laparoscopic prostatectomy: a prospective study in a national referral centre introduction and objective: caudal block is widely used in paediatric surgery. it provides satisfactory postoperative pain relief in lower abdominal operations with minimal complications. th is pilot study explores its eff ect on postoperative pain control and its safety in patients who underwent robotic assisted laparoscopic prostatectomy (ralp). from to , consecutive patients were randomised into groups of patients. th e intervention group received caudal block using ropivacaine immediately aft er operation, while the control group only received analgesia consisting of paracetamol, nsaids, and opioids. both groups were assessed using verbalised pain scores in recovery room, and , , , , hours aft er the operation. additional analgesic requirements were recorded in the intervention group. opioid-related adverse events and the time to passage of fl atus were also recorded. introduction and objective: th e dorsal venous complex (dvc) ligation and vesicourethral anastomosis (vua) are the most challenging parts during laparoscopic radical prostatectomy (lrp). th is study will introduce a unique technique without any knots for the dvc ligation and vua using the unidirectional single running self-retaining suture. th is study is to examine the eff ectiveness of our knotless laparoscopic radical prostatectomy compared with the conventional technique. materials and methods: from december to december , lrp were separated into groups: group of knotless lrp and group of conventional single-knot lrp. during knotless lrp, the dvc is sutured using a - / circle self-retaining suture with bites at the same place, and the vua is performed with a -cm - / circle barbed self-retaining suture with one needle driver. retroperitonoscopic pyeloplasty is a feasible approach in the management of pelviureteric junction obstruction with a crossing vessel. anterior transposition using the posterior approach demands a good experience. herein, we present a case with complex vascular anatomy representing a real surgical challenge for a retroperitonoscopic approach. in the period from - , cases with a crossing vessel were operated by a single surgeon using both transperitoneal and retroperitoneal approaches. we report here a y old girl with left sided pelviureteric junction obstruction presenting with recurrent loin pain. lateral retroperitoneal laparoscopic approach was used with trocars; mm optic trocar and two mm working trocars. th e pelviureteric junction was tightly pushed anteriorly and close proximity to complex crossing vessels. dissection from the crossing vessels was performed followed by anterior transposition of the pelviureteric junction and a diffi cult anastomosis was performed with antegrade dj insertion. smooth postoperative recovery, no leakage, dj is removed aft er . month; follow-up ultrasound revealed decompression of the pelvis with no recurrence of the symptoms during the follow-up period. conclusion: retroperitonoscopic lateral approach is feasible for the management of pelviureteric junction obstruction with crossing vessel even in the most diffi cult cases in well trained hands. robotic assisted laparoscopic reimplantation for iatrogenic ureteral injury franklin a, jones c, pokala n, cummings j introduction and objective: ureteral injuries are a source of morbidity in pelvic surgery. robotic approaches to these injuries have been proposed. we reviewed our experience with this approach to examine the outcomes in patients undergoing robotic assisted laparoscopic reimplantation (ralr) for iatrogenic ureteral injury. oncological outcomes of robotic prostatectomy in the victorian public sector basto m , , sathianathen n , te marvelde l , landau a , , graves r , , everaerts w , , birch e , lawrentchuk n , goad j , moon d , murphy d , , , , introduction and objective: following the installation of the davinci s at peter maccallum cancer centre in , we aim to report medium-term oncological outcomes of patients undergoing robot-assisted radical prostatectomy (rarp) and to identify factors that act as predictors for biochemical recurrence (bcr) and oncological failure (of). a prospective cohort of consecutive men who underwent rarp in a single victorian public hospital were followed up for a median time of . and . months for bcr and of respectively. of was defi ned as bcr (psa≥ . ng/ml) or the start of adjuvant therapy. however, longer-term data is still required to better evaluate oncological success. functional outcomes of robotic prostatectomy: the victorian public sector experience basto m , , sathianathen n , te marvelde l , landau a , , graves r , , everaerts w , , birch e , lawrentchuk n , goad j , moon d , declan murphy d , , , , introduction and objective: to report medium-term functional outcomes of men aft er undergoing robotic assisted radical prostatectomy (rarp). furthermore, the impact of the procedure on quality of life will also be analysed. a cohort of consecutive men who underwent rarp in a single victorian public institution was assessed post-operatively for continence and potency status. a 'prostate cancer research survey' that was distributed pre-operatively and at , , , and months post-rarp, in combination with hospital medical records were utilized to collect data. th e following validated questionnaires were included in the survey: expanded prostate cancer index composite for clinical practice (epic-cp), sexual health inventory for men (shim) and prostate cancer related quality of life scale (pcar-qols). th e latter primarily evaluated the impact of surgery on quality of life. results: utilising hospital medical records, of the ( %) men that had follow-up post-operatively, % ( / ) were fully continent at months using a zero pad defi nition and % ( / ) were continent using a zero or security pad defi nition. of those who completed the epic-cp questionnaire, preoperatively (n= responders), . % and . % were continent using a zero and security pad defi nition respectively. at -months (n= responders), . % of patients were fully continent using zero pads per day and . % of patients were continent using none or security pad per day. regarding erectile function, shim scores were available for men pre-rarp, of which % were considered to be potent. of this subset of men, only %, % and % are considered post-operatively potent at , and -months. none of the patients that were pre-operatively impotent regained their erectile function at months. sexual confi dence was the facet of life that was most impacted by rarp. other quality of life subdomains showed no signifi cant diff erences aft er robotic prostatectomy. conclusion: th ere has been satisfactory recovery of continence post-rarp, however, erectile dysfunction still remains an important adverse sequela of surgery. overall, robotic prostatectomy has been successfully implemented in the victorian public sector with satis-introduction and objective: to compare patterns of care and perioperative outcomes of robotic prostatectomy to other surgical approaches, and create an economic model to assess the viability of robotic prostatectomy in the case-mix public health funding system. we retrospectively reviewed all radical prostatectomies (rp) performed for localised prostate cancer in victoria, australia, between july and april from the victorian admitted episode dataset (vaed), a large administrative database that records all hospital inpatient episodes in victoria, australia's second most populous state. patterns of care, length of hospital stay (los) and blood transfusion rates (btr) were compared by surgical approach. we then created an economic model to evaluate the incremental cost of robotic assisted radical prostatectomy (rarp) over open radical prostatectomy (orp) and laparoscopic radical prostatectomy (lrp) incorporating the cost off set from diff erences in length of hospital stay and blood transfusion rates. th e economic model constructs estimates of the diagnosis related group (drg) costs of orp and lrp, adds the gross cost of the surgical robot (capital, consumables, maintenance and repairs), and manipulates these drg costs to obtain a drg cost per day which can be used to estimate the cost off set associated with rarp in comparison with orp and lrp. economic modelling was performed around a base-case scenario, assuming a -year robot lifespan and robotic cases performed per fi nancial year, and one and twoway sensitivity analyses performed for the -arm da vinci shd, si and si dual surgical systems (intuitive surgical ltd, sunnyvale, ca, usa). both situations present a challenge to the surgeon contemplating a radical prostatectomy for prostate cancer, due to surgical access and anomalous vascular and ureteric anatomy. open radical prostatectomy has been reported in transplant recipients, but very little has been described using a robot-assisted laparoscopic approach. a case series will be described, illustrating the challenges and techniques required to successfully perform transperitoneal robot-assisted radical prostatectomy in patients with a congenital pelvic kidney or renal transplant within the pelvis. operations were performed using the da-vinci surgical system. we will describe a series of patients between and who underwent transperitoneal ro-bot-assisted radical prostatectomy, including patients with a congenital pelvic kidney and a redo renal transplant within the pelvis. prostatectomy was performed using a partial nerve spare in all cases, and pelvic lymph node dissection was not performed. th ere was a mean console time of minutes with a mean estimated blood loss of ml. histopathology confi rmed gleason sum - disease confi ned to the prostate with no extraprostatic extension or seminal vesicle invasion (pt c), and surgical margins were free of tumour in all cases. th e tumour volume ranged from . to . cubic centimetres. th e psa became undetectable postoperatively and remained undetectable without further therapy. careful perioperative review of imaging and placement of ports under direct vision was essential in avoiding complications. stay suture is applied at glans. circumcision incision is applied leaving at least mm tissue of inner mucosal collar. penile skin is denuded down to the penoscrotal junction. minor degree of chordee is corrected by this procedure. a fr feeding tube in the urethra adds to identify the distal urethra which is just underneath the skin in these case, which removed at the end of procedure. mucosa is defi cient ventrally and is replaced by a triangular patch of skin. th is skin patch is excised and mucosal edges are approximated in the midline. th is simple maneuver gives glans penis an upward tilt and meatus appears almost on the tip of glans. redundant preputial skin is excised and mucocutaneous approximation is done with / pds. no dressing is required. we operated cases of glanular hypospadias between december and january . mean age of children was . ± . years. all cases were day cases. th ere was no need for catheterization and dressing. we used temporary dressing for mild bleeding immediate post op in cases only which were removed in recovery room. th ere was no immediate post-operative complication like urinary retention, severe pain, fever or urinary tract infection. th ere was no complication of meatal stenosis in follow-up ( - month follow-up). urine stream was good and cosmesis was satisfactory to parents. we had low complications in our set up and success of glanular hypospadias by our technique was good in terms of good urine stream and cosmesis. conclusions: th e goal of modern hypospadias surgery is a functional neourethra that appears to be normally circumcised penis. tubularized incised plate urethroplasty is a widely applicable technique for distal hypospadias repair. but our current series shows that modifi ed tubularized incised plate technique has low complication rate and excellent cosmetic results superior to tubularized incised plate urethroplasty for primary distal hypospadias repair. however, these results must be further evaluated by comparison study of large series. the impact (catalona, ) was performed in patients. occult metastatic disease was found in two patients ( groins) at the time of diagnosis and subsequently developed in patients during follow-up. th erefore, a total of ( %) of the patients developed metastatic disease. conclusions: current management protocols place moderately diff erentiated t penile scc without vascular invasion in a low risk group for lymph node metastases. for this reason a primary option for these patients expectant approach is currently recommended. our experience has shown that patients in this group are really at higher risk for metastatic disease, and we suggest early modifi ed groin dissection instead of expectant observation. introduction and objective: penile cancers are rare. in ghana, they account for less than % of all genitourinary cancers. data on penile cancers in ghana is scanty. we report on cases of penile cancers seen over the last years at the komfo anokye teaching hospital (kath). th e aim of the study was to describe the clinicopathological presentation and the mode of treatment of penile cancers in our setting. th is was a retrospective study of histologically confi rmed cases of penile cancers seen at kath from january to december . information gathered included age, the clinicopathological features and mode of treatment using a structured proforma. results: th ere were cases of histologically confi rmed penile cancers over the period. th e age range was from - years with a median age of years. eight were uncircumcised and were married. in only one did the lesion not originate from the glans penis rather aff ecting the base and upper part of the left of hemi-scrotum. in patients, the lesion was restricted to the glans penis, it had involved the distal penis in , midshaft in , proximal penile in and base of penis in one of whom had auto amputation. all were squamous cell carcinoma with majority being moderately well diff erentiated ( %). seven had ulcerative lesions and were caulifl ower-like. majority were advanced (t ) involving the corpora ( %). only one patient reported with a t lesion. eleven patients ( . %) had lymph node involvement and two had distant metastasis at presentation. only one patient had a penile sparing surgery with of them having partial penectomy at various levels with ure-throstomy at the stump ends. one had total penectomy with suprapubic urinary diversion whiles the one with auto amputation had radiotherapy as the primary treatment. eleven of the patients had lymph node dissection. four had adjuvant radiotherapy. conclusion: most patients present with advanced disease making any hope of achieving a functional and cosmetically acceptable penis aft er treatment impossible. further education is needed to ensure early detection and treatment. how does partial penectomy due to penile cancer affect the sexual life? even though the high incidence of penile cancer in brazil, the sexual life of its patients, as well as their partners, has never been evaluated before. th e aim of this study is to evaluate erectile function in patients who underwent partial penectomy due to penile cancer, describe the socio-demographic and clinical data as well as to assess the patient's partners' sexual function. we performed a prospective analysis in patients between and at pernambuco state cancer hospital in brazil. th e sample consisted of patients who were submitted to partial penectomy for the treatment of penile cancer. control group included volunteer couples from the general population with similar socio-demographic features. th e assessment of erectile function and female sexual dysfunction were evaluated with iief- and fsfi respectively. results: th e prevalence of erectile dysfunction (ed) in the group of individuals subjected to partial penectomy was . %, including severe ed in %, moderate ed in %, mild-to-moderate in %, mild ed in . %, and no ed in . % of the participants. th e prevalence of ed in men of the control group was . % and was typically characterized as mild ed (p < . ). between partners of partial penectomy and control groups, % and % reported sexual dysfunction, respectively (p = . ). a comparative analysis of the risk factors for the ed showed that there were not diff erences between both groups (body mass index (bmi); tabagism; diabetes; hypertension; dyslipidemia and hypogonadism). conclusion: th e actual incidence of erectile dysfunction in patients submitted to partial penectomy for penile cancer is . %. comparative analysis between patients who underwent partial penectomy and general population showed a higher dysfunction rate in addition to more severe ed. in despite of that, their partner's sexual function was similar between the analysed groups. the introduction and objective: androgens are essential for the development and growth of the genitalia. th ey regulate the erectile physiology by multiple mechanisms. several studies have examined associations among sex hormones' serum levels, erectile function and sex drive. we sought to identify a protocol for using testosterone in men with erectile dysfunction and late-onset hypogonadism (loh). during a -month period, men with erectile dysfunction who presented to the andrology clinic were selected. th ey underwent a complete physical examination and fi lled out the international index of erectile function- questionnaire. serum luteinizing hormone (lh) and testosterone levels were evaluated. patients received a single intramuscular injection of mg testosterone. th ereaft er, serum levels of lh and testosterone were measured weeks later. results: th e mean age was years old. aft er treating patients with testosterone, ( %) showed improvement in loh symptoms including libido, loss of energy, irritability and quality of life. th e mean international index of erectile function was and . , prior to and aft er treatment respectively. mean serum testosterone levels before and aft er treatment were . and . ng ml_ respectively (p = . ). mean serum lh revealed a signifi cant decrease aft er the study (p = . ) ( . and . ng ml_ , before and aft er the study respectively). our fi ndings suggested that testosterone replacement therapy improves libido and loh symptoms in individuals with almost normal or lower limit normal value of serum testosterone levels. does l-carnitine therapy add any extra benefi t to standard inguinal varicocelectomy in terms of deoxyribonucleic acid damage or sperm quality factor indices: a randomized study to evaluate if addition of l-carnitine therapy to standard varicocelectomy adds any extra benefi t in terms of improvement in semen parameters or deoxyribonucleic acid (dna) damage. one hundred patients enrolled in this study and were randomly divided into groups ( patients in each group). in group , standard inguinal varicocelectomy and, in group , standard inguinal varicocelectomy plus oral antioxidant therapy (oral l-carnitine, mg times a day) were performed for months. for all patients, routine semen analysis and dna damage test of spermatozoa (by methods of terminal deoxynucleotidyl transferase dutp nick end labeling and protamine damage assay) were performed at baseline and at and months postoperatively. results: in both groups, the improvement in semen analysis parameters and dna damage was observed, but there was not any statistically signifi cant diff erence between the groups in these parameters, although the slope of improvement in dna damage was slightly better in group (that was not statistically signifi cant). we observed that addition of mg of l-carnitine orally daily to standard inguinal varicocelectomy does not add any extra benefi t in terms of improvement in semen analysis parameters or dna damage. serum uric acid as a risk predictor for erectile dysfunction introduction and objective: testicular torsion is one of the few urological emergencies that require prompt diagnosis and treatment, since its delay leads to testicular ischemia inevitably leads to testicular necrosis and atrophy. we aimed to determine the pattern of presentation and early outcome of patients with testicular torsion managed at kcmc. th is was a hospital based descriptive retrospective and prospective study involving patients who were managed for testicular torsion between january and january . eighty three ( %) were at the age of years with a mean . and a standard deviation of . . results: left side was more aff ected by . %. th irty two ( . %) patients arrived at kcmc within six hours from the onset of symptoms. scrotal pain was the main complaint. seventy two ( %) patients were misdiagnosed at the peripheral health facilities and treated empirically with antibiotics. ninety six point nine percent of those with more than degrees of rotation and duration of arrival to kcmc beyond six hours were found with missed torsion compared to . % of those with a degree of rotation less than and less than six hours on arrival to kcmc (p-value . ). orchiectomy of the aff ected testis and fi xation of the viable was the mostly adopted treatment option by . %. eighty four percent of our clients had fi rm and smooth testis at follow-up of three months with % having atrophic testis at three months in both groups (retrospective and prospective arms). conclusion: testicular torsion aff ects more young adolescent males. all patients with testicular torsion presented with scrotal pain. most patients arrived to kcmc hospital beyond six hours majority of them being treated empirically with antibiotics at the peripheral health facilities. missed torsion is a common sequel to our patients outcome at three months is promising by having viable testis. ho:yag laser ablation for ulcerative interstitial cystitis tokyo women's medical university aoyama hospital, tokyo, japan introduction and objective: in cases of ulcerative interstitial cystitis are usually treated by tur or by electrocautery, resulting in improvement of pain. efficacy of electrocautery using laser remains unclear because of a very few number of case reports. we treated this time ulcers of interstitial cystitis by cautery using ho:yag laser to evaluate its effi cacy as well as safety. materials and methods: eight cases with hunner's ulcers whose pains were hardly controlled aft er drug therapy and/or hydrodistention were treated with ho:yag laser. patients were evaluated with interstitial cystitis symptom index (icsi), interstitial cystitis problem index (icpi), international prostate symptom score (ipss), quality of life (qol) index and a visual analog pain scale (vas) at base line, one, three and six months post operatively. statistical analysis was performed using the paired t test, in which p< . was considered statistically signifi cant. results: patients were all females aged to years. half of them were treated more than two times. scores obtained by the questionnaire survey were improved aft er the laser therapy. scores of icsi, icpi, ipss, qol index and vas were statistically signifi cantly decreased at one and three months. only vas was statistically signifi cantly decreased at six months. th ere was no severe complication associated by the therapy. conclusion: ho:yag laser therapy for ulcerative interstitial cystitis is effi cacious at least for three months. also this treatment is safe for aged patients. introduction and objective: th e use of methylene blue (mb) to highlight anatomic structures in urology is a well-established practice. a narrow urethral plate can be diffi cult to properly locate intraoperatively, particularly in panurethral strictures. our objective is to assess the value of intraurethral injection of mb during urethroplasty. th ere is cc of mb ( mg/ ml) diluted in cc of normal saline. th e mb is gently injected retrograde into the urethra. a penile clamp is applied for minutes to increase the contact time of the mb with the urethra. th e urethroplasty commenced and the urethra was opened. th e impact of the mb on the anatomy of the urethra was by subjective assessment of a single surgeon (s.b.k.). results: a total of consecutive cases were prospectively evaluated from - . precise staining of the narrow lumen was successfully observed in ( %). in these cases, the diseased urethral strictured portion of the urethra was subjectively stained blue with mb. th e grossly normal appearing urothelium remained pink and did not take up signifi cant mb stain. in ( %) cases minimal or no staining was observed. extravasation in to the spongiosa was seen in ( %) cases. in ( %) cases there was dense staining distal to the narrow lumen. th ere were no known allergic complications. conclusion: normal urothelium does not appear to be stained by mb. mb readily stains diseased and strictured urotheilum. intraurethral injection of mb is a useful tool in urethroplasty. it helps in delineation of stricture and identifying lumen. it guides us to the exact area of urethra to be augmented. it is a simple, non-costly and non-invasive tool. in our high volume tertiary referral unit, it is now standard to inject methylene blue in urethra immediately prior to urethroplasty. demography, preoperative imaging and surgical outcome in penile fracture results: condition was occurred in . % of patients during an abnormal sex such as masturbation, aggressive sex and also taghaandan. all patients except one that refused intervention were treated surgically. only four cases involved bilateral corporal injury. two involved unilateral corporal injury with an associated urethral injury, and one involved bilateral corporal injury with an associated urethral injury that all were repaired primary. urine analysis was performed for . % of patients. gross hematuria was seen in one and microscopic in two patients of urethral injury and did not see in others. retrograde urethrogram were not taken of patients with urethral injuries. diagnostic cavernosography or magnetic resonance imaging was not used in any of the patients. cystoscopy was performed in case of gross hematuria with complete urethral transection. no complications occurred in the patients in early follow-up. we are interested in that report entire result of this study such as longterm surgical outcome at congress. conclusion: based on islam promotion for early and inexpensive marriage, avoiding from abnormal sex can signifi cantly decrease penile fracture. in addition, we recommended immediate surgical exploration and repair of tunica albuginea without any preoperative diagnostic imaging. introduction and objective: cowper's glands are two exocrine glands, which are located in the perineal pouch between the fascia layers of the urogenital diaphragm. th ey excrete pre-ejaculate into the urethra to lubricate it and neutralize acid to enable sperm to pass through the urethra. th e glands form two ducts that are . to cm long. although anatomic variations exist, the majority of ducts combine to make one confl uent passage that opens at the posterior part of the bulbar urethra. cowper's gland collecting ducts dilatation is called syringocele, an uncommon and under-diagnosed anomaly in adults. in pediatric patients there are . % and . % found on autopsy studies. we are presenting case of an adult -year-old male, whose symptoms were unrecognized by many physicians, even experienced urologists. th e patient had diff erent treatments with antibiotics and other diff erent medications without success. results: th e patient's chief complaint was dribbling aft er voiding few drops of urine when smiling, coughing, sneezing, crouching and any kind of eff ort. he received treatment as an outpatient by family physician and dermatologist. a bulging on the perineum was found by palpation, hard to elastic consistency, walnut size formation in the corpus spongiosum, easily movable from the perineal skin. urethroscopy was performed and the fi nding in the bulbar urethra was a cystic formation, gray to white color with very thin blood vessels. it fi lled the lumen of the bulbar urethra, but with pressure very easily passed the urethra and verumontanum to the bladder. voiding and retrograde urethrography showed fi lling defects in the bulbar urethra. th is cystic formation was fi xed to the fl oor of the urethra. an incision and deroofi ng of the cystic wall by resection was done. th e patient aft er this procedure was without dribbling aft er voiding. introduction and objective: th e use of methylene blue (mb) to highlight anatomic structures in urology is a well-established practice. th ere are diff ering opinions regarding the management of short atraumatic bulbar strictures. some favor augmentation with buccal mucosal graft (bmg) while others favor excision and primary anastamosis (epa). th e divergence of opinion is unifi ed toward epa in the face of signifi cant spongiofi brosis. our objective is to determine if mb can be used to assess the degree of spongiofi brosis in short atraumatic bulbar strictures. we term the procedure methylene blue spongiography. five cc of methylene blue ( mg/ml) is diluted in cc of normal saline. th e dissection for the urethroplasty continues until the bulbar urethra is exposed. th e location of the stricture is identifi ed. insulin needles are inserted in three locations. one needle is placed in the sponge proximal to the stricture. another needle is placed in the sponge at level of stricture. th e third needle is placed in the sponge distal to the stricture. large atraumatic clamp is place at the most proximal extent of the bulb to limit the confounding blood fl ow from the bulbar artery. methylene blue is gently injected via distal needle. th e two remaining needles are then observed for mb effl ux. presence of mb effl ux in needle proximal to stricture implies a defi ciency of signifi cant spongiofi brosis and urethral transection with epa is not performed. absence of effl ux of methylene blue in proximal needle implies signifi cant spongiofibrosis and epa is performed. we performed mb spongiosography in short bulbar idiopathic strictures. mean length of the stricture was . (range to . ). in ( %) cases methylene blue was seen across the stricture and transecting urethra was avoided. in ( %) cases where no mb went across primary excision and anastomosis was performed. no patients had adverse reaction or complication of methylene blue. conclusions: methylene blue spongiography can be performed to guide the method of urethroplasty performed. it is a simple, cost eff ective, and time effi cient method to further evaluate the degree of spongiofibrosis. effi . th e allium bulbar urethral stent is a fully covered, self-expandable, large caliber metal stent, specially designed for the treatment of bulbar urethral strictures. th e indwelling time for the stents was planned to be months. all men underwent an internal uretrotomy procedure followed by an endoscopic stent placement. progressive decreasing of the urinary peak fl ow rate, recurrent urinary infection and stent migration were the early removal criteria. th e success criteria aft er the stent removal were: no evidence of stricture on urethrogram or endoscopy, urinary peak fl ow greater than ml/sec and no recurrent urinary tract infection. results: five stents were replaced since very early migration not more than one month period. none of the patients reported discomfort at the stent site. five patients complained of mild urinary incontinence which was resolved aft er stent explantation. all stents were removed very easily without any complication to months (mean . months) aft er implantation. follow-up period was meanly months ( to ) after stent explantation. clinical success was achieved in patients ( %). conclusion: based on our results, temporary placement of allium bulbar urethral stent, for management of the recurrent urethral strictures, is noninvasive, safe and eff ective procedure. the impact of testicular loss on the psychopathology we also compared the results of long-term treatment group and short-term treatment group. th is study showed that cases of long-term continuous administration of doc consisting of or more cycles among patients of castration-resistant prostate cancer (crpc) treated with doc from october to september at our institution, retrospectively. nineteen patients who had treated with doc or less cycles were defi ned as short-term dose group, and both groups were compared. doc was administered every to weeks at to mg/m , and was treated with prednisolone at mg/day as a general. results: th e median number of treatment cycles was (range to ), and the median age of patients was (range to ) years old. th e median psa levels at start of doc based chemotherapy was . (range . to . ) ng/ml. th irteen cases ( %) showed a decrease in psa levels and cases ( %) showed a decrease in psa levels of % or more, the -year survival rate of long-term dose and short-term dose group were % and %. adverse eff ects of grade or lower consisted of leukocytopenia in % and thrombocytopenia in %, stomatitis and general fatigue in some cases, however, grade or higher were not observed in long-term dose group. in multivariable analysis of parameters, long-term treatment was related to psa levels at start of treatment and alp levels. pattern of use of androgen deprivation therapy in prostate cancer: an italian multicenter cross-sectional analysis introduction and objective: androgen deprivation therapy (adt) for prostate cancer (pca) is widely used with diff erent indications, however, some discrepancies exist between clinical practice and the recommendations of the international guidelines. th e aim of this cross-sectional study was to evaluate patterns of use of adt in patients with pca in italy. we also aimed to measure the adherence of adt prescriptions to the recommendations of the eau guidelines. materials and methods: th e choice study was an italian multicenter cross-sectional studying conducted from december to january on patients treated with adt for pca (fi rst prescription or renewal of therapy). th e project involved radiotherapy departments and urology centers. inclusion criteria were: age ≥ years, previous diagnosis of pca and current adt. at baseline all the following information were included: charlson comorbidity index (cci), clinical stage, psa level at the time of the diagnosis, total prostate volume and gleason score; gleason score and pathological stage from radical prostatectomy (rp) when available. we subdivided the cohort into three risk categories for each treatment group, based on d' amico classifi cation. patients were categorized according to primary treatment into rp, radiotherapy (rt), rp + rt and adt only. radiotherapy comprised external beam therapy and brachytherapy. adt included bilateral orchiectomy, gnrh agonists or anti-androgens. th ree geographical areas were considered: northern, central and southern italy. adt change (adt-c) was defi ned as any modifi cation of therapy between previous adt and treatment prescribed aft er enrolment. the prevalence and outcomes of pt disease after neoadjuvant hormonal therapy plus radical prostatectomy in high-risk prostate cancer introduction and objective: to identify the prevalence and clinical outcomes of pt disease following neoadjuvant hormonal therapy (nht) and radical prostatectomy (rp) in high-risk prostate cancer. we retrospectively included patients who had received nht and rp for the treatment of high-risk prostate cancer. we classifi ed the patients into two groups, the pt group and the non-pt group depending on whether a residual tumor was observed or not. we identifi ed cases ( . %) with pt disease aft er reviewing all slides of the patients. th ere was no recurrence of disease in the pt group during a median follow-up of months. among the patients in the non-pt group, biochemical recurrence (bcr) developed in patients ( . %), with the median time to bcr being months. conclusions: among the patients with high-risk prostate cancer, we found cases that showed a pathologic complete response aft er nht and no recurrence of disease during the follow-up, which means that the androgen-deprivation therapy could potentially eradicate high-risk prostate cancer. th is is one of the largest studies demonstrating the prevalence of pt disease and its outcomes aft er nht among patients with high-risk prostate cancer. introduction and objective: in metastatic castration-resistant prostate cancer (mcrpc), data are limited regarding optimal combinatorial or sequential use of available treatments. p - (stride; nct ) is an ongoing, randomized, open-label, phase study evaluating concurrent vs. sequential administration of the androgen receptor inhibitor enzalutamide (enz) with the autologous cellular immunotherapy sipuleucel (sip-t). fift y-two patients (pts) with asymptomatic or minimally symptomatic mcrpc were randomized : to receive sip-t infusions with enz starting weeks before (n= , concurrent arm a) or weeks aft er (n= , sequential arm b) sip-t initiation. th e primary endpoint is peripheral t cell proliferation response to pa , the sip-t immunizing antigen. secondary endpoints include interferon (ifn)-γ elispot and humoral immune responses to pa and prostatic acid phosphatase (pap), product release parameters (total nucleated cell count, cd + cell counts, and antigen presenting cell activation [as measured by cd upregulation]), cytokine production, and adverse events (aes). results through week are described. results: pa -specifi c t cell proliferative response was signifi cantly elevated at all post-baseline time points (p< . ) and was sustained through week , including a > -fold increase at week in both arms. th is pa -specifi c response was observed in nearly all pts, . % in arm a vs. . % in arm b. both arms showed a signifi cant and sustained increase in humoral responses to pa and pap as well as ifn-γ elispot response to pa . sip-t product parameters were similar between arms. cytokines indicative of immune activation (such as ifn-γ, interleukin- , and tumor necrosis factor-α) were also elevated in both arms. aes were observed in % (arm a) and % (arm b) of pts. th e incidence of grade ≥ aes was similar between arms. materials and methods: tur specimens without hormonal use ( cases), specimens aft er three weeks of chlormadinone acetate (cma) ( cases), specimens aft er average six months of dutasteride ( cases), and specimens two weeks aft er initial use of degarelix ( cases) were studied using he and immunohistochemical staining with prostate specifi c antigen (psa), prostatic stem cell markers such as cd , cd , and vimentin. results: specimens treated with cma showed acinar dilatation and atrophy of glandular cells. specimens treated with dutasteride showed marked decrease of gland and increase of fi bromuscular tissue. specimens treated with degarelix showed prominent decrease of gland and glandular cells. psa was stained all of the prostatic glandular cells in all specimens. cd was stained at basal cells in normal prostatic tissue without hormones, however in hormone treated specimens, basal cells elongate and some glandular cells were also stained by cd , especially in cma treated specimens. cd was stained in many glandular cells without special patterns. vimentin was stained in all mesenchymal interstitial cells and a part of basal cells, and not stained in glandular cells. conclusion: elongation of basal cells and increased sensitivity to cd in glandular cells, especially treated with cma, were thought to the result of emt of prostatic glandular cells. th ree weeks use of cma might be a good model to observe emt of prostatic cells among these three hormone models, presumably because six months use of dutasteride is long enough to alter the structure of prostatic tissue, and degarelix has strong apoptotic activity to prostate cells in a short period. aryl plays an important role in normal physiologic responses such as development, cell cycle regulation, and immune function in various tissues. th e strong nuclear ahr expression was observed in the invasive phenotype and an elevated nuclear ahr expression was associated with a poor prognosis of human prostate. on the other hand, the ahr defi ciency results in a smaller volume and in increased susceptibility to prostate tumors in mouse model. in the present study, we investigated ahr expression and its role in the growth and invasiveness of human prostate cancer cells. we checked ahr proteins expression in prostate cancer cell lines and in human prostate cancer specimens by immunoblotting and immunohistochemistry respectively. we used a small interfering rna targeting ahr, constitutive active ahr expression vector, and ahr agonist and antagonist were used to moderate its expression and signaling to examine growth and invasion in prostate cancer cells. introduction and objective: androgen deprivation therapy (adt) has been increasingly used in patient with prostate cancer (pca). it has been considered that adt is associated with greater risk of incident cardiovascular disease (cvd). th e one of the reason is that hyperlipidemia was caused by adt may contribute to greater cvd risk. but the evidence remains inconclusive and sometimes contradictory. in our present study, we investigated an eff ect of adt on arterial atherosclerotic changes assessed by cardio-ankle vascular index (cavi) in pca patients. th e present study was participated in patients with prostate cancer before initiate adt. we recorded and statistically analyzed the data of the patients before adt and at months, months, and months aft er adt. and the patients' arterial atherosclerotic changes was evaluated by cavi at baseline. correlation between the degree of infl ammation and gleason score in prostate cancer patients alexandrescu e, geavlete p, georgescu d, geavlete b introduction and objective: hypothesis regarding the involvement of infl ammatory processes in prostate cancer has been the subject of several recent studies. chronic infl ammation generates the appearance of morphological changes of atrophic type, lesions located predominantly in the periphery of the gland, as well as prostate cancer (pca). th e aim of the study was to assess the possible infl uence of associated infl ammation on the gleason score in pca patients. results: th e gleason score - was detected in patients ( . %), score - in patients ( . %) and score - in patients ( . %). cases of aggressive disease (gleason score - ) were detected by prostate biopsy, while high-grade infl ammation has been mostly associated with pca cases incidentally detected by turp. no signifi cant correlations were found between the presence and degree of histologically proved infl ammation and the gleason score or the presence of pca. identifi cation of n -methyladenosine methylated mrnas in prostate cancer pang k , , cumberbatch m , , catto j , introduction and objective: rna methylation is a common epigenetic event in oncogenesis, and the most common form is the methylation of n -adenosine (m a). th e recent identifi cation of > , m a-methylated human mrnas from > human genes point towards novel epigenetic mechanisms. however, the distribution of m a in the prostate transcriptome is unknown. we aimed to predict the mrnas susceptible to m a-methyation in primary prostate cancer (pca) and castrate-resistant pca (crpc), and identify the functions of these mrnas. th e aim of this study was to assess the contribution of multiparametric mri and pca in pre-decision of initial biopsy in patients with serum psa level - ng/ml and normal digital rectal examination. th e study is planned as prospective and single-centered. patients whose serum psa level - ng/ml with normal digital rectal examination scheduled for initial prostate biopsy were included in the study between february and march . each patient underwent multiparametric mri (diff usion, spectroscopy, dynamic-contrast, t ) one week prior to biopsy. th e lesion seen at least in two mri was accepted as multiparametric mri lesion. twenty to thirty ml initial urine samples were taken aft er minutes prostate massage for pca examination before biopsy. pca score over was considered as signifi cant. guided biopsies were taken according to lesions seen in multiparametric mri. patients with high psa levels were separated into two groups as high pca scores and normal pca scores. each group, then, was separated into two groups due to mri results as lesion positive and negative. tumor incidence and positive predictive values were calculated in patients with high psa and pca scores with positive multiparametric mri lesion. tumor incidence and negative predictive value were also calculated in patients with high psa level but low pca score with negative multiparametric mri lesion. up. , figure . a biopsy-induced hemorrhage was defi ned as a case in which a subject complained of bleeding from the rectum and excretion of blood clots was confi rmed. we categorized signifi cant rectal bleeding into two grades for hemostasis management, including mild and severe. when the bleeding was classifi ed as mild, we inserted the gelatin sponge into the participants in either group b or reinserted it into those participants in group a. if the bleeding could not be stopped by this approach, we additionally used index fi nger pressure for ten minutes or more to promote hemostasis. in the severe cases, an endoscopic clipping was performed to control the bleeding because arterial bleeding was suspected. a blood test and a questionnaire survey, and pain related to biopsy was performed before and aft er biopsy. th e diff erence in background factors between groups a and b was assessed. to identify the independent predictive factors for rectal bleeding for all participants, background factors, including insertion of a gelatin sponge into the rectum were analyzed by logistic regression analysis. results: signifi cantly fewer patients in group a required hemostasis aft er biopsy compared to group b ( ( . %) vs. ( . %), p= . ). th e results of blood tests performed before and aft er biopsy and the results from the questionnaire did not diff er signifi cantly between the two groups. in multivariate analysis, only "insertion of a gelatin sponge into the rectum" emerged as a signifi cant predictor of hemostasis. our results suggest that the tissue elastic modulus of prostate cancer may increase with an increase in the gleason score and that the diff erence in the stiff ness between low-grade lesions and prostate hyperplasia may be slight. th ese basic fi ndings will contribute to the development of quantitative elastography technique. the results: th e median ipss was , the mean psa was . ng/ml; the mean size of prostate was . cc. of the total subjects, prostate cancer was detected in ( . %) patients. among subscores refl ecting specific luts, the nocturia was only symptom score predict the cancer detection. th e detection rate of patient with nocturia more than time a day was . %, but the cancer detection rate of patient without nocturia was only . %. at multivariate analysis adjusting infl uence of covariate of age, psa, prostate size and transitional zone size, frequency and nocturia scores were the two only factor predicting cancer detection. at the roc curve analysis measuring the benefi t of the additional consideration of the severity of nocturia and frequency, the additional consideration induced . % prediction accuracy elevation (from . to . ). conclusions: men with frequency or nocturia have lesser chance of prostate cancer detection rate than the men without luts. however, the infl uence of these storage symptoms seems not strong enough to change current consensus of indication to biopsy the prostate. routine in the discontinuing group were %, %, - . %, - . % and - . %, respectively (p= . ). th e median Δegfr at baseline, , , and months in the continuing group were %, %, - . %, - . % and - . %, respectively (p= . ). th e continuing group decreased months later. however, the renal function in the discontinuing group had a tendency to improve at months aft er treatment insignifi cantly. th ere was not statistical signifi cant diff erence in various factors between discontinuing group and continuing group. conclusions: it was possible that the recovery of testosterone was associated with the improvement of the renal function. it has been reported that the discontinuation of adt recovered the level of testosterone. namely, the discontinuation of adt for prostate cancer might revive the renal function. th erefore, it was suggested that intermittent adt might recover the renal function. introduction and objective: as more and more patients are getting diagnosed as carcinoma of prostate (cap), we would like to look into how prostate cancers are presented at the early age of forties and how they were treated. as cap is more popularised in the media, more and more people are asking gps for psa measurements. introduction and objective: irreversible electroporation (ire) is a novel ablative therapy for prostate cancer, with reported advantages of sparing surrounding essential structures. th ese properties could potentially help to reduce or avoid side eff ects. th e objective is to determine quality of life outcomes (qol) and side-eff ects of ire treatment. sixteen patients planned for radical prostatectomy (rp), were asked to participate in the study. all patients underwent an ire treatment one month before rp, using a focal or extended ablation protocol. th e safety was measured by the number of adverse events graded by the common terminology criteria for adverse events (ctcae). to determine qol validated questionnaires (expanded prostate cancer index composite (epic), the fi ve-item version of the international index of erectile function (iief- ) and international prostate symptom score (ipss)) were used. results: five developed a urinary retention (ctcae grade ) solved by an indwelling catheter or self-catheterisation. two patients developed a urinary tract infection (ctcae grade ), one progressed to urosepsis (ctcae grade ), both resolved without sequelae. mild haematuria (ctcae grade ) was noted in ten patients, spontaneously resolved within days. five patients experienced temporary incontinence with duration of - days, three suff ered from total incontinence and needed pads and pelvic fl oor training (ctcae grade ). two patients reported mild hematospermia, lasting one and thirty days. ipss showed no signifi cant diff erence between baseline (average of (avg) ± ) and four weeks postoperatively (avg ± ). iief showed no signifi cant diff erence between baseline (avg ± ) and four weeks postoperatively (avg ± ). epic outcomes, shown in figure , were not signifi cantly diff erent at baseline, one and four weeks aft er ire, regardless of the used ablation protocol. conclusion: ire treatment for prostate cancer is safe and shows only adverse events that lie within the range of what was expected and shows promising rates of genito-urinary functional preservation. introduction and objective: mri-guided transurethral ultrasound ablation (tulsa) is a novel minimally-invasive technology for treatment of prostate cancer aiming to provide local disease control with low morbidity. th e ultrasound device generates conformal volume of thermal ablation, shaped precisely to the prostate using real-time mri thermometry feedback control. aim of this prospective, multi-national phase i study is to determine safety and feasibility of mri-guided tulsa. biochemical recurrence (bcr) was defi ned using phoenix criteria (psa nadir + ng/dl) and positive biopsy in the treated area was considered recurrence. we compared the perioperative and oncologic outcomes following fc in patients with gs vs. gs ( + ) at initial trus biopsy. th e complications were reported using the clavien-dindo classifi cation. we found patients with gs and with gs ( + ). clinical and operative characteristics were similar (table ) . th e mean follow-up was . (± . ) months. th ere was no signifi cant diff erence noted between gs vs. gs in the biopsy recurrence ( % vs. %, p= . ) and bcr rates. th ere were complications in ( . %) patients. all were low grade, except two patients who had iii b complications (table ) . conclusion: th e perioperative and oncologic outcomes of fc -hemiablation for unilateral, organ confi ned pca appears to similar between gs and gs ( + ) disease. pentafecta in the evaluation of surgical results after open radical prostatectomy de la rosa h, rios s, martinez n introduction and objective: "pentafecta" has been used to evaluate the oncological and functional results in patients with prostate cancer treated with minimal invasive radical surgical techniques. in this study we evaluate, with this quality tool, the outcomes in a group of patients undergoing open radical prostatectomy. we analyzed retrospectively the database of surgeries performed at the urology department of the military hospital of guadalajara and the clinical fi les of patients with localized prostate cancer treated with radical prostatectomy. we describe the patients' characteristics including the charlson comorbidity index (cci) and identify the parameters that conform pentafecta as well as the variables that can infl uence the oncological and functional results using the fisher´s exact test. results: fift y four patients were treated with radical prostatectomy between and , fi nding in their fi les a minimum of months of follow-up. seven patients were discarded of the study because they undergo laparoscopic radical prostatectomy, and more because missing information at their fi les. th e average age was ( - ) and the cci average was . ( . - . ). mean operative time was min ( - ) and intraoperative bleeding cc ( - ). th e presence of potency, continence, biochemical recurrence-free survival, negative surgical margins and no perioperative complications were %, %, %, % and % respectively. seven ( %) patients achieved pentafecta, and patients ( %) failed to achieve. statistical analysis confi rmed the surgeon's experience as the only factor associated with achieving pentafecta. conclusions: th e fi rst cause of failure to achieve pentafecta in our study group was impotence, second were positive surgical margins and third surgical complications mainly intraoperative bleeding. pentafecta is a useful tool for objective assessment of oncological and functional outcomes of patients treated with open radical prostatectomy. plasma introduction and objective: hepatocyte growth factor (hgf) is a well-known multifunctional growth factor, the amount of evidence has accumulated suggesting that the hgf/met (hgf receptor) signaling axis is involved in cancer progression. macrophage stimulating protein (msp) is also known as a growth factor which activates not only macrophages but also cancer cells and osteoclasts through the activation of the specifi c receptor d' origine nantais (ron). hgf and msp are secreted as an inactive single-chain precursor (pro-hgf, pro-msp), which lacks biological activity and, therefore, requires proteolytic activation for conversion to an active two-chain form by hgf activator (hgfa). although, there have been reported a lot of study for hgf/met signaling with castration-resistant (cr) pc and bone metastasis, the report for examination of plasma protein is rare. in addition, msp/ron signaling axis is not well evaluated in pc. here, we analyzed the associations between pc progression and plasma levels of hgf and a closely related molecule, msp. conclusion: dehydroepiandrosterone (dhea) concentrations in blood were examined by newly developed ultra-sensitive quantifying method, lc-ms/ms. we confi rmed that low serum dhea levels in men with prostate were related to high gleason score and advanced clinical stage. th ese results suggest that serum dhea level may be useful as a prognostic factor in men with prostate cancer. introduction and objective: androgen/androgen receptor (ar) signal is known as a powerful driver of prostate cancer (pca) progression. previously we reported the limitation of prostate-specifi c antigen (psa), which is an ar-regulated protein, at diagnosis as a prognostic biomarker of pca. paradoxically pca patients with low psa < . ng/ml had a more advanced stage of cancer compared with those with psa between . and ng/ml. although serum total testosterone (tt) has also been reported as a pca prognostic biomarker, its usability is still controversial. we examine the potential and the character of tt as a biomarker, comparing to psa. serum tt level of patients who underwent prostate biopsy at kanazawa university hospital between and were measured and pca-specifi c survival (pcass), overall survival (os), and the correlation between tnm stage and tt level were analyzed. results: of total biopsied patients, were diagnosed with pca. median tt was . ng/ml (range: . - . ). when patients were divided into groups according to their tt at diagnosis, patients with tt < and ≥ ng/ml had worse pcass than those with ≤ tt < , ≤ tt < , and ≤ tt < ng/ml. os in patients with tt < and ≥ ng/ml also was worse than that in other groups. moreover, tt < and ≥ ng/ml showed worse pcass even in patients with advanced stage (t or n or m ). higher tnm stage was observed in patients with tt < and ≥ ng/ml than those with ≤ tt < ng/ml. low tt level has been reported as a predictive biomarker indicating worse outcomes in pca patients. th is study showed not only low but also high tt level may indicate poor prognosis. th ese data are consistent with our previous studies showing low psa (< . ng/ml) also might indicate poor prognosis as well as high psa. although poor prognosis of high tt and high psa strongly depends on androgen/ar signal, poor prognosis of low tt and low psa patients may be due to other signals than androgen/ar. usefulness of psa as a marker of prostate cancer in men treated with dutasteride takeda h, nakano y, narita h introduction and objective: to analyse whether the use of treatment-specifi c criteria for repeat biopsy maintains the usefulness of prostate-specifi c antigen (psa) level for detecting prostate cancers. th is study was a retrospective investigation to assess the eff ects of dutasteride on psa in asymptomatic men aft er negative st biopsy and on repeat prostate biopsy decision. th e usefulness of psa was evaluated using biopsy thresholds defi ned by three times consecutive rises and . ng/ml up in psa from nadir (the lowest psa level achieved while in the study) in the dutasteride group. prostate cancer pathological characteristics were compared. results: of men, (dutasteride) underwent at least one prostate biopsy during the study and were included in the analysis. mean follow-up (month) was . , ipsa was . ng/ml, mean prostate volume(cc) was . , psad was . ng/ml/cc. nine of ( %) were detected prostate cancer, % ( / ) of gleason and % ( / ) of gleason - cancers were detected in the dutasteride group. in the study, the incidence of gleason and gleason - cancers generally increased with greater rises in psa. sensitivity of psa kinetics with dutasteride was high as usual. conclusion: using treatment-specifi c biopsy thresholds, the present study shows that the ability of psa kinetics to detect prostate cancer is maintained with dutasteride in men with a previous negative biopsy. biopsy decisions based on three times consecutive increased and . ng/ml psa measurement from nadir in the dutasteride group are useful, indicating the importance of confi rmation of psa measurements. our goal was to develop a fi t-for-purpose assay that could be performed on rna from diagnostic needle biopsies, and provide improved risk stratifi cation in early-stage pca. to date, development and validation studies have included > , patients from four academic centers. in these studies, archival tissues were assayed following prospectively designed protocols with pre-specifi ed methods and statistical analysis plans. results: feasibility and development studies confi rmed gene expression and identifi ed genes whose expression was predictive of clinical recurrence, biochemical recurrence (bcr), prostate cancer death, and adverse pathology (ap) at surgery in the face of tumor heterogeneity and multifocality. analytic validation studies showed that the assay provided robust, reproducible results over a wide range of rna inputs, diff erent operators, instruments, and reagent lots. th e fi rst clinical validation study established gps as an independent predictor of ap in men with nccn verylow to intermediate-risk pca. exploratory analyses showed that gps is a robust predictor of ap despite inter-observer diff erences in pathologic grade and stage assessment. a second clinical validation study in a racially diverse population confi rmed the assay as a predictor of ap and validated the assay as a strong predictor of bcr (hr/ gps units= . ; p< . ). gps was also signifi cantly associated with metastatic disease (hr/ units= . ; p= . ). other exploratory analyses showed that the assay can predict ) likelihood of clinical recurrence aft er bcr, regardless of salvage therapy, and ) tumor aggressiveness when assessed in adjacent normal-appearing tissue. all four gene groups contribute to the predictive value of the assay. conclusions: th e development program for the assay addressed challenges of small sample size, tumor heterogeneity, multifocality, and biopsy under-sampling. validation in two large contemporary cohorts of men with pca in two prospectively designed studies provides level ib clinical evidence for gps as a predictor of ap. clinical and therapeutic implications of neuroendocrine prostate cancer: a long winding road to cure lu k, wang h, lin v, yu t introduction and objective: primary neuroendocrine cancer of prostate is an extremely rare variant of prostate cancer, comprising . % to % of prostate malignancies. th is entity encompasses various clinical contexts, ranging from the de novo small cell carcinoma (scc) to a treatment-emergent transformed phenotype that arising from typical adenocarcinoma (ad) of the prostate. th e rarity of these neoplasms poses a diagnostic and therapeutic challenge. little is known about neuroendocrine prostate cancer and the current knowledge of this disease is based on case reports or small series. our purpose was to characterize the cases treated at a tertiary academic center and to evaluate patient outcomes with the available treatment modalities. th is was a single-institute retrospective observational cohort study of patients with neuroendocrine prostate cancer followed at e-da hospital, kaohsiung city, taiwan between january , and october , . patient and tumor data were analyzed using descriptive statistical methods. results: among prostate cancers, six patients were identifi ed with primary neuroendocrine prostate cancer, comprising from de novo mixed variety (scc and ad) and from transformed phenotype (pure scc). th e median age at diagnosis was . years. th e most common presenting symptoms were obstructive symptoms (weak stream, incomplete empty and urine retention). th e morphological appearance of the tumor cells and their immunohistochemical reactivity for neuroendocrine markers, and prostate specifi c antigen (psa) helped establish the diagnosis. overall median survival was months from diagnosis of neuroendocrine prostate cancer/ prostate small cell carcinoma. conclusion: primary neuroendocrine prostate cancer is characterized by an aggressive clinical course with relatively short lifespan. although high response rate to cytotoxic chemotherapy, overall prognosis is poor. as there is no standard of care for patients with neuroendocrine prostate cancer, further eff orts should be directed at its early detection and made to develop more eff ective therapeutic strategy. association th e mean duration for the side eff ect to occur was months (range - months), the mean duration between the onset of side eff ect and beginning of hbo therapy was months (range - months). th e patient with both hemorrhagic proctitis and cystitis completely recovered, and the remaining patients had improvement of side-eff ects. conclusion: hbo therapy can be a choice of treatment for radiation induced side-eff ects. a treatment trend of the prostate cancer in japanese provincial hospital introduction and objective: th e prostate cancer patients can choose various treatment options for cancer. however, the choice is limited by a diff erence in the scale and/or the location of each medical institution. we examined a treatment trend of the prostate cancer in our japanese provincial hospital. we evaluated patients who had a diagnosis of prostate cancer between and . th ey were classifi ed four groups, cases of the middle-aged generation (range - years old), cases of the early advanced-aged generation (range - ), cases of the middle advanced-aged generation (range - ) and cases of the latter advanced-aged generation (range -). we sorted each groups using the d' amico risk classifi cation system. in the middle-aged generation, patients, except for metastatic cases, underwent radical prostatectomy or radiotherapy. in the early advanced-aged generation, of low-very high risk group patients ( %) chose radical prostatectomy or radiotherapy. on the other hand, in the same generation, of intermediate risk group cases ( %) were treated with hormonal therapy. in the middle advanced-aged generation, only of low-very high risk group patients ( %) underwent radical prostatectomy or radiotherapy, which was fewer compared with the early advanced-aged generation. th at means, they oft en chose hormonal therapy. in the latter advanced-aged generation, all patients, except for cases, were treated with hormonal therapy. th e cases belong to the low-intermediate risk group, chose watchful waiting (psa monitoring). introduction and objective: robot-assisted radical prostatectomy (rarp) has emerged as an excellent treatment option for men with localised prostate cancer. as with other surgical treatment options, urinary incontinence remains a signifi cant side eff ect of the procedure and has been associated with weak pelvic fl oor muscle (pfm) strength. we aimed to assess pfm strength preand post-rarp, its relevance to incontinence and relevant predictors of poor outcomes post-op. we conducted a retrospective analysis of a prospectively collected database of men undergoing rarp by urologists over a -month period. each man had a pelvic fl oor strength assessment pre-operatively and at week and weeks post-operatively. pfm strength was recorded as strong (grade ), moderate (grade ) or weak (grade ). continence rates were recorded at weeks post-op, with continence defi ned as no requirement for pads or continence aids. basic demographic data and histological data were also collected. introduction and objective: urethral trauma is reported to occur in . % of patients undergoing catheterisation but, in practice, seems to be more common than this. we have investigated its incidence retrospectively and prospectively and have evaluated a new approach to catheterisation to reduce the incidence of catheter-related trauma and its consequences, which has led to the development of a novel urethral catheterisation device (ucd) produced by urethrotech™. a total of patients being catheterised for cardiac surgery were reviewed retrospectively and studied prospectively to determine the incidence of urethral trauma due to urethral catheterisation. one hundred similar patients were then studied prospectively to trial a ucd to see if it reduced the incidence of trauma. ( ) lavh ( ) myomectomy ( ) lap. ovarian cyst excision ( ) ( ) nephrectomy ( ) ileal ureter substitution ( ) ureterolithotomy ( ) angioembolization ( ) urs c d-j stent ( ) ureteroneocystostomy ( ) ureteroureterostomy ( ) . hospitalization ( notes. none had documented consent and none had been counselled about potential complications. one hundred and forty-six were successfully catheterised. four ( . %) required a suprapubic catheter for traumatic and unsuccessful urethral catheterisation. no other adverse events were recorded. seventy-four consecutive patients were studied prospectively aft er counselling and consenting. th e incidence of urethral trauma was out of ( . %). five had urethral or perineal pain and urethral bleeding ( . %) and ( . %) additionally required a suprapubic catheter. having developed a practice of passing a urethral catheter over a guide wire in patients undergoing reconstructive urethral surgery in our unit we subsequently trialled the urethrotech™ ucd for routine urethral catheterisation. th is ucd was used for catheterisation in consecutive patients without complications. we conclude that urethral catheterisation has a signifi cant risk of trauma -ten times the reported incidence -and to reduce that risk the catheter should be passed over a guide wire, as with the ure-throtech™ ucd, as is the practice for passing catheters and similar tubes into other anatomical structures. th is should particularly apply in high risk patients, such as those being catheterised for cardiac surgery who are about to be heparinised, and in higher risk circumstances such as when catheterisation is being performed by junior medical or nursing staff . results: mean age at the time of transplantation was . ± . years with male to female ratio of . : . etiology of esrd included renal parenchymal diseases ( %), o vesicoureteric refl ux ( %) and o vesicoureteric refl ux due to posterior urethral valve ( %), urolithiasis ( %) and neurogenic bladder ( %). pre-transplant bilateral nephroureterectomies were performed in patients, augmentation ileocystoplasty with mitrofanoff conduit in patients while posterior urethral valve fulguration in patients. mean serum creatinine post-transplantation was . mg/dl and . mg/dl at week and months respectively. surgical complications occurred only in two patients; one developed lymphocele while other presented with febrile uti due to ureteric refl ux in the early postoperative period and was managed by doing a new ureteral reimplantation. th e mean graft and patient survival rates at one year were % and % respectively. one patient lost her graft at months which was turned out case of hyperoxaluria. acute rejection was seen in ( %) patients. all of these were successfully reversed with pulse therapy. none of the patients developed cytomegalovirus (cmv) infections or lympho-proliferative disease. symptomatic urinary tract infections aft er transplantation occurred in ( %) patients including pyelonephritis in ( . %) patients. two of these patients with pyelonephritis had prior bladder augmentation. ureteric stenosis is a well recognised major urological complication of renal transplantation. following initial antegrade decompression, defi nitive treatment options include long-term ureteric stenting, endoscopic stricture dilatation/division or ureteric re-implantation. th ere is minimal current data in the literature to help guide patient choice. we aimed to characterise the outcomes following management of ureteric stenosis at a large european regional transplant centre. a retrospective cohort study was performed for all patients following renal transplantation who required treatment for ureteric stenosis between august and august . case identifi cation was via a prospectively maintained database on all renal transplant patients and international classifi cation of disease procedure codes. results: of renal transplants performed during the study time period, patients developed ureteric stenosis requiring intervention ( . %). eleven patients underwent initial open ureteric re-implantation, had endoscopic management and had longterm ureteric stents. mean length of time between elective stent changes was . months (range - months). one patient opted for open re-implantation aft er a period of stenting with a good outcome. one experienced graft failure due to non-compliance with immunosuppression, otherwise renal function was preserved. of the patients having open re-implantation only one experienced re-stenosis -managed with long-term ureteric stenting and . % had satisfactory renal function at follow-up. two patients received successful balloon dilatation and patient had upper tract stenosis managed with pyeloureteroplasty. all patients have experienced no decline in graft function since. endoscopic, open reconstruction and long-term stenting can all provide satisfactory outcomes for the majority of renal transplant patients aff ected by this problem. medium-term graft function was well preserved. in recent years approximately half of patients have proceeded to open re-implantation. surgical and clinical factors impact the choice of treatment. however, patient choice also plays a significant role. th is study has provided up to date information to aid counselling patients. further prospective study is warranted to assess what variables infl uence patient choice and cost effi ciency of open re-implantation versus long-term ureteric stenting. the angiogenic mechanisms of endothelial progenitor cells in kidney transplantation patients introduction and objective: th e blood fl ow blocking during kidney transplantation oft en results in renal ischemic injury. in this process, endothelial cells and endothelial progenitor cells (epcs) are activated to participate in angiogenesis. epcs and endothelial cells participate in angiogenesis and tissue repair through diff erent signaling pathway. prostaglandin e (pge ) is a kind of metabolites of arachidonic acid, and is a mediator of infl ammation and ischemia. pge took part in angiogenesis and epcs diff erentiation according to our previous study. in this study we will demonstrate the angiogenic function of epcs of kidney transplantation patients and reveal the molecular mechanisms of angiogenesis. materials and methods: epcs from peripheral blood aft er kidney transplantation were isolated by density-gradient centrifugation. facs was used to identify the epcs. th e aa metabolites pge in epcs cultured medium was measured by liquid chromatography-tandem mass spectrometry (lc-ms/ms). q-pcr and wb were used to detect the expression of endothelial markers in human umbilical vein endothelial cells (huvecs) cultured with epcs conditional medium. tube formation assay was performed to elucidate the angiogenic ability of huvecs. results: epcs from kidney transplantation expressed c-kit and cd by facs analysis. multiple types of aa metabolites was detected in the conditional medium by lc-ms/ms and pge was increased to more than -fold aft er kidney transplantation. huvecs cultured with conditional medium highly expressed cd and ve-cadherin and also formed more tubes compared with control. huvecs given pge had the same biological characteristics like the conditional culture. conclusion: pge paracrine of epcs from kidney transplantation enhanced the capacity of angiogenesis in huvecs. graft survival, proteinuria and kidney growth: challenges between pediatric and adult deceased kidney donation basiri a , , , zare s introduction and objective: th e presence of widening discrepancy between supply and demand of donor and recipient in the fi eld of renal transplantation, has led us to compare the graft and patient survivals, post transplantation complications, rate and severity of proteinuria secondary to hyperfi ltration injury and the kidney growth of recipients who underwent transplantation from pediatric (group ) and adult deceased donors (group ). each groups contains patients. outcome measures included, patient and graft survivals, quality of graft function as assessed by serum creatinine (scr) and estimated gfr (egfr), surgical complications, proteinuria that was detected by routine urinalysis and then confi rmed by a -h urine protein > mg, and kidney length that measured by early and following ultrasonography. results: th e mean donor age in groups and were . (range . to y/o) and ( to y/o) respectively. th e nine kidneys ( %) from pediatric donors (group ) were off ered en-block. mean follow-up was month (range to ). th ere were no statistical differences in the incidence of dgf between two groups ( % versus %) (p= . ). group had a slightly higher incidence of acute rejection than group ( versus %), but the diff erence was not statistically signifi cant (p= . ). one year's graft survival were similar between two groups ( % and %). serum cre-atinine (scr) and estimated gfr (egfr) th ere were no statistically diff erences between two groups ( . versus . mg/dl and versus cc/min respectively) (p= . ). th e incidences of surgical complications that required surgical intervention (urinary leakage, ureteral stenosis, lymphocele, vascular thrombosis) were similar in both groups ( versus %) (p= . ). development of proteinuria was not diff erent between two groups ( % versus %) (p= . ). early kidney length within one week was signifi cantly lower in group than in group ( ± mm versus ± mm) (p< . ), but the rate of increase of kidney length in group was signifi cantly greater than group ( ± mm versus ± mm) (p< . ) under follow-up period. conclusion: although in this study, median-term outcomes and complications of single and en-block kidney transplantation from pediatric donors are acceptable and same as those from older donors. but assessment of functional and hemodynamic adaptation of small pediatric kidneys in adult recipients and subsequent hyperfi ltration eff ects requires the study with more cases and greater follow-up periods. george a, singh c, devasia a introduction and objective: th e need for vascular access for hemodialysis (hd) increases with the increasing number of patients with end stage renal disease (esrd) requiring hd, with increasing life span, and with more available facilities especially in developing countries. when the usual accesses (radiocephalic and brachiocephalic) have been utilised or failed, a ptfe graft is usually considered. we present here a 'bridging' option of a basilic vein transposition, as a doable, cost eff ective procedure before av graft ing. patients with end stage renal disease were included. th ey all either had poor cephalic veins at the wrist and cubital fossa, or had previously used and failed fi stulae. anasthesia: regional block (local anaesthetic). technique: th e basilic vein was exposed using three small incisions: cm above cubital fossa, mid arm (medial aspect), and upper arm (medial aspect up to axilla). th e vein was completely freed off surrounding structures, tributaries tied, distal end ligated, patency ensured and vein delivered out of the uppermost incision. using a tunneller, the vein was rerouted subcutaneously, anteriorly to reach the cubital fossa incision. th e brachial artery was identifi ed and looped. arteriovenous anastomosis was done using 'o' prolene, continuous sutures. (images in the poster). results: out of a total of venous access surgeries done during the study period, seven basilic vein transpositions were done. all had pre-operative doppler evaluation to assess size and patency of veins. all fi stulae created were functional at the time of discharge. th e fi stula is used for hemodialysis at - weeks, when the fi stula matures (arterialization of the vein implying good/suffi cient fl ow for dialysis). one patient needed exploration for a venous thrombus, hours later, which was removed with a venotomy and th congress of the sociÉtÉ internationale d'urologie -siu abstract book using a fogarty catheter. subsequently with anticoagulation for hours, the fi stula continued to function and is being used for access. th e second patient had exploration on the th post-operative day for evacuating a subcutaneous hematoma. th e fi stula is patent and will be used once it has matured. five of the seven done were uneventful and are being used for hemodialysis access. conclusion: basilic vein transposition, is the preferred option of vascular access over a ptfe graft , as it is cost eff ective, autologous and doable under regional anaesthesia. retrospective results: a total of renal transplants have been performed since . th e transplants were performed via an extraperitoneal approach with a modifi ed lich-gregoir ureteric anastamosis in most cases. jj-stents were not routinely used. th irty two urological complications were noted in transplants ( %). th ere were boys and girls with ages ranging from . to . yrs (mean . ). th e most common complication was vesico-ureteric refl ux (vur) occurring in patients ( %). all those with vur presented with recurrent urinary tract infections and bladder dysfunction was present in % (none were augmented). vur was managed successfully with reimplant in six and submucosal injection of defl ux in three; eight patients were managed conservatively. post-operative urine leaks occurred in patients ( %) and were managed with reimplant in two, uretero-ureterostomy in one, jj-stent in one and conservatively in two. ureteric stenoses presented in patients ( %) with hydronephrosis and worsening renal function and were managed initially with either percutaneous nephrostomy or jj-stent placement. surgical management was performed in four patients (three reimplants and one uretero-ureterostomy); two patients were managed conservatively with transient jj-stent placement. th ree patients ( %) developed unexplained hydronephrosis -one with worsening renal function due to chronic rejection and two with stable renal function. loss of graft occurred in patients ( %) as a direct result of their urological complication. th ere were deaths -two due to chronic rejection and one due to overwhelming sepsis immediately post uretero-ureterostomy for ureteric stenosis. conclusion: urological complications following paediatric renal transplantation are common and can cause signifi cant morbidity and even mortality. vur was the most frequently observed and, if presenting with recurrent utis, can be managed successfully with surgery. other urological complications observed included urine leaks, ureteric stenoses and unexplained hydronephrosis. kidney transplantation in abnormal bladder: analysis of outcome kumar a, gulia a, chauhan u, sharma a, yadav r, dassi v introduction and objective: kidney transplantation in abnormal bladder is a challenging situation and associated with poor outcome. we have analyzed outcome of our data of last years. materials and methods: from to , patients who had abnormal bladder had undergone kidney tx. average age at the time of transplant was years. average age at bladder reconstruction was years. four patients had neurogenic bladder who were practicing cic, using native urethra and one had appendix as a mirofenof procedure. two patients had bilateral nephrectomy for grade vur and their lower ureters were used for augmentation and other two had ileocystoplasty. four patients of grade vur refl ux had subsequent transplant in the bladder. four patients with puv had bladder augmentation and mitrofenof procedure due to poor compliance. one child with puv had augmentation by stomach patch when he was year old. one patient had cystectomy in the past and ileal conduit reconstruction where transplant ureter was implanted. all patients had very trabeculated and thick bladder during ureteric reimplantations. all patients had extravesical ureteroneocystostomy with stents. urethral catheter was kept on average of days. no patients had any ureteric leak or stricture in postoperative period. all four patients with cic through native urethra had recurrent uti in the postoperative period and required long-term chemoprophylaxis. one patient who had ileocystoplasty before transplant, died due to sepsis just before his transplant. incidence of uti was % in this group. six patients also had pyelonephritis, which was controlled by injectable antibiotic. rejection rate was % in this group in fi rst month which was higher than our normal bladder group. average serum creatinine was . mg% at months and . mg% at year which was high than normal bladder population. average follow-up is . years where serum creatine was . mg%. mean hospital admission was . times. conclusion: kidney transplant in abnormal bladder is a good option but long-term results are inferior. recurrent uti and pyelonephritis are still a troublesome problem. various techniques and procedures are required to overcome these diffi cult situations. analysis of results: th e mean operative time, warm ischemia time and blood loos were minutes, . minutes. ml respectively. th ere were major complications including hemorrhage and injury to organs like bowel, spleen and pancreas. fourteen of these patients required exploration to control bleeding or repair. two patients were explored for adhesive obstruction. th ere were minor complications which were managed conservatively. one patient died in immediate postoperative period due to slippage of a single hemolock clip. all patients have adequate vascular and ureteric length. th ere were cases of multiple vessels. th ere were two urinary fi stulae and one ureteric obstruction. mild atn was noticed in patients. no graft was lost. hospital stay was . days. operative time has also come down to from minutes. th e average cost of the laparoscopic donor nephrectomy is us$ . conclusion: lap donor nephrectomy is a safe and minimally invasive procedure. it is a cost eff ective procedures even for the developing country. prostate carcinoma in solid organ transplant recipients tillou x , guleryuz k , bouvier n , belin a , chiche l , bensadoun h , doerfl er a introduction and objective: improvements in immunosuppression and anti-infection drugs in solid organ transplantation have led to a signifi cant survival increase for patients and graft s. prostate cancer (pc), being the most common tumor in men and given the increasing number of old male recipients, should show an increasing incidence in solid organ transplant recipients (sotr). th e aim of this study was to analyze retrospectively our liver (ltr), kidney (ktr) and cardiac transplant recipients (ctr) treated for a pc. between january and december , we found pc in male sotr ( %): pc in ltr, in ktr and in ctr. a ge at diagnosis was . ± . ( . - . ) years old and the interval from transplantation to diagnosis was . ± . ( . - . ) months. mean psa level was . ± . ( . - ) ng/ml. clinical stages were t , t and t in respectively , and patients. diagnosis was suspected during screening, because of prostatitis or bone pain in respectively , and patients. th ree pc were discovered aft er prostate transurethral resection. results: th irty-one patients ( ktr and ltr) with a localized disease underwent radical prostatectomy (rp). histological fi ndings were pt c and pt tumors, with positive surgical margins. gleason score (gs) was in case, in cases, in cases and in case. one patient with positive pelvic lymph nodes was given hormonotherapy. another had a biochemical recurrence at months and was treated with salvage radiotherapy. with a mean follow-up of . ± . ( . - . ) months, two ktr died from kp, and years aft er hormonotherapy and rp respectively. conclusions: prevalence of pc in sotr remains controversial, even though a signifi cant increase can be expected in the coming decades. it is therefore recommended to systematically screen male transplant recipients aft er years of age because outcome is much better if pc is diagnosed and treated early. radical prostatectomy is feasible in ktr as well as in ltr. conservative introduction and objective: conservative surgery results in the transplanted population remain unknown because they are only presented in small series or case reports. our objective was to study renal conservative surgery for kidney graft renal cell carcinomas (rcc) in a multicenter cohort. nephron sparing surgery (nss), radiofrequency ablation (rf) and cryoablation (ca) were studied. iiib) . none of the patients treated by radiofrequency ablation or cryoablation had complications. th e mean time of follow-up was . months ( . - ). fift y-nine ( . %) patients had a functional kidney graft , without dialysis and no long-term complications. specifi c survival was % at the last time of follow-up. conclusion: nss has proven its effi ciency for treatment of small tumors of transplanted kidneys with good long-term functional and oncological outcomes, which prevent patients from returning to dialysis. cryoablation and radiofrequency ablation seem to be alternative therapies that can be chosen with good results, in selected patients. ureteric implantation into introduction and objective: conventional technique recommends ureteric anastomosis to the bladder during kidney transplantation in patients with bladder augmentation. we report our experience of kidney transplantation in augmented bladders with the transplant ureter implanted into the bowel portion of the cystoplasty. a total of patients (mean age, . years (range - years), female, deceased donors) with augmented cystoplasty and subsequent kidney transplantation by a single surgeon between and was reviewed. following standard arterial and venous anastomosis and reperfusion of the transplanted kidney, ureteric implantation involved continuous pds / anastomosis between the spatulated ureter and full thickness bowel portion of the cystoplasty over a size fr dj stent. a second layer of bowel plication was performed around the anastomosis to prevent refl ux using interrupted / vicryl sutures. chart review was performed to evaluate the short-term urological and kidney function outcomes. results: th e cause of renal failure was bilateral vesicoureteric refl ux in patients, posterior urethral valve with refl ux nephropathy in patients, tuberculosis of the urinary tract with infl ammatory ureteric stricture in patient, and lumbosacral agenesis with neurogenic bladder in patient. bladder reconstruction was performed at a median duration of months ( - months) before transplantation. gastrocystoplasty was performed in patients, while the colon and/or ileum were used in the remaining patients. all reconstructed bladders except had a mitrofanoff created for clean intermittent self-catheter drainage aft er transplantation between to x / day. aft er surgery, th e dose fi nding study, toxicokinetics of human bone marrow-derived mesenchymal stem cells, and study deciding timing and number of cell injection were conducted in order. results: from the dose fi nding study, × was selected as dose per an injection of human bone marrow-derived mesenchymal stem cells. from the toxicokinetics of human bone marrow-derived mesenchymal stem cells, days was selected as interval between repeat treatments. in the third study, the ratio of maximal intracavernous pressure to mean arterial pressure was signifi cantly lower in the control group than in the sham group ( . % vs. . %, p< . ). immediate single injection of human bone marrow-derived mesenchymal stem cells ( . %, p= . ) signifi cantly improved erectile function compared to that in the control group, whereas delayed single injection ( . %, p= . ) showed marginally signifi cant improvement. all histomorphometric changes were signifi cantly improved in the up. , figure . immediate or delayed single injection groups than in the control group. repeat treatments did not provide any incremental eff ect on recovery of erectile function and histomorphometric changes. conclusion: intracavernous injection of × human bone marrow-derived mesenchymal stem cells results in recovery of penile erection along with histomorphometric changes in a rat model of cavernous nerve injury, even when treatment was delayed by weeks following cavernous nerve injury. any incremental eff ect aff orded by repeat treatments remains to be undefi ned. relationship between metabolic syndrome, erectile dysfunction and hypogonadism abou farha m, el-abd s, el-gharbawy m, abou farha o introduction and objective: a strong association between erectile dysfunction (ed) and metabolic syndrome (ms) and hypogonadism was determined. aim of the work: to investigate the relationship between (ms), (ed) and the incidence of hypogonadism. th e correlation between hypogonadism and the metabolic risk factors was also determined. a total of patients with ed were included in the study, patients meet the criteria of ms were estimated. ed was classifi ed based on iief- domain score and the relation between severity of symptoms and the number of metabolic risk factors was determined. th e incidence of hypogonadism in ms patients was determined and the correlation between hypogonadism and metabolic risk factors was identifi ed. introduction and objective: peyronie's disease (pd) is a fi brotic disorder aff ecting the tunica albuginea of the corpora cavernosa. erectile dysfunction (ed) due to pd may be secondary to the penile deformity and the resultant changes in the hemodynamic parameters. th e aim of this study is to defi ne color doppler duplex ultrasound (cddu) characteristics in pd, with specifi c attention to describing the presence and etiology of ed in these patients. introduction and objective: th e cause of peyronie's disease (pd) is unknown. th e most accepted causative theory is trauma to tunica albuginea. because prevalence varies ( . - %), the potential for contributory cofactors have been proposed. we hypothesized that metabolic syndrome and other comorbidities may be found at higher rates in pd. retrospective chart review of patients presenting to a men's health clinic with a variety of complaints: erectile dysfunction (ed), premature ejaculation (pe), premarital checkup, small penis, decreased libido, lower urinary tract symptoms (luts) were screened for pd. variables collected: presence/absence of diabetes mellitus (dm), hypertension(htn), dyslipidemia (dl), body mass index (bmi), total testosterone (t), penile peak systolic velocity (psv) and end diastolic volume (edv), smoking, and glycosolated hemoglobin level (a c) in patients with dm. results: a total of patients, with a mean age of years (range - ) were analyzed. pd incidence ranged widely within individual clinics ( - %, average %). hypertension, bmi, t level, total number of comorbidities, low psv, abnormal edv, and mean a c were not associated with the presence of pd. th congress of the sociÉtÉ internationale d'urologie -siu abstract book diabetes was associated with pd (p= . ) and dm patients had a % higher incidence. patients with the highest a c levels (> . ) had an increased incidence of pd [or . (p= . , ci . - . )]. increased age was correlated with pd (p= . ); for each year of life, the likelihood increases by an or of . (~ % per year) (p= . , ci . - . ). dyslipidemia (p= . ) and smoking (p= . ) were associated with - % lower incidences of pd. conclusion: peyronies disease is found in about % of patients seen for other complaints. diabetes, particularly poorly controlled diabetes, is associated with an increased incidence. several other clinical factors appeared noncontributory. a decreased incidence of pd in smokers and patients with dyslipidemia is seen, but does not necessarily refl ect a protective role, but likely increased levels of erectile dysfunction in these groups--patients with inability to achieve erection are unlikely to complain of peyronies' disease. further research into the interaction of pd and dm are warranted. kim j, park j, chae j, oh m, park h, kim j, moon d introduction and objective: limited data are available concerning sexual behavior of korean men. th is study aimed to perform the national sex survey and to collect the basic data for establishment of the prevention strategies of sexually transmitted infections (stis) and hiv/aids. th is is a national survey performed on a sample of , individuals ( , men and , women) aged - years old. th e online surveys were carried out on a national scale in south korea. subjects were randomly selected from resident registration. a structured questionnaire was developed which elicited information concerning: demographic information, information on their sexual behavior, sexual identity, prostitution, experience of stis, and experience of sex education. results: th e majority of the subjects were either married or living with a partner. mean number of sexual intercourse is . ± . times a month. mean sexual satisfaction score using visual analog scale is . ± . . eighty-four percent had a fi xed sex partner; . % ( . % of men; . % of women) had experience through a speed dating or prostitution; . % of men and . % of women were sexually attracted to the same gender only, . % of men and . % of women were sexually attracted to both gender; . % of participants had the experience of the stis. only . % of the respondents had received sex education in the past year. we performed the national sex survey according to the nationwide distribution of population. it would be useful for establishment of the prevention strategies of stis and hiv/aids. to control stis and hiv/aids, powerful policies containing sex education and medical services will be needed. the introduction and objective: erectile function evaluated by international index of erectile function- (iief- ) tends to decrease in aging, obesity and hypogonadism, but the importance of body composition is unclear. in the present study, we evaluated associations between iief- , body composition and testosterone level (tt) in middle-aged men. design was a population-based cross-sectional study in middle-aged men. between march and september , police officers aged - years who had participated in a health examination were included. total , men underwent a detailed clinical evaluation using the validated international index of erectile function- (iief- ) questionnaires and body composition (measured by bioelectrical impedance analysis). weight, body mass index (bmi), waist-hip ratio (whr), and serum testosterone level were also established. results: data from men were analyzed. th e median age was . years, and median value of iief- score was . th e iief- score was inversely associated with age, whr, and body fat percentage (bfp) (r=- . ; p< . , r=- . ; p< . , r=- . ; p= . , respectively), and positively associated with body muscle percentage (bmp) and body skeletal muscle percentage (bsp) (r=- . ; p= . , r=- . ; p= . , respectively). testosterone level had no correlation with iief- score (p= . ). using logistic regression analyses, age, whr, bfp, and bsp predict moderate to severe erectile dysfunction (ed) in univariate analysis. age, whr, and bfp were independent predictive factors for moderate to severe ed in multivariate analysis (p< . , or . , % ci . - . ; p= . , or . , % ci . - . ; p= . , or . , % ci . - . , respectively). our data showed that erectile function in middle-aged men was closely associated with whr and bfp than with testosterone level and body muscle percentage. however, whr was identifi ed as a negative predictive factor for ed. further studies for the unique form of obesity pattern in korean men will be needed. in order to estimate the magnitude and outline the main components of adult male genital organs "dysmorphophobia" in greece, we surveyed the beliefs of men about parameters potentially aff ecting their sexual performance and activity as they relate with self-perceptions regarding adequacy of their external genitalia image. herein, we present preliminary results of this questionnaire based cross-sectional study. a specially designed self-administered questionnaire, consisting of demographic characteristics and main outcome measure questions aiming at defi ning whether and how beliefs regarding men's sexual image adequacy aff ect their sexual confi dence and function (answers scored - ), was fi lled in by males (aged - ) who consulted a single urology clinical setting, for symptoms unrelated to genital area pathology. statistical analysis was performed using spss- , p< . . results: th e majority of subjects ( . %) were highly satisfi ed of their sex organs image, while only one in seven ( . %) reported moderate to low levels of satisfaction. small penile size in the fl accid state was the most frequent ( . %) complaint followed by small erect penis dimensions ( %). in one out of two men ( . %), sex image inadequacy impression was based on self-assessment, in . % on sexual partner comments and in only . % on expert medical examination. nine out of ten men ( . %) considered external genitalia appearance the most signifi cant determinant of a man's sexual confi dence with . % believing they strongly fulfi l this requirement, while most of them ( . %) were highly satisfi ed with their whole body image. in only one in ten men ( . %) the impression of the sexual partner regarding sex image aff ects signifi cantly his sexual performance. most men ( . %) argued against resorting to surgical techniques to improve their sex image, % considered this option imperative for their well-being, while one in four ( . %) would consider surgery if a spectacular cosmetic result was guaranteed. various statistically signifi cant correlations between demographic and main outcome measures variables were recorded. conclusions: symptoms of genital organs dysmorphophobia, are expressed by one in seven men of the general population, in most cases complaints focus mainly at small penile size, while most frequently impression of inadequate sex image originates from self-assessment and negative sexual partner's comments. th e majority of men consider genital image a strong determining factor for sexual performance, while very few experience sexual relationships difficulties due to feelings of genital inadequacy. only a small minority of men would be strongly willing to undergo external genitalia surgery, which they consider imperative treatment for sexual image inadequacy. abou farha m, el-abd s, el-gharbawy m, abou farha o introduction and objective: metabolic syndrome is a public health problem associated with increased incidence of erectile dysfunction (ed). erectile dysfunction in patients with metabolic syndrome is diffi cult introduction and objective: erectile dysfunction (ed) and lower urinary tract symptom/ benign prostatic hyperplasia (luts/bph) has common pathophysiology. and phosphodiesterase type inhibitor (pde -i) partially reverses the prostatic tissue contraction, and increases cyclic guanosine monophos- phate to show antiproliferative eff ects in the prostatic smooth muscle cells and consequently, voiding symptoms were suggested to be improved. however, there was no defi nite mechanism of the eff ectiveness of pde -i on luts/bph. some previous study has reported the hypothesis which is pde -i improve the blood fl ow rate of prostate and it may improve the luts. in present study, by transrectal ultrasonography (trus), evaluated the change of blood fl ow rate of prostate aft er pde -i administration. materials and methods: total patients were included in this study. among enrolled patients, patients had once daily administrated mirodenafi l (mvix®, sk chemical, korea) mg for week, other patients had administrated placebo daily. peak systolic velocity (psv) and end diastolic velocity (edv) were estimated by trus at before medication and a day aft er last administration. results: baseline characteristics were no signifi cant diff erence between two groups. in mirodenafi l group showed . cm/sec increase of psv and placebo group showed . cm/sec increase of psv (p= . ). moreover, mirodenafi l group showed . cm/sec increase of edv and placebo group showed . cm/sec decrease of edv (p= . ). once daily administration of mirodenafi l mg showed improvement of blood fl ow rate of prostate. factors predicting outcomes of penile rehabilitation with udenafi l mg following radical prostatectomy introduction and objective: udenafi l is a selective phosphodiesterase type inhibitor (pde i) made available in recent years for the treatment of erectile dysfunction (ed). penile rehabilitation using pde is following radical prostatectomy (rp) has been advocated; however, there are no previous reports on the role of udenafi l for potency recovery aft er rp. herein, we evaluated independent predictors of potency recovery in rp patients who underwent penile rehabilitation with udenafi l mg. between january and december , a total of patients underwent rp at a single institute. among them, men were enrolled in a penile rehabilitation program using udenafi l mg every other day. uni-and multivariable cox regression analyses were used to determine independent predictive factors for potency recovery. results: th e overall potency rate was . % during the mean follow-up of . months. on the multivariate cox analyses, preoperative international index of erectile function (iief)- scores (hazard ratio [hr], . ; p = . ), alcohol consumption (hr, . ; p = . ), and gleason biopsy score (hr, . ; p = . ) were independent preoperative predictors for potency recovery. among post-rp variables, the use of robotic procedures (hr, . ; p = . ) and pathologic stage (hr, . ; p = . ) were significantly associated with potency recovery. conclusion: th is study identifi ed predictive factors for the recovery of potency in patients undergoing penile rehabilitation with udenafi l following rp. our results provide physicians with useful information for counseling rp patients and selecting optimal candidates for penile rehabilitation. introduction and objective: androgen replacement therapy (art) effi cacy on late-onset hypogonadism (loh) has been widely investigated in western countries; however, it remains controversial whether art can improve health and prolong active lifestyles. we prospectively assessed long-term art eff ects on the physical and mental statuses of aging men with loh in japan. of volunteers eligible patients > years with loh were randomly assigned to either the art (n= ) or the control groups (n= ). art was conducted with intramuscular injection of testosterone enanthate mg each time every four weeks up to times. th e primary endpoint was health-related quality of life assessed by questionnaires. secondary endpoints included glycemic control, lipid parameters, blood pressure, waist circumference, body mass index (bmi), body composition, muscular strength, bone mineral density (bmd), international prostate symptom scores (ipss), international index of erectile function (iief)- scores, and serum prostate-specifi c antigen levels. th e safety and tolerability of long-term art were also examined in these populations. results: fift y-two weeks aft er the initial treatment, art signifi cantly aff ected the role physical subdomain of the short form- health survey (sf- ) scale (p = . ). art was also associated with signifi cant decreases in waist circumstance (p = . ) and serum triglyceride (tg) (p = . ) and with signifi cant increases in whole-body and leg muscle mass volumes (p = . and . , respectively), serum hemoglobin (p < . ), ipss voiding subscore (p = . ), and the second question on iief- (p = . ). th ere was no signifi cant deference between the groups in terms of bmi, bmd, isometric handgrip strength, serum fasting blood sugar and hemoglobin a c, serum psa, and the incidence of sever adverse events. conclusion: long-term art for patients with loh have the benefi cial eff ects on role physical subdomain of the sf- scale, serum tg, waist circumstance, muscle mass volume, voiding subscore of ipss, and the second question of iief- . we hope our study will contribute to the future development of this area. introduction and objective: hyperoxaluria is characterised by a high urinary oxalate level. super-saturation of urine with oxalate will lead to nucleation, aggregation and the formation of calcium oxalate crystals leading to renal calculi. patients with hyperoxaluria are at increased risk of recurrent urolithiasis. objectives: to analysis the interventions and outcomes of new patients with enteric and dietary hyperoxaluria referred to a metabolic stone clinic. an analysis of patients with hyperoxaluria was performed. data examined included; age, sex, metabolic abnormalities, malabsorptive syndromes, previous treatments, stone composition, medical and life style interventions. all patients had or more hr collections of urine performed at median of months apart. twenty-four-month follow-up was performed to assess need of further stone treatment. results: a total of patients were identifi ed for study. twenty-fi ve were male, were female. th e median age is years, iqr ( - ). first median urinary oxalate level is . mm, iqr ( . - . ). patients that reduced their oxalate intake and increased their fl uid intake were signifi cantly less likely to need further long-term stone treatment. th e arr of increased urinary output and decreased urinary oxalate on the need for further stone surgery is th congress of the sociÉtÉ internationale d'urologie -siu abstract book . %, ci (- . - . ) . th e rrr for the need of stone surgery is . %, ci (- . - . ) . th e nnt to prevent one patient needed further stone treatment is . , ci ( . -- . ) . conclusion: hyperoxaluria is important cause of recurrent stone formation that requires management in a dedicated metabolic stone clinic. compliance with fl uid, dietary and medical management is limited. in compliant patients, urine parameters and stone recurrence rates can be altered. clinical using specifi c diagnosis codes from billing data, patients were identifi ed that met criteria for urosepsis secondary to an obstructive ureteral calculi. data was analyzed in the following areas: demographics, admitting hospital of origin, duration of admission before transfer, need for higher level of care, need for invasive procedures, and length of hospital stay. results: using the screening criteria patients were identifi ed. th e average age was ; % were female versus % male. patients transferred from an outside hospital made up % of the patients and overall hospital admission lasted . days. of the patients transferred % went to the icu for an average duration of . days. of the transferred patients % needed vasopressor/ionotropic therapy, and % required intubation. overall, over % needed urologic intervention; % had ureteral stent placement and % underwent nephrostomy tube placement. patients admitted from the ed made up % of the patients and had an average admission of . days. of these patients % went to the icu for an average of . days. only % and % needed vasopressor/ionotropic therapy and intubation respectively. also, % had ureteral stent placement and only % had a nephrostomy tube placed. conclusion: urospesis in the setting of an obstructive ureteral stone is a medical emergency that merits urgent relief of the obstruction. once this condition is identifi ed, any facility without the resources for prompt intervention should transfer these patients immediately to a center with these capabilities. th is is supported by our data, as transferred patients on average had a longer icu and hospital stay, and needed more aggressive interventions. clinical signifi cance of ureteral wall thickness adjacent to the stone in abdomen-pelvis ct in the patients treated with extracorporeal shock wave lithotripsy park m, yeo j, cho d introduction and objective: although, ivp was standard diagnostic tool for years, the use of abdomen-pelvis ct (apct) without contrast, particularly in an acute setting, is becoming increasingly common. th is study was planned to know the clinical signifi cance of ureteral wall thickness adjacent to the stone in apct in the patients treated with extracorporeal shock wave lithotripsy (eswl). : th e data of patients who took ap-ct to diagnose ureter stone and were treated with eswl was reviewed. aft er maximum zoom of the ap-ct image showing the longest diameter of stone, the ureteral wall thickness adjacent to the stone was measured by same physician. th e baseline characteristics of patients, the parameters related to ureter stone and effi cacy of eswl were investigated. th e correlation between ureteral wall thickness and those parameters was statistically analyzed. th en, the patients were divided into two groups by the median value of ureteral wall thickness and the diff erence of those parameters between two groups was also investigated. additionally, cut-off value of ureteral wall thickness contributing to the diff erence in the effi cacy of eswl was determined. in simple correlation analysis, bmi, stone length at kub, stone diameter in ct, number of eswl, and time to stone removal showed signifi cant positive correlation with ureteral wall thickness. th e median value of ureteral wall thickness was . mm and the patients were divided into two groups. in comparison of baseline characteristics between two groups, group ii showed more incidence of pyuria than group i and stone burden at kub and ct also showed statistical diff erence between two groups. in comparison of effi cacy of eswl, group ii showed more number of eswl and longer time to stone removal than group i. th e cut off value of ureteral wall thickness contributing to the diff erence in the effi cacy of eswl was . mm. conclusions: in addition to actual size of stone, ureteral wall thickness of ct also aff ects the treatment effi cacy of eswl. especially, the ureteral wall thickness greater than . mm has an impact on the results of the eswl. the introduction and objective: th e treatment of large volume bladder stones by current equipment continues to be a management problem in both developing and developed countries. ah- stone removal system (srs) invented by us is primarily used to crush and retrieve bladder stones. th is study evaluated the safety and effi ciency of transurethral cystolitholapaxy with srs to treat the large volume bladder stone. materials and methods: srs, which was invented by aihua li in , composed by endoscope, continuous-fl ow component, a jaw for stone handling and retrieving, lithotripsy tube, handle, inner sheath and outer sheath. a total of patients with bladder stones were performed by transurethral cystolitholapaxy with srs since . th ese patients were divided into four groups by the stone size. fift y nine patients with stone size < cm were in group a, patients with stone size from to . cm were in group b, patients with stone size from to . cm were in group c, and patients with stone size ≥ cm were in group d and the largest stone was . cm. results: characteristics of patients and stone removal time in variable size were evaluated. to patients with single stone, stone size was . ± . cm and the operating time was . ± . min in group a. stone introduction and objective: eswl has emerged as a primary modality of treatment for solitary renal calculi in modern era. th e size of calculus is a major factor for consideration before subjecting a patient to eswl procedure. stone size less than two centimetre is considered ideal for eswl. other factors like obesity, position of calculus, renal infundibular anatomy and stone composition etc. also determine clearance rates. given a choice patients in india still prefer one time clearance by pcnl than multiple eswl sittings for similar sized calculus. our study reiterates the benefi ts of eswl in developing world with multivariate data supporting it. th e objective of this study was to evaluate the feasibility and safety of minimally invasive percutaneous nephrolithotomy combined with fl exible ureteroscopy for upper urethral calculus aft er radical cystectomy urinary diversion. a total of patients underwent minimally invasive percutaneous nephrolithotomy combined with fl exible ureteroscopy from january to august . th ere were cases that were diagnosed urinary stones aft er bricker urinary diversion of radical cystectomy, case of studer orthotopic ileal neobladder, and case of cutaneous ureterostomy. th ere were cases with left side calculi and cases with right side ones, including renal calculus, ureteral calculus and ureterointestinal anastomotic calculus. th e upper urethral calculi were identifi ed by urinary tract ultrasound and the multiplanar ct. all of cases underwent minimally invasive percutaneous nephrolithotomy combined with fl exible ureteroscopy. th e ureteral stent was indwelled for weeks routinely. th e kidney ureter and bladder x-ray or a ct scan was examined weeks aft er the procedure to evaluate the clinical outcomes. any residual calculus larger than mm was taken as signifi cant. results: th e combined lithotripsy was carried out successfully in all the cases. th e mean operative time was ( ± . ) min. th e nephrostomic catheter was removed days aft er the surgery. th e average blood loss was less than ml. no residual calculus was found during the weeks' follow-up. th e average follow-up was months. one case had recurrent calculus months aft er the fi rst procedure, which was successfully managed by the fl exible ureteroscopy again. minimally invasive percutaneous nephrolithotomy combined with fl exible ureteroscopy for upper urethral calculus secondary to urinary diversion aft er radical cystectomy is technically feasible introduction and objective: th e main goal of any intervention for urolithiasis is complete stone removal in order to achieve a stone free status. complete stone removal assures resolution of the immediate adverse outcomes of the stone disease, and prevents possible long-term complications such as pain, obstruction and stone growth. percutaneous nephrolithotomy is an eff ective procedure which is being considered as the gold standard in the treatment of large/complex renal calculi. reported stone free rates are up to %, probably refl ecting the level of experience, stone properties and equipment employed in the procedure. it is well established that higher incidence of residual fragments increases the complication rates and needs further interventions. th e main reason for failure of complete radiolucent stone clearance is inability to visualize the residual stones either by nephroscope or by fl uoroscopy. th e use of intraoperative ultrasound for assessment of residual radiolucent stones during percutaneous nephrolithotomy, will help to increase stone free rate. materials and methods: between sept. and sept. intraoperative ultrasound was used in cases of large complex radiolucent renal stones. results: it showed stone free rate % in patients, false negative in patients ( %) and there was diffi cult scanning in patients ( %). conclusions: th e use of intraoperative ultrasound for assessment of residual radiolucent stones during percutaneous nephrolithotomy, it will help to increase stone free rate. intravenous acetaminophen decreases sedation requirements during extracorporeal shockwave lithotripsy conclusion: th ere is benefi t in pre-operative administration of intravenous acetaminophen in reducing the dose requirements of sedative analgesic for satisfactory pain control during the procedure of swl under conscious sedation. introduction and objective: while most of the bleeding associated with pcnl can be managed conservatively, few need angioembolisation. th ere are diff erent technical methods of embolisation with risk of varying degree of parenchymal damage. we present case of ultrasonography guided embolisation. materials and methods: right lower calyx pcnl was performed successfully in year female with mm renal stone in solitary kidney. she came back on th postoperative day with gross hematuria, with cm by cm clot in renal pelvis and mm arterio-venous fi stula at pcnl puncture site. patient was managed with iv higher antibiotics, strict bed rest, blood transfusion and iv tranexamic acid. but her renal function deteriorated (creatinine- . mg/dl). one haemodialysis was done and patient was explored by sub costal approach, with idea of removal of blood clots and suture ligation of av fi stula. renal pelvis was opened and clots were removed. during operation av fi stula was located with doppler usg and deep suture by - vicryl was attempted to close av fi stula, but due to oedematous kidney suture closure was not possible. so under usg guidance gauze lumber puncture needle was inserted into av fi stula, its position was confi rmed by saline jet on real time usg and cc histoacryl tissue adhesive (monomeric n-butyl- -cyanoacrylate) was injected into av fi stula. intraoperative embolisation of av fi stula was confi rmed by colour doppler. results: renal functions became normal in hours and patient was discharged on th postoperative day. aft er days ivp was done which demonstrated normally excreting whole kidney, showing successful superselective embolisation in solitary kidney. conclusions: usg guided procedure avoids the side eff ects of contrast media in case of acute renal failure. it avoids hazards of radiation and complications of angiographic catheterisation. th e main importance of this procedure is preserving maximum renal tissue, especially in case of renal insuffi ciency and in solitary kidney. th is procedure gives a new vision to do percutaneous usg guided embolisation by thin gauze needle without need of angiography, iv contrast, radiation and minimum morbidity. ultrasound th ree pregnant women in the th, th and th week of pregnancy presented with a symptomatic large renal stone in the fi rst and multiple renal stones in the second and third which were unresponsive to conventional medical therapy. th ey required defi nitive stone treatment. th e operations were done in nov , jun and feb . data was gathered prospectively. all steps of gaining access to the pyelocalyceal system including needle insertion, tract dilation, and amplatz sheath placement were performed under ultrasonography guidance. tract was dilated with single shot technique. th e fi rst two procedures were performed in supine position and the third procedure was performed in lateral fl ank position. results: two patients were stone-free postoperatively and one patient had only an asymptomatic mm residual stone. th ey were discharged on the nd postoperative day and had an uneventful postoperative course. no fever, bleeding or renal colic was noticed during postoperative hospitalization. th e fi rst two patients delivered their fetuses at term without any abnormality reported by the examining pediatric specialist aft er their birth. th e third patient was followed until week of pregnancy without any obstetric complication. conclusion: ultrasonography can be used as an imaging modality guiding all steps of obtaining percutaneous access in pregnant women. supine or fl ank ultrasound guided percutaneous nephrolithotomy can be off ered to pregnant women in whom conservative measures fail to the patient's well-being. introduction and objective: acute ureteral obstruction in pregnancy may result in severe pain, hematuria and serious complications like upper urinary track infection with consecutive sepsis. th e ureteral stenting has been usual in recent years. we evaluated the usefulness of ureteral stenting for ureteral obstruction with symptoms in pregnancy. fift y-three pregnant women participated in this study. abdominal ultrasonography, serum creatinine levels, white blood cell (wbc) counts, urinalysis and urine culture were done in all patients. of these pregnant women, women were treated by ureteral stenting because of not improving with conservative management (positioning, analgesia, antibiotics, etc.). th ey were completely followed-up to removal of ureteral stent. results: of these pregnant women, women who were treated by ureteral stenting, experienced signifi cant relief of pain at least for days. in abdominal ultrasound, patients ( %) had resolution of hydronephrosis. twelve of patients ( %) continued to have problems post-therapeutically irritative voiding symptoms with dysuria, urgency, frequency, and hematuria, but patients experienced relief of symptoms for days. a patient was taken remove of stent due to continuous complaint irritative voiding symptoms. aft er delivery, patients were taken ivp. of patients, were normal fi nding with ivp. four patients were diagnosed ureter stone (upper , mid , lower ). th ree patients were treated by extracoporeal shock-wave lithotripsy for the stone in upper and lower urinary tract. a patient was treated ureteroscopic lithotripsy. conclusions: since the ureteral stents were usually placed without any major problems and well tolerated with only minor and short post-therapeutic discomfort. we concluded that the ureteral stenting was a simple, safe and eff ective method of internal upper tract drainage in case of symptomatic ureteral obstruction during pregnancy. safety introduction and objective: to evaluate objective and subjective outcomes of retrograde intrarenal surgery (rirs) for the treatment of radiopaque - mm renal calculi. a retrospective analysis was performed for patients who underwent rirs to treat renal calculi sized with - mm between april and december . operative and postoperative data were collected for each patient such as stone burden, stone location, number of sessions, and auxiliary procedures. th e term of follow-up was one year at least. surgery was usually performed under general anaesthesia. flexible ureteroscopy with ureteral access sheath and holmium-yag laser were employed. patients were evaluated with simple radiography, abdominal ultrasonography, or ct without contrast. surgery success was determined as stone free rate (sfr) at three months aft er last session. re-treatment rates were also calculated. results: mean age was . ± . years old. th e highest-frequency location was pelvis ( %). single stones were described in % of patients although multiple urolithiasis were detected in the %, mainly located in the lower calyceal. average surgery time was . ± . min. th e auxiliary procedure rate and the re-treatment rate were . % and . %, respectively. th e overall sfr and sfr aft er a single session were . % and . %, respectively. although no serious complications were noted in all of patients (above clavien-dindo classifi cation level iii), clavien level i to ii complications were identifi ed in two-patients ( . %). all these patients were successfully treated conservatively. conclusion: our fi nding suggest that rirs represents a valuable treatment option of - mm radiopaque renal calculi for selected patients. rirs would be also a good therapeutic alternative to extracorporeal shock wave lithotripsy (eswl) and percutaneous nephrolithotomy (pnl). rirs should be considered as fi rst line treatment. prospective analysis is required to be corroborated these fi ndings. ureteroscopic lithotripsy for extremely old patients yoshioka t , uehara s , otsuki h , shimizu t , murao w , fujio k , kikuchi h , fujio k , wada k , araki m , ebara s , watanabe t , nasu y introduction and objective: one of the biggest problems in st century is an aging society. in , the number of old people (≥ years old) in japan was , , . th at is about % of all japanese population. japanese society is becoming not an "aging" society, but an "aged" society, and we have to prepare for this society. on the other hand, upper urinary stone is a common disease, and oft en occurs not only young people but also aged people. however, there are no standard treatments for aged patients of upper urinary stones, especially extremely old patients who are more than years old. in this study, we investigate the safety and effi cacy of ureteroscopic lithotripsy of upper urinary calculi for these patients. between january and october , ureteroscopic lithotripsy (urs) underwent in abiko toho hospital. of these cases, cases are for the extremely old patients (≥ years old). we retrospectively reviewed gender, age, body mass index (bmi), american society of anesthesiology (asa) physical score, stone size, reasons for operation (whether symptomatic or not), operative duration, and stone free rate (sfr) of all cases. all data were reviewed by one urologist, and asa physical scores were evaluated by one anesthesiologist. results: all cases were bedridden female. mean age was . (range to ), bmi was . kg/ m^ (range . to . ), asa physical score was . (range to ). cases had preoperative complicated pyelonephritis, and out of these cases were indwelled preoperative unilateral ureteral catheters. mean stone size was . mm (range . to . ), and operative duration was . minutes (range to ). postoperative complication was pyelonephritis (clavien grade ), and sfr was % ( / cases). in all cases, postoperative unilateral ureteral catheters were indwelled, and were withdrawn weeks later. th ere have been no recurrent stones and/or pyelonephritis (median observation time: . months). conclusion: although sfr was low, urs for extremely old patients can prevent recurrent complicated pyelonephritis even on infected stones. th ere were . % of patients who had a single urinary stone and . % (n = ) had or more. one hundred and nine stones were treated. sixty-three percent of stones were intrarenal. th ere were ( . %) postoperative complications: two stage clavien classifi cation infections (prostatitis at day and two pyelonephritis hours aft er the procedure); three stage b complications (two renal colics requiring ureteral stenting hours aft er discharge and symptomatic perirenal urinoma hours aft er discharge). th ere was one intraoperative complication ( . %): a ureteral wound with contrast leakage. th e rate of transfer to conventional hospitalization was . %. stone size infl uenced the stone-free status and the need for more than one sessions (p < . ). th ere was a signifi cant correlation between operative time and stone size above mm (p= . ). conclusions: flexible and rigid ureteroscopy are safe and effi cient procedures for upper urinary tract stones, and can easily be carried out in an outpatient introduction and objective: renal stone disease is one of commonest urological disorders. pakistan is located in stone belt region with high incidence of urolithiasis. th ere have been innovations and improvement in stone treatment modalities. eswl is one of them. here we share experience of single centre in terms of stone free rate and effi cacy in adults. a retrospective study in which we included adults (age above years old) who underwent eswl from january to december . eswl was done by standard technique. we used modulith sl x lithotripter th generation storz medical. number of shocks per session for kidney and for ureter. energy level for kidney is set at and for ureter at . rate of shock wave delivery is shocks/minute. we followed patients for to months aft er last eswl session done. stone free status was defi ned as residual stone not more than mm in size. we reviewed data charts of patients for diff erent variables mentioned in results. introduction and objective: yolk-sac tumor (yst) is formed almost % germ cell tumors of infant and children. yst is the most common type of testis tumors in prepubertal period, but adult pure yst is extremely rare. in this case we aim to share our surgical experience with an adult pure yst in the right testis. a year-old man was referred to our clinic from cardiovascular surgery department for right testicular mass which is detected during the evaluation of his deep vein thrombosis. th e patient stated having a slowly progressive increase in size of his right gonad. th ere is no history about testicular trauma or epididymoorchitis. physical examination revealed a painful right testis which was uniformly increased in size and presented a smooth surface. usg showed a volumetric increase in the right testis. mass size was detected as . x . x cm, which was characterized by cystic components in heterogeneous echogenicity. serum chemistry revealed a marked increase in afp while β-hcg and ldh levels were within the normal limits. results: a right radical inguinal orchiectomy was performed. during the orchiectomy, because of the invasion to scrotum skin, scrotum skin was removed. th e surgical specimen was rigid, its surface was smooth and necrotic areas were observed ( figure ). pathologic examination revealed a pure yst with positive spermatic cord, tunica albugea, tunica vaginalis and scrotum skin invasion and in light microscopy tumor cells with large hyperchromatic nuclei arranging concentrically around a small vessel were seen (schiller-duval or glomeruloid body). metastasis of lung adenocarcinoma to the testis is an extremely rare occurrence and very few cases have been reported to date. th e authors aim to review the current literature in regard to incidence, clinical manifestation, sources of primary tumour and mechanism of metastasis, in addition to retrospective ten year review of testicular pathology at a single institution. we report an unusual case of a -year-old non-smoking australian gentleman who presented with a six month history of cough and dyspnoea. a physical examination, complete laboratory and radiological work up was performed. a palpable left testicular mass was identifi ed, ct scan revealed multiple bilateral lung nodules and mediastinal lymphadenopathy, however testicular tumour markers were negative. th e patient underwent a radical left inguinal orchidectomy and endobronchial hilar lymph node biopsy with bronchial washings. medical records and pathology results for patients undergoing radical orchidectomy over the past ten years at our institution were obtained and analysed. results: histopathological examination of the left testis and lung biopsy revealed features of a moderately to poorly diff erentiated adenocarcinoma, with morphological and immunohistochemical appearances consistent with lung origin. th e prognosis is extremely poor. a total of patients underwent radical orchidectomy at our institution between january and february . th e mean patient age was ( - ). histopathology is summarised in table . cur-up. , figure . th congress of the sociÉtÉ internationale d'urologie -siu abstract book rent literature review confi rms testicular metastases are rare and may be discovered incidentally at autopsy or following diagnostic orchidectomy. autopsy series revealed testicular metastases in . to . % of specimens. th e most common primaries, excluding lymphoma and leukaemia, include prostate, melanoma, sarcoma, gastrointestinal tract, kidney and lung, with most testicular metastases being a fi nal manifestation of widespread tumours. conclusions: testicular metastases from lung adenocarcinoma origin are scarcely encountered in clinical practice and may create a diagnostic dilemma by mimicking primary testicular neoplasms. extensive pathologic evaluation and specifi c immunohistochemical staining is essential. in patients presenting with a testicular mass, the diff erential diagnosis must include metastatic carcinoma. by . on average compared to only . by non-users (p= . ). many of these fi ndings were only present with recent vge; heavy users from high school and middle school did not show similar trends (table ; figure ). conclusion: th is study shows that subjects with heavy vge perform better on the da vinci skills simulator than subjects who report no vge. th e improvements seen with recent vge are not apparent if stratifying for frequency of use during high school and middle school. th ese fi ndings may have important implications for the future of surgical training. 'virtual urology clinic': a feasibility study in a busy uk teaching hospital introduction and objective: urology is an advancing surgical specialty with a parallel increase in demands from health service commissioners to meet national targets and patients' needs. th is has been refl ected on the outpatient urology service with a rising burden and delays in patients' outpatients' assessments. in our busy tertiary unit, we estimated a total of overdue outpatient appointment (by months or more). th us we designed this virtual clinic feasibility study aiming to: prioritise patients according to their clini- cal needs, enhance their care and decrease the burden by assigning patients to our novel computer based follow-up models. we used the hospital information system to identify one urologist overdue appointments (by months or more). all included cases had thorough review of their medical notes, investigations and treatment before being stratifi ed according to their diagnosis then assigned one of outcomes: urology, cancer nurse specialist (cns) and gp follow-up. results: a total of cases were reviewed in this virtual clinic over a period equivalent to full working days. even though they were all waiting to see one urology cancer surgeon, only % had a primary diagnosis of cancer with the rest being diagnosed with a benign urological condition. th e clinical investigator recommended for only % of all patients to have a urology follow-up with % and % discharged to the gp and computer based follow-up respectively. all patients received a letter explaining the procedure of this clinic along with a tailored management plan. th ere was an evident gap between the dynamic changes in service provision with new available tools and our current practice. th is virtual clinic allowed bridging this gap by categorising the urological priorities and utilising existing resources such as our novel computer based follow-up models. over the last year more than patients' visits have been registered on our computer based clinic which is potentially a cost eff ective model. patients' perspectives of accessibility introduction and objective: patients undergoing major lower abdo/pelvic operations are oft en catheterised (idc) at the start of the procedure to monitor urine output and decompress the bladder to avoid bladder injury. early removal of urinary catheters aft er surgery has been associated with a decrease in urinary tract infections though increasing failure of trial of void (tov), thus being discharged with idc or prolonged admissions. th e aim of this study is to determine the optimal time for tov. th is is a retrospective study looking at patients undergoing abdominal or pelvic procedures due to colorectal/pelvic pathology in the townsville base hospital surgical unit from jan -dec . pre-procedure idc and the deceased were excluded. data was collected from the operating theatre database (ormis). results: out of the total, were female while male, abdominal and pelvic procedures. sixteen male patients had documented prostatic history which include bph, prostate cancer and prostatitis post radiation. four were discharged with an idc failing tov. fift y-seven percent of the patients had their catheters removed on day post-op; . % on day , % on day , . % on day and % > days. th ree patients developed a urinary tract infec-tion (uti) ( . %). patients with good pre morbid function and female tend to pass their trial of void on day post op for pelvic procedures. th e majority of patients had comorbidities and failed tov on day . th ere was no signifi cant diff erence between day and day in uti rates (increasing day onwards). conclusions: idc's should be removed in a timely manner to reduce complications, balanced with monitoring fl uid balance. we proposed that patients should have tov on day , due to increased rates of failed tov day in patients with comorbidities and no diff erence in uti rates between days and . th e limitation of this study is the lack of documentation of preoperative urinary function. to further this study, we can analyse the data to state diff erences between bladder dysfunction as well as tov in groups with various comorbidities. international urology journal club on twitter: a growing educational forum introduction and objective: urologists use urinary and thoracostomy drainage collection systems regularly. pleural and urine fl uid pools at the bottom of dependent loops of both thoracostomy and urinary drainage tubing systems, respectively. we hypothesized that fl uid pooled in a dependent loop ) diminishes the expected negative pressure-head delivered to the pleural space by a chest-tube, and ) obstructs antegrade catheterized urine drainage. we created an ex-vivo thocacostomy tube model, and, performed two separate clinical trials to test our hypothesis. a pleur-evac chest drainage system was connected to - cmh o wall-suction. a digital pressure transducer was connected to the drainage tubing close to the insertion of connection to a chest-tube. model: to simulate dependent loops observed in hospital patients, we created , , and cm-high dependent loops (distance between the bottom of loop and the highest-point en-route to the drainage box). th e pressure close to the (blind-ending) chest-tube was measured as the drainage tube was fi lled in ml. increments. fitted linear regression of pressure and loop-height was performed. clinical trials # . pressure within the drainage tube was measured in six icu patients with thoracostomy tubes in place following cabg surgery. clinical trial # : we performed early-morning hospital icu bedside bladder-scan us on patients with an indwelling urinary catheter and clear urine, to assess for un-drained residual urine. results: with an empty dependent loop, thoracostomy tube pressure equaled the suction pressure (- cm h o). pooled of fl uid within the dependent loop diminished proximal negative pressure (p< . ) in a volume (i.e. loop-height) dependent fashion. th e net range of proximal drainage tube pressure ranged from - to + cmh o. in icu patients, an identical relationship between loops and chest-tube pressure was observed. bladder scan of catheterized ward patients revealed high urine residuals (mean ml) with a dependent loop present, and ~zero residual when no loop present. conclusions: th oracostomy-tube negative-pressure is steadily diminished as a dependent loop fi lls with fl uid. th e resulting air-lock opposes antegrade drainage. th e weight of the fl uid column accounts for positive thoracic pressures, and could account for why many patients fail water seal trials. similarly, urinary tubing dependent-loops result in air-locks that prevent gravity dependent drainage. th oracostomy and urinary drainage tubing should always be positioned without dependent loops. single incision mid-urethral sling (miniarctm) and tension-free vaginal tape (tvt) procedure in women with stress urinary incontinence (sui) at months. a total women with sui were randomized to receive miniarc and tvt. th e primary outcomes were objective and subjective cure rates at a -month follow-up visit. objective and subjective cure of sui were defi ned as a negative cough stress test and absence of self-reported sui symptoms. cure rates of the two groups were compared at -month follow-up. results: a total of ( %) of women originally included in the study (miniarc: , tvt: ) were evaluated at -month follow-up. th ere were no signifi cant diff erences found in demographic and clinical preoperative parameters. objective cure rates for miniarc and tvt groups were % and % while subjective cure rates were % and %. th ere was no statistically signifi cant diff erence between groups (p> . ). conclusions: our -month randomized clinical trial showed that miniarc single incision sling is not inferior to tvt procedure with respect to objective and subjective cures at -month follow-up. introduction and objective: male sui is a debilitating and challenging problem to manage. insertion of transobturator sling off ers less invasive treatment than aus insertion. published data demonstrate cure rates of % but are limited by short follow-up. th e aim of our study was to report long-term outcomes for male transobturator slings for sui with a mean year (minimum year) follow-up. a single-centre retrospective audit of outcomes in male patients who underwent transobturator sling insertion for sui. follow-up was conducted via telephone or in outpatient clinic. incontinence was classifi ed as mild (≤ pads/day), moderate ( - pads/day) or severe (≥ pads/day). classifications post-surgery were: cured -dry; improved -≤ pads/day and ≥ % less pad use; failure -no change or worsened. results: in patients with mild/moderate incontinence, / patients (= . %) were cured/improved with tot. success rates were poor in severely incontinent patients, regardless of radiotherapy history ( %; n= ). of 'cured'/'improved' patients, ( . %) maintained that degree of continence for the duration of follow-up. one patient was lost to follow-up. th ree patients reported a later decline in continence; patients had had previous pelvic radiotherapy. one patient had progression of underlying prostate cancer. conclusion: durable success rates of . % are achievable in men with mild/moderate sui who have not had pelvic radiotherapy. pelvic radiotherapy may play a role in delayed failure of tots with % of patients with mild/moderate sui who were initially cured/improved declining in the second or third year aft er surgery. the mesh wallstent (urolume) in the treatment of detrusor external sphincter dyssynergia in men with spinal cord injury dept. of surgery, div. of urology, king saud university faculty of medicine, riyadh, saudi arabia introduction and objective: to evaluate the longterm effi cacy and safety of the urolume stent for the treatment of detrusor sphincter dyssynergia (dsd) in spinal cord injured (sci) patients. twenty-four spinal cord injured patients with neurogenic bladder and dsd associated with high detrusor pressures and incomplete emptying on pre-operative video-cystometrograms (vcmg) were retrospectively reviewed. twenty-one patients had cervical level injury whilst had a thoracic injury. eleven patients were on clean intermittent catheterization (cic) and with indwelling foley's catheter. all patients underwent urolume stent insertion according to standardized protocol. follow-up assessment included blood chemistry, ultrasound scan (upper tracts and residual urine) at one and three months aft er insertion, and a follow-up vcmg at six months. residual urine volume, autonomic dysrefl exia, catheter need, and presence of bladder stones and hydronephrosis were compared before and aft er treatment. post-operative patient and physician satisfaction, complications and re-obstruction rates were also analyzed. paired t-test is used and p value < . was taken as signifi cant. results: th e twenty-four patients had a mean (range) follow-up of . ( . - ) years. th e mean age was introduction and objective: at present, sacral neuromodulation (snm) with interstim® therapy is indicated for non obstructive urinary retention and overactive bladder, including urinary urge incontinence and signifi cant symptoms of urgency-frequency alone or in combination, in subjects who have failed or could not tolerate more conservative treatments and do not have any neurological disorder. th ere are also reports of the use of interstim® in the treatment of chronic pelvic pain and other conditions. we report our experience with the use of this device in patients with post-traumatic brain injury damage without anatomical anomalies and with severe urinary voiding dysfunction who had failed intensive medical and behavioral therapies. materials and methods: from november to november , patients underwent interstim® placement ( male and female). all had severe voiding dysfunction secondary to post-traumatic brain injury damage; ten of them had also defecatory disturbances ( a chronic constipation and fecal incontinence). th e main goal was to evaluate the improvement of the urinary symptoms and the second goal the improvement of the intestinal symptoms. success was defi ned as a ≥ % improvement in any of the two variables evaluated. results: with a mean follow-up of months, / patients reported ≥ % improvement in their urinary voiding symptoms ( %), in these patients urinary frequency decreased from to episodes per day, mean voided volume increased from cc to cc, incontinence disappeared in of patients and urgency disappeared in all patients. of patients with intestinal disturbances, showed a signifi cant improvement ( %). one patient showed a clavien iii complication (seroma and partial dehiscence of the surgical wound managed with conservative surgical treatment). conclusion: snm in post-traumatic brain injury patients is an eff ective and safe option for urinary and defecatory dysfunction when other conservative therapies have failed. to our knowledge the use of inters-tim® in this scenario has not been reported previously. a larger series and a longer follow-up are needed to validate this indication. introduction and objective: th ere were some reports that in the patients who have stress incontinence (sui) with detrusor underactivity, voiding symptoms aggravated aft er mid-urethral sling operation (mus). we report our experiences of mus cases on the patients who have sui with detrusor underactivity. conclusion: urethral sphincter and bladder function worsen immediately aft er rarp and recover over time. th e bladder storage function aft er rarp returns to almost the same level before rarp, the voiding function improves compared with the condition inserted into the rabbit bladder through the urethra and saline solution is infused using a disposable syringe into the bladder through the end cap. conventional cystometry was performed and the intravesical pressure was measured by prototype intravesical pressure sensor at the same time. we also evaluated the biocompatibility of ecofl ex® by checking changes in the levels of macrophages, macrophage migratory inhibitory factor, and infl ammatory cytokines in the bladder tissue and urine. cape town, south africa th congress of the sociÉtÉ internationale d'urologie -siu abstract book and urgency incontinence are signifi cantly detected luts in children with vur the -gene genomic prostate score assay: initial commercial experience of , patients th congress of the sociÉtÉ internationale d'urologie -siu abstract book th congress of the sociÉtÉ internationale d'urologie -siu abstract book pelvic strength physiotherapy percutaneous treatment of bladder stones in children: -year experience; is blind access safe? extirpative treatment of upper urinary tract urothelial carcinoma: an -year comprehensive review paik l th e overall complication rate was %. no hydronephrosis were seen thought the follow-up period. stricture rate was low, only one patient ( %) at one year, and none at years had urethral stricture. patients ( %) required re-stenting due to stent migration ( patients, %), or stricture ( patient, %), all of which happened during the fi rst year of surgery. patients ( %) required alpha-blockers to control bladder neck dyssynergia post operatively. stents ( %) were removed due to exacerbation of autonomic dysrefl exia symptoms (n = ); encrustation and stone formation (n = ). overall, % of patients and % of physicians felt there was improvement in urination at year. conclusions: th e treatment of detrusor sphincter dyssynergia in spinal cord injured patients with urolome stent is safe and eff ective sacral neuromodulation with interstim® therapy for urinary voiding dysfunctions in post-traumatic brain injury patients: a new therapeutic indication? hospital pablo tobon uribe, medellin, colombia th congress of the sociÉtÉ internationale d'urologie -siu abstract book between pre-and post-operative qmax abstract book before rarp; however, the urethral sphincter func male ( . %) ( %) . ** introduction and objective: we evaluated the clinical eff ect of alternative fl utamide therapy for metastatic prostate cancer that relapsed aft er initial maximum androgen blockade (mab), and investigated the relationship between the eff ectiveness of alternative fl utamide therapy and the eff ectiveness of initial mab. and december , patients with metastatic prostate cancer that relapsed aft er initial surgical or medical castration along with bicalutamide for mab were treated with fl utamide therapy ( mg daily). importantly, patients who had discontinued bicalutamide because of adverse events were excluded.results: of the patients treated with alternative fl utamide therapy, prostate-specifi c antigen (psa) levels decreased by > % (group a) in patients ( %), by - % (group b) in patients ( %), and by - % (group c) in patients ( %), but increased by > % in patients ( %). th e median duration of response was . , . , and . months for groups a, b and c, respectively. th e duration of response for patients ( %) was more than months. aft er alternative fl utamide therapy, decreased psa levels of > % were achieved in of patients ( %) with mab nadir psa levels of < . ng/ ml, in of patients ( %) with mab nadir psa levels of . to ng/ml, and in of patients ( %) with mab nadir psa levels of > ng/ml. during the observation period there were no severe side eff ects.conclusion: approximately % of patients with metastatic prostate cancer who relapsed aft er mab with bicalutamide achieved a decrease in their psa level with no severe side eff ects. th e nadir psa level during mab, however, was not a predictor for the eff ectiveness of alternative fl utamide therapy. th us, alternative fl utamide therapy is a reasonable treatment option for metastatic castration resistant prostate cancer. nevertheless, changing to another therapy should be considered in patients who achieve decreases in psa levels of < % with alternative fl utamide therapy, as the duration of response was relatively short in these patients. association of renal function and androgen deprivation therapy with prostate cancermasuda h, kanesaka m, sugiura m, hou k, araki k, kojima s, naya y introduction and objective: we evaluated the change of renal function by androgen deprivation therapy (adt) and examined the association of the occurrence of renal dysfunction and concomitant diseases. between january and april , patients who could measure estimated glomerular fi ltration rate (egfr) at pretreatment, , and months were evaluated retrospectively. all of them were diagnosed prostate cancer by prostate biopsy pathologically and had taken adt for at least months. we assessed the renal function of prostate cancer patients by using the egfr and investigated the time-independent change rate of the egfr (Δegfr) aft er adt. th e Δegfr was calculated by (post treatment egfr-pretreatment egfr)/pretreatment egfr × ). univariate and multivariate logistic analyses were carried out to identify clinical covariates signifi cantly associated with the risk factors for renal dysfunction at months later.results: th e incidence of the renal dysfunction at months was % ( / ). th e mean Δegfr at , , months were - . %, - . % and - . %, respectively (p= . ). th e incidence of the renal dysfunction at months was signifi cantly associated with the renal dysfunction at month (p< . ), at months (p< . ), hypertension (p= . ) and dyslipidemia (p= . ). th e renal dysfunction at pretreatment with adt did not aff ect the renal function months later (p= . ). th e renal dysfunction at months (odds ratio [or] . , p= . ), renal dysfunction at months ([or] . , p= . ), hypertension ([or] . , p= . ) and hyperlipidemia ([or] . , p= . ) were independent predictors of the renal dysfunction at months in the multivariate analysis.conclusions: it was suggested that the renal dysfunction with adt occurred relatively early. th e earlier renal dysfunction may cause the renal dysfunction at months later. so, when the treatment of adt began, it was thought that an examination of periodical renal function was necessary. th e present results suggested that it was necessary to control the blood pressure and lipid for receiving adt with prostate cancer. immune (pc) and isolated lymph node metastases aft er curative therapy are usually treated with an anti-androgen therapy. th e choline pet-ct is the method of choice in diagnostic of the recurrent psa. controver-sial in the latest debate is the oncological eff ectiveness of the local salvage therapy of isolated lymph node metastases. th e aim of this study is to compare the oncologic outcome of the salvage lymphadenectomy (la) alone versus the la in combination with adjuvant radiotherapy (ar) and androgen deprivation therapy (adt).materials and methods: th erefore we randomized patients with biochemical recurrence of a pc (psa: ≥ , ng/ml) aft er curative local therapy and detection of at least one lymph node metastasis. we applied two treatment arms. a (n= ): single la; b (n= ): la plus ar/adt (bicalutamide) over years. we determined the biochemical recurrence-free survival (bfs) and the time-to-treat (ttt) until complete androgen blockade. conclusion: compared for both treatment arms, the combination of la plus adt/ar is superior to la alone. however, both methods are to be seen as individual decisions in highly selected patients. th e oncological long-term eff ectiveness is questionable. stem cell transformation of prostatic cells after hormonal therapy we reviewed consecutive patients who underwent transperineal mri-trus fusion target biopsy followed by conventional transrectal systematic core biopsy between july and mar in our institution. in all patients, t low region was detected by prostate mri image and target biopsy was conducted for region of interest (roi) of the mri image utilizing biojet system. baseline characteristics and pathological outcome were analyzed.results: in analyzed cohort, mean age was . ± . years, median initial psa was . ng/ml (range, . - . ), median prostate volume (pv) was . ml (range, . - . ) , and median volume of roi was . ml (range . - . ). of patients, prostate cancer was detected in ( %) patients by target biopsy and ( %) patients by systematic biopsy. patients with positive biopsy was likely to be higher psa than men with negative biopsy (p= . ). median roi/pv was not signifi cant between them ( . vs. . : positive vs. negative, p= . ). cancer detection rates per core between target and systematic biopsy were . and . %, respectively (p= . ).regarding pathological results, mean gleason score of target biopsy was . compared with . of systematic biopsy, although which is not statistically signifi cant (p= . ).conclusion: mri-trus fusion target biopsy is gradually spreading in japan, since its higher cancer detection rate compared with conventional systematic biopsy. in our institution, substantial detection ability of prostate cancer by mri-trus fusion target biopsy was confi rmed, which encouraged future clinical trial for prostate focal therapy. multiparametric introduction and objective: sepsis has always been a concern in the traditional transrectal ultrasound (trus) guided biopsy of the prostate. however, rates of sepsis following trus biopsy have shown to be increasing around the world in addition to the emergence of multiresistant organisms found in rec-tal fl ora. as a result, our practice of seven urologists has switched to transperineal (tp) biopsy. we aim to determine the rate of hospital re-admission in our patients undergoing tp biopsy. an ethics approved prospective database of all men undergoing tp biopsy at our practice has been kept including antibiotics used as well as re-admission for infection. introduction and objective: robot-assisted radical prostatectomy (rarp) has become one of standard treatments for localized prostate cancer. however, a feasibility of rarp in elderly patients has not been clear yet. we performed a comparative analysis of peri-surgical / oncological outcomes for younger and elder patients underwent rarp. we reviewed and compared our initial consecutive patients who underwent rarp from / to / for peri-surgical outcomes, including surgical times, blood loss, complications, pathological fi ndings, continence recovery, and oncological outcomes stratifi ed by age less than and over years.results: in our cohort, men were age less than and men were ≥ . preoperative parameters (age, psa, gleason score) were similar in both younger and elder groups. operative time (mean: vs. minutes) and estimated blood loss were similar in both groups. one of elder patients ( . %) needed transfusion. peri/post-operative complications in both groups appeared to be minimal with no cases of intra-operative open conversion. one of younger patients needed a surgical settlement for port site herniation. surgical positive margin rates in organ-confi ned (pt ) disease were also similar ( . %, younger vs. . %, elder). continence at months was % in elder patients as opposed to % in younger patients. biochemical recurrences in short follow-up period (median vs. months) were observed . % in elder patients as opposed . % in younger patients.conclusions: in our study, although urinary continence recovery in elderly patients might show a short delay, rarp in elderly patients was relatively safe and yielded good oncologic results. rarp is feasible eve in elderly patients. quality in the fi rst study, community-based urologists ordering at least assays from / to / participated. clinicopathologic data, the gps and treatment were abstracted from medical records of gps patients and a clinically similar baseline group. th e proportion of men recommended and pursuing active surveillance (as) before and aft er the availability of the gps were computed. in the second prospective study, urologists at centers (academic and community) recorded tr on pre-and post-gps questionnaires, including changes in treatment intensity.results: fift een urologists completed the chart review study on men ( gps; baseline). th e relative increase in tr for as was %, ( % baseline, % gps; absolute diff erence of %). gps pts chose as more than baseline pts ( % gps; % baseline, absolute increase of %, relative increase of %). of men recommended as, % of gps and % of baseline pts chose it. in men in the prospective study, the relative increase in recommendation for as was % and absolute tr increase for as was also % ( % to %). % of tr changed post-gps and tr modality and/or intensity occurred in % of men ( decreased; increased; equivocal).conclusions: both studies, conducted with diff erent methodologies, demonstrate that use of gps provides meaningful change in tr and decisions in men with newly diagnosed pca and results in a net increase in recommendation and/or adoption of as. in the chart review study, tr changes appear to underestimate changes in actual treatment received and more gps patients than baseline patients were assigned to as supporting the clinical utility of gps in the initial assessment and management of men with low risk pca. comparison we prospectively evaluated in patients with clinically localized prostate cancer, the possible association between hce (≥ . mmol/l) and aggressive prostate cancer. pre-operative serum cholesterol levels (ch), triglycerides (tr), were prospectively assessed in men treated consecutively with radical prostatectomy from feb. to oct. . th e results were related to patient specifi c and clinico-pathologic data.results: patients with hce (n= ) had a more aggressive grade gleason score (gs) ≥ b, p< . )), a locally more advanced stage (≥pt a, p< . ), and lymph node metastasis (n+, p< . ). hce was also associated more frequent with a positive surgical resection margin (r , p< . ). in multivariate regression analysis hce is associated with a high-risk pc (hr . , % ci . to . , p < . ) -adjusted for psa, dre, age and poor biopsy score (gs ≥ ).conclusion: th e results indicate that hca is associated with high-grade and metastatic disease in men diagnosed with clinically localized pc. our fi ndings suggest that ch can be used as an additional predictive marker in therapy. conclusion: th e incidence of bs-positive tumours is low in men being staged for radical treatment except in high-risk disease. pelvic/prostate mpmri alone cannot be relied upon to exclude bone metastases in this group. hyperbaric oxygen therapy for radiation induced side-effects introduction and objective: to evaluate the effi cacy of hyperbaric oxygen (hbo) th erapy for prostate conclusions: in our japanese provincial hospital, the comparatively young patients chose a treatment according to treatment algorithm. however, according to aging, the patients tended to choose hormonal therapy regardless of algorithm. as for one of the reasons, it is thought as follows: even if the patients chose operation or radiotherapy, it may be diffi cult to visit the institutions that have such a treatment because public transport does not develop in our prefecture. nurse-led telephone follow-up for prostate cancer surveillanceturner b, tanabalan c, nargund v, pati j, wells p introduction and objective: we review the patients' experience of a nurse-led, telephone follow-up service for men with 'stable' prostate cancer, to measure satisfaction and quality. th e telephone follow-up service is based on the premise that psa measurement can be used as a surrogate for outpatient attendance. telephone follow-up service serves to reduce the number of patients attending hospital appointments. th is has led to increased clinic capacity and reduced waiting times, ensuring urgent care is available for patients who need it. a nurse-led, protocol based telephone follow-up service was set up for patients deemed to have 'stable' disease. questionnaires were sent to all patients. survey was voluntary and anonymous. we addressed a variety of aspects of the service, including time, duration and content of the telephone appointments, patients' preference for type of follow-up (telephone vs. hospital follow-up) and overall satisfaction with the service.results: response rate of %. reported high satisfaction with telephone follow-up ( % were either satisfi ed or very satisfi ed). majority of patients found the length of the conversations to be 'just right' ( %) with a lesser majority expressing that the calls were always at times convenient to them ( %) and that they were always called when they were told they would be called ( %). patients felt that the information given to them over the phone was always easy enough to understand ( %) and the majority felt that they always had the opportunity to ask questions during the conversations ( %). when asked whether they would prefer telephone follow-up or hospital follow-up, % of respondents reported that they would prefer telephone follow-up, citing convenience, time and privacy as the reasons for their preference. twenty-one percent of patients would prefer hospital follow-up, reporting ease of understanding, not liking the telephone and preference for face to face contact.conclusions: telephone follow-up relieves pressure on the outpatient department, increases capacity, reduces waiting times and brings care closer to home. patients perceive the service as a valuable addition to their care and report high levels of satisfaction with the service. prostate ' th e target sample sizes of australasian trials 'currently recruiting' ranged from to men (median= ), the majority of trials investigating medical and radiation oncological interventions. five of the trials 'currently recruiting' were recorded as single-centre studies in new south wales, victoria and queensland. of the remaining trials, % (n= ) were recorded as international, industry sponsored, multi-centre studies with australian and/ or new zealand recruitment sites.conclusion: australasian prostate cancer clinical trial activity (though likely under-recognised in this study, due to trial registration limitations) represents a relatively small fraction of international eff ort. continued investment will ensure that the talented and world-leading scientists and medical professionals across both nations can tackle the big challenges in prostate cancer through working collaboratively. assessment modifi ed laparoscopic intravesical nonrefl uxing ureteral reimplantation with psoas hitch using a submucosal tunneling introduction and objective: we aimed to study the safety and effi cacy of the cystoscopy-assisted nonrefl uxing ureteral reimplantation technique using sub-mucosal tunneling during laparoscopic ureteroneocystostomy (unc) with a psoas hitch in patients with distal ureter stricture aft er gynecologic surgery. we reviewed six female patients who underwent gynecological surgeries. all patients showed persistent postoperative distal ureter stricture or obstruction. th ese patients underwent laparoscopic nonrefl uxing unc with a psoas hitch using a submucosal tunneling technique combined with cystoscopy at our institute.results: th ey had corrective surgery at an average of . weeks aft er ureteral injury. th e short-term success was confi rmed either by voiding cystourethrography (vcu) or by diuretic isotope renal scan (mag- ) conducted months aft er the operation. none of the patients showed evidence of postoperative stricture at the reimplanted site and refl ux on either mag- renal scan or vcu. none of the patients showed major or minor complications during follow-up. it is safe and feasible to perform the laparoscopic nonrefl uxing unc with a psoas hitch using a submucosal tunneling technique combined with cystoscopy for ureteral stricture. upper ureteral injuries were more frequent in the urological surgery group than in the non-urological surgery group ( % vs. . %). complications or serious injuries were more frequent in the urological surgery group. th ere were no signifi cant diff erences in the mean durations of hospitalization and indwelling times between the groups. conclusion: th e occurrence of a ureteral injury during urological surgery is an infrequent but serious complication may occur. urologists should pay attention to the potential for ureteral injury, especially during a ureteroscopic ureterolithotomy for the treatment of an upper ureter stone. reducing the risks of trauma due to urethral catheterisation mundy a, yim i, tamini a, roberts n conclusion: isolated ureteric trauma can be managed successfully using minimally invasive endoscopic and radiological approach. a pcn initially helps in minimizing extravasation and ureteral wall edema subsequently facilitating stent placement. medium-and long- university of sydney, sydney, australia introduction and objective: urethral stricture is a common urological presentation for obstructive lower urinary tract symptoms. th e treatment of choice for a durable outcome is usually substitution urethroplasty using buccal mucosal graft . graft failure is not uncommonly encountered. we present the mediumand long-term outcomes of ventral buccal mucosal graft urethroplasty using spongio fl ap technique. a retrospective review of a single surgeons experience was reviewed for a period of years. data was collected from medical records, surgeon's notes and operation reports. inclusion criteria included reconstruction of anterior urethral stricture using bm graft positioned ventrally and graft support using spongio fl ap technique. patients who were lost to follow-up were excluded from analysis. graft patency was defi ned as having a lumen greater than fr. th is was assessed via cystoscopic examinations at , and months intervals post procedure.results: a total of male patients identifi ed with age ranging from to years and mean age of years. average length of bm graft used was . cm. total of ( %) achieved long-term successful outcome. of these ( . %) patients had successful outcomes with no further interventions, and ( . %) required gentle urethral dilatation at fi rst cystoscopy and subsequently achieved long-term patency. sixteen ( . %) of this cohort formed recurrent stricture at initial cystoscopy, and ( . %) of patients formed urethral stricture formed delayed stricture, despite the initial cystoscopic examination and urethral dilatation.conclusion: ventral buccal mucosal graft urethroplasty using spongio fl ap technique has very good short-term and long-term graft patency outcomes. outcome of paediatric kidney transplantation: single center experience nawaz g, jamil i, athar khawaja m, muhammad s, shohab d, ur rehman a, ali khan i, khan a, hussain i, akhter s introduction and objective: renal transplantation is the treatment of choice for children with end-stage renal disease (esrd) because in addition to making them off dialysis it also improves growth and development of the child. about - % of children have a lower urinary tract dysfunction due to congenital or acquired genitourinary anomaly as the etiology of esrd and they need a diversion or augmentation procedure prior to transplantation. we aim to deter-mine the outcome of paediatric renal transplant at year in term of graft survival and complications. we retrospectively reviewed the record of consecutive children underwent living related renal transplant between jan to jan . all were primary renal transplants and had living related renal donors. patient characteristics, causes of esrd and pre transplant surgical procedure were recorded. patients with lower tract abnormalities as cause of renal failure underwent reconstructive procedure prior to transplant. induction immunosuppression consisted of triple therapy with antithymocytic globulin (atg), prednisone and mycophenolate mofetil (mmf). cyclosporine was introduced when creatinine came down to > % of normal. all patients were treated as cmv positive with either acyclovir or ganciclovir and received daily dose of trimethoprim-sulfamethoxazole as prophylaxis for pneumocystis carnii pneumonia aft er transplantation. post transplant surgical and medical complication, graft and patient survival were recorded.conclusion: ureteric implantation into the bowel portion of augmented bladders appears safe in this population of patients with previously reported increased risk of ureteric complications and urinary tract infections aft er transplantation. transition of cavernous function after radical prostatectomy materials and methods: study subjects were ed patients with a history of rp (median age: ). intervals between rp and examination diff ered among patients (range: to months). we also performed doppler penile ultrasound examination using intracavernous injection of micrograms of prostaglandin e . we adopted an infusion rate of less than ml/min at mmhg of intracavernous pressure as the normal cavernous function limit for dicc.results: arterial velocity in ultrasonic examinations showed a tendency to decrease. cavernous function aft er rp clearly diff erentiated according to phospho-diesterase inhibitors (pde is) response ( figure ). in the pde is responder patient group ( cases), the rate of normal cavernous function was % at month, months, and months, but the rate increased to % at months, and % at months. a diff erent transition was seen in the pde is non-responder patient group ( cases). in this group, the rate of normal cavernous function was also % at month. however, from here, the rate increased to % at months, and then aft er this point, it decreased to % at months. sixteen -week-old sprague-dawley rats were induced diabetes by a onetime intraperitoneal injection of streptozocin ( mg/ kg). one week later, the diabetic rats were randomly divided into groups including a normal control, dm control and two uu treated group ( , and mg/kg/d). th e latter rats were fed uu by intragastric administration for weeks. aft er weeks, penile hemodynamic function was evaluated by measuring the intracavernosal pressure aft er electrostimulating cavernous nerve. we measured nitric oxide (no) and cyclic guanosine monophosphate (cgmp) activity. endothelial nitric oxide synthase (enos) and neuronal nos (nnos) protein expression was determined by western blot. masson's trichrome staining was also assessed.results: serum glucose level in dm +uu group was signifi cant lower than in that of the dm control groups. maximum intracavernosal pressure in dm control rats decreased signifi cantly compared to normal control rats and increased signifi cantly compared to untreated dm rats aft er uu supplementation. dm + uu group had signifi cantly increased no and cgmp level compared with the dm control group. decreased activity and expression enos and nnos were found in the dm groups compare with normal control group. decreased enos and nnos in diabetic rats were improved by uu administration. decreased the cavernous smooth muscle to collagen ratio was improved in dm + uu groups in the masson's trichrome staining.conclusions: uu eff ectively ameliorated erectile function in a streptozocin induced diabetic rat model of erectile dysfunction. you d , jung s , jang m , kim b , lee c , song g , choi k , shin h , suh n , kim y , ahn t , kim c the etiology and management of erectile dysfunction (ed) in patients with metabolic syndrome (ms). eighty-six patients suff ering from erectile dysfunction and metabolic syndrome were included in the study, patients were classifi ed based on iief- domain into three groups: mild ed (n= ), moderate ed (n= ) and severe ed (n= ). th ese patients were treated using upgraded regimen protocol (changing of the life style for months, on demand use of pde- inhibitors for months, chronic dosing with long acting pde- inhibitors for months and combination therapy of pde- inhibitors and intracavernosal injection for months) re-evaluation of the patients was done at the end of each stage by (iief-ef, waist circumference and laboratory investigations).results: aft er months of lifestyle modifi cation there was increase in the iief-ef but this change was not signifi cant the overall improvement was ( %), aft er on demand pde- inhibitors for months( . %) of patients with mild ed were improved, ( %) with moderate ed and ( . %) with severe ed were improved. non-improved patients in each group aft er on demand pde- inhibitors received pde- inhibitors chronic dosing for another months then re-evaluated ( . %) of patients with mild ed were improved, ( . %) with moderate ed and ( . %) with severe ed were improved, combination therapy in the form of tadalafi l mg daily and pge μg on demand were off ered to patient whom reported failure of pde- inhibitors chronic dosing patients with mild symptoms reported the maximum improvement ( %), patients with moderate symptoms reported fair improvement ( . %); however patient with severe symptoms reported no improvement at all.conclusion: pde inhibitors should be considered as the fi rst line phamaco-therapy in treatment of ed in metabolic syndrome patients. non-responders to pde inhibitors may have a benefi t from daily dosing of long acting pde- inhibitors. combination therapy of pde- inhibitors chronic dosing associated with intracavernosal injection of pge may play a role as a salvage therapy aft er failure of monotherapy. following this upgraded regimen case with ms and ed can have overall successful results in . %. comorbidity of premature ejaculation and erectile dysfunction: are they inseparable in chinese adult men?tang y, yang j, jiang x introduction and objective: premature ejaculation (pe) and erectile dysfunction (ed) are usually regarded as a symbol of incompetence. but in china for the inconsistent defi nitions of pe, some of them cannot correctly distinguish pe from ed. th erefore, to fi nd out the real relationship between pe and ed, a detailed investigation was implemented. were enrolled. all the subjects were evaluated by the face-to-face questionnaires of premature ejaculation diagnostic tool (pedt) and the international index of erectile function (iief- ). a professional urologist was invited to measure their lengths of penis and volumes of testes. all the data were analyzed by spss version . soft ware.results: a total of men aged from to years ( . ± . ) were categorized into lifelong pe (lpe) ( men), acquired premature ejaculation (ape) ( men), variable pe (vpe) ( men) and subjective pe (spe) ( men), respectively. th ere was no signifi cant diff erence among the four pe subtypes except for the ielts and the iief- . th e self-estimated ielt of spe was signifi cant longer than that of other subtypes, and the similar case could be seen in iief- . th e highest percentage was found in ape ( . %) for chronic prostatitis (cp) and in lpe ( . %) for ed.conclusion: vpe was the most common subtype, next ape, thirdly spe and the least one is lpe. consistent with the previous reports, we found that the incidence of cp in ape was the highest among all the four subtypes of pe, and cp was a signifi cant risk factor of ape but not for other subtypes. th ere has always been controversial about the relationship between pe and ed. th e results from our multinomial logistic regression analysis showed that ed was not only associated with pe, but also could be regarded as a risk factor of pe. introduction and objective: depression oft en overlapped with late-onset hypogonadism (loh) syndrome. clinically, many loh patients who have depressive symptom were treated with testosterone replacement therapy (trt). however, treatment efficacy of trt for these patients is unclear. in this study, we aimed to identify characteristics of loh patients on trt who had medical history of ongoing mental health treatment for depression syndrome. we reviewed consecutive patients who visited men's health clinic and underwent trt in our institution during june and december . prior to trt, patients received a physical examination and full hormonal evaluation including free testosterone (ft), lutenzing hormone (lh), and follicle-stimulating hormone (fsh). th e aging males' symptoms (ams) score was also evaluated. trt was conducted by mg monthly testosterone injection. effi cacy of trt was noted when diff erential of ams score between pre-and post-treatment was more than points. in the entire cohort of patients, the mean age was . ± . years and pre-trt ams score was . ± . . pre-trt ft, lh, and fsh were . ± . ng/ml, . ± . miu/ml, and . ± . miu/ml, respectively. of total patients, cases ( . %) had diagnosis of depression by psychiatrist and ongoing mental health treatment. patients with positive medical history of mental health treatment were found to be younger ( . vs. . years, p = . ), higher pre-trt ams score ( . vs. . , p < . ), lower lh ( . vs. . %, p = . ), and lower fsh ( . vs. . %, p = . ) compared to patients with negative medical history of mental health treatment. effi cacy of trt was greater in men who have mental treatment history ( . vs. . %, p = . ) based on ams improvements. while, there were no signifi cant diff erence in ft ( . vs. . ng/ml, p = . ), trt duration ( vs. days, p = . ), and trt discontinuation rate ( . vs. . %, p = . ) between two groups.conclusion: even though, loh patients who had diagnosis of depression and underwent medical treatment such as antidepressant, trt can be feasible approach for those patients. majority of those loh patients underwent mental health treatment at the same moment with trt, which may not harm treatment effi cacy of trt. the effect on blood flow rate of prostate in daily administration of mirodenafi l mg for benign prostatic hyperplasia patients: randomized paroxetine is the most eff ective ssris. in few studies, tramadol has been used to treat pe. considering the high incidence of pe in men and lack of consensus on its treatment, we decided to compare the therapeutic eff ects of tramadol, paroxetine and placebo in the treatment of primary pe. in this randomized, double-blind, placebo-controlled clinical trial, patients were randomly divided into groups. one group was treated with tramadol mg, the other group took paroxetine mg and the third group was treated with placebo. before starting treatment and aft er weeks, patients were asked to measure their average intravaginal ejaculation latency time (ielt) and fi ll the pep (premature ejaculation profi le) questionnaire. aft er collecting the data, they were recorded in spss version and were analyzed.results: patients in the groups in baseline characteristics, including mean age, ielt and pep were similar at the beginning of the study and there was no clinically signifi cant diff erence in the groups (p> . ). a total of patients completed the study period. at the end of the th week, the mean ielt and average of pep scores increased in all groups. th ese changes in tramadol group were signifi cantly higher than the paroxetine and placebo groups (p< . ). th ere were no signifi cant diff erences in terms of side eff ects between the groups. th e results showed that despite an increase in mean ielt and pep scores in all groups, the rate of improvement in tramadol group was considerably more than the other groups. th us, tramadol may be considered as an appropriate alternative therapeutic for long-life pe. the effi cacy and safety of tadalafi l mg once daily for the treatment of erectile dysfunction related to the vascular causes after robot-assisted radical prostatectomy: -year follow-updong-a university hospital, busan, south korea; jeil hospital, ulsan, south korea introduction and objective: to evaluate the effi cacy and safety of tadalafi l mg once daily use in the treatment of erectile dysfunction (ed) based on the vascular cause aft er robot-assisted radical prostatectomy (rarp). th e study retrospectively evaluated patients who underwent rarp and had a penile rehabilitation by tadalafi l mg once daily use at our medical center. th e patients were surveyed based on the abridged fi ve-item version of the international index of erectile function (iief- ) questionnaire, which was self-administered before the surgery, and at months, year and years aft er the surgery. th e patients were classifi ed into the tadalafi l group (n= ) and the non-tadalafi l group (n= ). each group was then classifi ed depending on the nerve-sparing (ns) procedure: bilateral ns and unilateral ns. additionally, patients who underwent a penile color-duplex u/s study to evaluate the cause of erectile dysfunction were also analysed.results: at months, year, and years, the total iief score of the tadalafi l group and that of the non-tadalafi l group were . ± . vs. . ± . , . ± . vs. . ± . , and . ± . vs. . ± . , respectively. statistically signifi cant improvements (p< . ) were observed in the tadalafi l group for all domains of iief- score, while in the non-tadalafi l group there was no signifi cant improvement in any of the domains at and years. fift y three patients had a penile color-duplex u/s study. arteriogenic and venogenic ed was seen in patients ( . %) and patients ( . %). fift een patients ( . %) showed unremarkable fi ndings. venogenic ed patients had little response compared to arteriogeinc ed patients by tadalafi l mg once daily use ( % vs. . %). th e overall side eff ects were hot fl ushing in . %, headache in . %, and dizziness in . %. in ed patients aft er ns ralp, a once daily dosage of tadalafi l mg was well tolerated and signifi cantly improved ef compared with the non-tadalafi l group until two years. but in the venogenic ed patients, response to a once daily dosage of tadalafi l mg was relatively limited compared to the arteriogenic ed patients. effects of long-term androgen replacement therapy on the physical and mental statuses of aging males with late-onset hypogonadism (earth): a randomized phase trial in japan introduction and objective: to determine the role of stone density and skin-to-stone distance (ssd) by non-contrast computed tomography of the kidneys, ureters and bladder (ct-kub) in predicting the success of extracorporeal shock wave lithotripsy (eswl). we evaluated patients who received eswl for renal and upper ureteric calculi measuring - mm, over a month period. mean stone density in hounsfi eld units (hu) and mean ssd in millimeters (mm) was determined on pre-treatment ct-kub at the ct workstation. eswl was successful if post-treatment residual stone fragments were ≤ mm.results: e wl success was observed in . % of the patients. mean stone densities were ± and ± hu in e wl successful and failure groups, respectively; this was statistically signifi cant (p < . , student's t-test). mean ssd were . ± . and . ± . cm in eswl successful and failure groups, respectively, this was not statistically signifi cant.conclusions: th is study shows that stone density can help in predicting the out-come of eswl. we propose that stone densities < hu are highly likely to result in successful eswl. conversely, stone densities > hu are less likely to do . th is should be accounted for when considering eswl. assessment th is prospective study was conducted upon children with mean age . ± . years. patients underwent retrograde intrarenal surgery (rirs) under general anesthesia as monotherapy. th e procedure was initially started by the semi-rigid ureteroscope (storz . f) and holmium laser and was completed by the fl exible ureterorenoscope (fl ex x ) for other parts of the stone which were not accessible by the semi-rigid ureteroscope. ureteral access sheath was not used and only hydrodilation was performed. patients were evaluated preoperatively by ultrasound and plain x-ray of the abdomen and pelvis. pre-intervention sterilization of urine was performed in all patients using culture guided antibiotics. follow-up lasted for months.results: stone-free rate aft er a single session treatment was % and % aft er second session. mean operative time was . ± . minutes. th e mean fl uoroscopy exposure time was . ± . seconds. mean hospital stay was . ± . days. all patients had jj stent inserted. no major complications (clavien iii-v) occurred. none of the children received blood transfusion. th ree patients needed a second session of rirs, patient required a pnl session.conclusions: retrograde intra renal surgery using combined semi-rigid and fl exible ureteroscope off ers eff ective and safe option for treatment of medium sized renal stones children with comparable results to shock wave lithotripsy (swl) and percutaneous nephrolithotomy (pnl). introduction and objective: calcium stones are associated with osteoporosis and manifested mainly by elevated fasting urinary calcium/creatinine ratio. th e objective of this study is to demonstrate the presence of abnormal metabolism of calcium and calciuria in women with osteoporotic fracture with no previous-ly known renal lithiasis compared to women without osteoporosis and without renal lithiasis. eighty-seven women were included in the study and divided into two groups: group : postmenopausal women with osteoporotic fracture and without renal lithiasis; group : postmenopausal women without osteoporosis and without history of renal lithiasis. th e following parameters of phospho-calcium metabolism were analyzed: calciuria h, oxaluria h, uricosuria h and citraturia h. th e presence of hypercalciuria, hyperoxaluria, hyperuricosuria and hypocitraturia was compared between the two groups. statistical signifi cance was determined as p≤ . . results: th e mean age was . ± . years in group and . ± . years in group (p = . ). women in group had higher levels of serum alkaline phosphatise (p< . ) and fasting urinary calcium/ creatinine ratio (p< . ) than women in group . th e percentage of women with hypercalciuria in group ( %) was higher compared to women in group ( . %) and statistically signifi cant (p = . ). th ere were no statistically signifi cant diff erences in the percentage of hyperoxaluria, hyperuricosuria and hypocitraturia between the two groups. th is paper has the limitations of cross sectional study in a unique center and with a low number of patients. dept. of urology, ulster hospital, dundonald, uk introduction and objective: bladder stones are more common found in children from developing countries. open cystolithotomy or transurethral cystolithalopaxy are the traditional treatment but a percutaneous approach has been advocated. we present our experience with percutaneous cystolithotomy in children with bladder stones without any ultrasonic or fl uoroscopic guidance. from april to october , a total of children ( boys and girls) with a mean (range) age of . ( - . ) years underwent percutaneous cystolithotripsy (pccl). th e mean (range) stone diameter was . ( . - ) cm. one hundred thirty-eight children ( %) had a solitary stone while nine ( %) had more than one stone. th e main component of the stones were calcium oxalate in patients ( . %).results: all children were stone-free aft er one pccl; no recurrent stones developed. th e mean (range) pccl procedure time was . ( to ) min and intraoperative blood loss was scant. perioperative complications were few. th e mean (range) hospital stay was . ( - ) days.conclusions: blind access pccl (without any ultrasonic or fl uoroscopic guidance) is a facile and safe approach for removing stones in the pediatric bladder stones. advantages include the lack of ionizing radiation, no need for opacifi cation by iodine contrast media and low relative cost. we recommend this minimally invasive technique for management of large bladder stones (larger than cm) in children. to our knowledge, this is the largest single center series re-ported on percutaneous cystolithotripsy of endemic bladder stones in children. retrograde intrarenal surgery (rirs) in an unusual kidney ( ), polycystic kidney ( )]; who underwent rirs for stone management was evaluated. stone size was less than mm in all the cases. bleeding being the commonest complication, hemoglobin drop was measured to fi nd out the blood loss. all patients were assessed by x-ray and usg on the fi rst postoperative day and month follow-up. th e other parameter of focus was operative time, hospital stay, stone free rate and the auxiliary procedure. th e auxiliary procedure was divided as (staged, follow-up ( month) or other-pcnl/swl) so that stone free was the main target for the patients. conclusion: urolithiasis occurs in an abnormal kidney, indeed challenging, but rirs can also be performed successfully. proper handling of instrument can increase the longevity of the instrument for cost eff ectiveness. although complete stone clearance cannot be achieved, but meritorious achievement is less morbidity, early recovery, minimal bleeding with less complication. th us, rirs can be performed effi ciently, effi caciously and successfully in an unusual kidney with prior exposure of rirs. value of intraoperative ultrasound in decreasing of the risk of residual radiolucent stone post-pcnl al shareef j, aboelmagd m introduction and objective: hemorrhage is the most concerning complication aft er tubeless percutaneous nephrolithotomy (pcnl). we compressed the access tract of the kidney with oxidized regenerated cellulose (surgicele) aft er pcnl to facilitate homeostasis for tubeless pcnl. since april to september , pcnl was performed at our hospital. all patients received one stage procedure with metal dilator. aft er the end of stone extraction, the access tract was cauterized and an f foley catheter was inserted to the renal pelvis through the working sheath then infl ated and gently retracted. th e working sheath was withdrawn to the renal capsule and the access tract of the renal parenchyma was packed with surgicele and compressed with small sized dilators through the working sheath for minutes. a bloodless tract usually could be obtained in nearly every patient and all patients underwent tubeless modifi cation. th e results of these patients were analyzed with retrospective chart review.results: th e age of these patients ranged from to (mean . ) years old. th e average stone size was . ( . - . ) cm and the average operation time was . ( - ) minutes. th e target stones had been removed in all patients and the overall stone free rate was . %. th e postoperative blood transfusion rate was . % with no patient underwent angiographic intervention or other management for severe hemorrhage. postoperative fever was noted in . % patients and sepsis was noted in . % patients. th is study was designed to evaluate the adverse eff ects of swl on the metal devices for spine fi xation and the hemoclips for hemostasis. a total of cases who underwent swl for treatment of upper ureteral and renal stones were investigated. th eir ages were from ~ years (mean . ± . ). male patient was one and female patients were . th e piezolith (wolf, germany) was used as the lithotripter. th e metal devices were hemoclips for cholecystectomy in one, and pedicle screw in fi ve patients and bone cement (polymethylmethacrylate) in one patient for spinal fi xation through l to s . th e locations of the stones were the kidneys in and the upper ureter in patients and their sizes were from . cm to . cm (mean, . ± . ) . th e numbers of the swl were . ~ . times (median, ) . th e distances between the stones and metal devices were . ~ . cm (mean, . ± . ). th ey were followed-up for . ~ . months ( . ± . ). th e complications were investigated in terms of pain, fever, damage of the devices (change of morphology and location in simple x-ray fi lm and their function). no patient showed fever and pain in sites of the devices requiring medication, injection or other management during or aft er swl. one patient was admitted for acute colick fl ank pain with tenderness in costovertebral angle caused by acute ureteral obstruction by a crumbled small piece of the stone. th ere was no complication concerning with the eff ect of the swl on metal devices. even though swl is one of the safe treatment modality in various clinical fi elds, it can't be said that swl is always safe without complication. however, it can be said that it would be safe when it being done following the instruction. a prospective study to identify risk factors of pleural injury during percutaneous nephrolithotomy a total of patients with renal/upper ureteric stones, undergoing pcnl between january and june were evaluated for pleural injury. an erect chest x-ray antero-posterior view on inspiration was done within -hours of pcnl. th e patients were divided into groups a and b depending on whether they developed or did not develop pleural injury. patient-, stone-, renal-and procedure-related factors were compared between the two groups. patients with any known disease of lungs or pleura, patients undergoing simultaneous bilateral pcnl, relook nephroscopy, concomitant other procedures such as endo-pyelotomy or retrograde ureterorenoscopy were excluded from study. tract dilatation up to -f was done using alken metal dilators and an amplatz sheath was placed into system. nephroscopy was done with rigid nephroscope and stones were fragmented with pneumatic lithoclast.results: pleural complications occurred in patients ( %). out of patients, had supra-costal puncture and ( . %) developed pleural injury; patients had infra-costal puncture and pleural injury occurred in ( % on multivariate analysis, only low bmi and mean age < -years was associated with higher risk of pleural injury. th e limitation is the small number of patients (as pleural injury is not common a very large number is needed to show signifi cance).conclusions: higher incidence of pleural injury was noted in patients with low bmi and younger age. large multicenter study can provide a true picture. flexible and rigid ureteroscopy in th e success rate was defi ned as radiopacities less than mm on plain fi lm at one month follow-up aft er the fl exible ureteronoscopic procedure. our tips included: tip , moving technique, refers to move the lower pole stones to the upper pole or middle pole depending on the convenient site for fragmenting the stones with the escape basket. if the stones were large or the lower pole orifi ce is narrow, we fragmented the stones into two or more pieces, trapped and moved the stones into the convenient pole. tip , holding technique, refers to hold the stones in the renal pelvis and insert a laser fi ber through the escape to fragment the stones. tip , sheath technique, refers to extract the large stones and pull the stones to the sheath distal side, the stone was too large to pull out, a laser fi ber was inserted though the escape, fragmented the stones. all the videos were recorded.results: overall success rate was . %. th e success rate in the renal pelvis stone, upper pole, middle pole and lower pole was %, . %, . %, . % respectively. th e operating time was . minutes on the average. th ree patients had fever over °c aft er the procedures. no urosepsis occurred.conclusion: our tips are feasible in the treatment of kidney stones with fl exible ureteronoscopy. satisfactory success rate, shortening operating time, less fl exible ureteronoscopy consuming and less complication were obtained in the procedures of fl exible ureteronoscopy with escape. ureteroscopic introduction and objective: patients with underlying diseases, especially in old-aged, the urinary tract obstruction with the ureter stone would progress to the severe condition like renal failure or sepsis. prompt urinary diversion like percutaneous nephrostomy or removal of the stone via ureteroscope is necessary for these patients. however, most of them have poor general conditions to endure regional or general an-esthesia. so, we tried to implement the ureteroscopic removal of stone (urs) without anesthesia for the patients with ureter stone who were in septic conditions or severe urinary tract infections (uti). fift een patients ( males and females) included this study and all of them had serious problems like sepsis, heart problems or lung problems which were diffi cult to endure anesthesia. most of them were inserted pre-operative percutaneous nephrostomy catheter (pcn) due to impending septic shock. all of the stones were impacted in the ureter and urs were successfully performed with painkiller like pethidine mg iv. success rate of stone removal, pain perception during operation using a visual analog pain scale were done. results: th e mean age of the patients was . (± . ). th e position of the stones was as follows; upper ureter, mid-ureter and lower ureter stones. and there was no patient that had to stop the operation because of intolerable pain. th e mean of vas (visual analogue pain scale) was . (± . ). overall success rate was %. however, % of cases were unable to fi nd the impacted calculi but stone debris and blood clots. th e general condition of the patients except one was improved quickly aft er operation and discharged aft er . (± . ) days.conclusion: most obstructive uropathy due to calculi was in serious conditions to need immediate procedures and urs were safely and successfully performed under intravenous analgesics. in some of female patients, urs is well-tolerated even without analgesics. prompt urs procedure with intravenous analgesics can recover these conditions with minimal morbidity. geavlete p, georgescu d, multescu r, geavlete b introduction and objective: percutaneous nephrolithotomy (pcnl) is nowadays a widely practiced procedure. despite the good stone-free rates, it still has a specifi c morbidity. our goal was to describe the complications of this method on a signifi cant series of patients. between january and january , patients (age between and years) underwent pcnl ( procedures). we used f rigid nephroscopes and f fl exible ones ( procedures). th e mean follow-up period was months (range to months).results: intraoperative incidents were encountered during procedures ( . %): losing the percutaneous traject ( cases), poor visibility due to bleeding and imposing the termination of the procedure ( cases) and descendant stone fragments' migration imposing antegrade ureteroscopic removal ( cases). th e overall complications' rate was % ( cases): signifi cant bleeding requiring blood transfusions ( cases), emobolisation ( cases) nephrectomy ( cases) or open surgical hemostasis ( cases), sepsis ( cases), fever ( cases), pyelocaliceal perforations ( cases), hemoperitoneum ( case), persistent lumbar uri-nary fi stulae requiring retrograde jj ureteral stenting ( cases) and extra-renal stone fragments migration ( cases). however, the majority of these complications were minor. th e mortality rate related to pcnl procedures was %.conclusion: according to our experience, pcnl is a safe and eff ective technique. most of the intraoperative incidents or complications are minor and easy to solve. however, an adequate training is imperative in order to reduce the associated morbidity. is spinal anesthesia adequate for percutaneous nephrolithotomy? introduction and objective: to evaluate the adequacy of spinal anesthesia in terms of patient and surgeon satisfaction and convenience during percutaneous nephrolithotomy. patients who were candidates for percutaneous nephrolithotomy and operated by two endourology fellows during july -september were enrolled. spinal anesthesia was performed using an injection of . mg/kg bupivacaine . % in the intrathecal space; no opium (fentanyl) agent was used. all procedures were performed with the patient in the prone position. access was achieved by fl uoroscopic guidance, and the tract was dilated using a single-stage technique. anestheisa duration was defi ned from injection of anesthetic medication to fi xation of nephrostomy tube. operation duration was defi ned from start of cystoscopy to fi xation of nephrostomy tube. patient pain and satisfaction during operation and surgeon satisfaction was measured by an ordinal likert-type scale and collected by an examiner blinded to the study objectives.results: a total of patients (mean±sd age, . ± . years; male) were enrolled during the study period. th e mean±sd of anesthesia and operation duration were . ± . and . ± . minutes respectively. severe pain causing signifi cant discomfort to the patient and surgeon was observed in patients ( %). in three patients the operation was prematurely terminated because of excessive pain and/ or agitation of the patient. mild-moderate pain was observed in eight patients ( %). vomiting and headache was observed in another two patients. the african : our experience of stenting ureters in outpatients without screening or ga introduction and objective: to review ureteric catheters/dj stents placed under local anaesthetic, with antibiotic coverage, without the use of screening, at groote schuur hospital (gsh) over the last years. a prospectively collected database exists from july until present. all patients signed informed consent and received pre-procedural oral antibiotics. a post-procedural abdominal kub radiograph was obtained to ensure correct placement. demographic data and variables (stent/catheter, indication, side, success/failure -including reasons for failure) were collected. patients were asked to subjectively rate the level of pain at the end of the procedure.th e data has been collected and tabulated into an ex-cel® worksheet.results: a total of procedures (average . per year) were performed with age range from to years (average: . years). th e average time taken was minutes (median: minutes). th e shortest procedure recorded was minutes, and longest was minutes (with a failure). th e failure rate totals . % and further inspection shows that . % of failures were with bilateral stents, . % right sided and . % left sided. stated diff erently, % ( / ) of bilateral stents failed, . % ( / ) of right sided stents failed, and . % ( / ) left sided stents failed. th ere was a success rate of . % with stenting under local anaesthetic. th e average subjective pain score was . , which is tolerable. sivalingam et al ( , urology : - ) showed the average cost for stenting under general anaesthetic was almost times more expensive than under local. th eir local group had a failure rate of . %, which was lower than our . %, but we had a larger group ( in years vs. in years).conclusion: flexible cystoscopy and stenting under local anaesthetic without screening is useful and feasible, with minimal morbidity, discomfort and failures. it can be practiced as a cost eff ective, offi ce-based procedure and is suitable for the third world environment. introduction and objective: urolithiasis is an ancient disease with global distribution and is an important health problem all over the world. th ere are diff erent results for stone clearance rate in diff erent renal and ureteric locations aft er eswl. here we share our experience of the comparison of stone free rates and complications in diff erent renal locations. a retrospective study in which we included adults (age above years old) who underwent eswl from january to december . eswl was done by standard technique. we used modulith sl x lithotripter th generation storz medical. we followed patients for to months aft er last eswl session done. stone free status was defi ned as residual stone not more than mm in size. we reviewed data charts of patients for diff erent variables mentioned in results. introduction and objective: tubeless percutaneous nephrolithotomy (pcnl) for staghorn calculi has been reported to be safe and eff ective in select patients. although outpatient pcnl has been recently been shown to be safe and eff ective in a series of patients, it requires further study before urologists embrace same day discharge following pcnl. th e objective of this study is to report our early experience in treating staghorn calculi with pcnl on a completely outpatient basis, assessing its safety and effi cacy. a review of all outpatient tubeless pcnl cases between march and may at two canadian centres was performed, including collection of preoperative, intraoperative and postoperative data. strict preoperative, intraoperative and postoperative criteria were used in the selection of candidates for outpatient pcnl: no intraoperative complications including signifi cant bleeding or collecting system perforation; postoperative hemodynamic stability; adequate pain control; reliable patient with supportive family.results: fift y patients underwent ambulatory pcnl during the study period. staghorn calculi were treated in patients including cases of bilateral staghorn calculi, resulting in a total of staghorn renal units treated by ambulatory pcnl. all patients were discharged home uneventfully - hours postoperatively. th ere were no major postoperative complications, emergency room visits, hospital readmissions or deaths. th e stone-free rate was %, with of the renal units being stone-free at follow-up.conclusion: th is small series represents the largest series of ambulatory pcnl for staghorn calculi to date. in very carefully selected patients, pcnl for staghorn calculi on a completely outpatient basis appears safe and may be feasible. further research on ambulatory pcnl for staghorn calculi is required prior to widespread adoption by urologists. introduction and objective: th e most diffi cult aspect of percutaneous nephrolithotomy (pcnl) is frequently the renal puncture. most are performed under fl uoroscopic control. parallax, the assessment of the displacement of an object when viewed along two lines of sight, is the concept which allows the surgeon to gauge the d relationship of the needle to the kidney from a d fl uoroscopic image. whilst most urologists appreciate successful access correlates with both kidney and stone images moving in unison on rotation of the c arm (or "reverse parallax"), confusion oft en arises with unsuccessful attempts in relating how to amend the puncture with the radiological fi ndings. we create a model to describe visual observation of parallax. by way of a short video we outline how it can be implemented seamlessly into routine pcnl.results: visualization of the theory followed by its application in theatre clearly demonstrates a failsafe technique to allow operators to reliably detect when their puncture needle is deep or superfi cial to the stone.conclusions: parallax, as an adjunct to routine fl uoroscopy during pcnl, allows the operating urologist to rapidly gauge depth of needle in relation to the collecting system in diffi cult access scenarios. familiarity with this technique is important to minimize radiation exposure, ensure satisfactory access to the collecting system and improve operating times. the signifi cance of non-enhanced compute tomography for renal colic has been overestimated in absence of pyuria kim t , ahn s , kang j , kim j , myung s , moon y , kim k , chang i introduction and objective: th e study was undertaken to compare clinical utility in patients undergoing non-enhanced computed tomography (nect) and intravenous urography (ivu) in patient with classic symptoms of renal colic without evidence of urine infection and to determine the clinical importance. th is was a retrospective observational analysis of all adult patients between and . all nect and ivu were reviewed and categorized as the cause of symptoms. non-urolithiasis cause were further categorized as "acutely important", "follow-up recommended", and "other unimportant cause". full record review blinding to imaging fi nding was underwent including demographics, diagnosis, and management. we compared stone characteristics on imaging study, and demographic, exact diagnosis, and management methods between nect and ivu groups.results: a total of , patients were available inclusion criteria and ( . %) patients were underwent ivu and patients were nect. th e incidence of nect was . % at , but . % at . nect group was older ( . ± . vs. . ± . years old, p< . ), less hematuria in urine analysis ( . vs. . %, p< . ) and more admit ( . vs. . %, p< . ) than ivu group. urinary stones were detected ( . %) patients. nect group showed higher proportion of renal stone, mid ureteral stone and multiple stones ( . vs. . %, p< . , . vs. . %, p< . , . vs. . %, p< . , respectively), and smaller stone ( . ± . vs. . ± . mm, p< . ), and more radiolucent stone ( . vs. . %, p< . ) comparing to ivu group. th e incidence of urolithiasis more than mm were no diff erence between nect and ivu groups ( . vs. . %, p= . on radiologic fi nding, and . vs. . %, p= . on full chart record). moreover, the incidence of "acutely important" among non-urolithiasis cause was similar between nect and ivu groups on full record review ( . vs. . %, p= . ) . th e incidence of the active management including surgery and extracorporal shock wave therapy (eswl) were not diff erence between nect and ivu group ( . vs. . %, p= . ).conclusions: nect is a rapid and accurate diagnosis test for suspected renal colic, and nowadays almost renal colic patients in our hospital underwent nect in ed. however, it did not show better advantage for the detection of clinically signifi cant urolithiasis and acutely signifi cant cause of renal colic in patient with renal colic and absence of pyuria. from january to july we reviewed the scrotal ultrasound images of all patients diagnosed with leydig cell tumor and treated with conservative surgery (group a). we considered only patients that were fi rst diagnosed at one of the participating centers. we create a random homogenous control group of patients (group b), in term of age and presentation, diff erent from the group a just for the defi nitive malignant histology. all the images were collected and we analyzed ultrasound features of the lesions classifi ed in terms of length, us lesion homogeneity, shape, presence of hypervascularization. th e collected data were analysed by an online regression (student's t-test, chi-square test, and logistic regression analysis).results: th irty fi ve patients with leydig cell tumor underwent conservative surgery at our centers. a random group b of patients was also considered. pa-tient mean age was . years (range to ) for the fi rst group and . years for the second one (range to ). patients presented either with a palpable testicular nodule ( patients group a, . % - patients . % group b) or a nodule diagnosed by ultrasound ( patients group a, . % - patients . % group b). mean ultrasound size was . cm and . cm for the two groups respectively (range . to . cm and . to cm). both groups had hypervascularization of the lesions with no signifi cant diff erences. patients presenting with lct (group a) had an homogenous ultrasound intralesional aspect and the shape is defi ned with an elliptic or spheroid mold while patients from group b had dis-homogenous intralesional aspect and non-defi ned margins (p> . ).conclusion: although most focal lesions will be malignant and require an orchiectomy, recognition of the benign entity may be challenging. in a small lesion mainly not palpable the presence of a well-defi ned shape with an homogenous intralesional ultrasound aspect do correlate with a lct. adult testicular pure yolk-sac tumor the association of torsion with testicular cancer: a retrospective study introduction and objective: testicular torsion is a medical emergency that usually requires surgical exploration of scrotum to allow reperfusion of the aff ected testis. nonetheless, such surgeries can be frequently resulted in orchiectomy due to tissue ischemia and necrosis. however, testicular malignancy has been anecdotally reported with the association of torsion in the surgical specimens and the literature remains scant on the association of torsion with testicular tumors. th is retrospective study was set to explore the association of torsion with testicular cancer in cases of testicular torsion undergoing orchiectomy during scrotal exploration. a chart review was performed for patients who admitted to our clinic and had a diagnosis of testicular torsion between january and february . data of patients' characteristics, the laterality of the torsion, time and type of intervention and pathological examination were recorded. results: overall, patients with a diagnosis of testicular torsion were identifi ed. th e mean age was . years (ranges from to years). all the patients had unilateral intravaginal testicular torsion aff ecting the left side in cases ( . %) and on the right side in cases ( . %). manual detorsion was successful in patients ( . %) all of whom underwent bilateral testicular fi xation surgery within hours via scrotal incision. twenty-six ( . %) patients underwent emergency surgery with a testicular detorsion and fi xation surgery in ( . %) cases (bilaterally in and right-sided in ) and orchiectomy in ( . %) cases ( in right side and in left side). th e type of incision was scrotal in cases, inguinal in cases and unspecifi ed in surgeries. pathological examination of specimens revealed ischemia and necrosis in cases, while patients underwent testicular removal via inguinal incision had malignancy including seminoma and malign mixed germ cell tumor.conclusion: our retrospective study, as the largest case series in the current literature, showed the association of intravaginal torsion with testicular cancer to be . %. further high-level evidences are needed to establish the optimal incision type in testicular torsion cases with surgical exploration to avoid scrotal violation resulted from suboptimal approaches. wong l , , dickson b , catton c , yap s , , alkasab t , van der kwast t , hamilton r , jewett m st vincent 's hospital, melbourne, australia; princess margaret hospital, toronto, canada; university of california davis, davis, usa introduction and objective: paratesticular sarcoma (pts) is an uncommon disease and the literature is mostly confi ned to small case series with short follow-up. herein we present an update on our institution's experience in the management of patients with pts. fift y-one men with pts at princess margaret cancer center, between and were identifi ed from retrospective chart review. important relevant clinical pathological variables were collected with study endpoints being local recurrence, metastasis and overall survival. univariate analysis of variables associated with survival end points was performed with cox proportional hazards regression.results: median follow-up of our cohort was . years (iqr . - . ) with a median overall survival of . years. at presentation . % (n= ) of men had localized disease. interval completion hemiscrotectomy (performed aft er initial unplanned diagnostic surgery) was done in men, in which % (n= ) had residual disease present. local recurrence (lr) occurred in patients ( . %). median time from diagnosis to lr was months. univariate analysis showed presence of positive margins at diagnostic surgery (hr . , p= . ) and upfront/ completion hemiscrotectomy (hr . , p= . ) to be signifi cant variables. at last follow-up, / men ( . %) with lr were alive and disease free, developed metastatic disease with pts-related mortalities, and deceased of other cancer type. metastasis was present in men ( . %), with median time to metastasis mo, and median to from metastasis to death . mo. at last follow-up, . % (n= ) of the patients were deceased with cases attributable to pts. on univariate analysis, there were no significant variables for metastatic disease, and age (hr . , ci . - . , p= . ) and non-localized disease at presentation (hr . , p= . ) were signifi cant for overall survival.conclusion: in our cohort of pts patients with median years follow-up, aggressive treatment of local recurrence ( . %) resulted in good disease free survival for of men. completion hemiscrotectomy, particularly for positive margin disease, may decrease local recurrence. a rare case of testicular metastasis from primary lung adenocarcinoma: case report and ten-year review of testicular pathology at a single institution demkiw s , jackett l , goad j , wong l introduction and objective: health care websites provide a valuable resource of health information to online consumers, especially patients. offi cial surgical and medical society websites should be a reliable fi rst point of contact. th e primary aim of this study was to quantitatively assess medical and surgical society websites for content and highlight the essential features required for a high-quality, user-friendly society website. twenty specialty association websites from each of the regions, australia, uk, canada, europe, and the usa were selected for a total of websites. medical and surgical specialities were consistent across each region. each website was systematically and critically analysed for content and usability.results: th e average points scored per website was . out of . of the total (n= ) websites, scored at least out of points and scored out of . as well, % ( . / ) of the websites had an infor-mation tab for patients on their respective homepages while % ( . / ) had download access to patient information. a minority of the websites included different forms of multimedia such as pictures and diagrams ( . / , %) and videos ( . / , %). we found that most society websites did not meet an adequate standard for delivery of information. half of the websites were not patient accessible, with the primary focus being for health professionals. as well, most required logins for information access. specialty health care societies should create patient-friendly websites that would be benefi cial to all online consumers. application materials and methods: students were selected by sampling in pbl group (n = ) and pbl-ebm group (n = ), and the two groups received clinical teaching of urology by pbl and pbl-ebm model respectively. at the end of the study, each student received objective and subjective evaluation.results: th ere was no signifi cant diff erence in results of the baseline on evidence-based medicine between two groups (p> . ), but the percentage of high-recommended-level research evidence obtained by the students in the pbl-ebm group was signifi cantly higher than that in pbl group (p< . ). and questionnaire showed more students in pbl-ebm group believed that this teaching model improved their ability of comprehensive analysis and application of medical evidence, and developed their skills in solving problem and obtaining information on various subjects (p< . ).conclusions: th e model of problem-based learning combined with evidence-based medicine is feasible and eff ective in clinical teaching of urology and optimize the outcomes from pbl education. by the pbl-ebm model teaching, students improve the ability to advantage in managing evidence from medical studies, analyzing and solving problem, obtaining and applying medical information. incidence (dvt) or pulmonary embolism (pe), is recognized as one of the most serious complications of surgery. in urologic surgery, this has not been well reported thus the objective of this study is to access the risk factors for the development of vte among patients undergoing major pelvic surgery for prostate and bladder cancer in an australian tertiary referral center. consecutive patients undergoing major pelvic uro-oncologic surgery, namely radical cystectomy and radical prostatectomy over a fi ve-year period ( - ) were identifi ed. patient variables, types of surgery, types of thromboprophylaxis (pharmacological and/or mechanical) used in this patient cohort were collected for analyses as predictive factors.results: an overall incidence of vte was . %. patients undergoing radical cystectomy were more likely to suff er a vte event compared to patients having radical prostatectomy. in this cohort, the risk factors for vte include, prolonged operative time of greater than hours, lymph node dissection (lnd) and patients requiring blood transfusions.conclusion: patient undergoing major pelvic uro-oncologic surgery have a % risk of developing vte. risk factors identifi ed in this study should be used to guide the use of early and prolonged thromboprophylaxis. optimal trial of void after idc insertion for pelvic surgery th am c , ho p introduction and objective: in , we pioneered the fi rst international twitter-based journal club (#urojc) to discuss urology articles on a monthly basis with diverse global participation. since that time, this model of an international twitter-based journal club has been adopted by several other medical specialties including general surgery, respiratory medicine and nephrology. th e objective of this study is to examine the development of the urology journal club into an innovative and thriving forum for exchange of ideas, information and opinions since its conception two years ago. monthly twitter analyses such as number of users, tweets and impressions for the journal club were obtained via a third-party service called symplur using the hashtag #urojc. qualitative analysis was also performed of each individual tweet to assess for relevance to the discussion. comparisons were made between data from the fi rst and second year of operation of the journal club, including the number and geographic location of participants, as well as the quantity and quality of tweets.results: see table for summary statistics. th e total number of unique users of #urojc almost doubled from year one to year two. th e mean number of total participants increased by seven per month, and mean number of total countries represented increased by three per month. while the number of tweets per month also increased from year one to year two, the proportion of content-relevant tweets remained stably high at approximately %. meanwhile, there was a greater degree of participation from authors of the study being discussed over time. journal club continues to draw robust participation from a global audience, and serves as a benchmark for twitter-based journal clubs in other specialties. th e majority of tweets are relevant to the content of the article, providing a novel forum to discuss new research fi ndings with a global audience. prognostic impact of perinephric fat stranding on computed tomography in ureteral urothelial carcinoma introduction and objective: ureteral urothelial carcinoma causes gradual ureteral obstruction. perinephric fat stranding is defi ned as linear areas of soft tissue attenuation in the perinephric space, which can result from any acute process or injury to the kidney. we analyzed the prognostic impact of perinephric fat standing as well as secondary signs of upper urinary obstruction on the oncologic outcomes of patients with ureteral urothleial carcinoma. a total of patients who were evaluated by abdominal-pelvic computed tomography (ct) preoperatively and were diagnosed with ureteral urothelial carcinoma aft er nephroureterectomy conducted between january and december were enrolled in this retrospective study. we analyzed the association between oncologic outcomes and clinical-pathologic fi ndings, including secondary signs of upper urinary obstruction on preoperative ct such as hydronephrosis grade, perinephric fat stranding, renal enlargement, kidney density diff erence, renal cortical thinning, periureteral fat stranding.results: preoperatively patients ( . %) had perinephric fat stranding on preoperative ct. multivariate analysis showed that perinephric fat stranding, higher pt stage (≥ t ), lymph node involvement of cancer, and positive surgical margin were independent prognostic factors of cancer-specifi c survival (p = . , p = . , p < . and p = . , respec-tively). and perinephric fat stranding, higher pt stage (≥ t ), lymphovascular invasion, and lymph node involvement of cancer were identifi ed as independent prognostic factors of recurrence-free survival in ureteral urothelial carcinoma (p = . , p = . , p = . and p = . , respectively).conclusion: perinephric fat stranding on preoperative ct in ureteral urothelial carcinoma was found to be an independent prognostic factor of disease recurrence and cancer-specifi c mortality. our fi ndings indicate that immediate radical surgery and adjuvant therapy should be considered in patients with perinephric fat stranding preoperatively. lower increased urinary tract malignancy in end-stage renal disease (esrd) has been reported. however, little is known in chronic kidney disease (ckd). th is study is designed to explore the association between ckd and upper urinary tract urothelial carcinoma (uut-uc). health insurance database, we included ckd patients between january and december . th e non-ckd controls were selected with the ratio : and frequency matched with gender, age group and index date. chi-square test and t-test were used to inspect sociodemographic information and comorbidities. logistic regression analysis was used to calculate hazard ratio (hr) and % confi dence interval (ci). a year-old man with a strong family history of various cancers presented with haematuria and was subsequently found to have a mass in the right pelviureteric junction suggestive of urothelial carcinoma. work-up confi rmed the diagnosis without evidence of metastatic disease and the patient went on to have an open transperitoneal nephroureterectomy. laparoscopic approach was initially attempted but abandoned due to dense adhesions thought secondary to previous open bowel resection for colorectal cancer. a fl ank incision was used; there were no specifi c operative complications and the specimen was easily retrieved without manipulation or rupture. post-operative recovery was unremarkable and histological analysis of the tumour revealed a non-invasive high-grade papillary urothelial carcinoma at the right pelviureteric junction with clear resection margins. approximately months post-operatively the patient re-presented with a rapidly enlarging mass at the fl ank incision. imaging demonstrated a circumscribed hypodense mass within the muscle layers at the site of the scar and biopsy revealed poorly diff erentiated carcinoma. surgery to excise the mass was subsequently performed and immunohistochemical analysis revealed a lack of staining for msh .results: abdominal wall metastasis following open nephroureterectomy for upper tract urothelial carcinoma is rare, with only one case reported previously. given patient's previous history of colorectal cancer, strong family history and immunohistochemical fi ndings are highly suggestive of lynch syndrome. incisional site tumour recurrence following surgery for urological malignancy is a very rare complication, with only a handful of case reports existing, mostly relating to port-site metastasis following laparoscopic surgery. wound recurrence following open surgery is an extremely uncommon but recognised event, more frequent in certain gynaecological and general surgical malignancies. ls involves inherited defects in the dna mismatch repair system, resulting in predisposition to a number of malignancies. urologists should consider the possibility of lynch syndrome in any patient with de-novo upper tract urothelial carcinoma, and strongly recommend genetic testing where patients meet the amsterdam ii criteria or are diagnosed under the age of . prognostic ) developed recurrent bladder cancer within years aft er nephroureterectomy, and the median interval between surgery and intravesical recurrence was . months (range to months). multifocal tumors, native aristolochic acid nephropathy and distal ureter invasion were determined as risk factors for intravesical recurrence by univariate analysis. however, by multivariate analyses, multifocality (hazard ratio = . , % ci = . - . , p = . ) and native aristolochic acid nephropathy (hazard ratio = . , % ci = . - . , p = . ) were identifi ed as independent predictors for the development of recurrent bladder cancer aft er surgery for uut-uc in renal transplant recipients.conclusions: th e incidence of intravesical recurrence aft er laparoscopic nephroureterectomy for uut-uc in renal transplant recipients is high, and most subsequent bladder cancers recur within years aft er surgery. tumor multifocality and native aristolochic acid nephropathy are signifi cant independent risk factors in developing initial intravesical recurrence aft er laparoscopic surgery for primary upper urinary tract urothelial carcinoma aft er renal transplantation.introduction and objective: transient urinary incontinence may occur in up to % of patients aft er holmium laser enucleation of the prostate (holep). however, there are few published data concerning the factors associated with de novo urinary incontinence (ui). th e aim of this study was to investigate the associated factors of de novo ui aft er holep. our study included patients who underwent holep. enrolled patients were divided into two groups according to the presence of ui. independent t test was used to compare between two groups. logistic regression was performed to analyze a correlation between de novo ui and other factors such as age, prostate volume, retrieved tissue weight, operative time, and the fi rst post-void residual (pvr) urine volume immediately aft er removing postoperative urethral catheter. urethral catheter was removed aft er bladder instillation with a ml normal saline via urethral catheter, and pvr urine volume was estimated immediately aft er the fi rst postoperative self-voiding. all defi nitions of ui corresponded to recommendations of the international continence society.results: aft er holep, patients ( . %) had de novo ui, most of which resolved within - months; had stress ui, had urgency ui, and had mixed ui. age and pvr urine volume were signifi cantly higher in ui group than non-ui group ( . ± . vs. . ± . years; p = . , . ± . vs. . ± . ml, p < . ). in a logistic linear regression analysis, only pvr urine volume was an independent predictor of de novo ui aft er holep. th e most optimal cut-off value of pvr urine volume for predicting de novo ui was defi ned as . ml in the receiver operating characteristics curve analysis (sensitivity, . %; specifi city, . %; auc, . ; p < . ).conclusion: about one-third of patients might undergo de novo ui following holep, and most of them might have been resolved within - months. high pvr urine volume aft er removal of postoperative urethral catheter is associated with de novo ui aft er holep, and could be used a practical tool to predict postoperative de novo ui. concomitant transurethral and introduction and objective: stress urinary incontinence is a common medical problem among women. th e urethral closure complex and/or the support mechanisms are responsible for incontinence in the majority of patients. several surgical procedures with diff erent degrees of invasiveness and outcomes have been reported to treat the problem. although many are reasonably eff ective, a general trend towards study of natural and biocompatible tissues is emerging over popular synthetic materials. here we report our experience with injection of autologous adipose-derived stem cells to the periurethral region as a new method of stress urinary incontinence treatment. ten women with symptoms of stress urinary incontinence were treated by injections of autologous adipose-derived stem cells into the periurethral region via transurethral and transvaginal approach under urethroscopic observation. th is report presents the short-term outcome of the patients. th e outcome measured by pad test results, iciq-sf scores and qmax.results: th e mean age of the participants was . ± . years. urinary incontinence signifi cantly decreased through the fi rst two, and weeks aft er the injection therapy. th e diff erence was signifi cant in pad test results (p< . ) and iciq-sf scores (p< . ), especially comparing results between and weeks and among and weeks, but not for and weeks compared to each other. surprisingly, qmax showed improvement aft er the study period (means . vs. . ; p= . ). th is study showed that injection of the autologous adipose-derived stem cells to periurethral region is a safe, yet shot-term eff ective treatment option for stress urinary incontinence. further studies with longer follow-up are needed to confi rm its longterm effi cacy. sparc sling system for treatment of female stress and mixed urinary incontinence in the elderly sung l, noh c, chung j, yoo j introduction and objective: th e aim of this study was to investigate the safety and effi cacy of the suprapubic arch (sparc) sling procedure for the management of urinary incontinence in elderly versus younger women. a total of women underwent the sparc procedure for female urinary incontinence. of these patients, were classifi ed younger women (sui, . mui, ) and (sui, . mui, ) were elderly (more than year). th e preoperative evaluations included a complete medical history, a female bladder questionnaires, urogynecological examination and urodynamic test with valsalva leak point pressure (vlpp). th e main outcome measures were perioperative morbidity, postoperative sui, persistent or de novo urge incontinence, postoperative complication and voiding dysfunction. th e objective and subjective success rate were evaluated by visual analogue score and global patient impression questionnaire at , , months. th e mean follow-up period was ± mo (range, - mo).results: th e incidence of sparc related morbidity was similar in both groups. for the operation outcome results, in younger group ( patients) there were cases of cure ( . %), cases of improvement ( . %), and cases of fail ( . %) and in elderly group ( patients) there were cases of cure ( . %), cases of improvement ( . %), a case of fail ( . %) (p> . ). th e operation satisfaction rate of patients was . % in the younger group and . % in the elderly group (p> . ). a total of patients ( . %) would like to recommend the sparc procedure to others. th e objective success rate and operation satisfaction rate of the younger group did not diff er from elderly group. no severe intraoperative or postoperative complications occurred in both groups.conclusions: th e sparc procedure is eff ective and off ers a satisfactory cure rate without signifi cant morbidity in elderly women. validity introduction and objective: urinary incontinence secondary to surgery or trauma is a debilitating condition for the patient, and for the urologist a diffi cult situation to manage. because of the complexity of reconstructive surgical techniques and the cost of the prosthetic devices used, there is a need for a simple procedure. aims: we here in report our experience in managing urinary incontinence secondary to sphincteric incompetence in patients using a modifi ed bulbar urethral sling procedure over a period of years. results: all patients were continent postoperatively, with only mild stress leakage in the erect posture in two patients, during a mean follow-up of . months (range - months) and required one or some time two pads per day to remain continent during the daytime. one patient required clean intermittent catheterization for a short period postoperatively. conclusions: th e male bulbourethral sling procedure using a polypropilene mesh is economical and safe but further experience is needed to establish this procedure as an alternative for the treatment of male urinary incontinence. investigation of a teikyo university, tokyo, japan; juntendou university, tokyo, japan introduction and objective: th is study compares the safety and benefi ts of administering anticholinergic agent propiverine hydrochloride in combination with adrenergic alpha- receptor antagonist silodosin (sp group) as therapy for patients diagnosed with benign prostatic hyperplasia with overactive bladder, as opposed to administering silodosin alone (s group). th is study included male patients aged or above who had an international prostate symptom score (i-pss) of or more, an overactive bladder, a qol index of or greater, an overactive bladder syndrome score (oabss) of or more along with an oabss urgency score of or greater, and a maximum urinary fl ow rate of < ml/s. at random, patients were assigned to the sp group, and to the s group. th e sp group was administered mg/day of silodosin along with mg/day of propiverine hydrochloride and the s group mg/day of silodosin only, for weeks respectively. i-pss, qol index, oabss urofl owmetry results, and residual urine were evaluated prior to therapy and , , and weeks post-therapy.results: th ere were no statistically signifi cant diff erences in patient background between the two groups. statistically signifi cant improvements were seen in i-pss total score, qol index, and oabss weeks post-therapy, but there were no statistically signifi cant diff erences between the two groups. both groups refl ected statistically signifi cant improvements in i-pss storage symptom scores and voiding symptom scores, but there were no diff erences between the two groups. analyzing by prostate volume, among those with lower prostate volume (average . ± . mm ), the sp group showed a statistically signifi cant improvement in i-pss total score and oabss as compared to the s "monotherapy" group. no serious side eff ects were shown in either group.conclusion: among benign prostatic hyperplasia patients with overactive bladder, those treated with silodosin alone showed statistically signifi cant improvements in both storage and voiding symptoms, as did those additionally treated with propiverine hydrochloride. results were even more benefi cial when both silodosin and propiverine hydrochloride treatment were used for patients with lower prostate volumes. the effi cacy and safety of fesoterodine in vulnerable elderly patients with overactive bladder takeda h, nakano y, narita h introduction and objective: we evaluated the efficacy and safety of fesoterodine in medically complex vulnerable elderly patients with overactive bladder. in this -week, patients were community dwelling men and women years old or older. patients with oab had scores of less or more on the ves- by nccn (vulnerable elders survey). we evaluated the changes of each parameter before and to weeks aft er the administration of fesoterodine mg per day. th e overactive bladder symptoms score (oabss), ipss were used as a subjective questionnaire for overactive bladder symptoms. we compare between vulnerable elderly group and no-vulnerable elderly groups. statistical comparisons before and aft er the administration were made using the wilcoxon signed-rank test. to examine the relation between oabss and ipss, spearman's testing was used for correlations between independent variables and p< . was considered statistically significant. safety evaluations included self-reported symptoms and post-void residual volume.results: a total of patients were enrolled (mean age . years, . % age years or greater). th e vulnerable elderly patients had high rates of comorbidities, polypharmacy and functional impairment. at week both group had insignifi cantly greater improvements in oabss (p= . ) and ipss (p= . ). adverse eff ects were generally similar.conclusions: fesoterodine improved overactive bladder symptoms not only in no-vulnerable elderly patients, but also in vulnerable elderly patients. the effectiveness and tolerability of fesoterodine mg in "real world" outpatient clinical settings the benefi cial effect of a combination of solifenacin and mirabegron on oab patients persu c, paraianu b, nita g, geavlete p introduction and objective: th e development of a new drug class intended for the treatment of oab patients opened a new and promising era for our patients. th e current study aims to evaluate the eff ects of a combination therapy using an antimuscarinic and mirabegron. we designed a prospective study including oab patients with or without wet episodes. treatment was started with two months of solifenacin mg, then mirabegron mg was added for the next two months. th e patients were evaluated using a bladder diary for three consecutive days at the end of each treatment period. we compared the total number of voidings, the number of urgency episodes and the number of urge incontinence episodes. th e statistical analysis included only the patients who fi nished the whole four month period. a total of fourteen female sprague-dawley® rats weighing - g were used, which were randomly divided into two groups. both the experimental group and the control group, fourteen rats were inserted intrathecal catheter in the spinal l -s segment. seven days later, all rats were catheterized through the bladder dome for saline-fi lling cystometry. in experimental group, seven rats were given intrathecal diff erent concentration ketanserin ( . - . mg/kg) dose-response curves for ketanserin were followed by doi ( . mg/kg) test.in control group, seven rats were given intrathecal normal saline. all rats were intravascularly perfused with % paraformaldehyde aft er the completion of the urodynamic recordings. th e l -s spinal cord were removed and pathological sections and immunohistochemical staining were made. meanwhile, we observed and recorded the distribution of -ht a receptors in the spinal motor neuron. results: th irty-four patients were included in the study. twenty-four of them completed the follow-up. twenty-one were female and were male with an average age of . years ( - years). detrusor sphincter dyssynegia was the most common abnormal urodynamic fi ndings in these patients. th ere was an improvement in bladder capacity, detrusor and sphincter action following de-tethering surgery.conclusion: urodynamics should be considered as a part of preoperative evaluation in all patients with primary tethered cord syndrome to decide the urological aspect of management. urinary bladder reinnervation with creation of a "somato-autonomic" refl ex pathway in rabbits -s ) and detrusor muscle (recipient, s -s ) were located. aft er their resection, intradural anastomosis of donor root to the recipient distal root stub was performed. th ose roots whose stimulation elicited the largest response were always selected. aft er - months (mean months), the artifi cial refl ex arc's function was examined (to date in rabbits). under general anaesthesia, skin segments l -s were peripherally stimulated and then the spinal root above the anastomosis was stimulated. detrusor response was measured using an emg strip electrode and intravesical pressure (pves) monitoring and sphincter response using an emg needle electrode. a root sample from under the anastomosis was resected for histology.results: electromyography confi rmed detrusor response to peripheral skin stimulation in ( %) animals and sphincter response in ( %). five ( %) animals displayed elevated intravesical pressure (pves) up to cm h o. root stimulation induced detrusor and sphincter emg response in ( %) and ( %) rabbits, respectively, and ( %) animals displayed increased pves up to cm h o. micturition was not induced in any animals. with confi rmed detrusor contraction (emg, elevated pves), external sphincter activity was never inhibited. somatic-to-autonomic anastomosis creation was histologically confi rmed in all samples. hind limb paresis occurred in ( %) animals and spinal lesion in ( %).conclusion: lumbar-to-sacral-nerve rerouting is a technically manageable method with donor root fibres verifi ably joining recipient roots. only in a limited percentage of cases, however, can the method achieve positive functional results, i.e. demonstrable detrusor contractions and elevated intravesical pressure. physiological micturition without detrusorsphincter dyssynergia as described in the literature did not occur in our experiment. development in this study, we evaluate the effi cacy of the prototype intravesical pressure sensor integrated into a catheter-like tube and in the rabbit and biocompatibility of ecofl ex® as a packing materials in the rats. th e catheter type wireless pressure sensor is manufactured by direct inserting the prototype sensor into the port split from the feeding tube between the sensor and the port so the tube could hold the bladder pressure. th e tip of the tube is results: th e measured resonance frequencies and the pressure data converted from those signals were compared to the reference pressure data obtained from a conventional cystometry. th e scale factor of the sensor to correlate the prototype sensor resonance frequencies to the reference pressure data is - . kpa/ mhz (=- . mhz/kpa), comparable to the result of its in-vitro measurement, a pressure responsivity of - . mhz/kpa. increased macrophage activity and mif in the bladder were revealed in the early phase aft er implantation of ecofl ex®. however, decreased macrophage activity and mif in the bladder were observed in the later aft er implantation. furthermore, decreased infl ammatory cytokines were also observed at that time. in this study, we demonstrated the feasibility of the catheter type which is non-invasive method and easy to apply to patients in actual examination. further investigation to overcome the limitation of the prototype intravesical pressure sensor is necessary for the application to the real life practice. in addition, ecofl ex is biocompatible materials for the implanted medical devices in the bladder. introduction and objective: urethral pressure profi le (upp) is a primary method for evaluating urethral continence function in human beings. however, upp recording in female rat, a widely used animal model, has been challenging because of the animal's small body size. th is study reports a novel method for recording upp in female rats. seventeen anesthetized female rats were studied. leak-point pressure (lpp) data of rats were included; the other rats were excluded due to animal die or abnormal urogenital organ. upp curves were recorded using a modifi ed method of water-perfusion catheter system, with the lateral hole facing -, -, -, -o' clock positions respectively in a randomized sequence. lpp, functional urethral length (ful), and maximum urethral close pressure (mucp) were the analysis parameters. in the era of aging society, an easy-to-use screening tool for voiding dysfunction refl ecting to activity of daily life is much-needed. bladder diary (frequency volume chart) is gold standard to check urine storage status, but diffi cult for elderly to measure and record all the time. urofl owmetry is useful to check voiding status, but limited to clinics or hospitals. we developed a portable device, p-urofl owdiary®, which records every urine fl ow with bladder diary at home. we elucidate the feasibility and the usefulness of this device. materials and methods: p-urofl owdiary® records voiding time and date, length of voiding, voided volume, fl ow rate and self-evaluation of every urination for a couple of days with gravimetric determination method. th e device consists of a disposable urine cup, a load cell and the circuit board on which microcomputer, clock, acceleration sensor, audio guidance, bluetooth and sd card mounted. self-evaluation of every urination is recorded by pushing one of the four buttons on the body-side, which represent "very good", "good", "bad" and "very bad". th e data in sd card are analyzed using the dedicated soft ware. accuracy of the measurement has been approved in a comparative study of the device and an existing urofl owmeter. th e infl uences of hand shaking are canceled by acceleration sensor and are smoothed by the soft ware.results: th e feasibility study were done under the approval of irb of nara medical university. first semester study in healthy volunteers focused on user-friendliness. th e results were almost acceptable except for female volunteers, especially in elderly. th e urine volume and peak fl ow rate as well as self-evaluation were linearly related in volunteers who measured multiple sessions. a clinical trial in patients with voiding dysfunction is in operation in seven institutions, and summarized data will be reported.conclusion: p-urofl owdiary® is light and small and easy-to-use at home even in elderly. although its practical usefulness as voiding diary have been proved, the usefulness as urofl owmetry and self-evaluation of every urination is not clarifi ed yet. however, p-urofl owdiary® seems to be a useful tool for screening of voiding dysfunction as well as assessment of therapeutic performance. to determine the continence position and the contributory factors in the female canine urethra. materials and methods: by using adult female dogs, we determined the continence function of each mm intervals of the urethra when we excluded these segments by progressively inserting a fr catheter and recording the abdominal leak-point pressure (alpp). th e urethral pressure profi le (upp) and alpp were determined before and min aft er occlusion of the abdominal aorta. each urethra specimen was split into segments averagely and the histological components were determined. th e relationship between the histological components and the urodynamic parameters were analyzed.results: th e striated muscle confi ned to the distal / urethra. th e anatomic structure of the proximal / urethra was found to be quite homogenous, which surrounded by circular smooth muscle. th e connective tissue constituted with abundant collagen fi bers and vascular plexus was most voluminous in the distal / urethra, and relatively richer near the bladder neck. upp had pressure zones: high pressure zone corresponding to the distal / urethra and low pressure zone corresponding to the proximal / urethra. alpp decreased sharply when exclusion progressed over the distal / urethra. alpp and mucp decreased about % and % aft er occlusion of aorta, respectively. th e distribution of the urethral pressure or pressure change is in accordance with the location of the striated muscle sphincter; there is no linear correlation with any other particular tissue component in the diff erent urethral segments.conclusion: th e strongest continence function locates at the distal / urethra with striated muscle layer; the remaining / proximal urethra lacking striated muscle has only weak continence function. striated muscle is the predominant contributory factor to continence and the other components like vascular sinusoids, smooth muscle, collagen fi bers are minor contributory factors. urodynamics in children: a -year experience persu c, mirciulescu v, geavlete p introduction and objective: urodynamics, in the modern defi nition of the term, developed rapidly from a state of the art gadget into an extremely useful tool in the armamentarium of the modern practitioner, who is no longer accepting the clinical exam as the mainstay of the diagnosis, but requires more and more in-depth data from paraclinical investigations.our study aims to review the particular aspects of the urodynamic examination in children. we retrospectively reviewed the data from our archive in patients aged less than years old, examined in our department in the last years. for analysis purposes, patients were divided into two groups, less than years old and more than years old, considering that compliance during the examination improves greatly with age. a total of children were evaluated, in the fi rst group and in the second. we noticed changes in the procedure over time, due to the lack of standardization.results: th e main conditions behind the urinary symptoms were spina bifi da, myelomeningocele, cerebral palsy, spinal cord injury, frontal dementia. children with chronic conditions showed a signifi cantly better compliance during the examination, providing "cleaner" traces and shorter examination times. in cases ( %), the results of the exam were considered unreliable. in the fi rst group, sensations are recorded in only cases ( %), the other traces are marked as pain or crying. in the second group, the sensations are reported by children ( %). in six cases ( %), more than one examination was available, and the intra-individual variability was higher than in adult patients. urodynamics in children is a challenging, yet useful investigation, which requires both a state-of-the-art equipment and dedicated and highly professional staff . th e main question when thinking about urodynamic testing in children is not whether it can be done, but if it is really needed for the management of the patient, keeping in mind not only the benefi ts but also the potential harm that it can do. the underactive bladder syndrome: a single center experience persu c, geavlete p introduction and objective: detrusor underactivity (uab syndrome) is defi ned as a contraction of reduced strength or duration, leading to obstructive symptoms of the lower urinary tract. our study aims to review our clinical experience with such cases. we reviewed the electronic fi les of the patients diagnosed with uab aft er urodynamics in the past years. our review focused on the referral diagnosis and other associated conditions, as well as on the symptoms reported by the patient during history taking or the examination itself. we tried to correlate symptoms with the parameters obtained during urodynamics. th e initial treatment offered was also recorded.results: a total of patients ( males, females) were analyzed. th e most common referral diagnosis was bladder outlet obstruction ( pts - %), followed by oab syndrome ( pts - %) and other conditions ( pts - %). most patients reported signifi cant dysuria ( pts - %), sensation of incomplete voiding ( pts - %) and the need for straining in order to void ( pts - %). other reported symptoms include recurrent utis ( pts - %), urgency ( pts - %), frequency ( pts - %) and urinary incontinence ( pts - %). th e initial treatment consisted of self-catheterization ( pts - %), α blockers ( pts - %), suprapubic cystostomy ( pts - %), double voiding ( pts - %) and neurostimulation ( pts - %).conclusion: th e most common causes for uab include neurogenic conditions and obstructive symptoms associated with aging. th ere are no specifi c symptoms to support this diagnosis but some might suggest it stronger than others. urodynamic evaluation is mandatory to assess the parameters of this condition. underactive bladder: clinical features, urodynamic parameters, and treatmenthoag n, gani j introduction and objective: underactive bladder is a complex clinical condition that remains poorly defi ned in the available literature. we aim to determine its prevalence among those with voiding dysfunction, presenting symptoms, risk factors, urodynamic fi ndings, and treatment undertaken. a retrospective chart review was conducted on consecutive urodynamic studies performed for voiding dysfunction between and , to identify patients with detrusor underactivity. underactive bladder was defi ned as bladder contractility index less than . charts and urodynamic tracing were examined for patient demographics, suspected risk factors, presenting symptoms, urodynamic parameters, and treatment undertaken.results: th e prevalence of underactive bladder in this series was % ( / ). average age was . (range - ). women represented . % ( / ) of patients. th e most common reported symptoms were: urinary urgency ( . %), weak stream ( . %), straining ( . %), nocturia ( . %), and urinary frequency ( . %). prior pelvic surgery and prior back surgery was noted in . % and . %, respectively. most common management was intermittent self-catheterization at . %, followed by observation/conservative treatment at . %, and sacral neuromodulation at . %.conclusion: underactive bladder is common, yet precise diagnosis and treatment remains nebulous. th ere exists signifi cant overlap in symptoms compared to other bladder disorders, and urodynamic evaluation is useful in determining those patients with impaired detrusor contractility. th is will help prevent mismanagement of these patients with surgery or medical therapy that may worsen their condition. th ere remains much work to be done to better understand this condition, and establish optimal management for patients. what is the relationship between the size of a patient's medical notes and their fitness?birring a, jelski j, burns-cox n introduction and objective: assessment of patients' co-morbidities is necessary when considering treatment options. comorbidity tools exist but aren't always used outside of studies. clinicians may infer a patient's fi tness from the size of their notes. th is is particularly apparent in multidisciplinary meetings when the patient, and sometimes the referring clinician, is absent. we aim to establish if any correlation exists between the thickness and weight of medical notes and patient comorbidity. th ickness and weight of medical notes was measured for consecutive patients admitted to a urology/surgical ward. comorbidity was assessed using the charlston comorbidity index (cci).results: mean (and range): age ( - ) years; thickness . ( . - . ) cm; weight ( - ) g; cci . ( - ). male to female ratio : . pearson's correlation (r) between thickness and cci was . (p= . ). th e correlation between weight and cci was . (p= . ). regression analysis showed, an . cm increase in thickness gives in a -point increase in cci (p= . ); and a g increase in weight gives a -point increase in cci (p= . ).conclusion: th ere is a statistically signifi cant relationship between the thickness and weight of a patient's notes and their cci (p= . ), but the strength of this relationship is extremely weak (r= . and . ). on average, an . cm or kg diff erence in size has only a -point diff erence in cci. th is change may reduce the -year survival of a patient by as little as %. size of notes is a highly misleading indicator of fi tness. patients should have a formal comorbidity assessment before deciding treatment options.did you know? siu academy... the endorsed event programme allows approved webcasts from high-quality meetings around the world to be presented and shared on the portal.off ers a wide range of content eligible for selflearning cme credits non-accredited content is eligible for self-learning credits. contact your national accreditation body to fi nd out how. navigate the portal to its full potential by using the top and bottom panels. this allows you to narrow down your search by selecting the type of content, topic, sub-topics and labels to fi nd exactly what you are looking for. what's trendingthe what's trending page gives you an overview of featured content and the most recent material at a glance. the "rate & comment" feature allows you to share your feedback on every piece of material available on the portal. share exciting new content with colleagues through facebook and twitter at the click of a button.www.siu-urology.orgregister today! siu academy reaches over , users.are you one of them?siu members span over countries and represent the full spectrum of clinicians and investigators from all the urological subspecialties, including established academic and non-academic urologists, as well as physicians undergoing full-time training in urology.siu membership gives you an equal voice in this influential organization. we believe that each member can contribute the knowledge and experience needed to forge valuable links between urologists, and between developed and developing nations. by working together, our members carry on the tradition of creating positive change in a changing world. as a new member, you will be a partner in the one urological association dedicated to creating sustainable educational projects and providing and improving urological resources worldwide.members are able to vote for siu leadership, organize siu-endorsed educational activities, become involved in the congress scientific programme, as well as contribute to various siu academy programmes. we strive to make each member feel valued, respected, and supported.the siu network, both virtual and live, is an unparalleled pool of global contacts. siu brings urologists together. key: cord- -rrverrsj authors: delano, margaret l.; mischler, scott a.; underwood, wendy j. title: biology and diseases of ruminants: sheep, goats, and cattle date: - - journal: laboratory animal medicine doi: . /b - - / -x sha: doc_id: cord_uid: rrverrsj nan since the first edition of this book, the use of ruminants as research subjects has changed dramatically. formerly, large animals were primarily used for agricultural research or as models of human diseases. over the past decade, ruminants have continued in their traditional agricultural research role but are now extensively used for studies in molecular biology, genetic engi-british stock with egyptian and indian goats. this breed is relatively heat tolerant and produces milk with the highest butterfat (about - %). fiber breeds include the angora and the cashmere. the angora, the source of mohair, originated in turkey. the cashmere breed is found primarily in mountainous areas of central asia. the la mancha, a newer breed of dairy goat first registered in the united states in , has rudimentary ears that are a genetically dominant distinguishing characteristic of the breed. the meat breeds include the boer, sapel, ma tou, kambling, and pygmy. the pygmy goat is small and is sometimes used for both meat and milk. the mubend of uganda and the red sokoto of west africa produce quality skins for fine leather (smith and sherman, ) . most breeds of cattle are classified as "dairy" or "beef"; a few breeds are considered "dual-purpose." common dairy breeds in the united states include holstein-friesian, brown swiss, jersey, ayrshire, guernsey, and milking shorthorn. holsteins have the largest body size, whereas jerseys have the smallest. of breeds in temperate regions, jerseys have been considered to be the most heat tolerant, but holsteins have been found to adapt to warmer climates. there are many beef breeds. the more common in the united states include angus (also called aberdeen-angus), hereford (both polled and horned), and simmental (briggs and briggs, ; schmidt et al., ) . breeds indigenous to other continents, such as the cape buffalo, have been found to have unique innate immune characteristics that protect them from endemic trypanosomiasis (muranjan et al., ) . more detailed information regarding these and other ruminant breeds is available in briggs and briggs ( ) . "rare" or "minor" breeds of sheep, goats, and cattle are studied for their genetic and production characteristics. discussions of these and efforts at conservation are described in detail elsewhere (national research council, ) . several terms are unique to ruminants. in relation to sheep, a ewe is the female, and a ram is the adult intact male. a lamb is the young animal, and ram lamb and ewe lamb are commonly used terms. a wether is a castrated male. the birthing process is referred to as lambing. with respect to goats, a doe or nanny is the female. a buck or billy is the adult intact male. a kid or goatling is a young goat. a young male may be referred to as a buckling, and a young female may be referred to as a doeling. a castrated male in this species is also called a wether. the birthing process is called kidding. with respect to cattle, an adult female is a cow, and an adult male is a bull. a calf is a young animal. a heifer is a female who has not had her first calf. a steer is a castrated male. calving refers to the act of giving birth. ruminants have been used as research models since the inception of the land grant college system, first in production agriculture and now also in basic and applied studies for the anatomic and physiologic sciences and in biomedical research for a variety of purposes. healthy, normal young ruminants serve as models of cardiac transplantation and as preclinical models for evaluation of cardiac assist or prosthetic devices, such as vascular stents and cardiac valves (salerno et al., ) . for many years, ruminants have been useful research subjects for reproductive research, such as research on embryo transfer, artificial insemination, and control of the reproductive cycle (wall et al., ) . several important milestones in gene transfer, cloning, nuclear transfer, and genetic engineering techniques have been developed or demonstrated using these species (ebert et al., ; schnieke, ; cibelli et al., a,b) (see fig. ). one of many proposed uses of genetically engineered ruminants is the production of proteins that will be secreted in the milk and later isolated (ebert et al, ; memon and ebert, ) . healthy sheep and goats are also often used for antibody production (hanly et al., ) . genome mapping developed rapidly during the s; extensive information is available and is increasing for sheep and cattle (broad et al., ; womack, ) . sheep are often selected for studying areas such as ruminant physiology and nutrition. these animals provide obvious bene-fits over the use of cattle in research from the standpoint of size, ease of handling, cost of maintenance, and docile behavior. sheep are also widely used models for basic and applied fetal and reproductive research (buttar, ; rees et al., ; ross and nijland, ) . the species is used for investigating circadian rhythms related to day length (lehman et al., ) , and the interaction between olfactory cues and behavior (kendrick et al., ) . the number and diversity of natural-and induceddisease research models in sheep are great and increasing. natural models include congenital hyperbilirubinemia/hepatic organic anion excretory defect (dubin-johnson syndrome) in the corriedale breed, congenital hyperbilirubinemia/hepatic organic anion uptake defect (gilbert syndrome) in the southdown breed, glucose- -phosphate dehydrogenase deficiency in the dorset breed, gm~ gangliosidosis in the suffolk breed, and pulmonary adenomatosis (jaagsiekte) in many breeds (hegreberg, l a) . induced models include arteriosclerosis, hemorrhagic shock, copper poisoning (wilson's disease), and metabolic toxocosis (hegreberg, lb) . goats are used in a wide variety of agricultural and biomedical disciplines such as immunology, mastitis, nutrition, and parasitology research. vascular researchers select the goat because of the large, readily accessible jugular veins. goats with inherited caprine myotonia congenita ("fainting goats") have been used as a model for human myotonia congenita (thomsen's disease) (kuhn, ) . a line of inbred nubians serves as models for the genetic disease [ -mannosidosis and prenatal therapeutic cell transplantation strategies (lovell et al., ) . (these disorders are discussed in more detail in section iii,b, .) goats are used as a model for osteoporosis research (welch et al., ) . cattle are often used as a source of ruminal fluid for research, teaching, or treatment of other cattle, by placing a permanent fistula in the left abdominal wall to allow sampling of ruminal fluid (dougherty, ) . cattle also serve as models of many infectious diseases, including zoonoses, and several inherited metabolic diseases. this species is useful for the basic and comparative research on the pathogenesis and immunology of inherited and infectious diseases. bovine trichomoniasis, caused by tritrichomonas (trichomonas)fetus, has been identified as a useful model for the human infection by trichomonas vaginalis (corbeil, ) . inherited cardiomyopathies have been found in the holstein-friesian, simmental-red holstein, black spotted friesian, and polled hereford with woolly coat (weil et al., ) . lipofuscinosis has been identified in ayrshires and friesians, and glycogenesis in shorthorns and brahmans. metabolic diseases such as hereditary orotic aciduria and hereditary zinc deficiency have been characterized in holstein-friesian or friesian cattle. holstein cattle also serve as a model for leukocyte adhesion deficiency syndrome (afip, ) . common breeds of normal, healthy ruminants are usually readily available, although seasonality may play a role, as noted below. agricultural sources and reputable farms may be located through land-grant universities or agricultural schools, cooperative extension and -h networks, regional ruminant breeders' associations, and farm bureaus. commercial sources of purposebred animals are found in technical publications and annual listings of research animal vendors. breeds carrying genetic traits of interest, either as animal models or as valuable production characteristics, may be located through literature or internet searches, animal science societies, breed or livestock conservation associations, and information resources such as the armed forces institute of pathology. organizations such as the institute for laboratory animal research (ilar), national center for research resources (ncrr), or the animal welfare information center (awic) may also serve as information sources about the animals needed. purpose-bred research sheep and goats are available from commercial vendors and are usually maintained in registered facilities under federal standards that are also acceptable to research animal accrediting agencies. these commercial animals are frequently described as specific pathogen-free (spf) and housed as biosecure or closed flocks. animal health programs are in place, and health reports or other quality assurance reports are usually available on request. agricultural sources of either small ruminant may be acceptable, but specific research needs may not have been addressed or may not be understood. lambs, kids, and milking goats may be difficult to locate in fall and winter months because most breeds of sheep and goats are seasonal breeders. management practices exist, however, to extend the breeding and milking seasons. most cattle used as animal models in research in the united states are from one of the dairy breeds, usually holstein, because this breed is now the most common. purpose-bred, specific pathogen-free research cattle are not typically available. because of selection and the management of dairy production units, calves and young stock are available year-round. availability of young beef cattle is more seasonal, according to production cycles typically followed by that industry. auction barns or sales are not appropriate sources for research ruminants. many of these animals are culls and will be poor-quality research subjects. they may be in poor body condition and stressed, may be sources of disease, and may contaminate other healthy animals, as well as the research facility. selection of the suppliers should be made only after research needs have been carefully considered. consistently working with and buying directly from as few sources as possible are best. certain types of research (i.e., agricultural nutrition studies) may better be served by selecting animals from local agricultural suppliers rather than commercial vendors located in a different geographical area. the selection of sources for research ruminants includes scrutiny of flock or herd record keeping; health monitoring, vaccination, and preventive medicine programs (including hoof care); production standards and management practices consistent with the industry; management of the breeding flock or herd; sanitation and waste handling programs; vermin and insect control measures (especially for flies and other flying insects); rearing programs for and condition of young stock; the location, health, and condition of the other animals on the premises; intensity of housing; and animal housing facilities. preliminary and periodic visits to the source farms should be conducted. it is important to establish a good relationship with the local attending large-animal veterinarians, who will be valuable resources for current approved therapies and practices. they may need to be oriented on the specific requirements of animal research. creative ways can be used to initiate and foster a good working relationship between the agricultural supplier and the research facility. supplying the vaccines or dewormers required for flock health programs, providing services such as quarterly serological testing or fecal examinations for the herd or flock, and paying a premium (rather than market price) for animals that meet the quality criteria established for the research animals are often helpful. a set of testing standards can be developed based on one high-quality supplier, and then flocks or herds can be "qualified" based on those standards. qualifying entails evaluations utilizing the facility and management aspects mentioned above and testing either a percentage of the herd or flock or the entire herd or flock for a number of infectious agents. the testing regimen itself should be carefully developed and evaluated. once qualified, each source farm should be reevaluated periodically to maintain its status. slaughter checks may be appropriate; otherwise necropsy of sentinel animals may be required. selected animals undergoing screening tests should be quarantined from the rest of flock or herd while awaiting test results. vaccination and deworming regimens can be instituted during these quarantine periods. a second quarantine should occur when animals arrive at the research facility. the animal screening process also depends on the origin of the animal (state, country) and the scientific program. federal and state regulations must be followed. socialization of the animals at the source facility should also be considered in terms of ease of handling and safety for personnel in the confinement of the research lab, barn, or farm. for example, frequently handled calves will be easier to manage, and adult dairy goats that have been acclimated to human contact are preferable. several texts provide information on industry standards for flock and herd management and preventive medicine strategies that can provide helpful orientation to those unfamiliar with these aspects. these references also provide information regarding vaccination products licensed for use in ruminants and typical herd and flock vaccination parasite control schedules ("current veterinary therapy," , "council report," ; "large animal internal medicine," ; smith and sherman, ) when designing a vaccination program during qualification of a source or at the research facility, it is important to evaluate the local disease incidence and the potential for exposure. vaccination programs should be conducted with an awareness of duration of passive immunity and stresses in ruminants' lives (e.g., weaning, grouping, management changes, and shipping) that may impair immunity or increase susceptibility to infectious diseases. it is also prudent to evaluate the cost-effectiveness of vaccination; labor and vaccine expenses may be much higher than the potential animal morbidity or mortality for diseases in a particular locality. not all of the vaccines mentioned subsequently will be necessary in all herds or flocks. vaccination needs for research animals will also depend on the local disease history, intent of the research, the age of the animals needed for research, and the length of time the animals will be housed. typical health screening programs for sheep include q fever (coxiella burnetii); contagious ecthyma; caseous lymphadenitis (corynebacterium pseudotuberculosis); johne's disease (mycobacterium paratuberculosis); ovine progressive pneumonia; internal parasitism such as nasal bots, lungworms, and intes-tinal worms; and external parasitism such as sheep keds. each supplier should be queried about vaccination programs for bluetongue, brucella ovis, campylobacter spp., chlamydia (enzootic abortion of ewes), clostridial diseases, pneumonia complex (parainfluenza , pasteurella haemolytica, and p. multocida), ovine ecthyma, rabies, dichelobacter (bacteroides) nodosus, arcanobacterium pseudotuberculosis, bacillus anthracis, and fusobacterium necrophorum. because of the limited number of biologics approved for small ruminants, products licensed for cattle have been used with success in sheep, and some licensed for sheep are used in goats ("council report," javma, ) . in some cases, approved feed additives, such as coccidiostats, are fed to sheep. the basic screening profile for goats should include q fever (coxiella burnettii), caprine arthritis encephalitis (cae), brucellosis, tuberculosis, and johne's disease (mycobacterium paratuberculosis) . goats may also be tested for caseous lymphadenitis, contagious ecthyma, or mycoplasma as needed. herd vaccination programs may include immunizations against tetanus and other clostridial diseases, chlamydia, campylobacter, contagious ecthyma, caseous lymphadenitis, corynebacterium pseudotuberculosis, and escherichia coli. cattle herds should be screened for johne's disease, brucellosis, tuberculosis, respiratory diseases, internal and external parasitism, and foot conditions such as hairy heel warts and foot rot. determination of the status of the herd with respect to bovine leukemia virus (blv) may be worthwhile. herd programs may include essential or highly recommended vaccines against bovine viral diarrhea virus (bvdv), infectious bovine rhinotracheitis virus (ibrv), bovine respiratory syncytial virus (brsv), parainfluenza (pi- ), leptospira pomona, tritrichomonas fetus, rotavirus, coronavirus, campylobacter (vibrio) , pasteurella haemolytica and p. multocida, and brucella abortus. other vaccination programs, dependent on herd status, endemic diseases, or geographic location, may include immunizations against the clostridial diseases, moraxella bovis (pinkeye), fusobacterium necrophorum (foot rot), staphylococcus aureus (mastitis), haemophilus somnus, rabies, tetanus, bacillus anthracis, enterotoxigenic e. coll anaplasma, and other leptospira species. some products considered to have limited efficacy include vaccines against salmonella dublin and s. typhimurium. some autogenous vaccines may be more effective than the commercially available products--for example, the bovine papillomavirus (warts) vaccines. rearing programs for dairy calves differ from those for the smaller ruminants, including the withdrawal of calves from their dams immediately or by hours after birth. in the cattle industry, antibiotics, ionophores (antibiotics that control selected populations of ruminal organisms), coccidiostats, probiotics, and other approved additives may be part of the milk replacers, grain and concentrate formulations, and/or creep feeding regimens. use varies by the segment of the industry, and regulations vary by country. subcutaneous hormonal implants (such as estradiol benzoate and progesterone combined, zeranol, or [~-estradiol) are administered, especially to beef calves destined for market rather than breeding, to promote growth. transportation of the animals from the source to the research facility must be carefully planned, and all applicable livestock travel regulations followed. it is best to have the animals transported in vehicles regularly utilized by the source farm. if commercial haulers are used, then disinfecting trucks, trailers, and associated equipment, such as ramps and chutes, beforehand is particularly important. the loading, footing, and distribution of the animals in the trailers and trucks, as well as environmental conditions during shipping, are important to consider to minimize stress and injury to the animals. sufficient time for acclimation to the facility, pens, handlers, feed, and water must be allowed once at the destination ("livestock handling and transport," ). recent publications address many general considerations as well as specifics about the facilities, husbandry, space requirements, and standard practices for research and production ruminants. institutions, private entities, researchers, and facility staff must also be aware of the recent adoption by the u.s. department of agriculture (usda) of specific guidelines for regulation of farm animals, such as ruminants, that are used in biomedical and other nonagricultural research. the usda animal care policy notes that the "guide for the care and use of agricultural animals in agricultural research and teaching" and the "guide for the care and use of laboratory animals" provide additional information to supplement the existing animal welfare act regulations (cfr, ; fass, ; hays et al., ; nrc, a; usda, ) . in all cases, stress should be considered and minimized in the husbandry and handling of ruminants. animals need to be provided adequate time to adapt to new surroundings. stress decreases feed intake, and the resulting energy, vitamin, and mineral deficiencies will affect the growth and development in younger animals. reproductive soundness and rumen function are affected by transport and similar stresses. standard practices such as weaning, castration, dehorning, vaccinations, deworming and treatments for external parasites, shipping and the associated feed and water deprivation, introduction to a new housing environment and new personnel, and intercurrent disease are all stressors (houpt, ) . animals should be acclimated to the use of halters and leads, temporary restraint devices, and other handling equipment associated with the research program. personnel in the research facility who are unfamiliar with ruminants should be trained in appropriate handling techniques. ap-preciation for ruminant behaviors has grown in recent years, and refined ruminant handling techniques have been published (houpt, ; grandin, ) . when ruminants are confinement-housed, care should be taken to provide adequate but draft-free ventilation. ammonia buildup and other waste gases may induce respiratory problems. in cold weather, if the ceiling, walls, or water pipes condense water, then the ventilation should be increased even at the expense of lower temperatures. even adult goats and younger cattle are quite comfortable in cold, even subfreezing temperatures, if provided with adequate amounts of dry dust-free bedding and draft protection. sheep, because of their wool, are remarkably tolerant to both hot and cold extremes. newborn lambs and recently shorn adults are susceptible to hypothermia, hyperthermia, and sunburn. therefore, in outside housing areas, sheep should be provided with shelters to minimize exposure to sun and inclement weather. animals housed under intensive confinement should be kept clean, and excreta should be removed from the pens or enclosures daily. feed and water equipment should be maintained in sound, clean condition and should be constructed to prevent fecal contamination. waterers should not create a muddy environment in paddocks or pens. there should be sufficient continuous-access waterers placed around the area to prevent competition or fighting. feeders should be constructed to conform to species size and feeding characteristics and to prevent entrapment of head and limbs. pens, other enclosures, passageways, chutes, and floors must be very sturdy to withstand such factors as the frequent cleaning; the strength, weight, and curiosity of all ages of animals; and the investigative and climbing behaviors of goats. chain-link fences are dangerous because goats (as well as some breeds and ages of sheep) are curious and tend to stand on their hind legs against fencing or walls. forelimbs may be caught easily in the mesh. floors in any areas where animals will be housed, led, or herded must ensure secure footing at all times to prevent slipping injuries. all ruminants are social and herding animals. therefore, they should be housed in groups or at least within eyesight and hearing of other animals. singly housed animals should have regular human contact. environmental enrichment should be governed by the experimental protocol or standard operating procedures, and durable play objects should be supplied to those animals that are housed in confinement. calves, in particular, that must be singly housed or that have been recently weaned, need play objects (morrow-tesch, ) . because sheep and goats are sensitive to changes in light cycle (especially reproductive parameters), photoperiod must be taken into account. normally, sheep and goats should be maintained on a cycle comparable to natural conditions. light intensity should be maintained at about lux (ilar, ; fass, ) . light cycles can be manipulated for experimental reasons. the development of the digestive system and the unique function of the rumen are among the most notable comparative anatomic and physiologic characteristics of ruminants. there is a three-compartment forestomach (rumen, reticulum, and omasum) and a true stomach (abomasum). the mature rumen functions as an anaerobic fermentation chamber in which the enzymes, such as cellulase, of the resident bacteria allow the animals to prosper as herbivores. digestion is also aided by other microorganisms, such as protozoa ( - /ml) and bacteria ( - ~ that contribute to rumen fermentation. the result is the production of volatile fatty acids (acetic, propionic, and butyric) . unlike in the monogastrics, fermentative digestion and volatile fatty acid absorption also occur in the large intestines. the main sources of energy for ruminants are volatile fatty acids (vfas) rather than glucose. glucose is formed from propionic acid (or from amino acids) for metabolism in the central nervous system (cns), uterus, and mammary glands. plasma glucose in ruminants is much lower than and is regulated differently from that in nonruminants. the rumen microorganisms also synthesize vitamins, such as b and k, and provide protein that is used by the animals' systems. large amounts of fermentation gases such as co and methane, and small amounts of nitrogen, are naturally eructed (hecker, ; schimdt et al., ) . intestinal immunoglobulin absorption by pinocytosis in the neonates is crucial to the success of passive transfer. this transfer mechanism is functional for approximately the first hr after birth. neonatal ruminants are immunocompetent, however, and this condition is used to advantage for vaccinations against some common diseases of the neonatal and later juvenile periods, such as infectious bovine rhinotracheitis (ibr) vaccine (using modified live virus vaccines) to calves when their dams' colostrum is lacking antibody against this virus. unlike hepatic lipogenesis in humans, lipogenesis in sheep primarily occurs in adipose tissue and the mamrnary gland (hecker, ) . in addition to normal lymph node chains, and as in other ruminants, sheep have small red "nodes" associated with blood vessels. inadvertently named hemal "lymph nodes," they contain numerous red blood cells. sheep have a relatively large pituitary gland, and accessory adrenal medullary tissue may be interspersed throughout the abdominal cavity. three major ovine histocompatability classes have been identified and designated as ovar (ovis aries) classes i, ii, and iii (franz-werner et al., ) . bovines are recognized as having several unique aspects involving their immune systems. the bovine lymphocyte antigen (bola) system ranks after the hu-man (hla) and murine (h- ) systems in terms of depth of knowledge (lewin, ) . cattle are considered free of autoimmune diseases (schook and lamont, ) . the complexity of the immunobiology of the bovine mammary gland is being studied extensively because mastitis is the most prevalent disease in the dairy industry. several innate immune mechanisms and cellular defenses, and their variation throughout lactation, have been described (sordillo et al., ) . hematology and clinical reference texts are available for the ruminant species and include overviews of normal values for age, sex, and breed-specific ranges, as well as discussions regarding the influences on the hemogram of many management, nutritional, geographic, metabolic, physiologic (including lactation), medication, and iatrogenic variables (duncan and prasse, ; jain, ; kaneko et al., ) . these references should be consulted when preparing to include blood collection data in research protocols and when reviewing hematologic findings. in addition, most veterinary diagnostic laboratories have also developed databases for normal ranges for hematologic and clinical chemistry values based on subjects from their service areas, and these may be useful as local and breed references. appropriate control groups must be incorporated into each research plan, however, to establish the normal values (see table i ) for the particular locale, diagnostic facilities, breed, age, sex, and research circumstances. normal hematologic and clinical biochemistry data are presented in tables ii and iii. some general statements apply to most ruminants. most ruminants have fewer neutrophils than lymphocytes. the blood urea nitrogen (bun) values cannot be used as an indicator of renal function because of the metabolism of urea nitrogen by rumen microflora. because of the large volume of rumen water, ruminants can generally go several days without drinking before significant dehydration occurs. erythrocytes may become more fragile during rehydration, resulting in some degree of hemolysis and hemoglobinuria. severe dehydration can occur quickly, however, in animals that are ill. urine ph is generally alkaline in adult ruminants. ruminant erythrocytes are smaller than those in other mammals, and hematocrits tend to be overestimated unless blood samples are centrifuged for longer amounts of time for packing of the cell pellet. increased red-cell fragility is also associated with the smaller erythrocyte. rouleau formation does not occur in cattle but does to a limited extent in sheep and goats. in addition to fetal hemoglobin, sheep are reported to have at least six different hemoglobins (hecker, ) . blood coagulation in sheep is similar to that in humans. (di / , dc / , dp / ) = (di / , dc / , dp / ) = (di / , dc / , dp / ) = permanent dental formula ( / , c / , m / ) = ( / , c / , m / ) = ( / , c / , m / ) = avital sign data for goats are from "large animal internal medicine" ( ) . sheep weight data represent weights of feeder lamb and adult dry ewe (federation of animal science societies [fass], ) . goat weight data are for a large-breed male goat. cattle weight data represent weights of female holstein or guernsey dairy cattle (fass, ) . life span data for sheep and cattle are from brooks et al. ( ) . erythrocytes in pygmy and toggenburg goats tend to be more fragile than erythrocytes from other goat breeds. normal caprine erythrocytes lack central pallor because they are fiat and lack biconcavity. normal caprine erythrocytes may exhibit poikilocytosis. at least five blood groups have been reported in goats: b, c, m, r-o, and x. because transfusion reaction rates may be as high as - %, cross-matching is advisable although not always practical (smith and sherman, ) . blood loss of up to % of the red cell mass at a single time point can be tolerated by healthy goats. blood may safely be obtained in volumes of ml/kg body weight and given in volumes of - ml/kg. in general, aspartate aminotransferase (ast) and lactate dehydrogenase (ldh) are not liverspecific in goats, and alanine aminotransferase (alt; formally serum glutamic-pyruvic transaminase, or sgpt) cannot be used to evaluate hepatic disease in goats. ~,-glutamyltransferase (ggt) and alkaline phosphatase (ap) are associated with biliary stasis, and elevations in ggt are generally associated with hepatic damage. the nutritional needs of ruminants vary considerably according to the species, breed type, different phases of development, the use of the animals, location, and different stresses in their lives. for example, mineral requirements and other nutritional requirements vary even among breeds of cattle. several references are available that describe the varying requirements and are useful for determining the requirements of ruminants consistent with the parameters noted above and the type of feeds available (jurgens, ; "large animal clinical nutrition," ; nrc, nrc, , nrc, , nrc, , b "large animal internal medicine," ) . preformulated commercial feeds, concentrates, and supplements are available specifically for the different species of ruminants. some of these provide complete energy and protein requirements or may be used as supplements for what cannot be provided entirely by pasture, forage, hay, or silage. concentrate mixtures contain salt, minerals, and other elements. concentrates should contain a protein source such as soybean meal, cottonseed meal, or linseed meal. computer programs are also readily available for those who may need to formulate and balance rations. the palatability of feeds should be taken into account. mineral deficiencies and supplementation have been shown to influence several physiologic parameters such as immune function. introduction of young stock should include continuation of the feeding program of the source or gradual transition to appropriate feed for the animals available in the region of the research facility (nrc, ) . good-quality pasture can support ruminants under certain circumstances. lush spring pastures, especially pastures containing alfalfa, can induce bloat, diarrhea, grass tetany, or nitrate poisoning. ruminants not acclimated to lush pasture should be fed good-quality hay and slowly introduced to pasture environments. when ruminants have access to pasture, it is important to be aware of different eating habits. sheep and cattle are grazers. goats are browsers and will readily eat grasses, as well as seeds, nuts, fruit, and woody-stemmed plants. goats, however, can also be selective eaters and will only eat the leafy, more nutritious parts of the plant. therefore, goats have a tendency to "waste" hay. other eating habits should also be considered. finely ground concentrates are not tolerated well by goats; pelleted concentrates are preferred because the goat will pick out large particles in mixes. generally, goats do not prefer "sweet" feeds that contain molasses and do not need supplemental concentrates if a good-quality pasture or hay is fed. when given access to a salt block, goats generally are self-regulating. grass-fed goats and lactating goats may need supplementation with calcium and phosphorus, whereas alfalfa-fed goats do not (bretzlaff et al., ) . horse and sheep feeds may be fed to goats provided that the feed does not contain much molasses (bretzlaff et al., ) . the copper content of horse feed is not excessive for goats, as it is for sheep. pelleted horse feeds with - % fiber and - % protein are good goat rations. goats will consume - % of body weight in dry-matter intake (whereas cattle will usually consume only % of body weight). goats enjoy human contact, and small alfalfa cubes make tasty treats for the goat. rations that have excessive calcium-phosphorus ratios or elevated magnesium levels may induce urinary calculi in male ruminants. these may also occur when forage grasses are high in silicates and oxalates. to increase ovulation rate in does, some producers "flush" females by feeding . - lb concentrate per head per day for several weeks before and after the initiation of the breeding season. thin pregnant dairy goats should be fed lb concentrate per ) . - . ( . ) . - . potassium (k; mmol/l) hp . - . ( . ) . - . ( . ___ . ) . - . ( . adata presented as ranges with mean and standard deviation in parentheses, s, serum; p, plasma; hp, heparinized plasma. clinical biochemistry data from kaneko et al. ( ) . day, with the amount increasing to . lb per head per day during the last weeks of gestation. forage should be fed ad libitum during this time. all newborn ruminants must receive passive immunity from colostrum, the first postpartum milk of a dam that contains concentrated protective maternal antibodies (most as igg ), functional leukocytes, cytokines, vitamins, minerals, and protein. colostrum also has laxative properties. trypsin inhibitors in the colostrum allow the passage of intact antibody molecules, by pinocytosis, through the neonate's gut wall and into the bloodstream during the first few days after birth. the quality of the colostrum is directly related to herd or flock management, vaccination programs, and the dam's overall condition and nutrition throughout gestation and at the time of parturition. ensuring effective colostrum transfer is also dependent on the timing and amount taken by the neonate. most neonatal ruminants can suckle well within hr of birth. those that do so have been shown to have significantly less diarrhea (naylor, ) . neonates weakened by dystocia or hypothermia, for example, should be hand-fed or tube-fed colostrum. if necessary, the dam should be hand-milked and the newborn fed colostrum (for example, - ml for kids) every - hr for the first - days. in typical management situations, dairy calves either are separated from their dams immediately after birth and bottle-fed colostrum, or they remain with their dams for only about hr and suckle fresh colostrum during this time. dairy producers then refrigerate and/or freeze the colostrum that cannot be consumed by the calf during that time and then feed this diluted : with warm water times a day to the calves during the next - days. extra frozen colostrum for emergencies may be obtained from dairy farmers; it is advantageous to obtain colostrum from well-managed herds and from the multiparous cows in the herd (not heifers) in the same geographic locale. holstein calves, for example, should receive a minimum of - liters within hr of birth and then be fed about - % of body weight in colostrum by hr of age. after days, calves are then placed on milk replacers. although young ruminants generally do well receiving their dams' milk, commercially available milk replacers are available and should generally be prepared and fed according to the manufacturer's recommendations. containers used to prepare and feed these replacers should be sanitized daily. the fat content of both calf and lamb milk replacers is excessive; however, calf milk replacers can be used for kids if care is taken not to overfeed. young ruminants can be offered good-quality hay (such as second cutting) to nibble on by week of age. calves may be provided with calf starter, a commercially available concentrate with appropriate levels of energy and protein, fed according to the manufacturer's recommendations at - weeks of age. they can be weaned off milk replacer by - weeks of age. young ruminants ( - months of age) need good-quality forage as well as grain and concentrate supplementation to promote development of the rumen. in farm management situations, forage can be silage, pasture, and hay. in a confinement situation like a research unit, good-quality hay, such as second cutting, is desirable. animals should not be overfed and should be offered a mineral mix free-choice. in contrast to dairy calves, beef calves remain with their mother cows until weaning at months of age. calves tend to suckle many times per day. as they mature, calves are creepfed, with the energy and protein content of the ration determined by the milk production of the dams and by the available forage, such as pasture. several useful references addressing ruminant reproduction in detail are available ("current veterinary therapy: food animal practice," practice," , practice," , "large animal internal medicine," ; "current therapy in large animal theriogenology," ; hafez, ) . sheep are seasonally polyestrous; most breeds will express estrus in the fall (northern hemisphere) and subsequently lamb in the spring. some breeds of sheep may cycle in both the fall and the spring. between seasonal periods of receptivity, the females undergo a long period of sexual quiescence called anestrus. in a research environment, ewes can be artificially stimulated to progress from anestrous to estrous cyclicity by maintaining the females in hr of light and hr of dark for - weeks. puberty is reached at about - months (or earlier) in both rams and ewes; rams will typically reach puberty before their female counterparts. ewes will display signs of estrus for about - hr and will ovulate spontaneously at the end of estrus. the estrous cycle length is - days, with an average of about days. following breeding, the average length of gestation is - days. slightly longer gestations are observed in animals carrying single lambs (singlets), in animals carrying rams, and in certain breeds such as those derived from merinos. prolificacy, or the number of lambs produced per gestation, tends to be dependent on the maturity of the dam (older dams tend to have multiple lambs) and on breed characteristics (some fine-wool breeds have fewer multiple births). the finn and dorset breeds are especially prolific. lambs vary in size at birth from about - lb up to lb. factors that affect birthweight include parental size, number of lambs in the litter (fewer lambs or singlets tend to be larger), age of the ewe (younger ewes have smaller lambs), lamb gender (males tend to be heavier), nutrition, and season or temperature (spring lambs tend to be larger than fall lambs). goats are seasonally polyestrous in temperate regions, so that young are born in favorable times of the year. they are shortday breeders, in that estrus (heat) is brought about by the decreasing light of shorter days. in temperate climates of the northern hemisphere, goats are normally anestrous during the summer and begin cycling in the fall. the actual length of the sexual cycle depends on day length, breed, and nutrition. most dairy goats cycle between august and february or march. nubians often have extended breeding cycles, and the sexual season of some breeds, including the alpine, can be extended by artificial means. the caprine gestation length averages days with a variation of - days. does bear singletons, twins, and triplets, with slightly shorter gestation when the doe is carrying triplets. cows are polyestrous. domestication of cattle has included selection against seasonality of the breeding season, particularly in dairy breeds but to some extent also in the beef breeds. in spite of this, cattle have been found to be still sensitive, in varying manifestations, to photoperiodicity. reproductive physiology in cattle is influenced by many factors. the reproductive programs in source herds and at well-managed facilities will be production-related. extensive coverage of both physiologic basics and specific industry-related criteriamfor retention of a cow as a breeder, for examplenare addressed in detail in texts and references oriented toward herd and production management ("current veterinary therapy," ). gestation in cattle is approximately days, with a range of - days. the length of gestation in cattle is influenced by fetal sex; fetal numbers; age and parity of the cow; breed; genotype of cow, bull, or fetus; nutrition; and local environmental factors. as noted, these factors are also important in sheep and goats. cows usually bear single calves, although twin births do occur. when twins are combinations of male and female calves, the female should be evaluated for freemartinism. ovine estrus detection is usually accomplished by the ram. nonetheless, because artificial insemination is achievable in ewes, clinical signs of estrus are important. typically, ewes in heat will show a mild enlargement of the vulva, with slight increases of mucus secretion. ewes may isolate from the flock and appear anxious. it is often better and clearly more reliable to employ the help of a sterile ram to mark females when they are in standing heat. two mating systems commonly employed include hand mating and group mating. with hand mating, ewes are placed either singly or in small groups with the ram of choice. ewes are removed as serviced. group mating involves placement of a mature ram with approximately - ewes for the entire -week breeding season. in either mating system, it is best to attach a marking harness to the male so that individual ewes can be identified as serviced. this is important so that parturition dates can be calculated. an easy, natural way to estimate pregnancy is by placing sterile teaser rams with the ewes at the end of the breeding season. any animal marked by the ram probably has not conceived. ultrasound scanners are also used for pregnancy detection. the ultrasound transducer is placed against the right abdomen; presence of a fetus is indicated on the machine. claims of % accuracy at weeks postbreeding have been made, although accuracy is generally best beyond days of gestation. interrectal doppler ultrasound probes detect fetal pulses. fetal heart rate is in the range of - beats per minute, whereas maternal heart rates tend to be - beats per minute. accuracy is best beyond days of pregnancy. rectal-abdominal palpation is an inexpensive alternative. a plastic probe is introduced intrarectally into the ewe, which is restrained on her back in a cradle. the plastic probe is then manipulated toward the abdomen while palpating for the fetus with the opposite hand. the age of the doe when she first expresses heat varies with breed. some does will express signs of heat between and months old. however, does should be - months old or at least - lb in weight before being bred. the caprine estrous cycle lasts - days. the duration of estrus is - hr but averages about hr. the estrous cycle can be more erratic in the beginning than in the end of the breeding season (smith, season (with winter delaying), and the level of nutrition (with higher levels hastening puberty). in some cases, the presence of mature cycling cows influences heifer puberty. with adequate nutrition, dairy breeds will reach puberty at - months and beef breeds at - months, and estrous cycles will occur regularly after the pubertal (first) estrus, maturing heifers will often have one or more ovulations before showing overt signs of estrus. only one follicle usually ovulates per estrous cycle (hafez, ) estrus, or standing heat, in cattle averages - hr in length, with a range of - hr ("large animal internal medicine," ) . detection of standing heat is important because it is closely related to the time of ovulation. ovulation occurs approximately - hr after estrus. detection of estrus is usually accomplished by visual observation of vaginal mucous discharge, mounting behavior by other females (i.e., the cow standing to be mounted is the individual in estrus), and receptivity to a bull (willingness to stand). successful visual detection of standing heat is dependent on observation skills of handlers, knowledge of the herd, stresses (e.g., detection decreased in bos taurus during heat stress), barn and yard surfaces (estrus detected better on dirt than on concrete), and maintaining a consistent observation schedule. teaser animals outfitted with marking devices are also used. other methods of detecting estrus include monitoring progesterone levels; glass slide and other evaluations of cervical mucus; change in vaginal ph; and body temperature changes (hafez, ) . estrous cycles are usually days in length, with a range of - days. it is recommended that a heifer deliver her first calf by years of age. after successful conception, progesterone levels in the cow remain elevated for most of the pregnancy, as the result of the ). "standing heat" is usually - hr but can be as short corpus luteum of pregnancy, and they decline only during the as a few hours. signs of estrus in goats include uneasiness, tail switching or "flagging," redness and swelling of the vulva, clear vaginal discharge that becomes white by the end of estrus, vocalization such as continuous bleating, and occasionally riding and standing with other does. a doe that is not in heat will not stand to back pressure or for attempts to hold her tail. does can be induced to show signs of heat by buck exposure and will ovulate within - days after introduction of the buck. goats ovulate during the later part of the estrous cycle, most between - hr after the onset of estrus. nevertheless, goats should be mated once signs of estrus are recognized and every hr until the end of estrus. most goats kid only once a year, although some goats near the equator may kid twice. once bred successfully, a goat will only rarely show signs of heat again. in fact, the first sign of pregnancy is usually a failure to return to heat, so animals should be carefully watched. pregnancy can be affirmed by a variety of means. goats will generally decrease milk production with pregnancy and should have at least a -to -week dry period for the udder to fully involute and prepare for the next milking period. in cattle, age of first estrus is dependent on the breed, the final month. conceptus implantation occurs beginning at about day . if the pregnancy fails before this time, the cow will begin to cycle again between days - , but if the pregnancy ends after day , there may be a delayed return to estrus. realtime ultrasonography can be used to determine pregnancy as early as days after insemination, with embyros seen by days - . fetal gender can also be determined by experienced personnel by this method by about day . detection of pregnancy can be successful by - days after conception by observation of failure to return to estrus or by palpation per rectum (detecting fetal membrane slip by days - and/or amniotic vesicle by days - ). palpation of the fetus is possible by day and placentomes by approximately days - . palpation later in presumed pregnancy will provide information based on differences in size of the two uterine horns, changes in the uterine wall, and fremitus in the miduterine artery. pregnancy can also be determined with reasonable success rates by determining if progesterone levels are elevated at days - after insemination. levels of bovine pregnancy-specific protein b may also be measured; this is produced by trophoblastic cells and is detectable by days - and elevated throughout pregnancy. placentation in sheep, goats, and cattle is epitheliochorial and ft. evaluation of a cow's udder prior to breeding and especotyledonary, in contrast to the diffuse or microcotyledonary cially as parturition approaches is important in order to assure placentas of horses and pigs. the placentomes, the infolded adequate nutrition and success of passive transfer by the functional units of the placenta, are formed as the result of fu-neonate. if the udder is edematous or if mastitis is present, for sion of the villi of the fetal cotyledons projecting into the crypts example, an alternate source of colostrum (such as frozen reof the maternal caruncles (specialized projections of uterine " serves) must made be available. poor udder conformation may mucosa). caruncles of sheep and goats are concave in shape, whereas those of cows are convex. the placentomes are distributed between the pregnant and nonpregant horns of the uterus in sheep, and there are - . in cattle, although the placentomes initially develop around the fetus, they will eventually be distributed to the limit of the chorioallantoic membrane even in the nongravid horn. the placentomes in the nongravid horn will be smaller than in the gravid horn. the total number will be - . the best birthing preparation for all dams is to ensure a proper plane of nutrition (not overnutrition) and adequate exercise. if possible, the dam should be confined to a birthing pasture or sanitized maternity pen a few days prior to parturition. the birthing environment will be very important in the overall health of the dam and offspring; stress minimization and a clean environment will benefit the immune health of both in the short and long term. outdoor parturition in a small birthing pasture has advantages. there is less stress and less intensity of pathogens. indoor maternity pens should be clean, dry, warm, well bedded, well ventilated but draft-free, and well lighted. adequate space per pen minimizes losses of neonates from being stepped and sat on by the dam. management of these pens, especially if concentrated in an area, is important to minimize pathogens to which dam and young are exposed. water troughs or buckets should be elevated or placed outside the pen, because lambs and kids have a tendency to fall or be pushed into them. soiled bedding should be removed from the birthing pen between dams, the area sanitized and allowed to dry, and fresh bedding installed for the next occupant. moving the female immediately before or during parturition may delay the birthing process. in goats, furthermore, in utero death may occur if parturition is unduly delayed. dams should be monitored closely during parturition for dystocias; these may result in loss of young or in young severely weakened from the prolonged birthing process. prior to parturition, ewes should be sheared or crutched. crutching refers to removing wool around the perineal and mammary areas; this minimizes fetal contamination during the birth process. foot trimming can be done at this time as well. the tail and perineal area of the doe should be clipped and cleaned to improve postbirth sanitation. in general, the pregnant doe needs a ft ( . m x . m) area for the birthing process, and area needs to be increased after birthing to allow spacing for kids. each cow should have a minimum pen area of ft x also be problematic; contingency plans should be made to ensure adequate support for the young if they cannot suckle from those udders. inexperienced heifers may react indifferently or aggressively to their offspring and should be monitored more closely than older, multiparous cows with uneventful calving histories. ewes approaching parturition generally isolate themselves from the flock, become restless, stamp their feet, blat, and periodically turn and look at their abdomen. the pelvic region will appear relaxed, and milk will be present in the udder. once hard labor contractions begin, lambs will usually be born quickly. animals that do not appear to be progressing correctly should be examined for dystocia. most cases of fetal malpresentation or malpositioning can be corrected via vagino-uterine manipulation. occasionally cesarean sections will be necessary. sanitation, cleanliness, and adequate lubrication are of utmost importance when performing obstetrical procedures. for about a week before parturition, rectal temperature of the doe will be above normal, or about ~ depending on environmental temperatures. approximately hr prior to birth, rectal temperature will fall to slightly below normal. many large dairy-goat facilities attempt to control the onset of parturition in order to assist birthing. the drug of choice to induce parturition in the goat is prostaglandin f ~ (pgf ~) (ott, ) . on day of gestation, goats given pgf ~ ( . - mg) will deliver kids within - hr. most goats prefer to kid alone and do so unaided. human interaction can actually interfere with normal birthing, especially in young or nervous does. some does may reject kids if extensive human interference occurs. does nearing parturition have an obviously swollen udder and a red, swollen vulva. pelvic ligaments at the base of tail relax. the doe may circle to make a bed, get up and down, look at her tail or sides, push other goats away, and bleat softly. signs of impending parturition include restlessness; vocalization (bleating softly); uneasiness, including getting up and down, pawing, and bedding; and a mucous discharge, leading to a moist tail. eight to hr prior to parturition, the cervix will dilate and the cervical mucous plug will be evident as a tan, smeared substance on the tail and perineum of the dam. kids should present within - hr in either anterior or posterior position. a posterior presentation can be recognized by the presence of upward-pointing feet. most does will rest between fetuses and are best left alone. however, if labor is prolonged more than hr, a vaginal exam is indicated. if the pregnant goat is housed with other goats, then herdmates will express great interest in the dam. unless moved prior to parturition, it is best to leave the dam with the group until after parturition, because removal may delay parturition. goats are not prone to retained placenta. normal kids will be quite active and will quickly attempt to stand and nurse. weak kids should be towel-dried, warmed (via heat lamp, heat pad, or warm water bottle), and assisted to nurse or fed colostrum. the goat is one of the few ungulate species that will exhibit "false pregnancy," or pseudopregnancy. this is a fairly common condition. does may have characteristically distended abdomens and may develop hydrometra and "deliver" large volumes of cloudy fluid at expected due dates. subsequent pregnancies can be normal. goats should be tested for pregnancy by days of age. veterinary use of prostaglandins has been successful in treating this condition. as in other species, parturition in cattle results from a combination of hormonal changes associated with the maturity of the fetus, notably acth (adrenocorticotropic hormone) and subsequent increases in fetal corticosteriods within days of birth. administration of acth to a fetus, or administration to the dam, results in premature birth. pregnancy is extended if fetal pituitary or adrenal glands are removed surgically. the fetal cortisol probably affects placental steroid production, accounting for sharp increases in the estrogens and estrogen precursors. coincident with this, maternal progesterone levels fall. the rising levels of estrogen cause release of maternal pgf ~ and induction of oxytocin receptors. most cows will separate themselves from the rest of the herd. a cow will lift her tail and arch her back when she is within a few hours of delivering the calf, and most cows are recumbent when delivering the calf. typically, the whole birthing process takes about min. the length of labor of cows carrying larger calves also will be longer. nervous heifers will take longer to deliver, and if they are disturbed, their labor may cease. all postparturient animals should be monitored for successful passage of these fetal membranes within hr of birth. veterinary intervention is required if not. cows occasionally eat placentas, which may subsequently obstruct rumen outflow and require surgical correction. for cattle, it is now recommended practice to remove membranes that have passed, in order to prevent ingestion. following lambing, it is critical that the newborns be "processed" so that they will have greatest survival chances. in a well-managed flock, many lambs and ewes will not need much assistance. when assistance is given, the newborn lamb's nose and mouth should be wiped free of secretions; gently swinging the lambs, head down, aids in removal of these fluids. the lamb should be dried off and stimulated through rubbing to aid its breathing. the lamb's navel should be dipped in an iodine solution to prevent subsequent navel infections. and the lamb should be identified by the application of an ear tag or ear notch. it is extremely important that the lamb be supplied with highquality colostrum within the first hr of birth. lambs that are not nursing on their own should be tube-fed with colostrum that has been collected and saved previously (i.e., frozen in ice cube trays) or collected from the mother after parturition. passive transfer can be assessed by measuring serum y-glutamyltransferase (ggt) levels (tessman et al., ) . after the first few days, colostrum changes over to milk. nursing lambs will ingest increasing amounts of milk as they grow. if the ewe cannot produce sufficient milk, the lamb should be "grafted" onto another ewe or fed artificially with a baby bottle. powdered milk replacers are commercially available; the content of ewe milk is much different from that of cow's milk; thus lamb milk replacer should specifically be used. one report notes that - % of lamb deaths occur during the first week of life and up to % occur within the first month. good management of ewes during gestation, care of the lamb at parturition, application of an appropriate vaccination program, and observation and intervention within the first several weeks of a lamb's life will minimize losses (ross, ) . immediately after birth, the placenta and any birthing materials should be removed from the doe's pen. kids do not usually need assistance. if kids are to be raised by the dam, they can be left alone; otherwise, kids should be towel-dried and removed from the dam. kids are cold-sensitive and may require a heat lamp or other source of added warmth in cold weather. navel cords should be dipped in tincture of iodine, and kids should be dehorned and castrated within the first several days of life. to control caprine arthritis encephalitis (cae), kids should be immediately removed from the dam and hand-fed heattreated colostrum. colostrum should be heat-treated for hr at ~ e the first feeding can be up to ml of colostrum. kids should receive a total of ml colostrum within the first - hr of birth. after day , kids can be placed on milk replacer. milk replacers should contain - % fat and - % milkbased protein. by days of age, kids should be consuming approximately . - . liters of milk per day. kids should be introduced to forages as soon as possible and may be weaned by - weeks or - lb body weight. milk that is fed can be reduced by weeks of age by decreasing either the volume fed or the number of feedings. as with other dams, a cow is usually very attentive to her newborn calf, cleaning and softly vocalizing to the neonate. calves typically are standing by hr after birth and are suckling within hr. as noted previously, dairy calves may be removed from the cow even before suckling, and the colostrum milked from the dam and given to the calf. assistance may be required for nervous heifers, after dystocias and in extreme circumstances such as severe cold. cleaning the newborn's nose and mouth, rubbing down the neonate, assuring that the calf does not get chilled, and assuring that it receives adequate colostrum are all important under any of these circumstances. a stressed calf's umbilical may be treated with an iodine or chlorhexidine solution, although some authors note no benefit of navel treatment, specifying that successful transfer of passive immunity and sound sanitary management of birthing area are the most crucial factors in preventing omphalitis (navel ill) (house, ; kersting, ; kasari and roussel, ) . because newborn calves can be deficient in vitamin a and iron, these may be injected to improve disease resistance (wikse and baker, ) . in cases in which the dams' colostrum is known to be deficient in antibodies against common diseases, vaccinations may be administered at day old and followed with boosters at regular intervals. dehorning is performed when horn buds appear. castration is performed between and weeks of age or later. sexing the young in any of the ruminant species is straightforward. the vulva of the female young is located just ventral to the anus. the genitalia of the male include a penis, located along the ventral midline, and a scrotum, located in the inguinal region. the phenomenon of the freemartin, a genetic female born as a twin to a male, is the result of anastomoses between placental circulations of the twin fetuses; the mixing of bloodforming cells and germ cells results in the xx/xy chimeras. this occurs in - % of phenotypic bovine females born as co-twins with males. the female will often have abnormal vulva and clitoris, and the vagina will be a blind end because of the lack of a cervix. sometimes singleton freemartins are born if the male fetus is lost after days' gestation. multiple births are selected for and are common in sheep; the freemartin phenomenon is regarded as rare. twinning is common in goats, and freemartinism occurs in about % of male-female pairs of twins. intersexes are seen in some goat breeds and when polled goats are mated. proof is usually based on evidence of abnormal genital development and reports of abnormal sexual behavior. prior to weaning, it must be established that lambs can nutritionally survive without mother's milk. thus, grain, and later roughage, should be offered to lambs well in advance of the day of weaning so that they can adjust to the feedstuff. to prevent the ewes from ingesting the lamb ration, a "creep" should be set up by building an area adjacent to the ewe-lamb pen and devising a slatted entry for the lambs to enter but not the ewes. therefore, the lambs will be accustomed to the new ration through this creep-feeding process. if lambs and ewes will be pastured later in the spring, it is still beneficial to creep-feed lambs until pasture growth is adequate enough to fulfill the requirements of the growing lambs. lambs that are consuming . - lb of creep feed per day may be weaned. depending on the individual program, lambs may be weaned as early as weeks of age, although - weeks of age is more common. if ewes are of a breed that will cycle twice a year, and if it is expected that they will be rebred, then the lambs must be weaned as early as possible so that lactational anestrus will resolve and ewes will recycle. another factor is the cost of lactation rations for the ewes; if lamb grain is more economical than ewe grain, then lambs should be weaned. about - days prior to weaning, feeding of the lactation ration to the ewes should be discontinued, and only roughage fed. at weaning, the lambs should be removed in the creep, and the ewes removed to an area that is not within sight (and preferably sound) of the lambs. the ewes should be monitored for postweaning mastitis and treated as necessary. ewes that have physical or disease problems or that have not been productive at lambing or feeding their lambs should be culled. the lambs should be monitored to assure that they continue to gain weight and are eating the new ration. kids should be introduced to forages within the first week of life because the natural curiosity of these animals will cause them to investigate sources of feed. kids can be weaned by - weeks or - lb. hand-fed milk should be reduced by weeks of age by reducing the volume fed or by decreasing the number of feedings. dairy calves are now usually removed from their dams immediately after birth. it is less common now to allow the calves to remain with their dams for about hr and suckle fresh colostrum during this time, because their intake will be inadequate. dairy producers refrigerate and/or freeze the colostrum produced during the first hr and feed this, diluted : with warm water, twice a day to the calves during the next - days. holstein calves, for example, should receive a minimum of - liters within hr of birth and then be fed about - % of body weight in colostrum by hr of age. after days, calves are then placed on milk replacers, preformulated powders reconstituted with water that provide complete nutrition. milk replacers are commercially available and should be fed according to manufacturer's recommendations vaccination programs for calves vary with the preventive medicine program for the overall herd. passive immunity provided by colostrum from cows on sound management programs will last until a calf is about - months old; normally vaccinations are not necessary and are contraindicated during those first months. the duration of passive immunity varies considerably among calves, however; some producers choose to begin vaccinating calves at - months of age and continue with monthly booster immunizations until the animals are months old, when passive immunity is no longer a possibility. artificial insemination (ai) in sheep is more difficult than in cattle because sheep are smaller and cannot be reproductively manipulated via the rectum and because the cervix of sheep is more difficult to traverse with the insemination pipette. breeding animals artificially with fresh semen produces pregnancy rates averaging % (not unlike that of cattle); artificial insemination with frozen semen is less successful. several artificial insemination techniques have been used. laparoscopic ai involves the surgical instillation of semen into the uterus through a small abdominal opening. the procedure is successful but is technically involved and costly. cervical ai involves the transvaginal introduction of semen into the cervix. a modification of this technique (transcervical ai) allows for penetration through the cervix into the uterus. this method (called the guelph system for transcervical ai) leads to successful penetration into the uterus in up to % of ewes when performed by an experienced inseminator. artificial insemination is now an integral part of dairy herding; natural insemination as a management practice is relatively rare. technicians performing the ai technique are available through commercial enterprises. dairy production employees are also trained. information regarding the management of the donors and recipients, the storage and handling of the semen, and the skills and record keeping required is covered extensively elsewhere (nebel, ) . because sheep are hormonally similar to other ruminants, estrous synchronization techniques are comparable. progesterone suppresses follicle-stimulating hormone (fsh) secretion, preventing animals from developing follicles and exhibiting estrus. artificial or natural progesterone can be administered in the feed, through parenteral injection, subcuticular implants, and vaginal pessaries. the progesterone is withdrawn in about - days, after which the fsh secretion will initiate the process of follicle development (trower, ) . estrus usually will occur in - hr (average is hr). a natural method of synchronization, often applied to promote flock breeding within a short period of time (and thus parturition will be within a narrow window as well), is the introduction of sterile rams with the ewes before the beginning of the normal fall mating period. pheromones released from males naturally stimulate the females to cycle and to synchronize their heats. it should be noted that introduction of a male during late anestrus will often stimulate ovulation in about days; however, this cycle will generally be without clinical signs of estrus (silent heat). vasectomy of rams is one method of producing sterile "teaser rams." introduction of the buck to a group of does will induce ovulation and may even synchronize does. does that are kept separate from the buck will show signs of estrus, will ovulate within - days, and will have normal pregnancies when introduced to a buck. bucks with horns and intact scent glands are better able to induce ovulation than dehorned bucks, whose scent glands often been removed. control of breeding in the goat has been studied mostly in dairy breeds in order to produce milk throughout the year and to reduce kidding labor. goats in the luteal phase of the estrous cycle, days - , are sensitive to pgf ~ ( . - mg im) and will show estrus in - hr postinjection (bretzlaff, ) . dosing cycling animals twice days apart will synchronize goats, and artificial insemination using this method has resulted in - % conception rates (bretzlaff, ; greyling and van niekerk, ) . programs for timed breeding have been described and involve administering progestogens (bretzlaff, ) . vaginal pessaries of fluorogestone acetate left in place for days in the doe followed by an injection of pregnant mare serum gonadotropin (pmsg) at the time of pessary removal have proven successful. also, when primed by pgf ~, an day regimen of fluorogestone acetate with pmsg given on day has been successful. synchronization of cattle estrous cycles and superovulation are used as management techniques in certain commercial cattle and dairy production settings where estrus synchronization or embryo transfer is advantageous to production and management. the methodology is also used in the research setting for coordinating donors and recipients of embryos or other genetically manipulated tissues for implantation. the options and dosing regimens are described in detail in veterinary clinical texts (wenzel, ; vanderboom et al., ) . in synchronization, the principle is lysis of the existing corpus luteum. the more common practices involve the use of products approved for use in cattle such as pgf ~, one of its analogs, or products containing estradiol valerate. progestogens are also used in conjunction with estradiol valerate. other approaches, involving management techniques combined with pharmacologic interventions, are considered less successful. superovulation regimens involve injections of fsh either alone or with pgf ~ at timed internals. estrus is expected hr after the final injection, and two inseminations are performed at hr intervals after estrus detection. preparation of recipients involves injection of pgf ~ or progestogens with gonadotropins such as pmsg. for greatest success as management tools, these must be combined with a consistent program that provides appropriate nutrition for all cattle involved. synchronization of animals is also influenced by several other factors, however, such as time in the cycle when hormones are administered, response by each individual animal, whether the cow is a dairy or beef animal, parity and maturity of the cows, success of heat detection after the luteolysis, and accurate record keeping. embryo transfer involves the removal of multiple embryos from a superovulated embryo donor and transferring them to synchronized recipients. this method maximizes the genetic potential of the donor animal. the donor animal is hormonally superovulated and inseminated. in sheep, about week after breeding, the embryos are surgically removed from the donor's uterus. in cattle, the procedure is nonsurgical. about % of expected embryos (determined by counting corpora lutea) can be recovered; successful recovery is affected by factors such as age of the donor, reproductive health, and experience of the surgeon or technician. furthermore, not all collected embryos are of transferable quality. recipients are hormonally synchronized with the donor animals. on the day of embryo collection, transferable embryos are implanted into the uterus of the recipient; laparoscopy has been used in the past and is now being replaced by nonsurgical methods. pregnancy rates average about %. if recipients are not available, embryos, like sperm, can be frozen and kept for later transfer. embryo transfer is commonly practiced in cattle as a herd improvement technique and as a research technique for engineered embyros. disease screening programs for all animals involved are important because several pathogens can be transmitted directly or indirectly, such as bovine viral diarrhea virus, bluetongue virus, infectious bovine rhinotracheitis virus, and mycoplasmal species. in sheep flocks and goat herds, as noted, male young are usually castrated by month of age. the elastrator method is the more popular for animals less than week of age. other methods include the emasculatome (crushing) and surgical removal ("knife method"). the distress associated with castration and tail docking in lambs is the subject of debate and has been researched recently (kent et al., ) . as noted, male calves are usually castrated as early as possible and no later than month of age. in some production situations, however, where maximum hormone responsive muscle development and grouping animals together for procedures dictate scheduling, the procedure may be performed on older males. open and closed techniques are used, depending on the age of animals and on veterinary or farm practice. breeding and vasectomized rams and bucks are usually maintained by medium to large production farms. smaller farms often borrow breeding males. breeding males are typically selected by production record, pedigree, and/or breed. vasectomized males are often retired breeders and should be tattooed or identified clearly to avoid any wasted breeding time. the vasectomy technique for both species is comparable (smith and sherman, ) . rams may be housed together for most of the year, whereas bucks are penned separately. because ewes will exhibit only a limited number of estrous cycles before becoming reproductively quiescent, it is critical that the male be capable of successfully breeding the female in an expeditious manner. any defects in the external genitalia, reproductive diseases, or musculoskeletal abnormalities may prevent successful copulatory behaviors. furthermore, it is impor-tant to know the semen quality of the ram as one indicator of fertility. semen can be collected via electroejaculation or by use of a teaser mount. once semen is collected, it should be handled carefully and kept warm to prevent sperm death, leading to improper conclusions about the male. typically, the characteristics usually evaluated as a determinate of sperm quality are volume (normal between . and . ml); motility (% of sperm moving in a forward wave; high quality is associated with motility of approximately %); concentration (sperm count per unit of volume as measured by a hemocytometer; high-quality semen should contain . x sperm per ml); morphology (live versus dead cells, as determined by special stains and the percentage of abnormal-appearing sperm; neither the abnormalities nor the dead sperm should exceed % in high-quality semen). the extensive use of artificial insemination in the dairy cattle industry has minimized the use of bulls on many farms, although a farm may maintain a few bulls for heat detection and for "cleanup" breeding. breeding bulls are maintained in beef production establishments. breeding bulls must be part of the herd vaccination program, with special attention to appropriate timing of immunizations for the commonly transmitted venereal diseases campylobacteriosis and trichomoniasis. tail docking is a relatively recent development in dairy herd management and is practiced in the belief that it will minimize bacterial contamination of the udder and therefore the milk. tails are typically docked to about inches in length. the practice is more popular in certain regions in the united states. to date, there is no published study indicating that this technique provides any distinctive advantage over keeping the tail switch hair clipped short. healthy ruminants have good appetites, chew cud, are alert and curious, have healthy intact coats, move without hindrance, and have clear, bright, clean eyes and cool dry noses. even adult animals, when provided sufficient space, will play. sheep and goats have tidy "pelleted" dark green feces. cattle have pasty, moist, dark green-brown feces. ruminants normally vocalize, and handlers will learn to recognize normal communication among the group or directed at caregivers in contrast to that when animals are stressed. excessive, strained vocalizations are often a sign of stress in cattle. "bruxism," or grinding of the teeth by a ruminant, is usually associated with discomfort or pain. other signs of discomfort, stress, or illness include decreased time spent eating and cud chewing, restlessness, prolonged recumbency with outstretched neck and head, and hunched back when standing. unhealthy ruminants may be thin, may arch their backs or favor a limb, or may have external lumps or swollen joints, an unusual abdominal profile, or rough or dull coats. all ruminants are herd animals to some extent and social individuals; therefore, every effort should be made to allow contact among animals, in terms either of direct contact or of sound, smell, or sight. human contact and handling should be initiated promptly and maintained regularly and consistently throughout the animal's stay in the research facilities. animals should be provided sufficient time to acclimate to handlers and research staff. cattle and sheep can hear at higher frequencies than humans can and may react to sounds not perceived by handlers. knowledge of the peculiarities of sheep behavior will increase the ease of handling and decrease stress-related effects in research. generally, fine-wooled breeds, such as rambouillet, are the most gregarious and are best handled in groups. the meat, or "downs," breeds tend to be less gregarious, and the long-wooled breeds tend to be solitary (ross, ; asia, ) . nonetheless, movement of animals is simplified by proper facility design. sheep have a wide-angle visual field and are easily scared by activities that are taking place behind them. sheep should be moved slowly and gently. to capture individuals within a flock, it is best to confine the flock to a smaller space and use a shepherd's crook or to gently catch the animal in front of the neck/thorax. grabbing the wool can injure the animals, as well as damage the wool and the underlying tissues. sheep move best in chutes that have solid walls, and individual animals will generally follow a lead animal. any escape route will be challenged and, if successfully breached, will disrupt the entire flock movement. sheep movement is also disrupted by contrasts such as light and shadows that impinge on a chute or corral. finally, like most animals, sheep have a flight zone (minimum zone of comfort), the penetration of which will result in sheep scattering. this minimal flight distance can be modified by increasing handling of the animals and working at the edge of the zone, but it should always be considered when working with animals in chutes, pens, or other confined areas. goats exhibit behavioral characteristics that make them quite distinct from other ruminants. their browsing activity makes them quite orally investigative. goats will readily nibble or chew just about anything they come in contact with, so researchers should keep all paperwork and equipment out of reach. a herd of goats will readily chew through wood gates and fencing, especially when confined in areas without alternatives for chewing behavior. goats are also inquisitive, restless, agile jumpers and climbers, and quite mischievous. if maintained in paddocks, strong high fences are essential, as are adequate spaces for exercise or boulders or rock piles for hoof maintenance and recreational climbing. goats are more tolerant of isolation and are more easily acclimated to human contact than sheep are, but goats will confront unfamiliar intruders and make sneezing noises. goats with horns will use them to advantage, and horns may also become entangled in fencing. although less strongly affected by flock behavior, goats are social animals. most goats raised in close human contact are personable and cooperative and can easily be taught to stand for various procedures, including blood collection. an understanding of breed behaviors, sources of stress in cattle, play behaviors, calf behaviors, and dominance determinants will contribute to prevention of injuries to handlers and better health and welfare of the animals. ruminants of all ages, especially cattle of all ages, should be handled with an appreciation of the serious injury to human handlers that may result (houpt, ) . cattle have a wide visual field, as sheep do, and a flight zone that varies in size, according to previous handling experiences (gentle handling and animal tameness make the flight zone smaller) and the circumstances of the moment (grandin, ) . groups of cattle are moved effectively around a facility by utilizing chute systems, with sequences of gates, that minimize chances of animals turning around. dairy cattle have been bred and selected over centuries for their docile, tractable characters and production characteristics. in contrast, beef breeds have not been selected for docility and are generally more difficult to handle and restrain. beef breeds, such as angus, are known for their independent natures and protective maternal instincts. all cattle respond well to feed as a reward for desired behavior. healthy cattle typically are very curious and watchful and are alert to sounds and smells. when not grazing or eating, they hold their heads up. when sleeping, the head and neck may be tucked back. because of ruminant digestive and metabolic needs, much of the day is spent eating or cud chewing. occasionally, adult cows sit upright like dogs. cattle maintained inside tend to be more docile. in addition to forced isolation from other cattle, sources of stress include rough attitudes of handlers and unfamiliar visual patterns, routines, or environments. these stressors may exacerbate signs of systemic illnesses. calves are known for non-nutritive suckling, bar licking, and tongue rolling. non-nutritive suckling behavior is greater in hungry calves and also right after a milk meal. it is best to provide nipples and other clean noninjurious materials for the animals to suck. non-nutritive suckling can be detrimental in group-housed calves because it can result in disease transmission and hair ball formation. environmental enrichment devices have been developed to cope with this behavior. the behavior diminishes as the animals are weaned onto solid food (morrow-tesch, ) . play activity and vocalizations of calves mimic adult dominance behaviors. play activity by young adult cattle is more common in males, can be quite rough, and is often triggered by a change in the environment. dominance behaviors are dependent on direct physical contact among the cattle, and dominance hierarchies are established within a herd. horns, age, and weight have been reported to be the most important determi-nants. aggressive behaviors in cattle may be triggered by newly introduced animals or unfamiliar visual patterns and by feeding when animals are very hungry. aggression is more common among intact adult males. this section focuses primarily on the more common diseases affecting sheep, goats, and cattle in the united states and elsewhere in north america and those that are reportable. for detailed information not included in this limited overview and for diseases of importance internationally, the authors recommend several excellent comprehensive and focused veterinary clinical texts and periodicals that address ruminant diseases, preventive medicine, and individual and flock or herd management. these are listed under "major references" in the reference list at the end of this chapter. recommendations for current drug therapies, both approved and off-label use in ruminants, including withholding prior to slaughter, formularies, and related information can be found in the references noted above and in formularies (hawk and leary, ; plumb, ) . in addition, the food animal residue avoidance databank (farad), accessible on the internet <http://www.farad.org>, should be used as a resource. farad is a food safety project of the u.s. department of agriculture and is an information resource to prevent drug and pesticide residues in food animals and animal products. food; may be anorexic, weak, unthrifty and depressed; and may salivate excessively. diagnosis is made based on clinical signs and is confirmed by culture. epizootiology and transmission. the organism penetrates wounds of the skin, mouth, nose, gastrointestinal tract, testicles, and mammary gland. rough feed material and foreign bodies may play a role in causing abrasions. actino bacillus lignieresii then enters into deeper tissues, where it causes chronic inflammation and abscess formation. lymphatic spread may occur, leading to abscessation of lymph nodes or infection of other organs. necropsy findings. purulent discharges of white-green exudate drain from the tracts that often extend from the area of colonization to the skin surface. exudates will also contain characteristic small white-gray (sulfurlike) granules. the pus is usually nonodorous. differential diagnosis. contagious ecthyma and caseous lymphadenitis are the primary differentials. diseases or injuries causing oral pain and discomfort, such as dental infections, foreign bodies, and trauma, should be considered. treatment. animals should be fed softer feeds. antibiotics such as sulfonamides, tetracyclines, and ampicillin are effective, although high doses and long durations of therapy are required. penicillin is not effective. weekly systemic administration of sodium iodide for several weeks is not as effective as antibiotic therapy. surgical excision and drainage are not recommended. etiology. actinobacillus lignieresii is an aerobic, nonmotile, non-spore-forming, gram-negative rod that is widespread in soil and manure and is found as normal flora of the respiratory, gastrointestinal, and reproductive tracts of ruminants. in sheep and cattle, a. lignieresii causes sporadic, noncontagious, and potentially chronic disease characterized by diffuse abscess and granuloma formation in tissues of the head and occasionally other body organs. this disease, called wooden tongue, has not been documented in goats. clinical signs. skin lesions are common. tongue lesions are more common in cattle than in sheep. lip lesions are more common in sheep. soft-tissue or lymph node swelling accompanied by draining tracts is observed in the head and neck regions, as well as other areas. animals may have difficulty prehending prevention and control. because the organism enters through tissue wounds, especially those associated with oral trauma, feedstuffs should be closely monitored for coarse material and foreign bodies. b. arcanobacterium infection (formerly actinomycosis, or "lumpy jaw") etiology. arcanobacterium (formerly known as actinomyces or corynebacterium) pyogenes and a. bovis are anaerobic, nonmotile, non-spore-forming, gram-positive, pleomorphic rods to coccobacilli. arcanobacterium bovis is a normal part of the ruminant oral microflora and is the organism associated with "lumpy jaw" in cattle; this syndrome is rarely seen in sheep and goats. this organism has also been associated with pharyngitis and mastitis in cattle. clinical signs and diagnosis. arcanobacterium bovis causes mandibular lesions primarily. the mass will be firm, nonpainful, and immovable. draining tracts may develop over time. if teeth roots become involved, painful eating and weight loss are evident. radiographic studies are helpful for determining fistulas. diagnosis is based on clinical signs, and culture is required to confirm arcanobacterium. the prognosis is poor for lumpy jaw. epizootiology and transmission. these organisms are normal flora of the gastrointestinal tracts of ruminants and gain entrance into the tissues through abrasions and penetrating wounds. necropsy. draining lesions with sulfurlike granules (as with actinobacillosis) are frequently observed. ious degrees of depression and anorexia, and purulent discharges may be seen draining from the umbilicus. involvement of the urachus is usually followed by cystitis and associated signs of dysuria, stranguria, hematuria, and so on. severe sequelae may include septicemia, peritonitis, septic arthritis (joint ill), meningitis, osteomyelitis, and endocarditis. research complications. young stock affected by omphalophlebitis may be inappropriate subjects because of growth setbacks and physiologic stresses from the infection. affected adult animals will not thrive and, even with therapy, may not be appropriate research subjects. pathogenesis. arcanobacterium pyogenes is known to produce an exotoxin, which may be involved in the pathogenesis. differential diagnosis. actinobacillus lignieresii and caseous lymphadenitis are important differentials for draining tracts. a major differential for omphalophlebitis is an umbilical hernia, which will typically not be painful or infected. there are many differentials for septic joints and polyarthritis: chlamydia spp., mycoplasma spp., streptococci, coliforms, erysipelothrix rhusiopathiae, fusobacterium necrophorum, and salmonella spp. tumors, trauma to the affected area, such as the mandible, and dental disease or oral foreign body should also be considered. prevention and control. arcanobacterium bovis lesions can be prevented or minimized by feeds without coarse or sharp materials. treatment. penicillin or derivatives such as ampicillin or amoxicillin are treatments of choice. sodium iodides (intravenous) and potassium iodides (orally) have been utilized also. extended antibiotic therapy may be necessary. surgical excision is an option. in addition to medications noted above, isoniazid is somewhat effective for a. bovis infections in nonpregnant cattle. research complications. the possibility of long-term infection and long therapy are factors that will diminish the value of affected research animals. omphalophlebitis, omphaloarteritis, omphalitis, and navel ill are terms referring to infection of the umbilicus in young animals. arcanobacterium pyogenes is the most common organism causing omphalophlebitis, an acute localized inflammation and infection of the external umbilicus. most cases occur within the first months of age, and animals are presented with a painful enlargement of the umbilicus. animals may exhibit var- etiology. bacillus anthracis is a nonmotile, capsulated, sporeforming, aerobic, gram-positive bacillus that is found in alkaline soil, contaminated feeds (such as bonemeal), and water. common names for the disease anthrax include woolsorters' disease, splenic fever, charbon, and milzbrand. clinical signs and diagnosis. anthrax is a sporadic but very serious infectious disease of cattle, sheep, and goats characterized by septicemia, hyperthermia, anorexia, depression, listlessness, depression, and tremors. subacute and chronic cases may occur also and are characterized by swelling around the shoulders, ventral neck, and thorax. the incubation period is day to weeks. bloody secretions such as hematuria and bloody diarrhea often occur. abortion and blood-tinged milk may also be noted. the disease is usually fatal, especially in sheep and goats, after - days. death is the result of shock, renal failure, and anoxia. diagnosis is based on the clinical signs of peracute deaths and hemorrhage. stained blood smears may show short, single to chained bacilli. blood may be collected from a superficial vein and submitted for culture. epizootiology and transmission. cattle and sheep tend to be affected more commonly than goats, because of grazing habits. older animals are more vulnerable than younger, and bulls are more vulnerable than cows. although the disease occurs worldwide, and even in cold climates, most cases in the united states occur in the central and western states, and outbreaks usually occur as the result of spore release after abrupt climatic changes such as heavy rainfall after droughts or during warmer, dryer months. spores survive very well in the environment. the anthrax organisms (primarily spores) are generally ingested, sporulate, and replicate in the local tissues. abrasive forages may play a role in infection. transmission via insect bites or through skin abrasions rarely occurs. necropsy. necropsies should not be done around animal pens or pastures, and definitive diagnoses may be made without opening the animals. incomplete rigor mortis, rapid putrefaction, and dark, uncoagulated blood exuding from all body orifices are common findings. blood collected carefully and promptly from peripheral veins of freshly dead animals can be used diagnostically. splenomegaly, cyanosis, epicardial and subcutaneous hemorrhages, and lymphadenopathy are characterisitic of the disease. pathogenesis. the rapidly multiplying organisms enter the lymphatics and bloodstream and result in a severe septicemia and neurotoxicosis. encapsulation protects the organisms from phagocytosis. liberated toxins cause local edema. differential diagnosis. although anthrax should always be considered when an animal healthy the previous day dies acutely, other causes of acute death in ruminants should be considered, e.g., bloat, poisoning, enterotoxemia, malignant edema, blackleg, and black disease. prevention and control. outbreaks must bereported to state officials. anthrax is of particular concern as a bioterrorism agent. any vaccination programs should also be reviewed with regulatory personnel. herds in endemic areas and along waterways are usually vaccinated routinely with the sterne-strain spore vaccine (virulent, nonencapsulated, live). careful hygiene and quarantine practices are crucial during outbreaks. dead animals and contaminated materials should be incinerated or buried deeply. biting insects should be controlled. the disease is zoonotic and a serious public health risk. treatment. treatment of animals in early stages with penicillin and anthrax antitoxin (hyperimmune serum, if available) may be helpful. amoxicillin, erythromycin, oxytetracycline, gentamicin, and fluoroquinolones are also good therapeutic agents. during epidemics, animals should be vaccinated with the sterne vaccine. research complications. natural and experimental anthrax infections are a risk to research personnel; the pathogen may be present in many body fluids and can penetrate intact skin. the organism sporulates when exposed to air, and spores may be inhaled during postmortem examinations. etiology. brucella is a nonmotile, non-spore-forming, nonencapsulated, gram-negative coccobacillus. brucella abortus is one of several brucella species that infects domestic animals but cross-species infections occur rarely. brucella abortus or b. melitensis may cause brucellosis in sheep, cattle, and goats. brucella melitensis (biovar , , or ) is the primary cause of sheep disease (garin-bastuji et al., ) . brucella ovis is more commonly associated with ovine epididymitis or orchitis than abortion. in the united states, clusters of brucellosis are still found in western areas contiguous to yellowstone national park. bang's disease is the common name given to the disease in ruminants. clinical signs and diagnosis. brucella melitensis in the adult ewe is generally asymptomatic and self-limiting within about months. however, because the organism may enter and cause necrosis of the chorionic villi and fetal organs, abortion or stillbirths may occur. abortion usually occurs in the third trimester, after which the ewe will appear to recover. it has been reported that up to % of infected ewes may abort more than once. rams will also be infected and may develop orchitis or pneumonia. the disease caused by b. ovis is manifested by clinical or subclinical infection of the epididymis, leading to epididymal enlargement and testicular atrophy. brucella ovis causes decreased fertility. brucella melitensis is the more common cause of brucellosis in goats. brucella abortus has been shown to infect goats in natural and experimental infections, and b. ovis has also been shown to infect goats experimentally. does infected with b. melitensis will also abort during the third trimester. infections with b. abortus in cattle produce few clinical signs. there may be a brief septicemia during which organisms are phagocytosed by neutrophils and fixed macrophages in lymph nodes. in cows, the organism localizes in supramammary lymph nodes and udders and in the endometrium and placenta of pregnant cows. infection may cause abortions after the fifth month, with resulting retained placentas. permanent infection of the udder is common and results in shedding of organisms in milk. in bulls, the organism may cause unilateral orchitis and epidydimitis and involvement of the secondary sex organs. organisms may be in the semen. in infected herds, lameness may also be a clinical sign. diagnosis of brucellosis can be made by bacterial isolation of the brucella organism from necropsy samples (especially the fetal stomach contents), as well as by supportive serological evidence. many serological tests are available, such as the tube and plate agglutination tests, the card or rose bengal test, the rivanol precipitation test, complement fixation, enzyme-linked immunosorbent assay (elisa), polymerase chain reaction (pcr), and others. test selection is often dependent on state requirements in the united states. epizootiology and transmission. the primary route of transmission of b. abortus is ingestion of the organism from infected tissues and fluids (milk, vaginal and uterine discharges) during and for a few weeks after abortion or parturition; contaminated semen is considered to be a minor source of infection. exposure to the organism may occur via the gastrointestinal tract (contaminated feed or water), the respiratory tract (droplet infection), or the reproductive tract (contaminated semen) and through other mucous membranes such as the conjunctiva. brucella ovis is transmitted in the semen, as well as orally or nasally through contaminated feed and bedding. necropsy findings. a sheep fetus aborted due to brucella will exhibit generalized edema. the liver and spleen will be swollen, and serosal surfaces will be covered with petecchial hemorrhages. peritoneal and pleural cavities often contain serofibrinous exudates. the placenta will be leathery. pathogenesis. ruminants are considered especially susceptible to brucella infection, because of higher levels of erythritol (a sugar alcohol), which is a growth stimulant for the organism. brucella utilizes erythritol preferentially over glucose as an energy source. placentas and male genitalia also contain high levels of erythritol. brucella organisms also evade lysis when phagocytosed by macrophages and neutrophils and survive intracellularly in phagosomes. abortion is the result of placentitis, typically during the third trimester of gestation. brucella ovis enters the host through the mucous membranes, then passes into the lymphatics, causes hyperplasia of reticuloendothelial cells, and is spread to various organs via the blood. the organism localizes in the epididymides, the seminal vesicles, the bulbourethral glands, and the ampullae. orchitis may be a sequelae of the disease. epididymitis can be diagnosed by identifying gross lesions by palpation of the epididymides, by serological evidence of antibodies to b. ovis, and by semen cultures. differential diagnosis. differential diagnoses include all other abortion-causing diseases. many other agents, such as actinobacillus spp., arcanobacterium (actinomyces) pyogenes, eschericia coli, pseudomonas spp., proteus mirabilis, chlamydia, mycoplasma, and others may be associated with ovine epididymitis and orchitis. a clinically and pathologically similar agent, actinobacillus seminis, has been isolated from virgin rams. this organism has morphological and staining characteristics similar to those of b. ovis and complicates the diagnosis (genetzky, ) . prevention and control. the rev vaccine has been recommended for vaccination of ewe lambs in endemic areas, but this vaccine is not used in the united states. separating young rams from potentially infected older males, sanitizing facilities, and vaccinating them with b. ovis bacterin can prevent the disease. over the past years, aggressive federal and state regulatory and cattle herd health programs in the united states have provided control and prevention mechanisms for this pathogen through a combination of serological monitoring of herds, slaughter of diseased animals, herd management, vaccination programs, and monitoring of transported animals. most states are considered brucellosis-free in the cattle populations; thus, procurement of ruminants that have been exposed to this infectious agent will be unlikely. cattle vaccination programs can be very successful when conducted on a herd basis to reduce likelihood of exposure. strain and the recently validated attentuated strain rb are live vaccines and can be used in healthy heifer calves - months old. vaccination for older animals may be done under certain circumstances. vaccination of bull calves is not recommended, because of low likelihood of spread through semen and possibility of vaccination-induced orchitis. the strain vaccine induces long-term cell-mediated immunity, protects a herd from abortions, and protects the majority of a herd from reactors during a screening and culling program. the vaccine will not, however, protect the animals from becoming infected with b. abortus. strain vaccine induces an antibody response in cattle. the rb vaccine does not result in antibody titers and therefore is advantageous because infection with brucella can be determined serologically. the rb vaccine has been designated as the official calfhood bovine brucellosis vaccine in the united states by the u.s. department of agriculture's animal and plant health inspection service (aphis) (stevens et al., ) . brucella vaccine should be administered to unstressed, healthy cattle, with attention to particular side effects of the vaccination material and to prevention of compounding stresses associated with weaning, regrouping, other management changes, and shipping. the rb is regarded as less pathogenic and abortigenic in cattle. clinical signs and diagnosis. ovine vibriosis is a contagious disease that causes abortion, stillbirths, and weak lambs. the organism inhabits the intestines and gallbladder in subclinical carriers. abortion generally occurs in the last trimester, and abortion storms may occur as more susceptible animals, such as maiden ewes, become exposed to the infectious tissues. it is reported that - % of the flock may become infected and up to % of the ewes will die (jensen and swift, ) . some lambs may be born alive but will be weak, and dams will not be able to produce milk. diagnosis is achieved by microscopic identification or isolation of the organism from placenta, fetal abomasal contents, and maternal vaginal discharges. tentative identification of the organism can be made by observing curved ("gull-wing") rods in giemsa-stained or ziehl-neelsen-stained smears from fetal stomach contents, placentomes, or maternal uterine fluids. epizootiology and transmission. campylobacteriosis occurs worldwide. campylobacter spp., such as c. jejuni, normally inhabit ovine gastrointestinal tracts. transmission of the disease occurs through the gastrointestinal tract, followed by shedding, especially associated with aborted tissues and fluids. in abortion storms, considerable contamination of the environment will occur due to placenta, fetuses, and uterine fluids. ewes may have active campylobacter organisms in uterine discharges for several months after abortion. the bacteria will also be shed in feces, and feed and water contamination serve as another source. there is no venereal transmission in the ovine. necropsy. aborted fetuses will be edematous, with accumulation of serosanguinous fluids within the subcutis and muscle tissue fascia. the liver may contain - cm pale foci. placental tissues will be thickened and edematous and will contain serous fluids similar to those of the fetus. the placental cotyledons may appear gray. pathogenesis. the organism enters the bloodstream and causes a short-term bacteremia ( - weeks) prior to the localizing of the bacteria in the chorionic epithelial cells and finally passing into the fetus. should be considered in late gestation ovine abortions. a bacterin is available to prevent the disease. carrier states have been cleared by treating with a combination of antibiotics, including penicillin and oral chlortetra-cycline. aborting ewes should be isolated immediately from the rest of the flock. after an outbreak, ewes will develop immunity lasting - years. treatment. infected animals should be isolated and provided with supportive therapy. prompt decontamination of the area and disposal of the aborted tissues and discharges are important. research complications. losses from abortion may be considerable. campylobacter ssp. are zoonotic agents, and c. fetus subsp, intestinalis may be the cause of "shepherd's scours." ii. clinical signs and diagnosis. preliminary signs of a problem in the herd will be a high percentage of cows returning to estrus after breeding and temporary infertility. this will be particularly apparent in virgin heifers that may return to estrus by days after breeding. long interestrous intervals also serve an indication of a problem. spontaneous abortions will occur in some cases, typically during the fourth to eighth months of gestation. severe endometritis may lead to salpingitis and permanent infertility. demonstration or isolation of the organism, a curved rod with corkscrew motility, is the basis for diagnosis. the vaginal mucous agglutination test is used to survey herds for campylobacteriosis. serology will not be worthwhile, because the infection does not trigger a sufficient antibody response. culture from breeding animals may be difficult because campylobacter will be overgrown by faster-growing species also present in the specimens. epizootiology and transmission. the bacteria is an obligate, ubiquitous organism of the genital tract. transmission is from infected bulls to heifers. older cows develop effective immunity. necropsy findings. necrotizing placentitis, dehydration, and fibrinous serositis will be found grossly. in addition, bronchopneumonia and hepatitis will be seen histologically. pathogenesis. campylobacter organisms grow readily in the genital tract, and infection is established within days of exposure. the resulting endometritis prevents conception or causes embyronic death. differential diagnosis. the primary differential diagnosis for campylobacteriosis is trichomoniasis. other venereal diseases should be considered when infertility problems are noted in a herd. these include brucellosis, mycoplasmosis, ureaplasmosis, infectious bovine rhinotracheitis-infectious pustular vulvovaginitis (ibr-ipv), and bovine virus diarrhea (bvd). leptospirosis should also be considered. in addition, management factors such as nutrition and age of heifers at introduction to the herd should be considered. prevention and control. killed bacterin vaccines are available, either as oil adjuvant or as aluminum hydroxide adsorbed. the former is preferred because of duration of immunity but causes granulomas. that vaccine also has specific recommendations regarding administration several months before the breeding season. the latter product is administered closer to the breeding season, and the duration of immunity is not as prolonged. in both cases, boosters should be given after the initial immunization and as part of the regular prebreeding regimen. only one bacterin product is approved for use in bulls. many combination vaccine products contain only the aluminum hydroxide adsorbed product. artificial insemination (ai) is particularly useful at controlling the disease, but bulls used for ai must be part of a screening program for this and other venereal diseases such as trichomoniasis. treatment. cows will usually recover from the infection, and treatment with antibiotics such as penicillin, administered as an intrauterine infusion, improve the chances of returning to breeding condition. etiology. the most common caprine bacterial skin infection is caused by staphylococcus intermedius or s. aureus and is known as staphylococcal dermatitis (smith and sherman, ) . the staphylococcus organisms are cocci and are categorized as primary pathogens or ubiquitous skin commensals of humans and animals. staphylococcus aureus and s. intermedius are classified as primary pathogens and produce coagulase, a virulence factor. clinical signs and diagnosis. small pustular lesions, caused by bacterial infection and inflammation of the hair follicle, occur around the teats and perineum. occasionally, the infection may involve the flanks, underbelly, axilla, inner thigh, and neck. staphylococcal dermatitis may occur secondary to other skin lesions. diagnosis is based on lesions. culture will distinguish s. aureus. pathogenesis. simple boredom may cause rubbing, followed by staphylococcal infection of damaged epidermis. differential diagnosis. the presence of scabs makes contagious ecthyma a differential diagnosis, along with fungal skin infections and nutritional causes of skin disease. treatment. severe infections should be treated with antibiotics based on culture and sensitivity. severe lesions and lesions localized to the underbelly, thighs, and udder benefit by periodic cleaning with an iodophor shampoo and spraying with an antibiotic and an astringent (smith and sherman, ) . h. clostridial diseases i. clostridium perfringens type c infection (enterotoxemia and struck) etiology. clostridium perfringens is an anaerobic, grampositive, nonmotile, spore-forming bacterium that lives in the soil, in contaminated feed, and in gastrointestinal tracts of ruminants. the bacteria is categorized by toxin production. toxins include alpha (hemolytic), beta (necrotizing), delta (cytotoxic and hemoltyic), epsilon, and iota. types of c. perfingens are a, b, c, d, and e. this is a common and economically significant disease of sheep, goats, and cattle. clinical signs and diagnosis. the beta toxin associated with overgrowth of this bacterium results in a fatal hemorrhagic enterocolitis within the first hr of a young ruminant's life. many animals may be found dead, with no clinical presentation. affected animals are acutely anemic, dehydrated, anorexic, restless, and depressed and may display tremors or convulsions as well as abdominal pain. feces may range from loose gray-brown to dark red and malodorous. morbidity and mortality may be nearly %. a similar noncontagious but acutely fatal form of enterotoxemia in adult sheep, called struck, occurs in yearlings and adults. struck is rare in the united states. the disease is also caused by the beta toxin of c. perfringens type c and is often associated with rapid dietary changes or shearing stresses in sheep. although affected animals are usually found dead, clinical signs include uneasiness, depression, and convulsions. mortality is usually less than %. diagnosis is usually based on necropsy findings, although confirmation can be made by culture of the organism. identification of the beta toxin in intestinal contents may be difficult because of instability of the toxin. necropsy findings. necropsy findings include a milk-filled abomasum, and hemorrhage in the distal small intestine and throughout the large intestine. petechial hemorrhages of the serosal surfaces of many organs, especially the thymus, heart, and gastrointestinal tract, will be visible. hydropericardium, hydroperitoneum, and hemorrhagic mesenteric lymph nodes will also be present. pulmonary and brain edema may also be seen. histologically, the gram-positive c. perfringens organisms may be visible in excess numbers along the mucosal surface of the swollen, congested, necrotic intestines. in cases of struck, necropsy findings include congestion and erosions of the mucosa of the gastrointestinal tract, serosal hemorrhages, and serous peritoneal and pericardial fluids. in late stages of the disease and especially if prompt necropsy is not performed, the organism will infiltrate the muscle fascial layers and produce serohemorrhagic and gaseous infiltration of perimysial and epimysial spaces. pathogenesis. hemorrhagic enterotoxemia is an acute, sporadic disease caused by the beta toxin of clostridium perfringens type c. neonates ingest the organism, which then proliferates and attaches to the gastrointestinal microvilli and elaborates primarily the beta toxins. the trypsin inhibitors present in colostrum prevent inactivation of the beta toxin. the toxins injure intestinal epithelial cells and then enter the blood, leading to acute toxemia. the intestinal injury may result in diarrhea, with small amounts of hemorrhage. associated electrolyte and water loss result in dehydration, acidosis, and shock. differential diagnosis. differential diagnoses include other clostridial diseases such as blackleg and black disease, as well as coccidiosis, salmonellosis, anthrax, and acute poisoning. clinical signs in chronic cases in older animals, such as adult goats, include soft stools, weight loss, anorexia, depression, and severe diarrhea, sometimes with mucus and blood. mature affected sheep may be blind and anorectic and may head-press. necropsyfindings. necropsy findings are similar to those seen with c. perfringens type c. additionally, extremely necrotic, soft kidneys ("pulpy kidneys") are usually observed immediately following death. (this phenomenon is in contrast to what is normally associated with later stages of postmortem autolysis.) focal encephalomalacia, and petechial hemorrhages on serosal surfaces of the brain, diaphragm, gastrointestinal tract, and heart are common findings. diagnosis can be made from the typical clinical signs and necropsy findings as well as the observation of glucose in the urine at necropsy. shock, probably through vascular damage. the noncontagious, peracute form of enterotoxemia occurs in suckling, fast-growing animals, either nursing from their dams or on high-protein, high-energy concentrates. the largest, fastest-growing animals generally are predisposed to this condition; for example, lambs, fat ewe lambs, and usually singleton lambs tend to be most susceptible. the hyperglycemia and glucosuria seen in acute cases are due to epsilon toxin effects on liver glycogen metabolism. should be administered to the pregnant animals prior to parturition. an alternative includes administration of an antitoxin to the newborn lambs. the disease may become endemic once it is on the premises. treatment. treatment is difficult and usually unsuccessful. antitoxin may be useful in milder cases, and the antitoxin and toxoid can also be administered during an outbreak. differential diagnosis. tetanus, enterotoxigenic e. coli, botulism, polioencephalomalacia, grain overload, and listeriosis are differentials. prevention and control. vaccination prevents the disease. maternal antibodies last approximately weeks postpartum; thus young animals should be vaccinated at about this time. feeding regimens to young, fast-growing animals and feeding of concentrates to adults should be evaluated carefully. research complications. this disease can be costly in losses of neonates and younger animals. treatment. treatment consists of support (fluids, warmth), antitoxin administration, oral antibiotics, and diet adjustment. toxin that is proteolytically activated by trypsin. this disease caused by c. perfringens tends to be associated with sheep and is of less importance in goats and cattle. clinical signs. the peracute condition in younger animals is characterized by sudden deaths, which are occasionally preceded by neurological signs such as incoordination, opisthotonus, and convulsions. because the disease progresses so rapidly to death (within - hr), clinical signs are rarely observed. hypersalivation, rapid respirations, hyperthermia, convulsions, and opisthotonus have been noted. in acute cases, hyperglycemia and glucosuria are considered almost pathognomonic. etiology. clostridium tetani is a strictly anaerobic, motile, spore-forming, gram-positive rod that persists in soils and manure and within the gastrointestinal tract. at least serotypes of c. tetani exist. clinical signs. infection by c. tetani is characterized by a sporadic, acute, and fatal neuropathy. after an incubation period of days to weeks, the animal exhibits bloat; muscular spasticity; prolapse of the third eyelid; rigidity and extension of the limbs, leading to a stiff gate; an inability to chew; and hyperthermia. erect or drooped ears, retracted lips, drooling, hypersensitivity to external stimuli, and a "sawhorse" stance are frequent signs. the animal may convulse. death occurs within - days, and mortality is nearly %, primarily from respiratory failure. diagnosis is based on clinical signs. musclerelated serum enzymes such as aspartate aminotransferase (ast), creatinine kinase (ck), and lactate dehydrogenase (ldh) might be elevated. (jensen and swift, ) . serum cortisol may also be elevated, and stress hyperglycemia may be evident. permanent lameness may result in survivors. contaminant and is often found as part of the gut microflora of herbivores. the organisms sporulate and persist in the environment. all species of livestock are susceptible, but sheep and goats are more susceptible than cattle. individual cases may occur, or herd outbreaks may follow castration, tail docking, ear tagging, or dehorning. mouth wounds may also be sites of entry. pathogenesis. tetanus, or lockjaw, is caused by the toxins of c. tetani. all serovars produce the same exotoxin, which is a multiunit protein composed of tetanospasmin, which is neurotoxic, and tetanolysin, which is hemolytic. a nonspasmogenic toxin is also produced. contamination of wounds results in anaerobic proliferation of the bacterium and liberation of the tetanospasmin, which diffuses through motor neurons in a retrograde direction to the spinal cord. the toxin inhibits the release of glycine and y-aminobutyric acid from renshaw cells; this resuits in hypertonia and muscular spasms. proliferation of c. tetani in the gut of affected animals may also serve as a source and may produce clinical signs. the uterus is the most common site of infection in postparturient dairy cattle with retained placentas. differential diagnoses. early in the course of the infection, differential diagnoses include bloat, rabies, hypomagnesemic tetany, polioencephalomalacia, white muscle disease, enterotoxemia in lambs, and lead poisoning. polyarthritis of cattle is a differential for the gait changes in that species. necropsy findings. findings are nonspecific except for the inflammatory reaction associated with the wound. because of the low number of organisms necessary to cause neurotoxicosis, isolation of c. tetani from the wound may be difficult. administering tetanus antitoxin (e.g., at least iu in an adult sheep or goat); vaccinating with tetanus toxoid; administering of antibiotics (penicillin, both parenterally [potassium penicillin intravenously and procaine penicillin intramuscularly] and flushed into the cleaned wound), a sedative or tranquilizer (e.g., acepromazine or chlorpromazine) and a muscle relaxant; and keeping the animal in a dark, quiet environment. supportive fluids and glucose must be administered until the animal is capable of feeding. if the animal survives, revaccination should be done days after the previous dose. prevention and control like other ubiquitous clostridial diseases, tetanus is impossible to eradicate. the disease can be controlled and prevented by following good sanitation measures, aseptic surgical procedures, and vaccination programs. tetanus toxoid vaccine is available and very effective for stimulating long-term immunity. tetanus antitoxin can be administered ( iu in lambs) as a preventive or in the face of disease as an adjunct to therapy. both the toxoid and the antitoxin can be administered to an animal at the same time, but they should not be mixed in the syringe, and each should be administered at different sites, with a second toxoid dose administered weeks later. animals should be vaccinated or times during the first year of life. does and ewes should receive booster vaccinations within months of parturition to ensure colostral antibodies. research complications. unprotected, younger ruminants may be affected following routine flock or herd management procedures. contaminated or inadequately managed open wounds or lesions in older animals may provide anaerobic incubation sites. etiology. clostridium novyi, an anaerobic, motile, sporeforming, gram-positive bacteria, is the agent of bighead and black disease. clostridium novyi type d (c. hemolyticum) is the cause of bacillary hemoglobinuria, or "red water." clostridium chauvoei is the causative agent of blackleg. clinical signs. bighead is a disease of rams characterized by edema of the head and neck. the edema may migrate to ventral regions such as the throat. additional clinical signs include swelling of the eyelids and nostrils. most animals will die within - hours. black disease, or infectious necrotic hepatitis, is a peracute, fatal disease associated with c. novyi. it is more common in cattle and sheep but may be seen in goats. the clinical course is - days in cattle and slightly shorter in sheep. otherwise healthy-appearing adult animals are often affected. clinical signs are rarely seen, because of the peracute nature of the disease. occasionally, hyperthermia, tachypnea, inability to keep up with other animals, and recumbency are observed prior to death. bacillary hemoglobinuria is an acute disease seen primarily in cattle and characterized by fever and anorexia, in addition to the hemoglobinemia and hemoglobinuria indicated by the name. animals that survive a few days will develop icterus. mortality may be high. blackleg, a disease similar to bighead, causes necrosis and emphysema of muscle masses, serohemorrhagic fluid accumulation around the infected area, and edema (jackson et al., ) . blackleg is more common in cattle than in sheep. the incubation period is - days and is followed by hyperthermia, muscular stiffness and pain, anorexia, and gangrenous myositis. the clinical course is short, - hr, and untreated animals invariably die. blackleg in cattle can be associated with subcutaneous edema or crepitation; these do not usually occur in sheep. most lesions are associated with muscles of the face, neck, perineum, thigh, and back. epizootiology and transmission. bighead is caused by the toxins of c. novyi, which enters through wounds often associated with horn injuries during fighting. the c. novyi type b organisms produce alpha and beta toxins, and the alpha toxins are mostly responsible for toxemia, tissue necrosis, and subsequent death. clostridium novyi type d is endemic in the western united states. it is hypothesized that the c. chauvoei organisms enter through the gastrointestinal tract. black disease and bacillary hemoglobinuria are associated with concurrent liver disease, often associated with fasciola infections (liver flukes); it is sometimes seen as a sequela to liver biopsies. the diseases are more common in summer months, and fecal contamination of pastures, flooding, and infected carcasses are sources of the organism. birds and wild animals may be vectors of the pathogen. ingested spores are believed to develop in hepatic tissue damaged and anoxic from the fluke migrations. necropsy. diagnosis of black disease is usually based on postmortem lesions. subcutaneous vessels will be engorged with blood, resulting in dried skin with a dark appearance. carcasses putrefy quickly. in addition, hepatomegaly and endocardial hemorrhages are common, and hepatic damage from flukes may be so severe that diagnosis is difficult. blood coagulates slowly in affected animals. pathogenesis. the propagation of the clostridial organisms is self-promoted by the damage caused by the toxins and the increased local anaerobic environment created. clostridium novyi proliferates in the soft tissues of the head and neck, and the resultant clostridial toxin causes increased capillary permeability and the liberation of serous fluids into the tissues. mixed infections with related clostridial organisms may lead to increasing hemorrhage and necrosis in the affected tissues. diagnosis is based on clinical signs. in black disease and bacillary hemoglobinuria disease, the ingested clostridial spores are absorbed, enter the liver, and cause hepatic necrosis. associated toxemia causes subcutaneous vascular dilatation; increased pericardial, pleural, and peritoneal fluid; and endocardial hemorrhages. the toxins produced by c. novyi, identified as beta, eta, and theta, and each having enzymatic or lytic properties or both, also contribute to the hemolytic disease. clostridium chauvoei spores proliferate in traumatized muscle areas damaged by transportation, rough handling, or injury. differential diagnosis. differential diagnoses include other clostridial diseases as well as photosensitization. hemolytic diseases such as babesiosis, leptospirosis, and hemobartonellosis should be included as differentials. treatment. for c. chauvoei infection (blackleg), early treatment with penicillin or tetracycline may be helpful. treatment for black disease is not rewarding even if the animal is found before death. carcasses from bacillary hemoglobinuria losses should be burned, buried deeply, or removed from the premises. prevention and control. vaccinating animals with multivalent clostridial vaccines can prevent these diseases. subcutaneous administration of vaccine material is recommended over intramuscular. vaccinations may be useful in an outbreak. careful handling of ruminants during shipping and transfers will contribute to fewer muscular injuries. for bighead, mature rams penned together should be monitored for lesions, especially during breeding season. control of fascioliasis is very important in prevention and control of black disease and in the optimal timing of vaccinations. etiology. clostridium septicum is the species usually associated with malignant edema, but mixed infections involving other clostridial species such as c. chauvoei, c. novyi, c. sordellii, and c. perfringens may occur. clostridium spp. are motile (c. chauvoei, c. septicum) or nonmotile, anaerobic, spore-forming, gram-positive rods. clinicial signs. malignant edema, or gas gangrene, is an acute and often fatal bacterial disease caused by clostridium spp. the incubation period is approximately - days. the affected area will be warm and will contain gaseous accumulations that can be palpated as crepitation of the subcutaneous tissue around the infected area. regional lymphadenopathy and fever may occur. the animal becomes anorexic, severely depressed, and possibly hyperthermic. edema and crepitation may be noted around the wound; death occurs within hr to days. epizootiology and transmission. the organisms are ubiquitous in the environment and may survive in the soil for years. the disease is especially prevalent in animals that have had recent wounds such as those that have undergone castration, docking, ear notching, shearing, or dystocia. necropsy findings. the tissue necrosis and hemorrhagic serous fluid accumulations resemble those of other clostridial diseases. pathogenesis. in most cases, the clostridial organisms cause a spreading infection through the fascial planes around the area of the injury; vegetative organisms then produce potent exotoxins, which result in necrosis (alpha toxin) and/or hemolysis (beta toxin). furthermore, the toxins enter the bloodstream and central nervous system, resulting in systemic collapse and high mortality. necropsy. spreading, crepitant lesions around wounds are suggestive of malignant edema. affected tissues are inflamed and necrotic. gas and serosanguineous fluids with foul odors infiltrate the tissue planes. large rod-shaped bacteria may be observed on histopathology; confirmation is made through culture and identification. intramuscular inoculation of guinea pigs causes a necrotizing myositis and death. organisms can be cultured from guinea pig tissues. treatment. infected animals can be treated with large doses of penicillin and fenestration of the wound is recommended. prevention and control. proper preparation of surgical sites, correct sanitation of instruments and the housing environment, and attention to postoperative wounds will help prevent this disease. multivalent clostridial vaccines are available. research complications. morbidity or loss of animals from lack of or unsuccessful vaccination and from contaminated surgical sites or wounds may be consequences of this disease. etiology. escherichia coli is a motile, aerobic, gram-negative, non-spore-forming coccobacillus commonly found in the environment and gastrointestinal tracts of ruminants. escherichia coli organisms have three areas of surface antigenic complexes (o, somatic; k, envelope or pili; and h, flagellar), which are used to "group" or classify the serotypes. colibacillosis is the common term for infections in younger animals caused by this bacteria. clinical signs. presentation of e. coli infections vary with the animal's age and the type of e. coli involved. enterotoxigenic e. coli infection causes gastroenteritis and/or septicemia in lambs and calves. colibacillosis generally develops within the first hr of life when newborn animals are exposed to the organism. the enteric infection causes a semifluid, yellow to gray diarrhea. occasionally blood streaking of the feces may be observed. the animal may demonstrate abdominal pain, evidenced by arching of the back and extension of the tail, classically described as "tucked up." hyperthermia is rare. severe acidosis, depression, and recumbancy ensue, and mortality may be as high as %. the septicemic form generally occurs between and weeks of age. animals display an elevated body temperature and show signs suggestive of nervous system involvement such as incoordination, head pressing, circling, and the appearance of blindness. opisthotonos, depression, and death follow. occasionally, swollen, painful joints may be observed with septicemic colibacillosis. blood cultures may be helpful in identifying the septicemic form. in ruminants, e. coli is is a less common cause of cystitis and pyelonephritis. the cystitis is characterized by dysuria and pollakiuria; gross hematuria and pyuria may be present. the infection may or may not be restricted to the bladder; in the later presentation, and in cases of pyelonephritis, a cow will be acutely depressed, have a fever and ruminal stasis, and be anorexic. in chronic cases, animals will be polyuric and undergo weight loss. escherichia coli may also cause in utero disease in cattle, resulting in abortion or weakened offspring. epizootiology and transmission. escherichia coli is one of the most common gram-negative pathogens isolated from ruminant neonates. zeman et al. ( ) classify e. coli infections into four groups: enterotoxigenic, enterohemorrhagic, enteropathogenic, and enteroinvasive. enterotoxigenic e. coli (etec) attach to the enterocytes via pili, produce enterotoxins, and are the primary cause of colibacillosis in animals and humans. fimbrial (pili) antigens associated with ovine disease include k and f . enterohemorrhagic e. coli (ehec) attach and efface the microviuus, produce verotoxins, and occasionally cause disease in humans and animals. enteropathogenic e. coli (epec) colonize and efface the microvillus but do not produce verotoxins. epec are associated with disease in humans and rabbits and cause a secretory diarrhea. enteroinvasive e. coli (eiec) invade the enterocytes of humans and cause a shigella-like disease. overcrowding and poor sanitation contribute significantly to the development of this disease in young animals. the organism will be endemic in a contaminated environment and present on dams' udders. the bacteria rapidly proliferate in the neonates' small intestines. the bacteria and associated toxins cause a secretory diarrhea, resulting in the loss of water and electrolytes. if the bacteria infiltrate the intestinal barrier and enter the blood, septicemia results. diagnosis of the enteric form can be made by observation of clinical signs, including diarrhea and staining of the tail and wool. necropsy findings. swollen, yellow to gray, fluid-filled small and large intestines, swollen and hemorrhagic mesenteric lymph nodes, and generalized tissue dehydration are common. septicemic lambs may have serofibrinous fluid in the peritoneal, thoracic, and pericardial cavities; enlarged joints containing fibrinopurulent exudates; and congested and inflamed meninges. isolation and serotyping of e. coli confirm the diagnosis. elisa and latex agglutination tests are available diagnostic tools. differential diagnosis. differential diagnoses include the enterotoxemias caused by c. perfringens type a, b, or c; campylobacter jejuni; coccidia, rotavirus, coronavirus, salmonella, and cryptosporidia. other contributing causes of abomasal tympany in young ruminants, such as dietary changes, copper deficiency, excessive intervals between feedings of milk replacer, or feeding large volumes should be considered. prevention and control. the best preventive measures are maintenance of proper housing conditions, limiting overcrowding, and frequently sanitizing lambing areas. attention to colostrum feeding techniques and colostral quality are important means of preventing disease. treatment must include intravenous fluid hydration and reestablishment of acid-base and electrolyte abnormalities. treatment. antibiotics such as trimethoprim-sulfadiazine, enrofloxacin, cephalothin, amikacin, and apramycin may be helpful; oral antibiotics are not recommended. vaccines are available for prevention of colibacillosis in cattle. etiology. corynebacterium pseudotuberculosis (previously c. ovis) are nonmotile, non-spore-forming, aerobic, short and curved, gram-positive coccobacilli. caseous lymphadenitis (cla) is such a common, chronic contagious disease of sheep and goats that any presentation of abscessing and draining lymph nodes should be presumed to be this disease until proven otherwise. the disease has been reported occasionally in cattle. clinical signs and diagnosis. abscessation of superficial lymph nodes, such as the superficial cervical, retropharyngeal, subiliacs (prefemoral), mammary, superficial inguinals, and popliteal nodes, and of deep nodes, such as mediastinal and mesenteric lymph nodes, is typical. radiographs may be helpful in identifying affected central nodes. peripheral lymph nodes may erode and drain caseous, "cheesy," yellow-green-tan secretions. the incubation period may be weeks to months. over time, an infected animal may become exercise-intolerant, anorexic, and debilitated. fever, increased respiratory rates, and pneumonia may also be common signs. exotoxin-induced hemolytic crises may occur occasionally. morbidity up to % is common, and morbid animals will often eventually succumb to the disease. diagnosis is based on clinical lesions; elisa serological testing is also available. smears of the exudate or lymph nodes aspirates can be gram-stained. lymph node aspirates may also be sent for culturing. epizootiology and transmission. the organism can survive for months or more in the environment and enters via skin wounds, shearing, fighting, castration, and docking. ingestion and aerosolization (leading to pulmonary abscesses) have been reported as alternative routes of entry. necropsy findings. disseminated superficial abscesses as well as lesions of the mediastinal and mesenteric lymph nodes will be identified. cut surfaces of the affected lymph nodes may appear lamellated. lungs, liver, spleen, and kidneys may also be affected. cranioventral lung consolidation with hemorrhage, fibrin, and edema are seen histologically. pathogenesis. corynebacterium pseudotuberculosis produces an exotoxin (phospholipase d) that damages endothelial and blood cell membranes. this process enhances the organisms' ability to withstand phagocytosis. the infection spreads through the lymphatics to local lymph nodes. the necrotic lymph nodes seed local capillaries and hematogenously and lymphatically spread the organisms to other areas, especially the lungs. differential diagnosis. differentials include pathogens causing lymphadenopathy and abscessation. treatment. antibiotic therapy is not usually helpful. abscesses can be surgically lanced and flushed with iodinecontaining and/or hydrogen peroxide solutions. abscessing lymph nodes can be removed entirely from valuable animals. during warmer months, an insect repellent should be applied to and around healing lesions. all materials used to treat animals should be disposed of properly. because of the contagious nature of the disease, animals with draining and lanced lesions should be isolated from cla-negative animals at least until healed. commercial vaccines are available (piontkowski and shivvers, ) . minimizing contamination of the environment, using proper sanitation methods for facilities and instruments, segregating affected animals, and taking precautions to prevent injuries are all important. research complications. this pathogen is a risk for animals undergoing routine management procedures or invasive research procedures, because of its persistence in the environment, its long clinical incubation period, and its poor response to antibiotics. etiology. corynebacterium renale, c. cystitidis, and c. pilosum are sometimes referred to as the c. renale group. these are piliated and nonmotile gram-positive rods and are distinguished biochemically. corynebacterium renale causes pyelonephritis in cattle, and c. pilosum and c. cystitidis cause posthitis, also known as pizzle rot or sheath rot, in sheep and goats. in many references, all these clinical presentations are attributed to c. renale. clinical signs and diagnosis. acute pyelonephritis is characterized by fever, anorexia, polyuria, hematuria, pyuria, and arched back posture. untreated infections usually become chronic, with weight loss, anorexia, and loss of production in dairy animals. relapses are common, and some infections are severe and fatal. diagnosis of pyelonephritis is based on urinalysis (proteinuria and hematuria) and rectal or vaginal palpation (assessing ureteral enlargement). urine culturing may not be productive. in chronic cases, e. coli and other gram-negatives may be present. posthitis and vulvovaginitis are characteriazed by ulcers, crusting, swelling and pain. the area may have a distinct malodor. necrosis and scarring may be sequelae of more severe infections. fly-strike may also be a complication. diagnosis is based on clinical signs and on investigation of feeding regimens. epizootiology and transmission. ascending urinary tract infections with cystitis, ureteritis, and pyelonephritis are widespread problems, but incidence is relatively low. the vaginitis and posthitis contribute to the venereal transmission, but indirect transmission is possible because the organisms are stable in the environment and present on the wool or scabs shed from affected animals. posthitis occurs in intact and castrated sheep and goats. necropsy findings. pyelonephritis, multifocal kidney abscessation, dilated and thickened ureters, cystitis, and purulent exudate in many sections of the urinary tract are common finding at gross necropsy. of bovine genitourinary tracts. the pilus mediates colonization. conditions such as trauma, urinary tract obstruction, and anatomic anomalies may predispose to infection. in addition, more basic ph urine levels may block some immune defenses. infections ascend through the urinary tract. the bacteria are urease-positive when tested in vitro, and the ammonia produced in vivo during an infection damages mucosal linings, with subsequent inflammation. corynebacterium cystitidis and c. pilosum are normally found around the prepuce of sheep and goats. high-protein diets, resulting in higher urea excretion and more basic urine, are contributing factors. posthitis and vulvovaginitis may develop within a week of change to the more concentrated or richer diet, such as pasture or the addition of high-protein forage. the ammonia produced irritates the preputial and vulvar skin, increasing the vulnerability to infection. differential diagnosis. urolithiasis is a primary consideration for these diseases. contagious ecthyma should be considered for the crusting that is seen with posthitis and vulvovaginitis, although the lesions of contagious ecthyma are more likely to develop around the mouth. ovine viral ulcerative dermatosis is also a differential for the lesions of posthitis and vulvovaginitis. prevention and treatment. because high-protein feed is often associated with posthitis and vulvovaginitis, feeding prac-tices must be reconsidered. clipping long wool and hair also is helpful. treatment. long-term ( weeks) penicillin treatment is effective for pyelonephritis. reduction of dietary protein, clipping and cleaning skin lesions, treating for or preventing fly-strike, and topical antibacterial treatments are effective for posthitis and vulvovaginitis; systemic therapy may be necessary for severe cases. surgical debridement or correction of scarring may also be indicated in severe cases. etiology. erysipelothrix rhusiopathiae is a nonmotile, nonspore-forming, gram-positive rod that resides in alkaline soils. clinical signs. erysipelothrix causes sporadic but chronic polyarthritis in lambs less than months of age. in older goats, erysipelas has been associated with joint infections. epizootiology and transmission. the disease may follow wound inoculation associated with castration, docking, or improper disinfection of the umbilicus. following wound contamination and a -to -day incubation period, the lamb exhibits a fever and stiffness and lameness in one or more limbs. joints, especially the stifle, hock, elbow, and carpus, are tender but not greatly enlarged. necropsy findings. thickened articular capsules, mild increases in normal-appearing joint fluid and erosions of the articular cartilage are usually found. the joint capsule is infiltrated with mononuclear cells, but bacteria are difficult to find. diagnosis is based on clinical signs of polyarthritis, and confirmation is made by culturing the organism from the joints. differential diagnosis. differential diagnoses include polyarthritis caused by chlamydia or other bacteria and stiffness caused by white muscle disease. other bacteria causing septic joints include areanobacterium pyogenes and fusobacterium necrophorum. caprine arthritis encephalitis (cae) should also be considered. prevention and control. proper sanitation and prevention of wound contamination are important in preventing the infection in lambs. screening of goat herds for cae is recommended. therapy. erysipelas is sensitive to penicillin antibiotic m. etiology. dermatophilus congolensis is an aerobic, grampositive, filamentous bacterium with branching hyphae. dermatophilosis is a chronic bacterial skin disease characterized by crustiness and exudates accumulating at the base of the hair or wool fibers (scanlan et al., ) . clinical signs. animals will be painful but will not be pruritic. two forms of the disease exist in sheep: mycotic dermatitis (also known as lumpy wool) and strawberry foot rot. mycotic dermatitis is characterized by crusts and wool matting, with exudates over the back and sides of adult animals and about the face of lambs. strawberry foot rot is rare in the united states but is characterized by crusts and inflammation between the carpi and/or tarsi and the coronary bands. animals will be lame. in goats and cattle, similar clinical signs of crusty, suppurative dermatitis are seen; the disease is often referred to as cutaneous streptothricosis in these species. lesions in younger goats are seen along the tips of the ears and under the tail. diagnosis is based on clinical signs as well as the typical microscopic appearance on stained skin scrapings, cultures, and serology. epizootiology and transmission. the disease occurs worldwide, and the dermatophilus organism is believed to be a saprophyte. transmission occurs by direct or indirect contact and is aggravated by prolonged wet wool or hair associated with inclement weather. biting insects may aid in transmission. necropsy findings. lymphadenopathy as well as liver and splenic changes may be observed. histopathologically, superficial epidermal layers are necrotic and crusted with serum, white blood cells, and wool or hair. dermal layers are hyperemic and edematous and may be infiltrated with mononuclear cells. pathogenesis. lesions typically begin around the muzzle and hooves and the dorsal midline. prevention and control. potash alum and aluminum sulfate have been used as wool dusts in sheep to prevent dermatophilosis. minimizing moist conditions is helpful in controlling and preventing the disease. in addition, controlling external parasites or other factors that cause skin lesions is important. lesions will resolve during dry periods. treatment. animals can be treated with antibiotics such as penicillin and oxytetracycline. treating the animals with povidone-iodine shampoos or chlorhexidine solutions is also useful in clearing the disease. n. etiology. two bacteria, dichelobacter (bacteroides) nodosus and fusobacterium necrophorum, work synergistically in caus-ing contagious foot rot in sheep and goats. other organisms may be involved as secondary invaders. both dichelobacter and fusobacterium are nonmotile, non-spore-forming, anaerobic, gram-negative bacilli. foot rot is a contagious, acute or chronic dermatitis involving the hoof and underlying tissues (bulgin, ) . it is the leading cause of lameness in sheep. at least serotypes of dichelobacter are known. arcanobacterium pyogenes may also contribute to the pathogenicity or to foot abscesses in goats. foot scald, an interdigital dermatitis, is caused primarily by d. nodosus alone. clinical signs. varying degrees of lameness are observed in all ages of animals within - weeks of exposure to the organisms. severely infected animals will show generalized signs of weight loss, decreased productivity, and anorexia associated with an inability to move. the interdigital skin and hooves will be moist, with a distinct necrotic odor. morbidity may reach % in susceptible animals. diagnosis is based on clinical signs. smears and cultures confirm the definitive agents. clinical signs of the milder disease, foot scald, include mild lameness, redness and swelling, and little to no odor. epizootiology and transmission. fusobacterium necrophorum is ubiquitous in soil and manure, in the gastrointestinal tract, and on the skin and hooves of domestic animals. in contrast, dichelobacter contaminates the soil and manure but rarely remains in the environment for more than about weeks. some animals may be chronic carriers. overcrowded, warm, and moist environments are key elements in transmission. outbreaks are likely in the spring season. shipping trailers and contaminated pens or yards should be considered also as likely sources of the bacteria. pathogenesis. both organisms are transmitted to the susceptible animal by direct or indirect contact. the organisms enter the hoof through injuries or through sites where strongyloides papillosus larvae have penetrated. fusobacterium necrophorum initiates the colonization and is followed by d. nodosus. the latter attaches and releases proteases; these cause necrosis of the epidermal layers and separation of the hoof from the underlying dermis. the pathogenicity of the serotypes of d. nodosus is correlated with the production of these proteases and numbers of pili. additionally, f. necrophorum causes a severe, damaging inflammatory reaction. differential diagnosis. foot abscesses, tetanus, selenium/ vitamin e deficiencies, copper deficiency, strawberry foot rot, bluetongue virus infection (manifested with myopathy and coronitis), and trauma are among the many differentials that must be considered. treatment. affected animals are best treated by manually trimming the necrotic debris from the hooves, followed by application of local antibiotics and foot wraps. systemic antibiotics such as penicillin, oxytetracycline, and erythromycin may be used. goats have improved dramatically when given a single dose of penicillin ( , u/kg) (smith and sherman, ) . footbaths containing % zinc sulfate, % copper sulfate, or % formalin (not legal in all states) can be used for treatment as well as for prevention of the disease. affected animals should be separated from the flock. vaccination has been shown to be effective as part of the treatment regimen. some breeds of sheep and some breeds and lines of goats are resistant to infection. individual sheep may recover without treatment or are resistant to infection. epizootiology and transmission. cases may be sporadic, or epizootics may occur. bos taurus dairy breeds and animals with wide interdigital spaces are more commonly affected. the factors here are comparable to those present in foot rot of smaller ruminants. necropsy findings. findings at necropsy include dermatitis and necrosis of the skin and subcutaneous tissues. although necropsy would rarely be performed, secondary osteomyelitis may be noted in severe cases by sectioning limbs. prevention and control. prevention and control programs involve scrutiny of herd and flock management; quarantine of incoming animals; vaccination; segregation of affected animals; careful and regular hoof trimming; discarding trimmings from known or suspected infected hooves; maintaining animals in good body condition; avoiding muddy pens and holding areas; and culling individuals with chronic and nonresponsive infections. dichelobacter nodosus bacterins are commercially available; cross protection between serotypes varies. biannual vaccinination in wet areas may be essential. some breeds may develop vaccination site lumps. footbaths of % zinc sulfate, % formalin (where allowed by state regulations), or % copper sulfate are also considered very effective preventive measures. goats are less sensitive than sheep to the copper in the footbaths. treating and controlling foot rot is costly in terms of time, initial handling and treatments and their follow-up, housing space, and medications. etiology. interdigital necrobacillosis of cattle is caused by the synergistic infection of traumatized interdigital tissues by fusobacterium necrophorum and bacteroides melaninogenicus. like f. necrophorum, b. melaninogenicus is a nonmotile, anaerobic, gram-negative bacterium. dichelobacter nodosus, the agent of interdigital dermatitis, may be present in some cases. this is a common cause of lameness in cattle. clinical signs. clinical signs include mild to moderate lameness of sudden onset. hindlimbs are more commonly affected, and cattle will often flex the pastern and bear weight only on the toe. the interdigital space will be swollen, as will be the coronet and bulb areas. characteristic malodors will be noted, but there will be little purulent discharge. in more severe cases, animals will have elevated body temperature and loss of appetite. the les~ons progress to fissures with necrosis until healing occurs. the diagnosis is by the odor and appearance. anaerobic culturing confirms the organisms involved. pathogenesis. the bacteria enter through the skin of the interdigital area after trauma to the interdigital skin, from hardened mud, or from softening of the skin due to, for example, constant wet conditions in pens. colonization leads to cellulitis. in addition, f. necrophorum releases a leukocidal exotoxin that reduces phagocytosis and causes the necrosis, whereas the tissues and tendons are damaged by the proteases and collagenases produced by b. melaninogenicus. zinc deficiency may play a role in the pathogenesis in some situations. differential diagnoses. the most common differentials for sudden lameness include hairy heel warts and subsolar abcesses. bluetongue virus should also be considered. grain engorgement and secondary infection from cracks caused by selenium toxicosis should also be considered. the exotic footand-mouth disease virus would be considered in areas where that pathogen is found. prevention and control. as with foot rot in smaller ruminants, management of the area and herd are important. paddocks and pens should be kept dry, well drained, and free of material that will damage feet. footbaths and chlortetracycline in the feed have been shown to control incidence. affected animals should be segregated during treatment. chronically affected or severely lame animals should be culled. new cattle should be quarantined and evaluated. ing within a week include cleaning the feet and trimming necrotic tissue; parenteral antimicrobials, such as oxytetracycline or procaine penicillin, or sulfonomethazine in the drinking water or tetracyclines in feed; and footbaths (such as % zinc sulfate, . % formalin, or % copper sulfate) twice a day. in severe cases, more aggressive therapy such as bandaging the feet or wiring the digits together may be needed. animals can recover without treatment but will be lame for several weeks. acquired immunity is reported to be poor. research complications are comparable to those noted for foot rot in smaller ruminants. fusobacterium necrophorum is also associated with foot abscesses, the infection of the deeper structures of the foot, in sheep and goats. only one claw of the affected hoof may be involved. the animals will be three-legged lame, and the affected hoof will be hot. pockets of purulent material may be in the heel or toe. etiology. bacteria such as fusobacterium spp., bacteroides spp., and dichelobacter nodosus have been isolated from bovine heel lesions. spirochete-like organisms have also been shown in the lesions of cows with papillomatous digital dermatitis (pdd), in the united states and europe; these have culturing requirements similar to those of treponema species. treatment. antibiotic and antiseptic regimens have been used successfully for this problem. antibiotics include parenteral cephalosporins and pencillins, as well as topical tetracyclines with bandaging. antiseptic or antibiotic solutions in footbaths include tetracyclines, zinc sulfate, lincomycin, spectinomycin, copper sulfate, and formalin. the footbaths must be well maintained, minimizing contamination by feces and other materials. tandem arrangements, such as the cleaning footbaths and then the medicated footbaths, and preventing dilution from precipitation are useful. other treatments such as surgical debridement, cryotherapy, and caustic topical solutions have been successful. research complications. infectious, contagious ppd is one of the major causes of lameness among heifers and dairy cattle and is a costly problem to treat. the outbreaks are generally worse in younger animals in chronically infected herds. the immune response is not well understood, and it may be temporary in older animals. clinical signs. all lesions occur on the haired, digital skin. one or all feet may be affected. most lesions occur on the plantar surface of the hindfoot (near the heel bulbs and/or extending from the interdigital space), but the palmar and dorsal aspect of the interdigital spaces may also be involved. progression of lesions, typically over - weeks, includes erect hairs, loss of hair, and thickening skin. moist plaques begin as red and remain red or turn gray or black. exudate or blood may be present on the plaque. plaques enlarge and "hairs" protrude from the roughened surface. lesioned areas are painful when touched. the lesions may or may not be malodorous. epizootiology and transmission. facility conditions and herd management are considered contributing factors. the following have been examined as contributing factors: nutrition, particularly zinc deficiency; poorly drained, low-oxygen, organic material underfoot; poor ventilation; rough flooring; damp and dirty bedding areas; and overcrowding. these interdigital lesions occur commonly in young stock and in dairy facilities throughout the world. the disease is seen only in cattle. pathogenesis. the organisms noted above, combined with poor facility and herd management, are critical in the pathogenesis. differential diagnosis. differentials for lameness will include sole abscesses, laminitis, and trauma. prevention and control. each facility and management condition noted above should be addressed in conjunction with appropriate antibiotic and/or antiseptic treatment regimens. all equipment used for hoof trimming must be cleaned and disinfected after every use. trucks and trailers should also be sanitized between groups of animals. etiology. haemophilus somnus is a pleomorphic, nonencapsulated, gram-negative bacterium. diseases caused by this organism include thromboembolic meningoencephalitis (teme), septicemia, arthritis, and reproductive failures due to genital tract infections in males and females. haemophilus somnus is a also major contributor to the bovine respiratory disease complex. haemophilus spp. have been associated with respiratory disease in sheep and goats. clinical signs. the neurologic presentation may be preceded by - weeks of dry, harsh coughing. neurologic signs include depression, ataxia, falling, conscious proprioceptive deficits; signs such as head tilt from otitis interna or otitis media, opisthotonus, and convulsions may be seen as the brain stem is affected. high fever, extreme morbidity, and death within hr may occur. respiratory tract infections are usually part of the complex with infectious bovine rhinotracheitis virus, bovine respiratory syncytial virus, bovine viral diarrhea virus, parainfluenza , mycoplasma, and pasteurella, and the synergism among these contributes to the signs of bovine respiratory disease complex (brdc). in acute neurologic as well as chronic pneumonic infections, polyarthritis may develop. abortion, vulvitis, vaginitis, endometritis, placentitis, and failure to conceive are manifestations of reproductive tract disease. in all cases, asymptomatic infections may also occur. diagnosis based on culture findings is difficult because h. somnus is part of the normal nasopharyngeal flora. paired serum samples are recommended; single titers in some animals seem to be high because of passive immunity, previous vaccination, or previous exposure. in cases of abortion, other causes should be eliminated from consideration. because the organism is considered part of the normal flora of cattle and can be isolated from numerous tissues, the distinction between the normal flora and the status of chronic carrier is not clear. outbreaks are associated with younger cattle in feedlots in western united states, but stresses of travel and coinfection with other respiratory pathogens are involved in some cases. adult cattle have also been affected. vaccination for viral respiratory pathogens may increase susceptibility. transmission is by respiratory and genital tract secretions. the organism does not persist in the environment. times of stress to the cattle is worthwhile. killed whole-cell bacterins are commercially available; these have been shown to be effective in controlling the respiratory disease presentation. control of other clinical aspects of the h. somnus disease by these bacterins has not been well described. treatment. rapid treatment at the first signs of neurologic disease is important in an outbreak. haemophilus somnus is susceptible to several antibiotics, such as oxytetracycline and penicillin, and these are often used in sequence until the cattle are recovered. necropsy findings. pathognomonic central nervous system lesions include multifocal red-brown foci of necrosis and inflammation on and within the brain and the meninges. many thrombi with bacterial colonies will be seen in these affected areas. ocular lesions may also be seen, including conjunctivitis, retinal hemorrhages, and edema. usually animals with neurological disease will not have respiratory tract lesions. the respiratory tract lesions include bronchopneumonia and suppurative pleuritis. when combined with pasteurella infection, the pathology becomes more severe. aborted fetuses will not show lesions, but necrotizing placentitis will be evident histologically. pathogenesis. inhalation of contaminated respiratory secretions from carrier animals is the primary means of transmission. the anatomical location of bacterial residence within the carriers has not been identified. after gaining access by way of the respiratory tract, the bacteria proliferate, and a bacteremia develops. the bacteria are phagocytosed by neutrophils but are not killed. the thrombosis formation is due to the adherence by the nonphagocytosed organisms to vascular endothelial cells, degeneration and desquamation of these cells, and exposure of subendothelial collagen, with subsequent initiation of the intrinsic coagulation pathway. antigen-antibody complex formation, resulting in vasculitis, is also correlated with high levels of agglutinating antibodies. other pathogens associated with neurological disease and respiratory disease such as pasteurella hemolytica, p. multocida, and p. aeruginosa. in smaller ruminants, corynebacterium pseudotuberculosis should be considered. prevention and control. stressed animals or those exposed to known carriers can be treated prophylactically with tetracycline administered parenterally or orally (in the feed or water). the late-stage polyarthritis is resistant to antibiotic therapy, because of failure of the antibiotic to reach the site of infection. planning vaccination programs carefully will decrease chances of outbreaks. for example, avoiding vaccinating animals for infectious bovine rhinotrachetitis and bovine viral diarrhea during clinical signs. leptospirosis is a contagious but uncommon disease in sheep and goats. the disease may cause abortion, anemia, hemoglobinuria, and icterus and is often associated with a concurrent fever. after a -to -day incubation period, the organism enters the bloodstream and causes bacteremia, fever, and red-cell hemolysis. leptospiremia may last up to days. immune stimulation is apparently rapid, and antibodies are detectable at the end of the first week of infection; crossserovar protection does not occur. during active bacteremia, hemolysis may result in hemoglobin levels of % below normal. hyperthermia, hemoglobinuria, icterus, and anemia may be observed during this phase, and ewes in late gestation may abort. abortion usually occurs only once. mortality rates of above % have been reported in infected ewes and lambs (jensen and swift, ) . subclinical infection is more common in nonpregnant and nonlactating animals. sheep infected with leptospirosis may display a hemolytic crisis associated with igm acting as a cold-reacting hemagglutinin. acute and chronic infections in cattle are more common than infections in sheep and goats. acute forms in cattle display signs similar to those in sheep. acute infection in calves may progress to meningitis and death. lactating cows will have severe drops in production. chronic cases may lead to abortion, with retained placenta, and weakened calves or animals that carry the infection. infertility may also be a sequela. epizootiology and transmission. leptospires are a large genus, and leptospirosis is a complicated disease to prevent, treat, and control. the organism survives well in the environment, especially in moist, warm, stagnant water. cattle, swine, and other domestic and wild animals are potential carriers of serovars common to particular regions. wild animals often serve as maintenance hosts, but domestic livestock may be reservoirs also. organisms are shed in urine, in uterine discharges, and through milk. animals become carriers when they are infected with a host-adapted serovar; sporadic clinical disease is more commonly associated with exposure to a non-hostadapted serovar (heath and johnson, ) . infection may occur via oral ingestion of contaminated feed and water, via placental fluids, or through the mucous membranes of the susceptible animal. placental or venereal transmission may occur. as the organisms are cleared from the bloodstream, they chronically infect the renal convoluted tubules and the reproductive tract (and occasionally the cerebrospinal fluid or vitreous humor). chronically infected animals may shed the organism in the urine for days or longer. necropsy. diagnosis is confirmed by identification of leptospires in fetal tissues. the leptospires are visible in silver-or fluorescent antibody-stained sections of liver or kidney. leptospires may also be seen under dark-field or phase-contrast microscopy of fetal stomach contents. fetal and maternal serology, and diagnostic tests such as the microscopic agglutination test, are useful; interpretation is complicated because of cross reaction of antibodies to many serovars. differential diagnosis. more than one serovar may cause infection in one animal, and each serovar should be considered as a separate pathogen. because of the associated anemia, differential diagnoses should include copper toxicity and parasites, in addition to other abortifacient diseases. prevention and control. polyvalent vaccines, tailored to common serovars regionally, are available and effective for preventing leptospirosis in cattle. immunity is serovar specific. because serological titers tend to diminish rapidly ( - days in sheep [jensen and swift, ] ), frequent vaccination may be necessary. other prevention measures such as species-specific housing, control of wild rodents, and proper sanitation should be instituted. treatment. antibiotic treatment is aimed at treating ill animals and trying to clear the carrier state. treatment methods for acute leptospirosis include oxytetracycline for - days. addition of oxytetracycline or chlortetracycline to the feed for week may be helpful. these antibiotics are considered best for removal of the carrier state of some serovars. vaccination and antibiotic therapy can be combined in an outbreak. research complications. leptospirosis is zoonotic and may be associated with flulike symptoms, meningitis, or hepatorenal failure in humans. etiology. listeria monocytogenes is a pleomorphic, motile, non-spore-forming, [ -hemolytic, gram-positive bacillus that inhabits the soil for long periods of time and has been often found in fermented feedstuffs such as spoiled silage. of the known serovars, several produce clinical signs in ruminants. listeria ivanovii (associated with abortions in sheep) is serovar . clinical signs. listeriosis is an acute, sporadic, noncontagious disease associated with neurological signs or abortions in sheep and other ruminants. the overall case rate is low. the disease may present as an isolated case or with multiple animals affected. three forms of disease are described: encephalitis, placentitis with abortion, and septicemia with hepatitis and pneumonia. the encephalitic form is most common in sheep; septicemic forms may occur in neonatal lambs (scarratt, ) . clinically, the encephalitic form begins with depression, anorexia, and mild hyperthermia after an incubation period of - weeks. as the disease progresses, animals exhibit nasal discharges and conjunctivitis and begin to walk in circles, as if disoriented. facial paralytic lesions, including drooping of an ear or eyelid, dilation of a nostril, or strabismus occur unilaterally on the affected side as the result of dysfunction of some or all the cranial nerves v-xii. the neck will by flexed away from the affected side. facial muscle twitching, protrusion of the tongue, dysphagia, hypersalivation, and nasal discharges may be noted. the hypersalivation may lead to metabolic acidosis in advanced cases in cattle. anorexia, prostration, coma, and death follow. the placental form usually results in last-trimester abortions in ewes and does, which typically survive this form of the disease. the affected females may be asymptomatic or may show severe clinical signs such as fever and depression, with subsequent retained placenta or endometritis. abortion usually occurs within weeks of listeria infection. in cattle, abortion occurs during the last months of gestation and has been induced experimentally - days after exposure. cows present with the range of clinical signs seen in smaller-ruminant dams. there is no long-term effect on the fertility of affected dams. epizootiology and transmission. the organism is transmitted by oral ingestion of contaminated feeds and water or possibly by inhalation. by the oral route, the organism enters through breaks in the oral cavity and ascends to the brain stem by way of nerves. when severe outbreaks occur, feedstuffs should be assessed for spoilage. listeria organisms can be shed by asymptomatic carriers, especially at the end of pregnancy and at lambing. diagnosis and necropsy findings. diagnosis is usually made from clinical signs. culture confirms the diagnosis (cold enrichment at ~ is preferable but not essential for isolation). impression smears will show the pleomorphic gram-positive characterisitics of the pathogen. tissue fluorescent antibody techniques may also be utilized. gross lesions are not observed with the encephalitic form. microscopic lesions include thrombosis, neutrophilic or mononuclear foci in areas of inflammation, and neuritis. the pons, medulla, and anterior spinal cord are primarily affected in the encephalitic form. microabscesses of the midbrain are characteristic of listeria encephalitis in sheep. aborted fetuses that are intact may show fibrinous polyserositis, with excessive serous fluids; small, necrotic foci of the liver; and small abomasal erosions. necrotic lesions of the fetal spleen and lungs may also be seen. in goats, listeria-induced neurological lesions occur only in the brain stem. placentitis, focal bronchopneumonia, hepatitis, splenitis, and nephritis may be seen with other forms. pathogenesis. with the encephalitic form, the organism penetrates mucosal abrasions and enters the trigeminal or hypoglossal nerves. the listeria organisms then migrate along the nerves and associated lymphatics to the brain stem (medulla and pons). in the septicemic form, the organism penetrates tissues of the gastrointestinal tract and enters the bloodstream, to be distributed to the liver, spleen, lungs, kidneys, and placenta. after infection, organisms are shed in all body secretions (infected milk is an important risk factor for zoonosis). a toxin produced by listeria monocytogenes is correlated with pathogenicity, but the mechanism of the pathogenesis of this molecule has not been elucidated. differential diagnoses. rabies, bacterial meningitis, brain abscess, lead toxicity, and otitis media must be considered as differentials. in sheep, the differentials include organisms that cause abortion, and neurological signs, such as enterotoxemia due to clostridium perfringens type d. in goats, the major differentials include caprine arthritis encephalitis viral infection and chlamydial and mycoplasmal infections. in both species, scrapie is a differential. in cattle, aberrant parasite migration or hemophilus somnus infection must also be considered. prevention and control. affected dams should be segregated and treated. other animals in the group may be treated with oxytetracycline as needed. aborted tissues should be removed immediately. proper storage of fermented feeds minimizes this source of contamination. when silage spoils, the ph increases, producing a suitable growth environment for the organism. commercial vaccines are not available in the united states. treatment. affected animals can be treated aggressively with penicillin, ampicillin, oxytetracycline, or erythromycin. exceptionally high levels of penicillin are required for treating affected cattle. severely affected animals should receive appropriate fluid support and other nursing care. treatment is less successful, and mortality is especially high in sheep. recovered animals tend to resist reinfection. research complications. in addition to the loss of fetal animals, stress to the dams, and risks to other animals, any aborted tissue by a ruminant should be regarded as a potential zoonotic risk. listeria can cause mild to severe flulike symptoms in humans and may be a particular risk for pregnant women and for older or immune-compromised individuals. listeriosis in humans is a reportable disease. etiology. lyme disease is caused by the spirochete borrelia burgdorferi. clinical signs and diagnosis. reports in ruminants indicate seroconversion to b. burgdorferi, but there are few definitive correlations to the arthritis that is present. diagnosis requires culturing from the affected joints and diagnostic elimination of other causes of lameness and arthritis. epizootiology and transmission. the organism is present throughout much of the northern hemisphere and has been reported in many mammals and also in birds. ticks of the ixodes ricinus complex are the major vectors of the spirochete and must be attached for hr for successful transmission. pathogenesis. the ixodes ticks have three life stages: larval, nymphal, and adult. feeding occurs once during each stage, and wild animals are the source of blood meals. the larval stages feed from rodents, such as the white-footed deer mouse, peromyscus leucopus, from which they acquire the spirochete. the nymphal stage is that which usually infects other animals. the adult ticks are usually found on deer. differential diagnosis. seroconversion to b. burgdorferi does not necessarily confirm the cause of arthritis. other causes of arthritis and lameness in ruminants include trauma, caprine arthritis encephalitis virus, mycoplasma spp., chlamydia psittaci, erysipelothrix spp., arcanobacterium pyogenes, brucella spp., and rickets. prevention and control. control of the tick vector is the most important factor in preventing the possibility of exposure or disease. treatment. antibiotic therapy, with tetracycline, penicillin, amoxicillin, and cephalosporins, is used for diagnosed or suspected lyme arthritis. research complications. lyme disease is zoonotic, and the lxodes ticks transmit the disease to humans. v. mastitis i. ovine mastitis mastitis in ewes may be acute, subclinical, or chronic. acute mastitis often results in anorexia, fever, abnormal milk, and swelling of the mammary gland. pasteurella haemolytica is the most common cause of acute mastitis. additional isolates may include, in order of prevalence, staphylococcus aureus, actinomyces (corynebacterium) spp., and histophilus ovis. escherichia coli and pseudomonas aeruginosa have also been found to cause acute mastitis. as many as six serotypes of pasteurella haemolytica have been isolated from the mammary glands of mastitic ewes. furthermore, intramammary inoculation of these organisms isolated from ovine and bovine pulmonary lesions has resulted in clinical mastitis in ewes (watkins.and jones, ) . subclinical mastitis is detected only indirectly, by counting somatic cells. the most common isolate from ewes with subclinical mastitis is coagulase-negative staphylococci. other isolates include actinomyces bovis, streptococcus uberis, s. dysgalactiae, micrococcus spp., bacillus spp., and fecal streptococci. most of these organisms are commonly found in the environment. diffuse chronic mastitis, or hardbag, results from interstitial accumulations of lymphocytes in the udder. both glands are usually affected, but no inflammation is present. serological evidence suggests that diffuse chronic mastitis is caused by the retrovirus that causes ovine progressive pneumonia (opp or maedi/visna virus). other bacterial agents or mycoplasma have not usually been isolated from udders with this type of mastitis. acute mastitis occurs in approximately % of lactating ewes annually, and it usually occurs either soon after lambing or when lambs are - months old (lasgard and vaabenoe, ) . subclinical mastitis occurs in - % of lactating ewes (kirk and glenn, ) . subclinical mastitis is more common in ewes from high-milk-producing breeds. skin or teat lesions and dermatitis increase the prevalence of disease. acute mastitis can be diagnosed in ewes with associated systemic signs of disease by physical examination of the udder and inspection of the milk. subclinical mastitis is often suggested by somatic cell counts elevated above x cells/ml. when high somatic cell counts are identified, subclinical mastitis can be diagnosed by milk culture. the california mastitis test may also be helpful as an indicator of mastitis. manual palpation of a hard, indurated udder as well as serological testing for the maedi/visna virus is helpful in confirming the diagnosis of diffuse chronic mastitis. treatment for acute bacterial mastitis should include aggressive application of broad-spectrum antibiotics (intramammary and systemic) and supportive therapy such as fluids and anti-inflammatory drugs. it is may be helpful to milk out the infected ud-der frequently; oxytocin injections preceding milking will improve gland evacuation. because somatic cell counting is often not routinely performed, treatment of subclinical mastitis is seldom done. there is currently no treatment available for diffuse chronic mastitis. ii. caprine mastitis lactating goats are subject to inflammation of mammary gland, or mastitis. the primary causative organisms are staphylococcus epidermidis and other coagulasenegative staphylococcus spp. clinical signs of mastitis include abnormal coloration or composition of milk, mammary gland redness, heat and pain, enlargement of the mammary gland, discoloration of the mammary gland, and systemic signs of septicemia. large abscesses may be present in the affected gland. staphylococcus aureus is also associated with caprine mastitis, and toxemia may be part of the clinical picture. this organism produces a necrotizing alpha toxin that can result in gangrenous mastitis. caprine mastitis may be clinical or subclinical, and the first indication of mastitis may be weak, depressed, or thin kids. diagnosis is based on careful culture of mastitic milk. treatment includes frequent stripping, intramammary antibiotics, and nonsteroidal anti-inflammatory drugs. oxytocin ( - u) may help milk letdown for frequent strippings. bovine mastitis products can be used in the goat; however, care should be taken not to insert the mastitis tube tip fully, because damage to the protective keratin layer lining the teat canal may occur. in severe acute systemic cases, steroids, fluids, and systemic antibiotics may be necessary. other less common causes of mastitis in goats include streptococcus spp. (s. agalactiae, s. dysgalactiae, s. uberis, and zooepidemicus). gram-negative causes of caprine mastitis include escherichia coli, klebsiella pneumoniae, pasteurella spp., pseudomonas, and proteus mirabilis. corynebacterium pseudotuberculosis can cause mammary gland abscessation, whereas mycoplasma mycoides may cause agalactia and systemic disease. "hard udder" can be caused by caprine arthritis encephalitis virus (caev). brucellosis and listeriosis can cause a subclinical interstitial mastitis (smith and sherman, ) . iii. bovine mastitis mastitis is the disease of greatest economic importance for the dairy cattle industry. the majority of the impact will be on the production and overall health of the cows, but low-incidence herds also diminish the risk of calves' ingesting or being exposed to pathogens. the most common bovine mastitis pathogens include staphylococcus aureus and streptococcus agalactiae, s. dysgalactiae, and s. uberis; coliform agents such as escherichia coli, enterobacter aerogenes, serratia marcescens, and klebsiella pneumoniae; mycoplasmal species such as mycoplasma bovis, m. bovigenitalium, m. californicum, m. canadensis, and m. alkalescens; and salmonella spp. such as s. typhimurium, s. newport, s. enteritidis, s. dublin, and s. muenster. many of these agents such as staphylococcus spp., salmonella spp., and the coliforms can cause both acute and chronic mastitis, as well as severe systemic disease, including fever and anorexia. these must be regarded as herd and environmental pathogens in terms of treatment and prevention. the pathogenesis of staphylococcal infections is comparable to that in goats. staphylococcus agalactiae can be cleared from udders because it does not invade other tissues, is an obligate resident of the glands, and is susceptible to penicillin. in contrast, s. uberis and s. dysgalactiae are environmental organisms and can be highly resistant to pencillin. mycoplasma bovis is the more common of the mycoplasmal pathogens and can cause severe infections. transmission of the mycoplasmas is not well defined but may be related to their presence in other organ systems. treatments for mycoplasmal mastitis are not successful; culling is recommended. there are many interrelated factors associated with prevention and control of mastitis in a herd, including herd health and dry cow management, order of animals milked, milking procedures, milking equipment, condition of the teats, and the condition of the environment. management of the overall herd includes aspects such as vaccination programs, nutrition, isolation of incoming animals, and quarantine and treatment of or culling diseased individuals. culturing or testing newly freshened cows and monitoring the bulk milk tank serve as indicators of subclinical mastitis. herd management will diminish teat lesions. bacterin vaccines are available for preventing and controlling coliform mastitis and s. aureus mastitis. at the time of dry-off, all cows must be treated by intramammary route. some infections can be successfully cleared during this time. younger, disease-free animals should be milked first; any animals with diagnosed problems should be milked after the rest of the herd and/or segregated during treatment. milkers' hands easily serve as a means of pathogen transmission, and wearing rubber gloves is recommended. teat and udder cleaning practices include washing and drying with single-service paper or cloth towels or pre-and postmilking dipping. milking equipment must be maintained to provide proper vacuum levels and pumping rates, and liners should be the appropriate size. facilities that provide clean and dry areas for the animals to rest, feed, and move will diminish teat injuries and reduce exposures to mastitis pathogens. in that regard, inorganic bedding such as clean sand harbors few pathogens in contrast to shavings and sawdust. w. etiology. moraxella bovis, a gram-negative coccobacillus, is the most common cause of infectious bovine keratoconjunctivitis (ibk) in cattle. this organism is not a cause of keratoconjunctivitis in sheep and goats. the disease includes conjunctivitis and ulcerative keratitis. the pathogenic m. bovis strain is piliated, and at least seven serotypes exist. clinical signs. lacrimation, photophobia, and blepharospasm are seen initially. conjunctival injection and chemosis develop within a day of exposure, and then keratitis with corneal edema and ulcers. anterior uveitis may be a sequela within a few days, and thicker mucopurulent ocular discharge may be seen. corneal vascularization begins by days after onset. reepithelialization of the corneal ulcers occurs by - weeks after onset. diagnosis is usually based on clinical signs, but culturing is helpful and fluoroscein staining is useful for demonstrating corneal ulceration. epizootiology and transmission. the disease is more severe in younger cattle. the clinical signs of ibk tend to be more severe in cattle that are also infected with infectious bovine rhinotracheitis (ibr) virus or those that have been vaccinated recently with modified live ibr vaccine. the bacteria are shed in nasal secretions and cattle with no clinical symptoms may be carriers. transmission is by fomites, flies, aerosols, and direct contact. incidence in winter months is very low. nonhemolytic strains are associated with the winter epidemics, and hemolytic strains are associated with summer epidemics. necropsy findings. necropsy is not typically performed on these cases. corneal edema, ulceration, hypopyon, and uveitis would be noted, depending on the stage of infection. pathogenesis. the pili ofm. bovis bind to receptors of corneal epithelium. the virulent strains of the bacteria then release the enzymes that damage the corneal epithelial cells. other factors contributing to infection include ultraviolet light and trauma from dust and plant materials. differential diagnoses. infectious bovine rhinotrachetitis virus causes conjunctivitis, but the central corneal ulceration that is characteristic of ibk is not seen with m. bovis infections. mycoplasma, listeria, branhamella (neisseria) , and adenovirus may be cultured from affected bovine eyes but none has been shown to produce the corneal lesions when inoculated into susceptible animals. prevention and control. cattle should not be immunized intranasally with modified live infectious bovine rhinotracheitis vaccine during ibk outbreaks; this will likely exacerbate the infection. new animals should be quarantined and treated prophylactically before introduction to herds. the available vaccines, containing. m. bovis pili or killed m. bovis, help decrease incidence and severity of disease; these preparations are not completely effective, because the m. bovis strain may not be homologous to that used for the vaccine preparation. other preventive measures include % permethrin-impregnated bilateral ear tags, pour-on avermectins, or dust bags or face rubbers containing insecticide (such as % coumaphos) to control flies throughout the season and premises; mowing of high pasture grass to minimize ocular trauma; provision of shade; control of dust and sources of other mechanical trauma; and segregation of animals by age. treatment. cattle can recover without treatment, but younger animals should be treated as soon as the infection is detected. antibiotic treatments include topical, subconjunctival administration and intramuscular dosing. several standard topical antibiotics have been shown to be effective, including oxytetracycline, gentamicin, and triple antibiotic combinations. these should be administered twice per day. subconjunctival injections of antibiotics, such as penicillin g, provide higher corneal levels of drug; these are typically administered only once or twice in severe cases. intramuscular doses of long-acting oxytetracycline, given on alternate days, are effective in larger herds, and doses hr apart eliminate carriers. third-eyelid flaps, temporary tarsorrhaphy, or eye patches may be useful in certain cases. epizootiology and transmission. although m. bovis can be killed by sunlight, it otherwise survives a long time in the environment and in cattle feces. animals acquire the infection from the environment or from other animals via aerosols, from contaminated feed and water, and from secretions such as milk, semen, genital discharges, urine, and feces. clinically normal animals may serve as carriers. the bacilli stimulate an initial neutrophilic tissue response. neutrophils become necrotic and are phagocytosed by macrophages, forming giant epithelioid cells called langhans' giant cells. an outer lymphocytic zone is formed, and fibrotic encapsulation creates the classical caseous nodules. vascular erosion and hematogenous migration of the organisms may lead to lesions throughout the body. necropsy findings. yellow primary tubercles (granulomas) with central areas of caseous necrosis and calcification are present in the lungs. caseous nodules are also associated with gastrointestinal organs and mesenteric lymph nodes. research complications. this pathogen does present a complication due to the carrier status of some animals, the likelihood of herd outbreaks, the severity of disease in younger animals, and the morbidity, possible progression to uveitis, and time and treatment costs associated with infections. the overall condition of the cattle will be affected for several weeks, and permanent visual impairment or loss, as well as ocular disfigurement, may occur. mycobacterium bovis infection (tuberculosis) etiology. mycobacteria are aerobic, nonmotile, non-sporeforming, acid-fast pleomorphic bacteria. most cases of tuberculosis in sheep are related to mycobacterium bovis or m. avium. cases in goats have been attributed to m. bovis, m. avium, or m. tuberculosis. mycobacterium bovis, or the bovine tubercle bacillus, is the cause in cattle but has been isolated from many domestic and wild mammals. other agents of mammalian tuberculosis include m. microti and m. africanum. clinical signs. tuberculosis is a sporadic, chronic, contagious disease of ruminants and is zoonotic. the infection is often asymptomatic later in the illness, and it may be diagnosed only at necropsy. the respiratory system (m. bovis) or the digestive system (m. avium) is the primary site of infection; other tissues such as mammary tissue and reproductive tract may be infrequently involved. locations of the characteristic tubercles will determine whether clinical signs are seen. respiratory signs may include dyspnea, coughing, and pneumonia. digestive tract signs include diarrhea, bloat, or constipation; diarrhea is most common. lymphadenopathy occurs in advanced cases. fever and generalized disease may be seen after calving. infected goats lose weight and develop a persistent cough. prevention and control. significant progress has been made in eradication programs in the united states during the past several decades, but during the s, infected animals continued to be found in domestic cattle herds and particularly in captive deer herds in hunting preserves. the intradermal tuberculin test, using purified protein derivative (ppd), is usually used as a diagnostic indicator in live animals. this test should be performed annually on bovine and caprine dairy herds (and bison herds); the official tests are the caudal fold, comparative cervical, and single cervical tests. notification to state officials is required following identification of intradermal-positive animals. great care must be exercised in any handling of tissue or necropsies of reactors, and state animal health officials should be consulted regarding disposal of materials and cleaning of premises following depopulation of positive animals. no treatment is recommended, and treatment is usually not allowed, because of the zoonotic potential, chronicity of the disease, and the treatment costs. slaughter is preferred, to prevent potential transmission to humans. paratuberculosis, or johne 's disease (mycobacterium paratube rculo sis) etiology. mycobacterium paratuberculosis, the causative agent of johne's disease, is a fastidious, non-spore-forming, acid-fast, gram-positive rod. the organism is actually a subspecies of m. avium, but m. paratuberculosis does not produce the siderophore mycobactin (an iron-binding molecule) of m. avium. clinical signs and diagnosis. johne's disease is a chronic, contagious, granulomatous disease of adult ruminants and is characterized by unthriftiness, weight loss, and intermittent diarrhea. in sheep and goats, chronic wasting is usually seen, occasionally with pasty feces or diarrhea. in cattle, chronic diarrhea and rapid weight loss are the most common clinical signs of the disease. usually older adult animals are infected, but over time in an infected herd, younger animals will become infected when sufficient doses of organisms are ingested. although clinical signs are nonspecific, johne's disease should be considered if the affected diarrheic animals have a good appetite and are on a good anthelmintic program. the disease is diagnosed based on clinical signs and laboratory analyses, although none of the tests is more than % sensitive. in addition, the sensitivity of the serological tests differs between species. the standard is the fecal culture that takes - weeks. theenzyme-linked immunosorbent assay (elisa) is now considered the most reliable serological test, but false negatives do occur. other serological tests such as agar gel immunodiffusion (agid) and complement fixation are useful. herd screening may be done using the agid or elisa serological tests. identification of the organism on culture, or the presence of acid-fast organisms on mucosal or mesenteric lymph node smears or from rectal biopsies, helps confirm the diagnosis. some animals serologically negative for johne's disease, however, have been found to be positive on fecal culture. commercial agid tests approved for use in cattle may be useful in diagnosing johne's disease in sheep (dubash et al., ) . serological tests cross-react with other species of mycobacterium, especially m. avium. epizootiology and transmission. the organism is prevalent in the environment and is transmitted to young animals by direct or indirect contact. although vertical transmission has been reported, the organism more commonly enters the gastrointestinal tract and penetrates the mucosa of the distal small intestine, primarily the ileum. chronic carriers may intermittently shed the organisms. parasite that grows only in macrophages of infected animals. nursing infected dams are a primary source of infection of neonates. if the organism is not cleared, it proliferates slowly in the tissue, leading to inflammatory reactions that progress through neutrophilic to mononuclear stages. the organism may penetrate the lymphatics and proliferate in mesenteric lymph nodes. after an incubation period of a year or more, some of the carriers will progress to clinical disease manifested by fibrotic and hyperplastic changes in the ileum, leading to the classic thickening in the region. gut changes result in intermittent diarrhea, with subsequent dehydration, electrolyte imbalances, and malnutrition, although this clinical sign is more common in cattle than in sheep or goats. necropsy and diagnosis. the ileum from infected cattle is grossly thickened; this is not seen in sheep and goats. ileal and ileocecal lymph nodes provide the best samples for histology and acid-fast staining. differential diagnosis. diseases causing chronic wasting and poor coat and body condition of all ruminants should be considered. these include chronic salmonellosis, peritonitis, severe parasitism, winter dysentery, and pyelonephritis. deer can be infected, and the lesions can be confused with those of tuberculosis. prevention and control. prevention is the most effective method to manage this pathogen. efforts should be focused on eliminating the disease through test and slaughter. neonates should not be reared by infected dams. some states have johne's disease eradication programs. facilities and pastures where animals testing positive for johne' disease were maintained should be thoroughly cleaned and kept vacant for a year after culling. other considerations. mycobacterium paratuberculosis is being investigated as a factor in the development of crohn's disease in humans. etiology. the most common organism causing infection of the umbilicus is arcanobacterium (formerly actinomyces, corynebacterium) pyogenes; other bacteria may be present. arcanobacterium spp. are anaerobic, nonmotile, non-sporeforming, gram-positive, pleomorphic rods to coccobacilli. other environmental contaminants are also associated with this disease, such as escherichia coli, enterococcus spp., proteus, streptococcus spp., and staplylococcus spp. clinical signs and diagnosis. navel ill is an acute localized inflammation and infection of the external umbilicus. animals present with fever and painful enlargement of the umbilicus. animals may exhibit various degrees of depression and anorexia, and purulent discharges may be seen draining from the umbilicus. involvement of the urachus is usually followed by cystitis and associated signs of dysuria, stranguria, and hematuria. other common severe sequelae include septicemia, pneumonia, peritonitis, septic arthritis (joint ill), meningitis, osteomyelitis, uveitis, endocarditis, and diarrhea. neonates, and most cases occur within the first months of age. cleanliness of the birthing and housing environment and successful transfer of passive immunity are important factors in the occurrence of the disease. dystocia resulting in weak neonates can be a factor predisposing to the development of the disease. navel ill is diagnosed by typical clinical signs. the presence of microabscesses and palpation of the umbilical area for firm intra-abdominal structures extending from the umbilicus are abnormal. assessment of colostral immunoglobulin transfer may contribute to determination of the prognosis. navel ill should always be considered for young ruminants with fever of unknown origin during the first week of life and for slightly older lambs, kids, or calves that are not thriving. arthrocentesis of affected joints and culture of the fluid for identification of the pathogen are also diagnostic options and essential for effective antimicrobial selection. differential diagnosis. the major differential is an umbilical hernia, which will typically not be painful or infected and can often be reduced. mycoplasmal arthritis is a differential in kids. in the past, erysipelothrix rhusopathiae was a common navel ill pathogen in sheep. treatment. omphalitis can be treated with a to day course of broad-spectrum antibiotics such as ampicillin, amoxicillin, penicillin, ceftiofur, florfenicol, and erythromycin. if an isolated abscess is palpable, it should be surgically opened and repeatedly flushed with iodine solutions. surgical reduction of the infected umbilicus is indicated if intra-abdominal structures are involved. the prognosis for recovery is good if systemic involvement has not occurred. prevention and control. the disease is best prevented and controlled by providing clean birthing environments, ensuring adequate colostral immunity, thoroughly dipping the umbilicus of newborns in tincture of iodine or strong iodine solution (lugol's), monitoring for dystocias, and maintaining young growing animals in noncontaminated environments. may invade the bloodstream, causing disseminated septicemia. clinically, the lambs may exhibit nasal discharge of mucopurulent to hemorrhagic exudate, hyperthermia, coughing, dyspnea, anorexia, and depression. with the respiratory form, auscultation of the thorax suggests dullness and consolidation of anteroventral lobes; this will be confirmed by radiographs. the disease is diagnosed by clinical signs, blood cultures from septicemic animals, blood smears showing bipolar organisms, and history of predisposing stressors. in cultures, p. hemolytica is distinguished from p. multocida by hemolysis on blood agar; only p. multocida produces indole. epizootiology and transmission. the organism is ubiquitous in the environment and in the respiratory tracts of these animals. younger ruminants, between and months of age, are especially prone to infection during times of stress, such as weaning, transportation, dietary changes, weather changes, and overcrowding. the pneumonic form appears as a complex associated with concurrent infections such as parainfluenza , adenovirus type , respiratory syncytial virus, mycoplasmas, chlamydia, pasteurella multocida and bordetella parapertussis (martin, ; brogden et al., ) . the organism is transmitted between animals by direct and indirect contact, through inhalation or ingestion. necropsy findings. necropsy lesions include areas of necrosis and hemorrhage in the small intestines and multifocal mm lesions distributed on the surfaces of the lungs and liver. with the pneumonic form, serofibrinous exudates fill the alveoli; ventral lung lobes are consolidated and are congested and purple-gray in color. fibrinous pleuritis, pericarditis, and hematogenously induced arthritis also may be evident.. the disease can be costly to treat, and the toll taken on young animals due to the consequences of systemic infection may detract from their research value. etiology. pasteurella hemolytica and p. multocida are aerobic, nonmotile, non-spore-forming, bipolar, gram-negative rods. biotype a serotypes are associated with pneumonia and septicemia in all ruminants (ellis, ) . serotype of p. hemolytica is considered a major cause of pulmonary lesions of bovine bronchopneumonia and fibrinous bronchopneumonia. clinical signs. pasteurellosis is an acute bacterial disease characterized by bronchopneumonia, septicemia, and sudden death. the organism invades the mucosa of the gastrointestinal tract or respiratory tract and causes localized areas of necrosis, hemorrhage, and thrombosis. the lungs and liver are frequent areas of formation of microabscesses. acute rhinitis or pharyngitis often precedes the respiratory form. the organism also pathogenesis. a leukotoxin is considered to be a key factor in the pathogenesis of the p. hemolytica infection. macrophages and neutrophils are lysed by the toxin as they arrive at the lung, and the enzymes released by the neutrophils cause additional damage to the tissue. treatment. treatment may include the use of antibiotics such as penicillin, ampicillin, tylosin, sulfonamides, or oxytetracycline. newer antibiotics, such as ceftiofur, tilmicosin, spectinomycin, and florfenicol, are very effective and approved for use in cattle. in outbreaks, cultures from fresh necropsies are helpful for determining sensitivities useful for the remaining group. prevention and control. the incidence of disease can be decreased by minimizing the degree of stress; by improving management, such as nutrition and control of parasitism; and, in cattle and sheep, by vaccinating for viral respiratory infections such as parainfluenza. early pasteurella hemolytica bacterin vaccines for use in cattle are not considered effective, but newer products based on immunizing against the leukotoxin and some bacterial capsule surface antigens are effective. pasteurella multocida bacterins and live streptomycin-dependent mutant vaccines are available. in young animals, passive immunity is protective. preventive measures also include maintaining good ventilation in enclosures and barns. new animals to the flock or herds should be quarantined for at least weeks before introduction. etiology. salmonella typhimurium is a motile, aerobic to facultatively anaerobic, non-spore-forming, gram-negative bacillus and is the organism associated with enteric disease and some abortions in ruminants. it is a common inhabitant of the gastrointestinal tract of ruminants. current nomenclature categorizes s. typhimurium as a serovar within the species s. enteritidis (the other two species are s. typhi and s. choleraesuis). salmonella typhimurium, s. dublin, and s. newport are the common species seen in bovine cases. salmonella typhimurium, s. dublin, s. anatum, and s. montevideo are seen in ovine and caprine cases, although a host-adapted species has not been identified in the goat. ovine abortions due to various salmonella species are not reported in the united states but are enzootic in other countries. salmonella serotypes have been associated with aborted fetuses in all ruminant species. clinical signs and diagnosis. salmonellosis causes acute gastroenteritis, dysentery, and septicemia (anderson and blanchard, ) . clinically, the animals become anorexic and hyperthermic. diarrhea or dysentery develops; feces may contain mucus and/or blood and have a putrid odor. animals become severely depressed and weak, losing a high percentage of their body weight. animals may die in - days because of dehydration associated with dysenteric fluid loss, septicemia, shock, and acidosis. morbidity may be %, and mortality may be high. septicemia may result in subsequent meningitis, polyarthritis, and pneumonia. chronically infected animals may have intermittent diarrhea. in goats, salmonellosis may be recognized as diarrhea and septicemia in neonates, as enteritis in preweaned kids and mature goats, and, rarely, as abortion. adult cases may be sporadic, with intermittent bouts of diarrhea, subacute or even chronic. morbidity and mortality will be highest in neonates, and some may simply be found dead. the older animals generally tend to fare better during the disease. abdominal distension with profuse yellow feces is common. kids become severely depressed, anorexic, febrile (with temperatures as high as ~ dehydrated, acidotic, recumbent, and comatose. salmonella abortions may occur throughout gestation. there may not be any other clinical signs, or abortion may be seen with diarrhea, fever, and vulvar discharges. hemorrhage, placental necrosis, and edema will be present. metritis and placental retention may occur. some mortality of dams may occur. diagnosis is based on clinical signs and can be confirmed by culturing fresh feces or at necropsy. because of intermittent shedding of organisms, culture may be difficult; repeated cultures are recommended. leukopenia and a degenerative shift to the left are not uncommon hematological findings. epizootiology and transmission. stresses associated with recent shipping, overcrowding, and inclement weather may predispose the animal to enteric infection. birds and rodents may be natural reservoirs of salmonella in external housing environments. transmission is fecal-oral. after ingestion, the organisms may proliferate throughout the gastrointestinal tract and may penetrate the mucosa of the intestines, invade the peyer's patches and lymphatics, and migrate to the spleen, liver, and other organs. animals that survive may become chronic carriers and shedders of the organisms, and this has been demonstrated experimentally (arora, ) . fecal-oral transmission is also associated with salmonella abortion; veneral transmission has not been reported. necropsy findings and diagnosis. animals will have noticeable perineal staining. intestines (particularly the ileum, cecum, and colon) may contain mucoid feces with or without hemorrhages. petechial hemorrhages and areas of necrosis may be noticed on the surface of the liver, heart, and mesenteric lymph nodes. the wall of the intestines, gallbladder, and mesenteric lymph nodes will be edematous, and a pseudodiphtheritic membrane lining the distal small intestines and colon may be observed. this membrane is not normally seen in the goat (smith and sherman, ) . splenomegaly may be present. aborted fetuses will often be autolysed. placentitis, placental necrosis, and hemorrhage are commonly seen. serologic evidence of recent infection can be demonstrated in the dam. salmonella can be isolated from the aborted tissues. pathogenesis. after ingestion, the organism proliferates in the intestine. damage to the intestines and the resulting diarrhea are due to the bacterial production of cytoxin and endotoxin. although the salmonella organisms will be taken up by phagocytic cells involved in the inflammatory response, they survive and multiply further. septicemia is a common sequela, with the bacteria localizing throughout the body. in latently infected animals, it is often shed from the gallbladder and mesenteric lymph nodes. younger animals may be susceptible because of immature immunity and intestinal flora and higher intestinal ph. carriers may develop clinical disease when stressed. differential diagnoses. in young animals, differentials include other enteropathogens: escherichia coli, rotavirus and coronavirus, clostridia, cryptosporidia, and other coccidial forms. these pathogens may also be present in the affected animals. differentials in adults include bovine viral diarrheas and winter dysentery in cattle and parasitemia and enterotoxemia in all ruminants. prevention and control. affected animals should be isolated during herd outbreaks. samples for culture should include herdmates, water and feed sources, recently arrived livestock (other species), and area wildlife, including birds and rodents. repeated cultures, culling of animals, intensive cleaning, and disinfection of facilities are all important during outbreaks. the bacteria survive for about a week in moist cow manure. vaccination using the commercially available killed bacterin or autologous bacterins may be useful in outbreaks involving pregnant cattle, although the j- bacterin is now considered better. treatment. nursing care includes rehydration and correction of acid-base abnormalities. antibiotic therapy may be useful in cases with septicemia, but it is controversial because it may induce carrier animals. gentamicin, trimethoprim-sulfadiazine, ampicillin, enrofloxacin, and amikacin antibiotics may be successful. negative, rod-shaped bacterium. type a is more virulent than type b. clinical signs. although tularemia is a disease of livestock, pets, and wild animals, sheep are most commonly affected. the disease is characterized by hyperthermia, muscular stiffness, and lymphadenopathy. infected animals move stiffly, are depressed, and are hyperthermic. anemia and diarrhea may develop, and infected lymph nodes enlarge and may ulcerate. mortality may reach %. animals that recover will have immunity of long duration. epizootiology and transmission. the disease is most commonly transmitted by ticks or biting flies. the wood tick, dermacentor andersoni, is an important vector in transmitting the disease in the western united states, and, as natural hosts, wild rodents and rabbits tend to be reservoirs of the pathogen. research complications. salmonellosis is zoonotic, and some serotypes of the organism have caused fatalities even in immunocompetent humans. attempts should be made to identify and cull carrier animals. pathogenesis. the organisms, entering the tick bite wound, move via lymphatics to lymph nodes and subsequently to the bloodstream, where they cause septicemia. the organisms can also be transmitted orally through contaminated water. etiology. spirochete-like organisms are associated with this disease; it is now recognized that the agent is not a chlamydial organism. the disease has been reported only in the foothills bordering the central valley of california. necropsy findings. ticks may also be present on the carcasses. suppurative, necrotic lymph nodes are typical. lungs will be congested and edematous. diagnosis is confirmed by prompt culturing of the organism from lymph nodes, spleen, or liver where granulomatous lesions form; p. tularensis does not survive for long periods in carcasses. serological findings may also be helpful. clinical signs. cows that become infected with the causative agent before months of gestation abort or give birth to weak calves without any clinical sign of infection. cows infected after months of gestation give birth to normal calves. affected cows rarely abort in subsequent pregnancies. the tick vector is ornitho- necropsy. fetuses show several pathological changes, including enlargement of the cervical lymph nodes, spleen, and liver. the calf's thymus will be small, and histologically there will be losses of thymic cortical lymphocytes. histologic changes in lymph nodes and spleen include vasculitis, necrosis, and histiocytosis. treatment. chlortetracycline treatment has been effective in controlling this disease. etiology. tularemia is caused by pasteurella (francisella) tularensis a nonmotile, non-spore-forming, aerobic, gram-control and prevention. eliminating the tick vectors can prevent tularemia. animals should be provided with fresh water frequently. the organism can survive in freezing conditions and in water and mud for long periods of time. caretakers, veterinarians, and researchers should take special precautions before handling the tissues of infected sheep, because this is a method of zoonotic spread. research complications. the disease is zoonotic, and transmission to people may result from tick bites or from handling contaminated tissues. although not a major disease of concern in sheep, researchers using potentially infected animals from western range states of the united states should be aware of it. the organism is antigenically related to brucella spp. etiology. yersiniosis is caused by infections with yersinia enterocolitica, a gram-negative, aerobic, and facultative anaerobe of the family enterobacteriaceae. there are serotypes reported for y. enterocolitica. yersinia pseudotuberculosis infections have also been seen in ruminants. enteric infections predominate in the diseases caused by these bacteria. clinical signs and diagnosis. clinical disease may be seen rarely in many groups of ruminants. goats of - months old suffer from the enteric form of the disease, which is characterized by sudden death or the acute onset of watery diarrhea lasting or more days. spontaneous abortions and weak neonates are also clinical manifestations of infection. lactating does may have mastitis that becomes chronically hemorrhagic. bacteremia results in internal abscesses, abortion, and acute deaths. yersinia pseudotuberculosis has been associated with laboratory goat epizootics (obwolo, ) . diarrhea in pastured sheep, stressed by other factors, has also been reported. diagnosis is based on culture and serology. epizootiology and transmission. the bacteria are carried by wild birds and rodents, and transmission is by ingestion of contaminated feed and water. research complications. yersinia is zoonotic. prevention and control. control measure are not well defined, because the epidemiology of the disease is poorly understood (smith and sherman, ) . tissues from affected goats must be handled and disposed of properly. areas housing affected goats must be thoroughly sanitized. treatment. in case of an abortion storm, treatment of goats with tetracycline has been useful. other broad-spectrum antibiotics may also be useful. clinical signs. contagious caprine pleuropneumonia is characterized by severe dyspnea, nasal discharge, cough, and fever (mcmartin et al., ) . infections with other mycoplasma species also have similar clinical signs. septicemia without respiratory involvement may also be a presentation. epizootiology and transmission. this disease is highly contagious, with high morbidity and mortality. transmission is by aerosols. mycoplasma mycoides subsp, mycoides has become a serious cause of morbidity and mortality of goat kids in the united states. necropsy. large amounts of pale straw-colored fluid and fibrinous pneumonia and pleurisy are typical. some lung consolidation may be present. meningitis, fibrinous pericarditis, and fibrinopurulent arthritis may also be found. diagnosis is usually made at necropsy by culture of the organism from lungs and other internal organs. differential dagnosis. in the united states, the principal differential for m. mycoides subsp, mycoides is caprine arthritis encephalitis. treatment. tylosin and oxytetracycline are effective. some infections are slow to resolve. prevention and control. vaccines are available in some areas. infected herds are quarantined. new goats should be quarantined before introduction to the herd. research complications. the worldwide distribution of the f biotype, as well as the aerosol transmission and high mor-bidity and mortality characteristics of mycoplasmal infectious, make these infections economically important diseases. considerable attention is presently given to this genus as a source of morbidity and mortality in goats. iv. mycoplasma conjunctivae (mycoplasmal keratoconjunctivitis) etiology. mycoplasma conjunctivae causes infectious conjunctivitis, or pinkeye, in sheep and goats with associated hyperemia, edema, lacrimation, and corneal lesions. mycoplasma mycoides subsp, mycoides, m. agalactiae, m. arginini, and acholeplasma oculusi have also been associated with keratoconjunctivitis in these species. respiratory disease and other infections, such as mastitis, may also be observed. clinical signs and diagnosis. all ages of animals may be affected. initially, lacrimation, conjunctival vessel injection, and then keratitis and neovascularization are seen. sometimes uveitis is evident. although the presentation is usually unilateral, bilateral involvement is possible. recurring infections are common. culturing provides the better diagnostic information, and cultures will be positive even after clinical signs have diminished. ily between animals by direct contact. animals can become reinfected, and carrier animals may be a factor in outbreaks. necropsy. it is unlikely that animals would die or be euthanized and undergo necropsy for this problem. conjunctival scrapings would include neutrophils during earlier stages and lymphocytes during later stages. epithelial cell cytoplasm should be examined for organisms. differential diagnosis. the primary differential in sheep and goats is chlamydia, as well as branhamella, rickettsia (colesiota) conjunctivae, and infectious bovine rhinotracheitis in goats only. it is important to consider these differentials if arthritis, pneumonia, or mastitis is present in the group or the individual. treatment. animals do recover spontaneously within about weeks. tetracycline ointments and powders are also used. third-eyelid flaps may be necessary if corneal ulceration develops. prevention and control. new animals should be quarantined and, if necessary treated, before introduction to the flock or herd. etiology. eperythrozoonosis is a rare, sporadic, noncontagious, blood-borne disease in ruminants worldwide caused by the rickettsial agent eperythrozoon. host-specific species of importance are e. ovis, the causative species in sheep and goats, and e. wenyoni, e. tegnodes, and e. tuomii, the causative agents in cattle. although the disease is of minor importance, it can cause severe anemia and debilitation in affected animals. haemobartonella bovis is also rare, and is usually found only in association with other rickettsial diseases. clinical signs and diagnosis. the disease is more severe in sheep. following an incubation period of - weeks, infected animals exhibit episodic hyperthermia, weakness, and anemia. losses may be greater in younger lambs. cattle are usually latently infected but may have swollen and tender teats and legs. fever, anemia, and depression will be present if the cattle are stressed by another systemic disease. diagnosis is based on clinical evidence of anemia and is confirmed by observing the rickettsiae on the surface of red blood cells in a blood smear. epizootiology and transmission. the rickettsial organisms are transmitted typically to young sheep by biting insects, ticks, contaminated needles or blood-contaminated surgical instruments. necropsyfindings. necropsy findings include splenic enlargement and tissue icterus. has resulted in transient hyperthermia, mild respiratory disease, and mastitis. abortions, stillbirths, and births of weak lambs are also seen. epizootiology and transmission. coxiella burnetii is extremely resistant to environmental changes as well as to disinfectants; persistence in the environment for a year or longer is possible. the organism is associated with either a free-living or an arthropod-borne cycle. coxiella burnetii is found in a variety of tick species, such as ixodid or argasid, where it replicates and is excreted in the feces. once introduced into a mammal, coxiella may be maintained without a tick intermediate. the organism is especially concentrated in placental tissues, replicates in trophoblasts, and will be in reproductive fluids. additionally, the organism is shed in milk, urine, feces, and oronasal secretions. necropsy findings. no specific lesion will be seen in aborted or stillborn fetuses, but necrotizing placentitis will be a finding in cases of abortion. the placenta will contain white chalky plaques and a red-brown exudate. the disease can be diagnosed by identifying the rickettsial organisms in smears of placental secretions. the organism has been found in the placentas of clinically normal animals. the organism stains red with modified ziehl-neelsen and macchiavello stains and purple with giemsa stain. pathogenesis. the organism invades and destroys red blood cells. it is believed that intravascular hemolysis and erythrophagocytosis contribute to the macrocytic anemia. as with other red blood cell parasites, splenectomy aggravates the disease. differential diagnosis. because of the organisms' similarity to chlamydia, confirmation must be made by culture techniques, immunofluorescent procedures, elisa, and complement fixation tests. differential diagnosis. clontridium novyi type d, babesiosis, and leptospirosis are the primary differentials. prevention and control. following strict sanitation practices for surgical procedures and controlling external parasites prevent the disease. treatment. treatment is not usually recommended, but oxytetracycline has been used. sheep will develop immunity if supported nutritionally during the disease. research complications. splenectomized animals are the experimental models used to study these diseases. ii. q fever, or query fever (coxiella burnetii) etiology. coxiella burnetii is a small, gram-negative, obligate intracellular rickettsial organism that causes query fever and is regarded as a major cause of late abortion in sheep. clinical signs. infection of ruminants with c. burnetii is usually asymptomatic. experimental inoculation in other mammals treatment. coxiella can be treated with oxytetracyclines. a vaccine is not commercially available. prevention and control. any aborting animals should be segregated from other animals, and other pregnant animals should be treated prophylactically with tetracycline. serologic screening of ruminant sources should be performed routinely. barrier housing, a review of ventilation exhaust, and defined handling procedures are often required. all placentas and all aborted tissues should be handled and disposed of carefully. q fever has been reported in many mammalian species, including cats. research complications. coxiella burnetii-free animals are particularly important in studies involving fetuses and placentation. because of its zoonotic potential, c. burnetii presents a unique problem in the animal research facility environment. a single organism has been shown to cause disease. some of the greatest concerns are the risk to immunocompromised individuals, pregnant women, and other animals, and the presence of carrier animals or those that may shed the organism in placentas, for example. etiology. the ruminant adenoviruses are dna viruses that cause respiratory and reproductive tract diseases. nine antigenic types of the bovine adenovirus have been identified, with type associated with respiratory disease. two of the ovine and two of the caprine antigenic types have been identified. clinical signs. signs of infection range from subclinical to severe, including pneumonia, enteritis, conjunctivitis, keratoconjunctivitis, weak calf syndrome, and abortion. respiratory tract and intestinal tract diseases may be concurrent. infections caused by this virus are often found associated with other viral and bacterial infections. epizootiology and transmission. the virus is believed to be widespread, but prevalence and characteristics of infection have not been characterized. transmission of adenoviruses in other species (e.g., canine) is by aerosols or fecal-oral routes. necropsy findings. lesions found after experimental infections include atelectasis, edema, and consolidation of the lungs. etiology. the bluetongue virus is an rna virus in the orbivirus genus and reoviridae family. five serotypes ( , , , , and ) have been identified in the united states, where it is seen mostly in western states. bluetongue is an acute arthropodborne viral disease of ruminants, characterized by stomatitis, depression, coronary band lesions, and congenital abnormalities (bulgin, ) . clinical signs and diagnosis. sheep are the most likely to show clinical signs. clinical disease is less common in goats and cattle. early in the infection, animals will spike a fever and will develop hyperemia and congestion of tissues of the mouth, lips, and ears. the virus name, bluetongue, is associated with the typical cyanotic membranes. the fever may subside, but tissue lesions erode, causing ulcers. increased salivary discharges and anorexia are often related to ulcers of the dental pad, lips, gums, and tongue, although salivation and lacrimation may precede apparent ulceration. chorioretinitis and conjunctivitis are also common signs in cattle and sheep. lameness may be observed associated with coronitis and is evident in the rear legs. skin lesions such as drying and cracking of the nose, alopecia, and mammary glands are also observed. secondary bacterial pneumonia may also occur. animals may also develop severe diarrhea and become recumbent. sudden deaths due to cardiomyopathy may occur at any time during the disease. hematologically, animals will be leukopenic. the course of the disease is about weeks, and mortality may reach %. if animals are pregnant, the virus crosses the placenta and causes central nervous system lesions. abortions may occur at any stage of gestation in cattle. prolonged gestation may result from cerebellar hypoplasia and lack of normal sequence to induce parturition. cerebellar hypoplasia will also be present in young born of the infected dams, as well as hydrocephalus, cataracts, gingival hyperplasia, or arthrogryposis. diagnosis is suspected with the characteristic clinical signs and exposure to viral vectors. virus isolation is the best diagnostic approach if blood is collected during the febrile stage of the disease or brains from aborted fetuses. fluorescent antibody tests, elisa, virus neutralization tests, pcr, and agar gel immunodiffusion (agid) tests are also used to confirm the diagnosis. necropsy findings. at necropsy, erosive lesions may be observed around the mouth, tongue, palate, esophagus, and pillars of the rumen. ulceration or hyperemia of the coronary bands may also be seen. many of the internal organs will contain petechial and ecchymotic hemorrhages of the surfaces, and hemorrhage may be seen at the base of the pulmonary artery. pathogenesis. the virus multiplies in the hemocoel and salivary glands of the fly and is excreted in transmissible form in the insect's saliva. after entering the host, the virus causes prolonged viremia. the incubation period is - days. the virus migrates to and attacks the vascular endothelium. the resulting vasculitis accounts for the lesions of the skin, mouth, tongue, esophagus, and rumen and the edema often found in many tissues. ballooning degeneration of affected tissues, followed by necrosis and ulceration, occurs. the effects on fetuses appear to be due to generalized infections of developing organs. differential diagnosis. differentials include other infectious vesicular diseases such as foot-and-mouth disease, contagious ecthyma, bovine viral diarrhea virus-mucosal disease, infectious bovine rhinotracheitis, bovine papular stomatitis, and malignant catarrhal fever. rinderpest is a differential in countries where it is endemic. photosensitization should be considered. foot rot is a differential for the lameness and coronitis. differentials for the manifestations such as arthrogryposis include border disease virus and genetic predispositions of some breeds such as charolais cattle and merino sheep. prevention and control. cellular and humoral immunity are necessary for protection from infection. the bluetongue virus is insidious because the genome is capable of reassortment, and some vaccines will not have the antigenic components represented in the local infection. in addition, there is little to no cross protection between strains. modified live vaccines are available in some parts of the united states but should not be used in pregnant animals. vaccinating lambs and rams in an outbreak is worthwhile, for example, but vaccinating lategestation ewes may cause birth defects or abortions. congenital defects are more common from vaccine use than from naturally occurring infection. minimizing exposure to the vector in endemic areas will decrease the incidence of the disease. treatment. supportive care and nursing care are helpful, including gruels or softer feeds, easily accessed water, and shaded resting places. nonsteroidal anti-inflammatory drugs are often administered. for the cases of secondary bacterial pneumonia and some cases of bluetongue conjunctivitis, antibiotics may be administered. research complications. this is a reportable disease because clinical signs resemble foot-and-mouth disease and other exotic vesicular diseases. etiology. bovine lymphosarcoma refers to lymphoproliferative diseases in young cattle that are not associated with bovine leukemia virus (blv) infection, and those in older cattle that are associated with b lv. b lv is a b lymphocyte-associated retrovirus (johnson and kaneene, a,b,c) . clinical signs. forms of bovine lymphosarcoma that are not associated with blv infection are calf, or juvenile; thymic, or adolescent (animals months to years old); and cutaneous (any age). the calf form is rare and characterized by generalized lymphadenopathy. onset may be sudden, and the disease is usually fatal within a few weeks. signs include lymphadenopathy, anemia, weight loss, and weakness. some animals may be paralyzed because of spinal cord compression from subperiosteal infiltration of neoplastic cells. the adolescent form is also rare, the course rapid, and the prognosis poor. the disease is seen most often in beef breeds such as hereford cattle and is characterized by space-occupying masses in the neck or thorax. these masses are also often present in the brisket. secondary effects of the masses are loss of condition, dysphagia, rumen tympany, and fatal bloat. the cutaneous presentation has a longer course and may wax and wane. the masses are found at the anus, vulva, escutcheon, shoulder, and flank; they are painful when palpated, raised, and often ulcerated. the animals are anemic, and neoplastic involvement may affect cardiac function. generalized or limited lymphadenopathy may be apparent. only the adult, or enzootic, form of bovine lymphosarcoma is associated with blv infection. many animals do not develop any malignancies or clinical signs of infection and simply remain permanently infected. some cows manifest disease only during the periparturient period. malignant lymphoma is the more common, whereas leukosis, due to b-lymphocyte proliferation, is rare. clinical signs are loss of condition and a drop in production of dairy cattle, anorexia, diarrhea, ataxia, paresis, and other signs dependent on the location of the neoplastic tissue. tumors are associated with lymphoid tissues. common sites also include the abomasum, spinal canal, and uterus. cardiac tumors develop at the right atrial or left ventricular myocardium, and associated beat and rate abnormalities may be auscultated. the common ocular manifestation of the disease is exophthalmos due to retrobulbar masses. many internal organs may be involved, and tumors may be palpable per rectum. secondary infections will be due to immunosuppression and the weakened state of the animal. sheep have acquired blv infection naturally and have been used as experimental models; in both situations, this species is susceptible to tumor and leukemia development. goats seroconvert but do not develop the clinical syndromes. diagnosis is based on the animal's age, clinical signs, serology, hematology findings according to the form, aspirates or biopsies of masses, and necropsy findings. kits are available for running agid, for which the blv antigens gp- and gp- are used; antibodies may be detected within weeks after exposure and may also help in predicting disease in clinically normal cattle. elisa and pcr diagnostic aids will also be helpful. worldwide. it is estimated that at least % of the cattle in the united states are infected with blv. as few as % of these animals develop lymphosarcoma, but the adult form of the disease described here is the most common bovine neoplastic disease in the united states. larger herds tend to have higher rates. genetic predisposition may be involved; in addition to the presence of blv, the type of bovine lymphocyte antigen (bola) may be correlated to resistance or susceptibility and to the course of the disease. transmission is believed to be by inhalation of blv in secretions; in colostrum; horizontally by contaminated equipment not sanitized between cattle; and by rectum (e.g., mucosal irritation during per-rectum exams or procedures). natural-service bulls may transmit the infection to cows. cows infected with blv may transmit the infection to their calves in utero. tabanid and other flies also serve as vectors, but these represent a minor means of transmission. necropsy findings. neoplastic infiltration of many organs and tissues are found in the calf form and the cutaneous forms. tumors may be local or widely distributed in the enzootic form. definitive diagnosis of neoplastic tissue specimens is by histology. pathogenesis. as with other retroviruses, the blv integrates viral dna into host target cell dna by means of the reverse transcriptase enzyme, creating a provirus. epizootiology and transmission. the virus is reported to be widespread. occurrence is often seasonal, and biting insects may be vectors. transmission with successful infection requires deep penetration of the skin. transmission may be by contaminated milkers' hands, contaminated equipment, and other fomites. differential diagnosis. differential diagnoses include other diseases that cause lesions on teats such as pseudocowpox, papillomatosis, and vesicular stomatitis. other vesicular diseases may be considered, but other more severe clinical signs might be associated with those. there is no vaccine for this disease. development and maintenance of a blv-free herd, or controlling infection within a herd, requires financial and programmatic commitments: blv-positive and blv-negative animals maintained separately; serologic testing (such as at least every months) and separating positive animals; and washing and then disinfecting instruments, needles (or using sterile singleuse products), and equipment for ear tagging and dehorning and other such equipment between animals. a fresh rectal exam sleeve and lubricant should be used for each animal examined. otherwise serologically positive cows may have undetectable antibodies during the periparturient period. embryo transfer recipients should be negative, and the virus will not be transferred by the embryonic stage. calves should be fed colostrum from serologically negative cows. treatment. treatment regimens of corticosteroids and cancer chemotherapeutic agents provide only short-term improvement. in cases where ova, embryos, or semen need to be collected, supportive care for the affected animals is essential. research complications. the united states and several countries, some in europe, have official programs for eradication of enzootic bovine leukosis. prevention and control. established milking hygiene practices are important control measures: having milkers wash their hands with germicidal solutions or wear gloves, cleaning equipment between animals, and separating affected animals. treatment. there is no treatment, and affected animals should be separated from the herd and milked last. lesions can be cleaned and treated with topical antibacterials. etiology. the bovine viral diarrhea virus (bvdv) is a pestivirus of the flaviviridae family. the flaviviridae include hog cholera virus and border disease virus of sheep. the virus contains a single strand of positive-sense rna. a broad range of disease and immune effects is produced by b vdv only in cattle. in addition, this virus is important in the etiology of bovine pneumonias. bovine viral diarrhea/mucosal disease (bvd/md) is one of the most important viral diseases and one of the most complex diseases of cattle. strains of bvdv are characterized as cytopathic (cp) and noncytopathic (ncp), based on cell-culture growth characteristics. the virus has also been categorized as type and type isolates. heterologous strains exist that may confound even sound vaccination programs. etiology. bovine herpesvirus causes bovine herpes mammillitis, a widespread disease characterized by teat and udder lesions, as well as oral and skin lesions. clinical signs and diagnosis. lesions begin suddenly with teat swelling; the tissue will be edematous and tender when touched. the udder lesions may extend to the perineum. the lesions progress to vesicles, then to ulcers; these may take weeks to heal. lesions rarely may also develop focally around the mouth and generally on the skin of the udder. secondary mastitis may occur, because of bacteria associated with the scabs. diagnosis is by clinical signs and serologically. clinical signs and diagnosis. signs of bvdv infections may be subclinical but also include abortions, congenital abnormalities, reduced fertility, persistent infection (pi) with gradual debilitation, and acute and fatal disease. the presence of antibodies, whether from passive transfer or immunizations, does not necessarily guarantee protection from the various forms of the disease. an acute form of the disease, caused by type bvdv, occurs in cattle without sufficient immunity. after an incubation period of - days, clinical signs include fever, anorexia, oculonasal discharge, oral erosions (including on the hard palate), diarrhea, and decreased milk production. the disease course may be shorter with hemorrhagic syndrome and death within days. clinical signs of b vdv in calves also include severe enteritis and pneumonia. when susceptible cows are infected in utero from gestational be found extending throughout the gastrointestinal tract to the days - , or gestational cows are vaccinated with a modi-cecum. the respiratory tract lesions will often be complicated fled live vaccine, abortion or stillbirth result. congenital defects caused by bvdv during gestational days - include impaired immunity (thymic atrophy), cerebellar hypoplasia, ocular defects, alopecia or hypotrichosis, dysmyelinogenesis, hydranencephaly, hydrocephalus, and intrauterine growth retardation. typical signs of cerebellar dysfunction will be evident in calves, such as wide-based stance, weakness, opisthotonus, hyperflexion, hypermetria, nystagmus, or strabismus. some severely affected calves will not be able to stand. ophthalmic effects include retinal degeneration and microphthalmia. fetuses can also be infected in utero, normal at birth, immunotolerant to the virus, and persistently infected (pi). the term mucosal disease is commonly associated with this form of the infection. many pi animals do not survive to maturity, however, and many have weakened immune systems. the pi animals are important because they shed virus and will probably show the clinical signs of mucosal disease (md) caused by a cp b vdv strain derived from an ncp b vdv strain. these md clinical signs include fever, anorexia, and profuse diarrhea that may include blood and fibrin casts, and oral and pharyngeal erosions, as well as erosion at the interdigital spaces and on the teats and vulva. many other associated clinical signs include anemia, bloat, lameness, or corneal opacities and discharges. secondary effects of hemorrhage and dehydration also contribute to the morbidity and mortality. animals that do not succumb to the disease will be chronically unthrifty, debilitated, and infection-prone. diagnosis in affected calves is based on herd health history, clinical signs, and antibodies to b vdv in precolostral serum. viral culturing from blood may be useful. in older animals, oral lesions, serology, detection of viral antigen, and virus isolation contribute to the diagnosis. leukopenia, and especially lymphopenia, are seen. serology must be interpreted with the awareness of the possibility of pi immunotolerant animals. vaccination against the disease carries its own set of side effects and potential problems, especially when using modified live vaccines, whether against cp or ncp strains. the condition of the animals is also a variable. epizootiology and transmission. bvdv is present throughout the world. transmission occurs easily by direct contact between cattle, from feed contaminated with secretions or feces, and by aborted fetuses and placentas. pi females transmit the virus to their fetuses. semen also is a source of virus. necropsy findings. in affected calves, histopathologic findings include necrosis of external germinal cells, focal hemorrhages, and folial edema. later in the disease, large cavities develop in the cerebellum, and atrophy of the cerebellar folia and thin neuropil are evident. older calves may have areas of intestinal necrosis. in cases where oral erosions occur, erosions will by secondary bacterial pneumonia. when the hemorrhagic syndrome develops, petechiation and mucosal bleeding will be present. pathogenesis. the cp and ncp strains are thought to be related mutations of the bvdv; the cp short-lived isolates are believed to arise from the ncp strains. the ncp strains are those present in the pi animals, and the strains are maintained in cattle populations. cp and ncp isolates vary in virulence, and classification of these types is based on viral surface proteins. considerable antigenic variation also exists between strains and types. other viral infections, such as bovine respiratory syncytial virus and infectious bovine rhinotracheitis, may also be present in the same animals. the pathology caused by b vdv is due to its ability to infect epithelial cells and impair the functioning of immune cell populations through out the bovine system. in type bvdv hemorrhagic syndrome, death results from viral-induced thrombocytopenia. in fetuses, the virus infects developing germinal cells of the cerebellum. the purkinje's cells in the granular layer are killed, and necrosis and inflammation follow. the immune effects are the result of the virus's interfering with neutrophil and macrophage functions and of lymphocyte blastogenesis. all of these predispose the affected animals to bacterial infections with pasteurella haemolytica. b vdv damages dividing cells in fetal organ systems, resulting in abortions and congenital effects. differential diagnosis. many differentials must be considered for the clinical manifestations of b vdv infections. differentials for enteritis of calves include viral infections, cryptosporidia, escherichia coli, salmonella, and coccidia. salmonella, winter dysentery, johne's disease, intestinal parasites, malignant catarrhal fever (mcf), and copper deficiency are differentials for the diarrhea seen in the disease in adult animals. respiratory tract pathogens such as bovine respiratory syncytial virus, pasteurella, haemophilus, and mycoplasma must be considered for the respiratory tract manifestations. oral lesions are also produced by mcf, vesicular stomatitis, bluetongue, and papular stomatitis. infectious bovine herpesvirus , leptospirosis, brucellosis, trichomoniasis, and mycosis should be considered in cases of abortion. prevention and control. combined with sound management in a typical cattle herd, vaccination is the best way to prevent b vdv and should be integrated into the herd health program, timed appropriately preceding breeding, gestation, or stressful events. vaccine preparations for b vdv are modified live virus (mlv) or killed virus. each has advantages and disadvantages. the former induces rapid immunity (within week) after a single dose, provides longer duration of immunity against sev-eral strains, and induces serum neutralizing antibodies. mlv vaccines are not recommended for use in pregnant cattle, may induce mucosal disease, and may be immunosuppressive at the time of vaccination. the immunosuppression is detrimental if cattle are concurrently exposed to field-strain virus because it will facilitate infection and possible clinical disease. the mlv strains may cross the placenta, resulting in fetal infections. the killed vaccines are safer in pregnant animals but require booster doses after the initial immunization, may need to be given - times per year, and do not induce cell-mediated immunity. passive immunity may protect most calves for up to - months of age. subsequent vaccination with mlv may provide lifelong immunity, but this is not guaranteed. annual boosters are recommended to protect against vaccine breaks. the virus persists in the environment for weeks and is susceptible to the disfectants chlorhexidine, hypochlorite, iodophors, and aldehydes. maintenance of a closed herd to prevent any possibility of the introduction of the virus is difficult. isolation of new animals, avoidance of the purchase of pregnant cows, scrutiny of records from source farms, use of semen tested bulls, minimization of stress, testing of embryo-recipient cows, and maintainenance of populations of ruminants (smaller or wild species) separately on the premises will minimize viral exposure. other management strategies may require a program for testing and culling pi cattle. this can be expensive but may be a worthwhile investment to remove the virus shedders from a herd. no specific treatment is available. supportive care and treatment with antibiotics to prevent secondary infection are recommended. animals that survive the infection should be evaluated a month after recovery to determine their status as pi or virus-free. etiology. cache valley virus (cvv), of the arbovirus genus of the bunyaviridae family, is a cause of congenital defects in lambs. cvv infection in fetal and newborn lambs include arthrogryposis, microencephaly, hydranencephaly, porencephaly, cerebellar hypoplasia, and micromyelia. stillbirths and mummified fetuses are seen. lambs will be born weak and will act abnormally. diagnosis is by evidence of seroconversion in precolostral blood samples or fetal fluids, as the result of in utero infection. western united states, although it has been isolated in a few midwestern states. although considered a disease of sheep, virus has been isolated from cattle and from wild ruminants and antibodies found in white-tailed deer. transmission is by arthropods during the first trimester of pregnancy. etiology. caprine arthritis encephalitis virus (caev) occurs worldwide, with a high prevalence in the united states. caprine arthritis encephalitis (cae) is considered the most important viral disease of goats. the caev is in the lentivirus genus of the retroviridae family. it causes chronic arthritis in adults and encephalitis in young. caev is in the same viral genus as the ovine progressive pneumonia virus (oppv). clinical signs and diagnosis. the most common presentation in goats is an insidious, progressive arthritis in animals months of age and older. animals become stiff, have difficulty getting up, and may be clinically lame in one or both forelimbs. carpal joints are so swollen and painful that the animal prefers to eat, drink, and walk on its "knees." in dairy goats, milk production decreases, and udders may become firmer. this retrovirus also causes neurological clinical signs in young kids - months old. kids may be bright and alert, afebrile, and able to eat normally even when recumbent. some kids may initially show unilateral weakness in a rear limb, which progresses to hemiplegia or tetraplegia. mild to severe lower motor neuron deficits may be noted, but spinal reflexes are intact. clinical signs may also include head tilt, blindness, ataxia, and facial nerve paralysis. older animals in the group may experience interstitial pneumonia or chronic arthritis. the pneumonia is similar to the pneumonia in sheep caused by oppv; the course is gradual but progressive, and animals will eventually lose weight and have respiratory distress. some animals in a herd may not develop any clinical signs. diagnosis is based on clinical signs, postmortem lesions, and positive serology for viral antibodies to caev. an agar gel immunodiffusion (agid) test identifies antibodies to the virus and is used for diagnosis. kids acquire an anti-caev antibody in colostrum, and this passive immunity may be interpreted as indicative of infection with the virus. the antibody does not prevent viral transmission. ep&ootiology and transmission. the virus is prevalent in most industrialized countries. the common means of transmission, from adults to kids, is in the colostrum and milk in spite of the presence of anti-caev antibody in the colostrum. transmission may occur among adult goats by contact. intrauterine transmission is believed to be rare. transmission to sheep has occurred only experimentally; there is no documented case of natural transmission. necropsy findings. necropsy and histopathology reveal a striking synovial hyperplasia of the joints with infiltrates of lymphocytes, macrophages, and plasma cells. other histologic lesions include demyelination in the brain and spinal cord, with multifocal invasion of lymphocytes, macrophages, and plasma cells. in severe cases of mastitis, the udder may appear to be composed of lymphoid tissue. tem, resulting in the formation of non-neutralizing antibody to viral core proteins and envelope proteins. immune complex formation in synovial, mammary gland, and neurological tissue is thought to result in the clinical changes observed. most commonly, the carpal joint is affected, followed by the stifle, hock, and hip. the infection is lifelong. differential diagnosis. the differential diagnosis for the neurologic form of caev should include copper deficiency, enzootic pneumonia, white muscle disease, listeriosis, and spinal cord disease or injury. the differential diagnosis for caev arthritis should include chlamydia and mycoplasma. prevention and control. herds can be screened for cae by testing serologically, using an agid or an enzyme-linked immunosorbent assay (elisa) test. the elisa is purported to be more sensitive, whereas the agid is more specific. individual animals show great variation in development of antibody. because cae is highly prevalent in the united states, and because seronegative animals can shed organisms in the milk, retesting herds at least annually may be necessary. recently, an immunoprecipitation test for cae has been developed that has high sensitivity and specificity. control measures include management practices such as test and cull, prevention of milk transmission, and isolation of affected animals. parturition must be monitored, and kids must be removed immediately and fed heat-treated colostrum ( ~ for hr). caev-negative goats should be separated from caevpositive goats. treatment. there is no treatment for caev. is also referred to as bovine herpesvirus (bhv- ) and is an alphaherpesvirus. ibrv causes or contributes to several bovine syndromes, including respiratory and reproductive tract diseases. it is one of the primary pathogens in the bovine respiratory disease complex. strains include bhv-i. (associated with respiratory disease), bhv . (associated with respiratory and genital diseases), and bhv . (associated with neurological diseases), which has been reclassified as bovine herpesvirus . clude conjunctivitis, rhinotracheitis, pustular vulvovaginitis, balanoposthitis, abortion, encephalomyelitis, and mastitis. the respiratory form is known as infectious bovine rhinotracheitis, and clinical signs may range from mild to severe, the latter particularly when there are additional respiratory viral infections or secondary bacterial infections. the mortality rate in more mature cattle is low, however, unless there is secondary bacterial pneumonia. fever, anorexia, restlessness, hyperemia of the muzzle, gray pustules on the muzzle (that later form plaques), nasal discharge (that may progress from serous to mucopurulent), hyperpnea, coughing, salivation, conjunctivitis with excessive epiphora, and decreased production in dairy animals are typical signs. open-mouth breathing may be seen if the larynx or nasopharygneal areas are blocked by mucopurulent discharges. neonatal calves may develop respiratory as well as general systemic disease. in these cases, in addition to the symptoms already noted, the soft palate may become necrotic, and gastrointestinal tract ulceration occurs. young calves are most susceptible to the encephalitic form; signs include dull attitude, head pressing, vocalizations, nystagmus, head tilt, blindness, convulsions, and coma, as well as some signs, such as discharges, seen with respiratory tract presentations. this form is usually fatal within days. abortion may occur simultaneously with the conjunctival or respiratory tract diseases, when the respiratory infection appears to be mild, or may be delayed by as much as months after the respiratory tract disease signs. infectious pustular vulvovaginitis is most commonly seen in dairy cows, and clinical signs may be mild and not noticed. otherwise, signs are fever, depression, anorexia, swelling of the vulvar labia, vulvar discharge, and vestibular mucosa reddened by pustules. the cow will often carry her tail elevated away from these lesions. these soon coalesce, and a fibrous membrane covers the ulcerated area. if uncomplicated, the infection lasts about - days, and lesions heal in weeks. younger infected bulls may develop balanoposthitis with edema, swelling, and pain such that the animals will not service cows. epizootiology and transmission. ibrv is widely distributed throughout the world, and adult animals are the reservoirs of infection. the disease is more common in intensive calf-rearing situations and in grouped or stressed cattle. transmission is primarily by secretions, such as nasal, during and after clinical signs of disease. modified live vaccines are capable of causing latent infections. necropsy findings. fibrinonecrotic rhinotracheitis is considered pathognomic for ibrv respiratory tract infections. there will be adherent necrotic lesions in the respiratory, ocular, and reproductive mucosa. when there are secondary bacterial infections, such as pasteurella bronchopneumonia, findings will include congested tracheal mucosa and petechial and ecchymotic hemorrhages in that tissue. lesions from the encephalitic form include lymphocytic meningoencephalitis and will be found throughout the gray matter (neuronal degeneration, perivascular cuffing) and white matter (myelitis, demyelination). intranuclear inclusion bodies are not a common finding with this herpesvirus. pathogenesis. in the encephalitic form, the virus first grows in nasal mucosa and produces plaques. these resolve within days, and the encephalitis develops after the virus spreads centripetally to the brain stem by the trigeminal nerve dendrites. latent infections are also established in neural tissue. differential diagnosis. the severe oral erosions seen with bvdv infections are rare with infectious bovine rhinotracheitis-infectious pustular vulvovaginitis (ibr-ipv). the conjunctivitis of ibr may initially be mistaken for that of a moraxella bovis (pinkeye) infection; the ibr will be peripheral, and there will not be corneal ulceration. bovine viral diarrhea virus and ibrv are the most common viral causes of bovine abortion. differentials for balanoposthitis include trauma from service. vated, attenuated, modified live, and genetically altered preparations. some are in combination with parainfluenza (pi- ) virus. the mlv preparations are administered intranasally; these are advantageous in calves for inducing mucosal immunity even when serologic passive immunity is already present and adequate. some newer vaccines, with gene deletion, allow for serologic differentiation between antibody responses from infection or immunization. bulls with the venereal form of the infection will transmit the virus in semen; intranasal vaccine may be used to provide some immunity. treatment. uncomplicated mild infections will resolve over a few weeks; palliative treatments, such as cleaning ocular discharges and supplying softened food, are helpful in recovery. antibiotics are usually administered because of the high likelihood of secondary bacterial pneumonia. the encephalitic animals may need to be treated with anticonvulsants. etiology. parainfluenza , an rna virus of the family paramyxoviridae, causes mild respiratory disease of ruminants when it is the sole pathogen. the viral infection often predisposes the respiratory system to severe disease associated with concurrent viral or bacterial pathogens. viral strains are reported to vary in virulence. serotypes seen in the smaller ruminants are distinct from those isolated from cattle. clinical signs and diagnosis. infections ranging from asymptomatic to mild signs of upper respiratory tract disease are associated with this virus by itself; infections are almost never fatal. clinical signs include ocular and nasal discharges, cough, fever, and increased respiratory rate and breath sounds. in pregnant animals, exposure to pi- can result in abortions. clinical signs become apparent or more severe when additional viral pathogens are present, such as bovine viral diarrhea virus, or a secondary bacterial infection, such as pasteurella haemolytica infection, is involved. greater morbidity and mortality will be sequelae of the bacterial infections. viral isolation or direct immunofluorescence antibody (ifa) from nasal swabs can be used for definitive diagnosis. presently it is assumed that the virus is widespread in goats, but firm evidence is lacking. for an infection of pi- only, findings will be negligible. some congestion of respiratory mucosa, swelling of respiratory tract-associated lymph nodes, and mild pneumonitis may be noted grossly and histologically. intranuclear and intracytoplasmic inclusion bodies may be present in the mucosal epithelial cells. findings will be similar but not as severe as those caused by bovine respiratory syncytial virus. immunohistochemistry may also be used. pathogenesis. pi- infects the epithelial mucosa of the respiratory tract; however, the disease is often asymptomatic when uncomplicated. differential diagnosis. differentials, particularly in cattle, include infections with other respiratory tract viruses of ruminants: ibrv, bvdv, bovine respiratory syncytial virus, and type bovine adenovirus. prevention and control. immunization, management, and nutrition are important for this respiratory pathogen, as for others. in cattle, modified live vaccines for intramuscular (im), subcutaneous (sc), or intranasal (in) administration are available. the im and sc routes provide immune protection within week after administration but will not provide protection in the presence of passively acquired antibodies. it is contraindicated for pregnant animals because it will cause abortion. the in route immunizes in the presence of passively acquired antibodies, provides immunity within days of administration, and stimulates the production of interferon. other vaccine formulations, about which less information is reported, include inactivated or chemically altered live-virus preparations; both are administered im, and followup immunizations are needed within weeks. booster vaccinations are recommended for all preparations within - months after the initial immunization. all presently marketed vaccine products come in combination with other bovine respiratory viruses as multivaccine products. the humoral immunity protects against pi- abortions. there is no approved pi- vaccine for sheep and goats. the use of the cattle formulation in these smaller ruminants is not recommended. sound management of housing, sanitation, nutrition, and preventive medicine programs are all equally important components in prevention and control. treatment. uncomplicated disease is not treated. etiology. the respiratory syncytial viruses are pneumoviruses of the paramyxoviridae family and are common causes of severe disease in ruminants, especially calves and yearling cattle. two serotypes of the bovine respiratory syncytial virus (brsv) have been described for cattle; these may be similar or identical to the virus seen in sheep and goats. clinicalfindings and diagnosis. infections may be subclinical or develop into severe illness. clinical signs include fever, hyperpnea, spontaneous or easily induced cough, nasal discharge, and conjunctivitis. interstitial pneumonia usually develops, and harsh respiratory sounds are evident on auscultation. development of emphysema indicates a poor prognosis, and death may occur in the severe cases of the viral infection. secondary bacterial pneumonia, especially with pasteurella haemolytica, with morbidity and mortality, is also a common sequela. abortions have been assciated with brsv outbreaks. diagnosis is based on virus isolation and serology (acute and convalescent). nasal swabs for virus isolation should be taken when animals have fever and before onset of respiratory disease. prevention and control. vaccination should be part of the standard health program, and all animals should be vaccinated regularly. vaccinations should be administered within - months of stressful events, such as weaning, shipping, and introduction to new surroundings. currently available vaccines include an inactivated preparation and a modified live virus preparation administered intramuscularly or subcutaneously; immunity develops well in yearling animals, and colostral antibodies develop when cows are vaccinated during late gestation. passive immunity from colostrum provides at least partial protection to calves in herds where disease is prevalent. but this immunity suppresses the mucosal iga response and serum antibody responses. the basis for successful immune protection is the mucosal memory iga, but this is difficult to achieve with present vaccine formulations. the virus is easily inactivated in the environment. preventive measures in preweaning animals should include preconditioning to minimize weaning stress. treatment. recovery can be spontaneous; however, antibiotics and supportive therapy are useful to prevent or control secondary bacterial pneumonia. in severe cases, antihistamines and corticosteriods may also be necessary. use of vaccine during natural infection is not productive and may result in severe disease. etiology. ulcerative dermatosis is a contagious disease of sheep only. it is caused by a poxvirus similar to but distinct from the causative agent of contagious ecthyma ("current veterinary therapy," ). epizootiology and transmission. these viruses are considered ubiquitous in domestic cattle and are transmitted by aerosols. teroventral lung lobes. edema and emphysema are present. as the name indicates, syncytia, which may have inclusions, form in areas of the lungs infected with the virus. necrotizing bronchiolitis, bronchiolitis obliterans, and hyaline membrane formation will be evident microscopically. crusts associated with the skin and mucous membranes of the genitalia, face, and feet (bulgin, ) . genital lesions are much more common than the facial or coronal lesions. discomfort may be associated with the lesions. paraphimosis occasionally occurs. these lesions are painful; during breeding season, animals will avoid coitus. morbidity is low to moderate, and mortality negligible if the flock is otherwise healthy. diagnosis is based on clinical signs. pathogenesis. the severe form of the disease, which often follows a mild preliminary infection, is thought to be caused by immune-mediated factors during the process of infection in the lung. virulence may vary greatly among viral strains. united states, ulcerative dermatosis is transmitted through direct contact with abraded skin of the prepuce, vulva, face, and feet. necropsy findings. necropsy would rarely be necessary to diagnose an outbreak in a healthy flock. findings will be similar to those described for contagious ecthyma. when no contact with cattle has occurred. persistently infected animals, such as lambs, are shedding reservoirs of the virus in urine, feces, and saliva throughout their lives. pathogenesis. following an incubation period of - days, the virus replicates in the epidermal cells and leads to necrosis and pustule formation. pustules rapidly break, forming weeping ulcers. the ulcers scab over and eventually form a fibrotic scar. the disease usually resolves in - weeks. rarely, the disease will persist for many months to more than a year. differential diagnosis. the main differential is contagious ecthyma, which is grossly and histopathologically associated with epithelial hyperplasia. this is also a feature of ulcerative dermatosis. imals, especially males, should not be used for breeding. treatment. affected animals should be separated from the rest of the flock. treatment is supportive, including antiseptic ointments and astringents. research complications. breeding and maintenance of the flocks' condition, because of the pain associated with eating, will be compromised during an outbreak. etiology. border disease, also known as hairy shaker disease (or "fuzzies" in the southwestern united states), is a disease of sheep caused by a virus closely related to the bovine viral diarrhea virus (bvdv), a pestivirus of the togaviridae family. goats are also affected. the virus causes few pathogenic effects in cattle. clinical signs and diagnosis. border disease in ewes causes early embryonic death, abortion of macerated or mummified fetuses, or birth of lambs with developmental abnormalities. lambs infected in utero that survive until parturition may be born weak and often exhibit a number of congenital defects such as tremor, hirsutism (sometimes darkly pigmented over the shoulders and head), hypothyroidism, central nervous system defects, and joint abnormalities, including arthrogryposis. later, survivors may be more susceptible to diseases and may develop persistent, sometimes fatal, diarrhea. the virus infection produces similar clinical manifestations in goats, except that the hair changes are not seen. diagnosis includes the typical signs described above, as well as serological evidence of viral infection. virus isolation confirms the diagnosis. wide, and reports of disease are sporadic. disease has occurred necropsy findings. lesions include placentitis, and characteristic joint and hair-coat changes in the fetus. histologically, axonal swelling, neuronal vacuolation, dysmyelination, and focal microgliosis are observed in central nervous system structures. pathogenesis. the virus entering the ewe via the gastrointestinal or respiratory tracts penetrates the mucous membranes and causes maternal and fetal viremia. infection during the first days of gestation causes embryonic death. in lambs infected between and days, the virus activates follicular development, diminishes the myelination of neurons, and causes dysfunction of the thyroid gland. infection after days of gestation results in lambs that are born persistently infected. infected lambs have high perinatal mortality; survivors have diminished signs over time but, as noted, continue to shed the virus. prevention and control. border disease can be prevented by vaccinating breeding ewes with killed-bvdv vaccine. congenitally affected lambs should be maintained separately and disposed of as soon as humanely possible. new animals to the flock should be screened serologically. if cattle are housed nearby, vaccination programs for bvdv should be maintained. treatment. there is no treatment other than supportive care for affected animals. etiology. contagious ecthyma, also known as contagious pustular dermatitis, sore mouth, or off, is an acute dermatitis of sheep and goats caused by a parapoxvirus. this disease occurs worldwide and is zoonotic. naturally occurring disease has also been reported in other species such as musk ox and reindeer. other parapoxviruses infect the mucous membranes and skin of cattle, causing the diseases bovine pustular dermatitis and pseudocowpox. clinical signs and diagnosis. the disease is characterized by the presence of papules, vesicles, or pustules and subsequently scabs of the skin of the face, genitals of both sexes, and coronary bands of the feet. lesions develop most frequently at mucocutaneous junctions and are found most commonly at the commissures of the mouth. off is usually found in young animals less than year of age. younger lambs and kids will have difficulty nursing and become weak. lesions may also develop on udders of nursing dams, which may resist suckling by offspring to nurse, leading to secondary mastitis. the scabs may appear nodular and raised above the surface of the surrounding skin. morbidity in a susceptible group of animals may exceed %. mortality is low, but the course of the disease may last up to weeks. diagnosis is based on characteristic lesions. biopsies may reveal eosinophilic cytoplasmic inclusions and proliferative lesions under the skin. electron microscopy will reveal the virus itself. disease is confirmed by virus isolation. epizootiology and transmission. all ages of sheep and goats are susceptible. seasonal occurrences immediately after lambing and after entry into a feedlot are common; stress likely plays a role in susceptibility to this viral disease. older animals develop immunity that usually prevents reinfection for at least or more years. resistant animals may be present in some flocks or herds. the virus is very resistant to environmental conditions and may contaminate small-ruminant facilities, pens, feedlots, and the like for many years as the result of scabs that have been shed from infected animals. transmission occurs through superficial lesions such as punctures from grass awns, scrapes, shearing, and other common injuries. necropsy findings. necropsy findings include ballooning degeneration of epidermal and dermal layers, edema, granulomatous inflammation, vesiculation, and cellular hyperplasia. secondary bacterial infection may also be evident. pathogenesis. the virus is typical of the poxviridae, resembling sheep poxvirus (not found in the united states) and vaccinia virus and replicating in the cytoplasm of epithelial cells. following an incubation period of - days, papules and vesicles develop around the margins of the lips, nostrils, eyelids, gums, tongue, or teats; skin of the genitalia; or coronary band of the feet. the vesicles form pustules that rupture and finally scab over. virus should be considered in both sheep and goats. an important differential in goats is staphylococcal dermatitis. prevention and control. individuals handling infected animals should be advised of precautions beforehand, should wear gloves, and should separate work clothing and other personal protective equipment. clippers, ear tagging devices, and other similar equipment should always be cleaned and disinfected after each use. colostral antibodies may not be protective. vaccinating lambs and kids with commercial vaccine best prevents the disease. dried scabs from previous outbreaks may also be used by rubbing the material into scarified skin on the inner thigh or axilla. animals newly introduced to infected premises should be vaccinated upon arrival. precautions must be taken when vaccinating animals, because the vaccine may induce orf in the animal handlers; it is not recommended to vaccinate animals in flocks already free of the disease. affected dairy goats should be milked last, using disposable towels for cleaning teat ends. treatment. affected animals should be isolated and provided supportive care, especially tube feeding for young animals whose mouths are too sore to nurse. treatment should also address secondary bacterial infections of the orf lesions, including systemic antibiotics for more severe infections. treatment for myiasis may also be necessary. the viral infection is self-limiting, with recovery in about weeks. research complications. carrier animals may be a factor in flock or herd outbreaks. contagious ecthyma is a zoonotic disease, and human-to-human transmission can also occur. the virus typically enters through abrasions on the hands and results in a large (several centimeters) nodule that is described as being extremely painful and lasting for as many as weeks. lesions heal without scarring. etiology. foot-and-mouth disease (fmd) is caused by the foot-and-mouth disease virus, a picornavirus in the aphthovirus genus. the disease is also referred to as aftosa or aphthous fever. seven immunologically distinct types of the virus have been identified, with subtypes within those . epidemics of the disease have occurred worldwide. north and central america have been free of the virus since the mid- s. this is a reportable disease in the united states; clinical signs are very similar to other vesicular diseases. cattle (and swine) are primarily affected, but disease can occur in sheep and is usually subclinical in goats. clinical signs and diagnosis. in addition to vesicle formation around and in the mouth, hooves, and teats, fever, anorexia, weakness, and salivation occur. vesicles may be as large as cm, rupture after days, and subsequently erode. secondary bacterial infections often occur at the erosions. anorexia is likely due to the pain associated with the oral lesions. high morbidity and low mortality, except for the high mortality in young cattle, are typical. diagnosis must be based on elisa, virus neutralization, fluorescent antibody tests, and complement fixation. epizootiology and transmission. domestic and wild ruminants and several other species, such as swine, rats, bears, and llamas are hosts. asymptomatic goats can serve as virus reservoirs for more susceptible cohoused species such as cattle. greater mortality occurs in younger animals. the united states, great britain, canada, japan, new zealand, and australia are fmd-free, whereas the disease is endemic in most of south america, parts of europe, and throughout asia and africa. the virus is very contagious and is spread primarily by the inhalation of aerosols, which can be carried over long distances. transmission may also occur by fomites, such as shoes, clothing, and equipment. human hands, soiled bedding, and animal products such as frozen or partially cooked meat and meat products, hides, semen, and pasteurized milk also serve as sources of virus. necropsy findings. vesicles, erosions, and ulcers are present in the oral cavity as well as on the rumen pillars and mammary alveolar epithelium. myocardial and skeletal muscle degeneration (zenker's) is most common (and accounts for the greater mortality) in younger animals. histological findings include lack of inclusion bodies. vesicular lesions include intracellular and extracellular edema, cellular degeneration, and separation of the basal epithelium. replicates in the pharynx and digestive tract in the cells of the stratum spinosum, and viremia and spread of virus to many tissues occur before clinical signs develop. virus shedding begins about hr before clinical signs are apparent. vesicles result from the separation of the superficial epithelium from the basal epithelium. fluid fills the basal epithelium, and erosions develop when the epithelium sloughs. persistent infection also occurs, and virus can be found for months or years in the pharnyx; the mechanisms for the persistence are not known. differential diagnosis. vesicular stomatitis is the principal differential. other differentials include contagious ecthyma (orf), rinderpest, bluetongue, malignant catarrhal fever, bovine papular stomatitis, bovine herpes mammillitis, and infectious bovine rhinotracheitis virus infection. products from endemic areas is regulated. quarantine and slaughter are practiced in outbreaks in endemic areas. quarantine and vaccination are also used in endemic areas, but vaccines must be type-specific and repeated or times per year to be effective and will provide only partial protection. autogenous vaccines are best in an outbreak. passive immunity protects calves for up to months after birth. the virus is inactivated by extremes of ph, sunlight, high temperatures, sodium hydroxide, sodium carbonate, and acetic acid. treatment. nursing care and antibiotic therapy to minimize secondary reactions help with recovery. humoral immunity is considered the more important immune mechanism, with cellmediated immunity of less importance. research complications. rare cases in humans have been reported. importation into the united states of animal products from endemic areas is prohibited. etiology. malignant catarrhal fever (mcf) is a severe disease primarily of cattle. the agents of mcf are viruses of the gammaherpesvirinae subfamily. alcelaphine herpesvirus and and ovine herpesvirus are known strains. the alcelaphine strains are seen in africa. the ovine strain is seen in north america. the alcelaphine and ovine strains differ in incubation times and duration of illness. disease may occur sporadically or as outbreaks. clinical signs and diagnosis. signs range from subclinical to recrudescing latent infections to the lethal disease seen in susceptible species, such as cattle. sudden death may also occur in cattle. presentations of the disease may be categorized as alimentary, encephalitis, or skin forms; all three may occur in an animal. corneal edema starting at the limbus and progressing centripetally is a nearly pathognomonic sign; photophobia, severe keratoconjunctivitis, and ocular involvement may follow. other signs include prolonged fever, oral mucosal erosions, salivation, lacrimation, purulent nasal discharge, encephalitis, and pronounced lymphadenopathy. as the disease progresses, cattle may shed horns and hooves. in north america, cattle will also have severe diarrhea. the course of the disease may extend to week. recovery is usually prolonged, and some permanent debilitation may occur. the disease is fatal in severely affected individuals. history of exposure, as well as the clinical signs and lesions, contributes to the diagnosis. serology, pcr-based assays, viral isolation, and cell-culture assays, such as cytopathic effects on thyroid cell cultures, are also used. because of the susceptibility of rabbits, inoculation of this species may be used. in less severe outbreaks or individual animal disease, definitive diagnosis may never be made. necropsy. gross findings at necropsy include necrotic and ulcerated nasal and oral mucosa; thickened, edematous, ulcerated, and hemorrhagic areas of the intestinal tract; swollen, friable, and hemorrhagic lymph nodes and other lymphatic tissues; and erosion of affected mucosal surfaces. lymph nodes should be submitted for histological examination. histological findings include nonsuppurative vasculitis and encephalitis; large numbers of lymphocytes and lymphoblasts will be present without evidence of virus. pathogenesis. the incubation period may be up to months. vascular endothelium and all epithelial surfaces will be affected. the virus is believed to cause proliferation of cytotoxic t lymphocytes with natural killer cell activities, and the resulting lesions are due to an autoimmune type of phenomenon. differential diagnoses. the differentials for this disease are bovine viral diarrhea/mucosal disease, bovine respiratory disease complex, infectious bovine rhinotracheitis, bluetongue, vesicular stomatitis, and foot-and-mouth disease. causes of encephalitis, such as bovine spongiform encephalopathy and rabies, should be considered. in africa, rinderpest is also a differential. other differentials are arsenic toxicity and chlorinated naphthalene toxicity. in north america, sheep, as well as cattle that have been either exposed or that have survived the disease, are reservoirs for outbreaks in other cattle. if there is concern regarding presence of the virus, animals should be screened serologically; once an animal has been infected, it remains infected indefinitely. lambs can be free of the infection if removed from the flock at weaning. the virus is very fragile outside of host's cells and will not survive in the environment for more than a few hours. lobes; and hematological findings indicate anemia and leukocytosis. the rare neurological signs include flexion of fetlock and pastern joints, tremors of facial muscles, progressive paresis and paralysis, depression, and prostration. death occurs in weeks to months. the disease can be serologically diagnosed with agar gel immunodiffusion (agid) tests, virus isolation, serum neutralization, complement fixation, and enzyme-linked immunosorbent assay (elisa) tests. sixty-eight percent of sheep in some states have been infected with the virus (radostits et al., ) . it is transmitted horizontally via inhalation of aerosolized virus particles and vertically between the infected dam and fetus. in addition, transmission through the milk or colostrum is considered common (knowles, ) . necropsy findings. lesions are observed in lungs, mammary glands, joints, and the brain. pulmonary adhesions, ventral lung lobe consolidation, bronchial lymph node enlargement, mastitis, and degenerative arthritis are visualized grossly. meningeal edema, thickening of the choroid plexus, and foci of leukoencephalomalacia are seen in the central nervous system (cns). histologically, interalveolar septal thickening, lymphoid hyperplasia, histiocyte and fibrocyte proliferation, and squamous epithelial changes are seen in the lungs. meningitis, lymphoid hyperplasia, demyelination, and glial fibrosis are seen in the cns. affected and any exposed animals should be isolated from healthy animals. there is no specific treatment for mcf; supportive treatment may improve recovery rates. corticosteroids may be useful. etiology. an rna virus in the lentivirus group of the retroviridae family causes ovine progressive pneumonia (opp), or maedi/visna. maedi refers to the progressive pneumonia presentation of the disease; visna refers to the central nervous system disease, which is reported predominantly in iceland. visna has been reported in goats but may have been due to caprine arthritis encephalitis infection. clinical signs and diagnosis. opp is a viral disease of adult sheep characterized by weakness, unthriftiness, weight loss, and pneumonia (pepin et al., ; de la concha bermejillo, ) . clinically, animals exhibit signs of progressive pulmonary disease after an extremely long incubation period of up to years. respiratory rate and dyspnea gradually increase as the disease progresses. the animal continues to eat throughout the disease; however, animals progressively lose weight and become weak. additionally, mastitis is a common clinical feature. thoracic auscultation reveals consolidation of ventral lung pathogenesis. the virus has a predilection for the lungs, mediastinal lymph nodes, udder, spleen, joints, and rarely the brain. after initial infection, the virus integrates into the dna of mature monocytes and persists as a provirus. later in the animal's life, infected monocytes mature as lung (and other tissue) macrophages and establish active infection. the virus induces lymphoproliferative disease, histiocyte and fibrocyte proliferation in the alveolar septa, and squamous metaplasia. pulmonary alveolar and vascular changes impinge on oxygen and carbon dioxide exchange and lead to serious hypoxia and pulmonary hypertension. secondary bacterial pneumonia may contribute to the animal's death. pulmonary adenomatosis is the differ-prevention and control. isolating or removing infected animals can prevent the disease. facilities and equipment should also be disinfected. ii. proliferative stomatitis (bovine papular stomatitis) etiology. a parapoxvirus is the causative agent of bovine papular stomatitis. this virus is considered to be closely related to the parapoxvirus that causes contagious ecthyma and pseudocowpox. it is also a zoonotic disease. the disease is not considered of major consequence, but high morbidity and mortality may be seen in severe outbreaks. in addition, lesions are comparable in appearance to those seen with vesicular stomatitis, bovine viral diarrhea virus, and foot-and-mouth disease. the disease occurs worldwide. clinical signs and diagnosis. raised red papules or erosions or shallow ulcers on the muzzle, nose, oral mucosa (including the hard palate), esophagus, and rumen of younger cattle are the most common findings. in some outbreaks, the papules will be associated with ulcerative esophagitis, salivation, diarrhea, and subsequent weight loss. lesions persist or may come and go over a span of several months. morbidity among herds may be %. mortalities are rare. bovine papular stomatitis is associated with "rat tail" in feedlot cattle. animals continue to eat and usually do not show a fever. no lesion is seen on the feet. the infection may also be asymptomatic. diagnosis is based on clinical signs, histological findings, and viral isolation. epizootiology and transmission. cattle less than year of age are most commonly affected, and disease is rare in older cattle. transmission is by animal-to-animal contact. necropsy findings. raised papules may be found around the muzzle and mouth and involve the mucosa of the esophagus and rumen. histologically, epithelial cells will show hydropic degeneration and hyperplasia of the lamina propria. eosinophilic inclusions will be in the cytoplasm of infected epithelial cells. pathogenesis. following exposure to the virus, erythematous macules most commonly appear on the nares, followed by the mouth. these become raised papules within a day, regressing after days to weeks; the lesions that remain will be persistent yellow, red, or brown spots. some infections may recur or persist, with animals showing lesions intermittently or continuously over several months. differential diagnosis. pseudocowpox, vesicular stomatitis, foot-and-mouth disease, and bovine viral diarrhea virus infection are the differentials for this disease. the differential for the "rat tail" clinical sign is sarcocystis infection. there is no vaccine available for bovine papular stomatitis. because of the similarity of this virus to the parapoxvirus of contagious ecthyma, it is important to be aware of the persistence in the environment and susceptibility of younger cattle. vaccination using the local strain, and the skin scarification technique for off, have been protective. handlers should wear gloves and protective clothing. treatment. cattle usually will not require extensive nursing care, but lesions with secondary bacterial infections should be treated with antibiotics. their hands at sites of contact with lesions of cattle. iii. pseudocowpox etiology. pseudocowpox is a worldwide cattle disease caused by a parapoxvirus related to the causative agents of contagious ecthyma and bovine papular stomatitis (see sections iii,a, ,m and iii,a, ,q,ii). lesions are confined to the teats. this is also a zoonotic disease. clinical signs and diagnosis. minor lesions are usually confined to the teats. these are distinctive because of the ring-or horseshoe-shaped scab that develops after days. additional lesions sometimes develop on the udder, the medial aspect of the thighs, and the scrotum. the teat lesions may predispose to mastitis. etiology. pulmonary adenomatosis is a rare but progressive wasting disease of sheep, with worldwide distribution. pulmonary adenomatosis is caused by a type d retrovirus antigenically related to the mason-pfizer monkey virus. jaagsiekte was the designation when the disease was described originally in south africa. progressive respiratory signs such as dyspnea, rapid respiration, and wasting. the disease is diagnosed by these chronic clinical signs and histology. epizootiology and transmission. the disease is transmitted by aerosols. body fluids of viremic animals, such as milk, blood, saliva, tears, semen, and bronchial secretions, will contain the virus or cells carrying the virus. necropsy. the adenomas and adenocarcinomas will be small firm lesions distributed throughout the lungs. the adenocarcinomas metastasize to regional lymph nodes. pathogenesis. as with ovine progressive pneumonia (opp), the incubation period is up to years long. adenocarcinomatous lesions arising from type ii alveolar epithelial cells may be discrete or confluent and involve all lung lobes. with or is a differential diagnosis for opp. etiology. cutaneous papillomatosis is a very common disease in cattle and is much less common among sheep and goats. the disease is a viral-induced proliferation of the epithelium of the neck, face, back, and legs. these tumors are caused by a papillomavirus (dna virus) of the papovaviridae family, and the viruses are host-specific and often body site-specific. most are benign, although some forms in cattle and one form in goats can become malignant. in cattle, the site specificity of the papillomavirus strains are particularly well recognized. designations of the currently recognized bovine papillomavirus (bpv) types are bpv- through bpv- . clinical signs and diagnosis. the papillomas may last up to months and are seen more frequently in younger animals. lesions have typical wart appearances and may be single or multiple, small ( mm) or very large ( mm). the infections will generally be benign, but pain will be evident when warts develop on occlusal surfaces or within the gastrointestinal tract. in addition, when infections are severe, weight loss may occur. when warts occur on teats, secondary mastitis may develop. in cattle, bpv- and bpv- cause fibropapillomas on teats and penises or on head, neck, and dewlap, respectively. bpv- causes flat warts that occur in all body locations, b pv- causes warts in the gastrointestinal tract, and b pv- causes small white warts (called rice-grain warts) on teats. warts caused by bpv- and bpv- do not regress spontaneously. prognosis in cattle is poor only when papillomatosis involves more than % of the body surface. in sheep, warts are the verrucous type. the disease is of little consequence unless the warts develop in an area that causes dis-comfort or incapacitation such as between the digits, on the lips, or over the joints. in adult sheep, warts may transform to squamous cell carcinoma. in goats, the disease is rare, and the warts are also of the verrucous type and occasionally may develop into squamous cell carcinoma. warts on goat udders tend to be persistent. diagnosis is made by observing the typical proliferative lesions. epizootiology and transmission. older animals are less sensitive to papillomatosis than young animals, although immunosupressed animals of any age may develop warts as the result of harbored latent infections. the virus is transmitted by direct and indirect (fomite) contact, entering through surface wounds and sites such as tattoos. pathogenesis. the incubation period ranges from to months. the virus induces epidermal and fibrous tissue proliferation, often described as cauliflower-like skin tumors. the disease is generally self-limiting. differential diagnosis. in sheep and goats, differentials include contagious ecthyma, ulcerative dermatosis, strawberry foot rot, and sheep and goat pox. for cattle) or autogenous vaccines must be used with a recognition that papovavirus strains are host-specific and that immunity from infection or vaccination is viral-type-specific. autogenous vaccines are generally considered more effective. some vaccine preparations are effective at prevention but not treatment of outbreaks. viricidal products are recommended for disinfection of contaminated environments. minimizing cutaneous injuries and sanitizing equipment (tattoo devices, dehorners, ear taggers, etc.) in a virucidal solution between uses are also recommended preventive and control measures. halters, brushes, and other items may also be sources of virus. treatment. warts will often spontaneously resolve as immunity develops. in severe cases or with flockwide or herdwide problems, affected animals should be isolated from nonaffected animals, and premises disinfected. warts can be surgically excised and autogenous vaccines can be made and administered to help prevent disease spread. cryosurgery with liquid nitrogen or dry ice has also proven to be successful for wart removal. topical agents such as podophyllin (various formulations) and dimethyl sulfoxide may be applied to individual lesions once daily until regression. etiology. pseudorabies is an acute encephalitic disease caused by a neurotropic alphaherpesvirus, the porcine herpesvirus . one serotype is recognized, but strain differences exist. the disease has worldwide distribution. it is a primarily a clinical dis-ease of cattle, with less frequent reports (but no less severe clinical manifestations) in sheep and goats. during the rapid course of this usually fatal disease. at the site of virus inoculation or in other locations, abrasions, swelling, intense pruritus, and alopecia are seen. pruritus will not be asymmetric. animals will also become hyperthermic and will vocalize frantically. other neurological signs range from hoof stamping, kicking at the pruritic area, salivation, tongue chewing, head pressing and circling, to paresthesia or hyperesthesia, ataxia, and conscious proprioceptive deficits. nystagmus and strabismus are also seen. animals will be fearful or depressed, and aggression is sometimes seen. recumbency and coma precede death. diagnostic evidence includes clinical findings; virus isolation from nasal or pharyngeal secretions or postmortem tissues; and histological findings at necropsy. serology of affected animals is not productive, because of the rapid course. if swine are housed nearby, or if swine were transported in the same vehicles as affected animals, serological evaluations are worthwhile from those animals. epizootiology and transmission. swine are the primary hosts for pseudorabies virus, but they are usually asymptomatic and serve as reservoirs for the virus. the infection can remain latent in the trigeminal ganglion of pigs and recrudesce during stressful conditions. other animals are dead-end hosts. the unprotected virus will survive only a few weeks in the environment but may remain viable in meat (including carcasses) or saliva and will survive outside the host, in favorable conditions, in the summer for several weeks and the winter for several months. transmission is by oral, intranasal, intradermal, or subcutaneous introduction of the virus. when the virus is inhaled, the clinical signs of pruritus are less likely to be seen. transmission can also be by inadvertent exposure (e.g., contaminated syringes) of ruminants to the modified live vaccines developed for use in swine. spread between infected ruminants is a less likely means of transmission, because of the relatively short period of virus shedding. transport vehicles used for swine may also be sources of the virus. raccoons are believed to be vectors of the virus. horses are resistant to infection. there is no pathognomonic gross lesion. definitive histologic findings include severe, focal, nonsuppurative encephalitis and myelitis. eosinophilic intranuclear inclusion bodies (cowdry type a) may be present in some affected neurons. methods such as immunofluorescence and immunoperoxidase staining can be used to show presence of the porcine herpesvirus . pathogenesis. the incubation period is - hr and duration of the illness is - hr. the longest duration is seen in animals with pruritus around the head. differential diagnoses. differentials for the neurologic signs of pseudorabies infection include rabies, polioencephalomalacia, salt poisoning, meningitis, lead poisoning, hypomagnesemia, and enterotoxemia. those for the intense pruritus include psoroptic mange and scrapie in sheep, sarcoptic mange, and pediculosis. prevention and control. pseudorabies is a reportable disease in the united states, where a nationwide eradication program exists; states are rated regarding status. effective disinfectants include sodium hypochlorite ( % solution), formalin, peracetic acid, tamed iodines, and quaternary ammonium compounds. five minutes of contact time is required, and then surfaces must be rinsed. other disinfectant methods for viral killing include hr of formaldehyde fumigation, or min of ultraviolet light. transport vehicles should be cleaned and disinfected between species. serological screening for pseudorabies of swine housed near ruminants is essential. there is no treatment, and most affected ani-research complications. swine housed close to research ruminants should be serologically screened prior to purchase, and all transport vehicles should be cleaned and disinfected between loads of large animals. humans have been reported to seroconvert. the porcine herpesvirus shares antigens with the infectious bovine rhinotracheitis virus. etiology. rabies is a sporadic but fatal, acute viral disease affecting the central nervous system. the rabies virus is a neurotropic rna virus of the lyssavirus genus and the rhabdoviridae family. sheep, goats, and cattle are susceptible. the zoonotic potential of this virus must be kept in mind at all times when handling moribund animals with neurological signs characteristic of the disease. rabies is endemic in many areas of the world and within areas of the unites states. this is a reportable disease in north america. clinical findings and diagnosis. animals generally progress through three phases: prodromal, excitatory, and paralytic. many signs in the different species during these stages are nonspecific, and forms of the disease are also referred to as dumb or furious. during the short prodromal phase, animals are hyperthermic and apprehensive. animals progress to the excitatory phase, during which they refuse to eat or drink and are active and aggressive. repeated vocalizations, tenesmus, sexual excitement, and salivation occur during this phase. the final paralytic stage, with recumbency and death, occurs over several hours to days. this paralytic stage is common in cattle, and animals may simply be found dead. the clinical course is usually - days. diagnosis is based on clinical signs, with a progressive and fatal course. confirmation presently is made with the fluorescent antibody technique on brain tissue. epizootiology and transmission. the rabies virus is transmitted via a bite wound inflicted by a rabid animal. cats, dogs, raccoons, skunks, foxes, wild canids, and bats are the common disease vectors in north america. virus is also transmitted in milk and aerosols. necropsy findings. few lesions are seen at necropsy. many secondary lesions from manic behaviors during the course of disease may be evident. histological findings will include nonsuppurative encephalitis. negri bodies in the cytoplasm of neurons of the hippocampus and in purkinje's cells are pathognomonic histologic findings. pathogenesis. after exposure, the incubation period is variable, from weeks to several months, depending on the distance that the virus has to travel to reach the central nervous system. the rabies virus proliferates locally, gains access to neurons by attaching to acetylcholine receptors, via a viral surface glycoprotein, migrates along sensory nerves to the spinal cord and brain, and then descends via cranial nerves (trigeminal, facial, olfactory, glossopharyngeal) to oral and nasal cavity structures (i.e., salivary glands). the fatal outcome is currently believed to be multifactorial, related to anorexia, respiratory paralysis, and effects on the pituitary. differential diagnosis. rabies should be included on the differential list when clinical signs of neurologic disease are evident. other differentials for ruminants include herpesvirus encephalitis, thromboemobolic meningoencephalitis, nervous ketosis, grass tetany, and nervous cocciodiosis. prevention and control. vaccines approved for use cattle and sheep are commercially available and contain inactivated virus; there is not one available in the united states for goats. ruminants in endemic areas, such as the east coast of the united states, should be routinely vaccinated. any animals housed outside that may be exposed to rabid animals should be vaccinated. vaccination programs generally begin at months of age, with a booster at year of age and then annual or triennial boosters. awareness of the current rabies case reports for the region and wildlife reservoirs, however, is important. monitoring for and exclusion of wildlife from large-animal facilities are worthwhile preventive measures. the virus is fragile and unstable outside of a host animal. research complications. aerosolized virus is infective. personal protective equipment, including gloves, face mask, and eye shields, must be worn by individuals handling animals that are manifesting neurological disease signs. bovine spongiform encephalopathy, a transmissible spongiform encephalopathy (tse), is not known to occur in the united states, where since it has been listed as a reportable disease. the profound impact of this disease on the cattle industry in great britain during the past two decades is well known. the disease may be caused by a scrapielike (prion) agent. it is believed that the source of infection for cattle was feedstuff derived from sheep meat and bonemeal that had been inadequately treated during processing. the incubation period of years, the lack of detectable host immune response, the debilitating and progressive neurological illness, and the pathology localized to the central nervous system are characteristics of the disease, and are is comparable to the characteristics of other tse diseases such as scrapie, which affects sheep and goats. in addition, the infectious agent is extremely resistant to dessication and disinfectants. confirmation of disease is by histological examination of brain tissue collected at necropsy; the vacuolation that occurs during the disease will be symmetrical and in the gray matter of the brain stem. molecular biology techniques, such as western blots and immunohistochemistry, may also be used to identify the presence of the prion protein. differentials include many infectious or toxic agents that affect the bovine nervous and musculoskeletal systems, such as rabies, listeriosis, and lead poisoning. metabolic disorders such as ketosis, milk fever, and grass tetany are also differentials. there is no vaccine or treatment. prevention focuses on import regulations and not feeding ruminant protein to ruminants; recent usda regulations prohibit feeding any mammalian proteins to ruminants. etiology. scrapie is a sporadic, slow, neurodegenerative disease caused by a prion. scrapie is a reportable disease. it is much more common in sheep than in goats. the disease is similar to transmissible mink encephalopathy, kuru, creutzfeldt-jakob disease, and bovine spongiform encephalopathy (mad cow disease). prions are nonantigenic, replicating protein agents. clinical signs and diagnosis. during early clinical stages, animals are excitable and hard to control. tremors of head and neck muscles, as well as uncoordinated movements and unusual "bunny-hopping" gaits are observed. in advanced stages of the disease, animals experience severe pruritus and will self-mutilate while rubbing on fences, trees, and other objects. blindness and abortion may also be seen. morbidity may reach % within a flock. most animals invariably die within - weeks; some animals may survive months. in goats, the disease is also fatal. pruritus is generally less severe but may be localized. a wide range of clinical signs have also been noted in goats, including listlessness, stiffness or restlessness, or behavioral changes such as irritability, hunched posture, twitching, and erect tail and ears. as with sheep, the disease gradually progresses to anorexia and debilitation. diagnosis can be made by clinical signs and histopathological lesions. a newer diagnostic test in live animals is based on sampling from the third eyelid. tests for genetic resistance or susceptibility require a tube of edta blood and are reasonably priced. epizootiology and transmission. the suffolk breed of sheep tends to be especially susceptible. scrapie has also been reported in several other breeds, including cheviot, dorset, hampshire, corriedale, shropshire, merino, and rambouillet. it is believed that there is hereditary susceptibility in these breeds. targhees tend to be resistant. genomic research indicates there are two chromosomsal sites governing this trait; these sites are referred to codons (q, r, or h genes can be present) and (a or v genes can be present). of the five genes, r genes appear to confer immunity to clinical scrapie in suffolks in the united states. affected suffolks in the united states that have been tested have been aa qq. the disease is also enzootic is many other countries. the disease tends to affect newborns and young animals; however, because the incubation period tends to range from to years, adult animals display signs of the disease. scrapie is transmitted horizontally by direct or indirect contact; nasal secretions or placentas serve as sources of the infectious agent. vertical transmission is questioned, and transplacental transmission is considered unlikely. necropsy findings. at necropsy, no gross lesion is observed. histopathologically, neuronal vacuolization, astrogliosis, and spongiform degeneration are visualized in the brain stem, the spinal cord, and especially the thalamus. inflammatory lesions are not seen. pathogenesis. replication of the prions probably occurs first in lymphoid tissues throughout the host's body and then progresses to neural tissue. differential diagnosis. in sheep and goats, depending on the speed of onset, differentials for the pruritus include ectoparasites, pseudorabies, and photosensitization. prevention and control. if the disease diagnosed in a flock, quarantine and slaughter, followed by strict sanitation, are usually required. the u.s. department of agriculture has approved the use of % sodium hydroxide as the only disinfectant for sanitation of scrapie-infected premises. prions are highly resistant to physicochemical means of disinfection. artificial insemination or embryo transfer has been shown to decrease the spread of scrapie (linnabary et al., ) . research complications. as noted, this is a reportable disease. stringent regulations exist in the united states regarding importation of small ruminants from scrapie-infected countries. etiology. vesicular stomatitis (vs) is caused by the vesicular stomatitis virus (vsv), a member of the rhabdoviridae. three serotypes are recognized: new jersey, indiana, and isfahan. the new jersey and indiana strains cause sporadic disease in cattle in the united states. the disease is rare in sheep. clinical signs and diagnosis. adult cattle are most likely to develop vs. fever and development of vesicles on the oral mucous membranes are the initial clinical signs. lesions on the teats and interdigital spaces also develop. the vesicles progress quickly to ulcers and erosions. the animal's tongue may be severely involved. anorexia and salivation are common. weight loss and decreased milk production are noticeable. morbidity will be high in an outbreak, but mortality will be low to nonexistent. diagnostic work should be initiated as soon as possible to distinguish this from foot-and-mouth disease. diagnosis is based on analysis of fluid, serum, or membranes associated with the vesicles. virus isolation, enzyme-linked immunosorbent assay (elisa), competitive elisa (celisa), complement fixation, and serum neutralization are used for diagnosis. epizootiology and transmission. this disease occurs in several other mammalian species, including swine, horses, and wild ruminants. vsv is an enveloped virus and survives well in different environmental conditions, including in soil, extremes of ph, and low temperatures. outbreaks of vs occur sporadically in the united states, but it is not understood how or in what species the virus survives between these outbreaks. incidence of disease decreases during colder seasons. equipment, such as milking machines, contaminated by secretions is a mechanical vector, as are human hands. transmission may also be from contaminated water and feed. transmission is also believed to occur by insects (blackflies, sand flies, and culicoides) that may simply be mechanical vectors. it is believed that carrier animals do not occur in this disease. necropsy. it is rare for animals to be necropsied as the result of this disease. typical vesicular lesion histology is seen, with ballooning degeneration and edema. there is no inclusion body formation. pathogenesis. lesions often begin within hr after exposure. the virus invades oral epithelium. injuries or trauma in any area typically affected, such as mouth, teats, or interdigital areas, will increase the likelihood of lesions developing there. animals will develop a long-term immunity; this immunity can be overwhelmed, however, by a large dose of the virus. differential diagnosis. foot-and-mouth disease lesions are identical to vs lesions. other differentials in cattle include bovine viral diarrhea, malignant catarrhal fever, contagious ecthyma, photosensitization, trauma, and caustic agents. prevention and control. quarantine and restrictions on shipping infected animals or animals from the premises housing affected animals are required in an outbreak. vaccines are available for use in outbreaks and have decreased the severity of lesions. phenolics, quaternaries, and halogens are effective for inactivating and disinfecting equipment and facilities. treatment. affected animals should be segregated from the rest of the herd and provided with separate water and softened feed. these animals should be cared for after unaffected animals. any feed or water contaminated by these animals should not be used for other animals; contaminated equipment should be disinfected. topical or systemic antibiotics control secondary bacterial infections. cases of mastitis secondary to teat lesions must be treated as necessary. any abrasive materials that could cause further trauma to the animals should be removed. research complications. animals developing vesicular lesions must be reported promptly to eliminate the possibility of an outbreak of foot-and-mouth disease. personal protective equipment, especially gloves, should be worn when handling any animals with vesicular lesions. vsv causes a flulike illness in humans. x. viral diarrhea diseases i. ovine. rotavirus, of the family reoviridae, induces an acute, transient diarrhea in lambs within the first few weeks of life. four antigenic groups (a-d) have been identified by differences in capsid antigens vp and vp . primarily group a, but also groups b and c, have been isolated from sheep. the disease is characterized by yellow, semifluid to watery diarrhea occurring - days after infection. the disease can progress to dehydration, anorexia and weight loss, acidosis, depression, and occasionally death. the virus is ingested with contaminated feed and water and selectively infects and destroys the enterocytes at the tips of the small intestinal villi. the villi are replaced with immature cells that lack sufficient digestive enzymes; osmotic diarrhea results. virus may remain in the environment for several months. the disease is diagnosed by virus isolation, electron microscopy of feces, fecal fluorescent antibody, fecal elisa tests (marketed tests generally detect group a rotavirus), and fecal latex agglutination tests. rotavirus diarrhea is treated by supportive therapy, including maintaining hydration, electrolyte, and acid-base balance. a rotavirus vaccine is available for cattle; because of cross-species immunity, oral administration of high-quality bovine colostrum from vaccinated cows to infected sheep may be helpful ("current veterinary therapy," ). coronavirus, of the family coronaviridae, produces a more severe, long-lasting disease when compared with rotavirus. clinical signs are similar to above, although the incubation period tends to be shorter ( - hr), and animals exhibit less anorexia than those with rotavirus. additionally, mild respiratory disease may be noted (janke, ) . like rotavirus, coronavirus also destroys enterocytes of the villus tips. the virus can be visualized with electron microscopy. treatment is supportive; close consideration of hydration and acid-base status is essential. bovine vaccines are available. ii. caprine. rotavirus, coronavirus, and adenoviruses affect neonatal goats; however, little has been documented on the pathology and significance of these agents in this age group. it appears that bacteria play a more important role in neonatal kid diarrheal diseases then in neonatal calf diarrheas. iii. bovine. rotaviruses, coronaviruses, parvoviruses, and bovine viral diarrhea virus (bvdv) are associated with diarrheal disease in calves. each pathogen multiplies within and destroys the intestinal epithelial cells, resulting in villous atrophy and clinical signs of diarrhea (soft to watery feces), dehydration, and abdominal pain. these viral infections may be complicated by parasitic infections (e.g., cryptosporidium, eimeria) or bacterial infections (e.g., escherichia coli, salmonella, campylobacter). treatment is aimed at correcting dehydration, electrolyte imbalances, and acidosis; cessation of milk replacers and administration of fluid therapy intravenously and by stomach tube may be necessary, depending on the presence of suckle reflex and the condition of the animals. diagnosis is by immunoassays available for some viruses, viral culture, exclusion or identification of presence of other pathogens (by culture or fecal exams), and microscopic examination of necropsy specimens. prevention focuses on calves suckling good-quality colostrum; other recommendations for calf care are in section ii,b, . combination vaccine products are available for immunizing dams against rotavirus, coronavirus, and enterotoxigenic e. coli. additional supportive care for calves includes providing calves with sufficient energy and vitamins until milk intake can resume. rotaviruses of serogroup a are the most common type in neonatal calves; -to -day old calves are typically affected, but younger and older animals may also be affected. the small intestine is the site of infection. antirotavirus antibody is present in colostrum, and onset of rotavirus diarrhea coincides with the decline of this local protection. transmission is likely from other affected calves and asymptomatic adult carriers. the diarrhea is typically a distinctive yellow. colitis with tenesmus, mucus, and blood may be seen. this virus may be zoonotic. coronaviruses are commonly associated with disease in calves during the first month of life, and they infect small-and large-intestinal epithelial cells. the virus infection may extend to mild pneumonia. transmission is by infected calves and also by asymptomatic adult cattle, including dams excreting virus at the time of parturition. calves that appear to have recovered continue to shed virus for several weeks. parvovirus infections are usually associated with neonatal calves. b vdv infections also are seen in neonates and also affect many systems and produce other clinical signs and syndromes that are described in section iii,a, ,e. iv. winter dysentery. winter dysentery is an acute, winterseasonal, epizootic diarrheal disease of adult cattle, although it has been reported in -month-old calves. the etiology has not yet been defined, but a viral pathogen is suspected. coronavirus-like viral particles have been isolated from cattle feces, either the same as or similar to the coronavirus of calf diarrhea. outbreaks typically last a few weeks, and first-lactation or younger cattle are affected first, with waves of illness moving through a herd. individual cows are ill for only a few days. the incubation period is estimated at - days. the outbreaks of disease are often seen in herds throughout the local area. clinical signs include explosive diarrhea, anorexia, depression, and decreased production. the diarrhea has a distinctive musty, sweet odor and is light brown and bubbly, but some blood streaks or clots may be mixed in with the feces. animals will become dehydrated quickly but are thirsty. respiratory symptoms such as nasolacrimal discharges and coughing may develop. recovery is generally spontaneous. mortalities are rare. diagnosis is based on characteristic patterns of clinical signs, and elimination of diarrheas caused by parasites such as coccidia, bacterial organisms such as salmonella or mycobacterium paratuberculosis, and viruses such as b vdv. pathology is present in the colonic mucosa, and necrosis is present in the crypts. etiology. chlamydia psittaci is a nonmotile, obligate, intracytoplasmic, gram-negative bacterium. clinical signs. enzootic abortion in sheep and goats is a contagious disease characterized by hyperthermia and late abortion or by birth of stillborn or weak lambs or kids (rodolakis et al., ) . the only presenting clinical sign may be serosanguineous vulvar discharges. other animals may present with arthritis or pneumonia. infection of animals prior to about days of gestation results in abortion, stillbirths, or birth of weak lambs. infection after days results in potentially normal births, but the dams or offspring may be latently infected. latently infected animals that were infected during their dry period may abort during the next pregnancy. ewes or does generally only abort once, and thus recovered animals will be immune to future infections. and specific antigens associated with the cell surface. the group antigen is common among all chlamydia; the specific antigen is common to related subgroups. two subgroups are recognized, one that causes eae and one that causes polyarthritis and conjunctivitis. the disease is transmitted by direct contact with infectious secretions such as placental, fetal, and uterine fluids or by indirect contact with contaminated feed and water. necropsy. placental lesions include intercotyledonary plaques and necrosis and cotyledonary hemorrhages. histopathological evidence of leukocytic infiltration, edema, and necrosis is found throughout the placentome. fetal lesions include giant-cell accumulation in mesenteric lymph nodes and lymphohistiocytic proliferations around the blood vessels within the liver. diagnosis is based on clinical signs and laboratory (serological or histopathological) identification of the organism. impression smears in placental tissues stained with giemsa, gimenez, or modified ziehl-neelsen can provide preliminary indications of the causative agent. immunofluorescence, enzyme-linked immunosorbent assay (elisa), and polymerase chain reaction (pcr) methods also aid in diagnosis. differential diagnosis. q fever will be the major differential for late-term abortion and necrotizing placentitis. campylobacter and toxoplasma should also be considered for late-term abortion. treatment. animals may respond to treatment with oxytetracycline. abortions are prevented through administration of a commercial vaccine, but the vaccine will not eliminate infections. this is a sheep vaccine and should be administered before breeding and annually to at least the young females entering the breeding herd or flock. research complications. in addition to losses or compromise of research animals, pregnant women should not handle aborted tissues. etiology. chlamydia psittaci is a nonmotile, obligate intracellular, gram-negative bacterium. chlamydial polyarthritis is an acute, contagious disease characterized by fever, lameness (bulgin, ) , and conjunctivitis (see section iii,a, ,c) in growing and nursing lambs. clinical signs. clinically, animals will appear lame on one or all legs and in major joints, including the scapulohumeral, humeroradioulnar, coxofemoral, femorotibial, and tibiotarsal joints. lambs may be anorexic and febrile. animals frequently also exhibit concurrent conjunctivitis. the disease usually resolves in approximately weeks. joint inflammation usually resolves without causing chronic articular changes. epizootiology and transmission. the disease is transmitted to susceptible animals by direct contact as well as by contaminated feed and water. the organism penetrates the gastrointestinal tract and migrates to joints and synovial membranes as well as to the conjunctiva. the organism causes acute inflammation and associated fibrinopurulent exudates. necropsy findings. lesions are found in joints, tendon sheaths, conjunctiva, and lungs. pathological sites will be edematous and hyperemic, with fibrinous exudates but without articular changes. lesions will be infiltrated with mononuclear cells. lung lesions include atelectasis and alveolar inspissation. diagnosis is based on clinical signs. synovial taps and subsequent smears may allow the identification of chlamydial inclusion bodies. treatment. animals respond to treatment with parenteral oxytetracycline. etiology. chlamydia psittaci, a nonmotile, obligate intracellular, gram-negative bacterium, is the most common cause of infectious keratoconjunctivitis in sheep. chlamydia and mycoplasma are considered to be the most common causes of this disease in goats. chlamydial conjunctivitis is not a disease of cattle. clinical signs. infectious keratoconjunctivitis is an acute, contagious disease characterized in earlier stages by conjunctival hyperemia, epiphora, and edema and in later stages by, corneal edema, ulceration, and opacity. perforation may result from the ulceration. animals will be photophobic. in less severe cases, corneal healing associated with fibrosis and neovascularization occurs in - days. lymphoid tissues associated with the conjunctiva and nictitating membrane may enlarge and prolapse the eyelids. morbidity may reach - %. bilateral and symmetrical infections characterize most outbreaks. relapses may occur. other concurrent systemic infections may be seen, such as polyarthritis or abortion in sheep and polyarthritis, mastitis, and uterine infections in goats. epizootiology and transmission. direct contact, and mechanical vectors such as flies easily spread the organism. necropsy. if the chlamydial or mycoplasmal agents are suspected, diagnostic laboratories should be contacted for recommendations regarding sampling. conjunctival smears are also useful. pathogenesis. the pathogen penetrates the conjunctival epithelium and replicates in the cytoplasm by forming initial and elementary bodies. the infection moves from cell to cell and causes an acute inflammation and resultant purulent exudate. the chlamydial organism may penetrate the bloodstream and migrate to the opposite eye or joints, leading to arthritis. diagnosis is suggested by the clinical signs. cytoplasmic inclusions observed on conjunctival scrapings and immunofluorescent techniques help confirm the diagnosis. differential diagnosis. nonchlamydial keratoconjunctivitis also occurs in sheep and goats. the primary agents involved include mycoplasma conjunctiva, m. agalactiae in goats, and branhamella (neisseria) ovis. a less common differential for sheep and cattle is listeria monocytogenes. other differentials include eye worms, trauma, and foreign bodies such as windblown materials (pollen, dust) and poor-quality hay; these latter irritants and stress may predispose the animals' eyes to the infectious agents. should be minimized whenever possible. quarantine of new animals and treatment, if necessary, before introduction into the flock or herd are important measures. shade should be provided for all animals. treatment. the infections can be self-limiting in - weeks without treatment. treatment consists of topical application of tetracycline ophthalmic ointments. systemic or oral oxytetracycline treatments have been used with the topical treatment. atropine may be added to the treatment regimen when uveitis is present. shade should be provided. a. protozoa i. anaplasmosis etiology. anaplasmosis is an infectious, hemolytic, noncontagious, transmissible disease of cattle caused by the protozoan anaplasma marginale. anaplasma is a member of the anaplasmatacae family within the order rickettsiales. in sheep and goats, the disease is caused by a. ovis and is an uncommon cause of hemolytic disease. anaplasmosis has not been reported in goats in the united states. some controversy exists regarding the classification. most recently it is classified as a protozoal disease because of similarities to babesiosis. it has also been classified as a rickettsial pathogen. this summary addresses the disease in cattle with limited reference to a. ovis infections, but there are many similarities to the disease in cattle. clinical signs and diagnosis. acute anemia is the predominant sign in anaplasmosis, and fever coincides with parasitemia. weakness, pallor, lethargy, dehydration, and anorexia are the result of the anemia. four disease stagesnincubation, developmental, convalescent, and carriermare recognized. the incubation stage may be long, - weeks, and is characterized by a rise in body temperature as the infection moves to the next stage. most clinical signs occur during the -to -day developmental stage, with hemolytic anemia being common. death is most likely to occur at this stage or at the beginning of the convalescent stage. death may also occur from anoxia, because of the animal's inability to handle any exertion or stress, especially if treatment is initiated when severe anemia exists. reticulocytosis characterizes the convalescent stage, which may continue for many weeks. morbidity is high, and mortality is low. the carrier stage is defined as the time in the convalescent stage when the animal host becomes a reservoir of the disease, and anaplasma organisms and any parasitemia are not discernible. common serologic tests are the complement fixation test and the rapid card test. these become positive after the incubation phase and do not distinguish between the later three stages of disease. definitive diagnosis is made by clinical and necropsy findings. staining of thin blood smears with wright's or giemsa stain allows detection of basophilic, spherical a. marginale bodies near the red blood cell peripheries. evidence will most likely be found before a hemolytic episode. a negative finding should not eliminate the pathogen from consideration. epizootiology and transmission. the disease is common in cattle in the southern and western united states. anaplasma organisms are spread biologically or mechanically. mechanical transmission occurs when infected red blood cells are passed from one host to another on the mouthparts of seasonal biting flies. sometimes mosquitoes or instruments such as dehorners or hypodermic needles may facilitate transfer of infected red cells from one animal to another. biological transmission occurs when the tick stage of the organism is passed by dermacentor andersoni and d. occidentalis ticks. the carrier stage covers the time when discernible anaplasma organisms can be found on host blood smears. recovered animals serve as immune carriers and disease reservoirs. necropsy. pale tissues and watery, thin blood are typical findings. splenomegaly, hepatomegaly, and gallbladder distension are common findings. pathogenesis. the parasites infect the host's red blood cells, and acute hemolysis occurs during the parasites' developmental stage. the four stages of the parasite's life cycle are described above because these are closely linked to the clinical stages. differential diagnosis. the clinical disease closely resembles the protozoal disease babesiosis. whole organism) programs are not entirely effective, and vaccine should not be administered to pregnant cows. neonatal isoerythrolysis may occur because of the antierythrocyte antibodies stimulated by one vaccine product. vaccinated animals can still become infected and become carriers. the cattle vaccine has shown no efficacy in smaller ruminants, and there is no a. ovis vaccine. identifying carriers serologically and treating with tetracycline during and/or after vector seasons may be an option. removing carriers to a separate herd is also an approach. interstate movement of infected animals is regulated. treatment. oxytetracycline, administered once, helps reduce the severity of the infection during the developmental stage. other tetracycline treatment programs have been described to help control carriers. ii. babesiosis (red water, texas cattle fever, cattle tick fever) etiology. babesia bovis and ba. bigemina are protozoa that cause subclinical infections or disease in cattle. these are intraerythrocytic parasites. babesia bovis is regarded as the more virulent of the two organisms. this disease is not seen in the smaller ruminants in the united states. clinical signs and diagnosis. the more common presentation is liver and kidney failure due to hemolysis with icterus, hemoglobinuria, and fever. hemoglobinuria indicates a poor prognosis. acute encephalitis is a less common presentation and begins acutely with fever, ataxia, depression, deficits in conscious proprioception, mania, convulsions, and coma. the encephalitic form generally also has a poor prognosis. sudden death may occur. thin blood smears stained with giemsa will show babesia trophozoites at some stages of the disease, but lack of these cannot be interpreted as a negative. the trophozoites occur in a variety of shapes, such as piriform, round, or rod. complement fixation, immunofluorescent antibody, and enzyme immunoassay are the most favored of the available serologic tests. babesiosis is present on several continents, including the americas. in addition to domestic cattle, some wild ruminants, such as white-tailed deer and american buffalo, are also susceptible. bos indicus breeds have resistance to the disease and the tick vectors. innate resistance factors have been found in all calves. if infected, these animals will not show many signs of disease during the first year of life and will become carriers. stress can cause disease development. prevention and control. offspring of immune carriers resist infection up to months of age because of passive immunity. vector control and attention to hygiene are essential, such as between-animal rinsing in disinfectant of mechanical vectors such as dehorners. there is no entirely effective means, however, to prevent and control the disease. vaccination (killed necropsy findings. signs of acute hemolytic crisis are the most common findings, including hepatomegaly, splenomegaly, dark and distended gallbladder, pale tissues, thin blood, scattered hemorrhages, and petechiation. animals dying after a longer course of disease will be emaciated and icteric, with thin blood, pale kidneys, and enlarged liver. pathogenesis. the protozoon is transmitted by the cattle fever ticks boophilus annulatus, b. microplus, and b. decoloratus; these one-host ticks acquire the protozoon from infected animals. it is passed transovarially, and both nymph and adult ticks may transmit to other cattle. only b. ovis is transmitted by the larval stage. clinical signs develop about weeks after tick infestations or mechanical transmission but may develop sooner with the mechanical transmission. hemolysis is due to intracellular reproduction of the parasites and occurs intra-and extravascularly. in addition to the release of merozoites, proteolytic enzymes are also released, and these contribute to the clinical metabolic acidosis and anoxia. the development of the encephalitis form is believed to be the result of direct invasion of the central nervous system, disseminated intravascular coagulation, capillary thrombosis by the parasites and infarction, and/or tissue anoxia. differential diagnosis. in addition to anaplasmosis, other differentials for the hemolytic form of the disease are leptospirosis, chronic copper toxicity, and bacillary hemoglobinuria. several differentials in the united states for the encephalitic presentation include rabies, nervous system coccidiosis, polioencephalomalacia, lead poisoning, infectious bovine rhinotracheitis, salt poisoning, and chlorinated hydrocarbon toxicity. prevention and control. control or eradication of ticks and cleaning of equipment to prevent mechanical transmission, as noted in section iii,a, ,a,i, are important preventive measures. some vaccination approaches have been effective, but a commercial product is not available. treatment. supportive care is indicated, including blood transfusions, fluids, and antibiotics. medications such as diminazene diaceturate, phenamidine diisethionate, imidocarb diprionate, or amicarbalide diisethionate are most commonly used. treatment outcomes will be either elimination of the parasite or development of a chronic carrier state immune to further disease. research complications. this is a reportable disease in the united states. iii. coccidiosis etiology. coccidiosis is an important acute and chronic protozoal disease of ruminants. in young ruminants, it is characterized primarily by hemorrhagic diarrhea. adult ruminants may carry and shed the protozoa, but they rarely display clinical signs. intensive rearing and housing conditions and stress increase the severity of the disease in all age groups. coccidia are protozoal organisms of the phylum apicomplexa, members of which are obligatory intracellular parasites. there are at least reported species of coccidia in sheep, of which several are considered pathogenic: eimeria ashata, e. crandallis, and e. ovinoidalis (schillhorn van veen, ). at least species of eimeria have been recognized in the goat (foreyt, ) . eimeria ninakohlyakimovae, e. arloingi, and e. christenseni are regarded as the most pathogenic. eimeria bovis and e. zuernii (highly pathogenic), and e. auburnensis and e. alabamensis (moderately pathogenic), are among the species known to infect cattle. eimeria zuernii is more commonly seen in older cattle and is the agent of "winter coccidiosis." clinical signs and diagnosis. hemorrhagic diarrhea develops days to weeks after infection. fecal staining of the tail and perineum will be present. animals will frequently display tenesmus; rectal prolapses may also develop. anorexia, weight loss, dehydration, anemia, fever (infrequently), depression, and weakness may also be seen in all ruminants. the diarrhea is watery and malodorous and will contain variable amounts of blood and fibrinous, necrotic tissues. the intestinal hemorrhage may subsequently lead to anemia and hypoproteinemia. depending on the predilection of the coccidial species for small and/or large intestines, malabsorption of nutrients or water may occur, and electrolyte imbalances may be severe. concurrent disease with other enteropathogens may also be part of the clinical picture. in sheep, secondary bacterial infection with organisms such as fusobacterium necrophorum may ensue. young goats may die peracutely or suffer severe anemia from blood loss into the bowel. older goats may lose the pelleted form of feces. cattle may have explosive diarrhea and develop anal paralysis. the disease is usually diagnosed by history and clinical signs. numerous oocysts will frequently be observed in fresh fecal flotation (salt or sugar solution) samples as the diarrhea begins. laboratory results are usually reported as number of oocysts per gram of feces. coccidia seen on routine fecal evaluations reflect shedding, possibly of nonpathogenic species, without necessarily being indicative of impending or resolving mild disease. epkzootiology and transmission. as noted, coccidiosis is a common disease in young ruminants. in goats, young animals aged weeks to months are primarily affected, but isolated outbreaks in adults may occur after stressful conditions such as transportation or diet changes. coccidia are host-specific and also host cell-specific. the disease is transmitted via ingestion of sporulated oocysts. coccidial oocysts remain viable for long periods of time when in moist, shady conditions. necropsy. necropsies provide information on specific locations and severity of lesions that correlate with the species involved. ileitis, typhlitis, and colitis with associated necrosis and hemorrhage will be observed. mucosal scrapings will frequently yield oocysts. various coccidial stages associated with schizogony or gametogony may be observed in histopathological sections of the intestines. fibrin and cellular infiltrates will be found in the lamina propria. pathogenesis. this parasite has a complex life cycle in which sexual and asexual reproduction occurs in gastrointestinal enterocytes (speer, ) . the severity of the disease is correlated primarily with the number of ingested oocysts. specifics of life cycles vary with the species, and those characteristics contribute to the pathogenicity. in most cases, the disease is well established by the time clinical signs are seen. oocysts must undergo sporulation over a -to -day period in the environment. after ingestion of the sporulated oocysts, sporozoites are released and penetrate the intestinal mucosa and form schizonts. schizonts initially undergo replication by fission to form merozoites and eventually undergo sexual reproduction, forming new oocysts. the organisms cause edema and hyperemia; penetration into the lamina propria may lead to necrosis of capillaries and hemorrhage. differential diagnosis. differential diagnoses include the many enteropathogens associated with acute diarrhea in young ruminants: cryptosporidia, colibacilli, salmonella, enterotoxins, yersinia, viruses, and other intestinal parasites such as helminths. in cattle, for example, bovine viral diarrhea virus and helminthiasis caused by ostergia must be considered. management factors, such as dietary-induced diarrheas, are also differentials. in older animals, differentials in addition to stress are malnutrition, grain engorgement, and other intestinal parasitisms. prevention and control. good management practices will help prevent the disease. oocysts are resistant to disinfectants but are susceptible to dry or freezing conditions. proper sanitation of animal housing and minimizing overcrowding are essential. coccidiostats added to the feed and water are helpful in preventing the disease in areas of high exposure. treatment. affected animals should be isolated. on an individual basis, treatment should also include provision of a dry, warm environment, fluids, electrolytes (orally or intravenously), antibiotics (to prevent bacterial invasion and septicemia), and administration of coccidiostats. coccidiostats are preferred to coccidiocidals because the former allow immunity to develop. although many coccidial infections tend to be self-limiting, sulfonamides and amprolium may be used to aid in the treatment of disease. other anticoccidial drugs include decoquinate, lasalocid, and monensin; labels should be checked for specific approval in a species or specific indications. animals treated with amprolium should be monitored for development of secondary polioencephalomalacia. pen mates of affected animals should be considered exposed and should be treated to control early stages of infection. mechanisms of immunity have not been well defined but appear to be correlated with the particular coccidial species and their characteristics (for example, the extent of intracellular penetration). immunity may result when low numbers are ingested and there is only mild disease. immunity also may develop after more severe infections. iv. cryptosporidiosis etiology. cryptosporidium organisms are a very common cause of diarrhea in young ruminants. four cryptosporidium species have been described in vertebrates: c. baileyi and c. meleagridis in birds and c. parvum and c. muris in mammals. cryptosporidium parvum is the species affecting sheep (rings and rings, ) . debate continues regarding whether there are definite host-specific variants. clinical signs and diagnosis. cryptosporidiosis is characterized by protracted, watery diarrhea and debilitation. the diarrhea may last only - days or may be persistent and fatal. the diarrhea is watery and yellow, and blood, mucus, bile, and undigested milk may also be present. infected animals will display tenesmus, anorexia and weight loss, dehydration, and depression. in relapsing cases, animals become cachectic. overall, morbidity will be high, and mortality variable. mucosal scrapings or fixed stained tissue sections may be useful in diagnosis. the disease is also diagnosed by detecting the oocysts in iodine-stained feces or in tissues stained with periodic acid-schiff stain or methenamine silver. cryptosporidium also stains red on acid-fast stains such as kinyoun or ziehl-neelsen. fecal flotations should be performed without sugar solutions or with sugar solutions at specific gravity of . (foryet, ) . fecal immunofluorescent antibody (ifa) techniques have also been described. epizootiology and transmission. younger ruminants are commonly affected: lambs, kids (especially kids between the ages of and days old), and calves less than days old. like other coccidians, cryptosporidium is transmitted via the fecal-oral route. in addition to local contamination, water supplies have also been sources of the infecting oocysts. the oocysts are extremely resistant to desiccation in the environment and may survive in the soil and manure for many months. necropsy findings. the lesions caused by cryptosporidium are nonspecific. animals will be emaciated. moderate enteritis and hyperplasia of the crypt epithelial cells with villous atrophy as well as villous fusion, primarily in the lower small intestines, will be present. cecal and colonic mucosae may sometimes be involved. gastrointestinal smears may be made at necropsy and stained as described above. pathogenesis. although cryptosporidium infections are clinically similar to eimeria infections (moore, ) , cryptosporidium, in contrast to eimeria, invades just under the surface but does not invade the cytoplasm of enterocytes. there is no intermediate host. the oocysts are half the size of eimeria oocysts and are shed sporulated; they are, therefore, immediately infective. within - days of exposure, diarrhea and oocyst shedding occur. the diarrhea is the result of malabsorption and, in younger animals, intraluminal milk fermentation. autoinfection within the lumen of the intestines may also occur and result in persistent infections. in addition, several other pathogens may be involved, such as concurrent coronavirus and rotavirus infections in calves. environmental stressors such as cold weather increase mortality. intensive housing arrangements increase morbidity and mortality. differential diagnosis. other causes of diarrhea in younger ruminants include rotavirus, coronavirus, and other enteric viral infections; enterotoxigenic escherichia coli; clostridium; other coccidial pathogens; and dietary causes (inappropriate use of milk replacers). in addition, these other agents may also be causing illness in the affected animals and may complicate the diagnosis and the treatment picture. eimeria is more likely to cause diarrhea in calves and lambs at - weeks of age. giardia organisms may be seen in fecal preparations from young ruminants but are not considered to play a significant role in enteric disease. blood. animals exhibit fever, dehydration, and depression. chronic cases may result in a "poor doer" syndrome with weight loss and unthriftiness. giardia can be diagnosed by identifying the motile piriform trophozoites in fresh fecal mounts. oval cysts can be floated with zinc sulfate solution ( %). standard solutions tend to be too hyperosmotic and to distort the cysts. newer enzyme-linked immunosorbent assay (elisa) and ifa tests are sensitive and specific. epizootiology and transmission. giardia infection may occur at any age, but young animals are predisposed. chronic oocyst shedding is common. transmission of the cyst stage is fecaloral. wild animals may serve as reservoirs. necropsy findings. gross lesions may not be evident. villous atrophy and cuboidal enterocytes may be evident histologically. prevention and control. precautions should be taken when handling infected animals. affected animals must be removed and isolated as soon as possible. animal housing areas should be disinfected with undiluted commercial bleach or % ammonia. formalin ( %) fumigation has proven successful (foryet, ) . after being cleaned, areas should be allowed to dry thoroughly and should remain unpopulated for a period of time. because enteric disease often is multifactorial, other pathogens should also be considered, and management and husbandry should be examined. no known drug treatment is available. the disease is generally self-limiting, so symptomatic, supportive therapy aimed at rehydrating, correcting electrolyte and acid-base balance, and providing energy is often effective. supplementation with vitamin a may be helpful. age resistance begins to develop when the animals are about month old. research complications. cryptosporidiosis is a zoonotic disease. it is easily spread from calves to humans, for example, even as the result of simply handling clothing soiled by calf diarrhea. adult immunocompetent humans are reported to experience watery diarrhea, cramping, flatulence, and headache. the disease can be life-threatening in immunocompromised individuals. v. giardiasis etiology. giardia lamblia (also called g. intestinalis and g. duodenalis) is a flagellate protozoon. giardiasis is a worldwide protozoal-induced diarrheal disease of mammals and some birds (kirkpatrick, ), but it not considered to be a significant pathogen in ruminants. clinical signs and diagnosis. diarrhea may be continuous or intermittent, is pasty to watery, is yellow, and may contain pathogenesis. following ingestion, each giardia cyst releases four trophozoites, which attach to the enterocytes of the duodenum and proximal jejunum and subsequently divide by binary fission or encyst. the organism causes little intestinal pathology, and the cause of diarrhea is unknown but is thought to be related to disruption of digestive enzyme function, leading to malabsorption. disturbances in intestinal motility may also occur (rings and rings, ) . prevention and control. intensive housing and warm environments should be minimized. cysts can survive in the environment for long periods of time but are susceptible to desiccation. effective disinfectants include quaternary ammonium compounds, bleach-water solution ( : or : ), steam, or boiling water. after cleaning, areas should be left empty and allowed to dry completely. treatment. giardia has been successfully treated with oral metronidazole. benzimidazole anthelmintics are also effective, but these are not approved for use in animals for this purpose. should be taken when handling infected animals. etiology. neosporosis is a common, worldwide cause of bovine abortion caused by the protozoal species neospora caninum. abortions have also been reported in sheep and goats. neonatal disease is seen in lambs, kids, and calves. until , these infections were misdiagnosed as caused by toxoplasma gondii. some similarities exist between the life cycles and pathogeneses of both organisms. clinical signs and diagnosis. abortion is the only clinical sign seen in adult cattle and occurs sporadically, endemically, or as abortion storms. bovine abortions occur between the third and seventh month of gestation; fetal age at abortion correlates with the parity of the dam as well as with pattern of abortion in the herd. although cows that abort tend to be culled after the first or second abortion, repeated n. caninum-caused abortions will occur progressively later in gestation (up to about months) and within a shorter time frame in the same cow (thurmond and hietala, ) . although infections in adults are asymptomatic other than the abortions, decreased milk production has been noted in congenitally infected cows. many neospora-infected calves will be born asymptomatic. weakness will be evident in some infected calves, but this resolves. rare clinical signs include exophthalmos or asymmetric eyes, weight loss, ataxia, hyperflexion or hyperextension of all limbs, decreased patellar reflexes, and loss of conscious proprioception. some fetal deaths will occur, and resorption, mummification, autolysis, or stillbirth will follow. immunohistochemistry and histopathology of fetal tissue are the most efficient and reliable means of establishing a postmortem diagnosis. serology (ifa and elisa) is useful, including precolostral levels in weak neonates, but this indicates only exposure. titers of dams will not be elevated at the time of abortion; fetal serology is influenced by the stage of gestation and course of infection. earlier and rapid infections are less likely to yield antibodies against neospora. none of the currently available tests is predictive of disease. epizootiology and transmission. the parasite is now acknowledged to be widespread in dairy and cattle herds. the life cycle of n. caninum is complex, and many aspects remain to be clarified. the definitive host is the dog (mcallister et al., ) . placental or aborted tissues are the most likely sources of infection for the definitive host and play a minor role in transmission to the intermediate hosts. the many intermediate hosts include ruminants, deer, and horses. transplacental transmission is the major mode of transmission in dairy cattle and is the means by which a herd's infection is perpetuated. a less significant mode of transmission is by ingestion of oocysts, which sporulate in the environment or in the intermediate host's body. reactivation in a chronically infected animal's body is the result of rupture of tissue cysts in neural tissue. seropositive immunity does not protect a cow from future abortions. many seropositive cows and calves will never abort or show clinical signs, respectively. some immunological cross-reactivity may exist among neospora, cryptosporidia, and coccidium. necropsy findings. aborted fetuses will usually be autolysed. in those from which tissue can be recovered, tissue cysts are most commonly found in the brain. spinal cord is also useful. histological lesions include mild to moderate gliosis, nonsuppurative encephalitis, and perivascular infiltration by mixed mononuclear cells. pathogenesis. as with toxoplasma, cell death is the result of intracellular multiplication of neospora tachyzoites. neospora undergoes sexual replication in the dog's intestinal tract, and oocysts are shed in the feces. the intermediate hosts develop nonclinical systemic infections, with tachyzoites in several organs, and parasites then localize and become encysted in particular tissues, especially the brain. infections of this type are latent and lifelong. except when immunocompromised, most cattle do not usually develop clinical signs and do not have fetal loss. fetuses become infected, leading to fetal death, mid-gestation abortions, or live calves with latent infections or congenital brain disease. it usually takes - weeks for a fetus to die and to be expelled. many aspects of the role of the maternal immune response and pregnancy-associated immunodeficiency in the patterns of neospora abortions remain to be elucidated. differential diagnosis. even when there is a herd history of confirmed neospora abortions, leptospirosis, bovine viral diarrhea virus (bvdv), infectious bovine rhinotracheitis virus (ibrv), salmonellosis, and campylobacteriosis should be considered. bvdv in particular should be considered for abortion storms. differentials for weak calves are b vdv, perinatal hypoxia following dystocia (immediate postpartum time), bluetongue virus, toxoplasma, exposure to teratogens, or congenital defects. prevention and control. the primary preventive measure is preventing contact with contaminated feces. oocysts will not survive dry environments or extremes of temperature. dog populations should be controlled, and dogs and other canids should not have access to placentas or aborted fetuses. dogs should also be restricted from feed bunks and other feed storage areas. preventive culling is not economically practical for most producers. a vaccine recently became available. if embryo transfer is practiced, recipients should be screened serologically before use. laxis. there is no known treatment or immunoprophy- clinical signs and diagnosis. clinical signs of sarcocystosis infection are seen in cattle during the stage when the parasite encysts in soft tissues. often the infections are asymptomatic. fever, anemia, ataxia, symmetric lameness, tremors, tail-switch hair loss, excessive salivation, diarrhea, and weight loss are clinical signs. abortions in cattle occur during the second trimester and in smaller ruminants days after ingestion of the sporulated oocysts. definitive diagnosis is based on finding merozoites and meronts in neural tissue lesions. clinical hematology results include decreased hematocrit, decreased serum protein, and prolonged prothrombin times. sarcocystis-specific igg will increase dramatically by - weeks after infection. there is no cross-reaction between sarcocystis and toxoplasma. epizootiology and transmission. infection rates among cattle in the united states are estimated to be very high. transmission is by ingestion of feed and water contaminated by feces of the definitive hosts. dogs are the definitive hosts for the species that infect the smaller ruminants. cats, dogs, and primates (including humans when s. hominis is involved) are the definitive hosts for the species that infect cattle. necropsy. aborted fetuses may be autolysed. lesions in neural tissues, including meningoencephalomyelitis, focal malacia, perivascular cuffing, neuronal degeneration, and gliosis, are most marked in the cerebellum and midbrain. lesions may be found in other tissues, such as lymphadenopathy, and hemorrhages may be found in muscles and on serous surfaces. cysts in cardiac and skeletal muscles are common incidental findings during necropsies. pathogenesis. ingestion of muscle flesh from an infected ruminant results in sarcocystis cysts' being broken down in the carnivore's digestive system, release of bradyzoites, infection of intestinal mucosal cells by the bradyzoites, differentiation into sexual stages, fusion of the male and female gametes to form oocysts, and shedding as sporocysts by the definitive hosts. the sporocysts are eaten by the ruminant and penetrate the bowel walls; several stages of development occur in endothelial cells of arteries. merozoites are the form that enters soft tissues, such as muscle, and subsequently encysts. prevention and control. feed supplies of ruminants must be protected from fecal contamination by domestic and wild carnivores. these animals should be controlled and must also not have access to carcasses. in larger production situations, monensin may be fed as a prophylactic measure. treatment. monensin fed during incubation is prophylactic, but the efficacy in clinically affected cattle is not known. etiology. toxoplasmosis is caused by the obligate intracellular protozoon toxoplasma gondii, a coccidial parasite of the family eimeridae. cats are the only definitive hosts, and several warm-blooded animals, including ruminants, have been shown to be intermediate hosts. the disease is a major cause of abortion in sheep and goats and less common in cattle. clinical signs and diagnosis. clinical signs depend on the organ or tissue parasitized. toxoplasmosis is typically associated with placentitis, abortion, stillbirths, or birth of weak young (underwood and rook, ; buxton, ) . it has also been shown to cause pneumonia and nonsuppurative encephalitis. the enteritis at the early stage of infection may be fatal in some hosts. hydrocephalus does not occur in animals as it does in human fetal toxoplasma infections. rare clinical presentations in ruminants include retinitis and chorioretinitis; these are usually asymptomatic. infection of the ewe during the first trimester usually leads to fetal resorption, during the second trimester leads to abortion, and during the third trimester leads to birth of weak to normal lambs with subsequent high perinatal mortality. congenitally infected lambs may display encephalitic signs of circling, incoordination, muscular paresis, and prostration. in sheep, weak young will develop normally if they survive the first week after birth. infected adult sheep show no systemic illness. infected adult goats, however, may die. diagnosis may be difficult, and biological, serological, and histological methods are helpful. serological tests are the most readily available. complement fixation and the sabin-feldman antibody test may assist in diagnosis. antibodies found in fetuses are indicative of congenital infection and are typically detectable days after infection; fetal thoracic fluid is especially useful in demonstrating serological evidence of exposure. biological methods, such as tissue culture or inoculation of mice with maternal body fluids, or with postmortem or necropsy tissues, are more time-consuming and expensive. epizootiology and transmission. this protozoon is considered ubiquitous. fifty percent ( %) of adult western sheep and % of feedlot lambs have positive hemagglutination titers ( : or higher) (jensen and swift, ) . transmission among the definitive host is by ingestion of tissue cysts. necropsy findings. at necropsy, placental cotyledons contain multiple small white areas that are sites of necrosis, edema, and calcification. fetal brains may show nonspecific lesions such as coagulative necrosis, nonsuppurative encephalomyelitis, pneumonia, myocarditis, and hepatitis. histologically, granulomas with toxoplasma organisms may be seen in the retina, myocardium, liver, kidney, brain, and other tissues. impression smears of these tissues, stained appropriately (e.g., with giemsa), provide a rapid means of diagnosis. identification of the organism in tissue sections (especially of the heart and the brain) also confirms the findings. toxoplasma gondii is crescent-shaped, with a clearly visible nuclei, and will be found within macrophages. pathogenesis. the protozoon has three infectious stages: the tachyzoite, the bradyzoite, and the sporozoite within the oocyst. the definitive hosts, felids, become infected by ingesting cyst stages in mammalian tissues, by ingesting oocysts in feces, and by transplacental transfer. ingested zoites invade epithelial cells and eventually undergo sexual reproduction, resulting in new oocysts, which the cats will shed in the feces. cats rarely show clinical signs of infection. one cat can shed millions of oocysts in gm of feces, but the asymptomatic shedding takes place for only a few weeks in its life. oocysts sporulate in cat feces after day. ruminants are intermediate hosts of toxoplasmosis and become infected by ingesting sporulated oocyst-contaminated water or feed. as in the definitive host, the ingested sporozoite invades epithelial cells within the intestine but also further invades the bloodstream and is transported throughout the host. the organism migrates to tissues such as the brain, liver, muscles, and placenta. placental infection develops about days after ingestion of the oocysts. the damage caused by an infection is due to multiplication within cells. toxoplasma does not produce any toxin. campylobacter, chlamydia, and q fever. prevention and control. feline populations on source farms should be controlled. eliminating contamination of feed and water with cat feces is the best preventive measure. sporulated oocysts can survive in soil and other places for long periods of time and are resistant to desiccation and freezing. vaccines for abortion prevention in sheep are available in new zealand and europe. treatment. toxoplasmosis treatment is ineffective, although feeding monensin during pregnancy may be helpful (underwood and rook, ) . (monensin is not approved for this use in the unites states.) weak lambs that survive the first week after birth will mature normally and will not deliver toxoplasmainfected young. research complications. because toxoplasmosis is zoonotic, precautions must be taken when handling tissues from any abortions or neurological cases. infections in immunocompromised humans have been fatal. etiology. trichomoniasis is an insidious venereal disease of cattle caused by tritrichomonas (also referred to as trichomonas) fetus, a large, pear-shaped, flagellated protozoon. the organism is an obligate parasite of the reproductive tract, and it requires a microaerophilic environment to establish chronic infections. in the united states, it is now primarily a disease seen in western beef herds. there are many similarities between trichomoniasis and campylobacteriosis; both diseases cause herd infertility problems. clinical signs and diagnosis. clinical signs include infertility manifested by high nonpregnancy rates as well as periodic py-ometras and abortions during the first half of gestation. often the problem is not recognized until herd pregnancy checks indicate many "open," delayed-estrus, late-bred cows, or cows with postcoital pyometras. the abortion rate varies from % to %, and placentas will be expelled or retained. tritrichomonas fetus also causes mild salpingitis but this does not result in permanent damage. other than these manifestations, infection with t. fetus causes no systemic signs. diagnosis is based on patterns of infertility and pyometras. for example, pyometras in postcoital heifers or cows are suggestive of this pathogen. diagnostic methods include identifying or culturing the trichomonads from preputial smegma, cervicovaginal mucus, uterine exudates, placental fluids, or abomasal contents of aborted fetuses. other nonpathogenic protozoa from fecal contamination may be present in the sample. the trichomonad has three anterior flagellae, one posterior flagella, and an undulating membrane; it travels in fluids with a characteristic jerky movement. culturing must be done on specific media, such as diamond's or modified pastridge. real exposure from breeding bulls or cows or, in some cases, contaminated breeding equipment. necropsy findings. nonspecific lesions, such as pyogranulomatous bronchopneumonia of fetuses and placentitis, may be seen in aborted material; some cases will have no gross lesions. histologically, trichomonads may be visible in the fetal lung lesions and the placenta; those tissues are also the most useful for culturing. pathogenesis. tritrichomonas fetus colonizes the female reproductive tract, and subsequent clinical manifestations may be related to the size of the initial infecting dose. tritrichomonas fetus does not interfere with conception. embryonic death occurs within the first months of infection. affected cows will clear the infection over a span of months and maintain immunity for about months. infections in younger bulls are transient; apparently organisms are cleared by the bulls' immune systems and are dependent on exposure to infected females. older bulls become chronic carriers, probably because of the ability of t. fetus to colonize deeper epithelial crypts of the prepuce and penis. differential diagnosis. campylobacteriosis is the other primary differential for reduced reproductive efficiency of a herd. other venereal diseases should be considered when infertility problems are noted in a herd: brucellosis, mycoplasmosis, ureaplasmosis, and infectious pustular vulvovaginitis. in addition, management factors such as nutrition and age of heifers at introduction to the herd should be considered. heifers, cows, and breeding bulls are vaccinated subcutaneously twice at to week intervals, with the booster dose administered weeks before breeding season starts. similar timing is recommended for administration of the annual booster; a long, anamnestic response does not occur. bulls used for artificial insemination (ai) are screened routinely for t. fetus (and campylobacter) . ai reduces but does not eliminate the disease. the use of younger, vaccinated bulls is recommcmded in all circumstances. new animals should be tested before introduction to the herd. control measures also include culling affected cows or else removing them from the breeding herd for months to rest and clear the infection. culling chronically infected bulls is strongly recommended. treatment. imidazole compounds have been effective, but the use of these is not permitted in food animals in the united states. therapeutic immunizations are worthwhile when a positive diagnosis has been made. these will not curtail fetal losses but will shorten the convalescence of the affected cows and improve immunity of breeding bulls. research complications. trichomoniasis should be considered whenever natural service is used and fertility problems are encountered. nematodes are important ruminant pathogens that cause acute, chronic, subclinical, and clinical disease in adults and adolescents. the major helminths may cause gastroenteritis associated with intestinal hemorrhage and malnutrition. nematodiasis is associated with grazing exposure to infective larvae; animals procured for research may have had exposure to these helminths. mixed infections of these parasites are common. generally, older animals develop resistance to some of the species; thus, animals between about months and years of age are most susceptible to infection. because of the parasites' effects on the animals' physiology, infection in these younger animals is a major contributor to a cycle of poor nutrition and digestion, compromised immune responses, and impaired growth and development. diagnosis is primarily based on fecal flotation techniques; however, because many of these nematodes have similar-appearing ova, hatching the ova and identifying the larvae are often required (baermann technique). a number of anthelmintics can be used to interrupt nematode life cycles. see zajac and moore ( ) and pugh et al. ( ) for comprehensive reviews of treatment and control of nematodiasis. i. haemonchus contortus, h. placei (barber's pole worm, large stomach worm) . haemonchus contortus is the most important internal parasite of sheep and goats, and the brief description here focuses on the disease in the smaller ruminants. haemonchus contortus and h. placei infections do occur in younger cattle and are similar to the disease in sheep. haemonchus is extremely pathogenic, and the adults feed by sucking blood from the mucosa of the abomasum. severe anemia may lead to death. weight loss, decreased milk production, poor wool growth, and intermandibular and cervical edema due to hypoproteinemia ("bottle jaw") are also common clinical signs. diarrhea is not seen in all cases but may sometimes be severe or chronic. the life cycle is direct. under optimal conditions, a complete life cycle, from ingestion of larvae to eggs passed in the feces, occurs in weeks. embryonated eggs may develop into infective larvae within a week. hypobiotic (arrested) larvae may exist for several months in animal tissues, serving as a reservoir for future pasture contamination. periparturient increases in egg shedding by ewes contribute to large numbers of eggs spread on spring pastures ("spring rise"). resistance to common anthelmintics has developed; currently ivermectin or benzimidazole products are used, with a minimum of dosings given - weeks apart. levamisole is also used. in severe cases, animals may benefit from blood transfusions and iron supplementation. because animals may easily acquire infective larvae from ingestion of contaminated feed and from contaminated pastures, general facility sanitation and pasture management and rotation are important preventive and control measures. haemonchus contortus is susceptible to destruction by freezing temperatures and dry conditions. ii. ostertagia (teladorsagia) circumcincta (medium stomach worm). ostertagia circumcincta is also highly pathogenic for sheep and goats and, like haemonchus, attaches to the abomasal mucosa and ingests blood. the life cycle is comparable to that of haemonchus, including the phenomenon of hypobiosis. larvae are especially resistant to cool temperatures, however, and will overwinter on pastures. larvae-induced hyperplasia of abomasal epithelial glands results in a change of gastric ph from about . to near . , leading to decreased digestive enzyme activity and malnutrition. clinical syndromes are categorized as type or type . the former type is associated with infections acquired in fall or spring and is seen in younger animals. the latter type is associated with emergence of the arrested larvae during spring or fall. clinical signs include anemia, weight loss, decreased milk production, and unthriftiness. diarrhea is usually seen in type only; the symptoms of type are comparable to those of haemonchus infections. anthelmintic drug therapy is comparable to that for haemonchus, and drug resistance is also a problem with ostertagia. iii. ostertagia ostertagi (cattle stomach worm). ostertagia ostertagi is the most pathogenic and most costly of the cattle nematodes. ostertagia leptospicularis and o. bisonis also cause disease. the life cycle is direct, and egg shedding by the cattle may occur within - weeks of ingestion of infective larvae. hypobiosis is also a characteristic of o. ostertagi. in the initial steps of infection, the normal processes of the abomasum are profoundly disrupted and cells are destroyed as the larvae develop within and emerge from the glands. moroccan leather appearance is the term to describe the result of cellular hyperplasia and loss of cell differentiation. cycles of infection and morbidity depend on geographic location, climate, and production cycles. type cattle ostertagiasis is associated with ingestion of large numbers of infective larvae, occurs in animals less than years old, and causes diarrhea and anorexia. type ostertagiasis occurs in cattle - years old and older adults, is the result of the emergence and development of hypobiotic larvae, and in addition to signs seen with type , hypoproteinemia with development of submandibular edema, fever, and anemia is a clinical sign. treatment options include ivermectin, fenbendazole, and levamisole; all are effective against the arrested larvae. ostertagia is susceptible to desiccation but is resistant to freezing. iv. trichostrongylus vitrinus, t. axei, t. colubriformis (hair worms) . trichostrongylus species favor cooler conditions, and some larvae may overwinter. although the different species may affect different segments of the gastrointestinal tract, the nematode attaches to the mucosa and affects secretion and/or absorption. trichostrongylus vitrinus and t. colubriformis infect the small intestine of sheep and goats. trichostrongylus axei infects the abomasum of cattle, sheep, and goats and causes increases in abomasal ph similar to those seen with ostertagia. mucosal hyperplasia is not seen. the prepatent period is about weeks. affected animals display unthriftiness, anorexia, decreased milk production, weight loss, diarrhea, and dehydration. these worms show intermediate resistance to freezing temperatures and dry conditions. v. nematodirus spathiger, n. battus (thread-necked worms vii. strongyloides papillosus. strongyloides papillosus is a small-intestinal parasite of sheep and cattle. strongyloides has a different life cycle from that of many nematodes. the eggs, expelled in the feces, are larvated, and when they hatch, they form both free-living males and females or parasitic females only. the parasitic females may enter the gastrointestinal tract through oral ingestion, such as in milk during nursing, or through direct penetration of the skin. penetrating larvae enter the bloodstream and are transported to the lungs, where they penetrate the alveoli, are coughed up, and then swallowed to ultimately enter the gastrointestinal tract. adult females may reproduce in the small intestines by parthenogenesis. clinical signs associated with strongyloides include weight loss, diarrhea, unthriftiness, and dermatitis in cases where large numbers migrate through the skin. the current broad-spectrum anthelmintics are effective against strongyloides. strongyloides, bunostomum infection may involve oral ingestion or direct penetration of the skin (followed by tracheal migration and swallowing). the larvae mature in the small intestines and suck blood. larvae are susceptible to desiccation and freezing. heavy infection with bunostomum may result in anemia, diarrhea, intestinal hemorrhage, edema, and weight loss. ix. oesophagostomum columbianum, o. venulosum (nodule worms) . oesophagostomum spp. primarily infect the large intestine and occasionally the distal small intestine, causing nodule worm disease, or simply gut. oesophagostomum columbianum and o. venulosum infect sheep and cattle. these nematodes may affect sheep from months to years of age, and the prepatent period is about weeks. larvae are highly sensitive to freezing and desiccation and rarely overwinter. larvae penetrate the large-intestinal mucosa but occasionally move into the deeper areas of the intestinal wall near the serosa. the resultant inflammatory reaction may lead to the formation of a caseous nodule that may mineralize over time. intestinal lesions may accelerate peristalsis, leading to diarrhea, or may inhibit peristalsis (later stages), resulting in constipation. clinical signs include weakness, unthriftiness, alternating episodes of diarrhea and constipation, and severe weight loss. nodular lesions are typical at necropsy. x. chabertia ovis (large-mouth bowel worm). chabertia ovis is a minor colon parasite of sheep, goats, and cattle and is seen primarily in sheep. signs of infection are not usually seen in cattle. prepatent periods are up to days. heavy infection, which may result from as few as worms located at the proximal end of the colon, may lead to hemorrhagic mucoid diarrhea, weight loss, weakness, colitis, and mild anemia. xi. trichuris (whipworms). trichuris spp. are mildly pathogenic nematodes and are usually attached to the cecal mucosa. trichuris has a rather long prepatent period, extending from to months. the oval eggs are double-operculated and survive well in pasture environmental extremes. the adult worms also have a characterisitic morphology, with one thicker end appearing as a whip handle. the nematodes cause a minor cecitis and will feed on blood. clinical infection is rare and results in diarrhea with mucus and blood. treatment and prevention methods are similar to those for other nematodes. xii. dictyocaulus (lungworms). dictyocaulus spp., or lungworms, are nematodes that cause varying clinical signs in ruminants. in sheep, dictyocaulus filaria, protostrongylus rufescens, and muellerius capillaris cause disease; dictyocaulus is the most pathogenic. goats are infected by the same species as sheep, but infections are uncommon. dictyocaulus viviparus is the only lungworm found in cattle, causing "fog fever." infections with these parasites in the united states tend to be associated with cooler, moister climates. lungworms induce a severe parasitic bronchitis (known as husk, or verminous pneumonia) in sheep between approximately and months of age. sheep infected with any of the lungworm species may display coughing, dyspnea, nasal discharge, weight loss, unthriftiness, and occasionally fever. coughing and dyspnea are symptoms in goats. diagnosis is suggested by persistent coughing and nasal discharge and is confirmed by identifying larvae in the feces or adults in pathological samples. the baermann technique, involving prompt examination of room-temperature feces, is usually used; zinc sulfate flotation is also used. dictyocaulus has a direct life cycle. the adult worms reside in the large bronchi. dictyocaulus produces embryonated eggs that are coughed up and swallowed; the eggs then hatch in the intestines, and larvae are expelled in the feces. the expelled larvae are infectious in about - days and, after ingestion, penetrate the intestinal mucosa and move through the lymphatics and blood into the lungs, where they develop into adults in about weeks. dictyocaulus filaria causes an especially severe bronchitis in sheep. protostrongylus inhabits smaller bronchioles. muellerius is of minor pathogenicity. protostrongylus and muellerius require the snail or slug as an intermediate host. infection occurs through ingestion of infected snails; infections are less likely than those caused by the direct ingestion of dictyocaulus larvae. immunity wanes over a year. viral and bacterial respiratory tract infections may be associated with the parasitic infection. more severe illness is seen after infections with cooperia and ostertagia, because of a synergism between the nematodes even if the cattle are not currently infected with those parasites. hypobiosis (arrested development of immature worms in lung tissue) is associated with dictyocaulus infections; cattle will be silent carriers, showing no clinical signs and serving as a means for the infection to survive over winter or a dry season. pastures can be heavily contaminated during the next grazing season. necropsy lesions include bronchiolitis and bronchitis, atelectasis, and hyperplasia of peribronchiolar lymphoid tissue. nematodes frequently reside in the bronchi of the diaphragmatic lung lobes and are frequently enmeshed with frothy exudate. prevention and control of the disease involve appropriate pasture management. elimination of intermediate hosts is important in sheep and goat pastures. in a laboratory setting, animals may be procured that are already harboring the disease. infected animals can be treated with anthelmintics such as ivermectin or levamisole. muellerius tends to be resistant to levamisole. there is no anthelmintic currently approved for goats, but fenbendazole, administered weeks apart, has been effective for all three tapeworms are rarely of clinical or economic importance. in younger animals, heavy infections result in potbellies, constipation or mild diarrhea, poor growth, rough coat, and anemia. moniezia expansa, and less commonly moniezia benedini, inhabit the small intestines of grazing ruminants. moniezia expansa has the widest distribution of the tapeworm species in north america. soil mites (galumna spp. and oribatula spp.) contribute to the life cycle as intermediate hosts, a period that lasts up to weeks. cysticercoids released from the mites are grazed, pass into the small intestines, and mature. no clinical or pathological sign is usually observed with moniezia infection; diagnosis is made by observing the characteristic triangularshaped eggs in fecal flotation examinations. infection is treated with cestocides. thysanosoma actinoides, or the fringed tapeworm, is a cestode that resides in the duodenum, bile duct, and pancreatic duct of sheep and cattle raised primarily west of the mississippi river in the united states. thysanosoma is of the family anoplocephalidae. the life cycle is indirect, and the intermediate host is the psocid louse. larval forms, or cysticercoids, are ingested by grazing animals, and the prepatent period is several months. typically, no clinical signs are observed with thysanosoma infection; nonetheless, liver damage, resulting in liver condemnation at slaughter, occurs. necropsy lesions include bile and/or ductal hyperplasia and fibrosis. thysanosoma is diagnosed premortem by identifying the gravid segments in the feces. ii. abdominal or visceral cysticercosis. abdominal or visceral cysticercosis is an occasional finding at slaughter. the socalled bladder worms typically affect the liver or peritoneal cavity and are the larval form of taenia hydatigena, the common tapeworm of the dog family. taenia hydatigena resides in the small intestines of canids, and its gravid segments, oncospheres, contaminate feed and water sources. after ingestion, the larvae penetrate the intestinal mucosa, are transported via the bloodstream to the liver, and cause migration tracts throughout the liver parenchyma. the larvae may leave the liver and migrate into the peritoneal cavity, where they attach and develop over the next - months into small fluid-filled bladders. the life cycle is completed only after these bladders are ingested by a carnivore, thus completing the maturation of the adult tapeworms. although larval migration may cause nonspecific signs such as anorexia, hyperthermia, and weight loss, affected animals are usually asymptomatic. at necropsy, the bladder worms will be observed attached to the peritoneal or organ surfaces. migration tracts may result in fibrosis and inflammation. diagnosis is usually made at necropsy. because of the migration through the liver, fasciola hepatica is a differential diagnosis. minimizing exposure to canine feces-contaminated feeds and water effectively interrupts the life cycle. research animals may have been exposed prior to purchase. echinococcosis, like cysticercosis, is an occasional finding at slaughter or necropsy. the hydatid cyst is the larval intermediate of the adult tapeworm echinococcus granulosus, which resides in the small intestines of dogs and wild canids. embryonated ova are expelled in the feces of the primary host and are ingested by herbivores, swine, and potentially humans. the eggs hatch in the gastrointestinal tract, and the oncospheres penetrate the mucosal lining, enter the bloodstream, and are transported to various organs such as the liver and lungs. the cystic structure develops and potentially ruptures, forming new cystic structures. clinically, echinococcosis presents minimal clinical signs; unthriftiness or pneumonic lesions may be associated with infected organs. cysts are typically observed at necropsy. prevention should be aimed at decreasing fecal contamination of feed and water by canids. additionally, tapeworm-infected dogs can be treated with standard tapeworm therapies. treatment of infected ruminants is uncommon. iv. gid. coenuris cerebralis, the larval form of the canid tapeworm taenia (multiceps) multiceps, is the causative agent of the rare condition called gid. the disease occurs in ruminants as well as many other mammalian species. the larval parasite, ingested from fecal-contaminated food and water, invades the brain and spinal cord and develops as a bladder worm that causes pressure necrosis of the nervous tissues. the resultant signs of hyperesthesia, meningitis, paresis, paralysis, ataxia, and convulsions are observed. diagnosis is usually made at necropsy. eliminating transfer from the canid hosts prevents the disease. the cercariae leave the intermediate host, swim to grassy vegetation, lose their tail, and become a cystlike metacercaria. the metacercariae may remain in a dormant stage on the grass for months or longer until ingested by a ruminant. the ingested metacercariae penetrate the small-intestinal wall and migrate through the abdominal cavity to the liver. there they locate in a bile duct, mature, and remain for up to years. acute liver fluke disease is related to the damage caused by the migration of immature flukes. migratory flukes may lead to liver inflammation, hemorrhage, necrosis, and fibrosis. fascioloides magna infections in sheep and goats can be fatal as the result of just one fluke tunneling through hepatic tissue. in cattle, infections are often asymptomatic because of the host's encapsulation of the parasite. liver fluke damage may predispose to invasion by anaerobic clostridium species such as c. novyi that could lead to fatal black disease or bacillary hemoglobinuria. chronic disease may result from fluke-induced physical damage to the bile ducts and cholangiohepatitis. blood loss into the bile may lead to anemia and hypoproteinemia. liver damage also is evidenced by increases in liver enzymes such as y-glutamyl transpeptidase (ggt). persistent eosinophilia is also seen with liver fluke disease. other clinical signs of liver fluke disease include anorexia, weight loss, unthriftiness, edema, and ascites. at necropsy, livers will be pale and friable and may have distinct migration tunnels along the serosal surfaces. bile ducts will be enlarged, and areas of fibrosis will be evident. diagnosis can be made from clinical signs and postmortem mites cause a chronic dermatitis. the principal symptom of these infections is intense pruritus. in addition, papules, crusts, alopecia, and secondary dermatitis are seen. anemia, disruption of reproductive cycles, and increased susceptibility to other diseases may also occur. mites are rare in ruminants in the united states, but infections of sarcoptes and psorergates mange must be reported to animal health officials. ruminants in poorly managed facilities are generally the most susceptible to infection, and infections are more frequent during winter months. diagnosis is based on signs, examination of skin scrapings, and response to therapy. no effective treatment for demodectic mange in large animals has been found. the differential for mite infestations is pediculosis. several genera of mites may affect sheep. these have been eradicated from flocks in the united states or are very rare and include psoroptes ovis (common scabies), sarcoptes scabiei (head scabies, barn itch), psorergates ovis (sheep itch mite), chorioptes ovis (foot scabies, tail mange), and demodex ovis (follicular mange). goats can also be infected by sarcoptic, chorioptic, and psoroptic mange. the scabies mite sarcoptes rupicaprae invades epidermal tissue and causes focal pruritic areas around the head and neck. the chorioptic mite, either chorioptes bovis or c. caprae, does not invade epidermal tissue but rather feeds on dead skin tissue. the chorioptic mite prefers distal limbs, the udder, and the scrotum and can be a significant cause of pruri-tus. the psoroptic mite psoroptes cuniculi commonly occurs in the ear canal and causes head shaking and scratching. repeated treatments of lime sulfur, amitraz, or ivermectin may be effective (smith and sherman, ) . goats are also susceptible to demodectic mange caused by demodex caprae. adult mites invade hair follicles and sebaceous glands. pustules may develop with secondary bacterial infection. psoroptes bovis continues to be present in cattle in the united states, although it has been eradicated from sheep. chorioptes bovis typically infects lower hindlimbs, perineum, tail, and scrotum but can become generalized. the sarcoptic mange mite s. scabei can survive off the host, so fomite transmission is a factor. the mange usually begins around the head but then spreads. this parasite can be transmitted to humans. demodex bovis infects cattle; nodules on the face and neck are typical. demodex bovis infections may resolve without treatment. lindane, coumaphos, malathion, and lime sulfur are used to treat psoroptes and psorergates. ivermectin is effective against sarcoptes and is approved for use in cattle. lice that infect ruminants are of the orders mallophaga, biting or chewing lice, and anoplura, sucking lice. these are wingless insects. members of the mallophaga are colored yellow to red; members of the anoplura are blue gray. lice produce a seasonal (winter-to-spring), chronic dermatitis. in sheep, biting lice include damalinia (bovicola) ovis (sheep body louse). sucking lice that infect sheep include linognathus ovillus (blue body louse) and l. pedalis (sheep foot louse). in goats, biting lice infection are caused by d. caprae (goat biting louse), d. limbatus (angora goat biting louse), and d. crassipes. suckir/g louse infections in goats are caused by l. stenopis and l. africanus. damalinia bovis is the cattle biting louse. sucking lice include l. vituli, solenopotes capillatus, haematopinus eurysternus, and h. quadripertusus. pruritus is the most common sign and often results in alopecia and excoriation. the host's rubbing and grooming may not correlate with the extent of infestation. hairballs can result from overgrooming in cattle. in severe cases, the organisms can lead to anemia, weight loss, and damaged wool in sheep and damaged pelts in other ruminants. young animals with severe infestations of sucking lice may become anemic or even die. pregnant animals with heavy infestations may abort. in sheep infected with the foot louse, lameness may result. lice are generally species-specific. those infecting ruminants are usually smaller than mm. goats may serve as a source of infection for sheep by harboring damalinia ovis. transmission is primarily by direct contact between animals. transmission can also occur by attachment to flies or by fomites. some animals are identified as carriers and seem to be particularly susceptible to infestations. biting or chewing lice inhabit the host's face, lower legs, and flanks and feed on epidermal debris and sebaceous secretions. sucking lice inhabit the host's neck, back, and body region and feed on blood. lice eggs or nits are attached to hairs near the skin. three nymphal stages, or instars, occur between egg and adult, and the growth cycle takes about month for all species. lice cannot survive for more than a few days off the host. all ruminant mite infestations are differentials for the clinical signs seen with pediculosis. animals that are carriers should be culled, because these individuals may perpetuate the infection in the group. lice are effectively treated with a variety of insecticides, including coumaphos, dichlorvos, crotoxyphos, avermectin, and pyrethroids. label directions should be read and adhered to, including withdrawal times. products should not be used on female dairy animals. treatments must be repeated at least twice at intervals appropriate for nit hatches (about every days) because nits will not be killed. fall treatments are useful in managing the infections. systemic treatments in cattle are contraindicated when there may be concurrent larvae of cattle grubs (hypoderma lineatum and h. bovis). back rubbers with insecticides, capitalizing on self-treatment, are useful for cattle. sustained-release insecticide-containing ear tags are approved for use in cattle. etiology. ruminants are susceptible to many species of ixodidae (hard-shell ticks) and argasidae (softshell ticks). many diseases, including anaplasmosis, babesiosis, and q fever are transmitted by ticks. clinical signs and diagnosis. tick infestations are associated with decreased productivity, loss of blood and blood proteins, transmission of diseases, debilitation, and even death. feeding sites on the host vary with the tick species. ticks are associated with an acute paralytic syndrome called tick paralysis. this disease is characterized by ascending paralysis and may lead to death if the tick is not removed before the paralysis reaches the respiratory muscles. diagnosis is based on identification of the species. epizootiology and transmission. ticks are not as host-specific as lice. ticks are classified as one-host, two-host, or three-host; this refers to whether they drop off the host between larval and nymphal stages to molt. pathogenesis of tick infestations. patterns of feeding on the host differ between argasidae and ixodidae. the former feed repeatedly, whereas the latter feed once during each life stage. pathogenesis of tick paralysis. following a tick-feeding period of - days, the tick salivary toxin travels hematogenously to the myoneural junctions and spinal cord and inhibits nerve transmission. removal of the ticks reverses the syndrome unless paralysis has migrated anteriorly to the respiratory centers of the medulla. in these cases, death due to respiratory failure occurs. insecticides. ticks can be treated using systemic or topical h. other parasites i. nasal bots (nasal myiasis, head grubs). nasal myiasis causes a chronic rhinitis and sinusitis. the disease is caused by the larval forms of the botfly oestrus ovis. the botfly deposits eggs around the nostrils of sheep. the ova hatch, and the larvae migrate throughout the nasal cavity and sinuses, feeding on mucus and debris. in - months, the larvae complete their growing phase, migrate back to the nasal cavity, and are sneezed out. the mature larvae penetrate the soil and pupate for - . months and emerge as botflies. clinically, early in the disease course, animals display unique behaviors such as stamping, snorting, sneezing, and rubbing their noses against each other or objects. hypersensitivity to the larvae occurs (dorchies et al., ) . later, mucopurulent nasal discharges associated with the larval-induced inflammation of mucosal linings will be observed. at necropsy, larvae will be observed in the nasal cavity or sinuses. mild inflammatory reactions, mucosal thickening, and exudates will accompany the larvae. the disease is diagnosed by observing the behaviors or identifying organisms at necropsy. up to % of a flock will potentially be infected; treatment should be employed on the rest of the flock. ivermectins and other insecticides will eliminate the larvae; but treatment should be done in the early fall, when larvae are small. fly repellents may be helpful at preventing additional infections. ii. screwworm flies. cochliomyia hominivorax (callitroga americana) is the the screwworm that causes occasional disease in the southwestern united states along the mexico border. eradication programs have been pursued, and the disease is reportable. large greenish flies lay large numbers of white eggs as shinglelike layers at the edges of open wounds (including docking and castration sites), soiled skin, or abrasions. eggs hatch within hr. larvae are obligate parasites of living tissue, and the cycle is perpetuated because the increasingly large wound continues to be attractive to the next generation of flies. larvae eventually drop off, pupate best in hot climates, and hatch in weeks. large cavities in parasitized tissue are formed, and lesions are characterized by malodor, large volumes of brown exudate, and necrosis. single animals or entire herds may be affected. treatment is intensive, with dressings and larvicidal applications. if there is no intervention, the host succumbs to secondary infections and fluid loss. effective current control regimens include subcutaneous injection of ivermectin and programs that release sterile male flies. iii. sheep keds ("sheep ticks"). in sheep and goats, sheep keds produce a chronic irritation and dermatitis with associated pruritus. the disease is caused by melophagus ovinus, which is a fiat, brown, blood-sucking, wingless fly; the term sheep tick is incorrectly used. the adult fly lives entirely on the skin of sheep. females mate and produce - larvae following a gestation of about - days. the larvae attach to the wool or hair and then pupate for about weeks. the adult female feeds on blood and lives for - months; the life cycle is completed in about - weeks. infection is highest in fall and winter. pruritus develops around the neck, sides, abdomen, and rump. in severe cases, anemia may occur. keds can transmit bluetongue virus. keds are diagnosed by gross or microscopic identification. ivermectin or other insecticides are useful treatment agents. portant, other immune mechanisms are not well understood. immunity may not be of long duration. recovery is enhanced by correcting nutritional deficiencies and improving housing and ventilation problems. a number of topical treatments, such as - % lime-sulfur solution, % captan, iodophors, thiabendazole, and . % sodium hypochlorite, can be used. in severe cases, systemic therapy with griseofulvin may be successful. prevention and control. the animals' environment and overall physical condition should be reassessed with particular attention to ventilation, crowding, sanitation, and nutrition. pens should be thoroughly cleaned and disinfected. research complications. ringworm is a zoonotic disease. etiology. dermatophytosis, or infection of the keratinized layers of skin, is caused mostly by species of the genera trichophyton and microsporum. the primary causes in sheep are t. mentagrophytes and t. verrucosum. in goats, the agents are t. mentagrophytes, m. canis, m. gypseum, t. verrucosum, t. schoenleinii, and epidermophyton floccosum. in cattle, t. verrucosum is the primary causative agent. dermatophytosis is a common fungal infection of the epidermis of cattle and is less common in sheep and goats. clinical signs and diagnosis. multiple, gray, crusty, circumscribed, hyperkeratotic lesions are characteristic of infection. lesions will vary in size. in all ruminants, lesions will be around the head, neck, and ears. in goats and cattle, lesions will extend down the neck, and in cattle, lesions develop particularly around the eyes and on the thorax. cattle lesions are unique in the marked crustiness, which progressively appears wartlike. hair shafts become brittle and break off. intense pruritus is often associated with the alopecic lesions. the disease can be diagnosed by microscopic identification of hyphae and conidia on the hairs following skin scraping and % potassium hydroxide digestion. dermatophyte test media (dtm) cultures are the most reliable means to diagnose the fungus. broken hairs from the periphery of the lesion are the best sources of the fungus. epizootiology and transmission. younger animals are more susceptible, and factors such as crowding, indoor housing, warm and humid conditions, and poor nutrition are also important. transmission is by direct contact or by contact with contaminated fomites, such as equipment, fencing, or feed bunks. pathogenesis. incubation can be as long as weeks. the organisms invade and multiply in hair shafts. treatment. spontaneous recovery occurs in all species in - months. although cell-mediated immunity is considered im- inverted eyelids are a common inherited disorder of lambs and kids of most breeds. generally, the lower eyelid is affected and turns inward, causing various degrees of trauma to the conjunctiva and cornea. young animals will display tearing, blepharospasm, and photophobia initially. if the disorder is left uncorrected, corneal ulcers, perforating ulcers, uveitis, and blindness may occur. placing a suture or a surgical staple in the lower eyelid and the cheek, effectively anchoring the lid in an everted position, successfully treats the condition. the procedure likely results in the formation of some degree of scar tissue within the lower lid, because when the suture eventually is removed, the condition rarely returns. other treatments include the injection of a "bleb" of penicillin in the lid, regular manual correction over a -day period early in the animal's life, and application of ophthalmic ointments, powders, and solutions. boric acid or % argyrol solutions have been used as treatments. because of the genetic predisposition, prevention of the condition requires removal of maternal or paternal carriers. [ -mannosidosis is an autosomal recessive lysosomal storage disease of goats. the disease affects kids of the nubian breed and is identified by intention tremors and difficulty or inability of newborns to stand. cells of affected animals are vacuolated because of a lack of lysosomal hydroxylase, which results in accumulation of oligosaccharides. newborn kids are unable to rise, and they have characteristic flexion of the carpal joint and hyperextension of the pastern joint. kids are born deaf and with musculoskeletal deformities such as domed skull, small narrow muzzle, small palpebral fissures, enophthalmos, and depressed nasal bridge (smith and sherman, ) . carrier adults can be identified by plasma measurements of [ -mannosidase activity. caprine congenital myotonia is an inherited autosomal dominant disease that affects voluntary striated skeletal muscles. goats with this disease are commonly known as fainting goats. "fainting" is actually transient spasms of skeletal musculature brought about by visual, tactile, or auditory stimuli (smith and sherman, ) . muscle fiber membranes appear to have fewer chloride channels than normal, resulting in decreased chloride conduction across the membrane, with subsequent increased membrane excitability and repetitive firing (smith and sherman, ) . contractions of skeletal muscle are sustained for up to min. kids exhibit the condition by weeks of age, and males appear to exhibit more severe clinical signs than females (smith and sherman, ) . electromyographic studies produce an audible "dive-bomber" sound characteristic of hyperexcitable cell membranes (smith and sherman, ) . i. congenital erythropoietic porphyria. congenital erythropoietic porphyria (cep) is an autosomal recessive disease of cattle seen primarily in holsteins, herefords, and shorthorns. the disease also occurs in limousin cattle, humans, and some other species. in the homozygous recessive animal, symptoms of the disease may vary from mild to severe and occur at different times of the year and in different ages of animals. a reddish brown discoloration of teeth and bones is a characteristic of the disease, as is discolored urine, general weakness and failure to thrive, photosensitization, and photophobia. bones are more fragile compared with bones of normal animals. a regenerative anemia occurs as the result of the shortened life span of erythrocytes, due to accumulations of porphyrins. the genetic defect is associated with low activity of an essential enzyme, uroporphyrinogen iii synthase, in the porphyrin-heme synthesis pathway in erythrocytic tissue. the ranges in the presentation of the disease are believed to be related to varying cycles of porphyrin synthesis. porphyrins are excreted in varying amounts in the urine and the discoloration fluoresces under a wood's lamp. diagnosis is based on these clinical and visible signs of porphyria; skin biopsy provides definitive diagnosis. heterozygotes may have milder symptoms. many other genetic defects, in all major organ systems, have been described in numerous breeds of cattle and are described in detail elsewhere ("large animal internal medicine," ) . in many cases, the genetic basis has been clarified, and associated defects also noted. many defects are reported in particular breeds, but as crossbreeding increases and new breeds are developed, these traits are appearing in these animals. the bovine genome continues to be further characterized, and more linkage maps and gene locations are forthcoming (womack, ) . some bovine genetic defects are also regarded as models of genetic disease, such as leukocyte adhesion deficiency of holstein cattle. some of the more commonly reported defects include syndactyly in holsteins and other breeds and polydactyly in simmentals; lysosomal storage diseases such as a-mannosidosis in some beef breeds; enzyme deficiencies such as citrullinemia in holsteins; and progressive degenerative myeloencephalopathy ("weaver") in brown swiss. ii. goiter of sheep. a defect in the synthesis of thyroid hormone has been identified in merino sheep (radostits et al., ) . lambs born with the defect have enlargement of the thyroid gland, a silky appearance to the wool, and a high degree of mortality. edema, bowing of the legs, and facial abnormalities have also been noted in animals with this disorder. immaturity of the lungs at birth causes neonatal respiratory distress and resuits in dyspnea and respiratory failure. spider lamb syndrome is an inherited, often lethal, musculoskeletal disorder primarily occurring in suffolk and hampshire breeds. severely affected lambs die shortly after birth. animals that survive the perinatal period develop angular limb deformities, scoliosis, and facial deformities. with time, affected animals become debilitated, exhibit joint pain, and develop neurological problems associated with the spinal abnormalities. radiologically, secondary ossification centers--especially the physis, subchondral areas, and cuboidal bonesmare affected. abnormal endochondral ossification leads to excess cartilage formation, notably apparent in the elbows. lambs will typically display abnormally long limbs, medial deviation of the carpus and tarsus, flattening of the sternum, scoliosis/kyphosis of the vertebrae, and a rounded nose. muscle atrophy is common. diagnosis can be based on typical clinical signs, which are similar to those seen with marfan syndrome in humans (rook et al., ) . long-term survival is rare; treatment is unsuccessful. i. abomasal and duodenal ulcers. abomasal and duodenal ulcers occur more frequently in calves and adult cattle than in sheep and goats. like rumenitis, abomasal and duodenal ulcers may be associated with lactic acidosis. concurrent disease, such as salmonellosis, bluetongue, or overuse of anti-inflammatory drugs, or recent shipping or environmental stresses may also lead to ulcer formation. copper deficiency, dietary changes, mycotic infections, clostridium perfringens abomasitis, and abomasal bezoars are associated with this disease in calves. in older adult cattle, abomasal lymphosarcoma may be the underlying condition. gastric acid hypersecretion in conjunction with insufficient gastric mucous secretion will physically destroy the gastric epithelium. deep ulceration may cause serious hemorrhage and/or perforation with peritonitis. chronic hemorrhage may lead to anemia. although ulcers are often asymptomatic in calves, perforation with peritonitis is more common than hemorrhage. dark feces or melena and abdominal pain may be observed. arched back, restlessness, kicking at the abdomen, bruxism, and anorexia are common signs of abdominal pain. fecal occult blood is as an easy diagnostic test. treatment includes gastrointestinal protectants and histamine antagonists. anemia may be symptomatically treated with parenteral iron injections and anabolic steroids. preventive measures in cattle herds include ensuring optimal passive immunity for calves, minimizing stress to calves, and striving for a herd free of bovine leukosis virus. ii. abomasal emptying defect. abomasal emptying defect of sheep is a sporadic syndrome associated with abomasal distension and weight loss. suffolks tend to be especially predisposed, although the disease has been diagnosed in hampshires, columbias, and corriedales. the mechanism of the disease is unknown. affected animals will exhibit a gradual weight loss with a history of normal appetites. feces will continue to be normal. ventral abdominal distension associated with abomasal accumulation of feedstuffs will be apparent in many of the animals. diagnosis is primarily based on history and clinical signs. elevations in rumen chloride concentrations (> meq/liter) are commonly found. radiography or ultrasonography may be helpful at identifying the distended abomasum. abomasal emptying defect is usually eventually fatal. medical treatment with metoclopramide and mineral oil may be helpful in early disease. iii. abomasal displacement. displaced abomasum (da) is a sporadic disorder usually associated with multiparous -to year-old dairy cows in early lactation, but the condition can occur even in young calves. displacement to the right (rda) may be further complicated by torsion (rta), a surgical emergency. left displacement (lda) is more common than rda. clinical signs include anorexia, lack of cud chewing, decreased frequency of ruminal contractions, shallow respirations, increased heart rate, treading, and decreased milk production. diagnosis is based on characteristic areas of tympanic resonance during auscultation-percussion of the lateral to lateral-ventral abdomen ("pings"), ruminal displacement palpated per rectum, and clinical signs. cow-side clinical chemistry findings include hypoglycemia and ketonuria; more extensive evaluations will often indicate moderate to severe electrolyte and acid-base abnormalities. da occurs because of gas accumulation within the viscus, and the abomasum "floats" up from its normal ventral location to the lateral abdominal wall. no exact cause of da has been identified, but it is commonly associated with stress; high levels of concentrate in the diet, leading to forestomach atony; and many disorders, including lack of regular exercise, mastitis, hypocalcemia, retained placenta, metritis, or twins. factors such as body size and conformation indicate the possibility of genetic predisposition. treatments include surgical and nonsurgical techniques for lda; the former has a better chance of per-manent correction. emergency surgery is necessary for rta; the disorder is fatal within hr. recurrence is rare after surgical correction. electrolyte and acid-base imbalances are likely in severe cases and especially with rta. prevention includes reducing stress, taking greater care in the introduction and feeding of concentrates, and reducing incidence of predisposing diseases noted above (rohrbach et al., ) . fat cow syndrome is seen in peri-or postparturient overconditioned or obese multiparous dairy cows. factors in the development of the condition include negative energy balance related to the normal decreased dry matter intake as parturition approaches; hormonal changes associated with parturition; and concurrent diseases of parturition that decrease feed intake and increase energy needs. the possible concurrent diseases include metritis, retained fetal membranes, mastitis, parturient paresis, and displaced abomasum. signs are nonspecific and include depression, anorexia, and weakness. prognosis is usually guarded. diagnosis is based on herd management, the animal's condition, ketonuria, and clinical signs. in prepartum cattle and in lactating cows, blood levels of nonesterified fatty acids (nefa) greater than ~teq/liter and - ~teq/liter, respectively, are abnormal (gerloff and herdt, ) . triglyceride analysis of liver biposy specimens are useful. in affected cows, body fat is mobilized, in the form of nefa in response to the energy demands. hepatic lipidosis occurs rapidly as the nefa are converted into hepatic triglycerides. the ability of the liver to extract the albumin-bound nefa from the blood is better than that of other tissues that need and can also use nefa as an energy source. treatment for any concurrent diseases must be pursued aggressively, as well as measures to increase and stabilize blood glucose, decrease nefa production, and increase forestomach digestion to improve production of normally metabolized volatile fatty acids. therapeutic measures include intravenous glucose drips, insulin (nph or lente) injections every hr, and transfaunation of ruminal fluid from a normal cow. prevention includes minimizing stress to lategestation cows. dry and lactating cows should be maintained separately; their energy, protein, and dry matter requirements are very different. cows with prolonged lactation or delayed breeding should be managed to prevent weight gain. i. bloat. bloat or tympanites refers to an excessive accumulation of gas in the rumen. the condition most frequently occurs in animals that have been recently fed abundant quantities of succulent forages or grains. bloat is classified into two broad categories: frothy bloat and free-gas bloat. frothy bloat is associated with ingestion of feeds that produce a stable froth that is not easily expelled from the rumen. fermentation gases such as co , ch , and minor gases such as n , , h , and h s incorporate into the froth, overdistend the rumen, and eventu-ally compromise respiration by limiting diaphragm movement. the froth is often derived from a combination of salivary mucoproteins, protozoal or bacterial proteins, and proteins, pectins, saponins, or hemicellulose associated with ingested leaves or grain. typical foodstuffs that cause frothy bloat include green legumes, leguminous hay (alfalfa, clover), or grain (especially barley, corn, and soybean meal). free-gas bloat is less related to feeds ingested; rather, it is caused by rumen atony or by physical or pathological problems that prevent normal gas eructation. some examples of causes of free-gas bloat are esophageal obstructions (foreign bodies, tumors, abscesses, and enlarged cervical or thoracic lymph nodes), vagal nerve paralysis or injury, and central nervous system conditions that affect eructation reflexes. clinically, the animal will exhibit rumen distension, and tympany will be observed in the left paralumbar fossa. additional signs may include colic-like pain of the abdomen and dyspnea. passage of a stomach tube helps to differentiate between free-gas bloat and frothy bloat; and with free-gas bloat, expulsion of gas through the stomach tube aids in treatment of the disorder. once rumen distension is alleviated with free-gas bloat, the underlying cause must be investigated to prevent recurrence. frothy bloat is more difficult to treat, because the foam blocks the stomach tube. addition of mineral oil, household detergents, or antifermentative compounds via the tube may help break down the surface tension, allowing the gas to be expelled. in acute, life-threatening cases of bloat, treatment should be aimed at alleviating rumen distension by placing a trocar or surgical rumenotomy into the rumen via the paralumbar fossa. limiting the consumption of feedstuffs prone to induce bloat can prevent the disease. additionally, poloxalene or monensin will decrease the incidence of frothy bloat. ii. lactic acidosis. lactic acidosis, or rumen acidosis, is an acute metabolic disease caused by engorgement of grains or other highly fermentable carbohydrate sources. the disease is most frequently related to a rapid change in diet from one containing high roughage to one containing excessive carbohydrates. diet components that predispose to acidosis include common feed grains; feedstuffs such as sugar beets, molasses, and potatoes; by-products such as brewer's grains; and bakery products. biochemically, ingestion of large amounts of the carbohydrate-rich diet causes the normally gram-negative rumen bacterial populations to shift to gram-positive streptococcus and lactobacillus species. the gram-positive organisms efficiently convert the starches to lactic acid. the lactic acid acidifies the rumen contents, leading to rumen mucosal inflammation, and increases the osmolality of rumen fluids, leading to sequestration of fluids and osmotic attraction of plasma and tissue fluid to the rumen. lactic acid-induced rumenitis predisposes the animal to ulcers, to liver abscesses from "absorbed" bacterial pathogens, to laminitis from absorbed toxins, and to polioencephalomalacia from the inability of the new rumen bacterial populations to produce sufficient thiamine needed to maintain normal nervous system function. clinically, animals will become anorexic, depressed, and weak within - days after the initial insult. incoordination, ataxia, dehydration, hemoconcentration, rapid pulse and respiration, diarrhea, abdominal pain, and lameness will also be noted rumen distension and an acetone-like odor to the breath, milk, or urine may also be observed. diagnosis is based on history and clinical signs. blood, urine, or milk ketones can be detected (moore and ishler, ) . additionally, rumen ph, which is normally above . , will drop to less than . and in severe cases may achieve levels as low as . . similarly, urine ph will become acidic, blood ph will drop below . , and hematocrit will appear to increase due to the relative hemoconcentration. necropsy findings will be determined by secondary conditions. the primary lactic acidosis will cause swelling and necrosis of rumen papillae and abomasal hemorrhages and ulcers. treatment must be applied early in the syndrome. in early hours of severe carbohydrate engorgement, rumenotomy and evacuation of the contents are appropriate. the t patient should be given mineral oil and antlfermentatlves to prevent the continued conversion of starches to acids and the absorption of metabolic products. bicarbonate or other antacids like magnesium carbonate or magnesium hydroxide introduced into the rumen will aid in adjusting rumen ph. furthermore, animals can be given oral tetracycline or penicillin, which will decrease the gram-positive bacterial population. iii. rumen parakeratosis. parakeratosis is a degenerative condition of the rumen mucosa that leads to keratinization of the papillary epithelium excessive and continuous feeding of diets low in roughage causes the mucosal changes generally, this condition is seen in feedlot lambs and steers that are fed an all-grain diet. clinically, animals may exhibit only poor rates of gain, due to changes in the absorptive capacity of the injured mucosa. at necropsy, papillae will be thickened and rough. they will frequently be dark in color, and multiple papillae will clump together. abscessation may be observed. histopathologically, papilla surfaces will have hyperkeratinization of the squamous epithelium. chronic laminitis may be observed. however, diagnosis of parakeratosis is generally made at necropsy. feeding adequate roughage, such as stemmy hay, will prevent the disease. antibiotics may be administered to prevent secondary liver abscess formation. iv. rumenitis. rumenitis is an acute or chronic inflammation of the rumen, which occurs most commonly as a sequela to lactic acidosis in addition to concentrate feeding, inadequate roughage in the diet is also associated with this disorder rumenitis may occur with contagious ecthyma infection or following ingestion of poisons or other irritants. because rumenitis is often associated with lactic acidosis, it tends to occur in feedlot animals. the inflamed ruminal epithelium becomes necrotic and sloughs, creating ulcers. endogenous rumen bacteria such as fusobacterium necrophorum may invade the ulcers, penetrate the circulatory system, and induce abscesses of the liver. clinically, the animals will appear depressed and anorexic. rumen motility will be decreased, and animals will lose weight. the disease may resolve in a week to days; mortality may reach %. necropsy lesions include rumen inflammation and ulcers in the anteroventral sac. granulation tissue and scarring may be observed following healing. rumenitis is not typically diagnosed clinically; thus, specific treatment is not commonly done. the disease can be prevented by minimizing the incidence of lactic acidosis. etiology. traumatic reticulitis-reticuloperitonitis is a disease of cattle related to their exploratory tendencies and ingestion of many different, nonvegetative materials. the disease is rarely seen in smaller ruminants. clinical signs. clinical signs range from asymptomatic to severe, depending on the penetration and damage by the foreign object after settling in the animal's forestomach. many signs during the early, acute stages will be nonspecific, ranging from arched back, listlessness, anorexia, fever, decrease in production, ketosis, regurgitation, decrease or cessation of ruminal contractions, bloat, tachypnea, tachycardia, and grunts when urinating, defecating, or being forced to move. the prognosis is poor when peritonitis becomes diffuse. sudden death can occur if the heart, coronary vessels, or other large vessels are punctured by the migrating object. epizootiology and transmission. this is a noncontagious disease. the occurrence is directly related to sharp or metallic indigestible items in the feed or environment that the cattle mouth and swallow. necropsy findings. in severe cases, necropsy findings include extensive inflammation throughout the cranial abdomen, malodorous peritoneal fluid accumulations, and lesions at the reticular sites of migration of the foreign objects. cardiac puncture will be present in those animals succumbing to sudden death. pathogenesis. consumed objects initially settle in the rumen but are dumped into the reticulum during the digestive process, and normal contraction may eventually lead to puncture of the reticular wall. this sets off a localized inflammation or a localized or more generalized peritonitis. the inflammation may also temporarily or permanently affect innervation of local tissues and organs. further damage may result from migration and penetration of the diaphragm, pericardium, and heart. diagnosis is based on clinical signs, knowledge of herd management techniques in terms of placement of forestomach magnets, and reflection of acute or chronic infection on the hemogram. radiographs and abdominocentesis may be useful. differential diagnosis. differentials include abomasal ulcers, hepatic ulcers, neoplasia (such as lymphosarcoma, usually in older animals, or intestinal carcinoma), laminitis, and cor pulmonale. infectious diseases that are differentials include systemic leptospirosis and internal parasitism. diseases causing sudden death may need to be considered. prevention and control. this problem can be prevented entirely by elimination of sharp objects in cattle feed and in the housing and pasture environments. adequately sized magnets placed in feed handling equipment and forestomach magnets (placed per os with a bailing gun in young stock at - months of age) are also significant prevention measures. treatment. provision of a forestomach magnet, confinement, and nursing care, including antibiotics, are the initial treatments. in severe cases, rumenotomy may be considered. etiology. pregnancy toxemia is a primary metabolic disease of ewes and does in advanced pregnancy. beef heifers are susceptible to protein energy malnutrition (pem) syndrome, which is also referred to as pregnancy toxemia. clinical signs. in sheep, this disease is characterized by hypoglycemia, ketonemia, ketonuria, weakness, and blindness. hypoglycemic and ketotic ewes begin to wander aimlessly and to move away from the flock. they become anorexic and act uncoordinated, frequently leaning against objects. advanced signs may include blindness, muscle tremors, teeth grinding, convulsions, and coma. body temperature, heart rate, respiratory rate, and rumen motility continue normally. up to % of infected ewes may die from the disease. the course of the disease may last up to a week. in goats, the disease usually occurs in the last weeks of gestation, especially in does carrying triplets. pregnancy toxemia should be considered with any goat showing signs of illness in late gestation. the doe may separate herself from the herd, stagger, or circle and may appear blind. appetite is poor, and tremors may be evident. a rapid metabolic acidosis results in subsequent recumbency. urinalysis will readily reveal ketonuria. if fetal death occurs, acute toxemia and death of the doe may result. in beef heifers, weight loss and thin body condition, weakness and inability to stand, and depression are clinical signs. some cows develop diarrhea. because the catabolic state is often so advanced, most affected heifers die even if treated. pregnancy toxemia is diagnosed by evidence of typical clinical signs. sodium nitroprusside tablets or ketosis dipsticks may be used to identify ketones in the urine or plasma of ewes and does. blood glucose levels found to be below mg/dl and ketonuria are good diagnostic indicators. in cattle, ketonuria is not a typical finding; hypocalcemia and anemia may be present. that are obese or bearing twins or triplets. the disease develops during the last weeks of pregnancy. pem most frequently occurs in heifers during the final trimester of pregnancy. necropsy findings. at necropsy, affected ewes will often have multiple fetuses, which may have died and decomposed. the liver will be enlarged, yellow, and friable, with fatty degeneration. the adrenal gland may also be enlarged. in cattle, heifers will be very thin, and in addition to a fatty liver, signs of concurrent diseases may be present. pathogenesis. rapid fetal growth, a decline in maternal nutrition, and a voluntary decrease in food intake in overfat ewes result in an inadequate supply of glucose needed for both maternal and fetal tissues. the ewe develops a severe hypoglycemia in early stages of the disease. the ruminant absorbs little dietary glucose; rather, it produces and absorbs volatile fatty acids (acetic, propionic, and butyric acids) from consumed feedstuffs. propionic acid is absorbed and selectively converted to glucose through gluconeogenesis. when the animal is in a state of negative energy balance, it hydrolyzes fats to glycerol and fatty acids. glycerol is converted to glucose while the fatty acids are metabolized for energy. the oxidation of fatty acids in the face of declining oxaloacetate levels (required for normal krebs cycle function) results in the formation of ketone bodies (acetone, acetoacetic acid, and [ -hydroxybutyric acid), thus causing the condition ketoacidosis. heifer cattle have high energy requirements for completing normal body growth and supporting a pregnancy. additional energy requirements are needed during pregnancy for winter conditions and during concurrent diseases. marginal diets and poor-quality forage will place the cows in a negative energy balance. differential diagnosis. hypocalcemia is a common differential diagnosis. in cattle, differentials include chronic or untreated diseases such as johne's disease, lymphosarcoma, parasitism, and chronic respiratory diseases. prevention and control. pregnancy toxemia can be prevented by providing adequate nutrition during late gestation and by maintaining animals in appropriate nonfat condition during pregnancy. in late pregnancy, the dietary energy and protein should be increased . - times the maintenance level. pem can be prevented by maintaining appropriate body condition earlier in pregnancy and supplying good-quality forage for the last trimester. treatment. in sheep, because the morbidity may be as high as %, treatment should be directed at the flock rather than the in-dividual. treating the individual is usually unsuccessful. oral administration of ml of propylene glycol or % glucose twice a day, anabolic steroids, and high doses of adrenocorticosteroids may be helpful. if ewes are still responsive and not severely acidotic or in renal failure, cesarean section may be successful by rapidly removing the fetus, which is the dietary drain for the ewe. in goats, pregnancy toxemia is best treated by removal of the fetuses either by cesarean section or induction of parturition. parturition can be induced in does by either dexamethasone ( mg) or pgf a ( ~tg). in addition, goats may be treated with % dextrose ( to ml iv) or propylene glycol ( ml per os or times a day). adjunctive therapy includes normalizing acid base and hydration status, administration of vitamin b and transfaunation. heifers may be force-fed alfalfa gruels, given propylene glycol per os, placed on iv % glucose drips, and treated for concurrent disease. research complications. in research requiring pregnant ewes in late stages of gestation, for example, this disease should be considered if the animals are likely to bear twins and will be transported or stressed in other ways during that time. f hypocalcemia (parturient paresis, milk fever) etiology. hypocalcemia is an acute metabolic disease of ruminants that requires emergency treatment; the presentation is slightly different in ewes, does, and cows. clinical signs and diagnosis. in sheep, the disease is seen in ewes during the last weeks of pregnancy and is characterized by muscle tetany, incoordination, paralysis, and finally coma. as calcium levels drop, ewes begin to show early signs such as stiffness and incoordination of movements, especially in the hindlimbs. later, muscular tremors, muscular weakness, and recumbency will ensue. animals will frequently be found breathing rapidly despite a normal body temperature. morbidity may approach %, and mortality may reach as high as % in untreated animals. affected does become bloated, weak, unsteady, and eventually recumbent. cows are affected within - hr before or after parturition. cows initially are weak and show evidence of muscle tremors, then deteriorate to sternal recumbency, with the head usually tucked to the abdomen, and an inability to stand. tachycardia, dilated pupils, anorexia, hypothermia, depression, ruminal stasis, bloat, uterine inertia, and loss of anal tone are also seen at this stage. the terminal stage of disease is a rapid progression from coma to death. heart rates will be high, but pulse may not be detectable. hypocalcemia is diagnosed based on the pregnancy stage of the female and on clinical signs. it is later confirmed by laboratory findings of low serum calcium. with hypocalcemia in ewes, the plasma concentrations of calcium drop from normal values of - mg/dl to values of - mg/dl. in cattle, plasma levels below . mg/dl are hypocalcemic; at the terminal stages levels may be mg/dl. ewes during the last weeks of pregnancy or during the first few weeks of lactation. the disease is not as common in the dairy goat as in the dairy cow. high-producing, older, multiparous dairy cows are the most susceptible, and the jersey breed is considered susceptible. cows that have survived one episode are prone to recurrence. in addition, dry cows must be managed carefully regarding limiting dietary calcium. the disease is not common in beef cattle unless there is an overall poor nutrition program. ing at necropsy. there is no pathognomonic or typical find-pathogenesis. during the periparturient period, calcium requirements for fetal skeletal growth exceed calcium absorbed from the diet and from bone metabolism. additionally, dietary calcium intake is thought to be compromised because, in advanced pregnancy, animals may not be able to eat enough to sustain adequate nutrient levels, and intestinal absorption capabilities do not respond as quickly as needed. after parturition, calcium needs increase dramatically because of calcium levels in colostrum and milk. recent information suggests that legume and grass forages, high in potassium and low in magnesium, create a slight physiological alkalosis (at least in cattle), which antagonizes normal calcium regulation (rings et al., ) . thus, bone resorption, renal resorption, and gastrointestinal absorption of calcium are less than maximal. prevention and control. maintaining appropriate nutrition during the last trimester is helpful in preventing the disease. in cows and does, for example, limiting calcium intake by removing alfalfa from the diet is helpful. treatment. hypocalcemia must be treated quickly based on clinical signs; pretreatment blood samples can be saved for later confirmation. twenty percent calcium borogluconate solution should be administered by slow intravenous infusion. response will often be rapid, with the resolution of the animal's dull mentation. less severely affected animals will often try to stand in a short time. relapses are common, however, in sheep and cattle. hypermagnesemia and hypophosphatemia often coincide with hypocalcemia. these imbalances should be considered when animals appear to be unresponsive to treatment. hypocalcemia in the goat can be treated with - ml of calcium borogluconate. heart rate should be monitored closely throughout calcium administration. if an irregular or rapid heart rate is detected, then calcium treatment should be slowed or discontinued. calcium gels and boluses are also available for treatment (rings et al, ) . prognosis is generally good if the animal is treated early in the disease, but the prognosis will often be poor when treatment is initiated in later stages of the disease. etiology. urolithiasis is a metabolic disease of intact and castrated male sheep, goats, and cattle that is characterized by the formation of bladder and urethral crystals, urethral blockage, and anuria (murray, ) . the disease occurs rarely in female ruminants. clinical signs and diagnosis. affected animals will vocalize and begin to show signs of uneasiness, such as treading, straining postures, arched backs, raised tails, and squatting while attempting to urinate. these postures may be mistaken for tenesmus. male cattle may develop swelling along the ventral perineal area. affected animals will not stay with the herd or flock. small amounts of urine may be discharged, and crystal deposits may be visible attached to the preputial hairs. additionally, in smaller ruminants, the filiform urethral appendage (pizzle) often becomes dark purple to black in color. the pulsing pelvic urethra may be detected by manual or digital rectal palpation, and bladder distention may be noticeable in cattle by the same means. as the disease progresses to complete urethral blockage, the animal will become anorexic and show signs of abdominal pain, such as kicking at the belly. the abdomen will swell as the bladder enlarges, and rupture can occur within hr after development of clinical signs. bladder or urethral rupture may cause a short-lived period of apparent pain relief; subsequent development of uremia will eventually lead to death. the disease may progress over a period of - weeks, and the mortality is high unless the blockages are reversed. diagnosis is made by the typical clinical signs. abdominal taps may yield urine. calculi are usually composed of calcium phosphate or ammonium phosphate matrices. clinical disease is usually seen in growing intact or castrated males. the disease may be sporadic or there may be clusters of cases in the flock or herd. necropsy findings. necropsy findings include urine in the abdomen with or without bladder or urethral rupture. renal hydronephrosis may be evident. calculi or struvite crystal sediment will be observed in the bladder and urethra. histologically, trauma to the urethra and ureters will be present. etary, anatomical, hormonal, and environmental factors. male sheep and goats have a urethral process that predisposes them to entrapment of calculi. in cattle, the urethra narrows at the sigmoid flexure, and calculi lodge there most frequently. additionally, the removal of testosterone by early castration is thought to result in hypoplasia of the urethra and penis. this physical reduction in the size of the excretory tube may predispose to the precipitation of and blockage by the struvite minerals. grains fed to growing animals tend to be high in phosphorus and magnesium content. these calculogenic diets lead to the formation of struvite (magnesium ammonium phosphate) crystals. other minerals associated with urolithiasis include silica (range grasses), carbonates (some grasses and clover pastures), calcium (exclusively alfalfa hay), and oxalates (fescue grasses). differential diagnosis. grain engorgement colic, gastrointestinal blockage, and causes of tenemus, such as enteritis or trauma, are differentials. trauma to the urethral process should be considered. urinary tract infections are uncommon in ruminants. prevention and control. one case often is indicative of a potential problem in the group. urolithiasis can be minimized by monitoring the calcium:phosphorus ratio in the diet. the normal ratio should be : . additionally, increasing the amount of dietary roughage will help balance the mineral intake. increasing the amount of salt (sodium chloride, - %) in the diet to increase water consumption, or adding ammonium chloride to the diet, at gm/head/day or % of the ration, to acidify the urine, will aid in the prevention of this disease. palatability of and accessibility to water should be assessed as well as functioning of automatic watering equipment. treatment. treatment is primarily surgical (van metre et al. ) . initially, amputation of the filiform urethral appendage may alleviate the disease since urethral blockage often begins here. as the disease progresses, urethral blockage in the sigmoid flexure as well as throughout the urethra may occur. in more advanced stages, perineal urethrostomy may yield good results. the prognosis is poor when the condition becomes chronic, reoccurs, or surgery is required. research complications. young castrated and intact male ruminants used in the laboratory setting will be the susceptible age group for this disorder. rickets is a disease of young, growing animals but rarely occurs in goats. it is a metabolic disease characterized by a failure of bone matrix mineralization at the epiphysis of long bones due to lack of phosphorus. the condition can occur as an absolute deficiency in vitamin d , an inadequate dietary supply of phosphorus, or a long-term dietary imbalance of calcium and phosphorus. the syndrome must be differentiated from epiphisitis (unequal growth of the epiphyses of long bones in young, rapidly growing kids fed diets with excess calcium). clinical signs include poor growth, enlarged costochondral junctions, narrow chests, painful joints, and reluctance to move. spontaneous fractures of long bones may occur. animals will recover when dietary phosphorus is provided and if joint damage is not severe. a. copper deficiency (enzootic ataxia, swayback) etiology. chronic copper deficiency in pregnant ewes and does may produce a metabolic disorder in their lambs and kids called enzootic ataxia. in goats, this deficiency also causes swayback in the fetuses. clinical signs and diagnosis. this disease results in a progressive hindlimb ataxia and apparent blindness in lambs up to about months of age. additionally, because copper is essential for osteogenesis, hematopoiesis, myelination, and pigmentation of wool and hair, ewes may appear unthrifty, may be anemic, and may have poor, depigmented wool with a decrease in wool crimp. affected kids are born weak, tremble, and have a characteristic concavity to the spinal cord, leading to the name swayback. when the deficiency occurs later during gestation, demyelination is limited to the spinal cord and brain stem. kids are born normally but develop a progressive ataxia, leading to paralysis, muscle atrophy, and depressed spinal reflexes with lower motor neuron signs. diagnosis is based on low copper levels found in feedstuffs and tissues at necropsy. diagnosis is based on clinical signs, feed analysis, and pathological findings. epizootiology and transmission. enzootic ataxia is rarely seen in western states; most north american diets have sufficient copper levels to prevent this disease. copper antagonists in the feed or forage at sufficient levels, such as molybdenum, sulfate, and cadmium, however, may predispose to copper deficiencies. pathogenesis. the maternal copper deficiency leads to a disturbance early in the embryonic development of myelination in the central nervous system and the spinal cord. copper is part of the cytochrome oxidase system and other enzyme complexes and is important in myelination, osteogenesis, hematopoiesis (iron absorption and hemoglobin formation), immune system development, and maintenance and normal growth (smith and sherman, ) . differential diagnosis. the differential diagnosis for newborns includes [ -mannosidosis, hypoglycemia, and hypothermia. for older animals the differential should include caprine arthritis encephalitis (goats), enzootic muscular dystrophy, listeriosis, spinal trauma or abscessation, and cerebrospinal nematodiasis. prevention and control. copper deficiency can be prevented by providing balanced nutrition for pregnant animals. necropsy findings. gross encephalomalacia has been noted. histopathologically, white matter of the brain and spinal cord displays gelatinization and cavitation. extensive nerve demyelination and necrosis are evident. postmortem lesions include extensive demyelination and neuronal degeneration. treatment. because the condition is developmental, supplemental copper may improve clinical signs but not eliminate them. necropsy findings. common findings at necropsy include icterus; a soft, dark, friable, enlarged spleen; an enlarged, yellow-brown friable liver; and "gun-barrel" black kidneys. hemoglobin-stained urine will be visible in the bladder. copper accumulations in the liver reaching - ppm are toxic. pathogenesis. hemolysis occurs when sufficient amounts of copper are ingested or released suddenly from the liver and is believed to be due direct interaction of the copper with red-cell surface molecules. stresses such as transportation, lactation, and poor nutrition or exercise may precipitate the hemolysis. etiology: acute or chronic copper ingestion or liver injury often causes a severe, acute hemolytic anemia in weanling to adult sheep and in calves and adult dairy cattle. growing lambs may be the most susceptible. copper toxicosis is rare in goats. differential diagnosis. other causes of hemolytic disease include babesiosis, trypanosomiasis, and plant poisonings such as kale. arsenic ingestion, organophosphate toxicity, and cyanide or nitrate poisoning should also be considered as the source of poisoning. urethral obstruction and gastrointestinal emergencies should be considered for the abdominal pain. clinical signs and diagnosis. the clinical course in sheep can be as short as - days, and mortality may reach %. hemolysis, anemia, hemoglobinuria, and icterus characterize the acute hemolytic crisis, associated with copper released from the overloaded liver. some clinical signs are related to direct irritation to the gastrointestinal tract mucosa. weakness, vomiting, abdominal pain, bruxism, diarrhea, respiratory difficulty, and circulatory collapse are followed by recumbency and death. hepatic biopsy is currently considered the best diagnostic approach; serum or plasma levels of copper and hepatic enzymes such as aspartate aminotransferase (ast) and y-glutamyltransferase (ggt) may provide some information, but it is generally believed that these will not accurately reflect total copper load or hepatic damage. and goats is the range of - mg/kg, and for cattle it is - mg/kg. chronic poisoning in sheep may occur when . mg/kg is ingested. copper-containing pesticides, soil additives, therapeutics, and improperly formulated feeds may potentially lead to copper toxicity. phytogenous sources include certain pastures such as subterranean clover. feed low in molybdenum, zinc, or calcium may lead to increased uptake of copper from properly balanced rations. a common cause of the disease in sheep is feeding concentrates balanced for cattle; cattle feeds and mineral blocks contain much higher quantities of copper than are required for sheep. chronic ingestion of these feedstuffs leads to copper accumulation and toxicity. copper toxicosis has been reported in calves given regular oral or parenteral copper supplements, and in adult dairy cattle given copper supplements to compensate for copper-deficient pasture. pregnant dairy cattle may be more susceptible to copper toxicity. rare sources of copper ingestion may include copper sulfate footbaths. control and prevention. the disease is prevented by carefully monitoring copper access in sheep and copper supplementation in cattle. sheep and goats should not be fed feedstuffs formulated for cattle, and dairy calf milk replacer should not be used for lambs and kids. molybdenum may be administered to animals considered at high risk. molybdenum-deficient pastures may be treated with molybdenum superphosphate. herd copper supplementation should be undertaken with the knowledge of existing hepatic copper levels, and existing copper and molybdenum levels, in the feedstuffs. treatment. oral treatment for sheep consists of ammonium or sodium molybdenate ( - mg/day), and sodium thiosulfate ( . - . mg/day) for weeks aids in excretion of copper. oral d-penicillamine daily for days ( mg/kg) has also been shown to increase copper excretion in sheep. ammonium molybdenate has been administered intravenously to goats at . mg/kg for treatments on alternate days. cattle have been treated orally with sodium molybdenate ( gm/day) or sodium thiosulfate ( gm/day). treatment for anemia and nephrosis may be necessary in severe cases. merino crosses and the british breeds, may be more susceptible to copper toxicosis caused by phytogenous sources. (nutritional muscular dystrophy, nutritional myodegeneration, white muscle disease, stiff lamb disease) etiology. white muscle disease, also known as stiff lamb disease, is a nutritional muscular dystrophy caused by a deficiency of selenium or vitamin e. clinical signs and diagnosis. clinically two forms of the disease have been identified: cardiac and skeletal. the cardiac form occurs most commonly in neonates. in these, respiratory difficulty will be a manifestation of damage to cardiac, diaphragmatic, and intercostal muscles. young will be able to nurse when assisted. in slightly older animals, the disease is characterized by locomotor disturbances and/or circulatory failure. clinically, animals may display paresis, stiffness or inability to stand, rapid but weak pulse, and acute death. mortality may reach % (jensen and swift, ) . paresis and sudden death in neonates with associated pathological signs are frequently diagnostic. with the skeletal form, affected animals are stiff and reluctant to move, and muscles of affected animals are painful. young will be reluctant to get up but will readily nurse when assisted. peracute to acute myocardial degeneration may occur in the cardiac form, and animals may simply be found dead. serum selenium levels are usually below ppb (normal is - ppb) (nelson, ) . diagnosis may also include determination of antemortem whole blood levels of selenium and plasma levels of vitamin e. glutathione peroxidase levels in red blood cells can be measured as an indirect test. clinical biochemistry findings of significant elevations of aspartate aminotransferase (ast) in creatinine kinase (ck) are also supportive of the diagnosis. epizootiology and transmission. selenium deficiency has been associated with formulated diets deficient in selenium, forages grown on selenium-deficient soils in certain geographic regions, and forages such as alfalfa and clover that have an inability to efficiently extract available selenium from the soils. rumen bacterial reduction of selenium compounds to unavailable elemental selenium may also contribute to the disease. necropsy findings. necropsy lesions include petechial hemorrhages and muscle edema. hallmarks are pale white streaking of affected skeletal and cardiac muscle. these are due to coagulation necrosis. pale striated muscles of the limb, diaphragm, and tongue are also seen. antioxidants that protect lipid membranes from oxidative destruction. selenium is a cofactor for glutathione peroxidase, which converts hydrogen peroxide to water and other nontoxic compounds. lack of one or both results in loss of membrane integrity. differential diagnosis. in neonatal ruminants presenting with respiratory and cardiac dysfunction, differentials include congenital cardiac anomalies. differentials generally for weak neonates or sudden or peracute neonatal deaths should include septicemia, pneumonia, toxicity, diarrhea, and dehydration. prevention and control. awareness of regional selenium deficiencies is important. control involves providing good-quality roughage, vitamin e and selenium supplementation, and parenteral injections prior to parturition and weaning. treatment. affected animals may be treated by administering vitamin e or selenium injections. administering vitamin e or selenium to ewes in late pregnancy can prevent white muscle disease (kott et al., ) . the label dose for selenium is . - mg/ kg of body weight. combination products are available and can be used in goats at the sheep dose (smith and sherman, ) . proper mineral balance in the diet is critical. selenium toxicity occurs most frequently as the result of excessive dosing to prevent or correct selenium deficiency or as the result of ingestion of selenium-converting plants. the main preventive measure for the former is the use of the appropriate product for the species. secondarily, the concentration of the available product should be double-checked. in the united states, ruminants in the midwest and western areas may be subject to selenium toxicity when pastured in areas containing selenium-converting plants. signs of overdosing include weakness, dyspnea, bloating, and diarrhea. shock, paresis, and death may occur. initial clinical signs of excessive selenium intake from plants are observed in the distal limb, with cracked hoof walls and subsequent infection and irregular hoof growth. etiology. polioencephalomalacia (pem) is a noninfectious, noncontagious disease characterized by neurological signs. growing and adult ruminants on high-concentrate diets are typically affected. animals exposed to toxic plants or moldy feed containing thiaminases, feed high in sulfates, or unusually high doses of some medications are also at risk. clinical signs and diagnosis. an early sign may be mild diarrhea. acute clinical signs include bruxism, hyperesthesia, involuntary muscle contractions, depression, partial or complete opisthotonus, nystagmus, dorsomedial strabismus, seizures, and death. in subacute cases of the disease, animals may appear to walk aimlessly as if blind or may display head-pressing postures. hypersalivation may be present, but body temperatures and ocular reflexes are normal. morbidity and mortality may be high, especially in younger animals. diagnosis is suggestive from clinical signs and from response to intensive parental thiamine hydrochloride. epizootiology and transmission. pem is caused by a thiamin deficiency. the disease tends to be seen more frequently in cattle and sheep feedlots where the concentrates fed are high in fermentable carbohydrates. pastured animals are also vulnerable if grain is feed. thiaminase-containing plants, such as bracken fern, are often unpalatable so will less likely be a contributing factor. recent studies have also indicated that high levels of sulfate in the diet, such as in the fermentable, low-fiber concentrates, may play an important role. medications such as as amprolium, levamisole, and thiabendazole have thiaminantagonizing activity when given in excessive doses. sherman, ) . vitamin a deficiencies associated with hyperkeratosis have been reported, as well as vitamin e-responsive and selenium-responsive dermatitis. necropsy signs. cerebral lesions characterized by softening and discoloration are grossly observed in the gray matter. microscopically, neurons will exhibit edema, chromatolysis, and shrinkage. gliosis and cerebral capillary proliferation may be observed. a lack of thiamin results in inappropriate carbohydrate metabolism and accumulation of pyruvate and other intermediaries that lead to cerebral edema and neuronal degeneration. differential diagnosis. several important differentials include acute lead poisoning, nitrofuran toxicity, hypomagnesemia, vitamin a deficiency, listeriosis, pregnancy toxemia, infectious thromboembolic meningoencephalitis, and type d clostridial enterotoxemia. prevention and control. the disease can be prevented by monitoring the diet and by providing adequate roughage necessary to prevent overgrowth of thiaminase-producing ruminal flora and to maximize ruminal production of b vitamins. if excess sulfur is the primary factor, immediate removal of the source is critical. neonatal ruminants are born without immunoglobulins and must receive colostrum by hr after birth. the morbidity and mortality associated with failure of or inadequate passive transfer, such as enteric and respiratory illnesses, can be severe. measures to assure passive immunity for neonatal ruminants are covered in section ii,b, , and clinical signs of illness associated with lack of immunity are addressed in the discussions of bacterial diseases (e.g., escherichia coli infections) and, of viral diseases (e.g., diarrheas) in section iii,a, and iii,a, . generally, transfer of less than mg/dl of immunoglobulins in the serum is classified as failure of transfer, - mg/dl is partial, and above mg/dl is complete transfer. methods to determine success of transfer should be performed within a week of birth and include single radial immunodiffusion (quantitates immunogloblin classes); zinc sulfate turbidity (semiquantitative); sodium sulfite precipitation (semiquantitative); glutaraldehyde coagulation (coagulates above specific level); and, y-glutamyltransferase (assays enzyme in high concentration in colostrum and absorbed simultaneously with colostrum). treatment. early aggressive treatment is essential to save animals. the disease is treated by frequent parenteral administration of thiamine hydrochloride, the first dose being administered intravenously. dexamethasone, b vitamins, and diazepam may also be required. treatment is less successful when sulfur plays a prominent role in the etiology. research complications. this disease is preventable. although the disease is less likely to occur in smaller groups of confined ruminants, the risks of feeding concentrates or moldy feed, for example, with minimal good-quality roughage, should be kept in mind. vitamin d toxicity can result either from iatrogenic overadministration or ingestion of the plant trisetum flavescens. serum calcium levels may be high enough that blood in edta tubes will clot. laminitis is common in ruminants and can be caused by sudden changes in diet, excess dietary energy, and grain overload (or overeating). laminitis is also associated with mastitis and metritis. facility conditions, such as concrete flooring, poor manure management, and inadequate resting areas may also contribute to the pathogenesis of the disease. the complete pathogenesis of laminitis is poorly understood; however, it is thought that changes in the diet cause changes in rumen microbial populations, resulting in acidosis and endotoxemia. dramatic changes in the vascular endothelium result in chronic inflammation of the sensitive laminae of the hoof, separation of corium and hoof wall, and rotation of the third phalanx. affected animals may be reluctant to get up or walk, will shift their weight frequently, and will grind teeth or walk on carpi. chronically, the hoof wall takes on a "slipper" appearance. treatment consists of identifying the underlying cause, administering antiinflammatories (phenylbutazone, flunixin meglumin), feeding good-quality forages only, and regular foot trimming. in goats, nutritional deficiencies often manifest as a generalized poor coat that is dry, scaly, thin, and erectile. zincresponsive dermatitis has been reported in goats (smith and otherwise normal, well-managed lambs, kids, and calves can develop loose, pasty feces due to a nutritional imbalance caused by overfeeding and/or improper mixing of milk replacers. only milk replacer formulated for the particular species should be used. once nutritional imbalances are corrected, the feces readily return to normal. sudden changes in diet can also result in loose feces. photosensitization is an acute dermatitis associated with an interaction between photosensitive chemicals and sunlight. the photosensitive chemicals are usually ingested, but in some cases exposure may be by contact. animals with a lack of pigment are more susceptible to the disease. three types of photosensitization occur: primary; secondary, or hepatogenous; and aberrant. primary photosensitization is related to uncommon plant pigments or to drugs such as phenothiazine, sulfonamides, or tetracyclines. secondary photosensitization is more common in large animals and is specifically related to the plant pigment phylloerythrin. phylloerythrin, a porphyrin compound, is a degradation product of chlorophyll released by rumen microbial digestion. liver disease or injury, which prevents normal conjugation of phylloerythrin and excretion through the biliary system, predisposes to photosensitization. the only example of aberrant photosensitization is congenital porphyria of cattle (see section iii,b, ). pathologically, the photosensitive chemical is deposited in the skin and is activated by absorbed sunlight. the activated pigments transfer their energy to local proteins and amino acids, which, in the presence of oxygen, are converted to vasoactive substances. the vasoactive substances increase the permeability of capillaries, leading to fluid and plasma protein losses and eventually to local tissue necrosis. photosensitization can occur within hours to days after sun exposure and produces lesions of the face, vulva, and coronary bands; lesions are most likely to occur on white-haired areas. initially, edema of the lips, corneas, eyelids, nasal planum, face, vulva, or coronary bands occurs. the facial edema, nostril constriction, and swollen lips potentially lead to difficulty in breathing. with secondary photosensitization, icterus is also common. necrosis and gangrene may occur. diagnosis is based on clinical lesions and exposure to the photosensitive chemi-cals and sunlight. treatment is symptomatic. the prognosis for hepatogenous type may be guarded if hepatic disease is severe. from excessive straining associated with dysuria from the pressure of the fetuses and/or abdominal contents on the bladder. if the prolapse obstructs subsequent urination, rupture of the bladder may occur. the vaginal prolapse can be reduced and repaired if discovered early, and techniques in small and large ruminants are comparable. the animal should be restrained, and the prolapsed tissue should be cleansed with disinfectants. best done under epidural anesthesia, the vagina is replaced into the pelvic canal and the vulvar or vestibular opening is sutured closed (buhner suture). alternatively, a commercial device called a bearing retainer (or truss) can be placed into the reduced vagina and tied to the wool, thereby holding the vagina in proper orientation without interfering with subsequent lambing. vaginal prolapses may have a hereditary basis in ewes and cows and may prolapse the following year. these animals should be culled. vaginal prolapses may occur in nonpregnant animals that graze estrogenic plants or as a sequela to docking the tail too close to the body (ross, ) . uterine prolapses occur sporadically in postpartum ewes and cattle. the gravid horn invaginates after delivery and protrudes from the vulva. the cause is unknown, but excessive traction utilized to correct dystocia or retained placenta, uterine atony, hypocalcemia, and overconditioning or lack of exercise have been implicated. in cattle, the uterine prolapses usually develop within week of calving, are more common in dairy cows than in beef cows, and are often associated with dystocia or hypocalcemia. cows may also have concurrent parturient paresis. initially, the tissue will appear normal, but edema and environmental contamination or injuries of the tissue develop quickly. clinical signs will include increased pulse and respiratory rates, straining, restlessness, and anorexia. if identified early, the uterus can be replaced as for vaginal prolapses. electrolyte imbalances should be corrected if present. additional supportive therapy, including the use of antibiotics should always be considered. tetanus prophylaxis should be included. oxytocin should be administered to induce uterine reduction. vaginal closures are less successful at retaining uterine prolapses. preventive and control measures include regular exercise for breeding animals, and management of prepartum nutrition and body condition. vaginal and uterine prolapses occur in ewes, does, and cows. the conditions are not common in does. vaginal prolapses usually occur during late gestation and may be related to relaxation of the pelvic ligaments in response to hormone levels. in sheep, these are most common in overconditioned ewes that are also carrying twins or triplets. overconsumption of roughages, which distends the rumen, and lack of exercise leading to intraabdominal fat may predispose an animal to vaginal prolapse by increasing intra-abdominal pressure. the condition may result f rectal prolapse rectal prolapse is common in growing, weaned lambs and in cattle from months to years old. the physical eversion of the rectum through the anal sphincter is usually secondary to other diseases or management-related circumstances. rectal prolapses may occur secondary to gastrointestinal infection or inflammation, especially when the colon is involved. diseases that cause tenesmus, such as coccidiosis, salmonellosis, and intestinal worms, may result in prolapse. urolithiasis may result in prolapses as the animal strains to urinate. any form of cystitis or urethritis, vaginal irritation, or vaginal prolapse and some forms of hepatic disease may lead to rectal prolapse. abdominal enlargement related to advanced stages of pregnancy, excessive rumen filling or bloat, and overconditioning may cause prolapse. finally, excessive coughing during respiratory tract infections, improper tail docking (too short), growth implants, prolonged recumbency, or overcrowded housing with animal piling may lead to prolapses. diagnosis is based on clinical signs. early prolapses may be corrected by holding the animal with the head down, while a colleague places a pursestring suture around the anus. the mucosa and underlying tissue of prolapses that have been present for longer periods of time will often become necrotic, dry, friable, and devitalized and will require surgical amputation or the placement of prolapse rings to remove the tissue. rectal prolapse may also be accompanied by intestinal intussusceptions that will further complicate the treatment and increase mortality. occasionally, acute rectal prolapse with evisceration will result in shock and prompt death of the animal. prognosis depends on the cause and extent of the prolapse as well as the timeliness of intervention. in all cases of treatment, determination and elimination of the underlying cause are essential. gastrointestinal accumulations or obstructions of hair (and/ or sometimes very coarse roughage, forming bezoars) occur in cattle and sheep. cattle that are maintained on a low-roughage diet, that lick their coats frequently, that have long hair coats from outdoor housing, or that have heavy lice or mite infestations and associated pruritus will often develop bezoars. in addition, younger calves with abomasal ulcers have been found to be more likely to have abomasal tric. hobezoars as well. clinical signs may be mild or severe according to size, number, and location. ruminal trichobezoars rarely result in clinical signs. obstruction will be accompanied by signs of pain, development of bloat, and decreased fecal production. serum profiles will show hypochloridemia; other imbalances depend on the duration of the problem. diagnosis is also based on abdominal auscultation, rectal palpation, and ultrasound (useful in calves and smaller ruminants). treatment is surgical, such as paracostal laparotomy (for abomasal), paralumbar celiotomy with manual breakdown, or enterotomy. supportive care should be administered as necessary to correct electrolyte imbalances and to prevent inflammation and sepsis. prognosis is generally good if the condition is diagnosed and treated before dehydration and imbalances become severe and peritonitis develops. prevention includes providing good-quality roughage and treating lice and mange infestations. wounds may be sustained from poorly constructed pens or fences, or from skirmishes among animals. predators will usu-ally be sources of bite wounds. standard veterinary wound assessment and care are essential for wounds or bites. tetanus antitoxin may be indicated. use of approved antibiotics may be appropriate. the lesion should be cleaned with disinfectants and repaired with primary closure if it is clean and uncontaminated. thorough cleaning, regular monitoring, and healing by second intention are recommended for older wounds. abscesses may also occur in the soft tissues of the hooves (sole abscesses; see section iii,c, ) because of entrapped foreign bodies or hoof cracks that fill with dirt. preventive measures include improvement of housing facilities, pens, and pastures; monitoring hierarchies among animals penned together; and implementing predator control measures, such as sound fencing, flock guard dogs, or donkeys, in pasture situations. acute anaphylatic reactions in sheep, goats, and cattle are often clinically referable to the respiratory system. anaphylactic vaccine reactions cause acute lung edema; lungs are the primary site of lesions if collapse and death are sequelae. the animals will also be anxious and shivering and will become hyperthermic. salivation, diarrhea, and bloat also occur. immediate therapy must include epinephrine by intravenous infusion at ( ml of : per kg of body weight for goats and : , ( . mg/ml) or . mg/kg (about ml) for adult cows.) furosemide ( mg/kg) may be beneficial to reduce edema. prognosis is usually guarded. recovery can occur within hr. in a research environment, catheter sites or experimental surgeries may be sources of iatrogenic infection. traumatic injuries to peripheral nerves can cause acute lameness. improper administration of therapeutics can easily cause this type of lameness. injections given in gluteals or between the semimembranosus and semitendinosus can cause irritation to the sciatic nerve and subsequent lameness. contraction of the quadriceps results in the limb being pulled forward. injections in the caudal thigh can damage the peroneal nerve and cause knuckling at the fetlock. traumatic injury to the radial nerve can result in a "dropped elbow" (nelson, ) . husbandry procedures such as tail docking, castration, dehorning, dosing with a bailing gun, and shearing may result in superficial lesions, dermal infections, or cases of tetanus. bailing-gun injuries to the pharynx may lead to cellulitis with coughing, decreased appetite, and sensitivity to palpation. standard veterinary assessment and care are essential for these cases. local and systemic antibiotics with supportive care may be indicated. swelling around peripheral nerves caused by inoculations may be reduced by diuretics and anti-inflammato-ries. mild cases of peripheral nerve damage may recover in - days. personnel training, including review of relevant anatomy, preprocedure preparation, appropriate technique, careful surgical site preparation, rigorous instrument sanitation, and sterile technique will minimize the incidence of potential complications from surgical procedures. albumin values and foaming urine. the proteinuria also distinguishes amyloidosis (and glomerulonephritis) from other causes of weight loss and diarrhea in cattle such as johne's disease, parasitism, copper deficiency, salmonellosis, and bovine viral diarrhea virus infection. prognosis is poor, and no treatment is reported. neoplasia and tumors are relatively rare in ruminants. lymphosarcoma/leukemia in sheep has been shown to result from infection by a virus related (or identical) to the bovine leukemia virus. pulmonary carcinoma (pulmonary adenomatosis) and hepatic tumors are found in sheep. virus-induced papillomatosis (warts), discussed in section iii,a, ,s, and squamous cell carcinomas have also been reported in sheep. in goats, thymoma is one of the two most common neoplasias reported, although no distinct clinical syndrome has been described. cutaneous papillomas are the most common skin and udder tumor of goats, and although outbreaks involve multiple animals, no wart virus has been identified. persistent udder papillomas may progress to squamous cell carcinoma. lymphosarcoma is reported rarely in goats. although adrenocortical adenomas have been reported frequently and almost exclusively in older wethers, no clinical condition has been described. lymphosarcoma of various organ systems and "cancer eye" (bovine ocular squamous cell carcinoma, or oscc) are the most commonly reported cancers in cattle. lymphosarcoma is described in section iii,a, ,c. lack of periocular pigmentation and the amount and intensity of exposure to solar ultraviolet light are considered important factors in oscc. genetic factors may also play a role. many cases occur in herefords. this is a disease of older cattle; no case has been reported in animals less than years of age. the cancer metastasizes through the lymph system to major organs. treatment in either lymphosarcoma or oscc is recommended only as a palliative measure. the extent of ocular neoplastic involvement is a significant criterion for carcass condemnation. papillomatosis (warts) are common in cattle (see section iii,a, ,s). dental wear is seen most commonly in sheep. as sheep age, excessive dental wear may lead to an inability to properly masticate feed, manifesting as weight loss and unthriftiness. several factors predisposing to dental wear should be considered. the diet should be properly balanced for minerals, especially calcium and phosphorus, because primary or secondary calcium deficiency during teeth development results in softening of the enamel and dentin. dietary contamination with silica (i.e., hays and grains harvested in sandy regions) will lead to mechanical wear on the teeth. likewise, animals grazing or being fed in sandy environments will have excessive tooth wear. sheep older than about years of age are especially prone to tooth wear and should be checked frequently, especially if signs of weight loss or malnutrition are evident. managing the content and consistency of the diets can best prevent the disease. of the ruminants, cows are the most frequently affected by subsolar absesses. dirt becomes packed into cracks in the horny layer of the sole of the hoof, and contamination eventually extends into the sensitive areas of the hoof, with lameness and infection resulting. animals maintained in very soiled or muddy conditions, combined with poor hoof care, are more likely affected. fusobacterium necrophorum is often the pathogen involved. separation of the animal, supportive care, surgical drainage, and antibiotic treatment are indicated. amyloidosis amyloidosis in adult cattle is due to accumulations of amyloid protein in the kidney, liver, adrenal glands, and gastrointestinal tract. the disease has been classified as aa type, or associated with chronic inflammatory disease, although other unknown factors are believed to be involved in some cases. clinical signs include chronic diarrhea, weight loss, decreased production, nonpainful renomegaly, and generalized edema. the loss of protein in the urine contributes to abnormal plasma advances in sheep and goat medicine animals and animal products, subchapter a, animal welfare formulary for laboratory animals domestic animal behavior for veterinarians and animal scientists schlam's veterinary hematology diseases of sheep animal feeding and nutrition guide for the care and use of laboratory animals veterinary drug handbook veterinary medicine: a textbook of the diseases of cattle, sheep, pigs, goats, and horses sheep production and management animal and plant health inspection service (aphis), policy # , farm animals used for nonagricultural purposes goats the clinical syndromes caused by salmonella infection armed forces institute of pathology (afip) ( ) the effect of stress on the carrier state of salmonella typhimurium in goats bibliography of naturally occurring models of human disease clinical signs, treatment, and postmortem lesions in dairy goats with enterotoxemia: cases control of the estrous cycle the goat industry: feeding for optimal production neurologic disease in sheep and goats modern breeds of livestock the sheep gene map pasteurella haemolytica complicated respiratory infections in sheep and goats ungulates as laboratory animals diagnosis of lameness in sheep an overview of the influence of ace inhibitors on fetalplacental circulation and perinatal development protozoan infections (toxoplasma gondii, neospora caninum, and sarcocystis spp.) in sheep and goats: recent advances cloned transgenic calves produced from nonquiescent fibroblasts transgenic bovine chimeric offspring produced from somatic cell-derived stem-like cells use of an animal model of trichomoniasis as a basis for understanding this disease in women council report: vaccination guidelines for small ruminants (sheep, goats, llamas, domestic deer, and wapiti) ( ) maedi-visna and ovine progressive pneumonia pathophysiology of oestrus ovis infection in sheep and goats: a review experimental surgery in farm animals evaluation of an agar gel immunodiffusion test kit for detection of antibodies to mycobacterium paratuberculosis in sheep veterinary laboratory medicine induction of human tissue plasminogen activator in the mammary gland of transgenic goats pasteurella haemolytica infections in sheep coccidiosis and cryptosporidiosis in sheep and goats the major histocompatibility complex region of domestic animal species brucella melitensis infection in sheep: present and future hemoglobin switching epididymitis in rams current veterinary therapy: food animal practice livestock handling guide: management practices that reduce livestock bruises and injuries, and improve handling efficiency. livestock conservation institute synchronization of oestrus in the boer goat doe: dose effect of prostaglandin in the double injection scheme. south afr guide to the dissection of domestic ruminants reproduction in farm animals review of polyclonal antibody production procedures in mammal and poultry considerations in the design and construction of facilities for farm species clinical update: leptospirosis the sheep as an experimental animal bibliography oflnduced animal models of human disease bibliography of naturally occurring models of human disease postpartum assessment and care of the newborn ruminant animal genetics guide for the care and use of laboratory animals blackleg: a new perspective on an old disease protecting calves from viral diarrhea bovine leukemia virus. part : descriptive epidemiology, clinical manifestations, and diagnostic tests bovine leukemia virus. part : risk factors of transmission bovine leukemia virus. part : zoonotic potential, molecular epidemiology, and an animal model. in "infectious disease in food animal practice bovine leukemia virus. part : economic impact and control measures brucella abortus strain rb vaccine: its advantages and risks current veterinary therapy: food animal practice neural control of maternal behavior and olfactory recognition of offspring comparison of the burdizzo and rubber ring methods for castrating and tail docking lambs postpartum care of the cow and calf advances in the control of foot rot in sheep mastitis in ewes giardiasis in large animals laboratory diagnostic tests for retrovirus infections of small ruminants effects of dietary vitamin e supplementation during late pregnancy on lamb mortality and ewe productivity myotonia congenita (thomsen) and recessive myotonia genetic and environmental causes of variation in mastitis in sheep the gnrh system of seasonal breeders: anatomy and plasticity genetic organization, polymorphism, and function of the bovine major histocampaticulity complex scrapie in sheep biochemical and morphological expression of early prenatal caprine beta-mannosidosis respiratory infections of sheep dogs are the definitive hosts of neospora caninum a century of classical contagious caprine pleuropneumonia from original description to aetiology sheep and goat practice gene manipulation in goats through biotechnology minimizing morbidity and mortality from cryptosporidiosis managing dairy cows during the transition period: focus on ketosis environmental enrichment for dairy calves and pigs the trypanocidal cape buffalo serum protein is xanthine oxidase oral rehydration therapy for diarrheic calves neonatal ruminant diarrhea techniques for artificial insemination of cattle with frozenthawed semen noninfectious causes of lameness neosporosis: its prevalence and economic impact a review of yersinosis (yersinia pseudotuberculosis infection) dairy goat reproduction maedivisna virus in sheep: a review evaluation of a commercially available vaccine against corynebacterium pseudotuberculosis for use in sheep ruminant production management: control programs for gastrointestinal nematodes in sheep and goats fetal brain injury following prolonged hypoxemia and placental insufficiency: a review managing cryptosporidium and giardia infections in domestic ruminants milk fever: seeking new solutions to an old problem recent advances on ovine chlamydial abortion risk factors for abomasal displacement in dairy cows the spider syndrome: a report on one purebred flock development of ingestive behavior current state of in vivo preclinical heart valve evaluation dermatophilus congolensis infections in cattle and sheep ovine listeric encephalitis coccidiosis in ruminants principles of dairy science human factor ix transgenic sheep produced by transfer of nuclei from transfected fetal fibroblasts the major histocompatibility complex region of domestic animal species clinical reproductive anatomy and physiology of the doe immunobiology of the mammary gland coccidiosis brucella abortus strain rb : a new brucellosis vaccine for cattle use of age and serum gamma-glutamyltransferase activity to assess passive transfer status in lambs effect of congenitally acquired neospora caninum infection on risk of abortion and subsequent abortions in dairy cattle artificial control of breeding in ewes toxoplasmosis infection in sheep bovine reproductive biotechnology transgenic dairy cattle. genetic engineering on a large scale the effect of intra-mammary inoculation of lactating ewes with pasteurella haemolytica isolates from different sources bovine surgery and lameness reduction of myocardial myoglobin in bovine dilated cardiomyopathy intraosseous infusion of prostaglandin e prevents disuse-induced bone loss in the tibia estrous cycle synchronization the bronchopneumonias (respiratory disease complex of cattle, sheep, and goats) the cattle gene map treatment and control of gastrointestinal nematodes in sheep diagnosis, treatment, and management of enteric colibacillosis key: cord- -s hdhh authors: zeimet, anthony; mcbride, david r.; basilan, richard; roland, william e.; mccrary, david; hoonmo, koo title: infectious diseases date: - - journal: textbook of family medicine doi: . /b - - - - . - sha: doc_id: cord_uid: s hdhh nan infections of the upper respiratory tract accounted for more than million ambulatory medical visits in , according to the national ambulatory medical care survey (cherry et al., ) . although a large percentage of these infections are viral in origin, antibiotics are still prescribed for more than % of patients with acute respiratory tract infection (arti). acute bronchitis, in the arti category, is defined as a respiratory infection in which cough is the predominant symptom and there is no evidence of pneumonia. antibiotics are often prescribed despite limited evidence that they shorten the duration of acute bronchitis. with increasing incidence of antibiotic resistance, bronchitis allows physicians to practice "prescriptive restraint" and to provide supportive therapy. consider using the phrase "chest cold" to help patients understand the viral and benign nature of this infection. chronic bronchitis is one of the manifestations of chronic obstructive pulmonary disease (copd) and is defined clinically as cough and sputum production on most days for months annually for years. chronic bronchitis is thought to be primarily inflammatory in origin, although infection may be associated with acute exacerbations; with increased sputum production and worsening dyspnea, antibiotics have proved effective in acute episodes. however, systemic corticosteroids are the mainstay of copd exacerbation management. the patient with acute bronchitis presents with cough, often productive. patients may report clear or colored mucus in association with the presumed diagnosis of acute bronchitis. despite what many patients believe, the color of sputum, even purulent sputum, is not predictive of bacterial infection. the cough of bronchitis can last up to weeks, sometimes even longer. typically, acute bronchitis is associated with other manifestations of infection, such as malaise and fever. respiratory viruses are thought to cause the majority of cases of acute bronchitis. influenza a and b, parainfluenza, respiratory syncytial virus (rsv), coronavirus, adenovirus, and rhinovirus are common pathogens in the viral category. clues to a specific virus may be found in the patient history; for example, rsv might be considered when there is household exposure to infected children. influenza typically presents with sudden onset of symptoms, including fever, myalgias, cough, and sore throat. neuraminidase inhibitors are modestly effective in shortening the duration of influenza in ambulatory and healthy patients (by about day), if initiated in the first hours of illness. the resistance patterns of influenza a and b have shifted in the last several years and may vary based on yearly viral strains. influenza b has remained, as of , sensitive to zanamivir (relenza) and oseltamivir (tamiflu). currently circulating strains of influenza a, both h n and h n , and influenza b have generally remained sensitive to both oseltamivir and zanamivir (fiore et al., ) . family physicians are advised to consider restraint in the prescribing of these agents, since resistance is of great concern. yearly influenza immunization and cough etiquette and hygiene are likely the most useful techniques for influenza management. studies have identified other pathogens, such as mycoplasma pneumoniae and chlamydophila pneumoniae, in a small minority of cases of clinical acute upper respiratory illness with cough as the predominant symptom. no significant benefit has been found in treating these infections with antibiotics. an exception in the treatment of acute bronchitis-like illness with antibiotics is when confirmed or probable bordetella pertussis is present. early treatment with a macrolide antibiotic and patient isolation will likely decrease coughing paroxysms and limit spread of disease (braman, ) . although common upper respiratory bacterial pathogens, such as moraxella (branhamella) catarrhalis, streptococcus pneumoniae, and haemophilus influenzae, may be isolated from patients with acute bronchitis, their relevance is questionable because these bacteria can be present in the respiratory tract of healthy individuals. obtaining sputum for culture when bronchitis is the diagnosis generally is not useful. antibiotics may offer a modest benefit in the treatment of acute bronchitis, with many studies showing no statistical significance in the outcome of treated versus not-treated groups. measures of function, such as duration of illness, loss of work, and limitation of activity, have not shown clinically significant improvement in those with acute bronchitis taking antibiotics. coupled with cost and the potential for side effects, the use of antibiotics for acute bronchitis is not recommended. if a provider decides to use an antibiotic in a specific patient situation, narrow-spectrum respiratory agents are preferred, such as a first-generation macrolide or doxycycline. treating the symptom of cough in acute bronchitis is an important concern for patients. in adults with acute bronchitis with signs of airway obstruction, evidenced by wheezing on examination or decreased peak expiratory flow rate, beta- agonists may be helpful in alleviating cough. these agents are not helpful for children with acute cough or adults with cough and no evidence of airway obstruction. side effects of tremor and an anxious feeling must be weighed against this benefit. patients often are primarily interested in alleviating symptoms caused by respiratory illness. unfortunately, there is mixed evidence for the use of over-the-counter (otc) and prescription cough medications. dextromethorphan and codeine may be somewhat effective, although they have not been evaluated in randomized, double-blinded, placebo-controlled trials for acute bronchitis. combination first-generation antihistamine-decongestant products may be effective for the cough associated with colds. naproxen showed efficacy against cough in one upper respiratory model study (sperber et al., ) . guaifenesin acts as an expectorant and may have some effect on cough by its mucus-thinning properties. community-acquired pneumonia (cap) is defined as an acute infection of the pulmonary parenchyma and, along with influenza, is the seventh leading cause of death in the united states. fever, cough, sputum production, pleuritic chest pain, and dyspnea are common symptoms of cap. nausea, vomiting, and diarrhea also may occur, and in elderly patients, cap may present with mental status changes. although its absence usually makes pneumonia less likely, fever can be absent in the elderly patient. other physical examination findings include an elevated respiratory rate, conversational dyspnea, tachycardia, and rales. egophony and dullness to percussion may be noted with focal consolidation. typical laboratory findings include leukocytosis. the diagnosis of pneumonia is based on the presence of symptoms and the presence of an infiltrate on chest radiograph. if infiltrate is not present, consider obtaining a chest tomography scan (which has higher sensitivity) to rule in or rule out cap. if negative, other diagnoses should be considered. the most common microbiologic agent of pneumonia is often not isolated (table - ). furthermore, studies have shown that bacteriologic causes of pneumonia cannot be determined by radiographic appearance (i.e., "typical" vs. "atypical"). in the proper clinical setting, certain clinical microbes should be considered because they can affect treatment considerations and epidemiologic studies. these include legionella spp., influenza a and b, and communityacquired methicillin-resistant staphylococcus aureus (mrsa). certain diagnostic tests are performed based on clinical setting. blood cultures are not routinely done in the outpatient setting but should always be done if the patient is being admitted to the hospital, ideally before antibiotics are given. the use of gram stain and sputum culture remains controversial but can provide more evidence of a bacterial cause (e.g., many pmns). if sputum cultures are being obtained, it is recommended that the physician have the patient expectorate directly into a specimen cup and have it sent immediately for processing. this can increase the yield of isolating streptococcus pneumoniae among antibiotics for the treatment of bronchitis is not recommended because of the cost, potential for side effects, and lack of clinical benefit (braman, ; smith et al., ) (sor: a). in the treatment of bordetella pertussis, early administration of a macrolide antibiotic and patient isolation will likely decrease coughing paroxysms and limit spread of disease (braman, ) (sor: a). in adults with acute bronchitis with signs of airway obstruction, as evidenced by wheezing on examination or decreased peak expiratory flow rate, beta- agonists may be helpful in alleviating cough (braman, ) (sor: b). for acute exacerbation of copd associated with purulent sputum and increased shortness of breath, treatment with antibiotics decreases mortality by % and treatment failure by % (ram et al., ) (sor: a). other respiratory pathogens. other tests include urine antigen tests for s. pneumoniae, legionella pneumophila serogroup , and nasal swab for influenza a and b. in young children, rsv, adenovirus, and parainfluenza in addition to influenza are common causes. nasal swab for rsv and influenza can be rapidly done, but the other causes can be determined with viral cultures, serology, enzyme-linked immunosorbent assay (elisa), and polymerase chain reaction (pcr), although results usually are received after resolution of the acute symptoms. perhaps the most important decision for clinicians is to determine the location of treatment. the american thoracic society (ats) and the infectious diseases society of america (idsa) recommend use of the pneumonia severity index (psi), which uses variables to risk-stratify the patient into five mortality classes, or the curb- , which measures five clinical variables in this decision making. the curb- may be the easiest and most convenient to use at the site of decision making. a score of or indicates treatment as an outpatient; a score of requires hospital admission to the general medical ward; and a score of or more indicates admission to an intensive care unit (icu) (box - ). treatment of cap should be targeted toward the most likely etiology (table - ). outpatient therapy for patients who have no comorbidities and have not received antibiotics within the last months includes doxycycline or a macrolide antibiotic. use of a fluoroquinolone antibiotic (levofloxacin or moxifloxacin) should be reserved for patients with more complicated pneumonia and those requiring hospitalization. patients who have comorbid conditions or recent antibiotic exposure, or who will be hospitalized, should receive a respiratory fluoroquinolone or combination therapy with a betalactam drug plus a macrolide, for to hours after fever abates (usually - days' total therapy). if an organism is isolated, therapy may be narrowed to cover the causative agent. the clinician should consider longer therapy and appropriate antibiotics to cover for infection by less common organisms such as staphylococcus aureus or pseudomonas aeruginosa. if the patient has no more than one abnormal value (temperature < . ° c, heart rate < , respiratory rate < , sbp > , o saturation > %, po > on room air) and the patient is able to maintain oral intake and has a normal mental status, the clinician can safely switch to oral therapy and discharge the patient from the hospital. unless the etiology of the pneumonia is known, the physician should switch to oral antibiotics in the same class as the intravenous antibiotics used. the u.s. preventive services task force (uspstf) along with idsa and ats recommend annual influenza vaccinations to those over years of age, those who are (or who reside with those who are) at high risk for influenza complications, and all health care workers. furthermore, the pneumococcal vaccine should be given to all those over age . smoking cessation is also important and should be discussed at each clinic visit. • concerns about development of resistant seasonal and h n swine-derived influenza virus should be considered in the decision to administer antiviral medications to healthy patients with these infections. • the abrupt onset of fever with chills, headache, malaise, myalgias, arthralgias, and rigors during "flu season" is sufficient to diagnose influenza. • prevention of influenza is generally with vaccination. influenza deserves special mention because it is an important cause of pneumonitis and can precede a bacterial pneumonia. influenza viruses are medium-sized enveloped ribonucleic acid (rna) viruses that consist of a lipid bilayer with matrix proteins with spiked surface projections of glycoproteins (hemagglutinins, neuraminidase) on the outer surface ( figure - ) . both influenza a and influenza b have eight segmented pieces of single-stranded rna. the only difference between influenza a and b is that b does not have an m ion channel. hemagglutinins, three types of which typically infect humans (h , h , h ), bind to respiratory epithelial cells and allow fusion with the host cell. neuraminidase, consisting of two types (n , n ), allows release of virus from the infected cells. a unique aspect of influenza is that antigenic variation occurs annually. antigenic shift is caused by a genetic reassortment between animal and human influenza strains, producing a novel virus that generally causes the worldwide pandemics. influenza viruses circulate mostly among humans, birds, and swine. sometimes; a human strain and an animal strain can intermingle and create a new, unique virus. this is what happened during spring , heralding the most recent pandemic and creating "novel h n influenza" (swine influenza). genotype analysis • score or : outpatient treatment • score : inpatient treatment on a general medical floor • score > : inpatient treatment in an intensive care unit bun, blood urea nitrogen. locally adapted guidelines should be implemented to improve the processing of care variables and relevant clinical outcomes in pneumonia (mandell et al., ) (sor: b) . objective criteria or scores should always be supplemented with physician determination of subjective factors, including the patient's ability to take oral medication safely and reliably and the availability of outpatient support resources (sor: b). for patients with curb- score of or higher, more intensive treatment (i.e., hospitalization or, where appropriate and available, intensive in-home health care services) is usually warranted (sor: c). of this strain determined that components came from an influenza virus circulating among swine herds in north america that combined with a virus circulating among ill swine in eurasia, creating a new influenza strain capable of causing disease in humans. because this virus had not previously infected humans, it had the potential to cause widespread morbidity and mortality worldwide. during pandemics, the u.s. centers for disease control and prevention (cdc) estimates an additional , to , deaths caused by influenza. although higher than in nonpandemic years, mortality was significantly less than initially predicted in . no recent antibiotic therapy a respiratory fluoroquinolone alone or an advanced macrolide plus a β-lactam † † an advanced macrolide plus a β-lactam, or a respiratory fluoroquinolone alone (regimen selected will depend on nature of recent antibiotic therapy) intensive care unit (icu) a β-lactam † † plus either an advanced macrolide or a respiratory fluoroquinolone pseudomonas infection is not an issue but patient has a β-lactam allergy a respiratory fluoroquinolone, with or without clindamycin pseudomonas infection is an issue ‡ ‡ (cystic fibrosis, impaired host defenses) either ( ) copd, chronic obstructive pulmonary disease; mrsa, methicillin-resistant staphylococcus aureus. * azithromycin or clarithromycin. † that is, the patient was given a course of antibiotic(s) for treatment of any infection within the past months, excluding the current episode of infection. such treatment is a risk factor for drug-resistant streptococcus pneumoniae and possibly for infection with gram-negative bacilli. depending on the class of antibiotics recently given, one or another of the suggested options may be selected. recent use of a fluoroquinolone should dictate selection of a nonfluoroquinolone regimen, and vice versa. ‡moxifloxacin, levofloxacin, or gemifloxacin. § dosage: g orally (po) three times daily (tid). ¶ dosage: g po twice daily (bid). ** high-dose amoxicillin ( g tid), high-dose amoxicillin-clavulanate ( g bid), cefpodoxime, cefprozil, or cefuroxime. † † cefotaxime, ceftriaxone, ampicillin-sulbactam, or ertapenem. ‡ ‡the antipseudomonal agents chosen reflect this concern. risk factors for pseudomonas infection include severe structural lung disease (e.g., bronchiectasis) and recent antibiotic therapy, health care-associated exposures or stay in hospital (especially in the icu). for patients with cap in the icu, coverage for s. pneumoniae and legionella species must always be considered. piperacillin-tazobactam, imipenem, meropenem, and cefepime are excellent β-lactams and are adequate for most s. pneumoniae and h. influenzae infections. they may be preferred when there is concern for relatively unusual cap pathogens, such as p. aeruginosa, klebsiella spp., and other gram-negative bacteria. § § piperacillin, piperacillin-tazobactam, imipenem, meropenem, or cefepime. ## data suggest that older adults receiving aminoglycosides have worse outcomes. ¶ ¶ dosage for hospitalized patients, mg/day. the abrupt onset of fever, along with chills, headache, malaise, myalgias, arthralgias, and rigors during "flu season," is sufficient to diagnose influenza. as the fever resolves, a dry cough and nasal discharge predominate. a rapid nasal swab or viral cultures can be used to confirm the diagnosis of influenza but is rarely needed. in fact, the sensitivity of these rapid tests can range from % to %, so a negative test does not rule out influenza. the primary care physician needs to determine if the patient has influenza or the common cold, because symptoms of both illnesses generally overlap (table - ) . treatment of influenza is generally not necessary because it is usually a self-limiting condition. treatment should be reserved for those with comorbidities who present within hours of symptom onset. neuraminidase inhibitors (zanamivir and oseltamivir) prevent the release of virus from the respiratory epithelium and are approved for both influenza a and influenza b. the m inhibitors (amantadine and rimantadine) are approved by the u.s. food and drug administration (fda) for the treatment of influenza a because these drugs block the m ion protein channel, preventing fusion of the virus to host cell membrane (influenza b has no m ion channel). the use of m inhibitors is limited because of increasing resistance among influenza a viruses, as well as causing central nervous system (cns) problems that are usually exacerbated in elderly persons, who are more likely to seek treatment for influenza (table - ). the major complication of influenza is a secondary bacterial pneumonia or exacerbation of underlying copd. initial improvement in clinical symptoms followed by deterioration usually suggests a secondary bacterial pneumonia, which can usually be confirmed with a chest radiograph showing an infiltrate. other, less common complications of influenza include myositis, myocarditis, pericarditis, transverse myelitis, encephalitis, and guillain-barré syndrome. prevention of influenza is generally with vaccination. box - outlines patients at risk for influenza complications who should be vaccinated yearly. although anyone wanting an influenza vaccine should be vaccinated, during periods of vaccine shortage, high-risk groups have priority. a well-matched vaccine can prevent influenza among % to % of adults and decrease work absenteeism. conversely, a poorly matched vaccine only prevents influenza in % of healthy adults. proper hand hygiene and covering one's cough are two additional important components in preventing the spread of influenza virus. • population-based vaccination programs have been highly effective in decreasing the incidence of many viral infections. • acyclovir can be used in adults and children with varicella to decrease symptoms if given in the first hours after rash onset, but its benefit must be weighed against its cost and the possibility of development of viral resistance. • antiviral medications should be considered to decrease the incidence of postherpetic neuralgia, particularly in older patients. early treatment (within hours of onset of symptoms) with oseltamivir or zanamivir is recommended for influenza a (jefferson et al., ) (sor: a). use of oseltamivir and zanamivir is not recommended for patients with uncomplicated influenza with symptoms for more than hours (kaiser and hayden, ) (sor: a). oseltamivir and zanamivir may be used to reduce viral shedding in hospitalized patients or to treat influenza pneumonia (sor: c). (from treanor jj: influenza viruses, including avian influenza and swine influenza. in mandell gl, bennett je, dolin rd (eds) . mandell, douglas, and bennett's principles and practices of infectious diseases, th ed. philadelphia, churchill livingstone, , p .) • measles has had a resurgence in recent years and should be suspected when a patient presents with cough, coryza, conjunctivitis, and head-to-toe rash. • epstein-barr virus and cytomegalovirus infections are generally not clinically distinguishable, and their treatment is primarily supportive. vaccinations have dramatically decreased the incidence of a number of historically common viral infections; smallpox has been eradicated through widespread vaccination. however, recent outbreaks of measles and mumps on college campuses underscore the need to remain vigilant in administering vaccines at the population level, even though no vaccine is available for many common viruses. varicella is one of the classic viral exanthems of childhood. before routine vaccination, having chickenpox was one of childhood's "rites of passage." the virus, a herpesvirus (human herpesvirus ), is effectively transmitted, causing outbreaks in schools and households. patients with primary varicella present with fever, headache, and sore throat. generally within to days of onset of symptoms, a papulovesicular rash erupts diffusely. the classic description of the chickenpox lesion is "a dewdrop on a rose petal," suggesting a central vesicle on an erythematous base. lesions continue to appear for to days. all lesions going from papule to vesicle to crusted lesion takes about weeks. patients are considered to be infectious, primarily through respiratory secretions, during the days before symptoms appear and until all lesions are crusted. treatment of varicella is generally supportive. control of spread may be a concern in group-living environments such as schools or residence halls. isolation of the infected patient away from those susceptible to varicella infection is standard practice. acyclovir can be started within the first hours after rash eruption to achieve an attenuation of the infectious course. in children, this means a decrease in the duration of fever by about day and a decrease in the number of lesions (swingler, ) . in adults, acyclovir decreases rash duration and the number of lesions, although the results are less significant than for children. adult dosing of acyclovir for varicella is mg five times daily. the marginal benefit must be weighed against the possible development of resistance at a population level and the cost of the medication. complications of varicella can include secondary infection of skin lesions, pneumonitis, encephalitis, and dehydration from vomiting and diarrhea. varicella is prevented primarily through administration of vaccine. the vaccine is highly effective in children, with recommended dosing at to months with a second dose at to years. varicella is now included in a measles-mumpsrubella (mmr) vaccine, which can be given between months and years of age. the varicella vaccine is a live, attenuated virus and should not be given to certain immunocompromised patients. the vaccine can also be administered to exposed immunocompetent contacts, although the benefit is clearer for children than adults. severely immunocompromised patients exposed to varicella (particularly those with advanced hiv disease) may be given high-dose acyclovir to prevent development of disease. herpes zoster is a reactivation of the neurotropic varicella virus, typically in a dermatomal distribution. this is more common in elderly or immunocompromised patients but can occur in healthy people as well. patients with zoster may note generalized malaise, hyperesthesia, numbness, tingling, and pain in the skin before development of a rash. the appearance of the rash is the same as for chickenpox, although most often isolated to a unilateral dermatome. the diagnosis of herpes zoster is clinical based on the history and the classic appearance of the rash. in immunocompromised patients, however, the rash may not be dermatomally isolated. when the diagnosis is unclear, viral culture can be obtained from the base of a lesion. antiviral medications are likely to decrease the incidence of postherpetic neuralgia and are recommended, particularly in elderly patients (wareham, ) . valacyclovir ( g three times daily) or famciclovir ( mg every hours) for days is likely more effective than acyclovir in achieving this result. either drug should be started as soon after the diagnosis as possible, preferably within to hours of rash onset. when patients have established postherpetic neuralgia, gabapentin and tricyclic antidepressants are helpful in alleviating the pain. the rash of zoster is infectious to the touch. patients should be advised to keep the rash covered until all the lesions have crusted. zoster of the trigeminal nerve can extend to the eye and warrants immediate ophthalmologic intervention. a vaccine to prevent herpes zoster in adults was released in . the zoster vaccine differs from the varicella vaccine in that the amount of attenuated virus is times higher in the zoster vaccine. the vaccine decreases the incidence of zoster by %. it is recommended for administration by the american academy of family physicians (aafp) to adults over age , regardless of prior varicella or zoster history. although generally well tolerated, the vaccine is somewhat costly. in , more measles cases were reported than in any other year since (cdc, ) . measles is the "first disease" of childhood from the history of medicine. in adults, measles infection may be acquired in the face of waning immunity from remote immunization. a booster dose of mmr vaccine is recommended before college entry. clinically, measles presents with cough, coryza (nasal irritation and congestion), and conjunctivitis. fever is common several days before the onset of the rash. the rash of measles typically spreads from head to toe and has an erythematous, papular appearance with a "sandpaper" feeling. koplik's spots are erythematous papules with a bluish center on the oral mucosa and appear early in measles. measles is highly contagious through droplets. lymphopenia and neutropenia are common laboratory findings with measles infection. complications of measles include primary infections such as pneumonia, gastroenteritis, encephalitis, and the rare subacute sclerosing panencephalitis. secondary infections such as otitis media, pneumonia, and adenitis may also occur. treatment is supportive, and the implications of measles infection are primarily in the public health realm. patients with measles should be isolated for at least days after the appearance of the rash. it is important to recognize that patients are contagious for days before the development of symptoms. careful verification of immunization status for close contacts is essential. clinical infectious mononucleosis is a common infection in adolescents and early adults. the clinical syndrome is most often caused by epstein-barr virus (ebv), although cytomegalovirus (cmv) may also be the source in this clinical syndrome, which includes fever, exudative tonsillitis, adenopathy (often including posterior cervical or occipital nodes), and fatigue. ebv is transmitted in oral secretions and may be transmitted sexually as well. b cells are infected with ebv either directly or after contact with epithelial cells, resulting in diffuse lymphoid enlargement. the diagnosis of infectious mononucleosis is made by recognizing the clinical symptoms of fever, pharyngitis, and adenopathy along with the laboratory findings of greater than % lymphocytes with % or more atypical lymphocytes (hoagland, ) . also, a positive serologic test for heterophile antibody assists the family physician in the diagnosis. to differentiate ebv from cmv mononucleosis, serology (igg and igm) may be obtained. results of these tests are generally not available in time to have a significant benefit clinically. splenic enlargement as part of this lymphoid hypertrophy can lead to splenic rupture ( . % risk) (dommerby et al., ) . athletes with infectious mononucleosis must be managed carefully to avoid their participation in sports that could result in abdominal trauma. other risks associated with infectious mononucleosis include upper airway obstruction, asymptomatic transaminase elevation, thrombocytopenia, and rash after the administration of ampicillin or amoxicillin. routinely obtaining transaminase levels in patients without clinical hepatitis is of little value and can increase the overall cost of management. treatment of infectious mononucleosis is largely supportive. patients should be instructed to treat fever with antipyretics, rest, and expect symptom duration of to weeks, although symptoms can last for several months. the use of steroids, such as prednisone, has shown limited benefit. data suggest an initial benefit hours after steroid administration, although this is lost within several days (candy and hotopf, ) . combination of steroid and an antiviral (valacyclovir) may have some positive effect on fatigue. • the most common presentation of tuberculosis is pulmonary disease. • tuberculosis is diagnosed by acid-fast bacilli smears and cultures. • standard first-line agents to treat tb are isoniazid, rifampin, pyrazinamide, and ethambutol. • high-risk patients with a positive purified protein derivative skin test or quantiferon-tb gold test should be treated for latent tb infection. • the current recommendation for first-line treatment for latent tb is months of oral isoniazid. tuberculosis skin testing should be interpreted without regard to bacille calmette-guérin (bcg) history, because bcg is administered in areas where tb is endemic and bcg does not provide complete protection from tb infection. tuberculosis (tb) is a disease that has plagued humans since antiquity, with evidence of spinal tb in neolithic and early egyptian remains. at present, tb affects approximately one third of the world's population. tb is the world's second most common cause of death from infectious disease after human immunodeficiency virus or acquired immunodeficiency syndrome (hiv/aids). tuberculosis is caused by mycobacterium tuberculosis, an acid-fast bacillus. tb is acquired by inhalation of respiratory droplets. these respiratory droplets are spread by coughing. brief contact carries little risk for acquiring tb, and infection generally does not occur in open air; open-air sanatoriums were the cornerstone of tb treatment before antimicrobial therapy. in the united states, tb incidence rates have been on the decline since , coinciding with the control of hivinduced aids by antiretroviral therapy. however, tb remains prevalent in certain high-risk groups (i.e. immigrants, iv drug use, homeless persons). most cases of tb are in people age to years. tb in elderly persons is generally caused by a reactivation of latent infection acquired in the remote past, whereas tb in young children indicates ongoing active transmission in the community. infection in children is more likely to progress to active tb and disseminated disease. persons with hiv infection have a disproportionately higher risk for acquiring tb than the general population. tuberculosis is most frequently manifested clinically as pulmonary disease, but it can involve any organ. extrapulmonary tb accounts for about % of disease in hiv-seronegative persons but is more common in hiv-seropositive persons. pulmonary tb typically manifest with fever, night sweats, chronic cough, sputum production, hemoptysis, anorexia, and weight loss. chest radiographs in patients with pulmonary tb typically reveal upper-lobe cavitary lesions and can reveal infiltrates or nodular lesions, as well as lymphadenopathy ( figure - ). tb in the setting of advanced hiv co-infection does not generally manifest in the typical manner (table - ) . acyclovir started within the first hours after varicella rash eruption can attenuate the infectious course, decreasing duration of fever by day and reducing the number of lesions (sor: a). administration of varicella vaccine to a susceptible child within days of exposure will likely modify or prevent disease (macartney and mcintyre, ) the diagnosis of pulmonary tb is made by the demonstration of acid-fast bacilli (afb) in sputum and the growth of m. tuberculosis in culture. these patients typically have an abnormal chest radiograph, as previously described. m. tuberculosis is a slow-growing bacterium, and cultures can take up to weeks to grow. a pcr assay developed for m. tuberculosis can be run on afb smear-positive sputum to hasten the diagnosis of pulmonary tb. a positive pcr on afb-positive sputum is diagnostic of pulmonary tb, but a negative test does not rule out the diagnosis. patients with afb positive smears from sputum samples should be started on anti-tb therapy while awaiting results of pcr and cultures. the treatment of tb always uses multiple agents with anti-tb activity. single agents should never be used. the standard first-line agents are isoniazid (inh), rifampin (rif), pyrazinamide (pza), and ethambutol (emb) (figure - and table - ). if administered, inh should be given with pyridoxine (vitamin b ; - mg orally daily) to prevent neuropathy. treatment of active pulmonary tb is generally for months regardless of hiv status, but treatment may need to be extended in certain situations. directly observed therapy (dot) is the preferred mechanism of administration to ensure compliance. many local county and state health departments have systems for dot. treatment of hiv-seropositive patients with tb who are receiving an antiretroviral (arv) regimen that contains a protease inhibitor is complicated by the latter's interaction with rifamycins (particularly rifampin). management of such patients should be coordinated with an infectious diseases specialist, who also should manage drug-resistant tb treatment. in the united states, latent tuberculosis infection (ltbi) is the most prevalent form of tuberculosis. ltbi is the term given to patients with a positive purified protein derivative (ppd) skin test without evidence of active tb. ppd has been used for more than years and relies on delayed-type hypersensitivity (dth) to m. tuberculosis cellular proteins. early late figure - treatment algorithm for tuberculosis. patients in whom tb is proved or strongly suspected should have treatment initiated with isoniazid, rifampin, pyrazinamide, and ethambutol for the initial months. a repeat smear and culture should be performed when months of treatment has been completed. if cavities were seen on the initial chest radiograph or the acid-fast smear is positive at completion of months of treatment, the continuation phase of treatment should consist of isoniazid and rifampin daily or twice weekly for months to complete a total of months of treatment. if cavitation was present on the initial chest radiograph and the culture at completion of months' therapy is positive, the continuation phase should be lengthened to months (total of months of treatment). if the patient has hiv infection and the cd + cell count is less than /mm , the continuation phase should consist of daily or three-times-weekly isoniazid and rifampin. in hiv-uninfected patients having no cavitation on chest radiograph and negative acid-fast smears at completion of months of treatment, the continuation phase may consist of either once-weekly isoniazid and rifapentine, or daily or twice-weekly isoniazid and rifampin, to complete a total of months (bottom). patients receiving isoniazid and rifapentine, and whose -month cultures are positive, should have treatment extended by an additional months (total of months). *emb may be discontinued when results of drug susceptibility testing indicate no drug resistance. †pza may be discontinued after it has been taken for months ( doses). ‡rpt should not be used in hiv-infected patients with tb or in patients with extrapulmonary tb. therapy should be extended to months if -month culture is positive. afb, acid-fast bacilli; cxr, chest radiograph (x-ray); emb, ethambutol; inh, isoniazid; pza, pyrazinamide; rif, rifampin; rpt, rifapentine. because ppd relies on dth, any factor that reduces the dth affects the host response to ppd. the most common clinical example is use of corticosteroids, which blunt the dth response and can complicate ppd interpretation. therefore, ppd testing should not be performed while a patient is taking corticosteroids. also, tb testing should be targeted to those with higher risk of infection and should not routinely be done in those with low risk (ats/cdc, ) . the ppd can also give false-positive results in patients with previous bacille calmette-guérin (bcg) vaccination or with infection by other mycobacterial infections. in the united states, this may cause difficulties in testing immigrants from countries who routinely use bcg vaccination programs. however, previous bcg vaccination should not change the interpretation of the ppd or willingness to treat such individuals accordingly. ‡when dot is used, drugs may be given days per week and the necessary number of doses adjusted accordingly. although there are no studies that compare five with seven daily doses, extensive experience indicates this would be an effective practice. § patients with cavitation on initial chest radiograph and positive cultures on completion of months of therapy should receive a -month ( weeks, either doses [daily] or doses [twice weekly]) continuation phase. ¶ five-days-a-week administration is always given by dot. rating for day per week regimens is aiii. ¶ ¶ not recommended for hiv-infected patients with cd + cell counts < cells/μl. ** options c and b should be used only in hiv-negative patients who have negative sputum smears at completion of months of therapy and who do not have cavitation on initial chest radiograph. for patients started on this regimen and found to have a positive culture from the -month specimen, treatment should be extended an extra months. the dth response can wane over time. to overcome this problem, nonreacting patients may undergo repeat ppd week after their initial ppd. the diagnosis of ltbi is made by interpretation of a ppd and by ascertaining the patient's risk factors for progression to active tb if left untreated . interpretation of the ppd should be based on the area of induration and not the area of surrounding erythema. persons whose ppds have converted from negative to positive within years are presumed to have been infected recently. the decision to use ppd means treating the patient for ltbi if the ppd test is positive. patients at increased risk for progression to active tb include those who have been recently infected (recent ppd converters); patients who are hiv seropositive; patients who have silicosis, diabetes, or chronic renal failure (including those receiving hemodialysis); solid-organ transplant recipients; patients with gastrectomy or jejunoileal bypass or head and neck cancer; injection drug users; patients with chest radiograph evidence of prior tb; and patients who weigh at least % less than ideal body weight. patients taking chronic corticosteroid therapy and those who are to receive tumor necrosis factor alpha (tnf-α) blockers (e.g., infliximab) are also at risk. patients taking corticosteroids also have higher risk of progression to active tb with larger doses and longer courses of corticosteroids. standard therapy for ltbi is inh, mg orally daily for months, regardless of hiv status. again, inh should always be administered with pyridoxine to prevent neuropathy. to overcome the false-positive results and confusion of ppd testing in certain populations, newer interferon-gamma (ifn-γ) release assays such as the quantiferon-tb gold (qft-g) test have been developed to detect latent m. tuberculosis. qft-g quantifies the release of ifn-γ from lymphocytes of the host's blood in response to three m. tuberculosis target antigens that are absent from bcg and most other nontuberculous mycobacterium spp. the advantages of using qft-g include one-time blood testing without the need for followup visit, no triggering of amnestic responses, and possibly more specific response to m. tuberculosis. however, qtf-g use in immunocompromised or anergic patients is limited, with indeterminate results. some studies also show discordant results in individuals tested with both ppd and qtf-g. in general, qtf-g may be used in all circumstances in which the ppd is used. however, whether the qtf-g is truly more specific or sensitive than the ppd in latent or active tb is yet to be determined. • the u.s. preventive services task force recommends "highintensity" behavioral counseling to at-risk adults and adolescents to prevent sexually transmitted infections. • be specific in addressing patients' sexual practices so as to provide appropriate prevention advice. hiv-positive persons recent contacts of tuberculosis patients fibrotic changes on chest radiography consistent with prior tuberculosis patients with organ transplants and other immunosuppressed patients (receiving equivalent of ≥ mg/day of prednisone for at least month) development in the primary prevention of stis is immunization against human papillomavirus (hpv). the vaccine can prevent infection with certain strains of hpv that cause cervical cancer and genital warts. trials are ongoing to determine the effectiveness of daily arv therapy in preventing transmission of hiv. vaccination investigation is ongoing for herpes simplex, chlamydia trachomatis, and hiv. this breadth of research effort holds promise for the future in the prevention of stis. the uspstf recommends "high-intensity" behavioral counseling to at-risk adults and adolescents to prevent stis. highintensity counseling involves multiple sessions and often is delivered to groups of patients. unfortunately, this type of intervention has limitations in its practicality for population-based delivery. no risk of harm was discovered in the delivery of counseling for sti prevention. vaccination is the most important form of primary prevention of common infectious diseases. two vaccines are currently on the market for hpv prevention-one that protects against four viral subtypes ( , , , ) and is licensed for use in males and females to years of age, and the other against two subtypes ( , ), licensed for females to years of age. hepatitis b is a sexually transmitted infection, and immunization is recommended for adolescents who have not been previously inoculated. this is a requirement in many states for school entry. hepatitis a can be transmitted by oro-anal sexual contact, and vaccination should be offered to patients who are contemplating engaging in this sexual practice. recommendations surrounding the use of barrier methods for sti prevention should be tailored to the sex practices of the client. for example, a percentage of women use anal sex as a method of birth control but may not consider the need for condom use with this practice. the question, "do you regularly use condoms?" has little relevance to infection control for many sexual practices. evidence supports the advice to use barrier methods of latex or other approved material in a manner that prevents the exchange of blood and body fluids in decreasing stis. condoms confer a % risk reduction for herpes simplex and up to an % risk reduction for hiv, when used correctly (weller and davis-beaty, ; martin et al., ) . the secondary prevention of stis is achieved through direct and nonjudgmental patient assessment and screening and avoiding assumptions about patient sexual practices. screening is a tool to prevent the inadvertent spread of infection as well as the sequelae of undetected disease. infectious genital ulcers are associated with herpes simplex virus (hsv), syphilis, chancroid, lymphogranuloma venereum, and granuloma inguinale. hsv is by far the most common, affecting million people in the united states. hsv- and hsv- are chronic, neurotropic viral infections that enter through epithelium and come to rest in the dorsal root ganglia. therefore, infection leads to lifetime presence of the virus, but the clinical manifestation of this condition is variable. a small percentage of those with serologic evidence of hsv- ( %- %) have had symptoms of clinical herpes infection. in addition, patients with hsv infection can shed the virus in the absence of symptoms, creating a prime opportunity for spread. herpes simplex outbreak may be followed by a prodrome of malaise, fever, and regional lymphadenopathy before the appearance of grouped vesicles on an erythematous base. the vesicles are typically quickly broken and become ulcerated in appearance, with each vesicle usually less than several millimeters in size. true first-time infections tend to present more severely than secondary presentations of previously infected individuals, with a prodrome present in % of cases. the lesions can be in any location around the genitals or rectum, on the proximal thighs and buttocks, inside the vagina, and in and around the mouth. the lesions are most who to screen? often painful, particularly when on mucosal surfaces, or itchy. in women, herpes simplex can present with cervicitislike symptoms with bleeding and discharge and cervical ulcerations on examination, or simply mucopurulent cervicitis. herpetic lesions around the urethra tend to be extremely painful and can make urination difficult. rectal hsv can be confused with irritation, perianal fissure, and even candidiasis because of its often beefy-red appearance and itching. vesicles typically appear days after infection and can last up to weeks in an initial infection. subsequent outbreaks tend to have a shorter duration and to be less uncomfortable for patients. confirmation of infection is helpful, but the diagnosis can be made primarily on the clinical appearance of the exanthema. vigorous sample collection from an ulcer (which the patient may not appreciate) to be sent for pcr identification and typing is the most readily available method of laboratory diagnosis. serum antibody testing is not useful in the initial hsv diagnosis because antibody levels will not be appreciable early in infection. the appearance of convalescent immunoglobulin g (igg) and igm levels several weeks after a suspected outbreak might help to support the diagnosis of hsv infection. the value of screening for hsv immunity is debatable and should generally not be recommended for asymptomatic individuals. in addition, the uspstf recommends against screening asymptomatic pregnant women for hsv to prevent transmission to the newborn. given that many patients with hsv infection never manifest symptoms, the value of knowing that one is hsv seropositive is questionable. in addition, hsv- and hsv- , although classically oral and genital, respectively, can "mix and match" based on sexual practices. it is often confusing for asymptomatic individuals to know that they have hsv antibody (do i have cold sores? do i have genital herpes? how should this change the way i live my life?). in monogamous couples with one partner known to be hsv positive and the other with unknown status, testing of the latter may indicate suppressive therapy in the seropositive partner if the other is found to be negative. regular barrier method use decreases transmission of herpes in both men and women, with patients using condoms % of the time having a % reduction in hsv acquisition from those who never use condoms (martin et al., ) . serodiscordant couples may also decrease transmission through antiviral suppressive therapy to the hsv-positive partner (table - ) . syphilis is a spirochetal infection that has resurged since , the nadir year since . syphilis infection rates are highest in men who have sex with men. syphilis is much less common than the other stis, with an infection rate of . per , population in the united states (vs. per , for chlamydia). syphilis presents in several stages. the primary phase of syphilis is a painless ulcer called a chancre (figure - ) . the chancre may be visible on the genitals, although it can also be inside the vagina, mouth, or rectum, making it difficult to find. this lesion will appear within weeks of transmission and will last for several weeks untreated. the secondary phase of infection is disseminated and involves a diffuse macular rash, typically with palm and sole lesions, generalized lymphadenopathy, fever, and condyloma latum (smooth, moist lesions on genitals without cauliflower appearance of condyloma acuminatum). tertiary syphilis is often asymptomatic but affects the heart, eyes, and auditory system and can be associated with gumma formation. gummas are soft, granulomatous growths in organs that can cause mechanical obstruction and weakening of blood vessel walls. latent infection often involves the cns. diagnosis of primary syphilis is challenging. the test of choice is darkfield microscopy, which is not readily available. direct fluorescent (monoclonal) antibody (dfa) testing may be available. antibody tests for syphilis, such as the rapid plasma reagin (rpr) and the less frequently used venereal disease research laboratories (vdrl), are often not positive early in infection and thus cannot be used to rule out primary syphilis based on a single reading. treponemal antigen testing (eia) may be available in some laboratories. the fluorescent treponemal antibody absorption (fta-abs) test may also be negative in the early infection. direct pcr for primary syphilis lesions has been tested but is not yet fda approved. a physician may choose to treat presumptively if a painless chancre and risk factors are present and may then do a convalescent rpr test in to weeks to confirm the infection by the appearance of a positive reaction. one would expect a fourfold change in titer of either test to indicate the presence of disease. primary and secondary syphilis are treated with a single injection of penicillin g, . million units. other regimens do not have proven effectiveness but can be used in the penicillin-allergic patient, including doxycycline, mg twice daily for days; ceftriaxone, mg to g intramuscularly (im) daily for to days; or azithromycin, g as a single oral dose, although resistance to azithromycin has been observed. patients treated for primary syphilis should have periodic clinical follow-up and serologic testing to determine a fourfold decrease in rpr reactivity within months. latent syphilis can be either early, meaning infection within the last year, or late, meaning infection beyond a year. early latent syphilis is treated with a single injection of penicillin g, . million units. syphilis of late latency or unknown duration is treated with three injections of penicillin g, . million units, in consecutive weeks. for penicillin-allergic patients, doxycycline, mg twice daily for days, is required. those with latent syphilis should have ophthalmic examination as well as evaluation for vascular gumma formation. suspected neurologic involvement of latent syphilis must be evaluated with cerebrospinal fluid (csf) examination and treatment with aqueous penicillin g, - million units intravenously (iv) every hours for to days. partners of patients with newly diagnosed syphilis are at risk for infection. partners within days of a diagnosis of primary syphilis should be tested, but treated presumptively even if serologic testing is negative. for partners prior to days before diagnosis, serology is generally reliable in detecting presence of infection and may guide treatment. patients with secondary syphilis should inform partners within months before diagnosis, or months for those diagnosed with tertiary syphilis (table - ). chancroid may occur in regional outbreaks and presents with a painful genital ulcer and suppurative regional adenopathy. herpes and syphilis should both be ruled out in the patient suspected of having chancroid infection. chancroid is caused by haemophilus ducreyi and there is currently no fda approved test to directly detect this organism. treatment with azithromycin ( g as single dose), ceftriaxone ( mg im as a single dose), ciprofloxacin ( mg twice daily for days), or erythromycin ( mg three times daily for days) are all alternatives (table - ). it may be necessary to perform incision and drainage on fluctuant inguinal nodes. patients should be reexamined in to weeks to ensure healing of the primary ulcer(s) and resolution of the adenopathy. partners who had contact with the infected patient starting days before development of the patient's symptoms should be treated, regardless of the presence of symptoms. less common ulcerating stis include lymphogranuloma venereum (lgv) and granuloma inguinale ( figure - ). lgv causes regional adenopathy and often an ulcer at the point of entry. rectal lgv may cause a proctocolitis with anal pain, discharge, bleeding, and diarrhea. lgv is caused by chlamydia trachomatis serotypes and can be detected by testing swabbed material from open lesions or aspirates from lymph nodes with culture, dfa, or nucleic acid detection. treatment is noted above (table - ) . granuloma inguinale, caused by klebsiella granulomatis, is rare in the united states and causes progressive ulcerative disease of the genitals. a second sti category includes those causing the clinical presentation of vaginal discharge, pelvic pain, dyspareunia, and dysuria in women and penile discharge and dysuria in men, as well as possible rectal pain and discharge in men and women. of this group, chlamydia trachomatis is the most common, causing . million infections in the united states in (cdc, ). in fact, chlamydia is the most frequently reported reportable infection. the majority of women with chlamydia infection are without symptoms. many men are asymptomatic as well. regular screening for chlamydia, as recommended by the uspstf, can significantly reduce the incidence of pelvic inflammatory disease (pid), one of the most serious sequelae of untreated infection. in women with untreated chlamydia infection, in addition to pid, tubo-ovarian abscess, tubal scarring and ectopic pregnancy, and infertility can all result. as previously mentioned, regular screening is currently recommended for all sexually active women under age , all pregnant women under , and at-risk pregnant and nonpregnant women over . chlamydia testing can be performed on several liquid-based papanicolaou (pap) tests. endocervical swabs for nucleic acid amplification are acceptable when a conventional pap smear is being used. given the recent liberalization of recommendations about pap testing for women under years of age, urine nucleic acid amplification is a readily available alternative for chlamydia testing. this can easily be done at a contraceptive counseling clinic. urine testing is also an acceptable method of testing for men, in addition to a urethral swab. rectal chlamydia infection can occur in individuals who practice receptive anal intercourse. an fda-approved method of testing should be used for screening and diagnosis of this infection. asymptomatic chlamydia infection is treated with either a single dose of azithromycin, g orally, the drug of choice, or doxycycline, mg twice daily, for days (table - ) . patient-delivered partner therapy (pdpt), the practice of dispensing treatment to diagnosed patients to treat their partner(s), has proved effective in reducing reinfection rates and further spread of infection. ept is legally allowable in states and potentially allowable in another . chlamydia infection may present symptomatically in men or women with symptoms of dysuria and with discharge and with pelvic pain and dyspareunia in women. the discharge of c. trachomatis, versus that of neisseria gonorrhoeae, is said to be more mucoid than purulent, although this characteristic is not specific enough to provide diagnostic accuracy. symptomatic chlamydia, without evidence of pid, is treated the same as asymptomatic infection. many practitioners will treat presumptively for chlamydia and gonorrhea in patients who present with the symptoms previously mentioned while they wait for confirmatory testing. neisseria gonorrhoeae infection may be asymptomatic in both men and women. the current uspstf recommendation is for screening women at risk. men with penile gonorrhea typically present with purulent penile discharge and dysuria with n. gonorrhoeae infection. mucopurulent discharge, dysuria, pelvic pain, and dyspareunia are typical symptoms in women. in patients who engage in anal intercourse, anal discharge, rectal pain, and bleeding can be presenting symptoms. gonococcal pharyngitis is within the differential of exudative pharyngitis in sexually active patients. when symptomatic, throat pain, tonsillar exudates, and anterior cervical adenopathy may be present. testing for gonorrhea can be done using liquid-based pap technologies, cervical or urethral swabs, or urine for nucleic acid amplification. in men with visible discharge, a gram stain with white blood cells (wbcs) and gram-positive intracellular diplococci has a high degree of sensitivity. culture testing may be preferred for suspected pharyngeal and rectal specimens pending fda approval of other methods. again, physicians may opt to treat patients with mucopurulent cervicitis or urethritis presumptively for gonorrhea and chlamydia while waiting for confirmatory testing. fluoroquinolone therapy is no longer recommended because of widespread resistance (table - ) . because reinfection with gonorrhea is common for several months after treatment, it may be advisable to retest patients with confirmed gonorrhea in the months after treatment. similarly, stis may be an indicator of risk behavior, and a complete risk history and testing for other stis is advisable if not completed at the initial visit. in male patients with symptomatic urethritis, a causative agent may not be identified, a situation often referred to as nongonococcal urethritis (ngu). technically, chlamydia is included in this category. organisms such as ureaplasma urealyticum and mycoplasma genitalium may be the cause and may be difficult to detect. treatment for these infections is the same as for symptomatic chlamydia, with azithromycin or doxycycline (table - ). it is recommended that partners of patients with ngu should be evaluated and treated. in some cases, testing of partners may detect a specific organism as the cause of infection (e.g., chlamydia). trichomonas vaginalis causes vaginitis in women, who may have a stereotypic frothy, green, and foul-smelling discharge. many women are asymptomatic with trichomoniasis. in addition to causing asymptomatic infection in men, t. vaginalis may cause urethritis. this organism may be suspected in men when patients have repeated treatment failures and no other explanation for symptoms. microscopic examination of vaginal discharge is % to % sensitive in women. a first voided urine specimen or urethral swab for microscopic exam may be helpful in identifying the protozoa. culture for trichomonas, which requires a special medium, may be necessary to identify this infection accurately in men. trichomonas is effectively treated with a single -g dose of metronidazole (table - ) . for non-sti causes of vaginal discharge, see the online discussion at www.expertconsult.com. pelvic inflammatory disease can be caused by a number of organisms, including chlamydia, and presents with pelvic pain and discharge. findings that contribute to the diagnosis of pid include fever greater than ° f, cervical or vaginal mucopurulent discharge, abundant wbcs on saline preparation of vaginal discharge, elevated erythrocyte sedimentation rate (esr), elevated c-reactive protein (crp), and evidence of n. gonorrhoeae or c. trachomatis infection. hospitalization with parenteral antibiotics may be necessary in pregnant patients, patients in whom surgical emergency cannot be ruled out, those who do not respond to oral treatment, those who cannot tolerate oral treatment, and patients who have severe illness or tubo-ovarian abscess. when treating pid parenterally, improvement of symptoms for hours may prompt a change to oral therapy (table - ) . conversely, if oral therapy is not producing significant improvement within to days, admission for parenteral therapy may be necessary. patient awareness of human papillomavirus infection has greatly increased in recent years, in large part related to the patient-directed advertising of the hpv vaccine. hpv is likely the most common sti. thirty types of hpv can infect the genital area, some causing genital warts, some causing malignancies of the genital organs, and most being asymptomatic. the gross categories most often used are "high risk" (most often types and ) and "low risk" (types and ) hpv infection, the former more often associated with genital cancer. prevention of hpv infection and cervical cancer was revolutionized with the release of the hpv vaccine, which is effective in reducing the incidence of hpv-associated disease. currently, two vaccines are licensed in the united states. gardasil (merck), released in , includes protection against viral types , , , and . it is approved for the prevention of vulvar and vaginal cancer and for the prevention of cervical cancer, cervical dysplasia, and genital warts in females age to . the vaccine was recently approved for males of the same age range for the prevention of genital warts. more recently, cervarix (glaxosmithkline) was approved for the prevention of cervical cancer and cervical dysplasia from hpv types and in women age to . ideally, the vaccine should be administered before initiation of sexual activity to prevent initial acquisition of these hpv types. patients who are already sexually active may also receive the vaccine. the transmission of hpv to men decreases with consistent condom use, from . % in men who never use condoms to . % in men who "always" use them. unfortunately, hpv can infect skin that is not covered by the use of traditional barrier methods (nielson et al., ) . male circumcision may decrease the transmission of hpv. patients have many questions about hpv, in particular about screening for asymptomatic infection. hpv infection occurs with high frequency in the sexually active population; up to % or more of sexually active individuals have hpv at some point in their life. in addition, hpv is effectively transmitted, even if contact does not involve genital-togenital touching (i.e., manual stimulation can transmit the virus). again, most hpv infections are without symptoms and resolve spontaneously through eradication by the intact immune system. for all these reasons, screening for the mere presence of hpv infection has minimal utility. there is no treatment for asymptomatic hpv infection. the most common presentation of hpv infection is in the context of an abnormal pap smear. hpv is directly linked to cervical dysplasia. for women over age and under , hpv testing with high-risk viral detection is common. the presence of high-risk hpv informs further management of the pap result. it is currently recommended that women over be automatically tested for high-risk hpv infection at the pap smear. patients may present with visible warts, or these may be detected at routine or sti screening. genital warts are often cosmetically unacceptable to patients, even though they are infrequently functionally problematic. in some circumstances, wart burden can be high enough to cause physical discomfort or relative obstruction of the vagina or rectum. vulvovaginal candidiasis and bacterial vaginosis are generally not thought to be sexually transmitted, although they are often in the differential diagnosis of sexually transmitted infection (sti). both these infections likely are related to changes in the vaginal ph and the normal flora distribution. it is not always clear which of these factors is primary and which is secondary, because at diagnosis, both ph and normal vaginal flora will often be abnormal. vulvovaginal candidiasis is a common infection causing typically white, curdlike discharge, itching, and sometimes dysuria. the causative organism is usually candida albicans but can be other candida spp. antibiotics can alter normal vaginal flora, so the recent use of antibiotics may predispose women to candidiasis. physical examination may reveal erythematous external genitalia as well as external and internal white, clumping discharge. usually, no distinctive odor is associated with vaginal yeast. wet preparation of vaginal specimen or treatment with potassium hydroxide (koh) may reveal branching pseudohyphae and yeast. when ph is performed, it should be directly on the vaginal discharge and not on the saline-diluted specimen because the saline will alter the ph of the specimen. typically, the ph of yeast discharge is less than . (normal vaginal ph, . - . ). bacterial vaginosis (bv) is the most common cause of infectious vaginal discharge (spence and melville, ) . many different organisms are associated with the diagnosis of bv, including gardnerella vaginalis and mycoplasma hominis. women with bv may report discharge, vaginal irritation, vaginal odor, and at times, dysuria. findings of bv are often detected during a normal screening pap smear or pelvic examination. physical findings may reveal signs of vaginal irritation. the discharge is usually thin and gray. an amine (fishy) odor may be produced with the application of koh. the finding of clue cells, or epithelial cells with adherent bacteria, under saline preparation microscopy and a decrease in normal lactobacilli are common findings. the amsel criteria are useful in bv diagnosis; other scoring systems (e.g., nugent criteria) have been used but require gram staining. the specific amsel criteria are ( ) milky, homogeneous, adherent discharge; ( ) discharge ph greater than . ; ( ) positive whiff test (fishy smell with addition of koh); and ( ) at least % clue cells on microscopic examination. if three of the four criteria are present, the likelihood of bv is %. in routine vaginal examination and bimanual examination for patients with vaginal discharge, signs and symptoms of vaginitis are poor predictors of the microbiologic cause of infection (schaaf et al., ) . the clinical examination and office testing, in fact, are fair predictors of the true cause of infection (lowe et al., ). many patients with vaginal discharge will use over-the-counter preparations before consulting a physician, which can delay correct diagnosis of the etiology of symptoms. patient-collected, low vaginal swabs may be as useful as provider-collected specimen in making a diagnosis for the patient with vaginal discharge. the purpose of bimanual examination is to evaluate for signs of pelvic inflammatory disease and is not necessary in the low-risk patient with vaginal discharge. treatment of asymptomatic bv or vaginal yeast is not necessary in the nonpregnant patient or usually is not needed to test or treat partners of patients with isolated yeast or bv. when infection is recurrent, particularly when a woman's male partner is uncircumcised, treatment of the male partner for carriage of either infection may be warranted. options for treatment of recurrent infections are presented in etable - . the treatment of warts is destructive and may serve to stimulate an immune response to the hpv-infected cells, which are typically "above" the surveillance mechanisms of the immune system in the epidermis. office methods of treatment include cryotherapy and trichloroacetic acid or podophyllin resin application. patients may apply podofilox . % solution or gel or imiquimod % cream (table - ) . for more extensive cases of warts or intra-anal or intravaginal infections that are difficult to treat using the previous methods, surgical techniques may be necessary to achieve resolution. untreated, warts may resolve spontaneously, remain the same, or worsen. patients with pediculosis pubis, or pubic lice, most often present with pruritus or with visible nits. pubic lice are visible on inspection of the pubic area, as are nits, which are adherent to the hair shaft. partners of patients with pubic lice should also be treated to prevent reinfection. linens and clothing should be laundered or dry-cleaned or kept in a closed plastic container or bag for hours. scabies diagnosis can be challenging. again, patients present with itching that can be anywhere on the body, although often in the genital area or on the buttocks when infection is sexual in origin. the pruritus associated with sarcoptes scabiei is a result of sensitization to the mite droppings underneath the skin as the mite burrows. the classic "burrow" or linear papular eruption is not always present. scraping of lesions with microscopic examination may be performed to identify the mite. as with pediculosis, close contacts should be treated. linens and clothing should be laundered or dry-cleaned or isolated in plastic containers for hours. the pruritus-associated with scabies can take several weeks to resolve after treatment. patients living in group settings (dormitories or apartments) may reinfect one another as a result of inadequate primary treatment of all contacts ( cryotherapy trichloroacetic acid (tca): small amount applied until wart whitens podophyllin resin, % to % all these may be repeated every to weeks until warts are resolved. podofilox . % solution or gel applied twice daily for days, followed by days of no therapy. imiquimod % cream applied once daily at bedtime three times a week for up to weeks; washed off to hours after application. urinary tract infection (uti) is defined as significant bacteriuria in the presence of symptoms. uti accounts for a significant number of emergency department visits; an estimated % of women experience a uti in their lifetime. the urinary tract is normally sterile. uncomplicated uti involves the urinary bladder in a host without underlying renal or neurologic disease. the bladder mucosa is invaded, most often by enteric coliform bacteria (e.g., e. coli) that ascend into the bladder via the urethra. sexual intercourse can promote this migration, and cystitis is common in otherwise healthy young women. frequent and complete voiding has been associated with a reduction in the incidence of uti. complicated uti occurs in the setting of underlying structural, medical, or neurologic disease. signs and symptoms of a uti include dysuria, frequency, urgency, nocturia, enuresis, incontinence, urethral pain, suprapubic pain, low back pain, and hematuria. fever is unusual. up to % of patients with symptoms of cystitis have a smoldering pyelonephritis, especially when symptoms have been present for more than week. a patient with pyelonephritis usually appears ill, with fever, sweating, and prostration, along with costovertebral angle (flank) tenderness in most cases. the differential diagnosis of uncomplicated uti includes use of diuretics or caffeine, interstitial cystitis, vaginitis, pregnancy, pelvic mass, pid, and benign prostatic hypertrophy (bph). if a uti is suspected, the initial test of choice is urinalysis, although with classic signs and symptoms of infection in women, this test is not always necessary. pyuria, as indicated by a positive result on the leukocyte esterase dip test, is found in the majority of patients with uti. the presence of urinary nitrites is fairly specific for uti. the combination of positive leukocyte esterase and nitrites improves sensitivity. on urine microscopy, levels of pyuria as low as two to five leukocytes per high-power field ( - wbcs/hpf) in a centrifuged specimen are significant in the female patient with appropriate symptoms, as is the presence of bacteriuria. urine culture and sensitivity are not needed in simple utis. cultures should be done in patients with recurrent utis, patients with pyelonephritis, and pregnant patients. antibiotic therapy can be given in a -day regimen for young, sexually active women. a -to -day course of antibiotics should be used in pregnant patients and patients with complicated utis. all the drugs listed in table - can be used in a -day or -to -day course. clinical practice guidelines that include telephone assessment and treatment have shown a decrease in unnecessary laboratory utilization while maintaining quality of care (saint et al., ) . trimethoprim-sulfamethoxazole (tmp-smx) has been a mainstay of uti therapy, but in some localities, resistance of e. coli to tmp-smx is % (mehnert-kay, ) . if a urine culture is done and the organism is resistant to the drug prescribed, a change in antibiotics is indicated only if the patient is still symptomatic. for symptomatic treatment, a bladder anesthetic can be used, such as phenazopyridine (pyridium), mg three times daily for days. patients should be warned that this produces an orange tinge in tears and urine. patients should also be instructed to increase fluid intake. pyelonephritis is suggested by a failure of a short course of antibiotics. signs and symptoms of pyelonephritis include shaking chills and fever higher than . ° c ( . ° f), flank pain, malaise, urinary frequency and burning, and costover-tebral angle tenderness. the infection can produce septic shock. a patient who is unable to tolerate oral intake should be hospitalized and given empiric iv antibiotics aimed at broad-spectrum gram-negative coverage, such as third-generation cephalosporins, fluoroquinolones, or aminoglycosides, while awaiting results of blood and urine cultures. a -day course of antibiotic therapy (iv or po) is recommended. although the most common bacterial infection during pregnancy, the incidence of uti in pregnancy is similar to that reported in sexually active nonpregnant women of childbearing age. up to % of pregnant women with tmp-smx, / mg q h trimethoprim, mg q h fluoroquinolones ‡ ciprofloxacin, - mg q h ciprofloxacin xr, mg qd gatifloxacin, mg qd levofloxacin, mg qd nitrofurantoin monohydrate/macrocrystals, mg q h nitrofurantoin macrocrystals, - mg qid amoxicillin, mg q h or mg q h cephalexin, mg q h, or other cephalosporin consider -day regimen. amoxicillin, mg q h or mg q h nitrofurantoin monohydrate/macrocrystals, mg q h nitrofurantoin macrocrystals, - mg qid cephalexin, mg q h, or other cephalosporin tmp-smx, / mg q h male gender, diabetes, symptoms for days, recent antimicrobial use, age > tmp-smx, § / mg q h fluoroquinolones, as per -day regimens cephalexin, mg q h, or other cephalosporin consider -day regimen. from hooton tm, stamm we. diagnosis and treatment of uncomplicated urinary tract infection. infect dis north am ; : . tmp-smx, trimethoprim-sulfamethoxazole; qd, every day; q h, every hours; q h, every hours; q h, every hours; qid; four times daily. * treatments listed to be prescribed before etiologic agent is known (gram stain may help); therapy can be modified when cause is identified. † characteristic pathogens are escherichia coli ( %- %) and staphylococcus saprophyticus ( %- %); other organisms account for less than % of cases and include proteus mirabilis, klebsiella pneumoniae, and enterococcus spp. ‡fluoroquinolones should not be used in pregnancy. § although classified as pregnancy category c, tmp-smx is widely used; however, avoid its use in the first and second trimesters. untreated bacteriuria in the first trimester develop acute pyelonephritis later in pregnancy. premature births and perinatal mortality are increased in pregnancies complicated by uti. therefore, in pregnant women, asymptomatic bacteriuria should be actively sought and aggressively treated with at least one urinalysis, preferably toward the end of the first trimester. nitrofurantoin, ampicillin, and the cephalosporins have been used most extensively in pregnancy and are the regimens of choice for treating asymptomatic or minimally symptomatic uti. tmp-smx should be avoided in the first trimester because of possible teratogenic effects and should be avoided near term because of a possible role in the development of kernicterus. fluoroquinolones are avoided because of possible adverse effects on fetal cartilage development. for pregnant women with overt pyelonephritis, admission to the hospital for parenteral therapy should be the standard of care; beta-lactam agents with or without aminoglycosides are the cornerstone of therapy. prevention of uti, including pyelonephritis, can be accomplished during pregnancy with nitrofurantoin or cephalexin taken prophylactically after coitus or at bedtime without relation to coitus. such prophylaxis should be considered for patients who have had acute pyelonephritis during pregnancy, patients with bacteriuria during pregnancy who have had a recurrence after a course of treatment, and patients who had recurrent uti before pregnancy that required prophylaxis. catheter-associated utis are associated with increased mortality and costs. risk factors for catheter-associated utis include the duration of catheterization, lack of systemic antibiotic therapy, female gender, age older than years, and azotemia. to help prevent infection, urinary catheters should be avoided when possible and used only as long as needed. the catheter should be inserted with strict aseptic technique by trained persons, and a closed system should be used at all times. treatment of catheter-associated uti depends on the clinical circumstances. symptomatic patients (e.g., those with fever, chills, dyspnea, and hypotension) require immediate antibiotic therapy along with removal and replacement of the urinary catheter if it has been in place for a week or longer. in an asymptomatic patient, therapy should be postponed until the catheter can be removed. patients with long-term indwelling catheters seldom become symptomatic unless the catheter is obstructed or is eroding through the bladder mucosa. in patients who do become symptomatic, appropriate antibiotics should be administered and the catheter changed. therapy for asymptomatic catheterized patients leads to the selection of increasingly antibiotic-resistant bacteria. recurrence of uncomplicated cystitis in reproductive-age women is common, and some form of preventive strategy is indicated if three or more symptomatic episodes occur in year. however, risk factors specific to women with recurrent cystitis have received little study (sen, ) . several antimicrobial strategies are available, but before initiating therapy, the patient should try such simple interventions as voiding immediately after sexual intercourse and using a contraceptive method other than a diaphragm and spermicide. ingestion of cranberry juice has been shown to be effective in decreasing bacteriuria with pyuria, but not bacteriuria alone or symptomatic uti, in an elderly population. cranberry juice may be effective for preventing uti in young, otherwise healthy women. if simple nondrug measures are ineffective, continuous or postcoital-if the infections are temporally related to intercourse-low-dose antimicrobial prophylaxis with tmp-smx, a fluoroquinolone, or nitrofurantoin should be considered. typically, a prophylactic regimen is initially prescribed for months and then discontinued. if the infections recur, the prophylactic program can be instituted for a longer period. an alternative approach to antimicrobial prophylaxis for women with less frequent recurrences (< a year) is to supply tmp-smx or a fluoroquinolone and allow the patient to self-medicate with short-course therapy at the first symptoms of infection. a minority of patients have relapsing uti, as evidenced by finding the same bacterial strain within weeks after completion of antimicrobial therapy. two factors can contribute to the pathogenesis of relapsing infection in women: ( ) deep tissue infection of the kidney that is suppressed but not eradicated by a -day course of antibiotics and ( ) structural abnormality of the urinary tract, particularly calculi. patients with true relapsing utis should undergo renal ultrasound, intravenous pyelogram (ivp), or voiding cystourethrogram, and longer-term therapy should be considered. urinary tract infection is one of the most common infections of childhood. factors predisposing to uti include taking broad-spectrum antibiotics (e.g., amoxicillin, cephalexin), which are likely to alter gastrointestinal and periurethral flora; incomplete bladder emptying or infrequent voiding; voiding dysfunction; and constipation. uti in young children serves as a marker for abnormalities of the urinary tract. imaging of the urinary tract is recommended in every febrile infant or young child with a first uti to identify children with abnormalities that predispose to renal damage. imaging should consist of urinary tract ultrasonography to detect dilation of the renal parenchyma. voiding cystourethrography is often ordered but does not appear to improve clinical outcomes in uncomplicated utis (alper and curry, ) . a common complication of uti in men is prostatitis. bacterial prostatitis is usually caused by the same gram-negative bacilli that cause uti in female patients; % or more of such infections are caused by escherichia coli. the pathogenesis of this condition is poorly understood. antibacterial substances in prostatic secretions probably protect against such infections. a national institutes of health (nih) expert consensus panel has recommended classifying prostatitis into three syndromes: acute bacterial prostatitis, chronic bacterial prostatitis, and chronic pelvic pain syndrome (cpps). acute bacterial prostatitis is a febrile illness characterized by chills, dysuria, urinary frequency and urgency, and pain in the perineum, back, or pelvis. the bladder outlet can be obstructed. on physical examination, the prostate is found to be enlarged, tender, and indurated. pyuria is present, and urine cultures generally grow e. coli or another typical uropathogen. chronic bacterial prostatitis is a clinically more occult disease and may be manifested only as recurrent bacteriuria or variable low-grade fever with back or pelvic discomfort. urinary symptoms usually relate to the reintroduction of infection into the bladder, with both pyuria and bacteriuria. a chronic prostatic focus is the most common cause of recurrent uti in men. cpps is the diagnosis for the large group of men who present with minimal signs on physical examination but have a variety of irritative or obstructive voiding symptoms; perineal, pelvic, or back pain; and sexual dysfunction. these men can be divided into those with and those without inflammation (defined as > wbcs/hpf in expressed prostatic secretions). the etiology and appropriate management in these patients, regardless of inflammatory status, is unknown. • laboratory findings in acute tick-borne infection often include a normal or low wbc count, thrombocytopenia, hyponatremia, and elevated liver enzymes. • doxycycline is the drug of choice for patients with rmsf. • appropriate antibiotic treatment should be initiated immediately with strong suspicion of ehrlichiosis. • if left untreated, lyme disease can progress to cognitive disorders, sleep disturbance, fatigue, and personality changes. in the united states, more vector-borne diseases are transmitted by ticks than by any other agent. tick-borne diseases can result from infection with pathogens that include bacteria, rickettsiae, viruses, and protozoa. most tick-borne diseases are transmitted during the spring and summer months when ticks are active. a knowledge of which species of tick is endemic in an area can help narrow the diagnosis (table - ) . rocky mountain spotted fever (rmsf) is the most severe and most often reported rickettsial illness in the united states. it is caused by rickettsia rickettsii, a species of bacteria that is spread to humans by ixodid (hard) ticks (figure - ) . initial signs and symptoms include sudden onset of fever, headache, and muscle pain, followed by development of rash. the disease can be difficult to diagnose in the early stage. rmsf is most common among males and children. risk factors are frequent exposure to dogs and living near wooded areas or areas with high grass. the presentation of rsmf is nonspecific, following an incubation of about to days after a tick bite. initial symptoms can include fever, nausea, vomiting, severe headache, muscle pain, and lack of appetite. later signs and symptoms include rash, abdominal pain, joint pain, and diarrhea. the rash first appears to days after the onset of fever. most often it begins as small, flat, pink, nonitchy spots on the wrists, forearms, and ankles. the characteristic red spotted rash of rmsf is usually not seen until the sixth day or later after onset of symptoms. as many as % to % of patients never develop a rash (figure - ) . no widely available laboratory assay provides rapid confirmation of early rmsf, although commercial pcr testing is available. therefore, treatment decisions should be based on epidemiologic and clinical clues. treatment should never be delayed while waiting for confirmation by laboratory results. routine clinical laboratory findings suggestive of rmsf include normal wbc count, thrombocytopenia, hyponatremia, and elevated liver enzyme levels. serologic assays are the most often used methods for confirming cases of rmsf. doxycycline is the drug of choice for patients with rmsf. therapy is continued for at least days after fever subsides and until there is unequivocal evidence of clinical improvement, generally for a minimum total course of to days. tetracyclines are usually not the preferred drug for use in pregnant women. whereas chloramphenicol is typically the preferred treatment for rmsf during pregnancy, care must be used when administering chloramphenicol late during the third trimester of pregnancy because of risks associated with gray baby syndrome. three species of ehrlichia in the united states are known to cause disease in humans. ehrlichia chaffeensis, the cause of human monocytic ehrlichiosis, occurs primarily in southeastern and south-central regions and is primarily transmitted by the lone star tick, amblyomma americanum ( figure - ) . human granulocytic ehrlichiosis is caused by anaplasma phagocytophila or anaplasma equi and is transmitted by ixodes ticks. ehrlichia ewingii is the most recently recognized human pathogen, with cases reported in immunocompromised patients in missouri, oklahoma, and tennessee. after an incubation period of about to days following the tick bite, initial symptoms generally include fever, pregnant women should be screened for asymptomatic bacteriuria in the first trimester of pregnancy (wadland and plante, ) (sor: a). pregnant women who have asymptomatic bacteriuria should be treated with antimicrobial therapy for to days (nicolle et al., ) (sor: b) . pyuria accompanying asymptomatic bacteriuria should not be treated with antimicrobial therapy (nicolle, ) (sor: c ). a -day course of tmp-smx (bactrim, septra) is recommended as empiric therapy of uncomplicated utis in women, in regions where the rate of resistant e. coli is less than % (warren et al., ) (sor: c). fluoroquinolones are not recommended as first-line treatment of uncomplicated utis, to preserve their effectiveness for complicated utis (warren et al., ) (sor: c). a randomized, placebo-controlled trial of women over months found that cranberry juice and cranberry extract tablets significantly decreased the number of patients having at least one symptomatic uti per year (stothers, ) appropriate antibiotic treatment should be initiated immediately when there is a strong suspicion of ehrlichiosis on the basis of clinical and epidemiologic findings. the treatment recommendations are the same as for rocky mountain spotted fever. rifampin has been used successfully in a limited number of pregnant women with documented ehrlichiosis. babesiosis is caused by hemoprotozoan parasites of the genus babesia. the white-footed deer mouse is the main reservoir in the united states, and the vector is ixodes ticks. most infections are probably asymptomatic. manifestations of disease include fever, chills, sweating, myalgias, fatigue, hepatosplenomegaly, and hemolytic anemia. symptoms typically occur after an incubation period of to weeks and can last several weeks. the disease is more severe in immunosuppressed, splenectomized, or elderly patients. diagnosis can be made by microscopic examination of thick and thin blood smears stained with giemsa, looking for the parasite in red blood cells (rbcs). options for treatment include clindamycin plus quinine or atovaquone plus azithromycin. lyme disease is caused by the spirochetal bacterium borrelia burgdorferi. ixodes ticks are responsible for transmitting lyme disease bacteria to humans. in the united states, lyme disease is mostly localized to states in the northeastern, mid-atlantic, and upper north-central regions, as well as northwestern california. lyme disease most often manifests with a characteristic bull's-eye rash (erythema migrans) accompanied by nonspecific symptoms such as fever, malaise, fatigue, headache, muscle aches, and joint aches (figure - ) . lyme disease spirochetes disseminate from the site of the tick bite, causing multiple (secondary) erythema migrans lesions. other manifestations of dissemination include lymphocytic meningitis, cranial neuropathy (especially facial nerve palsy), radiculoneuritis, migratory joint and muscle pains, myocarditis, and transient atrioventricular blocks of varying degree. if left untreated, the disease can progress to intermittent swelling and pain of one or a few joints (usually large weight-bearing joints such as the knee), cognitive disorders, sleep disturbance, fatigue, and personality changes. the diagnosis is based primarily on clinical findings, and it is often appropriate to treat patients with early disease solely on the basis of objective signs and a known exposure. serologic testing may provide valuable supportive diagnostic information in patients with endemic exposure and objective clinical findings that suggest later-stage disseminated lyme disease. treatment for to weeks with doxycycline or amoxicillin is generally effective in early disease. cefuroxime axetil or erythromycin can be used for persons allergic to penicillin or who cannot take tetracyclines. later disease, particularly with objective neurologic manifestations, can require treatment with intravenous ceftriaxone or penicillin for weeks or more, depending on disease severity. tularemia is caused by francisella tularensis, one of the most infectious pathogenic bacteria known. most cases in the united states occur in south-central and western states. humans can become infected through diverse environmental exposures, including bites by infected arthropods; handling infectious animal tissues or fluids; direct contact with or ingestion of contaminated food, water, or soil; and inhalation of infective aerosols. inhaled f. tularensis causes pleuropneumonitis. some exposures contaminate the eye, resulting in ocular tularemia; penetrate broken skin, result- ing in ulceroglandular or glandular disease; or cause oropharyngeal disease with cervical lymphadenitis. untreated, bacilli inoculated into skin or mucous membranes multiply, spread to regional lymph nodes, multiply further, and then can disseminate to organs throughout the body. the onset of tularemia is usually abrupt, with fever, headache, chills and rigors, generalized body aches, coryza, and sore throat. a dry or slightly productive cough and substernal pain or tightness often occur with or without objective signs of pneumonia. nausea, vomiting, and diarrhea can occur. sweats, fever, chills, progressive weakness, malaise, anorexia, and weight loss characterize continuing illness. rapid diagnostic testing for tularemia is not widely available. respiratory secretions and blood for culture should be collected in suspected patients and the laboratory alerted to the need for special diagnostic and safety procedures. streptomycin ( g im bid for days) is the drug of choice, and gentamicin is an acceptable alternative. tetracyclines and chloramphenicol can also be used. colorado tick fever is an acute viral infection transmitted by the bite of the dermacentor andersoni tick (figure - ) . the disease is limited to the western united states and is most prevalent from march to september. symptoms start about to days after the tick bite. fever continues for days, stops, and then recurs to days later for another few days. other symptoms include excessive sweating, muscle aches, joint stiffness, headache, photophobia, nausea, vomiting, weakness, and an occasional faint rash. routine blood tests might show a low wbc count, mildly elevated liver function, and mildly elevated creatine phosphokinase (cpk). diagnosis is confirmed by testing blood for complement fixation immunofluorescent antibody staining to colorado tick virus. treatment is removal of the tick and treatment of symptoms. physicians should advise patients who walk or hike in tickinfested areas to tuck long pants into socks to protect the legs and wear shoes and long-sleeved shirts. ticks show up on white or light colors better than dark colors, making them easier to remove from clothing. if attached, ticks should be removed immediately by using a tweezers, pulling carefully and steadily. insect repellents such as deet, alone or in combination with permethrin, may be helpful. • most cases of cellulitis are caused by staphylococci or streptococci, but other causes should be considered by clinical situation. • physicians must rule out more ominous causes of skin inflammation, such as necrotizing fasciitis and pyomyositis, when considering cellulitis. • edema-associated cellulitis is best treated by mobilizing edema fluid. cellulitis is an acute, spreading inflammation of the derma and subcutaneous issue. patients complain of tenderness, warmth, swelling, and spreading erythema. in contrast to erysipelas, cellulitis usually lacks sharp demarcation at the border. factors that predispose to cellulitis include trauma, an underlying skin lesion (furuncle, ulcer), or a complication arising from a wound, ulcer, or dermatosis. occasionally, cellulitis results from a blood-borne infection that metastasizes to the skin. pain and erythema usually develop within several days and are often associated with malaise, fever, and chills. the area involved is often extensive, red, hot, and swollen. patchy involvement with skip lesions can be seen. regional lymphadenopathy is common, and bacteremia can occur. several clinical entities resemble cellulitis, including pyoderma gangrenosum, gout, and insect bites. necrotizing fasciitis and gas gangrene are surgical emergencies. given that the predominant organism involved in most cases of cellulitis is a grampositive coccus, clinical history and morphology on physical examination usually suffice in the diagnosis and treatment of cellulitis. a history of freshwater exposure may implicate aeromonas hydrophila as the causative organism; saltwater appropriate antibiotic therapy should be initiated immediately when there is suspicion of rocky mountain spotted fever, ehrlichiosis, or relapsing fever rather than waiting for laboratory confirmation (bratton and corey, ; spach et al., ) (sor: c). treatment with doxycycline (vibramycin) or tetracycline is recommended for rmsf, lyme disease, ehrlichiosis, and relapsing fever (bratton and corey, ; spach et al., ) (sor: c). recommended actions to prevent tick-borne disease include avoidance of tick-infested areas; wearing long pants and tucking the pant legs into socks; applying diethyltoluamide (deet) insect repellents; using bed nets when camping; and carefully inspecting oneself frequently while in an at-risk area (bratton and corey, ; spach et al., ) (sor: c). antibiotic prophylaxis is not routinely recommended for a tick bite to prevent lyme disease, unless the risk of infection is high (wormser et al., ) (sor: b). recommended treatment for suspected tularemia is streptomycin or gentamicin given empirically before evidence of laboratory confirmation (bratton and corey, ; spach et al., ) (sor: c). exposure suggests vibrio spp. cellulitis in a patient with liver disease and shellfish ingestion moves vibrio vulnificans to the top of the differential. patients with soft tissue infection should have blood drawn for laboratory testing if signs and symptoms of systemic toxicity are present (e.g., fever or hypothermia, tachycardia, hypotension). laboratory testing should include blood culture and drug susceptibility tests; wbc count with differential; and measurement of creatinine, bicarbonate, cpk, and crp levels. hospitalization should be considered for patients with hypotension or an elevated creatinine level, low serum bicarbonate level, elevated cpk level (i.e., - times upper limit of normal), marked left shift, or crp level greater than mg/l ( . nmol/l). gram stain with culture and culture of needle aspiration or punch biopsy specimens should be performed to determine a definitive etiology, and a surgical consult should be considered for inspection, exploration, and drainage. findings that may signal potentially severe, deep, soft tissue infection and that may require emergent surgical evaluation include cutaneous hemorrhage, gas in the tissue, pain disproportionate to physical findings, rapid progression, skin anesthesia, skin sloughing, and violaceous bullae. radiologic studies may be helpful if abscess or osteomyelitis is a possibility. ultrasonography is helpful in detecting a subcutaneous collection of fluid. magnetic resonance imaging (mri) is also useful in differentiating cellulitis from necrotizing fasciitis. the diagnosis of necrotizing cellulitis is by direct surgical examination or by frozen pathology sections. empiric antibiotics for immunocompetent patients with cellulitis should be targeted toward gram-positive cocci (table - ) . broader coverage should be initiated for diabetic patients to include gram-positive aerobes, gram-negative aerobes, and anaerobes. patients who present with severe infection or whose infection is progressing despite empiric antibiotic therapy should be treated more aggressively; the treatment strategy should be based on results of appropriate gram stain, culture, and drug susceptibility analysis. in the case of staphylococcus aureus, the physician should assume that the organism is resistant, and agents effective against mrsa, such as vancomycin, linezolid (zyvox), or daptomycin (cubicin), should be used. the antibiotic may be switched from an intravenous drug to an oral drug when fever has subsided and the skin lesion begins to resolve, usually in to days. the total duration of therapy should be to days. longer duration may be required if the response is slow or is associated with abscess, tissue necrosis, or underlying skin processes (infected ulcers or wounds). treatment of cellulitis should include elevation and immobilization to decrease swelling. patients with interdigital dermatophytic infections should be treated with a concomitant topical antifungal applied once or twice daily. topical antifungals can also help reduce the risk of recurrence of the cellulitis. support stockings, good skin hygiene, and prompt treatment of tinea pedis helps with prevention of cellulitis in patients with peripheral edema, who are predisposed to recurrence. in patients who continue to have frequent episodes of cellulitis or erysipelas, prophylactic treatment with penicillin v, mg or mg orally twice daily, or erythromycin, mg once or twice daily (for penicillin-allergic patients), may be indicated. • the majority of furuncles and carbuncles are caused by staphylococcus spp., increasingly, community-acquired methicillin-resistant s. aureus. • drainage of pus is of primary importance in treating skin and soft tissue infections. • culture of sstis is important in guiding antibiotic treatment when initial measures of drainage are not effective. • for recurrent boils, consider referral to infectious disease specialist, possibly to eradicate carriage state. furuncles, or boils, are infections of the skin and soft tissue usually associated with a hair follicle. carbuncles are an extension of this skin and soft tissue infection continuum and involve more of the surrounding and subcutaneous tissue. the broad category skin and soft tissue infections (sstis) is used to describe this continuum that includes furuncles and carbuncles. sstis are common in both healthy and immunocompromised patients and likely initiate with some breach of the skin integrity, such as irritation of hair follicles from friction or microscopic trauma to the skin. up to % of furuncles and carbuncles are caused by community-acquired methicillin-resistant staphylococcus aureus (ca-mrsa) (cdc, ). other potential causative organisms include nonresistant staphylococcus spp. and streptococcus spp. it has become increasingly important to obtain culture of a lesion to direct antibiotic coverage given the increase in ca-mrsa. there is no reliable historical or examination element that will distinguish a ca-mrsa from a methicillin-sensitive staphylococcal skin lesion. stereotypically, patients report ca-mrsa lesions starting like a spider bite. furuncles and carbuncles can occur anywhere on the body, although the axillae, groin, and buttocks are particularly common sites. in addition, practices that cause skin trauma (e.g., shaving, waxing) are often noted in patients with these sstis. fever and malaise are uncommon with milder lesions but become more frequent with the increasing scope of localized infection. of primary importance in the management of carbuncles and furuncles is facilitation of drainage of any purulent material. with smaller lesions, this may be accomplished by heat application by the patient at home. as lesions increase in size and fluctuance, surgical drainage is essential to facilitate resolution of an ssti. it is important to consider culture penicillin, given parenterally or orally depending on clinical severity, is the treatment of choice for erysipelas (sor: a). for cellulitis, a penicillinase-resistant semisynthetic penicillin (amoxicillin/clavulanate) or a first-generation cephalosporin should be selected, unless streptococci or staphylococci resistant to these agents are common in the community (sor: a). for suspected mrsa skin infections, oral treatment options include trimethoprim-sulfamethoxazole, clindamycin, and doxycycline of purulent material when performing incision and drainage in the event that the patient fails to improve and antibiotic coverage becomes necessary. cure rates of lesions with drainage alone exceed %. careful follow-up after drainage is essential to ensure clinical improvement; daily dressing changes in the office after surgical drainage is effective. the addition of postdrainage antibiotics has not shown much added benefit. to prevent the spread of infection to others who come into contact with the patient recovering from an ssti, an occlusive dressing to prevent leakage of lesion fluid and careful hygiene are indicated. there is no evidence that extensive cleaning of common spaces (e.g., locker rooms) prevents the spread of ssti-causing bacteria more than routine cleaning measures. towels and soiled clothing should be laundered in hot water, and any common equipment should be cleaned per manufacturer recommendations. when lesions do not respond to heat, or when lesions are larger yet not amenable to drainage, antibiotics may be used. reasonable first-line antibiotic coverage for nonfluctuant lesions may include dicloxacillin, first-or secondgeneration cephalosporins, macrolides, or clindamycin. in patients with suspected ca-mrsa, better choices include tmp-smx, tetracycline, or clindamycin. it is important to note that up to % of ca-mrsa species will be resistant to clindamycin, particularly if the patient has been treated with other antibiotics in the previous weeks to months . oral administration of these antibiotics is acceptable in the nontoxic patient. patient signs and symptoms that would warrant hospital admission include fever or hypothermia, tachycardia, or hypotension as signs of sepsis and lesions greater than cm in size (table - ) . for patients with recurrent sstis, evaluation for the presence of nasal carriage with a nasal culture is indicated. the value of eradication of bacterial carriage is unclear. referral for infectious disease specialist evaluation may be indicated to guide decision making in the patient with recurrent furuncles and carbuncles. • the existence, severity, and extent of infection, as well as vascular status, neuropathy, and glycemic control, should be assessed in patients with a diabetic foot infection. • visible bone and palpable bone on probing suggest underlying osteomyelitis in patients with a diabetic foot infection. • before an infected wound of a diabetic foot infection is cultured, any overlying necrotic debris should be removed to eliminate surface contamination and to provide more accurate results. patients with diabetes are prone to skin ulcers caused by neuropathy, vascular insufficiency, and diminished neutrophil function. minor wounds can be secondarily infected, leading to ulcer formation. these ulcers often have extensive undermining with necrotic tissues and are often close to the anus, thus promoting an environment suitable for multiple species of microorganisms, including anaerobes. diabetic foot infections range in severity from superficial paronychia to deep infection involving bone. non-limb-threatening infections involve superficial ulcers with minimal cellulitis (< cm from portal of entry), no signs of systemic toxicity, and no significant ischemia in the limb. cure rates of fluctuant skin lesions with drainage alone is over %. postdrainage antibiotics do not significantly improve outcomes rajendran et al., ) (sor: a). trimethoprim-sulfamethoxazole (tmp-smx), clindamycin, and tetracycline are first-choice antibiotics when ca-mrsa is suspected. up to % of ca-mrsa species will be resistant to clindamycin, particularly in the patient previously treated with other antibiotics (sor: c). subcutaneous tissues, and prominent ischemia. infection in patients who have recently received antibiotics or who have deep, limb-threatening infection or chronic wounds are usually caused by a mixture of aerobic gram-positive, aerobic gram-negative (e.g., escherichia coli, proteus spp., klebsiella spp.), and anaerobic organisms (e.g., bacteroides, clostridium, peptococcus, and peptostreptococcus spp.) . surgery is necessary to unroof encrusted areas, and the wounds need to be examined and probed to determine the extent of the infection and check for bone involvement (dinh et al., ) . debridement or drainage should be promptly performed. deep wound cultures should be obtained if possible. if deep culture is not feasible, gram stain and culture from the curettage of the base of the ulcer or from purulent exudates may be needed to guide antibiotic therapy (figure - ) . plain radiography of the foot is indicated for detection of osteomyelitis, foreign bodies, and soft tissue gas. when plain radiography is negative but osteomyelitis is clinically suspected, radionuclide scan or mri should be performed. mri provides more accurate information regarding the extent of the infectious process. the presence of peripheral artery disease and neuropathy should be assessed. the antibiotic regimen should be based on meaningful bacteriologic data. however, the initial regimen for a previously untreated patient with non-limb-threatening infection should focus on s. aureus and streptococci. mild infections may be treated with dicloxacillin or cephalexin for weeks. amoxicillin/clavulanate may be used if polymicrobial infection is suspected. if msra is suspected, oral treatment options include tmp-smx or doxycycline. for limb-threatening infections, broad-spectrum antibiotics are recommended for coverage of group b streptococci, other streptococci, enterobacteriaceae, anaerobic gram-positive cocci, and bacteroides spp. treatment regimens include ampicillin-sulbactam or ertapenem (invanz), clindamycin plus a third-generation cephalosporin, and clindamycin plus ciprofloxacin. intravenous vancomycin should be added if mrsa infection is suspected. ciprofloxacin as a single agent is not recommended. in addition to antibiotic treatment, good glycemic control should be obtained and open wounds gently packed with sterile gauze moistened with ¼-strength povidone-iodine (betadine) solution. edema should be reduced by bed rest, elevation, and diuretic therapy as indicated. for prevention of diabetic foot ulcers, all patients with diabetes should have an annual foot examination that includes assessment for anatomic deformities, skin breaks, nail disorders, loss of protection sensation, diminished arterial supply, and inappropriate footwear. • the use of prophylactic antibiotics may be necessary in the initial management of bite wounds, particularly if the bite is on the hand or face or from a cat. • first-generation cephalosporins (e.g., cephalexin) are not effective as monotherapy for bite wounds because of resistance issues. • avoid primary wound closure in the management of bite wounds. it is estimated that bites account for , medical visits annually in the united states, making up % of emergency department visits. bite wounds consist of lacerations, evulsions, punctures, and scratches. the microbiology of bite wounds is generally polymicrobial, with an array of potential bacteria from the environment, the victim's skin flora, and the biter's oral flora. dog bites account for approximately % of all animal bites requiring medical attention, in which % are provoked attacks. most dog bites occur on the distal extremities, but children tend to sustain facial bites. patients who present for medical attention are often concerned about the care of disfiguring wounds or the need for appropriate vaccination (i.e., tetanus, rabies). however, up to % of medically treated wounds may become infected. these wounds are often contaminated with multiple strains of aerobic and anaerobic bacteria. local signs of infection with erythema, edema, pain, and purulent drainage are common with animal bite wounds. although the most frequently isolated pathogen related to dog and cat bite wounds is pasteurella multocida, the array of potential organisms is much greater. anaerobes such as bacteroides tectum, prevotella spp., fusobacteria, and peptostreptococci can be isolated from animal bite wounds % of the time, mostly from wounds with abscess formation. capnocytophaga canimorsus has also been associated with fatal infection from fulminant sepsis in asplenic patients. wounds inflicted by cats are often scratches or tiny punctures located on the extremity and are likely to become infected and lead to abscess formation. in the united states, venomous snakes bite approximately people yearly. envenomation in such snakebites account for the majority of morbidity and mortality associated with such bites. however, infection of soft tissue structures may also occur as a result of oral flora from the snake, which tends to be fecal in nature because live prey usually defecate in the snake's mouth with their ingestion. human bites are not uncommon, especially in children. human bites have a higher complication and infection rate than do animal bites. human bite wounds most often affect the hand and fingers and in some cases may present as "love routine wound swabs and cultures of material from sinus tracts are unreliable and strongly discouraged in the management of diabetic foot infection (pellizzer et al., ; senneville et al., ) nips" to the breast and genital areas. self-inflicted bites often include wounds of the lip and tissues surrounding the nail, such as paronychia. also included in this are clenched-fist injuries or "fight bites," which result in small lacerations to the knuckles when striking a person in the mouth. normal human oral flora, rather than skin flora, is the source of most bacteria isolated from human bite wound cultures (viridans streptococci, eikenella corrodens). management of bite wounds is the same as for any other wound: good wound care in the form of adequate irrigation and debridement of nonviable tissue as needed (table - ) . bite wounds in general do not require primary closure, but after adequate irrigation and debridement, wounds may be approximated and closed by delayed primary or secondary intention. an exception to this rule may include bite wounds to the face. general wound management measures such as tetanus toxoid administration should also be employed. bite wounds involving the hands should be evaluated by a hand surgeon, given the risk of adjacent tendon sheath, bone, or joint involvement and the dire consequences if such structures are involved. the transmission of rabies through the bites of domestic pets in the united states and developed countries is rare. in fact, the dog strain of rabies is considered eliminated in the u.s. dog population, and cat bites are often managed through observation of the animal, without the immediate need for rabies postexposure treatment (pet). however, wild mammal exposure, especially bat, skunk, or raccoon, often warrants pet, which involves thorough cleaning of the bite wound, ideally with povidone-iodine solution, along with rabies immune globulin given at the wound site and rabies vaccine given on days , , , and . bite wounds should be considered contaminated wounds from presentation, given the oral microbial flora of humans and animals, and most patients should probably receive antibiotics early. empiric antibiotics are used to eradicate oral flora inoculated from the mouth of the biter, whether human or animal, into the wound. all moderate to severe animal bite wounds, or wounds that have an associated crush injury or that are close to a bone or joint, should be considered contaminated with potential pathogens, and these patients should receive to days of "prophylactic" antimicrobial therapy. gram stains with culture of bite wounds are specific but not sensitive indicators of bacterial growth. nonetheless, gram stain can be used to help guide initial empiric antibiotic therapy. amoxicillin-clavulanic acid (amoxicillin-clavulanate; augmentin) or penicillin plus a penicillinase-resistant penicillin are normally first-line agents for empiric therapy directed at bite wounds. first-generation cephalosporins (e.g., cephalexin) are not effective as monotherapy because of resistance of some anaerobic bacteria and e. corrodens. a -to -day course of antibiotics is usually adequate for infections limited to the soft tissue, and a minimum of weeks of therapy is required for infections involving joints or bones. close follow-up is required in all bites to ensure adequate healing. of special consideration in human bite wounds is the potential for spread of viral pathogens, most notably hepatitis b virus (hbv) and hiv, if the source person is positive. hbv exposure in this setting should be handled in the same manner as other exposures, with administration of hbig and hbv vaccination. with regard to hiv, cdc guidelines for managing nonoccupational hiv exposure recommend handling each case individually in consultation with an infectious diseases specialist. • the diagnosis of osteomyelitis is based on radiographic findings (plain radiograph or mri) showing bony destruction along with histologic analysis and culture results. • chronic osteomyelitis is not an emergency, and antibiotics can be safely withheld until an etiologic diagnosis is established. • diabetic foot infections require a careful evaluation to assess perfusion and vascular supply, and corrective measures should be undertaken to reestablish adequate perfusion if necessary. • in diabetic foot ulcers, if one can probe to bone, the patient most likely has osteomyelitis. • orthopedic hardware infections are best managed in conjunction with an infectious diseases specialist and orthopedic surgeon. osteomyelitis is defined as progressive, inflammation leading to destruction of the bone, usually secondary to an infectious agent. bacteria can enter bone through hematogenous seeding or a contiguous focus after trauma, implantation of a foreign device, or a local soft tissue infection. acute osteomyelitis is defined as infection that evolves over a few weeks. chronic osteomyelitis implies persistent infection of several weeks to months. hematogenous osteomyelitis occurs primarily in children within the metaphyses of long bones (tibia and femur) and vertebrae in adults. in addition to local signs of inflammation and infection, patients generally have various systemic signs, including fever, irritability, and lethargy. physical findings include tenderness over involved area and decreased range of motion in adjacent joints. chronic osteomyelitis usually occurs in adults, caused by an open injury to bone and surrounding soft tissue. erythema, drainage around area, and bone pain are usually present on physical examination. systemic symptoms occur less frequently. the diagnosis of osteomyelitis is based on the clinical picture and supporting laboratory and radiologic findings. leukocytosis and elevations in crp and esr may use of antibiotic prophylactic after bites of the hand reduces the incidence of infection (medeiros and saconato, ) (sor: b) . antibiotic prophylaxis after bites by humans reduces incidence of infection (sor: c). animal bite: ascertain the type of animal, whether the bite was provoked or unprovoked, and the situation/environment in which the bite occurred. if the species can be rabid, locate the animal for days' observation or sacrifice. patient: obtain information on antimicrobial allergies, current medications, splenectomy, mastectomy, liver disease, and immunosuppression. record a diagram of the wound with the location, type, and depth of injury; range of motion; possibility of joint penetration; presence of edema or crush injury; nerve and tendon function; signs of infection; and odor of exudate. infected wounds should be cultured and a gram stain performed. anaerobic cultures should be obtained in the presence of abscesses, sepsis, serious cellulitis, devitalized tissue, or foul odor of the exudate. small tears and infected punctures should be cultured with a minitipped (nasopharyngeal) swab. copious amounts of normal saline should be used for irrigation. puncture wounds should be irrigated with a "high-pressure jet" from a -ml syringe and an -gauge needle or catheter tip. devitalized or necrotic tissue should be cautiously debrided. debris and foreign bodies should be removed. radiographs should be obtained if fracture or bone penetration is possible to provide a baseline for future osteomyelitis. wound closure may be necessary for selected, fresh, uninfected wounds, especially facial wounds, but primary wound closure is not usually indicated. wound edges should be approximated with adhesive strips in selected cases. prophylaxis: consider prophylaxis ( ) for moderate to severe injury less than hours old, especially if edema or crush injury is present; ( ) if bone or joint penetration is possible; ( ) for hand wounds; ( ) for immunocompromised patients (including those with mastectomy, liver disease, or steroid therapy); ( ) if the wound is adjacent to prosthetic joint; and ( ) if the wound is in the genital area. coverage should include pasteurella multocida, staphylococcus aureus, and anaerobes. treatment: cover p. multocida, s. aureus, and anaerobes. use oral medication if the patient is seen early after a bite and only mild to moderate signs of infection are present. the following can be considered for cat or dog bites in adults: • first choice: amoxicillin/clavulanic acid, / mg bid or / mg tid with food. • penicillin allergy: no alternative treatment for animal bites has been established for penicillin-allergic patients. the following regimens can be considered for adults: . clindamycin ( mg po qid) plus either levofloxacin ( mg po daily) or trimethoprim-sulfamethoxazole ( double-strength tablets po bid). . doxycycline, mg po bid. . moxifloxacin, mg po daily. . in the highly penicillin-allergic pregnant patient, macrolides have been used, but the wounds must be watched carefully. on emergency department discharge, a single starting dose of parenteral antibiotic, such as ertapenem ( g), may be useful in selected cases. if hospitalization or closely monitored outpatient follow-up is required, intravenous agents should be used. current choices include ampicillin/sulbactam and cefoxitin. the rising incidence of community-acquired s. aureus isolates that are methicillin resistant and therefore resistant to the drugs recommended here emphasizes the importance of susceptibility-testing any s. aureus isolates. indications include fever, sepsis, spread of cellulitis, significant edema or crush injury, loss of function, a compromised host, and patient noncompliance. give tetanus booster (td; tetanus and diphtheria toxoids for adults) if original three-dose series has been given but none in the past years. adults who have not received acellular pertussis vaccine (tdap), should be given this instead of td. give a primary series and tetanus immune globulin if the patient was never immunized. rabies vaccine (on days , , , , and ) with hyperimmune globulin may be required, depending on the type of animal, ability to observe the animal, and locality. elevation may be required if any edema is present. lack of elevation is a common cause of therapeutic failure. be seen but can also be normal. blood cultures may be positive in up to half of children with acute osteomyelitis. if plain radiographs show bone destruction and inflammation; the diagnosis of osteomyelitis is confirmed. typical findings on plain-radiographs will include osteolysis, periosteal reaction, and sequestra (segments of necrotic bone separated from living bone by granulation tissue). findings seen on plain radiographs usually denote a process that has been ongoing for at least weeks. bone scintigraphy (bone scan) is often performed on patients with suspected osteomyelitis; however, sensitivity is quite low, and a negative result can offer false reassurance to the physician, so its routine use is not recommended. if the plain-radiographs are negative but the suspicion for osteomyelitis is still high, an mri scan should be considered. once the diagnosis of osteomyelitis has been made, the next step is to obtain an etiologic diagnosis. histopathologic and microbiologic examination of bone is the "gold standard." cultures of sinus tracts are not reliable for identifying the causative organism. common causative bacteriologic organisms in neonates include staphylococcus aureus, group b streptococci, and escherichia coli. later in life, s. aureus is most common, and in elderly persons, gram-negative organisms such as pseudomonas aeruginosa and serratia spp. have increased incidence. empiric antibiotics are rarely required for chronic disease but are often necessary for acute osteomyelitis. ideally, surgical debridement of all necrotic tissue and inflammatory debris (pus) should be undertaken and multiple surgical cultures with bone histology samples obtained. antimicrobial therapy will be dictated by test results. generally, treatment is for to weeks. with the exception of the fluoroquinolone class of antibiotics, which achieve high serum levels with oral administration, bone antibiotic levels cannot exceed the minimum inhibitory concentration (mic) for the infecting organism; therefore, antibiotics must be given intravenously. this underscores the importance in obtaining a bacterial diagnosis so that the appropriate antibiotic can be used for the duration of treatment. acute osteomyelitis is usually readily curable; however, chronic osteomyelitis is generally more refractory to therapy and requires repeat debridement and antibiotic courses. patients with uncontrolled diabetes are at increased risk for development of osteomyelitis, especially in the presence of neuropathy or venous or arterial insufficiency. s. aureus and beta-hemolytic streptococci are the predominant organisms, although other gram-positive or gram-negative aerobic or anaerobic bacteria may also be seen. plain radiographs should be the initial test to evaluate for the presence of osteomyelitis, followed by mri if negative. if there is a draining sinus, the "probe to bone" test should be performed with a sterile probe; if bone is palpated, the diagnosis of osteomyelitis is highly likely. further evaluation of the diabetic patient should be to assess for vascular insufficiency with the use of ankle-brachial indices and transcutaneous oximetry. if significant compromise is found, arteriography followed by revascularization should be undertaken. surgical debridement is again the cornerstone of treatment, along with antibiotics directed toward the causative microorganism. infections secondary to orthopedic hardware devices have become common problems with the increasing incidence of hip, knee, and shoulder replacement surgeries. also, patients with traumatic injury resulting in a fracture often have hardware implanted to stabilize the bone. these patients present in one of the three following ways: . early: symptoms develop less than months after surgery and have an acute presentation with pain, erythema, and warmth, usually caused by s. aureus and gram-negative bacilli. . delayed: symptoms develop to months after surgery, generally with subtle signs of infection, including implant loosening and persistent pain, and usually caused by less virulent organisms such as coagulasenegative staphylococci and propionibacterium acnes. . late: symptoms develop months after surgery and are usually caused by hematogenous seeding from skin, dental, respiratory, and urinary infections. treatment requires debridement of the surrounding tissue and hardware removal, although this cannot always be done in patients with bone instability. it is recommended that treatment follow-up should occur at hours and perhaps hours for outpatients. reporting the incident to a local health department may be required. from goldstein ejc. bites. in mandell gl, bennett je, dolin rd (eds). mandell, douglas, and bennett's principles and practice of infectious diseases, th ed. philadelphia, churchill livingstone--elsevier, . po, orally; bid, twice daily; tid, three times daily; qid, four times daily. of these infections be done in conjunction with an infectious diseases specialist working with the orthopedic surgeon. septic arthritis is defined as infection within the joint space of two bones. the major causative organisms include s. aureus and in the sexually promiscuous individual, neisseria gonorrhoeae. intravenous drug users are likely to develop septic arthritis within unusual joints (e.g., sternoclavicular, sacroiliac). rheumatoid arthritis, presence of joint prostheses, and steroid use are predisposing factors for development of septic arthritis. diagnosis is usually based on clinical presentation of a warm, swollen joint with limitation in range of motion. a joint aspiration should be completed and the synovial fluid sent for gram stain with culture, wbc count with differential, and crystal analysis to rule out gout and pseudogout. blood cultures should also be drawn before initiation of antibiotics. gonococcal arthritis usually presents as an acute arthritis involving one or more joints in a sexually active individual. two thirds of patients have dermatitis with one or multiple, usually asymptomatic, lesions that progress from macular to papular and finally vesicular or pustular. joint fluid, urethral, and rectal cultures should also be obtained. treatment is generally with a third-generation cephalosporin intravenously until improvement, followed by oral therapy to complete a -week course of therapy. treatment of nongonococcal arthritis requires proper draining of the infected joint. this is often done surgically, although repeat needle drainage may also be successful if the joint is easily accessible. treatment generally depends on the gram stain and includes a third-generation cephalosporin, with the addition of vancomycin if gram-positive cocci in clusters are seen. duration of therapy is to weeks. • a comprehensive history and physical examination with laboratory and radiologic evaluation are important in the workup for fever of unknown origin (fuo). • if routine information is unrevealing, more specific testing for fuo is undertaken based on the patient's age, travel history, and disease process to develop a differential diagnosis. • the serum ferritin level (often elevated with malignancy) and naproxen test (reduces fever with malignancy) may be helpful in determining an underlying malignant process. • initiation of empiric antibiotics should be done only in specific fuo situations to prevent skewing culture results, thus maximizing isolation of the causative organism. patients who have a persistent fever despite workup are generally classified as having a "fever of unknown origin" (fuo). in , petersdorf and beeson described patients with persistent fever, otherwise known as fever of unknown origin. they introduced the standard, classic definition of fuo: fever higher than . ° c ( ° f) on several occasions, persisting without diagnosis for at least weeks, with week of investigational study in the hospital setting. with advancing technology, this definition has been revised to allow for more than two outpatient visits, or days if investigation is in the hospital setting. most patients with fuo have chronic or subacute symptoms and can be safely evaluated in the outpatient setting, with a median time to diagnosis of days. the differential diagnosis of fuo is quite broad and extensive. determining an etiologic diagnosis of an fuo depends on generating a differential diagnosis compatible with the patient's history and physical examination. the principal disease categories for fuo include infection ( % overall), neoplasms ( %), collagen vascular diseases ( %), and miscellaneous ( %) (box - ). because of this broad differential, a newer classification system divides fuo into four groups: classic, nosocomial, neutropenic, and hiv associated, which helps narrow the differential diagnosis. furthermore, classic fuo can be broken down into three subgroups: infants and children, elderly, and travelers. despite an extensive workup, the etiologic diagnosis usually remains elusive in % to % of patients (box - ) . the diagnostic workup of fuo should begin with a thorough history and physical examination, including documentation of the fever. the patient may provide a diary noting the date and time of fever. routine noninvasive investigations are recommended in all patients before diagnosing fuo (box - ). acute febrile illness is never called an fuo. the patient's medication profile is reviewed because numerous drugs can be the cause. if unrevealing, a workup is initiated based on the differential diagnosis for the patient's age, travel history, geographic location, and disease process. dukes criteria for infective endocarditis have % specificity in patients with fuo. when the initial investigations are not helpful in identifying a cause, imaging should be considered, such as computed tomography (ct) scans of the chest, abdomen, and pelvis; ct may reveal an abscess or suggest an underlying malignancy. an elevated serum ferritin level can suggest a neoplasm or myeloproliferative disorder and, if normal, greatly decreases the chance that the patient has an underlying malignancy. lower-extremity doppler ultrasound should be considered in the sedentary or obese patient to rule out deep venous thrombosis. a temporal artery biopsy should be considered in the elderly patient to rule out temporal arteritis. liver biopsy has a high diagnostic yield with minimal toxicity, whereas bone marrow cultures usually have a low yield and should be considered only in special situations. empiric therapy with antibiotics is rarely appropriate for the patient with fuo. a diagnosis is essential to guide treatment of osteomyelitis requires surgical debridement followed by a -to -week course of intravenous antibiotic therapy (sor: c). septic arthritis is usually caused by a gonococcus in a sexually active adult, and use of a third-generation cephalosporin is the mainstay of therapy (sor: a). nongonococcal arthritis should be treated with surgical debridement or repeated needle aspirations, with a third-generation cephalosporin and vancomycin if gram-positive cocci are seen (goldenberg, ) (sor: b). treatment, and use of antibiotics may delay determining a causative infectious agent. the naproxen test (naprosyn; mg po every hours for days) is helpful in determining if the fever is secondary to infection or malignancy. a dramatic decrease in the patient's temperature during the test generally indicates a malignant focus, whereas minimal or no response indicates an infectious etiology. the prognosis of fuo depends on the etiologic category. undiagnosed fuo has a very favorable outcome. patients in whom diagnostic investigations fail to identify an etiology should be followed clinically with serial history reviews and physical examinations until the fever resolves or new diagnostic clues are found. connective tissue diseases are more prominent. infections: malaria, hepatitis, pneumonia/bronchitis, uti/pyelonephritis, dysentery, dengue fever, enteric fever, tb, rickettsial infection, acute human immunodeficiency virus (hiv) infection, amebic liver abscess. postoperative urinary and respiratory tract instrumentation; use of intravascular devices; drug therapy; immobilization. septic thrombophlebitis, pulmonary embolus, clostridium difficile colitis, drug fever. fungal: % susceptible to empiric antifungals, % will be resistant to empiric therapy. bacterial: % not responding to empiric antimicrobial therapy and usually with cryptic focus. unusual pathogens: % will be toxoplasmosis (toxoplasma gondii) reactivation, atypical mycobacterial, tb, fastidious pathogens (legionella, mycoplasma, chlamydophila). viral: % of causes (hsv, cmv, ebv, hhv- , vzv, rsv, influenza, parainfluenza). other: % will be transplant related (e.g., gvhd) following stem cell transplant, % will be undefined. infections: mycobacterium avium complex (mac), pneumocystis carinii pneumonia (pcp), cytomegalovirus (cmv), histoplasmosis, viral (hcv, hbv, adenovirus, hsv esophagitis, vzv encephalitis), tb, other fungi, cerebral toxoplasmosis, disseminated cryptosporidiosis. neoplasms: lymphoma, kaposi's sarcoma. other: drug fever, castleman's disease. hsv, herpes simplex virus; ebv, epstein-barr virus; hhv, human herpesvirus; vzv, varicella-zoster virus; rsv, respiratory syncytial virus; gvhd, graft-versus-host disease; hcv, hepatitis c virus; hbv, hepatitis b virus. abscesses: hepatic, subhepatic, gallbladder, subphrenic, splenic, periappendiceal, perinephric, pelvic, and other sites. granulomatous: extrapulmonary and miliary tuberculosis, atypical mycobacterial infection, fungal infection. intravascular: catheter-related endocarditis, meningococcemia, gonococcemia, listeria, brucella, rat-bite fever, relapsing fever. viral, rickettsial, and chlamydial: infectious mononucleosis, cytomegalovirus, human immunodeficiency virus, hepatitis, q fever, psittacosis. parasitic: extraintestinal amebiasis, malaria, toxoplasmosis. collagen vascular diseases: rheumatic fever, systemic lupus erythematosus, rheumatoid arthritis (particularly still's disease), vasculitis (all types). granulomatous: sarcoidosis, granulomatous hepatitis, crohn's disease. tissue injury: pulmonary emboli, sickle cell disease, hemolytic anemia. familial mediterranean fever fabry's disease cyclic neutropenia intra-abdominal infections may either be uncomplicated (limited to the gut lumen, such as gastroenteritis or colitis) or complicated (extending through to the peritoneum) . the clinical presentation of complicated intra-abdominal infections can range from mild symptoms such as nausea, mild abdominal pain, and cramping to lifethreatening septic shock. clinical findings result from local or diffuse inflammation with or without abscess formation. fever and abdominal pain are typically present, with additional symptoms depending on the organ involved. elderly and immunocompromised patients present with atypical, usually milder symptoms. imaging studies form an important adjunct to diagnosis. management involves empiric antibiotic coverage for bowel flora-mainly streptococci, enterococci, enteric gram-negative rods, and anaerobes-as well as controlling the source of infection, usually through surgery. • spontaneous bacterial peritonitis usually occurs in the setting of ascites and chronic liver disease. • spontaneous bacterial peritonitis is a diagnosis of exclusion. • ascitic fluid culture yield improves with inoculation into blood culture bottles at bedside. spontaneous bacterial peritonitis (sbp) is a form of infectious peritonitis without a surgically correctable cause and is therefore a diagnosis of exclusion. the route of infection in sbp is usually not apparent and is often presumed to be hematogenous, lymphogenous, by transmural migration through an intact gut wall from the intestinal lumen, or in women, from the vagina via the fallopian tubes (levison and bush, ) . sbp occurs in the setting of ascites in most cases, and it is particularly common in patients with cirrhosis. in pediatric populations, those with postnecrotic cirrhosis or nephrotic syndrome are more often affected. in adults, almost % of patients who develop sbp have child-pugh class c liver disease, and % to % of hospitalized patients with cirrhosis and ascites have sbp (mowat and stanley, ) . sbp is almost always caused by a single organism, typically enteric gram-negative rods, most often e. coli, followed by klebsiella pneumoniae. gram-positive cocci account for about % of episodes of sbp, and streptococci are isolated most often. sbp caused by anaerobes is rare. growth of more than one organism should raise the suspicion of secondary peritonitis. signs and symptoms of sbp are subtle and require a high index of suspicion. fever greater than ° f ( ° c) is the most common presenting sign, occurring in % to % of cases. abdominal pain, nausea, vomiting, and diarrhea are usually present. peritoneal signs (abdominal tenderness or rebound tenderness) are common but may be absent in patients with ascites. in adults, mental status changes may also occur. sbp is often confused with acute appendicitis in children. in adults, sbp should be suspected in any patient with previously stable chronic liver disease who undergoes acute decompensation in clinical status. spontaneous bacterial peritonitis is diagnosed by analysis of ascitic fluid obtained by abdominal paracentesis. infection has been typically defined as an ascitic fluid wbc count higher than cells/mm , which is considered diagnostic even when the culture of the ascitic fluid is negative. in cases where bloody fluid is obtained ("traumatic paracentesis"), the wbc count should be corrected by wbc per rbcs/mm . the use of bedside dipstick for leukocyte esterase has a high false-negative rate and is not recommended (nguyen-khac et al., ) . ascitic fluid culture yield can be increased by inoculating blood culture bottles with ml of ascitic fluid at the bedside. blood cultures should also be obtained as part of the workup. after the diagnosis of peritonitis is established, secondary peritonitis should be ruled out. ct of the abdomen with oral and intravenous contrast can help direct the surgeon to a particular source of infection, as opposed to doing a full exploratory laparotomy. a high ascitic fluid total protein (> g/dl) or amylase level is suggestive of secondary peritonitis. the treatment of choice is generally a third-generation cephalosporin such as cefotaxime ( g iv every - hours) or ceftriaxone ( g iv once daily). patients who have an ascitic fluid wbc count higher than cells/mm should be given empiric intravenous antibiotics without delay. oral amoxicillin-clavulanic acid can be used for mild, uncomplicated cases (navasa et al., ) . duration of treatment varies diagnosis of fuo may be assisted by the dukes criteria for endocarditis, ct scan of the abdomen, nuclear scanning with a technetiumbased isotope, and liver biopsy (mourad et al., ) (sor: b) . routine bone marrow cultures are not recommended in the fuo workup (mourad et al., ) (sor: b) . empiric antibiotics should be initiated only in specific situations, to avoid skewing culture results and thus maximizing potential isolation of the causative organism (mourad et al., ) (sor: b). from to days depending on clinical response. patients usually respond to appropriate antibiotic therapy within to hours; otherwise, a repeat paracentesis should be performed. if the ascitic fluid wbc count does not decrease by more than %, alternative diagnoses should be considered. prophylaxis with a fluoroquinolone or trimethoprim-sulfamethoxazole should be considered, particularly in high-risk patients (garcia-tsao and lim, • bacterial meningitis is life threatening and requires urgent medical attention and treatment. • viral encephalitis should be treated with acyclovir until herpes simplex virus is ruled out. • most brain abscesses are caused by streptococci and staphylococcus aureus. • the cns infections most likely to be encountered in clinical practice include meningitis, encephalitis, and abscess. • all cns infections can be difficult to diagnose, and a high index of suspicion by the health care provider is sometimes indicated to ensure patient survival. • mri is the most sensitive neuroimaging test for encephalitis. • acyclovir should be started immediately and continued until hsv pcr testing is obtained. meningitis can be acute, subacute, or chronic. in otherwise healthy children, the three most common organisms causing acute bacterial meningitis are streptococcus pneumoniae, neisseria meningitidis, and haemophilus influenzae type b (hib). isolation of an organism other than these three organisms from the csf of a child older than months always requires an explanation or evaluation for unusual host susceptibility. children with cochlear implants, asplenia, hiv infection, or csf leak from basilar skull or cribriform fracture are at greater risk for pneumococcal meningitis. deficiencies in terminal components of complement lead to greater risk for meningococcal infection (saez-llorens and mccracken, ) . in adults, the common etiologic agents of acute meningitis include s. pneumoniae, n. meningitidis, and listeria monocytogenes. patients with acute meningitis most often present with fever, headache, meningismus, and altered mental status. infants can present with nonspecific symptoms such as inconsolable crying, irritability, nausea, vomiting, and diarrhea. lethargy, anorexia, and grunting respirations indicate a critically ill infant. older children may complain of headache, vomiting, back pain, myalgia, and photophobia; may be confused or disoriented; and may verbalize specifically that the neck is stiff or sore. seizures are noted in up to % to % of children before hospital admission or early in the course of the illness. in contrast, patients with subacute or chronic meningitis may have the same symptoms with a much more gradual onset, lower fever, and associated lethargy and disability. mycobacterium tuberculosis, treponema pallidum (syphilis), borrelia burgdorferi (lyme disease), and fungi (e.g., cryptococcus neoformans, coccidioides spp.) are the most common agents (tunkel et al., ) . physical examination should look for papilledema, middle ear and sinus infections, petechiae (common with n. meningitidis), nuchal rigidity, and in infants, a bulging fontanel. blood cultures should be taken. a lumbar puncture (lp) for csf analysis should be done as soon as possible. a brain ct scan before lp is not necessary if the patient has no evidence of immunocompromise, cns disease, new seizure, papilledema, altered consciousness, or focal neurologic deficit, and if a subarachnoid hemorrhage is not suspected. if neuroimaging is necessary, blood cultures should be taken and antibiotics given before the study; a delay in administration of antibiotics leads to a worse outcome. csf should be sent for cell count, wbc differential, glucose, protein, and gram stain with culture. acid-fast bacilli stain and cryptococcal antigen may be obtained when indicated. empiric antibiotics for the initial treatment of bacterial meningitis are listed in table - , but these should be tailored to the isolated organisms whenever possible. adjunctive dexamethasone is recommended for children and infants with hib meningitis, but not if they have already received antibiotics. in adults, adjunctive dexamethasone is recommended for pneumococcal meningitis (tunkel et al., ) . close contacts of patients with n. meningitidis should receive rifampin, mg/kg (not to exceed mg) twice daily for days, or ciprofloxacin, mg as a single dose, or ceftriaxone, mg im as a single dose. unimmunized persons exposed to h. influenzae meningitis should receive rifampin (turkel et al., ) . pregnant women should not receive rifampin or doxycycline. a repeat lp should be done if no clinical response is seen after hours of appropriate antibiotic therapy, particularly for patients with resistant pneumococcal disease and those who received dexamethasone. neonates with gram-negative bacilli and patients with ventriculoperitoneal (vp) shunts require documentation of csf sterility. the duration of antimicrobial therapy is days for patients with n. meningitidis or hib, to days for pneumococcal meningitis, and to days for streptococcus agalactiae. spontaneous bacterial peritonitis is treated with third-generation cephalosporins (cefotaxime or ceftriaxone), with ampicillin-sulbactam, fluoroquinolones, or carbapenems as alternative agents (solomkin et al., ) (sor: b) . patients with diffuse peritonitis should undergo an emergency surgical procedure as soon as possible, even if ongoing measures to restore physiologic stability need to be continued during the procedure (sor: b). viral meningitis viral meningitis manifests similar to bacterial meningitis, although its course is rarely aggressive. the diagnostic process and examination are similar to those for bacterial meningitis. viral meningitis is usually caused by enteroviruses, hsv, mumps virus, and hiv. along with the signs of meningitis, signs that suggest a viral etiology include genital lesions (hsv- ), diarrhea, or a maculopapular rash (enteroviruses). diagnosis is made by the history, examination, and csf results. early in the course, the csf might show predominantly neutrophils that can resemble bacterial meningitis. treatment is symptomatic. suppressive therapy should be offered to patients with recurrent hsv meningitis. although encephalitis can also be caused by bacteria and fungi, the great majority of cases are caused by viruses. herpes simplex accounts for % of cases. patients present with fever, acute decreased level of consciousness, and occasionally, seizures and language, memory, or behavior disturbances. mri is the most sensitive neuroimaging test for encephalitis and might show temporal lobe inflammation in early hsv encephalitis. csf studies and electroencephalography (eeg) are also recommended for all patients with encephalitis. herpes simplex pcr should be done, and acyclovir should be given immediately until hsv encephalitis is ruled out. during late summer and early fall, doxycycline should be considered to cover for tick-borne illnesses, and testing should include the mosquito-borne encephalitides such as west nile, st. louis, eastern equine, and western equine. treatment depends on the suspected etiologic agent but is generally supportive (tunkel et al., ) . a brain abscess is a focal, intracerebral infection that develops into a collection of pus surrounded by a well-vascularized capsule. although fungi and protozoa (particularly toxoplasma) can also cause brain abscesses, bacterial causes are much more common. streptococci are found in % of bacterial abscesses and are usually from oropharyngeal infection or infective endocarditis, whereas staphylococcus aureus accounts for % to % of isolates and is more often found after trauma. community-associated mrsa strains have been increasing. enteric gram-negative bacilli (e.g., e. coli; proteus, klebsiella, and pseudomonas spp.) are isolated in % to % of patients, often in patients with ear infection, septicemia, or immunocompromise and those who have had neurosurgical procedures. most clinical symptoms are caused by the size and location of the abscess rather than the systemic signs of an infection. headache is the most common complaint and may be accompanied by fever, mental status changes, evidence of increased intracranial pressure (nausea, vomiting, papilledema), or focal neurologic deficits. diagnosis is usually made by ct scan with iv contrast showing the characteristic hypodense center with a peripheral uniform ring enhancement, with or without a surrounding area of brain edema. mri is becoming the preferred imaging modality because of increased sensitivity, particularly for detecting satellite lesions. additional testing depends on risk factors and the likely underlying source of infection and may include blood cultures, chest imaging, testing for hiv and antibodies to toxoplasma, and transesophageal echogram. empiric therapy typically involves vancomycin, ceftriaxone, and metronidazole. optimal management also includes surgical drainage for most abscesses, both to find an etiologic microorganism and to improve chances of cure (turkel, ) . • most acute diarrheal illness is viral and can be managed symptomatically and with appropriate attention to hydration. • travelers' diarrhea is usually caused by diarrheogenic escherichia coli. • the infection in travelers' diarrhea is usually self-limited. • antibiotics may shorten the duration of diarrhea by to days. • the most common cause of antibiotic-associated diarrhea is clostridium difficile. • treatment of antibiotic-associated diarrhea involves discontinuing the offending agent, if possible. adjunctive dexamethasone is recommended for children and infants with h. influenzae type b meningitis, but not if they have already received antibiotics (tunkel et al., ) (sor: a). in adults, adjunctive dexamethasone is recommended for pneumococcal meningitis (tunkel et al., ) (sor: b). diarrhea is a common presenting complaint in the primary care physician's office. not all causes of diarrhea are infectious, and not all infectious causes of diarrhea require specific antibiotic therapy. diarrhea remains a major cause of morbidity and mortality, particularly for children in the developing world. diarrhea is an alteration of normal bowel function, characterized by an increase in the water content, volume, or frequency of stools. acute diarrhea is typically defined as present less than days, and diarrhea is considered chronic when symptoms persist longer than days (figure - ). infectious diarrhea seen in the primary care physician's office is most frequently caused by viruses. a number of viral agents can cause diarrheal illness (box - ). rotaviruses are the principal enteric pathogens in children less than years of age and the most important cause of hospitalization and infant mortality related to diarrheal illnesses. noroviruses evaluate severity and duration obtain history and physical examination [ ] [ ] [ ] [ ] [ ] treat dehydration report suspected outbreaks check all that apply: are the most common cause of food-borne disease worldwide. viral gastroenteritis is usually an acute self-limited illness, referred to as the "stomach flu." enteric viruses are easily spread by fecal-oral transmission, through contamination of food and water, fomites, and person-to-person spread. secondary attack rates can be high. nausea and vomiting are the most prominent symptoms of viral gastroenteritis. diarrhea, fever, headache, and constitutional symptoms may also be experienced. these viral infections can occur at any time during the year, but tend to occur more often in the winter. there is no specific therapy. treatment is supportive, with particular emphasis on adequate replacement of fluids and electrolytes. if rehydration can be accomplished enterally, it is preferred. both the pentavalent bovine-human reassortment (rv ) and the oral, live-attenuated monovalent (rv ) rotavirus vaccines are effective for prevention of severe gastroenteritis. the rv vaccine series is recommended for children at ages , , and months, whereas the rv vaccine should be administered to children and months of age. approximately % of travelers to developing regions of the world will develop diarrhea. bacteria are responsible for approximately % of diarrhea acquired by travelers. other important causes include viruses and parasites. the onset of the majority of cases of travelers' diarrhea is usually within to days after arrival. the presentation is typically a noninflammatory, nonbloody diarrhea associated with abdominal discomfort, fever, nausea, or vomiting. the duration is usually to days. enterotoxigenic e. coli is responsible for approximately % of travelers' diarrhea. enteroaggregative e. coli is the second most common bacterial agent and causes % of cases. salmonella, shigella, and campylobacter spp. are less often detected but are important causes of dysentery, particularly in asia and africa. dysentery is severe inflammatory diarrhea manifested by fever and bloody stools. most cases of travelers' diarrhea are self-limited, but chronic postinfectious irritable bowel syndrome may occur in up to % of those who experience diarrhea. prevention of travelers' diarrhea is an important component of pretravel counseling for high-risk countries. food should be boiled, cooked, or peeled and water boiled to avoid consumption of fecal contamination. if a person develops travelers' diarrhea, a short course of antibiotics with rifaximin, ciprofloxacin, or azithromycin can shorten the duration of illness by to days. antibiotic therapy is recommended for persons with bloody diarrhea or fever. rifaximin, a nonabsorbed antibiotic, is not effective against invasive pathogens and should not be administered for dysentery. ciprofloxacin or azithromycin should be used for dysenteric symptoms based on local antimicrobial susceptibilities. antibiotics are frequently prescribed in the primary care physician's office for a variety of infections. unfortunately, antibiotics can alter the normal host microflora that can be protective against other infections. antibiotic effects on the normal gastrointestinal tract microbiome can lead to antibiotic-associated diarrhea, which causes significant morbidity and mortality. administration of antibiotics usually precedes symptoms of antibiotic-associated diarrhea by about week but can be as distant as or months. strong associations with clindamycin (cleocin), cephalosporins, penicillins, and fluoroquinolones have been demonstrated, but any antibiotic can lead to antibiotic-associated diarrhea. the most important cause of antibiotic-associated diarrhea is clostridium difficile, an anaerobic, gram-positive, spore-forming rod. c. difficile is implicated as the cause in up to % of antibiotic-associated diarrhea cases, in % to % of antibiotic-associated colitis cases, and in more than % of antibiotic-associated pseudomembranous colitis cases. risk factors for c. difficile diarrhea include antibiotics, health care exposure (recent stay in hospitals or long-term care facilities), older age (> ), and comorbid conditions. the clinical presentation of c. difficile colitis is usually diarrhea, abdominal pain or cramping, and fever in a patient who recently received antibiotics. leukocytosis is common and may be profound; levels can be consistent with leukemoid reaction. a rare but potentially fatal complication is toxic megacolon. toxic megacolon manifests as acute colonic dilation to a diameter greater than cm, associated with systemic toxicity and the absence of mechanical obstruction. with its high associated mortality, any patient who develops toxic megacolon requires immediate surgical evaluation for possible colectomy. diagnosis of c. difficile diarrhea is achieved by demonstration of c. difficile toxin a or b in the stool by enzyme immunoassay (eia) or cell culture cytotoxicity assay in a symptomatic patient with a previous history of antibiotic use. asymptomatic patients should not be tested. with the improved sensitivities of these diagnostic assays, one stool sample is usually sufficient to test for c. difficile, unless symptoms recur. test of cure after therapy with repeat stool for c. difficile toxin is not recommended because stools may remain positive for c. difficile toxin despite clinical resolution. endoscopy can demonstrate pseudomembranes in the colon. pseudomembranes are diagnostic of c. difficile infection, but are often not present. endoscopy may only reveal the presence of nonspecific colitis. clostridium difficile colitis is treated by discontinuing the offending agent(s) if possible and initiating antibiotic therapy (box - ). antimotility agents should be avoided. oral metronidazole (flagyl), mg three times daily for to days, is recommended for mild-moderate c. difficile diarrhea. severe diarrhea should be treated with oral vancomycin. oral vancomycin is currently not recommended for all patients with c. difficile diarrhea because of concerns for the promotion of vancomycin-resistant enterococci (vre) and its expense. about % to % of patients experience relapse in travelers' diarrhea, in which enterotoxigenic e. coli or other bacterial pathogens are likely causes, prompt treatment with a fluoroquinolone, azithromycin, or rifaximin or, in children, azithromycin mg/kg/day once daily can reduce the duration of an illness from to days to to days (dupont, ) (sor: a). after therapy. for relapse, a repeat course of the original c. difficile treatment should be administered. patients who have mild to moderate cases without volume depletion or systemic toxicity can be treated as outpatients. discussions of the following infections can be found online at www.expertconsult.com: • infectious viral hepatitis • endocarditis treat mild-moderate c. difficile diarrhea with metronidazole (zar et al., ) evidence-based reviews of the diagnosis and treatment of many common clinical problems. www.mdcalc.com/curb- -severity-score-community-acquired-pneumonia curb- score calculator to determine the severity of communityacquired pneumonia and need for hospitalization. the complete reference list is available online at www.expertconsult.com. anthony zeimet hepatitis is defined as inflammation of the liver that is commonly induced by viruses that include the hepatitis viruses a through e, which will be the focus of this discussion. other viruses that can induce hepatitis include epstein-barr virus (ebv), cytomegalovirus (cmv), herpes simplex virus (hsv), varicella zoster virus (vzv), adenovirus, and coxsackievirus. various medications and alcohol abuse are two important nonviral causes. most infectious causes of hepatitis are self-limiting; however, hepatitis b and c viruses can cause a chronic infection that may lead to cirrhosis and eventual liver failure, as well as hepatocellular carcinoma. hepatitis a virus (hav) and hepatitis e virus (hev) are spread by the fecal-oral route and only cause an acute infection. hepatitis b, c, and d viruses (hbv, hcv, hdv) are spread through the blood and have an acute form of disease that sometimes can become chronic. the clinical presentation of hepatitis is clinically indistinguishable. asymptomatic infections are more common than symptomatic infection. symptoms generally include right upper quadrant (ruq) abdominal pain, anorexia, nausea, vomiting, diarrhea, dark-colored urine, pale stools, and generalized malaise; patients may notice a yellow hue to their skin or eyes. pruritus is common, caused by deposition of bilirubin in the skin. the physical examination generally reveals jaundice and sclera icterus in addition to ruq pain. hepatomegaly is seen in % and splenomegaly in % of patients with hepatitis. liver function tests reveal elevated levels of aspartate transaminase (ast), alanine transaminase (alt), and bilirubin, and to a lesser extent, alkaline phosphatase (alp). hepatitis a virus is the most common cause of viral hepatitis worldwide. poor hygiene practices in both the industrial and the developing world account for its prevalence. in the united states, hav is common among lower socioeconomic groups, daycare attendants and workers, men who have sex with men (msm), and illicit drug users. hepatitis a is often acquired by travelers to endemic areas. the incubation period is to days (mean, days). hav is highly contagious, and peak fecal shedding generally occurs at the onset of illness in most infected patients. viremia averages to days. hav infection manifests as an acute, self-limited illness, with the prodromal symptoms lasting about a week before the onset of jaundice. jaundice generally resolves after weeks, and most patients recover. fulminant hepatic failure is possible but extremely rare. diagnosis of acute hav infection is made by demonstration of anti-hav immunoglobulin m (igm) in the patient's serum. this may be negative if the patient presents early, and repeat testing may be necessary if hav is strongly suspected. anti-hav igg in the serum indicates remote infection or immunization (efig - ). treatment is primarily supportive, except in patients with fulminant liver failure, who may require a liver transplant. vaccination should be administered to all patients who are seronegative and to persons at increased risk for acquiring hav, including those about to travel to endemic areas, patients with chronic liver disease or receiving clotting factor concentrates, msm, hiv-positive patients, and illicit drug users. certain areas of the united states now require mandatory vaccination of children as well as those who work in the restaurant industry. the vaccine is safe and highly efficacious and is given as a two-dose series at and at to months. passive immunization with immune globulin is recommended for those exposed to the virus by a known contact, including household and sexual contacts, and those who are traveling to an endemic area for less than weeks but never vaccinated. any person who receives immune globulin should also start the vaccination series. hepatitis b virus infection can be acute or chronic. about , people die from acute hbv infection annually, and , die of cirrhosis and hepatocellular carcinoma caused by chronic infection. about million people worldwide are living with chronic hbv infection. in the united states, an estimated . million residents have chronic hbv infection, with to deaths each year. significant burdens of disease are seen in asia, pacific islands, sub-saharan africa, amazon basin, and eastern europe. most adults with acute hbv will clear the virus, with less than % progressing to chronic infection. chronic infection will develop in almost all children infected perinatally and in % of those who become infected at to years of age. hbv is transmitted through exchange of body fluids, sexually and perinatally. in the united states, most hbv cases are acquired during adolescence and early adulthood with onset of sexual activity, experimentation with drug use, and sometimes occupational exposure. fever, polyarthralgia, rash, and a serum sickness-like illness are features of hbv infection in addition to jaundice and may be seen in association with polyarteritis nodosa. clinicians have the most difficulty in interpreting the various serologic tests for diagnosis of hepatitis b (etable - ) . the mean incubation period is to days, with a range of of days after infection. diagnosis of acute infection can be detected by obtaining hbv surface antigen (hbsag), which can appear as early as week after exposure but generally by day . in a patient strongly suspected to have hbv infection, the clinician can consider checking the hbv dna viral load; which can be detected as early as week after exposure. eventually the patient will develop an anti-hbv surface antibody, which indicates recovery from the illness. the other viral serologies for hbv are rarely obtained in acute illness. in chronic hbv infection, there are three major phases of infection: . immune tolerant. active viral replication in the liver with high levels of hbv dna levels but essentially normal or minimal elevation of ast and alt. most patients eventually progress to the next stage. . immune active. more robust liver inflammation with alt elevation, and liver biopsy shows inflammation with or without fibrosis. hbv early antigen (hbeag) is detected along with hbsag. . inactive carrier state. as patients enter this phase, they clear the hbeag and develop anti-hbe antibody and have undetectable or low levels of hbv dna, with normalization of alt and liver inflammation. if patients become hbsag negative, they then develop anti-hbs and have resolved their infection; otherwise, they are considered a chronic carrier. treatment of acute hbv is primarily supportive. in the last decade, however, there have been significant advances in the treatment of chronic hbv infection. the use of interferon has long been the mainstay of treatment and has a defined, limited course but is generally poorly tolerated. with the advent of the hiv/aids epidemic and research into treatment of hiv disease, antiviral medications are now starting to replace interferon as the preferred treatment option for hbv patients. nucleoside/nucleotide analogs such as lamivudine, adefovir, entecavir, tenofovir, and telbivudine are generally given for long-term, indefinite therapy to prevent progression of liver disease and development of hepatocellular carcinoma. any patient with chronic hbv infection should be referred to an infectious diseases specialist or a hepatologist to determine the appropriate treatment course. universal vaccination of newborns and infants is routine in the united states since , and the incidence of hbv infection has declined. during primary care visits, the vaccination status of any adult or adolescent born before should be reviewed and the vaccine offered. the vaccine requires three doses given at , , and months. an unvaccinated person or neonate who is exposed to the body fluids of a hbv-infected individual should start the vaccination series in addition to receiving the hepatitis b immune globulin (hbig). hepatitis c virus infection is the most common cause of chronic viral hepatitis in the united states. hcv does have an acute form of infection but is usually subclinical and rarely diagnosed. the cdc estimates that there are more than . million people with hcv infection. hcv is generally transmitted parenterally, as in injection drug users who share needles. before , those who received a blood transfusion may have contracted hcv. sexual transmission acute hbv has been reported in monogamous couples, with one partner who has hcv infection and the other without infection who eventually acquires the virus. this occurs in % to % of couples and represents a rare mode of transmission. because the most common mode of acquisition is sharing needles, any patient who is hcv positive should be screened for hiv because these two infections often occur together (ebox - ). the diagnosis of acute hcv infection can be made by obtaining a hcv rna viral load; although this is rarely done because the initial infection is subclinical. chronic disease is generally discovered by a positive anti-hcv antibody along with an elevated hcv rna viral load. hcv genotype should also be obtained in any positive individual, because this has important prognostic factors with regard to therapy, with genotype a and b the predominant type in the united states and unfortunately having a poor response to therapy. as with hbv, chronic hcv infection can lead to cirrhosis and the development of hepatocellular carcinoma. treatment consists of to weeks of interferon and ribavirin therapy. any patient being considered for therapy should be referred to an infectious diseases specialist or hepatologist. a liver biopsy is often needed to determine appropriate treatment candidates. also known as the hepatitis delta antigen virus, hdv is a defective virus that requires the presence of hbv to be infectious. hdv should be suspected in any patient with chronic hbv who develops acute hepatitis. hepatitis d is endemic in the mediterranean, balkans, africa, middle east, and amazon basin. diagnosis is made through an anti-hdv antibody in the presence of someone with positive hbsag or anti-hb core antibody igm or igg. treatment is supportive. any person vaccinated against hbv cannot become infected with hdv. similar to hav infection, hev is spread by the fecal-oral route. hev only has an acute form and does not progress to chronic infection. most reported epidemics have been related to consumption of contaminated drinking water. hev is endemic to southeast and central asia, north africa, middle east, mexico, brazil, venezuela, and cuba. hepatitis e can be considered a cause of infectious hepatitis in the united states in the traveler returning from an endemic area. the incubation period is days. infection is of major concern during pregnancy, which can cause death in late pregnancy. diagnosis is made by demonstration of anti-hev antibody in serum. treatment is supportive. • endocarditis prophylaxis is now recommended solely for patients at high risk of a complicated course with a more narrow range of cardiac conditions. • routine prophylaxis for gi and gu procedures is no longer recommended. • the duke criteria represent a reliable scoring system for diagnosing endocarditis. • echocardiography is indicated to confirm suspected endocarditis. bacterial endocarditis is one of the most feared infections; although uncommon, it carries high morbidity and mortality. increase in antibiotic resistance among bacteria causing this infection has created challenges for effective treatment. the fundamental view of the american heart association (aha) in preventing infective endocarditis has shifted in recent years. views on pathophysiology have not changed substantially, but it is now recognized ebox - persons for whom hepatitis c virus (hcv) screening is recommended persons who have injected illicit drugs in the recent and remote past, including those who injected only once and do not consider themselves to be drug users. persons with conditions associated with a high prevalence of hcv infection, including: persons with human immunodeficiency virus (hiv) infection persons with hemophilia who received clotting factor concentrates before persons who have ever received hemodialysis persons with unexplained abnormal transaminase (aminotransferase) levels prior recipients of transfusions or organ transplants before july , including: persons who were notified that they had received blood from a donor who later tested positive for hcv infection persons who received a transfusion of blood or blood products persons who received an organ transplant children born to hcv-infected mothers health care, emergency medical, and public safety workers after a needle stick injury or mucosal exposure to hcv-positive blood current sexual partners of hcv-infected persons * modified from centers for disease control and prevention. recommendations for prevention and control of hepatitis c virus (hcv) infection and hcv-related chronic disease. mmwr ; (rr): - . *although the prevalence of infection is low, a negative test in the partner provides reassurance, making testing of sexual partners of benefit in clinical practice. • universal vaccination of infants with hepatitis b vaccine reduces the risk of acute hepatitis, chronic carrier state, and complications of chronic infection and may be more effective than selective vaccination of high-risk individuals (lee et al., ) (sor: a). • as part of a comprehensive health evaluation, all persons should be screened for behaviors that place them at high risk for hepatitis c infection (ghany et al., ) (sor: b). • liver biopsy may be considered in patients with chronic hcv infection to determine fibrosis stage for prognostic purposes or to make a treatment decision (ghany et al., ) (sor: b). that cumulative daily episodes of bacteremia likely carry more risk than the transient bacteremia caused by dental procedures. infective endocarditis likely begins with turbulent flow and damaged endothelium around heart valves, which allow platelet aggregation and thrombus formation, causing a "nonbacterial thrombotic endocarditis" (wilson et al., ) . the presence of bacteremia then allows this vegetation to become seeded with infection. bacterial "adhesins" are present to a greater degree in some species and allow for more effective attachment to the injured area of endothelium. with high concentrations of bacteria in the mouth, vagina, gi tract, and perhaps gu system, antibiotic prophylaxis was initiated when these anatomic locations were manipulated. recommendations for infective endocarditis prevention changed in - , with aha recognizing more likely benefit from providing adequate population-based dental care and good oral hygiene, and thus less significant ongoing bacteremia at home in brushing, flossing, and "toothpicking," than in providing antibiotic prophylaxis to patients undergoing a dental procedure. no prospective rct has shown that dental prophylaxis prevents infective endocarditis. with recognition of the risk associated with administration of antibiotics (gi upset, diarrhea, rash, anaphylaxis) and the risk of contributing to increasing antibiotic resistance, versus the likely negligible benefit, aha has substantially changed its advice on this long-held practice. a preexisting cardiac condition produces a predisposition to the development of infective endocarditis (ebox - ). for example, those who have valve replacement for infection of an infected native valve carry a lifetime risk of per , patient-years. the risk in the general population without known heart disease is per , patient-years. more concerning, however, is the risk to a given patient of poor outcome if the patient develops endocarditis, which drives current aha recommendations. those with an infected mechanical valve have a mortality rate of about %, versus % or less for patients with an infected native valve (wilson et al., ) . a summary of current recommendations for endocarditis prophylaxis is provided in etable - . of note, gi and gu procedures have been removed from those for which antibiotics are recommended, unless those systems are actively infected at the time of the procedure. the same is true for skin and soft tissue procedures, in that only infected tissue would warrant antibiotics to prevent infective endocarditis. it is still recommended to provide prophylaxis for respiratory tract procedures, if the respiratory wall will be invaded through biopsy or the procedure. in addition, respiratory procedures to treat infections (e.g., empyema) should be combined with antibiotic administration (nishimura et al., ) . antibiotic regimens for prophylaxis for dental procedures are still based primarily on synthetic penicillins as their cornerstone. this is with recognition that streptococcus viridans is both a mouth floral inhabitant and a common agent causing infective endocarditis. with other procedures, antibiotics should be targeted to bacterial pathogens causing any active infection in the system being manipulated. ebox - cardiac conditions associated with the highest risk of adverse outcome from endocarditis for which prophylaxis with dental procedures is reasonable prosthetic cardiac valve or prosthetic material used for cardiac valve repair previous ie congenital heart disease (chd) * unrepaired cyanotic chd, including palliative shunts and conduits completely repaired congenital heart defect with prosthetic material or device, whether placed by surgery or by catheter intervention, during the first months of the procedure † repaired congenital heart defect with residual defects at the site or adjacent to the site of a prosthetic patch or prosthetic device (which inhibit endothelialization) cardiac transplantation recipients who develop cardiac valvulopathy *except for the conditions listed above, antibiotic prophylaxis is no longer recommended for any other form of chd. †prophylaxis is reasonable because endothelialization of prosthetic material occurs within months after the procedure oral antibiotic william osler discussed "malignant endocarditis" in and its great diagnostic challenge. in the modified duke criteria remains a reliable tool for assessing patients with endocarditis. endocarditis is suspected in febrile patients without an obvious source, in those with recent bacteremia (including iv drug use), in those with underlying cardiac predisposition, and perhaps in patients with the clinical finding of a new cardiac murmur. in establishing a diagnosis of infective endocarditis, a patient is considered to have definite disease if two major or one major and three minor or five minor criteria are present. possible disease is defined as one major and one minor or three minor criteria (ebox - ). pathologic specimens showing changes consistent with endocarditis would make a definitive diagnosis. echocardiography is indicated in making the diagnosis of infective endocarditis. transthoracic echocardiography (tte) is helpful if vegetations are seen, although size of the patient and other disease (e.g., copd) may limit the ability of tte to view the cardiac valves adequately. if tte is negative and suspicion remains, transesophageal echocardiography (tee) is indicated. tte may be more widely available, depending on regional and institutional variation, and should be used rather than delaying this diagnostic test. bacteria present within valvular vegetations are often less metabolically active, which partly explains the requirement for longer courses of antibiotics for this type of infection. clearly, therapy for endocarditis should be targeted at the organism identified on blood culture, if any. the counting of antibiotic days should begin when the blood culture becomes negative and not at the start of the particular agent. recommendations for antibiotic use in infectious endocarditis are highly variable and based on the presence or absence of synthetic valvular material and the infectious agent (etable - ). generally speaking, a minimum of weeks of iv antibiotics is indicated. in cases of resistant organisms, up to weeks may be required. in either case, synergistic use of agents such as gentamicin may be indicated for the first several weeks of treatment, which then can be discontinued. the ability of a given patient to complete this course at home versus in a health care facility is dependent on the dosing frequency of the antibiotic, availability of inhome nursing services, and the type of intravenous access through which the antibiotic will be delivered. at the completion of endocarditis therapy, echocardiography should be repeated to re-assess the function of the valve(s) in question. valvular dysfunction at the completion of therapy is a good indication that the patient will need valve replacement in the future. there are circumstances, like the development of congestive heart failure in the face of endocarditis, in which primary surgery is indicated. typical microorganisms consistent with ie from separate blood cultures: viridans streptococci, streptococcus bovis, hacek group, staphylococcus aureus; or community-acquired enterococci in the absence of a primary focus; or microorganisms consistent with ie from persistently positive blood cultures, defined as follows: at least positive cultures of blood samples drawn > hours apart; or all of or a majority of ≥ separate cultures of blood (with first and last sample drawn at least hour apart). single positive blood culture for coxiella burnetii or anti-phase igg antibody titer > : echocardiogram positive for ie (tee recommended for patients with prosthetic valves, rated at least "possible ie" by clinical criteria, or complicated ie [paravalvular abscess]; tte as first test in other patients) defined as follows: oscillating intracardiac mass on valve or supporting structures, in the path of regurgitant jets, or on implanted material in the absence of an alternative anatomic explanation; or abscess; or new partial dehiscence of prosthetic valve; new valvular regurgitation (worsening or changing or preexisting murmur not sufficient) predisposition, predisposing heart condition, or idu fever, temperature > ° c vascular phenomena, major arterial emboli, septic pulmonary infarcts, mycotic aneurysm, intracranial hemorrhage, conjunctival hemorrhages, and janeway's lesions immunologic phenomena: glomerulonephritis, osler's nodes, roth's spots, and rheumatoid factor microbiologic evidence: positive blood culture but does not meet a major criterion as noted above * or serological evidence of active infection with organism consistent with ie echocardiographic minor criteria eliminated echocardiography should be performed in all patients with suspected infective endocarditis (baddour et al., ) there is no evidence that antibiotic prophylaxis is effective or ineffective for preventing infectious endocarditis after dental procedures in patients at risk (chung, ) (sor: c). regimen dosage * and route duration (wk) chronic cough due to acute bronchitis: accp evidencebased clinical practice guidelines interim recommendations for the use of influenza antiviral medications in the setting of oseltamivir resistance among circulating influenza a (h n ) viruses, - influenza season national ambulatory medical care survey: summary short-course antibiotic treatment in acute exacerbations of chronic bronchitis and copd: meta-analysis of doubleblind studies antibiotics for exacerbations of chronic obstructive pulmonary disease antibiotics for acute bronchitis effects of naproxen on experimental rhinovirus colds: a randomized, double-blind, controlled trial infectious diseases society-american thoracic society consensus guidelines on management of community-acquired pneumonia in adults emergence of a novel swineorigin influenza a (h n ) virus in humans acute pneumonia influenza. in: schlossberg d, ed. clinical infectious disease seasonal influenza in adults and children: diagnosis, treatment, chemoprophylaxis, and institutional outbreak management. clinical practice guidelines of the infectious diseases society of america antivirals for influenza in healthy adults: systematic review hospitalizing influenza in adults infectious diseases society-american thoracic society consensus guidelines on management of community-acquired pneumonia in adults influenza viruses, including avian influenza and swine influenza steroids for symptom control in infectious mononucleosis hepatosplenomegaly in infectious mononucleosis, assessed by ultrasonic scanning infectious mononucleosis vaccines for post-exposure prophylaxis against varicella (chickenpox) in children and adults centers for disease control and prevention (ats/cdc). targeted tuberculin testing and treatment of latent tuberculosis infection centers for disease control and prevention. extensively drug-resistant tuber culosis-united states short-course therapy with rifampin plus isoniazid, compared with standard therapy with isoniazid, for latent tuberculosis infection: a meta-analysis genital warts expedited partner therapy in the management of sexually transmitted diseases. atlanta: us department of health and human services center for disease control and prevention. sexually transmitted disease surveillance. division of std prevention accuracy of the clinical diagnosis of vaginitis compared with a dna probe laboratory standard a pooled analysis of the effect of condoms in preventing hsv- acquisition consistent condom use is associated with lower prevalence of human papillomavirus infection in men the limited value of signs and symptoms in the diagnosis of vaginal infections cervical cancer condom effectiveness in reducing heterosexual hiv transmission sexually transmitted diseases treatment guidelines genitourinary infections urinary tract infection in children diagnosis and management of uncomplicated urinary tract infections american geriatric society. guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults asymptomatic bacteriuria: when to screen and when to treat the effectiveness of a clinical practice guideline for the management of presumed uncomplicated urinary tract infection in women recurrent cystitis in non-pregnant women a randomized trial to evaluate effectiveness and cost effectiveness of naturopathic cranberry products as prophylaxis against urinary tract infection in women screening for asymptomatic bacteriuria in pregnancy: a decision and cost analysis guidelines for antimicrobial treatment of uncomplicated acute bacterial cystitis and acute pyelonephritis in women tick-borne infections tick-borne diseases tick-borne diseases in the united states the clinical assessment, treatment, and prevention of lyme disease, human granulocytic anaplasmosis, and babesiosis practice guidelines for the diagnosis and management of skin and soft tissue infections furuncles and carbuncles centers for disease control and prevention. health-care-associated methicillin-resistant staphylococcus aureus (mrsa) double-blind, placebo-controlled trial of cephalexin for treatment of uncomplicated skin abscesses in a population at risk for community-acquired methicillin-resistant staphylococcus aureus infection practice guidelines for the diagnosis and management of 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resource center program. management and treatment of patients with cirrhosis and portal hypertension: recommendations from the department of veterans affairs hepatitis c resource center program and the national hepatitis c program mandell, douglas, and b ennett's principles and practices of infectious diseases spontaneous bacterial peritonitis: diagnosis, treatment and prevention review article: the utility of reagent strips in the diagnosis of infected ascites in cirrhotic patients randomized, comparative study of oral ofloxacin versus intravenous cefotaxime in spontaneous bacterial peritonitis diagnosis and management of complicated intra-abdominal infection in adults and children. guidelines by the surgical infection society and the infectious diseases society of america acute bacterial meningitis beyond the neonatal period brain abscess practice guidelines for the management of bacterial meningitis the management of encephalitis: clinical practice guidelines of the infectious disease society of america acute meningitis guidelines on acute infectious diarrhea in adults. the practice parameters committee of the american college of gastroenterology a comparison of vancomycin and metronidazole for the treatment of clostridium difficileassociated diarrhea, stratified by disease severity acute cholecystitis nett's principles and practices of infectious diseases diagnosis and management of complicated intra-abdominal infection in adults and children: guidelines by the surgical infection society and the infectious diseases society of america infectious viral hepatitis national institutes of health consensus development conference statement: management of hepatitis b acute viral hepatitis hepatitis b virus infection chronic viral hepatitis chronic hepatitis diagnosis, management and treatment of hepatitis c: an update acute viral hepatitis hepatitis c virus infection effect of hepatitis b immunisation in newborn infants of mothers positive for hepatitis b surface antigen: systematic review and meta-analysis chronic hepatitis b: update infective endocarditis: diagnosis, antimicrobial therapy, and complications prescription of antibiotics for prophylaxis to prevent bacterial endocarditis experience with a oncedaily aminoglycoside program administered to adult patients acc/aha guideline update on valvular heart disease: focused update on infective endocarditis prevention of infective endocarditis: guidelines from the american health association. circulation key: cord- - ebmq t authors: duplantier, allen j.; shurtleff, amy c.; miller, cheryl; chiang, chih-yuan; panchal, rekha g.; sunay, melek title: combating biothreat pathogens: ongoing efforts for countermeasure development and unique challenges date: - - journal: drug discovery targeting drug-resistant bacteria doi: . /b - - - - . - sha: doc_id: cord_uid: ebmq t research to discover and develop antibacterial and antiviral drugs with potent activity against pathogens of biothreat concern presents unique methodological and process-driven challenges. herein, we review laboratory approaches for finding new antibodies, antibiotics, and antiviral molecules for pathogens of biothreat concern. using high-throughput screening techniques, molecules that directly inhibit a pathogen’s entry, replication, or growth can be identified. alternatively, molecules that target host proteins can be interesting targets for development when countering biothreat pathogens, due to the modulation of the host immune response or targeting proteins that interfere with the pathways required by the pathogen for replication. monoclonal and cocktail antibody therapies approved by the food and drug administration for countering anthrax and under development for treatment of ebola virus infection are discussed. a comprehensive tabular review of current in vitro, in vivo, pharmacokinetic and efficacy datasets has been presented for biothreat pathogens of greatest concern. finally, clinical trials and animal rule or traditional drug approval pathways are also reviewed. opinions; interpretations; conclusions; and recommendations are those of the authors and are not necessarily endorsed by the us army. the concept of bioterrorism and the intentional release of biothreat agents for purposes of harm to human and agricultural interests stimulates discussion of some unanswerable questions. questions ranging from protection of a nation's security to military defense tactics, all point to the gravity of the problem for which scientists are working together in many areas of study such as the development of novel medical countermeasures to combat lethal infections, the prevention of the spread of disease in the general populace, and design of field-worthy diagnostic tools. a biothreat organism is generally thought to be one causing severe or lethal disease or has potential to induce panic over the prospect of infection therewith; one with high pathogenicity and/or contagious infectivity; one with strong environmental stability or probable transmission as an aerosol; one with ease of large-scale production for far-reaching dissemination; and one that can be controlled for directing the release to only the intended target rather than accidental harm to the perpetrator [ ] . improved preparedness for intentional release of bacteria, viruses, and toxins will not only protect military positions and strategies but will also increase ability to combat disease in naturally occurring epidemics of diseases caused by some of these organisms. the priorities for the development of medical countermeasures against these organisms have been defined through international discussions [ ] [ ] [ ] . currently classified as tier select agents are those pathogens of grave concern, whereas other useful classification categories are in use by us government entities such as national institute of allergy and infectious diseases and the us centers for disease control and prevention (cdc) list, denoting the pathogens as category a, b, and c agents [ ] . various biothreat pathogens addressed in this chapter are grouped by general category and disease associated therewith (table . ). there are many organisms on the cdc list; consequently, not all of them are addressed in this chapter [ ] . the authors of this chapter have endeavored to provide a comprehensive survey of the literature and described the development hemorrhagic fever a crimean-congo hemorrhagic fever virus hemorrhagic fever a, b, c denote additional categorization into category a, b, and c pathogens, per niaid [ ] . a tier agents of human pathogenicity are presented [ ] . two more tier agents are rinderpest virus and foot-and-mouth disease virus, which are of agricultural concern (not covered in this chapter). b important non-tier agents for which countermeasures are described in this chapter [ , ] . see www.selectagents.gov for a comprehensive list of non-tier select agents and toxins.sars, severe acute respiratory syndrome; mers, middle east respiratory syndrome-related coronavirus. of medical countermeasures against high-priority bacterial and viral biothreat agents where the most progress has been made, and/or the most novel ground has been broken. bacteria cause disease in humans by invading tissue, altering the host immune response, and/or producing toxins or virulence factors. many of the bacteria described here are difficult to treat clinically. the potential bacterial threat agents that pose the greatest risk to national security are ones that can be easily disseminated and result in high morbidity and mortality rates. the former soviet union is known to have weaponized at least viral and bacterial agents, including several vaccine or drug-resistant strains [ ] . each agent has unique properties that present both a distinct threat and challenge for detection, prevention, and control. bacillus anthracis and clostridium botulinum are gram-positive bacterial agents of grave biothreat concern. b. anthracis is a spore-forming bacterium that causes cutaneous, respiratory, or intestinal forms of anthrax disease, which is an acute, rapidly progressing infection in any form. the b. anthracis spores are highly stable both in the environment and in the exposed individuals and can be easily disseminated via the aerosol route, thus making it a dangerous bacterium [ ] . the anthrax attacks in caused widespread panic, damage, disease, and death, which increased national awareness to the threat of bioterrorism. the bacterium produces a lethal toxin that disrupts the host innate responses during the early stages of infection and ultimately leads to septicemia and death of the host (fig. . a) . antibiotic treatment requires a lengthy dosing regimen and is effective only if it is initiated during the early stage of the infection. two monoclonal antibody (mab)-based anthrax antitoxin therapeutics [abthrax (raxibacumab) and anthim (obiltoxaximab)] have been approved by the us food and drug administration (fda) and included in the strategic national stockpile for treating inhalational anthrax [ ] . biothrax, the only licensed anthrax vaccine, is indicated for preexposure prophylaxis of disease in persons at high risk of exposure and postexposure prophylaxis of disease following suspected or confirmed b. anthracis exposure [ ] . botulinum neurotoxin (bont), produced by c. botulinum, is extremely potent, lethal, and easy to produce, transport, and misuse. the toxin itself is the select agent, but the clostridium organism, as an isolate capable of producing the toxin, is also classified as a tier select agent. there are seven serotypically distinct bonts (serotypes a-g) and they act by blocking neurotransmitter release and thereby preventing transmission of nerve impulses, which can lead to botulism, hallmarks of which are paralysis and respiratory arrest [ ] (fig. . b) . current treatment is limited to botulism immune globulin intravenous, human-derived antibotulism toxin antibodies for the treatment of infant botulism types a and b, and botulism antitoxin heptavalent (a-g), a mixture of immune globulin fragments developed from equine plasma for the symptomatic treatment of adult and pediatric botulism. the us army has developed a similar antitoxin based on equine neutralizing antibodies that is effective against a number of serotypes, but there is a limited supply and risk of horse serum sensitivity. an investigational vaccine also exists, but it offers limited protection and painful side effects [ ] . many of the bacterial agents of biothreat concern are intracellular gram-negative organisms. intracellular bacteria are particularly difficult to treat because the intracellular niche protects bacteria from the innate or adaptive immune surveillance. these bacteria can enter host cells through phagocytosis, and to prevent their destruction in the endocytic pathways, intracellular bacteria have adapted to survive in a host lysosome and replicate within the acidic endolysosomal compartment (e.g., coxiella burnetii). another intracellular bacteria brucella spp. can traffic from a mature lysosome to endoplasmic reticulum-derived compartments, while bacteria such as burkholderia mallei, burkholderia pseudomallei, francisella tularensis, and yersinia pestis can prevent acidification and maturation of the phagosome and escape to the cytosol, where they can replicate and then disseminate to neighboring cells [ ] [ ] [ ] . one characteristic feature of the b. mallei and b. pseudomallei intracellular life cycle is the fusion of infected mononuclear cells, forming multinucleated giant cells (mngcs). although the role of b. pseudomallei-induced mngcs is unclear, it is believed that cell fusion facilitates localized dissemination of the bacteria [ , ] (fig. . c) . brucella spp. are nonmotile bacteria that cause brucellosis, a world-wide chronic debilitating disease in both humans and animals. although not typically fatal, brucella spp. are stable and infectious as aerosols and can lead to sterility and abortions [ ] . the nonmotile bacillus b. mallei is the causative agent of glanders that usually infects equids but is highly infectious to humans at low doses, producing septicemia, severe pulmonary infection, and chronic inflammation of the skin and eyes. b. mallei can be easily aerosolized, and even with antibiotic treatment there are high mortality rates [ ] . the motile bacterium b. pseudomallei, the causative agent of melioidosis, is a close relative to b. mallei and can lead to severe illness in humans, such as pulmonary infection and septic shock. b. pseudomallei is an environmental saprophyte that is naturally resistant to many antibiotics [ ] . q-fever is caused by direct contact with the nonmotile bacterium c. burnetii that was previously weaponized because of its ease of aerosolization, its environmental stability, and its ability to infect animals or humans with a single bacterium [ ] . q-fever is not typically lethal but can be incapacitating, causing fever and difficulty breathing, and antibiotic therapy is not always effective, thus leading to persistent infections. f. tularensis is the causative agent of tularemia and is highly infectious, resulting in an acute, rapidly progressing local or systemic infection [ ] . y. pestis, the causative agent of plague, is a nonmotile bacterium that can be disseminated by aerosol, transmitted from person-to-person, and is characterized by a severe clinical disease course with potentially high case-fatality rates. there is a limited window for effective treatment against plague, since the resulting respiratory and circulatory collapse from septic shock is usually fatal [ ] . there are a great number of viruses on the list of select agents and toxins, and some of these can only be handled in the laboratory at the highest biocontainment level (biosafety level ). the causative agents of some of the most lethal hemorrhagic fever infections are filoviruses, paramyxoviruses, and arenaviruses. filoviruses such as ebola virus (ebov) and marburg virus infect humans and nonhuman primates (nhps) and have caused large outbreaks in recent years. these viruses are likely transmitted in nature by fruit bats and are spread from person to person via contact with body fluids or fomites [ ] . marburg virus was reportedly weaponized through activities carried out by the former soviet union [ ] . because of the large scale of recent ebov outbreaks, this virus may have become available to nefarious people through access to corpses and contaminated clinical waste. two more viruses transmitted in nature at least in part by fruit bats are the nipah and hendra paramyxoviruses that belong to the henipaviridae family and cause severe neurological and/or respiratory diseases in humans [ ] . these viruses can infect many domestic and agricultural animal species and are frequently transmitted between humans via droplets or fomites, leading to concerns of new human outbreaks in areas of malaysia, bangladesh, india, and australia where case-fatality rates range from % to % [ ] . arenaviruses, specifically lassa virus (lasv) and junin virus (junv), machupo, and other south american viruses are transmitted not by bats but by peridomestic rodent species [ ] . none of the filoviruses or henipaviruses has any fda-approved therapeutics or vaccines available for prevention or treatment of human disease, and while ribavirin is sometimes used to treat lassa fever, it is not a terribly effective drug against this viral infection [ ] . variola virus (varv) is the causative agent of smallpox, a human viral disease for which tecovirimat was recently approved as a therapeutic by the fda, a successful therapeutic development story [ ] . this pathogen has been eradicated since through successful vaccine campaigns [ ] , but because the vaccine is no longer administered in most countries, populations may be susceptible in the event that varv or an intentionally modified or related poxvirus with similar virulence factors and similar human lethality is resurrected [ ] . arthropod-transmitted alphaviruses and bunyaviruses are also biothreat concerns. for the alphaviruses specifically, the venezuelan encephalitis viruses (veev), eastern encephalitis viruses, and western equine encephalitis viruses belonging to the family togaviridae are found in the americas and cause equine disease [ , ] . these new world alphaviruses cause encephalitis-like symptoms, are stable in the environment, grow to high titers easily in cell culture, are highly infectious by aerosol, and affect humans with incapacitating neurological disease, sometimes with high morbidity rates [ ] . bunyaviruses such as rift valley fever virus and the related tick-transmitted nairovirus causing crimean-congo hemorrhagic fever also cause human diseases with high morbidity and mortality rates. some investigational new drug vaccines exist for these agents. these viruses replicate quickly in humans and cause rapid disease; therefore the timing for therapeutic intervention is short, making treatment postinfection very challenging. the lack of approved therapeutics available to combat biothreats may be in part attributed to the unique challenges for the discovery and development process of evaluating drugs that target select agents. foremost is the implementation of high-throughput screening (hts) efforts for the discovery of new compounds against authentic or wildtype biothreat bacterial and viral pathogens [ ] . specifically, the requirement of work to be performed in high-level biocontainment laboratories (bsl or bsl ) is a major limiting factor since laboratories with these capabilities are not widely available. in addition, highly trained personnel that can handle infectious agents use robotic instruments and adhere to operational, engineering, and government regulations are a critical requirement for working with biothreat agents [ ] . in the united states, strict guidelines have been instated for generating government-approved methods and processes for inactivation of pathogens before plates/samples can be brought out of biocontainment suites for further experimentation, and to track the inactivated material [ ] . other challenges that need to be considered include the prevention of pathogen aerosolization while handling screening plates in biocontainment laboratories and ensuring that inactivation chemicals and methods are compatible with downstream procedures. new therapeutics effective against both natural and engineered resistant forms of bacterium are vital to the biodefense armory. screening for novel antimicrobials is traditionally done by scoring for growth inhibition in vitro, using the standard clinical & laboratory standards institute guidelines. this generally involves performing a dose-response assay in a multiwell plate format and monitoring growth in the absence or presence of the test compounds. the compound concentration that shows no visible growth is considered the minimum inhibitory concentration (mic). over the years, this approach has led to the discovery of only a limited number of novel antimicrobial compounds and resistance has already been generated against most of the antibiotics used in the clinic. one disadvantage to this approach is the inability to identify potent immunomodulatory compounds against intracellular pathogens that require the host for replication. new approaches to understanding bacterial pathogenesis have enabled researchers to elucidate mechanisms that could be targeted to control and clear infection in lieu of simply targeting in vitro bacterial viability. targeting the host under in vivo-like conditions (e.g., in cell culture or animal models) will be a key feature of study design to combatting intracellular pathogens that require the host for invasion and replication and will likely identify new host-directed therapeutics. the development of host-directed therapeutic (hdt) strategy relies on an understanding of the interactions between pathogens and their hosts and appropriate tools and hts assays to screen and identify therapeutics. technological progress in assay miniaturization has emerged from a combination of advanced robotic systems, high-throughput microscopy, automated image analysis, and data analysis using powerful bioinformatics tools, and this has led to the development of high-content imaging (hci), allowing for large-scale quantification of multiple cellular phenotypes at the system level. such phenotypic screening platforms rely on physiologically relevant host cell types that are permissive to pathogen infection and have the potential to identify compounds that modulate relevant biological processes in an unbiased, target, and mechanism-agnostic fashion. this cell-based approach has the added advantage that compounds that have greater mammalian cell membrane permeability, reduced cellular toxicity, and target the host proteins will be readily identified in the context of their desirable function in cells. pharmacologically active compounds can be selected that inhibit the uptake or intracellular replication of the bacterium or disrupt the host-pathogen interactions. the general workflow for high-throughput, imagebased phenotypic screening approach to identify hdts is outlined in fig. . [ , ] . using bacterial antigen-specific antibody to detect bacteria, this method can quantitate the number of intracellular or cell-associated bacteria and the effect of the compounds in reducing the bacterial number (% inhibition of bacterial infection), and cellular toxicity (based on loss in cell number). alternatively, one can use hci to quantitate the morphological changes of mngcs based on nuclei number and mngc size/area and use this phenotype to screen and identify compounds that prevent bacterial spread [ ] . to overcome the problem of multidrug resistant bacteria, there is a growing focus on identifying small molecules that target drug resistant mechanisms or virulence factors, or agents that prevent/disrupt biofilm formation. virulence factors, such as secretion systems in gram negative bacterial pathogens, are promising therapeutic targets. specifically, the type secretion system (t ss) present in y. pestis is responsible for injecting effectors that target the cytoskeleton and proinflammatory signaling pathways. a number of techniques have been used to screen and identify potential t ss inhibitors that can be adapted for biothreat pathogens. these include an enzyme-linked immunosorbent assay (elisa)-based detection of proteins secreted from enteropathogenic escherichia coli (epec), inhibition of sheep erythrocyte lysis by epec, inhibition of induction of a yope luciferase fusion in yersinia pseudotuberculosis, and a pseudomonas aeruginosa cell-based bioluminescent reporter screen [ ] [ ] [ ] [ ] . using a high-throughput luminescence screening assay, three compounds were identified that inhibit y. pestis t ss-mediated cytotoxicity that relieves the growth inhibition associated with in vitro activation of t ss [ ] . another promising approach to disarm the bacteria is to prevent/disrupt biofilms, a barrier produced by bacteria to protect itself from the aggressive host environment. small molecule therapeutics that specifically disrupt or prevent the biofilm formation could be used in combination with antibiotics. the common method to quantitate biofilms is a colorimetric-based assay that utilizes a crystal violet dye to stain the biofilms and subsequent extraction of the dye using organic solvents or detergents [ ] followed by absorbance measurement. to improve sensitivity, robustness, and throughput, a fluorescent-dye-based assay was developed, wherein the biofilms are stained with fm - fluorescent dye and fluorescence signal is measured following organic extraction of the dye [ ] . screening of a small molecule library in this assay identified rifabutin and ethavarine, as potential inhibitors of b. pseudomallei (bp ) and acinetobacter baumannii biofilm production, respectively, without directly affecting the bacterial growth. phenotypic screening using high-throughput hci. cells susceptible to the pathogen of interest are seeded in hci plates. next day, cells are pretreated with appropriate concentration of the compounds and then infected with the pathogen of interest for optimal time wherein %- % infection results. the infected plates are then submerged in % formalin for h to inactivate the pathogen and to fix the cells. immunofluorescence staining is then performed, using a primary antibody specific to a pathogen antigen, and an appropriate fluorescence-labeled secondary antibody. dyes such as cell mask red and hoechst are added to detect the cell cytoplasm and nuclei, respectively. automated image acquisition and analysis is performed and data are analyzed using columbus software to quantitate the percentage of inhibition of pathogen infection and loss in cell number that represents cellular toxicity, in the presence of the compound [ ] . hci, high-content imaging. there is a possibility that therapeutics targeting the virulence factors or other drug resistance mechanisms may not be effective by themselves and will need to be evaluated in combination with antibiotics to treat multiple drug resistance (mdr) infections. thus screening experiments designed to find combination therapies are warranted. to determine the synergy of two drugs (antibiotic and nonantibiotic), conventional checkerboard assays are set up wherein the two drugs are tested in combination at varying concentrations and the mic of each drug either alone or in combination is then used to calculate the fractional inhibitory concentration [ ] . similarly, in the case of the biofilm assay, testing a biofilm disruptor and an antibiotic together at varying concentrations will help one to assess the effectiveness of combination therapies. unlike most bacteria, viruses require the mammalian host for replication. the virus life cycle can be divided into distinct stages that include the entry, uncoating, replication, genome packaging, assembly, maturation, and budding. various cell-based and in vitro biochemical assays have been developed to study virus life cycles as well as to screen and identify antivirals [ ] . the conventional plaque-forming assay used to evaluate antivirals is time-consuming, not amenable for hts, and not very robust. alternatively, in the absence of more sophisticated instruments or technologies, a virus-induced cytopathic effect can be used as an endpoint to test antivirals. with advances in imaging instruments and informatics, a cell-based hci platform ( fig. . ) that uses viral antigen-specific antibodies to detect and quantitate the viral infection is now a general approach to identify compounds that inhibit viral infection [ , , ] . however, this approach will not provide information on which steps in the viral life cycle the inhibitors are disrupting. to help one to deconvolute the mechanism of action of identified hits ( fig. . ), cells pretreated with an inhibitor prior to virus exposure can potentially identify compounds that inhibit viral entry, while treatment of cells after exposure (i.e., after the entry step) would identify compounds that inhibit intracellular replication and/or viral spread. assays utilizing recombinant noninfectious viruses have been generated to screen and identify inhibitors that target different stages of the viral life cycle [ ] (fig. . ). pseudotyped virion assays are well suited as safe alternatives for hts, since bsl and bsl wild-type pathogens are not required to complete the screens. these assays are based on viral vectors that harbor glycoproteins (gps) of different enveloped viruses and a reporter gene such as green fluorescent protein (gfp) or luciferase flanked by packaging signals, are used to generate chimeric replication-deficient viruses, and then used to screen and identify entry inhibitors. this approach has successfully identified entry inhibitors for lassa, ebola, and nipah viruses [ ] [ ] [ ] [ ] . cell fusion assays, including cell-cell or cell-virus fusions, have been developed to screen and identify hiv- fusion inhibitors, but to date no such assays have been developed for biothreat viruses [ ] . reverse genetic systems or minigenome assays have proven to be valuable models to study rna virus replication and transcription. this model system is used to screen and identify antivirals [ , ] . replication competent minigenome systems wherein some of the viral open reading frame is replaced with a reporter gene (gfp or luciferase) and the cdna copy cloned into a plasmid is cotransfected into mammalian cells with individual plasmids each containing a viral ribonucleoprotein (rnp). the target genes in the expression vectors are under the control of either a mammalian rna polymerase i or ii or t rna polymerase (which will require transfection of a plasmid containing the t rna polymerase) promoters. following transcription, the resulting viral rna is complexed with the rnp components and there is subsequent replication of the virus genome and expression of the reporter protein. minigenome systems have been developed for several biothreat pathogens, including filoviruses, arenaviruses, and bunyaviruses, and have been used to screen and identify small molecule inhibitors of filovirus and arenavirus replication [ ] [ ] [ ] [ ] [ ] . to study the viral assembly and budding, another surrogate model that can be used is based on virus-like particles (vlps) that are mimics of viral protein assemblies made by reconstituting the viral recombinant structural proteins. vlps are noninfectious as they do not contain any viral genome, but are intrinsically immunogenic, and hence are being extensively investigated as potential vaccine candidates [ ] . in the case of the ebov vlp-based assay, cotransfection of plasmids encoding the viral gp and the matrix protein (vp ) results in spontaneous formation of filamentous vlps that are released into the medium and can be quantitated by elisa [ ] ; thus this model can be useful in drug discovery research [ ] . to identify inhibitors of viral genome replication, in vitro biochemical assays targeting viral enzymes such as polymerases, methyltransferases, helicases, as well as viral and host proteases such as cathepsins or kinases have been developed. a number of antivirals that have been approved by the fda target either the dna or rna polymerases. incorporation of radioactive nucleotide either to a dna oligonucleotide by dna polymerase [ ] or to a homopolymeric rna as a template by rna polymerase are common methods to determine polymerase activity [ ] . a recent study reported the use of fluorescent dye to detect the double-stranded rna and the feasibility of developing this assay to screen and identify inhibitors of zika virus polymerase activity [ ] . the host lysosomal protease cathepsin l (cat l) is necessary for the processing and cleavage of the gp of enveloped viruses, so that the virus can fuse with the host cell membrane and gain entry into the host. thus cat l has been regarded as an ideal target for drug discovery. a fluorescence resonance energy transfer (fret)-based cat l enzymatic assay was developed, wherein peptides derived from gps of viruses such as ebola, nipah, hendra, and severe acute respiratory syndrome and middle east respiratory syndrome coronavirus and containing cat l cleavage site were chemically conjugated with a quencher -carboxytetramethylrhodamine at the n-terminus and -carboxyfluorescein fluorophore at the c-terminus [ ] . the intact peptides exhibited minimal to no fluorescence, but following cleavage of the peptide by cat l, there was an increase in fluorescence intensity. screening of a chemical library in this assay identified small molecules that selectively inhibited cat l-mediated cleavage of multiple viral peptides over host proneuropeptide y [ ] . viral proteases are also good drug targets as they play a vital role in viral replication. for example, the ns b-ns protease is highly conserved among the flaviviruses and a fret-based enzymatic assay using a synthetic peptide substrate [ ] was developed to identify west nile virus protease inhibitors [ ] . functional genomic screening using gene-trapping, crispr's gene editing, or rna interference (rnai) technologies has been applied to identify host factors that are required for replication or involved in pathogenesis of several biothreat viral and bacterial agents and are summarized in table . . the activities of several identified host factors can be perturbed by small molecules and thus serve as potential therapeutic platforms. for example, it was demonstrated that the novel host factor inositol-requiring enzyme α is required for brucella infection in mammalian cells [ ] . reducing the levels of either the retromer cargo-adapter complex or retromer-associated sorting nexins abrogated c. burnetii replication [ ] . multiple host kinases such as camp-dependent protein kinase, protein kinase b, and protein kinase c all play a role during c. burnetii infections [ , ] . zhou et al. [ ] identified tnfrsf and serpini that may promote activated macrophages in controlling f. tularensis replication. akimana et al. [ ] showed that f. tularensis utilizes host ubiquitin turnover in distinct mechanisms during the phagosomal and cytosolic phases and that phosphoinositide metabolism is essential for cytosolic proliferation of f. tularensis. connor et al. [ ] revealed that host proteins are required for intracellular survival of y. pestis. of particular, interest was the enrichment for genes involved in endosome recycling. using the gene trapping approach, carette et al. [ ] first identified several host factors that are required for ebov infection. these include a cholesterol transporter niemann-pick c factor involved in the fusion of endosomes and lysosomes (homotypic fusion and protein sorting complex), biogenesis of endosomes (pikfyve), lysosomes (bloc s , bloc s ), and targeting of luminal cargo to the endocytic pathway [ ] . many of these hits reoccurred in several crispr and small interfering rna (sirna)/shrna screenings [ , , ] . in addition, lysosomal protein (bri ) and a gtpase involved in the regulation of vesicle trafficking (rab b), pi k, calcium/ calmodulin kinase-related network, and de novo pyrimidine synthesis pathway are essential for ebov replication and transcription [ ] [ ] [ ] . the application of rnai screening has been utilized for other viral pathogens such as henipavirus, junv, poxvirus, vaccinia virus, and veev [ , [ ] [ ] [ ] [ ] [ ] . it is demonstrated that catalytic activity of fibrillarin, the enzymatic subunit of the snornp complex that is responsible for catalyzing the transfer of a methyl donor from a bound cofactor s-adenosyl methionine to ribose sugars of the target pre-rrna, is required for henipavirus infection [ ] . voltage-gated calcium channel (vgcc) subunits were shown to be important in junv-cell fusion and entry into cells. gabapentin, an fda approved anticonvulsant drug against α δ subunitcontaining vgccs, inhibited replication of the vaccine strain of junv in mice [ ] . other sirna-based screens against v. virus identified that amp-activated protein kinase (ampk) promotes viral entry through the control of actin dynamics, and knockdown of nuclear pore protein (nup ) arrests virion morphogenesis [ ] [ ] [ ] . lastly, an sirna screen identified trafficking host factors that modulate veev infection [ ] . an alternative approach to gain an in-depth understanding of host-pathogen interactions during infection is to construct a protein-protein interaction network between host protein and bacterial virulence factors. using a yeast two-hybrid (y h) library, memiševic´ et al. [ ] identified a molecular network that governs b. mallei infection. similarly, a y h study conducted by yang et al. [ ] showed the involvement of focal adhesion, regulation of cytoskeleton, leukocyte transendoepithelial migration, toll-like receptor (tlr), and mapk signaling pathways during y. pestis infection. to complement the y h study, reverse-phase protein microarray analysis was used to interrogate changes in protein expression and posttranslational modification. this further revealed the roles of ampk-α , src, and gsk β in regulating b. mallei and b. pseudomallei infection [ ] , and thus, as viable host targets for countermeasure development. prior to the initiation of medical countermeasure development against specific pathogens, a target product profile (tpp) is needed to define the required features of potential drug candidates (e.g., route of administration, prophylactic vs therapeutic, trigger to treat, and onset of action requirements). once a tpp is in place, a screening funnel is drafted that sets laboratory criteria and defines clear go/no-go decision points that are needed to progress countermeasures from discovery through preclinical development and into human clinical trials. irrespective of the types of assays used for countermeasure screening, compounds identified as having significant inhibition in primary screens are validated in subsequent dose-response experiments to determine the half maximal effective concentration (ec ) and cytotoxic concentration (cc ). potent compounds that have an adequate selectivity index (e.g., > ) that is defined as a ratio of cc / ec , are then often tested in orthogonal assays in appropriate cells/tissues to better understand or validate the antipathogen activity. ideally, compounds are further optimized for potency, selectivity, physicochemical, and pharmacokinetic (pk) properties and safety prior to in vivo evaluation to assess efficacy in appropriate animal models of infection ( fig. . ) . many of the therapeutics that are in different stages of either preclinical or clinical development for select biothreat pathogens include small molecule antivirals (tables . and . ), antibody (or antibody cocktails) against viruses or bacteria/virulence factors (table . ), and combination drug therapy (table . ). the increased use of antivirals and antibiotics has set the stage for rapid adaptation mechanisms that microbes can use to counteract them. the development of antimicrobial resistance is one of the biggest public health threats and hence alternative approaches to treat infectious diseases are urgently needed. table . lists the resistance mechanisms identified in each biothreat bacterial pathogen and provides references for targets of resistance. since stand-alone antibiotics may not be sufficient to overcome resistance and/or completely clear some biothreat bacterial infections, we have also included encouraging data on host directed therapeutics, and combination therapy. hdt is an emerging approach in the field of antiinfectives discovery. the strategies behind hdt can include modulation of host immune responses, or interference/manipulation/targeting of host-cell factors that are required for pathogen replication [ ] . for example, in a potential bioterror scenario, where the identity of the etiological agent causing the disease is unknown, stimulation of innate immunity may be particularly useful as induced immune responses are often capable of providing protection against a broad range of pathogens. although no fda-approved hdt therapies are yet available for treating infectious diseases, we have summarized in this section the antimicrobial primary screening of small molecule chemical libraries in the phenotypic hci assay will identify compounds that inhibit pathogen infection as well as those that may contribute to cellular toxicity. generally, hits that show ≥ % infection inhibition and ≤ % loss in cell number are then subjected to hit triage or in silico filtering wherein compounds with optimal physicochemical properties such as solubility, lipinski's rule of , metabolism are selected for potency testing in the phenotypic screening assays. compounds that exhibit an ec ≤ µm and si, which is a ratio of cc /ec > , are then further optimized through iterative cycles of synthesis, testing in cell-based and orthogonal assays and in in vitro admet studies to improve potency and physicochemical properties. if the target of the hit molecule is identified then a target-based screen is performed and the hits identified are optimized through the iterative structureactivity relationship cycle. the lead series candidates are then evaluated in vivo for their pharmacokinetic properties and then for efficacy in appropriate challenge models of infection. admet, absorption, distribution, metabolism, excretion, and toxicity; hci, high-content imaging; si, selectivity index. antibiotics aigiv combination therapy with antibiotics and aigiv is more effective than antibiotics alone in a rabbit model of inhalational anthrax and improved survival compared to the antibiotic treatment alone [ ] ciprofloxacin clindamycin treatment of rabbits with systemic anthrax with clindamycin and ciprofloxacin had improved efficacy compared to monotherapy and could be used to prevent relapse of infection [ ] ciprofloxacin combination therapy for anthrax, including antiprotective antigen (pa igg) antibodies and ciprofloxacin in a rodent anthrax model increased survival significantly compared to ciprofloxacin treatment alone [ ] levofloxacin raxibacumab combination therapy with raxibacumab, an igg monoclonal antibody that binds protective antigen, and the antibiotic levofloxacin provides protection in rabbits late in the disease course [ ] oligochlorophen antibiotics targeting cytoskeletal proteins such as ftsz with oligochlorophen analogs is a promising new treatment method that has a -fold lower development of resistance compared to antibiotics used for anthrax treatment in humans [ ] penicillin, meropenem, or rifampin linezolid treatment of antibiotic-resistant inhalation anthrax with linezolid and penicillin, meropenem, or rifampin had the inhibitory effect on mean lethal factor levels compared to the control groups and successfully treated fluoroquinolone-resistant b. anthracis infection [ ] rifampin clindamycin combination therapy for anthrax with rifampin and clindamycin was shown to be synergistic in vitro [ ] brucella spp. rifampin successful combination therapies used to treat pulmonary brucellosis in humans is doxycycline and rifampin for weeks [ ] burkholderia mallei antibiotic heat-killed vaccine combination of an antibiotic moxifloxacin, azithromycin, or sulfamethoxazole-trimethoprim, and vaccination using heat-killed b. mallei can protect balb/c mice from lethal glanders infection, potentially by stimulating immune responses, such as gamma interferon, which acts synergistically with antibiotic therapy to inhibit bacterial growth [ ] enrofloxacin, trimethoprim, and sulfadiazine doxycycline successful -week combination treatment of parenteral administration of enrofloxacin and trimethoprim with sulfadiazine followed by oral administration of doxycycline eliminated b. mallei from glanderous horses during an outbreak [ ] burkholderia pseudomallei combination therapy with farnesol a sesquiterpene alcohol that damages biofilm matrix and interferes with cell wall and peptidoglycan biosynthesis, facilitates antimicrobial penetration, and reduces the minimum biofilm eradication concentration for ceftazidime, amoxicillin, doxycycline, and sulfamethoxazole-trimethoprim in vitro [ , ] ceftazidime avibactam avibactam restores susceptibility to ceftazidime for genetically diverse extremely drug resistant isolates of burkholderia from cystic fibrosis patients by binding pena and the combination treatment significantly improved survival of larvae infected with the drug resistant isolates [ ] ceftazidime ifn-γ interferon gamma-induced reactive oxygen species with ceftazidime leads to synergistic killing of intracellular b. pseudomallei and markedly increases the effectiveness of antimicrobial therapy for the treatment of b. pseudomallei infection in mice [ , ] clostridium botulinum bont serotypes and subtypes differences present a significant challenge for creating monoclonal antibody treatments for neutralization, by diversifying the v-regions of mabs and selecting cross reactivity, a combination treatment of three antibodies neutralized bont/f , f , f , and f in mice and was times more potent than equine antitoxin [ ] coxiella burnetii doxycycline chloroquine combination therapy of doxycycline and hydroxychloroquine combination shortened the duration of therapy and reduced the number of relapses in patients with q fever endocarditis. and a case of q fever endocarditis with biological prosthetic aortic valve and aortic homograft was successfully treated with doxycycline and chloroquine combination therapy [ , ] francisella tularensis cytochalasin b, ly , wortmannin, nocodazole, mg , and xva inhibitors reduce f. tularensis update and reduce inflammatory cytokine production and can be used in combination with antibiotics to improve survival of infected mice [ ] gentamicin membrane antigen immunization postexposure immunization with membrane protein fraction antigens and treatment with low-dose gentamicin increased survival of mice and significantly reduced bacterial burdens in the liver and spleen [ ] potential of several small molecule immunomodulators and host cell factors that have been investigated to date. immunomodulators directly target the host rather than the pathogen (fig. . ). this is accomplished by targeting pattern recognition receptors, such as tlrs that are present on innate immune cells in the host to detect features of microbes known as pathogenassociated molecular patterns. since immunomodulators target host immune cells, they are an attractive candidate for use against bacterial agents as they are unlikely to result in the development of antibiotic resistance even after repeated use. in particular, the threat of an intentional release of a highly virulent bacterial pathogen that is either intrinsically resistant to antibiotics, or has been weaponized via the introduction of antibiotic resistance, makes immunomodulation an attractive complementary or alternative strategy to directly targeting bacterial biothreat agents. for example, a synthetic tlr agonist, '-c-phosphate-g- ' oligodeoxynucleotide (cpg odn), appears to be able to stimulate protective immunity against intracellular bacterial infection and/or eliminate chronic infections. indeed, studies in mice have demonstrated that the innate immune defenses activated by cpg odns protect against lethal challenge with b. anthracis, b. mallei, and combination therapy, including antibiotics with an efflux pump inhibitor, would be a novel mechanism to restore the efficacy of the antibiotic in resistant strains of y. pestis [ ] antibody therapy corticosteroid the addition of antiinflammatory methylprednisolone, a corticosteroid, in combination with antibody therapy correlates with improved mouse survival, with reduction in neutrophil and matrix metalloproteinase in the tissue, and the mitigation of tissue damage [ ] ciprofloxacin l- - a novel postexposure medical countermeasure l- - , an a adenosine receptor antagonist blocks lps-induced activation of immunomodulatory cytotoxic substance accumulation to prevent acute lung injury, and in combination with ciprofloxacin improves survival of rats following infection with y. pestis [ ] aigiv, anthrax immune globulin intravenous; ifn, interferon; lps, lipopolysaccharide; pa, protective antigen. aminoglycosides rnd-type efflux pumps, s-adenosyl-l-methioninedependent methyltransferase, amrr [ , ] β lactams pena a , nlpd , dacc, flgn, sch, tr _ , tr _ , ftsi, amrr, bper, bpet, spot, trna, rrna, proteins with unknown function, sers seryl-trna synthetase, and rnd efflux pump amrab-opra, and bpeef-oprc [ , [ ] [ ] [ ] [ ] [ ] macrolides amrab-opra efflux pump [ ] quinolones amrab-opra efflux pump, bpeab-oprb efflux pump [ ] sulfamethoxazole/ trimethoprim rnd bpeef-oprc efflux pump, lysr-type regulator bpet bpes, ptr , fola, amrr tetr-type regulator, amrab-opra, metf [ , ] quinolones gyra a [ ] tetracyclines putative protein secretion targets, biosynthesis of pantothenate and coenzyme a, aspartate biosynthesis, dna replication [ ] francisella tularensis β lactams blab [ ] chloramphenicol s rrna, the l and l ribosomal proteins, and overexpression of efflux pumps [ ] quinolones gyra a and gyrb [ ] f. tularensis or their surrogates [ ] . similarly, human monocyte-derived macrophages treated with poly(i:c), a synthetic tlr agonist, showed significantly reduced intracellular f. tularensis [both schu and lvs (live vaccine strains)] replication. mice administered with poly(i:c) before or after schu or lvs infection showed reduced bacterial burden in the lungs and prolonged survival. mice treated with poly(i:c), challenged with f. tularensis, and then treated with levofloxacin showed % survival relative to no survival in animals receiving levofloxacin alone [ ] . in addition to targeting innate immune cell receptors, there is a growing interest in modulating autophagy as an immunotherapeutic intervention. autophagy is a dynamic process that targets cellular cytoplasmic contents for lysosomal degradation. more specifically, xenophagy is a type of selective autophagy that specifically targets intracellular pathogens to lysosomes, retracing their replication and survival [ ] . the use of autophagy inducer rapamycin, decreased the survival of b. pseudomallei in vitro [ ] . however, several bacteria exploit autophagic machinery as part of their intracellular life cycles (i.e., brucella abortus, c. burnetii, and f. tularensis). therefore infection may be exacerbated by the induction of autophagy (fig. . c ) [ ] . research to further understand the balance between infective and protective cellular targets in the autophagy pathway may enhance its utilization as a therapeutic target. hts of fda-approved drugs is another approach to identifying compounds that were previously approved for other disease indications but may have the potential to be repurposed as antiinfectives. trifluoperazine (an antipsychotic), amoxapine (an antidepressant), and doxapram (a breathing stimulant) mitigated fatal y. pestis infection in a pneumonic plague murine model [ ] . at h postinfection, these drugs provided animals with up to % protection against challenge with bubonic or pneumonic plague agents when administered in combination with levofloxacin [ ] . multiple fda-approved drugs targeting g-protein coupled receptors and calcium fluxes inhibited c. burnetii and b. abortus, whereas drugs targeting cholesterol traffic attenuated c. burnetii [ ] . similarly, increasing evidence suggested statin, a -hydroxy- -methylglutaryl-coenzyme-a reductase inhibitor, possesses antibacterial activity by the inhibition of sterols, prenylation, and isoprenoids (c. burnetii), the inhibition of antiinflammatory cytokines (y. pestis), and the modulation of phagosome maturation (c. burnetii) [ ] . it was demonstrated that a low dose of gleevec, an anticancer drug inhibiting abl , c-kit, and related protein tyrosine kinases, can increase the number of myeloid cells in the bone marrow, blood, and spleen and enhance antimicrobial responses in a mouse model of f. tularensis infection [ ] . in the case of viruses, small molecule targeting of innate immune receptors has also shown efficacy in several relevant viral models of infection. for example, treatment with poly(ic:lc) has also been protective against ebov infection in nhps [ ] . prophylactic pulmonary administration of tlr ligand (tmx ) significantly protected mice from lethal infection with veev [ ] . tlr and tlr agonists have also been shown to improve the efficacy of postexposure therapeutics against smallpox [ ] . sometimes modulation of host pathophysiological responses can be evaluated as a target. hemorrhagic fever virus pathophysiology includes the stimulation of procoagulant pathways and increased permeability of the vascular endothelium; therefore these processes are being evaluated as possible targets for therapeutic intervention. this could be accomplished by utilization of an anticoagulant, such as recombinant nematode anticoagulant protein c (rnapc ) that blocks initiation of the extrinsic coagulation pathway by inhibiting the tissue factor-factor viia complex [ , ] . rnapc has been shown to be highly protective in macaques infected with a lethal dose of ebola zaire virus, when treatment was initiated day post viral challenge [ , ] . whereas hdt targets the host directly, antibody therapy is the passive process of activating the immune system to respond to microbial threats. sources of antibodies can include individuals that survive infection or have received a prophylactic vaccine against a microbe. alternatively, antibodies can also be generated ex vivo using cell culture. historically, antibody-based serum or plasma therapy has been widely used to treat a variety of infectious diseases. limitations for clinical use arise however from the polyclonal nature of serum antibodies, resulting in lot-to-lot variation, approaches for determination of correct dose levels and regimens, and a risk for allergic reactions and transmission of transfusion-borne diseases. in general, limited clinical applications for antibody therapy existed until the development of technology that allowed the production of mabs through the use of hybridomas [ ] . hybridomas allow for the production of homogenous antibodies with the same specificity of a single immunoglobulin class and isotype. further advancements made it possible to humanize or generate fully human mabs. research advancements in the past - years have resulted in numerous mab-based therapies that have been approved for inflammatory and neoplastic diseases. infectious diseases have not been included in approved treatments. although many mab products targeting infectious diseases are in different stages of development, to date, one mab-based product, synagis (palivizumab), is currently approved for use in infectious diseases (rsv) [ ] , while two mabs abthrax (raxibacumab) and anthim (obiltoxaximab) have been approved under the fda's animal efficacy rule for treatment of inhalation anthrax [ ] . for treatment of ebola infection, the single mab mab and zmapp, a cocktail of three "humanized" mabs, have advanced in product development and are being tested for efficacy in the ongoing ebola outbreak in the democratic republic of the congo (nct , www.clinicaltrials.gov). it is clear that mabs offer a highly specific, potent, and generally safe platform for antimicrobials and may be a useful alternative to immune plasma. it is imperative to find appropriate niches in infectious diseases, specifically those caused by biothreat agents, where new antibody-based treatments could prove to be efficacious [ ] . table . summarizes key research in antibody therapy across different bacterial and viral families of some current biothreat agents. the utilization of mab therapy for the prophylactic or therapeutic treatment of biothreat agents varies depending on the agent. in all cases however, the challenge for the development of effective therapeutic antibodies against viruses is the viruses' heterogeneity and mutability. a related problem is the low binding affinity of cross-reactive antibodies that are capable of neutralizing a variety of primary isolates. finally, the cost of large-scale production of mabs is a limiting factor for continued use. a solution to the challenges with viral mutagenicity may be found in the identification of potent new mabs that target highly conserved viral structures, which are critical for virus entry into cells. alternatively, utilization of combination therapy, whereby, a cocktail of several mabs may be used or mabs may be combined with other drugs, such as antiviral compounds, may overcome mutagenicity issues. these areas of research will continue to be a major focus of biothreat agent therapeutic research [ ] . for countermeasures against lethal viral infections (i.e., category a), table . lists reported studies in either mice or nhps that have shown significant benefits to survival in challenge models. the table also includes in vitro potencies, viral strains, specific animal species, dosing regimens, routes of administration, pks, and benefits to survivaldata necessary for the reader to relate in vitro potency to in vivo efficacy, assess/interpret results, and make comparisons. the corresponding chemical structures are provided in fig. . . table . displays the status/results of clinical trials for therapeutics used for the treatment of infections caused by ebov and lasv. noteworthy, most of these clinical trials were underpowered without appropriate controls and hence results may be speculative. combination therapies are an excellent approach to improve treatment outcomes, shorten treatment duration, and overcome microbial resistance mechanisms caused by biothreat pathogens. combination therapy may incorporate antibiotics or antivirals with hdt or antibody therapy at rationally designed treatment schedule. in this way the usage of multiple treatment modalities can synergize to optimize the mechanism of action of biothreat-targeted therapies. table . includes combination therapies that have been used to treat each biothreat bacteria. in the case of viral infections, while combination therapy has been used for treatment of patients with human immunodeficiency virus (e.g., combination of nucleoside, nonnucleoside, protease, and/or host-targeted inhibitors) or chronic hepatitis c virus infection (e.g., combination of polymerase and rna-binding protein ns a inhibitors), to date there are no reported studies for biothreat viral agents. several β lactam antibiotic drugs have been able to overcome deactivation when delivered in combination with inhibitors that target extended-spectrum β lactamases (enzymes that are overexpressed in the mdr pathogens, inactivate the β lactam antibiotic by cleaving the β lactam ring and thus one of the major contributors of antibiotic resistance). the β lactam/β lactamase inhibitor combination drugs that have been fda-approved include augmentin xr (amoxicillin/clavulanate combination), unasyn (ampicillin/sublbactam combination), and zosyn (piperacillin/tazobactam combination). in the case of biothreat bacteria, the combination of ceftolozone and tazobactam exhibited increased in vitro susceptibility to a variety of clinical, environmental, and animal strains of b. pseudomallei, but to date it has not been evaluated in in vivo efficacy studies [ ] . challenges to developing countermeasures against biothreat agents are many, but some of the unique and key challenges are pk differences in healthy versus infected subjects, mapping the biodistribution of the countermeasure to the biodistribution of the pathogen, and limited opportunities to run randomized, controlled clinical trials. preclinical studies typically require a pk study in healthy animals to guide dose selection prior to testing a countermeasure in an animal model of infection. in that regard, it is critical to understand what cells and tissues the pathogen is infecting over time so that countermeasures can be properly designed to reach infected tissue. for example, countermeasures against pathogens causing encephalitis require drug to reach the central nervous system (cns). in contrast, ebov was found to infect lymph nodes, spleen, and liver in nhps - days following viral challenge, and by days - the virus was detected throughout the body (fig. . ) [ ] . thus if one was designing a countermeasure against ebov infection, it would likely require a wide tissue distribution in order to be effective. to complicate things further, infected animals often have altered metabolizing enzymes (e.g., cytochrome p s) [ ] , tissues, and barriers (e.g., blood-brain barrier) making drug exposure difficult to predict. running pk experiments in the presence of infection would eliminate many of these variables, but this is seldom done for countermeasures to biothreat agents, since it requires running these experiments in biocontainment labs. because biothreat pathogens cause infrequent human cases and outbreaks in generally remote areas of the world, planning a traditional human clinical trial with large numbers of participants is not feasible. even when the west african ebola outbreak of more than , cases was unfolding in - , and now that there is a large outbreak unfolding in the democratic republic of the congo, the amount of clinical efficacy data that have been collected for ebov therapeutics is quite limited. the limitations are due to difficulty of performing clinical research in a remote outbreak setting where cultural, geographical, and political barriers may hinder or halt trial planning [ ] . the bulk of the efficacy data for ebola published in the literature has been garnered through animal studies. to enable product development for viral, bacterial pathogens as well as for chemical, toxin, and radiological threat agents for which outbreaks or cases are sparse, the fda issued an animal rule, codified cfr . in , that proposes to permit consideration of product development and efficacy data obtained from animal studies for drug licensing, in lieu of human clinical trials when such trials would be unfeasible or unethical [ ] . since introducing the animal rule in , the fda has approved more than a dozen products, including several therapeutics for anthrax, plague, botulinum toxin, and smallpox [ , ] . the animal rule does not provide an expedited pathway to fda approval for drugs and can certainly be more challenging than traditional drug development pathways. the developer must compile a significant body of data to prove efficacy of the drug against the target therapeutic indication. first in , and updated now into a formal document published in [ ] , the fda has released guidance for industry describing critical data elements required for animal efficacy studies for drug approval under the animal rule: ( ) the pathophysiology of disease and the mechanism of action by which the drug prevents or ameliorates disease must be reasonably well understood; ( ) it is desired that the efficacy must be demonstrated in two animal species, although multiple studies in one species can be acceptable if the animal model is sufficiently well characterized and accurately predicts the human response; ( ) the animal study end point must be clearly related to the desired human efficacy end point, such as enhancement of survival; and ( ) pk and pharmacodynamics data must be generated in the animal studies to allow selection of an effective dose in humans. under the animal rule, efficacy studies are expected to demonstrate that drug effectiveness in animals reliably indicates efficacy in humans. thus while traditional human clinical efficacy studies require demonstration that the therapy is effective, the animal rule imposes an additional burden on investigators to establish a drug candidate's mode of action in at least one animal model that reproduces accurate human disease pathology. further, the animal rule outlines considerations for the development of the model(s), to include the use of an isolate of the etiologic agent that was known to cause human disease (e.g., agent was isolated from a fatal human case if it is a lethal disease, such as ebola) [ ] . there is also a requirement that the infection model using the chosen pathogen strain must present the same or similar pathophysiology as the human disease. definitive animal model efficacy evaluations should be performed only after careful model development studies have been performed and accepted by the regulators. these studies are known as natural history studies and are carefully designed to investigate and describe the course of the disease in the animal species, through clinical, serological, and histopathological evaluations, to compare the features of the disease in the model to the features of disease in human cases. it is important to consider the route of pathogen exposure (nasal, oral, and aerosol routes) to the animal because this will model the natural or unnatural modes of exposure predicted for humans, where a biorelease would constitute an unnatural exposure. a dose of challenge agent that is thought to be predictive of the human exposure level in a biorelease scenario should be used to develop the model, and that dose should be well characterized and reproducible by a quantitative measure. the route of drug delivery, dose administration timing, and treatment regimen in response to a biorelease scenario must also be considered when designing the animal model studies for a drug under development for such an indication. it is possible that a biorelease scenario would not be immediately known, and a period of time might pass before people begin to develop symptoms. studies evaluating the cutoff time for drug to still be effective, and what are the triggers for treatment should be investigated in the animal model. animal rule pivotal efficacy studies are essentially performed in place of traditional phase clinical studies, so they must be done in the containment laboratory under a quality system [ ] . use of fda good laboratory practice or other comparable quality system with high levels of documentation and data integrity is paramount, so data packages can withstand regulatory review and audit [ ] . the studies must be designed so that the program will collect the same results and conclusions one would expect from a well-designed traditional phase trial, but in addition a pivotal animal efficacy study must describe a mechanism of action for the treatment modality to prevent or block disease or tissue infection and damage [ ] . the pathologic mechanism needs to be consistent and well understood across both the human and animal models, such as the mechanism of pathogen entry into the target host cell, toxicological mechanism of lethal factors, or germination of spores and dissemination of bacterial infection in target cells and tissues, all of which may be mechanisms the drug under study is known to block; this must be proven in the animal model. products developed under the animal rule are subject to postmarketing or field studies when the product is actually used in the scenarios for which it was developed, and this is required to verify a product's clinical benefit [ ] . part of the approval process is a requirement to have postmarketing study plans in place, for quick execution should an event occur in which the drug would be field tested. approval may also come with restrictions for off-label use, distribution, or access. actual use will also come with requirements to inform patients of the conditions under which the drug was approved by virtue of only animal efficacy data, making them informed consumers as to the risks of possible nonefficacy or unknown effects in cases of human disease. with the advancement of systems and synthetic biology and the ease of genetic modification, biothreats are becoming more complex and there is a growing need for novel treatments that can have broad-spectrum activity against new, remerging, and engineered pathogens. developing novel countermeasures that can effectively treat and prevent massive casualties is an ongoing challenge that remains a central priority for future research. the development of novel therapies relies on an improved understanding of the host-pathogen interactions. key virulence factors have been identified and targeted for potential treatment options, including biofilm and t ss inhibitors for bacterial infections, and viral entry or polymerase inhibitors for viral infections. combining hts with systems biology provides a robust, coordinated approach to identifying therapeutic targets. since stand-alone antibiotics or antivirals may not be sufficient to overcome resistant or engineered biothreat infections, a focus on combination therapy, antibodies, and hdts is the key countermeasure. although many challenges are faced when developing novel therapies for biothreat pathogens and no fda-approved hdts are yet available for treatment, there is potential for novel small molecule host-targeted immunomodulators to be developed. screening of fda-approved drugs is a powerful approach to possibly repurpose drugs for new disease indication and/or identify compounds that are safe and effective in humans, which can also have antibacterial or antiviral capabilities. three fda-approved drugs have shown potential in mice against pneumonic plague [ ] . serious challenges still remain with the prevalence of antibiotic resistance that 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studies key: cord- -afkeuwup authors: nan title: chapter emergency management of poisoning date: - - journal: haddad and winchester's clinical management of poisoning and drug overdose doi: . /b - - - - . - sha: doc_id: cord_uid: afkeuwup nan medical toxicology is one of the most important and dynamic fields in medicine today, since the practicing physician is continually faced with the management of poisoning, drug overdose, and adverse drug effects. the abuse of both prescription and illicit drugs in the united states continues unabated. because the process of drug approval is more rapid, it is often not until the agent has been in use for some time, during the postmarketing period, before its toxicity is fully appreciated. defining the incidence of human poisoning is not easy. there are multiple sources of data on drug overdose and substance abuse. the toxic exposure surveillance system (tess) of the american association of poison control centers tabulates referrals for human poisoning called into the nation's poison centers. in , it recorded , , exposures, with deaths; analgesics were the most common cause of a fatal outcome. the national institute of drug abuse surveys emergency department visits through its drug abuse warning network (dawn), and in reported that a total of deaths resulted from drug abuse, with cocaine being the most commonly implicated agent. , however, these sources vastly underestimate the number of toxic events in humans. for example, reports of intoxicated patients who die from trauma, drowning, and fires are not consistently included in any national data set, nor are those of patients with medical complications from therapy, such as chemotherapy or anesthetics. morbidity that results from chronic abuse (e.g., heart disease from cocaine or nicotine abuse and cirrhosis from alcohol abuse) or industrial exposures, and the long-term effects of environmental hazards, is not rigorously compiled and is probably impossible to quantify. the most common causes of poisoning-related death in the united states have been carbon monoxide poisoning, cocaine use, and tricyclic antidepressant overdose. poisoning with analgesics, aspirin, and acetaminophen also remains a leading cause of death. calcium channel blocker overdose has surpassed digitalis overdose as the most common cause of cardiovascular drug-related death. to poison means to injure or kill with a substance that is known or discovered to be harmful. thus, the term poisoning connotes clinical symptomatology. it also implies that the toxic exposure is unintentional (e.g., in the case of an elderly patient who misreads a drug label). in contrast, the term overdose implies intentional toxic exposure, either in the form of a suicide attempt or as inadvertent harm secondary to purposeful drug abuse. the terms poisoning and drug overdose often are used interchangeably, especially when prescription drugs are the agents, even though by definition a drug overdose does not produce poisoning unless it causes clinical symptoms. poisoning has a bimodal incidence, occurring most commonly in children who are to years of age and in the elderly. overdose, whether motivated by suicidal intent or the result of abuse, occurs through adulthood. toxic exposure in those between the ages of and years is uncommon; when it occurs, the patient must be assessed carefully to ensure that psychiatric follow-up is provided when indicated. the general approach to the poisoned patient can be divided into six phases: ( ) stabilization; ( ) laboratory assessment; ( ) decontamination of the gastrointestinal tract, skin, or eyes; ( ) administration of an antidote; ( ) elimination enhancement of the toxin; and ( ) observation and disposition. because overdose patients are often clinically unstable when discovered, resuscitation with establishment of the airway, adequate support of ventilation and perfusion, and maintenance of all vital signs (including temperature) must be accomplished first. continuous cardiac and pulse oximetry monitoring is essential. rapid-sequence intubation (rsi) may be indicated in patients with an airway in jeopardy. naloxone, mg intravenously (iv); thiamine, mg intravenously (iv); and % dextrose, ml iv (if patients are shown on dextrostix testing to be hypoglycemic) are generally given to all adults in coma, once an iv line has been established and appropriate blood studies have been performed. , maintenance of blood pressure and tissue perfusion may require the provision of volume, correction of acid-base disturbance, administration of pressor agents, and antidotal therapy. only for reversal of pure initial dose not to exceed mg benzodiazepine sedation β blockers glucagon adult: - mg (iv) initially stimulates camp synthesis, increasing child: - ug/kg (iv) initially myocardial contractility continuous infusion as needed calcium channel calcium chloride % g ( ml) (iv) over min as initial avoid extravasation; tissue destructive blockers dose; repeat as necessary in critical patients; doses up to g may be necessary to restore blood pressure insulin/glucose . - . u/kg initially then monitor serum potassium and glucose . - . u/kg/hr as needed to maintain systolic blood pressure therefore, this task requires a thorough understanding of advanced airway management principles and of their application in a manner that prevents worsening of the clinical situation. rsi is a method of rapidly obtaining airway control with minimal physiologic disturbance. the process of rsi involves a patterned sequence of preparation, drug administration, intubation, and postintubation management. [ ] [ ] [ ] in the emergency department, rsi has historically had its greatest role in the patient with severe head trauma in whom intubation could exacerbate already increased intracranial pressure. however, because it is designed to blunt or prevent all adverse responses associated with endotracheal intubation, rsi is the ideal method of intubation in the poisoned patient. with the use of drugs having a short duration of action, rsi also is advantageous because it is a measure that permits temporary airway control for the patient with mildly compromised airway reflexes who requires gastrointestinal decontamination (lavage followed by activated charcoal administration) but who does not require prolonged intubation. rsi requires several essential steps that include the use of pharmacologic agents (table a- ) . to be performed safely, rsi must occur in the following sequence. the clinician must first evaluate the patient's airway to determine the necessary equipment and the best technique for safe intubation. particular attention should be directed to abnormalities in the cervical spine and temporomandibular joint because these will significantly impede rapid and uncomplicated intubation. if there is any question about the stability of the cervical spine, immobilization must be maintained. the oral cavity should be closely examined for the presence of foreign bodies. in addition to basic airway management, many victims of poisoning require advanced management that includes endotracheal intubation. clinical situations in which endotracheal intubation may be necessary in poisoned patients are numerous (box a- ). intubation offers the advantages of complete airway control, protection from aspiration of gastric contents, provision of a route for suctioning of secretions, and a means of optimizing both oxygenation and ventilation. however, the process of intubating an awake patient is difficult and is associated with potential adverse effects, including coughing, gagging, vomiting, tachycardia or bradycardia, hypertension, hypoxia, and increased intracranial pressure. moreover, emergency intubation can be challenged by vocal cords that are obscured by secretions, unusual airway anatomy, a full stomach, or active vomiting. before intubation, all necessary equipment must be present so that serious delays or unforeseen complications can be prevented. an iv line should be established and the patient connected to a cardiac monitor and pulse oximeter. the equipment necessary for endotracheal intubation is outlined in box a- . the proper functioning of all equipment should be ensured before it is used. appropriate endotracheal tube size also should be determined (table a- ) . unanticipated difficulties with intubation are common; "difficult airway" equipment (e.g., illuminated or fiberoptic-directed endotracheal tubes) should be kept close at hand. oxygen should be administered for to minutes before intubation; this produces a washout of nitrogen from the lungs, replacing this gas with an oxygen reservoir. the oxygen reservoir allows several minutes of apnea during which intubation can be performed without the risk of producing hypoxia. assisted ventilation with bag-valve-mask apparatus should only be provided if the patient's own respiratory efforts are inadequate because it risks inflation of the stomach, which increases the likelihood of vomiting. patients who are breathing spontaneously should be given % oxygen by face mask for several minutes before intubation. pretreatment involves the administration of pharmacologic agents that prevent adverse physiologic changes that may occur during intubation. agents included in this category are lidocaine and atropine. iv administration of the anesthetic lidocaine appears to blunt the increase in intracranial pressure that concepts in medical toxicology anesthetics, ketamine can produce significant elevations in pulse, blood pressure, intracranial pressure, and myocardial oxygen consumption, and such an increase in any of these could worsen the patient's clinical condition. because ketamine has a potent bronchodilating effect, it retains its important role as an induction agent in the patient with severe bronchospasm. [ ] [ ] [ ] after administration of a sedative/anesthetic, skeletal muscle relaxation is performed. skeletal muscle relaxants, all of which interrupt acetylcholine function at the myoneural junction, are typically divided into depolarizing and nondepolarizing categories. depolarizing agents, of which succinylcholine is the model drug, produce muscle depolarization before paralysis; this results in initial generalized muscle fasciculation. nondepolarizing relaxants produce paralysis without initial depolarization. the nondepolarizing skeletal muscle relaxants include pancuronium, vecuronium, atracurium, and rocuronium. succinylcholine is the most popular muscle relaxant because it has several desirable properties, including a rapid onset of action (less than minute) and an extremely short duration of action. customary paralyzing doses of succinylcholine are to mg/kg iv. despite its efficacy and popularity, succinylcholine can produce several adverse effects. these include hyperkalemia, prolonged paralysis, malignant hyperthermia, and hemodynamic changes. hyperkalemia, which can be severe, has been most commonly associated with administration of succinylcholine to those with burns, crush injuries, select neuropathies (e.g., guillain-barré syndrome), and myopathies (e.g., childhood muscular dystrophies). prolonged paralysis can occur in those who have a genetic deficiency in serum cholinesterase, the enzyme that inactivates the drug. prolonged paralysis may also occur in patients with liver disease, the elderly, and those who have ingested anticholinesterase insecticides (carbamates or organophosphates). malignant hyperthermia is a syndrome characterized by muscle rigidity, hyperthermia, autonomic disturbances, acidosis, rhabdomyolysis, myoglobinuria, renal failure, and coagulopathy. occurring in genetically predisposed individuals, malignant hyperthermia may appear without warning in those who are given inhalation anesthetics or succinylcholine. the mortality rate associated with this syndrome is approximately % to %. a malignant hyperthermia-like picture can also occur in children with skeletal muscular disorders (e.g., muscular dystrophy) who are given succinylcholine. finally, succinylcholineinduced muscle depolarization can lead to transient increases in intracranial and intra-abdominal pressure, with accompanying changes in cardiac output. because of these potential adverse effects, nondepolarizing muscle relaxants are often recommended as adjuncts to or substitutes for succinylcholine use. as adjuncts, nondepolarizing agents, when given before succinylcholine, can prevent muscle fasciculation and its attendant physiologic effects. the so-called "defasciculating dose" of a nondepolarizing agent is approximately one tenth the full dose of that agent. for example, pancuronium can be given in a dose of . mg/kg iv before the accompanies intubation. although scientific proof of lidocaine's efficacy is sparse, it is appropriateparticularly in the patient with suspected intracranial hypertension-to administer lidocaine, . to . mg/kg iv, to minutes before intubation. [ ] [ ] [ ] bradycardia can accompany rsi in two circumstances. in young children, both posterior pharyngeal stimulation and administration of succinylcholine can result in severe bradycardia. therefore, in children younger than years, atropine should be administered before induction. the dose of atropine is . to . mg/kg (maximum, . mg). no less than . mg of atropine should be administered because smaller doses can produce paradoxical bradycardia. severe bradycardia can also occur in patients of any age who have been exposed to medications or toxins with negative chronotropic actions. for example, in patients who have ingested β antagonists (e.g., propranolol), calcium channel blockers, and digoxin, rsi can produce an abrupt decrease in heart rate or frank cardiac arrest. therefore, in patients who are undergoing rsi after exposure to these agents, atropine should either be administered prophylactically or kept immediately available should emergency administration become necessary. induction consists of two components: administration of a sedative/anesthetic agent to produce unconsciousness, and the subsequent administration of an agent that produces complete skeletal muscle relaxation (paralysis); both actions facilitate intubation. because administration of these drugs leads to apnea and paralysis, it is essential that induction proceed quickly and efficiently; this underscores the importance of having all intubation equipment immediately available and in working order. a number of medications of different pharmacologic classes are used to produce sedation before skeletal muscle relaxation (see table a - ). these drugs include benzodiazepines, opioids, barbiturates, propofol, etomidate, and ketamine. among the benzodiazepines, midazolam, when given in a dose of . mg/kg iv (up to a range of to mg in an adult), is ideal because its effects are rapid in onset and short in duration. the drug also offers the advantage of producing muscle relaxation and amnesia. opioids are another class of drugs that can be used; however, many opioids, such as morphine, may prompt histamine release, with resultant hemodynamic changes. fentanyl in a dose of to μg/kg is highly effective at producing rapid sedation and relaxation with minimal cardiovascular change. several barbiturates can produce rapid sedation and relaxation. the most popular of these is sodium thiopental (dose to mg/kg). equally effective but with a shorter duration of action are methohexital, propofol, and etomidate. finally, ketamine is a dissociative anesthetic that can produce rapid onset of a state in which the patient is insensitive to pain but maintains an awake appearance and continues to have protective airway reflexes. the typical iv induction dose of ketamine is to mg/kg. unlike other sedatives/ administration of succinylcholine to prevent fasciculation. nondepolarizing agents can also be used solely for skeletal muscle relaxation. however, they generally have a much slower onset of action (as long as to minutes) and produce a longer duration of paralysis. also, many nondepolarizing agents stimulate histamine release, producing significant hemodynamic changes. therefore, they are not ideal agents for rsi. rocuronium appears to have the most rapid onset of all nondepolarizing agents, approaching that of succinylcholine with regard to time to complete muscle relaxation in the less than ideal conditions generally found during emergency intubation. significant warnings to succinylcholine use in the pediatric population have been recently added, based on the possibility of life-threatening cardiac arrhythmias. according to these new warnings, children with undiagnosed myopathies (e.g., a muscular dystrophy) could develop hyperkalemia sufficient to produce a cardiac disturbance. intubation suction must be immediately available when intubation is performed. the patient undergoing emergency intubation often has a full stomach; the risk for vomiting and aspiration is therefore significant. this risk is minimized both by the rsi technique and by the direct application of pressure on the cricoid cartilage (sellick's maneuver), which occludes the esophagus. adequate preoxygenation and limiting the duration of the intubation attempt to less than to seconds should prevent significant hypoxia. the differences between the airway of the child and that of the adult have important implications for endotracheal intubation. . the child has a relatively large tongue; this makes direct visualization of the larynx difficult. . the child has larger tonsils, which also obscure visualization. . the infant's larynx is located more cephalad than that of the adult. as a result, the angle between the tongue and the glottis is more acute, and visualization of the larynx is impaired. . the subglottic area of the infant is the narrowest part of the larynx and may impede the passage of an endotracheal tube passed through the vocal cords. immediately after successful endotracheal intubation, placement of the endotracheal tube must be confirmed by detection of bilateral equal breath sounds on chest auscultation, end-tidal carbon dioxide monitoring, or chest radiography; of these, chest auscultation is the least sensitive method and should never be used in isolation to confirm endotracheal tube placement. after confirmation, the tube should be secured either with a strap or with benzoin and adhesive tape. inflation of the endotracheal tube cuff should be performed to minimize aspiration of gastric contents (although aspiration of activated charcoal around cuffed endotracheal tubes is a frequent occurrence). until recently, because the airway of the young child has an area of narrowing ("physiologic cuffing"), cuffed endotracheal tubes were not used in the pediatric patient. pediatric cuffed tubes are now available; their use is encouraged in most circumstances. if long-term intubation is necessary, sedatives/anesthetics and nondepolarizing muscle relaxants should continue to be administered. in unskilled or unprepared hands, emergency endotracheal intubation can have disastrous consequences. even when performed by the most experienced hands, this complex procedure can have complications that should be anticipated so that they can be quickly recognized and treated. these complications include: poisoned patients often present to the emergency department with hypotension or frank shock. provision of circulatory support through interventions that may include volume expansion, vasopressor therapy, antidote administration, and correction of electrolyte and acidbase disturbances is essential in initial management. many medications and toxins produce hypotension (box a- ). depending on the ingested substance, the low blood pressure may have a number of causes. for example, blood pressure depressions may occur from direct depression of myocardial contractility (e.g., quinidine), disturbances of central nervous system cardiorespiratory centers (e.g., clonidine), severe gastrointestinal fluid losses (e.g., acetaminophen, iron, arsenic, ricin, mushrooms), peripheral vasodilation (e.g., angiotensin-converting enzyme inhibitors), or a combination of these effects (e.g., theophylline, calcium channel blockers, tricyclic antidepressants). hypotension also can result from the secondary effects of toxins (e.g., cocaineinduced myocardial infarction). finally, blood pressure disturbances in the poisoned patient may represent accompanying trauma (e.g., severe spinal cord injury or internal hemorrhage). with the multitude of possible causes, the clinician, on the basis of the known pathophysiology of a particular drug and after having performed a thorough physical assessment, should determine, if at is mechanistically the source of intravascular volume loss, the use of colloid solutions may be preferred. whole blood is most valuable in situations in which there is frank blood loss. with severe hemolysis (e.g., after arsine or stibine exposure), exchange transfusion with whole blood may be necessary. usually, the adequacy of volume expansion is determined clinically by an increase in blood pressure. other clinical signs of improved cardiac output include resolution of cyanosis and normalization of capillary refill time. central venous pressure and swan-ganz catheter monitoring, although invasive, provide the best evidence of appropriate intravascular volume. fluid overload is a potential complication of volume expansion. this is most likely to occur in patients who receive excess fluids over a short period of time. also, after an overdose of a myocardial depressant such as tricyclic antidepressants or quinidine, a fluid bolus that could be tolerated by a healthy individual can produce pulmonary edema in the overdose patient. therefore, administration of modest boluses of fluid is generally recommended; if cardiac output remains inadequate after fluids have been given, vasopressor therapy should be initiated. in the patient with severe hypotension, vasopressor therapy is necessary if blood pressure is not satisfactorily improved after volume expansion. vasopressors are drugs that can be administered to maintain cardiac output. these agents have specific effects on the heart or blood vessels, augmenting myocardial function or increasing vasomotor tone, or both. with rare exception, vasopressors used in the acute management of hypotension are short-acting drugs that must be given by continuous iv infusion. vasopressors generally act at adrenergic (α and β), d (dopamine), or glucagon receptors (table a- ). the adrenergic system has been further defined with the recognition of two major α-adrenergic receptor subtypes (α and α ) and three β-adrenergic receptor subtypes (β , β , and β ). coupled with intracellular g proteins, these membrane-bound receptors effect an intracellular chain of events that includes changes in the activity of adenylate cyclase. this action goes on to modulate the level of intracellular cyclic adenosine monophosphate (camp), which in turn alters phospholipase activity or opens gated calcium channels. although the cellular mechanisms of this system have become much better defined, the general principles of vasopressor action remain unchanged. for example, α-adrenergic receptor agonists produce vascular smooth muscle contraction. β -adrenergic receptor agonists produce increased heart rate and contractility, whereas β -adrenergic receptor agonists promote generalized smooth muscle relaxation (including bronchial and vascular). vasopressor therapy is designed to improve cardiac output through manipulation of the specific receptor most appropriate for the clinical situation. a number of vasopressors can be used to provide blood pressure support (see table a - ) . the all possible, the probable cause of hypotension if he or she is to provide a specific intervention. appropriate cardiac output relies on the adequacy of intravascular volume. after poisoning, intravascular volume may decrease abruptly. this decrease can be absolute, occurring as a result of a direct loss of intravascular volume (e.g., pulmonary edema, gastrointestinal pooling), or relative, resulting from severe peripheral vasodilation (e.g., angiotensin-converting enzyme inhibitor or α-antagonist overdose). in either case, hypotension should first be treated with the administration of volumeexpanding agents. many fluids are acceptable for emergency volume expansion. normal saline and lactated ringer's solution are generally the most readily available isotonic agents. adults should receive up to -to -ml boluses of isotonic fluid while blood pressure is monitored; children should be given to ml/kg. after the administration of each bolus, the patient should be reassessed for improvements in cardiac output. alternative fluids that can be used for volume expansion in the poisoned patient include albumin and whole blood. each of these fluids has a role that is best determined by the pathophysiologic mechanism responsible for the hypotension. being colloid rather than crystalloid in nature, these fluids in theory maintain intravascular volume better than saline solutions do. in clinical situations in which a "leaky capillary syndrome" box a- ricin indications for the use of these drugs vary slightly, depending on the clinical circumstance. epinephrine elevates blood pressure primarily through its α-adrenergic-stimulating properties. this effect also is valuable in improving myocardial and cerebral blood flow. because it also has prominent β-adrenergic agonist effects, epinephrine is variably effective at producing marked increases in blood pressure. epinephrine therapy is initiated at a dose of . to . μg/kg/min. epinephrine is particularly effective in intoxications associated with hypotension and bronchospasm (e.g., hymenoptera envenomation and anaphylactic reactions). norepinephrine stimulates both αand β-adrenergic receptors, with slightly greater stimulation of α-adrenergic receptors. the effect is improved vasomotor tone in conjunction with increased myocardial chronotropy and inotropy. norepinephrine infusions are typically initiated in a dose of . to . μg/kg/min. dopamine is a precursor of norepinephrine. the most popular of vasopressors, dopamine appears to have at least three mechanisms of action: ( ) promotion of norepinephrine synthesis, ( ) a tyramine-like effect that stimulates release of preformed norepinephrine, and ( ) direct stimulation of vascular dopamine receptors. the cardiovascular effects of dopamine are variable, depending on the infusion rate. at relatively low doses ( to μg/kg/min), the drug dilates renal and mesenteric vessels without marked increases in heart rate or blood pressure. at doses of to μg/kg/min, β-adrenergic receptor stimulation predominates, producing significant increases in cardiac output. finally, at doses greater than μg/kg/min, α-adrenergic receptor stimulation is the primary action, resulting in marked peripheral vasoconstriction. the general dose range for dopamine infusion is to μg/kg/min. dopamine is safe and effective for any type of druginduced hypotension. in the past, there have been theoretic concerns that dopamine's β-adrenergic effect in the face of phenothiazine or tricyclic antidepressant intoxication would increase the peripheral vasodilatation associated with overdose, exacerbating hypotension. however, experimental data and clinical experience have failed to confirm this adverse effect from dopamine use. also, with hypotension after monoamine oxidase inhibitor overdose, dopamine's effects are somewhat unpredictable; it may be relatively ineffective (owing to the lack of preformed norepinephrine), or it can produce an exaggerated response (because of its tyramine-like action). dobutamine is a synthetic catecholamine with almost exclusive β-adrenergic receptor-stimulating effects. its primary mechanism of blood pressure improvement is direct myocardial inotropy; thus, reflex peripheral vasodilation may occur with its use. unlike dopamine, dobutamine does not release preformed norepinephrine. the usual dosage range for dobutamine is to μg/kg/min, although doses as high as μg/kg/min have been used. high-dose infusions often increase myocardial oxygen demands, which, if unmet, can result in myocardial ischemia. nonetheless, dobutamine is extremely effective in syndromes of heart failure. phenylephrine has both αand β-adrenergic receptorstimulating properties, although its α-adrenergic receptor actions predominate. phenylephrine is a potent stimulator of vasomotor tone; it is therefore very effective in patients in hypotensive states resulting from severe peripheral vasodilation (e.g., following overdose with an α-adrenergic antagonist, such as prazocin or a phenothiazine neuroleptic, e.g., chlorpromazine). phenylephrine centrations of extracellular calcium, particularly in the face of channel blockade (e.g., after overdose of calciumchannel blockers), sometimes improve contractility. administration of iv calcium chloride is indicated in the management of hypotension resulting from calcium channel blocker overdose (see table a - ), hyperkalemia, and hypocalcemia. a thorough history taking and physical examination are essential to the diagnosis of the toxic patient. poisoning should be suspected in any patient who presents with multisystem disturbance until proven otherwise. although the initial manifestations of poisoning are myriad, a patient with acute poisoning often presents with coma, cardiac arrhythmia, seizures, metabolic acidosis, or gastrointestinal disturbance, either together as symptom complexes or as isolated events. symptom complexes, or toxidromes (table a- ) , may give clues to an unknown poisoning. for example, a patient with a history of depression who presents with coma, seizures, a widened qrs complex or evidence of dysrhythmia on electrocardiography, and dilated pupils has likely taken a tricyclic antidepressant. hepatic, renal, respiratory, and hematologic disturbances are generally delayed manifestations of poisoning. the clinical evaluation, in addition to the history taking and physical examination, includes an assessment of major signs of toxicity presented by the patient and evaluation of the laboratory data. when one suspects poisoning or drug overdose, the primary goal of history taking is identification of the toxic agent. sometimes diagnosis is easy, as in the case of the toddler who ingests iron tablets in the mother's presence. sometimes it is difficult, as in the case of the patient who is hiding a history of drug abuse and passes out at work or who has an unexpected seizure. prior medical or psychiatric history, current medications, and allergies should be obtained from family or friends if the patient is unable to relate the information. the following questions may be revealing: what other medicines are in the house? what was the patient doing that day? does the patient live alone, did he or she just lose a job, or have there been recent emotionally traumatic events? is the patient eating a special diet or taking a new health food, alternative medication, or performance enhancer? could the patient inadvertently have taken too much of a prescribed medication? if it can be identified, is the substance nontoxic? (see box a- .) the physical examination can help in determining the extent of poisoning and may reveal the presence of a infusions are given in a typical dose range of . to . μg/kg/min. amrinone is a novel, nonadrenergic cardiac stimulant that improves myocardial contractility while inducing vasodilation. its mechanism of action appears to be direct inhibition of phosphodiesterase; the result of this is increased intracellular camp activity, an action that increases transmembrane calcium flux, potentiating cardiac chronotropy and inotropy. amrinone's effects have been compared with those of dobutamine and nitroprusside combination therapy. amrinone may be particularly valuable in the treatment of calcium channel blocker intoxication; its inhibition of camp breakdown results in greater phosphorylation of l-type calcium channels, potentially increasing their permeability. experimental data support its role in this specific poisoning. amrinone can be used to treat syndromes of left ventricular failure but should not be administered in the presence of myocardial ischemia; like dobutamine, it may increase myocardial demands, resulting in infarction. because of its potent vasodilating action, amrinone may cause a hypotensive response in those with low intravascular volume. the usual dosage range for this agent is to μg/kg/min; the total daily dose should not exceed mg/kg per day. glucagon is a single-chain pancreatic polypeptide that is an effective inotropic and chronotropic agent. its mechanism of action is direct stimulation of myocardial glucagon receptors; these receptors, when stimulated, increase the formation of myocardial camp. the resultant effect is positive inotropy and, to a lesser degree, positive chronotropy. glucagon is theoretically most effective after β blocker overdose, in which decreased β-adrenergic receptor activation leads to diminished camp production. the hormone may also provide therapeutic benefit in hypotension after calcium channel blocker overdose. glucagon is given in an initial dose of to mg ( to μg/kg in children). if effective in augmenting blood pressure, it can be given as a continuous infusion of to mg/hr ( μg/kg/hr in children). some preparations of glucagon are marketed as a lyophilized compound with a . % phenol-based diluent for reconstitution. while single doses of such a product can be given after standard reconstitution, glucagon for continuous infusion should be reconstituted with saline to prevent phenol toxicity. adverse effects from glucagon include hyperglycemia, nausea, vomiting, and ileus. calcium plays a key role in regulating cardiac inotropy through its binding to troponin c, an action that permits interaction between actin and myosin. although most of the calcium that produces this change resides in an intracellular calcium pool, extracellular calcium does diffuse into cells and contributes to increased contractility. although diffusion of calcium into the myocardium is "gated"-that is, it is tightly controlled-high con- hypoxia or prolonged pressure and are seen after sedativehypnotic overdoses (especially barbiturate overdose), carbon monoxide poisoning, and thermal burns. bullae may also follow rattlesnake envenomation. bullous lesions or soft tissue swelling should prompt evaluation for rhabdomyolysis, an occasional finding in patients following prolonged coma or severe hyperthermia, such as in cocaine abuse. it is important to smell the patient's breath. alcohol is the most common odor detected on the breath of an intoxicated patient in the emergency department. the accurate identification of other odors varies greatly among physicians. a fruity odor may be detectable in the patient with diabetic ketoacidosis. cyanide poisoning can be associated with the smell of almonds. the smell of cleaning fluid suggests carbon tetrachloride poisoning. gasoline, camphor, hydrogen sulfide, ether, turpentine, methyl salicylate, paraldehyde, phenol, and organophosphate insecticides all have characteristic odors. arsenic and tellurium intoxication is associated with the odor of garlic. a nasal examination may reveal chronic insufflation of cocaine. an edematous, often elongated uvula may be seen with marijuana use or exposure to corrosive agents. auscultation of the lungs may provide diagnostic clues. in narcotic or tricyclic antidepressant overdose, pulmonary edema may be a complication, leading to the appearance of adventitious noises. in all overdose patients, aspiration pneumonitis, the result of a depressed gag reflex, is a possibility. inhalation of toxic gases may produce wheezing and pulmonary compromise. pneumothorax may be detected in patients who smoke cocaine, methamphetamine, or any other heated, impure substance. mediastinal emphysema from marijuana or crack cocaine smoking also may be detected by auscultation. examination of the heart may reveal a new murmur, which in an intravenous drug abuser suggests endocarditis. bradycardia is common after the overdose of four classes of cardiac agents: calcium channel blocker, β blocking agents, digitalis preparations, and central α antagonists (e.g., clonidine or guanfacine). a ventricular arrhythmia on electrocardiography in a young patient suggests cocaine toxicity. an irregularly irregular heartbeat that is new in a patient on an alcoholic binge suggests atrial fibrillation-the so-called "holiday heart" syndrome. a boardlike abdomen in a patient with a history of spider bite is characteristic of black widow envenomation. examination of the abdomen in an overdose patient often reveals an adynamic ileus. in patients with abdominal pain, a surgical abdomen must be ruled toxic syndrome, of any underlying disease, or concomitant trauma. repeated assessment, especially of vital signs and of cardiac, pulmonary, and neurologic status, is critical to proper management of the toxicologic patient. the physical examination also can provide valuable clues as to the particular toxin involved (table a- ) . as part of the initial evaluation, complete determination of vital signs, including measurement of body temperature initially and throughout the emergency department assessment, is mandatory. obtaining a core body temperature measurement may be necessary. hyperthermia can occur with a number of ingestions and in infectious illness, but it is characteristic of poisoning with salicylates, anticholinergics, monoamine oxidase inhibitors, and dinitrophenol; it is occasionally also seen after intoxication with phencyclidine, lsd, or cocaine, especially following seizures. life-threatening malignant hyperthermia following drug overdose may occur. hypothermia is common and may occur because of exposure to cold, hypoglycemia, or overdose of a number of sedatives, especially barbiturates, ethanol, carbamazepine, narcotics, and phenothiazines. bradycardia can be seen with overdose of digitalis, cholinergic agents, β blockers, and calcium channel blockers, but it also may be seen with hypothermia or spinal cord trauma. hypertension is characteristic of intoxication with cocaine, amphetamines, phencyclidine, and sympathomimetics. the skin should be examined for needle tracks, burns, bruises, or lacerations. needle tracks may be confined to the groin or other areas that are not readily visible. a "boiled lobster" appearance suggests ingestion of a boric acid-containing roach powder insecticide. generalized flushing suggests an allergic reaction, niacin overdose, anticholinergic poisoning, scombroid fish poisoning, or an alcohol-disulfiram reaction. diaphoresis suggests hypoglycemia, salicylate or organophosphate poisoning, hyperthyroidism, drug or alcohol withdrawal, or shock from cardiac or other etiology. jaundice may follow overdose of acetaminophen, aspirin, iron, carbon tetrachloride, mushrooms, copper, or phosphorus. petechiae and ecchymoses suggest coumadin overdose. bullae may be secondary to skin out. hepatomegaly suggests liver congestion (e.g., with pyrrolizidine toxicity). all patients should undergo a careful neurologic examination. issues of major concern are concomitant head trauma and spinal cord trauma in comatose patients. serial neurologic examinations are key to proper assessment (see discussion of coma in section on level of consciousness). the extremities should be evaluated to detect thrombophlebitis, fracture or dislocation, or vascular insufficiency. rhabdomyolysis and the compartment syndrome are definite concerns in overdose patients, especially in those with prolonged coma or underlying trauma. the toxicologic patient presenting in the acute setting often exhibits the following, either alone or in combination: coma, cardiac arrhythmia, metabolic acidosis, gastrointestinal disturbance, and seizures. consciousness is defined as an awareness of self and the environment. coma is unarousable unresponsiveness. wakefulness implies the ability to be aroused. these three functional states are mediated by the ascending reticular activating system, a tract that courses through the diencephalon, midbrain, and pons. diseases produce coma either by diffusely affecting the brain or by encroaching upon the brainstem. coma may be produced by ( ) a supratentorial mass lesion, such as a subdural hematoma; ( ) a brainstem lesion (uncommon); or ( ) metabolic disorders that widely depress or interrupt brain function. one of the most common manifestations of acute poisoning is coma. the principles of coma management are relatively straightforward. patients in coma must be stabilized initially by establishment of an airway, proper oxygenation with continuous pulse oximetry, insertion of an iv line with normal saline, and resuscitation, if necessary (see earlier section on emergency management). the clinical evaluation of the comatose patient is invaluable not only in determining the depth of coma and assessing for trauma, but also in providing a baseline for repeated clinical assessment. coma can be assessed either using the simple avpu (alert, responsive only to verbal stimuli, responsive only to painful stimuli, unresponsive) or glascow coma scales. the major causes of coma in patients seen in the emergency department include poisoning (e.g., carbon monoxide poisoning), drug overdose, head trauma, cerebrovascular accident, anoxia, infection (e.g., meningitis), and diabetes and other systemic disorders such as renal failure, hepatic coma, and cardiac arrhythmia. the physician must rule out each condition before establishing the diagnosis of poisoning. supratentorial structural lesions are suggested by a rapid progression of signs, including changes in respiratory pattern, disconjugate gaze, lateralizing signs, or loss of doll's eyes movements. a metabolic cause of coma may be indicated by the persistence of the pupillary light reflex; a depression of respiration and consciousness more pronounced than other neurologic signs; preceding altered mental states; asterixis or fasciculations, or both; the presence of a ciliospinal reflex; and extracranial signs, such as jaundice. repeated assessment of the comatose patient is critical to proper management of poisoning. evaluation of the patient's pupils is most helpful. midpoint fixed pupils or a unilateral dilated pupil suggests a structural lesion. pinpoint pupils suggest overdose of opiates, clonidine, organophosphate insecticides, nerve agents (e.g., sarin), chloral hydrate, phenothiazines, or nicotine. dilated pupils are nonspecific. a disturbance of ocular movements (e.g., loss of doll's eyes movements) suggests a structural lesion. nystagmus suggests intoxication with phenytoin, phencyclidine, carbamazepine, and, occasionally, ethanol. it is important to note abnormal patterns of breathing. posthyperventilation apnea, cheyne-stokes respirations, and apneustic breathing strongly suggest that a structural lesion is the cause of the patient's coma. central neurogenic hyperventilation is a classic presentation of brainstem injury. kussmaul breathing can occur after salicylate or dinitrophenol poisoning. compensatory hyperventilation may accompany methanol or ethylene glycol poisoning or other toxin-producing metabolic acidosis. respiratory arrest is a common presentation in the patient who has taken a central nervous system depressant and may lead to multisystemic dysfunction resulting from severe hypoxic injury. decorticate and decerebrate posturing suggests a structural lesion. it is important to realize that patients with poisoning or drug overdose (e.g., tetrodotoxin intoxication) may appear brain dead; have fixed, dilated pupils; be in an unresponsive coma; and lack the cold caloric response, yet recover fully in time. a -lead electrocardiogram and continuous cardiac monitoring are essential for any patient with significant poisoning. evidence of an arrhythmia or other important diagnostic clues may be present on electrocardiography, such as a widened qrs complex in cyclic antidepressant overdose or a prolonged qt interval in trazadone or arsenic poisoning overdose. box a- lists common toxic causes of cardiac arrhythmia. the patient with life-threatening cardiac arrhythmia or cardiac arrest should be managed on the basis of the general principles of resuscitation and the american heart association's advanced cardiac life support causes of a high-anion gap metabolic acidosis are listed in box a- . the assessment of metabolic acidosis includes not only arterial (or, less ideally, venous) blood gas analysis, but also studies of serum sodium, potassium, chloride, carbon dioxide, blood urea nitrogen (bun), creatinine, glucose, acetone, serum osmolality, and urine ph, as well as urinalysis. determination of the anion gap is helpful in the diagnosis and management of poisoning. the clinician can measure serum osmolality either directly by determining the freezing point (osmometry) or by calculation. the formula for calculating osmolality is serum osmolality = × na + (meq/l) + bun (mg/dl)/ . + glucose (mg/dl)/ when laboratory data are expressed in international (si) units, the formula for calculation of serum osmolality simply equals × na + bun + glucose. the normal serum osmolality is to mosm/l. an osmometer measurement indicating a serum osmolality that is more than mosm/l greater than the calculated osmolality is termed an osmolar gap; it suggests the presence of an osmotically active substance that is not accounted for by the calculated osmolality. causes of an osmolar gap are listed in box a- . the most common cause of an osmolar gap is consumption of an alcohol. the osmolar gap can be used to estimate the serum concentration of an alcohol, based on that alcohol's molecular weight (table a- ) . a substance contributes to osmolality only if it achieves relatively high blood levels and has a low molecular weight. most drugs or intoxicants cannot be detected with use of the osmolar gap. the causes of toxic gastrointestinal disturbance are many. the patient with iron, arsenic, or ricin poisoning has severe, repeated episodes of vomiting and may develop gastrointestinal hemorrhage. theophylline overdose also causes persistent retching. acute lithium and arsenic poisoning characteristically produce massive diarrhea. patients with acute mercury poisoning have a mucous-type diarrhea, with the subsequent development (acls) guidelines. if cyclic antidepressant overdose is suspected, administration of iv sodium bicarbonate is indicated for correction of ventricular arrhythmia or conduction disturbances. sodium bicarbonate may also be effective in the treatment of other overdose by other agents associated with prolongation of the qrs interval, including diphenhydramine and cocaine. administration of iv calcium chloride is the primary therapeutic measure for calcium channel blocker overdose. use of digoxin antibody fragments is indicated for digitalis poisoning, and glucagon for β blocker overdose (see table a - ). in referred patients who have already been hospitalized elsewhere, ventricular arrhythmia may be due to hyperkalemia because renal failure may have ensued; in such patients, iv sodium bicarbonate, glucose/insulin, and, if necessary, calcium chloride administration may be warranted. magnesium has a singular role in the treatment of drug-induced prolongation of the qt interval, a conduction disturbance that is often the prelude to torsades de pointes and other lifethreatening disturbances. in all intoxicated patients, correction of hypoxia, metabolic acidosis, and fluid and electrolyte disturbance serves to reduce the incidence of cardiac arrhythmias. digoxin and other digitalis compounds lithium of hemorrhagic colitis. one of the most striking presentations is caused by phosphorus poisoning, which produces luminescent vomitus and flatus. the early presentation of organophosphate or nerve agent exposure is similar to that of acute gastroenteritis and is characterized by abdominal cramps, vomiting, and diarrhea, with subsequent development of neurologic signs. poisoning from mushrooms (see chapter ), toxic marine life (see chapter ), botulism, and food (see chapter ) should be included in the differential diagnosis. chemotherapeutic agents (see chapter ) are well-known causes of toxic gastroenteritis. the management of gastrointestinal disturbance in the toxic patient includes following the general principles of blood, fluid, and electrolyte resuscitation, when indicated; judicious use of parenteral antiemetics to control persistent vomiting; specific measures such as antidotal therapy (e.g., in iron or organophosphate poisoning); or interventional therapy, such as charcoal hemoperfusion (in theophylline overdose) or hemodialysis (in lithium overdose), when indicated. common agents that cause seizures are listed in box a- . almost any drug or toxin is capable of producing a seizure. delayed seizures occurring during a recovery period may be a sign of sedative-hypnotic or alcohol withdrawal. seizures should be managed first with establishment of an airway and oxygenation. patients with a simple isolated seizure may require only observation and supportive care, whereas repetitive seizures or status epilepticus, which can be life threatening, must be managed aggressively. some seizures are particularly difficult to control, such as those seen with theophylline or cocaine overdose. the standard regimen for seizure control in overdose of an unknown agent is use of the full therapeutic dosages of benzodiazepines (e.g., diazepam or lorazepam), followed by administration of phenytoin or a barbiturate (e.g., phenobarbital or pentobarbital). in patients with status epilepticus, rsi may be necessary and the use of thiopental is indicated, with electroencephalographic monitoring to ensure control of electrical seizure activity; the use of additional paralytics, such as pancuronium bromide, may be warranted. specific measures to control seizures may be indicated, such as administration of pyridoxine for isoniazidinduced seizures. box a- lists specific blood studies whose results may be used for diagnosis and to direct therapy of the overdose patient. in every significant poisoning, routine studies include a complete blood count; determination of serum electrolytes, glucose, bun, creatinine, and calcium; urinalysis; prothrombin time; pulse oximetry; end-tidal co monitoring, and -lead electrocardiography. arterial blood gas analysis is necessary for evaluating respiratory status and acid-base abnormalities, particularly in the comatose or seizure patient. the measurement of serum salicylate and acetaminophen levels is generally added in the case of the patient with overdose of an unknown substance, because these agents are often co-ingestants or are contained in combination drugs. measurement of hepatic enzymes is important in the evaluation of acetaminophen toxicity. the advantage of a toxicologic drug screen in initial management is equivocal. box a- gives a partial list of drugs and toxins not commonly ph monitoring is helpful in the management of salicylate overdose. urine is the best specimen to use for "drug screening" purposes. a urinalysis is also useful in the early identification of acute renal failure or rhabdomyolysis with myoglobinuria. the intravenous drug abuser requires special blood testing, such as evaluation for human immunodeficiency virus, a hepatitis profile, a blood culture to identify bacteremia, and evaluation for rhabdomyolysis. chest radiography is an aid for diagnosing aspiration pneumonia or pulmonary edema. box a- lists agents that are radiopaque on plain film radiography of the abdomen. computed tomography may be useful if underlying trauma is suspected. finally, lumbar puncture may be indicated for ruling out meningitis in a patient with fever and coma. ocular decontamination see chapter . being the largest and most superficial organ in the body, the skin is often subject to exposure to toxins and is affected in . % of reported cases. at least % of occupational illnesses involve the skin. the effects of these exposures can be local or systemic (box a- ) . the skin provides many barriers to the absorption of toxins. the stratum corneum forms an important first barrier and is highly effective when it is completely intact. however, when skin wounds are present, when the wounds are wet, and when exposure is to certain highly lipophilic substances (e.g., organophosphate insecticides), significant absorption of toxin through the skin can occur. the skin of infants is notable for being more permeable than that of adults to substances of all classes. detected with routine drug screening. further laboratory blood studies are tailored to assess the individual diagnostic and therapeutic needs of the patient. it is extremely important to remember to "treat the patient, not the lab." one should never withhold therapy while waiting for a confirmatory drug level in a critical patient, such as a patient with tricyclic antidepressant overdose who is exhibiting a widened qrs complex. in contrast, performing hemodialysis on a completely asymptomatic patient with lithium overdose on the basis of one test result indicating an elevated serum lithium concentration would be equally unwise. serial blood level determinations are often helpful in guiding therapy in patients undergoing hemodialysis; in patients in whom concretions have formed, such as those with barbiturate, iron, salicylates, or meprobamate intoxication; or in patients receiving antidotal therapy (e.g., serial measurement of lead level is useful in patients receiving iv cana edta for management of lead poisoning). a urinalysis is necessary. performing a urine pregnancy test is wise in all women of childbearing age. urine the range of dermal toxins is broad. most of these substances are corrosive agents capable of producing burns that may become full thickness (i.e., third degree). other types of agents are irritants, sensitizers (including photosensitizers), allergens, vesicants, and exfoliants. as with ocular exposures, the general principles of management after exposure to dermal toxins are many. as soon as a toxic dermal exposure is recognized, decontamination efforts should begin. if the victim is immersed in a toxic fluid, the first step in management is his or her extrication without injury to the assistant. the victim should disrobe him-or herself at the scene. if the victim requires assistance, undressing should be done as safely as possible. protective gear should be donned before assistance with decontamination is rendered. unless the agent is highly reactive (e.g., elemental sodium), it is appropriate to wash the victim thoroughly with water, preferably in a nearby decontamination shower. generally speaking, water should not be used to decontaminate skin in exposures to sodium, phosphorus, calcium oxide, chlorosulphonic acid, and titanium tetrachloride. when emergency medical personnel arrive to the scene, they should continue skin decontamination. again, if the agent is known to have significant dermal absorption, emergency medical personnel should provide themselves every available level of self-protection. certain toxins such as organophosphates can contaminate the air within the ambulance and produce ill effects among personnel if prehospital decontamination efforts are inadequate. upon arrival at a health care facility, the victim may require quarantine, depending on the nature of the agent. skin decontamination in a decontamination shower should continue. particular caution should be exercised in the decontamination of victims of organophosphate insecticide or organophosphate-based nerve gas exposure; health care personnel have been overcome secondarily by contaminants on victims when they assisted in their care without donning proper protective gear. water is the most commonly used skin decontaminant and is highly effective for most dermal exposures. in select cases, specific agents should be used to assist in management (table a- ) . without exception, toxin-induced skin burns should be treated according to existing burn management guidelines. these include wound débridement and dressing, monitoring for infection, fluid management, and surgical consultation when appropriate. after the ingestion of a toxic substance, with the exception of agents that have a direct toxic effect on the gastrointestinal tract (e.g., iron or corrosives), that substance must be systemically absorbed and circulated before it reaches a target organ and exerts clinical toxicity. preventing the absorption of toxin is therefore the foundation of treatment after ingestion of a toxin has occurred. the term gastrointestinal decontamination (gid) has been coined to describe those interventions that are useful in preventing toxin absorption. with the exception of rare interventions such as gastroscopy, gid is considered to have only three components: ( ) gastric evacuation, ( ) administration of adsorbent, and ( ) catharsis. gastric evacuation is accomplished through gastric lavage. syrup of ipecac, once used as an emetic for treatment of toxic ingestions, is no longer routinely recommended for this purpose. there are several agents that can adsorb toxic substances, reducing their systemic absorption and subsequent toxicity (table a- ) . of these, activated charcoal is the most important adsorbent; there are few substances that activated charcoal will not adsorb (box a- ). catharsis, once an integral part of management, also has a diminishing role in the treatment of poisoned patients. gastrointestinal decontamination is discussed in greater detail in chapter b. with the development of sophisticated new antidotes and the changing spectrum of clinical poisoning, the use of emergency antidotes is assuming an increasing role in clinical toxicology. however, antidotes are useful in only a fraction of poisonings. table a - lists the common emergency antidotes. in poisoning with a known substance, early antidote use is indicated for emergency stabilization, often within the first hour. ( ) urine alkalinization. potential roles for these interventions are found in table a- and box a- . further discussion of elimination of a substance that has already been absorbed is provided in chapter c. observation and supportive care are the mainstays of therapy for the poisoned patient. indiscriminate use of gastric lavage, antidotes, and drugs should be avoided. all too often, the toxic agent is unknown, multiple drugs have been taken, or the patient is too unstable to undergo an aggressive therapy such as hemodialysis. monitoring of vital signs, cardiac telemetry, and oxygen saturation is mandatory. hospitalization in an intensive care unit is generally indicated for the patient with serious poisoning. multisystem monitoring with blood studies and assessment of other parameters are indicated, and upon detection of any specific system disturbance, appropriate subspecialty consultation is warranted. some agents such as iron, mercury, acetaminophen, paraquat, carbon tetrachloride, and amanita phalloides toxin have a latent phase, in which the patient appears to recover from the initial insult, only to decompensate to hours postingestion. patients with overdose of sustained-release capsules, such as calcium channel blocker or theophylline preparations, also may have delayed manifestation of poisoning. rarely, the tricyclic antidepressants have been known to cause fatal arrhythmia up to days following ingestion. some effects are not seen until later, such as hypertension following phencyclidine ingestion, hemorrhagic colitis following mercury ingestion, and disseminated intravascular coagulation following snakebite. one must also watch for the delayed pulmonary (see chapter ), hepatic (see chapter ), renal (see chapter ) , and hematologic (see chapter ) manifestations of poisoning. hyperbaric oxygen can provide oxygen at pressures greater than normal atmospheric pressure, which is given as atmosphere (atm) or mm hg. three atmospheres is the maximal pressure humans can tolerate over a reasonable period of time; hyperbaric units generally do not exceed . to . atm. the use of hyperbaric oxygenation is becoming standard therapy for patients with significant carbon monoxide poisoning, and it is becoming more available (see chapter ) for carbon tetrachloride poisoning, and possibly for cyanide and hydrogen sulfide poisoning. admission to an intensive care unit following antidotal therapy for further management and observation is generally indicated. further discussion of each antidote and its use is provided in the chapter on the specific poison. patients may require observation because of an underlying disease that may be exacerbated because of the overdose, such as diabetes, congestive heart failure, cardiac rhythm disturbances, or chronic lung disease. observation may be necessary to evaluate or treat complications, such as in a patient with an overdose who fell and sustained trauma or in a patient who develops aspiration pneumonitis or interstitial pulmonary edema. the iv use of illicit drugs is associated with multiple complications; observation is especially indicated for patients experiencing these complications, which include bacterial endocarditis, rhabdomyolysis, and neurologic sequelae. the disposition of the patient with intoxication may involve medical and psychiatric care as well as social follow-up. all patients admitted to the hospital with intentional overdose warrant close observation and the institution of suicide precautions. these patients may need appropriate restraint or observation if further injury or additional overdose attempts are to be prevented. overt or subtle attempts or gestures indicate the need for psychiatric evaluation. often, outpatient follow-up is necessary; for example, a child with kerosene ingestion may require further examination and chest radiography, and a child who has ingested anticoagulant rat poison may require serial outpatient monitoring of prothrombin times. the issue of child abuse or neglect may need consideration whenever a pediatric patient is treated. finally, long-term follow-up may be indicated; for example, hepatitis and hiv testing may be needed in the iv drug abuser. concepts is very difficult in a single center or even multiple centers. confirmation of exposure by laboratory studies is often unavailable, requiring the clinician to depend on the history (which may be inaccurate) and physical findings (which may be nonspecific) in arriving at the diagnosis of poisoning. there are likewise problems with randomization schemes, and basic inclusion and exclusion criteria. in addition, there are problems with the process of evidence-based reviews themselves. language bias occurs in some evidence-based reviews, such that non-english language publications, potentially of good quality, are often excluded from consideration. in addition, the premises on which the evidence review is based may not be universally applicable. the conclusions reached, based on studies performed in urban tertiary care centers where hospitals are capable of providing state-ofthe-art intensive care, may not apply equally to a remote hospital in a rural area, or even less so to a clinic in a developing country. thus, while careful consideration should be given to position papers and consensus conference proceedings, individual judgment will necessarily enter into the decision to employ any decontamination method for a given case of exposure. unfortunately, an unintended consequence of the publication of position papers is that they may in fact squelch further research. a number of methods of decontamination exist and may be employed depending on the circumstances of exposure. decontamination of the skin and eyes, as well as the gastrointestinal tract, will be discussed. extracorporeal methods of purification (hemodialysis, charcoal filtration, etc.) are covered in chapter c. decontamination of the skin and eyes is employed to reduce local tissue injury (chemical burns or irritation) and/or absorption that may result in systemic consequences. the decision to perform skin and eye decontamination is often based on the presence of symptoms, such as burning or itching. this is an insensitive evaluation method; thus, decontamination of these organs should primarily depend on careful consideration of the circumstances of exposure and the physical and toxicologic properties of the compound. protection of personnel during eye and skin decontamination is important to avoid secondary contamination of health care providers. the choice of personal protective equipment is beyond the scope of this chapter. the reader is referred to chapter and to the recent occupational safety and healthy administration (osha) best practices document. in almost all cases, clothing, jewelry, and shoes should be rapidly and completely removed prior to washing. it has been suggested in studies of radionuclide contamination that this process alone can remove the majority of a contaminant. this will, of course, depend on the physical properties of the toxicant but is a logical first step. solids and dust should be gently brushed away before decontamination with a solution. in this way, the heat generated from water reactive compounds can be diminished, as is caking of solids. in some cases, water or other decontamination solutions may be unavailable or in short supply. in such cases, dry decontamination, using an absorbent material (charcoal, flour, earth) followed by brushing or wiping may be attempted. the selection of skin decontamination solutions has historically been a choice between water for polar (watersoluble) compounds and water plus a mild soap or detergent for nonpolar compounds. water alone is typically employed for initial eye decontamination. physiologic saline and other saline-based eye washes are often employed for eye decontamination in health care and industrial settings. the use of these solutions has been largely empiric and practical, based on widespread availability rather than on critical evaluation of their efficacy. yano and colleagues studied water irrigation of burns involving mol/l hcl in rats, measuring subcutaneous ph as a measure of penetration of the acid and efficacy of decontamination. these investigators found that maximal subcutaneous ph depression had occurred by minutes following application of the acid. animals undergoing water irrigation at or minutes postexposure demonstrated some benefit; however, animals irrigated at minutes had no appreciable improvement in ph, compared with control. these investigators had previously demonstrated lack of efficacy of water irrigation after minutes in a n naoh burn model. clearly time is of the essence in irrigation of corrosive exposures. with regard to eye exposures, kuckelkorn and colleagues pointed out that water is hypotonic to corneal stroma, allowing edema and increased penetration by chemicals. they recommend use of amphoteric solutions to avoid these problems. in recent years, a number of novel decontamination solutions have come to market. diphoterine (prevor laboratories, moulin de verville, france), an amphoteric solution has been proposed for use in both acid and alkali exposures of eyes and skin, with emphasis on immediate irrigation (at the scene of the incident) rather than for hospital treatment. a recent article that compared diphoterine to physiological saline in alkaline eye burns demonstrated more rapid healing of grade and burns with diphoterine than with saline. the study suffers from a number of deficiencies, including lack of randomization and significant delays and variability in initial irrigation (in the field) and secondary irrigation in hospital (with either diphoterine or saline). nonetheless, the time to corneal reepithelialization was approximately six times as long after saline for grade burns and almost twice as long for grade burns, compared with diphoterine-treated eyes. there were an insufficient number of grade burns to detect any significant difference between groups. despite its shortcomings, this study suggests the potential for improved healing using diphoterine in alkaline eye burns and warrants further investigation. the same study group had previously shown in a study of ammonia burns in new zealand albino rabbit eyes that early application (within minutes) of diphoterine rapidly corrected ph, whereas saline irrigation did not. furthermore, saline-treated eyes had stromal edema, whereas diphoterine-treated eyes did not. the need for early irrigation is emphasized by this experimental study; however, the cited clinical study demonstrates some benefit even with delayed treatment (mean . hours). cavallini and casati studied diphoterine in experimental skin burns in rats involving % hydrochloric acid. skin flushing with diphoterine reduced substance p release during the first hours after burn and was associated with better wound healing and higher concentrations of β-endorphin days later when compared with normal saline or % calcium gluconate. hall and colleagues most authors recommend against neutralization of acid and base burns due to the risk for exothermic reaction leading to thermal burns. simple dilution with water or milk after oral ingestion of corrosives is uncommon in europe, but the norm after ingestions in the united states. penner demonstrated in an ingestion model that dilution of concentrated sulfuric acid with an equivalent volume of water results in a temperature elevation of approximately °c. neutralization results in even greater heat production. he suggested that vigorous gastric aspiration (likewise considered controversial given the risk for esophageal or gastric perforation) prior to cold fluid lavage is the treatment of choice in patients treated immediately following acid ingestion. a recent experimental study involving irrigation of rat skin exposed to n naoh with % acetic acid suggests that neutralization may not always be contraindicated. the investigators demonstrated more rapid correction of ph, no difference in peak temperatures, and improved outcomes in animals treated with % acetic acid rather than water. these findings cannot inundated with contaminated casualties. decontamination protocols that are not deployable within minutes (preferably to minutes) after an incident may serve little purpose in protecting the facility and health care providers from contamination. serious consideration should be given to the complexity of the setup process, one that typically will not be employed frequently. one example of a locally developed immediate deployment sheltered outdoor decontamination unit is shown in figure b - . this unit can be deployed in less than minutes and provides for decontamination of both ambulatory and stretcher patients. it is common practice to utilize physicians, nurses, and other critical emergency department (ed) staff to do decontamination. this is probably not advisable for a number of reasons. first, decontamination does not require great technical skill, and very little stabilization be generalized, but indicate the need to readdress current dogma regarding neutralization. the ideal duration of eye and skin decontamination is yet to be determined. recommendations for copious irrigation are common, without further precision. fifteen minutes is probably the most commonly recommended duration for eye irrigation. kuckelkorn and colleagues have recommended a minimum of minutes for eye irrigation after chemical exposures. one retrospective study of eye burn victims suggested that outcomes were better among those who had prolonged ( to hours) irrigation. irrigating to a relatively neutral ph is often attempted. if this is employed, it is helpful to remember that the ph of saline for intravenous injection (often employed for eye irrigation) is appreciably acidic (approximately . ) so that one should wait a few minutes after irrigation to measure the ph in order to allow the patient's own tears to replace the saline irrigation fluid in the conjunctival sac. the appropriate temperature for decontamination fluids has also been poorly studied. while increasing temperature of decontamination liquids reduces the likelihood of hypothermia in inclement climes and improves water solubility, heat also dilates skin pores and blood vessels, which may lead to increased absorption. if excessive, it may aggravate chemical or thermal burns. osha's recently published best practices guide for first receivers recommends a -minute wash with tepid water, based on recommendations from the u.s. army for chemical decontamination. mcintyre and colleagues recommend "warm, but not excessively warm" water for decontamination. eye irrigation should be performed with room temperature solutions. careful thought should be given to environmental conditions and risk for exposure when decontamination must be done out of doors. the duration and type of skin and eye decontamination performed in mass casualty situations may vary from that in cases involving single patients based on triage considerations. management of mass casualties is covered in chapter . a great number of options have been developed in recent years for skin decontamination, due to the increased interest in hazardous materials and chemical terrorism issues. examples of decontamination stretchers and facilities are shown in figures b- to b- . many others exist. one of the overriding considerations in determining the kind of decontamination facilities and equipment to purchase should be their capacity for rapid deployment. the experience with the sarin terrorist attack in tokyo revealed that hospitals may be rapidly can be performed during the decontamination process. furthermore, if there are problems and decontaminating personnel are unable to continue, such a practice results in incapacitation of primary emergency care providers. neither should security personnel, in general, be tasked with this responsibility, since a mass casualty situation will require their services for security itself. a number of alternatives have been suggested. some hospitals train housekeeping staff to perform decontamination. others have nurses from other units (burn units have extensive experience in wound care and cleaning) don protective clothing and prepare for decontamination while the ed staff prepares the decontamination facility and the ed proper to receive casualties. decontamination of radionuclides from the skin may be performed in a manner analogous to chemical exposures. uranium hexafluoride exposures should be treated in a manner analogous to that for hydrofluoric acid burns. wounds heavily contaminated with radionuclides may require surgical débridement and should be covered after initial decontamination. see chapter regarding radiation emergency management for further information. hydrogen fluoride, ammonium biflouride, and other soluble fluorides may pose a unique case in terms of decontamination. while an initial quick flush with water is appropriate, the patient may benefit from rapid decontamination with a substance that can bind the fluoride. hexafluorine has been reported to prevent significant skin burns in both humans and experimental animals when applied immediately after exposure. , two randomized studies in rats found, however, that hexafluorine was no better than water in preventing electrolyte disturbances caused by fluoride , and perhaps less effective than water or water plus calcium gluconate in reducing burn injury. thus, hexafluorine's efficacy in fluoride injury remains controversial. researchers in hydrogen fluoride manufacturing facilities frequently recommend skin irrigation with benzalkonium chloride solution based on studies performed in pigs. , calcium gluconate irrigation of skin and eyes has also been recommended to bind fluoride and prevent further injury. other investigators have found calcium gluconate to be no more effective than water or saline and perhaps detrimental in eye irrigation. , in summary, the ideal decontamination of hydrogen fluoride burns to skin and eyes remains to be determined. phenol is unique in its capacity to cause nonpainful burns and systemic toxicity. water irrigation may increase phenol absorption. generally accepted skin irrigation therapy consists of isopropanol , or polyethylene glycol solutions. , white phosphorus is pyrophoric (i.e., it burns in the presence of air). it is thus indispensable to provide adequate copious irrigation with water. the application of copper sulfate has been recommended, but an experimental study in rats demonstrated increased lethality in animals receiving topical treatment with % copper sulfate. eldad and colleagues have evaluated various phosphorus burn treatment recommendations and have concluded that copious water irrigation is superior to other treatments. high-pressure injection injuries should be mentioned here due to their requirement for special care and high all eye and skin exposures resulting in violation of the epithelium should prompt consideration of the need for tetanus toxoid administration. the only emetic currently recommended for use in humans is syrup of ipecac. previously employed emetics continue to be responsible for significant pathology, however. the administration of table salt has long been condemned in the literature ; nonetheless, recent reports illustrate that its use has not been completely abandoned and that it remains potentially lethal. , liu reported that copper sulfate continues to be used in china for emetic purposes and has resulted in multiple fatalities in recent years. the dose of ipecac is to ml in children to months of age or ml in children to years of age. this should be followed by to ml water per kg body weight. older children and adults should receive ml ipecac followed by to ml of water. ipecac is contraindicated in the following situations: ingestion of petroleum distillates ingestion of strong acids or bases ingestion of strychnine or other proconvulsants unconsciousness or absence of gag reflex ipecac has a number of potential adverse effects, including lethargy, cramps, and diarrhea. when taken chronically, it may induce muscle cramps and both skeletal and cardiac myopathy. it is subject to frequent abuse by patients with eating disorders, a factor that led to a review of the product's safety by the fda in . the american academy of clinical toxicology (aact) and the european association of poisons centres and clinical toxicologists (eapcct) reviewed the medical literature regarding the use of ipecac in . this combined task force more recently examined their previous findings and literature that had appeared since their earlier review. in brief, they concluded that syrup of ipecac should not be administered routinely in the management of poisoned patients. they pointed out that in experimental studies the amount of marker removed by ipecac was highly variable and diminished with time. furthermore they concluded that there is no evidence from clinical studies that ipecac improves the outcome of poisoned patients and recommended that its routine administration in the ed be abandoned. finally, they signaled the absence of data to support or exclude ipecac administration soon after poison ingestion, the administration of ipecac potentially reducing the effectiveness of activated charcoal, oral antidotes, and whole bowel irrigation (wbi). there are indications that the use of syrup of ipecac has dramatically declined in recent years, and it is likely that this trend will continue. , bond examined the evolving use of ipecac in u.s. poison centers, comparing rates of referral to the ed and moderate or greater outcomes in patients younger than years with unintentional ingestions. this comparison was carried out according to the frequency with which centers recommended use of ipecac. overall, use of ipecac was extremely rare ( . %) and significant adverse outcomes even lower ( . %). comparing the two groups of centers each, there were no significant differences in referral rates or adverse outcomes. bond concluded that there was no reduction in resource utilization (ed referral) or improvement in patient outcome from the use of syrup of ipecac at home and that while the data could not exclude a benefit in a very limited set of poisonings, such a benefit remained to be proven. shannon, in an editorial in the same issue, sounded the demise of ipecac on the basis of lack of proven efficacy, changing patterns in poison center approaches to the management of pediatric ingestions (including preference for activated charcoal when decontamination is indicated), and the move by the fda to rescind ipecac's over-the-counter status. this prediction was prescient, since the american academy of pediatrics, based on bond's article and the factors cited by shannon, revised its position statement on ipecac use, calling for abandonment of the regular stocking of it in the home. more recently, a u.s. government-convened review panel of experts published their conclusions regarding ipecac use. the panel concluded that the use of ipecac syrup might have an acceptable benefit-to-risk ratio when: there is no contraindication to the use of ipecac syrup. there is substantial risk of serious toxicity to the victim. there is no alternative therapy available or effective to decrease gastrointestinal absorption (e.g., activated charcoal). there will be a delay of more than hour before the patient will arrive at an emergency medical facility. ipecac syrup can be administered within to minutes of the ingestion. ipecac syrup administration will not adversely affect more definitive treatment that might be provided at a hospital. given these restrictions, rural residents might consider keeping ipecac on hand for home use under poison center direction. otherwise, these recommendations sharply limit the applicability of the drug and, thus, the induction of vomiting in general. are many unknowns in any clinical trial, the most significant of these being the time between ingestion and treatment and the amount of toxicant ingested. it is fair to say that the evidence for efficacy is currently deficient, but that lack of efficacy has not been proven either. the use of endoscopy in the diagnosis of caustic injuries is addressed in chapter . its use in the retrieval of foreign objects, such as batteries, firearm cartridges, and various pill fragments [ ] [ ] [ ] [ ] [ ] [ ] has been reported in humans and studied in animals, but has not been systematically addressed in humans. faigel and colleagues report that endoscopic use of the roth net was most effective in removal of button batteries. like other forms of decontamination, endoscopy to retrieve tablet fragments has been associated with significant complications; thus, the decision to perform endoscopy in these circumstances should be carefully weighed against the risks. surgical gastrointestinal decontamination has been employed for button battery ingestions, - cocaine and narcotic drug packets, [ ] [ ] [ ] [ ] [ ] [ ] [ ] and bezoars of iron and theophylline, among others. batteries passing the esophagus usually are expelled in the feces and are generally believed to require no intervention, although recent reports of early battery leakage have called the "wait and see" approach into question. , button batteries, when impacted in the esophagus, should generally be removed by endoscopy unless perforation is suspected. , , the trend toward use of smaller batteries by manufacturers has decreased the incidence of this problem. in the case of cocaine and heroin bodypackers/stuffers, many cases can be managed conservatively with wbi or other purgatives. most researchers agree, however, that acute toxicity (drug leakage) and bowel obstruction are indications for immediate laparotomy. , , charcoal binds to diverse substances, rendering them less available for systemic absorption from the gastrointestinal tract. it is obtained as a product of pyrolysis of numerous organic compounds (petroleum, wood, peat) and "activated" by heating it to º f to º f, in the presence of steam, carbon dioxide, or air. this gives the product a small particle size and large surface area. while charcoal adheres to many substances, a significant number of compounds and classes of compounds are poorly absorbed by charcoal. these include metals (lithium, sodium, iron, potassium) and alcohols. thallium appears to be an exception, being relatively well absorbed by charcoal. the employment of gastric lavage is controversial and varies markedly depending on geographic area and the background and training of the practitioner. gastric lavage involves blind placement of a large-bore gastric tube into the stomach, in a patient who can either protect his or her own airway or in whom the airway has been protected by an endotracheal tube, with the goal of removing toxicant remaining in the stomach through a combination of instillation of water or physiological saline, followed by suction or gravity-induced drainage. this cycle of instillation/drainage is repeated until the effluent is clear or until several liters of water/saline have been passed through the tube. this procedure has been widely popular in the past and continues to be employed in many eds around the world. it is, however, a largely unproven therapy. the indications for gastric lavage are recent ingestion (generally less than hour, unless the ingestion involves agents that decrease gastric motility, such as anticholinergics) of a substance of sufficient quantity to be likely to cause serious harm in the absence of removal. the procedure should be given greater consideration in ingestions for which inadequate treatment modalities exist (paraquat) or in cases where delivery of proven effective therapy (antidotes or extracorporeal removal) is likely to be delayed. ingestion of low-viscosity petroleum products, corrosives (acids and alkalis) and inability to protect the airway (unless tracheal intubation has been performed beforehand) are contraindications to gastric lavage. serious adverse effects of gastric lavage are relatively rare but may be significant. the procedure may induce hypoxia, perforation of the gastrointestinal tract or pharynx, , fluid and electrolyte abnormalities, inadvertent tracheal intubation, as well as aspiration pneumonitis. tracheal intubation is not completely protective against aspiration. the aact/eapcct recently reviewed the animal and clinical literature regarding gastric lavage and published a position statement, which states in part that gastric lavage should not be employed routinely, if ever, in the management of poisoned patients. the study group pointed out that in experimental studies, the amount of marker removed by gastric lavage is highly variable and diminishes with time and that few clinical studies have demonstrated a beneficial effect on outcome. the quality of the gastric lavage literature is, for the most part, lacking. few studies have the power to detect significant differences in outcome for a single toxicant, and it seems unscientific to compare outcomes after ingestion of widely varying products. furthermore, there activated charcoal products containing sorbitol should be avoided where possible because ( ) the efficacy of cathartics is lacking (see below); ( ) sorbitol is emetogenic and can increase the risk for vomiting the charcoal; and ( ) sorbitol administration in infants is associated with dehydration and other life-threatening events. activated charcoal is administered as a slurry, either in water or sorbitol, orally or via a nasogastric tube. dose recommendations vary, but generally a larger dose is considered better, to assure that binding capacity exceeds the amount of toxicant present. the recommended dose is . to g/kg in children or to g in adults. in general, to be maximally effective, charcoal should be administered as soon as possible after ingestion of the toxicant, preferably within hour. green and colleagues studied this issue in healthy volunteers in a randomized crossover study. after giving g (the equivalent of eight extra-strength tablets) of acetaminophen to patients, then giving charcoal at , , or hours after ingestion, they found no differences in the area under the curve of plasma acetaminophen. the investigators stated that "data do not support the administration of activated charcoal as a gastrointestinal decontamination strategy beyond hour after drug overdose." while there are obvious problems in extrapolating toxicokinetic results from a study involving a nontoxic dose to all overdoses, the results do suggest that benefit clearly decreases over time. as for most decontamination measures, the indications for single dose activated charcoal are controversial. the recently released revision of the single-dose activated charcoal position statement of the aact/ eapcct states that single-dose activated charcoal should not be administered routinely in the management of poisoned patients, but that it may be considered if a patient has ingested a potentially toxic amount of a poison (which is known to be adsorbed to charcoal) up to hour previously. the researchers state that the potential for benefit after hour cannot be excluded. finally, they emphasize that there is no evidence that the administration of activated charcoal improves clinical outcome. charcoal administration is generally considered contraindicated in ingestions of caustics, since it is probably ineffective in reducing their potential for harm and furthermore makes endoscopy difficult. charcoal generally should not be administered when there is a high risk for gastrointestinal hemorrhage or perforation. charcoal is likewise contraindicated in any patient in whom the airway protection is not assured. it should not be administered in the presence of hydrocarbons with high aspiration potential. charcoal should not be administered in the case of ileus or mechanical bowel obstruction. one of the most common adverse events associated with charcoal administration is vomiting, which occurs in approximately % to % of patients. abdominal bloating is also quite common. both diarrhea and constipation may occur. complications have been described, including pulmonary aspiration and direct administration into the lungs via misplaced nasogastric tube. aspiration appears to be relatively rare, but may have serious consequences. , [ ] [ ] [ ] [ ] multiple-dose activated charcoal (mdac) has been proposed for use in the case of drugs that undergo extensive enterohepatic or enteroenteric circulation. drugs with small volumes of distribution are particularly susceptible to removal by adsorption to charcoal in the gut, which has sometimes been referred to as "gastrointestinal dialysis." although experimental and volunteer studies have demonstrated that mdac increased elimination of a number of compounds, there is little proof of clinical benefit. the aact/eapcct has concluded that although many studies in animal and volunteer studies have demonstrated mdac increases drug elimination significantly, there are no controlled studies in poisoned patients that demonstrate mdac reduces morbidity and mortality. pending further evidence of direct benefits, the study group recommended that mdac be considered only if a patient has ingested a life-threatening amount of carbamazepine, dapsone, phenobarbital, quinine, or theophylline. the contraindications for mdac are essentially those of single-dose activated charcoal. the admonition for use in intestinal obstruction is of even greater import in the case of mdac. the presence of decreased peristalsis (often associated with anticholinergic drugs and opiates) should provoke extreme caution in the administration of mdac. prussian blue is an effective absorbent for the management of thallium and cesium intoxications. see chapters and for further information. fuller's earth is often recommended for gastrointestinal decontamination of paraquat (see chapter ) . although effective for this purpose, this substance is found in few hospitals. activated charcoal is an effective absorbent of paraquat and should be employed when fuller's earth is not available. hypermagnesemia may result in cardiac dysrhythmias. elderly patients and those with renal dysfunction are at particular risk. [ ] [ ] [ ] massive doses of cathartics may result in cardiopulmonary arrest. wbi involves the administration, by mouth or nasogastric tube, of large amounts of an iso-osmotic polyethylene glycol electrolyte solution (go-lytely [braintree laboratories, braintree, ma], co-lyte [schwarz pharma, mequon, wi], and others) with the goal of removing unabsorbed toxicant from the gastrointestinal tract as rapidly as possible by rectal expulsion. one rationale for its use includes the fact that some compounds are poorly absorbed by charcoal, particularly iron and lithium. wbi may be of particular interest in the case of sustainedrelease or enteric-coated compounds and in the case of drug packets (body packers). the aact/eapcct's consensus panel concluded that wbi should not be used routinely and that there is no conclusive evidence that it improves the outcome of poisoned patients. based on evidence from volunteer studies, the group recommended that wbi be considered for potentially toxic ingestions of sustained-release or enteric-coated drugs, particularly in those patients who present more than hours after drug ingestion. they more strongly endorsed wbi for patients who have ingested substantial amounts of iron because the morbidity is high and there are no other effective options for gastrointestinal decontamination. another potential indication cited for the use of wbi is expulsion of ingested packets of illicit drugs. polyethylene glycol electrolyte solution (e.g., go-lytely, co-lyte, nulytely [braintree laboratories, braintree, ma]) is administered by mouth or nasogastric tube at to ml/kg/hr until the rectal effluent is clear or until the desired effect is otherwise demonstrated (e.g., passage of drug packets demonstrated by imaging studies). computed tomography (ct) with contrast has often been used to identify retained packets, but a recent case report demonstrated incomplete sensitivity of ct to detect all unexpelled drug packets. wbi is contraindicated in the presence of mechanical or functional (ileus) bowel obstruction or perforation and in the presence of significant gastrointestinal hemorrhage. it should likewise be avoided if the patient is hemodynamically unstable. nausea and vomiting are not uncommon. abdominal bloating and cramping may occur. vomiting in the case of an unprotected airway may result in pulmonary aspiration. cathartics comprise another group of compounds recommended since ancient times for the purpose of eliminating toxicants from the gastrointestinal tract. the two most common categories of cathartics are the magnesium salts (e.g., magnesium citrate, magnesium sulfate) and nondigestible carbohydrates (e.g., sorbitol). despite their long history of use, there is virtually no evidence of their efficacy. on the contrary, cathartics may induce significant harm in certain groups of patients, particularly children and those with renal disease. there are no evident indications for the use of a cathartic alone in the treatment of poisoning. an aact/eapcct position statement concluded that experimental data are conflicting regarding the use of cathartics in combination with activated charcoal. the study group found no published clinical studies that investigated the ability of a cathartic, with or without activated charcoal, to reduce the bioavailability of drugs or to improve the outcome of poisoned patients. they went on to say that based on available data, the routine use of a cathartic in combination with activated charcoal is not endorsed and that if a cathartic is used, it should be limited to a single dose in order to minimize adverse effects of the cathartic. the dose of sorbitol is approximately to g/kg. when given in combination with activated charcoal for single dose-activated charcoal therapy, the dose should be determined on the basis of charcoal dosing. if multiple doses of charcoal are to be administered, repeated use of sorbitol is not recommended. for magnesium citrate, the dose is to ml/kg in children and to ml in adults. cathartics are contraindicated in the presence of bowel obstruction, in the absence of bowel sounds, or in the case of recent bowel surgery or intestinal perforation. they should likewise not be employed in the case of corrosive ingestions or when significant electrolyte disturbances, dehydration, or hemodynamic instability are present. magnesium-containing cathartics must be avoided in patients with renal insufficiency and heart block. caution should be employed in patients at extremes of age. cathartics frequently cause cramping, nausea, and vomiting. significant dehydration may occur if catharsis is excessive, with resultant hypotension. cathartic-related the decision to employ decontamination methods in an individual case must be determined based on the factors present in that individual case. first and foremost in the decision to attempt decontamination is a determination of whether a significant exposure has occurred. this is critical for numerous reasons: ( ) needless decontamination procedures may delay other definitive therapy for systemic toxicity; ( ) conversely, failure to adequately decontaminate the skin may increase morbidity of contaminated patients and result in secondary contamination of health care providers and facilities; and ( ) decontamination, as discussed, is not without risks. it is vital to recall hippocrates' admonition: primum non nocerum. dose/ exposure assessment is extremely difficult on an acute basis due to the great number of unknowns. young children cannot recount the quantity or quality of what they have ingested. self-harm attempts are often accompanied by attempts to conceal or, conversely, to exaggerate the consumption of potentially toxic compounds. it is rare that contemporaneous exposure information (air concentrations or even product identification) is available after environmental exposures associated with hazardous materials releases or acts of terror. fear associated with these events may result in psychogenic illness at times indistinguishable from that of the toxic exposure. when doubt exists, it may be safer to decontaminate, but this should be a considered decision. once it is established that an exposure has occurred (or if exposure cannot be excluded) and some attempt has been made to determine the magnitude of the exposure, one must examine the toxic potential of the compound(s) in question, keeping in mind that the toxicity of combined substances is not always equal to the sum of their individual toxicities. approaches to the treatment of poisoning are deeply rooted in personal experience and colored by bias in the literature. recent studies have reexamined the need to decontaminate victims of certain exposures that were previously approached aggressively from a therapeutic standpoint. , decisions around decontamination must be individualized. a suggested approach is found in figure b - . this nonvalidated algorithm should simply be considered a pathway for considering options. there are numerous potential exceptions to the general suggestions in the figure. one might consider gastric lavage alone in the case of presentation of poisoning within hour of ingestion by a highly toxic compound that is not readily absorbed by charcoal. lithium is one such example. reiterating, gastric lavage is most likely to be effective in an early-presenting, potentially lethal ingestion. cyanide is an example of a highly toxic compound that might be removed by lavage, but is also readily absorbed by charcoal. yes. illicit drug packets containing cocaine or heroin may leak. a dose of activated charcoal given prophylactically (in the absence of symptoms) could theoretically absorb eventual leakage, while wbi accelerates passage of the packets. as a reminder, clinical evidence of toxicity (leakage) is an indication for laparotomy. similarly, charcoal followed by wbi may be indicated for ingestions of enteric coated tablets. in cases in which ingestion of a substance known to be effectively eliminated by wbi (such as lead, zinc, or iron) is not recent (and thus not likely to benefit from gastric lavage) and when the substance is not readily absorbed by charcoal, wbi alone may be indicated. it should be clear from the discussion that the previously common "reflex arc" of ingestion-decontamination should not apply. the decision to apply a particular procedure or combination may not be simple. for this reason, consultation with a regional poison center and/or medical toxicologist is strongly suggested in cases of uncertainty. . irritants, corrosives, and substances toxic by skin absorption should be removed. liquids with high volatility and potential for secondary contamination (organic solvents) should likewise be removed. when in doubt, decontamination is appropriate; however, life-saving interventions (abcs) take precedence over decontamination. personnel should wear protective garments appropriate to the hazard. . if the history is reliable and the ingestion is clearly nontoxic, no decontamination is required. the urge to "do something" should be weighed against the maxim to "first, do no harm." . single-dose activated charcoal (sdac) is considered most effective when administered less than hour after ingestion of a toxic substance. there is insufficient evidence to support or condemn its use with toxic ingestions presenting more than hour later. in general, metals (lithium, iron, but not thallium) and alcohols are poorly absorbed. . multiple-dose activated charcoal (mdac) should be considered primarily if a patient has ingested a life-threatening amount of carbamazepine, dapsone, phenobarbital, quinine, or theophylline. multiple-dose activated charcoal increases the elimination of amitriptyline, dextropropoxyphene, digitoxin, digoxin, disopyramide, nadolol, phenylbutazone, phenytoin, piroxicam, and sotalol, but evidence is insufficient to support its use in these ingestions. . whole bowel irrigation should not be performed in the presence of ileus or bowel obstruction. . if uncertainty exists about the need for decontamination procedures, contact the regional poison control center and/or a medical toxicologist. effective adsorbent ; it may even limit the adsorptive capacity of activated charcoal. two theories have been advanced to account for the observed acceleration of drug clearance associated with the use of mdac after the drug's absorption from the gastrointestinal tract. one theory explains this acceleration by charcoal's interruption of the enterohepatic recirculation of hepatically metabolized drugs. the other is aptly called "gastrointestinal dialysis," a term coined by levy in an editorial that accompanied the seminal work on this topic by berg and colleagues. , using an animal model of intravenous theophylline poisoning, kulig and colleagues measured bile theophylline concentrations and were able to demonstrate that the observed increase in theophylline clearance with mdac was not due to interruption of enterohepatic recirculation of the drug. arimori and colleagues demonstrated in an experimental model that the exsorption rate of theophylline into the intestinal lumen increased in proportion to the administered dose of theophylline, suggesting that the gastrointestinal dialysis effect may increase with escalating dose for some toxins. given that overall mortality from overdose is low, that the efficacy of gastrointestinal decontamination techniques declines significantly with advancing time after ingestion, and that significant delay to clinical presentation occurs in the majority of ingestions, elimination enhancement techniques, including mdac, have come under recent scrutiny. tenenbein cited case reports of complications from mdac with a lack of proven clinical benefit in arguing that its role in the treatment of poisoning required reassessment. these cautions notwithstanding, review of the available evidence suggests that mdac can accelerate drug clearance, achieving rates comparable to more invasive techniques such as hemodialysis. moreover, a recent study of complications associated with mdac use found that they occurred infrequently. there are also data suggesting that mdac improves outcome in selected poisoning cases. one report describes two presentations of the same patient with phenytoin toxicity, one in which mdac was not used and a second in which it was; the second hospitalization was days shorter despite the patient having a higher serum phenytoin level. a recent single-blind, randomized, placebo-controlled trial performed in sri lanka demonstrated a significant reduction in mortality from yellow oleander poisoning once a drug or toxin has been absorbed, a number of means exist to enhance its elimination. chapter d addresses extracorporeal techniques of toxin removal from the blood (e.g., hemodialysis and hemoperfusion), which, when performed on an emergency short-term basis such as for poisoning, are done intermittently using a large double-lumen catheter in a central vein with flow through the circuit driven by a pump. other types of dialysis exist that also usually do not require arterial access and are more versatile in that they do not pose as great a hemodynamic stress to the patient; however, they also are generally much slower in their rates of clearance. one of these alternatives, multiple-dose activated charcoal (mdac), involves use of the patient's own gastrointestinal mucosa as a dialyzer. all of these techniques share in common with dialysis the underlying principle of filtering a toxin from the blood using a semipermeable membrane in order to enhance its clearance. a number of substance-related factors affect the clearance rates that can be achieved by dialysis techniques. first, a toxin must distribute primarily into the intravascular compartment-that is, have a low volume of distribution, in order to be removed by a dialysis technique at a clinically significant rate. second, molecular size is important, with low molecular weight substances crossing the dialysis membrane from an area of high concentration (blood) to an area of low concentration (dialysate). even higher molecular weight substances can cross and thus be removed from the blood by convection when dialysis is supplemented with ultrafiltration, which relies on a membrane with a high permeability coefficient and a high transmembrane pressure. finally, high protein binding presents a large molecular size to the membrane (i.e., a protein-bound drug), thus limiting the rate of clearance, unless the toxin is adsorbed from the serum proteins such as with the use of a charcoal cartridge in hemoperfusion. delayed absorption may occur after toxic ingestion: ( ) with sustained-release preparations, ( ) if tablet conglomerates form in the gastrointestinal tract, ( ) if the substance delays gastrointestinal motility. or, ( ) if a poorly absorbed substance (e.g., phenytoin) is ingested. multiple doses of activated charcoal have been used in these situations to enhance preabsorptive elimination. whole bowel irrigation, the other treatment modality used to enhance preabsorptive elimination, appears to provide no additional benefit when administered to treat a drug overdose for which activated charcoal is an curtis p. snook, md ■ daniel a. handel, md, mph c with mdac therapy when compared with treatment with single-dose activated charcoal. further study is needed to define the circumstances in which the benefits of mdac appear to justify its risks. however, some predictions can be made based on available data. mdac has been demonstrated to accelerate the clearance of a number of toxins (box c- ). chyka and colleagues found in a porcine model that mdac enhanced elimination of acetaminophen, digoxin, and theophylline but not valproic acid. drugs with relatively lower intrinsic clearance (digoxin, theophylline) were cleared with mdac more rapidly than were drugs with higher intrinsic clearance (acetaminophen). interestingly, volume of distribution, half-life, and protein binding were not significantly correlated with mdac enhancement of clearance. however, therapeutic doses were administered in this study, limiting application of these results to the overdose setting. a volunteer study of dapsone ingestion using a randomized crossover design along with data from two overdose cases showed a doubling of elimination with mdac in healthy volunteers and a greater increase in the overdose patients, again suggesting that the effectiveness of mdac also may be a function of dose for a given toxin. significant adverse effects with mdac preclude its use in patients for which no significant clinical benefit is expected. there are some drugs or drug classes for which data are conflicting (box c- ). for example, the available studies suggest that mdac likely would not be beneficial in unselected cases of digoxin poisoning. however, one volunteer study of mdac for enhancement of digoxin clearance applied kinetic predictions to suggest that greater clearance with mdac would occur in patients with renal impairment ; animal data support this assertion. in a case of chronic digoxin poisoning, mdac effectively accelerated drug clearance when digoxin antibody fragments were unavailable and hemodialysis had been unsuccessful. box c- lists the drugs investigated for which mdac has not been shown to accelerate clearance. mdac often is poorly tolerated. virtually all patients in one study complained of poor palatability and bloating with mdac, with one patient withdrawing because of repeated vomiting. transient constipation may occur with mdac use in susceptible patients. protracted vomiting also has been reported to limit the usefulness of mdac in theophylline poisoning. aspiration of charcoal is another well-recognized complication of mdac. in one published case, an unintubated patient treated for phenobarbital and carbamazepine overdose with gastric lavage followed by mdac vomited and aspirated hours after therapy was initiated, eventually dying on hospital day . another reported patient with theophylline overdose was treated with ipecac followed by mdac. he went on to develop convulsions followed by aspiration, eventuating in his death. in the most sobering case, a patient aspirated activated charcoal despite airway control. this patient received mdac after intubation and gastric lavage for desipramine and thiothixene overdose. after extubation the next day, the patient vomited, aspirated charcoal, and had a cardiorespiratory arrest from which he could not be resuscitated. in a similar case, a patient who ingested thioridazine and imipramine underwent endotracheal intubation and gastric lavage after he had a seizure. he received g of activated charcoal by nasogastric tube followed by g and then g with sorbitol every hour for hours. when the nasogastric tube was removed, the patient vomited, became cyanotic and had a respiratory arrest. charcoal was suctioned from the patient's lungs until hospital day seven. rau mdac, multiple-dose activated charcoal. and colleagues described three deaths from charcoal aspiration among patients treated with charcoal for central nervous system-depressant overdose without airway protection. their subsequent six overdose patients were intubated prior to charcoal administration and no cases of aspiration occurred. in light of this experience, any patient at risk for aspiration (i.e., one in whom diminished consciousness, depressed airway reflexes, or seizures are present or anticipated), should have a firm indication for mdac and a protected airway before undertaking the procedure. equally important, there appears to be a ceiling effect for charcoal adsorption such that increasing dose or frequency beyond a certain point results in no additional therapeutic benefit. overdose victims with decreased gastrointestinal motility may develop bowel obstruction with use of mdac. a number of cases have reported mdac resulting in small bowel obstruction, abdominal distension, constipation, rectal bleeding, and even intestinal perforation when either the overdose itself or the therapy for the overdose involved anticholinergic drugs. [ ] [ ] [ ] [ ] [ ] [ ] appendicitis in association with mdac use has been reported. another patient with chronic theophylline toxicity treated with mdac developed small bowel obstruction and was found on laparotomy to have adhesions at the ileocecal valve secondary to a previous hysterectomy; multiple pieces of charcoal were found in the bowel at the site of obstruction measuring . × × cm in aggregate. cathartics are ineffective as a means of elimination enhancement after poisoning. however, to avoid constipation and charcoal inspissation, cathartics often are coadministered. sorbitol is the usual choice because of its rapid onset and palatability. sorbitol is typically marketed in a % concentration with activated charcoal because it is bacteriostatic at this concen-tration. , using excessive or multiple doses of sorbitol with activated charcoal in poisoning is associated with significant morbidity, including hypernatremia resulting in death, and should be avoided. magnesium citrate or sulfate occasionally are used instead of sorbitol. patients with premorbid magnesium abnormalities or those receiving excessive doses of magnesium cathartic can suffer serious morbidity, including hypermagnesemia, which can be fatal. the optimal dosing for activated charcoal in mdac is unknown. the commonly accepted dose is g/kg (maximum of g) of activated charcoal initially, followed by . g/kg (maximum g) every hours thereafter. others have suggested a dose of g/kg of activated charcoal in . ml/kg body weight of % sorbitol every hours until the first charcoal stool appears. in children, the same weight-based dose of activated charcoal is recommended. a third set of published guidelines for adults has suggested an initial dose of to g, with additional doses given at a rate of at least . g/hr until the patient is improving clinically and by relevant laboratory parameters. this latter set of recommendations includes lower dosing ( to g) for children younger than years of age, smaller doses more frequently along with antiemetic use in vomiting patients, and no use of cathartics, particularly in young children. mdac has been used safely in infants and neonates , ; it has even been used to treat neonatal hyperbilirubinemia. patients receiving mdac should be intubated, ideally with a cuffed endotracheal tube, if they are obtunded or have diminished airway reflexes or seizures. the charcoal should be diluted with at least ml of water per gram of charcoal. mdac should not be administered in the presence of ileus or bowel obstruction. coadministration of anticholinergic agents should be avoided during mdac. charcoal should be withheld hours prior to extubation. gastric contents should be aspirated with a nasogastric tube prior to extubation to avoid the complications previously discussed. magnesium cathartics should be used with caution, particularly in patients with decreased renal function, and are best avoided in such patients given that safer alternatives are available. it is a common practice to give the first dose of charcoal with a cathartic, usually sorbitol, and to give subsequent doses without cathartic. the availability of only sorbitol-charcoal preparations can be problematic in hospitals with such rigid stocking patterns. electrolytes should be closely monitored if more than one dose of cathartic is administered. box c- summarizes the indications, contraindications, and dosing guidelines for mdac use in poisoning. myoglobin in an animal study and in humans from drug-and exercise-induced rhabdomyolysis has been removed successfully by cvvh. [ ] [ ] [ ] severe lactic acidosis induced by propofol improved significantly with the use of cvvh. cvvh has been shown to be safe and effective in treating radiocontrast-induced acute renal failure after percu- continuous veno-venous hemofiltration (cvvh) and similar modalities used for what is termed "continuous renal replacement therapy" increasingly are being used in the therapy of critically ill patients, including those suffering from poisoning. cvvh offers a number of useful advantages over traditional dialysis techniques. first, it can be used in patients with renal failure who are hemodynamically unstable and require large volumes of parenteral nutrition. in cvvh isotonic fluid is removed from the femoral vein slowly and continuously rather than in -to -l increments over a -to -hour treatment session, the typical pattern for hemodialysis (hd). also, the diffusion clearance inherent to hd results in the return of a hypo-osmolar fluid to the intravascular space, resulting in a further loss of intravascular volume in comparison with cvvh. the latter restores volume losses with isotonic replacement fluid and fluid refilling from the overhydrated body parenchyma. second, trained nursing staff can administer cvvh, though it requires their continuous attention. finally, the typical rebound in serum drug levels from redistribution observed after hd are not seen with continuous modalities such as cvvh. the main disadvantage of cvvh in comparison with hd is the slower rate of toxin removal it can achieve. this disadvantage is significant if rapid toxin removal is critical to the patient's survival, which often is the case. thus, the use of cvvh for a toxin whose elimination is enhanced by dialysis techniques should be considered only when hemodynamic instability precludes the use of hd, when hd is not available, or if the inherently slower rate of toxin removal is clinically acceptable. cvvh does not require arterial access-a pump is used to provide the pressure gradient necessary for filtration. anticoagulation is required to optimize the lifespan of the apparatus (which requires replacement when it becomes clotted). however, the need for anticoagulation is less than for arteriovenous techniques because of the controlled blood flow provided by the pump, particularly in smaller pediatric circuits. animal data demonstrate that cvvh can achieve adequate flow rates with pediatric-sized filters and circuits. the blood is passed through a highly permeable hemofilter, forming an ultrafiltrate made up of plasma and filtered solutes. hemodiafiltration refers to the use of a dialysate fluid on the opposite side of the filter from the blood flowing in a counter current direction. box c- lists the toxins for which cvvh has been shown to speed elimination. toxin-related factors determining clearance by cvvh include the sieving coefficient (dependent upon molecular weight and protein binding) taneous coronary interventions. hypothermia is associated with poisoning, particularly when central nervous system depressants result in excessive exposures to cold ambient temperatures. cvvh has been used with success in rewarming a patient with severe accidental hypothermia. toxins for which cvvh has not been shown to speed elimination are listed in box c- . one patient treated with a lorazepam infusion developed toxicity from the propylene glycol diluent, despite receiving cvvh with dialysis (cvvhd), suggesting that the glycol was not effectively removed. care should be exercised in choosing the replacement fluid; lactate-buffered solutions have been reported to induce hyperlactatemia. since cvvh requires systemic anticoagulation, contraindications include recent surgery and gastrointestinal or intracranial hemorrhage. however, regional heparinization can be used with those patients for whom cvvh is necessary but who cannot tolerate systemic heparinization. trisodium citrate is a useful alternative to heparin as a regional anticoagulant with cvvhd to minimize the risk of hemorrhage and thrombocytopenia. however, caution should be exercised in patients with decreased hepatic function as use of trisodium citrate in this context is associated with severe hypercalcemia. a summary of the indications and contraindications for cvvh in poisoning are listed in box c- . though the first use of peritoneal dialysis pd dates back to , experiments with peritoneal lavage were carried out as early as . numerous advances have been made since this early work was done, including the addition of substrates to the dialysate to enhance the elimination of certain drugs. given the ease in most medical centers of obtaining hd, pd has fallen out of favor in most instances for the treatment of acute intoxication, although it continues to be used as a bridge when hd is not available or as an adjunct to enhance elimination. because of its "second-tier" status, recent literature and research on its use in poisoning are sparse. the peritoneal surface area of an adult has been estimated to be , cm , allowing this structure to serve as an excellent semipermeable membrane for dialysis. pd involves in principle the passive movement of drug or toxin down its concentration gradient from the intravascular space in capillaries dispersed throughout the lining of the peritoneum into the dialysis solution infused into this cavity. as with other dialysis techniques, pd is particularly effective in removing drugs with small volumes of distribution and low protein binding. the intermittent method of pd involves the use of one catheter to introduce the dialysate by gravity, removing it at a later time through the same access. this process also can be carried out using two catheters. two liters of fluid ( ml/m or ml/kg in children) are used per exchange, with the fluid typically left in the peritoneal cavity for to minutes. in contrast, during continuous ambulatory peritoneal dialysis (capd), dialysate is left in the peritoneum for much longer periods of time. extending this period beyond hours or leaving the catheter in place between courses of pd increases the risk of infection. various additives, such as glucagon, albumin, prostaglandin e (pge ), lipids, furosemide, streptokinase, and chelating agents, have been added to dialysis fluid in the attempt to enhance elimination with varying degrees of success. - a mildly hypo-osmolar solution is used to prevent water removal during dialysis, with electrolyte concentrations similar to that of extracellular fluid. when the osmolality of the dialysate is increased, increased solute removal occurs at the expense of a negative fluid balance with each exchange. whereas pd can be a continuous process, its elimination rate is significantly less than that of hd and other more invasive methods of extracorporeal therapy. blood flow via mesenteric circulation in pd cannot be adjusted as it can in hd, and the mechanics of instilling and draining in the pediatric population, pd is contraindicated when there is severe intraperitoneal hemorrhage that is sometimes seen in hemolytic-uremic syndrome with thrombocytopenia. the presence of focal peritonitis, a fecal fistula or colostomy, abdominal adhesions, and recent abdominal surgery with use of a prosthetic material, a major vascular anastomosis, or an open wound, are relative contraindications for pd. box c- lists the toxins for which peritoneal dialysis has not been found effective in accelerating clearance. a summary of the indications and contraindications for peritoneal dialysis in poisoning are listed in box c- . dialysate into and from the peritoneum limit achievable clearance rates. the time required to eliminate a given amount of toxin is three to six times greater with pd than with hd, depending on the properties of the agent. the elimination of small molecules that are highly membrane permeable is rate-limited by blood and dialysate flow rates, whereas the elimination rate of large molecules depends primarily on membrane surface area. in severe poisoning from a dialyzable toxin, the difference in achievable clearance rates between hd and pd can have enormous clinical significance, as one case series of methanol poisoning illustrates. thus, pd should not be substituted for hd in such cases unless the latter is absolutely inaccessible. if hd is not available in one treating facility but patient transfer is possible, the patient should be transferred. pd may be used as an adjunct during the transfer to speed toxin elimination. similar to other methods of extracorporeal elimination enhancement, pd can produce electrolyte shifts and loss of serum proteins. pulmonary complications, including bronchitis/pneumonia, pleural effusions, and atelectasis, also are known adverse effects. bowel perforation from catheter misplacement occurs with an incidence of . % according to one report. the other major complication of pd, especially capd, is peritonitis, which usually limits the long-term use of this technique. the dialysate additive icodextrin has been reported to cause a blistering skin reaction that resolves upon cessation of the use of the substance. pd can be used for toxins of up to , daltons in molecular weight and when a filtration rate of no greater than ml/min is required. it can be used when hd is not currently available and the patient's clinical status is critical. it can be used also when anticoagulation is contraindicated due to comorbidities. pd has been more widely used in the pediatric population, especially in the contexts of acute renal failure seen in hemolyticuremic syndrome, congestive heart failure, chronic renal failure, and hyperkalemia. , because of the difficulties of vascular access in small children as well as the difficulty in removing excess fluid gained between courses of dialysis without causing profound hypotension, pd offers distinct advantages in this population. the toxins for which pd hastens clearance and those for which its effects on clearance have been equivocal are listed in boxes c- and c- , respectively. note that there are toxins listed in box c- that are eliminated by the kidneys, such as baclofen, for which pd has been found useful in poisoning accompanied by renal failure even though pd effects on clearance are small when renal function is normal. also, pd has proven useful in treating toxin-induced renal failure apart from effects on toxin clearance. hypercalcemia from overadministration of vitamin d in an anephric child has been effectively box c- chapter c addresses the use of peritoneal dialysis, various forms of hemofiltration, and multiple-dose activated charcoal (mdac) as so-called "gastrointestinal dialysis." this chapter discusses the more classic methods for extracorporeal removal of toxicants, namely, hemodialysis (hd) and hemoperfusion (hp). in addition, we briefly discuss a newer methodology, the molecular adsorbents recirculating system (mars, also referred to as albumin dialysis), which was developed primarily for the treatment of fulminant liver failure (flf), but has recently been employed in the treatment of a variety of poisonings. as has been pointed out in previous chapters, extracorporeal methods for toxicant removal should be viewed as important adjuncts rather than as primary approaches to specific poisonings. the most effective method of removal of toxicants from the body in most cases is maintenance of properly functioning kidneys, liver, and lungs through excellent supportive care. the ultimate evaluation of efficacy of extracorporeal methods is in fact through direct comparison with spontaneous elimination by the body. in the absence of careful attention to resuscitation and supportive care, these adjuncts may be of little use; they may even be dangerous. further-more, while dozens of toxicants have been shown to be removed by hd or hp, evidence-based support for significant clinical improvement from these procedures is often lacking. as will be shown, each of these procedures has benefits and risks, which must be carefully weighed against other methods of treatment. it is difficult to ascertain the frequency with which hd and hp are employed in the treatment of poisoning. based on the most recent toxic exposure surveillance survey, it would appear that use of hd (n = ) largely exceeds that of hp (n = ). both procedures were far more commonly performed in adults older than years ( % of hd cases and % of hp cases) than in children. use of these extracorporeal removal techniques in children younger than years was rare (seven cases of hd, one case of hp). these figures are undoubtedly underestimates of real use, since reporting to poison centers by physicians is voluntary and incomplete. nonetheless, they suggest that extracorporeal purification therapies have a limited role in management of poisoning in the united states. hd requires the passage of blood from the body through an external circuit, in which it is anticoagulated and placed in sustained contact with a selectively permeable membrane prior to being returned to the patient. opposite the membrane and flowing in countercurrent direction is a heated dialysate, the composition of which can be varied according to the indications for dialysis. the variation of electrolyte concentrations, addition of buffers, and sometimes other additives allow the operator to manipulate the passage of these elements from one side of the membrane to the other. hd operates on the basis of three principles: diffusion, osmosis, and ultrafiltration. diffusion relies on concentration gradients, with solutes moving from an area of higher concentration to an area of lower concentration, ultimately resulting in equilibration. osmotic pressure results in the movement of water from one side of a semipermeable membrane to the other, dependent on a higher concentration of solutes on the other side. manipulation of plasma sodium concentrations (sodium profiling) during dialysis can induce a net flow of water from cells into the plasma, allowing for its ultimate removal from the plasma. ultrafiltration involves movement of fluid across the membrane due to the presence of a pressure gradient. this principle allows control of fluid loss during dialysis and can be manipulated via varying dialysate pressure (pressure control) or by variation of dialysate flow volumes (volumetric control). volumetric control is more common in modern dialysis machines. in the case of toxicants, diffusion into the dialysate is the primary end point, although amelioration of acid-base and electrolyte conditions is often an important additional goal. dialyzer specifications (blood flow rate, surface area, and membrane construction) determine, in part, the efficacy of drug or chemical removal from the blood. pharmacodynamic and pharmacokinetic factors (molecular weight, lipid solubility, protein binding, toxicant concentration gradient, and volume of distribution [vd] ) are equally critical factors which will be discussed in further detail below. hp implies the passage of blood through a device containing absorbent particles. it may be performed alone or in combination with hd and has been employed for a number of years in the management of poisonings. resin hp with variants of amberlite xad (rohm & haas, philadelphia, pa) was viewed as promising in the s and s. however, very few recent reports of resin hp have been published. [ ] [ ] [ ] [ ] [ ] [ ] this is likely in part due to unavailability of medical-grade resin cartridges in many geographic areas. activated charcoal appears to be the most commonly used absorbent material based on published reports, but hospital availability of even these cartridges appears to be limited. a recent survey of new york city -receiving hospitals revealed that only about one third of those surveyed had charcoal hemoperfusion (chp) cartridges readily available (only one hospital had pediatric cartridges). just of responding hospitals had used chp within the previous years. reasons cited by the authors for limited cartridge availability and use of chp were decreasing clinical use of phenobarbital and theophylline and improved efficacy of hd. chp irreversibly binds water-and lipid-soluble drugs and chemicals in the molecular weight range of to , da, a much larger range than that for hd (<~ da). plasma drug extraction ratios for hp are superior to those for hd for acetaminophen (paracetamol), digoxin, glutethimide, paraquat, phenobarbital, and theophylline. however, further examination of this list may reveal, in part, why hp is seldom employed in the united states. nacetylcysteine is effective for acetaminophen poisoning, widely available, and less invasive. digoxin fab fragments are far more effective than hp in binding and eliminating digitalis glycosides. glutethimide is rarely prescribed in the united states. paraquat poisonings are rather rare in the united states, and hp has not been shown to alter outcomes, despite of reduction of plasma concentrations. as mentioned previously, phenobarbital and theophylline have largely been replaced in clinical use by other agents, and the less invasive mdac has been shown to be effective in reducing plasma concentrations of these agents, although it has not been proven to alter outcomes. the molecular adsorbents recirculating system (mars) is a relatively new method of extracorporeal decontamination, which employs dialysis across a membrane impregnated with albumin and a % albumin dialysate, line has a molecular weight of . da, but is poorly removed by hd. this is due to its very large vd. the vd is the theoretical volume into which a drug distributes in the body and is generally expressed in liters or liters/kg body weight. substances with a small vd (< l/kg) reside to a greater extent in the bloodstream and can generally be effectively removed by using extracorporeal methods. the vd of a drug is the most important determinant of the efficacy of hp. even when extracorporeal methods are very efficient in removing toxicants from the blood, if the theoretical vd is high, the pharmodynamic effect achieved is likely to be minimal, as the concentration at the drug target tissue may be virtually unchanged. a third critical factor in predicting efficacy of extracorporeal methods is protein binding. hd is of limited value for substances that are highly protein bound. chp, on the other hand, remains effective in cases of drug overdose with substances of high protein binding capacity. a study conducted in patients treated with hp, with drug overdoses involving different drugs, showed that the efficacy of drug removal through absorption by activated charcoal was dependent on the binding affinity, which is related to the protein binding percentage. this study concluded that drugs that are protein bound at levels of up to % are effectively removed from the blood with hp. following hd or hp, substances with a higher vd and high protein binding percentage tend to redistribute from storage tissues to plasma. for this reason, a single extracorporeal substance removal session may be insufficient. water solubility is also an important factor in determining dialyzability. water-soluble substances like ethanol, methanol, ethylene glycol, salicylates, theophylline, lithium, and valproate tend to have limited distribution in adipose tissues, thus limiting their vd. this property makes them ideal for extracorporeal drug removal. poisoning by a substance susceptible to extracorporeal removal is not in itself an adequate justification for the procedure. in general, extracorporeal methods should be reserved for poisonings for which toxic metabolic activation is anticipated (e.g., methanol, ethylene glycol), for which blood concentrations or the amount of toxicant absorbed foretell very serious toxicity, and for patients who have not improved despite of appropriate supportive care (volume repletion, acid-base correction, use of vasopressors, ion-trapping diuresis, and administration of specific antidotes). winchester identifies six clinical considerations for hd or hp in poisoning: ( ) progressive deterioration; ( ) depression of midbrain function leading to hypoventilation, hypothermia, and hypotension; thus attracting highly protein-bound substances. in addition, charcoal and anion exchange resin cartridges are employed to filter the dialysate, regenerating it for continued use. mars may be of interest in the setting of poisons that have a predilection for liver toxicity, as the system is capable not only of removing certain hepatotoxins, but also reducing hyperbilirubinemia, restoring hemodynamics, diminishing hepatic encephalopathy, and improving renal function. mars has been used to maintain patients in liver failure during the peritransplant period. [ ] [ ] [ ] [ ] the existing data for mars in general are encouraging, but the evidence base is limited. this caveat is even truer in the setting of poisoning. a number of factors determine the suitability of use of hd or hp as extracorporeal methods of removal of a given toxicant. in the case of hd, chemical and drug removal are determined by factors as blood flow rate, dialysate flow rate, dialyzer surface area, and pore structure of the chosen membrane and by pharmacodynamic and pharmacokinetic factors such as molecular size (usually < da), lipid solubility, protein binding, vd, and concentration gradient. for hp, the selection of filter material has historically been important (charcoal vs. resin cartridges). with scarce availability of resin cartridges, the choice has essentially reverted to charcoal. hp is typically reserved for drugs with a low vd and high protein binding, but as mentioned previously, compounds of larger molecular weight may be removed. hd frequently causes hypotension, whereas this is reportedly less often a problem in hp. as such, in instances where hemodynamic instability after poisoning is an issue, hp may be preferable even if less efficacious for a particular toxicant. vasopressors such as dopamine and norepinephrine are absorbed by the cartridges and therefore should be administered in the circuit after the sorbent. a definite role for mars therapy in poisoning has not yet been established. in general, substances that are highly bound to albumin and poorly susceptible to other forms of treatment, including hd and hp, should prompt consideration of mars, particularly in the setting of liver failure. in order to be effectively hemodialyzed, toxicants should ideally be of low molecular weight (< da). a low molecular weight alone is not sufficient, however, to assure effective dialyzability. for example, nortripty-( ) development of, or predisposition to, complications of coma, such as pneumonia or septicemia; ( ) impairment of drug excretion; ( ) poisoning of substances possessing metabolic and/or delayed effects; and ( ) poisons extractable at a rate exceeding endogenous elimination. these considerations could be condensed to ( ) patients who are very sick or likely to become so and ( ) toxicants for which hd/hp are effective in removal and known to make a clinical difference in outcome. blood concentrations of certain toxicants (e.g., methanol and ethylene glycol) have been proposed as indicators for hd. historically, a plasma concentration of mg/dl has been used as a threshold for the need for dialysis in both ethylene glycol and methanol poisonings. the availability of fomepizole, a safe and effective inhibitor of alcohol dehydrogenase, has altered the indications for hd. [ ] [ ] [ ] [ ] while hd continues to be a useful and often necessary adjunct in the treatment of toxic alcohol poisonings, an elevated blood concentration of the alcohol alone is no longer considered sufficient to require hd. severe metabolic acidosis accompanying methanol and ethylene glycol, as well as other toxic alcohol poisonings, is a clear indication for hd, regardless of blood concentration. in these cases, hd not only effectively removes the toxicants and their acidic metabolites, but helps in directly correcting the acid-base balance of the patient. even when the toxicant's molecular weight, protein binding, or vd do not conform to the criteria necessary for dialyzability, hd should be considered in the setting of severe metabolic acidosis and/or renal failure. an example of this can be found in overdoses by metformin. metformin would be expected to be poorly dialyzable on the basis of its very large vd. however, metformin toxicity results in severe metabolic acidosis, which may be ameliorated by application of hd techniques. , both hd and hp may be performed in children, but both pose greater challenges than in adults. vascular access is obviously more difficult in small children. for this reason, peritoneal dialysis has been historically used more often in children. however, use of peritoneal dialysis for acute renal failure in children appears to be decreasing and use of hd increasing over time. as mentioned before, availability of chp cartridges suited to use in children may be extremely limited, even in major metropolitan areas. however, it appears that if antidotal therapy for ethylene glycol is administered before the onset of renal insufficiency, hd, even in children, may be safely avoided. given the long half-life of methanol, hd is still considered advisable in children after treatment with fomepizole. obviously, poisonings by substances normally eliminated by the kidneys may require hd or hp in patients with chronic renal failure. both hd and hp are associated with potential serious complications (box d- ). the most serious complications associated with hd include hypotension (which by extension may lead to myocardial or brain infarction) and bleeding associated with anticoagulation. an addi- concepts in medical toxicology box d- to the onset of acidosis and end-organ damage (renal failure or visual disturbances). while fomepizole is relatively expensive, a multiple-day icu admission and hd might exceed drug costs. in other situations, hd or hp may shorten icu or hospital stays and be cost conscious procedures. a formal cost-benefit analysis of these various treatment options would be useful. the evaluation of efficacy of extracorporeal methods of blood purification should ultimately rest on improvement in patient outcomes. however, a good outcome after hd or hp is not equivalent to established efficacy. indeed, the literature is replete with case reports of the "successful use" of hd and hp in cases of poisoning in which the procedure may have had little impact at all on outcome. as mentioned in the beginning, the efficacy of extracorporeal purification procedures must be compared with the efficacy of elimination of the substance in question by the kidneys, liver, and lungs. thus, one cannot estimate the utility by simply measuring blood concentrations before and after hd/hp. rather, the amount of extracted drug should be measured directly in the dialysate or via elution from the cartridge, or alternatively, indirectly from hourly differences in simultaneously arterial (inlet)-venous (outlet) concentrations multiplied by the purification system blood flow. these amounts can then be compared to the concentrations in urine (determination of spontaneous renal clearance) and to the quantity believed to have been absorbed to determine efficacy. before and after blood concentrations give some idea of the combined efficacy of corporeal and extracorporeal elimination, but the interpretation may be clouded by ongoing intestinal absorption or redistribution of the toxicant. elimination by other routes (pulmonary, sweat) should be likewise considered. the list of toxic substances that have been subjected to hd and/or hp is quite long. winchester provides a list of more than substances removed with dialysis and hp. as already mentioned, the ability to remove a toxic substance by hp or hd is not equivalent to an indication for these procedures. one must take into account the patient's underlying health (renal or hepatic insufficiency), the toxicity of the absorbed substance, the presence of or likelihood of advancing to severe illness, the availability of these procedures, and the availability of acceptable alternatives (good supportive care, antidotes). a list of a few substances that have frequently been subjected to extracorporeal removal follows (table d- ) . the list is not comprehensive and does not necessarily imply an indication for hd/hp. the reader is referred to individual chapters for detailed indications for these and other forms of therapy. tional significant consequence is reduction of therapeutic levels of drugs, which may result in unmasking of conditions protected by these agents. complications appear to be relatively fewer in hp, but may nonetheless be important. hp is associated with the destruction of platelets, such that significant thrombocytopenia and bleeding may occur. this complication has been reduced by coating of the sorbent particles with a polymer solution. hypocalcemia likewise may occur. rahman and colleagues recently reported on the case of a patient treated with chp for valproate poisoning. despite of the use of coated charcoal, the patient developed severe hemolysis, which the researchers attributed to mechanical damage to red cells by the high flow rate through the cartridge. the patient required packed red blood cells, platelets, and fibrin transfusions, developing oliguricanuric renal failure that required days of hd over a period of several weeks. she ultimately regained her normal renal function. transfer hd and hp are not universally available. thus, transfer to centers capable of performing these procedures may at times be required. the decision to transfer a patient for these therapies should rest on evaluation of several elements: ( ) is the patient stable for transport? ( ) will the patient's outcome likely be significantly better if the procedure is undertaken? ( ) are there acceptable alternatives to hd or hp? each of these issues should be studied prior to committing a patient to prolonged and expensive or potentially hazardous transport to another facility for extracorporeal decontamination procedures. as mentioned above, hd and hp have significant potential for complications. in certain poisonings, such as ethylene glycol and methanol intoxications, where hd was formerly routinely prescribed in the presence of high blood concentrations, recent improvements in specific antidotes have led to therapeutic alternatives. for example, if a patient with significant ethylene glycol poisoning arrives at the hospital before the onset of acidosis and renal failure, early treatment with fomepizole alone may preempt the need for hd. , , even in the case of methanol, hd may be avoided in selective cases after early treatment with fomepizole. methanol's elimination half-life is much greater than that of ethylene glycol, however, and may require prolonged antidotal treatment in the absence of hd. requirement for acute hd and/or hp generally implies costly intensive care unit (icu) admission. as mentioned above, early administration of fomepizole may forego the need for hd and icu admission in ethylene glycol and selected methanol poisonings, if administered prior the alcohol and glycols generally have toxicity that is inversely related to molecular weight. this, along with limited protein binding, small volumes of distribution, and relatively high water solubility, makes them particularly amenable to removal by hd. ethylene glycol (see chapter b) has a molecular weight of da, it has no significant protein binding, and it distributes primarily in total body water (vd = . - . l/kg), rendering it readily removable by hd. , additionally, glycolate, the toxic by-product of ethylene glycol responsible for acidosis, is effectively removed by hd. , the indications for hd in ethylene glycol poisoning have been reviewed. , , pizon and brooks have stated that an extremely high ethylene glycol level should be considered an indication for hd regardless of the patient's acid-base status or renal function due to hyperosmolarity. methanol (see chapter a) is likewise small ( da), with minimal protein binding and a vd of . l/kg. formic acid, the toxic by-product of methanol responsible for acidosis and retinal toxicity, is removed by hd. hovda and colleagues have suggested that hd may be performed on an "elective" basis in selected methanol poisonings if patients are rapidly treated with bicarbonate and fomepizole. , several researchers have recently reviewed the indications for hd after methanol poisoning. , , isopropanol (see chapter c) may also be removed by hd, although the indications for hd are limited, due to generally good outcomes with supportive care. , hd has been proven to be effective in removing both isopropanol and acetone from the plasma. lacouture and colleagues have recommended hd in cases where the blood isopropanol concentration exceeds mg/dl. salicylates (see chapter ) are compounds of low molecular weight. they are moderately to highly protein bound ( %- %), with very small volumes of distribution. although salicylates are highly protein bound at therapeutic concentrations, the fraction of unbound drug increases in the setting of overdose, rendering it amenable to removal by hd or hp. early hd is recommended due to the high propensity of salicylates to cause serious toxicity and death. the importance of concurrent alkalinization of the urine has been underscored by higgins and colleagues. because of acid-base and electrolyte abnormalities associated with salicylate poisoning, acute hd, rather than hp, is generally preferred. theophylline (see chapter ) has a low molecular weight and small vd with moderate protein binding. shannon addressed the use of hd and hp in theophylline poisoning in a -year prospective, observational study. the study included acute, chronic, and acute-ontherapeutic poisonings. the incidence of major toxicity was significantly greater in those undergoing hd. shannon concluded that while hp provides a higher theophylline clearance rate than hd, the latter appears to have comparable efficacy in reducing the morbidity of severe theophylline intoxication and is associated with a lower rate of procedural complications. lithium carbonate (see chapter ) remains a commonly used therapeutic agent in the treatment of bipolar disorder. while its vd is low, it concentrates in brain matter, rendering effective treatment more difficult. it has minimal protein binding and a very small molecular weight, and thus is amenable to treatment with hd. indications for dialysis remain controversial. recently, newer forms of extracorporeal purification for lithium poisoning have been proposed (see chapter c) which allow slower removal of lithium without rebound levels. annual report of the american association of poison control centers toxic exposure surveillance system management of intentional overdose in a&e departments diagnosis and management of the drug overdose patient pediatric rapid sequence intubation: a review rapid sequence intubation rapid-sequence intubation: a safe but ill-defined procedure rapid sequence induction medications: an update in patients with head injury undergoing rapid sequence intubation, does pretreatment with intravenous lignocaine/lidocaine lead to an improved neurological outcome? a review of the literature lidocaine and rapid sequence intubation acute asthma in emergency room does ketamine have a role in managing severe exacerbation of asthma in adults? emergency department use of ketamine in pediatric status asthmaticus in patients with head injuries who undergo rapid sequence intubation using succinylcholine, does pretreatment with a competitive neuromuscular blocking agent improve outcome? a literature review rocuronium versus succinylcholine for rapid sequence induction intubation pharmacologic management of the hypotensive patient management of calcium channel antagonist overdose drug-induced prolongation of the qt interval single-dose oral activated charcoal in the treatment of the self-poisoned patient: a prospective, randomized, controlled trial prospective evaluation of gastric emptying in the self-poisoned patient management of acutely poisoned patients without gastric emptying randomized study of the treatment of phenobarbital overdose with repeated doses of activated charcoal the revised position papers on gastric decontamination selecting the language of the publications included in a meta-analysis: is there a tower of babel bias? occupational health and safety administration: osha best practices for hospital-based first receivers of victims from mass casualty incidents involving the release of hazardous substances effects of washing acid injuries to the skin with water: an experimental study using rats experimental study on alkaline skin injuries-periodic changes in subcutaneous tissue ph and the effects exerted by washing emergency treatment of chemical and thermal eye burns alkali ocular burns in martinique (french west indies). evaluation of the use of an amphoteric solution as the rinsing product is there a delay in bathing the external eye in the treatment of ammonia eye burns? comparison of two ophthalmic solutions: physiological serum and diphoterine a prospective, randomized, blind comparison between saline, calcium gluconate and diphoterine for washing skin acid injuries in rats: effects on substance p and beta-endorphin release diphoterine for emergent eye/skin chemical splash decontamination: a review acid ingestion: toxicology and treatment the treatment of alkaline burns of the skin by neutralization poor prognosis of severe chemical and thermal eye burns: the need for adequate emergency care and primary prevention management of chemical eye injuries with prolonged irrigation army center for health promotion and preventive medicine (usachppm): personal protective equipment guide for military medical treatment facility personnel handling casualties from weapons of mass destruction and terrorism events weapons of mass destruction events with contaminated casualties: effective planning for health care facilities hexafluorine for emergent decontamination of hydrofluoric acid eye/skin splashes efficacy of hexafluorine for emergent decontamination of hydrofluoric acid eye and skin splashes hexafluorine vs. standard decontamination to reduce systemic toxicity after dermal exposure to hydrofluoric acid topical treatments for hydrofluoric acid burns: a blind controlled experimental study topical treatments for hydrofluoric acid burns: a blind controlled experimental study hydrofluoric acid dermal burns. an assessment of treatment efficacy using an experimental pig model topical treatments for hydrofluoric acid dermal burns. further assessment of efficacy using an experimental piq model comparison of topical magnesium and calcium treatment for dermal hydrofluoric acid burns the role of calcium gluconate in the treatment of hydrofluoric acid eye burn the efficacy of calcium gluconate in ocular hydrofluoric acid burns ocular hydrofluoric acid burns: animal model, mechanism of injury and therapy effects of isopropyl alcohol, ethanol, and polyethylene glycol/industrial methylated spirits in the treatment of acute phenol burns efficacy of topical phenol decontamination strategies on severity of acute phenol chemical burns and dermal absorption: in vitro and in vivo studies in pig skin chemical skin burns phosphorus burns: a practical approach to local treatment the phosphorous burn-a preliminary comparative experimental study of various forms of treatment phosphorous burns: evaluation of various modalities for primary treatment hand injuries due to highpressure injection devices for painting in shipyards: circumstances, management, and outcome in twelve patients high-pressure hand injection injuries caused by dry cleaning solvents: case reports, review of the literature, and treatment guidelines fatal hypernatremia from exogenous salt intake: report of a case and review of the literature fatal hypernatremia from saltwater used as an emetic fatal hypernatremia after using salt as an emetic-report of three autopsy cases death following cupric sulfate emesis lacomis d: case of the month rapidly reversible cardiomyopathy associated with chronic ipecac ingestion position statement: ipecac syrup. american academy of clinical toxicology; european association of poisons centres and clinical toxicologists conservative management of cocaine-packet ingestion: experience in milan, the main italian smuggling center of south american cocaine a massive, near-fatal cocaine intoxication in a body-stuffer. case report and review of the literature heroin body packers cocaine-condom ingestion. surgical treatment the cocaine 'body packer' syndrome. diagnosis and treatment surgical removal of iron tablets endoscopic removal of pharmacobezoar of slow release theophylline release of toxic metals from button batteries retained in the stomach: an in vitro study systemic absorption of lithium following ingestion of a lithium button battery button battery ingestion: an analysis of cases comparative efficacy of thallium adsorption by activated charcoal, prussian blue, and sodium polystyrene sulfonate how long after drug ingestion is activated charcoal still effective? position paper: singledose activated charcoal activated charcoal administration in a pediatric emergency department the frequency of complications associated with the use of multiple-dose activated charcoal chronic lung disease after activated charcoal aspiration incidence of aspiration pneumonia in intubated patients receiving activated charcoal american academy of clinical toxicology; european association of poisons centres and clinical toxicologists: position statement and practice guidelines on the use of multi-dose activated charcoal in the treatment of acute poisoning effects of fuller's earth and activated charcoal on oral absorption of paraquat in rabbits position paper: cathartics acute hypermagnesemia after laxative use hypermagnesemia induced by massive cathartic ingestion in an elderly woman without preexisting renal dysfunction severe hypermagnesemia due to multiple-dose cathartic therapy position paper: whole bowel irrigation a prospective study of acute, unintentional, pediatric superwarfarin ingestions managed without decontamination acute, unintentional pediatric brodifacoum ingestions position paper: ipecac syrup home syrup of ipecac use does not reduce emergency department use or improve outcome ipecac syrup-induced emesis . . . no evidence of benefit the demise of ipecac poison prevention: poison treatment in the home guideline on the use of ipecac syrup in the out-of-hospital management of ingested poisons changes in arterial oxygen tension after gastric lavage for drug overdose gastrointestinal tract perforation with charcoal peritoneum complicating orogastric intubation and lavage esophageal tear following forceful removal of an impacted oral-gastric lavage tube aspiration pneumonia following severe self-poisoning position paper: gastric lavage severe esophageal damage due to button battery ingestion: can it be prevented? bite the bullet: lead poisoning after ingestion of lead bullets successful treatment of theophylline toxicity by upper gastrointestinal endoscopy radiopacity of clomipramine conglomerations and unsuccessful endoscopy: report of cases urine sugar reagent tablet ingestion causing gastric and duodenal ulceration device choice and experience level in endoscopic foreign object retrieval: an in vivo study hazards of battery ingestion swallowed button batteries: is there a consensus on management? is surgical decontamination definitive treatment of "body-packers"? whole-bowel irrigation as adjunctive treatment for sustained-release theophylline overdose interaction between whole-bowel irrigation solution and activated charcoal: implications for the treatment of toxic ingestions acceleration of the body clearance of phenobarbital by oral activated charcoal gastrointestinal clearance of drugs with activated charcoal intravenous theophylline poisoning and multiple-dose charcoal in an animal model dose-dependency in the exsorption of theophylline and the intestinal dialysis of theophylline by oral activated charcoal in rats european association of poisons centres and clinical toxicologists: position statement and practice guidelines on the use of multi-dose activated charcoal in the treatment of acute poisoning multiple doses of activated charcoal: time for reappraisal? the frequency of complications associated with the use of multiple-dose activated charcoal use of multiple-dose activated charcoal in phenytoin toxicity multiple-dose activated charcoal for treatment of yellow oleander poisoning: a single-blind, randomized, placebo-controlled trial correlation of drug pharmacokinetics and effectiveness of multiple-dose activated charcoal therapy oral activated charcoal and dapsone elimination acceleration of digoxin clearance by activated charcoal digoxin toxicity in chronic renal failure: treatment by multiple dose activated charcoal intestinal dialysis characteristics of vomiting associated with acute sustained release theophylline poisoning: implications for management with oral activated charcoal fatal pulmonary aspiration of oral activated charcoal a fatality resulting from multiple dose activated charcoal therapy (abstract) aspiration of activated charcoal (letter) pulmonary aspiration of activated charcoal: a complication of its misuse in overdose management fatal pulmonary aspiration of oral activated charcoal (letter) activated charcoal surface area and its role in multiple-dose charcoal therapy gastrointestinal obstruction associated with multiple-dose activated charcoal charcoal bezoar. small bowel obstruction secondary to amitriptyline overdose therapy rectal ulcer with massive hemorrhage due to activated charcoal treatment in oral organophosphate poisoning intestinal pseudo-obstruction following the use of enteral charcoal and sorbitol and mechanical ventilation with papaveretum sedation for theophylline poisoning charcoal stercolith with intestinal perforation in a patient treated for amitriptyline ingestion treatment with activated charcoal complicated by gastrointestinal obstruction requiring surgery multiple doseactivated charcoal as a cause of acute appendicitis small-bowel obstruction secondary to activated charcoal and adhesions position statement: cathartics. american academy of clinical toxicology; european association of poisons centres and clinical toxicologists palatability of sucrose-, sorbitol-, and saccharinsweetened activated charcoal formulations dosage recommendations for activated charcoal-sorbitol treatment the genesis of the square meter-hour hypothesis methanol intoxication: comparison of peritoneal dialysis and hemodialysis treatment peritoneal dialysis in children: survey of its indications and applications allergic reactions to the polymeric glucose-based peritoneal dialysis fluid icodextrin in patients with renal failure pharmacokinetic evaluation of forced diuresis, dialysis, and hemoperfusion current concepts: peritoneal dialysis vitamin d intoxication in an anephric child acute digoxin overdose in a newborn with renal failure: use of digoxin immune fab and peritoneal dialysis carbamazepine overdosethe effects of multiple dose activated charcoal carbamazepine poisoning in adolescent suicide attempters. effectiveness of multiple-dose activated charcoal in enhancing carbamazepine elimination pediatric carbamazepine intoxication effect of oral charcoal and urine ph on dextropropoxyphene pharmacokinetics treatment of digitoxin overdose with oral activated charcoal the effects of activated charcoal on digoxin and digitoxin clearance enhancement of phenytoin elimination by multiple-dose activated charcoal treatment of phenytoin toxicity with repeated doses of activated charcoal multiple-dose activated charcoal in management of phenytoin overdose multiple-dose activated charcoal compared to urinary alkalinization for the enhancement of phenobarbital elimination pharmacokinetics of phenobarbital during certain enhanced elimination modalities to evaluate their clinical efficacy in management of drug overdose the effect of activated charcoal on the bioavailability of piroxicam in man ma: thallium and arsenic poisoning in a small midwestern town accelerated clearance of intravenously administered theophylline and phenobarbital by oral doses of activated charcoal in rats. a possibility of the intestinal dialysis effect of administration of activated charcoal and fibre on absorption, excretion and steady state blood levels of digoxin and digitoxin. evidence for intestinal excretion of the glycosides multiple doses of charcoal in digoxin poisoning activated charcoal increases digoxin elimination in patients misadventures with activated charcoal and recommendations for safe use treatment of phenobarbital poisoning with multiple dose activated charcoal in an infant multiple-dose activated charcoal in an accidental vancomycin overdose treatment of neonatal hyperbilirubinemia with repetitive oral activated charcoal as an adjunct to phototherapy prevalence of sorbitol in multiple-dose activated charcoal regimens in emergency departments continuous venovenous hemofiltration for the treatment of contrast-induced acute renal failure after percutaneous coronary interventions continuous arterial-venous diahemofiltration and continuous veno-venous diahemofiltration in infants and children functional characteristics of pediatric veno-venous hemofiltration rapid removal of vancomycin by continuous veno-venous hemofiltration is continuous veno-venous hemofiltration for acetaminophen-induced acute liver and renal failure worthwhile? hyperphosphatemia in tumor lysis syndrome: the role of hemodialysis and continuous veno-venous hemofiltration myoglobin clearance during continuous veno-venous hemofiltration with or without dialysis acute rhabdomyolysis after gemfibrozil therapy in a pregnant patient complicated with acute pancreatitis and hypertriglyceridemia while receiving continuous veno-venous hemofiltration therapy significant myoglobin removal during continuous veno-venous haemofiltration using f membrane (letter) lactic academia and bradyarrhythmia in a child sedated with propofol severe accidental hypothermia: rewarming with cvvhd propylene glycol toxicity associated with lorazepam infusion in a patient receiving continuous veno-venous hemofiltration with dialysis the acid-base effects of continuous hemofiltration with lactate or bicarbonate buffered replacement fluids profound hypercalcemia in continuous veno-venous hemofiltration dialysis with trisodium citrate anticoagulation and hepatic failure (letter) ueber die beseitgung giftiger stoffe aus blute durch dialyse peritoneal dialysis: a review fine rn: peritoneal dialysis update pharmacokinetics of drugs during various detoxification procedures for overdose and environmental exposure extracorporeal therapy in the treatment of intoxication interactions of drugs and peritoneal dialysis dialysis of poisons and drugs-annual review evaluation of the effects of multiple-dose activated charcoal on the absorption of orally administered salicylate in a simulated toxic ingestion model an evaluation of the effect of repeated doses of oral activated charcoal on salicylate elimination does multiple-dose charcoal therapy enhance salicylate excretion? multiple-dose charcoal and whole-bowel irrigation do not increase clearance of absorbed salicylate effect of multiple-dose activated charcoal on the clearance of high-dose intravenous aspirin in a porcine model effect of activated charcoal on absorption of nortriptyline effect of single and repeated doses of activated charcoal on the pharmacokinetics of doxepin lack of effect of oral activated charcoal on imipramine clearance pharmacokinetics of amitriptyline influenced by oral charcoal and urine ph effect of orally administered activated charcoal on vancomycin clearance failure of oral activated charcoal to accelerate the elimination of amiodarone and chloroquine the effect of activated charcoal on the absorption and elimination of astemizole effects of charcoal, sodium bicarbonate, and ammonium chloride on chlorpropamide kinetics tenenbein m: diltiazem overdose: pharmacokinetics of diltiazem and its metabolites and effect of multiple dose charcoal therapy effect of activated charcoal on the pharmacokinetics of pholcodine, with special reference to delayed charcoal ingestion the effect of repeateddose activated charcoal on the pharmacokinetics of sodium valproate in healthy volunteers effect of oral activated charcoal on tobramycin clearance elimination of amrinone during continuous veno-venous haemofiltration after cardiac surgery acute barium intoxication and hemodiafiltration pharmacokinetics of ceftriaxone in patients undergoing continuous veno-venous hemofiltration ethylene glycol antifreeze poisoning pharmacokinetics of imipenem-cilastatin in critically ill patients undergoing continuous venovenous hemofiltration continuous venovenous haemofiltration versus continuous veno-venous haemodialysis in severe lithium self-poisoning:a toxicokinetics study in an intensive care unit clearance of metformin by hemofiltration in overdose three case reports of the use of haemodiafiltration in the treatment of salicylate overdose vancomycin and tobramycin clearance in an infant during continuous hemofiltration amikacin pharmacokinetics during continuous veno-venous hemofiltration (letter) acute arsenic poisoning treated by intravenous dimercaptosuccinic acid (dmsa) and combined extrarenal epuration techniques hemodialysis versus continuous veno-venous hemodiafiltration in the management of severe valproate overdose peritoneal dialysis in acute poisoning: successful treatment of a -month-old child ingesting times the adult dose of achrocidin the early removal of amatoxins in the treatment of amanita phalloides poisoning (author's translation) management of amikacin overdose acute potassium dichromate poisoning: treated by peritoneal dialysis peritoneal dialysis for removal of copper role of albumin-enriched peritoneal dialysate in acute copper poisoning treatment of ethylene glycol poisoning with peritoneal dialysis intensified dialysis treatment of ethylene glycol intoxication treatment of glutethimide poisoning: a comparison of forced diuresis and dialysis peritoneal and hemodialysis for acute glutethimide treatment of glutethimide intoxication: an in vivo comparison of lipid, aqueous, and peritoneal dialysis with albumin peritoneal dialysis for isopropanol poisoning peritoneal dialysis for lithium poisoning lithium intoxication treated by peritoneal dialysis lithium intoxication with acute renal failure and death meprobamate poisoning treated by peritoneal dialysis meprobamate intoxication treated with peritoneal dialysis meprobamate poisoning: successful treatment with peritoneal dialysis amphetamine poisoning and peritoneal dialysis: a case report the use of peritoneal dialysis in acute methyl alcohol poisoning methanol poisoning in an infant: successful treatment with peritoneal dialysis acute mercury poisoning by intentional ingestion of mercuric chloride peritoneal dialysis for severe methyprylon intoxication peritoneal dialysis for severe methyprylon intoxication (letter) propoxyphene hydrochloride poisoning: report of the first fatality propoxyphene hydrochloride poisoning: report of a case treated with peritoneal dialysis acute propoxyphene hydrochloride intoxication peritoneal dialysis in quinine sulfate intoxication peritoneal dialysis in quinine intoxication quinine extraction during peritoneal dialysis: the role of nonionic diffusion hemodialysis, peritoneal dialysis, plasmapheresis and forced diuresis for the treatment of quinine overdose amitriptyline hydrochloride poisoning: unsuccessful treatment by peritoneal dialysis fatal chloroquine poisoning in a child: experience with peritoneal dialysis chlorpropamide intoxication-treatment with peritoneal dialysis accidental poisoning with isoniazid and rifampicin in an infant: role of peritoneal dialysis peritoneal dialysis and haemodialysis in methaqualone (mandrax) poisoning peritoneal dialysis in methaqualone overdose peritoneal dialysis and lysol poisoning thallium ingestion with survival: ineffectiveness of peritoneal dialysis and potassium chloride diuresis valacyclovir neurotoxicity in a patient with end-stage renal disease treated with continuous ambulatory peritoneal dialysis comparison of peritoneal and hemodialysis: treatment of methanol intoxication peritoneal dialysis for severe salicylism: an evaluation of indications and results rapid correction of acute salt poisoning by peritoneal dialysis toxicologic and pharmacokinetic evaluation of a case of vancomycin intoxication during continuous ambulatory peritoneal dialysis use of peritoneal dialysis in experimental amphetamine poisoning baclofen neurotxicity in uremic patients: is continuous ambulatory peritoneal dialysis less effective than intermittent hemodialysis? peritoneal dialysis in the treatment of boric acid poisoning acute boric acid poisoning: report of an infant successfully treated by peritoneal dialysis asymptomatic boric intoxication: value of peritoneal dialysis ingestion of boric acid by infants bromate poisoning treatment of bromate poisoning (letter) near-fatal caffeine intoxication treated with peritoneal dialysis dialysis treatment of acute chromium intoxication and comparative efficacy of peritoneal versus hemodialysis in chromium removal chromic acid burns: early aggressive excision is the best method to prevent systemic toxicity brief clinical and laboratory observations: management of neonatal gentamicin overdosage removal of mercury by peritoneal dialysis chapter emergency management of poisoning winchester jf: dialysis and hemoperfusion in poisoning annual report of the american association of poison control centers' national poisoning and exposure database toltec international inc: how hemodialysis (dialysis) works combined hemoperfusion and hemodialysis treatment of poisoning with cholinesterase inhibitors acute poisoning with bromofosmethyl (bromophos) use of hemoperfusion and cholinesterase in acute poisoning with organophosphate cholinesterase inhibitors-clinical analysis of patients the availability and use of charcoal hemoperfusion in the treatment of poisoned patients elimination of paraquat multiple-dose activated charcoal: a review of relevant clinical studies the role of the molecular adsorbents recirculating system (mars) in the management of liver failure preconditioning by extracorporeal liver support (mars) of patients with cirrhosis and severe liver failure evaluated for living donor liver transplantation-a pilot study application of mars artificial liver support as bridging therapy before split liver retransplantation in a -month-old child application of molecular adsorbent recirculating system in patients with severe liver failure after hepatic resection or transplantation: initial single-centre experiences experiences with mars liver support therapy in liver failure: analysis of patients of the international mars registry mars preconditioning for living donor liver transplantation: panacea or placebo? how tightly can a drug be bound to a protein and still be removable by charcoal hemoperfusion in overdose cases? extracorporeal therapies for acute intoxications quantitative pharmacogenetics of nortriptyline: a novel approach fomepizole for the treatment of ethylene glycol poisoning fomepizole for the treatment of methanol poisoning fomepizole in treatment of uncomplicated ethylene glycol poisoning current management of ethylene glycol poisoning references . bismuth c: biological valuation of extra-corporeal techniques in acute poisoning fomepizole may change indication for hemodialysis in methanol poisoning: prospective study in seven cases current recommendations for treatment of severe toxic alcohol poisonings severe lactic acidosis treated with prolonged hemodialysis: recovery after massive overdoses of metformin combination of intermittent haemodialysis and highvolume continuous haemofiltration for the treatment of severe metformin-induced lactic acidosis acute kidney failure: a pediatric experience over years treatment of severe pediatric ethylene glycol intoxication without hemodialysis childhood methanol ingestion treated with fomepizole and hemodialysis chronic renal disease patients with severe star fruit poisoning: hemoperfusion may be an effective alternative therapy extracorporeal techniques in the treatment of poisoned patients acute hemolysis with acute renal failure in a patient with valproic acid poisoning treated with charcoal hemoperfusion hemodialysis complications intradialytic complications during hemodialysis high-flux hemodialysis-an effective alternative to hemoperfusion in the treatment of carbamazepine intoxication high-efficiency dialysis for carbamazepine overdose high-flux haemodialysis treatment as treatment for carbamazepine intoxication management of carbamazepine overdose efficacy of charcoal hemoperfusion in massive carbamazepine poisoning repeat charcoal hemoperfusion treatments in life threatening carbamazepine overdose osmol gap as a surrogate marker for serum propylene glycol concentrations in patients receiving lorazepam for sedation use of the osmolal gap to guide the start and duration of dialysis in methanol poisoning removal of propylene glycol and correction of increased osmolar gap by hemodialysis in a patient on high dose lorazepam infusion therapy unusual d-lactic acid acidosis from propylene glycol metabolism in overdose treatment of the alcohol intoxications: ethylene glycol, methanol and isopropanol life-threatening isopropyl alcohol intoxication: is hemodialysis really necessary? extracorporeal management of valproic acid toxicity: a case report and review of the literature acute valproate poisoning: pharmacokinetics, alteration in fatty acid metabolism, and changes during therapy successful use of hemodialysis in acute valproic acid intoxication successful treatment of valproic acid overdose with hemodialysis high-flux hemodialysis without hemoperfusion is effective in acute valproic acid overdose efficiency of highflux hemodialysis in the treatment of valproic acid intoxication extracorporeal management of valproic acid overdose: a large regional experience valproic acid toxicity: overview and management glycolate kinetics and hemodialysis clearance in ethylene glycol poisoning. meta study group glycolate causes the acidosis in ethylene glycol poisoning and is effectively removed by hemodialysis formate kinetics in methanol poisoning an evidence based flowchart to guide the management of acute salicylate (aspirin) overdose alkalinization and hemodialysis in severe salicylate poisoning: comparison of elimination techniques in the same patient concepts and controversies in salicylate toxicity severe theophylline poisoning: charcoal haemoperfusion or haemodialysis comparative efficacy of hemodialysis and hemoperfusion in severe theophylline intoxication phosphorus-enriched hemodialysis for the treatment of patients with severe methanol intoxication validation of a method to predict required dialysis time for cases of methanol and ethylene glycol poisoning acute phenobarbital intoxication effectiveness of hemodialysis in the extracorporeal therapy of phenobarbital overdose conventional haemodialysis significantly lowers toxic levels of phenobarbital hemodialysis following butoxyethanol ingestion repeated ingestion of -butoxyethanol: case report and literature review the treatment of severe drug intoxication with charcoal hemoperfusion in series with hemodialysis critical, acutely poisoned patients treated with continuous arteriovenous hemoperfusion in the emergency department when should dialysis be performed in lithium poisoning? a kinetic study in cases of lithium poisoning hemodialysis followed by continuous hemofiltration for treatment of lithium intoxication in children hyperosmolality: another indication for hemodialysis following acute ethylene glycol poisoning ethylene glycol toxicity: the role of serum glycolic acid in hemodialysis hemodialysis as a treatment of severe ethanol poisoning intravenous -methylpyrazole as an antidote for diethylene glycol and triethylene glycol poisoning: a case report successful treatment of a child with fulminant liver failure and coma caused by amanita phalloides intoxication with albumin dialysis without liver transplantation molecular adsorbent recirculating system in dealing with maternal amanita poisoning during the second pregnancy trimester: a case report successful use of molecular absorbent regenerating system (mars) dialysis for the treatment of fulminant hepatic failure in children accidentally poisoned by toxic mushroom ingestion mars: optimistic therapy method in fulminant hepatic failure secondary to cytotoxic mushroom poisoning-a case report phenytoin intoxication in critically ill patients experience with albumin dialysis in five patients with severe overdoses of paracetamol mars procedure as a bridge to combined liver-kidney transplantation in severe chromium-copper acute intoxication: a paediatric case report childhood diethylene glycol poisoning treated with alcohol dehydrogenase inhibitor fomepizole and hemodialysis the role of continuous renal replacement therapy in the treatment of poisoning methanol and formate kinetics during treatment with fomepizole rethinking the toxic methanol level isopropyl alcohol intoxication: a diagnostic challenge acute isopropyl alcohol intoxication. diagnosis and management methods used to decrease lithium absorption or enhance elimination treatment of lithium intoxication with continuous venovenous hemodiafiltration successful treatment by direct hemoperfusion of coma possibly resulting from mitochondrial dysfunction in acute valproate intoxication treatment of severe theophylline poisoning with the molecular adsorbent recirculating system (mars) molecular adsorbent recirculating system-mars as a bridge to liver transplantation in amanita phalloides intoxication successful treatment of an adult with amanita phalloides-induced fulminant liver failure with molecular adsorbent recirculating system (mars) carbamazepine has a relatively low molecular weight ( da), but a fairly large vd ( - l/kg) and is about % protein bound at therapeutic levels. its active metabolite , -epoxide (cbze), is approximately % protein bound. , because of the high protein binding, activated charcoal and chp have generally been favored in treatment; however, high-efficiency dialysis may also be effective. valproic acid (see chapter ) is a low molecular weight ( da) anticonvulsant with a small vd and saturable protein binding. at therapeutic concentrations, % to % of valproic acid is protein bound, but in overdose the degree of protein binding is relatively less (i.e., there is more unbound drug available for extracorporeal purification). saturation of protein binding sites occurs at levels greater than μg/ml, at which % to % of the drug is protein bound. at a level of μg/ml, % of valproic acid is protein bound, , , rendering it amenable to extracorporeal drug removal techniques. , both hp and hd, alone and in combination, have been used in cases of valproate toxicity. valproic acid elimination has been shown to be enhanced about tenfold by the use of extracorporeal methods. while the half-life of the drug is effectively diminished, the precise role of these procedures in valproate toxicity remains to be established. a nonexhaustive list of substances for which mars has been used in poisoning includes theophylline, cytotoxic mushrooms, - phenytoin, acetaminophen (paracetamol), and a copper-chromium-containing solution. mars appears to improve liver failure from multiple causes, but further prospective studies are needed to determine the role this technique should play in patient care. in conclusion, hd and hp remain important, but secondary methods of treatment in poisoning by specific substances. these modalities cannot be substituted for excellent supportive care, and in some cases the need for them has been supplanted by effective antidotes. both hd and hp are associated with complications and are not universally available. careful evaluation of individual cases should guide the decision to use extracorporeal circulation. mars or albumin dialysis may be of clinical benefit in selected poisonings. key: cord- - lu sce authors: stokholm, jakob; chawes, bo l; vissing, nadja h; bjarnadóttir, elín; pedersen, tine m; vinding, rebecca k; schoos, ann-marie m; wolsk, helene m; thorsteinsdóttir, sunna; hallas, henrik w; arianto, lambang; schjørring, susanne; krogfelt, karen a; fischer, thea k; pipper, christian b; bønnelykke, klaus; bisgaard, hans title: azithromycin for episodes with asthma-like symptoms in young children aged – years: a randomised, double-blind, placebo-controlled trial date: - - journal: lancet respir med doi: . /s - ( ) - sha: doc_id: cord_uid: lu sce background: bacteria and viruses are equally associated with the risk of acute episodes of asthma-like symptoms in young children, suggesting antibiotics as a potential treatment for such episodes. we aimed to assess the effect of azithromycin on the duration of respiratory episodes in young children with recurrent asthma-like symptoms, hypothesising that it reduces the duration of the symptomatic period. methods: in this randomised, double-blind, placebo-controlled trial, we recruited children aged – years, who were diagnosed with recurrent asthma-like symptoms from the copenhagen prospective studies on asthma in childhood cohort; a birth cohort consisting of the general danish population of zealand, including copenhagen. exclusion criteria were macrolide allergy, heart, liver, neurological, and kidney disease, and, before each treatment, one or more clinical signs of pneumonia (respiratory frequency of ≥ breaths per min; fever of ≥ °c; c-reactive protein concentration of ≥ · nmol/l [≥ mg/l]). each episode of asthma-like symptoms lasting at least days was randomly allocated to a -day course of azithromycin oral solution of mg/kg per day or placebo after thorough examination by a study physician at the copenhagen prospective studies on asthma research unit. each episode was randomly allocated independently of previous treatment from a computer-generated list of random numbers in blocks of ten (generated at the pharmacy of glostrup). investigators and children were masked until the youngest child turned years of age and throughout the data validation and analysis phases. the primary outcome was duration of the respiratory episode after treatment, verified by prospective daily diaries and analysed with poisson regression. analyses were per protocol (excluding those without a primary outcome measure or who did not receive treatment). this trial is registered with clinicaltrials.gov, number nct . findings: between nov , , and jan , , we randomly allocated asthma-like episodes in children ( [ %] to azithromycin and [ %] to placebo). the mean duration of the episode after treatment was · days for children receiving azithromycin compared with · days for children receiving placebo. azithromycin caused a significant shortening of the episode of · % ( % ci · – · ; p< · ). the effect size increased with early initiation of treatment, showing a reduction in episode duration of % if treatment was initiated before day of the episode compared with % if initiated on or after day (p< · ). we noted no differences in clinical adverse events between the azithromycin ( [ %] of episodes included in final analysis) and placebo ( [ %] of ) groups (p= · ), but we did not investigate bacterial resistance patterns after treatment. interpretation: azithromycin reduced the duration of episodes of asthma-like symptoms in young children, suggesting that this drug could have a role in acute management of exacerbations. further research is needed to disentangle the inflammatory versus antimicrobial aspects of this relation. funding: lundbeck foundation, danish ministry of health, danish council for strategic research, capital region research foundation. childhood asthma is often preceded by recurrent episodes of troublesome lung symptoms in relation to airway infections in the fi rst years of life. , treatment of such episodes represents a major unmet clinical need; they are the most common cause of admission to hospital in young children, are a reason for stress and anxiety for families, and cause a major draw on health-care resources. [ ] [ ] [ ] we discovered in our birth cohort, the copenhagen prospective studies on asthma in childhood (copsac ; a previous birth cohort of children born to mothers with asthma), that airway bacteria (haemophilus infl uenzae, streptococcus pneumoniae, and moraxella catarrhalis) and respiratory viruses (at least one of picornavirus, respiratory syncytial virus, coronavirus, parainfl uenzavirus, infl uenza virus, human metapneumovirus, adenovirus, or bocavirus) are equally closely associated with episodes of asthma-like symptoms in the fi rst years of life. bacteria and viruses occurred together in most cases, challenging the previous hypothesis that episodes with asthma-like symptoms in this age group are largely virally induced. [ ] [ ] [ ] this fi nding suggested that bacteria might play an equal part in the pathogenesis of such episodes and that treatment with antibiotics might ameliorate symptoms. at present, guidelines do not recommend antibiotics for treatment of early asthma-like episodes, yet they are widely used. we did a randomised controlled trial (rct) of azithromycin for treatment of episodes of troublesome lung symptoms in young children who were followed up prospectively in our new unselected copenhagen prospective studies on asthma in childhood (copsac ) birth cohort. in this randomised, double-blind, placebo-controlled trial, we recruited children from the copsac cohort, which is a single-centre, population-based birth cohort of children recruited from the general danish population of zealand, including copenhagen, at week of age and followed up prospectively at the copenhagen prospective studies on asthma in childhood (copsac) research unit (copenhagen and naestved, denmark) with deep clinical phenotyping. children aged - years diagnosed with recurrent asthma-like symptoms (troublesome lung symptoms) as defi ned in the procedures section were eligible each time they had an episode of troublesome lung symptoms lasting at least days. exclusion criteria were macrolide allergy, heart, liver, neurological, and kidney disease, and, before each treatment, one or more clinical signs of pneumonia (respiratory frequency of breaths per min or higher, fever of °c or higher, or c-reactive protein [crp] concentration of · nmol/l [ mg/l] or higher). most mothers from the copsac cohort also participated in other medical trials while pregnant and may have received dietary supplements or an infl uenza vaccination (nct , nct , and nct ). , additional details of baseline characteristics of the cohort are outlined in the copsac cohort design report. this trial was approved by the ethics committee for copenhagen (h- - - ), danish data protection agency ( - - ), and danish health and medicines authority ( - ). parents of children gave written and oral informed consent before enrolment of participants. the complete biobank is publicly available at the danish national biobank. the entire copsac dataset, including the rct-specifi c data, are currently being transferred to a publicly available database (the danish data archive). each episode of troublesome lung symptoms that occurred up to the age of years or up to a maximum of seven treatments per child was randomised individually to either azithromycin or placebo. treatments were randomly allocated at the pharmacy of glostrup (copenhagen, denmark) with a computer-generated list of random numbers in blocks of ten. copies of the randomisation code were kept in sealed envelopes at the research site and the pharmacy. investigators and participating families were masked to treatment assignment until the youngest child turned years of age and throughout the data validation and analysis phases. those assessing the primary outcome were masked; those doing subanalyses were not. evidence before this study findings from a publication from the copenhagen prospective studies on asthma in childhood showed that both bacteria and viruses are equally associated with the risk of acute episodes of asthma-like symptoms in young children, suggesting that antibiotics such as azithromycin could help in management of such episodes. we searched pubmed up to oct , , with no language limits, for various combinations of the search terms "rct", "childhood", "asthma", "wheeze", and "antibiotics". we identifi ed all previous randomised controlled trials of treatment with antibiotics for asthma and wheezy exacerbations, but focused mainly on childhood asthma. the search led us to new articles, but also identifi ed other relevant old publications for background material. investigators of two randomised trials concluded no benefi cial eff ect of β-lactam treatment for acute exacerbations, which has led to present guidelines not recommending antibiotic treatment for episodes of acute asthma-like symptoms. this study is, to our knowledge, the fi rst randomised controlled trial of azithromycin treatment of acute episodes of asthma-like symptoms in children aged - years with a history of recurrent episodes and its fi ndings show a clinically signifi cant shortening of symptom duration by % after intervention. present guidelines do not recommend antibiotics for treatment of episodes of asthma-like symptoms in young children, yet antibiotics remain among the most commonly prescribed drugs in these episodes. our fi ndings suggest that azithromycin might be benefi cial after medical assessment of an acute asthma-like episode in young children with a known history of such symptoms and without clinical signs of pneumonia. how the eff ect of azithromycin is compared with narrow-spectrum antibiotics and whether long-term eff ects are associated with recurrent use of azithromycin need to be investigated. troublesome lung symptoms, consisting of cough, wheeze, or dyspnoea, severely aff ecting the wellbeing of the child, were monitored using daily diary cards fi lled out by the parents from birth. we defi ned an episode as at least consecutive days of troublesome lung symptoms, at which point we requested that the parents brought the child to the copsac research unit for an acute visit. we used the composite score of troublesome lung symptoms to describe asthma-like symptoms in the children, a score previously validated , and used in our clinical observational cohort studies of young children , - and a randomised controlled trial. at each acute visit, the diary cards were reviewed with the family by trained copsac paediatricians to validate symptom defi nitions and severity. additionally, the research paediatrician did a thorough physical examination, consisting of assessment of fever, tachypnoea, chest recessions, wheezing, and lung and heart auscultation, and examination of the skin, ears, nose, and throat. furthermore, we measured crp concentration (detection limit of · - · nmol/l [ - mg/l]) in the peripheral blood with the quickread instrument (orion diagnostica, espoo, finland). we collected a hypopharyngeal aspirate using a soft suction catheter passed through the nose into the hypopharynx, as previously described. we cultured the samples and isolated the airway bacterial pathogens h infl uenzae, s pneumoniae, and m catarrhalis. we obtained a nasopharyngeal aspirate for viral identifi cation with pcr. the viral airway pathogens analysed were rhinoviruses, respiratory syncytial virus (rsv), and enteroviruses. we treated episodes of troublesome lung symptoms with the β agonist salbutamol (airomir; teva, kongens lyngby, denmark) inhaled from a pressurised metered dose inhaler delivered via a spacer (aerochamber; trudell medical international, london, on, canada) as needed. we added mg of montelukast in the evening for weeks in children who had previously benefi ted from this treatment. we added prednisolone - mg/kg per day for days for severe episodes at the discretion of the attending paediatricians in the copsac research unit. recurrent troublesome lung symptoms were diagnosed if a child had: daily diary recordings of fi ve episodes of troublesome lung symptoms within months; weeks of continuous symptoms; or a severe acute episode needing oral prednisolone or hospital admission. this diagnosis algorithm had previously been validated in our at-risk copsac birth cohort. , at diagnosis of recurrent troublesome lung symptoms, we gave children a -month course of × μg fl uticasone (flixotide; glaxosmithkline, uk) inhaled from a pressurised metered dose inhaler delivered via a spacer twice daily. if a second relapse of troublesome lung symptoms occurred after cessation of inhaled corticosteroids, we initiated a -month course of inhaled corticosteroids. children diagnosed with recurrent troublesome lung symptoms and participating in this trial were prescribed azithromycin or placebo at the copsac research unit when subsequent acute episodes of troublesome lung symptoms occurred after diagnosis. we gave azithromycin as an oral solution of mg/kg per day in closed bottles (teva) for consecutive days or a matching placebo of similar look and taste (pharmacy of glostrup). the primary outcome was diary-verifi ed duration of episodes of troublesome lung symptoms after initiation of treatment. secondary outcomes were the time from treatment to the next episode of troublesome lung symptoms, the number of episodes that turned into severe exacerbations (need for oral steroids or admission to hospital), and the duration of β agonist use after treatment. serious adverse events, any adverse events, gastrointestinal symptoms, or other infections were documented with daily diary cards and hospital records. we based our power calculations on the duration of episodes of troublesome lung symptoms at age - years in the children of the previous copsac cohort. , , independent episodes were needed to detect a diff erence of day duration of episodes with a power of %, a p value of · , and an sd of the duration of an episode of · days. , , we analysed the duration of an episode of troublesome lung symptoms and β agonist use after treatment with poisson regression with a log link. this type of regression is ideal for modelling counts because it captures both skewness and variance heterogeneity and provides an easy-to-interpret quantifi cation of eff ects as relative change in mean counts. the model includes fi xed eff ects of the categorical variable episode number and an eff ect of treatment. we included a random eff ect of child to account for heterogeneity between children. we analysed factors potentially modifying the treatment eff ect with robust poisson regression to account for within-child correlation. we obtained inference by means of the generalised estimating equations procedure with a working independence assumption. we analysed gap times between episodes with cox regression, including γ-distributed frailties shared by gap times within each child to account for between-child heterogeneity. we included fi xed eff ects of treatment at the preceding episode in the model and stratifi ed baseline hazards by episode number. we obtained estimates with maximum likelihood estimation with wald % cis and a · p value cutoff . we did analyses using r version . . and the add-on package lme . primary analyses were per protocol (excluding those without a primary outcome measure or who did not receive treatment). safety analyses included those without a primary outcome measure but who did receive the study treatment. this trial was monitored by the good clinical practice unit at copenhagen university hospital (copenhagen, denmark). this trial is registered with clinicaltrials.gov, number nct . the funders of the study had no role in study design, data collection, data analysis, data interpretation, or writing of the report. js, cbp, and hb had access to the raw data. the corresponding author had full access to all the data in the study and had fi nal responsibility for the decision to submit for publication. ( %) of the children enrolled in the main cohort were diagnosed with recurrent troublesome lung symptoms during the fi rst years of life; between nov , , and jan , , we randomly allocated episodes for trial treatment ( [ %] to azithromycin and [ %] to placebo; fi gure ) from ( %) of these children. before analyses, we excluded ten ( %) episodes from the analysis (fi ve [ %] in each group), nine ( %) because of missing diary information (azithromycin four [ %]; placebo fi ve [ %]) and one ( %; in azithromycin group) because the treatment was never given to the child. mean age at randomisation was · years (sd · ). the mean number of randomisations for each child was · treatments (sd · ). in ( %) of the episodes analysed ( [ %] in the azithromycin-treated episodes and [ %] in the placebo-treated episodes), the child received concurrent treatment with inhaled corticosteroids. in ( %) episodes, the child received concurrent treatment with montelukast ( [ %] in the azithromycin-treated episodes and [ %] in the placebo-treated episodes). treatment was complied with in ( %) of episodes: one ( %) azithromycin treatment was never given and three ( %) treatments were discontinued after initiation; one ( %) in the azithromycin group and two ( %) in the placebo group. ( %) of children had complete clinical followup from inclusion in the study until age years. baseline characteristics did not diff er signifi cantly between participants in the trial and other children diagnosed with recurrent troublesome lung symptoms from the copsac cohort who did not participate in the ; table ). the mean total duration of respiratory episodes was · days. the episode duration after randomisation was unrelated to sex, mother's smoking status, allergic sensitisation to inhalant or food allergens at months or months, atopic dermatitis, or q genetic risk variant (appendix). figure shows the proportion of symptomatic children day-by-day during the days after treatment, showing a shortening of the symptomatic period after treatment with azithromycin. the average number of symptom days after azithromycin treatment was · days versus · days after placebo, corresponding to a calculated reduction in episode length of · % ( % ci · - · ; p< · ) within a child due to azithromycin treatment (table ) . restriction of the analysis to the fi rst randomised treatment in each child substantiated a signifi cant reduction of symptom duration by · % ( · - · ; p< · ) after treatment with azithromycin, corresponding to a mean duration of · days after azithromycin versus · days after placebo. the eff ect of azithromycin was increased when the duration of symptoms before treatment was shorter, showing a reduction in episode duration of % if treatment was initiated before day of the episode compared with % if initiated on or after day (p< · ). figure shows the reduction of episode duration after azithromycin treatment as a function of episode duration before treatment (less than or more than the median value of days). we noted no diff erential eff ect for episodes presenting with fever of ≥ °c or with increased crp concentration of ≥ · nmol/l (≥ mg/l), and treatment was equally eff ective in episodes with and without objective wheeze during examination in the research clinic (table ) . presence of any pathogenic bacteria did not signifi cantly modify the treatment eff ect compared with episodes without detection of bacteria, but azithromycin was more eff ective in episodes positive for h infl uenzae (table ). presence of any virus did not modify the treatment eff ect of azithromycin. none of the detected viruses signifi cantly modifi ed treatment eff ects (table ) . concurrent treatment with inhaled steroids (p value for interaction= · ) or montelukast (p value for interaction= · ) did not signifi cantly modify the treatment eff ect, and responses were equal (appendix). we noted no diff erences between treatment groups during the days after treatment with respect to serious or any adverse events, gastrointestinal symptoms, or other infections, as documented by daily diary cards and hospital records (appendix). azithromycin signifi cantly reduced the duration of physician-verifi ed episodes of asthma-like symptoms in children aged - years with a history of recurrent asthma-like symptoms. the duration was decreased by about % after azithromycin treatment, with more improvement if treatment was started early in the episode. azithromycin had no long-term eff ect on risk of subsequent episodes. this study is substantially strengthened by the prospective, longitudinal, daily diary recordings of lung symptoms before development of attacks, validated by study paediatricians at -monthly and acute visits. copsac served as the primary health-care centre for the birth cohort, ensuring a standardised approach to diagnosis and treatment, which improves reliability of diagnoses compared with reporting from community doctors and retrospective information from parents. [ ] [ ] [ ] diagnosis was based on an algorithm of symptom quantity, which has been analysed and validated in detail and applied in our previous rct of inhaled corticosteroids in young children in the at-risk copsac birth cohort. such strict diagnostic procedure is paramount to clinical assessments, diagnoses, and treatments, which are otherwise poorly standardised in the community and more diffi cult in young children than later in life. the in-depth clinical assessment of each respiratory episode by the study paediatrician before randomisation, including a thorough objective examination and crp concentration measurement in the research clinic, ensured validity and homogeneity of the primary outcome and exclusion of children with clinical signs of pneumonia. this assessment minimised the possibility of the azithromycin eff ect being driven by treatment of bacterial pneumonia misclassifi ed as an episode of asthmalike symptoms. another strength is the centralised longitudinal clinical follow-up of the cohort by a research team with a well established routine of doing clinical cohort studies. this routine ensured a high follow-up of the cohort, with % of the randomised children completing full followup until years of age and only % of randomised treatments being unavailable. we obtained airway samples before treatment in % of episodes, with only episodes missed. our results are generalisable to a similar group of children with a known history of recurrent asthma-like symptoms, with or without concomitant treatment with inhaled steroids and with an episode duration of at least days. an important limitation is that our data pertain to children with a episode duration before treatment detailed clinical history and acute worsening judged by the study clinician. they cannot be generalised to a more liberal setting, such as initiation at home by parents or children with mild disease. this study is the fi rst, to our knowledge, to investigate and show an eff ect of azithromycin for treatment of acute respiratory episodes in young children with a history of recurrent asthma-like symptoms, in a cohort designed and powered to explore such eff ects. a third of all children will experience an episode of asthma-like symptoms in relation to airway infections before years of age. shortening of such episodes by % is therefore clinically signifi cant to the child, families, health-care user, and society. we noted that azithromycin had a marked eff ect in relation to any given type of episode independently of the trigger, clinical presentation, or symptom duration before the intervention, which suggests a broad application. the sensitivity analysis restricting episodes to the fi rst randomisation validated the primary fi nding. asthma-like episodes in young children probably represent a heterogeneous clinical syndrome. importantly, we excluded typical pneumonia based on predefi ned clinical criteria. furthermore, most children (more than %) had undetectable concentrations of crp and no fever at randomisation, and the treatment eff ect was similar in these children, strongly suggesting that the eff ect of azithromycin is not due to misclassifi cation of pneumonia. azithromycin treatment was particularly eff ective in children who were treated shortly after symptom debut. this fi nding makes us speculate that azithromycin is mainly acting on the acute infl ammatory or infectious , processes related to exacerbations, rather than a persistent underlying infl ammation. this hypothesis is supported by the absence of eff ect on time to next episode. alternatively, azithromycin acts by clearing bacterial pathogens indirectly responsible for the respiratory episode through subsequent co-infection by a viral trigger, and therefore the treatment was more eff ective when initiated early in the episode than when initiated late. this study is based on our previous birth cohort study in which we discovered that pathogenic airway bacteria and respiratory viruses are equally closely associated with acute episodes of asthma-like symptoms in young children and mostly occur together. our fi nding in this study that the treatment eff ect was strong, even in episodes for which no bacterial pathogen was detected, suggests that the eff ect of azithromycin is not only antibacterial. macrolide antibiotics are active against both common airway pathogenic bacteria and atypical bacteria, [ ] [ ] [ ] but also have anti-infl ammatory activity and, possibly, antiviral eff ects. studies of macrolides in adults with severe asthma episodes are ambiguous, , and macrolides reportedly reduce exacerbations in adults with an asthma type characterised by chronic neutrophilic infl ammation. , indeed, recurrent asthma-like symptoms in young children are also characterised by neutrophilic infl ammation, , , which, in particular, might be present for episodes triggered by h infl uenzae. this corresponds with our fi nding of a stronger azithromycin eff ect in episodes triggered by h infl uenzae. viral infection in general did not predict an altered eff ect of azithromycin treatment. low numbers in some viral species groups limit the conclusions drawn about eff ect modifi cation by specifi c viruses. thus, the antibacterial, anti-infl ammatory, and antiviral pathways of azithromycin could have contributed to the shortening of episode length observed in this study. we cannot rule out that the eff ects noted are mainly anti-infl ammatory because episodes triggered by h infl uenzae induce neutrophilic infl ammation and azithromycin also reduced episode duration in children without any evidence of bacterial infection. an rct of treatment with azithromycin in rsv-positive children showed a reduction of the neutrophilic marker interleukin at day after azithromycin treatment. this fi nding could point towards an anti-infl ammatory eff ect as the primary mediator of our fi ndings and also explain why fi ndings from previous rcts , have failed to show treatment eff ects of non-anti-infl ammatory antibiotics in acute exacerbations of childhood asthma. present guidelines do not recommend antibiotics for treatment of episodes of asthma-like symptoms in young children and yet they are among the most commonly prescribed drugs for such episodes in both the usa and europe. our data suggest an eff ect of azithromycin on acute asthma-like episodes and thereby identify a potential future treatment, but do not provide suffi cient evidence to recommend this treatment in clinical practice. how the eff ect of azithromycin compares with narrowspectrum antibiotics and whether any long-term eff ects are associated with recurrent use need to be investigated. we are keenly aware of the potential ecological issues relating to use of antibiotics in terms of bacterial ecology and resistance. macrolide resistance in organisms causing respiratory illness in children is already an issue. future research should establish the choice of antimicrobial treatment and criteria for treatment, taking societal aspects into consideration. we did not identify strong eff ect modifi ers from the objective clinical measures, concomitant treatments, or the microbiological profi le other than the presence of h infl uenzae. our data suggest that the eff ect increases by starting early in the episode. future studies might help to identify specifi c disease phenotypes or biomarkers directing the treatment to specifi c groups of young children. the results of this study identify a potential treatment for a common childhood disease for which better treatment options are needed than are currently available. better treatments might help to alleviate a substantial disease burden for children, families, and society. hb conceived, designed, and carried out the study, acquired, analysed, and interpreted data, and wrote the report. js, blc, and kb contributed to design of the study. js acquired, analysed, and interpreted data and drafted the report. cbp did the statistical analyses. ss and kak cultured and identifi ed the bacteria. tkf identifi ed the viruses. blc, nhv, eb, tmp, rkv, a-mms, hmw, st, hwh, la, and kb collected and interpreted data and wrote the report. all coauthors have contributed substantially to the analyses or interpretation of the data and have provided important intellectual input and approval of the fi nal version of the manuscript. hb has received funds for research and for members of research staff and been paid as a consultant for chiesi. all other authors declare no competing interests. the global burden of asthma: executive summary of the gina dissemination committee report viruses and bacteria in acute asthma exacerbations-a ga² len-dare systematic review variations in pediatric asthma hospitalization rates and costs between and within nordic countries prevalence of asthma-like symptoms in young children practice imperfect-treatment for wheezing in preschoolers association of bacteria and viruses with wheezy 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intermittent inhaled corticosteroids in infants with episodic wheezing chromosome q gene variants are associated with asthma and exacerbations but not atopy in early childhood the copenhagen prospective study on asthma in childhood (copsac): design, rationale, and baseline data from a longitudinal birth cohort study elevated exhaled nitric oxide in high-risk neonates precedes transient early but not persistent wheeze asthma and wheezing in the fi rst six years of life. the group health medical associates eff ect of clarithromycin on cytokines and chemokines in children with an acute exacerbation of recurrent wheezing: a double-blind wheeze in preschool age is associated with pulmonary bacterial infection and resolves after antibiotic therapy nasopharyngeal bacterial colonization during the fi rst wheezing episode is associated with longer duration of hospitalization and higher risk of relapse in young children detection of viral, chlamydia pneumoniae and mycoplasma pneumoniae infections in exacerbations of asthma in children mycoplasma pneumoniae and asthma in children importance of acute mycoplasma pneumoniae and chlamydia pneumoniae infections in children with wheezing azithromycin induces anti-viral responses in bronchial epithelial cells eff ect of clarithromycin on acute asthma exacerbations in children: an open randomized study the eff ect of telithromycin in acute exacerbations of asthma azithromycin for prevention of exacerbations in severe asthma (azisast): a multicentre randomised double-blind placebo-controlled trial is there a role for macrolides in severe asthma? bronchoalveolar cells in children < years old with severe recurrent wheezing airway remodeling and infl ammation in symptomatic infants with reversible airfl ow obstruction randomized trial to evaluate azithromycin's eff ects on serum and upper airway il- levels and recurrent wheezing in infants with respiratory syncytial virus bronchiolitis double-blind study of the eff ectiveness of a broad spectrum antibiotic in status asthmaticus routine antibiotics in hospital management of acute asthma spreading us macrolide resistance copenhagen prospective studies on asthma in childhood (copsac) is funded by private and public research funds all listed on www.copsac.com. the lundbeck foundation, danish ministry of health, danish council for strategic research, and capital region research foundation have provided core support for copsac. we express our gratitude to the children and families of the copsac cohort for all their support and commitment. we likewise acknowledge and appreciate the unique eff orts and teamwork of the copsac research team. steff en lynge jørgensen is thanked for microbiological technical assistance. key: cord- -oq pax authors: morris, chad d.; garver-apgar, christine e. title: nicotine and opioids: a call for co-treatment as the standard of care date: - - journal: j behav health serv res doi: . /s - - - sha: doc_id: cord_uid: oq pax the u.s. is in the midst of an opioid epidemic. at the same time, tobacco use remains the leading cause of preventable death and disability. while the shared biological underpinnings of nicotine and opioid addiction are well established, clinical implications for co-treatment of these two substance use disorders has not been emphasized in the literature, nor have researchers, clinicians, and policy makers adequately outlined pathways for incorporating co-treatment into existing clinical workflows. the current brief review characterizes the metabolic and neural mechanisms which mediate co-use of nicotine and opioids, and then outlines clinical and policy implications for concurrently addressing these two deadly epidemics. screening, assessment, medication-assisted treatment (mat), and tobacco-free policy are discussed. the evidence suggests that clinical care and policies that facilitate co-treatment are an expedient means of delivering healthcare to individuals that result in better health for the population while also meeting patients’ substance abuse disorder recovery goals. healthcare providers have a critical opportunity to concurrently address tobacco and opioid dependence. the policy spotlight on the u.s. opioid epidemic and the dramatic increase in overdose deaths presents an opportunity to bring renewed focus on strategies that potentiate addiction treatment, including nicotine addiction treatment. over-prescription of opioid pain relievers beginning in the s led to a rapid escalation of dependence, a resurgence of heroin use, and arrival of powerful synthetic opioids such as fentanyl which increased % from to . , in , there were , drug overdose deaths in the u.s., and heroin overdoses more than tripled from to . in the face of these dire statistics, smoking is often seen as less harmful and a lower treatment priority than opioids which represent a clear, imminent risk. yet, smoking combustible tobacco products, not opioid use, remains the leading cause of death and disability in the u.s., with at least , dying annually due to smoking-related causes. the general prevalence of current cigarette smoking among u.s. adults is % ( % for men and % for women). smoking is highest among those aged - ( %) and - ( %) . hispanic adults ( %) are less likely to be current smokers compared with non-hispanic black ( %) and non-hispanic white adults ( %). in comparison, smoking prevalence among patients using illicit opioids or who are receiving methadone maintenance treatment is between and %. [ ] [ ] [ ] [ ] [ ] this is an extremely high rate of co-use even when compared to co-use with other illicit drugs or alcohol. for instance, % of heroin users in one study of methadone or buprenorphine treatment used an average of cigarettes or a pack per day. co-occurring tobacco and opioid use creates an additive effect of increasing toxicity and related health consequences across all body systems, leading these users to face unnecessarily high mortality and morbidity. , while the shared biological underpinnings of nicotine and opioid addiction are well-established, clinical and policy implications have garnered limited attention. smoking is a primary risk factor for opioid addiction, and there is ample evidence that co-treatment of tobacco and opioid use leads to better outcomes among those seeking treatment for drug use generally and opioid addiction specifically. this article summarizes the neurobiological and clinical evidence suggesting that there is a clinical and ethical imperative to promote co-treatment models as a necessary standard of care. using both opioids and tobacco may enhance subjective positive effects and satisfaction with drug use, reduce withdrawal symptoms for both substances, and act as a substitution when one drug is unavailable. , co-use leads to the increased use of one or both substances through priming, extending reinforcement, and cross-tolerance, thus making abstinence from either substance more difficult. , , in part, cross-tolerance occurs because combustible tobacco use produces polycyclic aromatic hydrocarbons which induce faster metabolism of opioids through induction of hepatic cytochrome p- a -isoenzymes. while infrequent, this effect can lead to opioid toxicity when patients quit smoking. there is also evidence that past smokers using nicotine replacement therapy (nrt) use opioids at the same level as current smokers. as nrt does not produce polycyclic aromatic hydrocarbons, this indicates additional biological mechanisms of cross-tolerance. these bidirectional priming and tolerance between nicotine and opioids include illicit drugs as well as prescribed use of methadone and buprenorphine. , in addition to cross tolerance, polysubstance use heightens reinforcement because opioids and tobacco similarly stimulate reward pathways including the dopaminergic, cannabinoid, and nicotinic-acetylcholine (nachr) systems. , as a result of these related metabolic and neural processes, smoking increases opioid use, including opioid replacement medication use. at the same time, opioid use including prescription replacement drugs reinforces smoking patterns. , chronic pain is also implicated in co-use of tobacco and opioids. current smoking among persons suffering chronic pain ranges from to %, , and findings suggest that there are no significant associations between smoking status and ethnicity, sex, or age. paradoxically, acute nicotine use is known to have short-term analgesic effects, but ongoing use leads to chronic pain. nicotine initially releases endogenous opioids [ ] [ ] [ ] and potentiates opioid-induced antinociception and activates the pain inhibitory pathways in the spinal cord. [ ] [ ] [ ] chronic nicotine exposure leads to tolerance to this analgesic effect. indeed, ongoing smoking becomes a risk factor for the onset or exacerbation of back pain, sciatica, arthritis, fibromyalgia, and chronic headache. [ ] [ ] [ ] [ ] [ ] nicotine (or perhaps another component in tobacco smoke) may sensitize pain receptors, decrease pain tolerance, and increase pain awareness. prospective cohort studies of adolescents bear this out, demonstrating that smoking early in life causes chronic back pain leading to related hospitalizations, initial opioid use, and potential opioid addiction persisting into adulthood. [ ] [ ] [ ] logically, it would follow that smoking cessation might then be a treatment for chronic pain, , but randomized controlled trials have not substantiated this hypothesis. continued research is needed to further elucidate the complex relationship between smoking and pain. regardless of causality, smokers are at increased risk for chronic pain of higher intensity, increased number of painful sites, and more associated disability and adverse effects on occupational and social functioning. , , [ ] [ ] [ ] smokers have higher pain scores and higher need for opioids during surgery and postoperatively compared to nonsmokers. and studies have found that, in comparison to non-smokers, smokers are more likely to be on opioid pain treatment for longer durations and at higher dosages. higher levels of reported pain among smokers may also be related to elevated levels of depression, and in turn, anxiety and depression heighten the motivation to smoke and increase severity of nicotine withdrawal and pain sensitivity. therefore, there is some evidence that treating psychiatric symptoms will lead to improvements in pain symptoms, which may then potentiate reductions in polysubstance use. there is mounting evidence that addressing smoking and other drug use concurrently leads to improved psychiatric and polysubstance use outcomes. [ ] [ ] [ ] [ ] [ ] [ ] at minimum, research has found that smoking cessation while in treatment has no effect on other drug use outcomes. , encouragingly, meta-analysis of randomized controlled trials of smoking cessation interventions found that individuals who treat their addiction to tobacco and other substances simultaneously are % more likely to sustain their recovery, compared to individuals who do not address tobacco while in treatment from other drugs. as an extension of this meta-analysis, mckelvey and colleagues synthesized the evidence across studies to show the positive impact of smoking cessation on substance use disorder (sud) outcomes. both quitting smoking and smoking cessation treatment interventions had either a positive impact or no impact on substance use outcomes. positive sud impacts included reduced drug use and continued abstinence. in contrast to many healthcare providers' beliefs, patients in treatment for opioids desire assistance with smoking cessation, with % to % of methadone maintenance clients wanting to quit smoking. , the longer patients receive methadone maintenance therapy, the more motivated they become to quit smoking. , [ ] [ ] [ ] due to sud patients' overlapping genetic, neurobiological, and environmental characteristics, similar population level, behavioral, medication, and social service interventions are effective across substance use disorders. but despite the clear benefits of co-treatment and the fact that patients desire to quit smoking, tobacco cessation services remain infrequently offered in sud treatment settings. , less than half of sud treatment centers ( - %) offer tobacco cessation services. , generally, there are an insufficient number of addiction specialists, and among addiction medicine professionals, the majority receive little training regarding integration of tobacco cessation screening, assessment, referral, and treatment into daily practice. there are a number of oft cited barriers to addressing smoking in treatment settings including concerns that agency census levels and completion rates will drop, tobacco users will be less likely to seek addiction treatment, patients are neither interested in tobacco cessation nor able to successfully quit tobacco, patients will relapse to alcohol or drug use if they attempted to quit tobacco, tobacco-free policies will be difficult to enforce, clinicians lack the skills to effectively treat tobacco dependence, and clinicians have too many competing demands preventing attention to smoking cessation. , - also, few treatment agencies have a designated leader or formalized procedures related to smoking cessation services, the ability to prescribe smoking cessation pharmacotherapies, or an existing budget for cessation interventions. historically, many addiction treatment facilities have not only allowed but actively reinforced smoking. healthcare providers continue to widely hold the perspective that smoking cannot be treated concurrently with other substance use. in many cases, smoking is directly or indirectly condoned in treatment settings, with a large proportion of sud treatment providers smoking themselves and smoking with patients while in treatment. , indeed, many patients with sud report that they first began smoking in addictions or other psychiatric treatment environments. additionally, compared to treatment settings where smoking is not allowed, continued smoking in treatment settings is associated with increased opioid withdrawal and cravings, more cigarette use at follow-up, and lower detox completion. , [ ] [ ] [ ] organizational affiliation has also played a role in smoking cessation efforts in sud and other healthcare settings. over the last decade, cessation services in federally qualified healthcare centers (fqhcs) have been reinforced by health resources & services administration (hrsa) tobacco use measures, the ability to bill under the centers for medicare and medicaid services (cms), and the patient protection and affordable care act. in the behavioral health sector, early state intiatives mandating tobacco policy and cessation services for substance disorder treatment facilities , have been reinvigorated on a national level through the efforts of such organizations as the national association of state mental health program directors (nasmhpd), federal substance abuse and mental health services administration (samhsa), smoking cessation leadership center (sclc), and national council for behavioral health (national council). while the cultural shift has been slow, co-treatment of opioids and nicotine addiction among statefunded sud treatment agencies and opioid treatment centers continues to gather momentum. tobacco-free policy facilitators for adequately addressing both tobacco and opioid use include having a lower number of clinicians who smoke, patient incentives, senior leadership support, and ongoing staff training in evidence-based treatment strategies. , tobacco-free policies also heighten clinical effectiveness. ample evidence suggests that tobacco-free campus policies support co-treatment and should be implemented by treatment agencies. , when treatment agencies implement comprehensive tobacco-free policies that include the facility grounds, patients' attitudes about quitting are improved, they receive more tobacco cessation services, and the intent to quit smoking increases. tobacco policies not only support quit attempts, but also prevent the initiation of smoking which is associated with higher odds of drug use relapse. policies can be created by individual agencies or mandated statewide. new york has, among other states, instituted statewide policies among funded sud treatment agencies. , within inpatient treatment settings, neither forced quit attempts, i.e., smoke-free policies, nor smoking cessation treatment interventions negatively affect other drug use treatment outcomes. furthermore, studies show no evidence that smoke-free policies instituted in inpatient treatment settings adversely impact patient census rates. screening, brief interventions, and referral a systematic screening, treatment, and referral structure is necessary to adequately address drug use. in behavioral health treatment settings, screening, brief intervention, and referral to treatment (i.e., sbirt) were originally developed to detect risky substance use and direct providers to intervene early using motivational enhancement strategies. [ ] [ ] [ ] while sbirt has been demonstrated to be effective for risky alcohol use, there is growing yet varied evidence of effectiveness for other drug use. [ ] [ ] [ ] recently, bernstein and d'onofrio made modifications to sbirt, creating a model referred to as stir (screening, treatment initiation, and referral). the primary difference between sbirt and stir is that stir prompts clinicians to initiate pharmacotherapy for illicit opioid or tobacco use during the initial visit. recent studies of stir in emergency departments have demonstrated increased patient engagement and decrease in both tobacco and opioid use. the equivalent of sbirt in tobacco control environments is referred to as the " as" (ask about tobacco use, advise to quit through clear personalized messages, assess willingness to quit, assist to quit, and arrange follow-up and support). , implementation of the as in heterogeneous healthcare settings has been an impetus for greater attention to tobacco use, with brief advice from physicians and other clinicians associated with patients' successful quit attempts. , utilizing the sbirt, stir or the as model, healthcare providers in sud or primary care settings are much more likely to screen for tobacco use, assess, and advise abstinence, but unfortunately are less likely to follow these actions by providing brief treatment, medicationassisted treatment (mat), or appropriate referral. [ ] [ ] [ ] this is a substantial practice gap that has been difficult to narrow. , the infrequency of appropriate referrals and evidence-based treatments point to the necessity of interdisciplinary healthcare teams as physicians are less responsive than other providers (e.g., nurse practitioners and physicians' assistants) to systemic efforts to increase tobacco cessation treatment. additionally, regardless of the screening and brief intervention model employed, establishing a sud patient registry, which includes both opioids and nicotine use, within a practice-based research and/or health care network allows for better data aggregation, patient identification, and stratification to appropriate treatment levels. medication-assisted treatment appropriate treatment across substance use disorders typically involves mat, consisting of a combination of behavioral interventions and medications. the synergistic effects of mat apply as equally to smoking cessation as it does to opioid maintenance treatment. research shows that both tobacco and opioid use treatment should include fdaapproved medications to treat dependence and maximize healthcare utilization. for opioid dependence, methadone and buprenorphine are approved, as well as naloxone for overdose. for tobacco cessation, a combination of behavioral strategies and seven fda-approved medications are the most effective means of quitting smoking. medications plus behavioral counseling lead to tobacco cessation rates of - % compared to unaided quit attempts with a success rate of - %. for the general population, all fda-approved cessation pharmacotherapy improves the chances of smoking cessation at -month follow-up or longer, compared to placebo. a review of reviews found that nrt and bupropion increase the likelihood that a person will be abstinent from tobacco at months post-quit by about %, while varenicline more than doubles the likelihood of abstinence at months compared to a placebo. the eagles study further demonstrated the superior efficacy of varenicline for both psychiatric and non-psychiatric populations and confirmed past findings that there were no significant increase in neuropsychiatric adverse events attributable to varenicline or bupropion relative to nicotine patch or placebo. , for persons abusing opioids or taking opioid replacement medications, the interaction between opioids and nicotine may explain the reduced efficacy of nrt for this population. this is further supported by the finding that the lower the dose of opioid replacement medications taken, the more likely patients are to quit smoking. due to mixed findings regarding the efficacy of nrt for patients in opioid dependence treatment, unless contraindicated or unavailable, bupropion which acts on dopaminergic neurons or varenicline which is a partial agonist of the α β nicotinic acetylcholine receptor will be better first-line options. , [ ] [ ] [ ] this is particularly the case if providers can address general low adherence to taking medication capsules. importantly, clinician training is necessary to ensure that cessation medications are prescribed in combination and at therapeutic dosages meeting individual dependence levels. this is imperative, as treatment failures often result from under-dosing cessation medications. patients should be directed to use combination medications, such as veranicline, bupropion, or long-lasting nrt (e.g., patch) with rescue medication (e.g., nrt gum, or lozenge) to control break-through cravings. , currently, there is a great amount of attention to vaping as a potential harm reduction strategy among smokers. many smokers are using vaping products as the primary means of quitting or reducing smoking. while safer than combustible tobacco use, vaping is not necessarily safe. vaping, as well as smoking, may put individuals at increased risk for respiratory illness and infectious diseases like covid- . the end goal for all patients is abstinence from all nicotine products. electronic nicotine devices (ends) are not fda-approved smoking cessation aids, and the efficacy of these products for long-term abstinence from conventional cigarettes is uncertain. ends may help some smokers quit; however, the data are mixed, with some studies finding that ends users do not completely discontinue combustible tobacco products, resulting in no improvement in health outcomes, , , and others continue ends use indefinitely. similar to nicotine addiction, mat is also the most effective treatment option for individuals who abuse opioids. mat doubles opioid abstinence rates , and should be provided days or longer. all fda-approved medications for opioid use disorder are clinically effective, with opioid agonists (methadone) or partial agonists (burprenorphine) reducing withdrawal symptoms and the addictive effects of illicit opioids. methadone is the most commonly used and studied medication. some medications have been shown more effective, , with buprenorphine shown effective in maintaining treatment engagement and abstinence. more than half of patients addicted to prescription opioids treated with buprenorphine and naloxone reported they were not misusing opioid prescription drugs months after starting treatment. buprenorphine has the advantage of flexible administration, either daily, monthly, or every months, but is limited by what type of healthcare providers is able to prescribe buprenorphine and what number of patients they can treat. extended-release injectable naltrexone, and opioid antgonist, is also approved for treatment of people with opioid use disorder. any prescriber can provide naltrexone following a medically managed withdrawal. there is evidence that naltrexone both reduces cravings from opioids and helps with short-term smoking abstinence, particularly for individuals with depression or alcohol dependence. [ ] [ ] [ ] for both opioid and tobacco use, behavioral treatment components of mat include motivational interviewing (mi) or motivational enhancement techniques which are effective across substance use disorders. , these interventions increase motivation for behavioral change and treatment engagement. during brief mi, non-judgmental, open-ended reflective responses, affirmations and well-timed summaries serve to mirror and reinforce the benefits of behavior change and patients' self-efficacy. once in treatment, contingency management (e.g., monetary reinforcement), cognitive behavioral therapy (cbt), and other variants of cognitive and behavioral interventions are proven treatments. relapse prevention is also necessary to train individuals to mitigate pain, avoid high-risk situations, and practice replacement coping skills. , behavioral strategies might be employed whether individuals are initially seeking treatment for tobacco use, opioid use, or chronic pain. for example, patient pain motivates a large proportion of physician visits, and such visits could provide a "teachable moment" for addressing smoking and pain medications. one study found that, when educated about the relationship between pain and tobacco use, patients seeking outpatient pain treatment were over seven times more willing to consider quitting smoking. it also may be helpful for clinicians to assess the role of anxiety and depression in the intersection of pain, smoking, and opioid use. the "quadruple aim" of the healthcare system is to deliver quality, lower cost healthcare to individuals, and improve the work life of healthcare providers resulting in better population health. , one of the most expedient means of accomplishing the quadruple aim is to address patients' concurrent smoking and opioid use. co-treatment models address the fact that polysubstance use is the norm, not the exception. the majority of adults with sud are interested in quitting smoking and motivated to quit at rates consistent with the general population, but they are not afforded timely, evidence-based treatment options as detailed in the public health service guidelines. as a result, patients may overcome their opioid addiction to then die or have severe health issues which are smoking related. while additional work is needed to better understand how overlapping neural mechanisms contribute to opioid and nicotine addiction, the existing evidence supports co-treatment, buttressed by tobacco-free policies, as a standard of care. screening and brief intervention is one of the three top preventive services in terms of cost savings and the potential to improve overall population health. , moreover, promotion of mat and appropriate referral across addictions (e.g., telephonic services for polysubstance use) hold great promise. multilevel changes are needed to foster co-treatment in sud treatment settings. at an organizational level, the first goal of co-treatment is the denormalization of tobacco use and other nicotine products by implementing and reinforcing a comprehensive tobacco-free policy. as part of a comprehensive policy, all patients who smoke, vape, or are at risk for relapse to nicotine use should be offered mat. to do so, agencies must provide the infrastructure for mat using the standardized as model (or sbirt, stir variant previously described) with the expectation that clinicians ask, advise, and assess for opioid and nicotine dependence simultaneously. there are proven steps toward taking inpatient, outpatient, and residential treatment settings tobacco free and providing mat services. one such resource, the dimensions tobacco free policy toolkit provides guidance, timelines, and templates for written policy and workflow implementation. at a provider level, interdisciplinary staff must be trained in evidence-based practices for engaging patients, assessing use, and providing treatments for both opioids and tobacco. a number of evidence-based resources are available from the university of colorado including tobacco-free treatment toolkits, as and mi video training modules, and interdisciplinary workflow models (https://www.bhwellness.org/resources). these resources detail behavioral interventions and pharmacology, including how medication levels may be affected by tobacco use reduction and quit attempts. providers are further encouraged to take advantage of the resources and model programming continuously updated by the national behavioral health network for tobacco and cancer control (nbhn) (www.bhthechange.org) administered by the national council. nbhn is one of the eight centers for disease control and prevention (cdc) national networks created to eliminate tobacco-and cancer-related disparities. the smoking cessation leadership center is another site with a wealth of archived training opportunities (https:// smokingcessationleadership.ucsf.edu). several states are building on these training resources to additionally offer opioid treatment program opportunities to participate in a community of practice (cop). the cop is a virtual peer learning environment which fosters discussion of barriers and facilitators to care, as well as specific issues such as mat, polypharmacy, treatment planning, billing, and health systems change. a current example is the washington state department of health which funds the tobacco free behavioral health initiative where opioid treatment network staff are invited to receive tobacco treatment specialist training and also participate in a cop. simultaneous opioid and tobacco treatment planning is typically appropriate, and providers will treat tobacco dependence more effectively if it is considered "opt-out" care. all patients will benefit by brief mi interventions to build motivation for treatment. while studies have demonstrated the feasibility of treating nicotine dependence in patients with sud, there is still some debate as to whether tobacco and other sud treatment should be delivered simultaneously or sequentially. there are valid concerns that fewer patients will engage in delayed treatment, but opt-out care is best operationalized as a person-centered, strength-based approach aligned with each patient's motivation, readiness, and available resources. patients should partner with providers to determine to what degree nicotine and opioid use are simultaneously treated. as detailed earlier, standard mat, including proven fda medications, should be utilized during co-treatment of opioids and tobacco. providers should adhere to standards of care for the general population, but be able to tailor the dosage of pharmacotherapy and counseling to sud patients that will typically have high nicotine dependency levels and complex care needs. regarding behavioral strategies, education on polysubstance dependence can be provided in a synergistic manner and readiness to quit nicotine use should be routinely reassessed. the majority of issues polysubstance users face are cross-cutting and the proven behavioral therapies previously discussed are appropriate in varied modalities and formats for opioid or nicotine dependence and can be utilized to simultaneously or independently to address polysubstance dependence. at a minimum, providers can make warm hand-offs to state quitlines at - -quit-now which are available in every state. quitlines offer varied combinations of telephonic counseling, pharmacotherapy, and online and texting resources at no cost. that said, siloed systems and treatment protocols can lead to patient burden, lower quality of care, and non-adherence. referrals to quitlines and other community resources are encouraged. at the same time, agencies should provide treatment onsite employing a collaborative care model, team-based care, patient-centered resources, registries, and other sufficient infrastructure. [ ] [ ] [ ] there are limitations to the extant knowledge base. further work needs to determine if concurrent versus sequential or staged treatment models are most effective, and if this effectiveness differs by type of treatment setting. new technology platforms, accountability mechanisms, payment approaches, and incentive systems for the hardest to reach underserved populations also require testing. that said, pain clinics, behavioral health treatment settings, methadone, and other opioid treatment programs represent opportunities to also address smoking. patients with polysubstance use are largely motivated for co-treatment to overcome addictions which are biologically, psychologically, and socially overlapping. with relatively little additional training and favorable attitudes, interdisciplinary healthcare professionals have the ability to concurrently address two deadly epidemics, opioid and nicotine addiction. conflict of interest the authors declare that they have no conflict of 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title: ectes abstracts date: - - journal: eur j trauma emerg surg doi: . /s - - -y sha: doc_id: cord_uid: sizuef v nan the gertality-score: a feasible and adequate tool to predict mortality in geriatric trauma patients introduction: a large number of prediction models and subsequent outcome scores for trauma mortality have been developed over the last decades. however, feasible scoring systems for the severely injured geriatric patient are lacking. the aim of this study was to develop a new mortality prediction model for severily injured geriatric patients. materials and methods: the german trauma registry was utilized and all geriatric individuals (c years) admitted between and with an iss [ ] c were included. patient and trauma characteristics, diagnostics, therapy and outcome data were gathered. the specific odds of all variables for mortality were calculated. relevant variables were added to the novel gertality-scoring system. subsequently, this score as a sole predictor for mortality was compared with the geriatric trauma outcome score , iss, patient's age and max ais. results: a total of . trauma patients with a mean age of years were included. based on the univariable analysis, the following five variables were included in the gertality-score: age c years, pbrc-transfusion requirements from admission to ward, asa-score c , gcs b , ais c . the values of a given parameter are added to reach the total gertality-score (range - points). the auc found in the novel gertality-score was . , whereas the geriatric trauma outcome score had an auc of . . conclusions: the novel gertality-score is a simple and feasible scoring system that enables an adequate prediction of the probability of mortality in severely injured geriatric patients by using only five specific parameters. references: . champion hr, et al. the major trauma outcome study: establishing national norms for trauma care. j trauma. ; : - . . zhao fz, et al. estimating geriatric mortality after injury using age, injury severity, and performance of a transfusion: the geriatric trauma outcome score. j palliat med. ; ( ) : - . the longer the better! 'extending thawed plasma shelf life to days' introduction: major bleeding is one of the most common causes of death after severe polytrauma. one of the most recent interventions that aims for bleeding control is resuscitative balloon occlusion of the aorta (reboa). this study aims to compare macro-and microcirculatory changes of intraabdominal organs and the lower extremity during the use of reboa. materials and methods: six pigs were anesthesized and received a median laparotomy. the reboa catheter (reliant balloon, medtronic) was inserted via the inguinal artery and occluded in zones , and . the occlusion of the reboa was vizualized with fluoroscopy. the balloon was inflated for min per zone. during this time the local microcirculation was measured with oxygen to see (o c, lea). between each zone the balloon was deflated for min. blood pressure was measured at the carotis artery and the femoral artery. results: baseline values of microcirculation differ significantly among organs. the flow rate is significantly higher in intraabdominal organs (colon . a.u., stomach . a.u.) compared to the extremity ( . a.u., p \ . ). blood pressure measured at the carotic artery increased significantly after inflation of the balloon (p \ . ). this increase depends on the zone of inflation (increase of ? mmhg in zone compared to baseline). the increase of blood pressure after inflation in zone is comparable to the baseline value. the colon is most sensitive to changes of microcirculation whereas the stomach and the extremity are most robust. conclusions: reboa is a new device to control for massive bleeding. different organ systems react differently to the same occlusion of the aorta. the systemic blood pressure does not mirror the local microcirculation of the abdominal organs. during emergency resuscitation with reboa these changes should be kept in mind. none of the authors have any conflicts of interests to declare. investigation of coagulopathies and its relevance with mortality and transfusion rates using thromboelastography in trauma patients introduction: fibrinolysis shutdown after injury is a common and lethal coagulopathic phenotype. patients with polytrauma, especially those with brain hemorrhage, require delayed initiation of prophylactic or therapeutic anticoagulation despite a measurable hypercoagulable state. to understand and modulate the post-trauma coagulation milieu, we assess patients with daily thromboelastography(teg). we hypothesized that persistently high clot strength and low dissolution is associated with thrombotic adverse outcomes in severely injured patients. materials and methods: adult patients with blunt or penetrating injuries admitted to the icu of a level i urban trauma center from jan-jul were included. adverse outcomes were defined as death, ventilator-free-days (vfd) = , acute lung injury (ali), acute kidney injury (aki), and venous thromboembolic events (vte). we assessed trends of clot dissolution (fibrinolysis, ly %) and strength (maximum amplitude, ma) in the first icu days using linear mixed models to account for repeated measures and missing observations. ly % was box-cox power-transformed to approximate normality. significance for pairwise comparisons at each time was adjusted by false-discovery-rate. results: patients: median age -years, % female, iss (iqr - ), % blunt mechanism, median icu days . overall, % developed one or more of the following; %vfd = , %ali, %aki, %vte, %death. ly was persistently lower in patients with adverse outcomes compared to those without (interaction time*adverse_outcomes p = . ), with fdr-adjusted significant differences at icu days and (fig ) . conversely, ma did not differ significantly by adverse outcome status(interaction time*complications p = . , fig ) . conclusions: low clot dissolution, not clot strength, is associated with adverse outcomes in severely injured trauma patients. additional work is underway for earlier identification of sd phenotypes and strategies to mitigate impaired fibrinolysis. introduction: angioembolization (ae) is can be both diagnostic and therapeutic in management of a hemodynamically unstable trauma patient. however, patients who would benefit from ae typically require emergent surgery for their injuries. the critical decision of transferring a patient to the operating room versus the interventional radiology suite can be bypassed with the advent of intra-operative angioembolization (ioae) . while the ability to perform such an intervention was previously limited by the availability of costly rooms termed raptor (resuscitation with angiography, percutaneous techniques and open repair) suites, it has been suggested that using c-arm digital subtraction angiography (dsa) is a comparable alternative. this case series aims to establish the feasibility and safety of ioae. materials and methods: we conducted a retrospective anlaysis of all trauma patients at our level trauma centre who underwent ioae with a concomitant surgical intervention from january to april . results: a total of patients ( . % male, . ± . years, . % blunt) underwent ioae using the c-arm dsa. all but one patient underwent exploratory laparotomy, . % of which underwent an additional surgical procedure (ex. exploratory thoracotomy, orthopaedic). either gelfoam ( . %), coils ( . %), or a combination of both ( . %) were used for embolization. internal iliac embolization was performed in . % of cases ( . % bilateral) and five patients ( . %) required hepatic embolization. ae was successful in all but one case, inferior vena cava filters were placed in . % of cases, and . % of patients required a second ae. the -day mortality was . %. conclusions: our results suggest ioae is a feasible and safe management option in severe trauma patients with the advantage of concurrent operative intervention and ongoing active resuscitation with good success in hemorrhage control. introduction: partial resuscitative endovascular balloon occlusion of the aorta (reboa) is a new concept of aortic occlusion to reduce the ischemic injuries below the occlusion level. it is, however, difficult to determine when the occlusion is partial in a clinical setting. end-tidal carbon dioxide (etco ) is a product of aerobic metabolism and its production is reduced during ischemia and anaerobic metabolism. the aim of this study was to investigate if etco is a good predictor of the degree of aortic occlusion during normovolemia and hemorrhagic shock in a porcine model. methods: nine pigs, - kg, were anesthetized and surgically prepared. then, gradual zone aortic occlusion by %, % and % was induced, during first normovolemia and then controlled hemorrhagic grade iv shock. hemodynamic/respiratory variables, blood gases, aortic/mesenteric blood flow, blood pressure of common femoral artery and etco were measured continuously. oxygen consumption and carbon dioxide production were calculated for each timepoint for correlation measurement to different methods for partial occlusion determination. background: acute appendicitis is one of the most common surgical emergencies worldwide. the aim of this meta-analysis of randomized controlled trials was to compare the safety and efficacy of antibiotic treatment versus appendicectomy as the primary treatment for patients diagnosed to have acute appendicitis. methods: a systematic online search was conducted using the following databases: pubmed, scopus, cochrane database, the virtual health library, clinical trials.gov and science direct. only randomized controlled trials (rcts) that compared antibiotics treatment (a) versus surgical treatment (s) as primary treatment of appendicitis were included. results: eight rcts with . patients were included: in the antibiotics group and in appendicectomy group. higher rate of treatment success was noted in appendicectomy group . % versus only . % in the antibiotics group (p \ . ) (fig. ). follow up period for recurrence was one year in all studies and the recurrence at year was reported in . % ( / ) of patients treated with antibiotics and . % ( / ) of them underwent appendicectomy. moreover, rate of overall were . % in a group and . % in s group (odd ratio . [ . - . ], ci %, p-value: . ) (fig. ) . a longer length of hospital stay was reported among antibiotics group ( . ± . in a group versus . ± . in s group, p . ). conclusions: appendicectomy has significantly higher efficacy rate but higher complications rate when compared to antibiotics treatment. most of the studies included in this meta-analysis conveyed a high risk of bias, hence more well-designed rcts are recommended. introduction: post-operative adhesions are associated with increased risk of morbidity and mortality. up to date no effective measures has been introduced to decrease intra-abdominal adhesions following laparotomy. oxiplex-ap gel has been used in extra-abdominal surgical procedures to prevent adhesions. in the current study oxiplex-ap was tested in a mural animal model to investigate its efficacy in reducing post-surgical intra-abdominal adhesions. materials and methods: forty rats subjected to laparotomy were randomly divided into groups of . a serosa injury was made on the small intestine and three different treatments were applied: simple suture, simple suture ? oxiplexap, and oxiplex-ap only; the last group received no treatment of the injury before closure of the abdomen. all animals were kept alive for days, and a second laparotomy was done to measure the intra-abdominal adhesion by the nair classification. results: at second look laparotomy a significant difference in adhesion was noticed between the simple sutures and simple suture ? oxiplex-ap were the latter had developed less adhesions. there was also a trend towards less adhesion development between the simple sutures and oxiplex-ap only group, with less adhesions in the latter. conclusions: the use of oxiplex-ap was associated with decrease adhesion formation in the current animal model particularly without suturing. further investigations into these findings are needed. introduction: emergency abdominal surgery is known to result in high morbidity and mortality. furthermore, evidence suggests that unplanned admissions to the intensive care unit (icu) are associated with higher in-hospital mortality than those patients with planned icu admissions . the aim of the study was to describe the patient population who required an unplanned admission to icu following emergency laparotomy at the royal melbourne hospital. materials and methods: a single-centre retrospective observational study was performed using prospectively collected data between and . patients who underwent an emergency laparotomy and experienced an unplanned icu admission were included. patients who underwent a trauma laparotomy were excluded from the study. results: emergency laparotomies were performed. of these, ( . %) required an unplanned admission to icu. fourty-two patients ( %) were female, and patients ( %) were aged years and above. sixty-three ( %) were admitted due to single organ dysfunction (clavien-dindo iva). the median time to icu admission was days in patients classified to have experienced clavien-dindo iva, while it was days in patients who experience multi-organ dysfunction (clavien-dindo ivb). thirty-seven patients ( %) were admitted to icu due to complications classified as cardiopulmonary. conclusions: recognising that emergency laparotomy is a high risk procedure, with the elderly patients accounting for the majority of unplanned icu admissions, it is imperative to utilise risk stratification methods to guide optimal peri-operative management. this should result in improved utilisation of critical care resources and overall patient outcomes. introduction: the way of reconstruction following intestinal resection in the emergency settings is still controversial. the question which is better between hand-sewn and stapled anastomosis in trauma and emergency surgery occasionally arises; however, there have been few reports comparing these methods. materials and methods: a record-based retrospective study was performed to compare hand-sewn with functional end-to-end anastomoses in trauma and emergency operations from october to october in one of the largest trauma and emergency centers in japan. the patients who had intestinal resection with functional endto-end or hand-sewn anastomosis in an emergency surgery were included. the patients who had covering ileostomy or colostomy, or who underwent surgery as an elective operation were excluded. the primary outcome is the rate of complication associated with anastomosis. the statistical analyses were performed using a chi introduction: injuries are the fourth leading cause of death in europe. laparotomy is the standard treatment for penetrating abdominal wounds. because of the morbidity and the high rate of negative laparotomies, the nonoperative treatment is effectively developing. the aim of this study is to analyze the complications and the quality of life of the patients after laparotomy for this kind of wounds. materials and methods: a retrospective cohort of patients was studied between and at the laveran military teaching hospital in marseille. one hundred and eighty-six trunk gunshot or stab wound were recorded, including abdominal wounds. thirtyfour patients were managed by laparotomy and included in this study. the patients and their referring general practitioners were contacted to complete missing data and the sf- quality of life score. results: among the patients included, the average age was years and most of them were men. the indication for laparotomy was mainly based on the hemodynamic instability, then according to the results of the computed tomography in case of suspicion of specific lesions: bowel injuries, major vascular injury, mesenteric or mesocolic vascular injury, diaphragmatic injury and intraperitoneal bladder rupture. only laparotomies were negatives. eleven complications after laparotomy were found ( , %), including early (within the days) and late. no complication was found after negative or non-therapeutic laparotomies. the quality of life of the patients after one year is similar to those of the general population. conclusions: the most common indication for laparotomy for abdominal penetrating trauma is hemodynamic instability. the rate of laparotomy complications for penetrating abdominal trauma is similar to those of scheduled surgeries. the quality of life after this care remains unchanged. these results may insist on the fact that the ''gold standard'' treatment for penetrating abdominal injury remains the laparotomy objectives: splenic artery embolization (sae), a routinely used adjunct in the non-operative management (nom) of splenic injuries(si), was widely adopted in trauma about two decades ago. we examined complications that occurred with this modality at a level trauma center over a recent -year period and compared this to the prior years. methods: patients who had sae for si between - were identified. sae complications were noted. splenic abscess, splenic infarction and contrast-induced renal insufficiency were considered major complications. coil migration, fever and pleural effusions were regarded ''minor'' complications. the results were compared with data from a prior study examining similar indices at the same trauma center between and . fishers exact test was used for comparison. results: there were patients admitted with si in the recent period, of which ( %) underwent immediate splenectomy. sae was performed in ( . %) of the patients who underwent nom. of these sae patients, % had a contrast blush and . % were either aast grade or . five sae patients ( . %) had splenectomy for continued bleeding. the overall complication rate was . %. major complications occurred in patients ( . %) and minor in patients ( . %). embolization location in the splenic artery was proximal in . %, distal in . % and in both in . %. there was no association between complications and coil location by logistic regression. differences between the two periods shown in table . conclusion: sae continues to be a useful adjunct in nom of si and has seen increased utilization. complications continue to occur,although fewer minor complications were noted in the second period. no association between embolization location and complications was noted in the recent period. judicious utilization of sae is imperative given the complications that continue to be noted from this procedure. the effect of the time spent in the emergency department on the mortality rates and cause of death in patients who underwent emergent laparotomy introduction: the purpose of this study was to a) examine the effect of the time spent in the emergency department (ed) on hypotensive patients in need of emergent laparotomy and b) to determine the mortality rates and cause of death in these patients. materials and methods: between - , patients were included ( men and women, mean age . years) who underwent laparotomy less or equal to min from ed admission. of the patients, (group ) had a systolic blood pressure (sbp) greater than mmhg and had a sbp less or equal to mmhg. all patients had abdominal injuries with an injury scale score (iss) between and . the in-hospital mortality represented the primary outcome, while secondary outcomes included cause of death and time to death. results: in this study both groups spent a median of min in the ed, but the time from the ed to the operating theatre was shorter in the group ( min versus min). in total, the mortality rate was %, but in the group the mortality was %. the sbp on arrival in the ed was strongly associated with the risk of death. furthermore, we observed significant positive correlation between the probability of death and the time spent in the ed, with an increase of probability of death equal to . % per minute spent in the ed. in both groups the hemorrhage was the commonest cause of death ( %). the results of this study indicate that, in patients with abdominal injuries requiring emergent laparotomy, the probability of death is proportional to both extent of hypotension and the length of time spent in the ed. especially, in patients who were presented with a sbp inferior of equal of mmhg, this probability increased as much as % for each min. despite many advances in trauma surgery, half of hypotensive patients are going to die in the first h. introduction: injury to the pancreas may lead to significant morbidity and mortality. we studied the prevalence of pancreatic endocrine and exocrine functions and evaluated the morphological regenerations in pancreas following partial pancreatectomy. materials and methods: patients with pancreatic trauma were recruited ambispectively from january to december . endocrine functions were assessed at the time of admission and at months follow up with g oral glucose tolerance test (ogtt), serum insulin and c-peptide levels, hba c estimation and exocrine functions were assessed with faecal elastase test. pancreatic volumetry was done with imaging studies at -and -months post discharge. results: twenty patients were studied with a median age of years at the time of injury. all the patients were normoglycemic on admission; only one patient who underwent pancreatic resection developed diabetes mellitus requiring insulin on follow up. patients ( %) were found to have prediabetes by american diabetes association (ada) criteria. patients ( %) had pancreatic exocrine insufficiency. pancreatic volume increment, from mean pancreatic volume of . cm to . cm , was noted in partial pancreatectomy patients. conclusions: overt endocrine and exocrine insufficiency is rare in pancreatic trauma patients. but subsets of patients are biochemically predicted to have higher risks of endocrine dysfunction and exocrine insufficiency. hence, while dealing with pancreatic trauma patients, one should remember the possible metabolic disorders associated and the need for specific investigations. pancreatic volume increment is a new finding which opens up more opportunities for further research. hospital de santo espírito da ilha terceira, general surgery, angra do heroísmo, portugal, hospital de santo espírito da ilha terceira, orthopedics and traumatology, angra do heroísmo, portugal introduction: rope bullfights are traditional events in the azores islands, where a bull is set on the streets, arrested by a rope on its neck. around events happen every year and it is already part of the island's touristic attractions. inevitably, every year, people get injured either from direct trauma with the bull or from falls when trying to escape from the animal. the aim of this study was to characterize the type of injuries that occur in these bullfighting events, as to their incidence, mechanism of injury, anatomical affected area and severity. materials and methods: we prospectively registered all cases of injured people who suffered any type of trauma during rope bullfights and received emergency therapy in the local hospital, between and . results: patients recured to the emergency department, . % female, with mean age of . years. regarding the mechanism of injury, . % occured due to direct trauma to the animal while in the remaining . % resulted from falls during escape or handling of the rope. the most commonly affected anatomical areas were the limbs ( . %) followed by the head and neck ( . %) and thorax ( . %). in , % of the cases, patients suffered from multiple traumas. in . % of the cases the treatments performed were wound care, wound closure and/or symptomatic therapy. in total, patiens were hospitalized, patients required interventions in the operating room ( closed fracture reductions and exploratory laparotomy with splenectomy) and patients were hemodynamically unstable upon admission (hypovolemic shock due to splenic fracture and cet). conclusions: the rare articles published describe the mechanisms of injury associated with bullfights in spanish centers and injuries resulting from wild cow accidents in indian cities. this is the first local descriptive study on the prevalence of traumatic injuries associated to this specific type of rope bullfights. introduction: the two-stage splenic rupture is seldom, its risk is unpredictable and a precise diagnosis of a ct and/or mri imaging unexpectable or unexcludable. generally, and due to our experience and current literature a two-stage rupture occurs within one week after trauma. though dramatic courses after two or three weeks are known. therefore, it is suggested to perform a prophylactic angioembolization in (still) hemodynamically stable patients. materials and methods: a retrospective study in a level-one trauma centre of switzerland did analyse all patients that underwent a prophylactic angioembolisation after an explicit diagnose by ct and/or mri of a splenic parenchymal lesion after trauma between and . further inclusion criteria were hemodynamical stability (sys rr [ mmhg) and missing indication for immediate laparotomy. results: patients ( f, m) with an average age of ± years underwent preemptive angioembolisation after traumatic lesions of the spleen. the ais abdomen was in and in patients. besides a splenic injury patients did also have a kidney injury. the overall iss was ± points. patients suffered additional thoracic or head trauma. in patients the angioembolisation was performed on admission, in on the st, in at the nd and respectively in the rd and th day of. in case an uncomplicated selective embolization of a main duct of the splenic artery was performed. in patients the trouble-free proximal embolization of the splenic artery was done. the average stay was ± . days. no deaths or complications seen due to angioembolisation or splenic rupture. there were no complications or operative introduction: traumatic abdominal wall hernias (tawhs) are uncommon, and the optimal management is debated. tawhs most often result from blunt trauma and are associated with severe intraabdominal injuries. our institutional protocol mandates primary repair only if the patient undergoes laparotomy for other reasons and is without mesh. since , primary repair of lumbar hernias included bone anchors when indicated. we wanted to describe the tawh patients treated operatively during initial hospitalization focusing on injury mechanism, diagnosis, associated injuries, operative techniques, early complications and outcomes. materials and methods: we performed a retrospective, descriptive cohort-analysis of data from the institutional trauma registry from - . all operatively managed tawhs were identified based on ais codes, ncsp codes and relevant key words. results: of the identified patients, ( %) were women. median age was years (range - ). median iss was and patients had iss [ . injury mechanism was blunt except for one explosion. patients ( %) had been in a mvc, and of these ( %) had seat belt injuries. of these patients had a disruption of the muscle from the iliac crest, and one had a hernia through a fractured iliac wing. bicycle falls and fall from height had hernias in the anterior abdominal wall. two meshes were placed, with no known complications. bone anchors (twinfix Ò , mm) were used in patients. no recurring hernias were identified in the patients with routine follow-up ( - months) . conclusions: surgery for tawh is uncommon in our institution. tawh is often associated with severe torso injuries and primary repair is only done when laparotomy for other reasons is indicated. primary suture of the muscle, including use of bone anchors seems to be adequate treatment, as we have identified no recurrences. a longterm follow-up study is warranted for operated and non-operated patients with tawh. a comparison of sub-specialty operative adolescent patient outcomes in adult and pediatric trauma centers introduction: adolescent trauma victims may be treated at either an adult (atc) or pediatric trauma center (ptc). these centers have different resources, surgeon training and overnight in-house coverage. it is not known how outcomes compare with regards to the very small subset of patients that actually undergo a surgical trauma intervention. we hypothesized that presentation to a ptc would yield increased mortality when subspecialty intervention was required and that this would be most pronounced at night when in-house attending coverage is absent at all state ptcs. materials and methods: a review of the pennsylvania trauma outcome study (ptos) database was performed to capture patients aged - who underwent any non-orthopedic trauma surgery. cohorts were created for cranial, thoracic, abdominal or vascular surgery from - . trauma centers were divided as adult level (atc ), adult level (atc ) or pediatric (ptc). groups were created based on time of arrival with am- pm being dayshift and : pm- am being night shift. age, race, mechanism of injury, vital signs, gcs, iss, los and mortality were evaluated. ancova was utilized to control for iss variation. spss was used for all analyses. results: patients met initial criteria. atc s saw more minority patients and more males than other center types. atc s saw an overall older cohort ( . years vs . years in atc and . years in ptc, p \ . ). despite this age difference, presenting systolic blood pressure was lowest at the atc s ( . mmhg vs . mmhg at atc and . mmhg at ptc, p \ . ). iss and triss and overall mortality were not different and this included when grouped by day or night shift. of note, trauma thoracotomy was more likely to be performed at night in adult centers. hospital length of stay was significantly lower for atc ( . days vs . in atc vs and . in ptc). conclusions: adult and pediatric trauma centers see different patients. operative trauma cases are surprisingly low at our state's ptcs and trauma thoracotomy was more likely to be performed at night in atcs than ptcs. broader study is needed to uncover differences in operative care and outcomes. treatment of dislocation of the patella as a result of sports injuries in children. forecast and consequences in adulthood k. furmanova , o. loskutov , a. naumenko medinua clinic and lab, ortopedics, dnepr, ukraine introduction: dislocations of the patella with a rupture of the medial patellofemoral ligament (mpfl) account for - % of acute injuries of the knee joint [ , ] . inadequate therapeutic tactics of these injuries in childhood and youth, as a result of sports injuries, are fraught with complications in the form of the instability of the knee joint, residual deformities and contractures in patients in adulthood [ , ] . materials and methods: in the period from to cases of rupture of mpfl among children aged - years who were involved in sports were observed. the examination included conducting a clinical examination, axial radiography with flexion of the joint at angles of °and °, mri of the knee joint. results: in . % ( cases) the integrity of the mpfl(with a reduced number of sutures) was restored using a yamamoto suture, and in cases ( . %), the autoplasty of the mpfl was performed. excellent medium-term ( years) clinical and functional results according to the ikdc scale were noted in . % of cases, good in . %, satisfactory in . %. in patients ( . %) there was a relapse of dislocation after performing an mpfl suture during the first year after surgery mainly due to noncompliance with the recommendations. conclusions: injury to the knee joint with the patella dislocation in childhood and adolescence, associated with a sports injury is an indication for surgical treatment in order to adequately restore the integrity of the mpfl and prevent disabling complications. our yamamoto suture technique is more optimal for treating young patients with instability of the patella and is recommended for widespread use in pediatric orthopedists due to its undeniable clinical advantages. osteotomy with a defect cm placed cm below tibial plateau. types of fixation have been simulated: plate fixation of only a medial pillar, plate fixation of only a lateral pillar, plate fixation of both pillars, and locking intramedullary nailing. results: in case of plate fixation of only a medial pillar, the injury to an interosseal membrane causes an expressed valgus deformation at axial loading, leading to a reasonable ( . mpa) overload of the fixator in the osteotomy area. the use of a lateral plate leads to excessive loading on an external pillar, while the medial pillar remains unsupported. this causes overloads of the fixator in the osteotomy area ( . mpa). the double plate fixation is typical of the lowest extent of bone fragments displacements ( . mm) . this is a super-rigid type of osteosynthesis, able to cause a stress-shielding syndrome in the adjacent bone. it has been estimated that the method of im nailing is an optimal fixation method, with minimum loading of the fixator ( . mpa) and the best distribution of changed elastic strains in the bone-implant system. conclusions: the mathematical simulation demonstrates that fixation by a medial plate is possible only if support functions of the ligament system and interosseal membrane remained intact. if an injury is a high-energy one, nailing is preferable. introduction: treatment of large bone defects is one of the great challenges in contemporary orthopedic and traumatic surgery. grafts are necessary to support bone healing. a well-established allograft is demineralized bone matrix (dbm) prepared from donated human bone. a recent development is a new fibrous demineralized bone matrix (f-dbm) with a high surface-to-volume ratio. in this study we examine toxicity of an innovative dbm fibers preparation. materials and methods: f-dbm was transplanted to a mm, platestabilized, femoral critical-size-bone-defect of mm in sprague-dawley (sd)-rats (n = ). healthy animals were used as control. after months histology, hematological analyses as well as serum biochemistry was performed. were measured as indicators of free radical exposure. there were no significant differences between the control group and animals receiving f-dbm. hematology as well as biochemistry did not differ between operated animals and control. histologically no evidence of damage to liver and kidney and a good bone healing could be observed in most cases. conclusions: taken together, these results provide evidence for no systemic toxicity of the bone allograft. i have received no significant financial interest, consultancy or other relationship with products, manufacturer(s) of products or providers of services or financial support related to this abstract. • i hereby confirm that my abstract is based on previously unpublished data and that i own the rights to the written summaries of research or observations presented in the abstract, or that i have obtained permission for the acknowledged sources for other excerpts taken from copyrighted works. • in submitting an abstract i hereby agree that the copyright of my abstract is transferred to the european society of trauma and emergency surgery. • i hereby confirm that i will present my abstract at the congress in case it is accepted. sponsor: german institute for cell and tissue replacement (dizg, gemeinnützige gmbh), berlin, germany. intramedullary nailing through suprapatellar approach in distal tibia fractures: a retrospective study evaluating clinical and radiographic results d. bustamante recuenco , a. gómez , j. m. pardo garcía , e. garcía , p. castillón , p. caba doussoux hospital de octubre, madrid, spain, madrid, spain, hospital mutua terrasa, orthopaedics, barcelona, spain introduction: distal tibia fractures (dtf) can be operated either by intramedullary nailing (imn) or by orif with plates. the current literature shows a higher rate of malalignment and consolidation delay with imn when compared to plates. in these studies, an infrapatellar approach for the imn is performed. recent studies show a better alignment in dtf treated with imn by suprapatellar approach, though functional and biological outcomes have not been analyzed yet. our goal is to assess the clinical and radiographic results of the treatment of dtf with imn using a suprapatellar approach. materials and methods: a two-center retrospective study was performed, collecting the cases with dtf treated with suprapatellar imn from / to / . results: a total of patients were obtained, with a mean age of . years. the average follow-up was months. % of the fractures were ao type a, presenting the remaining % intra-articular involvement. patients presented complications, corresponding in of them to superficial infections. as for clinical results, complete mobility in the knee and ankle was obtained in almost all cases. at the radiographic level, a total of % ( ) of distal malalignment cases were detected, defined as more than °deviation from normal axis in the coronal and sagittal planes. most of the fractures consolidated in a period of - months. there were cases of delayed consolidation, from which developed pseudoarthrosis. conclusions: intramedullary nailing through a suprapatellar approach for dtf offers good clinical and radiographic results, with low rates of malalignment and lack of consolidation. more studies are required to compare the results obtained with other fixation methods for these fractures. reference: avilucea fr, triantafillou k, whiting ps, perez ea, mir hr. suprapatellar intramedullary nail technique lowers rate of malalignment of distal tibia fractures. j orthop trauma. ; ( ) : - . the clinical consequences of follow-up radiographs in ankle fractures are unclear and indications for these radiographs are seldom well-defined. routine radiographic imaging in the follow up of patients with an ankle fracture adds to treatment costs, although retrospective studies dispute its usefulness. the aim of this study was to assess if a protocol with a reduced number of routine radiographs would lead to cost savings, without compromising clinical outcomes. materials and methods: a multicentre randomized controlled trial was conducted. patients were randomly assigned in a : ratio to usual-care (consisting of routine radiography at one, two, six and twelve weeks) or reduced-imaging (radiographs only obtained for a clinical indication at six and twelve weeks). functional outcome was assessed using the omas and aaos ankle questionnaires, quality of life was measured with eq- d- l and sf- questionnaires. other outcome measures included complications, pain, the number of radiographs, health perception and self-perceived recovery. costs were measured with self-reported questionnaires results: the study group consisted of participants, of which ( %) received operative treatment. patients in the reduced-imaging group received median radiographs, whilst patients in the usual care group received median radiographs (p \ . ). omas, aaos scores, quality of life, pain, health perception and self-perceived recovery did not differ between groups. we observed complications in the reduced imaging group. this did not differ significantly from the usual care group ( complications p = . ). a significant reduction in radiographic imaging costs was observed (-€ per patient, % ci - to - ). overall costs per patient were comparable ( [ % ci - to ]). conclusions: implementation of a reduced imaging protocol in the follow up of ankle fractures leads to cost savings and more importantly does not lead to worse functional outcomes. results after percutaneous and arthroscopically assisted osteosynthesis of calcaneal fractures w. grün , m. molund , f. nilsen , a. stødle oslo university hospital, orthopaedic department, ullevål, oslo, norway, Østfold hospital, orthopaedic department, grålum, norway introduction: operative treatment of calcaneal fractures using the extensile lateral approach is associated with high rates of soft tissue complications. during the last years there has been a trend towards less invasive fixation methods. percutaneous and arthroscopically assisted calcaneal osteosynthesis (paco) combines the advantages of good visualization of the posterior facet of the subtalar joint with a minimally invasive approach. materials and methods: we conducted a clinical and radiographic follow-up of patients with calcaneal fractures treated by paco with a minimum follow-up of year. there were sanders ii and sanders iii fractures. the mean follow-up period was . months (sd . ). our primary outcome was the american orthopaedic foot and ankle society (aofas) ankle-hindfoot score. secondary outcomes were the calcaneus fracture scoring system (cfss), the manchester-oxford foot questionaire (moxfq), the visual analog scale (vas) for pain and the incidence of complications. radiographs were obtained to evaluate the reduction of the fractures as well as the presence of subtalar osteoarthritis. results: the median aofas score was (range, - ), the cfss score ( - ), the moxfq score . ( - . ). the vas pain score was ( - . ) at rest and . ( - . ) during activity. the böhler angle improved from mean . degrees (sd . ) preoperatively to . degrees ( . ) postoperatively. however, the follow-up radiographs showed subsidence of the fractures and a böhler angle of . degrees ( . ). % of the operated feet showed signs of posttraumatic subtalar osteoarthritis. there were no wound healing complications. two patients were reoperated with screw removal due to prominent screws. conclusions: our results suggest that paco gives good clinical results and a reduced risk of complications in selected calcaneal fractures. prospective longterm studies will be necessary to better evaluate the potential advantages and limitations of paco. with the nascent state of microsurgical services in the region the application of negative pressure wound therapy (npwt) has proven to be very helpful. an improvised npwt has made it locally available to patients. this report aims to show how this has improved the management of open fractures of the lower limb in a resource restricted setting. materials and methods: a -month review of cases of lower limb open fractures managed at a regional trauma centre in nigeria was done. the type of wounds were classified based on region and need for soft tissue coverage. results: a total of cases were reviewed approximately % of these case were gustilo and anderson type iii. of these had npwt as part of their management. some of the benefits of observed were; reduced frequency of wound dressings, and shorter time to optimize wound for closure. conclusions: the locally improvised npwt has proven to be an affordable and cost-effective tool in the management of open lower limb fractures. it remains an invaluable alternative of care in the absence of microsurgical skills and patented device with are far from reach owing to financial constraints. references: . hussain a, singh k, singh m. cost effectiveness of vacuum assisted closure and its modifications: a review. isrn plast surg. ; : - . . isiguzo c, ogbonnaya i, uduezue a. modification of negative pressure wound therapy in the economically constrained region: a preliminary report. vol. , nigerian j plast surg. joytal printing press; . p. - . . mba u, nevo a. challenges of limb salvage in a resource limited environment: case report and review of literature. niger j plast surg. ; ( ): . . novak a, wasim sk, palmer j. the evidence-based principles of negative pressure wound therapy in trauma and orthopedics. open orthop j. ; : - . introduction: lower extremity vascular trauma may result in limb loss or mortality. this study examined outcomes of lower extremity vascular trauma (levt) and potential associations to amputation/mortality. materials and methods: a retrospective cohort study of patients (n = ; limbs) with levt between and in a single trauma center. only patients requiring a vascular procedure were included. data were extracted from the swedish vascular registry (swedvasc) and the swedish trauma registry (swetrau). results: mean age ± years; men % ( / ); trauma mechanism % ( / ) blunt and % ( / ) penetrating. % of patients underwent preoperative cta; % of patients ( / ) were transferred to hybrid operating room. arterial injury was present in / limbs ( %) and venous injury in / limbs ( %). the most frequently injured artery was popliteal artery ( / ; %) followed by superficial femoral artery ( / ; %). most common vascular operative procedure was arterial bypass/interposition graft ( / ; %). a vascular shunt was used in % of cases ( / ). fasciotomy was performed in % ( / ) of limbs. four patients were lost to follow-up after less than five days. there were eleven limbs ( / ; %) amputated within -day postoperative follow-up. all amputations were caused by blunt trauma. % ( / ) of arterial injuries below-the-knee led to amputation. thirty-day mortality rate was . % ( / ) . univariate analysis showed that fractures (p \ . ), soft tissue injury (p \ . ), multiple injuries (p = . ), and blunt mechanism (p \ . ) were associated with amputation and mortality after levt. conclusions: this study showed that amputations after levt are caused by blunt trauma. also levt combined with fractures, soft tissue injury, or multiple injuries increased the risk of amputation and mortality. multi-center study enabling multivariate analysis to adjust for potential confounding factors is imperative to confirm these findings. incidence, treatment and financial burden of tibial plateau fractures in belgium between and describe the incidence, evolution in management and financial burden of tpf in belgium between and . we compare national data with data from uz leuven (uzl), the largest university hospital in belgium. materials and methods: this study includes all tpf treated in belgium between and . we identified . tpf, of which fractures were treated in uzl. despcriptive statistics were used to analyze the data. results: the annual incidence increased from . to . / , /y. an increase in number was true for both operatively treated patients (otp) and non-operatively treated patients (notp), but was more pronounced in the latter ( % vs. % increase). the rate of surgery (ros) decreased from . % to . %. the mean ros for uzl was . %. the total financial burden in belgium increased with %, mainly driven by increasing costs in otp. hospitalisation rates for notp decreased from % to %, as day hospital admission occured more commonly. the mean hospitalisation cost was € , for otp and € , for notp. costs for uzl inpatients were € , and € , . nursing days accounted for % of the cost in otp and % in notp. the mean los was . days for otp and . days for notp. uzl patients had a mean los of . and . days. conclusions: tpf are associated with increasing hospital related healthcare costs. as nursing days determine the majority of the financial burden, measures should be taken to avoid prolonged los. introduction: rotational malalignment (rm) is a common postoperative complication after intramedullary (im) nailing of tibial shaft fractures. computed tomography (ct) is commonly used for detection of malrotation, however reliability is frequently questioned. the purpose of this study is to evaluate the intra-and inter-observer reliability of low-dose protocolled bilateral postoperative ct-assessment of rotational malalignment after im nailing of tibial shaft fractures. materials and methods: a total of patients were prospectively included with tibial shaft fractures that were treated with imn in a level-i trauma center. all patients underwent postoperative bilateral low-dose ct-assessment (effective dose of . - . mgy) as per hospital protocol. four observers performed the validated reproducible measurements of tibial torsion in degrees, based on standardized techniques. the intra-class coefficient (icc) was calculated to evaluate intra-and inter-observer reliability. the intra-and inter-observer reliability was categorized according to landis and koch. results: intra-observer reliability for quantification of rotational malalignment on postoperative ct after imn of tibial shaft fractures was excellent with . ( % ci = . - . ). the overall inter-observer reliability was . ( % ci = . - . ), also excellent according landis and koch. discussion and conclusion: first, bilateral postoperative low-dosesimilar radiation exposure as plain chest radiographs-ct assessment of tibial rotational alignment is a reliable diagnostic imaging modality to assess rotational malalignment in patients following imn of tibial shaft fractures and it allows for early revision surgery. second, it may contribute to our understanding of the incidence, predictors, and clinical relevance of postoperative tibial rotational malalignment in patients treated with imn for a tibial shaft fracture, and facilitates future studies on this topic. the trauma emergency laparotomy audit (tela) t. collaborators , m. marsden , p. vulliamy , r. carden , o. najiuba , n. tai , r. davenport tela collaboration, natric, n/a, united kingdom, queen mary university of london, centre for trauma science, london, united kingdom introduction: mortality for shocked trauma patients undergoing emergency laparotomy remains unchanged for years. the tela study aimed to describe the contemporary peri-operative management and patient outcome following abdominal injury. materials and methods: a prospective multicentre observational study of all patients undergoing emergency abdominal surgery within h of injury was performed in the uk and ireland for six months from the st january . shock was defined as the receipt of blood transfusion, with clinical or biochemical evidence of hypoperfusion. results: the study included patients from hospitals, of whom ( %) were shocked and received a median of units red blood cells. shocked patients were more likely to have a blunt mechanism of injury ( % vs %, p \ . ) and had a % mortality ( / ). half of these deaths occurred in the operating room (or). patients that died were more severely injured (injury severity score (iqr - ) vs (iqr - ), p = . ) and had a greater degree of shock at hospital arrival (base deficit . (iqr . - . ) vs . ( . - . ) , p \ . ). processes of care were equivalent or better among non-survivors, with a higher proportion of patients that died undergoing laparotomy within min of arrival in the emergency department ( % vs %, p = . ) and a lower proportion receiving crystalloid in the or ( % vs %, p \ . ). however, delays to achieving definitive haemorrhage control and delivering balanced blood transfusion ratios were observed among both survivors and non-survivors. conclusions: damage control resuscitation principles are followed most closely in patients that die. despite better processes of care, in shocked patients died in this study justifying the continued search for novel therapeutic approaches. pre-operative temporary haemorrhage control and pharmacological mitigation of the effects of shock may be productive avenues of research to improve patient outcomes. introduction: tranexamic acid (txa) has been shown to reduce mortality in bleeding trauma patients, with greater effect if administered early. normally administered intravenously, txa can also be administered intramuscularly, which could be advantageous in low resource and military settings. intramuscular use has only been tested in healthy patients, and it is likely that shock will reduce intramuscular uptake. materials and methods: in a prospective experimental study norwegian landrace pigs ( - kg) utilised in a surgical course in haemostatic emergency surgery were subjected to various abdominal and thoracic trauma. after h of surgery the pigs were injected with mg/kg txa either intravenously or intramuscularly. blood samples were drawn at , , , , , , and min. the samples were centrifuged and analysed with liquid chromatography-mass spectrometry (lc-ms/ms). results: preliminary results from animals in the intramuscular and animals in the intravenous group. mean plasma concentration with sd of txa as a function of time is shown in figure . plasma concentration in the intramuscular group was near ug/ml min after administration, and rose above ug/ml after min. conclusions: plasma concentrations reported to inhibit fibrinolysis in vitro is - . ug/ml ( , ) . if this extrapolates to the clinical situation intramuscular administration would yield plasma levels within the lower end of therapeutic range after min. in ongoing haemorrhagic shock plasma concentrations of txa after intramuscular administration were considerably lower than after intravenous administration, but within therapeutic range . introduction: fallowing laparoscopic cholecystectomy(lc), patients suffer from postoperative pain, especially in the abdomen. intraperitoneal local anesthesia (ipla) reduces pain after laparoscopic cholecystectomy(lc). acute cholecystitis(ac)-associated inflammation, increased gallbladder wall thickness, dissection difficulties, and a longer operative time are several reasons for assuming a benefit in pain scores in urgent lc with ipla application. the aim was to determine the postoperative analgesic efficacy of high-volume lowdose intraperitoneal bupivacaine in urgent lc. materials and methods: fifty-seven patients, american society of anesthesiologists(asa) physical status i or ii were randomly assigned to receive either normal saline(group a) or intraperitoneal bupivacaine(group b) at the beginning or at the end of the surgery in urgent lc. the primary outcome was the scores of postoperative pain by visual analogue scale score (vas) after surgery. results: postoperative vas scores at st and th hours were significantly lower in group b than group a (p \ . ). postoperative vrs scores at st, th and th hours were significantly lower in group b than group a (p \ . , p: . , p: . ). anelgesic use was significantly higher in group a at st postoperative hour than group b (p \ . ). shoulder pain was significantly lower in group b than in group a (p \ . ). patient satisfaction was significantly higher in group b than in group a (p \ . ). conclusions: high-volume low-concentration intraperitoneal bupivacaine instillation resulted in better postoperative pain control along with reduced incidence of shoulder pain and analgesic consumption in comparison to control group in urgent lc. introduction: in-hospital resuscitative thoracotomy is an established procedure for patients with penetrating cardiac injuries. the survival rate is dismal in patients with cardiac arrest prior to admission. prehospital resuscitative thoracotomy (prt) was introduced by the london hems with the highest published survival rate of %. we aimed to identify the number of patients who could potentially benefit from prt in our major trauma center catchment area. materials and methods: data from to were collected from the institutional trauma registry and electronic records. we included patients [ years, with penetrating cardiac injury, or penetrating chest trauma and cardiac arrest, or penetrating chest trauma and sbp \ mmhg. commonly used criteria for prt are tamponade with cardiac arrest lasting \ min at the time of ambulance arrival and with [ min remaining transportation time to hospital. results: cardiac injury was found in of included patients. of these , arrived at the hospital with signs of life and survived. of the patients who died had tamponade. criteria for prt were not met in of patients with tamponade. two patients could have been eligible for prt. one patient was found in oslo with cardiac arrest lasting min. the patient had multiple stab wounds to the chest and had several perforations of the right atrium, not technically manageable in a prehospital setting. the second patient was injured outside our primary catchment area and arrested with prehospital personnel present. prt was performed and the tamponade relieved, but compression of the aorta was necessary. the patient was declared dead shortly after hospital admission. conclusions: in years in a population of . million, two patients met london hems criteria for prt. prt was performed in one patient who was declared dead shortly after hospital admission while one patient suffered from injuries which are unmanageable in a prehospital setting. isolated tissue injury leads to fibrinolytic shutdown, tpa resistance and alterations in clot structure in a porcine model introduction: trauma-induced coagulopathy includes a spectrum of hypo-to hypercoagulable phenotypes with differing levels of fibrinolysis and tpa sensitivity. fibrinolysis shutdown is associated with increased late mortality and shown in small animal studies to be driven by tissue injury. utilizing a novel method of clot structure analysis, we hypothesize that isolated tissue injury provokes fibrinolysis shutdown, tpa resistance and is associated with altered clot structure resulting in enhanced clot stability. materials and methods: all male pigs (n = ) underwent anesthesia, intubation, femoral artery cannulation and mini-laparotomy. tissue injury (n = ), was inflicted with bilateral chest wall muscular cutdowns and bilateral femoral fractures using a captive bolt pistol. mean arterial pressure was maintained at [ mmhg. timed blood samples analyzed using tpa challenged and citrated native teg to evaluate tpa resistance and fibrinolytic shutdown respectively. after mm punch biopsy induced splenic injury, clot was collected, washed, and chemically fractioned by strong cation exchange chromatography. tandem mass spectrometry and bioinformatic analysis were used to evaluate clot structure and factor xiiia cross-linking patterns and covalently associated proteins. results: tissue injury pigs showed increased tpa resistance (change tpa-teg ly : - . % vs - . % p = . ) and a trend of fibrinolytic shutdown evidenced by teg compared to control (fig. ) . splenic clot structure analysis demonstrated altered clot structure (fig. ) and identified elevated levels of protease inhibitors such as alpha macroglobulin and alpha antiplasmin at h post tissue injury compared to baseline. conclusions: in a porcine model, isolated tissue injury provokes fibrinolysis shutdown and tpa resistance resulting in altered clot structure with an increased incorporation of anti-protease proteins resulting in enhanced clot stability. there is a high incidence of rotational malalignment after intramedullary nailing of tibial shaft fractures: a prospective cohort series of patients n. j. bleeker amsterdam medical centre, flinders university, department of orthopedics and trauma surgery, amserdam, netherlands introduction: intramedullary nailing (imn) is the treatment of choice for most tibial shaft fractures due to its minimalistic surgical approach, superior fracture healing, and rapid recovery. however, an iatrogenic pitfall is rotational malalignment (rm). the aim of this prospective cohort study was to determine the incidence of rm and to evaluate the efficacy of protocolled bilateral postoperative computed tomography (ct) assessment of rotational tibial alignment. materials and methods: between and we prospectively included patients ( male ( %)), with a mean age of years, with a unilateral tibial shaft fracture. as per hospital protocol, patients underwent a routine low-dose bilateral postoperative ct to assess rm. forty-two patients ( %) suffered open injuries; ( %) were involved in a multi-trauma sustaining more than one injury. according to the ao/ota classification, there were simple ( %), wedge ( %), and complex fractures ( %). fracture location within the tibial shaft varied with six patients ( %) being within the proximal third, ( %) middle third, and ( %) distal third. there were segmental ( %) fractures that involved more than one third of the tibia. results: fifty-five patients ( %) had post-reduction rm including patients ( %) between °- °, seven patients ( %) with a rm between °- °, and two patients ( %) with a rm greater than °w hen compared to the uninjured side. of the patients with rm, the tibia was externally malrotated in patients ( %). three patients ( % of cohort or % of those with rm) underwent revision surgery to correct the rm as detected on ct scan. conclusions: this study reveals a high incidence of rm following tibial nails ( %) with a surprisingly low revision rate ( % of those with rm). a subsequent study should aim to assess clinical relevance of rm in terms of functional outcome and gait analysis. for now ctrotational-profiling provides a platform for early recognition and correction of rm secondary to tibial imn. level of evidence: therapeutic level ii -prospective cohort study. materials and methods: the tarn database was analysed retrospectively to quantify the number of trauma team activations, patients with major trauma (mt), causes of injury, and subspecialty-specific trauma procedures. crude and risk-adjusted mortality rates, observed to expected (o/e) mortality ratio, and risk-adjusted rates of survival from mt were also calculated. results: the number of trauma team activations has risen by a factor of . the predominant injury mechanism that resulted in mt was a fall from less than m. there has been a fivefold increase in the overall number of trauma surgical procedures. orthopaedic surgeons have performed % of trauma procedures, followed by neurosurgeons, oral and maxillofacial surgeons, and visceral trauma surgeons. the rate of trauma laparotomies per consultant fluctuated between . and . per month. a fall from less than m, road traffic accident and a fall from more than m were the three leading causes of death from mt. the overall o/e mortality ratio was . . conclusions: aintree trauma profile has significantly changed since . this change highlights the potential need for a review of how mt services are offered at aintree to reduce the o/e mortality ratio. this may be achieved through more co-ordinated provision of trauma care, prevention, audit and research programmes. the role of visceral trauma surgery should be reconsidered within the context of the surgical patients' needs and demands, and fundamental requirements of the profession. inter-hospital variation in surgical intensity for trauma admissions: a multicenter cohort study l. moore , m. p. patton , i. farhat , p. a. tardif , c. gonthier , a. belcaid , f. lauzier , a. turgeon , j. clément université laval, social and preventive medicine, québec, canada, chu de québec-université-laval, québec, canada, introduction: guidelines for trauma patients are increasingly moving away from surgical management towards less invasive procedures but there is a knowledge gap on how these recommendations are influencing practice. we aimed to assess inter-hospital variation in surgical intensity for trauma patients and identify determinants of surgical intensity. materials and methods: we conducted a retrospective multicenter cohort study based on the trauma centers of an inclusive canadian provincial trauma system. we included adults admitted for major trauma between and . analyses were stratified for orthopedic (n = , ), neurological (n = , ) and thoracoabdominal surgery (n = ). surgical intensity was quantified with the number of surgical procedures during the first h. inter-hospital variation was assessed with the intra-class correlation coefficient (icc) from multilevel poisson regression models. relative risks (rr) were generated to identify determinants. results: moderate inter-hospital variation was observed for orthopedic surgery (icc = . %, % confidence interval [ci]: . - . ) whereas variation was low for thoracoabdominal surgery (icc = . %, % ci: . - . ) and neurosurgery (icc = . %, % ci: . - . ). level iv centers had similar surgical intensity for thoracoabdominal injuries (rr: . , % ci: . - . ) but lower intensity for orthopedic injuries (rr = . , % ci: . - . ) than level i/ii centers. during the study period, we observed a decrease in intensity for neurosurgery (rr for (rr for - versus . , % ci: . - . ) and thoracoabdominal surgery (rr = . , % ci: . - . ). conclusions: the observed inter-hospital variation in risk-adjusted surgical intensity suggests that there may be opportunities for quality improvement in surgical care for injury admissions. a better understanding of how surgical intensity influences clinical outcomes is needed to inform quality improvement activities. pre-hospital injury diagnosis a. easthope , m. marsden , g. grier barts and the london medical school, london, united kingdom, royal london hospital, centre for trauma science, london, united kingdom introduction: accurate pre-hospital diagnosis of a patient's injuries may improve care by facilitating effective intervention at the scene and reducing time to definitive treatment in hospital . we sought to assess the diagnostic accuracy of injuries by london's air ambulance (laa) clinicians and identify conditions in which clinical accuracy may deteriorate. materials and methods: a retrospective review was undertaken of all patients conveyed to the royal london hospital by laa from october for six-months. pre-hospital injury scores, coded using the abbreviated injury score (ais) were compared to hospital discharge ais. patient outcomes were evaluated in the case of underscored injuries. results: during the study period patients were seen and met eligibility. mean clinical sensitivity and specificity was % and % respectively. chest injury identification was most sensitive ( %) and pelvic injury least sensitive ( %). the relative risk (rr) of underscored injuries to the chest, abdomen and pelvis increased with decreasing glasgow coma scale (gcs) peaking at . (iqr . - . ). the average accuracy of injury identification was % with a negative predictive value of %. no overt patient morbidity resulted from a missed, or under-scored injury. all missed injuries were subsequently identified in the emergency department. conclusions: the pre-hospital diagnosis of injuries has reasonable sensitivity and excellent specificity. accurate pelvic injury diagnosis is more challenging than chest or abdomen. with decreasing gcs, the risk of missing injuries increases. clinicians should be aware of the potential for error when treating trauma patients with impaired conscious levels. comorbidities, injury severity and complications predict mortality in severe thoracic trauma: a retrospective analysis from the norwegian national trauma registry of epidemiology, clinical factors and risk factors for mortality of patients with thoracic injuries. materials and methods: adult patients treated for severe thoracic trauma (injury severity ais c ), between and at haukeland university hospital were included. data were extracted from ( ) the haukeland university hospital local trauma registry, and ( ) the norwegian trauma registry. additional data on comorbidities and complications was collected from patient records. the factors age, gender, comorbidities [charlson comorbidity index (cci)], anticoagulant use, injury severity [revised trauma score (rts)], [injury severity score (iss)] and complications [clavien-dindo scale (cds)] were analyzed for being predictive of in-hospital mortality. multivariate logistic regression analyses with backward selection methods were used. results: data of patients were analyzed, of which ( %) patients died. median iss was in the non-survivors (iqr , ) and (iqr , ) in survivors (p = . ). data of patients were used in the risk factor for mortality analysis. two or more comorbidities measured by cci (or: . , p = . ), injury severity measured with the rts (or: . , p = \ . ), and grade c complications on the cds (or: . , p = . ) were significant predictors for mortality. conclusions: severe comorbidities significantly decreased the chances of survival after thoracic trauma. injury severity was also found to be a significant predictor of mortality. physiological injury severity, measured by rts, appeared to be a stronger predictor of mortality than iss after thoracic trauma. finally, severe complications led to considerably higher risk of mortality following thoracic trauma. the psychosocial impact of e-bike accidents and changing values of older patients in the netherlands, a qualitative study s. berben , l. vloet , e. c. t. tan , m. edwards , , a. brants , , , g. olthuis , , , , a. oerlemans , , , , f. haverkamp , , introduction: the mechanical impact of e-bike accidents, increasingly used by older persons, has shown to be higher compared to regular bike accidents. however, the psychological impact of e-bike accidents in older trauma patients, their experiences in emergency and follow-up care, and the possible change in values and beliefs in response to the accident is still unknown. materials and methods: we used a qualitative design and included older patients ( ? years) with a variety of (severe) injuries, who were admitted to the emergency department after an e-bike accident (n = ) and their relatives (n = ). they were interviewed within one month (t ) and after three months (t ) of the date of accident. interviews were transcribed verbatim and analyzed via a thematic analysis approach using an ethical perspective. results: many patients required (in)formal care after hospital discharge. in general patients were satisfied with the provided emergency surgical care, although some patients reported limited and insufficient information on rehabilitation and homecare support. the analysis yielded impaired physical condition, anxiety, increased vulnerability and dependency of care givers as psychosocial impact. freedom impairment, shifting relational autonomy, and confrontation with vulnerability and mortality were reported changes in values. central values as mobility and freedom, vitality and health, social participation and recreation were put under pressure and needed to be negotiated again after the accident in order to decide whether to use the e-bike again. conclusions: follow-up information of surgeons and emergency physicians after initial hospital care for older trauma patients with an e-bike accident shows room for improvement, with more specific consideration for the psychological impact of trauma and changes in values after e-bike accidents. eur j trauma emerg surg. . https://doi.org/ . /s - - - . traumatic subaxial cervical fractures: functional prognostic factors and survival analysis introduction: the main goal of this study is to identify the risk factors for poor functional outcomes and to analyze the overall survival (os) and complications rate in patients with traumatic cervical spinal cord injury (sci) and subaxial cervical fracture (sacf) treated with open surgical fixation. materials and methods: the authors retrospectively reviewed sixtyfive consecutive patients from one single center with traumatic unstable sacf and associated sci treated surgically between and . we exclude cervical fractures with concomitant severe head injury, brachial plexus injury, lumbar plexus injury, superior or inferior limb fractures and patients who were lost during the followup period. statistical analysis using a chi square test, student's t-test and logist regression were used to identify factors associated with poor functional outcomes after surgical treatment. os analyses were performed using kaplan-meier curves. results: the -year survival rate was . %. four patients died in the first days after surgery and , % need a reoperation. the median time from injury to surgery was . days. the complication rate was %, being respiratory failure the most common one. preoperatively, % had an asia \ c. about % of the patients with asia between a-d had improve one or more asia grades. logistic regression analysis show that older age, sacf above c , asia \ c pre-surgery and long time from injury to surgery were related with poor prognosis. the os rate was higher in patients with neurological improvement, without signs of neurogenic shock at presentation and in sacf bellow c . conclusions: our results suggest that sacf should be treated as soon as possible in order to improve the os rates and functional outcomes. older patients, lower asia at presentation and sacf above c are related with worst functional outcomes. introduction: compression fractures of multilevel vertebral bodies are common in children. due to segmental plasticity, several adjacent vertebral bodies are compressed to a lesser degree at each body. plain ap and lateral x-ray is the first diagnostic examination in the emergency department (ed), but a proper diagnosis is often delayed or missed. materials and methods: this is a retrospective, monocentric study in children falling on their back who showed up at the orthopedic ed, between december and september . nine children ( f, m) with an average age of . years were included. trauma occurred playing games and doing sports in all cases. all children were subjected to x-ray, followed by mri scans for doubtful findings on the plain x-ray or persistent mild pain (t , t , t -stir sequences). results: cuneiform vertebral fracture or vertebral body height reduction was diagnosed with x-ray in five vertebrae while mri showed fractures in vertebrae including compression and edema of adjacent vertebrae in the t -stir sequence. therefore only . % vertebral fractures have been detected by plain x-ray. the injured vertebral bodies were so distributed: t n = , t n = , t n = , t n = , t n = , t n = , t n = , t n = , t n = , t n = , l n = , l n = , s n = , s n = . the most involved spine section was between t and t with fractures. conclusions: vertebral fractures are not always related to hyperflexion or forward hinging mechanism. mri showed vertebral compression fractures and the t -stir sequence showed edema as post-traumatic evidence that had not been detected by x-ray. in absence of a radiologically visible lesion, the persistence of pain should be investigated by performing mri scans. the middle thoracic spine level appeared to be the most involved one in pediatric vertebral fractures. introduction: occipitocervical fixation (ocf) is an effective surgical method to treat various craniovertebral junction (cvj) pathologies. a rigid fixation achieved from ocf displaces other techniques of cvj stabilization unfortunately during procedure deep and wide wound is performed. aim of this study is to share our experience in ocf and lately performed percutaneous ocfs with intraoperative ct guided navigation system. materials and methods: of patients who underwent ocf were performed percutaneously. o-arm ct scans were used to illustrate and measure radiologic parameters. screws were implanted in c lateral masses ( ) , isthmus of c ( ) and c pedicles ( ) and assessed according gertzbein robbins (gr) in modification of bredow classification from a to e. results: a total screws were implanted, of them was performed in open surgery and percutaneously. outcome in gr classification for screws implanted in open surgery was: a ( , %), b ( , %), c ( , %), d ( , %) and e ( , %) while in percutaneous: a ( , %) and b ( , %) . in open surgery one screw was revised. conclusions: percutaneous occipitocervical fusion seems to be a good option to achieve desirable effect in cervical pedicle screws implantation. during procedure whole nuchal muscles are preserved. ct guided surgery and microscope view are necessary to perform percutaneous ocf. introduction: studies have found higher risk of traumatic deaths in rural areas in norway combined with a paradoxically decreased prevalence of severe, non-fatal injuries ( ) . this study investigates the risk of fatal and non-fatal injuries among all adults in norway in the period - . materials and methods: all traumatic injuries and deaths among persons with residential address in norway from - were included. data was collected from the norwegian patient registry and the norwegian national cause of death registry. all cases were stratified according to six groups of centrality based on statistics norway's classification of centrality . mortality-and injury rates was calculated per , inhabitants per year. results: the mortality rate differed significantly according to the levels of centrality (p \ . ). the mortality rate in the most urban group ( ) was . and in the most rural group ( ) . . the lowest mortality rate was found in centrality group ( . ). there was an increased risk of death between centrality group and group with a relative risk of . (ci: . - . , p \ . ). the most common cause of death was transport injuries, self harm, fall injury and other external causes. the highest urban-rural gradient was seen in transport injuries with a relative risk of . (ci . - . , p \ . ) comparing group to group . group had the lowest risk of nonfatal injuries ( ) and group the highest ( ). the risk of nonfatal injuries increased with higher grade of rurality, comparing group and revealed a relative risk . (ki . - . , p \ . ). conclusions: the more rural the higher risk of traumatic deaths and non-fatal injuries. transport injuries had the highest urban-rural gradient. references: . bakke hk, hansen is, bendixen ab, morild i, lilleng pk, wisborg t. fatal injury as a function of rurality-a tale of introduction: virtual fracture clinics (vfcs) are an alternative to conventional fracture clinics for management of musculoskeletal injuries. they have been shown to be a safe and effective model for upper and lower limb injuries. there is limited data to support their use for specialist thoracolumbar fracture follow-up. materials and methods: lean methodology including process mapping was applied to identify a safe virtual alternative for the pathway. first cycle analysis of consecutive referrals to a traditional specialist thoracolumbar fracture clinic. second cycle analysis of consecutive referrals six months after introduction of a vfc. results: mean time to first outpatient review in first cycle was days. referrals led to booked outpatient appointments and were missed ( % non-attendance). % of referrals had or more scheduled appointments. / were ao type a - and all of these received non-operative treatment. / were ao type a or b and of these received non-operative treatment. patient received operative stabilisation (ao type b). process mapping identified two pathways-virtual review with advice letter and physiotherapy referral (outcome a-ao type a - ) or face to face review (outcome b-ao type a or b). mean time to outpatient review in second cycle was days. / received outcome a. / ( %) made a telephone call for advice and only / ( %) asked for a face to face appointment. / received outcome b and all were discharged after one visit. patients in cycle required operative stabilisation. statistically significant reduction in number of scheduled face-to-face reviews ( versus ; p \ . ) and mean time to first review ( days versus days; p \ . ). conclusion: virtual thoracolumbar fracture clinics are a safe and clinically effective alternative to traditional fracture clinic models. lean methodology can be uses to extend virtual clinic pathways to specialist trauma clinics. treatment prognosis of cases of fragility fracture of pelvis m. yoshida fujita health universityhospital, emergency, aichi, japan introduction: the number of cases of fragility fracture of pelvis in the elderly has been increasing in recent years, but there are still not enough reports of surgical treatment as a treatment method, but there is still no certainty how to treat. so we investigated prognosis of cases of fragility fracture of pelvis. materials and methods: subjects were fragility fracture of pelvis treated at a single center from april to april , males, females, average age ± . years. only cases that had ct scan were included. we examined rommens classification, the presence of injury, presence of hip implants, functional prognosis, and -year mortality. results: the breakdown of rommens classification is type ia cases, ib cases, iia cases, iib cases, iic cases there were cases of iiia, cases of iiic, case of iva, cases of ivb, and cases of ivc. surgical treatment was indicated in cases ( . %) (iic case, iiia cases, ivb cases, ivc cases) there were cases ( . %) with no injury mechanism and cases ( %) with hip implants. cases ( %) were able to follow up for more than year including telephone surveys, and . % of them did not recover to functional level before injury. the one-year mortality rate was . %. conclusions: in the cases studied here, cases ( . %) were indicated for surgery. the prognosis and mortality rate are almost the same as those reported overseas, and as with proximal femoral fractures, there is a possibility that it may be greatly involved in adl decline in the elderly. we think that further study is needed in the future. conclusions: patients with a femoral neck fracture who received a hip hemiarthroplasty and used anticoagulation had no significant longer delay to surgery and had a higher mean loss of hemoglobin points. as a clinical consequence of this, more packed cells were supplemented. also more postoperative hematomas were found in the population with anticoagulation. no differences were found in mortality rates at -days and one year. results: on all eight patients the easy-approach was applied without adverse events. in four cases the plate osteosynthesis was done completely endoscopically with excellent results for the patients regarding pain relief and scar development. in the remaining four cases the endoscopic stabilization was not performed for the following reasons: in the first overall case primarily only the endoscopic approach was planned. in the fourth overall case, ventilation showed high end-expiratory co -levels after endoscopic situs preparation, so we converted to the open plating. in the fifth overall case, the easyapproach was applied to evacuate a retrosymphyseal hematoma in a patient with a stable pubic rami fracture. in the eighth overall case, the anterior pelvic ring injury was a bilateral multifragmentary pubic rami fracture in combination with a disruption of the symphysis. after endoscopic situs preparation with clipping of the corona mortis vessel, reduction of the displaced symphysis could not be done endoscopically. conclusions: we demonstrated that the endoscopic plate osteosynthesis of the anterior pelvic ring is feasible with existing standard laparoscopic instruments. the evaluation of the easy-approach in the clinical setting is going on, while the development of suitable reduction tools is one major goal of future studies. introduction: retrograde intramedullary pubic ramus screw fixation is less invasive method and biomechanically stable compared to the plate fixation. the purpose of this study is to examine the feasibility of screw insertion using computed tomography (ct). materials and methods: we analyzed sixty ct data ( cases in male and female each). by using ct analyzing software, the virtual column with . mm diameter was inserted so that we analyzed the feasibility of the screw insertion. and the intramedullary diameter of the pubic ramus at the parasymphyseal area, base, and acetabulum were measured. results: the virtual . mm diameter screws could be inserted in % ( / ) in male and . % ( / ) in female. the cause that screws insertion was impossible was penetration to the hip joint in all cases. the screw inserting point was . mm and . mm from the medial border of the pubic symphysis and . mm and . mm from the upper border of the pubic symphysis in male and female respectively (p [ . ). the intramedullary diameter of pubic ramus was . mm, . mm and . mm at parasymphyseal area, . mm, . mm and . mm at the base of pubis, and . mm. . mm and . mm at the acetabulum in male, female who had the screw corridor and female who didn't have the screw corridor respectively. the diameter of the pubic ramus of the female who didn't have the screw corridor was significantly small compared to male and pubic ramus in three measuring points (p \ . ). , % of the screws were revised. there were no neurovascular or urologic complications. radiographic nonunion was observed in % with a minimum follow-up of months, this correlated with a peri-implant infection (p . ), operation [ months after trauma (p . ) and non-significantly with implant loosening (p . ). there was no correlation of nonunion with patient's age, the fracture mechanism or a non-excellent reduction. in total, . % of the patients were re-operated, in . % a re-osteosynthesis was conducted. conclusions: retrograde trans-pubic screws show good clinical results with lower or similar complication rates compared to alternative methods as plate fixation or external fixator. fracture union did not depend on fracture mechanism or age. hence, this minimal-invasive method is especially attractive in elderly patients with an ffp. because it is an internal fixation of the superior pubic ramus with relative stability, an anatomic open reduction is not necessary to achieve fracture union. the need for extraperitonal pelvic packing -finally confirmed to be vanishing? introduction: the presence of cerebral venous thrombosis (cvt) is increasingly recognized in traumatic brain injury (tbi), but its complication rate and effect on outcome remains undetermined. in this study, we characterize the complications and outcome-effect of cvt in tbi patients. materials and methods: in a retrospective, case-control study of patients included in the oslo university hospital trauma registry and radiology registry from - , we identified patients with cvt (cases) and without cvt (controls). groups were matched regarding abbreviated injury severity (ais) head region score - . cases were identified by ais or icd-code for cvt and a ct/mr venography confirmed to be positive for cvt, whereas controls had no ais or icd-code for cvt and a ct/mr venography confirmed to be negative for cvt. risk of mortality was assessed using multivariate logistic regression adjusting for initial gcs, iss and rotterdam score. results are also reported for subgroups according to cvt location ( fig. introduction: the aims of this prospective cohort study were (i) to identify trajectories of recovery in patients with mild traumatic brain injury (mtbi) during the first two years after trauma and (ii) assess patients and injury characteristics for these trajectories. materials and methods: all adult trauma patients with mtbi (aisseverity or and an injury severity score \ ) who were admitted to a hospital in a region of the netherlands from august to november were asked to complete questionnaires. the questionnaires could be completed at week, and , , , and months and included the euroqol- -d for health status, including a cognition dimension, the hospital anxiety depression scale (hads-d and hads-a for symptoms of depression and anxiety respectively) and the impact of event scale (ies) (for post-traumatic stress symptoms). latent class trajectory analysis was used to determine trajectories of recovery in latentgold . , patient and injury characteristics of the classes were assessed in ibm spss . . results: a total of patients ( % of total) completed at least one follow-up questionnaire. the number of classes (trajectories) ranged from for cognition to for depression. poor recovery classes of cognition and health status consisted of mostly females, patients with low education, higher age, longer length of stay at the hospital and frail patients. the class with full recovery consisted of young patients, with most recovery occurring during the first six months after injury. patients who reported poor health status before injury scored significantly lower health status after injury and showed no recovery over time. conclusions: different recovery patterns were present in patients with mild traumatic brain injury. especially frail elderly patients who reported poor health status before injury have poor outcome up to months after injury. post-concussive symptoms in children and adolescents with traumatic brain injury: a center-tbi study introduction: acute respiratory is associated with high morbidity and mortality. in addition, its etiologies are heterogeneous and the outcome depends on the underlying cause. the aim of the present study is to analyze, whether the mortality of posttraumatic ards is affected ( ) over time, ( ) attributable to geographic distribution, ( ) related to the used definition and ( ) introduction: many factors of trauma care have changed in the last decades. this review investigated the effect of these changes on overall and cause-specific mortality in polytrauma patients admitted to the intensive care unit (icu). moreover, changes in trauma mechanism over time and differences between continents were analyzed. materials and methods: a systematic review of literature on overall mortality in polytrauma patients admitted to the icu was conducted. overall and cause-specific mortality rates were extracted as well as the trauma mechanism of each patient. linear regression on changes in overall and cause-specific mortality rates was performed. results: thirty studies, which reported mortality rates for , observed patients, were included and showed a decrease of . % in overall mortality per year ( fig. ). brain-related death has become more common over the years, whereas multiple organ dysfunction syndrome (mods), acute respiratory distress syndrome and sepsis became less prevalent (fig. ) . mods was the most common cause of death in north america and brain-related death was the most common in asia, south america and europe (fig. a) . penetrating trauma was most often reported in north and south america and asia (fig. b) . conclusions: overall mortality in polytrauma patients admitted to the icu has been decreasing as a result of the improvements in trauma care. a shift from mods to brain-related death could be observed. more research on preventative measures for the latter is required to ensure a further decline in mortality. moreover, we have shown geographical differences in cause-specific mortality, which may provide learning possibilities between similar trauma centers resulting in improvement of trauma care introduction: aim of the current study was to assess an association between trauma patient volume of the intensive care unit and inhospital mortality. materials and methods: from data of the japan trauma databank, this retrospective cohort study selected adult (c y) trauma patients hospitalized in the intensive care unit with the injury severity score of c . after applying a multiple imputation on all the study variables, a logistic regression generalized estimating equation after adjustment for age, sex, mechanism of trauma, and the injury severity score as covariates and hospitals as a cluster assessed an association between quartile of patient volume in intensive care unit and hospital mortality. introduction: quality and content of early fracture hematoma (fh) dictate the healing process in long bone fractures. different reaming protocols for intramedullary nailing (imn) are available. however, the impact of reaming strategies on immune cell characteristics of early fracture hematoma is unclear. we hypothesized that the application of reaming irrigation and aspiration (ria) techniques optimizes cellular content of fracture hematoma. materials and methods: twenty-four pigs underwent standardized femur fracturing. then, animals were exposed to different protocols of imn. group a underwent no reaming prior to imn. group b was treated with conventional reaming plus imn and group c composed of animals treated with ria and subsequent nailing. fracture hematoma was collected h after reaming. fh-immune cells were isolated and studied by flowcytometry. cell viability was tested by annexin-v-labelling. neutrophil activation was determined by mac- /cd bcell surface expression levels, whereas fcyriii/cd -receptor expression was utilized to investigate neutrophil maturation. results: all animals survived the observation period. propertions of white blood cell subtypes in fh did not differ between conditions. however, the percentage of viable fracture hematoma immune cells was significantly higher in the ria-group, compared with conventional reaming (respectively mean . % vs. . %, p = . ). additionally, both neutrophil cd -expression (- %) and cd bexpression (- %) were significantly lower in those animals treated with ria compared with the conventional reaming condition. conclusions: this experimental study reveals that reamed irrigationaspiration (ria) prior to imn is associated with increased immune cell viability and less neutrophil senescence/activation in early fracture hematoma. this underlines the important role of imn in optimizing local cellular immune homeostasis during the formationphase of early fracture hematoma. introduction: the study and determination of the traumatic pattern in bicyclists-delivery employees. the recording of personal protective equipment and evaluation of the selection criteria of their self protection. materials and methods: a total of patients ( men and woman) with mean age of . years ( - years) were included over a study period from january to march . twenty-one patients admitted to the hospital with a total of injuries treated operatively, whereas injuries were treated conservatively. we recorded and evaluated the use of adequate personal protective equipment of these delivery employees. results: the mean hospitalization time was . days ( - days) . a total of thoracic injuries, traumatic brain injuries, spine injuries, lower extremity injuries and upper extremity injuries were recorded. surgical treatment concerned patients with upper extremities and patients with lower extremities injuries and the anatomic regions involved were the distal radius ( ), pelvic ring injury ( ), femoral fractures ( ), tibial plateau fractures ( ), patella fractures ( ), diaphyseal tibial fractures ( ), and ankle fractures ( ) . conclusions: the lack of an adequate personal protective equipment due to their low financial status in combination with the absence of driving professional education among workers in this category of delivery employees results in lower extremity injuries with the majority requiring hospitalization and surgery. further investigation is needed, as well as constant training and setting right criteria for the pursuit of such employment. results: a total of nine rct's ( patients) and the sixteen observational studies ( patients) were included. the pooled nonunion rate did not differ significantly between both treatment groups (risk difference: %; or . , % ci . - . ). more patients treated with nailing required re-intervention (risk difference: %; or . , % ci . - . ) with shoulder impingement being the most predominant indication. more patients treated with pate fixation developed radial nerve palsy compared to nailing (or . , % ci . - . ). notably the absolute risk difference is small ( %) and during follow-up the palsy resolved spontaneously in the majority of patients. nailing lead to a faster time to union (mean difference: . week, % ci . - . ), lower infection rate (risk difference: %, or . , % ci . - . ) and shorter operation duration (mean difference: min, % ci . - . ). functional scores were comparable in both groups (standardised mean difference: - . , % ci - . to . ). there was no difference between effect estimates form observational studies and rct's. conclusion: there appears to be no difference between plate fixation and nailing for humeral shaft fractures with regard to non-union rate and functional outcome. patients treated with plate fixation have a higher risk for infection and radial nerve palsy, but lower risk for reintervention. the absolute differences, however, are small. nailing does differ significantly from plate fixation in terms of shorter operation duration and time to union. the pooled estimates from randomised clinical trials did not differ significantly from estimates obtained from observational studies. post-traumatic complications are more often after medial clavicle injuries compared to lateral clavicle injuries introduction: medial clavicle injuries (mci) are widely unexplored, especially in contrast to lateral clavicle injuries (lci). current research concerning mci assumes a higher severity of mci, e.g. concerning concomitant injuries. our aim is to evaluate by big data analysis if these rare injuries would also lead to a higher number of post-traumatic complications. materials and methods: we focused on the mci subgroup consisting of medial clavicle fracture and sternoclavicular joint dislocation. the lateral clavicle fracture and the acromioclavicular joint dislocation were summarized to the subgroup of lci. the midshaft clavicle fracture was analyzed for comparison. the data are based on icd- codes of all german hospitals as provided by the german federal statistical office. anonymized patient data from to were evaluated. the retrospective analysis addresses the fracture healing in dislocation, delayed union and non-union. results: the proportion of all patients suffering from complications was . %, which were attributed to one of the three post-traumatic complications. each complication rate for the single injury and the single complication was rather low with a maximum of %. mci were more likely to be affected by post-traumatic complications than lci with a ratio of . to . times (p \ . ). the midshaft clavicle fracture was similarly frequently affected by complications with . % of all complications as the mci ( . %). the lci accounted for the smallest proportion at . %. conclusions: we proved that mci are more often associated with post-traumatic complications than injuries of the other parts of the clavicle. this is another hint that mci appear to be more complex than lci. this could be due to a missing standard procedure and the higher number of concomitant injuries in mci. further representative clinical studies are required since miscoding is a frequent issue in research concerning clavicle injuries, especially in a big data analysis. quantification of trauma center accessibility using gis-based technology introduction: there is no generally accepted methodology to asses trauma system access and optimal geographical trauma center distribution. the goal of this study is to determine the influence of trauma center(tc) distribution during high and low traffic density using geographical-information-system(gis)-technology. methods: using arcgis-pro, we calculated differences in transport time (tt) and population coverage in seven scenarios with , , or tcs during rush [r]-and low traffic [l] hours in a densely-populated region with tcs in the netherlands (fig. ) . results: in the seven scenarios, the population that could reach the nearest tc within (\) min, varied between - % ( fig. ) in the three-tc-scenario, roughly % of the population could reach the nearest tc \ min in [r] and [l] . the hypothetical scenarios with two geographically well-spread tcs showed similar results as the current three-tc-scenario. in the one-tc-scenarios, the population reaching the nearest tc \ min decreased by - % in both [r] and [l] compared to the three-tc-scenario. in the three-tcscenario the average tt increased with about . min to almost min in [r] , in comparison to min during [l] (fig. ) . similar results were seen in the scenarios with two geographically well-spread tcs. in the one-tc-scenarios and the geographically close two-tcscenario the average tt increased by - min [l] and - min [r] in comparison to the three-tc-scenario. conclusion: this study shows that a gis-model for trauma center access offers a quantifiable and objective method to evaluate trauma system configuration in areas with different geography and demography. applying this technology to one of the most densely populated areas in the netherlands shows that the transport time from accident to trauma center would remain acceptable if the current situation with three trauma centers would be changed to a scenario with two geographically well-spread centers. classifying posttraumatic stress disorder courses in physical trauma patients: an observational prospective cohort study introduction: the aim was to identify different courses of posttraumatic stress disorder (ptsd) in physical trauma patients. then, to examine whether these classes could be characterized by sociodemographic, clinical, psychological, and personality outcomes. methods: patients completed the impact of event scale-revised (ies-r), m.i.n.i.-plus after inclusion, , , , and months after injury to examine different courses. the hospital anxiety and depression scale, neo-five factor inventory, state-trait anxiety inventory-trait, and the whoqol-bref were completed after inclusion only. latent class analysis, chi square tests, and anova were performed to analyze the aims. results: in total, patients were included. the mean age was . (sd = . ) and % were male patients. the ies-r (see figure ) and the m.i.n.i-plus had five classes ( : moderately, : little bit, : worse, : none, : quite a bit of ptsd symptoms). patients in class are diagnosed with ptsd (cut-off score c ). on both questionnaires, patients (proportion & %) in class or , scored higher on anxiety, depressive symptoms, neuroticism, and trait anxiety compared to the other classes over months after trauma. lower scores on all domains, except for social domain on the ies-r, were found compared to the other classes (ies-r; physical domain: class vs. (mean ± sd): . ± . vs. . ± . , p-value = \ . ). psychological and personality outcomes were significantly different on all courses. also, patients in class or were younger compared to the other classes (ies-r; class vs. : . ± . vs. . ± . , p-value = \ . ). no medical outcomes for ptsd were found. conclusions: about % suffer from ptsd symptoms months after trauma. different courses were defined by sociodemographic, psychological, and personality characteristics. professionals can, short after trauma, recognize patients at risk for ptsd when they focus on these characteristics. then, an intervention can be offered. six meter, the criterion for severe adult trauma to falls from heights in cdc field triage needs to be lowered introduction: trauma is one of major public health care issue which is costly to society. differences vary from region to region, but blunt trauma accounts for a large part of the total trauma, and the rates of the falls from heights among the blunt trauma is getting higher. it is serious that falls from heights is often accompanied by severe multiple trauma. therefore, authors studied the relationship between the height of the fall/other related factors and outcomes including hospital stay/mortality. materials and methods: retrospective cohort study of the adult falls-from-heights patients visited a regional trauma center for years (from . . to . . ). results: of total patients, the number of d.o.a patients were . the height from falls of the deceased patients was statistically significantly higher than that of the survived patients. ( . ± . m vs. . ± . , p \ . ) the auc of the roc curve of the height from fall to mortality was . . (figure) the sensitivity of . m was . % and . m was . %, respectively. the traumatic brain injury, pelvis fracture, visceral organ injury, age, and the height from fall were statistically significant risk factors in multivariate analysis for mortality (p = \ . , . , , , . , and . respectively). conclusions: the height from the fall is closely related with mortality. we think the current height for the severe fall injury in cdc field triage for trauma is high and needs to be lower to . introduction: operative management of severe trauma is a team effort, requiring excellent communication skills. surgeons, anesthesiologists and nurses need to coordinate effectively in order to ensure an excellent clinical outcome. the definitive surgical trauma care (dstc), definitive anesthesia trauma care (datc) and definitive perioperative nurses trauma care (dpntc) courses provide an excellent opportunity to train efficient teamwork. we aimed to study the impact of the joint dstc-datc-dpntc courses in candidates' perceptions and skills in perioperative communication. materials and methods: study population of candidates ( surgeons, anesthesiologists and nurses) participating in a joint dstc-datc-dpntc course in coimbra, portugal. median age of years (range - ). female gender in ( %) of cases. all participants attended joint lectures, case discussions and surgical skills session, emphasizing intraoperative communication. postcourse survey on several aspects of peri-operative communication, with responses on a likert scale. participants were also asked which aspects of intraoperative communication they valued the most. statistical analysis with spps, . (wilcoxon signed rank test, significance with p-value \ . ). results: all participants responded to the survey. results displayed an increase in the self-assessed importance of team briefing and intraoperative communication, particularly routine periodic communication, rather than only at critical moments (p \ . ). postoperative team debriefing was also valued as highly relevant. closed-loop and direct, by-name communication were highly rated (p \ . ). self-reported communication skills improved significantly during the course (p \ . ). conclusions: joint training in the dstc-datc-dpntc courses provides a unique opportunity to improve candidates' self-awareness and skills in intraoperative communication. a public health approach to knife related trauma in liverpool: a geospatial study r. shellien , n. misra , , j. germain , m. whitfield aintree university hospital, emergency general surgery and trauma unit, liverpool, united kingdom, liverpool john moores university, public health institute, liverpool, united kingdom introduction: liverpool is a city that has undergone recent rapic socioeconomic change. despite reductions in overall deprivation, incidents of stabbings have increased by % in the last years. this study will describe the trend in knife crime, drawing on governmental data and policies to conclude the reasons behind the trend. materials and methods: a retrospective cohort study of patients presenting to north-west ambulance service (nwas) with a penetrating injury in liverpool between and . data collected included patient demographics, geography and timing of incidents and correlation to datasets of multiple indices of deprivation and knife crime prevention outreach education programmes. results: incidents of stabbings have increased by % between and . victims were more likely to be males ( %) between the ages of and ( %). the peak rate was between : - : ( . %) and trough between : - : ( . %). there is a spike in incidents of stabbings of - year olds from : to : , correlating with school closure. there appears to be statistically poor correlation between deprivation of lower super output areas and stabbings (r = . , . and . for , and respectively). however, when the data is split into larger areas, middle super output areas (msoas), deprivation appears to be a further risk factor. this study has identified certain geographical areas as high risk. conclusions: this study allows for targeted public health interventions at populations most at risk of knife trauma, including geographical mapping of high-risk areas, so that interventions can be distributed appropriately. references: ministry of housing, communities and local government ( government ( , government ( , introduction: trauma teams treat complex patients with injuries posing significant resuscitative and management challenges. effective teamwork is essential to optimise patient outcomes and improve survival, with failure contributing to adverse events [ ] . the role of multidisciplinary (mdt) trauma training has been demonstrated by the military operational surgical training course (most) [ ] . it is imperative that civilian trauma training adopts similar methodology to optimise team work. materials and methods: the three-day multidisciplinary trauma course comprised cadaveric-based skills teaching supplemented by lectures and real-life scenario discussion. delegates were senior surgical and anaesthetic registrars and consultants, alongside trauma team leaders (ttl), scrub staff and operating department practitioners (odp). pre-and post-course questionnaires assessed perceptions of multidisciplinary trauma simulation and confidence in specialty specific skills. results: all delegates reported mdt simulation clarified each role, including their own, in the trauma team. post-course, scrub staff and odps felt confident gaining intraosseous access (p \ . ), surgical delegates had improved confidence performing all skills (p \ . ), with anaesthetists and ttls more confident in haemorrhage control and performing resuscitative thoracotomy (p \ . ). conclusions: mdt trauma training improves team understanding of role and effectively teaches skills. mdt courses with experienced faculty are one way of improving mdt trauma team function. further careful evaluation is required to assess performance of trauma teams in real scenarios. introduction: despite a dramatic rise in youth knife crime, the factors associated with it remain underexplored, especially in the critical pre-college years, which hinders effective counter-knife carrying interventions. the current research is the first to addresses this deficit. materials and methods: british male school students (mean age = . , sd = . ) coming from four different schools completed a short -min survey. they indicated their standing on a number of dimensions (school-adapted and shortened-scale-based predictors) derived from theories of violence, developmental psychology and related research (i.e. violence acceptance, need for respect, belief in self-defence, belief in a just world, narcissism, psychopathy, impulsivity, sensation seeking, and need for closure). results: for perceived knife harmfulness (i.e., the knife's assumed value in inflicting injury and death)-the total variance explained by the model was . %, r = . ; f( , ) = . . the only statistically significant predictors were: right-wing authoritariamism (b = . , p = . ) and need for respect (b = . , p = . ). the other factors were not statistically significant. for the perceived value of knife defence (i.e., its assumed defensive worth in violent confrontations) -the total variance explained by the model was . %, r = . ; f( , ) = . , pviolence acceptance (b = . , p = . ), followed by need for closure (b = . , p = . ), narcissism (b = . , p = . ) and psychopathy (b = . , p = . ). conclusions: this study provides evidence for future knife-carrying prevention interventions, such as talks in schools or social media videos, to focus more on how to increase self-esteem, stimulate empathy for and better understanding of other people, and approach problems from multiple (rather than just two) perspectives, emphasizing the ultimate superiority of the human intellect over brute force. introduction: the physician's response unit (pru) is a novel service that operates from the royal gwent hospital's emergency department (ed), in newport, south wales. it involves an emergency medicine consultant and a paramedic responding to calls in a rapid response vehicle. their aim is to treat and, hopefully, discharge patients at the scene, reducing ed admissions. the pru can also refer patients on to other departments, e.g. the medical assessment unit, allowing patients to bypass the ed. methods: the author spent six weeks out in the pru and in the ed to observe and speak to patients. to assess whether ed admissions were reduced, the dispositions of patients seen by the pru were recorded on a daily log sheet. the service users' satisfaction with the pru was evaluated using simple questionnaires. this included both patients and paramedics, who can request the pru for support with a patient. results: the pru saw patients during the project's timeframe. % (n = ) of these patients were discharged at scene, while % (n = ) were sent to the ed. % (n = ) of patients asked described the care they received from the pru as equal to or better than care they have received previously. % (n = ) of patients rated their overall satisfaction with the pru as / . conclusions: the pru is very well received by both patients and paramedics and has been shown to reduce the number of patients attending the ed. this system excellently implements the principles of prudent healthcare introduction: in germany reducing alcohol related harms in youth is still a priority, because adolescents and young adults still have the highest accident risk in road traffic. therefore, the p.a.r.t.y.-project aim to increase awareness of alcohol and risk-related issues. the purpose of this study was to analyse the risk behaviour of adolescents before and after a prevention project in two different hospitals in germany. materials and methods: during a one-day prevention project, young people within the age of to years got an overview of the route an accident victim go through from the ambulance until the rehabilitation. before and after the prevention day, a structured written survey was completed by the adolescents. results: students participated in the p.a.r.t.y. program between and . the gender distribution of the participating students were balanced. the average age of the adolescent was years. according to the program, the risk assessment and risk behaviour improved through the project significantly (\ . ). the evaluation of the students' satisfaction was rated as good. the majority of students prefer to repeat the project day after years. conclusions: the prevention program shows that the program increase for short-term the awareness for risk related trauma in youth. nevertheless, long-term studies are necessary to receive data regarding the long-lasting effect. references: the present study is funded by the ministry for energy, infrastructure and digitization of the country mecklenburg-vorpommern, germany. development of a claims-based risk adjustment model for trauma introduction: duodenal injury is rare. the diagnosis requires a high index of suspicion which might result in delayed treatment. there is limited data on the delayed diagnosis group, especially high grade duodenal injuries. the purpose of this study is to determine the characteristics and outcomes of delayed high grade duodenal injuries. materials and methods: charts of all patients from - who had history of small bowel injuries are reviewed. the inclusion criteria were age between - years old, diagnosis with duodenal injuries at least grade with delayed operation at least h after injuries. baseline characteristics and postoperative outcomes were recorded. results: of the small bowel injuries, ( %) were duodenal injuries. the overall mortality was %. delayed diagnosis more than h with at least grade of duodenal injuries were cases. the overall in-hospital mortality rate of the delayed group was . % ( / ) who had concomittent hemorrhagic shock and low initial systolic blood pressure. cases ( . %) were diagnosed within h and had better outcomes without leakage. they could step diet within days and had shorter length of hospital stay (mean = days). patients ( . %) presented with delayed diagnosis more than h (the maximum was h after injuries). all these patients had anastomosis leakage and need reoperation. they had initial low level of serum albumin (mean . mg/dl), high white blood cell count, low serum bicarbonate and presented with preoperative acute kidney injury. conclusions: delayed diagnosis and surgical treatment of high grade duodenal injuries lead to poor outcome. low initial blood pressure associated with mortality and delayed treatment more than h had higher morbidity. references: gary sa, frederick am, charles sc, et al. delayed diagnosis of blunt duodenal injury: an avoidable complication. acs meeting. ; ( ) : - . routine follow-up imaging has no advantage in the non-operative management of blunt splenic injury in adult patients modality. the aim of this study was to investigate the incidence and time to failure of nom as well as to evaluate the relevance of follow-up imaging. materials and methods: all adult patients with bsi admitted to our level i trauma center, including two associated hospitals, between / / and / / were retrospectively analyzed. demographic data, injury severity score, splenic injury grade, modality, results and consequences of follow-up imaging were retrospectively analyzed. results: a total of patients with a mean age of . ± . years ( - years) met inclusion criteria. patients ( . %) underwent immediate intervention. patients ( . %) were treated by nom. failure of nom occurred in patients ( . %). failure was significantly associated with active bleeding (or . , % ci . , . , p = . ) , and liver cirrhosis (or , % ci . , . , p = . ) . patients ( . %) in the nom-group received followup imaging by ultrasound (us, n = ) or computed tomography (ct, n = ). in cases, routine imaging examinations were conducted ( us and ct scans) without prior clinical deterioration. ( . %) of these imaging results revealed no new significant findings. every failure of nom was detected following clinical deterioration. conclusions: to our knowledge this study includes the largest monocentric patient cohort undergoing ultrasound as first-line followup imaging modality in the nom setting of bsi in adult patients. the results indicate that a routine follow-up imaging, regardless of the modality, has no therapeutic advantage. indication for radiological follow-up should be based on clinical findings. if indicated, a ct scan should be used as preferred imaging modality. the association between bmi and mortality of renal injuries in adult trauma patients introduction: the role of body mass index (bmi) on solid organ injuries remains debatable. while some studies have shown no association between bmi and hepatic or splenic injuries, others have reported that severe hepatic injuries were more common in pediatric patients with bmi [ . the aim of this study is to examine the association of bmi and mortality, as well as any significant differences between operative vs. non-operative management. materials and methods: this was a retrospective study using the american college of surgeons-trauma quality improvement program database to identify all adult patients (ages to \ ) with traumatic renal injuries. the primary analysis showed a different pattern of mortality between patients with bmi \ and those with bmi c kg/m . then, the study population was divided into patients with bmi \ and those with bmi c kg/m . multivariable logistic regression was conducted to assess any association of mortality with age, gender, bmi, and injury severity score (iss). results: adult trauma patients were identified. a greater proportion of males ( . %) and females ( . %) had bmi \ kg/m (p = . ). the average age of patients with bmi \ kg/m was . (sd = . ) years which was significantly younger than that in patients with bmi c kg/m , . (sd = . ) years (p = . ). patients with bmi \ kg/m were found to have a significantly higher mortality rate of . % vs. . % in patients with bmi c kg/m (p = . ). however, there was no significant difference in type of operative or nonoperative management between patients with bmi \ vs. bmi c kg/m . after multivariable logistic regression, mortality was associated with age, bmi and iss. no effect modification of sex was observed in the relationship of mortality and bmi. conclusions: adult patients with renal injuries and bmi \ kg/m have significantly higher rates of mortality compared with adult patients with renal injuries and bmi c kg/m . introduction: trauma is an ever-evolving surgical discipline. trauma remains a major source of global mortality. the operative and non-operative options for trauma patients has steadily increased. the development of trauma protocols, advancement in transport to trauma centres and radiological techniques has seen a shift in trauma surgery caseload. observing and understanding this shift from operative management to an increasing non-operative management of trauma cases will better prepare the acute medical team in this setting. materials and methods: prospective trauma registry data was collected and analysed retrospectively. patients presenting to a tertiary referral hospital between jan to dec with an injury severity score of [ were reviewed. patients who were transferred to another facility for management were excluded. the demographic data and surgical outcome data were collected and analysed. trend analysis of the operative cases performed for each specialty. results: major trauma patients presented to the john hunter hospital between january to dec . there was a non-statistically significant increase in the number of presentations ( pt in vs in , p = . ). there was a decreasing rate of operations performed for trauma patients ( % in vs % in , p \ . ). there was an increasing rate of orthopaedic surgery cases and operative time compared to other specialties ( in vs in , p \ . ). general surgical major trauma operating cases noted a significant decline over the study time ( in vs in , p \ . ). conclusions: there is a sizeable shift in the caseload of different surgical specialties in regard to major trauma patients over the course of years from to . orthopaedics has seen a significant increase in operative caseload and surgical time required to adequately manage major trauma presentations. the workload and experience of general surgical teams will likely be affected by these changes. the distribution of resources needs to be reflected in the changing work demands of each surgical subspecialty. traumatic internal hernia with delayed small bowel strangulation after pelvic ring injury hospitalization, follow up abdomen ct checked. there was no other specific change than increased thigh hematoma. eight days after hospitalization, ct was re-examined due to abdominal pain with abdominal distraction. an ct showed peritonitis with pneumoperitoneum and small amount of ascites. small bowel herniation through right pubic bone fracture site with ischemic change also noted. diagnosis: diagnosis was traumatic pelvic hernia with delayed small bowel strangulation. therapy and progressions: an emergency operation was performed. ileal loop was hernitated and perforation was found. emphysematouns change and fluid collection was exsited at perineal area and left high. after small bowel loop segmental resection, wound vac was applied at thigh area. comments: traumatic pelvic hernia is rare. diagnosis is challenging in the acute setting and often delayed due to lack of awareness. when diagnosed, efforts should be made to look for other serious injuries as traumatic pelvic hernia usually associated with concomitant intraabdominal injuries. the optimal management of traumatic hernia should be individualised based on the mechanism and severity of injury, presence of concomitant injuries, size of defect, and presence of incarceration. delayed treatment may read to fatal outcomes. careful inspection of the patient is important. references: vincent k, cheah sd. traumatic abdominal wall hernia-a case of handlebar hernia. med j malaysia. ; ( ): - . angio-embolization in pediatric trauma patients with blunt splenic injury: a systematicreview t. nijdam , r. spijkerman , l. hesselink , t. hardcastle , l. leenen , f. hietbrink umc utrecht, traumasurgery, utrecht, netherlands, inkosi albert luthuli central hospital, trauma, durban, south africa introduction: non-operative management (nom) for children with blunt splenic injury (bsi) is nowadays a commonly used treatment in pediatric trauma departments. in adult trauma departments the addition of splenic angio-embolization (sae) is suggested to decrease the failure rate of nom in high grade splenic injuries. however, the use of sae in pediatric trauma departments is very uncommon and it is unknown if sae is of additional value in pediatric trauma patients. therefore, the aim was to analyze the available literature on sae in pediatric trauma patients with bsi. materials and methods: a literature search was performed to find eligible studies that analyzed sae in pediatric patients with bsi. the primary outcome was failure of treatment in these patients. secondary outcomes were the success rate of sae, length of stay and mortality. the relative risk (rr) was calculated to compare primary outcome between study groups. results: in total studies were identified through the search, a total of studies matched our inclusion criteria and were selected for this review. studies included a total of . pediatric patients, of whom underwent sae. patient age ranged from &lt; year to years, mean age was . years. both injury severity score and spleen injury grade were higher in the sae group compared to the nom group. failure rate of sae was %. no spleen related morality was observed in the sae group. conclusions: the literature suggests that sae might be of added value in a very selective group of pediatric trauma patients with high grade splenic injures. however, since limited evidence is available concerning the use of sae in pediatric trauma patients with bsi, no firm conclusions can be drawn about safety and effectiveness. introduction: the management algorithms for trauma have changed with the development of specialised trauma centres. the aim of this study was to review the management and outcomes of patients with traumatic small bowel (sb) and colonic injuries. material and methods: patients treated for sb and colonic injuries between - at aintree university hospital (liverpool) were identified using the prospective trauma audit and research network database. the management and outcomes of the patients included were analysed. results: patients sustained sb and colonic injuries. there were ( . %) sb injuries and ( . %) colonic injuries ( patients had a sb and colonic injury). patients ( . %) of injuries were due to knife stabbing wounds, ( . %) patients were due to gunshot wounds, and ( . %) patients were due to road traffic accidents/ blunt blows. damage control surgery was performed in ( . %) patients. colonic injuries included ( . %) haematomas and ( . %) perforations. a resection and stoma (rs) procedure was performed in patients ( . %), primary repair (pr) in patients ( . %) and resection with anastomosis (ra) in patients ( . %). sb injuries included ( . %) haematomas and ( . %) perforations. pr was performed in ( . %) cases and ra in ( . %) cases. the overall complication rate after sb and colonic injury was % ( patients) with a significant complication rate ( patients, p value = . ) for patients undergoing rs in colonic trauma. the -day mortality rate was . % ( patient). conclusions: pr in sb and colonic injuries appears safe. in our dataset, rs appeared to have a higher complication rate. our study highlights that such injuries are uncommon with a high complication rate. surgeons need to provide individualised treatment. introduction: nowadays, patients with high grade bsi are preferably treated using spleen preserving treatments (spt). it is assumed that patients with low grade bsi treated with spt have a good splenic function after recovery. however, there is no consensus on splenic function after high grade bsi. in several institutions, asplenic/hyposplenic infection prevention protocol will be executed in all patients who had spt after high grade bsi, where other institutions evaluate splenic function first. scintigraphy is believed to be the best flow/activity test to approximate splenic functionality. the aim of the study was to analyze whether spleen injury grade is associated with diminished splenic function. secondarily, we aimed to evaluate whether splenic function testing is necessary in pediatric patients after bsi. material and methods: a retrospective study was performed from january to january . in our institution patients with bsi grade iv of v are assumed hyposplenic and will receive a splenic function test. we included all patients with a minimum follow-up test period of days. all tests were analyzed by the radiology specialist. for each patient we furthermore collected clinical data, including the date of trauma, gender, age, mechanism of injury, ais of splenic injury and iss. results: patients consisted of male and female, with a median (iqr) age of . ( . - . ) . median iss was . ( - . ) and the median spleen ais was ( ) ( ) . nom was used in patients, sae in five patients and two patients were treated with surgical mesh technique. the median follow-up time of all performed tests was ( - ) days. a total of patients ( %) had a grade iv or v splenic injury. scintigraphy was utilized to test most patients. a total of out of patients had an adequate splenic function, including all sae patients. conclusions: even high grade splenic injuries show adequate splenic function in the follow-up of pediatric trauma patients after bsi. therefore routine diagnostic follow-up by scintigraphy is not necessary in this specific patient group. evaluation of abdominal injuries treated at stavanger university hospital: occurrence, severity and mortality j. w. larsen , k. søreide , , j. a. søreide , , k. tjosevik , k. material and methods: retrospective evaluation of data recorded prospectively in the hospital's trauma registry between january and december . patients with abbreviated injury scale (ais) code for abdominal injury were included. descriptive analyzes are presented for demographic data, injury type, mechanism, and severity, as well as -days mortality. results: a total of patients with abdominal injuries were included ( . % of all trauma patients). % where men. median age was . the injury mechanism was blunt in %. transport accidents were the most frequent cause of injury ( %). median iss was , and median niss . overall -days mortality was . %, with a median trauma injury severity score (triss) of , . multiple abdominal injuries were recorded in % of the patients. % had associated injuries in other body regions, most frequently in the thoracic region ( . %). solid organ injury occurred in % of the patients, with liver injury ( %), splenic injury ( %), and kidney injury ( %) encountered most frequently. an ais score c was found in % of liver injuries, % of splenic injuries, and in % of patients with kidney injuries. hollow viscus injuries were found in % of the patients. injuries to the small intestine ( %) and colon ( %) were most frequent. abdominal vessel injuries were encountered in %, and % of these had an ais score c . conclusions: abdominal injuries are dominated by solid organ injuries following blunt injury mechanism and are often associated with concomitant thoracic injury. patients who dies within days from admission are characterized by a low probability of survival shown by triss. pancreatic trauma management in a third level centre a. gonzález-costa , r. gracia-roman , s. montmany-vioque , a. campos-serra , r. lobato-gil , c. zerpa-martin , f. j. garcía-borobia , p. rebasa-cladera , s. navarro-soto management. the aim of the study is to review the management and describe the most frequent complications of pancreatic trauma in our centre. material and methods: observational study with prospective collection of data, from march to march . inclusion criteria: trauma patients older than admitted to the emergency department who were admitted to icu or died before admission. demographic data has been collected, also vital signs, iss, mechanism of action, mortality, complications, and lesions. results: between and , polytraumatic patients were registered. only had pancreatic trauma ( . %). the male: female ratio was : ; with an average age of . years (sd . ) . mean iss of . (sd . ), mean ais of . (sd . ) and mortality of . % ( patients). the most frequent pancreatic lesion was at the head of the pancreas ( patients; . %), followed by body-tail ( patients; . %) and two patients with full section ( . %). . % of patients were treated with non-operative management. five patients required urgent surgery ( %), requiring corporocaudal pancreatectomy in cases and drainage in patients. an embolization of a gastroduodenal artery aneurysm was performed in patient. respiratory complications were the most frequent. patients developed a pancreatic fistula ( . %), although in surgical patients this complication was much higher ( % in our series). one of them required puestow pancreaticojejunostomy and patient developed necrotizing pancreatitis ( . %). conclusions: pancreatic trauma is very uncommon. its management can be difficult, depending on the degree of injury (aast), with a high rate of complications. therefore, combined management and monitoring by the surgery and intensive care team will be very important. introduction: the aim of this retrospective study was to evaluate and compare the clinical outcomes of conservative versus surgical treatment in a series of patients with liver injury. material and methods: between - , there were included patients. according the treatment chosen, the patients were subdivided in two groups. non-operative management was considered in hemodynamically stable patients. the failure of conservative treatment was defined as need to resort to operative management after a period of strict monitoring when the reason was related to the liver or associated injuries or need for late angioembolization. all hemodynamically unstable patients were subjected surgical treatment. results: conservative treatment was selected for patients and only in of them was failed due to associated delayed bleeding and small bowel injury. patients underwent emergent surgery which included packing, lobectomy and splenectomy. operative findings revealed grade iii liver injuries in % and grade iv in %. pneumonia, sepsis and ards were the most frequently associated complications. the overall mortality rate was . %. in patients of conservative group, non-surgical treatment failed with surgery being required. the mortality in the group of patients who underwent emergent laparotomy on admission was of patients. conclusions: conservative treatment of blunt traumatic hepatic injuries is applicable in patients presenting hemodynamic stability with mild hepatic injuries and it could be successful even in high graded injuries with low morbidity and mortality. surgical treatment is indicated in grade v injuries. nevertheless, failure of conservative treatment does not necessarily lead to an increase in the incidence of complications or mortality. with the trend towards more conservative management strategies, surgeons' exposure to laparotomies for blunt injuries in rtas has decreased. the aim of this study was to examine surgeons' exposure to laparotomies following blunt trauma which remains important to maintain low patient morbidity and mortality rates. material and methods: data was collected for adult patients admitted to mater dei hospital (malta) following rtas with ctproven intrabdominal injuries between january and january . results: patients ( ( . %) males vs. ( . %) female (p value \ . ), mean age = . years) were included in the study. patients ( . %) were car occupants whilst patients ( . %) were pedestrians. ( . %) patients had single intraabdominal organ injury, whilst ( . %) had multiple intraabdominal organ injuries. the -day mortality rate was . % ( patients). liver injuries occurred in ( . %) patients, splenic injuries occurred in ( . %) patients, kidney injuries in ( . %) patients and other organs were injured in ( . %) patients. conservative management was followed in ( . %) patients, angioembolisation was utilised in ( . %) patients and operative management was performed in ( . %) patients during the -year period. this resulted in trauma laparotomies following rtas per year. conclusions: only a minority of patients require operative management after rtas. surgeons in small countries have limited exposure to complex rta's. in view of the low exposure to emergency laparotomies following rtas, changes to our local training programme was done. trauma courses, lectures and fellowships in eu have been implemented to maintain surgical skills to an optimal level. references: european commission, annual accident report. european commission, directorate general for transport june . case history: a year old female presented to the accident and emergency department h post colonoscopy with complaints of left sided abdominal pain. this colonoscopy was requested under a -week wait for a history of chronic diarrhoea. this was a complete and uneventful examination ath the time, with random colonic and ileal biopsies taken. she attended a ? e with left sided abdominal pain increasing in severity. clinical findings: she was found to have an exquisitely tender abdomen, experienced more in the left upper quadrant. she was clinically shocked with a marked hypotension and tachycardia. investigation/results: a ct of her abdomen and pelvis showed free fluid within the abdomen and pelvis, with active bleeding and large haematoma adjacent to the spleen. the grade of splenic injury however was not commented upon by the reporting radiologist. interventional radiological embolism was considered but unfeasible as patient not stable haemodynamically. diagnosis: she was diagnosed with a splenic injury post-colonoscopy, with internal bleeding and haemodynamic instability. therapy and progressions: she underwent an emergency splenectomy overnight and was transferred to the intensive care unit for postoperative care. she recovered well, was stepped down to ward level care and was discharged with post splenectomy protocols, including all necessary vaccinations. comments: splenic rupture post-colonoscopy is a very rare event, with less than cases reported worldwide since . however, it still should be considered as a cause of a ? e presentation in patients with upper abdominal pain and haemodynamic instability after recent colonoscopy. we wanted to present this rare case to the international audience of estes congress to raise awareness of this rare complication. clinical findings: hemorrhagic shock and consciousness disorder were observed. her abdomen was distended, and she was intubated in the emergency room. investigation/results: ct revealed massive intra-abdominal bleeding. diagnosis: massive intra-abdominal bleeding due to hepatic laceration. therapy and progression: damage control surgery (dcs) and transcatheter arterial embolization (tae) were performed. she was transported to a hybrid operating room. she experienced cardiac arrest before operation. cardiopulmonary resuscitation was immediately initiated, resulting in the return of spontaneous circulation. laparotomy with perihepatic packing (php) was performed, but she experienced two more episodes of cardiac arrest during operation. then, tae was performed for right hepatic artery extravasation. after physiological function restoration, including rewarming, coagulopathy correction and hemodynamic stabilization in the intensive care unit. she gradually became hemodynamically stable. however, incomplete hemostasis was obtained at second-look laparotomy h later. because of bleeding, we repeated php. we performed cholecystectomy and abdominal closure after confirming complete hemostasis ( h post-accident). she was discharged ambulatory without neurological deficit (day ). comments: prognosis of traumatic cardiac arrest is generally poor, and survival without considerable neurological deficit is very rare. we reported a surviving patient with severe hepatic laceration. sharing of strategies and tactics, such as blood transfusion, tae, trauma team approach to surgery, early decision of dcs improves outcome of patients with severe abdominal trauma. references: resuscitation. ; : - . introduction: the spleen is the most commonly injured organ after blunt trauma. non operative treatment (nom) of splenic injuries has gained wide acceptance. transcatheter embolization of the splenic artery is considered a useful adjunct in aast lesions c without active bleeding. we report a retrospective review of all patients admitted to a level trauma center with blunt splenic injury from to and compare their treatment and outcome with a previous series from to , when angioembolization was performed only in case of contrast blush at ct scan. patients and results: from to june , patients with blunt splenic injuries were admitted to the ed of a level university hospital in milan, italy. men to female ratio was : ,the mean age . ± years (range - ), and the iss ± . (range - ). eight patients ( . %) underwent emergent splenectomy due to hemodynamic instability. of the stable patients treated with nom, those with aast lesions c (n = ) were submitted also to angiography and to embolization of the spleen ( %), either proximally ( ) or distally ( ). two nom failed, and the patients were submitted to splenectomy or distal embolization. the median hospital stay was . ± . days. the total spleen salvage rate was %. no associated abdominal injuries were missed in the nom group. in the previous series of patients (mean age . ± . years, range - , #:$ = : , iss ± , range - ), underwent emergency splenectomy ( %), and ( %) were treated conservatively, with only embolization ( , %) in case of aast c at ct scan. failure of nom were , and the spleen salvage rate . %. liver injury following multiple cardiopulmonary resuscitations case history: this is a case of a year old woman who presented to the emergency department (ed) due to worsening dyspnea complicated by two lengthy cardiac arrests. after the first resuscitation and return to spontaneous circulation (rosc), echocardiography was done and showed severely dilated right ventricle with strain, suggestive of massive pulmonary embolism, for which rtpa was given. arrest occurred again, and post rosc, heparin was started and the patient was transferred to the icu. extracorporeal membrane oxygenation (ecmo) was initiated but complicated by severe hemodynamic instability and a third cardiac arrest, so cardiopulmonary resuscitation (cpr) was performed till rosc and massive transfusion protocol was started for suspected intraperitoneal bleeding. clinical findings: after ecmo cannulation, abdominal distention was noted with a severe drop in hemoglobin and an increased intraabdominal pressure ( mmhg). abdominal bedside ultrasound showed significant amount of dense free fluid. the decision for an urgent exploratory laparotomy was made and the patient was taken to the operating room. therapy and progressions: deep liver laceration over the right hepatic dome with rupture of the capsule and an estimated hemoperitoneum of l were found intra-op. controlling the bleeding was difficult due to the laceration site and the patients coagulopathic status, so packing was done and the patient was transferred to icu for correction of the coagulopathy and re-evaluation in h. the liver was unpacked after h, bleeding sites were cauterized and sutured and the liver was wrapped with a mesh with an attempt for a tamponade effect. the patient's stay in icu was complicated with kidney injury requiring chronic dialysis but otherwise recovered well. comments: liver injury is a rare but serious complication after cpr that should be considered in case of persistent hemodynamic instability along with bedside findings. this case is intriguing due to the right sided liver injury with no overlying rib fractures. blunt renal trauma after electrical injury: a series of curious events. a. nixon , e. falidas , d. davris , a. botou , g. sofos chalkida general hospital, department of surgery, chalkida, greece case history: a yr old patient was referred to the emergency department (ed) of our hospital from a primary health center after sustaining an electrical injury ( v ac). the patient experienced loss of consciousness (loc) and promptly fell to the ground in a supine position. the patient arrived approximately h after the incident. clinical findings: vital signs: bp: / mmhg, hr: bpm. the patient's major complaint was left flank and abdominal pain. no obvious thermal injuries were observed or any other signs of external trauma. a left abdominal mass developed which was evident on physical examination. in addition, examination of urine revealed gross hematuria. investigation/results: ekg monitoring documented sinus tachycardia without evidence of cardiac arrhythmias. fast indicated the presence of a massive retroperitoneal hematoma. the fast exam indicated the left kidney as the probable source of hemorrhage. the initial hematocrit (hct) from the primary health facility was % while results from the ed recorded a hct of %. diagnosis: grade v renal trauma. therapy and progressions: a massive transfusion protocol was initiated. the patient underwent an emergency laparotomy and a left nephrectomy was performed. subsequent imaging did not reveal other injures. comments: the history of electrical injury could have misdirected investigation efforts towards cardiogenic shock. this case suggests that even in the absence of a high energy impact, sustained hemodynamic instability should always be attributed to hemorrhagic shock until disproven. in addition, the management of grade v renal trauma in blunt injury remains a controversial topic, however we believe that in cases of class iv shock, surgical management is imperative. case history: y.o. female with a history of chagas' disease of years duration and esophageal involvement in the last few months. she's admitted for a first endoscopic balloon dilatation due to dysphagia, which is performed according to protocol, and a tear of the mucosa layer is observed during it. clinical findings: she's stable for the first h but with continuous thoracic pain of moderate intensity according to the gi specialist. on the second day there's a general worsening of the patient's condition, with dyspnea, fever, desaturation and tachycardia. results and diagnosis: she develops leukopenia and elevations of acute phase reactants, and a ct scan reports a distal esophageal perforation with free extravasation of contrast in the mediastinum and bilateral pleural effusions. therapy and progressions: emergency surgery is performed through a midline supraumbilical laparotomy which shows peritonitis around the epigastric area. after opening the hiatus, a very long transmural esophageal tear with devitalized tissues and severe contamination are observed. a trans-hiatal esophagectomy was decided and, given the hemodynamic stability, a gastroplasty is performed and brought up to the neck without anastomosis, along with a terminal cervical esophagostomy and feeding jejunostomy. the patient did well in the postop period. we were able to do the esophagogastric anastomosis in the neck days later, during the same admission. comments: the surgical technique in esophageal perforation depends mainly on the time elapsed since the perforation, and on the condition of the patient. esophagectomy is sometimes unavoidable, and a gastroplasty can be brought up to the neck at the same time in selected cases, with reconstruction of the upper gi tract during the same admission. introduction: the spleen is one of the most frequently injured abdominal organ. the anatomy of the lesion defines the degree according to aast, ranging from grade i to v in increasing complexity. the diagnosis of splenic trauma may be difficult, as % of patients may show no signs or symptoms at primary survey. the approach involves two main strategies: conservative or surgical. the strategy should take into account four aspects: hemodynamic status, anatomy of the lesion, associated injuries and organizational structures of the evaluation site. this study aims to evaluate the type of approach performed on different degrees of splenic trauma during years in a portuguese trauma center. material and methods: we conducted a retrospective study including all patients diagnosed with splenic trauma during a period of seven years. by consulting the patient's clinical files we evaluated and compared: demographic data, trauma kinetics, degree of splenic injury and the approach taken as well as morbidity and mortality. results: of the patients studied, most were male with blunt trauma. in patients the inicial approach was surgery and in the option was conservative treatment. in grade iii or iv lesions conservative treatment failed in % of patients. patients in whom the surgical approach was first chosen had predominantly grade iv lesions, with total splenectomy being the preferred approach. in grade iii lesions, the option was mainly conservative surgery of the spleen. conclusions: the initial approach of splenic trauma results essentially of the experience of emergency teams and support structures for surveillance and intervention (intervention radiology and -h operating room availability). the attempt to try conservative strategy is increasing over time. introduction: for decades, helicopter emergency medical services (hems) contribute greatly to prehospital trauma patient's care by performing advanced medical interventions on scene. unnecessary dispatches, resulting in cancellations, cause these vital resources to be temporarily unavailable. these cancellations contribute to overtriage and provide additional costs to society. an earlier study showed a cancellation rate of % in our trauma region. however, little empirical knowledge exists about reasons for cancellations for different mechanisms of injury (moi) and type of dispatch. this study aims to examine the current cancellation rate in our trauma region over a -year period. additionally, insights in cancellation reasons for different moi and type of dispatch are evaluated. methods: a retrospective study was performed, using data derived from the hems database of trauma region north west netherlands, between april st and april st . information regarding patient's characteristics, date and time of day, moi, type of dispatch, and cancellation reason were compared. results: in total, , patients were included. hems was cancelled in . % of dispatches. the majority of dispatches ( . %) were cancelled because the patient was physiologic-and neurologically stable. dispatches simultaneously activated with ems were cancelled . % of times, compared to . % when hems assistance was additionally requested by ems on scene. no differences were found between dayand night-time dispatches. trauma related dispatches were cancelled more frequently compared to non-trauma related dispatches. conclusions: this study found a considerable-and increased cancellation rate compared to previous research. an explanation for this finding could be better adherence to dispatch protocols. furthermore, a great variety in cancellation rates was found among different moi's. therefore, continuous critical evaluation of hems triage is important and dispatch criteria should be adjusted if necessary. case history: two separate cases of high speed road traffic collision. the first is years old female without significant past medical history. the second is years old male who had short extremitis due to history of spastic quadriplegic cerebral palsy alongside congenital kyphosis and postural scoliosis. clinical findings: on examination the first patient was hemodynamically stable with soft abdomen and bruising over the left pelvic area. the second patient had left side neck and right side chest bruises; furthermore, he was tachycardic with normal blood pressure, but he was generally pale, getting clammy and significantly sweaty. investigation/results: fast scan for both patients showed free fluid in the abdomen and ct scan was uncertain of the source in the first patient. in the second, a large mesenteric haematoma was evident on ct with contrast extravasation with corresponding significant drop in hemoglobin and raised lactate levels. diagnosis: case : hemodynamically stable blunt abdominal trauma. case : hemodynamically unstable blunt abdominal trauma. therapy and progressions: the first patient was managed conservatively initially but worsened overnight with a drop in haemoglobin and increase in lactate mandating emergency laparotomy. hemoperitoneum and cm of ischaemic bowel with tear in the mesentery was found. she had an uneventful recovery after resection and primary anastomosis. the second patient underwent immediate emergency laparotomy. there was evidence of hemoperitoneum ( l) and similar mesenteric tear with ischemia involving cm of the terminal ileum. resection with end to end anastomosis was done. patient was then transferred to itu; however, he developed chest infection which prolonged hospital stay. comments: hemodynamic instability is a major factor in mandating urgent exploratory laparotomy in bat and bucket-handle injury is not uncommon following road traffic accidents. introduction: incisional hernias are one of the most common complications post-abdominal surgery, affecting between - % of patients undergoing a laparotomy. a number of risk factors are associated with their development such as age, bmi, type of surgery and co-morbidities. these risk factors also affect their levels of recurrence which is why the technique undertaken to repair these is of such interest. the primary purpose of this meta-analysis was to examine which repair technique is associated with the lowest level of recurrence whilst a secondary aim was to examine whether the frequency of common complications was dependent on the type of repair utilised. material and methods: this systematic review and meta-analysis was conducted by both co-authors. the following information sources were utilised; cochrane/embase/google scholar/pubmed/scopus. in relation to the eligibility criteria-papers that were published from onwards and in the english language were included with any length of follow-up. study selection was as per the inclusion/exclusion criteria below and only cohort studies/rcts/systematic reviews/ meta-analyses and case control studies were included. inclusion criteria: abdominal incisional hernias, all types of repairmesh/open/laparoscopic/sutured repair/primary repair etc. in terms of the exclusion criteria-any hernia repair that was not incisional was excluded. results and conclusions: in terms of the primary question posed by this repair, meta-analysis shows that there is a significant difference between open vs laparoscopic technique and recurrence rates in relation to the primary question posed by this paper whilst the use of mesh impacts negatively on post-operative wound infection rates. this invites an interesting debate on the merits of each technique whilst demonstrating the need for a multicentre randomised controlled trial. laparoscopic approach in penetrating abdominal trauma: case study and review of the literature b. vieira , v. taranu , a. silva , d. galvão , a. soares hospital de santo espírito da ilha terceira, general surgery, angra do heroísmo, portugal introduction: laparoscopy(ls) has greatly improved surgical outcomes in many elective abdominal procedures. the use of ls in acute care is becoming widely accepted. however, a number of safety issues have limited its application in abdominal trauma. notwithstanding with the reports and studies of the past decade proving its safety and accuracy, ls is slowly replacing the need for exploratory laparotomies. case report: a yo male sustained with penetrating stab wound on the left flank. he was hemodynamically stable. ct confirmed intraperitoneal positioning of the knife, without free fluid or air nor any evidence of organ injury. an exploratory ls was performed and confirmed the intraperitoneal positioning of the knife. abdominal exploration revealed a jejunal transfixating lesion about m from treiz's angle that was manually closed. the patient maintained a favorable po evolution and was discharged on the thpo day. discussion/conclusion: a number of concerns have limited the use of ls in abdominal penetrating trauma. initially, it resulted in high rates of missed injury, mainly of the small bowel, generating considerable criticism. the development of systematic abdominal explorations in ls, as described by choi and kawahara, resulted in a rate of missed injuries close to zero. moreover, direct visualization using ls has shown superior specificity and sensitivity in identifying peritoneal penetration, hollow viscus injuries and diaphragmatic lesions when compared to ct. in the case reported here, ct didn't show any image suspected of perfuration such as free air or fluid, and yet ls showed a small bowell injury. besides its advantages as a diagnostic tool avoiding negative laparotomies in more than % of the cases, thanks to evolving techniques and improved practice, it may also be therapeutic and allow safe definitive treatment for many types of injuries as described here. method: this is a monocentric retrospective study from a database entered prospectively. all patients admitted to the university hospital in nice with splenic trauma between / / and / / were included. the primary endpoint was performing splenectomy as a failure of a nom. results: patients were included in our study. the majority of splenic lesions were severe grades, that is to say greater than . in total, splenectomies were performed urgently, i.e. % of patients; angio-embolizations were performed, i.e. % of patients with a success rate greater than %; . % of patients who had not anterior angio-embolization required secondary splenectomy; . % of the patients who had anterior angio-embolization required secondary splenectomy. in the patient group with successful angio-embolization, the mean age was years vs . years in the nom failure group (p = . ). a decrease in hemoglobin between admission and h after admission was found in the nom failure group compared with the successful embolization group (p = . ). conclusion: hemoglobin monitoring in the hours following admission of a patient with splenic trauma may be an important factor in the surveillance of hemodynamically stable patients. prospective studies could confirm these results. missed ureteric injuries in gunshot injuries of the abdomen: how to avoid? introduction: traumatic ureteral injuries are uncommon. penetrating rather than blunt trauma is the most common cause of ureteral injuries. the aim of this study is to make a strategy to avoid missing ureteric injuries in gunshot injuries of the abdomen. material and methods: patients were operated in our hospital in years period. all patients were managed according to atls guidelines. for stable patients, full radiological work up was done, while hemodynamically unstable patients were shifted to or immediately for laparotomy and exploration. all patients demographic and clinical data were recorded these include :patient age, sex, mechanism of injury, hemodynamic state on arrival to the rr, anatomical site of gunshot injury, associated injuries, ureteric injuries detected early or late, early repair, delayed presentation and morbidly associated with delayed discovery. results: ureteric injuries were found in patients out of patients who underwent laparotomy for gunshot injuries had ureteric injury in an incidence of . %. ureteric injuries were missed in the first laparotomy in patients. associated injuries of other abdominal viscera include; colon injuries affecting ascending and descending colon in all the patients. conclusions: ct and pyelogram are the modalities of choice in stable patient but in unstable patients the early recognition of ureteric injuries depends on high index of suspicion leading to surgical exploration of the ureter along its course. case history: we present a case of a year old man, who was injured by his agricultural machine in the abdomen. clinical findings: he was transferred in the emergency department and he was hemodynamically stable. he had several traumas in his abdominal wall. from the largest one, in the left iliac fossa, omentum, transverse colon and loops of the small intestine were protruded out of the abdominal wall. the small bowel was ischemic and ruptured. investigation/results: computed tomography investigation, revealed small amounts of liquid and air in the abdominal cavity. diagnosis: the patient was immediately operated. the destroyed loop of the small bowel was resected with the use of a stapler and the field was washout. then with a midline incision the abdomen was opened. there were no other injuries inside the abdomen cavity. there was an extensive injury with a creation of a large gap in the anterolateral abdominal wall. it was impossible to identify the left rectus abdominis muscle as also the lateral muscles (external and internal oblique and transversus abdominis). therapy and progressions: a side to side entero-enteric anastomosis was created and a meticulous observation and washout of the abdomen were performed. for the closure of the abdominal wall a double-sided mesh from polypropylene coated with silicone on one side ( cm) was placed and the operation was completed. all the other wounds of the abdominal wall were closed with loop nylon stitches no . a closed suction drain was placed above the mesh. the patient had a very good postoperative course. he was dismissed from the hospital after days in a very good condition. comments: the usage of mesh was very useful for the reconstruction of the abdominal wall. there is no conflict of interest. strategy shift from damage control surgery to primary radical surgery improve the outcome of blunt hepatic injury involving inferior vena cava introduction: the diagnosis of abdominal trauma is a real challenge even for surgeons experienced in trauma. clinical findings are usually unreliable, and abdominal examination is made up of various factors. diagnostic tools that help the attending physician make critical decisions, such as the need for laparotomy or conservative treatment, are mandatory if we propose a favorable outcome. material and methods: the study was performed in the clinic i surgery, the county clinical emergency hospital craiova, between - and analyzed a number of abdominal traumas hospitalized, investigated and treated in the clinic. the methods of paraclinical diagnosis are evaluated comparatively, the study analyzing the evolution and the tendencies during the studied period, from , to . results: the study allowed an evaluation of the diagnosis and treatment methods compared to the data in the literature. conclusions: thus ct scan remains the standard criterion for detecting solid organic lesions. in addition, a ct scan of the abdomen may reveal other associated lesions. fast ultrasound is an important and valuable alternative for diagnosing abdominal trauma, especially for patients who are hemodynamically unstable and cannot be mobilized. there is a tendency in the treatment of abdominal trauma, as evidenced by the literature data on the use of conservative versus surgical treatment for a larger number of cases introduction: antiplatelet agents and anticoagulant drugs are widely used in prevention of cardiovascular incidents, which poses a challenge in surgical emergencies. the drafting of a multidisciplinary protocol for the treatment of pharmacological induced coagulopathy in patients who require urgent surgery standardizes management and increases patients' perioperative safety. material and methods: aims of the study were to describe the results from the protocol implementation. a retrospective study was conducted by examining reports of every patient presenting pharmacological induced coagulopathy and undergoing emergent surgery, recorded in our center from to inclusive. different algorithms used were explained and data such as need of transfusion, reintervention rate and perioperative complications were analyzed. results: data from patients were analyzed, median age of , ( %) men. patients ( %) used anticoagulant drugs. fresh frozen plasma transfusion and/or prothrombin complex concentrates were used according to the guideline. ( %) patients used antiplatelet agents. % of them underwent a delayed h surgery directly. tirofiban therapy was established in patients on dual therapy due to medium-high risk of cardiovascular event. regarding surgical approach, ( %) were laparoscopic, ( %) open and conversion occurred in ( %) cases, but only of them due to intraoperative hemorrhagic complication. only cases of postoperative hemorrhagic complications led up to reintervention and only one isolated case of thrombotic complication was reported. finally, ( %) mortality cases were reported, but none was caused by hemorrhagic nor thrombotic complications. conclusions: establishment of a guideline on management of pharmacological induced coagulopathy in emergent surgery is crucial in all surgical emergency units and has proven to be effective and safe. introduction: digestive haemorrhage is a frequent pathology. most of the episodes are self-limited, but in some cases massive haemorrhage occurs, leading to a % mortality rate. severe problems occurs when endoscopic treatment is not effective, requiring emergent surgery with poor prognosis. the aim of this study is to evaluate the implementation of interventional radiology techniques on short-term results. methods: a retrospective descriptive study was performed reviewing patients who underwent radiological embolization after failure of endoscopic conventional treatment between - in our hospital. a total of patients were included. results: patients were male. cases were from lower gi track and were from the upper gi with a similar death rate between them, with a higher rebleeding rate in upper gi ( . % vs . %). % of the arteriographies did not show any bleeding site, of them developed a new bleeding episode. overall patients who undergo embolization, urgent surgery was avoided in of the patients diagnosed as upper gi haemorrhage and in of the patients diagnosed as lower gi haemorrhage. patients died, those death occurred later on the recovery of the acute bleeding episode and embolization, all of them related to patients comorbidities. conclusions: arterial embolization has become an important tool in order to treat massive haemorrhages of the gastrointestinal tract. it seems to decrease the mortality and morbidity rate, but some complications can be associated such as rebleeding or bowel ischaemia. massive transfusion protocol with early administration of platelet and fresh-frozen plasma along with packed red cells in the initial phase of resuscitation is associated with improved outcomes introduction: massive transfusion (mt) in a ratio of : : (prbc:platelet:ffp) is the standard of care in hemorrhaging trauma patients. the aim of our study was to compare the outcomes of patients who receive near balanced resuscitation (nbr) compared to unbalanced resuscitation (ubr) during the initial phase of resuscitation. material and methods: we performed a -year analysis of the acs-tqip. all adult patients (age [ ) who received mt (defined as transfusion of prbc c units in -h) were included. patients were stratified into two groups: nbr defined as prbc:platelets:ffp in : [ . : [ . and ubr ( : \ . : \ . ) in the first h of resuscitation. primary outcome measure was mortality. secondary outcome measures were complications, and hospital length of stay. propensity matching was performed to match the two groups. results: a total of , patients received mt. mean age was ± years, median iss was [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] . overall h mortality was . %. only % patients received nbr while % received ubr in the first -h. using propensity score matching, patients were matched for demographics, ed vitals, iss, ais and injury parameters. patients who received nbr in the early resuscitation phase had lower mortality ( % vs. %, p = . ), lower overall complications ( % vs. %, p = . ), with no difference in hospital length of stay ( days vs. days, p = . ) compared to the ubr group. conclusions: only one-third of patient receiving massive transfusion receive prbc, ffp and platelet in a ratio closer to : : in the initial -h and they have lower mortality and complications compared to patients with unbalanced resuscitation. material and methods: the goal is to assess mtp strategies in level- trauma centres in the netherlands and compare these with each other and (inter) national guidelines. a trauma surgeon or anaesthesiologist involved in compiling the mtp in each level- trauma centre in the netherlands and dutch ministry of defence was approached to share their mtp and comment on their protocol in a survey or oral follow-up interview. results: all eleven level- trauma centres responded. content of the packages and transfusion ratio (red blood cells/plasma/platelets) was : : , : : , : : , : : , : : , : : , : : and : : . tranexamic acid was used in all centres and an additional dose was administered in eight centres. fibrinogen was given directly (n = ), with persistent bleeding (n = ), based on clauss fibrinogen (n = ) or rotem Ò (n = ). standard coagulation monitoring are used in all centres, but most hospitals use also rotational thromboelastometry (rotem Ò ) (n = ), thromboelastography (teg Ò ) (n = ) or both (n = ). all centres used additional medication for patients using anticoagulants, but its use was ambiguous. conclusions: mtps in dutch level trauma centres differs from (inter) national guidelines in transfusion ratio and additional medication, which could be explained by misinterpretation of the : : ratio, changes in components and following an outdated dutch national guideline. whether these differences in mtps actually leads to different patient outcomes will follow from data that is currently being collected. this study is sponsored by the dutch ministry of defence. anastomotic bleeding after colorectal surgery: incidence, management and complications introduction: postoperative anastomotic bleeding (pab) is a frequent minor complication ( - %) that usually resolves by a conservative approach. hemodynamic instability and anemization may develop requiring urgent management. the aim of our study is to describe pab and its treatment. material and methods: observational retrospective cohort study of patients with pab collected between july and september . pab was defined as an episode of lower gi bleeding after colorectal surgery with at least one anastomosis. characteristics of patients, surgery, length of hospital stay, morbidity and mortality, and management of pab were reviewed. results: a total of ( . %) patients with pab was collected. median age was of years (iqr - ), with a median estimated asa grade of . the most common procedure was a right hemicolectomy ( %), followed by sigmoidectomy ( %). % of surgeries were laparoscopic. only cases were converted to an open approach. % of patients had the first episode of pab during the first h after surgery, while % after the third postoperative day. pab was treated conservatively in % of the cases. the remaining % required urgent endoscopic management identifying the bleeding through the anastomosis line, using clips in patients and hemospray in patient to control it. no complications were recorded after endoscopic treatment. just case required surgical reintervention. a total of ( %) patients required blood transfusion with a median of (iqr - . ) units. length of hospital stay was . days. no mortality related to pab was registered. conclusions: pab is a mild complication after colorectal surgery. most of the patients respond to conservative management. urgent endoscopic treatment seems to be effective and safe to control pab even during the first postoperative day. introduction: hemorrhagic shock and associated reperfusion injuries are davastating situations during the treatment of polytrauma patients. the aim of this study was to analyze and compare alterations of the local circulatory changes of various body regions during hemorrhagic shock and after fluid resuscitation. material and methods: this study was conducted on male pigs. they suffered a standardized polytrauma including femoral fracture, blunt thoracic trauma and liver laceration. further, the suffered a hemorrhagic shock for h (aimed map mmhg). fluid resuscitation with three times drawn blood volume after hemorrhagic shock. retrograde nailing for femoral fracture and chest tube in case of pneumothorax liver packing. measuring circulation at liver, colon, stomach, and extremity. results: inclusion of animals. local circulation at the extremity decreased significantly compared to baseline values during hemorrhagic shock ( . a.u. versus . a.u., p \ . ). after resuscitation the flow rate at the extremity was comparable to baseline values. the stomach was least sensitive to hemorrhagic shock, whereas the oxygen delivery rate at the colon decreased during shock phase and remained decreased during fluid resuscitation (p \ . ). conclusions: different body regions react differently to hemorrhagic shock. the colon appears to be most vulnerable to changes based on hemorrhage. the delayed improvement of circulation in liver, colon, and extremities may represent a trigger for systemic hyperinflammation and subsequent sirs and sepsis. none of the authors have any conflicts of interest to declare. massive transfusion in penetrating trauma: the search for a specific prediction system introduction: prediction systems of massive transfusion (mt) were developed from cohorts with a small proportion of penetrating trauma. some of them required laboratory tests. we aimed to evaluate abc score and to identify independent predictors of mt in a cohort of torso penetrating trauma (tpt) material and methods: adults with tpt, managed in a level-i trauma center, who received one or more packed red blood cells (prbc), were included. variables obtained during the evaluation in the trauma bay were registered prospectively. the ability to predict mt was evaluated with simple, multiple logistic regressions and roc curves. results: we included patients; . % were male, and . % received fire-arm wounds. twenty-one ( %) received mt. mt patients were intubated more frequently in the pre-hospital, had lower sbp, higher hr, lower gcs, and received more frequently vasopressors (p \ . ) when compared with the no-mt patients. trauma mechanism, number or localization of the wounds, and positive fast could not discriminate mt (p [ . ). hypotension, tachycardia, and alteration of the glasgow coma scale or its motor response behaved as independent predictors of mt. models created with these variables showed better discriminative ability than abc score, with adequate goodness to fit. conclusions: prediction models of mt, based on heart rate, systolic blood pressure, and neurologic alteration outperformed abc score in a tpt cohort. introduction: rectus sheath hematoma presents with abdominal pain and anterior abdominal wall mass. it can be followed conservatively and rarely causes mortality ( ) . in this study we aimed to review rectus sheath hematoma cases consulted to our department and to present our management. material and methods: the data of patients admitted with rectus sheath hematoma between and was collected using hospital database. treatment modalities, demographic data and complications were reviewed retrospectively. results: all the cases presented with abdominal pain and/or with a palpable abdominal mass. . % of the patients (n = ) were receiving anticoagulant therapy at the time of admission. the mean inr value was . . patients were followed up with es&ffp transfusion and conservative treatment. patients not eligible for conservative care underwent inferior epigastric artery embolization and hematomas in patients were evacuated via a percutaneous drainage catheter. patient went through laparotomy for an infected hematoma and one patient underwent laparotomy plus packing. the patient who had laparotomy plus packing died due to intraabdominal hematoma and sepsis. conclusions: rectus sheath heamatoma is a rare cause of acute abdominal pain. the patients diagnosed early and have suitable indications can be treated conservatively ( ) . rectus sheath hematoma should be considered in the differential when a patient with a history of anticoagulant drug use presents with acute abdominal pain in order to prevent unnecessary surgery and complications. introduction: an early delivery of blood products when massive transfusion protocols (mtp) are triggered is mandatory to improve trauma patients survival. scores predicting massive transfusion (mt) have already been described ( ) . the aim of our study is to compare scores for predicting mt and identify the best trigger for mtp. material and methods: multicentric retrospective study from the trauma registry of the spanish surgeons' association. severe trauma patients (injury severity score [iss] c ), admitted to different level trauma centers, from january to september were included. demographic and clinical information was recorded, and predictive scores for mt were assessed. results: patients were included. medium age was . ± . years, ( . %) were male. median iss was (iqr ). in % of the patients a mt (defined as c units of packed rbc) was necessary, while a mtp was triggered in . %. surgery was performed in . %. the overall mortality was of . %. predictive scores for mt were compared: gap (glasgow coma scale, age, systolic blood pressure), shock index (si), assessment of blood consumption (abc) and mabc (modified abc). auroc for gap was . ± . , si . ± . , abc . ± . and mabc . ± . , showing differences between gap (the worst score) and the others, p \ . . no differences were found between si, ab and mabc. best cut-off points were calculated. si c . better predicts mt with a sensitivity %, specificity . %, positive and negative predictive values . % and %. conclusions: si, abc and mabc are all good scores for predicting mt in our population. appealing by its simplicity, we recommend si as the best trigger for mtp. protocols should be standardized to improve the accuracy of mtp activation for trauma patients. introduction: the prevalence of knife-related offences is rising in the uk. successful management of trauma patients requires the co-ordinated response of specialist services, including transfusion. we aimed to assess the impact of knife-crime on transfusion support within a uk adult major trauma centre (mtc). material and methods: retrospective review of patients admitted to a uk mtc following knife injuries resulting from interpersonal violence during a three-year period (may -april ). source material included electronic patient records, tarn database and massive transfusion protocol (mtp) logbook. patient characteristics, resource utilisation including transfusion, mtp activation and outcome were collated. results: patients were identified, ( %) were male. median age was years. ( %) were under the age of . patients ( %) presented with circulatory compromise (sbp \ ). patients ( %) had attended our hospital previously for violencerelated trauma. % arrived at hospital between h to h. ( %) required one or more surgical procedures. median length of stay was days. patients ( %) received blood transfusion. median units transfused were prbc, ffp, platelets (atd). mean component use was pbrc (range - ), . ffp ( - ), platelets . ( - ), cryoprecipitate . ( - ). annual mtp activations increased from to during the study period (total ). stabbings accounted for . % of these ( patients), of which ( %) were transfused. conclusions: knife crime presents a burden to blood transfusion, accounting for a quarter of mtp activations. patients typically present out of hours with implications for service planning and delivery. patient profile together with repeat healthcare attendance and surgery requiring transfusion has implications for red cell allo-immunisation. we recommend timely baseline blood grouping and triage to optimise the safe use of rhd positive cellular components. introduction: spontaneous intramural small bowel hematoma is a very rare complication of anticoagulant therapy. nowadays, the prevalence is increasing due to the widespread use of computerized tomography and the increasing number of patients receiving anticoagulant therapy. material and methods: patients admitted to our center between january and june and treated with the diagnosis of intramural hematoma were retrospectively evaluated. results: the median age of the patients was years ( - ) and ( %) were male. at the time of appeal, warfarin intoxication was present in cases ( %) and the median inr was . ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . one patient had known factor deficiency. diagnosis was made by computerized tomography in all cases. one intramural hematoma was localized in the duodenum ( . %), nine in the jejunum ( %), and five in the ileum ( . %) six patients ( %) had ileus findings. all patients underwent fresh frozen plasma replacement due to high inr levels and bleeding. median tdp transfusion was units ( - ). only patients ( %) required erythrocyte suspension replacement. all cases were followed up conservatively and there was no need for intensive care. the median hospital stay was ( - ) days. conclusions: due to the limited number of studies in the literature with a large number of cases, retrospective evaluation of singlecenter cases may be helpful. spontaneous intramural small bowel hematoma should be considered in the elderly population under warfarin therapy who present with abdominal pain, especially if inr values are above therapeutic limits spontaneous regression is seen in the majority of cases. non operative management and correction of coagulopathy with fresh frozen plasma replacement is the preferred approach. references: abbas ma, et al. spontaneous intramural small-bowel hematoma: clinical presentation and long-term outcome. arch surg. ; ( ) : - . pre-hospital decision-making: identifying the challenges assessing and managing traumatic haemorrhage and coagulopathy m. marsden , r. bagga , k. gillies , r. lyon , s. kellett , r. davenport , n. tai expert pre-hospital clinicians in making decisions about the diagnosis and treatment of patients with major haemorrhage and suspected tic. methods: semi-structured interviews were conducted with senior pre-hospital consultants from london's air ambulance and air ambulance kent, surrey and sussex. interviews probed clinicians on how they make decisions relating to the pre-hospital assessment of major haemorrhage and tic and subsequent blood product transfusion. the interviews were analysed using descriptive thematic analysis. results: all clinicians agreed that identifying and treating major haemorrhage was vital. half of the clinicians reported making no conscious assessment for tic and six reported tic should be managed in a hospital setting. four broad themes were identified: collation of information, weighing utility of different approaches, influence of experience and evaluation of unknowns. collating information from multiple sources drove clinical decision-making. decisions on blood product transfusion were made after weighing potential benefits (e.g. improve microvascular perfusion) against harms. clinical experience was reported as key to nuance clinical assessment, detect subtle signs and identify patterns. uncertainty complicated clinical decision-making in two domains; incomplete knowledge of a patient's injury and uncertainty of best clinical practice. conclusion: the pre-hospital identification and treatment of major haemorrhage was recognised as challenging and fundamental. necessity of pre-hospital tic diagnosis and treatment divided opinion. identifying these four themes allows for a greater understanding of the factors involved in making these decisions and will guide the creation of more accurate decision support tools to aid pre-hospital clinicians. nothing to declare. introduction: massive transfusion (mt) is defined as the administration of c packed red blood cells (prbc) in h. alternative definitions have been proposed; however, there is little understanding about the discriminative ability of different mt definitions with regards to mortality and multiorgan failure (mof). we aim to assess and compare the discriminative ability of different definitions of mt concerning mortality and mof. material and methods: we included patients who arrived to the emergency department and required trauma team activation at a level i trauma center in the city of cali, colombia between - . demographics and trauma characteristics were evaluated. the following mt definitions were measured: units of blood products in h (t ), u prbc in (t - ), u prbc in h (t - ), prbc in h (t - ), the combination of t - and t (t-combi), prbc in h (t - ), prbc in h (t - ) and units of prbcs in min. the operative characteristics were calculated for each definition. mof was defined as a sofa score of c points. results: we included subjects, . % male. trauma mechanism was penetrating in . %. the median and interquartile range (iqr) of age was years iqr ( - ) and of iss ( - ). lesions were located in the torso in . % of patients, and . % had a positive abc score. a total of ( %) received at least unit of prbc. tables and presents the operative characteristics of definitions of mt with respect to mortality and mof, respectively. conclusions: although all definitions showed an association with higher odds with the outcomes of interest, none of them showed an accurate diagnostic capacity regarding mof and mortality. thus, we advise caution when relying on the classical definition of mt ([ rbc units in h) to guide the flow of care of severely injured patients. trauma and coagulation: trends in coagulation factors in the severely injured trauma patient introduction: trauma-induced coagulopathy (tic), affects about - % of the major trauma patients. in the past, tic was considered as a consequence of the coagulation factors' dilution after a highvolume colloid administration. today tic is seen as a phenomenon that can arise after trauma; the first event is the c-protein activation by the tissue damage and hypoperfusion, resulting in the subversion of the hemostatic process. material and methods: the patients of the pilot study ''trauma and coagulation'' run in irccs san raffaele scientific institute have been reviewed and analyzed using a suite of experimental coagulation factors including rotem parameters, activated protein c (apc), thrombomodulin, endothelial protein c receptor, thrombin-antithrombin complex (tat), plasminogen activator inhibitor (pai- ), seselectin, interleukin- (il- ), interleukin- (il- ), d-dimer (xdp), antithrombin iii (atiii), and prothrombin fragment f ? (f ? ). new patients have been enrolled to validate the results of the pilot study. results: there is a statistically significative correlation between clinical scores of severity of trauma and risk of massive transfusion (iss, abc and tash) and some of the experimental coagulation factors analyzed. case history: to evaluate the role of negative pressure wound-care systems applied to the pleural cavity in case of severe acute empyemas and frail patients not amenable to conventional surgery. clinical findings: we report the case of a yrs old male critically ill patient suffering from complications of cardiac surgeries who developed a severe right empyema with broncho-pleural fistula through the site of a previous pulmonary hernia. investigation/results: we review the actual indications of negative pressure therapy in thoracic surgical emergencies especially in septic patients unfit for surgery. in our case the repeated application of negative pressure with dedicated dressings through the initial thoracotomy was the chosen damage control approach because of the sepsis and poor conditions. diagnosis, therapy and progressions: air leaks were later found to originate from a subsegmentary branch of middle lobe bronchus. subsequent video-assisted debridement procedures followed by negative pressure therapy managed to ( ) control the infection, ( ) reduce the thoracotomy incision into a thoracoscopic access and ( ) heal the pleural cavity, restoring eventually better general conditions of the patient. the closure of the bronchial fistula required further procedures after the acute phase when sepsis was overcome. comments: negative pressure systems can be applied to the pleural cavity with many advantages in selected critically ill patients. they allow to contain, treat and resolve infections both of chest wall and pleural cavity in case of severe empyemas reducing also wound pain and eliminating the need of chest drains. air leaks may also be managed by negative pressure therapy with adequate indications and particular attention to its settings. references: sziklavari z. mini-open vacuum-assisted closure therapy with instillation for debilitated and septic patients with pleural empyema. eur j cardiothorac surg. . flail chest: the renaissance of rib osteosynthesis c. leite , a. oliveira , a. lemos , b. barbosa , c. casimiro centro hospitalar tondela-viseu, general surgery, viseu, portugal case history: we present the clinical case of a male patient of years old. injury mechanism: fall from his own height over the right hemithorax. clinical findings: rib fractures with flail chest and significant displacement of bone edges. symptoms: intense thoracic pain. diagnosis: rib fractures with flail chest. therapy and progressions: multimodal analgesia. on the th day, he presented a tension pneumothorax. after adequate intercostal drainage, the pneumothorax relapsed. on the th day, he underwent a right posterolateral thoracotomy, open reduction and internal fixation of ribs with plates and screws and intercostal drainage. evolution: he received respiratory kinesiotherapy and was discharged on the th pos op day. follow-up at st and th months, without functional impairment and with preservation of quality of life. comments: rib fracture is the most common injury in the setting of thoracic trauma and is associated with a higher morbimortality. in the last years, positive pressure mechanical ventilation was the first line treatment of respiratory insufficiency caused by rib fractures. however, severe complications associated with prolonged mechanical ventilation, have elicited the rising implementation of open rib reduction and internal fixation techniques. the most consensual indications are: flail chest with fracture of at least ribs, significant displacement of bone edges or uncontrolled pain. rib osteosynthesis is a simple method but requires clinical experience in thoracic approaches and handling of specific instruments and material. its implementation in non-ventilated patients reduces the need for mechanical ventilation, pain, length of stay and allows preservation of quality of life. yokohama city university medical center, advanced critical care and emergency center, yokohama, japan, saiseikai yokohama-shi nanbu hospital, department of surgery, yokohama, japan, yokohama city university, department of general surgery, yokohama, japan, yokohama city university, department of emergency medicine, yokohama, japan introduction: although americans and europeans report emergency room thoracotomy (ert) is of value in penetrating trauma patients, most of ert is performed for blunt trauma in japan. after the establishment of the local government-directed major trauma center in the city of yokohama, the unexpected trauma survivor rate increased in the single center study. we report our experience in ert and surveyed the effect of the establishment. material and methods: patient characteristics (backgrounds, mechanism of injury, indication for ert, anatomic injuries, interventions and survival) of those who underwent emergency thoracotomy compliant with the guideline of western trauma association, between october and september were analyzed. results: fifty-eight patients ( males) underwent emergency thoracotomy. median age was . ( - ) years. fifty-seven were performed for blunt trauma ( %) and only for penetrating injuries. twenty-three patients presented with cardiac arrest on arrival, while thirty-five had deep and refractory hypotension. overall, survival rate improved from ( / ) to % ( / ) (p = . ) after the establishment of the trauma center. of patients presenting with cardiac arrest, only one survived. conclusions: the establishment of major trauma center seemed to affect the survival rate of the patient edt was performed. introduction: more than % of polytrauma events involve chest injuries. one third of these patients sustain thoracic instability due to serial rib fractures. thanks to numerous innovations in implant development several approaches currently exist for surgical rib stabilization (srs). however, no consensus exists regarding patient selection for srs to date. material and methods: retrospective single center cohort analysis in trauma patients. serial rib fracture was defined as three consecutive ribs confirmed by chest ct. cohort includes patients that were treated conservatively and patients that underwent srs by plate osteosynthesis. demographic patient data, trauma mechanism, injury pattern, injury severity score (iss), glasgow coma scale (gcs) and hospital course were analyzed. two matched pair analyses stratified for iss ( pairs) and gcs ( pairs) were performed to minimize selection bias. results: the majority of patients was male ( %) and aged ± years. serial rib fractures were located left/right/bilateral in %/ %/ % of cases. other thoracic bone injury included sternum ( %), scapula ( %) and clavicula ( %). visceral injury consisted of pneumothorax ( %), lung contusion ( %) and diaphragmatic rupture ( %). average iss was ± . . overall hospital stay was . and icu stay . days. in hospital mortality was %. srs did not improve hospital course or postoperative complications in the complete study cohort. however, patients undergoing srs had significantly reduced gcs ( . ± . vs . ± , ; p = . ). matched pair analysis stratified for gcs showed a reduced need for blood substitution and shorter icu stays ( vs days; p = . ) including shorter respirator time ( vs h; p = . ) and reduced in hospital mortality ( vs %). conclusions: patients with serial rib fractures and simultaneous severe cerebral injury benefit from surgical rib stabilization. tracheal and bilateral recurrent laryngeal nerve disruption injury secondary to accidental strangulation by dupatta case history: year old female brought to trauma emergency with a/h/o accidental strangulation injury with dhupatta at farm field while working with thresher machine after h of injury. patient had severe dyspnoea, dysphagia, paining neck clinical findings: primary survey revealed threatened airway with extensive surgical emphysema, rr- /min, spo - % on high flow oxygen mask, hemodynamically stable, and had no neurological deficits. patient was immediately intubated, however ventilation could not be maintained and surgical emphysema worsened hence immediate tracheostomy was established. investigation/results: computed tomography (ct) head and ct angiography of neck with venous phase study of neck and chest with ct esophagogram revealed complete disruption of cricotracheal junction with extensive cervical and upper thoracic surgical emphysema and no other injuries. diagnosis: disruption of trachea from cricoid cartilage with crushed trachea with loss of approximately cm, cricoid and thyroid cartilage fracture, complete avulsion of bilateral recurrent laryngeal nerves and serosal tear of esophagus. therapy and progressions: neck exploration with debridement of tracheal margins and anastomosis between trachea and cricoid cartilage with repair of cricoid, laryngeal cartilage and esophageal serosal repair was performed. comments: post-operatively patient underwent fibreoptic bronchoscopy and revealed paramedian location of vocal cords. at present patient is with tracheostomy tube in situ undergoing speech therapy and is able to generate comprehensible sounds. further laryngeal framework surgery is being planned. introduction: emergency resuscitative thoracotomy (ert) is a lifesaving procedure in selected patients and it is often considered a controversial ''last chance'' method of resuscitation. objectives of ert are to resolve pericardial tamponade, to repair heart injuries, to perform an open cardiac massage, to cross-clamp the aorta to redistribute blood flow to the myocardium and brain, to control intrathoracic bleeding and air embolism in the bronchial venous system. outcome mostly in blunt trauma is believed to be poor. material and methods: we retrospective reviewed patients c years who underwent ert at san camillo-forlanini hospital (rome, italy) between january and september with traumatic arrest for blunt or penetrating injuries. results: of ert, ( . %) were for blunt trauma, ( . %) were for penetrating trauma. . % of patients were male. the collectively reported overall survival was % (n = ). when including erts designated as done in the emergency department for blunt mechanism, only patient survived ( . %). survival after erts for penetrating trauma was % ( of ). conclusions: our experience suggests that ert is a technique that should be utilized for patients with critical penetrating injuries. the reported outcome after ert in european civilian trauma populations is favorable with an overall survival of %. multicenter, prospective, observational data are needed to validate the modern role of ert in blunt or penetrating trauma. references: narvestad jk, et al. emergency resuscitative thoracotomy performed in european civilian trauma patients with blunt or penetrating injuries: a systematic review. eur j trauma emerg surg. ; ( ) case history: an -year-old male driving a car collided with a wall at a speed of km/h and was brought to a hospital near the scene. he was diagnosed with right multiple rib fractures and hemopneumothorax, and transferred to our emergency center for definitive care. clinical findings: the patient's consciousness was clear and his heart rate, blood pressure, respiratory rate, and o saturation (room air) on arrival were /min, / mmhg, /min, and %, respectively. subcutaneous emphysema was identified on the right side of his chest and his right breathing sound decreased on auscultation. there was no tenderness and rebound on abdominal examination. investigation/results: an enhanced whole-body computed tomography scan revealed a small disruption on the right diaphragm behind the sternum and free air in the abdomen. diagnosis: the diagnosis was right traumatic diaphragmatic injury, sternum fracture, and right multiple rib fractures with pneumohemothorax. there was free air in the abdomen but without evidence of perforation of the digestive tract as there was no finding of peritonitis on physical examination. thus, pneumoperitoneum from the thorax was strongly suspected. therapy and progressions: laparoscopic observation revealed a . cm-length of disruption on the diaphragm in the right sternocostal triangle. this was covered with falciform ligament using extracorporeal knot tying method because there was little seam allowance in front of the disruption on the sternum side, and direct suture was not possible. prognosis was good following surgery, and the chest drain was removed on postoperative day and the patient was discharged on postoperative day . comments: laparoscopic repair of the diaphragm using extracorporeal knot tying method is often used for retrosternal (morgagni) hernias. however, the method was also useful in this case because the diaphragmatic injury occurred in the sternocostal triangle. rib fractures associated with pneumo-and/or hemothorax; does everyone need a chest tube? v. snartland , p. a. naess , c. gaarder , m. hestnes , p. majak , , faculty of medicine, university of oslo, oslo, norway, oslo university hospital, department of traumatology, oslo, norway, oslo university hospital, trauma registry, oslo, norway, oslo university hospital, department of cardiothoracic surgery, oslo, norway introduction: pneumo-and/or hemothorax are often seen in trauma patients with rib fractures (rfs). standard treatment for pneumothorax (ptx), hemothorax (htx) and hemopneumothorax (hptx) is tube thoracostomy (tt). however, a non-operative approach can be applied in selected patients. we wanted to assess our practice in patients with rib fractures and associated ptx, htx or hptx. material and methods: all adult patients (c years) with rf, admitted by a trauma team at oslo university hospital in were identified retrospectively and those with associated ptx, htx or hptx were then included in the study. patients who underwent tt prior to arrival and those who died were excluded. spss v was used for statistical analysis. results: of the patients with rfs, a total of patients had ptx, htx or hptx. fifty-one percent ( / ) of these patients were treated with tt and % ( / ) of the patients underwent tt within h after arrival. the presence of opacification (p \ . ), chest wall deformity (p \ . ) and pneumothorax size (p \ . ) were significantly higher on chest x-ray in the tt group compared to the nonoperative group. intubation at arrival was also significantly more common in patients treated with tt (p \ . ). there was no difference in the presence of subcutaneous emphysema between the groups. the tt group was sicker than the non-operative group (had a significantly lower systolic blood pressure, a lower gcs and a higher lactate on arrival). oxygen saturation, heart rate, respiratory rate, ph and hemoglobin did not differ significantly between the groups. conclusions: in trauma patients with rf concurrent ptx, htx or hptx should be suspected. in our study only half of these patients were treated with tt, and % of tubes were inserted within h after admission. size of the ptx, radiological presence of opacification and deformity of the chest wall should be addressed when choosing treatment strategy. introduction: emergency department thoracotomy (edt) is a potentially life-saving surgical procedure performed in the emergency department (ed) in patients presenting with cardiac arrest following penetrating thoracic trauma. however, it is not clear if all surgeons are prepared or motivated to perform this procedure. furthermore, not all institutions are equipped, either in terms of logistics or team training, to perform edt. our purpose was to perform a pilot study in a cohort of polish surgeons of various specializations, in order to ascertain who would and who would not (and why) perform edt in their departments. material and methods: study population of surgeons ( specialists, residents) from various hospitals in poland, mean age: - years, . % men, . % women. study respondents were asked to fill in a questionnaire on the indications and motivation to perform edt in their clinical practice. results: most respondents (n = , %) correctly recognized the indications to perform edt. however, only ( %) declared they would perform it. the reasons for not performing edt were: lack of team training ( . %); lack of equipment ( %); lack of motivation among ed personnel ( . %); the ed is not prepared ( . %); the respondent is not prepared ( %). only participants ( . %) declared that their institutions had the edt protocol. conclusions: this survey demonstrates that, although most surgeons agree on the indications for edt, the level of preparedness in its execution is lacking. the main reasons are the lack of team training, the lack of equipment and the lack of motivation among ed personnel. other relevant reasons were the lack of preparation of either a surgeon or a department. these results demonstrate that improvements in institutional logistics as well as in team and individual training can translate into improved care. we strongly advise the performance of a pan-european survey on edt to address other unrecognized issues. mediastinum widening: how to manage it? a. gonzález-costa , r. gracia-roman , s. montmany-vioque , m. s. santos-espi , r. lobato-gil , m. pascua-solé , a. campos-serra , a. luna-aufroy , p. rebasa-cladera , s. navarro-soto parc tauli hospital universitari, trauma and emergency general surgery department, sabadell, spain, parc tauli hospital universitari, esofagogastric general surgery department, sabadell, spain, parc tauli hospital universitari, angiology and vascular surgery, sabadell, spain case history: a -year old male was admitted to our emergency department as a polytrauma code, because of a gunshot wound in the neck. clinical findings: his airway was compromised with expansive cervical hematoma. intubation was difficult. he was hemodynamically unstable with cervical bleeding, in which manual compression was applied. results: chest x-ray showed mediastinal widening without pneumo or hemothorax. diagnosis: urgent sternotomy while maintaining manual compression on the cervical bleeding, followed by left antero-lateral cervicotomy. injuries: section of left jugular vein and left carotid artery, lesions of unnamed vein. free cervical chylous fluid. left pleura and pericardium were opened without identifying major injuries. therapy and progressions: jugular vein was repaired with continuous suture and carotid artery with patch sutured. unnamed vein was sectioned between ligatures. thoracic duct was ligated. after surgery, ct scan showed cervical and mediastinal hematomas without signs of active bleeding, and correct permeability of the vessels, with no cranial lesions. the patient was admitted to the intensive care unit. tracheostomy was performed. fibrobronchoscopy, fibrogastroscopy and esophagogastricoduodenal discarded airway and esophageal lesions. he presented the following complications: • small mediastinal collection • right diaphragmatic paralysis. • paralysis of vi left cranial nerve (mononeuritis of vascular origin). the patient was discharged on the th postoperative day. comments: in this kind of trauma is essential the airway management with intubation when necessary. it is important that mediastinal widening visualized in the chest x-ray in a traumatic patient, should be an indication of surgery. in our case, it was essential to start it with sternotomy while maintaining manual neck compression, and in a second time, perform the cervical approach since that prevented the patient from suffering a greater blood loss. background: clavicular fracture is very common in childhood. otherwise, the medial third of the clavicle is the less affected. the current report describes a new pattern of clavicular injury, in which a medial third clavicular fracture and posterior sternoclavicular joint (scj) dislocation occur together in a skeletally immature patient. clinical findings: an -year-old boy sustained a direct impact to his left shoulder resulting from the fall of a sofa. at admission, he complained of severe pain in the clavicular and shoulder associated with functional limb impotence. physical examination revealed deformity of the proximal third clavicle, with swelling and tenderness to palpation along the medial left clavicle. no signs of skin pression or neurovascular impairment were found. the anteroposterior radiograph of the left clavicle showed a fracture of the proximal third shaft and an asymmetry of the scj. computed tomography confirmed the association of a greenstick fracture of the proximal third clavicular shaft, accompanied by a mild posterior scj dislocation. therapy and progressions: the left limb was immobilized with a sling during weeks, after which physical therapy was initiated to improve range of motion using active and gentle active-assisted exercises. at the months medical consultation, he presented asymptomatic, with good bone healing, full range of motion of the shoulder and absence of relevant aesthetic deformity. comments: in the immature skeleton, scj dislocation and epiphyseal fracture of the proximal clavicle are very rare entities due to the multiple strong ligaments that stabilize the scj. trauma in the proximal third of the clavicle typically results in fractures in the region of the physis and only more rarely culminate in dislocations of the scj. these injuries warrant a high index of suspicion, and early ct scanning is recommended. although treatment may be conservative, in situations of major displacement, surgery should be considered. use of rib fracture scoring systems in a uk major trauma unit: a retrospective audit and lessons learnt introduction: rib fractures are detected in % of trauma patients [ ] . significant morbidity and admission to intensive care units (itu) is common [ ] . rib fracture scores do not have strong validity as a predictor, but are a useful screening tool to identify patients at higher risk, of morbidity. the aim of this study was to audit the use of rib fixation scores in a single major trauma centre. material and methods: a retrospective audit of trauma patients with rib fractures presenting to a single major trauma centre over a -year period subsequently admitted to itu was performed. demographics, length of itu stay, rib fracture score (rfs) and ribscore were recorded and comparisons made between patients who had surgical rib fixation and those who did not. results: patients with traumatic rib fractures were admitted to itu over -year, of whom had rib fixation. mean age of patients undergoing surgery was compared to in the non-surgical cohort. average rfs was higher in the surgical cohort ( vs ; p = \ . ), as was average ribscore ( vs ; p = \ . ). incidence of flail segment was higher in surgical cohort ( % vs %; p = \ . ), as was number of rib fractures ( vs ; p = \ . ) and incidence of st rib fracture ( % vs %, p = \ . ). rib fractures treated surgically had a longer itu stay ( . days vs . ; p = \ . ). conclusions: surgical rib fixation patients were older and had longer itu stay. higher rib fracture scores correlated with need for surgical intervention. this highlights the need for careful patient selection for rib fixation, as they appear to fall in a more vulnerable patient demographic. there is a need for a score combining ribscore and rfs, ensuring the nature of fractures and presence of flail segments are interpreted in the context of patient age, to ensure this vulnerable patient group undergoes surgical fixation only when necessary. jichi medical university, shimotsuke tochigi, japan case history: an -year-old female individual hurt her back while walking during a hospital rehabilitation program after experiencing a brain stroke. her hemoglobin level gradually decreased to . g/dl on the th day after injury. a non-enhanced abdominal ct scan revealed a burst fracture of the lumbar spine. the patient was brought to our emergency center for a thorough examination. clinical findings: her vital signs on arrival were gcs: e v m , hr: , bp: / , rr: , and bt: . . her back presented a severe kyphotic spine. the palpebral conjunctiva was anemic and there were no injuries on her surface. no abnormalities were detected upon auscultation of the thorax and no tenderness and rebound was detected upon physical examination of the patient's abdomen. investigation/results: hemoglobin level was . g/dl and lactate . mmol/l on arrival. an enhanced chest and abdominal ct scan revealed a burst fracture of the th lumbar spine, a large hematoma around it, and a pseudoaneurysm of the lumbar artery. diagnosis: a pseudoaneurysm of the lumbar artery and a burst fracture of the th lumbar spine was diagnosed. therapy and progressions: the angioembolization of the lumbar artery was abandoned because the distance between the abdominal aorta and the aneurysm was \ mm. endovascular aneurysm repair (evar) was finally performed. after the successful completion of the surgery, the patient was discharged on the th day after evar. comments: slight injury caused the fracture of the lumbar spine, possibly yielding pseudoaneurysm of the lumbar artery. such pseudoaneurysms are rare and employing evar for its treatment is equally rare. blunt lumbar artery injury may be a differential diagnosis for the elderly patients who present burst spine fractures with extreme anemia or shock, even if it results from a minimal injury. case history: a year old co-driver was hit by another car on her side. air rescue found the patient with gcs and right tension pneumothorax. oral intubation, decompression with chest tube and transportation to the nearest level one trauma center was undertaken. clinical findings/investigation/results: on presentation in the emergency room the patient was hemodynamically instable with free fluid in efast-sonography and a haemoglobin of . g/dl. she was immediately taken to the operation room where laparotomy was performed. liver rupture and right diaphragm rupture was found. diagnosis: right hilar bronchial disruption. therapy and progressions: despite packing of the liver the patient remained instable. due to continuous bleeding from diaphragm rupture side right anterolateral thoracotomy was performed. bronchial disruption close to the hilus was detected leading to total pneumonectomy. after surgery the patient recovered under intensive care. six weeks after initial trauma the patient presented with ileus. a gastric tube was placed without complications. chest x-ray was performed showing intrathoracal displacement of the gastric tube. in an emergency operation the insufficient bronchus trunk was covered with an intercostal muscle flap. comments: this case shows the rare necessity of total pneumonectomy after blunt chest trauma and its typical complication with insufficiency of the bronchial trunk. after total pneumonectomy surgery covering the bronchial trunk should be performed as soon as possible to prevent insufficiency. in these patients gastric tubes should only be placed under endoscopic vision. because of the high complication rate total pneumonectomy should only be performed as a last resort procedure in the context of damage-control surgery. introduction: multiple rib fractures continue to be a challenging problem as the associated pain leads to a compromise in respiration. proper analgesia is required for physiotherapy, and to prevent development of respiratory failure. ultrasound-guided serratus plane block (spb) has recently been described as a regional anesthetic technique to provide analgesia to a hemithorax by blocking the lateral branches of the intercostal nerves. material and methods: from sept we applied the serratus plane block for pain control in patients with multiple rib fractures. we administered . - . % bupivacaine solution with easypump for - days, the infusion rate was ml/h. after admission we measured pulmonary function of patients and recorded the forced vital capacity (fvc). we repeated the test after the catheter insertion on the - - days. in our control group ( patients introduction: rib fractures are the most frequent injury after blunt thoracic trauma. it is very important to choose the most appropriate interventions to minimize or prevent complications. but who will benefit most of those interventions remains a challenge. material and methods: a retrospective study with a prospective data collection from march to december . there have been included all traumatic patients older than years old, that were admitted to the icu or who were died before the admission and had a plain chest radiograph (cxr) and thoracic or thoraco-abdominal scan (ct scan) in the first h. demographic data has been collected, vital signs, iss, mechanism of action, need of ventilation or intubation, lesions, complications, cause of death. a total of cxr were reevaluated by one general surgeon (one of the authors) and one radiologist, who were blinded to the results of the subsequent chest ct scan, the written radiology report and the patient's outcome. rib fractures, pneumothorax, hemothorax, pulmonary contusion, laceration and atelectasis were described. results: attending to the number of fractures, the kappa between the radiologist, the surgeon and the ct report is very low: surgeon-ct k = . , radiologist-ct k = . , and radiologist-surgeon k = . . both radiologist and surgeon under-diagnosed rib fractures. we tried to predict respiratory failure and pneumonia using the number of fractures, and scores (chest trauma score, ribscore and rib fracture score). results are shown on the table. conclusions: plain radiography seems not to be a good diagnostic method for rib fractures. both radiologists and surgeons under-diagnosed rib fractures. scores based on radiography seem un-useful given that this under-diagnoses rib fractures; but with a precision of % by the surgeon evaluating cxr and using a score like rfs perhaps it is enough to decide which patients require a ct scan or more specific treatment in the icu. surgical experience of traumatic diaphragm injury in a single regional trauma center for years introduction: this study is a retrospective review of the experience with the management of traumatic diaphragm injury in our trauma center from to . material and methods: we identified a total of patients with the traumatic diaphragm injury coded from the institutional trauma registry. we reviewed the radiographic finding of radiologists and the electronic medical record (emr). results: the mean of injury severity score (iss) was . ± . . except for case, the plain chest x-ray was evaluated in the patients before surgery, only patients were revealed positive finding for diaphragm injury (n = / , %). the computed tomography (ct) was performed for patients, the positive finding was . % (n = / ). according to the clinician impression before surgery, the diagnosis for diaphragm injury was showed . % (n = / ). approaches were laparotomy in patients ( . %), thoracotomy in ( . %), thoracoscopy in ( . %), laparoscopy in ( . %), open conversion after thoracoscopic or laparoscopic exploration in ( . %), median sternotomy in ( . %). the occurrence of herniation was ( . %). the mean of the calculated rupture size in the operation field was . ± . cm. in our study, the herniated peritoneal organ was observed in more than cm size rupture of the diaphragm. patients were performed surgical management of diaphragm rupture after h. conclusions: without herniation of organs, the radiologic evaluation was difficult to detect diaphragm injury. and, detect of diaphragm injury with herniation of organ, the injury of the diaphragm was predicted a larger than cm. case history and clinical findings: a -year-old man presented to the emergency room with a single self-inflicted left chest gunshot wound at the level of nd rib. on arrival patient was conscious, with systolic blood pressure mmhg and heart rate bpm. extremities were pale, cold. jugular veins distended. investigation/results: fast scan was negative. chest radiograph revealed a metal foreign body with the size of mm at the projection of heart. a ct scan of chest and abdomen demonstrated bullet inside the dorsal wall of the left ventricle and blood in pericardium and left pleural cavity (figs. , ) . therapy and progression: patient was taken to the operation room for median sternotomy. due to severe deterioration of patient's condition, ml of blood was aspirated from the pericardium prior to sternotomy. during subsequent pericardiotomy ml of blood was evacuated. main pulmonary artery wall gunshot injury was detected above the pulmonary valve. the wound was sutured, after which the hemodynamics stabilized. cardiac surgeon was consulted about the air gun bullet inside the myocardium. it was decided that removal of the bullet is not indicated. the patient was observed in the icu for the next h, later transferred to the thoracic surgery ward. the postoperative course was uneventful. an echocardiogram demonstrated a perforation of the anterior leaflet of mitral valve with a mild to moderate regurgitation, otherwise no abnormalities. patient was discharged on day . patient has been followed up on an annual basis for the last years. patient's exercise tolerance and cardiac function according to repeated echocardiography remains unchanged with no evidence of dyskinesia or other abnormalities. bullet is retained in the same location (fig. ) . comments: this case illustrates a successful management of usually lethal injury of main pulmonary artery and reflects that retained myocardial foreign body does not necessarily cause any complications. profile of penetrating chest injuries in hostile environment: a three year study introduction: penetrating chest injuries are one of the leading causes of death and major morbidity in operations involving high energy weapon systems. this study aimed at assess the profile of penetrating chest injuries suffered during armed combat operations in a hostile environment over a three year period. material and methods: a retrospective and prospective, non-randomized study designed to assess the profile of chest injuries in armed combat operations over years. all patients with penetrating chest injuries were included in the study. results: there were trauma cases out of which patients suffered penetrating chest injuries. the age range of patients was - years and all were male. a total of casualties were brought dead ( . %). there were lung injuries and two diaphragmatic injuries. thoracotomy was required in patients ( . %) and intercostal chest drainage (icd) in patients ( . %). average blood loss was ml and duration of hospital stay ranged from to days. conclusions: ballistic injuries to the chest are frequently fatal due to injuries to the heart, major vessels and tracheobronchial tree. prompt and efficient pre hospital treatment, expedient evacuation to a surgical facility and swift management by critical care specialists and surgeons can be instrumental in reducing mortality and morbidity. the cornerstone of management is bedside intercostal chest drain insertion as a formal thoracotomy is seldom needed. penetrating chest injuries can be managed by general surgeons with training in thoracotomy and repair of intra-thoracic structures does the number of a-or low symptomatic but intervention requiring complications justify regularly chest x-ray controls after less than rib fractures? c. deininger , , f. wichlas , , s. deininger , v. hofmann , university hospital of salzburg, orthopedics and traumatology, salzburg, austria, universitätsklinikum salzburg, klinik für orthopädie und traumatologie, salzburg, austria, universitätsklinikum salzburg, universitätsklinik für urologie und andrologie, salzburg, austria introduction: fractures of less than ribs may still cause delayed complications ( ) . the aim of this retrospective study is to determine whether standardized control imaging in a-or low symptomatic patients reveals a significant number of intervention requiring complications and therefor should be recommended. material and methods: all patients with less than rib fractures presenting in our emergency department after any trauma mechanism in the study period of years ( - ) and available for follow up were included retrospectively in the study. results: we included patients in this study, ( . %) of which were male, female ( . %), with a median age of . ± . years. in patients ( . %) rib was affected, in patients ( . %) , the fractured ribs being true ribs ( - ) in cases ( . %), false ribs ( - ) in cases ( . %) and both in cases ( . %). the affected thorax half was the left side in cases ( . %), the right side in cases ( . %) and both thorax halves in cases ( . %). the trauma mechanisms were falls at home, traffic accidents, sporting accidents, work accidents, fighting related and minor trauma in ( . %), ( . %), ( . %), ( . %), ( . %) and ( . %) cases, respectively. the median follow up time was ± days. patients ( . %) required delayed intervention: case of hemopneumothorax and cases of pneumothorax all treated with chest tube. conclusions: planned chest x-ray controls seem not to be necessary. symptom triggered reappearance for patients after rib fractures in hospitals seems to be sufficient and more economical compared to regularly re-imaging ( ) is computed tomography a first line modality in stable blunt chest trauma elderly patients? a. becker , , y. berlin , , d. hershko , emek medical center, department of surgery a, afula, israel, technion-israel institute of technology, haifa, israel, emek medical center, surgery, afula, israel introduction: adult older, patients aged [ years, represent up to - % of all trauma patients admitted to the trauma centers. chest trauma in older patients have been recognized to strongly influence mortality. the estimated of % mortality and pneumonia rate for these patients was observed ( , ) . based on low diagnostic accuracy of cxr, interpretation difficulties due to aging chest wall deformities, we hypothesized that ct chest should be the first imaging modality in stable elderly blunt chest trauma patients. patients and methods a retrospective analysis of all blunt trauma admissions at emek medical center between - years was performed in order to identify patients with blunt chest trauma. only stable trauma patients with abbreviated injury score (ais). results: among patients that met inclusion criteria, there were ( %) patients aged - years old and ( %) patients aged c . in the first group of patients ( - ), had ct chest on arrival. in the second group of patients (aged c ), there were ( . %) patients with missed injuries. in this group, patients who had ct chest on arrival, of ( . %) patients had missed injuries. eleven of ( %) patients who had no ct chest on arrival, diagnosed with missed injuries (p- . ). readmission rate in the first group of patients ( - ) was of ( %) who had ct chest on arrival, and of ( %) who had cxr on arrival only (p- . ). in the second group (c ), readmission rate was of ( . %) patients with ct chest on arrival, and of who had cxr on arrival only ( %) (p- . ). conclusions: based on our study result we conclude that ct chest should be a first imaging tool in stable elderly patients with blunt chest trauma. no disclosures. efficacy and safety of small-bored tube thoracotomy for chest trauma: large-bored chest tubes will no longer be needed introduction: tube thoracostomy drainage is an important treatment for traumatic pneumothorax and hemothorax. traditionally, largebored chest tubes have been recommended for successful drainage and prevention for clogging by clots. however, there is little evidence that large-bored tubes are more effective than smaller ones. in consideration of invasiveness, in our emergency room (er), we use fr chest tube for all trauma patients when chest thoracotomy is indicated. the aim of our study is to investigate the efficacy and safety of small-bored tubes for chest trauma patients. material and methods: we conducted a retrospective observational study. we included the adult patients ([ years old) who had undergone tube thoracostomy with fr chest tubes for chest trauma during the years from october to september in our er. the patients with cardiopulmonary arrest on contact or on arrival were excluded. we evaluated tube-size related complications defined as obstruction and worsening of pneumothorax/hemothorax due to ineffective drainage. results: there were eligible patients, % were male, mean age was . and the average injury severity score was . (± . ). sixty-six tube thoracostomies were performed by emergency physicians and were performed by thoracic surgeons. the average duration of tube placement was . days (± . ). there were not any tube-size related complications nor any patients who required additional tube insertion. case history, clinical findings: different stable hemodynamic cases with thoracoabdominal penetrating trauma and negative fast evaluation were enrolled in study. subsequent hemo/pneumothorax was managed initially by tube thoracostomy. investigation/results: hence laparoscopic investigation is an effective method for evaluation of diaphragmatic injuries in thoracoabdominal penetrating trauma, patients underwent diagnostic laparoscopy. in case , classic approach was done by open technique mm port insertion in sub umbilical. two mm ports inserted in lower abdomen at the level of midclavicular line. then mm port was added in subxiphoid area and by introducing zero-degree camera through it a better exposure was obtained. in case , mm sub umbilical port, mm port in subxiphoid and another mm working port at the level of umbilicus and right midclavicular line were applied. a -degree camera used. exposure, working space and exploration maneuvers were much easier to perform in compare with case . in case , port placement was identical to case but zerodegree camera was used. due to poor exposure, subxiphoid port was replaced by a mm one and used for camera insertion, then an acceptable exposure was obtained. in case , port placement of case was used by using -degree camera which resulted in a great exposure. diagnosis, therapy, progressions: patients tolerated the operation well and underwent appropriate management according to their intra operation findings; post-op courses passed without any complications. comments: in patients with suspicious diaphragmatic injury and according to available facilities in our centers, in unilateral injuries we suggest that a mm port in subxiphoid area can be used instead of contralateral midclavicular mm port. in bilateral injuries, if enough exposure doesn't achieve, a mm port in subxiphoid can be added. in absence of degree cameras, mm port use in subxiphoid can give surgeons better exposure. hemodynamic instability in patients with extremity injuries: motor vehicle accidents and shot wounds vs. explosions a. mahamid , i. ashkenazi hillel yaffe medical center, hadera, israel introduction: we previously reported that hemorrhagic instability (hs) was a complication of extremity injuries in as many as of of patients treated in one medical center following explosions. the objective of this study was to evaluate whether the prevalence of hs in patients with other high energetic injuries such as motor vehicle accidents and shot wounds (mva/sw) is different or not. material and methods: victims following mva/sw with extremity injuries and hs treated in one medical center during were identified with the aid of the national trauma registry and the center's blood bank. hs was defined as tachycardia (pulse [ /min) and/or hypotension (systolic pressure \ mmhg) in need of blood transfusions to reverse instability. patients in whom hs could be attributed to injuries other than the extremity injury were excluded. these were compared to patients treated following bomb explosions ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) conclusions: the proportion of patients in need of blood transfusion is much higher in patients whose extremity injury was caused by an explosion. the relative risk for hs is almost times higher in these patients. new technologies in soft tissue wound management limit reconstruction complexity and enhance recovery introduction: large soft tissue losses are associated with infection, increased morbidity and mortality, increased costs and poor outcome functionality. the purpose of this study was to evaluate the efficacy of a combination treatment of combined topclosure Ò tension relief system (trs) and administration of regulated oxygen and antibiotic irrigation negative pressure-assisted wound therapy (roi-npt) in the treatment of patients suffering from significant soft tissue loss. patients with open abdomen, large infected wounds, and extensive soft tissue loss treated with trs and roi-npt. results: full wound closure was achieved in [ patients treated without skin grafts or flaps. primary failure was successfully followed with secondary closure with the same system. the trs system allowed early postoperative physiotherapy with good to excellent functional results. limitations and complications will be discussed. . trs is a novel device for stretching, and securing wound closure, applying stress relaxation and mechanical creep for primary closure of large skin defects that otherwise would have required closure by skin grafts, flaps or tissue expanders. . irrigation may accelerate the evacuation of infectious material from the wound and may provide a novel method for antibiotic administration. . supplemental oxygen to the wound reverses reduced o levels in the wound's atmosphere inherent to the conventional negative pressure-assisted wound therapy restricting vacuum use in anaerobic contamination. moris topaz is the inventor and patent holder of the topclosure Ò and vcarea Ò . attendees' perceptions about tourniquet safety use aboard, easiness of application, and preference among four devices tested assessed. material and methods: the descriptive study design assessed employing a post-seminar survey, participants' perceptions of tourniquet safety use, application easiness, and preference among the four devices tested (cat, sam-xt, swat-t, and rats). the first two variables measured on a one-to-ten scale (being ten the easiest or safest, and one the least easy or least safe), while preference was measured by frequency count, with only one device to select as the preferred. frequencies and percentages for categorical variables and averages calculated and compared using the anova test (p \ . ). results: a total of sailors, ( %) females, and ( %) males, aged between and , participated in the workshop and completed the survey. the mean for the perception of safety regarding onboard usage was . . as for application easiness, cat and sam-xt ranked equally high ( . ), followed by swat ( . ) and rats ( . ), and the only statistical difference found was for rats (p \ . ). cat was reported as preferred by participants ( %), followed by sam-xt ( %), swat-t ( %), and rats ( %). conclusions: jse crewmembers (non-medical personnel) considered safe the use of tourniquets on board. of the four devices assessed, cat and sam-xt were regarded as equally easy to use and rats the least of all. cat was reported as preferred by almost three out of every four respondents. introduction: surge capacity is the ability to manage the increased influx of critically ill or injured patients during suddenly onset crisis, like a mass-casualty incident (mci) or disaster. during such an event all ordinary resources are activated and used in a systematic, structured and planned way. there are, however, situations where conventional healthcare means are insufficient and additional resources must be summoned. this study investigates the possibility of using community resources such as primary health care centers, nonmedical professionals and non-standardized facilities together with educational initiatives to increase surge capacity in a flexible manner. purpose: to investigate the possibility of an increased and flexible surge capacity during a crisis, disaster or mass casualty incident (mci) by examining the main components of surge capacity (sc) (staff, stuff, structure, and system) in the västragötaland region of sweden. method: this thesis uses a mixed methods research approach with an explanatory sequential design. a literature search was performed by using standard search engines utilizing relevant keywords, questionnaires and semistructured interviews were used for data collection from primary health care centers, dental and veterinary clinics, schools, hotels and sports facilities to determine capabilities, barriers, limitations and interest to be included in a flexible surge capacity system. results: preliminary findings indicate that there is interest, capacity and capability in the investigated municipalities to partake in a fscplan: primary healthcare centers can be toned up with drills and exercises, civilians can be educated in advanced first aid procedures (immediate responders) and focused leadership (scene management), schools, hotels and sports facilities can be prepared with advanced first aids kits and be used as alternative care facilities. these alternatives together represent the concept of flexible surge capacity. conclusion: flexible surge capacity can be a possible approach to create extra resources in disaster situations, mci's, or whenever supporting infrastructure is not intact. new educational initiatives, drills and exercises, laymen empowerment and organizational and legal changes might be needed to realize a flexible surge capacity. introduction: a hospital may need partial or total evacuation because of internal or external incidents, such as in natural disasters and or armed conflicts. an evacuation aims either to transport a large number of patients to other medical facilities or to prepare enough space to receive a large number of victims. despite many publications and reports on successful and unsuccessful evacuations, and lessons learned, there is still no standardized guide for such an evacuation, and many hospitals lack the proper preparedness. we aimed to analyze the preparedness of hospitals for a total evacuation by looking into some key parameters necessary for a successful performance. material and methods: a literature search was performed by using the standard search motors in the related fields, and by using relevant keywords. eleven questions were sent to representatives from euand non-eu countries. results: our findings indicate that there is neither a full preparedness nor a standard guideline for evacuation within the eu or other non-eu countries included in this study. some countries did not respond to our questions due to the lack of relevant guidelines, instructions, or time. conclusions: hospitals are exposed to internal and external incidents and require an adequate evacuation plan. there is a need for a multinational collaboration, specifically within the eu, to establish a standardized evacuation plan. references: nero c, Ö rtenwall p, khorram-manesh a. hospital evacuation; planning, assessment, performance and evaluation. j acute dis. ; ( ): - . introduction: the importance of and the need for medical management during any armed conflict is a fact. many medical achievements have been accomplished due to wars and armed conflicts. the world is, however, divided into countries with and without related military healthcare services. there is a need for joint structure with the civilian in the former, while in the latter the civilian healthcare is responsible for offering services to the military. this study aims to identify the needs of military healthcare system and military medicine as an independent specialty. material and methods: a literature search was performed by using the standard search motors in the related fields, and by using relevant keywords. relevant professionals were asked about the pros and cons of having established military healthcare. the data was collected and analyzed. results: although our findings indicate a need for military medicine/ healthcare as a professional specialty, the organizational divisions between military and civilian healthcare systems seems to be changing. the current security issues worldwide, the pattern of injuries and resource scarcity indicates a need for improved collaboration and maybe a fusion between these entities. conclusions: new security threats, modern technology, the pattern of medical injuries, and the lack of adequate surge capacity may indicate a very close collaboration between military and civilian healthcare systems. such a close collaboration may develop to fusion and a total defense healthcare system that can act both in peace and during conflicts. references: ringel js. the elasticity of demand for health care. a review of the literature and its application to the military health system. https://apps.dtic.mil/docs/citations/ada khorram-manesh, a. facilitators and constrainers of civilian-military collaboration: the swedish perspectives. eur j trauma emerg surg. . https://doi.org/ . /s - - - . alternative methods of mandibular comminuted fracture fixation in severe maxillofacial injured patients introduction: severe maxillofacial injuries refer to significant facial trauma with communitive bony fractures and soft tissue loss. they result in violent trauma as firearm injuries (wartimes injuries, terrorist attack, suicide attempt) and high velocity motor vehicle accidents. the initial management consist of fighting hemorrhage, fighting asphyxia, wounds debridement and suture, and fractures stabilization, especially mandibular fracture stabilization. our study aims to share thoughts on the alternative methods of comminuted mandibular fracture fixation within the context: kind of injury, multitrauma patients, mass-casualty situation, precarious situation or hostile environment. material and methods: based on our experience (clinical cases), on senior surgeons questioning and on medical literature data, we sought to identify, to evaluate and to compare the different available methods to stabilize comminuted mandibular fractures in severe facial injured patients. results: open reduction and stable internal fixation (using macro plate), external pin fixation and closed reduction with maxillomandibular fixation are the methods of treatment which are the most classically used and described. however, some methods using kirschner wires are reported: in cross extrafocal pinning ( fig. ) , external fixation and handmade splints. all these methods differ in their complexity of use, in their availability, and in their possibilities to treat one kind of mandibular fracture or another. conclusions: the stabilization method of comminuted mandibular fracture will be choose depending on material availability, on surgeon's abilities, on the time available (mass-casualty situation) and on the patient's overall condition. even if stabilization methods using wires are less commonly used, they appear to us to be useful in the initial management of the severe maxillofacial injured patient with comminuted mandibular fracture, especially in austere conditions. causes of combat casualties' death at medical treatment facilities (mtf) in modern conflicts: russian experience i. samokhvalov , v. badalov , k. golovko , t. suprun , v. chupriaev material and methods: data including mechanism of injury, physiologic and laboratory variables, staged surgical treatment and cause of death were obtained from the combat trauma registry of the kirov military medical academy war surgery department. the combat trauma registry includes russian wounded in military conflicts over the past decades, of them ( . %) dead of wounds (dow) at the mtf. results: . % of the total dow number died at the role ii field medical units, . % died at the forward military role iii hospitals, and . % died at the role iv hospitals. the causes of dow patients delivered to the mtf were nonsurvivable traumatic brain wound ( . %), life-threatening consequences of injuries-mainly massive blood loss due to external and internal bleeding and acute respiratory failure ( . %), as well as the late septic complications ( . %). terms of death depended on the cause of dow. so for nonsurvivable traumatic brain injuries, they amounted to . ± . days, for lifethreatening consequences of wounds- . ± . days, and in the development of complications- . ± . days. conclusions: there is a high mortality rate among the combat casualties delivered to mtf in modern asymmetric warfare ( . %). moreover, half of these patients ( . %) die at role ii field medical units mostly from nonsurvivable injuries and from acute irreversible blood loss that occurred at the prehospital stage. the main cause of hospital combat mortality is severe septic complications of combat trauma. in consideration of the present counterterrorism practices, prevention and initial treatment for primary blast injury by shock waves constitute a particularly urgent subject because blast injuries and gunshot wounds account for the majority of terrorism deaths. in japan, due to strict ethical standards in animal experiments, there is no appropriate animal model of blast injury. we established an original small animal model of blast injury using a laser-induced shock wave at the national defense medical college (ndmc). however, since the experiments were conducted using only small animals, such as mice and rats, it was necessary to establish a medium-sized animal model aimed to test the applicability in human patients in the long term. correspondingly, we established a blast tube, which was authorized globally as a shock wave-generating device that causes blast injury based on air pressure differences, in the ndmc research institute using the budget of advanced research on military medicine of japan in . this allowed us to conduct scientific studies on blast injury using mediumsized animals. in this presentation, we will introduce the structure and function of the blast tube installed in the ndmc and present some of the results of our research thus far. this research is financially unfortunately, even if hospital and their staff are an essential key for successful response to mcis, the plan are seldom well-known and, above all, exercises are quite neglected at local and national levels. due to mci rarity, simulation exercises are the only way to achieve proficiency in mci response. therefore, we tested an original mci training system (macsim Ò ) adapted to the pemaf of a large university hospital in milan (italy). material and methods: the original mci training format called macsim-pemaf (emergency plan for massive influx of casualties)was developed for the italian society for trauma and emergency surgery (sicut) in . it uses macsim Ò , a simulation tool scientifically validated for training and assessment of healthcare professionals in mci management. between and the course was held for the emergency department staff of a single university hospital of milan (italy) (foundation cà granda-ospedale maggiore policlinico). macsim Ò was used to reproduce the hospital resources, with different mci scenarios. during the simulation the participants had the opportunity to test the local pemaf, in adjunct to their knowledge and skills. course effectiveness was evaluated by a pre-and post-course self-assessment questionnaire. results: macsim-pemaf was tested in seven courses, for a total of participants. pre-and post-test questionnaires showed a significant improvement in hospital staff self-perception of knowledge and skills in mci management. on a - scale, the improvement value was from . ± . to . ± . (p \ . ). conclusions: macsim-pemaf is a useful tool to test single hospital pemaf. it is versatile enough to adapt to specific realties, mimicking different traumatic scenarios. participants, acting in their usual professional roles, can increase their self-perception to be able to respond to a mci with in-hospital resources. introduction: emt are field health facilities, specifically structured to operate in case of disaster, where local healthcare resources are insufficient. there are types of emt. ''emt regione piemonte'' is the first italian emt to be certificated by who. it's a type , meaning that more than triage and stabilization of emergency cases it's provided with an icu, a / working operation room, a test lab, radiological and ultrasound devices. it can admit up to inpatients. cyclone idai made landfall on / / in the district of dondo in mozambique. it brought torrential rains and strong winds and had heavy impacts on the city of beira and surrounding areas resulting in loss of communication and access. in addition important damage and destruction to shelter, settlements, health and wash facilities occurred. on / italian government approved the aid mission, from march st to th three italian military aircraft transported the medical staff and the boxes containing the hospital to maputo and then in beira. on / , the hospital began working, treating an average of patients and performing - surgeries per day, involving mozambican staff who immediately well integrated with the italian colleagues. results: days of activities. surgeries ( orthopaedic, general surgery, gynaecology, plastic surgery). . % of the cases related to cyclone. mean tiss: ( - ). mean age ( - ) females, males. types of anaesthesia: % locoregional, % general, % analgosedation. conclusions: our first experience in a mass casualties' scenario showed how important is to refresh team skills through periodic drills. the leadership is of paramount importance to keep the team united and to support collaboration with other nations' teams and with the local population. adaptability and open-mindedness are fundamental. emts do not arrive in loco immediately so that longer periods of mission and integration with local medical staffs should be programmed. introduction: in utrecht, the netherlands, a worldwide unique major incident hospital is continuously standby to receive multiple victims during mass casualty events. each year, different types of mass casualty events are simulated with a varying number of victims, to train command and control under extreme circumstances. in utrecht, on march th , a terrorist opened gunshot fire in crowded public transport. the aim of the study is to compare our experiences in simulation versus reality. material and methods: an internal evaluation was performed by questionnaires completed by participants and an external evaluation was performed by interviews. results: all five victims were brought to the major incident hospital, of whom two were dead on arrival, one died seven days after due to multiple organ failure and two survived after multiple surgical procedures. all victims arrived within min after the major incident hospital was activated. a sufficient number of medical staff was alarmed for these five victims, however, since the event occurred during office hours, at least a double amount of staff showed up. among some medical staff on commanding key positions fear arose about their own safety and of relatives outside the hospital. this was exaggerated by incomplete and incorrect provided information from the scene. although medical care of the victims was not affected at all, occasionally the anxiety negatively influenced the command and control structure. conclusions: the combination of anxiety and a surplus of awaiting and benevolent curious medical staff resulted in occasional insufficient performance of the existing command and control structure, despite proper training. however, simulation of fear in a training is very difficult. nowadays, with the increasing threat of terror attacks, one should be aware of the influence of fear and anxiety on personnel, even with low numbers of victims. ethic and law issues during mass casualties management operations in foreign countries introduction: mass casualties incidents occur even more frequently during the last years globally. international help in order to manage them, when needed and asked, has to take into consideration special aspects of ethics and local law status in order to successfully fulfill its expectation. purpose: to demonstrate the ethic and law issues that arise during mass casualties management operations in foreign countries. material and method: literature review from recent management operations in syria, iran and sub saharan africa. results: during such operations a lot of ethical and law issues arise. the knowledge of ethics and laws in the country that these take place is essential and critical for the successful result of them. special care must be taken for the management of women, children and dead people. traditions and religion status of the local populations also must be taken into consideration and actions must take place in accordance to respect of the local authorities and social conditions. conclusions: mass casualties management operations in foreign countries is a challenging mission. ethic and law issues arise and must be taken into consideration for the success of the mission. western surgical experience is one thing, but surgical practice in countries in conflict zones is another. the pathologies are different, the thermal conditions are often difficult and the follow-up of the patients is fundamentally modified. humanitarian surgery is becoming more professional and most organizations are setting up a training program for new surgeons embarking on the humanitarian adventure. international committee of the red cross (icrc) has implemented an onboarding-surgeon experience, before to become a fully icrc surgeon. i hereby present my personal onboarding experience in south sudan: how to learn a new type of surgery, how to come with an helicopter to collect patients in the bush and then, how much you learn about yourself. conflict of interest: i only represent my own experience and i do not represent icrc. surgical clinical reasoning during the war in the period between and , i was the head of operating rooms and icu at the clinic for orthopedic surgery and traumatology, in sarajevo. working in the operating room whose walls are shaking because of the sniping and shelling was not remembered by any other generation of surgeons. there were around traumatized citizens of sarajevo. thousands of injured, dying patients were seeking for help from a small number of surgeons. the duty of a surgeon working in the war conditions, without water, electricity, medicines, or heat, is not easy at all, and there were a lot of difficult situations. for example, one day, operated children were again wounded by direct shelling on the walls of pediatric department of our clinic. after we re-operated the children, we also operated the injured nurses. th may, , th february, , and th august, were the most painful experiences in the surgical treatment of disaster in the center of sarajevo, with a large number of massively traumatized patients. while you were helping one casualty, others were pulling our arms or legs. while you were helping one patient, others were dying in the cramp of pain. during the war, a series of traumatic events happened. above many thousands of them, i admitted a -year-old girl, severely injured, with traumatic lower leg amputation of the leg, and severe injuries of the thigh, pelvis, and neck. we operated on her through the night. during the surgery, she received whole blood transfusions. following the surgery, she was stabilized on pediatric department of our clinic. one day, i saw her mother brought her a gift, immensely valuable in those days, a small canister of pure water. in the , one girl approached me, and asked me if i remembered her. i remembered the canister of pure water. she was happy to show me how she can walk now, and told me she lives in canada and works as a university assistant. i was more than happy to see her walk proudly, as she was leaving. she injury pattern of earthquake in athens, greece: the panic-effect introduction: earthquakes are devastating events. greece is known to be in the first place of seismicity in europe and sixth worldwide. lately, a . richter earthquake shook the greek capital, and fortunately no substantial construction damage was sustained. the aim of the study is to evaluate the classification and severity of all injuries, as well as the type of orthopedic surgical procedures performed, in addition to the role that panic plays on the occurrence of these kind of trauma material and methods: prospective case-series study, conducted in the emergency department of our hospital after the july th, earthquake. the study included patients treated by our department, who sustained injuries in their attempt to run away from the scene. age range was from to years old (mean . y.o), were female and were male. results: a total of injuries reviewed. upper extremities were involved in of all cases, lower extremities in and one patient suffered minor head trauma. four patients required hospitalization and all of them underwent surgical treatment. open reduction and internal fixation performed in patients ( calcaneus fracture and olecranon fracture), patient underwent intramedullary nail fixation (tibial shaft fracture) and external fixation was applied to another (distal tibia fracture). six patients were conclusions: panic is an independent contributing factor in natural disaster associated trauma. prior education, preparedness and combined team effort are clearly needed, in order to reduce the incidence of these injuries. regardless of age, panic may result in various types of fractures, even in cases there are no substantial construction damages after an earthquake. digital and analogue record system for mass casualty incidences at sea: results, reliability and validity introduction: mistriage may have serious consequences for patients in mass causality incidences (mci) at sea. therefore, an exercise was conducted to compare the reliability and validity of an analogue and tablet based recording system for triage of sample patients. material and methods: volunteers were asked to triage with the start-algorithm (black, red, yellow and green) patients in a given time using an analogue and tablet based system. triage score distribution and agreement between the two triage methods and a predefined standard were reported. the present study assessed the triage results as well as the reliability through cronbachs alpha and kappa. for testing of validity and internal consistency, the sensitivity, specificity and predictive value was measured. results: forty-eight participants completed a total of triages. while the number of triaged patients in the given time was significantly higher with the analogue system compared to the digital system (p-value . , t-test), the validity measured with the cronbachs alpha and unweighted cohens kappa was higher with the digital system. for each triage category, higher values were gained with the digital system. the sensitivity, specificity and predictive value for the digital system was higher than for the analogue system. conclusions: this study gives reliable and valid results comparing a digital versus an analogue triage system for a mci at sea. significant differences could be found for the number of triages and the number of under triage. the results of the study show that the used digital system has a slightly higher reliability and validity than the analogue triage system. references: the present work is part of the project improved emergency treatment and organization in the event of a mass casualty of casualties at sea (venomas), planned within the framework of the research network ''kompetenz und organisation für den massenanfall von patienten in der seeschifffahrt'' (kompass) and funded by the federal ministry of education and research (grant number: n ). predicting outcome for extremity wounds in pediatric casualties of war introduction: during the early s, the international committee of the red cross (icrc) implemented the red cross wound classification (rcwc) for penetrating wounds. wound grades of , and describe the amount of kinetic energy transferred to the tissue (low, high and massive, respectively). currently, this classification system mostly serves as a descriptive tool, but it is hypothesized it could also support clinical decision making. the aim of this study is to assess whether the wound grade of a pediatric patient's extremity wound correlates with patient outcomes. material and methods: this study included pediatric patients (age \ years), who have been treated by the icrc for conflictrelated extremity injuries between and . the correlation of the following variables with the wound grade were analyzed: number of surgeries required, length of stay, and in-hospital mortality. results: the study cohort consisted of pediatric patients. the higher the wound grade, the more surgeries were performed per patient (p \ . ), with a mean of surgeries per patient if they had a wound grading of . there were no significant differences in mortality rates between any of the wound grades, which were . % ( / ), . % ( / ) and . % ( / ) for wound grade , and respectively. pediatric patients with wound grade were hospitalized for the longest period (mean . days), followed by wound grade (mean . days) and wound grade (mean . days; all with p \ . ). conclusions: the wound grade of pediatric patients' extremity wounds appears to correlate with some patient outcomes, but not with mortality. grading of extremity wounds according to the rcws could support clinical decision making in pediatric patients. introduction: during the last few decades, french armed forces have regularly deployed in asymmetric conflicts. surgical support for casualties of these conflicts occurs in nato role and medical treatment facilities (mtf); definitive surgical care occurs in france following a strategic medical evacuation. the aim of this study was to describe the combat injury profile of these soldiers who presented with either non-exclusively orthopedic and/or non-exclusively brain injuries. material and methods: this descriptive study is a retrospective analysis of the surgical management of french casualties performed in role or mtf in afghanistan, mali, niger, djibouti and the central african republic between january and december . results: one hundred patients were included. forty had fragment wounds. the most severe lesions were of the head, neck or thorax. the average injury severity score (iss) was . (ic % . - ). damage control procedures were performed. thirty patients died with a mean iss of (ic % - ); deaths were considered as preventable deaths. the most frequent surgical procedures in the mtf were digestive (n = ) and thoracic surgery (n = ). thirty patients needed second-look surgery in france; eleven had severe complications. no patient died following medical evacuation to france. conclusions: results from this study indicate that the mortality following non-exclusively brain or orthopedic injuries remains high in modern asymmetric conflicts. introduction: telemedicine has been applied to disasters and extreme environments for more than years, however, despite the many lessons learned so far, telemedicine is still not a common part of the immediate disaster response. for this reason, a review of the literature was conducted to investigate whether telemedicine technology can be used to address medical and non-medical needs in extreme environments. material and methods: this systematic review included studies published in the period - , originating from literature search bases medline, scopus, cinahl and pubmed. the case of neemo project were studied so to evaluate the diagnostical and surgical care of the patients regarding the emergency response in a remote and constricted area, with limited human medical resources and using the telecommunications and telerobotic technologies. results: the majority of the included studies have highlighted the importance of telemedicine interventions in extreme environments, stressing that it is a viable solution to health care provision. in addition, it has been found that telemedicinal technology provides the possibility of virtual collaboration between healthcare professionals with various specializations. projects neemo , , engaged to eliminate the challenges of telesurgery. conclusions: future studies such as large multicentre randomized trials will have to be conducted that will lead to safe conclusions on the usefulness and efficiency of telemedicine applications in extreme environments. introduction: tourniquets are a critical tool in the immediate response to life-threatening extremity hemorrhage. the optimal tourniquet type and effectiveness of non-commercial devices is unclear, and the aim of this study. material and methods: this prospective observational cadaverbased study was performed using a perfused cadaver model with a standardized superficial femoral artery injury bleeding at ml/ min. five devices were tested: cat (combat application tourniquet), rats (rapid application tourniquet system), swat-t (stretch, wrap, and tuck tourniquet), a triangle bandage and a stick and a leather belt. volunteer medical students with no prior clinical tourniquet experience participated. each student underwent a practical hands-on demonstration of each of the tourniquets, prior to the test. using a random number generator, they then placed all tourniquets in random order. outcomes measures included time to hemostasis, total time to secure devices, estimated blood loss (ebl) and difficulty rating. a one-way anova repeated measures was used to compare efficacy between the tourniquets in achieving the outcomes. results: participants' mean age was ± . years and ( %) were male. all participants were able to stop the bleeding with of the tourniquets. with the rats there was a % failure rate. among the five types of tourniquets, time to hemostasis and ebl were not statistically significantly different (p [ . ). the swat-t required the longest time to be secured ( . ± . ), while the belt was the fastest ( . ± . ; p \ . ). conclusions: all five tourniquets, including the non-commercial devices, were effective in achieving hemostasis. a standard leather belt was the fastest to place and able to stop the bleeding. however, it required continuous pressure to maintain hemostasis. nevertheless, in an emergency setting where commercial devices are not available, improvised tourniquets may be an affective lifesaving bridge to definitive care. hospital preparedness for mass gathering events and mass casualty incidents in matera, european capital of culture for introduction: mass casualty incidents (mci) may occur during mass gathering events (mge). lack of preparedness of health system increases mortality. education and training are crucial. hospital mci plans are mandatory in italy, but they are poorly known. on , matera was declared italian host of european capital of culture for : the local hospital decided to revise the hospital plan for massive influx of injured (pemaf) and to start a program to train the staff. material and methods: the pemaf was reviewed through simulations that involved all the staff. a partnership with mrmi-italia (italian chapter of the international association medical response to major incident and disaster-mrmi&d) leaded to the support of experts and to the organization of residential courses based on the macsim Ò (mass casualty simulation) simulation tool. educational capacity of the residential events was tested through a self-assessment tool. results: alert, coordination and command sequences were defined. all the available resources were recorded and the functional areas identified. the communication network was improved. documentation and registration system was prepared. standard operational procedures (action cards) were created for the key positions. residential educational events of macsim-pemaf were organized. the educational capacity was tested through self-evaluation: knowledge of participants resulted improved. conclusions: mge are a great opportunity for the hosting community but they also represent an increased risk of mci. preparedness is mandatory for health system. the format macsim-pemaf seems to be adequate to review the existing plans and transfer skills to attendants. introduction: the cruise industry is facing a constantly growth of infectious diseases. some of them are reaching the extent of mass casualty incidences (mci), which are overwhelming the capacity of the local rescue system. our aim was to improve the ability to act in a mci due to an infectious emergency regarding the situation at sea/in the port. hamburg, as one of the largest ports in europe, was chosen for analysis. material and methods: the collaborative project ''adaptive resilience management in the port'' (armihn) is funded by the german federal ministry of education and research. scenarios due to an infectiological emergency were developed together with the university central department of occupational medicine and maritime medicine and the hamburg port health center in hamburg, germany. these scenarios were specified with all key stakeholders in the port. the organizational structure of the current emergency management was analyzed and a new concept was developed. results: for the ship and the port, emergency strategies dealing with mass casualties of injured persons are available. nevertheless, current concepts regarding this special situation of an infectiological mci were missing. we developed a new concept, which based on the models concerning mass casualties of injured persons. for this purpose, emergency surgeons can be recommended as experts regarding coping with a major emergency and for developing adaptive training concepts. conclusions: new operational concepts coping with mci of infectious patients were developed. in a second step, an emergency plan and a training concept for relevant stakeholders in the port will be developed. these will be evaluated in a full exercise in the port of hamburg and tested for their suitability. the results will be transferred to comparable infrastructures to cope with a major case incident with infected people in the port area. emergency surgeons should be involved in these steps due to their expertise. the work was funded by the german federal ministry of education and research ( n ). no further significant relationships. war surgery training, the use of swine model in military simulation center introduction: due to the international instability, our forces are deployed in many place and our military surgeons have to deal with ballistics trauma and improvised explosive devices related trauma. in order to be well prepared and effective in these isolated situation, the val de grace school (our military health service academy) provide a years course to train the young surgeon. this year surgical courses ended with war trauma surgery simulation on a swine model. material and methods: this use of the swine alive model is incorporated in the cesimco (military surgical simulation center) and also use for the training of our fully registered surgical team. this laboratory responds to all civilian authorizations and ethical considerations as enacted by european rules (felasa). results: the aim of this presentation is to show the different procedures and the teaching provided in this structure to improve surgical skills in war condition. all procedures are approved by the ministry in charge of the animal experimentation and respond to the animal welfare regulation. the number of swine used in these teaching is reduced to the minimum. we think that this animal model and its use in military forward surgical facilities, is the end point of the years military surgical course provided by the val de grace school. conclusions: this model is actually the most reliable and ethically acceptable teaching procedure we've found. during these teaching the students have to deal with open trauma and hemorrhagic lesions in damage control situation. we try to follow the different type of war related lesions observed in french military in order to stick to the reality of the field. this teaching is now mandatory before being deployed as a military surgeon on field. case history: -year-old male, previously healthy, admitted to the er due to shotgun injury to the right hip. during transport, the bleeding open wound was covered, two iv catheters were introduced, and saline and painkillers were administered. on admission, the patient was conscious, eupneic and normotensive, with a gcs score of . clinical findings: after the primary survey and exclusion of cranial, thoracic and abdominal lesions, the limb injury was addressed, showing a cm oval-shaped wound. the right leg was shortened and externally rotated. pulses were present but the patient referred calf and foot hypoesthesia. investigation/results: x-rays showed a comminuted pertrochanteric fracture and the presence of metallic foreign bodies. diagnosis: open right pertrochanteric fracture. therapy and progressions: initially, the wound was covered, and iv antibiotics and supportive therapy were given. in the or, irrigation, surgical debridement, and foreign body removal were performed, followed by orif with one dall-miles cable and a cephalomedullary femoral long nail. after surgery, the patient maintained lower limb hypoesthesia and had plantar flexion and foot dorsiflexion grade motor deficit. during follow-up, soft tissues recovered uneventfully and bone healing successfully occurred. full weight-bearing was tolerated at weeks post-op but the neurological deficits persisted despite physiatric treatment. electromyography confirmed severe partial lesion of the sciatic nerve. comments: generally, clean wound, fracture stability, restoration of circulation and skin closure of neurovascular structures are a priority and should be a reason for delayed nerve repair. introduction: despite mass casualty incidents (mci) are becoming a common concern, particularly regarding the care of paediatric victims, pure paediatric trauma centres (ptc) are still rare in europe. the purpose of this study is to assess the capacity of the hospitals in the metropolitan area of milan in case of mci involving the paediatric population, with focus on the pre-impact planning phase. material and methods: relevant literature and existing guidelines were reviewed by the representatives of four referral centres for the management of either trauma or paediatric patients. minimum standard requirements of care of paediatric trauma and consequently the maximal surge capacities for each hospital were defined based on the severity of injuries and personnel/equipment availability. results: overall, the four hospitals are able to treat patients with the highest priority (t ), to patients with intermediate priority (t ), and patients with deferrable priority (t ). severely injured patients \ years old should be preferentially transported to the hospitals with paediatric expertise, whereas patients between to years of age can be managed in multi-speciality structures. conclusions: in case of mci it is not always possible to rely on the availability of a ptc. hospitals with paediatric trauma care expertise can work in synergy with ptcs, or offer an alternative if there is no ptc, and should therefore be included in disaster plans for mci involving paediatric victims. case history: we present a case of a -year-old male with a proximal radius and ulna gunshot fracture associated with a complete lesion of the brachial artery, which was urgently repaired by grafting in his native country. a partial proximal radius excision was also performed. three months later, after soft tissue recovery, the ulna fracture was fixed with a dcp plate plus iliac crest bone graft. at months follow up x-rays showed hardware loosening, so the plate was removed and an external fixator was implanted. in this situation the patient attended to our clinic months after the initial injury. clinical findings: findings included proximal pin purulence, an elbow varus deformity and a limited joint motion: flexion °, extension °, supination/pronation °. investigation/results: x-rays and ct scan showed proximal ulna pseudoarthrosis. diagnosis: proximal ulna pseudoarthrosis after a gunshot fracture. therapy and progressions: a two-stage procedure was performed. initially we performed a wide debridement and external fixator removal. an ulna nail combined with gentamicin and vancomycin pmma spacer was implanted. s. aureus was identified in intraoperative cultures. in a second stage, year after, the nail and spacer were removed and a vascularized fibula graft with saphenous loop was implanted and fixed with a va-lcp plate. the central band of the interosseous membrane was repaired with a prosthetic device. currently, the patient presents full flexion range, hyperextension of °, active pronation of °and supination of °. x-rays show graft consolidation. comments: gunshot fractures are complicated lesions with significant soft tissue damage and high risk of vascular and nervous injury. a thorough study and initial systematic approach is mandatory in order to avoid later complications. introduction: the purpose of our study was to independently analyze pediatric trauma data, especially that of preschool-aged children, including demographics, injury patterns, the associated mechanism of injury, and outcomes, at a single institution in korea to gain a better understanding of current trends in non-regional trauma centers. material and methods: we conducted a retrospective review of preschool-aged children with trauma, who presented to the emergency department a single center between march and december . results: overall, there were pediatric patients who experienced trauma admitted during this study period. the frequency of admissions was similarly high in all seasons except winter. falls were the most common mechanism of injury at all ages, except , , and years of age, according to comparative analysis by age and mechanism. the most common place of trauma at - years of age was at home, and outside the home at the age of years or older. the most common injury region was to an extremity ( . %). mean injury severity score was ± . , and the mean hospital stay was . ± . days. conclusions: although mortality from trauma is low in pediatric patients, we must continue to improve treatment outcomes for children. it is unlikely for a hospital to have a pediatric trauma specialist, such as a pediatric orthopedic surgeon or plastic surgeon, due to manpower constraints. in order to further improve the outcome of treatment with insufficient resources, it is necessary to recognize agespecific characteristics. question: the new safety situation in europe and the lessons learnt civilian events of damage show that hospitals have to be prepared for mass casualties. the shift of the operational mode to ''emergency medicine'' have to be planed and practiced. the reporting tool for this is the hospital action plan (hap) that every hospital should have. the efficiency of the existing plan is already proven in different largescale exercises. in germany the legislator obligates the hospitals to enable there staff to properly perform the different tasks of the hap. in addition, the have to develop and evaluate proper training and exercises. goal of this study was to establish along the hap of a level one trauma center an modular mass casualty training (manv ) that would help to analyze the tasks to face and to deepen the existing structures of communication. method: we set a scenario with casualties and evolved the different shifting phases of the trauma center (alarming-, mobilization-, constitution phase). setting the concept of training outside the regular service period we took in account that there will be a lack of resources and material. we did not exercise in a large-scale but trained in small groups modular. we also did a screen adaption of the hap of the trauma center to have a mind set for the staff and a starting point to the scenario. to teach our operative procedure we simulated our '' columns concept'' (medical, personal and infrastructure) to the staff. specific to the different task groups (medical doctors, technicians, nurses) we exercised and the different sectors (er, triage, or, command etc.) and the necessary shifts of the different hospital sectors when a mass casualty occurs. before and after we did a query of the staff to see how much impact the modular exercise would have on the hap-knowledge of our staff. results: we were able to simulate realistically an identical mass casualty scenario to different staff groups of our hospital. knowledge about the hap increased significant from to % after the trainings. % of the staff see a clear improvement of information about the hap. also, the specific shifting-phases and the enrolment of the plan to move in an ''emergency medicine mode'' understand % better. % of the staff fell now a much better preparedness than before. % think that through modular exercises and small group training the communication in between working groups improved. conclusion: we could manage to improve a significant increase of knowledge about the hap in our staff. all the small group modular training in the different sector can be easily but together in large-scale exercise and other teams like police, military or fire-department can easily be added. introduction: dstc course focusses on surgical skills for trauma care. it is designed to teach surgical techniques for the definitive treatment of severe trauma. currently, it has evolved into an international trauma team course. our objective was to assess faculty members' opinion regarding course content, educational methods, and incorporation of non-technical skills. material and methods: a descriptive study was designed using an anonymous online survey issued from may to august , . senior international faculties' opinion from countries assessed. the survey inquired views of courses content, duration, adequacy of hands-on practice, need for updates, and usefulness of incorporating non-technical skills to the course. results: from the surveys issued, were ( %) answered. the course content was valued as very satisfactory by %; % were very satisfied or satisfied with courses educational method. % considered the time devoted to lectures, case discussions, and skills lab very adequate or adequate. course duration ( days) was valued suitably by % of responders. the inclusion of non-technical skills was considered as very important by %, important %, of some importance %, of little importance by %, and unimportant by %. this result reflects the insufficient sense of significance, among some, of the importance of trauma team dynamics. course content updates were seen as convenient by % of the surveyed population, suggesting them at least every - years. conclusions: dstc international faculty response to the online survey tool was inadequate, receiving % of the targeted study population. of the assessed faculty, most were satisfied with course content, duration, and educational methods. the surveyed population lacked a uniform perception of the importance of incorporating nontechnical skills. introduction: dstc is an iatsic course emphasizing on teaching surgical skills for trauma care. in many countries, it is an essential course focused on the ''second hour'' beyond atls and teamwork. initially centered on the surgeon, it currently seems to be adopting a trauma team training (ttt) model, incorporating the anesthetist to the program (ds-datc). our objective was to review this changing trend in three countries: spain, portugal, and brazil. material and methods: a descriptive study was designed by faculty from the three countries examining course records and analyzing its evolution during the last five years. number and types of courses delivered in each country from to reported, and the proportion of dstc to ds-datc scrutinized. frequencies and percentages calculated for categorical variables and the proportion of course types also determined. results: during the -year studied period, dstc courses were issued: ( %) in spain, ( %) in brazil, and ( %) in portugal. a total of ( %) ds-datc courses in the three countries, and the percentage of total delivered in each country was as follows; spain ( %), portugal ( %) and brazil ( %). overall ds-datc to dstc ratio was : , detailed as follows: portugal : , spain : , and introduction: thailand is a disaster-prone country with a high dependency on tourism. it has been affected by both natural and manmade emergencies. the thai emergency healthcare system consists of emergency physicians working at hospitals and prehospital levels, emphasizing their essential role in emergency management of any incident. we aimed to investigate the thai emergency physicians' level of preparedness by using tabletop simulation exercises and three different scenarios. material and methods: using the lc (three level collaboration) method, two training sessions were arranged for over thai emergency physicians, who were divided into three groups of prehospital, hospital, and incident command staff. three scenarios of a terror attack and explosion, riot and shooting, and high building fire were discussed in the groups. results: our findings indicate that the initial shortcomings in command and control, communication, coordination, and the ability of situation assessment increased in all groups step by step and after each scenario. new perspectives and innovative measures were presented by participants, which improved the whole management on the final day. conclusions: tabletop simulation exercises increase the ability, knowledge, and attitude of thai emergency physicians in managing major incidents in strategic, tactical, and operative managerial levels, and should be included in their professional curriculum. introduction: non-operative management of traumatic injuries has led to decreased surgical exposure for trauma trainees [ ] . while simulation using cadavers may improve exposure to damage control techniques, tissue handling realism is variable depending on embalmment and perfusion techniques [ ] . objective: to evaluate the feasibility of perfused thiel cadaver use for trauma surgery simulation. material and methods: thiel cadavers were cannulated in the ascending aorta and right atrium to create a left-to-right perfusion system. a magnetic pump was used to achieve a pulsatile flow with a gelatin-based solution, aiming for a flow of l/min. peripheral circulation was improved with arteriovenous fistulas (carotid-jugular, femoro-femoral and brachio-brachial). a left common iliac vein injury was performed laparoscopically through the sigmoid mesentery. the surgical trainee was blinded to the initial injury and assisted by a staff surgeon. results: a trauma laparotomy was performed. the small bowel was eviscerated and all four quadrants were packed with gauze. a left, expanding zone iii hematoma was detected. the left sigmoid colon was mobilized to achieve proximal control of the left iliac vessels. the left common iliac vein was actively bleeding and ligated according to damage control principles. the left ureter was uninjured. the sigmoid mesentery was closed, without active bleeding. the remaining of the abdominal cavity was explored without other injuries. time from laparotomy to closure was min. tissue handling and circulation dynamics were highly realistic due to thiel embalmment and pulsatile perfusion. conclusions: pulse-perfused thiel cadavers represent a realistic simulation option for surgical trainees. widespread implementation may provide accurate simulation for lifesaving procedures rarely performed in an era of non-operative management of traumatic injury. a new concept of intra-operative performance monitoring and self-assessment in hepato-pancreato-biliary surgery and other surgical specialties s. kharchenko , , m. yanovsky colmar civil hospital, university of strasbourg, department of general surgery, colmar, france, hepato-biliary institute henri bismuth, paris, france, interceg, kharkiv, ukraine introduction: currently, the majority of learning curve studies for surgical interventions associated with simple chronometric estimation in a whole: from incision to closure. a selective approach for step-bystep time fixation of all hpb interventions (hepatectomy, others) or other surgical specialties can bring a new vision of correlation between intra-operative timing and the clinical outcome. material and methods: every operation can be divided into step items so standardized worldwide, for example, planned or urgent laparoscopic cholecystectomy e.g. incision to port placement, exposure, dissection to cholangiography, cholangiography, extraction, closure. results: the prototype named chronoi of infrastructure for automated monitoring (simulator of time tracking activities, web-service for request processing, database and knowledge base collection subsystems, learning curve representative and analytics software) is designed and to be implemented. individual self-assessment is available in a real-time fashion. the learning curve changes are shown per procedure. up to our knowledge, we can firstly in the world describe the surgeons, incl. in hpb, as speedy, standard or nonstandard depending on the surgeon's ''individual speed'' in operative performance. it's to be documented in their e-logbooks according to the current fellowship standards or practice re-certification. conclusion: the intra-operative monitoring and worldwide standardization give a new vision of the surgical practice in hpb surgery meaning an introduction of monitoring-based clinical outcomes (timing with morbi-mortality or other). only new trials will approve the role of the presented concept in hpb surgery as well as in general, emergency and trauma. introduction: the management of patients victims of war weapons and collective emergencies represents a major public health issue in france, but also abroad. terrorist events in recent years on the national territory have highlighted the need for training the population and caregivers in the management of these injuries. because of his experiment in the domain, the french military medical service (fmms) was requested to cooperate with the french prehospital teams in order to improve knowledge and teaching in this area. today, a continuing medical education, easily available and free access is needed in this area. material and methods: development of video podcasts (infographics) of a few minutes on the theme of management of patients victims of war weapons and collective emergencies. the working group ensures the production and quality of educational messages. production is provided by the communication establishment of defense. the broadcast is displayed on the channel you tube of the fmms. results: the title of the traum'cast podcast is the contraction of trauma and podcast. twelve episodes are scheduled on a -weeks rhythm. the podcast program is as follows: conclusion: fmms knowledge and experiment in managing patients victims of war weapons is unique. teaching can take various forms, theoretical, practical, academic, or through publications. traum'cast is a major innovation in the dissemination of this knowledge and each episode focuses on a specific skill. traum'cast will highlight the applicability of military medicine concepts in a civilian environment. traum'cast will be translated in an english version. project was supported by grants of french ministry of defense (innovation department). splenectomy in current surgical practice: a tricky and elusive procedure for the surgical resident? introduction: splenic rupture and oncologic resections are the most common indications for splenectomy, but technical expertise is progressively being taken over by non-operative and more conservative approaches. material and methods: retrospective review of all total splenectomies performed between february and january at an italian academic hospital, assessing demographics, diagnosis, operating surgeon, surgical approach, complication rate, postoperative critical care admission, and -day mortality. results: over years, consecutive splenectomies were performed by different surgeons, of whom surgical trainees, with unplanned (i.e. emergency/iatrogenic injury) and planned (i.e. benign/malignant disorders) procedures and an average of . and . procedures per year respectively. over the study period, only surgeons performed at least procedures and only performed at least procedures. laparoscopy was performed in . % of cases, predominantly during planned procedures, with an overall . % conversion rate mostly related to technical difficulties (i.e. spleen dimension, difficult vascular visualization). overall major postoperative complication rate (clavien-dindo c ) was . %, slightly higher in emergency procedures although not significantly different ( . % vs. . %, p = . ). reintervention rate was . %, due to hemorrhage in more than half of cases. overall -day mortality rate was . %, with elective -day mortality rate of . % (p = . ). conclusions: splenectomy may be required ever more rarely but potential risks are not irrelevant. competence for surgical trainees should be achieved elsewhere (e.g. simulated/cadaveric training case history: an year old femal patient underwent changing of the components of the tha because of aseptic loosening. due to circumstances the surgeon decided to implant a cemented femoral component. the procedure was without any significant abnormalities. the first postoperative radiograph was planned after recovery-as usual. the x-ray imaging showed a misplaced femoral component. therefore a ct-scan was performed additionally and the malposition of the cemented femoral component was confirmed. the patient had to undergo another surgery-removing of the cemented femoral component and implantation of a new well placed one. therapy and progressions: after prompt resuscitation, an emergency laparotomy was performed and an anastomotic leak was found, requiring re-do ileo-ileal anastomosis. postoperative course was complicated by intra-abdominal collection treated by antibiotics alone (clavien-dindo grade ). the patient was discharged on th pod. at pathological report, segmental absence of intestinal musculature (saim) was diagnosed. the revision of past specimens confirmed the same finding. comments: usually recognized in neonates/premature infants, saim is generally an incidental finding in adults [ ] , often undiagnosed and more frequently described in the colon [ ] . in such scenario, main differential diagnosis is ischemia. etiology is unclear and can be classified as either primary/congenital or secondary. the former is characterized by acute onset of symptoms, whereas in the latter a longer history of intestinal symptoms is usually present [ , ] . most authors agree upon a congenital pathogenesis. generally, saim is associated with hollow viscus perforation and treated with surgical resection. contrary to our experience, no recurrence of intestinal perforation has been reported [ ] virgen del rocío university hospital, general surgery, seville, spain, hospital regional de málaga, general surgery, málaga, spain, hospital de estella, general surgery, navarra, spain, hospital gregorio marañón, general surgery, madrid, spain, complejo hospitalario de jaen, general surgery, jaen, spain introduction: specific training in the management of trauma patients is essential for surgeons. training through courses in this area (atls, dstc, musec) directly impacts the care of these patients. the aim of this study is to know the specific training in trauma care of spanish surgeons. materials and methods: a national survey has been sent to all member surgeons of the spanish surgeons association. it has evaluated their degree of participation in emergency surgery acute care, and therefore the possibility of attending trauma patients, their participation in the initial care at their hospital, as well as their specific training in this area. results: the survey has been completed by surgeons from spanish regions, and most surgeons who responded were from catalonia and andalusia. ( . %) of those surveyed take calls for the ed. only ( . %) report having a hospital registry of trauma patients. . % of surgeons answer that in their hospital the general surgeon is not involved in the initial care of trauma patients. . % have taken the atls course, . % the dstc course, and . % the musec course (or another course on e-fast). despite this, . % consider the atls course should be mandatory during residency, and . % of those surveyed consider trauma care in their hospital as very bad or deficient. conclusions: according to this survey, specific training in trauma care is still deficient in spain and with many aspects that can be improved. only % of those surveyed have received specific training in definitive surgical management of severe trauma. despite this, a large percentage of surgeons take calls for the ed routinely, and face the challenge of managing these patients. exploring team leaders' decision-making challenges in civilian and military complex trauma introduction: in the nordic countries professionals may work in both civilian and military trauma care. timely and effective decisionmaking in complex trauma is essential in improving survival benefits. the mindset and management priorities differ among medical professionals, and correlate with different experience levels. trauma leaders are usually senior surgeons with extensive experience and well-developed decision-making skills. simulation training has been shown to be effective in practicing decision-making. the aim of this study is to explore the team leaders' decision-making challenges in complex trauma care and structure them with the activity theory framework (at). material and methods: video recordings at a trauma center in johannesburg and live observations of complex trauma training in gothenburg focusing on team leaders' decision-making challenges were analyzed and systemized using the at. results: the team leaders' activities were mapped onto the main elements of at ( fig. ) whereby the decision making challenges were classified into six categories (table ) . conclusions: the at framework may benefit and inform the design of educational interventions by structuring key issues of complex activities. introduction: trauma is one of the main causes of mortality worldwide and prevention stands out as one of the main ways to modify its incidence. a prime example of such initiatives is the prevent alcohol and risk-related trauma in youth program (p.a.r.t.y.). it aims to raise awareness of the population most at risk for trauma, young people from to years. the study objective was to evaluate the program impact on students' knowledge and behavior. material and methods: a quantitative, uncontrolled intervention cohort study was conducted through the responses of the p.a.r.t.y. in and . data collection occurred through the application of a questionnaire to participating and non-participating students of public schools in the city of campinas, after a few months of participation in the program. results: among answers, . % were male, . % between and years, and . % program participants. time between participation and answers was . (± . ) months. regarding the first conducts when facing traffic trauma, . % of those who participated chose the correct answer, against . % of those who did not. about the first care while the service does not arrive, . % of the first group answered correctly, compared to . % of the second. concerning about the service that should be called in the event of a trauma, . % of participants would call correctly against . % of non-participants. in questions related to traffic laws, . % of participants opted for the correct answer as to what should be done in the face of a running over, against . % of non-participants. conclusions: students who had participated in the program had a higher rate of correct answers, a few months after the event, compared with students who did not attend. thus, it is concluded that there is a impact over the time caused by it. introduction: currently, intraosseous (io) devices are necessary for the resuscitation of severe trauma patients. however, opportunities to learn io device insertion are limited for residents. the aim of this study was to conduct a simulation of io device insertion for residents and to evaluate its effectiveness. material and methods: in this simulation, residents inserted io needles into the sternum of pigs under general anesthesia with the instructor's guidance. comprehension tests and questionnaires about satisfaction level and self-efficacy were conducted before and after the simulation. the objective evaluation was the io access success rate, and the subjective evaluation was obtained from points on comprehension tests and questionnaires. results: thirty-six residents participated in this study. just one resident had successfully obtained io access clinically. success rate of establishing io access in the simulation was %. the rate of test completion was % and that of questionnaire with survey response was %. the comprehension test results improved from . ± . to . ± . (mean ± standard deviation, p = . ) out of points. the questionnaires concerning satisfaction level changed from . ± . to ± . (p \ . ) out of points. the questions specifically concerning self-efficacy dramatically increased from . ± . to . ± . (p \ . ) out of points after the simulation. conclusions: the simulation in this study improved the knowledge, satisfaction level, and self-efficacy of the residents for io access. the success rate of confirmation of io access in this study was %. this experience may positively affect their clinical performance in trauma care. case history: case . a -year-old white man presented to the ed complaining of intense abdominal pain and vomiting. he referred at least two previous episodes with associated fever which resolved spontaneously. case . a years old white man consulted at the ed for intense abdominal pain, nausea, anorexia and constipation for the last h. none history of abdominal surgery were registered. clinical findings: in both cases, the abdomen was distended without bowel sounds. investigation/results: case . abdomen xr: distended small bowel loops localized at the right side. ct scan: an encapsulated cluster of dilated small bowel loops into the ascending mesocolon. case . ct scan: an encapsulated nonrotated small bowel in the right side of transverse mesocolon and mesenteric vascular pedicle displaced. diagnosis: intestinal obstruction secondary right paraduodenal hernia therapy and progressions: emergency midline laparotomy that evidenced a rpdh which was reduced before closing the mesentery defect. the postoperative was uneventful. comments: paraduodenal hernias are a type of internal hernia and a rare cause of intestinal obstruction accounting for about . % of all hernias. right paraduodenal hernias are far less common than left ones. symptoms of paraduodenal hernias are nonspecific. preoperative diagnosis of pdh by imaging techniques is difficult. contrastenhanced ct scan is highly recommended as the most specific method of diagnosis for pdh. with the increased use and improved enhancement of ct scans, paraduodenal hernias currently can be diagnosed preoperatively. this advancement in diagnostics coupled with increasing experience and facility of general surgeons in using laparoscopic techniques has led to the initiation of laparoscopic repair of internal hernias. case history: a -year-old female patient who goes to the emergency department due to vomiting and abdominal pain. since the accident, the patient reported post-prandial discomfort and gastroesophageal reflux, as well as self-limited abdominal cramps. clinical findings: soft, depressible abdomen. bowel sounds on left hemithorax. investigation/results: cxr: right hemidiaphragm elevation. lab test: leukocytosis. thorax and abdomen ct: right anterior diaphragmatic hernia and passive atelectasis secondary to ascent of dilated small intestine and colon. diagnosis: intestinal obstruction secondary post trauma diaphragmatic hernia. therapy and progressions: emergency laparotomy due to symptoms compatible with intestinal obstruction secondary to incarcerated diaphragmatic hernia. it is right diaphragmatic chronic rupture chronic with omental incarceration, antrum, small bowel and ascending colon with reversible signs of suffering. chelotomy and content reduction, herniorrhaphy with loose spots with non-absorbable material are performed. endothoracic drainage is left removed at h. the postoperative course is uncomplicated. comments: trauma events should be considered in the diagnostic process to avoid delayed treatment. case history/clinical findings: we present a -year-old male patient with a history of large pelvic mass in the rectum-prostate space under study, since months. he were admitted into the emergency unit, days after the mass biopsy, with fever up to °c and rectorrhagia. the patient rapidly developed septic shock with hemodynamic instability and elevation of acute phase reactants. abdominal ct was performed: pelvic mass of . . cm, of heterogeneous content, with areas of blood density. we decided doing an emergency surgical exploration of this mass as the only suspected origin of infection. investigation/results: in the surgical exploration the mass was protruding on the anterior rectum wall. the mass was drainaged with an output of ml of purulent material mixed with clots and necrotic tissue. foley no. probe was placed inside the cavity. in the postoperative period, the patient showed significant hematochezia, so he was reoperated performing hemostasis and rectal tamponade. it was effective and a new foley catheter was replaced at h. when the purulent drain gave way, the catheter was removed and the patient evolved favorably. diagnosis: cytology analysis: mesenchymal type lesion, morphologically and immunophenotypically compatible with gist (gastrointestinal stromal tumor). ihq profile: cd , dog , c-kit positive. therapy and progressions/comments: the complications of gist are usually acute abdomen due to peritonitis secondary to perforation or hemorrhage. however, the formation of intratumoral abscesses is very inusual, although is described in the literature. emergency surgery is often necessary due to the significant affectation of the general condition of the patient and the difficulty of the diagnosis. fournier's gangrene (fg) is a surgical emergency defined by an obliterating endarteritis of the subcutaneous tissue arteries of infectious etiology, with progressive necrotizing fasciitis of the perineal, abdominal, thoracic or lower limbs, which can lead to multiorgan failure. a years old woman was admitted in our er presenting with a week worsening vulvar pain. clinical exam showed vulvar and mons venus erythema, without lesions, bp was / mmhg and she had a fever of . °c. blood work showed leukocytosis ( . /ll), neutrophilia ( . /ll) and crp of mg/ l. past medical history of obesity, right thp and total thyroidectomy. vulvar cellulitis was the initial diagnosis and empirical atb was implemented. on d , due to an evolution into septic shock and spread of an emphysematous inflammatory process to the right thigh and buttock, the diagnosis of fg was made. during emergent surgery we observed extensive fascial and tissue necrosis from the asis and suprapubic region to the proximal third of the right thigh and perineum. extensive necrosectomy, drainage of purulent exudate and transversostomy were performed. empirical second-line broad-spectrum atb was started. she underwent new necrosectomies and surgical debridements on po days and and needed icu stay for days. daily dressing changes were performed with povidone iodine and later with octenidine. microbiology sample showed polymicrobial infection with gram positive and negative organisms as well as anaerobes, thus confirming the diagnosis of fg type i of vulvar origin. after surgical and hd stabilization, the patient underwent plastic reconstructive surgery, with local flaps and partial skin graft. the postoperative period was uneventful and the outcome was great. introduction: appendicitis is not uncommon in the elderly but may often be mis-diagnosed [ ] . the aim of this study was to explore the specific traits and treatments of this group in a swedish context to better understand where to optimize the management. material and methods: all acute appendectomies registered in the southern general hospital registry between january and june constituted the cohort (n = ). patients were stratified into two groups; c and \ years of age. significances were computed with pearsons chi and anova. results: the older group made up % of the study population (n = ). the elderly population was female to a larger extent (or . , p \ . ), triaged higher in the emergency department (p \ . ) and had higher asa classifications (p \ . ). the elderly were also perceived as sicker at the time of decision for surgery, expressed as having higher priorities for surgery (p \ . ). no significant difference between the groups in time from arrival to decision for surgery was found, nor for the time from arrival to surgery. there was a higher rate of perforations in the elderly group ( . % vs . %, p \ . ), twice the length of hospital stay (p \ . ) but no significant differences in complication rates ( . vs . %, p = . ). twenty-eight day mortality rate was % in the younger group and . % in the older group (p \ . ). conclusions: this study shows that an elderly group of appendicitis patients are more frail and more acutely sick when presenting to the hospital. in spite of higher priority for surgery, the elderly experience longer hospitalization and higher mortality rate, but not more complications. the findings are consistent with antecedent research. introduction: existing evidence points towards the notion that patients undergoing emergency surgery receive a poorer consenting quality when compared to their elective counterparts. with , cholecystectomies in england a year, cholecystectomy is one of the most frequently performed procedures both in the emergency and elective settings. however, to date, no studies have explored the relationship between consenting quality and the setting of cholecystectomy. we aimed to measure the quality of informed consent (ic) for patients who underwent emergency vs elective cholecystectomy. material and methods: the final review included the analysis of ic forms completed between - . percentage proportions were calculated to demonstrate the degree of completeness of consenting against a total of components of information. binary regression was utilised for subgroup analysis. results: patients undergoing emergency surgery were more likely than elective patients to be warned of severe perioperative complications such as cardiac disorders ( . % vs . %, p = . ), fluid collection ( . % vs . %, p = . ), and infected bile spillage ( . % vs . %, p = . ). elective patients were more likely to be counselled about the risk of less serious side effects of cholecystectomy such as diarrhoea ( . % vs . %, p = . ). patients in asa - group were more likely to be counselled about the occurrence of pulmonary embolism. interestingly, patients were more likely to receive a patient information leaflet if they were females and under . conclusions: the results of this study demonstrate multiple inconsistencies in the level of disclosed information to patients undergoing cholecystectomy. the results suggest that the consenting physicians make assumptions regarding the information that the patient would like to receive based on patient demographics and clinical factors, highlighting the need for more consistent consenting procedures. acute calculous cholecystitis and the timing of cholecystectomy: advocating early surgery i. moutsos , r. lunevicius liverpool university hospitals nhs foundation trust, general surgery, liverpool, united kingdom introduction: cholecystectomy cures acute calculous cholecystitis (acc) in nearly all patients and, according to nice, augis, tokyo and wses guidelines, should be conducted at the earliest opportunity, within days of the diagnosis. the present audit aimed to measure whether the care of patients with acc meets the standards of best practice and to assess whether early cholecystectomy was a more beneficial and safer intervention as compared to delayed cholecystectomy. material and methods: a ''snapshot'' sample of patients operated on between / and / with an index admission diagnosis of acc was reviewed. the selected patients were divided into three subgroups according to the timing of their surgery: - (early), - , and[ days. the other measures used in this audit were the rates of conversion to open surgery, subtotal cholecystectomy (stc), perioperative complication-specific morbidity, secondary interventions, and admission to intensive therapy unit (itu). results: nine patients ( %) underwent early cholecystectomy-laparoscopic (n = ) or primary open (n = ); of the other patients-delayed laparoscopic cholecystectomy. the rates of stc were similar in both subgroups- . % ( / ) vs . % ( / ). delayed cholecystectomy was related to five side effects: higher rates of postoperative collections (three patients, . %), external bile leak (one patient, . %), ercp ( . %), emergency re-operations (two patients, . %), and admission to itu ( . %). they all occurred in the delayed [ weeks surgery subgroup of patients. conclusions: although no significant associations were found when comparing early to delayed cholecystectomy, this analysis shows that postoperative morbidity, the rates of secondary interventions and admissions to itu were higher when surgery was delayed. this audit advocates that early cholecystectomy should become a standard of practice as per national and international guidelines. esophagopericardial fistula following primary repair for chronic esophageal ulceration presenting with pericardial tamponade: a case report and outline of management and treatment case history: a -year-old man with chronic esophageal ulcerations presented with substernal pain, fever, and shortness of breath. a radiograph revealed a right pleural effusion and pneumomediastinum consistent with an esophageal perforation (fig. ). he underwent a right thoracotomy, primary esophageal repair with intercostal muscle flap buttress, and gastrojejunostomy feeding access. a post-procedural gastrograffin study demonstrated an anastomotic leak (fig. ) . a right thoracostomy drain was placed for diversion. the patient was discharged home and returned days later. clinical findings: he presented with substernal pain, hypotension, and fatigue. thoracic computed-tomography (ct) revealed a pneumopericardium and an esophagopericardial fistula (epf) manifesting as pericardial tamponade (fig. ) . diagnosis: epf. therapy and progressions: the patient underwent a subxiphoid pericardial window and mediastinal drain placement for decompression. an esophagogastroduodenoscopy revealed an exposed right atrium, thus precluding esophageal stenting. sepsis and antibioticassociated clostridium difficile colitis complicated his post-operative course. once resolved, the patient underwent a partial esophageal resection, epf ligation, and esophagogastrostomy. the postoperative gastrograffin study did not demonstrate an anastomotic stricture or leak. the patient tolerated a regular diet and was discharged home. comments: esophagopericardial fistula is a rare clinical entity most often caused by benign disease. prompt diagnosis and treatmentpericardial decompression and fistula ligation-is critical. due to wide use of proton pump inhibitors and development of interventional radiology (ir), causative reasons are changing. introduction: secondary peritonitis yields high morbidity and mortality rates. besides rapid source control, adequate antimicrobial therapy is essential to improve outcomes. thus initial empiric therapy has to take suspected germ spectrum as well as possible resistance rates into account. microbial selection and resistances may pose problems during prolonged administration of antibiotics. however, a possible negative effect of multi-resistant germs on mortality has not yet been clarified. the choice of a suitable antibiotic and the relevance of its efficacy on isolated germs as well as the relationship between germ spectrum and clinical condition of the patients need to be clarified. material and methods: intraabdominal swabs from consecutive patients from to requiring intensive care due to secondary peritonitis were evaluated retrospectively. patient characteristics and outcomes, germ spectrum and resistance rates were collected. changes over the course of therapy and development of resistance as well as influences on the clinical course were analyzed. introduction: complicated intra-abdominal infections (c-iai) represent challenging diseases with high mortality rates. depending on different selection criteria and therapy strategies the reported mortality rates vary between . and %. usually a distinction between community (cap) and hospital acquired peritonitis (hap) is made. hap can further be classified as postoperative peritonitis (pop) or non-postoperative peritonitis (hap-non-pop). we conducted a retrospective analysis of patients with c-iai requiring intensive care therapy. material and methods: all patients with c-iai requiring surgery and intensive care treated at the danube hospital in vienna from to were retrospectively analyzed. a total of patients where included into the study and grouped as cap, hap-non-pop or pop. for each group comorbidity and patient characteristics, source and cause of infection, hospital and icu stay, apache ii, saps ii and sofa-scores, mortality and outcome were calculated and compared to each other, using fisher exact test or mann-whitney-u-test. results: a total of c-iai were treated, consisting of . % cap, . % hap-non-pop and % pop. concerning the patient characteristics and comorbidities no significant differences were seen between the groups, except for malignant diseases which were significantly higher in pop. the postoperative (source control) apache ii and saps ii values did not differ between cap and pop (apache ii mean: cap . , pop . ) whereas both were significantly higher in hap-non-pop (apache ii mean: . ). mortality rates were not significantly different in cap and pop ( . % vs. . %): however, hap-non-pop was complicated by a nearly doubled death rate ( . %). conclusions: although patients with pop are described to have a higher mortality in the literature, this could not be shown in our study. postoperative survival was comparable between cap and pop patients. hap-non-pop demonstrated a significantly higher mortality. acute appendicitis and acute diverticulitis presenting concurrently treated surgically and conservatively clinical findings: on examination the abdomen was soft but there was tenderness and guarding in the right iliac fossa and suprapubic region. her observations were stable on admission and she was afebrile. investigation/results: laboratory tests demonstrated a wcc . ( /l) and crp of . (mg/l). urinalysis was normal. a ct of the abdomen and pelvis with intravenous contrast demonstrated acute appendicitis with non-perforated sigmoid diverticulitis (fig. , fig. ). diagnosis: concurrent acute appendicitis and non-perforated sigmoid diverticulitis. therapy and progressions: the patient underwent a laparoscopic appendicectomy. intraoperative findings included a retrocaecal inflamed appendix and diverticulitis in the pelvis which was not disturbed. there was no pus in the pelvis. she recovered well postoperatively and was discharged home to complete one week of oral antibiotics the following day. the histology demonstrated acute appendicitis. comments: there are very few reports in the literature of concurrent appendicitis and sigmoid diverticulitis despite these two pathologies being amongst the most common presentations of abdominal pain. this case demonstrates the value of cross sectional imaging, ct imaging is a helpful diagnostic tool and is highly sensitive and specific for both diverticulitis and appendicitis.the challenge in this case is balancing the two differing managements of these two conditions. most cases of diverticulitis are managed conservatively with dietary modification and antibiotics. operative management is only usually considered if there are associated complications such as intraabdominal perforation. this is in contrast to appendicitis where the standard treatment is to undergo surgery. references millions of people die from major trauma annually. - % of these deaths are due to exsanguination, with nearly half dying prior to hospital arrival. when properly managed, these deaths are preventable. this paper summarizes data relating to the extent of hemorrhage as a cause of mortality in the traumatic arena. an overview of the pathophysiological steps occurring during massive bleeding and their clinical implication is presented. a variety of treatment options, both historical and current, is then discussed, including vascular occlusion methods and hemostatic dressings, along with their limitations and complications. finally, woundclot, a new hemostatic gauze, is introduced, which not only requires no compression when it is applied, but allows the first responder to rapidly and effectively treat more than one casualty within seconds. additionally, it is adaptable to a wide array of clinical applications, both traumatic and surgical, including situations where vascular occlusion methods are not practical or are contraindicated. i am the clinical research administrator for core scientific creations treating acute colonic diverticulitis with extraluminal pericolic air; a multi-centre retrospective cohort study background: since the emergence of acute care surgery as an entity encompassing trauma and emergency general surgery there have been several studies evaluating patient outcomes noting a higher unexpected survivorship and expedited operative times, shorter hospital stays, and fewer complications for patients undergoing procedures such as appendectomy; however, these superior outcomes have not been demonstrated across the array of emergency surgical cases. the aim of this investigation is to determine whether patients operated on by acute care surgeons in a trauma center benefit from the trauma model of in-house availability, earlier availability of surgical care, and care dictated by evidence-based protocol. we examined our health care system's data to determine if trauma centers were to able to provide more timely care with improved outcomes, by focusing on truly emergent general surgery cases. this was examined by identifying and quantitatively comparing time to operative intervention, need for re-operation, hospital length of stay, duration of stay spent in intensive care unit, and patient disposition at time of discharge. methods: this is a retrospective cohort study. patients presenting with emergency general surgery conditions (incarcerated hernia, perforated viscus, sbo, necrotizing soft tissue infection) who underwent surgery within h of presentation were selected. outcomes were compared between patients presenting to our two trauma centers versus our two non-trauma centers. n = results: at this time we are nearing the finalization of our data interpretation. we are examining mean time to operation, los, icu los, need for re-operation, and disposition at discharge. discussion: although our data analysis is not complete we feel that the results of our data will shed valuable and needed light onto the care delivered to emergency general surgery patients by surgeons in this increasingly complex population. anastomosis leakage after hartmann removal, with conservative treatment at the beginning but after, bad evolution, a surgery was performed with colostomy and vac system. patient. after h, he develop a compartmental syndrome and a vac system was applied. investigation/results: patient. after the first change the distance between the two layers was cm and botulinum toxin was applied. pat. the distance between the two layers of abdomen was cm and botulinum toxin was applied. patient. the distance between the two layers was cms and toxin was applied. unfortunately, he suffered from a hepatorenal syndrome and died. diagnosis: open abdomen with distance between the two layers: cm, and cm. therapy and progressions: we have added botulism toxin with doses of units in each side of abdominal wall. patient. three changes after, the abdomen wall was closed. months later, the abdominal wall is ok. patient. a reduction of % was got. comments: the use of open abdomen in patients suffer from septic shock or after an abdominal compartment syndrome often poses a challenge in the abdomen closure. we have developed a protocol, dividing our patients according to the distance between the two layers in two group: more than cm or cm or less. in the first group ([ ), we present our first cases in our protocol. conclusions: botulinum toxin can make easier abdomen closure when the distance between the two layers is more than cms incidentally discovered splenic peliosis in a patient with no comorbidity clinical findings: a -year-old man with no comorbidities visited our emergency medical center based on a complaint of chest pain. the chest and abdomen radiographs, electrocardiogram, and cardiac markers showed no abnormalities; therefore, he was discharged from the hospital. two months later, he returned to our hospital with abdominal pain and distension. he was hemodynamically stable, and there were little tenderness and rebound tenderness on his abdomen, although he complained a slight abdomen discomfort investigation/results: no abnormalities were found on the laboratory examinations, including complete blood cell count, cardiac markers, and coagulation profile. an abdomen computed tomography revealed multiple hemorrhagic cysts on spleen with moderate amount of hemoperitoneum. diagnosis: ruptured splenic peliosis with hemoperitoneum. therapy and progressions: laparoscopic splenectomy was done because recurrent rupture of hemorrhagic cysts was strongly anticipated. on histologic examination, the blood-filled cysts were welldemarcated, distributed in red pulp congestion. no vascular-endothelial cells were observed, and normal lining cells were disappeared in the wall. comments: a peliosis is a rare disorder characterized by widespread, blood-filled cystic cavities within the parenchymatous organs. the liver is the most commonly involved organ, and an isolated splenic peliosis is extremely uncommon. patients are often asymptomatic; therefore, early recognition and withdrawal of offending agents is crucial. in cases with the rupture of surface lesions, which can occur spontaneously or by the minor trauma, prompt surgical management is necessarily required. splenectomy offers the advantage of a definite histological diagnosis with the complete elimination of the risk of recurrent hemorrhage. introduction: despite an evident success and advantages of endoscopic surgery, the discussion on reasonability of endoscopic surgeries in children with acute appendicitis is still going on. purpose: to assess the effectiveness of laparoscopic techniques for treating appendicular peritonitis in children. material and methods: children with appendicular peritonitis were operated in our hospital ( ) ( ) ( ) . they aged - years ( ± . ); . % of boys, . % of girls. appendicular peritonitis was registered in . % cases of acute appendicitis. three ports were used for the approach: appendectomy was performed by the ligature technique with roder loop. results: laparoscopic surgery is indicated in all forms of appendicular peritonitis, except appendicular abscess stage , and total abscessing peritonitis. in appendicular abscess stage , we perform a puncture and drainage under ultrasound control. - months later appendectomy is made. total abscessing peritonitis is an indication for laparotomy. laparoscopic surgery in patients with peritonitis has the following stages: diagnostic laparoscopy; sanation of the abdominal cavity by the aspiration of purulent exudate; ligature appendectomy; in diffuse and combined peritonitis a pelvic aspiration drainage is made. in appendicular abscess stage , we additionally put the aspiration drainage in the cavity of destructed abscess. conclusions: laparoscopic technique applied for surgeries in children with acute appendicitis has considerably improved outcomes introduction: nighttime emergency surgery is associated with increased postoperative morbidity and mortality [ ] , and delayed appendectomy due to acute appendicitis is not linked to a higher rate of postoperative complications (pc) [ ] . the aim of this study was to determine whether appendectomy on-call (oc) was associated with higher risk of pc. ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . two patients underwent major thigh amputation. negative pressure wound therapy and hyperbaric oxygen therapy were used in and patients, respectively. three patients died (mortality rate = %). conclusions: the mortality and major amputation rates ( % and %, respectively) were lower than those reported previously. in this study, even when patients had multiple organ failure or septic shock, major amputation was not always needed because of effective communication between the infection control team and intensive care specialists, resulting in radical debridement without amputation. material and methods: a systematic search in pubmed/medline, embase, cinahl and central was performed. the primary outcomes were mortality and amputation. these outcomes were related to the following time related variables ( ) time from onset symptoms to presentation; ( ) time from onset symptoms to surgery; ( ) time from presentation to surgery; ( ) duration of the initial surgical procedure. for the meta-analysis, effects were estimated using random-effects meta-analysis models. results: a total of studies ( patients) were included for qualitative analysis, of which patients died ( . %). a total of studies ( nsti patients) were included for the different quantitative analyses performed. mortality was significantly lower for patients with surgery within h after presentation compared to when treatment was delayed more than h (or . ; % ci . - . ). surgical treatment within h resulted in a % mortality rate compared to % when surgical treatment was delayed more than h. also, surgery within h reduced the mortality compared to surgery after h from presentation (or . ; % ci . - . ). patient delay (time from onset of symptoms to presentation or surgery) did not significantly affect the mortality in this study. none of the time related variables assessed reduced the amputation rate. conclusions: average mortality rates reported remained constant (around %) over the past years (fig. ) . surgical debridement as soon as possible lowers the mortality rate for nsti with almost %. thus, a sense of urgency is essential in the treatment of nsti. altemeiers procedure in an emergency setting case history: three patients with irreducible incarcerated rectal prolapsed were referred to our department for treatment. all patients were female and their age was , and years old. all patients suffered from severe co-morbidities. clinical findings: all patients presented with incarcerated rectal prolapse. in one patient there was macroscopic evidence of mucosal necrosis, whereas the other two patients had evidence of ischemia. the former patient was febrile whereas the latter did not exhibit signs or symptoms indicative of sepsis. investigation/results: blood panels demonstrated leukocytosis and elevated levels of c-reactive protein (crp) in all patients. apart from routine imaging upon admission (e.g. chest radiography), no other imaging modalities were performed. diagnosis: irreducible incarcerated rectal prolapse. therapy and progressions: initially manual reduction of the prolapsed was attempted without success. all patients were evaluated as high risk surgical candidates. altemeier's procedure was selected as a safer alternative to an abdominal approach. all patients were successfully discharged after resumption of bowel function. comments: incarcerated rectal prolapse is a rare clinical condition. initial management involves manual reduction of the prolapse. when this is not feasible, urgent surgical management is mandatory. in patients with severe co-morbidities, altemeir's procedure is a safe and effective treatment when performed by an experienced practitioner. introduction: treatment options for sigmoid volvulus are decided by its severity. uncomplicated cases are usually treated by endoscopic detorsion followed by elective surgery and complicated cases or cases can't be detorsioned are treated with emergency surgery. in this study we aim to review a single center experience in long term management of sigmoid volvulus cases. material and methods: data of the sigmoid volvulus cases between - were collected using hospital database. files of patients were reviewed for treatment modalities, demographic info and complications. patients were dropped from the study due to inadequate long term follow-up. results: were men and were women. mean age was , . endoscopic detorsion was attempted in cases. success rate was % (n = ). of these patients were followed up with elective surgery. patients with complicated cases and unsuccessful detorsion patients were managed by emergency surgery. hartman procedures, anterior resections, left hemicolectomies, subtotal colectomy and transverse loop colostomies were done. a stoma was created in cases. patients had their stoma created in the primary surgery and an additional of stomas were created due to anastomosis leakage. mortality rate in the first days was % (n = ) in patients with a stoma (n = ). asa and charlson co-morbidity scores were exceptionally high in the mortality group. in the remaining patient group, stoma closure rate was . %. conclusions: endoscopic detorsion is a powerful and highly successful management option in uncomplicated cases when done by an experienced staff. emergency surgery shouldn't be delayed in complicated cases or after unsuccessful detorsion attempts. introduction: esophageal perforation has high mortality rates when not treated aggressively. treatment options are conservative approach, endoscopic intervention and surgery. purpose of this study is to review cases of esophageal perforation in a single center and to evaluate types of diagnosis and treatment options. material and methods: using hospital database we collected data of patients diagnosed with esophageal perforation between - . we reviewed treatment modalities, demographic data and complications. patient was removed from the study due to insufficient long term data. results: were female and were male. average age was . . average time between the onset of symptoms and admission was . days. the most common etiology was iatrogenic (n = ) followed by consumption of corrosive substances in patients, spontaneous perforation in patients, esophageal tumour in patients and foreign body ingestion in patients. patients were treated surgically, patients were treated with endoscopic stenting and patient was treated with surgery following stenting. patients were managed conservatively with antibiotherapy. average time in intensive care was . days and average hospital stay was . days. mortality was seen in patients treated with surgery and patients treated with stents. conclusions: esophageal perforations are mainly iatrogenic but also can be caused by multiple reasons. especially in cases developed after endoscopy, rapid intervention can be a significant factor that can decrease both mortality and morbidity rates. introduction: spontaneous rupture of liver tumors (rlt) is a rare but potentially life-threatening condition. damage control techniques, namely perihepatic packing (php), is a resource for the most physiologically compromised patients, with more stable patients undergoing transarterial embolization (tae) or immediate resection. decision algorithm depends on patient status, available resources and liver function. the authors present their center experience in managing rlt and propose a management algorithm. material and methods: eighteen consecutive patients who underwent surgery for rlt in our department (january -october ). inclusion criteria: spontaneous rupture and evidence of intraperitoneal bleeding. fourteen patients were male. mean age of . years ( - ). thirteen patients ( %) presented in hemorrhagic shock. mean tumor size was . cm ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . most frequent pathological diagnosis were: hepatocellular carcinoma in cases ( %); adenoma in three cases ( %); metastases in two cases ( %); liver sarcoma in one case ( . %). median of seven units transfused by patient ( - ). statistical analyses with spss tm version . results: six patients ( %) needed immediate surgery (php in three and resection in three). five ( %) underwent urgent ([ h and \ h) and seven ( %) delayed ([ h) resection. hepatectomy was performed on all (fifteen minor and two major) but one patient php only. eight patients ( %) underwent tae prior to resection, two of them ( %) between php and hepatectomy. median length of stay days . major morbidity in three patients ( %); mortality in three patients ( %). number of transfused units associated with increased risk of complications (p = . ). conclusions: rupture of liver tumors is a severe complication. although hepatic resection, with or without preoperative tae, should be considered gold standard, damage control techniques such as php are the only option for physiologically compromised patients (fig. ) . seasonal variability of cellulitis: a five year retrospective cohort study introduction: it is commonly purported that the incidence of cellulitis is highly seasonal but there is little empirical evidence supporting this assertion. this year retrospective cohort study set out to identify whether there is a statistically significant relationship between an increase in temperature and incidences of cellulitis. as a corollary to this proposition, length of hospital stay for cellulitis was examined in relation to the level of inflammatory markers upon admission and micro-organism identified on culture. material and methods: this is a year retrospective single centre cohort study of all patients admitted with cellulitis to tallaght university hospital from to inclusive. the patient cohort was identified via the use of a prospectively managed database of all surgical admissions and corroborated via examination of clinical chart records. dates of admission were correlated with the average temperature of dublin as provided by the meteorological office of ireland. site of infection, inflammatory markers and the prevalent micro-organism were also identified whilst the length of admission was extrapolated from hipe (hospital inpatient enquiry) records. results: there were admissions for cellulitis with cases of necrotising fasciitis. there was a statistically significant (p \ . ) relationship between temperature and cellulitis with admission peaking in late summer/autumn. age correlated significantly with readmission. furthermore, the level of crp had a statistically significant prognostic value as an independent predictor for the length of hospital stay with a high level resulting in a prolonged admission. conclusions: there is a statistically significant relationship between a rise in temperature and the incidence of cellulitis. furthermore age is an independent risk factor for re-admission with same whilst inflammatory markers at time of admission can be used as a prognostic marker for length of stay. case history | clinical findings: a -year-old female patient, with history of type ii diabetes, high blood pressure and major depressive syndrome, was admitted in the emergency room department complaining of abdominal pain. based on the patient's history and physical examination, a presumptive diagnosis of renal colic was initially made. however, after days, the patient showed signs of fever, aggravated abdominal pain and vomiting. investigation/results | diagnosis | therapy and progressions: a ct scan showed the presence of a radiopaque foreign body near the duodenum, the presence of air bubbles outside the intestinal lumen and an hepatic abscess. we agreed to perform a laparoscopy, drainage of hepatic abscess and fish bone removal after successfully identification. after days, the laboratory findings showed persistent leukocytosis and raised cpr, which led to a second ct scan with maintenance of the hepatic abscess. the decision was to perform a percutaneous drainage. after the second drainage, the patient had an uneventful recovery. comments: foreign body ingestion into the gastrointestinal (gi) tract is rare and typically accidental in adults. most ingested foreign bodies pass through the gastrointestinal tract without the need for any intervention. gi perforation is rare and can occur at any site. surgical intervention is required in less than % of the cases. fish bones are the most commonly ingested objects. preoperative diagnosis, when possible, is made with ct scan, identifying a linear high-density structure. high level of suspicion is of paramount importance. in cases of delayed diagnosis, perforation may lead to intraperitoneal abscess formation. reports of hepatic abscess secondary to fish bone perforation has been limited to isolated case reports in the literature. case history: description of two cases of appendicular goblet cell carcinoid tumors, which debuted as acute appendicitis. patient a was a -year-old woman with a -h evolution of classic symptoms of acute appendicitis. patient b was a -year-old female that consulted for chronic abdominal pain in rlq that recently increased pain intensity and fever. clinical findings: patient a had pain and defense in rlq without a fever. patient b had a chronic painful fluctuating mass in rlq, with fever over °c. investigation/results: patient's a lab test showed leukocytosis and us findings of acute appendicitis. the patient's b ctscan showed an intra-abdominal abscess fistulized to the abdominal wall, along with formation of a phlegmonous mass related to appendicular plastron. diagnosis: the anatomopathological reports for both patients were informed as appendicular goblet cell carcinoid tumor. therapy and progressions: both underwent laparoscopic exploration. after appendicectomy in patient a, when the diagnosis of gcct was made, the case was discussed at our mdt meeting and a right hemicolectomy was indicated and performed shortly after. in the patient b a right hemicolectomy was performed in the initial surgery due to the magnitude of tissue involvement. currently, both are receiving chemotherapy with xelox without signs of recurrence or tumor spread on follow up. comments: the gcc is a rare entity of appendicular tumors with a less favorable prognosis than the appendicular pure neuroendocrine tumors. it behaves like a low-grade adenocarcinoma and often presents as disseminated disease. therefore, sometimes surgical treatment with appendicectomy is not enough, needing the right hemicolectomy to avoid recurrence. this is recommended for tumors [ cm, pt or t and higher grade histology. introduction: among the post-pancreatoduodenectomy complications post pancreatoduodenectomy hemorrhage (pph) is the least common complication, but severe form may be life-threatening without an urgent treatment. late pph are more likely due to a complex physio-pathological pathway secondary to different etiologies. the understanding of the etiology and such a pathway could therefore be of great interest to guide the treatment of potential lifethreatening late severe pph. results: during the aforementioned period patients underwent pd, of whom ( . %) developed pph. early pph was reported in one patient ( . %) with severe bleeding from the gastric stapler line. late pph were reported in of these patients ( . %). the most common causes were bleeding from a vascular pseudoaneurysm reported in patients of which, one had mild and had severe hemorrhage and bleeding from gastro-enteric anastomosis marginal ulcer in patients, all with mild hemorrhage. no etiology was fond in patients with mild hemorrhage. a significant association was found between the severity of late hemorrhage and the vascular pseudoaneurysm as a cause of bleeding (p \ . ). all pseudoaneurysm bleeding occurred in cases complicated by a postoperative pancreatic fistula (popf) with a significant statistical association (p \ . ). conclusions: the most common cause of pph was bleeding from a vascular pseudoaneurysm, most of them were severe bleeding with late presentation and all were associated with a popf. in these cases, early detection by cta is mandatory, allowing an urgent treatment by angiography of such a bleeding vascular complication following pd. ventral hernia in hostile situation introduction: there is no consensus about the benefit or harm derived from adding a mesh hernioplasty at the same time as an urgent intraperitoneal surgery for another cause. the use of a prosthesis in contaminated fields is controversial, but suture repair has a high risk of recurrence. the main objective has been to analyze the impact of the simultaneous repair of uncomplicated midline hernias at the same time as emergency surgery for another cause, in relation to the presentation of complications, the surgical site infection rate (isq) and recurrences. material and methods: retrospective, observational study of all urgently operated patients (surgery open and laparoscopic) in the period between - who underwent a simultaneous midline primary ventral hernioplasty. the background, circumstances of the surgery and postoperative complications during the first month and long term through the basis of prospective data of emergency surgery and complications of our surgery department. results: a total of patients ( female) met the inclusion criteria with a mean age of . years (sd = . ), average bmi of . kg/ m (sd = . ). the most frequently performed interventions were: appendectomy ( . %); cholecystectomy ( . %); and lysis of adhesions ( . %). the . % of all interventions were performed by laparoscopic approach. they presented associated peritonitis in . % of the cases. the . % of patients presented some complication, in . % surgical site infection ( . % organ space). during the followup three recurrences were detected ( . %), no patient has presented chronic infection related to the use of prostheses. conclusions: in our series the simultaneous performance of hernia repair of the midline in the context of emergency surgery for another cause has been safe and not associated with long-term complications and low recurrence rate. the open abdomen: our experience introduction: ''open abdomen'' refers to a solution in which the abdominal content is left deliberately exposed under a temporary cover for a variable amount of time. since this method has been used more and more for the treatment of severe intra-abdominal infections. starting from the s the concept has been also applied in trauma surgery. material and methods: between / we have treated patients with this technique. in cases the etiology was traumatic, in the remaining cases the abdominal pathology was inflammatory. in the last years we also started to use it in some cases of treatment of surgical complications. the techniques we used were different and changed during the time. at the beginning of the experience we've completed drainages of the abdominal cavity according to mickulizt, laparostomies with mesh, bogota bags. these techniques have been abandoned since the negative pressure therapy came out. we started with the barker vacuum pack ( cases), followed by the vac (vacuum assisted closure) and ab thera kci Ò ( patients) systems and in the last three years we used the cnp suprasorb Ò of lohmann and raucher ( patients case history: year old lady presented at the a&e with few days history of constipation, faeculent vomiting, abdominal distension and pain in the lower abdomen. she had hysterectomy many years ago through a lower midline incision. her urgent ct scan of the abdomen and pelvis confirmed an incarcerated right obturator hernia containing a small bowel loop causing bowel obstruction. clinical findings: elderly, frail patient with mild tachycardia, distended abdomen and lower abdominal tenderness with guarding in the left iliac fossa. per rectal examination was unremarkable. investigation/results: inflammatory markers were raised, lactate, liver and kidney function was in normal limits with only mild hypokalaemia and hyponatraemia. ct abdomen and pelvis confirmed small bowel obstruction at the mid ileal level due to right obturator hernia. diagnosis: incarcerated right obturator hernia causing small bowel obstruction. therapy and progressions: patient was taken to the operating theatre for urgent laparotomy. dilated small bowel loops and incarcerated right obturator hernia was found with proximal ileal loop in it. after blunt stretching and dilatation of the obturator foramen, the involved ileal loop was reduced. it was deemed viable, therefore no bowel resection was required. the defect at the right obturator foramen was closed with suture. post-operatively the patient was transferred to the intensive care unit for further management. comments: obturator hernias are a rare type of pelvic hernias. their real incidence is unknown but it is thought to be less than % of all hernias worldwide and due to its non-specific symptoms and late diagnosis, they require bowel resectional surgery in nearly % of the cases. howship-romberg sign is helpful in diagnosing such a hernia, but the ultimate diagnostic choice is ct scanning which is the only way to find this condition early and avoid bowel ischaemia. case history: a -year-old woman without previous medical history presented to the emergency department with abdominal pain and dysphagia associated with nausea, vomiting and absolute constipation. during previous months, she reported having ingested hair. clinical findings: abdominal examination revealed a distended abdomen with rebound tenderness and tinkly bowel sounds. investigation/results: ct-scan showed a distended stomach with a mussel-shaped, heterogeneous and non-enhancing mass. an esophagogastroduodenoscopy revealed hair inside the lower esophagus and the stomach. diagnosis: high intestinal obstruction due to a gastric trichobezoar. therapy and progressions: the patient underwent laparotomy, gastrotomy and trichobezoar removal (fig. ) . the postoperative period was uneventful and she was discharged home on the th pod with a psychiatric evaluation scheduled. comments: bezoars are rare conditions consisting of compacted material that is unable to pass through the gastrointestinal tract. this condition usually involves the stomach; rarely, it can extend into the small bowel and even the colon, giving the so-called rapunzel syndrome. bezoars could be composed by vegetable material (phytobezoars), hair (trichobezoars), drugs (pharmacobezoars), or other materials. , a trichobezoar is the result of trichotillomania, trichophagia or other psychiatric disorders. always consider bezoars in differential diagnosis. introduction: the effectiveness of different step-up approaches is increasingly evaluated but results are controversial. we assessed the results of a standardized step-up approach protocol in the treatment of acute severe necrotizing pancreatitis, with a special focus on patient stratification to obtain an early identification of those deserving a more aggressive strategy. matherials and methods: this is a retrospective analysis of patients with acute severe pancreatitis over a period of years. the variables taken into account were: etiology and severity of the disease, sepsis, organ failure, hemodynamic stability, treatment, los, morbidity, mortality. since , patients with infected necrosis underwent a standardized step-up approach: percutaneous drainage only; percutaneous and endoscopic procedure; surgery. the results were compared with the standard care delivered from to . results: among patients, ( . %) were identified as affected by severe necrotizing disease. overall mortality was . %. the initial management was non operativein all patients. mortality in the step-up group was % ( / ) vs % ( / ) in the standard care group. conclusion: a standardized step-up approach protocol offers better results than standard care in the management of acute severe necrotizing pancreatitis. however, a better stratification of patients. introduction:the appendix stump closure in complicated appendicitis has been widely practiced in different ways such as metal clip, hem-o-lok clip, endoloop and endostapler. the treatment of complicated appendicitis with necrosis and perforation of the appendix base is controversial. we aimed evaluate the efficacy of laparoscopic partial caecum resection with endostapler in complicated appendicitis with necrosis and base perforation. material and methods:from january to october , we evaluated consecutive patients who underwent a laparoscopic partial caecum resection in complicated appendicitis with necrosis and perforation of the appendix base. partial caecum resection was performed with the endostapler to close the appendix base at ileocaecal junction. results:the laparoscopic partial caecum resection with endostapler was used in % . of the cases. the mean operative time was . ± . min. there were necrosis of appendix base in , perforation of appendix base and diffuse peritonitis in , perforation of the appendix base and localized peritonitis in of the patients. the wound and intra-abdominal infection rates were . % and . %, respectively. there were no operative complications and the conversion rate was . %. the average length of hospital stay was . ± . days. there was no leakage on the stapler line. conclusions:the laparoscopic partial caecum resection with endostapler in complicated appendicitis with necrosis and perforation of the appendix base, is a safe and effective technique. introduction: the term ''''volvulus'''' comes from the latin ''''volvere''''meaning twist. if left unattended, sigmoid volvulus can compromise the blood supply of the involved segment,leading to ischemia,gangrene,perforation and death. the mainstay of sigmoid volvulus management has been through proctoscopic or colonoscopic decompression when feasible, followed by surgery either during the same admission or electively. the aim of our study is to identify patients which can benefit of immediate surgical approach and prognostic factors associated with failure of conservative/endoscopic treatment. materials and methods: charts of patients admitted for sigmoid volvulus to our institute were retrospectively analysed. we revised ct scan images and laboratory tests of all the patients to identify risk factors for conservative treatment failure. results: patients underwent surgical procedures; in cases after a failure of an initial conservative approach; patients were managed with endoscopic approach only. elective surgery was performed in patients. case history: we report a -year-old male case presenting left hand middle finger pain after pressured paint gun shot in volar proximal phalanx clinical findings: on physical examination swelling and tenderness on the volar side of the hand was observed (fig. ) investigation/results: pain was remarkably more intense with passive finger extension. distal nerurovascular status was unscathed. there was no fracture reported on radiography. leukocytosis and acute phase reactants rise was observed on laboratory examination diagnosis: after physical, radiological and laboratory examination the diagnosis of acute flexor tenosynovitis was made. therapy and progressions: open debridement and irrigation following bruner incisions on middle finger was undertaken within h of injury. paint impregned in tissues could be observed in subcutaneous tissue, palmar fascia and flexor tendon sheath. paint affected tissues samples were analysed in microbiology laboratory (fig , ) after checking nerurovascular indemnity, g drainage was left in deep tissues and skin suture was performed with - monofilament non absorbable suture. the patient followed days intravenous antibiotical therapy followed by weeks oral treatment. he attended physiotherapy program postoperatively, reporting no functional disability or wound complications after weeks. comments: chemical flexor tenosynovitis is an important emergency which must be correctly diagnosed and treated due to quick progression and potential morbidity if not treated effectively ( ) in our experience, case was managed by open debridement and irrigation but different treatments can be followed depending of patientsclinical situation, such as iv antibiotics with serial examinations or percutaneous drainage. it should also be noted that australia does not have a specific subspecialty in emergency surgery. the acute surgical unit at the tch was set up in in order to provide a dedicated acute unit to service the ever increasing demand acute surgery. previous model was that the acute surgical service was integrated into the elective work. additional beds were provided to the unit including the positions of a dedicated director and chief nurse. the achievement of the unit has been the decreased time to theatre, less after-hours operating, standardised treatment approaches, and dedicated emergency surgery medical staff. the difficulties have included clinician engagement, competing resources with elective surgery, emergency surgical presentations increasing by - % each year, and the unit''s beds being used for non-acute patients as the hospital approaches regular %. the acute surgical unit has evolved into a specialised acute care that enables rapid assessment and treatment of patients with staff dedicated with skills in this area. treating pyogenic liver abscesses secondary to diverticulitis in a patient using immunosuppressants for crohns disease by performing a sigmoid colectomy introduction: pyogenic liver abscess (pla) formation due to microbial contamination of the liver parenchyma is often seen secondary to intra-abdominal infections. pla formation due to crohn''s disease (cd) is a rare complication and not well-documented in current literature. as symptoms often mimic a cd exacerbation, diagnosis is often delayed and severe disease may develop. optimal treatment for this group of patients remains debatable. case presentation: a -year-old man was admitted to the hospital with a -week history of overall malaise, fever and night sweats. patient''s history solely stated a -year treatment of cd that was stable over the past period with infliximab and azathioprine. investigations and treatment: biochemical analysis revealed a c-reactive protein of mg/l and a white blood cell count of . /l. an abdominal ct scan showed multiple abscesses in the right lobe of the liver and a thickening of the wall in the transition of the descendent colon to sigmoid. the patient''s immunosuppressants were paused, intravenous antibiotics were administered and a percutaneous drainage of the biggest pla was performed. however, the clinical condition of the patient did not improve. colonoscopy and pet-ct scan did not reveal any other sites of infections. as patient remained septic and previous imaging revealed mild diverticulitis rather than active cd, an emergency hartmann''s procedure was performed. hereafter, the patient recovered rapidly and the plas resolved completely. conclusion: diverticulitis of the sigmoid colon should be considered as causative pathology in patients presenting with multiple pyogenic liver abscesses and a history of crohn''s disease that is in full remission with immunosuppression. when the abscesses exceed cm in size and are multilocular, resection of the inflamed colon can be a treatment option of value. clinical findings: epigastric pain and recent episode of hematemesis. pain at deep palpation of the epigastrium, no signs of peritoneal irritation investigation/results: abdominal x-ray and ct showing a large right sided strangulated paraesophageal peh, with pneumatosis of the gastric wall diagnosis: right sided strangulated peh therapy and progressions: emergent laparotomy. peh reduced, ischemic portion of the stomach recovering viability. closure of diaphragmatic defect with non-absorbable suture, reinforcement of lower esophageal sphincter with round ligament (ligamentum teres hepatis) and anterior partial fundoplication (dor). postoperative course uneventful, patient discharged on th pod. comments: peh are mediastinal displacements of abdominal organs, most often the stomach, associated with laxity or a hole in the phrenoesophageal membrane, large enough to allow the gastric fundus to herniate. because the stomach is attached to the gastroesophageal junction, it tends to rotate around its axis leading to organoaxial volvulus. occurrence and size increases with age. peh account for - % of all diaphragmatic hernias. in patients without prohibitive operative risk, they should be surgically corrected, avoiding the risk of acute and potentially life-threatening complications when emergent surgical repair is required. the risk of developing these complications is less than %/yr and associated mortality rate is approximately %. case history: patient was a previously healthy -year-old female with an unremarkable past medical history, non-smoker with a high body mass index (bmi [ ). she first presented to a level medical facility with acute left upper leg pain and swelling. one week prior to this she had a progressive cough, swinging fever, and malaise. clinical findings: patient was transferred to our hospital haemodynamically unstable, acidotic, hypoxemic and delusional. tachypnea and oliguria were present. she continued to deteriorate clinically with pyrexia (t , oc), resistant shock, and toxaemia. on examination her left leg was found to be paresthetic below the femoral-inguinal fold. investigation/results: abg samples showed lactic acidosis with a ph of . and lactate of . mmol/l. hypoxia and hypocapnea were present.her biochemical profile showed acute kidney injury (aki) with raised creatinine kinase (cpk) and serum creatinine (cr) . . chest x-ray illustrated bilateral lung infiltrations (ards image). diagnosis: patient was urgently referred to a ct scan of the left femur with i.v. contrast for suspected necrotising fasciitis. ct findings highlighted a deep muscular femoral abscess with multiple regional fluid collections and necrotizing inflammation from the femur diaphysis to the patella. therapy and progressions: the patient was immediately transferred to or for emergency surgical exploration and debridement. almost the entire anterior compartment of the femur was necrotic and hence an extensive excision of the dead tissues and packing with npwt was performed. comments: severe snm can cause marked systemic toxic effects, namely, the streptococcal toxic shock syndrome (stss). stss secondary to snm is a life-threatening host response to gas superantigens with a mortality rate as high as %. clinical findings: patient had a diffusedlty tender abdomen and had not passed flatus proceeding his admission to the a ? e department and was vomiting. investigation/results: ct abdomen showed small bowel dilatation with abrupt cut-off point proximal to the icv diagnosis: a diagnosis of small bowel obstruction was made based on the clinical and ct findings. therapy and progressions: patient was taken to theatre for laparoscopy ? -proceed and a 'slipped' bowel lopp was noted within the peritoneal flap that had been created a week prior during the original hernia repair. the 'v lock'' suture line was found to be loose which is thought to have led to this complication. the bowel loop was reduced, deemed viable and an internal hernia repair was performed. post-operative period was unremarkable and the patient was discharged day posy-operatively. comments: during lap tapp hernia repair, there are currently at least options avaiable for peritoneal flap closure; (sutures, tackers and glue.) suregons prefernce prevails over the chosen approach. when sutures are chosen, most surgeons prefer the self-locking v-lock stitch. by adopting this technique, meticulous periotneal closure is impoartan, as loose suturing of the peritoneum can lead to post operative complications of internal herniation and small bowel obstruction, as described in this case. a multi-centre prospective study would be welcomed, to compare efficacy and safety of all types of peritoneal closure devices. introduction: peer review assessment of medical treatment has been shown to be a robust way of improving quality of care in trauma in our institution and globally. in we introduced regular morbidity and mortality meetings at the department of gastrointestinal surgery. severe complications (revised accordion classification [ ) after surgery were identified on a weekly basis, evaluated and data included in a local quality registry with the aim of revealing suboptimal surgical quality and continuously improving our results. material and methods: retrospective analysis of collected data from the described quality registry. all adult patients who had undergone gastrointestinal surgery in were assessed. results: of surgical procedures performed, % were emergency procedures. a total of % ( / ) experienced a severe complication after surgery and % ( / ) required reoperation. in the group of upper gastrointestinal surgery [n = ( %)] % were emergency procedures. anastomotic leak (al) was identified in % ( / ) undergoing thoraco-laparoscopic esophagectomy and in % ( / patients) after gastrectomy. of laparoscopic cholecystectomies, % were emergency procedures with % ( / ) reoperation. of hernia repairs, % required reoperation. in the group of lower gastrointestinal surgery [n = ( %)] % were emergency procedures. al was diagnosed in % of colonic resections and % of patients after rectal resection. in emergency colorectal resections(n = ) there were no al. of appendectomies, patients ( %) required reoperation. the most frequent cause of reoperation was revision of stoma ( ), followed by reoperation for al ( ), abscess ( ), and wound dehiscence ( ). patients died after surgery of which were emergency surgical patients. conclusions: systematic assessment of all severe complications helps reveal surgical procedures which can be improved but also to identify surgical procedures with low complications rates. plans are being developed to improve the quality of the identified procedures. all surgical departments should have regular and thorough assessment of their activity. acute surgical patients operated by emergency surgeons has less risk of post-operative complications and mortality d. gumaa east kent hospitals university nhs foundation trust, general surgery, ashford, united kingdom introduction: in england and wales, we perform over , emergency laparotomy every year. days mortality rate is around - %. in our study we are trying to demonstrate if have dedicated emergency surgery service will make a difference in the outcome of emergency laparotomy. material and methods: retrospective study on prospectively collected data from nela database done in a large district general hospital. all patients over years old who underwent emergency laparotomy for acute surgical condition between november and january were included in the study. mortality and post-operative complications were the primary outcomes. results: total of patients were included in the study, operations were performed by emergency surgeons (es). days mortality rate was %, while it was . % for the none emergency surgeons group (nes) post-operative complications were . % compared to % for patients operated by nes. there was shorter itu stay with average of . days, while the itu stay for the other group was . days, but the es group had higher chance of unplanned return to theatre. . % of the patients went back to theatre compared to % of the other group. reasons of unplanned return to theatre was mainly post-operative collection or wound dehiscence. conclusions: emergency surgeons has better outcomes when they perform emergency laparotomy, may be because they perform higher number of laparotomy compared to their peers. emergency surgery has been a growing subspeciality recently, and with no doubts having surgical emergency units has improved the patient's care around uk. the advantage of g over g of prophylactic cefazolin in surgical site infections in trauma surgery below the knee introduction: the rate of surgical site infections(ssi) after foot/ankle surgery remains high, despite the implementation of antibiotic prophylaxis ( ) . recently guidelines suggest a single dose of g instead of g of cefazolin for implant surgery, this decision is largely based on pharmacokinetic studies ( ) . however, the clinical effect of this higher dose has never been investigated in this region. this retrospective cohort study therefore investigated the effect of g compared to g of prophylactic cefazolin on the incidence of ssis in foot/ankle surgery. material and methods: all patients undergoing trauma-related surgery of the foot, ankle or lower leg between september and march were included. primary outcome was the incidence of a ssi. ssis were compared between patients receiving g and g of cefazolin as surgical prophylaxis. results: a total of patients received g and patients received g of cefazolin. the groups did not differ in gender, age, weight, co-morbidities or intoxications. the overall number of ssis was ( . %) in the g group and ( . %) in the g group. corrected for the confounders ''age'', ''smoking'' and ''blood loss'' this was not statistically significant (p = . ). conclusions: even though the decrease in ssi rate from . to . % was found not to be statistically significant, it might be clinically relevant considering the reduction in morbidity, mortality and healthcare costs. research linking pharmacokinetic and clinical results of prophylactic cefazolin is needed to establish whether or not the current recommendations and guidelines are sufficient for preventing ssis in foot/ankle surgery. introduction:right-sided colonic diverticulitis (rd) is much rarer than left-sided (ld) and subsequently, controversies concerning the most appropriate treatment remain unsolved. our experience let us believe that mild rd can benefit from an outpatient management. material and methods: we performed a single center retrospective comparative study in which we included all our diverticulitis patients that were treated as inpatient in our unit. we divided in two groups:rd and ld group. the ld group was created by randomization from a prospective ld patients database. results: we included rd and ld patients treated in our unit from july to july . median age was . in rd and . in ld, with a . % of females in rd vs . % in ld. asa classification was significantly lower in rd (asai: . % vs %, asaii: . % vs , , asaiii: vs . %, asaiv: vs . % p = . ). the presence of neumoperitoneum in ct scan was significantly higher in ld . % vs . % p = . ) surgery was performed in . % of the left-sided diverticulitis compared to of the rd group (p = . ). antibiotics of third line (imipenem and meropenem) were only required for ld ( vs . % p = . ). length of hospital stay was significantly shorter (p = . ) in rd ( . ± . ) than in ld group ( . ± , ) conclusions: in our series, patients with right diverticulitis had fewer perforations in the ct scan, they required lower spectrum antibiotics and did not required any surgical treatment with a shorter length of hospital stay. we consider that mild right diverticulitis could benefit from an outpatient treatment with oral antibiotic following similar recommendations to those followed for mild ld patients. when surgery should not be immediate, a night of hospitalization in a specialized environment is performed and surgery deferred overnight. in some selected patients, a return home is possible with a scheduled emergency surgery the next day. the pa.r.c.o.ur protocol is set up in the surgical emergencies of the university hospital of lille after a suitable medical treatment and enlightened information. this retrospective study assesses whether this deferred surgical management allows a return home on the day of the operation. methods: between / / and / / , records of patients operated for an abscess, appendicitis, cholecystitis or symptomatic inguinal hernia were reviewed. patients who did not have criteria for immediate surgical management (peritonitis, occlusion, sepsis, cellulitis, intravenous treatment need) agreed to return to their home for an os the next day. results: / % interventions were performed in os and allowed a return home at day , within a median time of h [iqr - ]. conclusions: the pa.r.c.o.ur protocol makes it possible to reserve the availability of the entire technical platform (operating rooms and beds) to the most serious pathologies with a failure rate of %. the medico-economic benefits, the efficiency in the management of the beds and the satisfaction of the patient and medical staff of this protocol must be evaluated prospectively. a years old woman was admitted in our er presenting with a h sharp epigastric and ruq pain, fever, nausea and vomiting, hd stable. the patient had a past medical history of tachyarrhythmia, open-angle glaucoma and lower limb venous insufficiency. her past surgical history included an hysterectomy and bilateral salpingooophorectomy, appendectomy and left inguinal hernioplasty. during clinical examination, signs of peritoneal irritation were present. ct scan revealed a small pneumoperitoneum in the luq and multiple small and large bowel diverticula, without free peritoneal fluid. blood work showed mild leukocytosis and neutrophilia. we performed an urgent exploratory laparoscopy in which dozens of small intestine diverticula were found, increasing proximally in number. one of them, cm distally from the treitzs angle, showed signs of perforation, with a small abscess and surrounding fibrin. the affected bowel was externalized through a cm laparotomy for segmental resection and a manual double-layer terminoterminal jejunojejunostomy was performed. in the perforated jejunal diverticulum, a mm cod fishbone was identified as the cause of the perforation. the histopathological examination of the extracted cm tissue sample, found several diverticular structures of the muscular wall, one of which with a mm perforation and a granulocytic infiltrate with serosa involvement. complicated cases of small bowel diverticulosis are best managed by segmental resection surgery. despite being quite rare, every surgeon should be aware of such acute abdomen presentation. asymptomatic cases benefit from a watch-and-wait approach. case history: a -year-old female consulted to the emergency department for a h epigastric pain. it was accompanied by nausea without vomiting. clinical findings: the patient was hemodynamically normal and the abdomen was soft with minimal distention. investigation/results: x-rays showed large gastric dilation. the abdominal ct scan showed mesenteric axial gastric volvulus with minimal free fluid. suddenly, the patient presented diffuse abdominal pain with diaphoresis, mucocutaneous pallor, hypotension and tachycardia. diagnosis: a gastric volvulus with gastric ischemia was suspected. broad-spectrum antibiotic therapy and resuscitation measures were started. emergency surgery was indicated. therapy and progressions: a decompressive gastrostomy, gastric reduction and devolvulation, transverse colon resection due to ischemia and splenectomy were performed. after h, she required total gastrectomy and right hemicolectomy due to ischemia secondary to severe septic shock associated with disseminated intravascular coagulation. comments: the gastric volvulus is an uncommon entity, being the mesenteric-axial type so rare. there are very few cases described whose manifestation is accompanied by hypovolemic shock secondary to splenic laceration, which occurred due to the great gastric distention. early diagnosis is the key to start treatment as quickly as possible, due to high mortality the main mechanism of death is usually vascular involvement, perforation and multiorgan failure. results: we analyzed , pediatric ogis, and . % of pediatric cases occurred in the - age group, . % in - , . % in - , and . % in - . the average age of the cohort was . years and . % of cases occurred in boys. racial distribution revealed . % of cases in caucasians, . % in african americans, and . % in hispanics. most ( . %) cases were documented in the southern united states. of our , cases, . % underwent vitrectomy, . % underwent enucleation, and . % developed endophthalmitis. the rate of endophthalmitis development after ogi was highest ( . %) in the asian/pacific islander group. the average length of stay for the entire cohort was . days, and the average cost per day was $ , . . table contains a breakdown of our statistics. conclusions: as documented in the nis, ogi occurs more commonly in boys than in girls at a ratio of approximately : . the rates of vitrectomy and enucleation are higher in boys. we noted a higher of rate of enucleation in asian/pacific islanders and african americans. the plurality of ogis occur in the - age group; this age group also has the highest relative rate of enucleation. with respect to location, ogis occurring in the western united states had the highest average cost per day of inpatient stay. autologous tissue from intramedullary channel parietes for femur nonunions management introduction: a reamer-irrigator-aspirator (ria) method is deeply reliable for getting high volumes of bone graft/mscs. high rates of successful outcomes have been reported after the use of ria bone fragments to cure non-unions. material and methods: being supported by histomorphological examination of the material acquired while drilling intramedullary channels of patients with femur nonunions ( -hypertrophic, oligotrophic), we have discovered that nevertheless, expressions of the dystrophy and necrosis in bone tissue and marrow in pseudoarthrosis areas depend on time since fracture occurrence, the microscopic study of the material cm above and below a fracture line has demonstrated ordinary structures of bone tissue and marrow in all cases. introduction: this study aimed to evaluate the outcomes of ankle fractures with posterior malleolus fragments (pmfs) involving \ % of the articular surface treated with or without screw fixation. material and methods: among patients with ankle fractures and pmfs who underwent surgery between march and february , with type pmfs involving \ % of the articular surface were included. of these patients, underwent screw fixation for pmfs and lateral and/or medial malleolar fracture fixation (group a) and underwent internal fixation for malleolar fractures without screw fixation for pmfs (group b). ankle joint alignment and fracture healing were measured using plain radiography and computed tomography (ct). clinical outcomes were determined using the american academy of orthopaedic surgeons foot and ankle questionnaire, short form- , and american orthopaedic foot & ankle society scale. results: nonunion was not noted in either group. however, we detected union with a step-off of mm or more in cases from group b. with regard to ankle joint alignment, case in group a and cases in group b showed mild asymmetry of the medial and lateral clear spaces on ct at months. clinical outcomes at and months after surgery were better in group a than in group b. conclusions: screw fixation of pmfs was effective for fracture healing and maintaining ankle alignment. additionally, it improved short-term clinical outcomes, which we believe was due to stabilization of ankle fractures with pmfs involving\ % of the articular surface. references: level ii, prospective comparative study. how accurate can gaps and step-offs be determined in acetabular fracture treatment? introduction: the assessment of gaps and steps in acetabular fractures is challenging. studies evaluating the value of various imaging techniques to enable accurate quantification of acetabular fracture displacement are limited. this study aimed to assess the inter-and intraobserver variability of gap and step-off measurements using pelvic radiographs, intraoperative fluoroscopy and computed tomography (ct). material and methods: sixty patients, surgically treated for acetabular fractures, were included. five observers measured the gap and step-off on all the pre-and postoperative pelvic radiographs and ct scans. intraoperative fluoroscopy images were reassessed to determine the presence of gaps and/or step-offs. the inter-and intraobserver variability were calculated for the measurements using pelvic radiographs or ct scans. kappa was calculated for the intraoperative fluoroscopy assessment. results: for the preoperative displacement, the intraclass correlation coefficient (icc) was . (gap and step-off) using pelvic radiographs, and . (gap) and . (step-off) using ct scans. for the postoperative displacement the icc was . (gap) and . (step-off) using pelvic radiographs and . (gap) and . (step-off) using ct scans. the average kappa for the intraoperative gap and/or step-off assessment using fluoroscopy was . (- . to ) both for the inter-and intraobserver assessment. conclusions: there is little agreement between the observers regarding the measurements of the preoperative displacement, the presence of gaps and step-offs intraoperatively and the measurements of the postoperative displacement. a possible explanation for this is that the acetabulum has a three-dimensional spherical shape with multiple fracture lines and fragments going in different directions. single radiographic or ct-based gap or step-off measurements do not seem to be representative for the fracture characteristics, therefore the use of d measurements should be considered. introduction: long-term intake of glucocorticoids leads to pathologic changes in bone and cartilage tissues. material and methods: to understand how to prevent the occurrence of the pathology, we studied the use of vitamin d, vitamin e and a combination thereof on the background of the intake of prednisolone, . mg/ g of body weight. the experiment involved male rats of wistar linear breed. the animals were months old and weighted . ± . g. the experiment included series of animals, rats in each, namely: the first group-intact animals; the rest of the animals received prednisolone, . mg/ g of body weight. the rats of the third series received additionally iu of vitamin d . the animals from the fourth group also received . iu ( . mg) of vitamin e. results: long-term administration of prednisolone to the experimental animals has caused significant structural and functional disorders in their bone and cartilage tissues. they can be construed as simulated glucocorticoid-induced osteochondropathy. the combination of the vitamins d and e has demonstrated its ability to promote restoration of histomorphologic features of bone and articular cartilage in proximal femur epiphysis and epiphyseal cartilage of proximal femur epimetaphysis in animals with simulated glucocorticoid-induced osteochondropathy. the combination of the vitamins d and e has demonstrated a better effect on the background of the glucocorticoid-induced osteochondropathy, compared to the vitamin d alone. conclusions: preventive administration of the vitamins d and e while treatment with prednisolone leads to avoidance of the majority of pathologic changes, resulting otherwise from glucocorticoid-induced osteochondropathy. konyang university hospital, orthopaedic, deajeon, south korea introduction: the purpose of this study was to evaluate clinical, radiological and functional outcomes of patients had osteochondral autograft harvested from the ipsilateral femoral head for a femoral head defect after posterior hip fracture dislocation material and methods: this study was approved by irb at our institution. a retrospective chart review of a prospectively performed operation was performed at two university hospital between march , , and june , . all fracture was classified by the ao/ota classification. we included the patients had minimum months of follow up periods. ten displaced head fractures were addressed through posterior surgical dislocation and two patients had no posterior dislocation was operated using smith-peterson approach. an osteochondral graft was harvested from inferior non-weight bearing articular surface and grafted to osteochondral defect. all patients were full weight bearing by months results: we had femoral head fracture dislocation. patients were excluded due to lost to follow up. twelve of with type i/ii pipkin fracture dislocation with the articular defect and reduced within h of injury was identified for review. the patients were followed up for a mean of . months. there was no osteonecrosis. decreased joint space was identified in two patients. all fractures achieved union. the mean harris hip score of last follow up was . ( - ) one patient who operated using the smith-peterson approach had femoral nerve palsy. conclusions: the clinical and radiological results after treatment of femoral head fracture dislocation with articular defect by osteochondral autograft harvested from its own non-weight bearing articular surface show good outcomes. hospital universitario fundacion jimenez diaz, madrid, spain, hospital universitario de octubre, madrid, spain, hospital universitario la paz, madrid, spain introduction: preoperative computerized tomography scan provides important information about ankle fractures associating posterior malleolus, helping us distinguishing fractures affecting distal tibiofibular joint. the aim of our paper is to describe our series of patients suffering an ankle fracture with posterior malleolus involvement. methods: fifty-two consecutive patients, with ankle fracture involving posterior malleolus were evaluated prospectively. all of them were assed with a preoperative ct scan, demographic data, fracture mechanism, surgical approaches, posterior malleolus size measured classification and treatments were analyzed. results: most frequent posterior malleolus pattern according to bartonicek classification was type ii, twenty-two patients ( . %). an alternative surgical approach was performed in thirty-three patients ( %) as a consequence of information provided by ct scan. no statistical differences were observed when measuring posterior malleolus in conventional x-rays or ct scan. analysis of variance showed a p value less than . when comparing pm size and haraguchi and bartonicek classifications. discussion and conclusion: ct scan is required to perform an adequate preoperative study of ankle fractures involving posterior malleolus, using this information to provide a better outcome to our patients. effect of atorvastatin and losartan on gene expression and cell count in a rat model of posttraumatic joint contracture of the knee-a blinded and randomized animal study introduction: myofibroblasts have been associated with increased posttraumatic joint contracture, which has a massive impact on articular function. atorvastatin and losartan have shown to reduce the proliferation of cardiac, hepatic and pulmonary myofibroblasts. the aim of this study was to evaluate the effect of atorvastatin and losartan on gene expression, cell count and collagen deposition in the posterior joint capsule , and weeks after trauma in a rat model of posttraumatic joint contracture of the knee. material and methods: posterior capsular injury and kirschner-wire immobilization of the knee were performed in sprague-dawley rats. atorvastatin, losartan, or placebo was administered daily orally. the rats were sacrificed at either (n = ), (n = ) or (n = ) weeks after initial surgery. rats euthanized at week had their k-wire removed at week , followed by a remobilization period of another weeks. the results were evaluated via qpcr and immunohistochemistry. results: losartan reduced the number of myofibroblasts in comparison to the control at week and , whereas atorvastatin lowered myofibroblasts only at week (p \ . ). atorvastatin reduced the collagen deposition at week , whereas losartan had no effect on collagen deposition. losartan decreased gene expression of connective tissue growth factor (ctgf) at week and of tgf-b at week . clinical findings: positive anterior drawer test, grade iii valgus instability, and a palpable gap below the patella were assessed. no neurovascular alterations were found and ankle-brachial index scored [ . . investigation/results: initial immobilization with a splint was performed. radiographs showed a high patella with no other lesions. mri revealed a complete rupture of the patellar tendon and a complex multiligamentous injury with complete anterior cruciate ligament (acl) tear, avulsion of distal medial colateral ligament (mcl), and a complex rupture of both meniscus. diagnosis: knee dislocation with patellar tendon rupture. therapy and progressions: definitive treatment was performed days after the initial lesion, with arthroscopic resection of the posterior horn of the external meniscus and reconstruction of the acl with posterior tibial tendon allograft, as well as open repair of the patellar tendon and the internal meniscus, with subsequent mcl distal reinsertion. immediate partial weight-bearing with an extension orthosis was allowed. the patient is currently progressing with rehabilitation. comments: knee dislocation is a rare injury, and most cases are due to highenergy trauma. concomitant rupture of the patellar tendon is very unusual, and most cases are described in the context of open injuries. surgery is mandatory in order to restore full stability of the knee, with either one intervention or a staged surgery, including repair of the collateral ligaments and the patellar tendon followed by arthroscopic reconstruction of the cruciate ligaments. postoperative management consists on early rom restoration and weight-bearing as tolerated. introduction: apophyseal anterior inferior iliac spine (aiis) fractures are rare injuries. they most commonly occur in athletes in adolescence period. because the ossification of pelvis is not completed, apophyses are the weakest part of musculo-tendinous unit during this period, thus avulsion fractures are more frequent than muscle ruptures. aiis avulsions are the result of sudden and forceful contraction of rectus femoris muscle concentrically or eccentrically. material and methods: we report a clinical case of a aiis avulsion fracture in a young male football player, after being misdiagnosed as muscle strain. results: our patient was treated with conservative treatment including bed rest, analgesia, using crutches and toe-touch weight bearing, progressing to full weight bearing as tolerated and nonsteroidal anti-inflammatory drugs. at follow-up, he showed relief from his pain and mechanical symptoms and regained full range of motion and returned to his previous levels of activity. conclusions: diagnosis requires careful attention to the physical examination and imaging. in this case, the fracture was managed successfully with a conservative approach. good results and return to previous levels of activity can be achieved with conservative treatment. when misdiagnosed as a simple strain, the late diagnosis may cause chronic pain with decreased sportive performance in the future. therefore, a carefully taken anamnesis and physical examination with comparative anterior-posterior pelvic x-rays are needed not to miss avulsions in adolescents; also in some instances, more advanced scanning methods must be considered. introduction: the problem of meniscus damage in children is due to unsatisfactory treatment results, which is associated with the frequent execution of meniscectomies. amount of unjustified meniscectomies and the incidence of osteoarthritis can be reduced if menisci are repaired. material and methods: during the period january -august children with injuries of the meniscus were treated in morozov children's clinical hospital. children underwent meniscus repair by suturing using three techniques: ''all inside'', ''inside out'' and ''outside to inside''. meniscus suture decision was made taking into account the assessment of the severity of the damage. the period from the moment of injury wasn't taken into account. the technique of meniscus suture was determined depending on the location and type of damage. we met children with damage to the discoid meniscus who underwent partial resection and meniscus suture. children underwent a meniscectomy due to severe traumatic and degenerative changes. children had mri of the knee after months and x-ray after months. results: children achieved a satisfactory functional result; operated children are at the rehabilitation stage. we faced a complication-limitation of flexion in the knee joint in child. in all children on the control mri, the absence of synovitis, the safety of the reconstructed meniscus contour and the decrease in the intensity of the hyperechoic signal in the gap zone in dynamics are determined. conclusions: the introduction of a technique for repair meniscus integrity in the daily practice of an arthroscopist makes it possible to reduce the number of meniscectomies, which will reduce the number of unsatisfactory treatment results for this pathology and prevent the development of early osteoarthritis of these, children revealed a fracture-dislocation of the patella. in children, a tangential fracture of the lateral condyle of the femur was noted. in children, the dislocation was repeated. we met children with bilateral damage. all children with complete damage to the medial patellofemoral ligament, fracture-dislocation of the patella and dysplastic dislocation were performed tendon plastic using the quadriceps femoris tendon. the technique includes: transplanting a graft quadriceps tendon graft without cutting off the patella. next, the transplant is subfascial carried out in the medial direction and is fixed with a bio-integrated screw in the femur. results: the rehabilitation period was months. % of children have a satisfactory result (there is a limitation of flexion in the knee joint to °). % have an excellent clinical result: the full range of motion in the knee joint, the absence of pain and a return to sports. none of the operated children had relapses of dislocation. conclusions: it is recommended to consider the technique of tendon plasty of the medial patellofemoral ligament using the quadriceps femoris tendon as a method of choosing the treatment for patellar dislocation in children. case history: a -year-old boy who was injured while playing baseball. he was playing as a catcher and was bumped into the runner, therefore his ankle got twisted. he was immediately taken to the hospital. clinical findings: x-ray the distal tibial epiphyseal growth plate was irregular. although the ankle joint was not dislocated. in the ct, the proximal fibular fragment was caught behind the posterior edge of epiphysis of the distal tibia and was trapped there. investigation/results: the patient must be operated in order to repair the ankle. but the reduction of the entrapped distal tibia epiphysis was not easy without open. diagnosis: we diagnosed with bosworth like fracture. therapy and progressions: reduction was not easy, however we performed it by the pulling the fibula towards to outside, pulling out the curled anterior tibiofibular ligament, and then pushing into the tibia. we performed screw fixation after reduction of distal tibial epiphysis. furthermore, we fixed the fibula with plate. we made him to do range of motion exercise and toe touch gait from next day, and full weight bearing from weeks. we removed the implant months after the surgery. he did well subsequently, and at years after injury, he had normal function of the ankle, and normal x-ray. and he has returned to sports without pain. introduction: judo is the most popular martial art in the world and the first martial art recognized since as an olympic sport. worldwide, the international judo federation has registered countries with about million judo practitioners. like martial arts, judo mainly involves grip and throwing techniques. the competition rules in judo have been subject to constant adjustment and optimization in recent years. injuries prevalence is an important factor in the contact martial arts. material and methods: a prospective cohort study of all registered international athletes ( ) at three different european judo contests in germany were accomplished with the aim to investigate the injury rate as well as the pattern of injury. the age of the athletes ranged between and years. injury incidence rates were calculated per athlete-exposures (iirae) and per min of exposure (iirme). independent variables were sex and weight division. subgroups were compared by calculating the injury incidence rate ratio. results: severe injuries by judo tournaments are rare. the most frequently injured regions were the hand and head. the fights of the main block are riskier than the finals. the incidence of injury in heavyweight division differed with lightweight competitors. the risk of injury for female and male competitors differed slightly. conclusions: further studies are needed to determine a judo specific injury patterns and factors especially in the pre-competitional phase. investigation of prevention-strategies like the adaptation of competition rules etc. makes sense. does garden''s classification of femoral neck fracture match between orthopedic specialist and clinical resident? t. inoue , s. inoue , t. muraoka prefectural miyazaki hospital, orthopedics, miyazaki, japan introduction: garden''s classification is the most popular classification of femoral neck fractures. femoral neck fracture should be operated^ h; however poor agreement make waiting time longer because it takes more time to prepare implants and biological clean room. we investigate the agreement of the garden''s classification (non-displacement type or displacement type) between clinical resident and orthopedic specialist. material and methods: the examiner are a clinical resident ( nd year) and an orthopedic specialist ( th year). the subjects were cases of femoral neck fractures treated at our hospital between january and december . first, the examiners classified them into a non-displacement type and a displacement type (test ). second, the examiners studied the literature about unclassifiable type. third, the examiners classified cases month later once more (test ). finally, we compared the first test with the second test using the agreement (the number of matched patients/total) and kappa coefficient. results: the test showed that the agreement and kappa coefficient were . % and . . the test showed agreement was . %, . . the intra-observer agreement of clinical resident was . % and kappa coefficient was . . the orthopedic specialist was . %, and kappa coefficient was . . at test , cases did not match. cases of those were unclassifiable type, which were valgus type with medial fracture line. with slight displacement, agreement will get lower; some doctors consider it displacement type. conclusions: unclassifiable type makes us confused. it makes agreement better to discuss about unclassifiable type. introduction: the aim of this retrospective study was to describe the profile of missed hand and foot fractures in multitrauma patients and to elucidate risk factors for the delayed diagnosis. material and methods: from to , there were included patients. missed fractures were defined as fractures, which were not diagnosed during primary and secondary survey. patients were assessed for age, sex, glasgow coma scale, injury severity score, and length of stay in hospital (los). timing of hand or foot diagnosis related to admission date (measured in days) was noted. results: overall, . % of patients had a delayed diagnosis of hand fracture, . % ha a delayed diagnosis of foot fracture. the mean gcs for patients with delayed diagnosis was , whereas patients with diagnosis the day of admission had and mean gcs of (p \ . ). patients with delayed diagnosis had a mean iss of . versus . for those diagnosed the day of admission (p \ . ). furthermore, patients with delayed diagnosis had a mean los of . days, whereas those diagnosed at the time of admission had a mean los of days (p \ . ). concerning delayed diagnosis hand fractures, metacarpal and phalangeal fractures were the most common injuries overall ( . % and . %, respectively). concerning delayed diagnosis foot fractures, metatarsal fractures ( cases) and calcaneus fractures were the most common injuries overall, followed by talus fractures and toe fractures. conclusions: this study revealed that with a decreased gcs and increase in iss, polytrauma patients are increasingly at risk for delayed diagnosis of hand and foot fractures with a concomitantly increased los. as a delayed diagnosis has significant impact on the final functional outcome, correct and careful primary, secondary and tertiary survey is essential. introduction: the aim of this study was a) to determine the methods of hemorrhage control currently being used in clinical practice and b) to analyze pelvic fracture mortality rates before and after initiation of a multidisciplinary pelvic fracture protocol. material and method: between and , we included trauma patients with pelvic fractures (group ). a similar retrospective examination was performed on a number of trauma patients without pelvic fractures (control group). there were collected injury severity score (iss), the highest abbreviated injury scale (ais) score in each anatomic region and methods of pelvic hemorrhage control. there were also recorded hospital lengths of stay (los) and in-hospital mortality. results: the average follow-up was -months. the average iss in group and group was respectively . and . . in both groups the commonest mechanism of injury was motor vehicle crash ( . %). in group , angioembolization and external fixator placement were the commonest used method of hemorrhage control. patients underwent diagnostic angiography with contrast extravasation noted in patients. patients with pelvic fracture had a mean hospital los of . days. the overall in-hospital mortality rate of patients with pelvic fractures was . %, while in group the overall in-hospital mortality was . %. age, shock, severe head injury and increasing iss, are all significantly associated with mortality in the pelvic fracture group. conclusions: the findings from this study demonstrate no clear relationship between the choice of hemorrhage control intervention used and the patient's clinical status. in healthier patients with unstable pelvic fractures, the mortality rate was similar to that of patients with stable fracture patterns. introduction: various percutaneous screw placement for pelvic and acetabulum fractures is often difficult because of complex anatomical morphology, however, it becomes very beneficial to set enough fixation stability if we can insert the long screws. d-ct navigation system for the screw placement is beneficial for precise screw insertion. we investigated the accuracy of screws with d-ct navigation. material and methods: our retrospective case series were assessed by the accuracy of screws with d-ct navigation for pelvic and acetabulum fractures. twenty-six patients who sustained pelvic fractures and thirteen patients who sustained acetabular fractures were included in this study and . mm cortical screws or . mm cannulated screws were inserted with d-ct navigation. we investigated the number of screws and screw positions which is measured by postoperative ct scan and classified by smith criteria. results: we inserted tits (transiliac-transsacral) screws and is (iliosacral) screws for pelvic fractures. of screws ( . %) were placed in correct position (grade or ). screw for s lesion was placed in incorrect position. meanwhile we inserted antegrade pubic screw, anterior column screws, posterior column screws and infra-acetabular screws. of screws ( . %) were placed in correct position (grade or ). screws were in incorrect position and they were all cortical screws. and there was no complication related to screw insertion. conclusions: our study highlights that d-ct navigation system reduced the malposition rate of screw insertion for pelvic and acetabular fractures. however, we sometimes had difficulty in inserting tits screw for s lesion and cortical screw for acetabular fractures. we assumed that this was caused by narrowness of s corridor and flexibility of drill or inserting cortical screws in wrong position manually. we should pay much more attention even using d-ct navigation. is operative therapy still warranted for dislocated acetabular fractures in elderly patients? introduction: the incidence of acetabular fractures in elderly patients is increasing. there is no consensus about the right treatment for the impaired elderly patient with an acetabular fracture. the aim of study was to investigate acetabular fractures in the elderly patient and the risk of a secondary tha. material and methods: a retrospective study was performed from till in the radboudumc nijmegen. all patients with an acetabular fracture were reviewed. they were divided into two groups, younger than and or older. ct scans were used for classification according to letournel and for the quality of the reduction according to matta. there was a follow-up of minimal years. results: in total, patients attended at the radboudumc with an acetabular fracture, of which were years or older. in the younger group, patients received surgery and elderly patients. according to matta, an anatomical reduction was achieved in % of the young patients and % of the elderly patients. imperfect reduction was achieved in % of the younger patients and % of the elderly patients. thirteen percent of younger group and % of the older group needed a tha based due to the posttraumatic arthritis, the younger group after months and the older group after months on average. one younger patient with anatomical reduction needed a tha, none of the elderly patients. twenty-three percent of the younger patients and % of the elderly patients, all with a poor reduction, needed a tha. age, the complexity of the fracture and the quality of the reduction were important factors leading to a secondary total hip arthroplasty. conclusions: elderly patients are two times more likely to need a secondary total hip arthroplasty. after an anatomical reduction, the risk is very low, even in the elderly. surgery for dislocated acetabular fractures is a good option when there is a possibility for a good reduction. references: letournel e. matta jm. introduction: in japan, as a definition of basicervical fractures of the proximal femur, a fracture line is placed into and out of the joint capsule of the hip joint. however, in fact there are various fracture types.we classified these fracture types based on treatment methods and reported on these results. material and methods: cases of proximal femoral fractures treated in our hospital from january to december . basicervical fractures occurred in cases ( . %). all cases diagnosed with x-ray and d-ct, and observed for months or more after surgery. results: there are two types of basicervical fractures: the fracture line exists around the just inside of the intertrochanteric part: normal type(n type); cases ( . %), and fracture line exists subcapital at ventral side, the coronal plane in the center of the neck and the trochanteric fossa at the dorsal part: coronal shear type(c type); cases ( . %).c type was further classified by treatment method depending on existence of posterolateral fragment and anterior wall fracture. c type without comminution ( part:c- type) was cases ( . %). with posterolateral fragment ( part:c- type) was cases ( . %), with posterolateral fragment and anterior wall fragment ( part:c- type) was cases ( . %).n type and c- type were treated by sliding hip screw (shs) with anti-rotation screw. c- type: shs with trochanteric stabilizing plate, c- type because of the bony contact area is very small: hemi-arthroplasty with calcar replacement was performed. cut out occurred in cases of c- type and case of c- type, but others obtained union.. one case of c- type occurred peri-prosthetic fracture intraoperatively. conclusions: we classified cases of basicervical fractures, and according to its classification, treatment method was decided and good clinical results were obtained. strategies aimed at preventing chronic opioid use after trauma: a scoping review c. cô té , m. berube université laval, faculty of nursing, québec city, canada, chu de quebec research center, université laval, trauma, emergency, critical care medicine, québec city, canada introduction: a high incidence of chronic opioid use (up to %) has been documented after trauma. solutions are urgently needed considering the importance of this public health issue. we aim to identify strategies to prevent chronic opioid use in the trauma population and to assess their level of evidence. material and methods: we initiated a scoping review of literature to identify research articles and guidelines on preventive strategies. several databases and websites of trauma were searched. strategies were classified according to their types and targeted trauma populations. the level of evidence was summarized according to an adaptation of oxford center for evidence-based medicine classifications and strategies effectiveness. results: close to items have been screened until now from which studies - and one guideline were found eligible. two studies - combined education with mandatory limit of opioid prescriptions (level iii) in the orthopaedic trauma population and the other study used tailored physical training after whiplash injury (level i). findings showed reduction of opioid use or complete weaning at and weeks after trauma, however the effect was not maintained beyond weeks. guidelines on orthopaedic trauma made the following recommendations: prescribe the lowest effective dose for the shortest period (strong, high-quality evidence), avoid long-acting opioids in the acute setting (strong, moderate-quality evidence), and prescribe precisely (avoiding ranges of dose and duration) (strong, low-quality evidence). conclusions: chronic opioid use is an important issue in trauma patients. findings highlighted the need for more research to reduce the burden associated with chronic opioid use in this population. references material and methods: we analyzed clinical cases: men- and women- , mean age years. trauma circumstances: habitual trauma- cases, traffic accident- , precipitation- , sport- , aggression- . for cohort analize schatzker classification was used: especially type i was meet in cases, ii- , iii- , iv- , v- , vi- ; close, open. for paraclinic examination were used x-ray and ct. surgical management consisted of: close reduction, internal fixation- cases ( -percutaneus canulated screws arthroscopic assisted, -external fixator), open reduction, internal fixation- cases. bone graft was done in cases. results: postoperative follow up was performed at , , , weeks. patients were evaluated according to the lysholm knee scoring scale, obtaining an average score of points. bone healing was achieved in a period of between to weeks. postoperative complication developed in cases. results were depending on the stability of osteosynthesis, precocity, rightness of functional reeducation and patient compliance. conclusions: favorable functional results and less complication were met in cases of individual approach of surgical management, a good choice of implants and minimally invasive surgical techniques. fractures of the shoulder processes-a case report case history, clinical findings and diagnosis: -year-old male, low-speed motorcycle crash with subsequent polytrauma. he presented with right shoulder pain, swelling and pain to the touch. articular ct revealed a type i fracture of the coracoid base, type iii acromion fracture and scapular body fracture without displacement. results, therapy and progressions: he was submitted to surgical treatment days later. a superior ''sabercut'' approach with open reduction and osteosynthesis of the coracoid process was performed with a cancellous screw and washer and fixation of the acromion with k-wires and tension band wire. fracture of the scapular body followed a conservative treatment. immediate postoperative period was uneventful and he presented with favourable evolution in the subsequent -week, -week and -month follow-up. at present time, at -month follow-up, maintained anatomical reduction in radiological control, complete arm abduction and no limitation with efforts. comments: conservative treatment is generally indicated for all shoulder body fractures without displacement. fractures of the coracoid or acromion with [ cm displacement are described as an indication for surgical treatment. fractures of the acromium without displacement may follow conservative treatment with sling immobilization. surgical fixation can be achieved with screws, plate and screws or tension band wire. although controversial, surgical treatment for coracoid fractures is preferred, especially in active young patients with open reduction and fixation with screws or, if necessary, with plate and screws. the treatment applied in the present case, all approaches described in the literature as being effective and with good results, is in agreement with the options described in the literature and constitutes a corroborative example of its efficient results. case history: a -year-old male, hand worker, attended to our emergency department after a traffic accident complaining about pain and swelling in his left wrist. initial radiographs revealed an isolated dorsal dislocation of the lunate that went unnoticed. two and a half months later he was referred to our clinic. clinical findings: findings included dorsal wrist deformity and pain. he presented a decreased passive wrist flexion and extension range of motion, with normal finger tendinous function. investigation/results: plain x-rays showed persistence of the lunate dorsal dislocation without any associated injuries. diagnosis: chronic isolated dorsal dislocation of the lunate therapy and progressions: open reduction was performed using a dorsal approach. the scapholunate, lunotriquetal and scaphocapitate spaces were stabilized with a compression screw and kirschner wires respectively. the patient persisted with pain and functional limitation after the surgery, showing an insufficient reduction of the scapholunate space on the x-ray. nine months after the initial surgery, he developed a purulent fistula on the ulnar edge of the carpus. after it was resolved, a total wrist arthrodesis was performed using the mannerfelt technique. at the months follow up, he was clinically stable, consolidation of the arthrodesis was documented and he had returned to his previous normal activities. comments: isolated dorsal dislocation of the lunate is a rare lesion. the delay in the diagnosis of carpal dislocations is frequent. this compromises the final outcome of reconstructive techniques and the risk of residual instability, hence increasing the risk of chronic pain associated with posttraumatic osteoarthritis. in the case of chronic lesions, treatment with palliative techniques such as proximal carpectomy or joint arthrodesis should be taken into consideration. references: siddiqui n., sarkar s. isolated dorsal dislocation of the lunate. open orthop j. ; : - is ultrasound-guided regional anesthesia safer than landmark technique? one-hospital experience introduction: according to the literature the application of ultrasound (us) in performing regional anesthesia had a significant impact on patient safety by increasing the success rate [ ] . in a donated ultrasound device became available in the institute of emergency medicine, chisinau, republic of moldova. due to lack of equipment both us guided and landmark techniques have been performed. the aim of this study was to analyze the two methods of performing regional anesthesia, in order to estimate the potentials benefits of of us guided techniques (succes rate and doses). results: the bivariate analysis showed that, out of anesthetics in lmg, a number of were reported as unsuccessful, compared with a number of in usg. the v test with corrections for continuity did not determine significance (test value . , df = , p = . , effect size = . ), rr being . ( % ci . - . ). linear regression for dose (lidocaine) modeling, in patients included in the research, showed a decrease of the dose by mg in lmg, the confidence interval being quite wide ( % ci -. , -. ). that is, the actual decrease is within the limits of and mg. conclusions: the tendency towards higher failure rate in successfully performing an us guided regional anesthesia and relative ''uncertain'' decreasing of dosage are in contradiction with the international statistical data. this in turn evidenced probable deficiencies in the training of the practitioners in field of ultrasound guided techniques in our country. the prospective research to confirme/infirme these results and estimate the complication rate follows. references: . barrington mj, uda y. did ultrasound fulfill the promise of safety in regional anesthesia? current opinion in anaesthesiology ; ( ) results: average age years old ( - ).all were active labour patient. the most frequent mechanism was high energy trauma (traffic accident), of who presented gustilo grade iiib open fractures operated in the country of origin. most frequent pattern of fracture was -c. ( cases) and -c. ( cases). initial conservative treatment was performed in of the cases. one persistent pseudoartrhosis with osteosynthesis material failure. in every case, preoperative ct and early surgical intervention were carried. in cases, an additional procedure was associated at the radioulnar distal joint. in all cases consolidation occurred. one patient required reintervention for persistent pseudoarthrosis. average consolidation time months ( ) ( ) ( ) ( ) ( ) ( ) ( ) .average follow-up of months ( - ). average active joint balance: flexion °( °- °), extension °( °- °), pronation °( °- °), supination °( °- °). average dash . ( - . ).force reduction greater than % compared to contralateral in of the cases. radiological parameters:radial height . mm ( - ),radial inclination °( - °),volar angulation . °( . °- °), ulnar variance . mm ( ) ( ) ( ) ( ) ( ) . conclusions: malunion of the distal radius is an uncommon and severe complication with increasing incidence that requires early and personalized surgical treatment to achieve the correction of the deformity, preserving mobility acquiring consolidation with acceptable functional results case history: isolated ulnar translocation of the carpus is unusual. when the translation occurs without injury of the radius, ulna or carpal bones are often misdiagnosed. early diagnosis is key, to avoid further complications such as redislocation of the carpus ( ). clinical findings: in our case a young male patient suffered a high energy motorcycle accident. he had no a b c d problem investigation/results: the ulnar translation of the left carpus was evident but comparison x-rays were taken on both wrist for further evaluation. the distance between the line, drawn through the axis of the radius and the center of the capitate bone was measured bilaterally. the results were . mm vs . mm. diagnosis: isolated, open ulnar translocation of the radiocarpal joint, dumontier type i, was diagnosed. treatment: the primary treatment was debridement, reposition and fixation with ex fix. after the wound healing on th days we made reconstruction. volar approach was used, we re-reponate the carpus and fixated the position with two mm smooth kirschner wires. the radioscaphocapitate and long radiolunate and radioscaphoid ligaments were reattached to the volar margins of radius using mitek mini anchors. we put the ex fix and left the bended wires percutaneously. after weeks the ex fix and the k wires were remove. wrist motion exercises were initiated under supervision of physiotherapist. comments: after weeks the wrist was in good alignment, the flexion-extension were - , the deviations were - °. the radiographic signs of this injury are unusual and often misdiagnosed. it can be useful to compare with contralateral x-rays. the radiolunate and radioscaphocapitate ligaments is considered crucial in prevention of ulnar translation. in our opinion the radiolunate arthrodesis can be reserved for failed ligament repairs. introduction: within the orthopaedic paediatric population, there is a distinct paucity of literature in regard to post-operative paediatric analgesic regimes. supracondylar humeral fractures account for % of all paediatric limb fractures and there has been a marked divergence in recent literature concerning the most appropriate choice of analgesia for this cohort with recent studies recommending the routine inclusion of an opioid agent post-operatively on prescription. opioids have deleterious side effects pertinent to paediatrics. in our institution, patients'' only receive a prescription for acetaminophen and nsaids upon discharge. our study assessed postoperative analgesic satisfaction rates in all paediatric patients who underwent crpp for supracondylar humeral fractures in our institution from january to december . material and methods: this is a retrospective multi-surgeon case series of all paediatric patients who underwent crpp from january to december . patient data was extrapolated from theatre records and clinical charts. for each patient, all analgesic agents given were identified, the dosage, route and frequency of administration in addition to the length of their hospital stay and time from injury to operation. following discharge, patients'' guardians were contacted retrospectively and a questionnaire was administered which ascertained the efficacy and duration of analgesia used by the patient postoperatively. results: fifty patients were identified for inclusion within the study who met the inclusion and exclusion criteria. there was a % satisfaction rating amongst the responders with the analgesic regime recommended-acetaminophen & nsaids. conclusions: in stark contrast to papers which we discuss throughout our paper, our study conclusively demonstrates that opioid prescriptions are not required upon discharge for supracondylar fractures within a paediatric population case history: a -year old man suffered an isolated injury of his right hand in a motorcycle accident. clinical findings: the patient presented with a swollen hand, a subtotal amputation of the middle finger at the level of the middle phalanx and lacerations to the other fingers (fig. ) . investigation/results: after excluding injuries to other body regions, radiographs and a ct of the hand were performed (fig. ) . diagnosis: closed fracture dislocation of cmc joints from ii. to v. finger, comminuted fracture of the middle phalanx of the middle finger, closed fracture of the proximal phalanx of the middle finger, other lacerations to the iv. and the v. finger. therapy and progressions: urgent open reduction and internal fixation (orif) with k wires of the cmc joints. exploration of the middle finger reviled heavy contamination and comminution of the phalanx, with injury to one neurovascular bundle. a phalangectomy with acute finger shortening was performed with creation of a new ip articulation (distal to proximal phalanx) (fig. , ) . progression after the surgery was uneventful. there was no sign of infection. the shortened finger was sufficiently perfused and the patient reported a sense of touch. k wires were removed after weeks and physical therapy was started. the patient has limited rom in his neo ip joint with minimal pain (vas - ) (fig. ) . comments: middle phalangectomy of the hand was described in the literature only in two papers which report treatment of chronical or congenital diseases. the authors propose this method as an alternative to amputation in selected trauma cases. results: patients ( m, f, mean age y) with fractures were included. kidney-tpl, lung-tpl, liver-tpl, heart-tpl, kidney/pancreas-tpl. all patients got treated with at least two immunosuppressive drugs. cause of accident: . % sports/leisure, % work/household, . % traffic accidents, % without trauma. the operation was performed under perioperative long-term antibiosis, often with a combination of two or three drugs. patients were hospitalized for an average duration of . days and were also examined by the particular organ specialists. osteosynthesis: in % primary operative fracture treatment, in % two-step procedure. plates distal radius and ulna [healing period (h) conclusions: the fracture healing was possible but significantly delayed. the wound healing took longer. the immunosuppressive therapy may be responsible for these problems. the rehabilitation of movement and weight bearing has to be adapted to the slowed fracture healing. introduction: the prevalence of fragility fractures of the pelvis (ffp) increases, including in up to % a lesion of the posterior pelvic ring. an operative therapy is indicated in cases of prolonged or immobilizing pain or in a displaced dorsal fracture. methods: patients suffering an ffp treated with a minimal-invasive trans-sacral bar through s from to were included. the patients or their relatives were contacted to ask about mortality, the present mobility and place of residence. % of all patients still alive could be included in follow-up. results: females and males with a mean age of . ± . years ( - ) were included. concomitant stabilization of the anterior pelvic ring was performed in %. . % underwent an operative revision ( % evacuation of hematoma, % peri-implant infection, % hardware removal-combinations possible). the trans-sacral bar was removed in one case due to malpositioning. the length of stay was ± days. at discharge, % were mobile on the ward, % in their room, % for transfer to sitting position and % were bedridden. % were discharged to their home, % in geriatric rehabilitation unit, the remaining to other rehabilitation or to a nursing home. during follow-up, mortality was %, one patient died during hospital stay. the patients died in average ± weeks after discharge. after a follow-up of ± weeks, % lived at their home, thereof one-third with assistance. % needed a walking aid, % were mobile without walking aid, % were bedridden or only mobile to sitting position. conclusion: the trans-sacral bar in s is a valuable minimal-invasive stabilization method to recover mobility in elderly with an ffp. a relatively long in-hospital stay could be explained by the initial trial of conservative treatment and due to intra-and inter-departmental cogeriatric services. the high mortality and need for assistance reflects this geriatric, multi-morbid patient collective. case history: a -years-old woman was admitted in the emergency room after being run over by a bus. clinical findings: at the emergency room, she was conscient and hemodynamic stable. head, thoracic or abdominal trauma were excluded. the patient presented with an open wound in left popliteal area with massive bleeding with exposure of gastrocnemius and soleus muscles and achilles tendon investigation: radiologic images didn't show any fracture. a limb angiography showed complete perfusion of the leg, without any lesion on major arteries. diagnosis: open aquilles tendon avulsion through the popliteal fossa therapy and progressions: the patient was taken to the operating room. we approach the popliteal area and found a small laceration of popliteal vein, which was sutured with prolene / . then, we reference the achilles tendon, and tunneled the posterior face of the leg, and passed the tendon through the tunnel. a distal approach, above the insertion of achilles tendon was done, and two suture anchors preloaded with sutures were inserted in the medial and lateral sides of the calcaneal tuberosity, then we did an krackow suture. we also did a fasciectomy on the lateral side of the leg, to prevent compartmental syndrome. the patient was put in a posterior cast with of flexion for weeks. the immediate post-operative time was in an intermedia unit care, to control possible multiorgan failure. in days, she was discharged to orthopedics nursery. due to the degloving of subcutaneous tissue, she evolved with some blisters which made her stay inpatient about weeks. after some time, she developed some areas of skin necrosis, which needed some intervention by plastic surgery with skin graft. now, she has skin completely healed, some loss of strength in the leg, with loss of plantarflexion, and is under prolonged rehabilitation program. therapy and progressions: she was rushed into the or and submitted to external fixation of the humerus and bones of the forearm, debridement, and primary closure of the forearm and hand. successive dressings and debridement was maintained and, at th postoperatory day(po) the external fixator of the left humerus was removed and a nailing was performed as well as an osteosynthesis of the clavicle fracture with anatomical plate. at thpo the external fixator of the forearm bones was removed and an open reduction and internal fixation of the radius with lcp plate and closed reduction and internal fixation of the ulna with an anterograde ten nail was performed. at thpo, she underwent an autologous skin graft of the forearm and hand wounds. good clinical evolution of the wounds and fractures, all of which evolved to consolidation, although m fracture malunion was verified as well as deficit of thumb abduction and extension of rd- th fingers. uefi of / . comments: the approach of polytrauma patients should be sequential, according to the atls protocol, preserving life, limb and function. treatment of these lesions is complex and, if poorly managed, can be associated with high morbidity, as most patients combine severe and contaminated lesions, extensive skin loss, open fractures, postoperative infection. a sequential approach is required, which involves injury assessment, infection prevention, soft tissue treatment and fracture stabilization. introduction: pelvic fractures, though rare ( - %), are often associated with high mortality ( - %). the factual outcomes in polytrauma patients with the additional burden of pelvic fractures are unknown. the purpose of this study is to provide an in-depth analysis of pelvic fractures in seriously injured patients. material and methods: this is a retrospective analysis of prospectively maintained trauma registry from to . we included all trauma patients with iss c . group i, which had an additional burden of pelvic fractures, was compared with group ii, consisted of patients without pelvic fractures. a double-adjustment propensity score match (psm) analysis was utilized to minimize confounding and unbiased estimation of the impact of pelvic fractures. . ± . , asmd = . ).patients in group i had higher number of genitourinary surgery (p = . ), exploratory laparotomy (p = . ). therequirement of angio-embolization was similar in between two groups (p = . ). while there were no difference in mortality (or . , % ci . - . , p = . ), group i had higher odds of severe sepsis (or . % ci . - . , p = . ) and ventilator-associated pneumonia (or . , % ci . - . , p = . ) conclusions: pelvic fractures in polytrauma patients did not translate into higher mortality. however, there was an increased risk of sepsis and vap. evidence-based management at tertiary care specialized centers can further enhance the outcomes. investigation/results: ap pelvis x-ray reveals a complex left proximal femur fracture with neck and trochanteric extension. a ct-scan was obtained and showed a complex fracture pattern with subcapital and trochanteric extension. blood analysis showed a hemoglobin of . g/dl. diagnosis: therapy and progressions: at admission, patient refused erythrocytes'' concentrate transfusion and was hospitalized for pain control and hemodynamic stabilization. despite alternative measures such as intravenous iron supplementation and erythropoietin, hemoglobin values remained lower than . g/dl, thus preventing any surgical procedure. at day , patient finally decided to accept packed red blood cells and was then transfused. at day and with a hemoglobin of . g/dl, the patient was finally submitted to a total hip arthroplasty with an uncemented revision femoral stem. at day , the patient initiated the rehabilitation protocol with hospital discharge at day with a hemoglobin of . g/dl. comments: proximal femur fractures arise as one of the major problems of present traumatology. comorbidities frequently prevent surgical treatment within the golden hour (first h) and thus limiting the postoperative results. in this particular case, a timely surgical approach would have made it possible to try a more conservative procedure with femoral osteosynthesis. the surgical delayed due to low hemoglobin values limited the surgical options and forced a more aggressive procedure. routine versus on demand removal of the syndesmotic screw; a multicenter randomized controlled trial on functional outcome introduction: syndesmotic injuries are common, being present in approximately - % of surgically treated ankle fractures . one of the most commonly used ways of fixation is the syndesmotic screw (ss). traditionally, this screw is removed after - weeks as it is thought to hamper ankle function and cause pain. however, a recent study showed that implant removal does not always result in improvement of functional outcome . with the relatively high complication rate of implant removal in mind, retaining sss could be beneficial. we therefore aimed to investigate the effect of retaining the ss on functional outcome. material and methods: in this multicenter rct, patients were randomized between routine and on demand removal (upon patients request). the primary outcome was functional outcome at months after ss placement, measured by the olerud-molander score (omas) with a non-inferiority limit of points ( % power, a = . ). secondary outcomes include quality of life, range of motion, complications and costs of ss removal. results: a total of patients were randomized, of which for routine removal and for on demand removal. the mean age was years old and % was male. follow up of all participants will be completed in march . results of the primary outcome analysis are therefore not yet available, but will be at the conference. conclusions: if on demand removal of the ss is non-inferior to routine removal in terms of functional outcome, this will offer a strong argument to adopt this as standard practice of care. this means that patients will not have to undergo a secondary procedure, resulting in fewer complications and subsequent lower costs. introduction: treatment options for pertrochanteric fractures of the hip are extra-or intramedullary fixation. the aim of this study is to identify risk factors for the development of complications: varus deformity, neck shortening, revision and cut-out. material and methods: retrospective cohort study in which radiographs of patients with pertrochanteric fractures, treated at the uz brussel between and , were reviewed. fracture type, type of the device, cut-out and revision where noted. measurements for the centrum-collum-diaphyseal angle (ccd) of the two hips, impaction, tip apex distance (tad), parker''s ratio were realized. statistical analyzes were made with logistic and multiple linear regression analyzes. results: patients were included. bmi (p = , ), type of osteosynthesis (p = , ), dhs ? plate (p = , ), short nail (p = , ) and the tad (p = , ) are independent risk factors for the development of varus deformity after consolidation. for impaction are bmi (p = , ), short nail (p = , ), long nail (p = , ) and fracture type a (p = , ) independent risk factors. we identified a marginal statistical significant risk factor for cut-out: tad (p = , ). conclusions: , % of the patients had varus deformity after consolidation. the risk of varus deformity rises with a higher bmi and a higher tad. the risk for this complication was higher when using a nail. neck impaction was shown more together with a high bmi and less in fracture type a and with the use of a short or long nail. in the prevention of cut-out, it is important to keep the tad low. case history: -year old female with previous distal femoral plating ( years ago) and ipsilateral proximal femoral nailing ( months ago) presented with a diaphyseal femur fracture. clinical findings: extremity was swollen, painful, neurocirculatory intact, no shortening or external rotation was seen. she was unable to lift her leg. scars showed no sign of infection. investigation: x-ray revealed a spiral fracture including distal pfna locking screw, unhealed proximal femur fracture without loss of reduction, protruding pfna blade and a healed distal femoral fracture. diagnosis: peri-implant fracture classification proposed by the singapore group presented a discrepancy between nail type subtype b and plate type subtype. by simplification, we disregarded the distal (healed) fracture to choose the first option. therapy: firstly, the distal femoral plate was removed as the preoperative simplification dictated. secondly, pfna distal locking screw was removed and the pfna blade shortened. after open reduction cerclage wires were applied. a long lcp plate was initially fixed through the plate and pfna locking hole, adjusted in line, fixed proximally with screws through a locking attachment plate and cerclage, distally locking screws were used. comments: distal femoral callus prevented the use of a long nail. as the proximal fracture was not yet healed, we avoided full implant removal. as the pfna was unstable, fixation through the plate and pfna distal locking hole enabled implant coupling to strengthen the construct. the plate covered the entire bone to bridge the possible loci minori left by the plate removal and minimize stress risers. background: we have been reported the usefulness of intra-medullary antibiotics perfusion (imap) and intra-soft tissue antibiotics perfusion (isap) for suppressing open fracture and bone infection. imap and isap was a method of antibiotics delivery with the continuous administration of high-dose aminoglycosides. however, the best dose was not obviously. the purpose of this study was to evaluate translation of aminoglycosides from imap or isap. as follows: males and females, average age was . years old, intramedullary nails and plates. one dialysis patient was including. we measured concentration of gentamicin from imap, isap and in blood, outflow. results: average administration concentration of all cases was . lg/ml. average blood concentration of all cases was lg/ml and outflow concentration were . lg/ml. average blood and outflow concentration of each dosage were shown as follows: lg/ ml: . lg/ml, lg/ml, lg/ml: . lg/ml, . lg/ml, lg/ml: . lg/ml, lg/ml, lg/ml: . lg/ml, . lg/ml. in dialysis patient case, lg/ml administration lead concentration of blood as . lg/ml, outflow as lg/ml. side effect were not observed. discussion: local antibiotic administration using imap and isap showed increasing blood concentration depend on administration dose. under lg/ml administration dose showed safe blood concentration(\ lg/ml). on the other hand, lg/ml administration dose achieve trough concentrations over - times of minimum inhibitory concentration. furthermore, we need to pay attention for administration dose in dialysis patient case. conclusion: lg/ml administration dose achieved safe and effective local concentration. introduction: distal radius fractures and supracondylar humerus fractures are two of the most common fractures seen in children. most can be treated with non-operative treatment but a small number require operative reduction and surgical stabilisation, often with percutaneous kirschner wires. this study aims to identify whether an early review is required before planned removal of the wires. materials and methods: retrospective review of paediatric patients undergoing surgical reduction and stabilisation with percutaneous kirschner wires for upper limb injuries. data collected over threemonth period (june-august ). number and type of outpatient reviews, imaging episodes and clinical interventions recorded. results: consecutive patients with mean age years (range - ). distal radius fractures and supracondylar humerus fractures. patients transferred to another unit. / patients received a week check and then a second review where the wires were removed. mean time to first outpatient review . days (sd . ). at initial appointment all patients had a change of cast and a satisfactory radiograph. mean time to second outpatient review was . days (sd . ). at the second appointment / patients had the wires and cast removed and subsequent satisfactory radiograph. / required a further period of casting. / had a third appointment. / required formal physiotherapy after cast removal. there was one transient anterior interosseous nerve palsy after supracondylar fracture stabilisation. clinical union of the fracture and good functional outcome was seen in all cases. conclusion: the initial outpatient review at - weeks allows a lighter weight cast to be applied but in this series the radiograph taken after the cast was changed did not alter management. our findings support a cast change alone at weeks and then clinician review with radiographs at the time of wire removal. introduction: the aim of this study was to describe surgical technique, report on patient-based functional outcomes and complications following open reduction and internal fixation in patients with scapular fractures. methods: the study comprised patients who were treated with open reduction and internal fixation (orif) of a scapular fractures between september and july . surgical indications were as follows: medial/lateral displacement greater than mm; shortening greater than mm; angular deformity greater than °; intraarticular step-off greater than mm and double shoulder suspensory injuries (including fracture of clavicle, coracoid or acromion with displacement greater than mm). all patients underwent x-ray examination (true ap, y scapular view) and computed tomography (ct) scans. fractures were classified according to the revised (ao/ota) classification system. functional outcome were measured using the constant-murley score. results: seven patients had glenoid fossa fracture, six patients had scapular body fracture and one patient had acromion process fracture. all glenoid fossa and scapular body fractures were exposed via the judet approach. eleven of patients were reviewed with constant-murley score at the final follow-up examination, three patients were lost for follow-up. the mean follow-up after injury was months ( - months). we found in four patients infraspinatus muscle hypotrophy. mean constant-murley score was . (± . ) for injured arm and . (± . ) for uninjured arm. mean score between injured and uninjured arm was . (± . ) which is excellent functional outcome according to grading the constant-murley score. conclusions: open reduction and internal fixation of displaced scapular fractures is a safe and effective treatment option that results in reliable union rate and good to excellent functional outcome. introduction: the aim of this study was to evaluate clinical and radiological results of intramedullary radius and ulna nails in treatment of adult forearm fractures. methods: the retrospective study included patients who were treated with intramedullary nailing of forearm fractures between january and september . the medical records and radiographic images of all patients, taken preoperatively and postoperatively, were reviewed. fractures were classified according to the ao/ota classification system by reviewing the radiographs. we analayzed time to union, union rate, clinical outcome and complications. results: primary intramedullary osteosynthesis were performed in patients with forearm diaphyseal fractures. the average time to union was months (range, - months) in primary osteosynthesis cohort. secondary intramedullary osteosynthesis were performed in four patients following removal of plates and screws due to pseudoarthrosis. the average time to union was months (range, - months) in secondary osteosynthesis cohort. overall union rate was , % in forearms with fractures or pseudoarthrosis of the radius, ulna, or both bones, which were treated with intramedullary nail with compression screw. overall complications were one nonunion, one postoperative rupture of the extensor pollicis longus tendon and one postoperative transitory radial nerve palsy. conclusions: intramedullary nailing of adult forearm fractures is a safe and effective treatment option that results in reliable union rate and good to excellent clinical outcome. key words: forearm fractures, intramedullary nailing, biological fixation, union rate results: transverse or short oblique fractures of the middle third of the humeral shaft were treated using a retrograde approach. spiral fractures of the middle third of the humeral shaft were treated through the antegrade approach. comminuted fractures of the proximal third of the humeral shaft were treated mostly through the antegrade approach. comminuted fractures of the distal third of the humeral shaft were usually treated using the retrograde approach. whenever possible, we prefer retrograde insertion because the approach through the shoulder joint is avoided. reduction with retrograde nailingnis easier because upper arm was placed on the radiolucent operating table extension. interlocking screw insertion by freehand techique is also easier to perform because there is no danger of radial nerve injury. nonunion was found in eight patients ( , %). there were five patients ( , %) with postoperative transitory radial nerve palsy that fully recovered within months. conclusions: the choice of approach to the medullary canal depends on the fracture type and the fracture site. therefore, antegrade nailing should be performed for proximal third humeral shaft fractures and complex middle third humeral shaft fractures, while retrograde nailing should be perforemd for distal third humeral shaft fractures and simple transvese or short oblique middle third humeral shaft fractures. keywords: humeral shaft fractures, intramedullary nailing, radial nerve palsy, nonunion the diaphyseal aseptic tibial nonunions after failed previous treatment options managed with the reamed intramedullary locking nail i. kostic , m. m. mitkovic clinical center nis, university hospital, orthopaedics and traumatology, nis, serbia, university of nis, serbia, orthopaedics and traumatology, nis, serbia introduction: in this article, we present our approach to the surgical treatment of noninfected tibial shaft nonunions. material and methods: between and , patients with aseptic diaphyseal tibial nonunion was treated by reamed intramedullary nailing and were retrospectively reviewed. all patients, preoperatively, were evaluated for the signs of the infection, by the same protocol. results: the time that elapsed from injury to intramedullary nailing ranged from to months (mean months).open intramedullary nailing was unavoidable in cases ( , %), while closed nailing was performed in patients ( , %). all patients were followed up in average period of years postoperative (range - years), and ( , %) patients achieved a solid union within the first months. conclusions: in conclusion, a reamed intramedullary nail provides optimal conditions for stable fixation, good rotational control, adequate alignment, early weight-bearing and a high union rate of tibial non-unions. percutaneous figure of suture as a novel technique for treating closed tendinous mallet injuries following failed splinting therapy. t. eltantawy , a. yousif , k. maheshwari , a. hartpinto bedford hospital, plastic surgery, bedford, united kingdom introduction: mallet injuries are common injuries affecting the hand. majority of them are managed using conservative method, however a small percentage of patients that do not do well on conservative treatment need an operative intervention. we wish to evaluate the efficacy of percutaneous figure of suture as a new technique for treating closed tendinous mallet injuries resistant to splinting therapy, as a minimally invasive treatment option. material and methods: we present a case series of patients who had persistence of more than degree extensor lag, despite splinting minimally for weeks. all of these were treated with a percutaneous figure of suture placed across the dorsum of dipj, which provided splinting for further weeks. this technique provides fixation for the dipj in hyperextension position by going through the periosteum on both sides and was done under local anaesthesia. results: the mean age of our patients was years, with a single digit involved in all patients. all the five cases had nearly fully straight dipj with less than °extensor lag following weeks of percutaneous stitch placement. there was no further recurrence with mobilisation or overlying skin necrosis. conclusions: percutaneous figure of suturing technique can be an effective, minimally invasive and safe technique to treat closed tendinous mallet injuries not responding well for conservative splinting. introduction: osteosynthesis of pertrochanteric fractures (pf) is a frequently performed procedure in orthopaedic trauma care. dynamization of the osteosynthesis during fracture healing can lead to dynamization of the lag screw. which can cause debilitating complaints. a spontaneous femoral neck fracture (sfnf) after implant removal was seen in patients over a month period. based on these cases we evaluate the different aspects of the pathophysiological and mechanical mechanisms of lag screw dynamization, complaints and complications in pf healing. material and methods: pubmed search on incidence of chronic pain, gait impairment associated with dynamization of osteosynthesis, risk factors for dynamization and complications after implant removal. based on research data preventive recommendations are suggested. results: literature describes complaints as reduced mobility, gait impairment and chronic pain in association with lag screw dynamization. an important risk factor is the ao-classification of pf, a type fractures are significantly associated with more dynamization and the onset of trochanteric pain and gait disturbances. partial implant removal can reduce complaints in the majority of symptomatic patients, and induce symptoms in % of asymptomatic patients. literature study shows a sfnf after lag screw removal with an incidence of %, affecting mostly vulnerable elderly patient resulting in a high mortality rate. risk factors associated with an increased risk of this complication are pre-existing systemic osteoporosis, stress-shielding, pre-loading of the implant. most importantly the removal itself, a sfnf with the implant in situ is very uncommon. conclusions: the clinical indications for implant removal in healed pf are not well established, and should be restricted to specific cases. after removal, partial weight bearing and good patient counselling is extremely important. replacement with shorter lag screw should be considered. metal osteosynthesis of pathological bone fractures with metastatic lesion of plates with a spray on their surface of hydroxyapatite and % silver v. protsenko , a. abudayeh , v. chornyi , y. solonitsyn institute of traumatology and orthopedics of nams of ukraine, onco-orthopedics, kiev, ukraine, bogomolets national medical university, kiev, ukraine introduction: surgical intervention in the case of pathological bone fracture against the background of metastatic lesion involves performing osteosynthesis. for more effective integration of the metal plate with the bone, a material based on bioactive glass was sprayed on their surface. bioactive glass-based material is an osteoinductive and osteoconductive biomaterial that integrates quickly with bone, forms a bone-ceramic complex, and is transformed into bone over time. material and methods: metal osteosynthesis of pathological bone fractures with metastatic lesion of plates with spraying on their surface of hydroxyapatite and % silver was performed in patients. the functional result of the operated limb was calculated on the msts scale. evaluation of pain was performed on the scale of r.g. watkins. the quality of life of patients was evaluated using the eortc qlq-c system. the evaluation of the integration of the plate with the bone was performed by radiological examination and by osteoscintigraphy. results: postoperative complications were found in ( , %) patient, recurrence of metastatic tumor was noted in ( , %) patients. the functional result of the operated limb after metal osteosynthesis was , %. the degree of pain decreased from , % to , %. the quality of life of patients after metal osteosynthesis improved from to points. x-ray examination revealed the formation of callus within a shorter timeframe, as evidenced by the more intense accumulation of radioisotope during osteoscintigraphy. introduction:the aim of this study was to evaluate the results in patients who had heal intertrochanteric fracture but did not receive adequate mobilization and rehabilitation support. material and methods:sixty patients over years old age were included in our study. the rehabilitation emphasized pain relief, muscle strength, range of motion, endurance, balance challenges, and proprioceptive enhancement for all patients. it started postoperative first day and was delivered twice a day by the physical therapist until discharge. patients were discharged on average . days ( - days) after surgery. the mobilization of patients was evaluated with the parker and palmer mobility scoring system, the clinical evaluation was performed with the haris hip scoring and daily living activities were evaluated with the barthel life index before and at the end of the fracture. results: female male patients were included in our study. the mean age was , ( - ) years and the mean follow-up period was , ( - ) months. patients had a type, patients had a type intertrochanteric femur fracture. in the last follow-up, all patients had fracture union. patients' mobility, daily life activity and clinical evaluations were found to be statistically significantly worse in the last control than before surgery. conclusions:the success of the surgical treatment and the union of the fracture after fixation are not sufficient for the successful mobility,daily life activity,and clinical results.the success in the functional results are significantly related with the ambulatory ability.although early mobilization and rehabilitation support are important in intertrochanteric femur fractures after surgery,the continuity of mabilization and rehabilitation support after hospital discharge is more important.the rehabilitation which administered by the patient''s ralations after hospital discharge is not sufficient.therefore,the importance of home-based rehabilitation is increased. the prognostic value of the hip screw position in trochanteric fractures i. gárgyán , î csonka , t. ecseri university of szeged, department of traumatology, szeged, hungary introduction: in our study, we analyzed one of the hungarian population's most frequent injuries, the hip fracture, focusing mainly on the lateral femoral neck and the pertrochanteric fractures. according to the classification of the swiss association for ostheosynthesis (ao), we focused on -a and -a fractures, the incidence of which increases by ageing. material and methods: between and , we analyzed the data of patients. all of the fractures were stabilized with intramedullary nails. patients received stryker gamma Ò , whereas patients' fractures were solved with synthesis pfna Ò nail. in all cases, closed reduction method was used with fluoroscopy on an extension table. the surgeries were done in general or epidural anesthesia and performed by traumatology residents or specialists using standard lateral exploration. data were collected using gepacs software and statistical analysis was done with ms excel. results: cut-out occurred in cases ( , %): out of that ( . %) were left sided and were ( , %) right sided. ( . %) patients were treated with gamma nail, and in ( , %) cases pfna nail was used. the average tad-index was mm. conclusions: according to recommendations of the tad-index value, when using dynamic hip screw, it should be mm or lower. the average index value was mm which was equal in the complicated and non-complicated groups. our study shows that the cutout is independent from the tad-index value, thus this recommendation cannot be applied for intramedullary nails. oita university hospital, acute trauma, emergency, and critical care center, yufu, japan, oita university, orthopaedic surgery, yufu-city, oita, japan introduction: dome impaction fragments (difs) in acetabular fractures are typically accompanied with anterior column fragments and recognized as the gull sign on plain radiographs. meanwhile there are some difs which do not fit into typical difs. the aims of this study were to define atypical dif and describe tips for diagnosis and intraoperative visualization. material and methods: this study was a retrospective case review. we defined atypical difs as the fragments which were independent of anterior column fragments and did not show the gull sign on plain radiographs. from jan to july , there were patients of acetabular fractures, and patients ( . %) had difs. among them, patients ( . %) were identified as the cases with atypical difs. all of them were male. the ages were from to . results: the atypical difs were not obvious on x-rays (fig. ) . all three atypical difs were located at posteromedial weight bearing zones of the acetabulum. case and were displaced in accordance with posterior column fragments, and were visualized clearly on the sagittal view of ct images (fig. ) . case was impacted posteriorly into a posterior part of the ilium as a free fragment, and well visualized on ct sagittal and coronal views. anterior intrapelvic approach was chosen in all patients to treat atypical difs. the iliac oblique view was useful to visualize the atypical difs intraoperatively in case and . in both cases, the reverse gull sign appeared after reduction of posterior column fragments (fig. ) . in case , the inlet view was useful to visualized the atypical dif intraoperatively.the fragments were reduced and fixed with supra-acetabular screws (fig. ) . results: we found prospective two to years after acetabular osteosynthesis , % complications. avn of the femoral head was present in , % of the hips reduced within h and , % of the hips reduced more than h after the injury [p = , ; = , ; or = ( % ci = , - , ) ]. post-traumatic oa of the hip we found in , % (fig. ) infections we found in , % ( deep, superficial), iatrogenic nerve palsy in ( , %), traumatic nerve palsy in , % ( ), dvt in , % ( ) , and ho in , % ( ) cases. in one case ( , %) revision surgery was done. conclusions: acetabular fractures are followed with complications. some complications depend on surgery, meanwhile others cannot be affected on (type of fracture, impaction of acetabulum, injury of the femoral head, dislocation of femoral head). good knowledge of acetabular anatomy, surgical technique, experienced surgical team, early surgery, anatomical reduction and stable orif, early mobilization, can significantly influence excellent/good functional outcomes and reduce possibility for complications. introduction: reduction is one of the important factors in surgical treatment of femoral trochanteric fractures. in this study, postoperative reduction status was examined and the relationship between this reduction status and unsatisfactory cases was investigated. material and methods: cases of femoral trochanteric fractures over years treated with pfna-ii were investigated. postoperative reduction status was evaluated in ap and lateral view of x-ray and ct. anatomical reduction means medial or anterior cortex is reduced anatomically (abbreviation am and aa). intramedullary reduction means medial or anterior cortex of proximal fragment is inside the shaft (im, ia). extramedullary reduction is medial or anterior cortex of proximal fragment is overlapped to cortex of shaft (em, ea). unsatisfactory cases were ununited cases until months and excessive sliding cases over mm. reduction status of these cases was evaluated. results: postoperative status was classified with combination of medial and anterior reduction status. so there are nine groups and number of each group are as follows; im-ia: case, im-aa: cases, im-ea: case, am-ia: cases, am-aa: case, am-ea: cases, em-ia: cases, em-aa: cases, em-ea: cases. non-united cases until months were cases. reduction status of non-united cases were; im-ia: cases, im-ea: cases, am-ia: cases, am-aa: cases, em-ia: cases, em-aa: cases. there was no case in extramedullary reduction of anterior cortex. excessive sliding of blade over mm was cases. there was also no case of extramedullary reduction of anterior cortex in these cases ( cases were cut out). conclusions: our results show there are no ununited cases and excessive sliding cases in extramedullary reduction of anterior cortex. this means extramedullary reduction of anterior cortex is important to reduce unsatisfactory results in surgical treatment of femoral trochanteric fractures. male injured open lateral condyle fracture of femur by to be bitten by a pig. after months from initial debridement, i confirmed the size of bone defect was cm( ) cm in depth. the same size of bone was harvested from iliac crest and transplanted in the bone defect area of lateral condyle of the femur. after months from bone transplantation, i confirmed bone union and two . mm diameter osteochondral grafts and . mm diameter osteochondral graft were transplanted for the chondral defect lesion. case ; seventy year old male injured open lateral condyle fracture of femur by traffic accident. after months from first debridement, i confirmed the bone defect (size cm( ) cm in depth) and the same size of bone was harvested from iliac crest and transplanted in the bone defect area. and simultaneously two mm diameter osteochondral grafts were transplanted for the chondral defect lesion. case ; year old male injured open lateral condyle fracture of femur by traffic accident. i confirmed the size of bone defect was cm( ) cm in depth. the same size of bone was harvested from iliac crest and transplanted in the bone defect area of lateral condyle of the femur. after month from bone transplantation, he had undergone autologous chondrocyte implantation. investigation/results: at last follow-up, average flexion angle of knee was degrees. in all cases, lysholm knee scoring scale was good. diagnosis: large traumatic osteochondral defect of the weightbearing articular surface of the knee comments: treatment of large traumatic osteochondral defect of the weight-bearing articular surface of the knee is a difficult condition to treat. combination of bone transplantation and osteochondral autograft transfer or autologous chondrocyte implantation is useful strategy for the injury. references: tegner y., lysholm j., clin orthop relat res., , - , pr treatment of double tension band wiring method with ai wiring system for transcondylar distal humeral fractures m. uchino hakujikai memorial general hospital, orthopaedic surgery, tokyo, japan introduction: as ai wiring system is united the pin with the cable due to compressed sleeve, the pin is never deviated. we review the treatment of transcondylar distal humeral fractures with ai wiring system in geriatric patients. patients and methods: were identified as receiving this surgery. all patients were female and their mean age was years. they were assessed union rate, range of motion for elbow joint, postoperative complication and functional outcome for japanese orthopedic score. results: union rate was %. the mean arch of motion was °at latest follow-up. the complications were detected cases which were temporary ulnar palsy for cases and hardware failure for case. the average of functional outcome was points ( / ). conclusion: tension band wiring of transcondylar distal humeral fractures with ai wiring system provides stable fixation for osteoporotic bone and tiny fragment. introduction: the purpose of this study was a comparative evaluation of the complications related to the treatment of trochanteric fractures using -screw proximal femoral nail (pfn) versus proximal femoral anti-rotational blade nail (pfna). material and methods: a retrospective review was conducted between march and march . the study included patients treated surgically for trochanteric fractures. the mean age was , ± , ( - ) years. patients were treated by pfn ( patients, , %) or by pfna ( patients, , %). implant related complications were the primary objectives. infection and revision surgery were also recorded. results: complications were observed in ( . %) patients in pfn group and ( , %) patients in pfna group (p = . ). screw backout (n = ) and cut-out (n = ) occurred in , % patients treated with pfn. in the pfna group, cut-out occurred in , % (n = ) of cases. infection (n = ) represented , % in pfna patients and , % (n = ) in pfn group. there were no statistically significant differences in both groups considering implant-related complications (p = , ) and infections (p = . ). revision surgery was performed in ( , %) patients. soft tissue problems are more likely in fractures due to high energy impact than low energy type fractures. high energy type present with horizontal fractures of tibia and fibula (i.e. on the same level), whereas in low energy type tibia fractures they present with spiral or oblique fracture patterns often associated with concomitant fractures of the posterior rim of the distal tibia (i.e. volkmann's triangle). posterior malleolus fractures occur regularly but are often missed and seen only on ct scans obtained either for preoperative planning or to verify postoperative rotation. in literature these mostly undisplaced fractures are treated with screw fixation mostly from anterior. but is this really necessary? material and methods: we retrospectively analysed consecutive tibia shaft fractures operatively treated over the past years at our regional hospital analysing the fracture pattern. results: out of patients with tibia shaft fractures patients presented with a posterior rim fracture of the tibia. no routine stabilisation of the volkmann fragment was performed, in all cases the posterior rim fragments healed uneventful. angles of °and above seem to present themselves with a concomitant fracture of the posterior malleolus. they are mostly undisplaced and the trauma mechanisms is low energy and torsion. none out of the patients had known osteoporosis. conclusions: low energy and torsion-type tibia fractures with an angle of [ °seem to have an accompanying undisplaced fracture of the posterior malleolus. these fractures are usually undisplaced and do not need to be addressed. as a consequence there seems to be no need to actively rule them out with ct scans prior to surgery. concomitant ankle fractures including posterior rim fractures should be addressed like isolated ankle fractures. the dangers of bouncing: a prospecive cohort study of injuries associated with trampolines and bouncy castles over a month period in a paediatric population. introduction: within the orthopaedic paediatric population, there is an increasing incidence of presentation of fractures associated with both trampolines & bouncy castles. whilst this phenomenon has been depicted frequently within the media in recent years given the dramatic upsurge in trampoline and bouncy castle usage, there have been few studies documenting either the incidence of fractures associated with either. materials and methods: this was a prospective cohort study conducted within our institution over a month period june to august inclusive . all paediatric patients who sustain a fracture and present to the national childrens'' hospital are referred to the orthopaedic department either whilst as an inpatient or as an outpatient depending on the assessment of the severity of injury. a standardised mixed questionnaire was given to all parents''/guardians which recorded the type of injury, type of trampoline/bouncy castle, inherent awareness of safety precautions governing the usage of either and application of same was recorded. the type of fracture was corroborated via examination of x-ray in addition to the recording of any complications via examination of clinical chart records. results: there were patients who sustained a fracture directly related to the usage of either a trampoline or bouncy castle for which the majority required operative intervention. there was wide variability in the nature of injuries recorded; supracondylar/radial fractures were the most common whilst more complex injuries such as an open fracture of the femur was rarer. conclusions: awareness and application of necessary safety precautions was low ( %) amongst parents'' supervising parents''/guardians highlighting the need for greater public awareness of same. furthermore, the incidence of severe injury relating to usage of trampolines/bouncy castles is not uncommon highlighting the high risk activity that trampolining is. introduction: conventional plate fixation (pf) of distal fibular fractures in elderly patients is associated with a high risk of wound and implant related complications. intramedullary fixation (imf) using a fibular nail is a minimally invasive alternative to pf that provides superior biomechanical strength and allows immediate full weight-bearing postoperatively. aim: to compare the postoperative complications of minimally invasive intramedullary nail fixation to conventional pf for lauge-hansen supination external rotation type fractures in patients aged years or older treated in a single geriatric trauma unit in the netherlands. methods: a retrospective cohort study was performed including unstable ankle fractures in patients aged years or older treated with either imf or pf between january to january . the primary outcome measure was the total number of wound related complications. results: a total number of patients were included with a mean age of . years (range to ). the imf-cohort (n = ) had a significantly higher mean age ( . versus . years, p = . ) and charlson co-morbidity index ( . versus . , p = . ) compared to the pf-cohort (n = ). the total number of postoperative complications was lower after imf ( %) compared to pf ( %), although this relative difference was not statistically significant (p = . ). all complications observed in the imf-cohort were wound related but demanded no debridement or implant removal. wound related complications did not differ significantly from pf ( % versus %, p = . ). no implant related complications, hospital-acquired complications or mortality were observed after imf. conclusion: despite the higher mean age and co-morbidity status of patients treated with a minimally invasive intramedullary nail, the total number of postoperative complications was lower after imf compared to pf. this technique might be a promising alternative in a selected group of patients. the authors declare that they have no commercial associations that might pose a conflict of interest. no funding or other compensation was received for the research, authorship or publication of this article. gustilo type ii and gustilo type iii fractures. the treatment protocol was external fixation at admission and definitive osteosynthesis with plate at ± days. a single approach to the tibia was performed in patients, and a combined anterior and posterior approach was used in . the incidence of complications was %: cases of poor soft tissue evolution, of which were infections. patients evolved to nonunion. osteoarthritis appeared in % of patients ( . % grade ), and only one patient needed arthrodesis. . % had a valgus ldta (\ °) and . % a varus deformity ([ °). we found a significant relationship between the history of open fracture and the development of complications (p \ . ). we found no relationship between the incidence of complications and the approach. conclusions: tibia ao c fractures have a high percentage of complications and evolve to well-tolerated osteoarthritis. open fracture seems to significantly influence the poor postoperative outcomes of these patients. clinical findings: a -year-old male, who suffers a closed chest trauma with pneumothorax, right pulmonary contusion and poor pneumoperitoneum. also a grade iiia open fracture of the right femur, with a cm bone defect. investigation/results: upon arrival at the hospital, he needs orotracheal intubation, as well as blood transfusion with red blood cell concentrates. external fixator is placed on the right femur. diagnosis: a iiia grade diaphyseal open fracture of the right femur with cm bone defect, bearing external fixator with one broken proximal pin and positive culture for s maltophila in the distal pin. therapy and progressions: antibiotic treatment and medical optimization are performed, cemented intramedullary nailing (t -stryker) with antibiotic (vancomycin-tobramycin), as well as cement spacer with antibiotic (masquelet's first stage) in the defect area. in second time, withdrawal of spacer and contribution of ria autograft of contralateral femur and allograft respecting membrane. the patient begins the protected weight bearing with two crutches immediately, without using them months after the surgery. bone consolidation without pain or limitation after year. comments: the induced membrane technique is a simple and effective technique for the reconstruction of segmental bone defects and can be used as a first time technique together with the initial stabilization, leaving the defect ready for graft delivery in the second time. introduction: carpal metacarpal dislocation is a rare entity that accounts for less than % of all carpal injuries. dorsal dislocations are the most common and occur most frequently after violent trauma in young individuals and are easily overlooked and may lead to longterm sequelae. material and methods: we present the case of a carpal metacarpal dislocation from d to d . male, years old, no relevant personal history. brought to the emergency service after a motorcycle accident with projection. he had a symphysis pubis diastasis, a distal radius fracture on the right wrist and a fracture of the left forearm bones. no other apparent injuries associated. at week , he presented edema and dorsal deformity of the left hand associated with limited finger movements. neurovascular assessment was normal. the radiological evaluation showed a carpal metacarpal dislocation from m to m . it was an unstable reduction so open reduction was performed, with debridement of fibrous material, until exposure of the articular surfaces, and reduction and fixation with k wires of the three metacarpals (from d to d ). similarly, m was stabilized with a k-wire due to clinical instability observed intraoperatively. results: it is necessary to reduce and stabilize these lesions to avoid vasculonervous compression and skin distress. open reduction is indicated in irreducible cases allowing debridement and excision or os of small osteochondral fragments and fixation of associated fractures. conclusions: combined dislocation of multiple metacarpals is a rare lesion that compromises the functional prognosis of the hand in the absence of adequate treatment. instability and post traumatic arthrosis are among the sequelae of this lesion. identify the lesion to allow the appropriate treatment usually leads to good results. case history: -year-old suffered direct trauma to his right hand after falling off his bicycle. clinical findings: on physical examination showed edema and bruising from the base of the thumb and thenar eminence, tenderness over the cmc joint and functional disability speacialy in pincer grasp. no neurovascular injuries investigation/results: the x-ray revealed a comminuted fracture of the base of the thumb metacarpal. diagnosis: we identifed a rolando fracture. therapy and progressions: on the day after the trauma, he was submited to open reduction and osteosinthesis with lateral-palmar plate and screws, through radiopalmar aproach of the thumb base. intra operatively no dorsal fragments werefound to be left undisplaced. two months after surgery, the patient went back to the hospital for sudden pain and inability to extend the thumb. clinically with rupture of the long extensor of the thumb. on the x-ray, the fracture was aligned. the latero-lateral tenorrhaphy with kessler suture was preformed and intraoperatively a bony spicule was identified in the proximal stump of the tendon, which was removed. months after the initial trauma, the patient has a consolidated neck and no limitation of the mobility of the thumb. comments: rollando fracture is relatively rare in adolescents. the aim of treatment should be exact reduction usually with open technics. the main complications are stifness and early arthrosis. there are also records of conflicts with the plates and even rupture of the extensor tendon, so the radiopalmar placement of the plate was chosen. nevertheless, the rupture occurred due to conflict with an unidentified bone fragment during surgery causing an unexpected complication in this case. the immobilization necessary after tenorrhaphy could have caused joint stiffness, but in this case the teenager fully recovered after physical therapy case history: periprosthetic and periimplant femoral fractures are an increasingly frequent pathology. in many cases they are a challenge with limited or too aggressive therapeutic options. it is important to investigate new approaches that increase the arsenal of the orthopedic surgeon. the recently described mipo (minimally invasive plate osteosynthesis) approach for the medial aspect of the femur may seem like a dangerous procedure because of the anatomical structures that run along the medial aspect of the thigh, but it is a viable and useful option in selected cases. clinical findings: we present the case of a -year-old patient with a total hip replacement who presented a first periprosthetic vancouver b fracture of the femur that was treated with a lateral blocked plate. subsequently the patient presented a second supracondylar femur fracture below the first plate (vancouver c). investigation/results: after thinking over the possible therapeutic options, we decided to treat our patient by means of the medial femoral mipo approach with a long medially placed blocked plate, managing to stabilize the fracture and superimpose the plate on the previous implants without the necessity of removing the previous lateral plate. diagnosis: periprosthetic and periimplant supracondylar left femoral fracture. therapy and progressions: we used the surgical technique of the medial femoral mipo approach as described by apivatthakakul . comments: we consider that the medial femoral mipo approach is a useful therapeutic tool to consider. it seems a safe and low-invasive option for the resolution of cases in which the lateral mipo approach is not a feasible option. references: c. jiamton y t. apivatthakakul, « the safety and feasibility of minimally invasive plate osteosynthesis (mipo) on the medial side of the femur: a cadaveric injection study » , injury, vol. , n.o , pp. » , injury, vol. , n.o , pp. - » , injury, vol. , n.o , pp. , nov. . posterior knee dislocation with neurovascular injury associated-a case report case history, investigation and diagnosis: a -year-old male was brought in after h following a heavy straw bale fall. he presented with a posterior knee dislocation that had already been reduced and an open wound in the popliteal fossa. the limb was flushed and pale on the extremity, with absence of the pedis and posterior tibial pulses. stability tests revealed unstable knee in all axes. an anterior shoulder dislocation was diagnosed and reduced. therapy and progressions: an emergent surgery was performed, involving a transarticular external knee fixation and a femoro-popliteal bypass above the knee (angiogram revealed a stop sign at the level of the interarticular popliteal artery). he developed circulatory shock and was admitted to the intensive care unit. on the stpostoperative day(po) was diagnosed a compartment syndrome that was treated with fasciotomies. these incisions showed a slow but progressive evolution, that required vacuum dressings and underwent autologous skin graft on the thpo day. the external fixator was removed on the stpo day and rehabilitation was started. on a -month follow-up, the patient had a good evolution of the wounds, but a knee with valgus and anteroposterior laxity and severe complete peroneal, tibial and sural neurological injury, confirmed with electromyography, and neuropathic pain. introduction: isolated iliac wing fractures represent only a small part of all pelvic fractures. these fractures are associated with severe injuries, but are considered benign. the literature lack information about the function and quality of life of these patients. our objective was to evaluate the long-term effects of isolated iliac wing fractures. material and methods: patients with pelvic fractures treated at oslo university hospital, ullevaal, in the time period - , were extracted from the local fracture registry. patients were registered in this period. a search was also made in the hospital''s administrative electronic database for patients registered with diagnose code s . in icd- in the same period. patients were identified. in total, patients had an isolated iliac wing fracture, and these were invited to a follow-up examination, including proms (eq- d- l and majeed score), clinical examination, and pelvic x-ray. results: nine patients agreed to participate in the study, median years after the fracture (range - ). all of them were injured from high energy trauma, with mean niss , (range - ) . four of the fractures were open, and seven of the patients had associated injuries. five were treated with internal fixation. the mean eq- d vas was (range - ). five patients reported pain, one of them related to the pelvic fracture. the mean majeed score was (range - ). seven patients had sensory deficit in the lateral thigh. one patient had difference in range of motion between the two hips. the x-rays showed healed fractures in all the patients. eight of them showed ectopic ossification. conclusions: our study confirms previous studies that isolated iliac wing fractures are results of high energy trauma with severe associated injuries. however, the majority of this group of patients seem to have a good general state of health, which is in accordance with the general assumption of the injury as a benign one. fenton's syndrome-a case report of a common underdiagnosed entity case history: a right handed -year-old male, construction worker, was admitted in our emergency department, after a meters fall. the authors report a case of fenton's syndrome in a politrauma scenarium. clinical findings: both right elbow and left wrist were painful, swollen and with a remarkable restriction of the range of motion (rom). patient also reported lower back pain. no neurovascular injuries were detected. investigation/results: x-ray and ct scan confirmed a fracture of a lumbar vertebra, fracture of the right olecranon and, on is left wrist, a carpal fracture-luxation mayfield of both scaphoid and capitate associated with rotation of the last one proximal pole-fenton''s syndrome. diagnosis: this syndrome is an atypical presentation of perilunate fracture dislocation and, therefore, difficult to diagnose. few reports were found in literature. after an open reduction of the fractures, a definitive fixation with headless herbert screws was achieved. percutaneous kw and immobilization of the wrist were performed to further stabilization of the lunotriquetral joint. weeks later consolidation was noted. a decrease of °in extension and flexion were detected when compared with the contralateral wrist. grip strength test was similar on both hands. osteosynthesis of the right olecranon was also realized. comments: a careful neurovascular assessment is important. although it is rare, injuries of median nerve were already reported associated to this complex fractures. open reduction and osteosynthesis are necessary due to the great instability and the risk of nonunion and osteonecrosis of the rotated proximal segment. introduction: intramedullary nailing has been popularly applied for the femoral shaft fractures. the current study aimed to analyze the femur geometry for development of implant design with dimensional skeletonization. material and methods: we acquired computed tomography (ct) images of both femur reviewed in a single center from to . the total participants were enrolled and they were divided into subgroups according to age (decades) and gender. each subgroup included persons, respectively. these images are used to produce d samplings. with the skeletonization, we obtained the geometry parameter; ( ) femur shaft length from the tip of the greater trochanter to the bicondylar line, ( ) the minimum diameter of the medullary canal and its location, ( ) anteroposterior (ap) diameter and lateral diameter of the entire femur, ( ) radius of curvature (roc) of the femur (bowing). we compared all parameters according to sex and age. results: the average age of the participants were . years (range - years) and the number of each gender was exactly same. the femur length was . ± . mm (range, . - . mm) and the femur shaft length was . ± . mm (range . - . mm), both of them were longer in male (p = . , \ . ). the minimum diameter of the medullary canal was . ± . mm (range . - . mm). the roc was . ± . mm (range . - . mm) . the rate of the minimum diameter less than mm and mm was . % and . %, respectively. the rate of roc with less than mm and mm was . % and . %, respectively. conclusions: this geometry analysis showed that there are mismatch problem between the current nail and the medullary canal in . % and the roc of the femur was smaller than that of the current nail systems ( - mm). the result indicates potential mismatch problem in clinical cases and the problem can be resolved with newly designed nail system. the study was funded by national reserach foundation of korea (nrf- r d a b ). safe zone of the infracacetabular screw: virtual mapping of three-dimensional hemipelvises for quantitative anatomic analysis introduction: an infra-acetabular screw can provide increased stability in fixating acetabular fracture. we conducted this study to define the incidence of the safe corridor for infra-acetabular screw and to determine the correlation between the safe corridor and other demographic factors such as age, sex and height. material & methods: pelvis computed tomography (ct) of participants was extracted with evenly age-and sex-allotted. virtual three-dimensional ( d) model was generated. a search was performed to find the maximum-with corridor connecting two points. the entry and exit point was displaced in the template. the maximum diameter of each corridor was measured in automatic procedure. a minimum mm corridor diameter, sate corridor, was defined as a cutoff for placing a . mm cortical screw in clinical setting. all data were presented as mean and range or mean and standard deviation. two-sample t test and regression analysis were used to compare difference between groups based on sex, age, and height. results: among hemipelvis, hemipelves ( . %) satisfied a minimum safe corridor diameter of mm. when divided into a subgroup by the patient's gender, the incidence of the safe corridor of a male group was statistically higher than a female group ( . % vs . %), with the mean corridor diameter of . mm ( % ci, . ) and . mm ( % ci, . ), respectively (p \ . ). in correlation analysis, only the height showed a positive correlation with the diameter of the safe corridor of a total population (r = . ; p \ . ). conclusions: the study provided the safe corridor was found in % of male and % of female, and the taller had the higher incidence of the safe corridor. the patient''s height was correlated with the corridor diameter of the infra-acetabular screw, whereas the patient''s age did not correlate with the corridor diameter. introduction: femoral neck fractures in middle-aged and older patients represent one of the most common orthopedic conditions. osteosynthesis, as a primary treatment option for femoral neck fractures has shown to have successful outcomes. however, this is not the case for old fractures. the purpose of this study was to evaluate the outcomes of treatment of femoral neck fractures in which cementless total hip arthroplasty was indicated. the aim of our study was to analyze the prosthetic failure, i.e., the reasons for unsuccessful outcome, in order to suggest the indications for primary osteosynthesis which could guide the femoral neck fracture management. material and methods: a total of patients were analyzed in this study, with femoral neck fracture treated with osteosynthesis. reviewing the radiological findings, as well as the course of the treatment, we set up the criteria, on the basis of which we could advice the immediate implantation of total hip prosthesis for the femoral neck fracture. results: old fractures, varus deformity of the femoral head and neck, dislocation, as well as the comminuted fractures, are all factors affecting the surgical outcomes of osteosynthesis. additionally, medical and technical equipment of medical institution, personnel competence, and minutious surgical technique affect the treatment outcomes. introduction:proximal ulnar fractures are usually osteosynthesized by means of angle stable plate osteosynthesis. despite good functional results of this procedure, complications such as high access morbidity and disruptive osteosynthesis material with a high rate of material removal are described. the aim of our study was the development of a new locking nail and test setup for comparison with a plate osteosynthesis on artificial bones. material and methods: in our biomechanical laboratory, a jupiter b fracture of the proximal ulna was standardized on sawbones and stabilized by means of the newly developed nail or anglestable posterior plate osteosynthesis. a servopneumatic testing machine, the specimens were flexed under a cyclic load ( - n) in the physiological range of movement of the elbow from °to °.the maximum elastic deformation of the specimens and the loosening of the implants were evaluated after test cycles. results: the primary stability of the constructs at the anterior cortical bone after nail osteosynthesis was significantly greater ( . ± . mm) than in the angle-stable plate osteosynthesis ( . ± . mm, p \ . ).after passing through the test cycles, both implants showed a low loosening rate. in the area of the anterior cortex, the locking nail showed a significantly lower rate of loosening (nail . ± . mm, plate . ± . mm, p \ . ). at the dorsal cortex, there were no differences between plate and nail in both series of measurements. conclusions: intramedullary implants provide biomechanical benefits in fracture stabilization. good biomechanical results have already been shown in the literature after nailing olecranon fractures . nevertheless, due to the complex anatomy and the resulting difficult implantation technique, ulnar nails could not prevail in practice. the presented nail allows a safe stability with simple surgical technique. introduction: adequate treatment of tibial plateau fractures is crucial to minimize patient disability, development of posttraumatic arthritis and subsequent need for a total knee arthroplasty (tka). however, due to the complexity of the fracture, adequate reduction cannot always be achieved which could result in the early conversion to a tka. in this study we introduce a quantitative d fracture assessment method and investigate whether it could help to identify patients that are at risk of conversion to a tka. material and methods: we retrospectively included patients, who were treated for a tibial plateau fracture between and . patients developed severe posttraumatic arthritis and underwent conversion to a tka. from all patients, d models were created using the pre-operative ct-scans. for each patient, the d gap area between the fracture lines, representing an innovative combined gap and step-off measurement in d, was determined in order to quantify the displacement (figure ). roc curve analysis was performed to determine a critical cut-off value for the d gap area. kaplan-meier survival curves were created to assess the association between d fracture anatomy and risk on a tka at follow up. results: a critical cut-off value of mm was found to give highest combined sensitivity and specificity for d gap area and the risk of tka at follow-up. kaplan-meier survival curves showed . % knee survival (no tka) at year follow up in the group with a gap area of \ mm , whereas in the group with a gap area of c mm a knee survival of . % was found. at year follow up knee survival was . % and . %, respectively, for the two groups (\ mm and c mm ). conclusions: we developed an innovative method to quantify the amount of displacement in d. pre-operative d fracture assessment could be used as an addition to the current fracture classification methods to help identify patients who have a high risk on conversion to tka at follow-up. introduction: soft tissue sarcomas (sts) in the anterior compartment of the thigh are frequent. the extent of quadriceps resection is controversial. the aim of the present study is to communicate our results in complete quadricectomies due to high-grade sts. material and methods: we present sts, in stage iiib of the ajcc, with a mean craniocaudal diameter of cm ( - ). there were women and men, with a mean age of years ( - ). six were undifferentiated pleomorphic sarcomas, myxofibrosarcoma and clear cell sarcoma. in every case, total quadricectomy was performed with wide margins. posterior reconstruction with local muscle transfers was performed, expect for the younger patient, who received a vascularized contralateral vastus lateralis transplant. in all cases, complementary radiotherapy was indicated, and in patients adjuvant chemotherapy. results: three patients required friedrich due to necrosis of the edges of the surgical wound. one patient died months after the intervention as a result of multiple metastasis, and two due to medical complications after week and months, respectively. the average follow-up time for the rest was months , with no local recurrence. as for functional outcomes, mean msts score was ( - ), with deficit of active knee extension in most of them. the functional result of the patient with the vascularized muscle transplantation was excellent. all of them were satisfied with the results of the treatment. conclusions: quadricectomy provides good functional and acceptable cancer results, although it is not exempt from complications in frail patients. vascularized muscle transplantation, though complex, can improve functional results, especially in younger patients. introduction: operative treatment is a valuable option in displaced proximal and/or middle one-third diaphyseal humeral fractures. although plate osteosynthesis is preferred to intramedullary nailing, surgery can be complicated by radial nerve palsy. a helical plate could avoid this high-impact complication. to date there is however a lack of published evidence in literature, although recent asian case reports show promising results. material and methods: we retrospectively reviewed patients who were treated with open reduction and internal fixation with a helical plate consecutively from october until august at az groeninge, kortrijk. a deltopectoral approach was used in combination with a distal anterolateral incision, whether or not in continuity. a self-molded long philos plate was used in the first patients, while in our last patients the a.l.p.s plate (zimmer Ò ) was used. standard radiographs were obtained pre-and postoperatively. we retrospectively searched for complications, e.g. radial nerve palsy, infection and/or loosening. in autumn , patients were reassessed. patient''s general health status was evaluated using the eq- d- l score. constant-murley scores and dash scores were used for evaluating shoulder function and disability measures consecutively. results: all humeral fractures consolidated at months. there were no radial nerve palsies due to surgery. one plate was removed after year due to a late infection. with a minimum follow up of year, the mean dash score was ( - ) and the mean constant-murley score was ( - ). the dash score was inversely proportional with the constant-murley score and patient''s general health status. conclusion: a helical plate avoids neurological complications with similar healing rates and good to excellent shoulder function at year follow up in the treatment for proximal and/or middle one-third diaphyseal humeral fractures. the use of antibiotic-impregnated cancellous bone grafts in onestage surgery for chronic orthopaedic infection: preliminary clinical results k. dendoncker , g. putzeys , az groeninge, tissue bank, kortrijk, belgium, az groeninge, orthopaedic center, kortrijk, belgium introduction: the use of cancellous bone allografts is an established technique in reconstructive orthopaedic surgery. unfortunately, its use is generally avoided in the presence of a local infection. antibiotic impregnated cancellous bone grafts has shown its effectiveness as an local antibiotic delivery system [ ] [ ] [ ] . in this clinical study, we report our first personal experience with the use of vancomycin-impregnated cancellous bone grafts in one-stage surgery for periprosthetic joint infections (pji) and fracture-related infections (fri). material and methods: between december and march nine patients were treated during a one-stage surgery with vancomycinimpregnated cancellous bone grafts, containing g vancomycin per cc bone. regular clinical, laboratory and radiographic follow-ups were performed for at least months after surgery. results: the procedures included revision of pjis (hip and humerus) and fris (tibia, femur and clavicula). one tibia required further revision because of recurrent infection and one hip has an uncertain infection state, however the remaining patients stayed free from infection during a follow-up of at least months. interestingly, in one patient the vancomycin concentration could be determined in the drainage fluid from the wound. radiographic examination revealed no signs of osteolysis or loosening, good incorporation of the bone graft and progressive consolidation. conclusions: within the limits of the study, the use of vancomycinimpregnated cancellous bone grafts in one-stage surgery to treat pji and fri yielded positive outcomes in terms of clinical, laboratory and radiographic follow-up. this technique might offer new treatment strategies in often devastating injuries. references: . putzeys g., et al. orthopaedic proceedings. ; -b:supp_ , - . with the modified arthroscopic approach (group b). the prospective follow-up included the lysholm score, the subjective questionnaire of the ikdc score and the specifically extended oak score for clinical evaluation. the rolimeter Ò was used to test the translational mobility of the knee joint. the statistical significance level was set at %. results: the follow-up was . ± . months and . ± . months postoperatively in group a and b, respectively. the subjective scores were tested. group a and b achieved a mean lysholm score of . ± . and . ± . points respectively. in the subjective ikdc assessment, group a achieved . ± . points and group b . ± . points. the clinical oak score was . ± . points in group a and . ± . points in group b. the following values could be recorded for the stability of the posterior cruciate ligament: the side difference in the rear drawer test was . ± , mm in group a and . ± . mm in group b. in the reversed lachman test, a difference of . ± . mm and . ± . mm was measured in group a and b, respectively. all values mentioned were comparable between the two evaluated groups. conclusions: the results of the two surgical techniques were comparable. therefore the arthroscopic approach is the preferred method in our institute. simple correction technique of femoral malrotation after pfn-a osteosynthesis of trochanteric fracture k. pavotbawan , p. stillhard , c. sommer kantonsspital graubünden, department of trauma surgery, chur, switzerland introduction: malrotation after intramedullary nailing in femoral shaft fractures are well known. but malrotation after nailing of trochanteric fractures is an underestimated problem. during surgery the axial alignment can easily be evaluated by fluoroscopy in both planes. but the torsional alignment is difficult to assess especially with the patient placed on the traction table. in literature a malrotation after pfna is described in up to % of the cases. a revision with replacement of the blade, especially in patients with poor bone quality, may result in a reduced stability. to our knowledge there is no publication till to date to give a treatment pathway for this problem. we developed a rather easy technique to derotate a malrotated femur after pfna fixation. material and methods: the basic idea is to leave the usually well placed blade insitu in the femoral head, just rotating the distal main fragment around the nail. therefore, a small u-shaped osteotomy with a chisel is performed in the femoral cortex just anterior of the entry site of the blade. the length (l) of this osteotomy can be calculated, following the formula: l = d x p x a/ (d = diameter of femur, a = angle of malrotation). then the distal locking bolt is removed, the leg derotated and finally locked again. the procedure is controlled by two schanz''screws separately inserted in both main fragments angulated to each other in the angle ''a''. results: since patients were detected with a clinically relevant femoral malrotation. all patients had an internal malrotation from to degrees confirmed and measured by ct scan. all of them were successfully revised in the above described technique - days after initial fixation. conclusions: first, we believe that malrotation after trochanteric fracture fixation is an underestimated problem. and second our method is a simple salvage procedure for malrotated trochanteric fractures after pfna, leaving the blade in situ in the femoral head. optimal intramedullary nailing for trochanteric fractures: the importance of distal locking screw and reduction position t. waki , t. yano , k. ito , s. matsushima akashi medical center, orthopaedic surgery, akashi, japan introduction: distal locking issue for trochanteric fractures is still controversial. therefore, the purpose of this study was to investigate the complications between distal unlocked group and distal locked group. further, the relationships were evaluated between these complications rates and their reduction positions after operation. material and methods: operations were performed for trochanteric fracture (ao a ?a ) from to . of these, patients with f/u periods [ month were . gamma im nailing system (stryker) was used for all patients. patients (unlocked group) from to operated without distal locking screw. patients (locked group) from to operated with distal locking screw. we retrospectively analyzed those patients who suffered complications such as delayed healing and postoperative periimplant fractures and cut-out of the lag screw. further, in lateral view of their radiographs, we evaluated the position of the proximal fragment compared with distal fragment. the reduction positions were divided into groups: anterior (subtype-a), neutral (subtype-n), and posterior (subtype-p). results: in unlocked group, complication was shown in patients (complication group). delayed healing was shown in / ( . %) in unlocked group and / ( . %) in locked group. peri-implant fracture was shown in / ( . %) in unlocked group and / ( %) in locked group. cut-out of the lag screw was shown in / ( . %) in unlocked group and / ( . %) in locked group. in complication group, subtype-p was more than non-complication group. conclusion: in the current study, higher number of complications was seen in the distal unlocked group. and, our study showed the reduction position might be associated with post-operative complications. we concluded that nailing without distal locking screw might be dangerous and subtype-p should be avoided. introduction: heterotopic ossification (ho) after acetabular fracture surgery has been one of the common complications and often limits function with the range of motion severely. surgical resection is challenging and only effective treatment for established ho. we herein report four cases who underwent surgical resection and mobilization for ho after acetabular fractures surgery. material and methods: four cases with severe ho after acetabular fracture surgery were included in this study. the mean age at operation was years old, and all patients were males. in judet-letournel classification, there were three cases classified as posterior wall fracture, and one case as transverse and posterior wall fracture. two of four cases were combined with posterior dislocation of the hip. in all cases, the first operation was performed using with the kocher-langenbeck (kl) approach. results: surgical resection of ho was performed using with the kl approach at . months (range - months) after the first operation. the median operating time and intraoperative bleeding were respectively . h and ml. intraoperative d navigation was used in one case. as postoperative complications, one case developed sciatic nerve palsy and another case sustained the iatrogenic femoral neck fracture. all cases have no recurrence with a follow-up of . years after the surgical resection. conclusions: surgical resection is the only treatment for symptomatic ho. but that requires preoperative planning and must be performed carefully because the extent of resection is still controversial and that may develop severe complications such as nerve palsy and iatrogenic fractures. by using navigation, we can determine the extent of resection easily and operated safely. case history: -year-old male, previously healthy, turned to the hospital after a motorbike crash, resulting in high energy direct trauma of the right wrist. clinical findings: upon admission, cranial, thoracic, abdominal and other traumatic injuries were excluded. the patient presented with pain, swelling and visible deformity of the right wrist and hand, hypoesthesia of the th finger, and no perfusion deficits. investigation/results: x-rays showed volar perilunate carpal dislocation with associated comminuted scaphoid fracture, radial styloid avulsion, and metacarpal phalangeal dislocation of the th digit. under sedation, closed reduction of the metacarpal phalangeal joint was accomplished, and reduction of the carpal dislocation was attempted unsuccessfully. the wrist was temporarily immobilized in a cast and taken to the or. diagnosis: transcaphoid-transradial-styloid-perilunate volar dislocation therapy and progressions: surgical treatment comprised loose bodies removal, reduction of the perilunate dislocation, orif of the scaphoid using a herbert screw, and stabilization of the carpal rows using two percutaneous kirschner wires. after surgery, a thumb spica cast was applied. post-operatively, neurovascular status was normal. at weeks, x-rays showed signs of bone healing, the cast and k wires were removed, and physical therapy was initiated. at months, scaphoid fracture consolidation was achieved. the patient remained with a mild deficit in wrist extension but reported no pain nor important limitation in daily living activities. comments: perilunate injuries with displacement or dislocation usually require surgery. persistent instability is a described complication, often progressing to secondary post-traumatic arthritis of the wrist and carpus, termed scapholunate advanced collapse. introduction: this study was conducted to study the patient characteristics, classification, treatment, complications and functional outcome of operatively treated displaced intra-articular calcaneal fractures (diacf) in a level trauma center in the netherlands material and methods: patients with an diacf, classified as sanders c and operatively treated with percutaneous screw fixation (psf) or open reduction and internal fixation (orif) between january and december were identified. pre-and postoperative radiological assessment was performed. functional outcome, range of motion and change in footwear were evaluated with the use of the american orthopaedic foot & ankle society (aofas) score and the maryland footscore. general health and patient satisfaction was assessed using the short form- (sf- ) and the visual analogue scale results: in total, patients with an operatively treated diacf were identified. patient with diacf completed the questionnaires. there were males and females, mean age at trauma was years. average follow up was years. were classified as sanders type , and as respectively type and . were joint depression and were tongue-type fractures. there were no differences in sanders classification between the group treated with orif and psf. for orif and psf there were ( - %), ( - %) and ( - %) for respectively sanders type , and fractures. mean aofas, mfs, sf- and vas was ( - ), ( - ), ( - ) and ( - ) for respectively orif and psf. mean pre-and post-bohler angle was ( - ) and ( - ) for respectively psf and orif. underwent an ankle arthrodesis. surgical site infection and deep infection occurred in ( , - %) and ( , - %) in respectively psf and orif conclusions: long-term comparison shows no significant differences between orif and psf in treatment of sanders fracture type, bohler angle reduction, on functional outcome or complication rates introduction: the prevalence of hand injury in the pediatric population is attributed to their curiosity, limited fear of pain and diminuted motor coordination. the seymour fracture, which was first reported by seymour in , represents a transverse extra-articular open fracture of the distal phalanges associated with nail bed injuries. the fracture includes salter-harris type i and ii fractures as well as juxta-epiphyseal injuries. material and methods: the aim of this report is to present a case of a seymour fracture in a young boy and describe the injury mechanism associated with misuse of the newly emerging vehicle, the hoverboard. results: our patient was treated promptly and provided with appropriate management following the standard of care in our hospital for such injuries: disimpaction and repair of the nail bed, reduction of the fracture, and k-wire fixation across the distal interphalangeal joint. the patient was discharged with a volar slab and was prescribed an oral antibiotic. the patient recovered well with no major deficits. conclusions: the timely recognition and management of seymour fractures is crucial. the surgical treatment has good results however, conservative management can be an option in some specific cases. antibiotics are always required. we report a case of a fracture pattern resulting from the improper use of an hoverboard. although improper use was a factor, design fault also plays a role in causing the injury. hoverboards are a new transport technology that has been introduced in recent years. because of the number of injuries that have resulted from hoverboards, they should be used in the most controlled way possible to prevent any unnecessary injuries. case history: we report the case of a years old male from bangladesh, with months of progressively increasing pain, limited range of motion and swelling on his left knee, with kg of weight loss and inguinal lymph nodes. clinical findings: knee radiography and mri of the knee demonstrated a voluminous soft tissue mass surrounding the distal femur with intraarticular and posterior extension. a toracic-abdominal-pelvic ct showed supra and infradiaphragmatic lymph nodes. c-reactive protein level was , mg/dl. investigation/results: the clinical picture suggested a lymphoproliferative syndrome. a biopsy was performed, revealing cm of purulent material. synovial fluid had leucocytes/ul, % of polymorphonuclear cells, % of mononuclear cells and undetectable glucose. acid-alcohol resistant bacilli test and pcr test for mycobacterium tuberculosis were positive. diagnosis: mycobacterium tuberculosis knee arthritis therapy and progressions: the patient was treated with polytherapy consisting on rifampin, isoniazid, pyrazinamide and ethambutol. months later, the patient reports no pain, and tumor size has decreased. comments: mycobacterium tuberculosis infection is not a common disease in developed countries. however, the incidence in europe is increasing due to immigration. even though the lung is the most affected organ, osteoarticular tuberculosis represents around % of extra-pulmonary cases. tuberculosis simulates several diseases. because of non-specific symptoms and radiological signs, it can be difficult to diagnose. in a patient with chronic knee pain and limited range of motion, tuberculosis infection should be kept in mind, among other differential diagnoses, such as fibromatosis, pigmented villonodular synovitis or soft tissue sarcomas. clinical findings: the patient presented with a valgus deformity of the knee, the medial femoral condyle protuding on the medial side of the knee. neurovascular status was intact. investigation/results: xray revealed lateral dislocation of the knee. mri revealed mcl, pcl and acl rupture. diagnosis: knee dislocation (kd) grade iii (schenck). therapy and progressions: the patient underwent emergent closed reduction. neurovascular status was intact after resuction. due to important oedema and blisters, the lower limb was immobilized with a brace to allow for skin surveillance. after weeks, the brace was replaced by a long leg cast for more weeks. after months, the patient maintained residual pain, rom - / and minor instability. comments: kd are unusual injuries, associated with high energy trauma, therefore they often result in disruption of at least major ligaments and associated injuries, from soft tissue to vascular structures. emergent reduction is mandatory, and definitive treatment can be conservative, or early/late surgical repair/reconstruction of the ruptured ligaments. there is a lack of large prospective clinical studies comparing the different types of treatment. even so, data tend to associate early surgical treatment with better functional outcomes, though there is no statistic evidence supporting its improvement of the range of motion or stability. long term complications most frequently include residual pain, instability or rigidity. rarely the knee returns to its pre-injured state, independently of the treatment used. references: dwyer, t., et al. ( ) . outcomes of treatment of multiple ligament knee injuries. the journal of knee surgery, ( ), - . advising a reduction after a fracture of the distal radius, reliability with and without use of expert based criteria introduction: distal radius fractures (drf) are common, however many aspects of its management remain subject of debate . this study assessed the interobserver reliability of surgeons concerning the recommendation for a reduction and the improvement of expert based criteria for reduction. material and methods: we sent out surveys to members of the science of variation group. the first survey divided participants in groups, each rated - radiographs of drf. resulting in rated fractures by participants. each observer indicated whether they would advise a reduction or not. the second survey randomized participants ( surgeons) to either receive or not receive criteria for reduction and participants indicated if they would recommend reduction. results: the reliability for advising a reduction was poor, kappa . ( % ci . - . ). multivariable linear regression analyses indicated that each additional degree of dorsal angulation increased the change of recommending a reduction by % (beta . , % ci . - . p \ . ). criteria for reduction did not increase interobserver reliability for recommending reduction (no criteria kappa . % ci . - . vs. criteria . % ci . - . ). the likelihood of recommending a reduction was higher in the group using the criteria ( . vs . , p = . ). conclusions: poor interobserver reliability is associated with greater practice variation. dorsal angulation is the main drive for recommending a reduction. the liberal use of the criteria in combination with a specific focus on dorsal angulation leads in our opinion to less variation in treatment recommendation for distal radius fractures. this is something future study could assess for distal radius fractures in actual practice introduction: the number of pertrochanteric hip fractures increases proportionally to the increase in life expectancy. currently, the most used treatment in these fractures is the antegrade nailing. suffering a second fracture in the same femur around an antegrade nail is an uncommon complication, but it has a great impact on the patient. the aim of this study is to describe the type of perinail femoral fractures observed in our center, the treatment performed and the medium-term results. material and methods: between and , patients presented a perinail femoral fracture. were women and one was male, with an average age of . initial fractures were classified according to the ao classification: were a , were a and were a . of them were synthesized by short pfn-a (synthes), with short pfn (synthes) and with gamma (stryker). the average time since osteosynthesis of the proximal femur fracture and the perinail fracture was . years ( month- years). results: of the peri-implant fractures occurred at the level of the nail tip or the distal locking screw. the remaining fractures occurred in the distal femur. these supracondylar fractures and of the fractures at the level of the nail tip were synthesized with a va condylar plate (synthes), overlapped with the nail. in the rest of the fractures around the tip of the nail, the short nail was removed and replaced by a long pfn-a nail. one of the patients died in the immediate postoperative period. two patients died during the first year. in the rest of the patients, a complete consolidation of the fracture was observed, and their previous baseline situation was recovered. conclusions: peri-implant femur fracture is a rare but very severe condition, which requires good surgical planning, and is not without complications. gamagori city hospital, department of orthopedics, gamagori, japan, nagoya daini redcross hospital, department of orthopedics, nagoya, japan introduction: hip fracture is a leading worldwide health problem for the elderly. a missed diagnosis of hip fracture on radiography leads to a dismal prognosis. the application of a computer-aided diagnosis (cad) system using artificial intelligence (ai) to detect hip fracture can potentially improve the accuracy and efficiency of hip fracture diagnosis. material and methods: cad system using ai was trained using cases, plain frontal pelvic radiographs (pxrs) between and from each institution. the accuracy, sensitivity, falsenegative rate, and area under the receiver operating characteristic curve (auc) were evaluated on independent pxrs. the authors mixed resnext as classification algorithm and ssd as object detection algorithm to train cad system. results: the algorithm achieved an accuracy of . %, a sensitivity of . %, a false-negative rate of %, and an auc of . for identifying hip fractures. the visualization algorithm showed an accuracy of . % for lesion identification. conclusions: our cad system using ai not only detected hip fractures on pxrs with a low false-negative rate but also had high accuracy for localizing fracture lesions. the cad system using ai might be an efficient and economical model to help clinicians make a diagnosis without interrupting the current clinical pathway. medical faculty university of nis, orthopaedic surgery, nis, serbia, clinical center nis, orthopaedic and traumatology clinic, nis, serbia, orthopaedic word of medical center, cuprija, serbia introduction: bone reconstruction and limb lengthening usually refers to application of ilizarov or other ring external fixation devi-ces . we present here series of posttraumatic reconstruction and limb lengthening, by the use of new concept of d unilateral external fixation device. material and methods: as a clinical material, we present series of patients with different posttraumatic deformities ( ) and limbs discrepancy ( ) as a result of severe traffic accidents and wars. all patients have been treated by specially designed unilateral d external fixation system. that system is not bulky and it is more comfortable in comparison to ring fixators. procedure is relatively simple, so patients handle the device by themselves. during biomechanical testing, it was found that stability of this device is similar to ring systems. the last version of the device includes computer program and two sensors. results: all deformity corrections have been achieved successfully. sliding graft procedure has successfully been performed in all patients with bone defect reconstruction from to cm. in one patient with complex deformity and shortening, correction couldn''t be achieved during one procedure, so additional operations, by the use of the same system have been performed and correction completed. superficial pin tract infection rate was . % and we didn''t have deep infection. there were no other complications including dvt, joint stiffness, neurovascular injuries. conclusion: unilateral external fixation device with balanced d stability provides the same success of bone reconstruction and limb lengthening as ring fixators, but it is more comfortable and more easy for handling. references: treatment principles in bone reconstruction and limb lengthening of the lower extremity. olesen uk, nygaard t, kold sv, hede a. ugeskr laeger. nov ; ( ) at this moment author has licence agreement with the producer of external fixation devices. all patients were classified into the isolated hip fracture and the concomitant fracture. we analyzed these patients'' characteristics such as age, gender, bone mineral density (bmd), body mass index (bmi), korean version of mini-mental state examination (mmse-k), injury mechanism, and length of hospital stay. results: the most common site of upper extremity fracture was distal radius fracture of patients ( . %), followed by proximal humeral fracture of ( . %). concomitant fractures occurred on the same side in patients ( . %). the mean age of patients with a concomitant fracture was younger than that of patients with an isolated hip fracture (p \ . ). mean preinjury mmse-k was . in isolated hip fracture and . in concomitant fracture patients (p \ . ). mean length of hospital stay was statistically significant different between two groups (p \ . ). according to fracture site of hip, there was no statistically different prevalence of upper extremity fracture in femoral intertrochanteric fracture compared to the neck fracture. conclusions: we found a . % prevalence of concomitant hip and upper extremity fractures. it was found that the younger the age with preserved cognitive ability in elderly patients with a hip fracture, the higher the prevalence of upper extremity fracture. in addition, it is important to keep in mind that patients with a concomitant fracture have a longer hospital stay and difficulty in rehabilitation. on the other hand, the amount of bleeding was ml in group e and ml in group l, and there was no significant difference between the two groups. poor cases on postoperative images were % in group e and % in group l, and the joa hip score was . (groupe) and . (group l). in clinical results is significantly improved in group l. conclusions: the treatment results improved significantly in group l. as the number of experienced cases increased from these results, the reduction accuracy and treatment results improved, so experience was considered important for improving the treatment results of acetabular fractures. the additional value of the weight-bearing and gravity stress radiograph in determining stability of isolated type b ankle fractures introduction: the goal of the current study is to investigate whether the weight-bearing and gravity stress radiographs have additional value in determining stability in isolated type b fibular fractures. this in order to make the important distinction between fractures that need surgical treatment and fractures that can be safely treated conservatively. material and methods: patients with an isolated type b ankle fracture, without medial or posterior fracture, and a medial clear space (mcs) \ mm on the regular mortise radiograph were included. in the emergency room, a gravity radiograph was performed (in accordance with out protocol). within week, an additional mri scan was made. at this moment, in patients a weight-bearing radiograph was performed too. the mcs measurements of these regular mortise, gravity and weight-bearing radiograph were compared with the mri findings. the mri scan was set as reference standard to detect injury of the deltoid ligament in order to determine (in)stability. results: mean mcs on mortise radiograph was . mm (range . - . ); in ( . %) patients the mcs was [ mm and in patients ( . %) the superior clear space (scs) was [ mcs ? mm. in ( . %) patients, the scs [ mcs ? mm. on the gravity stress radiograph, . % of the patients had a mcs [ mm. the weight-bearing radiograph showed a mcs [ mm in ( . %) patients. in ( . %) patients, the mri showed a complete rupture of the deltoid ligament. in ( . %) patients a partial rupture was seen. patients ( . %) received surgical treatment. in all conservatively treated patients, no secondary dislocation occurred and there was no need for postponed surgical treatment. conclusions: the gravity stress view has a tendency to overestimate the mcs. thus, potentially too many stable fractures are incorrectly diagnosed instable and receive unnecessarily surgical treatment (with additional costs and risks). the weight-bearing radiograph, on the contrary, does not overrate the medial injury and can safely be used in the decision making process of treating conservatively and weightbearing (for example by using a brace) introduction: the purpose of this study was to identify the effect of the intravenous iron supplementation on demand of perioperative blood transfusion and post-operative hemoglobin recovery in geriatric hip fractures. material and methods: a retrospective cohort study was performed on patients who underwent surgery with proximal femoral nail for hip fracture and age years old or older between jan and may in a single center. the participants were divided into groups according to preoperative intravenous iron supplementation (iron isomaltoside, monofer Ò , pharmacosmos, holbaek, denmark); group (n = ) with monofer mg before surgery and group (n = ) without monofer. transfusion was preformed when the hgb was less than mg/dl). primary endpoint was incidence of perioperative transfusion. secondary endpoints were various hemoglobin (hgb) levels. results: the average age of the participants were . years old, and average body mass index (bmi) was . . demographic data including age, sex, bmi, comorbidity (charlson comorbidity index) of each group showed no difference. the complications from intravenous iron administration were not occurred. the preoperative hgb was . mg/dl (group . ± . vs, group . ± . , p = . ). the hgb at the postoperative day was . mg/dl (group . ± . vs group . ± . , p = . ). the average hgb at the postoperative month was . mg/dl (group . ± . vs group . ± . , p = . ). transfusion rate was . % ( / ) and the rate showed no difference between groups ( . % vs . %, p = . . the recovery of hgb between postoperative month and preoperative state showed statistically difference (group . vs group -. , p = . ), and iron supplementation group had more recovery. conclusions: intravenous iron supplement before the hip fracture surgery in elderly helped to recover hgb at postoperative month. comminuted subtrochanteric femur fractures-our experiences introduction: subtrochanteric femoral fractures account for approximately % of all the hip fractures and their treatment represents a challenge because of the short proximal fragment and highenergy forces. material and methods: a total of patients with subtrochanteric, highly comminuted fractures, were included in this study, with age range from to years. the mechanism of injury in all patients was high-energy trauma. in each case we applied a long gamma nail (limma lto) without focus opening. results: in all patients, good clinical and radiologic results were accomplished, in addition to early weight-bearing, without shortening of the legs, or consequences on the state of the hip and morbidity in general. conclusions: although the comminuted subtrochanteric femur fractures represent a challenge for the orthopedic surgeons, osteosynthesis using long gamma nail without the focus opening provides outstanding results. introduction: this study analyzed the association between the postoperative reduced position obtained on using short femoral nails (sfns) and the amount of sliding after fixation in unstable trochanteric fractures. material and methods: this retrospective study included patients with unstable trochanteric fractures with posterolateral support deficiency who underwent osteosynthesis with sfns and were followedup for months or longer. the study included men and women with a mean age of . years at the time of fracture. closed or open reduction was performed to achieve anatomical to medial type position on frontal view and anatomical to extramedullary type position on lateral view, followed by fixation with sfns. immediately and extramedullary type in patients immediately after surgery. three months after surgery, the reduced position worsened from the anatomical to intramedullary type in patients. according to the reduced positions at months after surgery, the mean amount of sliding was . mm in patients with intramedullary type, . mm in those with anatomical type, and . mm in those with extramedullary type. the amount was larger in those with intramedullary type than in those with anatomical and extramedullary types. moreover, excessive sliding was observed in patient with intramedullary type. conclusions:to prevent excessive sliding by ensuring anteromedial bony support in unstable trochanteric fractures with posterolateral support deficiency, open reduction should be aggressively performed to overcorrect to the extramedullary type when reduction performed on a traction table results in either anatomical or intramedullary type positioning. in this paper, we report patient previously studied for osteomyelitis caused by high-energy missile trauma, in . that study involved a total of patients with osteomyelits, divided into two groups, according to the treatment protocol applied. the group included patients treated using classic surgical methods, including debridement, curretage, forage, perfusion drainage and sequestration. the group included patients treated using recommended surgical methods and used pmma antibiotic beads. years after, we tried to contact all of the patients, for the purpose of follow-up. however, only patient was available for analysis. among patients we followed-up, were treated using recommended surgical protocol, while the remaining patients were treated using classic surgical methods. we present the patients' general status, as well as the local surgical status and radiographic analysis, years after. we obtained long-term results of both treatment protocols applied. from the group , patients developed chronic recurrent osteomyelitis, while only one patient from the group developed such condition. introduction: the aim of this study was to evaluate the treatment results using anterior subcutaneous internal fixation(infix) for the pelvic fractures and to consider an improvement strategy for the complications. material and methods: from to , pelvic fractures were enrolled. there were two males and females. the average age was years. there were fragility fractures and five high energy fractures. our operative procedure was as below: the connection between screws and rod was just above the fascia of the sartorius muscle. the connection bar was pre-bended before the operation using the initial axial ct scan. we assessed bone union, additional fixation, the distance between the femoral artery and connection rod (dar), the distance of protruded bar lateral to the connection (dpb), and complications. results: bone union achieved in out of cases. there was one nonunion and three early deaths because of medical complications. seventeen out of cases required additional posterior fixations. the average dar was . ( . - . mm) , and the dpb was . ( - ) mm. thirteen out of cases ( . %) had complications. there were seven lateral femoral cutaneous nerve (lfcn) symptoms ( required implant removal (ir)), two infections ( required ir), one hematoma (ir), one irritation (ir), one heterotopic ossification, one loosening (re-operation). there were no femoral vessels and nerve-related symptoms. to release lfcn and surrounding soft tissues decreased the nerve symptoms. conclusions: to connect the screws, and the rod just above the sartorius fascia could avoid major vessels and nerve complications, and also irritations. although this study found a high complication rate of infix, to release the lfcn and around soft tissue could decrease the complications. introduction: several studies have reported that posterior or anterior tilt increases the risk of reoperation in undisplaced femoral neck fractures (garden i/ii) after internal fixation performed using nonangular stable devices such as pins and multiple screws. however, to the best of our knowledge, there is limited research involving angular stable devices. the present study aimed to investigate the clinical outcomes in undisplaced femoral neck fractures after internal fixation using angular stable devices. material and methods: this retrospective study included patients (mean age, . [range, - ] years) who underwent internal fixation using angular stable devices between january and january . undisplaced femoral neck fractures with garden alignment index (gai) b °(posterior tilt angle c °) or gai b °( anterior tilt angle c °) were included (posterior: , anterior: ) in this study. patients were followed up for at least months (mean, . months). we analyzed the preoperative and last-followed gai on lateral radiographs, non-union, and late segmental collapse (lsc). results: among the patients, non-union was identified in ( . %) and lsc was observed in ( . %). the mean preoperative gai was . °(range, °- °), and the mean last-followed gai was . °( °- °). the overall complication (non-union and lsc) rate was . % ( / patients). among patients with gai c °, lsc occurred in ( . %). conclusions: in undisplaced femoral neck fractures, preoperative posterior c °is a risk factor for postoperative complications even when internal fixation is performed using angular stable devices; thus, primary arthroplasty may be considered. case history: the patient is a -year-old female who had undergone lumpectomy at the age of when she was diagnosed with breast cancer. she had antiresorptive drug therapy for bone metastasis, since years after the lumpectomy. she fell down from standing height and was diagnosed as right femoral subtrochanteric fracture. her femur was fixed with short femoral nail. she complained left hip pain at age .she complained left hip pain from july . clinical findings: she could walk with crutch.rom of left hip was normal. investigation/results: breast surgeon took mri and there was metastasis in the proximal part of femur. he thought the cause of pain was this metastasis. however, there was fracture line at the height of lesser trochanter when she visited our department. diagnosis: atypical fracture was strongly suspected, however, fracture line was little higher as normal atypical fracture. therapy and progressions: osteosynthesis with long femoral nail was performed months after first visit to our department because of increasing pain. pathological findings were metastasis and fracture. after surgery, radiation to femur was performed. she can walk without pain by crutch and fracture line is almost disappeared on months after surgery. comments: atypical femoral fractures (affs) are recently observed as a complication of antiresorptive drugs for bone metastasis. however, there were metastasis and atypical fracture in this case. introduction: in the present study we aim to evaluate the articular surface reduction quality by means of postoperative computer tomography (ct), in complex tibial plateau fractures, treated with an illizarov frame. materials and methods: this retrospective case series covers the period from - to - . forty-four patients with a mean age of years (range - years), with a complex intrarticular proximal tibia fracture were included. fracture types iii to vi according to schatzker's classification were included. the majority were closed injuries, apart from cases (a gustilo anderson type a and a type ). all patients were placed on a fracture table. a mini-open reduction of the articular surface was followed by application of a knee spanning illizarov frame. post-operatively all patients were subject to ct of the injured knee. outcomes were measured using the american knee society score. results: mean outpatient follow up was of at least months (range of - months). mean time for fracture consolidation . weeks (ranging from to weeks). according to the degree of postoperative articular surface depression patients were grouped as follows: had under mm, had - mm and over mm of depression. those with less than . mm of collapse had % chances of an excellent result according to akss. on the contrary, those with more than . mm of articular surface collapse had % chances for low scores and functional results. the achievement of a mechanical axis within °of the contralateral limb was positively correlated with good functional results but did not have a correlation with the akss. conclusions: complex tibial plateau fractures may be treated successfully with mini open reduction and the application of an illizarov frame. post-operative ct denotes the exact degree of displacement of the articular surface, which is prognostic regarding outcome. postoperative x-rays may be misleading, since they can underestimate articular surface collapse. introduction: a new trauma center building was constructed in march , and the process from the trauma bay to the operation room is faster. we hypothesized that this process improved the survival rate of trauma patients in need of trauma laparotomy. material and methods: the new trauma center separates the trauma bay from the emergency room, and the trauma team exam patients initially. it also has a separate operation room that is always available for emergency surgery. therefore, the decision to perform laparotomy and time to operation has been shortened. from january to december , trauma patients who underwent emergency laparotomy were included. those younger than years, who had delayed operation, underwent surgical observation, delayed admission by patient, or underwent angiography first were excluded. patients were dichotomized to the before-trauma-center (bc) and after-traumacenter (ac) groups, and their characteristics and clinical outcomes were compared. results: of patients, were included in the bc group and were included in the ac group. the times from admission to operation introduction: acute care is a growing worldwide burden with increasing visits to the emergency department (ed). the acute care system in the netherlands is almost overloaded and costs are increasing. almost % of ed visits have surgical disease. there is no nationwide acute care surgery (acs) model implemented yet, and resources and infrastructure are organized differently in almost every hospital. this study provides an overview of the existing systems nationwide, and basis for a national uniform model. material and methods: an online survey was distributed through the dutch surgical society and sent to all dutch hospitals. after sending a reminder, the survey was closed and results were analyzed. results: thirty-two hospitals ( %) participated in the survey. in % a surgeon (trauma, vascular or gastro-intestinal) was assigned as consultant and responsible for ed admissions, emergencies in-house, and in some cases also emergency surgeries. % of hospitals have an ed observation unit (edou). a dedicated emergency surgery operating room (esor) is available in % ( / available in %), and used efficiently in % primarily due to the following challenges: elective surgery scheduled at esor ( %), necessary stop of esor when elective programs are delayed ( %). in hospitals without an esor, the emergency surgeries are scheduled in between elective surgeries resulting in extending programs into the evening. finally, % of respondents was familiar with acs, with % being positive about exploring options of implementing such a model in our country, and % of the respondents opts for more focus on acs in surgical residency. conclusions: in the netherlands the organization of acute care varies. the main common bottleneck is the logistics around the or. implementation of a dedicated esor and unconditional availability / of this or seem to be the most important factors for optimal efficiency. although there needs to be more focus on acs in general, implementing a uniform model nationwide seems challenging at this moment. trauma team activations (tta) at an european trauma center: cases analyzed s. saar , , e. lipping , h. vospert , r. volmer , h. k. laas , j. lepp , k. g. isand , p. talving , north estonia medical centre, division of acute care surgery, tallinn, estonia, university of tartu, tartu, estonia, north estonia medical centre, tallinn, estonia introduction: the north estonia medical centre (nemc) is the largest trauma center in estonia with evolving capabilities. however, studies scrutinizing trauma team activations (tta) are currently lacking. thus, we initiated an investigation to document tta profile and outcomes. material and methods: all tta patients admitted to the nemc between / and / were retrospectively identified. data collected included demographics, injury severity score (iss), management, hospital length of stay (hlos), and in-hospital outcomes. primary outcome was -day mortality. results: overall, patients were included. mean age was . ± . years and . % were male. penetrating and blunt trauma accounted for . % and . % of the cases, respectively. non-ground level falls were the predominant mechanism of injury constituting . % of the admissions. mean iss was . ± . and . % of the patients were severely injured (iss [ ). blood alcohol level (bal) was positive at . %. a total of . % of the patients had an emergent operation. mean hlos was . ± . days.overall -day mortality and mortality of severely injured patients was . % and . %, respectively. conclusions: the current investigation documents comparable outcomes with established european trauma facilities [ , ] . blunt injury patterns predominate, however, high penetrating trauma incidence for european settings was noted. high rate of positive bal in tta patients warrants national preventive measures. introduction: the acute care surgery (acs) model was initially developed as a dedicated service for the provision of high quality / non-trauma emergency surgical care. after implementation in the united states (us), the model has been adopted in several variations around the world.in this systemic review we investigated which components are essential for a potential uniform acs model, by giving an overview of the current available acs models worldwide and their state of implementation. material and methods: a literature search ( - ) was conducted using pubmed, medline, embase, cochrane library and web of science databases following the prisma guidelines. all relevant data of acs models were extracted from included articles. results: sixty-five articles describing acs models in different countries were included in this review. the majority consist of a dedicated surgical service, providing non-trauma emergency surgical coverage, with daytime on-site attending coverage by an attending surgeon who is cleared from elective duties, and / in-house resident coverage. emergency department coverage and access to an acute care operating room varied widely across countries. critical care is fully embedded in the original us model as part of the acute care chain (acc), while in most other countries it is still a separate unit. while in most european countries acs is not a recognised specialty yet, there is a tendency towards more structured acute care, with training and separation from elective practice. conclusions: acs is gradually implemented worldwide. however, large national and international heterogeneity exists in the structure and components of the model. critical care is still a separate unit and specialty in most systems while it is essential to be part of the acc in order to provide the best peri-operative care of the physiologically deranged patient. universal acceptance of one global acs model seems challenging, however a global consensus on essential components would benefit any healthcare system. introduction: the recent financial crisis in greece is coped mainly with reformations towards cost effectiveness and rationality in the management of public expenses. the goal of the study is to evaluate the cost and time effectiveness in the management of the surgical patients admitted in emergency department (ed). methods: for a period of h/day in consecutive days, surgical cases presented in the ed of a tertiary university hospital of athens were followed. inclusion criteria were need for laboratory tests or imaging examinations or an immediate resuscitative intervention. data recorded regarding demographics, vitals, critical time points, disease and management. physician related data and cost of examinations were also collected. case severity was calculated by early warning score [ ] . results: she average waiting time for each patient was min and the average total time until final decision was : h. blood tests costs reached an average of , € per case and imaging an average of , €. the striking finding was that only one out of patients was of medium clinical risk, while all the others were of low. thus, substantial symptoms and clinical findings were lacking and as the ''tertiary care'' character of the hospital was mandating conclusive diagnosis, exams were ordered. this approach absorbs time and funds putting at risk the very few severe cases which are the target population for the magnitude of the facility. the current study indicates that the use of a tertiary hospital as a primary health care center by the public, is disorganizing the system, and increase the cost in time, funds, and preventable morbidity and mortality. a pre-hospital triage and management of the low severity cases system is pending to be established in our environment and becomes top priority in an era of prolonged financial crash. for years, surgical emergencies in ecuador have been managed without significant standardization. scarce numbers of specialists, lack of a constant presence of full-time teaching faculty versed in emergency surgery and lack of continuity with surgical trainees led to variability in clinical and surgical decision-making. to address these issues, the regional hospital vicente corral moscoso (hvcm) adapted and implemented a model of ''trauma and acute care surgery'' (tacs) to the reality of cuenca, ecuador. a cohort study was carried out, comparing trauma and acute care surgery patients exposed to the ''traditional care model'' before the implementation of the tacs model. variables assessed included: surgical wait times, number of hospital visits, number of surgical interventions, number of surgeries performed per surgeon and inhospital mortality. higher mortality was found in the traditional care model (rr of . , p b . ) compared to the tacs model. we observed a statistically significant decrease in surgical wait time ( . - . h for emergency general surgery, . - . h for trauma, p b . ). lengthof-stay decreased in trauma patients ( - days p b . ). the total number of surgical interventions increased ( , . - , . , p b . ) ; by extension, the total number of surgeries performed per surgeon also increased ( . - . , p b . ) . the implementation of tacs model in a typical resource-restrained, tertiary care hospital in latin america had a positive impact by decreasing surgical waiting time in trauma and emergency surgery patients, and length-of-stay in trauma patients. we also noted a statistically significant decrease in mortality. while cost could not be objectively evaluated with the available data, savings to the overall system and patients can be inferred by decreased mortality, length-ofstay and surgical wait times. to our knowledge, this is the first implementation of an tacs model that has been described in latin america. introduction: traumatic injuries constitute one of our major public health challenges. the most effective means to reduce the impact trauma has on individuals and society is primary injury prevention, reducing the incidence of traumatic events, which relies on detailed knowledge of risk factors. the aim of this study is to facilitate targeted injury prevention through improved data collection and analysis on impairing substances as risk factors for traumatic injuries. material and methods: idart is a national prospective observational study including analyses of the toxicological profile of all patients c year of age admitted via trauma team activation to any norwegian trauma hospital (n ) during a month study period. residual blood from routinely drawn blood samples at trauma admission is analyzed for alcohol, illegal and psychoactive drugs. toxicological data will be linked to clinical data from the national trauma registry. results: the study period started march st, , and during the first months patients were included from trauma hospitals. more than % of the included patients tested positive for psychoactive substances according to preliminary data. data on the prevalence of different psychoactive substances disaggregated by mechanism of injury, demography and geography from the month study period will be presented. conclusions: the idart study will provide a detailed descriptive analysis on the prevalence of alcohol, illicit and medicinal drug use among all patients admitted to a norwegian hospital with suspected severe injury. subgroup analyses will include prevalence of alcohol and other substances in subgroups analyses on patient and injury characteristics and geographical variations. analyses will aim to identify high risk groups according age, gender, circumstances of the injury, geographical location and type of psychoactive substance. the dutch nationwide trauma registry: the value of capturing all acute trauma admissions m. driessen , l. sturms , l. leenen lnaz/umcu, trauma surgery, nijmegen, netherlands introduction: twenty years ago the dutch government decided to reform the trauma care system and designated level regional trauma centers (rtcs). these centers, in collaboration with ambulance services and regional hospitals, have managed to set up regionalized inclusive trauma systems. moreover, they set up the dutch national trauma registry (dntr) as a quality evaluation and epidemiology resource. in this resource all acute hospital admissions were included, in order to measure the hospital and prehospital processes and outcomes. in the current study we demonstrate its current status and compare it with national trauma registries from the uk and germany. material and methods: the dntr includes all injured patients treated at the ed of % of all hospitals in the netherlands within h after the trauma followed by direct admission, transfer to another hospital or death at the ed. a representative descriptive analysis of extracted data from is demonstrated. results: between and a total of , trauma cases have been registered in the dntr. hospital participation has increased from % up to %. in alone, a total of . patient were included, % concerned males, the median age was years. % of all admissions had an iss c , of which % was treated at a rtc. from this cohort, in comparison, only % and % of the dntr patients met tr-dgu or tarn inclusion criteria. particularly children, elderly and patients admitted at non rtcs are not captured in the tr-dgu or tarn. also, part of iss c and fatal cases do not meet tr-dgu or tarn inclusion criteria. conclusions: the dntr has evolved into a comprehensive wellstructured nationwide population-based trauma register, with an annual number of , cases being entered in the database the dtr has grown to be one of the largest trauma databases in europe. the registry enables studies on the injury burden and quality and efficiency of the entire trauma care system encompassing all traumareceiving hospitals. introduction: trauma mortality is not distributed evenly. rural areas have higher incidence rates of trauma mortality than urban areas. the rural northern part of the nordic countries have common challenges with sparsely populated areas, long distances, and an arctic climate. the aim of this study was to compare the cause and rate of fatal injuries in the northernmost area of the nordic countries over a fiveyear period. material and methods: in this retrospective cohort we used the cause of death registries and collated all deaths from to with an external cause of death (icd- , v -y , except y - and t - ). the study area was the three northernmost counties in norway, the four northernmost counties in finland and sweden and the whole of iceland. we used % confidence intervals (ci ) to test for differences between the countries. results: there were deaths in the study area during the -year period. low energy (le) trauma constituted % and high energy (he) trauma % of deaths. northern finland had the highest incidence for both high energy trauma and low energy trauma. iceland had the lowest incidence for high-, and low energy trauma. iceland had the lowest prehospital share of deaths at % and the lowest incidence of injuries occurring in a rural location. the incidence rates for he trauma death was , / . /year in northern finland, , / . /year in iceland, , / . /year in northern norway and , / . /year in northern sweden. conclusions: there were significant and unexpected differences in the epidemiology of trauma death between the countries. the differences suggest that a comparison of the trauma care systems and preventive strategies in the countries is required. the diurnal and seasonal relationships of pedestrian injuries secondary to motor vehicles in young people introduction: there remains a significant morbidity and mortality in young pedestrians that are hit by motor vehicles, even in the era of pedestrian crossings and speed limits. the aim of this study was to compare incidence and injury severity of motor vehicle-related pedestrian trauma according to time of day and season in a young population. we hypothesised that injuries in young people would be more prevalent during dusk and dawn and during autumn and winter. material and methods: data was reviewed from patients in the - year old age group in the trauma audit and research network (tarn) national database, who had been involved as a pedestrian in a motor vehicle accident between and . the incidence of injuries, their severity (using the injury severity score [iss]), hospital transfer time and mortality were analysed according to the hours of daylight, darkness and seasons. results: . % of injuries occurred during time of darkness post sunset, while . % occurred during daylight. the incidence of injuries in motor vehicle accidents, in absolute terms, was highest during - , with a second peak at - . the greatest injury rate (number of injuries/hour) occurred during - and - with respective rates of . and . injuries scoring an iss over occurred . % at - and a further . % until . mortality was greatest during - involving out of the total deaths. autumn was the predominant season and lead to . % of injuries, with a further . % in winter. this demonstrated a clear difference to . % and . % in spring and summer. conclusions: we have identified a relationship between reduced daylight and the frequency and severity of pedestrian trauma in young people suggesting that reduced visibility may play a significant role which could be addressed through a targeted public health approach to implement change. enhancing cost effectiveness in a system in crisis: a , patient study a. tsolakidis , c. christou , p. smyrnis , a. prionas , a. tooulias , g. tsoulfas , v. n. papadopoulos aristotle university of thessaloniki, st department of surgery, papageorgiou general hospital, thessaloniki, thessaloniki, greece introduction: to date, there is no national trauma database in greece. the goal of our study is to record and evaluate trauma management at our university hospital as well as to measure the associated healthcare cost, while laying out the foundations for a national database. material and methods: retrospective study of trauma patients (n = , ) between and . demographic information, injury patterns and severity, outcomes and cost were recorded. results: the proportion of patients that were transferred to the hospital by the national emergency medical services was , %, whereas ( %) of our trauma patients did not meet the us trauma field triage algorithm criteria. over-triage of trauma patients to our facility ranged from . to . %, depending on the criteria used. ( . %) of our patients received operative management and % ( ) of them had postoperative complications. an iss [ was seen in ( %) of our patients and their mortality was , %. the overall non-salary cost for trauma management was . . euros. the cost resulting from the observed over-triage ranged from . to . . euros. furthermore ( . %) of our patients underwent at least one ct scan that did not show any significant traumatic lesion. the cost of hospitalization of these patients was . euros. conclusions: the prehospital triage of trauma patients in the greek national health system is ineffective, with significant over triaging, leading to excessive costs. appropriate use of criteria for diagnostic procedures and algorithms may lead to a, much-needed, reduction of these costs. introduction: in japan, there are emergency and critical care centers nationwide (one center for approximately every , people), and a system is in place to accept local critically ill patients h a day, irrespective of whether their conditions are intrinsic or extrinsic. however, manpower and medical care systems differ depending on the emergency and critical care center, and the establishment of a system for consolidating severe trauma patients has been particularly problematic. material and methods: this study examined cases where the patient had some sign of life when encountered by ambulance teams of the cases of traffic accident deaths that occurred in chiba prefecture between and . thirteen emergency and critical care center representatives in chiba prefecture met to verify each case based on data from the police, fire department, and medical institutions. the cases were classified into ( ) preventable trauma death (ptd) cases, ( ) suspected ptd cases, and ( ) non-life-saving cases; the problems (causes of ptd) in each case were examined. result: there were cases ( %) of ptd and suspected ptd. sixty-eight of these cases were transported to emergency and critical care centers. the most common cause of death was bleeding, accounting for cases and the locations where the problems that caused ptd occurred were outside of the hospital (n = ) and in the hospital (n = ). the problems that occurred in the hospital (including duplications) include circulatory management (n = , %), the treatment plan (n = , %), delay of lifesaving surgery (n = , %), and delay of diagnosis (n = , %). most of these occurred in the initial emergency care room. conclusion: this study clarified that ptd still occurs in relation to bleeding control in the current trauma care system in chiba prefecture. it is vital to establish a national ''trauma center'' and to thoroughly consolidate trauma cases to eradicate ptd. analysis of the impact of the implementation of a trauma team in a trauma center from an upper-middle-income country introduction: trauma teams (tt) improve the care process and the outcomes. a multidisciplinary tt was conformed in september to achieve a rapid response by specialists in emergency medicine, trauma surgery, diagnostic imaging services, and blood bank in a level i trauma university hospital in southwestern colombia. objective: to evaluate the impact of a tt implementation in terms of times of attention and mortality. material and methods: retrospective study. all the patients with the highest level of tt activation treated in the months after the tt implementation were included. the subjects triaged to the trauma center in the months pre tt were taken as controls. four hundred sixty-four patients were included, before the implementation of the tt (btt) and after (att). demographic data, trauma characteristics, times to tomography, and trauma surgery and mortality were recorded. the analysis was made on stata , Ò . categorical variables were described as quantities and proportionscontinuous variables as mean and standard deviation or median and interquartile range (iqr). categorical variables were compared by chi or fisher's test. continuous variables with student's t or wilcoxon-mann-withney. a multiple logistic regression model was created to evaluate the impact on mortality if being treated att, adjusted by age, trauma severity, and physiologic response on admission. results: the time from admission to the ct scan was min (iqr - ) in the btt group and min (iqr - ) in the att group, p &lt; . . the time to trauma surgery was min (iqr - ) in the btt group and min iqr - ) in the att group, p &lt; . . mortality in the btt group was . % and . % in the att group. adjusted or was . ( . - . ) p = . conclusions: the implementation of a multidisciplinary trauma team associated with a reduction of the times to tomography and surgery and with a decrease in mortality risk. no prediction of an unfavourable outcome after surgical treatment of chronic subdural hematoma patients using machine-learning l. riemann , a. younsi , c. habel , j. fischer , a. unterberg , k. zweckberger university hospital heidelberg, neurosurgery, heidelberg, germany introduction: chronic subdural hematomas (csdh) are expected to become the most frequent neurosurgical disease by the year . although often perceived as a ''benign'' condition, considerable rates of mortality and poor outcome have been reported. we therefore evaluated factors associated with an unfavorable outcome after surgical treatment of csdh patients by developing a predictive model using machine-learning. material and methods: consecutive patients treated for csdh with surgical evacuation between and at a single institution were retrospectively analyzed. potential demographical, clinical, imaging and laboratory predictors were assessed and a decision-tree predicting unfavorable outcome (gos - ) was subsequently developed using the classification and regression tree (cart) algorithm. out-of-sample model performance was evaluated using repeated cross-validation (fivefold with repetitions). results: eligible patients were analyzed. median age was (iqr - ) years and % were males. mortality rate was . % and rate of unfavorable outcome was . %. the developed decision-tree to predict unfavorable outcome had splits and included the following clinical variables (in descending order of calculated importance): gcs, comorbidities, hb, and age. after cross-validation, the following model performance metrics were obtained: a model accuracy of . ( . - . ), sensitivity of . ( . - . ), and specificity of . ( . - . ). conclusions: gcs, comorbidities, hb, and age were identified as the most important clinical predictors for an unfavorable outcome in csdh patients after surgery. the developed model was simple and still displayed a high accuracy and very high specificity, the sensitivity was however rather low. our results might help clinicians to better assess the prognosis in patients with csdh. introduction: in most developing countries access to tertiary care neurosurgical setup is uncommon. majority trauma including neurotrauma & medical conditions requiring emergency neurosurgical interventions present to a general surgeon. this study is an attempt to highlight the importance of emergency neurosurgery as a skill amongst general surgeons & also focus on the challenges in managing such cases in austere environments material and methods: this study was a retrospective analysis of progressively collected data of trauma patients with a specific focus on head injuries & emergency neurosurgical interventions for both traumatic & non traumatic indications in a level trauma centre in a semi urban area over a period of years from august to september results: a total of patients of trauma were analysed out of which were head injuries. road traffic accidents accounted for nearly % of head injuries. atypical trauma especially in rural setup e.g. train collision, animal related causes were also seen. males accounted for majority (m:f = . : ). mean age was yrs. patients had imaging findings suggestive of severe head injury. acute sdh was the commonest post traumatic finding and mca territory infarct in non traumatic group. patients underwent emergency neurosurgical intervention with a survival of %. factors associated with poor outcome were delayed presentation (p \ . ), sdh with diffuse axonal injury. alcohol consumption was a significant factor. conclusions: emergency neurosurgery is an essential skill for general surgeons. performing such cases in a low resource environment in absence of modern day facilities for imaging, icp monitoring & powered equipment presents a significant challenge. general surgeons should be able to perform operative interventions with basic handheld instruments. operative management whenever indicated should be done & helps improve outcomes. head trauma in polytraumatized patient. analysis of risk factors and neurological prognosis b. castro , , , m. morote gonzález , , , l. cebolla , , , a. sada , , , l. seisdedos , , , , , j. gil , c. rey valcárcel , , f. j. turégano fuentes , , c. tristan , c. ruiz moreno hgugm, surgery, madrid, spain, hospital, madrid, spain, hospital, madrid, spain, hospitall, madrid, spain, hospital, madrid, spain, hospital, madrid, spain, hospital, madrid, sri lanka introduction: severe trauma is one of the most frequent causes of death and disability and traumatic brain injury (tbi) in polytrauma is the main cause of death and disability in survivors. the aim of this study is to analyze mortality associated to tbi in the last years, prognostic factors associated with it and neurological outcomes in survivors with tbi. methods: retrospective observational study that includes risk factors and functional neurologic evaluation in polytrauma patients attended in gregorio marañon hospital between - . inclusion criteria were severe trauma patients (iss c ) with a tbi and abnormal ct of the head. we analyzed mortality trend in two periods : - and - , and neurological evolution and outcome at discharge with functional scores (ramkin scale and gos) in the second one. results: from to , severe trauma patients were admitted, ( , %) with brain or central nervous system injuries visible on head ct. median age was ' ; . % were men. the global mortality of the cohort has been , %, . % of them for neurological causes. ischemic heart disease, anticoagulation, abnormal pupils or eye opening, the need for surgery, shock, gos, iss, niss, cranial ais are significant associated with higher mortality (p \ , ).the mortality rate due to neurological causes decreases in the second period from , to , %, this descent being statistically significant (p = , ). between and , % patients died from cnsi, and , % of tbi survivors had a vegetative status at discharge, , % had major disability, and , % had a good neurological recovery. conclusions: mortality due to tbi decreased in the last years, but this improvement after tbi was at the expense of a high rate of vegetative status and great disability, showing the need for continuous research in this area. introduction: severe traumatic brain injury (tbi) constitutes one of the most frequent causes of intensive care unit admissions and is a major cause of death and disability among young people. decompressive craniectomy (dc) is a life-saving measure used to relieve intracranial pressure (icp). this procedure is related with low mortality rates and poor functional outcomes. the aim of this study is to analyze the survival rates and prognostic factors related with functional outcomes after dc for severe tbi. material and methods: retrospective, single center study of patients with severe tbi in whom a dc was performed between the years and . demographic features, clinical parameters, radiological findings and clinical outcomes were included in the study. for the statistical analysis we used anova, chi-square, kaplan meyer, cox regression and logistic regression. a p value of less than . was considered to indicate statistical significance. results: the mean initial glasgow coma scale was , ± , and the mean initial motor response (imr) was , ± , . the mean icp after dc was , ± , . the -day survival after dc was %. twenty percent of the patients improve ate least point in the glasgow outcome scale (gos) between and months after surgery. twelve patients improve from unfavorable gos to favorable gos. at -month follow-up, % of the patients has gos [ . younger age, high irm a post-operative icp were the factors significantly associated with a higher chance of outcome improvement. conclusions: dc is useful for the management of refractory intracranial hypertension related to severe tbi, and in selected patients is associated with good functional outcomes. introduction: antiplatelets and anticoagulation, commonly referred to as antithrombotic therapy, are frequently used in patients c years. the use of antiplatelets and anticoagulation are associated with increased incidence of intracranial bleeding ( , ) . there are two research questions addressed in this study: ( ) does preinjury antithrombotic therapy affect survival in elderly patients with tbi? ( ) are direct oral anticoagulants (doacs) associated with better survival than vitamin k antagonists (vka) in tbi patients on anticoagulation? materials andmethods: retrospective cohort study based on data extracted from the oslo tbi registry. included in the study are tbi patients c years admitted to ouh with cerebral-ct showing signs of acute trauma (hemorrhage, fracture, vascular injury) in the time period - . the impact of age, comorbidity, antithrombotic medication and antithrombotic reversal protocol for survival will be explored. results: the patient inclusion is ongoing. preliminary data will be presented at the st ectes in april . the estimated number of tbi patients c years with cerebral-ct showing signs of acute trauma in the study period is * . in this patients group, the expected preinjury use of antiplatelet and anticoagulation medication is * % and * %, respectively. conclusions: the knowledge regarding impact of preinjury antithrombotic therapy on survival in elderly tbi patients is clinically relevant, and may improve patient management in the acute phase of injury. references: introduction: traumatic acute subdural hematoma (asdh), especially the large ones in need of surgical evacuation, is associated with high mortality. contemporary population-based series of surgically treated asdh are sparse. the two main aims of this single-center study from oslo university hospital (ous) were to estimate incidence of surgery for asdh in the population of helse sør-Øst, and estimate in-hospital and -month survival of these patients. treatment of tbi at ous adheres to the brain trauma foundation guidelines, with icp controlled therapy and evacuation of asdh when gcs \ and hematoma volume c cm or midline shift c mm or hematoma width [ mm. the goals of tbi treatment for adults have been to maintain icp \ mmhg and cerebral perfusion pressure (cpp) c mmhg. methods: from . . all patients with traumatic brain injury (tbi) with positive head ct, admitted to ous, living in helse sør-Øst ( . million inhabitants) and having a norwegian social security number, have been included in our approved tbi-quality register. included in the present study are all patients with asdh undergoing evacuation of the hematoma within days of trauma. the following data were extracted from the register; demographic variables, date of injury and trauma mechanism, severity of head injury according to hiss grade, rotterdam ct score, surgical procedures, multitrauma, glasgow outcome scale at discharge and date of death. results: asdh patients were operated in the -year period - , % males, mean age was years ( - ), the most frequent trauma mechanism was falls ( %), % were under influence of ethanol, % had severe tbi and % had multitrauma. the incidence of surgically treated asdh in helse sør-Øst was / . /year. in-hospital and -month mortality was . % and %, respectively. conclusion: the presented data for incidence and mortality will be compared with earlier reports. age-related difference in impacts of coagulopathy in patients with isolated traumatic brain injury: an observational cohort study w. takayama , a. endo , y. otomo tokyo medical and dental university hospital of medicine, trauma and acute critical care, tokyo, japan background: age and trauma-induced coagulopathy (tic) have been reported to be the predictors of poor outcome following traumatic brain injury (tbi). whether the impact of brain injury induced coagulopathy on outcomes have age related differently is unknown. objectives: we evaluated the age-related difference in the impact of tic on outcomes in patients with isolated tbi. methods: a retrospective observational study was conducted in two tertiary emergency critical care medical centers in japan from to . the patients with isolated tbi [head abbreviated injury scale (ais) c , and other ais \ ] were included. we evaluated the impact of coagulopathy (international normalized ratio c . , and/or platelet count \ /l, and/or fibrinogen b mg/dl) on the outcomes [glasgow outcome scale-extended (gos-e) scores, inhospital mortality and ventilation free days (vfd)] in both group using univariate and multivariate models. furthermore, we visualized the impact of coagulopathy on gos-e according to age, by using a generalized additive model. results: of the patients studied, they were divided based on their age: non-elderly group (n = , - years) and elderly group (n = , age c years). although, in the multivariate model, age and coagulopathy were significantly associated with lower gos-e, in-hospital mortality and shorter vfd in the non-elderly group, significant impact of coagulopathy was not observed for all the outcomes in the elderly group. the correlation between coagulopathy and lower gos-e decreased with age after round years old. conclusions: in patients with isolated tbi, impact of coagulopathy on functional and survival outcomes was lower in geriatric patients. no difference in mortality between isolated tbi and polytrauma with tbi: it is all about the brain introduction: despite improvements in trauma and critical care mortality caused by traumatic brain injury (tbi) remains high. [ ] as polytrauma is naturally associated with increased mortality, this study compared mortality rates in isolated tbi (itbi) patients and polytrauma patients with tbi admitted to icu. material and methods: a -year retrospective cohort study included both consecutive trauma patients with itbi with ais head c (ais of other body regions b ) and polytrauma patients with ais head c admitted to a level-i trauma center icu. patients \ years of age, injury caused by asphyxiation, drowning, burns and transfers from and to other hospitals were excluded. patient demographics, shock and resuscitation parameters, denver multiple organ failure scores and acute respiratory distress syndrome (ards) data were collected. [ ] data is shown as medians with interquartile ranges. p-values \ . were statistically significant. results: a total of patients were included. the median age was ( - ) years, ( %) patients were male, median iss was ( - ). seventy-nine ( %) of all patients died. polytrauma patients developed more often ards ( % vs % p = . ) but had similar mods rates ( % vs % p = . ). polytrauma patients stayed longer on the ventilator ( vs. days p b . ), longer in icu ( vs. days p b . ) and longer in hospital ( vs. days p b . ). there was no distinction in in-hospital mortality of itbi and polytrauma patients ( % vs. % p = . ). tbi contributed to all deaths in itbi patients and all but three deaths ( %) in polytrauma patients. conclusions: tbi was the main cause of death in both groups. there was no difference in mortality rates between polytrauma patients with tbi and itbi patients, even though polytrauma patients were more severely injured. references: [ ] dewan mc et al. estimating the global incidence of traumatic brain injury. j neurosurg. ; ( ): - . no significant relationships or conflict of interests. how modeling the brain ventricles could help brain trauma understanding ( ). in pathological cases as in hydrocephalus, or in brain trauma, it is likely that each patient's ventricle structure has an impact on the way they behave. for instance, a shock wave may turn out differently according to the ventricle's shape. this can explain why for a same shock, the clinical translation is not the same. the aim of the study is to implement a finite element model of the cranio-cerebral system and to analyse the impact of a trauma simulation. material and methods: this is amonocentricretrospective study from . the database contains ct scans of healthy patients. we used itk-snap software to segment the ventricles and matlab to implement the model. results: the mean volume of the total ventricles is ml (sd = ). the median is ml (table ) .to identify the correlation between the parameters acquired we performed a pearson test. we found multiple significant correlations and one of the most relevant one is between the ventricular volume and the width of the third ventricle ( table ). showing that the total ventricular volume is statistically correlated to the width of the third ventricle is clinically interesting. we could potentially simplify our analysis of the ventricular system in head trauma by measuring less coordinates and yet come up to an accurate prognosis. the ventricle volumes are used as neuroimaging marker of brain changes in health and brain trauma. to our knowledge, it is the first time they are studied in vivo on ct-scan. this study and the existing correlations are relevant for the configuration of the finite element model on going. it can surely help the comprehension of the interaction between the structural parts of the cranio-cerebral system during brain trauma. (excitatory-glutamate, and inhibitory-c-aminobutyric acid, gaba), is crucial for the normal cerebral functioning. gaba concentrations vary in different cerebral zones [ ] responsible for different cerebral tasks. in this study, [gaba] is measured in the posterior cingulate cortex (pcc) of children with acute mtbi. material and methods: acute mtbi patients (\ h since injury, . ± . y.o) and healthy controls ( . ± . y.o). mri scanner philips achieva t was used. standard mri protocol for tbi revealed no pathological lesions in brain of any subject. magnetic resonance spectroscopy (mega-press [ ] ) was applied to obtain gaba signal without macromolecules. spectroscopy voxel is demonstrated on fig. . intensities of gaba, glutamate ? glutamine, creatine and water signals were calculated in gannet program [ ] . absolute concentrations were calculated. mann-whitney was used to reveal the statistical significance of between-group differences. results: typical gaba spectrum processing in gannet is demonstrated on fig. . no changes in glx were found. the values of [gaba] in pcc are demonstrated on fig. : the increase in gaba is not statistically significant. conclusions: this is the first study of [gaba] in pcc of children with acute mtbi. the result of current work disagrees with our previous study, where gaba was increased (p \ . ) in the anterior cingulate cortex of children with mtbi [ ] . this indicates to a necessity of further data collecting in order to reveal any [gaba] alterations in various cerebral loci. this would help to identify the causes of an inhibition/excitation imbalance and to predict possible dysfunctions of cns following mtbi. results: tnaa and naag concentrations along with stable naa concentration were found to be reduced in patient group. reduced asp and elevated mi concentrations were also found. the main finding of the study is that tnaa signal reduction in wm after mild traumatic brain injury is associated with the drop of the naag concentration rather than of naa one, as it was thought previously. this highlights the importance of separation of these signals at least for wm studies to avoid misinterpretations of the results. naag plays an important role in its selective activation of the mglur receptors, thus providing neuroprotective and neuroreparative function immediately after mtbi. it might have potential for the development of new therapy strategy for patients with injuries of various severity. introduction: traumatic brain injury (tbi) is globally recognized as a major health and socioeconomic issue. however, reported numbers vary and often represent subgroups. the number of hospital-admitted tbi has an important impact on hospital resources. thus, the monitoring of hospitalized tbi patients is needed. in , oslo neurosurgical tbi registry was established and includes patients admitted to oslo university hospital (ouh) with traumatic intracranial injury identified by neuroimaging. the aim is to introduce the registry; describe the patient group and volume. material and methods: descriptive study from oslo neurosurgical tbi registry. results: patients from south-east region were included in - (population million). mean age was years (sd ), % were males. most frequent cause of injury was falls ( %), increasing with age. % was influenced by alcohol at time of injury. preinjury antithrombotic therapy was common ( %). most of the patients had multiple pathologies on ct caput, e.g. simultaneous cranial fracture, sdh, tsah and brain contusion (four most frequent). accompanying injuries were found in %. % was transported to ouh directly form accident scene. % was classified as severe tbi upon arrival ouh, % was intubated, and trauma team was activated in %. median annual and monthly numbers of cases were (range - ) and (range - ), respectively. no clear change in case load between years and months, except a slight decline in march. admission rate peaked during the weekend. patients were continuously admitted throughout day and night, [ % between : and : . conclusions: patients included in the registry were older than those included in previous tbi studies. the numbers of cases admitted were stable across the months and years. however, the majority of patients were admitted during weekends and nights; thus handled by duty staff. relationship between brain-body temperature difference and neurologic outcomes in patients with severe head trauma introduction: brain is one of the most vulnerable organ to temperature. the association between core body temperature(ct) and neurologic outcomes in patients with post-cardiac arrest, severe head trauma and stroke has been reported. there were few reports comparing brain temperature(bt) with ct and peripheral temperature(pt). we investigated the association of differences among bt, ct and pt with neurologic outcomes in patients with severe head trauma. material and methods: we retrospectively reviewed data for patients with severe head trauma who underwent monitoring intracranial cerebral pressure(icp), bt, ct and pt simultaneously between january and december . results: we evaluated patients with a median age of years (range - years). glasgow outcome scale(gos) at discharge were as follows: good recovery(gr) , severely disabled(sd) , vegetative state(vs) , death(d) . table showed the average values of icp, cerebral perfusion pressure(cpp), bt, ct, pt, differences between each temperature (bt-ct, ct-pt, bt-pt) and gos in each patients. there was remarkable difference between bt and ct in the dead patient, whereas less differences were found in the other alive patients. we found greater difference between bt/ct and pt in the vs patients than gr patients. conclusions: greater differences between bt/ct and pt can be related to poorer neurologic outcomes introduction: minor head traumas are difficult to assess even with guidelines, hence head cts are often requested. as head cts are increasingly accessible, the demand on the radiology department often exceeds its capacity. there has been an increase in head cts at the oslo emergency department (oed), norway. the scandinavian guidelines for initial management of head injuries in adults (sg) is standard practice in the oed when assessing patients with head trauma.the aim of this study is to assess the number of patients with traumatic brain injury, evaluate guideline compliance and false negative initial reports by junior radiologists. material and methods: a consecutive cohort of patients from jan-june who received a head ct at oed due to minor head trauma was assessed. data was gathered from the ct request form, radiology report and ct images. the data points analyzed were: type of trauma, gcs, anticoagulants, loss of consciousness, nausea and vomiting, positive traumatic ct findings, and number of head cts within a year period. results: intracranial bleeds were reported in ( %) patients, ( . %) required neurosurgical intervention. skull fractures were reported in ( . %) patients, however no intracranial bleeds were present. it was impossible to assess guideline compliance because % of the referrals lacked adequate clinical information. ten bleeds were missed, however no further action was needed. % received more than head cts in years conclusions: head injury guidelines can improve clinical practice and reduce unnecessary ct scans; thus minimizing radiation exposure. based on the low number of positive findings, we hypothesize that sg compliance can be improved at oed. compliance was not assessable for nearly half of the patients, due to vital clinical factors missing. implementation of a standardized ct referral form based on the sg and educating junior ed doctors may decrease the number of unnecessary head cts. introduction: to date, there is no ideal allograft that provides local antibiotic release. along with this, existing fillers are expensive material, which complicates their application in practice. all this leads to the need to look for new ways to solve this problem. material and methods: gentamicin was used as an antibacterial drug because of its wide spectrum of action and thermal stability. for the study, staphylococcus aureus attc was used as a microbial strain. the antibiotic release from the studied materials was determined by equilibrium dialysis over the entire observation period. gentamicin antibiotic concentration was determined by hplc. results: an allograft impregnated with an antibiotic, prepared according to the marburg system in the area of the subcortical part of the bone, suppresses the staphylococcus aureus attc strain twice as much as perossal. when comparing bone allografts impregnated in various ways, the longest release time showed a perforated allograft.a bone graft impregnated with an antibiotic by incubation showed a % longer release time compared to perossal granules (p \ . ).when in vitro incubation of the antibiotic gentamicin with the drug ''perossal'', the dissociation rate is more than % in the first two days. when the antibiotic gentamicin with a bone allograft is incubated in vitro on the second day, dissociation into the extracellular space makes up more than % of the drug from the previously bound (p \ . ), which also indicates a longer release time from the bone allograft. conclusions: in vitro, a bone allograft impregnated with an antibiotic is able to reversibly bind the antibiotic gentamicin and gradually release it over a period of days. the use of a bone allograft impregnated with an antibiotic suppresses the growth zones of staphylococcus aureus strains. references: rudenko a., impregnation of the bone allograft: comparison of heads coloring. european journal of trauma and emergency surgery (suppl) p. acute appendicitis and pregnancy: from incidence to modern management: literature review and proposal for consensus estes experts guidelines a. l. bubuianu , a. mihailescu , g. pokusevski tameside general hospital, general/emergency surgery, ashtonunder-lyne, united kingdom introduction: acute abdominal pathology during pregnancy has historically been a challenging decision for the emergency surgeon, that had to deal with patients at same time. acute appendicitis has probably the highest prevalence of all. early involvement of the gynaecological team was considered paramount and the ongoing debate laparoscopic versus open intervention, has been more recently challenged by case reports where antibiotics alone have been a successful strategy. material and methods: literature review has been conducted by the investigating team, using the following search algorithm: reviewers screened pubmed portal to conduct a thorough search of the most important medical databases, cochrane's library, medline and embase. case reports and low quality case series have been excluded from the literature review. results: there is currently no general consensus in regards to operative strategy in acute appendicitis during pregnancy, but most authors described safety of laparoscopic intervention in the first trimesters and favoured open approach in a mother closer to term. the antibiotic treatment alone can only be considered in presumed early appendicitis, where there are no features of pending perforation, presence of phlebolith or established peritonitis and should be done under the close monitoring of experienced general surgeons. conclusions: an expert consensus is required in first instance, (set of questions submitted to audience at end of presentation for their expert opinion) regarding optimal treatment strategy in acute appendicitis during pregnancy, followed by a multicenter prospective randomised control trial, which we are hopeful to engage with help of numerous european hospitals where estes members activate. introduction: deep tissue pressure injuries (dtpi) are complex and difficult to treat. the higher prevalence is observed in paraplegic and elderly populations. primary closure of large, stage- dtpis is rarely feasible and flap closure is customarily applied. presented is a technique using tension relief system (trs; topclosureÒ tension relief system) and regulated oxygen and irrigation negative pressure wound therapy (roi-npt; vcareaÒ) to facilitate simple primary wound closure of dtpis. methods: large, stage- dtpis were closed by a limited surgical procedure entailing conservative debridement, en-bloc primary wound closure based on the application of trs and roi-npt. results: details of the closure of consecutive large dtpis in patients is presented. immediate primary closure was achieved in cases, while three others were closed over - days. surgery time ranged between . and h and hospitalization between and days. following a median follow-up of months (range - months), all wounds healed with one late recurrence. post-operative wound infection observed in one patient was successfully treated with systemic antibiotics. minor skin damage inflicted by the tension sutures at the anchoring sites healed spontaneously. gradual return to partial loading of the operated area was enabled within - weeks and full weight-bearing was achieved within - weeks. introduction: chronic pain is a disabling condition affecting - % of trauma patients. considering the burden of chronic pain, interest in interventions to prevent this disorder after trauma has grown. a descriptive review of literature was undertaken to assess the evidence on these interventions. material and methods: medline, cinahl and cochrane library databases were searched to identify interventional studies published up to august . websites of injury, critical care and pain organizations were also consulted to retrieve relevant guidelines. the literature search used combinations of medical subject headings and keyword under the themes of pain, trauma, surgery and preventive interventions. results: many knowledge syntheses relevant to the population of trauma published between and were found. low to moderate level of evidence was reported for pharmacological interventions such as the administration of ketamine, neuropathic pain medication and multimodal analgesia. local or regional nerve block in the presence of factures was associated with a high level of evidence. very low to low evidence was described for nonpharmacological interventions including cryotherapy and early mobilization. finally, psychological interventions were associated with a low to moderate level of evidence and multimodal pain management interventions (pharmacological and non-pharmacological) with a high level of evidence. conclusions: research is still needed to define the role of interventions to prevent chronic pain in trauma patients. thus far, multimodal pain management interventions involving multidisciplinary team management appear to be the most promising. implementing such interventions could reduce the negative consequences associated with chronic pain. introduction: chronic use of opioids has been documented % of trauma patients. accordingly, the tapering opioids prescription program in trauma (topp-trauma) was developed. the aim of this study was to assess the feasibility of topp-trauma and explore the efficacy of topp-trauma in reducing opioid use. material and methods: a -arm pilot rct was conducted in patients presenting a high risk for chronic opioid use. we aimed to recruit participants to receive either topp-trauma or an educational pamphlet. topp-trauma comprised educational and counseling sessions. the feasibility assessment of topp-trauma was based on the ability to provide its components. the morphine equivalent dose (med) per day as well as pain intensity and pain interference with activities were measured at and weeks following discharge. results: preliminary findings based on data collected in participants showed that counseling sessions were most frequently needed to completely taper opioids. sessions attendance reached %. nearly % of eligible patients accepted to participate and an attrition rate of % was found. even though the experimental group consumed a higher med h prior to hospital discharge compared to the control group ( . vs . ), its med/day intake was lower at weeks ( . vs . ) and weeks ( vs . ). these self-reported data were validated by the total med delivered by participants'' pharmacy at both time points ( . vs . at weeks; . vs . at weeks). minimal mean score differences were observed in both groups with regard to pain intensity and interference with activities. conclusions: data collected until now provided evidence on the feasibility of topp-trauma and on the program potential efficacy. challenges that will require to be addressed in future rct include the acceptance to take part in the study and participants' drop out. introduction: head preserving surgical treatment for ao-type b fractures with little to no dislocation consists of three canullated screws or a dynamic hip screw (dhs). there is a new alternative: the femoral neck system (fns). the fns has some advantages over dhs. the anti-rotation screw provides extra rotational stability because of the diverging design. furthermore, the incision is smaller in fns and only one locking screw is necessary for plate fixation. we present the first results of this new surgical fixation of femoral neck fractures with fns. material and methods: during the period of november until october , all patients with femoral neck fractures treated with fns, were included in this prospective single center cohort study. patient characteristics, fracture classification (ao, garden, pauwel), perioperative parameters and postoperative complications were registered. patients were allowed to mobilize based on the principle of permissive weightbearing. follow up was planned after weeks and weeks. primary outcome measure was cut-out rate within months. results: twenty-four patients with a femoral neck fracture (ao-type b) were surgically treated with fns. median age was , (range - ). median operation time was mins (range - ). mean duration of in hospital stay was days (range - days). twentytwo ( , %) patients completed the regular follow up of weeks. one patient ( %) had a reoperation due to a cut-out. during follow up one patient developed a wound-infection ( %) which was treated with intravenous antibiotics conclusions: femoral neck system as surgical treatment for femoral neck fractures shows promising first results. low cut-out rate, limited operation time, low mortality and short duration of in-hospital stay make this device a possible alternative for dhs of canullated screws. definitive conclusions should be made after studying long term results in larger cohorts. references: none. new personalized approach to enteroatmospheric fistulas using d bioprinting device introduction: enteroatmospheric fistula is a challenge for surgeons. it presents a great clinical variability. this diversity means that, despite having tried multiple devices and techniques to achieve local control of the intestinal effluvium over the rest of the wound, there is currently no technique that can solve this problem in all patients. d printing is a novel therapy that allows the customization of the devices according to the needs of each patient. the aim of this study is to describe the technique of manufacturing a custom device designed by bioscanner imaging and manufactured using a d printer for use in the management of enteroatmospheric fistula. we describe our initial results. materials and methods: we present four patients with enteroatmospheric fistula. the intestinal segment involved, the dimensions of the wound, the intestinal debit and the size of the exposed intestinal surface are substantially. all require an average of - daily cures by the nurse. after obtaining images of each fistula with a bioscanner, a personalized device was designed and made by a d printer. the polycaprolactone device was placed including inside the fistulous orifices and surrounding it with npwt in order to accelerate the healing of the wound to ostomize the fistula or achieve its definitive closure. results: four devices with different designs have been manufactured. the wound remained isolated from the intestinal contents after placement, favouring the granulation of the surrounding tissue with npwt and thus avoiding contamination of the wound. the system remained without leaks for an average of h, reducing the need for daily cures, improving patient comfort and avoiding complications. conclusions: the use of a manufacturing model using d bioprosthesis printing in order to create a personalized device that fits the characteristics of the patient's wound is feasible and offers promising results in the management of enteroatmospheric fistulas. new approaches in bone tissue engineering: innovative scaffold design for principle unlimited size bone substitutes introduction: in bone tissue engineering (bte), autologous boneregenerative cells are combined with a scaffold for large bone defect treatment. microporous, polylactic acid scaffolds showed good healing results in bone defects in small animals. transfer to large animal models, however, is challenging and not easily achieved simply by upscaling the design. increasing diffusion distances has a negative impact on cell survival and nutrition supply. this can lead to cell death and ultimately implant failure.this approach focuses on scaffold architectures, that meet all the requirements for a modern bone substitute. biological-functional, porous subunits in a loadbearing, compression-resistant frame structure characterise the innovative design. an open, macro-and microporous internal architecture provides optimal conditions for oxygen and nutrient supply in the inner areas of the implant by diffusion. material and methods: during the design process, prototypes (temple (figure a) , grid (figure b) , onion (figure c)) were dprinted (fused filament fabrication) using polylactic acid (pla). -after incubation with saos- (sarcoma osteogenic) cells for days (measurements on days , , and ), cell morphology, distribution and survival (fluorescence microscopy, ldh-based cytotoxicity assay), metabolic activity (mtt test) and osteogenic gene expression were determined. results: all designs not only showed cell colonization, but cells also sustained their ability to differentiate (already after days) and to divide. the open, hierarchical-structured design, with its innovative porous structure, provides a good basis for cell settlement and proliferation. the modular design allows easy upscaling and offers potential solutions to previous limitations scaffold developement in bone tissue engineering. references: the value of d reconstructions in determining post-operative reduction in acetabular fractures: a pilot study introduction: in patients with acetabular fractures, the reconstructed three-dimensional ( d) model of the contralateral acetabulum could be used as a mirrored template for the anatomic configuration of the affected joint. this has not been validated. material and methods: computer tomography (ct)-scans of twenty patients with unaffected acetabula were used. the symmetry of the generated d models was evaluated through; ( ) mirroring of the acetabulum; ( ) initial rough matching; ( ) automatic optimisation of the matching via surface-based matching; ( ) calculation of distances between surfaces by evaluating the euclidean (straight-line) error distance between the closest points between left and right. the percentages of surface-points of the left and right acetabulum with a distance smaller than . , . , . and . mm were calculated and evaluated, in relation to matta's criteria, for acetabular fracture reductions. the analysis was performed using the mirrored left acetabulum matched onto the right original structure (left mirrored to right original; ''lm ro'') and the right mirrored to left original (rm lo). to determine the inter-observer agreement the procedure was repeated by a second assessor for the first ten patients. results: patients had a mean ± sd age of . ± . years, % was male. the mean distance deviation was less than . mm in all comparisons. the calculated distances in . % of the surface points of the left and right acetabulum were below the tolerance threshold of . mm, based on matta's anatomical reduction critera (table ). absolute differences between assessors were\ . mm per patient with an overall moderate agreement of %. conclusions: d reconstructed models of healthy left and right acetabula are highly similar and could potentially be used as mirrored duplicates. the next step will be to investigate these results in patients with reduced acetabular fractures. : matta, j. ( ).j bone joint sur am. : - pr minimally invasive plate osteosynthesis technique for distal humeral fracture: a cadaveric study v. hofmann , c. deininger , t. freude , f. wichlas university hospital salzburg, orthopedics and traumatology, salzburg, austria introduction: in our study we want to evaluate the feasibility of minimally invasive plate osteosynthesis (mipo) technique for distal humeral fracture using anatomically precontoured double plate osteosynthesis. material and methods: eight elbows from four thiel fixed cadavers were included. on unfractued cadavers we tested the minimally invasive approach with two separate incisions, one at the lateral and one at the medial epicondylus. the preformed plates were inserted directly into the bone on sides and fixed with percutaneous screws. then we created an ao type a and c fracture. the reduction was performed under x-ray control and stabilized with k-wires. then we also inserted the plates in mipo technique. in the case of an intraarticular fracture, an olecranon osteotomy was additional performed in a minimal invasive way to control the distal humeral joint surface. after finishing reduction and fixation the approach were extended to control the fracture alignement, position of the plates and to expose the ulnar nerve. results: the plate position was satisfactory and we could not detect any major soft tissue damage or ulnar nerve injury by using the minimally invasive plate osteosynthesis technique. in the extraarticular fractures, reduction was achieved with k-wires and was acceptable in all cases. the intra-articular fractures were controlled by an additional olecranon osteotomy using the mipo technique with a good view on the joint surface of the distal humerus. conclusions: the findings of the present study show that mipo technique in distal humerus fracture is feasible and save especially for ao type a fractures. in ao type c fractures the olecranon osteotomy provided enough visibility to evaluate the distal humeral joint surface. the surgical technique is demanding, and care must be taken not to injure the ulnar nerve. never the less it is an effective surgical treatment method and an alternative option to open techniques. correlation between pelvic incidence and acetabular orientation in anteversion and inclination-an analysis based on a d statistical model of the pelvic ring introduction: the pelvic ring is a complex bony structure with a central role for the human''s mobility building the connecting part between the upper body and the lower extremities. pelvic incidence and acetabular orientation are two important parameters used in the description of pelvic anatomy and are of central importance for understanding the biomechanical interaction of spine, pelvis and hip joints. the objective of the study was the analysis of a potential correlation between pelvic incidence and acetabular orientation. material and methods: a d statistical model of the pelvic ring consisting of individual ct scans of european adults without bony pathologies was used to analyse pelvic incidence and acetabular orientation in anteversion and inclination. an additional analysis on the correlation between those parameters was performed using the software spss. results: a slight positive correlation between pelvic incidence and acetabular anteversion could be shown (r = . ; p = . ) as well as a strong positive correlation between anteversion and inclination (r = . ; p \ . ). pelvic incidence and acetabular inclination showed none statistically significant correlation (r = . ; p = . ). conclusions: the results of the study might contribute to a better understanding of the biomechanical interaction between the axial skeleton and the lower extremities and deliver valuable information concerning preoperative planning in orthopaedic and trauma surgery of the lumbar spine, the pelvis and the hip joints like for example reconstructive surgery after trauma, operative treatment of congenital or acquired deformities or total joint arthroplasty. references: boulay et al., ''pelvic incidence: a predictive factor for three-dimensional acetabular orientation-a preliminarystudy. '' anat res int. ; : . doi: . / . epub . introduction: the majority of distal clavicle fractures (dcfs) are displaced fractures and are prone to delayed-or non-union. there are several options for surgical reconstruction, open reduction and fixation or hook plate, but in patients with a comminuted or small fracture they are known to have a high complication and failure rate, and secondary surgery for removal is often necessary. we hypothesize that resection of the distal fracture fragment and subsequent stabilization with the lockdown device, is an alternative for selected patients with dcfs. methods: eleven patients with a comminuted dcf were treated with a lockdown device. data on pain and range of motion were documented and the constant shoulder score (css), oxford shoulder score (oss) and nottingham clavicle score (ncs) were assessed at one year follow-up. results: eight patients underwent surgery within weeks, compared to patients where the surgery was delayed ([ weeks) due to persisting pain and delayed-union. none of the patients had postoperative complications. in months after treatment, patients were complaint-free. one patient had hardware removal due to pain at the site of the screw head. four patients were assessed after one year follow-up. the mean pain score was . . the mean flexion , °, abduction , °, exorotation °and extension °. the css had a mean of . , oss . and the ncs a mean of . conclusions: all patients had a good short-term clinical outcome and hardware complications did not occur. we are the first to describe the use of the lockdown device in dcfs. this device is not dependent on fracture healing and secondary surgery is not necessary, therefore it can be an alternative in the treatment of dcfs. a larger series and longer follow-up is necessary to confirm this conclusion. in this ongoing study, the remainder seven patients will be included and presented at the estes. moore type i tibial head fractures are one of the most challenging fractures to treat. material and methods: we performed the following approaches on eight thiel fixed cadavers: the anterolateral (with an osteotomy of the tuberculum gerdyi, a subcapital fibula-osteotomy and an osteotomy of the tuberositas tibia), the medial approach (with submeniscal arthrotomy and a dissection of the medial collateral ligament) and the posterior approach with a submeniscal athrotomy. the reachable borders of the articular joint surface have been marked by a k-wire. the visual joint surface has also been radiographically documented by inserting k-wires into the tibia head. finally the results have been photo documented on the exarticulated joints. results: the reachable areas of the articular surface have been defined and documented. the combination of the subcapital fibulaosteotomy and the submeniscal arthrotomy showed the most increase in accessibility to the articular surface in the dorsal part. an additional osteotomy of the tuberculum gerdyi increased the vision on the entire lateral and anterior articular surface. the submeniscal arthrotomy, at the medial approach, has not a good view on the surface. the posterior approach showed only a limited view on the lateral and medial articular surface at the dorsal part. none of the surgical approaches sufficiently visualizes the intercondylar region. conclusions: a fracture-specific approach strategy is critical for the preoperative planning of complex tibia-head fractures. subcapital fibula osteotomy is the most efficient surgical approach to reach the posterior and lateral articular surface. for the anterior articular surface, the best overview was achieved by an osteotomy of the tuberculum gerdyi. it was not possible to see and control the intercondylar region with any approach. introduction: osteosarcoma (os) is the most common bone carcinoma in humans. at the time of the first diagnosis are already in about % metastases present. the current treatment strategies include above all radical surgical resection and chemotherapy. in the search for alternative therapy methods. treatment with cold atmospheric plasma (cap) shows promising prospects. at the cellular level, this leads to various cellular mechanisms and finally to induction of anticancerogenic effects such as growth inhibition, apoptosis, and changes in the cell-cell interactions. the impact of cap on the integrity of the cell membrane of os cells, however, is unknown. material and methods: suspended cells from two human osteosarcoma cell lines (u -os, mnng) were treated for s, s, and s with cap. cell proliferation was determined after h, , , , and h using casy cell counter. dye loss assay was performed by using fluorescein diacetate (fda). this was followed by indirect treatment with cap for s. in the cell-free supernatant was determined by tecan multireader the dye emission. flow cytometry assay was used after cap treatments and incubation with fda. the mean fda fluorescence intensity of individual cells in the flow cytometer was measured. results: cell kinetics showed significant inhibition of cell proliferation in both cell lines after cap treatment. the assays for determination of the dye level showed a significantly increased membrane permeability of both cell lines after cap treatment. the significant effect on the membrane integrity correlated with treatment duration. conclusions: this confirms a modulating influence of cap on the functionality of the cell membrane and may support the anti-proliferative effect of the cap treatment. thus, cap is a promising therapy option, especially for chemotherapy-resistant entities introduction: osteosarcoma (os) is the most common bone cancer in humans. standard therapy includes radical surgical resection and chemotherapy, but due to strong toxic effects, new treatment options are urgently needed. currently, there is a discussion about expanding the oncological therapy spectrum and treat with cold atmospheric plasma (cap). it is a reactive ionized gas rich in radicals, photons, and electromagnetic rays. its biological effects are primarily mediated by reactive oxygen and nitrogen species (rons). due to its low temperature, cap is suited for medical applications. in vitro studies have shown the antitumoral effect of cap also for pancreatic cancer, melanoma, ovarian, breast, and colon cancer. material and methods: human os cell lines u -os and mnng/ hos were used. proliferation assay. the growth of cap-treated cells was examined using a casy cell counter. caspase / assay. following cap treatment, the activities of caspase- and caspase- were measured using a specific substrate peptide coupled with a fluorescent dye (cellevent tm ). single-cell gel electrophoresis comet assay. dna damage after cap treatment was identified using alkaline microgel electrophoresis. dna migration was measured using comet score software. the percentage of tail dna was used to indicate the relative fluorescence intensity of the head and tail. tunel assay. after cap treatment tunel analysis was performed. results: the results revealed that the cap treatment of os cell lines leads to significant inhibition of cell growth. subsequently, the activation of caspases and the induction of apoptotic dna fragmentation was demonstrated. the treatment of os cells with cap leads to an induction of apoptosis and a reduction of cell growth. introduction: extra peritoneal packing (epp) is a quick and highly effective method to control pelvic hemorrhage. we hypothesized that this procedure may be as safely and efficiently performed in the emergency room (er) as in the operating room (or). methods: retrospective study of patients who underwent epp in the er or or in two trauma centers in israel between - . material and methods: retrospective study of patients who underwent epp in the er or or in two trauma centers in israel between - . results: patients were included in our study, in the er-epp group and in the or-epp group. the mean injury severity score (iss) was . ± . . following epp, hemodynamic stability was successfully achieved in of patients ( . %). a raise in the mean arterial pressure (map) with a median of mmhg (mean . ± . , p = . ) was documented. all patients who did not achieve hemodynamic stability after epp had multiple sources of bleeding or fatal head injury and eventually succumbed. the overall mortality rate was . % ( / ) with no difference between the or and er-epp groups. patients who underwent epp in the er showed higher change in map (p = . ). no differences were found between er and or epp in the amount of transfused blood products, surgical site infections and length of stay in the hospital. however, patients who underwent er epp were more prone to develop deep vein thrombosis (dvt): % ( / ) vs % ( / ) in er and or-epp groups respectively (p = . ). conclusions: epp is equally effective when performed in the er or or with similar surgical site infection rates but higher incidence of dvt. level of evidence: retrospective cohort study, level iv. introduction: application of supraacetabular schanz screws is usually performed under image intensifier guidance. the aim of this study was to perform it without imaging, with the hypothesis that, respecting anatomical landmarks, pre-and intraoperative fluoroscopy can be avoided. material and methods: insertion of the supra-acetabular schanz screws was performed in human adult cadavers. with cadavers placed in supine position, the anterior superior iliac spine (asis) was palpated. starting from this landmark, cm were measured in a distal and cm in the medial direction. at this point, a cm long oblique skin incision was performed. through this approach, mm schanz screws were drilled bilaterally into the supra-acetabular corridor with an angulation of °to distal as well as °to medial. combined obturator oblique-outlet views (cooo) were taken bilaterally to prove the screw position. six of the specimens underwent a d-ctscan. images were evaluated concerning correct screw positioning. skin and subcutaneous tissues were removed in the ilioinguinal region and possible lesions to the lateral femoral cutaneous nerve (lfcn) or to the joint capsule were evaluated. results: during radiographic evaluation of the cooo-scans ( specimens) and the d-scans ( specimens), the schanz screws were placed inside the supra-acetabular corridor in all specimens ( / ). during dissections, no intracapsular screw placements or lfcn lesions were found. conclusions: using our technique, all schanz screws could be sufficiently inserted without intraprocedural x-ray imaging. references: . karaharju, e. and p. slätis, external fixation of double vertical pelvic fractures with a trapezoid compression frame. inhury, . : p. - . . mears, d. and f. fu, external fixation in pelvic fractures. orthop clin north am, . : p. - . . mears, d. and f. fu, modern concepts of external skeletal fixation of the pelvis. clin orthop, . : p. - . pr epidemiology of self-inflicted major trauma r. stoner , n. misra , l. mason aintree university hospital, liverpool, united kingdom introduction: in the united kingdom, severely injured patients are taken directly to a major trauma centre (mtc). whilst deliberate self harm (dsh) is a known mechanism for this, there is limited prior research. - % of major trauma is thought to be self inflicted , . our aim was to describe the epidemiology of presentation to our mtc resulting from dsh. material and methods: retrospective review of patient records in our mtc for adult trauma team activations between / / and / / . data was collected on patient demographics, location type, injury severity score (iss), mechanism of injury and mortality. results: episodes of dsh made up . % of all trauma cases, involving patients; . % re-attended. z-scores show no change in incidence over time, but significant variability month by month, with / months [ sd from mean. mean patient age years (range - ). . % were male. . % came from residential location and . % from prison. most common mechanism was penetrating trauma ( . %). in-hospital mortality was % ( . % in males vs . % in females, chi p = . ). conclusions: this is the largest review of self inflicted trauma cases in a uk mtc, with a similar incidence to prior studies. there was no observed correlation with season or trend over time. mortality was higher in male patients, in keeping with national statistics on suicide, whilst dsh in females was linked to less severe injury; severity is related to mechanism of injury. injury from self stabbing/cutting was most common in patients from residential locations, whilst hanging was more common in prisoners. this study identifies preventable risk factors for major self inflicted injury. introduction: the distribution of trauma deaths was classically described following a trimodal pattern. during the last decade improvements in trauma care as damage control resuscitation (dcr) have minimized resuscitation injury. we hypothesized that the implementation of dcr in severely injured trauma patients is associated with less mortality and modifies mortality pattern. material and methods: we performed a -year ( - ) retrospective cohort analysis of all severely injured trauma patients (niss c ) who underwent surgery at our level trauma center. since , dcr was implemented including damage control surgery, minimizing crystalloids and increasing the use of blood products. our patients were stratified into two phases: pre-dcr ( - ( ) and post-dcr ( . results: a total of patients were identified. there were patients ( . %) in the pre-dcr group and patients ( . %) in the post-dcr group. mean age ( . vs . , non significant (ns)), mechanism of injury (blunt trauma: . % vs . %, ns) and shock on admission ( . % vs . %, ns) were similar between groups. there is a significant reduction in the rate of overall mortality ( . % vs . %, p \ . ). while early deaths from traumatic brain injury ( . % vs . %, ns) and hemorrhage ( . % vs . %, ns) are alike, mortality secondary to multisystem organ failure (msof) is lessened ( . vs . %, p \ . ). conclusions: dcr has helped in reducing overall mortality and mortality due to msof in our severely injured trauma patients. introduction: the mangled extremity severity score (mess) was constructed as an objective quantification criterion for limb trauma. a mess of or greater than was proposed as a cut-off point for primary limb amputation. opinions concerning the predictive value of the mess vary broadly in the literature. the aim of this study was to evaluate the applicability of the mess in a contemporary civilian central european cohort. material and methods: all patients treated for extremity injuries with arterial reconstruction at two centres between january and december were assessed. the mangled extremity severity score (mess) and the amputation rate were determined. results: seventy-one patients met the inclusion criteria and could be evaluated for trauma mechanism and injury patterns. the mean mess was ). seventy-three percent of all patients ( / ) had a mess b and % ( / ) of c . eight patients ( %) underwent secondary amputation. patients with a mess c showed a higher, but statistically not significant secondary amputation rate ( . %; / ) than those with a mess b ( . %; / ; p = . ). the area under the roc curve was . (ci . ; . ). conclusions: based on these results, the mess seems to be an inappropriate predictor for amputation in civilian settings in central europe possibly due to therapeutic advances in the treatment of orthopaedic, vascular, neurologic and soft tissue traumas. introduction: in polytrauma victims the acute respiratory distress syndrome (ards) is a major cause of morbidity and mortality. it presents a complex pathophysiology that is characterized by pulmonary activated coagulation and reduced fibrinolysis. due to the fact that the pulmonary endothelium is considered a key modulator of ards and that tpa in plasma is predominantly synthesized and secreted by vascular endothelial cells, we hypothesized that the time courses of serum tissue-type plasminogen activator (tpa) and its main inhibitor, the plasminogen activator inhibitor type- (pai- ), might indicate a clinical approach to preventing ards in polytrauma victims. material and methods: twenty-eight consecutive polytraumatized patients with concomitant thoracic trauma, age c years, iss c , who were directly admitted to our level i trauma center, were evaluated. blood samples were taken initially and on day , , , , , , and during hospitalization. luminex multi-analyte-technology was used for analysis of tpa and pai- antigen levels. results: both levels were particularly high at admission. although they significantly declined within three and seven days, respectively, they remained elevated throughout three weeks. throughout this observation period mean tpa antigen levels were higher in polytrauma victims suffering ards than in those without ards, whereas mean pai- levels were higher in polytrauma victims sustaining pneumonia than in those without pneumonia. noteworthy, in each patient, who developed ards, the tpa antigen level raised up to the onset of the syndrome and declined afterwards. conclusions: the development of ards has to be expected in a polytrauma victims if the tpa antigen level continues to rise after admission. potentially, in patients with a low risk of excessive bleeding the onset of the syndrome might be prevented by the timely administration of recombinant profibrinolytic proteins. motocross is a dangerous business: small bowell perforation case report case history: a year-old male, previously healthy, was admitted to the ed after being involved in a motorcross accident. he suffered blunt abdominal trauma. clinical findings: at admission, patient presented pale but haemodinamically stable. physical examination was unremarkable except for an evident abdominal wall hematoma and abdominal guarding over the left quadrants. investigation/results: abdominal ultrasound showed an intestinal loop with decreased peristalsis with a small amount of liquid adjacent (fig ) . due to the patient's haemodynamic stability, ct scan was performed (fig . ) which showed liquid in the left flank and iliac fossa, but without an identifiable intrabdominal lesion. diagnosis: the patient was admitted to the operating theatre with acute abdomen. therapy and progressions: intraoperatively fecal peritonitis was evident from a cm-hole on the antimesenteric border of the jejunum, the enterotomy was closed and profuse lavage was done; the abdominal wall closed without drainage. the patient went through an empirical antibiotic cycle. liquids per os were started on the first postoperative day and the patient progressed without issues. he was discharged at the th postoperative day. the remaining follow-up was uneventful. comments: small bowel perforation after blunt abdominal trauma is rare. sbmi has a high morbidity and mortality that increase with delayed diagnosis; however, clinical and radiographic signs of perforation are often absent, like in the case presented. ct is considered the gold-standard. in our specific situation, the small bowel perforation did not produce any pneumoperitoneum in a young patient with very good physiologic status that kept him hemodynamically stable. the prognosis of pelvic injury is closely related to the severity of vascular injury rather than the complexity of bony fracture y. wu , c. hsieh , c. fu chang gung memorial hospital, trauma and emergency surgery department, taoyuan city, taiwan introduction: pelvic injuries are among the most dangerous and deadly trauma. although complex pelvic fractures are often associated with vascular injuries, it is still unclear regarding the impact of the severity of vascular injury to the outcome of patients. we hypothesized that, in addition to the complexity of bony fracture, the severity of pelvic vascular injury plays a more decisive role to the patients'' outcome. material and methods:medical records of patients with pelvic fracture in a single trauma center between jan and dec were retrospectively reviewed. those who had an abbreviated injury scale (ais) c other than pelvis were excluded. based on ct results, the type of pelvic fracture was classified according to young-burgess classification, and the severity of vascular injury were recorded as minor (fracture with or without hematoma) or severe (hematoma with contrast pooling or extravasation). the patient demographics, clinical parameters, and outcome measures were compared between the groups. results: among the patients, severe vascular injury were noted in patients. patients with severe vascular injuries had significantly increased amount of red blood cell transfusion (rbct) ( . vs. . units, p = . ), longer icu stay (is) ( . vs. . days, p = . ) and total hospital stay (hs) ( . vs. . days, p = . ) compared to minor vascular injuries. on the other hand, those with complicated pelvic fracture (lc type ii/iii, apc type ii/iii, vs and combined type) had similar amount of rbct and is compared to that of simple pelvic fracture (lc type i, apc type i) except a longer hs ( . vs. . days, p = . ). conclusions: our results indicated that the severity of vascular injury is more closely correlated to the outcome of patients with pelvic fractures than the type of bony fracture does. in addition to the type of bony fracture, the grade of vascular injury should be considered as an important part of pelvic injury classification. associated abdominal injuries do not influence reduction quality in operatively treated pelvic fractures-a multicenter cohort study from the german pelvic registry results: . patients with pelvic injuries were treated during this period. . % had a concomitant abdominal trauma. the mean age was . ± . years. comparing the two groups, patients with a combination of pelvic and abdominal trauma were significantly younger ( . ± . vs. . ± . years; p \ . ). both, complication rates ( . % vs. . %; p \ . ) and mortality ( . % vs. . %;p \ . ) were significantly higher. in the subgroup of acetabular fractures, the time until definitive surgery of the pelvis was significantly longer in the group with the combined injury ( . ± . vs. . ± . days; p \ . ) . the grade of successful anatomic reduction did not differ between the two groups. conclusions: patients with a pelvic injury have a concomitant abdominal trauma in about % of the cases. the clinical course is significantly prolonged in patients with a combined injury, with increased rates of morbidity and mortality. however, the quality of the postoperative results is not influenced by a concomitant abdominal injury. a. martins rangel , r. pozzi , j. alfredo cavalcante padilha , s. sardinha , f. eduardo silva , d. teixeira rangel heat, trauma center, são gonçalo, brazil f.f.c., male, years old, was admitted to the trauma center about h after a stabbing wound in the neck. upon examination the patient was mechanically ventilated and hemodynamically stable, with an exposed sectioned trachea, which had a tracheostomy tube applied. the penetrating injury itself was mostly allocated in zone ii. he had a ct angiography and was referred to the or for surgical treatment. the cervicotomy found that both the external and internal right jugular veins had been injured alongside the sternocleidomastoid, sternohyoid and homohyoid muscles, the thyroid cartilage, just above the vocal cords, which had exposed the anterior larynx and the epiglottis the right anterior jugular vein and smaller tributaries of the right internal jugular vein, were ligated; a tracheostomy was performed and the thyroid cartilage and anterior laryngopharyngeal wall were reconstructed with the epiglottis implantation, sternoid, homohyoid and sternocleidomastoid muscle sutures, after which the platysma was closed but not the skin, left to secondary healing. patient was extubated within h, discharged from icu on the fifth postoperative day. thickened oral diet was introduced on the th day, and by the th day he was discharged without the tracheostomy tube, with a normal diet. comments: the cervical region is an area susceptible to serious injury due to the presence of vital structures, with massive hemorrhage, airway obstruction, cervical spine injuries and cerebral ischemia as the leading causes of death. initial management of penetrating injuries follows the principles of trauma care with airway control initially. references: bhatt nr-penetrating neck injury from a screwdriver: can the no zone approach be applied to zone i injuries? bmj yan wang-penetrating neck trauma caused by a rebar-a case report. medicine ( ) introduction: annually, approximately , people decease as a result of a fall in the netherlands, according to the statistics netherlands. the aim of this study is to evaluate the demographic parameters, fall characteristics and resulting injury patterns of this group in the region of amsterdam. methods: all patients deceased as a result of injury due to a fall in the period july st until july st in the region of amsterdam were included. data were collected from the database (formatus) of the department of forensic medicine (public health service amsterdam). results: during the study period , patients deceased after a fall. the mean age was years ( - years) and % was male. a psychiatric disease was diagnosed or suspected in % of the population of which cognitive impairment, including dementia, was encountered in most of the cases ( %). the majority of the falls happened at home ( %) or at nursing facilities. a minority ( . %) was work related. over % of the falls was from standing position, . % was not from standing position of which . % regarded falls from stairs, the majority was male. multitrauma patients accounted for . % of the population. from the remaining , patients, . % sustained one or more injuries to the pelvis or extremities. central nervous system (cns) injuries were described in . % of the patients. mortality was in . % of the cases due to primary cns injury, . % was due to complications of which clinical deterioration ( . %) and infection ( . %) were the most common. conclusions: in the region of amsterdam the majority of deaths due to a fall regards the geriatric population. fall from standing position and mortality due to complications, mainly clinical deterioration, accounted for the majority of deaths. intervention to prevent falls and thereby complications need more awareness to reduce mortality. results from a multidisciplinary blunt splenic injury protocol introduction: the majority of splenic injuries are currently managed non-operatively. failure of non-operative management includes grade iv or v splenic injury or vascular abnormalities that are suitable for embolization. the primary indication for operative management of blunt splenic injury is hemodynamic instability. in our center, the last twenty splenic injuries, admitted during two years, were not managed according to published guidelines. ten patients ( %) underwent splenectomy, being unstable only of them ( % of the whole sample). material and methods: staff from anesthesiology, interventional radiology and trauma surgery came up with a joint protocol. grade iii splenic injury non-operatively management, including fluid responsiveness (achieving shock index (ht/bp) below . after a bolus of colloids) and, focus placed only on hemodynamic stability instead of on vascular abnormalities are our principal modifications regarding already published protocols. results: seventeen patients with blunt spleen trauma were admitted after starting up our protocol. six ( grade iii, grade ii and grade i) splenic injuries were successfully managed non-operatively. prophylatic embolization was performed in five patients: were grade iv spleen trauma and were grade iii spleen trauma with vascular abnormalities. one grade iii splenic trauma was embolized due to a pseudoaneurysm detected in ct scan performed h post injury. five grade v spleen trauma required urgent surgery. of them presented with shock index [ . . conclusions: our multidisciplinary protocol has helped in improving outcomes in blunt splenic injuries. we have achieved an almost full compliance to our protocol. case history: -year old male experienced severe blunt trauma after a bus accident. clinical findings: he is found alert (gcs = ), hemodynamically stable and with a patent airway. he presented catastrophic lower left limb where tourniquet was applied. gram of tranexamic acid (txa) and ml of crystalloids were administered. he was intubated in the site of injury and transfered to our center, being always hemodynamically stable. on hospital admission he was normotensive (bp = / mmhg, sinus rithm ppm), shock index \ . . he suffered uneventfully amputation of the limb with no need for blood products transfusion. his past medical history was only pertinent for hypertension. investigation/results: following urgent damage control surgery, ct scan was performed where acute bilateral pulmonary embolism was diagnosed. diagnosis: asymptomatic acute bilateral pulmonary embolism therapy and progressions: during icu stay, the patient kept hemodynamically stable. endotracheal tube is removed one day later and he is successfully transfered to the ward three days later. comments: hypercoagulability can occur after severe tissue injury, that is likely related to tissue factor exposure and impaired endothelial release of tissue plasminogen activator (tpa). in contrast, when shock and hypoperfusion occur, activation of the protein c pathway and endothelial tpa release induce a shift from a procoagulant to a hypocoagulable and hyperfibrinolytic state with a high risk of bleeding. it can be inferred that a patient presenting with severe tissue injury without shock is at high risk of perioperative thrombosis and txa might not be administered. ( ) . it signifies high energy force, representative of severe overall trauma. study reported mortality of blunt pelvic trauma to reach . - % ( ) . injury severity score (iss), hypotension, head injury, posterior fracture & haemorrhage have been implicated ( ) . however, there is a paucity of data in developing countries. this study identifies the problem burden, management outcomes and factors predicting mortality. material and methods: patients had pelvic trauma, retrospectively from jan to dec and prospectively from may to april . patients was included after excluding less than years and coagulation disorder results: majority were males ( . %),with a mean age of . . mechanism was rti ( . %) followed by fall from height ( %), railway accidents ( . %). mean iss & rts was . and . respectively. associated injury were long bone fractures ( . %), chest injuries ( . %).head injury ( . %). lateral compression ( . %), was the most common followed by anteroposterior compression ( %) & combined ( . %).majority underwent operative intervention ( . %) for pelvis or associated injury. the mortality rate was . % secondary to haemorrhagic shock ( . %) and sepsis ( . %). the factors were male gender, age, iss, rts, head injury, unstable pelvis. however, no association with haemoglobin, long bone fracture, and massive transfusion protocol was found conclusions: our study showed a mortality of . % which is comparing with previous study introduction: the number of patients admitted to oslo university hospital (ouh) due to bicycle trauma is increasing. we aimed to identify possible predictors of serious and fatal bicycle injury. material and methods: the ouh trauma registry was searched for patients treated for bicycle trauma between and . data extraction included putative predictors of serious and fatal injuries, defined as iss c and death within days, respectively. univariate analyses were performed and reported as odds ratios (or). p \ . was regarded as statistically significant. results: bicyclists were admitted, % were males, median age was years (range - ). injury mechanisms were single bicycle crash in %, collision with a motorized vehicle in %, bicycle vs. bicycle in % and others in %. serious injuries were seen in % and . % died. predictors for serious and fatal bicycle trauma are presented in figure . conclusions: we identified age c , high comorbidity and loss of consciousness (gcs b ) as predictors for both serious and fatal injury after bicycle trauma. single bicycle crash was the most common cause of serious bicycle injury in our trauma center. diagnosis, investigation and results: all case reports represent polytrauma patients with clinical worsening and admission to the icu, with subsequent development of acute respiratory distress syndrome (ards) refractory to primary measures. therapy and progressions: different mechanisms led to the development of ards in the different cases. on a primary approach, standard measures such as curarization, recruitment maneuvers, prone positioning and peep increase were applied whenever possible. an absence of improvement led to an almost inevitable need of extracorporeal membrane oxygenation (ecmo) rescue therapy. all patients responded positively to this treatment without major complications and were eventually discharged from the icu. comments: ards is a major cause of respiratory failure in polytrauma patients. among the many therapeutic options, ecmo emerges as a powerful tool as rescue therapy in respiratory failure refractory to all other measures, being the present case reports corroborative examples of its efficiency. introduction: nowadays when cities are improving fast and significantly, including transportation system, even more we encounter with high energy trauma . still the most vulnerable on the roads are pedestrians. material and methods: the analysis of the data collected prospectively from january to october was performed including the mechanism and diagnosis of polytrauma, patient demographics and the main outcomes. results: in total, patients were assessed according to the polytrauma protocol. the median age of the cohort was years (iqr - ), male patients, . % vs. . % females, p = . . the most frequent mechanism was a pedestrian struck by a vehicle in . % cases, and falling from a height of over m in . %. of those patients who had musculoskeletal injuries, in . % the trauma mechanism was a fall from a height and in . % pedestrians were struck by a vehicle, . % of patients who fell from a height and . % of those struck by a vehicle suffered visceral injuries. the most common cause of neurotrauma was a fall from a height in . %, and pedestrians involved in car accidents in . %. from the whole cohort, patients were not saved, resulting in a . % mortality rate. most patients ( ) who died had iss [ . the mortality reached . % among pedestrians struck by a vehicle and . % among patients who fell from a height of over m. conclusions: the most common mechanism in the cohort was a pedestrian struck by a vehicle, followed by falling from a height, with a predominant involvement of male patients. similarly, the most frequent cause of musculoskeletal injuries and visceral injuries was falling from a height and pedestrians struck by a vehicle, demonstrating an important direction for polytrauma prevention. introduction: recent reviews of uk trauma data show altering demographics. patients are increasingly older and sustain lower energy injuries, with falls \ m being the most common ( ) . material and methods: data collected over years in a major trauma centre was used to calculate injury specific admission rates, case fatality rates and injury specific mortality attribution. data on patient age, footwear, lighting, alcohol intoxication and previous admissions were collected in falls \ m resulting in mortality. results: patients sustaining falls \ m represented % of admissions and % of mortalities. all falls represented % of admissions and % of mortalities. case fatality of falls of \ m and [ m was . % and . %. all fall case fatality was . %. this was significantly higher than the case fatality of stabbings ( . %) and rtas ( . %). in falls \ m causing fatality, mean patient age was . years. % of patients aged - were under the influence of alcohol when falling, with % aged - , but only % patients aged - . % aged - who died when falling were wearing slippers. this increased to % in those aged - , and % aged - . % of falls occurred under daylight/full light. % of patients aged - who died after falling had been admitted to hospital within the last year, although this increased to % in those aged - , and % aged - . conclusions: falls were the most common cause for hospital admission, had the highest case fatality of injury mechanisms and caused the most patient mortality. alcohol intoxication was associated with falls in younger patients who died after falling, but this was less common in older patients. wearing slippers was less common in the young but significantly associated with fatal falls in older patients. these results offer a range of therapeutic targets when developing fall prevention strategies. introduction: the treatment of splenic lesions is determined by the hemodynamic situation, the degree of injury and the presence of bleeding. arterial embolization has expanded the indications of the conservative treatment. retrospective observational study on splenic traumatism and its therapeutic options. material and methods: a total of patients with splenic injury have been treated at our centre between and . patients were hemodynamically stable: were embolized and received a conservative treatment. patients were hemodynamically unstable: had a good response to the resuscitation treatment so they were embolized, but there was one patient who deceased because of other causes. from these patients, patients received splenectomy. results: the main objective of this study is to review the management of the trauma patient with splenic injury. of the total of patients with splenic trauma, average iss of , underwent splenic embolization, underwent urgent splenectomy and were treated with conservative treatment. the embolized, were hemodynamic unstable at arrival but responded to the fluid therapy, had a splenic lesion grade iv, a grade iii, grade ii and another a grade i. the success rate of embolization was % in the embolized patients. patient died, only one of them in the embolization group and was not related to the splenic trauma nor embolization, were in the urgent splenectomy group due to severity of trauma, died before receiving any treatment and in the conservative treatment group due to other complications. conclusions: patients who respond to volume or are hemodinamically with high-grade lesions, arterial embolization would be less aggressive treatment options with excellent results. haukeland university hospital, surgical unit/ regional traumacenter, bergen, norway, norwegian university of science and technology, trondheim, norway, haukeland university hospital, physical and rehabilitation medicine, bergen, norway, university of bergen, bergen, norway, st olavs hospital, physical and rehabilitation medicine, trondheim, norway introduction: during the past decades acute trauma care has improved through the development of highly specialized trauma centres and teams. since patients are considerable young when being affected, trauma may lead to life-long physical, cognitive and emotional constraints interfering with an independent self-determined life ( , ) . in , a revised national plan for the treatment of trauma patients in norway was published ( ) . the plan emphasizes the importance of rehabilitation and the need for early interdisciplinary rehabilitation. this study will examine in which extent patients receive rehabilitation in early phase after trauma as recommended in the norwegian national plan. in addition we will examine what follow-up patients receive after trauma, quality of life, functional level and use of health care and next-of kin resources. material and methods: patients admitted to regional trauma center in mid-or western norway in with niss c are recruited to participate. data will be collected from national trauma register, the norwegian patient register, the municipal patient and user register, data from statistics norway, the electronic patient record (epj) and the patient/relatives questionnaire. discussion: the results will be useful in the preparation of patient courses that comply with strong recommendations in the national trauma plan, ensuring equal treatment and raising awarness about rehabilitation for trauma patients. introduction: diaphragmatic lesions involve wounds and rupture of the diaphragm, through penetrating wounds or thoraco-abdominal trauma. their incidence is - %. the diagnosis may be late, despite the technical advances made by medical imaging. the choice of surgical approach and technique is still controversial. mortality is usually related to the associated injuries. the present paper analyzes the incidence of diaphragmatic lesions that occur in thoraco-abdominal trauma, their epidemiology, diagnosis and treatment. material and methods: we performed a retrospective study over a -year period ( - ) , in the surgical units of the emergency county hospital of braila, including all patients diagnosed with diaphragmatic lesions. results: during the study period, patients had thoracic-abdominal trauma. there were cases of blunt trauma and thoracic-abdominal trauma. our study involved cases of diaphragmatic injuries ( . %), by road accident and by white weapon. the sex ratio was : . the average age was years. chest radiography was a contributory preoperative diagnosis in cases. the diaphragmatic wound was on the left side in cases, and its average size was cm. the surgical procedure involved the reduction in the abdomen of the herniated viscera and the monoplane suture of the diaphragm by nonabsorbable ''x'' points in all cases. chest aspiration was the rule. there was only one death in a complex polytrauma case. case history: we report the one case which performed tae, angioplasty, thoracotomy, laparotomy and preperitoneal pelvic packing (ppp) in the hybrid emergency room (h-er). the patient was male in the s, who was riding on his motorcycle and fell from a m height. clinical findings: he was in shock state. diagnosis: we scanned cect and diagnosed subdural hematoma, traumatic subarachnoid hematoma, lt hemopneumothorax, lung contusion, multiple costal bone fracture, intercostal artery injury, splenic injury (gradeiii), pelvic bone fracture. therapy: we inserted the drainage tube to the hemopneumothorax and did the tae for the pelvic bone fracture and splenic injury. after tae, he was in still shock state. the bleeding volume from the lt drainage tube increased, so trauma surgeons did the emergency thoracotomy and thoracic endovascular aortic repair (tevar) for intercostal artery injury. we suspected he also had abdominal compartment syndrome due to recanalization of tae, and they performed the emergency laparotomy and did ppp for the pelvic bone fracture. comments: we install an ivr-ct system in our trauma resuscitation room in october . we named it h-er, as it enables us to do all examinations (sonography, ct and fluoroscopy) and treatments (ir, operation) required for trauma in a single room. we have to perform prompt diagnosis and treatment, especially in cases of severe polytrauma cases. a retrospective study proved that the h-er had shortened the time of ct initiation and emergency procedure and that lead to improve mortality ). h-er is a novel trauma resuscitation room to do all treatments required in the only one room for severe traumatic patients introduction: according to the previous advanced trauma life support (atls) guidance, the early assessment of trauma patients with haemorrhage were classified upon the vital signs. recently, national trauma registry analyses suggested to extend the assessment criteria with the base deficit (bd), referring to the metabolic status. our objective was to investigate the relevance of bd and to explore new prognostic factors in the early assessment of the severely injured. material and methods: our study included patients registered between . . and . . on our emergency ward for whom the trauma team was activated. they were grouped into severity groups (i-iv) according to either the vital signs (classical) or the extended criteria with bd. the data were extracted from medical documentations of the early phase of treatment. as primary outcome, we compared the -h mortality rate of the patient groups. we studied the need for massive transfusion and intensive care unit care as secondary outcomes. results: according to the classical assessment, % of the patients were assigned to group i (lowest risk for haemorrhagic shock) and % to group ii. the remaining % were grouped into groups iii and iv (higher risk). with taking bd into consideration, % were reassigned to a higher risk group; however, this change affected only groups i and ii. the -h mortality changed only in group i ( . % vs . %; p = . ). bd did not affect the need for massive transfusion. in groups i and ii, . % of the patients, in groups iii-iv % needed intensive care unit treatment. conclusions: bd is an effective prognostic factor in the early assessment of trauma patients. however, compared to the vital signbased evaluation, it provides extra informaton only in less severe cases. according to our findings, it may help to assess the need for the administration of blood products. grants: nkfi k ; ginop- . . - - - ; efop- . . - - - . complejo hospitalario de jaén, servicio de cirugía general y del aparato digestivo, jaén, spain, complejo hospitalario de jaén, servicio de anestesiología y reanimación, jaén, spain case history: years old male, with history of hypertension and dyslipidemia, suffered a backhoe accident and was admitted in a regional hospital. on initial assesment he presented contusion and two laceration wounds in left chest and in lumbar region. body ct informed subcutaneous emphysema and left rib fractures from th to th, left hemidiaphragm edema, laminar left pneumothorax and contusive lung. posterior lumbar hematoma and no intra-abdominal free fluid. laceration wounds were partially sutured, with drainages through the wounds clinical findings: he was transferred to our emergency department, presenting dyspnea, tachycardia, sweating, painful luq and left hemithorax worsening with breathing investigation/results: reviewed by our radiologist, tc images showed herniation of abdominal organs into the chest diagnosis: traumatic hernia in left costophrenic recess. multiple rib fractures therapy and progressions: the hernia contents (left colonic flexure and omentum) were reduced and defect closed with primary repair in emergency surgery. rib fractures treated by osteosynthesis.on th pod left renal artery dissection and renal infarction were evidence in a new ct. comments: diaphragmatic injuries are caused by blunt or penetrating thoraco-abdominal trauma. potentially life-threatening due to the herniation of abdominal organs and severe associated lesions. clinical suspicion is important as prompt diagnosis and treatment are necessary for good outcomes. in our case, the initial clinical assessment was incorrect and the transfer put the patient in danger as an emergency surgery should have been performed before transfer. this enhances the importance of a correct initial management of polytrauma patients. introduction: the fractures of the calcaneus account for about - % of all fractures of the human skeleton. the majority of these fractures ( %) are intra-articular and surgical intervention is a widely accepted way of treatment material and methods: the aim of this study was to evaluate the results of open reduction and internal fixation for di-afc.in a period of years ( - ) patients ( patients with bilateral fractures) with age range from to years old, were treated surgically using the lateral extensile approach. follow-up was - years. the results were evaluated based on x-ray parameters (calcaneal morphology, bohler''s and gissane''s angles), active range of motion, footwear problems and time needed to return to work. the sf- health survey was used for outcome assessment. results: fracture mean healing time was , weeks. the outcome was excellent in cases, good in cases and poor in cases. the complications were malposition of fixation in patients, superficial wound slough in patients, reflex sympathetic dystrophy in patients, deep infection in patients who were treated with antibiotics and metalwork removal following union of the fracture. one patient resulted in metal breakage with consequent pseudarthrosis. finally one patient developed chronic osteomyelitis and is under treatment. the treatment with open reduction and internal fixation for di-afc is indicated, provided that the restoration of calcaneal shape, alignment and height is achieved. long term functional results with mild pain, few alterations in activities of daily living or work, and essentially no footwear problems, can be expected from a properly performed open reduction and internal fixation. extraperitoneal rectal injury in emodinamically unstable patient treated after dcs with external traction applied in an endorectal balloon r. somigli hospital, general and emergency surgery, pistoia, italy case history: a -year-old man was crushed between two vehicles while he was working. he arrived in er hemodynamically unstable, so he underwent to emergency surgery. clinical findings: at rectal examination there was evidence of almost complete antero-lateral anorectal laceration. at abdominal examination there was evidence of anorectal full-thickness laceration and urethra full laceration. investigation/results: no diagnostic was required in preop because of patient instabilty. diagnosis: pelvic fracture with hemodynamic instability, severe rectal injury and complete prostatic urethra transection. therapy and progressions: el, lateral colostomy, pelvic paking, cistostomy and hip external binder. damage control surgery was performed. on pod second look was carried out and an almost complete extraperitoneal rectal injury was found during pelvic depaking. properitoneum was drained and a baloon probe was introduced in the rectum to allow the proximal rectal flap to advance to the distal rectum. stomal washes were performed with no rectal leak and rectal baloon traction mantained for days. radiological and endoscopic check haven't shown any leak and a good mucosal reconstruction. mri no sphincteral anatonical defects. waiting for emg before stoma reversal. comments: the optimal managment for extraperitoneal rectal injuries remains controversial. an approach with lateral colostomy and conservative treatment of rectal lacerations with rectal trac-tion baloon, could represent a safe treatment alternative in those cases with sphincter preservation, with a lower risk of complication. exploring differences between iss and niss scores for -day mortality in adult and elderly trauma patients in a norwegian national trauma cohort m. introduction: injury severity score (iss) and new injury severity score (niss) with a threshold over is commonly used to define severe injury and to define the study population in trauma registrybased studies for both adult and elderly trauma patients ( ) . for elderly patients (c years) this might be unreasonably high and might lead to exclusion of significantly injured elderly with increased risk of mortality. the aim of this study was to assess whether there were significant differences in -days mortality between adults and elderly trauma patients for different frequently used iss and niss thresholds material and methods: the norwegian trauma registry was interrogated to identify all adult (c years) trauma patients included in the registry from january through december . data were dichotomized to age groups ''adult'' and ''elderly'' ( - and c respectively) with -days mortality as primary endpoint. mortality rates were assessed for iss and niss thresholds of [ , [ and [ . we applied descriptive statistics and chi-squared test for comparisons. results: patients with available information about age, -days mortality and iss and niss scores were included in the analysis, of which patients were - years old and patients were c years. adult and elderly patients died, giving overall mortality rates of . % and . % respectively. for iss and niss [ there was a significantly higher -days mortality in elderly trauma patients ( . % and . % respectively) than adult patients ( . and . % respectively) (p \ , ), as for all other iss and niss thresholds tested. conclusions: this study demonstrates that elderly trauma patients has a significantly higher mortality risk than adult trauma patients at all iss or niss-thresholds analysed. this group has a significant mortality even at iss and niss above . introduction: the trauma tertiary survey (tts) is a widely accepted tool in the prevention of missed injury. existing literature on its effectiveness focusses on multitrauma patients. this study investigates the yield of the tertiary survey in trauma who are admitted for tts, without having any significant injury. material and methods: a single center retrospective cohort study was performed in a level ii trauma center. trauma patients without any clinically significant injury at the primary and secondary survey were included. the primary outcome was missed injury found during tts (type ). secondary outcomes were missed injury found after tts but during admission (type ), mortality and hospital length of stay [ days. results: from included patients, patients ( . %) had a type missed injury. alcohol consumption was associated with an increased risk for type missed injuries (odds ratio = . , % ci: . - . ) . a type missed injury was only found once, it concerned the only case of trauma related mortility. out of nonoperated patients, ( . %) were admitted for more than two days. these patients were significantly older ( vs. years, p \ . ) and had a higher asa classification, - vs. - ( . % vs. . %, p \ . ). conclusions: tts showed missed injuries in only . % of trauma patients who had no clinical significant injury found during primary and secondary survey. high costs of admission, together with a low yield found for this study's population the cost benefit of hospitalizing these patients is for discussion. future research should therefore focus on the identification of predictors of a positive tertiary survey. references: . advanced trauma life supportÒ student course manual. . keijzers, et al., the effect of tertiary surveys on missed injuries in trauma: a systematic review. . enderson et al., the tertiary trauma survey: a prospective study of missed injury. the -h rule in the emergency department and its association with surgical mortality in one public hospital in israel: retrospective study i. ashkenazi hillel yaffe medical center, hadera, israel introduction: in order to improve patient treatment the -h rule in the emergency department (ed) was introduced in many countries as well as in israel. within four h, patients attending the ed must be seen, treated, and a decision must be reached whether these patients are to be admitted or discharged. though a popular performancebased measure, whether the -h rule in ed is associated with a decrease in mortality is controversial. the primary objective of this study was to evaluate the association between time in the ed and surgical mortality in one public hospital in israel. material and methods: included in this retrospective study were patients admitted to the ed of hymc during . patients dying on the first day were excluded. . results: included in this study were , patients. of these, , ( . %) patients were hospitalized and the rest were discharged. overall, patients died. general surgery accounted for , patients of which died ( . % of hospital deaths; . % of all surgical patients; . % of patients hospitalized in general surgery). internal medicine together with general surgery and orthopedic surgery accounted for . %, . % and . % of the mortalities observed in patients with decisions made within - h, in patients with decisions made beyond h and in all the patients respectively. forty-five patients with decisions made within h died compared to with decisions made beyond h. these represent . % and . % of all surgical patients in the ed (whether hospitalized or discharged) and . % and . % of those hospitalized. conclusions: general surgery is the second largest contributor to hospital morality. in both absolute terms and relative terms, mortality was not increased by delays in decisions made beyond h. the adoption of this performance-based measure should be questioned. introduction: trauma is an important cause of mortality [ , ] . researchers are looking for optimal death/survival predictive models in trauma population. one way is to validate traumatic scores for different medical systems [ ] . the aim of our study was to validate the new injury severy score (niss) in severe trauma ( introduction: the international classification of diseases-based injury severity score (iciss) has been proposed as a reliable tool to measure trauma system performance especially in countries where a trauma registry has not been yet established. the purpose of this study is to assess the predictive capability for in-hospital mortality of iciss with international and adjusted survival risk ratios (srrs) in greek trauma population. material and methods: this single center, retrospective cohort study was conducted in a greek tertiary care hospital between january to december . the trauma population was defined as hospitalized patients with a principal hospital discharge diagnosis in the range icd- s -t . duplicated injury icd codes, readmissions, transfer to another hospital and missing data were excluded. the primary outcome was in-hospital mortality. adjusted srrs was calculated from patients with multiple injuries and the following two iciss scores were evaluated: multiplicative-injury (iciss) and singleworst-injury (swi). the models were assessed in terms of their discrimination, measured by receiver operating curve (roc) analysis and calibration measured using calibration curves. results: a total of patients were included in the study. median age was ± years and mortality rate was , %. based on international srrs, the area under the curve was , ( % ci . - . ) for iciss-multiplicative and , ( % ci . - . ) for iciss-worst injury. both modes had statistically significant better performance with adjusted greek srrs (aur = , % ci . - . and aur = , % ci . - . , respectively). conclusions: this analysis has demonstrated the validity iciss model for in-hospital mortality prediction in greek trauma population. further research is warranted to confirm the performance of iciss using a sufficiently sized sample to define national srrs. introduction: the occurrence of intra-abdominal abscesses is the most serious post-operative infective complication after appendectomy. a significant amount of research has been conducted in an attempt to identify those patients at greatest risk. pct is initially described as an early, sensitive and specific marker for sepsis associated with bacterial infection. we hypothesize that pct could serve as a predictor of the development of intraabdominal abscess and postoperative infective complication material and methods: the present study is a prospective, single centre, observational cohort study involving patients undergoing emergency appendectomy. all patients admitted to the acute care surgery ward for appendicitis were screened for study eligibility. pct poc samples will be obtained preoperatively (t ) and post procedure (t ) at h (t ), h (t ), and days (t ) post procedure. the primary objective of this study was to assess the diagnostic accuracy of point-of-care testing for pct in identifying post appendectomy abscess. the secondary objective was to determine the diagnostic accuracy in identifying any infective complication conclusions: we expect the incidence of abscess and infective complication to be increased in the pct elevated group compared with the control group. previous investigations indicate the overall morbidity related to infective complication is approximately - % of patient undergoing laparoscopic appendectomy. our pilot study revealed that the incidence could be as high as % in patients with prolonged elevated pct levels. introduction: hand trauma is a common cause for attendance to the accident and emergency (a&e), accounting for nearly - % of all patients . it is essential that accurate treatment and management is done as the implications of mismanagement are long term, which may lead to disability, loss of work and income, livelihood, and even psychological issues . the presence of a specialised hand surgeon is essential for management of these injuries , but in the a&e setting it is not always possible to have such specialised care and there is a need for an efficient triage system. materials and methods: we did an audit in our department and found a delay in the referral of patients from a&e to our trauma clinic, which was quite expected due to a high patient inflow. we devised a trauma pathway for the a&e, known as the d-system which outlines for them till what day from trauma is a particular hand patient safe to be sent to the hand clinic or who needs an urgent referral to a higher trauma centre, based on urgency of need of intervention. the pathway is in the form of a simple flowchart, which is easy to understand even for junior members of the team. we intend to do another audit after implementation of the pathway to assess change in practice. conclusion: it is essential to have simplified pathways for non-specialist areas in order to streamline treatment and offer the best care, in the limited availability of resources, especially at smaller hospitals. our aim is to develop one such system and assess it's effective in delivering better care. introduction: a quantitative method for measuring trauma severity has many potential applications. the intent of this study was to evaluate the accuracy of the mgap score and its components in prediction of in-hospital mortality versus the accuracy of the revised trauma score rts at a trauma center. material and methods: this study included patients with trauma. data regarding age, mechanism of injury, systolic blood pressure, glasgow coma score and respiratory rate were collected at trauma center of alberto torres hospital. mgap and rts scores were calculated, and their accuracy to predict survival/death outcome. results the study included patients, ranging in age from to years, % male. from the total sample, patients who suffered from penetrating trauma and patients who suffered from blunt trauma were observed. in the comparison of the scores, rts and mgap, there was no significant superiority in any of them for predicting the outcome -which in our study was hospital discharge or death -even when compared by trauma mechanism. the gcs proved to be a very sensitive criterion in both scores, especially in patients with traumatic brain injury, totaling patients in our statistical analysis, of which , % had a negative outcome. rts was slightly superior than mgap in patients classified by the score as high chance of mortality, with % versus % of assertiveness. conclusions: up to the moment, there is no evidence to support the superiority of one of the analyzed scores as a predictor of mortality in the patients evaluated. although the rts score is more widely used in trauma centers, the application of the mgap score is more feasible in pre or in-hospital care of polytrauma patients, since it does not use respiratory rate in its parameters. validation of d-dimer for screening for venous thromboembolism in pelvic and lower extremity trauma patients t. uehara , , t. noda , t. yumoto , n. kobayashi , a. nakao , t. ozaki okayama university, emergency healthcare and disaster medicine, okayama, japan, okayama university, orthopaedic surgery, okayama, japan, okayama university, musculoskeletal traumatology, okayama, japan, okayama university, emergency and critical care medicine, okayama, japan, okayama saidaiji hospital, okayama, japan introduction: venous thromboembolism (vte) is a life-threatening complication after major trauma patients. we previously reported that the patients with higher injury severity score (iss) and lower extremity trauma had high risk for vte. additionally, high d-dimer levels (cut-off d-dimer value, . lg/ml) on day were useful for screening for vte in major trauma patients. we validated d-dimer levels for vte screening for patients with pelvic and lower extremity trauma. material and methods: a retrospective study was undertaken between april and august at the okayama university hospital. patients with pelvic or lower extremity trauma were included (median iss, ). we collected following data; age, sex, iss, the number of operation times, value of d-dimer in screening, incidence of vte and use of anticoagulants. results: eleven patients showed high d-dimer levels in screening, furthermore, six patients were diagnosed vte using contrast-enhanced computed tomography. symptomatic pulmonary embolism was not occurred. patients with vte had undergone orthopaedic surgeries two or more times. fourteen patients received therapeutically or prophylactic anticoagulation therapies. conclusions: measurements of d-dimer levels after pelvic or lower extremity trauma patients were useful for screening of incidence of vte. direct oral anticoagulants were convenient for treatment to vte. trauma patients often needed several times of surgeries, heparin was also useful in perioperative period. introduction: early assessment of the clinical status of severely injured patients is crucial for guiding surgical treatment. several scales are available to differentiate between risk categories. we compared four established scoring systems in regard to their predictive abilities for early versus late in-hospital complications. methods: database from a level i trauma center. the following four scales were tested: the clinical grading scale (cgs; covers acidosis, shock, coagulation, and soft tissue injuries), the modified clinical grading scale (mcgs), the polytrauma grading score (ptgs), and the early appropriate care protocol (eac; covers acid-base changes). admission values were selected from each scale and the following endpoints were compared: mortality, pneumonia, sepsis, death from hemorrhagic shock, and multiple organ failure. results: in total, severely injured patients were included (mean age, . ± years; mean iss, . ± . points; incidence of pneumonia, . %; incidence of sepsis, . %; death from hem. shock, . %; death from multiple organ failure (mof), . %; mortality rate, . %). istinct differences in the prediction of complications, including mortality, for these scores (or ranging from . to . ). the ptgs demonstrated the highest predictive value for any late complication (or = . ), sepsis (or = . , p = . ), or pneumonia (or = . , p = . ). the eac demonstrated good prediction for hemorrhage-induced early mortality (or = . , p \ . ), but did not predict late complications (sepsis, or = . and p = . ; pneumonia, or = . and p = . ) cgs and mcgs are not comparable and should not be used interchangeably (krippendorff a = . ). conclusion: our data show that prediction of complications is more precise after using values that covers different physiological systems (coagulation, hemorrhage, acid-base changes, and soft tissue damage) when compared with using values of only one physiological system (e.g., acidosis). none of the authors have any conflicts of interest to declare. mortality rate related to trauma mechanisms in trauma center at alberto torres hospital from january to july r. p. pereira , r. adriana martins , j. a. c. padilha , f. e. silva , , d. rangel alberto torres hospital, trauma center, são gonçalo, brazil, federal university of rio de janeiro, niterói, brazil introduction: to demonstrate the healthcare services of the trauma center of rio de janeiro based on epidemiological data and on the specificity of the type of initial care delivered to multiple trauma patients, comparing the mortality rate at the second peak of death with the worldwide literature. materials/methods: retrospective study extracted from ''ct heat'' database. polytraumatized patients of both sexes were included and the mortality rate was calculated taking into account the second peak of death from trauma, gender, age and primary mechanisms of injury. discussion: the data collected show % mortality in the second peak, with firearm projectiles ( %) followed by traffic accident and fall as the primary causes of death. conclusion: because of the structural and health care profile of this trauma center, it was possible to reach the desirable mortality rate according to the worldwide literature (less than %). introduction: trauma patients are sometimes in critical condition upon arrival and need aggressive treatments to survive. despite all efforts many end up dying. it seems necessary to try to identify those patients with a very high risk of death to avoid futile treatments. the aim of our study was to develop a simple clinical tool to predict mortality in trauma patients that can be easily calculated in the ed. material and methods: we analyzed data from all trauma patients arriving at a spanish trauma hospital from june to june . patient demographics, physiologic trauma scores, vital signs, and glasgow coma scale (gcs) were recorded. our primary outcome was mortality. logistic regression analysis (lra) was performed using three variables (age, shock index (si), and gcs) to determine the appropriate weights for predicting mortality. using them, we constructed a simple score to calculate mortality. results: patients were studied. the mortality rate was . %. our score was constructed using weights derived from lra for age [ y ( points), si [ ( points) , and gcs conclusions: our score is easy and quick to calculate and could be a useful tool to predict mortality using early available parameters upon arrival in the ed. acknowledging the ethics involved in this topic, this score could sort out patients with a very high risk of death and in whom aggressive therapeutic measures could be limited early or withdrawn in agreement with family members references: haider a, et al ( ) ( ) ( ) states the average cost for an a&e attendance and non-elective inpatient stay is £ and £ , respectively highlighting the importance for schemes to reduce hospital admissions. assess impact of ambulatory care, surgical emergency assessment unit (seau) and ''emergency surgeon of the week'' (esw) on hospital admissions for surgical referrals (gp/ a&e). material and methods: retrospective analysis of prospectively collected data of hospital admissions from the patient centre database before and after implementation of seau (in november ) and esw (in november ), including the units'' activities. emergency general surgeon followed : (monday-thursday, - ) rota based at seau. results: since ( months), seau has reviewed (new ; follow ups ) patients. surgical admissions (sa) pre and post implementation seau were * and */month respectively, a drop by %. esw helped a further drop by another % to */month. % of new referrals were admitted and overall % of all patients reviewed were admitted. juniors (st /st ) and seniors (st - /staff grades/consultants) admitted % and % of the referrals respectively. uss and ct were performed in dedicated seau slots. % attending seau were likely to recommend the unit to friends or relatives. conclusions: in the face of unprecedented demand for hospital beds (more so in the winter), ''emergency surgeon of the week'' based at seau could be the answer to relieving the capacity, financial pressures and providing high quality safe patient care for our already strained nhs. surgical emergencies, an educational and medico-economic challenge introduction: surgical emergencies are a frequent reason for consultation in the emergency department and are responsible for significant morbidity and mortality. our study aims to present the number of patients admitted for a surgical emergency in a french level trauma-center and the volume of patients operated in emergency depending on the different specialties. method: we conducted a retrospective, single-center study of the hospital emergency department (uas) of the university hospital center of nice between january and december . we studied the volume represented by surgical emergencies according to the different specialties. results: the emergency department welcomed , patients, of which , surgical emergencies patients accounted for % of the total activity; patients were operated on urgently, which represents % of all surgical procedures in our hospital. conclusion: surgical emergencies are an important part of the activity of our hospitals. an academic definition is difficult to achieve. a regional organization is needed for the management and optimal care of these patients. the creation of regional centers, as for the trauma centers, seems indispensable, especially for the most serious patients, allowing both a better medico-economic and educational management of surgical emergencies. introduction: every new admission to the icu prompts a handover from the referring department to the icu staff. this step in the patient pathway provides an opportunity for information to be lost and for patient care to be compromised. mortality rates in intensive care have fallen over the last years, however, % of patients admitted to an icu will die during their admission ( ) . communication errors contribute to approximately two-thirds of notable clinical incidents; over half of these are related to a handover ( ) . nice have concluded that structured handovers can result in reduced mortality, reduced length of hospital stay and improvements in senior clinical staff and nurse satisfaction ( ) . material and methods: a checklist was created to review to score the handover. this was created with doctors and nurses and is relevant for handovers between all staff members. information was gathered prospectively by directly observing handovers on the icu. results: there is a notable discrepancy in the quality of handovers of new patients. this is true of handovers between doctors, nurses and a combination of the two. % (n = ) of patients weren't handed over to a doctor. the most commonly missed pieces of information were details of the patient's weight ( %, n = ), their height ( %, n = ), whether the patient has previously been admitted to an icu ( %, n = ) and whether the patient has any allergies ( %, n = ). conclusions: the handover of new patients to the icu is often unstructured and important information is missed. this can be said for all staff members and grades, and for handovers from all hospital departments. introduction: bowel resection for acute mesenteric ischaemia (ami) in elderly is associated with significant morbidity and mortality, and increasing age and frailty are associated with increased risk. this study aims to assess the short-term outcomes for elderly patients undergoing surgery for ami, and to assess the accuracy of surgical risk calculators in this population, to determine their utility in preoperative discussions. introduction: intertrochanteric femoral fracture of the super-elderly is often difficult to treat because good surgery does not always lead to good functional prognosis. we investigated the factors affecting the functional prognosis in patients with intertrochanteric fracture over years old. material and methods: cases of intertrochanteric fracture over years old who had undergone surgical treatment at our hospital between december and september were examined. nine men and women, age at injury ranged from to years, with a median of years. the average postoperative follow-up period was . months. for these cases, the mobility was classified into independent walking, assisted walking (cane, walker), wheelchair, bedridden, and the transition of pre-and postoperative mobility was analyzed. the significance test was performed using the mann-whitney u test, and p \ . was considered significant. results: by fracture type, when jensen classifications i and ii were stable, iii, iv, and v were unstable, mobility of unstable type was significantly reduced (p = . ). when the waiting period for surgery is divided by the median of days, there was no difference in mobility reduction between groups of less than days and groups of more than days (p = . ). although there was no significant difference in the presence or absence of preoperative rehabilitation intervention (p = . ), there was a tendency for less decline in mobility when preoperative rehabilitation intervention was performed. conclusions: in the treatment of this fracture, early surgical treatment after injury is recommended, but in the case of very elderly people, waiting is often required due to existing diseases and poor general condition . this study suggests the importance of preoperative rehabilitation intervention during the waiting period for surgery to prevent disuse disorders. references: . kelly-pettersson et al. waiting time to surgery is correlated with an increased risk of serious adverse events during hospital stay in patients with hip-fracture: a cohort study international journal of nursing studies ( ) - . older patients with traumatic shock exhibited lower pulse pressure compared with younger patients; an analysis of nationwide trauma data base in japan introduction: the study purpose was to assess the effect of age on the relationship between pulse pressure (pp) and systolic blood pressure (sbp) in patients with traumatic shock. material and methods: in this retrospective cohort study using nationwide trauma data base in japan from april to may , trauma patients years of age and older with sbp \ mmhg were selected. patients with severe traumatic brain injury (the abbreviated injury scale on head [ ) and cardiac arrest (hr = and sbp \ mmhg) were excluded. linear regression analysis assessed association between pp and sbp interacted by age group dichotomized as \ or c years old. results: during the study period, patients were included. the linear regression analysis indicated the significant association between pp and sbp in overall population (ec, estimated coefficient = . %ci [ . , . ], p \ . ). association between pp and sbp was significantly interacted by the age group (ec = . %ci [ . , . ] introduction: high rates of trauma in south africa (sa) predominantly affect the youth, yet the geriatric population is not exempt. in addition to inherent challenges of age, elderly trauma patients are further compromised by resource constraints. we aimed to assess injuries and outcomes in elderly patients admitted to a tertiary trauma unit in sa. material and methods: a retrospective record review was done of all patients years and older, admitted to the trauma unit over an -month period. injury severity score (iss), mechanism of injury (moi), in-hospital complications and length of hospital stay were documented. results: patients (mean age: years; % female) were included with mean iss of . the most frequent mois included nontraumatic falls ( %), falls from height ( %), motor-vehicle collisions ( %), pedestrian vehicle collisions ( %), and blunt injuries ( %, % intentionally inflicted). eighty patients ( %) experienced at least one in-hospital complication. the mortality rate was %. the mean length of hospital stay was days. conclusions: despite the known vulnerablities of the elderly, the mortality rate and isss of this cohort were relativley low. however, when compared to first world literature, intentionally inflicted injuries and certain preventable mois (e.g. fall from height and pedestrian vehicle collisions) were common, [ ] [ ] introduction: the majority of new colorectal cancer is diagnosed in people [ years, yet the elderly are less likely to undergo curative surgery. chronological age is poorly correlated with post-operative outcomes and is not an acceptable measure of risk. conversely, frailty is a strong predictor of poor outcomes following surgery and presents an opportunity for patient optimisation. the aim of this systematic review is to assess the available evidence between frailty and outcomes in patients of all ages undergoing surgical resections for colorectal cancer. material and methods: pubmed was searched for articles reporting outcomes for patients deemed frail undergoing elective or emergency colorectal cancer resection up until august . the primary outcome was mortality ( and day). secondary outcomes; length of stay, readmission, reoperation & post-operative complications. results: studies identified, studies were deemed eligible for inclusion. study types, frailty assessments & outcomes measured were variable. despite this heterogeneity, categorisation of ''frailty'' was associated with higher rates of post-operative mortality, complications, readmission, and length of stay. conclusions: based on current evidence, frailty is a strong predictor of poor clinical outcomes in patients undergoing surgery for colorectal cancer. standardisation of frailty assessment and measure of outcomes is needed for more robust analysis. accurate risk stratification of patients will allow us to make informed treatment decisions and identify patients who may benefit from prehabilitation and intensive tailored post-operative care. introduction: pneumatosis intestinalis (pi) and hepatic portal venous gas (hpvg) are two radiological findings associated with a broad range of medical conditions. pi can be primary ( % of cases),usually with a benign course, or secondary ( % of cases),which results from obstructive or ischemic gastrointestinal diseases. only a minority of pi is associated to free abdominal air. in literature there is no consensus on radiological and biochemical markers of favourable outcome nor on treatment options-medical or surgical. we tried to identify prognostic markers in a series admitted to a single university hospital. material and methods: the medical records of patients with pi and/or hpvg admitted to ospedale maggiore policlinico (milan, italy) in the period - were collected the ct scan were reviewed by a single radiologist. results: mean age was . ± years ( - ). pi was primary in , % of the patients (n = ), and secondary in , % (n = ). at ct, pi was associated to portal gas in patients ( %) ( dead, alive) and to free air in patients ( %) ( dead, alive). linear or rounded gas collections were equally distributed in primary and secondary pi. the colon was involved in patients ( %), followed by the small intestine in ( , %),and the stomach (n = ). in patients serum lactate was [ , and died. leucocytosis (wbc [ , /mm ) was present in patients ( alive).four patients had peritonitis and abdominal tenderness. laparotomy was performed in primary (alive) and secondary pi ( deaths).in two patients it was diagnostic; in and associated to right or left colectomy, in to ileal resection and in to other procedures.surgery was judged futile in patients; all died a few hours after emergency department access. conclusions: we could not found any relationship between clinical, biochemical and radiological findings and outcome of pi. mesenteric and portal gas is a ominous finding, but did not reach significant value. successful transcatheter arterial embolization for a giant pseudoaneurysm of gluteal muscle due to ground level fall in elderly woman with direct oral anticoagulants t. kadoya , r. nakama , k. arakawa , t. ogura , k. kase saiseikai utsunomiya hospital, department of emergency medicine and critical care medicine, utsunomiya, japan, saiseikai utsunomiya hospital, department of radiology, utsunomiya, japan case history: a 's year-old woman using apixaban fell on the ground and was transferred to previous hospital. magnetic resonance imaging was taken and she was diagnosed as gluteal hematoma. she was treated conservatively but hemoglobin (hb) level was gradually decreased. although she was administered red blood cell as needed, anemia progressed. contrast-enhanced ct showed expanding hematoma of gluteal muscle. she transferred our hospital for advanced treatment including surgery on th day on hospital. clinical findings: vital signs were stable on arrival at our hospital. extensive subcutaneous hematoma was found in the right thigh and gluteal lesion. investigation/results: laboratory test showed that hb . g/dl and normal coagulation status. contrast-enhanced ct showed a giant pseudoaneurysm inside the gluteal muscle. therapy and progressions: angiography showed a giant aneurysm of peripheral branch of internal iliac artery. we performed transcatheter arterial embolization (tae) for it by gelatin sponge. after tae, there was no complication and progressive anemia was stopped. she was transferred to another hospital for rehabilitation six days after tae. comments: increase use of direct oral anticoagulants in elderly people could induce severe hemorrhagic trauma by minimal mechanism. tae is minimal invasive and safety procedure for such trauma case. introduction: the number of elderly people will increase during the next few decades. more importantly, the number of people aged or above are projected to increase % in developed countries. in spain, people over age were . % of the population in , and this will increase to . % in . that has implications in the health services and in the management of trauma patients. material and methods: we did a retrospective cohort analysis of trauma patients c y.o. admitted to our level i trauma center during the time-period of - . demographic data, icu care, and mortality were assessed. results: trauma patients c y.o. were admitted during that period. this is a % increase compared with the number of patients admitted during the previous decade ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . mean age was . ± . years, and median new injury severity score (niss) was (interquartile range to ). % were male. the mechanism of injury was % falls, and % pedestrian runovers. patients were admitted to icu, with median niss of and mortality rate of %. among severely injured trauma patients (niss c ) the hospital mortality rate of those c years was %, much higher than in the age group of - years ( %), with a significant difference (p \ . ). no differences mortality rates between - years and youngers with the same niss. conclusions: the geriatric trauma patient population is on the rise worldwide. this should be taken into account in our trauma centres in order to be able to adapt and try to improve trauma care in these patients. introduction: frailty is a geriatric syndrome which has been considered as a risk factor in the elderly, increasing adverse events in terms of global health, as hospitalization, increase of falls, need of institutionalization, and mortality. the aim of this study is to evaluate relationship between frailty, and the presence of major complications in the postoperative course of patients older than years undergoing emergency surgery. material and methods: prospective, longitudinal, cohort study, using four different scales of frailty as a predictor of risk for short-term adverse events, for patients during the postoperative course of emergency surgery (may -september ). the sample is categorized according to four frailty scales (clinical frailty scale, frail score, trst and share-fi) . we analyze the variables regarding diagnoses, clinical examination at admission, surgical procedures, and postoperative outcomes during the first days. clavien-dindo classification was used in order to graduate the severity of complications. results: patients were included with a mean age of , years (sd , ) . , % of the simple are women. frailty prevalence ranges, according to the frailty scales, from , % to %. median hospital stay was days ( iqr , ) . all four frailty scales show statistical differences to predict major complication in our simple. trst and frail scales show the strongest measure of association (or , and , , respectively). the frail phenotype, is also related to an increased of mortality, and frail scale is the frailty scale with largest or (or = , ).only frail show association with longer hospital stay ([ days), and reoperation rate. conclusions: frailty represents a predictive marker of major complications and mortality, for patients older than years undergoing emergency surgery. frail score, shows the strongest relationship with mortality and complications. introduction: age has been identified as a predictor of trauma mortality [ ] and it is known that even low energy trauma may cause severe injuries in the elderly [ ] . the aim of this study was to explore how the elderly trauma patients, and the care thereof, differ from the younger ones in a swedish context. material and methods: the swedish trauma registry (swetrau) was used. consecutive recorded trauma cases that presented at one level ii trauma hospital during december -august were included (n = ). patients were stratified into groups; those c and those results: in the c years group, sex distribution was more even (female . vs . %, p \ . ), physical status according to pretrauma asa classification was higher (mean . vs . , p \ . ) and the trauma mechanism was predominantly low-energy (falls from no height) as opposed to the conclusions: the trauma among elderly swedish patients are more often of low energy compared to the younger population. in spite of this, the elderly are more severely injured, require more surgical interventions, and their short term mortality is increased -fold. measures aimed at prevention of low energy trauma of the elderly are therefore much needed. introduction: there are intramedullary or extramedullary methods in internal fixation od trochanteric fractures. seldynamisalbe internal fixator with two sliding screws (sif), as an extramedullary method, and gamma nail (gn), as an intramedullary method, are in routine trochanteric fractures treatment at our institution for last two decades. material and methods: health related quality of life and hip function were assesed at least two years after surgery, in the series of patients with a surgically treated ao a or a fracture type. there were two groups of patients: group treated by sif and group treated by gn. examination had been performed using sf- test, with its physical component score (pcs) and mental component score (mcs), and harris hip score (hhs) tests. results: in sif group, mean pcs was , , mean mcs was , and mean hhs was , . in gn group mean pcs was , , mean mcs was , and mean hhs was , . there was no significant difference regarding all these parameters between the groups of patients (p [ , ). there was correlation between all evaluated parameters, both in groups of patients particularly and in all patients (p \ , we identified undertriage in , % ( / ). falls from own height ( - m) was found in patients with iss [ , / ( %) of them was found to have been undertiaged (p . ). we found an association between gcs \ and undertriage (p = . ). % ( / ) falls between - m and % ( / ) of these without trauma team. falls between - m , % ( / ) without trauma team. all with fall [ m had trauma team. mortality was % ( / ), no association between height of fall and mortality (p . ). undertriage was not associated with increased mortality (p = , ). median age in mortality group was years versus years in surviving group (p \ . ). in univariate analysis there was association between prehospital bp \ (p . ), gcs \ (p \ , ), iss (p \ . ), prehospital rr [ , rts \ (p \ . ) asa score [ (p \ . ) and mortality. conclusions: we found significant undertriage in the geriatric trauma population with fall injuries. gcs \ and low energy falls was associated with undertriage but not with mortality. laparoscopic direct repair of an incarcerated spigelian hernia c. bergamini , v. iacopini , r. de vincenti , a. bottari , g. alemanno , p. prosperi aou-careggi, emergency surgery, firenze, italy spigelian hernia occurs through a defect in the anterior abdominal wall adjacent to the semilunar line. it is in itself very rare and more over it is difficult to diagnose clinically. it has been estimated that it constitutes . % of abdominal wall hernias. the majority of patients present with symptomatic incarceration of preperitoneal fat or intraabdominal viscera. radiographic studies are beneficial in confirming the diagnosis. the high rate of incarceration with or without strangulation mandates operative repair once the diagnosis is confirmed. the spigelian hernia has been repaired by both conventional and laparoscopic approach. laparoscopic management of spigelian hernia is well established. most of the authors have managed it by transperitoneal approach either by a direct repair or by placing the mesh in intraperitoneal position or raising the peritoneal flap and placing the mesh in extraperitoneal space. there have also been case reports of management of spigelian hernia by total extraperitoneal approach. we present the case of an obese eighty-four y.o patient. complaining for a sudden onset abdominal pain in the right low quadrant, mimicking an appendicitis. the ct scan demonstrated a typical picture of a spigelian hernia containing an intestinal loop. the loop showed classical signs of parietal wall ischemia. the video describes the surgical laparoscopic approach of this case which was able to confirm the diagnosis e to reduce the loop into the abdomen. the loop initially appeared diffusely ischemic, but after the intra-abdominal reduction some signs of vitality started to be noticed. however, they were incomplete; thus the loop was resected. the hernia defect was successively repaired in a direct way because of the small caliber (\ cm of diameter) and the possible contamination coming from the intestinal resection. post-operative course was particularly benign and the patient was discharged on the seventh post-operative day in good health. introduction: trauma audit & research network (tarn) data shows older persons falling from standing height and sustaining significant injury has become the commonest trauma presentation in england and wales . we aimed to assess whether frailty predicts poor outcomes in the elderly. material and methods: retrospective database review of tarn eligible patients [ years old admitted in a week period with documented rockwood clinical frailty score . age, injury severity score (iss), length of stay (los) and mortality were noted. the inhospital mortality group was sub-analysed. logistic regression was performed (stata v ), odds ratios and % ci reported. results: older age was associated with higher cfs in the patients studied. increasing cfs was associated with increased overall mortality (cfs - vs cfs - or . ; % ci . - . ), decreased likelihood of pre-hospital trauma alert and increased length of stay (cfs - stayed days more than cfs - ). all deaths had cfs [ and head or chest injury. adjusting for age and cfs those with chest injury were . times more likely to die (or . %ci . - . ). mortality in those with rib fracture was times higher in cfs - vs cfs - (or . %ci . - . ). conclusions: increasing age and cfs (especially - ) are associated with poor outcomes in elderly trauma, thus cfs is a useful prognostic tool in severely injured elderly patients. chest injuries are a major cause of mortality in this group, especially with increasing frailty. major trauma centres must develop practice management guidelines to appropriately manage these patients. introduction: major trauma causes activation of the complement system, which plays a key role in development of systemic inflammatory response syndrome and multiple organ failure. complement is known to be activated early after trauma , but the relationship between outcome and the extent of complement activation during the first critical hours after injury is unknown. we hypothesized that complement activation in the first hours after trauma displays a highly dynamic pattern which is associated with outcome. material and methods: complement activation was assessed by plasma terminal c b- complement complex (tcc) using elisa in a prospective cohort of trauma patients. samples were obtained at admission, after , , and h, and daily in the intensive care unit. the extent of complement activation was assessed as area under the concentration curves - h after injury (tcc-auc - ). the relative contribution of complement activation, base excess (be) and new injury severity score (niss) to outcome was analyzed by multivariable analyses. results: niss and be were associated with tcc-auc - in bivariate analyses (spearmans rho (p) was respectively , (p = . ) and - . (p = . )). in multivariable analyses, niss and initial tcc alone predicted % of the variability in ventilatorfree days (vfds), whereas initial tcc and tcc-auc - predicted %. tcc auc - alone contributed with % to the model. tcc-auc - was also significantly higher in patients deceased at day ( . ; . - . (median; quartiles) vs. . ; . - . , p = . introduction: massive transfusion protocols [mtp] have been widely adopted for the care of bleeding trauma patients but their actual effectiveness is unclear. this study aims to conduct an updated meta-analysis to evaluate the effect of implementing an mtp on the mortality of trauma patients. material and methods: medline, pubmed, google scholar and cochrane library databases were systematically searched for relevant articles published from january , to july , using a combination of key words and additional manual searching of reference lists. three reviewers independently screened the articles for potential inclusion. eligible articles were original articles in english, included trauma patients and compared mortality outcomes before and after institutional implementation of a mtp. primary outcomes were h and overall mortality. results: nineteen studies met inclusion criteria, analyzing outcomes from , trauma patients. there was a wide range of outcome and process indicators utilized by the different authors. mtps significantly reduced over-all mortality, pre-mtp- . % and post-mtp . % [or . ( . - . )] for trauma patients. -h mortality was not significantly reduced [or . ( . - . )]. conclusions: the institution of an mtp has a significant over-all mortality reduction for trauma patients. we encourage that researchers use standard nomenclature and indicators, provide more details regarding protocols and patient populations and incorporate advances in the management of bleeding trauma patients in all future mtp studies. introduction: when resuscitating patients with hemorrhagic shock following trauma, fluid volume restriction and permissive hypotension prior to bleeding control are emphasized with good outcomes for penetrating trauma patients. however, evidence that these concepts apply well to the management of blunt trauma is lacking. this study aimed to assess the impact of vasopressor use in patients with blunt trauma in severe hemorrhagic shock. material and methods: in this single-center retrospective study, we reviewed records of blunt trauma patients with hemorrhagic shock and included patients with a probability of survival \ . . patient's characteristics, examinations, severity and administrated therapies were compared between survivors and non-survivors. data are described with median ( - % interquartile range) or number. results: thirty patients were included and median injury severity score in survivors vs non-survivors was ( - ) vs ( - ) (p = . ), with no significant difference in probability of survival. despite no significant difference in injury severity, non-survivors were administered vasopressors significantly earlier after admission and at significantly higher doses. total blood transfusion amount administered within h after admission was significantly higher in survivors ( [ conclusions: vasopressor administration and high-dose use for hemorrhagic shock following severe blunt trauma are significantly associated with increased mortality. although the transfused volume of blood products tends to be increased, early termination of vasopressor should be considered. all authors have no significant relationships with regard to this study. early amplitudes of citrated functional fibrinogen in thromboelastography to predict massive transfusion introduction: this study aims to evaluate the role of early amplitudes of the thromboelastography measure of citrated functional fibrinogen (cff) to predict massive transfusion (mtx) defined as transfusion of c of any blood products within an hour of arrival to a major trauma centre. material and methods: trauma patients c years requiring activation of the major haemorrhage protocol with teg performed on a tegÒ s hemostasis analyser were eligible for inclusion. exclusion criteria were arrival [ h after injury, pregnancy, bleeding disorder or anticoagulant use. patient demographics and transfusion requirements were obtained from medical notes. teg manager was accessed to extract amplitudes at min (a ), min (a ) introduction: hyperfibrinolysis, remains a significant characteristic of acute traumatic coagulopathy induced mortality. s a , a cell surface protein, when shed creats an occult hyperfibrinolytic subtype. annexin a (a ), a multicompartment protein that co-localizes with s a and contains a tissue plasminogen activator (tpa) binding site has been shown to enhance tpa activity -fold and thus behaves as marker of hyperfibrinolysis. we hypothesize that increased concentrations of a in blood will enhance tpa fibrinolysis. material and methods: blood was collected from ( ) healthy volunteers. recombinant a in concentrations , , , , , lg/ ml was added blood and then combined with tpa ng/ml. samples were assessed using thromboelastography (teg). blood samples were collected from trauma activations from -current at a single, urban, level- trauma center. samples were assessed using a combination of rapid, citrated native and tpa challenge teg. a levels were established via proteomic analysis. results: a - (lg/ml) significantly increased tpa mediated ly % vs tpa alone (a ? tpa [ - ] median . % vs tpa . % p \ . ). a without tpa had no significant effect on ly % and was similar to the lysis of control (a lg/ml . % vs control . % p = . ). a - (lg/ml) significantly increased r time from control and tpa alone (control normalized to vs a median . -fold increase in minutes p \ . and tpa . -fold decrease vs a median . -fold increase p \ . ). rapid teg for patient vs patient in our ongoing study was . % vs . % and . % and . % respectively on tpa challenge teg. proteomic analysis of a relative activity found a . -fold a activity in patient compared to patient . conclusions: exogenous cell free a significantly increases tpa mediated fibrinolysis measured by teg. preliminary data from our ongoing trauma study evaluating a levels and hyperfibrinolysis coincide with our in vitro study. introduction: massive transfusion protocol can be activated to mobilize the blood products resource in a timely and effective manner. blood products, however, are still wasted or overused. we aimed to study what proportion of patients who met the abc criteria for massive transfusion received or more units packed rbc (prbc). material and methods: a retrospective study all level i trauma patients admitted with arrival systolic blood pressure of or less (july to may ) was recruited. transfusion was complied with stts. all clinical and laboratory findings, and management procedures were populated from the data registry. results: of admitted trauma patients met the inclusion criteria. of patients who where admitted with hypotension, of patients ( . %), who met the abc criteria for receiving or more prbc were stabilized with or units. in other words, stts enabled us to save units of prbc. arrival data, i.e. blood pressure (cut of point: mmhg and p value: . ), shock index (cut of point: . and p value: . ) and pulse rate (cut of point: beat/min and p value: . ) were significantly different in patients prescribed or more units prbc. after initial resuscitation, blood pressure (cut of point: mmhg and p value: . shock index cut of point: . and p value: . ), pulse rate(cut of poinan beat/min and p value: . ) presence of pelvic fracture, positive fast,and base deficit [ were significantly different in the group received or more units prbc. conclusions: massive transfusion protocol with abc criteria may lead to wasted or overused blood products.consideration of dcr continuation strategy complied with stts along with the findings of this study has resulted in a refined protocol characterized by more effective and efficient blood product resource allocation. references: -chang r, holcomb jb. optimal fluid therapy for traumatic hemorrhagic shock. critical care clinics. jan ; ( ) case history: we present the clinical case of a female patient of years old who had been taking aspirin. mechanism of injury: a fall from her own height, resulting in head trauma. clinical findings: dysphonia and stridor, having underwent an immediate orotracheal intubation. investigation/results: she had a head ct done that was normal; and a cervical column and neck ct that showed a large retropharyngeal hematoma, without an associated vertebrae fracture. diagnosis: large retropharyngeal hematoma. therapy and progressions: she was admitted to the intensive care unit for mechanical ventilation. on nd day, she underwent a surgical tracheostomy. on th day, underwent weaning from mechanical ventilation. on h day, was transferred to the ent ward, had the tracheostomy tube removed and was discharged from hospital. comments: a hematoma in this potential space may constitute an immediately life threatening emergency due to airway compromise. in , thomas et al found only cases described in the literature since . the most common cause is the blunt cervical trauma (in % of the cases). other causes are the cervical hyperextension injury, cervical vertebrae fracture, cough, sneeze, strain, blunt head trauma, swallow a foreign body, retropharyngeal infection, carotid artery aneurism, internal jugular vein puncture, metastatic disease, coagulopathy, anticoagulants, etc. in the setting of trauma, the mechanism of injury generally permits explaining the presenting injuries. in this case, the clinical severity expressed by the patient seemed to be disproportional to the resultant injury. however, the presence of haemorrhage contributing factors associated with the existence of fascial spaces in the neck, should warn us of the possibility of formation of deep cervical hematomas that may cause an occult airway obstruction. case history: a -year-old male with a personal history of consumption of alcohol, cannabis, smoked cocaine and heroin. he was found in decubitus position and in a situation of cardiac arrest. the last time he was seen in his baseline situation was h before. after performing cpr and administration of naloxone and flumacenyl, sinus rhythm was achieved. clinical findings: h after admission, increased tension was observed in left leg, thigh and gluteal region. absence dorsalis pedis, tibialis posterior and popliteal pulse was observed in a doppler examination. investigation/results: intracompartmental pressure measurement revealed a result of mmhg in the deep posterior compartment and mmhg in the superficial (diastolic bp mmhg). at admission k levels were . meq/l, creatinine . mg/dl and ck u/l. diagnosis: opioid-related compartment syndrome. therapy and progressions: urgent fasciotomies of the leg and thigh were performed h after diagnosis with a posteromedial and anterolateral approach in the first case and with a lateral approach in the latter. herniation and signs of poor viability in all the compartments were observed. after the surgery, he persisted with anuria and a ck peak of , u/ l, which was next normalized. debridements were performedfor the next days. subsequently, after the isolation of p. stutzeri and mucor in the wound and the absence of signs of vitality, a supracondylar amputation was performed. after, hemodynamic status improved. weeks after the amputation it was possible to withdraw hemodialysis, which he had required since admission. comments: opioid misuse is a topic of growing interest. recent works have reported a worse prognosis in the case of opioid-related compartment syndrome. a high level of suspicion is necessary to make a prompt diagnose in these patients. introduction: the pelvic binder is a mechanical device designed to compress instable pelvic ring fractures and minimize dead space in order to limit blood loss. it is generally recommended to apply a pelvic binder if an unstable injury is suspected and the patient presents with a ''c-problem''. the effectiveness remains questionable though. material and methods: a total of trauma patients between and were retrospectively evaluated regarding instable pelvic injury. patients were admitted with a pelvic binder applied. the correct application was evaluated using ct scout. four groups were generated: group with correct pelvic binder application, group with incorrect placement, group with no pelvic binder at time of admission, group with pelvic binder applied in er. total outcome was determined based upon iss, age, preclinical time, time to ct, shock index, hemoglobin at admission, survival rate, administration of blood products as well as total hospital and icu days. results: % of all pelvic binders were applied incorrectly. patients ( %) suffered an instable pelvic fracture. patient survival was not influenced by the preclinical application of a pelvic binder ( % group vs. , % group , p = , ). no significant statistical difference was found for total icu days , vs. , , p = , ; total hospital days , vs. , , p = , ; rbc transfusion , vs. , , p = , ; iss , vs. , , p = , . conclusions: the correct application of a pelvic binder seems to pose problems preclinically. while the need to minimize blood loss is crucial, our collective did not benefit from this device. additionally, survival rates of the patients that suffered an instable pelvic fracture were unaffected. the iss remains the strongest predictor of total patient survival in pelvic trauma. trauma resuscitation times in a level trauma center in the netherlands: a prospective overview introduction: in trauma, time is considered to be an important factor influencing patient's outcome. in the first hour after injury, appropriate care has the greatest effect on trauma patient's survival. previous research showed that measuring in-hospital trauma resuscitation times, contributes to insights and improvement of the resuscitation process. however, despite developments of atls guidelines, no recent empirical knowledge regarding resuscitation times exists. the aim of this study is to examine in-hospital trauma resuscitation times in a level trauma center in the netherlands. material and methods: a prospective study was performed in level trauma center amsterdam umc location vumc, between may and august . trauma patients, aged c , presented during daytime at the trauma resuscitation room were included. information regarding patient's characteristics, trauma-and injury type, handover duration, duration till start of diagnostics and intervention, total resuscitation time, patient's disposition and survival were compared. results: in total, patients were analyzed. motorized traffic accident ( %) and blunt injury ( %) were the most common mechanism-and injury types. median prehospital to in-hospital handover time was . min (iqr . ) . median duration till start of diagnostics and intervention were . (iqr . ) and . min (iqr . ) respectively. median total resuscitation time showed to be . min (iqr . background: terrorist attacks and civilian mass casualty events are frequent, and some countries have implemented tourniquets for uncontrollable extremity bleeding in civilian settings. we summarized current knowledge on the use of pre-hospital tourniquets in civilian settings to assess whether their use increases the survival rate in civilian patients with life-threatening hemorrhages from the extremities. methods: using the preferred reporting items for systematic reviews and meta-analyses (prisma) guidelines, we searched medline (ovid), embase (ovid), cochrane library, and epistemonikos in january . all types of studies that examined the topic in a pre-hospital setting published after january , , were included. the protocol was registered in prospero (crd ). results: among screened records, studies were identified as relevant. due to a lack of relevant civilian studies, military studies were also included. the studies were highly heterogeneous, with low quality of evidence. most studies reported increased survival in the tourniquet group, but few had relevant comparators, and the survival benefit was difficult to estimate. most studies reported a reduced need for blood transfusion, with few and mainly transient adverse effects from tourniquet use. conclusion: the data suggest that the use of commercial tourniquets in a civilian setting to control life-threatening extremity hemorrhage is probably associated with improved survival, reduced need for blood transfusion, and few and transient adverse effects. the effect of venous infusion by emergency medical service personnel on the prognosis of severe traffic accident patients: a nation-wide study in japan y. katayama , t. kitamura , , t. hirose , y. nakagawa , t. shimazu osaka university graduate school of medicine, department of traumatology and acute critical medicine, suita, japan, osaka university graduate school of medicine, environmental and population science, suita, japan introduction: in japan, the law of paramedic was revised in , and it became possible for paramedic in japan to secure an infusion route before cardiac arrest for severe patients. however, the effect of this treatment on the prognosis of severe trauma patients has not been assessed. we assessed this effect on the prognosis of severe traffic accident patients with using population-based ambulance record and nation-wide hospital-based trauma registry in japan. material and methods: this study was a retrospective observational study and the study periods was years between january to december . we linked the nation-wide hospital based trauma registry (jtdb) and the population-based ambulance record in japan in case. in this study, we included the traffic accident patients with iss score more than and excluded cardiopulmonary arrest patients on the arrival of ems on the scene and missing data cases. the main outcome was cardiopulmonary arrest on hospital arrival. mcnemar's test and conditional logistic regression analysis were used to assess the association between the securing a infusion route by ems personnel and the primary outcome after one-to-one propensity score matching for securing a infusion route or not. results: traffic accident patients were eligible for analysis and patients were dripped by ems personnel. after one-to-one propensity score matching, the proportion of cardiopulmonary arrest on hospital arrival were . % ( / ) in patients dripped by ems personnel and . % ( / ) in patients not dripped by ems personnel, respectively (p = . ). the adjusted odds ratio for securing a infusion route was . [ % confidence interval; . - . , p = . ]. conclusions: in this study, there was no association between the securing a infusion route and outcome of traffic accident patients. the association between trauma patient characteristics and adverse laboratory values: which patient characteristics are most predictive? introduction: in more than countries worldwide, laboratory testing is protocol driven since when it was included in the practice guideline of the advanced trauma life support course (atls). however, it is not clear yet which patient characteristics are associated with unfortunate laboratory values. the aim was to create an overview of the characteristics that were associated with adverse laboratory values. material and methods: this cohort study was performed at amsterdam umc, location amc (level trauma center), including patients during a period of years. data concerning age, gender, asa scores, injury severity scores (iss), glasgow coma scores (gcs), mechanism of injury, type of injury (blunt or penetrating) and the presence of helicopter emergency medical services (hems) were obtained. the hematology panel included hemoglobin, hematocrit, mcv, leucocyte and thrombocyte values. the coagulation panel included inr, pt, aptt, fibrinogen and d-dimer values. other panels include arterial blood gas, kidney and liver panels. the association between trauma patient characteristics and laboratory values were determined by using binary and multinomial logistic regression. results: a total of patients were included, consisting of predominantly men ( %) with a mean age of years old. an increase in age and iss was correlated with abnormal laboratory values (p = . ). additionally, male gender, iss [ , blunt trauma and the absence of hems was associated with a deviation in laboratory values (p \ . ). other patient characteristics did not show a significant correlation with adverse laboratory values. case history: a -year-old man presented with a classic case of pituitary apoplexy with a history of headache, nausea and vomiting. clinical findings: he was found to have a sellar and suprasellar mass with internal cystic and hemorrhagic component consistent with a pituitary macroadenoma. investigation/results: he underwent transsphenoidal sugery for a pituitary macroadenoma. because the tumor was invaded to left cavernous sinus, we left small portion of the tumor. eighth day after surgery, he underwent gamma-knife surgery (gks) for residual tumor. after two weeks, he complained of left ptosis. we considered the rd nerve palsy to be a post-radiation reaction at first. after months, the symptoms had been continuous and mri showed increased size of cystic lesion involving left cavernous sinus. diagnosis: ct angiogram demonstrated a saccular aneurysm at left distal ica. endovascular coil embolization was performed. therapy and progressions: after months of the intervention, the rd nerve palsy was partly improving. comments: our case report emphasizes the necessity of cerebrovascular imaging before surgery for pa. mr angiography/ct angiography is not currently obligatory in patients with pituitary adenoma, but in cases with the symptoms of displacement of the neuro-vascular structures it can be of great value. even in patients without such presentations, it may be helpful to evaluate the vascular involvement. case history: a -year-old boy during the preparation for a fishing session was pierced to the left orbitary region by a high-speed spearfishing steel. clinical findings: upon arrival the patient was conscious and responsive with a gcs of , he followed commands appropriately and there were no motor of sensory deficits. investigation/results: plain skull radiographs showed the spear crossing the skull from the left orbit to the posterior part of the parietal bone. diagnosis: the patient was immediately intubated to prevent involuntary movement of the foreign body. ct scan showed the fracture of the left orbitary roof where a centimetres long metallic object crosses the cerebral parenchyma of the left hemisphere and perforates the left parietal skull. therapy and progressions: under direct visualization via transorbital approach the foreign body was removed together with bone fragments, hemostasis was done and orbitary roof repaired. serial cranial ct scan showed progressive reduction of frontal and parietal hematoma. the movement of the eye improved after a few days, normalizing with the regression of periorbital edema. upon discharge at th postoperative day the patient had a gcs score of , no motor deficit and minimal visual loss. comments: penetrating injury of the skull and brain are relatively uncommon events, representing about , % of all head injuries. orbital roof is relatively thinner part of the skull that can provide easy access to projectile objects, which can penetrate into cranial cavity and damaging the brain parenchyma. the principles of treatment are removal of bone fragments and foreign body, control of persistent bleeding and intracranial hypertension, prevention of infection though debridement of all contaminated and necrotic tissue and at the same time preservation of as much nervous tissue as possible. multitraumapatients whith severe head injury (ais ‡ ) are more quickly carried out ct scan on than a patient without severe head injury v. giil-jensen , k. andersen , t. k. helle haukeland univercity hospital, sugical department, bergen, norway, haukeland univercity hospital, ambulance service, bergen, norway introduction: trauma patients who are prone to severe head injuries during trauma may profit from obtaining a rapid clarification of the injury magnitude when using ct examination. in the case of a delayed ct examination, the consequence of the head injury could be more extensive. in this study, we wanted to see if those with severe head injury (ais c ) received a faster ct survey than those who had no severe head injury. material and methods: retrospective registry study of severely injured patients (iss [ ) which had been hospitalized as a trauma patient at haukeland university hospital in the period - . in the study, we have excluded all patients entered as multitrauma but who have iss \ and all patients who have not defined ct time. it turns out that over half of the patients lacked the registration of accurate time for the ct survey in the national trauma register. the number is still considered large enough to find a result. results: patients were received as multitraumatic at haukeland university hospital during the period. of these, was severely injured. of these, patients had severe head injuries and they again had head injuries as the only serious injury (ais c ). median time from arrival receipt to start ct, for this group was min. in the control group that was severely injured but without severe head injury is the same time min. there was patients in the control group. conclusions: for the patients in this study who had severe injuries (n: ), the median time from the arrival in the emergency department to the ct starts was min shorter for severe head injuries than for the group without severe head injuries. introduction: the patients with severe traumatic brain injury (stbi) who needs surgical intervention often experience acute traumatic coagulopathy (atc). earlier transfusion with high blood product ratios (plasma, platelets, and red blood cells via : : ratio) is recommended for severely injured patients. however, recommended blood product ratio for stbi is still controversial. material and methods: we retrospectively reviewed successive adult stbi who underwent surgical treatment in our hospital between january and december . we have transfused plasma aggressively to maintain blood fibrinogen above - mg/dl. we evaluated the total amount of transfusion and mortality. we exclude cases administered fibrinogen concentrate. results: patients were enrolled. the amount of transfusion for h is rbc . units, ffp . units, pc . units . stbi with severe other trauma needs higher ratio of plasma. discussion: tissue injury of stbi causes severe coagulopathy and : : transfusion was thought to be insufficient for stbi in order to maintain fibrinogen. we agressively transfused plasma but we achieved fibrinogen value above only in % of stbi with severe other trauma. agressive plasma transfusion had limitation for hyperfibrinolysis so we expect other product, for example fibrinogen concentrate. introduction: traumatic brain injury (tbi) remains a leading cause of hospital admission and mortality amongst trauma patients. intracranial hemorrhage (ich) can occur with tbi and presents a severe complication. low complication tolerance in developed countries and uncertainty on actual risk cause excessive diagnostics and hospitalization, considered unnecessary and expensive. methods: tbi cases indicated for cranial computer tomography (ct) according to international guidelines, at our level i trauma center between - were retrospectively included. multivariate logistic regression was performed for ich, progression and mortality predictors. results: tbi patients (m: . ; age at trauma: . ± . ), were included. ct was performed in . %, skull fracture diagnosed in . %, ich in . %, ich progression in . %. in patients \ a, chronic alcohol consumption (p = . ) and neurocranial fracture (p \ . ) were significant ich risk factors in a multivariate analysis. in patients between - a, chronic alcohol consumption (p \ . ) and skull fracture (p \ . ) revealed as significant ich predictors. in patients [ a, age (p = . ), anticoagulation (p = . ) and neurocranial fracture (p \ . ) were significant risk factors for ich, age (p = . ) was an independent risk factor for mortality. late onset ich only occurred in cases with at least of factors: age [ , anticoagulation, neurocranial fracture. overall hospitalization might have been reduced by . % via low risk cases. conclusions: triggered by decreasing error tolerance, international guidelines for mild tbi focus on safety maximization. repeated ct in initially ich negative cases should only be considered in high risk patients. non-ich cases aged \ years do not gain safety from observation or hospitalization. recommendations from our data might, without impact on patient safety, reduce costs by unnecessary hospitalization and diagnostics. references: to be added by the authors. evaluation of low-value clinical practices in acute trauma care: a multi-center retrospective study l. moore , k. soltana , j. clément , a. turgeon , î mercier , r. krouchev , p. a. tardif , s. bouderba , a. belcaid université laval, social and preventive medicine, québec, canada, chu de québec-université-laval, québec, canada, université-laval, québec, canada, introduction: low-value clinical practices have been identified as one of the most important areas of excess healthcare spending and are associated with adverse health outcomes. the objectives of this study were to estimate the frequency low-value practices in injury care and assess inter-hospital variations. material and methods: we identified low-value clinical practices from internationally recognized clinical guidelines. we conducted a population-based retrospective cohort study using data from an inclusive canadian trauma system ( - ) to calculate frequencies and assessed inter-hospital variations with intra-class correlation coefficients (icc). results: we identified low-value practices of which could be measured and validated using trauma registry data. the three lowvalue clinical practices with the highest absolute and relative frequencies were pelvic x-rays in hemodynamically stable patients with a negative physical exam for pelvic injury ( . %), head ct in adults with minor head injury who were negative on a validated clinical decision rule ( . %) and chest x-ray in hemodynamically stable patients with a normal physical exam ( . %). we observed high inter-hospital variation for surgical management of penetrating zone ii neck injury without hard signs (icc = %), and moderate variation for head ct in adults with minor head injury who were negative on a validated clinical decision rule (icc = . %). conclusions: we have developed and validated algorithms to evaluate nine potentially low-value clinical practices using trauma registry data. highest frequencies were observed for imaging in the emergency department and the highest inter-hospital variation was observed for inappropriate surgical management. these data can be used to advance the agenda on low-value care for injury admissions. dysfunction of functional connectivity between default mode network and cerebellar structures in patients with mtbi in acute stage. rsfmri and dti study introduction: mild traumatic brain injury (mtbi) occupies one of the first places in children injuries. among all brain networks at the resting state, the default mode network (dmn) is the most widely studied network. the aim of this study is to examine functional connectivity in normal-appearing cortex in acute period of mtbi using rsfmri. material and methods: mr negative participants were studied in age from to years (mean age- . years). group of patients consisted of children with mild traumatic brain injury in acute stage. age-matched healthy volunteers comprised control group. all studies were performed at phillips achieva . t mri scanner using -channel head coil. fmri data were processed using functional connectivity toolbox conn. seed-based analysis was performed in order to reveal disturbances in functional connectivity. statistical processing was performed using statistica . results: dti analysis didn't show any changes in values of apparent diffusion coefficient (adc) and fractional anisotropy (fa) between two groups (see fig. ). no statistically significant differences in correlation strength between dmn parts were observed in two groups (see fig. ). intergroup seed-based analysis revealed statistically significant (p \ , ) difference in neural correlations between dmn parts and vermis (cerebellum structural part): positive link in control group and negative link in group of patients. conclusions: one of the most common symptoms of mtbi is dizziness as a result of impaired movements coordination. vermis as an essential cerebellum part plays an important role in the vestibuloocular system which is involved in the learning of basic motor skills in the brain. vermis aids in the synchronization of eye and motor functions in order for the visual field and the motor skills to function together.our results show that mtbi appears to be a possible reason of connectivity malfunction in normal-appearing vermis. references: predictors of developing post-traumatic endophthalmitis introduction: h magnetic resonance spectroscopy ( h mrs) allows to study structural and metabolic brain disorders in various pathological conditions in vivo. non-invasive method determines its advantage for use in children in serious condition with acute cerebral injuries. this determined the purpose of the study: to identify criteria of irreversible brain damage based on the h mr spectra analysis in comatose children with acute traumatic brain injury (tbi) or anoxia. material and methods: patients ( months- years) were examined in the acute period of severe cerebral injury (gcs score - ): six were in acute and subacute period of severe tbi, one patient was examined on the seventh day after drowning, and one-a day after acute cerebral blood flow (hemorrhage). all patients died in - days after the study. control group included healthy children aged from to years. single voxel h mrs and d h mrs was performed on t scanner. h spectroscopic voxel (te/tr = / ms, voi = cm , nsa = ) was oriented on mri intact areas: cortex of frontal, parietal and occipital lobes (fig. ) , thalamic nuclei (fig. ) , cerebellum, brainstem (fig. ) . for d h mrs a spin-echo point-resolved spectroscopy (press) sequence was used (te/tr = / ms) with the spectroscopic voi of cm on frontal lobes. results: in all spectra lactate (lac) signal, dominating all other signals, was detected. n-acetylaspartate (naa) was reduced by % and creatine/phosphocreatine (cr)-by %. conclusions: h mrs is a non-invasive prognostic method in patients with acute cerebral brain damage in coma. the cause of patients' death is the shift of cerebral glucose metabolism to an anaerobic type, as evidenced by the accumulation of lac. disturbance of energy metabolism causes a decrease of cr and a decrease in the neuronal marker naa. the combination of these patterns in acute cerebral injury, regardless of etiology indicates irreversible brain tissue damage. introduction: scalds and contact burns are the most common burn injuries both in children and adults. data are conflicting regarding which type of burns are more severe. we compared scalds, contact, and flame/fire burns at our burn center to determine which type were more likely to result in full thickness injuries and prolonged length of stay (los). material and methods: we conducted a structured retrospective medical record review of all patient admissions to a regional burn unit over a -year period between and . data included demographic, clinical, and specific burn characteristics. the association between patient predictor variables and outcomes (full thickness burns, los) was explored using chi-square and stepwise logistic regression. results: there were , patients with either scald (n = , %), fire/flame (n = , %) or contact burns (n = , %). burn depth was not available for cases ( %). mean (sd) age was ( ), % were male. mean (sd) total body surface area (tbsa) was ( )%. % of burns contained areas of full thickness injury. patients with scalds were younger than those with contact or fire burns ( ± vs. ± vs. ± years respectively, p \ . ). the percentage of burns that were full thickness by etiology were contacts ( %), fire/flame ( %) and scalds ( %); p \ . . after adjusting for age, location, and tbsa, scalds were less likely to result in full thickness injuries than contact burns (odds ratio . , %%ci, . - . ). adjusting for multiple testing, univariate analysis (as well as the multivariate analysis) showed no difference in % rd degree burns between fire and contact burns, but scalds were significantly lower than each of those. los for scalds ( ± ) and contact burns ( ± ) was significantly shorter than for fire/flame ( ± days, p \ . ). conclusions: while less common, contact and flame burns were more likely to result in full thickness injuries than scalds. references: epidemiology, treatment, costs, and long-term outcomes of patients with fireworks-related injuries (rocket); a multicenter prospective observational case series introduction: the aim of this study is to provide detailed information about the patient and injury characteristics, medical and societal costs, and clinical and functional outcome in patients with injuries resulting from fireworks. material and methods: a multicenter, prospective, observational case series performed in the southwest netherlands trauma region, which reflects % of the netherlands and includes a level i trauma center, a burn center, and an eye hospital. all patients with any injury from consumer fireworks, treated at a dutch hospital between december , and january , , were eligible for inclusion. exclusion criteria were unknown contact information or insufficient understanding of dutch or english language. the primary outcome measure was injury characteristics. secondary outcome measures included treatment, direct medical and indirect societal costs, and clinical and functional outcome until one year after trauma. results: out of patients agreed to participate in this study. the majority was male (n = ; %), % were children \ years, and % were bystanders. injuries were located to the upper extremity or eyes and were mostly burns (n = ; %) of partial thickness (n = ; %). fifteen ( %) patients were admitted and ( %) patients needed surgery. the mean total costs per patient were € , ( % ci € , to € , ). patient-reported quality of life and functional outcome was not significantly different during follow-up compared with pre-trauma. conclusion: the most common injuries afflicted by consumer fireworks were burns, mostly located to the upper extremity, and eye injuries. fireworks can result in severe injuries, for which ( %) patients needed hospital admission and ( %) patients needed surgical treatment. although some injuries resulted in permanent disability, year after trauma it in general did not have major or longlasting impact on patients'' self-reported quality of life or functional abilities. persistent inflammation, immunosuppression and catabolism syndrome after polytrauma: a rare syndrome with major consequences. l. hesselink , r. spijkerman , r. hoepelman , l. koenderman , l. leenen , f. hietbrink umc utrecht, trauma surgery, utrecht, netherlands, wilhelmina children's hospital, center for translational immunology, utrecht, netherlands introduction: more severely injured patients survive the critical first phase after trauma nowadays. a substantial portion of these patients require long-term critical care support and suffer from recurrent infections. this clinical condition fits in a syndrome referred to as ''persistent inflammation, immunosuppression and catabolism syndrome'' (pics). the aim of this study was to investigate the incidence of pics and clinical outcomes of trauma patients with pics in a level one trauma center. material and methods: all trauma patients c years admitted to the intensive care unit (icu) for c days between and , were included. patients with isolated neurological injuries were excluded. pics patients were identified by icu stay c days, c infectious complications and increased catabolism. infectious complications included infections during hospitalization and readmissions due to an infection. increased catabolism was defined as weight loss [ %, a body mass index. results: of the , polytrauma patients, patients had an icu stay c days. after exclusion of patients with isolated neurological injuries, patients were included. of these patients, developed pics. pics patients sustained infectious complications on average (compared to in the non-pics group, p \ . ) and . % of the pics patients developed sepsis. also, pics patients had a longer hospital stay (mean of days versus days, p \ . ) and sustained more surgical procedures (mean of versus per patient, p \ . ). infectious readmissions occurred until years after the initial trauma. conclusions: patients who develop pics experience long-term inflammatory complications that lead to frequent readmissions and surgical procedures. therefore, despite its low incidence, this clinical condition forms a burden on patients and a substantial financial burden on society. hyperbilirubinemia as a risk factor of the trauma icu patient introduction: hyperbilirubinemia is common in the intensive care unit (icu). hyperbilirubinemia has been considered as a risk factor of the icu patient. hyperbilirubinemia can have various causes. the hyperbilirubinemia has never been studied for the trauma icu patient. the aim of this study is to elucidate the incidence and effects of the hyperbilirubinemia for the trauma icu patient. material and methods: retrospective review of the trauma icu patients from . . to . . . initial bilirubin serum level, h bilirubin level, day bilirubin level, highest bilirubin level, overall morbidity and mortality and other clinical variables were identified and evaluated. the patients who have highest bilirubin level c . mg/dl were defined as hyperbilirubinemia group. results: a total patients were enrolled in this study. hyperbilirubinemia above serum bilirubin c . mg/dl were appeared in patients. the mortality of the hyperbilirubinemia group was higher than the other group ( . % vs . %, p = . ). the icu stay of the hyperbilirubinemia group was longer than the other group ( . day vs . day, p = . ). the hyperbilirubinemia group had more incidences of pneumonia, acute kidney injury, and sepsis than the other group ( . % vs %, p = . / . % vs . %, p = . / % vs %, p \ . ). conclusions: the hyperbilirubinemia is a risk factor of the trauma icu. if the hyperbilirubinemia is appeared, the cause of the hyperbilirubinemia should be evaluated and make an effort to correct hyperbilirubinemia for the each cause of the hyperbilirubinemia. case history: we present the clinical case of a male patient of years old. injury mechanism: a firework burst on his right forearm. clinical findings: injury: a large area of carbonization of the muscles of the flexor compartment. signs and symptoms: intense pain in the hand and forearm with local oedema and tension. diagnosis: deep burn of the forearm. therapy and progressions: surgical debridement and fasciotomy of this compartment; followed by deferred and progressive primary closure by means of rubber bands that were tightened as the oedema diminuished-shoelace technique. evolution: discharged from hospital on the th pos op day; follow-up at rd and th month without functional impairment, with a good healing evolution. comments: deep burns that reach the subfascial planes of the limbs, increase the pressure in the muscular compartments, and may progress to a compartment syndrome. there is no specific cutoff value of pressure for this diagnosis; consequently, the final decision to proceed with a fasciotomy relies on the clinical experience. surgical debridement and fasciotomy may result in large wounds, sometimes difficult to close. grafts and flaps result in another wounds and carry a risk of pain, infection, scar shrinking and necrosis. the diagnosis of a limb compartment syndrome is almost always a clinical one and requires a high index of suspicion so as to the fasciotomy is done in time. the shoelace technique is a simple, reproducible and cost-effective method of deferred closure of a large wound, preserving functionality and resulting in a good final cosmesis. references: johnson ls et al, management of extremity fasciotomy sites prospective randomized evaluation of two techniques, am j surg. . the use of propranolol in the management of acute thermal burn injury: evaluation of the effect of fixed dosages in african patients c. jac-okereke , i. onah , esut teaching hospital, surgery, enugu, nigeria, national orthopaedic hospital, enugu, nigeria introduction: propranolol has been shown to improve outcomes in burn patients. its effects are achieved at doses that reduce the heart rate by - %. africans have a different propranolol pharmacogenetic profile as compared to other races. there is paucity of literary works on the use of propranolol in africans with burns. in our study, we explored the effectiveness of fixed dosages of propranolol in nigerian patients. material and methods: this was a prospective comparative study of adult burn patients; two test groups received propranolol mg/day and mg/day respectively. the average daily pulse rate prior to and after the administration of propranolol were compared. results: patients in the control group had no effective reduction in their pulse rate. patients who received propranolol at a dose of mg/day had a reduction c %. no adverse events were observed. conclusion: it is important to establish the effective dosage of propranolol in burn patients of african-descent and explore its potential benefits in their treatment. although we cannot draw strong case history: the authors present in their paper three cases of blunt abdominal injury caused by seat belt in car accident. in the first two cases there was no diagnostic problem thanks to clear clinical finding. in the third case there was no clinical correlation and even repeated auxiliary examinations did not indicate the need for surgical intervention of the abdominal cavity. clinical findings: case no. -male y. old, haemodynamic stability, thoracic an abdominal pain, fast positivity, on ct free fluid in abdominal cavity, small spleen laceration, positivity of peritoneal symptomatology. case no. -male y. old, haemodynamic stability, bilateral hypogastric pain without peritoneal symptomatology, fast with small perihepatic fluid, on ct fluido-pneumoperitoneum. case no. -female y. old, haemodynamic stability, thoracic pain, massive oedema on the right side of the neck and supraclavicular area, without abdominal symptomatology. fast with small subhepatal fluid collection- mm, ct scan with large neck haematoma and fracture of st rib, apical pneumothorax- mm. intraabdominal only subhepatal fluid stripe- mm, suspected of small hepatic laceration. after days the clinical status rapidly changed, during h peritoneal symptomatology occured. on control ct scan fluido-pneumoperitoneum was detected. investigation/results: all patients underwent surgical procedure diagnosis: bowel mesenteric injury therapy and progressions: the first patient underwent ileo-caecal and hartmann resection, by the second patient was small intestine and col. sigmoideum resection needed, and the last one underwent ileal resection and npwt. comments: despite the current diagnostic methods blunt abdominal injuries, unlike the penetrating ones, can present a certain diagnostic problem especially when they are accompanied by other serious conditions such as manifest chest injuries. introduction: patients with hypertension and peritonitis must undergo a laparotomy. in isolated parenchymal lesions of the liver, the spleen or kidneys interventional or conservative approaches are more frequently used. to miss a hollow viscus organ lesion, that would need an operative procedure, is a constant fear. it is the aim of this study to identify significant predictors of the simultaneous presence of a hollow viscus lesion in patients with parenchymal organ lesions. material and methods: data of over ' inpatients of a levelone-trauma centre between and were analysed. only hemodynamically stable patients with a splenic-, liver-, or kidney injury (independent of grade) after blunt abdominal trauma were included. significant predictors were detected in bi-and multivariant analysis. results: of the patients with an average age of ± years % (n = ) had a splenic-, % (n = ) a liver-and % (n = ) a kidney rupture. the total iss was ± points. in patients ( %) a hollow viscus injury could be found (stomach n = , small bowl n = , colon n = , rectum n = ). injuries of the thorax ( %), the extremities ( %), the head ( %), the vertebra column ( %) and the pelvis ( %) were diagnosed as concomitant injuries. due to multivariant analysis neither age, gender, heart frequency at admission, gcs, base excess, the coagulation parameters, the hemoglobin value nor the separate injury regions could be identified to be predictive factors for the presence of a hollow viscus lesion. conclusions: clinical parameters taken at admission are not useful to predict hollow viscus injuries. the ct-scan is currently seen to be the best possible imaging modality, but it can be false negative, especially within the first min after trauma. repetitive clinical examination is necessary. in doubt a diagnostic laparoscopy or even laparotomy has to be performed. introduction: a heavy abdominal trauma is associated with a high morbidity and mortality. it is the aim of this study to show injury patterns in the abdomen and concomitant injuries in polytraumatized patients as well as to identify risk factors of the decease. material and methods: data of over ' inpatients of a level-one trauma centre between and were retrospectively analysed. only patients with a relevant abdominal trauma (ais abdomen c ) were included. the ais score was determined either with a contrast enhanced computed tomography or intraoperatively. significant risk factors were detected in bi-and multivariate analysis. results: patients with an averaga age of ± years were included. % (n = ) had an ais abdomen of , % (n = ) of and % (n = ) of . the overall iss was ± points. the mechanism of injury was mainly blunt ( %). a splenic rupture was present in % (n = ), a liver rupture in % (n = ) and a kidney rupture in % (n = ). hollow viscus injuries were present in % (small bowl n = , colon n = , stomach n = , rectum n = , bladder n = ). concomitant injuries were determined in % of the patients. of these % were diagnosed a thoracic injury, % injuries at the extremities, % head injuries. % spinal injuries and % pelvic injuries. the mortality was % (n = ). a liver rupture (p = . , or . ), pelvic injuries (p = . , or . ), age (p = . , or . ), hypotension (systolic blood pressure \ mmhg) (p = . , or . ) and a low gcs at admission (p \ . , or . ) were determined to be significant risk factors. conclusions: in our trauma department life threatening abdominal traumata are treated about every days. lethal abdominal injuries were mostly associated with serious liver ruptures or pelvic injuries. due to our experience we recommend the use of an early ct-scan as thereby the injury severity can be fast and precisely assessed. case history: a yo female was tranferred to our icu on day of a severe acute necrotizing alchoolic pancreatitis with mof. crrt with cytosorb was immediately started. on day after onset (dao ) an acs with a new organ failure (lung) showed up. open abdomen (oa) and tac with mesh-mediated/npwt got a temporary improvement. clinical findings: on dao (oa ), reopening of the mesh entailed a sudden fascial retraction of cm. a new larger mesh was positioned. on dao (oa ) the fascial defect measured both on ct slices and in or was cm. provision of a longterm oa was done. therapy and progressions: a new fascial traction device (fas-ciotensÒ, germany) was positioned on dao (oa ), with a continuous traction weight of - kg. revision was scheduled any - days, according to clinical needs, including combined anterior and retroperitoneal necrosectomy. progressive traction allowed to get a cm fascial gap under traction on dao (oa ). anterior cst was thus performed and fascia primarily closed. completion of necrosectomy was done through the bilateral lumbar incisions and npwt. comments: early fascial closure is a goal in oa. mesh-mediated traction/npwt is the most effective strategy, but primary fascial closure is sometimes impossible. the duration of oa is a key point. fasciotensÒ allowed to overcome the failure of mesh-mediated option and avoided fascia retraction in a longterm oa. it was quickly managed by the nurse staff, allowed a easier access to the abdomen and a proper positioning of the protective film. its effectiveness in this demanding case makes it an interesting option for shortening fascial closure in septic oa too. background: small bowel obstruction (sbo) caused by intra-abdominal adhesions is one of the main surgical emergencies. in most of the time, adhesions are created by previous abdominal surgeries. without any severity signs, the medical treatment is first proposed to avoid superfluous surgery. we noticed that the failure of medical treatment is frequently seen in patients previously operated of appendicectomy. the purpose of this study is to determine the eventual relation between a previous appendicectomy and failure of medical treatment in sbo. methods: we conducted a retrospective data collection using a diagnostic code for bowel obstruction in patients who have consulted in emergency from . . to . . at the salengro university hospital in lille. using the administrative database, patients were identified. we excluded all children, patients with wrong diagnosis and those whose outcome was not known. finally, patients with sbo on intra-abdominal adhesions confirmed on ct-scan were reviewed. the patients were separated in two groups. the group (g ) included patients who required surgical management during hospitalization ( patients) and group (g ) patients with successful medical treatment ( patients). we compared the rate of previous appendectomy in these two groups using a pearson's chi-squared test. in a second step, we tried to find out if there were others factor associated with failure of medical management. results: there was significant difference between the two groups with a higher rate of appendectomy in the surgical management group g (p = . ). this difference was even more pronounced if appendectomy was the only surgical history. in the subgroup analysis of patients with previous appendicectomy, the laparoscopic approach or laparotomy didn't influence the outcome of the management of the sbo. conclusion: this study shows the difference between the two groups of sbo, with more surgery sanction in the group of patients previously operated of appendicectomy. perhaps because this surgery involves the very distal part of the small bowel and decrease the efficiency of a proximal nasogastric aspiration. these results should not change the initial management of sbo by medical treatment in absence of severity signs. however, knowing this data, we have to consider that a history of appendicectomy is a risk factor of failure of medical treatment in this situation. introduction: diaphragmatic injuries are a rare consequence of closed thoraco-abdominal trauma that could be difficult to detect due to paucity of clinical signs and frequent erroneous interpretation of radiological images. the overall incidence of diaphragmatic injury is , - , % in blunt trauma. if the injury is not recognized it could lead to considerable risk of late morbidity and mortality. this study reviews our years experience in the management of this patients. material and methods: a retrospective review of trauma registry of our tertiary referral centre was performed. preoperative, intraoperative and postoperative data were analysed to assess determinants of mortality, morbidity and effect of therapeutic delay by univariate analysis models. penetrating injuries were excluded from the study. results: over years patients with diaphragmatic injury due to blunt trauma were identified: had a simple laceration of the diaphragm without hernia, had acute and chronic diaphragmatic hernia. the mean patient age was years (range -- years). overall mortality was %. the site of injury was the left diaphragm in cases, the right diaphragm in cases and bilateral in case.the hernia content was stomach ( ), colon ( ), spleen ( ), liver ( ), omentum ( ) and multiorgan ( ). all acute patients were managed with primary suture repair via laparotomy except for two patients that required additional thoracotomy; chronic patients were treated laparoscopically in cases ( , %), in which a synthetic or a biosynthetic mesh was used to reinforce the suture. higher morbidity and mortality was seen in multiple associated injuries, head injuries associated, right diaprhagm injury, age [ years and treatment delay [ h. conclusions: delayed treatment of diaphragmatic injuries could be dramatic: it is importnat not to misinterpreter the radiological findings and to reassess the patient mantaining a high level of suspicion of these injuries. trauma opposing vector forces resulting in distal avulsion of internal oblique muscle: a case report p. spada , p. fransvea , g. altieri , m. di grezia , v. cozza , g. pepe , a. la greca , g. sganga fondazione policlinico universitario agostino gemelli irccs, catholic university of rome, division of emergency surgery, roma, italy case history: abdominal muscle injuries after blunt trauma are rare but increasingly recognized. here we report a case of blunt trauma resulting in a complete disinsertion of the distal part of the internal oblique muscle. case report: y.o. male, was involved in a roll over motor vehicle accident. primary survey was carried out according to atlsÒ approach with good response. he had a seatbelt sign. according to the dynamic of the trauma he underwent a ct. diagnosis: a ce-mdct revealed complete disinsertion of the oblique muscles of the left abdomen from their iliac insertion, with herniation of adipose tissue and hematoma of the soft tissues without active blushing. no other traumatic injuries were identified. therapy progressions: a conservative treatment of the hematoma of the left abdominal wall was adopted. the patients was then ischarged from hospital after days. no late complications were observed. comments: the overall incidence in all traumatic admission is . - . %. a deep knowledge of vector force involved in trauma and their influence in the specific anatomical changes of the abdominal wall muscle can lead to suspicious of this rare injuries even if no other lesion are detected. in our opinion this trauma case is useful in reminding us to look for it because the radiologist or a no well experienced trauma surgeon may miss it fondazione policlinico universitario agostino gemelli irccs, catholic university of rome, division of emergency surgery, roma, italy introduction: the best and correct management of patients with open abdomen (oa) is nowadays still unclear. our algorithm consists of using an intra abdominal negative pressure wound therapy device plus an early medial mesh mediated fascia traction (''step by step'' procedure). the aim of this study was to asses outcomes of this algorithm technique based on patient conditions and open abdomen technique performed. materials and methods: we performed a retrospective analysis of patients treated with open abdomen technique from / / to the / / . variables taken into account were: initial diagnosis, open abdomen technique used, number of surgical interventions, abdominal wall closure technique, length of stay in the icu, inhospital morbidity and mortality rates. we collected also data on the post-operative development of incisional hernias and entero-atmospheric fistula. results: / of open abdomen were done after trauma. in the remaining cases open abdomen was done for non-traumatic disease. patients have been treated following our algorithm (with negative pressure wound therapy abthera device and step by step approach with medial mesh mediated fascia traction). in this group fascial retraction was significant lower and definitive direct abdominal wall closure rate was statistically higher. conclusion: an early fascia traction mediated with a mesh lead to an earlier fascia closure with a lower need of mesh positioning for definitive closure; the rate of post incisional hernia is similar among the two groups references: case history: a year old male presented in the er with malaise, fatigue and loss of appetite. he was recently hospitalised due to a peritonsillar abscess and during investigations he was first-diagnosed with non-hodgkin lymphoma. his medical and surgical history were otherwise unremarkable. clinical findings: on admission the patient was febrile and tachycardic (hr bpm) but remained hemodynamically stable (bp: / mmhg). clinical examination revealed abdominal distention and rebound tenderness in the right abdomen. investigation/results: blood tests were significant for leukocytosis (wbc: . /ll-neut: %), acute kidney injury (urea: mg/dl, cr: . mg/dl), elevated crp ( mg/l) and ldh ( iu/l), hyponatremia (na: mmol/l) and hypoalbuminemia. chest and abdominal x-rays were non-diagnostic, while abdominal ultrasound showed increased air presence along the medial line. investigations concluded with an abdominal ct scan that revealed pneumoperitoneum, small bowel distention and multiple enlarged mesenteric lymph nodes. diagnosis: the patient was transferred to the or for an explorative laparotomy. he was diagnosed with ileo-cecal intussusception causing bowel ischemia and perforation at the ileocecal valve. enlarged lymph nodes were observed along the mesentery. therapy and progressions: the affected ileus and colon were removed and a subtotal colectomy with end ileostomy was performed. the pathology report confirmed infiltration of the dissected bowel and lymph nodes by lymphoma cells. the patient continued treatment in the icu. he was discharged on the th postoperative day. comments: intussusception is rare in adults and, contrary to children, is highly associated with malignancies. resection without reduction has been advocated-wherever possible-in order to ensure better oncological outcomes. introduction: emergency surgeries are oftenly related to contaminated/infected fields, where the implantation of non reabsorbable meshes for reconstruction of the abdominal wall may not be recomendable. we aim to evaluate the results of polyvinylidenfluoride (pvdf) meshes used for complicated ventral hernia in the acute setting material and methods: retrospective analysis of patients with vh undergoing emergency surgery on which a pvdf mesh was required, in a third level hospital (november -september ). we analyzed early and late postoperative complications and -year recurrence rates. association between grade of contamination, mesh placement and infectious complications and recurrences was investigated using binary and multiple regression. results: we collected patients with a mean age of '' years, mean bmi of '' kg/m and mean cedar index of '' . '' % of patients had a grade - ventral hernia according to rosen''s index. concomitant procedures included al least one organ resection in '' % of surgeries and previous contamined mesh explantation in '' %. a pvdf mesh was placed using an intraperitoneal onlay mesh (ipom) technique in '' % of cases and an interposition location in '' %. readmission rate was '' %, one-month recurrence '' % and recurrence after a year '' %. overall mortality rate was . %. risk of recurrence was related with patients with a rosen score over (p \ . ) and also with postoperative ssi (p = . ). higher recurrence rates were not found regarding the pdvf meshes placement. postoperative seroma and hematoma rates were '' % and '' %. enteroatmospheric fistula rate was '' %. conclusions: pvdf prosthesis seems to be an useful material for complicated ventral hernia repair, specially in the acute setting, showing similar recurrence and infectious complication (fistula, chronic mesh infection, surgical site infection) rates with regard to different prosthesis used in the literature. operative vs non-operative management in liver trauma patients in a uk major trauma centre conclusions: the airs can predict the histologic severity and the intra operative findings in patients with a high clinical suspicion of aa. airs could be useful to reduce negative appendectomy and predict the postoperative stay to evaluate the deformity progression in spine injuries (dorsal, dorsolumbar, lumbar) managed by internal fixation. introduction: there continues to be controversy surrounding the management of thoracolumbar burst fractures. numerous methods of fixation have been described for this injury, but to our knowledge, spinal fusion has always been part of the stabilising procedure, whether this involves an anterior or a posterior approach. material and methods: patients with spinal injury (dorsal, dorsolumbar, lumbar) were included. all patients had dorsal, dorsolumbar, lumbar spine injuries managed with posterior short segment pedicle screw fixation and were followed up for at least one year after surgery. preoperative, post operative and follow up lateral radiographs were examined for cobb''s angle, anterior wedge compression angle and upper and lower adjacent intervertebral disc heights anteriorly, middle and posteriorly. results: at final follow up, the mean improvement in cobb''s angle post operatively was . °. the mean loss of correction of cobb''s angle was . °with sd of . °compared to post operative. the mean improvement in anterior wedge compression angle was . °post operatively. the mean loss of reduction in anterior wedge compression angle was . °with sd of . °. the increase in cobb''s angle was statically significant (r = . , p = . ) with the loss of reduction of anterior wedge compression angle at follow up and loss in intervetebral disc height at upper intervetebral disc anteriorly only(r = . , p = . ). the mean period at which sitting and standing was initiated was . months and . months respectively and mean periods for which brace was used was . months. conclusions: pedicle screw fixation is good but related to loss in reduction of anterior wedge compression angle and decrease in upper intervertebral disc height anteriorly. references: p. l. sanderson:short segment fixation of thoracolumbar burst fractures without fusion. introduction: with the newly implemented ao upper cervical spine classification system a modern, pragmatic system has been established. to what extent the simplification is helpful or whether an adjustment of the new ao classification may be discussed, forms the question of this work. material and methods: retrospective analysis of upper cervical spine injuries with ct/mri diagnostics presented to trauma surgeons with several years' experience to do classification and suggest treatment. results: the classification according to the known systems showed a relatively good agreement in the exact classification and therapy. the classification according to the new ao upper cervical spine was simple and consistent but revealed different treatment recommendations for two subtypes (iii type a and iii type b). conclusions: the new ao upper cervical spine classification system leads to a simplification. uncertainties remain with the most frequent fractures on the upper cervical spine, the c fractures. these will be managed under iii type a. however, just these injuries require completely different treatment concepts. further adaptation is required for type iii b because there uncertainties regarding the therapy also remain. case history: a -year-old woman, on treatment with acenocoumarol due to atrial fibrillation, and interatrial communication, suffered a compression fracture of the vertebrae l to l after a lowenergy trauma. due to poor pain control, she underwent a percutaneous transpedicular kyphoplasty, with no intraoperative complications. clinical findings: during the immediate postoperative period, she developed dysarthria and claudication of barré in her right upper limb. investigation/results: an angio-ct scan was performed, showing endovascular material in the left middle cerebral artery (mca) and within the lungs, compatible with cement emboli. mri showed cortico-subcortical ischemic areas in mca territory. cement-embolism stroke after percutaneous kyphoplasty therapy and progressions: conservative treatment was chosen due to the high number of emboli and the favorable evolution of the patient, with resolution of the neurologic symptoms in h without sequelae. days later, she suffered a transient ischemic attack, with no changes in the ct-scan compared to the previous images, which also solved with no residual deficits. one month after this episode, the patient died due to a spontaneous cerebellar hemorrhage related to acenocoumarol overdose. comments: kyphoplasty is a safe technique performed to treat vertebral compression fractures in elderly patients, with good clinical results and a low complication rate. its main complications are related to the leakage of cement from the vertebral body, usually well tolerated. other complications are exceptional, such as cerebral strokes, cardiac perforation, or death. the present case, although infrequent, shows us the need to assess the risk-benefit balance when operating fragile patients, as life-threatening complications may happen in these procedures. references: . marden fa, putman cm. cement-embolic stroke associated with vertebroplasty. ajnr am j neuroradiol. nov; ( ): - . survival rate and application number of total hip arthroplasty in patients with femoral neck fracture: an analysis of clinical studies and national arthroplasty registers g. hauer , a. heri , s. klim , p. puchwein , a. leithner , p. sadoghi medical university of graz, department of orthopaedics and trauma, graz, austria introduction: total hip arthroplasty (tha) is an increasingly popular treatment option for fractured neck of femur (nof) [ , ] . the aim of this study was to systematically review all literature on primary tha after fractured nof to calculate an overall revision rate. furthermore, we wanted to compare primary tha implantations after fractured nof between different countries in terms of tha number per inhabitant. material and methods: all clinical studies on tha for femoral neck fractures between and were reviewed and evaluated with a special interest on revision rate. revision rate was calculated as ''revision per component years'' [ ] . tha registers were compared between different countries with respect to the number of primary implantations per inhabitant. results: twenty-two studies showed a mean revision rate of . % after ten years. we identified eight arthroplasty registers that revealed an annual average incidence of tha for fractured nof of . per , inhabitants (table ) . conclusions: we found similar annual numbers of thas for fractured nof per inhabitant across countries. revision rates in clinical studies are higher compared to registry data [ , , ] . the results of this analysis can be used to rank present and future national tha numbers within an international context. early clinical predictors of pneumonia in patients with acute spinal cord injury without bone injury: a retrospective study t. sakamoto , s. kanezaki , n. notani oita university, oita, japan introduction: pneumonia is still significant complication that associates with mortality and duration of hospitalization in patient with acute spinal cord injury without bone injury (sciwobi). the purpose of this retrospective study is to clarify early clinical predictors of pneumonia in patients with sciwobi. material and methods: we reviewed the medical records of patients with sciwobi who admitted between january and november . spearman's rank-correlation coefficient was used to test the relationship between each parameter. multiple logistic regression analysis was performed to determine the factors that influenced pneumonic morbidity. results: a total of patients with acute sciwobi, who were evaluated for neurological impairment within h after injury, were reviewed. pneumonia occurred in patients ( %), seven patients injured at c and four at c . according to spearman's rank method, asia motor score, beginning period of nutrition, ventilator use, neurological level of injury (nli) ] c , low prognostic nutritional index (pni) were correlated with onset of pneumonia. logistic regression found ventilator use to be most predictive of pneumonia (odds ratio [or] = . , % confidence interval [ci] . - ), followed by nli ] c (or . , % ci . - . ), beginning period of nutrition (or . , % ci . - . ), pni (or . , % ci . - . ). conclusions: in addition nli, low pni increases the risk of pneumonia. we consider that improving nutritional status, especially early initiation of enteral nutrition, decrease the incidence of pneumonia. bicycle-related cervical spine fractures e. helseth , j. ramm-pettersen , s. f. eng , i. naess , m. mejlaender-evjensvold , h. linnerud oslo university hospital, neurosurgery, oslo, norway introduction: the incidence of traumatic cervical spine fractures (cs-fx) in the norwegian population is / , /year, and % of these injuries are bicycle-related ( , ) . materials and methods: prospective cohort study of all bicyclerelated cs-fx in the south-east norwegian population ( . million) in the time period - . the data were retrieved from our quality control database for traumatic cs-fx in south-east norway. in the database all cs-fx patients (c (occipital condyle) to c /th ) are prospectively registered. results: during the four-year study period patients with bicyclerelated cs-fx were registered, ( %) were males, and mean age was years (range - ). the cs-fx was located in the upper cervical segment (c -c ) in ( %) patients, lower cervical segment (c -th ) in ( %), and at both segments in ( %). the most common fx subtype was c -fx. spinal cord injury secondary to cs-fx was registered in patients ( %). fracture stabilization was achieved with open surgery in ( %), external immobilization with a stiff collar alone in ( %,) and without treatment in ( %). conclusions: severe bicycle-related cervical spine injuries are not uncommon. the increasing political desire to move commuting from motorized vehicles to bicycles warrants a heightened focus on road safety. introduction: the need for cervical immobilization is predicted by the atls, the standard of care in trauma since , because cervical trauma is a important cause of disability. however, its discontinuation was linked to x-rays, a fact that has been changed thanks to the development of two algorithms that assess the severity of cervical trauma: the canadian c-spine rule (ccr) and the national emergency x-radigraphy utilization study (nexus). material and methods: this study aims to compare the reduction values in the number of ct scans required after the application of both algorithms in a level- trauma center and to verify the degree of adherence of residents in the use of each. cohort study with randomized application by residents of the algorithms in all patients suffering from blunt trauma with cervical collars who were admitted from august to october . the conducts had their frequencies analyzed to obtain an inference about the efficacy of each method in the abstention of x-rays and case resolution, in addition to verifying if the indicated conduct was followed by the resident, inferring on the confidence in the algorithm. results: cases were evaluated during this period, of which were by the ccr algorithm and by the nexus. the indication rate for ccr imaging was . % and nexus was . %, showing no statistical difference between them (p = , ; ci = %). in the evaluation of the effective conduct, which evaluated the reliability of the algorithm, there was no disagreement between them (p [ , ; ci = %). conclusions: neither method demonstrated superiority to the other in reducing the indication of imaging exams and its uses had equal adherence by resident physicians. panacek case history: a year old lady presented with severe neck pain following a fall and cervical hyper-extension injury. she had previously undergone anterior cervical discectomy and fusion at c / with placement of artificial interbody bone graft. postoperatively, the patient reported an excellent clinical outcome and later imaging confirmed interbody fusion. clinical findings: on examination, the patient was neurologically intact but reported severe mid-cervical neck pain with reduced range of movement. investigation/results: imaging included ct and mri of the whole spine diagnosis: imaging revealed an unstable hyper-extension injury of the cervical spine. a fracture extended through the caudal end of the fused graft-vertebral interface at c / with disruption of the posterior elements. therapy and progressions: given the severity of the injury surgery was recommended. the patient underwent uneventful c -t posterior instrumentation and fusion with excellent outcome (follow up two years). comments: this is the first report of a cervical spine fracture through the site of an anterior cervical discectomy and fusion. it is hypothesised that the fused cervical segment resulted in increased stress at the fused caudal graft-vertebral interface during hyper-extension, this combined with reduced tensile strength at the graft-vertebral interface resulted in this unusual transverse fracture pattern. the clinician should be aware that patients presenting with cervical spine trauma in the context of previous cervical spine surgery are prone to greater mechanical forces. there should be a high index of suspicion for serious injury prompting thorough assessment and investigation. pr s -screw-fixation: computer aided study prevent unguided missile r. krassnig , w. pichler , e. viertler , a. schwarz , r. wildburger , g. hohenberger auva rehabilitation clinic tobelbad, tobelbad, austria, boldin und pichler og, graz, austria, medical university graz, graz, austria, auva unfallkrankenhaus, graz, austria, medical university graz, orthopaedics and trauma, graz, austria introduction: transiliosacral screw fixation of unstable dorsal pelvic ring fractures is not much present neither in literature nor in practice. in cause of the complex anatomy and the varying narrow safe bony corridors its a demanding procedure. limited information is available on optimal placement and the geometry of safe zones for screw insertion in the pelvis. material and methods: d-reconstructions of consecutive ct scans of polytraumatic injured patients ( female, male) were the basis to insert two virtual cad bolts (representing screws) into the first two sacral segments as performing during screw fixation. results: in s the narrowest point was reached after a mean of . mm respectively . mm, depending on the selected way of measurement. for s the mean distance to the tricky constriction area amounted to . mm, respectively . mm. the average height in s measured . mm and the average width . mm. according, the average height for s was . mm and the average width . mm. the measurement results didn't show a significant difference between male and female pelvis bones for any distance of interest. conclusions: an optimal screw position is very important, because in the areas of bony narrowing are the exit points of the sacral nerves, which exit through the foramina anteriorly and posteriorly. damage to this nerve structures can cause severe long-term consequences such as numbness or paralysis. knowledge of predefined distances may aid in preoperative planning, decrease operative and radiation times and may prevent unguided missiles. clinical findings: there were absent breath sounds on the right side of the thorax, ultrasound showed an extensive pleural effusion. a chest tube was inserted and l of bloody-milky fluid was drained. investigation/results: ct scan showed fractured c -c and th -th vertebral bodies, fractured lateral osteophytes of th - and probable injury of the thoracic duct at th - level. pleural effusion analysis showed raised cholesterol and triglyceride levels. diagnosis: traumatic chylothorax; fractures th -th , th -th , c -c therapy and progressions: patient was kept on ventilatory support for days. primarily she was treated with total parenteral nutrition followed by no fat and hypolipidemic diet. the chest tube was removed after days. she was discharged in stable condition the following day. at the month check-up she was stable and eupnoic. comments: traumatic chylothorax caused by blunt chest trauma is extremely rare. there are hypotheses that injuries to the thoracic duct are caused by hyperextension of the spine or by increased thoracic/ abdominal pressure (seat-belt injuries). in our case, chylothorax probably resulted from fractured lateral osteophytes. patients are usually successfully treated with pleural drainage and total parenteral nutrition. if there is no improvement after weeks or if drainage exceeds . l/day or l/day for more than days, thoracic duct ligation should be considered. conservative treatment resulting in t-l or lumbar kyphosis can worsen the quality of life of the patient whereas traditional open surgery may be an overtreatment in some cases, considering blood loss, possible complications, hospital stay and delayed functional recovery. in this setting, a good option can be a percutaneous minimally invasive surgery. the advantages of percutaneous pedicle screw fixation are: preservation of posterior musculature, less blood loss, shorter operative time, lower infection risk, less postoperative pain, shorter hospital stay and easier implant removal after bone union. limitations such as inability to achieve direct spinal canal decompression can be dealed by combination with open techniques. the objective of this study was to report the results of ppsf on these fractures and the technical problems we had to overcome. methods: patients are included, treated with percutaneous transpedicular fixation and stabilization with minimally invasive technique from december to october . patients were males, females; average age was , years (range from to ). in all cases, system pathfinder-nxt (zimmer) was used. results: most of the patients presented an early post-operative mobilization with amelioration concerning pain and a low complication rate. limitations in mobilization were mainly due to coexistent injuries, polytrauma or non-reversible neurological deficit. conclusion: ppsf is a reliable and safe procedure which does not replace the open technique but adds to treatment options by restoring a good sagittal alignment similar to those reported for open surgery. removal of hard material is advocated after fracture healing to preserve the lumbar spinal mobility and avoid zygapophyseal joint osteoarthritis. critical surgery within the first hour of presentation: is it a feasible intervention for better trauma care outcomes in low and middle income countries? introduction: in low and middle-income countries (lmic) golden hour care concept is almost nonexistence due to resource constraints. in this study, we analyzed one novel concept of critical surgery within the first hour of admission as a possible intervention which could be applied in the existing scenario in these countries without much resource requirement. material and methods: a retrospective analysis of a prospectively maintained data registry under a project named titco (towards improved trauma care outcome) was done. registry data from a level - trauma centre in india were analyzed from october to september . all patients who admitted and underwent critical surgical interventions within the first hour of presentation were analyzed. these patients were divided into two groups depending upon primary presentation or referred from another facility. statistical analysis was done between these two groups to compare the outcome. results: sixty-one ( . %) patients were directly admitted from the site of the incident whereas forty-five ( . %) were transferred from other hospitals for surgical needs. the median time from injury to presentation for primary patients was min with interquartile range (iqr) of . in the referred patient median time gap between the injury to our center (not referring center) was min with iqr of . this difference was statistically significant. major outcome indicators in the form of median icu and total stay, as well as mortality, were not significantly different conclusions: proposed concept might be a useful hospital-based intervention in existing trauma system in lmic to improve the outcome of injured patients along with improving prehospital services. oslo university hospital, ullevål, orthopedic department, oslo, norway, extrastiftelsen, oslo, norway introduction: it is well-known that physical activity is good for us. although the skeletal muscle is the main organ which is directly affected, exercise affects the whole body. the mechanisms responsible for these beneficial effects are gradually becoming known to us through extensive research. this might make it easier for physicians to prescribe exercise as a therapy equally and even more beneficial than drugs regarding effect and risk profile. the aim of this thesis was to review the current literature on the molecular mechanisms of exercise-induced health benefits. material and methods: a search in medline and embase resulted in articles. they were sorted by title and abstract, then by reading the full text. relevant articles from the reference-lists were included. sources were found outside of the search. results: when we exercise, the skeletal muscle is subjected to several mechanical and chemical stimuli, which in turn activate a set of kinases and phosphatases. these are molecules that regulate transcription-factors and co-activators, and this leads to adaption of the muscle-cells. i addition, the muscle secretes a number of proteins called myokines, which conduct the effect of exercise to other organs and tissues. some lead to increased cerebral neuroplasticity, hypertrophy and angiogenesis (bdnf, vegf and igf- ). several interleukins have also been identified as myokines, and they mediate an anti-inflammatory effect which is favorable in the prevention and management of conditions like atherosclerosis and type diabetes. lastly, we found that exercise leads to epigenetic changes, altering the genetic expression in several types of tissues. some studies suggest that the epigenome is affected by exercise even before we are born, giving babies born to physically active mothers a favorable epigenetic expression. conclusions: we should use this knowledge to support the implementation of physical activity in treatment and preventive health care. impact on undertriage and mortality after changing from a twotiered to one-tiered trauma team activation protocol costs. prognostic factors may assist in identifying high cost groups with potentially modifiable factors for targeted preventive interventions, hence reducing costs and increase rtw rates. evaluation of long-term follow-up and consequences of gunshot and stab wounds in a french civilian population introduction: the data concerning long-temr follow-up of patients and consequences of gunshot wound (gsw) and stab wound (sw) are almost inexistent in the literature. in finland, a study showed that % of patients with trunk wounds died secondarily from alcohol-related or violent problems [ ] , highlighting the secondary importance of long-term care for these patients. the main objective of our study was to analyze the hospital and posthospital follow-up of patients with gsw or sw and to evaluate late complications and the consequences of these traumas. material and methods: from january to january , patients were hospitalized for gsw or sw management in laveran military hospital. hospital data were collected via informatic patient file and post-hospital data via a telephone questionnaire with the general physician (gp). results: median hospital follow-up was days . seventy-six patients had a follow-up visit with their gp ( %). median follow-up was mois . twenty-four patients were totally lost to follow-up ( . %). global follow-up identified patients with longterm consequences ( . %), psychiatrics and organics. seventeen cases of recurrence were found ( . %). high iss, age, gsw and gp identified in patient medical file were significantly linked to long-term consequences occurrence. conclusion: this study showed a high number of long-term consequences occurrence among patients with gsw or sw. however, the extra-hospital follow-up seems insufficient. it is therefore imperative to strengthen the compliance and adherence to the care network of these patients. awareness and involvement of medical, paramedical teams and gp role seems essential to screening and management of these consequences. introduction: focused assessment with sonography for trauma(-fast) is an effective tool for assessments of severely injured patients, especially in the settings of helicopter emergency medical service(hems) because of limited devices and time. the objective of this study is to investigate accuracy of trauma ultrasound in helicopter emergency service compared with enhanced ct scan. material and methods: we investigated the trauma patients in years which was demonstrated fast and delivered to the advanced critical care center in gifu university by hems. accuracy of the fast was determined by comparison to the presence of injury, primarily determined by computed tomography, and to required interventions. results: patients were included in this criteria. there were and patients in which we found fluids in thoracic or abdominal cavity by enhanced ct scans and ultrasounds in hems, respectively. sensitivity and specificity, positive predictive value, negative predictive value, accuracy were . , . , . , . , . . if we limited the data for abdominal fluids, each data were . , . , . , . , . . in the patients of negative fast with positive ct, no patient died due to hemorrhage in thoracic or abdominal cavity. conclusions: it has been reported that sensitivity of fast in hems was lower compared with in er. in the settings of prehospital trauma care, advantages of portable ultrasound could be limited because of peculiar environments. and also, the thoracic or abdominal fluids could increase with time by organ injuries and it causes fast negative in acute phases.in this series, we could not find cases which has possibility of death because of negative fast and might influence the treatment. repeated fast or careful assessment of patients based on the other findings could be beneficial. references: the sensitivity of fast in hems was low and demonstrating fast for several times could be effective to detect the thoracic or abdominal hemorrhage. pre-hospital trauma care in switzerland and germany: do they speak the same language? los angeles county ? usc medical center, department of surgery, divison of acute care surgery and surgical critical care, los angeles, united states introduction: field amputation can be life-saving for entrapped patients requiring surgical extrication. under these austere conditions, the procedure must be performed as rapidly as possible with limited equipment, often in a confined space, while minimizing provider risk. the aim of this study was to determine the optimal saw for a field amputation. material and methods: this was a prospective cadaver-based study. four saws (gigli, hand pruning, electric oscillating and reciprocating) were tested in human cadavers. each saw was used to transect four separate long bones (humerus, ulna/radius, femur and tibia/fibula). the time required for each saw to cut through the bone, the number of attempts, slippage, quality of proximal bone cut and extent of body fluid splatter as well as the physical space required by each device during the amputation were recorded. univariate analysis (fisher's exact and kruskal-wallis or mann-whitney u-test) was used to compare the outcomes between the different saws. results: the fastest saw was the reciprocating followed by oscillating ( . [ . - . ] sec vs . [ . - . ] sec, p = . ). the number of attempts required to amputate ( . [ . - . ] , p = . ) and the amount of slippage ( . [ . - . ], p = . ) were highest with the pruning saw. the reciprocating saw had the worst proximal bone cut quality ( % poor, p = . ) and the largest blood splatter ( . [ - ] , p = . ). the physical space required to perform an amputation ranged from cm with the oscillating to cm with the reciprocating saw. overall, the oscillating saw outperformed the others in number of attempts, slippage and quality of bone cut and physical space requirements, and was the second fastest ( table ) . conclusions: the speed, precision, safety, space required, as well as the highly adjustable blade in the oscillating saw make it ideal for a field amputation. a gigli saw is an excellent backup for when electrical tools cannot be used or fail. impact of air medical transport on the survival of major trauma patients in thailand e. surakarn , w. siriwanitchaphan bangkok hospital headquarters, bangkok trauma center, bangkok, thailand introduction: air medical transport is an alternative mode of interfacility transfer for injured patients who required a higher level of trauma care in thailand. this study assessed the impact of air medical transport on the survival of major trauma patients transferred from local hospitals to a tertiary care hospital. material and methods: trauma registry of - was reviewed. major trauma patients transferred by air ambulance were identified. injury severity score (iss), predicted mortality and actual survival to hospital discharge were studied and compared between two subgroups, the seriously injured patients (iss - ) and the severely injured patients (iss [ ) . the predicted mortality was calculated from the probability of survival (ps) of trauma and injury severity score (triss). results: there were major trauma patients (iss [ ) transferred by air ambulance in five years period. patients were severely injured (median iss = ), and patients were seriously injured (median iss = ). the range of flight time was - min. the overall survival rate was . %. the predicted mortality in the severely injured group was cases ( . %), but the actual mortality was nine ( . %), . % lower than predicted mortality. the predicted mortality in the seriously injured group was one case ( . %), while the actual number was two ( . %). the eleven deaths in this study were eight cases of severe traumatic brain injury(tbi) patients, two cases of massive bleeding with subsequent multi-organ failure and one drowning. conclusions: air medical transport significantly improved the survival of severely injured patients who need higher level of trauma care. severe tbi and the presence of multi-organ failure associated with unfavorable outcomes. however, a detailed analysis of the trends and epidemiology of rtis affecting the most vulnerable children in qatar, under years of age, has not been conducted. this study's primary objective of is to describe the epidemiology of rtis and deaths in young pediatric patients in qatar. material and methods: data, for all young pediatric [under years] victims of rti''s and rti deaths from january , , through december , , from the trauma registry of the hamad trauma center [htc], the national level trauma referral center of qatar, was analyzed. this data was correlated and compared with data from the hamad general hospital mortuary and vital statistics data from the qatar ministry of development planning and statistics, the vital statistics annual bulletin, for the years - . results: the htc attended to patients, under years, with severe rtis and in-hospital rti deaths were reported during the study period. males made up . % of the injured and % of fatalities.the average age of the injured was years and for fatalities was it was . years. the rti incidence rate per , for both sexes, under years, has been unchanged ( in and in ) . the road mortality rate, per , , has decreased significantly, from . in to . in . since , the proportion of pre-hospital deaths has been increasing, - %, and the in-hospital death rates has been reduced to %. conclusions: rapid improvements in pre and in-hospital post-crash care in qatar have resulted in marked reductions in in-hospital deaths for young children with rtis. the emergence of pre-hospital road deaths of under ''s must be made a priority for road safety in qatar. the implementation of proven prevention programsshould be fast tracked in order to directly address this issue. introduction: despite improving survival of patients in prehospital traumatic cardiac arrest (tca), initiation and/or discontinuation of resuscitation of tca patients remains a subject of debate among prehospital emergency medical service providers. the aim of this study was to identify factors that influence decision making by prehospital emergency medical service providers during resuscitation of patients with tca. methods: twenty-five semi-structured interviews were conducted with experienced ambulance nurses, hems nurses and hems physicians individually, followed by a focus group discussion. participants had to be currently active in prehospital medicine in the netherlands. interviews were encoded for analysis using atlas.ti. using qualitative analysis, different themes around decision making in tca were identified. results: the causes of bleeding were grouped into several categories.the most frequent cause with cases in a row is attributed to diverticular bleeding,other causes of bleeding were angiodysplasia,post polypectomy bleeding,gist tumor,rectal ulcers and inflammatory disease.no case presented mortal or serious complications,secondary to the procedure. only cases presented a mild complication: focal mucosal ischemia of the embolized intestinal segment that was resolved with conservative treatment.lesions in charge of bleeding in those cases in which the angiographic treatment failed,were:ulcer in cases,a case of bleeding after endoscopic polypectomy, a case of diverticular bleeding and bleeding secondary to a coagulation disorder.among these patients, the definitive treatment was the following: -a second angiographic treatment was effective in the case of bleeding due to coagulation disorder. -a case of self-limited bleeding. -surgical treatment was the definitive treatment in both cases of bleeding in the context of and patient with bleeding after polypectomy. we have not observed a significant relationship neither the type of lesion or its location with the probability of failure of the angiographic treatment. nor do we observe a significant relationship between the type of material used for embolization and the risk of treatment failure. comments: our data show that angioembolization is an effective and safe technique to treatment lgi bleeding. references: clin endosc . endoscopic therapy for acute diverticular bleeding introduction: the use of resuscitative endovascular balloon occlusion of the aorta (reboa) as adjunct for temporary hemorrhage control in patients with major torso hemorrhage is increasing. specifications and characteristics of available aortic occlusion balloons (aob) are diverse. in order to minimize the risk of failure and complications it is important to choose a device that fits the requirements per medical situation. the aim of this study is to provide guidance in the choice of an aob in a specific situation. material and methods: aob were assessed for characteristics and different properties of each are outlined. the bending stiffness was measured with a three-point bending device. results: although all aob tested are small caliber devices ranging from (er-reboa tm ) to french (codaÒ ), some need large bore access sheaths up to french (fogarty Ò and lemaitre tm ) or even insertion via surgical cut-down (equalizer tm ). the bending stiffness of the aob varied from . n/mm (± . sd) with the codaÒ to . n/mm (± . sd) with the russian prototype. guidewire-free devices are generally stiffer than over-thewire catheters. the tokai rescue balloon tm showed kinking of the shaft at low bending pressures. the er-reboa tm , fogarty Ò , lemaitre tm , reboa balloon Ò , and rescue balloon tm are the only catheters with external length marks to assist blind positioning. the only aob using a non-compliant balloon is the reboa balloon Ò . conclusions: specifications of available aob are diverse. in resource-limited settings, reboa should be performed with a rather stiff device that can be placed without wire and fluoroscopy, such as the er-reboa tm , fogarty Ò , and lemaitre tm . of these aob, the er-reboa tm is the only catheter compatible with a small french sheath. use of non-compliant balloons without real-time fluoroscopy is not advised given the potential risk of aortic rupture. when fluoroscopy is available, a guidewire can be considered. case history: year old male patient presenting with an initially uncomplicated pertrochanteric fracture, treated by an intramedullary nailing system (figs. and ) . days after the operation and mobilization without any adverse events the patient was readmitted. clinical findings: massive swelling, hematoma and pain. investigation/results: sudden fall of hb values down to , g/dl, ct scans showed the lesser trochanter located directly to the deeper femoral artery after mobilization (fig. ) . diagnosis: perforation of the deep femoral artery and several veins by the dislocated lesser trochanter therapy and progressions: blood transfusion, intraoperative cardiopulmonary resuscitation, several revision surgeries to stop the bleeding by oversewing the deep femoral artery and ligation of the veins, removal of the lesser trochanter fragment (fig. ) . admission to intensive care unit. subsequent plastic coverage. comments: according to literature, bleeding complications and injuries of the deep femoral artery can occur even several days after an initially uncomplicated pertrochanteric hip fracture. besides acute life-threatening bleeding, false aneurysm can occur ( ) ( ) ( ) . even if those late complications are very rare, the consequence for the patient can be devastating. these rare cases show the clear obligation to a thorough follow up treatment and regularly dressing changes. investigation/results: arterial colour doppler of the popliteal artery showed hypoechoeic contents and narrowed lumen. biphasic flow was seen in both popliteal and posterior tibial arteries. diagnosis: popliteal artery injury with delayed repair therapy and progressions: two incision and four compartment fasciotomy was done under regional block the next day which revealed a non contractile posterior compartment. superficial and deep muscles of the posterior compartment had doubtful viability. left distal sfa to infragenicular popliteal artery bypass graft was placed on day post injury. blood flow was established upto the ankle and foot, confirmed on check angio. however, foot drop of the patient persisted. after appearance of a healthy granulation tissue at the wound site ( days), a split thickness skin graft was placed to give coverage with % uptake of the graft. comments: blunt popliteal artery injury has been reported to result in amputation rates of nearly - %.the importance of a detailed vascular examination of a blunt trauma patient is emphasized as a limb can be salvaged if timely intervention is done. in this case even with an unfavourable mess score. case history: a healthy -year-old male, with no history of interest, suffers a high-energy trauma as a water bottle rushes over his left knee. clinical findings: go to the emergency room with pain and functional impotence in the left knee, with its anatomical deformity. knee x-ray pa and l are performed and the distal pulses that are present are taken. ankle-brachial index [ . . closed reduction is performed in emergencies under sedation and control x-ray is requested, aiming at correct reduction. it was decided to keep under observation for - h before discharge from hospital to schedule regulated ligament reconstruction surgery after studying with mri. therapy and progressions: at h of evolution after the accident and after having reduced the dislocation, the patient who has the leg with a temperature equal to the contralateral is reassessed, however, there is no palpable dorsal pedis pulse or posterior tibial palpation in the affected leg. it is decided to urgently request an angiotc and it is objective thrombosis of popliteal artery. vascular surgeon is contacted and emergency surgery is decided. a by-pass is performed with vena safena. diagnosis: traumatic knee dislocation and popliteal artery injury comments: in the st century, complementary tests in diagnosis are becoming increasingly important. however, in this case we want to management of aseptic tibial nonunion anastasios g. c. reamed interlocking intramedullary nailing for the treatment of tibial diaphyseal fractures and aseptic nonunions. can we expect an optimum result? results of a systematic approach to exchange nailing for the treatment of aseptic tibial nonunion management of tibial non-union using reamed interlocking intramedullary nailing the radiographic union scale in tibial (rust) fractures: reliability of the outcome measure at an independent centre pelvic trauma: wses classification and guidelines damage control orthopaedics in unstable pelvic ring injuries references: beuran, m. trauma scores: a review of the literature glasgow coma scale, age, and arterial pressure (mgap): a new simple prehospital triage score to predict mortality in trauma patients. critical care medicine. champion hr. a revision of the trauma score proximal femoral nail antirotation versus gamma nail for intramedullary nailing of unstable trochanteric fractures. a randomised comparative study results of the femur fractures treated with the new selfdynamisable internal fixator (sif) dhs helical blade for elderly patients with osteoporotic femoral intertrochanteric fractures the hypermetabolic response to burn injury and interventions to modify this response racial differences in propranolol enantiomer kinetics following simultaneous i.v. and oral administration propranolol dosing practices in adult burn patients the hypermetabolic response to burn injury and modulation of this response: an overview. wound heal south africa management strategies and outcome of blunt traumatic abdominal wall defects: a single centre experience blunt traumatic abdominal wall hernias: a surgeon's dilemma blunt traumatic abdominal wall hernias: associated injuries and optimal timing and method of repair traumatic abdominal wall herniation: case series review and discussion trauma patients with open abdomen: do they differ from others? a single center experience h. fagertun , a. seternes department of circulation and medical imaging, trondheim, norway introduction: treatment with open abdomen is demanding for patients, staff and hospital. a multidisciplinary approach is mandatory. the aim of this study was to compare trauma patients with open abdomen (oa) and patients treated with oa for other reasons, regarding outcome and resources spent. material and methods: retrospective study of patients treated with oa in a tertiary hospital in norway. ten were trauma patients vacuum-assisted wound closure and mesh-mediated fascial traction for open abdomen therapy-a systematic review prospective study examining clinical outcomes associated with a negative pressure wound therapy system and barker's vacuum packing technique thoracic-abdominal trauma with diaphragm lesions n. vlad , i. streanga , a. morar , i st. spiridon'' hospital iasi. we have analyzed clinical data, trauma mechanism, pathology of the lesion, time trauma-diagnostic, associated lesions, treatment, and follow-up. results: there have been patients ( men, women), mean age . location of diaphragmatic tears has been on the left hemidiaphragm ( cases), on the right hemidiaphragm ( cases), or bilateral ( cases). the trauma mechanism has been blunt ( cases) or penetrant ( cases). all patients had associated visceral lesions and had been operated right diaphragmatic injury and lacerated liver during a penetrating abdominal trauma: case report and brief literaturereview traumatic diaphrag-matic ruptures: clinical presentation, diagnosis and surgicalapproach in adults traumatic rupture of the diaphragm: experiencewith patients % ( / ) were aast grade or . in the total group, median age was years, . % were male and . % were blunt injuries. median iss in the nom group was and in the om group. median iss for those with grade or injury was . . % ( / ) underwent nom, compared to . % ( / ) of those with aast grade or . for each mmhg increase in systolic blood pressure, patients with grade or injury were % less likely to have an operation (or . , p = . ) and for each beat increase in heart rate intra-operative grade i was revealed in patients ( , %), grade ii in ( , %), grade iii in ( , %) grade iv in ( , %) and grade v in ( , %). histologic finding of catarral appendicitis was found in ( , %) patients, ( %) had phlegmonous appendicitis and ( , %) had gangrenous appendicitis. the airs difference was statistically significant with histological findings quality of publications regarding the outcome of revision rate after arthroplasty swedish hip arthroplasty register annual report joon yung lee: risk factors for failure of nonoperative treatment for unilateral cervical facet fractures in , patients were included in the trauma registry. median iss was and patients had an iss [ . of these patients / ( %) were undertriaged with a mortality of / ( %). the total mortality in was , % ( / ). i , median age was years for the patients with no tta vs years for those patients who did receive a tta (p \ . ) prognostic factors for medical and productivity costs, and return to work after trauma: a prospective cohort study l results: a total of trauma patients ( % of total study population) responded to at least one follow-up questionnaire. mean medical costs per patient (€ , ) and mean productivity costs per patient (€ , ) varied widely. prognostic factors for high medical costs were higher age, female gender, spine injury, lower extremity injury, severe head injury, high injury severity, comorbidities, and pre-injury health status. productivity costs were highest in males, and in patients with spinal cord injury, high injury severity, longer length of stay at the hospital and patients admitted to the icu. prognostic factors for rtw were high educational level, male gender, low injury severity swiss and german (pre-)hospital systems, distribution and organisation of trauma centres differ from each other [ , ]. it is unclear if outcome in trauma patients differs as well. therefore, this study aims to determine differences in characteristics, therapy and outcome of trauma patients between both german-speaking countries. material and methods: the traumaregister dguÒ (tr-dgu) was between - and - were included if they required icu care or died. trauma pattern trauma care in germany trauma systems in europe practical assessment of different saw types for field amputation: a cadaver-based test study these themes were: factual information (e.g., electrocardiography rhythm)educational programs and future guidelines. references: rosemurgy as, prehospital traumatic cardiac arrest: the cost of futility blunt vertebral vascular injury in trauma patients: atlsÒ recommendations and review of current evidence treatment-relater outcomes fron blunt cerebrovascular injuries. importance of routine follow-up arteriography provided the catheters used for this study. no other support was provided diagnosis: the probe had perforated the ivc wall. therapy and progressions: open repair was performed through a xifopubic laparotomy and the cattel-braasch maneuver to expose the ivc (fig. ). a retroperitoneal hematoma was observed anteriorly to the infrarenal ivc, without active bleeding. the ivc was dissected out sufficiently to permit proximal and distal vascular control (fig. ), the probe was then removed and the laceration on the infrarenal ivc closed with a running suture. the postoperative course was uneventful. comments: to our knowledge this is the first reported case of symptomatic ivc laceration by an ice probe during ca. references: enriquez a. use of intracardiac echocardiography in interventional cardiology complications of catheter ablation for atrial fibrilla iatrogenic percutaneous vascular injuries: clinical, presentation, imaging, and management vascular complications during catheter ablation of cardiac arrhythmias: a comparison between vascular ultrasound guided access and conventional vascular access false aneurysm of the profunda artery resulting from intertrochanteric fracture. a case report profunda femoris arterial laceration secondary to intertrochanteric hip fracture fragments. a case report with major thoraco-abdominal vascular injuries (aorta, inferior vena cava and main branches). data on demographic, clinical status and imaging was recorded. descriptive and kaplan meir survival analysis was performed. results: patients were included. median age was years (iqr - ), ( . %) were male. aorta was the most frequently damaged vessel ( , %) the median iss was (iqr - )interventional procedure. overall mortality was %, with % of deaths during the first hour, . % in the first h and . % afterwards. median survival was days (ic - ). we compared survival curves in periods abdominal vascular trauma. trauma surg acute care open history: popliteal artery injuries are frequently seen with fractures, dislocations, or penetrating injuries. a thirty one year old pathologies. references: natsuhara, k.m. et al, what is the frequency of vascular injury after knee dislocation knee dislocation and vascular injury: -year experience at a uk major trauma centre and vascular hub can vascular injury be appropriately assessed with physical examination after knee dislocation? introduction: this retrospective cohort study investigated the prevalence of and risk factors for preoperative venous thromboembolism (vte) in patients with a hip fracture and a delay of [ h from injury to surgery. material and methods: this observational study included patients with a hip fracture surgically treated at university hospital. patients underwent indirect multidetector computed tomographic (mdct) venography for preoperative vte detection after admission. overall vte risk and median time from injury to ct scan were calculated. age, sex, fracture type, time from injury to ct scan, body mass index, preinjury mobility score, previous anticoagulation treatment, previous hospitalization for vte, varicose veins, and medical comorbidities were considered potential risk factors. results: the prevalence of preoperative vte was . % ( of patients). the mean time from injury to ct scan was . days. the delay from the time of injury to ct scan averaged . days for patients who developed preoperative vte, compared with . days for patients who had not developed vte. in the adjusted models, female sex, subtrochanteric fracture, pulmonary disease, cancer, previous hospitalization for vte, and varicose veins were risk factors for vte. the final multivariate logistic regression analysis introduction: vertebral compression fractures constitute a large percentage of traumatic injuries of spine. the initial management plays an important role in the final outcomes. the present study aims to study the profile of vertebral injuries in rural & semi urban population & to analyse the role of level two hospitals in initial management of vertebral injuries. material and methods: this study was a retrospective analysis of progressively collected data of patients presenting with vertebral injuries in a level two hospital catering to semi urban & rural population in india. the initial presentation along with the age & sex profile was noted. etiological factors leading to compression fractures were noted. any neurological deficit either at the time of admission or transfer to a tertiary care neurocentre was noted as per asia scale. initial management was carried out in accordance with the atls guidelines. results: a total of out patients admitted with complaints of back pain were diagnosed to have compression fractures of the spine. the mean age was . years. male: female ratio was approx : . the lumbo sacral spine region was the most comply affected region. two patients were incidentally detected to have vertebral fractures as a result of metastatic malignancy. a due note was made regarding patients who had deteriorated during the transfer in terms of neurological deficit & evidence of spinal shock. conclusions: road traffic accidents contribute a significant portion of vertebral trauma . smaller hospitals & general surgeons have an important role to play in terms of initial stabilisation of such patients particularly the ones presenting with neurogenic shock. a good initial management has sigificant bearing on outcomes. analysis of risk factors for tracheostomy in cervical spinal cord injury without bone injury n. notani , s. kanezaki , t. sakamoto , h. tsumura oita university, orthopaedic surgery, yuhu, oita, japan introduction: there are many cases that require tracheostomy in the acute phase of cervical spinal cord injury, and various risk factors have been reported so far. however, there has been no report on cervical spinal cord injury without bone injury. the aim of this study is to evaluate risk factors for tracheostomy in patients with cervical spinal cord injury without bone injury. material and methods: we conducted a retrospective observational study. patients who were treated for cervical spinal cord injury without bone injury in our hospital were divided into groups: tracheostomy (tc) group and no tracheostomy (no tc) group. we compared variables, including age, sex, asia impairment scale (ais), neurological level of injury (nli), injury severity score (iss), vital signs, blood gas analysis, tracheal intubation, chest complication, smoking history between two groups. results: there were patients in tc group, and patients in no tc group. on univariate analysis, there were significant differences in age, ais a, tracheal intubation, nli ] c . on multivariate analysis, nli ] c was an independent predictor of tracheostomy. conclusions: in this study, we demonstrated that nli ] tc could be useful to predict tracheostomy in patients with cervical spinal cord injury without bone injury. case history: many fractures of the articular processes of the cervical spine are associated with displacement and instability, approximately % of all traumatic cervical spine injuries involve isolated fracture of the articular processes non-displaced or minimally displaced. [ ] this case demonstrates a isolated facet fracture of the cervical spine with c radiculapathy treated with minimally invasive spine surgery techniques clinical findings: a -year-old male was admitted to the neurosurgery department due to severe neck pain (vas / ). the pain radiating to the right upper extermity along dermatome c . neck and trunk rotation worsened the pain. investigation/results: furthermore, physical examination revealed hyperaesthesia in the right index finger without muscle weakness. ailments suddenly appeared weeks earlier after getting up in the morning. imaging demonstrated isolated, unilateral fracture of the right superior articular process of c diagnosis: imaging demonstrated isolated, unilateral fracture of the right superior articular process of c therapy and progressions: the patient was treated by microsurgical c decompression and fusion of c - under navigation guidance. intraoperative ct scans were performed to evaluate sufficient bone removal.after the surgery, the neck and upper extremity pain subsided. the patient had returned to his usual job and sport activities. comments: this case illustrates the value of the navigation and intraoperative ct in the evaluation of bony decompression, anatomy and location of implants. navigation minimized iatrogenic injury resulting in reducing postoperative complications like chronic pain, kyphotic deformity and muscular atrophy.introduction: resuscitative endovascular balloon occlusion of aorta (reboa) is a technique initially developed in the military for trauma patients injured in combat . recently, there has been much debate on its role in civilian trauma cases in controlling non-compressible torso haemorrhage (ncth) . this review aims to provide an update on current literature on the outcomes and concerns of this procedure. material and methods: a systematic literature search according to prisma guidelines was performed over the period of january to august across embase, medline and cochrane databases. patient characteristics, mechanism and severity of injury, survival rates and post-reboa complications between survivors and non-survivors were compared. results: a total of studies were included in this review. % and % of the reboa cases were penetrative and blunt cases respectively. the survival rates ranged from to % across the studies. systolic blood pressure (sbp) was significantly elevated post-procedure, from . to . mmhg in the survivor group (p \ . ) and . to . mmhg in the non-survivor group (p = . ). the injury severity score (iss) was lower in the survivor group ( . vs . ; p \ . ) whereas their glasgow coma scale (gcs) was higher ( . vs . ; p = . ). the survivors also had a shorter duration of aortic occlusion ( . vs . min; p = . ). common complications noted following the procedure include renal injury, lower limb ischaemia and thrombosis. conclusions: pre-reboa sbp, iss, gcs and duration of aortic occlusion were found to be associated with survival. complications directly due to the procedure were difficult to ascertain. a prospective study in a multiple trauma centre is needed for further evaluation of the indications, feasibility and complications involved in reboa. references: introduction: traumatic vertebral artery injury (vai) is a wellknown complication of cervical spine injury and often causes posterior circulation stroke. we report preventive effect of acute phase endovascular intervention for traumatic vai. material and methods: all patients with cervical spine injury were surveyed with post-contrast computed tomography for vai. when vai was diagnosed, the affected vertebral artery (va) was occluded with endovascular intervention before spine reduction and fixation. brain ischemic lesion was evaluated before and after the treatment. results: forty-one patients with vai associated with cervical spine injury underwent endovascular intervention. the affected va was occluded with endovascular coils before cervical spine reduction and fixation in patients, and after treatment in one patient. va stenting was done for another two. six presented new brain infarctions after spine surgery. of these, two had endovascular intervention after spine reduction. out of patients who had endovascular embolization before spine reduction, four had newly developed infarctions after spine surgery, of which two were symptomatic. there were no complications related to the endovascular procedure. conclusions: in conclusion, endovascular embolization for traumatic vai before spine reduction and fixation was found to be effective to prevent symptomatic brain infarction. introduction: the use of drug coating balloons (dcb) in primary or secondary angioplasty for peripheral vascular disease is a new tendency. the use of paclitaxel decelerates the growth and hyperplasia of neo-intima tissue which can cause re-stenosis and total occlusion in the spot of pta is a very promising technique in long lasting results of balloon ptas. purpose: to demonstrate our experience and results of the technique of dcb pta with the use of drag coating balloons. material and method: in the period between march and september , patients with sfa lessions were treated with pta with dcb for acute limb ischemia. were males and females. mean age was , y.o (± . ). patients were examined pro operationally and immediate post operationally in abi difference and their post operational follow up included measurement of abi and u/s triplex scan on the st, rd, th and th month(where chronically available) after pta. results: the mean immediate post operative increase of abi was , (± , ). were chronically available the increase of abi remained to , in the months follow up, , in the months and , in the th month follow up while patency of the artery treated remained in all patients. of the patients suffered from acute complications during or short after the pta ( with peripheral embolization and with retroperitoneal hematoma) which were treated immediately and left no consequences. conclusions: the use of dcb for pta in acute ischemia is a quite new, promising technique for maintaining patency of treated arteries for long time post operative period. the medium time results from its use in our clinic seem to be satisfactory. jichi medical university hospital, tochigi, japancase history: a -year-old male hit his neck hard against the fence. thereafter, he experienced difficulty in breathing and severe neck pain. he was brought to the emergency center by ambulance. clinical findings: his vital signs on arrival were gcs: e v m , hr: , bp: / , rr: , spo : ( lo ). significant neck edema and tracheal deviation were noted. inspiratory stridor was not heard with no signs of retracted breathing or subcutaneous emphysema. investigation/results: an enhanced ct scan of the neck revealed tracheal deviation and compression with ruptures of the left thyroid lobe. a large hematoma and arterial extravasation from a branch of the inferior thyroid artery were noted. diagnosis: rupture of the left thyroid lobe and injury around the distal portion of the left inferior thyroid artery. therapy and progressions: after securing the airway by intubation, angiography of the neck was performed; extravasation from a branch of the left inferior thyroid artery was suspected. angioembolization was continued for hemostasis using gelatin sponge. neck edema improved in the intensive care unit. following extubation on the hospital day , the patient was discharged on the th day with no complication. comments: thyroid injury due to blunt neck trauma is rare and surgical intervention such as hemithyroidectomy is generally prescribed. the patient''s condition, in this case, improved by angioembolization without any invasive surgical procedures. catheter procedure may, thus, be effective for hemostasis on thyroid injury after the confirmation of airway placement. introduction: the indication for resuscitative endovascular balloon occlusion of the aorta (reboa) is hemodynamically unstable patients in life-threatening hemorrhage below diaphragm. it was unclear that the difference of indications for reboa affects mortality in trauma.material and methods: this study used data from the japan trauma data bank (jtdb) ( - ), a nationwide trauma registry, to describe the epidemiology of reboa. adult trauma patients used reboa were included. patients were excluded if they had cardiac arrest at the scene or dead on arrival, or had an unsurvivable injury of any region of the body as defined by the abbreviated injury scale. patients were classified by whether patients had indications for reboa. the indications for reboa were defined by indications for hemostasis to intraabdominal, retroperitoneal, pelvic or extremity hemorrhage. the indications were decided by the delphi method with the cooperation of experts in trauma for this study. the contraindications were defined by brain injury needed intervention and hemorrhage above diaphragm. the logistic regression was used to assess the mortality after adjustment for injury severity score. as a sensitivity analysis, a generalized linear mixed model with random effects of a facility was performed. results: of , patients registered in the jtdb, patients underwent reboa. had indications for reboa and underwent reboa without indications. the physiological variables were similar, but the consciousness was worse in the no-indications group. injury severity of brain and chest were higher in the no-indications group. the indications group had . % and the no-indications group had . % contraindications for reboa. the mortality was similar ( . % versus . %, or . , %ci . - . ). a sensitivity analysis showed the same result as the primary analysis (or . , %ci . - . ). introduction: most incident first responders have a primary nonmedical role, but are frequently the only professionals initially at the scene. early hemorrhage control via advanced techniques such as resuscitative endovascular balloon occlusion of the aorta (reboa) can save lives. training first responders these techniques has therefore the potential to improve outcomes. this study evaluates the ability to train quick response team fire fighters (qrt-ff) to gain percutaneous femoral artery access and place a reboa catheter, using a comprehensive theoretical and practical training program. material and methods: six qrt-ff participated in the training. sof medics from a previous training served as control group. a formalized training curriculum included basic anatomy and endovascular materials for percutaneous access and reboa catheter placement. key skills were: ( ) preparation of an endovascular toolkit, ( ) achieving vascular access in the model and ( ) placement and positioning of the reboa catheter. results: qrt-ff had significantly better baseline knowledge of surgical anatomy (p = . ) compared to medics. they also scored significantly better on using endovascular materials (p = . ), performing the procedure without unnecessary attempts (p = . ) and overall technical skills (p = . ). the median time from start to reboa inflation was : min for qrt-ff and : min for medics. procedure times improved in all qrt-ff and of the medics in a second attempt of gaining vascular access and reboa placement. conclusions: our comprehensive theoretical and practical training program proves suitable for percutaneous femoral access and reboa placement training of qrt-ff without prior ultrasound or endovascular experience. repetition reduces procedure times. training in the use of advanced hemorrhage control techniques such as reboa, as a secondary occupational task, has the potential to improve outcomes for severely bleeding casualties in out-of-hospital settings. prytime medical tm devices, inc. provided the reboa access task trainer (ratt) and the catheters used for this study. no other support was provided.the authors declare that there are no conflicts of interest that could inappropriately influence (bias) their work. introduction: angioembolization (ae) has become an important component in the management of bleeding from severe pelvic fractures. timely availablity of ae is required for both, level and trauma centers. the aim of this study was to assess the utilization of this procedure in level and trauma centers and effect on oucomes. material and methods: retrospective, -year ( - ) study using the the american college of surgeons tqip database, including adult patients with isolated severe pelvic facture (ais [ ] [ ] [ ] . patients who underwent laparotomy or preperitoneal packing within h from admission were excluded, operative management for bleeding control between and h was considered as failure. univariate analysis was used to compare patients in level vs centers, multivariate regression analysis was performed to determine factors predictive for mortality and overall complications.results: patients ( in level ; in level centers) met the criteria for inclusion. overall, ( . %) underwent ae, with a trend toward higher ae rate in level centers ( . % vs . %, p = . ). no significant differences were observed in timing and failure rate of ae between the levels. particulary in the ae subgroup there was a significantly lower blood product utilization in the first h in level i centers (prbc . vs . units, p = . ; plasma . vs . units, p = . ). mortality and overall complication rates were similar. table the level of trauma center was not a predictive factor for mortality (or . , p = . ) and overall complications (or . , p = . ). conclusions: in isolated severe pelvic fractures, there was a trend toward higher ae rate and significantly lower utilization of blood products in level centers. there were no significant differences in mortality or complications. the ae subgroup in level centers had a higher blood products use without outcome benefit, suggesting more restrictive transfusion policy may be considered. portal vein thrombosis after distal splenopancreatectomy: successful recanalization using fogarty balloon catheter case history: intraoperative lesion of smv during distal splenopancreatectomy is repaired using peritoneal patch harvested from anterior abdominal wall clinical findings: postoperative increase in serum lactate and d-dimer without signs of peritonitis prompts bedside doppler us showing no blood flood within portal vein (pv) investigation/results: ct angiography is performed suspecting acute mesenteric ischemia, but no abnormal bowel enhancement/ thickness is seen despite complete pv thrombosis. anticoagulation with unfractioned heparin is started, but clinical conditions deteriorate diagnosis: at reintervention, bowel is viable, so the surgeon performs fogarty balloon catheter thrombectomy successfully reestablishing blood flow within pv. no intestinal resection is required therapy and progressions: pv patency is regularly evaluated with us. anticoagulation with low molecular weight heparin is prosecuted for months and then suspended since no recurrence is recorded meanwhile comments: pv thrombosis is uncommon but can follow injury to portal venous axis during surgery. anticoagulation with heparin should be started as soon as the diagnosis is made and maintained for at least - months postoperatively to prevent recurrence. patients with persisting/worsening symptoms - h after initiation of anticoagulation, or those with peritonitis who are poor surgical candidates may be considered for interventional radiological treatment. otherwise, surgical intervention is required and may encompass resection of necrotic bowel. thrombectomy and/or balloon dilation/vascular stent placement may be helpful in recently developed pv thrombosis since risk of recurrence seems to be decreased references: acute mesenteric ischemia: guidelines of the world society of emergency surgery (world j emerg surg ); mesenteric venous thrombosis (j clin exp hepatol ); contemporary management of acute mesenteric ischemia in the endovascular era (vasc endovascular surg ) key: cord- -s rxzm t authors: burnouf, thierry title: modern plasma fractionation date: - - journal: transfus med rev doi: . /j.tmrv. . . sha: doc_id: cord_uid: s rxzm t protein products fractionated from human plasma are an essential class of therapeutics used, often as the only available option, in the prevention, management, and treatment of life-threatening conditions resulting from trauma, congenital deficiencies, immunologic disorders, or infections. modern plasma product production technology remains largely based on the ethanol fractionation process, but much has evolved in the last few years to improve product purity, to enhance the recovery of immunoglobulin g, and to isolate new plasma proteins, such as α -protease inhibitor, von willebrand factor, and protein c. because of the human origin of the starting material and the pooling of to donations required for industrial processing, the major risk associated to plasma products is the transmission of blood-borne infectious agents. a complete set of measures—and, most particularly, the use of dedicated viral inactivation and removal treatments—has been implemented throughout the production chain of fractionated plasma products over the last years to ensure optimal safety, in particular, and not exclusively, against hiv, hepatitis b virus, and hepatitis c virus. in this review, we summarize the practices of the modern plasma fractionation industry from the collection of the raw plasma material to the industrial manufacture of fractionated products. we describe the quality requirements of plasma for fractionation and the various treatments applied for the inactivation and removal of blood-borne infectious agents and provide examples of methods used for the purification of the various classes of plasma protein therapies. we also highlight aspects of the good manufacturing practices and the regulatory environment that govern the whole chain of production. in a regulated and professional environment, fractionated plasma products manufactured by modern processes are certainly among the lowest-risk therapeutic biological products in use today. protein products fractionated from human plasma are an essential class of therapeutics used, often as the only available option, in the prevention, management, and treatment of life-threatening conditions resulting from trauma, congenital deficiencies, immunologic disorders, or infections. modern plasma product production technology remains largely based on the ethanol fractionation process, but much has evolved in the last few years to improve product purity, to enhance the recovery of immunoglobulin g, and to isolate new plasma proteins, such as a protease inhibitor, von willebrand factor, and protein c. because of the human origin of the starting material and the pooling of to donations required for industrial processing, the major risk associated to plasma products is the transmission of blood-borne infectious agents. a complete set of measures-and, most particularly, the use of dedicated viral inactivation and removal treatments-has been implemented throughout the production chain of fractionated plasma products over the last years to ensure optimal safety, in particular, and not exclusively, against hiv, hepatitis b virus, and hepatitis c virus. in this review, we summarize the practices of the modern plasma fractionation industry from the collection of the raw plasma material to the industrial manufacture of fractionated products. we describe the quality requirements of plasma for fractionation and the various treatments applied for the inactivation and removal of blood-borne infectious agents and provide examples of methods used for the purification of the various classes of plasma protein therapies. we also highlight aspects of the good manufacturing practices and the regulatory environment that govern the whole chain of production. in a regulated and professional environment, fractionated plasma products manufactured by modern processes are certainly among the lowest-risk therapeutic biological products in use today. a elsevier inc. all rights reserved. c ollected human plasma may be used as a therapeutic product (known as bclinical plasmaq or bfresh frozen plasmaq) or as source material for the production of pharmaceutical fractionated products (also called bplasma productsq or bplasma derivativesq). this complex biologic material contains hundreds of proteins covering a myriad of physiological functions. many components still have undiscovered roles. the most abundant proteins, albumin and immunoglobulin (ig) g, are present at about and g/l, respectively, representing about % of all plasma proteins. less abundant proteins include the protease inhibitors, like a -antitrypsin (aat) ( . g/l) and antithrombin (at) ( mg/l), and the coagulation factors such as factor viii (fviii) (a few ng/l), which exhibit potent physiologic activity. currently, about different plasma protein therapeutics are used for treating life-threatening diseases or injuries associated to bleeding and thrombotic disorders, immunological diseases, infectious conditions, as well as tissue degenerating diseases, thus addressing the clinical needs of countless patients. an updated list of the major therapeutic applications of plasma protein products can be found elsewhere. this industrial process used to isolate therapeutic plasma proteins is known as bfractionation.q over to million liters of human plasma are fractionated each year in the world, in batches of several thousand liters, in about factories. modern plasma fractionation combines manufacturing steps to isolate, in a sequential and integrated manner, the crude fractions that are further purified into individual therapeutic products. validated dedicated steps inactivate and/or remove infectious agents potentially present in the starting plasma pool. this sophisticated industrial process is performed under highly hygienic conditions in licensed facilities (plasma fractionation plants) that are operated in compliance with good manufacturing practices and following quality assurance principles. over the years, plasma fractionation has evolved from a medical service activity mostly oriented toward the needs of local communities into a global manufacturing industry conforming to high regulatory standards. these strict requirements start from the collection of plasma for fractionation and include product manufacture and distribution steps. in this article, we review the most current practices encompassing the collection of plasma for fractionation, the core industrial plasma fractionation process, and the purification and pathogen reduction technologies of individual plasma products. the practices used for the collection of plasma for fractionation have direct influence on the safety profile of protein products since individual donations contribute to large plasma pools used to manufacture therapeutic preparations intended for hundreds or even thousands of patients. it is therefore logical that the production of plasma is regarded as an integral part of the manufacture of modern fractionated products. collection requirements of plasma for fractionation may differ from those relevant to fresh frozen plasma. in a regulated environment, plasma for fractionation is collected by licensed/registered blood establishments (blood centers and apheresis collection centers) that are inspected by the relevant national regulatory authorities (nras). compelled by the same safety concerns, the plasma fractionators conduct audits to verify that the contractual plasma collection and quality and safety measures, agreed upon with the plasma supplier, are met. areas of specific relevance include (a) procedures for donor screening and donation testing; (b) labeling, documentation, and traceability requirements; and (c) the handling of blood and plasma. such information is part of the marketing license of plasma products and, in europe, is assembled into a document called the bplasma master file.q various requirements for the collection of plasma for fractionation have been described in various guides, eg, from the pharmaceutical inspection convention and pharmaceutical inspection cooperation scheme (jointly referred to as pic/s), us food and drug administration (fda) and in recent world health organization recommendations. they are summarized below. candidate donors are provided with educational materials and undergo a medical interview to establish the absence of risks or signs of infections and to prove compliance for a donation of plasma for fractionation (table ) . potential donors presenting a health hazard are asked to exclude themselves. medical information of donors is acquired and archived. continuous epidemiologic surveillance of the donor population is being required in some jurisdictions. it helps to establish the background level (prevalence and incidence) and trends of known infectious markers (eg, hiv and antibodies, hepatitis c virus [hcv] antibodies, and hepatitis b surface antigen [hbsag]) in the population. this is also of interest for the early detection of emerging diseases, allowing early implementation of counter measures (such as more stringent donor screening processes or requirements for additional testing procedures). donors eligible to donate plasma for fractionation are individuals who meet donation criteria (such as age and donation frequency), do not present risk factors of blood-born infectious agents, and comply with requirements defined by the plasma fractionator and the nras of the country of plasma collection and of use of the products. in most situations, eligibility of whole blood donors and apheresis donors overlap, apart from donation frequency which is higher for plasmapheresis donors. eligibility criteria take into account scientific information about the risks of transmission of infectious agents by pooled plasma products (which may differ from those by blood components). special criteria may exist for the collection of hyperimmune plasma (used to make hyperimmune igg preparations), such as procedures for donors' immunization and minimal antibody titer. currently, about % of the plasma fractionated in the world is obtained by centrifugation of whole blood (brecoveredq plasma), and % is obtained by apheresis. blood/plasma collection, processing, and storage may affect plasma quality, as well as having an impact on the recovery of the most labile proteins such as fviii. in particular, risks of activation of the coagulation, complement, and fibrinolytic systems, which may lead to generation of plasma proteases, should be avoided. to better preserve the integrity of recovered plasma and limit risks of activation of the coagulation cascade and of cellular components, (a) good mixing of the blood with the anticoagulant solution (a sodium citrate based solution ) should be ensured from the initiation till the end of the collection process; (b) the duration of the collection should not exceed minutes; and (c) temperature variations of the blood should be avoided. a few hours after donation, whole blood is subjected to a centrifugation that separates the cellular elements (most specifically red cells) from plasma. the mean plasma volume obtained from one whole blood donation is about ml but varies depending upon the volume of collected whole blood (most often - ml) and donor's hematocrit. apheresis plasma (also called bsource plasmaq) is collected from donors through a process where blood is removed from the donor, anticoagulated (generally with a % sodium citrate solution), and immediately separated by physical means (centrifugation or filtration, or a combination of both) into components. at minimum, the red cells are returned to the donor while plasma is retained and collected in a container (bag or plastic bottle). the duration of a typical plasmapheresis procedure depends on the number of cycles (and, hence, the volume of plasma collected) and lasts generally from to minutes. apheresis plasma volume may range from to ml, depending upon the country's regulations and collection protocol. apheresis plasma can also be prepared as a byproduct of plateletpheresis (bconcurrent plasmaq), a procedure used primarily for the collection of platelets. both recovered and apheresis plasmas are suitable for the manufacture of the whole range of fractionated plasma products. the mean content in coagulation factors, more particularly fviii, is lower in recovered than in apheresis plasma because of (a) longer processing time before freezing (whole blood must be further processed to separate cellular components and plasma), (b) higher ratio of anticoagulant and, possibly, (c) the higher level of cellular contamination that may release proteolytic enzymes affecting the stability of coagulation factors. apheresis plasma contains less igg when collected from frequent donors. protein content and quality of fractionated proteins is apparently not affected by the apheresis system used, although residual cell content differ based upon the type and configuration of the cell separation device. plasma from membrane apheresis procedures, as does recovered plasma prepared from whole blood leukoreduced on positively charged filters, may performed by most fractionators. ymandatory in europe for hcv. zmay contribute to viral clearance but does not necessarily result in robust and consistent removal. §for small viruses, robust removal is achieved by narrow pore size membranes (v nm). texpected contribution based on experimental studies using spiked tse agents, in the absence of information of the biological nature of the tse-human plasma associated agent. contain more activated complement component and (c a, c a) anaphylatoxins, - but the impact on the quality or yield of fractionated products is unknown. various infectious agents have been identified as potential contaminants of human blood. bacteria, parasites, and intracellular viruses are not transmitted by plasma products because they are destroyed by freeze-thaw steps or removed by the . -to -lm filtration steps used during the processing of fractionated products. pathogenic plasma-borne viruses include hiv, hcv, hepatitis b virus (hbv), west nile virus (wnv), hepatitis a virus (hav) and parvovirus b (b ). the various complementary safety nets in place during the production chain of fractionated products, from donor selection to industrial product extraction, to optimize safety against these agents are summarized in table . the importance of viral testing on the safety of plasma products has been reviewed. , , the extent of viral testing of plasma for fractionation takes into account the ability of validated fractionation processes to eliminate viral risks. some testing is performed by blood establishments, other by plasma fractionators (table ) . individual plasma donations must be negative for anti-hiv and , anti-hcv, and hbsag. genomic assays of plasma minipools for nonenveloped hav and b may be performed. , relevance of testing for the absence of hiv p ag or wnv nucleic acid testing (nat), which may be justified for the safety of non-virally inactivated blood components, is arguable for plasma for fractionation subjected to robust viral reduction steps of enveloped viruses. the industrial manufacturing pool (usually the cryo-poor plasma that is the first homogeneous pooled plasma fraction) is also tested to confirm the absence of serologic and/or genomic viral markers of hiv, hbv, hcv, hav, and b . in spite of the most rigorous donor screening and donation testing, infectious viruses may still be present in plasma fractionation pools. therefore, the viral inactivation-removal steps that have been deliberately introduced during plasma products manufacture-and that are described below-play a most critical role in ensuring safety. altogether, these overlapping tests should ensure that the viral load of the manufacturing should is both minimal and significantly below the viral reduction capacity of the manufacturing processes used. preserving fviii during blood/plasma collection and preparation is important for most fractionators preparing coagulation factor concentrates. apheresis plasma can generally be frozen quickly, ensuring optimal fviii preservation. by contrast, whole blood has to be centrifuged to separate the various components. when blood is cooled to c after collection, plasma should be separated and frozen within to hours to preserve fviii, but when cooled rapidly at constant c using devices like butanediol plates, coagulation factors are stable for up to to hours. plasma frozen within hours is suitable for igg and albumin production. after separation from cellular elements, plasma for fractionation should be frozen rapidly below À c, À c, or À c, depending upon local regulations. plasma used to manufacture only albumin and igg may be frozen below À c within hours of collection. in the us code of federal regulations, apheresis plasma should be stored at À c or colder immediately after collection. rapid plasma freezing, to ensure rapid ice front velocity and core temperature of À c, preserves fviii and appears more important than the actual freezing temperature itself. plasma for fractionation is stored at less than À c, or colder, typically for several months or more. storage temperature should be as constant as possible, including the transportation to the fractionation facilities. cross-continent or intercontinent shipment of plasma for fractionation is frequent. production steps taking place at fractionation plants are summarized in figure , and typical plasma protein downstream methods are presented in table . physical compliance with shipping requirements is verified at delivery of the plasma frozen plasmas are expelled from the plastic containers and pooled for cryoprecipitation and further manufacturing steps, as described below. intermediate fractions generated during production may be stored for subsequent pooling and processing. purified sterile-filtered products are aseptically dispensed into final containers (glass vials or bottles). albumin bottles undergo terminal pasteurization. many products, but albumin and some igg preparations, are freeze-dried, typically for a duration of to days, depending upon physicochemical characteristics and filled volumes. batches are quarantined while quality controls and checks of production files take place. batches meeting specifications are labeled and packaged and subsequently boxed and shipped for distribution. in a few countries, product batches may be released by regulatory authorities. the production cycle of fractionated products takes a few weeks to several months. current core fractionation technology largely relies on a backbone process encompassing cryoprecipitation and cold ethanol precipitation steps, as developed in the s by cohn et al in the united states, or modified by kistler and nitschman in europe. this process involves successive processing steps at defined ethanol concentrations, associated with shifts in ph, temperature, and osmolality that result in selective precipitation of proteins, most notably igg and albumin. precipitates are separated by centrifugation or filtration. in the last few years, the complexity of the fractionation process has increased by (a) the introduction of chromatography to isolate new proteins from existing fractions such as cryoprecipitate, cryo-poor plasma, and cohn fractions; (b) the integration of chromatography to the ethanol fractionation process to increase igg recovery; and (c) the implementation of dedicated viral inactivation or removal steps. chromatography was introduced in the s; however, its application developed mostly in the mid/late s. anion-exchange chromatography and affinity chromatography are frequently used to capture proteins at physiological ph and ionic strength, therefore best preserving functional activity. , immobilized heparin and monoclonal antibodies are common affinity chromatography ligands. chromatography is used for specific goals: (a) improvement of products purity, (b) extraction of trace labile proteins, (c) optimization of protein recovery, and (d) removal of viral inactivation agents. figure illustrates a typical industrial fractionation scheme of standard plasma. plasma packs (typically for a batch of - l) are opened under hygienic conditions, and plasma is expelled from the containers and thawed at c to c. cryoprecipitate is isolated using refrigerated continuous centrifuges, recovered from the centrifugation bowls and frozen at À c or colder for storage until further pooling and processing. the cryo-poor plasma is immediately processed for primary chromatographic capture of labile coagulation factors (such as the factor ix [fix] complex and its components) and protease inhibitors (such as at and c esterase inhibitor [c -inh]). the prepurified intermediates may be stored frozen until further processing. the coagulation factors/ anticoagulant-depleted plasma undergoes sequential ethanol precipitation steps. this leads to successive precipitations of fibrinogen, igg and albumin fractions, and intermediates for extraction of other therapeutic proteins, such as aat (fraction iv- ), or igm (fraction iii). depth filtration is preferred to centrifugation to separate precipitates and improve protein recovery. the fractionation of hyperimmune plasma (eg, anti-rhesus) is usually performed on small plasma batch sizes, increas- ingly using full chromatographic processes to optimize the recovery of igg. no documented transmission of hiv, hbv, or hcv by products subjected to dedicated viral inactivation treatments has been recorded since the end of the s. viral reduction treatments include inactivation steps (where viruses are bkilledq) and removal steps (where viruses and proteins partition into distinct fractions). use of one, or preferably two, distinct dedicated viral reduction treatments is the current bgold standardq for all plasma products. the first treatment is performed primarily to inactivate the most pathogenic viruses (hiv, hbv, and hcv), whereas the second reduction step targets nonenveloped viruses but also contributes to added safety against all agents. most viral reduction treatments are integrated with the protein fractionation process (bin-processq treatments), but some currently based on heat inactivation procedures are applied on products filled in their final container (terminal treatment). fractionators are required by regulatory authorities to conduct down-scale experimental validation studies using relevant model viruses to establish the efficacy and robustness of viral reduction procedures. the robustness of the viral reduction procedures in place is exemplified by the absence of transmission of wnv, an emerging virus. similarly, the lipid-enveloped severe acute respiratory syndrome coronavirus has been shown to be inactivated by core viral inactivation treatments of plasma products. , it is also likely, but not proven by validation experiments yet, that avian flu and simian foamy viruses, which also have a lipid envelope, would be inactivated by current processes in place if present in plasma. details on viral validation procedures can be found elsewhere. , the major characteristics of current viral reduction treatments are summarized in table , and discussed briefly here. in-process viral inactivation treatments. the solvent-detergent (sd) treatment, developed in the mid s, remains the most frequent core viral inactivation procedure of plasma products. protein solutions are incubated for to hours at c to c in the presence of . % to % tri-n-butyl phosphate (tnbp) and % tween- or triton x- . typically, lipid enveloped viruses are inacti-vated in a matter of minutes, and the functional activity of even the most labile plasma proteinswith the possible exception of some serine prolease inhibitors-is well preserved, but nonenveloped viruses (less pathogenic in most individuals) are not inactivated. the sd agents are removed down to a level of a few parts per million usually by chromatographic adsorption or specific precipitation of proteins, or selective adsorption on hydrophobic chromatographic support. pasteurization, another common viral inactivation procedure, is a heat treatment of protein solutions for hours at c, a treatment that denatures viral proteins and inhibits virus replication. pasteurization can inactivate both enveloped and nonenveloped viruses, but stabilizers, needed to limit loss of protein functionality, may decrease the rate and extent of viral inactivation. stabilizers may be removed by ultrafiltration, protein precipitation, or chromatography. vapor heat has also been used by one company; extent of virus inactivation is influenced by the temperature, duration, and pressure during treatment. risk of neoantigen formation, which can enhance protein immunogenicity, should be considered when using heat-based inactivation processes. low ph incubation, usually at ph , at c to c for more than hours, was introduced in the early s to allow the intravenous infusion of igg. this form of treatment was subsequently found to inactivate most lipid-enveloped viruses. caprylic (octanoic) acid precipitation/incubation at ph below is a recently introduced treatment of human igg that can inactivate lipid-enveloped viruses. , terminal viral inactivation treatments. in modern plasma fractionation, heat treatment of lyophilized products (dry heat) is used, due to limitations, mostly as a secondary viral inactivation step rather than the core inactivation treatment. the treatment is applied to some coagulation factor concentrates. performed at c for hours or at c for minutes, generally in the presence of protein stabilizers, it provides added safety against havand other heat-sensitive viruses but may not be sufficient to exclude b transmission. terminal (liquid) pasteurization at c for hours is the bgold standardq treatment of albumin preparations. the fatty acids, caprylate, and tryptophanate, which protect albumin from heat denaturation, are added at doses compatible with therapeutic use and, therefore, are not removed before product infusion. viral removal treatment. nanofiltration is a specific viral filtration process applied to protein solutions using -to -nm multi-layers membranes, or equivalent systems, to remove viruses mostly by a sieving mechanism. , introduced in the early to mid s, it has reached wide acceptance as a robust viral removal step for essentially all products, apart from albumin. nanofiltration is used to complement the core viral inactivation treatment and to provide enhanced safety against nonenveloped viruses or other resistant infectious agents. virus removal can also incidentally take place during protein precipitation, chromatography, or filtration steps; these steps contribute to the lowering of virus load from the protein production stream; they are difficult to monitor; and therefore do not guarantee, as standalone procedures, sufficient safety margin. prion removal methods. variant creutzfeldt-jakob disease (vcjd) can be transmitted by red blood cell concentrates, but to date, transmission has not been identified from plasma or plasma products. because of its biological nature, the prion agent is thought to be resistant to current viral inactivation procedures used during plasma fractionation. the methods known to inactivate abnormal misfolded prion proteins associated with transmissible spongiform encephalopathies (prp tse ) (such as oxidation, treatment with strong base, chaotropic agents, and extreme heat) destroy plasma proteins and, therefore, cannot be used. still, modern processes of fractionated products would seem to ensure significant removal of prp tse , as suggested by experimental spiking studies. as scale-down and experimental transmissible spongiform encephalopathy (tse) spiking models are developed, knowledge on the capacity of manufacturing processes of plasma proteins to remove prions is growing rapidly, although much uncertainty remains because the unknown biological nature of the human plasma associated infectious agent. several processes for manufacturing fviii, fibrinogen, von willebrand factor (vwf), fix, igg, and albumin products have been shown to be capable of removing prions in a consistent and reproducible manner. [ ] [ ] [ ] generally, multistep fractionation processes are thought to be a contributing factor to prp tse elimination. two to more than log removals of spiked prions occur during standard protein purification steps such as precipitation with ethanol or polyethylene glycol (peg), anion-exchange chromatography, and depth filtration. , , mechanism of removal that may encompass an adsorption mechanism is still not fully understood and appears to be influenced by ph and the concentration of the precipitating agent. the partitioning process may reflect some prion aggregation because of prion hydrophobicity and insolubility. the removal capacity of nanofiltration membranes with pore sizes less than or nm has been extensively investigated, , and prion removal is likely due in part to molecular sieving. extent of removal is related to the pore size of the filters and, presumably, to the aggregation state of prp tse . removal is superior with membrane of pore sizes of nm, compared to nm. the nature and origin of the spiking agent used for prp tse clearance studies is of critical importance because various spikes differ in size and characteristics. brain homogenate or brain-derived microsomal fractions from infected animals have usually been used as the source of prp tse spiking material. the most reliable and quantitative detection method of prp tse is based on animal bioassays, which require many animals and a time frame generally longer than months. in vitro immunochemical methods, such as a western blot assay, are being used, at least as a first marker of the presence of prp tse and associated infectivity, by detecting the protease-resistant fragment. thus, the risk transmission of vcjd by human plasma products appears remote, but caution should prevail since the biochemical nature of the infectious agent in human blood is not known. technologies to extract coagulation factors, protease inhibitors, and igg have evolved considerably in the last years, leading to the development of products with improved safety and purity profiles. a description of major manufacturing techniques is given below. factor viii. several generations of fviii preparations have been developed since the mid- s, providing (a) safety from hiv and then hcv and hbv, (b) improved purity, and (c) enhanced safety from hav and b . current development efforts focus on establishing prion removal. all currently licensed plasma-derived fviii concentrates are purified from cryoprecipitate. in a typical process, cryoprecipitate is subjected to a combination of aluminium hydroxide adsorption and precipitation, or precipitation only (eg, using glycine), to reduce the level of trace vitamin k coagulation factors (as they may activate fviii during the downstream purification steps) or load proteins such as fibrinogen. the purified cryoprecipitate extract usually undergoes viral inactivation typically by sd or pasteurization. many processes include subsequent chromatography by anion exchange, monoclonal antibody affinity (using anti-fviii or anti-vwf murine antibodies), or immobilized heparin affinity to remove protein contaminants (such as fibrinogen or fibronectin), most or part of the vwf, and the sd agents. immunopurified fviii eluate is further purified by chromatography to remove murine igg ligands that may have leached. prior to formulation and sterile filtration, some fviii products are nanofiltered using membranes with a pore size of , , or even nm if a partial dissociation of fviii and high-molecular-weight vwf multimers is initiated. alternatively, some freeze-dried preparations are subjected to heat treatment at c or c to inactivate nonenveloped viruses like hav. recovery of fviii, as expressed per liter of plasma, is usually comprised between and iu ( iu is defined as the physiological activity present in ml of plasma). factors lowering fviii yield include cryoprecipitation (ca % loss), chromatographic purification (ca % to %), and viral heat inactivation ( %- %). current fviii concentrates have a specific activity between and iu/mg. some products are formulated with human plasma-derived albumin, whereas others contain copurified vwf that helps stabilize fviii. purity of fviii concentrates has not been convincingly demonstrated to enhance immunological safety. long-term clinical experience indicates that the alleged reduced immunosuppressive effects of immunopurified preparations compared to lowerpurity plasma-derived preparations, as claimed in the late s, were probably unfounded. processes used that, in part, influence residual vwf, may have an impact on the immunogenicity of plasma-derived fviii products. retrospective studies of previously untreated patients show that an sd-treated, nanofiltered, ion-exchange purified fviii product containing vwf appears to be times less likely to induce anti-fviii inhibitors in hemophilia a patients than full-length recombinant fviii concentrates. von willebrand factor. because fviii chromatographic purification removes all, or part, of vwf, fviii products effective in treating von willebrand disease (vwd) are generally low-purity (bintermediate purityq) preparations prepared from cryoprecipitate by precipitation steps coextracting vwf and fviii in a ratio of higher than . the low purity and the high protein content of these products technically restrict the choice of viral inactivation treatments to pasteurization or terminal dry heat at c for hours. one highly purified vwf concentrate, largely devoid of fviii and, therefore, specific for vwd treatment, is prepared from cryoprecipitate by a -step chromatographic procedure (integrated with fviii and fibrinogen purification processes) using anion exchangers and immobilized gelatin polishing (to remove fibronectin). viral reduction is by sd, -nm nanofiltration, and terminal dry heat at c for hours. fibrinogen. there are registered fibrinogen preparations available for treating a fibrinogenemia or hypofibrinogenemia. traditional preparations are obtained by multiple precipitation steps of plasma or cryoprecipitate using ethanol and glycine, whereas other modern products are purified by chromatography. viral reduction is achieved by sd treatment, often complemented by -nm nanofiltration or terminal dry heat treatment. single-step pasteurization at c for hours is used for product. fibrin sealants. fibrin sealants (fibrin glues) comprise fibrinogen-rich and purified thrombin concentrates. when mixing the components, a strong adhesive clot exhibiting hemostatic, sealing, and healing properties is formed almost instantaneously or within a few seconds, offering multiple topical surgical applications. fibrinogen is prepared by precipitation methods from cryoprecipitate, or from the cohn fraction i; the fraction may also contain fibronectin, vwf, or factor xiii (fxiii), which may confer other physiological functions. fibrinogen fractions are virally inactivated by sd, pasteurization, vapor-heat treatment, and/or nanofiltration. the fibrinogen concentration is typically above g/l and may be formulated in the presence of an antifibrinolytic agent. prothrombin complex. prothrombin complex concentrate (pcc) is a mixture of vitamin kdependent coagulation factors in which fix, factor ii, and factor x and proteins c and s have a low specific activity between . and iu/mg. a few products contain also factor vii (fvii), but usually at levels lower than that of fix. the manufacture is usually based on a s method that involves diethylaminoethyl (deae) sephadex or deae cellulose adsorption of cryo-poor plasma, but downstream ethanol fractions can also be used as starting materials. anion exchangers coextract proteins sharing the presence of gamma-carboxyglutamic acid residues, whereas bulk plasma proteins, such as albumin and igg or at and aat remain in the unbound fraction. precipitation with tricalcium phosphate is used for one product. viral reduction is most often achieved by sd (tnbp-tween ) treatment, complemented by -or -nm nanofiltration or by terminal dry heat. pasteurization and vapor heat are applied to products. viral inactivation treatment by sd requires one subsequent ionexchange chromatographic step for removal of the virus-inactivating agents. recovery is in the range of to iu of fix per liter of plasma. single fix. high-purity fix products were developed in late , leading to reduced risks of thromboembolism, compared to pcc, in hemophilia b patients. fix is isolated by chromatographic purification of the pcc using anion exchange combined with either immobilized heparin, metal chelate affinity, or monoclonal antibody. these processes yield fix concentrates with a mean specific activity in the range of to iu/mg and a yield between and iu/l of plasma. factor vii. three specific concentrates rich in fvii and with reduced amount of other vitamin kdependent clotting factors are currently licensed to control bleeding in deficient patients. the manufacturing process includes ion-exchange chromatography or aluminium hydroxide adsorption, following a downstream procedure similar to that of pcc and fix. viral inactivation is achieved by sd treatment, vapor heat, or dry heat. factor xi. two factor xi (fxi) concentrates are currently available for deficient patients. one, of low purity, is purified by chromatography of cryo-poor plasma on deae cellulose and immobilized heparin. after freeze-drying, the product is virally inactivated by dry heat. in the other product, fxi is captured by adsorptive filtration then highly purified by cation-exchange chromatography. this product undergoes dual viral reduction processing by sd and -nm nanofiltration. factor xiii. factor xiii is a transglutaminase that catalyzes the final step in the coagulation cascade, cross-linking the loose fibrin polymer into a highly organized structure. the early generation of fxiii concentrates for the treatment of fxiiideficient patients was extracted from placenta, but plasma-derived products have subsequently been developed. one is purified from a cold-ethanol fraction from cryoprecipitate supernatant, purified by precipitation with sodium citrate and removal of fibrinogen by heating. the product is pasteurized in sorbitol solution, ultrafiltered to remove sorbitol, adsorbed with bentonite, and freeze-dried. the other product is obtained by precipitation steps and is also pasteurized. factor xiii is also a component of some fibrin sealants. although still subject to discussion, the presence of fxiii is claimed to contribute to fibrin c-chain cross-linking and tensile strength, possibly improving the hemostatic effect. activated coagulation factors. human thrombin concentrates are available so far only as components of fibrin sealant. thrombin is prepared by activation of the pcc, usually in the presence of calcium chloride, followed by viral inactivation treatment by sd, purification by cation-exchange chromatography, and viral removal by -nm nanofiltration. final thrombin concentration is usually between and iu/ml, but preparations with lower potency are available when a slower speed for clot formation of the sealant is preferred for some surgical applications requiring longer time for tissue gluing. a procedure for large-scale production of a purified plasma-derived fviia has been developed in japan. fvii is purified by anion exchange and immunoaffinity chromatography and converted to fviia by autoactivation on an anion-exchange resin and incubation in the presence of ca + for hours at c. this preparation is virally reduced by nanofiltration and dry-heating and is intended for the treatment of hemophiliacs with antibodies against fviii or fix. antithrombin. antithrombin concentrates were the first plasma products extracted by affinity chromatography. production from cryo-poor plasma usually comprises ion exchange chromatography to remove the pcc components, followed by capture of at on immobilized heparin. viral inactivation is traditionally achieved by pasteurization in the presence of sodium citrate or a combination of sucrose and glycine, although sd treatment is used as well. because heat treatment may partially denature at, a second adsorption step on immobilized heparin can be used to remove altered molecules. recovery is between and u/l of plasma. fraction iv- is an alternative starting material, but yield is significantly lower. a -antitrypsin (a -protease inhibitor). there are now several licensed aat concentrates, including in the united states. a -antitrypsin augmentation therapy is indicated for the treatment of patients with lung emphysema secondary to congenital aat deficiency. because aat shares many physicochemical properties, in particular, molecular weight and isoelectric point, with albumin, it has been difficult to design production methods for aat not affecting the existing production process for albumin. most preparations are recovered from fraction iv [ ] [ ] [ ] [ ] . purification from this waste fraction is rather cumbersome and involves peg precipitation and ion-exchange chromatography, considerably compromising recovery (~ . g/l). the first preparations developed in the s were virally inactivated by pasteurization, but dual viral reduction steps using sd and nanofiltration are also now used. recent isoelectrofocusing studies have provided evidence indicating that new anodal aat variants are present in at least one of the fda-licensed product, suggesting alteration of some isoforms during purification. loss of a c-terminal positive charged lysine, secondary to carboxypeptidase activity, was proposed as an explanation for these isoelectrofocusing migration shifts. under circumstances when clinical demand for albumin decreases, extracting aat from upstream fractions, such as the supernatant ii+iii, appears a logical trend, offering the possibility of a more effective production scheme, characterized by a recovery of . to g/l. protein c. there are protein c concentrates manufactured in europe and in japan. in one process, the pcc undergoes cascade purification on ion exchangers, whereas in the other, immunoaffinity and affinity chromatographic processes are combined with ion exchange. viral reduction is achieved by sd treatment, which can be combined with -nm nanofiltration or vapor-heat treatment. c -esterase inhibitor. c -esterase inhibitor concentrates are used for the treatment of acute phases of angioedema, primarily in the oropharyngeal region and gastrointestinal tract in patients with congenital or acquired c -inh deficiency. there are products licensed in europe. products are generally purified by chromatography from the cryo-poor plasma after extraction of the pcc and, potentially, at. viral inactivation is achieved by pasteurization, vapor heat, or sd, possibly combined with nanofiltration. essentially all therapeutic albumin preparations are prepared by fractionation of cryo-poor (or pccpoor and/or at-poor and/or c -inh-poor) plasma by ethanol fractionation. a critical upstream process step (precipitation ii+iii) separates the igg fraction. to optimize recovery, the precipitates generated during the ethanol fractionation process are separated by depth filtration. albumin recovery of % to % ( - g/l) and purity of % to % are typically obtained. some processes combine ethanol fractionation with a polishing ion exchange chromatography, which generally improves product purity to ca %, whereas in one production method, albumin is purified mostly by anion exchange, cation-exchange, and size-exclusion chromatography. the adjustment of the concentration of the purified fraction, typically from % to %, is achieved by ultrafiltration. the standard viral inactivation method is pasteurization, which, according to most pharmacopeias, should be performed in the final container rather than on the albumin batch before aseptic filling. current mean albumin yield is to g/l of plasma. polyvalent igg preparations, either for intramuscular or intravenous uses, are traditionally prepared from the fraction ii that is obtained by stepwise fractionation of cryo-poor plasma using cold ethanol at concentrations up to %. increasingly, igg products are extracted from up-streamed ethanol precipitated fractions, such as supernatant iii or precipitate ii+iii, to optimize recovery. intermediate igg fractions are subjected to ion-exchange chromatography, caprylic acid, or peg precipitations to remove protein contaminants, proteolytic enzymes, and/or aggregates. most current viral inactivation procedures are low ph incubation, pasteurization, or sd; the caprylic acid treatment, recently introduced in the manufacture of human igg products, is also a robust viral inactivation process of igg. dedicated viral removal by -to -nm nanofiltration is commonly used to increase the safety against nonenveloped viruses, especially in a situation when the core viral inactivation treatments target only lipid-enveloped viruses. the igg recovery has long been in the . -to . -g/l range when combining traditional ethanol fractionation processes and centrifugation. depth-filtration and/or chromatographic purification from upstream fractions have improved the mean recovery to the . -to . -g/l range, or more. total chromatographic procedures are increasingly used for the production of hyperimmune igg products because such processes are amenable to the fractionation of smaller plasma volumes and can optimize recovery. the manufacturing process includes at least dedicated viral reduction treatments. other protein components have been fractionated at pilot-scale and subjected to experimental or human trials. inter-a-trypsin inhibitor (iti) is a kunitz-type serine proteinase inhibitor. its inhibitory capacity is carried by bikunin, a chondroitin -sulfate proteoglycan, which is covalently linked to its heavy chains h and h , but can be released by proteolytic cleavage. an iti concentrate has been obtained by fractionation of the prothrombin complex on an anion exchanger followed by immobilized heparin and viral inactivation by sd. iti, as a reservoir of bikunin, may be involved in control of inflammatory processes. in a porcine model of endotoxin shock, iti improved the hemodynamic, oxygenation, and coagulation parameters. administration of iti very early after the onset of sepsis or repeated injections at later time points ( and hours) maintains cardiovascular stability and significantly reduces mortality in a rat model. transferrin is the major iron binding plasma protein which may prevent cytotoxic effects or predisposition to septic infection due to accumulated free non-transferrin-bound iron when normal iron use is hampered and/or apotransferrin production is decreased. a liquid apotransferrin concentrate has been obtained from cohn fraction iv by ion exchange chromatographic steps and ultrafiltration. viral safety was ensured by sd treatment, nanofiltration, and peg precipitation. the product had intact iron binding capacity, and maintained the bacterial growth inhibitory effect in serum. in hematological stem cell transplant patients, the product prevented the appearance of non-transferrin-bound iron. apolipoprotein a-i is the principal protein component of the plasma high-density lipoproteins. it prevents the accumulation of cholesterol-loaded macrophages which deposit on the arterial wall as foam cells. apolipoprotein a-i inhibits hepatic lipase and lipoprotein lipase in vitro. a concentrate has been isolated by precipitation from cohn fraction iii. intravenous injections in men were well tolerated in an early clinical trial; clinical observations were consistent with combined inhibition of hepatic lipase and lipoprotein lipase activities. possible clinical applications include the treatment of hypercholesterolemic patients and atherosclerosis. recombination with lecithin forms a high-density lipoprotein complex that could help limit inflammation, endotoxin-induced activation of coagulation, and fibrinolysis in septic conditions. mannan-binding lectin (mbl) is a component of the innate (aspecific) immune system that can bind repetitive structures of mannan groups, such as those on the surface of micro-organisms, activating the complement system and leading to the destruction of a large variety of micro-organisms. the relatively frequent congenital deficiency of mbl is associated to recurrent infections, especially in infants when the specific immune system has not yet matured. an mbl concentrate has been produced from cohn fraction iii. plasmin is the major fibrinolytic enzyme in plasma. encouraging results as a new fibrinolytic agent have been obtained in animal models where plasmin was applied directly to the clot through a catheter to treat peripheral arterial occlusion. von willebrand factor cleaving protease (vwf-cp, adamts ) cleaves ultra-large multimers of vwf that enter the blood stream directly after biosynthesis by endothelial cells. if developed, a purified vwf-cp could be useful to treat, in place of plasma, patients with thrombotic thrombocytopenic purpura with congenital or acquired deficiency of vwf-cp. activated protein c can be of value for the treatment of sepsis, as demonstrated through the clinical use of a recombinant preparation. there is no therapeutic plasma-derived activated protein c products available yet for therapeutic use, although a process for a highly purified preparation, where cryo-poor plasma is purified by immunoaffinity and anion-exchange chromatographic steps, and sd viral inactivation has been described. there is also research needed to investigate alternative indications for currently available products. potential clinical use of c -inh, aimed at benefiting from its role as inhibitor or attenuator of the activation of complement and contact systems, include septicemia, myocardial infarction, capillary leak syndrome, pancreatitis, and organ transplantation. intravenous use of a fxiii concentrate was found to increase epidermal growth factor and transforming growth factor-b, suggesting that it may accelerate wound healing of anastomotic leaks and nonhealing fistulas. factor xiii was also found to have osteoinductive properties, suggesting use in bone tissue engineering. a review on plasma fractionation should also cover the role played by national and international regulatory authorities. over the last few years, assuring the safety of large-pool plasma products has posed formidable challenges to regulatory authorities and fractionators alike. the complexity of the field, encompassing the diversity in blood and plasma product types and manufacturing processes, made it difficult to enact balanced decisions toward ensuring both product safety and guarantee of supply. since the s, the agencies regulating the plasma fractionation industry have developed a comprehensive set of measures to ensure the viral safety of plasma products. multiple layers of regulatory oversight of the plasma industry have been established to ensure overlapping safeguards against the risks of the transmission of bloodborne infectious agents. several regulations, guidances, position statements have been issued by agencies like the us fda and the european medicine evaluation agency, which are updated as needed. those cover important safety aspects required at all stages of the manufacturing chain, from activities at blood establishment preparing plasma for fractionation, extending to the manufacturing and distribution of plasma products. regulatory oversight includes epidemiologic surveillance of the donor population; donor deferral policies and screening practices; mandatory donation testing; testing of manufacturing plasma pools; validation of viral reduction procedures and other production steps; as well as the assessment of product quality, safety, and efficacy for marketing authorization. most of relevant information on plasma collection is assembled in europe in the plasma master file, which allows establishing key levels of information regarding the quality and safety of the plasma raw material. post marketing, reports on adverse reactions associated with plasma products should be transmitted to nras and could prompt emergency response procedures and product recalls. some harmonization of the requirements for manufacture and supply of plasma products in the united states, europe, and japan is taking place under the auspices of the international conference on harmonisation, but much work remains to be done. such measures, nonetheless, provide the framework through which modern plasma products now exhibit a very high level of quality, safety, and efficacy. however, the rigidity of the regulatory system has been an impediment to more significant technological evolution of the plasma fractionation process because process changes are currently associated to major regulatory work. the cohn plasma fractionation method initially designed to obtain albumin has, over the years, developed rather successfully into a well-established industrial procedure isolating a wide range of clinically useful products. today, more than different protein products, and more if one considers the variety of hyperimmune igg preparations, can be extracted through large-scale fractionation of human plasma. the soundness and large-scale adaptability of the technology, on the one hand, and the rigidity of the current regulatory framework, on the other, explains why this technology remains the main core method in use at industrial scale, although it implies suboptimal yield for most proteins, apart from albumin. the technology has increased in complexity over the years, with the greatest progresses in purification being, without doubt, associated with the use of chromatographic methods that have made possible the development of new protein therapeutics and impressive improvements in product purity and quality. the fractionation scheme has also changed dramatically through the introduction of in-process viral reduction treatments, which have required the addition of downstream techniques such as chromatography and ultrafiltration. the change in protein drivers, with the prominent clinical role now played by igg, and the requirements to increase protein recovery and optimize the fractionation process may crystallize the incentive for most fractionators to abandon relative technical conservatism and introduce significant technological changes in processing technology. the production of igg from precipitate (i)+ ii+iii, already implemented by some manufacturers and, possibly, that of aat from supernatant (i)+ ii+iii, are signs of a gradual evolution in the direction of total chromatographic processing. with so much gained, over the last few years, in the understanding of the key parameters building plasma product quality, safety, and efficacy, one can hope that the regulatory paths, in particular, with regard to clinical studies, to license known protein therapeutics prepared by improved, more efficient technology should be simplified. this would, in turn, contribute to an improved supply. as the plasma fractionation industry has so far been targeting mostly proteins that were obvious candidates for replacement therapy, it is also hoped that it will invest more into developing new products because plasma remains a unique source of potential therapeutic proteins. proactive research and development work should be encouraged to isolate and evaluate new therapies among the well characterized plasma proteins with still unknown function. finally, one should not forget that plasma protein therapies are expensive and largely inac-cessible to the developing world. the new market drivers in rich countries are likely to diminish economical interest in the manufacture of fviii that remain a major protein therapy in need in the developing world. the belief that decreased use of plasma-derived fviii or fix in developed economies (as hemophiliacs are switching to recombinant therapies) would increase the supply of products to developing countries may be not economically viable. rather, this switch to recombinant products in rich countries can make poor countries unable to afford the increased cost of products no longer subsidized by the premium price paid in rich countries. it therefore remains important to develop affordable viral inactivation and processing technologies gradually allowing developing countries to make use of local plasma resources in a safe manner. guideline on epidemiological data on blood transmissible infections. for inclusion in the guideline on the scientific data requirements for a plasma master file current instrumentation for apheresis. apheresis: principles and practice assessment of complement activation during membrane-based plasmapheresis procedures the effect of leukocyte depletion on the quality of fresh-frozen plasma current safety of the blood supply in the united states farrugia a: guide for the assessment of clotting factor concentrates for the treatment of hemophilia. www.wfh.org. montreal, world federation of hemophilia preparation and properties of serum and plasma proteins. iv. a system for the separation into fractions of the protein and lipoprotein components of biological tissues and fluids eight years experience with the alcohol fractionation procedure of nitschmann, kistler and lergier tabor e: the epidemiology of virus transmission by plasma derivatives: clinical studies verifying the lack of transmission of hepatitis b and c viruses and hiv type contribution and interpretation of studies validating the inactivation and removal of viruses (revised) inactivation of viruses in labile blood derivatives. i. disruption of lipidenveloped viruses by tri(n-butyl)phosphate detergent combinations pasteurization of antihemophilic factor and model virus inactivation studies enveloped virus inactivation by caprylate: a robust alternative to solventdetergent treatment in plasma derived intermediates evaluation de l'efficacité des procédés de purification des proteins plasmatiques à éliminer les agents transmissibles non conventionnels distribution of a bovine spongiform encephalopathy-derived agent over ionexchange chromatography used in the preparation of concentrates of fibrinogen and factor viii al: influence of the type of factor viii concentrate on the incidence of factor viii inhibitors in previously untreated patients with severe hemophilia a in vitro study of a triple-secured von willebrand factor concentrate fibrin sealant: scientific rationale, production methods, properties, and current clinical use properties of a highly purified human plasma factor ix:c therapeutic concentrate prepared by conventional chromatography large-scale production and properties of human plasma-derived activated factor vii concentrate effects of inter-alpha-inhibitor in experimental endotoxic shock and disseminated intravascular coagulation delayed administration of human inter-alpha inhibitor proteins reduces mortality in sepsis a minipool process for solvent-detergent treatment of cryoprecipitate at blood centres using a disposable bag system key: cord- -r y sgb authors: tiwari, nidhi; upadhyay, jyoti; nazam ansari, mohd; joshi, rohit title: novel β-coronavirus (sars-cov- ): current and future aspects of pharmacological treatments date: - - journal: saudi pharm j doi: . /j.jsps. . . sha: doc_id: cord_uid: r y sgb the novel coronavirus outbreak has reported to be rapidly spreading across the countries and becomes a foremost community health alarm. at present, no vaccine or specific drug is on hand for the treatment of this infectious disease. this review investigates the drugs, which are being evaluated and found to be effective against ncovid- infection. a thorough literature search was performedon the recently published research papers in between january to may , through various databases like “science direct”, “google scholar”, “pubmed”,“medline”, “web of science”, and “world health organization (who)”. we reviewed and documented the information related with the current and future aspects for the management and cure of covid- . as of st july, a total of , , confirmed cases of coronavirus and , deaths have been reported world-wide. the main clinical feature of covid- ranges from asymptomatic disease to mild lower respiratory tract illness to severe pneumonia, acute lung injury, acute respiratory distress syndrome (ards), multiple organ dysfunction, and death. the drugs at present used in covid- patients and ongoing clinical trials focusing on drug repurposing of various therapeutic classes of drug e.g. antiviral, anti-inflammatory and/or immunomodulatory drugs along with adjuvant/supportive care. many drugs on clinical trials shows effective results on preliminary scale and now used currently in patients. adjuvant/ supportive care therapy are used in patients to get the best results in order to minimize the short and long-term complications. however, further studies and clinical trials are needed on large scale of population to reach any firm conclusion in terms of its efficacy and safety. novel-coronavirus (ncovs) is spherical in shape, enveloped with single-stranded rna, and considered as the largest viral . coronaviruses (covs) belongs to group of zoonotic viruses having enormous diversity of animal hosts i.e. birds & humans. the infection caused by cov varies variably and greatly from asymptomatic-symptomatic to severe disease, depending on the species of virus and the host. this virus subdivided into four families: α, β, γ, δ-coronavirus. the γ, δ-covs are mainly infected birds, whereas α, and β-covs largely infected the mammals (yin and wunderink, ) . earlier, global spread of two β-coronavirus such as severe acute respiratory syndrome coronavirus (sars-cov), origin from foshan (china) in november (zhong et al., ) and middle east respiratory syndrome coronavirus (mers-cov) occurred in saudi arabia in june (zaki et al., ) . at present, a novel coronavirus (sars-cov- ) reported first case in china (wuhan) on december , later on february , world health organization (who) given named as covid- (huids et al., ; who, ) . it has spread rapidly, affected many countries all over the world and declared by who, as covid- emergency/outbreak, a pandemic (dong et al., ) . sars-cov- is highly infectious and transmittable diseases, highly vulnerable to entire population worldwide via a directly contact with infected person through respiratory droplets (zheng, ) . according to recent evidences, this epidemic also known as zoonotic disease, a disease transmitted from animals to humans. several genealogical analyses documented that novel cov considerably identical to the sequence of bat sars-like coronavirus (benvenuto et al., ) .the replication and transcription phase of sars-cov- starts when virus (host) enters into the cell and interacting with spike proteins (s-protein) present at the surface of target receptor. mainly two target receptors are present within the cell to which virus binds either with angiotensin converting enzyme- (ace- ) receptor or with the serine protease tmprss (hoffmann et al., ) . however, exact mechanism is still unknown and need to investigate whether novel coronavirus employs ace- and tmprss for the entry into the cytoplasm. novel-coronavirus infection is a community transmission disease, primarily affected person to person, via respiratory droplets (li et al., ) . sometimes these droplets can land on objects and surfaces such as tables, doorknobs and handrail. in most of the cases, person can become infect by touching these objects and then touching their eyes, nose and mouth. the most common symptoms are fever, dry cough, tiredness, nasal congestion, sore throat and develop breathlessness. in severe cases patient symptoms can be characterized to organ failure i.e. kidney & respiratory.however, geriatrics population and person with preexisting medical condition (diabetes, hypertension,heart and lung problems) chances are higher for developing symptoms (rawat et al., ) . apart from these symptoms this infection can be associated with lymphopenia, interstitial pneumonia and elevated levels of pro-inflammatory cytokines like as interleukins (ils), interferons (ifns), granulocyte-colony stimulating factor (g-csf), tumor necrosis factor (tnf-α), etc. this condition sometimes also called "cytokine storm" can induce patient's death (guo et al., ) . currently, only symptomatic treatments are available to minimize the symptoms like self-isolation/quarantine, supplemental oxygen, mechanical ventilation, paracetamol for fever and antibiotics only for hospitalized patients for control bacterial co-infection. till date, there are no vaccines or drug therapy approved by the u.s. food and drug administration (fda) for the treatment of this pandemic virus covid- (βcoronavirus). due to varying nature of this virus, development of novel pharmacological treatment takes several years. many scientist or researchers work day and night and trying to focus on drug repurposing, which already are in use in some other conditions for competently control and spread of pandemic situation all over the world (kruse, ) . from this review, our aim is to provide a basic overview about currently available drugsand drugs under clinical trial for covid- patients. based on many evidences from laboratory, animal and clinical studies,all are focusing on anti-viral, anti-inflammatory and immune-modulators drugs for the treatment of the novel-coronavirus. here, we discussed all currently used treatment, under clinical development and outlook clinical trial for the treatment of covid- . patients with covid- characterized by abnormal in respiration rate (hypoxia), hear rate, fever,irregular neutrophil counts (neutropenia), and higher level of plasma cytokines i.e. interleukins (il- , il- , etc.), and tnf-α. all these symptoms are the reason to promote disease severity. sars-cov- virus detected in both types i and ii pneumocytes present in the ciliated epithelial cells of nasal, bronchial and bronchiolar mucosae of respiratory system. type i pnemocytes is responsible for gaseous exchange whereas type ii has main role in the production and secretion of surfactants. destruction of both types of pnemocytesis, resulting in hypoxia and alveolar collapse. ace- act as a target receptor for the treatment of covid- infection, whereas tmprss protein, enhance the transmissibility of the virus. increase in the production of leukocytes (neutrophil) leads to the formation of highly reactive oxygen species (ros), and oxidative stress inside alveoli, resulting in the formation of mucus (cough) and alveolar damage. figure describes the potential targets with pathogenesis pathway for broad-spectrum antiviral agents, anti-inflammatory and immuno-modulatory agents in treatment of covid- . antiviral drugs are beneficial for several infectious diseases such as herpes, hepatitis, hiv, influenza and flu like symptoms (razonable, ) . researchers and scientists are endeavoring to find drugs, which are effective in the treatment of covid- . drug repurposing is widely acceptance at present, because of immediate impact of ncovs outbreak into the society and public health emergency concern (muralidharan et al., ) . many drugs that approved by usfda for some other disease conditions are under preclinical and clinical development for the management of covid- . here, we review and examine all the antiviral drug therapies and its relevance in the treatment of coronavirus as per available pharmacokinetic and pharmacodynamics data of clinical studies. several studies has been documented that antiviral drugs delivered abruptly after beginning of symptoms and continue last up to days (sputum peak around - days). these drugs minimizing the chances of infection to others by reducing release of virus from the hostand replication into the respiratory secretions of infected person, and diminishrisk of infection by prophylactic targeted treatment (mitja andclotet, ) . classification, mechanism of action, adverse effects and therapeutic uses of all antiviral agents (currently used and under clinical development) against covid- are shown in table . lopinavir (lpv) and ritonavir (rtv) are effective agents that inhibit the protease activity of coronavirus. lpv and rtv act as an antiretroviral used for the treatment of aids/hiv virus (hiv- & hiv- ). rtv enhances the plasma concentration of lpv through inhibition of cytochrome p (cyp a)-mediated metabolism of lpv (soliman et al., ) . previous studies reported that lpv blocks virus replication in the later stages steps of mers-cov cycle (de wilde et al., ) and abate the activity of sars-cov by inhibition of proteinase activity (hurst and faulds, ) . in a randomized, controlled and open-label trial involving adults sars-cov positive patients, patients were divided into two groups (lpv-rtv treated & standard-care group). there is no remarkable changes were observed in both the groups in terms of improvement and mortality. et al., ) . another study reported that, patients were assigned randomly in phase -trial and administered days combination of lpv ( mg), rtv ( mg) and ribavirin ( mg) in every h with ifn beta- b to improve the antiviral response. this combination seems to be better, superior and provides best output to lpv-rtv alone and also diminished the virus desquamation, reduces symptoms of patients, and often promoting discharge of patients in the mild-moderate covid- (hung et al., ) . another invitro study reported that ribavirin, analogue of guanosine nucleotide having wide spectrum of antiviral activity, used along with lpv/rtv to treat sars-cov- viral infection in china (chictr ) . earlier this combination was wellestablished for the treatment of sars-cov infection along with minimal risk of acute respiratory distress syndrome (ards) and mortality rate (chu et al., ) . moreover, future clinical studies are needed to check this combination with other antiviral-combination against sars-cov- . the drug was developed in , for the treatment of ebola and marburg virus infections. rdv is a prodrug of nucleotide (adenosine) analogue and having a broad-spectrum antiviral activity. in body, it is metabolized into active metabolite gs- . the antiviral mechanism of rdv is to inhibit rna-dependent rna polymerase (rdrp) enzyme, necessary for virus replication (al-tawfiq et al., ) . earlier invitro studies reported that rdv inhibits single stranded rna virus replication such as sars-cov and mers-cov (agostini et al., ) .another mouse model study reported that combination of rdv and ifn-beta is better than lpv& rtv for the treatment of mers-cov (sheahan et al., ) . currently preclinical study reported that association of rdv & chloroquine is greatly efficient for preventing sars-cov- infection . in addition, phase clinical trials conducted in participants to check efficacy and safety of the rdv (loading dose, mg on day only followed by mg maintenance dose, od for days) in covid- patients (cao, ) . rdv shows promising output in some of the us patients with covid- (holshue et al., ) . furthermore, beigel et al. reported remdesivir shows possible efficacy better as compared to placebo group in hospitalized patients for the treatment of sars-cov- virus. a randomized, doubleblind and placebo-controlled clinical trial has been conducted and the patients received remdesivir i.v. {day loading dose ( mg) + daily maintenance dose ( mg) up to additional days}. patients are assigned randomly and total of, infected patients are enrolled and divided into two groups, remdesivir group: patients and placebo group: patients. the overall time to recovery rate is better in remdesivir and also lowers infection in respiratory system as compared to placebo. in addition, various evidences suggested serious adverse event i.e acute respiratory failure and sudden death in few patients and strict monitoring is required to manage dose at the time of treatment. from this report, we can conclude antiviral treatment always need supportive care or supplemental oxygen to prevent other negative outcomes (brigel et al., ) . recently, hetero pharma company launched covifor vials, brand name of remdesivir, a game-changer drug for treatment of covid- . this drug is restricted used in patients who already have kidney problems, pregnant and lactating women (https://www.pharmaceutical-technology.com/news/cipla-hetero-remdesivir-covid- /). hence, further research is requisite to evaluate its pharmacological and pharmacodynamics characteristics against sars-cov- virus. favipiravir (avigan) is an antiviral drug, firstly developed by japan in the year , for treatment of influenza virus infections (furuta et al., ) . it is a nucleotide (guanine) analogue, & converted into active metabolite by phosphorylation, then inhibits the synthesis of rna (rdrp) and virus mutagenicity (vanderlinden et al., ) . it has been documented by invitro study that fpv inhibits sars-cov- in vero e cell (ec = . μm) (du and chen, ). an open & controlled study designed to determine the efficacy of fpv ( mg bd, on day followed by mg bd on - days) vs lpv/rtv ( mg/ mg bd) along with ifn-α b, bd) for the treatment of covid- . preliminary results showed that there is significant difference between viral clearance & chest improvement rate . in india, glenmark is the first company to initiates the phase trials on fpv by enrolled participants, duration of treatment maximum of days and total study duration of an individual maximum upto days, with mild to moderate covid- under restricted emergency used. recently, on june , glenmark permitted fpv, under brand name of fabiflu tablets ( mg bd on first day followed by mg bd from day to day ) into the market for treatment of mild to moderate cases of covid- patients (baravkar et al., ) . umifenovir (arbidol) is a dual-acting direct antiviral/host-targeting agent used as a prophylaxis in the influenza and respiratory infections. a cohort study enrolled adult patients characterized by lymphopenia showed no significant difference in the results obtained between the survival and nonsurvival groups by receiving treatment with antiviral, antibiotic and glucocorticoid therapy. however, there is a significant data and less mortality rate for those patients who receive arbidol . this combination of drug used as an antiretroviral in the treatment of hiv/aids. darunavir is a hiv protease inhibitor and cobicistat enhances the plasma concentrations of darunavir by blocking its metabolism by cyp enzyme (deeks, ) . preclinical studies documented that this combination showed beneficial effects in the sars-cov- virus infections (lin et al., ; omotuyi et al., ) . the effectiveness and safety concern of darunavir/cobicistat combination is being evaluated under development of clinical trials phase by enrolling covid- patients and estimated completion of study on december , . lastly, the primary outcomes measures shows the clearance rate of virological salivation, less throat infections and decreases respiratory secretion at day (time frame: day after first randomization) (lu, ) . initially, camostatmesilate and nafamostatare used in postoperative reflux esophagitis and in chronic pancreatitis (uno, ) . camostatmesilate andnafamostat, both drugs act on attractive target tmprss , a serine protease inhibitor and block the entry of the virus into the lung alveolar cells (hoffmann et al., ) . recently, camostat mesilate enters into the phase trials by taking participants (administered dose approx. mg for days, tid). the outcomes obtained like changes in covid- symptoms (frequency and severity), body temperature and changes entry in sars-cov- viral load. ivermectin is a fda approved drug, used as an anti-parasitic and in the treatment of many types of virus infections such as hiv, dengue, influenza and zika (caly et al., ) . recent study showed that ivermectin, inhibits the growing of virus in cell culture approximately for hrs. till date, test is only carried out in-vitro, for confirmation, strong clinical trials are needed to evaluate its safety and efficacy in the treatment of covid- patients (scavone et al., ) .clinical studies of ivermectin in covid- patients are underway by enrolling confirmed cases of covid- , as per hospital protocol. this study is in progress and might be getting its primary outcomes about its safety and clinical efficacy by theend of july (budhiraj and mishra, ) . earlier data about coronavirus (sars & mers) showed, cell infiltration and cytokine storm (cs) leads to acute cell lung injury, adrs and death of many patients (channappanavar and perlman, ; chousterman et al., ) . recently, covid- infection, which is due to sars-cov- virus, accompanied by rapid replication of virus and a massive release of cytokine profile as same in other two reported coronavirus sars and mers (teijaro, ) . currently, study documented that cytokines like interleukins (il- b, il- , il- , il- & il- ); g-csf; ifns; interferon-γ-inducible protein (ip ); monocyte chemoattractant protein (mcp ),tumor necrosis factor (tnfα), vascular endothelial growth factor (vegf), platelet derived growth factors (pdgf)and other pro-inflammatory mediators are increase in covid- patients (huang et al., ) . another studies reported extensively elevation in the level of il- in critically severe poorly in covid- infected patients (ruan et al., ; zhou et al., ) . classification, mechanism of action, adverse effects and therapeutic uses of all anti-inflammatory and immunomodulatory drugs(currently used and under clinical development) against covid- are listed in table . it is an anti-malarial and over the counter (otc) drug, activity similar to chloroquine. recently, it was reported that hcqs shortened the time to clinical recovery on the sars-cov- patients. due to its interferon blocking property, it has diminished the immune response to a viral infection. this immunomodulatory property makes its useful in autoimmune disorder such as rheumatoid arthritis (ra) and systemic lupus erythematosus (sle). the safety profile of hcq is superior as compared to chloroquine during long term used in covid- patients and little concern about drug-drug interactions (yao et al., ) . several invitro studies reported cqs/hcqs are used as an effective treatment in sars-cov- virus. as they are weak bases and enhance ph of endosomal in host cell organelles, inhibit fusion of autophagosome-lysosome and inactivates enzyme require for replication of virus. they also have a potential to deactivate ace- glycosylation, for which coronavirus may enters into the cell (ferner and aronson, ) . currently studies showed that hcq administered for - days, effective in clearing viral nasopharyngeal carriage of sars-cov- in most of the covid-macrolide antibacterial drug was shown to be successful in the treatment of zika and ebola viruses by in-vitro studies (madrid et al., ; bosseboeuf et al., ) . previous studies reported that combination of hcq and azithromycin showed synergistic effect and prevent respiratory tract infections when administered by viral infection patients (bacharier et al., ) . recently, world health organisation (who) updated information on june , about safety and efficacy of chloroquine (cqs)/hydroxychloroquine (hcqs) and compared it with standard care treatment for covid- patients. the overall outcomes showed that there is no significant difference in case of mortality when compared with standard care treatment. in addition, some reports evaluated hcqs cause's serious adverse effects like prolongation of qt interval, ventricular fibrillation, arrhythmia and sometimes leads to abrupt death. the safety and efficacy assurance for cqs/hcqs, there is necessitate that other clinical studies are needed to be performed and exemplify with safety concern (cochrane, ). further, us fda summarized details on july with safety concern, and permitted used of cqs/hcqs is now accessible to take care of patients with covid- but some strict monitoring are required while treatment as it shows various heart related problems, blood and lymph disorders, renal injury and hepatic failure (us fda, ). interferons are types of cytokines effective in the management of infections & infectious diseases (arnaud, ) . it is a broad-spectrum antiviral, antiproliferative & immunomodulatory drug interacting with the toll-like receptors and inhibits viral replication and protein synthesis (uematsu and akira, ) . there are three types of ifn (α, β, and γ). ifn-β shows high potent specificity as compared to ifn-α in reducing the replication of mers-cov (hart et al., ; shalhoub, ) . in human lung tissue (shalhoub, ) . further, several future studies are being conducted to determine its efficacy & safety along with other antiviral drug in treatment of covid- . interleukin plays a major role in the pathogenesis of all three coronavirus sars-cov- , mers & sars-cov- infections (lau et al., ) . recent study reported several pro-inflammatory mediators plays a major role in the lung damage such as interleukins (il- , il- etc) and inflammatory markers (d-dimer, ferritin, and c-reactive protein) (conti et al., ; kuppalli and rasmussen, ) . several ils antagonist drugs are under ongoing trials to check its safety and efficacy against sars-cov- viral infections. anakinra is a recombinant il- receptor antagonist and may be helpful in covid- patients. it prevents the binding of il- α and il- β to interleukin- receptors, which is used in the treatment of autoimmune disorders (cavalli et al., ) . recently, retrospective cohort study showed high dose of anakinra ( mg/kg, bd,iv) produces beneficial and efficacious effects in % covid- infected patients associated with ards (cavalli et al., ) . in addition, anakinra alleviated hyperinflammation and respiratory distress in sars-cov- infected patients (tufan et al., ) . another studies reported anakinra ( mg repeated after h, sc for days) administered along with remdesivir ( mg ld, followed by mg after h, iv for days) used in the treatment of respiratory dysfunction in covid- patients (franzetti et al., ) . however, several clinical trials in large population are required for confirmation of its efficacy. a human monoclonal antibody particularly targets and neutralizes il- β thus blocking its binding with il- receptors (dhimolea, these classes of drugs blocks interleukin (il- ) mediated signaling pathways by binding competitively with soluble and membrane bound il- receptors (sil- r and mil- r). il- involved in various physiological process like activation of t-cells, b-cell, hematopoietic cell proliferation and differentiation, hepatic acute-phase protein synthesis initiation and also immunoglobulin secretion (tanaka et al., ) . it is a monoclonal antibody, firstly initiates and tested by china to decrease the lung related complications in patients with covid- . a randomized and retrospective study showed that tocilizumab plays a beneficial role as an adjunctive therapy in covid- patients. preliminary data proved that percentage of lymphocyte, concentration of crp, and computed-tomography clarity changes and reduces the hospitalization duration of these patients (xu et al., ) . at present, three clinical trials are under advancement to assess its safety and efficacy alone or in combination with some other drugs by taking participants with sars-cov- infection (barrett, ; de paris, ; regeneron pharmaceuticals, infected patients (henriksen, ) . it is a humanized recombinant igg anti-cd monoclonal antibody, used for the treatment of moderate to severe plaque psoriasis, rheumatoid arthriris and autoimmune disorders (saavedra et al., ) . intially, it was developed by biocon in bengaluru and approved in in psoriatic patients. recently, biocon repositioning the drug into patients with moderate to severe covid- associated with cytokine release syndrome (crs) and acute respiratory distress syndrome (ards). in addition, drug controller general of india (dcgi) allowed use of alzumab ( mg/ ml injection) in sars-cov- patients as an emergency treatment and capable to save numerous seriously sick patients with covid- (https://www.pharmaceutical-technology.com/news/biocon-itolizumab-approval/). itolizumab is also acts as a immunomodulator and binds with cd receptor along with suppress many proinflammatory mediators (cytokines) and downregulates the t-cell activation at site of inflammation (saavedra et al., ). an open-label randomized and controlled study performed by biocon, in participants associated with moderate to severe symptoms of sars-cov- virus. the study being conducted in two groups, first group taken itolizumab+ supportive care while second group only with supportive care. the overall outcomes showed there is no mortality rate and all patients are recovered well as compared to second group. further, clinic-pathological observations i.e release of pro-inflammatory cytokines (il- & tnf-α) significantly decrease in first group when compared to second group (jolla, ; uttamani et al., ) . moreover, several clinical studies are required to confirm its safety and efficacy in covid- patients. it is a vasoactive intestinal polypeptide (vip) analogue used in the treatment of erectile dysfunction, acute lung injury and besnier-boeck-schaumann disease. the significance of aviptadil in ards, because it has been documented by animal studies that vip is extensive concerted in the lungs and inhibits nmda-induced caspase- activation, il and tnf-α production and also protects against acidic (hcl)-induced lung edema. in the various animal models, aviptadil protects lungs and other organs from damage or failure by restoring barrier function at the alveolar interface (petkov et al., ; said, ) . in a phase clinical trials,conducted under european regulatory authority (era), patients were successfully treated with intravenous infusion of aviptadil on escalating doses and restores all the functioning of pulmonary hypertension, acute lung injury and ards. few adverse effects related to cardiovascular system such as change in blood pressure, heart rate or ecg was noticed. eculizumab is a monoclonal protein based monoclonal antibody (mab) used to treat paroxysmal nocturnal hemoglobinuria (pnh), atypical hemolytic uremic syndrome (ahus), and neuromyelitis optica (wong and kavanagh, ) . the main target of eculizumab is complement protein c , preventing cleavage to c a and c b, and the formation of the terminal complement complex c b- , which is involved in many autoimmune diseases (gralinski et al., ) . based on case study of patients with sars-cov infection and also confirmed severe pneumonia and ards treated with i.v. infusion of eculizumab along with anticoagulant therapy (enoxaparin iu/day s.c), antiviral therapy (lpv mg/day + rtv mg/day), hydroxychloroquine mg/day, ceftriaxone g/day iv, vitamin c g/day for days. all patients showing decrease in the inflammatory markers including c-reactive protein (crp) (diurno et al., ) . more clinical study is needed for confirmation its safety and efficacy as ananti-inflammatory in the treatment of covid- . jak are the intracellular enzymes located on cellular membrane, transmits signal by binding with various cytokines and growth receptors. after binding with receptor, enzymes phosphorylation occurs, which modulating the changes in the gene expression and thus, activates the signal transducers and activators of transcription proteins (stats) (seif et al., ) . jak pathway is key enzyme and plays a crucial role in the activation of immune system, hematopoiesis and inflammation. inhibitors of jak, prevents the enzymes phosphorylation and activation of stats proteins (o'shea et al., ) . it is reversible and competitive inhibitor of jak & jak , and firstlyaccepted by us fda in the treatment of autoimmune disorder i.e. rheumatoid arthritis. it also have broad immunosuppressive effect, and used in many autoimmune disorders (winthrop, ) . it blocks the enzymes protein no significant adverse effect reported in baricitinib-treated patients (cantini et al., ) . further studies are needed to confirm its clinical safety and efficacy in the treatment of covid- infection. others jak inhibitors are also under clinical development and data are being evaluated in the treatment of covid- are ruxolitinib and tofacitinib (smith and prosser, ) . isotretinoin,a retinoid derivative of vitamin a, is used in the treatment of severe acne. it is the strongest down-regulator of ace- receptors. it has been documented that isotretinoin is a protease inhibitors and can be a taken as a target therapy in covid- (wu et al., a) . based on the above mechanism, isotretinoin currently tested under phase clinical trials in the adult patients with positive sars-cov- viral infections.current outcomes showing there is large difference at the onset of clinical signs and symptoms treated patients with isotretinoin, standard therapy or combined therapy and checked by on a daily basis. corticosteroid therapy is only used as supportive care in patients of covid- with refractory shock or ards (wu et al., b) . according to who, corticosteroids are recommended only for some conditions like asthma, chronic obstructive pulmonary disease (copd), and septic shock (who, b) . earlier studies showed corticosteroids i.e. methyl-prednisolone directly not supported the patients having symptoms of viral-pneumonia in covid- (jin et al., ) , only act as an antiinflammatory and reduces inflammatory mediators i.e. interleukin (il- &il- ), mcp , th chemokine,ip etc. (sung et al., ; wong et al., ) . dexamethasone, another cheap and widely steroid drug used in the treatment of many inflammatory disease conditions and disorders like asthma, severe skin allergies, chronic obstructive lung disease and certain cancers. recently, it has been documented that dexamethasone could be lifesaving drug in critically ill patients with covid- (who ). a retrospective cohort study showed daily administered of dexamethasone ( mg upto days) reduces the mortality rate among patients with covid- who needed supplemental oxygen and mechanical ventilation. there is no advantage of dexamethasone observed in patients who did not necessitate mechanical support or/ ventilation (horby et al., ) . it is an antibody-rich plasma, collected from the patients who already have recovered from diseases caused by virus e.g. polio, measles, ebola, h n influenza, hepatitis b, and now currently in sars-cov- responsible for covid- . on may , , us fda permitted issued guidelines to healthcare providers, make ensure the safety and efficacy of investigational product by collecting plasma from recovered patients under demand of public health emergency (stephen and hahn, ) . a newly reports showed that use of plasma therapy in five ventilated coronavirus patients, all patients improved after one week of transfusion. moreover, this report was not a clinical trial, further research is essential to confirm its potential and managing patients in sars-cov- infected patients (https://clinicaltrials.gov/ct /show/study/nct ). bronchodilators are preferred only as a supportive care for covid- patients associated with copd, asthma and other respiratory disorders (lippi and henry, ) . due to concern of safety precautions, both standard nebulizers and metered dose inhalers (mdi) are risky to covid- patients, as it requires opening of ventilator circuit. regular administration of bronchodilator may be needed, to minimize the virus transmission to others multiple health care patient. in order to alleviate these hazards, aeroneb solo (aerogen©, galway, ireland) has been successfully made for covid- patients which continuously delivers medication via inhalation without circuit opening and requires minimal health-care workers for handling (miller and epstein, ) . these are the agents that breakdown plasminogen to plasmin on the surface of thrombi, thus produced fibrinolysis (chapin and hajjar, ) . a study was done in seriously unwell patients, already suffered with ards and respiratory collapse/failure. patients administered with alteplase along heparin improves pao /fio (p/f) ratio momentary approximately by - % (moore, ). further, detailed studies are required to check its clinical efficacy among large population. others supportive fibrinolytic agents are also being evaluated for covid- patients e.g. defibrotide (fabio, ) . coronavirus patients have a higher risk of venous thromboembolism (vte), deep vein thrombosis (dvt) and pulmonary embolism (porfidia andpola, ) . coagulopathy is one of the main reasons of mortality in the majority of covid- patients. a recent report suggested anticoagulant therapy such as low molecular weight heparin (lmwh) administered to patients showed low mortality risk (kollias et al., ) . aspirin is also used as a prophylaxis treatment in case of post-discharge vte covid- patients(ash, ). further, additional data needed regarding its efficacy and safety in covid- patients. due to pandemic of covid- disease, no vaccine or drug is approved to eliminate the virus. drug development and discovery is broad and extensive process, due to utmost necessity of the treatment, drug repurposing is suitable for treatment of covid- infection. at present, numerous drugs are ongoing clinical trial and tested directly in patients with covid- , strict monitoring is mandatory at the time of treatment of patients to assure its safety and efficacy of unknown profile of drugs. based on the exposed and revealed structure and transmission mechanisms of novel coronavirus, the available treatment option is antiviral, anti-inflammatory & immunomodulatory drugs. this review provides detailed description of all available in-vitro & in-vivo studies, mechanism, clinical spectrum of disease, symptoms and safety concern profile of currently available treatment and concerning drugs, which are progress under clinical development. in conclusion, while waiting for the most effectual pharmacological treatment with less adverse effects, many trials are currently ongoing and will available around at the end of , according to clinical trials government website. hope, their consequences will definitely provide us good outcome and help worldwide in significant the greatest approach to cure or treat covid- along with symptoms and complications. the authors declare that they have no conflict of interests. this research did not receive any specific grant from funding agencies in the public, commercial, or not-forprofit sectors. table classification, mechanism of action, adverse effects and therapeutic uses of anti-inflammatory &immunomodulatory agents against covid- name of drug(s) coronavirus susceptibility to the antiviral remdesivir (gs- ) is mediated by the viral polymerase and the proofreading exoribonuclease remdesivir as a possible therapeutic option for the covid- the interferons: pharmacology, mechanism of action, tolerance and side effects covid- and vte/anticoagulation: frequently asked questions version . early administration of azithromycin and prevention of severe lower respiratory tract illnesses in preschool children with a history of such illnesses: a randomized clinical trial corona virus and covid- treatment of moderate to severe coronavirus disease (covid- ) in hospitalized patients remdesivir for the treatment of covid- -preliminary report the -new coronavirus epidemic: evidence for virus evolution biocon's drug itolizumab gets approval to treat covid- . updated on azithromycin inhibits the replication of zika virus to study the effectiveness of ivermectin with standard of care treatment versus standard of care treatment for covid cases experimental treatment with favipiravir for covid- : an open-label control study. engineering (beijing) the fda-approved drug ivermectin inhibits the replication of sars-cov- in vitro baricitinib therapy in covid- : a pilot study on safety and clinical impact a phase randomized, double-blind, placebo-controlled, multicenter study to evaluate the efficacy and safety of remdesivir in hospitalized adult patients with severe a trial of lopinavir-ritonavir in adults hospitalized with severe covid- clinical features and short-term outcomes of patients with corona virus disease interleukin- blockade with high-dose anakinra in patients with covid- , acute respiratory distress syndrome, and hyperinflammation: a retrospective cohort study pathogenic human coronavirus infections: causes and consequences of cytokine storm and immunopathology fibrinolysis and the control of blood coagulation cytokine storm and sepsis disease pathogenesis role of lopinavir/ritonavir in the treatment of sars: initial virological and clinical findings cipla and hetero launch remdesivir to treat covid- in india targeted update: safety and efficacy of hydroxychloroquine or chloroquine for treatment of covid- ross r, frydasi. induction of pro-inflammatory cytokines (il- and il- ) and lung inflammation by coronavirus- (covi- or sars-cov- ): antiinflammatory strategies convalescent plasma trial in covid- patients. nih u.s library of medicine the national institutes of health (nih) covid- treatment guidelines panel provides recommendations for dexamethasone in patients with covid- cohort multiple randomized controlled trials open-label of immune modulatory drugs and other treatments in covid- patients -sarilumab screening of an fda-approved compound library identifies four small-molecule inhibitors of middle east respiratory syndrome coronavirus replication in cell culture darunavir/cobicistat/emtricitabine/tenofoviralafenamide: a review in hiv- infection eculizumab treatment in patients with covid- : preliminary results from real life asl napoli nord experience an interactive web-based dashboard to track covid- in real time response to" dose rationale for favipiravir use in patients infected with sars-cov- use of defibrotide to reduce progression of acute respiratory failure rate in patients with covid- pneumonia chloroquine and hydroxychloroquine in covid- interleukin- receptor antagonist anakinra in association with remdesivir in severe coronavirus disease : a case report favipiravir (t- ), a broad spectrum inhibitor of viral rna polymerase hydroxychloroquine and azithromycin as a treatment of covid- : results of an open-label non-randomized clinical trial complement activation contributes to severe acute respiratory syndrome coronavirus pathogenesis the origin, transmission and clinical therapies on coronavirus disease (covid- ) outbreak-an update on the status interferon-β and mycophenolic acid are potent inhibitors of middle east respiratory syndrome coronavirus in cell-based assays effectiveness of interleukin- receptor inhibitors in the management of patients with severe sars-cov- pneumonia: an open-label sars-cov- cell entry depends on ace and tmprss and is blocked by a clinically proven protease inhibitor first case of novel coronavirus in the united states clinical features of patients infected with novel coronavirus in wuhan the continuing -ncov epidemic threat of novel coronaviruses to global health: the latest novel coronavirus outbreak in wuhan, china triple combination of interferon beta- b, lopinavir-ritonavir, and ribavirin in the treatment of patients admitted to hospital with covid- : an open-label, randomised a rapid advice guideline for the diagnosis and treatment of novel coronavirus ( -ncov) infected pneumonia (standard version) clinical trial shows itolizumab reduces mortality in patients hospitalized with covid- . equillium thromboembolic risk and anticoagulant therapy in covid- patients: emerging evidence and call for action therapeutic strategies in an outbreak scenario to treat the novel coronavirus originating in wuhan, china a glimpse into the eye of the covid- cytokine storm delayed induction of proinflammatory cytokines and suppression of innate antiviral response by the novel middle east respiratory syndrome coronavirus: implications for pathogenesis and treatment early transmission dynamics in wuhan, china, of novel coronavirus-infected pneumonia molecular modeling evaluation of the binding effect of ritonavir, lopinavir and darunavir to severe acute respiratory syndrome coronavirus proteases chronic obstructive pulmonary disease is associated with severe coronavirus disease (covid- ) potential therapeutic agents against covid- : what we know so far efficacy and safety of darunavir and cobicistat for treatment of covid- evaluation of ebola virus inhibitors for drug repurposing baricitinib: a novel fda-approved small molecule inhibiting janus kinases. pharmaceuticals safe bronchodilator treatment in mechanically ventilated covid- patients: a single center experience use of antiviral drugs to reduce covid- transmission fibrinolytic therapy to treat ards in the setting of covid- infection: a phase a clinical trial computational studies of drug repurposing and synergism of lopinavir, oseltamivir and ritonavir binding with sars-cov- protease against covid- phase multicenter, randomized, double-blind, placebo-controlled study to assess the efficacy and safety of canakinumab on cytokine release syndrome in patients with covid- -induced pneumonia darunavir disrupts critical nodes in metastable -ncov-rbd/ace- complex the jak-stat pathway: impact on human disease and therapeutic intervention vasoactive intestinal peptide as a new drug for treatment of primary pulmonary hypertension venous thromboembolism and heparin use in covid- patients: juggling between pragmatic choices, suggestions of medical societies case study: -year-old female presenting with shortness of breath antiviral drugs for viruses other than human immunodeficiency virus an adaptive phase / , randomized, double-blind, placebo-controlled study assessing efficacy and safety of sarilumab for hospitalized patients with covid- clinical predictors of mortality due to covid- based on an analysis of data of patients from wuhan, china an anti-cd monoclonal antibody (itolizumab) reduces circulating il- vasoactive intestinal peptide in pulmonary arterial hypertension current pharmacological treatments for covid- : what's next? the role of jak-stat signaling pathway and its regulators in the fate of t helper cells interferon beta- b for covid- comparative therapeutic efficacy of remdesivirand combination lopinavir, ritonavir, and interferon beta against mers-cov covid- drug therapy-potential options boosted protease inhibitors and the electrocardiographic measures of qt and pr durations coronavirus (covid- ) update: fda encourages recovered patients to donate plasma for development of blood-related therapies severe acute respiratory syndrome: report of treatment and outcome after a major outbreak il- in inflammation, immunity, and disease cytokine storms in infectious diseases covid- , immune system response, hyperinflammation and repurposing antirheumatic drugs toll-like receptors and type i interferons camostatmesilate therapy for covid- fda cautions against use of hydroxychloroquine or chloroquine for covid- outside of the hospital setting or a clinical trial due to risk of heart rhythm problems therapeutic modalities in the management of covid- : a worldwide landscape distinct effects of t- (favipiravir) and ribavirin on influenza virus replication and viral rna synthesis remdesivir and chloroquine effectively inhibit the recently emerged novel coronavirus ( -ncov) in vitro who welcomes preliminary results about dexamethasone use in treatingcritically ill covid- patients world health organization, a. draft landscape of covid- candidate vaccines clinical management of severe acute respiratory infection (sari) when covid- disease is suspected the emerging safety profile of jak inhibitors in rheumatic disease plasma inflammatory cytokines and chemokines in severe acute respiratory syndrome anticomplement c therapy with eculizumab for the treatment of paroxysmal nocturnal hemoglobinuria and atypical hemolytic uremic syndrome risk factors associated with acute respiratory distress syndrome and death in patients with coronavirus disease pneumonia in wuhan, china analysis of therapeutic targets for sars-cov- and discovery of potential drugs by computational methods effective treatment of severe covid- patients with tocilizumab in vitro antiviral activity and projection of optimized dosing design of hydroxychloroquine for the treatment of severe acute respiratory syndrome coronavirus (sars-cov- ) mers, sars and other coronaviruses as causes of pneumonia isolation of a novel coronavirus from a man with pneumonia in saudi arabia sars-cov- : an emerging coronavirus that causes a global threat epidemiology and cause of severe acute respiratory syndrome (sars) in guangdong, people's republic of china clinical course and risk factors for mortality of adult inpatients with covid- in wuhan, china: a retrospective cohort study key: cord- -qa uph authors: nan title: poster discussion session pds date: - - journal: allergy doi: . /all. sha: doc_id: cord_uid: qa uph nan objectives: since bradykinin is a short-lived, low-abundance mediator in the systemic circulation, the discovery of additional biochemical biomarkers correlating hae disease activity with contact system dysregulation may be useful for further elucidation of hae pathophysiology and pharmacodynamic therapeutic modulation of the contact system. results: activated pkal cleaves single chain high molecular weight kininogen to generate bradykinin and cleaved chain hmwk. cleaved -chain hmwk was measured in human plasma using both a semi-quantitative western blot assay with fluorescent detection (licor) and a novel elisa with a capture antibody that specifically binds -chain hmwk. the western blot assay was previously used to monitor pharmacodynamic activity in hae patients treated with lanadelumab, a fully human antibody inhibitor of pkal that is in clinical development for hae attack prophylaxis. lanadelumab inhibited -chain hmwk generation following contact system activation in vitro, confirming that -chain hmwk is a product of pkal activity. plasma -chain hmwk levels from hae patients during or between attacks were compared to that from healthy volunteers using both the western blot assay and elisa. roc curve analyses with both methods suggest that -chain hmwk is a trait-specific biomarker capable of differentiating hae patients from healthy volunteers. the elisa was able to differentiate samples from hae patients collected during an attack from those collected between attacks with moderate sensitivity and specificity (c-statis-tic= . ). a comparison of -chain hmwk levels in citrated plasma versus plasma that contains protease inhibitors (scat plasma) provides estimates of endogenous versus ex vivo activation. the measurement of -chain hmwk using the specific assays described may find use in further dissecting the role of the contact system in disease pathology, to identify additional indications for modulators of this pathway, and to investigate therapeutics targeting the contact system. | g protein coupled receptor kinase (grk ) regulates endothelial permeability induced by bradykinin | pharmacokinetics (pk) and pharmacodynamics (pd) of c esterase inhibitor of chronic urticaria challenges most commonly identified were the following: time of onset of disease; frequency/duration of and provoking factors for wheals; diurnal variation; occurrence in relation to weekends, holidays, and foreign travel; shape, size, and distribution of wheals; associated angioedema; associated subjective symptoms of lesions; family and personal history regarding urticaria, atopy; previous or current allergies, infections, internal diseases, or other possible causes; psychosomatic and psychiatric diseases; surgical implantations and events during surgery; gastric/ intestinal problems; induction by physical agents or exercise; use of drugs; food allergies; relationship to the menstrual cycle; smoking habits; type of work, hobbies; stress; quality of life and emotional impact; previous therapy and response to therapy, and previous diagnostic procedures/results. we included all of these aspects in our guide and as a result we developed a chronic urticaria check list. conclusions: our guide of clinical history for chronic urticaria (gur) contributes to have an easy tool in order to achieve a better diagnosis and evaluation of chronic urticaria. | clinical and diagnostic features in acquired cold urticaria patients in a coruña sanitary area, spain physicians and dermatologists/allergists; c/sa patients were more likely to visit dermatologists/allergists ( % vs. %) and less likely to visit general physicians ( % vs. %) than european patients. emergency room visits due to cu were more common in c/sa ( %, mean [sd] number= . [ . ] ) than europe ( %, mean [sd] number= . [ . ] ). conversely, hospital admissions due to cu were more likely to occur in europe ( %) than c/sa ( %), but the average (sd) number of admissions among those hospitalised was greater in c/sa ( . [ . ] vs. . [ . ]). variations were seen in subregion comparisons. mean (sd) overall wpai scores were . ( . ), . ( . ), . ( . ), and . ( . ) for absenteeism, presenteeism, work productivity loss, and activity impairment, respectively; patients in c/sa reported a higher rate of impairment (range, %- %) on all domains compared with patients in europe. conclusions: cu is associated with substantial hru and work and activity impairment in both europe and c/sa. general physicians should be considered key members of the treatment team in the care of patients with cu in these regions. objectives: cu patients (n= ) received monthly subcutaneous injections of omalizumab for up to six months. urticaria-related symptoms were assessed by both the urticaria control test (uct) and the chronic urticaria quality of life score (cu-q ol). peripheral blood was drawn prior to each injection for determining the concentration-dependent reactivity of patients' basophils to specific anti-fceri and unspecific fmlp stimulation by basophil activation test. furthermore, the impact of anti-ige treatment on ige-bearing cell populations was characterized by flow cytometry analyzing the surface expression of both fceri (e.g. on monocytes, dendritic cells, basophils) and the low-affinity receptor for ige, fcerii (e.g. on b cells, eosinophils). results: anti-ige treatment of cu patients significantly improved clinical symptoms of cu already after the first injection as evaluated by cu-q ol and uct, the latter of which correlated with an increase of basophil numbers and a decrease of basophil surface bound ige. of note, cell-bound ige on fcerii-expressing cells was not altered. furthermore, while clinical amelioration also was accompanied by reduced fceri expression on basophils, the basophil responsiveness to anti-fceri stimulation increased in % ( / ) of treated patients. in contrast, ige-independent activation of basophils by fmlp was unchanged. conclusions: clinical improvement of cu patients treated with omalizumab is associated with characteristic immune alterations in basophils, like rapid, cell-specific reduction of surface bound ige and fceri-expression as well as normalization of basophil responsiveness to fceri-stimulation. while our findings might help to better understand the mode of action of anti-ige therapy in cu, they also can shed new light on the pathomechanisms underlying cu. | omalizumab in patients with severe active chronic spontaneous urticaria (csu) heavily treated with corticosteroids and cyclosporine introduction: increased levels of blood d-dimers (d-d), the byproducts of fibrin degradation, is linked to the severity of chronic spontaneous urticaria (csu) and to poor response to antihistamines h (ah ). omalizumab (oma) is a human monoclonal anti-immunoglobulin-e antibody registered as an add-on treatment of csu in adults and adolescent (≥ years old) and with insufficient response to ah . the sunrise study assessed the efficacy of omalizumab on csu symptoms and the correlation between d-d levels and response over time to treatment with oma to explore its potential predictive value. objectives: sunrise was a french prospective non comparative phase study. included patients had to have been diagnosed with csu for at least months, be resistant to ah treatment, and have a uct score (assessed by patient over the last weeks, values from (maximal disease)to (full control)) < , indicative of a poorly controlled disease. the widely used uas score (assessed by patients over week which captures intensity of pruritus and number of hives, values ranging from (no disease) to (severe disease)) was further used to evaluate the proportion of patients achieving a well controlled disease(uas≤ ). all patients received mg oma by sub-cutaneous injections at day , weeks (w) and . blood levels of d-d were assessed (turbidimetric immunoassay) at d , w and w . response to treatment was evaluated at w by means of the uas . results: median level of d-d assessed at d in patients was increased at baseline ( ng/ml, extremes - ) and normalized as early as w reaching ng/ml ( - ) at w . correlation between d-d concentration and uas score at w was weakly positive (spearman coefficient . ). among the patients with a very high baseline de d-d level (> ng/ml) were responder (uas ≤ ) at w . conclusions: baseline d-d levels were increased in more than half of patients of this study in line with relevant literature. a fast normalization was observed with oma as early as w of treatment. d-d levels at w were weakly correlated with uas . subgroup analyses may help to better understand the link between d-d and clinical response, as these preliminary results do not yet allow the predictive use as a biomarker. the sunrise study explored for the first time in a prospective way the impact of oma on dd and found weak correlations were measured between dd level and response to oma. further studies will be needed to evaluate its predictive value for response. (crp, esr, il- , il- , il- , ccl /mcp- ), and the disease severity in patients with chronic spontaneous urticaria introduction: pru p is the primary sensitizer of some fruits and responsible for severe reactions in the mediterranean area. sublingual immunotherapy (slit) using peach extract enriched in pru p (prup -enriched-slit) brings a new perspective to treat patients with reactions to peach considering that currently the treatment of the allergy to peach is based on avoidable ingestion of fruit. we performed a pilot study to examine the immune modulation by slit in patients with peach allergy over a -year treatment period. objectives: we aimed to evaluate the effect of the slit during one year in patients with peach allergy. we analysed the capacity pru p enriched-slit to modulate immune response, from a th to th response with increases of treg cells. we studied three groups of subjects: peach allergic patients who received prup -enriched-slit for year, peach allergic patients non treated, and healthy controls who tolerated peach. monocyte-derived dendritic cells (dcs) maturation, peripheral blood mononuclear cell phenotype and lymphocyte proliferation after prup stimulation were assessed by flow cytometry from samples obtained before, and , and months during slit. results: we found statistically significant differences in dcs activation and maturation between allergic patients and controls at the basal state. when we analyzed the effect of prup -enriched-slit over time, we found a significant reduction of activation and maturation markers (ccr , cd , cd , cd and cd ) at the first month of treatment that was maintained after year. concerning lymphocytes, we observed a significant decrease of effector cells immune cells. recent studies showed that fructo-oligosaccharides (fos) increase the efficacy of oral immunotherapy (oit) in a mouse model for cow's milk allergy, however, the mechanism is unknown. objectives: investigating the effect of oit+fos on the effector response and the process of tolerance induction. methods: female c h/heouj mice ( - weeks old, n= /group) were sensitized to the cow's milk protein whey ( mg in pbs, intragastrically (i.g.)) with cholera toxin ( lg) once a week for weeks (d -d ). the mice received a diet with % fos or a control diet from d -d . oit ( mg in pbs or pbs) was provided days a week for weeks (d -d ). intradermal (i.d.) and i.g. challenges were performed to measure the acute allergic response. serum, bone marrow, caecum content, small intestines and mesenteric lymph nodes (mln) were collected at d , d and d . spleen-derived t cell fractions (whole spleen, cd +cd -and cd +cd +, using macs) were transferred to na€ ıve recipient mice at d . the recipients were sensitized and challenged as described for the donor mice. conclusions: this study shows that oit+fos results in an early induction of functional tregs and a reduction of mast cell degranulation upon challenge. the latter may be caused by inhibition of mast cell activation by galectin- and/or butyric acid. moreover, the effect of fos on bone marrow suggests possible epigenetic changes reducing development of mast cells. further research is needed to investigate if this approach may be of potential value to treat food allergies. | safety and feasibility of slow low-dose oral immunotherapy sugiura s; kitamura k; tajima n; takasato y; kato t; tajima i; ono m; tagami k; sakai k; nakagawa t; ito k aichi children's health and medical center, obu, japan introduction: slow low-dose oral immunotherapy (sloit) is an ongoing clinical trial conducted in our institute (umin registry number ). this is a type of oral immunotherapy with a low dose antigen increased very slowly. objectives: to evaluate the safety and feasibility of the protocol. results: sloit enrolled the patients who were diagnosed as severe egg, milk or wheat allergies, with a threshold dose of g (or ml) or less in the oral food challenge (ofc, -minutes boiled egg white, whole milk, udon noodle). subjects were divided into two groups, intervention (sloit) group or elimination (control) group, based on their preference. sloit group began to ingest / to / amount of the final dose of the ofc based on the severity of provoked symptoms. intake was continued everyday with an increasing dose less than . times/ month, expecting a times increase from the starting dose after months. feasibility was evaluated based on the proportion of patients who complied the protocol. safety was evaluated based on the frequency of immediate allergic reactions observed in the programmed intakes. fifty-nine patients were enrolled from april to december , and of them (egg: , milk: , wheat: ) preferred the sloit group. among them, patients ( . %) dropped out from the study protocol because of provoked allergic symptoms (n= ) or the other personal reasons (n= ). among a total of ingestions by patients who continued the protocol over months, mild symptoms were observed times ( . %), to which rescue medicine such as oral antihistamines was used in cases ( . %). no one needed an emergency visit or an adrenalin auto-injector. low threshold dose at the initial ofc ( . g or less, n= ) was associated with higher proportion of provoked allergic symptoms in the protocol (low threshold: . %, non-low threshold: . %, p=. ). the level of specific ige titer was not associated with the safety. conclusions: sloit protocol has sufficient safety and feasibility, but low threshold patients should be monitored closely. the efficacy of this protocol is being evaluated by an ofc after - months of the treatment, and the overall data will be presented after march . objectives: the aim of this phase i, randomized, non-controlled, multicenter, opened, with parallel groups clinical trial, is to evaluate the safety and tolerability of subcutaneous immunotherapy (scit), in a polymerized mixture ( / ) depot presentation. patients with rhino-conjunctivitis polysensitized to olea europaea/ phleum pratense received a schedule consisting of two weeks of initiation with three weekly injections; or a program comprising two administrations in the same day separated by minutes. both treatments continued with a maintenance period of three months with a monthly administration. the primary outcomes are the number, percentage, and severity of adverse reactions. secondary endpoint included subrogate efficacy parameters evaluation: changes in immunoglobulin titers (specific ige, igg and igg ) and changes in cutaneous reactivity at different concentrations. systemic reactions were registered, representing . % of the included patients: one grade , described as general discomfort plus dizziness and one grade i, such as rhinoconjunctivitis. there were no local reactions. all were classified as of mild intensity and took place with the cluster schedule. symptomatic treatment was not required. conclusions: both schedules with polymerized mixture of phleum pratense/olea europaea, ( / ), presented a good safety and tolerability. a statistically significant decrease in cutaneous reactivity to olive and grass allergens was observed after immunotherapy. a | design of the pivotal phase iii study to assess the efficacy and safety of subcutaneous hdm allergoid immunotherapy in patients with hdm induced allergic rhinitis/ rhinoconjunctivitis introduction: in order to comply with ema guidelines on development of allergen immunotherapy products, a clinical development program was started to obtain full marketing authorization for a allergoid subcutaneous immunotherapy (scit) product for the treatment of house dust mite (hdm) allergy. previously, the safety and tolerability of increasing doses of this allergoid scit product was evaluated in patients with hdm-induced allergic rhinitis/rhinoconjunctivitis (arc) [eudract - - ] . no safety or tolerability issues were identified for doses up to aueq. subsequently, a dose-finding study to identify the optimal, i.e. effective and safe dose in hdm arc with or without concomitant asthma was performed [eudract - - ; pfaar, allergy ] . this study demonstrated a dose response relationship with doses of aueq ( . ml of aueq/ml) up to aueq ( . ml of aueq/ml) showing significant improvements compared to placebo. the current pivotal phase iii study [eudract - - ] aims to confirm safety and efficacy of this hdm allergoid scit product at a dose level of aueq/ml ( . ml) compared to placebo after one year of treatment in patients with hdm-induced arc. objectives: the current study is a multi-center ( clinical study centers in european countries) randomized, double-blind, placebocontrolled, parallel-group study in adult patients, with moderate to severe hdm induced arc with or without mild to moderate persistent asthma. the primary outcome of the study is the difference in mean combined symptom and medication score (nasal symptoms only) (csms (n)) between aueq/ml allergoid scit and placebo treatment, assessed during the last weeks of the approximately year treatment period. results: patients from centers, (mean age . years) have been included and analyzed. the . % are men, . % presented associated asthma. a large majority of patients have received subcutaneous sit ( . %), and . % of them containing a single allergenic source. . % in polymerized formulation and . % in depot. accelerated schedule has been the most prescribed ( . %), followed by clustered one ( . %). from the patients who have completed the study, . % of them improved from persistent to intermittent rhinoconjunctivitis (p<. ) and . % from moderate/severe to mild intensity (aria) (p<. ). moreover, % of asthmatic patients at baseline, did not have any bronchial symptoms after -year treatment. the improvement in quality of life was possible to be analyzed in patients. mean values in rqlq questionnaire (total score) decreased from . to . points ( . % of score reduction) in final visit, reflecting a statistically significant improvement (p<. ). mean value of treatment satisfaction was . (sd= . ) and . (sd= . ) for physician and patients respectively. for safety assessment, out of analyzed patients, only systemic reactions were reported in patients ( . %). seven of them were classified as grade i, and one as grade ii according to eaaci grading system. strasbourg is a m chamber, located into the university hospital of strasbourg at less than to minutes to the intensive care unit. one of the characteristics of this unit is that the maximum parameters are controlled: temperature, relative humidity, ventilation rate, particles number and particles size, concentration of airborne of der p and airborne voc. mite allergens extract were nebulized through a nebulizer. airborne der p concentrations were sampled using glass fiber filters and measured with an elisa assay. particles number and particles size were monitored continuously during nebulization, using particles counters distributed inside the exposure room. the cleaning process was also controlled and validated. objectives: to validate the technical parameters of the environmental exposure chamber (eec) of strasbourg with mite allergens. results: the reproducibility was excellent for the indoor temperature, relative humidity and airflow ( cv interassay < %). three concentrations of der p were measured: , , ng/m (n= ). for all concentrations, the cv intra-assay of airborne der p was ae . %, the interassay was less than %. for the particle size . - and - lm, the cv interassay was and %, respectively (n= ). the cv of the mmad was . % (n= ). no measurable airborne der p was detected in the toilets and the medical supervision room (n= ) neither in the exposure room minutes after the end of the allergen exposure (n= ). no airborne voc was measured in the chamber and the other rooms of the clinical unit (n= ). there was no significant change in particles size and number when to persons entered the room (n= ). introduction: pathogenesis of systemic sclerosis (ssc) includes vasculopathy with endothelial dysfunction which is considered to be one of the earliest changes in the pathogenesis of ssc. several biological molecules, including e-selectin (e-sel), inter-cellular adhesion molecule (icam- ), endothelin (et- ), von willebrand factor (vwf) and interleukin (il- ) have been associated with endothelial activation. objectives: we aimed to determine if these vascular biomarkers are associated with distinct capillaroscopic ssc patterns and/or more severe disease in ssc patients. results: correlations between serum levels of all vascular biomarkers were good to moderate and statistically significant, with r indices varying between . and . , the only exception being et- which did not correlate with e-sel. good correlations (r . to . ) were also found between all biomarkers and crp. patients with severe vasculopathy, as reflected by the nfc "late" pattern, had higher levels of il- (median . vs . pg/ml, p=. ), et- (median . vs . pg/ml, p=. ), vwf (median vs iu/ml, p=. ) and e-sel (median . vs . ng/ml, p>. ), compared to patients with nfc "early" or "active" patterns. there was a significant, negative correlation between lung transfer for carbon monoxide (dlco) and e-sel, icam- (both p<. ) and vwf (p=. ). et- was higher in patients with more severe disease (dcssc, patients positive for anti-topoisomerase antibodies and patients with a history of digital ulcers-all p<. ). conclusions: serum endothelial activation biomarkers are elevated in patients with more severe ssc-associated vasculopathy and correlate with serum crp. together with nfc data they may be used for assessing vasculopathy severity in ssc. objectives: here we present the imagination findings of eye involvement in a family whose members have mws. method: clinical data was collected during the course of ongoing patient care. results: we evaluated the clinical features of patients who were referred to our center. the median age of the patients was years (range: - years). the ratio of females /males was . ( / ). all patients had arthritis with exacerbation on exposure to cold and ocular involvement, mostly in the form of conjunctivitis and far less other forms. the median age of onset of ocular involvement was years ( - y). chronic eye damage were detected in three patients. corneal involvement and clouding was detected in four patient. two conclusions: in this study, it has been shown that eye findings related to mws can vary from conjunctivitis to severe uveitis. we want to emphasize that ocular involvement in mws should be carefully assessed, since it can lead to visual impairment. | antiretroviral activity of the conjugates '-azido- 'deoxythymidine and derivatives of , -diacylglycerides case report: aids epidemics remain the critical problem due to both their emergent and long development. treatment of aids with azt reduces p antigenemia, increases cd + lymphocyte counts, reduces the frequency and severity of opportunistic infections and prolongs life. however, zidovudine and other dideoxynucleotides do not decrease the ability to isolate hiv from pbmc, and in addition, these drugs are very toxic. this phenomenon is caused by insufficient inhibition of hiv due to low levels of nucleoside kinases in ccr -positive cells, including in macrophages, which are a major reservoir of hiv. potential advantages of these liponucleotide prodrugs include: greater in vivo efficacy and lower toxicity due to a greater delivery to monocytes/macrophages, ability to bypass the initial anabolic phosphorylation due to the presence of the phosphorous center in the structure, and the prospect of improved pharmacokinetics and prolonged intracellular persistence. the aim of this work is the study of cytotoxicity and anti-hiv activity of glycerolipids derivatives of azt. evaluation of the cytotoxicity of azt and test compounds was per- | bone mineralisation defect in patients with hax- deficiency and osteopenia (z score <À ) in patients. bone mineralisation defect was found in all female patients while only one male had osteopenia (table ) . conclusions: in this study, a significant decrease ( . %) of bone mineralization was observed in patients with hax- deficiency. female patients were found more prone to bone mineralisation defect. to conclude on this subject, more studies are needed with large number of patients having not only hax- deficiency but also ela- mutations. gene mutation age ( introduction: bronchopulmonary diseases are kept as one of the actual problems of the pediatricians. nevertheless fulfilment of several scientific works on study of these diseases, presently we meet the complication of the respiratory diseases, recurrency, changing to the chronical type. objectives: the main purpose of our work to study the cytokine status and substance p, mutual connection they in frequently ill chil- results: in fic with respiratory diseases in the acute period of the disease increase of levels proinflammatory cytokines il- beta, il- , il- , tnf-alpha and substance p,decrease of levels il- and ifngamma was marked. clinical remission in these children is not accompanied by normalization of cytokine status and substance p. the high level of proinflammatory cytokines and substance p testifies to proceeding of inflammatory process that is possible connected with persistence of the infections agent. acute decrease in level of cytokines il- and ifn-gamma in these children,most likely, is caused by the presence of a immunodeficiency of cellular type. conclusions: in this connection it is necessary to carry out an adequate therapy of fic with arvi. introduction: atopic diseases are known to be characterized by a t helper (th) -skewed immunity. th -skewed immunity at birth, th -associated cc chemokine ligand (ccl)- , appears to be associated with high total ige levels but not of allergic outcomes later in life. the prevalence of asthma increases with a rapid upward trend after age ; however, there are few studies addressing the changes of ccl chemokine levels during infancy related to the development of atopic diseases in early childhood. objectives: we investigated children followed up regularly at the clinic for years in a birth cohort study. the levels of th related chemokine ccl were quantified in cord blood and age . by multiplex luminex kits. specific immunoglobulin e antibodies against food (egg white, milk, and wheat) and inhalant allergens (d. pteronyssinus, d. farina, and c. herbarum) were measured at months as well as . , , and years of age. results: a total of pairs of ccl chemokine levels from birth to age . were recruited in this study. k-means clustering was performed using r software and package mfuzz and this resulted in groups of ccl chemokine levels that declined from around to pg/ml (cluster a, n= ), from around to pg/ml (cluster b, n= ) , and raised from around to pg/ml (cluster c, n= ) . in children with raised ccl chemokine levels appeared to be associated with a higher prevalence of house dust mite sensitization at age . . furthermore, raised ccl levels during infancy were significantly associated with higher risk of asthma at age (p=. ). conclusions: raised ccl chemokine levels during infancy appear not only to be associated with an increase in the prevalence of house dust mite sensitization but also the risk of asthma in early childhood. | serum periostin is "not" a biomarker for pediatric asthma suzuki n ; hirayama j ; nagao m ; kameda k ; kuwabara y ; kainuma k ; ono j ; ohta s ; izuhara k ; fujisawa t mie national hospital, tsu, japan; shino-test corporation, kanagawa, japan; saga medical school, saga, japan introduction: periostin is a matricellular protein induced by type helper t-cell cytokines, expressed by airway structural cells and is thought to contribute to airway remodeling and progressive lung function decline in severe asthma in adults. we sought a possible clinical utility of serum periostin in children with asthma. objectives: we recruited volunteer children and adolescents (age range, to years) who were otherwise healthy except for allergic diseases including bronchial asthma. allergic diseases were classified with isaac questionnaire and serum levels of periostin were measured with elisa. abstracts | results: a total of volunteers were enrolled. among them had no allergic diseases (na), had only allergic rhinitis (ar) and the rest of had bronchial asthma (ba) and/or atopic dermatitis (ad) . serum levels of periostin in na younger than were significantly higher than the older counterpart and the levels in children < years old were similar across each age. data distribution of serum periostin in ar were very similar with that in na and we defined na and ar groups as reference population. reference values, geometric mean (+ geometric sd range), for serum periostin were ( ) and ( ) ng/ml in children/adolescents < and ≥ , respectively. there were no gender differences in serum periostin in the reference population. we then compared the serum levels of periostin in ad and/or ba with the reference group and found that serum periostin in ad and ad+ba, not ba, in < years old were significantly higher than the reference group. in addition, severity of asthma had no association with serum periostin levels in age group of < . on the other hand, the levels in ba aged ≥ were slightly higher than non-ba (statistically significant). conclusions: serum periostin is physiologically high in children and adolescents, possibly in growing age, and the levels are elevated in those with ad, not ba. serum periostin is "not" a useful biomarker for pediatric asthma. | clinical, biochemical and radiological factors for response to aspirin desensitization in patients with aspirin exacerbated respiratory disease-pilot study introduction: aspirin desensitization is regarded as an effective and well-tolerated therapy for patients with aspirin exacerbated respiratory disease (aerd). despite many studies investigating the pathophysiology of aerd, the underlying mechanism responsible for the beneficial effects of aspirin therapy has not yet been clarified. the aim of the study was to evaluate the influence of aspirin desensitization on clinical, biochemical and radiological changes in aerd individuals. objectives: this is a prospective study of twenty-one aerd patients subjected to one-year aspirin desensitization. all participants were hospitalized three times over the period of one year. at baseline and during each follow-up visit ( nd and th month) blood, urine, induced sputum (is) and nasal lavage (nl) were collected from all participants. the acquired material was processed in order to evaluate ) is and nl cell count ) concentrations of is and nl eicosanoids ) leukotriene e (lte ) in urine and ) periostin in blood. additionally, participants underwent a ct scan of the paranasal sinuses at baseline and after months of aspirin therapy. the lund-mackay score values were compared. for statistical analysis, summary statistics and repeated measures anova with post-hoc test were applied. results: twenty participants completed a one-year aspirin therapy. there was a statistically significant decrease in the number (p=. ) and percentage (p=. ) of eosinophils in is between baseline and after aspirin desensitisation. significant increase of urine lte in the course of aspirin therapy was observed (p=. ). the levels of prostaglandins and leukotrienes in is and nl as well as blood periostin level and the differential cell count in nl did not change during aspirin desensitization. in ct scan images the regression of the lesions in paranasal sinuses was observed in %, the worsening in % and in % of patients no changes were noted. in is count of eosinophils in aspirin-sensitive individuals, which may potentially be used in disease monitoring and tailoring asthma therapy. aspirin desensitization did not lead to significant changes in local eicosanoid levels in is and nl. blood periostin level is not a good marker for patient's response to aspirin desensitization. introduction: one of the main severe asthma phenotype is the "severe eosinophilic" or "eosinophilic refractory" asthma, for which novel biologic agents are emerging as therapeutical options. in this context, blood eosinophils count are one of the most reliable biomarker. objectives: the aim of our study is to evaluate the performance of a point-of-care peripheral blood counter in a clinical setting of severe asthmatics. seventy-six patients with severe asthma were evaluated, for blood cells count, by both a point-of-care and a standard analyser. results: the inter-and intra-assay variation was acceptable for leukocytes, neutrophils, lymphocytes and eosinophils. this was not the case of monocytes and basophils. a significant correlation between blood eosinophils assessed by the two devices was found (r = . , p<. ); similar correlations were found also for white blood cells, neutrophils and lymphocytes. the point-of-care device showed ability to predict blood eosinophils cutoffs used to select patients for biologic treatments for severe eosinophilic asthma, and the elen index, a composite score useful to predict sputum eosinophilia. introduction: over years ago there was revealed periostin should play an important role in pathogenesis of allergic inflammation including asthma and processes of tissue remodeling and fibrosis. its expression has been observed in the thickened basement membrane as well as in serum of asthmatic patients. thus, measuring of periostin serum levels may shed some light on these elusive asthma features. periostin has already demonstrated a convenient value in clinical studies as a companion diagnostics for lebrikizumab, tralokinumab or omalizumab treatment. however, to date, the changes of periostin serum levels following asthma therapy except for inhaled corticosteroids remain unclear. objectives: to emphasize this issue we have collected clinical and laboratory data including serum periostin of asthma patients ( males/ females) in a cross-sectional study. all patients were treated either by conventional therapy comprising inhaled corticosteroids (n= ) or by inhaled corticosteroids with additional biological therapy (omalizumab) (n= ). asthma phenotype, control, complications, comorbidities and other available biomarkers have been assessed and statistically analysed. results: we have observed a weak but statistically significant correlation between serum periostin and total ige levels (p=. ) and absolute eosinophil count (p=. ). association between periostin and total ige had nonlinear character (p=. ), and was expressed particularly in non-severe asthma patients without omalizumab treatment (p=. ). despite mutual correlation between serum periostin a total ige levels, both biomarkers showed different reaction on asthma treatment. multivariate analysis demonstrated, that only periostin levels, in contrast to all other assessed biomarkers, were significantly decreased in severe asthma patients treated by omalizumab (p=. ). this relationship was independent of asthma control (assessed by asthma control test -act), exacerbation rate, hrct or spirometry measurement results or comorbidities, except chronic rhinosinusitis with nasal polyps (crswnp) (p<. ). conclusions: we demonstrate, serum periostin levels are dependent on therapy, thus it may contribute not only to asthma phenotype stratification, prediction of treatment responsiveness, complications such as remodeling but probably more precise monitoring of therapy effect too. | usefulness of serum pteridines as a biomarker for childhood asthma kasuga s ; hamazaki t ; fujitani h ; fujikawa s ; niihira s ; shintaku h department of pediatrics, osaka city university graduate school of medicine, osaka, japan; the national institute of special education, tokyo, japan introduction: reliable and stable biomarker of airway inflammation is essential to determine intensity of asthma treatment. exhaled nitric oxide (feno) has been introduced to assess useful marker of airway inflammation but it fluctuates depending on steroid inhalation. nitric oxide is produced by nitric oxide synthase which requires tetrahydrobiopterin (one of pteridines) as a cofactor. objectives: to assess pteridines as a biomarker of childhood asthma control. results: asthmatic children were recruited for periodical asthma checkup program in japan to assess asthma control status by using objective questionnaire, respiratory function tests, airway resistance, feno, and serum pteridine levels. serum pteridine levels were measured by high performance liquid chromatography. total japanese children ( - years) were participated in this program. children who have no asthma attack over three years were divided as remission group to evaluate the long-term asthma control. the other children were divided as asthma group. furthermore, we divided asthma group for three groups by childhood asthma control test (c-act) scores to evaluate the short-term asthma control. and we had age matched children as control group. pteridine levels tended to decrease in patients who showed higher feno in asthma group. asthmatic children showed lower pteridine levels than other groups. there are significant differences between control group and remission groups and asthma groups (p<. , tukey's honestly significant difference test). but there are no significant differences between the three groups in asthma group (well-controlled group, partly-controlled groups and uncontrolled groups) which were divided by c-act scores. the low concentration of serum pteridines in children with stable asthma may indicate poor long-term control of asthma. but that not indicate poor short-term control of asthma. since pteridine biosynthesis pathways were suppressed by th mediated immune response, these results suggest that th mediated immune response was dominating the th response in asthmatic children. therefore, serum pteridines could be a novel biomarker of stable asthmatic children. introduction: asthma is a syndrome with chronic airway inflammation. the goal in the treatment of asthma is to control the inflammation. however, there has been a scarcity of useful noninvasive tests for monitoring the airway inflammation in clinical setting. metabolites of the eicosanoids pathways in induced sputum of the patients with asthma could be valuable biomarkers that can reflect the airway inflammation. objectives: to investigate eicosanoid metabolites and to find out their phenotypic differences, induced sputum supernatants from patients with refractory asthma, patients with controlled asthma, and normal control subjects were analyzed by using liquid chromatography tandem mass spectrometry. in addition, we evaluated the relationship between asthma exacerbation and eicosanoid metabolites. results: among metabolites which were measured, metabolites were detected in the induced sputum. we found that normal control subjects had higher concentrations of prostaglandin (pg) d (normal subjects vs controlled asthma vs refractory asthma, median conclusions: eicosanoid profiles in induced sputum supernatant were different between patients with refractory asthma, those with controlled asthma, and normal control subjects. our findings suggest that they could be biomarkers to differentiate refractory asthma from controllable asthma or non-asthma. this work was supported by the research program funded by the korea centers for disease control and prevention ( -er - ) . | serum periostin in asthma is related to disease severity, eosinophilia and il- introduction: introduction: asthma is a chronic inflammatory disease where more than powerful inflammatory mediators are associated with airway hyperresponsiveness, mucus hypersecretion, activation of fibroblasts and hyperplasia and hypertrophy of smooth muscles of the airways and if they do not use preventive antiasthma treatment can cause irreversible airway remodeling. objectives: the aim of this study was to determine the effect of adding montelukast to combined therapy icss/labas in patients with uncontrolled asthma by analyzing of serum level of il- , il- , eosinophils and symptom score. methods: in study we included patients, they were treated with icss/labas ( / mcg-twice daily) plus montelukast ( mgdaily). in each of them were measured serum levels of il- and il- by the elisa method, value of eosinophils were obtained with visual examination of peripheral blood smear, and assessing symptom scores with -point likert scale of breathlessness at the beginning and after months of therapy. objectives: this study has been focussed on a detailed comparison of two samplers-cyclone and chemvol-and on the parameters that could influence their efficiency. results: airborne concentrations of two key olive and grass allergens, ole e and phl p , respectively, were monitored over two years with different weather patterns, and , in c ordoba, located in south-western spain. allergenic particles were quantified by elisa assay and results were compared with pollen concentrations monitored using a hirst-type volumetric spore trap over the same study periods. the influence of weather-related parameters on local airborne pollen and allergen concentrations was also analysed. inter-year differences were observed with regard to pollen season timing and intensity. for both olive and grass, the pollen season was longer and the pollen index (pi) higher in ; that year the peak value was higher and it was recorded earlier. although a positive correlation was detected between results obtained using the two samplers during the pollen season, results for the cumulative annual allergen index varied considerably. the two samplers revealed a positive correlation between pollen concentrations and both minimum temperature during the warmer year ( ) and maximum temperature during the cooler year ( ); a negative significant correlation was observed in both cases with rainfall and relative humidity. conclusions: in summary, although differences were observed between the two samplers studied, both samplers may be suitable for allergen detection. objectives: the scientific council of rnsa was asked to update the allergy potency (ap) of plant species that can be established in urban areas. to update the allergy potency of plant species, the rnsa used scientific work on the subject, and also the opinions of allergists and botanists. the pollen grains of anemophilous species are transported by wind; they produce very large quantities of pollen grains so that the fertilization of female flowers has a greater chance of being effective. the majority of allergenic species are anemophilous. results: the pollen allergy potency of a plant species is the ability of its pollen to cause an allergy to a significant part of the population. the allergenic potential can be: low or negligible: no problem to plant them in urban garden moderate: only a few species can be planted in the same garden high: this species cannot be planted in urban places. the table presented on the poster will permit to know the level of allergy potency of more than species. conclusions: species or genus with a strong ap should be labeled as "not to be planted in habitation or residence area ", those with moderate ap should be labeled as "not to be planted in big quantities in habitation or residence area". other species with low or negligible ap may not be affected by public information. gadermaier g ; metz-favre c ; stemeseder t ; de blay f ; pauli g universit e de salzbourg, salzbourg, austria; chru strasbourg-allergologie, strasbourg, france introduction: the purpose is to study the profile of cutaneous and molecular sensitization of patients sensitized to plantain pollen living in the north-east of france. objectives: the sera of patients with seasonal pollinosis and cutaneous polysensitization including a positive test to plantain, are investigated through immunoblot (ib), elisa and immunocap. the plantain immunoblot is inhibited with plantain, grass, ash and birch pollen extracts as well as with pla l . the specific iges against pla l , phl p - and profilin are measured. results: pla l , the major plantain allergen is detected by ib in cases out of , either in glycosylated or non-glycosylated form. an allergen of kda is detected in out of cases, always and exclusively inhibited by the grass extract. the intensity of the spot is proportional to the anti-phl p / phl p ige levels, and corresponds to an allergen which is cross-reacting with grass. other cross-reacting allergens with grasses are detected at kda ( / ), and at - kda ( / ). at the molecular weights of to kda, we detected in addition to pla l , cross-reacting allergens with grass, ash and birch pollen which predominantly corresponded to profilin which was confirmed by specific ige measurements in cases. conclusions: among the patients included in this study, only % had genuine sensitization to plantago, which never corresponded to a monosensitization in our cohort. most often cutaneous sensitizations to plantain pollen were based on ige cross-reactivity with grass pollen allergens mainly through a kda allergen and/or profilin. the strong environmental grass pollen pressure, compared to the low plantain pollen exposure, seems to be at the origin of this profile of molecular sensitization. these results reinforce the superiority of molecular diagnosis in patients with pollinosis, who are polysensitized. | sensitisation to peach tree pollen in a highly exposed population results: the % of subjects were sensitized to pp, which was the most prevalent after olive tree, grass and cypress pollens, respectively. sensitization to peach fruit was %. pru p spt was tested in / pp positive cases, being % positive ( / ). specific ige to pru p was detected in / pp sensitized individuals. immunoblot showed specific ige to different components in the pp extract, being the most frequent band recognised a - kda protein. conclusions: pp is a prevalent inhalant allergen in highly exposure areas. in our population pru p was not identified as the major allergen. other pp molecular components need to be identified and their clinical relevance should be further investigated. introduction: allergic respiratory diseases increase after an exposure to airborne pollen, as asthma and allergic rhinitis, are deeply increasing and nowadays, they represent one of the major public health problems. olive pollen is one of the main causes of allergic disease in the mediterranean area, especially in northwest and west of the turkey. olive pollen has been characterized proteins with allergic activity and ole e is the major allergen of olea pollen. objectives: the aim of this study was to estimate the correlation between daily airborne olive pollen and ole e in the atmosphere. aeroallergen load of ole e detected by cascade impactor (chemvol) using prewashed polyurethane foam and pollen counts recorded by hirst trap. chemvol sampler collects particles at l/minutes and it contains impaction stages pm> micron and >pm> . lm. this sampler is being tested in the frame of the project hialine. results: generally, similar behaviour of pollen count and total allergenic load of ole e was observed during the main pollen season. nevertheless, in some occasions, before and later of main period, airborne ole e activity was recorded and some differences between pollen grain/m and allergen concentration/m were detected. pollen from different days released -fold different amounts of ole e per pollen. average allergen release from pollen was much higher in ( . pg ole e /pollen, r =. ) than in ( . pg ole e /pollen, r =. ). indeed, yearly olive pollen counts in were . times higher than in , but ole e concentrations were . times higher. these results have shown that ole e is mostly associated with olive pollen grains but aeroallergen load was not always directly proportional to airborne pollen counts. this suggests that ole e quantification is a better marker for olive allergen exposure. in conclusion, aeroallergen monitoring may contribute to a better understanding of the ole e exposure from airborne pollen. objectives: to describe the clinical profile of the patients sensitized to alt at and to assess the sensitivity of the prick test with the alternaria extract in comparison to the patients sensitized to both allergens alt a and alt a . out of the patients, ( . %) were sensitized to alternaria with specific ige of ≥ . isu to alt at or alt a . twenty patients ( females and males, age - years old) who were sensitized to alt a were selected. we analyzed the clinical profile, total ige values, other co sensitizations as well as the clinical relevance of alternaria sensitization in these patients. : of the patients sensitized to alternaria, ( . %) were sensitized to alt a , of which ( . %) were monosensitized to alt at . the mean age was lower in monosensitized (ẋ . vs . ). among the patients monosensitized to alt a , ( %) had prick test negative with the alternaria extract. eight out of patients were polysensitized to more than three different aeroallergens and were asthmatics ( persistent). the median total ige was higher in monosensitized ( ku/l vs ku/l). of these patients, alternaria sensitization has clinical relevance in ( %), of which have positive prick test to alternaria. all the patients ( / ) sensitized to both allergens have positive prick test to alternaria. ten of them were polysensitized, were asthmatic ( persistent) and sensitized patients showed clinical relevance. introduction: the role of vitamin d as a potential immune-modulator has been recently elucidated. dendritic cell, a key regulator driving towards th immune response in allergic diseases is known to be affected by vitamin d. however, the role of vitamin d in the pathogenesis of allergic rhinitis is unclear and its anti-allergic effect has not been established yet, especially in the mouse model. objectives: the aims of this study are to evaluate ) the anti-allergic effect of topically applied vitamin d in the allergic rhinitis mouse model, and ) the effect of vitamin d on dendritic cell activation. results: balb/c mice were intraperitoneally sensitized with ovalbumin (ova) and alum, and they were intranasally challenged with ova. intranasal , -dihydroxyvitamin d was given to treatment group and solvent was given intranasally to sham treatment group. allergic symptom scores, eosinophil infiltration, cytokine mrna levels (il- , il- , il- , il- , ifn-c) in the nasal mucosa, serum total and ova-specific ige, igg , and igg a were analyzed and compared with negative and positive controls. cervical lymph nodes were harvested for flow cytometry analysis. in the treatment group, allergic symptom scores, eosinophil infiltration, and the mrna levels of il- and il- were significantly reduced compared to positive control. il- mrna level, serum total ige, and ova-specific ige and igg levels showed a tendency to decrease in the treatment group, but did not reach to a significant level. il- did not show a significant difference between groups. cd c + , mhcii hi , cd + activated dendritic cells were significantly reduced in the treatment group. cd + , cd + , foxp + treg cells tended to increase in the treatment group, however it was not significant. the intranasal instillation of , -dihydroxyvitamin d has an anti-allergic effect in the allergic rhinitis mouse model. we believe that the anti-allergic effect of vitamin d is mediated by the inhibition of dendritic cell activation, and therefore decreased objectives: we wanted to assess whether treatment with cyclosporine and tacrolimus allows children with vkc to improve the level of vitamin d due to the higher summer sun exposure for good control of the ocular symptoms. objectives: our objective was to assess the expression of smad and smad proteins in patients with asthma in correlation with clinical parameters and the expression's changes in response to allergen and methacholine challenge test. the study included patients with asthma and healthy volunteers. spirometry, skin prick tests (spt), allergen and methacholine provocation tests were performed in compliance with standards. personalized clinic surveys including act tm were collected. venous blood was collected before and after provocation. the expression levels of il- and il- and smads were evaluated by qrt-pcr using isoform-specific primers. results: we showed correlation between the mrna expression of smad and the asthma control according to act tm (p<. ). the expression of smad is higher in the group of uncontrolled ( -Δct = . , p<. ) and in the group of partially controlled patients ( -Δct = . , p<. ) in comparison to the group of patients with controlled asthma ( -Δct = . ). we proved that expression of mrna of smad correlates significantly with expression of il- and il- in patients with asthma (il- r= . ; il- r= . ) and in the control group (il- r= . ; il- r= . ) (p<. ). expression of smad elevates more after methacholine provocation test (median -Δct = . ) rather than after allergen provocation test (median -Δct = . ; p=. ). we showed also that skin prick test results correlate positively with smad level after the provocation (p<. ). conclusions: the loss of asthma control is connected with expression of smad , which is part of tgf-ßrii related pathway. il- and il- correlates with smad expression, which can indicate the participation of these cytokines in the regulation of this pathway. the expression of smad elevates after methacholine and allergen provocation as well as it correlates positively with skin prick test results, which can be useful clinically. to sum up, tgf-ß-tgfßrii-smad proteins are an important mediators of inflammation in asthma. | deletion of nfatc in t lymphocytes affects th and th cell differentiation as well as il- -mediated mast cell activation in allergic asthma objectives: analysing the role of nfatc in the allergic trait of human asthma. additionally, we investigated the influence of nfatc on t cell differentiation and immunoglobulin class switch and explored its impact on mast cell differentiation in experimental asthma. with the children s hospital in erlangen, we studied nfatc mrna expression in freshly isolated pbmcs from pre-school children with and without asthma. in asthmatic children, we found increased nfatc mrna expression, especially in those with a positive skin test. these results were confirmed in the asthma bio-repository for integrative genomic exploration (asthma bridge) study, where the isoform a and d of nfatc were found significantly increased in asthmatic adults with a positive skin test. moreover, il- was also found increased in the supernatants of pbmcs of asthmatic children with a positive skin test. furthermore, mice with a deficiency of nfatc in cd + t cells display significantly lower levels of il- . additionally, these mice show reduced numbers of lung th and th cells. moreover, basic leucine zipper atf like (batf), which is known as an important transcription factor for t cell differentiation as well as immunoglobulin class switch, was found decreased in these mice. consequently, ova-specific ige and total igg levels were found significantly decreased after allergen exposure and in the absence of nfatc . furthermore, nfatc deletion also resulted in decreased mast cell numbers. we then analyzed the effect of il- on mast cell differentiation and histamine release. we observed that bone marrow differentiated mast cells incubated with ova and il- had an induced histamine release. conclusions: thus, nfatc deficiency in t cells results in defective ige production affecting ige-orchestrated mast cell activation mediated through il- . therefore, nfatc emerges as a novel target for anti-allergy intervention. | efficiency of the use of nitric oxide donors for the treatment of bronchial asthma bazarova s; djambekova g center of therapy, tashkent, uzbekistan introduction: to study the influence of nitric oxide donor-l-arginine-on indicators of endothelial system in patients with bronchial asthma. objectives: patients aged - years ( ae . years) with moderate persistent bronchial asthma were examined. ratio of men to women was / . two age-and sex-matched groups were randomly selected. main group ( patients) received nitric oxide donor -l-arginine in addition to standard background therapy (gina, ) . the medication ( ml of . % solution, tivortin, "yuria-farm", ukraine) was administered intravenously once daily for days. the control group ( patients) only received the background therapy. the efficiency was assessed with the use of conventional methods of study (clinical laboratory methods, instrumental methods: spirography, peak flow monitoring, bronchomotor tests). concentration of nitric oxide stable metabolites in exhaled breath condensate (ebc) and in blood was studied. their ratio was also assessed. results: baseline data in patients of both groups demonstrated the increase of level of nitric oxide stable metabolites in blood ( . ae . mmol/l) and in ebc ( . ae . mmol/l). after the treatment the positive clinical efficiency of inclusion of l-arginine was much higher than that in the control group (p<. ). in the main group, reduction of requirement for beta -agonists, decrease of frequency of night-time symptoms, decrease of frequency of lowest pef rate in the morning and improvement of respiratory function were observed on average on the rd/ th day compared to the control group were such improvements were evident on the th/ th day. in the main group the concentration of nitric oxide stable metabolites significantly increased in blood ( . ae . mmol /l, p<. ) and in ebc ( . ae . mmol/l, p<. ). in the control group the concentration of nitric oxide stable metabolites changed in blood ( . ae . mmol/l) and in ebc ( . ae . mmol/l), but not significantly. introduction: abpa is currently believed to be an exaggerated form of aspergillus sensitization, and is probably the first step in its development. objectives: the aim of this study was to investigate the clinical and immunologic characteristics of fungal-sensitive asthma (fa), nonfungal-sensitive asthma(nfa) and abpa. conclusions: there were different clinical and immunological features among nfa, fa and abpa. the abpa had worse function as well as higher percentage of bronchiectasis, and higher dose of oral corticosteroid. besides, the sensitivity to aspergillus was more severe in abpa. the level of sige-a.f was associated with the damage of lung function. | self-reported allergic rhinitis and/or allergic conjunctivitis associate with il rs genotypes in finnish adult asthma patients introduction: the increased prevalence of asthma and allergic diseases is a major public health problem worldwide. atopy, family history, inhaled irritants, and upper airway inflammation are known risk factors of asthma. a population-based sample of finnish adult asthma patients (n= ) and matched controls (n= ) filled a questionnaire. asthma was diagnosed based on a typical history of asthma symptoms and lung function tests. skin prick tests (spt) with aeroallergens and blood tests including analysis of interleukin (il ) rs (g/a) genotypes were performed for a subsample (n= ). objectives: our aim was to observe in adult asthmatics with and without allergic co-morbidities e.g. subject-reported allergic rhinitis and/or allergic conjunctivitis (ar/ac) association with il rs genotypes and other factors. results: the proportion of asthmatics reporting ar was . % and ac was . %. after adjustments, the presence of il rs aallele (or= . ci= . - . , p=. ) or multi-sensitization (adjusted or= . , ci= . - . , p=. ) associated with ar/ac-asthma. nasal polyps and aspirin-exacerbated respiratory disease associated also with ar/ac-asthma. conclusions: adult ar/ac-asthma could putatively be a phenotype, characterized by the presence of atopic and/or eosinophilic factors and a high prevalence of the il rs a-allele. studies on the mechanisms behind this and in other populations are needed. | immunoregulatory role of nfatinteracting protein (nip) in adaptive and innate immune responses in allergic asthma introduction: nfat-interacting protein (nip) is a th associated transcription factor. after t cell receptor stimulation, the arginine methylation domain of nip supports the interaction with nfat, thereby enhancing the production of the th cytokine il- . moreover, nip deficient mice have been shown to be deficient in il- and ifn-gamma production indicating that nip controls both th and th cytokine production and might therefore play a protective role in allergic asthma . objectives: we wanted to analyze the importance of nip in allergic asthma in pre-school children as well as adults. furthermore, we investigated the role of nip in a murine model of allergic asthma to find out more about its contribution to adaptive as well as innate immune responses in the disease. results: in the european study predicta, in collaboration with the children s hospital in erlangen, we analyzed nip mrna expression by using quantitative real time pcr in rna extracted from pbmcs isolated from pre-school children with and without asthma. in the pbmcs of the asthmatic children, nip mrna expression was found significantly increased compared to healthy control children. furthermore, nip mrna expression was also found induced in cd + t cells in adult asthmatics from the asthma bio-repository for integrative genomic exploration (asthma bridge) study. we further analyzed the importance of nip in a murine model of allergic asthma. after allergen sensitization and challenge nip (-/-) mice showed decreased airway hyperresponsiveness, inflammation and mucus production, three of the main patho-physiological features of asthma. additionally, we discovered that nip (-/-) mice released decreased th type cytokines and also expressed less st , which is the receptor for il- , after allergen challenge. furthermore, a defect in innate lymphoid cell type (ilc ) differentiation was observed in the absence of nip in allergic asthma and in bone marrow differentiated ilc s indicating a crucial role for nip in mediating asthma via ilc s. conclusions: in summary, we found that the lack of nip influences not only immune responses of the adaptive immune system but also influences components of innate immunity resulting in a abstracts | protective phenotype to allergic diseases such as asthma. objectives: in the study were included ap and healthy controls (hc). fraction of exhaled no (feno), standard lung function parameters, complete blood count and absolute count of cells, serum ige, crp, il- , il- a and periostin were measured. results: four clusters were identified by cluster analysis: cluster (c )(n= )-late-onset, non-atopic, eosinophilic asthma with impaired lung function, cluster (c )(n= )-late-onset, atopic asthma, cluster (c )(n= )-late-onset, aspirin sensitivity, eosinophilic asthma and cluster (c )(n= )-early-onset, atopic asthma. we have found higher levels of il- in all clusters ap as compared to hc (c : p=. , c : p=. , c : p=. and c : p=. ). tendency for higher levels of serum il- in c compared with c or c (p=. or p=. , respectively) was observed. periostin levels were significantly higher in c (p<. ), c (p<. ) and c (p<. ) as compared to hc. there were no differences in periostin levels between all clusters (anova, p=. ). il- a levels were significantly higher only in c as compared to hc or to c and c (p<. , for each comparison). we have found correlation between il- and crp (r=. ; p=. ) in c , il- a and periostin in c (r=. ; p=. ) and in c (r=. ; p=. ). interestingly, we have observed negative correlation between the duration of asthma and il- a (r=À. ; p=. ), but positive between the duration of asthma and crp (r=. , p=. ) in c . our results have shown higher levels of il- in all clusters as compared to hc that are associated with marker for systemic inflammation. periostin levels were significantly elevated in c , c and c as compared to hc with no differences between the clusters. a positive correlation between periostin and il- a in c and c was observed, that rising the question about their interrelationship in the pathogenesis of late-onset asthma. serum il- a was significantly higher in c in comparison with hc or c and c suggesting that th mediated immunity may be involved in early-onset, atopic asthma. these data support the concept of heterogeneity of the bronchial asthma. | eosinophil activation with autophagy and extracellular dna traps is involved in severe asthma results: il- +lps treatment significantly increased autophagy and eet levels from pbes of the study subjects (p<. for all), which were in a positive correlation (r=. , p<. ). compared to nsa patients, both untreated and il- +lps-treated pbes from sa patients had significantly higher autophagy levels (p=. and . , respectively), while only il- +lps-treated pbes from sa patients had higher eet level (p=. ). eet level from untreated pbes was correlated with serum eosinophil cationic protein level (r= . , p= . ) and fev % predicted value (r=À. , p=. ). co-culture of aec with pbes slightly increased il- production, which was significantly enhanced by il- +lps treatment (p<. ). the il- production in co-culture system was reduced by pretreatments with dexamethasone ( mm, p=. ), antibodies against major basic protein ( ng/ml), il- receptor ( mm) and il- receptor ( mm, p=. for all), but increased by cotreatment with micrococcal nuclease ( iu/ml, p=. ). conclusions: pbes from sa patients are highly susceptible to be activated to produce high levels of autophagy and eet, which could enhance and maintain airway inflammation. we suggest that steroid and anti-il- /il- receptor antibodies may be beneficial to control airway inflammation in severe eosinophilic asthma via inhibition of eet production, while dna digesting reagents may increase airway inflammation. introduction: it has been demonstrated that exposure to stress induce hyporeactivity of the hpa system by modifying the secretion of cortisol and also that psychosocial stressors such as poor social status are associated with an increased risk of childhood asthma, decreased serum cortisol and high ige response. thus, from this concept it could be postulated that a blunted hpa axis response may increase the risk for allergic inflammatory reaction. objectives: aim of this study was to evaluate the association of serum cortisol in pediatric allergic bronchial asthma and its influence on the ige immune response in a poor children community with psychosocial chronic stress. results: this was a pilot analytical case control study( ipa positive subjects and healthy control paired by age and gender, both from poor areas of barranquilla objectives: in order to characterize bp an immunoproteomics analysis was conducted, i.e. electrophoretic separation of cypress pollen extracted proteins, ige western blotting using cypress pollen allergic patient's sera and mass spectrometry (lc/ms/ms) for identification of ige-binding proteins. results: ms analysis using chymotrypsin identified in bp a peptide also found in the family of protein snakin/gibberellin-regulated protein (grp). the snakin- , an anti-microbial peptide of potato, produced as a amino-acid recombinant protein (homologous to the c-terminal part of grp), is recognized by ige from cypress pollen allergic patients with ige to bp . this ige reactivity is abolished after reduction of disulfide bridges and is inhibited by a cypress pollen extract. ige reactivity to bp is however barely inhibited by the recombinant potato snakin- . conclusions: bp exhibits a molecular mass closer to grp than to snakin and the absence or very low inhibition of the ige reactivity to bp with snakin may be explained by peptidic ige epitopes on the n-terminal part of bp . the potato snakin- share % sequence identity with peamaclein, the peach allergen pru p , also shown in citrus. these results might explain the peach/cypress and citrus/cypress syndromes described and point out bp as the cross reactive allergen. the proteins of snakin/grp family present in many fruits and vegetables might include allergens involved in pollen/food associated syndromes. introduction: exposure to high levels of grass pollen may lead to a high degree of allergic inflammation, sensitization to minor allergens, such as profilin, and development of severe profilin mediated food reactions, similar to those described due to sublingual immunotherapy (slit). objectives: our objective here was to identify genetic biomarkers in order to generate a model that can improve the classification and treatment of patients with a higher probability of developing severe adverse reactions. results: healthy subjects (group , control) and patients with mild (group ) or severe (group ) profilin mediated food reactions were studied. rna extraction was performed on ficoll-isolated pbmcs using the rneasy ® mini kit (qiagen) and its integrity was analyzed with experion rna stdsens analysis kit (bio-rad). the gene expression profile of all the samples was analyzed using the gene-chip ® wt plus reagent kit (affymetrix) and two specific software: affymetrix ® expression console ™ and affymetrix ® transcriptome analysis console (tac). finally, the microarray data was validated by quantitative real-time pcr (qpcr). the hierarchical clustering of the samples shows the separation of the patients into three clusters coincident with the three established clinical groups (control, mild and severe). genetic profile of patients with mild reactions is similar to healthy patients while severe subjects were significantly different from the other two groups. genes regulated in the severe group were related to histone modification pathways, human complement system, cell adhesion and tgf-b and its receptor. these changes may be associated with the different degree of inflammation between patients in each experimental group. in the course of our study we found out that severe patients had different rna expression patterns compared to mild and non-allergic patients. this lead to the identification of genetic biomarkers useful for the generation of a model able to predict severe reactions and/or adverse reaction during immunotherapy, thus improving the diagnosis and treatment of this type of allergic results: his-tagged recombinant allergens, namely parvalbumin, aldolase, enolase and tropomyosin from c. idella and l. crocea, as well as cod parvalbumin, were synthesized in e. coli and purified using immobilized metal-chelate chromatography. children with history of immediate-type fish allergy were included in this study and their serological ige reactivity to the fish allergen components were measured by elisa. children were positive to at least one allergen component, with nine of them being positive to parvalbumin. despite the high similarity between l. crocea, c. idella and cod parvalbumins ( . - . %), three children only reacted to l. crocea and c. idella parvalbumin but not to cod parvalbumin, while the other six children were positive to all three parvalbumins. competitive inhibition elisa revealed that c. idella parvalbumin inhibited > % of the binding of specific ige to both l. crocea and cod parvalbumin, while reciprocally only inhibition of % and % could be achieved respectively. two children were reactive to aldolase and enolase but not parvalbumin. one of them had positive sige to both enolase and aldolase from l. crocea, while the other reacted to aldolase from both species. these two children exhibited relatively mild subjective allergy symptoms (itchy skin and throat). notably, three children were non-reactive to all components tested, and two of them were outgrowing fish allergy clinically. introduction: anti-a-gal antibodies are naturally produced in response to the gastrointestinal flora. in red meat allergy, patients develop ige antibodies towards the a-gal epitope, which itself are structurally closely related to the blood group b antigen. objectives: this study aimed to explore the relationship between a-galand b-antigen-specific antibodies in red meat allergic patients compared to healthy individuals with blood group b or a/o. sera from red meat allergic patients and healthy blood donors of whom belonged to blood group b and to blood group a or o were included. ige reactivity against a-gal and the b-antigen were determined using immunocap. allergen-specific igg, igg , igg , igg , igg and ige were assessed by indirect elisa assay. statistical analysis was performed using spearman rank correlation and unpaired t-tests. results: all red meat allergic patients, of the healthy a/o and of the healthy b donors were ige positive to a-gal. however, the ige levels to a-gal were significantly higher in the allergic group compared to the healthy a/o and b individuals. the majority of the meat allergic patients, but none of the healthy individuals had ige antibodies against the b-antigen. a moderate correlation between a-gal and b-antigen specific ige was noted (r =. ). the red meat allergic patients had significantly higher igg levels against a-gal with igg and igg antibodies as the predominant difference compared to the healthy individuals. the healthy a/o ige positive individuals had significantly higher igg , igg and igg compared to the ige negative individuals. the igg response to the b-antigen followed the same pattern as to a-gal. there was a low correlation between the igg levels against a-gal and the b-antigen in both meat allergic patients and healthy a/o individuals (r =. and . ). introduction: fx , a food mixture of milk, egg white, fish, peanut, wheat and soybean, is largely used for food allergy detection. besides the fact that it is questionable if this is the better approach to identify a food allergy, the information that the test provides may represent a pitfall because a positive or negative result does not mean food allergy presence or absence, respectively. objectives: the goal of our study was to access the reason for fx request in a pediatric hospital and to analyze its suitability. methods: the fx requests, performed in a pediatric population of d. estefânia hospital over a five months' period, were analyzed, concerning demographic data, reason for request and attitude taken due to the result. this test was requested due to respiratory symptoms in patients, gastrointestinal symptoms in patients, cutaneous symptoms in patients and nonspecific complaints in patients. all of these symptoms were not directly related with food intake. a positive result was obtained in patients; of those, only were referenced to our immunoallergology department. in all of them a detailed clinical history was obtained and diagnostic tests (skin prick tests and specific ige) were performed in the ones considered suitable. food allergy was diagnosed in only one patient. conclusions: in the vast majority of patients, fx was asked for nonspecific complaints and often without a clinical history suggestive of food allergy. moreover, a positive fx test does not mean clinical reactivity or food allergy. on the other hand, the clinical history allows us to identify a suspect trigger in most of the children with food allergy. in such cases, it is preferable to request the specific ige towards the allergen, which gives a more precise and accurate result, instead of the fx . as our results showed, in the majority of the cases, the fx request was often made without complying with a reasonable criterion, implying unnecessary costs. the high number of requests verified may be explained because it is an easily accessible analysis but this attitude should be discouraged. tuppo l ; alessandri c ; pasquariello s ; petriccione m ; giangrieco i ; tamburrini m ; rafaiani c ; ciancamerla m ; mari a ; ciardiello ma istituto di bioscienze e biorisorse -ibbr-cnr, naples, italy; caam -centri associati di allergologia molecolare, rome, italy; cra, research unit on fruit trees, caserta, italy introduction: pomegranate, punica granatum l., is one of the oldest cultivated fruit trees. the fruit contains the arils, which are seeds covered by a red pulp, that is a juice sac. the arils are surrounded by the white and fleshy mesocarp. pomegranate can trigger allergic reactions, but the allergenic pattern of this fruit is still poorly characterized and only one allergen, the ltp pun g , was reported. objectives: the aim of this study was the investigation of the allergen pattern in pomegranate tissues and cultivars. reported symptoms were food impaction ( %), dysphagia ( %), heartburn ( %) and vomiting ( %). the first symptoms were more frequent in adolescents and adults ( %). children's main complaint was vomiting ( %) and cases presented failure to thrive. most patients had associated allergic diseases ( %), % had previous food allergy and % were sensitized to aeroallergens. endoscopic evaluation revealed esophageal stricture in patients. at least half of diagnostic esophageal biopsies had > eosinophils per highpower field and % showed microabscesses. food sensitization was found in % of the patients, mainly to cow's milk ( %), nuts and peanut ( %), cereals ( %) and egg ( %). considering therapeutic approach, % were treated with swallowed fluticasone and dietary elimination was recommended in %. oral corticosteroids were prescribed in patients. at present time patients had done endoscopic reevaluation, ( %) showed histologic resolution. five patients had clinical and histologic relapse during follow-up. conclusions: eoe has a balanced distribution but a distinctly clinical presentation accordingly to age group: children may present unspecific symptoms like vomiting, whereas adolescents and adults complain of food impaction and dysphagia. other atopic diseases and food sensitization is very common. introduction: air pollution, particularly ambient air particulate matter (pm), is considered as one of the most important environmental risks for human health. pm could potentially disrupt immune regulatory mechanisms and predispose exposed individuals to asthma. in contrast, children exposed to traditional farm environment seem to have a natural resistance to asthma. this phenomenon links with exposure to stable dust and subsequent immune regulatory mechanisms initiated in the airways. the underlying exposure agents and definitive pathways determining the risk of asthma are still to be identified. objectives: our aim was to investigate the effect of urban air pm (high risk environment) and farm dust (protective environment) on immune responses in finnish children. briefly, peripheral blood mononuclear cells (pbmcs) of -year-old children (n= ) were stimulated with farm dust extract ( lg/ml, stable in northern savonia, finland) and pm samples ( lg/ml, pm . - , pm - . or pm < . , nanjing, china) for hours. expression of immunogenic cd and tolerogenic ilt in circulating myeloid dendritic cells (mdcs) and plasmacytoid dcs (pdcs) and monocytes were analyzed by flow cytometry. pm samples were analyzed for polycyclic aromatic hydrocarbons (pahs), inorganic ions and elements. farm dust sample will be analyzed for microbial content. results: pm stimulation decreased the percentage of cd + monocytes and dcs among children's pbmcs, whereas farm dust stimulation increased the percentage of cells positive for this marker. the percentage of tolerogenic ilt + was decreased in all cell types after stimulation with pm. farm dust also decreased the percentage of ilt + monocytes, but not dcs. specific metals and pahs in pm associated with the studied immunological parameters. conclusions: samples from high risk and protective environments have differing capacities to influence immunogenic and tolerogenic properties in children's immune cells. the importance of these findings in relation to the risk of asthma in exposed populations will be studied further. introduction: alterations in cell surface glycosylation pattern is a common feature of tumor cells that might be related to immune evasion and malignancy. objectives: to study the capacity of the carbohydrate a (ca ) located in the surface of murine ehrlich tumor (et) cells and also in certain human adenocarcinomas to condition the phenotype and function of human dendritic cells (dcs) and the capacity to polarize t cell responses. results: nf-jb/ap- are not activated in thp cells by ca , however, this carbohydrate partially impairs the activation of these transcription factors induced by the tlr ligand pam csk. ca induces the expression of the tolerogenic marker pdl in human monocyte-derived dcs (hmodcs) as well as the production of il- and il- , analyzed by flow cytometry and elisa assays respectively. ca -activated hmodcs generate functional il- -producing cd + cd high cd -foxp + regulatory t (treg) cells that were able to inhibit the proliferation of cd + t cells from pbmcs in a dose-dependent manner. supporting the role of ca in the induction of treg cells, our in vivo data showed that the ca is present in the sera of tumor bearing mice and the percentage of foxp + treg cells is increased in the regional (inguinal) lymph nodes from tumor bearers. our results showed that ca -activated hmodcs induce the generation of foxp + treg cells both in vitro and in vivo, which might well condition the immune response against the tumor and promote the tumor escape. | assessment of changes in expression of immune system biomarkers to assist the differential diagnosis of acute bacterial infections introduction: biomarkers for acute infections include c-reactive protein, mmp- , sicam- , procalcitonin, and neutrophil band counts for bacterial infection. a rapid means of assessment of acute bacterial infections via biomarker assessment was sought. objectives: the expression of toll-like receptors (cd and cd ), complement receptors (cd and cd ), integrins (cd b and cd c), fc-receptors (cd and cd ) and l-selectin (cd l) on the surface of blood neutrophils and monocytes stimulated with inactivated e. coli, l. acidophilus, e. coli derived bacterial ghosts, e. coli lps and l. acidophilus cell walls was assayed using flow cytometry. both the percent of expression and mean fluorescence intensity (mfi) were analyzed for each molecule. results: all the bacterial components used exerted similar activation capabilities even in low concentrations. while the expression of cd b, cd c, cd , cd and cd was enhanced by both neutrophils and monocytes under activation, the expression of cd significantly increased only in neutrophils. the expression of tlr and tlr was slightly increased by neutrophils and monocytes. the expression of cd l by monocytes and neutrophils (the percent of activated cells as well as the mfi) was decreased during activation. there was a negative correlation between cd l expression and integrins (cd b and cd b). the activation index was calculated for each molecule as a ratio of expression of molecule by activated cells vs cells used as a negative control (resting). the highest values for the activation index was seen with cd b, cd c, cd , cd , cd l and cd mfi by neutrophils and monocytes, and the percent of cd expression by neutrophils. conclusions: e. coli and bacterial ghosts significantly increased the expression of cd b, cd c, cd , cd , cd l and cd by neutrophils and monocytes even in very low concentrations, suggesting use as potential biomarkers in the differential diagnosis of the etiology of acute infections. objectives: the aim of this study was to evaluate changes in peripheral blood monocyte expression of cd , cd , cd , cd , hla-dr, and cd in kidney allograft recipients. in total, patients who underwent renal transplantation from a deceased donor were enrolled in the study. the phenotype was evaluated by a multicolor flow cytometry in defined time points and in the case of complications requiring fine needle aspiration biopsy procedure. the results confirmed our pilot data, proportions of peripheral cd +cd + monocytes were downregulated during the first week after the kidney transplantation while the percentage of cd +cd + monocytes dramatically increased early after the kidney transplantation and remained high for at least four months in most patients. the expression of cd (marker of m macrophages) was limited only to a small population of monocytes (less than % in most patients) but the receiver operating characteristic (roc) curve analysis showed its potential importance by significant correlation with acute rejection with a sensitivity of % and specificity of . % (area under the roc curve . , p-value: . ). no correlation between two different m markers cd and cd has been found. the expression of cd (dc-sign) was low and did not show any changes in time or association with acute rejection. hla-dr (mhc ii) and cd (integrin associated protein) were constitutively expressed without any significant changes in patients with acute rejection of the allograft. we assume from our data that kidney allograft transplantation is associated with early reciprocal modulation of monocyte subpopulations (cd +cd + and cd +cd +). a decreased proportion of cd positive blood monocytes seems to be associated with an increased risk of acute rejection of kidney allograft. introduction: thioredoxin (trx), a -kda oxidoreductase enzyme, is well known to be a redox-active protein that regulates reactive oxidative metabolism. in addition to its anti-oxidative activ- | progranulin-dependent regulation of th airway inflammation by house dust mite allergen introduction: progranulin is a growth factor that consists of amino acids including / repeats of cysteine-rich motifs, and produced by variety kinds of cell. progranulin is involved in the regulation and maintenance of inflammatory response, and its role is wellstudied in neuronal and metabolic diseases such as neurodegeneration and type diabetes. however, the role of progranulin during the development of airway inflammation induced by inhaled allergen is still obscure. objectives: in this study, we evaluated the role of progranulin in the development of th airway inflammation induced by house dust mite allergen. results: to find the main source of progranulin, we stimulated each cell line with various doses of house dust mite allergens. the production of each cytokine, including progranulin, was estimated in culture supernatant by elisa. to investigate the role of progranulin in airway inflammation, we intranasally administrated house dust mite allergens to -week-old female progranulin knock-out mice (macrophage-specific) or littermate mice. lung inflammation and immunological parameters were evaluated at h after first sensitization with allergen or h after final allergen challenge. the production of progranulin was significantly elevated by house dust mite allergen stimulation in innate immune cells, especially in alveolar macrophages over other cells. in the house dust mite allergeninduced airway inflammation model, we found that the level of progranulin increased earlier than other pro-inflammatory cytokines. in addition, in macrophage-specific progranulin knock-out mice, airway inflammation was down-regulated in the earlier phase after exposure to house dust mite allergen. moreover, we stimulated mice with house dust mite allergen for a longer period to observe the changes in the adaptive immune response of th airway inflammation, which was found to be decreased in conditional knock-out mice. conclusions: these findings indicate that th airway inflammation induced by house dust mite allergen is dependent on progranulin. objectives: the aim of the present study was therefore to investigate the immunomodulatory effect of epinephrine on m a macrophages and its consequence on cross talk to mast cells in a human model of allergic inflammation. results: primary monocytes from healthy pbmcs were first differentiated into m a macrophages using m-csf in the presence of il- and il- cytokines. after overnight incubation with epinephrine, supernatants were collected and analyzed by elisa for il- , tnf, il- , ccl , il- and ifn-c, whereas cell surface markers including cd , cd and cd were evaluated using flow cytometry. subsequently, both m a and epinephrine-treated m a supernatants were transferred onto cord blood-derived mast cells (cbmcs) for further overnight incubation, after which ige-mediated degranulation was assessed by the ß-hexosaminidase release assay. after overnight epinephrine treatment, m a macrophages showed an increase in il- , ccl , tnf and il- production, but no ifn-c and il- expression was observed. epinephrine treatment also downregulated surface markers cd and cd and upregulated cd . when supernatants from epinephrine-treated m a macrophages were added to cbmc cultures, ige-mediated degranulation was impaired compared to cbmcs treated with supernatants of unstimulated m a macrophages. conclusions: taken together, epinephrine promoted a phenotypic shift of m a polarized human macrophages toward an m b-like regulatory phenotype that was able to reduce the ige-mediated degranulation of cbmcs. we conclude that prolonged acute stress exposure in allergic patients may attenuate symptoms of acute allergy by directing macrophages towards an immunosuppressive phenotype, which can further dampen mast cell degranulation. objectives: a murine local lymph node assay was used to investigate the effect of oa on the immune response to the known skin sensitizer hexyl cinnamic aldehyde (hca, % w/v). the ear lobes tape stripped prior to immunization. test solutions ( ll) were applied on the dorsal side of each ear on three consecutive days. female balb/c mice ( groups a mice), were exposed to the vehicle acetone:olive oil ( : ) alone, or in combination with hca, with or without oa in the concentrations , and %, or oa alone ( , and %). on day , the animals were weighed and exsanguinated by cardiac puncture. the auricular lymph nodes were harvested for single cell preparation, stimulation with cona and cytokine release of il- and il- . the earlobes were excised and fixed for immunohistochemistry. results: no group differences were found for bodyweights or bodyweight change, number of lymph node cells or il- secretion. il- showed a tendency of dose-related increase, but a significant difference were only found between hca and hca+ % oa (p=. ) in one out of the two experiments. in he stained sections, the epidermal thickness was significantly increased in groups given hca + and % oa (p≤ . ). sections immunostained with anti-ly g showed significant increase in neutrophil influx for the same groups as above (p≤ . ). oa alone showed no effects or effects significantly lower than hca + oa. objectives: we hypothesized that plasma s p levels in cf patients might be associated with cftr mutations and could influence disease presentation. results: plasma was collected with a defined standard operation procedure to impede unspecific s p release from blood cells from double lung transplanted adult cf patients as well as sex-and age-matched, non-allergic healthy controls all being fasted overnight. total plasma s p was measured by mass spectrometry and unbound plasma s p by elisa. levels were correlated with cftr mutation status, routine laboratory parameters and clinical symptoms. we observed higher total and unbound plasma s p levels in healthy controls compared to cf patients with the latter value reaching statistical significance (p=. ) after exclusion of two statistical outliers. unbound plasma s p levels were significantly higher in df homozygous cf patients compared to patients with df heterozygosity (p=. ). patients with other mutations were excluded. levels of unbound s p were positively correlated with hemoglobin and negatively correlated with triglyceride levels. additionally, we observed a positive correlation of total plasma s p levels in cf patients with hba c. gastrointestinal symptoms were more common in df heterozygous ( / ) compared to df homozygous cf patients ( / ). fecal calprotectin levels were found to be significantly higher in df homozygous compared to heterozygous cf patients (p=. ). differences in unbound s p levels were not correlated with immunosuppressive treatment after transplantation. conclusions: to the best of our knowledge this is the first clinical study directly correlating plasma s p levels with cf genotypes and clinical presentation in cf patients. we emphasize to evaluate s p as a potential novel disease biomarker as well as a therapeutic target for cf in future studies. supported by the austria science fund grant kli (to eu). ochoa-grull on j ; tejera-alhambra m ; guevara k ; guzm an-fulgencio m ; benavente cm ; mart ınez r ; p erez c ; peña a ; rodr ıguez de la peña a ; llano hern andez k ; rodr ıguez-fr ıas e ; s anchez-ram on s objectives: we show preliminary data of one study aimed to evaluate the use of this strategy in the prevention of rrti in infants and preschool children. results: patients: children ( male and female, age range - months) were included in a randomized double blind and placebo-controlled study (eudract - - ) . all of them showed negative in vivo and in vitro allergy tests. active treatment consisted in a suspension of a mixture of selected strains, grown and inactivated in optimal conditions, of s. aureus ( %), s. epidermidis ( %), s. pneumoniae ( %), k. pneumoniae ( %), m. catarrhalis ( %) and h. influenzae ( %) in physiologic saline solution with % glycerol at a concentration of formazin turbidity units (ftu)/ml (equivalent to bacteria/ml). placebo did not contain any bacteria. patient were treated for a period of months, receiving daily sublingual puffs of active or placebo and with a follow-up of other months (total period of evaluation was year). symptom (cough, dyspnea, wheeze, mucus, fever, discomfort) and medication (inhaled corticosteroids, beta adrenergics, montelukast, antibiotics) scores were evaluated since the first day of treatment to the end of the study ( year) . any adverse event was recorded to assess safety. for the comparison between both groups, t test was used. patients who received active treatment experienced an improvement of % over placebo in overall symptoms and % in medications scores (p<. ). in the combination of symptoms and medication scores the improvement was % (p<. ). no adverse events related to treatment were recorded. conclusions: immunostimulation with these selected strains of bacteria is safe and can be successfully used in infants and preschool children in order to prevent rrti. introduction: to reduce the duration and the risk of the allergen specific immunotherapy using commonly used allergen extracts, new highly immunogenic and non reactogenic vaccines are needed. objectives: the goal of the present study was to employ the ap spytag/catcher system to develop a virus-like particle (vlp) vaccine based on the major house dust mite (hdm) allergen der p and to evaluate its reactogenicity in vitro. spycatcher-ap vlps and recombinant der p , fused at the c-terminus to the amino acid spytag binding-partner, were expressed in e. coli. purified spytagged der p was mixed with spycatcher-vlps, which resulted in covalent conjugation of der p to the surface of spycatcher-vlps. excess unbound der p was removed by dialysis. dynamic lightscattering (dls) was used to analyse the size and aggregation state of vlp-der p . the ige reactivity of vlp-der p was assayed by direct elisa and by rat basophil degranulation assays. conclusions: our results demonstrate that coupling of spy-tagged der p to ap spycatcher-vlps dramatically reduces the reactogenicity of the allergen, suggesting that vaccination with ap vlp-der p may be a safe and effective treatment for hdm allergy. objectives: the qm s hybrid protein is a qm variant where cysteine amino acids have been replaced by serine. the expression of qm s hybrid protein was performed in e. coli bl (de ) after iptg induction. the purification of qm s protein was performed from inclusion bodies by a three-step chromatography process. the stability of qm s was analyzed by sds-page and total protein assay. qm s ige-binding capacity was compared with natural der p and der p by elisa-inhibition and allergenicity was studied by mediator release from rbl cells. immunogenicity was evaluated in mice by analysis of the specific igg response to der p and der p . results: qm s was expressed in complex media as inclusion bodies that were solubilized in urea. soluble protein was purified by anionic ion exchange, hydrophobic interaction, and size exclusion chromatography in the presence of a detergent. qm s purification process was shorter and more efficient than that of qm . the purity obtained was > %. elisa inhibition assay showed that qm s hybrid protein was almost unable to inhibit ige-binding to the hdm extract, less than % in all the range of concentrations tested ( . - ng/ml) and representing a -fold reduction as compared to qm . qm s showed a great reduction of the b-hexosaminidase release in rbl cells, compared to der p and der p . qm s was able to induce der p -and der p -specific lgg antibodies responses comparable with those induced by the mixture of wildtype allergens. mouse igg antibodies induced by the hybrid proteins qm s and qm showed similar ige-blocking antibodies properties to mixture of der p and der p . the stability of qm s was studied in solution at °c, °c, and - °c and lyophilized at °c, being the frozen and lyophilized forms the best conservation conditions. the qm s hybrid exhibited less ige-binding activity than qm and the natural der p and der p while retained the immunogenicity. these properties together with the improved manufacturability made qm s a good candidate for sit to hdm allergy. objectives: slit tablets of cockroach, slit tablets of parthenium, slit tablets containing both allergens together (mix) and slit bilayer tablets containing one layer with parthenium allergen and other layer with cockroach allergen, compress to single tablet were prepared. punches and dies of mm were used for compression. slit drops containing cockroach, slit drops of parthenium and slit drops containing both allergens together, were prepared and filled in ml amber colored dropper vials. results: tablet formulations were evaluated for thickness ( . - . mm), weight variation ( - mg), hardness ( . - . kg/cm ), disintegration time (not more than min.), and biologically active content ( %- % of the stated label claim). in-vitro dissolution test was performed as per usp using distilled water as the medium and the release was shown between to % in minutes. the liquid formulations were analyzed for ph ( . - . ), the biological content ( % - % of the label claim), specific gravity ( introduction: virtually all patients suffering from the common birch pollen allergy exhibit ige against the bet v relevant allergen. as such, an elisa method for the quantification of bet v was selected and validated as part of the bsp project, aiming to establish reference methods for the european pharmacopoeia. herein, we report the mapping of the epitopes recognized on recombinant bet v allergen by the two specific murine monoclonal antibodies (mabs) used for the accurate and precise quantification of bet v within birch pollen extracts. objectives: in order to investigate the ability of mabs b and h to recognize various bet v isoallergens, we first carried out immunochromatography combined with electrophoresis. epitope mapping was performed by hydrogen/deuterium exchange (hdx) coupled with mass spectrometry (ms) analysis, using a gmp-grade purified rbet v molecule. results: immunochromatography unveiled that both mab b and mab h capture most of bet v isoallergens present within birch pollen natural extracts. those two mabs cross-react with the aln g allergen from alder pollen but do not react with the cas s chestnut pollen allergen. hdx-ms experiments combined with site-directed mutagenesis evidenced that mabs b and h target two distinct epitopes. the hdx-defined b epitope is discontinuous and contains a dominating sequential element (i.e., loop ile -lys ). the hdx-defined h epitope is also discontinuous and mainly composed of regions ile -lys and arg -phe . conclusions: overall, this study provides a precise molecular characterization of epitopes within bet v recognized by mabs b and h , confirming that these two antibodies target distinct non-overlapping epitopes and recognize the vast majority of currently introduction: short or common ragweed (ambrosia artemisiifolia), belonging to the aster plant family, sheds enormous amounts of highly allergenic pollen late in the summer. due to its high allergenic potential ambrosia artemisiifolia is becoming a health threat in north america and europe. hal allergy is developing a subcutaneous immunotherapy for patients suffering from ragweed pollen allergy. a standardized ragweed pollen extract, chemically modified and adsorbed to aluminium hydroxide (al(oh) ), is being investigated for its potential use in immunotherapy. objectives: ragweed extract (re) was modified by glutaraldehyde followed by adsorption to al(oh ). in vitro, a mediator release assay (mra) using hurbl (humanized rat basophil leukemia) cells was performed. hurbl cells were pre-sensitized using individual sera of ragweed-allergic patients and challenged with serial dilutions of re and modified re starting at lg/ml followed by eight / dilutions ( - . ng/ml). antigen-specific release of ß-hexosaminidase was measured and calculated in relation to % release values. in vivo, the immunogenic potency of modified re was evaluated by measuring the induction of re-specific igg in mice. female balb/c mice (n= per group) were subcutaneously (s.c.) injected with . aueq/ml re or modified re adsorbed to al(oh) ( . mg/ml) per mouse on days , , and . control mice (n= ) were injected with matrix only. specific igg titres were determined in serum obtained at days - , and . results: the potency of modified re in mra was drastically reduced in all patients, with a mean reduction of fold or more. chemical modification resulted in a later onset of activation as well as a lowering of the maximum release of ß-hexosaminidase. in vivo, both re and modified re show comparable levels of re-specific igg antibodies in mice at day of the immunogenicity model. shown that chemical modification impairs the capacity of re to activate basophils while retaining its capability to be immunogenic. therefore, chemical modification of re may be a promising approach for the development of a safe and effective immunotherapy for ragweed allergy. objectives: the children who had taken subcutaneous conventional venom immunotherapy in our pediatric allergy outpatient clinic between and were evaluated with respect to the side effects. in addition, each child was called to ask if the patient was exposed to bee sting and the result of a sting during immunotherapy. introduction: the major unmet needs for allergen immunotherapy (ait) are improved efficacy with good tolerability, and high adherence. to achieve these, allergoids, peptides and recombinant proteins are potentially the answer but their low rate of systemic aes make selection of the optimal dose difficult. to select the dose for an ultra-short course subcutaneous birch ait, the company has adopted the use of a conjunctival provocation test (cpt), a wide range of doses and the multiple comparison procedure -modelling (mcp-mod) statistical analysis to test for a dose response and to determine the shape of the dose response curve. objectives: a range of dose regimens of su, , and su were compared with placebo with respect to reduction of total symptom score elicited by cpt after treatment. patients were administered weekly injections outside the pollen season. cpt was performed at screening, at baseline and weeks after completion of treatment. the study was undertaken in sites in germany and austria with patients. the primary efficacy analysis was performed on a modified full analysis set (fas). the mcp-mod methodology was used to test for a dose-response using the placebo and above doses to describe the shape of the dose response curve. three candidate models were pre-specified: a maximum possible effect for the agonist (emax) model, a logistic model, and a linear in log-dose model. a statistically significant dose-response (p<. ) was shown for the range of cumulative doses, which approached a plateau with the su dose. the median effective dose (ed- ) was su. only minor differences were observed between the six active treatment groups in prevalence of treatment-emergent adverse events (between . % and . % of patients with overlapping % two-sided confidence intervals), majority of which were local reactions, short-lived and mild. teaes classified as systemic reactions were seen in . % ( su group) and in up to . % ( su group) of patients in the active treatment groups, and in . % of patients in the placebo group. no treatment related saes were observed. adherence was > % in all treatment arms. the ed- was su, demonstrating that the currently marketed dose ( su) is effective. the highest su dose will be further investigated in a pivotal phase iii trial having achieved an increase in efficacy by % without differences in the onset of aes between the treatment arms. introduction: in order for allergen immunotherapy (ait) to induce long-term immunological and clinical effects prolonged administration is required. therefore adherence to treatment is crucial for its efficacy. there is currently limited data available on ait adherence beyond clinical trials i.e. in real-life clinical practice. objectives: this eaaci immunotherapy interest group endorsed survey aimed to prospectively evaluate adherence to sublingual and subcutaneous immunotherapy in adults with allergic respiratory diseases and hymenoptera venom allergy in real life practice across different european countries. in addition, the reasons for lack of adherence and discontinuation of treatment were explored. this was a prospective, multi-centre, observational survey which took place in eight countries: czech republic, georgia, germany, greece, italy, poland, portugal and spain. data collection involved an online survey that followed participants four-monthly for a period of months from the start date of ait. results: a total of participants were included in the analysis. introduction: allergic rhinitis is a multiple gene-regulated disease involved in many immune cells such as mast cells and eosinophils, and various inflammatory mediators, and mirna probably plays a critical regulatory role in its pathogenesis. therefore, studies on the functions of critical mirna and its regulatory mechanisms in activated mast cells will lay an important theoretical foundation for our understanding of ar pathogenesis and the development of therapeutic strategies. objectives: to investigate the effect of mir- a- p on mast cell activation in an ar mouse model. the number of sneezes and the frequency of nasal rubbing in ar+mir- a- p group were significantly reduced compared to those for ar+mir-nc group (p<. ). histological examination showed that inflammation in the nasal mucosa from ar+mir- a- p group was slighter than that in ar+mir-nc group. the number of mast cells in ar+mir- a- p group was increased compared to ar+mir-nc group (p<. ). the levels of histamine and il- in nasal lavage fluid supernatants, histamine in plasmas and il- in sera were significantly decreased in ar+mir- a- p group compared to ar+mir-nc group (p<. ). conclusions: upregulation of mir- a- p can reduce allergic inflammation in the nasal mucosa of ar and alleviate ar symptoms through inhibiting mast cell activation in vivo. mir- a- p probably becomes a new target for gene therapy of ar. | correlation between chronic cough and chronic rhinosinusitis in adults: nationwide, population-based, and cross-sectional study the second hospital of shandong university, ji nan, china; national university of singapore, singapore, singapore introduction: nasal polyp implies a refractory clinical course in case of chronic rhinosinusitis (crs). although hypoxia is believed to be associated with nasal polyposis, little is known about the mechanism underlying polypogenesis. objectives: the aim of this study was to assess mrna and protein introduction: nasal polyp is a multi-factorial disease commonly associated with inactive ciliary beating frequency (cbf), a condition partly attributed to the mis-localization of dnah , a component of the outer dynein arm in ciliary axoneme. so far however, there have yet to be a systematic histopathological investigation directly linking dnah localization pattern in nasal polyps. therefore, we sought to examine the localization of dnah in cilia structure of both nasal polyps and inferior turbinates from healthy individuals, and assess whether there are any localization changes that can account for the extensive inactive cbf observed in nasal polyps. objectives: the focus of this work is to compare the localization of dnah from the nasal polyps biopsies (n= ) and normal inferior turbinates (n= ) by immunofluorescence. the characterization of each sample was obtained from an average of fields at magnification. results: from the samples, we observed three distinct localization patterns of dnah in the nasal cilia. the three patterns were as follows: ) the localization of dnah in normal cilia is present throughout the entire axoneme (pattern a); ) the localization of dnah is within the axoneme except at their proximal regions (pattern b); ) the localization of dnah is restricted exclusively at the ciliary base and not present in the entire axoneme (pattern c). approximately % of the samples exhibited more than one distinct localization patterns for dnah within the observed fields. the percentage of pattern a, pattern b and pattern c were observed in . %, . %, and . % fields for samples from nasal polyps. correspondingly, . %, . %, and . % were observed for samples from healthy controls. the results indicated that the predominance of "pattern c" in nasal polyps countered by "pattern a" in inferior turbinates from healthy individuals. conclusions: our study indicated that there is a significant increase in the mis-localization of dnah among the cilia in nasal polyps as compared to controls. this mis-localization may account for the inactive cbf, a hallmark characteristic, observed in nasal polyps. zhao l ; zhi l ; jin p ; zi x ; tu y ; li a ; li t ; shi l ( . , . - . , p<. ) and +gc np patients ( . , . - . , p<. the results showed that the number of th + cells were correlated with eosinophil cells and macrophage (r=. , p<. , r=. , p <. ), but no correlation was found between th + cells and neutrophil cells. the significantly correlation were found between il- objectives: this study aimed to reveal if some features of the sinus wall and content (as homogeneity and density of the sinus content, or the continuity, thickness and density of the sinus wall), differ between the afrs and other forms of crs. we tried also to establish early diagnostic parameters for recognition of fungal rhinosinusitis on ct. results: the study included adult patients (mean age: . ae . years, m:f ratio= . : ) with clinically diagnosed crs. out of all maxillary sinuses (n= ) from study patients, ( . %) were opacified, and only these sinuses were included in further analyses. we found out that: ( ) positive fungal finding had % ( / ) crs patients and % ( / ) of these patients had severe forms of crs, ( ) patients with positive fungal finding had more often positive specific ige ab than those without fungi in sinuses ( . % vs. . %, p=. ), ( ) foci of non-homogeneity, mean and maximum densities and wall density were more common found in maxillary sinuses with present fungi than those without fungi (p=. , p=. , p=. ; respectively) and ( ) patients with crs lasting more than years had more often foci of non-homogeneity and presence of hyperattenuation centres, than patients with shorter length of crs. results: neutrophil-related gene mpo and eosinophil recruitment genes ccl and ccl showed higher expression level in acp than in controls, which were in line with the significantly elevated neutrophils and eosinophils infiltration in acp compared to control. increased cd + t cells, macrophages and cd + t cells infiltration in acp were also observed. the expression level of t-reg transcription factor foxp was significantly higher in patients with acp than in controls, but the expression of th /th /th transcription factor tbet, gata and rorc were significantly decreased in acp vs controls. we further investigated the relationships between these t-cellassociated genes in acp. the expression of foxp was positively correlated with t-bet, gata , il r and il a, while no significant correlation with rorc was evident. il was observed positively correlated with t-bet, gata , foxp , and il r. il had significant correlation with t-bet and il a. objectives: the aim of this study was to find the olfactory change pattern of crs after ess in short-term and the differences between crswnps and crssnps, secondary aim were to identify the relationship among olfactory dysfunction, ct scores and quality of life(qol). in this study, crs patients who underwent ess were evaluated preoperative by t&t recognition threshold tests, snot- score and lund-mackay ct score. patient outcomes were re-evaluated at clinical follow-up month, months and months postoperative. analysis of variance was performed and correlation was calculated, with results analysed separately for crswnp and crssnp subgroups. . subgroups of crs differed in the degree of olfactory dysfunction reported before and after the ess. a significant difference in the changes of olfactory dysfunction between the two groups was found at month postoperative. . the mean t&t and snot- scores showed significant improvement within months after ess in both crswnp and crssnp subgroups, however, no significantly recovery of olfactory dysfunction was observed at months compared to month postoperative. there is a plateau of olfactory recovery at months postoperative. . in crswnps, the mean t&t scores preoperative were correlated with lund-mackay ct score significantly(r=. , p<. ; r=. , p<. ). however, no relations were found in crssnps and the changes of olfactory dysfunction at the months postoperative with lund-mackay ct score. . olfactory scores, before and after the ess, and their changes did not correlate with sont- scores. conclusions: olfactory dysfunction was more severe in crswnps. olfaction and qol of crs patients were significantly improved after ess in both groups, but there was a plateau of olfactory recovery at months postoperative. ct scan may predict olfactory disorder, but the olfactory scores were not related with the qol. objectives: in this study, we investigated the effect of hgf, tgf-b , and pge as effective components for allergic rhinitis treatment using in vitro and in vivo mouse model studies. results: pge decreased infiltration of eosinophil in nasal mucosa. tgf-b decreased the infiltration of eosinophil in nasal tissue and increased the number of treg in spleen. however, there was no antiallergic effect of hgf in this experiment condition. in case of the combination treatment group (tgf-b +pge +hgf), eosinophil infiltrations and the expression of eotaxin- were reduced in the nasal tissue, and treg was increased in the spleen. in all treatment group, serum ige and systemic cytokine levels were not decreased due to intranasal administration rather than systemic administration. in vitro study showed that phosphorylation of map kinases such as erk, jnk, and p and translocation of p were inhibited after treatment of hgf, tgf-b and pge , suggesting their anti-allergic mechanism. conclusions: we found that tgf-b , and pge decreased allergic inflammation and these effects might be derived from changes in the frequency of treg and the activation of map kinase and p in the t cell receptor signaling pathway. furthermore, we hypothesized that tgf-b , and pge would be effective components for allergic rhinitis therapy. introduction: interleukin (il)- is implicated in suppression of allergic inflammation. the role of il- in the early-phase reaction in type hypersensitivity has been unclear, however. we investigated the contribution of il- in a mouse model of the ige-mediated early-phase reaction in allergic conjunctivitis. objectives: ige-mediated allergic conjunctivitis was induced in c bl/ -kit(+/+) wild-type mice, kit(+/+) il- -deficient mice, and kit(w-sh/w-sh) mast cell-deficient mice by means of passive conjunctival anaphylaxis. the mice were thus subjected to subconjunctival injection with anti-dinitrophenol ige (dnp-ige) followed after h by intravenous injection with dnp antigen. kit(w-sh/w-sh) mice that had received a subconjunctival graft of cultured bone marrowderived mast cells from kit(+/+) wild-type mice or kit(+/+) il- deficient mice were similarly treated. vascular permeability of the conjunctiva was examined min after antigen injection by colorimetric evaluation of the extravasation of evans blue dye. results: passive transfer of dnp-ige followed by intravenous antigen injection increased vascular permeability in the conjunctiva of kit(+/+) wild-type mice but not in that of kit(w-sh/w-sh) mice, suggesting that this effect was dependent on mast cells. vascular permeability was increased to a significantly greater extent in kit(+/+) il- -deficient mice than in kit(+/+) wild-type mice. reconstitution of kit(w-sh/w-sh) mice with kit(+/+) wild-type or kit(+/+) il- deficient mast cells restored the dnp-ige-and dnp-induced increase in vascular permeability to similar extents. our results suggest that il- produced by cells other that mast cells suppresses the mast cell-mediated early-phase reaction in ocular allergy. objectives: our aim was to evaluate the effectiveness and the safety of ccl treatment for keratoconus in children with vkc. forty-two boys (mean age . ae . years) and girls (mean age . ae years) with vkc were included in the study. tarsal, limbal and mixed vkc were detected in . %, . % and . % of the subjects, respectively. evaporative dry eye was detected in children out of ( . %), schirmer test results were < mm/ minutes in . % and < mm (severe dry eye) in out of children ( . %) and % of the subjects (n= ) had confirmed keratoconus/forme fruste keratoconus with corneal topography (sirius, cso, italy). allergic symptoms were controlled with topical steroids, cyclosporine, dual action antihistaminic/mast cell stabilizers and lubricant agents before the procedure. ccl surgery was performed under topical anesthesia. the children were followed-up at least year and preoperative and postoperative corneal topographic parameters were compared using paired sample t test. results: the visual acuity was between . and . (moderate visual loss) in . % of the subjects and less than . (severe visual loss) in . % of the children. ccl procedure was performed to eyes of children. at the end of one year, the disease was stable in all children with no differences in k and k corneal parameters before and after cxl (p>. ). there was a statistically significant improvement in maximum keratometry value after the procedure (before . ae d, after . ae . d, p=. ). in one subject, a corneal infiltrate was detected days after ccl, which was treated successfully with topical moxifloxacin. otherwise, no complications were observed in the postoperative period. conclusions: as keratoconus is common in vkc, these children should be referred to ophthalmologists for an eye examination and corneal topography. ccl seems to be a safe and effective option to halt the progression of keratoconus, which might be very aggressive in children with vkc. results: surprisingly, we found among them cases of celiac disease, cases of thyroid dysfunction (thyroiditis), cases of crohn's disease and case of ulcerative colitis, case of anterior uveitis and case of pemphigus respectively. we realized that an average percentage of % of the total of vkc cases are affected by an "autoimmune" systemic disease. limbal form of vkc was prevalent and more than % of children showed it. we can suppose that a racial and genetic predisposition to systemic diseases can coexist with vkc or that there is a group of vkc affected subjects in which the immune disorder is predominant on the allergic disease. introduction: nasal polyposis (np) is a heterogeneous inflammatory disease of nasal mucosa affecting - % of the population with a high rate of recidivism. polyps arise from nasal sinuses to nasal cavity and are often associated with a strong local eosinophilia. the pathophysiology of np remains controversial, as it seems to be a phenotypic manifestation of multiple possible immunologic processes, such as respiratory allergy, despite a lack of correlated systemic response. here we propose a multiparametric assessment of np patients, in order to shed light on the underlying mechanisms of the disease in allergic and non-allergic patients and aiming to find new predictive biomarkers. objectives: our main aim was to unravel the link between systemic and local allergic inflammation and polyp development, as well as the nasal epithelium condition in polyps and surrounding healthy tissue. methods: four groups of patients were included in the study: healthy donors with or without allergy and np patients with or without allergy. in this regard, several different approaches were followed: a metabolomics serum study, a polyp and nonpolypous nasal epithelium histology and transcriptomic study. results: as for the histological study, luna staining revealed differences in eosinophilia between allergic and non-allergic patients, especially when patients were polysensitized, including perennial allergens; and between nonpolypus tissue and polyps being higher in polyps. pas staining showed differences in epithelium integrity and submucous and goblet cell (pas positive) distribution. immunohistochemistry for cd + and cd c+ reveal a significant inflammatory infiltration in polyps. this inflammatory response was also asses by abstracts | gene expression quantitation. no differences were seen in the metabolic profile in patient sera between groups. for the first time, nasal epithelium from polyps and neighboring tissue were studied. histology techniques and image analysis revealed differences in eosinophil concentration in both mucosa and submucosa areas, as well as different features in epithelium and submucous tissue structure. some of these findings were confirmed by gene expression quantitation. conclusions: our data show an increased eosinophilia and inflammatory infiltration in polyp tissue suggesting a role for allergic inflammation in the progression of np. additionally, we provide clues for the role of inflammation in the damage on nasal mucosa and the following progression of the disease. | is specific immunotherapy effective in subjects suffering from vkc? a tertiary referral center ten years experience. objectives: our work shows the results of sit additional to usual treatments, in children suffering from vkc and followed in our tertiary referral center (lavagna hospital, genova, italy). we retrospectively analyzed the clinical data of subjects ( males and females); their mean age at the beginning of treatment was ae . years. the patients were treated both with scit (sub-cutaneous immune-therapy- . %) and slit (sub-lingual immune-therapy - . %) depending on patient's wishes. they had to be mono-sensitized to one of the usually more frequent allergens (dust-mites, grass pollen, and pellitory) which was detected by means of recombinant rast, prick test and conjunctival provocation test (cpt); these tests were performed after a complete ophthalmological and allergological history and examination. children selected for sit needed to be positive to all performed allergy tests. systemic involvement included cases of asthma, cases of atopic dermatitis and case of rhinitis; the remaining cases were asymptomatic. local involvement included only vkc cases, the % of which were of the limbal type and only subjects were suffering from the tarsal papillary type. mean follow-up was . years. all the patients included into the study completed their treatment and followed the therapeutic protocol. after one year of sit, no variation in clinical course and treatment was recorded. after the third year of sit, an average improvement in symptoms and signs score ( %) and an average decreased need for allergy systemic medications ( %.) (i.e. antihistamines and corticosteroids) was registered. also topical therapy (including steroid and cyclosporine eye-drops) was discontinued in % of children, in this group, short courses of steroid drops were necessary in less than % of children (as rescue treatment in the acute phases of the disease). these positive results after sit treatment were stable for the following years. few (only local sub-cutaneous) side effects were recorded and the treatment was generally well-tolerated. conclusions: our experience shows positive results with sit in vkc which can have sensitive-to sit-treatment subtypes. results: deaths occurred in children ( boys, %). median age at death was years (iqr - ). pamr of any cause was . ( %ci, . - . ) per children per year, with a decreasing rate over time (annual change: - . %; %ci, - . to . ). triggers were iatrogenic causes (n= , %), insect venom (n= , %) and food (n= , %). unspecified causes were frequently reported (n= , %). there was no difference in overall pamr between boys and girls (p=. ). there was no age group related differences in fatalities: preschool children (< years) (n= , %), school children ( - years) (n= , %), adolescent and toddlers (> years) (n= , %). the number of fatal cases was similar comparing the southern (n= , %) and the northern regions of france (n= , %) (p=. ). the first episode of anaphylaxis for each patient was captured to calculate incidence. we estimated incidence rate ratios using poisson regression models. results: between and there were anaphylaxis episodes in patients younger than years in hong kong. the incidence of admission for anaphylaxis increased markedly from . to . per person-years during the study period (p<. ). the incidence of food-related anaphylaxis increased significantly from . to . (p<. ). increases in anaphylaxis and food-related anaphylaxis were seen in all age groups, with the largest increase in those aged to years. at the beginning of the study period ( ), medication was a more common trigger for anaphylaxis than food ( . vs . per person-years). by , food had become the predominant trigger ( . vs . per personyears for medication). the incidence of medication-related anaphylaxis decreased significantly (p<. ). the incidence rate of anaphylaxis was significantly higher in boys than girls in the - and - year age groups, while there was no significant gender difference in the - year age group. the most common food triggers of anaphylaxis were peanuts, seafood, eggs, milk products, tree nuts & seeds (in descending order). conclusions: even though the incidence of anaphylaxis among children in hong kong is lower compared with other western countries, it has recently increased significantly, with food-related anaphylaxis predominant. | prevalence of anaphylaxis and prescription rates of epinephrine self-injector in korea based on national health insurance data results: the prevalence of anaphylaxis over the years were . %. the annual prevalence of anaphylaxis increased over the years. anaphylaxis was more prevalent in male than female ( % vs. %) and in population aged - years old. for the regional prevalence of anaphylaxis in korea, gangwon province showed the highest prevalence of anaphylaxis ( . per individuals) and relatively low prescription rates ( . %) of epinephrine self-injector for the patients with anaphylaxis. on the contrary, seoul showed relatively low prevalence of anaphylaxis ( . per individuals) and the highest prescription rates ( . %) of epinephrine self-injector for patients with anaphylaxis conclusions: the prevalence of anaphylaxis has increased annually in korea. the prevalence of anaphylaxis and prescription rates of epinephrine self-injector showed regional difference in korea. objectives: the aim of the study was to analyze the prevalence of allergic symptoms and anaphylaxis in mastocytosis patients analyzed in the registry of the ecnm. results: methods: a total of patient with mastocytosis were enrolled. in these patients, the prevalence of allergy, anaphylaxis, triggers of allergic reaction, and disease subtypes were analyzed. results: symptoms of allergy were observed in % of all patients. the most affected group were patients with bone marrow mastocytosis (bmm: . %) and indolent systemic mastocytosis (ism: . %). insect venom allergy (iva) was reported in . % of all subjects. in ism/bmm patients iva affected . % of the cases, while in other patient groups, only . % of the cases were affected (p<. ). most patients ( %) had wasp allergy, % had bee allergy, % polistes allergy, and . % allergy to more than one venom. in . % the culprit insect was not identified. food allergy was reported in . %, drug intolerance/allergy in . %, inhalant allergy in . %, and physical triggers in . % of patients. in mastocytosis patients iva is the most prevalent cause of anaphylactic reactions exceeding the prevalence of iva in the general population by far. iva affects mainly bmm and ism patients ( . % of cases). but ( . %) subjects didn't know whether adrenaline was administered. only within patients who had adrenaline autoinjectors used their autoinjectors during an anaphylaxis attack. most common symptoms were skin (n= , . %) and respiratory symptoms (n= , . %). syncope, hypotension or hypoxemia were present in cases( . %), at least three organ dysfunctions in ( . %) cases; patients ( . %) had to be hospitalized (f: , m: ).nearly a third ( . %) of the patients had stage - anaphylaxis and patients( . %) had stage - reactions. in cases ( . %), basal tryptase levels were examined and the average value was correlated with the severity. concomitant drugs being used by the patients were antihypertensives ( . %),oral antidiabetics ( . %); angiotensin converting enzyme inhibitors or angiotensin receptor blockers( . %), beta blockers( . %), diuretics( . %) and nsaid's ( . %). conclusions: male sex was noted as a risk factor for severe reactions and recurrent anaphylaxis. anaphylaxis requiring hospitalization was more frequent in the patients using oral antidiabetics or diuretics. baseline tryptase levels were higher in patients with neurological and gastrointestinal symptoms. cardiovascular symptoms were found to be higher if a cofactor was present. skin symptoms were seen more frequently and higher rate of hospitalization occurred in anaphylaxis in the presence of infections or nsaid use. this study is important to elucidate the factors affecting anaphylaxis severity. | serum levels of a, ß-pgf in combination with apolipoprotein a or cysleukotrienes are reliable biomarkers of anaphylaxis objectives: we analyzed mast cell mediators in sera derived from patients with acute anaphylactic symptoms (n= ) versus patients with acute cardiovascular or febrile reactions (n= ) and patients with a history of anaphylaxis but without displaying any symptoms when sera were taken (n= ). in addition, we identified proteins with substantial changes during anaphylaxis. matched serum samples were used to compare basal mediator levels with corresponding levels during acute anaphylaxis in the same patient (n= ). roc curve analysis was performed to determine the sensitivity/specificity of each mediator. results: serum levels of histamine and tryptase were not increased upon anaphylaxis and showed no relation to anaphylaxis severity. however, serum a, ß-pgf , a metabolite of pgd , was significantly increased in acute anaphylactic patients (~ -fold) and abstracts | correlated well with anaphylaxis severity. a, ß-pgf distinguished anaphylaxis from cardiovascular or febrile reactions and showed the highest diagnostic power observed by roc curve analysis. cys-leukotrienes (cys-lts=ltc , ltd , lte ) were increased upon anaphylaxis while apolipoprotein (apo) a was significantly decreased. the highest diagnostic power was observed with the combination of a, ß-pgf and apoa . conclusions: in conclusion, histamine might only be used to detect anaphylaxis when assessed shortly after onset of an anaphylactic response because of its short half-life, whereas tryptase is a useful biomarker if the baseline level of the same patient is known. a, ß-pgf seems to be the most reliable marker as demonstrated by the distinct increase upon anaphylaxis and could be supported by apoa or cys-lts. further investigations are needed to prove the suitability of these markers. objectives: objective of this study was to estimate the long-term bv of tryptase using certain chronic disease models and to compare it with those in food and drug allergy. results: serial determinations of tryptase concentrations (n≥ data points per patient) obtained from patients diagnosed with mastocytosis (n= ) or chronic urticaria (n= ) during a period of sometimes several years were measured by the immunocap assay and evaluated using sigmaplot software. polynomial curve fitting was performed and data points outside the % confidence interval of the curve were appointed as outliers and excluded. because the data points were not normally distributed due to long-term fluctuations in homeostatic set-point, a non-linear fitting was applied and used to compute the standard error of the estimate. these standard errors of the fit divided by the estimates themselves were used to calculate the total coefficient of variation within a subject (cv t ). the analytical cv (cv a ) was calculated based on quality control samples ( levels, n= data points) in a conventional way, while the within-subject bv (cv i ) was defined as cv l =(cv t À cv a ) ½ . eleven patients with a chronic disease were selected, of which patient was treated as a potential outlier and patients had to be excluded because of cv t <cv a . the between-subject bv (cv g ) was without the outlier . ae . % (n= data points during a period . ae . years) and with the outlier . ae . % (n= data points during a period of . ae . years). as a food and drug allergy control group additional patients were selected with an uncomprehended food (n= ) or drug allergy (n= ). this cv g was calculated under the same conditions and proved to be . ae . % (n= data points during a period of . ae . years). the long-term between-subject biological variation of tryptase concentrations of patients in chronic disease models was smaller than that of patients with an uncomprehended food or drug allergy. chronic disease models may be of interest to determine the long-term "physiological" biological variation of tryptase. vilà-nadal g; rodr ıguez-sanz a; s anchez-villanueva r; fiandor-roman a; dom ınguez-ortega j; bell on-heredia t introduction: hypersensitivity reactions during hemodialysis sessions have been reported. our aim was to study the mechanisms of the allergic or "pseudoallergic" reactions to synthetic polysulfone (ps) dialysis membranes in "ps-allergic" patients who tolerated cellulose triacetate (cta) membranes. objectives: ten patients with adverse reactions to ps and control non-allergic patients in hemodialysis were studied. ml of blood were collected and an ex-vivo hd were performed on experimental external circuits with low or high priming volumes and pediatric membranes (fx-paed helixone . m and sureflux). serum tryptase levels, basophil degranulation (hla-dr À cd + cd + leukocytes), and t cell activation (cd expression on cd + and cd + subpopulations) were analysed in pre-and post-dialysis samples. objectives: the aim was to investigate the influence of asa and alcohol on egg allergy. donor sera from egg allergic patients (i-iv) with s-ige to ovalbumin at (i) . , (ii) . , (iii) . , and (iv) ku/l were injected intracutaneously to the forearm of healthy/nonallergic volunteers. they were then orally challenged separately with: ) egg white ) egg white + asa and ) egg white + alcohol. 'time to wheal' and 'wheal size' were compared between the three experiments. results: two sera (i-ii) with the lowest s-ige to ovalbumin did not react sufficiently and where excluded from further analysis. the remaining sera (iii-iv) significantly decreased 'time to wheal' with both asa (p=. ) and alcohol (p=. ) added as co-factor compared to baseline. increase in 'wheal size' was only found with co-factors added for the less reactive serum (iii) and not for the serum with the highest s-ige (iv). introduction: eaaci have published numerous guidance documents providing evidence-based recommendations for the recognition, risk factor assessment and management of anaphylaxis. these guidelines clearly advocate intra-muscular adrenaline firstline for the treatment of anaphylaxis, and list absolute indications when an adrenaline auto-injector (aai) must always be prescribed; eg for those who have previously experienced an anaphylactic event, those who have a mast cell disorder and for those with co-existing unstable or moderate/severe asthma and a food allergy. furthermore, eaaci recommends that an aai should be prescribed to those at risk of anaphylaxis (termed relative indications), and that aais should be prescribed and carried by patients at all times. despite widespread dissemination of these guidelines, anaphylaxis hospitalizations continue to rise in many european countries. objectives: in this environment eaaci developed the anaphylaxis survey (axis) as part of its allergy awareness initiative to gain insight into guideline awareness. this survey was sent by email to eaaci members. members from countries responded. data were anonymous and analysed descriptively. results: . % (n= ) reported familiarly with the eaaci anaphylaxis management guidelines, and of these . % (n= ) reported following them. . % (n= ) responded that they would use adrenaline firstline for the treatment of anaphylaxis (although . % (n= ) would still administer it subcutaneously). however, when confronted with a list of indications, only . % (n= ) of eaaci members would prescribe an aai for all absolute indications. furthermore, although . % (n= ) of respondents considered they would prescribe an aai for those at risk, when provided with a list of relative indications, % would prescribe an aai for all of them. there was also a lack of consensus about when an aai should actually be used, with . % of respondents (n= ) considering aai use when individuals experienced breathing difficulties and felt that they were going to collapse. conclusions: these results reflect the latest findings that aais are under-prescribed in daily practice. there appears to be a mismatch between perception of guideline compliance and aai prescription behaviour. continued training, further simplification and wider dissemination of guideline messages are required. objectives: the aim of this study was to analyse the clinical practice of emergency physicians concerning the management of anaphylaxis in alsace and lorraine, a region of . million inhabitants, in france via an electronic survey. results: the response rate was . % ( ). fifty percent of physicians were female. . % ( ) ( ). in case of grade reactions, intramuscular adrenaline injection was performed by . % ( ) of physicians as first-line treatment, intravenous adrenaline injection by . % ( ), antihistamines (oral route or iv) by % ( ) and corticosteroids (oral route or iv) by . % ( ). in case of grade reactions, intramuscular adrenaline injection was performed by . % ( ) of physicians as first-line treatment, intravenous adrenaline injection by . % ( ), iv antihistamines by . % ( ) and corticosteroids (oral route or iv) by % ( ). following an acute anaphylaxis episode, only . % ( ) of physicians systematically recommended an allergy assessment, . % ( ) sometimes, and . % ( ) never. conclusions: this study highlights the discrepancies between current guidelines for the management of anaphylaxis in emergency departments and common clinical practice. our results emphasised the need for specific programs to improve clinical management of anaphylaxis in ed. conclusions: a significant number of individuals among those surveyed reported a severe allergic reaction requiring an eai, yet less than a quarter used an eai. the study also identifies most common challenges faced by at-risk individuals including eai availability, cost, and concerns over short expiry dates. objectives: to evaluate the implementation of a stock epinephrine (stock epi) program in a mall setting. stock epinephrine devices are not prescribed for a particular person and can be used in anaphylactic emergencies. methods: a mixed methods approach was used to evaluate the implementation of the stock epinephrine program regarding its acceptability and adoption by diners, food service, mall administration and security personnel; and the appropriateness, costs (included costs for personnel, epinephrine auto-injector devices, and training materials), fidelity, reach, and sustainability (measured by the national health service (nhs) sustainability model, united kingdom) of the program in this setting (hamilton, ontario, canada). the study revealed that individuals with food allergy and food service establishments were in favour of a stock epi program. a total of individuals with food allergy completed our national online survey. approximately % dine out once or twice per month, and one-third had experienced an allergic reaction. we also completed in-person surveys with diners at the mall food court. of these, % had a food allergy and % reported carrying their epinephrine auto-injector when dining out. the mean nhs sustainability score was among survey participants, well above the mean considered a sustainable program (> ). total cost of the stock epi program over a one-year period varied by ontarian stakeholders: $ for the mall, $ for fast-food restaurants, and $ for sitdown restaurants. conclusions: this is the first study to evaluate the implementation of a stock epi program. the stock epi program was well received abstracts | and sustainable. implementing a stock epi program provides enhanced access to emergency medication, however it does not replace the responsibility of individuals with food allergy to self-manage. objectives: to identify the optimal needle length for epinephrine prefilled syringe. results: three hundred seventy-two children aged month to years were enrolled. skin to muscle depth (stmd) and skin to bone depth (stbd), which can represent the minimum and maximum needle length respectively, were measured using an ultrasonography at the mid-anterolateral thigh. number of children who had stbd less than needle length (too long needle) and stmd greater than needle length (too short needle) were calculated. one hundred thirty-seven children weight < kg, children weight > - kg, and children weight > kg were enrolled: ( . %) children were male. one inch needle was too long in ( . %) children weight < kg, ( . %) children weight > - kg. it was too short in ( . %) children weight > kg. age≥ months, weight≥ kg, height≥ cm, bmi≥ kg/m and thigh circumfer-ence≥ cm, provided the sensitivity of - % in predicting the appropriateness for using inch needle for children weight < kg. in children weight > kg, thigh circumference≥ . cm provided the sensitivity of % and specificity of % for predicting the inappropriateness for using inch needle. objectives: we present a patient with a probable mdh syndrome to unusual drugs, including ah and cct. results: we report a case of a -years-old female, with history of moderate-persistent asthma and chronic urticaria, who experienced angioedema and exacerbation of urticaria hours after the administration of multiple ah (desloratadine, loratadine, cetirizine), systemic cct (hydrocortisone, methylprednisolone, deflazacort) and nonsteroidal anti-inflammatories (nsaids) (paracetamol, ibuprofen, flurbiprofen). patch tests (pt) with excipients (bial arestegui ® ) and drug provocation test (dpt) with placebo were negative. skin prick tests (spt) and intradermal tests (id) with hydroxyzine, hydrocortisone, methylprednisolone and prednisolone were positive to hydroxyzine ( mg/ml) and pt with corticosteroids (bial arestegui ® ) and hydroxyzine were negative. dpts with desloratadine and an alternative ah, dimetindene, were positive with facial angioedema and generalized urticaria within hours. lymphocytic transformation test (ltt) was positive to desloratadine, ebastine and clemastine. dpt with dexamethasone was negative, however, when administered as treatment, a reproducible reaction occurred. since dpt with montelukast was also positive, omalizumab mg was initiated to control angioedema and chronic urticaria. after year of treatment, dpt with nimesulide was negative. omalizumab dose was reduced to half after the patient found out she was pregnant. there were no further episodes after anti-ige therapy introduction and pregnancy went uneventfully. conclusions: mdh syndrome is rare, more so when the drugs reported are ah and cct. hr to ah was confirmed, but diagnostic workup remains incomplete, postponed due to the patient's pregnancy. this case is as challenging in terms of diagnosis as it is in terms of therapeutic, so much so that omalizumab was initiated as an off label therapy, maintained during pregnancy based on the premise that risk was lower than benefit. objectives: in this study, we aimed to present our patients who were admitted with oral iron hypersensitivity. conclusions: according to our clinical experience, we think that oral iron salts with different conjugates are safe and acceptable option in patients with suspected oral iron hypersensitivity. introduction: antineoplastic agents are consider nowadays an essential treatment for many kinds of cancer. the increased use of these drugs in recent years is in parallel with a high rise of hypersensitivity reactions to them. these reactions range from mild to severe and as other allergic reactions, are not predictable. a nursing protocol in the desensitization schedules with these drugs is essential in allergy daily hospitals. objectives: the aim of this study are to describe a nursing protocol during desensitization schedules with antineoplastic agents carried out in our allergy unit in order to detect symptoms suggestive an allergic reaction during drug administration and to assess a correct intervention in case of reaction. conclusions: an appropriate nursing protocol in desensitization schedules with antineoplastic agents is essential in order to achieve the correct administration of the treatment in safety conditions. | long term clinical effects of aspirin desensitization in patients with nerd: comparison of maintenance doses of mg vs mg aspirin Çelik ge ; karakaya g ; erkekol f € o ; dursun ba ; gelincik a ; celebioglu e ; y€ ucel t ; yorulmaz i ; dursun e ; tezcaner Ç ; s€ ozener zÇ ; b€ uy€ uk€ ozt€ urk s ; kalyoncu f ; aydin Ö introduction: aspirin desensitization (ad) treatment has been shown to be effective in relieving the respiratory symptoms as well in reducing recurrency of nasal polyps in patients with nsaids exacerbated respiratory diseases (nerd). however, a conflict occurs about effective maintenance doses of aspirin on clinical parameters. objectives: in this study, our aim was to compare the effects of two different maintenance doses of aspirin on clinical outcomes for years of ad. this was a multicenter study which involved tertiary centers. patients who completed at least one year of ad treatment were included to analysis. study outcomes were number of nasal surgery, sinus infections, asthma morbidity (number of severe asthma attacks, hospitalization) as well as medication uses for both clinical conditions. the study included subjects, of whom were under mg aspirin daily as maintenance treatment whereas remaining on mg aspirin for a mean of . ae months of ad duration. regardless of maintenance doses, number of nasal polyp surgery gradually decreased at ( . ae . /year) and years ( . ae . /year) compared to that of before ad ( . ae . /year) (p<. ) in all subjects and were comparable in and mg. considering asthma outcomes, decrease in asthma attacks were observed only in mg aspirin group (p<. ) at and years whereas hospitalization due to asthma and systemic corticosteroid use decreased in both groups at and years. conclusions: ad has a reducing effect on nasal polyp recurrence for at least years in patients with nerd. this effect was similar for both and mg maintenance doses of aspirin. considering both treatment arms provided decreased hospitalization due to asthma and systemic corticosteroid use, we think that at years evaluation both and mg/day aspirin has comparable effects on asthma as well. however, reducing effect of ad on asthma attacks was only existed in patients taking mg. aspirin. objectives: pregnant women with syphilis and history of immediate hypersensitivity reaction (hsr) to penicillin were enrolled. according to the risk stratification, which was based on the initial hsr, serum specific ige and skin tests, patients were re-exposed to penicillin either through desensitization or provocation. patients with a clinical history suggestive of penicillin-anaphylaxis and/or positive serum specific ige to penicillin and/or positive immediate skin test were considered at high risk and were desensitized. the remaining patients underwent penicillin provocation test. results: we evaluated pregnant women with latent syphilis and history of penicillin allergy. clinical history was suggestive of immediate hsr in out of these ( %) patients, who were desensitized. all of them had negative serum specific ige to penicillin. intradermal tests were positive in / ( %). three out of those four were desensitized with an oral protocol and reacted during the procedure. one patient had a severe breakthrough reaction with uterine contraction and did not finish the procedure. the only patient with positive intradermal test that didn't react during the rdd underwent an intravenous protocol. the remaining / ( %) patients had negative skin tests and an uneventfully rdd. there was a statistically significant association between positive intradermal tests and breakthrough reactions during the rdd (p=. ). the other / ( %) patients with inconclusive history and negative skin test were submitted to penicillin provocation, which were negative in all of them. conclusions: risk stratification based on the initial clinical reaction and skin testing to guide penicillin re-introduction was safe and effective, as well as rdd. skin testing identified allergic patients to penicillin with increased risk of reactions during rdd. | utility of basophil activation test for monitoring the acquisition of clinical tolerance after subcutaneous desensitization to brentuximab-vedotin in two patients many hypersensitivity reactions (hsrs) produced by biologic agents have been seen and their true incidence is unknown. desensitization is a method to counter hsrs from monoclonal antibodies in patients with no other adequate alternative options. objectives: we describe a successful rapid desensitization to bv in two patients with scleronodular type hl, refractory to several lines of chemotherapy and asct. this clinical tolerance to bv is easily observed through the basophil activation test (bat) as a decrease in activated basophils after desensitization was done as a treatment of hsrs. because there was no therapeutic alternative in the two patients, we planned to pursue bv administration using a rapid desensitization -step protocol. a total dose of mg of bv was given through increasing rate and concentration. the patients completed their infusion without difficulty. after desensitization to bv, bat was done in both patients. the percentage of activated stimulated basophils with bv descended in both patients. both values are similar to their corresponding negative controls. conclusions: the bat continues to be a useful in vitro tool for the study of drug allergic disease. also, the bat in flow cytometry is able to monitor an acquired tolerance induced by a desensitization treatment in hsrs to bv. however, studies involving a larger number of patients will be required to assess the safety and efficacy of this approach to bat as a method to validate rapid desensitization in patients with hsr to bv. objectives: we retrospectively reviewed desensitizations in patients with a history of ihsrs to chemotherapy agents performed in our center from january to december . the protocol consists of increases in infusion rate every to minutes, in a to steps depending on the drug. in all cases the protocol was performed without premedication (only using regular medication according to instructions for every drug). results: a total of patients with a history of (ihsrs) received desensitization protocol without premedication to chemotherapy agents. the most common involved drug was carboplatin in ( . %) patients (of these % presented positive skin test (st)), followed by paclitaxel in ( . %) patients (of these . % presented a positive st) and oxaliplatin in ( . %) patients (of these . % o the st were positive). other chemotherapy agents involved were cetuximab, rituximab, irinotecan, epirrubicin, etoposide, cisplatin and cyclophosphamide. all patients were able to successfully complete the desensitization protocol without premedication and none of them need to withdraw the drug. conclusions: this protocol for rapid desensitization to chemotherapy without premedication is safe and effective. in addition, minimizes secondary effects of the premedication in these patients that are polymedicated. | rapid desensitization for the management of hypersensitivity reaction to biologicals-infliximab and adalimumab in inflammatory bowel disease patients objectives: to identify barriers to best practice with regards to drug allergy history taking and documentation, and to elaborate the potential strategies to overcome them. results: a total prescribers responded to the survey: doctors in training . % consultants . % non-medical prescribers . % most respondents . % ( %ci . - . %) were not aware of the availability of penicillin allergy testing in our trust. among those that were aware of it, . % ( %ci . - %) had not referred any penicillin-allergic patient to immunology during the past year. barriers to accurate allergy history collection: . % ( %ci - . %) concurred that often it is not possible to draw a firm conclusion based on history alone. . % ( %ci . - . %) agreed with the statement saying that, regardless of the details of the allergy history, it is always better to "play it safe" and not to use alternative beta-lactams in patients labelled as being penicillin-allergic (figure will be attached in the poster). among the interventions proposed; practical educational sessions, an interactive questionnaire to guide allergy history taking and classification and a modified antibiotic policy to guide prescribing based on the allergy classification, were all rated as useful (average score > on a scale from -not useful at all-to -very useful). | the regulatory role of germinal center maturation during the early b cell response to inhalant allergens investigated in the piama cohort using the medall allergen microarray introduction: in contrast to common belief, igg to airborne allergens is higher in allergic subjects, even before immunotherapy. one of the confusing aspects of the allergic immune response is that not only the igg response, but also the ige response can follow more than a single trajectory (with or without gc maturation). for ige we assume that the direct isotype-switching pathway (igm to ige) is the most relevant for the initial, mature-gc independent phase of sensitization to low-dose airborne allergens (such a pollen, mite). in later phases and for higher exposure situations as well as for other immunization routes, indirect switching is assumed to be the more relevant pathway. methods: ige, igg and igg antibodies were measured using the medall allergen microarray in children from the piama cohort at age and . these results were analyzed in relation to the ige levels at age and . objectives: to find support for the hypothesis that the ige/igg ratio reflects not only exposure, but also details on immunological processes during sensitization, such as germinal center maturation. results: sigg and sigg levels to the major inhalant allergens were low at age and remained in general low at age . however, children who at that time were positive for ige an allergen had a significant increased sigg to the allergen in question. sigg also appeared, but this response was low. the sigg level at age in sigenegative children was not consistently predictive for sige at age . conclusions: the initial igg response to inhalant allergens is synchronized with the ige response. this result fits with the hypothesis abstracts | that in the initial phase of sensitization to inhalant allergens the allergen initiates a weak and incomplete germinal center response that allows parallel ige-and igg production. one of the consequences of the multiplicity of b cell developmental pathways is that the igg/ige ratio is potentially diagnostic: if a subject has sigg levels in the microgram range, and thus a high sigg/sige ratio, this indicates involvement of mature gcs and the indirect class-switching pathway for some or all of the sige in this subject. | synthetic allergoid consisted of plga nanoparticles covered with synthetic peptides from bet v objectives: the aim of this study was to test a hypothesis that the ahr signaling is critical in controlling sl homeostasis through the regulation of key sphingolipid enzymes involved in the s p synthesis. results: we found that an ahr ligand and a tryptophan photoproduct, -formylindolo ( , -b) carbazole (ficz; nm), induced a increase in s p level in a ros and ca + -dependent manner, leading to the degranulation as well as il- secretion in mast cells, when compared to those seen in vehicle-treated cells. this was concomitant with an increased level of sphk phosphorylation and with a reduction in the enzymatic activity of s p lyase, which could be reversed by the addition of an anti-oxidant, nac. moreover, s pl was found to be directly oxidized by ros in vitro and in vivo. conclusions: our findings suggested that ahr-mediated ros and ca + signals are critical for controlling sl homeostasis through regulating sphk and s pl metabolic pathways, providing a new regulatory pathway in mast cells. methods: peptide cytokine mimetics were selected by phage display technology. flow cytometry, elisa, elispot, t cell proliferation, reporter gene, mediator release, intravital microscopy and peritonitis assays were conducted to evaluate the capacity of the mimetic peptides to modulate the immune response. results: the synthetic tgf-b -like peptide was able to down-regulate the production of tnf-a, il- , ifn-c and il- , up-regulate il- , decrease basophil degranulation and induce t reg cell differentiation. furthermore, this peptide was able to decrease leukocyte rolling and neutrophil migration during an inflammatory condition in vivo. the synthetic il- -like peptide was able to decrease basophil degranulation and to inhibit the proliferation of allergen-specific t cell lines established from the peripheral blood of birch pollen-allergic patients. conclusions: the peptide cytokine mimetics tested herein, were able to modulate the immune response in the tested conditions. they, thus, represent promising novel candidates for therapeutic approaches. nonetheless, most studies focus on changes occurring early in life and there are rare data on differences in responses between allergic and non allergic subjects. objectives: we aimed to evaluate i) the maturation trajectory of the tlr antiviral pathway ii) if this trajectory varies between atopics and non atopics. peripheral blood mononuclear cells (pbmcs) were isolated from otherwise healthy atopic and non atopic subjects. atopy was assessed by medical history and skin prick testing to common aeroallergens and egg white. selected cytokines involved in the antiviral response were measured by luminex multiplexing technology in hour culture supernatants of poly:ic-stimulated pbmcs. data were analyzed by estimating the non-parametric correlation between age and cytokine expression in atopics and non atopics and comparison of regression curves for each cytokine between the groups was performed. results: the analysis comprised data from atopic and non atopic patients (mean age . years, age range - and mean . years, range - . , respectively). significant age-related increases in the production of ifn-a , ifn-c, il- b, il- a, tnf-a, and mip- b were found only in non atopics and of il- and il- in both groups. significant differences in the trajectories (slopes) of cytokine responses over time between atopics and non atopics were observed for ifn-a , ifn-c, il- , il- b, tnf-a and mip- b, with suboptimal production in atopics. conclusions: age-related increases in cytokines implicated in innate antiviral responses were observed mostly for non atopics. atopy was associated with suboptimal trl- induced cytokine responses. differences in the developmental pattern of those cytokines between atopics and non atopics may account for the reported increased susceptibility of atopics to infections. | a systems-immunology approach identifies a set of micrornas in shaping the th phenotype in allergic airway inflammation introduction: mouse allergy is a common disease in inner city households, affecting up to % of children who are exposed as determined by house dust analysis. it is associated with allergic rhinitis, atopic dermatitis and asthma and it has been reported that exposure and sensitization to mouse allergens is a strong predictor for asthmatic disease. despite a strong link between mouse exposure and asthmatic disease, the allergic immune response to mouse has been significantly understudied. to date, only one major allergen in mouse, mus m , has been identified and very little is known about the targets of the allergic immune response against mouse. objectives: using a proteomic/transcriptomic approach, we sought to identify t cell targets in mouse allergic and asthmatic patients. results: mouse urine and epithelial extracts were analyzed by d-ige/igg immunoblots using pooled sera from mouse-sensitized donors. mass spectrometry of selected protein spots identified novel antibody reactive proteins. predicted mhc binding peptides from these novel proteins and mouse homologs to mammalian allergens were screened for t cell reactivity in pbmcs from mouse allergic patients. overlapping peptides from the major mouse allergen mus m and its major urinary protein isoforms were screened in parallel. our screen for t cell responses in pbmc from mouse allergic donors demonstrated that major urinary proteins account for > % of the total t cell response but they are not the only target of mouse-specific t cell responses. reactivity to mouse peptides homologous to other mammalian allergens, specifically guinea pig, was also detected. conclusions: in summary, our data demonstrates that the cellular and serological targets of the allergic response overlap, with mus m being the major target for both t cells and antibodies. to the best of our knowledge, this is one of the first comprehensive studies of t cell epitope targets in mouse allergy, which provides important insights into cellular and serological targets. this data may form the basis for the development of a mouse-specific immunotherapeutic approach. introduction: food allergy has a complex etiology with many potential underlying factors proposed to contribute to and modify its development and progression. the use of a databases to collect and analyse all relevant data related to incidents of food allergy is essential to fully understand causal factors and improve treatment. objectives: we developed a database using sql, hibernate and java server pages (jsp) that was designed to allow allergy professionals to easily add and modify patient data, including medical history, reaction details and in vitro/in vivo test results. we then filled this database with clinical data relating to reactions to plant-based foods for patients who visited the allergy service of the regional university hospital of malaga between - . these data were then analysed in various ways. cluster analysis of skin test results was used to search for relationships between different allergens based on similarities between patient sensitisation profiles; descriptive statistics and graphical analysis were performed to search for relationships between food type, age of first reaction, number of reactions and reaction severity. results: cluster analysis placed the different skin test allergens in distinct groups, which generally correlated with the type of allergen. for example, nuts, rosacea plant-food, mites, trees and weeds formed distinct clusters. analysis of patient history data showed that the first reaction occurred most frequently between ages - , with a right skewed distribution. a relationship was also found between age at first reaction and reaction severity, being urticaria and angioedema more common when the initial reaction occurs at a younger age, and anaphylaxis when the initial reaction occurs later in life. oas remained relatively prevalent at all ranges (around a quarter of all reactions in all age groups). we found fruits to be the most frequent triggers, followed by nuts; within fruits peach and banana were the most frequent. conclusions: this preliminary study show the importance and utility of recording patient allergy information in a well-structured and easily managed database. future work is currently underway to collect a new set of patients from the same geographical area and to analyse similar data from a different area in order to identify what results are replicable within our population and which results are generalizable to other areas. introduction: cow's milk allergy is very common in children and its correct diagnosis is important to prevent possible dangerous allergic reactions. the aim of the present work was to evaluate the prevalence of allergic sensitization to both cow's milk and to its main proteins. with medcalc ® . normality distribution of data was evaluated through the kolmogorov-smirnov test. patients were divided into three age groups ( - years, - years- - years). chi-squared test was performed to verify a statistical difference between sensitization to whole milk and to its main proteins and patients' age. introduction: the order fagales represents an important cause of tree pollen allergy, which is ubiquitous in the northern hemisphere. a high degree of allergenic cross-reactivity has been observed among allergens from these plants, mainly represented by pathogenesis-related protein class (pr- ) pr- s, including inhalant and food allergens. conclusions: testing ige reactivity to a panel of pr- s unveils important associations between sensitization profiles and clinical presentation, and allows the identification of novel cluster patterns potentially useful to predict disease severity in patients with pr- allergy. results: patients were included, seven boys and four girls, with a median age at diagnosis of six months. the most common offending foods were cow's milk protein (cmp, n= ) and rice (n= ). other foods were fish, egg, chicken, wheat, carrot and potato. average time of symptom onset was . hours. the most frequent symptoms were vomiting (n= ) and diarrhea (n= ). six patients had a history of hospital admission related to this problem. seven patients had concomitant atopic diseases, being the most frequent allergic comobility atopic eczema (n= ). skin prick tests and/or specific ige to culprit foods were negative at diagnosis, except for one patient with low specific ige to cmp. another patient become sensitized to cmp during follow-up. open food challenges were performed in patients starting from six months of age. resolution was achieved in patients, at a medium age of months. results: a total of cases of immediate-type fa among children were reported, with . % involving patients younger than years of age. the major causative foods were hen's egg ( . %), cow's milk ( . %), walnut ( . %), wheat ( . %), peanut ( . %), soybean ( . %), and shrimp ( . %). the most common causative food in each age group was cow's milk ( - years), walnut ( - years), walnut and hen's egg ( - years), and buckwheat ( - years), respectively. the symptom onset time was less than minutes in %. food-induced anaphylaxis was reported in ( . %) out of cases, and the major causes were cow's milk ( . %), hen's egg ( . %), walnut ( . %), wheat ( . %), peanut ( . %), buckwheat ( . %), and shrimp ( . %). the proportion of anaphylaxis was highest in buckwheat ( . %), followed by walnut and pine nut ( . % each). korean children were hen's egg, cow's milk, walnut, wheat, and peanut, with distinctive distributions according to different age groups. anaphylaxis was reported in . % among immediate-type fa. results: a total of children with a median (inter-quartile) age of . years ( . - . ) were enrolled to the study; (male . %). their ages at diagnosis were . years ( . - . ); follow-up times were . years ( . - . ) and milk specific ige levels at diagnosis were . ku/l ( . - . ). in . % of the children there was only cma; the other children were polyallergic to different foods having most frequently egg white allergy. concomitant diseases were . % atopic dermatitis, . % were asthma, . % were allergic rhinitis. during the follow-up milk tolerance was developed in . %, . % and . % at the ages of , and years respectively. the specific ige level at the beginning of the disease was found to be a risk factor for the persistence of the disease (p<. ). conclusions: cma is frequently present with other food allergies. nearly half of the patients develop tolerance to cm up to the age of years; whereas / becomes tolerant when they are at the age of years. most frequent concomitant diseases are atopic dermatitis and asthma. objectives: two survey tools were used; a questionnaire based on similar surveys done overseas, and the validated food allergy quality of life questionnaire (faqlq). this was distributed throughout paediatric allergy clinics at two metropolitan centres. children and adolescents aged - completed the questionnaire independently, whilst parents assisted with children aged - years. results: surveys have been collected at the time of writing of which were answered by parents for young children. overall, / ( %) reported bullying, with a higher portion in older children and adolescents ( / ; %). of this group, / ( %) reported being bullied or teased because of their food allergies. from parental reports, / ( %) stated that their child had experienced bullying or teasing because of food allergies. for those not bullied, parents mentioned that this may be due to their child having friends at school, being too young for bullying or because other children at school had a good understanding of the severity of allergies and were educated by teachers. the most common location for bullying was "in the playground or sportsground" ( / ). the most common form of bullying involved being "teased, called names or someone has said mean things to me" ( / ). whilst food allergens were involved in bullying in many cases ( / ), there were no reports of children being forced to eat food to which they are allergic. of concern however, two adolescents reported experiencing an allergic reaction as a result of the bullying. the majority reported experiences of sadness from bullying ( / ) while seven stated that it had no effect. conclusions: our current research shows that % of children and adolescents with food allergies experience bullying, and that % ( / ) experience bullying specifically because of their food allergies. this indicates a significant social problem that requires addressing to positively assist those children living with food allergies. introduction: recently we demonstrated that intake of specific foods, types of fat and micronutrients was associated with inflammation and mucosal integrity in adults with eosinophilic oesophagitis (eoe). the current study aimed to compare dietary intake of these patients with dietary guidelines and intakes of the general dutch population to further investigate our hypotheses on the protective or allergy-provoking role of specific nutrients in eoe. results: the total faqlq score was low when assessed by teenagers and children ( . and . , respectively) and moderately low when assessed by parents ( . ). experience of anaphylaxis and having multiple food allergies impaired hrql according to faqlq parent form (p<. ). gender, having prescribed an adrenaline-auto injector, experience of food provocation test, peanut allergy and faim did not contribute to different hrql. hrql in kindergarten and schools were moderately diminished (sum score . in schools and . in kindergartens) (p>. ). perceived disease severity was moderately present with total faim scores being . , . and . , when assessed by children, teenagers and parents, respectively (p>. ). % of participants' reported at least some possibility of dying if child/teenagers would accidently eat a food allergen. after fulfilling faqlq and faim, all participants expressed content, ten children/teenagers decided to approach food provocation tests de novo, employees of children's schools/kindergartens were encouraged in written invitations to assess anaphylaxis training programs, and four families accepted additional psychological support. conclusions: food allergies impair hrql in children and teenagers. allergies to multiple foods and experience of anaphylaxis were associated with more severe impairment of hrql. hrqlq and faim are useful, additional tools to assess and discuss child's/teenager's/parent's fears and obstacles because of food allergy and identify further needs of support. introduction: fruit allergy is the most common cause of food allergy in children older than years and adults. regional variations have been observed in europe but there are few studies in pediatric population. objectives: in the context of a prospective and multicentric study on pollen and vegetable food allergy in spain, we enrolled patients (median age , range - , female %), who had suffered at least two episodes of immediate symptoms after ingestion of fruits and had positive skin test to the implicated fruits. immunocap isac was analyzed in all patients. our aim was to describe the clinical characteristics with the fruits involved and the usefulness of the allergens included in the immunocap isac to improve its characterization. symptoms were categorized into oral allergy syndrome (oas), systemic symptoms (ss) and anaphylaxis. results: a total of patients were included. all of them had symptoms with more than one fruit. patients had pollen sensitization. the main offending food associated with allergic reactions were peach ( %), kiwi ( %), melon ( %), apple ( %) and banana ( %). allergic patients to peach had oas, ss and anaphylaxis, were recognized prup in all patients with anaphylaxis, in patients witch oas and in with ss, also prup associated with abstracts | prup in patients with ss. for allergy to kiwi, patients had oas and ss, were recognized actd in patient with sao and patients with ss. actd in patient with ss. conclusions: in our population, the most prevalent fruit allergy was the peach, as in spanish adults. patients allergic to peach were the ones that presented the most ss and anaphylaxis, followed by allergic to apple. as previously have been reported most of them had sige to its components in isac; being prup the most prevalent ( % had prup ). only patients with ss with kiwi were sensitized to kiwi allergens .the majority of patients allergic to apple, melon and banana were not diagnosed by immunocap isac. introduction: studies have shown that asthma and allergy are prevalent among production workers processing seafood, particularly in workers processing crustaceans. a major ige-reactive proteins is the muscle protein tropomyosin. specific ige to tropomyosin is suggested as a central marker for crustacean allergy, however it is not the only protein characterised as an allergen in crab processing. objectives: the aim of our study was to characterise tropomyosin exposure and prevalence of sensitisation to allergens in workers processing king crab (paralithodes camtschaticus) and edible crab (cancer pagurus) in land based processing plants in norway. results: personal air samplers collected air from the workers' breathing zone during crab processing. workers' blood was collected for ige testing. extracts of both king crab and edible crab raw meat, cooked meat, intestines and shell were made in our lab and used for skin prick testing and immunoblotting. while processing cooked crab yielded highest tropomyosin levels in the edible crab plant, processing raw crab yielded highest levels in king crab plants. ten ( . %) edible crab and ( . %) king crab workers had positive ige test (> . ku/l blood, immunocap systems) to crab. four ( %) of skin prick tested king crab workers and ( %) of skin prick tested edible crab workers had one or more positive reactions to edible crab extracts. more workers reacted to cooked crabmeat extracts than to raw crabmeat extracts. immunoblotting showed ige binding to a large number of proteins in all four extracts of both king and edible crab. binding was found to high molecular weight proteins in all four extracts of the crab tested, and the ige-reactive proteins differed between king crab and edible crab. conclusions: workers are exposed to tropomyosin in their breathing zone during crab processing. both king crab and edible crab workers are sensitised to crab, shown with immunocap specific ige test to crab, as well as positive skin prick tests and immunoblots to four different crab extracts made in our lab. workers processing crab in norwegian processing plants have an increased risk for developing sensitisation to crab. objectives: the aim of the study was to assess frequency of skin symptoms in surgery clinic employees, to evaluate burnout as a predictor of the frequency of skin symptoms, and to determine latexspecific ige in surgery nurses with skin symptoms. results: skin symptoms were significantly more frequent in surgery nurses ( %) than in surgeons ( . %), other physicians ( ), and other nurses ( . %) (v = . ; p=. ). skin symptoms were also significantly more frequent in workers with high/medium than in workers with low emotional exhaustion ( . % vs . %; v = . ; p=. ), as well as in participants with burnout than in subjects without burnout introduction: baker's asthma sensitization pattern is changing due to the introduction of different types of grains and seeds. objectives: a year-old ecuadorian man showing ocular, nasal and pulmonary symptoms when handling grain flours (with or without seeds), while baking for the last years. he tolerated grain flours oral intake, but had oropharyngeal symptoms, rhinoconjunctivitis and dyspnea when eating sunflower and sesame seeds, mustard, and beer with alcohol. he tolerated alcohol-free beer. we performed an allergy study: prick-test with commercial extracts of pollens, dust and storage mite, fungus, animal danders, cereals, yeasts and mustard. prick by prick with patient's products: wheat, multicereals and seeded flour, sunflower seeds, regular and alcoholfree beer spirometry and niox. serial peak flow measurement at and away from work, handling tests with wheat flour and sunflower seeds. laboratory studies: specific ig e to cereals and seeds (cap-isac-microarrays). immunoblot with regular beer (at room temperature and boiled), wheat flour and sunflower seeds, and sequential chromatography. results: skin tests were positive with commercial mustard and all provided products except for the alcohol-free beer. spirometry was normal. niox: ppb. peak-flow monitoring showed a % variability during working period, remaining stable during holidays. handling tests with wheat flour and sunflower seeds were positive. specific ig e was positive for grains, malt, gluten, mustard and sunflower seed. the specific determinants were positive to s-viciline, -s globulin, several prolamins ( s-albumine, alfa-amylase inhibitors and gliadin) and ltp. immunoblot detected a band lower than kda in both regular beer extracts (not detected in alcohol-free beer) identified as barley's ltp, a band of kda in the sunflower seed extract ( salbumine), and two bands lower than kda in wheat flour extract (two kinds of alfa-amylase inhibitors). we present a non-atopic baker with occupational rhinoconjunctivitis and asthma due to prolamins (alfa-amylase inhibitor and gliadin of wheat flour together with s-albumin sunflower seed), and anaphylaxis when eating seeds ( s-albumins, s-vicilin and s-globulin) or drinking beer (sensitization to barley's ltp). it is interesting that the manufacturing process of non-alcoholic beer (high temperature and high pressure) seems to degrade barley's ltp, as suggested by both tolerance to its ingestion and loss of immunoblot band. objectives: the main objective of this study is to evaluate longitudinal change of lung function in workers employed in food preparation and distribution potentially exposed to food allergens. spirometries performed between and as part of medical surveillance of food-handlers workers were evaluated. data about occupational task, work years, smoking habits and diagnosis of atopy, asthma and copd were collected from a clinical database. differences in prevalence were calculated by chi-square test, differences in means were calculated using spirola software referred to european predicted values. results: the majority of workers were females (n= ; . %) and caucasians (n= ; . %). ( . %) subjects were current smokers, ( . %) were ex smokers, ( . %) were atopic and no one reported a diagnosis of asthma or chronic obstructive pulmonary disease. % workers were canteen service employees and % were cookery employees. mean yearly values of the pair-wise within person variation of fev and fvc were respectively À ml and À ml. . % of last observations had a fev below lln and . % of last observations had a fvc below lln. conclusions: this study may help in planning preventive programs and in facilitating early recognition and diagnosis of work-related respiratory diseases. wheat, foods and latex allergens may determine decline in fev and fvc; furthermore, in our study, a significant proportion of workers reported exposure to tobacco smoke. excessive loss in fev over time should be evaluated using a percentage decline ( % plus loss expected due to aging) that we will make afterwards adding more years of follow up spirometries. intervention of smoke avoidance are needed. | prevalence of wood dust sensitization in occupationally exposed workers in germany-what can be tested? objectives: in serum samples from patients with suspiciously allergic symptoms to wood dust overall specific (s)ige-tests with standardized wood-dust extracts coupled to streptavidin-immu-nocaps were conducted. additionally, ccd as known source of non-protein ige-target was evaluated. sensitization rates were calculated for different wood species. most frequently requested wood dust allergens were obeche (n= ), beech (n= ), oak (n= ), spruce (n= ) and pine wood (n= ) followed by - requested sige-tests to mahogany, ash, larch and maple wood. results: overall wood dust sensitization rate was about % (range: - %) with obeche, box wood and kambala as most prominent sensitization sources obtaining each more than % sensitization. no sensitizations were detectable to red cedar and meranti wood in more than requested tests, respectively. in patients at least one sige-sensitization to any wood was measured. there from were additionally tested with ccd resulting in % positive and % negative ige responses to ccd. some wood species were exclusively recognized by ccd-positive subjects: ash, maple, alder, mahogany, teak, mansonia and palisander. whereas other woods were recognized by sige of subjects with / or without sige to ccd: obeche, box wood, spruce, oak, beech, limba, pine and kambala. relevance of wood sensitization next to ccd was investigated in eight double positive subjects (wood + / ccd +). specific ige-binding to wood allergens was completely inhibited by ccd in three samples. these subjects were supposed to have no clinically relevant wood sensitization. whereas in five samples sige-binding to selected wood species was not significantly reduced by ccd. in four of these patients skin prick tests (spt) and challenge tests (bronchial and/or nasal) with corresponding wood allergens were performed. three of four challenge tests were positive with the respective wood extract and all spts with wood extracts whose sige-binding was not affected by ccd inhibition showed positive reactions. here clinical relevance of sige-mediated wood sensitization could be demonstrated. conclusions: in summary, our data demonstrate that standardized wood extracts and ccd tools are necessary for valid in-vitro diagnosis of wood dust sensitization. introduction: respiratory symptoms have been reported frequently among seafood processing workers. since seafood processing workers handle the raw material and participate in processing activities during work, they are exposed to inhalable bioaerosols. this put them at risk of developing respiratory symptoms, asthma and allergy. there is little knowledge about the respiratory health status among fish production workers on board fishing trawlers. objectives: the aim of this study was to assess the respiratory health status among norwegian fish production workers, processing fish on board fishing trawlers. the study population consisted of fish production workers, machinists, support crew members and non exposed controls, all were males. written informed consent was the fish production workers had a significantly decreased fev % predicted compared to the non-exposed control group, b=À . , % ci [À . , À . ], when controlling for age, pack-years and family history of asthma/allergy/eczema. the effect did not change when controlling for doctor diagnosed asthma or after dividing fish production workers by doctor diagnosed asthma. machinists and support crew members showed a similar decrease in fev % predicted, but the difference from the non-exposed control group was not statistically significant. furthermore fish production workers, reported a non-significantly increased prevalence of wheezing and daily morning cough compared to the non-exposed control group. conclusions: fish production workers, processing fish on board fishing trawlers, showed reduced lung function values compared to a non-exposed control group, and this finding is in accordance with previous findings in seafood industry worker populations from our research group. results: study group comprised patients with work-related respiratory symptoms suggesting wra. the research completion with sic allowed to recognise wra in persons ( oa and wea) and to exclude asthma in cases qualified to reference group (gr). workers with wea occupationally exposed do lmw-a manifested the highest level of baseline non-specific bronchial hyperresponsiveness (nsbhr) in comparison to the other groups (table ) . patients with oa exposed to lmw-a more frequently than exposed to hmw-a revealed nsbhr before sic (p=. ) with lower level of median (me) provocative methacholine concentration value causing % fall in fev (pc induced sputum (is) was obtained before and h after sic from patients ( gr and wra). in all gr samples and samples possessed before sic from wea subjects exposed to hmw-a, intermediate profile of is (neutrophils (ne)< % and eosinophils (eo)< %) dominated ( results: eg: in "granulation" exposure is relatively high and the number of different enzymes handled is low; here the risk of sensitization is highest. in contrast in the pilot plants the exposure compared to granulation in general is lower but the number of enzymes handled concurrently is higher. still the sensitization risk is lower than the range for granulation. conclusions: even though this approach may seem crude and not free from bias and potential misclassification, data does not support the hypothesis that the number of enzymes increases risk of sensitization, whereas increasing exposure level seems to be a risk factor. this suggests that each enzyme exposure acts as a risk in its own right and that the "cocktail effect" seems to be of minor relevance. phospholipids. bioinformatic studies of sequence homology conducted prior to this study showed no similarity between the mpla s and known allergens including ves v . however, the common enzymatic activity in ves v and the mpla s might still lead to crossreactivity. the goal of this project was therefore to test for possible cross-reactions between sige towards ves v and three different mpla s. methods: serum from known wasp allergic persons with sige towards ves v spanning from . ku/l to ku/l were used for inhibition studies. from each, ll serum was incubated with ll of either saline solution (negative control), lg/ml alk soluprick solution (positive control) or one of three mpla s, each in three concentrations (either . lg/ml, lg/ml and lg/ml (n= ) or lg/ml, lg/ml and lg/ml (n= )). the level of sige towards ves v was measured using the i immunocap, and a decrease in this level was calculated as %inhibition compared to the sige measured from serum incubated with the negative control. inhibition by mpla s would indicate cross-reactivity. results: the positive control caused . ae . % (n= ) inhibition of sige towards ves v . this was lower than expected but was found to be caused by a few sera where the fraction of sige towards ves v was < % of all sige towards wasp venom. in the remaining sera, %inhibition was . ae . % (n= ). for all three mpla s, no inhibition was found for any serum tested (n= ) at the highest concentration tested with %inhibition being . ae . %, . ae . % and . ae . % respectively. conclusions: no inhibition of sige to ves v was found to any of the three microbial phospholipases tested. this indicates that no cross-reaction is found between the phospholipase a in wasp, ves v , and phospholipase a from microorganisms despite the common enzymatic activity. objectives: the aim of study was to evaluate the prevalence and the impact of polyvalent ige-mediated allergy on the course of ad and the occurrence of allergic symptoms from other organs and systems in infants and young children. conclusions: polyvalent ige-mediated allergy is common in young children with ad and seems to be a risk factor for the severe course of the disease. introduction: non-steroid anti-inflammatory drugs (nsaid) are the second most common cause of drug allergies in childhood. objectives: the aim of the study is to determine the frequency of nsaid hypersensitivity in asthmatic children. results: patients who were being followed up for asthma were included in this study. the mean age of the patients was . ae . years, while . % ( ) were male. % (n= ) of the patients had a reaction history to nsaid (ibuprofen in , flurbiprofen in , diclofenac potassium in , metamizole+acetylsalicylic acid in , paracetamol+acetylsalicylic acid in and ibuprofen+acetylsalicylic acid in ). nsaid sensitivity was confirmed in ( . %; / ) patients who were tested with suspected drugs, while the provocation test was found negative in one patient who described reaction with ibuprofen. of the children who were assessed as a control group, only had a reaction history to acetylsalicylic acid and no reaction developed in the provocation test. conclusions: nsaid hypersensitivity is more common in patients with asthma. thus, these patients should be evaluated for nsaid hypersensitivity. results: from jan to dec , pediatric cases were received by kaers. of pediatric patients, . % were male, . % were female and . % were unknown. these pediatric cases included a total of adr events with an approximate average of . adr events per report. of those cases, . % were in infants (age - years), . % were in young children (age - years), . % were in old children (age - years), . % were in adolescent.(age - years) and unknown were . %. male to female ratio was : . and the mean age was . ae . years. regarding categorical ranking of reported adr agent groups, the most common group were antibiotics ( . %) followed by antineoplastic agents ( . %), vaccine ( . %), antipyretics ( . %), opioids ( . %), sedatives ( . %), antiepileptic drugs ( . %), contrast media ( . %), steroids ( . %). the most common adr symptoms were gastrointestinal system disorder in . %, skin-appendage disorder in . %, abstracts | body as a whole-general disorder in . %, central-peripheral nervous system disorder in . %. regarding seriousness of adrs, events ( . %) had episodes requiring hospitalization and were considered life threatening. of these, cases had anaphylaxis or anaphylactoid reactions. introduction: multiple drug allergy is an adverse reaction to two or more structurally unrelated drugs that appears to occur by immune mediated mechanism. patients with a history of reaction to two or more drugs often apply to allergy clinics. objectives: the aim of this study is to evaluate the test results of the patients who have a history of multiple drug allergies and underwent drug provocation tests. results: during the study period, drug provocation tests were performed in patients ( drug provocation tests). of these patients, ( . %) had a history of drug reactions to or more drugs. the mean age of the patients who had a history of reactions to two or more drugs was . ae . years, and . % (n= ) toms, and autoimmune manifestation in comparison to igm/iga responders (respectively, pneumonia: %, % and %; chronic diarrhea: %, % and %; autoimmunity %, % and %; autoimmune cytopenias: %, % and %). malignancies were found more frequently in the non-responders and igm-only responders groups in comparison to igm/iga responders (respectively, %, % and %). eleven ( %) patients died during the study time. survival analysis according to the igm/iga responder status showed that the -years estimated survival for non-responders vs igm-only vs igm/iga responders was respectively after one year %, % and %; after two year: %, % and %; after three years: %, % and %%; after years: %, % and %; after years: %, % and %; after years: %, % and %. interesting, in our series only two deaths were due to infective complications: five were consequent to malignancies, one to autoimmune cytopenias and three to not-cvid related conditions. between-infusions intervals ( - days) than pid patients ( - days). finally, a small number of patients with anti-cd -related sid was able to discontinue scig replacement therapy after recovery of spontaneous igg production. conclusions: this is, to our knowledge, the biggest single center cohort of scig-treated patients ever described. results suggest that safety and effectiveness of scig is similar in pid and sid, irrespective of the mechanisms underlying igg depletion. moreover, in sid a lower igg dosage is required and ig replacement does not always need to be lifelong, with obvious pharmacoeconomic implications. a | should we screen children with bronchial asthma for primary immune deficiencies? miteva d ; perenovska p ; papochieva v ; georgieva b ; lazova s ; naumova e ; petrova g the patient became febrile and cultures were repeated, being positive to campylobacter jejuni, resistant only to ciprofloxacin (blood) and to campylobacter coli, susceptible only to gentamicin and amoxicillin/ clavulanic acid (stools). treatment was thus switched to amoxicillin/ clavulanic acid ( / mg / h). the patient became apiretic at day and improvement of local inflammatory signs was noticed, treatment was prolonged for six weeks. one week after cessation, skin lesion worsened again in the same location, in association with fever. blood and stool cultures were repeated and gentamicin ( mg/day; iv) and cefixime ( mg / h) were started, in agreement with previous cultures results. curiously, there was no history of diarrhea, but the patient referred a period of recurrent abdominal colicly pain, before cutaneous lesions appear. conclusion: bacteremia with campylobacter species requires specific laboratory workup. diagnosis of campylobacter jejuni bacteremia should be considered in hypogammaglobulinemic patients with recurrent fever, particularly when typical copper color erysipela-like skin lesions occur. campylobacter eradication can only be achieved with prolonged antibiotic therapy guided by antibiogram in cultures. conclusions: in this study, genetic defects of five higm patients have been identified, for other patients further genetic investigation such as next generation sequence (ngs) is required. the study results can help diagnose of the disease more definitively and also can provide valuable information for genetic counseling especially for those who have a history of immunodeficiency in their families and also for prenatal testing. conclusions: mutation analysis of unc d gene can help the families with hlh patients give genetics counseling for carrier detection and prenatal diagnosis. woelke s ; valesky e ; bakhtiar s ; bader p ; schubert r ; zielen s department for children and adolescents, division of allergology, pulmonology and cystic fibrosis, goethe university hospital, frankfurt, germany; department of dermatology, venereology and allergology, goethe university hospital, frankfurt, germany; department for children and adolescents, division for stem cell transplantation and immunology, goethe university hospital, frankfurt, germany introduction: ataxia telangiectasia (a-t) is a devastating multi-system disorder characterized by progressive cerebellar ataxia, growth retardation, immunodeficiency, chronic pulmonary disease and genetic instability with an increased risk for malignoma. as described in other primary immunodeficiencies cutaneous granulomas are a known phenomenon also in a-t. still treatment indication and strategies remain controversial. objectives: from our cohort of classical a-t patients, eight patients in the aged to years presented with granulomas. histopathology of the lesions confirmed the presence of granulomatous inflammation without detection of any microbiological agent in all patients. five patients suffered from cutaneous manifestation, in two patients we detected a bone and in one a joint involvement. both patients with bone involvement (patients and ) as well as one patient with massive skin manifestation (patient ) were treated with tnf inhibitors (infliximab). the patient with granulomas in his finger joint (patient ) was bone marrow transplant (bmt) for other reasons. year led to a total remission for three years now. in patients and treatment with tnf inhibitors led to a partial regression of granulomas. treatment interruptions caused deterioration again. in the course of treatment the effects of infliximab diminished most likely caused by drug antibodies. after changing treatment to subcutaneous adalimumab a further regression could be detected. in patient granulomas totally disappeared with immune reconstitution after successful bmt. partially successful in treatment of granulomas. due to the known immunodeficiency in a-t patients, indication for immunosuppressive therapies as tnfa inhibitors should be held strictly. woelke s ; hess u ; knop v ; krausskopf d ; kieslich m ; schubert r ; zielen s of to years regarding c-reactive protein (crp), liver enzymes, abdominal ultrasound and neurological status (ataxia score). we divided the patients into two age groups of a-t patients aged to years and a-t patients aged years to years. ataxia score (r= . ), although the underlying pathomechanism is unclear. ultrasound revealed nonalcoholic fatty liver disease in only one young patient ( . %) compared to older patients ( . %). one female patient aged years died due to a hcc. conclusions: liver disease is present in almost all older a-t patients. structural changes, nonalcoholic fatty liver disease and fibrosis are frequent findings. there is a considerable risk for hcc. prospective studies are necessary using noninvasive techniques for the assessment of liver fibrosis (eg transient elastography) and to establish the risk of hcc in a-t patients. objectives: in this study, it was aimed to determine the frequency of pollen-food syndrome in children who have sensitization to pollens. results: pollen-sensitized patients were included in this study. the mean age of the patients was . ae . years, while . % (n= ) were male. in . % (n= ) of the patients, allergic rhinitis was concomitant with asthma. . % (n= ) of the patients described symptoms related to pfs. % ( / ) of them had a history of anaphylaxis with suspected food. the mean age of the patients describing pfs was . ae . years and % (n= ) of them were female. in ( . %) of these patients, skin tests performed with suspected food was positive, but in one patient the skin test was negative while specific ige was positive. suspected food was fruit/ vegetables in patients. in patients with pollen allergy, oropharyngeal symptoms related to fresh fruit, vegetables, dried fruits and nuts should be enquired. it should be noted that these patients might experience serious systemic reactions including anaphylaxis. patel nb ; vazquez-ortiz m ; lindsley s ; abrantes g ; bartra j ; dunn galvin a ; turner pj conclusions: there is no evidence that the occurrence of anaphylaxis at fc, and self-treatment with an adrenaline auto-injector device, result in adverse impact on hrql measures. the impact of a reaction at food challenge appears to confer greater benefit on the parent than the child. the relationship between confidence in management and hrql needs further assessment, since it is likely that these outcomes will be affected in different ways following therapeutic interventions. results: fifty-one patients ( females, males) (median age: . years, range - ) with cma were studied. spt to cm was . ae . mm as mean diameter. forty-eight out of fifty-one ( . %) patients underwent dm-opt ( patients refused to underwent opt due to positive spt or s-ige to dm introduction: bovine milk is the most common food allergen in children under years of age. milk allergy is treated by eliminating milk from the diet. the milk elimination diet endangers the child's energy intake and also exposes the child to shortage of multiple nutrients. this study was needed because there are no previous systematic reviews about this subject. objectives: the aim of the present study was to examine if the milk allergy or the other factors associated with milk elimination diet have an influence on child's growth. the present study was conducted according to international guidelines for systematic reviews. results: a total of studies were initially identified, of which three fulfilled our criteria. these three studies included children with cow's milk allergy and control children. in all these three studies, children with cow's milk allergy were lighter than controls. in addition, in two studies, the growth of the children with cow's milk allergy was stunted. in two studies the milk elimination was substituted with special infant formula. also in one study where both the growth and the weight were stunted, no major differences in energy or nutrient intake between cow's milk allergic cases and controls were reported. conclusions: current evidence suggests that milk allergy is associated with stunted growth in childhood, but reasons for this are unclear. in order to clarify the effect of cow's milk elimination diet on growth in childhood and the underpinning mechanisms, more studies need to be conducted. in addition, special attention to the diet and growth of children with cow's milk allergy is needed. results: a total of children were surveyed in this -year period (annual average: ). in , children ( . %) were diagnosed with food allergy, including cases of pfas, cases of egg allergy, and cases of dairy-product allergy. in , children ( . %) were diagnosed with food allergy, including cases of pfas, cases of egg allergy, and cases of dairy-product allergy. over this -year period, the prevalence of pfas increased . fold (from . % to . %). among the pfas cases, the prevalence of rosacea and apple allergy increased . -and . -fold, respectively. the most prevalent was apple allergy ( . %), followed by peach ( . %), loquat ( . %), plum ( . %), pear ( . %), and strawberry ( . %). the prevalence increased significantly for pfas but not for other types of food allergy (egg and dairy-product allergy). in the future, nationwide studies are needed to further elucidate the relationship between pfas and allergic rhinitis. | immune profile after oit in children with cow s milk allergy patients with elimination diet, group : patients with natural tolerance, group : healthy control). in all groups specified laboratory tests were performed at onset and also at month to treatment groups. in desensitization group at month of treatment we evaluated increase in total ige level, sp iga and igg antibody responses, decrease in cow's milk spige levels and an increase in il- , il- , tgf-b cytokine responses without a difference in cd +cd +fox-p % levels. il- levels were similar with pre-treatment levels whereas foxp mrna expression was similar with tolerance group. in elimination group at month treatment, there was a decrease in cow's milk spige whereas there was no change in sp iga levels and a minimal increase in igg levels. there was no change in il- and il- cytokine levels. and an increase in tgf-b cytokine response less than group , decreased il response, a foxp mrna expression differed from tolerance group was identified. objectives: although hyperuricemia has a significant prevalence in the general population, and has been related to exercise-induced asthma, could be related to bronchial asthma and nasal polyposis. hitherto, its possible association with hypersensitivity to nsaids and its convenience as biomarker have not been acquainted. conclusions: in our population, hyperuricemia has not demonstrated to be a reliable biomarker related to nsaids allergy and could not be used as a risk factor for assessing the triad nsaids allergy, asthma and nasal polyps. to study the vas of the total score was seen significant variance in: nsaid-cu ( . pt) and nsaid-pa ( . pt) (p=. ), nsaid-cu conclusions: data support that cutaneous manifestations have a common response with aerd to cox inhibitors. conclusions: this study showed that in a positive drug oral provocation test, respiratory symptoms were accompanied with nitric oxide changes in both nasal and exhaled way. barrionuevo e ; doña i ; salas m ; bogas g ; guerrero ma ; sanchez mi ; cornejo-garcia ja ; torres mj allergy unit, regional university hospital of malaga-ibima, malaga, spain; research laboratory, ibima-regional university hospital of malaga-uma, malaga, spain introduction: non-steroidal anti-inflammatory drugs (nsaids) are the most frequent triggers of drug hypersensitivity reactions, being cross-hypersensitivity reactions (chr) the most frequent. the categories included in chr are nsaids-exacerbated respiratory disease (nerd); nsaids-exacerbated cutaneous disease (necd) and nsaids induced urticaria/angioedema (niua). however, it has been reported patients with chr to nsaids who developed a combination of skin and respiratory symptomatology (blended reactions). objectives: our aim was to analyse the characteristics of patients with blended reactions and compare with those developing symptoms exclusively respiratory (nerd) or cutaneous (niua). episodes of cutaneous and/or respiratory symptoms after the intake abstracts | of ≥ different nsaids included strong cox- inhibitor (acetylsalicylic acid (asa) and/or indomethacin); ii) if they had < episodes of cutaneous and/or respiratory symptoms induced by < different nsaids, a positive drug provocation test (dpt) with asa was required; iii) if patients had respiratory symptoms accompanied or not by cutaneous involvement, a positive nasal provocation test with lysine aspirin (npt-lasa) was required. atopy was assessed by skin prick test using a panel of inhalant and food allergens. objectives: subjects with nsaids hypersensitivity were divided into two groups: a) those from to years and b) those from - years. diagnosis was established by a clinical history and controlled challenge with asa. atopic status was verified with a detailed allergological study including skin testing to inhalant allergens. clinical entities were classified in three categories: urticaria/angioedema, anaphylaxis and respiratory (asthma and/or rhinitis). cases. no differences were observed in the atopic status between both groups. there were significant differences between males/ females (p<. ). when we compared the clinical entities there were more cutaneous manifestations, mainly angioedema, in the group a) and more anaphylaxis in group b) although there were no significant differences due to sample size. conclusions: significant sex differences between hypersensitivity reactions to nsaid occurs with predominance of males in the first group (a). although there are also a predominance of clinical entities, an increase number of cases is needed to establish significance. studies on this direction are in progress. show an increase in all age groups. etiologic analysis was limited as the study was carried out using the icd- code (nhic records) and database of self reporting systems (kaers). so, further study was needed. introduction: genetic variants from the q locus are the strongest known genetic determinant for early-onset childhood asthma, and have also been associated with uncontrolled asthma despite asthma treatment. objectives: the aim of the study was to assess whether there is an association between a single nucleotide polymorphism (snp) in the q locus (rs ) and asthma exacerbations despite the objectives: our hypothesis is that the arg allele is associated with increased use of prescribed asthma medication, over a -year period. to explore this hypothesis, we have undertaken a secondary analysis of breathe, a study of gene-environment associations with asthma severity. breathe data were collected on participants with asthma, aged - years, between and , in tayside conclusions: in children and adults, the homozygous arg/arg status is associated with long-term increased prescribing for asthma medication compared to those carrying at least one gly allele. defining subgroups of individuals requiring more medicines could help predict treatment costs and develop targeted management strategies. objectives: considering the role of ptgdr in allergy, the goal of this study was to analyze the effect of ptgdr expression on cytokine levels in the a cell line. analyze ptgdr expression in a cell cultures. cytokine production assays in the culture supernatant were measured by cytometric bead assay using the bioplexpro tm human cytokine standard -plex, group i. the assays were conducted with bioplex high-throughput fluidics system, powered by the luminex technology. every sample was run at least in triplicate. the ptgdr expression in the transfected cells with the haplotypic variants differed by orders of magnitude relative to control cells (p<. ). we found significant differences in ptgdr expression between ctct and cccc haplotypic variants. the cccc (À c, À c, À c, and À c) introduction: c t polymorphism in the cd gene has been suggested in susceptibility to asthma. cd is a multifunctional receptor endotoxin, which is expressed on the surface of macrophages, monocytes and neutrophils. it is likely to play a role in the inflammation pathway. though data is available regarding association of cd gene with asthma but independent studies are in conflict. objectives: the present study was conducted to examine the association of promoter c t single nucleotide polymorphism (snp) in the cd gene for indian children with atopic asthma. we characterize the c t polymorphism in children with asthma ( ), cohort group ( ) and healthy control group ( ) by pcr rflp. association analysis was performed using v tests. we also analyzed the association of cd (c t) with total ige levels by elisa and foxp expression using flow cytometry. in this snp a base pair (bp) pcr product was generated using the standard primers. after restriction products showed that homozygous c allele was appeared as a single bp band, the homozygous t allele as bands of bp and bp, and heterozygous exhibits all three bands ( , and bp). the or of cc genotype frequency abstracts | was . in study group and . in cohort group and the or of c allele frequency was . in study group and . in cohort group. total ige level were found to be significantly higher in cc genotype compared to ct and tt genotype. foxp level is significantly higher in control group in all genotypes compared to cohort and study group. conclusions: the present study concludes that in cd gene polymorphism cc genotype was not significantly associated with asthma but other factors ie total ige and foxp showed significant association of cc genotype with asthma. on the other hand, there was significant association of c allele with asthma. | the disbalance of tlr , tlr gene expression and cytokines production in children with bronchial asthma svitich oa ; gankovskaya lv ; namazova-baranova ls ; bragvadze bg ; alekseeva aa ; gankovskii va objectives: examined were patients with bronchial asthma aged from to years and healthy children of the same age. cytokines were determined by elisa. determination of mrna expression in scrapings from the mucous membranes of the respiratory tract and in peripheral leukocytes was carried out polymerase chain reaction in real time. results: in scrapings from the mucous in patients with moderate to severe asthma found a significant increase in the gene expression of tlr , times, the gene tlr in times in comparison with the control group. in children with severe asthma also found a significant increase in the gene expression of tlr . times compared to healthy children, p≤. ). indicators of tlr gene expression in this group of patients have a tendency to increase, but not statistically significant. when comparing the indicators of innate immunity in samples with a leukocyte mass in the group of children with severe asthma showed a decreasing expression of tlr compared with the index in healthy children. also decreased the expression of tlr . in children with moderate ba similarly, a significant decrease of tlr gene expression in times. the trend towards reduced expression of tlr remains in this group, but is not reliable. in washings from the nasopharynx shows that patients with bronchial asthma il- is increased . times compared to the norm, to pcg/ml, tnf increased in times and pcg/mg in severe asthma, and . pkg/ mg-for mild, il- increased in times ( pcg/mg), pkg of . / mild blood, il- also increased . -fold and equal to . pkg/mgwith heavier with easy- . pkg/mg, normal À pkg/mg. ie is an increase in proinflammatory and anti-inflammatory cytokines. conclusions: the overexpression of tlr , tlr accompanied by increasing, the production of cytokines. this is a violation of mechanisms of innate immunity at the level of the mucous membrane of the nasal cavity on the role of inflammation in the pathogenesis of tlr. | sustained reduction in risk of experiencing asthma symptoms and using asthma medication in years following grass slittablet treatment-results from the paediatric gap trial were: wheezing, cough (for more than consecutive days), shortness of breath, chest tightness. the odds ratio for having asthma symptoms, using asthma medication, or having asthma symptoms and using asthma medication was significantly lower in the grass slit-tablet group during the followup years. for asthma symptoms, the results were: or= . , p=. days with csms< were defined as "no or minimal symptoms" and days with csms > were defined as severe symptoms. csms score was significant lower in the ilit group than in the placebo group for , and . in mean csms was . roth-walter f ; schmutz r ; mothes-luksch n ; zieglmayreer p ; zieglmayer r ; jensen-jarolim e objectives: here, we investigated whether the immune molecule lipocalin (lcn ) may discriminate between allergic and sensitized individuals, and between responding and non-responding patients. results: lcn -concentrations were assessed in sera of healthy and allergic subjects (n= ) as well as of house dust mite (hdm) allergies that underwent hdm-sublingual immunotherapy (slit) in a randomized, double-blind, placebo controlled trial for weeks. sera pre -, post-slit and at least months after slit were assessed for lcn and correlated with total nasal symptom score (tnss) obtained during chamber challenge at week in patients receiving hdm-(n= ) or placebo-slit (n= ). allergic individuals had significant lower lcn -levels than healthy controls, with women having lower lcn -levels than men in the patient cohort. hdm-allergic patients who received hdm-slit had a significant increase in hlcn months after termination of hdm-slit, whereas in subjects receiving placebo no increase in hlcn was observed. within the hdm-slit treated group, lcn -levels were significantly higher in patients whose symptoms improved during slit in contrast to those in which symptoms became more severe. hence, time-course of lcn in an allergic individual was predictive to assess clinical reactivity to hdm. objectives: here, we present the benefits of treatment in terms of nnt to prevent one additional child from having asthma symptoms and asthma medication use. children treated with grass slit-tablet had a reduced risk of asthma symptoms and asthma medication use during the -year follow-up period compared with placebo (or= . [ . , . ] for sq grass slit-tablet (n= ) vs placebo (n= ), p<. , relative risk reduc-tion= %). the risk reduction was independent of age at treatmentstart. younger children had a higher predicted probability of developing asthma symptoms and asthma medication use than older children. thus, the younger the children were at treatment-start, the greater the percentage was prevented from having asthma symptoms and asthma medication use during follow-up off treatment. for children aged at treatment-start, the risk was reduced from % to % and for those aged it was reduced from % to %. consequently, the nnt to prevent one additional child from having asthma symptoms and asthma medication use during the -year follow-up increased with age, with nnt= for children aged and nnt= for children aged . conclusions: the grass slit-tablet reduced the risk of asthma symptoms and asthma medication use during the -year follow-up period; the risk reduction was independent of age. however, the nnt increased with age as younger children had a higher risk of developing asthma symptoms and asthma medication use, emphasising the importance of treatment-start early in life. results: participants were screened for birch and grass allergy, of whom ultimately met randomization criteria and were treated with either slit-t or placebo for months. treatment was preceded by a successful baseline birch pollen challenge in the eeu where a minimum tnss of was achieved in the first of hours of pollen exposure. participants attended the post treatment challenge in the eeu, also hours in duration. no significant differences were noted in the reduction of birch-induced tnss compared to baseline between the slit-t and the placebo treated participants (the primary outcome measure). adverse events with a minimum % frequency occurred in % of participants in the placebo arm and % of participants in the active arm, with upper respiratory tract infection ( % in active arm and % in placebo arm) being the most common. oropharyngeal itch was the most common adverse event with causality at least possibly related to study medication ( % in active arm and % in placebo). no serious adverse events occurred including no anaphylaxis. objectives: here, we present a pooled subgroup analysis in adolescents from phase ii/iii-iii trials with the hdm slit-tablet ( sq-hdm dose), p in north america and to- - - in japan. results: to- - - was a randomised, dbpc phase ii/iii trial investigating the efficacy and safety of the hdm slit-tablet in japanese adolescents and adults ( to years) with moderate-tosevere hdm ar (n= , of which were adolescents). subjects were randomised to treatment with the hdm slit-tablet in doses of sq-hdm, sq-hdm or placebo for year. p was a randomised dbpc phase iii trial investigating the efficacy and safety of the hdm slit-tablet in north american adolescents and adults (≥ years) with moderate-severe hdm ar with or without asthma (n= , of which were adolescents). subjects were randomised to treatment with sq-hdm or placebo for up to year. in both trials, the primary endpoint was the average total combined rhinitis score (tcrs) during the last weeks of treatment. the pooled analysis was performed on mean values using a linear mixedeffects model. treatment with sq-hdm of the hdm slit-tablet resulted in a statistically significant reduction in the average tcrs of . ( %, p=. ) compared to placebo in the last weeks of treatment. statistically significant differences were seen for both components of the tcrs, the rhinitis medication score (difference= . , p=. ) and rhinitis symptom score (difference= . , p=. ). furthermore, treatment with sq-hdm resulted in a statistically significant reduction of the conjunctivitis symptom score compared to placebo (differ-ence= . , p=. ). treatment was well tolerated. the most frequent adverse events were mild-to-moderate local allergic reactions. the pooled subgroup analysis showed that the hdm slit-tablet ( sq-hdm) was effective in treating hdm allergic rhinitis in adolescents ( - years old). the reduction in the primary endpoint tcrs was statistically significant and comparable to what has been observed in adults. results: at the time of the data-cut for this analysis, a total of european patients were screened ( % male). % of the subjects were aged - , % were aged - , and % were adults. the mean age of the sample was . [sd . ] years, with a minimum of and a maximum of years. in europe were children. many were allergic to foods other than peanut, and most had at least one other atopic condition. even if allergic to multiple foods, patients and their families were nonetheless keen to participate in the trial. the majority of the screened patients were highly sensitive to peanut, reacting to mg (cumulative) or less of peanut protein but a significant proportion of screening failures were due to lack of reactivity to this dose. | efficacy of ir -grass pollen sublingual tablet: improvement in subjects with grass pollen-induced allergic rhinoconjunctivitis based on well days and severe days evaluation objectives: four phase ii/iii dbpc studies, in adults and one in children/adolescents, were conducted worldwide. participants were abstracts | randomised to receive the ir tablet or placebo starting months ( m) prior to the pollen season and continuing for its duration. data from the first season of the trials in adults were pooled. the well days were defined as those with not more than one moderate symptom or mild symptoms of the evaluated symptoms (sneezing, rhinorrhoea, nasal pruritus, nasal congestion, ocular pruritus, watery eyes) and no use of rescue medication. the severe days were defined as either at least one moderate symptom in subjects using rescue medication, or at least moderate symptoms or one severe symptom whether rescue medication was taken or not. for each subject, the proportions of well days and those of severe days were evaluated during the pollen period while on treatment. treatment groups were compared using a wilcoxon -sample test. introduction: the safety of subcutaneous immunotherapy (scit) has been proven in several studies, but the occurrence of side effects (se) remains a concern in daily clinical practice and understanding of their risk factors and avoidance strategies remains limited. objectives: the aim of presented study was to assess the incidence and risk factors of early and late side effects in patients undergoing scit. we conducted a year-long observation of over patients undergoing scit in our outpatient clinic. we recorded detailed information for each administration and screened subjects for both immediate and late reactions. we compiled the records with medical histories to build a database, which was analyzed using multiple logistic regression. casein is a major cow s milk allergen and very resistant to high temperatures. higher levels of ige towards caseins have been reported to associate with persistent cow s milk allergy and higher risk of adverse reactions before and during the milk oit. a follow-up study on oit to milk started in with a six-month built-up phase. seventy-six children (mean age . years) with challenge-verified cma participated the milk oit and their immunological changes were analyzed employing crd. during the year , long-term follow-up report was collected by questionnaires ( %, n= ) and blood samples ( %, n= ). specific antibody responses were characterized before oit and on long term follow up and compared to long-term questionnaire results: milk consumption (yes/no) and side-effects from milk from past months (yes/no). objectives: to define the utility of crd in long-term follow-up after milk oit. results: mean follow-up time was ( - ) years. ten patients ( %) avoided milk completely and patients ( %) reported routine consumption of dairy products. side effects after milk consumption from last months were reported by % of the patients. increased specific ige levels towards caseins were seen among patients who did not consume milk at the long-term (p=. *). there was no significant association between the long-term milk consumption and ige levels to whole milk (p=. ), caseins (p=. ), alpha-lactalbumin (p=. ) and beta-lactoglobulin (p=. ) measured before the oit in this small sample. patients who consumed milk at the longterm follow-up and reported side effects had higher specific ige levels towards caseins before oit (p=. *). conclusions: there was a high incidence of side effects even after eight years of milk consumption, which may indicate desensitization instead of true tolerance. component-resolved diagnostics may corroborate in predicting prognosis, as suggested by higher incidence of side effects among patients with high levels of ige towards caseins also in the long-term follow-up. objectives: retrospective study of patients who underwent subcutaneous ait for allergic rhinitis ( % had concomitant asthma). patients with less than months of treatment were excluded. large local reactions (wheal≥ mm) and systemic reactions were defined according to who grading system. patient's satisfaction was defined by vas score. results: the mean age of patients ( % males) was ae (range - ) years ( %< years).the most prevalent immunizing allergens were house dust mite ( %), olive ( %) mix of grasses ( %) and pets ( %). % of patients were immunized against a single allergen whereas % were immunized with≥ allergens. patients were followed for ae months. following ait the vas score decreased from . ae . to . ae . (p<. ). % of the patients declared that they will recommend immunotherapy to their relatives. systemic adverse reactions ( % class i, % class ii) were observed in introduction: metabolomics, one of the core disciplines of system biology, is a high-dimensional biology method that may allow hypothesis-free profiling of biomarkers, rather than a traditional hypothesis-driven approach. objectives: this study aimed to apply the metabolomic approach to serum to longitudinal alterations during allergy immunotherapy (ait) in dermatophagoides pteronyssinus (der p) sensitized asthmatic children. results: a robust hydroxyeicosatetraenoic acids (hetes) of inflammatory responses was found for discriminating during ait, including -hete, -hete and -hete. -hete and -hete were significantly decreased continuously from through months of ait. moreover, compared with baseline of ait -hete was detected in very low level during and months. the metabolomic profiling could clearly longitudinal alterations biochemical-metabolic profiles in der p-sensitized children during ait. these markers might be involved in asthma pathophysiology but also represent the therapeutic target for ait. background: metabolomics, one of the core disciplines of system biology, is a high-dimensional biology method that may allow hypothesis-free profiling of biomarkers, rather than a traditional hypothesis-driven approach. this study aimed to apply the metabolomic approach to serum to longitudinal alterations during allergy immunotherapy (ait) in dermatophagoides pteronyssinus (der p) sensitized asthmatic children. methods: in this longitudinal study, we recruited der p-sensitized asthmatic children with ait for months. serum samples were analyzed using a metabolomic approach based on mass spectrometry. results: a robust hydroxyeicosatetraenoic acids (hetes) of inflammatory responses was found for discriminating during ait, including -hete, -hete and -hete. -hete and -hete were significantly decreased continuously from through months of ait. moreover, compared with baseline of ait -hete was detected in very low level during and months. the metabolomic profiling could clearly longitudinal alterations biochemical-metabolic profiles in der p-sensitized children during ait. these markers might be involved in asthma pathophysiology but also represent the therapeutic target for ait. we performed desensitization with asa according to the wong protocol (doses of . , . , , , , , , , , mg of asa at intervals of - min). we pre-medicate with cetirizine mg. our patient successfully reached the necessary dose: mg of asa ( . , . , , , , , , and mg) conclusions: approximately % of patients with asthma undergo respiratory symptoms due to exposure to aspirin, meanwhile . % and . % of the population shall undergo hives when exposed to it. desensitization with aspirin is an efficient and safe treatment in patients with hypersensitivity type i, iii and iv. due to the benefits and low toxicity of the wong protocol, we recommend this protocol in order to desensitize patients with allergy to aspirin who undergo rheumatologic or cardiovascular disorders and need antiplatelet treatment. we finally recommend our patients to take mg of asa premedicated with mg of cetirizine every day. we warn that if you interrupt the administration of asa for more than hours, it shall have to be administered again under medical supervision. semedo fm ; cruz c ; reis r ; tomaz e ; in acio f horiuchi t ; takazawa t ; saito s department of anesthesiology, gunma university hospital, maebashi, japan; intensive care unit, gunma university hospital, maebashi, japan introduction: sugammadex is a synthetic c-dextrin derivative that is designed to selectively bind to steroidal neuromuscular blocking agent molecules. although sugammadex has been used in many cases of general anesthesia, there are several reports of anaphylaxis following its use. skin testing is the gold standard for detecting the causative agent of anaphylaxis. however, the test itself sometimes precipitates serious complications, including recurrence of anaphylaxis. hence, development of a novel test that can be performed in vitro without causing such complications is desired. recently, the basophil activation test (bat) has been established as a tool to detect the causative agent of anaphylaxis with high sensitivity and specificity. yet, there are few studies examining the utility of the bat in diagnosing sugammadex-induced anaphylaxis, besides our previous report. although both cd and cd c are currently used as the major markers for activated basophils, which one of them is more suitable for the bat depends on the targeted drugs. objectives: the aim of this study was to investigate whether bat could be utilized to diagnose sugammadex-induced anaphylaxis. in addition, we compared the capability of cd c and cd as markers for activated basophils. seven patients with perioperative anaphylaxis demonstrating a positive skin test for sugammadex were included. furthermore, individuals who tolerated sugammadex and had a negative skin test for allergy to this drug were enrolled as controls. results: the ratios of activated basophils in the patients were much higher than those in controls (mann-whitney u test, p<. ). cd c up-regulation. this was also true for cd . in the case of cd c, the sensitivity of bat for sugammadex was % and specificity was %, while sensitivity and specificity for cd were % and %, respectively. there were no significant differences between cd c and cd in the areas under the roc curve. conclusions: this study showed that bat is a reliable instrument to diagnose sugammadex-induced anaphylaxis. we did not find any difference between cd c and cd as markers for activated basophils in the bat for sugammadex. objectives: we report a retrospective study of patients who were referred to our allergology departments between and with a suggestive history of immediate hypersensitivity to ppis. our purpose was the analysis of the clinical presentations and the allergological investigation performed in order to confirm the diagnosis of drug hypersensitivity to ppis and to study the cross-reactivity among ppis. results: the culprit drugs were pantoprazole (n= ), omeprazole (n= ) and lansoprazole (n= ). the allergological investigation confirmed the diagnosis of hypersensitivity to ppis in patients ( by skin tests and oral challenge). we observed cross-reactions between omeprazole, pantoprazole and esomeprazole (n= ), omeprazole and pantoprazole (n= ), respectively omeprazole and esomeprazole (n= ). in patients the severity and the recurrence of the reaction did not allowed the provocation test with the culprit drug. two oral challenges allowed the use of an alternative ppi (based on the pattern of less cross-reactivity depending on the chemical structure: pantoprazole for a patient who had a grade iii anaphylaxis to lansoprazole and lansoprazole for a patient who had a grade ii anaphylaxis to pantoprazole). conclusions: a complete allergological investigation (skin tests and cautiously, oral challenge) is needed in order to confirm the diagnosis of drug hypersensitivity to ppis and to take a therapeutic decision. the diagnostic approach is limited by the low sensitivity of skin tests and the patient's background (comorbidities and severity of the reaction) which do not always allow the oral provocation test. an ige dependent mechanism may be involved in hypersensitivity reactions to ppis or their metabolites. herrero-lifona l ; muñoz-rom an c hospital quironsalud campo de gibraltar, los barrios, spain; hospital regional universitario de m alaga, m alaga, spain introduction: hypersensitivity reactions to beta-lactams are an important problem to study, especially in children, given that these antibiotics are the gold standard for the treatment of many infectious diseases in the infancy. most hypersensitivity reactions to betalactams in children are due to non-immediate response and to diagnose them is essential to perform a drug challenge test. although hypersensitivity is usually ruled out in children by drug challenge test, it is positive test up to %- %. objectives: a year-old boy is suspected to have experienced two drug reactions after the intake of amoxicillin with and without clavulanic acid for pharyngitis treatment. in the first one, he presented a maculopapular eruption in the back after one day treatment with amoxicillin-clavulanic acid. in the second reaction, two hours after the intake of amoxicillin, it appeared an itching maculopapular eruption in the back that was resolved with symptomatic treatment. in both cases, the patient tolerated treatment with cefuroxime afterwards. results: intradermal test with amoxicillin was negative in immediate and delayed reading. oral drug challenge test with amoxicillin ( mg/kg/day, total cumu- oral drug challenge test with penicillin v (total cumulative dose mg): it was well tolerated and the patient continued taking it for epicutaneous patch testing with amoxicillin in the lesion area and in an unaffected area: in the lesion area, it appeared mild erythema, but it was considered a negative result in both areas. conclusions: we report a case of an amoxicillin-induced multiple fixed exanthema: an unusual non-immediate reaction in childhood. most cases of non-immediate hypersensibility need to be confirmed by drug challenge test, given that skin testing lacks sensitivity both intradermal and patch tests. the patient presents a selective hypersensitivity to amoxicillin, being tolerant to penicillin and cephalosporins. jimenez-rodriguez t ; soriano-gomis v ; gonzalez-delgado p ; cueva-oliver b ; venegas-diaz ij ; fernandez j results: data from patients were analyzed, of which . % ( ) were women. the overall mean age was . ae . years, with no statistical difference between sexes. the . % ( ) of the patients presented symptoms with a single group of nsaids, and . % ( ) with or more different groups. the % ( ) of patients presented a history of atopy. in patients with rhinitis % had symptoms with only one nsaid and % with two or more groups of nsaid, while patients with asthma, % reacted to one nsaid and % to two or more groups. the most frequent clinical manifestations were: urticaria/angioedema in % ( ), pruritus in . % ( ), bronchospasm in . % ( ), other respiratory symptoms in % ( ) and anaphylaxis in % ( ) patients. the most frequently involved nsaids were: metamizole ( . %) and ibuprofen ( . %). skin tests were performed in only patients, of whom ( %) were positive to metamizol. dpt was performed in . % ( ) objectives: fifty patients diagnosed with "dress" ( - ), in a tertiary center were retrospectively analyzed, with cases meeting the regiscar criteria. we collected demographic, clinical, laboratory and therapeutic data from the electronic medical records. results: all cases occurred during hospitalization and in several hospital areas. the mean age was . years ( - ) with . % women and % of caucasian origin. reported clinical manifestations were skin rash ( %), fever ( . %), digestive symptoms ( . %), respiratory ( . %), neurological ( . %), head and neck ( . %), urological ( . %), ophthalmologic ( . %) and musculoskeletal ( . %). the most relevant laboratory findings were eosinophilia ( %), elevated transaminase levels ( %), lymphocytosis ( %), altered coagulation ( %) and altered renal function ( %). virus serology was positive in cases ( . %) involving hhv- , ebv, cmv and hiv. antinuclear antibodies were positive in / cases ( . %). skin biopsy, performed in cases ( . %) revealed findings suggestive of drug induced skin reaction. suspected culprit drugs were antibiotics ( %), nsaids ( %), antiepileptic drugs ( %), and antiparasitic agents ( %). one case was related to the administration of heparins and other to a monoclonal antibody. in % of cases, the episode was not related to a particular drug. treatment was accomplished by the administration of corticosteroids ( %), antihistamines ( %), and immunosuppressant drugs in cases. fluids and other medications were administered attending to symptoms. death occurred in patients, although only in case it was related to dress syndrome. the average time from reaction to death was . months. allergy evaluation, performed in cases addressed the potential role of drugs. skin tests were positive in / patients ( . %) and basophil activation test was negative ( / cases). results: from patients admitted with possible diagnosis of scar, only met the inclusion criteria ( f/ m, age - , average . years-old). they were all admitted to a medicine ward. five patients had diagnosis criteria of dress, of sjs and of ten. as for the drugs related with the reaction, antiepileptic drugs were the most frequent ( patients); allopurinol ( ), betahistine ( ), ciprofloxacin+nimesulide ( ) were the causative drugs in the remaining patients. average time to the beginning of symptoms was . days ( patients unknown). in patient the cause was unknown (he had criteria of ten and also diagnosis of malaria and was transferred to another hospital). there were no deaths. objectives: the objectives of the present study were to determine the efficacy of nfeno to: . establish the diagnosis of rhinitis; and . discriminate allergic rhinitis (ar) from non-allergic rhinitis (nar). material and methods: prospective and controlled study with healthy subjects, which included patients with rhinitis. ar and nar were phenotypically defined according to positive or negative prick test results, respectively; the control group was collected from people without upper or lower respiratory tract disease and the prick test was negative. in all sample included the following measurements were performed: feno and nfeno (novario analyzer) were performed; spirometry; eosinophil counts in blood and nose (by nasal brushing); bilateral nasal endoscopy; and acoustic rhinometry. results: we included cases (ar= , nar= and controls= ), with a mean age of (sd . ) years, % men. the table below shows the results of the variables analyzed by group. patients with rhinitis compared to controls had significantly greater feno production, as well as a higher proportion of eosinophils in blood and nose, but not in nfeno production. however, when the two subgroups of rhinitis were compared, ar patients had significantly higher feno and nfeno than nar, in addition to blood and nose eosinophils. there were no differences in acoustic rhinometry values between groups. conclusions: although nfeno does not appear to identify patients with rhinitis, it may be useful in discriminating ar from nar. in routine clinical practice, it could help guide to identify an ar in cases with inconclusive results of the complementary tests commonly used in its diagnosis. introduction: fractionated exhaled nitric oxide (feno) is used as a marker of eosinophilic airway inflammation in asthma, whereas clinical presentation of nasal no (nno) is unknown. objectives: the objective of this study was to evaluate the factors influencing nno levels. in patients with chronic nasal symptoms, total-nasal-symptom-scores (tnss) were calculated; skin-prick-test conclusions: in conclusion nasal no is useful in allergic inflammation in the absence of sinus obstruction in nasal cavity. however, its value is limited with paranasal sinus ostium occlusion. were recruited across australia and the uk via a patient panel. the aim was to assess which ar treatment attribute(s) drove patient preference. results: table shows the willingness to pay (wtp) for each attribute. all attributes were significant predictors of treatment choice, except administration method. however, patients in both countries showed a considerable preference for treatments that were more efficacious, fast acting and affordable. conclusions: although treatment relief remains of primary concern, time to treatment benefit and cost could dictate treatment preference. these data may be of value in optimizing the acceptability of future ar treatments and informing trial endpoint selection. australia ( izquierdo l; chiriac am; molinari n; demoly p introduction: allergic rhinitis is a frequent disease with an important impact on quality of life. self-administrated control assessment tests can help achieve a better management of this disease. however, none of these tools has been validated in teenagers. test in its original version, following the same protocol as the original study in adults. we designed a multicentre, observational, cross- conclusions: while the number of included patients is low, the first results are promising. indeed, a significant improvement of the rhinitis control score was found between d and d . this led us to the hypothesis that this questionnaire could be used as is to estimate the control of the allergic rhinitis in teenagers. analyses concerning the validation of the questionnaire itself do not reach at the moment the threshold of significance, the recruitment is on-going, to increase its power. objectives: the objective of this study was to evaluate the role of serum vitamin d in patients with symptomatic allergic rhinitis and active asthma during the allergy season and observe the effect of montelukast mg daily as treatment. results: this study included asthmatic and seasonal allergic rhinitis patients following a single-blind, placebo run-in period of - days, patients were randomized to oral montelukast mg (n= ) or placebo (n= ) daily during the -week, double-blind, active-treatment period. the serum vitamin d was also evaluated in both the groups. the serum vitamin d levels were found to be higher in patients taking montelukast compared to placebo after weeks (p<. ). montelukast reduced the daily rhinitis symptoms score: difference between montelukast and placebo (p<. ). similar improvements were seen in daytime nasal symptoms (p<. ) and nighttime symptoms (p<. ). conclusions: montelukast provides significant relief from symptoms of seasonal allergic rhinitis, while also conferring a benefit for asthma, in patients with both allergic rhinitis and asthma. further, it has a beneficial role in improving vitamin d levels. venegas-diaz ij ; jimenez-rodriguez t ; canto-reig vj ; lindo-gutarra m ; soriano-gomis v ; gonzalez-delgado p ; cueva-oliver b ; fernández j allergy section. general hospital alicante. isabial, alicante, spain; allergy section. general hospital alicante. isabial-umh, alicante, spain introduction: local allergic rhinitis is an accepted entity, which only can be recognized by nasal provocation test (npt) in patients with clinical rhinitis with negative skin tests or specific ige (sige). our aim was study this entity in our patients in alicante, spain. objectives: patients with symptoms of rhinitis with skin tests, and sige negative for common aeroallergens were selected, since . half of them ( ) most were young adults, % belonging to the range of age between - years; more than % had family history of atopy; the mean age of onset of symptoms was years and up to . % had had symptoms before the age of years; . % were nonsmokers. regarding comorbidity, . % of the patients presented with concomitant symptoms of conjunctivitis and . % of asthma. symptoms in . % of the patients were persistent and most of moderate ( %) to severe ( . %) intensity. the majority of patients ( . %) presented perennial symptoms and a tpn positive to mites in . %, to salsola pollen in % and to cypress pollen in . %. but patients ( . %) were simultaneously positive to allergens. conclusions: local allergic rhinitis represents an important proportion of patients with clinical rhinitis with negative skin tests and sige. we have to pay attention to identify clinical and demographic factors of ral and to use npt to demonstrate it. objectives: we report the extent of sinus involvement at baseline (bl) in pts with bilateral np refractory to intranasal corticosteroids from a dupilumab phase a study (nct ). ct scans from enrolled pts, adults < years with nasal polyp score of ≥ / , were pooled and analyzed at bl. for opacification, standard lund-mackay (lmk) scoring ( =normal, =partial opacification, =total opacification) in maxillary, anterior/posterior ethmoid, sphenoid, frontal sinuses was used. ten sinus scores plus bilateral ostiomeatal complex (omc) score ( =not occluded, =occluded) were summed to a bilateral total lmk ( - ). zinreich modified lmk score (zlmk), providing more granularity on opacification degree, was evaluated post-hoc; each sinus was given a - score based on opacification % from mucosal thickening ( = %, = %- %, = %- %, = %- %, = %- %, = %); omc results: the prevalence of asthma at the age of years was . %. % of them had an act tm value below , ie uncontrolled asthma, median . (range - ). independent risk factors for uncontrolled asthma at the age of were current doctor diagnosed rhinitis (adjusted or, aor . ; % ci . - . ), wheeze triggered by exercise (aor . ; . - . ) and cat at home (aor . ; . - . ). if at least one of the parents had higher education the risk of uncontrolled asthma was decreased (aor . ; % ci . - . ). six children reported hospitalisation due to asthma during the last months (ie . %) at years of age. hospitalisation was more common in individuals with uncontrolled asthma (or . ; . - . ) or when mites (or . ; . - . ) or pollen (or . ; . - . ) was reported as trigger factors. also, oral corticosteroids (betamethasone), in the last months increased the risk for hospitalisation (or . ; . - . ). to have a parent with asthma ( % compared to %, or . ; . - . ) or higher education ( % compared to %, or . ; . - . ) was numerically less common for children who were hospitalised for asthma but did not reach statistical significance. conclusions: uncontrolled asthma was associated with current allergic rhinitis, having a cat and exercise as trigger factor. at least one parent with higher education reduced the risk. hospitalisation due to asthma was more common in individuals with uncontrolled asthma. abstracts | adolescent asthma in relation to severity and gender-data from a prospective population based cohort study introduction: asthma often debuts early in life, but recent studies show that the development of asthma is a dynamic process with disease turnover throughout child-and young adulthood. objectives: to describe adolescents' asthma with focus on severity and gender. the study population consisted of adolescents participating in the cohort, followed since birth up to years of age with questionnaires and clinical investigations. blood samples from adolescents ( . %), sera analyzed for specific ige against common inhalant allergens. asthma at years was defined as fulfilling at least of the following criteria: symptoms of wheeze and/or breathing difficulties in the last months, ever doctor's diagnosis of asthma and/or asthma medicine occasionally or regularly last months. uncontrolled asthma was based on parental information on symptoms of asthma in the last months prior the -year follow-up, including or features: nocturnal asthma, activity limitation, wheeze times and hospitalization due to acute asthma. we looked into phenotypes; late-onset, defined as asthma at , or , but not at , and years of age and persistent, defined as asthma at , or and , or years of age. severe asthma, defined as asthma as above combined with prescribed and dispensed corticosteroids used within the last months plus uncontrolled asthma and/or lung function (fev < % of predicted). results: at years of age, . % (n= ) fulfilled the study definition of asthma, . % late onset and . % persistent asthma. persistent asthma was more frequent among boys than girls . % vs . % (p=. ). overall ige sensitization was common among adolescents with asthma, . % were sensitised to common inhalant allergens, and equally common in late-onset and persistent asthma ( . % vs . %, p=. ). however, more boys than girls were sensitised ( . % vs . %, p<. ). in total . % (n= ) adolescents had severe asthma, . % (n= ) boys and . % (n= ) girls (p=. ). the overall prevalence of severe asthma in the cohort was estimated to . %. severe asthma did not significantly differ among adolescents with late-onset compared to persistent asthma ( / , / , p=. ). conclusions: among adolescents with asthma, late-onset (age ≥ years) and persistent asthma were equally common. persistent asthma were more common among boys. there were no difference in asthma severity, or proportion of ige sensitization among adolescents with late-onset or persistent asthma. however, data investigating associations with wheeze and asthma in later childhood are scarce. objectives: our aim was to explore the association of maternal milk fatty acid composition with childhood wheezing phenotypes and asthma up to age years. breast milk was collected weeks and months post-delivery in the ulm birth cohort study (n= and n= , respectively). concentrations of - carbon atom chain length fatty acids were measured by high-resolution capillary gas-liquid chromatography. to control for constant sum constraint, concentration data were transformed using the centered log ratio method. compositional biplots and correlation matrices were used to group fatty acids based on within sample correlation. adjusted risk ratios with parent-reported wheezing phenotypes and doctor-diagnosed asthma were computed using a modified poisson regression. results: we observed no straightforward evidence of associations between overall breast milk fatty acid composition and specific wheeze phenotypes or doctor-diagnosed asthma. conclusions: despite our use of sophisticated statistical methodology, our results may have been biased toward the null by several cohort-specific factors associated with breast milk collection and fatty acid composition. to overcome potential selection bias by maternal lifestyle, further research should investigate fatty acid intake during the first year of life including sources other than breast milk among children who were never or not exclusively breastfed. introduction: fall is the most common season for asthma exacerbation. previous studies found that exposure and sensitization to house dust mites (hdms) can exacerbate asthma. the seasonal variation in indoor hdm concentration is highest in the fall, correlating with the incidence of asthma exacerbation. most of the studies conducted to date have focused on the effect of hdm exposure on the incidence of acute asthma exacerbation, but reports about the effect of hdm sensitization are few. thus, we aimed to determine whether sensitization to hdms acts as a risk factor of asthma exacerbation in the fall. in addition, we investigated whether asthma exacerbation in the fall had any distinctive features by comparing levels of various cytokines and chemokines with those in other seasons. objectives: we enrolled children aged - who visited the emergency department because of acute asthma exacerbation from january to december ( . %, males; mean age, . ae . years). they were treated in accordance with the standardized treatment protocol. blood samples were collected from the children during the course of treatment. by using residual sera from the blood samples, we measured the levels of total immunoglobulin e (ige), hdm-specific ige (sige), eosinophil cationic protein (ecp), and various cytokines and chemokines, and classified them according to season. we compared the date divided into fall group (from september to november, n= ) and other season group (from december to august, n= ). ci, confidence interval; or, odds ratio; der f-sige, dermatophagoides farinae -specific immunoglobulin e; der p-sige, dermatophagoides pteronyssinus-specific immunoglobulin e; ecp, eosinophil cationic protein; ige, immunoglobulin e. data are presented as n (%) or as meansaesems and median (range). p value refers to the difference between the fall and "other season" groups and was calculate by the chi-square statistics, fisher's exact test, student's t-test, or wilcoxon rank-sum test. a adjusted for total ige. results: this retrospective study obtained archived nasopharyngeal aspirate (npa) samples from patients aged below years who were hospitalized for acute respiratory illnesses in a university-affiliated hospital during the periods september-november and january-april . their clinical information was retrieved from computerised record. hrv was detected by rt-pcr, and isolates were sequenced to determine the genogroups and serotypes. ninety patients whose npa was positive for hrv and patients being negative for an extended panel of respiratory viruses by multiplex pcr method were identified. mean age of these groups was . years and . years respectively. hrv infection was significantly associated with asthma exacerbation (or . , results: a total of children were included: . % were boys; . % aged months to years, . % aged - years, . % aged - years and . % aged - years; . % were hospitalized, results: the long-term remission (≥ years without treatment) rate years after initiating early anti-inflammatory therapy was . % (intermittent asthma, %; mild persistent asthma, . %; moderate persistent asthma, . %; severe persistent asthma, . %). longterm remission rates improved compared with past asthmatic conva- objectives: the aim of this study is to explore the potential value of feno level for diagnosing chronic cough in children. objectives: in this study, we aimed to compare the efficacy of classical spirometry and impulse oscillometry (ios) in evaluation of late reversibility in children who received treatment with the diagnosis of atopic asthma. we enrolled patients aged - years who were diagnosed with atopic asthma. exclusion criteria were having received asthma treatment during the previous two months, having acute asthma exacerbation findings, having any other respiratory disease or cardiac disease that may affects the lung function test results. allergic sensitization was determined by skin prick test performed according to eeaci guidelines. lung function test measurements were performed at enrollment and after two months of inhaled steroid treatment. conclusions: classical spirometry is more valuable compared to ios in evaluation of late airway hyperreactivity in children with atopic asthma in children older than seven years age. | computer bronchophonographyfrequency analysis of the respiratory cycle. objectives: we performed mct in children with symptoms suggestive of asthma and without respiratory symptoms. after each inhalation step oscillometry and spirometry was performed. parameters analysed for ios were z , r , r , x , x and ax (the integrated impedance reactance at r and above) and fev for spirometry. a fall of % in fev from baseline after mtc was considered as a positive challenge. pc -fev and pc r , x and ax were calculated. results: a total of patients, female, with a mean age of . (ae . ) years were enrolled. had a ≥ % fall in fev after mtc. the mean variation in fev was % (- . %/ + . %), the mean variation in z , r , r , x , x , ax and fres were . % objectives: the objective of our study was to synthesize cationic peptides and study their antiviral activity (aa) in vitro. results: peptides were synthesized by solid phase method with different structures (linear, helical and dendrimeric). cytotoxicity of the peptides was studied by mtt assay using hela cells. objectives: the aim of the study is to evaluate the changes of il- results: subjects aged - years were enrolled in this study, which were divided into groups: patients with diagnosed moderate to severe ba ( st group), ba patients with rvi ( nd group), subjects with rvi only ( rd group) and healthy volunteers ( th group). all patients with ba from group and received inhaled corticosteroids. clinical blood test revealed increase of eosinophils in patients with ba and ba accompanied with rvi up to % and %, respectively. fev was decreased in st and nd groups to % and % compared % and % for rd and th groups, respectively. conclusions: this study is alarming for asthmatic nosocomial hazards in this govt. hospital. identification of ige specific reactive components of predominant fungal allergens and cross-reactivity among each other, delined in this study could minimize the hazard of therapeutic and diagnostic use of these cross-reactive components, in fungal allergen-specific immunotherapy. objectives: we conducted a longitudinal prospective study to examine the development, composition and diversity of the gut microbiota in healthy and allergic children. we followed children from months to years of age with clinical evaluation; specific ige levels and skin prick testing. fecal samples were collected at , , months and years. s rrna sequencing was used to profile the gut microbiome using illumina miseq. the composition and diversity of the gut microbiome were assessed using quantitative insights into microbial ecology (qiime). comparisons between groups were made using the lefse pipeline; non-parametric factorial kruskal-wallis test, unpaired wilcoxon rank test and linear discriminant analyses (lda) with score > . . to assess the interaction effect, the likelihood ratio test (lrt) was applied using r statistical program. p<. was considered significant after correction for multiple testing. results: to achieve our aim we divided balb/c mice into groups: mice with viba ( st group), mice with viba treated with nonspecific sirna against gfp (sigfp) ( nd group) and against il- (siil- ) ( d group). th group was intact mice. groups - were i.p. sensitized on days , , with ovalbumin (ova) mixed with aluminum hydroxide and i.n. challenged with ova on days - . the same mice were i.n. infected with tcid /mouse rsv strain a on day . mice from group and were i.n. treated by sirnas on days - in dose lg/mouse. on day hyperresponsiveness (ahr) to methacholine was measured. on day and lungs were removed for histological analysis. viral rna (vrna) load and il- gene expression were evaluated by qpcr in lungs. bronchoalveolar lavage (bal) was collected for differential cell count by light microscopy. so i.n. administration of siil- suppressed il- gene expression in lungs by % compared to sigfp treated mice. there were no significant changes in body weight and lung vrna amounts between mice received sigfp and siil- . mice treated with siil- demonstrated the tendency to improve lung function compared to mice of group - , that expressed in % reduction of specific resistance of airways and % increase of peak expiratory flow. bal cell count revealed decrease of total cell number, eosinophils and lymphocytes in mice received siil- by %, % and % compared to sigfp treated mice, that indicate reduction of inflammation, that was confirmed by histopathological studies showed % leukocyte reduction. downregulation of il- resulted in -and . -fold decrease of bronchial epithelium metaplasia and hyperplasia. and femur length measurements were collected from routine antenatal screenings. these and derived head to abdominal circumference ratio and estimated fetal weight were converted into z-scores adjusted for gestational age and gender and categorized as "low" (≤ sd below mean), "normal," or "high" (≥ sd above mean). ad cases were children with parent-or pediatrician-report of physician ad diagnosis assessed yearly up to age years and supplemented by clinical diagnoses during dermatological exams at . , , and years. modified poisson regression models were used to compute risk ratios (rr) adjusted for potential confounders. conclusions: these results provide further evidence for a role of fetal growth as an influence on atopic disease outcomes. unlike previous studies, our data suggests several patterns of fetal growth beginning as early as the st trimester may influence ad outcomes. objectives: we aimed to examine the role of eosinophil cationic protein (ecp), eosinophil derived neurotoxin (edn) and total immunoglobulin (ig) e as a bio-marker of disease severity. we examined the difference in level of total ige, ecp and edn between the two groups and whether any correlation existed between disease severity and ecp or edn. objectives: we aimed to identify the subgroup of ad patients with a good clinical response to probiotic treatment. we recruited children who suffered from moderate to severe ad with the scoring ad (scorad) index of or higher. after weeks of washout period, all patients were given lactobacillus plantarum cjlp at a dosage of colony-forming units once a day for weeks. we measured eosinophil counts in the peripheral blood, the proportion of cd + cd + foxp + regulatory t (treg) cells in cd + t cells, serum total ige levels, and specific ige to common allergens before the start of the treatment (t ) and at discontinuation (t ). logistic regression models were used for the statistical analysis. seventy-six patients ( boys and girls) with a mean age of . ae . years completed the study. there were responders and non-responders after probiotic treatment. the median scorad was reduced from . (range . - . ) at t to . (range . - . ) at t in the responder group (p<. ). in multivariable logistic regression analysis, a good clinical response was significantly associated with high total ige levels (aor . , % ci . - . ), increased expression of , and high proportion of cd + cd + foxp + cells in cd + t cells (aor . , % ci . - . ). in responder group, the proportion of cd + cd + foxp + cells of cd + t cells were significantly increased after weeks of treatment (p=. ), while the levels of tgf-b mrna expression were decreased (p=. ). there were no differences in total ige levels between t and t (p=. ) conclusions: the therapeutic effect of l. plantarum cjlp on ad is more pronounced in children with high total ige levels, objectives: the objective of the study was to examine the effect of a specific synbiotic mixture of short-chain galacto-, long-chain fructo-oligosaccharides (scgos/lcfos, ratio : ) and bifidobacterium breve m- v on the severity of ad and correlation to serum chemokines in infants with moderate to severe ad and elevated ige. in an exploratory randomized, double-blind, placebo-controlled trial the effect of extensively-hydrolyzed whey-based formula without intervention. serum obtained prior to start and at the end of intervention were analysed using luminex. six chemokines and nine ratio's thereof were correlated to ad severity (sample size= ). introduction: dyshidrotic eczema is one of the most common skin conditions. contact allergy is often associated with dyshidrotic eczema although the exact impact and the influence of contact allergens in different forms of dyshidrotic eczema remain unknown. hypersensitization to nickel is one of the most common contact allergies associated with pompholyx. the standard of care protocol is to use a medical treatment with topical corticosteroids and calcineurin inhibitors to treat the symptoms, together with occlusive barrier creams to avoid skin exposure to the allergens. after the symptoms have been cleared with the topical treatment, the recommendation is to use occlusive barrier creams to prevent recurrence of the symptoms. objectives: a new emollient with specific metal-scavenging agents and no occlusive ingredients has recently been developed and made commercially available. the aim of this study was to evaluate the effect of such cream to provide relief for patients with dyshidrotic eczema associated with nickel allergy. results: thirty-two subjects with dyshidrotic eczema and a positive patch test ppt (contact sensitized) reaction to nickel were selected. these were divided into two randomized groups, group-a was given nickel-scavenging cream (skintifique creamtm, paris) after medical treatment, (n= ) and group-b followed the standard protocol for pompholyx, (n= ). hand eczema was scored according to the dyshidrotic eczema area and severity index (dasi). dasi scores were evaluated at the beginning of the study (day- ), after the medical treatment (day- ) and two months after the end of medical treatment (day- ). results show a significant difference in the efficacy of treatment between the two groups at day- . a higher percentage of at least % reduction of initial dasi score ( . %) and a higher percentage of total clearance ( %) in patients using nickel-scavenging nonocclusive moisturizing cream was observed as compared to standard-of-care occlusive creams ( . % and %, respectively). objectives: the goal of this study was to investigate whether long-term emollient therapy is associated with alterations of skin barrier function and shifts of the skin microbiome in infants at high risk for developing ad. we prospectively enrolled newborns with a family history of ad to be randomized to either emollient treatment group or control group. at months of age, we tested the skin barrier (transepidermal water loss/tewl, water capacitance/cap, ph) and skin microbiome ( s rdna sequencing of skin swabs from cheek, dorsal and volar forearm). results: the emollient group (n= ) had significantly lower skin ph compared to controls (n= ) (p=. ), but without a statistically significant difference in tewl or cap. the emollient group had higher numbers of different bacterial taxa (chao richness) at cheeks (p=. ), dorsal forearms (p=. ), and volar forearms (p=. ) as compared to controls. both streptococcus pneumoniae and s. salivarius statistically significantly contributed to the observed skin microbiome differences between patient groups. s. salivarius was significantly more abundant in emollient subjects at all sampling sites (p=. ). we then analyzed our previous larger cohort of older children with ad and also observed higher s. salivarius proportions in ad patients with treated and less severe disease (p=. ). objectives: to evaluate the effect of overnight treatment with a temperature-controlled laminar airflow (tla) device in children/adolescents with severe eczema over a -month period. in an open-label study, subjects aged - years (median years) with longstanding severe eczema attended visits during the run-in period lasting - weeks (median . weeks) to optimize eczema management. the run-in was followed by a month treatment period using overnight tla device (airsonett ® , sweden), which included study visits. we used scorad-index results: the median duration of eczema was . months (interquartile range - . ). all subjects were sensitised to ≥ perennial allergen, and had multiple comorbidities ( / rhino-conjunctivitis, / food allergy, / asthma). there were no significant changes during the run-in period in any of the outcome measures. we observed a significant improvement in scorad after the -month tla-treatment period, from . [ . - . ] to . [ . - . ] , p=. . iga improved significantly from a median of [ - ] to [ ] [ ] [ ] , p=. . improvement in symptoms was paralleled by a significant reduction in medication usage. by months, there was a significant improvement in . ] to [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] , p=. ), and an improvement in cdqli (marginal, p=. ). however, we observed no changes in poem (p=. ) . post-hoc cluster analysis of the patterns of changes in scorad over the month treatment period identified two clusters, with participants classified as responders and as non-responders. introduction: intestinal degradation has been shown to determine allergenicity of food allergens. however, it is unclear how allergens are degraded inside pivotal immune cells such as dendritic cells (dc), and how this affects the subsequent immune response to these allergens. in our studies, we determined whether we are able to measure uptake and degradation of allergens inside dc and whether differences in above mentioned factors exist between allergens. objectives: using mouse bone marrow-derived dc and fluorescent-labeled proteins, we studied the cellular uptake of the peanut proteins ara h , , , and . results: first, we observed that dc uptake of ara h was much higher than ara h , and . using blocking reagents and receptor binding assays for various uptake routes in dc, we observed that one of the principal routes of uptake for ara h was the mannose receptor. other uptake routes, and the routes of uptake for ara h , and are currently under investigation. second, using proteins coupled to beads we observed that intracellular protein degradation was higher for ara h and ara h than for ara h and . finally, cd +t cells from ara h , , or sensitized mice were added to matching allergen-pulsed dc. we observed that while ara h , and to lesser extend ara h elicited strong th type responses, ara h did not elicit any t cell responses. conclusions: together, we show that allergenicity of (peanut) proteins may be, at least partly, determined at the level of allergen uptake and breakdown inside the antigen presenting cell. these findings may be relevant to risk evaluation of existing allergens but also of novel or modified proteins. this also illustrates the usefulness of in vitro, cell based assays to examine initial processes of allergenic sensitization to proteins. | sensitising capacity of unmodified and acid hydrolysed gluten through the skin-a comparative study in na€ ıve vs tolerant brown norway rats ballegaard ar; madsen cb; bøgh kl national food institute, technical university of denmark, søborg, denmark introduction: allergic sensitisation to foods may occur in infancy without prior oral exposure to the offending food. this has led to the assumption that food allergy sensitisation may occur through alternative routes, such as the skin, supported by the observed correlation between skin barrier disruption and food allergy. recently, concerns have been raised regarding the safety of use of cosmetic and personal care products containing hydrolysed wheat proteins, since these products have been shown to induce allergy towards acid hydrolysed wheat through the skin, and even to cause an abrogation of the already established oral tolerance against unmodified wheat. objectives: the aim of the study was to compare the sensitising capacity of an unmodified and an acid hydrolysed wheat product via slightly damaged skin, in order to evaluate differences in conditions necessary for skin sensitisation in na€ ıve vs tolerant individuals. brown norway rats were raised and bred on either ( ) a diet free from wheat, resembling individuals with a na€ ıve immune system, or ( ) a conventional wheat containing rat chow, resembling individuals tolerant to wheat. results: in the na€ ıve rats both products were able to induce a statistically significant specific antibody response after application of the products on the slightly damaged skin, whereas in the wheat tolerant rats, only the acid hydrolysed wheat product was able to induce a statistically significant antibody response. for both the na€ ıve and the wheat tolerant rats the response was dose-dependent. in the na€ ıve rats both products were able to sensitise through the skin, inducing a specific ige response, whereas in the tolerant rats only the acid hydrolysed product were able to induce a specific ige response, though this ige response was much lower than in the na€ ıve rats. results from competitive elisas demonstrated that new epitopes had developed as a result of acid hydrolysis, though original epitopes were maintained at the same time. this may explain why only the acid hydrolysed wheat could induce specific antibody responses in the tolerant animals. conclusions: this study showed that the sensitising capacity through the skin of two different wheat products is heavily influenced by the tolerance status of the immune system and the degree of modification of the wheat products. results: using a germ-free c h/hen mouse model of food allergy, we examined the presence of a major peanut allergen, ara h , in the blood after intraperitoneal injection in previously sensitized and control (non-sensitized) mice using an untargeted, quantitative proteomic approach. previously sensitized mice underwent physiological (core temperature decrease, clinical symptoms) and biochemical (mast cell protease increase, ara h specific ige positivity) changes associated with severe allergic reactions. we were able to confidently detect multiple peptides derived from the ara h protein after intraperitoneal injection in both control and ara h sensitized mice. however, the ara h protein was present at - fold higher levels if mice were previously sensitized, suggesting increased transit across the peritoneal mesothelium with sensitization. an untargeted proteomic approach also allowed changes in the blood proteome of mice undergoing a severe allergic response to be examined. we identified proteins with significantly altered quantity in serum between control and sensitized mice and were therefore apparently associated with the allergic response. we demonstrate the applicability of untargeted proteomics to the study of the allergen transport and proteomic changes which co-occur with a resultant allergic reaction. the transit of allergens into the bloodstream is heavily dependent upon previous sensitization. we are continuing this work to examine the specificity of observed increases in trans-mesothelial transport and to address transport of allergens after intragastric challenge. | iga to cow's milk differs between breast milk and serum for its epitope specificity objectives: we sought to assess whether the profile of epitopespecific iga differs between mother's serum and bm. we also examined how infants' food epitope-specific iga develops in early infancy and the relationship of iga epitope recognition with development of cow's milk allergy (cma). results: . we measured iga specific to an array of overlapping peptides in major cow's milk allergens (alpha s -, alpha s -, betaand kappa-caseins and beta-lactoglobulin). diversity of peptide-specific iga (ie epitope diversity) was determined in paired maternal and infant sera as well as breast milk samples in mother-infant dyads within the first postpartum months utilizing peptide microarray. microarray data was converted to z-scores and filtered for noise. peptide epitopes were determined based on jaccard distance between neighboring peptides, and intra individual correlation between sample types was estimated using phi coefficient. comparisons between groups and individuals was done using non-parametric tests. we noted marked discordance in epitope recognition in paired breast milk and maternal serum samples. at least one shared epitope was recognized by both milk and serum samples ranging from % of mothers for alpha-s casein to % for kappa-casein. epitopespecific iga was detectable in infants' sera starting at less than months of age. sera of mothers with a cma infant had increased binding of epitope-specific iga to cow's milk proteins compared to those with a non-cma infant (p<. for all five proteins). conclusions: these findings support the concept that mothers' milk represents a product of the mucosal immune system that has an antibody repertoire distinct from that of peripheral blood. results: multiple ige-binding proteins were detected in the different wn preparations and many of which were dissemblance in dblotting. profiles of detectable proteins (peptides) of raw, roasted and boiled wn extracts were profoundly different in emi analysis. introduction: consumption of tree nuts is on the rise due to their beneficial health effects. however, tree nuts can led to severe allergic reactions in sensitized patients. thermal processing can modify the structure and function of food proteins and may alter (increase or decrease) their allergenic properties. knowledge about the effects of thermal processing on tree nuts such as cashew or pistachio is rare and based on traditional in vitro immunoassays. objectives: to elucidate the influence of thermal treatments (boiling and heat / pressure) on the ige reactivity of cashew and pistachio proteins, by means of traditional in vitro immunoassays and mediator release assays (mra). results: the allergenicity of untreated and treated cashew and pistachio nuts was evaluated by ige-elisa, ige-immunoblot and elisa inhibition assays using sera from spanish patients with clinical allergy to cashew and pistachio. rat basophilic leukaemia cell line transfected with the a-chain from the human high-affinity ige receptor fceri, was sensitized with a pooled sera and used for mra. sensitized cells were stimulated with untreated and treated protein extracts, in order to investigate the capability of untreated and treated cashew and pistachio proteins to cross-link ige on effector cells. the results showed that heat and pressure treatment at the harshest conditions considered in this study produced a higher decrease of the ige-binding capacity of cashew and pistachio proteins than boiling without pressure or soft conditions of heat and pressure. interestingly, although the treatments of heat and pressure seemed to affect cashew allergens to a greater extent than pistachio allergens (evaluated by ige-elisa and elisa inhibition), the results of mra using the cell line rbl- indicated that cashew proteins treated with heat and pressure, still retained some capacity to cross-link ige. introduction: previous research has indicated an important role for dietary non-digestible oligosaccharides in decreasing the incidence of atopic dermatitis in children at risk of allergy. it is assumed that these prebiotics promote colonization of beneficial bacteria in the gut. children with atopic dermatitis receiving a diet of galacto-and long chain fructo-oligosaccharides (scgos/lcfos) with bifidobacterium breve m- v had enhanced serum galectin- levels. galectin- has ige-binding capacities and can hereby suppress degranulation of mast cells and basophils. next to their function in the gut, oligosaccharides may also affect other immune cells directly, since they were found in plasma and urine. objectives: we investigated whether non-digestible oligosaccharides or galectin- can have a direct effect on immune cells, by determining the effect on basophil degranulation in peanut-allergic patients. whole heparinized blood samples were collected from peanut-allergic adult patients and incubated for hours with either a mixture of . % : scgos/lcfos or scfos/lcfos, or galectin- ( or lg/ml) at °c in the presence of il- ( . ng/ml). after hours, a basophil activation test (bat) was performed. basophils were stimulated for minutes at °c with increasing concentrations of whole roasted peanut extract or human anti-ige. degranulating basophils were determined as cd + cells and calculated as percentage positive cells. results: in each patient, the concentration of anti-ige or peanut extract that induced maximal degranulation in the untreated control sample was used as reference value to compare degranulation of the samples pretreated with scgos/lcfos, scfos/lcfos, or galectin- . pre-treatment of whole blood with scgos/lcfos resulted in an average decrease in degranulation of approximately %, while a significant reduction of % was observed after pre-treatment with scfos/lcfos (p<. ). pre-treatment with lg/ml galectin- decreased basophil degranulation with %, whereas lg/ml galectin- caused a significant decrease of % (p<. ). no differences were observed in the ec , indicating that the basophils are not becoming less sensitive to the peanut extract or anti-ige. the prebiotic mixture scfos/lcfos and galectin- can contribute to decreased degranulation of basophils in a igemediated bat assay using whole blood. further analysis is warranted to define the exact working mechanism of these oligosaccharides. introduction: the intestinal mucosa plays a key role in the development of food allergies. we studied the interaction between intestinal epithelial cells (iecs) and pbmcs of peanut-allergic patients in a transwell co-culture model. exposure of iecs to a mixture of galacto-and/or long chain fructo-oligosaccharides (scgos/lcfos) in combination with synthetic cpg dna (tlr ligand),modulated the cytokine response of activated pbmcs, driving away from the allergic phenotype. objectives: our aim was to compare the efficacy of scgos/lcfos with a scfos/lcfos mixture and to evaluate these effects in an allergen-specific co-culture model. iecs (ht- , human colon adenocarcinoma) were grown on transwell filters until confluence. iecs were apically exposed to . % : scgos/lcfos or scfos/lcfos either or not in combination with . lmol l À cpg dna to mimic presence of dna of beneficial bacterial in the gut. these iecs were co-cultured with basolateral pbmcs from peanut-allergic patients, either activated with anti-cd /cd ( hours) or peanut-extract (pe, days).cytokines ifn-c, il- , il- and tnf-a were measured in the basolateral supernatant and t-cell polarization of the pbmcs was determined (th , th , treg and tfh). results: apical exposure of iecs to cpg dna increased basolateral ifn-c and il- production by anti-cd /cd activated pbmcs (p<. ), and was enhanced by both oligosaccharide mixtures (p<. ). cpg exposure in transwells with pe stimulated pbmcs also increased ifn-c and il- production, which was further enhanced by scfos/lcfos (p<. ). in this pe-specific model, percentages of th and treg cells increased upon cpg exposure of iecs, and th frequency was increased by scfos/lcfos (p<. ). cpg dna exposed iecs suppressed il- and tnf-a production by anti-cd / cd activated pbmcs. both scgos/lcfos and scfos/lcfos reduced tnf-a production in combination with cpg dna (p<. ). tfh cells can produce il- , inhibiting class-switching to ige . upon cpg exposure of iecs, we observed an increase in tfh cells (p<. ) and similar tendency for cd + il- + cell frequency in anti-cd / cd activated pbmcs. conclusions: epithelial exposure to both scgos/lcfos and scfos/lcfos enhances the cpg dna induced th and regulatory il- response in an anti-cd /cd co-culture model, whereas only scfos/lcfos was effective in an peanut-specific co-culture model. introduction: in areas of spain with high level of grass pollen exposure, % of grass allergic patients were sensitized to profilin, and most of them developed severe profilin mediated food reactions. this specific population of patients constitute an ideal model to study the relation among respiratory and food allergy objectives: our aim here was to analyze the links between epithelial barrier integrity and inflammation in oral mucosa. methods: allergic patients and controls were included in the study. allergic patients were stratified into mild or severe according to their clinical history and response to profilin oral challenge test. immunohistochemistry (ihc) for cd c, cd , cd , claudin- ; and dapi nuclear staining were performed in formalin-fixed, paraffin embedded sections of oral mucosa biopsies. rt-pcr was performed to analyze il b and il gene expression and the number of circulating cd + cells in pbmc was measured by flow cytometry. additionally, basophil activation test was carried out in whole blood samples upon profilin stimulation and the ec was calculated. results: regarding epithelial barrier integrity, claudin- expression resulted inversely proportional to pollen-associated food allergy severity. furthermore, by dapi staining, we noticed a lower number of epithelial cells in allergic patients than in non-allergic, and the gene expression of il b and il resulted significantly increased in oral mucosa from severe group. as for immune response in oral mucosa, the number of cd c and cd + cells resulted significantly higher in severe group. in allergic patients, double ihc for cd c-cd showed an increase colocalization of t cells and apcs in the interface between epithelium and connective tissue. a decrease in blood circulating cd + cells was detected in allergic patients compared to non-allergic. as for the basophil sensitivity, ec in severe patients was -times lower than in mild. our results show that damage in oral mucosa epithelium, probably induced by high grass pollen exposure, might allow profilin to penetrate inside oral mucosa and induce inflammation with local recruitment of immune cells. furthermore, analyzing the immune response developed by effector cells, basophils from severe group result more sensitive to profilin as they react to a lower allergen concentration. these data explain the differences in food allergy severity between mild and severe group and propose oral mucosa as a new sensitization route. introduction: th cells producing the hallmark cytokines il- , il- and il- have been found to constitute the majority of the allergen-specific th cell responses in allergic diseases. subpopulations of the th responses have been described with an early primed th subtype characterized by production of il- and il- , and a highly differentiated th subtype, which in addition produce at least il- . objectives: we aimed to investigate the polarity of tree nut and peanut allergen-specific th cells in subjects with confirmed tolerance or allergy to multiple nuts, and hereby detect differences in allergenspecific th cell responses within the same study population. we also wanted to stress the question whether a th phenotype dominates in asymptomatic sensitization. methods: pbmcs from donors all assessed for clinical reactivity to hazelnut, walnut, cashew nut, pistachio nut and peanut was stained with cfse and stimulated ( cells/ml) with and without whole nut extracts ( - lg/ml) for days. allergen-specific cd + t cell phenotypes and cytokine release was analyzed with flow cytometry and luminex, respectively. the allergen-specific th cells of the allergic donors showed a trend of more highly differentiated il- +il- + th cells and higher abstracts | release of il- than in the tolerant donors. unexpected, except in the cashew nut stimulated cells, no difference was found in the relative percentage of the less differentiated th cells (single il- + allergen-specific cd + t cells) when comparing allergic with tolerant donors. when subdividing the tolerant donors into asymptomatically sensitized or ige-negative (< . kua/l), increased frequency of highly differentiated il- +il- + allergen-specific th cells were found in asymptomatically sensitized compared to tolerant-ige-negative donors. interestingly, a positive association of the allergen-specific ige level and the frequencies of allergen-specific il- +il- + and il- + th cells were found in hazelnut, pistachio nut and cashew nut but not in walnut and peanut allergic subjects. conclusions: an overrepresentation of allergen-specific highly differentiated il- +il- + th cells and an elevated il- production were observed in allergic subjects compared to subjects that tolerated the nuts. we furthermore found a trend that subjects asymptomatically sensitized to nuts differed from tolerant-ige-negative subjects by having relatively more highly differentiated il- +il- + allergen-specific th cells. introduction: it remains largely unknown which features of food proteins that render them allergenic vs tolerogenic. however, it has been suggested that the protein-chemical features affects protein uptake in the intestine, and that protein uptake route may impact on the risk of sensitisation. objectives: the aim of this study was to investigate the interplay between protein-chemical characteristics, the allergenic vs tolerogenic properties and the intestinal uptake of two protein products. the allergenic vs tolerogenic capacity of a heat-treated whey product, consisting of partly denatured and aggregated proteins, was compared to an unmodified whey product in: ( ) results: though this study showed that both unmodified and heattreated whey had immunogenic, sensitising and eliciting capacities as well as tolerance inducing capacity, significant differences between the two products were observed. the heat-treated product was found to have a lower allergenicity combined with high tolerogenicity compared to the unmodified product. competitive igg elisas indicated that heat-treatment of whey induced de novo epitopes while the original epitopes were maintained. newly established methods to study in vivo intestinal uptake were successfully applied to compare the uptake kinetics of the two products in different small intestinal tissues and serum. collectively the in vivo and in vitro uptake experiments suggested that uptake kinetics and the major intestinal uptake route differed between the heattreated and unmodified product. conclusions: this study showed that heat-treatment, which induces partly protein denaturation and aggregation, changes the immunological properties and intestinal uptake of a whey protein product. the heat-treated product was found to have a lower allergenicity combined with high tolerogenicity compared to the unmodified product, which highlights this products promising potential for induction of cow's milk tolerance. objectives: in this study, we enumerated tregs in esophageal tissue of patient with eoe, gerd and normal controls. ten patients with eoe, patients with gastroesophageal reflux disease (gerd), and patients with normal endoscopy and normal esophageal tissue were included. tregs were enumerated in paraffin embedded esophageal biopsy blocks, using immunohistochemistry assay. tregs were identified as foxp +, cd + cells. results: tregs were counted in high power fields (hpf, ) for patients and the average of hpf was recorded. the number of tregs in esophageal tissue of patient with eoe (mean . cells/ hpf) was significantly more than gerd(mean . cells/hpf) and control groups(mean . cells/hpf) (p value <. ). conclusions: there is an increase in number of regulatory t cells in esophagus of patients with eoe in comparison to gerd and control groups. the presence of these cells might be due to eosinophilic inflammation and help controlling the inflammation. objectives: to evaluate whether anti-cd (daratumumab) treatment results in a reduction of total and specific ige levels. results: samples from patients with relapsed/refractory multiple myeloma, treated with daratumumab monotherapy or daratumumab plus lenalidomide-dexamethasone in the umc utrecht between april and august , were tested for total ige levels as well as presence of specific ige against common inhalant allergens. in patients with detectable ige at baseline, the total and specific ige levels were evaluated during treatment up to weeks. of eight patients receiving treatment, four had detectable ige levels at baseline. one patient demonstrated sensitization to common inhalant allergens. for this patient, levels of total ige gradually decreased during weeks of treatment (from to ku/l; %), as well as specific ige against timothy grass ( . - . ku/l; %) and house dust mite ( . - . ku/l; %). a second patient, not sensitized to common inhalant allergens but with ige levels of ku/l at baseline, also demonstrated a decrease in ige levels, to ku/l ( %). the last two patients had total ige levels < ku/l at baseline, which dropped below detection limit after eight weeks of treatment. conclusions: this proof of concept demonstrates that (specific) ige depletion occurred during treatment with anti-cd (daratumumab). anti-cd could potentially play a role in the management of severe ige-mediated diseases. objectives: following individual and assessment, patients established and stable on omalizumab have been commenced on home therapy. training and education in self-administration has been provided. a service assessment has been carried out to review the ongoing safety, quality and patient experience of the service. results: to date, over doses of omalizumab have been self administered in the community with no adverse events or incidents related to home therapy. conclusions: self-administration of omalizumab at home by patients offers the potential to improve quality of life while also providing efficiency savings. introduction: chronic idiopathic/spontaneous urticaria (csu) is a chronic urticarial subtype, defined as itchy hives that last for at least weeks, with or without angioedema, and that have no apparent external trigger. although csu is more frequent in adult populationup to . %- %-, it can affect children and generally has a prolonged duration and has a detrimental effect on patients' quality of life. before the fda and ema approval of the anti-ige monoclonal therapy omalizumab for adults and children years and above, nonsedating h -antihistamines were the only agents licensed for use in patients with csu. however, a majority of patients did not respond to these drugs, even when they were administered at three to four times their licensed dose. objectives: we present pediatric patients (≥ years old) with csu non-responding to antihistamines, treated with omalizumab. results: at the diagnosis of csu, the patients were , , years old, respectively. a trial with non-sedating h -antihistamines, administered up to three to four times their licensed dose, were performed for all patients, without clinical efficacy. omalizumab was started at , , years, respectively. before anti-ige therapy, the urticaria activity score (uas) was , , respectively, indicating poor symptom control. omalizumab therapy was administered every weeks for months at the dosage of mg s.c. after month of therapy, all patients were symptom free with uas ; the patients remained asymptomatic for all the months of duration of monoclonal therapy and antihistamines were discontinued. by now, after , , months respectively from discontinuation of omalizumab, all patients are asymptomatic with uas . introduction: mepolizumab is a humanized monoclonal antibody directed against il- , and is licensed for the treatment of severe asthma in patients aged > years (eu only adults) with an eosinophilic phenotype as an add-on treatment. we were interested to know whether the substance has an antiallergic effect, too. objectives: here, we report the case of a year old man (non- results: in march he was switched from omalizumab to mepolizumab ( mg/month) weeks after the last omalizumab because of two asthma exacerbations under omalizumab in the last months and eosinophils/ll blood under mg prednisolone/day. after two injections of mepolizumab his fev increased from % to % pred., the act from to points, feno decreased from to ppb and the amount of prednisolone from mg to mg/day. but -the patient reported new nasal symptoms after the nd injection of mepolizumab, mainly blocked nose which has not been observed under omalizumab. he agreed to be challenged in the mobile gae²len exposure chamber* with house dust mite allergen for min. the total symptom score increased from to points after min exposure time remaining stable till the end, the positive nasal inspiratory flow decreased from to l after min and l after min, the fev decreased from % to % pred. following the inhalation of salbutamol the fev reversed. conclusions: mepolizumab has an anti-asthmatic effect but the anti-allergic efficacy seems to be small or absent. methods: all patients treated with omalizumab for severe allergic asthma or chronic spontaneous urticaria at the department of respiratory medicine and allergy at aarhus university hospital (n= ) were grouped after their home municipality. the number of omalizumab treated patients/inhabitant in these municipalities was correlated to the distance to the treatment centre at aarhus university hospital. results: mean distance to the treatment centre was . km for all inhabitants in the central region, while patients treated with omalizumab lived in average . km away. we found a negative linear correlation between the number of patients treated with omalizumab/inhabitant and the distance from the municipality to the treatment centre (slope: À . %ci: À . to À . ), p=. , n= ). conclusions: patients living at long distance from the treatment centre are less likely to be offered omalizumab treatment for severe allergic asthma or chronic spontaneous urticaria. objectives: demographics, clinical characteristics, and response to mepolizumab, were evaluated for atopic and non-atopic subgroups. sensitization to any one of the following; house dust mite, dog dander, cat dander, alternaria, or cockroach was considered as atopic, as assessed by specific serum ige of ≥ . ku/l. mensa (nct ) was a gsk sponsored study. results: of the severe asthma patients, ( %) were considered atopic, ( %) were considered non-atopic and atopic status was missing for ( %) patients. the majority of atopic patients (n= ) were sensitized to ≥ antigens. compared to the non-atopic sub-group the atopic sub-group was younger with a mean age of vs years of age, had a longer mean duration of asthma ( . vs . years), and a higher total baseline ige level ( u/ml vs u/ml). mean number of exacerbations in the months prior to the study was similar in the atopic and non-atopic subgroups ( . vs . ) as was the mean baseline peripheral blood eosinophil level ( cells/ll vs cells/ll). with mepolizumab an % reduction in eosinophils was achieved by week irrespective of atopic status and maintained throughout the treatment period. mepolizumab reduced the rate of exacerbations relative to placebo by % in the atopic subgroup and by % in the non-atopic subgroup. conclusions: the mensa study recruited an equivalent portion of atopic and non-atopic severe asthma patients. the atopic population was younger and had a longer duration of asthma than the non-atopic subgroup. while the baseline total ige level was > times greater in the atopic subgroup, the pharmacodynamic and efficacy response to mepolizumab treatment was similar. introduction: a treatment goal in the management of oral corticosteroid (ocs) dependent severe asthma is to reduce daily ocs use due to the side effects associated with long term use. anti ige treatment is used in atopic patients to reduce daily ocs. this analysis characterizes ocs reduction and asthma control in the sub-set of atopic and non-atopic ocs-dependent severe eosinophilic asthma (sea) patients from the -week sirius ocs reduction study. objectives: sirius study participants (n= ) were sub-grouped by atopic status in a post-hoc analysis; demographics, clinical characteristics, and response to mepolizumab were evaluated. sensitization to any one of the following; house dust mite, dog dander, cat dander, alternaria, or cockroach was considered as atopic, as assessed by specific serum ige of ≥ . ku/l. sirius (nct ) was a gsk sponsored study. results: of the ocs-dependent sea patients, ( %) were considered atopic ( % female), ( %) were considered non-atopic ( % female), atopic status was missing for patients ( %). compared to the non-atopic sub-group, the atopic sub-group was younger; mean age of vs years of age, while the mean duration of asthma was the same irrespective of atopic status ( years). the mean ocs daily dose and acq- score at baseline were similar between subgroups ( . mg vs . mg and . vs . , in the atopic and non-atopic subgroups respectively). the mean baseline peripheral blood eosinophil level was comparable in both subgroups ( cells/ll vs cells/ll) while the total ige level was higher in the atopic subgroup ( u/ml vs u/ml). mepolizumab lead to a ≥ % reduction in eosinophils by week irrespective of atopic status and eosinophil reduction was maintained throughout the study. mepolizumab reduced the ocs dose in the atopic group and non-atopic subgroups (odds ratio of a greater ocs reduction category of . ( % ci . , . ) and . ( % ci . , . ), respectively) and led to improvement in asthma control with a change in acq- of À . ( % ci À . , . ) in the atopic subgroup and À . ( % ci À . , . ) in the non-atopic subgroup. in an ocs dependent sea population mepolizumab reduced eosinophils independent of ige level and atopic status. in this limited post-hoc analysis, mepolizumab was an effective ocs sparing agent while improving asthma control in both atopic and non-atopic patients. patients who responded to retreatment had a similar mean time to response between the st dosing period ( . weeks) and nd dosing period ( . weeks). of all patients who were retreated (n= ), symptom control (uas ≤ ) after two doses was achieved in % ( st period) and % ( nd period) of patients; complete response (uas = ) occurred in % ( st period) and % ( nd period) of these patients. omalizumab was well-tolerated during both dosing periods. conclusions: omalizumab retreatment is safe and effective in patients with ciu/csu who respond to initial treatment and relapse after withdrawal, with most patients regaining symptom control after a nd course of omalizumab. : total ige reactivity of the grass allergoid formulation was diminished compared with native unmodified extracts. a difference in igg profiles was observed and indicated enhancement of accessible reactive igg epitopes across size distribution profiles of the grass allergoid formulation. detailed analysis of the epitope specificity showed retention of six lol p igg binding epitopes in the grass modified extract. all epitopes were mapped on the solvent exposed area of lol p homology model accessible for igg binding. one of the epitopes was identified as an "immunodominant" lol p igg binding epitope ( -ifkdgrgcgscfeik- ) and classified as a novel epitope. lastly, lol p igg antibodies showed functional capacity to block up to % of ige binding sites which provides evidence in protective function of immunotherapy induced antibodies against native allergens. the structural and immunological changes which take place following the grass allergen modification process were further unravelled revealing distinct igg immunological profiles. the results from this study support the concept that modification not only enhances the safety profile of scit but allows shorter-course objectives: design targeted sirna delivery system into liver cells. results: liposome surface was modified by lactose derivatives with different structures: lac(c ) and (lac) lac(c ) . the basic physicochemical and biological properties of the carriers have been examined. it is shown that glycoconjugate introduction has no effect on the physico-chemical characteristics. however the carbohydrate modification of the liposomal surface leads to increasing in transfection efficiency on a specific cell line hepg . moreover, the introduction of mono-carbohydrate derivative increases the transfection efficiency better than using a branched derivative of lactose. in the pharmacokinetic study target effect also was shown. unmodified liposomes start to be detected in the liver at minutes after administration, whereas modified liposomes were detected at minutes after administration. similarly, the excretion of modified liposomes from the liver was more slowly. also worth noting the high concentration of modified liposomes in the liver. furthermore liposomes modified by carbohydrates reduces the intensity of its accumulation in the lung. conclusions: it was shown that increasing attraction of drugs to the liver cells can be achieved by using liposome modification with lactose derivative. | sialylated fetuin-a is a candidate predictive biomarker for successful grass pollen allergen immunotherapy objectives: to identify new biomarkers of ait efficacy, pre-treatment sera obtained from grass pollen allergic patients responding or not to sublingual ait were differentially assessed by d-dige or label-free mass spectrometry. the role of fetuin-a in allergy physiopathology was studied by using gene silencing in a mouse asthma model, human dendritic cell stimulation assays and surface plasmon resonance. results: using comparative proteomics, we provide evidence for an increased o-linked sialylation of fetuin-a in sera collected before treatment from patients exhibiting clinical responses, when compared with low responders. whereas feta may either inhibit or promote chronic inflammation, no specific role in allergy had been ascribed to it until now. in ovalbumin-sensitized mice, silencing of the fetuin-a gene increased airway hyperresponsiveness and th responses. fetuin-a, but not its non sialytated counterpart, synergizes with lps and grass pollen or mite allergens in a tlr -dependent pathway to enhance the proallergic profile of human monocyte-derived dendritic cells. conclusions: quantification of sialylated fetuin-a glycoforms in the blood before treatment allows to identify patients more likely to benefit from grass pollen immunotherapy. validation of the hypothesis that this marker associated with "an inflammation status" can be used to predict ait efficacy is ongoing in larger cohorts of patients. introduction: kawasaki disease (kd) is a vasculitis that mainly affects small to medium-sized vessels, particularly the coronary arteries, and is a leading cause of acquired heart disease in children. previously, we found that the development of kd is associated with an elevation of both th and th immunity. gene hypomethylation is abstracts | an important form of epigenetic regulation, which results in increased gene expression. because m macrophages are associated with inflammation and th immunity while m macrophages are associated with immune regulation and th immunity, we hypothesize that kd is associated with hypomethylation of both m and m macrophage related genes. objectives: our objective was to investigate the methylation profile of m and m related genes in patients with kawasaki disease. twenty-four patients with kd and age-matched healthy controls (hc) were included in this study. in patients with kd, blood was sampled hours before ivig therapy (kd ) and days after ivig therapy (kd ). after dna extraction, samples were analyzed using human methylation bead chip (illumina) to examine the methylation ratios of genes related to m macrophages ( genes, cpg sites) and m macrophages ( genes, cpg sites). cpg sites with more than % difference in methylation levels and a pvalue less than . between groups were considered significant. objectives: primary aim of the study is the identification of differentially expressed genes (deg) associated with allergic rhinitis (ar) by using genome-wide transcriptomics data from blood immune cells. this set of candidate genes will then be used to define gene networks relevant for onset, severity and potential treatment outcome of house dust mite associated ar. with different ethnicity or populations exposed to a different environment is currently in preparation. introduction: allergic patients display abnormal immune responses to harmless antigens, leading to various symptoms from hay fever to life-threatening conditions. these responses include abnormal type immunity polarization and induction of allergen-specific memory t and b cells, resulting in development of allergy instead of immune tolerance. allergen-specific immunotherapy (ait) is currently the only causative treatment of allergic disorders. yet, in depth understanding of the underlying differences in allergen-specific cd + t cell and treg responses between allergy and tolerance and their changes during immunotherapy is lacking. objectives: we investigated whole-genome transcriptomics of circulating birch (bet v ) and grass (phl p a)-specific cd + t cells in allergic patients before and at , , and months of ait, as well in non-allergic healthy controls in corresponding seasonal time points. detailed immunophenotyping with flow cytometry and cd + mhc class ii tetramer staining with low rna/single cell next generation sequencing were performed. results: at baseline, out of the pollen season, there were more allergen-specific cd + t cells in allergic patients than in controls. at this time, over genes were significantly changed in allergenspecific as compared to total cd +t cells in patients, yet we found substantial differences in signal transduction and inflammatory response gene expression when compared to healthy controls. during ait we noted significant increase of allergen-specific cd + cells in patients with subsequent gene expression changes in the immune tolerance pathways. finally, we found increase in allergen-specific treg cells in patients upon ait, but not in tolerant controls in corresponding seasons. of interest yet, at early ait time points, allergenspecific treg cells displayed gene profiles suggesting their insufficient suppressive functions. conclusions: in summary, in vivo allergen exposure causes profound changes in the transcriptomic profiles of allergen-specific t cells. these gene profiles seem to be deficient at baseline in allergic patients, but ait is skewing them into the tolerant controls levels. introduction: the variability of the pharmacological response to beta (b )-agonists may be due to the polymorphism of the gene of results: singled out statistically significant differences of the genotype distribution. the gly/gly homozygous allele was discovered twice as often in the group with an insufficient response to b -agonists than in the group with a good response ( vs %, p<. ), while the distribution of heterozygous allele was detected the opposite pattern ( vs %, p<. ). in the arg/arg genotype distribution, there were no considerable differences in both groups ( % in each group). in the subgroups of children, receiving the high doses of the inhaled glucocorticoids, there was a trend for the prevalence of gly/gly homozygous allele prevalence. we have discovered the association of the gly/ gly genotype of the adrb gene with an insufficient effect of broncholytic therapy by means of short-term b -agonists; we also revealed the participation of the gly allele in the phenotype formation with the severe run of bronchial asthma and tolerance towards the therapy both by b -agonists and inhaled glucocorticoids. mckenna oe ; posselt g ; lackner p ; schmitt a ; h€ ollbacher b ; briza p ; wessler s ; gadermaier g ; ferreira f universit€ at salzburg, salzburg, austria; georg august-universit€ at g€ ottingen, g€ ottingen, germany introduction: an excess of million people worldwide have a reported allergy to birch pollen. proteases in such allergen sources have been suggested to contribute to primary sensitisation and exacerbation of allergic disorders. until now the protease content of betula pendula, a species endemic to the northern hemisphere, has not been studied in detail. hence, we aim to identify and characterise pollen and bacterial derived proteases found within betula pendula pollen. objectives: birch pollen transcriptome was constructed via de novo transcriptome sequencing. reads were assembled using the trinity software suite.. analysis of the birch pollen proteome was achieved via mass spectrometry and use of zymographic gels with the embedded substrates gelatinase and casein, which enabled visualisation of proteolytic activity. further to this, protease activity was quantified using a fluorescently labelled casein substrate protease assay. results: by using mass spectrometry, we were able to identify up to proteases within birch pollen. we could cluster the proteases into specific families based on their distinct proteolytic activities. further comparative analysis of the proteome and transcriptome revealed the relationship between transcript levels and the proteins they encode. zymographic methods enabled distinct visualisation of proteolytic activity for both casein and gelatin substrates. using fluorescently labelled casein, the birch pollen protease activity was quantified as . lg/ml when compared to a trypsin standard curve. additionally, bacterial isolates of the birch pollen were identified, and the proteolytic activity analysed. we report successful discovery of pollen and bacterial derived proteases endogenous to betula pendula. whilst none of the known birch pollen allergens have been recognised as a protease, we aim to investigate the role of tight junction degradation within epithelial cells and further enhance understanding of proteolytic activity on immune-polarization. objectives: to investigate the frequency and reasons of shortand long-term reintroduction failure in adults after a negative fc. method:: these are preliminary results of an ongoing prospective study. after a negative fc, patients receive standardized aftercare consisting of an introduction scheme to introduce the food at home and consultation by phone for advice and support hours, - weeks and months after the fc. short-term data about the frequency that patients failed introduction, defined as not completing the introduction scheme or patient-reported allergic complaints repeatedly during introduction, was obtained using a telephone interview. long-term data ( - months after negative fc) about frequency and reasons of reintroduction failure in daily diet, defined as not eating the food or only eating products with traces of the food, was obtained using a patient-reported questionnaire. results: from until now patients were included (mean age: years, male: %), who underwent a total of fcs with: hazelnut ( %), other nuts ( %), fruit ( %), composite meals ( %), fish and crustaceans ( %), cow's milk ( %), hen's egg ( %) and other ( %). in ( %) of the negative fcs, introduction using an introduction scheme was advised. in %, patients did not receive standardized aftercare for different reasons, eg negative fc with a composite meal. in %, introduction with an introduction scheme failed. long-term information was available for fcs. introduction failed in fcs ( %), including patient that even avoided traces of the food. patient-reported reasons for introduction failure were (n= ): symptoms after ingestion of the food (n= ), fear for allergic reactions (n= ) and not like the taste of the food (n= ). conclusions: short term introduction with an introduction scheme failed in %. however on the long-term in almost one third of the negative fcs, patients failed to reintroduce the food in daily diet, despite careful aftercare. it is recommended to give these patient even more intensive and tailored support. introduction: in order to help allergic patients manage often severe symptoms, food manufacturers are required to list allergens on labels and take precautions to avoid inadvertent contamination of foods with allergens. existing tools using generic immunoassays do not provide precise identification or quantification of specific food allergens. furthermore, existing elisa immunoassays are not able to be run simultaneously and are often unreliable. objectives: our goal was to develop and validate an accurate, sensitive and high throughput immunoassay that would enable simultaneous quantification of multiple allergens in foods. fluorescent beads coupled to allergen specific monoclonal antibodies were used to develop a multiplex array for simultaneous quantification of major allergens from peanut (ara h ), milk (bos d ), egg (gal d ), and shrimp tropomyosin (pen a ). target allergens were detected using biotinylated antibodies and streptavidin conjugated fluorochrome. the array was quantified using highly purified natural allergens as standards. allergen content was measured in various samples including samples spiked with purified allergen and allergen incurred food matrices. the results were compared to elisa. a multi laboratory validation was performed to validate the performance characteristics of the assay. results: there was a high correlation between the multiplex array and allergen specific elisa. the limit of detection of the array was as low as pg/ml. no significant cross reactivity was observed between the various food allergen assays. the recovery of allergen from spiked samples was generally between and %. inter and intra assay variability was observed to be less than %. in conclusion, an accurate, sensitive and reliable multiplex array for major food allergens was developed and validated. the flexibility of the microsphere technology allows for further expansion to produce a comprehensive array for the most important food allergens. this quantitative multiplex array may help to reduce the risk of inadvertent contamination of food. objectives: our aim was to create a food allergy web-based educational program for both schools and restaurants professionals. results: an interactive platform that hosts a free learning program, conclusions: the program and the toolkit are currently available online and are being implemented in schools at the north of portugal. we expect that fac program will give us an important insight on the professionals' knowledge about food allergy. additionally, acting as free integrated service and awareness effort, this program could be an educational tool easily adapted and disseminated, which may improve professionals 'commitment and skills to deal with food allergy in the community. | development of parallel reaction monitoring (prm) methods for soy and milk detection: consideration of allergen-derived ingredients chen s ; krawitzky m ; yang ct ; downs m university of nebraska-lincoln, lincoln, united states; thermo fisher scientific, san jose, united states introduction: the presence of undeclared food allergens poses both regulatory and health risks. in order to assess the magnitude of these risks, accurate quantitative detection methods are required. for some allergenic foods, the food industry uses not only the allergenic source but also a number of source-derived ingredients. some detection methods (both immunoassays and mass spectrometry methods) may fail to accurately detect and quantify these allergen-derived ingredients if they are not taken into consideration during development. objectives: the objective of this work was to select peptide targets for parallel reaction monitoring (prm) mass spectrometry methods that are suitable for detecting a variety of soy-and milk-derived ingredients. six soy-derived and six milk-derived ingredients were obtained for this study. the ingredients were extracted ( mmol l À tris-hcl, ph . , with mol l À urea, mmol l À dtt, and % pvpp) and subjected to in solution trypsin digestion. discovery proteomics analysis was conducted by lc-ms/ms using a q exactive tm plus orbitrap tm running in top data-dependent acquisition mode. peptides were identified using proteome discoverer . and relative, labelfree quantification was conducted on high-confidence (fdr< . ) peptides. selected peptides were subsequently analyzed in a targeted prm mode. results: the relative abundance of identified peptides varied among both the soy-derived and milk-derived ingredients. in the case of soy ingredients, for example, there were particularly marked decreases in the abundances of numerous peptides, across different proteins, in a hydrolyzed soy protein isolate. in the milk ingredients, variation in peptide abundance could be more directly attributed to differences in product protein fractionation (eg a decrease in abundance of whey proteins in a sodium caseinate product), although some peptides and proteins maintained consistent abundance across ingredients. after applying specificity and performance criteria, peptides from soy proteins and peptides from milk proteins were selected for further analysis in a targeted prm method. conclusions: peptide abundances vary widely among ingredients derived from allergenic foods. consideration of these peptide differences during ms method development by incorporating discovery proteomics may lead to more versatile and widely-applicable quantitative detection methods for food allergens. introduction: milk and its derivates are usual ingredients in many food products, which must be excluded by cow's milk allergic (cma) patients. oit protocols in patients with cma appear to be safe and effective in inducing desensitization and milk introduction in the diet. objectives: we conducted a survey in cma patients after successful completion of an oit programme, to assess their dietetic profile after introduction of fresh milk and dairy products (unrestricted diet) we considered cma patients (pts), males and females, age - (median . ), who successfully completed the oit protocol. these patients were on an unrestricted diet for milk and derivates, and they had been recommended to assume at least ml of fresh milk or yogurt every day. patients were given an ad hoc questionnaire to assess the milk/dairy products intake at least months after oit completion. results: from our investigation all of the pts have been assuming milk protein everyday without significant reactions after oit. % of the interviewee ( pts) referred to be drinking fresh milk at least three times a week, in a quantity of ml or higher. of note, % have to add cocoa powder ( pts) or coffee ( pts) to mask milk taste. dislike of milk taste was the cause of the refuse to take fresh milk in pts (over patients that didn't take milk at all); pts who didn't drink milk had at least ml yogurt instead, almost every day. fresh cheese was eaten at least once a week by % of all the pts; hard cheese was eaten as main course almost once a week by %. % of patients consumed biscuits and sweet baked products containing milk/derivates at least once a week, % every day. pizza was also present in the diet of the majority of pts ( %), once a week/month. ice cream was appreciated by all the patients and regularly assumed especially during the summer time. conclusions: taste seems to be the main factor that directs the daily choice of milk derivates or milk containing products. all pts easily consume baked products containing milk/derivates, and the majority of them accept fresh milk as advised in order to maintain unresponsiveness. our survey confirms that oit is effective in expanding food choice, but for some patients the change of dietetic habits is hampered due to taste reasons. a more detailed, qualitative and quantitative analysis of the milkunrestricted diet will derive from the -days food diary given to these patients. | frozen-defrosted dried skimmed milk is a suitable product for sublingual immunotherapy for cow's milk allergy introduction: sublingual immunotherapy (slit) is a promising treatment for cow's milk allergy (cma) due to its favourable safety profile. however, its efficacy is limited-probably due to the small volumes and doses that can be delivered sublingually, especially in children. milk products with preserved allergenicity that allow higher protein concentrations in smaller volumes might potentially improve the efficacy of slit for cma. dried skimmed milk (dsm) could fulfill these characteristics. in addition, once dsm is reconstituted, freezing individual vials from the same batch for further administrations could increase dose-consistency throughout the treatment, which would help ensure safety. however, little is known about whether processing to produce dsm, and further freezing-defrosting, may alter its allergenicity. objectives: to evaluate the allergenic protein composition of dsm, including once frozen-defrosted, in comparison to fully-allergenic usually consumed fresh milk. methods: sodium dodecyl sulfate polyacrylamide gel electrophoresis (sds-page) followed by silver staining was performed following the laemmli method to determine the soluble protein composition of the following products: fresh pasteurized milk (friesland campina, amersfoort, the netherlands), dsm (marvel, the premier foods group ltd, london, uk) and frozen-defrosted dsm to identify all protein bands present. western blot with anti-whey and anti-casein antibodies was performed to identify the specific allergenic proteins. results: no significant differences were found amongst the milk products tested, with sds-page displaying all the bands corresponding to the major allergenic proteins in milk (alpha-lactalbumin, beta-lactoglobulin and alpha-, beta-and kappa-caseins) and the western blot showing recognition to all proteins with similar intensity. the major allergenic proteins present in unprocessed milk are well-preserved in dsm, even after freezing-defrosting, making it a convenient product for sublingual immunotherapy. results: nineteen children were randomized into the low dose group (n= ) and the elimination group (n= ). there were no significant differences in background between these groups. after weeks of therapy, the rate of passing the oral food challenge test with / th of a whole egg was significantly higher in the low dose group ( / ( %) vs / ( %), p=. ). ovomucoid-specific ige levels in the low dose group after weeks were significantly lower than those at baseline. adverse events associated with both therapies did not occur during the study period. conclusions: these results show that low dose ingestion of egg is safe and effective for tolerance or desensitization induction in children with egg allergy, without the need for dose elevation. | another brick in the wall: toward a national food allergy strategy for canada introduction: the world is experiencing an apparent epidemic of food allergies. with rising prevalence and increasing global spread, basic scientists continue to search for causes while clinical and social scientists continue to study the consequences. these include life-long chronic illness, fear and anxiety, social exclusion and stigma, all of which are underscored by inequalities across vulnerable groups (eg, low income families, immigrants, indigenous peoples). concomitantly, consumer organizations and patient support groups attempt to influence policy in order to maximize choice and minimize risk for individuals and families affected by food allergy, both directly and indirectly. this includes food labeling legislation, food safety regulations, and policies and practices in public places such as schools, restaurants and transportation modes (eg, airplanes). objectives: in canada, with the support of + years of science undertaken by the allergy genes and environment (allergen) networks of centre of excellence in allergic disease, we are leading a national team that aims to establish the building blocks for a national food allergy strategy. conclusions: the greatest challenges to building a national food allergy strategy are not those related to the basic or clinical science, but rather the activities and commitment of individual stakeholders. while gaps remain in the science, the challenges of transdisciplinary integrated knowledge translation hinder progress. we present lesions learned regarding culture shifts that will facilitate the progress we need to maximize choice and minimize risk for canadians affected by food allergy. | component resolved diagnostics reduces diet restrictions by half among finnish school children savolainen j ; mascialino b ; pensamo e ; hermansson l ; silvan m ; borres mp ; korhonen k university of turku, turku, finland; department of allergology, uppsala, sweden; thermo fisher scientific-immunodiagnostics, turku, finland; university of turku, uppsala, sweden; thermo fisher scientific-immunodiagnostics, lieto, finland introduction: there are - special diets because of food allergy in finnish schools. the finnish allergy program - was launched to reduce problems and costs induced by allergies. one of the special aims was to reduce diets caused by food allergy will by %. the h€ ark€ atie social and health care service region schools have required doctor's certificates for diets for over abstracts | years. all diets are listed in a register and checked on a regular basis. objectives: the purposes of this study were to evaluate whether it is possible reduce the special diets when the special diet system appears to be working well and to assess the added value of immu-nocap ® isac allergen component diagnostics in the intervention. results: there were children attending the schools in the h€ ark€ atie region. there were children with diet due to food allergy. children were recruited to study from the diet register and contacted by a nurse's phone interview. there were children who refused the study leaving children for the assessment of the diet. children were not following any diet and in children the diet was not regarded necessary by the study nurse. children agreed to take part in the study and were referred to laboratory tests for food specific ige and isac. children dropped out leaving children in the study. after the food specific ige results were available, children were contacted by physician. based on the results and/or interview a free diet was allowed for children. children were eating small amounts of the food and were encouraged to increase the use of the foods. children were advised to avoid the foods only if they caused symptoms. only children were advised to continue diet. after the results of isac were available, children conclusions: the study confirmed that it is possible to have diets decreased over % in accordance to the finnish allergy program. additionally, the study showed that food allergic children can benefit from the use of component resolved diagnostics. | omalizumab treatment for severe food allergy caused by lipid transfer protein: a preliminary case series mari a; zennaro d; ferrara r; bernardi ml; alessandri c caam-centri associati di allergologia molecolare, rome, italy introduction: lipid transfer proteins (ltp) are allergens from plantderived foods causing symptoms ranging from oas to anaphylaxis. ltp are present in almost all kind of plant species used for human feeding. ltp allergic patients suffer of reactions to a broad variety of foods, with a very personal reactivity profile which can involve few or many foods. in addition, patients who start to record severe reaction to several foods begin to be afraid of eating any other related or non-related food, leading to a poor diet. omalizumab (ozm) has been documented to be effective in treating food allergies with sensitization to other allergens. objectives: to document the approach for recruiting, studying, monitoring ltp allergic patients, and do a preliminary evaluation of the clinical impact of ozm therapy. results: six adult patients with documented reactions to plantderived foods in the last months and diagnosed to be ige positive to multiple ltp by using multiplex testing, namely isac at the beginning and faber during the follow up, were recruited. ozm was offered as an off label treatment adopting an open label study design. a questionnaire was submitted to each patient before, during and after the treatment. foods listed as "no more eaten" where considered for reintroduction, starting from those excluded because of fear, going for those with an increasing risk of reactions. re-introduction was done at home after receiving detailed instructions, having all rescue medication at hand. the allergist was connected real time with the patients using one or more ict tools. one patient dropped out because was not complying with the scheduled reintroduction. three patients completed the treatment with a successful re-introduction of all or almost all excluded foods, in two cases peach was reintroduced. the last two patients reintroduced %- % of the excluded foods, including some of those previously causing reactions. the attempt of re-introducing the most risky foods failed causing local allergic reactions promptly controlled by the therapy. all foods re-introduced were tolerated once the treatment was stopped. conclusions: ozm seems to be a promising treatment for severe ltp allergics, improving their qol. starting from the recruitment phase to the re-introduction, the overall procedure looks quite complicated and deserve much resources. ige sensitization to ltp, carefully defined before treatment, can be monitored during the ozm course as the drug doesn't interfere with faber test ige detection. | oral immunotherapy with peach-juice in lipid transfer protein (ltp) allergy: is it possible to reach tolerance? introduction: food allergy to rosaceae fruits and nuts, due to sensitization to lipid-transfer protein (ltp), is frequent in the mediterranean area countries. based on milk allergy oral immunotherapy (oit) protocols, a study is proposed to obtain an oit regimen in patients allergic to ltp. objectives: we included patients with anaphylactic reactions due to ltp-food allergy, from january/ to october/ . skin prick test (spt) was performed with a food and inhalant battery, ltp bial-aristegui ® ( . mg/ml), prick by prick (pbp) with a specific commercial peach-juice (dilutions to endpoint), and determination of pru p ige levels (immunocap). the presence of pru p protein in the peach-juice, was confirmed by sds-page and elisa method, and quantified with anti-pru p . we elaborated an oit guideline with progressive administration of peach-juice, - - - drops ( drops= . ml), sublingually, starting concentration chosen according to the endpoint spt results, up to ml daily dose. the dose reached at the allergy service, was continued at home, daily, for - weeks. all the increasing doses were performed at the allergy service, after pbp with peach-juice and ltp control spt. after a time, an oral challenge up to ml peach-juice was performed. patients were instructed on the importance of maintaining regular intakes and avoiding cofactors. results: patients started this protocol ( male/ female), aged - (media . ). peach-juice analysis in agarose gel electrophoresis, showed a kda band quantified as . lg/ml of ltp. there was no difference between wheal diameter on spt for ltp bial-aristegui ® and pbp with commercial peach-juice along all the study. average concentration on pbp to endpoint: / ( ), / ( ), / ( ). pru p ige level average: . ku/l. none anaphylactic or serious reactions during the oit protocol appeared. only five patients ( %) reported mild occasional symptoms (oral pruritus and mild located urticaria). patients reached ml daily dose ( . %), and of them ( %) completed oral food challenge with peach-juice up to ml, with good tolerance. this pattern also allowed us to reintroduce withdrawn foods from the diet due to previous reactions, with good tolerance. results: children (age - years) sensitized to dog dander extract (median . ku a /l), with or without known dog induced allergic airway disease, were included. nasal provocation testing with dog dander extract was performed. measurement of ige to dog dander extract and to can f -can f was performed with immunocap. an ige level ≥ . ku a /l was considered positive. among all children sensitization to can f ( %) and can f ( %) was most frequent. corresponding numbers for can f , can f , can f and can f were %, %, % and % respectively. based on the results from the nasal challenges three groups were identified; no (n= ), mild (n= ) and strong reaction (n= ). the median ige levels to dog dander and to all allergen molecules were higher in the strong reaction group than in the mild and the no reaction group. among children with a strong reaction, ige to can f was found in % ( / ) compared to % ( / ) among children with no reaction (p=. ). ige to can f showed a similar pattern (p=. ). % ( / ) of the children with a strong reaction were sensitized to can f compared to . % ( / ) of the patients with no reaction (p=. ). no associations were found between the ige levels to can f , can f and can f and the no reaction or strong reaction groups. using multiple regression analysis, with all allergens in the model, sensitization to can f showed a statistically significant difference between the groups. conclusions: molecular allergology may improve diagnostics of dog allergy in children. sensitization to the lipocalin can f was significantly associated to a strong positive nasal reaction implying its usefulness as a marker of clinically relevant dog allergy. tsolakis n ; malinovschi a ; nordvall l ; janson c ; mattson l ; lidholm j ; borres m ; alving k uppsala university, women's and children's health, uppsala, sweden; uppsala university, medical sciences, uppsala, sweden; thermo fisher scientific, uppsala, sweden introduction: cat allergy is common worldwide and a major trigger of asthma in many countries. molecular patterns of cat sensitisation vary between individuals but their relationship with allergic inflammation has not been extensively studied. objectives: the aim was to investigate the prevalence of ige to different cat allergen components and their relationship to type- inflammation and bronchial responsiveness in young asthmatics. conclusions: ige sensitisation to cat serum albumin (fel d ) and cat lipocalins (fel d , fel d ) , but not to secretoglobin (fel d ) or cat dander extract, were independently associated with feno and b-eos count. we suggest that cat serum albumin and cat lipocalins can be used as markers for increased risk of type- inflammation in young asthmatics, as shown in multiple regression analyses. | complete sequence and recombinant production of horse dander allergen equ c lidholm j; lundgren t; larsson h; mattsson l thermo fisher scientific, uppsala, sweden introduction: horse dander is an increasingly important cause of respiratory allergy. equ c was one of the first horse allergens to be recognised but only a small part of its amino acid sequence has been reported. objectives: the aim of this study was to determine the complete sequence of equ c and express it as an immunoreactive recombinant protein. methods: equ c was purified by size exclusion, hydrophobic interaction, anion exchange and reversed phase chromatography. recombinant equ c was expressed as a hexahistidine tagged protein in e. coli and purified by immobilized metal ion affinity and ion exchange chromatography. ige antibody reactivity to natural and recombinant equ c and other horse dander allergens was determined in sera of subjects allergic to horse. results: a putative equ c sequence predicted from genomic data revealed a lipocalin protein of amino acids with a highest sequence identity among known lipocalin allergens of % to can f . n-terminal sequencing and mass spectrometric analysis of purified natural equ c confirmed . % ( / residues) of the predicted sequence. recombinant equ c displayed ige antibody binding activity comparable to that of purified natural equ c (r=. ). of the horse allergic subjects studied, ( %) showed ige antibody binding to equ c , ( %) to equ c , ( %) to equ c and ( %) to equ c . the complete sequence of equ c was established. as a fully immunoreactive recombinant protein, it represents an important addition to the panel of allergens useful in the diagnosis of allergy to horse. | component resolved diagnosis using guinea-pig allergens elucidates allergen sensitization profiles in allergy to furry animals objectives: to identify major guinea-pig allergens and to evaluate their potential as reliable markers for a specific ige-diagnosis in comparison to dander extracts. results: forty-three patients with a clinical history of allergy to guinea-pig and patients allergic to cat and/or dog were recruited for the study. major guinea-pig allergens were identified by ige-immunoblot and n-terminal sequencing of ige-reactive proteins. corresponding cdnas were cloned and allergens were expressed as recombinant proteins in e. coli. specific ige to animal dander, fel d and can f were determined, specific ige to fel d , can f and to guinea-pig allergens were quantified by elisa. two new guinea-pig lipocalin allergens, cav p and cav p , were identified in guineapig dander. the combination of guinea-pig allergens, the new allergens and the previously isolated lipocalins cav p and cav p , enabled the identification of out of patients sensitized to guinea-pig. the vast majority of the patients had specific ige to cav p ( %). cav p shares % sequence identity with fel d and can f and was found to be cross-reactive with these cat and dog allergens. in the group of cat and/or dog allergic patients, % had also specific ige to guinea-pig dander. nearly half of those ( %) had ige to cat serum albumin fel d or to fel d ( %) and to can f ( %), explaining the high degree of cross-reactivity to guinea-pig dander. only % of the cat/dog allergic patients with a positive isle test to guinea-pig dander had specific ige to any of the non crossreactive guinea-pig allergens cav p , cav p or cav p . however, none allergen has been characterized from mongolian oak. objectives: in this study, we tried to characterize a major allergen from mongolian oak. results: a molecule homologous to pathogenesis-related protein , a putative que m , was cloned by rt-pcr and its recombinant protein along with que a , an allergen from white oak (q. alba) was produced. cloned que m sequence shares . %- . % amino acid sequence identity ( . %) with pr- -like allergens from various plants. allergenicity and diagnostic value of recombinant que m abstracts | , que a and bet v proteins were compared by elisa using sera from oak sensitized subjects. specific ige to recombinant que m , que a , and bet v were detected in . %, . %, and . % of serum samples from korean tree pollinosis patients. recombinant que m was able to inhibit ige reactivity to que a and bet v , indicating its strong cross-reactivity. activation pattern of basophils from five patients was similar in terms of cd c expression and protein concentration of challenged bet v and que m . objectives: over the course of one year, all patients who were seen at our immunoallergology clinic for the first time underwent spt with our standard series, to which four olive tree cultivar extracts were added (arbequina, blanqueta, hojiblanca e picual). we then recorded wheal size diameters, considering a wheal > mm to correspond to a positive test. we recorded individual sessions of spts, in which presented at least one positive result. two hundred and thirtysix of these patients ( . %) had a positive spt for olive tree pollen, only one of them being monosensitized. when looking only at pollen-sensitized patients, twenty-two patients ( . %) tested positive solely for olive tree pollen. in all allergic patients, the most frequent cultivar sensitization was to the cultivars hojiblanca ( . %) and arbequina ( . %), followed by the cultivars picual ( . %) and blanqueta ( %). twenty-six patients ( % of all olive pollen sensitizations) had a positive spt for the conventional extract and negative spt for the cultivars; patients ( . %) had a positive spt for both. we noted that . % (n= ) of patients sensitized to olive tree pollen had a negative spt with the conventional extract and positive with one of the cultivar extracts. the cultivar hojiblanca was the most frequent in this group ( . %, n= ), followed by the arbequina cultivar ( . %, n= ). in the group as a whole, there was a positive correlation between the results of the spts with the conventional extract and each of the cultivar extracts. this correlation was weaker with the cultivar hojiblanca (r=. ). conclusions: some patients, sensitized only to the pollen of certain olive tree cultivars, are not identified with the conventional extract. spt with the hojiblanca cultivar could identify most of these patients in our country, and therefore should be considered in patients with a history of pollinosis and a negative spt for the common extract of olive tree pollen. | structural and immunological comparison of heat treated pru p and art v , the non-specific lipid transfer proteins of peach and mugwort pollen wildner s ; stock l ; regl c ; alessandri c ; mari a ; huber c ; stutz h ; gadermaier g objectives: recombinant art v . and pru p . were expressed in e. coli rosetta-gamib plyss and purified using cation exchange chromatography. proteins were analyzed in gel electrophoresis and mass spectrometry. proteins were incubated at °c in time intervals up to min using buffers at ph . and . . physico-chemical properties of native and heated allergens were analyzed by circular dichroism spectroscopy, dynamic light scattering and size exclusion chromatography (sec). using sera from italian patients sensitized to pru p and art v (n= ), ige binding to native and heat-denatured allergens was investigated in elisa. results: highly pure recombinant pru p and art v were obtained as non-tagged proteins from e. coli. identity and formation of disulfide bonds was verified by mass spectrometry. circular dichroism showed high thermal stability of both proteins at acidic ph. the alpha-helical fold of art v was lost upon heating for min at ph . while pru p was already altered after min. purified pru p and art v are monomeric molecules with a hydrodynamic radius of . and . nm, respectively. structural relaxation is observed upon heat treatment which is not attributed to protein aggregation as determined by sec. the ige reactivity to both allergens was largely unaffected upon heating at ph . . notably, ige reactivity to art v was already significantly decreased upon min heating and was completely abrogated to both proteins after min denaturation at neutral conditions. conclusions: even though the fold of pru p is more compact compared to art v , susceptibility to structural changes upon thermal treatment at neutral conditions are more pronounced which do however not directly translate to lower ige binding capacities. particularly the buffer environment needs to be considered when formulating ltp-containing products which undergo heat treatment. objectives: we sought to determine the ige binding capacity and potential diagnostic value of a recombinant hybrid molecule. results: the codon-optimized nucleotide sequences of a hybrid molecule comprising the full sequences of blo t and der p at the amino and carboxyl ends respectively, here named bp- , was cloned into a plasmid vector and expressed in escherichia coli as a xhis tag protein. two hundred and thirty three sera from colombian (n= ) and cuban (n= ) allergic patients were tested by elisa for ige reactivity. thirty seven sera from non-allergic subjects and negative skin test (spt) to mites were used as controls. all subjects provided written informed consent to their participation in this study. hdm allergy was diagnosed on the basis of clinical symptoms in combination with mite extract spt. potential diagnostic value of bp- specific ige was determined by receiver operating characteristic (roc) analysis and area under roc curve (auc) calculated. positive serum ige values to hybrid molecule were defined as optical density (od) higher than . (mean od plus standard deviations in nonallergic subjects). in respiratory allergic patients, the overall frequency of positive ige reactivity to bp- was . %, in non-allergic subjects the frequency was %. serum ige levels to bp- were positively correlated to spt to b. tropicalis (spearman r=. , p=. ), and to d. pteronyssinus (spearman r=. , p=. ). using spt to mite extracts as gold standard, the sensitivity and specificity of serum ige levels to bp- were . % and . % respectively, with an auc of . ( % confidence interval . - . ). conclusions: these data suggest that bp- could be a useful reagent for identifying allergic patients sensitized to b. tropicalis and/or d. pteronyssinus. | igg, ige and igg specific antibodies to molecular allergens of aspergillus fumigatus introduction: in clinical allergy, alongside with skin prick tests, in vitro determination of specific ige for a particular patient contributes to the diagnosis and helps to estimate the risk associated with different food allergens. however, with commercial methods of specific ige antibodies detection (component-resolved diagnosis, crd), the clinician is typically limited by the list of the available allergens. objectives: to overcome this limitation, we developed two component-resolved diagnostic tests for food allergy in which natural extracts can be used. in the first developed method, the crd is performed using immunoaffinity capillary electrophoresis (iace) coupled with matrixassisted laser desorption/ionization mass spectrometry. meanwhile, the second method is based on in-tube immunomagnetic separation (ims) with mass spectrometry identification (mass spectrometry or peptide mass fingerprinting). in both techniques, magnetic beads coated with antihuman ige antibodies are used to extract the ige antibodies from the blood serum of the allergic patient. then, the immunocomplex, obtained on the magnetic beads, is used to quantify the total ige level or to probe the ige binding with standard allergens or natural allergenic extracts. afterwards, the identification of the extracted proteins, ie potential allergens, is performed by mass spectrometry with or without ce separation. after optimisation, the proposed methods have been successfully applied to a commercial blood sample of a patient with a known allergy to cow's milk, with results confirmed by standard tests. as a proof-of-concept, the sensitization profile of a patient suffering from protein contact dermatitis to the cow's whey fraction has been determined. we confirmed the presence of circulating ige antibodies binding lactoferrin and bovine serum albumin. cross-reactivity tests were also performed using goat and sheep milk and revealed the patient sensitivity to serum albumins from these two milks. such approaches open the possibility for direct identification of ige-bound allergens molecular mass and structure. these methods allow the discovery of yet unknown allergens and could be useful for precise personalized allergy diagnosis, allergens epitope mapping, and cross-reactivity studies. objectives: the objective of this study was to investigate the validity of cord blood ige for predicting atopy at years of age. methods: a total of children born in participated in the longitudinal investigation of global health in taiwanese schoolchildren (lights) cohort. total ige was measured in umbilical cord blood at birth. perinatal history was collected from medical records in the chang gung memorial hospital, taiwan. total and specific serum ige and questionnaires were carried out at years of age. receiver-operating characteristic (roc) curves were used to determine the validity of cord blood ige for predicting atopy at years of age. logistic regression models were applied to assess the association between cord blood ige and atopy at years of age. results: cord blood ige levels was significantly associated with total serum ige level at years of age (r=. , p<. ). the cord blood ige levels in atopic children aged years (meanaesd, . ae . ku/l) were significantly higher than those in nonatopic children ( . ae . ku/l) (p<. ). the area under the receiveroperating characteristic (roc) curve of cord blood ige for predicting atopy at years of age was . . the sensitivity, specificity, and positive and negative predictive values of cord blood at the optimal cutoff of . ku/l on the roc curve for predicting atopy were . %, . %, . %, and . %, respectively. higher cord blood ige levels (≥ . ku/l) was associated with a higher likelihood of atopy at years of age (or= . ; % ci: . - . ; p<. ). our results indicate that cord blood ige is a potential predictor of atopy at school age, with an optimal cutoff of . ku/l. bogomolov a vinnitsa national pirogov memorial medical university, vinnitsa, ukraine introduction: allergen sensitization is being diagnosed by commonly available methods in clinical practice-skin prick tests (spts) and specific immunoglobulin e test (sige). recently, a new thermographic (th) method for the assessment of spt was developed, and it was demonstrated that the th measurements of forearm temperature distribution during spt, supported by a mathematical model, offer a new quantification method of allergen-induced skin reactions. objectives: the aim of this study is a comprehensive comparison of the th method with spt and sige techniques. the group of patients who were participated in this study consist of patients. among them were patients ( . %) with allergic rhinitis and patient ( . %) with asthma, . % of them were men and . % were women aged - years (mean age . ae . years). spt and sige testings were performed by the standard techniques. for th analyses, set of thermograms of both forearms were acquired after prick and analyzed with the use of developed software. all results were converted into categorized scale for comparison. after counting patients who were true positive (tp), true negative (tn), false positive (fp), and false negative (fn), the sensitivity, specificity, and accuracy were calculated according to the following formula using the results of spt as the standard; sensitivity=tp/(tp+fn), specificity=tn/(tn+fp), and efficacy=(tp+tn)/(tp+tn+fp+fn). the results showed high correlation coefficients between the methods equal to . - . . the sensitivity and accuracy of the th assessment in respect of both the classical methods is at a good level ( . - . ). the acceptable level of specificity . - . was also achieved for the majority of allergic reactions. the best accordance was observed between th and sige results (r=. ), while th-spt was the most divergent pair r=. . in case of particular allergens, the biggest correlation was . , while the smallest value amounted to . . the results of diagnostic indicators of thermographic measurement of skin reactivity in comparison with the classical methods of determining the sensitivity to allergens show the prospect of using the method in routine practice. the main advantages of this method are its higher measuring ability and objectivity, by which the possibility of making error in diagnosis is significantly reduced. introduction: chronic urticaria symptoms may be worsened by factors such as temperature, exercise, hormones and stress. a salicylate rich diet has been reported to worsen symptoms in these patients. the mechanism by which natural salicylates do this is unclear but, like aspirin, is thought to be due to their ability to interfere with the arachidonic pathway via cyclooxygenase inhibition. studies have shown that low dose aspirin increases serum il- levels in patients with antiphospholipid syndrome. il- is important in basophil and mast cell function, inducing mediator release and cd c upregulation in the absence of ige stimuli. objectives: the gold standard for diagnosing salicylate exacerbated chronic urticaria is by challenge testing. there is no in vitro laboratory test approved for routine diagnosis. this study investigated whether il- levels are raised in patients with chronic urticaria and if these levels were affected by salicylate intake. we aimed to find an optimum method of measuring il- levels by comparing levels in serum and salivary samples. the quantikine human il- enzyme linked immunosorbent assay (elisa) was validated and used on both saliva and serum of patients with chronic urticaria and normal controls. this was a case control study of medicated patients with chronic urticaria and controls at university hospital southampton, to see whether there were any correlations with il- , and degree of salicylate intake (based on a questionnaire). introduction: since the introduction of molecular components in allergy, a big challenge of allergy diagnostics is to connect clinical symptoms with optimal test use and correct interpretation of results. objectives: the aim of the study was to ( ) develop an algorithm that would meet that need, and ( ) to evaluate the effect of introduction of algorithm to clinical practice. the algorithm was developed which groups clinical symptoms into six categories: rhinoconjunctivitis/ asthma, oral allergy syndrome (oas), urticaria/angioedema, eczema, anaphylaxis, and a combination of symptoms and combines them with knowledge of possible allergen specificity. this information is combined with two basic allergen mixtures (panels), reflex testing of selected food molecular components and accompanied by interpretative comments. the introduction of our algorithm led to less inhalation screenings, more food screenings and an increase in the requested molecular components. the oas was seldom recognized or used as a symptom by specialists. the reduction in costs, by using the possibility that the disease presentation may be a consequence of an relatively not dangerous oas, was therefore not achieved. all pr- positive proteins in various allergen sources showed also positivity for birch antigen. the screening based on this algorithm has potential to enable clinicians/general practitioners with a tool to increase the pre-test probability of allergy for the most frequently occurring allergens. allergy diagnostics may be more efficient if pr- component of birch (r bet v ) is included in early screening and can help in early recognition of oas. helbling a department of otorhinolaryngology-head and neck surgery | clinical and immunological evolution of patients who failed milk-oral immunotherapy there is lack of evidence on evolution among failures. objectives: to analyze clinical and immunological evolution of patients who failed milk-oral immunotherapy. data were obtained from medical records of a cohort of patients who failed moit in the past years in hospital infantil universitario niño jesus ( %) patients failed during build-up phase [ ( %) due to adverse events (ae) and ( %) to family decision. failed during maintenance phase: ( %) due to eosinophilic esophagitis, ( %) to family decision, to psychiatric disorder and (range - ). the most frequent aes were cutaneous and gastrointestinal symptoms. / ( %) patients underwent a second moit and was successful in . the second moit was performed between and years after the first one. there was no statistical differences between specific ige(ku/l) levels at baseline and months after the moit end portugal introduction: fish allergy is common in countries where consumption is high. parvalbumins present in fish muscle are the major allergens. allergy to multiple fish species is caused by parvalbuminspecific cross-reactive ige. cross-reactivity with parvalbumin from baltic cod retrospective study of patients with fish allergy followed in our immunoallergology department. fish tolerance acquisition was evaluated by oral food challenge. statistical analysis was performed using spss version (descriptive statistics, student test results: pts were included ( male, female), children and adults (age ae years). ( %) had previous history of rhinitis, ( %) of asthma and ( %) of eczema age of first contact with fish averaged . ae . months (min , max ) and the possible types of contact were: oral in ( %), cutaneous in ( %) and inhalation of cooking fish vapours age of first clinical manifestation (excluding the pts who developed allergy in adulthood) was at ae months (min , max ) the clinical manifestation of the reaction was: angioedema/urticaria ( %), gastrointestinal symptoms ( %), eczema ( %), respiratory symptoms ( %), oral allergy syndrome ( %), cardiovascular symptoms ( %) age at the first immunoallergology out-patient clinic consult averaged ae years (min . , max ) and time from first symptom to first thermo-fisher) was evaluated before and after acquisition of tolerance to at least fish. before tolerance, sige (ku/l) averaged roc curve (area under curve . ) showed that, for gad c ku/l, pts had a sensitivity of . % and specificity of . % that they would have a negative oral food challenge to a fish an sige< . ku/l had sensitivity of % of a negative challenge ku/l had specificity of . % of a positive challenge. conclusions: fish allergy is a common allergy in early childhood however, acquisition of tolerance is possible. rgad c appears to be a good marker for fish tolerance and could help allergologists as to when start testing for fish tolerance key: cord- - w kc c authors: ramiro, sofia; mostard, rémy l m; magro-checa, césar; van dongen, christel m p; dormans, tom; buijs, jacqueline; gronenschild, michiel; de kruif, martijn d; van haren, eric h j; van kraaij, tom; leers, mathie p g; peeters, ralph; wong, dennis r; landewé, robert b m title: historically controlled comparison of glucocorticoids with or without tocilizumab versus supportive care only in patients with covid- -associated cytokine storm syndrome: results of the chic study date: - - journal: ann rheum dis doi: . /annrheumdis- - sha: doc_id: cord_uid: w kc c objectives: to prospectively investigate in patients with severe covid- -associated cytokine storm syndrome (css) whether an intensive course of glucocorticoids with or without tocilizumab accelerates clinical improvement, reduces mortality and prevents invasive mechanical ventilation, in comparison with a historic control group of patients who received supportive care only. methods: from april , patients with covid- -associated css, defined as rapid respiratory deterioration plus at least two out of three biomarkers with important elevations (c-reactive protein > mg/l; ferritin > µg/l; d-dimer > µg/l), received high-dose intravenous methylprednisolone for consecutive days ( mg on day followed by mg on days – ). if the respiratory condition had not improved sufficiently (in %), the interleukin- receptor blocker tocilizumab ( mg/kg body weight, single infusion) was added on or after day . control patients with covid- -associated css (same definition) were retrospectively sampled from the pool of patients (n= ) admitted between march and march, and matched one to one to treated patients on sex and age. the primary outcome was ≥ stages of improvement on a -item who-endorsed scale for trials in patients with severe influenza pneumonia, or discharge from the hospital. secondary outcomes were hospital mortality and mechanical ventilation. results: at baseline all patients with covid- in the treatment group (n= ) and control group (n= ) had symptoms of css and faced acute respiratory failure. treated patients had % higher likelihood on reaching the primary outcome (hr: . ; % ci . to . ) ( days earlier), % less mortality (hr: . ; % ci . to . ) and % less invasive mechanical ventilation (hr: . ; % ci . to . ). treatment effects remained constant in confounding and sensitivity analyses. conclusions: a strategy involving a course of high-dose methylprednisolone, followed by tocilizumab if needed, may accelerate respiratory recovery, lower hospital mortality and reduce the likelihood of invasive mechanical ventilation in covid- -associated css. objectives to prospectively investigate in patients with severe covid- -associated cytokine storm syndrome (css) whether an intensive course of glucocorticoids with or without tocilizumab accelerates clinical improvement, reduces mortality and prevents invasive mechanical ventilation, in comparison with a historic control group of patients who received supportive care only. methods from april , patients with covid- associated css, defined as rapid respiratory deterioration plus at least two out of three biomarkers with important elevations (c-reactive protein > mg/l; ferritin > µg/l; d-dimer > µg/l), received high-dose intravenous methylprednisolone for consecutive days ( mg on day followed by mg on days [ ] [ ] [ ] [ ] . if the respiratory condition had not improved sufficiently (in %), the interleukin- receptor blocker tocilizumab ( mg/kg body weight, single infusion) was added on or after day . control patients with covid- -associated css (same definition) were retrospectively sampled from the pool of patients (n= ) admitted between march and march, and matched one to one to treated patients on sex and age. the primary outcome was ≥ stages of improvement on a -item who-endorsed scale for trials in patients with severe influenza pneumonia, or discharge from the hospital. secondary outcomes were hospital mortality and mechanical ventilation. results at baseline all patients with covid- in the treatment group (n= ) and control group (n= ) had symptoms of css and faced acute respiratory failure. treated patients had % higher likelihood on reaching the primary outcome (hr: . ; % ci . to . ) ( days earlier), % less mortality (hr: . ; % ci . to . ) and % less invasive mechanical ventilation (hr: . ; % ci . to . ). treatment effects remained constant in confounding and sensitivity analyses. conclusions a strategy involving a course of highdose methylprednisolone, followed by tocilizumab if needed, may accelerate respiratory recovery, lower hospital mortality and reduce the likelihood of invasive mechanical ventilation in covid- -associated css. cytokine storm syndrome (css), a state of systemic hyperinflammation, is a rare and potentially lethal complication of various infections, malignancies and autoimmune diseases such as systemic juvenile idiopathic arthritis. css is found in alarmingly high frequencies ( %- %) in patients with covid- pneumonia and may cause significant morbidity, including multiorgan failure, and mortality. css can be suspected if patients experience rapid respiratory deterioration, in combination with high fever and disproportionally high c-reactive protein (crp) and serum ferritin, among others. while a curative therapy for covid- is still lacking, intensive immunosuppressive treatment may ameliorate covid- -associated css and improve the outcome. to date, information about immunosuppressive treatment of covid- associated css is only anecdotal. [ ] [ ] [ ] [ ] key messages what is already known about this subject? ► covid- -associated cytokine storm syndrome (css) is an important complication of severe acute respiratory syndrome coronavirus infection in up to % of the patients, often responsible for a fatal outcome. what does this study add? ► a strategy involving a course of high-dose glucocorticoids, followed by tocilizumab if needed, has shown to accelerate respiratory recovery, lower hospital mortality and reduce the likelihood of invasive mechanical ventilation compared with supportive care only in covid- -associated css. how might this impact on clinical practice or future developments? ► css should be recognised and considered as a treatable complication of covid- and immunosuppressive treatment should be started timely. ► a treatment with high-dose glucocorticoids is a convenient choice since glucocorticoids are safe, widely available and inexpensive. the zuyderland medical center (zmc) is a large teaching hospital responsible for the care of . inhabitants in the south of the province of limburg. south limburg has an ageing population and a relatively poor health status and the covid- pandemic has hit the region hard. between march and march more than patients with severe covid- were admitted for hospital care. thirty per cent had symptoms of covid- -associated css, many of whom required intensive care treatment and over % died. by the end of march , zmc physicians agreed to start an experimental treatment protocol for covid- -associated css and follow these patients meticulously in a prospective observational study. rheumatologists were consulted because of their expertise in immunosuppressive treatment, as advised in recent european league against rheumatism recommendations. the protocol responded to the broadly felt need among physicians to do more than 'only' providing supportive care to them. the clinicians refuted the seemingly obvious choice for a randomised controlled trial (rct) with intensive immunosuppressive treatment versus supportive care alone in patients with css, with reference to the unacceptably high hospital mortality under supportive care only conditions, the reluctance to confront critically ill patients with an estimated % mortality and a one-to-one gamble of not receiving additional experimental treatment, and the overwhelming time pressure of the unprecedented pandemic. here we describe the results of patients with covidassociated css who have been treated according to the protocol (period ) in comparison to patients with covid-associated css who had received supportive care before the protocol was in effect (period ) (covid high-intensity immunosuppression in cytokine storm syndrome (chic) study). each patient in the treatment group was matched one to one to a control patient in order to create pseudorandomisation. in order to avoid exhaustion of the hospital care system, the zmc had agreed upfront with local general practitioners and nursing home physicians to not refer (suspected) patients with covid- to the hospital for diagnosis and supportive care if severe pre-existing clinical frailty was present, life expectancy was obviously limited or severe comorbidity in combination with covid- was expected to have a very unfavourable outcome. all patients admitted to zmc for covid- were registered in the zuyderland covid- registry (elvis) from which demographic data, clinical signs and symptoms at presentation could be retrieved. all patients in the elvis received written information about the registry as well as an opt-out form in case they did not want to participate. none of the patients included in the chic study objected to participation. treatment group (period ): patients eligible to the chic treatment protocol had to have a diagnosis of covid- and evidence for concomitant css. a diagnosis of covid- involved the presence of clinical signs and symptoms suggestive of covid- in combination with either a positive pcr test for severe acute respiratory syndrome coronavirus (sars-cov- ) or a chest ct result of covid- ct classification (co-rads) or . in order to meet the criteria for css in this study, patients had to have an oxygen saturation at rest ≤ % (ambient air) or tachypnoea (> /min). in addition, they had to meet at least two out of the following three biomarker criteria: high crp (> mg/l), high serum ferritin (> µg/l at one occasion, or a twofold increase of the level at admission within hours) and high d-dimer level (> µg/l). there were no pertinent exclusion criteria for the treatment protocol. every patient was fully informed about the off-label character of the treatment strategy and the potential side effects. informed consent was obtained before the start of the treatment strategy. if the patient was incapable of executing permission, informed consent was given by the closest relative. control group (period ): patients potentially eligible to the retrospectively assembled control group had to be admitted between march and march . their data were collected retrospectively for the presence of covid- pneumonia as described above. in addition, clinical data about daily respiratory status were retrieved, as well as crp, serum ferritin and serum d-dimer levels. missing laboratory tests were determined afterwards in stored serum samples, when available. the criterion for respiratory deterioration was checked as described above. css biomarker criteria were applied as described above. the eligibility of all control patients was independently checked in the patient's electronic file by two physicians (cd and cmc) and cases of disagreement were decided by consensus with a third physician (sr), without knowledge of the clinical course and outcome. the primary outcome was discharge from the hospital or improvement of at least two stages (compared with baseline; whatever came first) on a who-endorsed -point ordinal scale, originally developed for trials with patients with influenza pneumonia, and used in several trials with patients with covid- . - the stages are: ( ) non-hospitalised, able to resume normal activities; ( ) non-hospitalised, but unable to resume normal activities; ( ) hospitalised, not requiring oxygen therapy; ( ) hospitalised, requiring additional oxygen therapy; ( ) hospitalised, requiring high-flow nasal oxygen therapy, non-invasive mechanical ventilation or both; ( ) hospitalised, requiring extracorporeal membrane oxygenation, mechanical ventilation or both; and ( ) death. in our study we used the scale from to , as we could not (yet) collect information on whether discharged patients are able to resume normal activities. key secondary outcomes were hospital mortality and the need to start invasive mechanical ventilation. other secondary outcomes were improvement of one stage in the who score, who score at days and , independence from oxygen therapy, duration of mechanical ventilation in the survivors and duration of hospitalisation in the survivors. baseline and time points of primary and secondary outcomes, if met, were determined prospectively for all treated patients and in retrospect by chart review for all control patients. the treatment protocol included two steps: ( ) immediate treatment with methylprednisolone (mp) mg intravenously on day , followed by mp mg intravenously on days - , and an option for a -day extension if considered necessary and safe; ( ) escalation of immunosuppressive treatment with a monoclonal antibody directed against the interleukin- receptor, tocilizumab (tcz), between day and day (single-dose tcz, mg/kg body weight intravenous, max mg). criteria for escalation with tcz were lack of clinical improvement or worsening in respiratory status (assessed on the who scale). criteria for a -day extension of mp at day were clear clinical improvement in respiratory status (≥ stage improvement on the who scale) but a partial decrease of biomarkers (crp reduction less than %). close multidisciplinary monitoring was an integral part of the strategy and was assured by daily meetings (rlmm, rbml, cmc, sr, cmpd, rp, mg, ehjvh, jb) in which all patients in the protocol were discussed and treatment was optimised. discussions focused on immunosuppressive treatment decisions, treating secondary infections, thromboembolism and cardiac complications. glucose levels were assessed twice daily during treatment with mp. cointerventions: all patients received ceftriaxone ( g every hours for days) and up to may in the presence of oxygen saturation < % chloroquine mg every hours following a loading dose of mg unless the corrected qt interval on an ecg was prolonged (> ms). informed consent was obtained for this off-label therapy. complications during hospitalisation were closely monitored. complications of special interest were well-known adverse events related to short-term high-dose mp and tcz administration, and included bacterial or fungal infection, acute-onset congestive heart failure or aggravation of existing congestive heart failure, arrhythmia and gastrointestinal bleeding. matching procedure: after the first selection step, the two data files containing patients from the treatment group and patients from the control group were : matched on sex (m, f) and age (five age classes: < , - , - , - , ≥ years) using the match command in stata. the best matching result yielded two groups of patients each ( % of potentially available patients could be matched). comparability at baseline of treatment group and control group was analysed descriptively for a wide range of variables and common univariable statistical tests for between-group differences were applied to test if the null hypothesis of no difference had to be rejected. patients in the treatment group and control group were compared on a time-to-event basis, using proportional hazards regression analysis (cox). censoring of follow-up took place: ( ) when the patient died; ( ) when the patient was discharged; or ( ) at the end of follow-up on may (whatever came first). by convention, a patient who had died during the course of the study could not have improved ('zero improvement'). because of the relatively small sample in relation to the relatively high number of variables at baseline, a prespecified analysis for effect mediation and confounding preceded the final selection of variables for multivariable adjustment. this analysis involved a two-step procedure, in which effect modification was excluded first by testing per baseline variable the interaction of that variable with treatment group, under adjustment for the main effects. thereafter, confounding was checked per variable by investigating if the magnitude of the association between treatment group and outcome changed > % by adding the variable to the model. it was decided upfront that-apart from treatment group, age and sex (default variables)-only variables with a clinically relevant interaction and a p value < . were to be analysed in separate strata, and that only variables with true confounding potential that met the definition for confounding were to be included in the final multivariable models. the proportional hazards assumption was checked by graphical diagnostics and statistical testing using stata v. . kaplan-meier survival plots were constructed and the survival curves for treated and control groups were compared using a log-rank test. the effect size for treatment in the final multivariable models was challenged for robustness by several sensitivity analyses. the three sensitivity analyses were of the same type as the main analyses but on different patient selections: ( ) all patients minus those who were already on mechanical ventilation at baseline; ( ) all patients minus those who had received tcz; or ( ) all patients minus those in the lowest (< years) and highest (≥ years) age groups (trimming). at the start of the chic study there was only provisional information available about hospital mortality in patients with covid- -associated css under supportive care only conditions. we assumed % hospital mortality based on early experience. in order to declare an observed absolute difference of % or more statistically significant ( % mortality reduction, at alpha= . and beta= . (power: %)), at least patients per group were required. there was no funding source of this study. the corresponding author had full access to all the data in the study and had final responsibility for the decision to submit for publication. after matching, patients ( per group) were available for analysis. all patients and controls were caucasians. mean age and sex distribution were similar. the age range was wide; younger and older patients were appropriately represented (online supplementary table s ). table shows a broad array of variables that describe the make-up of both groups. in general, the distribution of variables across groups was well balanced, but a few differences stood out. mean body mass index (bmi) was high in both groups, but almost units higher in the control group than in the treatment group. covid- pcr positivity was slightly higher in the control group, which was the consequence of an imminent shortage in test capacity over time, in combination with increasing confidence in the diagnostic value of chest ct under high a priori probability conditions (the co-rads scores were balanced across groups). differences in comorbidities at baseline were found in either direction. the control group contained more patients with diabetes (p< . ). the treatment group had more patients with cardiovascular disease (p= . ) and arrhythmias (p= . ). the charlson comorbidity index was low on average but slightly higher in the control group (p= . ). the mean who score at baseline was similar in both groups, with the notion that the distribution across stages is skewed towards more patients requiring mechanical ventilation in the control group, offset by more patients requiring high-flow oxygen in the treatment group. biomarkers of css showed very high mean levels for crp, serum ferritin and d-dimer in both groups, but serum ferritin (p= . ) and d-dimer (p= . ) levels were slightly higher in the control group. both ferritin and d-dimer had a non-normal distribution with outliers, and more than % of d-dimer levels in the control group were missing. all patients in both groups (except for one in the treatment group) received antibiotic treatment by protocol, and almost table shows the primary and secondary outcomes. as compared with patients in the control group, patients in the treatment group had a % higher likelihood of reaching the primary outcome of two-stage improvement in respiratory status (hr: . ; % ci . to . , table ) and they reached it on average days (median) earlier, all of them before discharge. their who scores at days and (table ) were consistently better (p< . ). the development of who clinical improvement per group is visualised in figure . curves start to separate from to days of follow-up. hospital mortality was % lower in the treatment group than in the control group (hr: . ; % ci . to . ; table , figure ). at hospital day , ten patients in the treatment group had deceased as compared with in the control group (p< . ) (table ). the likelihood to evolve to mechanical ventilation due to respiratory deterioration was % lower in the treatment group (hr: . ; % ci . to . ; table , online supplementary figure s ). among patients who were not mechanically ventilated at baseline (table ), the daily incidence of mechanical ventilation (new start) was . % vs . % (p= . ). once mechanically ventilated, the duration of mechanical ventilation was not different across groups. the analyses of effect modification and confounding revealed one clinically relevant interaction (treatment group vs serum ferritin level at baseline) and six relevant confounders (bmi, smoking status, hypertension, diabetes, cardiovascular disease and arrhythmia). the effect size of treatment was higher in patients with serum ferritin levels above the median the six relevant confounders were entered as covariates, together with age and sex, in the multivariable models for all outcomes (table ) . adjustment for confounding increased rather than decreased the estimated treatment effect for all seven analysed outcomes. all models were checked for not violating the proportional hazards assumption (online supplementary figure s ). all main effects remained constant and statistically significant in the three sensitivity analyses (table ) . of note, in the sensitivity analysis that excluded the % patients who had received tcz, the treatment effects for all outcomes increased and maintained statistical significance, suggesting that a clinically relevant treatment effect can be reached by high-dose gc alone (table , online supplementary table s ) . patients tolerated the short but intensive immunosuppressive therapy well. complications were balanced between groups (table ). bacterial infections were diagnosed during hospitalisation in patients ( in the treatment group vs in the control group). there was a trend towards more pulmonary embolism in the treatment group (p= . ). arrhythmias occurred in both groups, but slightly less frequently in the treatment group (p= . ). this historically controlled comparison of a strategy with intensive immunosuppression and close monitoring versus a strategy with supportive care only in patients with covid- -associated css suggests that clinically relevant improvement of respiratory status is % more likely, and can be accelerated by a median of days, that hospital mortality can be reduced by % and that the need for mechanical ventilation during admission can be reduced by %. these outcomes were robust and, especially if confirmed in randomised trials later on, highly relevant from a medical and societal perspective. it should be emphasised that this study cannot be read and interpreted as an rct. prognostic similarity at baseline cannot be assumed, in spite of several efforts to match the control patients as closely as possible to the treated patients. residual confounding by unmeasured variables is likely. while patients were almost perfectly matched for age and gender and efforts were made to assure that control patients were only sampled if they had evidence of css, certain baseline differences remained, although in both directions. diabetes and obesity were slightly more prevalent in the control patients and some biomarkers of css were slightly higher too. cardiovascular comorbidity and arrhythmias, on the other hand, were more prevalent in the treated patients. a rigorous confounding analysis revealed that none of these potential confounders had a reducing influence on the magnitude of the treatment effect, which importantly adds to the credibility of the univariable results. instead, hrs seemed to increase rather than decrease after adjusting for confounders, an observation that may point to statistical overfitting and therefore of limited relevance. however, a potential (time) period effect may have affected the results. such an effect is inherent to the design of the study and cannot be adjusted for. all control patients were admitted at least weeks earlier than the patients in the treatment group. these patients got sick in period , the initial phase of the pandemic, and it cannot be precluded that covid- -associated css was more severe in period than in period , that patients received less than optimal supportive care during the first hectic weeks of the pandemic or that infected patients of the first hour simply had worst health. this argument, however, can also be reversed. during period intensive care capacity still was relatively high and there was some consensus among experts to start lowthreshold mechanical ventilation, while patients in period had to 'compete with' those that already occupied high-care facilities and staff got exhausted. that more patients in the control group than in the treatment group already received mechanical ventilatory support at baseline is reflective of this situation. adjustment for this imbalance did not affect the treatment effect. the argument that covid- -associated css was more severe in period as compared with in period also lacks substantiation. the start of our protocol coincided with the peak in covid- admissions in the netherlands ( april) and preceded the peak in mortality by - days. the incidence density of admissions and mortality increased during period and decreased during period , but mortality as a fraction of number of hospital admissions in the netherlands was actually higher in period than in period . while this is an indirect argument, it argues against a better prognosis of patients with covid- -associated css in period . still, we are dealing with a new disease and the standard of care is rapidly evolving. changing policies with respect to the start of mechanical ventilation, diagnosing thrombosis and anticoagulation therapy occurred even within the time frame of our study. the trend of finding more pulmonary embolism in the treatment group, for instance, is a reflection of searching with more scrutiny for thrombosis over time. such developments have an impact on the external validity (generalisability) of our study and of others to be published, and may be responsible for treatment effects in daily practice that seem less dramatic than the contrasts found in this early study. several experts, including the who, warned against treating critically ill patients with a sars-cov- infection with gcs, an advice with potentially serious implications for many patients. the risk profile of such a short course of gc for treatment of css needs to be separated from pre-existing chronic use of gc for conditions like rheumatic and musculoskeletal diseases (rmd). they particularly feared impaired virus clearance and secondary bacterial infection. however, patients in the chic study tolerated the immunosuppressive therapy remarkably well and we did not find evidence for impaired viral clearance nor for bacterial superinfection. longer follow-up, however, is needed to give final resolution about the safety and efficacy of the strategy. speculating about which component of the strategy yields most benefit is tempting but risky. we think it is the combination of early intervention (the 'window of opportunity hypothesis'), the intensive immunosuppression and the close monitoring by a multidisciplinary team that best explains the favourable results. the results of the chic study also suggest that the timely administration of high-dose gcs alone may provide significant benefit in more than half of the patients and that tcz is only needed in those cases that had insufficient clinical improvement on mp alone. this is an important finding given the limited availability of tcz in many countries and tcz's high costs. it is not unthinkable that treatment with other compounds than gc and tcz that are often used by patients with rmds, such as tumour necrosis factor alpha inhibitors, or interleukin- receptor antagonists, may have similar beneficial effects. our choice for high-dose mp, broadly available and with a wellknown profile in severe systemic inflammatory diseases, and tcz, with an existing niche indication for a rare form of iatrogenic css, was to some extent serendipitous. future rcts may give resolution but will take time. our definition of css was rather pragmatic and arbitrary but sufficed to select the ~ patients with covid- and css from a total pool of approximately ( %). when untreated, mortality in this severe subgroup was more than %. in addition to the clinical criterion of rapid deterioration of respiratory status, we used commonly available biomarkers for css at cutoff levels based on our experience with the early patients with covid- . that the treatment benefit was highest in patients with serum ferritin levels above the median value of µg/l can be seen as an important endorsement for the hypothesis that covid- -associated css determines the immediate prognosis of covid- . fine-tuning these thresholds for css and introducing other biomarkers for diagnosing css may further improve the definition of css and optimise treatment effects. the choice for the who-endorsed classification of outcomes designed for patients with severe influenza pneumonia, next to hospital mortality, appeared rational and workable. the definition of an improvement of at least two stages or hospital discharge indeed reflected clinical improvement properly. in fact, all discharged patients also met the criterion of two-stage improvement. while we in principle advocate to further study strategies like ours in rcts, it is an interesting philosophical question whether rcts with 'supportive care only' in the control group will be justifiable in future. 'supportive care only' for covid- -associated css is ethically arguable in light of the biological plausibility of css complicating covid- and its high mortality, given the likely benefit of immunosuppressive therapy, such as reported here, even though formal evidence stemming epidemiology from rcts is lacking. while the magnitude of the treatment effects found in the chic study may be somewhat downplayed by formal methodological reasoning, it is unlikely that the entire contrast is only due to residual confounding. the evaluation of the treatment of covid- -associated css may have been caught up by the crisis itself. in conclusion, we have shown here that a strategy involving a course of high-dose mp, followed by tcz in case of insufficient improvement, may accelerate respiratory recovery, lower hospital mortality and reduce the likelihood of invasive mechanical ventilation in covid- -associated css. despite these promising results, further confirmation is still needed. familial and 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management of rheumatic and musculoskeletal diseases in the context of sars-cov- co-rads -a categorical ct assessment scheme for patients with suspected covid- : definition and evaluation a trial of lopinavir-ritonavir in adults hospitalized with severe covid- remdesivir in adults with severe covid- : a randomised, double-blind, placebo-controlled, multicentre trial who r&d blueprint. novel coronavirus, outline of designs for experimental therapeutics understanding the effects of age, period, and cohort on incidence and mortality rates world health organization. clinical management of severe acute respiratory infection (sari) when covid- disease is suspected trials of anti-tumour necrosis factor therapy for covid- are urgently needed the authors extensively thank the healthcare professionals from zuyderland medical center who made this study possible, despite the pandemic situation, as well as the board of zmc for the trust in the study team and the support in the conduction of the study. additionally, the authors would like to thank the medical students (susan voncken, marlieke elsendoorn, jasper broerse, twan feron, mandy jongbloed and sophie laven) involved in data entry and employees from the research department (bureau wetenschappelijk onderzoek, bwo), namely anke linssen, esther bergman, christel jacquot, marijke lemmens and audrey merry. the authors also acknowledge professor d van der heijde for her critical reading of the manuscript.contributors sr, rlmm, cmc and rbml designed the study. all authors contributed to data collection. sr and rbml analysed the data. sr, rlmm and rbml critically interpreted the results and drafted the first version of the manuscript. all coauthors discussed the findings together, critically reviewed the manuscript and approved its final version. the authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors. competing interests sr reports personal fees from abbvie, personal fees from eli lilly, grants and personal fees from msd, personal fees from novartis, personal fees from ucb, personal fees from sanofi, outside the submitted work. rlmm reports personal fees from boehringer ingelheim, personal fees from roche, personal fees from galapagos, outside the submitted work. cmc is a clinical trial investigator for a study sponsored by lilly and was a subinvestigator for a study sponsored by gsk. cvd reports personal fees from novartis, personal fees from roche, outside the submitted work. td reports grants from adrenomed, grants from inotrem, grants from roche, grants from shionogi and co, other from castor, outside the submitted work. mg reports personal fees from roche, personal fees from msd, outside the submitted work. mdk reports personal fees from alk, personal fees from astrazeneca, personal fees from boehringer ingelheim, personal fees from sanofi genzyme, outside the submitted work. ml reports grants from astrazeneca, grants from pfizer, personal fees from roche, outside the submitted work. rp reports grants and personal fees from pfizer, grants and personal fees from abbvie, outside the submitted work. rl reports personal fees from abbvie, personal fees from bms, personal fees from galapagos, personal fees from gilead, personal fees from jansen, personal fees from novartis, personal fees from pfizer, personal fees from roche, personal fees from ucb, outside the submitted work; and owner and director of rheumatology consultancy, a company that provides consultancy and read services for clinical trials.patient and public involvement patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research. ethics approval the medical ethics committee and the board of zmc approved the study protocol and the study started enrolling patients on april .provenance and peer review not commissioned; externally peer reviewed. data availability statement data may be obtained from a third party and are not publicly available.this article is made freely available for use in accordance with bmj's website terms and conditions for the duration of the covid- pandemic or until otherwise determined by bmj. you may use, download and print the article for any lawful, non-commercial purpose (including text and data mining) provided that all copyright notices and trade marks are retained.orcid ids sofia ramiro http:// orcid. org/ - - - robert b m landewé http:// orcid. org/ - - - key: cord- -a ie fs authors: nan title: digestive system, liver, and abdominal cavity date: - - journal: the cat doi: . /b - - - - . - sha: doc_id: cord_uid: a ie fs nan these complex pathways highlight the need to consider the whole cat and not just the cat's gastrointestinal vomiting can be defined as the ejection of part or all of the contents of the stomach and/or upper intestine through the mouth, usually in a series of involuntary spasmodic movements. the disturbances in gastrointestinal (gi) motility are coordinated with respiratory and abdominal muscle contractions and mediated by the central nervous system (cns). vomiting begins with retching, a series of brief negative intrathoracic pressure pulses that coincide with positive abdominal contractions. these pressure changes occur as a result of repeated herniations of the abdominal esophagus and cardiac portion of the stomach into the esophagus. during retching, food freely moves back and forth in the esophagus, which is now dilated because of the ingesta. ultimately, the diaphragm rapidly moves cranially, resulting in positive intrathoracic pressure that leads to expulsion of these contents. vomiting is such an active process that it seems to involve the whole cat, and so it is little wonder that it concerns owners so much. since vomiting is mediated by the cns with input and influence from just about anywhere in the body, it is important to summarize this physiology so it can be appreciated when managing clinical cases. vomiting results from stimulation of the "vomiting center," which is located in the brainstem; there are four main pathways that stimulate the vomiting center, and these are summarized below and in figure (though not all older cats have grown out of this habit). some extragastrointestinal problems, such as hyperthyroidism and renal disease are more likely to occur in older cats. most texts and references instruct clinicians to distinguish between vomiting and regurgitation, with the latter noted as being quite passive. , , in practice, it can be hard to make this distinction, because it is the author's experience that cats with esophageal disease can have quite forceful, spasmodic movements when ejecting ingesta by regurgitation-although it is also possible for regurgitation to be a passive process. given that the physiology of vomiting, as described above, results in ingesta being forced to and then evacuated from the esophagus, it is hardly surprising that it can resemble regurgitation. fortunately, regurgitation and esophageal disease do vary from vomiting in other ways! vomiting . blood and urine testing . imaging (radiography, ultrasonography) . biopsy samples . treat and manage underlying problem the decision to proceed to steps and is based on the assumption that the prior steps have narrowed down the underlying cause as gastrointestinal, pancreatic, or hepatic in origin. the important aspects of the clinical history are given in chronic kidney disease. the author has found that some cats with dental disease can gorge their food, resulting in vomiting; so, paying attention to the state of the teeth and gums is important. of course, some cats have multiple problems, and correction of dental disease may not resolve vomiting if there is another process. in the examination, it is also important to note consequences of both the underlying process and the vomiting itself; these include the demeanor of the cat, hydration status, and abdominal pain. the physical examination findings, together with the clinical history, help determine the next appropriate steps. well cats that are not continually vomiting and are appropriately hydrated, with no other specific signs, may be treated as outpatients by fasting them for hours, then returning to food with a bland diet, such as plain cooked chicken or commercial, low-residue prescription diets designed for this purpose. follow-up is important to ensure signs do not progress. cats with nonspecific signs may require supportive care with subcutaneous or intravenous fluids and perhaps analgesia (with opioids). if clinical signs do not resolve, the pursuit of a specific diagnosis should be attempted. the practitioner must ask the following important questions: • are ancillary tests appropriate? • is supportive care necessary? • are any medications required? routine serum/plasma biochemistries, hematology, urinalysis, and total thyroxine (t ) (for older cats) testing is not only important to distinguish primary from secondary gastrointestinal disease but to look for consequences of vomiting that may need to be addressed, such as hydration status and electrolyte abnormalities. careful interpretations should be made. severe azotemia, even with hyperphosphatemia, can occur as a result of primary gastrointestinal disease, and the distinction from renal disease usually requires an assessment of urine specific gravity. cobalamin, folate, feline trypsin-like immunoreactivity (ftli), and feline pancreatic lipase immunoreactivity (fpli) tests are useful markers of intestinal and pancreatic disease, , , , but it is important to note that they mostly do not give a precise diagnosis. more detail about the utility of these tests is noted below in the section approach to the cat with diarrhea. is usually preceded by the cat licking its lips, salivating, or making attempts to swallow. regurgitated ingesta is often in a tubelike structure and if undigested can be covered with frothy saliva. partially digested food suggests vomitus, and the presence of bile or digested blood confirms this. it is important to determine if the cat vomits regularly. many owners have seen their cats vomit on a regular basis with no evidence of the cat being unwell, and this is noted frequently in the veterinary literature. , hairballs can cause gastric irritation, and it may be that eating quickly also stimulates the peripheral sensory receptors that contribute to vomiting. if a cat does vomit regularly, it is important to assess if the cat is presenting for a change in the vomiting pattern (e.g., frequency or timing in relation to eating) and if the cat is unwell in any way, such as anorexia or weight loss. the pattern of vomiting is important in all cases, because cats presenting with acute gastritis usually have a sudden onset of frequent vomiting compared with those with chronic disease processes that may vomit every few days. the timing in relation to eating can be helpful, because the stomach should empty by to hours after a meal; so, vomiting longer than hours after a meal can suggest motility or retention disorders. the description of the vomitus can be helpful. if bile is present, the pylorus is not obstructed; the presence of blood (digested or fresh) indicates ulceration. hair in the vomitus can indicate hairball gastritis, and the possibility of trichobezoar obstruction should be considered. access to foreign bodies or toxins is an important aspect of the clinical history. has the cat been seen playing with an insect, mouse, or other prey? are there any medications unaccounted for (e.g., a dropped aspirin tablet)? are lilies present in the house? vomiting is the major sign of gastric disease, but given the number of potential organ systems that can be involved, a thorough physical examination should be undertaken. because linear foreign bodies are a common cause of vomiting, all cats presenting for anorexia or vomiting should have the underside of the tongue evaluated for the presence of string caught there. applying gentle pressure with a thumb in the intermandibular space to elevate the tongue is an effective way to visualize lesions or foreign bodies in the sublingual area (see . a thorough examination may reveal specific signs, such as a palpable thyroid nodule and tachycardia in the case of hyperthyroidism or palpably small kidneys with and analgesia, many cats recover uneventfully. one survey assessed that % of cats undergoing exploratory laparotomy survived the hospitalization, and although complications occurred in % of cats, these were more likely to be associated with the underlying disease process and not surgery or anesthesia. laparoscopy is not readily available in all veterinary clinics. this alternative is less invasive and allows exploration of the abdomen but not as thoroughly as with laparotomy. organs are usually exteriorized for biopsy. there is the possibility of anesthetic complications associated with insufflating the abdomen. endoscopy is the least invasive procedure and is the only alternative that allows examination of the intestinal lumen. this option limits the parts of the gastrointestinal tract that can be biopsied; it does not allow examination or sampling of any other part of the gastrointestinal tract and does not enable full-thickness biopsy samples. one study found that, of cats investigated for gastrointestinal disease, of cats ( %) had no pathology recognized proximal to the jejunum (i.e., the effective length of diagnostic endoscopes would have precluded diagnosis), and other organs were affected in of cats with inflammatory bowel diseases and of cats with intestinal small cell lymphoma. careful case selection for endoscopy from survey ultrasonography can reduce the number of missed diagnoses from endoscopy, but the possibility still remains. the quality of endoscopically obtained biopsy samples varies greatly with the skill of the endoscopist. it has been stated that "it is exceedingly easy to take inadequate tissue samples with a flexible endoscope." in an assessment of endoscopically obtained biopsy samples, two laboratories were compared, one that received samples from any practitioner and the other that received samples only from practitioners trained to take, mount, and submit endoscopy samples. all slides were reviewed by three pathologists who found that, of samples from the first laboratory, % of the slides were considered inadequate for diagnosis, % were considered questionable, and only % were adequate. by comparison, in the second laboratory (with samples from experienced practitioners) % of slides were inadequate, % were questionable, and % were considered adequate for diagnosis. in the case of distinguishing between lymphocytic intestinal infiltrates (commonly known as inflammatory bowel disease) and lymphocytic neoplasia (small cell lymphoma), endoscopically obtained samples can give an incorrect diagnosis. many of these problems can be minimized with experienced operators and careful case selection from prior ultrasonography. radiography is most useful for identifying foreign bodies or signs of intestinal obstruction from other causes. the major findings are noted below in the section intestinal obstruction. contrast radiography can aid the diagnosis for both discrete and linear foreign bodies but should be used with caution, because intestinal perforation may be present. nonionic iodinated agents that are typically used for myelography (such as iopamidol or iohexol) should be used, since barium irritates the peritoneum and oral iodine compounds are hypertonic. hypertonic compounds may draw fluid into the stomach and intestines after oral administration, with the potential of creating further fluid and electrolyte imbalances in an already compromised patient. ultrasonography is a useful diagnostic adjunct and helps to detect and characterize localized thickening of the stomach or intestinal wall, lymphadenopathy, radiolucent foreign bodies, and changes in the size and echogenicity of the pancreas, liver, kidneys, or spleen. abdominal effusions can be assessed and sampled. ultrasound-guided fine-needle aspiration can be used to sample masses, bile, or peritoneal fluid. it should be recognized that in most cases of gastrointestinal disease, imaging will not give a definitive diagnosis and biopsy will be required, usually using either endoscopy or laparotomy. ultrasonography can be a considered as a means to "survey the field," assessing • the nature of the underlying disease, such as • thickened intestines with or without discrete layers • lymph node involvement • other organ involvement • the location of disease, for example, • diffuse or focal • proximal duodenum (reachable by endoscope) versus distal ileum these factors may be used to assess the appropriateness of endoscopy versus laparotomy to obtain diagnostic samples. most commonly used antiemetics all control vomiting by different mechanisms and include mirtazapine, metoclopramide, dolasetron/ondansetron, maropitant, and the phenothiazines (tables - and - ) . metoclopramide functions both as an antiemetic and prokinetic in cats, while cisapride functions solely as a prokinetic. mirtazapine, a piperazinoazepine, antagonizes the presynaptic alpha -adrenergic receptor, increasing noradrenergic and serotonergic neurotransmission; the primary mechanism targeted for its use is as an antidepressant in humans. mirtazapine is also a potent antagonist of the postsynaptic serotonergic receptors ( -ht and -ht ) and histamine h receptors. because of its antiserotonergic and antihistaminic effects, mirtazapine is used as an entiemetic and appetite stimulant in cats. anorexia is a common clinical problem in ill cats, and in some anorexic or partially anorexic cats the use of an appetite stimulant as adjunctive therapy to nutritional support (i.e. feeding tubes) may be of clinical benefit. prior to the development of mirtazapine, cyproheptadine was used as an appetite stimulant in cats, with variable clinical results. recently, the pharmacokinetics and pharmacodynamics of mirtazapine have been reported in cats. in a group of healthy cats, mirtazapine was found to be an effective appetite stimulant, with a shorter half-life than that reported in humans. the recommended oral dose is . mg/cat every hours. a in humans, age and kidney and liver dysfunction affect mirtazapine metabolism (hepatic cyp enzymes) and clearance (excreted in urine and feces), suggesting that dose adjustment may be necessary. a side effects reported in cats treated with mirtazapine include behavior changes (vocalization and interaction), tremors, muscle twitching, and hyperactivity. a, a metoclopramide is both an antiemetic and prokinetic drug that acts peripherally on the gastrointestinal tract and centrally within the central nervous system (cns). at low doses metoclopramide inhibits dopaminergic (d ) transmission, and at higher doses it inhibits serotonergic -ht receptors in the chemoreceptor trigger zone (crtz). , metoclopramide also acts peripherally as a prokinetic at the level of the gastrointestinal smooth muscle of the stomach and duodenum, triggering gastric emptying and duodenal contractions. multiple mechanisms mediate metoclopramide's prokinetic activity, including augmentation of acetylcholine release and increased smooth muscle sensitivity to cholinergic neurotransmission, which may in part be because of antagonism of dopamine, but more recently, serotonergic ht receptor activation has been suggested. , metoclopramide has been reported to increase the lower esophageal sphincter tone in humans, although in cats metoclopramide's affect on the lower esophageal sphincter is reported to be weak. adverse central nervous system, extrapyramidal signs occur secondary to dopamine (d ) antagonism, including excitement and behavior changes. extrapyramidal signs are most often seen at the higher doses needed to block -ht receptors. because of metoclopramide's prokinetic properties, an intestinal obstruction should be ruled out prior to its use. dopamine is a less important neurotransmitter in the chemoreceptor trigger zone of cats than alpha adre nergic and -ht -serotonergic receptors, suggesting that d -dopaminergic antagonist may be a less effective antiemetic in cats. clinically metoclopramide commonly controls vomiting in cats, although this clinical response may be secondary to -ht antagonism and/ or its prokinetic effects. , extrapolated from the short elimination half-life of metoclopramide in dogs ( minutes), frequent be clinically significant side effects. phenothiazines have the potential to lower the seizure threshold; their use is not recommended in patients with a known seizure history. other cns-associated side effects linked to d antagonism occur at higher doses and produce extrapyramidal signs, including rigidity, tremors, weakness, and restlessness. antagonism of the histaminergic receptors carries the risk of sedation. because of the need for frequent dosing ( . to . mg/ kg subcutaneously every hours) and the risk of hypotension and sedation, the clinical use of phenothiazine antiemetics is limited to hospitalized patients with refractory vomiting and should be avoided in patients who are dehydrated or hypotensive. cisapride is a serotonergic -ht agonist that increases propulsive gastrointestinal motility from the lower esophageal sphincter to the colon. cisapride binds serotonergic -ht receptors in the myenteric plexus, increasing the release of acetylcholine in gastrointestinal smooth muscle. in dogs cisapride has greater prokinetic activity in the stomach relative to metoclopramide. cisapride has no direct antiemetic effect, although it is indicated in a vomiting cat with colonic dysmotility secondary to megacolon. colonic distention can trigger the vomiting reflex in cats. cisapride induces colonic smooth muscle contractions in cats with megacolon that is dependent on the influx of extracellular calcium and is only partially cholinergic dependent. other potential indications include refractory generalized ileus or gastroesophageal reflux. dosage recommendations based on the pharmacokinetics in healthy cats is . mg/kg orally every hours. prior to the use of cisapride, an intestinal obstruction should be ruled out because of its strong prokinetic effects. side effects reported in humans are cramping and diarrhea. potentially life-threatening side effects include qt prolongation and ventricular arrhythmias, the primary concern in humans that led to cisapride's removal from the market in the united states. in cats qt prolongation associated with cisapride administration requires times the therapeutic dose. because of the risk of prolongation of the qt interval and ventricular arrhythmias, the concurrent use of cisapride and dolasetron is not recommended. other potential drug interactions associated with cisapride include concurrent therapy with azole antifungals (ketoconazole and itraconazole), because of their inhibition of hepatic cyp a isoenzyme system and the inhibition of cisapride metabolism. diet trials are commonly used in cats with idiopathic gastrointestinal signs or in cats with suspected or known intermittent dosing or delivery by a constant rate infusion (cri) is necessary. empirical dosing in cats is . to . mg/kg subcutaneously or orally every hours or to mg/kg/day as a cri. approximately % of metoclopramide is excreted in the urine, thus dose reduction is recommended in cats with underlying renal azotemia. dolasetron and ondansetron are selective serotonin antagonists that inhibit central and peripheral -ht receptors. their main antiemetic effect is through antagonism of the peripheral -ht receptors in the gastrointestinal tract. in cats -ht antagonism of the crzt is also likely important in the antiemetic effect of dolasetron and ondansetron. dolasetron and ondansetron were originally used for vomiting secondary to chemotherapy because of their superior clinical efficacy. the clinical use of dolasetron and ondansetron in cats has not been associated with reported side effects, and experimental studies report minimal toxicity in animals at doses times the antiemetic dose. side effects reported in humans include headaches, elevated liver enzymes, rare hypersensitivity reactions, prolongation of the qt interval, and arrhythmias. , dolasetron is commonly used for parenteral administration and ondansetron for oral administration, dictated primarily based on the tablet sizes available and cost. recommended dosing of dolasetron is . to mg/kg intravenously every hours and ondansetron . mg/ kg orally every hours. maropitant is a neurokinin- (nk- ) receptor antagonist, blocking the binding of substance p to the nk- receptors located in the emetic center, crtz, and the enteric plexus. in cats maropitant has been reported to be efficacious in treating xylazine-induced vomiting and motion sickness. recommended dosing in cats is mg/ kg intravenously, subcutaneously or orally every hours for up to days. maropitant is reported to be well tolerated in cats. prochlorperazine and chlorpromazine are considered broad-spectrum antiemetics by antagonism of d dopaminergic, histaminergic (h and h ), and cholinergic (muscarinic) receptors within the crtz and, at high doses, the alpha-adrenergic receptors (alpha and alpha ) within the vomiting center. in cats alpha -receptors play a key role in emesis (recall xylazine is the emetic of choice in cats), suggesting cats may be more sensitive to the antiemetic effects of the phenothiazines. prochlorperazine and chlorpromazine produce an antiemetic effect at relatively low doses, thus avoiding profound sedation; although, because of antagonism of the alpha-receptors, vasodilation and hypotension can hyperacidity alone is not considered a common cause for vomiting in cats, but famotidine is effective in treating vomiting in cats associated with gastric ulcers or gastritis. recommended dosage in cats is . mg/kg every to hours. ranitidine is also a competitive inhibitor of the h receptor associated with gastric parietal cells. in addition, ranitidine increases lower esophageal sphincter tone and functions as a prokinetic agent (increasing gastric emptying and stimulating intestinal motility, including colonic motility), because of its anticholinesterase food hypersensitivities. dietary strategies used to control vomiting in cats focus on either a highly digestible diet or an elimination (novel protein/carbohydrate or hydrolyzed protein) diet. the empirical use of elimination diets in cats is reported to be relatively successful, with approximately % of cats with idiopathic gastrointestinal signs responsive to a novel protein/carbohydrate diets within to days. interestingly, traditional diet trials are recommended for a minimum of to weeks, but in this group of diet-responsive cats with chronic gastrointestinal disease, clinical improvement was reported within days. thus if a cat is going to be diet responsive, clinical improvement to a diet trial should be noted relatively early. highly digestible diets enable more effective absorption and assimilation of nutrients in the face of a compromised digestive tract. these diets contain highly digestible proteins and carbohydrates, moderate to low fat, soluble fiber but low concentrations of insoluble fiber, and are supplemented with omega- fatty acids. these diets are recommended when food allergy or intolerance is suspected. these diets contain a single highly digestible novel carbohydrate source and novel protein source. alternatively, diets formulated with hydrolyzed proteins can be used as an alternative to novel protein/carbohydrate diets. see tables - and - for information on gastrointestinal ulcers. famotidine has no direct antiemetic effect but is a competitive inhibitor of the histamine (h ) receptors associated with the gastric parietal cells. the h -receptor is the dominant receptor involved in gastric acid secretion. h receptor antagonism is reported to result in a % to % reduction in acid production. famotidine is more effective at suppressing gastric acid secretion relative to ranitidine. famotidine is well tolerated, although, with chronic therapy, there is the potential for hypoacidity and gastric bacterial overgrowth. in humans dose reduction is recommended in association with renal dysfunction. famotidine is not an inhibitor of the hepatic microsomal cytochrome p- enzyme system, therefore significant drug interactions are not anticipated. activity. , significant drug interactions associated with hepatic microsomal cytochrome p- enzyme system inhibition are not a clinical concern with ranitidine. an adverse effect to be aware of in cats treated with ranitidine is transient hypotension associated with ranitidine administered as an iv bolus. in humans dose reduction is recommended in patients with renal azotemia. ranitidine is effective in decreasing gastric acid in cats. ranitidine would be a logical choice in a cat with gastrointestinal ulceration and/or atony. the reported dosage recommendation for ranitidine in cats is . mg/ kg orally every hours or . mg/kg intravenous every hours. omeprazole omeprazole is a proton pump inhibitor that targets the h + /k + atpase pump on the luminal surface of partial cells. omeprazole is effective at suppressing parietal cell acid secretion, and its effects persist for ≈ hours after drug withdrawal because of drug accumulation in the parietal cell (by ion trapping). indications for omeprazole therapy are for the treatment and prevention of nonsteroidal antiinflammatory drug (nsaid)-induced ulcers. omeprazole is enteric coated to prevent its degradation by gastric acid; therefore oral formulations should not be crushed. based on human studies, omeprazole is a hepatic microsomal cytochrome p- enzyme inhibitor with known drug interactions with diazepam. the extent of clinically significant drug interactions in cats has yet to be studied. omeprazole is reported to be effective in reducing gastric acid secretion in cats. the recommended empirical dosage in cats is . to mg/kg orally once daily. long-term use in humans and dogs is associated with gastric polyps and parietal cell hyperplasia, respectively, but the effect of long-term use in cats is currently unknown. sucralfate is a disaccharide complexed with aluminum that dissociates to sucrose octasulfate and aluminum hydroxide upon exposure to gastric acid. the sucrose octasulfate spontaneously polymerizes, producing a viscous material capable of binding ulcerative lesions in the gastric mucosa. once bound to the exposed mucosa, it prevents back diffusion of h + , inactivates pepsin, absorbs bile acids, and increases mucosal prostaglandin synthesis, collectively supporting ulcer healing. sucralfate is not systemically absorbed but does prevent the absorption of drugs capable of chelating with aluminum, including fluoroquinolones, tetracyclines, and digoxin. if sucralfate is indicated in a cat being treated concurrently with fluoroquinolones, tetracyclines, or digoxin, the recommendation is to administer the other drug hours prior to the administration of sucralfate to optimize drug absorption. clinical indications for the use of sucralfate in cats are for the treatment of gastric ulcers and esophagitis. dosage recommendation in cats is mg orally every hours. sucralfate can be crushed, suspended in water, and administered as slurry. diet trials are used in some cats with diarrhea if the underlying cause is from known or suspected food hypersensitivities. dietary management includes either a highly digestible diet, an elimination (novel protein/ carbohydrate or hydrolyzed protein) diet (see above for both), or a diet high in fiber. high-fiber diets contain a mixture of both soluble and insoluble fiber that can be beneficial in patients with signs of large bowel diarrhea. insoluble fiber, such as cellulose, functions to increase the bulk of the stool, bind fluid, and regulate intestinal motility. soluble fiber, including fruit and vegetable pectins and beet pulp, functions as a source of butyric acid that can be used by the colonic mucosa and decreases proinflammatory cytokines. , cobalamin cobalamin (vitamin b ) is an essential vitamin needed by a number of different enzymes, including key enzymes involved in methionine metabolism and the conversion of methylfolate to tetrahydrofolate needed for dna synthesis. cobalamin and folate are intimately linked, and hypocobalaminemia can lead to a functional deficiency of folate. ingested cobalamin requires intrinsic factor binding for enterocyte absorption at the level of the ileum. hypocobalaminemia is commonly associated with distal small intestine diseases in cats, including inflammatory bowel disease. in addition, low cobalamin has a negative impact on enterocyte function; therefore in many cats with intestinal disease and hypocobalaminemia, cobalamin supplementation is necessary for resolution of clinical signs. , quantification of serum cobalamin levels is recommended in cats with clinical signs of small bowel diarrhea, ones suspected to have an infiltrative disease of the small intestine (inflammatory bowel disease or gastrointestinal lymphoma), or ones with pancreatic dysfunction. when hypocobalaminemia is identified, supplementation is recommended mannanoligosaccharides, inulin, chicory, and lactosucrose. reports on the use of prebiotics in cats are limited to their use in healthy cats; healthy cats fed fructooligosaccharides were reported to have a trend toward an increase in fecal concentrations of lactobacilli and a decrease in concentration of c. perfringens and e. coli relative to the controls. to date no reports are available on the use of prebiotics in cats with gastrointestinal disease. probiotics and prebiotics potentially have a supportive role in the treatment of gastrointestinal disease in cats. the important clinical consideration in the use of probiotics as an adjunctive therapy is to ensure the use of live nonpathogenic microorganisms that have been documented to colonize the intestinal tract of cats. gastrointestinal flora co-evolve with their host. gastrointestinal microorganism colonization varies among species and within each individual animal. the distribution of fecal microflora for a given individual is considered unique but stable over time. antimicrobial and antiparasitic therapies for the treatment of feline diarrhea are indicated based on the specific diagnosis of infectious diarrhea, bacterial enteritis, or as adjunctive therapy for inflammatory bowel disease. infectious pathogens more commonly associated with feline diarrhea include bacterial enteropathies (clostridium, campylobacter), protozoal enteropathies (tritrichomonas foetus, giardia spp.), and helminthic enteropathies associated with ascarids, hookworms, whipworms, and tapeworms. only the more common anthelminthic, antimicrobial, and antiprotozoal therapies are discussed below (tables - and - ) . more information about antimicrobials and antiparasitics is found under specific infections in the discussions of infectious enteritis and gastrointestinal parasites. fenbendazole is an anthelmintic used to treat common helminth infections, including ascarids, hookworms, whipworms, and a single species of tapeworm, taenia pisiformis. giardia spp. are also considered susceptible to fenbendazole. fenbendazole binds beta-tubulin subunits of microtubules, interfering with their polymerization. side effects include vomiting and diarrhea, although both are considered rare. fenbendazole is not approved for use in cats in north america but is commonly used clinically, and an empirical dosage of mg/kg ( µg/cat every days) while the underlying cause of cat's malabsorption is being investigated and at initiation of targeted therapy. probiotics probiotics are ingested live microorganisms intended to benefit the host, specifically to support the microflora environment of the gastrointestinal tract as well as to provide an overall benefit to the body's immune function by immunomodulation. , , probiotics chemically modify ingesta and intestinal mucus, as well as affect immune cells, enterocytes, and goblet cells within the intestinal mucosa through direct receptor interactions and indirectly through the action of cytokines. the microorganisms commonly used are nonpathogenic bacteria and yeast that have a vital role in gastrointestinal health, including lactobacillus spp., enterococcus faecium, bifidobacterium spp., and saccharomyces spp. for example, lactobacilli synthesize b vitamins, digestive enzymes, and folate coenzymes. clinical indications for the use of probiotics are diverse, including primary gastrointestinal disease, chronic renal disease, and pancreatitis. the rational use of probiotics in the treatment of gastrointestinal diseases include their ability to modulate gastrointestinal flora, minimize colonization by pathogenic bacteria, and decrease the likelihood of bacterial translocation. in healthy cats, lactobacillus acidophilus is reported to reduce fecal clostridium counts. when lactobacillus acidophilus was used adjunctively with antimicrobial therapy, fecal shedding of campylobacter was reduced in cats with campylobacter-induced diarrhea relative to cats treated with antimicrobials alone. specifically, in cats with gastrointestinal disease, available research supports the probiotic enterococcus faecium as clinically beneficial in resolving diarrhea in kittens. relative to the control group, the kittens treated with probiotics had increased fecal bifidobacteria and blood iga concentrations and decreased fecal counts of clostridium perfringens. prebiotics are dietary supplements used to select for the more beneficial enteric flora, support gastrointestinal function, and prevent the overgrowth of pathogenic bacteria, including salmonella, escherichia coli, clostridium, or campylobacter. for a food additive to be considered a prebiotic, it must be nondigestible by the gastrointestinal tract (resistant to gastric acidity, gastrointestinal hydrolysis and absorption), yet fermentable by gastrointestinal microflora to short-chain fatty acids to stimulate the growth of "good" intestinal bacterial. prebiotics include nondigestible oligosaccharidescommonly, oligofructose, fructo-oligosaccharides, pyrantel pamoate is a nicotinic anthelmintic used primarily for the treatment of ascarids, but its spectrum of activity also includes hookworms and the stomach worm, physaloptera spp. pyrantel is toxic to susceptible parasites through its selective action on their nicotinic acetylcholine receptors, resulting in depolarization and spastic paralysis. pyrantel is not approved for use in cats but is considered safe in cats and is commonly used clinically. the dosage recommendation in cats is mg/ kg orally once, repeat in weeks, and finally repeated in months. metronidazole is a nitroimidazole antibiotic with an anaerobic antibacterial spectrum with antiprotozoal activity against giardia spp. in an anaerobic environment, metronidazole is converted to unstable intermediates (nitroso free radicals) that disrupt bacterial dna synthesis. immunomodulatory properties capable of inhibiting cell-mediated immunity have been described for metronidazole, although its immunomodulatory properties are reported at dosages well beyond what is recommended for clinical use, raising questions about the clinical use of metronidazole as an adjunctive therapy for treating inflammatory bowel disease. , resistance to metronidazole is considered rare. the most common adverse reaction is gastrointestinal upset, including inappetence, anorexia, nausea, and vomiting. profuse salivation can occur in cats after oral administration of metronidazole base (formulation used in standard tablets), which has lead to the use of metronidazole benzoate (a compounded formulation not approved by the food and drug administration) in some cats because of its better oral palatability. at high doses (> mg/ kg/day) benzoic acid is reported to be neurotoxic in cats, but with appropriate clinical dosing of metronidazole benzoate benzoic acid toxicity is unlikely. dose-related metronidazole toxicity in cats results in cerebellovestibular ataxia secondary to gamma-aminobutyric acid (gaba) inhibition at dosages greater than or equal to mg/kg/day , ; clinical signs include nystagmus, head tilt, ataxia, seizures, and obtundation. in cats with inflammatory bowel disease, the dosage recommendation for the metronidazole base is to mg/kg/day. metronidazole benzoate contains approximately % metronidazole base by weight, translating to an empirical dosage of mg/kg/day of metronidazole benzoate (equivalent to . mg/kg/day of metronidazole base). little is known about the safety of chronic metronidazole use in cats, but oral metronidazole has been reported to disrupt dna within feline peripheral mononuclear cells following days of therapy. this metronidazole-induced genotoxicity is reversible and is no longer detected days after antibiotic therapy is discontinued. ronidazole is a nitroimidazole antibiotic (similar to metronidazole) and available as a powder-on-feed antibiotic. ronidazole is not approved for use in cats but has immunosuppressive therapies used in cats with inflammatory bowel disease include glucocorticoids, cyclosporine, and chlorambucil (tables - and - ). more information on the treatment of inflammatory bowel disease is found elsewhere in this chapter. glucocorticoids are considered first-line therapy in the treatment of cats with inflammatory bowel disease. glucocorticoids bind their intracellular glucocorticoid receptors, modifying the expression of genes with glucocorticoid response elements. immunomodulation is achieved through inhibition of cytokine release and response, including decreasing leukocyte phagocytosis, chemotaxis, and antigen expression. the more common side effects in cats include gastrointestinal ulceration, opportunistic infections (e.g., urinary tract infections), pancreatitis, and diabetes mellitus. cats are less susceptible to iatrogenic hyperadrenocorticism than dogs. initial therapy is usually with oral prednisone or prednisolone. prednisone is a prodrug that is metabolized to its active form prednisolone. cats are reported to be less efficient in the conversion of prednisone to prednisolone ; therefore prednisolone may be preferred in cats, especially in cats refractory to prednisone therapy. been used off-label to effectively treat tritrichomoniasis in naturally and experimentally infected cats ( mg/kg orally every hours for days). t. foetus reduces nitroimidazoles to their nitroso free radicals. ronidazole has been reported to have better in vitro and -fold higher in vivo activity against t. foetus relative to metronidazole. , , ronidazole resistance is beginning to be reported in t. foetus isolates from cats with diarrhea. side effects include hepatoxicity and neurotoxicity. neurotoxicity is associated with high doses and has been reported in cats. the use of ronidazole is recommended only for confirmed cases of t. foetus, and dosing should not exceed mg/kg once daily in cats, especially in cats at risk for neurotoxicity. ronidazole is not registered for human or veterinary use in the united states; therefore its use in cats requires owner informed consent and client education of the potential human hazards. immunosuppressive therapies are considered the standard of care for cats with gastrointestinal biopsies consistent with inflammatory bowel disease (lymphoplasmacytic or eosinophilic inflammation). the common alternative forms of glucocorticoids can be considered in specific patient populations. in patients with severe malabsorption, injectable dexamethasone may provide improved bioavailability and clinical response. also dexamethasone maybe preferred in patients with a history of heart failure, fluid retention, or hypertension because of its lack of mineralocorticoid activity relative to prednisone/prednisolone. dexamethasone's potency is to times that of prednisolone; therefore a dose reduction is necessary when prescribing dexamethasone (the dexamethasone dose is one seventh that of prednisolone). , budesonide is an oral, locally active, highpotency glucocorticoid that is formulated to be released in the distal gastrointestinal tract (based on the ph differential between the proximal and distal small intestine), where it is absorbed and is locally immunomodulating at the level of the enterocyte. the amount of systemically absorbed budesonide is minimized, because % to % of the budesonide absorbed from the gastrointestinal tract undergoes first-pass metabolism in the liver. some systemic absorption does occur, as evidenced by a blunted adrenocorticotropic hormone (acth) stimulation test in dogs treated with budesonide at mg/m for days. , the use of budesonide in cats remains anecdotal, with a suggestive empirical dose of . to mg/cat/day. initial glucocorticoid therapy for cats with inflammatory bowel disease consists of antiinflammatory ( . to mg/kg/day) to immunosuppressive ( to mg/kg/ day) dosages, with dosages based on the potency of prednisone/prednisolone. the goal of therapy is to achieve clinical remission and slowly taper the dose of glucocorticoids to the lowest dose that will control the cat's clinical signs. some cats may be completely weaned off therapy, while others require long-term lowdose therapy. the tapering of therapy should be slow, with a % to % dose reduction every to weeks. cyclosporine is considered a second-tier immunosuppressive drug used to treat inflammatory bowel disease in cats. use of cyclosporine in the treatment of diarrhea associated with inflammatory bowel disease in cats is extrapolated from its use in dogs to treat glucocorticoid refractory inflammatory bowel diarrhea. cyclosporine suppresses t-lymphocyte-mediated inflammation in the gastrointestinal tract secondary to suppression of inflammatory cytokines. specifically, cyclosporine attenuates t-lymphocyte activation and proliferation through the inhibition of interleukin- (il- ) production. side effects of cyclosporine in cats include dose-dependent inappetence and vomiting, which may occur at the onset of therapy and are generally responsive to dose reduction. other less common side effects reported in cats are opportunistic infections, including toxoplasmosis and hepatoxicity. the microemulsion formulation of cyclosporine has higher oral bioavailability and less variable pharmacokinetics. a suggested initial dosage of cyclosporine is mg/kg every or hours. serum cyclosporine levels can be used to monitor for excessive trough plasma concentration (> ng/ml) as determined using a highperformance liquid chromotography (hplc) analytical method. chlorambucil is a slow-acting nitrogen mustard that alkylates and effectively cross links dna, leading to altered protein production. the immunosuppressive effects of chlorambucil are the result of its cytotoxic effect on lymphocytes, similar to other nitrogen mustards. bone marrow suppression is considered mild to moderate and is rapidly reversible. neurotoxicity and myoclonus has been reported in a cat accidently overdosed with chlorambucil. chlorambucil is used as a second-tier drug in cats to treat immune-mediated disorders, in part because of ease of administration and its low risk of myelosuppression. for the treatment of inflammatory bowel disease, the recommended dosing in cats is mg/cat every hours in cats greater than kg and mg/cat every hours in cats less than kg. chlorambucil is commonly used in combination with glucocorticoids in the treatment of immune-mediated diseases, including inflammatory bowel disease, overlooked. awareness about feline esophageal diseases is low, the clinical signs are often not specific, and imaging beyond survey radiographs may be required for diagnosis. the esophagus is composed of four layers (from inner to outer): mucosa, submucosa, muscularis, and adventitia (there is no serosal layer). in the dog, the muscle layer is entirely composed of skeletal muscle, but in cats, the distal third of the esophagus is composed of smooth muscle. the upper esophageal sphincter prevents reflux of esophageal contents into the pharynx and minimizes aerophagia. the lower esophageal sphincter prevents gastroesophageal reflux and relaxes during swallowing to allow food and fluid to enter the stomach. clinical signs of esophageal disease include drooling, dysphagia, pain on swallowing (odynophagia), and, most classically, regurgitation. weight loss may occur secondary to inadequate food intake when disease is severe or chronic. other clinical signs, such as anorexia, cough, dyspnea, and fever, may occur if complications such as aspiration pneumonia or esophageal perforation occur. regurgitation is passive expulsion of food or fluid from the esophagus. the food is undigested and often accompanied by mucus and saliva. mucosal erosions may produce frank blood in the regurgitated material. regurgitation must be differentiated from vomiting (table - esophageal disease is uncommon in the cat when compared with dogs, but it is also likely that problems such as esophagitis and esophageal strictures are often salivation, retching, and abdominal contractions. the vomitus consists of partially digested food from the stomach and/or intestines and may be mixed with bilestained fluid. some cats will have both vomiting and regurgitation. expectoration may also be confused with vomiting or regurgitation. expectoration is associated with coughing, but cats that cough excessively may also stimulate vomition so that a careful history is needed to characterize the clinical signs correctly. coughing may also occur in cats that have aspirated as a result of regurgitation. drooling, dysphagia, and odynophagia are most commonly seen with conditions of the oropharynx and/or proximal esophagus. odynophagia is most commonly associated with esophagitis and foreign bodies. dysphagia and regurgitation together most commonly indicate oral or pharyngeal dysfunction; if regurgitation is not accompanied by dysphagia, esophageal dysfunction is likely. regurgitation in cats with esophageal disease is caused by obstruction or muscular dysfunction. causes of obstruction include vascular ring anomaly, foreign object, stricture, and neoplasia. causes of muscular dysfunction include congenital disease, esophagitis, myopathies, neuropathies, and dysautonomia. regurgitation may occur immediately after eating if the lesion is in the proximal esophagus. however, a dilated esophagus provides a reservoir for food and fluid so that regurgitation may not be associated in time with eating. young cats with signs of esophageal disease should be suspected of congenital defects, such as vascular ring anomaly, or a foreign body. adult cats with esophageal disease may have a recent history of general anesthesia, administration of certain oral medications, or ingestion of irritant chemicals. acute onset of clinical signs may suggest a foreign body, while chronic, slowly worsening signs may indicate a stricture or tumor. all cats suspected of esophageal disease should have a minimum database as part of the diagnostic plan (complete blood cell count, serum chemistries, urinalysis, and other tests as indicated by age or concurrent diseases, such as serum total t and blood pressure measurement). an important part of diagnosis is observation of the cat while eating food, to localize the location of the dysfunction. if the cat is unwilling to eat while in the veterinary clinic, the owner can make a video of the cat eating at home for the clinician to view. the general diagnostic approach to regurgitation in cats is found in figure - . plain and contrast radiography and endoscopy are important diagnostic tools for esophageal disease. fluoroscopy is valuable for the diagnosis of motility disorders, but availability is limited to universities and referral centers because of the cost of equipment. ultrasonography is limited to evaluation of * references , , , , , . the cervical esophagus and a small segment of abdominal esophagus between the cardia of the stomach and the diaphragm. the entire esophagus should be evaluated with cervical and thoracic radiographs. thoracic radiographs may also show evidence of complications such as aspiration pneumonia or esophageal perforation. the normal esophagus is not visualized on plain radiographs, but may be seen if food or fluid are retained or a foreign body or mass is present. radiographic contrast agents useful for esophagrams in cats include liquid or paste barium. a water-soluble iodinated contrast agent (e.g., iohexol, gastrografin) is preferred if there is any risk the esophagus is perforated, because these agents are less irritating and more rapidly reabsorbed. esophagrams are most useful for diagnosis of luminal obstructions, extraluminal compression, mucosal irregularities, and possibly alterations in motility. dilute liquid barium can be administered with a syringe or it may be mixed with canned food, especially if a motility disorder or stricture is suspected. multiple lateral radiographs are taken rapidly, starting within seconds of swallowing the contrast agent. contrast is rapidly cleared from the normal esophagus by peristalsis. if the contrast in the esophagus terminates abruptly, an obstruction is likely. if the contrast is retained throughout the esophagus, muscular dysfunction is suspected. some conditions, such as esophagitis, are difficult to diagnose radiographically, because contrast agents may or may not adhere to ulcerated mucosa. flexible endoscopy is a noninvasive diagnostic tool for esophageal disorders and is often used if plain and contrast radiographs have failed to establish a diagnosis. it is most sensitive for diagnosis of masses, ulcers, perforations, and obstructions. in addition, it is often possible to retrieve foreign bodies using endoscopy as well as to assist with dilatation of strictures or placement of gastrostomy feeding tubes if required. biopsy of the esophageal mucosa is more difficult than biopsy of gastric or intestinal mucosa and is not commonly performed with the exception of mass lesions. esophagitis may result from various causes of inflammation, such as contact irritation from foreign bodies (including trichobezoars lodged in the esophagus), chemical irritants or caustic medications, gastroesophageal reflux, persistent vomiting, hiatal hernia, or general anesthesia. inflammation disrupts the esophageal mucosa and exposes the submucosa. an important part of the treatment plan is identification and treatment of the underlying cause. clinical signs include dysphagia, regurgitation, salivation, and repeated swallowing, although signs may be absent in cats with mild esophagitis. cats with odynophagia may repeatedly extend the head and neck while swallowing. if the esophagitis or underlying disease is severe, weight loss and dehydration may occur secondary to anorexia. if the submucosa and muscularis are damaged, strictures may form as a result of the production of fibrous connective tissue and compromise the esophageal lumen. neoplasia is an important cause of esophageal stricture in humans, but not in cats. most cases have single strictures, but multiple strictures are possible. in two studies, the mean stricture diameter was reported as mm. , most strictures are less than cm in length. clinical signs associated with strictures appear to days after the esophageal injury and may be present for weeks before definitive treatment is pursued. regurgitation typically occurs immediately after eating, although if the stricture is long standing, a pouch may form cranial to the lesion where food accumulates. survey radiographs may be normal in cats with esophagitis and strictures, but are useful to rule out other causes for the clinical signs, such as a foreign body, or to detect related problems, such as aspiration pneumonia. in some patients, dilation of the esophagus with fluid or air may be seen. a contrast esophagram may disclose irregularities of the mucosa in cats with severe esophagitis. segmental dilation may occur with severe inflammation. strictures may be diagnosed with an esophagram (figure - ) ; however, in some cases, it may be difficult to differentiate a stricture from intramural thickening (e.g., because of neoplasia). endoscopy is useful for diagnosis of esophagitis; findings include mucosal erythema, hemorrhage, and erosions or ulcerations. if gastroesophageal reflux is present, the lesions will be most severe in the distal esophagus, and the lower esophageal sphincter may be dilated. endoscopy is often used for definitive diagnosis of esophageal stricture as well as to visualize the lesion during treatment by bougienage or balloon catheter dilation. strictures appear as a ring of white fibrous tissue that narrows the esophageal lumen. if endoscopy is performed after a barium esophagram, hours should be allowed to elapse between the procedures or the barium will obscure visualization with the endoscope. general anesthesia is an important cause of esophagitis (sometimes leading to stricture formation) in cats, probably because gastroesophageal reflux appears to occur commonly in anesthetized cats.* for example, in a series of seven cats with benign esophageal stricture, recent anesthesia for ovariohysterectomy was the suspected cause in five cases. clinical signs appeared up to days after anesthesia. abnormal esophageal tissue was performed in two cases. the authors noted that the esophageal mucosa may appear grossly normal, but submucosal inflammation may be found on histopathologic examination of biopsies. a consequence of chronic severe gerd in humans is the development of metaplastic columnar epithelium (barrett esophagus) that replaces the normal squamous epithelium. one case series reported on barrett-like esophagus in three cats. two cases were associated with hiatal hernia and one with cardial incompetence. drug-induced esophageal damage and stricture formation is well known in humans and cats (see . in humans over drugs have been implicated, and most are antibacterials or nsaids. implicated drugs in the cat include tetracycline, doxycycline, and clindamycin in tablet or capsule form administered without a food or water bolus. , , , , clinical signs (dysphagia, regurgitation, salivation, anorexia) appear to days after drug treatment is started. strictures commonly form in the midcervical esophagus or over the heart base in the thoracic esophagus. doxycycline hyclate is most commonly associated with esophageal strictures in cats, and the principle reason for its irritating properties is an acidic ph. the monohydrate salt of doxycycline is less irritating and is marketed as tablets and a palatable paste licensed for use in dogs and cats in some countries. in humans esophageal ulceration after doxycycline therapy is more common than stricture formation. although the development of strictures in cats would appear to be uncommon, it seems possible the incidence of esophagitis is underestimated, because the clinical signs (e.g., odynophagia, chest pain) may go unrecognized. esophageal transit studies of normal cats have shown that the passage time of dry-swallowed tablets and capsules is often prolonged (longer than seconds). , complete entrapment (retention for more than minutes) in the midcervical region occurs commonly. however, a small bolus of food or water is sufficient to ensure immediate passage of the medication into the stomach. , the risk of esophageal retention can also be lessened by coating a tablet or capsule with butter or a gel dietary supplement (nutri-cal; vétoquinol, fort worth, tex.). one study determined that tablets or capsules administered using a one-step pill gun with flavored liquid (flavorx pill glide; flavorx, columbia, md.) or a pill delivery treat (greenies pill pockets; nutro products, franklin, tenn.) ensured an average transit time of seconds or less. delayed esophageal transit of medications allows tablets and capsules to disintegrate within the esophagus, exposing the mucosa to irritating chemicals. cats may be at risk of delayed esophageal transit, because they do not typically drink water with medication, and they do not have an upright posture. in addition, medications are often given to sick or dehydrated patients many preanesthetic drugs and induction agents reduce lower esophageal sphincter pressure. , other predisposing factors may be intraabdominal surgery and a head-down position on the surgery table. reflux fluid with a ph less than is likely to cause esophageal mucosal damage, as is prolonged contact time. esophageal defense mechanisms include clearance of the reflux fluid by peristalsis and neutralization of the acidic ph by the bicarbonate present in saliva. in a study of kittens less than weeks of age, risk of gastroesophageal reflux during anesthesia was evaluated with use of a laryngeal airway mask versus endotracheal intubation. gastroesophageal reflux was observed in % of kittens with use of the laryngeal airway mask but more importantly in % of kittens with endotracheal intubation. the reflux episodes occurred shortly after anesthesia induction. in a study of cats anesthetized with thiopentone or propofol, gastroesophageal reflux occurred in %. reflux also occurred shortly after anesthesia was induced and lasted for a mean of minutes. it is unknown why esophageal strictures form only in a small number of cats that experience gastroesophageal reflux during anesthesia. gastroesophageal reflux disease (gerd) is a commonly reported cause of esophagitis in humans, but it is rarely reported in cats when not associated with general anesthesia. , the true incidence is unknown, and diagnosis may be hampered by scant knowledge about the clinical presentation and diagnosis. clinical signs and diagnostic procedures are as for other causes of esophagitis. in one case series of three cats, diagnosis of gerd was based on clinical signs, contrast radiography, and endoscopic findings. biopsy and histopathology of obtained from a compounding pharmacy in most countries and can only be given orally. h -receptor antagonists are competitive inhibitors that block parietal h receptors and decrease the amount of gastric acid produced. proton pump inhibitors are noncompetitive inhibitors that act on the h + /k + atpase enzyme system at the secretory surface of gastric parietal cells. they are considered superior for decreasing gastric acid secretion and are therefore the first choice, despite their greater cost. a drawback of proton pump inhibitors is that they must be administered orally. sucralfate may be beneficial for reflux esophagitis, because it binds to mucosal erosions in an acid environment and provides a protective barrier. it is given as oral slurry, ideally separate from meals or other medications. antibiotics are not commonly recommended unless aspiration pneumonia is present or the eroded mucosa is at risk of bacterial infection in a patient with severe disease or a compromised immune system. corticosteroids are often recommended for cats with esophagitis to reduce esophageal inflammation and impair the formation of fibrous connective tissue. however, the benefit of corticosteroids in cats with esophagitis has not been investigated and administration must be weighed against potential adverse effects, especially in patients with aspiration pneumonia. treatment of esophageal stricture typically requires dilation with either bougienage or a balloon catheter; both are used with endoscopic visualization under general anesthesia. appropriate analgesia should be provided, because dilating the stricture is painful. it does not appear that placement of a gastrostomy feeding tube is specifically required to recover from dilation procedures, although a tube may be placed in some anorexic cats to ensure nutritional intake and administer oral medications. a bougie is a long, narrow, oblong, mechanical dilator available in various sizes (typically -to -mm sizes are used in cats) that is gently passed through the stricture, usually over a guide wire. established criteria for selection of bougie diameter and dilation end points are not available. in one study, the initial bougie chosen was approximately the same size as the estimated diameter of the stricture, or no more than mm larger. once the first bougie is passed, subsequent bougies of increasing diameter are employed. two to four bougies of increasing size may be passed in a single session, with the goal of dilating the stricture without causing esophageal tear or perforation. determining when dilation should be stopped is a matter of clinical judgment. the procedure may be repeated as needed to maintain improvement; the total number of procedures required is variable. in one retrospective case series of eight cats treated with bougienage, the median number of procedures was . , and a good outcome was achieved in % of the cases. in some cases, the endoscope tip itself has been used for that may be at greater risk of esophageal retention of medication. all oral medication given to cats in tablet or capsule form should be followed with food or a liquid. mild esophagitis will resolve on its own, especially if an underlying cause can be removed or treated. frequent meals of canned food should be provided. cats with moderate to severe esophagitis will require medical therapy, and those with difficulty eating or weight loss may also require gastrostomy tube feeding. esophagostomy or pharyngostomy feeding tubes should be avoided in these patients. treatment is provided to control inflammation and promote healing while reducing gastric acid secretion and increasing lower esophageal sphincter tone. the length of medical treatment will vary from about one week to several weeks, depending on the underlying cause and severity of disease. medications indicated for esophagitis include prokinetics, h -receptor antagonists, proton pump inhibitors, and sucralfate (table - ) . prokinetic drugs enhance gastric emptying and increase lower esophageal sphincter tone. metoclopramide also has antiemetic effects, which may be beneficial in patients with chronic vomiting. it can be administered by the subcutaneous (sc) route, an advantage in a vomiting or regurgitating patient. cisapride may be more effective at enhancing both gastric emptying and lower esophageal sphincter tone, but it must be stent placement has recently been described in cats with esophageal strictures with variable results. a -year-old cat presented with a -week history of dysphagia and regurgitation caused by a single cervical esophageal stricture after treatment with oral clindamycin. guided balloon dilation was performed times over a period of weeks, but stricture formation always recurred. a self-expanding metal stent was placed using endoscopy and fluoroscopy after another dilation procedure. the cat did well eating a canned diet from an elevated position for months, but by months, the cat was no longer able to eat even liquid food and was euthanized. on necropsy, the stent had migrated and was obstructed by swallowed hair. in another case, a biodegradable self-expanding stent was used to successfully treat an -year-old cat that presented with a stricture in the cervical esophagus after anesthesia for dentistry. balloon dilation was performed twice, but regurgitation recurred days after the last procedure. the stricture was dilated a third time with a balloon catheter, and a tubular selfexpanding polydioxanone stent was placed with fluoroscopic guidance. the life span of the stent was estimated to be to weeks, sufficient time to allow healing of the esophagus. foreign bodies are less commonly found in the esophagus of the cat than in other gastrointestinal locations. reported foreign bodies include string, needles, fish hooks, and bones. trichobezoars may cause obstruction when they become lodged in the esophagus during vomiting ( figure - ). recurrent esophageal trichobezoars have been infrequently reported in the literature. , it is not known if an esophageal motility disorder is the underlying cause for recurrent obstructions. in one case, an esophageal diverticulum developed in association with recurrent trichobezoars. treatment for recurrent trichobezoars includes prokinetic drug therapy (e.g., cisapride), moderate to high-fiber diets, and shaving of long-haired cats. common areas for foreign bodies to lodge include the thoracic inlet, the heart base, and the esophageal hiatus in the diaphragm. obstruction of the esophageal lumen may be complete or partial. clinical signs include acute onset of gagging, salivation, repeated swallowing, dysphagia, and regurgitation. however, chronic esophageal foreign bodies have been reported in cats with dysphagia, intermittent regurgitation, and weight loss over a period of weeks or months. bougienage when bougies or balloon catheters were not available. balloon catheter dilation has become a popular method in recent years. , , although some clinicians feel this is a safer procedure than bougienage, there is no data in the literature to support this assumption. the catheter can be placed through the endoscope biopsy channel, alongside the endoscope, or with the aid of a preplaced guide wire. as for bougienage, established criteria for selection of balloon diameter and dilation end points are not available, and the clinician's best judgment must be used. various balloon sizes are available; in one study, the size was selected so that the inflated diameter was mm larger than the stricture diameter. the balloon is passed into the stricture with endoscopic guidance. it is then inflated to a predetermined pressure for to minutes to stretch the stricture, usually with saline, but contrast agents may also be used if fluoroscopy is used. as for bougienage, some cases may require more than one dilation procedure (typically two to four). cuffed endotracheal tubes are not appropriate substitutes for balloon catheters. regardless of the method used, after the dilation procedure, the endoscope should be used to look for other strictures and should be passed into the stomach to look for potential causes, such as causes of chronic vomiting. after treatment, medical management to decrease ongoing gastroesophageal reflux, resolve inflammation, and prevent further stricture formation should be instituted (as described previously). most cats are able to eat the day following the dilation procedure. corticosteroid treatment after dilation is controversial, and no controlled studies in animals are available. antibiotics are not routinely recommended. the prognosis for cats undergoing esophageal dilation is generally good based on the ability to eat canned food with minimal episodes of regurgitation. however, published studies show % to % of cats died or were euthanized despite multiple episodes of dilation, and up to % could only be fed liquid diets. , , , even among cats with good outcomes, a return to a dry kibble diet may not be possible. the dilation technique employed may be dictated by the clinician's experience, the equipment available, and the cost. potential complications of both methods include esophageal tear or perforation, hemorrhage, infection, and aspiration. esophageal tears or perforations may lead to pneumothorax or pneumomediastinum. repeated stricture formation is also possible, leaving only less desirable treatment options, such as long-term percutaneous gastrostomy tube feeding or surgery. esophageal surgery is generally avoided whenever possible, because it is difficult and invasive (requiring a thoracotomy), with risk of serious complications, such as failure of anastomosis, necrosis, and stricture formation. closure of incisions in the esophagus is following uncomplicated foreign body removal, the esophagus should be carefully inspected for lesions and bleeding before the endoscope is withdrawn. food and water should be withheld for to hours. supportive care includes fluid therapy and analgesia; a gastrostomy feeding tube may be required in selected cases for nutritional support. broad-spectrum antibiotics are administered to control bacterial infection and therapy for esophagitis should be instituted as described previously. careful follow-up should include evaluation for stricture formation. if an esophageal perforation has occurred, conservative management may be sufficient if the defect is small. a broad-spectrum antibiotic should be administered along with other supportive care, such as fluid therapy and analgesia. feeding through a gastrostomy tube for several days is recommended as well as close monitoring for complications such as pleuritis. large perforations require thoracotomy for surgical repair. megaesophagus is a diffuse hypomotility disorder that may be classified as congenital versus acquired or idiopathic versus secondary to other diseases. it is uncommon in cats compared with dogs. at least two dog breeds have been identified with heritable congenital megaesophagus. a heritable form of megaesophagus has been suggested for cats, particularly for siamese cats, although no detailed studies have been performed. , it is often frustrating to determine the underlying cause of acquired megaesophagus. megaesophagus may be a manifestation of neuromuscular diseases, such as dysautonomia or myasthenia gravis (see chapter ) . megaesophagus may also develop secondary to esophagitis from chronic vomiting or gerd. , other uncommon causes of megaesophagus are found in the literature. one case report describes a young cat with megaesophagus secondary to a large nasopharyngeal polyp that extended into the cervical esophagus. megaesophagus resolved once the polyp was removed. in another report, a young cat with diaphragmatic hernia was diagnosed with megaesophagus and gastric dilation. megaesophagus resolved with medical treatment and surgical correction of the diaphragmatic defect. clinical signs are typically those of esophageal dysfunction; regurgitation is the most consistently found sign. regurgitation may not be closely related in time to eating if the esophagus is markedly distended and holds food. cats with long-standing disease may suffer from weight loss or secondary rhinitis. the appetite is typically normal or increased. additional signs may occur if systemic neuromuscular disease is present. aspiration pneumonia may cause fever, dyspnea, and cough. two case reports describe cats with idiopathic cough, mucopurulent nasal discharge, and fever may be found if aspiration has occurred. trauma to the esophagus may cause esophagitis and even esophageal stricture. perforation of the esophagus by the foreign body may lead to pneumothorax, pneumomediastinum, or pyothorax with signs of depression, anorexia, fever, and dyspnea. if the perforation occurs in the cervical esophagus, swelling, cellulitis, and drainage of serous or purulent material may be noted. many foreign bodies are readily diagnosed with survey radiographs, especially if they are radiopaque. other radiographic findings include an esophagus dilated with fluid or air. radiolucent objects may be detected with an esophagram. care must be taken when performing esophagrams on cats that may have an obstruction, because aspiration is a concern. if abnormalities that could be consistent with an esophageal perforation (e.g., periesophageal gas or fluid, pleural effusion) are detected on survey radiographs, an aqueous iodine contrast solution should be used. removal of esophageal foreign bodies should be performed as soon as possible to minimize esophageal trauma and pressure necrosis. endoscopy can be used to confirm the diagnosis and often to remove the object. both rigid and flexible endoscopes may be used along with accessories such as various forceps and foley catheters. care should be taken to remove the object as atraumatically as possible, especially if the object is sharp or pointed. if the object is in the caudal esophagus and it cannot be grasped and removed, an attempt should be made to gently push it into the stomach, where it can be retrieved using laparotomy and gastrotomy. if esophageal perforation has occurred, esophagotomy is recommended and is described elsewhere. , removal of fish hooks may require a combination of surgery and endoscopy. , a surgical approach to the esophagus is made, but the esophagus is not incised; rather, the portion of the hook protruding through the esophagus is cut and removed, and the endoscope is used to retrieve the remainder. clinical sign is regurgitation, and most patients are underweight. a distended cervical esophagus may be palpated, and secondary aspiration pneumonia may occur. a history of regurgitation since weaning is very suggestive of a vascular ring anomaly, but other causes of regurgitation must be ruled out. survey radiographs show a dilated esophagus cranial to the heart, while the caudal esophagus is usually normal. the bulge of the aortic arch normally seen on a ventrodorsal radiographic view is absent. an esophagram is used to confirm the location of the obstruction and the severity of disease. definitive treatment is surgical repair of the vascular defect (i.e., ligation and transection of the ligamentosum arteriosum). some patients will require nutritional support through gastrostomy tube feeding and treatment for aspiration pneumonia before surgery. early diagnosis and surgical intervention brings the best prognosis for return of normal esophageal function. some affected cats are left with residual esophageal hypomotility, which is managed as for idiopathic megaesophagus. esophageal neoplasia is rare in the cat as in the dog. although parasitic granulomas caused by spirocerca lupi are associated with esophageal neoplasia in dogs, this parasite does not infect cats. both primary and metastatic esophageal tumors can occur in the cat. squamous cell carcinoma is the most common primary esophageal tumor in cats and is often found in the caudal two thirds of the esophagus. , , , affected cats are middle aged or older. clinical signs are typically those associated with esophageal obstruction, such as regurgitation, dysphagia, odynophagia, and salivation. patients with advanced disease may suffer anorexia, depression, and weight loss. on physical examination, an esophageal mass may or may not be palpable. survey and contrast radiographs reveal esophageal dilation, a soft tissue mass, or periesophageal lesions that displace the esophagus. computed tomography is useful to identify periesophageal or intraluminal masses. definitive diagnosis is made with endoscopy and biopsy. mucosal biopsies are difficult to obtain, because the esophageal mucosa is tough; exfoliative cytology may also be helpful. treatment is rarely undertaken, because disease is often advanced at the time of diagnosis, and many patients have complications such as aspiration pneumonia. palliation may be attempted with chemotherapy or radiation, although data on efficacy is unavailable. in general, squamous cell carcinomas in other anatomic locations respond poorly to treatment. surgical resection may be attempted if anastomosis can be accomplished without excessive tension. megaesophagus and chronic vomiting associated with intermittent gastroesophageal intussusception. , survey and contrast radiographs may identify a dilated esophagus (figure - ), but contrast fluoroscopy is the diagnostic tool of choice when available, because it allows for assessment of peristalsis. care must be taken with contrast studies because of the risk of aspiration. treatment of megaesophagus is largely symptomatic and supportive unless an underlying disorder can be identified and treated. frequent small meals are offered with the cat feeding in an upright position. the upright position should be maintained for at least minutes after eating to allow for gravity-assisted passage of food into the stomach. this is best accomplished by having the owner hold the cat over their shoulder so that the esophagus is in a vertical position. different types of diets should be offered to determine which is best for the individual patient; calorically dense diets may be beneficial for patients with weight loss. prokinetic drugs, such as cisapride, stimulate smooth muscle, but since most of the esophagus is skeletal muscle, the efficacy of such drugs is questionable for treatment of megaesophagus. prokinetic drugs also increase lower esophageal sphincter tone and may increase esophageal transit time, neither of which is desirable in patients with megaesophagus. vascular ring anomalies are congenital malformations of the great vessels that entrap the thoracic esophagus and cause obstruction. the most commonly reported anomaly is persistent right aortic arch. the esophagus is entrapped by the aorta on the right, the ligamentum arteriosum and the pulmonary trunk on the left, and the heart base ventrally. other vascular anomalies are rarely described in cats, such as a double aortic arch described in a siamese cat. onset of clinical signs occurs around the time of weaning to solid food so that most affected cats are presented at less than months of age. the most common surgery. surgery is the treatment of choice for large defects, especially in young cats with congenital disease or cats that have failed medical management. various reconstructive surgical techniques have been described. disorders of the hiatus are rare in cats. hiatal hernia is protrusion of the distal esophagus and stomach through the esophageal hiatus of the diaphragm into the thoracic cavity; the protrusion may be intermittent ("sliding") or persistent. other organs are occasionally involved, such as the omentum. this is distinct from a gastroesophageal intussusception where the stomach is prolapsed into the lumen of the distal esophagus. , both congenital and traumatic hiatal hernias have been described in cats. , , , , congenital hernias appear to be more common than acquired hernias, and affected cats typically present with clinical signs before year of age. it is suspected that increased inspiratory effort associated with upper airway obstruction, such as a nasopharyngeal polyp, may also lead to development of hiatal hernia. hiatal herniation reduces lower esophageal sphincter pressure. clinical signs associated with hiatal hernia, such as intermittent vomiting and regurgitation, may be because of reflux esophagitis, hypomotility, or obstruction. large hernias and secondary aspiration pneumonia may be associated with respiratory distress. survey radiographs may reveal a gas-filled soft tissue density in the caudal dorsal mediastinum. an esophagram will show the gastroesophageal junction and gastric rugae cranial to the diaphragm (figure - ) . both fluoroscopy and endoscopy may be useful for diagnosis but are not typically necessary. the prognosis for cats with hiatal hernia is considered to be good. a trial of medical management (as for reflux esophagitis) for month has been recommended before the stomach is a frequent site for gastrointestinal problems in cats, and the most common gastric problems are described in this chapter. some conditions such as gastric dilatation-volvulus are often reported in dogs but rarely reported in cats. in one report of three feline cases, all were associated with diaphragmatic hernia. gastric parasites, the diagnostic approach to the vomiting cat, the gastric emptying time of normal cats is shorter than that of other mammals. in one study, the gastric emptying half-time for solid food in normal cats was . to . hours. this implies prolonged fasting (longer than hours) in preparation for anesthesia and surgery is unnecessary. the main clinical sign of gastric disease is vomiting, but it is important to note that vomiting is also associated with many nongastric problems, including concurrent intestinal disease, such as enteritis or colitis. vomiting patients therefore require a thorough physical examination and diagnostic plan to determine the cause. vomiting must be distinguished from regurgitation, which is primarily associated with esophageal disease (see table - ). vomitus often contains food, hair, refluxed bile, and therapeutics for vomiting are covered elsewhere in this chapter. the anatomy of the feline stomach is similar to that of other mammals having a simple glandular stomach. most of the stomach is situated on the left side of the abdominal cavity. it has five regions, starting from the lower esophageal sphincter: cardia, fundus, body, antrum, and pylorus ( figure - ) . the pylorus of the cat is unique compared with other species in that it is narrow and has high resistance in order to maintain a tight seal ( figure involve a wide variety of objects, including linear objects (e.g., dental floss, thread with or without a needle, tinsel, string). the owner may or may not be aware of the ingestion. ingestion of multiple foreign bodies may be seen in cats with pica ( figure - ). in one case report, a young domestic shorthair cat required gastrotomy for removal of copper pennies. some patients require multiple surgeries, because of repeated foreign body ingestion. in such cases, a behavioral diagnosis should be sought and treatment instituted (see chapter ) . trichobezoars (large masses of hair) also represent a type of foreign object. both long-and shorthaired cats may be affected. hair is normally ingested during grooming and is eliminated in vomitus and feces. cats lack the strong peristaltic contractions ("housekeeper" contractions) that clear the stomach of undigested contents normally found in other species. this may explain why cats seem to be susceptible to gastric trichobezoars. gastric motility dysfunction is suspected to cause repeated gastric trichobezoars in some cats. intestinal , and esophageal , obstruction with trichobezoars has also been documented. traditional treatments for cats with recurrent trichobezoars include regular grooming, shaving the hair coat of long-haired cats, flea control, or blood. fresh blood may appear as large or small clots. older blood clots have a brown "coffee ground" appearance. gastric bleeding may also cause melena. other clinical signs may be associated with gastric disease, such as anorexia, weight loss, pain, lethargy, bloating, and nausea. gastritis may be acute or chronic in nature, and this distinction may be useful in assessing the potential cause. for example, cats with acute gastritis may be suspected of foreign body or plant ingestion, drug or toxin exposure (see chapter ), or dietary indiscretion. cats with chronic gastritis may be suspected of parasitism, helicobacter spp. infection, or dietary intolerance or hypersensitivity (see chapter ) . chronic lymphocytic plasmacytic gastritis of unknown etiology is also a common cause of chronic vomiting. whenever possible, a specific underlying cause should be sought and treated. patients with sudden onset of vomiting may have an obvious cause in the history (e.g., dietary indiscretion), but in many cases, the cause is not apparent. abdominal radiographs should be taken if foreign body ingestion is possible, especially in a young cat. if the patient is systemically well, further diagnostic testing may be postponed pending response to therapy. treatment for uncomplicated acute gastritis is symptomatic and supportive. clinical signs are expected to resolve in to hours; if signs persist, re-evaluation and further investigation is warranted. subcutaneous fluid therapy using an isotonic balanced electrolyte solution may be used to correct mild fluid deficits (< %). oral intake of fluids and food should be discontinued for up to hours. a highly digestible diet, either commercial or homemade, is introduced with a gradual transition back to the normal diet over the next several days. antiemetic therapy may be indicated for acute uncomplicated gastritis if the vomiting is frequent or the cat has signs of nausea (see table - ). protectants, such as kaolin and pectin, are difficult to administer to cats and are without proven efficacy. bismuth subsalicylate is controversial; it is considered contraindicated by some experts, because of the cat's sensitivity to salicylates, yet is commonly used in clinical practice. cats ingest foreign bodies less commonly than dogs. in one study of cases of gastrointestinal foreign body ingestion, only % were in cats. foreign body ingestion is most likely to be seen in young cats and may a b taken just before surgery to ensure the object has not moved further down the gastrointestinal tract. postoperative management after gastrotomy includes maintenance of hydration and electrolyte balance. hypokalemia is common with anorexia and vomiting and should be treated by supplementation of iv fluids with to meq/l potassium chloride (not to exceed . meq/kg/hour). refractory vomiting should be treated with an antiemetic. a highly digestible diet can be introduced the day after surgery. in general, the prognosis for recovery is good. in one study, % of cats with gastrointestinal foreign bodies survived to discharge. those cats that did not survive had linear foreign bodies of long-standing duration with subsequent peritonitis. helicobacter are spiral or curved gram-negative bacteria that inhabit the glands, parietal cells, and mucus of the gastric antrum and fundus. helicobacter contain large amounts of urease, which alters the ph in the vicinity of the bacteria and allows for colonization of the acidic environment of the stomach. in the early s, the discovery of the association of helicobacter pylori with gastric disease (gastritis, peptic ulcers, and neoplasia) in humans revolutionized treatment of those diseases. since then, helicobacter spp. have been associated with gastric disease in various veterinary species, including cats and dogs. several helicobacter spp. (e.g., h. heilmannii, h. bizzozeronii, h. felis) have been identified in cats, some of which have the potential to infect humans, although transmission is thought to be rare. , the prevalence of helicobacter infection in cats varies geographically and may be very high (> %) in some locations. , , , , the importance of helicobacter as a cause of gastric disease is cats is unclear; the bacteria may be found in the stomach of both clinically normal cats and cats with gastritis. the prevalence of helicobacter infection is not higher in cats with gastritis compared with normal cats. determination of the role of helicobacter is also hampered by the paucity of controlled clinical trials that evaluate eradication of gastritis and clinical signs in infected cats. an immune response to infection characterized by gastric lymphoid hyperplasia is common, although the local immune response in cats is generally less severe than the response in humans infected with h. pylori. to date gastrointestinal ulcers have not been associated with helicobacter infection in cats. recent studies have suggested a possible association between helicobacter infection and gastric lymphoma in cats, although more research is needed to confirm the association and understand the pathogenesis. , helicobacter spp. may be commensal in most cats, and perhaps loss of tolerance explains the development of gastritis in some individuals. another possibility is that the inflammatory response is normally well managed and disease may treatment of underlying dermatologic disorders, and administration of semisolid petroleum laxatives. more recently, commercial diets have been formulated for control of trichobezoars. cats with recurrent trichobezoars causing illness and suspected motility disorders may benefit from treatment with prokinetic drugs such as cisapride. clinical signs of gastric foreign bodies are variable but typically involve intermittent or persistent vomiting because of gastric outflow obstruction, distention, and mucosal irritation. gastric obstruction may be partial or total. patients with complete obstruction will present with more dramatic signs, including anorexia and depression. the base of the tongue should always be examined, because linear foreign bodies are sometimes anchored either in this location, or they may be lodged in the pylorus, causing intestinal plication. gastric foreign bodies may also be asymptomatic and found incidentally. physical examination may be unremarkable or may reveal dehydration or abdominal pain. if the stomach is markedly distended, the foreign body may be palpable in some patients. survey radiographs are always indicated when foreign body ingestion is suspected. radiopaque foreign bodies may be readily diagnosed, although some, along with radiolucent objects, will require a contrast study for diagnosis ( figure - ) . barium is commonly used as a contrast agent, although if gastric perforation is suspected, an aqueous iodinated agent is preferred. ultrasonography is also useful for detection of gastrointestinal foreign bodies. removal of some foreign bodies can be attempted endoscopically, particularly if the object does not have sharp edges and is not too large. successful removal of fish hooks, particularly single-barb hooks, using endoscopy has been described. otherwise, foreign objects are best removed using gastrotomy through a ventral midline laparotomy. a radiograph should always be to know when treatment should be attempted. one expert recommends treating only patients with clinical signs of gastritis that have biopsy-confirmed helicobacter infection with a treatment regimen of amoxicillin ( mg/kg, every hours, po), clarithromycin ( . mg/ kg, every hours, po) and metronidazole ( mg/kg, every hours, po) for days. a common dilemma would be determining the treatment of choice for patients with lymphoplasmacytic inflammation of the stomach and small intestine and confirmed helicobacter infection. are such patients best treated for inflammatory bowel disease, helicobacter infection, or both? currently, guidelines for determining the best treatment approach are lacking. also, few studies on the efficacy of combination therapy have been conducted in cats. long-term eradication of infection may be difficult, and histopathologic resolution of gastritis may not be possible, which raises the question of whether helicobacter is the true underlying cause. , in one study, two cats with clinical gastritis and helicobacter infection were treated with oral metronidazole, amoxicillin, and bismuth subsalicylate for weeks and were also fed a commercial elimination diet. posttreatment gastric biopsies were obtained a mean of weeks after the cessation of treatment. resolution of clinical signs occurred rapidly, and clearance of helicobacter spp. was achieved at that time point, but gastric inflammation persisted in post-treatment biopsies. in another study, cats with asymptomatic helicobacter infection were treated with oral omeprazole, amoxicillin, metronidazole, and clarithromycin for days. treatment failed to eradicate infection in of the cats based on molecular analysis of post-treatment gastric biopsies. it is unclear if treatment failure is because of recrudescence or reinfection. the reader is referred to excellent reviews of helicobacter in cats for more information. , , chronic gastritis chronic gastritis is common in cats with chronic intermittent vomiting. ollulanus tricuspis is a worm that infects the stomach of cats, causing chronic gastritis, and it is difficult to diagnose (see below, gastrointestinal parasites). the worm is occasionally found on histologic examination of gastric biopsy samples. it is reasonable to treat empirically (fenbendazole mg/kg, once daily, po × days) for this parasite when the cause of gastritis is not apparent. the frequency of vomiting in cats with chronic gastritis is highly variable, ranging from once or twice per week (and not necessarily every week) to more than once daily. most patients are otherwise well, although other clinical signs (inappetence, anorexia, depression, or weight loss) are possible depending on disease severity. results of routine laboratory testing are typically normal but may show neutrophilic leukocytosis, result when there is an abnormality of the immunoregulatory system. the most commonly used methods for diagnosis of helicobacter infection in cats are based on gastric specimens obtained during endoscopy (or laparotomy): exfoliative cytology, histopathologic examination of biopsy specimens, and rapid urease testing of biopsy specimens. however, it is important to note that even when helicobacter organisms are identified, the infection may not be the cause of the patient's clinical signs, and other causes of vomiting should always be evaluated. exfoliative cytology is the least expensive and most easily performed diagnostic test. in one study, it was also the most sensitive diagnostic method when compared with urease testing and histologic examination. brush cytology samples gathered during endoscopy are airdried on microscope slides and stained with wright's stain. the slide is examined at × magnification under oil immersion. spiral bacteria are readily seen if present. at least oil-immersion fields on two slides should be examined before determining a specimen is negative for helicobacter-like organisms. since helicobacter produce abundant urease, a rapid urease test (e.g., clotest, ballard medical products, draper, utah) may be used for diagnosis. the kit consists of an agar gel impregnated with urea and a ph indicator. a gastric biopsy sample is applied to the gel, and if urease is present, ammonia will form and change the ph (and thus the color) of the gel. the gel may change color rapidly (within minutes), but hours must elapse before the test can be considered negative. the more rapidly the color changes, the higher the bacterial load. both false-positive and false-negative results are possible with rapid urease testing for various reasons, giving the test a sensitivity of % to %. , histopathologic examination of gastric biopsy samples using hemotoxylin and eosin (h&e) or silver stains is highly sensitive and specific in human studies for detection of helicobacter-like organisms. the organisms are not equally distributed; so, examination of biopsy specimens from multiple sites will increase sensitivity. the bacteria may be seen in mucus on the surface epithelium as well as in the gastric pits, glandular lumen, and parietal cells. organisms may also be seen submucosally within gastric lymphoid follicles. histopathologic examination of biopsy samples also allows for assessment of other abnormalities. mild to severe lymphocytic-plasmacytic or lymphocytic gastritis may be present. in humans combination therapy with antibiotics and antisecretory drugs is recommended to reduce the risk of gastric ulcers and cancer from h. pylori infection. treatment is highly successful at eradicating both clinical signs and histologic changes in the gastric mucosa. since helicobacter infection is common in cats, yet no clear pathogenic role has been established, it is difficult cases. depending on the underlying cause and severity of disease, abdominal pain, anorexia, lethargy, pale mucous membranes, and drooling may also be seen. cats with neoplastic disease may have prolonged clinical signs and are more likely to present with anorexia and weight loss. cats with perforated ulcers may or may not present with signs of shock. diagnosis may be problematic because the clinical signs and physical examination findings are often not specific, even in cats with perforated ulcerations. the causes of gastric ulceration in cats are not well characterized. in dogs the most common cause is the administration of ulcerogenic drugs, particularly nsaids, either alone or in combination with corticosteroids. several cases of nsaid-induced gastroduodenal ulceration or perforation have been reported in cats. , , additional cases may be reported in the future, because long-term administration of these drugs is gaining in popularity for treatment of chronic diseases such as osteoarthritis. nsaids cause direct mucosal damage and interfere with prostaglandin synthesis. although inhibition of the cox- enzyme is thought to be the cause of adverse effects, such as gastric ulceration, even cox- -selective drugs have been associated with adverse effects, and safety in sick cats is not well evaluated. recently, guidelines for the long-term use of nsaids in cats were published by the international society of feline medicine and the american association of feline practitioners. the recommendations include administering nsaids either with or shortly after food, withholding therapy if inappetence or anorexia develops, determining dose based on lean body weight, and titrating to the lowest effective dose. neoplastic causes of gastric ulceration include systemic mastocytosis, mast cell tumor, lymphosarcoma, adenocarcinoma, and gastrinoma (zollinger-ellison syndrome). cats with chronic renal disease may suffer mucosal damage from uremic toxins and increased gastric acid production secondary to hypergastrinemia (because of decreased renal metabolism of gastrin). hepatic disease is a cause of gastric ulceration in dogs but is uncommonly reported in cats. recent anesthesia and surgery have been implicated as a cause of gastric ulceration and perforation, perhaps through hypovolemia, hypoperfusion, or stress. , other non-neoplastic causes reported for gastric or gastroduodenal ulceration in cats include parasites (e.g., ollulanus tricuspis, toxocara cati, aonchotheca putorii, gnathostoma spp.), bacterial infections, toxins, inflammatory bowel disease, and foreign bodies. one case report describes a cat with severe gastric ulceration caused by intoxication with dieffenbachia leaves. in some case reports, the cause for the gastric ulcerations could not be determined. a minimum database should be collected for cats suspected of gastric ulceration, to identify underlying diseases. anemia, usually regenerative, may be present. eosinophilia, or hypoproteinemia. survey and contrast radiographs are often normal. the most common finding on histopathologic examination of biopsy samples is lymphocytic plasmacytic (lp) gastritis ( figure - ) . some patients will also have concurrent evidence of lp inflammation in the small intestine, pancreas, and/or liver. such patients will be treated for their concurrent problem; treatment of inflammatory bowel disease, pancreatitis, and cholangiohepatitis is covered elsewhere in this chapter. some cats with chronic lp gastritis respond to treatment for dietary intolerance or hypersensitivity with a limited antigen diet (see chapter ) . patients with moderate to severe lp gastritis may be best treated with a limited antigen diet and immunosuppressive therapy (prednisolone to mg/kg/day, po tapering to every other day at the lowest dose that controls clinical signs). patients that fail this initial treatment approach may require additional immunosuppressive therapy, such as chlorambucil (see table - ) . occasionally, cats with chronic gastritis are diagnosed with eosinophilic inflammation on histopathologic examination of biopsy specimens. treatment is similar to that for lp gastritis, although such patients should be evaluated for evidence of hypereosinophilic syndrome and eosinophilic enteritis. eosinophilic fibrosing gastritis was suspected to be caused by toxoplasmosis in one case report. gastric or gastroduodenal ulcerations are uncommon in the cat compared with the dog and may be caused by a variety of disorders, both gastric and nongastric. classical clinical signs include vomiting, hematemesis, and melena. however, in one review of eight cats, hematemesis and melena were present in less than one third of suturing of the ulcer site as well as collection of biopsy samples for histopathologic examination. the prognosis for recovery was excellent in two studies, particularly for cats with non-neoplastic causes of gastric or gastroduodenal ulceration. , in one study of seven cats with perforated gastric or duodenal ulcers, the survival rate was low ( %). disorders of gastric motility are better characterized in dogs than in cats. the most common clinical sign is vomiting of undigested food hours or more after a meal. if outflow obstruction is present, vomiting may be projectile. there may also be a history of recurrent trichobezoars. various disorders are associated with impaired gastric motility, such as chronic gastritis, drug therapy (e.g., anticholinergic and narcotic drugs), dysautonomia, gastric neoplasia, metabolic disorders (e.g., hypokalemia), and temporary postsurgical gastroparesis. in some cases of chronic motility dysfunction, no cause can be identified. outflow obstruction may be caused by neoplasia, foreign bodies, and extragastric masses. pyloric stenosis is infrequently documented in young cats, often siamese cats. , , since the range of underlying disorders is diverse, the diagnostic approach should allow for detection of both gastric and nongastric disorders. a minimum database (cbc, serum chemistries, urinalysis, feline leukemia virus [felv] and feline immunodeficiency virus [fiv] serology) is used to establish overall health status. radiographs are used to confirm presence of food in the stomach for longer than hours. ultrasonography may detect gastric lesions, such as masses. endoscopy is used to identify outflow obstruction as well as other lesions, such as ulcers, and evidence of gastritis. assessment of gastric emptying using nuclear scintigraphy is the most accurate method but is limited to referral centers. gastric emptying times for liquids, canned food, and dry diets have been established using nuclear scintigraphy. , , however, emptying times are variable, depending on the amount and type of diet fed as well as the amount of water ingested. even the shape of kibble affects emptying time. radiographic contrast series are widely used, but gastric emptying times are variable for barium in either liquid form or mixed with canned food. contrast radiography using liquid barium ( to ml/kg) is performed in a fasted patient. radiographs are taken immediately after administration of the barium and again at and minutes, in some cases, also at and hours. liquid barium is expected to enter the duodenum no more than minutes after administration, and the stomach should be completely empty of barium within hours. the clinician should be aware that some cats with gastric motility disorders will have other findings will be dependent on the presence of underlying diseases; for example, azotemia and isosthenuria may indicate renal disease. electrolyte and acidbase abnormalities may be because of chronic vomiting and anorexia. survey and contrast radiographs and ultrasonography are primarily useful to rule out other causes for the clinical signs, such as foreign bodies. cats with perforated ulcers may have evidence of pneumoperitoneum (sometimes severe) on plain radiographs or ultrasonographs, and this is an indication for surgical exploration. , , , , evidence of peritonitis on imaging studies should be followed with peritoneal fluid analysis. a definitive diagnosis may be made using endoscopy, which allows direct visualization of lesions and collection of biopsy samples. however, some cats with gastric ulceration present in poor condition, which may preclude the use of endoscopy because of anesthetic risk and risk of ulcer perforation. the location of ulcers is typically pyloroantral or fundic in cats with nonneoplastic disease. , areas of erosion may appear pale or hemorrhagic; the mucosa is often friable and bleeds easily. fresh or clotted blood may be seen in the stomach lumen. in some cases, mucosal ulceration must be distinguished from ulcerated tumors. nsaid-induced ulcers are typically found in the antrum and do not have marked mucosal thickening; ulcerated tumors frequently have thickened edges and surrounding mucosa. biopsy samples should be taken at the periphery of the ulcer to avoid perforation. treatment should be directed at any underlying disorder. treatment for nsaid toxicity is described in chapter . general supportive measures include fluid therapy and electrolyte replacement; blood transfusion may also be required (see chapter ) . gastric acid production can be decreased with the use of h -receptor blockers or proton pump inhibitors, and sucralfate is used as a mucosal protectant (see table - ). sucralfate may inhibit absorption of other oral medications and should be given hours apart from other drugs. if vomiting is severe or persistent, antiemetic therapy is warranted (see table - ). analgesia should be provided for painful patients; a good choice is the opioid buprenorphine (see table - ). broad-spectrum antibiotic therapy is indicated for patients with significant mucosal barrier dysfunction, perforation, leukopenia and/or neutrophilia, fever, and melena. surgical intervention is warranted for patients with life-threatening hemorrhage, failure to respond to medical management, or evidence of perforation. the entire abdominal cavity and gastrointestinal tract should be thoroughly explored to locate extragastrointestinal lesions, non-perforated ulcers, and multiple ulcers. in one case series, nonperforated ulcers were detected at laparotomy by association with adhesions or a gastric mass. surgical management includes débridement and months. physical examination findings are nonspecific, although occasionally a gastric mass or gastric thickening may be palpated if the stomach is markedly enlarged. results of routine diagnostic testing are generally nonspecific; anemia may be associated with ulceration. survey or contrast radiography may reveal a mass ( figure - , a); other findings include delayed gastric emptying, impaired motility, and mucosal ulceration. ultrasonography is also useful for diagnosis and can be used to guide needle aspirates of masses ( figure - , b). endoscopy allows for visualization of lesions as well as the ability to obtain partial thickness biopsy samples. problems with interpretation of endoscopic biopsy samples include detection of necrosis, inflammation, and ulceration rather than the primary lesion. in dogs some neoplastic lesions are submucosal, making it very difficult to obtain diagnostic samples by endoscopy. therefore several biopsies should be taken and masses should be biopsied multiple times in the same place to sample deeper tissues. the center of ulcerated lesions should not be biopsied. surgical biopsies are more reliable for diagnosis. a normal gastric emptying time with liquid barium. barium can also be mixed with canned food and fed as a meal; retention of barium-containing food in the stomach for more than to hours is abnormal. gastric emptying time may also be established with the use of barium impregnated polyspheres (bips; med i.d. systems, grand rapids, mich.) and radiography. gastric emptying times for bips have been established in healthy fasted and fed cats as well as in sedated cats, , but the values do not correlate well with scintigraphic studies. a mixture of small ( . mm) and large ( mm) spheres are administered with food, and two to four radiographs are taken over the next hours. the small spheres are intended to mimic liquid transit time and the large spheres solid transit time. however, studies assessing the clinical relevance of this method are lacking. one review concluded that bips are probably sufficiently sensitive to detect grossly delayed gastric emptying. treatment of gastric emptying disorders is directed at identifiable causes. treatment for gastric ulcers, chronic gastritis, and foreign bodies is described elsewhere in this chapter. pyloric stenosis is managed surgically. if no outflow obstruction exists, treatment with prokinetic agents, such as metoclopramide or cisapride, may be beneficial (see table - ). gastric tumors account for less than % of malignancies in dogs and cats. benign gastric tumors are even less common than gastric malignancies. gastric smooth muscle hamartoma has been reported in one -year-old cat. although adenocarcinoma is the most common gastric cancer of the dog, lymphoma is the most common gastric cancer in the cat. feline gastrointestinal lymphoma occurs as two major types: small cell (lymphocytic) and the more aggressive large cell (lymphoblastic) form. small cell lymphomas are more frequently enteric. in one study of cats with gastric lymphoma, diffuse large b-lymphocyte tumors of immunoblastic nuclear type predominated. gastric lymphoma is not associated with felv, and the role of helicobacter in the development of gastric lymphoma in cats requires investigation. adenocarcinoma, , , plasmacytoma, and gastric carcinoid have also been described. the siamese cat may be predisposed to adenocarcinoma. , as would be expected, most cats with gastric neoplasia are older cats. as for most gastric diseases, vomiting is the most common clinical sign of neoplasia. the vomitus may contain blood and melena may be present. other clinical signs include anorexia, weight loss, bloating, and depression. perforation of the tumor may occur, leading to pneumoperitoneum or septic peritonitis. clinical signs present gradually and are often present for weeks to surgical resection is the most common treatment for gastric neoplasia other than lymphoma ( figure - ). the prognosis for most patients is poor, typically because of debilitation, concurrent diseases, and recurrent or metastatic disease. the success of chemotherapy for lymphoma depends on cell type, with small cell tumors carrying a better prognosis than large cell tumors. in diarrhea can be defined as increased volume and/or increased frequency of defecation of stools with increased water content. approaches to diarrhea, as for any clinical sign, need to take into account the individual animal. for example, neoplasia is much less likely to occur in a kitten than in a geriatric cat. in many cases, the precise diagnosis of gastrointestinal disease cannot be reached without biopsy samples. the decision to obtain biopsy samples should follow a logical pathway that is appropriate to the cat's condition. these are summarized in figure - . for example, many cases of acute diarrhea in a well cat can resolve with limited or no intervention, and so do not require a precise diagnosis. the diagnostic steps are . signalment and clinical history . physical examination . fecal assessment . blood and urine testing . imaging (radiography, ultrasonography) . biopsy samples these steps do not include treatment/diet trials or other empiric therapies that are appropriate in many cases. steps and are often undertaken at the same time, and there is no definite order for these steps. they are divided here for reasons of clarity. in a younger cat, where infectious causes are more likely, thorough fecal testing is more important; in an older cat, extragastrointestinal diseases, such as hyperthyroidism, are more likely; so, blood and urine testing is more important, but fecal assessment should not be neglected. the decision to proceed to step (and each subsequent step) should take into account several considerations. the main considerations in assessing and managing a cat with diarrhea are • is there an acute onset or a chronic time course? • are there any dietary changes or indiscretion? consider treatment trials: antibiotics (e.g., amoxicillin/ clavulanate ؉ metronidazole). food trials with novel proteins (e.g., rabbit, kangaroo, venison). • is the cat well or unwell? • is there primary or secondary gastrointestinal disease? • is there small or large bowel diarrhea? the components of the clinical history for cats with diarrhea are detailed in table - . after establishing the cat's age, breed, vaccination, and deworming history, it is important to establish the duration and nature of the diarrhea. chronic diarrhea is usually defined as greater than weeks in duration and mostly warrants at least some degree of a diagnostic workup, whereas acute diarrhea is often self-limiting in a well cat. a description of the feces helps determine whether the diarrhea is small or large bowel in origin (table - ); this will affect how any investigations might proceed. important questions to ask concern frequency of defecation (and how this compares with the normal state), tenesmus (straining usually indicates large bowel diarrhea, since an irritated colon leads to urgency), volume of feces (smaller volumes are typical of large bowel diarrhea; larger volumes are more typical of small onset and duration of diarrhea acute versus chronic? acute diarrheas are abrupt in onset and of short duration, and generally they are self-limiting. chronic diarrheas persist usually longer than weeks and fail to respond to symptomatic therapy. appearance of diarrhea quantity and quality of the stool (color, consistency, character, presence of blood or mucus)? loose to watery feces that contain fat droplets, undigested food, melena, and variable colors suggests small intestinal disease. the volume is always increased with small intestinal disease. loose to semisolid feces containing excess mucus and fresh blood (hematochezia) indicates large intestinal disease. the volume may be normal to slightly decreased with large intestinal disease. description of defecation process tenesmus (straining) and dyschezia (painful defecation)? these are hallmarks of large intestinal disease (e.g., inflammatory or obstructive lesions of the colon, rectum, or anus). frequency is normal to slightly increased with small bowel disease, but greatly increased with large bowel disease. associated physical signs vomiting, anorexia, weight loss, and dyschezia may help localize the disorder to a specific part of the gastrointestinal tract. clinical signs relating to problems in other organs or body systems should be noted and may suggest a more generalized disease. vomiting may occur as a consequence of small intestinal inflammation in some cats with diarrhea. weight loss may result from decreased caloric intake (anorexia), decreased nutrient assimilation (maldigestion/malabsorption), or excessive caloric loss (protein-losing enteropathy or nephropathy). weight loss is observed uncommonly with large bowel disease. in many cases, the answers to these questions are obvious. for example, a cat may seem well but has had access to lilies (the author has seen diarrhea as a primary presenting sign for this!) or has a palpable abdominal mass. substantial weight loss is an indicator that further investigations are warranted sooner rather than later. if the decision is made for empiric management and outpatient care, it is vital to follow up either by scheduling a recheck visit or calling the client, because simple acute problems can turn into complicated chronic problems. if the diarrhea has been present for less than a week and the cat has no weight loss, dehydration, fever, or palpable abdominal abnormalities, it is appropriate to manage the cat as an outpatient. even in the absence of fecal testing, it is appropriate to deworm the cat (see the section gastrointestinal parasites). the cat should be fasted for hours ( hours, if less than months old) and then fed a bland diet (such as plain, cooked, skinless chicken, or low-residue prescription diets designed for cats with gastrointestinal problems). it is appropriate to maintain the cat on the low-residue diet for at least to days and then slowly reintroduce the regular diet. fecal assessment is mostly used to assess infectious agents, such as parasite-associated diarrhea, but the importance of assessing feces, even when parasitic or bacterial infections are not suspected, should not be underestimated. gross examination of feces can determine if melena or fresh blood or mucus are present to help distinguish large from small bowel disease when the owner's observations may be misleading. occult fecal blood can be an indicator of gastrointestinal inflammation in cases of subtle disease, and undigested starches and fats can indicate maldigestion or malabsorption. for assessment of feces for parasites, the fecal sample should ideally be fresh (< hour old). refrigeration (for no longer than one week) can preserve ova, oocysts, and cysts but not protozoal trophozoites. feces should be assessed by a. to assess for trophozoites bowel), how formed the stool is (from soft stool to cow-pat consistency to liquid tea; usually more watery stool relates to small intestinal disease), color (darker indicates digested blood), and presence of any mucus or blood (presence relates to large bowel). most household toxins, such as plants, cause signs additional to diarrhea such vomiting or neurological signs, but it is important to ascertain if the cat has had access to anything unusual. likewise, it is important to find out if the cat has had any possible exposure to dietary indiscretions; this can include if the cat has been seen with or is known to hunt prey including insects. cockroaches carry pathogenic bacteria , and other prey such as birds and rats can carry salmonella; salmonellosis in cats has been dubbed songbird fever. simple causes of self-limiting diarrhea include dietary change (either a new flavor or a new style of food, such as dry food for the first time); so, the owner must also be quizzed if anything new has been offered, either new cat food or treats (such as greasy fish or chicken). although the physical examination will usually determine how unwell a cat is, the owner's impressions are also important, because cats can hide signs from strangers, particularly in a practice setting. lethargy and inappetence are important signs, as ill cats typically do not eat well. the cat's general demeanor can be an indicator of how unwell a cat is and therefore dictate the extent of diagnostic testing required. this can be noted by assessing how interested the cat is in its surroundings or any behavior changes from previous visits, such as if a normally difficult-to-handle cat is placid. body weight should be assessed and, if possible, compared with that of previous visits (even those noted on a clinical record from another veterinarian). the body condition score (bcs) should also be assessed and can be very important when there is no prior weight information. dehydration is usually a sign that a cat needs more involved management. abdominal palpation should be performed to assess pain (where?), any masses (foreign bodies, lymph nodes, or even focally thickened intestines, such as with neoplasia), or turgid intestines. fever often indicates infection but can also reflect neoplasia or other inflammatory changes. a thorough examination of all body systems should always be performed, no matter what a cat presents for. in the case of diarrhea, extragastrointestinal signs can be of vital importance, such as a palpable thyroid and tachycardia suggesting hyperthyroidism. after the clinical history has been taken and the physical examination performed, the veterinarian must make the important decisions of whether any interventions are required and whether the patient should be factors affecting interpretation include whether the growth is a heavy and pure growth of a known pathogen, such as salmonella, campylobacter, yersinia, or clostridium difficile. further information about the relevance of culture and pcr results is contained below in the section infectious enteritis. investigations begin by assessing if the diarrhea is the result of primary gastrointestinal disease or secondary to another process, by performing routine serum/plasma biochemistries, hematology, urinalysis, and total t (for older cats). in most cases of secondary gastrointestinal disease, diarrhea is not usually the primary presenting complaint, but since the approach to investigations and management diverge so much, this is an important step to take. biochemistry and urine tests may also show the consequences of diarrhea, such as dehydration and electrolyte abnormalities. a. can aid in the visualization of internal structures of some protozoa . fecal flotation (preferably with centrifugation) a. to find cysts, oocysts, and ova fecal culture should be undertaken with the understanding that bacteria will be cultured; so, interpretation is based on the relevance of the positive culture result. used to evaluate the smear for the presence of trophozoites, such as giardia spp. and tritrichomonas foetus. . place peppercorn size amount of feces on a warm slide and mix with a drop of . % saline (smear must not be too thick, because trophozoites will be easily missed). . apply coverslip. . evaluate systematically for motile organisms using the × magnification. . confirmation at × magnification. adding iodine to a wet mount through the edge of the coverslip can aid in the visualization of internal structures of some protozoa. the direct wet preparation must be examined without any stain for motility first, because staining the preparation kills the organism. methylene blue is useful for identifying trophozoites, particularly those of entamoeba histolytica. this method has little to no diagnostic value for the diagnosis of bacterial-associated diarrhea. used to find cysts, oocysts, and ova in feces. standing (gravitational) flotation methods are easier and quicker but have much poorer sensitivity than centrifugation methods. solutions used in centrifugation flotation methods include zinc sulfate and sheather sugar. . weigh out to g of feces. . mix feces with approximately ml of flotation solution. . pour mixture through a tea strainer into a beaker or fecal cup. . pour strained solution into a -ml centrifuge tube. . fill tube with flotation solution so that a slight positive meniscus forms, being sure not to overfill the tube. . place a coverslip on the tube, and put the tube in the centrifuge. . make sure the centrifuge is balanced. . centrifuge at rpm ( × g) for minutes. . remove the tube and let stand minutes. . remove the coverslip, and place it on a glass slide. systematically examine the entire area under the coverslip at × magnification (i.e., × objective). you may wish to use the × objective lens to confirm your diagnosis and make measurements; however, with practice, most parasites can be identified using the × objective ( × magnification). (fpli) are useful markers of intestinal and pancreatic disease, [ ] [ ] [ ] [ ] but it is important to note that they typically do not give a precise diagnosis. cobalamin and folate are water-soluble vitamins and are readily found in commercial cat foods so that dietary insufficiency is rare, and decreased levels are almost always because of gi disease. these vitamins are taken up by specific receptors in different areas of the small intestine. chronic inflammatory gastrointestinal disease may damage the receptors and lead to decreased serum concentrations of one or both vitamins, provided the disease process is severe and long standing enough to deplete body stores. serum cobalamin and folate concentrations may also be decreased in cats with exocrine pancreatic insufficiency (epi). trypsin-like immunoreactivity is a pancreasspecific marker, and assessment of serum tli is used for diagnosis of epi and pancreatitis in the cat, although the sensitivity of the assay for pancreatitis is low. pli is a marker for pancreatic inflammation and is more sensitive than tli for the diagnosis of pancreatitis. since inflammation of the small intestine may be seen concurrently with pancreatitis, serum tli and pli are useful adjunctive tests in the diagnosis of diarrhea. tli, pli, and cobalamin are stable in serum at room temperature for several days, but folate is unstable so that samples for cobalamin/folate analysis should be frozen (table - ) . samples submitted for folate concentration should not be hemolyzed, because red blood cells contain high levels of folate. in addition, folate is light-sensitive, and samples should be wrapped to exclude light. severe lipemia may interfere with common assays for tli and pli. the main utility of these tests are to indicate that further investigation of gastrointestinal disease is warranted. when a cat presents for weight loss with no overt signs of gi disease, decreased cobalamin or folate can indicate that further investigations with imaging and, ultimately, biopsy sampling are warranted. many clients are more willing to proceed with hematology can be normal in some cats, with changes expected, and so should not be used to rule out any condition. it can be useful, for example, if there is a left shift neutrophilia, indicating acute infection, or eosinophilia, reflecting parasitism. monocytosis can suggest chronic disease that was not suggested by the clinical history. in the case of acute onset diarrhea, the cat may be unwell as a consequence of the diarrhea (e.g., from dehydration) and not because of the cause of the diarrhea. if rehydration is required (with intravenous or subcutaneous fluids, depending on severity of illness), then it is important that biochemistry tests are performed before fluid administration so that any diagnostic clues are not lost by alteration of the profile from the fluid therapy. fever and neutrophilia may indicate the need for antibiotic therapy. if infection is suspected, fecal sampling (see step ) should occur before starting antibiotics. if a cat is unwell from dehydration, then further testing may not be warranted. the clinician should be alert that linear foreign bodies can result in diarrhea (see the section intestinal obstruction). diarrhea of chronic duration (greater than weeks) does require a more thorough investigation at the outset. however, if clinically well, the cat can be managed as an outpatient in the first instance, at least while waiting for results of diagnostic testing. a diet trial with a novel protein is appropriate for a well cat with stable weight. as with any patient managed as an outpatient, follow-up is vital and, in this scenario, includes scheduling revisits. cobalamin, folate, feline trypsin-like immunoreactivity (ftli), and feline pancreatic lipase immunoreactivity invasive diagnostics when a specific marker of the disease in the organ involved has been recognized. caution should be exercised, because either cobalamin or folate may not be reduced with gi disease. in one study of small cell lymphoma, only % of cats were hypocobalaminemic, meaning that if this was the only instigating factor to investigate, nearly one fourth of cats would not have been investigated further. also, cobalamin may be reduced in nonalimentary illness. . to detect hypocobalaminemia that may indicate the need for supplementation for clinical improvement. to recognize pancreatic pathology when fpli is increased. it is important to note that an elevated value gives no indication of the nature of the pancreatic pathology. . to make a diagnosis of epi when the ftli is low. it should be noted that epi can result from other pathology that may require further investigations. veterinarians if the patient is new to the practice) are usually helpful. body condition scoring (using a -point or -point scale) for every cat seen is helpful in recognizing those that are underweight. weight loss often occurs with loss of muscle mass in cats, and muscle mass can be assessed over the ribs and pelvis as well as scapulae and nuchal crest. thickened intestines are also a subjective finding; it is the author's opinion that thickened intestines are actually intestines with increased turgidity, since differences between normal intestines and those with inflammatory infiltrates can be as little as . mm. perhaps more important during the history taking and physical examination are those signs that can point to extragastrointestinal disease. when confronted with a cat showing weight loss or vomiting or diarrhea (or a combination of signs), the clinician should start with trying to distinguish the signs as being either primary gastrointestinal or secondary signs. examples of clues pointing to extragastrointestinal diseases include tachycardia and palpable thyroid nodule, indicating hyperthyroidism, or polydipsia/polyuria, which has a variety of causes but is not typical of primary intestinal disease. inflammatory bowel disease has traditionally been considered an immune-mediated disease. the local immune system of the intestinal mucosa no doubt plays an important role, but recent work has also shown the importance of the normal bacterial population in perpetuating and, perhaps, even initiating pathology. it is known for certain that ibds are an expression of an overanxious immune response, with a recent study indicating increases in inflammatory (il- ), type- immunity (il- p ), and immunomodulatory (transforming growth factor [tgf]-beta, il- ) cytokines. other researchers have found an association with bacterial counts (enterobacteriaceae, e. coli, and clostridium spp.) and abnormalities in mucosal architecture, indicating that mucosal bacteria are involved in the etiopathogenesis. we can summarize these theories by saying that ibds are likely to be a consequence of hypersensitivity reactions to antigens from the intestinal lumen (e.g., bacterial, parasitic, or dietary antigens). this hypersensitivity may occur because of failed immunoregulation (suppressive function) of the gut-associated lymphoid tissue (galt). it is known that granulomatous colitis in boxer dogs is associated with infection, and pathogens may well be found in at least some cases of ibd in cats that cause the immune response and subsequent inflammatory infiltrate of the lamina propria typically seen. although not described specifically in cats, chronic intestinal inflammatory change can impair motility. inflammatory bowel disease (ibd) refers to intestinal inflammatory infiltrates of the small or large intestine (or both) of unknown etiology. the term ibd should strictly be applied to mean idiopathic ibd, thus excluding inflammatory enteritis because of food sensitivities, although common usage has led to ibd referring to intestinal inflammatory infiltrates of both known and unknown causes. ibd is not a diagnostic end point but a description of a series of intestinal diseases that have similar histopathology. recent efforts by the world small animal veterinary association (wsava) gastrointestinal standardization group have led to both diagnostic and classification guidelines , , that encompass chronicity, nonresponse to symptomatic treatment, no specific cause found, as well as histologic confirmation of non-neoplastic intestinal inflammatory changes. there are no obvious breed or gender predispositions, and although cats of any age can be affected, inflammatory intestinal diseases are more likely to occur in middle-aged to older cats ( to years of age or older) than in younger cats. presenting clinical signs include vomiting, diarrhea, and weight loss with increased or decreased appetite. these signs can occur in isolation or together. weight loss without vomiting or diarrhea deserves special mention because not only have several studies , shown this to be the most common presenting sign for ibd, but many veterinarians do not consider primary intestinal disease without the presence of vomiting or diarrhea. weight loss despite normal to increased caloric intake can represent poor absorption of food because of small intestinal disease, although it can also represent maldigestion associated with exocrine pancreatic insufficiency or increased metabolism associated with hyperthyroidism, or even lack of energy utilization associated with diabetes mellitus. conversely, appetite may be reduced, most likely because of nausea. if the large bowel is affected, signs are typically discomfort when defecating, resulting in frequent small volumes of diarrhea, often with mucus and blood; if the large bowel alone is affected, there may be no weight loss. physical examination findings are often nonspecific, but the most consistent findings for small intestinal disease are weight loss (or being underweight in a cat not seen previously) and palpably "thickened" intestines. noting a cat as underweight can be subjective, and prior recorded weights (even from previous paper has suggested that ultrasonographic thickening of the muscularis layer is more likely in cats with intestinal small cell lymphoma than those with ibd, but this change was also seen in % of cats with normal small intestine. inflammatory bowel diseases require histologic findings obtained from biopsy samples for diagnosis, but diagnosis should not be made solely on these findings. the wsava international gastrointestinal standardization group has proposed "an all encompassing definition of inflammatory bowel disease" that comprises clinical criteria, imaging criteria, as well as pathophysiologic criteria. the clinical criteria for the diagnosis of ibd include there are no typical laboratory findings in ibd, and many cats may have entirely normal results from routine biochemical and hematologic investigations. moderate liver enzyme elevations may be seen , , , even in the absence of recognizable hepatic pathology, and this may reflect subclinical secondary hepatic disease, secondary cholestasis, or showering of the liver with inflammatory cells from the small intestine through the portal circulation. other changes can reflect consequences of the intestinal disease, such as azotemia or hemoconcentration reflecting dehydration, or hypokalemia reflecting inappetance. the chronic inflammation may be reflected by neutrophilia, monocytosis, , , , or hyperglobulinaemia. hypocobalaminemia can reflect ileal inflammation, and low serum folate can reflect proximal small intestinal inflammation. typical ultrasonographic findings consistent with ibd are focal or diffuse intestinal wall thickening ( figure - ) ; normal wall thickness is less than or equal to . mm for the duodenum and less than or equal to . mm for the ileum, and large mesenteric lymph nodes with hypoechoic changes may be seen. one study found that ultrasonographic findings correlated with histologic grade of ibd. there is no clear distinction between ultrasonographic changes from ibd and those from small cell lymphoma. one recent therapeutic trial, follow-up visits are vitally important. many cats with small intestinal disease may show initial improvement simply because of the diet having lower residue, since there is decreased substrate for intestinal bacteria to digest and lower osmotic potential. the corollary of this is that failure of one novel protein diet does not mean that all novel protein diets will fail. when food sensitivities are responsible for gastrointestinal clinical signs in cats, the responsible food ingredient is usually a dietary staple. commonly incriminated ingredients are beef, fish, wheat, and corn gluten. a careful dietary history is therefore important. large bowel inflammation typically improves with higherfiber diets, , and attempting a trial with such a diet is certainly appropriate. immune suppressive therapy is the mainstay of ibd treatment, and glucocorticoids, such as prednisolone, are most commonly used. sulfasalazine use for large bowel signs has not been critically evaluated but seems safe and effective. in cats with substantial weight loss or severe clinical signs, such as chronic diarrhea, the author prefers to start with corticosteroid therapy, even if dietary causes have not yet been ruled out. the diet should also be changed to one containing a novel protein, and, if and when clinical signs resolve, an attempt is made to wean the cat from corticosteroid therapy, hopefully to the point of being discontinued. a diet challenge can then be used to confirm the diagnosis of food sensitivity. there are no universal guidelines for doses of corticosteroids. the author prefers the use of orally administered prednisolone to reduce the chance of side effects and will choose the starting dose based on the severity of disease. the starting dose is usually mg/kg, once daily, po ( mg/cat/day for most cats) starting days after biopsies have been obtained to allow time for the mucosa to heal. if there is an improvement noted after a recheck at weeks, the higher dose is maintained for a further to weeks, at which point, many cats are back to their normal weight and are not exhibiting clinical signs. if this is the case, the corticosteroid dose can be weaned down to mg/kg, po (often mg/cat/day) for several months, with continued rechecks scheduled to assess weight, clinical signs, and diet. the goal is to wean down to the lowest effective dose. if hypocobalaminemia is present, cobalamin supplementation may be required. cobalamin is administered parenterally at µg/cat subcutaneously weekly for weeks, then every second week for weeks, then monthly. owners can be shown how to inject their cats (as practitioners routinely do with diabetics). clinicians often consider the assessment of histologic samples to be out of their hands; however, it is important to work with the pathologist by providing good quality samples and a good clinical history, as well as having an open dialogue if the findings are not within expectations. for example, with lymphocytic/plasmacytic infiltrations, the pathologist has the difficult task of distinguishing diseased from normal tissue in a site that is laden with lymphocytes in the healthy state. once deciding the tissue has pathology, the pathologist's next task is distinguishing inflammatory infiltrate from neoplastic infiltrate with normal, mature lymphocytes (as seen in small cell lymphoma). inflammatory change also results in changes to normal tissue architecture, with thickened villi, edema, or erosion of the epithelium being typical changes. clinicians should expect morphologic descriptions as well as assessments of degree and type of inflammation. these difficulties are further compounded with the recognition that histologic grading of mild, moderate, or severe does not necessarily correlate with severity of clinical signs. this means that a cat with severe clinical signs of weight loss and vomiting or diarrhea may have only mild histologic changes (and vice versa). concurrent inflammation of the pancreas and liver with intestinal inflammation was first described in the mid- s, and despite constant reference to this phenomenon at conferences and veterinary websites, there has been little description since then, though one study found % of ibd cases had liver inflammation and % had pancreatic inflammation. the term "triaditis" has frequently been used, but the author prefers to spell this "tri-iditis" to distinguish it from inflammation of the hepatic portal triads. there has been no assessment of prognosis when the pancreas and/or liver are involved, but the author has found no difference in prognosis. many cases diagnosed with intestinal inflammatory infiltrates have these changes because of dietary sensitivity. in one study, % of cats with histologic gastrointestinal changes improved with dietary elimination therapy alone. interestingly, improvement was noted within days compared with the longer duration of weeks often recommended for improvement of dermatologic manifestations of food sensitivities. this careful study made note of the cat's prior diets and likely dietary causes of sensitivities. another study found dietary therapy to be unsuccessful in of cats but no specifics of diets tried are noted. as with any national cancer institute working formulation (nci wf) system. for most veterinarians in practice, the most important distinction is the histologic grade, because low-grade (lymphocytic or small cell) lymphoma has a much better prognosis (and requires different treatment) compared with high-grade (often lymphoblastic) or intermediategrade lymphoma. for the purposes of simplicity and practicality, only small cell lymphoma and high-grade lymphoma will be addressed here. the prognosis and treatment for intermediate-grade intestinal lymphoma should be considered as for high-grade lymphoma. small cell lymphoma was first described in human pathology in . earlier, small lymphocytes were considered end-stage cells without the ability to divide. in cats small cell lymphoma is most commonly associated with the gastrointestinal tract or skin. small cell neoplasia can be a confusing concept, since our traditional ideas of malignant neoplasia focus on rapidly dividing cells. the confusion is compounded by various terms used in the literature, such as lymphocytic lymphoma, low-grade lymphoma, well-differentiated lymphoma, or diffuse lymphoma; another term, epitheliotropic malignant lymphoma predominantly applies to small cell lymphoma, and other papers fail to distinguish these lymphomas from lymphoblastic lymphosarcoma (the traditional, aggressive form). "small cell lymphoma" seems to be most widely used term, though the author prefers "lymphocytic lymphosarcoma," since it is more descriptive. intestinal small cell lymphoma can be considered as a severe lymphocytic intestinal infiltrate, the most common form of which is commonly called ibd. not only is lymphocytic ibd hard to distinguish histologically from lymphocytic lymphosarcoma, but the approaches and treatments are similar. several reports have suggested a relationship between the two conditions in that inflammatory infiltrates may become neoplastic over time. , , prevalence the true prevalence of intestinal small cell lymphoma is unknown, but several recent studies have indicated similar rates to inflammatory bowel diseases, with kleinschmidt et al noting small cell lymphoma cats compared with with intestinal lymphocytic infiltrates, evans et al reporting cases compared with with ibds , and baral et al diagnosing cases compared with with ibds. traditionally, % of feline lymphosarcoma is regarded as intermediate or high grade, but this may not be the case within the gastrointestinal tract. fondacaro et al found % of gastrointestinal lymphoma to be lymphocytic ; a more recent paper found some cats seem resistant to conventional therapy. if this is the case, the diagnostic findings should be re-assessed to ensure no steps were missed or findings disregarded; the cat should be reexamined to look for emergence of other signs; and the pathologist who reads the histology should be contacted to recheck the findings. some cases of apparently resistant ibd are actually food sensitive, but it can be difficult to find the incriminating diet source, and commercial diets are not always effective. if underlying infectious causes have been entirely ruled out and the practitioner is certain of the diagnosis of idiopathic disease, immune suppressive therapy can be increased by either increasing the dose of prednisolone or using other agents, such as chlorambucil, typically at mg/cat, po, every second day. it has been suggested that cats with eosinophilic inflammation may be more likely to be refractory to standard therapy. side effects of immunosuppressive therapy are rare but include inducing diabetes mellitus, immune suppression, delayed healing, and gastrointestinal ulceration. reported doses of sulfasalazine to manage large bowel ibd are to mg/kg, po, once daily for to days. because this drug is usually only available as mg tablets, one eighth of a tablet, providing a dose of . mg, is usually appropriate for most cats. in some countries, it is possible to have a compounding pharmacist formulate the drug into more convenient tablet sizes or as an oral suspension. cats are generally regarded as susceptible to salicylates, and possible side effects include vomiting or diarrhea, or anemia. the exact pharmacodynamics of this drug are not known; so, caution for extended use should be exercised and the drug withdrawn if any possible adverse signs are noted, but there are anecdotal reports of extended use of this drug without adverse consequences. a survey of the online veterinary cancer registry (http://www.vetcancerregistry.com) identified % of all submitted feline tumors to be intestinal tumors. approximately % of reported feline small intestinal tumors were lymphomas. adenocarcinomas accounted for %, and other tumor types reported included mast cell tumors and leiomyosarcomas. "lymphoma in veterinary medicine: no longer a oneword diagnosis" was the title of an editorial in a recent issue of the veterinary clinical pathology journal, and this is nowhere truer than in the feline gastrointestinal tract! a recent study classified cases of feline gastrointestinal lymphoma both histologically and immunophenotypically, and it found eight different categories according to the revised european and american lymphoma/world health organization (real/who) classification system and six categories according to the approximately equal numbers of high-grade and lowgrade gastrointestinal lymphoma. older cats are more at risk of small cell lymphoma, with mean or median ages reported from to years. younger cats with the disease have, however, been recognized. , , , no breed or gender predispositions have been definitively recognized. two larger studies have suggested a skew to males with males compared with females in one report, and males compared with females in the other ; most other studies looking at gender and breed did not clearly distinguish between lymphoblastic and lymphocytic neoplasia. clinically, it is impossible to distinguish cats with ibds from cats with small cell lymphoma. this is hardly surprising when even histologic distinction can be difficult! therefore cats will present with weight loss or vomiting or diarrhea at a similar frequency to those with ibd. weight loss has been recognized as a presenting sign in % to % of cases, diarrhea in % to % of cases, and vomiting in % to % of cases, with various combinations of these signs also possible. other variable signs are lethargy and inappetence or, conversely, polyphagia. , , , these findings can be summarized by stating that cats with gastrointestinal small cell lymphoma can present with any combination of signs relating to the gastrointestinal tract. intestinal small cell lymphoma is typically a diffuse disease, and therefore multiple areas of the alimentary tract are usually affected. in studies where different locations of the small intestine were assessed, the jejunum was most commonly affected ( %), with the ileum frequently affected ( % to %), and duodenal pathology slightly less prevalent ( % to %). , although the numbers of cats assessed in these studies are small, the important fact that the duodenum is not always affected needs to be recognized, which has important implications for how biopsy samples are obtained, because lesions beyond the duodenum are likely to be beyond the reach of an endoscope. further difficulties in precise diagnosis may arise, since non-neoplastic lymphocytic infiltrates (e.g., ibd) are often found in other locations along the intestinal tract. , , the stomach is also affected in % to % of small cell lymphoma cases. , , although not fully assessed, involvement of the colon appears rare. local lymph node involvement is common, being noted in up to % of cases. this percentage may be even higher, because many studies assessed lymph node cytology from ultrasound-guided fine-needle aspirates, which may miss spread to the lymph node, because the population of neoplastic lymphocytic cells is indistinguishable from the normal population of lymph node cells. histology is required to assess changes in lymph node architecture. liver involvement is not uncommon but not thoroughly assessed. one study noted liver lymphocytic neoplasia in of cats with small intestinal lymphocytic neoplasia, another found of affected cats in which the liver was biopsied, another noted of cats had liver involvement, and a further study detected neoplasia "in the lymph nodes, liver, or both" in all cats with intestinal small cell lymphoma. the pancreas may also be involved. , this may be akin to the noted association of lymphocytic inflammation of intestine, pancreas, and liver that has been dubbed tri-iditis. ultrasound findings may not suggest extragastrointestinal involvement. in the case of liver pathology, ultrasonography may show no changes in as many as % to % of cases. , focal nodular changes and he patomegaly have been recognized as ultrasonographic signs of hepatic small cell lymphoma. both lymphocytic ibd and lymphocytic neoplasia are often recognized simultaneously in the same cat, , and numerous authors have suggested that lymphocytic ibd may be a precursor to intestinal lymphoid neoplasia. , if this is the case, then antigenic factors, such as bacterial population changes or food sensitivities, could be considered primary initiating factors for small cell lymphoma since they are potential underlying etiologies of ibds. however, neoplasia also requires genetic mutations to occur (often affecting regulation of cell death and cell survival), and these may be initiated by the inciting antigenic factors or the ongoing inflammatory changes. as opposed to other feline lymphoid neoplasia, no association has been made with felv infection. , , , intestinal lymphocytic lymphosarcoma begins in the superficial mucosa and progresses to involve the entire mucosa and submucosa; then advancing in a perivascular pattern into the tunica muscularis, eventually infiltrating all four intestinal tunics. lymph node and other organ (such as liver or pancreas) involvement likely represent metastasis through lymphatics and perhaps hematogenously. more distant metastasis is not reported. serum or plasma biochemistry and hematologic findings are typically nonspecific. however, this testing is important as part of the diagnostic workup to rule out extra-gi disease, such as hyperthyroidism or diabetes mellitus. common biochemistry findings are mild to moderate increase of liver enzymes, such as alanine aminotransferase (alt), aspartate aminotransferase (ast), and/or alkaline phosphatase (alp). , , , as with ibds, these liver enzyme changes may or may not represent overt hepatic disease. albumin may be reduced but is normal in most cases , , ; azotemia may be present and may be of prerenal origin or represent concurrent renal disease. in one study, of cats were hypocobalaminemic; of cats had low folate, but of had elevated folate; and of cats had increased ftli. hematologically, a mature neutrophilia with or without monocytosis is sometimes present, representing the inflammatory response; lymphopenia may be present as a stress response. anemia may be present and may occur as a result of chronic slow gi blood loss, and in some cases, ulceration, or it may be because of chronic disease; hemoconcentration is also possible, reflecting dehydration. , , , palpable or ultrasonographically visible thickened intestines ( % to % of cases) , , , or mesenteric lymph nodes ( % to % of cases) , , , are no more or less likely to be present in comparison with ibds. there are no defined ultrasound guidelines for cats with intestinal small cell lymphoma, because most prior papers do not distinguish between small cell and lymphoblastic neoplasia. , a more recent paper found of cats undergoing ultrasound examination had diffuse small intestinal wall thickening, with a mean of . mm (range, . to . mm; median, . mm), and focal mural thickening of mm was noted in one cat. in many cases, against expectations, intestinal wall layering was preserved. these findings also mean that of cats had ultrasonographically normal intestinal wall thickness (≤ . mm for the duodenum and ≤ . mm for the ileum). if affected, jejunal lymph nodes may appear as hypoechoic and enlarged; in the same study, of cats had lymph node changes with a mean diameter of . mm (range, . to mm; median, mm) compared with the normal diameter of less than or equal to . mm. none of these findings can definitively distinguish small cell lymphoma from ibds; although one recent paper has suggested that ultrasonographic thickening of the muscularis layer is more likely in cats with intestinal small cell lymphoma (figure - ) than those with ibd, this change was also seen in % of cats with a normal small intestine. however, thickening of the muscularis layer together with lymphadenopathy was recognized in % of those cats with small cell lymphoma compared with % of those with ibd and % of cats with no small intestinal pathology. biopsy samples and histopathology are required for definitive diagnosis. an example of jejunal and mesenteric lymph node appearance at laparotomy is shown in figure it is difficult to distinguish between lymphocytic inflammation and small cell lymphocytic neoplasia in any location; some histopathologic features that might help in differentiating the ends of the spectrum may include therefore become known as the fondacaro protocol. this consists of a combination of prednisolone and chlorambucil given orally by the client at home (table - ). the rationale is that a slow alkylating agent, such as chlorambucil, is more appropriate to use for the slowly dividing, well-differentiated lymphocytes that cause disease. this can be contrasted to the aggressive chemotherapeutic agents required for the rapidly proliferating cells in lymphoblastic neoplasia that is typically associated with lymphosarcoma. reported response rates to this protocol are excellent, with % to % of cats achieving complete clinical remission, reported median survival times ranging from to months for those cats responding to therapy, and reports of individual cats surviving as long as months. , , the original reported protocol comprised prednisolone ( mg/cat, po or mg/kg, po) given daily with chlorambucil pulsed by administration of mg/m for days every weeks. a more recent study dosed prednisolone similarly, but chlorambucil was given as continuous therapy of mg/cat, po every second or third day. no mucosal congestion, edema, or fibrosis in lymphocytic neoplasia, compared with ibd . epitheliotropism, or homing of neoplastic t lymphocytes to the mucosal epithelium in lymphocytic neoplasia these features can be seen in figure - . each of these criteria may be useful but are unlikely to be definitive. further studies that may not be routinely available but which may be helpful are immunophenotyping; most reports have found purely t lymphocytes in most cases of intestinal small cell lymphoma , , , (figure - ). . clonality; the detection of a clonal population of cells, as recently described for intestinal lymphocytic lymphosarcoma, would be closest to providing the basis for definitive diagnosis. effective treatment of feline intestinal small cell lymphoma was brought to light by fondacaro et al and has cat to be weaned off corticosteroids, with chlorambucil continued as monotherapy (as is often the case with humans). iatrogenic diabetes mellitus usually needs to be managed with insulin therapy, at least initially (see chapter ) . high-grade lymphoma or lymphosarcoma is the traditional style of aggressive, rapidly dividing lymphoid neoplasia that carries a much poorer prognosis than small cell lymphoma. most early studies do not distinguish grade of neoplasia; so, the prevalence of low-grade and high-grade alimentary lymphoma are difficult to assess. several recent studies found a similar prevalence of each, , but the seminal paper describing small cell lymphoma found only cases of lymphoblastic lymphoma compared with cases of small cell lymphoma. this ratio of approximately one high-grade gi lymphoma case for every three low-grade cases more closely approximates the rate found in the author's practice. the reported median ages of affected cats range from to years, but cats as young as year old have been diagnosed. most papers note that males are overrepresented, and siamese cats may also be overrepresented although most affected cats are domestic shorthairs. , , , , precise signalment is difficult to determine from the literature, because many papers assess all anatomic locations of lymphoma without necessarily breaking down epidemiologic data for each anatomic site. also, there are few comparisons to a reference population. the association of lymphoma with felv infection is well established and documented and is covered in chapter ; fiv has also been shown to be lymphomagenic. , since the control of felv through vaccination began in the s, nonretroviral-associated lymphoid neoplasia has become more common, and the rates of intestinal lymphoma have, in fact, increased since felv infection rates have decreased. the underlying causes for this increase are not known. the association with inflammation from ibds was noted for small cell lymphomas, and perhaps there is a spectrum from lymphocytic ibd to small cell lymphoma to high-grade lymphoma. that some cats are more likely to have inflammatory changes become neoplastic is suggested by a paper noting higher lymphoma rates in cats with vaccine-associated sarcomas (a neoplastic condition where the role of chronic inflammation is well noted). similar protocols are used in humans with both lowgrade (i.e., lymphocytic) lymphosarcoma and chronic lymphocytic leukemia. , some studies with humans have indicated that continuous therapy with chlorambucil results in prolonged survival, although metaanalyses have not been able to determine optimum dosing and scheduling of administration of chlorambucil or other alkylating agents in these conditions in humans. , although we do not have enough data to critically compare pulsed therapy to continuous dosing, the study assessing continuous dosing appeared to have a lower number of cats completely responding, although those cats that did respond had a longer median survival than those in the studies assessing pulsed chlorambucil dosing. , the differences may also relate to the definitions used for complete response. the chlorambucil dose of mg/cat, po every second day (or third day) is often chosen because of the ready availability of mg coated tablets, the breaking of which can expose the owner to these cytotoxic medications. chlorambucil can be compounded into smaller doses, thus allowing daily dosing of mg capsules. the author has used this dose to apparent good effect, but there has been no critical assessment. it is unknown whether involvement of lymph nodes or other organs, such as the liver, affects prognosis. the only study of substantial size to include extra-gi locations found anatomic location was not prognostic for response or survival time. in another study, of the five cats with liver involvement, two cats did not survive more than months, yet the other three lived longer than years, with two surviving longer than years. a study of hepatic small cell lymphoma suggests the density of neoplastic lymphocytes may influence survival, and density may relate to the stage of the disease when diagnosis occurs. adverse effects of chlorambucil are rare, but gastrointestinal signs, myelosuppression, and myoclonus have all been reported. gastrointestinal signs, such as vomiting, diarrhea, or inappetence, can be difficult to distinguish from continuation of the gastrointestinal disease diagnosed. these signs are usually self limiting. myelosuppression is also possible with thrombocytopenia reported. , monoclonus has been reported on one occasion. it is ideal to check hematologic parameters every months for cats receiving chlorambucil. continuous therapy using lower doses of chlorambucil may be less likely to lead to these adverse effects. high doses of corticosteroids can induce diabetes mellitus, and thus blood glucose should be checked regularly. if diabetes occurs, the author has found that budesonide ( mg budesonide is generally considered to be equivalent of mg prednisolone) can be substituted for prednisolone, since it has reputed lower systemic effects (though no assessments of this drug's effectiveness in cats have been made). an alternative is for the of distinction of intestinal layering as shown in figure - . the area of lymphomatous infiltration is hypoechoic, because it contains a uniform cell population without much reactionary fibrous tissue. mesenteric lymphadenomegaly is common (figure - ) , as are changes in other organs, such as kidney, liver, or pancreas. ascites may also be seen. , although ultrasonographic distinctions predominate, there is considerable overlap between ultrasonographic findings with small cell lymphoma and high-grade lymphoma. the clinician must not lose sight of the fact that microscopic distinctions are required to diagnose either condition. cytologic diagnosis of high-grade lymphoma from fine-needle aspirates (fna) is much more likely than with small cell lymphoma. this is because there is usually a focal lesion, and the neoplastic cells are a monomorphic population of large, immature cells (i.e., that are not normally seen in tissue). sometimes, mixed lymphoid whether the underlying cause is retroviral or chronic inflammation or anything else, the pathogenesis of highgrade intestinal lymphoma, as with small cell lymphoma and other neoplasia, depends on chromosomal changes that affect regulation of cell growth and death, resulting in malignant transformation and clonal expansion of immature lymphocytes. metastasis can occur in one third to two thirds of cases, , with involvement of mesenteric lymph nodes most commonly noted, but spread to liver, spleen, kidneys, and thorax is also possible. a recent survey of gastrointestinal lymphoma found that most cases ( of ) involved the small intestine (including that also involved the stomach and that also involved the large intestine), and of cases involved the large intestine only. cats with high-grade alimentary lymphoma often present similarly to those with other gastrointestinal diseases. typical clinical signs are weight loss, anorexia, lethargy, vomiting, diarrhea, or a combination of these signs. repeated studies have found cats with no vomiting or diarrhea; in one study, of cats had only anorexia or weight loss on presentation. cats with large bowel pathology usually present, as with other causes of colitis, with increased urgency, and small, frequent amounts of diarrhea, often with blood or mucus. cats with large bowel neoplasia of any form can present for constipation caused by intestinal obstruction. palpation of an abdominal mass has been recognized in % to % of cases, , but the corollary of this is that % to % of cases did not have a palpable mass. it is also important to note that up to % of cats with intestinal small cell lymphoma, and a number with ibds, have palpable mesenteric lymph nodes; so, a palpable abdominal mass is not a specific indication of high-grade neoplasia. many cats have palpably thickened bowel loops. hematology and plasma or serum biochemistry findings are also nonspecific. increased liver enzymes may or may not indicate liver involvement. anemia may be recognized and can be non-regenerative, reflecting chronic disease or slow blood loss, or regenerative if there is more substantial blood loss associated with mucosal ulceration. hypoalbuminemia can be because of blood loss or intestinal protein loss. hypercalcemia of malignancy is a possibility but not commonly reported. despite nonspecific signs, laboratory testing is important to rule out extra-gi diseases and help manage consequences of enteric disease, as with small cell lymphoma and ibds. ultrasonography commonly shows a focal intestinal thickening (of to mm) with partial or complete loss although noted as the next most common intestinal neoplasia, after the various forms of lymphoma, adenocarcinoma is seen relatively infrequently in practice. most cats are more than years old, , , males may be overrepresented, and several studies have recognized a distinct overrepresentation of siamese cats. , three distinct forms have been described : cats typically present with nonspecific signs of gastrointestinal disease but can present with obstructive signs. cats with large bowel neoplasia can present for tenesmus or hematochezia and even constipation, if the lesion is obstructive (or partially obstructive). on physical examination, an abdominal mass is palpable in approximately % of cases, but other findings are usually nonspecific. anemia can be found if mucosal ulceration has occurred, but there are no distinctive laboratory findings. lesions can occur anywhere along the intestinal tract. one study of cases found % of feline intestinal adenocarcinoma lesions were present at the ileum or ileocolic junction. twenty-five to percent of cases have metastasis at the time of the diagnosis, and this is a poor prognostic indicator. , , radiology may show a mass lesion or intestinal obstruction, and ultrasonography can localize lesions to an intestinal origin. the ultrasonographic appearance of the proliferative, circumferential, outwardly expansile populations (of immature lymphoblasts and mature lymphocytes) are seen if a germinal lymphoid follicle is aspirated, and precise diagnosis may be difficult if there are a large number of lymphoblasts. fna samples are best obtained with ultrasound guidance. the cytologic sample quality is greatly improved by not aspirating when the needle is visualized in the mass but merely "pecked" into the mass so that the needle is merely acting to finely "core" the mass. on removing the syringe and needle, the hub of the needle is removed before drawing air into the syringe, the hub is replaced, and the sample within the needle is expressed onto a slide. usually, the decision to diagnose by cytology from fna is based on the ultrasonographic appearance of a mass. since there is substantial crossover of ultrasonographic appearance of intestinal masses, laparotomy for excision is often performed with the affected bowel submitted for histology. except when intestinal obstruction has resulted, there is no therapeutic benefit of excising a gastrointestinal lymphoma (which requires excision and anastomosis), but there is minimal room for doubt when a histologic diagnosis is achieved. the response to therapy for high-grade intestinal lymphoma is significantly worse than that for small cell lymphoma. , further, response to therapy for highgrade intestinal lymphoma appears to be worse than for lymphoma in other anatomic locations. precise remission rates and survival times are difficult to quantify, because many studies assess lymphoma from multiple locations and do not necessarily differentiate response of gastrointestinal lymphoma or report the grade of lymphoma. with remission rates reported from % to % , , and a median survival time of up to weeks (range, to weeks), it can be said with some certainty that some cats respond to therapy for reasonable durations. multiple authors have noted that the best prognostic indicator is response to an initial treatment cycle, , , which should prompt clinicians to encourage owners to start therapy and decide whether to continue based on the cat's response. there are several published chemotherapeutic protocols, , , , , but all follow the same principles of using medications to target specific phases of the cell division cycle (such as l-asparaginase and vincristine) with other medications that interrupt multiple phases of the cell cycle (cyclophosphamide and doxorubicin). targeting the cancer cell in different ways enables more cells to be killed, reduces the toxicity of the individual drug used, and reduces the likelihood of resistance to a specific drug. several authors have noted increased success with the addition of l-asparaginase and doxorubicin to protocols. , , chemotherapy for lymphoma is covered in more detail in chapter , oncology. look promising, but only two cats assessed had gastrointestinal mast cell neoplasia. lomustine was used unsuccessfully in one cat with sclerosing mct; another cat with sclerosing mct received eight treatments of vinblastine and had a survival time of greater than years. adenomatous polyps have been reported in the duodenum and ileum and can result in intussusception. cats of asian ancestry, predominantly siamese, are greatly overrepresented, and most reported cases have been males. cats usually present for vomiting or hematemesis that, surprisingly, can be very acute in onset; complete intestinal obstruction may result. , , resection is curative, with survival times of more than years reported. eosinophilic sclerosing fibroplasia has recently been described in a series of cases and is not strictly neoplasia. the ulcerating mass lesions that can occur anywhere from the stomach to the colon are often grossly and histologically mistaken for neoplasia. there appears to be no breed predisposition or age predisposition (with ages ranging from weeks to years), but of cases ( %) were castrated males cats compared with of ( %) female spayed cats. eighty-four percent of cats presented for vomiting, % presented for weight loss, and of ( %) cats had peripheral eosinophilia. all cases had a palpable abdominal mass. the pyloric sphincter was the most common site, and lesions in this location were mostly considered unresectable. fourteen of cats ( %) had bacterial colonies within microabscesses and necrotic foci within the lesion. the bacteria recognized were predominantly gram-negative rods, but antibiotics did not seem to be clinically effective. the bacteria are suspected to initiate the lesions, having been embedded after foreign body penetration. there are no specific treatment recommendations, but excision, where possible, would be prudent; corticosteroids appear to be helpful adjunctive therapy. survival times are difficult to estimate since many cats were euthanized because neoplasia was suspected and follow-up times were short (up to months) for the remaining cats. there are very few reports of intestinal leiomyosarcomas in cats, , which have been reclassified as gastrointestinal stromal tumors. these tumors may be more likely to arise from the ileocecocolic junction. resection, if possible, is usually recommended, with survival times of to months reported before recurrence. the author owns a cat with this tumor where resection was not form is better described than the annular, constrictingband form with minimal outward enlargement. in these cases, sonographically, a solitary segmental intestinal mural mass is present and characterized by circumferential bowel wall thickening with transmural loss of normal sonographic wall layers. the thickening can vary in echogenicity but may be hypoechoic and may be symmetric or asymmetric. there is no definitive distinction, however, from lymphosarcoma, mast cell tumor, smooth muscle origin tumors, or even segmental benign inflammatory bowel disease. surgical resection is the treatment of choice. there seem to be two distinct groups in terms of survival time postresection: . short-duration survival (euthanasia or death within weeks of surgery) . long-duration survival (mean survival time of months, with a number of cats surviving greater than years) , because clean margins improve prognosis, for large bowel adenocarcinoma, subtotal colectomy may be required for complete excision. because of the potential for success after resection, it is recommended to excise unidentified masses at the time of surgery. other forms of intestinal neoplasia are recognized infrequently, and include intestinal mast cell tumors, adenomatous polyps, eosinophilic sclerosing fibroplasia, gastrointestinal stromal tumors (leiomyosarcoma), and hemangiosarcoma. mast cell tumors (mct) are often cited as the third most common form of feline gastrointestinal tumor, but the intestines are a far less common site than cutaneous, splenic, or hepatic mast cell neoplasia. , masses are usually segmental nodular thickenings that occur in older cats. the masses are indistinguishable ultrasonographically from other tumors, such as lymphoblastic lymphosarcoma. a recent series of cases described a variant of feline intestinal mast cell tumor, dubbed sclerosing mast cell tumor, for which neoplastic cells form a trabecular pattern with dense stromal collagen. additionally, eosinophilic infiltrates were moderate to marked in most cases. these cases can be confused histologically with eosinophilic enteritis, gastrointestinal stromal tumor, or fibrosarcoma. surgical resection is recommended, but lesions are commonly infiltrative or metastasize widely, and there are few reports of successful treatment. lomustine (dosed to mg/m , po every to weeks) has recently been assessed as adjunctive chemotherapy for mast cell neoplasia in various locations, and results recognized in that many intestinal bacteria can be found in healthy animals. further antibiotic administration can result in increase of other bacteria. fungal causes of diarrhea are usually recognized from histology of biopsy samples. it remains to be seen whether the recent ready availability of pcr panels looking at a number of infectious causes of diarrhea will be beneficial for recognizing pathogens that had previously been misdiagnosed or a hindrance for readily recognizing commensal organisms not necessarily causative of the clinical signs being investigated. the most common viral, bacterial, and mycotic causes of diarrhea in cats are described below. parasitic gastrointestinal diseases are covered later in this chapter. viral causes of diarrhea are not usually specifically diagnosed, since, with the exception of the canine fecal elisa possible, and the cat appears healthy months past diagnosis (figure - ). cats with intestinal hemangiosarcoma often present with anemia, and the disease appears to be highly metastatic. the intestines appear grossly thickened by dark red tissue. the small and large intestines seem to be affected with similar frequency. removal of macroscopic disease is recommended, but often the full extent of the severity is only recognized at surgery. the prognosis is poor. suspicions of infectious causes of diarrhea should be aroused in younger cats, cats from shelters, or cats with immune suppression. when considering infectious causes of diarrhea, clinicians should assess whether the diarrhea is large bowel or small bowel in origin and correlate this with specific pathogens that are likely to cause clinical signs as shown in table - . to increase the diagnostic yield of fecal examination for parasitic causes of diarrhea, wet smears and appropriate fecal flotations should be performed on fresh fecal samples (< hour old). it is appropriate to administer broad-spectrum anthelminthics, even if fecal tests are negative. bacterial and viral causes of diarrhea should be considered when the cat is systemically unwell with fever. fecal culture should be performed in these circumstances, but the limitations of this testing need to be yersinia enterocolitica current theory of fip pathogenesis involves initial infection with fecv and then mutation to fipcv in small numbers of susceptible individuals. , routine serologic testing for fecv in cats with diarrhea would neither prove correlation with the clinical signs nor affect how the disease is managed and so is not recommended. cats with fecv diarrhea should be managed with symptomatic therapy of fasting, then reintroducing a bland diet and supportive care with fluid therapy if necessary. other viruses, such as astrovirus, reovirus, rotavirus, and torovirus-like agent, have been recognized to cause diarrhea in cats, but their roles as pathogens are unclear. they are not routinely recognized in practice, since electron microscopy of fecal samples is necessary for diagnosis and is not routinely performed. management is supportive care with appropriate fasting, then reintroduction of bland diets and fluid and electrolyte replacement if necessary. successful identification of a known bacterial pathogen from a fecal sample does not necessarily mean that the agent found is the cause of disease in the cat. although a number of bacterial pathogens have been demonstrated to cause diseases when specific pathogen-free (spf) cats are experimentally infected, these same organisms can be found in healthy cats. the differences between healthy and diarrheic cats that have bacteria found in their feces may relate to virulence factors of the organism, or host factors (local or systemic immunity) of the cat. there is no definitive answer for this quandary. the author's opinion is that • if a diarrheic cat is systemically unwell and has a fever, then feces should be cultured. • if an organism is isolated that is known to cause signs consistent with those the cat is showing, the cat should be treated appropriately. campylobacter diarrhea is usually caused by c. jejuni. clinical signs of infection are poorly documented, but most cats are asymptomatic. younger cats are more likely to have clinical signs and hemorrhagic, mucoid diarrhea has been reported. diagnosis can be from culture of feces or swabs, and the organism is quite hardy; so, it usually survives transport to the laboratory. in individual cases, the organism has not been cultured after antibiotic treatment, , but it is not definitively proven that antibiotic therapy affects the natural course of the disease. antibiotics that can be used are amoxicillin-clavulanate ( mg/kg, every hours, po) for parvovirus, routine definitive tests are not available. clinical signs of panleukopenia (feline parvovirus infection) are more likely to occur in kittens, with the highest morbidity and mortality occurring between and months of age. subclinical cases in older (susceptible) cats probably go unrecognized. the organism is very stable in most environments, and infections mostly occur from environmental contact. peracute cases can result in death within hours, with little or no warning signs. acute cases often have fever, depression, and anorexia, with signs beginning approximately to days before presentation. vomiting is usually bile tinged and unrelated to eating. diarrhea does not always occur, and when it does, it is usually later in the course of the illness. leukopenia is not pathognomonic, because this can also occur with acute bacterial infection (e.g., salmonellosis can present identically). commercially available elisa tests for canine parvovirus antigen in feces can detect feline parvovirus; however, shedding may have ceased by the time clinical signs occur, and vaccination can result in positive test results for up to weeks. aggressive fluid therapy, usually at twice maintenance rates, is usually required. broad-spectrum antibiotic coverage is used to prevent or treat secondary bacterial infection from viral injury of intestinal mucosa. parenteral antibiotics are preferred to prevent the possibility of further gastrointestinal irritation. the author recommends calculating iv doses and introducing appropriate amounts of antibiotics to the fluids bag to create a constant rate infusion (cri); cefazolin can be used in this way at mg/kg/ hours, and betalactam cris are commonly used in human medicine. aminoglycosides or fluoroquinolones can be used concurrently at routine doses if fever persists after hours or the cat is moribund on presentation, but care must be used with these agents. aminoglycosides are potentially nephrotoxic, and fluoroquinolones have been reported to result in cartilage damage in growing animals, although this has not been demonstrated clinically in cats. fluoroquinolone retinal toxicity has been seen in all animals. cats that survive the first week usually recover, and prior infection imparts lifelong immunity. vaccinations are highly effective for disease prevention. feline enteric coronavirus (fecv) mostly causes mild, self-limiting diarrhea and must be distinguished from feline infectious peritonitis coronavirus (fipcv), which is essentially always fatal and for which diarrhea is not a typical sign (but is possible). the most widely accepted or fluoroquinolones, such as enrofloxacin ( mg/kg, once daily, po) for durations of to days. macrolides, such as erythromycin ( to mg/kg, every hours, po), are regarded as the drug of choice for humans but can cause gastrointestinal side effects. clostridium difficile has been recognized in up to % of diarrheic cats. clinical signs are typically acute onset watery diarrhea and anorexia. diagnosis has been made with detection of toxin a or toxin b in fecal samples using elisa. although these tests have not yet been validated for cats, they may prove to be a useful aid to diagnosis and are available for testing of equine feces at some commercial laboratories. nontoxigenic strains exist; so, positive culture alone does not ensure diagnosis. metronidazole ( mg/kg, every hours, po) for approximately days is the treatment of choice. clostridium perfringens typically results in large bowel diarrhea with tenesmus, mucus, and hematochezia, but small bowel signs can also be seen. pcr testing for enterotoxin a is commercially available and may prove to be a useful adjunct in diagnosis. antibiotics that can be used include metronidazole ( mg/kg, every hours, po), tylosin ( to mg/kg, twice daily, po), or amoxicillin-clavulanate ( mg/kg, every hours, po) for days. escherichia coli is a ubiquitous organism within the feline intestinal tract, and it would be unusual not to successfully culture e. coli from the feces of both healthy and unwell cats. when e. coli is associated with clinical signs of gastrointestinal disease, it is mostly as an opportunistic pathogen, with overgrowth resulting from changed environmental conditions, such as inflammation from other pathology or another pathogen. there are also specific strains of e. coli that are true pathogens because of virulence factors not present in commensal e. coli; these include enteropathogenic e. coli and enterotoxigenic e. coli, which both induce a watery diarrhea, and enterohemorrhagic e. coli, which produces a diarrheal syndrome with copious bloody discharge and no fever. pcr testing is commercially available to identify pathogenic strains of e. coli , ; although not offered at routine veterinary laboratories, this testing is available to veterinarians, and laboratories offering these services can readily be found online. diagnosis should also document histologic lesions corresponding to the strain of e. coli identified. there is emerging resistance to e. coli worldwide in all species of animals, including humans. this includes the typical therapies for gram-negative bacteria of beta-lactamenhanced penicillins and fluoroquinolones. a major risk factor is prior antibiotic usage, because commensal organisms are exposed to antibiotics. pcr testing does not enable antibiotic sensitivity testing, and fecal culture may not be able to distinguish pathogenic from nonpathogenic strains; so, sensitivities may not be an accurate reflection of the pathogenic organism. pcr testing for genes that impart resistance to e. coli have recently been described but are not yet commercially available. in some circumstances, supportive care with fluid and electrolyte replacement may be all that is required while the cat's immune system combats the infection. empiric therapy could include beta-lactam-enhanced penicillins (such as amoxicillin-clavulanate at mg/kg, every hours, po), fluoroquinolones (such as enrofloxacin at mg/kg, once daily, po), or cefovecin ( mg/kg, every weeks, sc), but the clinician must be aware of possible drug resistance. salmonella typhimurium infection is possible from ingestion of infected prey, infected food sources, or from a contaminated environment, including the veterinary hospital. the resulting clinical signs depend on the number of infecting organisms, the immune status of the cat, and the presence of concurrent diseases. infection rates in cats (and humans) have been correlated with seasonal bird migrations, and the illness has been dubbed songbird fever, but there is no distinction between this and other salmonella infections. clinical signs usually begin to days after exposure, starting with fever (often > ° c [ ° f]), malaise and anorexia, and progressing to diarrhea, vomiting, and abdominal pain. hematology can show leukopenia with a left shift and nonregenerative anemia, and biochemistry results are usually nonspecific. diagnosis is based on isolation of the organism by culture or identification with pcr, but care should be taken to correlate pathogen identification with clinical signs since, as with most gi pathogens, the organism can be isolated from healthy animals. as with e. coli, antibiotic resistance is widespread, with one united kingdom survey finding the multiple drugresistant strain dt to be the most frequent bacteriophage type identified. treatment should be reserved only for those cats showing systemic signs, because routine antibiotic use in treating salmonellosis induces drug-resistant strains and prolongs the convalescent excretion period. antibiotic choice should be based solely on sensitivity findings, since resistances are so widespread and unpredictable. this means that if the organism has been identified by pcr, then culture of feces must also be undertaken. the duration of treatment must be long enough to eliminate fecal excretion of the organism, prevent the chance of relapse, and reduce the chance of resistance developing; up to days has been advocated. , these cautions are particularly important because of the zoonotic potential of salmonellosis. linear foreign bodies have traditionally been considered more common than discrete foreign bodies in cats, , , but a study from a primary care facility indicated only % of foreign body cases were because of linear foreign bodies. the larger case load of linear foreign bodies at referral institutions noted in earlier studies may indicate the abilities of primary care practitioners to recognize and effectively deal with discrete foreign body obstructions. most studies have found that cats with intestinal foreign bodies are generally younger (mean, . to . years), with a notable exception being obstruction from trichobezoars where three of five cats in one study were years or older; the greatest risk factor appears to be length of hair coat. no specific breed predispositions have been described but siamese and siamese-related cats have been noted to have oral fixations and so may be expected to be overrepresented with intestinal foreign bodies. clinical signs will vary depending on the type of foreign body (linear or discrete), the position of obstruction, and the time since obstruction. most cats present for anorexia or vomiting. partial obstruction can result in diarrhea (which can be bloody). foreign body obstruction is typically considered an acute condition, with duration of obstruction because of a linear foreign body, measured from the onset of clinical signs to diagnosis, reported to range from to days. , , however, one paper demonstrated chronic, intermittent, gastrointestinal disease from a linear foreign body of a -month duration demonstrating that partial obstruction can result in a chronic course. physical examination may or may not reveal abdominal pain, palpable abdominal mass (or plication), dehydration, or fever. all cats presenting for anorexia or vomiting should have the underside of the tongue evaluated for the presence of a linear foreign body. applying gentle pressure with a thumb in the intermandibular space to elevate the tongue is an effective way to visualize lesions or foreign bodies in the sublingual area (see figure - ) . life-threatening consequences can result from the interactions of local and systemic factors that arise from intestinal obstruction. locally, damage to the mucosa from traction and pressure of the foreign object can cause hemorrhage, ischemia, and necrosis. systemically, hypovolemia, toxemia, and acid-base and electrolyte imbalances can ensue. complete intestinal obstruction by discrete masses results in gas and fluid distention of the lumen proximal other bacterial causes of diarrhea have been reported in cats, such as yersinia enterocolitica, yersinia pseudotuberculosis, clostridium piliforme (tyzzer's disease), and anaerobiospirillum sp. specific diagnosis of these (and other bacterial infections) may be found in the course of investigation. management follows the principles of supportive care and appropriate antibiosis based on sensitivity testing. small intestinal bacterial overgrowth (sibo) has not been specifically described in cats. the criteria defined for dogs is a fasting bacterial count in duodenal juice of greater than organisms/ml and is often recognized with other chronic gastrointestinal diseases. healthy cats appear to have at least this number of upper intestinal bacterial with a range of to /ml recognized. bacterial overgrowth could potentially occur with ileus or intestinal inflammation of any underlying cause. foul-smelling small bowel diarrhea with no specific pathogen recognized may be an indicator of this condition, as could an increase in bacterial metabolites, such as folate. if suspected, it is appropriate to manage with broad-spectrum antibiotics, such as metronidazole ( to mg/kg, every hours, po) or amoxicillin ( mg/ kg, every hours, po) for an extended duration such as to days. alterations in intestinal flora have been recognized after such treatment ; however, any advice for this "condition" is entirely empirical. all efforts should be directed at identifying a precise underlying cause. mycotic and other infectious agents are only rarely recognized as intestinal pathogens in cats. diagnosis is made by histologic and microbial analysis of samples obtained at biopsy. possible agents include histoplasma capsulatum, aspergillus spp., candida albicans, and pythium insidiosum. intestinal obstructions arise most commonly as a result of neoplasia in older cats and foreign body ingestion predominantly in younger cats. , , less common causes include intussusception and granulomatous inflammation (e.g., from fip) ; tapeworm infection, with greater than worms acting as a linear foreign body, has also been reported. other listed causes are volvulus, intestinal torsion, incarceration of bowel in a hernia, adhesions or stricture, intramural abscess or hematoma, and congenital malformations. may not occur if the obstruction is partial or intermittent, or if vomiting results in less fluid present. since most foreign body obstructions in cats are proximal, identifiable dilatation may not be recognized for this reason. linear foreign bodies present further challenges for radiographic recognition; the following typical radiographic signs , may or may not be present: to the obstruction. most gas accumulation is a result of swallowed air, which is predominantly nitrogen that cannot be absorbed by the intestinal mucosa. gas also arises from bacterial fermentation. fluid accumulates as a result of increased secretions (saliva, bile, and secretions of gastric, pancreatic, and small intestinal origin) and retention of fluid already ingested, and it can be augmented by local hemorrhage. since most intestinal obstructions in cats do not reach the midjejunum, reabsorption of fluids that normally occurs at the jejunum and ileum is impaired. linear foreign bodies, such as string, dental floss, or elastic toys, require proximal anchoring, usually under the tongue or in the pylorus (for example, by part of a toy attached to elastic). peristalsis moves the free end of the "string" through the intestinal tract, resulting in pleats of intestines around the foreign body. as the foreign body is forced against the intestinal mucosa, the mucosa becomes edematous, and even partial penetration affects mucosal integrity, allowing systemic entry of bacteria. intraluminal bacterial populations increase for both discrete and linear foreign bodies as a result of stasis. mucosal permeability can be affected by prolonged luminal distention, allowing entry of bacteria and toxins systemically or into the peritoneal cavity. direct entry of bacteria to the peritoneal cavity, causing septic peritonitis, can result from perforation of the intestinal wall from linear foreign bodies or sharp discrete foreign bodies, such as toothpicks or plastic toys. definitive diagnosis requires identification of the foreign body retrieved at surgery or in some cases, by endoscopy. this may be aided greatly prior to surgery by diagnostic imaging. however, imaging findings, particularly in the case of partial obstructions, may be subtle enough that obstruction of no identifiable cause is recognized or no overt signs are apparent. laboratory findings are not helpful in the precise diagnosis but are important to assess fluid and electrolyte balances that must be corrected. cats rarely help practitioners by ingesting radiopaque objects, but on the rare occasions that they do, these can be observed easily on plain radiographs. nonopaque foreign bodies depend on dilatation of the intestine from gas and fluid accumulation proximal to the obstruction for radiographic recognition (figure - ) . one study has suggested that if the jejunal diameter is greater than . times the length of the cranial end plate of the second lumbar vertebra, then intestinal obstruction is the most likely abnormality. care must be taken that the jejunal and not duodenal diameter is measured and that the radiographs must be positioned strictly lateral, because an oblique view can alter the measurement of the lumbar vertebra. however, dilatation of an obstructed intestine successful treatment of foreign body obstruction requires evacuation or removal of the foreign body as well as correction of any bacteremia or endotoxemia, acid-base or fluid imbalances. discrete foreign body obstruction requires surgery or endoscopy to remove the object. in some specific circumstances, linear foreign body obstruction may be managed conservatively by cutting the anchor point below the tongue and allowing the cat to pass the foreign body by peristalsis. however, the decision to manage a cat conservatively must be done with the cat hospitalized, with fluid therapy and antibiotic coverage and a clear recognition on behalf of the practitioner and the owner that surgery may subsequently be required. cutting a sublingual linear foreign body may be achieved in a conscious cat by applying pressure with the thumb of one hand in the intermandibular space to elevate the tongue and gently grasping it using gauze with the other hand while a second person cuts the line with a suture cutter. there is a chance of a small nick on the sublingual surface. if the cat will not tolerate the procedure, sedation is appropriate. when cutting the line, the nature of the linear foreign body should be assessed (i.e., is it more or less likely to cut mucosa). in one study, cats with linear foreign bodies were managed conservatively with cats subsequently requiring surgery. the authors of that paper created guidelines that will be adapted here. conservative management should be attempted if the cat • is presented acutely (within days) after known ingestion of a linear foreign body • has a sublingually fixed linear foreign body that can be cut • has no overt signs of peritonitis • altered gas pattern with luminal gas collecting in small bubbles instead of normal curved tubular columns. this can be subtle when there is only minimal involvement of the intestine but overt when involving the entire small intestine. commashaped gas patterns are more likely to occur with linear foreign bodies. contrast radiography can aid diagnosis for both discrete and linear foreign bodies but should be used with caution because intestinal perforation may be present. nonionic iodinated agents that are typically used for myelography (such as iopamidol or iohexol) should be used, since barium is irritating to the peritoneum and oral iodine compounds are hypertonic. hypertonic compounds may draw fluid into the stomach and intestines after oral administration, with the potential of creating further fluid and electrolyte imbalances in an already compromised patient. ultrasonography is a very useful diagnostic tool, particularly for discrete foreign bodies, where, in most cases, there is overt distention of the small intestines with intraluminal fluid apparent (figure - ) . this modality has not been extensively assessed as an adjunct to diagnosis of foreign body intestinal obstruction in cats specifically, although there are several papers assessing dogs and small numbers of cats that agree with its utility. , , linear foreign bodies are more difficult to assess ultrasonographically, but plicated bowel can be recognized, sometimes with the foreign body seen as a hyperechoic line centrally. si a technique has been described for removal of linear foreign bodies by making a single enterotomy incision proximally and passing a red rubber catheter over the linear foreign body aborally, milking the foreign body within the catheter through the colon for retrieval from the cat's anus by an assistant. this technique is not always effective, because it can be hampered if the foreign body is knotted or does not run smoothly through the red rubber catheter. if the affected bowel segment demonstrates evidence of necrosis or perforation on the mesenteric border of the intestine, resection and anastomosis should be performed. necrosis is indicated by dark discoloration, thin intestinal wall, poor arterial pulsation, poor capillary bleeding, or lack of peristalsis. end-to-end anastomosis can be accomplished using a simple interrupted appositional pattern or a modified simple continuous appositional pattern with the same type of suture material used for enterotomy closure. , intraabdominal masses causing intestinal obstruction are often presumed to be neoplastic but can also be of infectious origin. resection, where possible, is always recommended, because resection of neoplasia (if no metastasis) can offer a good prognosis, , , , and infectious causes may be managed with adjunctive therapy after definitive diagnosis. intestinal obstruction in older cats is more likely to be secondary to neoplasia. any neoplasia can cause obstruction, but adenocarcinoma , and adenomatous polyps , are reported to cause obstruction more often surgical intervention is mandatory if • clinical signs (e.g., vomiting or anorexia) persist or deterioration occurs with conservative management • the cat has overt signs of peritonitis • the linear foreign body is fixed at the pylorus some authors disagree with attempting conservative management, since a perforated intestine from a linear foreign body reportedly carries a % mortality rate, , and early surgical intervention is never an incorrect decision. this should be balanced with the observation that cats can carry a linear intestinal foreign body, such as an elastic cord for a -month duration without intestinal perforation. however, fishing line, for example, would not be so forgiving! surgery to remove an intestinal foreign body (figures - and - ) should be considered an exploratory laparotomy. that is, the aim of the surgery is not only to remove the foreign body but to assess the entire intestinal tract and abdomen for other foreign bodies or pathology. enterotomy to remove discrete foreign bodies should always be distal to the obstruction, because the intestine is likely to be compromised proximal to as well as overlying the obstruction, thus delaying healing and creating the potential for surgical dehiscence. linear foreign bodies require multiple enterotomy incisions, since pulling the object out through a single incision could create iatrogenic intestinal perforation. the anchor point (either sublingual or pylorus by gastrotomy) must be released in the first instance. enterotomy incisions are closed with / synthetic, monofilament, absorbable suture material, such as polydioxyanone (pds) or equivalent, in either a simple interrupted or simple continuous pattern. , removal of a discrete foreign body (a piece of leather) at laparotomy. enterotomy to remove discrete foreign bodies should always be distal to the obstruction, because the intestine is likely to be compromised proximal to as well as overlying the obstruction. this is the same cat as in the radiology image in figure - . affected bowel is required, with anastomosis of the healthy tissue. there appears to be no benefit to enteroplication, which can result in significant ileus. there is no benefit to performing resection-anastomosis if the intussusception does reduce manually. , the prognosis depends on the underlying disease process and the chronicity of the intussusception, and therefore how debilitated the cat is at presentation, however, prognosis is mostly good, with survival reported in up to % of cases, though recurrence can occur in some cats with idiopathic disease, often at different locations of the intestinal tract. constipation is defined as infrequent or difficult defecation associated with retention of feces within the colon and rectum. prolonged constipation results in harder than other types of neoplasia. please refer to the sections on intestinal neoplasia earlier in this chapter for more details. granulomatous inflammation causing a single focal intestinal lesion can lead to obstruction in the same way that neoplastic change can. feline infectious peritonitis (fip) can present as focal lesions, often in the colon or ileocecocolic junction. in the case of fip, the focal lesion is usually an indicator of multisystemic disease; so, resection does not help prognosis. the fungus-like organism, pythium insidiosum has also been reported to cause granulomatous lesions, resulting in intestinal obstruction from large extraluminal masses that are approximately fist sized. resection with adjunctive itraconazole ( mg/kg) for months after surgery was a successful treatment. intussusception refers to invagination or prolapse of one portion of the intestine into the part of the tract that either precedes or follows it. there is a bimodal age distribution with intussusceptions in older cats, most likely associated with neoplasia (or ibd in some cases) ; underlying causes for younger cats are ill defined and may be idiopathic in many cases, , but associations with parasitism and, in one case, a linear foreign body, have been made. siamese and burmese cats seem to be overrepresented. the most common locations are the ileocolic region and the jejunum. , , , affected cats present with nonspecific signs of gastrointestinal disease, such as anorexia and lethargy. vomiting is not necessarily a presenting sign; diarrhea may occur. abdominal palpation reveals a mass in most cases. plain and contrast radiography only show evidence of obstruction and usually do not help define that the bowel has intussuscepted. , , , ultrasonography is very useful for diagnosis, because a distinctive pattern of alternating hypoechoic and hyperechoic concentric rings (figure - ) is present in transverse sections. , sometimes, the target lesion seen can be hard to distinguish from the pathology of other intraabdominal masses, such as lymph nodes, and in these cases, the size of the lesions can help, because the width will always be greater than mm with an intussusception (because the sum of at least four intestinal wall widths cannot be less) and is often greater than mm. surgical correction is always required, and manual reduction is typically not possible because there is usually significant venous infarction, edema, and congestion (figure - ) as well as adhesions from fibrin and effusions from the affected bowel. , if the intussusception does not reduce manually, resection of the and drier feces that become impacted, and this is known as obstipation. chronic, recurrent constipation and obstipation can result in megacolon, which refers to persistent increased bowel diameter that is not responsive to therapy. megacolon is not a specific disease entity; it may be considered the most advanced stage in the spectrum of chronic constipation. in most cases, constipation can be managed quite simply if the underlying cause is determined and dealt with. a comprehensive list of causes of constipation is noted in table of course, multiple factors can interact. for example, an older cat may have renal disease and so will be dehydrated to some degree and have arthritic hips and so be reticent to squat. the presenting signs of constipation are usually evident to owners and include straining in the litter box and producing hard dry feces, if at all. sometimes, however, owners can misinterpret signs. cats can strain because of lower urinary tract problems, and, if no urine is produced, some owners assume the problem is because of constipation. some constipated cats can intermittently have diarrhea because of direct colonic irritation from hard dry feces and so may present for diarrhea and not constipation. cats can also present for less specific signs, such as anorexia, lethargy, weight loss, and even vomiting. , vomiting can occur because of colonic receptors stimulating vagal afferent endings, which, in turn, can stimulate the chemoreceptor trigger zone. sometimes owners are concerned that their cat is defecating less, but the cat has just changed its diet to a much lower-residue diet and so is producing less feces. a full dietary history is an important aspect of the initial assessment. physical examination should confirm presence of feces in the colon and assess the degree of impaction. the presence of feces can usually be confirmed by abdominal palpation. in constipated cats, the colon is often palpated as a long firm tube extending cranially; sometimes, feces can be palpated to and around the colic flexure. alternatively, the feces may be palpated as large, discrete fecal concretions (that can sometimes be hard to distinguish from intraabdominal masses such as lymph nodes). if there is any doubt of the presence or degree of fecal impaction, survey abdominal radiographs should be taken. a lateral view taken in a conscious cat should be adequate to confirm the diagnosis. the physical examination should also assess for contributing causes, including musculoskeletal conditions. any recent trauma should be taken into account. the hips and lumbosacral region should be assessed for pain. the degree of flexion and extension of the hips should be gently assessed. the lumbosacral spine can be assessed by running two fingers on either side of the spinous processes. the cat will flinch in painful areas. any arthritic change is magnified in an underweight cat, since there may be less muscle mass and the joints may bear a heavier load. any suspicions of underlying musculoskeletal abnormalities can be confirmed with radiographs. neurologic assessment should also be performed. subtle changes just affecting colonic innervation will not be apparent on physical examination alone. however, an assessment of proprioception, placing reflexes, and gait should at least be performed to assess for lumbosacral spinal cord disease. anorectal abnormalities or lesions should be evaluated. impacted or infected anal sacs can lead to reticence to defecate; and therefore anal sacs should be assessed and expressed. because this is painful for most cats, the cat should be held by an experienced assistant. the author prefers expressing one anal sac at a time with well-lubricated gloves and the index finger within the rectum and the thumb positioned externally. a rectal exam can be performed with a well-lubricated (gloved!) middle finger, feeling over the pelvic rim for masses as well as assessing if the colon closes over (squeezes) the finger. if the colon feels open around the finger, this can be an indicator of impaired colonic innervation but does not imply that this is a permanent change. if there are impacted feces continuing to the anus, rectal examination is not possible until this has been cleared. if a cat finds anal gland expression or rectal examination too painful to tolerate (based on the clinician's judgment), these procedures should be done under sedation. hydration and electrolyte status are also important factors in the constipated cat. chronic renal disease is defined by azotemia (in conjunction with inadequately concentrated urine), which means the cat must be dehydrated to some degree. plasma or serum biochemistry and urinalysis can be used to diagnose renal disease, assess degree of renal disease, or recognize prerenal dehydration. electrolyte changes including hypokalemia and hypocalcemia may also contribute to reduced colonic smooth muscle function. in young to middleaged cats of apparent good health and hydration, blood difficulty defecating and pass hard, dry stools but do not have fecal impaction at the time of examination. after the obstructing feces have been removed, steps must be taken to ensure colonic motility and smooth passing of feces. medical management of constipation traditionally involves laxatives and prokinetic agents. these may not be required in straightforward cases. as long as there is no obstructive lesion, cisapride at . mg/ cat, every hours, po is very safe and can be instituted with a view to reducing the dose to once daily after to days and discontinuing if signs remain abated. doses of up to . mg/cat, every hours, po have been reported. cisapride is only available from compounding agencies in most countries. an osmotic or lubricant laxative (table - ) may be used concurrently at reduced doses as necessary. reducing the fecal bulk produced is an important part of long-term management. traditional dietary recommendations are to increase the amount of fiber. , , , increased dietary fiber results in production of shortchain fatty acids, which have been demonstrated to stimulate feline colonic smooth muscle contractions. however, dietary fiber is also classified as a bulk laxative and so, by definition, will increase fecal bulk. in humans dietary fiber has been considered a mainstay of therapy for constipation, but a recent review concluded that many patients with more severe constipation have worsening symptoms when increasing dietary fiber intake. because megacolon is believed to be the end result of chronic dilatation, , it is the author's firm belief that initial dietary efforts should be directed to reducing fecal bulk and thus introducing a low-residue diet. reduced dry matter intake reduces stool volume, and the author has found that recurrence rates of constipation reduce greatly when cats are transitioned to entirely wet food diets. wet food diets also help ensure adequate water and urine assessments are usually not required at an initial presentation for constipation. in all cases, the same principles of management apply: . ensure removal of obstructing feces . ensure colonic motility and smooth passage of feces . reduce fecal bulk . ensure adequate hydration . manage underlying problems the first step is to ensure obstructing feces are removed. in simple cases, the cat will evacuate feces after use of a glycerin or sorbitol pediatric rectal suppository. another option is administration of a microenema, such as microlax (mcneil consumer healthcare, fort washington, pa.), which contains ml of sodium lauryl sulfoacetate. these products act to lubricate the colon wall and therefore facilitate the passage of feces. the author prefers to use one or two of these within the consult room to observe the cat defecating (the cat must be provided with a litter tray!). the outside tube should be lubricated with the suppository contents before carefully inserting and then expressing the rest of the contents. there are also stimulant laxatives (containing bisacodyl) and emollient laxatives (containing sodium docusate) that have reportedly been used. if a rectal suppository vial cannot easily be inserted because hardened fecal content obstructs its entry, a more substantive enema will be required (sometimes requiring sedation or anesthesia), and this is covered in the next section on management. some cats present for the abdominal wall with the other hand, but great care must be taken with this maneuver, because the devitalized colon can be perforated more easily. , enemas as described are painful for the cat, and opioid analgesia is recommended at the time of anesthesia. opioids can reduce peristalsis in humans, but having evacuated the bowel, the pain relief is more important than this transient effect. an alternative to enemas is administration of an oral polyethylene glycol (peg ) solution (e.g., colyte, golytely). a nasoesophageal tube is placed and the solution is given as a slow trickle ( to ml/kg/hour) over to hours. defecation usually results in to hours. in a retrospective study of cats, median time to defecation was hours and the median total dose of peg was ml/kg. a no adverse effects were noted. a cat that has been obstipated needs supportive therapy when discharged. there are no controlled comparisons of the various therapies noted in table - ; the author prefers cisapride . mg, every hours to every hours, po (first thing in the morning, when the owner returns from work, when the owner goes to bed), and lactulose syrup ml/cat, every hours, po. a cat that has been so severely obstipated that an enema under anesthesia is required can be expected to continue these medications lifelong. to reduce fecal bulk and decrease the opportunity for recurrence, low-residue canned foods (or sachets) are preferred for cats that have become obstipated. some cats may benefit from high-fiber diets. as with simple initial episodes, canned food helps maintain adequate hydration, and at home subcutaneous fluids may be used additionally in cats with chronic kidney disease. with repeat episodes or severe obstipation, investigations for an underlying cause should be thorough and include evaluation for colonic mass obstructions. a review of published cases indicated that % of cases of megacolon are accounted for by idiopathic megacolon ( %), pelvic canal stenosis ( %), nerve injury ( %), or manx sacral spinal cord deformity ( %). although most cases are idiopathic, an attempt should be made to identify and treat any specific underlying causes. megacolon is not specifically defined in cats. it has been described as "generalized colonic dysfunction manifesting as severe colonic dilation and fecal impaction," or a "severely and irreversibly dilated and hypomotile" colon and "a subjective evaluation of the diameter of the colon, usually based on radiographic assessment." there are specific radiographic guidelines for humans with megacolon, in that a colonic diameter of more than . cm at the level of the pelvic brim is considered diagnostic. intake and therefore help maintain hydration. however, increased dietary fiber is beneficial for some cats, and trial and error may be required to determine whether a high-fiber or low-residue diet will be of benefit to each individual cat. in one report, cats with recurrent constipation refractory to traditional medical and dietary management were successfully treated with a psylliumenriched dry extruded diet. a after month on the diet, cats had no clinical signs of constipation. the remaining cat was clinically normal after months on the diet. improvement was noted in of cats after only days of dietary therapy. measures should be taken to ensure adequate hydration. maintaining adequate hydration is particularly relevant for cats with chronic kidney disease that have impaired ability to conserve water. changing to wet food diets helps increase water intake. some cats with chronic kidney disease may need additional fluid support, such as subcutaneous fluids administered by the owner at home on a regular basis. underlying problems may be minor and simple to manage, such as an anal gland abscess, or more involved, such as reduced pelvic outflow, as a result of prior trauma. arthritis is a common underlying factor in many older cats and may be managed with prudent use of nonsteroidal agents (see chapter ) . in cases of obstipation, the cat is more likely to be debilitated to some degree; so, laboratory investigations to assess plasma or serum biochemistry parameters as well as hematology and urinalysis are ideal. any hydration deficit or electrolyte abnormalities should be corrected before the anesthesia that is often required to remove the obstructing feces. rectal suppositories and microenemas are usually ineffective in obstipated cats. enemas are often required to remove impacted feces in such circumstances. the enema solution must be warmed and introduced slowly to avoid vomiting. the typical volume required is to ml/kg (so, up to approximately ml/cat). the enema solution can be an isotonic electrolyte solution or tap water, and mild soap can be added (but any soap used must not contain hexachlorophene, which is neurotoxic if absorbed); mineral oil can be used ( to ml/cat) as a lubricant or docusate as an emollient ( to ml/cat), but the two agents must not be used together since docusate promotes mucosal absorption. sodium phosphate-containing enemas must not be used, because they can induce severe hypernatremia, hyperphosphatemia, and hypocalcemia in cats. often, the enema solution alone is insufficient to reduce the fecal mass, and manual manipulation of the feces by abdominal palpation is required. sometimes the feces must be broken down by a gloved finger perrectum while the colon is massaged manually through radiographically, in the lateral view, the normal colon should be approximately the same diameter as the length of the body of the second lumbar vertebra. in cats, however, "there are no published guidelines for determining megacolon, so, diagnosis of abnormal colonic dilatation is subjective." however, one author has suggested that "as a rule of thumb, the diameter of the colon should be less than the length of the body of the seventh lumbar vertebra (l )." this author continues, "enlargement of the diameter of the colon beyond times the length of the body of l is indicative of chronic large bowel dysfunction and an explanation must be sought." a recent paper found that of cats with no gastrointestinal disease had a colon diameter greater than the length of l ; however, no assessment of constipated cats was made. in practice, many cats with megacolon have a colonic diameter far exceeding this guideline ( figure - ). one study of cats with megacolon found the mean diameter of the colon was . times greater than the length of the seventh lumbar vertebra (median, . ; range, . to . ), but in general, objective descriptions of this condition are lacking in the veterinary literature. the definition of megacolon in cats should include functional as well as radiographic guidelines. in the absence of broadly recognized radiographic recommendations, the author proposes that the o'brien rule-ofthumb guidelines (as noted above) be introduced until a more comprehensive study can establish other radiographic diagnostic criteria (or confirm these). the author therefore proposes to define megacolon as dilatation of the colon, to more than . times the length of the seventh lumbar vertebra, which is refractory to medical and dietary management. practitioners can expect the radiographic assessment of colonic dilatation to exceed this guideline in cats with megacolon and, conversely, there are likely to be cats having colonic distention greater than this amount that will respond to medical and dietary management and can therefore not be defined as having megacolon. by the definition used above, megacolon is refractory to medical and dietary therapy; so, to be defined as having megacolon, a cat may have had several episodes of obstipation managed by enema as well as dietary trials (with both low-residue and high-fiber diets) and medical therapy with cisapride and an osmotic or emollient laxative; yet the cat will still obstruct with feces. in these circumstances, the only possible therapy is subtotal colectomy. subtotal colectomy refers to surgical excision of % to % of the colon, whether it is grossly diseased or not with preservation of the ileocolic junction (icj). this approach has resulted in a more favorable clinical response than when the icj is also excised. , when preserving the icj, it has been noted that, in some rare cases, it can be difficult to join the proximal segment of colon to the distal piece of descending colon because of the tethering effect of the ileocecocolic blood vessels. in these cases, sacrificing these vessels and removing the icj (i.e., total colectomy) is recommended to facilitate approximation of the ileum to the distal colonic segment. a recently described technique using a biofragmentable anastomosis ring, compared with sutured anastomoses, showed no discernible effect on prognosis. prognosis following subtotal colectomy is generally good. a review of multiple papers, totaling over cats that had undergone subtotal colectomy, found the most commonly reported perioperative complication was diarrhea or loose stools immediately after surgery. in the majority of individuals, stool consistency improves without further treatment so that within to weeks of the surgery soft, formed stools are developed. diarrhea can persist in a small number of cases. in the longer term, in some cats, constipation can eventually return, but this can usually be managed by dietary and medical therapies. pathology of the rectum or anus is relatively rare in cats and therefore poorly described in the veterinary literature. consequently, published information is often not referenced, suggesting it expresses the authors' opinions. readers are directed to surgical texts for details and approaches about surgical corrections. the anal sacs are paired cutaneous evaginations situated between the internal and external sphincter muscles. these sacs store secretions from alveolar and sebaceous glands that reside within the sacs. each anal gland has an associated duct that opens to the skin surface just lateral to the anus. , normal anal gland secretions have only very recently been described and vary markedly; the color can be white, brown, orange, yellow, tan or gray, and consistency can range from watery to thick and creamy, with two thirds of cats having solid portions within the secretion. on microscopic examination, epithelial cells are commonly seen, with most cats having some neutrophils present. bacteria are commonly recognized as are, on some occasions, yeasts. bacteria seen in this study were mainly gram-positive cocci ( %) or gram-negative cocci ( %). gram-negative or grampositive rods were also seen but were rarely the dominant bacterial population. with such a wide range of normal secretions, it is difficult to diagnose any pathology from the nature of the secretion alone. however, blood is infrequently recognized, and neutrophils are typically present in only small numbers in normal secretions. anal sac diseases described in cats include impaction, inflammation (sacculitis), infection, abscessation, and neoplasia (essentially the same as in dogs). , it has been contended in dogs that sacculitis and abscessation are an extension of impaction. it is not known in dogs or cats what the predisposing causes are, but suggested underlying reasons are loose stools (that are less effective at expressing the sac during defecation), local swelling or edema occluding the duct, and obesity. the author's observations have also indicated that constipation can result in anal sac impaction because of less frequent expulsion of the sac contents; the resultant pain of the anal sac impaction can lead to further constipation, thus establishing a cycle. the retention of secretions may predispose to sacculitis, but impacted anal sacs do not always result in inflammation. abscessation is a likely sequel to sacculitis. cats usually present for licking, scratching, or biting at the perineal area and can present for scooting (or dragging their anus) as dogs do. other presenting signs can be inability to sit or settle, a lump seen by the owner, or a generally unwell state. expression is the only management required for impacted (and not infected) anal sacs. the author prefers expressing one anal sac at a time with well-lubricated gloves and the index finger within the rectum and the thumb externally. this is painful for most cats; so, the cat should be held by an experienced assistant, and it is sometimes not possible without some degree of sedation. with frequent episodes, underlying causes should be investigated. sometimes, trial-and-error diet change to manipulate the nature of the feces to either more (highfiber diets) or less (low-residue diets) bulk help reduce the frequency of episodes. obesity should be managed by reduced caloric intake, but dietary management for this should also take into account the nature of the feces. overt infection may be recognized by pus secretion from the anal sacs, which will have a high numbers of neutrophils. this can be managed by broad-spectrum antibiotics, such as amoxicillin/clavulanate or cephalosporins. a single treatment with a nonsteroidal antiinflammatory drug, such as meloxicam, can be given in animals with appropriate hydration and without other illness. anal sac abscesses often present already open and draining. many heal well by secondary intention with antibiotic treatment until they are closed over; so rechecks are required before the completion of an antibiotic course. large abscesses may require surgical drainage with the insertion of a penrose drain and management as for a cat fight abscess. it must be remembered that wounds in this area are easily re-infected by fecal contamination. recurrent impaction, sacculitis, or infection may require anal sacculectomy (as in dogs). this procedure should be delayed until infection is cleared. the procedure is similar to that performed in dogs. reports of anal sac/gland neoplasia were confined to sporadic case reports, , until a large case series was recently published. in this study, cases of anal gland carcinoma were recognized at a private diagnostic laboratory during a -year period, with submissions from practices. this indicates that, for most practices, this condition will be seen, at most, once every years. affected cats ranged in age from to years (median and mean, years); female (mostly spayed) cats were overrepresented ( % of cases), and siamese cats may have been over-represented ( . % of cases). the number of siamese cats with anal sac neoplasia was times greater than the number of siamese cats in the laboratory reference population. affected cats presented for dyschezia, recurrent constipation, change in the nature or volume of feces, b). a low-residue wet diet is recommended to reduce fecal bulk during the healing period. rectal prolapse occurs as a result of a disease process that causes chronic straining, such as intestinal conditions that result in diarrhea and tenesmus . conditions that result in constipation or other intestinal obstruction . lower urinary tract diseases . dystocia and/or perineal swelling or ulceration, sometimes with purulent or hemorrhagic discharge. most tumors were originally interpreted as and initially managed as anal sac abscess. presumptive metastasis in liver, lung, or abdominal lymph nodes was recognized by physical examination or radiography in six cats; one cat was hypercalcemic. excision appeared to be curative (with a -to -year follow-up period) in of cats undergoing surgery for resection or debulking (others had only incisional biopsy performed). for the remaining cats with known postsurgical outcome, median survival was only months, with a % -year survival rate (with none of these cats surviving to years). atresia ani is a developmental defect of the anal opening or terminal rectum (see figure - ). kittens usually present within days or weeks of birth with abdominal distention, discomfort, tenesmus, restlessness, vomiting, and/or loss of appetite. there are several anatomic variations : • type i: a membrane over the anal opening remains, with the rectum ending as a blind pouch just cranial to the closed anus. • type ii: the anus is closed as in type i, but the rectal pouch is located somewhat cranial to the membrane overlying the anus. • type iii: the rectum ends as a blind pouch cranially within the pelvic canal (rectal atresia), whereas the terminal rectum and anus are normal. • type iv: occurs in females and atresia ani exists with a persistent communication between the rectum and the vagina (rectovaginal fistula). this fistula can occur with a normal anal opening as well. most reported cases have been type iv, , , , , and this has also been recognized with concurrent sacrococcygeal agenesis. surgical correction has been described for type ii and type iv , atresia ani in cats. the reader should consult these references for surgical advice; possible complications include megacolon after prolonged obstruction, postsurgical anal stricture, and fecal incontinence because of sphincter dysfunction. foreign bodies in cats rarely obstruct the gastrointestinal tract distal to the jejunum ; however, large fecal balls resulting from constipation can, additional to constipation or obstipation, cause distention of the anus. this distention can result in inflammation of the anal sphincter with loss of tone ( figure - , a) , which, in the author's experience, is temporary with correction of the underlying cause of constipation. it can take some weeks for the dilated anus to return to normal (figure - , with antibiotics, such as cephalosporins, and regular cleansing. prolapses are usually classified in three ways. first degree: prolapse of only mucous membrane . second degree: prolapse of full rectal wall thickness . third degree: prolapse is sufficient to bring mesorectum outside the anus the prolapsed rectum is obvious but must be differentiated from ileocolic intussusceptions, which have been described with neoplasia. this distinction can be made by inserting a thermometer through the anus alongside the prolapsed mass. insertion will not be possible for an intussusception but will be for an anorectal prolapse. the prolapsed tissue must be assessed for viability, and management must include determining and managing the underlying cause as well as management of the prolapse. in simple cases where the mucosa is viable, the prolapse can be reduced with lubrication and gentle pressure. a temporary purse-string suture may be required to prevent recurrence. perineal dermatitis is often confused with gastrointestinal or urogenital disease, because there are often copious sebaceous secretions that can mimic fecal or urinary secretions. perineal dermatitis can result from flea or other allergies but also fecal or urine scalding associated with diarrhea or urinary incontinence, respectively. skin fold dermatitis can also occur in obese cats ( figure - ). episioplasty has been described to correct this, but the author has found that stringent dieting can result in improvement while managing the skin fold dermatitis these populations. the reported prevalence for each parasite varies greatly with the population studied, the geographic location of the population, and the sensitivity of the diagnostic test used to study that population. the presence or absence of diarrhea is not a reliable predictor of whether a particular cat is infected with or shedding a parasite. in fact, most cats with diarrhea do not harbor enteric protozoa. on the other hand, most cats with diarrhea because of enteric pathogens will shed those organisms, often intermittently. it is important to remember that infection with most gastrointestinal parasites may not cause clinical signs. therefore detection of a pathogenic parasite in a cat with diarrhea does not necessarily prove causation. a search should always be undertaken to identify other causes of diarrhea prior to convicting a cat of having diarrhea because of a particular parasite. in addition, co-infections or the presence of other noninfectious causes of diarrhea can result in more severe diarrhea that is often refractory to treatment for the parasite. treatment will be more rewarding if all potential causes of diarrhea are identified in the patient. enteric parasites with zoonotic potential occur commonly enough that cats, particularly those with diarrhea and who are owned by immunocompromised persons, should be evaluated for those pathogens. , the following is a discussion of the most common enteric parasites found in cats. for more on parasite prevention and control, see chapter , and for more on zoonotic enteric parasites, see chapter . ollulanus tricuspis is an almost microscopic nematode worm infecting the stomach of domestic and wild cats. the worm measures less than mm long. the larvae of o. tricuspis develop and hatch within the uterus of the female worm. they develop to maturity in the stomach of the cat where it is capable of re-infecting the host. the worm is transmitted to other cats that ingest the vomitus of an infected cat. clinical signs shown by infected cats include vomiting, anorexia, and weight loss. , histologic findings in infected cats include lymphocytic-plasmacytic gastritis, lymphoid hyperplasia, and mucosal fibrosis. gross lesions may be absent, or the cat may develop nodular gastritis. one report suggested the parasite may have been a contributing factor in the carcinogenesis of a gastric adenocarcinoma in an infected cat. . a common theme when discussing the prevalence of most gastrointestinal parasites in cats is that they occur more commonly in younger cats and in cats housed in crowded conditions, such as catteries and shelters. it is likely an increased chance for transmission exists in lungs. after further development in the lungs, the parasite migrates up the trachea and is swallowed. adult s. felis and s. planiceps burrow into the wall of the small intestine, while adult s. tumefaciens lives in the colonic mucosa. ova may be shed in the feces or hatch in the intestinal tract. autoinfection occurs if larvae become infective and penetrate the intestinal wall before being shed. ova and larvae that are shed develop into freeliving adult worms. the prepatent period is between and days. , clinical signs and diagnosis signs of a strongyloides spp. infection are usually absent. , lung migration may cause cough or respiratory distress. the presence of the parasite in the intestinal tract may result in diarrhea and weight loss. strongyloides tumefaciens is associated with the formation of small, worm-filled nodules in the colon. identification of strongyloides spp. larvae using the baermann fecal concentration technique is required to diagnose most infections. unless the infection is heavy, examination of a fresh fecal smear is insensitive for identification of these larvae. the nodules formed by s. tumefaciens infection can be visualized during colonoscopy. histopathology of the biopsied nodules should reveal many adult worms. infection with strongyloides spp. can be treated with fenbendazole, pyrantel pamoate, thiabendazole, , or ivermectin. to evaluate efficacy, repeat a fecal examination to days after the treatment ends. because of the presence of free-living adult worms in the environment and the ability of larvae to cause infection by penetrating intact skin, prevention is difficult. keeping cats indoors in warm, humid climates may be an owner's only means of preventing infection with strongyloides spp. parasites. infections with trichuris vulpis rarely occur in cats and are considered to be clinically unimportant. , the two species of roundworms commonly infecting cats are toxocara cati (figure - ) and toxascaris leonina (figure - ) . the latter also has the ability to infect dogs. cats are infected with t. cati in several ways. most commonly, infection is by ingestion of contaminated food, water, or infected paratenic hosts such as rodents. transuterine transmission has not been reported. the diagnosis of infection with o. tricuspis is difficult, because ova are not shed in the feces; rather, the vomitus must be examined for worms or larvae. the worms may also appear in gastric mucosal biopsy samples. a report of cats undergoing endoscopic examinations found the parasite in gastric biopsy samples from cats. fenbendazole may be effective in treating infections with o. tricuspis. preparations with febantel may also be expected to successfully treat these infections. transmission can be prevented by appropriately treating infected cats. other cats should not be allowed to ingest infected vomit. this parasite is of no zoonotic concern. physaloptera another parasite rarely inhabiting the stomach in cats is in the genus physaloptera. larger than ollulanus tricuspis, this blood-sucking worm infects cats that have ingested intermediate hosts, such as cockroaches, crickets, or flour beetles. preying on transport hosts, such as mice that have eaten an intermediate host, is another way cats become infected with this parasite. clinical signs of infection with physaloptera spp. include vomiting, anorexia, and melena. a diagnosis of physaloptera infection can be made after identifying the ova in the patient's feces or adult worms in the vomitus. occasionally, the worms may be seen during gastroscopy. the adult worms must be differentiated from ascarids. infection can be treated with ivermectin, pyrantel pamoate, or fenbendazole. because there is no migratory phase of the life cycle, the treatment does not need to be repeated. three species of strongyloides infect cats. strongyloides felis infects cats in india and tropical australia, , s. tumefaciens is a rare parasite of cats in the southeastern united states, and s. planiceps is found in cats in malaya and japan. strongyloides stercoralis, found in dogs and humans, produces experimental infections in cats, but natural infection with this species has not been observed. feline infection with strongyloides spp. is considered by most to be rare. however, one report from australia identified s. felis in of necropsied cats. infection with strongyloides spp. occurs after ingestion of infective larvae. infection can also take place after the larvae penetrate the skin of the cat. ingested larvae penetrate the intestinal wall and migrate through the diaphragm into the lungs. after cutaneous penetration, the larvae enter the venous circulation and enter the clinical illness because of roundworm infection is uncommon. illness, when it does happen, most often occurs in kittens signs may be mild and can include vomiting, diarrhea, weight loss, poor growth, and a "pot belly." a heavy infection with t. cati can result in catarrhal enteritis. severe infections can lead to intestinal obstruction and, possibly, perforation. much less dramatic changes arise after infection with t. leonina, although enteritis may occur. roundworms are frequently diagnosed with a fecal floatation. the centrifugal floatation technique is more sensitive than the simple fecal floatation technique many hospitals use. occasionally, adult worms will be passed with the feces. the goals of treating roundworms include disease prevention in an individual cat or kitten, prevention of environmental contamination by cats defecating outside, and the prevention of zoonotic infections. many effective and safe anthelmintics are available (table - ) . benzimidazoles, such as fenbendazole, act on the parasite's microtubular structure, leading to disintegration of the worm's intestines, muscular layer, and hypodermis. pyrantel in the pamoate formulation is poorly absorbed and causes paralytic parasite death. macrocyclic lactones, such as milbemycin, also lead to paralytic parasite death. these compounds act on the parasite's gamma-aminobutyric acid (gaba)-and glutamate-controlled ion channels. these channels are lacking in tapeworms, accounting for the lack of efficacy against these parasites. lastly, emodepside (a cyclic octadepsipeptide) has been combined with praziquantel in the product profender (bayer animal health). this topical parasiticide has been shown to be both safe and effective. these drugs appear to be so safe that overdosing is almost impossible. kittens can be dewormed starting at two weeks of age and again at , , , , and weeks. older kittens and adults can be dewormed every month to months. because of the safety of these drugs, the possibility of false-negative tests and, more importantly, the zoonotic potential of these infections, perhaps all kittens should be dewormed, not just those testing positive. roundworm ova are very hardy and can remain infective for years. they survive sewage treatment and composting, and there is no practical means of decreasing the ova population once the environment is contaminated. thus it is best to attempt to prevent contamination in the first place. when practical, keeping cats indoors allows appropriate control of potentially transmammary infection occurs, but only if the queen is acutely infected late in pregnancy. chronically infected queens do not pass t. cati ova in their milk. after ingestion, t. cati larvae migrate through the small intestinal wall, into the liver, and then to the lungs where they are coughed up and swallowed. these larvae then infect the small intestine. some of the migrating larvae become encysted in the cat's muscle tissue. larvae from ova ingested through the milk tend not to undergo migration and mature directly in the small intestine. the prepatent period is approximately weeks. infection with t. leonina occurs after ingestion of infective ova or an infected paratenic host. unlike t. cati, very few t. leonina larvae migrate through the cat's tissues. most develop in the wall of the small intestine. the prepatent period is to weeks. toxascaris leonina ova can become infective within days of being passed in the feces when the ambient temperature is ° c but normally require to weeks. lungs, and kidneys. ocular larval migrans results in granulomatous retinitis that is often misdiagnosed as retinoblastoma in older children. this can lead to unnecessary enucleation. toxocara cati appears, however, to be less important than t. canis as an infection in humans. the species of hookworms that infect cats are ancylostoma tubaeforme and ancylostoma braziliense (see figure - ). they are reported to be an uncommon infection in cats. , ancylostoma braziliense can also infect dogs. hookworm infections occur after ingesting food or water contaminated with hookworm larvae or eating contaminated fecal material. if the pet cat is allowed outdoors, attempts at preventing hunting may reduce the possibility of infection. keep children's play areas, such as sand boxes, inaccessible to cats when children are not at play. feeding only well-cooked food can prevent infection by contaminated food. finally, empirical, preventative deworming for cats that go outdoors should be performed to times yearly. any less frequently does not lead to an appreciable decrease in the prevalence of the parasite. roundworms easily infect humans who ingest the ova, particularly children. visceral larval migrans occurs after infection with toxocara canis in humans. infection can lead to the formation of nodules in the brain, liver, tapeworm infections are well tolerated by the cat. usually there are no signs of infection other than finding segments on the feces or attached to perianal hair. because both d. latum and spirometra tapeworms absorb vitamin b across the cuticle, megaloblastic anemia is possible, but unlikely. tapeworm infections are diagnosed by identifying the typical appearance of the segments or the egg packets within the segments. the segments of t. taeniaeformis are flat, while those of d. caninum have been described as appearing like a grain of rice. the segments should be handled carefully, because they are friable and rupture may result in exposure of the handler. the operculated ova of d. latum and spirometra spp. must be differentiated from trematode ova. even though tapeworm infections are well tolerated, cats should be treated for reasons of owner discomfort and public health concerns (see table - ) . these infections are easily treated, because drug treatment is highly effective. re-infection must be controlled using preventative measures, especially flea control to prevent re-infection with d. caninum. praziquantel and infected paratenic hosts. the larvae can survive for months in the tissues of paratenic hosts. infection also occurs after larval migration through the skin. in either case, the worm matures in the small intestine. unlike dogs, transmammary infection has not been reported in cats. , the prepatent period is between and days, depending on the route of infection. the time to patency after transcutaneous infection is longer than for direct colonization. infective l larva develop to days after the ova are passed. developing larvae attach to the mucosa of the small intestine where they ingest copious amounts of blood. because the worms can remove a significant volume of blood from kittens, weakness from iron-deficiency anemia or blood-loss anemia may be noted. melena and diarrhea may also be recognized. signs are uncommon in adult cats. identification and treatment of hookworm infections are similar to that for roundworm infections (see table - ) . hookworm larvae are not as hardy as roundworm eggs. soil contamination may be a temporary problem in areas that experience a hard frost. hookworm larvae will not develop in temperatures less then ° c or greater than ° c. frequent, appropriate disposal of feces, cleaning surfaces with a % bleach solution, and deterring hunting may prevent infections. migration through the skin of persons coming into contact with the larvae of a. braziliense is the most common cause of cutaneous larval migrans, particularly in the southeastern united states. this is an erythematous, pruritic skin eruption often found on the soles of the feet of infected children. the tapeworms most commonly found in cats are dipylidium caninum and taenia taeniaeformis. diphyllobothrium latum, spirometra spp., and echinococcus multilocularis occasionally infect cats. the latter is important, because it can lead to alveolar echinococcosis in humans. spirometra tapeworms are found in north america (s. mansonoides) and far-east asia (s. mansoni and erinacei), while d. latum prefers temperate climates. unnoticed, but the cat may cough or experience hemoptysis. diagnosis involves demonstration of fluke ova in the feces. although therapy may be unnecessary, praziquantel or epsiprantel are effective in eliminating the intestinal population of the fluke. platynosomum spp. are flukes living in the gall bladder, bile ducts, and pancreatic ducts. these flukes are most prevalent in the southeast united states and caribbean islands and require two intermediate hosts. the first host is a snail, while the second intermediate host is a lizard, toad, gecko, or skink. cats become infected with this fluke after ingesting an infected second intermediate host. the prepatent period for the fluke is weeks. most infections are subclinical. if clinical signs do occur, they may include weight loss, vomiting, diarrhea, icterus, hepatomegaly, or abdominal distention. diagnosis involves identification of ova shed in the feces using a fecal sedimentation method or by finding adult flukes in the gall bladder or bile ducts during abdominal surgery. treatment involves administering praziquantel ( mg/kg, q h, po for to days) and/or surgical removal of the flukes. two species of coccidians are the most common to infect cats, isospora felis and isospora rivolta (figure - ) . the genus isospora may be renamed cystoisospora. these are epsiprantel are safe and effective. fenbendazole is effective against t. taeniaeformis, but not d. caninum. without controlling exposure to intermediate hosts, tapeworm infections are difficult to eliminate. flea control is imperative in eradicating infections with d. caninum. controlling predation helps prevent ingestion of t. taeniaeformis-infected rodents. infection with d. caninum occurs in young children who are most likely to eat fleas. infection results in only minimal signs of illness. the larval stage of t. taeniaeformis is of little zoonotic importance. although cats are uncommonly infected with echinococcus multilocularis, potentially life-threatening alveolar damage occurs in north american humans infected with this tapeworm. plerocercoids of spirometra spp. can penetrate the mucous membranes or open skin wounds of humans and migrate around the subcutaneous connective tissue, forming nodules, a condition called sparganosis. megaloblastic anemia, as a result of vitamin b deficiency, may occur in humans infected with d. latum or spirometra spp. tapeworms. alaria marcianae flukes reside in the intestinal tract of cats and the mammary glands of lactating queens. miracidia hatch underwater from ova shed in the feces and penetrate the skin of a snail. after further development, cercariae penetrate the skin of leopard frog tadpoles and are able to survive the metamorphosis to the adult frog. if the tadpole is eaten by a snake, bird, or mammal, the parasite enters the host's tissues but does not undergo further development. after a male or nonlactating female cat ingests the infected intermediate host, the parasite penetrates the wall of the small intestine, passes through the diaphragm, and enters the lungs for further development. finally, the parasite is coughed up and swallowed to complete maturation and reproduce in the small intestine. if, however, an infected host is ingested by a lactating queen, the parasite migrates through the tissues to the mammary glands, rather than the lungs. once shed in the milk, the parasites develop into mature adults in the kittens. some of the mesocercariae remain in the mammary glands to infect future litters. clinical signs associated with worms in the small intestine are uncommon. migration through the lungs often goes species-specific obligate intracellular parasites. , they are able to survive in the environment for months. a detailed description of the coccidial life cycle can be found elsewhere. , simply put, direct transmission is by ingesting oocyst-contaminated food or water or by grooming contaminated body parts. indirect transmission occurs after ingesting a mechanical vector or the infected tissues of paratenic hosts. after ingestion by a cat, the oocyst excysts in the small intestine and enters the enterocyte where further development occurs. the parasite may also migrate through the intestinal wall to form cysts in mesenteric lymph nodes. these cysts may serve as a source for reinfection. , the prepatent period is to days and the shed oocyst becomes infective after several days of exposure to warmth and moisture. infection with isospora spp. is usually subclinical. signs, if they occur, range from mild, transient watery diarrhea to severe mucohemorrhagic diarrhea with vomiting and resultant dehydration and weight loss. , signs are most commonly recognized in severely infected neonatal kittens, particularly those with concurrent illness, and arise because of small intestinal congestion, mucosal erosion, or villus atrophy. signs may also be noted in immunosuppressed adult cats. isospora species are readily found in fecal floatation or wet-mount examinations. shedding can be intermittent, but most cats with diarrhea caused by coccidial infection shed large numbers of oocsyts. fortunately, in most cats, the diarrhea from isospora spp. infection is self-limiting. in fact, if a kitten is persistently shedding oocysts despite appropriate treatment or the parasite is identified in an adult cat with chronic diarrhea, attempts should be made to identify co-infections or other diseases that may cause diarrhea. anticoccidial drugs are either coccidiostatic or coccidiocidal (table - ) . coccidiostatic drugs are the most commonly used drugs for individual pet cats. trimethoprim-augmented sulfadiazine (tribrissen; intervet/schering-plough animal health, summit, nj) or another sulfa-containing antibiotic, sulfadimethoxine (albon; pfizer animal health, madison, nj), can be used. supportive care for severely affected kittens, such as parenteral rehydration, should be used as needed. coccidiocidal drugs are often reserved for use in densely populated situations such as catteries or shelters. however, many veterinarians are now using them as a first-line defense against isospora spp. infection. ponazuril (marquis oral paste; bayer animal health, shawnee mission, kan.), formulated for horses, is effective and can be safely administered to cats. for more on the use of ponazuril in cats, see chapter . a related drug, diclazuril, is also available and may be administered once at mg/kg po. while not available in north america, toltrazuril (baycox, bayer animal health) may be administered once at mg/kg po or mg/kg po once daily for days. a a second course of therapy days later may be required to completely eliminate the oocysts. sanitation is very important, because the oocyst requires several days to become infective. frequent removal of feces, preferably daily, is recommended to prevent re-infection and transmission to other cats. controlling a cat's ability to hunt reduces the chance of ingesting an isospora-infected rodent. control of mechanical vectors, such as cockroaches and flies, is also useful. since a cat can become infected after grooming an infected cat's perineum, consideration should be given to treating all cats in contact with the patient. in addition, catteries and shelters should ensure all food is well cooked, litter boxes are cleaned daily, and surfaces are well cleaned with steam or % ammonia. where recurrent isospora spp. infections are a problem, prophylactic treatment of all -to -week-old kittens with ponazuril should be considered. despite all wellintentioned efforts at hygiene and treatment, isospora spp. infection can still be transmitted to other cats. because these are species-specific parasites, transmission of i. felis and i. rivolta from cats to humans does not occur. the flagellated protozoal parasite, giardia duodenalis, has seven microscopically indistinguishable genotypes or assemblages. assemblages a and b infect humans, while assemblage f is harbored by cats. cats will occasionally harbor assemblages a and b. infection with g. duodenalis occurs after ingesting cystcontaminated feces, by grooming an infected cat or from contaminated fomites. re-infection may occur by selfgrooming. only a small number of cysts need be ingested to establish an infection. in humans as few as cysts are required to cause infection. after ingestion of infective cysts, trophozoites begin to excyst in the stomach. this process is completed in the proximal duodenum. the trophozoites adhere to enterocytes along the length of the small intestine using the ventral suction disk. intermittent shedding of immediately infective cysts begins to days after infection. proteins released during encystment of the trophozoites are detected by the fecal antigen tests. cysts may adhere to the perianal region, facilitating re-infection by self-grooming. occasionally, trophozoites are found in examinations of fresh, watery feces. these do not survive for long and are not infective. the mechanisms of disease induced by g. duodenalis are still unclear. after the trophozoite attaches to the brush border of the enterocyte, the tight junction between cells is disrupted, increasing intestinal permeability. the brush border becomes attenuated, further exacerbating malabsorption of water, electrolytes, and other nutrients. the alteration in intercellular adhesion results in t-lymphocyte activation and mucosal cell injury. infection also promotes mucosal cell apoptosis (preprogrammed cell death). in addition, small intestinal bacterial overgrowth may accompany g. duodenalis infections, resulting in more severe clinical signs. fortunately, most cats infected with g. duodenalis show no clinical signs. , the most common sign is acute, transient, small bowel diarrhea without systemic illness, such as fever or vomiting. less commonly, a cat might have profuse, watery malodorous diarrhea with mucus. also possible, but uncommon, is weight loss , or abdominal pain. the severity of clinical signs exhibited in an individual cat depends on the age and general health of the cat. cats co-infected with cryptosporidium felis or tritrichomonas foetus may have more severe diarrhea that is more difficult to control, as will the presence of bacterial overgrowth. the diagnosis of g. duodenalis requires demonstration of trophozoites or cysts in a fecal examination, or detection of encystment proteins or giardial dna in a fecal sample. a reliable diagnosis may be difficult to obtain for several reasons. cysts are small, easily missed, and must be differentiated from plant debris or yeast. trophozoites are short lived outside the body and can only be found in very fresh, watery feces or, better yet, in diarrheic feces collected directly from the cat's rectum. shedding of cysts is usually intermittent, and the intensity of shedding varies greatly. , because of these difficulties, the absence of the organism in a fecal sample does not eliminate it as the cause of diarrhea. it is often necessary to test multiple fecal samples, using at least two different techniques in order to find the organism. , the easiest test to perform is a fecal smear or wet mount examination to identify trophozoites or cysts (figures - and - ). the sample examined should be very fresh, warm, diarrheic feces. one drop of feces is placed on a slide along with a drop of . % saline or lugol iodine. trophozoites are identified by their characteristic structure (table - ) . the motile trophozoites have a motion described as appearing like the back and forth rolling motion of a falling leaf. since lugol iodine stain kills the trophozoite, there will be no motion to detect. this test is not very sensitive; however, with trained examiners, the test has a high specificity. increased sensitivity can be gained by performing a centrifugal flotation using zinc sulfate. the sample should be warm, fresh feces or feces refrigerated for no more than days. the processed sample is examined for the same structures as the wet mount. the sensitivity of examining one sample is % and increases as more samples are examined. the sensitivity of looking at three samples is % , ; therefore the test is not considered negative until three specimens have been found free of the organism. a fecal antigen test that identifies the encystment protein is available. the snap giardia antigen test (idexx laboratories) uses fresh or frozen feces, or feces refrigerated for less than days. since the antigen is continuously shed, this test avoids the problem of intermittent shedding of the whole organism. the sensitivity of the test is %, with a specificity of %. by combining the antigen test with a zinc sulfate fecal centrifugal flotation, the sensitivity improves to . %. it is unknown how long the antigen remains in the feces after treatment. thus a zinc sulfate centrifugal flotation examination should be used to evaluate therapeutic efficacy. , the use of this test in cats without diarrhea is controversial, because these cats are unlikely to shed cysts. the zoonotic significance of a positive antigen test in a cat not shedding cysts is unknown and may cause confusion. polymerase chain reaction detection of giardia dna is available, but the test has not been standardized across all diagnostic laboratories. one needs to ensure the laboratory performing the test has validated it for assemblage f. the test may also be used to identify cats harboring the zoonotic assemblages a and b. the sensitivity of this test is unknown. two commonly available drugs are used most frequently to treat infections with g. duodenalis (see table - ) . fenbendazole may be effective and can be used in pregnant queens and in cats co-infected with roundworms, hookworms, and taenia spp. tapeworms. however, in one small study, only four of eight cats infected with both g. duodenalis and cryptosporidium felis stopped shedding giardia permanently after receiving fenbendazole. febantel, in the combination product drontal plus (bayer animal health), is converted to fenbendazole. when six experimentally infected cats received . mg/ kg of febantel q h po for days, four of them stopped shedding g. duodenalis cysts. metronidazole has been the traditional drug used to treat g. duodenalis in pets. the drug is also useful for treating concurrent small intestinal bacterial overgrowth and clostridial infections. the administration of metronidazole may eliminate shedding in % of cats. neurologic side effects may occur at the dose recommended for treatment of giardia (see above, therapeutics for vomiting and diarrhea). the use of a giardia vaccine was ineffective in clearing infection by itself. the combination of fenbendazole and metronidazole has been suggested as the initial treatment of choice for g. duodenalis infections. although controlled studies are lacking, they may work synergistically by acting on two different targets within the parasite. febantel would be expected to have the same synergism with metronidazole. drug therapy may not be necessary in cats without diarrhea that are infected with g. duodenalis, because it is uncommon for a cat to carry the assemblages required to infect humans. the veterinarian may be obligated to treat a healthy cat if the owner wants to treat, the owner is immunocompromised, or the goal is eradication of an infection from a multicat home or prevention of parasite transmission to giardia-naïve cats is attempted. what may appear to be treatment failure is more likely to be re-infection. in addition to drug therapy, steps should be taken to prevent re-infection. all cats with diarrhea positive for g. duodenalis should be treated along with their housemates. sanitation is imperative in the fight against re-infection and transmission of g. duodenalis. dispose of old litter pans and scoops and use disposable litter boxes during treatment. when the infection is eliminated, not just controlled, new litter boxes and scoops may be purchased. bathe all cats during treatment to remove cysts from the hair coat. since giardia spp. cysts are susceptible to desiccation, blowdry all cats using a warm air blower, paying particular attention to the perineal area. disinfect bowls, housing, and other utensils with bleach. in addition to antiprotozoal drugs and sanitation, supportive care may become necessary. probiotics and a highly digestible, bland diet may be offered to cats with small bowel diarrhea, while a high-fiber diet may be useful for those few cats with large bowel diarrhea. where required, hydration and electrolyte imbalances must be corrected and antiemetics used to control vomiting. therapy can be evaluated by retesting feces with a zinc sulfate centrifugal flotation examination to days after the end of treatment and again weeks later. a positive test immediately posttreatment is most likely because of therapeutic failure. if the cat is negative immediately after treatment ends, but is positive weeks later, re-infection is likely. since the fecal antigen test may remain positive long after the infection is eradicated, this test is inappropriate for evaluating therapy. , re-treatment of fecal flotation-positive, recovered cats may be handled in a manner similar to the positive healthy cat mentioned above. cats with diarrhea that continue to shed cysts may be re-treated for g. duodenalis infection along with dietary modification and empirical treatment for other common intestinal parasites. however, serious consideration should be given to investigation into other potential causes of diarrhea. the giardia vaccine has been found to be ineffective in preventing infection and production has been discontinued. this means prevention of giardia infection involves avoiding exposure, stress and re-infections. providing a clean environment, feeding only processed foods, and controlling potential transport hosts will help reduce the chances of exposure. isolation of cats with diarrhea may be important, too. municipal sanitation control is difficult as the cyst survives for weeks in cool, moist environments. cysts are also able to survive water treatment and can pass through attempts at water filtration. giardiasis is associated with debilitating diarrhea in some humans, particularly those who are immunocompromised. however, cats do not commonly carry the assemblages needed to infect humans. transmission of g. duodenalis from cats to humans is rare and unproven. still, it seems prudent to consider the owner's health when contemplating management of giardial infections in cats. to avoid human health risks, cats with diarrhea that test positive for g. duodenalis should be treated with the goal of controlling the diarrhea. since no treatment for g. duodenalis is completely effective or % safe, treatment of positive cats without diarrhea should only begin after a discussion of the benefits and risks of the treatment with the owner. tritrichomonas foetus is best known for causing bovine reproductive infections. it is an obligate anaerobic parasite that also colonizes the lower intestinal tract of cats. there are enough differences between the two isolates that the feline isolate does not cause disease in heifers and vice versa. the parasite depends on the host's normal intestinal flora and secretions for obtaining nutrition. a report from the united states of purebred cats tested at an international cat show found t. foetus in of the cats tested, a prevalence of %. this parasite seems to have a higher prevalence in purebred cats than nonpurebred cats. a study of pet cats visiting veterinary hospitals across the united states reported of purebred cats were positive for t. foetus, while only of nonpurebred cats were positive. in this same study, of the positive tests were from purebred cats. a study from the united kingdom of diarrheic fecal samples sent to a veterinary diagnostic laboratory reported similar results. purebred cats represented of the cats testing positive for t. foetus. the u.k. study also found the siamese and bengal breeds each represented of positive cats; only two other breeds tested positive. transmission like most other protozoal parasites, t. foetus is transmitted by ingestion of the parasite, in this case, the trophozoite. unlike most of the other parasites, t. foetus does not form cysts and only survives up to days outside the body in moist feces. a cat becomes infected through the use of a shared litter box with an infected cat. after walking into the box, the parasite is transferred from the infected feces of one cat to the paws of the other. infection then occurs through ingestion of the trophozoites during grooming. after infection, t. foetus colonizes the distal ileum and colon, followed by shedding of infective trophozoites to days later. there are several mechanisms by which t. foetus causes diarrhea. these include alteration of the cat's normal bacterial flora population, increases in local inflammatory cytokine concentrations, production of enzymes, and direct mucosal injury. the resulting injury leads to plasmacytic-lymphocytic and neutrophilic colitis. although most infections involve only the mucosa of the colon, one study reported two of seven cats with diarrhea and t. foetus infections as having trophozoites in deeper layers of the colonic wall. co-infection with cryptosporidium felis or giardia duodenalis can be associated with increased numbers of t. foetus trophozoites and increased severity of diarrhea. signs of infection are most frequent in kittens and young cats, although infections without clinical signs can occur. adult cats, however, may also show signs of t. foetus infection. the most common sign is a foulsmelling large bowel diarrhea with increased frequency of defecation, mucus, blood, and flatulence. the consistency of the diarrhea may wax and wane, but the presence of diarrhea does not. cats with diarrhea are otherwise in good health and maintain their body condition. , severe diarrhea can result in anal swelling and fecal incontinence. diarrhea may respond to the use of antibiotics because of changes in the cat's intestinal microbial flora. however, it always returns at the cessation of therapy. , many cats experience a spontaneous resolution of the diarrhea within years of diagnosis. , since t. foetus causes reproductive infections in heifers and bulls, there is speculation the parasite also infects the reproductive tract in cats. tritrichomonas foetus was found in the uterus of a queen with pyometra. however, in a study of breeding male and female cats from catteries, no cytologic or molecular evidence of t. foetus was found in the reproductive tract. the authors reported colonic infection with t. foetus in of the cats representing of the catteries. detection of the trophozoites in a sample of feces is the most expedient means of diagnosing an infection with t. foetus (figure - ). an index of suspicion is required, because the clinical presentation of t. foetus infection is often mistaken for infection with giardia duodenalis. if a cat is not responding to treatment for that parasite, consider t. foetus as a cause of the diarrhea. the sample required for the diagnosis of t. foetus is a fresh, nonrefrigerated sample of watery feces. refrigeration kills the trophozoites, and they are not found in normal feces. the sample may be freshly passed diarrhea, feces collected using a wire loop passed into the colon, or collected by a colonic flush using a red rubber catheter and ml of saline. a wet mount or smear examination of the feces should be performed on all cats with diarrhea. examination of multiple samples may be required to find the t. foetus trophozoites with this technique because it is insensitive. the trophozoites must be differentiated from giardia duodenalis based on structural differences and motility patterns (see table - ). the trophozoites of t. foetus can be cultured using the inpouch tf system (biomed diagnostics). this test is more sensitive than the fecal wet mount examination and detects trophozoites per sample. the number of parasites shed by a cat with diarrhea is high enough to be routinely detected with this method. the test should be performed in-house, because the parasite is unlikely to survive the trip to the laboratory. the test pouch is inoculated with µg of freshly collected feces, about the size of a peppercorn. any more than this increases the chances of bacterial overgrowth. the pouch is incubated at ° c and examined under the microscope for motile trophozoites every other day for days. the pouch should be tapped gently to dislodge the parasites, which tend to collect along the seams. the test is considered negative if parasites are not found after days. one benefit of this system is that it does not support growth of giardia duodenalis or pentatrichomonas hominis. if a fecal wet mount examination and culture are both negative and infection with t. foetus is still under consideration, a pcr test can be performed. this test detects dna from live or dead trophozoites, but is more expensive than other diagnostic methods. this test is more sensitive than the other two methods and can detect parasites per sample. the sample size is mg of feces not contaminated by litter preserved in to ml of rubbing alcohol shipped at room temperature. trophozoites of t. foetus are sometimes found in colonic biopsy samples adhered to the surface or in the lumen of crypts. the most effective drug for the treatment of t. foetus in cats is ronidazole. the drug has a bitter taste and should be compounded into capsules. veterinary staff and owners should use gloves when handling ronidazole. if a confirmed relapse occurs, another course of treatment may eliminate the parasite. diarrhea may take several weeks to resolve after elimination of the parasite, because significant colitis is often present. effectiveness of treatment can be evaluated by performing fecal pcr tests and weeks after the end of treatment. apparent treatment failures may occur because of re-infection, co-infection with giardia duodenalis or cryptosporidium felis, or the presence of another concurrent diarrhea-causing disorder. a more worrisome cause for treatment failure is a recent report of parasite resistance to ronidazole in two cats. fortunately, diarrhea ultimately resolved in both cats despite the continued presence of the parasite. if the cat retests negative and the diarrhea is not improving after weeks, consider the possibility that another disease may exist. nonspecific treatment for diarrhea is unhelpful and may prolong the duration of diarrhea. diarrhea may respond to antibiotics as they alter the intestinal flora population; however, once treatment is stopped, the diarrhea will return. an important and potentially serious adverse effect of ronidazole administration in cats is a reversible neurotoxicity. onset of signs often begins within week of the onset of therapy and may last between and weeks after cessation of therapy. these signs can include depression, ataxia, seizures, behavioral changes, weakness, hyperesthesia, and trembling. neurotoxicosis usually requires only supportive care along with discontinuation of the drug. the neurologically affected cat should be retested for the parasite, because it may have been eliminated. because of the potential for neurotoxicity, the use of ronidazole should be restricted to cats with confirmed infections with t. foetus. crowded conditions should be avoided, because transmission of t. foetus trophozoites is more efficient in these settings. cats testing positive should be isolated from other cats during treatment. providing a clean environment will help prevent transmission of trophozoites. although there is a report of an infection in one immunocompromised person, transmission of t. foetus trophozoites from cats to healthy humans has not been reported. still, prudence dictates handling feces infected with t. foetus trophozoites carefully. recent genetic evaluations have shown that most feline infections with cryptosporidium spp. are with c. felis; not, as previously thought, with c. parvum. cryptosporidium parvum seems to be limited to farm animals. cryptosporidium felis is an obligate intracellular parasite infecting the small intestine. infective oocysts are ingested from contaminated feces during self-grooming of contaminated body parts and from contaminated food and water. , after infection, the parasite attaches to the brush border of the enterocyte. the prepatent period is to days, and the oocysts are infective as soon as they are shed, making this a very contagious disease. like most intestinal parasites, shedding is often intermittent. the pathogenic effects of c. felis infections are not well understood. direct cytotoxicity and inflammation causes villus atrophy and decreased surface area for absorption of water, electrolytes, and other nutrients. , apoptosis (preprogrammed cell death) of the mucosal cells may be accelerated, adding to the malabsorption. most infections with c. felis are subclinical. signs, if present, range from a mild, self-limiting small bowel diarrhea to chronic intermittent small bowel diarrhea. severe diarrhea with weight loss and anorexia may also occur. , clinically apparent infections are most common in kittens, adult cats with concurrent gastrointestinal diseases, and cats co-infected with giardia duodenalis or tritrichomonas foetus. cats with co-infections may experience more severe clinical signs. a fecal flotation, which should be performed on all cats with diarrhea, may reveal c. felis if there are large numbers of oocysts (figure - ) . the fecal floatation test, however, is often negative because of intermittent shedding. the parasite is small and floats in a higher plane than helminth ova; the high-power lens and appropriate adjustment of the microscope stage is required to find the parasite. the small size of the oocyst makes identification difficult, particularly if the examiner is not specifically looking for them. a modified ziehl-neelsen stain of a thin fecal smear may help in the identification of the oocysts. this technique works well in humans with large numbers of oocysts. once signs resolve or the oocyst numbers decline, a single examination of a stained smear becomes insensitive. when only one sample is available, testing for c. felis antigen is a good choice. the prospect microplate assay (alexon biomedical, sunnyvale, calif.) is more sensitive and specific for the diagnosis of c. felis than is the examination of a stained smear. immunofluorescent antibody testing is available from some laboratories. fecal c. felis dna can be detected using pcr testing. this test is available at many veterinary diagnostic laboratories; however, at present, there is no test standardization among laboratories. the clinical and zoonotic significance of a positive pcr test combined with an oocyst negative test is unknown. therefore a positive pcr test in a cat without diarrhea presents a confusing situation for the attending veterinarian with regard to recommendations for the owner. unfortunately, there are no completely effective and safe treatment protocols available for c. felis. , a concerted attempt to find other causes of diarrhea should take place prior to convicting a cat of having diarrhea solely from c. felis infection. most reports on therapy for c. felis are uncontrolled and anecdotal. a number of drugs have been discussed. azithromycin for at least days appears safe but produces variable results. paromomycin, an oral aminoglycoside, may be effective. however, one study reported acute renal failure in of cats receiving the drug. deafness also occurred in three of those four cats. nitazoxanide is a drug approved for treating humans with diarrhea caused by cryptosporidium spp. infections. the administration of nitazoxanide to cats at mg/kg q h po for at least days up to days may be effective. however, nitazoxanide is a gastrointestinal irritant and commonly results in vomiting and foul-smelling diarrhea. co-infections with giardia duodenalis and/or tritrichomonas foetus are more difficult to control. if diarrhea from c. felis infection improves but does not resolve at the end of therapy, the duration of treatment may be prolonged. additional diagnostic testing should also be performed to ensure the only cause of the diarrhea is infection with c. felis. environmental control of c. felis is difficult, because it is extremely hardy. it is resistant to chlorination and most disinfectants. oocysts remain viable at temperatures above freezing up to ° c. the parasite is difficult to filter and survives treatment at municipal water treatment facilities. steam-cleaned housing and utensils may be beneficial in controlling parasite numbers, and they are susceptible to % ammonia solutions; however, the required contact time is hours. cryptosporidium spp. are relatively species specific, and there are no reports of waterborne outbreaks of human cryptosporidiosis associated with c. felis. cryptosporidiosis can cause life-threatening diarrhea in hivpositive persons. fortunately, humans are rarely infected with c. felis. in fact, the zoonotic species most commonly found in humans (often veterinary students), is c. parvum found in young heifers. regardless of a person's health, feces from a cat with diarrhea should be handled carefully. if a cat infected with cryptosporidium spp. is owned by an immunocompromised person, a pcr test may be useful in determining the species of the parasite and its zoonotic risk. like other coccidians, toxoplasma gondii is an obligate intracellular parasite. domestic cats and other felids are the only animals that shed oocysts. any warmblooded animal, including humans, can be infected with this parasite. toxoplasma gondii can be transmitted by ingestion of infective oocysts in fecally contaminated food or water after ingestion of tissue cysts through carnivorism, or by transplacental or trans-mammary transmission of the parasite. the parasite enters into one of two cycles, depending on the host species. the enteroepithelial cycle only occurs in cats and results in shedding of oocysts after sexual reproduction of the parasite. after a cat ingests an infective oocyst or a tissue cyst, the parasite enters the mucosal cells of the small intestine, where it may undergo development and sexual reproduction, after which oocysts are shed. the prepatent period after ingesting an infective oocyst is to days, while shedding after ingesting tissue cysts starts in to days. fecal shedding, which occurs only after initial infection, lasts for to weeks , and the oocysts become infective to days after they are shed. the extraintestinal cycle occurs in any animal, including cats. after ingestion, the parasite penetrates the cells of the small intestine and rapidly replicates in the enterocytes and associated lymph nodes into tachyzoites. after hematogenous and lymphatic spread, tachyzoites infect cells in all tissues of the body. tissues most commonly infected include the brain, liver, pancreas, and lungs. if a pregnant queen becomes infected, tachyzoites cause placentitis, after which they infect the fetus. in weeks, the host's immune response slows parasite replication, and the resultant bradyzoites form tissue cysts in the brain, striated muscle, and liver, and they remain viable for the life of the animal. immunosuppressive drugs or disease may dull the suppression of parasite division by the host immune system and allow the slowly dividing bradyzoites in tissue cysts to begin rapid division, thereby reactivating the infection with tachyzoites. none of the forms of t. gondii produces a toxin. rapid replication of tachyzoites within a cell leads to rupture of the cell and necrosis of the tissue in which they are located. the most commonly injured tissues are the brain, lungs, liver, and pancreas. prenatal infection leads to more severe illness, because the immature immune system is unable to slow down replication by tachyzoites, allowing continued damage to tissues. prenatal infection is more likely to result in ocular infections, and neonatal death is usually caused by pulmonary or hepatic infection. type ii and iv hypersensitivities may be involved in the pathogenesis of chronic disease from bradyzoites in tissue cysts. kittens infected perinatally can be stillborn or die shortly after birth. they may also suffer from hepatomegaly and ascites, central nervous system signs resulting from encephalitis, respiratory distress, or uveitis. , clinical signs of infection in healthy adult cats are uncommon (box - ). diarrhea from enteroepithelial development of the parasite is rare. cats that develop clinical disease often have an episodic course with vague signs that depend on the body system affected. onset of illness may be acute or chronic, and the most commonly affected organs include the brain, lungs, liver, heart, pancreas, and the eyes. signs are the result of spread of tachyzoites after initial infection or after reactivation of tissue cysts. cats suffering from uveitis may develop lens luxation and glaucoma. the best way to identify a cat shedding t. gondii oocysts is to demonstrate them with a centrifugal fecal flotation technique using sheather sugar solution. the oocysts are about a quarter of the size of isospora felis oocysts ( figure - ). oocysts of t. gondii are morphologically indistinguishable from hammondia or besnoitia spp. oocysts. detection of fecal t. gondii dna using a pcr test can be used to definitively differentiate t. gondii oocysts from similar coccidians. it is probably best, however, to assume suspicious oocysts are those of t. gondii until proven otherwise. proving infection with t. gondii is responsible for a cat's systemic illness is also difficult. finding tachyzoites in cytology samples is uncommon. they are most likely to be identified from body cavity effusions. the most common method of identifying an infected cat is by detecting t. gondii-associated immunoglobulins using immunofluorescent antibody or elisa techniques. since cats are infected for life, a seropositive cat has been infected at some point in its life. however, use of serology alone is insufficient to diagnose an active t. gondii infection. serum immunoglobulin m (igm) is produced within to weeks after infection, but increased igm titers may persist for months to years. serum immunoglobulin g (igg) begins to rise later; in some cats, igg may not be detectable for to weeks. by the time igg is detectable, shedding will have ceased. maternally acquired igg persists in kittens for to weeks. a rising igg titer is associated with an active infection, but the degree of increase is not associated with the severity of the clinical signs. if a cat becomes seronegative, it is more likely the titer has fallen below the sensitivity of the test rather than the parasite has been eliminated from the body. because of the vague nature of the clinical signs, many cats are presented later in the course of the disease. by this time, they may have switched from igm to igg production or passed the time of maximal igg production. thus a negative igm titer or a lack of rising igg titer does not rule out t. gondii infection. also, reactivation of tissue cysts is rarely associated with rising igg titers. ultimately, the diagnosis of an active systemic t. gondii infection requires demonstration of an igm titer greater than : or a fourfold increase in igg titers over a -to -week period along with signs consistent with toxoplasmosis, the exclusion of other disorders that may cause the clinical signs, and response to appropriate anti-t. gondii treatment. although serum igm titers may be increased in otherwise healthy cats, increased igm titers in cerebrospinal fluid or aqueous humor only occurs in cats with active cns or ocular infections. the goals of treating a cat infected with t. gondii are to reduce shedding of oocysts and to control the clinical signs in sick cats. shedding can be reduced by using ponazuril, toltrazuril, or high doses of clindamycin. the drug options for treating a sick cat include clindamycin, trimethoprim-augmented sulfadiazine, or azithromycin for at least weeks (see table - ) . recurrences are more common if the cat is treated for less than weeks. , the antifolate drug pyrimethamine may be more effective than trimethoprim, but megaloblastic anemia develops in many cats. supplementation with folinic acid ( mg/cat, once daily, po) or brewer's yeast ( mg/kg, once daily, po) may prevent or reverse the anemia. no drug clears all of the tissue cysts; so, cats remain infected for life. if uveitis is also present, use appropriate topical, oral, or parenteral corticosteroids. for a cat with proven t. gondii-associated uveitis alone, a topical ocular glucocorticosteroid is the only required treatment; no antibiotics are necessary unless the uveitis is persistent or recurrent. • wash hands after handling cats, especially if you are pregnant or immunocompromised. • remove fecal material from the home environment daily, since shed oocysts require a minimum of hours to become infective. • do not have immunocompromised persons clean the litter box. if they must clean the litter box, they should wear gloves and wash hands thoroughly when finished. • use litter box liners, and periodically wash the litter box with scalding water and detergent. • wear gloves when gardening, and wash hands thoroughly when finished. • cover children's sandboxes when not in use to avoid fecal contamination by outdoor cats. • only feed cats cooked or commercially processed food. • control potential transport hosts, such as flies and cockroaches, that may bring the organism into the home. • filter or boil water from sources in the environment. • cook meat for human consumption to ° c for minutes minimum (because of uneven heating, microwave cooking does not kill all t. gondii ). • freeze meat at − ° c for hours. • wear gloves when handling meat, and wash hands thoroughly with soap and water when finished. clinical signs such as malaise, fever, and muscle pain should begin to resolve in to days. if there is no response within days, switch to or add another drug. if there is still no response, search for another condition that may cause the observed clinical signs. however, ocular and cns signs resolve more slowly and thoracic radiographic changes may take weeks to resolve. some cns changes may never completely resolve. cats co-infected with feline immunodeficiency virus (fiv) do not respond to anti-t. gondii treatment as well as fivnegative cats respond. feeding cats commercially processed cat food and avoiding undercooked or raw meat can prevent exposure to t. gondii. controlling hunting reduces access to paratenic hosts with infective tissue cysts. access to mechanical carriers of t. gondii, such as earthworms or cockroaches, should be minimized. human infection with t. gondii is common, more so in warm, humid climates where the prevalence of t. gondii seropositive persons approaches %. the number of persons seropositive for t. gondii is estimated to be around , , worldwide. infective oocysts are hardy and may remain viable in the environment for up to months. human infection most often occurs after eating raw or undercooked meat infected with tissue cysts or by transplacental infection. seropositive cats are finished shedding and are unlikely to resume shedding even if the infection becomes reactivated. cats found to be shedding oocysts should be quarantined at a veterinary hospital until shedding ends. oocysts of t. gondii have not been found on the hair coat ; so, transmission of toxoplasmosis does not occur after touching a cat. pregnant women infected with t. gondii for the first time, or chronically infected women who are also hiv positive, can transmit the parasite to their unborn child. transplacental infection can result in stillbirths, cns, or ocular disease. more severe fetal disease may occur if the infection happens in the first half of the woman's pregnancy. toxoplasma gondii infection of immunocompetent humans usually results in a self-limiting fever and malaise. steps useful in preventing transmission of t. gondii to humans can be found in box - . pancreatitis refers to inflammation of the pancreas only, with no implication of the underlying cause or pathology. for example, acute necrotizing pancreatitis (anp) with pancreatic auto-digestion, requiring predominantly supportive care by maintaining fluid and electrolyte balances and pain relief, must not be confused with chronic pancreatitis (cp) caused by lymphocytic infiltration, and commonly associated with lymphocytic inflammatory bowel disease (ibd), and often requires corticosteroids to manage. these two conditions (and others) can only be definitively distinguished histologically. in many cases, the clinical signs of cats with acute pancreatitis will resolve with supportive care before a precise diagnosis is reached and will thus remain undiagnosed. there are no formal classifications for feline pancreatitis, but most authors , , use the terms • acute pancreatitis • acute necrotizing pancreatitis, characterized by severe peri-pancreatic fat necrosis • acute suppurative pancreatitis, characterized by neutrophilic infiltration • chronic pancreatitis, characterized by lymphocytic infiltration the exact prevalence of feline pancreatitis is unknown. necropsy studies from the s to s reported prevalence of feline pancreatitis ranging from . % to . %. , a more recent study found % of cats had evidence of pancreatitis. however, this included pancreatic pathology in % of apparently healthy cats, which suggests that mild pathology is unlikely to cause clinical signs. these studies all show lymphocytic pancreatitis to be significantly more prevalent than acute pancreatitis. this may underestimate the true prevalence of acute pancreatitis, since it is understood that no permanent histopathologic changes are present after resolution of acute pancreatitis. it is also possible that studies assessing pathology in necropsy cases do not reflect clinical practice. there are no specific age, breed, or sex predispositions. although one study reported siamese cats to be at increased risk of acute pancreatitis, subsequent studies have recognized the majority of cases are domestic shorthair cats, suggesting no specific breed predispositions. , , , most studies have indicated older cats ( to years of age) are more likely to be affected, , , , but these studies most likely underrepresent cats with less severe clinical disease for which definitive diagnosis may not be reached and which may be younger. no association has been made with a high-fat diet or obesity. in most cases of both acute and chronic pancreatitis, no specific cause is found, and the disease is primarily considered to be idiopathic. , there are, however, some specific underlying causes that are sporadically recognized. these include infections with herpesvirus, calicivirus, , feline infectious peritonitis (fip), liver fluke and pancreatic fluke, , and toxoplasmosis. however, a recent paper found no association between serum feline pancreatic lipase immunoreactivity (fpli) concentrations and toxoplasma gondii serology. pancreatitis has also been recognized subsequent to trauma and organophosphate poisoning. the association of pancreatitis with inflammatory bowel disease and cholangitis is frequently mentioned (triaditis) but poorly described in the literature. one study found % of ibd cases to have histologic evidence of pancreatic involvement, and another found fpli concentrations were elevated in % of cases with histologically confirmed ibd. it is the author's experience that many cases of pancreatitis recognized with ibd have no specific clinical signs attributable to pancreatitis and should therefore be diagnosed and treated as intestinal disease. diabetes mellitus is a recognized co-morbidity of pancreatitis in cats. a recent study found fpli concentrations were significantly higher in diabetic cats compared with non-diabetics. no association could be made between fpli concentrations and the degree of diabetic control. one study found of cats ( %) histologically diagnosed with hepatic lipidosis were also histologically diagnosed with acute pancreatitis. it is not known if pancreatitis is a cause, consequence, or coincident disease of hepatic lipidosis. for example, anorexia associated with acute pancreatitis could predispose to fatty infiltration of the liver. however, the high rate of concurrent disease has important implications for ensuring cats with pancreatitis receive adequate caloric intake. ongoing or recurrent pancreatitis may lead to pancreatic cysts or exocrine pancreatic insufficiency, which are both covered later in this chapter. although pancreatitis has been experimentally induced in cats, , , the pathophysiology of spontaneous pancreatitis remains unknown. acute pancreatitis is initiated by an increase in secretion of pancreatic enzymes that leads to inappropriate cellular activation of trypsin and subsequently other digestive zymogens. these activated digestive enzymes lead to local effects including inflammation, hemorrhage, acinar cell necrosis, and peripancreatic fat necrosis. , , chronic pancreatitis may result from any of several underlying processes: ongoing, low-grade acute pancreatitis episodes may instigate chronicity; chronic pancreatitis, with a predominance of lymphocytic inflammation has been induced experimentally within weeks by narrowing the main pancreatic duct to approximately % of its normal diameter ; and the association with ibd may suggest an immune-mediated cause. the clinical signs of pancreatitis in cats are nonspecific. a review of eight prior series totaling cases of acute pancreatitis in cats found anorexia ( % of cases) and lethargy ( %) to be the most common historical findings. vomiting was recognized in % of cases, diarrhea in %, and weight loss in %. physical examination findings were similarly nonspecific with dehydration ( %) being the major finding; fever was recognized in only % of cases and abdominal pain in %. it is important to note that vomiting and abdominal pain, key features of pancreatitis in dogs, are not consistently recognized in cats. similar, nonspecific findings indistinguishable from ibd are recognized in cats with chronic pancreatitis. , diagnosis because the presenting signs and physical examination findings are nonspecific, the diagnosis of pancreatitis can be challenging, requiring not only clinical suspicion but a combination of diagnostic modalities. for the most part, hematology and plasma biochemistry findings are unremarkable, although a combination of findings may increase clinical suspicion. for example, moderate elevations in liver enzymes, bilirubin, and glucose are present in approximately % of cases and hypocalcemia in approximately two of three of cases; hypocalcemia infers a poorer prognosis. hypoalbuminemia is seen in approximately one of three of cases and has important implications for fluid therapy. amylase and lipase elevations are not reflective of pancreatitis in cats. feline trypsinlike immunoreactivity (ftli) is the diagnostic test of choice of exocrine pancreatic insufficiency, but elevations in pancreatitis are not seen consistently enough to warrant use of this test for this purpose. , , the biggest recent advance in feline pancreatic diagnostics has been the characterization of feline pancreatic lipase, leading to the development of a radioimmunoassay for the measurement of feline pancreatic lipase immunoreactivity (fpli). it must be remembered, however, that an increase in fpli only tells the clinician that pancreatic pathology is present, but not the cause of pathology, which may be, for example, neutrophilic or lymphocytic pancreatitis or neoplasia, and it may or may not involve the intestines or liver. fpli should therefore be used as a screening test, with elevated results not suggesting a diagnostic end point. further, the high interassay variability of this test would suggest that mild cases may be missed as shown in one study and that the test may not be appropriate for serial monitoring. fpli is currently available as "spec fpl" from commercial laboratories and has a sensitivity of % and a specificity of % when . µg/l is used as the diagnostic cut off compared with . µg/l, which is the listed reference range high point. in an acutely unwell cat (less than days) with only mild to moderate signs of disease, further diagnostics may not be warranted, and many cats will improve with supportive therapy of balancing fluid and electrolytes, pain relief, and antinausea/vomiting therapy. cats with chronic duration of signs and acutely unwell cats that do not improve with supportive therapy warrant further diagnostics. the underlying disease process cannot be assumed from an elevated fpli; in one study of cases, acute necrotizing pancreatitis could not be distinguished from chronic nonsuppurative pancreatitis by signalment, duration of signs, or clinical findings. the major utility of diagnostic imaging is to rule out other differential diagnoses, such as an intestinal foreign body, and perhaps confirm that the pancreas is affected. radiography is non-specific for diagnosis of pancreatitis, but findings may include decreased abdominal detail (sometimes associated with ascites), soft tissue density in the right cranial quadrant of the abdomen, hepatomegaly, or gas-filled intestines , , (see . additionally, thoracic radiographs may show pleural effusion. one study found of cats with pancreatic necrosis had such a change ; the mechanisms resulting in pleural effusion are not precisely defined. ultrasonography has high specificity (> %) but low sensitivity (< %) for recognizing pancreatitis in cats, , , , with findings dependent on operator skills, quality of equipment, and severity of lesions. typical findings are hypoechogenicity of the pancreas, which may be enlarged or irregular; hyperechogenicity of the peripancreatic fat; the possible presence of abdominal effusion; and abnormal findings with other organs, such as liver or intestine, may add to the clinical picture , , , . one study indicated that contrast-enhanced doppler ultrasonography can provide further diagnostic insights. a recent study suggested that endosonography may be useful in cases where transabdominal ultrasonography is difficult, for example, because of obesity, hyperechoic mesentery, or excessive intestinal gas. for more than years, computed tomography (ct) has been a commonly used modality to confirm pancreatitis in humans, but this reliability has not been demonstrated in cats, where sensitivity may be as low as %. , definitive diagnosis of pancreatitis, including differentiation of the inflammatory process, can only be made by cytologic assessment of pancreatic tissue. in most cases, ultrasound-guided fine-needle aspiration (fna) of the pancreas is technically difficult because of the small dimension of the feline pancreas; there appears to be no assessment of feline pancreatic fna findings in the literature. gross inspection of the pancreas and samples for histologic assessment can be obtained during laparotomy , (see or laparoscopy. , because pancreatitis often occurs concurrently with pathology of other organs, thorough evaluation of the abdomen by ultrasonography or gross inspection is recommended, as are multiple biopsies of, for example, intestines, liver, and mesenteric lymph nodes, where appropriate. clinicians may be reluctant to biopsy the pancreas because of perceived risks of deleterious effects. studies of pancreatic biopsy in healthy cats dispel the concern that the pancreas is unforgiving to mild manipulation and biopsy , a and the author's clinical experience is consistent with these findings. supportive care comprising correction of fluid/ electrolyte imbalances, pain management, and nutritional support are the mainstay of therapy for cats with figure - gross appearance of pancreas at laparotomy; this was histologically diagnosed as chronic pancreatitis (i.e., lymphocytic infiltration was recognized). gross appearance of pancreas at laparotomy; this pancreas was found to be histologically normal. it does look smaller than is typically seen; pancreatic atrophy can look similar to this, grossly. pancreatitis. , , specific underlying causes, when diagnosed, should be managed, as should concurrent diseases. follow-up evaluation is determined on a case-by-case basis; reduction or resolution of clinical signs is the main criterion for success of therapy. serial fpli values may be monitored when initial results are extremely high but are of limited value for mild increases because of assay variability. dehydration, acid-base and electrolyte abnormalities should be corrected during the first to hours. hypocalcemia, if present, should be treated with a calcium gluconate infusion of to mg/kg during to hours, with continued assessment of plasma calcium concentrations. plasma transfusions can be considered in cats with hypoalbuminemia. , , although abdominal pain is not commonly described in cats with pancreatitis, it is likely to be present in most cases and may contribute to anorexia. historical concern about exacerbation of pancreatitis with opioids is no longer accepted, and this class of drugs is considered appropriate. meperidine ( to mg/kg sc or im) every to hours, butorphanol ( . to . mg/kg sc) every hours, or sustained-release buprenorphine ( µg/kg sc) every hours are alternatives. , , the author uses one dose of methadone ( . to . mg/kg sc, im, or iv) initially and places a fentanyl patch for longer-term pain management. the traditional recommendation for management of pancreatitis across all species has been nil per os for several days. this recommendation is appropriate for cats with severe vomiting, but there is no evidence to support this approach in cats that are not vomiting and that are eating normally. further, nutritional support is vital for those cats with concurrent hepatic lipidosis. if the cat is not eating voluntarily, nutritional support by tube feeding is often warranted. , , a recent paper found nasogastric tube feeding of cats with pancreatitis was tolerated well and resulted in few clinically significant complications. other reported nutritional strategies for cats with pancreatitis incorporate partial parenteral nutrition (ppn; . % amino acids, % lipids), or total parenteral nutrition (tpn; % amino acids, % lipids, % dextrose), or both instead of enteral feeding. , , cats do not seem to benefit from feeding of specially formulated low-fat diets; commercially available, veterinary liquefied diets appear to be well tolerated despite their high-fat contents. other therapy may be appropriate in individual cases. all cats with pancreatitis that are vomiting should be treated with antiemetics. examples of drugs that can be used are -ht antagonists, such as dolasetron ( . to . mg/kg iv or po, once to twice daily); ondansetron ( . to . mg/kg iv every to hours); and maropitant, an nk -inhibitor ( . to . mg/kg sc once daily). these drugs are covered in detail earlier in this chapter under therapeutics for vomiting and diarrhea. dopaminergic antagonists, such as metoclopramide, are less effective antiemetic agents in cats than the other choices mentioned. , in most cases, pancreatitis begins as a sterile process, and antibiotic therapy is controversial. pancreatic necrosis and inflammation may predispose to bacterial colonization of the pancreas as demonstrated in experimental models. , this has not been demonstrated in spontaneous disease, and no comparison of outcomes has been made of cats with pancreatitis treated with or without antibiotics. cefotaxime ( to mg/kg iv, im) has been used to prevent bacterial colonization in experimental models. other broad-spectrum cephalosporins or ampicillin may act similarly. antibiotic considerations are possibly more important for acute pancreatitis than for treatment of chronic disease. cats with demonstrated lymphocytic pancreatitis, with or without concurrent ibd or lymphocytic cholangitis, should be treated with corticosteroids (e.g., prednisolone, to mg/kg once to twice daily) with tapering to the lowest effective dose. there is no justification for use of corticosteroids in cats with acute necrotizing or acute suppurative pancreatitis, or cats for which the cause of pancreatitis has not been diagnosed histologically. use of corticosteroids in cats with pancreatic disease creates a risk of iatrogenic diabetes mellitus. surgical intervention is warranted to relieve any bile duct obstruction that may result or for the débridement of pancreatic abscesses or necrotic tissue; in many cases, cats will survive multiple years after such corrective surgery. pancreatic cysts, pseudocysts, and bladders have been described sporadically in cats.* pancreatic cysts are lined by a single layer of cuboidal epithelium and do not communicate with the pancreatic duct; pseudocysts are enclosed by a wall of fibrous tissue, lacking the epithelial lining characteristic of true cysts and can form secondary to pancreatic inflammation; cystic dilations of the pancreatic duct are referred to as pancreatic bladder. true pancreatic cysts have been described in three cats , , ; a congenital pancreatic cyst with associated inflammation was described as an incidental finding in an adult cat ; multiple pancreatic cysts were described in a cat with concurrent polycystic disease in the kidney and liver ; and a another cat had multiple recurrent pancreatic cysts with concurrent mild pancreatic inflammation and atrophy associated a with rapid clinical course resulting in diabetes mellitus. cysts, pseudocysts, and bladders may be identified ultrasonographically or by ct. they may be benign, but the associated pancreatic inflammation and other sequelae, such as diabetes mellitus, may need to be managed. pancreatic bladders may result in biliary obstruction, and surgical correction may be required. pancreatic nodular hyperplasia is recognized quite frequently as an incidental finding in older cats or at necropsy. neoplasia of the exocrine pancreas is rare in cats. its frequency was assessed in the s when one study estimated . cases per , patients per year at risk, and another found pancreatic tumors in of feline necropsies. a more recent study recognized, from , feline admissions over a -year study period, only two cats with pancreatic adenomas ( . % of admissions) and eight with pancreatic adenocarcinomas ( . % of admissions). adenomas appear as small, solitary or multifocal nodules and are not typically associated with adjacent pancreatic inflammation. they do not cause clinical signs, unless large, when any clinical signs result from the physical size and are usually an incidental finding. , few generalities can be made about the presentation for pancreatic adenocarcinoma. the age range is large ( to years), there is no sex predisposition, and no clear breed predispositions are present. , only cytology or histopathology can distinguish pancreatitis from pancreatic carcinoma in cats antemortem, yet it is important to differentiate the two conditions, because, in contrast to adenomas, pancreatic adenocarcinoma is associated with a grave prognosis. the presence of lesions consistent with metastases on radiography or ultrasonography may suggest malignancy, but one study could not distinguish neoplasia from pancreatic nodular hyperplasia ultrasonographically based on the appearance of the pancreas alone (figures - and - ) . pancreatic adenocarcinomas in cats can result in a paraneoplastic dermatologic condition consisting of nonpruritic, symmetric alopecia affecting the face, ventral body, and medial aspect of the limbs of cats. the skin is usually glistening but not fragile, and there can be crusty lesions on the footpads.* the pathogenesis of this dermatologic disease is unknown. in one case, surgical excision of the pancreatic carcinoma resulted in resolution of dermatologic disease, indicating that the process is reversible (although signs recurred as the tumor re-emerged). diabetes mellitus is a recognized complication of pancreatic adenocarcinoma. the mechanism is unknown and may simply be secondary to compression or invasion of islet cells by the tumor. in some cats, diabetes is recognized ahead of pancreatic neoplasia. , , obstructive jaundice has also been described with pancreatic adenocarcinoma. most cases of pancreatic adenocarcinoma in cats have metastasized by the time of diagnosis, and most reported cases die or are euthanized within days of diagnosis. surgical excision is a potential option if neoplasia is confined to one limb of the pancreas, but recurrence is possible even if there is no evidence of metastasis and excision seems complete at the time of surgery. exocrine pancreatic insufficiency (epi) is a condition caused by insufficient synthesis and secretion of pancreatic digestive enzymes from the exocrine portion of the pancreas. in humans it has been reported that % of pancreatic acinar cells must be lost before clinical signs of epi are seen. epi is considered rare in cats but is perhaps being recognized more frequently because of increased awareness. there are less than fifty cases described in the veterinary literature* with one of these papers describing only cases from five institutions, with prevalence described as . % to . % of cats seen over a -year period. in contrast to this, the gastrointestinal laboratory at texas a&m university recognized samples with serum ftli concentrations at or less than . µg/l, which is diagnostic for epi, out of , submissions, which equates to . % of cats with known or suspected gastrointestinal disease. all studies indicate a wide age range of cats can be affected, from kittens less than months of age to cats more than years old, with a median age of approximately years. there is no apparent breed predisposition. , , one paper recognized of ( . %) cats to be male, and another recognized of ( %) male cats, suggesting a possible sex predisposition. chronic pancreatitis is believed to be the most common cause of epi in cats, acinar atrophy (paa) is recognized as the most common cause of epi in dogs, and has been definitively described in two feline cases and mentioned as a cause for three other cases. other potential causes of epi include disruption of pancreatic enzyme flow at the duodenal papilla following duodenal resection and pancreatic fluke infection (eurytrema procyonis), , and amyloid deposition and neoplasia are other possible causes of pancreatic cell damage that have not definitively been described in cats. congenital pancreatic hypoplasia or aplasia has not definitively been reported in cats, but reports of epi in cats as young as months of age , suggest this possibility. since chronic pancreatitis is a common cause of epi and chronic pancreatitis has a strong association with ibd, many cats may have concurrent lymphocytic pancreatitis and enteritis. , , therefore cats failing to respond to therapy for epi may require further diagnostics and management of an underlying condition. further, destruction of functional exocrine pancreatic tissue can also affect pancreatic endocrine tissue, resulting in concurrent diabetes mellitus. several studies have indicated that all cats with epi will have weight loss when diagnosed, unless a kitten, in which case ill-thrift is recognized. , diarrhea is not necessarily present, being described in % to % of cats; the nature of feces can vary from voluminous, malodorous stools that can be discolored (yellow or pale), sometimes with steatorrhea, to normal feces in other cats. increased frequency of defecation and the presence of mucus in the feces of some cats can lead to the diarrhea being characterized as large bowel. only about % to % of cats are polyphagic, some described as having a ravenous appetite; conversely, some cats present with anorexia. vomiting has also been described. since cats with epi often have concurrent disorders, such as ibd, the clinical signs recognized may reflect the concurrent disease and not necessarily epi alone. physical examination findings are similarly nonspecific, with thin/ emaciated body condition being the most common finding. hematologic findings are non-specific, but a mild nonregenerative, normocytic, normochromic anemia may be recognized as well as lymphopenia or neutrophilia. plasma biochemistry results may show a mild to moderate increase in alanine aminotransferase (alt) and a mild increase in alkaline phosphatase in some cats. mild to moderate hyperglycemia may be seen, as may mild hypoglycemia or normoglycemia. , , hypocobalaminemia is recognized in nearly all cats with epi. , , , , this may be because of insufficient production of intrinsic factor, a cobalamin-binding protein only produced by the pancreas in cats and necessary for ileal absorption of cobalamin ; it may also be because of failure of pancreatic enzymes to liberate cobalamin from binding by r protein in the duodenum or small intestinal bacterial overgrowth (sibo), not yet specifically described in cats. folate concentrations may be reduced (because of concurrent intestinal malab sorption), normal, , or increased, which may relate to reduced pancreatic bicarbonate secretion, secondary to severe hypocobalaminemia, or associated with sibo. none of these presenting complaints, physical examination findings, or routine testing results are specific to epi. therefore epi requires a degree of clinical suspicion and/or thorough diagnostics to ensure the diagnosis is not missed. a low level of serum ftli is diagnostic for epi. , , samples can be sent to the gastrointestinal laboratory at texas a&m university from anywhere worldwide (with instructions about sample handling requirements on their website: http://vetmed.tamu.edu/gilab/). the reference range for serum ftli is to µg/l, with concentrations at or less than . µg/l diagnostic for epi. since the clinical signs and routine laboratory findings are nonspecific for epi, it is ideal to test serum for ftli in any cat with weight loss or ill-thrift. the texas a & m gastrointestinal panel also includes testing for levels of cobalamin, folate, and fpli, ensuring concurrent hypocobalaminemia will not be missed and potentially providing indications of other gastrointestinal disease. conversely, although a low level of serum ftli confirms a diagnosis of epi, it is not necessarily a diagnostic end point, since epi is so often recognized concurrently with other gastrointestinal disease. failure to respond to therapy should prompt the clinician to consider and investigate further for concurrent processes. most cats with epi can be successfully managed with dietary supplementation of pancreatic enzymes. commercial products (e.g., viokase [axcan pharma, birmingham, ala.], pancrezyme [virbac, fort worth, tex.], and creon [abbott laboratories, abbott park, ill.]) are available, and powder is considered more effective than tablets or capsules (some capsules can be opened and the contents sprinkled onto food, like powder). the required dose can vary quite substantially from cat to cat. it is appropriate to start with one teaspoon of powder with food twice daily, and adjustments can be made depending on the response; most cats accept the powder readily if it is mixed thoroughly through canned food, but other flavors (e.g., fish oil or brine from canned tuna) can be used to disguise the taste if necessary. raw pancreas (e.g., from beef or pork) may also be used, with to g twice daily an appropriate starting dose. since most cats with epi are hypocobalaminemic, supplementation by subcutaneous injection is required (oral supplementation is not effective since cobalamin deficiency leads to cobalamin malabsorption). an appropriate dose for most cats is µg, and it is usually given weekly for weeks, then every second week for a further six doses; it is appropriate to continue dosing every month beyond that. owners can be taught to inject their cats at home (as owners of diabetic animals are taught to do with insulin). because some cats may have sibo, antibiotics such as metronidazole ( to mg/kg po every hours for days) may be warranted. an elevation of folate may arouse suspicion of sibo, but it is appropriate to try antibiotics in a cat failing to respond to enzyme and cobalamin supplementation. concurrent diseases, such as lymphocytic, chronic pancreatitis, or ibd may need to be managed with corticosteroids, or diabetes mellitus with insulin. no studies have assessed specific dietary requirements in cats with epi. most cats respond to appropriate treatment, with a return to normal weight and normal feces. with ongoing therapy, cats can lead normal lives for a full life span. the feline liver is a large, complex organ involved in a variety of essential metabolic, functional, and detoxification processes that can be affected, individually or collectively, by disease or dysfunction. cats have a unique set of liver diseases that occur more commonly in this species compared with the typical diseases that occur in dogs, and these include hepatic lipidosis, feline cholangitis syndrome, and infectious hepatopathies (e.g., fip, flukes, histoplasmosis, toxoplasmosis). , , , , nevertheless, these conditions often present with characteristic clinical, laboratory, and histopathologic changes that are necessary for proper diagnosis and management. the goal of this section is to review the interpretation of clinical and laboratory changes that occur in these feline liver diseases, provide an approach for separating the more common diseases by their clinical footprint, and then discuss therapy of each liver disease based on our current level of understanding of hepatoprotectants, antioxidants, and drugs used for specific therapeutic purposes. the clinical signs of liver disease in cats are often vague and nonspecific; however, recognition of certain clinical and laboratory abnormalities and their association with liver disease can greatly aid the diagnostic process. the most common early clinical signs observed in cats with liver disease are anorexia, lethargy, and weight loss, which are signs present in many (if not most!) feline diseases. , because these early indicators of disease do not point specifically toward liver disease, a delay in diagnosis will occur unless the clinician carefully considers all possibilities and performs other tests to further evaluate the situation. for example, feline hepatic lipidosis is the most common form of liver disease in cats in the united states, united kingdom, japan, and western europe, occurring with a prevalence of nearly % in one study. however, the most common, and often only, clinical sign associated with onset of this condition is anorexia; the signs of serious hepatic disease (especially jaundice and vomiting) do not occur until later (days or weeks) in the course of the disease. , recognition that anorexia in a cat, even for a few days, is a risk factor for development of hepatic lipidosis is essential, and this risk is increased in obese cats. , further, the clinical signs of liver failure develop much more slowly; many cats with hepatic lipidosis present alert and responsive until much later in the course of the disease, thus delaying onset of appropriate therapy. a similar clinical situation exists for the second most common form of liver disease in cats, feline cholangitis syndrome. , , this complex of diseases in the cat can be associated with signs ranging from anorexia and lethargy to vomiting and jaundice, and these signs can vary in severity and prevalence. the key point is that except for development of jaundice, there is no constellation of clinical signs that are classic clinical indicators of liver disease in cats. , as with many feline diseases, the subtle clinical signs of anorexia, lethargy, or inactivity are often the only signs of illness and should be further investigated. there are few changes that occur in the complete blood count that are specific indicators of primary liver disease in cats. the most common finding is the presence of poikilocytes, which are red blood cells with an irregular shape, speculated to be caused by changes in membrane lipids as a result of liver dysfunction. other abnormalities may occur, such as anemia of chronic disease or neutrophilia, but these findings are nonspecific and occur with variable frequency. perhaps the most important reason for obtaining a hemogram is in icteric cats, because this test is essential to help rule out hemolysis as the cause of the hyperbilirubinemia. the serum chemistry profile can be very helpful, but there are several critical points in interpretation of these values that are important to review. the hepatic transaminases (alanine aminotransferase [alt] and aspartate aminotransferase [ast]) are leakage enzymes but do not discriminate among hepatobiliary disorders, nor do they provide an indicator of severity or disease origin. thus although increases in alt may be noted in cats with liver disease, they are also present in a variety of other systemic infectious, inflammatory, neoplastic, and and protein-losing nephropathies can also cause loss of albumin and affect cholesterol, it is essential to evaluate the cat for these problems when interpreting these results. finally, bilirubin metabolism is a critical function of the liver, but interpretation of hyperbilirubinemia requires a careful consideration of bilirubin disposition. hyperbilirubinemia develps because of one of three possible causes: ( ) excessive hemolysis of red blood cells (rbc) (also known as prehepatic icterus)-high bilirubin in the blood stream occurs because of an overload of the mononuclear/phagocyte system with heme pigments from rbc destruction, ( ) hepatic parenchymal disease or insufficiency (also known as hepatic icterus)-resulting in lack of normal bilirubin metabolism in hepatocytes and regurgitation of the pigments into the blood stream when they are not taken up into cells and excreted in bile, and ( ) disease of gall bladder, biliary tract, or pancreatic duct (also known as posthepatic icterus)resulting in obstruction of the bile ducts or loss of bile into the abdomen (duct or gall bladder rupture and bile peritonitis). the bottom line is that in any cat with hyperbilirubinemia, an assessment of the packed cell volume and rbc morphology should be completed to determine whether icterus is caused by hemolysis. once hemolysis is ruled out, then assessment of primary endocrine diseases, including hyperthyroidism, feline heartworm disease, fip, and neoplasia.* alternatively, the cholestatic membrane-associated enzymes alkaline phosphatase (alp) and gamma glutamyltransferase (ggt) are especially useful for recognizing disorders involving biliary or pancreatic ductal components. unlike the dog, these enzymes will only increase modestly in cats, even in severe disease, and there is no glucocorticosteroid or drug induction of the enzymes to influence interpretation. , thus increases in alp in the adult cat represent a release of enzyme from the hepatobiliary tree and should be considered clinically important. both alp and ggt are produced in other tissues than the liver, with the highest ggt activity present in the kidney and pancreas; however, sources other than the liver do not contribute to the activity of these enzymes in health. recent studies of the effects on these enzymes in cats with pancreatitis, cholangitis, extrahepatic bile duct obstruction (ehbdo), and hepatic lipidosis reveal some important characteristics in interpreting increases in these enzymes. first, both alp and ggt are increased in cats with pancreatitis, cholangitis, or ehbdo, because inflammation in the biliary tree also affects the pancreatic ducts (and vice versa, figure - ) , and if the fold increases in these enzymes are similar, the diagnosis is likely one of the three. conversely, in cats with hepatic lipidosis (without concurrent inflammatory disease of the biliary or pancreatic duct system), large increases in alp are observed, but ggt will remain normal or only slightly increased. thus if the increase in alp is to times, while ggt is not increased or is only increased to times, then the likely diagnosis is hepatic lipidosis. [ ] [ ] [ ] other than enzymes on the biochemistry panel, which are of limited value for assessing liver function, there are several key tests that can be used to help assess liver function cats with elevated liver enzymes. these five tests found on most routine biochemistry panels are helpful functional indicators: cholesterol, bilirubin, glucose, albumin, and urea nitrogen (bun). however, none are immune to outside influences on their interpretation, including bilirubin and cholesterol, which are the most liver specific. in cats with severe liver disease or failure, bilirubin levels tend to be quite elevated, while bun, albumin, cholesterol, and glucose concentrations tend to be significantly decreased, reflecting inability to metabolize urea (lack of arginine), inability to produce albumin or cholesterol, and abnormal metabolization of glucose. however, these changes represent severe loss of liver function and thus are not sensitive indicators of liver function because the changes occur quite late in the course of the disease. nevertheless, in cats with elevated liver enzymes and clinical signs of liver disease, these values should be carefully assessed. because gi disease of hepatic failure. in nonicteric cats with severe liver disease or in young cats suspected of having a portosystemic shunt, serum bile acids are the more reliable indicator of hepatic insufficiency. the measurement of serum bile acid concentrations, preprandially and postprandially, is the most reliable, readily available, and sensitive test of hepatic function in nonicteric cats. , that being said, although increases in bile acids are accurate indicators of hepatic insufficiency, the levels cannot be used to assess severity of disease or the type of dysfunction. further, bile acid assays are most effective when paired samples (preprandial-and postprandial) are compared, because single, fasting, or random bile acid samples can result in a falsenegative (normal) result. however, cats will often not eat in the hospital or when they are sick, and this prevents collection of a postprandial sample. however, this does not invalidate the results, because if the result of the single bile acid sample is abnormal, it does reliably indicate liver dysfunction. an alternative to using serum for testing bile acids in cats is urine bile acid analysis. healthy cats excrete a small percentage of conjugated bile acids in the urine ; however, in cats with liver disorders that cause increased serum bile acids (and especially cholestatic liver diseases) a significant increase in urine bile acid excretion occurs. when urine bile acids (uba) were collected to hours after a meal and measured (normalizing the value with urine creatinine: uba/ucr) and compared with serum bile acids in a study of cats with hepatic disease, cats with nonhepatic disease, and normal cats, the results were highly correlated. the utility of the urine bile acid test is that it does not require a paired sample (postprandial test), and it is not as affected as the serum test is by hemolysis or lipemia of the blood sample. normal cats will have an uba/ucr of less than . µmol/mg, while values greater than . are considered evidence of significant hepatic dysfunction. it is well known that the liver plays a central role in coagulation homeostasis and is the single site of synthesis of many coagulation proteins, anticoagulant proteins, and fibrinolytic factors. vitamin k is one of the most common factors found to be inactive or deficient in cats with liver dysfunction, and it is essential for normal functioning of factors ii, vii, ix, and x; protein c and s; and thrombin. insufficient or inactive vitamin k can occur for a variety of reasons, including dietary restriction (e.g., anorexia or diet deficiency), disruption of the enteric microflora that synthesize vitamin k (e.g., chronic antibiotic therapy), diseases causing fat malabsorption (e.g., ibd, exocrine pancreatic insufficiency), ingestion of vitamin k antagonists, or liver dysfunction. for example, in cats with hepatic lipidosis, approximately % will have an increased prothrombin time (pt), % will have an increased partial thromboplastin time (ptt), but % of cats will have increased pivka parenchymal disease versus disease of the biliary tree is completed by evaluating the clinical presentation, laboratory values, and imaging of the biliary tree and abdomen for possible evidence of biliary or pancreatic disease. a urinalysis is also an important part of the minimum database, and it is no different in a sick cat with suspected liver disease. in cats the presence of hyperbilirubinuria is abnormal at any urine concentration, because they do not conjugate bilirubin in their renal tubules. however, like bilirubinemia, presence of bilirubin in the urine can occur because of any of the three possible causes of hyperbilirubinemia: prehepatic, hepatic, and posthepatic; thus further evaluation is necessary once bilirubin is detected. ammonium biurate crystalluria suggests the presence of hyperammonemia, which in the cat is either because of a congenital portosystemic shunt (less common in cats than in dogs) or because of severe, end-stage liver disease resulting in portal hypertension, which is typically caused by cirrhosis or advanced polycystic liver disease. , the most common feline liver diseases are hepatic lipidosis and feline cholangitis syndrome, which are two diseases that often result in development of clinical or biochemical icterus. thus because hyperbilirubinemia is a more sensitive indicator of liver function than bile acids or other liver function tests, the need for further testing is moot. however, there will be circumstances when further assessment of liver function is indicated, and for this, serum bile acids, blood ammonia levels, and urine bile acids may be needed. there are several situations where liver function testing may be indicated, but the most common indications for additional testing would be a cat with persistently elevated liver enzymes of unknown origin, a cat that develops urethral obstruction because of urate stones (suggestive of portosystemic shunting) or a cat with possible polycystic liver disease. one of the oldest tests of liver function, because of its association with development of hepatoencephalopathy, is measurement of blood ammonia levels. however, although this test is the only practical way to diagnose hepatoencephalopathy in dogs, the test has a number of limitations, including differences in ammonia levels between arterial and venous (lower) samples and significant sample handling issues (ammonia is labile and results are affected by improper sample handling or lack of immediate measurement) that make its use difficult in practice. in cats hyperammonemia is even less common than in dogs likely because of their highfunctioning urea cycle pathways ; the assays have not been validated for feline blood in most laboratories, and as such, the test is not recommended as the sole indicator uncommon in cats, the most common causes are neoplasia (primarily of the pancreas, but cholangiocarcinomas can occur) or chronic pancreatitis, which can occur concurrently with cholangitis in cats, resulting in both intrahepatic and extrahepatic cholestasis in some cats. , the bile ducts are affected in cats with chronic pancreatitis, because the feline biliary system and pancreatic duct system merge at the level of the pancreas to form a single duct that empties into the duodenum. thus in cats with either pancreatitis or biliary disease, recent evidence has shown that the inflammation affects both organs. , further, in chronic pancreatitis, either persistent inflammation or development of fibrosis can result in dilation or obstruction of the common bile duct. in cats with chronic ehbdo, the common bile duct will become widely dilated and tortuous, a finding easily seen on abdominal ultrasonography but a problem not easily managed (figures - and - ) . interestingly, the gallbladder is often not enlarged, and may in fact be small in cats with this condition, because the remaining fluid in the gallbladder is white bile (highly concentrated mucinous bile from which the pigment has been resorbed). in addition, variable filling of the gall bladder is a normal phenomenon; thus gallbladder size is not an indicator of ehbdo. (proteins induced by vitamin k antagonists or absence). nevertheless, although pivka is a very sensitive test for abnormalities of vitamin k function, most cats with liver disease that have a normal pt/ptt, but abnormal pivka do not represent clinical evidence of bleeding. in any case, abnormalities in the clotting cascade related to vitamin k deficiency in cats with liver disease are common, whether or not they show evidence of active bleeding. and because the balance of the coagulation system in a cat with liver disease can be disrupted by a procedure that initiates small amounts of bleeding (e.g., a biopsy), all cats with liver disease should be given vitamin k as a precautionary measure before and after invasive procedures, even if the clotting times (pt and ptt) are normal. this may be especially important in cats with hepatic lipidosis, because their vitamin k clotting status is likely to be even more affected by the concurrent anorexia and disruption of enteric microflora. the dose of vitamin k (phytonadione, aquame-phyton [merck, west point, pa.]) used prophylactically is . mg sc, im, or po q h for to days, then weekly until recovered. see box - for a summary of the causes of icterus. cholestasis is the reduction of bile flow, which can occur at any point along the biliary tree; bile production occurs in hepatocytes, and flow is connected to the distal concentrating components (gallbladder and common bile duct) by the bile ductules. thus cholestasis can occur inside the liver's biliary tree (intrahepatic cholestasis) or outside the liver in the gallbladder and common bile duct (extrahepatic cholestasis). intrahepatic cholestasis most often occurs in diseases involving hepatocellular damage, leakage, or swelling, such as infections (e.g., bacterial cholangiohepatitis, toxoplasmosis, fip, or other diseases causing inflammation), infiltrative diseases (e.g., lymphoma), metabolic diseases (e.g., hepatic lipidosis), or diseases causing disruption of architecture (e.g., cirrhosis or severe polycystic disease). intrahepatic cholestasis occurs in zone of the liver lobules (periportal zone); at the level of hepatocytes, canaliculi or bile ductules; and is damaging to cells because of the emulsifying properties of lipid on membrane lipids. however, because the liver has a large reserve capacity, clinical icterus (e.g., jaundice) only occurs in the most severe cases when the liver is affected diffusely. thus severe or persistent intrahepatic cholestasis can serve to perpetuate the inflammation and cell damage if it is not corrected. extrahepatic cholestasis or extrahepatic bile duct obstruction (ehbdo) is less common than intrahepatic cholestasis and is most commonly associated with obstruction of the common bile duct. since gallstones are icterus is the result of cholestasis, and the underlying cause can be either hemolysis or hepatobiliary disease, for which further clinical examination will be needed to determine if rbc destruction or liver disease is occurring. in most hepatobiliary diseases of cats, cholestasis is occurring, but there may be no clinically apparent icterus because the degree of hyperbilirubinemia must be at least to times greater than the normal values to exceed the capacity of the liver to process the excess bilirubin. in cats with hyperbilirubinemia not caused by hemolysis, whether it is clinical or subclinical, there is no need for further evaluation of liver function (e.g., bile acid assays), because bilirubin is a more sensitive indicator of liver function than bile acids. the degree of hyperbilirubinemia does not suggest differentiation of intrahepatic versus extrahepatic cholestasis; however, the presence of acholic feces (white feces) is diagnostic for extrahepatic bile duct obstruction (ehbdo), because lack of stercobilinogen (the brown/black pigment in feces) is only found in cats with complete obstruction of the bile duct. finally, the presence of intrahepatic cholestasis and clinical icterus in a cat indicates a diffuse hepatobiliary disease, such as cholangitis or hepatic lipidosis, as focal liver disease, even if severe, will not cause clinical hyperbilirubinemia because of the tremendous reserve capacity of the liver for bilirubin uptake. portal hypertension is an abnormally high venous pressure in the portal system and is typically caused by increased resistance to portal blood flow. there are potentially three regional causes of portal hypertension: prehepatic (disease in the portal vein itself), hepatic (intrahepatic diseases causing compression or decreased flow), and posthepatic (diseases of the caudal vena cava, right heart or pulmonary vasculature). the most common cause of portal hypertension in the cat is cirrhosis or portal venous thrombosis, because portal vein hypoplasia (formerly known as microvascular dysplasia) is known to occur only in the dog, and the other causes of portal hypertension (budd-chiari syndrome, heartworm caval syndrome, pulmonary hypertension) are rare and more likely to occur in the dog. , in any case, the clinically recognizable effects of portal hypertension are development of ascites (unusual in the cat), acquired portosystemic shunting (reported in cats), and development of hepatic encephalopathy (less common in cats than in dogs, because of their profound ability to handle protein wastes). , , most cats and dogs that develop hepatic encephalopathy (he) secondarily to portal hypertension do so because of reduced liver function (because of portosystemic vascular shunting [pss] or cirrhosis and the acquired shunting that develops). cats can develop another form of chronic he because of hepatic lipidosis, but this is believed to be because of the combination of liver failure and prolonged fasting, resulting in arginine deficiency and impaired ammonia detoxification. portosystemic vascular anomalies, also called portosystemic shunts or portovenous shunts (pss), although less common than in dogs, also occur in cats. these vascular anomalies can be either congenital or acquired, single or multiple in number, and occur as extrahepatic vascular shunts or within the liver itself (intrahepatic shunts). the shunting of blood around the liver is the cause of hepatic atrophy and reduced hepatic function that results in an accumulation of toxins, particularly ammonia that leads to the development of hepatoencephalopathy. the two most common veins that serve as the connection point for the shunting portal venous blood are the caudal vena cava and the azygous. in cats a single, extrahepatic, portocaval shunt is the most commonly reported form, and occurs in % of cats with pss. as in dogs, specific breeds of cats may have pss more commonly, and these include domestic shorthair cats, burmese, siamese, persian, and himalayan breeds. in contrast to dogs, males may be more predisposed to pss than females, but the clinical signs relate to the three body systems most affected: the central nervous system, gi tract, and urinary tract. the most common presenting complaints in cats are weight loss or poor/stunted growth, and dull, bizarre or lethargic behavior, especially after eating. signs of gi disease common in dogs, such as vomiting, diarrhea, or inappetence, are less common in cats, but in one report, % of cats with pss drooled. finally, cats with pss often present with signs of lower urinary tract disease (e.g., hematuria, stranguria, or even obstruction) because of the development of urate uroliths (which are radiolucent, thus difficult to detect). because the most common signs of he are apathy, listlessness, and decreased mental alertness, they are often not recognized specifically as indicative of brain dysfunction but as part of the constellation of signs of the liver disease. however, with progression of the has not been reported. the clinical presentation is typically nonspecific (the most common signs are vomiting, lethargy, and anorexia), and there are no laboratory changes that are suggestive of hepatic neoplasia. thus the diagnosis must be made by identification of disease, other signs will develop, including ataxia, salivation, stupor, or coma. the best and only practical diagnostic test for he is plasma measurement of ammonia levels. however, as previously noted, the test has many technical issues that make its clinical utility in the practice setting difficult at best, and there are few laboratories that have validated ammonia measurement in the cat. cancer of the liver can occur as a primary disease (table - ) or as a result of metastasis of neoplastic disease occurring elsewhere and, most typically, the abdominal cavity. the most common neoplastic infiltration of the liver that is not a primary liver tumor is lymphoma (figures - and - ), followed by visceral mastocytosis. as with many other types of cancer, hepatobiliary neoplasia is most common in middle-aged to older cats, and it is relatively rare, with a reported incidence of . % to . %. benign tumors, such as biliary cystadenoma ( figure - ) , carry a good prognosis if they are amenable to surgical resection. the incidence of metastatic neoplasia (including lymphoma and mast cell tumors) the most common clinical signs are related to spontaneous rupture of the enlarged and friable liver. affected cats may present with lethargy, anorexia, pale mucous membranes, and a heart murmur secondary to anemia. clinical signs of liver disease are usually absent. hepatomegaly and hypotension may also be found. results of routine laboratory testing (mild to marked increases in alt and globulins while alp and ggt are typically normal) and ultrasonographic examination (hepatomegaly, generalized increase in hepatic parenchymal echogenicity) a of the liver may be supportive, but definitive diagnosis relies on histopathologic examination of a liver biopsy. fna of the liver is not helpful because amyloid is rarely detected with this method. hemostasis should be evaluated carefully before any biopsy procedure is planned. the most important differential diagnoses are fip, hepatic lipidosis, and hepatic lymphoma. scintigraphic imaging using i- serum amyloid p component has potential as a noninvasive test. a there is no specific treatment for amyloidosis in cats, so therapy is primarily supportive care (antioxidants, vitamin k, blood transfusion). attention should be paid to identification and control of any underlying chronic inflammatory disease. unfortunately, the long-term prognosis is poor as most affected cats die of intra-abdominal bleeding. survey abdominal radiography is the simplest and most readily available imaging modality to assess structures in the abdominal cavity. radiographs are most useful to assess liver size, will reveal large hepatic masses, and provide evidence of radiopaque masses or other abnormalities in the abdomen. however, the preferred imaging modality used to assess hepatic structures in cats with suspected liver disease is abdominal ultrasonography (aus). the reasons why ultrasonography is a more useful tool for assessment of the liver in cats are numerous, but because feline liver diseases are primarily diffuse, infiltrative, or metabolic diseases that also affect the biliary tree, ultrasonography is the only imaging tool that will give reliable diagnostic information. this widely available diagnostic tool can be helpful in determining liver size and parenchymal echogenicity, in identifying mass lesions, evaluating the biliary tree and gallbladder, quantifying flow (doppler techniques), and identifying vascular anomalies. as with all diagnostic modalities, the skill and experience of the operator is vital to accurate procurement and interpretation of the images. further, it is important to remember that although ultrasonographic images are extremely useful in the clinical evaluation of a cat with possible liver disease, the images themselves do not represent a histologic diagnosis. structural abnormalities by hepatobiliary imaging and subsequent examination of the tissue either by fna or biopsy techniques. historically, amyloidosis has been recognized as primarily a renal disease, especially in abyssinian cats. more recently, cases of hepatic amyloidosis without renal involvement have been diagnosed in siamese and related breeds, as well as in nonpedigreed cats. a, a, a the majority of cases have been described in australia, the united kingdom, and europe. amyloid a is deposited in the liver, probably in response to chronic inflammation in another organ. in the siamese breed, a genetic component may contribute. a the amyloid a protein occurring in the siamese breed differs from that known in the abyssinian breed. a contraindicated in cats, because they may cause a lethal shock reaction. a similar reaction may be seen with penetration of the larger bile ducts or gallbladder with a large-bore biopsy needle, because these tissues have a significant autonomic innervation in the cat that may result in bradycardia and shock following the procedure. , , it is particularly important to recognize this as a risk in cats with ehdbo or dilated bile ducts, and this risk factor reiterates the need for ultrasound examination of the liver prior to making biopsy decisions. nonetheless, owners should be informed of these potential risks, in addition to the risk of bleeding from biopsy sites in any cat undergoing liver sampling. , biopsy techniques liver biopsies, whether they are obtained by needle, laparoscopy, or surgical means, should be taken from a location that represents the primary liver pathology, handled appropriately to ensure accurate interpretation of the sample, and the histopathologic description should be interpreted according to the guidelines set by the wsava standards for clinical and histologic diagnosis of canine and feline liver disease. , guidelines for obtaining and handling surgical biopsies of the liver are reviewed elsewhere and will not be further discussed. because needle aspirates/biopsies, tru-cuttype biopsies, and laparoscopic biopsies are commonly used to obtain liver tissue in cats, the benefits and limitations of each of these techniques will be discussed. as a general rule, the more tissue that can be obtained, the better the pathologist's interpretation of the tissue abnormalities will be. for example, most pathologists believe that at least six portal areas are necessary to make a diagnosis of inflammation liver disease in cats. this will require either a -or -gauge needle size or larger piece of tissue than is obtained with smaller needles or an aspirate. the amount of tissues required to view at least six portal areas is approximately mg, and mg will be required for culture of the tissue. if other analyses of the tissues are considered (e.g., metal analysis), approximately to mg of liver is needed. a typical laparoscopic cup biopsy forceps will provide mg of liver tissue, a -g tru-cut-type biopsy needle provides to mg, and an -g needle biopsy provides only to mg of liver tissue. thus, depending on the clinical circumstances and considered differentials, the best approach for obtaining the needed tissue must be considered prior to planning the procedure. fine-needle aspiration to obtain liver tissue for cytologic examination is commonly performed in cats with liver disease for good reason. the procedure is inexpensive, easy to do, is relatively low risk, and often requires only sedation to complete. further, samples obtained by this method can be diagnostic for hepatic lipidosis, hepatic lymphoma or other round cell tumors, and in for the most common liver diseases of cats (hepatic lipidosis, feline cholangitis syndrome, and neoplasia/ lymphoma), aus examination provides a useful means of obtaining clinical clues and tissue to support or refute the differentials. for example, in cats with hepatic lipidosis, the liver is quite enlarged and typically diffusely hyperechoic, while in cholangitis or other inflammatory diseases, the liver is more often diffusely hypochoic. however, these sonographic findings are very nonspecific and can easily lead to errors in diagnosis if the tissue is not subsequently sampled for confirmation. , thus one of the most important utilities of the aus is the ability to obtain liver tissue (either by aspiration or guided-needle biopsy) and for aspiration of the gallbladder to obtain bile for culture. , these techniques alone have made the aus an extremely important diagnostic tool in the evaluation of liver disease in cats. the diagnosis of most liver diseases requires a histopathologic sample of liver tissue, and this is particularly true in the most common feline liver diseases, which tend to be diffuse diseases affecting the entire liver. cats with one of these diffuse diseases can be sampled randomly using any one of these commonly employed techniques: ultrasound-guided fine-needle aspirates (fna), ultrasound-guided needle biopsy, laparoscopic biopsies, or biopsies obtained surgically. some types of neoplasia (particularly round cell tumors) and vacuolar hepatopathies (hepatic lipidosis) can often be diagnosed by cytology using fna techniques. however, differentiation of liver cell tumors (adenomas and carcinomas) and inflammatory diseases of the liver cannot be diagnosed without a larger sample of tissue and histopathologic examination. , further, even in cats with classic hepatic lipidosis changes, concurrent diseases such as cholangitis or lymphoma can be missed if only fna techniques are employed. thus it is essential to consider that in many liver diseases the lesions, although typically diffuse, may also have focal components; for example, inflammation may be throughout the liver, but fibrosis will be present only in focal areas. thus the results of fna or tru-cut needle biopsies should always be considered in the light of the clinical, laboratory, and ultrasonographic evidence. prior to scheduling a cat for a biopsy, the risk-tobenefit ratio of performing a liver biopsy should always be considered. this is primarily because heavy sedation or anesthesia will be essential in most cats undergoing a liver fna, and for all cats undergoing a liver biopsy (needle or otherwise). in addition to anesthesia risks, the use of automatic spring-loaded biopsy guns to obtain ultrasound-guided biopsies of liver tissue is equipment, the interested reader is referred to several recent reviews on the subject. , to maximize the histopathologic accuracy, biopsies taken at laparoscopy or surgically should be taken from both normal-appearing and abnormal areas in the liver. further, if there is a need to obtain samples from the deeper tissues, the laparoscope can be used to direct a tru-cut needle biopsy to the best location for sampling. one of the major advantages of the laparoscopic technique is that it allows the operator to observe the biopsy sites for excessive bleeding, which is unusual, but if observed can be staunched by using pressure on the site, gelatin coagulation material placement, or electrocautery. with experienced operators, the complication rate for laparoscopy is very low (less than %), and most complications were because of anesthesia, bleeding, or air embolism. finally, although not necessary to have direct visualization to obtain an aspirate of gallbladder bile, laparoscopy allows easy sampling of bile for culture, which is important in all cats with suspected inflammatory liver disease or hepatobiliary disease. once a diagnosis of liver disease is made in the cat, specific therapy for the cause (if available) should be instituted; however, for many feline liver diseases, no specific therapy is available, and thus hepatoprotective therapy is used concurrently to aid in the recovery of the liver from the insult. in this section, therapy of two of the most common diseases of the feline liver will be considered, with a special emphasis on nutritional aspects of treatment, nutraceutical therapy, and the unique needs of cats. the most common liver disease of cats is idiopathic hepatic lipidosis (figures - and - ) , a disease that results in liver failure because of a combination of factors including hepatic lipid accumulation, insulin resistance, fasting, and protein (especially arginine) deficiency. , , , thus, unlike many diseases of the liver, the primary focus of therapy and the essential component for recovery is nutritional support. as in any patient with serious liver disease, initial therapy is always aimed at correction of any fluid or electrolyte abnormalities that may exist, because these may be profound if the cat has been vomiting. in addition, normalization of electrolytes is particularly important in cats that have been anorexic for an especially long time ( to weeks), because refeeding syndrome may be triggered with the initiation of feeding, resulting in sudden drops in potassium, phosphate, and magnesium. although this phenomenon is less common and usually less profound in cats fed enterally versus areas where appropriate, definitive diagnosis of certain infectious diseases (e.g., histoplasmosis). however, even with these relatively straightforward diseases, fna of liver tissue has significant limitations, the most important of which is the failure to accurately identify the primary disease. for example, although it is easy to make a diagnosis of hepatic lipidosis using this technique, a paper recently showed four cats that were incorrectly diagnosed with hepatic lipidosis instead of lymphoma because the fna samples were obtained from areas that did not have lymphoma infiltration. in another study, reviewing the agreement between fna cytologic samples of liver and the histopathologic diagnosis, only % of the cases had overall agreement. thus although cytology of fna samples of liver tissue in cats with diffuse hepatic disease remains a useful first step, it is important for the clinician to carefully interpret the results and discuss the potential limitations of this technique with owners. there are several needle biopsy techniques available for sampling liver tissue, but not all are suitable or safe for use in cats. the menghini technique is one such approach that is not suitable for use in cats, because it is a blind procedure using a large-bore needle that cannot be used with ultrasound guidance. the second option among the needle biopsy techniques that is not recommended for cats is the biopsy gun device. tru-cut biopsy guns are operated by a triggering device that can result in the induction of a lethal vagotonic shock reaction in the cat immediately following the procedure. for most ultrasound-guided liver biopsy procedures, either the manual or, preferably, the semiautomatic tru-cut device is recommended for use in obtaining needle biopsies from cats. as a general rule, the tru-cut device will advance into the liver to a depth of cm; so, it is essential to carefully note the amount of liver tissue available during the ultrasound assessment before advancing the needle for tissue collection. properly obtained tru-cut needle biopsies are a valuable technique for obtaining a representative sample of liver tissue ; however, because of the risk for bleeding or liver fracture with any movement, it is essential that cats be anesthetized for this procedure. laparoscopy is an intermediate step between needle biopsy and surgical laparotomy for obtaining liver tissue for histopathology in cats. , this technique is becoming more widely used as more specialists are trained for this procedure that allows visualization of tissues to be biopsied without opening the entire abdomen. although this technique does require general anesthesia, the limited degree of invasiveness, the large biopsy sample size, and rapid patient recovery make laparoscopy a valuable tool for obtaining liver tissue, and it can be used to obtain biopsies from the spleen, pancreas, kidneys, lymph nodes, or to aspirate the gallbladder. for a detailed discussion of laparoscopic techniques and lipidosis. the echogenicity of the parenchyma is uniformly increased, which is more apparent when compared with other ultrasonographic images presented in this chapter. additionally, the gall bladder is distended. hepatic lipidosis in this cat was secondary to anorexia associated with primary intestinal disease. (courtesy dr. randolph baral.) liver gb figure - gross appearance of liver from a cat with hepatic lipidosis. note the pale tan and exaggerated reticular pattern. in most cases, the edges appear more rounded than is evident here. hepatic lipidosis in this cat was secondary to anorexia associated with primary intestinal disease (same cat as in figure - ) . (courtesy dr. randolph baral.) those started on intravenous nutrition, it can be a significant source of morbidity if electrolyte replacement and monitoring are not carefully attended. once the cat is hemodynamically stable, the next step in treatment planning in cats with hepatic lipidosis is re-introduction of nutrition, which must include placement of a feeding tube (box - ). however, because many of these cats are extremely ill and are not good candidates for anesthesia, placement of a nasoesophageal (ne) tube to allow initiation of enteral feeding is often the most appropriate step for the first few days. when administering food through a feeding tube, there are several important points: . the food should be room temperature (not too hot or cold). . the tube should be flushed with water following feeding, to remove any particles of food or medication that may cause the tube to clog. . if the cat is volume sensitive, it is important to carefully calculate how much water is used for flushing the tube, because a significant volume of fluid can be infused, creating a potential fluid overload. if the cat is fluid sensitive, the total amount of fluids (amount in the food, amount added to food if blenderized, and amount of flush) must be determined, and the amount of fluid used in flushes or food preparation may have to be reduced. force feeding is to be strongly discouraged in these sick cats for several reasons: • it is highly stressful and will further increase the stress response and insulin resistance phenomena that are perpetuating the hepatic lipidosis. • it can be dangerous to the cat (aspiration) or operator (scratches/biting). • it is rarely able to meet the necessary nutritional goals set for the patient. • it may induce food aversion, a phenomenon unique to cats, but creating a profound aversion to the chosen food that can be lifelong. although ne tubes are excellent choices for short-term feeding of cats unwilling to eat, there are several disadvantages to their long-term use, including the nasal irritation that occurs, the relative ease with which cats can (and will) remove them, and the need to use liquid enteral diets. thus once the cat is deemed stable enough for general anesthesia, a long-term feeding tube solution is needed, and this typically is either an esophageal (e) tube ( figure - ) or percutaneous endoscopic gastrostomy (peg) tube. , both feeding options are generally well tolerated methods for providing long-term feeding, but e tubes have the advantage of being placed without the need for any specialized equipment, and if complications occur, they are generally easily addressed, because the most common complications are infection at the tube site or premature removal of the tube by the cat. placement of a peg tube, although relatively easy to learn to place, requires having the appropriate endoscopic equipment, and if complications occur as a result of infection or tube removal, more significant morbidity can result. because there is no advantage to placement of peg tubes easiest to use, and are an acceptable choice in most situations. finally, because many cat stomachs are volume sensitive with initiation of feeding, it is very important to start conservatively with small-volume feeding on a more frequent schedule. with prolonged fasting, the stomach volume of a cat with hepatic lipidosis may be reduced dramatically, preventing normal expansion and limiting intake to as little as % of normal. thus to avoid vomiting when feeding, the starting volume may have to be as small as to ml every to hours. a good rule of thumb is to start with estimation of resting energy requirement (rer) ( to kcal/kg is a good estimate of rer), and then attempt to meet % of rer the first day. if no problems are encountered, increase the amount to % of rer the second day, and so on, but during this period, keep the frequency as high as possible (feed four to six meals per day) so that the volume remains relatively small at each meal. once full rer has been achieved with multiple meals per day, the frequency of feeding can be gradually reduced to three to four meals per day. most cats will eventually tolerate three meals per day well, and some can tolerate two meals per day, but this is quite variable and should not be attempted during the first weeks of feeding. in general, most cats with hepatic lipidosis will require tube feeding for a minimum of to weeks before they will show interest in food and begin eating again on their own. the tube should be retained until the cat has been eating on his or her own for at least week or longer and can be maintained for a longer duration if it is being used to administer medications, because cats can eat normally with the e tube in place. the other therapeutic considerations for cats diagnosed with hepatic lipidosis are directed toward dealing with the complications of the disease and reducing the oxidative stress on the liver with hepatoprotective therapy (table - ) . in cats that are vomiting, in cats versus e tubes, placement of e tubes is advocated as the best approach for most practice situations. interested readers are referred to several recent reviews on tube placement for specific details on each method and to chapter . , diet selection is the next step in treatment planning for cats with hepatic lipidosis. in contrast to the belief that animals in liver failure need lower quantities of protein to reduce the workload on the liver, cats with hepatic lipidosis actually need protein to recover. in fact, the work of biourge and coworkers showed that protein was the essential nutrient in reducing hepatic lipid accumulation, was essential to eliminate the negative nitrogen balance, and also appeared to minimize muscle catabolism. further, diets high in protein can improve insulin sensitivity and assist weight loss in recovery from obesity. , conversely, although carbohydrates are a readily available energy source, they are often associated with gastrointestinal distress (diarrhea, abdominal cramping) and hyperglycemia (secondary to the insulin resistance in place as a result of obesity and hepatic lipidosis). thus diets selected for cats with hepatic lipidosis should ideally be high in protein (> % metabolizable energy [me]) and have lower amounts of carbohydrates (< % me), with the remaining calories coming from fat. the diets that best fit this profile are the diets formulated for diabetic cats; however, kitten food, many adult cat foods, and some of the enteral recovery diets have this high protein/low carbohydrate profile. many of the intestinal diets are not higher protein and are higher in carbohydrates, and so would not be the ideal choice. the key to using any of the foods that are not designed for use in a feeding tube is to blenderize them (and if necessary, strain the food) so that the food will easily go through the -or -g feeding tube without clogging it. enteral diets designed for use in feeding tubes are the because the primary starting point of the inflammatory disease in cats is the bile ducts (cholangitis), with inflammation extending to the hepatic parenchyma (cholangiohepatitis) only with time and severity, the term cholangitis syndrome has become the preferred terminology. the disease syndrome has been further classified by the wsava liver diseases group into one of three primary types: neutrophilic or suppurative, chronic lymphoplasmacytic (figures - and - ) , and lymphocytic (non-suppurative). each of the forms appears to behave quite differently clinically as well as in their progression and outcome. in general, cats with the suppurative form of cch typically have an acute onset of illness, which often includes fever, anorexia, and vomiting, and they may become icteric quite quickly (figure - ) . , the nonsuppurative form of cch (lymphocytic form) tends to be a more chronic condition, with affected cats showing nonspecific signs of illness that may include partial anorexia and lethargy, but the signs may wax and wane or are non-progressive. , because of the feline pancreatic and bile duct anatomy, it is common for cats with cch to have pancreatitis and vice versa, and in some cases, cats will also have concurrent ibd; the constellation of the three conditions occurring together is called triaditis. this combination is increasingly recognized in cats, and recent reports suggest from % to % of cats with one syndrome have all three diseases. , , , at this time, the etiology of each of these syndromes and the pathogenesis is not well understood; however, the enteric microflora are presumed to play an important role in the suppurative form, and immune mechanisms are presumed to be the cause of the chronic inflammation found in the chronic nonsuppurative antiemetic therapy is beneficial, because it is imperative that the cat continues to receive some food, and vomiting will complicate this. metoclopramide is often used in cats because of its ready availability and low cost, but it is a very weak antiemetic in cats and thus may not be the best choice. in most cats, the novel nk- receptor antagonist maropitant has been a safe and effective choice. the most commonly used antiemetics in the author's feline practice are maropitant ( mg/kg iv, sc or through the e tube q h), ondansetron ( . mg/kg iv q - h), or dolasetron ( . mg/kg iv, sc q h). in addition to control of vomiting, all cats with hepatic lipidosis should be given vitamin k ( . mg/cat po, sc) daily for a week, then weekly until the cat has recovered, and vitamin b (cobalamin) ( µg/cat sc) weekly for weeks, then monthly until blood values are normal. other vitamins may become deficient, such as some of the b vitamins and vitamin e; however, feeding is likely to rapidly replenish these deficiencies if they exist. this is also likely true of amino acid deficiencies, but supplementation of l-carnitine ( mg/day po) may be beneficial by improving fatty acid oxidation. finally, hepatoprotectant and antioxidant therapy with s-adenosylmethionine (same) ( mg/kg po q h) has been advocated to increase glutathione and may be beneficial in cats with hepatic lipidosis. , , it is important to note that if same is given through the tube (and thus the tablets must be crushed), the dose must be increased by approximately % to allow for the loss of absorption from loss of the enteric coating. because drug metabolism is often impaired in cats with hepatic lipidosis, appetite stimulants, such as mirtazapine, cyproheptadine, and clonazepam, should not be used in cats because dosing and side effects can be unpredictable. benzodiazepine agonist drugs (e.g., diazepam) should be completely avoided in cats with possible lipidosis-induced hepatoencephalopathy, because they will exacerbate the signs and may cause fulminant liver failure. , fortunately, most cats with idiopathic hepatic lipidosis that receive immediate and aggressive therapy and feeding for their disease will recover completely. cats that develop hepatic lipidosis secondary to other serious diseases (e.g., lymphoma) have a much lower chance of complete recovery and often die of their disease or its complications. the most common inflammatory liver disease in the cat is a complex syndrome with multiple subgroups of disease previously termed cholangitis/cholan giohepatitis complex (cch) but currently recognized under the terminology feline cholangitis syndrome. this disease is quite variable in both its presentation and severity, and it may occur as a primary process or secondary to/ concurrent with other diseases (e.g., pancreatitis, ibd). ultrasonographic appearance of liver with lymphocytic/plasmacytic inflammation. note the varying echogenicity throughout the hepatic parenchyma; areas of hypoechogenicity likely reflect inflammatory cell infiltration. the gall bladder is distended; its shape is distorted by pressure from the transducer. (courtesy dr. randolph baral.) liver gb [ mg/kg po q h]), and if pancreatitis is concurrent, pain control with opioid pain relievers (e.g., buprenorphine . to . mg/kg po, sq q - h). if culture is not possible, combination therapy with enrofloxacin ( mg/kg po q h) and metronidazole ( mg/kg po q h) is reasonable. in cats with chronic lymphoplasmacytic forms of cholangitis, management must be tailored to the individual situation and often requires therapy with either immunosuppressive doses of prednisolone ( to mg/kg po q h) or chlorambucil ( mg/m po q d), along with the hepatoprotectants and cholerectics, and concurrent treatment of other diseases (pancreatitis or ibd) that may be occurring. the lymphocytic or lymphoplasmacytic forms of cholangitis may wax and wane in intensity over time, and may require long-term continuous or intermittent therapy to control the disease. there is no specific diet that is recommended for cats with inflammatory liver disease, but protein restriction should not be initiated unless the cat has clear evidence of severe hepatoencephalopathy. the diet should be selected based on other conditions (such as ibd), for which the diet may be more critical in the management. monitoring of serum chemistry values (especially glucose), clotting times, cobalamin levels, and pli/tli concentrations are recommended every few months, as well as careful monitoring of the cbc for all cats on chlorambucil. in all cats with chronic inflammatory liver disease, prior to initiation of immunosuppressive therapy, a careful assessment of the cat for other possible causes of inflammation should be completed (box - ). as in dogs, if a cat with pss can have surgical closure of the shunting vessel (ligation, placement of an ameroid constrictor, intravenous coiling), the long-term forms. however, whether or not these syndromes are related, a continuum of disease or completely different diseases remains undetermined. once a definitive diagnosis is obtained by histopathology of the liver tissue and culture of bile, treatment can be tailored to needs of the cat. cats with the more aggressive suppurative form of cholangitis often require intravenous fluid therapy, antibiotic therapy (based on results of culture whenever possible), and supportive therapy (antiemetics, vitamin k , hepatoprotectants such as same [ important antioxidant and stabilizes membrane functions • n-acetylcysteine-a precursor to glutathione and antioxidant, also improves tissues oxygen delivery • ursodeoxycholic acid (tertiary bile acid)-used to replace hepatotoxic, hydrophobic bile acids and increase bile flow • silymarin (milk thistle)-a free radical scavenger and anti-inflammatory/antifibrotic agent • vitamin e-an antioxidant and antiinflammatory vitamin* although few clinical trials of these nutraceuticals have been performed in feline liver disease, a few studies have recently appeared showing that same, ursodeoxycholic acid, silymarin, and n-acetylcysteine all are hepatoprotective, have few adverse side effects, and may be beneficial in many types of liver disease in cats. , , , , feline liver disease is a common problem that requires careful consideration of the presenting complaint, clinicopathologic findings, imaging results, and, if available, histopathologic interpretation to be able to provide an accurate diagnostic and therapeutic plan. a variety of insults can be responsible for liver dysfunction or failure, but hepatic lipidosis and feline cholangitis syndrome remain the most common reasons for cats to present prognosis for function and quality of life is generally very good. however, even if surgical correction is anticipated, and especially if surgical correction is impossible or not completely successful, medical management of he is indicated. see table - for the basic therapeutic approach to medical management of cats with he resulting from pss. because hepatocytes, by their position in the body between the gi tract and rest of the body, as well as their critical role in metabolism and detoxification, are uniquely susceptible to oxidative injury and reactive intermediates of metabolism, they must be able to protect themselves. the natural defenses of the liver include superoxide dismutase and glutathione, free-radical scavengers such as vitamin e and ascorbate, and other prosurvival signaling pathways that are controlled by hormones and growth factors. however, in injury or overwhelming infection or inflammation, the natural defenses of the liver can be overwhelmed, and then it is essential for medicines and nutraceutical therapy to be included in the treatment plan to help reduce inflammation and fibrosis, protect against oxidant injury, and enhance bile flow. the cytoprotective agents most commonly used in liver diseases to assist in these processes (table - ) are: • s-adenosylmethionine (same)-a precursor in the synthesis of glutathione and an important methyl donor to dna and proteins, is an with icterus or liver failure. therapy must be tailored to the individual, but nutritional support is critical in the management of hepatic lipidosis, and appropriate supportive therapy with hepatoprotectants may be crucial to treatment success. resorption from that space. effusion accumulation is therefore correlated to increased capillary hydrostatic pressure, widening of the oncotic pressure gradient, increased endothelial permeability, increased interstitial hydrostatic pressure, or loss of effective lymphatic drainage or a combination of these factors. , , peritonitis of any cause results in vascular dilation, increased capillary permeability, and the migration of inflammatory cells into the peritoneum in response to immunomodulatory mediators. the inflamed peritoneum becomes a freely diffusible membrane, allowing a massive outpouring of fluid and plasma proteins from the circulation. , ascites is not commonly seen in practice; one study recognized ascites in only three cats out of admissions to an american veterinary teaching hospital, but the prevalence may be greater in primary care practice. in that study, dilated cardiomyopathy (dcm) was the most common disease associated with peritoneal effusion; however, dcm was diagnosed in most of these cats before , when taurine deficiency was found to be a primary cause of this form of cardiomyopathy in cats. neoplasia was the most common cause after . feline infectious peritonitis (fip) was by far the most common cause of feline ascites diagnosed over a -year period at the feline centre at the university of bristol, comprising % of all cats with recognized ascites. cats with ascites usually present with nonspecific clinical signs, such as anorexia or lethargy. the owners may present the cat because they recognize abdominal enlargement ( figure - ), but in many cases, owners perceive this as weight gain. clinicians should be aware that sudden weight gain in a chronically underweight cat may be because of fluid accumulation (which can be intrathoracic fluid if ascites is not present), particularly if muscle mass seems reduced. ascitic cats presenting subsequent to trauma may have intraabdominal hemorrhage or urinary tract rupture. fever in a young ascitic cat will often suggest fip, and cats with fip may or may not be jaundiced. presence of jugular distention or even a jugular pulse can suggest right-sided heart failure. a palpable fluid thrill can help to distinguish ascites from other causes of abdominal enlargement, such as organomegaly, abdominal masses, bladder distention, abdominal wall weakness, obesity or, occasionally, accumulations of gas within the abdominal cavity (table - ) . recognizing a fluid thrill involves gently tapping one side of the abdominal wall with the fingers of one hand while feeling for a sensation of fluid movement the peritoneum is the serous membrane lining the abdominal cavity, as well as covering the organs of the abdomen. it comprises a single layer of squamous mesothelial cells resting on a deeper layer of loose connective tissue. the layer of peritoneum that lines the inner surface of the abdomen is called parietal peritoneum; the abdominal organs are lined by visceral peritoneum. the total surface area of the peritoneum is one to one-and-ahalf times that of the total cutaneous area of the body. , the peritoneal cavity contains a small amount of fluid (less than ml/kg body weight) that reduces friction between the abdominal organs as they slide over each other. the fluid is a pure transudate and contains solutes in the same concentration as serum (box - ). this fluid is absorbed from the abdominal cavity predominantly through lymphatic vessels lying beneath the mesothelial basement membrane on the surface of the diaphragm. lymphatic drainage occurs predominantly to the sternal lymph nodes. , ascites is the abnormal effusion and accumulation of fluid in the abdominal cavity. fluid exchange across the capillary bed is determined by starling forces, that is, the balance between hydrostatic pressure, which causes transudation of fluid out of blood vessels, and the colloid osmotic pressure, which acts to retain fluid within blood vessels. the amount of peritoneal fluid is therefore determined by the balance of these, as well as vascular permeability, with excess fluid drained by the lymphatic system. accumulation of fluid within a body cavity results when the rate of filtration of fluid into a space is greater than the rate of fluid routine laboratory findings are usually nonspecific but may provide clues to the underlying cause of ascites. for example, neutrophilia may point towards septic peritonitis but can also occur with fip; most cats with hemoperitoneum are anemic at presentation ; uroperitoneum often results in azotemia and electrolyte abnormalities; hypoglycemia may reflect sepsis with septic peritonitis, and a recent study recognized % of cases of septic peritonitis had ionized hypocalcemia ; elevated liver enzymes may be associated with inflammatory, infectious or neoplastic hepatopathies including fip; elevation of serum globulins occurs in many cats with fip but can also be associated with neoplasia or septic peritonitis; and a finding of hypoalbuminemia (which can cause a pure transudate) should prompt for an assessment of urine protein : creatinine ratio to assess if there is renal protein loss. imaging may be required to confirm the presence of fluid as well as to aid in diagnosis of the underlying cause. radiographic findings can vary greatly depending on the amount of abdominal fluid present and the underlying etiology. loss of normal detail or presence of a "ground glass" appearance to the abdominal cavity is suggestive of the presence of fluid (figures - and - ). very young, thin or dehydrated cats may also have a loss of detail that can mimic the presence of fluid. ultrasonography of the abdomen (figures - and if a large volume effusion causes discomfort because of abdominal distention, a three-way stopcock may be used so large volumes can be drained from one puncture (figure - ) . however, removal of large volumes of ascitic fluid can be detrimental, because it may prevent the subsequent reabsorption of valuable protein and/or red blood cells; the resulting reduction in intraabdominal pressure may encourage further accumulation of fluid; and rapid removal of large volumes can lead to fluid shifts causing cardiovascular collapse. fluid can be collected into ethylenediaminetetraacetic acid (edta) tubes (for total nucleated cell count, packed cell volume, total protein, and cytology), serum tubes (for biochemistry, such as albumin, bilirubin, creatinine, potassium, triglyceride, glucose, lactate, and lipase), sterile tubes for culture, and/or other tubes for effusion-specific tests such as pcr. samples should be prioritized according to the volume of fluid available and to the suspected underlying disease process. initial assessment of fluid retrieved is made on the basis of color and protein concentration, and much information can be gleaned from this simple assessment, even before cell numbers and types are assessed. although this brief, initial assessment is useful to refine the differential diagnoses, a thorough assessment based on underlying etiology and pathophysiology is required for definitive diagnosis and therefore appropriate management (table - ) . ascitic fluid, classified according to its pathophysiologic cause, can be divided into transudates, modified transudates, exudates (septic or nonseptic), or effusions (chylous or hemorrhagic). , can allow the detection of even very small volumes of fluid. it also enables evaluation of the size and structure of intraabdominal organs, such as the liver and spleen, which can help determine the underlying cause of ascites. abdominocentesis confirms the presence of abdominal fluid (in cases of low-volume effusion) and assessment of the fluid is required to diagnose the underlying cause of ascites. most cats tolerate abdominocentesis without sedation and the cat can be held in a standing position or in lateral recumbency (whichever is more comfortable for the cat and familiar to the clinician). the abdomen is clipped and aseptically prepared. a -to -gauge butterfly needle may be used with a -to -ml syringe. in cases with low-volume effusion, ultrasonography can help to guide fine needle aspiration from small pockets of abdominal fluid. diagnostic peritoneal lavage can be used if ultrasound-guided aspiration is unsuccessful. for this procedure, to ml/kg of warmed, sterile fluid is infused into the abdomen over to minutes after aseptic preparation of the site. the cat is gently rolled from side to side or allowed to stand; gentle massage of the abdomen also helps distribute the fluid. the fluid is allowed to dwell for a minimum of to minutes before aseptic preparation is repeated before paracentesis. no attempt is made to remove all the fluid. it must be remembered that, since the recovered fluid has been diluted by this procedure, cell counts and biochemical analyses will be affected. transudates are a consequence of altered fluid dynamics. protein-poor transudates (commonly referred to as pure transudates) form predominantly as a result of severe hypoalbuminemia, which causes a lowered colloid osmotic pressure. since there is no change in endothelial or mesothelial permeability, as fluid accumulates, there is no concurrent cell leakage; so, there is a decrease in the cell count through a dilutional effect. consequently, transudative effusions are typically clear and colorless. , , other pathologic causes of proteinpoor transudates include cirrhosis, lymphatic obstruction, and noncirrhotic portal hypertension (presinusoidal and sinusoidal). since hypoalbuminemia is the most common cause of transudates, serum albumin concentrations must be measured to guide further diagnostics. if the serum albumin concentration is normal (or only minimally decreased), then radiographs, abdominal ultrasonography, and/or echocardiography are indicated to assess cardiac function and for urinary bladder rupture. one review of feline ascitic cases found % of effusions were protein-poor transudates, of which % were the result of hepatic failure or primary renal disease. modified transudates can result from increased hydrostatic pressure within the postsinusoidal vessels of the liver secondary to right-sided congestive heart failure (e.g., tricuspid insufficiency) or potentially from mass lesions (such as neoplastic masses) obstructing blood flow from the hepatic vein or caudal vena cava into the right side of the heart. the increase in hydrostatic pressure within the vessels of the liver causes a protein-rich fluid to leach out of the liver into the abdominal cavity. since cell membrane permeability does not change, cells do not accumulate in the effusion. modified transudates can also result from increased vascular permeability in the early stages of an inflammatory process, in which case cellularity will be increased. modified transudates were described as the most common type of ascitic effusion identified in cats in one study, with most being resulting from neoplasia and congestive cardiac failure; however, this study partially included cases prior to , when right-sided heart failure associated with dilated cardiomyopathy (dcm) was prevalent. the recognition of the role of taurine deficiency in this condition and the subsequent addition of this amino acid to feline diets now means that right-sided heart failure is only rarely encountered as a cause of ascites in cats. exudates are a consequence of altered mesothelial and/ or endothelial permeability. this permeability results from a cytokine-mediated inflammatory response of any underlying cause (e.g., infectious, neoplastic, immune mediated). exudates have high protein and moderate to high cell concentrations and are classified as nonseptic or septic. exudates are often primarily composed of neutrophils. nondegenerate neutrophils (and the absence of organisms) points to a nonseptic exudate (mostly fip but also neoplasia). fip is the most common cause of exudative effusion in cats and was the most common cause of feline ascites diagnosed over a -year period at the feline centre at the university of bristol. the presence of neoplastic cells rules in neoplasia, but the absence of such cells does not rule out this diagnosis since many cases of neoplastic ascites are not associated with exfoliated neoplastic cells. other causes of nonseptic exudates include pancreatitis, lymphocytic cholangitis, and viscus rupture, such as the gall bladder or urinary bladder. degenerate neutrophils typify septic exudates (i.e., septic peritonitis), and their presence should instigate investigation for causes of infection (mostly leakage of gastrointestinal contents). chylous effusions appear as milky or pink opaque fluid, and small mature lymphocytes initially predominate in cell counts. after drainage, more macrophages and nondegenerate neutrophils may be found. chyle is typically classified as an exudate, but its physical characteristics can be consistent with a modified transudate (protein content between and g/l); biochemical analysis of triglyceride and cholesterol levels in the fluid are required to confirm the diagnosis. pseudochylous effusions resemble true chyle both in appearance and cytology but do not contain fat. similar conditions result in both chylous and pseudochylous effusions. chylous abdominal effusions are rarely reported in the cat and only accounted for % of cases of ascites in one study. the described causes of chylous ascites in cats are predominantly neoplastic. in a series of nine cats, chylous ascites was associated with nonresectable abdominal neoplasia in four cases (i.e., hemangiosarcoma and paraganglioma), with intestinal and mesenteric lymphoma in two cases and lymphangiosarcoma of the abdominal wall in another. one described case in a -year-old cat was thought to be because of fip. figure - shows an ultrasonographic image of a cat with chylous abdominal effusion associated with pancreatitis. other potential causes include right-sided congestive cardiac failure, steatitis (inflammation of fat), biliary cirrhosis, and lymphangiectasia. hemoperitoneum in companion animals is categorized as traumatic or spontaneous. traumatic hemoperitoneum is further divided into blunt causes of trauma (i.e., motor vehicle accidents and high-rise falls) and penetrating trauma (i.e., gunshot wounds and bite wounds). , inadvertent splenic aspiration, venipuncture, or acute severe hemorrhage should be suspected if the cytology is consistent with peripheral blood including platelets but without erythrophagocytosis or if the blood clots readily. when there is no history of trauma, coagulopathy or spontaneous rupture of a vascular neoplasm should be considered. in one study of feline cases of spontaneous hemoperitoneum, cases ( %) were associated with hepatic pathology such as neoplasia, necrosis, and amyloidosis. in another study of cases of spontaneous hemoperitoneum, % ( of ) of cats had abdominal neoplasia, and % ( of ) had non-neoplastic conditions. cats with neoplasia were significantly older and had significantly lower packed cell volumes (pcvs) than cats with non-neoplastic disease. hemangiosarcoma was the most often diagnosed neoplasm ( of , %), and the spleen was the most common location for neoplasia ( of , %). coagulopathies ( of , %) and hepatic necrosis ( of , %) were the most common causes of non-neoplastic hemoperitoneum. other nonneoplastic causes of hemoperitoneum include ruptured bladder, hepatic rupture secondary to hepatic amyloidosis, gastric/duodenal ulcer, hepatic hematoma, hepatitis, perinephric pseudocyst, feline infectious peritonitisinduced liver rupture, and feline infectious peritonitisinduced nephritis. , the prognosis of cats with spontaneous hemoperitoneum is poor. in two studies, only approximately % of cases survived to be discharged from hospital. , median survival time for cats that were discharged in one of those studies was days (range, to days). feline infectious peritonitis (fip) comprised % of cats with recognized ascites over a -year period at the feline centre at the university of bristol, and, as a rule of thumb, when ascites is recognized in a younger cat, fip should be considered the major rule-out. the abdominal effusion found with fip is typically straw to golden yellow (although the color can be very variable, for example, chyle may be present), may contain fibrin clots, and has a high protein concentration. the total protein content is greater than g/l and often greater than g/l, with globulins comprising % or more. one study described an effusion with total protein greater than g/l as % specific, % sensitive, and having a . positive predictive value to diagnose fip. the rivalta test evaluates the fluid's globulin content, and was found to be very sensitive but only % specific; this test is performed by adding one drop of acetic acid ( %) to ml of distilled water. this fluid is mixed thoroughly, and then one drop of effusion is gently placed on the surface of the mixture. if the drop stays at the top of the fluid or slowly floats to the bottom, the test is considered to be positive. this test can give inaccurate results if inappropriate technique is used or if there is a significant temperature difference between the fluid sample and the acetic acid solution. a positive rivalta test can result from lymphosarcoma, septic, or fip effusions; these can be distinguished by cytology and culture. immunofluorescence staining of coronavirus antigen in macrophages had a positive predictive value of . but a negative predictive value of . . the potential clinical presentations, diagnosis, and management of fip are covered in detail in chapter . one study found neoplasia to be the most common cause of ascites in cats, and neoplasia should be considered the major rule-out in older cats with ascites. the effusion from cats with ascites resulting from neoplasia may be a modified transudate, resulting from compression of hepatic veins or the caudal vena cava, or metastases to the peritoneum; hemorrhage from neoplasia can cause hemoperitoneum; chylous effusions may result from reduced lymphatic drainage or rupture of lymphatic vessels; and raised vascular permeability caused by neoplastic infiltration can result in an exudative effusion. carcinomas, mesotheliomas, and discrete (round) cell neoplasms (e.g., lymphoma, mast cell tumors, malignant histiocytosis) exfoliate cells into effusions more readily than sarcomas, and of these, lymphosarcoma is the most common malignancy of cats. cytology of ascitic fluid reveals neoplastic cells in less than a quarter of cases; so the absence of such cells does not rule out a diagnosis of neoplasia. in these circumstances, the diagnosis may be achieved by ultrasound-guided fine-needle aspiration of affected organs, or even biopsy samples obtained at laparotomy. the specific approaches will depend on the specific neoplasia diagnosed. exudates caused by septic inflammation usually result from bacterial contamination of the peritoneal cavity secondary to gastrointestinal tract leakage or penetrating wounds associated with trauma. gastrointestinal tract leakage may occur as a result of ulceration associated with neoplasia or inflammatory disease or as a result of penetration of a sharp object ingested (such as a toothpick), it can also occur subsequent to prior abdominal surgery. , , , primary septic peritonitis in which no apparent cause can be identified has also been described in cats. septic exudates are usually yellow to tan in color, with yellow particulate matter and are foul-smelling. microscopically, the fluid is characterized by the presence of degenerate neutrophils and bacteria. bacteria are often seen intracellularly within neutrophils. the condition is associated with high morbidity and mortality rates, with survival rates reported between % and %. , , , , the history and clinical signs are often vague and nonspecific but can include abdominal pain, vomiting, lethargy/depression, and anorexia. abdominal pain is an inconsistent finding, being recognized in only % of cats in one study and % in another. some cats may have an inappropriately low heart rate. , hematologic and serum biochemistry findings are also inconsistent; neutrophilia with a left shift may be present, as may neutropenia or a normal neutrophil count. similarly, cats may be hypoglycemic, hyperglycemic, or normoglycemic, and they may be hypoalbuminemic. , , one study recognized ionized hypocalcemia in % of cats with septic peritonitis at the time of diagnosis, and another suggested hyperlactatemia, when present, may be associated with a poorer prognosis. radiographic findings are usually typical of ascites of any cause, but presence of pneumoperitoneum in a cat that has not undergone recent surgery may suggest the presence of gas-forming bacteria or rupture of an abdominal viscus and warrants immediate surgical intervention. ultrasonography does not directly aid the diagnosis of septic peritonitis. exploratory laparotomy to determine and correct an underlying problem, such as full-thickness gastrointestinal perforation (often requiring partial resection) is required, as is copious abdominal lavage with sterile, warmed fluids ( figure - ). there are no statistically significant survival differences between postsurgical primary closure, open peritoneal drainage, or closed suction drainage postsurgical lavage; however, a trend toward a higher survival rate has been seen in cats treated with primary closure. , treatment also involves antibiotics, initially parenterally, based on culture and sensitivity findings. consistent with intestinal contents, most bacteria recognized are gram-negative aerobes, such as e. coli or enterobacter spp., but mixed infections are usually found. , anaerobes seem more common in cats with primary septic peritonitis, which perhaps suggests these cases may result from healed over-bite wounds into the abdomen. amoxicillin/ clavulanate would be an appropriate empirical choice of figure - fulminant peritonitis associated with gastrointestinal perforation. in this case, the effusion volume was low but the high degree of serosal inflammation is evident. antibiotics while awaiting sensitivity results. there are no definitive guidelines for duration of antibiotic treatment; the author uses extended treatment courses of to weeks. supportive care with intravenous fluids to maintain fluid and electrolyte balances is also required perioperatively. bile peritonitis is infrequently reported in cats but has been recognized in association with gunshot or motor vehicle trauma, with biliary obstruction from gall stones , and subsequent to percutaneous ultrasoundguided cholecystocentesis in a cat with infectious cholangitis. concurrent bacterial infection was recognized in each case; this increases severity of inflammation and worsens the prognosis, although full recovery was achieved in most reported cases. , , bile peritonitis has the potential to result in small-volume effusions; so, if abdominocentesis does not yield a sample of effusion but bile peritonitis is high on the differential list, then diagnostic peritoneal lavage is appropriate. since repair of or removal of the gall bladder and abdominal lavage are required, exploratory laparotomy is an appropriate means to diagnose this condition. management should be considered as for septic peritonitis of other causes. trauma, including blunt abdominal trauma, urethral catheterization, and bladder expression, is the most common cause of uroperitoneum in cats. it is also recognized as a complication of ureteral surgery. the bladder is the most frequent site of urine leakage after blunt abdominal trauma, whereas the urethra is most commonly injured following catheterization. cats with ruptured bladders may still have a palpable bladder and the ability to urinate. common historical complaints are anuria ( . %) and vomiting ( %). azotemia is a common finding, and hyperkalemia is seen in around % of cases. drainage of urine from the peritoneal cavity seems to improve patient stabilization. morbidity and mortality depended largely on the severity of associated injuries. regardless of the site of injury or the cause of uroabdomen, the first goal of treatment is patient stabilization. isotonic replacement fluids are used for initial resuscitation. treatment of hypovolemic shock, if present, is the first order of fluid therapy. after fluid resuscitation, drainage of urine from the abdomen should be established. continuous passive drainage of the urine is necessary for stabilization and allows effective diuresis to occur. indwelling catheterization of the urinary bladder is recommended to keep the bladder decompressed and reduce urine flow into the abdominal cavity in patients with bladder and proximal urethral injury. if the urethra is traumatized and a catheter cannot be placed, prepubic tube cystostomy may be necessary to achieve temporary urinary diversion. the decision to treat the uroabdomen patient surgically or conservatively should be based on the location and severity of the underlying injury, the condition of the patient at presentation, and the patient's response to initial stabilization. , congestive heart failure has become an uncommon cause of ascites in cats since the late s/early s, from which time dilated cardiomyopathy has been largely eradicated. , ascites does still result from rightsided congestive heart failure in conditions such as tricuspid insufficiency, arrhythmogenic right ventricular cardiomyopathy, myocardial fibrofatty infiltration, or restrictive cardiomyopathy. , concurrent pleural effusion or pulmonary edema is often, but not necessarily, present with cardiac induced ascites. a heart murmur is not necessarily noted. noting a jugular pulse or thrill is helpful diagnostically, if present. the ascitic fluid is typically a modified transudate, but a chylous effusion is also possible. cardiac diseases are covered in chapter . in some cases, hepatic lipidosis has been reported to cause ascites, particularly in association with pancreatitis. these cats are often hypoalbuminemic, with the possibility of intravenous fluid therapy contributing to the ascites by raising hydrostatic pressure. other liver diseases which can result in ascites include lymphocytic cholangitis, , neutrophilic cholangitis, cirrhosis, necrosis, neoplasia, and suppurative cholangiohepatitis. portosystemic shunts in cats rarely result in ascites, compared with dogs. hypoalbuminemia and hepatic failure result in transudates; portal hypertension and cirrhosis cause higher protein ascites because of raised capillary hydrostatic pressure causing leakage of high protein 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body cavity fluids a retrospective study of surgically treated cases of septic peritonitis in the cat chronic lymphocytic cholangitis in three cats primary bacterial septic peritonitis in cats: cases pneumoperitoneum in dogs and cats: cases chylous abdominal effusion in a cat with feline infectious peritonitis restrictive cardiomyopathy in a cat with hypereosinophilic syndrome kirk's current veterinary therapy xii: small animal practice feline infectious peritonitis: a review of clinicopathological changes in cases, and a critical assessment of their diagnostic value differential diagnosis of ascites in cats abdominal paracentesis and diagnostic peritoneal lavage peritoneal effusion in cats: cases ( - ) *when present for any length of time, a pure transudate will become modified. this is particularly true of transudates that develop slowly, such as those associated with congestive heart failure or portal hypertension. modified transudates are therefore more common than pure transudates. adapted from tasker s, gunn-moore d: differential diagnosis of ascites in cats, in practice : , . key: cord- - qlndtuo authors: kim, hwan soo; sol, in suk; li, donghe; choi, miyoung; choi, yun jung; lee, kyung suk; seo, ju hee; lee, yong ju; yang, hyeon-jong; kim, hyun hee title: efficacy of glucocorticoids for the treatment of macrolide refractory mycoplasma pneumonia in children: meta-analysis of randomized controlled trials date: - - journal: bmc pulm med doi: . /s - - - sha: doc_id: cord_uid: qlndtuo background: mycoplasma pneumoniae is one of the most common pathogens causing community acquired pneumonia in children. although the rate of macrolide-refractory mycoplasma pneumoniae (mrmp) has increased, systemic glucocorticoids as a treatment option has not been validated yet. the purpose of this study was to assess the efficacy of glucocorticoids add-on in the treatment of mrmp in children through systematic review and meta-analysis. methods: data sources a systematic literature search was conducted using ten electronic bibliographic databases including english, korean, chinese and japanese languages, up to march , . study selection the study was conducted according to preferred reporting items for systematic reviews and meta-analyses checklist and selected randomized control trials which compared the efficacy of glucocorticoids add-on to macrolide in the treatment of mrmp in children. data extraction two independent reviewers extracted: primary outcomes as hospital days, fever duration, and change in c-reactive protein (crp) and main analysis was performed through meta-analysis with random effects model. results: twenty-four unique randomized controlled trials met the inclusion criteria. the mean length of hospital stay in glucocorticoids treatment group was significantly shorter than that in conventional macrolide-treatment group (weighted mean difference (wmd) = − . days). the mean length of fever duration was significantly shorter in the glucocorticoid treatment group in comparison with the conventional treatment group (wmd = - . days). level of crp after treatment was significantly lower in the glucocorticoid treatment group than that in the conventional treatment group (wmd = - . ). sensitivity analysis and subgroup analysis showed no significant improvement in heterogeneity. as limitations of the study, most of the studies included were from a single country and we were unable to control for heterogeneity across interventions, lack of standardized measures, and different time points of assessments across studies. conclusions: glucocorticoid add-on treatment for mrmp can significantly shorten the duration of fever and hospital stay and decrease the level of crp. these results should be confirmed by adequately powered studies in the future. mycoplasma pneumoniae (m. pneumoniae) is one of the major pathogens causing community acquired pneumonia and bronchitis in children. treatment of m. pneumoniaerelated respiratory infection is based on symptomatic treatment with antibiotics. macrolides have been used as first line treatment. however, macrolide-refractory m. pneumoniae (mrmp) strains are increasing abruptly, particularly in east asian countries including korea, japan, and china [ ] [ ] [ ] . most patients with mrmp do not show improvement of fever when they are treated with macrolides. some may develop refractory or severe clinical course that requires additional treatment. treatment for mrmp includes tetracyclines, fluoroquinolones, and systemic glucocorticoids [ ] . secondary antibiotics such as tetracyclines and fluoroquinolones are considered as effective alternatives in the treatment of mrmp. however, they are of limited use due to safety-concerns of teeth discoloration and musculoskeletal toxicity, particularly in children. glucocorticoids can be also considered as alternative treatment options due to two reason. first, the pathogenesis of m. pneumoniae infection is associated with amplified host immune response and virulence of m. pneumoniae [ ] . second, adverse effects of glucocorticoids have been well established. further risk is not likely to be added in the treatment of mrmp. however, previous studies on the effect of glucocorticoids have shown conflicting results [ ] [ ] [ ] . the objective of this study was to assess the efficacy of glucocorticoids for treatment of mrmp in children through systematic review and meta-analysis. systematic review and meta-analysis protocols (prisma-p) were used for this systematic review and metaanalysis [ ] . the population-intervention-comparison-outcome (pico) question used for our search strategy was: "does use of glucocorticoids help improve the outcome of mrmp in children?" we performed a systematic search utilizing a protocol designed by two independent medical librarians (d.w.s. and m.l) specifically for this study with electronic databases: pubmed, embase, cochrane library, and core journal (korean, japanese, and chinese journal) full-text database. the search encompassed articles published from january, to march , . we used search terms listed in additional file to search pubmed, cochrane, embase, and database of core countries. we imposed no language or publication restrictions. the first screening was executed by two independent reviewers (h.s.k. and i.s.s.) who evaluated the titles and abstracts obtained from the search. records were managed using endnote (version x ; clarivate analytics, philadelphia, pa, usa). from this initial screening, articles that did not focus on glucocorticoid use in mrmp and review articles were immediately excluded. after initial exclusion process, full texts of the remaining articles were reviewed independently by two authors (h.s.k. and i.s.s.) to determine whether any articles met the predetermined eligibility criteria described in the next section. disagreements between the two reviewers regarding the inclusion or exclusion of particular studies were settled by consultation with a third reviewer (y.j.l.). the following inclusion criteria were applied: ( ) randomized control trial (rct) which compare the efficacy of glucocorticoids add-on to macrolide alone in children with mrmp, ( ) mrmp which was diagnosed with serology or polymerase chain reaction, and that refractories were defined clinically, ( ) only included children < years of age, and ( ) outcome measures with hospital days, fever duration, and level of c-reactive protein (crp) change. review articles, published abstracts without full-text publications, and case-study reports with participants or less were excluded. our search strategy included non-english articles in our initial search results. non-english articles were then translated and included for evaluation. two reviewers (h.s.k. and i.s.s.) independently screened titles and abstracts of the studies identified in our systematic search. studies focusing on mrmp were included after review of abstracts. full texts from included studies were reviewed to evaluate for eligibility. reference lists of selected studies and previous reviews were also examined to determine any relevant publications overlooked by the electronic search. disagreements between the two reviewers in the selection of particular studies were settled after discussion with a third reviewer (y.j.l.). cochrane collaboration risk of bias tool was used by the two reviewers (h.s.k. and i.s.s.) who independently evaluated the risk of bias in included studies [ ] . risk of bias was determined as hi, low or unclear by evaluating random sequence generation, blinding of participants and personnel, incomplete outcome data, and selective reporting. disagreements between the two reviewers regarding the risk of bias assessment of particular studies were settled after discussion with a third reviewer (y.j.l.). two reviewers (h.s.k. and i.s.s.) used a structured form to extract data from each eligible study. data extracted from each study could be characterized as characteristics of the sample, intervention details, and measurement of outcomes. disagreements between the two reviewers regarding the data extraction of particular studies were settled by consultation with a third reviewer (y.j.l.). primary outcomes of the current study were hospital days, fever duration, and change in crp. the estimated mean effect of glucocorticoid add-on treatment on hospital days, fever duration, and change in c-reactive protein (crp) and the associated % confidence intervals (cis) were extracted or calculated for the studies included in the meta-analysis with review manager . (the cochrane collaboration, london, united kingdom). random-effects model was used for studies included in the analysis. heterogeneity was calculated using i statistic. the i statistic threshold should always be interpreted with care. a rough estimate of % denotes low heterogeneity while % denotes moderate heterogeneity, and % denotes high heterogeneity [ ] . we conducted sensitivity analyses when heterogeneity was noted. this was performed by removing a study from the analysis to determine changes in i values and assess which studies play a significant role resulting in heterogeneity [ ] . to assess the risk of publication bias, we used funnel plots for visual inspection, and egger test and trim-and-fill method were performed for statistical identifying. all statistical a total of citations were identified initially. of these, studies were discarded after reviewing titles and abstracts, leaving articles for full text review (fig. ) . a total of studies were excluded after full text review due to no proper subject, inadequate study protocol, review article, or no relevant outcome. a total of studies were included in our systematic review and meta-analysis . all studies were rcts. (additional file for search strategies for database, additional file for prisma checklist). participants of studies enrolled in our meta-analysis was a total of patients. all these studies examined fever duration. fifteen studies examined hospital days while studies examined crp level after treatment (table ) . the mean length of total duration of fever was significantly shorter in the glucocorticoid add-on group than that in the conventional treatment group (weighted mean difference, wmd = − . , %ci: − . -- . , z = . , p < . ). however, there was a high between-study heterogeneity of this effect (i = %; fig. ). the mean length of hospital stays in the glucocorticoid add-on treatment group was significantly shorter than that in the conventional treatment group (wmd = − . , % ci: − . -- . , z = . , p < . ). however, there was a high between-study heterogeneity of this effect (i = %; fig. ) . the level of crp after treatment was significantly lower in the glucocorticoid add-on treatment group than that in the conventional treatment group (wmd = − . , %ci: − . -- . , z = . , p < . ). however, there was a high between-study heterogeneity of this effect (i = %; fig. ). sensitivity analyses was performed because of high level of heterogeneity. we removed a study from the analysis to determine which studies contributed most significantly to the heterogeneity by determining the changes in i values. we found that i values of fever duration, hospital days, and crp level did not change. use of glucocorticoids included the use of any type of glucocorticoids (e.g., methylprednisolone, dexamethasone, and fig. comparison of fever duration between glucocorticoid therapy and macrolide therapy prednisolone). the use of different types of glucocorticoids was different across studies. this might have contributed to the heterogeneity in the overall use of glucocorticoids. thus, we stratified the meta-analysis by subgroup analyses. in subgroup meta-analysis for use of methylprednisolone compared with the use of other glucocorticoids for the length of hospital stay, the use of other steroids did not show any significant subgroup differences (figs. , and ) . all funnel plots were symmetric, indicating an absence of significant publication bias within these studies except for crp outcome. egger test results were − . (p = . ) for fever duration, . (p = . ) for hospital days, and − . (p = . ) for crp. trim-and-fill method for adjusting publication bias on crp outcome was performed. the mean difference changed from - . (p = . ) to − . (p < . ). these results indicated that there was substantial evidence of publication bias in crp outcome (fig. ). this systematic review and meta-analysis identified and assessed rcts on the use of glucocorticoids in children with mrmp. we specifically investigated effects of glucocorticoids on fever duration, length of hospital stay, and crp level after treatment in comparison with conventional macrolide therapy. results revealed positive effects of glucocorticoid treatment on all outcome measures. m. pneumoniae is a common pathogen causing community acquired pneumonia. the clinical course of m. pneumoniae infection is diverse, ranging from selflimiting to severe pneumonia with extra-pulmonary complications [ ] . macrolide is considered the first-line treatment for m. pneumoniae infection [ ] . in adults, one study reported that prednisone treatment for days in patients with community-acquired pneumonia admitted to hospital can shorten time to clinical stability without increase in complications [ ] . however, another study reported that glucocorticoid use did not show any benefits in children [ ] . pulmonary injury associated with severe mycoplasma pneumonia could be caused by host immune response rather than by direct microbial damage [ , ] . overly active cell-mediated immunity and cytokine responses play a significant role in mrmp [ ] . severe m. pneumoniae infections and mrmp show similar laboratory findings with severe acute respiratory syndrome such as increased levels of non-specific markers of inflammation such as serum crp, lactate dehydrogenase, and d-dimer [ ] . since mrmp can be considered as an immune-mediated disease, use of immune modulatory therapy could seem rational. for cases with mrmp infection, secondary treatment options are limited due to adverse effects of tetracycline or fluoroquinolones, especially in children [ ] . the use of systemic steroids, in addition to antimicrobial therapy, to diminish host immune response in mrmp has been used in children and demonstrated satisfactory effects [ , , ] . glucocorticoids have shown to improve clinical features and reduce lung injury in children and adults [ , , ] . the use of glucocorticoids in m. pneumoniae infection showed reduced lung histopathologic score by reducing cytokines and decreasing inflammatory response ultimately leading to lower mortality [ , , ] . therefore, glucocorticoids have been considered suitable as adjunctive therapy to macrolide therapy. although previous studies have reported the efficacy of glucocorticoids in the treatment of severe mrmp, treatment protocols varied from oral prednisolone of mg/kg/day to intravenous methylprednisolone mg/kg/day for days [ , ] . these variable treatment protocols are due to the lack of guidelines for glucocorticoids treatment in severe mrmp to date [ , ] . in our study, the mean length of total duration of fever, mean length of hospital stay, and level of crp after treatment in the glucocorticoid treatment group were significantly shorter or lower than that those in the conventional treatment group. however, heterogeneity in all outcome measures was high and sensitivity analysis resulted in no significant difference. subgroup analysis showed no significant decrease in heterogeneity. in spite of high level of heterogeneity, all studies reported favorable outcomes of hospital stays and fever duration after the use of glucocorticoids in mrmp. for crp level, only one study reported unfavorable result after the use of glucocorticoids in mrmp. therefore, we could consider that the use of glucocorticoids has significantly favorable effects on outcomes of mrmp. the strength of this review is that it summarized the current evidence on the efficacy of glucocorticoids from rct. conducting rcts offers the potential to produce the most definitive evidence to confirm or refute whether glucocorticoids can help improve outcomes of mrmp. this review has some limitations. firstly, almost all studies included in this review had at least one methodological flaw. secondly, publication bias was significant for change in crp level. it might be due to small sample sizes in most studies and the fact that most studies were conducted in a single country. as a result, the robustness of these outcomes should be explored with future studies. thirdly, most of the studies included were from a single country. lastly, we could not evaluate other outcomes such as improvement in chest x-ray infiltration or other symptoms such as cough because these data were not available in each study. despite these limitations, with our review and metaanalysis, this is the first study to date to synthesize the efficacy of glucocorticoids in mrmp. in conclusion, even though some studies have reported the efficacy and effectiveness of systemic glucocorticoids in the treatment of mrmp , this is the first systematic review and meta-analysis to investigate the effectiveness of glucocorticoids in mrmp. we found that the use of glucocorticoids could shorten hospital days, shorten fever duration, and lower crp levels after treatment. however, these results should be interpreted cautiously, and future studies should also assess other outcomes to clarify the effect of glucocorticoids in mrmp. supplementary information accompanies this paper at https://doi.org/ . /s - - - . prevalence and clinical manifestations of macrolide resistant mycoplasma pneumoniae pneumonia in korean children infection with and carriage of mycoplasma pneumoniae in children epidemiology of mycoplasma pneumoniae infections in japan and therapeutic strategies for macrolide-resistant m pneumoniae mechanism of resistance acquisition and treatment of macrolide-resistant mycoplasma pneumoniae pneumonia in children mycoplasma pneumoniae pneumonia in children dexamethasone and length of hospital stay in patients with community-acquired pneumonia: a randomised, double-blind, placebo-controlled trial effects of methylprednisolone pulse therapy on 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the clinical manifestations of severe acute respiratory syndrome and mycoplasma pneumoniae pneumonia macrolide-resistant mycoplasma pneumoniae: its role in respiratory infection methylprednisolone pulse therapy for refractory mycoplasma pneumoniae pneumonia in children the impact of steroids given with macrolide therapy on experimental mycoplasma pneumoniae respiratory infection effects of prednisolone on refractory mycoplasma pneumoniae pneumonia in children publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations we thank misoon lim and dong won shin for providing assistance and support for the systematic search. key: cord- -p ukyhx authors: mikulska, malgorzata; nicolini, laura ambra; signori, alessio; di biagio, antonio; sepulcri, chiara; russo, chiara; dettori, silvia; berruti, marco; sormani, maria pia; giacobbe, daniele roberto; vena, antonio; de maria, andrea; dentone, chiara; taramasso, lucia; mirabella, michele; magnasco, laura; mora, sara; delfino, emanuele; toscanini, federica; balletto, elisa; alessandrini, anna ida; baldi, federico; briano, federica; camera, marco; dodi, ferdinando; ferrazin, antonio; labate, laura; mazzarello, giovanni; pincino, rachele; portunato, federica; tutino, stefania; barisione, emanuela; bruzzone, bianca; orsi, andrea; schenone, eva; rosseti, nirmala; sasso, elisabetta; da rin, giorgio; pelosi, paolo; beltramini, sabrina; giacomini, mauro; icardi, giancarlo; gratarola, angelo; bassetti, matteo title: tocilizumab and steroid treatment in patients with covid- pneumonia date: - - journal: plos one doi: . /journal.pone. sha: doc_id: cord_uid: p ukyhx introduction: coronavirus disease (covid- ) can lead to respiratory failure due to severe immune response. treatment targeting this immune response might be beneficial but there is limited evidence on its efficacy. the aim of this study was to determine if early treatment of patients with covid- pneumonia with tocilizumab and/or steroids was associated with better outcome. methods: this observational single-center study included patients with covid- pneumonia who were not intubated and received either standard of care (soc, controls) or soc plus early (within days from hospital admission) anti-inflammatory treatment. soc consisted of hydroxychloroquine mg bid plus, in those admitted before march (th), also darunavir/ritonavir. anti-inflammatory treatment consisted of either tocilizumab ( mg/kg intravenously or mg subcutaneously) or methylprednisolone mg/kg for days or both. failure was defined as intubation or death, and the endpoints were failure-free survival (primary endpoint) and overall survival (secondary) at day . difference between the groups was estimated as hazard ratio by a propensity score weighted cox regression analysis (hr(ow)). results: overall, adults were included in the analyses. they were mainly male ( . %), with comorbidities ( . %) and severe covid- pneumonia ( . %). median age was . years (range, – ) and median pao( )/fio( ) mmhg (iqr – ). among them, received early anti-inflammatory treatment with: tocilizumab (n = , . %), methylprednisolone (n = , . %), or both (n = , . %). the adjusted failure-free survival among tocilizumab/methylprednisolone/soc treated patients vs. soc was . % ( %ci, . – . ) vs. . % ( %ci, . – . ), hr(ow) . , %ci, . – . ; p = . . the overall survival among tocilizumab/methylprednisolone/soc patients vs. soc was . % ( %ci, . – . ) vs. . % ( %ci, – ), hr(ow) . , %ci: . – . , p = . . conclusion: early adjunctive treatment with tocilizumab, methylprednisolone or both may improve outcomes in non-intubated patients with covid- pneumonia. coronavirus disease can lead to respiratory failure due to severe immune response. treatment targeting this immune response might be beneficial but there is limited evidence on its efficacy. the aim of this study was to determine if early treatment of patients with covid- pneumonia with tocilizumab and/or steroids was associated with better outcome. this observational single-center study included patients with covid- pneumonia who were not intubated and received either standard of care (soc, controls) or soc plus early (within days from hospital admission) anti-inflammatory treatment. soc consisted of hydroxychloroquine mg bid plus, in those admitted before march th , also darunavir/ ritonavir. anti-inflammatory treatment consisted of either tocilizumab ( mg/kg intravenously or mg subcutaneously) or methylprednisolone mg/kg for days or both. failure was defined as intubation or death, and the endpoints were failure-free survival (primary a a a a a pandemic coronavirus disease (covid- ) caused by sars-cov- coronavirus has recently emerged [ ] . although most of the infected patients will remain asymptomatic or develop mild symptoms, up to % may develop severe disease with pneumonia and respiratory failure [ ] . oxygen administration is the cornerstone of supportive treatment and is required in approximately % of cases, while invasive mechanical ventilation is necessary in up to - % of severe cases [ ] [ ] [ ] . since mortality in patients with invasive ventilation can be very high, halting the progression from moderate to severe respiratory failure should reduce the mortality in covid- [ ] . at the beginning of covid- pandemics, based on the experience with previous studies in viral pneumonia, including sars-cov and mers, the use of steroids was discouraged, mainly due to undocumented benefit and fearing potential increase in viral proliferation and side effects [ , ] . however, with the increasing knowledge about covid- , a biphasic model of the disease has been proposed [ , ] . according to this model, the first phase is caused directly by viral replication, while in the second phase, the symptoms and respiratory failure are due to inflammatory response, and could be treated with agents which reduce inflammation, such as corticosteroids, or inhibitors of pro-inflammatory interleukins and janus kinase (jak) [ ] [ ] [ ] . indeed, some real life experiences in covid- patients showed that the use of antiinflammatory treatments might be beneficial [ ] . in fact, short-term steroid therapy was associated with lower mortality in patients with acute respiratory distress syndrome (ards) [ ] . additionally, following the data on presence of inflammatory cytokine storm in severe covid- , tocilizumab use has been advocated. this monoclonal antibody, which binds to interleukin (il- ) receptor and blocks the il- mediated inflammatory response, is approved for treatment of rheumatologic disorders and cytokine-release syndrome associated with chimeric antigen receptor t-cell (car-t) administration. it was reported to reduce covid- -associated inflammation, and was approved in china for this indication [ , ] . based on the first evidences, we formulated the hypothesis of potential benefit of antiinflammatory treatment, and progressively modified our therapeutic approach to covid- . we started using tocilizumab in patients with respiratory failure, and subsequently, we introduced into our protocol early administration of methylprednisolone treatment, followed in more severe cases by the administration of tocilizumab. we hypothesized that outcomes such as no need for intubation and survival of patients with severe covid- pneumonia in whom tocilizumab and/or methylprednisolone were administered in addition to standard of care (soc) could be better than in those who received only soc. in this observational single-center study, adult patients admitted to the san martino university hospital, genova, italy, for covid- pneumonia were included as cases if treated with tocilizumab and/or methylprednisolone, not intubated, not treated with remdesivir and not pregnant. the outcomes of patients treated with tocilizumab/methylprednisolone were compared to data from consecutive patients admitted to our hospital for covid- pneumonia who received only soc, mainly because they were admitted before the routine use of tocilizumab/ methylprednisolone (control group). all patients provided a verbal informed consent because of isolation precautions for treatment with off label agents according to the local protocol approved by hospital authorities, for data collection and for participation in the study, in accordance with national drug agency communication, ver. april th . the study was carried out in accordance with the principles of the declaration of helsinki and approved by the regional ethic committee (n. cer liguria / -id ). data were collected from hospital information system by a standard based automatic procedure and stored in an online database with pseudo-anonymization features suitable for secondary use of clinical data [ ] . controls were identified through this prospectively collected database of hospital-admitted covid- patients. patients who had any of the following features at the time of, or after, admission were classified as having severe pneumonia: ( ) respiratory distress (� breaths per min); or ( ) oxygen saturation at rest � %; or ( ) ratio of partial pressure of arterial oxygen to fractional concentration of oxygen inspired air (pao /fio ) � mm hg; or ( ) severe disease complications (e.g., respiratory failure, requirement of mechanical ventilation, septic shock, or non-respiratory organ failure) [ , , ] . systemic inflammation was defined as presence at baseline of one of the following: fever > ˚c, c-reactive protein (crp) times above the upper limit of normal (uln) of mg/dl, ferritin times above the uln ( μg/l), or il- times above the uln of . ng/l. the first results obtained at hospital admission, and in any case not later than within day of admission were considered. adverse events possibly or probably related to steroid and tocilizumab treatment, such as neutropenia, anemia, thrombocytopenia, increase in alanine aminotransferase (alt) levels, (unl < u/l), microbiologically documented infections and allergic reactions were evaluated for both treated patients and controls. adverse events were collected up to the last available follow up from starting of tocilizumab and/or methylprednisolone in treatment group and from hospital admission in the control group. the common terminology criteria for adverse event (ctcae) version . was used. the diagnosis of covid- was made with a positive rt-pcr assay performed on nasal swab or broncoalveolar lavage fluid according to world health organization interim guidance [ ] . patients received treatment with oral hydroxychloroquine mg bid, unless glucose- -phosphate dehydrogenase deficient. until march th , darunavir/ritonavir / qd was also administered [ ] . thereafter, the protocol was amended and darunavir/ritonavir was withdrawn [ ] . short-term antibiotic coverage was prescribed at admission. low-molecularweight heparin prophylaxis was administered unless contraindicated. these treatments were defined as soc. since march th , we started adding tocilizumab to soc in case of severe covid- pneumonia and systemic inflammation. tocilizumab was administered intravenously at the dose of mg/kg (maximum mg), with the possibility of repeating the dose after hours if no response was obtained. due to a temporary shortage of intravenous formulation, the available subcutaneous formulation ( mg) was administered. following an internal review of risks and benefits of steroid treatment in patients with severe covid- , since march th methylprednisolone ( mg/kg for days intravenously, then . mg/kg for days) was included in the protocol. tocilizumab was added in case of systemic inflammation or rapid respiratory function deterioration. no sample-size calculations were performed. the primary end point was time to failure, defined as intubation and mechanical ventilation or death, whichever occurred first, within days from the hospital admission. the secondary endpoint was overall survival (os). time was calculated from time of hospitalization for the comparison between tocilizumab/methylprednisolone/soc and soc patients and from the date of starting anti-inflammation treatment for the comparison among treatment groups. the landmark analysis was applied in order to minimize the potential immortal time bias that can arise in non-randomized studies and is related to the fact that patients treated after a longer time from admission must have not experienced the event up to that time, and that patients with a very early event (e.g. death) were more likely assigned to the untreated group. this is a conservative analysis which reduced the risk that the treatment choice was motivated by the patient's disease course. therefore, day from hospital admission was set as a landmark time point: those who died, were intubated or discharged from the hospital before day were excluded, while patients were included in the tocilizumab/methylprednisolone treatment group if the treatment was started within days from hospital admission (see fig ) . to minimize baseline differences between treated and untreated patients a propensity score-based analysis was performed. propensity score (ps) was derived by a logistic regression model including the following baseline variables: age, gender, presence of comorbidities and week of treatment start, ratio of partial pressure of arterial oxygen to fractional concentration of oxygen inspired air (pao /fio ), non-invasive ventilation (niv), time from symptoms onset to hospital admission, il- , ferritin, c-reactive protein (crp) and d-dimer serum levels. positivity assumption of ps was checked after the calculation. for each patient, the overlap weight (ow) based on ps was calculated [ ] . to assess the balance of covariate distribution between the two groups, cohen's standardized mean differences were calculated between the two groups in the original samples and after weighting. an absolute value of difference < . was considered an acceptable balance. the ow-weighted cox proportional hazard regression model was used to calculate the adjusted hazard-ratio (hr ow ) of tocilizumab/methylprednisolone/soc vs soc patients. weighted cumulative probability of failure or death was calculated by mean of kaplan-meier (km) survival curves. to define risk factors associated with outcomes and to compare the three treatment groups, adjusted hrs were estimated by a multivariable cox proportional hazard regression model. the same baseline variables used in the calculation of ps were considered for the multivariable analysis. to avoid overfitting, only those characteristics who showed a pvalue � . at univariable analysis and after inclusion in the multivariable model were considered, with age and gender forced into the model. for a better interpretation and to avoid the influence of outliers on estimation, the il- , ferritin, crp and d-dimer were logtransformed before the analysis due to the highly skewed distribution. all results were reported as hr with % confidence interval ( %ci). a subgroup analysis was performed to assess if the treatment effect of tocilizumab versus methylprednisolone on primary outcome was different between subgroups defined according to categorized baseline variables. an interaction test was used to assess a different treatment effect in subgroups. the sensitivity analysis was pre-planned, and the comparison between tocilizumab/methylprednisolone/soc and soc patients was reassessed excluding from the soc group the patients that received tocilizumab or methylprednisolone after days from hospitalization. the ps and ow were recalculated. p was considered significant if � . . stata (v. ; statacorp.) was used for the computation. overall, patients were evaluated: ( . %) received tocilizumab/methylprednisolone within days from hospitalization, ( . %) were treated after days from hospitalization and were included in the soc group, and ( . %) patients received only soc. after excluding the patients who were discharged or developed a failure event (intubation or death) before the day set for landmark analysis, patients were included ( tocilizumab/methylprednisolone/soc and soc patients) (fig ) . patients were mainly male ( . %), with a median age of . years (range, - ), and most of them ( . %) had comorbidities ( table ). the median pao /fio was mmhg (interquartile range, iqr - ), and ( . %) had severe pneumonia (pao /fio < mmhg). the median time from the onset of symptoms to anti-inflammatory treatment in patients was days, iqr: - ; range - . in univariable and multivariable analyses, older age, male gender, higher baseline inflammatory markers, especially il- , and pao /fio < mmhg were identified as risk factors for failure ( table ) . differences between the two groups were consistently reduced after ow. ow weighted characteristics of two groups of patients are shown in table . after (fig ) . the cox regression analysis adjusted by ow weighted propensity score estimated a significant effect of therapy in reducing the risk of failure (hr ow = . %ci, . - . ; p = . ). within the cohort of treated patients, ( . %) received methylprednisolone, ( . %) tocilizumab and ( . %) combined therapy. patients in combined treatment group were younger and with fewer comorbidities but with comparable inflammatory markers, the frequency of low pao /fio and niv (table ) . after a median follow-up of days (range - , interquartile range - ), failures were observed: in / ( . %) patients receiving methylprednisolone, / ( . %) tocilizumab ( subcutaneously and intravenously) and / ( . %) in combined treatment group. tocilizumab and steroid treatment in patients with covid- pneumonia at days of follow-up from treatment start, the failure-free survival (fig ) was % ( % ci, . - . ) in methylprednisolone group, . % ( %ci, . - . ) in tocilizumab group and . % ( ci, . - . ) in combined therapy group. no significant differences between the three treatment groups were identified in a multivariable analysis adjusted for the baseline risk factors (p for heterogeneity among treatment groups = . ) ( table ). it was not possible to identify subgroups, based on demographic or clinical characteristics, with different benefits of tocilizumab versus methylprednisolone or tocilizumab versus combination therapy. as a sensitivity analysis, we run the comparison between tocilizumab/methylprednisolone/ soc and soc patients excluding the patients that received tocilizumab/methylprednisolone treatment after days from hospital admission ( methylprednisolone, tocilizumab and both), and experienced ( %) failures. the weighted failure-free survival in the soc group was now . % ( %ci, . - . ) at days and . % ( %ci, . - . ) after days. the ow weighted difference between tocilizumab/methylprednisolone/soc and soc patients was amplified (hr ow = . ; %ci, . - . ; p = . ). among patients who received tocilizumab/methylprednisolone/soc at any time, ( %) developed alt increase (grade - : / , % and grade : / , %): . % of those who received methylprednisolone/soc and % of those who received tocilizumab/ soc +/-methylprednisolone. microbiologically documented infections were recorded in crp, c reactive protein; il- , interleukin ; niv, non invasive ventilation; pao /fio , ratio of partial pressure of arterial oxygen to fractional concentration of oxygen inspired air. https://doi.org/ . /journal.pone. .t ( . %) patients: bloodstream infections, ventilator-associated pneumonias and urinary tract infections. in tocilizumab/methylprednisolone/soc group, grade transient neutropenia and grade maculopapular rash occurred in patient each. among soc patients, grade - alt increase occurred in ( %) and patient developed urinary tract infection. there were no cases of significant decrease of hemoglobin or platelet levels. in this observational study in non-intubated patients with mainly severe covid- pneumonia, the early addition of tocilizumab and/or methylprednisolone to soc resulted in adjusted failure-free survival of . % and . % at day and , which was, respectively, . % and . % higher than in soc patients. even though only the minority of patients develop the severe form of covid- ( % in the chinese cohort of . patients), the outcomes in this group are poor, with . % rate of failure (intubation or death) reported in patients with severe disease [ , ] . the observation that covid- -associated respiratory failure can be caused by cytokine storm rather than viral progression is the rationale for administering anti-inflammatory treatments, including tocilizumab [ , , ] . the initial studies on tocilizumab in covid- reported a clinical benefit in retrospective cohorts of and patients with moderate to critical covid- pneumonia, in whom steroids were also administered [ , ] . however, none of studies reported and evaluated the impact of steroid co-administration, nor included a control group which did not receive tocilizumab. subsequently these treatments were recommended by chinese diagnosis and treatment protocol for novel coronavirus pneumonia (version and ) and experience from larger cohorts in europe have been published [ , , ] . however, considering the rapid widespread increase in severe cases of covid- worldwide, the availability and the cost of anti-il- treatment might limit its use. therefore, at the peak of covid- epidemics in our city, we implemented the early use of corticosteroids and the use of subcutaneous tocilizumab if intravenous formulation was not readily available. we acknowledge that the benefit of subcutaneous formulation might be lower and slower than in case of intravenous drug, but no standard intravenous dose for covid- has been established, as one study used mg and the other the range of doses from mg to mg, irrespective of the patients' weight [ , ] . the first study that reported the impact of steroid treatment in covid- , showed that it was administered to . % of patients, mainly in case of more severe disease, and was associated with a significant reduction of the risk of death in patients with ards (hr = . ) [ ] . while other cohorts reported steroid use in approximately % of severely ill patients, they did not analyze their influence on outcome [ , ] . subsequently, an observational study reported a benefit of early administration of steroid therapy on composite outcome of icu admission, mechanical ventilation or death at days ( . % vs. . %) and overall survival ( . % vs. . %) [ ] . in addition to these data, we were able to demonstrate that, after minimizing as much as possible the differences between the groups through ow adjustment, the outcome of patients was better in case of early treatment with tocilizumab and/or methylprednisolone. indeed, in soc group the rate of failure at day of . % was very similar to what reported in other cohorts with severe pneumonia ( . %), while it was reduced to . % in our tocilizumab/methylprednisolone/soc group [ ] . our data show that this benefit was also present with month-long follow up (overall hr ow of . ), which is important in establishing long term prognosis of these patients. moreover, the benefit of early tocilizumab/methylprednisolone was also noted on overall survival, both at and days (respectively, . % vs. . % and . % vs. . %). compared to the study with steroid use only, the -day survival was higher in our cohort, providing background for the hypothesis that combined tocilizumab/steroid treatment might be warranted [ ] . finally, preliminary results of the recovery trial reported higher survival rate in patients with severe covid- pneumonia treated with dexamethasone, although the detailed results are not available yet. interestingly, our observational study documented that these patients were treated at a median time of days after the onset of symptoms, which is compatible with the timing of cytokine storm, and therefore might be optimal for the effect of anti-inflammatory treatment. consistent with other studies, we identified older age, high il- levels and poor respiratory function as independent predictors of failure, with possible impact also of crp and d-dimer levels [ ] . possibly due to a limited sample size, we were unable to document which of three treatment groups provided most benefit, and if there were predictors of better response to tocilizumab/methylprednisolone compared to methylprednisolone alone in any subset of patients. however, the rate of failure-free survival was the highest in the combination treatment group. in addition, based on our sensitivity analyses, adding the anti-inflammatory treatment later after hospital admission might still provide some clinical benefit. in fact, including in the soc group patients who received anti-inflammatory treatment later during the infectious course possibly reduced the difference between the study arms, supporting the overall benefit of an early anti-inflammatory treatment. the limitations of this study include the non-randomized design, yet the inclusion of consecutive patients using the same soc but not treated with tocilizumab or methylprednisolone, and adjustment for the outcome-associated variables, allowed to note the improvement in patient outcomes. nonetheless, it is possible that some benefit observed was partially due to general improvements in patient clinical care that occur with time. additionally, this being a single-center experience might limit the applicability to other settings, since our hospital managed to rapidly increase the capacity for hospitalization and ventilation support, potentially improving general patient care. however, the adjustment for the differences between patient groups through propensity score and conservative approach with the use of landmark analysis were directly at minimizing the risk associated with an absence of randomization. finally, we believe that the rate of failure observed in this study of . % at days in those with severe covid- treated with soc and tocilizumab/methylprednisolone might help to better define the expected rate of response and calculate the number of patients needed to include in the studies assessing various treatment options. in conclusion, the negative impact of immune response in covid- might be mitigated by early administration of anti-inflammatory therapy with tocilizumab, methylprednisolone or both. randomized studies are warranted to establish the best treatment options, their timing and limitations. pao /fio , median (iqr), mmhg clinical course and risk factors for mortality of adult inpatients with covid- in wuhan, china: a retrospective cohort study characteristics of and important lessons from the coronavirus disease (covid- ) outbreak in china: summary of a report of cases from the chinese center for disease control and prevention baseline characteristics and outcomes of patients infected with sars-cov- admitted to icus of the lombardy region severe acute respiratory infections treatment centre: practical manual to set up and manage a sari treatment centre and sari screening facility in health care facilities. geneva: world health organization clinical course and outcomes of critically ill patients with sars-cov- pneumonia in wuhan, china: a single-centered, retrospective, observational study. lancet respir med presenting characteristics, comorbidities, and outcomes among patients hospitalized with covid- in the new york city area clinical management of severe acute respiratory infection (sari) when covid- disease is suspected. interim guidance clinical evidence does not support corticosteroid treatment for -ncov lung injury. the lancet the use of anti-inflammatory drugs in the treatment of people with severe coronavirus disease (covid- ): the perspectives of clinical immunologists from china covid- illness in native and immunosuppressed states: a clinical-therapeutic staging proposal pharmacologic treatments for coronavirus disease (covid- ): a review effective treatment of severe covid- patients with tocilizumab risk factors associated with acute respiratory distress syndrome and death in patients with coronavirus disease issued by: china national health commission from liguria hiv web to liguria infectious diseases network: how a digital platform improved doctors' work and patients' care laboratory testing for novel coronavirus ( -ncov) in suspected human cases balancing evidence and frontline experience in the early phases of the covid- pandemic: current position of the italian society of anti-infective therapy (sita) and the italian society of pulmonology (sip) a trial of lopinavir-ritonavir in adults hospitalized with severe covid- overlap weighting: a propensity score method that mimics attributes of a randomized clinical trial clinical characteristics of coronavirus disease in china the cytokine release syndrome (crs) of severe covid- and interleukin- receptor (il- r) antagonist tocilizumab may be the key to reduce the mortality tocilizumab treatment in covid- : a single center experience impact of low dose tocilizumab on mortality rate in patients with covid- related pneumonia tocilizumab for the treatment of severe covid- pneumonia with hyperinflammatory syndrome and acute respiratory failure: a single center study of patients in brescia clinical characteristics of hospitalized patients with novel coronavirus-infected pneumonia in wuhan early short course corticosteroids in hospitalized patients with covid- clinical predictors of mortality due to covid- based on an analysis of data of patients from wuhan, china. intensive care med we would like to thank all the patients and the hospital staff, with particular mention of mrs enrica lombardi, who helped us to get through these difficult weeks.this study was supported by the efforts of all members of gecovid group. key: cord- -hj s ipp authors: agostoni, angelo; aygören-pürsün, emel; binkley, karen e.; blanch, alvaro; bork, konrad; bouillet, laurence; bucher, christoph; castaldo, anthony j; cicardi, marco; davis, alvin e; de carolis, caterina; drouet, christian; duponchel, christiane; farkas, henriette; fáy, kálmán; fekete, béla; fischer, bettina; fontana, luigi; füst, george; giacomelli, roberto; gröner, albrecht; erik hack, c.; harmat, george; jakenfelds, john; juers, mathias; kalmár, lajos; kaposi, pál n.; karádi, istván; kitzinger, arianna; kollár, tímea; kreuz, wolfhart; lakatos, peter; longhurst, hilary j.; lopez-trascasa, margarita; martinez-saguer, inmaculada; monnier, nicole; nagy, istván; németh, Éva; nielsen, erik waage; nuijens, jan h.; o'grady, caroline; pappalardo, emanuela; penna, vincenzo; perricone, carlo; perricone, roberto; rauch, ursula; roche, olga; rusicke, eva; späth, peter j; szendei, george; takács, edit; tordai, attila; truedsson, lennart; varga, lilian; visy, beáta; williams, kayla; zanichelli, andrea; zingale, lorenza title: hereditary and acquired angioedema: problems and progress: proceedings of the third c esterase inhibitor deficiency workshop and beyond date: - - journal: j allergy clin immunol doi: . /j.jaci. . . sha: doc_id: cord_uid: hj s ipp hereditary angioedema (hae), a rare but life-threatening condition, manifests as acute attacks of facial, laryngeal, genital, or peripheral swelling or abdominal pain secondary to intra-abdominal edema. resulting from mutations affecting c esterase inhibitor (c -inh), inhibitor of the first complement system component, attacks are not histamine-mediated and do not respond to antihistamines or corticosteroids. low awareness and resemblance to other disorders often delay diagnosis; despite availability of c -inh replacement in some countries, no approved, safe acute attack therapy exists in the united states. the biennial c esterase inhibitor deficiency workshops resulted from a european initiative for better knowledge and treatment of hae and related diseases. this supplement contains work presented at the third workshop and expanded content toward a definitive picture of angioedema in the absence of allergy. most notably, it includes cumulative genetic investigations; multinational laboratory diagnosis recommendations; current pathogenesis hypotheses; suggested prophylaxis and acute attack treatment, including home treatment; future treatment options; and analysis of patient subpopulations, including pediatric patients and patients whose angioedema worsened during pregnancy or hormone administration. causes and management of acquired angioedema and a new type of angioedema with normal c -inh are also discussed. collaborative patient and physician efforts, crucial in rare diseases, are emphasized. this supplement seeks to raise awareness and aid diagnosis of hae, optimize treatment for all patients, and provide a platform for further research in this rare, partially understood disorder. this supplement, like the c esterase inhibitor deficiency workshop and the many patient and physician remain little known in clinical practice and thus frequently misdiagnosed and inappropriately treated, often resulting in unnecessary suffering. similarities to allergic conditions and inappropriate framing as part of the urticariaangioedema syndrome frequently lead patients with hae to be considered allergic and treated with antihistamines and corticosteroids, ineffective in this disorder. abdominal edema may so closely resemble an acute abdomen that some patients with hae have undergone unnecessary surgical explorations, often more than once. because untreated edema of the larynx may be fatal, inappropriate management may result in death. for many, hae and aae present an ongoing clinical challenge. despite the recurrent nature of angioedema attacks, their acute treatment is often suboptimal, sometimes delayed, and often requires lengthy hospital stays. in some countries, including the united states, no safe and effective acute attack therapy is available. even the prophylactic management of these disorders is inconsistent across centers and nations, and, because of the side effects of antifibrinolytics and steroids currently in use, requires a lifelong, individualized calculation of benefits and risks. these drawbacks are well known to the small community of physicians who deal frequently with these diseases and are a feature of life for those patients who suffer frequent or severe attacks. nonallergic angioedema as a model for the treatment of rare diseases in recognition of these challenges, several national and international physician and patient initiatives have begun in the past decades. in many ways, the field of nonallergic angioedema, and especially hae, is becoming an exemplar for the understanding and management of rare diseases. the estimated frequency of hae is : , . as in many uncommon conditions, hae's infrequent incidence fosters collaboration, forcing clinicians and researchers to pool their anecdotal experiences and data to attain statistical significance. nonetheless, hae is an attractive field because it offers doctors a chance to improve the lives of their patients dramatically through study but also via educated case management. as such, it has brought together a group of motivated and compassionate physicians. the pharmaceutical industry has also been welcomed to the c esterase inhibitor deficiency workshop and other hae initiatives, fostering free exchanges between academia, industry, and patients. indeed, perhaps the most distinctive feature of hae physician initiatives is their inclusion of patients with hae, not only in a traditional capacity of raising awareness and research funding but also as ethical advisors and welcomed guests for the presentation of scientific abstracts and talks. the first c esterase inhibitor deficiency workshop, held in hungary in , was the earliest meeting to follow this model. since then, the subsequent workshops and other patient-association gatherings in the united states and canada have followed its inclusive precedent. such a high level of patient involvement reflects not only the close relationship between knowledgeable physicians and their patients but also regional shortcomings in diagnosis and treatment. because of the incapacitating and life-threatening aspects of the disease, patients and their families from areas where hae is largely unknown have been forced to become educated enough to explain the disorder to strangers and, often, emergency department personnel to obtain the proper treatment. even patients whose cases are managed by a competent local practitioner may have attacks while traveling or when their doctor is unavailable and thus may need to articulate their condition to someone entirely unfamiliar with the disease. by incontrovertible necessity, patients with hae are one of the best-educated patient populations, and this is especially true in areas where satisfactory therapy for acute attacks is unavailable. for patients and physicians alike, the internet facilitates increasingly more communication, both personal and scientific. for patients with hae, it can help to reduce the isolation of having a rare disease. many patients first contact their national patient association online and use email to stay in touch with fellow patients. the internet is also being used by physicians and scientists to support a private patient registry and a public, constantly updated human c -inh gene (c nh) mutation database. through this online contact and regular meetings open to all, information about nonallergic angioedema is shared rapidly among a small, concerned group. nonetheless, the need to educate more physicians and the general public remains. the rarity of nonallergic angioedema increases the likelihood that clinicians, especially general practitioners or emergency department personnel, may never have seen a case. patient organizations and other groups have thus worked to create emergency passports for patients with known hae to carry and educational materials to distribute to emergency departments. scientific opportunities and current areas of controversy (kayla williams, bs, ma, mfa, cambridge, mass) nonallergic angioedema is a puzzle with relatively welldefined borders: many specific c nh mutations resulting in hae have been identified, and the symptomatic results are known. however, several central pieces are missing. despite recognition of functional c -inh deficiency as the cause of most forms of nonallergic angioedema, the specific mechanism of attack generation has not been definitively described. likewise, symptoms similar to those of nonallergic angioedema have now been reported in patients with normal amounts of functional c -inh. multiple pathways have been proposed for the chemical cause of angioedema attacks. the murine hae model developed by han et al shares similarities with the human form of the disease but diverges from typical hae in the triggering of angioedema. despite homozygous c -inh deficiency, the mice, with few exceptions, have not been observed to have typical angioedema attacks. attacks, manifesting solely as local increases in vascular permeability, could be provoked by the application of mustard oil. rather than representing a shortcoming of the mouse model, such a high threshold for attacks might parallel the course of those human heterozygotes, identified via a family member with active hae, who nonetheless never have an attack (for documentation of such patients, see agostoni and cicardi ). the absence of spontaneous attacks despite profound c -inh deficiency suggests that multiple biological events must transpire for angioedema to manifest. equally fascinating is the range of human disorders associated with functional c -inh deficiency. on the mild end of the spectrum, the american physicians luong and nguyen have reported a group of apparently unrelated vietnamese women presenting to their california clinic with lower extremities discomfort of unknown etiology. all of these women were found to have reduced amounts of serum c -inh, and danazol treatment resolved both the c -inh deficiency and the discomfort. at the opposite end of the c -inh deficiency spectrum, some patients with hae have periods of weekly or nearcontinuous angioedema attacks. in the most severe cases, laryngeal attacks may extend far enough into the thorax that even tracheostomy cannot maintain airway patency. it is unclear whether discerning the mechanism of some forms of hae, aae, and c -inh deficiency-associated disorders may elucidate others, but the attraction of a unified theory is obvious. however, among other factors, the inhibitory promiscuity of the c -inh molecule and its predisposition to mutation may not lend themselves to a simple answer. nonetheless, given the many proposed pathways for attack generation, information gained toward a full understanding of nonallergic angioedema attacks may lead to a greater knowledge of or more chemical cascades, including the classical complement pathway, kinin generation, and the intrinsic coagulation pathway. the areas of greatest controversy include which vasoactive peptide is ultimately responsible for the increased vascular permeability that results in angioedema. bradykinin and second component of the complement cascade (c )-kinin have been proposed, , with recent research contributing evidence to the importance of bradykinin. [ ] [ ] [ ] [ ] nonetheless, within the current understanding of coagulation, kinin, and complement pathways, neither peptide seems to perfectly explain all of the symptoms of angioedema. although bradykinin is the only candidate mediator for which there is direct clinical evidence, it is possible that yet another system, intermediary, or molecule may be involved in edema-generating vascular leakage. specific triggers for vasoactive peptide release are also unknown. it is proposed that the activation of factor xii is crucial to attack generation, and that factor xii activation may be a result of phospholipids released from damaged or apoptotic cells. recently, endothelial cells have been implicated in the generation, via kallikrein, of bradykinin, both in the presence and absence , of factor xii. these hypotheses explain how illness or localized tissue damage may precipitate attacks but do not account for other triggers, which are themselves not well defined. in large part, triggers seem to vary from patient to patient and, in several attacks, may not be apparent. of these, the most scientifically documented and explored are hormonal triggers, made all the more interesting by relatively recent reports of patients with normal c -inh concentrations and hae-like symptoms provoked or exacerbated by increased levels of estrogen. the importance of hormones in the regulation of nonallergic angioedema has long been acknowledged via its prophylaxis with androgens. increasingly, the effects of estrogen, progesterone, and other sex hormones are being explored. in some women, estrogen results in an increased frequency of angioedema attacks, , but others appear unaffected. depending on the patient and trimester, pregnancy may reduce or increase the number and severity of attacks. , in this supplement, the role of progesterone is debated, with visy et al finding a positive correlation between serum progesterone values and attack frequency, whereas bork et al note no increase in attack frequency among patients whose oral contraceptive (oc) contained progesterone and estrogen compared with those receiving estrogen alone. indeed, bork et al refer to several published works in which progestins were used, with varying success, to ameliorate hae symptoms. a- a in contrast, danazol, a common prophylaxis, alters multiple biological mechanisms but is known to block progesterone receptors and increase progesterone's metabolic clearance. given these conflicting findings, the influence of progesterone seems a likely area for further study. karen binkley graciously shared her work on very short notice and dr. alvin davis iii provided a valuable review; dr. shih-wen huang's contribution to the us hae association newsletter informed me of the full range of c -inh deficiencies, dr. alvin schmaier explained the mystery of angiotensin ii receptor blocker-associated angioedema, and dr. erik nielsen, both thorough his online hereditary angioedema thesis and quick correspondence, provided information and inspiration. many thanks go to dr. ineke bos, whose model of the c esterase inhibitor molecule graces our cover; chrystal mcdonald who worked tirelessly to secure reprint permissions; dr. brunello wüthrich who provided images of hae attacks; and drs. werner müller and georg dewald for their additions to the text. i would also like to recognize mr. anthony castaldo of the us hae association for his review of text pertaining to the patient experience and his indomitable, sustaining sense of humor. lastly, i would like to dedicate this supplement to its many contributing authors and all the hae, aae, and non-allergic angioedema patients they strive to help. in the first part of this section, cicardi and zingale describe the varied ways in which hae can manifest and discuss other diseases that published case reports and their clinical case series have associated with hae. the symptoms of hae are caused by the extravasation of plasma into the deeper cutaneous or mucosal layers as a result of or more locally released vasoactive peptides. the edema in hae is nonwhealing, nonpruritic, and generally unrelieved by antihistamines, suggesting that histamine is not involved in its induction. the biological characteristics of the vasoactive peptides released in c -inh-deficient sera indicate that the peptides belong to the kinin family. however, the discussion is not entirely closed on whether bradykinin, released because of contact system activation, or a peptide originated from c on classical complement pathway activation and the generation of plasmin, is the main mediator of symptoms in patients with hae. , nonetheless, recent lines of evidence coming from c -inh knockout mice, studies in patients' plasma, and analysis of c -inh mutants from patients with hae support the bradykinin hypothesis. , , kinin peptides participate in inflammatory processes and increase vascular permeability, activating intracellular pathways that lead to the release of nitric oxide. , vascular leakage can occur without anatomical damage and rapidly revert when the release of mediator molecules ceases. hence, edema usually resolves within hours. in some cases, it may resolve within hours, but in others, it may persist as long as days. urticaria, a condition analogous to angioedema but with plasma leakage into the upper cutaneous layers, is typically absent or minimal and short-lasting in patients with hae. typical symptoms. the recurrence of cutaneous angioedema, abdominal pain, and asphyxia caused by laryngeal edema is the full clinical pattern of hae, present in about % of adult patients. attacks usually evolve within a single site, but it is not uncommon for some patients to have simultaneous or closely spaced cutaneous and abdominal involvement. most patients recognize several hours in advance that an attack is coming. they may have sudden mood changes, anxiety, or complete exhaustion. cutaneous symptoms. skin edema is nonpitting and nonerythematous, with ill-defined margins. it typically affects the face (fig ) , extremities, and genitals (fig ) . it usually spreads to disfigure the affected site, temporarily depriving it of function. most often, a single site is affected by an extended edema that grows and then regresses within to days. alternatively, edema may persist, although reduced in size, and migrate to different cutaneous locations. in contrast with edema of other etiologies, edema associated with hae does not principally manifest in the perioral region. edema can localize subcutaneously in any body part, including the trunk. abdominal symptoms. recurrent abdominal pain, a consequence of gastrointestinal wall edema, is reported by % to % of patients with hae. , , this is a distinguishing feature of c -inh deficiency because abdominal involvement is rarely seen in angioedema of other origins. it presents with symptoms that may vary from mild discomfort to severe, intractable pain accompanied by vomiting and/or diarrhea. in this setting, hypovolemia can result from a combination of fluid loss, plasma extravasation, and vasodilation and can progress to hypovolemic shock. , ascites resulting from extravasation into the peritoneal cavity, edema of the bowel wall, or changes in splenoportal axis caliber have been described during abdominal attacks as detected by ultrasounds or computed tomography. [ ] [ ] [ ] [ ] [ ] [ ] gastrointestinal endoscopy performed during an abdominal attack revealed gastric involvement. interestingly, during the healing process after a prominent gastric edema, several small nodules and raised erosions developed over the entire gastric mucosal surface. within days, the gastric mucosa had returned to normal. the similarity between bowel angioedema and surgical emergencies is confirmed by the fact that approximately e of patients with undiagnosed hae undergo unnecessary surgery during abdominal attacks. however, even after a diagnosis of hae has been established, differentiating angioedema of the bowel from a surgical emergency remains a critical task for the physician. the physical examination can show the presence of an abdominal defense reaction. moderate or sometimes even marked leukocytosis can be part of an angioedema attack. abdominal ultrasounds and computer-assisted tomogra-phy scans demonstrate the presence of free peritoneal fluid and edematous intestinal mucosa. , , however, all of these signs are clearly not specific to angioedema. the authors note that this symptomatic generality should be borne in mind to avoid the situation that occurred with a patient in their case series. surgery was inappropriately delayed when acute appendicitis was mistaken for intestinal angioedema. the efficacy of c -inh plasma concentrate in resolving symptoms may help to distinguish angioedema from a true surgical emergency. laryngeal symptoms. laryngeal edema is the most dramatic clinical event for patients with hae. half of them have it at least once in their lives, but a history of recurrent episodes of suffocation caused by laryngeal edema is not uncommon, and deaths still occur as a result. in the past, % to % of patients with hae died from laryngeal edema. this percentage has dramatically dropped for patients who are appropriately diagnosed because of the availability of effective treatments in several countries. nevertheless, because of previous life-threatening experiences, some patients with hae still carry permanent tracheal cannulae, allowing them to breathe by bypassing the larynx when edema occurs. as mentioned, angioedema without urticaria is the hallmark of c -inh deficiency. however, a discrete number of patients, % in a survey by frank et al, have erythematous mottling, erythema multiforme, or erythema marginatum, always mild and transient, that inconstantly heralds or attends their angioedema. some patients recognize this symptom as announcing an attack, and when on prophylactic treatment, can still have a rash not followed by swelling. fig depicts several erythematous rashes experienced by patients before or during attacks of angioedema. unusual symptoms. reports in the literature suggest that edema caused by c -inh deficiency could occur in locations other than the characteristic sites of manifestation. [ ] [ ] [ ] [ ] frank et al reported transient pleuritic symptoms with pleural effusion in patients. local cerebral edema has been considered responsible for transient seizures and hemiparesis seldom described in patients with hae. , this assumption, despite its attraction and its occurrence in other forms of angioedema, has not been confirmed so far. neurologic disorders and the potential manifestation of cerebral edema remain a rarity in patients with hae. although atypical, urinary symptoms mimicking an infection have been described, and in patient, the presence of bladder edema was documented by endoscopy and biopsy. , pulmonary edema as a consequence of c -inh deficiency has occasionally been suggested but never clearly demonstrated. in the authors' experience, such an event was never observed to accompany an angioedema attack. they suggest that the high efficiency of the pulmonary vascular tree in the inactivation of bradykinin accounts for the lungs' protection from its effects. age of onset and frequency of symptoms. c -inh deficiency is present at birth, and a minority can have perinatal angioedema symptoms. most commonly, symptoms begin at school age. half of patients with hae had symptoms within the first decade of life, and another third had symptoms by the second decade. asymptomatic adults carrying a c nh mutation, detected because of the presence of offspring with clinically overt disease, have been described and are estimated to account for % of all patients with hae. the frequency at which bouts of angioedema recur is extremely variable among subjects and may vary in the same individual during different stages of life. a survey of the italian case list showed that slightly less than e of untreated patients with hae have more than angioedema attack per month, % have to swellings per year, and the remaining % are infrequently symptomatic or completely symptom-free. this range of phenotypic expression has no significant correlation with plasma concentrations of c -inh and is usually inconsistent among family groups. it should therefore be concluded that factors other than c -inh deficiency intervene to determine a subject's tendency to develop angioedema. these factors might be genetic or environmental. the hypothesis that symptom frequency correlates with specific functional polymorphisms of some of the proteins involved in pathogenesis is attractive but thus far unproven. an initial report suggesting that a polymorphism within the bradykinin receptor could distinguish oligosymptomatic from polysymptomatic patients has not been confirmed. farkas et al found that patients with hae infected with helicobacter pylori are more susceptible to symptoms than uninfected patients, and that eradication of the infection reduces the frequency and severity of swellings, particularly angioedema of the bowel. if confirmed in a larger group of patients, these findings could support those of several groups suggesting that infections increase susceptibility to angioedema in the general population as well as in patients with hae. , , [ ] [ ] [ ] clinical and laboratory criteria for diagnosis are provided in table i ; a severity scale for the evaluation of nonallergic angioedema is provided in table ii . these tools are based on contributions elaborated from experts from european countries who received a grant from the european commission for a project called novel methods for predicting, preventing, and treating attacks in patients with hereditary angioedema (prehaeat), consisting of a concerted action in the framework of the specific research and a technologic development program, quality of life and management of living resources, designed to improve the lives of patients with hae. diseases associated with c -inh deficiency. most often, patients with hae are substantially healthy apart from problems associated with swelling. however, there are several reports of autoimmune diseases in patients with hae, [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] and systemic lupus, in particular, has been described rather often. in a systematic study, of patients with hae had some kind of autoimmune disorder. moreover, patients with hae, because of defective control of the classical pathway of complement activation, have a deficiency of the fourth component of the complement cascade (c ) and c , a condition that increases the risk of autoimmune diseases. a large epidemiologic study in based on major autoimmune diseases estimated the prevalence of autoimmune diseases in americans to be in ( . %). given that all autoimmune diseases were not evaluated in this general population study, one cannot definitively conclude that patients with hae have a higher risk of autoimmune disease, but it appears likely. the association of hae with other inherited and noninherited conditions has occasionally been reported, but these observations remain isolated. [ ] [ ] [ ] [ ] last, patients with hae can be exposed to risk through needed treatments. several cases of hepatitis c virus (hcv) in the italian case series were a result of receiving plasma-derived products. these cases occurred before the introduction of viral inactivating procedures for plasma products. no cases of hiv were reported, but because of hcv, approximately % of their patients now have liverrelated problems. in this section, harmat et al describe the results of a study of hungarian patients with hae in whom ultrasonography was used to evaluate acute abdominal attacks of hae. background and rationale. ascites can result from diverse causes. the most common etiology, found in approximately % of cases, is the decompensated liver (cirrhosis). the remaining % result from other pathologies, such as malignancy in the abdomen ( %); various inflammatory diseases and other disorders, such as nephrotic syndrome, exudative enteropathy, chylous ascites, and mesenteric thrombosis; and others. however, hae is very seldom mentioned as a cause of ascites. this is a real problem, because ascites are a significant diagnostic sign of this uncommon but serious disease. the most common symptoms of hae appear in the form of ascites that cause acute abdominal attacks. for diagnosing this state, ultrasonography is the most potent tool. , , methods. ultrasonographic assessment is especially well suited to investigating the cause of abdominal symptoms. this study was performed to evaluate the usefulness of ultrasonographic diagnosis and included patients ( pediatric) from the hungarian hae center database. of these, had hae type i and had hae type ii. the male to female ratio was : , and patient age ranged from . to years. patient follow-up continued for a decade. in addition to biochemical studies, ultrasound investigations were performed at -month intervals. patients with typical symptoms of hae were hospitalized if the presence of other pathologies could be ruled out and if the manifestation was associated with hypovolemia and included recurrent paroxysms of acute colicky pain, nausea and vomiting, or profuse diarrhea, not responding to symptomatic therapy. all hospitalized patients underwent ultrasonography. during each abdominal attack, ultrasound examinations were performed before treatment and repeated at and hours post-treatment. , ultrasonographic investigations were performed by using a hitachi , a hitachi eub (hitachi medical systems, zug, switzerland), or an aloka ssd- diagnostic system (aloka co, ltd, tokyo, japan), with a . -mhz or -mhz convex transducer or a linear . -mhz transducer. subdiaphragmatic and pelvic regions were scanned with the patient in a supine position. kidneys were explored and the presence of free peritoneal or retroperitoneal fluid was ascertained with the patient in the supine and lateral positions or, when necessary, standing. free fluid, when detected, was classified into of categories, as follows: ( ) small-volume free peritoneal fluid was visible only in the subhepatic or subsplenic space, and in every case, in the douglas cul-de-sac. clinical criteria major ( ) self-limiting, noninflammatory subcutaneous angioedema without major urticarial rash, often recurrent and often lasting more than hours ( ) self-remitting abdominal pain without clear organic etiology, often recurrent and often lasting more than hours ( ) recurrent laryngeal edema minor ( ) family history of recurrent angioedema and/or abdominal pain and/or laryngeal edema laboratory criteria ( ) c inhibitor antigenic levels < % of normal at separate determinations with patient in basal condition and after the first year of age ( ) c inhibitor functional levels < % of normal at separate determinations with patient in basal condition and after the first year of age ( ) mutation in c inhibitor gene altering protein synthesis and/or function diagnosis can be established in presence of major ( - ) clinical criterion and laboratory criterion ( ) moderate-volume ascites, in addition to ascites found in these regions, included those identified in the sublienal space and among the intestinal loops. the intestinal walls were also swollen (thickness in excess of mm ). results. an ultrasound image taken during an acute abdominal attack (fig ) clearly illustrates the abdominal manifestations of hae. in this medial sagittal section of the pelvic area, a large amount of free peritoneal fluid can be observed in the douglas cul-de-sac, distal to and well separated from the urinary bladder. a floating intestinal loop can be seen. during the attack, an edematous thickening of the intestinal wall and a thin, echo-free fluid layer around the bowels also could be observed, as illustrated in edema of the portal veins, biliary ducts, and cholecyst wall, causing gross structural changes in the liver, was also observed. the liver parenchyma generally appeared less echogenic, whereas the walls of the portal vein radicles displayed increased echogenicity, resulting in a so-called starry sky texture that could be observed during the acute phase. because of local edema, the pancreatic region also displayed an increased echogenicity (fig ) . in addition to the hepatic portal vein, the wall of the cholecyst was also echogenic (fig ) . after treatment with c -inh concentrate, the former brightness disappeared, and the echo pattern of the liver returned to normal (sonogram not shown). discussion. early recognition of acute abdominal attacks is of utmost importance because incorrect or delayed diagnosis often leads to unnecessary surgical intervention. in undiagnosed patients, ultrasound examination can be a differential diagnostic means for recognizing hae in the abdominal organs because of its ability to detect nonspecific but sensitive clues such as thickening of the intestinal wall, free peritoneal fluid, intestinal hypermotility or hypomotility, and echo pattern fig . sagittal and transverse sonograms during an hae attack before and after treatment. sagittal sections are shown above, transverse below. a, a large amount of free peritoneal fluid has accumulated in the pouch of douglas and, in the sagittal section, a floating intestinal loop is visible. the urinary bladder appears below. b, soon after treatment with c -inh concentrate, the amount of peritoneal fluid is somewhat decreased. c, only a minimal amount of fluid is present in the pouch of douglas hours after c -inh treatment. several sonograms have previously been published in slightly different format. , transverse panels b and c reprinted with permission from acta paediatrica. sagittal panels a-c reprinted with permission from the european journal of gastroenterology and hepatology. fig . transverse sonogram during an abdominal hae attack: liver and pancreas. increased hepatic reflection (starry sky liver) and thickened, echogenic portal veins (arrow); the pancreatic region is also hyperechoic (double arrows). reprinted with permission from acta paediatrica. changes of the liver and pancreas. ultrasound examination has therefore proven very useful as a complementary, quick, and painless tool for recognizing the early phase symptoms of hae. patients presenting with skin symptoms (erythema marginatum) or acute pains, nausea, vomiting, or profuse diarrhea of unknown origins should be immediately hospitalized and investigated with ultrasound. ultrasound follow-up in known cases of hae is also capable of proving the efficacy and expeditiousness of acute attack treatment. in rare cases in which patients with known hae present with abdominal symptoms unresponsive to c -inh concentrate, ultrasonography may help distinguish between a refractory hae attack and an unrelated surgical emergency. abdominal and pelvic ultrasound examination is a highly reproducible and informative diagnostic tool and thus is indicated during acute abdominal attacks of hae unresponsive to c -inh concentrate. conversely, a search for hae is warranted when the typical sonographic features are ascertained in a patient with abdominal symptoms. angioedema may be caused by reasons as various as allergies, inherited or acquired deficiencies of c -inh, or drug reactions. , for the life of a patient presenting with unexplained airway swelling, the most important etiologic distinction is that between angioedema of allergic, histaminergic origins and the far rarer c -inh-associated or nonallergic angioedema. when allergic angioedema has been ruled out, nonallergic angioedema is next determined to be hereditary or acquired, and subclassification is pursued. allergic angioedema, with histamine as its major mediator, may best be defined by its clinical response to antiallergic drugs such as antihistamines and cortico-steroids. in this type of angioedema, reaction of specific ige antibodies with an allergen induces the release of histamine and other mediators from mast cells. it is often associated with urticaria. in contrast, angioedema caused by c -inh deficiency is not known to be triggered by an allergic reaction, is not usually associated with hives, and likely has bradykinin as its principal mediator. current systems for classifying hae and aae describe the disorders in terms of c -inh deficiency type. although observed convention supports the classification of major types, some further classifications, such as aae types, are more fluid. in the case of the more recently described estrogen-sensitive angioedema, a new formal description is suggested here. in the interest of both definition and the elucidation of mechanism that these differences imply, the divisions of hae and aae type are presented. for an example of prevalence, table iii presents agostoni's -patient angioedema case series by type. hereditary angioedema related to c inhibitor deficiency is a well-defined autosomal dominant trait. its variants include types i (hae-i) and ii (hae-ii), associated with mutations of the c inhibitor gene (c nh or serping ), , and a newly described type not associated with c -inh deficiency , , further defined and discussed in another section. the disease results from a large variety of mutations of the c nh gene, located in the q -q . subregion of chromosome . according to the relative concentrations of antigenic and functional c -inh, types of hae have traditionally been described. the defective gene produces either no c -inh (hae-i) or a dysfunctional c -inh (hae-ii). , , , in either case, it is associated with low functional activity of c -inh, low levels of c , and normal levels of the third component of the complement in hae-i (; % of patients with c -inh-associated hae), defective expression of allele results in low antigenic and functional concentrations of c -inh. in hae-ii (; % of patients with c -inh-associated hae) , concentrations of functional c -inh are low, but c -inh antigenic levels are normal or increased, with the presence of a dysfunctional mutant protein. for both, c -inh function is usually % to % of normal, instead of the % expected if the single normal allele were fully expressed. this difference is ascribed to permanent c and contact phase activation, with subsequent c -inh consumption in the periphery. , interestingly, the description of low levels of nonfunctional c -inh mutants in patients with hae-i has demonstrated that the distinction between hae-i and hae-ii is not absolute. this finding occurred in patients with mutations to exon at the carboxy terminus of the c nh gene, thought to be responsible for the proper folding necessary for transport outside of the cell and exposure of the reactive site loop. thus, although these patients with low antigenic concentrations of c -inh appear to have hae-i, they are in fact expressing nonfunctional c -inh that cannot efficiently exit the cell. estrogen-dependent and estrogen-associated inherited angioedema (previously hae type iii) (karen binkley, md, frcpc, and alvin e. davis iii, md, toronto, canada, and boston, mass) a type of angioedema, to date manifest only in women, has recently been described. , , its symptoms closely resemble those associated with functional c -inh deficiency but occur in the presence of normal c -inh concentrations; the genetic defect responsible is currently unknown. although this type of angioedema has been referred to as hae type iii (online mendelian inheritance in man [omim] ), others have argued that this designation is both redundant and misleading. the following piece by binkley and davis explores their work in a kindred with estrogen-dependent inherited angioedema, more fully describes estrogen-sensitive forms of inherited angioedema, and proposes a rational system of nomenclature. overview. the authors investigated a family with symptoms of angioedema restricted to conditions of high estrogen levels. although this investigation was undertaken to provide better care for the affected family members, it also presented a unique opportunity to better understand the effects of estrogen and androgens on c -inh. however, instead of altered hormonal regulation of c -inh, this family seemed to possess a completely novel abnormality, as suggested by the absence of identifiable mutations in either the coding or the # regulatory regions of the c nh gene and normal c -inh function and activity in a pregnant, symptomatic family member. the exact mechanisms responsible for angioedema in these patients have yet to be identified. the importance of kinin degradation pathways and aminopeptidase p (app) in the control of angioedema generation has been independently recognized in studies of angiotensin-converting enzyme (ace) inhibitor-related angioedema. bradykinin and its active metabolite, des-arg-bradykinin, are metabolized largely by enzymes, ace and app. [ ] [ ] [ ] with ace inhibitor administration, app becomes the primary enzyme responsible for inactivating bradykinin and des-arg-bradykinin. in fact, individuals with low plasma concentrations of app appear to be predisposed to developing angioedema during ace inhibitor treatment, when neither ace nor app is available to inactivate these kinins. kinin inactivation pathways might also modulate clinical symptoms in classic hae. for example, decreasing kinin inactivation in patients with hae with the use of ace inhibitors can result in exacerbation of angioedema. [ ] [ ] [ ] [ ] given the important contribution of kinin inactivation pathways to the control of angioedema, this may be an avenue for further investigation. case histories and investigation of the index family. the index family presented with histories of episodic, hae-like angioedema. these episodes occurred only during pregnancy, oc use, or estrogen replacement therapy. symptoms began to days after conception, or within to days of starting endogenous hormones. no episodes occurred in the postpartum period. one patient's description was particularly compelling: ''my period was just a day or two late, but when one side of my face swelled up, i knew i must be pregnant, because this is just like what happened to my mother and sisters every time they were pregnant.'' in affected individuals, symptoms occurred in all pregnancies and with each course of estrogen therapy. unaffected individuals had no symptoms at any time. there were affected women in generations and obligate male carrier. transmission was consistent with an autosomal dominant inheritance. complement values, c -inh, c -inh function, prekallikrein, factor xii, and high molecular weight kininogen were normal in patients during asymptomatic periods. genetic investigations were undertaken for the following reasons: ( ) the patients were asymptomatic at the time of presentation, ( ) baseline biochemical investigations were unremarkable, and ( ) exposing patients to estrogens for the purpose of detecting resultant biochemical abnormalities was unethical in light of the risk of laryngeal edema. the striking clinical similarity to classic hae focused initial investigations on the c nh gene. however, no abnormalities in the coding sequences of the c nh gene or in the # regulatory region were detected. when patient iii- became pregnant and developed recurrent angioedema, biochemical investigations were undertaken. c -inh antigen and function were both normal. the mechanism by which increased estrogens precipitate symptoms thus remains under investigation. related phenotypes: hae with normal c inhibitor activity in women. most of the women with angioedema in families reported by bork et al appeared to have a phenotype different than that of estrogen-dependent angioedema, because only of patients had attacks exclusively during pregnancy. in of patients, attacks occurred more frequently during oc use but were not limited to these periods. by extrapolation, of these patients had angioedema apparently unrelated to use of ocs or pregnancy. age of onset of symptoms in the patients of bork et al was variable and was not reported as directly correlating with onset of exogenous estrogen use or pregnancy. symptoms in at least patient started as early as year of age, before significant hormonal effects were likely as the authors note. these features are in sharp contrast with those of patients with estrogen-dependent inherited angioedema, in whom episodes of angioedema occurred exclusively during pregnancy or exogenous estrogen therapy, and suggest that a different underlying defect might be responsible for the different phenotypes. in the women described by bork et al, c -inh and c levels were normal in the affected individuals without symptoms. normal measurements of c and c -inh during symptomatic periods were also obtained in some individuals. other pedigrees have also been reported. nomenclature. until further biochemical and molecular genetic studies elucidate the underlying defects in these pedigrees, it remains unclear whether the different pedigrees represent subtle abnormalities in the same underlying pathway or distinct biochemical and clinical entities. therefore, affected patients can currently be classified only on the basis of phenotype, without reference to the underlying defect. this has implications for the nomenclature applied to these conditions. the term hae type iii may be misleading because it implies that these patients have a defect similar to hae-i (inadequate c -inh concentration) and hae-ii (inadequate c -inh function). this is clearly not the case, because c -inh concentration and function are normal in several pedigrees. , further confusion arises because the term hae type iii had been previously suggested to apply to a form of angioedema resulting from inadequate c -inh function caused by a mutation resulting in inappropriate binding to albumin. , although hae type iv was suggested for the patients of bork et al to address this latter concern, the term still erroneously implies a defect in c -inh function. the authors thus suggest that patients should be categorized on the basis of their phenotype and recommend the terms estrogen-dependent inherited angioedema and estrogenassociated inherited angioedema , until molecular studies suggest an alternate, rational nomenclature. clinical implications. further studies are required to identify the factors that contribute to angioedema in patients with estrogen-dependent angioedema. unaffected family members might then be identified through biochemical or genetic assays so that they might use ocs or plan pregnancies freely. identification of affected family members would allow these individuals to avoid ocs, bypassing a trial of therapy and the attendant risk of laryngeal edema. should effective treatment became available, affected individuals wishing to use ocs or become pregnant could begin treatment prophylactically or, at least, ensure its availability beforehand. if a particular factor is conclusively shown to be reduced in these patients, symptomatic individuals might be treated by replacing the missing factor. other possible treatments include novel strategies to reduce kinin formation or enhance kinin inactivation. prenatal diagnosis of fetal status (affected or unaffected) might also be relevant to the management of pregnancy in these individuals. the reported kindred showed significant variation in symptom severity during pregnancy, with some individuals experiencing relatively mild symptoms. in at least affected individual, it is likely that symptoms during a pregnancy with an affected fetus (identified as such only later in life) were accurately recalled as being particularly severe (binkley, unpublished data, march ) . it is interesting to speculate that an affected fetus would not provide the missing factor to the affected pregnant mother, and this might explain the severity of the symptoms. conversely, an unaffected fetus might act as a source of the otherwise missing factor during pregnancy and might mitigate symptoms in an affected pregnant mother. if pregnancies could be identified early as being at high or low risk for severe angioedema on the basis of fetal status, follow-up and management could be guided accordingly. at least direction for further study of the mechanisms responsible for symptoms in patients with estrogenassociated angioedema is suggested by the reduced kinin inactivation in ace inhibitor-associated forms of angioedema. elucidation of the defect responsible for this phenotype would allow better diagnosis and possibly specific treatment. general strategies to reduce kinin formation and/or enhance inactivation might also be helpful for the amelioration of symptoms. concerning hae-i and hae-ii, just as variations in serum concentrations of app appear to determine which individuals in a normal population develop angioedema with a second perturbation of kinin metabolism, such as the use of ace inhibitors, it could be speculated that variations in either kinin activation or inactivation pathways might contribute to the differences in severity of angioedema in individuals with a pre-existing perturbation in kinin metabolism, such as a mutation in c -inh (as occurs in hae). thus, it is possible that some of the variation in symptom severity seen between different members of the same family, carrying the same c -inh mutation, comes from variation in other kinin pathways. identification of the defects in estrogen-dependent and estrogen-associated angioedema might illuminate potential candidate factors. knowledge of kinin production and inactivation pathways and how they are influenced by sex hormones may also offer insight into some perplexing issues regarding the effects of sex hormones on c -inh values and angioedema symptoms in hae. androgens are effective in reducing episodes of angioedema and are used clinically for this purpose in hae. , although androgens increase plasma concentrations of c -inh, the amount of c -inh increase does not correlate well with symptom diminution. it is tempting to speculate that androgens may also increase kinin inactivation pathways, and this, perhaps in combination with slightly higher amounts of c -inh, contributes to the observed reduction in angioedema with androgen therapy. further studies will be necessary to explore this possibility as well. use of estrogen therapies typically results in some lowering of plasma c -inh concentration in normal individuals, and use of estrogen therapy tends to exacerbate angioedema in patients with hae. however, during pregnancy, estrogen concentrations are high, c -inh concentrations decrease, [ ] [ ] [ ] and paradoxically, episodes of angioedema may decrease, especially in late pregnancy. these puzzling observations have long suggested that a second mechanism is important in controlling angioedema. kinin inactivation pathways may be one such mechanism. speculation about possible mechanisms of symptom reduction in pregnancy suggests potential fruitful areas for further study. for example, are there hormonal factors in pregnancy, not operative during estrogen therapy, that increase kinin inactivation or other factors and reduce angioedema, despite an estrogeninduced lowering of c -inh? is the fetus or placenta a source of kinin inactivation factors or other factors that mitigate the effects of estrogen-induced lowering of c -inh? does variation in fetal production of kinin-inactivators or other factors underlie any variation in angioedema symptoms between pregnancies in the same individual, or between individuals in the same families, all with the same c -inh mutation? acquired angioedema is typically caused by ace inhibitor treatment, and less commonly is caused by autoantibodies directed at c -inh. general strategies to reduce kinin formation or/and increase kinin inactivation, identified through characterization of the elements of these pathways as well as their regulation, may be applicable to these patients as well. moving ahead. the discoveries of estrogen-dependent and estrogen-associated inherited angioedema are likely to focus attention on mechanisms other than c -inh that control angioedema. pathways involving kinin production and inactivation may be fruitful areas of further study in these conditions, a better understanding of which might provide new therapeutic opportunities potentially relevant to all types of angioedema. angioedema may be acquired, mainly in association with lymphoproliferative disorders or occasionally with autoimmune, neoplastic, or infectious diseases. aae also includes various other types of secondary c -inh deficiency, angioedema caused by certain antihypertensive medications, urticaria-associated angioedema, and idiopathic angioedema. , in the laboratory, aae is characterized by low functional c -inh, low amounts of c , and normal amounts of c . concentrations of c q are often very low. angioedema caused by acquired c -inh deficiency: type i and type ii distinguished. (marco cicardi, md*, andrea zanichelli, laurence bouillet, md, cca,* and emel aygören-pürsün, md, milan, italy, grenoble, france, and frankfurt, germany) in this section, cicardi et al review the current classifications of aae and discuss the possible pathogenic mechanisms on which these distinctions are ostensibly based. angioedema caused by acquired deficiency of the inhibitor of the first component of human complement (c -inh), usually referred to as acquired angioedema, is a rare, life-threatening disease first described by caldwell et al. characteristic of acquired c -inh deficiency are the increased consumption of c -inh and the hyperactivation of the classical pathway of human complement. as a consequence, these patients have almost undetectable serum levels and/or activity of c -inh, c , c , and c q, r, and s. usually, these abnormalities are constantly present, but temporary normalization of or more of these parameters has been reported. the clinical manifestations of the disease mimic those of the inherited defect of c -inh and include subcutaneous, nonpruritic swelling without accompanying urticaria; involvement of the upper respiratory tract manifested as dysphagia, voice change, or respiratory stridor; and partial obstruction of the gastrointestinal tract presenting as colicky abdominal pain. angioedema caused by acquired c -inh deficiency differs from hae by the absence of a family history of angioedema and a late onset of symptoms (in the fourth decade of life or later). response to treatment varies compared with hae caused by the c -inh hypercatabolism characteristic of acquired c -inh deficiency. acquired c -inh deficiency is frequently reported in association with b lymphoproliferative diseases. different forms of b lymphoproliferation can occur, ranging from benign monoclonal gammopathies of undetermined significance (mgus) to true malignancies. in , autoantibodies inactivating c -inh were first detected in patients with acquired c -inh deficiency. initially, autoantibodies inactivating c -inh were identified in otherwise healthy patients. on the basis of this observation, it was proposed that separate forms of acquired c -inh deficiency existed: type i, paraneo-plastic, mainly associated with lymphatic malignancies; and type ii, autoimmune, caused by autoantibodies to c -inh. the latter form appeared to be characterized further by elevated serum levels of cleaved c -inh. , because cleaved c -inh was not invariably found to be present in the serum of patients with so-called autoimmune acquired c -inh deficiency, this division has been questioned. , furthermore, autoantibodies to c -inh were later described in patients with associated diseases. these autoantibodies were found to be common in patients with mgus and frequently exhibit the same isotype of the m component. , , autoantibodies to c -inh impair c -inh function. although the exact mechanism for such impairment remains controversial, , the majority of these autoantibodies appear to enhance c -inh cleavage by target proteases, preventing their inactivation. a recent article on patients with acquired c -inh deficiency followed for as long as years (median, years) demonstrated that half of the patients with malignancies also had autoantibodies to c -inh, either at the time of onset of angioedema or later in the course of disease, indicating that autoimmune acquired c -inh deficiency is not distinct from the acquired c -inh deficiency that occurs in the setting of malignancies or other diseases. detection of autoantibodies to c -inh in a patient with acquired c -inh deficiency should not decrease the importance of considering the possibility of an associated pathologic condition. compared with the general population, patients with acquired c -inh deficiency presented higher risk for b-cell malignancies. in patients with acquired c -inh deficiency, the risk for progression of mgus to malignancy was not higher than in other patients with mgus. (angelo agostoni, md, milan, italy) new causes of aae, especially drug-related aae, are still being discovered, posing the question whether all types of aae share a common biomechanism if not a common etiology. in the descriptive sections that follow, agostoni surveys several classes of aae by cause. idiopathic nonhistaminergic angioedema. cicardi et al describe a subset of angioedema patients having normal complement values, no history of provoking drug treatment, and who are unresponsive to antihistamines. this condition, with a clinical presentation similar to that of c -inh deficiency, is deemed idiopathic nonhistaminergic angioedema. it is possible that this classification might overlap, at least in part, with that of estrogensensitive angioedema. ace inhibitor-related angioedema. angioedema may be a consequence of an adverse drug reaction not induced by an allergic or parallergic mechanism. ace inhibitor-related angioedema occurs in . % to . % of patients taking the drug. decreased bradykinin degradation is implicated because ace, also known as kinase ii, activates both angiotensin i and bradykinin. ace inhibitor-related angioedema may be an underestimated side effect because it can appear after years of ace inhibitor use, thus obscuring its relationship with the drug. unlike patients with c -inh deficiency, patients who develop ace inhibitor-related angioedema show no evidence of the cleavage products of high molecular weight kininogen (hk) in their plasma, despite high plasma concentrations of bradykinin. because the cleavage of hk generates bradykinin, the pathogenic mechanism of ace inhibitor-related angioedema probably resides in the catabolic side of bradykinin metabolism instead. when ace is inhibited, app plays a major role in plasma bradykinin catabolism. to identify patients at risk of developing angioedema during ace inhibitor treatment, adam et al evaluated blood concentrations of app. their results indicated lower plasma concentrations of app in patients who had previously had ace inhibitorassociated angioedema, suggesting an inverse relationship between app concentration and the tendency to develop angioedema. it is evident that ace inhibitor use should be avoided in patients with hereditary or acquired c -inh deficiency. angioedema related to other drugs. rare instances of angioedema have been reported with angiotensin ii (at ) receptor antagonsists, although this adverse effect seems to occur less frequently with at receptor antagonists than with ace inhibitors. it is unknown whether the adverse drug reactions share the same mechanism. scattered reports have suggested the possibility of angioedema associated with the use of estrogens, fibrinolytic agents, psychotropic agents, and antihypertensives other than ace inhibitors. the molecular diagnosis of angioedema is primarily based on evidence of the decrease or lack of c -inh function, which is routinely stated by its control capacity toward the target protease c s in spectrophotometric assays. molecular sizing of circulating c -inh can subsequently be assessed by sds-page and immunoblot. as discussed in greater detail in the pathogenesis and pathobiology of hae and aae section, c -inh controls several proteases, including c r and c s, the mannosebinding protein associated serine protease (masp) system, kallikrein, coagulation factors xiia and xia, plasmin, and tissue plasminogen activator. [ ] [ ] [ ] [ ] [ ] [ ] therefore, c -inh plays a key role in regulating the early steps of complement and the contact system of kinin formation. this broad inhibitory ability ensues from a property unique to the serpin class: highly efficient complex formation with target proteases. thus, mutations of the c nh gene typically affect many pathways. to add further complexity, many different c nh mutations resulting in hae have been discovered. through the study of these mutations, it is hoped that more complete knowledge of the many functions of c -inh can be gained, ultimately contributing to a better biochemical knowledge of hae. mutation analysis of the c nh gene in this section, drouet et al review the methods currently available for detecting c nh mutations and describe the powerful online mutation database that has grown out of such efforts. c nh gene. the c nh gene maps to chromosome . theriault et al, by using in situ hybridization in , localized it to q -q . ; a year later, janson et al mapped it to q -q . . it consists of exons distributed over a dna stretch of kb, with introns containing repetitive alu sequences (fig ) . the structural abnormalities in the c nh gene in patients with hae have been found to be very heterogeneous. illustrative examples explain the generation of c nh gene defects: large deletions or, less frequently, partial duplications involving alu repeats distributed along the c nh gene , ; deletions resulting from a peculiar consensus sequence or an alternative secondary structure ; and mutations based on cytosine-phosphateguanine (cpg) methylation and subsequent cytosine deamination to thymine. , as shown in table iv , more than mutations have been reported in unrelated patients, with pathogenic amino acid substitutions distributed over the entire length of the coding sequence. , in addition, the frequent de novo mutations in the c nh gene underline the presence of multiple hot spots, including those containing a cpg dinucleotide. all of these lead to an apparent failure to synthesize or secrete functional c -inh protein. in the context of a normal steady-state c -inh mrna content in almost all cases of hae-i and hae-ii, defective expression has been related to impaired protein secretion, , transinhibition of c -inh translation, or extensive consumption. the consequences of several missense mutations have been determined at the functional and intracellular processing level by transfection of an in vitro mutagenized construct into cos cells. point mutations help map amino acid residues critical for proper molecular folding and processing, with subsequent conversion of the serpin as a substrate, determination of target protease specificity, , , or spontaneous multimerization. , , hence, many different mutations can lead to dysfunctional c -inh, as recently reviewed. , strategies for mutation analyses of the c nh gene. molecular genetic analysis of c nh gene anomalies in patients serves as a supplementary diagnostic tool for accurate diagnosis at the molecular level. it contributes to the understanding of dna mutagenesis processes, protein folding and processing, and the structure-function relationships of the c -inh serpin. , , , such studies may also help the collection of population distribution data, potentially deepening understanding of the relationship between de novo mutation formation and distinct, independent founder effects in different geographical locations. c -inh deficiency is heterogeneous at the gene level and is caused by subtle changes affecting or several nucleotides, large deletions, or duplications. , , this heterogeneity prompted the authors to develop suitable methods for the detection not only of mutations previously identified in probands but also of as yet unknown mutations. de novo c nh mutations, including exon deletions, account for nearly % of cases of angioedema. this finding has implications relevant to the genetic epidemiology of and genetic counseling for this disease. the following sections describe the principles, advantages, critical parameters, and drawbacks of some technical strategies, including successful developments in the detection of c nh gene anomalies. scanning methods for point mutations or small deletions or insertions. methods based on heteroduplex dna and single-strand conformation analyses are of proven efficiency in the screening of large segments of genomic or complementary dna. , specific pcr amplification is first performed on exons and flanking intronic sequences or cdna. any variation detected is then sequenced to characterize the molecular change. in the following text, whenever possible, methods are accompanied by citations for reviews describing their advantages and limits. chemical cleavage of mismatches (ccm) technology is based on selective reactions of mismatched thymine and cytosine with oso and hydroxylamine, respectively. the modified mismatched bases are subjected to piperidine cleavage reactions, and the resulting fragments are separated and identified by gel electrophoresis. this method is, in principle, well suited to detect mutations independent of the length and sequence composition of the examined region and capable of detecting nearly all single-base mismatches. it has been successfully developed in a large number of studies (reviewed in ellis et al ) , including those of the c nh gene to detect pathogenic mutations and analyze its polymorphism. even if all mutations could potentially be detected, the efficiency of chemical modification and cleavage of the ccm depends on type of the mispairing and the stability of the adjacent sequences. in consequence, some mismatches are poorly cleaved, with their mutations subsequently undetectable via ccm. the need for a method suited to identifying most anomalies in the c nh gene, including point mutations and short and medium-sized deletions or insertions, prompted some groups to take advantage of ccm and fluorescent probes with the development of fluorescenceassisted mismatch analysis. , , denaturing hplc (dhplc) uses an alkylated nonporous poly(styrene-divinylbenzene) matrix and an amphiphilic ion gradient enabling separation of homoduplexes and heteroduplexes by means of ion-pair reversephase liquid chromatography (reviewed in xiao and oefner ) . illustrative examples of its application in c nh gene studies are given in fig . the most important advantage of the dhplc method is its easy automation by using a mechanical sampler. denaturing gradient gel electrophoresis is based on the migration of double-stranded dna molecules through polyacrylamide gels containing linearly increasing concentrations of a denaturing agent (reviewed in fodde and losekoot ). c nh-specific primers have been designed to amplify genomic dna segments ranging from to bp. the amplified fragments identified as forming heteroduplexes were directly sequenced. single-stranded conformational analysis (ssca) is an electrophoretic method using a nondenaturing gel, in which the mobility of heat-denatured single strands is dependent on their folding according to individual secondary structure formation. since its introduction in , it has gained popularity for its technical simplicity, low cost, and high sensitivity sufficient to detect most mutations (reviewed in nataraj et al ) . the method has been used in c nh gene studies , , (fig ) . analysis of dna rearrangements. because large genomic rearrangements account for nearly % of the total spectrum of the observed changes (reviewed in tosi ), methods adapted to analyzing dna rearrangements are required every time the aforementioned strategies are unsuccessful. southern blot analysis. southern blot analysis was first used for c nh gene analysis by groups who compared dna from multiple members of families with hae against dna from unrelated patients, yielding the first indication that a defective structural gene was responsible for the disease. , digestion of genomic dna with bcli can detect most deletion/insertion boundaries, because the -kb-long c nh gene lies within a -kb bcli fragment (fig ) . to localize gene alterations more precisely, other enzymes have been used in single or multiple digestions: bamhi, bglii, ecori, hindiii, saci, sali, pvui, and psti. , quantitative exon multiplex pcr. southern analyses are difficult to set up and time consuming. to ensure complete molecular characterization of c -inh deficien-cies, a fluorescent multiplex assay has been constructed to amplify exons of c nh and exon of the brca gene simultaneously. in brief, after c nh exon amplification, the fluorescence intensities of c nh exons are compared quantitatively with those of a control exon (eg, brca exon ) under conditions in which template concentration is rate limiting. the method has been further validated in exploring large deletions and insertions. reliable estimates of relative gene dosage can be obtained by comparing peak levels in the test dna with those of appropriate controls in deletion/insertion situations (fig ) . c nh promoter sequence analysis. the promoter of the c nh gene is unusual because it contains no tata sequence, but instead contains a tdt-like initiator element at nucleotides to and a polypurine-polypyrimidine tract between nucleotides and . only a few mutations have been reported to affect promoter sequence transcriptional activity, and among them, an interesting promoter variant (a c-to-t transition at position ) was found in an exceptional family with recessive trans- mission of the disease. however, subsequent transcriptional alteration remains to be demonstrated. these anomalies have been successfully detected via mismatch scanning (fluorescence-assisted mismatch analysis) in reactions with external and internal primers specific for the promoter sequence. sequencing and expression of sequence data. the most widespread, gold standard technique for mutation detection is direct sequencing. this technique is now commonly available with a high degree of automation and a parallel decrease in labor and cost. the principle is based on dideoxy chain termination reactions using fluorescent dideoxy nucleotides followed by automated gel or capillary electrophoresis. direct sequencing identifies the complete nucleotide sequence of a selected and pcr-amplified dna fragment and detects heterozygosity. the resulting data must be carefully interpreted. any newly discovered missense mutation has to meet the following criteria: ( ) the complete coding sequence and splice sites of the c nh gene were screened/sequenced; ( ) the new mutation is not present in general population chromosomes; and ( ) the new mutation segregates with the disease, ie, affected members carry the mutations whereas healthy relatives do not. novel interactive, locus-specific mutation database of the c nh gene. published c nh gene mutations were periodically summarized in reviews, , but such collections became quickly outdated when several new studies described a multitude of novel mutations. , , , , c nh gene mutations are also represented in large universal databases (omim ; human gene mutation database ), but these databases update their contents infrequently, with poor interactions and heavy requests. one of the goals of the european concerted action (prehaeat) is to perform systematic analyses of c nh gene mutations in several laboratories for structure-function relationships and consequence on disease expression. to achieve this goal, a mutation database (http://hae.biomembrane.hu) was created with the following purposes: ( ) to help the comprehensive collection of information on genetic alterations of the c nh gene, ( ) to create a database in which data can be searched and compared, and ( ) to provide additional help in deciding whether a new mutation segregates with the disease. c -inh serpin function defect: contributions from understanding c nh mutations. the need to ascertain the consequence of c nh mutation on c -inh expression and function prompted investigators to develop experimental systems adapted to both transcription and protein expression studies. patient peripheral blood monocytes and fibroblasts were successfully developed to study c -inh synthesis in pathological conditions. , [ ] [ ] [ ] it then became interesting to correlate c nh gene anomalies with transcription and translation defects, specifically with reference to serpin function, without the need for patient cells. pathological mutations can now be introduced in c -inh cdna expression systems and transfected into cell lines suitable for biosynthesis experiments. , , [ ] [ ] [ ] [ ] serpin function is routinely assessed in plasma samples (see varga et al in the following laboratory diagnosis section). some type ii mutant c -inh proteins have been described with respect to their atypical interactions with the target protease. a more complete model of nonfunctional c -inh mutants can yield insights into the c -inh inhibitory mechanism and aid in the development of a relevant dynamic -dimensional model of the c -inh molecule. knowledge of these type ii mutant c -inh proteins allows every mutation to be associated with its corresponding serpin control failure, as proposed in a category classification scheme : class i includes mutations that lead to altered exposure of the active site, with consequences on protease specificity (denoted § in table iv) ; class ii mutations convert c -inh protein into a substrate, with subsequent inefficient protease trapping (denoted à and k in table iv) ; and class iii encompasses mutations with a spontaneous insertion of the reactive loop, either into the same molecule or another molecule entirely (denoted k and { in table iv) . finally, as posited by cumming et al, it is important to correlate mutations with disease expression. however, on the basis of most clinical data, disease expression cannot be attributed to specific mutant proteins. variable clinical presentation is thought to result from genetic or nongenetic elements distinct from the c nh gene. in laboratory practice. every index case characterized by impaired c -inh serpin function and ruled not to be of an acquired origin can be submitted to a genetic analysis. to ensure an economical and reliable strategy, an algorithm is proposed in fig . currently, to be exhaustive, the conjunction of scanning methods and southern hybridization or exon multiplex technology is required to detect most mispaired or unpaired sequences and rearrangements, respectively. every nucleotide change detected from the index case has to be analyzed in the family members, keeping in mind that de novo mutations are not uncommon. as stated, and in particular when detected in introns, every new mutation without a known significance has to be distinguished from a polymorphism in the c nh gene after establishing its absence in the relevant healthy population (from at least chromosomes) and its segregation with the disease. the interpretation of biochemical data on c -inh serpin function and of c nh gene anomalies is of great importance to establish a better knowledge of the pathogenic effects of c nh gene mutations. moreover, the possibility of c -inh polymorphisms affecting disease expression should be considered. generating a c -inh molecular model should be of great help in the understanding and treatment of hae type ii and discerning which c -inh residues are essential for efficient control of all its target proteases. the uniform resource locators for data related to this section are as follows: from a pathogenetic perspective, the form of angioedema most extensively studied is that resulting from c -inh deficiency. nonetheless, the pathogenesis of this clinical condition remains incompletely understood. in the following section, hack briefly reviews the biochemistry and biology of c -inh as well as the biochemical changes that occur in persons with c -inh deficiency during both attacks and symptom-free periods. on the basis of these reviewed data, hack then discusses the potential pathogenesis of c -inh deficiency angioedema. often, hae results from a deficiency of c -inh. an interesting feature, revisited in the previous clinical manifestation and diagnosis section, is the great variance of the disease's clinical course. some patients are virtually free of attacks even in the absence of treatment, whereas others, despite therapy, have attacks nearly every week. angioedema attacks result from the extravasation of fluid caused by increased vasopermeability. unlike angioedema of allergic origins, angioedema caused by hae typically does not itch. pain is often not a primary feature of such angioedema, although it may manifest secondary to the localization of the angioedema, eg, severe pain caused by obstruction of the bowel lumen. in spite of decades of research, the pathogenesis of hae attacks is still unclear. c -inh biochemistry and biology. c -inh belongs to the family of serine protease inhibitors, or serpins, which also includes proteins such as a -antitrypsin and antithrombin iii [ ] [ ] [ ] [ ] (fig ) . most serpins have only or a few target proteases, but c -inh is exceptional in this respect. it is the major inhibitor of several proteases, including ( ) c s and c r-two serine proteases that, together with c q, constitute the c complex of the classical pathway of complement, ( ) the mannan-binding lectin (mbl)-associated serine proteases or masps, and ( ) the contact system proteases factor xia, factor xiia, and kallikrein. in addition, c -inh may interact with several proteases such as thrombin, plasmin, and tissue-type plasminogen activator (tpa). thus, c -inh regulates the activity of several inflammatory, clotting, and fibrinolytic proteases and is therefore an inhibitor of several pathways of inflammation. in comparison with other serpins, c -inh is a relatively weak inhibitor, approximately times less effective than other serpins. however, the inhibitory activity of c -inh toward c r, c s, and factor xia can be remarkably potentiated by heparin and other glycosaminoglycans. , the inhibitory activity of c -inh to factor xiia and kallikrein cannot be potentiated. dextran sulfate is the most effective glycosaminoglycan, enhancing c -inh function -fold in vitro and -fold in plasma. however, the in vivo effect of dextran sulfate is transient, probably because of dissociation of the dextran sulfate-c -inh complex and the subsequent rapid clearance of dextran sulfate. mature c -inh consists of amino acids and is heavily glycosylated (approximately % by weight). although on sds-page gels it migrates with an apparent molecular weight of kd, its calculated molecular weight is kd. the c -inh molecule has at least glycosylation sites and possibly glycosylation sites, part of them linked to threonine residues. most carbohydrate groups are located at the n-terminal region; their function is largely unknown. the c -inh molecule is composed of an n-terminal domain of amino acids and a serpin domain of amino acids. although the function of the n-terminal domain is unknown, recent evidence suggests that it helps to stabilize the central bsheet by forming disulfide bridges linking cysteine to cysteine , and cysteine to cysteine . the structure of the serpin domain is homologous to that of other serpins and is essential for the inhibitory capacity of the molecule. recently, a novel -dimensional model of c -inh was proposed on the basis of the crystal structure of other inhibitory serpins. similar to other serpins, c -inh inhibits proteases by binding to their active site via its reactive center. this reaction follows the equation in the first step, a reversible complex is formed between the target protease and c -inh; c -inh then undergoes conformational changes caused by insertion of part of its reactive center loop into a -stranded b-sheet. this results in the formation of modified c -inh (c -inh* in the equation) that is tightly bound to the target protease (step ). mutations of the residues at the p , p , and p positions in the reactive center interfere with efficient loop insertion and cause the reaction to proceed to step . in that case, c -inh has become a substrate for its target proteases. such mutations have been found in some patients with hae-ii (characterized by the presence of dysfunctional c -inh protein). complexes between modified c -inh* and proteases are very stable and only very slowly dissociate into an inactive, modified c -inh (with changed conformation caused by a completed insertion of the cleaved active site loop into the -stranded b-sheet) and an active target protease (step in the equation). most of the stable complexes will be removed from the circulation before dissociation via receptors specific for complexed serpins. this mechanism ensures efficient removal of biologically active proteases. c -inh is an acute phase protein, of which plasma concentrations may increase as much as -fold during uncomplicated infections. woo et al reported that the synthetic rate of c -inh may increase as much as . times the normal rate in patients with rheumatoid arthritis. cytokines such as interferon-g stimulate the synthesis of c -inh. in normal volunteers, the fractional catabolic rate of c -inh is . % of the plasma pool per hour, which results in an apparent plasma half-life time of clearance of about hours. the half-life time of clearance of human c -inh in rabbits is comparable, at hours, whereas that in rats is considerably shorter, at about . hours. the apparent half-life time of clearance is markedly longer in patients with hae, in whom it may exceed hours, as determined by assessing the course of plasma concentrations after the intravenous administration of exogenous c -inh. however, at low plasma concentrations of c -inh, such as occur in untreated patients with hae, c is autoactivated and consumes functional c -inh. at higher c -inh concentrations such as occur after the administration of exogenous c -inh, this autoactivation is inhibited, leading to a decreased consumption of c -inh. hence, monitoring of plasma concentrations after a therapeutic dose of c -inh may lead to an overestimation of the half-life caused by inhibition of consumption of endogenous c -inh. removal of sialic acids greatly enhances the clearance of c -inh from the circulation, yielding an apparent half-life of to minutes, presumably by binding to asialoglycoprotein receptors in the liver. subsequent removal of penultimate galactosyl residues largely restores the clearance rate to a value similar to that of normal c -inh. activation of cascade systems in hae. as mentioned, c -inh regulates the activation of at least different so-called plasma cascade systems, ie, the classical and mbl pathways of complement via its effect on c r, c s, and the masps; the contact system via its effects on kallikrein and activated factor xii (factor xiia); and the intrinsic pathway of coagulation via its effect on activated factor xi (factor xia). in addition, it may regulate coagulation to some extent via its effects on thrombin, and it may regulate fibrinolysis through its effect on tpa and plasmin. except for the mbl pathway, there is evidence for activation of all of these systems in patients with hae. the classical pathway of complement consists of c q, c r, and c s, together forming the c complex; c and c ; as well as the inhibitors c binding protein and factor i. typically, patients with hae have low c and c but normal c values even during attack-free periods. low c and c result from uncontrolled activation of activated c because the concentration of activation products of c , c b/c, or c d is elevated. , activation of c is typically low or absent, probably because of efficient control of activation at the level of c by c binding protein and factor i. this continuous activation of the classical pathway is attributed to enhanced autoactivation of c , because this autoactivation process is dependent on functional c -inh values. however, it is now clear that the classic pathway of complement may be activated by apoptotic cells through various mechanisms. [ ] [ ] [ ] hence, one could postulate that the excessive activation of the classic pathway in untreated patients with hae results from activation of this pathway by cell debris. indeed, familian and hack have observed increased amounts of complement activation products in patients with hae (unpublished data, november ), reflecting activation via the penetraxin serum amyloid p component, of the proteins that can bind to apoptotic cells. ongoing activation of the classical pathway in untreated patients continuously produces activated c . the contact system of coagulation consists of the proteins factor xii (also known as hageman factor), prekallikrein, and high molecular weight kininogen. the system is activated in vitro on contact with negatively charged surfaces, but the nature of potential activators in vivo is currently unknown. activation of the system yields factor xiia and kallikrein. c -inh inhibits both proteases. in addition, kallikrein can also be inhibited to some extent by a -macroglobulin. kallikrein can cleave hk, yielding cleaved hk and bradykinin. the latter nonapeptide is a potent inducer of vasodilation and increased vasopermeability. activation of this system is often assessed by measuring factor xiia-c -inh and kallikrein-c -inh complexes, although these parameters are unsuitable to assess activation in hae. alternatively, activation can be measured by detecting increased amounts of cleaved hk or decreased antigenic quantities of the contact system proteins. activation of the contact system in hae typically occurs during attacks and is hardly detectable during attack-free periods. in particular, increased amounts of cleaved hk are found in most, if not all, patients with attacks. , , remarkably, nearly all hk is often cleaved during attacks, such that native hk is hardly detectable. it is questionable whether all hk cleaved during an attack gives rise to bradykinin, given its extremely potent activity as a vasodilator. bradykinin is known to cause a significant drop in blood pressure even at low concentrations, yet hypotension is not characteristic for hae. however, there are no data supporting the cleavage of hk via other degradation pathways during hae attacks such as would generate minimal or no bradykinin. it should be noted that the measurement of bradykinin in plasma or other body fluids is hampered by its rapid degradation by carboxypeptidases and is only possible using samples collected in special inhibitor cocktails to prevent enzymatic degradation. few studies have attempted to measure bradykinin according to such protocols in hae, but these studies have shown increased bradykinin generation during attacks and not during symptom-free periods, particularly when samples are drawn from the site of the edematous swelling. , , c -inh is a major inhibitor of factor xia of the intrinsic pathway of the intrinsic pathway of coagulation , and also inhibits thrombin, although inhibition of this latter enzyme is likely physiologically inconsequential. the role of factor xi in coagulation is not yet resolved. originally, coagulation was considered to proceed via at least different pathways, the intrinsic and the extrinsic, merging at the level of factor x into a common pathway of thrombin generation. the extrinsic pathway is initiated by exposure of factor vii to tissue factor, whereas the intrinsic pathway is triggered by factor xii activation, eg, upon contact of blood with negatively charged surfaces such as glass. in this view, activation of factor xii led to thrombin generation via activation of factor xi, which then activated factor ix, which together with factor viiia activated factor x, which then together with factor va activated prothrombin. this traditional distinction between intrinsic and extrinsic pathway has been left behind, and the intrinsic pathway is now considered to amplify extrinsic pathway activation in that factor ix amplifies factor viia-induced activation of factor x, whereas factor xi, activated by thrombin, activates additional factor ix. according to this revised scheme of coagulation, the activation of factor xi is no longer mediated solely by factor xiia but also may occur with significant thrombin generation. in the traditional scheme of coagulation, c -inh is expected to have a major effect on intrinsic pathway activation because it blocks the activity of factor xiia, kallikrein, and factor xia, whereas according to the current understanding, c -inh has only a limited effect on coagulation, with its main effect the inhibition of factor xia-mediated amplification of factor ix activation. clinical observations in hae do not support that c -inh deficiency is a major risk for thromboembolic disease, although some generation of thrombin may occur during attacks. this mild effect of c -inh is easily understood through the revised scheme of coagulation. although c -inh inhibits plasmin and tpa in vitro, and to some extent in vivo, this inhibition is weak. nonetheless, significant plasmin formation, as measured by the formation of plasmin-a -antiplasmin complexes, occurs during attacks in patients with hae but hardly at all during symptom-free periods. at present there is no evidence for tpa or urokinase-type plasminogen activator involvement in the formation of plasmin during hae attacks. as such, this generation most likely results from factor xii activation. although debated in the literature, convincing in vivo evidence exists to support the activation of plasminogen in human beings by factor xiia. , angioedema attack pathogenesis: mediators of angioedema. angioedema is a frequently experienced side effect for patients receiving ace inhibitors. this angioedema does not itch, is not associated with urticarial lesions, and does not respond at all to corticosteroids or antihistamines, features also typical of angioedema associated with c -inh deficiency. ace inhibitors slow down the processing of c-terminal arginine residues of various vasoactive peptides such as angiotensin and bradykinin, thus prolonging the biological activity of these compounds. the association between ace inhibitors and angioedema is a strong argument that this condition may result from exposure of the endothelium to increased levels of vasoactive peptides. considering the similarities between ace inhibitor-related angioedema and that caused by c -inh deficiency, the latter form also likely results from enhanced exposure of the endothelium to vasoactive peptides. studies in a few patients indicate that bradykinin may be the vasoactive peptide involved. , , considering that contact activation in hae mainly, if not exclusively, occurs during attacks, and that activation of this system results in the liberation of bradykinin from hk, most investigators currently believe that c -inh deficiency angioedema results from the local generation of bradykinin caused by uncontrolled proteolytic activity of factor xiia and kallikrein (fig , bottom) . kallikrein has important effects in contact activation: it ( ) amplifies factor xii activation via so-called reciprocal activation, and ( ) releases bradykinin from hk. this mechanism of contact activation and bradykinin generation as the basis for angioedema is supported by observations in the murine model of c -inh deficiency, because the enhanced vasopermeability in this model can be blocked with bradykinin receptor antagonists. according to this mechanism, inhibiting kallikrein or blockading bradykinin receptors (bkr- ) would be therapeutic options; as discussed in the treatment section of this supplement, both are currently being investigated in clinical trials. activation of the contact system holds several attractions as an explanation for angioedema attacks. first, fig . different pathways of kinin generation in c -inhibitor deficiency state. low c -inhibitor leads to uncontrolled activation of factor xii, which generates kallikrein and plasmin. kallikrein liberates bradykinin from hk, whereas plasmin cleaves off c -kinin from activated c . activated c is continuously produced during baseline complement activation, which is increased as a result of insufficient control of autoactivation of c caused by c -inh deficiency. factor xii activation can be triggered by chemical activators and may well occur in bouts. second, bradykinin is a potent vasoactive peptide that can enhance vasopermeability. third, ace inhibitors have been shown to result in the delayed breakdown of bradykinin, and part of their hypotensive effects are actually blocked by bradykinin receptor antagonists. however, some strong arguments exist against this mechanism as the sole explanation for angioedema. first, bradykinin is a strong vasodilating agent and among the most hypotensive agents known, whereas hae attacks are not known to be associated with clear hypotensive reactions. nonetheless, one could argue that most bradykinin is generated locally, at the site of edema formation, rather than in the circulation. second, the local injection of bradykinin results in a strong pain sensation, whereas primary, localized pain is not typical for hae attacks. third, contact activation cannot explain the efficacy of antifibrinolytic agents such as tranexamic acid. it has been suggested that these agents are efficacious by reducing plasmin formation during attacks, which would lead to the reduced consumption of functional c -inh by plasmin. in spite of this, it is difficult to understand how active plasmin would be capable of mediating c -inh consumption, because it is rapidly inhibited by a potent plasmin inhibitor, ie, a -antiplasmin. moreover, in most patients with hae, rather than being elevated, the concentration of cleaved c -inh (free c -inh* in the equation) is fairly low. finally, although vasopermeability seems to be enhanced and dependent on bradykinin formation in c -inh-deficient mice, these permeability changes do not appear to occur in bouts and are otherwise atypical for angioedema. for all of these reasons, other mechanisms may be involved in hae attacks. some decades ago, another vasoactive peptide was thought to be involved in angioedema formation. this peptide can be generated by cleavage of the c b fragment, but not from native c , by plasmin, and is therefore called c -kinin. this c-terminal fragment of c b can be generated by c s or plasmin. mediation of attacks by this fragment requires activation of multiple plasma cascade systems: ( ) complement, to generate activated c ; ( ) the contact system, to generate factor xiia; and ( ) the fibrinolytic system, to generate the c -kinin generating enzyme, plasmin. according to this mechanism, attacks are triggered by factor xii activation that then yields plasmin, which in turn cleaves the c -kinin sequence from c b (fig , top) . the attractive aspects of this controversial mechanism include its explanation of the efficacy of antifibrinolytic agents. furthermore, one may postulate that c -kinin does not induce vasodilation, explaining why hae attacks are not associated with hypotension and may not induce sensations of pain, and why angioedema in general does not hurt. nevertheless, it should be noted that the biologic properties of c -kinin are not well established, and thus, it is not truly known whether this kinin's properties are consistent with the description. moreover, receptors for this kinin have not been identified, and it is therefore unknown whether their distribution correlates positively with the localization of attacks. in addition, there are no data regarding concentrations of c -kinin in patients with hae. finally, if correct, the c -kinin mechanism provides no explanation for the profound cleavage of hk and the apparent lack of biological activity of bradykinin. these mechanisms are not necessarily exclusive and may be simultaneously involved in attacks. furthermore, the involvement of other, as yet unknown vasoactive peptides in the pathogenesis of attacks cannot be excluded. triggers of angioedema attacks. clinically, hae attacks are often triggered by trauma or emotional stress. attacks of hae are specifically associated with activation of the fibrinolytic and contact systems, whereas complement activation occurs continuously, independent of clinical symptoms. activation of the fibrinolytic system can occur via plasminogen activators: tpa, urokinasetype plasminogen activator, and factor xii. there is no evidence that the former are involved in plasmin formation during attacks; hence, it likely results from factor xii activation. thus, attacks are triggered by activation of factor xii. though factor xii (hageman factor) was discovered in the s, physiological activators of this contact system protein have not yet been identified. in vitro, factor xii is easily activated by glass and other negatively charged compounds such as dextran sulfate. obviously, these compounds are not relevant as activators of the contact system in vivo. the author writes that recently, his group has studied the generation of thrombin by phospholipid microparticles released in vivo from activated platelets and damaged cells. by using various specific mabs against tissue factor, factor vii, factor xi, and factor xii, they noticed that a small but significant part of thrombin generation by microparticles purified from human plasma was dependent on factor xii. indeed, earlier studies have clearly indicated that factor xii can be activated by phospholipids in vitro. , apparently, factor xii can be activated by phospholipid microparticles in vivo. damaged or apoptotic cells generate such particles, and one may therefore postulate that these particles constitute triggers for contact activation. under normal conditions, ie, at normal concentrations of c -inh, this weak activation will never yield substantial contact activation. however, in the absence of sufficient amounts of this inhibitor, the system may become profoundly activated by even small amounts of microparticles via the principle of reciprocal activation (factor xii activates prekallikrein into kallikrein, which in turn activates additional factor xii, and so on). microparticles and damaged cells are likely generated during trauma, which may explain why this is a trigger for angioedema attacks. emotional stress as a trigger for attacks is more difficult to understand, although one may speculate that it predisposes patients to microtrauma. support for this hypothesis is that occasional patients have been described who, in spite of acquired c -inh deficiency, are free of symptoms. two such patients had detectable antibodies against phospholipids. these antibodies might interfere with the binding of factor xii to phospholipid microparticles or damaged cells. further studies are needed to provide evidence toward this hypothesis of hae attack generation. attack frequency. the angioedema attack rate in persons with c -inh deficiency may vary widely, ranging from no attacks to an attack every week. the molecular mechanism for the variation in attack rate is unknown. in the previous paragraph, mechanisms to explain the trigger for attacks are discussed. both mechanisms claim that attacks are initiated by activation of factor xii. therefore, one may speculate that the frequency of attacks is strongly linked to an individual's tendency toward factor xii activation. if true, attack rates might be influenced by the concentration of factor xii as well as by the amount of factors that compete with factor xii for binding to its activator molecules. as discussed, in the case of phospholipid microparticles, antiphospholipid bodies may prevent factor xii from binding to the particles, conferring protection against the activation of factor xii. older literature has revealed several proteins capable of competition with factor xii for binding to artificial activators. , the concentrations of these competing proteins might well determine whether factor xii may become activated on exposure to an activator and therefore influence hae attack frequency. future research will test this hypothesis. in summary. angioedema attacks caused by c -inh deficiency are likely mediated by the excessive release of vasoactive peptides such as bradykinin and c -kinin. this release is initiated by the uncontrolled activation of factor xii, leading to kallikrein and plasmin formation. the trigger for attacks may be phospholipids, released from damaged cells, that activate factor xii. factor xii's ease of activation may be determined by its concentration as well as the concentration of proteins that compete with it for binding to activators, and may explain the variable frequency of attacks in patients. others, assuming bradykinin to be the principal mediator of nonallergic angioedema attacks, have begun work toward bridging the gap between c -inh deficiency and local angioedema generation. bolstered by the increasing evidence that ace inhibitors [ ] [ ] [ ] can cause aae in a small percentage of individuals, investigators have sought to determine whether-independent of c nh gene sequence-an increased liberation of bradykinin, a decrease in its catabolism, or a combination of the may contribute to the angioedema experienced in hae, aae, and related disorders. phenotypic characteristics. mating of heterozygousdeficient mice produced the expected : : mendelian ratio of c -inh / :c -inh / :c -inh / mice. as observed in human heterozygotes, c -inh expression was less than % of normal in heterozygous mice; homozygous c -inh knockouts did not produce detectable plasma concentrations of c -inh. in male but not in female mice, carrying the defective c -inh gene correlated with a slight but statistically significant decrease in weight. the growth of both heterozygous-deficient and homozygous-deficient mice appeared normal, with no more newborn deaths observed than in wild-type littermates. limited analysis of serum c concentration in heterozygous-deficient and homozygous-deficient mice revealed that homozygotes had % to % as much c as their wild-type littermates, constituting a significant mean difference from wild-type; c in heterozygotes was more variable, ranging from % to % of wild-type. the group also reported that total hemolytic complement activity in the sera of null homozygotes was reduced compared with wild-type. although the c -inh / and c -inh / mice were not observed to have spontaneous attacks of skin edema, heterozygotes and homozygous knockouts developed spontaneous abdominal distension secondary to intestinal wall edema. because these mice were euthanized, it is unclear whether these episodes would have spontaneously resolved. no such episodes of abdominal edema were observed in wild-type littermates. measuring increased vascular permeability. evans blue dye was used to visualize differences in vascular permeability between the types of mice. within to minutes of injection into the tail vein of wild-type mice, the dye caused a faint blue coloration, particularly visible around the nose and eyes and on the feet. after similar injections, c -inh / and c -inh / mice showed a much more saturated blue color in these areas, with homozygous null mice producing the most saturated blue. these differences could be quantitated spectrophotometrically, as shown in fig . the mice were euthanized and the dye extracted from the area in question by using formamide, then read at an absorbance of nm. han et al noted that unlike in the feet and face, there were no apparent vascular permeability differences in the ears of mice of all genotypes after evans blue injection. however, when mustard oil, a local irritant, was applied to the ears of injected mice, a pronounced permeability increase correlating with c nh mutation could be spectrophotometrically demonstrated. this increase could be reversed if the mice were given human c -inh concentrate. intestinal vascular permeability was also investigated in a few mice; although of borderline statistical significance because of the sample size, intestinal permeability was also increased in c -inh / versus wild-type mice (fig ) . bradykinin type receptor assays. groups of heterozygous and homozygous c nh-deficient mice were treated with the plasma kallikrein inhibitor dx- , the bradykinin receptor antagonist hoe (icatibant; jerini, berlin, germany), or the ace inhibitor captopril (figs and ). both interference with plasma kallikrein (and thus contact system-mediated bradykinin generation) and disruption of the bradykinin receptor interaction with its ligand decreased vascular permeability. treatment with the bradykinin receptor antagonist des-arg ,[leu ]-bradykinin had no effect. treatment with captopril dramatically increased vascular permeability. when c nh knockout mice were crossed with bradykinin receptor knockout mice, the resulting offspring were overtly phenotypically normal. as shown in fig , absence of the bradykinin receptor was able to reverse the vascular permeability observed in both c -inh / and c -inh / mice. in conclusion, although this mouse model does not exclude the possibility of other contributing mechanisms, it strongly supports the hypothesis that bradykinin mediates angioedema. bradykinin-mediated angioedema? (kayla williams, bs, ma, mfa, cambridge, mass) in this section, williams reviews recent information on the role of bradykinin in both drug-related angioedema and hae and explores the contributing factors that may influence the generation of bradykinin-mediated angioedema. drug-related angioedema: a growing problem. as the use of ace inhibitors, at receptor antagonists (at blockers), and related, next-generation drugs increases, it is projected that the incidence of drug-related angioedema will also increase. , although angioedema is a relatively rare adverse effect of such medications, the medications are commonly and increasingly prescribed. the incidence of angioedema during ace inhibitor treatment has been estimated at between and per patients. these cases of drug-induced angioedema are interesting because, unlike other forms of nonallergic angioedema, the role of bradykinin in ace inhibitor-related angioedema is fairly well established. also of note and concern are reported racial differences in the response to this vasoactive peptide. bradykinin, race, and ace. in , gainer et al published the results of a clinical trial evaluating wheal response to bradykinin among african americans and white americans. in this randomized, double-blind study, increased bradykinin dose, hypertension, and african american race each correlated with an increased wheal response to bradykinin. further investigations by the same group compared the effects of short-term ace inhibition in normotensive and hypertensive individuals of both races. in this study, the hypotensive effects of the ace inhibitor captopril were shown to be greatly reduced in all subjects by concomitant administration of the bradykinin receptor antagonist icatibant. icatibant was also shown to significantly alter the change in plasma renin activity in response to ace inhibition. these results not only confirmed the importance of bradykinin in the short-term effects of ace inhibitors but also suggested that bradykinin contributes to the effects of ace inhibition on the renin-angiotensin system. in addition, when considered together, these results suggest that clinicians prescribing ace inhibitors for patients of afro-caribbean descent should be especially aware of the possibility for drug-related angioedema, a warning beginning to be supported by case analysis. , further antihypertensive-related angioedema. initially, at blockers were thought to be a safer alternative for patients who had angioedema associated with ace inhibitors. unlike ace inhibitors, at blockers have not been shown to increase bradykinin concentrations. nonetheless, further case reports documented angioedema after therapy with at blockers. , in a survey of the literature, % of these patients also had similar episodes in conjunction with ace inhibitor treatment. additional documented cases of at blocker-associated angioedema threw bradykinin's role in the pathogenesis of such episodes into doubt because increased concentrations of bradykinin are not associated with at blocker use. however, very recent work has shown that increased concentrations of at , such as would occur during a blockade of at receptors, are associated with an increase in the expression of bradykinin receptors that may be almost -fold. thus, increased opportunities for bradykinin binding may explain angioedema in the absence of extra bradykinin. the mediator for this receptor crosstalk effect has been shown to be the at receptor . (presumably, this phenomenon could occur in the presence of at receptor blockers only in the absence of a total blockade.) meanwhile, the new drug application for the vasopeptidase inhibitor omapatrilat, a dual inhibitor of both ace and neutral endopeptidase (nep), was voluntarily withdrawn when the food and drug administration raised questions regarding the comparative incidence of angioedema reported within the new drug application database. in response to these questions, a large ( , -patient) multinational trial was initiated to compare the efficacy and safety of omapatrilat versus the ace inhibitor enalapril in patients with heart failure. the results of this study have recently been reported. angioedema occurred in . % of subjects receiving omapatrilat compared with . % of subjects receiving an ace inhibitor alone. two of the dual inhibitor-treated subjects had angioedema with airway compromise. an editorial published after the trial results were released but before their publication noted that the rates of angioedema were much higher in african americans receiving the dual inhibitor ( . %) than in those receiving the ace inhibitor alone ( . %). of smokers receiving the dual inhibitor, . % had angioedema, versus . % of smokers receiving the ace inhibitor alone. the biologic activity of nep must account for this several-fold increase in angioedema. indeed, among its many possible functions, nep has been shown to metabolize bradykinin to an inactive form. a combination of ace and nep inhibition could thus be expected to prevent efficiently the degradation of bradykinin to inactive metabolites, thereby increasing the risk of angioedema. in certain subgroups with altered responses to bradykinin or altered pathways for its generation or degradation, these effects could be especially pronounced, and such predisposing factors may also be involved in the generation of c -inh deficiency-related angioedema. implications for c -inh deficiency angioedema. early investigations have confirmed that bradykinin may be at work in c -inh deficiency angioedema. the transience of bradykinin has complicated measurements of this nonapeptide; however, several small studies of plasma bradykinin concentrations in patients with angioedema have revealed that high concentrations of this vasoactive peptide occur during edematous attacks. , , this increase in plasma bradykinin was demonstrated both for patients with hae with c -inh deficiency and for patients with drug-associated angioedema who had an angioedematous attack in conjunction with ace inhibitor treatment. patients receiving ace inhibitors showed elevated plasma bradykinin concentrations throughout ace inhibitor therapy, both during attacks and during periods of remission. as documented in patient, this increase reverted to normal on discontinuation of ace inhibitor therapy. in contrast, patients with c -inh deficiency were shown to have high concentrations of bradykinin during their attacks but have been documented to have normal or marginally increased amounts of bradykinin during periods of remission. at least in c -inh deficiency, bradykinin increases may be highly localized; in previously studied c -inh-deficient patients, bradykinin concentrations in blood draining from an angioedematous site were and times as high as those measured in systemic circulation. thus, bradykinin appears to be important in various currently identified forms of nonallergic angioedema. following the example put forth in the large-scale trial of antihypertensive agents that showed ( ) african descent and, to a lesser extent, ( ) smoking to correlate with increased angioedema risk, clinicians and researchers may wish to investigate the interaction of these variables with c -inh deficiency. bradykinin magnified. even if bradykinin is the major mediator of nonallergic angioedema, many questions regarding the triggering and localization of angioedema attacks remain. why should patients with ace inhibitorinduced angioedema have this angioedema in bouts if bradykinin is constantly elevated? what is different about the small percentage of patients taking ace inhibitors who have angioedema? what regulatory pathways are involved? how, chemically, does one proceed from insufficient functional c -inh to localized, full-blown angioedema? the past decade of research indicates that the answers may reside in a surprisingly multifactorial system. bradykinin-mediated effects can result from increased amounts of bradykinin, the reduced breakdown of bradykinin to inactive metabolites, the increased conversion of bradykinin to active metabolites, and/or the increased uptake of these active metabolites. each of these mechanisms may be involved in at least form of nonallergic angioedema. pathways for the breakdown of bradykinin are depicted in fig . decreased or alternative catabolism. molinaro et al have demonstrated that in human plasma, bradykinin is metabolized mainly by metallopeptidases: ace, app, and kininase i (carboxypeptidase n). of these, ace and app, respectively, are the first and second major pathways of inactivation. kininase i represents a minor pathway unless ace is inhibited, whereupon kininase i transforms bradykinin into its active metabolite des-arg -bradykinin, which, in turn, is inactivated by app and ace, with app the major inactivating metallopeptidase. nep, as discussed in the context of vasopeptidase inhibition, likely represents another minor pathway. once formed, bradykinin and des-arg -bradykinin are short-lived and thus exert their effects locally at the site of their formation, stimulating b and b receptors, respectively. , during ace or vasopeptidase inhibition, patients with low app activity may be subject to angioedema. in fact, adam et al have found a correlation between low app activity with a history of angioedema among patients receiving ace inhibitors. likewise, in their estrogen-dependent and estrogen-associated inherited angioedema piece earlier in this supplement, binkley and davis propose reduced app activity as a contributing element in estrogen-sensitive inherited angioedema. in addition, they note that estrogen may decrease gene expression of ace. , to demonstrate further the delicate balance of enzymes and receptors, it should be noted that mathews et al observed angioedema in a subject with familial serum carboxypeptidase n deficiency. because the subject's sister had an equally depressed serum carboxypeptidase value but no reported episodes of angioedema, it is possible that another defective control mechanism, possibly app, contributed to the angioedema. pathways for bradykinin generation and metabolism. on the endothelium, bradykinin generation likely initiates independent of factor xii; however, once kallikrein is generated, it soon catalyzes factor xii activation, thus amplifying the response. increased anabolism. as hack discussed in the pathogenisis and pathobiology of hae and aae section, c -inh is known to inhibit not just c esterase but also other serine proteases, including factor xii (hageman factor). in addition, c -inh inhibits the serine protease kallikrein. without the controlling effects of c -inh, it is possible that both of these serine proteases may contribute to an increased generation of bradykinin. this reaction is thought to occur at the endothelial cell surface. the way in which this unchecked bradykinin generation starts has been debated, with recent evidence supporting the secondary role of factor xii, , and placing the conversion of prekallikrein to kallikrein, likely by an enzyme such as prolylcarboxypeptidase, , foremost, at least under resting physiologic conditions. it is thought that once kallikrein is present, it catalyzes the activation of factor xii. only in the presence of activated platelets, neutrophils, or lymphocytes can the high local concentration of free zinc ions necessary for factor xii to bind to the endothelial cell surface-and thus initiate bradykinin release-occur. this provides yet another example of how infection or tissue damage might aggravate an existing tendency to angioedema. in vitro, kallikrein and plasmin together have been shown to exert a synergistic effect on the release of kinins from hk. of interest, plasmin's digestion of hk in this model could be inhibited by e-aminocaproic acid. because c -inh is also known to inhibit plasmin, and antifibrinolytics show at least partial efficacy in the treatment of hae, this enhancing mechanism might well be operative in c -inh deficiency angioedema. in addition, because angioedema has been reported in patients treated for acute ischemic stroke who received recombinant tissue-type plasminogen activator (rtpa; often concomitantly with an ace inhibitor), molinaro et al undertook an in vitro comparison of human plasma incubated with and without rtpa in the presence of an ace inhibitor. their results showed that rtpa generates bradykinin that is further metabolized to des-arg -bradykinin; this effect could be recreated to a similar extent in the absence of rtpa by the addition of negatively charged glass beads, thus mimicking contact activation. joseph et al , have identified yet another possible mechanism active at the endothelial cell level, showing that the cytosol of endothelial cells contains a factor capable of converting prekallikrein to kallikrein in the absence of factor xii. they identified this factor as heat shock protein . perhaps this mechanism might account for angioedema attacks that occur in the wake of trauma or infection when ruptured cells spill their contents into local circulation. indeed, increased kallikrein may be a feature of mechanical trauma: an experiment conducted more than years ago demonstrated that mechanically generated blisters in of patients with hae contained active kallikrein that could be inactivated by c -inh concentrate or antibodies to plasma kallikrein. in contrast, blister fluids from of healthy subjects did not contain detectable amounts of plasma kallikrein. last, these anabolic effects might be created or magnified by hormonal interactions. as noted by binkley and davis, estrogens may increase the expression of factor xii , - and prekallikrein. increased uptake. various factors may increase gene expression of the b and b receptors. not normally expressed, the b receptor has a high affinity for kinin metabolites. expression of b receptors may be induced during inflammation and tissue damage. , although b receptors are constitutively expressed, their expression may be increased by estrogens and at receptor antagonists. in summary. despite increasing evidence that bradykinin is indeed the major mediator of nonallergic angioedema, this knowledge does not represent a simple answer given the many variables governing bradykinin and its metabolites. however, an understanding of this web of chemical interactions may yield more successful management algorithms for the various types of nonallergic angioedema. this recent knowledge also suggests a place for bradykinin receptor antagonists and kallikrein inhibitors for the control of nonallergic angioedema, especially when it occurs in the presence of functional c -inh. the current scientific understanding of the triggering of angioedema attacks ranges from the anecdotal to that supported by relatively large and rigorous studies. patients with hae, aae, or related forms of angioedema, especially patients who have angioedema attacks in the absence of a formal diagnosis, pay particular attention to the events that precede their angioedema attacks; however, even in the same patient, these events may vary among attacks. various patients have implicated exposure to cold; mechanical trauma sustained during routine activities such as gardening; prolonged sitting or standing; eating certain foods, such as eggs; exposure to pesticides or chemicals in new fabrics and clothing; infection or illness; or excitement or stress in triggering their attacks (k. williams, unpublished data, august ). however, as with other, better studied triggering events, these conditions or activities did not always predictably provoke attacks. ethical concerns and the small patient populations available to would-be investigators prevent the systematic investigation of most patient-reported angioedema attack triggers. those triggers more readily quantifiable via laboratory assays without necessitating patients' increased risk of developing attacks have received the most scientific attention, largely restricting the study of attack triggers to the possible role of hormones. (laurence bouillet, md, cca,* grenoble, france) in the first part of this section, bouillet reviews his group's clinical experience and other reports linking sex hormones and hae. on the basis of the literature, he proposes possible pathogenic mechanisms by which these influences might manifest. these relationships are discussed with a final view toward patient care. current literature. it is currently known that hae is influenced by the fluctuation of female hormones, but the effects sometimes appear to vary greatly among women. some patients seem to be estrogen-dependent: puberty, pregnancies, or estroprogestative contraception can precipitate attacks, whereas menopause impairs the disease. however, the course of some women's disease seems to be unaffected by estrogen. reports have highlighted the close relationship between female hormones and angioedema. yip and cunliffe described cases of hae occurring in a mother and her daughter whose symptoms appeared to be estrogen-influenced. their first attack happened around puberty; angioedema worsened premenstrually and when they took ocs. likewise, a woman with hae-ii associated with turner syndrome was reported as experiencing an increase in both the severity and the frequency of her angioedema attacks on beginning estrogen physiological replacement at age years. mcglinchey and mccluskey also described hae manifesting after the initiation of estrogen replacement therapy. bork et al, as discussed later in this supplement, reported their evaluation of the effect of oc use or hormone replacement therapy on the frequency and the severity of hae attacks, finding that % of women with hae taking these drugs presented with new or worsened angioedema. some kinin-mediated angioedema appears to be related to estrogen therapy. the first cases of angioedema during oral contraception were described in a report by warin et al a in which sisters presented with hae only after taking oral contraception and during pregnancy: c -inh concentration and complement components were normal. bouillet's group has also reported women whose angioedema attacks manifested after starting oral contraception. a study of c -inh biological function revealed a lowered c -inh activity with marked protein cleavage on the immunoblot. clinical and biological anomalies ceased after oral contraception was discontinued. hypoandrogenism has been associated with insufficient production of c -inh in women taking cyproterone acetate as well in men with hypogonadism. in , pichler et al reported the cases of women taking the contraceptive drug cyproterone acetate who developed clinical hae reversed by discontinuation of this contraceptive; also described were the cases of men with hypogonadism who had recurrent angioedema successfully cured by androgen treatment. as discussed in previous sections, reports described a new estrogen-influenced hae. , , only women had angioedema, and their attacks were precipitated when estrogen concentrations were increasing because of pregnancies, oral contraception, or hormone replacement therapy. no c -inh abnormalities have been reported in these cases. hormone-related pathogenesis. for these clinical events to be understood, they must be placed in a biochemical context. as discussed, the complement, contact, and fibrinolytic systems are involved in the genesis of angioedema attacks, , , and all are regulated, at least to some extent, by c -inh. bradykinin is thought by many to be the principal candidate mediator of angioedema genesis, and a mouse model demonstrated that angioedema is mediated by bradykinin via b receptor. in human beings, studies have shown local elevations in bradykinin concentration during hae attacks. , it is speculated that factor xiia, kallikrein, and thrombin may be increased as well. an elevation of plasmin-a antiplasmin complexes is also noted. in ovariectomized rats, studies showed that b-estradiol favored the increase of factor xii by stimulating its gene transcription. , [ ] [ ] [ ] this hormone also increased kininogen and kallikrein concentrations. in addition, estrogens regulate b receptor gene expression and function: when reduced in ovariectomized rats, the vasodepressor response to bradykinin and b receptor mrna levels could be restored by estrogen substitution. progesterone did not modify factor xii concentration but seemed to increase the amount of kallikrein cdna. in healthy women taking oral contraception, there is an increase of the fibrinolytic proteins: plasmin and factors vii, x, and ix are increased, whereas plasminogen activator inhibitor is decreased. , , these effects appear to be estrogen dose-dependent. plasma samples from these women showed enhanced in vitro fibrinolysis. the contact system is also altered: factor xii, prekallikrein, kallikrein, and hk increase. [ ] [ ] [ ] last, c -inh levels are decreased, correlating with the increase in factor xii. , , hormone replacement therapy (hrt), although using a weaker estrogen dose than oral contraception, appears to have the same effects. fibrinolytic proteins are also increased (plasminogen and tpa), whereas plasminogen activator inhibitor decreases. [ ] [ ] [ ] hrt increases factor xii, prekallikrein, c , and c concentrations. , , moreover, some studies have shown hrt to influence the bradykinin system: ace activity decreases, whereas bradykinin concentration increases. , , toward treatment. this imbalance in these systems appears to trigger angioedema attacks in some estrogensensitive women. each physician should identify these estrogen-sensitive patients to manage specifically their contraception needs, pregnancies, and choices regarding hrt. further studies to determine predictive biological, genetic, and clinical parameters would be of use. role of sex hormones in hae, part ii most reported studies have investigated the influence of exogenous sex hormones on the frequency and severity of hae attacks. here, visy et al very briefly summarize a study they undertook measuring serum concentrations of endogenous sex hormones in women with hae and correlating these results with the occurrence of hae attacks. this work has since been published in clinical endocrinology. objective. the fluctuations of sex hormone concentrations at the beginning of adolescence, in the perimenopausal period, and during pregnancy or oc use can precipitate hae attacks. edematous attacks usually disappear after the onset of menopause. the authors undertook their study to establish any relationship between serum concentrations of sex hormones and the incidence of hae attacks. patients and measurements. serum concentrations of luteinizing hormone (lh), follicle-stimulating hormone, progesterone, estradiol, testosterone, prolactin, and sex hormone binding globulin (shbg) were measured in patients (mean age, . years; range, - years) with hae. a questionnaire was used to explore the medical history of adult patients to characterize the evolution and properties of attacks. results. twenty-one patients had been symptom-free before menarche. symptoms in of patients first occurred during adolescence, whereas the remaining patients had no attacks in the pubertal period. edema during the perimenstrual period was reported by . %. pregnancy was associated with a higher incidence of attacks in %; edema formation was less common in %, and % had no change in the frequency of symptoms despite pregnancy. of the patients using ocs, reported an increase in the frequency and severity of edematous symptoms compared with the period before hormonal contraception had been initiated. serum concentrations of sex hormones were normal in the majority of patients; however, more than half of the subjects had progesterone values above the upper limit of the normal range. during the -year follow-up, the attack rate was times higher in female patients with high progesterone concentrations (above the menopausal threshold of nmol/l) than in women with normal or low serum concentrations. the eminent role of this hormone is also confirmed by the observation that only progesterone was higher in more than % of subjects than the serum level considered normal for sex, age, and stage of menstrual cycle. therefore, serum progesterone concentrations above the postmenopausal threshold are predictive of a higher incidence of edematous attacks in female patients with hae. in addition, multiple logistic regression analysis demonstrated a significantly lower attack frequency during -year follow-up in patients with higher ( nmol/l) shbg level (odds ratio, . confidence interval; . - . ; p = . ). this difference existed independently of age and danazol dose (fig ) . looking ahead. in view of these results, the monitoring of progesterone and shbg concentrations can prove useful in the prediction of hae attacks. further inves-tigations might address whether this increased progesterone is a cause or a result of frequent attacks, or whether progesterone itself exerts any direct effects on vascular permeability. last, progesterone's effects on relevant gene expression might represent another valuable avenue of exploration. influence of ocs or hrt on hereditary forms of recurrent angioedema (konrad bork, md,* and bettina fischer, md, mainz, germany) in this section, bork et al write of a systemic study undertaken after they noticed women in their clinic with new or worsened angioedema in response to oral contraception or hrt. their study crosses the barriers of c -inh deficiency and hae type classifications to investigate the effects of exogenous hormones on hae. the new type of inherited angioedema recently described by their group has clinical features highly similar to classic hae-i and hae-ii; however, it is not associated with a c -inh deficiency. currently, the genetic defect is unknown. until now, the disease has been observed exclusively in women , , ; however, in families the existence of clinically unaffected male carriers has been deduced. , in the following report, the authors show that estrogens play a similar role in hae-i and this new type of inherited angioedema, herein described as hae with normal c inhibitor (hae type iii) in accordance with the original report of this condition by bork et al. among their case series, the authors observed female patients with hae who had newly developed recurrent angioedema after receiving ocs or postmenopausal hrt. in addition, other women had a worsening of their preexisting angioedema after initiating ocs or hrt, suggested that these treatments might trigger hae. however, this possible relationship has not formally been investigated, nor is angioedema listed as an adverse effect of ocs or hrt. [ ] [ ] [ ] information regarding the relationship between hormone administration and the first occurrence or worsening of hae symptoms is limited to anecdotal reports. , - , , , , , , , , a, in this study, a systematic approach was used to obtain information about the relationship between the use of oc or hrt and the clinical manifestation of hae-i and hae with normal c -inh (hae type iii). methods. the case series by bork et al included women with recurrent angioedema who had taken oc, hrt, or both. of these, this study investigated women with hae-i and women with hae with normal c -inh (hae type iii). the ocs used by all patients were combinations of estrogen (ethinyl estradiol) and progestin. medications used for hrt contained only estrogens, as was standard medical practice in germany until recently. all patients underwent a thorough clinical examination, and a standardized medical and family history was taken. in particular, patients were questioned about the frequency, intensity, and organ involvement of their angioedema since the very first manifestation of their disease. the start date and duration of administration of sex hormones, with special emphasis on oc and hrt, were recorded. patients were asked whether their angioedema occurred shortly after beginning this hormonal medication. if yes, the time between starting oc or hrt and the onset of angioedema was recorded. patients who had recurrent angioedema before the intake of oc or hrt were asked whether their angioedema episodes were more frequent or severe after beginning treatment. concentrations of c -inh, c , and c q were assayed by radial immunodiffusion, and c -inh functional activity was determined by using the chromogenic substrate c h co-lys(e-cbo)-gly-arg-pna (immunochrom c -inh; immuno diagnostics, vienna, austria). , results. as shown in table v , oc, hrt, or both treatments were associated with angioedema attacks in % of women with hae-i and % of women with hae type iii. among the group of patients whose angioedema attacks were newly induced by estrogen-containing medications, there was a high preponderance of hae type iii, whereas in the patient group with an exacerbation of symptoms, there were more patients with hae-i (fig ) . in women- with hae-i and with hae type iii-occurrence of skin or gastrointestinal angioedema manifested for the first time after the administration of oc. because of the assumed intolerance, several women tried different oc formulations, and all trials were followed by recurrences of angioedema episodes so severe that all oc had to be discontinued. the interval between starting oc and episode occurrence ranged from to days (mean, days). in of the women, symptoms were limited to the period of oc administration and ended after discontinuation. all had hae type iii. in the other patients, angioedema attacks recurred despite oc discontinuation. episodes occurred less frequently and less severely in , whereas symptoms were unchanged in women. there was occurrence of angioedema for the first time after starting postmenopausal hrt. one woman initially developed recurrent angioedema after starting hrt with estradiol ( mg/d). the patient continued to take oral estradiol over a period of years. after a consultation in the outpatient clinic, hrt was discontinued. symptoms persisted but occurred less frequently and were milder. the patient's daughter had recurrent skin angioedema and gastrointestinal pain attacks since age years; therefore, with a normal c -inh concentration and activity in both mother and daughter, a diagnosis of hae type iii was assumed. in women, the administration of oc induced a severe exacerbation of their pre-existing angioedematous disease. because of this exacerbation, women switched to another oc, some trying many different preparations. all of these oc doses were followed by recurrences of severe angioedema such that oc had to be discontinued. five women with previous recurrent angioedema of the skin and the gastrointestinal tract developed an exacerbation of their disease after starting hrt. of these, only were eventually able to tolerate such therapy. in of the , their angioedema also had exacerbated when on oc several decades before. discussion. the results indicate that in % of women with hae-i and in % of women with hae type iii, the use of oc or hrt was associated with either the initial appearance of angioedema attacks or with a severe exacerbation of previously existing angioedema. correspondingly, although also taking oc or receiving hrt, % of women with hae-i and % of women with type iii tolerated these medications without any negative influence on their disease; their disease was neither estrogen-dependent nor estrogen-sensitive. the results demonstrate that estrogen sensitivity is not a feature specific to hae type iii because it occurs in a similar percentage of women with hae-i. results from several case reports have suggested that administration of estrogens may exacerbate clinical manifestations of hae-i. frank et al mentioned young women with an exacerbation of hae associated with the use of oc. similar effects of the administration of oc or hrt on the clinical condition of patients with hae-i have been documented by others. - , , , , a, as in the current study, initiation of hormonal therapy was associated with the onset of clinical disease or a marked increase in the frequency and severity of angioedema attacks. with respect to hae-ii, fletcher and weetman described a patient with hae-ii and coexisting turner syndrome who had a severe exacerbation of angioedema attacks after initiation of a hrt with a combination of conjugated estrogen and progesterone. another type of hae, not associated with a c -inh deficiency, has been recently described. , , this disease has been reported exclusively in women and was termed hae type iii by bork et al and estrogen-dependent inherited angioedema or estrogen-associated inherited angioedema by others. , ten of the women described as having hae type iii in a previous study by bork et al took estrogen-containing oc and reported either the first appearance of clinical symptoms or a severe exacerbation of the disease in association with this treatment. in additional families with this new type of hae, , of affected women, developed angioedema after starting oc, as did after initiating hrt. warin et al a described sisters with estrogen-associated urticaria/angioedema. with the exception of urticaria, the symptoms in these women closely resemble those of patients bork et al have described as having hae type iii. it is highly probable that the agent responsible for worsening of pre-existing angioedema or provocation of initial symptoms in the women studied was estrogen rather than progestin. six of the women evaluated in their study had new angioedema attacks or exacerbation of preexisting disease after receiving estrogens alone, and their symptoms did not differ from those of women who received estrogens plus progestins. moreover, progestins have even been used for treatment of hae caused by c -inh deficiency, and improvement of disease has been observed in at least some of the patients treated. [ ] [ ] [ ] most important in the current context, progestin treatment has not been associated with worsening of angioedema. the causative role of estrogens in disease exacerbation suspected in this and other reports is also supported by the fact that attenuated androgens are effective in preventing edema attacks in hae caused by c -inh deficiency. all of these observations are consistent with the view that estrogens and not progestins are responsible for provocation of angioedema attacks or worsening disease in women with inherited angioedema who take oc or receive hrt. the pathophysiological mechanisms underlying the occurrence of angioedema in association with estrogencontaining medications is not known. as stated, available evidence suggests that bradykinin is involved in the development of symptoms in patients with hae caused by c -inh deficiency. , , in addition to its inhibitory effects on c s and c r, c -inh blocks the activity of other plasma proteases including kallikrein and factor xiia/xiif, enzymes that participate in bradykinin formation. bradykinin is generated from hk by kallikrein; the activation of prekallikrein to kallikrein is mediated by activated factor xii. the degradation of bradykinin to des-arg bradykinin and finally vasoinactive peptides is mainly mediated by carboxypeptidase n (kininase i) and angiotensin i converting enzyme (kininase ii). estrogencontaining medications might favor edema formation by influencing both kinin generation and degradation. gordon et al showed that c -inh levels in the plasma of women taking oc are lowered. administration of estrogens also leads to increased factor xii levels, possibly via a functional estrogen response element in the promoter of the gene encoding factor xii. , , plasma concentrations of prekallikrein have also been shown to be increased in women using estrogen-containing oc. estrogens might also influence the degradation of bradykinin via their influence on ace. it has been demonstrated that hrt in postmenopausal women leads to a decrease in ace activity. , , nogawa et al also observed an increase in plasma bradykinin levels in such women, a finding consistent with the action of ace in the breakdown of bradykinin. the mediator responsible for edema formation in hae type iii is not known. however, many clinical similarities exist between hae-i and type iii, and the percentages of women whose disease is negatively affected by estrogencontaining medications is similar in the conditions. these facts could permit speculation that estrogen-associated effects in women with hae type iii may also be related to the kinin pathway. however, whether the influence of estrogen-containing oc or hrt on the kinin pathway actually plays a role in favoring angioedema formation in patients with inherited angioedema is far from being clear today. the current results suggest that among patients with underlying hae, administration of estrogen does not always result in the appearance or worsening of symptoms. for example, other factors that might predispose women with hae to new or exacerbated symptoms when treated with estrogens could include a functionally or quantitatively relevant genetic polymorphism in the kinin system. information about such polymorphisms might be important in differentiating women whose angioedema would be aggravated by administration of estrogen-containing medications. recent guidelines for urticaria and angioedema released by the british association of dermatologists define hae as angioedema without urticaria and highlight the need for a specific treatment for this condition. toward this end, the newly created european prehaeat network proposes a list of diagnostic criteria for angioedema caused by functional c -inh deficiency ( table i) . because of the tendency of nonallergic angioedema to mimic other disorders, these criteria rely on both clinical and laboratory assessments. in addition, in the case of asymptomatic or newborn family members of relatives with known hae, laboratory measures, and genetic analyses represent the sole means of learning whether they, too, have the disease and might have future attacks. these points underscore the importance of laboratory measures in the definitive diagnosis of hae and related disorders. laboratory findings not only permit more complete diagnosis and classification of angioedema caused by inadequate c -inh function but also form a key part of the evolving understanding of the genetic and biochemical aspects of these diseases. however, currently, no valuable laboratory criteria are available for the recently detected estrogen-dependent inherited angioedema. , , in the report that follows, varga et al, in an international collaboration arising out of the third c esterase inhibitor deficiency workshop, set forth guidelines for the proper laboratory investigation of suspected hae, aae, and related disorders. for diagnostic purposes, the c -inh protein phenotypes of the various types of angioedema without an allergic or pseudoallergic background are important (table vi) . mutations in the coding region of the c -inh gene leading to hae are all heterozygous conditions. (there is known exception, an italian family with a homozygous defect in the gene control region that might have evolved because of multiple consanguinity. however, even as a homozygous mutation, this defect did not lead to a complete deficiency of c -inh. , ) hae-i is defined as the presence of mutant c -inh gene whose gene product is undetectable in the circulation by routine methods. however, ultrasensitive methods might detect abnormal protein in some patients diagnosed with hae-i by routine analysis. in these patients, a reduced amount of normal c -inh is found (table vi) . hae-i may result from the production of a missing mutant protein, eg, from a mutation resulting in a stop codon, production of a mutant protein that is subsequently degraded intracellularly, production of a mutant protein that is not secreted and that might accumulate intracellularly, or production of a mutant protein that is released but rapidly catabolized or degraded in the circulation. hereditary angioedema type ii is defined as c -inh gene producing a dysfunctional protein that is released and coexists with the normal protein in patients' circulation. the current routine analytic tools for detecting c -inh antigen are unable to distinguish between normal and abnormal forms of circulating c -inh. as a consequence, normal or elevated concentrations of the protein are found (table vi) . notably, the distinction between hae-i and a transient rise in bradykinin can be measured during attacks. àat least patient with normal c q level was reported. §female patients and male patient with recurrent edema caused by androgen deficit. hae-ii is not absolute because some mutant protein can be detected in selected patients diagnosed with hae-i by using the most sensitive detection systems rather than routine methods. thus, the classification or diagnosis of hae-i or hae-ii might depend on the sensitivity of the analytic system used. independent of the type of hae, the affected heterozygous individuals show concentrations of native, functional c -inh far below % of normal. estrogen-dependent inherited angioedema patients (formerly hae type iii) show no abnormalities in c -inh concentration or function (table vi) . tissue swelling in the presence of normal c -inh concentration and function in this form of inherited angioedema might be understood through the assumption that attacks are related to transient increases in bradykinin concentration. for the classification of the acquired forms of angioedema, the presence of a pathogenic autoantibody to c -inh is relevant: type i shows no such pathogenic autoantibody, whereas in patients with type ii, such autoantibodies are detectable. however, the distinction between type i and type ii aae may become obsolete over a disease course, because patients might present with symptoms in the early stage of aae without detectable autoantibodies, whereas at later stages, autoantibodies can be detected. regarding the distinction between the types of aae, the diagnostic tools used and their sensitivities or accuracy of assessment might be crucial for classification. the presence of anti-c -inh autoantibodies causes hypercatabolism of c -inh; increased amounts of a cleaved c -inh with a reduced molecular weight are found in the circulation in patients with aae. finally, a few patients with recurrent, nonallergic angioedema in association with androgen deficit have been reported. the report mentions an affected male patient in addition to affected female patients; disease manifestation was reversible by appropriate correction of androgen levels. inheritance was not reported. it remains open whether this form fits best to aae. according to comprehensive family studies and case reports, the onset of hae-i can manifest during an affected child's first years of life. [ ] [ ] [ ] as early as , a high number of colicky babies were reported in families with hae. several authors have observed the onset of the disease beginning in children . years of age. , farkas et al found clinical manifestations of hae in children from . years. in a large hae-affected family in northern norway, children with the disease had their first typical symptoms at to years of age. however, in case, a mother noticed different phonation, edema of the mouth and tongue, and enlargement of the uvula in her -month-old child, arising during a period of primary teeth eruption. even if hae often makes it debut later, the statement in a review on the management of hae in pregnancy in the journal anesthesia that ''hae is always asymptomatic in infancy'' is misleading. early infancy is a likely age for the first manifestations, and physicians dealing with newborns with hae-affected parents should suspect an underlying c -inh deficiency as a potential cause of symptoms such as unspecific recurrent abdominal pain, diarrhea, upper respiratory disease, or skin rashes. therefore, a reliable diagnosis of children born to hae-affected parents is required as soon as possible. a c -inh concentration or functional activity < % of normal, in conjunction with low c concentration, supports a diagnosis of hae. tools for laboratory diagnosis. life-threatening laryngeal edema in association with inadequate c -inh function in untreated or poorly treated patients has been reported to have a lethality of % to %. , , because c -inh functional deficit might remain clinically silent for decades, the high lethality because of acute airway obstruction underscores the importance and significance of awareness of this syndrome and the availability of an expert laboratory to assess c -inh functional deficiency. laboratory analyses should be performed under at least minimal quality assurance conditions. test systems using calibration curves with only points must be considered as not meeting the standard; through points, every curve fitting is possible. the test system must also include quality control specimens: normal to high and low. a test is valid only if the quality control measurements are within a range of predefined values. it is advisable to assess the laboratory's own normal range. the number of normal sera/plasma used (in bern) for such a purpose is > . a standard specimen is prepared by pooling equal aliquots of each serum/plasma; next, testing individual plasma samples against the pool provides the normal range. material for analysis. for complement protein concentration measurements, edta-treated plasma is best suited. in the event that citrated plasma is used, normal ranges assessed with citrated plasma must be applied to correct for dilution by the citrate. for assessment of c -inh function, serum or citrated plasma is convenient; heparinized plasma should not be used. a diagnosis of any type of c -inh deficiency or dysfunction should be confirmed with at least assessments by using samples drawn to months apart with the patient in basal condition. for the early diagnosis of newborns born to parents with hae-i, sufficient blood can easily and painlessly be obtained from the placenta or the umbilical cord at birth. because newborns have a very high hematocrit of . and a consequently low plasma portion, the amount of protein will be diluted when using citrate as anticoagulant. this should be kept in mind when comparing reference values from newborns; citrate dilution of samples must also be considered with samples from adult patients. c -inh concentration. the concentration of c -inh protein can be assessed by several routine methods such as radial immunodiffusion, nephelometry, or elisa. the mean serum concentration in normal individuals is around . g/l. in the sera of newly diagnosed patients with hae-i or patients with hae-i patients who do not need medication because of mild symptoms, the mean concentration of c -inh protein is considerably reduced (table vii) . in patients with hae-ii, the serum c -inh concentration is approximately % or may be elevated to % to %. the latter excess is a consequence of an arg cys mutation of the reactive site, resulting in a free sulfhydryl group, enabling the mutated c -inh protein to bind to other serum proteins (table vii) . in the sera of patients with aae, the concentration of c -inh can be low or normal. normal antigenic amounts of c -inh can be detected if interaction with autoantibodies against the -kd c -inh protein results in a cleaved, nonfunctional -kd protein. c -inh function. c -inh function can be assessed by several methods. when analyzing samples from a patient with hae-i before and minutes after c -inh concentrate infusion, considerable differences emerge in rise of apparent c -inh function, depending on which method is applied (table viii) . c -inh function, when assessed by enzyme-based chromogenic assays, results in a linear relationship with the antigenic concentration of the c -inh protein. the chromogenic substrates used are etco-lys (e-cbo)-gly-arg-pna (formerly from immuno, vienna) or meco-lys (e-cbo)-gly-arg-pna (aventis behring, marburg, germany). some reports favor the assessment of c -inh function by loss of immunologically reactive c r. the method uses the natural substrate c r of c -inh as the indicator and works exclusively with endogenous complement. by using this inexpensive type of assay system, one can observe a functional threshold value for c -inh concentration and function. formation of c -inh-c r or c -inh-c s complexes can be assessed by an elisa test system that also uses the natural but exogenous substrate of c -inh as an indicator. by commercial elisa tests based on the detection of formed c -inh-c s complexes, the median functional concentration is less than % of normal at the time of diagnosis (table ix, (table ix) . this observation is somewhat discordant with numerous observations made in bern, reported in table viii . analysis of other complement components. to exclude or to confirm an acquired form of c -inh de- the concentration of c may be assessed by nephelometry or radial immunodiffusion by using polyclonal antibodies. a substantial part of the already diminished c actually consists of c split products, as can be measured with a monoclonal antibody specific for a neoepitope on c split-products. , the ratio of c splitproducts over c was . for a normal subject and . for the subject's cousin with hae. functionally active c can be determined by hemolytic assay. in aae with diminished c , the replacement of c must be considered, because the low c value may hamper c assessment. the antigenic or functional concentration of c is very low in almost all newly diagnosed or untreated cases of hae (table x) and aae. in hungary, a borderline c concentration was found in only of newly diagnosed patients with hae. thus, for an inexpensive follow-up, assessment of c concentration might suffice. indeed, increased c -inh concentration and function because of therapy that resulted in a reduction in edematous attacks was associated with a measurable increase of c concentration to nearly normal when using polyclonal antibodies to assess c (fig ) . it should be noted that such a test system is unable to distinguish between natural and cleaved c . a diminished antigenic level of c is extremely rare in hae, but in % to % of cases, even in of in newly diagnosed patients with hae, a slightly depressed concentration of c was measured in hungary. there is no correlation between the concentration of c q and c . detection of pathogenic anti-c -inh autoantibodies. the majority of patients with aae have autoantibodies to c -inh in their serum (aae type ii). these antibodies bind epitopes within or close to the reactive site of c -inh. anti-c -inh autoantibodies that bind to c-inh with different and generally low affinities can belong to each class (igg, iga, or igm). anti-c -inh autoantibodies are detected by elisa. diagnosis of c -inh deficiency in newborns at risk. in adults with angioedema caused by c -inh deficiency, determination of c and c -inh antigenic and functional concentrations nearly always allows a correct diagnosis. however, these complement components show considerable age-specific variations in children. the concentration of c -inh antigen measured in umbilical cord blood, as a rule, is approximately f the concentration found in adults. [ ] [ ] [ ] [ ] [ ] a reference range for the common functional c -inh test in newborn cord blood was published in . the percentiles are presented in table xi . functional assays even allow the prompt detection of the rare form of hae, ie, hae-ii, in which the antigenic concentration of c -inh is normal or even higher than normal, but mostly consists of a dysfunctional protein. whereas in the study the mean c -inh functional activity in healthy newborns was approximately % of the mean adult value, sonntag et al found a somewhat higher c -inh function (; %) in their study in citrated cord blood. during the child's first days, c -inh and c values rapidly rise and may reach . times values found in adults. andrew et al found that near-adult values are achieved for c -inh by months of life. in healthy premature infants, c -inh concentrations reached the normal adult range by week of age. norman et al found large variation in c , which in their opinion limits the diagnostic usefulness of quantitative c concentrations in children. diagnostic problems and strategy. several consequences result from the aforementioned experiences. to confirm or disprove a suspicion of clinical hae-i, measuring the concentration of c -inh protein is satisfactory; however, this is not adequate to detect hae-ii or aae type ii. assessment of c -inh function is therefore required. normal functional c -inh concentrations can be observed in patients with hae under therapy when measured by assays based on the formation of c -inh-c r/c s complexes. if the analyzing laboratory is unaware of this fact and receives a sample from a patient not known in the laboratory, a diagnosis of hae might be missed. in contrast, c -inh measurements using commercial enzyme-based chromogenic assays yielded a false diagnosis of hae in % of samples. the positive predictive value for a diagnosis of c -inh deficiency was only % with the chromogenic assay, whereas it was % with the c -inh-c s elisa test kit. the negative measurement of c concentration can be used as a screening marker when hae is suspected. however, low c is not sufficient for diagnosis, because this is seen in many conditions with classic pathway activation. if c and the antigenic concentration of c -inh are both normal, c -inh functional deficiency can be excluded. low c concentration is also a characteristic feature of aae. diminished amounts of c or its subcomponents, preferably c q, are indicative of an acquired c -inh deficiency. however, low c (q, r, s) together with low c is not a proof for aae (table vi) . a normal complement profile (normal antigenic c -inh, c q, and c ) was reported in patients with aae. , in the latter case, a transient improvement in c -inh function was associated with a transient loss of anti-c -inh autoantibodies. on the basis of the listed diagnostic possibilities, the authors suggest an algorithm for the diagnosis of any type of suspected c -inh deficiency, as shown in fig . the use of such an algorithm is strongly advised because, on follow-up of patients. according to the literature, c -inh concentrations in hae-i patients greater than % to % of normal are sufficient to provide inhibition of classical pathway activation, a finding that is confirmed by clinical observations. thus, in such patients, the dose of attenuated androgens should not be increased with the aim to reach antigenic c -inh levels approximately % of normal. ignorance of this fact might provoke higher and higher doses of, eg, attenuated androgens that bring no added benefit for c -inh function and might harm the patient's liver. enzyme-based chromogenic substrate assays are excellent for initial diagnosis of deficient c -inh function, but seem less well suited for monitoring during therapy (table viii) . measurement of c concentration is an inexpensive and generally useful parameter, even to follow up therapy, and especially in aae. concentrations of c close to the lower limit of normal, ie, at the lower % limit of confidence, have been found to indicate sufficient function of c -inh to allow patients to be attack-free (fig ) . in summation. for definitive diagnosis of angioedema associated with c -inh functional deficiency (hae-i, hae-ii, and aae), the assessment of c -inh concentration and/or function and, in some cases, the concentration of at least of the c subcomponents are the routine diagnostic tools. for laboratory diagnosis, measurements should be performed twice, at an interval of at least month, showing c -inh concentration and/or function < % of normal. laboratory diagnosis in newborns is difficult and needs special consideration. assessments of other complement parameters, such as c concentration, are to be considered surrogate markers, although excellent ones. no laboratory analyses to reveal estrogen-dependent inherited angioedema are thus far available. because purified c -inh concentrate is derived from human plasma, virus safety is critical. as mentioned earlier, in to , patients developed a non-a, non-b hepatitis related to the administration of c -inh concentrate, probably because of a contaminated batch. since the introduction of viral inactivation steps, transmissions of infectious agents have not been reported. side effects of c -inh concentrate are rare and include fever and headache. to date, the formation of autoantibodies to c -inh as a result of c -inh concentrate administration has not been observed in any patient with hae. c -inh concentrate is expensive because of high production costs, the low number of patients with hae, and the relatively low dose per patient compared with other blood products, such as those used in hemophilia. c -inh concentrate is now available in most countries, at least on a named-patient basis, but is not available in the united states. fresh frozen plasma. fresh frozen plasma (ffp) is also effective and can be used if c -inh concentrate cannot be obtained. because ffp is not virally inactivated, the risk of transmitting infectious agents is relatively high. the administered volume is larger and requires a longer infusion time, which might be critical in emergency situations. the use of ffp is associated with several adverse effects, including urticaria, anaphylactic shock, and hemolysis. other. corticosteroids and antihistamines are usually ineffective. attenuated androgens require at least a few days to become effective and therefore are usually not administered in acute attacks of hae. the same is typically true for antifibrinolytics; however, some patients with mild attacks respond to g tranexamic acid by mouth every to hours for to hours. for abdominal pain during attacks, spasmolytics such as butylscopolamine may be used symptomatically and are of benefit in milder attacks. future treatment options for acute edema episodes. kallikrein inhibitors. the candidate mediator of angioedema caused by c -inh deficiency is bradykinin, released upon kallikrein activation. more than years ago, aprotinin, a kallikrein inhibitor extracted from bovine lungs, was shown to be effective in treating hae attacks. because of the risk of fatal anaphylactic reactions, its use was discontinued after substitutive therapy with c -inh concentrate became available. a novel kallikrein inhibitor has recently been developed. it is a synthetic kunitz domain protein designed by phage display technology to bind to human kallikrein. it has a high affinity and is highly selective for kallikrein. it is effective in abating acute attacks of hae but is not yet commercially available. bradykinin antagonists. because bradykinin is assumed to be the key mediator of hae, blocking its b receptors might be therapeutically useful. icatibant is a synthetic peptide with a structure similar to bradykinin. however, it contains nonproteinogenic amino acids and is not degraded by the main bradykinin cleaving enzymes, carboxypeptidase and ace. a potent antagonist, icatibant has the same affinity for b receptors as bradykinin across several tested species, including human beings. it is specific for b bradykinin receptors and does not interact with receptors of other peptides. preliminary studies were performed in human beings with asthma and seasonal allergic rhinitis, , and icatibant was also shown effective in reversing increased vascular permeability in the murine hae model. recently, the results of a phase ii single-dose trial for the treatment of acute hae attacks in patients were reported. in this european trial conducted by bork et al. a icatibant appeared effective and well tolerated. recombinant c -inh. during recent years, a recombinant c -inh produced in the milk of transgenic rabbits has been developed. however, because of glycosylation differences, it has a shorter half-life than c -inh derived from human plasma. initial results in patients with hae concerning tolerability and safety are encouraging. the interim results of a phase ii trial conducted by levi et al a in acute attacks of hae appear positive. long-term prophylaxis. long-term prophylactic treatment is indicated for patients with many harmful and disturbing edema episodes, usually patients with more than attack per month. long-term prophylaxis may be performed with attenuated androgens, antifibrinolytic agents, and c -inh concentrate. all of these medications are associated with potential adverse effects, limiting their use as standard, life-long prophylactic treatment. attenuated androgens. in , spaulding reported the striking efficacy of methyltestosterone in hae, describing both a decrease in the severity and number of attacks. later, further androgens, fluoxymestrone in men and oxymetholone in women (with fewer virilizing effects than methyltestosterone), were tested. in , stanozolol was synthesized, having of the largest anabolic/androgenic ratios. in , danazol, a synthetic analogue of ethinyltestosterone and less virilizing than the early synthetic androgens, was developed. in , the attenuated androgen danazol was shown to considerably reduce the number of hae attacks. since then, attenuated androgens ( -a alkylated androgens), mostly danazol or stanozolol, have been widely used for long-term prophylaxis in hae. , although -a alkylated androgens are more efficient than other androgens, they are metabolized by the liver. thus, hepatotoxicity and the induction of liver cell adenoma or carcinoma are major concerns. androgens' mechanisms for exerting beneficial effects in patients with hae are unknown. major contraindications for treatment with androgens are pregnancy, lactation, childhood, and prostate cancer. however, as discussed later, there are a few reports on the successful use of androgen treatment in children. danazol. a widely used regimen is to start with an induction dose of to mg daily for weeks and then taper down to the lowest maintenance dose that provides symptomatic relief. most patients' hae is controlled with to mg daily or every other day. long-term administration may be associated with several adverse effects, including weight gain, amenorrhea, decreased libido, menstrual irregularities, virilization in women (hirsutism, deepening of the voice, and decreased breast size), acne, muscle cramps, myalgia, fatigue, headaches, hemorrhagic cystitis, arterial hypertension, and hepatic necrosis or cholestasis. [ ] [ ] [ ] [ ] recently, hepatocellular adenoma and liver cell carcinoma have been reported in patients with hae taking danazol for many years. [ ] [ ] [ ] laboratory changes may include decreased sex-hormone binding protein and thyroxine-binding protein, increased aminotransferases and cholesterol, and polyglobulia. stanozolol. stanozolol is used in initial doses of to mg per day for month, then tapered to the minimal effective dose ( . - mg daily). potential adverse effects may be similar to those of danazol but seem to occur less frequently. however, this needs further confirmation, because fewer patients treated with stanozolol have been reported in the literature compared with patients receiving danazol. other androgens. several patients have been treated with an oxandrolone. a small number of patients do not respond to androgens. antifibrinolytic agents. antifibrinolytic agents may also be used for the continuous prophylactic treatment of hae. however, their efficacy is lower than that of androgens. in about % of patients, attacks occur less frequently and are usually milder. a considerable reduction of the number and severity of attacks is reached in only approximately % of patients. if long-term prophylaxis is necessary in children, tranexamic acid may be preferable to androgen treatment because androgen treatment should be avoided in childhood. presumably, antifibrinolytic agents act through the inhibition of plasmin. all antifibrinolytics bear the risk of thromboembolic events. e-aminocaproic acid is effective and reduces the frequency of attacks. the daily dose is usually to g in equally divided doses. it is associated with various side effects such as thrombosis, postural hypotension, muscular pain and weakness associated with an increase in creatine kinase and aldolase, anal pruritus, and myositis. because of the many adverse effects associated with e-aminocaproic acid, tranexamic acid is the antifibrinolytic of choice. the daily tranexamic acid dose is usually to g per day. side effects are uncommon but include abdominal discomfort, mild transient diarrhea, nausea, headache, and anal pruritus. c -inh concentrate. not only an acute attack therapy, c -inh concentrate has been found effective in the longterm prophylaxis of hae. in , the first patients were treated with u c -inh concentrate or times weekly for year or more. a report of patients who received c -inh concentrate twice weekly was published in . short-term prophylaxis before surgery. because of the risk of developing angioedema and possibly experiencing life-threatening laryngeal edema after dental surgery, endoscopy, endotracheal intubation, and other surgical procedures, preoperative treatment has been attempted. to date, available information is limited to case reports or small patient series. furthermore, even in the absence of preoperative prophylaxis, not all patients with hae develop edema attacks after surgery. patients who undergo multiple dental surgeries may develop edema episodes after some tooth extractions but not others. it is therefore difficult to assess the efficacy of a recommended preoperative prophylaxis until studies with larger numbers of patients are available. such prophylaxis has been performed with ffp, antifibrinolytics, attenuated androgens, and c -inh concentrate. in several patients, ffp has been used prophylactically before dental surgery; in some patients, mild attacks occurred despite pretreatment with ffp. [ ] [ ] [ ] antifibrinolytics such as e-aminocaproic acid and tranexamic acid , have also been used for preoperative prophylaxis in some patients. because antifibrinolytics are less effective in long-term hae prophylaxis, preoperative treatment focuses on attenuated androgens and c -inh concentrate. in patients with known hae caused by c -inh deficiency, preoperative prophylaxis with attenuated androgens, either danazol or stanozolol, has been shown to be effective in many patients, , [ ] [ ] [ ] although some patients nonetheless developed swelling. , for short-term prophylaxis, attenuated androgens may be administered from days before to days after the event, danazol at a dose of mg/kg/d, maximum mg per day, or stanozolol at a dose of mg per day. currently, c -inh concentrate has been used as preoperative prophylaxis in only a few patients; for this purpose, the dose of c -inh concentrate was or u. , the risk of developing angioedema attacks secondary to dental surgery or other oral manipulations cannot be completely avoided by preoperative prophylaxis. as such, it is important to inform the patient that an angioedema attack might occur, to describe the clinical symptoms of laryngeal edema, and to educate the patient about what to do in case a laryngeal edema occurs. in this section, cicardi et al describe the typical treatment of aae and discuss the special considerations unique to this disorder. from pathogenesis to treatment. like other acquired forms of protein deficiencies, the course of acquired c -inh deficiency can be related to the course of the underlying disease. the possibility of reversing the biochemical and/or clinical abnormalities of acquired c -inh deficiency by curing the associated disease was reported by cohen et al and subsequently confirmed. , , [ ] [ ] [ ] however, the response can be temporary, even without evidence of relapse of the associated disease. analogous to hae, patients with acquired c -inh deficiency have received attenuated androgens for prophylaxis and c -inh concentrate to treat acute attacks. , nevertheless, these patients are frequently resistant to attenuated androgens, , whereas they tend to benefit from antifibrinolytic agents. , , antifibrinolytics are thus more effective for long-term prophylaxis in this population and represent the first choice for patients with acquired c -inh deficiency. replacement therapy with c -inh plasma concentrate is the treatment of choice for life-threatening laryngeal attacks. however, patients with aae partially resistant to this treatment have been reported. , , , the response to treatment differs from hae because of the rapid catabolism of c -inh that characterizes aae. higher doses of c -inh plasma concentrate were required in patients with a slow response to treatment. slow responsiveness is a high-risk condition because it seems to increase with subsequent treatment. a new peptide, dx- , a synthetic kallikrein inhibitor based on the same functional domain (kunitz domain) of aprotinin, is under study for treating angioedema in patients with hae. , by inhibiting kallikrein activation, this peptide can stop generation of the vasoactive peptide bradykinin from hk, for hae and related conditions, plasma-derived c -inh concentrate remains the acute attack therapy of choice. in this section, juers and gröner detail the steps that are taken to ensure the high margin of virus safety for berinert p, produced at aventis behring gmbh, a zlb behring company. before the advent of specific therapy, the hae mortality rate caused by laryngeal edema was as high as %; even today, rates as high as % mortality associated with hae have been published. , the introduction of c -inh concentrate (berinert in in germany) was followed by the german registration of a pasteurized c -inh concentrate (berinert p) in . these drugs significantly changed the treatment procedures for acute attacks in patients with hae, becoming the treatment standard in the countries where berinert p is available. in countries where berinert p or another c -inh concentrate was not available (for example, the united states), treatment of acute attacks was and sometimes still is usually performed with ffp. however, during the preparation of ffp, no reduction of potentially present viruses is achieved, in contrast with the plasma-derived c -inh concentrate berinert p. similarly, although solvent-detergent treated ffp might seem an alternative, this treatment does not inactivate nonenveloped viruses. the following sections describe the current status of virus safety of berinert p. methods. berinert p is produced from pooled human plasma, primarily from source plasma, ie, plasma collected by plasmapheresis. in general, plasma-derived products may potentially transmit infectious and/or pathogenic viruses. this risk is minimized by careful selection of donor centers with regard to virus marker rates (epidemiology) and careful selection of donors; each donor, including qualified donors (ie, repeat donors), is evaluated before each donation for vital signs including temperature and blood pressure and subjected to an intensive questionnaire. details have been described recently. furthermore, every donation is tested with serologic methods for hepatitis b surface antigen (hbsag) and antibodies against hcv, hiv- , and hiv- as well as elevated alanine aminotransferase levels. in addition, sample pools of donations are tested by using nucleic acid amplification technique (nat)/pcr for genomic material of hepatitis a virus (hav), hepatitis b virus (hbv), hcv, hiv- , and high titers of parvovirus b (b v). reactive donations are discarded. furthermore, the plasma pool for fractionation is tested and released for further processing only if the pool is nonreactive (negative) for hbsag and nonreactive for antibodies against hcv, and hiv- , and hiv- as well as nonreactive for hav rna, hbv dna, hcv rna, and hiv- rna, and for b v dna not exceeding iu/ml. the third main step ensuring virus safety is the elimination and inactivation of possible viral contaminants by the manufacturing procedure, whose capacity for virus reduction is tested in virus validation studies. the virus inactivation/removal steps used in the manufacture of berinert p use treatment in aqueous stabilized solution at °c for hours (pasteurization) and specific chromatography. results. in virus validation studies designed to assess the capacity of the manufacturing process to inactivate and/or eliminate intentionally added virus, high overall virus reduction factors were demonstrated (table xii) . these virus validation studies were performed in accordance with the applicable committee for proprietary medicinal products (cpmp) notes for guidance. viruses covering a wide range of physicochemical properties were used in these studies (hiv- and hav are relevant viruses, bovine viral diarrhea virus [bvdv] and canine parvovirus [cpv] are specific model viruses for hcv and b v, respectively, and pseudorabies virus (prv) is a nonspecific model virus for large enveloped dna viruses). the results demonstrate that the pasteurization and the manufacturing process of berinert p effectively inactivate and/or eliminate relevant human pathogenic viruses. to demonstrate that the manufacturing steps explored in the virus validation studies were very robust and that variations in the manufacturing procedure had no effect on the virus reduction capacity, specific studies covering parameters beyond production specification were performed. these studies showed that even under these conditions, a very effective virus inactivation occurred. regarding analysis of postmarketing surveillance for berinert p from until now, no cases of proven virus transmission, according to the assessment of the global pharmacovigilance department at aventis behring, were reported, although a total of almost million units of berinert p were administered. discussion. the outbreak of aids in the s and the resulting infections caused by blood transfusion and treatment with certain plasma derivatives, mainly factor viii concentrates, showed that virus safety in plasma proteins is a field of permanent attention, screening, and continuous research. since the former behringwerke ag introduced pasteurization in the s (developed by heimburger primarily for hemophilia products), no hiv transmission via the company's pasteurized products has occurred. [ ] [ ] [ ] this pasteurization procedure has been adapted to aventis behring's plasma products, including c -inh concentrate. the pasteurization procedure has been shown to have an excellent track record of virus safety, and the validity of the pasteurization for virus inactivation was confirmed in scientific articles. [ ] [ ] [ ] pasteurization is a very effective and robust virus inactivation method, but there are also limits. animal parvovirus, for example, is inactivated by pasteurization only to a certain degree. however, because of recent findings, it should be kept in mind that the human b v is heat-sensitive and can be effectively inactivated by pasteurization; preliminary data from the group's own experiments (data not shown) also confirm this observation for stabilized aqueous solutions. in addition, antibodies against b v in the plasma pool for fractionation and in intermediates derived from that pool will neutralize b v to a high degree. furthermore, regarding cpv, the specific chromatographic step was validated for its capacity to remove cpv, and a very effective and robust removal could be demonstrated. in conclusion, on the basis of the data from virus validation studies, independent effective virus reduction steps in the production procedure for berinert p, effective for a wide range of enveloped and nonenveloped viruses, could be demonstrated. as outlined in the cpmp guideline (cpmp/bwp/ / ), the aim of virus validation studies is ''(i) to provide evidence that the production process will effectively inactivate/remove viruses which are either known to contaminate the starting materials, or which could conceivably do so, and (ii) provide indirect evidence that the production process might inactivate/remove novel or unpredictable virus contamination.'' so far, all new emerging viruses or members of the same virus family, which may be of severe concern in a blood transfusion setting, were shown to be reduced through manufacturing procedures. this was especially demonstrated for west patients had medical, psychologic, and economic difficulties attributable to hae or aae. among patients with a home supply of c -inh concentrate, patients had avoidable adverse effects. one developed severe anxiety and depression requiring outpatient psychiatric care on being diagnosed with aae. another was unable to work as a baker on several occasions because of severe hand edema. the third had frequent angioedema and longstanding severe temperomandibular pain, which resolved when she was started on regular c -inh concentrate. this patient required frequent absences from work. of patients who did not have access to c -inh concentrate at home, patients had avoidable adverse effects. as fig illustrates, patients had avoidable admissions to hospital, attributable to c -inh concentrate treatment not being given or being delayed, resulting in suboptimal response to therapy. one man required intubation and a -day stay in the intensive care unit when no c -inh concentrate could be found in the department. the same man was listed for surgery (tracheotomy for laryngeal edema and laparotomy for acute abdominal pain and guarding) on occasions despite carrying a letter giving advice concerning the emergency management of his aae. on both occasions, after calls to his regular physician, he responded to treatment with c -inh concentrate, and surgery was canceled. in addition, patients were treated with ffp, a product that is likely to be less safe and possibly less efficacious than c -inh concentrate. , one woman received an average of units of ffp each month at her local emergency department, where personnel were unwilling to prescribe c -inh concentrate. one patient had severe anxiety and depression and was unable to work. she improved when started on the home therapy program. however, she had a severe exacerbation of her psychiatric condition when funding difficulties put the future of her home therapy in doubt. four additional patients had day or more per month of absence from work or school because of symptoms, and patient requested a private prescription of c -inh concentrate to enable him to travel abroad safely, despite being entitled to c -inh concentrate funded by the uk national health service. discussion. many uk patients have difficulty in accessing appropriate emergency treatment for hae or aae, with avoidable medical, psychiatric, and economic consequences. the events recorded here are the most serious. many patients have ongoing anxiety concerning access to treatment. some are reluctant to travel; many accept frequent painful attacks and disruption of education or work without complaint (price; uk hae network; personal communication, june ). this audit suggests that patients who carried their own supplies of c -inh concentrate were less likely to have difficulties in accessing appropriate care and were less likely to have ill effects. reasons for pcts' reluctance to fund home c -inh concentrate included lack of familiarity with the use of c -inh, reluctance to use a product not licensed in the uk, lack of national management guidelines for hae and aae, lack of agreement among uk specialists of the necessity for a home c -inh supply, expense of the product, and the mistaken belief that the hospital had funds to prescribe c -inh concentrate. on the basis of their experience, the author's group recommends that all patients with hae or aae should carry their own supply of c -inh concentrate and that their local hospital should stock additional supplies so that this can be replaced immediately after use. to improve access in the uk, the author recommends negotiation with uk primary care trusts to fund costs of hae or aae treatment for all patients, development of national and international guidelines concerning hae management and supply of c -inh concentrate, and improved education for medical staff. in this companion piece, longhurst and o'grady describe a program allowing patients with hae to selfinfuse c -inh concentrate and detail its outcome. the benefit and safety of home therapy is well established for many patient groups, including those requiring blood products such as igs for antibody deficiency and factor viii for hemophilia a. , in the uk, patients with hae are advised to attend their local emergency department for treatment of severe or potentially life-threatening angioedema attacks. patients with frequent attacks are also offered prophylaxis with attenuated androgens, such as danazol, or tranexamic acid. , despite prophylaxis, a minority of patients with c -inh deficiency require repeated emergency hospital visits for administration of c -inh concentrate to treat life-threatening laryngeal swelling and severe abdominal pain. waiting times in uk emergency departments can be several hours, and personnel may be unfamiliar with managing hae. as a result, hospital attendance is disruptive to the patient, who may be tempted to wait until the attack is severe, with potentially serious consequences. methods. the authors have introduced a home therapy program to improve access to treatment, thereby improving quality of life for people with severe hae and reducing the use of emergency services. patients entering the home therapy program must fulfill the following criteria: ( ) proven c -inh deficiency ( ) prophylactic therapy optimal ( ) required infusions of c -inh concentrate at least every months ( ) infusion partner available ( ) commitment to program of patients considered for the program, patients from the same family were already self-administering (under the care of their general practitioner) and received a refresher course. six further patients' symptoms were not controlled after optimizing prophylactic therapy. of these, patients met the criteria for inclusion, patient was refused funding, and patient did not wish to have home therapy. all patients were trained and successfully use c -inh home therapy. a minimum of hours training over a period of visits was followed by a formal assessment of patient and infusion partner. patients kept a record sheet of all attacks and contacted the specialist nurse if they infused. records were reviewed and infusion technique (using sterile saline) and knowledge were assessed at -month intervals. case reports. patient a, a -year-old female patient, was initially treated with danazol. this was stopped because of persistently abnormal liver function. tranexamic acid was only partially effective. she had attacks of severe angioedema affecting the skin, abdomen, and occasionally the larynx, requiring treatment with iu of c -inh concentrate at least once a week. intractable temperomandibular pain developed. she was started on c -inh concentrate (berinert p) iu twice weekly. her temperomandibular pain improved, and she had fewer angioedema attacks. patient b, a -year-old female patient, had discontinued danazol because of excessive weight gain and voice abnormalities. she had subsequently received depot methyltestosterone mg subcutaneously every months without side effects for many years, in combination with tranexamic acid g twice daily. however, she had cutaneous and severe abdominal angioedema every to days. her mother had died of hae despite knowledge of the diagnosis, and the patient developed severe anxiety, necessitating specialist psychiatric treatment. after inclusion on the home therapy program, the patient infused to iu c -inh concentrate approximately once a month, as required for severe symptoms, and reported an improvement in her quality of life. however, the threat of suspension of her home therapy because of funding problems led to an increase in her anxiety and the number of angioedema attacks, a well-recognized consequence of psychologic distress, such that iu of c -inh concentrate was required once or twice per week. resolution of the funding problems led to an immediate restoration of well-being and reduction in use of medical services, but she continued to require to infusions of iu c -inh concentrate per month. patient c, a -year-old female patient, had frequent abdominal hae attacks, requiring an average of days off work per month. she attended her local hospital emergency service approximately once per month and on each occasion received units of ffp. after inclusion in the home therapy program, she reported a greatly improved quality of life, no time off work, and no further exposure to ffp. she infused to iu of c -inh concentrate approximately once per month. patient d, a -year-old female patient who had infrequent attacks without prophylaxis, developed severe abdominal attacks, occurring once or twice a week from the th week of her first pregnancy. she was treated with iu of c -inh concentrate twice weekly from week until weeks after delivery of a healthy boy. she had only mild abdominal attack during her pregnancy and continued full time work until the th week. after delivery, her attacks were infrequent, despite discontinuation of c -inh concentrate. she chose to withdraw from the home therapy program but plans to retrain if necessary during any future pregnancies. family e, a -year-old mother, her sons ( and years), and her daughter ( years), had been trained in the use of c -inh concentrate by their family doctor, and had been using this for treatment of acute attacks for years without significant side effects. this family was the inspiration for the establishment of home therapy service. all members of this family have been able to complete tertiary education, pursue demanding professional careers, and travel extensively, including to regions where medical care is not readily available, despite, in case, severe hae. results. in all cases, home therapy resulted in improved quality of life as a result of improved access to treatment and reduced use of emergency services. no patient used c -inh concentrate inappropriately. no adverse incidents occurred. discussion. despite the existence of successful home therapy programs for ig and factor viii, patients also retain the option of hospital treatment if conditions for home therapy are not optimal. these results show that use of c -inh concentrate is appropriate and that, in general, c -inh concentrate usage is not increased by home therapy. use of emergency and routine medical services and time off work is reduced, and all patients report great improvements in their quality of life. (jan h. nuijens, md, phd, and c. erik hack, md, phd,* leiden and amsterdam, the netherlands) as discussed, recombinant c -inh is among the therapies currently being investigated for the future treatment of hae. in this section, nuijens and hack describe the potential advantages of such a therapy and the steps being taken toward realizing this means of treatment. functional deficiency of the plasma protein c -inh in patients with hae and aae accounts for the recurrent attacks of localized submucosal and/or subcutaneous swelling that can cause serious discomfort and are sometimes life-threatening. intravenous supplementation with human plasma-derived c -inh is the preferred treatment of severe attacks of angioedema, and this treatment appears very effective and well tolerated. , [ ] [ ] [ ] however, plasma-derived products are of limited availability for reasons related to their human blood origin, supply, safety concerns, and/or development costs. three different plasma-derived c -inh preparations are licensed by regulatory authorities in to european countries each. even where licensed and/or available, treatment with plasma-derived c -inh often is restricted to laryngeal attacks with risk for suffocation, severe abdominal attacks, and preoperative prophylactic use. these restrictions have grown out of viral safety concerns, although the risks of transmission of human pathogenic viruses may nowadays be considered minimal. long-term prophylactic treatment with plasmaderived c -inh, although apparently safe and efficacious, occurs only on a very small scale. plasma-derived c -inh has also been tried in several serious pathological conditions such as sepsis, vascular leakage syndromes, and acute myocardial infarction, ie, in conditions associated with excessive activation of the complement and contact systems and/or absolute or relative deficiency of functional c -inh. , although its application in these conditions appeared safe, its efficacy was not yet demonstrated unequivocally. rationale for production of recombinant human c -inh. until very recently, all animal and clinical studies with c -inh used human blood plasma-derived c -inh. although the advantage of this c -inh preparation is that it has normal clearance kinetics, normal specificity, and no antigenicity, the apparent disadvantages are that the source material is limited and potentially contaminated with blood-borne pathogens. in particular, the limited source is an obstacle to develop c -inh for indications other than hae because these indications require more c -inh than for the treatment of hae (eg, approximately - u/kg body weight for an hae attack vs u/kg for the treatment of myocardial infarction). hence, availability of recombinant c -inh is warranted. major advantages of production of human c -inh via recombinant dna technology are that the recombinant material is not derived from a human source, that the production can more easily be controlled, and that the production can be scaled up to meet the requirements for the investigational treatment of hae as well as other potential indications. on cloning of c -inh by bock et al, recombinant functional c -inh was expressed in cos- cells by eldering et al in the late s. the c -inh expressed in this way was fully active, but expression levels were low (approximately mg/l), thus allowing only structurefunction relationship studies. expression in escherichia coli was also attempted. though much larger quantities of protein were expressed, only a fraction (a few percent) was active, whereas the majority was denatured (hack et al, unpublished data, january ). similar observations have been made by lamark et al, although these investigators could obtain more functional c -inh preparations by using different vectors and different strains of e coli. hence, other expression systems are needed to produce recombinant c -inh for clinical applications. two such systems, expression in transgenic animals and a yeast system, are discussed here. generation of recombinant human c -inh transgenic rabbits and pharmaceutical development of transgenic recombinant human c -inh. expression of c inh via the mammary gland of transgenic animals was first attempted in rabbits, among others, because of rabbits' short generation time. in addition, a lactating rabbit may produce l milk per year; because of this, transgenic rabbits may yield sufficient quantities of recombinant human c -inh (rhc -inh) for the hae indication. a mammary gland-specific expression vector containing a bovine milk-specific promoter sequence (as casein) functionally linked to the gene encoding human c -inh was introduced into the rabbit germ line by microinjection of fertilized oocytes isolated from superovulated female donor animals. a production line was selected with a relatively low transgene copy number and that expressed rhc -inh in milk at levels exceeding g/l. to ensure continuous availability of a herd of transgenic animals from the selected founder line and to restrict potential rearrangements of the transgene through subsequent generations, a master transgenic bank and a manufacturing working transgenic bank have been established. production herds are housed in specially designed and validated facilities subject to stringent environmental monitoring. animal health is continuously monitored, and the rabbits are regularly tested for the presence of a wide range of rabbit and human pathogens. rabbits showing any abnormality are excluded from being milked. this health monitoring system ensures that the production herd is a specified pathogen-free rabbit population. milk is collected by using a specially designed rabbit-milking device. the raw milk is analyzed for compliance with internal criteria before release for downstream processing. the purification of rhc -inh from raw milk is composed of skimming the milk, cationexchange chromatography, viral inactivation by solventdetergent incubation, anion-exchange chromatography, zinc-chelating chromatography, virus removal by nanofiltration, ultrafiltration, final filtration, filling, and lyophilization. stability studies of vialed rhc -inh have indicated a shelf life of at least years. the downstream process of rhc -inh has been the subject of a virus removal or inactivation validation study using a panel of viruses representing different viral classes and sizes (enveloped and nonenveloped, single-stranded and double-stranded rna and dna viruses). characterization of transgenic rhc -inh protein. nonreduced and reduced sds-page of rhc -inh showed rather broad (single-chain) protein bands with an estimated relative molecular mass (mr) of approximately , . the observed heterogeneity in mr on sds-page of rhc -inh as well as the difference in mr (approximately , and , on nonreduced and reduced sds-page) of rhc -inh and plasma-derived c -inh most likely results from differential glycosylation. this follows from the observation that both the n-terminus and c-terminus of the protein are intact as determined by n-terminal and c-terminal amino acid sequence analyses. moreover, liquid chromatographymass spectrometry peptide mapping data revealed approximately % recovery of the amino acid sequence of rhc -inh and conformity with the expected amino acid sequence. the theoretical molecular mass of the polypeptide backbone of c -inh is approximately kd. the use of matrix-assisted laser desorption ionization-time of flight mass spectroscopy revealed a molecular mass of approximately kd and approximately kd for rhc -inh and plasma-derived c -inh, respectively, and suggests that approximately % and approximately % of the molecular mass of rhc -inh and plasmaderived c -inh can be ascribed to carbohydrate structures. monosaccharide analysis of the major monosaccharides in glycoproteins (fuc, galnac, glcnac, gal, man, and neu ac) confirmed that rhc -inh consists of approximately % carbohydrates. n-glycolyl neuraminic acid, a sialic acid that is not found in normal human tissue, as well as a-galactosyl were not detected on monosaccharide analysis of rhc -inh. mass spectrometric and nuclear magnetic resonance analyses of the glycans released from rhc -inh indeed showed the presence of at least different o-linked and at least different n-linked carbohydrate structures, including oligomannose and hybrid and complex-type carbohydrates. n-linked glycan profiling indicated that most of the n-linked complex structures of rhc -inh appeared to be monosialylated. the inhibitory potency of rhc -inh toward the target proteases c s, kallikrein, factor xia, and factor xiia was found to be comparable with that of plasma-derived c -inh. in addition, no difference in the inhibition of plasmin and thrombin was observed. physicochemical characterization to demonstrate identity, purity, potency, and consistency between different batches of rhc -inh revealed that it was consistently being produced as an active, intact molecule, with purity exceeding . %, containing no detectable amounts of cleaved rhc -inh, endogenous rabbit c -inh (less than ppm), and rabbit milk proteins (less than ppm). summary of experiments in animals with transgenic rhc -inh. the purpose of the preclinical safety program was to assess the initial safe dose in human beings and to identify safety parameters for clinical monitoring. the package contained safety pharmacology in dogs ( u/ kg), acute single-dose toxicity in rats and dogs ( - u/kg), -week subchronic toxicity in rats ( - u/kg), repeated dose toxicity in dogs ( u/kg/day for days), and local tolerance in rabbits (intravenous, perivenous, or intra-arterial microinfusions). overall, no adverse clinical signs were observed and no or negligible effects were reported on clinical laboratory parameters. on the macroscopic level, some minor findings were reported, but histopathological analyses revealed no treatment-related findings. rhc -inh was cleared more rapidly from the circulation of the rat and the dog in comparison with plasma-derived c -inh. in rat serum samples from animals in the highest dosage group (single-dose, u/kg; subchronic, u/kg), a mild specific immune response was noted. there was no evidence for the generation of neutralizing antibodies. on the basis of these studies, it was concluded that rhc -inh may be considered safe. phase i study of rhc -inh in asymptomatic subjects with hae. an open-label phase i study of the safety, tolerability, pharmacokinetics, and pharmacodynamics of ascending intravenous doses of rhc -inh ( . - u/kg) in asymptomatic subjects with hae was conducted at the centre for human drug research (leiden, the netherlands; cohen et al). the study subjects were invited to participate by levi (department of internal medicine, academic medical centre, amsterdam, the netherlands) in close communication with the dutch association of patients with hae and quincke's edema. all subjects were without angioedema symptoms at the time of the trial and received rhc -inh on occasions with an interval of at least weeks (table xiii) . the subjects were assessed clinically, and blood samples were taken to evaluate laboratory safety parameters and immunogenicity as well as the clearance and biological effects of rhc -inh. assays of pharmacokinetics and pharmacodynamics parameters were performed at sanquin research (hack, amsterdam, the netherlands). safety results were as follows. rhc -inh appeared safe and well tolerated: no probable product-related adverse events (eg, allergic reactions) or changes in electrocardiogram, vital signs, or routine laboratory parameters were observed. neither clinically significant increases in anti-c -inh or antirabbit milk protein nor evidence of c -inh neutralizing antibodies was noted. pharmacokinetics results were as follows. infusion of rhc -inh resulted in dose-dependent increases of functional c -inh response parameters maximum concentration (above baseline), area under effect curve above baseline, dose-normalized area under effect curve, and of time above . u/ml, whereas dose-normalized maximum concentration appeared constant (approximately . u/ml/u/kg). the profiles of functional c -inh showed a full initial recovery and a dose-dependent clearance of rhc -inh that indicated a saturable mechanism of elimination. after the infusion of rhc -inh at u/kg, a clearance of approximately ml/min, a half-life of about hours, a volume of distribution of about l, and an endogenous infusion rate of about u/min were observed by using a standard -compartment model of analysis. application of a -compartment model with michaelis-menten elimination provided dose-independent estimates of v max , k m , volume of distribution, and endogenous infusion rate of approximately u/min, approximately . u/ml, approximately l, and approximately u/min, respectively. thus, the half-life of rhc -inh in the subjects with hae appeared reduced compared with historical data of plasma-derived c -inh. , , this likely relates to the differential glycosylation and lower degree of sialylation in rhc -inh. the increased clearance of rhc -inh from the bloodstream likely occurs mainly through endocytic asialoglycoprotein and mannose receptors on hepato- cytes. after dosing with rhc -inh at u/kg, functional c -inh was at least -fold the normal level for about hours and remained above . u/ml for about hours. activation of the cascade systems releasing inflammatory mediators responsible for the generation of edema is thought to be sufficiently controlled with functional c -inh levels exceeding . u/ml. pharmacodynamics results were as follows. rhc -inh displayed biological activity in the subjects as evidenced by plasma c increases and inhibition of c cleavage. the dose-dependent increase in mean normalized c was highly variable within dosage groups and was approximately -fold increased after the infusion of rhc -inh at u/kg. c peak levels occurred at approximately hours postinfusion, similar to c responses after plasmaderived c -inh, and thereafter gradually declined to baseline. , an immediate dose-dependent effect of rhc -inh on plasma c b/c was observed. the magnitude and the duration of the decrease in c b/c appeared dependent on the dose of rhc -inh. cleavage of c appeared to occur once functional c -inh dropped below a level of approximately % of normal. taken together, the phase i results suggest that an adequate dosage of rhc -inh will be able to correct c -inh activity in blood for a sufficiently long period to halt the progression of a swelling episode and to allow the resolution of edema. that is, the results warrant clinical studies of the safety and efficacy of rhc -inh in symptomatic patients with hae. phase ii and phase ii/iii studies of transgenic rhc -inh for the treatment of acute attacks in patients with hae. a phase ii exploratory open-label study of the safety, tolerability, and efficacy as well as pharmacokinetics and pharmacodynamics of rhc -inh at u/kg in symptomatic patients with hae with severe attacks of angioedema in the abdomen, the facial-oro-pharyngeal region, and/or the genito-urinary region is currently being performed in the netherlands (levi) . on the basis of the initial encouraging results of the phase ii study, a multicenter phase ii/iii study of rhc -inh at sites in several european countries is being initiated. expression of wild-type c -inh in the yeast pichia pastoris. the yeast pichia pastoris is increasingly used as an expression system to produce recombinant proteins on a large scale. hence, recombinant c -inh has been expressed in this system as well. however, development of yeast-expressed rhc -inh for clinical use is still at an early stage. initial expression of c -inh was achieved by using the vectors ppiczaa and ppic . without optimization, expression of as much as g of recombinant protein per liter was observed. though some of the c -inh preparations produced in p pastoris were fully active, compared with plasma c -inh, other preparations were inactive because of proteolytic inactivation of the recombinant molecule by contaminating proteases. inactivation in particular was observed when the yeast was cultured for more than days. the recombinant protein was secreted in the culture supernatant and constituted at least %, in most cases > %, of the total amount of protein, which may make this system attractive for commercial production applications. recombinant c -inh was purified to > % homogeneity on sds-page on laboratory scale by using hplc cationexchange chromatography. plasma c -inh is a heavily glycosylated molecule, owing approximately % of its molecular mass to carbohydrate groups. in the original publication by bock et al describing the nucleotide sequence of cdna coding for human c -inh, glycosylation sites were identified. however, the number of potential glycosylation sites (n-linked and o-linked) may be as high as . the function of these carbohydrate groups is not completely clear, although there is conclusive evidence that incomplete glycosylation and/or undersialylation of the carbohydrate groups is involved in the clearance of the molecule in vivo. on the basis of migration patterns of yeast-expressed c -inh on sds-page as well as current knowledge of glycosylation by yeast (mainly mannose), it is expected that carbohydrate groups on yeast-expressed c -inh will need to be modified to achieve normal clearance in vivo. indeed, in a rat model, accelerated clearance of pichia-expressed c -inh was observed (half-life, minutes for pichia-c -inh vs . hours for plasma derived c -inh; bos et al). , expression of c -inh mutants. c -inh mutants have been made for different purposes, ie, to study the structure and function, to study glycosylation, and to modify function toward applicability in inflammatory conditions. regarding application in inflammatory conditions, c -inh, like many other serpins, can be catalytically inactivated by neutrophil elastase, which may limit its use in inflammatory diseases. to improve the potential performance of c -inh at sites of inflammation, it may be beneficial to enhance the resistance of the molecule to catalytic inactivation by elastase, because this would reduce the amount of inhibitor needed. c -inh mutants with amino acid replacements at the so-called p and p positions of the reactive center (this is the domain interacting with target and nontarget proteases) have been developed. these mutants have a nearly normal function but are much more resistant to inactivation by elastase than wild-type c -inh. until now, these mutants have never been tested in animal models to prove the principle that they indeed perform better in inflammatory conditions. as indicated, pichia-expressed c -inh is glycosylated differently (mainly mannose) than plasma-derived c -inh (mainly complex-type carbohydrate groups). most glycosylation sites are located in the n-terminal part of the molecule. the function of this part is currently unknown, although according to the latest data, the most c-terminal amino acids of this n-terminal part serve to stabilize the so-called central b-sheet of c -inh, which is essential for serpin function. to evaluate the role of the n-terminal portion in the functional activity of c -inh, deletion mutants lacking or amino acids of the n-terminus have been expressed in pichia. the functional activity of these mutants has yet to be studied in detail but at first glance looks normal. in contrast, a mutant lacking the complete n-terminal part was inactive. the mutant lacking amino acids is interesting in that it seems to have normal functional activity despite having only carbohydrate groups left. experiments with endoglycosidase h and concanavalin a reveal that these groups are n-linked (asn ; asn and asn ). for the future. recombinant protein technology not only offers the possibility of producing large amounts of protein at acceptable costs but also allows for mutation of the protein to adapt its function. expression of wildtype human c -inh has been successfully achieved in transgenic rabbits, and this recombinant inhibitor is now in phase ii clinical development for the treatment of acute attacks in patients with hae. pichia-expressed c -inh may constitute another alternative to plasmaderived c -inh but is still at a very early stage of development. kallikrein inhibition and nonallergic angioedema. the kallikrein inhibitor dx- was generated via phage display, a technique for rapidly identifying target-specific protein binders. the phage display process involves generating many possible binders specific for each desired target, in this case human plasma kallikrein, and then selecting the binder with the highest affinity. as such, this process resulted in a molecule with an extremely high ( pmol/l) binding affinity for human plasma kallikrein. kallikrein is known to catalyze the conversion of kininogen to bradykinin. assuming bradykinin is the major mediator of nonallergic angioedema, plasma kallikrein inhibition should be beneficial during angioedema attacks. kallikrein has also been shown to influence the renin-angiotensin system by promoting the conversion of prorenin to renin ; however, as discussed in the pathogenesis section of this supplement, the renin-angiotensin system likely plays a much lesser role in angioedema generation. phase i normal volunteer study. in a study conducted in scotland, dx- was administered to healthy male or female volunteers; pharmacokinetic and safety parameters were assessed. two patients each received or mg dx- , and patients each received or mg dx- . half-life measurements ranged from . to . hours. phase ii european study. an open-label study of dx- for the treatment of nonallergic angioedema attacks was conducted in centers in europe. of the treated patients, patients had hae, and had aae. patients presented with facial/lip, hand, genital, or abdominal attacks; patient was treated for simultaneous hand and abdominal edema. in this dose-ranging study, patients each received mg, mg, or mg intravenous dx- . one patient ( mg dx- ; genital edema) had a drugrelated anaphylactoid reaction. patient-reported times to the start of attack resolution ranged from to minutes (mean, minutes); patient-reported times to complete resolution ranged from to hours (mean, . hours). the authors note that dx- could potentially advance the treatment of hae by reducing patients' reliance on anabolic steroids or plasma-derived products. attenuated anabolic steroids are the most common prophylaxis for hae and associated disorders. although these agents are effective in many patients, they carry a wide range of side effects, many of which are undesirable. their mechanism of action in these diseases, and indeed the full extent of their systemic effects, is not entirely known. as illustrated by the following investigations, attenuated androgens such as danazol may have other, at least transiently positive effects in addition to their better-documented risks. attenuated androgens effectively prevent swelling attacks in hae. the attenuated anabolic steroid danazol is mainly used in the therapy of many estrogendependent diseases such as endometriosis, cystic fibrotic mastopathy, primary menorrhagia, primary pubertas praecox, and gynecomastia. , however, its other, less known clinical indication is the prophylaxis of hae. the high androgen and low estrogen levels caused by this drug , are responsible for some side effects. among these, seborrhea, acne, hirsutism, weight gain, hair loss, voice changes, clitoral hypertrophy, vaginitis, irregular menstruation or amenorrhea, and reduced breast mass are the most common. methods. this study investigated the effects of danazol on bone metabolism. low estrogen concentrations have previously been shown to play a role in the development and progression of osteoporosis. the authors' current investigation sought to discover how reduced estrogen production caused by danazol therapy influences bone turnover. according to available data, danazol's effects on bone metabolism have been investigated only in patients with endometriosis. [ ] [ ] [ ] [ ] these investigations gave contradictory results. in addition, the authors note that the danazol doses given to treat endometriosis in these studies far exceed the doses administered in hae. rock et al have reported a temporary increase in bone mineral density (bmd) lasting only for the weeks of treatment, which then decreased such that bmd values measured at the nd week were lower than the initial values. according to dodin et al, the lumbar bone mass slightly increased by the end of the third and sixth months. , dmowski et al found no significant change in bmd during the danazol treatment. the current investigation measured the degree to which the minimum effective dose of danazol for hae control influenced bone turnover. all patients cared for at the hungarian hae center were involved in this study. the control group contained patients not treated with danazol. concentrations of alkaline phosphatase, calcium, phosphate, parathyroid hormone, dehydroepiandrosterone sulfate, b-cross laps, and osteocalcin were measured in blood serum. dual-energy x-ray absorptiometry was also performed in patients older than years. results. significant correlations have been found by using multiple logistic regression analysis between the variable of b-cross laps, osteocalcin values, z score values detected by the femoral neck, and danazol treatment. b-cross laps and osteocalcin concentration (markers of bone resorption) have shown a negative correlation, whereas z score values (markers of bone formation) have shown a positive correlation with danazol treatment. in the authors' study, it was evident that b-cross lap concentration was lower in the danazol-treated group than in the control group. changes in serum osteocalcin concentrations, like those in b-cross lap values, showed a negative correlation. osteocalcin concentrations in patients treated with danazol were considerably decreased. however, the authors note that both osteocalcin and b-cross lap concentrations oscillated in the normal range. z scores measured by the femoral neck showed that positive results were much more frequently detected in the danazoltreated group, whereas values in the untreated control group were always between and . . thus, bone mineral density was significantly higher in the danazoltreated group. the authors propose that the increased androgen level may have compensated for the deleterious effect of decreased estrogens, citing that the anabolic effect of androgens on bone metabolism have been well documented in the literature. discussion. comparing the results of this study with those reported in the literature on the effects of high-dose danazol treatment in endometriosis, the authors suggest that the minimum effective dose treatment in hae does not cause osteoporosis and, indeed, may protect the bone from mineral loss. ovulation is the result of complex, interrelated mechanisms initiated by the surge of lh and characterized by resumption of meiosis and germinal vesicle breakdown, initiation of luteinization of the granulosa cells, rupture of the follicle wall, and release of a fertilizable ovum. hormonal control of ovulation and biochemical and morphologic changes of the preovulatory follicle, including collagenolysis and vascular changes, have been extensively studied. ovarian follicular fluid (ff) is an enzyme reservoir controlling the permeability of the capillaries of the antrum and proteolytically degrading collagen, thus leading to the rupture of the follicle wall. the plasminogen-activator-plasminogen hypothesis is the most likely explanation of the mechanism initiating the cascade that leads to follicular rupture. the preovulatory follicle, stimulated by gonadotropins, secretes urokinasetype plasminogen activator, which can convert plasminogen to plasmin. a latent collagenase activated by plasmin attacks collagen, and the resulting telopeptidefree collagen can be attacked and degraded by nonspecific proteases. the decrease of the tensile strength of the follicle wall then allows the rupture of the follicle by the action of the existing intrafollicular pressure. in addition to several multifactorial systems (eg, kinins and fibrinolysis) that have been demonstrated and characterized in human ff, the presence of active complement has also been demonstrated in amounts similar to those present in normal human serum. plasmin's activation of complement in ff is very important for the function of the enzymatic multifactorial mechanism of ovulation. after complement activation in ff, biologically active peptides such as c a, c a, and c a are released via the complement cascade. complement activation is also important for the assembly of the membrane attack complex on the follicle wall. complement activation and ovulation: consequences in hae. it has been clearly demonstrated that women of reproductive age with hae who were not under danazol treatment and off any therapy, including ocs, frequently had cystic ovaries with an ultrasound pattern of polycystic ovaries (pcos; approximately %) or of multifollicular ovaries (mfos; approximately %). although pcos in women not affected with hae are associated with increased lh and testosterone concentrations, and mfos with almost normal values of these hormones, in patients with hae, normal concentrations of lh and testosterone (and of prolactin, cortisol, and acth) are almost always demonstrable independently from the ultrasound pattern (pco, mfo, normal) but in the presence of significantly reduced follicle stimulating hormone and slightly increased lh:follicle stimulating hormone ratio. menstrual irregularities and oligomenorrhea are frequent features of the patients studied, and hirsutism is sometimes present in patients with hae both with pco and mfo. neuroendocrine connection? in hae, the role of c -inh deficiency in the development of clinical symptoms and in the management of the disease has been explored. nevertheless, some interesting questions remain. the proposed relationship between physical and/or psychologic stress and the onset of acute episodes has yet to be proven fully. likewise, the effects of repeated stressful situations, such as the attacks themselves, on patients' neuroendocrine systems have yet to be completely explained. however, some possible links between the neuroendocrine system and hae have been studied and reported. perricone et al have previously found high plasma bendorphin concentrations without simultaneous elevation of acth during hae attacks as well as during symptomfree periods. this provides evidence of a possible massive release of b-endorphin from the readily disposable pool present in the pituitary and/or for an increase in the turnover of the peptide as evaluated by b-endorphin: b-lipotropin ratios and, in turn, of a pituitary abnormality in the patients. also in the group of patients with hae affected with cystic ovaries (studied off therapy and in symptom-free periods), significantly high plasma b-endorphin concentrations and normal acth have been detected. the very high prevalence of pco and mfo in hae again emphasizes the possible presence of hypothalamic-pituitary abnormality in these patients. in fact, both pco and mfo are linked to hypothalamic-pituitary dysfunction, and in hae, of the features of such a dysfunction, ie, high plasma b-endorphin concentrations and normal acth, is present in many patients, including men, postmenopausal women, and girls who are not of reproductive age. influences on ovulation. the presence of both complement and ovarian abnormalities in patients with hae and the role of ff complement in ovulation induced the authors to study complement function in the ff of women of reproductive age affected with hae. they found that impaired complement function is present in ff obtained from female patients of reproductive age affected with hae. in fact, contrary to what had been observed both in previously studied women not affected with hae and in controls, hae patients' ff showed a dramatically decreased classic pathway activity as well as undetectable functional and antigenic c -inh, and very low c . in addition, the authors observed a slightly reduced or within normal serum range values for alternative complement pathway activity, including c and factor b. this complement profile was also detected in the patients' sera. it is well known that the multifactorial mechanism of ovulation involves relevant steps modulated by c -inh: ( ) the formation of plasmin, and ( ) the plasmin-dependent complement classical pathway activation. activation of ff complement is important for the correct continuation of the ovulatory process, and the lack of c -inh, which facilitates the formation of plasmin and plasmin-dependent complement activation, can, in theory, be beneficial. on the contrary, when the activation of complement is massive, as occurs during hae attacks, a significant release of biologically active complement products can induce consistent inflammation and, in turn, pain. abdominal pain is frequently encountered in female patients with hae during attacks and during ovulation as well. however, because complement is chronically consumed during remissions and dramatically consumed during hae attacks, the potential of complement activation in hae ff is indeed the result of complex interrelated phenomena. if significant consumption of complement components occurs as a result of hae attacks shortly before the periovulatory period, ff complement will represent a defective reservoir of components unable to support further activation during ovulation. such a situation occurred in patient: a few days before ovulation, an attack characterized by edema of the extremities and abdominal pain occurred; thereafter, the patient manifested neither abdominal pain nor detectable ff complement activities and c cleavage fragments during the periovulatory period. in another patient, the periovulatory period (as well as the time of the study) was far away from attacks ( days); at this time, abdominal pain (without other symptoms of the disease) in the presence of reduced but detectable ff complement activities and of c cleavage fragments occurred. notwithstanding the presence of some important mechanisms of proven efficacy that can compensate for the complement deficiency (eg, the activation of a latent collagenase and the action of lysosomal enzymes), it is possible that, in the presence of impaired complement function, the rupture of the follicle wall is more difficult. however, once significant time has elapsed since the last hae attack, complement function can ameliorate; if ovulation coincides with such a condition, it will meet an only mildly reduced complement that will be capable of participating in the rupture of the follicle wall. these considerations can explain the apparently undiminished reproductive capacity of female patients with hae. on the other hand, hae patients' ff complement supports a certain degree of activation by seminal plasma, possibly caused by the relative integrity of the alternative pathway supporting its participation in the phenomenon. it is nonetheless possible that the more difficult rupture of some follicles in hae and the consequent altered intraovaric regulation by atresic follicles can result in the pco and mfo frequently observed in the disease. it is known that in cystic ovaries, the rupture of the cysts is very painful; thus, the authors cannot exclude that in patients with hae, the rupture of ovarian cysts might contribute to the genesis of the dramatic abdominal pain during attacks. danazol and ovulation: conclusions. one of the mainstays in the management of hae is long-term therapy with danazol, a mild androgen capable of correcting low c -inh concentrations and of greatly reducing the typical symptoms of the disease. the authors therefore studied the effects of danazol on ovarian ff c -inh and on ovarian ultrasound pattern. six patients with hae affected with cystic ovaries ( with pco and with mfo) who had been off any therapy for at least year were treated with danazol ( mg daily). as a result of danazol treatment, hae clinical symptoms consistently improved, and c -inh serum concentrations increased. after months of therapy, these patients were monitored by pelvic ultrasound scanning, and their ovaries were found normal. serum c -inh and ff c -inh also increased. furthermore, when the ultrasound pattern of the ovaries was studied in another group of patients, women with hae of reproductive age who were usually under danazol treatment, cystic ovaries were found in only of patients ( %). taken together, these data suggest a further link between the neuroendocrine and immune systems, describing a pathology involving both hypothalamic-pituitary dysregulation and an immunologic disorder. recent research has contributed to a less anecdotal and more systematic appreciation of the differences between adult and pediatric hae and the special age-related concerns that attend hae from the first months of life through puberty. here, prospective follow-ups of pediatric case series are reported. most patients have the first manifestation of hae during childhood. unfortunately, treatment of acute attacks that manifest with circumscribed swelling of the skin and the subcutaneous tissues can be performed successfully only by administering c -inh concentrate. other medications that are usually helpful in edema of other origins (eg, antihistamines or corticoids) are not effective here. the authors report that f of their patients, when anamnestically well evaluated, had edema of the mucous membranes of the respiratory tract at least once; remarkably high lethality rates (as high as %) have been associated with this disease in the past. , , even recently, a mortality rate as high as . % was published in an article summarizing experiences with austrian, swiss, and german patients with hae. as previously discussed, bradykinin seems to be the major mediator of edema, but discussions have not yet been finalized. because this disease still bears unknown details thus far identified, the authors chose to examine the baseline parameters of patients with hae to broaden the general database available and to enhance the understanding of the medical and scientific community. methods. data from patients with hae have been collected in the database at the department for pediatric hematology, oncology and hemostaseology of the johann wolfgang goethe university, frankfurt/main, germany. as of this march analysis, this database contained a total of pediatric patients (age < years) with diagnosed hae. these patients had been followed up for a period of as long as . years. the baseline characteristics of a total of patients from different families with hae were analyzed. the authors further monitored c -inh plasma activity and c -inh plasma antigen and supplemented these values with analyses of c and c and measurement of the total hemolytic activity (ch ) in the patients' plasma. finally, the frequency and localization of attacks, the history of each patient, and the efficacy and safety of replacement therapy with c -inh concentrate (berinert p) were investigated. antigenic c -inh levels were determined by radial immunodiffusion with nor-partigen plates (dade behring, deerfield, ill). functional c -inh concentration was determined by chromogenic assay with berichrom c -inhibitor (dade behring). results and discussion. all patients showed low c -inh activity, with a median activity of % of normal (normal value, % to %; range, . % to %). all acute hae attacks were successfully treated with to units c -inh concentrate per kilogram body weight. in these pediatric hae patients, c -inh concentrate was effective and well tolerated. no side effects or seroconversions for hav, hbv, hcv, hepatitis g virus, hiv- , or hiv- were observed. the gold standard of treatment for acute attacks in pediatric patients with hae is the administration of a c -inh concentrate, preferably that is specifically virus-inactivated. the authors always used a pasteurized c -inh concentrate (berinert p) and did not observe any problems regarding safety or efficacy. in , the transmission of hepatitis g virus in patients with angioedema treated with a steam-heated concentrate of c -inh was reported. the authors have not observed a seroconversion with regard to hepatitis g virus in their patients treated with pasteurized c -inh concentrate. , as treatment of pediatric patients with hae with c -inh concentrate is not registered all over the world, some pediatric patients have to be treated with danazol therapy. introduced in by gelfand et al, this treatment seems to have a rationale in long-term prophylaxis of patients with hae. however, because this treatment sometimes loses efficacy over time despite increased doses of danazol and is often associated with severe side effects, especially in children, the authors recommend the treatment of pediatric hae exclusively with c -inh concentrate if possible on a named-patient basis through personal importation programs. in their experience, this approach should also be feasible for women of childbearing age and all other patients with hae who cannot tolerate the side effects associated with danazol treatment. methods. between and , ninety patients were registered in the hungarian hae center database. what follows is a review of the clinical data of pediatric patients from families. the male to female ratio was : , and the age at time of diagnosis ranged from . to years (mean, . years). ch total complement levels were measured by the standard hemolytic titration method, using sensitized sheep erythrocytes. the c complement fraction was determined by single radial immunodiffusion using anti-c antibodies (atab, stillwater, minn), and results were expressed as the percentage of standard, normal serum values. the c -inh concentration was also measured by radial immunodiffusion; c -inh activity was measured by kinetic assay using a commercially available diagnostic kit (behringwerke ag, marburg, germany). the activity of the c -inh in the serum was determined by photometry and expressed as the percentage of standard, normal values. in the follow-up protocol, the first occurrence, frequency, and localization of clinical manifestations, duration of the disease, as well as potential precipitating factors of edematous attacks were ascertained. d a pedigree analysis was performed in all cases. d long-term prophylaxis was elected if edematous attacks recurred frequently (! attack per month) or a life-threatening episode could be identified in the history. d the following tests were performed in patients receiving long-term danazol prophylaxis: -anthropometric assessment of growth (comparison of body height and weight development to agespecific normal values). -bone age determination (hand x-rays). -development of secondary sexual characteristics and time of puberty compared with control population. -mental development (performance at school). d short-term prophylaxis was administered before surgical or diagnostic procedures performed on the head and neck. d changes in serum complement fractions and clinical manifestations were monitored during therapy. potentially drug-related adverse effects of treatment were also recorded. d in patients undergoing long-term prophylaxis, laboratory tests (complete blood count, liver function tests, creatine kinase activity, and urinalysis) were repeated at -month to -month intervals, and abdominal ultrasound was performed semiannually during the first years of treatment. subsequently, asymptomatic individuals or patients with mild symptoms were checked every months to detect potential liver damage. d patients with an acute attack of submucosal (laryngeal or severe abdominal) edema were always hospitalized and abdominal ultrasound performed if the attack involved the gastrointestinal tract. hospitalization for an acute abdominal attack was considered justified when the presence of other acute abdominal pathologies could not be ruled out with certainty and/or manifestations were severe-that is, the attack was associated with obvious signs of hypovolemia (paleness of skin, prostration, dehydration, tachyarrhythmia) and included recurrent paroxysms of acute colicky pain unresponsive to symptomatic therapy, nausea and vomiting, or profuse diarrhea. d the c -inh concentrate used in this study was screened for hepatitis b and c by the manufacturer. nevertheless, in observance of the safety precautions pertinent to blood products, hbsag and hcv specific antibody were tested by using commercially available immunoassays in all patients who had received c -inh concentrate. acute edematous attacks were treated by administering c -inh concentrate (berinert p injection; centeon, vienna, austria), and e-aminocaproic acid (acepramin; pannon pharma, pecsvarad, hungary), tranexamic acid (exacyl; sanofi synthe labo-chinoin, budapest, hungary), and danazol (danoval; krka, novo mesto, slovenia) were used for prophylaxis. results. the initial manifestations of hae were observed within an age range of . to years (median, . years). six children were asymptomatic at the time of diagnosis, which was established only after hae was ascertained in their symptomatic parents. pedigree anal-ysis revealed familial occurrence of the disease in cases (from families) but failed to identify hae in firstdegree relatives of children; therefore, in these patients, c -inh deficiency must have resulted from a new c nh mutation (table xiv) . the localization of clinical signs was variable. in the majority of patients ( children; %), edema formation involved subcutaneous tissues, whereas gastrointestinal manifestations occurred in patients ( %) and laryngeal edema developed in patients ( %). subcutaneous edema of the extremities or genitals usually persisted for to days, then resolved spontaneously. edematous swelling of the skin was not accompanied by itching but caused an unpleasant sensation of distension within the involved region. in children, generalized, nonpruritic skin rash (erythema marginatum) was observed before and during edematous attacks of hae. the exploration of potential precipitating causes invariably identified mechanical trauma; however, upper airway infection was another important factor (table xv) . according to the results of serum complement studies, children had hae type i, whereas had hae type ii (table xvi) . all children with an acute edematous attack manifesting as laryngeal edema or severe acute abdominal complaints were hospitalized. emergency treatment was implemented by the parenteral administration of u c -inh concentrate exclusively (table xvii) . the injection accomplished substantial symptomatic relief within minutes to hour. this was accompanied by the regression of edematous swelling; however, complete resolution of clinical signs and symptoms took to hours. administration of an additional u dose (ie, a u cumulative dose) was necessary in patients ( with laryngeal and diffuse facial edema, with acute abdominal attack) to achieve a satisfactory rate of improvement. all patients hospitalized with an acute abdominal attack underwent abdominal ultrasound examination. ascites was invariably ascertained in all cases, whereas edema of the intestinal wall was detected in % of patients (fig , a) . as evidenced by follow-up ultrasound, appropriate treatment (c -inh concentrate) achieved complete disappearance of free peritoneal fluid and edematous swelling of the intestinal wall within hours. long-term drug prophylaxis with antifibrinolytic agents (tranexamic acid or e-aminocaproic acid) was initiated in cases because of frequent (weekly or monthly) recurrence of edematous attacks or the presence of life-threatening attacks in the history. complete remission was achieved in girls maintained on to g/d tranexamic acid; however, antifibrinolytic agents were ineffective in cases. transferring these patients to treatment with to mg danazol/d completely eliminated serious edematous attacks (table xvii) . to taper the cumulative dose, the dosage interval of danazol ( mg) was increased to to days after months of clinical remission. switching to this intermittent regimen (ie, doses repeated every other day or at -day intervals) from continuous dosage was successful in cases. in patients maintained on long-term prophylaxis, doubling the daily dose for several days aborted prodromal symptoms or prevented the progression of mild clinical manifestations to full-blown attacks. a similar protective effect was observed in cases exposed to a precipitating factor (eg, upper airway infection or mechanical trauma). no adverse effects potentially related to long-term prophylaxis necessitating the withdrawal of treatment were observed. the bone age, skeletal growth, and weight development were not substantially different from the agespecific averages of the hungarian pediatric population. the age at appearance of secondary sexual characteristics and the onset of puberty were also similar to the national average in children, but in girl, menarche was delayed (to the age of years), and her menstruation was irregular. hirsutism was not observed in patients receiving long-term danazol prophylaxis. monitoring of laboratory parameters revealed normal values in all children tested, and abdominal ultrasound showed no abnormalities. the efficacy of danazol treatment was demonstrated by the significant increases of c and c -inh concentrations in the serum (fig ) . nine children had only mild, subcutaneous symptoms, and even these resolved spontaneously within to days. accordingly, long-term prophylaxis was withheld, and treatment was administered only when prodromal symptoms and signs occurred. in patients, tranexamic acid ( g/d) given for to days reduced the severity and duration of subcutaneous manifestations. follow-up visits were scheduled at -month intervals for these children. short-term prophylaxis was necessary in boys (age and years) undergoing dental extraction, because both had facial and laryngeal edema precipitated by similar procedures in their history. danazol ( mg/d) initiated days before and continued days after dental treatment successfully prevented edema formation. the elimination of known precipitating factors also substantially reduced the incidence of edematous attacks. discussion. in % of hae cases, a known family trait of the disease facilitates diagnosis. in the remaining %, in which no afflicted relatives can be identified, hae results from a new gene mutation. in the hungarian pediatric population analyzed by the authors, the proportion of such cases was % and %, respectively. according to the literature, % of patients with hae have type i and % have type ii disease. the percentage distribution of type i and type ii cases was % and % in the hungarian series. in general, the clinical manifestations of hae first develop before years of age ; the median age of the hungarian study population was . years. however, no occurrences have been observed in newborns, and only infant ( -month-old) case has been reported in the literature. according to the experience of the authors, adolescence is often associated with substantial changes in the activity of the disease, particularly in girls, warranting closer follow-up during this period. in particular, cluster- ing of edematous attacks during the menstrual period was observed in girls. nowadays, contraception is initiated in early adolescence. however, ocs can precipitate acute attacks, and therefore, these agents are not recommended for girls with hae. the incidence and severity of characteristic manifestations show substantial interindividual variation. less than % of patients with hae are asymptomatic, and % had symptoms only sporadically. manifestations of the disease are common in % of patients and severe in % of this subpopulation. eleven of the children followed up in this study had frequent and severe attacks. usually, mechanical trauma is reported as the most common precipitating factor. through their experience, the authors confirm this and identify upper airway infection as another potential triggering factor. considering the importance of physical activity and sports on growth and development, restrictions should be determined carefully and individually. in children, as in adults, edema of the extremities is the dominant manifestation; furthermore, abdominal attacks are more common than laryngeal edema. , nevertheless, even rare occurrences of laryngeal edema should be considered real emergencies. because of the small diameter of upper airways in children, relatively mild swelling of the mucosal lining causes substantial obstruction, and suffocation can therefore rapidly ensue. in view of these risks, referral to intensive care is justified to monitor the clinical course and ascertain the efficacy of treatment. in some patients, repeated administration of c -inh concentrate may be necessary to achieve satisfactory control of edematous manifestations. this fact and the ineffectiveness of conventional agents (eg, antihistamines, corticosteroids, and epinephrine) account for the invariably high mortality of the disease and emphasize the importance of accurate diagnosis. the striking similarity between the clinical manifestations of abdominal hae attacks and surgical emergencies is an apparent diagnostic pitfall. failure to evade this trap often leads to unnecessary interventions on patients already prostrated by the consequences of the acute edematous attack. , the authors reviewed the medical history of their patients before diagnosis, revealing that children had undergone exploration or laparoscopy during an acute abdominal attack, of them twice. these interventions were clearly unwarranted, because no abnormality other than the edematous swelling of intestinal wall was ascertained. to avoid this diagnostic pitfall, the authors recommend close monitoring of the patient, volume replacement, parenteral medication, and assessment of therapeutic efficacy, all achievable by observing the patient for to hours. abdominal ultrasound is a noninvasive and readily accessible diagnostic test that yields reproducible results, features particularly advantageous in pediatric practice. the authors identify free peritoneal fluid and edema of the intestinal wall as invaluable sonographic clues for distinguishing abdominal hae attacks from other pathologies commonly associated with ascites formation (such as intra-abdominal inflammation, autoimmune disease, tumors, and so forth). they recommend that, when all other acute abdominal disorders had been ruled out, c -inh concentrate should be administered to afebrile patients without laboratory abnormalities, particularly to those with known hae. prompt symptomatic relief (or lack thereof) after c -inh concentrate administration can then confirm or refute the tentative diagnosis. during life-threatening hae attacks, appropriate measures can include the administration of ffp. this preparation contains c -inh; however, its use may be associated with alloimmunization or the transmission of infections. the most appropriate therapy is the intravenous administration of c -inh concentrate. its dosage is the same for children and adults (ie, - u). in this study, acute hae attacks were treated with c -inh concentrate exclusively. this approach was highly effective, resolving clinical symptoms within an hour, and was not associated with adverse effects. c -inh concentrate has been suggested as an ideal agent for permanent substitution, particularly for pediatric patients. unfortunately, the short ( -hour) half-life and high cost ($ per vial) of the concentrate preclude its use for continuous administration. furthermore, c -inh concentrate is a blood product, and the theoretical risk of blood-borne infections cannot be completely excluded. nevertheless, viral (hiv, hbv, hcv) safety of the concentrate is promoted by heat treatment as well as the establishment and continuous validation of safe plasma pools. , in the hungarian in pediatric patients, antifibrinolytic agents are the first choices for long-term prophylaxis because their safety profile is more favorable than that of attenuated androgens. , , , nevertheless, antifibrinolytic agents can cause adverse effects such as muscle weakness, myalgia, elevation of creatine kinase activity, vascular thrombosis, postural hypotension, and myonecrosis. the experience of the authors showed tranexamic acid to be better tolerated than e-aminocaproic acid, which often caused gastrointestinal discomfort. however, when these agents fail to achieve satisfactory improvement, treatment with attenuated androgens (eg, danazol, stanozolol) is necessary. numerous studies performed on adult patients have demonstrated the efficacy of a-ethyltestosterone (danazol) manifested by the substantial relief of symptoms as well as the elevation of serum c and c -inh concentrations. their mechanism of action has not yet been fully elucidated, and limited experience with their pediatric use has been obtained only in patients treated for idiopathic thrombocytopenic purpura. potential adverse effects of danazol include weight gain, myalgia, headache, tremor, libido changes, elevation of serum transaminase levels, microhematuria, menstruation irregularities, and hirsutism. in addition, reports have been published on hepatocellular adenoma formation observed in adults undergoing long-term, high-dose danazol therapy. nevertheless, using the lowest effective maintenance dose and intermittent dosage regimens can prevent adverse effects that would require the withdrawal of treatment. in the study population, the longest duration of danazol prophylaxis was years. no drug-related adverse reactions or impairment of growth was recorded in these pediatric patients, with the exception of case of delayed menarche with subsequent irregular menstruation probably caused by long-term treatment with mg/ d danazol. compared with age-specific percentiles of the hungarian population, somatomental development was normal in all cases. treatment prevented edematous attacks and elevated c and c -inh concentrations significantly. effective therapy eliminated the need for frequent hospitalizations for acute symptoms-along with their unfavorable psychologic sequelae-and thereby improved the patients' quality of life. the authors emphasize the essential importance of close follow-up, with appropriate tests performed at regular intervals. the diagnosis of hae can be made as early as at birth by assessing c -inh antigenicity and function. prenatal screening is not yet feasible. importantly, baseline complement concentrations are of no use for predicting the severity and frequency of future attacks; for example, some patients are asymptomatic during a patient's first years of long-term prophylaxis, laboratory tests should be performed every to months and abdominal ultrasounds scheduled at -month intervals. the clinical course of hae and reactions to treatment should be monitored to recognize potential adverse effects and ascertain the rate of somatomental development as well as the need for therapy modification. in view of their favorable experience, the authors suggest that danazol administered in the lowest effective dose seems to be well tolerated by pediatric patients and is probably appropriate for long-term therapy. nevertheless, adverse reactions can occur sporadically. in particular, case of delayed menarche and irregular menstruation was observed in this series; however, the abnormality was readily reversible on discontinuing danazol treatment. short-term prophylaxis is indicated for patients undergoing surgical or diagnostic interventions of the head and neck region. such procedures most commonly include dental procedures and tonsillectomy, but the potential consequences of endotracheal intubation for general anesthesia must also be emphasized. , although short-term prophylaxis is required less frequently for children than for adults, antifibrinolytic agents or attenuated androgens provide adequate protection if administered in higher than usual doses. nevertheless, prophylaxis with c -inh concentrate is the method of choice in patients with a history of severe attacks precipitated by similar procedures. in addition, follow-up should also include the education of patients and their parents, as well as advice on the most suitable means of lifestyle modification. the activity of patients' self-help groups can lend vigor to such efforts. early health education and meticulous follow-up initiated in childhood can successfully prevent social stigmatization and guarantee an improved the quality of life for adulthood. it is prudent to provide patients with hae with a medical information card summarizing essential knowledge and methods of emergency help in several languages. when justified by their history, patients should be supplied with c -inh concentrate to be kept at hand, ie, in the refrigerator at home, for emergencies. the data contained on the medical information card can prove an extremely useful aid for medical professionals relatively unfamiliar with hae and help to ensure patients' safety. this article first appeared in a slightly different form as although all patient and physician groups share the common goals of increased knowledge of hae and related disorders and optimized therapy, patient and physician experiences differ among countries. the following accounts demonstrate the range of perspectives, treatment options, and concerns found in europe and the united states, concluding with a short history of past c -inh deficiency workshops in which representatives from these and other countries have met to further their common aims. an international approach to patient registries (marco cicardi, md,* and john jakenfelds, md, milan, italy, and chalfont st. giles, uk) the concept of a european patient registry grew out of the first c -inh deficiency workshop. in this section, cicardi and jakenfelds describe the process of creating the european hae register and how the register will work. in , the european group of patients, clinicians, and scientists interested in hae met for the first c -inh workshop in visegrád, a hungarian town near budapest. workshop members identified the creation of a register containing the clinical and laboratory data of patients with hae as an obvious first step. there is a real need for a better insight into the full presentation of hae, the different ways it is managed, and the various outcomes (including clinical, functional, and economical variables) associated with different disease management strategies. currently, there are significant differences in the way patients with hae are treated in various hae expert centers. there is no consensus on the state-of-the-art treatment of hae, and there is a lack of data to develop uniform, evidence-based treatment guidelines. as a result, an enormous gap exists between resources already or potentially available and their exploitation. furthermore, the low awareness of this disease causes only a minority of patients to reach correct diagnosis and treatment. small and dispersed case lists and the lack of epidemiologic data lessen the value of clinical studies and discourage public and private investment in research aimed at developing new therapeutic strategies or tailoring existing ones to hae. given this situation, an international patient register could play a significant role in the development of a better understanding of hae and its management. first steps. two pharmaceutical companies, pharming and baxter, encouraged the establishment of an hae register in . baxter already had a product for the treatment of the disease (plasma-derived c -inh) in some european countries, and pharming was developing a recombinant version (rhc -inh). pharming became the major contributor until , when a group of hae experts from different european countries received a grant from the european commission for a project called prehaeat, consisting of a concerted action in the framework of the specific research and technologic development program, quality of life and management of living resources. establishing a european register for hae was the first work package of the project and was started accordingly by using the pharming-funded register as a starting point for further refinement. in this new register, physicians will enter completely anonymized patient data into a web-based data capture tool. princeton healthcare will be responsible for the central server and software, accessible by all sites and individuals wishing to enter data (fig ) . princeton is registered under the uk data protection act to store personal information as part of its ongoing work with clinical systems, which have been in use for several years. the register will work by using the internet. by connecting to the web and entering the site's name, the password-protected entry screen will be viewable (fig ) . on filling out details, the user will be taken to a menu of options, including the entry of new data or the viewing of reports covering anonymized patient records (either individual or for the group under treatment at the clinic). only the treating physician, by knowing a code, will be able to link an individual report to an individual patient. access initially will be restricted to the physicians participating in the concerted action and eventually will be open to any hae-treating physician on request. efforts will be taken to publicize maximally the existence of the register. access to data: ownership and management. each patient owns his or her own data. in order for the data to be entered into the register, patients must give consent to share their anonymized data. all clinicians contributing to the register will have access to their own data as individual or group reports. the board, consisting of the participants to the concerted action and of patient association representatives, will manage the anonymized database and may access aggregated reports but not individual data sets. no single member of the board can use or publish the data without the consent of the board and the contributors as a whole. the goal of the register is to develop a better understanding of the current benchmarks of care for hae and the outcomes that result to improve the ways in which patients are treated. for each patient, there will be an initial entry form and or more follow-up visit forms (fig ) . the initial entry form is structured to capture the natural course of hae in a patient. it will contain the past history before diagnosis of hae was recognized and/or specific treatment established. it will contain anagraphic data, information on characteristics and severity of symptoms, presence of associated diseases, and laboratory data at the time of diagnosis. the follow-up visit forms can be replicated indefinitely. they will collect the same data, updated according to the changes occurring in the course of the disease, and detailed data on the different therapies. specific care has been taken to record effectiveness and side effects of hae treatments. expected achievements and perspectives. this register is expected to become a reference database in hae. efforts have already begun to promote the harmonization of similar data collection systems on this topic around the world such that compatible formats will allow pooled data analysis. information describing the natural history of hae and the effect of treatment should be obtained. this database should also be used to provide policy makers and the pharmaceutical industry with data showing exactly how the disease affects the lives of patients who have it. the absence of an approved hae acute attack therapy in the united states of america represents a catastrophic unmet medical need. patients are suffering needlessly and in some cases are dying. indeed, the united states hae association (haea) is aware of hae-related deaths over the period of the past months. the most pressing near-term goal of the haea is to work with industry, the research community, and regulators to encourage usbased clinical trials that will result in licensure of an acute attack therapy. clearly, the lack of a therapy to treat an hae attack once it has begun poses a tragic and unnecessary risk to every us hae patient's life. fortunately, a phase ii clinical trial for an acute hae attack therapy sponsored by dyax corp is now up and running in the united states. the patient community is excited about the prospects for dyax's therapy on the basis of some promising safety and efficacy data developed during phase i and ii trials conducted in europe. the haea is working closely with dyax to recruit patients and complete this vital clinical trial. if the us phase ii results are as promising as results seen in phase i/ii european trials, the researchers hope that dyax will request an expedited licensing review by the food and drug administration. the haea is committed to ensuring that patients, industry, and the food and drug administration work together and strike an intelligent balance that permits an expeditious path to meeting a catastrophic unmet medical need while simultaneously protecting the public health and safety. meetings such as the one in budapest have provided the opportunity for patients with hae to interact and share information. this networking has spawned a movement that should soon result in the creation of a legally recognized international hae patient organization. clearly, an international hae organization can provide the world's hae groups with information, analysis, and guidance on key issues regarding hae management, diagnosis, and the direction of future research. indeed, researchers active in establishing an international hae group have already begun the process of examining the state-of-the-art for hae treatment in different parts of the world. this process has uncovered some strongly held views among the world's patients who are not satisfied with the current treatment options and standards. this drumbeat of concern is prompting international leaders to re-examine the hae treatment paradigm that almost always features androgens for prophylaxis, with acute attack therapy (c -inh concentrate) administered only for gastrointestinal and/or life-threatening attacks. there is some very exciting and innovative work going on in germany that quantifies patient dissatisfaction with the current treatment norm. specifically, the german data show that when given an option, many patients discontinue androgens and opt for on-demand (usually homebased) treatment with an acute attack therapy that they infuse during the attack prodrome. in sum, the treatment of hae in the united states is best described as medieval. without access to an acute attack therapy, patients must rely exclusively on prophylaxis with androgens. these drugs are highly toxic and have harsh side effects, particularly in women. the haea is working hard to assist companies interested in licensing an acute attack therapy in the united states. there is much hope that once formally established, an international hae organization will help to create and rationalize a partnership between the world's hae patients, researchers, regulators, and industry to ensure new therapies can be expeditiously tested, approved, and marketed. the hungarian experience: assisting the few to live a better life (istván nagy, arianna kitzinger, and henriette farkas, md, phd,* székesfehérvár, sopron, and budapest, hungary) in this section, hungarian physician farkas and patientresearchers nagy and kitzinger describe the importance of the hungarian hae center and its infrastructure, as well as their case series and approach to hae. creating an infrastructure. the hungarian complement laboratory in budapest was founded by prof. george füst in . the first article detailing hae patients' cases was published in . these achievements were followed by several milestones leading to the establishment of the hungarian hae center: d accumulating relevant knowledge from the international literature, adapting foreign experiences to domestic conditions, and developing hungarian protocols for clinical work-up and treatment d undertaking retrospective screening for patients by using archived laboratory test results (complement values) d communicating pertinent knowledge to medical professionals, graduate and postgraduate education programs, and others via publications d establishing a results-based referral system: if laboratory complement measurements are suggestive of hae, accessibility information for the hungarian hae center is printed on the laboratory test slip the development of research ran in parallel with the increasing number of patients diagnosed with hae. fig illustrates the rate of case accrual. currently, there are patients in hungary (total population: million people), of whom live in budapest and its suburbs. hungarian hae center. the headquarters of the hungarian hae center are located on the premises of semmelweis university in budapest. each facility has its assignments, as shown in fig . assignments of the allergy and angioedema outpatients' clinic at semmelweis university include the following: the complement laboratory functions as a unit of the hae center and is properly equipped to perform total complement profiling (ch , c , c q, c -inh concentration and functional activity, anti-c -inh antibodies, anti-c q antibodies). the molecular biology laboratory and the research laboratory of the third department of internal medicine conduct genetic testing and mutation analysis on all patients with hae. furthermore, the center participates in undergraduate and postgraduate education and also pursues scientific activities. case management standards. the hungarian algorithm for hae treatment, in the light of its symptoms, therapy, and management is as follows: d mild or infrequent subcutaneous edema does not require special treatment. self-management of symptoms will suffice, and medical monitoring can consist of yearly complement measurements. d severe or frequent subcutaneous and submucosal edematous symptoms are treated by either long-term prophylaxis (danazol, e-aminocaproic-acid, tranexamicacid) or short-term prophylaxis (danazol, e-aminocaproic-acid, tranexamic-acid, c -inh concentrate). such patients require regular medical and self-control. medical control involves liver function monitoring and blood cell and complement measurements twice yearly. d in case of acute abdominal or laryngeal edematous attacks, inpatient therapy with c -inh concentrate is needed. patients experiencing these symptoms also require regular medical and self-control. postattack follow-up is necessary. hungarian hae patients' association. established in , the hungarian hae patients' association organizes annual meetings at which patients can meet doctors and exchange views with each other. a foundation has been established to support patients with hae, and a hungarian hae web site is now being created. the hungarian hae patients' association recently collected patient diaries, drawing attention to topics important among the patient population. the association is now beginning to make a systematic survey of social background and its effect on the disease, which ideally will lead to a deeper understanding of hae and an improvement in patients' quality of life. the patients' association maintains fruitful relationships with foreign patients' self-help groups. as with all uncommon diseases, the elucidation of its epidemiologic features and pathomechanism, the establishment of current diagnostic algorithms, and the development of effective and safe treatment protocols all require international effort. this recognition led to the establishment of the european c -inh deficiency working group in . during its first conference held in rhodes, greece, this professional organization identified accomplishing these goals as its ultimate objective. since that time, the hungarian hae work group has been the main organizer of the european c -inh deficiency workshops, the basis for this supplement. much progress has been made since the first steps taken in the s. in addition to the results described, the association is glad to welcome several humanitarian changes. patients with the diagnosis of hae are now under regular medical control, in contrast with perpetual uncertainty of the past. as a result of patient education and counseling (ie, sufficient familiarity with the disease), patients are understood and helped more effectively by those in their environment. instead of isolation, patients feel integration, trust, and confidence: a major change and an impressive outcome in the case of this life-threatening disease. as shown in table xviii , all of this progress has helped patients to find an appropriate lifestyle. however, without doctors' professional knowledge and its perpetual updating, these developments in hungarian hae research could not have been achieved. many doctors regard their job as their hobby and also feel a commitment to help at both the domestic and international levels. their compassionate care for patients is both noticed and appreciated by those in need. portions of this article appeared in farkas h, varga l. the hungarian hae experience. transfus apheresis sci ; : - . they are reprinted with permission. the german experience: hae and selfmedication with berinert p (ursula rauch, aldenhoven/siersdorf, germany) in this section, rauch, a member of the german hae patient association, hae vereinigung e. v., writes of her experiences as she presented them at the c esterase inhibitor deficiency workshop in budapest. the german hae patient association's motto is nicht mehr allein, ''no longer alone.'' to introduce myself, i would like to tell you a little bit about my career as an hae patient. i think all the hae-affected here have had the same or similar experiences. so, here is the short version of my story. i am years old and have hae-i. i had my first attack at the age of ½, diagnosed as allergy; it was followed by tests and experiments with antiallergic remedies and corticoids, which were, of course, useless. there was an increase in my attacks during puberty, and i received the correct diagnosis at age . there was no remedy at that time, but it was a relief to know it was hae and to stop the antiallergy experiments. sometimes i went for months without an attack; sometimes i would spend weeks with a permanent attack; but to a certain degree i managed to arrange my life around my disease. but after my second pregnancy, the attacks greatly increased. i often needed help to care for my children. i became depressed and could not hold down a job because i was ill too often. not week went by without an attack, and i often had nonstop attacks that lasted to days. in , i finally found our support group, got a lot of information, and was told about the hae center in frankfurt. i made an appointment at the university hospital in frankfurt, where i received very good counseling, and weeks later i went to my first hae group meeting. with the help of the physicians of the university hospital in frankfurt and my practitioner, i learned to infuse myself in an emergency. so i was much more independent and felt much safer than before. after training with normal saline, when i tried my first injection, i went to my practitioner in order to have a supervisor-and it did work! and today? no endless pain, vomiting, and breakdowns of my circulation. no waiting for emergency medical personnel, especially on saturday or sunday, or at night. no more useless claims that corticoids always help, even though my emergency passport says differently. no hurrying to a hospital, breathless and in panic, because of a laryngeal edema. no waiting there for a tired physician who already has hours of work behind him. no enduring questions about whether my husband could have beaten me because my face looks just like a boxer's. i was able to participate in further professional education. i look after my children myself. i can again go on vacations, which always seemed too dangerous before. and i am active in the patient group as much as i can be. i learned how helpful and important it is to work together and fight for a better and more effective therapy. to me, it is absolutely incredible that in most countries, families do not have even package of c inhibitor at home for emergency cases, and that there are doctors who give androgens to children, even though they are still growing and the doctors should know how dangerous these androgens can be. and it is horrible that a lot of affected people are still misdiagnosed and therefore constantly living in danger. we must create the opportunity for every hae-affected person to get the right diagnosis and the same help, so that children can grow up as normally as possible, without missing school very often, and so that we all can go to work and enjoy life-just like the nonaffected, without horrible pains and horrible fears about the risk of suffocating to death or dying of pain. we are a minority-in every country-but together we are strong enough not to be stopped. in recent years, patient associations have had a fundamental role in the fight against rare diseases. many organizations now exist in various parts of the world, even for hae, to perform the important task of sharing information and maintaining a connection between patients and doctors. such associations perform indispensable functions, useful to both doctors and researchers. aims. aaee was founded as a nonprofit voluntary association in milan on march , , and has the following aims: d to spread knowledge of the disease and allow correct diagnosis d to make high-quality medical care and adequate treatment available to all patients d to issue an officially recognized health identification document describing the disease and its emergency therapy and containing the contact information of doctors who can be called for further information d to promote social and scientific meetings and congresses at a national and international level d to encourage meetings and exchanges among patients, between patients and doctors, and among doctors services. aaee represents approximately members and, in more than years of activity, has created a series of services to benefit patients: d in collaboration with the doctors of the diagnosis and cure center in milan, a -hour emergency telephone number was activated. d all patients have an emergency identification document indicating their diagnosis and its suggested treatment in more than language. d a direct link has been established with the pharmaceutical company that produces c -inh concentrate to locate this life-saving medicine at any time. d the minister of health and welfare has added hae to the list of rare diseases for which patients are exempted from paying for medicine. d a multilingual internet site (http://www.angioedemaereditario.org) offers medical and scientific information, useful addresses, and contact information for all hae associations worldwide. d regional representatives permit a more direct connection between patients and the association. d gynecologic and dental consultations are available. d to spread medical and scientific information as well as the association's activities, radio and television broadcasts have been organized. d every year, a national meeting is held in addition to regional meetings to exchange information between doctors and patients and between patients and the association. d some patients who have social roles in the community offer their experience and assistance to the association to deal correctly with various bureaucratic problems. d there are now other centers in addition to the in milan available to patients who need treatment, in rome, palermo, and civitanova marche. recent initiatives. recently, the association prepared a very simple form to collect data on the frequency of hae attacks in italian patients. information will be collected over the period of the next months as a brief trial. this will help aaee evaluate replies received from patients to make all necessary modifications and adapt the survey as much as possible to each involved country's needs and requirements. data will be collected in a proposed specific database. to make better use of the information, the aaee intends to put their internet site at everyone's disposal. in the last few weeks, the international pages have been modified, transforming them into a very simple but functional place where hae information and links throughout the world can easily be found. with the representatives of other associations, the members of aaee are working to create an international umbrella organization. after last year's short meeting on hae in palermo, where the first ideas were elaborated and after the budapest workshop, an international statute proposal now exists. during the last meeting, which took place in milan on october and , , an international committee and a medical panel of doctors and researchers were formed. hereditary angioedema and related disorders are characterized by acute episodes of unexplained swelling that are not responsive to antihistamines or corticosteroids. attacks may manifest in or more locations, most frequently the upper airways, face, hands, feet, genitalia, or intra-abdominal contents. untreated laryngeal swelling can result in death; angioedema of the small intestine can result in obstruction and mimic an acute abdomen. ultrasound may be useful to distinguish between abdominal pain attributable to hae and a true surgical emergency. occasionally, erythema marginatum or a similar, nonwhealing, nonurticarial rash may precede angioedema attacks; at other times, there may be no warning. episodes of hae may present as early as late infancy and may vary, even within the same individual, in frequency, severity, and location. attacks typically resolve within hours but may persist as long as days. aae, although much rarer than hae, often follows lymphoproliferative disorders or occasionally autoimmune, neoplastic, or infectious diseases. drug-induced angioedema may closely follow initiation of a drug regimen (often an antihypertensive agent) or appear many months later, whereas estrogendependent angioedema seems to follow initiation of pregnancy, ocs, or hrt more immediately. hereditary angioedema types i and ii are associated with various mutations to the c nh gene, located on chromosome . a frequently updated online database of these mutations is available to the public at http:// hae.biomembrane.hu; at the time of writing, different c nh mutations were known. the progression from low functional c -inh concentrations to attack genesis is still under debate; however, bradykinin has been identified as a mediator of angioedema attacks, and, unlike other proposed mediators, has been found to correlate with attack localization in early studies. nonetheless, this nonapeptide is unstable and cannot be measured via routine laboratory analyses. it is hypothesized that the local generation of bradykinin results in regional increases in vascular permeability. the presence of other mechanisms, intermediaries, and moderating factors has not been discounted. case reports have shown that in some women, the occurrence or frequency of hae attacks appears to be influenced by estrogen. in these patients, puberty, pregnancy, or taking estrogen-containing ocs or hrt may initiate attacks. patients have also been described with normal concentrations of functional c -inh who nonetheless have angioedema attacks in response to increases in estrogen. bork et al found that approximately % of women with hae-i or hae type iii have a worsening of their attacks because of pregnancy or exogenous estrogen. laboratory diagnosis c -inh antigenic and functional assays are sufficient to diagnose hae-i, hae-ii, and aae. low c concentration is often a reliable confirmation but is not exclusive to c -inh deficiencies. currently, no routine laboratory methods can detect estrogen-dependent angioedema (formerly hae type iii). ideal prophylactic regimens are highly individualized and should consider the severity and frequency of the patient's attacks. -a alkylated androgens, antifibrinolytics, or c -inh concentrate have been used successfully for hae maintenance prophylaxis and/or short-term prophylaxis surrounding surgical or dental procedures. bork et al describe c -inh as an effective, if less frequently used, prophylactic agent. in some patients, antifibrinolytics may be sufficient to prevent attacks; however, attenuated androgens more often reduce the frequency and severity of attacks. patients receiving longterm androgens, especially pediatric patients, should be monitored for undesirable hepatic effects and other consequences such as virilization or delayed menarche; farkas et al suggest laboratory work-ups at intervals of to months. androgen overdosing is to be avoided; varga and other members of the workshop laboratory diagnosis panel note that, in hae-i, antigenic c -inh concentrations approaching % to % of normal are often sufficient to prevent attacks, and therefore, aiming steroid prophylaxis to achieve a % antigenic concentration subjects patients to an unnecessary risk. for the prophylaxis of aae, antifibrinolytic agents are recommended because patients with this condition are frequently resistant to attenuated androgens. danazol is a common prophylaxis for patients with hae who have frequent, severe angioedema attacks. despite known associated adverse effects such as virilization, weight gain, and decreases in hepatic function, the administration of danazol may result in an improvement of some conditions. contrary to findings in patients receiving high-dose danazol treatment for endometriosis, kollár et al reported that patients with hae receiving the minimum effective dose of danazol necessary to control their angioedema attacks did not have osteoporosis. indeed, their data suggest that such a danazol regimen may have a protective effect against bone loss. perricone et al noted a higher prevalence of polycystic or multifollicular ovaries in women with hae but found that danazol administered in hae-management doses, at least in a small sample of patients, improved ovarian condition. treatment varies depending on the location and severity of angioedema. peripheral edema often requires no treatment. for attacks involving the airways or severe abdominal manifestations, c -inh concentrate is the current acute attack therapy of choice for patients with hae. in countries where this is not available, personal importation of c -inh concentrate may be an option; alternatively, the administration of ffp or an antifibrinolytic, although less effective, may be of some benefit in emergencies. supportive measures such as rehydration, antiemetics, and pain control may be necessary depending on the site and severity of the attack. new uses for existing therapy, such as prophylactic or home administration of c -inh concentrate, have been studied on a small scale and proven successful. new therapies, including versions of recombinant c -inh, a kallikrein inhibitor, and a bradykinin receptor- antagonist, are in development. (marco cicardi, md,* milan, italy) since the first comprehensive clinical description of hae in , knowledge of the disease has been expanding. as have many other genetic defects, hae has benefited in the last years from the spread of molecular biology, which brought a tremendous advance in the understanding of the molecular basis of the disease. however, what appears remarkably unique to hae is that within the last years, this bulk of information has been directly transferred into therapeutic approaches. the dream of research from the bench to the bedside is becoming real in hae, and the rule that there is no interest in developing drugs for treating a small number of patients seems to have vanished. revolutionary new techniques for identifying and producing drugs, such as peptide selection from phage display libraries and transgenic animals as source of recombinant proteins, have been implemented to obtain agents active in hae. currently, completely new compounds, a kallikrein inhibitor, a bradykinin receptor antagonist, and a recombinant c -inh, are under clinical evaluation for the treatment of hae. this disease is facing the new pharmacology. chemicals antagonizing biologic systems are being substituted with disease-tailored agents, and in hae, this does not necessarily mean gene therapy. this close relationship between a pharmacologic agent and a disease results in the need for a close relationship between patients and industry. in , the first c esterase inhibitor deficiency workshop was held in hungary with the idea of having patients, scientists, physicians, and industries contributing with equal authority. since that time, a real hae community has been created, and patient support groups are actively involved in designing and carrying clinical studies and are supporting initiatives, such as the hae register, aimed to improve the understanding of the disease and its treatment. aside from the new scientific knowledge or the new therapeutic compounds, recent years' frank and open discussion between different parties is a major achievement for the advancement of the hae cause. many sections of this supplement have repeatedly highlighted how disabling and risky it has been for most patients living with hae, but patients can now have great hopes for the future. the major concern remains the difficulty that many patients still have in reaching correct diagnosis and treatment. deaths caused by hae and similar angioedematous disorders still occur in developed countries because the majority of physicians, ignoring the existence of hae, still label these patients as allergic. we hope that this supplement will help bring more hae, aae, and nonallergic edema patients to the correct diagnosis. institute in the netherlands, and has consulting agreements with genmab and lev pharmaceuticals. m. juers is an employee of aventis behring gmbh, a zlb behring company, and has aventis stock options. h. longhurst has received support/funding from dyax corp., pharming, aventis behring, and jerini. j. nuijens is employed by pharming group nv, a biotechnology company developing recombinant c nh. c. o'grady has received support/funding from dyax corp., pharming, aventis behring, jerini, and baxter. p. späth is a collaborator of zlb behring. k. williams is an independent writing contractor paid for this and other projects by dyax corp.; her husband is a senior-level employee of dyax corp. and owns shares of dyax corp. stock. all other authors-none. hereditary angioneurotic edema: report of a large kindred with defect in c' esterase inhibitor and review of the literature the house of the seven gables on giant urticaria Ü ber akutes umschriebenes hautö dem hereditary angio-neurotic oedema a biochemical abnormality in hereditary angioneurotic edema: absence of serum inhibitor of c' -esterase hereditary and acquired c -inhibitor deficiency: biological and clinical characteristics in patients clinical, biochemical, and genetic characterization of a novel estrogen-dependent inherited form of angioedema increased vascular permeability in c inhibitor-deficient mice mediated by the bradykinin type receptor complement abnormalities with lower extremities discomfort in vietnamese immigrants role of the second component of complement (c ) and plasmin in kinin release in hereditary angioneurotic edema kinin formation in hereditary angioedema plasma: evidence against kinin derivation from c and in support of ''spontaneous'' formation of bradykinin bradykinin-mediated angioedema plasma bradykinin in angio-oedema the pathogenesis of hereditary angioedema bradykinin and the pathophysiology of angioedema activation of factor xii and cleavage of high molecular weight kininogen during acute attacks in hereditary and acquired c -inhibitor deficiencies endothelial cells contribute to vascular leakage in patients with c inhibitor deficiency and angioedema heat shock protein catalyzes activation of the prekallikrein-kininogen complex in the absence of factor xii activation of the bradykinin-forming cascade on endothelial cells: a role for heat shock protein exogenous oestrogen as an alternative to food allergy in the aetiology of angioneurotic oedema hormonally exacerbated hereditary angioedema effect of sex hormones on the complement-related clinical disorder of hereditary angioedema hereditary angio-oedema: new clinical observations and autoimmune screening, complement and kallikrein-kinin analyses danazol: endocrine pharmacology and therapeutic applications hereditary angio-oedema: a review with particular reference to pathogenesis and treatment local bradykinin generation in hereditary angioedema role of the p residue of complement inhibitor (ala ) in determination of target protease specificity: inhibition of complement and contact system proteases post-translational mechanisms of endothelial nitric oxide synthase regulation by bradykinin pathways for bradykinin formation and inflammatory disease hereditary angioedema: the clinical syndrome and its management type i hereditary angio-oedema: variability of clinical presentation and course within two large kindreds pathogenetic and clinical aspects of c inhibitor deficiency hypovolemic shock caused by ascites in hereditary angioedema hereditary angioneurotic edema with severe hypovolemic shock hereditary angioedema: an infrequent cause of abdominal pain with ascites sonographic appearances of the abdominal manifestations of hereditary angioedema changes in splenoportal axis calibre and flow in a patient affected by hereditary angioedema sonographic findings in abdominal hereditary angioedema ct of angioedema of the small bowel image of the month: hereditary angioedema (hae) hereditary angioedema with gastrointestinal involvement: endoscopic appearance abdominal attack of hereditary angioedema associated with marked leucocytosis: a case report hereditary or acquired angioedema caused by functional deficiency of c inhibitor-a still unfamiliar disease picture asphyxiation by laryngeal edema in patients with hereditary angioedema treatment of episodes of laryngeal edema with c inhibitor concentrate in patients with hereditary angioedema erythema marginatum preceding an acute oedematous attack of hereditary angioneurotic oedema bladder involvement in hereditary angioedema neurological manifestations of angioedema: report of two cases and review of the literature hereditary angioneurotic edema, i: case reports and review of the literature hemodynamic effects of bradykinin on systemic and pulmonary circulation in healthy and hypertensive humans analysis of an exon polymorphism of the b bradykinin receptor gene and its transcript in normal subjects and patients with c inhibitor deficiency eradication of helicobacter pylori and improvement of hereditary angioneurotic oedema contributions to the study of the favouring role of chronic urinary infections in inducing and starting drug-allergic-type reactions acquired angioedema associated with sinusitis helicobacter pylori infection and skin diseases hereditary angioedema associated with subacute cutaneous lupus erythematosus rheumatoid arthritis and hereditary angioedema immunoregulatory disorders associated with hereditary angioedema, i: clinical manifestations of autoimmune disease immunoregulatory disorders associated with hereditary angioedema, ii: serologic and cellular abnormalities lupus erythematosus associated with c inhibitor deficiency c inhibitor deficiency in a patient with rheumatoid arthritis-increased risk of adverse effects of penicillamine? glomerulonephritis and hereditary angioedema: report of cases a family with hereditary angioedema and multiple immunologic disorders association of systemic lupus erythematosus and sle-like syndromes with hereditary and acquired complement deficiency states long-term follow-up of non-systemic lupus erythematosus glomerulonephritis in patients with hereditary angioedema: report of four cases a case of hereditary angioneurotic edema associated with systemic lupus erythematosus inherited deficiencies of complement components in man epidemiology and estimated population burden of selected autoimmune diseases in the united states hereditary angioneurotic edema and charcot-marie-tooth disease in the same family association of hereditary angioedema and hereditary breast cancer association of celiac disease and hereditary angioneurotic edema coincidence of hereditary angioedema (hae) with crohn's disease reduction in transmission of hepatitis c after the introduction of a heat-treatment step in the production of c -inhibitor concentrate ultrasonography in the diagnosis of hereditary angioneurotic oedema ultrasonography for early diagnosis of hereditary angioneurotic oedema ultrasonography in the diagnosis and monitoring of ascites in acute abdominal attacks of hereditary angioneurotic oedema clinical management of hereditary angio-oedema in children acute abdominal attack of hereditary angioneurotic oedema associated with ultrasound abnormalities suggestive of acute hepatitis angioedema: manifestations and management hereditary angioedema: a broad review for clinicians detection of c inhibitor mutations in patients with hereditary angioedema a review of the reported defects in the human c esterase inhibitor gene producing hereditary angioedema including four new mutations hereditary angioedema with normal c -inhibitor activity in women hereditary angioedema type iii: an additional french pedigree with autosomal dominant transmission hereditary angioneurotic edema: two genetic variants c inhibitor and hereditary angioneurotic edema behavior in vivo of normal and dysfunctional c inhibitor in normal subjects and patients with hereditary angioneurotic edema crucial residues in the carboxy-terminal end of c inhibitor revealed by pathogenic mutants impaired in secretion or function estrogen-dependent inherited angioedema serum interspecies differences in metabolic pathways of bradykinin and [des-arg ]bk: influence of enalaprilat handbook of immunopharmacology: the kinin system des-arg -bradykinin metabolism in patients who presented hypersensitivity reactions during hemodialysis: role of serum ace and aminopeptidase p aminopeptidase p in individuals with a history of angio-oedema on ace inhibitors possible contraindication of angiotensin converting enzyme inhibitors in patients with hereditary angioedema exacerbation of angioedema by an angiotensin converting enzyme inhibitor in a patient with variant form hereditary angioedema angioedema due to angiotensin-converting enzyme inhibitors hereditary angioedema first apparent in the ninth decade during treatment with ace inhibitor reply (hereditary angioedema type iii: an additional french pedigree with autosomal dominant transmission) inherited and acquired deficiencies of c esterase inhibitor in man hereditary angioedema and normal c -inhibitor activity in women methyltestosterone therapy for hereditary episodic edema (hereditary angioneurotic edema) acquired c esterase inhibitor deficiency and angioedema: a review hereditary angioedema: a decade of management with stanozolol rapid fibrinolysis, augmented hageman factor (factor xii) titers, and decreased c esterase inhibitor titers in women taking oral contraceptives c inactivator level in pregnancy c -esterase inhibitor in uncomplicated pregnancy and mild and moderate preeclampsia c esterase inhibitor in pregnancy acquired c inhibitor deficiency in lymphosarcoma the metabolism of c inhibitor and c q in patients with acquired c -inhibitor deficiency acquired angioedema and anti-c -inhibitor autoantibody autoimmune c inhibitor deficiency: report of eight patients relevance of lymphoproliferative disorders and of anti-c inhibitor autoantibodies in acquired angio-oedema acquired angioedema with lymphoproliferative disorder: association of c inhibitor deficiency with cellular abnormality acquired c inhibitor deficiency in a case of lymphosarcoma of the spleen: reversal of complement abnormalities after splenectomy acquired c inhibitor deficiency with angioedema symptoms in a patient infected with echinococcus granulosus acquired angioedema associated with chronic hepatitis c angioedema due to acquired c -esterase inhibitor deficiency in a patient with helicobacter pylori infection angiooedema due to acquired deficiency of c -esterase inhibitor associated with leucocytoclastic vasculitis acquired deficiency of the inhibitor of the first component of complement: report of five additional cases with commentary on the syndrome recurrent febrile panniculitis and hepatitis in two patients with acquired complement deficiency and paraproteinemia acquired c inhibitor deficiency associated with systemic lupus erythematosus affecting the central nervous system acquired c esterase inhibitor deficiency in two patients presenting with a lupus-like syndrome and anticardiolipin antibodies angioedema with acquired deficiency of the c inhibitor: a constellation of syndromes an igg autoantibody which inactivates c -inhibitor autoantibody facilitated cleavage of c -inhibitor in autoimmune angioedema acquired c inhibitor (c -inh) deficiency type ii: replacement therapy with c -inh and analysis of patients' c -inh and anti-c -inh autoantibodies autoimmune c -inhibitor deficiency acquired angioedema with c inhibitor deficiency: is the distinction between type i and type ii still relevant? prevalence of monoclonal gammopathy in patients presenting with acquired angioedema type clinical and biological distinctions between type i and type ii acquired angioedema autoantibodies and lymphoproliferative diseases in acquired c -inhibitor deficiencies idiopathic nonhistaminergic angioedema drug-induced angioedema without urticaria valsartan-induced angioedema quantification of c -inhibitor functional activities by immunodiffusion assay in plasma of patients with hereditary angioedema-evidence of a functionally critical level of c -inhibitor concentration interaction of i-labelled complement subcomponents c- r and c- s with protease inhibitors in plasma inactivation of factor xii active fragment in normal plasma: predominant role of c- -inhibitor distribution of plasma kallikrein between c- inactivator and alpha -macroglobulin in plasma utilizing a new assay for alpha -macroglobulin-kallikrein complexes on the role of c -inhibitor as inhibitor of tissue-type plasminogen activator in human plasma inactivation of factor xia in human plasma assessed by measuring factor xia-protease inhibitor complexes: major role for c -inhibitor proteolytic activities of two types of mannose-binding lectin-associated serine protease the serpin superfamily of proteinase inhibitors: structure, function, and regulation regional assignment of the human c -inhibitor gene to q -q detailed physical map of human chromosomal region q - shows high meiotic recombination rate around the men locus complete nucleotide sequence of the gene for human c inhibitor with an unusually high density of alu elements recombinations between alu repeat sequences that result in partial deletions within the c inhibitor gene recombinational biases in the rearranged c -inhibitor genes of hereditary angioedema patients contiguous deletion and duplication mutations resulting in type hereditary angioneurotic edema cpg mutations in the reactive site of human c inhibitor molecular genetics of c inhibitor frequent de novo mutations and exon deletions in the c inhibitor gene of patients with angioedema cooh-terminal substitutions in the serpin c inhibitor that cause loop overinsertion and subsequent multimerization transinhibition of c inhibitor synthesis in type i hereditary angioneurotic edema the catabolism of c (-)-inhibitor and the pathogenesis of hereditary angio-edema c inhibitor. functional analysis of naturally-occurring mutant proteins c inhibitor hinge region mutations produce dysfunction by different mechanisms unique c inhibitor dysfunction in a kindred without angioedema, ii: identification of an ala -val substitution and functional analysis of the recombinant mutant protein a hinge region mutation in c -inhibitor (ala -thr) results in nonsubstrate-like behavior and in polymerization of the molecule structural and functional aspects of c -inhibitor c inhibitor gene sequence facilitates frameshift mutations c inhibitor gene and hereditary angioedema the rapid detection of unknown mutations in nucleic acids enzymatic methods for mutation scanning reactivity of cytosine and thymine in single-base-pair mismatches with hydroxylamine and osmium tetroxide and its application to the study of mutations chemical cleavage of mismatch: a new look at an established method c inhibitor mutations which affect intracellular transport and secretion in type i hereditary angioedema current methods of mutation detection efficient detection of point mutations on color-coded strands of target dna exhaustive mutation scanning by fluorescence-assisted mismatch analysis discloses new genotype-phenotype correlations in angiodema denaturing high-performance liquid chromatography: a review mutation detection by denaturing gradient gel electrophoresis (dgge) five novel mutations in the c inhibitor gene (c nh) leading to a premature stop codon in patients with type i hereditary angioedema single-strand conformation polymorphism and heteroduplex analysis for gel-based mutation detection molecular defects in hereditary angioneurotic edema detection of c inhibitor (serping /c nh) mutations in exon in patients with hereditary angioedema: evidence for novel mutations molecular basis for the deficiency of complement inhibitor in type i hereditary angioneurotic edema altered c inhibitor genes in type i hereditary angioedema restriction fragment length polymorphism analysis of the c -inhibitor gene in hereditary c -inhibitor deficiency rapid detection by fluorescent multiplex pcr of exon deletions and duplications in the c inhibitor gene of hereditary angioedema patients the effect of sequence variations within the coding region of the c inhibitor gene on disease expression and protein function in families with hereditary angio-oedema the promoter of the c inhibitor gene contains a polypurine.polypyrimidine segment that enhances transcriptional activity mutation screening of the c inhibitor gene among hungarian patients with hereditary angioedema hereditary angioedema with a de novo mutation of exon in the c inhibitor gene showing recurrent edema of the hands around the peripheral joints: importance for the differential diagnosis of joint swelling type i c inhibitor deficiency with a small messenger rna resulting from deletion of one exon synthesis of c inhibitor in fibroblasts from patients with type i and type ii hereditary angioneurotic edema impaired production of both normal and mutant c inhibitor proteins in type i hereditary angioedema with a duplication in exon expression of functional human c inhibitor in cos cells characterization of recombinant c inhibitor p variants characterization of c inhibitor-ta: a dysfunctional c inh with deletion of lysine c inhibitor: analysis of the role of amino acid residues within the reactive center loop in target protease recognition a surprising new protein superfamily containing ovalbumin, antithrombin-iii, and alpha -proteinase inhibitor primary structure of the reactive site of human c -inhibitor molecular cloning of human c inhibitor: sequence homologies with alpha -antitrypsin and other members of the serpins superfamily the serpins are an expanding superfamily of structurally similar but functionally diverse proteins: evolution, mechanism of inhibition, novel functions, and a revised nomenclature c -esterase inhibitor: an anti-inflammatory agent and its potential use in the treatment of diseases other than hereditary angioedema in vitro interaction of c -inhibitor with thrombin c inactivator inhibition by plasmin plasminogen activator in normal subjects after exercise and venous occlusion: t-pa circulates as complexes with c -inhibitor and pai- potentiation of c inhibitor by glycosaminoglycans: dextran sulfate species are effective inhibitors of in vitro complement activation in plasma modulation of contact system proteases by glycosaminoglycans: selective enhancement of the inhibition of factor xia the potentiation of human c -inhibitor by dextran sulphate is transient in vivo: studies in a rat model human c inhibitor: primary structure, cdna cloning, and chromosomal localization the functional integrity of the serpin domain of c -inhibitor depends on the unique n-terminal domain, as revealed by a pathological mutant simultaneous turnover of normal and dysfunctional c inhibitor as a probe of in vivo activation of c and contact activatable proteases regulation of c inhibitor synthesis the role of sialic acid in the functional activity and the hepatic clearance of c -inh clearance of human native, proteinase-complexed, and proteolytically inactivated c -inhibitor in rats a randomized, controlled trial to study the efficacy and safety of c inhibitor concentrate in treating hereditary angioedema a new role for c- -inhibitor in homeostasis: control of activation of the first component of human complement activation of the complement, coagulation, fibrinolytic and kallikrein-kinin systems during attacks of hereditary angioedema activation of the fourth component of complement (c ): assessment by rocket immunoelectrophoresis and correlation with the metabolism of c i-pla( ) activation during apoptosis promotes the exposure of membrane lysophosphatidylcholine leading to binding by natural immunoglobulin m antibodies and complement activation c-reactive protein binds to apoptotic cells, protects the cells from assembly of the terminal complement components, and sustains an antiinflammatory innate immune response: implications for systemic autoimmunity c q binds directly and specifically to surface blebs of apoptotic human keratinocytes: complement deficiency and systemic lupus erythematosus revisited chromatin-independent binding of serum amyloid p component to apoptotic cells surface-mediated defense reactions: the plasma contact activation system quantification of plasma factor xiia-c -inhibitor and kallikrein-c -inhibitor complexes in sepsis prekallikrein activation and high-molecular-weight kininogen consumption in hereditary angioedema activation of the coagulation cascade in c -inhibitor deficiencies generation of plasmin during acute attacks of hereditary angioedema inactivation of factor xia in vivo: studies in chimpanzees and in humans reduction of contact activation related fibrinolytic activity in factor xii deficient patients: further evidence for the role of the contact system in fibrinolysis in vivo the role of factor xii in contact system activation effect of bradykinin-receptor blockade on the response to angiotensin-converting-enzyme inhibitor in normotensive and hypertensive subjects roles for the kallikrein-kinin system in inflammatory exudation and pain: lessons from studies on kininogen-deficient rats angioedema induced by a peptide derived from complement component c microparticles from patients with multiple organ dysfunction syndrome and sepsis support coagulation through multiple mechanisms binding and activation properties of human factor xii, prekallikrein, and derived peptides with acidic lipid vesicles dextran sulphate inhibits phospholipid and sulphatide mediated autoactivation of factor xii inhibition of the activation of hageman factor (factor xii) by platelet factor inhibition of the activation of hageman factor (factor xii) by beta -glycoprotein i angioneurotic edema of the upper airways and antihypertensive therapy vasopeptidase inhibition: a double-edged sword? hereditary angioedema: genealogic studies and clinical considerations on genetic forms in a case study of patients late angioedema caused by ace inhibitors underestimated angioedema due to ace inhibitors: common and inadequately diagnosed increased sensitivity to bradykinin among african americans angioedema and cough in nigerian patients receiving ace inhibitors angioedema due to ace inhibitors: increased risk in patients of african origin angiotensin ii receptor blocker-associated angioedema: on the heels of ace inhibitor angioedema angiotensin ii receptor blockers in patients with ace inhibitor-induced angioedema angioedema associated with angiotensin ii receptor antagonists: challenging our knowledge of angioedema and its etiology mechanisms of angiotensin ii-induced expression of b kinin receptors omapatrilat: bristol-myers squibb omapatrilat and enalapril in patients with hypertension: the omapatrilat cardiovascular treatment vs. enalapril (octave) trial omapatrilat-the story of overture and octave vasopeptidase inhibitors-concepts and evidence biochemical basis of angioedema associated with recombinant tissue plasminogen activator treatment: an in vitro experimental approach bradykinin and des-arg( )-bradykinin metabolic pathways and kinetics of activation of human plasma bioregulation of kinins: kallikreins, kininogens, and kininases bradykinin receptors effects of hormone replacement therapy on serum angiotensin-converting enzyme activity and plasma bradykinin in postmenopausal women according to angiotensin-converting enzyme-genotype hormone replacement therapy and serum angiotensin-convertingenzyme activity in postmenopausal women decreased synthesis of serum carboxypeptidase n (scpn) in familial scpn deficiency familial carboxypeptidase n deficiency factor xii does not initiate prekallikrein activation on endothelial cells activation of the plasma kallikrein/kinin system on endothelial cell membranes the plasma kallikrein-kinin system counterbalances the renin-angiotensin system the physiologic basis of assembly and activation of the plasma kallikrein/kinin system mechanism of enhanced kinin release from high molecular weight kininogen by plasma kallikrein after its exposure to plasmin detection of active kallikrein in induced blister fluids of hereditary angioedema patients dose-dependent effects of postmenopausal estrogen and progestin on antithrombin iii and factor xii increased euglobulin fibrinolytic potential in women on oral contraceptives low in oestrogen-levels of extrinsic and intrinsic plasminogen activators, prekallikrein, factor xii, and c -inactivator molecular basis of estrogen regulation of hageman factor xii gene expression contact factors in plasma from women on oral contraception-significance of factor xi for the measured activity of factor xii biochemical and molecular pharmacology of kinin receptors transcription factor nuclear factor kappab regulates the inducible expression of the human b receptor gene in inflammation receptors for kinins: from classical pharmacology to molecular biology mechanisms regulating the expression, self-maintenance, and signaling-function of the bradykinin b and b receptors regulation of bradykinin b -receptor expression by oestrogen coexistence of hereditary angioedema and turner's syndrome hereditary angioedema precipitated by estrogen replacement therapy in a menopausal woman recurrent episodes of skin angioedema and severe attacks of abdominal pain induced by oral contraceptives or hormone replacement therapy recurrent angioedema: familial and oestrogen-induced angioedema and oral contraception recurrent angioedema associated with hypogonadism or anti-androgen therapy estrogen induction and contact phase activation of human factor xii enhanced expression of factor xii (hageman factor) in isolated livers of estrogenand prolactin-treated rats the influence of estrogen and prolactin on hageman factor (factor xii) titer in ovariectomized and hypophysectomized rats differential regulation of kininogen gene expression by estrogen and progesterone in vivo the effect of oestrogen dose and progestogen type on haemostatic changes in women taking low dose oral contraceptives effects of a very low-estrogen oral contraceptive on clotting factors, carbohydrate metabolism and plasma lipids and lipoproteins contact activation factors in plasma from women using oral contraceptives-increased levels of factor xii, kinin-free high molecular weight kininogen and acetone-activated kallikrein estrogen-associated thromboembolism contact factor mediated fibrinolysis is increased by the combined oral contraceptive pill prospective randomized study of effects of unopposed estrogen replacement therapy on markers of coagulation and inflammation in postmenopausal women positive impact of hormone replacement therapy on the fibrinolytic system: a long-term randomized controlled study in healthy postmenopausal women postmenopausal hormone replacement therapy increases coagulation activity and fibrinolysis effect of long-term hormone replacement therapy on angiotensin-converting enzyme activity and bradykinin in postmenopausal women with essential hypertension and normotensive postmenopausal women estrogen regulation of angiotensin-converting enzyme mrna sex hormones in hereditary angioneurotic oedema the complete drug reference bethesda: american society of health-system pharmacists drugdexÒ system hereditary angioedema and oral contraception effects of methylamine and heparin on a rapid chromogenic assay of c -esterase inhibitor in plasma effect of time, temperature and additives on a functional assay of c inhibitor effects of estrogen replacement therapy on the renin-angiotensin system in postmenopausal women management and diagnostic guidelines for urticaria and angio-oedema hereditary angioneurotic oedema in three families: symptomatic heterogeneity, complement analysis and therapeutic trials hereditary angioneurotic oedema in finland: clinical, immunological and genealogical studies hereditary angioedema due to deficit of c esterase inhibitor hereditary angioneurotic edema: a clinical survey c -inh defect as an example of deficiency disease hereditary angioedema: danazol therapy in a -year-old child hereditary angioneurotic oedema: current management in pregnancy a multicentre evaluation of the diagnostic efficiency of serological investigations for c inhibitor deficiency inherited and acquired deficiencies of c esterase inhibitor in humans c is activated in hereditary angioedema, and c /c -inhibitor complexes rise during physical stress in untreated patients contact system in healthy term newborns: reference values in cord blood application of a monoclonal antibody against a neoepitope on activated c in an elisa for the quantification of complement activation via the classical pathway c inhibitor and diagnosis of hereditary angioedema in newborns complement components in newborns and their mothers determined by electroimmunoassay angioedema: a review on the acquired, allergic or non-allergic, and the hereditary forms serum complement levels in infancy: age related changes influence of age and sex on serum complement components in children development of the human coagulation system in the full-term infant plasma protease inhibitors in premature infants: influence of gestational age, postnatal age, and health status serum complement profiles in infants and children misdiagnosis of hereditary angio-oedema type and type acute consumption of c inhibitor in a patient with acquired c -inhibitor deficiency syndrome normal complement c values do not exclude hereditary angioedema hereditary angioneurotic oedema treatment of hereditary angioedema with a vapor-heated c inhibitor concentrate replacement therapy in hereditary angioedema: successful treatment of acute episodes of angioedema with partly purified c inhibitor c inh concentrate in the therapy of hereditary angioedema c -esterase inhibitor transfusions in patients with hereditary angioedema replacement therapy in hereditary angioedema: successful treatment of two patients with fresh frozen plasma c -inhibitor deficiency and angioedema treatment of hereditary angioedema letter: anaphylactic reaction to aprotinin dx- and hae: a developmental perspective the synthetic kunitz domain protein dx- to treat angioedema in patients with hereditary angioedema role of kinins in seasonal allergic rhinitis: icatibant, a bradykinin b receptor antagonist, abolishes the hyperresponsiveness and nasal eosinophilia induced by antigen efficacy and tolerability of icatibant (hoe ) in patients with moderately severe chronic bronchial asthma jerini announces positive phase ii study results with icatibant for the treatment of hereditary angioedema a phase i study of recombinant human c -inh in asymptomatic patients with hereditary angioedema-hae pharming features clinical results of c inhibitor at investigator meeting [press release treatment of hereditary angioedema with danazol: reversal of clinical and biochemical abnormalities morphologic evaluation of the liver in hereditary angioedema patients on long-term treatment with androgen derivatives side effects of long-term prophylaxis with attenuated androgens in hereditary angioedema: comparison of treated and untreated patients the long-term safety of danazol in women with hereditary angioedema long-term treatment of hereditary angioedema with attenuated androgens: a survey of a -year experience danazol therapy: an unusual aetiology of hepatocellular carcinoma hepatocellular adenomas in patients taking danazol for hereditary angio-oedema danazol-induced hepatocellular adenoma in patients with hereditary angio-oedema a case of hereditary angioneurotic oedema, successfully treated with epsilonaminocaproic acid: studies on c' esterase inhibitor, c' activation, plasminogen level and histamine metabolism long-term prophylaxis with c -inhibitor (c inh) concentrate in patients with recurrent angioedema caused by hereditary and acquired c -inhibitor deficiency pharmacokinetic parameters of c -inhibitor concentrate in patients with hereditary angio-oedema (hae)-a prospective study acute airway obstruction following tooth extraction in hereditary angioedema oral manifestations and dental management of patients with hereditary angioedema hereditary angioedema: report of case prophylactic use of epsilon aminocaproic acid for oral surgery in a patient with hereditary angioneurotic edema tranexamic acid: preoperative prophylactic therapy for patients with hereditary angioneurotic edema intravenous tranexamic acid in the management of hereditary angio-oedema potentially fatal hereditary angioedema: a review and case report the efficacy of short-term danazol prophylaxis in hereditary angioedema patients undergoing maxillofacial and dental procedures successful off-pump coronary artery bypass graft surgery in a patient with hereditary angioedema preoperative prophylaxis for c esterase-inhibitor deficiency in patients undergoing oral surgery: a report of three cases hereditary angioedema: uncomplicated maxillofacial surgery using short-term c inhibitor replacement therapy c -esterase inhibitor concentrate prevents upper airway obstruction in hereditary angio-oedema acquired angioedema as the presenting feature of lymphoproliferative disorders of mature b-lymphocytes spontaneous regression of acquired c esterase inhibitor deficiency associated with splenic marginal zone lymphoma presenting with recurrent angio-oedema acquired angioedema associated with rectal carcinoma and its response to danazol therapy: acquired angioedema treated with danazol activation of the contact system and fibrinolysis in autoimmune acquired angioedema: a rationale for prophylactic use of tranexamic acid angioneurotic edema with acquired c -inhibitor deficiency and autoantibody to c -inhibitor: response to plasmapheresis and cytotoxic therapy purity, activity, and virus safety of a pasteurized antithrombin concentrate a factor viii concentrate, highly purified and heated in solution virus-safe plasma proteins: elimination of viruses of risk by the manufacturing procedure inactivation of hepatitis a virus by pasteurization and elimination of picornaviruses during manufacture of factor viii concentrate absence of anti-human immunodeficiency virus types and seroconversion after the treatment of hemophilia a or von willebrand's disease with pasteurized factor viii concentrate absence of hepatitis after treatment with a pasteurized factor viii concentrate in patients with hemophilia and no previous transfusions effectiveness of alternative treatments for reducing potential viral contaminants from plasma-derived products inactivation of parvovirus b during pasteurization of human serum albumin a novel coronavirus associated with severe acute respiratory syndrome virus safety of pasteurized clotting factor concentrates: an eleven year follow up hepatitis c and pasteurized c -inhibitor concentrate prospective virus safety follow-up after therapy with a pasteurized c -inhibitor concentrate prophylactic treatment with pasteurised c inhibitor in herditary angioedema (hae)-a prospective months follow up prospective follow up of clinical manifestation and therapy in children with hereditary angioedema (hae) high-titer screening pcr: a successful strategy for reducing the parvovirus b load in plasma pools for fractionation prospective audit of adverse reactions occurring in primary antibody-deficient patients receiving intravenous immunoglobulin state of care for hemophilia in pediatric patients hereditary angioedema treatment of acute attacks of hereditary angioedema with c -inhibitor concentrate clinical studies of sudden upper airway obstruction in patients with hereditary angioedema due to c esterase inhibitor deficiency proteolytic inactivation of plasma c -inhibitor in sepsis expression of active human c inhibitor serpin domain in escherichia coli n-and o-glycans of recombinant human c inhibitor expressed in the milk of transgenic rabbits production of complex human glycoproteins in yeast recombinant human c -inhibitor produced in pichia pastoris has the same inhibitory capacity as plasma c -inhibitor recombinant human c -inhibitor produced in pichia pastoris has the same inhibitory capacity as plasma c -inhibitor recombinant c inhibitor p /p variants display resistance to catalytic inactivation by stimulated neutrophils the effect of danazol in the treatment of chronic cystic mastitis danazol-induced pseudomenopause in the management of endometriosis effects of danazol on pulsatile gonadotropin patterns and on serum estradiol levels in normally cycling women cortical and trabecular bone mineral content in women with endometriosis: effect of gonadotropin-releasing hormone agonist and danazol a comparison of the skeletal effects of goserelin and danazol in premenopausal women with endometriosis evidence of similar increases in bone turnover during nafarelin and danazol use in women with endometriosis the effects of nafarelin and danazol on vertebral trabecular bone mass in patients with endometriosis zoladex (goserelin acetate implant) in the treatment of endometriosis: a randomized comparison with danazol. the zoladex endometriosis study group bone mass in endometriosis patients treated with gnrh agonist implant or danazol excretion of urinary n-telopeptides reflects changes in bone turnover during ovarian suppression and indicates individually variable estradiol threshold for bone loss mechanism of mammalian ovulation complement, complement activation and anaphylatoxins in human ovarian follicular fluid cystic ovaries in women affected with hereditary angioedema increased plasma beta-endorphin levels in hereditary angioedema elevated levels of plasma beta-endorphin and gamma -melanocyte stimulating hormone in the polycystic ovary syndrome impaired human ovarian follicular fluid complement function in hereditary angioedema functionally active complement is present in human ovarian follicular fluid and can be activated by seminal plasma inherited and acquired deficiency of c esterase inhibitor in humans transmission of hepatitis g virus in patients with angioedema treated with steam-heated plasma concentrates of c inhibitor loss of danazol responsiveness in angioedema with c inhibitor deficiency complement and complement fixation immunochemical quantitation of the third, fourth and fifth components of human complement: concentrations in the serum of healthy adults recurrent abdominal pain as the sole manifestation of hereditary angioedema in multiple family members danazol therapy for hereditary angio-oedema in children epsilon aminocaproic acid therapy of hereditary angioneurotic edema: a double-blind study danazol for children with immune thrombocytopenic purpura hereditary angio-oedema in children tonsillectomy in a patient with hereditary angioedema after prophylaxis with c inhibitor concentrate a cluster of mutations within a short triplet repeat in the c inhibitor gene dysfunctional c inhibitor ta: deletion of lys- results in acquisition of an n-glycosylation site characterisation of nucleotide sequence variants and disease-specific mutations involving the # end of the c -inhibitor gene in hereditary angio-oedema an rna splice site mutation in the c -inhibitor gene causes type i hereditary angio-oedema a point mutation in exon of the c -inhibitor gene causing type i hereditary angioedema a novel donor splice site mutation in the c inhibitor gene of a patient with type i hereditary angioneurotic edema nonsense mutations affect c inhibitor messenger rna levels in patients with type i hereditary angioneurotic edema identification of a novel mutation of c inhibitor gene in a chinese family with hereditary angioedema a single base deletion from the c -inhibitor gene causes type i hereditary angio-oedema c -inhibitor gene nucleotide insertion causes type ii hereditary angio-oedema substrate properties of c inhibitor ma (alanine -glutamic acid): genetic and structural evidence suggesting that the p -region contains critical determinants of serine protease inhibitor/substrate status identification of type i hereditary angio-oedema (hae) mutations type ii hereditary angioneurotic edema that may result from a single nucleotide change in the codon for alanine- in the c inhibitor gene a dysfunctional c inhibitor protein with a new reactive center mutation type ii hereditary angio-oedema associated with two mutations in one allele of the c -inhibitor gene around the reactive-site coding region c -inhibitors and their genes: an update identification of a c/t mutation in the reactive-site coding region of the c -inhibitor gene and its detection by an improved mutation-specific polymerase chain reaction method identification of a new p residue mutation ( arg-ser) in a dysfunctional c inhibitor protein contained in a type ii hereditary angioedema plasma a mutation unique in serine protease inhibitors (serpins) identified in a family with type ii hereditary angioneurotic edema a de novo deletion in the c inhibitor gene in a case of sporadic hereditary angioneurotic edema a point mutation in the c -inhibitor gene causes type i hereditary angiooedema clusters of intragenic alu repeats predispose the human c inhibitor locus to deleterious rearrangements structural and functional aspects of c -inhibitor n, none; r, rare (< attack/mo); f, frequent (> attack/mo). *e-aminocaproic acid is not shown because it had no effect or caused intolerance, and therefore, it was replaced by tranexamic acid.cover. carbon backbone of a -dimensional model of c -inhibitor, with amino acids involved in hae. this model is made by homology modeling and is based on the crystal structure of other serpins. the a-helices are depicted in red, the b-strands in light blue. amino acids mutated in hae patients are depicted in yellow ball-and-stick. the reactive site, p -arg, is depicted in magenta ball-and-stick. ineke bos. adapted with permission from bos et al. key: cord- -pd o l authors: li, lanjuan title: translation: expert consensus on the application of artificial liver blood purification system in the treatment of severe and critical covid- : national clinical research center for infectious diseases, state key laboratory for diagnosis and treatment of infectious diseases date: - - journal: nan doi: . /im . sha: doc_id: cord_uid: pd o l the prevention and treatment of covid- nationwide has entered a tackling phase. effective treatment of severe and critically ill patients is the key to reducing the fatality of the disease. the artificial liver blood purification system can remove inflammatory factors, alleviate the damage of the inflammatory response to the body, and has important value for the treatment of severe covid- . led by academician lanjuan li, based on the experience of treating patients across the country, integrating the opinions of experts from all over the country, the center summarized and formulated the consensus including the basic principles, treatment indications, relative contraindications, mode selection, monitoring indicators, and efficacy evaluation of artificial liver, which provides reference for treatment of severe covid- patients. translation: expert consensus on the application of artificial liver blood purification system in the treatment of severe and critical covid- national clinical research center for infectious diseases, state key laboratory for diagnosis and treatment of at present, the prevention and treatment of covid- has entered a critical stage. effective treatment of severe and critical patients is the key to reduce the fatality of this disease. the acute severe respiratory infectious diseases have common clinical characteristics: rapidly progressing inflammation of the lungs, severe hypoxemia and multiple organ failure. the respiratory failure, shock, multiple organ failure and uncontrollable secondary infection are the main causes of death finally. [ ] [ ] studies have revealed that severe cases of sars, avian influenza h n and h n virus infections all present a "cytokine storm", which is the main factor of disease progression. - therefore, blocking the "cytokine storm" is a key intervention for the treatment of shock, hypoxemia and multiple organ failure. studies have shown that the artificial liver support system (alss) can remove inflammatory factors and block the "cytokine storm", thus reducing damage to the body caused by the inflammatory response, which is of great value for the treatment of severe and critical patients. [ ] [ ] [ ] clinical practices have shown that li's alss has played an important role in the treatment of patients with severe h n viral infection. [ ] [ ] after discussions by the expert panel, the consensus has been reached on the principles, indications, contraindications, monitoring indicators and efficacy evaluation of alss for the treatment of severe and critical covid- patients. alss integrates plasma replacement, adsorption, perfusion, blood/plasma filtration and other techniques, to remove inflammatory mediators, endotoxins, and small and medium molecules of toxic and harmful substances, to supplement albumin, coagulation factors and other beneficial substances, and to regulate water electrolytes, acids and bases balance. it can block "cytokine storm", reduce pulmonary inflammation and improve respiratory function. at the same time, it can help to restore immune homeostasis, improve metabolic spectrum disorder in the body, facilitate accurate volume management, improve functions of liver, kidney and other organs, so as to increase the rescue success rate and reduce the fatality rate of severe and critical covid- patients. patients should receive alss treatment if they meet criteria ( ) & ( ), or only ( ). ( ) the inflammatory factors (such as il- , etc.) are no less than times the upper limit of the normal value, or the daily increase is greater than times; ( ) pulmonary imaging shows rapid progression, ct or x-rays indicate that the percentage of lung involvement progresses % or more per day; ( ) patients with basic diseases that require alss for treatment. there are no absolute contraindications for alss during the rescue of patients with critical illnesses. but prudent use is necessary in the following situations: ( ) patients with serious active bleeding or disseminated intravascular coagulation； ( ) patients who have serious allergies for the blood products or drugs used in the treatment, such as plasma, heparin, protamine, etc.; ( ) patients with acute cerebrovascular accidents or severe head injury; ( ) patients with cardiac dysfunctions or cardiac function grade iii and above; ( ) patients with uncorrected hypotension or shock; ( ) patients with severe arrhythmias. after fully evaluating the patients, the appropriate treatment mode may be selected as following: ( ) when plasma is available, it is recommended to conduct plasma exchange in combination with plasma adsorption or double plasma molecular adsorption, perfusion and filtration; plasma exchange volume (l) = body mass (kg)×( / )×( -hematocrit/ ); if plasma is in short supply, it is recommended to exchange more than ml of plasma at least. ( ) when plasma is not available or less than ml, it is recommended to carry out plasma adsorption or double plasma molecular adsorption, perfusion and hemofiltration combination treatment. in case of renal insufficiency, sequential combined hemodialysis and/or continuous hemofiltration should be performed. ( ) clinical symptoms and signs: vital signs, pulmonary manifestations, etc.; oxygen supply mode, flow rate and concentration; ( ) blood type, blood routine test (brt), c-reactive protein (crp), procalcitonin (pct), coagulation function, biochemical indexes, immunoglobulin, arterial blood gas analysis + lactic acid, peripheral blood il- , arterial oxygen partial pressure (pao )/oxygen absorption concentration (fio ), and pulmonary imaging (x-ray or ct) examinations; ( ) the detection of cytokines such as il- , il- , tumor necrosis factor-α (tnf-α) and peripheral blood lymphocyte subsets can be added if the tests are available; ( ) pneumonia severity index (psi) score. ( ) daily record of clinical signs and symptoms: vital signs, lung performance, etc.; oxygen supply pattern, flow and concentration; ( ) daily monitor brt, crp, pct, coagulation function, biochemical indexes, arterial blood gas analysis + lactic acid, il- and pao /fio ; testing for il- , il- and tnf-α may be added if available; ( ) daily record psi scores; ( ) monitor immunoglobulin levels every days; and lymphocyte subsets may be monitored if available; ( ) complete lung imaging (x-ray or ct) examinations every days. includes the efficacy evaluation of each treatment and survival rate. based on the changes of monitoring indicators before and after each treatment, mainly the cytokines (il- , etc.) and psi scores. includes -day and -week survival rate. if criterion ( ) in combination with any of the criteria ( ) to ( ) is met, treatment termination could be considered, except for the condition that patients need continued treatment for basic diseases. ( ) temperature has been normal for days, and respiratory symptoms improve significantly; ( ) inflammatory cytokines (such as il- ) have dropped below times the normal level for days; ( ) disengaged from respiration supporting therapy; ( ) blood lactate has been below . mmol/l for days; ( ) pulmonary imaging shows significant improvement for one week, and the pulmonary lesion area is absorbed by more than % compared with before. it should be noted that the current alss expert consensus for the treatment of severe and critical covid- patients are based on the empirical data from several centers in zhejiang, hubei, henan and shaanxi provinces. this consensus can be used as a treatment recommendation for implementation of effective treatment measures during the covid- pandemic. we should make every effort to reduce the fatality rate of covid- . a novel coronavirus emerging in china -key questions for impact assessment plasma inflammatory cytokines and chemokines in severe acute respiratory syndrome severe acute respiratory syndrome: historical, epidemiologic, and clinical features mers-cov infection in humans is associated with a proinflammatory th and th cytokine profile fatal outcome of human influenza a (h n ) is associated with high viral load and hypercytokinemia the serum profile of hypercytokinemia factors identified in h n -infected patients can predict fatal outcomes plasmapheresis adjusts inflammatory responses in potential kidney transplant recipients evaluation of plasma exchange and continuous veno-venous hemofiltration for the treatment of severe avian influenza a (h n ): a cohort study clinical findings in cases of influenza a (h n ) virus infection artificial liver management of corona virus disease- (covid- ): the zhejiang experience key: cord- -rtqkvf authors: padberg, stephanie title: anti-infective agents date: - - journal: drugs during pregnancy and lactation doi: . /b - - - - . -x sha: doc_id: cord_uid: rtqkvf infections may be hazardous to the health of the mother, the course of pregnancy, and the unborn child. they can lead to premature labor or premature rupture of membranes and thereby increase the risk for spontaneous abortion and prematurity. furthermore, certain germs can pass to the unborn child and harm it directly. therefore, an anti-infective treatment which should be both effective and safe for the mother and the unborn child is often required. the use of penicillines and older cephalosporines is well documented and considered to be safe. consequently, they are the drug of choice during pregnancy. in selected cases of bacterial resistance or intolerance to first-line antibiotics, other anti-infective agents might be recommended. especially for life-threatening infections, a therapy with not so well-tried agents might be needed. the potential benefit of treatment in such cases most often outbalances the potential risk for the unborn child. infections may be hazardous to the health of the mother, the course of pregnancy, and the unborn child. they can lead to premature labor or premature rupture of membranes and thereby increase the risk for spontaneous abortion and prematurity. furthermore, certain germs can pass to the unborn child and harm it directly. therefore, an anti-infective treatment which should be both effective and safe for the mother and the unborn child is often required. the use of penicillins and older cephalosporins is well documented and considered to be safe. consequently, they are the drug of choice during pregnancy. in selected cases of bacterial resistance or intolerance to first-line antibiotics, other anti-infective agents might be recommended. especially for life-threatening infections, a therapy with not so well-tried agents might be needed. the potential benefit of treatment in such cases most often outbalances the potential risk for the unborn child. stephanie padberg . . . erythromycin and other macrolides pharmacology erythromycin and other macrolides inhibit bacterial protein synthesis and are bacteriostatic. macrolides are primarily applied in the treatment of infections with gram-positive germs, but are also effective against haemophilus influenzae and intracellular pathogens such as chlamydia. macrolides offer an alternative for patients with penicillin allergy. erythromycin is the oldest medication of this group. its resorption can be delayed in the third trimester. gastrointestinal side effects can lead to lower than therapeutic plasma concentrations, resulting in treatment failure (larsen ) . only - % of the maternal erythromycin concentration is obtained in the fetus. therefore, erythromycin is not a sufficiently reliable drug for fetal or amniotic infections. the newer macrolide antibiotics azithromycin, clarithromycin, dirithromycin, josamycin, midecamycin, roxithromycin and troleandomycin have a similar antibacterial spectrum as erythromycin, but to some degree less gastrointestinal side effects. spiramycin is used for toxoplasmosis in the first trimester. telithromycin is the first ketolide antibiotic for clinical use. it is structurally related to erythromycin. erythromycin has always been considered a safe and effective antibiotic during pregnancy. data on several thousand first trimester exposures do not support an association between erythromycin and congenital malformations (e.g. czeizel a ). however, an analysis of the data from the swedish birth registry showed a weakly significant increase in malformations in , children whose mothers took erythromycin in early pregnancy compared to offspring whose mothers used phenoxymethylpenicillin (källén a ). this was based on an increased rate of cardiovascular malformations, especially ventricular and atrial septal defects. an update of the swedish data verified an association between the use of erythromycin during early pregnancy and cardiovascular defects (källén ). an increased incidence of pyloric stenosis was discussed by the same author (källén a) . this observation after intrauterine exposure in the first trimester is biologically not plausible; but it should be mentioned that a link has been suggested between a neonatal treatment with erythromycin during the first two weeks and the development of pylorus stenosis (e.g. mahon ) . other studies have failed to find a higher rate of septum defects, pyloric stenosis or other malformations (bahat dinur , lin , romøren , malm , cooper , louik . in summary, the experiences argue against an increased embryo-and fetotoxic risk for erythromycin. there are several reports of maternal hepatotoxic changes when erythromycin estolate was administered in the second half of pregnancy. these women developed a cholestatic icterus during the second week of treatment that abated within weeks when the treatment was discontinued, without evidence of permanent damage or signs of fetal compromise (e.g. mccormack ) . azithromycin, clarithromycin and roxithromycin have also been studied in several publications without any indication of embryo-or fetotoxic effects (bar-oz , bar-oz , chun , sarkar , drinkard , einarson ). in the case of clarithromycin, there was some . anti-infective agents pregnancy initial concern as animal experiments demonstrated teratogenic effects, and for instance, in some studies cardiovascular defects were induced in rats. recently a danish cohort study based on a prescription register observed an increased risk of miscarriage after clarithromycin in early pregnancy, but no increased risk for major malformations (andersen a) . experience with dirithromycin, josamycin, midecamycin, spiramycin, and troleandomycin is very limited (czeizel b) . spiramycin has been used in many first trimesters for the treatment of toxoplamosis. although these reports did not focus on a possible teratogenic effect, numerous normal births after spiramycin exposure are reassuring. there is no published experience with the use of the ketolide telithromycin in the first trimester. the animal experiments did not show that this agent is teratogenic. a local treatment with macrolides is quite safe for the fetus. yet, because resistance develops quickly and allergies are frequent, macrolides should be used with some reservation. clindamycin and lincomycin belong to the lincosamide group. they inhibit bacterial protein synthesis and can be bactericidal or bacteriostatic depending on concentration and sensitivity. after an oral dose the resorption is almost complete. about half of the maternal concentration can be attained in the umbilical veins. there were no signs of embryo-or fetotoxic effects in several hundred pregnant women treated with lincomycin at different points in pregnancy (czeizel c , mickal . there were also no problems found for clindamycin. pseudomembranous enterocolitis is a dangerous maternal complication of clindamycin treatment that may also happen after vaginal application. pregnancy complications due to bacterial vaginosis are not sufficiently preventable by vaginal clindamycin therapy (joesoef ) . it should be noted though, that other investigators found a reduction in late abortions and prematurity when treating several hundred patients with oral clindamycin for an abnormal vaginal flora (ugwumadu ) . recommendation. erythromycin, clarithromycin, azithromycin, and roxithromycin may be used in pregnancy when the resistance spectrum requires them, or in cases of an allergy to penicillin. because of hepatotoxicity, erythomycin estolate should not be given during the second and third trimester. spiramycin is the treatment of choice for toxoplasmosis in the first trimester. telithromycin and other makrolides should only be given during pregnancy when no alternatives are available. recommendation. clindamycin and lincomycin should only be used when penicillins, cephalosporins and macrolides have failed. clindamycin should not be routinely used after dental procedures. the bacteriostatic effect of tetracyclines is based on an inhibition of the bacterial protein synthesis. these broad-spectrum antibiotics, especially tetracycline itself, form stable chelates with calcium ions. the standard agent today is doxycycline. minocycline is especially lipophilic and displays a somewhat wider antibacterial spectrum than doxycycline. the older derivatives such as oxytetracycline and tetracycline are now rarely used as they are poorly resorbed. chlortetracycline, demeclocycline, and meclocycline are only used as local agents. tigecycline is a minocycline derivative that belongs to the glycylcyclines; it has a very broad-spectrum and is especially effective against multi-resistant pathogens such as mrsa. tetracyclines cross the placenta. according to current knowledge an increased risk of malformation is not expected when tetracyclines are used (cooper , czeizel . the results of a population-based case-control study suggested that oxytetracycline was associated with an increased incidence of congenital malformations (czeizel d) . however, the number of cases in this study was small, and there are no other studies confirming this suspicion. a danish cohort study found an association between oral clefts and maternal tetracycline exposure in the second month, but this result was based on only two exposed cases (mølgaard-nielsen ) . from the sixteenth week of pregnancy when fetal mineralization takes place, tetracyclines can bind to calcium ions in developing teeth and bones. in the s numerous publications described the brown/yellow discoloration of teeth in children who were prenatally exposed to tetracyclines. such dental discoloration is the only proven prenatal side effect of tetracyclines in humans. under discussion were also enamel defects leading to an increased risk of caries, inhibition of the growth of the long bones, specifically the fibula and further, cataracts due to depositions into the lens. as doxycycline has a weaker affinity to calcium ions than the older tetracyclines, the risk appears to be lower for doxycycline exposures. a discoloration of milk teeth is not to be expected prior to the sixteenth week of gestation. even thereafter, at worst, only the first molars of the permanent teeth would be affected when the usual therapeutic regimens if current dosings are adhered to. a bigger risk for the described development abnormalities can possibly expected with higher tetracycline doses during the second and third trimester that are necessary, for example, in malaria treatment. in the past, the use of tetracyclines, especially in high doses or via intravenous administration in the second half of pregnancy, has been associated with severe maternal hepatic toxicity (e.g. lewis ) . in most cases these were patients with kidney problems whose serum concentrations were markedly above the therapeutic range. no untoward effects have been described in pregnant women who applied tetracyclines locally during pregnancy. there is a lack of experience with tigecycline; no statement can be made about its tolerance in pregnancy. for local application silver sulfadiazine is used for burn injuries and sulfacetamide for eye infections. sulfonamides attain - % of the maternal concentration in the fetus and compete with bilirubin for binding sites on albumin. today, sulfonamides are seldom used as monotherapy because their spectrum is limited and resistance develops rapidly. combined with a folate antagonist such as trimethoprim or pyrimethamine (section . . ), sulfonamides are indicated among others in the treatment of toxoplasmosis and malaria. the fixed combination of the sulfonamide sulfamethoxazole and trimethoprim is available as co-trimoxazole. both agents in this combination are not subject to pregnancy-induced variation in clearance that would require dose modifications. trimethoprim is effective as a monotherapy in uncomplicated urinary tract infections with sensitive pathogens. to date, there are no indications that sulfonamides, trimethoprim, and their combinations have a teratogenic potential in humans (nørgård , czeizel ). an embryotoxic potential has been discussed from time to time, because antagonists to folic acid can lead to malformations in animal experiments, and in humans the spontaneous incidence of neural tube defects (spina bifida) can be decreased by the administration of folic acid during early pregnancy (chapter . ). the fact that human folic acid reductase is much less sensitive to trimethoprim than the bacterial enzyme, could explain that teratogenic problems have so far not been documented in humans when antibiotics with folic acid antagonists were used. trimethoprim has been used for many decades in pregnant women. at present, there is an ongoing discussion concerning the association between the use of folic acid antagonists and an increased risk of congenital malformations. a retrospective case-control study discusses the causal relationship between treatment with trimethoprim and other folic acid antagonists, and the development of neural tube defects, cardiovascular abnormalities, cleft lip and palate, and urinary tract anomalies (hernandez-diaz ) . authors' views on a preventative dose of multivitamin and folic acid preparations vary. additional case-control studies, some of them with notable methodological problems, found weakly recommendation. all tetracyclines are contraindicated after the fifteenth gestational week. prior to this, they are antibiotics of second choice. doxycycline should be preferred in such cases. inadvertent use of tetracyclines, even after the fifteenth week, is not an indication for termination of pregnancy (chapter . ). if really necessary, a local application to a small area may be conducted throughout pregnancy. tigecyclin is reserved for special situations when sufficiently tested antibiotic are not effective. significant evidence for the development of cardiovascular defects, urinary tract anomalies, anencephaly, limb defects, and orofacial clefts (e.g. mølgaard-nielsen , crider , czeizel c ). an increased risk for preterm birth and low birth weight has also been observed after exposure to trimethoprim/sulfamethoxazole (santos , yang . a danish cohort study based on a prescription register found a doubling of the hazard of miscarriage after trimethoprim exposure in the first trimester (andersen b ). based on the same prescription register, an increased risk of heart and limb defects was observed after preconceptional exposure (during the weeks before conception) to trimethoprim (andersen c) . beside methodological problems, such an association seems unlikely because a short-term therapy with trimethoprim does not usually lead to a relevant folic acid deficiency as a possible cause for birth defects. trimethoprim and sulfonamides are not drugs of first choice, but they exhibit no established teratogens. according to current knowledge the teratogenic risk of a trimethoprim and sulfonamide therapy is negligible. actually, there are no sufficiently convincing arguments to support the recommendation of an additional folic acid administration during an antibiotic therapy with the discussed medications, see chapter . . for additional discussion concerning folic acid usage. extensive, generally reassuring experiences in the use of co-trimoxazole for common urinary tract infections during pregnancy, do not include the conclusion that this medication is safe when used at a much higher dose for opportunistic infections such as a pneumocystis pneumonia in the context of an hiv infection. so far, there have been no reports of malformations when such therapy was used in pregnant women. there are no systematic studies about the local application of sulfonamides during pregnancy. as sulfonamides compete with bilirubin for binding sites with plasma proteins, it has been argued that the risk of neonatal kernicterus is increased when sulfonamides are given at the end of gestation. with current surveillance, the danger of kernicterus is not tangible. however, a rise in bilirubin, especially in premature infants, cannot be excluded when sulfonamides have been used until birth. a danish population-based study could not find an association between sulfamethoxzole exposure near term and an increased risk of neonatal jaundice (klarskov ). quinolones inhibit the bacterial enzymes topoisomerase ii and iv that are important for the nucleic acid metabolism of bacteria. quinolones recommendation. sulfonamides, trimethoprim, and co-trimoxazole are antibiotics of second choice throughout pregnancy. if high dose co-trimoxazole is used for a pneumocystis pneumonia during the first trimester, based on theoretical grounds, folic acid should be supplemented and a detailed ultrasound examination should be offered to ascertain the normal development of the fetus. if a premature birth is threatening, sulfonamides should be avoided in view of the bilirubin levels of the newborn. a short-term local treatment is acceptable, especially if the site is small. have a high affinity for cartilage and bone tissue which is highest in immature cartilage. pipemidic acid and nalidixid acid belong to the group of older quinolones. they have been displaced by the newer fluoroquinolones. the most important fluoroquinolones include ciprofloxacin, enoxacin, levofloxacin, moxifloxacin, norfloxacin, and ofloxacin. several substances have been removed from the market because of severe side effects. garenoxacin, lomefloxacin, pefloxacin, rosoxacin, and sparfloxacin are still available in some countries. gatifloxacin and nadifloxacin are only used as local agent. quinolones cross the placenta and are found in the amniotic fluid at low concentrations.when moxifloxacin is used about % of the maternal serum concentration can be measured in the amniotic fluid, and with lovofloxacin about % (ozyüncü ) . quinolones have not been found to be teratogenic in animals but severe, irreversible damage to joint cartilages was noted in young dogs treated after birth with quinolones (e.g. gough ). such alterations have not been described in prenatally exposed children. many publications failed to show indications of joint cartilage damage or an increased risk of malformations (bar-oz , cooper , larsen , loebstein , schaefer , berkovitch . one study expressed concern that the prenatal use of fluoroquinolones may be associated with an increased risk of bone malformations (wogelius ) . although not resembling each other, in three out of four birth defects the skeleton was affected. however, in this study of women who redeemed a prescription for fluoroquinolones during the first trimester, or days before conception, the total malformation rate was not increased (wogelius ) . in a prospective cohort study with women who were exposed to a fluorquinolone during the first trimester, neither the rate of major birth defects, nor the risk of spontaneous abortion were increased compared to a control group (padberg ) . altogether, most data are available for norfloxacin and ciprofloxacin and, to a lesser extent, for levofloxacin, moxifloxacin, ofloxacin and pefloxacin. there are few or no data for the other fluoroquinolones. there have been no reports of undesirable side effects after topical use of quinolones during pregnancy. nitrofurantoin is a chemotherapeutic agent for drug-resistant urinary tract infections (utis) and for the prevention of recurrent utis. it acts as a bacteriostatic, but is also bactericidal at higher concentrations. details of its mechanism of action remain to be clarified. after an oral dose, therapeutic effective levels are attained only in the urinary tract. several publications do not support an association between nitrofurantoin and congenital malformations (nordeng , goldberg quinolones are antibiotics of second choice during pregnancy. in well-founded situations, when better studied antibiotics are ineffective, those quinolones that are well documented may be preferred such as norfloxacin or ciprofloxacin. a detailed ultrasound examination may be offered after exposure with the other fluoroquinolones during the first trimester. local treatment with quinolones is acceptable throughout pregnancy. czeizel d , ben david , although in a number of studies, some of them with methodological faults, weakly significant findings were noted for craniosysnostosis, ophthalmic malformations, oral clefts, and cardiovascular defects (crider , källén b , källén . a case-control study observed an increased risk of craniosynostosis after intrauterine exposure to nitrosatable drugs (gardner ) . as nitrofurantoin lowers the activity of glutathione reductase, discussions arise periodically as to whether an intrauterine exposure could trigger a fetal hemolysis. bruel ( ) reported a mature newborn with hemolytic anemia whose mother took nitrofurantoin during the last gestational month. nitrofurantoin is often used during pregnancy, and fetal hemolysis has not been commonly observed; therefore, a relevant risk is not likely. however, nordeng ( ) observed an increased risk of neonatal jaundice after maternal nitofurantoin treatment in the last days before delivery. there is a case report of a pregnant woman who developed a toxic hepatitis after having been exposed to nitrofurantoin in her thirty-sixth week (aksamija ). in another case a woman took nitrofurantoin in her thirty-third week and was interpreted to present a gestational nitrofurantoin-induced pneumonia (mohamed ) . the nitrofurantoin derivative nifuroxazide is used for the treatment of diarrhea. there are no documented reports of its tolerance in pregnancy nor evidence of effectiveness. nifurtimox is a nitrofuran used for treatment of chagas disease. experience for pregnancy is very limited and the world health organization recommends that nifurtimox should not be taken by pregnant women (who a). one study about safety included pregnant women, but did not give information about the pregnancy outcome (schmid ) . for local treatment the nitrofurans furazolidone, nitrofural, and nifuratel are available. there has been no evidence of embryo-or fetotoxic risk in local applications. the use of local nitrofurans, especially as vaginal therapy, remains controversial and needs to be critically assessed not only during pregnancy. methenamine is a uti medication that releases the antiseptic formaldehyde into the urine. methenamine mandelate had been used for chronic utis due to e. coli and unproblematic germs. effectiveness and tolerance of the agent remain controversial. embryo-or fetotoxic problems have not been reported. there are no reports about the use of the hydroxy-quinolone derivative nitroxoline in pregnancy. fosfomycin is a broad-spectrum antibiotic that is bactericidal by inhibiting the synthesis of the bacterial cell wall. it is used as an intravenous injectable and as a reserve antibiotic in severe infections such as osteomyelitis. fosfomycin tromethamine is an orally taken salt of fosfomycin used for the treatment of uncomplicated utis. some authors also recommend the oral use during pregnancy (e.g. falagas , bayrak . these studies, however, are primarily focused on the effectiveness of fosfomycin tromethamine, not on the risk for the newborn. overall, the experience argues against a teratogenic and fetotoxic potential in humans. nitroimidazoles are effective bactericidal agents against anaerobes and protozoa. they are converted into metabolites that impede intracellular bacterial dna synthesis. the main representative of the nitroimidazoles is metronidazole. metronidazole is now being recommended by some investigators for the treatment of bacterial vaginosis in pregnancies at high risk for preterm delivery, as a strategy to decrease this risk (review by joesoef ) . others, however, failed to notice an improvement in the incidence of prematurity ( shennan , andrews , klebanoff . after oral and intravenous administration, concentrations as high as those in the mother are reached in the embryo/fetus. significant systemic absorption occurs after vaginal application, exposing the fetus as well. the pharmacokinetic profile of metronidazole did not change at the different time points assessed during pregnancy, and did not differ from nonpregnant patients (wang ) . like all nitroimidazoles, metronidazole displays an experimentally mutagenic and cancerogenic potential (review by dobias ) that has not been confirmed in humans. an investigation that ranged over years did not show any indication of an increased risk of cancer when metronidazole was used (beard ) . on the basis of over , analyzed pregnancies, it can be stated that metronidazole has no teratogenic potential in humans (e.g. koss , diav-citrin , czeizel . suggestions from the hungarian malformation registry of a link between vaginal therapy with metronidazole and miconazole during the second and third month, and an increased appearance of syndactylies and hexadactylies have not been confirmed by other investigators (kazy a) . nimorazole and tinidazole, both registered for the treatment of trichomonas infections, amebiasis, and bacterial vaginosis, cannot be evaluated sufficiently because of the lack of human data -the same applies to ornidazole. so far, there are no reports of human teratogenicity. the aminoglycoside antibiotics amikacin, framycetin, gentamicin, kanamycin, neomycin, netilmicin, paromomycin, ribostamycin, streptomycin, recommendation. nitrofurantoin can be given during pregnancy to treat urinary tract infections when the antibiotics of choice have been ineffective. if possible, it should be avoided towards the end of pregnancy. the use of nifuroxazide, nifurtimox, local nitrofurans, methenamine, and nitroxoline should be avoided during pregnancy. when the antibiotics of choice in pregnancy cannot be used, fosfomycin tromethamine may be used to treat urinary tract infections in pregnancy. the intravenous application of fosfomycin should be restricted to severe bacterial infections with problematic germs. recommendation. metronidazol may be used in pregnancy when indicated. a single oral dose of g is preferable to vaginal administration spread over several days, particularly as there are doubts about the effectiveness of the vaginal application. a parenteral administration is only indicated for a serious anaerobic infection. metronidazole is to be preferred to the less examined nitroimidazoles. and tobramycin inhibit protein synthesis and are bactericidal primarily for gram-negative germs. after oral administration only a minimal portion of aminoglycosides is resorbed. after parenteral administration of about - % of the maternal plasma concentration is detectable in the fetus. spectinomycin is an aminocyclitol antibiotic closely related to the aminoglycosides. oto-and nephrotoxic side effects are also known to occur in nonpregnant patients when aminolgycosides are used parenterally. there are case reports about the parenteral use of kanamycin and streptomycin during pregnancy describing auditory problems, even deafness, in children exposed in utero (e.g. jones , conway , robinson . a similar case was reported in connection with gentamicin (sánchez sainz-trápaga ). an investigation of the hearing ability of children whose mothers had received gentamicin intravenously during pregnancy found no deficiencies. this argues against a major ototoxic risk of gentamicin when used in pregnancy (kirkwood ) . theoretically, a fetal nephrotoxic risk exists because aminoglycosides concentrate in the fetal kidneys. a case report about a connatal kidney dysplasia after maternal gentamicin therapy (hulton ) does not prove a clinically relevant human risk, nor does a case of a hydronephrosis and suspected stenosis at the uteropelvic junction with lethal outcome, where the mother had been treated for uti first with ciprofloxacin and then with gentamicin at weeks - (yaris ) . except for these case reports, studies argue against a high oto-or nephrotoxic risk of gentamicin in the fetus and newborn. there has been no increase in the observation of malformations (czeizel e) . no untoward effects have been described with aminoglycosides as local treatment during pregnancy. experience with spectinomycin is insufficient to analyze a risk in pregnancy. glycopeptide and polypeptide antibiotics  glycopeptide antibiotics the glycopeptides vancomycin and teicoplanin are bactericidal only for gram-positive pathogens by inhibiting their cell wall synthesis. they are considered reserve antibiotics to be used against msra and multiresistant enterococci. to avoid the development of resistance, their application should be critically appraised, and possibly limited only to fighting problematic pathogens. oral glycopeptides are hardly resorbed. this is useful when treating pseudomembranous enterocolitis with vancomycin. however, in this situation metronidazole (section . . ) should be considered as an alternative, as vancomycin therapy is more expensive, and to prevent the selection for vancomycin-resistant enterococci. vancomycin crosses the placenta reaching the fetus in relevant quantities (laiprasert ) . it has not shown teratogenic effects in animal studies. experience with treatment in human pregnancy is limited to a recommendation. aminoglycosides should only be used parenterally in life-threatening infections with difficult gram-negative pathogens and when firstchoice antibiotics fail. the serum levels need to be monitored regularly during the treatment. a risk-based termination of pregnancy or invasive diagnostic are not required (chapter . ). if the parenteral therapy had been extensive, renal function should be monitored in the neonate and an auditory test should be performed. if local or oral application of aminoglycosides is indicated, they can be given because systemic absorption is minimal by these routes. pregnancy few case reports. there were no observations of malformations, kidney damage, or hearing deficits (reyes ) . experience with teicoplanin and the new lipoglycopeptides dalbavancin, oritavancin and telavancin is insufficient to analyze a risk in pregnancy. in vitro telavancin crosses the human placenta, with fetal concentrations reaching less than % of maternal concentrations (nanovskaya ) . daptomycin belongs to a new class of cyclic lipopeptides and is effective exclusively against gram-positive bacteria. it works by interfering with the bacterial cell membrane and protein synthesis, and is indicated to treat complicated infections with difficult pathogens. in animal experiments, daptomycin crossed the placenta and was not teratogenic. two children whose mothers took daptomycin in the fourteenth and twentyseventh weeks were unremarkable (stroup , shea ). polymyxins belong to the polypeptide antibiotics that are bactericidal by interfering with the transport mechanism of the cell wall. while the polymyxin colistin is today mostly used locally, it can also be applied parenterally where there is an infection with multi-resistant gram-negative germs. in patients with mucoviscidosis it is used as an inhalative. enterally colistin is not resorbed; therefore its oral administration is used to selectively decontaminate the intestinal tract. the polypeptide antibiotics bacitracin, polymyxin b, and tyrothricin are used locally. only limited experience is available in the application of polypeptide antibiotics during pregnancy and do not indicate a substantial risk (kazy b ). other antibiotics chloramphenicol and tiamphenicol inhibit bacterial protein synthesis and have bacteriostatic activity. chloramphenicol is relatively toxic, and can cause severe agranulocytosis. it crosses the placenta well and can reach therapeutic concentrations in the fetus. in premature and term births it may lead to the grey baby syndrome. chloramphenicol can reach toxic levels in the neonate even when only the mother has been treated. there have been no suggestions of malformations (czeizel f ). recommendation. glycopeptides should only be used in cases of life-threatening bacterial infections; vancomycin should then be preferred. recommendation. the use of daptomycin is limited to cases of life-threatening bacterial infections. recommendation. the parental use of colistin is limited to cases of lifethreatening bacterial infections. the local and oral application of polypeptide antibiotics need to be critically assessed. experience with thiamphenicol is insufficient to analyze a risk in pregnancy. dapsone, used among other indications against leprosis, apparently has no teratogenic potential (e.g. lush , bhargava . however, cases of hemolytic anemia have been reported in mothers and newborns. as dapsone bears a structural similarity to the sulfonamides, it has been argued that it might compete with bilirubin for protein binding, and thus could lead to hyperbilirubinemia in the newborn. fidaxomicin is a macrocyclic antibiotic which is approved for the treatment of infections with clostridium difficile. enterally fidaxomicin is very poorly resorbed. no experiences have been reported about its use during pregnancy. linezolid is a member of the oxazolidinone class, a new group of antibiotics. it acts bactericidally by inhibiting bacterial protein synthesis and is indicated in the treatment of multi-resistant pathogens. there is just one case report about the use of linezolid during pregnancy. after intrauterine exposure from gestational weeks to a healthy infant was delivered at term (mercieri ). the antiprotozoal agent pentamidine, among others effective in pneumocystis pneumonia, has not been evaluated sufficiently in pregnancy to recommendation. the systemic use of chloramphenicol and thiamphenicol is contraindicated throughout pregnancy. exceptions are life-threatening maternal infections that do not respond to less toxic antibiotics. when systemic treatment is absolutely necessary before birth, it is important to observe the newborn for toxic symptoms. a local application is also to be avoided during pregnancy. recommendation. during pregnancy, dapsone should be reserved for specific indications. if treatment took place in the first trimester, a detailed ultrasound examination should be offered to ascertain the normal development of the fetus. recommendation. fidaxomicin should be avoided in pregnancy. if treatment took place in the first trimester, a detailed ultrasound examination should be offered to ascertain the normal development of the fetus. recommendation. with the lack of experience, linezolid should only be used for severe infections with problematic germs. if treatment took place in the first trimester, a detailed ultrasound examination should be offered to ascertain the normal development of the fetus. pregnancy estimate its embryotoxic potential for humans. usually it can be replaced by other antibiotics, e.g. co-trimoxazole (section . . ). rifaximin is an antibiotic to treat travelers' diarrhea. there is not enough experience regarding its use in pregnancy. minimal enteral resorption and negative animal testing suggest that a high embryotoxic risk is unlikely. streptogramins are a group of cyclic peptide antibiotics that inhibit, like macrolides and lincosamides, the synthesis of bacterial proteins. they are derivatives of the naturally occurring pristinamycin. the later developed derivatives quinupristin and dalfopristin are used in a fixed combination. streptogramins should only be applied as reserve antibiotics for infections with highly resistant gram-positive germs. reports about use in pregnancy have not been available. active tuberculosis (tb) requires treatment in pregnancy, as the disease endangers not only the mother, but also the fetus. pregnancy does not seem to affect the course of tb. the prevalence of congenital tb is less than % where no treatment is initiated. lin ( ) investigated newborns of mothers who had received treatment for tb during the gestation. their children were smaller and had lower birth weights than the control group of children of healthy mothers. there are slight differences in the recommendations of the different organizations in the world, such as the who ( a), the international union against tuberculosis and lung disease (iuatld), and several national organizations (e.g. blumberg ) . treatment considerations depend on disease status and drug resistance. first-line drugs for the treatment of tb during pregnancy are isoniazid (+pyridoxine), rifampicin, ethambutol and pyrazinamide. these standard medications have not shown teratogenic or fetotoxic effects in humans (e.g. bothamley ) . as far as we know today, tb drugs reach the fetus in relevant quantities. an increasing development of resistance makes it harder to choose the right medication in pregnancy. pregnant women with multidrugresistant tb (mdr-tb) may also require second-line antituberculous recommendation. pentamidine is to be reserved in pregnancy for special situations when better tested antibiotics are not effective. if treatment took place in the first trimester, a detailed ultrasound examination should be offered to ascertain the normal development of the fetus. recommendation. if possible, rifaximin should be avoided during pregnancy. recommendation. streptogramins are to be avoided during pregnancy. if treatment took place in the first trimester, a detailed ultrasound examination should be offered to ascertain the normal development of the fetus. drugs; the necessity for treatment should be weighed against the risk for the fetus on an individual base. current experiences in the management of mdr-tb argue against a high risk of the reserve drugs for the newborn (drobac , shin . streptomycin, however, should be avoided because of its ototoxic potential. ethambutol is a bacteriostatic drug used against tuberculosis. it can cross the placenta, but the risk of congenital malformations when used during pregnancy appears to be low. there are no reports indicating that ethambutol can cause ocular toxicity in the fetus, as it does in adults, when given in higher doses. isoniazid (inh) has proven to be a highly effective drug against many strains of mycobacterium, and can be used for tuberculous prophylaxis and for treatment of an active disease during pregnancy. although inh can cross the placenta, it does not appear to be teratogenic, even when given during the first trimester. the older literature contains case reports of different malformations and neurological damages in prenatally exposed children. inh intake, lack of pyridoxine, co-medication, and even the tb disease itself was blamed. newer publications did not confirm a teratogenic risk (e.g. taylor . in summary, experiences speak against a major risk. inh increases pyridoxine metabolism, which may be responsible for cns toxicity. to prevent a possible vitamin b deficiency, inh should be given during pregnancy in combination with pyridoxine. pyrazinamide (pza) is an antibiotic with specific effectiveness against mycobacterium tuberculosis. as its structure resembles nicotinamide, it is assumed that it intervenes with the nucleic acid metabolism of the bacterial cell. pza has effective bactericidal properties. systematic studies of its tolerance in pregnancy are lacking. so far, there has been no evidence of embryo-or fetotoxic effects in humans. the use of pza during pregnancy is recommended in several guidelines (e.g. who a). the american thoracic society recommends in its guidelines to hold pza as a reserve drug during pregnancy, as there are currently insufficient data about its teratogenicity (blumberg ) . if pza is not used, treatment may be prolonged. recommendation. ethambutol is a first-line drug for treatment of tuberculosis during pregnancy. recommendation. isoniazid is a first-line drug for treatment of tuberculosis during pregnancy. it needs to be given together with pyridoxine. rifampicin also called rifampin, inhibits bacterial rna polymerase and is effective as a bactericidal agent against different pathogens, particularly mycobacteria. rifampicin can cross the placenta. in animal experiments, teratogenic effects were seen with doses - times higher than in human treatment. because rifampicin inhibits dna-dependent rna polymerase, there has been concern that it might interfere with fetal development. until now, no reports in the literature have confirmed this fear. there is apparently no increased risk of malformations. a long-term therapy of the mother could result in inhibition of vitamin k synthesis, and result in a higher bleeding tendency in neonates. streptomycin is an aminoglycoside that is used parenterally in the treatment of tb. it is bactericidal, particularly affecting germs that proliferate extracellularly. its ototoxicity can also hurt the fetus (section . . ). aside from the above discussed first-line drugs for tb, reserve medications are available and used in cases of resistance or intolerance. no systematic studies exist on the tolerance of -aminosalicylic acid (p-aminosalicylic acid; pas). so far, no evidence for embryo-or fetotoxic effects has been found in humans (e.g. lowe ) . capreomycin, ethionamide, protionamide, rifabutin, rifapentine, thioacetazone, and terizidone, a prodrug of cycloserine, are all second-line agents used internationally for mdr-tb. the extent of documented experiences in pregnancy is limited, and insufficient for a differentiated risk assessment. single case reports argue against a high teratogenic risk of these drugs (e.g. lessnau , drobac . for additional reserve drugs for multi-resistant tb such as amikacin, see section . . , and diverse quinolones, see section . . ; for other anti-infective agents, view the relevant sections of this chapter. recommendation. pyrazinamide may be used during pregnancy to treat active tb. recommendation. rifampicin is a first-line drug for treatment of tuberculosis during pregnancy. when used near term the newborn should receive an extended vitamin k prophylaxis (chapter . ). regarding other infections such as mrsa, rifampicin should only be administered when the drugs of first choice for pregnancy cannot be used. recommendation. streptomycin is contraindicated during pregnancy because of its ototoxic properties. inadvertent exposure does not require risk-based termination of pregnancy or invasive diagnostic procedures, but hearing tests should be performed after birth (chapter . ). generally, each external antibiotic treatment needs to be examined carefully to see whether or not the bacterial infection is more effectively treated with systemic medication. the potential of local treatment is often overestimated. further, with topical therapy, sensitization and resistance development need to be considered. fusafungine has bacteriostatic and anti-inflammatory effects and is used as a spray for the treatment of infections of the nose and throat area. there is insufficient experience about its application in pregnancy. fusidic acid is an antibiotic that is almost exclusively used externally; its prenatal tolerance has not been examined systematically, although the medication has been available for a long time. it has a narrow spectrum of effectiveness against gram-positive bacteria (staphylococci) and is not recommended for an untargeted treatment. mupirocin is primarily bacteriostatic, affecting staphylococci and streptococci by inhibiting bacterial protein synthesis. it is especially used as a nasal ointment to eliminate mrsa. mupirocin has not been examined systematically, but there is no evidence of undesirable effects in pregnancy. retapamulin is the first representative of the pleuromutilins that is approved for human treatment. it is applied as an ointment for short-term treatment of superficial skin infections. retapamulin inhibits bacterial protein synthesis and is bacteriostatic, primarily for gram-positive germs. systemic resorption is minimal with topical use, but nevertheless, as experience in pregnancy has been limited, its application needs to be critically examined. taurolidine is an antimicrobial solution that can be used for lavage in peritonitis and for the prevention of infections with catheters. as a bactericidal agent, its mechanism of action is only partially clarified. there are no reported experiences in pregnancy. see the corresponding sections for the local application of aminoglycosides (section . . ), chloramphenicol (section . . ), quinolones (section . . ), macrolides (section . . ), nitrofurans (section . . ), nitroimidazoles (section . . ), polypeptide antibiotics (section . . ), sulfonamides (section . . ), and tetracyclines (section . . ). apart from pregnant women living in malaria areas, pregnant women are increasingly traveling to tropical countries and need a suitable malaria prophylaxis. increased resistance of malaria pathogens make it more difficult to suggest a general recommendation. the guidelines of tropical medicine recommendation. the reserve drugs discussed here should only be used for multi-resistant tuberculosis when standard therapy is not indicated. an inadvertent exposure during pregnancy does not require a risk-based termination or invasive diagnostic, but a detailed ultrasound examination should be carried out (chapter . ). recommendation. externally used antibiotics are not suspected to be teratogenic. nevertheless, the application of local antibiotics needs to be critically assessed. antibiotics that are safe when used systemically may also be used locally. if another local antibiotic is absolutely necessary, it may be used in pregnancy. should be followed, also in pregnancy, according to the travel destination. especially difficult is the management of malaria tropica caused by plasmodium falciparum. pregnancy enhances the clinical severity of falciparum malaria, especially in the primiparous and non-immune woman. pregnancy alters a woman's immunity to malaria, making her more susceptible to malaria infection and increasing the risk of illness, severe anaemia, and death. maternal malaria increases the risk of spontaneous abortion, stillbirth, prematurity, and low birth weight, and thus results in excess infant mortality (e.g. bardaji , shulman . therefore, mosquito-bite prevention, prophylaxis, and treatment of malaria should not be shortened or omitted in an ongoing pregnancy. traveling to areas with multidrug-resistant malaria should be avoided if possible. the choice of drug for malaria prophylaxis and treatment during pregnancy depends on the local pattern of antimalarial drug resistance, the severity of the malaria, and the degree of pre-existing immunity. it is important to be well informed about the current recommendations for prophylaxis and treatment of malaria in the area to be visited. for travelers to malaria-endemic areas, a general recommendation is difficult because of increasing resistances. depending on the drug, the chemoprophylaxis must be continued for up to weeks after leaving the malarial region. for women living in falciparum-endemic areas with stable transmission, the world health organization recommends the use of insecticide-treated nets (itns) and intermittent preventive treatment (ipt) with sulfadoxine-pyrimethamine during pregnancy (who b , nyunt . ipt reduces maternal malaria episodes, maternal anaemia, placental parasitaemia, low birth weight, and neonatal mortality (review by mcclure ). a prompt diagnosis and effective treatment of malaria infections is vital. although data from prospective studies are limited quinine, chloroquine, proguanil, and clindamycin (section . . ) are considered safe during early pregnancy. pregnant women in the first trimester with uncomplicated malaria tropica should be treated with quinine plus clindamycin (if available) (who b). for the second and third trimester the world health organization recommends artemisinin derivatives. the choice of combination partner is difficult because of limited information. reserve medications include the following: amodiaquine, atovaquone, dapsone (section . . ), lumefantrine, mefloquine, piperaquine, and pyrimethamine plus sulfadoxine. doxycycline is contraindicated after the sixteenth gestational week (section . . ). halofantrine and primaquine should be avoided. see the relevant sections of this chapter about the specific active substrates. during gestation plasma concentrations of many antimalaria agents are lower and their elimination is enhanced. this can result in treatment failure. thus, in each patient dose and dose interval need to be assessed individually. recommendation. generally, the physician should discuss with a patient if the trip to a tropical region could be postponed (section . . ). the risk of exposure can be reduced by long clothes, mosquito netting, and repellents. in no case should medications be denied for prophylaxis or treatment on behalf of a pregnancy, as the potential risk for the unborn child predominates. if medications with inadequate pregnancy experience are used in the first trimester, a detailed ultrasound examination should be offered. a risk-based termination is not justified when the above-described medications have been used in pregnancy (chapter . ). amodiaquine, like chloroquine, belongs to the group of -aminoquinolines. it can cause severe side effects such as liver damage and agranulocytosis, and for this reason, is unsuitable for prophylaxis. its use is limited as a reserve medication for malaria. there has been no evidence of tetatogenicity (review by thomas ) , but experiences are limited. with regard to early pregnancy, only single case reports have been published. one study found only mild maternal side effects in pregnant women who had been treated in the second or third trimester. an increase in miscarriages, prematurity, stillbirth, or malformations was not observed (tagbor ). artemisinin and its derivatives artemether, artemotil, artesunate, and dihydroartemisinin, are increasingly used against malaria as plasmodium falciparum has developed resistance to other drugs. these compounds combine rapid blood schizonticide activity with a wide therapeutic index. artemisinins should be given as combination therapy to protect them from resistance. typical combinations of such artemisinin-based combination therapy (act) are artemether plus lumefantrine, artesunate plus amodiaquine, artesunate plus mefloquine, artesunate plus sulfadoxine-pyrimethamine, and dihydroartemisinin plus piperaquine first trimester experiences with the use of artemisinin derivatives are limited. a number of studies contain data of more than pregnant women treated with an artemisinin derivative during the first trimester, without showing evidence of a teratogenic risk (mosha , adam , clark , who . manyando ( ) more commonly found umbilical hernias in an additional children whose mothers had been treated with artemether and lumefantrine. after months most of these hernias were not detectable anymore. there are experiences with more than , pregnant women who used artemisinin derivatives in the second and third trimester (e.g. piola , bounyasong , deen , mcgready , phillips-howard . in summary, these studies did not find an increased risk in miscarriages, stillbirths, and malformations. to some degree the artemisisin derivatives were better tolerated by pregnant women, and were more effective than treatments of the control group. as plasma levels of artemether are decreased during pregnancy, it has been suggested that the dose and the dose interval may have to be adjusted (e.g. tarning , morris ). these reassuring data led the who ( b) to recommend using artemisinin derivatives as medications of choice for malaria tropica in the second and third trimester. it does not specify what combination is recommended in the context of act. during the first trimester, based on a lack of experiences, the who views artemisinin derivatives as reserve medications that should not be withheld in an individual case where needed. recommendation. amodiaquine may be used as a reserve medication for the treatment of malaria. atovaquone is a broad-spectrum anti-protozoal drug that is also used in pneumocystis pneumonia. monotherapy quickly leads to resistance, thus it is combined with proguanil when used for malaria prophylaxis and treatment. experience with atovaquone is limited in pregnancy. a danish cohort study based on a prescription register with women exposed during their first trimester to atovaquone, of them exposed at any time in weeks through after conception, found no increased risk for birth defects (pasternak ) . when used in the second and third trimester, small studies observed no adverse effects (mcgready , na-bangchang . available data are insufficient for a differentiated risk assessment, but do not suggest a teratogenic risk. mcgready ( ) discusses the need of a dose adjustment as clearance increases and levels decrease during pregnancy. chloroquine, an antimalaria drug of the group of -aminoquinolines, works well and effectively as a schizonticidal drug against the erythrocytic forms of all types of plasmodia. today though, almost all pathogens of the potentially lethal malaria tropica have become resistant to this rather well tolerated, and for many decades, useful medication. resistance has also been noted for plasmodium vivax, the pathogen of the less severe malaria tertiana. plasmodium ovale and plasmodium malariae still remain mainly sensitive to chloroquine. chloroquine is not embryo-and fetotoxic when used at the usual dose for malaria prophylaxis or for a three-day treatment of a typical malaria attack (mcgready , phillips-howard . current evidence does not suggest fetal ocular toxicity when chloroquine was used as antimalarian medication during pregnancy (review by osadchy ). lee ( ) examined pregnant women and nonpregnant controls, and did not find any changes in the pharmacokinetics or the serum level of chloroquine. the anti-inflammatory properties of chloroquine are used also for antirheumatic therapy (section . . ). antirheumatic doses of chloroquine are higher than those used for malaria prevention. recommendation. artemisinin derivatives may be used in the second and third trimester. in the first trimester they are reserve medications for the treatment of malaria. recommendation. atovaquone may be used as a reserve medication for the treatment of malaria. recommendation. chloroquine may be used throughout pregnancy for the prophylaxis and treatment of malaria. if chloroquine resistance of the parasite is likely or has been demonstrated, other drugs must be used. halofantrine has a rapid schizonticidal effect upon the erythrocytic forms of those plasmodia that are resistant to chloroquine and other antimalarials. halofantrine prolongs the qt interval in the ekg. becauses it can provoke life-threatening cardiac arrhythmias in patients with heart disease, or in conjunction with other arrhythmogenic medications, halofantrine is no longer recommended. the limited experiences in pregnancy allow no differentiated risk analysis. lumefantrine belongs to the group of arylamine alcohols like quinine, mefloquine, and halofantrine. artemether plus lumefantrine is currently a popular artemisinin-based combination therapy. few experiences are available regarding its application in the first trimester without showing evidence of a teratogenic risk (e.g. mosha ) . for the second and third trimester, studies with several hundred patients have been reported and do not indicate a major risk (piola . manyando ( ) found only a mild increase in umbilical hernias in children whose mothers took artemether and lumefantrine during the first trimester. most of these had disappeared when follow-up examination was conducted months later. in summary, current experiences do not suggest a major embryo-or fetotoxic risk of lumefantrine. during pregnancy, the plasma concentration is lower and the elimination enhanced, thus increasing the risk of treatment failure (e.g. tarning ). mefloquine displays an effective and rapid activity against the erythrocytic forms of all plasmodia. current experiences with more than , treated pregnant women, several hundred of them in the first trimester, do not suggest a teratogenic or fetotoxic potential in humans (e.g. schlagenhauf , bounyasong , mcgready . one single study of the use of mefloquine has been debated as finding an increased rate of stillbirths. this study compared pregnant women who received mefloquine for malaria, and found them to have a significantly higher rate of stillbirth than those who had been treated with quinine and other antimalarials (nosten ) . other studies, however, have not confirmed this risk, and mefloquine has been an established medication in pregnancy for some time. recommendation. halofantrine is only to be used in cases of acutely threatening malaria that cannot be managed with better tested and less toxic drugs. when cardiac problems are an issue, other antimalaria medications must be used. recommendation. lumefantrine may be used as a reserve medication for the treatment of malaria. recommendation. mefloquine may be used throughout pregnancy for the prophylaxis and treatment of malaria if there is no resistance. a fixed oral combination of the bisquinolone piperaquine and dihydroartemisinin (dhp) is a new and promising artemisinin-based combination therapy. the mechanism of action of piperaquine is unknown. an indonesian observational study detected a higher rate of abortion after first trimester exposure to dihydroartemisinin-piperaquine (poespoprodjo ) . this observation was based on five abortions among eight pregnancies ( %). the same study found a lower risk of perinatal mortality after dihydroartemisinin-piperaquine in the second and third trimester compared to quinine-based regimens. the limited experiences in pregnancy allow no differentiated risk analysis. no significant pharmacokinetic differences between pregnant and nonpregnant women were reported in two small studies , hoglund ). primaquine, an -aminoquinoline derivative, is effective against the intrahepatic permanent forms of plasmodium vivax and plasmodium ovale. it is used for the complete elimination of pathogens in combination with a blood schizontocide for the erythrocytic parasites. primaquine should not be used in pregnancy because of the potential risk of hemolytic effects in the fetus. as yet, there are no studies that permit a well-grounded risk assessment. however, there is no substantial evidence for a teratogenic potential in humans (phillips-howard ). proguanil, an older medication for malaria prophylaxis belonging to the folic acid antagonists, is experiencing a renaissance as it has become useful in the face of increasing chloroquine resistance. most often it is applied in combination with the synergistic atovaquone. there is no evidence of an embryotoxic potential in humans (e.g. pasternak , mcgready . mcgready ( ) discuss the need to adjust the dose as clearance is increased and blood levels decreased during pregnancy. pyrimethamine is an inhibitor of folic acid synthesis that is also used in the treatment of toxoplasmosis and pneumocystis pneumonia. in malaria recommendation. piperaquine may be used as a reserve medication for the treatment of malaria. recommendation. primaquine is not a therapeutic option during pregnancy. a prophylactic elimination of hepatic spores should usually be postponed for a time after birth. recommendation. proguanil may be used throughout pregnancy for prophylaxis and treatment of malaria provided there is no resistance. treatment it is only applied in combination with another folic acid antagonist such as sulfadoxine (section . . ). this particular combination is used for intermittent preventive treatment (ipt) during pregnancy. however, increasing resistance has started to limit the effectiveness of this popular combination (newman ) . as animal experiments indicated embryotoxic effects, concerns had been raised about the use of these folic acid antagonists in early pregnancy. numerous investigations, however, have not demonstrated an increased malformation risk in humans (e.g. manyando , phillips-howard . some studies suggest that pregnancy adversely alters the pharmacokinetics of pyrimethamine and sulfadoxine (e.g. karunajeewa , green . as data are inconsistent, a general recommendation about dose adjustments in pregnancy is difficult. when sulfadoxine-pyrimethamine is given in early pregnancy, it should be supplemented by folic acid until the tenth week. the who recommends . - . mg per day, as a coadministration of high dose ( mg daily) compromises the efficacy of sulfadoxine-pyrimethamine in pregnancy (who b). quinine is the oldest antimalarial agent. it works well and effectively as a schizonticidal drug against the erythrocytic forms of all plasmodium species. despite a relatively high toxicity and a narrow therapeutic range, it is used again increasingly in the treatment of chloroquine-resistant malaria. in combination with clindamycin (section . . ) its effectiveness is increased. concentrations in the fetus are just as high as in the mother, and are potentially toxic. in some case reports it was observed that children had auditory or visual defects after the use of quinine in pregnancy. however, in those cases considerably higher doses had been administered than currently in use. there is no evidence of an increased risk of abortion or preterm delivery with the use of a standard dosage of quinine for treatment of acute malaria (phillips-howard ) . these findings were confirmed by other studies with several hundred pregnant women exposed during the first trimester, where no increased rates of spontaneous abortion, congenital malformations, stillbirth or low birth weight were found (e.g. adam b , mcgready . quinine increases the secretion of insulin (elbadawi ) . especially in the last part of pregnancy, severe maternal hypoglycaemia has been induced by quinine therapy. due to the risk of hypoglycemia, the who ( b) guidelines prefer to use an artemisinin combination for the management of malaria tropica from the second trimester on. a study of the metabolism of quinine in pregnant and nonpregnant women failed to show significant pharmacokinetic differences. the authors concluded that dose adjustment is not necessary during pregnancy (abdelrahim ) . induction of contractions with high doses of quinine cannot be excluded. recommendation. pyrimethamine in combination with sulfadoxine may be administered for the treatment of malaria. for toxoplasmosis it is the drug of choice when combined with a long-term sulfonamide, especially after the first trimester. when pyrimethamine is given in early pregnancy, it should be supplemented with folic acid, see also chapter . . . quinine is a component of some analgesic compounds and of certain beverages, although in lower and apparently nonembryotoxic doses. azole antifungals azole derivatives inhibit the ergosterol biosynthesis, thereby causing disturbances in the permeability and functions of the fungal cell membrane. azole antifungals include two broad classes, imidazoles and triazoles. in animal experiments azole antifungals cross the placenta and are teratogenic at high doses. with regard to the use of the triazole derivative fluconazole in pregnancy, there was a report of three children (two of them siblings) with craniofacial, skeletal, and cardiac malformations, similar to those seen in animal studies (pursley ) . because of meningitis, their mother had used high doses of fluconazole ( - mg daily) through or beyond the first trimester on a long-term basis. additional case reports have described two births involving craniofacial, limb, and cardiac defects in two mothers who used fluconazole (lopez-rangel , aleck ). those cases shared some characteristics with the antley-bixler syndrome. however, there was no evidence of an increased risk of malformation in a prospective cohort study with women exposed during the first trimester (mastroiacovo ) . in several other studies, first trimester exposure to low-dosage regimens of fluconazole for vaginal candidiasis did not appear to cause an increased risk of malformations (e.g. jick , campomori , inman . danish cohort studies based on a prescription register also could not find an increased risk of birth defects after first trimester exposure in several thousand pregnant women (nørgaard , sørensen ). an extended analysis of the danish data observed an increased risk for tetralogy of fallot based on seven cases (prevalence . %) compared to unexposed pregnancies (or . ; % ci . - . ). the rate of major birth defects was not increased (mølgaard-nielsen ). in most cases the low and single dose consisted of mg fluconazole usually used for a vaginal yeast infection. itraconazole is a triazole derivative with wide-spectrum activity. there has been no evidence of teratogenicity in prospective studies examining several hundred women with first trimester exposure (e.g. de santis , bar-oz ; most of the exposures were short-term. a danish register analysis did not find an increased risk of birth defects among women with a first trimester prescription of itraconazole (mølgaard-nielsen ). recommendation. despite its toxicity, quinine belongs to the drugs of choice when dealing with chloroquine-resistant malaria tropica in pregnancy. in this situation the potential risk of treatment is much smaller for the fetus than the danger of a severe maternal disease. attention needs to be paid to possible maternal hypoglycemia. even though embryotoxic effects due to quinine in analgesic compounds are not to be expected, these agents should be avoided because they do not conform to good therapeutical practice. the same holds for the regular or excessive consumption of quinine drinks. the imidazole derivative ketoconazole is usually avoided in systemic use because it is poorly tolerated and has many suitable alternatives. ketoconazole is administered on occasion for the treatment of cushing syndrome as it inhibits steroid synthesis. theoretically, by decreasing testosterone synthesis, it might impede the sexual development of male foetuses; however, this has not been described. ketoconazole has been used in several cases in pregnancy with good maternal and fetal outcome (e.g. boronat , berwaerts , amado . a retrospective study from data of the hungarian malformation registry based on exposed subjects shows no evidence of an increased risk of malformations after systemic use of ketoconazole (kazy c ). an analysis of a danish register did not observe a significantly increased risk of birth defects among pregnant women with a prescription for this agent during first trimester (mølgaard-nielsen ). for posaconazole and voriconazole which are used for aspergillosis and other invasive mycoses, information is lacking about use during pregnancy. there is only one published case report of a normal child, born after voriconazole treatment of the mother in the second and third trimester (shoai tehrani ). a multitude of poorly resorbed topical azole derivatives are available for the treatment of superficial fungal infections. the drugs of this group that had been introduced first, namely clotrimazole and miconazole, are most thoroughly investigated for use in pregnancy. regarding clotrimazole, there are extensive studies about the treatment of vaginal yeast infections that do not indicate an embryotoxic potential (e.g. czeizel b , king . also, there is no suggestion that there is an increase in miscarriages. czeizel ( a) noted a decrease in prematurity when vaginosis was treated locally with clotrimazole. experiences with several thousand pregnant women are available for miconazole (e.g. czeizel b , mcnellis . a suggestion by the hungarian malformation registry about a link between vaginal therapy with miconazole plus metronidazole during the second and third gestational month, and an increase in syndactyly and hexadactyly, has not been substantiated by other studies (kazy a ). an israeli report describes two cases of severe skeletonal anomalies after the use of bifonazole that are reminiscent of anomalies seen after systemic use of fluconazole. in the first case, bifonazole was taken orally from week to , in the second case mg/d vaginally throughout pregnancy and clearly at a higher dose than recommended (linder ) . at dose levels which are reached with nomally recommended topical application no teratogenic risks have been noted, yet systematic studies are lacking. for ketoconazole see above (azole antifungals for systemic use). recommendation. if a systemic treatment with an azole derivative becomes absolutely necessary, fluconazole and itraconazole are to be preferred as the better-tested medications. if possible, treatment should start after the first trimester. an inadvertent exposure during pregnancy does not require a risk-based termination or invasive diagnostic, but a detailed ultrasound examination should be carried out (chapter . ). clearly less experience has been collected about the local applications of butoconazole, croconazole, econazole, fenticonazole, isoconazole, omoconazole, oxiconazole, sertaconazole, sulconazole, terconazole, and tioconazole. teratogenic effects have not been observed (king ) . this was confirmed for vaginal econazole treatment in a study of pregnant patients (czeizel a ). amphotericin b is a broad-spectrum antifungal agent of the polyene group. it binds to ergosterol at the cell membrane of fungi and disturbs cell wall permeability. it can be used intravenously, orally, and locally. with oral application, it is poorly resorbed and thus has only a local effect in the intestinal tract. conventional amphotericin b given parenterally has a number of side effects, primarily nephrotoxicity. newer lipid formulations of amphotericin b such as liposomal amphotericin b are characterized by a markedly better tolerance and less nephrotoxicity. amphotericin passes the placenta. relevant plasma concentrations could be measured in a newborn, although the mother had taken her last dose four months prior (dean ). this could be due to placental accumulation or delayed elimination by the fetal kidneys. several case reports do not indicate an increased risk of malformations with amphotericin b (e.g. costa , ely , king ). more than pregnancy courses with liposomal amphotericin b also argue against an embryo-or fetotoxic risk (e.g. mueller , pagliano , pipitone ). these experiences are insufficient for a differentiated risk assessment. as resorption is minimal with oral or local use, a risk appears unlikely. echinocandins are a new antifungal medication group. these parenteral synthetic lipopeptides inhibit the synthesis of , -β-d-glucan, a key ingredient of the fungal cell wall. anidulafungin, caspofungin, and micafungin are currently approved. in animal experiments echinocandins cross the placenta. there have been no reports of their use in pregnancy. yalaz ( ) described the successful postnatal application of caspofungin in a dystrophic premature newborn of the twenth-seventh gestational week. recommendation. clotrimazole and miconazole belong to the local antifungal medications of choice in pregnancy. the other azole derivates are antimycotic drugs of second choice. recommendation. amphotericin b should only be used parenterally in cases of serious disseminated fungal infections. the liposomal formulation may be preferred. if treatment took place in the first trimester, a detailed ultrasound examination should be offered to ascertain the normal development of the fetus. oral and local use of amphotericin b is acceptable in pregnancy. flucytosine is effective against cryptococcus neoformans and many candida species. it inhibits the dna synthesis. within the mycotic cell flucytosine is partially converted into the cytostatic -fluorouracil. to a smaller degree this reaction has to be expected in humans as well. due to a high incidence of resistance, flucytosine should only be administered in combination with another antifungal drug such as amphotericin b. in animal experiment, fluycytosine has a teratogenic effect at doses below those used in humans. as yet, no malformations have been reported in humans; however, there is, as yet, no published experience with the use of flucytosine in the first trimester. case reports about application in the second and third trimester for dangerous disseminated cryptococcosis have not shown evidence of fetal damage (e.g. ely ). griseofulvin is an organically derived antifungal agent that is used orally for several weeks against fungal infections of the skin, hair and nails. as it is deposited within the keratin, it is especially suited for the management of fungal infections of nail mykoses. in animal experiments griseofulvin is teratogenic and, at high doses, cancerogenic. it crosses the placenta at term (rubin ) . one publication, based on birth defects data, reported two pairs of conjoined twins after the use of griseofulvin in early pregnancy (rosa ) . this observation could not be confirmed in other publications (knudsen , metneki . a population based case-control study with some exposed pregnant women did not demonstrate an increased risk of malformations (czeizel c ). these experiences are insufficient for a differentiated risk assessment. recommendation. as there is insufficient data regarding the use of echinocandins in pregnancy, they should only be used where no alternatives are available and the mycosis is life-threatening. if treatment took place in the first trimester, a detailed ultrasound examination should be offered to ascertain the normal development of the fetus. recommendation. flucytosine should only be used for life-threatening disseminated fungal infections during pregnancy. as it is not indicated as a monotherapy, it needs to be assessed critically if its use as a second mycotic drug is really necessary. if treatment took place in the first trimester, a detailed ultrasound examination should be offered to ascertain the normal development of the fetus. recommendation. as griseofulvin is not used to treat life-threatening fungal infections, its application in pregnancy should be avoided. if treatment took place in the first trimester, a detailed ultrasound examination should be offered to ascertain the normal development of the fetus. terbinafine is used for both oral and topical treatment of fungal infections of the nails and other dermatophytoses. a prospective study reported on pregnant women exposed to terbinafine which showed no evidence of a teratogenic potential (sarkar ) . of these women were exposed during the first trimester and had an oral exposure. these data are insufficient for a differentiated risk analysis. when used topically, less than % is resorbed making a risk unlikely. regarding the topical use of azole derivatives such as clotrimazole and miconazole, see section . . ; for amphotericin b, section . . ; and for terbinafine, section . . . nystatin is an antifungal drug from the polyene group. like the closely related amphotericin b it binds with ergosterol of the mycotic cell wall and interferes with its function. nystatin is an effective local antifungal drug for candidiasis of the skin or mucosa. when taken orally, it is poorly resorbed and only works locally in the intestinal tract. the indication for intestinal cleansing needs to be critically assessed in immunocompromized patients. nystatin is used frequently, and there is no evidence of embryo-or fetotoxic effects (e.g. king ) . a population-based case control study did not show an increased risk of malformation after first trimester exposure. when treatment was performed in the second and third trimester, slightly more cases of hypospadia were noted (czeizel b ). however, a low resorption rate, methodological weaknesses of the study, and the low number of only pregnant women place the result in question. a retrospective study of the hungarian malformation register, with exposed subjects, did not reveal signs of an increased risk of malformation when natamycin was applied vaginally (czeizel c) . based on the same register, a case-control study discussed a possible association between cardiovascular malformations and maternal use of tolnaftate in pregnancy (czeizel d) . this observation was based on exposed cases, of which four cases had varying types of cardiac defects (or . , %; ci . - . ). these data are insufficient for a differentiated risk analysis. amorolfine, butenafine, ciclopirox, haloprogin, naftifin, and tolciclate are insufficiently investigated with regard to prenatal human toxicity. as yet, there is no substantial indication for an increased risk of malformations after local use. recommendation. terbinafine should be avoided during pregnancy as safety data are lacking and fungal nail infections do not require urgent treatment. if treatment took place in the first trimester, a detailed ultrasound examination should be offered to ascertain the normal development of the fetus. a topical application is likely to be harmless. recommendation. nystatin, like clotrimazole and miconazole is an antifungal drug of choice during pregnancy. where possible, these drugs should be preferred. external treatment with amorolfine, butenafine, ciclopirox, haloprogin, natamycin, naftifin, tolciclate, and tolnaftate should be avoided during pregnancy. more than billion people are infected with helminths worldwide. soil-transmitted helminths have been recognized as an important public health problem in many developing countries. severe hookworm and other helminth infections during pregnancy may cause anemia, reduced birth weight and increased perinatal mortality. a routine application of anthelmintics during the second and third trimester for women in areas endemic for hookworm infection has been suggested, with the argument that this may improve maternal anemia, birth weight, and neonatal mortility (e.g. who c, christian ). however, a randomized placebo-controlled study showed no advantage for newborns whose pregnant mothers had received albendazole or praziquantel . recently, it has been discussed if routine anthelmintic treatment during pregnancy might lead to an increased risk for allergies in infancy (mpairwe ). the benzimidazole derivatives albendazole, flubendazole, mebendazole, thiabendazole, and triclabendazole inhibit the uptake of glucose and thereby kill the parasites. in animal experiments benzimidazole derivative with anthelmintic activity showed teratogenic effects. albendazole and mebendazole are poorly resorbed from the gastrointestinal tract, except when there is an inflammation. however, enteral absorption may be increased due to high-fat diet. mebendazole is a highly effective and well tolerated anthelmintic drug used against nematodes (such as pinworms, roundworms, whipworms, and hookworms). there have been reports describing children with various malformations after in utero exposure to mebendazole, but a distinct pattern of malformations could not be discerned (review by schardein ) . an increased risk of congenital malformations was not observed in a study of over pregnant women exposed to mebendazole in the first trimester (de silva ) . this was confirmed in a controlled prospective study covering first trimester exposed pregnant women (diav-citrin ) . another study with first trimester exposures also found no increased risk for malformations or miscarriages ( mcelhatton ) . although numbers are too small for any definite conclusion, mebendazole does not appear to represent a major teratogenic risk. significantly more experience has been collected with exposure during the second and third trimester showing no evidence of a fetal risk (e.g. gyorkos ) . albendazole is a newer, highly effective broad-spectrum anthelmintic which combined with operative interventions has become the treatment of choice for alveolar and cystic echinococcosis. limited experience in the first trimester has not shown evidence of a major risk (gyapong , cowden . there are several thousand pregnancies with the use of albendazole in the second or third trimester without any obvious adverse reactions reported (e.g. , ndyomugyenyi . two abstracts from korea which reported the outcome of pregnant women after the first trimester exposure to flubendazole showed no evidence of a teratogenic potential (choi (choi , . however, the data is insufficient for a differentiated risk assessment. there are no reports of thiabendazole and triclabendazole use during human pregnancies. ivermectin is a broad-spectrum anthelmintic agent which is mainly used in humans in the treatment of onchocerciasis (river blindness), lymphatic filiriasis and strongyloidiasis. it is also effective against other worm infections and some epidermal parasitic skin diseases, such as scabies. ivermectin is well resorbed after oral administration. animal experiments do not suggest a teratogenic potential, although at maternally toxic exposures malformations were noted in rodents. a number of case reports describing accidental treatments during the first trimester have not shown malformations in the children (gyapong , chippaux , pacque ). however, data are insufficient for a differentiated risk assessment. a study encompassing more than women who took ivermectin during the second trimester found no significant anomalies in the newborns (ndyomugyenyi ). niclosamide is an anthelmintic that is effective against tapeworms (cestodes). it affects the energy metabolism of the parasites and is practically not resorbed by the intestinal tract. this agent had been used extensively in the past and is not suspected to cause malformations, but has not been systematically studied in humans. praziquantel is a highly effective broad-spectrum anthelmintic agent against many trematodes and cestodes. it is mainly used for the treatment of schistosomiasis (bilharziosis). no teratogenicity has been reported in animal studies. over the last decades millions of pregnant women have been inadvertently treated with praziquatel during routine anthelmintic programs without an obvious adverse reactions reported. a few publications recommendation. mebendazole may be used during pregnancy to treat relevant worm diseases. albendazole may be used in cases of echinococcosis. the other benzimidazole anthelmintics should only be used with a compelling indication, and when more established anthelmintics are ineffective. after first trimester exposure a detailed ultrasound examination should be offered to ascertain the normal development of the fetus. recommendation. with a compelling indication ivermectin may be used in pregnancy. after first trimester exposure a detailed ultrasound examination should be offered to ascertain the normal development of the fetus. recommendation. niclosamide may be given during pregnancy to treat relevant tapeworm infections. application in the first trimester needs to be critically assessed as tapeworm infections are generally not a great hazard to the mother or unborn child. after first trimester exposure, a detailed ultrasound examination should be offered to ascertain the normal development of the fetus. also found no evidence of a teratogenic potential after mothers had been treated in the first trimester (adam a , paparone . in a study from uganda encompassing more than , pregnant women, treatment with praziquantel in the second and third trimester was not associated with an increase in adverse outcomes (ndibazza ) . the who ( ) recommends the use of praziquantel for schistosomiasis during pregnancy. pyrantel is a broad-spectrum anthelmintic that acts by inhibition of cholinesterase, causing spastic paralysis and subsequent death of the parasite. no teratogenicity has been reported in animal studies. pyrantel is poorly absorbed from the gastrointestinal tract. published experience on its use during pregnancy is not sufficient to determine risk. pyrvinium is effective against pinworms (enterobius). after oral administration it is hardly absorbed. therefore, it is unlikely to reach the fetus in relevant amounts. there are no reports of embryo-or fetotoxic effects. however, there has been no published experience with the use of pyrvinium during pregnancy. a danish cohort study based on prescription registers identified women redeeming a prescription for pyrvinium ( during first trimester). the pregnancy outcome was not considered in this article (torp-pedersen ). diethylcarbamazine is used for the treatment of filiriasis and onchocercosis. no teratogenicity was reported in animal studies. no publications regarding its use during human pregnancies have been located. levamisole is used as anthelmintic and as an immunomodulator. a retrospective study with data from the hungarian malformation registry based on subjects (four first trimester exposures), shows no evidence of an increased risk of malformations after use of levamisole (kazy ) . oxamniquine is used for the treatment of schistosomiasis. no experiences have been reported about its use during pregnancy. recommendation. praziquantel should be reserved for specific severe indications like schistosomiasis. usually for other indications better-established anthelmintics are available. after first trimester exposure a detailed ultrasound examination should be offered to ascertain the normal development of the fetus. recommendation. pyrantel should be avoided in pregnancy because better tested alternatives are available for all indications. after first trimester exposure a detailed ultrasound examination should be offered to ascertain the normal development of the fetus. recommendation. pyrvinium may be used during pregnancy. the standard agent of this group is acyclovir which is used against the varicella-zoster virus (vzv) and herpes simplex virus (hsv) type and . the manufacturer's case collection contains over , women treated systemically with acyclovir during pregnancy, of them during the first trimester; with no evidence of embryo-or fetotoxic risk (stone ) . a study of a danish registry with , women with prescriptions in the first trimester, showed no increased risk after acyclovir (pasternak ) . although these studies had some methodological weaknesses, the experiences argue against the risk of acyclovir in pregnancy. valacyclovir, the prodrug of acyclovir, is converted quickly and completely to acyclovir in the body. orally it is distinctly better resorbed than acyclovir of which only about % is resorbed. the manufacturer did not find an increased risk of malformation in women who had received valacyclovir during pregnancy, of these during the first trimester (glaxo wellcome ) . also, the above cited study of the danish registry did not show evidence of embryo-or fetotoxic risk in pregnancies, in which the mother filled a prescription for valacyclovir during the first trimester (pasternak ) . ganciclovir and its prodrug valganciclovir are effective in cytomegalus virus infections (cmv). in animal experiment, teratogenic effects were only seen with plasma levels that were twice as high as those recommended in human therapy. there are a few case reports describing normal pregnancy outcome after the first trimester treatment during early pregnancy (pescovitz ) . puliyanda ( ) describes a successful oral treatment with ganciclovir for an intrauterine cmv infection after the nd week. these experiences are insufficient to evaluate the safety of ganciclovir in pregnancy. famciclovir is quickly converted after enteral resorption into the virostatic penciclovir. neou ( ) reported a newborn whose mother took mg famciclovir daily in her fifth week. the boy who succumbed to a severe neonatal infection had a hypoplastic thymus, a mild stenosis of the pulmonary valve, an ostium secundum defect, and an enlarged liver with stenotic extrahepatic biliary ducts. a retrospective study of data from the danish birth registry contained women who took oral famciclovir during the first trimester, and showed no increase in the malformation rate (pasternak ) . there is insufficient data about the use in pregnancy for brivudine, cidofovir, foscarnet, and fomivirsen. in animal experiments, small doses of foscarnet sodium trigger skeletal anomalies in rats and rabbits. no experience is reported for the combination therapy of dimepranol and inosine that is used to stimulate the immune system against viruses of the herpes group. recommendation. diethylcarbamazine, levamizole and oxamniquine should be avoided during pregnancy as better tested alternatives are available for most indications. after first trimester exposure a detailed ultrasound examination should be offered to ascertain the normal development of the fetus.  herpes medication for local use acyclovir, foscarnet, ganciclovir, idoxuridine, penciclovir, trifluridine, and tromantadine are locally applied in hsv infections. none of these agents has been suspected to give rise to teratogenic effects. acyclovir may be used in pregnancy systemically and is harmless in local application. in the above cited danish registry study , women had used acyclovir and women penciclovir locally during the first trimester, and no increased malformation risk was noted (pasternak ) . the other agents lack studies about local application. docosanol is a newly approved agent for topical application in herpetic cold sores. the mechanism of action is unknown. there has been no experience about its use in pregnancy; however, a risk is unlikely with its minimal resoption. the local application of zinc sulfate and of patches containing hydrocolloid particles is harmless in pregnancy. antiviral drugs for hepatitis  antiviral drugs for hepatitis b nucleoside/nucleotide analogs and α-interferon (chapter . ) are used for the management of chronic hepatitis b. a general therapeutic recommendation cannot be made for pregnancy as data are inadequate. experience so far did not reveal serious signs of teratogenic or fetotoxic damage in humans. if there is a very active hepatitis b or cirrhosis, antiviral treatment might be considered. passive-active immunoprophylaxis of infants have reduced mother-to-child-transmissions. however, in high viremic mothers immunoprophylaxis might fail. no consensus has been reached if pregnant women who are hbsag positive, and highly viremic should be treated in the third trimester to prevent a perinatal transmission to the infant (e.g. pan ). for lamivudine and tenofovir see section . . . adefovir dipivoxil, the prodrug of adefovir, is an orally-administered nucleotide analog. no teratogenicity has been reported in animal studies. the antiretroviral pregnancy registry ( ) received reports of births after a maternal adefovir dipivoxil regimen in the first trimester. no birth defects were observed in the infants. entecavir has shown teratogenic effects in animal studies where, in high doses, more vertebral and tail malformations occurred. of recommendation. if an antiviral therapy is indicated for a severe maternal disease, or to protect the fetus from an intrauterine infection, acyclovir or valacyclovir should be used as the best evaluated medication whenever possible. the other antiviral agents are only indicated in infections where they have a therapeutic advantage over acyclovir. after the application of one of the less well examined drugs during first trimester, a detailed ultrasound examination should be offered to ascertain the normal development of the fetus. recommendation. where indicated, local remedies for herpes may be used during pregnancy. drying agents and patches for herpes are harmless. where possible, acyclovir should be preferred as the best evaluated antiviral drug. infants whose mothers were exposed to entecavir during first trimester, two babies were born with birth defects (no details available) (antiretroviral pregnancy registry ). one case report describes a healthy baby born after entecavir exposure for days in the second trimester (kakogawa ) . telbivudine raised no suspicions for teratogenicity in animal experiments. among pregnancies of women who received telbivudine before or in early pregnancy the abortion rate was . %. fifty mothers delivered infants. one pregnancy was terminated because of cleft lip and palate and one infant showed right ear accessories, no other birth defects were reported (liu ) . in the antiretroviral pregnancy registry ( ) no birth defects were observed in infants after first trimester exposure to telbivudine. in a prospective study, infants were born after maternal treatment with telbivudine in late pregnancy to prevent perinatal transmission. exposure took place from the twentieth to thirty-second gestational week until at least month after delivery. there were no significant differences in infant outcomes compared to a control group. no serious adverse events were noted in the infants . there is an ongoing discussion as to whether telbivudine should be given to women with a high virus load during late pregnancy to prevent intrauterine transmission (review by deng ). the nucleoside analog ribavirin inhibits both dna-and rna-viruses, displaying a relatively broad antiviral spectrum experimentally. among other applications, it is used to treat respiratory syncytial virus (rsv) infections in infants, and, combined with α-interferon (chapter . ), against hepatitis c. ribavirin has teratogenic and mutagenic effects in animal experiments. nine women who were treated during the second half of pregnancy for severe measles delivered healthy infants (atmar ) . a woman treated for sars (severe acute respiratory syndrome) in the first trimester with ribavirin by injection for days gave birth to a normal child (rezvani ) . in its pregnancy registry, the manufacturer noted eight women with ribavirin exposure in the first trimester, and women with exposure within months of the last menstrual period (roberts ) . the authors found no evidence of a teratogenic risk for humans. in summary, current data is insufficient for a risk assessment for ribavirin. an embryo-or fetotoxic risk is not apparent with the available case reports. the level of ribavirin is twice as high in seminal fluid as in sperm. there has been no increased risk of malformations after paternal ribavirin treatment and interferon in pregnancies reported as case reports (review by hofer ), and pregnancies of the ribavirin pregnancy registry (roberts ) . these numbers are inadequate to assess a possible risk after paternal exposure. the protease inhibitors boceprevir, simeprevir and telaprevir have been approved for the treatment of chronic hepatitis c. there are no experiences with their use in pregnancy. the same applies to sofosbuvira recently approved polymerase inhibitor for the treatment of chronic hepatitis c. amantadine enhances dopamine activity at the receptor and thus is also used as an antiparkinson drug. as an antiviral medication, it inhibits the membrane protein hampering the ability of the virus to enter the cell nucleus. because of rapid resistance and frequent neurologic side effects, it is not recommended any more as an antiviral agent. for amantadin in parkinson disease, see chapter . . the neuraminidase inhibitors oseltamivir, peramivir and zanamivir are used to treat patients whose influenza requires therapy. oseltamivir has not shown teratogenic effects in animal studies. a prospective investigation at two japanese centers did not see an increase in malformations where women had been treated in the first trimester (review by tanaka ). another study involving exposed offspring, of them in the first trimester, also did not find a higher risk (greer ) . the manufacturer, too, noticed no increased risk in women who had used oseltamivir during pregnancy, of these during the first months (donner ) . one study with pregnant women exposed to oseltamivir, in the first trimester, found an increased risk of late transient hypoglycaemia compared to an unexposed control group. no other increased risks of adverse birth outcomes among the infants have been observed. one child had a ventricular septal defect. this was the only major malformation after exposure in the first trimester (svensson ) . another publication included pregnant women exposed to oseltamivir, of them in first trimester. the overall rate of major malformation after first trimester exposure was . % (saito ) . in a french publication, a total of mothers received at least one prescription of oseltamivir during pregnancy. one congenital heart defect was observed among infants who were exposed during first trimester. no significant association between adverse fetal outcomes and exposure to oseltamivir during pregnancy could be found (beau ) . dunstan ( ) could also find no signs of embryo-or fetotoxic effects in exposed pregnant women. no birth defects were observed in eight first trimester exposures. a population-based retrospective cohort study analyzed data from , women who received oseltamivir during pregnancy. compared to a control group, there were no associations between maternal use of oseltamivir with preterm birth and low apgar score. women who recommendation. ribavirin and the other antiviral agents discussed here should only be used during pregnancy when compellingly indicated. treatment during the first trimester is not a justification for a risk-based termination of pregnancy (chapter . ). in such a situation a detailed ultrasound examination should be offered to ascertain normal fetal development. pregnancy took oseltamivir during pregnancy were less likely to have a small for gestational age infant. however, birth defects and time of exposure were not mentioned (xie ) . two studies looked into the pharmacokinetics of oseltamivir and its active metabolite oseltamivir carboxylate during gestation. greer ( ) compared the pharmacokinetics of pregnant women in each group during the last trimester and found no significant differences. beigi ( ) examined the pharmacokinetcs in pregnant women (average gestational age . weeks) in comparison to nonpregnant women, and found the pregnant group to have lower oseltamivir carboxylate level. however, it remains unclear if the dose needs to be adjusted during pregnancy. zanamivir is applied by inhalation and very little is resorbed. no teratogenicity was found in animal experiments. a case series study from japan reported infants born after intrauterine zanamivir exposure, of them were exposed in the first trimester. no malformations have been observed (saito ) . a prospective surveillance study did not provide a case that use of zanamivir in pregnancy is associated with an increased risk of adverse pregnancy outcomes among women exposed to zanamivir during pregnancy. no major malformations were reported in zanamivir first trimester exposures (dunstan ) . experience and the presence of low systemic concentrations, make it unlikely that there is an increased embryo-or fetotoxic risk. experience during pregnancy with peramivir is insufficient for a risk assessment. the aim of antiretroviral therapy (art) during pregnancy is the prevention of a vertical transmission of the human immunodeficiency virus (hiv) from mother to child, and also the optimal management of the hiv-infected mother, whereby unwanted side effects are to be kept at a minimum for her and the child. art in pregnancy has become an integral part in the prophylaxis of hiv transmission after data revealed the protective effect of perinatal prophylaxis, with the nucleoside analog reverse transcriptase inhibitor (nrti) zidovudine that could prevent a possible vertical transmission during the last trimester and labor (connor ) . national and international guidelines recommend a standard therapy for both nonpregnant and pregnant hiv-infected women take a combination of at least three antiretroviral medications (eacs , oarac , who c . this highly active antiretroviral therapy (haart) typically consists of two nrtis and either a protease inhibitor (pi), or a non-nucleoside analog reverse transcriptase inhibitor (nnrti). the intention is that the suppression of the plasma hiv load (hiv-rna) should be as close to < copies/ml at least by the end of the pregnancy. when an effective haart is applied during pregnancy and lactation, the hiv rate of transmission can be decreased from its former levels of recommendation. if indicated, neuraminidase inhibitors oseltamivir and tanamivir may be used in pregnancy. peramivir should be avoided. amantadine is no longer recommended for the treatment of influenza. when used during the first trimester, a detailed ultrasound examination should be offered to ascertain normal fetal development. - % to < % (townsend , warszawski . the decision of what regimen to use is already complicated in nonpregnant patients, but more so in pregnancy. how to balance individual needs and risks should be considered, especially in view of the timing of the start of treatment, a possible interruption of therapy during the first trimester in women already under treatment, and the selection of appropriate antiretroviral medications. the risks from intrauterine exposure to combinations of antiretroviral agents are difficult to assess, as data are limited concerning the pharmakinetics and the developmental toxicity for most of the drugs. there is no data about the long-term toxicity of the exposure to intrauterine retroviral substances. information about the safety of retroviral drugs in pregnancy are limited to experiments in animals, single case reports, a few clinical studies, and analyses of registries such as the antiretroviral pregnancy registry ( ) in the usa that contains most of the information about the safety of antiviral substances in pregnancy. overview of the antiretroviral medications , darunavir, fosamprenavir, indinavir, lopinavir, nelfinavir, ritonavir, saquinavir, and tipranavir. . entry inhibitors: enfuvirtide and maraviroc. . integrase inhibitors: raltegravir, dolutegravir and elvitegravir. data currently available do not allow for a summarizing differentiated risk analysis for antiretroviral medications in pregnancy. with the exception of efavirenz, there have been no serious signs of teratogenic or fetotoxic damages in humans (e.g. watts , ecs . prospectively documented pregnancies do not demonstrate a higher risk of malformations and, like retrospective case reports, fail to reveal any distinct pattern of anomalies. when antiretroviral agents are used in the first trimester, the embryotoxic risk appears to be generally small (phiri , floridia , antiretroviral pregnancy registry , joao . nevertheless, substances that might be embryotoxic should be eschewed in early pregnancy. common side effects in children treated in utero or after birth with zidovudine or antiretroviral combinations consist of hematologic problems, especially anemias and neutropenias (dryden-peterson , feiterna-sperling , le chenadec . it is being debated if antiretroviral treatment with or without protease inhibitors favors prematurity (chen , patel , kourtis , cotter , tuomala . the maternal risks of therapy are discussed with the specific medications. the medical treatment of hiv infection during pregnancy is a prime example for the need to sometimes utilize insufficiently tested medications -because of the acute danger for mother and child. in individual cases it needs to be critically assessed if an ongoing or maternally indicated treatment is absolutely necessary during the time of embryogenesis, or if it can be temporarily suspended. data from clinical studies during pregnancy in women are available for abacavir, didanosine, emtricitabine, lamivudine, stavudine, tenofovir, and zidovudine. with the exception of didanosine, the nrtis showed comparable levels in the maternal serum, and the umbilical cord blood suggested an easy placental passage (pacifici ) . having an affinity to mitochondrial γ-dna polymerases, nrtis can induce mitochondrial dysfunction. the greatest risk for mitochondrial toxicity is exhibited in vitro for didanosine, stavudine, and zidovudine. the question if a perinatal nrti exposure could lead to mitochondrial problems in children is currently under discussion; a final consensus has not been reached (benhammou , blanche . lamivudine and zidovudine are the nrtis that should be preferred during pregnancy because of extensive experience. abacavir, emtricitabine and tenofovir are alternative nrtis which also might be used. didanosine and stavudine should only be used in special circumstances (oarac ). abacavir can lead to skeletal anomalies when given to rats at a high dosage. there is no evidence of teratogenicity in humans. abacavir readily crosses the placenta (chappuy ) . data from the antiretroviral pregnancy registry ( ) with birth defects in cases, indicate a malformation rate of . % after exposure during the first trimester, similarly as seen in the general population of the usa. in animal experiments didanosine given at high doses did not show teratogenic effects. didanosine crosses the placenta only in limited recommendation. antiretroviral medications may be used in pregnancy. specific risks for the prophylaxis of transmission and the therapy of maternal hiv infection need to be observed. the choice of medication and the timing of treatment have to be decided on an individual basis. when choosing medications it should be noted that some of the retroviral substances should be avoided during pregnancy, if possible. this concerns efavirenz (teratogenic effects) and the combination stavudine/didanosine (lactic acidosis). for newer medications such as maraviroc, raltegravir and etravirine, few or no data are available concerning their use in pregnancy. caution is called for when nevirapine is used in women with cd cell counts of < /mm mm (hepatotoxicity). if nevirapine is used during pregnancy, transaminases need to be checked regularly, especially during the first weeks of treatment; also, clinical symptoms are to be watched. the short-term use of nevirapine for transmission prophylaxis does not seem to carry a similar risk. when exposure occurs during the first trimester, a detailed ultrasound examination should be offered to ascertain the normal development of the fetus. it is recommended that the pregnant patient is cared for in a specialized center. physicians should report pregnancies involving the use of hiv medications shortly after diagnosis to the antiviral pregnancy registry (www.apregistry.com). amounts (wang ) . the data of the antiretroviral pregnancy registry ( ) show a slightly increased malformation rate after first trimester exposure at . % ( of births), in comparison to . % in the general us population. however, no distinct pattern of birth defects has been discovered. in a study where hiv infected women were treated at - weeks with didanosine, neither maternal nor neonatal side effects were noted (wang ) . cases of lethal lactic acidosis have been described in pregnant women treated with a combination of stavudine and didanosine (mandelbrot , sarner . due to the risk of fatal lactic acidosis, combination treatment with didanosine and stavudine should only be used in cases where no alternatives are available (bristol-myers squibb ) . emtricitabine has not shown evidence of teratogenicity in animal experiments or in humans. it crosses the placenta readily (stek , hirt b ). among cases of first trimester exposures reported to the antiretroviral pregnancy registry ( ), the prevalence of birth defects was . % ( of , births), similar to the rate in the general us population. lamivudine, one of the best evaluated nrtis, is also approved for the treatment of chronic hepatitis b. levels measured in the umbilical cord blood correspond to those of the mother. data from the antiretroviral pregnancy registry ( ) indicate an unsuspicious malformation rate of . % ( of , births). a larger study to prevent perinatal transmission was conducted in france where pregnant women received zidovudine and lamivudine after gestational week , and their newborns were also given the combination for weeks ( mandelbrot ) . in this study newborns displayed significant side effects that included lethal mitochondriopathies. however, lamivudine and zidovudine are medications that are preferred in pregnancy because of extensive experience. there is no evidence that stavudine leads to teratogenic effects in animal experiments or humans. stavudine crosses the placenta easily ( chappuy ) . the malformation rate after exposure in the first trimester is . % ( of births) according to data from the antiretroviral pregnancy registry ( ), thus similar as in the general us population ( . %). good tolerance of a staduvine-lamivudine combination has been described in a small phase i/ii study with mother-child pairs (wade ) . cases of lethal lactic acidosis have been described in pregnant women treated with a combination of stavudine and didanosine (mandelbrot , sarner . due to the risk of a fatal lactic acidosis, combination treatment with didanosine and stavudine should only be used in cases where no alternatives are available (bristol-myers squibb ). in animal experiments, offspring of monkeys that received high doses of tenofovir have a decreased fetal growth rate and diminished fetal bone density (tarantal ) . during pregnancy tenofovir crosses the placenta easily (flynn , hirt a . there is no evidence that tenofovir is teratogenic in humans. according to the data of the antiretroviral pregnancy registry ( ) the malformation rate after exposure during the first trimester is . % ( of , births), similar to the . % rate in the general us population. in clinical studies hiv patients, primarily children, displayed decreased bone density when treated with tenofovir. the clinical significance of these findings is still unclear. one study did not reveal any risk for adverse effects of in utero tenofovir exposure in pregnant women (gibb ). however, tenofovir should be used with caution during pregnancy, because of the risk of fetal bone changes and the paucity of other data about its pregnancy-related risks. zidovudine, also known as azidothymidine (azt), is the oldest antiviral drug used for antiretroviral therapy. it readily crosses the placenta. in rats, maternal toxic doses lead to an increased malformation rate during organogenesis, an effect not seen with lower doses. there are no signs of teratogenicity in humans. according to data from the antiretroviral pregnancy registry ( ) the malformation rate of . % ( of , births) was not significant higher than that of the general us population. the application of zidovudine has been well studied in pregnancy and is considered to be safe in regard to shortterm and medium-term toxicities. a common side effect, when zidovudine is used in the perinatal period, is a transient anemia in newborns (sperling , connor . a follow-up study of children who had been exposed to zidovudine in utero did not display any physical, immunological, or cognitive anomalies. the median age of children at the time of last follow-up was . years (range, . - . years) (culnane ) . also, there was no evidence of an increased risk for neoplasia in more than children after pre-and perinatal exposure (culnane , hanson . there are no data regarding long-term toxicity, especially for cancerogenicity. data from clinical studies about the safety in human pregnancy for nnrt is are limited. nevirapine is the agent that should be preferred if a nnrti is required during pregnancy. efavirenz might be used in special circumstances. for etravirine and rilpivirine the data are insufficient to recommend use during pregnancy (oarac ). delavirdine is not recommended as part of an initial therapy. delavirdine caused an increased incidence of ventricular septal defects in rats. experience in humans is limited to births after first trimester exposure reported to the antiretroviral pregnancy registry ( ). although no birth defects have been observed, these data allow no differentiated risk analysis. most guidelines do not recommend delavirdine as a part of antiretroviral regimens for initial treatment of hiv infection because of inferior efficacy. in animal experiments efavirenz showed evidence of teratogenicity. three of prenatally exposed cynomolgus monkeys showed malformations when plasma levels were similar to the therapeutic levels in humans. anencephaly with unilateral anophthalmia was observed in one fetus, microphthalmia in another, and cleft palate in a third. there are case reports in humans about neural tube defects in children whose mothers had received efavirenz during the first trimester (de santis , fundaro . according to the data of the antiretroviral pregnancy registry ( ) the malformation rate of . % ( of births) after first trimester exposure is comparable to the background rate of . % in the general us population. the birth defects included one infant with myelomeningocele. another child was born with anophthalmia, severe facial cleft and amniotic banding. in total, the antiretrorviral pregnancy register received six retrospective reports of neural tube defects; four of them were exposed to efavirenz. a meta-analysis, including nine prospective studies together with , live births, did not detect an increased risk of overall birth defects after exposure to an efavirenz-containing regimen during the first trimester. including retrospective studies, one neural tube defect was reported in , live births (ford ). an update of this meta-analysis which included additional subjects had similar results (ford ) . in contrast to these reassuring findings, another study analyzes data of , infants born between and . a significantly increased risk of congenital anomalies after exposure to efavirenz during first trimester was observed. six of infants with first trimester exposure to efavirenz had congenital anomalies (adj.or . , %; ci: . - . ) (knapp ) . however, the six observed major and minor defects (patent foramen ovale, gastroschisis, postaxial polydactyly, arnold-chiari malformation, talipes equinovarus, plagiocephaly), do not present a distinct pattern. with the available published experience, the british hiv association guidelines panels concluded that there are insufficient data to support the former position and furthermore recommend that efavirenz can be both continued and commenced in pregnancy (taylor ) . however, the united state guidelines are more restrictive. they recommend that an efavirenz-based regimen may be continued in women who present for antenatal care in the first trimester, provided the regimen produces virologic suppression (oarac ). animal experiments have not shown that etravirine is teratogenic. experience in pregnancy is limited to case reports (jaworsky , furco ). according to the data of the antiretroviral pregnancy registry ( ) no birth defects were reported in infants born after first trimester pregnancy exposure to etravirine. experiences are insufficient to analyze a possible risk in pregnancy. there is no evidence in animal experiments or human experience that nevirapine is teratogenic. nevirapine crosses the placenta easily and attains levels in the neonate that correspond to those of the mother ( benaboud , mirochnick . according to the data of the antiretroviral pregnancy registry ( ) the malformation rate after first trimester exposure is . % ( of , births), which is no higher than that of the general us population. studies indicate that viral transmission is blocked when mg p.o. nevirapine is given to the mother at the beginning of labor, and the newborn receives a single dose of mg/kg to hours after delivery (guay ) . there is a high risk of developing viral resistance even after a single dose (low resistance barrier and long half-life of nevirapine), thus nevirapine should only be administered in a combination regimen. reports have been published describing single cases of liver toxicity in pregnant women who took nevirapine (e.g. knudtson ). this event is often rash-associated and potentially fatal. liver toxicity is primarily observed in patients with higher cd cell counts (> /mm ); in these patients the risk of symptomatic hepatic events is twelve times greater than in women with lower cd cell counts (< /mm ). studies indicate that pregnancy per se is a risk factor for liver toxicity. pregnant patients using haart that includes nevirapin have no higher risk of hepatotoxicity than those who use haart without nevirapine (ouyang , ouyang ). these data suggest that the risk of liver toxicity of nevirapine is similar in pregnant and nonpregnant patients. however, if nevirapine is used in pregnancy, physicians should be aware of hepatotoxicity. animal experiments failed to show that rilpivirine is teratogenic. in the antiretroviral pregnancy registry ( ) no birth defects were reported in infants born after first trimester exposure to rilpivirine. one publication describes two healthy infants after rilpivirine exposure during pregnancy (colbers ) . experiences are insufficient to analyze a possible risk in pregnancy. pis are being used increasingly in pregnancy. they are recommended in regimens combined with two nrti drugs. pi therapy can lead to the disturbance of glucose tolerance and even to the manifestation or exacerbation of diabetes mellitus. it remains unclear if pregnancy itself increases the risk even further. generally, pis pass the placenta poorly ( gingelmaier , marzolini , mirochnick . therefore, fetal toxicity would seem to be unlikely. lopinavir/ritonavir and atazanavir with low-dose ritonavir boosting are the preferred pis during pregnancy. alternative pis include ritonavir-boosted saquinavir and darunavir. indinavir and nelfinavir should only be used in special circumstances. data is too limited to recommend the routine use of fosamprenavir and tipranavir in pregnant women (oarac ). atazanavir has not shown evidence of teratogenicity in animal experiments or human experience. according to the data of the antiretroviral pregnancy registry ( ), the malformation rate of . % ( of births) after first trimester exposure is comparable to the rate of . % in the general us population. a number of studies are available, including pharmacokinetic evaluations in pregnant women using haart with atazanavir , ripamonti . some experts recommend an increased dose in late pregnancy. the umbilical cord blood of neonates shows atazanavir levels of - % of those seen in the maternal serum. atazanavir inhibits the uridin glucuronosyl transferase that metabolizes indirect bilirubin. thus, as a common side effect, atazanavir treatment may lead to higher indirect bilirubin levels. while case numbers are relatively small, investigations showed that neonates of atazanavir-treated mothers did not show pathological elevations of indirect bilirubin. , ripamonti ). darunavir did not demonstrate evidence of teratogenicity in animal experiments. some case reports demonstrated a limited placental transfer. like with other pis a reduction in plasma levels has been observed in late pregnancy (pinnetti ) . in the antiretroviral pregnancy registry ( ) five birth defects were reported in infants born after first trimester exposure to rilpivirine (prevalence . %). few experiences about its use in pregnancy are available (e.g. jaworsky , ivanovic ). these data are insufficient for a differentiated risk assessment. in animal experiments no evidence was found that fosamprenavir leads to teratogenicity. human data about its use in pregnancy are very limited. transplacental passage analyzed in seven cases was relatively high compared to other pis. the authors detected a median ratio of . of cord blood to maternal amprenavir level (the active metabolite of fosamprenavir) (cespedes ) . one publication did not report adverse effects in nine infants after intrauterine exposure to fosamprenavir (martorell ) . two birth defects among births were reported to the antiretroviral pregnancy registry ( ) after first trimester exposure to fosamprenavir. these data are insufficient for a differentiated risk assessment. evidence for teratogenicity is not evident for indinavir in animal experiments or human reports. little of indinavir crosses the placenta ( mirochnick ) . according to the data of the antiretroviral pregnancy pregnancy registry ( ) the malformation rate of . % ( of births) after first trimester exposure is comparable to that in the general us population. these data are insufficient for a differentiated risk assessment. there is a theoretical concern that physiologic hyperbilirubinemia might be exacerbated due to indinavir. lopinavir is used in conjunction with its pharmacological booster ritonavir. in animal experiments with high doses of lopinavir, rats displayed evidence of embryotoxicity with an increased rate of miscarriages, less fetal viability, lower fetal weight, and skeletal changes. these problems were not apparent in rabbits. there is no evidence of teratogenicity in humans. like most pis, lopinavir/ritonavir crosses the placenta poorly (gingelmaier ) . according to the data of the antiretroviral pregnancy registry ( ) the malformation rate is . % ( of , births) after first trimester exposure, and thus not increased in comparison to the general us population. studies with hiv-infected pregnant women indicate that the treatment with lopinavir/ritonavir is well tolerated. pharmacokinetic investigations show lower plasma levels, primarilty in the last trimester (best ) . it is unclear if pregnant women require a higher dose or just a continuation of the pi standard therapy. a report of infants who received lopinavir/ ritonavir after birth observed an association with transient adrenal dysfunction in the infants (simon ) . a systematic review about the safety and efficacy of lopinavir/ritonavir during pregnancy included nine studies involving , pregnant women. no concerns with the use of these agents were suggested (pasley ). nelfinavir did not display evidence of teratogenicity in animal experiments. according to the data of the antiretroviral pregnancy registry ( ), the malformation rate is . % ( of , births) after first trimester exposure which is a modest evaluation compared to the general population ( . %). no distinct pattern of birth defects defects has been discovered. in studies with hiv-infected pregnant women it was noted that a small amount crosses the placenta (bryson , mirochnick . when nelfinavir is used as an unboosted pi in pregnant women who need treatment for hiv, it is inferior to newer, low-dose ritonavir boosted pis, but is useful as an alternative pi in combination with nrtis for the prophylaxis of hiv transmission. however, nevirapine should only be used under special circumstances during pregnancy. ritonavir should be used in combination with other pis as a low-dose booster to increase levels of a second pi. only a small amount crosses the placenta (mirochnick ) . there is no evidence that ritonavir is teratogenic in animal experiments or humans. according to the data of the antiretroviral pregnancy registry ( ) the malformation rate is . % ( of , births) after first trimester exposure, thus similar to the general us population. saquinavir has not demonstrated evidence of teratogenicity in animal experiments or human experience. like with other pis only small amounts of the drug cross the placenta (mirochnick ) . pharmacokinetic studies indicate that the newer tablet formulation that has replaced the former capsule formulation, leads to plasma concentrations similar to nonpregnant patients (van der lugt ). thus, it is not necessary to adjust the doses in pregnancy. seven birth defects among first trimester exposures were reported to the antiretroviral pregnancy registry ( ). these data are insufficient for a differentiated risk assessment. tipranavir shows no teratogenicity in animal experiments. there are no data about its ability to cross the placenta. aside from single case reports of pregnant patients with multiple resistances (weizsaecker , wensing , there are no other data about the use of tipranavir in pregnancy. no birth defects were reported to the antiretroviral pregnancy registry ( ) among four first trimester exposures to tipranavir. experiences are insufficient to analyze a possible risk in pregnancy. entry inhibitors are antiretroviral agents that inhibit viral binding or fusion of hiv to the cell, either by inhibition of the fusion of the viral capsule with the cell membrane or by blocking cd -or co-receptors. data about the use of enfuvirtide or maravorioc during pregnancy are insufficient to recommend their use during pregnancy (oarac ). in animal experiments no evidence was observed that enfuvirtide is teratogenic. a number of single case reports suggest that enfuvirtide apparently does not cross the placenta (weizsaecker , brennan-benson . according to the data of the antiretroviral pregnancy registry ( ) no birth defects have been reported among first trimester exposure to enfuvirtide. thus, it can be assumed that the risk of fetal toxicity is likely to be small. enfuvirtide may be used in pregnant women with multi-resistent hiv in combination with other potent agents as a therapeutic option, but current experience in pregnancy is very limited. maraviroc is a ccr inhibitor that is used to treat pretreated hivinfected adults in combination with other antiretroviral medications, when exclusively ccr -tropic hiv type- have been proven to be present. animal experiments using rats and rabbits did not show evidence of teratogenicity for maraviroc. there are no data indicating to what degree pregnancy maraviroc crosses the placenta. while there has been no indication that the use of maraviroc leads to a higher rate of malignancy, a theoretical concern remains based on the method of its action. maraviroc should only be used when the benefit justifies the potential fetal risk. there is a lack of data about its application in pregnancy. among cases with first trimester exposure reported to the antiretroviral pregnancy registry ( ) no birth defects have been observed. integrase inhibitors block integrase, a hiv-coded enzyme, and thereby hiv replication. the use of raltegravir during pregnancy can be considered in special circumstances when preferred and alternative agents cannot be used (oarac ) . there is insufficient data for the new integrase inhibitors dolutegravir and elvitegravir. in animal experiments no evidence was seen that dolutegravir is teratogenic. placental transfer has been described in animals. no experiences have been reported about its use during human pregnancy. there are also no reports about the use of dolutegravir to the antiretroviral pregnancy registry ( ). elvitegravir is combined with colbicistat which has no known antiretroviral activity. colbicistat is a pharmacokinetic enhancer which inhibits enzymes that metabolize elvitegravir. animal studies of elvitegravir have shown no evidence of teratogenicity. only one report about the use of elvitagravir during the first trimester has been reported to the antiretroviral pregnancy registry ( ). no birth defects were observed in this case. development studies in rats and rabbits did not show raltegravir to be teratogenic. however, there was a slightly increased incidence of supernumerary ribs in the offspring of rats that had received raltegravir at doses about . times higher than those recommended in human treatment. potential human risks are not known at this time. according to the few data about its use during pregnancy, raltegravir crosses the placenta well (mckeown ). in a case series of five women raltegravir was well tolerated (taylor ) . three birth defects were observed among pregnant women with first trimester exposures reported to the antiretroviral pregnancy registry ( ). because experience is increasing, the united states guidelines recommend allowing a regimen including raltegravir in special circumstances, when preferred and alternative agents cannot be used (oarac ) . however, the data on the use of raltegravir during pregnancy allow no differentiated risk analysis. more than years ago animal experiments demonstrated that an increase in the body temperature can cause malformations (review by graham , edwards , miller . this problem has also been discussed for humans. neural tube defects, in particular (suarez , shaw ), but also kidney, heart and abdominal wall defects (abe , chambers , have been reported in association with febrile infections in early pregnancy, even though the overall malformation risk is absent or only mildly increased. moretti ( ) performed a meta-analysis about the risk of neural tube defects and hyperthermia. they included studies with , cases and found a significant correlation (or . ; %; ci . - . ), both in the nine case-control studies and the six cohort studies. lowering fever in pregnant women seems to reduce the risk (suarez ) . it has been debated if the use of sauna, electric blankets, or other factors that bring about a short-term increase in body temperature could lead to similar effects as high fever (suarez ) . in finland, where this issue had been investigated repeatedly, visits to saunas occur frequently during pregnancy and is considered safe. the use of electric blankets and heated water beds has not shown, in other investigations, that they are linked to an increased malformation risk. one study observed that children between the ages of and had more frequent emotional and cognitive deficits where there were reports about high fever during the second and third trimester (dombrowski ) . in summary, it appears that there is a slightly higher risk of malformations when high fever (> °c and > hours) occurs, especially during the first weeks after conception. during long-distance travel and flights during pregnancy, a number of potential risks need to be considered: □ prevention of infections (malaria prophylaxis, see section . . .; vaccinations, see chapter . ). □ the risk of other infections (fever, fluid loss), and required therapy. □ during long-distance flights: -risks of thrombosis -ionizing cosmic radiation recommendation. if there is an infection with high fever, especially during early pregnancy, the fever should be controlled with acetaminophen (paracetamol) or ibuprofen (chapter . ). ibuprofen should not be taken after gestational weeks. non pharmacological measures of fever control such as cool wrappings, and sufficient fluid intake should also be considered. in cases of high fever episodes in early pregnancy, a detailed ultrasound examination should be offered to ascertain the normal development of the fetus. a fever episode does not justify a risk-based termination of pregnancy (chapter . ). visits to a sauna should be limited to less than minutes, and hot or long baths need to be avoided as well as other sources that can overheat the body. -decrease of the partial oxygen pressure equivalent to an altitude of , m -dry air. □ physical and psychological stress. specific developmental anomalies have not been found in pregnant women undergoing vaccinations or recommended malaria prophylaxis, nor were such problems seen as a result of long-distance flights. however, it needs to be noted that the stress of a long-distance trip, especially in predisposed women, might increase the risk of miscarriage. also, aside from typical infectious diseases, "common" infections may be more prevalent due to altered hygienic standards in the destination country. the accompanying dehydration, fever, or other complications may also endanger the fetus. the dose of cosmic radiation on a long-distance flight varies markedlydepending on solar activity. yet, according to current knowledge, no doses are reached that are high enough to lead to an increased risk of malformations. pharmacokinetics of quinine and its metabolites in pregnant sudanese women with uncomplicated plasmodium falciparum malaria maternal febrile illnesses, medication use, and the risk of congenital renal anomalies is praziquantel therapy safe during pregnancy? safety of artemisinins during early pregnancy, assessed in sudanese women quinine for chloroquine-resistant falciparum malaria in pregnant sudanese women in the first trimester pharmacokinetics of piperaquine in pregnant women in sudan with uncomplicated plasmodium falciparum malaria 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during pregnancy a population-based case-control teratological study of oral nystatin treatment during pregnancy a case-control teratological study of vaginal natamycin treatment during pregnancy preterm birth reduction after clotrimazole treatment during pregnancy population-based case-control teratologic study of topical miconazole a population-based case-control study of oral griseofulvin treatment during pregnancy tolnaftate spray treatment during pregnancy effect of mebendazole therapy during pregnancy on birth outcome periconceptional exposure to efavirenz and neural tube defects first-trimester itraconazole exposure and pregnancy outcome: a prospective cohort study of women contacting teratology information services in italy use of amphotericin b during pregnancy: case report and review the safety of the combination artesunate and pyrimethamine-sulfadoxine given during pregnancy birth outcome of pregnancies after exposure to phenoxymethylpenicillin in utero the effects of 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and d anti-infectives is associated with increased risks of preterm birth and low birth weight gentamicin use in pregnancy. a renal anomaly key: cord- -wpnq wc authors: riechelmann, rachel p; peixoto, renata d’alpino; fernandes, gustavo dos santos; weschenfelder, rui f; prolla, gabriel; filho, duílio rocha; andrade, aline chaves; crosara, marcela; rego, juliana florinda m; gansl, rene c; coimbra, felipe; aguiar, samuel; carvalho, elisângela; hoff, paulo m; coutinho, anelisa k title: evidence-based recommendations for gastrointestinal cancers during the covid- pandemic by the brazilian gastrointestinal tumours group date: - - journal: ecancermedicalscience doi: . /ecancer. . sha: doc_id: cord_uid: wpnq wc purpose: as of , the world is facing the great challenge of the covid- (coronavirus disease ) pandemic, caused by the sars-cov- virus. while the overall mortality is low, the virus is highly virulent and may infect millions of people worldwide. this will consequently burden health systems, particularly by those individuals considered to be at high risk of severe complications from covid- . such risk factors include advanced age, cardiovascular and pulmonary diseases, diabetes and cancer. however, few data on the outcomes of cancer patients infected by sars cov- exist. therefore, there is a lack of guidance on how to manage cancer patients during the pandemic. we sought to propose specific recommendations about the management of patients with gastrointestinal malignancies. methods: the brazilian gastrointestinal tumours group board of directors and members sought up-to-date scientific literature on each tumour type and discussed all recommendations by virtual meetings to provide evidence-based—and sometimes, expert opinion—recommendation statements. our objectives were to recommend evidence-based approaches to both treat and minimise the risk of covid- for cancer patients, and simultaneously propose how to decrease the use of hospital resources at a time these resources need to be available to treat covid- patients. results: overall and tumour-specific recommendations were made by stage (including surgical, locoregional, radiotherapy, systemic treatments and follow-up strategies) for the most common gastrointestinal malignancies: esophagus, gastric, pancreas, bile duct, hepatocellular, colorectal, anal cancer and neuroendocrine tumours. conclusions: our recommendations emphasise the importance of treating cancer patients, using the best evidence available, while simultaneously taking into consideration the world-wide health resource hyperutilisation to treat non-cancer covid- patients. the year of will be forever remembered as the year of the covid- (coronavirus disease ) pandemic, caused by a new coronavirus named sars-cov- . the new coronavirus surged in the chinese province of hubei in early december and as of may th more than , , people around the globe have been infected and nearly , have lost their lives throughout countries and territories. individuals mostly at risk of severe complications are those with cardiovascular and/or pulmonary diseases, diabetes mellitus and the elderly. because of an inherent immunosuppressive condition, cancer patients are considered to be particularly prone to developing serious complications from covid- . in the chinese experience from wuhan, patients out of , infected by sars-cov- had solid tumours and, in comparison with non-cancer patients, they experienced more serious events (intensive care admission with or without mechanical ventilation or death): % versus %. cancer patients who received chemotherapy or underwent surgery in the previous month were at an even higher risk of severe events: three ( %) out of four versus six ( %) out of patients [ ] . because, it is estimated that approximately % of patients with covid- will need hospitalisation, an overload, or even a collapse, of health systems is expected. such a burden will certainly impact on the treatments of millions of people with various different diseases, including cancer. since cancer is a severe disease, patients with malignancies need to be promptly treated for their tumours. hence, health institutions around the world will have to balance how they will manage medical care for covid- and cancer patients (plus all other severe medical conditions). foreseeing that hospitals and medical staff will be burdened by the pandemic, international oncology societies have sought to provide general guidelines about systemic and surgical cancer treatments with the aim to decrease health resource utilisation, such as medical visits, exams and delay surgical procedures [ ] [ ] [ ] . the society of surgical oncology, for example, recommends that all cancer patients who are candidates for oncological surgeries be tested for covid- prior to surgery [ ] , given that asymptomatic patients with sars-cov- undergoing elective surgery experience significant worse clinical outcomes, including higher mortality [ ] . the american society of clinical oncology website provides information for patients and medical staff about infection prevention as well as overall tips about reducing the number of hospital visits for patients (e.g., if possible, choose oral rather than intravenous cancer-directed therapies) (https:// www.asco.org/asco-coronavirus-information). the european society of medical oncology (esmo) website delivers sessions on frequent questions and answers about covid- , encourages telemedicine and also offers guidance on how to reduce hospital visits and information for patients (https://www.esmo.org/covid- -and-cancer?hit=ehp). yet, specific and detailed treatment recommendations by tumour types and related treatments have not been widely available. ahead of other oncology societies, esmo has issued more specific recommendations for some gastrointestinal cancers (colorectal, esophagus and pancreatic) and propose treatments based on priority levels; however, direct treatment recommendations for each tumour stage are not provided [ ] . therefore, we think it is useful to propose practical and precise recommendations on how to manage patients with gastrointestinal malignancies during the covid- pandemic. this initiative was developed by the board of directors of the brazilian gastrointestinal tumours group (gtg), a nonprofit organisation founded in and devoted to medical education and research in gastrointestinal cancers. we sought up-to-date literature to provide all recommendations for each clinical and/or pathological stage of the most common gastrointestinal cancers (esophageal, gastric, pancreas, bile duct, hepatocellular, neuroendocrine, colorectal and anal cancer). we had virtual meetings to discuss all the topics, reaching consensus on all statements. all recommendations made here were based on the best available scientific evidence, such as randomised clinical trials, meta-analyses and large cohort studies. however, in some scenarios where solid evidence was lacking, we used common sense to provide an expert opinion recommendation (marked in the text as 'eor'). all the recommendations proposed in this manuscript, besides being evidencebased, aimed at the following objectives: ( ) to prioritise curative-intent cancer treatments during the pandemic; ( ) to support the treatment of aggressive tumours when effective therapies are available; ( ) to decrease the number of or delay oncological non-priority surgeries; ( ) to decrease hospital visits (e.g., substitute intravenous for similarly effective oral drugs; propose when and to whom treatments delays/ interruption/watchful waiting can be offered); ( ) to minimise anticancer therapy-related immunosuppression in specific high-risk groups (here defined as: elderly, comorbid illnesses [especially diabetes, cardiovascular and/or pulmonary concurrent diseases], fragility, ecog or higher). all recommendations are made for scenarios where services still have the capacity to treat cancer patients but are expected to destiny some of their space, beds and staff to manage covid- patients. • social distancing mandates that every in-person interaction between patients and the health care system be scrutinised and only essential physical contacts between patients and health care professionals occur to diminish the risk of viral exposure to patients. thus, minimise blood tests, scans and routine tests. telephone and telemedicine visits should replace routine face-to-face clinic visits whenever possible. • whenever covid- is clinically suspected or confirmed, systemic treatments should be suspended, and surgery should be postponed unless an urgent procedure is necessary. (eor) • whenever surgery is indicated, sars-cov- testing should be considered [ , ] . • there are insufficient data to recommend in favour or against an open versus minimally invasive approach. proven benefits of minimally invasive surgeries of reduced length of stay and complications should be considered individually [ ] . nevertheless, whenever minimally invasive surgeries are indicated, the use of devices to filter released co for aerosolised particles or techniques to treat the intra-abdominal gas whenever it should be emptied, are strongly advised [ ] . • central venous catheter flushing intervals should be increased to every (younger and fit patients) or to every (older, frail patients with multiple comorbidities) days. (eor) • for early stage (ct / cn ) colorectal, biliary, hepatocellular, esophagus and gastric tumours, where neoadjuvant treatment is not standard, consider deferring surgical resection to up to weeks. if delays beyond weeks are expected, repeat staging exams. (eor) • radiation schedules should be hypofractionated, whenever possible. • follow-up imaging and appointments should be reserved for those with symptoms suggestive of disease relapse. asymptomatic patients not on active treatment should avoid imaging and follow up appointments, delaying tumour markers and colonoscopies, for example, for until the pandemic is over. (eor) in such cases, if possible, telemedicine or telephone consultation is indicated. • dypd screening is indicated whenever possible, before the use of fluoropyrimidines [ ] . • adjuvant treatment for colon [ ] and other gastrointestinal tumours, when recommended, should start in to weeks after primary tumour resection. monitoring blood counts at every cycle can be done by telemedicine if patients are asymptomatic. • infusional fu should be substituted for capecitabine in the following regimens: folfox, cisplatin and fu, monotherapy or when combined with radiotherapy [ ] [ ] [ ] . exceptions are patients with severe renal dysfunction (creatinine clearance ≤ ml/minute); in patients with moderate ( to ml/minute) renal dysfunction when upfront dose reduction of % is recommended. • in curative-intent treatments, we encourage to maintain dose-intensity with the use of colony-stimulating growth factor (csgf), if needed. (eor) • in the metastatic setting, consider dose-reduce chemotherapy instead of adding csgf, if the latter requires more hospital visits. (eor) • in the metastatic setting, omit bolus fu in folfox or folfiri regimens to minimise toxicity. (eor) • whenever possible, chemotherapy holidays may be considered in patients with low-volume metastatic disease, who are responding or experiencing tumour stabilisation and when there is no major risk of complications for site-specific progression (e.g., peritoneum, biliary obstruction). if maintenance is considered to be beneficial instead of chemoholidays (e.g., more aggressive disease), prefer capecitabine alone, without bevacizumab. • standard second or further lines of anticancer therapies should be recommended for ecog or patients. preferably, when there is clinically relevant overall survival gain demonstrated by randomised phase iii trials (e.g., second-line for colorectal cancer) [ ] . • anti-pd immune check point inhibitors are recommended in second or further lines of treatment for all gastrointestinal malignancies with microsatellite instability, regardless of the diagnostic method [ ] . • for those in which immunotherapy monotherapy is indicated, we recommend the weeks schedule with pembrolizumab [ ] . • multidisciplinary team discussions (mdt) by web conferencing systems are highly encouraged. we think mdt are key to help with decisions about risks and benefits of cancer-directed therapies during the covid- pandemic. • in all cases, clinical individual judgment is advised and decisions should be shared with patients. additionally, the anticipated survival benefit for each patient versus the risks of exposure to the virus should be discussed with patients, taking into consideration the individual's comorbidities and degree of frailty, as well as caregivers and family members at home. • clinical trial enrolment: • patients who are candidates for clinical trials should be encouraged to enrol in the following situations: studies testing orphan drug indications, experimental treatments where benefits are very likely to outweigh the risks (e.g., immunotherapy combo of ipilimumab and nivolumab for microsatellite unstable metastatic colorectal cancer (checkmate hw -nct ) or rare tumours. however, institutions and principal investigators should discuss and align with sponsors and institutional research ethical boards about how to minimise hospital visits (e.g., all lab and image tests performed in one single day), implement telemedicine in certain moments of trial conduction (lab checks for fit patients who are tolerating well the trial therapy, for example), extend intervals between hospital visits, if possible. • for patients already on trial, treatment should continue based on clinical judgement that should balance tolerance versus benefit. the same principles cited above to decrease hospital visits should be sought. early stage -ctis, ct a/b cn : • ct a lesions amenable to endoscopic resection may preferentially undergo endoscopic management [ ] . pt b adenocarcinomas may also be considered for endoscopic resection when there is no evidence of lymph node metastases, or lymphovascular invasion and/or poor differentiation, or in elderly and/or high-risk patients. (eor) • if endoscopic treatment is not possible, consider deferring the intervention up to weeks in younger and fit patients or up to weeks in older, frail patients (see overall recommendation). -ct -t and/or clinically lymph-node positive (cn+): • staging with -fdg-pet should be performed, because it detects up to % more distant metastasis in comparison to conventional computerised tomography (ct) [ ] . • staging laparoscopy is not recommended, to avoid aerosol exposure of staff involved in the procedure [ ] . • perioperative chemotherapy with flot with csgf is preferred over chemoradiation in gastroesophageal junction and siewert iii adenocarcinoma [ ] (and eor). if the patient is responding, consider performing all cycles of programmed chemotherapy preoperatively. (eor) • in siewert i and ii subtypes, chemoradiation following the cross regimen is advised [ ] . • for patients who did not receive neoadjuvant chemotherapy, adjuvant treatment should be prescribed whenever indicated (pt or higher and/or pn+) and may be postponed up to weeks after surgery [ ] . • adjuvant radiation therapy alone should be avoided, except for r resection. • squamous cell carcinoma should be treated with neoadjuvant chemoradiation. the association of carboplatin, paclitaxel and radiotherapy (cross trial protocol) should be preferred due to better toxicity profile. radiation dose should be limited to . gy to reduce the number of visits to the clinic [ ] . • patients with squamous cell carcinoma and complete clinical response to chemoradiation could avoid surgery [ ] . • in locally advanced/unresectable esophageal cancer, chemotherapy alone may be considered, instead of chemoradiotherapy. (eor) when definitive chemoradiation is indicated, weekly carboplatin and paclitaxel should be considered and radiation dose should be increased to gy. (eor) • patients with obstructive symptoms or haemorrhage may be treated with endoscopic measures and proceed to surgery if these measures fail [ ] . if radiotherapy is necessary, ultra-hypofractioned schemes are recommended. • doublets (oxaliplatin + capecitabine or cisplatin + capecitabine) are preferred over triplets and should be prescribed until progression if tolerance allows. • consider up-front or on-treatment dose-reductions up to % according to risk-benefit assessment. (eor) • earlier imaging (every weeks) is recommended. consider discontinuation of systemic treatment when results are not favourable. • for patients with ecog or , second line pembrolizumab is indicated in adenocarcinoma or squamous cell tumours with cps >= [ ] . • for patients who are not candidates for systemic treatment but require management of local symptoms, consider palliative radiotherapy (single fraction or hypofractionated schemes) or stent. early stage • ct a lesions amenable to endoscopic resection should preferentially undergo endoscopic management [ ] . given the concerns for aerosolisation with endoscopic procedures, ensuring patients are covid- negative and/or postponing the procedure should be considered (see overall recommendations). • ct b cn cancers should be resected, although surgery could be temporarily postponed up to weeks after mdt. (see overall recommendations) • ct cn cancers could either be considered for upfront surgery or neoadjuvant therapy. (eor) • ct or higher and/or cn+ should be treated with neoadjuvant systemic therapy [ , , ] . patients should initiate chemotherapy without delays whenever possible. those who are already on neoadjuvant chemotherapy and responding to it with reasonable tolerance should complete all perioperative treatment so that surgery could be postponed. (eor) • diagnostic laparoscopy to rule out metastatic disease should be avoided whenever hospital resources or space is critical. however, when not previously done, consider diagnostic laparoscopy after neoadjuvant therapy. (eor) • adjuvant treatment should be prescribed whenever indicated (pt or higher and/or pn+) and may be postponed up to weeks after surgery [ ] . • adjuvant radiation therapy should be avoided, except for r resection and/or d gastrectomy. • for patients with msi-h tumours and localised disease, surgery should be the only treatment; no chemotherapy or radiation is indicated [ ] . • triplets, such as dcf and flot, should be avoided in the metastatic setting to minimise the risk of hospital admission. • metastasectomies should be avoided [ , , ] . • primary tumour complications, such as bleeding and obstructions, should be discussed in mdt and managed according to local resources. • consider staging with -fdg pet-ct to avoid surgery in subclinical stage iv patients [ ] . • consider neoadjuvant therapy for all patients, including upfront resectable (e.g., ct cn ) patients who are fit and obvious candidates for adjuvant treatment [ , ] . histological diagnosis is mandatory before starting chemotherapy. • neoadjuvant treatment is strongly recommended for patients with borderline tumours based on vascular or biological criteria (i.e., ca . > u/ml; enlarged regional lymph nodes • systemic treatment only for ecog - patients. ecog - patients are candidates for best supportive care only. • modified folfirinox or gemcitabine and nab-paclitaxel are recommended for first line [ , ] . gemcitabine and nab-paclitaxel require less hospital visits and could avoid surgery to implant the totally implantable catheters. • reduction of chemotherapy intensity (panoptimox trial strategy) is strongly recommended for patients whose tumour are responding/stable on folfirinox [ ] . • patients with known pathogenic or likely pathogenic brca germline mutations may receive cisplatin and gemcitabine as a first or second-line therapy [ ] . (and eor). maintenance with olaparib can be offered to fit patients who are responding to a platinum-based regimen. localised disease • barcelona clinic liver cancer (bclc) staging and a patients: organ transplantation should not be delayed [ ] . • -fdg pet-ct should be performed, if available, to avoid surgery in subclinical metastatic disease [ ] . • bclc stages a and b patients should be evaluated for locoregional therapy [ ] . • bclc a patients should be considered for minimally invasive treatments: prefer radiofrequency ablation or stereotactic radiotherapy over surgery to avoid major complications. (eor) • when chemoembolisation is the chosen option, try to diminish hospitalisation time by monitoring liver function on an outpatient basis. (eor) • bclc stage b patients who are not candidates for locoregional therapy and bclc stage c patients should be offered systemic therapy. select patients who are most likely to benefit based on performance status, child-pugh score and comorbidities. • atezolizumab and bevacizumab should be considered, when available, as the first line of choice, for fit patients, based on performance status, child-pugh score and comorbidities [ ] . if this option is not available, sorafenib or lenvatinib are the recommended first-line treatments [ , ] . • consider omitting radiology response assessment and continue to clinical progression according to tolerance and tumour marker alpha-fetoprotein. (eor) • regorafenib should be used in second line for ecog / patients who experienced good tolerance to first line multi-kinase inhibitor [ ] . regorafenib should preferably be initiated in a dose-escalation schedule, (eor) resembling the redos scheme administered for metastatic colorectal cancer [ ] . • consider ramucirumab for second line if alpha fetoprotein is > ng/ml in patients who are intolerant to multi-kinase inhibitors [ ] . • avoid any systemic treatment for child-pugh b patients [ ] . localised net: • surgical procedures in patients with net should follow standard recommendations [ ] . galium- dotatate pet-ct. if functioning images are negative, we suggest bland hepatic embolisation for liver-predominant disease [ ] . • for pancreatic net: prrt or sunitinib are recommended for more indolent tumours [ , ] . • for more aggressive nets, we recommend capecitabine and temozolamide [ ] . • for liver-predominant disease, hepatic embolisation can be used and repeated to treat progressive disease and/or refractory carcinoid syndrome, if adequate liver function is preserved [ ] . • we suggest avoiding the use of everolimus during the pandemic because of the risk of severe and opportunistic infections [ ] . poorly-differentiated neuroendocrine carcinomas (nec): • in patients with small localised nec, surgery should be performed without delay. for cn+ or bulky nec, start with systemic chemotherapy (see metastatic disease). consider staging patients with -fdg pet-ct scan prior to surgery to rule out metastatic spread [ ] . • for localised rectal or esophageal nec, chemoradiation with cisplatin and etoposide should be initiated [ ] . for patients who undergo r resection and with good performance status, consider to cycles of adjuvant cisplatin and irinotecan or etoposide. (eor) • metastatic disease should be treated with cisplatin-based regimens. • evaluate msi status in tumour tissues if immunotherapy is available for metastatic disease. • we have adapted our recommendations from the recently published esmo recommendations on rectal cancer [ ] . • high rectal tumours (intraperitoneal location) follow the same recommendations for colon cancer. • for ct - or ct a n (middle and low with sphincter preservation), with clear circumferential margins (crm), proceed with total mesorectum excision (tme) without pre-operative radiotherapy. • for low-risk t , transanal endoscopic microsurgery (tems) can be considered. • for ct b/c or cn+ (middle or low rectum) with clear circumferencial margins, we recommend short course radiation therapy with delayed surgery. (eor) if major response is needed for sphincter preservation, we favor long-course chemoradiation. (eor) importantly, short course radiotherapy, while leading to less hospital visits, is associated with more g or treatment-related adverse events (mainly gastrointestinal) when compared with long-course radiation [ ] . • for ct , or threatened/involved crm, or lateral pelvic lymph nodes, or suspected cn /bulky lymph nodes involvement, we favour total neoadjuvant therapy with long-course chemoradiation with capecitabine followed by four to six cycles of chemotherapy (mfolfox ) or short-course radiotherapy followed by four to six cycles of chemotherapy (mfolfox ). capox can substitute for mfolfox in younger and/or fit patients with normal renal function and without an ileostomy [ ] [ ] [ ] . chemotherapy followed by chemoradiation is also an adequate option in total neoadjuvant therapy for rectal cancer. institutions should start with the promptest modality. (eor) • patients in complete clinical remission after completion of neoadjuvant therapy can have surgery delayed and might be offered a watch-and-wait approach for low rectal tumours. patients whose tumours have been clearly downstaged can have surgery delayed or avoided if a further follow-up demonstrates complete clinical remission [ , ] . • postoperative chemoradiation should be considered in patients who did not have pre-operative radiation and with adverse pathological features, such as: positive circumferential margin, incomplete mesorectal resection, extranodal deposits, nodal deposit with extracapsular spread close to the mesorectal fascia, extensive extramural vascular invasion/perineural invasion close to the mesorectal fascia, and/or pn low tumours within cm of the anal verge [ ] . • the decision regarding adjuvant chemotherapy for patients who were operated upfront will be the same as discussed in colon cancer section. • in elderly and/or frail patients or those not fit for chemotherapy or standard chemoradiation, we recommend short course radiation with a delay of to weeks to surgery. (eor) • diverting stoma is highly recommended for all extraperitoneal colorectal anastomoses during the pandemic, as it minimises the severity of complications. (eor) early stages • depending on the pandemic phase and availability of hospital beds, it is acceptable to start neoadjuvant chemotherapy [ ] if surgery is expected to be delayed by more than weeks. • adjuvant chemotherapy for stage ii colon cancer is recommended in patients with the only following high-risk features: less than examined lymph nodes and/or pt and/or perforated tumours and microsatellite stability (mss) • for up-front or borderline resectable disease consider chemotherapy with capox for up to eight cycles. the timing of surgery can be flexible but evaluate response by radiological images every to months. (eor) • -fdg pet-ct is recommended for staging prior to first chemotherapy, with the aim to detect subclinical metastatic disease [ ] . incurable metastatic disease: • in first line, prefer capecitabine + bevacizumab for low volume of disease and/or age years or older [ , ] . • doublets with or without monoclonal antibodies in moderate/high volume of disease, following the standard options, but always taking into consideration patient's comorbidities, ras/brafv e mutation status, msi-h status and sidedness. • when a plateau of response is achieved, consider maintenance with capecitabine or chemotherapy holidays, with images performed every weeks [ ] . • avoid triplet chemotherapy regimens (folfoxiri) with or without monoclonal antibodies [ ] , except for patients with high burden of disease and young/fit patients and/or with braf v e mutated tumours [ ] . (and eor) • synchronic metastatic colon or rectal tumours should be initially treated with systemic treatment. (eor) these cases should be discussed and their management decided in mdt. • regarding second-line treatments, follow the standard rationale, taking in consideration clinical performance status, first line regimens, responses, volume of disease and molecular markers. • for patients who have failed standard chemotherapy and monoclonal antibodies, regorafenib or trifluridine/tipiracil are indicated. when regorafenib is used, start with a dose-escalation schedule as studied in the redos trial [ ] . • in later lines, for patients whose cancers have either her amplification, braf v e mutations, or are ras/raf wild-type, need treatment and are refractory to -fu/capecitabine, consider switching to targeted therapies alone, without concurrent use of cytotoxic agents [ ] . • weekly cetuximab should be avoided. instead, use every-other-week anti-epidermal growth factor receptor (egfr) dosing [ ] . • patients with ct n m tumours can be treated with local excision if a cm margin can be achieved [ ] . • patients with ct - n - m should receive standard chemoradiation with mitomicyn or cisplatin combined with capecitabine mg/m bid (ref) on radiation treatment days [ ] . • patients with ct n m and years or older and/or with multiple comorbid illness can be treated with radiation alone with or without capecitabine. (eor) • for patients with locally relapsed/persistent/progressed tumours, salvage anorectum amputation should be performed; if available, an -fdg-pet-ct should be performed to avoid unnecessary radical surgery in the context of metastatic disease [ ] . • the first line recommended regimen for metastatic disease is carboplatin and paclitaxel, because it offers less serious adverse events over conventional cisplatin and infusional -fu [ ] . • the modified dcf regimen can be used in selected ecog and fit patients with bulky visceral metastatic disease [ ] . • in second-line, immune check point inhibitors should be considered for ecog ps - [ , ] . • particularities in anal cancer in patients with hiv infection: • localised non-metastatic disease: initiate full chemoradiation in patients with cd count higher than cell/mm ; cisplatin or mitomycin offer similar outcomes [ ] . it is acceptable to dose reduce chemotherapy in patients with cd count of less than cell/mm although there is no standard schedule. (eor) • anal cancer in hiv-infected patients take longer time to achieve clinical complete response, with nearly two thirds presenting complete response after months. therefore, we recommend waiting longer (at least one year for those without local progression) before recommending salvage anorectum amputation in these patients [ ] . • treatment for metastatic disease should follow the same principles for non-hiv-infected patients. given the unprecedented moment health care systems and oncologists are facing worldwide, the recommendations proposed here by the brazilian gastrointestinal tumours group provide a balance of how to best manage gastrointestinal tumours in the face of the sars cov pandemic, taking into consideration the limited health resources available in many countries. we think that a practical and detailed set of recommendations may help general oncologists to better (and safely) treat their patients with gastrointestinal cancers. cancer patients in sars-cov- infection: a 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cell carcinoma of the anus according to hiv-infection the gtg group would like to gratefully acknowledge the support of dr helano freitas who helped us with formatting and referencing the manuscript. key: cord- -uwpkb lm authors: cavaliere, giulia title: non-essential treatment? sub-fertility in the time of covid- (and beyond) date: - - journal: reprod biomed online doi: . /j.rbmo. . . sha: doc_id: cord_uid: uwpkb lm nan t he extremely difficult circumstances that fertility patients find themselves in force them to reconcile with acute losses and profound uncertainties. sometimes what hurts the most is the loss of the child desired and imagined (lesnik-oberstein, ) , which becomes a tangible loss in the event of a failed implantation or a miscarriage. sometimes it is the loss of a partner due to the strain that fertility treatments can put on a relationship (martins et al., ) . in other instances, uncertainty about the outcome of treatment can become unbearable. the outbreak of sars-cov- in the first few months of confronted fertility patients with a new set of losses and uncertainties that came suddenly and unexpectedly. due to the implementation of stringent social distancing measures and the suspension of 'non-essential' medical treatments and procedures, fertility treatments were halted in the usa, the uk and other european countries, (ferguson, ; miller, ) . at the time of writing, many countries have slowly moved towards allowing fertility clinics to resume their activities. however, given the disruption caused, my contention in this brief commentary is that it is necessary to engage in conversations on the social value of offering fertility treatments and on whether it is justifiable to suspend them in the event of a health crisis of this proportion. following the guidance of the british fertility society (british fertility society, ) , the american society for reproductive medicine (asrm) (asrm, ) and the european society of human reproduction (eshre) (eshre, ) , several countries issued directions to suspend fertility treatments (with the exception, for instance in the uk, of fertility preservation for cancer patients) (british fertility society, ) . this suspension has had a severe impact on fertility patients. media outlets have been filled with stories of patients whose treatment has been suddenly halted and of how this has taken a very serious toll on their mental health. for some, the suspension has added an undefined amount of time to the years trying to conceive before becoming eligible for treatment, and to the months on the waiting list after referral. for others, the suspension has been issued after they had undergone hormonal injections, close monitoring of one's sleep, diet, mental and physical health, and arranging life's plans around the treatment schedule. considering that time is a key element in assisted reproduction, i believe in the importance of prioritising discussions on how to administer treatments during a health emergency over discussions on whether to administer treatments in these circumstances. while it has been reported that only a few months of delay may not necessarily affect the chances of success of fertility treatment (romanski et al., ) , waiting times from initial diagnosis of sub-fertility to the start of fertility treatment can be lengthy. additionally, it is unclear whether there will be further suspensions in the event of a sustained rise in infections. but are these really issues that should concern us, considering the unprecedented situation we are confronted with? should we be concerned with the suspension of fertility treatments considering the large number of deaths caused by sars-cov- and the degree to which all manner of treatments and procedures have been suspended worldwide? these are tricky ethical questions. on the one hand, one could argue that fertility treatments are indeed non-essential and should be suspended to protect patients and staff and to devolve resources to more urgent and critical treatments and procedures. trivially, contrary to the case of cancer services, no one is actually dying or missing out on life-saving diagnoses or treatments (hiom, ) . on the other hand -and it is here that my allegiances lie -the toll that these suspensions is taking on fertility patients would call for a more nuanced engagement with these questions. while current circumstances are indeed exceptional, the disagreement on whether fertility treatments should be considered essential is not new. for instance, some scholars have argued against the investment of public resources to offering fertility treatments or the development of new assisted reproductive technologies (mcternan, ; rulli, ) . the idea is that these technologies would only benefit a small subset of individuals and couples who wish to have genetically related children and who are unable to do so unassisted. considering that there are alternatives in place, such as adoption, fertility treatments and having genetically related children through ivf is often not regarded as something essential. another argument that questions the value and the essential nature of fertility treatments focuses instead on social norms. the gist of such an argument is that social norms surrounding parenting seem to place having genetically related children as a superior parental project to other forms of family formation. for subfertile women and couples, these norms are likely to contribute to the negative psychological effects of their inability to have (genetically related) children, and motivate women's willingness to undergo fertility treatment, even if such a treatment is psychologically and physically taxing. these views are relevant for the present discussion. the scale of the outbreak has put an unprecedent strain on healthcare systems. the measures enacted by the uk and other governments to mitigate the spread of the virus have had a severe economic impact, which is likely to cause the loss of significant part of people's livelihood, thus increasing their risk of falling ill. sars-cov- has had a disproportionate impact on people with low socio-economic status and from ethnic minorities groups (bambra et al., ) . considering then the unprecedented health and economic crises that our societies are facing, and the burdens and costs associated with fertility treatment, one could conclude that this pandemic -and the consequent suspension of fertility treatments -might represent an opportunity to re-think the social value of genetic relatedness and fertility treatments. it is my view that every opportunity is a good opportunity to question the social value of having genetically related children. feminist scholars have long criticised the predominance of the genetic tie, the harms associated with undergoing fertility treatments and the justice issues associated with the fertility industry. but -and there is a 'but' to all this -for fertility patients and those longing to have (their own, genetically related) children, questioning the social value of fertility treatments, and what is, to them their preferred parenthood project, may come across as disregarding something that they feel very strongly about. this poses a dilemma: interventions aimed at questioning such social value and treating fertility treatments as 'non-essential' might benefit present and future fertility patients by lessening the pressure to conform to social norms. this is however a paternalistic approach, one that firstly assumes that their preferred parenthood project is the product of social norms and that secondly prioritises what to third parties may seem beneficial to these patients rather than what they may feel is beneficial to them. the feminist philosopher sally haslanger maintains that there are two strategies to combat the negative effects of oppressive social norms. she argues: "[o]ne is to provide resources so that everyone can come as close as possible to fitting the schema, another is to combat the dominance of the schema" (haslanger, , p. ) . following her line of argument, interventions aimed at reducing the negative impact of oppressive social norms could take two forms. the first is considering fertility treatments as essential during a pandemic and devolving resources to making them more accessible. this strategy would provide people with a means to 'come as close as possible to fitting the schema'. suspending fertility treatments and using the sars-cov- outbreak as an opportunity to rethink the social values of offering these treatments more broadly and to promote alternative ways of achieving parenthood is instead a second strategy that would 'combat the dominance of the schema'. while i would argue that it is important to question the social value of genetic relatedness and mitigate the negative effects that social norms can have on women and couples, i have also strong normative and conceptual views on the need to protect and promote prospective parents' reproductive freedom and enable them to satisfy their preferred parenthood project. how should these tensions be addressed? it is true that sub-fertility has profoundly negative psychological implications, especially for women (mcleod and ponesse, ) . the suspension of fertility treatments during the first wave of the sars-cov- outbreak has exacerbated such implications. framing fertility treatments as 'essential' and a priority for the state during a pandemic, and increasing funding in normal times may lend support to the view that having a genetically related child is indeed the only valuable way of becoming a parent. despite this, people's freedom to make meaningful decisions in reproductive matters is of value (brock, ) . having children and, also, having certain kinds of (genetically related) children can be for some such a core activity that thwarting the enjoyment of this possibility can have a significant impact on their sense of self and well-being. it is my view that whilst social norms influence people's preferences and decisions to undergo fertility treatments, this does not mean that women or couples undergoing such treatments lack capacity to critically engage with these norms and formulate informed views concerning their preferred procreative projects (cavaliere, ) . in addition, i would resist the idea that the decision needs to be either fitting the schema or combatting its dominance. rather, i argue that it is necessary to operate on both levels. people's desires to have genetically related children and to undergo fertility treatments should be protected by offering such treatments and making sure that they are considered a high priority even during health emergencies. this entails for instance providing detailed and transparent information regarding the reasons why treatments ought to be suspended, and open them to scrutiny from patients and the lay public. it entails also making decisions that are proportionate and that consider the costs of suspending these treatments for patients. lastly, it entails providing psychological support to people on the waiting list and mitigating the negative effects that suspensions may have on them. at the same time, it is important to critically engage with oppressive social norms and with the material conditions that sustain them. this cannot be done in a short period of time and on the shoulders of fertility patients. it is a long processes that entails questioning the predominance of the genetic tie and the value that it is attributed to it; promoting other ways of family formations; supporting individuals and couples who opt for these alternatives with legal, economic and social means; and counselling sub-fertile couples in ways that open up alternatives that are not necessarily medically assisted. but all this should be complementary to offering material and moral support to people who are currently experiencing sub-fertility. this truly is essential. asrm, . asrm issues new guidance on fertility care during covid- pandemic: calls for suspension of most treatments the covid- pandemic and health inequalities guidance for the care of fertility patients during the coronavirus covid- pandemic shaping future children: parental rights and societal interests ectogenesis and gender-based oppression: resisting the ideal of assimilation a statement from eshre for phase -guidance on fertility services during pandemic thousands lose last hope of having a baby as lockdown closes ivf clinics. the observer haslanger, s. resisting reality: social construction and social critique how coronavirus is impacting cancer services in the uk on having an own child: reproductive technologies and the cultural construction of childhood marital stability and repartnering: infertility-related stress trajectories of unsuccessful fertility treatment infertility and moral luck: the politics of women blaming themselves for infertility should fertility treatment be state funded american society for reproductive medicine urges suspension of fertility treatments because of coronavirus delay in ivf treatment up to days does not affect pregnancy outcomes in women with diminished ovarian reserve what is the value of three-parent ivf key: cord- -xa x authors: nazari, nabi; sadeghi, masood; ghadampour, ezatolah; mirzaeefar, davod title: transdiagnostic treatment of emotional disorders in people with multiple sclerosis: randomized controlled trial date: - - journal: bmc psychol doi: . /s - - - sha: doc_id: cord_uid: xa x background: multiple sclerosis (ms) is a neurodegenerative disease of the central nervous system. ms is significantly associated with a high rate of psychological, behavioral, and emotional consequences. despite the frequent mental disorders, high rate of psychological comorbidities, and emotional problems in people with ms (pwms), these conditions are often underdiagnosed and undertreated. this study aimed to examine the efficacy of a group format of the unified protocol for the transdiagnostic treatment of emotional disorders in adult pwms associated with an emotional disorder. methods: seventy adult pwms were randomized using an internet-based computer system to either the unified protocol (n = ) or treatment as usual condition. the assessment protocol included semi-structured clinical interviews and self-reports evaluating diagnostic criteria, depression, anxiety and worry symptoms, emotional dysregulation, and affectivity. results: the parametric test of analysis of covariance, followed the intent to treat analyses, revealed the unified protocol significantly changed depression symptoms (cohen’s d = . ), anxiety symptoms (cohen’s d = . ), worry symptoms (cohen’s d = . ), emotion dysregulation (cohen’s d = . ), positive affect (cohen’s d = . ), and negative affect (cohen’s d = . ) compared with the control group. the unified protocol also significantly improved outcome scores at the end of treatment relative to baseline (p < . ). conclusion: the findings support that the unified protocol could be an additional efficient psychological treatment for pwms. trial registration irct, number: irct n . registered october , https://en.irct.ir/user/trial/ /view. and emotional dysregulation were the most potent predictors that have predictive accuracy for suicidal ideation as many as % [ ] . this neurological disease that affects the limbic system will induce emotional disturbances. also, comorbidity has an additive adverse effect on patients' mental quality of life and is associated with an increased risk of debilitating complications, further increasing disease burden. for instance, during the ms, risk-related behaviors may expose an individual to various problematic environmental agents [ ] . despite the frequent mental disorders, comorbidities, and emotional problems in pwms, these conditions are often underdiagnosed and undertreated [ ] . several reasons for this underdiagnosed condition have been documented. in a neurologic setting, evidence highlights the weakness of the dsm criteria application [ ] . also, the ms syndrome's heterogeneous nature and the potential for confusing specific somatic complaints of ms (e.g., fatigue) with depression symptoms may lead to falsely elevated underdiagnoses rates. moreover, disorder-specific interventions and treatments based on primary and secondary diagnoses are not suggested to be effective with complex cases [ ] . furthermore, disorder-specific protocols can be difficult to justify when the clinical reality is complex, and comorbidities are the norm, particularly in chronic somatic disease (e.g., ms) [ ] . cognitive behavioral therapy (cbt) programs have demonstrated effectiveness in promoting mental health in pwms for treating depression [ ] . nevertheless, effective treatments for anxiety are lacking [ ] . recent findings have shown that cbt was less efficient than other interventions in the psychological treatment of pwms [ ] . transdiagnostic and integrated therapies have emerged as recommended approaches for the treatment of several co-occurring mental health disorders, as they provide a more parsimonious [ ] and more efficient strategy to working with comorbid presentations [ ] . some studies have suggested that a transdiagnostic treatment approach for pwms can be appropriate [ ] . transdiagnostic approaches refer to identifying the etiology and maintenance mechanisms that are common in multiple disorders [ ] . in emotional disorders, neuroticism has been considered a key etiology mechanism shared by all emotional disorders [ ] . other mechanisms identified have been rumination, suppression, anxiety sensitivity, and misappraisal [ ] , frequently reported in pwms [ ] . these mechanisms can increase or maintain persistent negative emotions and may affect physical and psychological functioning. from this perspective, transdiagnostic treatment consists of techniques that serve to target an identified set of underlying core processes [ ] . emotion regulation seems to play a critical role in the treatment of complex cases, diagnoses with a combination of psychological risk factors, or comorbidities [ ] . pwms experience higher rates of negative emotions related to different situations such as support family members, body image, pregnancy worry, uncertainty about the relationship, and sexual dysfunction [ , ] . the unified protocol is a cbt transdiagnostic emotion-focused skill-based therapy [ , ] . the unified protocol has been manualized to be applied to the treatment of anxiety disorders, depression, and other emotional disorders in which emotion dysregulation is a core component [ ] . the protocol has been adopted in to sessions in a group format [ ] . numerous studies have supported the efficacy of the unified protocol in improvements on anxiety and depression symptoms, functional impairment, and well-being [ , ] chronic diseases [ ] , and social, job, and general performance [ ] . the unified protocol is equally effective as gold-standard specific disorder protocols for individuals with comorbid emotional disorders [ ] . regarding the prevalence of emotional disorders, high comorbidities, frequent emotional problems, and the high prevalence of the riskybehaviors during the ms [ ] , the application of unified protocol, as an emotion-focused, skill-based intervention, could be beneficial through targeting emotion regulation mechanism, improvement emotional disorder comorbid conditions, and temperamental changes concerning neuroticism. however, there is a lack of empirical evidence on the unified protocol and ms. the purpose of the study was to examine and develop the efficacy of a group format of the unified protocol for adult pwms with depression or anxiety symptoms. we hypothesized that at post-intervention, treatment group participants would show significant improvements in measure of depression, measures of anxiety and worry, the measure of emotion regulation, and the measure of affectivity relative to the treatment-as-usual (tau) group. also, we hypothesized that treatment group participants would demonstrate significantly improve on dependent variable scores compared with baseline at post-intervention. the consort diagram is illustrated in fig. exclusion criteria included (a) present or history diagnosis of schizophrenia, psychosis, or organic mental disorder, (b) other chronic physical illnesses, (c) pregnancy or breast-feeding, (d) risk or history of threatening behaviors, (e) missed three consecutive sessions (f ) receiving psychological or psychiatric treatments during the study (e.g., antidepressant or anxiolytic medication), (g) moderate to high cognitive impairment or physical disabilities. structured clinical interview for dsm-iv axis i disorders [scid i-iv: , ] was used in the current study. the diagnosis was moderate to good (kappa coefficient higher than ( . ). most interviewees and interviewers reported the desirable implementation of the local version of scid-i. kappa was higher than . for all the diagnoses except for generalized anxiety disorders. the kappa was above . in most of the diagnoses, and in half, it was above . , indicating acceptable reliability the hospital anxiety and depression scale [hads : ] . the hads is a highly reliable screening measure for assessing anxiety and depression in pwms. the hads consists of -items, two sub-scales, -items for anxiety (hads-a), and seven items for depression (hads-d). a suggested cutoff score of demonstrated high sensitivity ( %) and specificity ( %) for the anxiety subscale and high sensitivity ( %) and specificity ( %) for the depression subscale [ ] . this scale demonstrated acceptable reliability in this study (α = . ). difficulties in emotion regulation scale [ders : ] . the ders is a -item, self-report questionnaire that measures overall difficulties in emotion regulation. the ders consists of six subscales: ( ) no acceptance of emotional responses, ( ) difficulties engaging in goal-directed behavior, ( ) impulse control difficulties, ( ) the lack of emotional awareness, ( ) limited access, and ( ) lack of emotional clarity. respondents rated their emotional state on (almost never) to (almost always). the total score range of - . a recent study has found that a ders total score above identified a clinical sample [ ] . ders has high internal consistency (α = . ). internal consistency in the current study was acceptable (α = . ). the positive and negative affect schedule [panas : ] . the panas is a brief self-report scale that determines positive and negative affects with two independent ten descriptors. the panas demonstrates the two core dimensions of mood positive affect (pa) and negative mood affect (na). each item is rated on a five-point scale with a range from very slightly ( ) to extremely ( ), indicating the extent that the participant has experienced that feeling over the past month. the panas has shown highly internally consistent, largely uncorrelated positive affect ( . ) to negative affect ( . ), whereas the discriminant correlations are quite low [ ] . internal consistency in the current study was acceptable (α = . ). penn state worry questionnaire [pswq : ] . the pswq is a -item self-report measure that determines an individual's tendency to worry and intensity and excessiveness of worry on a scale of (not at all typical of me) to (very typical of me). the pswq has demonstrated reliable psychometric properties, suitable internal consistency, and test-retest reliability in the local ms population. this measure is suggested for transdiagnostic approach assessments. internal consistency in the current study was acceptable (α = . ). the study was a single-blind, parallel randomized controlled trial comparing psychological intervention group, based on the unified protocol, with a tau control group. the study, including all assessments and treatments, was conducted at the ms clinic, located within the ms centre. the study's methods and procedures were reviewed and approved by the institutional human research ethics committee and the national institute for medical research and development, prospectively. "we used the consort checklist and the tidier checklist when writing our report (see additional file ). " first, interested pwms were notified about the study's goals, benefits, and risks, session numbers, randomization, and group allocation chance through telephone or face-to-face interviews. only who gave verbal informed consent to participate in the study were asked to present their physician agreement or refer to the study participation. the neurologists and clinical psychologist evaluated physician agreements, referrals, medical documents for recent medication prescriptions, and examined the subjects. the eligibility criteria are related to medical conditions obtained; the participants completed the assessment protocol. individuals who met the scid-i-iv criteria for depression or anxiety disorders were requested to sign the consent form. all participants obtained a signed written consent form. at last, only consented subjects who received a valid depression or anxiety diagnosis were selected for randomization. the outcomes were assessed at two timepoints: time : pretreatment to pre-allocation includes baseline, time : immediate after intervention: posttreatment assessment. the sample size for analysis of covariance (ancova) was conducted using g*power . analysis [ ] . a priori power analysis was conducted, using an alpha of . , a power of . , and medium to large effect size (cohen's f = . ) to determine the sample size. according to g*power, the desired total sample size was . therefore, participants recruited, allowing for a % loss of data (dropping out prior treatment, end treatment assessment). randomization was performed using a computer-generated sequence (www.rando mizer .org). a list of anonymous participant identification numbers was used to randomly allocate participants to treatment or control without any restrictions. an independent statistician performed new randomization after each -participants allocated. the concealed was disclosed at the end of the study. the independent statistician carried out the randomization and informed the patients and the monitoring board about the allocation. to masking condition assisting, participants were instructed not to disclose any information about the intervention and diagnostic status. psychological evaluators, data collectors, assessors, and statistic investigators were blinded to the intervention, participants' group, and pervious diagnostic status. the program and sessions were structured based on the latest comprehensive published manual developed by barlow and colleagues [ ] [ ] [ ] . group therapy consists of weekly -h sessions. the treatment content is included topics about motivation, psychoeducation, mindfulness, cognitive flexibility, emotion-driven behavior, and emotional avoidance, interoceptive exposure (ie), in vivo exposure, and relapse prevention. the summary of each module content and intervention schedule is demonstrated in table . (see additional file for the more detailed description.) the control group received the tau that consists of weekly two hour sessions. the program included psychoeducation and life-long ms considerations ( sessions), sharing experiences ( sessions), and marital and parental counseling ( sessions). this treatment could be considered as a psychoeducation intervention routine medical and psychological evaluations were accomplished before all activities (e.g., assessments, interviews, and treatment sessions). regarding safety, the medical health care staff included two physicians and four experienced nurses also alerted in case of emergency conditions during all activities. the followup phase coincided with a viral epidemic. therefore, in order to ensure the safety of participants, no follow-up was performed. all analyses were conducted with spss software version (version , spss inc., chicago, il), two-tailed with an alpha level of . to determine statistical significance, following an intention-to-treat (itt) analysis approach. with the itt approach, study participants are analyzed as members of the treatment group to which they were randomized regardless of their adherence to, or whether they received, the intended treatment. given that the analysis was based on itt principles, the data for all randomized individuals were included in the final report. to handle missing data, the last provided data (the last observation-carried-forward (locf) were considered as a next point for dropping data. an independent t-test was conducted to explore whether the participant was equivalent at baseline (time ). the parametric test of analysis of covariance (ancova) was conducted to compare the effectiveness of the unified protocol intervention and tau at post-treatment (time ). the scores on the baseline are treated as a covariate to control for pre-existing differences between the groups. preliminary checks were conducted to ensure no violation of the assumptions of normality, linearity, homogeneity of variances, and homogeneity of regression slopes. levene's test was used to determine normality and homogeneity of variance. also, the homogeneity of regression slopes assumption was tested. a paired t test was conducted for all measures between (time -time ) to investigate within groups' changes. the within-group effect size was calculated for both groups. effect sizes are reported as partial eta squared. standardized effect size cohen's d was calculated for pre-post treatment changes based on means and standard deviations [ ] . effect size estimates were interpreted conservatively, with . , . , . , reflecting small, medium, and large treatment effects, respectively. there were no significant differences in terms of demographic features, age, duration, education, and other dependent variables at baseline (see table ). there was no significant difference between participants with depressive disorders and participants with anxiety disorders in the study (χ = . , p = . ). the unified protocol participants' ages ranged from to years, with a mean of . years (sd = . ). the tau participants' ages ranged from to years, with a mean of . years (sd = . ). seven ( %) from the unified protocol group left the experiment before time . on average, participants had a very high degree of adherence and protocol well tolerated; ( %) of the unified protocol group completed the treatment sessions and completed all the post-treatment measures. also, ( %) of the tau group dropped out at post-treatment. finally, ( %) of all participants completed the study. a one-way between groups ancova was conducted to assess the impact of the unified protocol of reported all measures. the ancova assumptions were examined before submitting the test results. the ancova was conducted on hads-d. the results showed a significant main effect for group, f( , ) = . , p < . , η p = . , and cohen's d = . . for the group, the unified protocol significantly less hads-d scores than tau. the adjusted post-treatment mean for the unified protocol group (m = . ) was significantly less than that for the tau group (m = . ). anxiety treatment results the ancova results showed a significant main effect for group, f( , ) = . , p < . , η p = . , and a cohen's d = . . for groups, the unified protocol significantly less hads-a scores than tau. the adjusted post-treatment mean for the unified protocol group (m = . ) was significantly less than that for the tau group (m = . ). emotion dysregulation treatment results the ancova was conducted on ders. the results showed a significant main effect for group, f( , ) = . , p = . , η p = . , and a cohen's d = . . for the group, the unified protocol significantly lower ders scores than tau. the adjusted post-treatment mean for the unified protocol group (m = . ) was significantly less than that for the tau group (m = . ). affectivity treatment results the ancova was con- a paired t test was carried out to examine treatment effectiveness between time and time . these findings revealed the unified protocol had a significant effect on symptom improvement (see table ). means and standard deviations were calculated at time and time (see table ). there were no adverse events associated with this trial. a comparison test between time and time revealed no significant differences for the tau group. the scid-i -iv demonstrated of participants in the unified protocol group ( %) no longer met the diagnostic criteria for their principal diagnosis at the end of the study. the scid-i-iv demonstrated no worse condition for all participants at time . ms is associated with a broad array of emotional disorders, negative symptoms, social interference, and physical disability that compromise well-being [ ] . this study aimed to examine the efficacy of a group format of the unified protocol for the transdiagnostic treatment of emotional disorders and symptoms in adult pwms. our approach was based on the key development of the emotion regulation mechanism outlined in the unified protocol transdiagnostic treatment framework for emotional disorders. the results revealed that pwms, who participated in the unified protocol intervention group, demonstrated significant improvements in depressive and anxiety and worry emotion regulation, and affectivity outcomes at post-treatment compared with those who participated in the tau group. our findings revealed significant changes in depression measure, in anxiety measure, and in worry, in emotion regulation measure, and affectivity measure in the unified protocol group at posttreatment relative to baseline. the results are consistent with studies that indicate the unified protocol is effective in improving emotional disorders [ ] [ ] [ ] . the core modules of the unified protocol are relevant to depression. briefly, negative affect (e.g., sadness, shame, anger) and maladaptive, avoidant reactions to negative affect are targeted in the unified protocol. for example, in emotional disorders, worrying is a critical maladaptive cognitive process contributing ( . ) to the maintenance of the disorder, and worrying can be effectively targeted by promoting adaptive emotion regulation strategies [ ] . pwms focus on the disease consequences, which may be concluded to catastrophizing future, over-estimate threat, and under-estimate their abilities to cope. present-focused emotion, a core module in the unified protocol, helps the patients recognize their thoughts and feelings, and concentrate on the current condition demands, making emotional experiences feel more under control and manageable. the improvement of emotion regulation can be associated with an improvement in depression and anxiety symptoms [ ] . findings revealed significant changes in ders at posttreatment regarding with tau group. this study develops the unified protocol benefits on difficulties emotion regulation scale have improved other clinical outcomes [ ] . also, the results provide supports for the application of emotion regulation in promoting adaptive emotion regulation among people with mental disorders [ ] . in line with our investigation, numerous researches have replicated the emotional regulation implication in the treatment of depression [ ] , anxiety disorders [ ] , excessive worry, and psychological stress [ ] . a large cohen's d in the negative and positive affect was found with a higher significant effect on negative affect than positive affect. these results are the same that previous rct, applying unified protocol in emotional disorders samples that have found changes in neuroticism/negative affect after unified protocol intervention [ ] . some studies have also found differences in extraversion/positive affect [ ] . the reduction in neuroticism scores confirms the unified protocol's theory, an emotion regulation intervention targeting specifically neuroticism/negative affect [ ] , a psychopathology mechanism associated with the etiology of the emotional disorders [ ] . these results suggest unified protocol, which typically focuses on reductions in negative affect, may also improve positive affect. positive affect is a malleable construct and can be influenced by unified protocol. change in positive affect can be potentially associated with improved both psychological and clinical outcomes [ ] . one possible reason could be that unified protocol helps patients understand the relevant function of all range of emotions, including "positive emotions" such as happiness, joy, pride. another possibility could be related to the group format delivery. group therapy facilitates the normalization of ms-related experiences, and sharing with similar people reduces the stigma associated with psychological treatment. the current study could develop the unified protocol as a transdiagnostic approach, consisting of five core modules and practical techniques for addressing different aspects of emotion regulation. emotion dysregulation predicts quality of life, independently of disease severity and cognitive functioning [ ] . moreover, emotional distress associated with maladaptive coping strategies is led to poor well-being rather than disease duration or severity [ ] . for example, emotional problems among mothers with ms negatively associate with the mother's ability to cope with the disease and positively associate with depressive symptoms in their healthy partners [ ] . the unified protocol components, such as psychoeducational courses, emotional skills, and stress self-management techniques can be beneficial to enhance well-being in ms [ ] . awareness of thoughts, beliefs, and interactions facilitates coping in pwms [ ] . interoceptive exposure is another component of the unified protocol. pwms are more sensitive to visceral sensations than healthy individuals [ ] . dysfunctions in interoceptive inference could underlie a range of pathologies such as anxiety [ ] . in pwms, bodily sensations are usually associated with high anxiety. interoceptive exposure may be beneficial and facilitate a controlled coping behavior, and less stress react, gradually [ ] . also, individuals with better interoceptive perception demonstrate greater self-regulatory ability in experimental social interaction [ ] . meta-analytic evidence supports the use of the mindfulness-based intervention in pwms to improve fatigue [ ] . the study revealed surprising findings. there was no significant difference between the participants who received a depressive disorder diagnosis and those who received an anxiety disorder diagnosis at baseline. this finding is contrary to current insight and epidemiologic data in pwms [ ] . this finding is critical because anxiety receives far less attention in ms. ders scores are related to both depression and anxiety levels in the ms sample [ ] . according to ders mean score at baseline, difficulties with emotion regulation is very high in pwms. we investigated the unified protocol's feasibility in a group format to an ms transdiagnostic sample with emotion regulation problems. according to evidence considering that emotion dysregulation is connected with less willingness to participate in psychological trials [ ] , we classified the sample as challenging to treat. according to the treatment retention rate in this study ( %), the treatment was well tolerated. also, the results are in line with the data provided previous trials [ , ] confirm a significant improvement of patients treated in a group format. the results from this trial should be interpreted in the context of several limitations. first, the participants were generally well-educated, which can be enhanced their abilities to gain more the unified protocol and diminish the results' generalizability. a priori power analysis was conducted, using an alpha of . . however, for three primary outcomes variables (hads-a, hads-d, and ders) an alpha of . should have been considered. the next limitation was that the no-follow-up made it difficult to assess prevention effects. one strength point of this study was the scid-i-iv application at enrollment and post-treatment. overall the findings provide the support that the unified protocol could be an additional efficient as a parsimonious, transdiagnostic treatment of emotional disorders for adult pwms. although the results are promising, more research should be conducted to extend the findings obtained in this study. transdiagnostic research has the potential to represent better the clinical and scientific reality of mental health problems, reflecting the complexity and comorbidity that is the norm in clinical practice. the unified protocol is equally effective as goldstandard specific disorder protocols in people without ms. future trials are required to investigate the unified protocol effectiveness, compared with gold-standard specific disorder protocols in the pwms. further studies are required to assess the cost-effectiveness and efficacy of the unified protocol intervention with larger samples to promote it as part of routine care for pwms. economic evaluations can be simultaneously incorporated in future trials, as this has not yet been formally evaluated. there would be value in adding qualitative components into future trials to establish the unified protocol interventions' acceptability for both clinicians and clients. the findings developed the unified protocol as a mechanistically transdiagnostic approach might be applied across multiple disorders. in a unified approach, thoughts, behaviors, feelings, and body sensations are interacting dynamically, and emotional experiences influence each of them. unified protocol transdiagnostic intervention facilitates pwms to learn how to respond to their unpleasant emotions more adaptively. given the negative consequences of anxiety and depression in pwms, interventions such as this may reduce the risk of these adverse outcomes and produce benefits for pwms. the cognitive effects of anxiety and 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regulation and dysregulation: development, factor structure, and initial validation of the difficulties in emotion regulation scale dialectical behavior therapy skills for transdiagnostic emotion dysregulation: a pilot randomized controlled trial development and validation of brief measures of positive and negative affect: the panas scales penn state worry questionnaire statistical power analyses using g*power . : tests for correlation and regression analyses becoming a behavioral science researcher health-related quality of life in multiple sclerosis: temperament outweighs edss treating depressive disorders with the unified protocol: a preliminary randomized evaluation an idiographic analysis of change processes in the unified transdiagnostic treatment of depression applying the unified protocol transdiagnostic treatment to nonsuicidal self-injury and co-occurring emotional disorders: a case illustration • fast, convenient online submission • thorough peer review by experienced researchers in your field • rapid publication on acceptance • support for research data, including large and complex data types • gold open access which fosters wider collaboration and increased citations maximum visibility for your research: over m website views per year • at bmc, research is always in progress. learn more biomedcentral.com/submissions ready to submit your research ready to submit your research ? choose bmc emotion regulation as a transdiagnostic treatment construct across anxiety, depression, substance, eating and borderline personality disorders: a systematic review application of a transdiagnostic treatment for emotional disorders to body dysmorphic disorder: a randomized controlled trial examining emotion regulation as an outcome, mechanism, or target of psychological treatments emotion regulation and depressive symptoms: close relationships as social context and influence emotion regulation and the transdiagnostic role of repetitive negative thinking in adolescents with social anxiety and depression unified protocol transdiagnostic treatment in group format unified protocol for transdiagnostic treatment of emotional disorders: a randomized controlled trial transdiagnostic models of anxiety disorder: theoretical and empirical underpinnings changes in positive affect in cognitive-behavioral treatment of anxiety disorders difficulties with emotion regulation in multiple sclerosis: links to executive function, mood, and quality of life towards a better understanding of ms pain: a systematic review of potentially modifiable psychosocial factors gender-specific differences in the process of coping in families with a parent affected by a chronic somatic disease a systematic review of the effectiveness of self-management interventions in people with multiple sclerosis at improving depression, anxiety and quality of life evaluation of an adjustment group for people with multiple sclerosis and low mood: a randomized controlled trial frequency, type, distribution of pain and related factors in persons with multiple sclerosis interoceptive inference, emotion, and the embodied self mindfulness and interoceptive exposure therapy for anxiety sensitivity in atrial fibrillation: a pilot study the body beyond the body: expectation of a sensory event is enough to induce ownership over a fake hand effects of mindfulness-based interventions on physical symptoms in people with multiple sclerosis-a systematic review and meta-analysis differences in the burden of psychiatric comorbidity in ms vs the general population emotional expression and the decision to seek therapy: the mediating roles of the anticipated benefits and risks transdiagnostic group cbt for anxiety disorders: the unified protocol in mental health services publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations not applicable. supplementary information accompanies this paper at https ://doi. org/ . /s - - - . authors' contributions nn and ms designed the study protocol with important contributions from eg translated the original unified protocol manuals. nn and dm and all their collaborators are in charge of recruiting study participants. all authors contributed in drafted the manuscript. all authors participated in the review and revision of the manuscript and have approved the final manuscript to be published. eg and dm were the study methodologist. eg also contributed to the revision. all authors read and approved the final manuscript. the authors received no financial support for the research, authorship, and/or publication of this article. the data that support the findings of this study are available on request from the corresponding author. the study has been performed in accordance with the declaration of helsinki and has been approved and registered by the ethical and research committees from the following collaborating centers. the study, including all assessments and procedures for the study, was reviewed by the national institute for medical research and development (nimad); prospectively (number: irct n ; registered at octobe , https ://en.irct.ir/user/ trial / /view). all participants provided a signed written consent. not applicable. the authors declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.received: april accepted: october key: cord- -g oes authors: nemzek, jean a.; lester, patrick a.; wolfe, a. marissa; dysko, robert c.; myers, daniel d. title: biology and diseases of dogs date: - - journal: laboratory animal medicine doi: . /b - - - - . - sha: doc_id: cord_uid: g oes historically, the dog played an important role as a laboratory animal in biomedical research. although numbers are declining, the use of dogs continues to be common in pharmacokinetics and cardiovascular studies. the normal biology of the dog as both a laboratory and a companion animal has been well studied and reference values are presented here as a clinical and experimental resource. this provides the necessary background to discuss the spontaneous diseases, including infectious and neoplastic conditions, prevalent in purpose bred as well as random source dogs used in biomedical research. in addition, diseases and conditions that arise secondary to the housing and experimental manipulation of dogs is discussed with emphasis on treatment and prevention. laboratory animal medicine mellitus. a comprehensive but concise review of the use of the dog as a research subject is available in gay ( ) . the breed of dog most commonly bred for use in biomedical research is the beagle. some commercial facilities also breed foxhounds or other larger dog breeds for use in surgical research studies. some specific breeds with congenital or spontaneous disorders have also been maintained by research institutions (see examples below). random-source dogs used in research are most frequently mongrels or larger dog breeds (e.g., german shepherd, doberman pinscher, labrador and golden retrievers) that are used for surgical research and/or training. according to a computerized literature search for "beagle" for the years - , a significant portion of the biomedical scientific publications identified were in the fields of pharmacology or toxicology. especially common were studies focusing on pharmacokinetics, alternative drug delivery systems, and cardiovascular pharmacology. other common areas of research using beagles were dental and periodontal disease and surgery, orthopedic surgery, skeletal physiology, and imaging studies. other research areas that utilized beagles included canine infectious disease, prostatic urology, and ophthalmology. most large-sized dogs (either purpose-bred or randomsource) are used in biomedical research because of their suitability for surgical procedures. anesthetic protocols and systems for dogs are well established and the organs of larger dog breeds are often an appropriate size for trials of potential pediatric surgical procedures. surgical canine models have been used extensively in cardiovascular, orthopedic, and transplantation research. there are also some unique spontaneous conditions for which dogs have proven to be valuable animal models. a colony of gray collies had been maintained at the university of washington (seattle) for the study of cyclic hematopoiesis. this condition is manifested by periodic fluctuations of the cellular components of the blood, most notably the neutrophil population. these dogs can be used to study the basic regulatory mechanisms involved with hematopoiesis, as well as possible treatments for both the human and the canine conditions (brabb et al., ) . golden retrievers affected with muscular dystrophy have been used as models of duchenne muscular dystrophy in human children. duchenne muscular dystrophy is caused by an absence of the muscle protein dystrophin, inherited in an x-linked recessive manner. the dystrophy in golden retrievers is caused by the absence of the same protein and is inherited in the same way. the clinical signs (such as debilitating limb contracture) are also similar between the canine and human conditions (kornegay et al., ) . other genetic disorders studied in dog colonies include hereditary canine spinal muscle atrophy (cork, ) and narcoplepsy in doberman pinschers (ripley et al., ) . bedlington terriers have been used to study copper storage diseases (such as wilson's disease) and the development of spontaneous diabetes mellitus and hypothyroidism has been studied in several breeds of dogs for comparisons with the human conditions. although historically the dog has been a common laboratory animal, their use in research has waned over the past years. according to the u.s. department of agriculture (usda), animal and plant health inspection service ( , ) , the number of dogs used in research has declined from , in to , in (prior to the previous edition of this text) and , in . this decrease was caused by a variety of factors, including (but not limited to) decreased availability, local restrictive regulations, conversion to other animal models (such as livestock or rodents), increased cost, and shift in scientific interest from pathophysiology to molecular biology and genetics. dogs used for research are generally segregated into two classes: purpose-bred and random-source. purposebred dogs are those produced specifically for use in biomedical research; they are intended for use in long-term research projects and/or pharmacologic studies in which illness or medication would require removal from the study. usually these dogs are either beagles or mongrel foxhounds, although other breeds may be available. purpose-bred dogs typically receive veterinary care throughout their stay at the breeding facility. they are usually vaccinated against rabies virus, canine distemper virus, parvovirus, adenovirus type , parainfluenza virus, leptospira serovars canicola, icterohaemorrhagiae, grippotyphosa, and pomona, and bordetella bronchiseptica (jasmin, personal communication). purpose-bred dogs are also usually treated prophylactically for intestinal helminths and ectoparasites, and possibly given a heartworm preventative. random-source dogs are not bred specifically for use in research. they may be dogs bred for another purpose (e.g., hunting and racing) or stray dogs collected at pounds or shelters. the health status of these dogs can be the same quality as purpose-bred dogs, or it can be an unknown entity. random-source dogs that have been treated and vaccinated in preparation for use in research are termed conditioned dogs. these dogs are then suitable for long-term studies or terminal preparations that require unperturbed physiologic parameters. conditioned dogs are often tested for heartworm antigen because of the implications that infestations can have on cardiovascular status and surgical risk. nonconditioned random-source dogs are useful only in a limited number of research studies, such as nonsurvival surgical training preparations and tissue/organ harvest. options for procurement of dogs for biomedical research typically include purchase from a usdadesignated class a or class b licensed dealer or directly from a municipal pound. the requirements for usda licensure are detailed in code of federal regulations (cfr), title , chapter ( - - edition), subchapter a, animal welfare, . definitions, and . requirements and application (office of the federal register, ) . briefly, class a licensees are breeders who raise all animals on their premises from a closed colony. class b licensees purchase the dogs from other individuals (including unadopted animals from municipal pounds) and resell them to research facilities. there are additional regulations that apply to class b dealers (such as holding periods and record-keeping documentation) because of the public concern that stolen pets could enter biomedical research facilities in this manner. in december , the national institutes of health (nih) issued notice not-od- - entitled notice regarding nih plan to transition from use of usda class b dogs to other legal sources (national institutes of health, ) . this nih policy begins in the fiscal year and prohibits the procurement of dogs from class b dealers using nih grant funds. from that point forward, dogs on nihfunded studies will have to be obtained from class a vendors, privately owned colonies (such as institutional breeding colonies), or client-owned animals (e.g., animals participating in veterinary clinical trials). the best resource for identification of possible vendors are online 'buyer's guide' sites or 'buyer's guide' issues of trade periodicals. online sites include the buyer's guide of the american association of laboratory animal science (http://laboratoryanimalbuyersguide.com), and the trade journals lab animal (http://guide.labanimal. com) and animal lab news (http://www.alnmag.com/ content/buyers-guide). a 'buyer's guide' typically lists sources for both purpose-bred and random-source dogs, and denotes such features as pathogen-free status, health status, and availability of specific breeds and timed pregnant females. some suppliers also have separate advertisements within issues of the journals. federal regulations promulgated by the animal and plant health inspection service, usda, in response to the animal welfare act ( cfr . , . , and . [g] ) are described in cfr chapter ( - - edition), subchapter a, animal welfare (office of the federal register, ) . regulations pertaining specifically to the care of dogs used in research are found in subpart a, specifications for the humane handling, care, treatment, and transportation of dogs and cats of part (standards) of subchapter a. particular attention should be paid to section . c (primary enclosures-additional requirements for dogs) because the space required for housing dogs is calculated using body length rather than weight (a parameter used for other species and also for dogs in the national research council (nrc) guidelines). section . (exercise for dogs) describes the requirements that dealers, exhibitors, and facilities must follow in order to provide dogs with sufficient exercise. the institute for laboratory animal research (ilar) has written the guide for the care and use of laboratory animals (national research council, ) . the 'guide' is the primary document used by institutional animal research units to develop their programs and by animal care evaluation groups, such as the association for assessment and accreditation of laboratory animal care international (aaalac international), to facilitate site visits and inspections. the primary difference between the th and th editions of the 'guide' (national research council, regarding the care of dogs is the notation that "enclosures that allow greater freedom of movement and unrestricted height (i.e., pens, runs, or kennels) are preferable." the ilar committee on dogs authored dogs: laboratory animal management (national research council, ) . this publication describes "features of housing, management, and care that are related to the expanded use of dogs as models of human diseases" and includes "an interpretive summary of the animal welfare regulations and the requirements of the public health service policy on humane care and use of laboratory animals." the reader is encouraged to use these publications to obtain further information on care and husbandry of dogs in the biomedical research setting. the information presented in the tables represents a range of normal values that can vary depending on the analytical method, as well as the age, breed, and sex of the animal. cohen, covance laboratories, inc., cumberland, va ( ) . physiological data for a mixed population of dogs of both sexes. fig. . demonstrates the normal weights and corresponding ages for both male and female beagle and hound dogs. tables . and . feature hematology data from beagles of both sexes from two commercial facilities. tables . and . list serum chemical data for beagles of both sexes from two commercial facilities. representative blood gas, coagulation data, and normal urinalysis parameters can be found in tables . - . , respectively. finally, the reviews in arterial and venous blood gas anaylses (rieser, ) and the manual of canine and feline cardiology (tilley et al., ) are excellent resources. good nutrition and a balanced diet are essential to the health, performance, and well-being of the animal. the nrc of the united states national academy of sciences is the leading provider of nutrient recommendations for dogs and provides average requirements needed to maintain growth and prevent deficiencies (subcommittee on dog and cat nutrition, ) . the nrc publications form the basis for the association of american feed control officials (aafco) nutrient profiles, which are updated periodically (baldwin et al., ) . the aafco is an advisory body comprising state representatives from across the united states. it provides a mechanism for developing and implementing uniform and equitable laws, regulations, standards, and enforcement policies, and establishes nutrient profiles for cat and dog foods (dzanis, ; thatcher et al., ) . additional resources should be consulted for details on the nutritional requirements for dogs of all ages (dzanis, ; subcommittee on dog and cat nutrition, ; baldwin et al., ; thatcher et al., ; hand et al., ) . recommendations for feeding the appropriate amount of diet are determined by the dog's metabolic requirements. the maintenance energy requirement (mer) is the amount of energy used by a moderately active adult animal in a thermoneutral environment. the mer for most breeds may be calculated using the following equation: mer (metabolizable kcal/day) = bw × . × kj de, where bw = body weight (kg), kj = kilojoules, de = digestable energy (kienzle and rainbird, ) . in-depth overviews of diets used in biomedical research are available in diet-specific literature. open-formula diets have defined concentrations of all ingredients and the information is publicly available. this allows researchers to control for this important environmental variable and enables retrospective analysis of possible diet composition effects on research results (barnard et al., ) . open-formula diets occasionally may require changes in formulation to maintain nutrient composition or meet changing nutrient requirements. these changes in quantitative ingredient formulation are made public when open-formula diets are modified. in contrast, closed-formula diets are commercially available, balanced diets that meet and label the minimum requirements for protein and fat and the maximum values for ash and fiber; however, the exact composition of ingredients may vary from batch to batch. ingredient composition varies as the manufacturer applies a leastcost strategy, referring to formulating diets to maximize profit by using the least-expensive ingredients. although the ingredients are listed, the quantitative ingredient formulation is not publicly available and can vary without public disclosure, due to proprietary nature of commercial diets produced and marketed under vendor trade names. closed-formula diets have also been referred to as as 'fixed formula' or 'constant nutrition' (labdiets, pmi nutrition international, st. louis, missouri) by manufacturers (barnard et al., ) . in fixed-formula diets, the quantitative ingredient formulation does not change; however, this information is proprietary and therefore laboratory animal medicine not disclosed publically (barnard et al., ) . semipurified and purified diets provide the strictest control of ingredients and are formulated from purified components: amino acids, lipids, carbohydrates, vitamins, and minerals. although purified and semipurified diets do differ in the types of ingredients used, the terms are generally used to mean the same thing. purified-ingredient diets are generally 'open' formulas, meaning that they are published and available to the scientific community. the animal care provider should be aware of the manufacture date of the diet, which should be clearly visible on the bag. as a general rule, diets are safe for consumption up to months following the manufacture date when stored at room temperature. refrigeration may prolong the shelf-life, but the best strategy is to feed only fresh diets and use each lot based on the date of manufacture. specifications for feeding and watering of dogs are provided in the regulations of the animal welfare act. management of a breeding colony requires broad knowledge of the dog's anatomy, reproductive physiology, and behavioral needs during breeding, gestation, and parturition. although a comprehensive discussion of the biology of canine reproduction is beyond the scope of this chapter, essential features of the broad topics noted above are presented. from dr. asheley wathen, covance laboratories, inc., madison, wi, and dr. kimberley cohen, covance laboratories, inc., cumberland, va ( ) . overall health, body condition, nutrition, and age greatly influence reproductive efficiency (gavrilovic et al., ; johnson, ) . therefore, only normal, healthy animals in excellent body condition should be used in breeding programs. beagles between and . years of age have the best conception rates and litter size with the lowest neonatal mortality. after years of age, conception rates and litter size decline and neonatal mortality increases (johnson, ) . the vagina is a long, musculomembranous canal that extends from the uterus to the vulva. during physical examination, the gloved finger or examination instrument should be introduced through the dorsal commissure of the vulva, avoiding the deep ventral clitoral fossa. examination should proceed at an angle of approximately ° until the instrument or fingertip has passed over the ischial arch, after which it can be directed further craniad toward the cervix. the uterus consists of the cervix, uterine body, and uterine horns. the cervix is an abdominal organ, located approximately halfway between the ovaries and the vulva. when the bitch is in proestrus and estrus, the cervix can be distinguished during abdominal palpation as an enlarged, turgid, walnut-shaped structure. female dogs are monoestrous, typically nonseasonal, spontaneous ovulators that have a spontaneous luteal phase approximately days longer than the ± days of pregnancy followed by obligate anestrus. puberty (beginning of the first estrus) occurs between and months in most breeds. the time of onset positively correlates with the body size (concannon, ) . the canine cycle is divided into four phases: proestrus, estrus, diestrus, and anestrus. the duration of laboratory animal medicine proestrus is - days with an average of days and reflects the follicular phase rise in estrogen. during this stage, the vulva is enlarged and turgid, and a serosanguinous vaginal discharge is present (concannon, ) . estrus may be from to days in duration but generally lasts days. the endocrine feature of estrus is the first abrupt increase in progesterone (> ng/ml), which occurs concomitantly with the luteinizing hormone (lh) surge % of the time, followed by ovulation within - h. the vulva is softer and smaller than in proestrus. the vaginal discharge persists and may remain serosanquinous or become straw colored. diestrus begins approximately days after the onset of standing heat. the end of this stage is days later, which would be coincident with whelping if the bitch had become pregnant. defined behaviorally as starting when estrous behavior ceases (concannon, ) , diestrus represents the peak of serum progesterone. anestrous may last from to days and is the stage of reproductive quiescence. it is characterized by an absence of ovarian activity and serum progesterone levels of less than ng/ml. the onset of puberty in the male ranges from to months of age and is affected by breed, season, nutrition, and disease status. this process is initiated by the secretion of lh from the anterior pituitary, which stimulates the production of testosterone by the interstitial or leydig's cells. at this time, the testicular growth is rapid, the seminiferous tubules begin to differentiate, and sertoli cells form the blood-testis barrier. secretion of follicle-stimulating hormone (fsh) by the anterior pituitary stimulates the production of other key hormones by the sertoli cells, including, inhibin, androgen binding protein, and estrogen. fsh stimulates spermatogenesis in the presence of testosterone, whereas inhibin and estrogen provide negative feedback to the pituitary gland to decrease fsh production. spermatogenesis in the dog is completed in days, with subsequent maturation of sperm occurring in the epididymis for approximately days. thus, the entire process from the initiation of spermatogonial mitosis to the delivery of mature sperm to the ejaculate is days. a breeding soundness exam should be conducted to assess the probability of a male dog's successful production of offspring. factors affecting male fertility include libido, ability to copulate, testicular size, and quality semen production. supression of sexual behavior and problems with libido may occur in dogs due to early weaning, isolation, or inherited abnormalities. animals with poor hind limb conformation or trauma to the back may be unable to properly mount the female. there is a positive correlation between scrotal circumference and the number of sperm produced. finally, the quality of sperm is assessed by motility, morphology, volume, and concentration. an ejaculate ( ml) that contains approximately million progressively motile sperm without significant morphological abnormalities is a good indicator of normal male fertility. complete anatomy of the bitch and dog can be found in miller's anatomy of the dog (evans and de lahunta, ) . cells of the vaginal epithelium mature to keratinized squamous epithelium under the influence of estrogen. because of the rise in estrogen throughout proestrus, with peak levels occurring just prior to the onset of standing heat, the vaginal smear can be used as an indicator of the bitch's readiness for breeding. the smear will not confirm the presence of ovulation nor is it of prognostic value in normal bitches during anestrus. the percentage of vaginal epithelial cell cornification is an index of estrogen secretion by the ovarian follicles. cornification occurs approximately days prior to the estrogen peak and days prior to standing heat. as cornification of vaginal epithelial cells proceeds, the cells become larger, with more angular borders. the nuclear/ cytoplasmic ratio decreases until the nuclei reach a point where they no longer take up stain (coincident with the onset of estrus). the cells appear 'anuclear' and are classified as 'cornified' or 'anuclear squames.' the vaginal cytology smear of the bitch changes from predominantly cornified to noncornified days after ovulation. the day of this change is the first day of diestrus. other epithelial cell types noted on vaginal cytology include superficial cells (large, angular cells with small nuclei); intermediate cells (round or oval cells with abundant cytoplasm and large, vesicular nuclei); and parabasal cells (small round or elongated cells with large, well-stained nuclei, and a high nuclear/cytoplasmic ratio). based on vaginal cytology, the estrous cycle is classified as follows: although vaginal cytology is a useful tool, observation of behavioral estrus is the best criterion to use in breeding management. during proestrus, the male is attracted to the bitch and will investigate her hindquarters, but she laboratory animal medicine will not accept breeding. estrus is characterized by proactive receptivity to mounting by males and increased male-seeking behavior (concannon, ) . during this stage, the bitch will exhibit 'flagging,' or elevation of her tail with muscular elevation of the vulva to facilitate penetration by the male. in order to maximize the conception rate and litter size, it is recommended to breed the bitch on days , , and of the standing heat. due to the long life span of canine sperm, fertilization occurs in the oviduct up to days after coitus. the ovulated oocyte is a primary oocyte that must undergo two meiotic divisions before fertilization can occur. this overall maturation process takes approximately days. after maturation, the oocyte remains viable for - days. optimal conception rates tend to occur when the bitch is bred from days before to days after ovulation; best litter size is achieved when the bitch is bred days after ovulation. implantation is evident by areas of local endometrial edema - days after breeding. there is no correlation between the number of corpora lutea and the number of fetuses in the corresponding uterine horn, suggesting transuterine migration of embryos. the dog has endotheliochorial placentation. the endothelium of uterine vessels lies adjacent to the fetal chorion, mesenchymal, and endothelial tissues, so that maternal and fetal blood are separated by four layers. the canine placenta is also classified as zonary, indicating the placental villi are arranged in a belt, and deciduate, reflecting that maternal decidual cells are shed with fetal placentas at parturition. the length of gestation is - days. luteal progesterone is responsible for maintaining pregnancy and canine corpora lutea retain their structural development throughout gestation. serum progesterone rises from less than ng/ml in late proestrus to a peak of - ng/ml during gestation, and then declines to - ng/ml just prior to parturition. progesterone is essential for endometrial gland growth, secretion of uterine milk, attachment of the placentas, and inhibition of uterine motility (johnson, ; verstegen-onclin and verstegen, ) . pregnancy detection can be performed by several methods. abdominal palpation of the uterus may be most informative at approximately days after breeding. the embryos and chorioallantoic vesicles form a series of ovoid swellings and are approximately inches in length at - days. by day , the uterus begins to enlarge diffusely and the vesicles become difficult to identify by palpation. radiology can be used to confirm pregnancy and facilitate determination of gestational age, beginning days after the lh surge (lopate, ) . bitches in which a difficult whelping is anticipated should be radiographed in late pregnancy to determine the litter size and to evaluate the size of the fetal skulls in relation to the bony maternal birth canal. ultrasonography can be used to confirm pregnancy beginning on days - , at which point the gestational sacs will be approximately cm in diameter, and until parturition (shille and gontarek, ; lopate, ) . ultrasonography can assess fetal viability by visualizing fetal heartbeats and fetal movement beginning on gestational days - and , respectively (lopate, ) . it can also predict gestational age using the inner diameter of the chorionic cavity in early pregnancy and the biparietal diameter in late pregnancy luvoni and beccaglia, ) . however, ultrasonography for determination of gestational age is most accurate at day of pregnancy when using correction factors for small (< kg) and large (> kg) body weight dogs (kutzler et al., ) . thermal support should be provided prior to parturition. dogs housed on grated flooring should be provided with mats and those on solid floors would benefit from blankets placed in a corner of the primary enclosure. shavings are discouraged because they may adhere to the umbilical cord and predispose to ascending infections. heat lamps may be placed h prior to parturition and remain until all neonates demonstrate vigorous suckling behavior. however, the use of heat lamps necessitates strict supervision in order to prevent thermal burns. if possible, whelping bitches should be housed in a quiet corridor in order to decrease periparturient stress, especially in primiparous or young mothers. monitoring of parturition is important, but human intervention should be minimal in order to prevent stressinduced cannibalism. an abrupt drop in body temperature to less than °f indicates impending parturition within - h. the process of parturition has been divided into three stages. stage of labor lasts - h and is characterized by uterine contractions and cervical dilation. during this stage, the bitch may appear restless, nervous, and anorexic. other common clinical signs include panting and increased pulse rate (johnson, ) . fetal expulsion occurs during stage , which lasts approximately - h. as the fetus engages the cervix, there is release of oxytocin, referred to as the ferguson reflex, which strengthens the uterine contractions and may elicit abdominal contractions as well. the bitch is able to inhibit this stage of labor if disturbed. the chorioallantois ruptures either during passage of each neonate through the birth canal or by the bitch's teeth at birth. interestingly, posterior presentation is common in dogs but does not predispose to dystocia. the time interval between deliveries of each pup is irregular, but the average is less than h between pups. veterinary assistance laboratory animal medicine is necessary if the bitch remains in stage for more than h without delivering the first pup, or for more than h before delivering subsequent pups. during stage of labor, the placentas are expelled either immediately or within min of delivery of each pup. if two pups are delivered from alternate uterine horns, then the birth of both puppies may precede expulsion of the respective placentas. the bitch will lick the newborn vigorously to remove the membranes from its head and to promote respiration. she will also sever the umbilical cord. the bitch may ingest the placentas, although they confer no known nutritional benefit and may induce a transient diarrhea. the peripartum use of oxytocin is required only in the event of uterine inertia, stillbirths, or agalactia. oxytocin should not be used in the event of systemic illness or abnormalities precluding vaginal delivery. indications for its use include lack of delivery h after onset of stage labor, greater than h of unproductive stage labor, inadequate contractions, or abnormal vaginal discharge. in these cases, radiographs are recommended to assess fetal size in relation to the birth canal and any possible obstructions, followed by . - . iu of oxytocin intramuscularly or subcutaneously. the oxytocin can be repeated - min after the first dose for a total of two doses (plunkett, ) . in some cases, treatment with . - . ml/kg of % calcium gluconate, delivered slowly iv while monitoring closely for bradycardia, and % dextrose iv may be indicated. uterine involution occurs during anestrus within - weeks of parturition. during this time, a greenish to red-brown vaginal discharge, or lochia, is considered normal. the presence of an odiferous, purulent discharge, accompanied by systemic signs of illness, indicates metritis or pyometra. desquamation of the endometrium begins by the th postpartum week, with complete repair by months. newborn puppies are easily sexed by examination of the anogenital distance. in female puppies, the vulva is evident a short distance from the anus, whereas the prepuce of male puppies is nearly adjacent to the umbilicus. eyes are open at approximately days, and ears are patent at approximately - days. solid food can be introduced between . and weeks of age, and puppies can be weaned at - weeks. artificial insemination (ai) is indicated when the male is physically incapable of mounting or penetrating the bitch, when there are vaginal abnormalities such as a vaginal-vestibular stricture, narrow vagina, vaginal septum, and vaginal hyperplasia, or if there is a behavioral incompatibility between the male and female dogs (kutzler, ) . semen is collected using a plastic centrifuge tube and rubber latex artificial vagina. the male is introduced to the scent of an estrous bitch and manually stimulated. the first two fractions are collected followed by a sufficient amount of the third fraction (predominantly of prostatic fluid) to bring the total semen volume to - ml. the semen can be introduced into the cranial vagina or directly into the uterus either through trans-cervical catheterization with a norwegian ai catheter or utilizing fiberoptic endoscopy. use of the norwegian ai catheter for intrauterine insemination of frozen-thawed, fresh, and chilled-extended semen results in significantly higher whelping rates than intravaginal insemination (linde-forsberg et al., ; thomassen and farstad, ) . for trans-cervical insemination, the bitch is either standing on all four legs or standing with hindquarters raised. the ai catheter and guiding tube are inserted into the vestibulum as far as the pseudocervix. firm abdominal palpation is then used to locate and fix the cervix in the other hand, at which point the catheter is further inserted along the dorsal vaginal fold until the cervical opening is located and semen is deposited into the uterus lumen (thomassen and farstad, ) . surgical and laparoscopic ai has been used successfully for intrauterine and intratubal insemination; however, these techniques are invasive and require anesthesia. therefore, the nonsurgical techniques mentioned above are recommended, as these approaches are less invasive and can be completed without anesthesia in nonsedated or sedated dogs depending on the experience of the personnel and personality of the dogs. ai with freshly collected sperm can be done on days , , and of standing heat or on days of maximal vaginal cornification. the viability of frozen-thawed sperm is significantly reduced compared to fresh or chilled sperm that may live up to or days in the reproductive tract of the bitch; frozen-thawed sperm live only a few hours. therefore, the ova must be mature and insemination with frozen-thawed semen must be done - days after ovulation in the bitch as determined by serum progesterone concentrations (thomassen et al., ) . false pregnancy (pseudocyesis), a stage of mammary gland development and lactation associated with nesting or mothering behavior, is common in the bitch. the condition occurs after the decline in serum progesterone toward the end of diestrus. there is no age or breed predisposition. pseudopregnancy does not predispose the bitch to reproductive disease or infertility. a comprehensive review of canine pseudocyesis exploring its cause, clinical features, and treatments is covered by c. gobello (gobello et al., ) . reproductive performance in the bitch is optimal prior to years of age. cycling does not completely cease; however, after - years of age, bitches demonstrate significant decreases in conception rate and the number of live pups whelped. by - years of age, pathologic conditions of the uterus, such as cysts, hyperplasia, atrophy, and neoplasia, are extremely common. dogs prefer living in a social environment. dogs have well developed olfactory glands, vision, and auditory and tactile senses that allow them to gain environmental cues and information from other dogs and humans (field and jackson, ; joint working group on refinement, ) . much of their instinctive behavior is dependent on learning to interact with other members of their species. beagles have been a popular animal model because of their docile nature. they are easily handled and, for the most part, respond favorably to repetitive manipulations such as body weight measurements, physical examination, electrocardiograms (ecgs), oral gavage, and venipuncture. although sexually mature by - months of age, dogs are not socially mature until - months of age. the socialization process should begin early during development, when puppies are receptive to conspecific and human contact. for example, from to weeks of age, puppies are most capable of learning about how to interact with other dogs. between weeks and , puppies are most capable of learning how to interact with people. by - weeks of age, dogs voluntarily wander and explore new environments. thus, early handling and mild stress (such as vaccination) appear to be extremely beneficial components of a dog's social exposure. canid social systems use signals and displays that minimize the probability of outright aggression. these behavior patterns are most likely elicited during distressful situations, such as strange environments, being handled by strange people, or encountering new animals. an excellent, illustrated discussion of normal canine behavior patterns can be found in the canine behavior section of the manual of clinical behavioral medicine for dogs and cats (overall, ) . by virtue of the dog's status as a companion animal, there are many veterinary publications and reference texts on the diagnosis, medical management, pathology, and epidemiology of its disorders. the authors of this chapter have chosen to emphasize those diseases that are more frequently encountered in the research setting, especially infectious diseases associated with the use of random-source dogs and conditions seen frequently in the beagle. for more thorough and detailed discussion of these diseases, as well as those not discussed in this chapter, the reader should consult standard veterinary textbooks. etiology canine infectious respiratory disease (cird) is a highly contagious illness and several organisms have been incriminated including bordetella bronchiseptica; streptococcus equi subsp. zooepidemicus; canine parainfluenza virus (cpiv); canine influenza virus (civ); canine respiratory coronavirus; canine adenovirus type (cav- ); canine herpesvirus; canine reovirus types , , and ; and mycoplasma and ureaplasma. naturally occuring infection can result in coinfection by two or more organisms (garnett et al., ; ford, ) . clinical signs cird can be subdivided into mild or severe forms. the mild form is more common and is characterized by an acute onset of a loud, dry, hacking cough. increased formation of mucus sometimes results in a productive cough, followed by gagging or retching motions. cough may be elicited by tracheal palpation and may be more frequent with excitement or exercise. otherwise, dogs are typically asymptomatic. mild tracheobronchitis usually lasts - days, even when untreated. the severe form results from poor general health, immunosuppression, or lack of vaccination. secondary bronchopneumonia can occur and can be the determinant of severity (sherding, ) . animals are clinically ill and may be febrile, anorexic, and depressed. productive cough and mucopurulent naso-ocular discharge are more common than in the mild form. epizootiology and transmission the natural reservoir for b. bronchiseptica is the respiratory tract (bemis, ) , and it is very easily spread by aerosol and direct contact. transmission is heightened by confined housing of multiple animals. bordetella bronchiseptica is highly infectious with an incubation period of - days. pathogenesis the most common clinical isolates are cpiv and b. bronchiseptica (mochizuki et al., ) . however, b. bronchiseptica is often recovered from clinically healthy animals (chalker et al., ) . during clinical infection, b. bronchiseptica attaches to the cilia of the upper airway epithelium, causing suppurative tracheobronchitis and bronchiolitis. infections with cpiv laboratory animal medicine or cav- alone are usually subclinical but can cause necrotizing tracheobronchiolitis (dungworth, ) . diagnosis and differential diagnosis diagnosis is often based on clinical signs and known history; however, cough elicited by tracheal palpation may be inconsistent and should not be used for definitive diagnosis. presumptive diagnosis can be made by isolation of b. bronchiseptica or mycoplasma by nasal swabs. viral isolation or paired serology is often impractical and expensive. if cough persists for more than days, other disease conditions should be considered. differential diagnoses include civ, canine distemper virus, pneumonia, heartworm disease, tracheal collapse, mycotic infections, and diseases resulting in tracheal compression (johnson, ) . prevention prevention is best achieved by avoiding exposure to infected animals. dogs should be vaccinated prior to or upon admission to the animal facility. intranasal vaccines protect against infection and disease and can be given to dogs as young as weeks of age (greene and levy, ) . combination vaccines for b. bronchiseptica, cav- , and cpiv are preferred. vaccinations should be boostered every months when multiple animals are housed in a confined area. control staff must practice proper hygiene to prevent transmission by fomites. sanitation, proper ventilation, and proper humidity are critical for control. symptomatic animals should be isolated and kennels should be disinfected with agents such as bleach, chlorhexidine, or quaternary ammonium chloride. treatment bordetella bronchiseptica is sensitive to potentiated sulfas, chloramphenicol, quinolones, tetracyclines, gentamicin, and kanamycin. use of antibiotics is indicated when severe or persistent clinical signs occur and should be continued for days. for severe or unresponsive infection, treatment should be based on bacterial culture/sensitivity patterns. nebulized gentamicin or kanamycin may be helpful in severe cases. antitussives should be avoided if the cough is productive; however, their use is indicated if coughing is causing discomfort or interfering with sleep. bronchodilators such as aminophylline, theophylline, or terbutaline can be helpful in reducing reflex bronchoconstriction. research complications due to the altered respiratory tract physiology, infected animals should not be used for pulmonary studies. etiology β-hemolytic lancefield's group c streptococcus (s. equi ssp. zooepidemicus) is a gram-positive, non-spore-forming coccus that causes pneumonia and sepsis in dogs. clinical signs clinical signs vary based on the organ system affected. pneumonic disease is typically associated with sudden onset of clinical signs including coughing, weakness, fever, dyspnea, and hematemesis. the rapid progression of disease is similar to that seen in humans with toxic shock syndrome (tss) caused by streptococcus pyogenes. peracute death has been reported in research and shelter dogs (bergdall et al., ; pesavento et al., ) . epizootiology and transmission streptococcus equi ssp. zooepidemicus is not considered a commensal of healthy dogs as most of the β-hemolytic commensal organisms belong to group g, specifically streptococcus canis. asymptomatic carriers are suspected to be the route by which infection enters populations. streptococcus equi ssp. zooepidemicus is considered an opportunistic pathogen and stressful factors such as transport can predispose to disease (priestnall et al., ) . pathologic findings in peracute cases, hemorrhage from the mouth and nose and within the pleural cavity can be the most striking lesion. ecchymotic and petechial hemorrhages can be noted on several organs ( fig. . ). 'bull's-eye' lesions may be observed on the pleural surface of affected lung lobes. histologic lesions can include fibrino-suppurative, necrotizing, and hemorrhagic pneumonia. gram-positive cocci can be found in intracellular clusters throughout the lung ( fig. . ), tonsils, and spleen of affected animals (bergdall et al., ; priestnall and erles, ) . pathogenesis predisposing factors such as transport stress and viral coinfection have been shown to contribute to the virulence of s. zooepidemicus (priestnall and erles, ) . due to the similarities with the clinical signs seen in human cases of tss, superantigens are thought to contribute to the virulence of s. zooepidemicus in cases of acute hemorrhagic pneumonia. these superantigens work by bypassing the conventional mechanisms of antigen presentation and binding to major histocompatibilitity complex class ii receptors. as a result, there is a hyperactive proinflammatory response and an 'avalanche' of cytokines including interleukin β (il- β), interleukin (il- ), and tumor necrosis factor alpha (tnf-α). three novel superantigen-encoding genes have been identified from a case of acute fatal hemorrhagic pneumonia, szef, szen, and szep. however, it is currently unclear what effect these superantigens have in vivo priestnall et al., ) . while superantigens have been detected in some isolates, there is not enough data to determine if superantigens play a role in the pathogenesis (byun et al., ; kim et al., ) . diagnosis and differential diagnosis definitive diagnosis is based on bacterial culture of nasal swabs or transtracheal lavage. polymerase chain reaction (pcr) can be done on post-mortem lung tissue. bacterial pneumonias or bacteremias can be caused by other pathogenic streptococcus spp., staphylococcus spp., escherichia coli, pasteurella multocida, pseudomonas spp., klebsiella pneumoniae, and b. bronchiseptica. nonbacterial causes of respiratory disease include rodenticide intoxication, coagulopathies, heartworm disease, pulmonary thromboembolism, ruptured aneurysm, and left-sided congestive heart failure. prevention and control there is no vaccine for prevention of s. zooepidemicus. the organism has been isolated from the environment during active outbreaks (pesavento et al., ) , so dogs diagnosed with s. zooepidemicus should be quarantined and any potential fomites (e.g. food bowls, enrichment) should be properly disinfected. treatment antibiotic therapy should be based on culture and sensitivity. resistance to doxycycline and tetracycline has been demonstrated (garnett et al., ; pesavento et al., ) . research complications dogs with severe hemorrhagic pneumonia or systemic disease are not appropriate for research study. the association between epizootics of this disease and transportation supports operational policies that require adequate acclimation periods for animals upon arrival. etiology serovars canicola, bratislava, and grippotyphosa result in renal or hepatic disease, whereas serovars icterohaemorrhagiae and pomona predominantly result in hepatic disease . clinical signs canine leptospirosis can present as subclinical, acute, or chronic disease. clinical signs in acute infection can be nonspecific and include lethargy, depression, abdominal discomfort, stiffness, anorexia, vomiting, muscle tenderness, and pyrexia. clinical signs can be related to renal failure including polyuria and polydipsia, with or without azotemia, oliguria, or anuria. leptospirosis can also lead to hepatic failure with signs such as icterus or bleeding abnormalities. peracute leptospirosis is characterized by shock, vascular collapse, and rapid death. uveitis, abortions, stillbirths, and pulmonary hemorrhage have also been associated with leptospirosis (klopfleisch et al., ; van de maele et al., ) . bivalent vaccines against the most common canine serovars, icterohaemorrhagiae and canicola, have resulted in the increased prevalence of other serovars including grippotyphosa, pomona, bratislava, and autumnalis. increased movement of wild animal reservoirs (rats, raccoons, skunks, opossums) into urban/suburban areas have also contributed to the greater prevalence of previously uncommon serovars (sykes et al., ) . transmission occurs primarily through environmental contact, although direct transmisson between hosts may also occur. leptospires passing from urine into water is the most common route of contamination (goldstein, ) . leptospirosis is a zoonotic disease. pathologic findings the kidneys consistently have gross and microscopic lesions. in the acute phase, the kidneys are swollen with subcapsular and cortical ecchymotic hemorrhages. petechial or ecchymotic hemorrhages and swelling of the lungs may also be noted. hepatic lesions during the acute phase consist of diffuse hemorrhage and necrotic foci (searcy, ) . in chronic stages of leptospirosis, the kidneys become small and fibrotic. endothelial cell degeneration and focal to diffuse lymphocytic-plasmacytic interstitial nephritis are the characteristic histopathological findings. pathogenesis the severity and course of leptospirosis depend on the causative serovar as well as the age and immune status of the dog. infection occurs after the leptospires penetrate a mucous membrane or abraded skin. the organisms then invade the vascular space and multiply rapidly, reaching the renal tubular epithelium several days postinfection. acute or progressive renal failure leading to oliguria or anuria may occur. nephritis may or may not be accompanied by hepatitis, uveitis, pulmonary hemorrhage, and meningitis. disseminated intravascular coagulation is often a secondary complication. diagnosis and differential diagnosis paired serology for the microscopic agglutination test is the most reliable means of definitive diagnosis, and successive serum sampling should be done - days after the first sample. pcr can be used to identify active infection early in the disease when serologic testing is negative or in previously vaccinated animals (sykes et al., ) . differential diagnoses include other causes of acute renal failure and hepatitis. prevention and control according to the american animal hospital association's vaccination guidelines, vaccination for leptospirosis is recommended based on geographic location and exposure risk (welborn et al., ) . both quadrivalent and bivalent inactivated bacterins are available. quadrivalent bacterins protect against canicola, icterohaemorrhagiae, grippotyphosa, and pomona serovars, whereas bivalent bacterins cover only canicola and icterohaemorrhagiae. immunization does not prevent the development of the carrier state or protect against other serovars. control requires preventing contact with wildlife reservoirs as well as identification of carrier animals. treatment doxycycline is the drug of choice as it can eliminate renal colonization. if vomiting or allergic reactions prohibit treatment with doxycycline, ampicillin or other penicillins should be utilized. aggressive fluid therapy and supportive care may also be needed. research complications due to the zoonotic potential, dogs with clinical leptospirosis should not be used in research studies. etiology campylobacter spp. are thin, curved or spiral, microaerophilic, thermophilic motile gram-negative rods. many species of campylobacter have been isolated from normal and diarrheic animals; however, the most common pathogenic species include campylobacter jejuni ssp. jejuni and c. coli (marks et al., ) . clinical signs most adult animals infected with c. jejuni are asymptomatic carriers; clinical signs are most commonly noted in dogs that are less than months of age (greene, ; burnens et al., ) . in cases of clinical illness, mild and intermittent mucoid or watery diarrhea, with or without frank blood, is most commonly noted. signs typically last - days but can persist for several months. tenesmus, inappetance, vomiting, and a mild fever may accompany the diarrhea (marks et al., ) . bacteremia and cholecystitis secondary to c. jejuni have also been documented in dogs (fox, ) . epizootiology and transmission the role of campylobacter spp. as a primary pathogen has been questioned; it may require a coenteropathy to produce disease (sherding and johnson, ) . stress or immunosuppression may make animals more susceptible. transmission is via the fecal-oral route, mostly through contaminated food or water. campylobacter jejuni can be zoonotic with immunocompromised individuals at greatest risk. pathologic findings lesions depend on the mechanism of the enteropathy (van kruiningen, ) . enterotoxin production results in dilated, fluidfilled bowel loops, with little or no histopathologic alteration. cytotoxin-mediated disease results in a friable, hemorrhagic mucosal surface. histologically, the mucosa is ulcerated with lymphoplasmacytic infiltration. translocation can result in edema and congestion of the lamina propria with focal accumulation of granulocytes. epithelial hyperplasia and decreased goblet cell numbers are also noted. campylobacter jejuni may be visualized between enterocytes with warthin-starry silver-stained sections. pathogenesis clinical disease may be produced by several different mechanisms as campylobacter spp. have a variety of virulence factors including enterotoxins, cytotoxins, and adherence or invasion properties. campylobacter jejuni can cause an erosive enterocolitis by invasion of epithelium and production of the cytolethal distending toxin (cdt) (fox, ; van kruiningen, ) . in addition, c. jejuni can produce illness via translocation to regional lymph nodes causing a mesenteric lymphadenitis. diagnosis and differential diagnosis fresh feces (per rectum) can be used for presumptive diagnosis by demonstration of highly motile, curved or spiral organisms with dark-field or phase-contrast microscopy. gram-stained c. jejuni appear as gull-winged rods. definitive diagnosis requires isolation of the organism (sherding and johnson, ) . culture requires selective isolation media, and growth is favored by reduced oxygen tension and a temperature of °c. a pcr multiplex assay for differentiation of c. jejuni, c. coli, c. lari, c. upsaliensis, and c. fetus ssp. fetus has been developed (wang et al., ) . any disorder that can cause diarrhea in dogs should be considered as a differential diagnosis. prevention and control proper environmental sanitation, waste disposal, and food storage can prevent campylobacteriosis. in enzootic situations, group housing should be avoided. outbreaks are controlled by isolation and treatment of affected individuals. treatment antibacterial treatment should be considered in severely ill dogs. erythromycin, neomycin, enrofloxacin, clindamycin, and doxycycline are all effective. resistance to quinolones and ciprofloxacin has been documented (acke et al., ) . treatment should be a minimum of - days with bacterial cultures repeating and weeks after treatment. research complications dogs with clinical campylobacteriosis have temporary derangements to digestive and absorptive functions. etiology helicobacters are gram-negative, microaerophilic, spiral bacteria that infect the gastrointestinal tract. helicobacter spp. can be separated into gastric and enterohepatic groups. the gastric helicobacters commonly identified in dogs are referred to as non- (haesebrouck et al., ; joosten et al., ) . the most common enterohepatic species found in dogs include h. bilis, h. canis, and h. cinaedi (castiglioni et al., ; dewhirst et al., ; fox, (haesebrouck et al., ; fox, ) . clinical signs most infections are subclinical in the dog. gastric infections may present with vomiting, diarrhea, and fever, accompanied by anorexia, pica, or polyphagia. enterohepatic helicobacters have been linked with inflammatory bowel disease in experimental animal models. heavy infections in dogs have been associated with inflammatory lesions of the large intestine (castiglioni et al., ; nguyen et al., ) . epizootiology and transmission the epizootiology and transmission of helicobacter spp. in the dog remain unknown. both oral-oral and fecal-oral routes for transmission have been suggested in humans, but transmission via canine saliva is a less reliable source of infection (craven et al., ) . enterohepatic infections of pet dogs are as high as % (castiglioni et al., ) . prevalence of gastric helicobacter infections in colony or shelter dogs can be as high as - % (fox, ; hermanns et al., ) . pathologic findings gastritis is usually mild and characterized by reduced mucus content of the surface epithelium with vacuolation, swelling, karyolysis, and karyorrhexis of parietal cells. multifocal infiltrates of plasma cells and neutrophils occur around blood vessels and between gastric pits (hermanns et al., ) . intestinal lesions include mild to moderate lymphoplasmacytic infiltration as well as crypt dilation and crypt hyperplasia (castiglioni et al., ) . pathogenesis gastric helicobacters are urease positive, which assists with survival in the acidic environment of the stomach (kusters et al., ; uberti et al., ) . enterohepatic helicobacters are urease negative and typically reside in the lower intestine. the mechanism by which enterohepatic helicobacters colonize the liver is thought to be through portal circulation after uptake by enterocytes or through retrograde movement from the intestine into the bile duct (fox, ) . diagnosis and differential diagnosis organisms may be demonstrated with histopathology on endoscopic or surgical biopsy tissue samples. warthin-starry silver stain may increase the sensitivity for histopathologic diagnosis. culture may be difficult depending on the helicobacter spp. for species that produce urease, a positive urease test on a gastric biopsy specimen may give a presumptive diagnosis. the urea breath test has been successfully used to diagnose helicobacter spp. in laboratory beagles with a sensitivity and specificity of % (kubota et al., ) . western blot has been used to detect serum antibodies to enterohepatic species and pcr can be used to detect helicobacter spp. in fecal samples (oyama et al., ; wadström et al., ) . any causes of acute or chronic vomiting and diarrhea in the dog are differential diagnoses. prevention and control until more is known about the epizootiology and transmission of helicobacter spp., specific recommendations cannot be made for prevention and control. treatment for gastric species, combination therapy of amoxicillin ( mg/kg q h), metronidazole ( mg/kg q h), and sucralfate ( . - . mg/kg q h) has proven to be most effective (hall and simpson, ) . replacing sucralfate with famotidine, omeprazole, or bismuth subsalicylate may also be effective (marks, ; jenkins and bassett, ; denovo and magne, ) . recurrence rates within days of treatment can be as high as % (anacleto et al., ) . treatment of enterohepatic helicobacters may depend on species susceptibility. aminoglycosides have been successful in treating h. cinaedi, but resistance to fluoroquinolones has been documented (tomida et al., ) . combination therapy of amoxicillin, clarithromycin, metronidazole, and omeprazole in medicated chow has been successful in eliminating various enterohepatic helicobacters from mice (del carmen martino-cardona et al., ) . long-term antibiotic treatment at a minimum of days is suggested for enterohepatic and gastric helicobacters. research complication dogs used in gastrointestinal physiology or oral pharmacology studies should be free from helicobacteriosis. etiology parvoviral enteritis in dogs is caused by canine parvovirus strain (cpv- ) of the family parvoviridae, genus protoparvovirus, species carnivore protoparvovirus . currently, there are three antigenic variants, a, b, and c. parvoviruses are nonenveloped, single-stranded dna viruses. clinical signs while parvoviral infection can affect the gastrointestinal tract, bone marrow, myocardium, and nervous tissues, the most common manifestation of disease is acute enteritis. clinical signs usually appear days after fecal-oral inoculation and include anorexia, fever, depression, vomiting, and profuse intractable diarrhea which may become hemorrhagic. excessive fluid and protein losses through the gastrointestinal tract result in rapid and severe dehydration. dogs can develop severe leukopenia with a total leukocyte count of cells/μl or less. repeated hemograms may provide prognostic value, as rebounds in leukocyte counts are indicative of impending recovery. terminally ill dogs may develop hypothermia, icterus, or disseminated intravascular coagulation due to endotoxemia. epizootiology and transmission parvovirus can infect dogs of any age, but puppies between and weeks of age are particularly susceptible. puppies less than weeks of age are protected by passive maternal antibody. strain cpv- c has been associated with severe disease in adult vaccinated dogs (calderon et al., ) . pathogenesis canine parvovirus has an affinity for rapidly dividing cells of the intestine and causes acute enteritis with intestinal crypt necrosis and villus atrophy. the virus also has tropism for the bone marrow and lymphoid tissues; thus, leukopenia and lymphoid depletion accompany the intestinal destruction. diagnosis and differential diagnosis parvovirus can be detected with a commercially available fecal enzyme-linked immunosorbent assay (elisa). due to intermittent and brief shedding of the virus, fecal elisas can have false-negative results. pcr can be used to confirm an elisa result and to differentiate the viral strain. at necropsy, diagnosis is based on gross and histopathologic evidence of necrosis and dilatation of intestinal crypt cells with secondary villous collapse. prevention and control parvoviral-positive animals should be quarantined for at least days as the infectious virus is shed for several days after onset of clinical signs. although pcr has been used to detect viral dna in feces for up to weeks (decaro et al., ) , it is currently unknown if the material being shed at this time is still infectious. disinfection of exposed areas with dilute bleach ( : ) or a commercial disinfectant is essential for elimination of the virus. six-week-old puppies should be vaccinated every - weeks with a modified live vaccine until at least weeks of age. treatment treatment is largely supportive and aimed at restoring fluid and electrolyte balance. antimicrobial therapy is recommended due to intestinal compromise and risk of sepsis. early nutritional support continued throughout the disease has been shown to decrease recovery times (mohr et al., ) . research complications infection with parvovirus precludes the use of a particular dog in an experimental protocol. due to the significant discomfort of the animal, as well as the intensive therapy required, humane euthanasia is usually chosen in a research setting. etiology rabies virus is a lyssavirus belonging to the family rhabdoviridae. clinical signs clinical progression of neurologic disease occurs in three stages. the first, prodromal, stage is characterized by a change in species-typical behavior. the loss of the instinctive fear of humans by a wild animal is a classic sign of impending rabies. in the second, furious, stage, animals are easily excited or hyperreactive to external stimuli and will readily bite at inanimate objects. the third, paralytic, stage is characterized by incoordination and ascending ataxia of the hindlimbs due to viral-induced damage of motor neurons. death due to respiratory failure usually occurs after onset of the third stage. wild animals such as raccoons, skunks, and bats are common reservoirs of infection for domestic animals, which in turn are the principal source of infection for humans. transmission occurs primarily by contact with infected saliva, usually via bite wounds. pathogenesis the incubation period for rabies is - weeks to the onset of clinical signs but can range from week to year. bites to the head and neck result in shorter incubation periods due to the close proximity to the brain. following infection, the virus migrates centripetally via peripheral nerve fibers to neurons within the brain, resulting in neurologic dysfunction. on reaching the brain, the virus migrates centrifugally to the salivary glands, thus enabling shedding and subsequent transmission. diagnosis and differential diagnosis definitive diagnosis is based on immunofluorescence of the virus in negri bodies of hippocampal cells. submission of the whole, unfixed brain, including the cerebellum and proximal brain stem, should be done within h of collection. the tissue should be kept refrigerated as freezing can cause delays in testing. differential diagnoses laboratory animal medicine include pseudorabies, canine distemper, bacterial meningitis, and toxicants that affect neurologic function. prevention and treatment puppies should be vaccinated by weeks of age, again at year, and then annually or triennially, depending on state and local laws. research complications immuno-prophylaxis is recommended for animal care and research personnel who may have work-related risks of exposure. due to risk of human exposure, animals with suspected infection should be humanely euthanized and brain tissue should be submitted for confirmation. giardiasis giardia lamblia, also known as g. duodenalis and g. intestinalis, is a binucleate flagellate protozoan that usually causes subclinical infestation of the small intestine. clinical disease is usually seen in young dogs and the characteristic sign is voluminous, light-colored, foul-smelling, soft to watery diarrhea, which is the result of malabsorption and hypersecretion. giardia has a direct life cycle with infection resulting after consuming cyst-contaminated food or water. the change in ph between the stomach and duodenum activates excystation and trophozoites then attach to the enterocytes. for diagnosis, direct fecal smears are considered best for observing trophozoites and zinc sulfate centrifugation is preferred for detection of cysts. a commercial elisa kit is licensed for use in dogs, but the positive predictive value is poor and zinc sulfate centrifugation techniques should be used in conjunction with elisa (rishniw et al., ) . pcr assays are also available for diagnosing giardiasis. differential diagnoses for giardiasis include bacterial and protozoal enteritis, coccidiosis, and whipworm infestation. metronidazole at - mg/kg po q h for - days is effective at treating giardiasis as well as other enteric protozoans, which may be potential differential diagnoses or coinfections. albendazole, fenbendazole, pyrantel, and praziquantel are also effective. coccidiosis intestinal coccidia associated with enteropathy in dogs include isospora canis, i. ohioensis, i. neorivolta, i. burrowsi, and hammondia heydorni (dubey and greene, ) . coccidian oocysts can be found in feces of clinically healthy dogs, as well as animals with diarrhea. clinically affected animals are young or immunosuppressed and develop diarrhea, which can vary from soft to watery and may contain blood or mucus. vomiting, dehydration, lethargy, and weight loss can also be seen. coccidia oocysts are typically spread by fecal-oral transmission, but dogs can ingest monozoic cysts in intermediate host tissues. the coccidian life cycle is both sexual and asexual, and results in the release of unsporulated eggs, which sporulate under appropriate environmental conditions. other causes for diarrhea should be excluded before a coccidial etiology is implicated. treatment may not be necessary, as infections are typically self-limiting and clinically insignificant. treatment may help to limit the number of oocysts shed in a kennel-housing situation and may be necessary in cases of protracted clinical illness. possible choices for treatment include daily administration of sulfadimethoxine ( - mg/kg po q h for - days) or trimethoprim sulfa ( mg/kg po q h for days). ascarids roundworms of dogs are most often toxocara canis; however, toxascaris leonina can also affect dogs. clinical illness is usually only seen in young animals with large worm burdens. diarrhea, vomiting, dehydration, and abdominal discomfort with vocalization can be seen. puppies may have a classical 'potbellied' appearance. heavy infestations can cause intussusception and/or intestinal obstruction. puppies that experience lung migrations of larval worms can develop fatal pneumonia. toxascaris canis can infect dogs by transplacental migration, transmammary migration, or ingestion of infective eggs. the infective stage of t. canis is the third-stage larva (l ). in transplacental infections, puppies may be born with l larvae in their lungs (sherding, ) . for diagnosis, large ( - μm in diameter) and relatively round ascarid eggs can be seen by standard fecal flotation methods. monthly administration of milbemycin or ivermectin plus pyrantel pamoate is recommended for prevention (hall and simpson, ) . most anthelmintics are effective for treatment. puppies should be treated early and often (every other week until weeks of age) because of the possibility of prenatal or neonatal infection. pregnant bitches can be treated with extended fenbendazole therapy ( mg/kg po once a day from day of gestation through day of lactation). hookworms the most common and most pathogenic hookworm of dogs is ancylostoma caninum. ancylostoma braziliense can also be found in dogs, but only a. caninum infestation typically results in clinical illness. puppies with hookworm infections can present as anemic with bloody diarrhea or melena. other clinical signs include lethargy, anorexia, dehydration, vomiting, and poor weight gain. these signs are a direct result of the worms' consumption of blood and body fluids. infective larvae (l ) are ingested from the environment and develop directly in the intestinal tract. infestation can also be transmammary, from ingestion of a paratenic host, and, less often, by transplacental migration. on histological sections, embedded worms with mouthparts may be identified. diagnosis is made by identification of eggs or larvae by either fecal flotation or direct smear. a differential diagnosis of parvovirus should be considered for puppies with bloody diarrhea, and autoimmune hemolytic anemia should be considered in young dogs with anemia. pyrantel pamoate is the anthelmintic of choice because it is safest in young ill animals. monthly administration of milbemycin or ivermectin plus pyrantel pamoate is recommended for prevention and control (hall and simpson, ) . due to transplacental or milkborne infection, puppies should be treated q weeks from to weeks of age. whipworms trichuris vulpis, the canine whipworm, can cause acute or chronic large intestinal diarrhea. the adult worm resides in the cecum or ascending colon. most infections are subclinical, but in symptomatic cases, the typical clinical sign is diarrhea with blood and/or mucus. abdominal pain, anorexia, and weight loss may also be seen. dogs may have eosinophilia, anemia, and/or hypoproteinemia on clinical hematology. trichuris vulpis has a direct life cycle with eggs passed in the feces. the penetration of the adult worm into the enteric mucosa, and the associated inflammation, can lead to diarrhea. factors that influence development of clinical symptoms are the number and location of adult whipworms; the severity of inflammation, anemia, or hypoproteinemia in the host; and the overall condition of the host. whipworm infestation is diagnosed by the presence of barrel-shaped, thickwalled eggs with bipolar plugs on fecal flotation. adult worms intermittently release eggs; therefore, negative results do not exclude infection. differential diagnoses for whipworm infestation include giardiasis, coccidiosis, and bacterial enteritis. fenbendazole, oxibendazole, and milbemycin have all been recommended for treatment of whipworms. treatment for whipworm infestation should be at monthly intervals for months (jergens and willard, ) . several species of cestodes parasitize the small intestine of dogs. the most common is dipylidium caninum. other species include taenia pisiformis and, more rarely, echinococcus granulosus, multiceps spp., mesocestoides spp., and spirometra spp. most cestode infestations are subclinical, but severe infestations with dipylidium can cause diarrhea, weight loss, and poor growth. the cestode requires an intermediate host, which for d. caninum are fleas and lice. ingestion of these arthropods results in transmission of the tapeworm. definitive diagnosis is usually made by the identification of egg capsules or proglottids (tapeworm segments) on the surface of the feces or around the anus. the most significant means to limit cestode infestation is to control flea and/or louse exposure. praziquantel at - . mg/kg orally or subcutaneously is the standard treatment for cestodiasis, especially taenia or echinococcus species. fenbendazole, mebendazole, or oxfendazole may also be effective against d. caninum (hall and simpson, ) . demodicosis canine demodicosis is caused by demodex canis, a commensal mite that lives in the hair follicles and is passed from dams to nursing pups. localized demodicosis is typically asymptomatic, but disease can present with variable and nonspecific clinical signs, such as alopecia, erythema, pruritus, crusts, and hyperpigmentation. it can occur anywhere on the body but is often seen on the feet and face, and around the ears (demanuelle, a). generalized demodicosis can develop in juvenile or adult populations and is indicative of an underlying immunosuppressive disorder. demodex has a characteristic 'cigar shape' and can be identified from deep skin scrapings mounted on mineral oil (campbell, ; noli, ) . differential diagnoses include dermatophytosis, allergic contact dermatitis, and seborrheic dermatitis. the primary differential diagnosis for generalized demodicosis is primary bacterial pyoderma, which is also a common secondary complication of generalized demodicosis. ivermectin at - μg/kg and oral milbemycin at - mg/kg/day are effective treatments. treatment duration can be extensive and must be accompanied by repeated skin scrapings. sarcoptic mange canine sarcoptic mange is caused by sarcoptes scabiei var. canis, which is zoonotic. the most common clinical sign is an intense pruritus, usually beginning at sparsely furred areas of the ear pinnae, elbows, ventral thorax, and abdomen. lesions are characterized by alopecia and yellowish dry crusts with a macular papular eruption. these lesions may be exacerbated by excoriation due to the pruritic nature of the condition. adult mites, mite eggs, or mite feces may be observed on superficial skin scrapings, but diagnosis may be difficult because multiple skin scrapings may yield negative results. even if scrapings are negative, a therapeutic trial should be initiated if the clinical signs and history suggest a sarcoptes etiology. demonstration of anti-mite ige either in the serum or via an intradermal antigen test can be used as a diagnostic aid (campbell, ) . histologic examination is nondiagnostic; however, suggestive lesions include small foci of edema, exocytosis, degeneration, and necrosis . an important differential diagnosis is flea allergy dermatitis (fad). unless antiparasitic therapy would interfere with research objectives, all dogs with sarcoptic mange should be treated. in addition, their kennel mates should also be treated due to the contagious nature of the disease and its zoonotic potential. the usual means of treatment is either ivermectin at - μg/kg q days or milbemycin at mg/kg q days for three oral doses . ticks ticks are obligate arachnid parasites that require vertebrate blood as their sole food source. genera that more commonly infest dogs in the united states include species of rhipicephalus, dermacentor, amblyomma, and ixodes. the primary significance of tick infestation is vector-borne infectious diseases, including rocky mountain spotted fever (rickettsia rickettsii), lyme disease (borrelia burgdorferi sensu stricto), thrombocytic anaplasmosis (anaplasma platys), and canine monocytic ehrlichiosis (ehrlichia canis). ticks alone cause minimal signs unless the dog develops a hypersensitivity reaction leading to a more granulomatous response at the bite location (merchant and taboada, ) . some species (primarily dermacentor andersoni and d. variabilis) produce a salivary neurotoxin that causes an ascending flaccid paralysis (malik and farrow, ) . uncomplicated tick bites and tick-bite paralysis are diagnosed by identification of the tick and clinical signs of paralysis. dogs with tick-bite paralysis usually show improvement within h of tick removal, with complete recovery within h (malik and farrow, ) . formamidines (amitraz), pyrethroids, and phenylpyrazoles (fipronil) are available as spot-ons, collars, sprays, and foggers to treat tick infestations in both the animal and the environment (halos et al., ; beugnet and franc, ) . differential diagnoses for tick-bite paralysis include botulism, snakebite, polyradiculoneuritis, and idiopathic polyneuropathy (malik and farrow, ) . fleas the most common flea to infest dogs is ctenocephalides felis felis, the cat flea (sousa, ) . flea infestations usually cause foci of alopecia and pruritus. dogs that are hypersensitive to antigenic proteins in flea saliva develop severe fad, which features papules, crusting, and excoriations over the lumbosacral region, flanks, thighs and abdomen. these animals may require oral corticosteroids to relieve clinical signs (muller et al., ) . secondary bacterial and fungal infections can also develop. fleas can also transmit other parasitic diseases, such as dipylidium tapeworms. flea infestations and fad are definitively diagnosed by observing the fleas on the host's skin; however, the presence of flea excrement can support a presumptive diagnosis (demanuelle, b) . treatment of flea infestations should use an integrated pest management (ipm) approach that targets adult fleas, immature stages, and environmental contamination in order to limit the risk of chemoresistance. combining ovicidal treatments, such as lufenuron and selamectin, with adulticidal treatments, such as fipronil, spinosad, selamectin, and imidacloprid, is recommended (halos et al., ; beugnet and franc, ; dryden et al., ) . certain chemicals (i.e., imidacloprid and selamectin) have both adulticidal and larvacidal abilities, but the principles of ipm preclude the use of one product solely for both adulticidal and larvacidal properties (schwassman and logas, ). differential diagnoses include mite and louse infestations, bacterial folliculitis, and allergic or atopic conditions that present with skin lesions in dogs. canine dermatophytoses are commonly caused by microsporum spp., trichophyton spp., and epidermophyton spp. (moriello and deboer, ) . uncomplicated infections are characterized by circular areas of alopecia and crusting with or without follicular papules, usually around the face, neck, and forelimbs. dermatophytes infect the hair shaft and follicle, as well as the surrounding skin. infected hairs become brittle and broken shafts remain infective in the environment for months. dermatophytoses are zoonotic and easily transmitted to other animals through the environment or by direct contact. definitive diagnosis is made using dermatophyte test medium for culture. hair and crust material from infected sites can be plucked and placed on culture; however, the 'toothbrush' method is more effective for sampling multiple sites. the brush is used to comb hairs and scales from several infected sites and then pressed into the culture media. media plates should be visually inspected daily for days. positive cultures will become red at the same time as growth of a fluffy white colony. microscopic examination of hairs and scales to visualize fungal elements can be done using skin scrapings in % koh or mineral oil; however, this method is not very sensitive. topical and systemic therapy should be initiated together after all suspected areas are clipped to reduce spreading of contaminated fragile hairs. wholebody topical therapies with antifungal shampoos, rinses, and creams are recommended rather than spot treatment. systemic therapy can be achieved with griseofulvin, ketoconazole, itraconazole, or fluconazole. due to the highly infective nature of this disease, animals should be isolated and the environment thoroughly disinfected. chlorhexidine and virkon ® s are ineffective at clearing environmental spores, but lime sulfur ( : ), enilconazole ( . %), and bleach ( : ) are effective across many strains of microsporum canis (moriello and deboer, ) . although the incidence of hypothyroidism in the canine population is not high (kemppainen and clark, ) , deficiency in thyroid hormone can significantly laboratory animal medicine affect basal metabolism and immune function. because these factors are important in many biomedical research studies, it is imperative that laboratory animal veterinarians be able to recognize, diagnose, and treat this problem. etiology primary hypothyroidism affects the thyroid gland directly, whereas secondary hypothyroidism has indirect effects through dysfunction of the pituitary gland (seguin and brownlee ) . both of these causes result in a gradual loss of functional thyroid tissue (avgeris et al., ; kemppainen and clark, ) . the majority of cases of canine hypothyroidism are due to lymphocytic thyroiditis, an autoimmune disorder, or idiopathic atrophy of the thyroid gland. lymphocytic thyroiditis is the major cause of hypothyroidism in laboratory beagles and appears to be familial in that breed (tucker, ; beierwaltes and nishiyama, ; manning ) . rarely, congenital defects or nonfunctional tumors may cause hypothyroidism (peterson and ferguson, ; kemppainen and clark, ) . clinical signs because it affects metabolism in general, hypothyroidism can produce a large number of clinical signs referable to many organ systems. an individual dog with hypothyroidism may have one or any combination of clinical signs. hypothyroidism reduces the dog's metabolic rate, which then produces such signs as obesity, lethargy, cold intolerance, and constipation. additionally, hypothyroidism can produce several dermatologic abnormalities, including nonpruritic, bilaterally symmetrical alopecia, hyperpigmentation, seborrhea, and pyoderma (avgeris et al., ; peterson and ferguson, ; panciera, ) . several clinicopathologic abnormalities have also been reported in a large percentage of hypothyroid dogs. these aberrations include increased serum cholesterol and triglycerides due to a decrease in lipolysis and decreased numbers of low-density lipopolysaccharide receptors (peterson and ferguson, ; panciera, ) . normocytic, normochromic, nonregenerative anemia may be seen in approximately one-half of the cases (avgeris et al., ) . increased serum alkaline phosphatase and creatine kinase have also been reported in a significant number of hypothyroid dogs (peterson and ferguson, ; panciera ) . neurologic signs of hypothyroidism, which include lameness, foot dragging, and paresis, may be caused by several mechanisms such as segmental nerve demyelination or nerve entrapment secondary to myxedema (peterson and ferguson, ) . mental impairment and dullness have also been reported in hypothyroid dogs, secondary to atherosclerosis and cerebral myxedema (peterson and ferguson, ) . hypothyroidism has been implicated in other neurological abnormalities such as horner's syndrome, facial nerve paralysis, megaesophagus, and laryngeal paralysis; however, these conditions do not always resolve with treatment (bichsel et al., ; panciera, ) , and a true causal relationship with hypothyroidism has not been completely defined (panciera, ) . myopathies associated with hypothyroidism are caused by metabolic dysfunction and atrophy of type ii muscle fibers and can present with signs similar to neurological disease (peterson and ferguson, ) . hypothyroidism can also cause abnormalities of the cardiovascular system including bradycardia, hypocontractility, increased vascular volume, and atherosclerosis (seguin and brownlee ) . abnormalities that may be detected by ecg include a decrease in p-and r-wave amplitude (peterson and ferguson, ) and inverted t waves (panciera, ) . these ecg abnormalities are caused by lowered activity of atpases and calcium channel function. an association between hypothyroidism and von willebrand disease has been suggested. however, the relationship is probably one of shared breed predilection and not a true correlation. contradictory studies have shown either deficient (avgeris et al., ) or normal (panciera and johnson , ; avgeris et al., ) von willebrand factor antigen and bleeding times in hypothyroid dogs. most importantly, hypothyroidism does not appear to cause overt, clinical von willebrand disease. however, it may exacerbate existing subclinical von willebrand disease (seguin and brownlee, ) . epizootiology the prevalence of hypothyroidism in the general canine population is reportedly less than % (panciera, ) . the disorder occurs most often in middle-aged, larger breed dogs (avgeris et al., ) , and reports suggest a higher incidence of hypothyroidism in spayed, female dogs (panciera, ; peterson and ferguson, ) . doberman pinschers and golden retrievers appear to have a higher incidence of hypothyroidism compared with other breeds (panciera, ; peterson and ferguson, ; scarlett, ) . there have been several reports about hypothyroidism in laboratory colonies of beagles (manning, ; tucker, ; beierwaltes and nishiyama, ) . diagnosis and differential diagnosis because of the large number of clinical manifestations in dogs, the recognition of hypothyroidism is not always straightforward. likewise, the diagnosis of hypothyroidism can be difficult because of the lack of definitive diagnostic tests available for the dog. a complete understanding of the diagnosis of hypothyroidism requires a familiarity with thyroid hormone metabolism and function that is beyond the scope of this writing. for additional information, the reader is referred to one of several manuscripts available (peterson and ferguson, ; ferguson, ) . currently, the ability to diagnose hypothyroidism relies heavily on the measurement of serum total t (thyroxine) and free t (peterson and ferguson, ; ferguson, ) . t serves primarily as a precursor for t and is heavily protein bound. free t represents the laboratory animal medicine unbound fraction that is available to the tissues (peterson and ferguson, ) . the measurement of total t carries a sensitivity of around % and can be used as a good screening tool. with the measurement of both serum total t and free t , hypothyroidism can usually be ruled out if the values are within the normal range or higher. if both hormone concentrations are low, it is highly likely that the patient has hypothyroidism, and a therapeutic trial may be in order (peterson and ferguson, ) . however, nonthyroidal illnesses and some drugs (e.g., glucocorticoids, anticonvulsants, phenylbutazone, salicylates) can falsely lower these values (peterson and ferguson, ; ferguson, ) . therefore, low values do not always indicate that hypothyroidism is present and animals should not be treated solely on the basis of serum hormone levels if clinical signs are not present. if the clinical signs are equivocal or only total t or free t is decreased, further diagnostic testing is warranted (peterson and ferguson, ) . although t is the most biologically active form of thyroid hormone, the measurement of serum t levels is an unreliable indicator of hypothyroidism (peterson and ferguson, ; ferguson, ) . serum t can be falsely lowered by many nonthyroidal illnesses and many drugs (see above). in addition, t may be preferentially released and conversion of t to t may be enhanced by the failing thyroid (peterson and ferguson, ; ferguson, ) , particularly early in the disease. in one study, t was within normal limits in % of the hypothyroid dogs (panciera, ) . autoantibodies can be responsible for false elevations in the concentrations of t and t found in these respective assays. it has been recommended that free t , measured by equilibrium dialysis, be assayed in dogs that are suspected of hypothyroidism and have autoantibodies with normal or high t and t . autoantibodies have been found in less than % of the samples submitted to one laboratory (kemppainen and behrend, ) . other means of diagnosing hypothyroidism have been described. in humans, endogenous thyroid-stimulating hormone (tsh) levels provide reliable information on thyroid status, and an assay is available for dogs. however, endogenous tsh levels can be normal in some dogs with hypothyroidism and high tsh levels have been noted in normal dogs and sick animals that are actually euthyroid. it is therefore recommended that tsh levels be considered along with other information (clinical signs, t ) prior to diagnosis and treatment (kemppainen and behrend, ) . tsh stimulation testing using exogenous bovine tsh provides a good and reliable method for establishing a diagnosis. unfortunately, the availability and expense of tsh limit the use of this diagnostic tool (peterson and ferguson, ; ferguson, ) . another drawback of tsh testing is that the test must be postponed for weeks if thyroid supplementation has been given (peterson and ferguson, ) . when tsh is available for testing, there are several recommendations for dosage, routes of administration, and sampling times. one recommendation is . u of tsh per pound of body weight (up to a maximum of u) to be administered iv. for this protocol, blood samples are taken prior to administration of tsh and h after. a normal response to the administration of tsh should create an increase of t levels at least μg/dl above the baseline levels or an absolute level that exceeds μg/dl (peterson and ferguson, ; wheeler et al., ) . treatment the treatment of choice for hypothyroidism in the dog is l-thyroxine (sodium levothyroxine). a recommended dosing regimen is . - . mg/kg once a day (avgeris et al. ). if drugs that decrease thyroxine levels are being administered concurrently, it may be necessary to divide the thyroxine dose for twice daily administration. after the supplementation has begun, the thyroid hormone level should be rechecked in - weeks, and blood samples should be drawn - h after the morning pill. a clinical response is usually seen in - weeks and would include weight loss, hair regrowth, and resolution of other signs (panciera, ) . ecg abnormalities also return to normal (peterson and ferguson, ) . for dogs with neurologic signs, the prognosis is guarded, because the signs do not always resolve with supplementation (panciera, ) . weight gain and eventual obesity are frequent findings in dogs in the research environment. because obesity can adversely affect several body systems as well as general metabolism, the laboratory animal veterinarian must address obesity and its potential effects on animal welfare and research results. etiology obesity is defined as a body weight - % over the ideal. in general, obesity occurs when the intake of calories exceeds the expenditure of energy, the result of overeating or eating an unbalanced diet. overeating is a common cause of obesity in pet dogs and may be triggered by boredom, nervousness, or conditioning (macewen, ) . in addition, pet animals are often subjected to unbalanced diets supplemented with high-fat treats. in the laboratory animal setting, overeating is less likely than in a household because access to food is more restricted, and diets are usually a commercially prepared balanced ration. however, obesity can still be a problem if specific guidelines for energy requirements are not followed. in addition, the necessary caging of dogs in the research environment and limitation to exercise reduces energy expenditure. it is also important to realize that other factors may predispose dogs to obesity, even when guidelines for caloric intake and energy laboratory animal medicine expenditure are followed (butterwick and hawthorne, ) . as in humans, genetics plays an important role in the development of obesity in dogs, and certain breeds are more predisposed toward obesity. in a study of dogs visiting veterinary clinics in the united kingdom, labrador retrievers were most likely to be obese. other breeds affected included cairn terriers, dachshunds, basset hounds, golden retrievers, and cocker spaniels. the beagle was also listed as a breed predisposed to obesity in the household environment (edney and smith, ) . several metabolic or hormonal changes are also associated with obesity. it has been well established that neutering promotes weight gain. in one study, spayed female dogs were twice as likely to be obese compared with intact females (macewen, ) . the authors proposed that the absence of estrogen promotes an increase in food consumption. a similar trend toward obesity was found in castrated male dogs (edney and smith, ). in addition, hypothyroidism and hyperadrenocorticism may present with obesity as one of the clinical signs (macewen, ) . differential diagnosis the diagnosis of obesity is somewhat subjective and relies on an estimate of ideal body weight. the ideal body condition for dogs is considered to be achieved when the ribs are barely visible but easily palpated beneath the skin surface. when the ribs are not easily palpated and/or the dog's normal function is impaired by its weight, the animal is considered obese. there are few objective, quantifiable methods for establishing this diagnosis. ultrasound has been evaluated for measurement of subcutaneous fat in dogs, and measurements taken from the lumbar area can be used to reliably predict the total body fat (wilkinson and mcewan, ) . after a diagnosis of obesity has been made, additional diagnostic tests should be performed to determine if there is an underlying cause for the problem. a complete physical exam should be performed to look for signs of concurrent disease and to establish if obesity has adversely affected the individual. serum thyroid hormones should be evaluated (see above), and serum chemistry may reveal an increased alkaline phosphatase associated with hyperadrenocorticism. treatment restricting food intake readily treats obesity, and this is easily done in the research setting. it has been suggested that a good weight loss program involves restriction of intake to % of the calculated energy requirement to maintain ideal body weight. it has been shown that restriction of calories down to % produces no adverse health effects. however, t levels will decrease in direct proportion with caloric intake. ideally, weight loss will occur at a rate of - % of body weight per week (laflamme et al., ) . with more severe calorie restriction and more rapid weight loss, the individual is more likely to have rebound weight gain after restrictions are relaxed. there has been a great deal of attention in humans as to the correct diet to encourage weight loss. likewise, the type of diet fed to dogs has been examined. as mentioned above, the restriction of calories is most important, and feeding less of an existing diet can do this. alternatively, several diet dog foods are available, and there is some evidence that these diets are superior to simple volume restriction (macewen, ) . there has been much concern about the addition of fiber to the diet as a method for reducing caloric intake while maintaining the volume fed. studies in dogs have examined the addition of both soluble and insoluble fibers to calorie-restricted diets. these studies have shown that the addition of fiber does not have an effect on satiety in dogs and therefore does not have a beneficial effect in weight loss protocols (butterwick et al., ; butterwick and markwell, ) . research complications it is important to control weight gain in research animals because of the association of obesity with metabolism. although an association between obesity and reproductive, dermatologic, and neoplastic problems has been reported (macewen, ) , this relationship is not consistently apparent (edney and smith, ) . joint problems including osteoarthritis and hip dysplasia have also been related to obesity (macewen, ; kealy et al., ) . in addition, diabetes mellitus has been linked to obesity and obesity-induced hyperinsulinism in several experimental models (macewen, ) . a recent study demonstrated metabolic disease, typified by hyperinsulinemia and hypoadiponectinemia, in approximately % of obese dogs (tvarijonaviciute et al., ) . research that requires anesthesia may be complicated by a greater risk of cardiovascular diseases (edney and smith, ) including hypertension and compromise to the respiratory tract. etiology in the laboratory setting, the majority of traumatic wounds will be small in size and quickly observed. occasionally, dogs may sustain minor trauma during transport or have a small, previously undetected, chronic wound upon arrival at the facility. when dogs are group housed, they may sustain bite wounds during early socialization periods. under these conditions, proper initial treatment will lead to uncomplicated wound healing. complications such as infection and delayed healing arise when wounds are not noticed immediately or when the basic principles of wound management are not followed. clinical signs the signs and appearance of a traumatic wound will vary with the cause and the duration of time since wounding. abrasions, sustained by shear forces, are partial thickness skin wounds characterized laboratory animal medicine by minimal bleeding or tissue disruption. puncture wounds have a small surface opening but penetrate into deep tissues with the potential for contamination. lacerations are wounds caused by sharp separation of skin that may extend to deeper tissues. acute wounds are characterized by bleeding tissue, sharp edges and no obvious devitalization. they have variable degrees of contamination. chronic wounds generally do not exhibit active bleeding and will have curled or rounded edges. these wounds often have necrotic tissue and are considered contaminated. treatment to aid decision making about wound therapy, several classification systems have been developed for traumatic injuries. at one time, decisions about wound therapy were largely based upon the length of time since wounding, or the concept of a 'golden period.' it is now recognized that several factors must be considered prior to initiating wound care, including (but not limited to) the type and size of the wound, the degree of wound contamination, and the competence of the host's defense systems (swaim, ; waldron and trevor, ) . one of the most widely used classification systems is based upon wound contamination and categorizes wounds as clean, clean-contaminated, contaminated, or dirty (see table . ). the vast majority of the wounds seen in the laboratory setting will fall into the clean and clean-contaminated categories. these wounds may be treated with the basic wound care described below and primary closure of the wound. contaminated and dirty wounds require more aggressive therapy. postsurgical infections or complications of initial therapy would be considered dirty wounds. when in doubt as to the classification of a wound, the worst category should be presumed in order to provide optimal therapy and reduce the chance for complications. the initial treatment of a wound is the same regardless of its classification. when first recognized, the wound should be covered with a sterile dressing until definitive treatment can be rendered. bleeding should be controlled with direct pressure; tourniquets are discouraged because of the complications that may arise with inappropriate placement (swaim, ) . it is best to avoid using topical disinfectants in the wound until further wound treatment (culture, debridement, lavage) has been performed (swaim, ) . anesthesia or analgesia may be necessary and the choice of agent will depend on the size and location of the wound as well as the preference of the clinician. if the wound is contaminated or dirty, bacterial cultures, both aerobic and anaerobic, should be performed. then a water-soluble lubricant gel may be applied directly to the wound to prevent it from further contamination during the hair removal process. a wide margin of hair should be clipped and a surgical scrub performed around the edges of the wound. povidone-iodine alternating with alcohol or chlorhexidine gluconate scrub alternating with water is most often recommended for surgical preparation of the skin surface (osuna et al., a, b) . simple abrasions that involve only a partial thickness of the skin do not generally require further treatment. full-thickness wounds require further attention, including irrigation with large quantities of a solution delivered under pressure. several irrigation solutions have been recommended (lozier et al., ; waldron and trevor, ; sanchez et al., ) , but type may not be as important as the volume and pressure of delivery. it has been suggested that psi is required to obtain adequate tissue irrigation, and this may be achieved by using a -ml syringe with an -or -gauge needle (waldron and trevor, ) . for wounds that are contaminated or dirty, debridement is an important part of initial therapy. debridement usually proceeds from superficial to deeper layers. skin that is obviously necrotic should be removed. although it is often recommended to remove skin back to the point at which it bleeds, this may not be feasible with large wounds on the limbs. in addition, other factors such as edema or hypovolemia may reduce bleeding in otherwise viable skin (waldron and trevor, ) . if one is unsure about tissue viability in areas that are devoid of waldron and trevor ( ) . extra skin, the tissue may be left (swaim, ; waldron and trevor, ) , and nonviable areas will demarcate within - days (waldron and trevor, ) . necrotic fat should be resected liberally, because it does not have a large blood supply and will provide an environment for infection. often, resection of subcutaneous fat is necessary to remove debris and hair that could not be removed during wound irrigation. damaged muscle should also be liberally resected (swaim, ) . the wound should be irrigated several times during debridement and again after completion. after initial wound treatment, the options concerning wound closure must be weighed. the principles of basic surgery are discussed in several good texts, and readers are encouraged to pursue additional information. primary wound closure is defined as closure at the time of initial wound therapy and is the treatment of choice for clean and clean-contaminated wounds. closure is performed in two or more layers, carefully apposing tissues and obliterating dead space. if dead space will remain in the wound, a drain should be placed. subcutaneous closure should be performed with absorbable suture such as polydioxanone, polyglactin , or polyglycolic acid. it is best to use interrupted sutures and avoid leaving excess suture material in the wound. it may be necessary to choose tension-relieving suture patterns, such as horizontal mattress. skin closure is generally performed with nylon ( - or - ). in situations where gross contamination cannot be completely removed, closure of the wound should be delayed or avoided. after debridement and irrigation, the wound should be bandaged. the wound may be covered by a nonadherent dressing such as vaseline-impregnated gauze (swaim, ) . the contact layer is covered by cotton padding, and the entire bandage is covered by a supportive and protective layer. the bandages should be changed once or twice daily, depending upon the amount of discharge coming from the wound. wound closure within - days of wounding (prior to the formation of granulation tissue) is considered delayed primary closure. when the wound is closed after days, this is considered secondary closure (waldron and trevor, ) . second-intention healing involves allowing the wound to heal without surgical intervention. this type of healing is often used on limbs when there is an insufficient amount of skin to allow complete closure (swaim, ) . it is important to note that second-intention healing will take longer than with surgical repair, and, in the case of large wounds, it will be more expensive because of the cost of bandaging materials. several factors must be weighed when considering the use of antibiotics in traumatic wound care, including the classification and site of the wound, host defenses, and concurrent research use of the animal. when wounds are clean or clean-contaminated, antibiotics are seldom necessary unless the individual is at high risk for infection. when wounds have been severely contaminated or are dirty, antibiotics are indicated and the type of antibiotic will ultimately depend on culture and sensitivity results. until such results are available, the choice of antibiotic is based on the most likely organism to be encountered. topical application of bacitracin, neomycin sulfate, and polymixin b combinations may be used in wounds with minor contamination. in skin wounds with more extensive contamination, staphylococcus spp. are generally of concern, whereas pasteurella multocida should be considered in bite wounds. when systemic antibiotics are necessary, cephalosporins, amoxicillinclavulanate, and trimethoprim sulfas are often recommended for initial antibiotic therapy (waldron and trevor, ) . prevention in facilities with good husbandry practices and a diligent staff, potentially injurious equipment or surfaces are identified quickly. appropriate attention to surgical technique and to initial wound care will generally reduce the occurrence of postprocedure wound infection. etiology pressure sores (decubital ulcers) can be a problem in long-term studies and housing situations that require chronic skin contact with hard surfaces. decubital ulcers often develop over a bony prominence such as the elbow, tuber ischii, tarsus, or carpus. the compression of soft tissues between hard surfaces results in vascular occlusion, ischemia, and ultimately tissue death (swaim and angarano, ) . several factors that increase pressure at the site and/or affect the integrity of the skin will predispose an individual to develop pressure sores, including poor hygiene, self-trauma, low-protein diet, preexisting tissue damage, muscle wasting, inadequate bedding, and ill-fitting coaptation devices (swaim and angarano, ) . clinical signs initially, the skin will appear red and irritated. over time, constant trauma can result in full-thickness skin defects and can progress to necrosis of underlying tissues. the severity of the sores may be graded from i to iv according to the depth of the wound and the tissues involved, from superficial skin irritation to involvement of underlying bone (waldron and trevor, ) . epizootiology the problem usually occurs in large dog breeds, but any type of dog can be affected. prevention and control minimizing or eliminating predisposing factors is important to both the prevention and treatment of this condition. if a dog will experience long periods of recumbency, adequate bedding or padding must be provided. recumbent animals should be moved frequently, ideally every h, to prevent continuous compression on a specific laboratory animal medicine area (waldron and trevor, ) . skin hygiene is of the utmost importance when trying to prevent or treat pressure sores. the skin should be kept clean and dry at all times. if urine scalding is a problem, the affected area should be clipped, bathed, and dried thoroughly at least once or twice daily. finally, an appropriate diet to maintain body weight will minimize compressive forces experienced over areas susceptible to ulceration (swaim and angarano, ) . treatment the treatment of pressure sores must involve care of the wound and attention to the factors causing the wound. the extent of initial wound management will largely depend on the depth of the wound. for simple abrasions and small wounds involving the skin only, simple wound cleansing and openwound management provide adequate treatment. when wounds involve deeper tissues, including fat, fascia, or bone, more aggressive diagnostics and therapy must be performed. the affected area should be radiographed to assess bone involvement and the wound should be cultured. all of the damaged tissue should be debrided and basic wound management guidelines should be followed (see above). when a healthy granulation bed has formed over the entire wound, a delayed closure over a drain may be performed (swaim and angarano, ) . with extensive lesions, reconstruction with skin flaps may be necessary (waldron and trevor ) . bandaging should be performed on all full-thickness wounds; however, it is important to remember that illfitting or inadequately padded bandages or casts may worsen the problem. the area over the wound itself should not be heavily padded. the wounded area should be lightly covered and then a doughnut, created from rolled gauze or towel, should be fitted around the wound, in order to displace pressure over a larger area and onto healthier tissue. the doughnut is then incorporated into a padded bandage. if a cast has been applied to the area for treatment or research purposes, a hole can be cut over the wound to reduce pressure in that area and allow treatment of the wound (swaim and angarano, ) . bandages should be removed at least once or twice a day to allow wound care. etiology an acral lick granuloma is a skin lesion caused by self-trauma. in a few cases, the self-trauma is due to initial irritation caused by an identifiable neurologic or orthopedic condition (tarvin and prata, ) . allergy may also be a source of irritation that leads to self-trauma. however, the majority of cases begin because of repetitive licking by dogs that are confined and lack external stimuli (swaim and angarano, ) . it has been theorized that the self-trauma promotes the release of endogenous endorphins, which act as a reward for the abnormal behavior (dodman et al., ) . the laboratory environment could promote the abnormal behavior and lead to acral lick granuloma. epizootiology the lesions associated with acral lick granuloma are seen most often in large dog breeds, particularly dobermans. however, any type of dog can be affected (walton, ) . clinical signs early lesions appear as irritated, hairless areas usually found on the distal extremities (swaim and angarano, ) . the predilection for the limbs may be due to accessibility or possibly a lower threshold for pruritus in these areas. as the lesions progress, the skin becomes ulcerated and the wound develops a hyperpigmented edge. the wounds may partially heal and then be aggravated again when licking resumes. diagnosis and differential diagnosis acral lick granulomas must be differentiated from several other conditions, including bacterial or fungal infection, foreign bodies, and pressure sores. in addition, mast cell tumors and other forms of neoplasia can mimic the appearance of acral lick granuloma. many of the aforementioned problems can be ruled out by the history of the animal. however, a complete history may be unavailable in the laboratory setting. fungal cultures and allergy testing may aid in diagnosis. biopsy of the affected area would rule out neoplasia. an uncomplicated acral lick granuloma would feature hyperplasia, ulceration, and fibrosis without evidence of infection or neoplasia (walton, ) . prevention and control behavior modification and relief of boredom are important aspects of preventing (and treating) acral lick granuloma. environmental enrichment including exercise, co-housing and various toys is already a basic requirement and may be increased to combat self injurious behaviors. treatment several treatments have been reported for acral lick granuloma and the selection of a treatment should be based on the underlying cause. one of the most important aspects of treatment is to break the cycle of self-trauma. mechanical restraint with an elizabethan collar is one of the easiest methods to accomplish this goal. several direct treatments have been examined, including intralesional and topical steroids, perilesional cobra venom, acupuncture, radiation, and surgery (swaim and angarano, ; walton, ) . opioid antagonists have been applied as treatments for acral lick granulomas and self-injurious behaviors with the theory that this will block the effects of endogenous opioids. naltrexone and nalmefene have been used successfully to reduce excessive licking behaviors and resolve associated lesions. however, lesions did recur after the drugs were discontinued (dodman et al., ; white, ) . the topical administration of a mixture of flunixin meglumine, steroid, and dimethyl sulfoxide has also been shown to be effective (walton, ) . in addition, psychoactive drugs have been suggested to relief of laboratory animal medicine boredom or anxiety. these have included phenobarbital, megestrol acetate, and progestins. however, side effects have been reported (swaim and angarano, ) . other behavior-modifying medications such as clomipramine may be effective in the treatment of compulsive anxiety disorder. the potential for effects that could interfere with experimental results must be determined prior to initiation of treatment. it is important to note that none of the above-mentioned treatments have been successful in all cases. the overall prognosis for acral lick granuloma should be considered guarded since the lesions often recur when treatment is discontinued. etiology hygromas are fluid-filled sacs that develop as a result of repeated trauma or pressure over a bony prominence. the area over the olecranon is most frequently affected, but hygromas have been reported in association with the tuber calcis, greater trochanter, and stifle (newton et al., ) . epizootiology elbow hygromas are most frequently reported in large and giant breeds of dogs, less than years of age (johnston, ; white, ; cannap et al., ) . elbow hygromas are seen infrequently in the laboratory animal setting because the commonly affected breeds are seldom used in research. however, the housing environment of research dogs, especially cage bottoms and cement runs, may predispose them to hygromas. for this reason, laboratory animal veterinary and husbandry staff should be familiar with this condition. clinical signs the clinical presentation will depend upon the chronicity of the problem. a dog with an elbow hygroma usually presents with a painless, fluctuant swelling over the point of the elbow without signs of lameness. the condition may be unilateral or bilateral. over a long period of time, elbow hygromas may become inflamed and ulcerated. if the hygroma becomes secondarily infected, the animal may exhibit pain and fever (johnston, ; white, ) . pathology the fluid-filled cavity in the hygroma is lined by granulation and fibrous tissue. hygromas lack an epithelial lining and therefore are not true cysts. the fluid within the cavity is a yellow or red serous transudate. this fluid is less viscous than joint fluid and elbow hygromas do not communicate with the joint (johnston, ) . treatment the treatment of elbow hygromas should be conservative whenever possible. conservative management of the elbow hygroma is aimed at relieving the source of pressure at the point of the elbow. in early and mild cases, simply providing padding to cover hard surfaces will result in resolution of the hygroma. a soft padded bandage or doughnut bandage around the affected site may also be of benefit. neoprene/polyester sleeves that cover the elbows and fit over the shoulders are also available as an option for either prevention or treatment of hygromas (cannap et al., ) . more aggressive therapies, including needle drainage and injection of corticosteroids into the hygroma, have been described but are not recommended due to the risk of infection (johnston, ) . surgical options should be reserved for complicated or refractory cases. even simple excision can be associated with complications such as wound dehiscence and ulceration (johnston, ) due to the location of the bony prominence at the surgical site. this issue may be avoided by using a skin advancement flap (white, ) that allows intact, healthy skin to cover the boney prominence. a muscle advancement flap has also been described (green et al., ) . regardless of the method used to treat an elbow hygroma, recurrence of the problem is likely unless the predisposing factors are identified and relieved. etiology in the research environment, corneal ulcers are most often associated with direct trauma, contact with irritating chemicals, or exposure to the drying effects of air during long periods of anesthesia. chronic or recurrent corneal ulcers may also be associated with infection or hereditary causes in some breeds of dogs; however, these would be rare in the laboratory setting. clinical signs the signs of corneal ulceration are blepharospasm, epiphora, and photophobia. the eye may appear irritated and inflamed. in minor cases, the cornea may appear normal however, in cases of deeper ulceration, the cornea may appear roughened or have an obvious defect. in addition, the periocular tissues may be swollen and inflamed because of self-inflicted trauma from rubbing at the eye. diagnosis a tentative diagnosis of corneal ulcer or abrasion may be based on the clinical signs. a definitive diagnosis of corneal ulcers is made by the green appearance of the cornea when stained with fluorescein dye. when a corneal ulcer has been diagnosed, the eye should be inspected for underlying causes such as foreign bodies, abnormal eyelids, or abberant cilia. treatment the treatment of corneal ulcers will depend on the depth and size of the affected area, as well as the underlying cause. superficial abrasions are generally treated with topical application of antibiotics. a triple antibiotic ointment that does not contain steroids given three times a day for - days usually provides adequate treatment. simple corneal ulcers are restained with fluorescein after days and should show complete healing at that time. if the ulcer is not healed, this may indicate that the ulcer has an undermined edge impeding proper healing. topical anesthetic should be applied to the eye, and a cotton-tipped applicator can be rolled over the surface of the ulcer toward its edge. this will remove the unattached edge of the cornea and healing should progress normally after debridement. deep ulcers may require further debridement and primary repair. in such cases, a third eyelid or conjunctival flap may be applied to the eye until experienced help can be obtained. in all cases, an elizabethan collar or other restraint may be necessary to prevent additional trauma to the eye. ulcers caused by entropion, ectropion, or dystichiasis will not resolve until the condition is repaired, and descriptions for this can be found elsewhere. prevention the proper application of lubricant eye ointment at the time of anesthesia will prevent drying due to exposure and may also protect the eye from scrub solutions applied near the eye. early treatment of superficial ulcers should prevent self-trauma and progression of the wound. etiology research protocols often require the placement of chronic implants. implants such as cardiac or other biomedical devices may be the primary focus of the research study. implants may also be used as chronic monitoring devices, for delivery of compounds, or to collect serial samples. infection may occur at the time of implant. alternatively, the implant may serve as a nidus after hematogenous spread from other sources. one of the most common sources of infection is from colonization of the device from an external component, which is a frequent complication with indwelling catheters. the actual incidence of complications associated with indwelling vascular catheters in dogs is unknown. one study (hysell and abrams, ) examined the lesions found at necropsy in animals with chronic indwelling catheters, which included traumatic cardiac lesions, visceral infarcts, and fatal hemorrhages. these lesions were primarily associated with catheter-induced trauma or secondary to embolization of fibrin. in a veterinary clinical setting, infections in peripheral catheters were more likely when the catheters were used for blood collection immediately after placement and when a 't' connector rather than a 'y' connector was used. . intestinal access ports have been used to study the pharmacokinetics of drugs at various levels in the intestinal tract. these catheters are usually vascular access ports with several modifications to allow secure placement in bowel (meunier et al., ) . the most frequently reported complication associated with these catheters is infection around the port site (meunier et al., ; kwei et al., ) . clinical signs dogs with implant infections may not exhibit signs initially . localized swelling around the implant may occur. in the case of indwelling catheters, signs may include redness and swelling of the skin around the external port or discharge from the skin wound. vascular access ports may develop fluctuant subcutaneous abscesses. in more severe cases, systemic signs may be noted (bach et al., ; hysell and abrams, ) . the systemic signs of infection are covered elsewhere in this chapter. treatment the treatment of catheter infections almost invariably requires removal of the catheter, as demonstrated in both dogs and monkeys (ringler and peter, ; darif and rush, ). superficial wound irritation or infection may be treated locally with antibiotic ointment, sterile dressing changes, and efforts to minimize catheter movement; however, more extensive problems require aggressive therapy. localized abscesses or sinus tracts may be managed by establishing drainage and copious flushing. aerobic and anaerobic cultures of blood and locally infected sites should be performed prior to initial treatment (ringler and peter, ) . systemic antibiotic therapy should be initiated for a -day period. the choice of drug will ultimately be based on previous experience and culture results. if retention of a catheter is important, the catheter lumen may be safely disinfected with chlorine dioxide solution (dennis et al., ) . the solution is removed after min and replaced with heparinized saline. all of the extension lines and fluids used with an infected catheter should be discarded. the blood cultures should be repeated days after the antibiotic therapy has ceased. if bacteria are still cultured, the catheter must be removed. prevention it is highly desirable to prevent complications that may result in loss of an implanted device. catheters and other implants should be made of nonthrombogenic material and be as simple as possible. a catheter with extra ports or multiple lumens requires additional management and supplies more routes for infection. the initial placement of an indwelling catheter must be done under aseptic conditions by individuals who are familiar with the procedure. intravenous catheters that are used for delivery of drugs or blood sampling should be positioned in the vena cava and not in the right atrium, thereby minimizing trauma to the tricuspid valve. ideally, catheters are secured to reduce movement and irritation of the skin, which may predispose to infection around external ports. the use of vascular access ports that lie entirely under the skin eliminates many problems with infection. it has also been found that long extension tubing connected to the port may actually reduce the potential for infection of the catheter (ringler and peter, ) . for intestinal access ports, catheter security may be improved with a synthetic cuff added to the end of the catheter allowing better attachment to the intestine (meunier et al., ) . after any catheter placement, animals should be observed daily for signs of either local or systemic infection. the catheter entry site should be disinfected, coated with antibiotic ointment, and rebandaged every other day. once a month, the catheter line may be disinfected with chlorine dioxide. in addition, a solution of the antibiotic ceftazidime used on alternate days with the heparin locking solution has been shown to effectively reduce infections in indwelling vascular catheters (bach et al., ) . throughout the life of the catheter, injections into and withdrawals from the catheter should be done in a sterile manner, and the number of breaks in the line should be kept to a minimum. periodically, the placement of an indwelling catheter may be verified by radiography. when placed and managed correctly, catheters and ports of any kind may remain in place for months without complications. etiology sepsis is defined as the systemic response to infection caused by bacteria (gram negative and/or gram positive), fungi, or viruses. in laboratory animals, sepsis is most often seen as a complication of surgical procedures or associated with chronic implants. sepsis may also be seen as a complication of infectious diseases such as parvovirus. clinical signs the signs of sepsis can vary, depending on the source of the infection and the stage of the disease. early in the course, dogs may present with signs of a hyperdynamic sepsis, including increased heart rate, increased respiratory rate, red mucous membranes, and a normal-to-increased capillary refill time. systemic blood pressure and cardiac output will be increased or within the normal range. the animals will often be febrile. later in the course of the syndrome, the animals may show classic signs of septic shock including decreased temperature, pale mucous membranes, and a prolonged capillary refill time. cardiac output and blood pressure are decreased as shock progresses. peripheral edema and mental confusion have also been reported (hauptman and chaudry, ) . pathogenesis the pathophysiology of sepsis is complex and is mediated by immune responses involving mediators such as cytokines, eicosinoids, complement, superoxide radicals, and nitric oxide. the body responds to overwhelming infection with an attempt to optimize metabolic processes and maximize oxygen delivery to tissues. however, if inflammation is left unchecked, the system may be unable to compensate, and the result is cardiovascular collapse. diagnosis in general, a presumptive diagnosis of sepsis is made based on the occurrence of several in a group of signs, including altered body temperature, increased respiratory and/or heart rate, increased or decreased white blood cell (wbc) count, increased number of immature neutrophils, decreased platelet count, decreased blood pressure, hypoxemia, and altered cardiac output. however, extreme inflammation without infection (e.g., pancreatitis, trauma) may create similar signs. one study examined the diagnosis of sepsis in canine patients at a veterinary hospital based on easily obtainable physical and laboratory findings. that study found that septic individuals had higher temperatures, wbc counts, and percentage of band neutrophils than nonseptic individuals, whereas platelet counts were lower in the septic dogs. there were no differences in respiratory rate or glucose levels between the groups. using these criteria, the results had a high sensitivity and a tendency to overdiagnose sepsis (hauptman et al., ) . ultimately, the presence of a septic focus simplifies diagnosis greatly; however, the focus may not be obvious. if the signs of sepsis are evident but the focus is not, several areas should be evaluated for infection, including the urinary, reproductive, respiratory, alimentary, and cardiovascular systems, as well as the abdominal cavity (kirby, ) . treatment the treatment of sepsis has three aims. the first aim is to support the cardiovascular system. all septic animals should be treated with fluids to replace deficits and to maximize cardiac output. crystalloids are most frequently used to maintain vascular volume, primarily because of their low cost. colloids offer the advantage of maintaining volume without fluid overload and may have other positive effects on the cardiovascular system. acid-base and electrolyte imbalances should also be addressed. after the animal has stabilized, the treatment of sepsis should be aimed at removing the septic focus. obvious sources of infection should be drained or surgically removed. if an implant is infected, it should be removed. antibiotic therapy should also be instituted. the choice of antibiotic will ultimately depend upon the results of culture; however, the initial choice of antibiotics is based on previous experience, source of infection, and gram stains. the organisms associated with sepsis are often gram-negative bacteria of gastrointestinal origin or are previously encountered nosocomial infections. ideally, the antibiotic chosen for initial therapy should be a broad-spectrum, bactericidal drug that can be administered intravenously. second-or thirdgeneration cephalosporins provide good coverage, as does combination therapy with enrofloxacin plus metronidazole or penicillin. finally, the treatment of sepsis is aimed at blocking the mediators of the systemic response. this category of sepsis treatment is the focus of much research. several studies have examined the effects of steroids, nonsteroidal anti-inflammatory drugs, and antibodies directed against endotoxin, cytokines, or other mediators of the inflammatory response; however, none of these treatments have proven greatly effective in clinical trials. consequently, there is no 'magic bullet' for the treatment of sepsis at this time. successful therapy remains dependent on aggressive supportive care coupled with identification and elimination of the inciting infection. etiology in research animals, aspiration may occur accidentally during the oral administration of various substances or by the misplacement of gastric tubes. aspiration of gastric contents may also occur as a complication of anesthesia. in pet animals, aspiration is often seen as a result of metabolic and anatomical abnormalities; however, such occurrence would be rare in the research setting. pathogenesis aspirated compounds can produce direct injury to lung tissue, but more importantly, the aspiration provokes an inflammatory response, probably mediated by cytokines. the result is a rapid influx of neutrophils into the lung parenchyma and alveolar spaces. the inflammation leads to increased vascular permeability with leakage of fluid into the alveolar spaces and can eventually lead to alveolar collapse. if the condition is severe, it may result in adult respiratory distress syndrome and respiratory failure. it should be noted that infection is not present in the early stages of this condition but may complicate the problem after - h. clinical signs the severity and clinical manifestation of aspiration lung injury are dependent upon the ph, osmolality, and volume of the aspirate. the signs of aspiration lung injury may include cough, increased respiratory rate, pronounced respiratory effort, and fever. when respiration is severely affected, the oxygen saturation of blood will be decreased. the diagnosis of this problem is based on witness of aspiration, history consistent with aspiration, and/or the physical findings. classically, radiographs of the thorax demonstrate a bronchoalveolar pattern in the cranioventral lung fields. however, these lesions may not appear for several hours after the incident of aspiration. in addition, the location of the lesions may be variable, depending on the orientation of the animal at the time of aspiration. treatment the treatment of aspiration lung injury is largely supportive and depends upon the severity of the inflammation and the clinical signs. if the aspiration is witnessed, the mouth and, idealy, the upper airway should be cleared of residual material. when small amounts of a relatively innocuous substance (e.g., barium) have been aspirated, treatment may not be necessary. when severe inflammation is present, systemic as well as localized therapy may be necessary. oxygen therapy may be instituted; however, the concentration and time frame are controversial, because lung injury may be exacerbated by long-term administration of oxygen at high concentrations (nader-djahal et al., ) . fluid therapy may also be necessary in severe cases; however, cardiovascular support should be performed judiciously as fluid overload could lead to an increase in pulmonary edema. the use of colloids is also controversial because of the increase in vascular permeability that occurs in the lungs. several studies have addressed the use of anti-inflammatory agents to reduce lung injury associated with aspiration; however, none are used clinically in human or veterinary medicine at this time. corticosteroids are contraindicated (raghavendran et al., ) . in humans, antibiotics are reserved for cases with confirmed infection, in order to prevent the development of antibiotic-resistant pneumonia. it has been suggested that dogs should be immediately treated with antibiotics when the aspirated material is not acidic or has potentially been contaminated by oral bacteria associated with severe dental disease. amoxicillin-clavulanate has been recommended as a first line of defense, reserving enrofloxacin for resistant cases (hawkins, ) . the presence of pneumonia should be verified by tracheal wash and cultures. prevention aspiration of drugs and other compounds may be avoided through careful administration of oral medications by experienced individuals. likewise, gavage or orogastric administration of liquids should be performed by experienced individuals, and the procedure should be aborted if coughing or other respiratory signs occur. the aspiration of stomach contents can largely be avoided by appropriate fasting prior to anesthesia for at least h for food and h for water. if appropriate fasting times are not observed, anesthesia should be postponed whenever possible, particularly if intended procedures require manipulation of the viscera or head-down positioning of the dog. if anesthesia cannot be avoided, it should be rapidly induced and the dog should be intubated. during recovery from anesthesia, the endotracheal tube should be removed with the cuff partially inflated and with the dog in a head-up position (haskins, ) . based on the source of energy, burn wounds may be categorized into four groups: thermal, chemical, radiation, and electrical. in laboratory animals, accidental burns are usually the result of thermal injury (heating pads, water bottles), chemicals (strong alkalis, acids, disinfectants, drugs), or experimental irradiation protocols. etiology inappropriate use of external heating devices is the most common cause of burns in laboratory animal medicine. the insult to the skin results in desiccation of the tissue and coagulation of proteins. in addition, the severely injured area is surrounded by a zone of vascular stasis, which promotes additional tissue damage. even small burns can result in significant inflammation that could affect the outcome of some research investigations and cause considerable discomfort to the animal. the proper and immediate treatment of burn wounds can reduce the effects of the injury on both the individual and the research. clinical signs the clinical signs vary with the depth, location, and surface area of burn injury. classification systems for thermal burns are generally based on the depth of the injury, varying from superficial involvement of only epidermis to complete destruction of skin and subcutaneous tissues (bohling, ) . superficial burns appear erythematous and inflamed. in some cases, matting of the overlaying hair with exudate may be the first sign of a previously undetected skin lesion. progressive hair and skin loss may be evident over the first few days after injury (johnston, ) . although blistering is a characteristic of partial thickness burns in humans, this is rarely seen in dogs (bohling, ) . uncomplicated, superficial burn wounds heal by reepithelialization within - days. deeper burn wounds are characterized by a central area of nonviable tissue surrounded by edematous, inflamed tissues. a thick eschar, composed of the coagulated proteins and desiccated tissue fluid, develops over deep burn wounds. these wounds heal by granulation under the eschar, which will eventually slough. the amount of pain associated with burns depends upon several factors including the depth and area of the wound, procedural manipulations, and movement at the affected site (bohling, ) . pain associated with superficial burn wounds usually subsides in - days. theoretically, deep burns destroy nerve endings and result in less pain than superficial burns. however, inflammatory pain may still be present due to the tissue reaction around the necrotic site. in addition, sharp procedural pain and breakthrough pain have been described in humans during the healing phases of burn injuries and should be considered as potential complications in dogs as well (bohling, ) . severe and widespread accidental burn injury can result in clinical signs associated with multiple organs including the pulmonary, gastrointestinal, hematopoietic, and immune systems. in addition, extensive burn injury can predispose to infection and even sepsis. this type of injury with the associated complications would be extremely rare in the laboratory setting. treatment appropriate and timely treatment of a burn wound will reduce the extent of tissue damage and associated pain. thermal injuries should be immediately exposed to cool water ( °c) to reduce edema and pain. exposure to very cold water and ice does not improve outcomes (bohling, ) . topical wound dressings are recommended in the early stages of treatment for both partial-and full-thickness burns that are of small size. systemic antibiotics are unable to penetrate eschar and are not adequately distributed through the abnormal blood supply of burned tissues. therefore, a thin film of a water-soluble, broad-spectrum antibiotic ointment should be applied to the wound surface. silver sulfadiazine has a broad spectrum, penetrates eschar, and is often the preparation of choice for burn wound therapy. povidone-iodine ointment will also penetrate thin eschar and provides a broad spectrum. mafenide has a good spectrum that covers gram-negative organisms well and is often used to treat infected wounds, although it has been associated with pain upon application (demling and lalonde, ) . once a topical antibiotic has been applied, a nonadherent dressing should be placed on the wound. burn wounds covered in such a manner tend to epithelialize more rapidly and are less painful than uncovered wounds (demling and lalonde, ; bohling, ) . after the initial treatment, burn wounds should be gently cleansed two to three times a day, followed by reapplication of the topical antibiotic and rebandaging (demling and lalonde, ) . systemic antibiotics are indicated in cases where local or systemic infection is present and their ultimate selection should be based on culture results. burn wounds can be extremely painful, and analgesia should be instituted immediately and adjusted accordingly throughout the treatment period. surgical intervention may be necessary in some cases. with small or moderately sized wounds, the eschar over the burn wound may actually impede wound contraction and reepithelialization. in such cases, once the eschar has become fully defined, a complete resection may improve wound healing. with large and severe burn wounds, repeated debridement by surgery or other means might be necessary. in the laboratory setting, a decision to pursue extensive surgical intervention would be dependent upon full consideration of the effects on animal welfare and research results. prevention thermal burns can be prevented in the research setting. electric heating pads and heat lamps should be avoided if possible. only heated water blankets or circulating warm air devices should be used to provide warmth to the animals. in rare instances, heated water blankets have also caused burns; therefore, these devices should be carefully monitored. as a precaution, a thin towel may be placed between the animal and the water blanket. basic fire prevention precautions should be taken particularly around oxygen sources and flammable agents etiology chemical injury may be due to skin contact with concentrated solutions such as disinfectants or inadvertent exposure to laboratory chemicals. in addition, perivascular injection of certain drugs (pentobarbital, thiamylal, thiopental, thiacetarsemide, vincristine, vinblastine, and doxorubicin) have been associated with extensive tissue damage (swaim and angarano, ; waldron and trevor, ) . the mechanism of action will vary depending upon the ph, osmolality, and chemical composition of the agent and may include oxidation, reduction, disruption of lipid membranes, or other reactions (bohling, ; swaim, ; waldron and trevor, ) . clinical signs surface contact with chemicals may result in mild irritation and redness of superficial layers of the skin. however, many agents may cause progressive injury until the chemical reaction has been neutralized. this may result in tissue necrosis and secondary infection. the immediate signs of perivascular injection are withdrawal of the limb or other signs of discomfort and swelling at the injection site. the area may appear red, swollen, and painful as inflammation progresses. there may eventually be necrosis of the skin around the injection site. in cases of doxorubicin extravasation, signs may develop up to a week after the injection, and the affected area may progressively enlarge over a -to -month period. this is because the drug is released over time from the dying cells (swaim and angarano, ) . treatment in cases of skin contact with chemical agents, the affected area should be thoroughly and repeatedly lavaged with warm water to dilute or remove the substance. the material safety data sheet for the substance should be consulted for any possible neutralization protocol. additional treatment will depend upon the severity of the tissue damage and will follow the same guidelines as for the thermal injury described earlier. for the treatment of perivascular injections, dilution of the drug with subcutaneous injections of saline is recommended. in addition, steroids may be infiltrated locally to reduce inflammation. topical application of dimethyl sulfoxide (dmso) may also be helpful in reducing the immediate inflammation and avoiding the development of chronic lesions. the addition of lidocaine to subcutaneous injections of saline has been used in cases of thiacetarsemide injection (hoskins, ) . the local infiltration of hyaluronidase accompanied by warm compresses has been suggested for perivascular vinblastine (waldron and trevor, ) and for doxirubicin. the use of dmso or another free radical scavenger, dexrazoxane, infused at the site has also been suggested for doxorubicin toxicities. despite these treatments, necrosis of skin may be observed and would require serial debridement of tissues with secondary wound closure or skin grafting. in cases of doxorubicin extravasation, early excision of affected tissues is advocated to prevent the progressive sloughing caused by sustained release of the drug from dying tissues (swaim and angarano, ) . in all cases, the condition can be painful and analgesia should be addressed. prevention prior to the use of any substance, the investigator should be aware of its chemical composition and the potential for problems. the material safety data sheets should be available for all compounds and storage recommendations followed closely. for intravenous administration of toxic compounds, insertion of an indwelling catheter is extremely important. prior to the injection, the catheter should be checked repeatedly for patency by withdrawal of blood and injection of saline. any swelling at the catheter site or discomfort by the subject indicates that the catheter should not be used. access to a central vessel such as the cranial or caudal vena cava is preferred over the use of peripheral vessels. when peripheral catheters are used, the injection should be followed by a vigorous amount of flushing with saline or other physiological solution and removal of the catheter. additional injections are best given through newly placed catheters in previously unused vessels. the repeated use of an indwelling peripheral catheter should be approached cautiously and done only out of necessity. etiology radiation burns are generally a complication of therapeutic administration and are a result of free oxygen radical formation (waldron, ) . the severity of radiation burns and their treatment will depend upon the dose, frequency, total surface area, and location of the radiation. damage to epithelial layers of the skin can lead to desquamation. direct injury to fibroblasts results in decreased collagen production and poor wound healing. in addition, there may be fibrosis of blood vessels (pavletic, ) and subsequent hypoxia causing necrosis of deeper tissues. clinical signs the tissues most often affected are the skin and mucus membranes. with superficial injury, affected skin may exhibit hair loss and erythema, and produce a clear exudate. the intensity of the inflammation may increase for - weeks after the completion of radiation treatment. deeper and more serious injury manifests with subcutaneous fibrosis and can lead to disfigurement . the skin and underlying deep structures including the bone may become necrotic over several weeks (pavletic, ) . these deeper injuries are prone to infection due to their lack of blood supply. systemic signs such as vomiting are rare in dogs unless there has been direct radiation treatment to organs . treatment with superficial skin burns, the wound should be kept clean and should be covered if possible. in cases of oral mucous membrane damage, there may be special feeding requirements. when wounds are ulcerated, avascular tissues should be excised. treatments with silver sulfadiazine, mafenide acetate, or other topical agents are recommended to control infection. in addition, infection is avoided by closure of the wound as soon as possible. the goal of surgery is to cover the wound with healthy tissue to promote vascularization of the area. in some cases, this may require muscle and/ or skin grafts. prevention radiation burns can be limited by selection of appropriate, fractionated therapy and application of shielding to reduce exposure. prompt treatment of the injuries can reduce the occurrence of infection. since radiation is associated with poor wound healing, complications may arise when additional procedures are required. it is recommended to wait at least week (pavletic, ) or even longer (laing, ) prior to administering radiation to a surgical site. after radiation, routine surgeries should be avoided for - months (pavletic, ). the prevalence of cancer in the general canine population has increased over the years (dorn, ) . this can be attributed to the longer life spans resulting from improvements in nutrition, disease control, and therapeutic medicine. because of these changes, cancer has become a major cause of death in dogs (bronson, ) . in a lifetime cancer mortality study of intact beagles of both sexes, albert et al. ( ) found death rates similar to the death rate of the at-large dog population (bronson, ) . approximately % of the male beagles died of cancer. the majority of the tumors were lymphomas ( %) and sarcomas ( %), including hemangiosarcomas of the skin and fibrosarcomas. of the female beagles dying of cancer ( % of the population studied), three-quarters had mammary cancer ( %), lymphomas ( %), or sarcomas ( %). of the sarcomas in females, one-third were mast cell tumors. in addition to these tumors that cause mortality, the beagle is also at risk for thyroid neoplasia (hayes and fraumeni, ; benjamin et al., ) . because of the popularity of the beagle as a laboratory animal, discussion of specific neoplasms will focus on the tumors for which this breed is at risk, as well as tumors that are common in the general canine population. a complete review of clinical oncology in the dog is beyond the scope of this chapter but can be found elsewhere (withrow et al., ) . fine-needle aspirates are generally the first diagnostic option for palpable masses, because they can easily be performed in awake, cooperative patients. this technique allows for rapid differentiation of benign and neoplastic processes. in cases where cytologic results from fine-needle aspirates are not definitive, more invasive techniques must be used. needle-punch or core biopsies can also be performed in awake patients with local anesthesia. an instrument such as a tru-cut ® needle (travenol laboratories, inc., deerfield, illinois) is used to obtain a -mm × - . -cm biopsy of a solid mass. a definitive diagnosis may be limited by the size of the sample acquired using this technique. incisional and excisional biopsies are utilized when less invasive techniques fail to yield diagnostic results. excisional biopsies aid in histopathological examination and are the treatment of choice when surgery is necessary, because the entire mass is removed. surgical margins should extend at least cm around the tumor and cm if mast cell tumors are suspected (morrison et al., ) . incisional biopsies are performed when large softtissue tumors are encountered and/or when complete excision would be surgically difficult or life-threatening. when performing an incisional biopsy, always select tissue from the margin of the lesion and include normal tissue in the submission. etiology lymphomas are a diverse group of neoplasms that originate from lymphoreticular cells. canine lymphoma represents - % of canine tumors and a majority ( %) of canine hematopoetic disease (ettinger, ; vail and young, ) . whereas retroviral etiologies have been demonstrated in a number of species (e.g., cat, mouse, chicken), conclusive evidence of a viral etiology has not been established in the dog. in humans, data implicate the herbicide , -dichlorophenoxyacetic acid as a cause of non-hodgkin's lymphoma, but studies in dogs with similar conclusions have come under scrutiny (macewen and young, ) . in addition, tobacco smoke, environmental chemicals, and waste emissions are considered possible risk factors (marconato et al., ; gavazza et al., ) clinical signs multicentric high-grade lymphoma (mhgl) accounts for the majority of reported cases of canine lymphoma. depending upon grade, immunophenotype, and location involved, dogs with mhgl usually present with painless, enlarged lymph nodes and nonspecific signs such as anorexia, weight loss, polyuria, polydypsia, fever, and lethargy. when the liver and spleen are involved, generalized organomegaly may be felt on abdominal palpation. less commonly, dogs develop alimentary, mediastinal, cutaneous, and extranodal lymphomas. alimentary lymphoma is associated with vomiting and diarrhea, in addition to clinical signs associated with mhgl. dogs with mediastinal lymphoma often present with respiratory signs (dyspnea and exercise intolerance) secondary to pleural effusion or cranial vena caval syndrome. hypercalcemia is most frequently associated with this form of lymphoma and may result in polyuria, polydypsia, and weakness. cutaneous lymphoma is an uncommon epitheliotrophic form of lymphoma. it is often referred to as mycosis fungoides and is typically of a cd + t-cell immunophenotype. it varies in presentation from solitary to generalized and may mimic any of a number of other inflammatory skin disorders including oral mucosal lesions. the lesions may occur as erythema, plaques, erosions, scales, nodules, crusts, hypopigmentation, and alopecia (fontaine et al., ) . approximately half of the cases are pruritic. a number of extranodal forms of lymphoma have been reported, including tumors affecting the eyes, central nervous system, kidneys, or nasal cavity. clinical presentation varies, depending on the site of involvement (e.g., nervous system: seizures, paresis, paralysis). epizootiology the incidence of lymphoma is highest in dogs - years old, accounting for % of cases. although the neoplasm generally affects dogs older than year, cases in puppies as young as months have been reported (dorn et al., ) . no gender predilection has been reported. diagnosis and pathologic findings a fine-needle aspirate is initially performed on accessible lymph nodes. thoracic radiographs and abdominal ultrasound ± fine needle aspiration of the liver or spleen can be used if mediastinal or abdominal involvement is suspected. additional staging can be determined through complete blood counts, serum biochemistry, flow cytometry for immunotyping, bone marrow aspiration, or surgical lymphadenectomy and histology. enlarged neoplastic lymph nodes vary in diameter from to cm and are moderately firm. some may have areas of central necrosis and are soft to partially liquefied. the demarcation between cortex and medulla is generally lost, and on cut section, the surface is homogenous. the spleen may have multiple small nodular masses or diffuse involvement with generalized enlargement. the enlarged liver may have disseminated pale foci or multiple large, pale nodules. in the gastrointestinal tract, both nodular and diffuse growths are observed. these masses may invade through the stomach and intestinal walls. flow cytometry and lymphoblastic markers (cd ) can aid in diagnosis and subtyping of tumors. in addition, positron emission tomography is being explored for detection of extranodal and metastatic lymphoma (leblanc et al., ; marconato, ; elstrom et al., ) . classification of lymphoma types is based upon cytological, morphological, and immunological characteristics using the kiel classification criteria (vail and young, ) . histologically, the most common lymphomas are classified as intermediate to high grade and of large-cell (histiocytic) origin. the neoplastic lymphocytes typically obliterate the normal architecture of the lymph nodes and may involve the capsule and perinodal areas. lymphoma subtypes can be further characterized based upon genetic, molecular, and immunological criteria (ponce et al., ) . pathogenesis all lymphomas regardless of location should be considered malignant. a system for staging lymphoma has been established by the world health organization. the average survival time for dogs without treatment is - weeks. survival of animals undergoing chemotherapy is dependent on the treatment regimen as well as the form and stage of lymphoma (macewen and young, ) . median survival time with aggressive therapy is generally less than months. hypercalcemia is a paraneoplastic syndrome frequently associated with lymphoma. the pathogenesis of this phenomenon is not fully understood but may be a result of a parathormone-like substance produced by the neoplastic lymphocytes. differential diagnosis differential diagnoses for multicentric lymphoma include systemic mycosis; salmon-poisoning and other rickettsial infections; lymph node hyperplasia from viral, bacterial, and/or immunologic causes; and dermatopathic lymphadenopathy. alimentary lymphoma must be distinguished from other gastrointestinal tumors, foreign bodies, and lymphocytic-plasmacytic enteritis. in order to make a definitive diagnosis, whole lymph node biopsies and full-thickness intestinal sections for histopathologic examination may be needed. treatment therapy for lymphoma primarily consists of one or a combination of several chemotherapeutic agents. in addition, radiation therapy and bone marrow transplantation have been utilized. the treatment regimen is based on the staging of the disease, the presence of paraneoplastic syndromes, and the overall condition of the patient. although treatment may induce clinical remission and prolong short-term survival, most treatment is palliative and aimed at improving quality of life. a thorough discussion of therapeutic options for the treatment of lymphomas in the dog can be found elsewhere (chun, ; marconato, ) . future directions include development of molecular and cellular targeted therapies to enhance traditional chemotherapy treatment, prolong remission, and treat immunologic subtypes of lymphoma (e.g., t-cell lymphoma). research complications given the grave prognosis for lymphoma with or without treatment, euthanasia should be considered for research animals with significant clinical illness. etiology mast cells are derived from cd + bone marrow progenitor cells. neoplastic proliferations of mast cells are the most commonly observed skin tumor of the dog and may account for up to % of canine skin laboratory animal medicine tumors (bostock, ; welle et al., ) . mast cells are normally found in the connective tissue beneath serous surfaces and mucous membranes, and within the skin, lung, liver, and gastrointestinal tract. current research has linked mast cell tumor development to multifactorial causes including breed predisposition and a genetic component, chronic inflammation, and mutations in the surface growth factor, c-kit (ma et al., ; reguera et al., ; webster et al., ) . clinical signs well-differentiated mast cell tumors are typically solitary, well-circumscribed, slow-growing, -to -cm nodules in the dermis and subcutaneous tissue. alopecia may be observed, but ulceration is not usual. poorly differentiated tumors grow rapidly, may ulcerate, and may cause irritation, inflammation, and edema to surrounding tissues. mast cell tumors can be found on any portion of the dog's skin but frequently affect the trunk and hind limb extremeties along with perineal and preputial areas. the tumors usually appear to be discrete masses, but they frequently extend deep into surrounding tissues. abdominal organs are rarely involved but may be associated with anorexia, vomiting, melena, abdominal pain, and gastrointestinal ulceration. mast cell tumors have also been reported in extracutaneous areas such as the salivary glands, larynx, nasopharynx (london and thamm, ) and conjunctiva (fife et al., ) . mast cell tumors within the perineal, preputial, or inguinal areas are associated with a greater predilection for recurrence or metastasis (misdorp, ) . epizootiology these tumors tend to affect middleaged dogs but have been observed in dogs ranging from months to years (pulley and stannard, ) . pathologic findings because of the substantial variation in histologic appearance of mast cell tumors, a classification and grading system described by patnaik et al. ( ) has become widely accepted. in this system, grade i has the best prognosis and are well differentiated, with round to ovoid, uniform cells with distinct cell borders. the nuclei are round and regular, the cytoplasm is packed with large granules that stain deeply, and mitotic figures are rare to absent. grade ii (intermediately differentiated) mast cell tumors have indistinct cytoplasmic boundaries with higher nuclear-cytoplasmic ratios, fewer granules, and occasional mitotic figures. grade iii (anaplastic or undifferentiated) mast cell tumors have the worst prognosis. the cells contain large, irregular nuclei with multiple prominent nucleoli and few cytoplasmic granules. mitotic figures are much more frequent. cells are pleomorphic with indistinct borders. in addition to associated skin lesions (e.g., ulceration, collagenolysis, necrosis, and infection), mast cell tumors have been associated with gastric ulcers in the fundus, pylorus, and/or proximal duodenum, most likely secondary to tumor production of histamine. histamine stimulates the h receptors of the gastric parietal cells, causing increased acid secretion. gastric ulcers have been observed in large numbers (> %) of dogs with mast cell tumors (howard et al., ) . pathogenesis although all mast cell tumors should be considered potentially malignant, the outcome in individual cases can be correlated with the histologic grading of the tumor. grade iii tumors are most likely to disseminate internally. this spread is usually to regional lymph nodes, spleen, and liver, and less frequently to the kidneys, lungs, and heart. diagnosis and differential diagnosis using fineneedle aspiration, mast cell tumors can be distinguished cytologically from other round cell tumors (such as histiocytomas and cutaneous lymphomas) by using toluidine blue to metachromatically stain the cytoplasmic granules red or purple. mast cell granules can also be stained with wright's, giemsa, and romanowsky stains. in addition, mast cells may contain tryptase, chymase, or both (fernandez et al., ) . histological evaluation is generally required for grading. examination of regional lymph nodes may be warranted if metastatic or systemic disease is suspected. in addition, radiographs and ultrasound with guided aspirates of the liver, spleen, or sublumbar lymph nodes can be used to determine metastatic disease. treatment depending upon the grade, initial treatment for mast cell tumors is generally wide surgical excision ( -cm margins), which may be followed by radiation, chemotherapy, or glucocorticoid therapy. aspiration or surgical removal of regional lymph nodes is recommended if lymphatic tumor drainage is suspected. if the tumor is not completely resectable or is grade ii or iii (moderately to undifferentiated), then debulking surgery and adjunct therapy may be used. treatment algorithms are outlined elsewhere (withrow et al., ) research complications because of the potential for systemic release of substances such as histamine, vasoactive substances, heparin, eosiniphilic chemotactic factor, and proteolytic enzymes, along with the possibility of delayed wound healing and tumor recurrence, dogs with mast cell tumors are not good candidates for research studies. grade i mast cell tumors may be excised, allowing dogs to continue on study; however, monitoring for local recurrence should be performed monthly. grade ii tumors are variable; animals that undergo treatment should be monitored for recurrence monthly, and evaluation of the buffy coat should be performed every - months for detection of systemic mastocytosis. because of the poor prognosis for grade iii tumors, treatment is unwarranted in the research setting. etiology also known as infectious or venereal granuloma, sticker tumor, transmissible sarcoma, and contagious venereal tumor, the canine transmissible venereal tumor (ctvt) is transmitted horizontally to the genitals by coitus (nielsen and kennedy, ) . ctvt is a 'parasitic-like' tumor that appears to have originated from dogs or wolves thousands of years ago and despite immense mutation, ctvt adapted, survived, and spread across multiple continents making it the oldest known continuously passaged somatic cell line (rebbeck et al., ; murchison et al., ; murgia et al., ) . it has been described as a round cell tumor of histiocytic origin. although this tumor has been reported in most parts of the world, it is most prevalent in tropical or temperate climates (macewen, ) . clinical signs the tumors are usually cauliflowerlike masses on the external genitalia, but they can also be pedunculated, nodular, papillary, or multilobulated. these friable masses vary in size up to cm, and hemorrhage is frequently observed. in male dogs, the lesions are found on the caudal part of the penis from the crura to the bulbus glandis or on the glans penis. less frequently, the tumor is found on the prepuce. females typically have lesions in the posterior vagina at the junction of the vestibule and vagina. when located around the urethral orifice, the mass may protrude from the vulva. these tumors have also been reported in the oral cavity, skin, and eyes. epizootiology and transmission ctvts are most commonly observed in young, sexually active dogs. transmission takes place during coitus when injury to the genitalia allows for exfoliation and transplantation of the tumor. genital to oral to genital transmission has also been documented (nielsen and kennedy, ) . extragenital lesions may be the result of oral contact with previously traumatized areas. pathologic findings histologically, cells are arranged in compact masses or sheets. the cells are round, ovoid, or polyhedral, and have large, round nuclei with coarse chromatin. the cytoplasm is eosinophilic with small vacuoles arranged in a 'string of pearls' pattern. pathogenesis tumor growth occurs within - months after mating or implantation, and then growth generally slows. metastasis is rare (< - % of cases) but may involve the superficial inguinal and external iliac lymph nodes as well as distant sites. spontaneous regression may occur within - months of tumor development. diagnosis and differential diagnosis transmissible venereal tumors have been confused with lymphomas, histiocytomas, mast cell tumors, and amelanotic melanomas. however, cytological examination of impression smears, swabs, and fine-needle aspirates generally provide a definitive diagnosis. although not usually required, histopathology of a biopsy from the mass can aid in diagnosis. prevention thorough physical examinations prior to bringing new animals into a breeding program should prevent introduction of this tumor into a colony. control removing affected individuals from a breeding program should stop further spread through the colony. treatment surgery and radiation can be used for treatment, but chemotherapy is the most effective. vincristine ( . - . mg/m ) iv once weekly for four to six treatments will induce remission and cure in greater than % of the cases (macewen, ) . research complications experimental implantation of ctvts has been shown to elicit formation of tumor-specific igg (cohen, ) . this response may occur in natural infections and could possibly interfere with immunologic studies. etiology dogs are susceptible to a wide variety of mammary gland neoplasms, most of which are influenced by circulating reproductive steroidal hormones. clinical signs single nodules are found in approximately % of the cases of canine mammary tumors. the nodules can be found in the glandular tissue or associated with the nipple. masses in the two most caudal glands (fourth and fifth) account for a majority of the tumors. benign tumors tend to be small, well circumscribed, and firm, whereas malignant tumors are larger, invasive, and coalescent with adjacent tissues. inflammatory mammary carcinomas may mimic mastitis or severe dermatitis and must be ruled out to prevent misdiagnosis. epizootiology mammary tumors are uncommon in dogs under years of age with the incidence rising sharply after that. the median age at diagnosis is - years. a longitudinal study of a large beagle colony showed that significant risk for development of mammary tumors begins at approximately years of age (taylor et al., ) . mammary tumors occur almost exclusively in female dogs, with most reports in male dogs being associated with endocrine abnormalities, such as estrogen-secreting sertoli cell tumors. pathologic findings the t (tumor size), n (lymph node involvement), and m (metastasis) system is commonly used to stage mammary tumors. based on histologic classification of mammary gland tumors, approximately half of the reported tumors are benign (fibroadenomas, simple adenomas, and benign mesenchymal tumors), and half are malignant (solid carcinomas, tubular adenocarcinomas, papillary adenocarcinomas, anaplastic carcinomas, sarcomas, and carcinosarcomas) (bostock, ) . histopathologic grades are scored based upon tubule formation, nuclear pleomorphism, and mitosis (elston and ellis, ) . extensive discussions of classification, staging, and histopathologic correlations can be found elsewhere (moulton, ; sorenmo et al., ) . pathogenesis mammary tumors of the dog develop under the influence of hormones. receptors for both estrogen and progesterone can be found in - % of tumors. malignant mammary tumors typically spread through the lymphatic vessels. metastasis from the first, second, and third mammary glands is to the ipsilateral axillary or anterior sternal lymph nodes. the fourth and fifth mammary glands drain to the superficial inguinal lymph nodes where metastasis can be found. many mammary carcinomas will eventually metastasize to the lungs and extraskeleton. diagnosis and differential diagnosis both benign and malignant mammary tumors must be distinguished from mammary hyperplasia, mastitis, and severe dermatitis. cytological evaluation from fine-needle aspirates correlates well with histological examination of benign and malignant tumors (simon et al., ) . radiographs and possibly ultrasound should be performed to rule out metastatic disease prior to surgery. prevention the lifetime risk of developing mammary tumors can effectively be reduced to . % by spaying bitches prior to the first estrus (schneider et al., ) . this is commonly done in the general pet population at months of age. the protective effects of early spay rapidly decrease after several estrus cycles. dogs spayed prior to the first estrus had a risk of . %, whereas dogs spayed after the first and second estrus had risks of % and %, respectively. treatment surgery is the treatment of choice for mammary tumors, because chemotherapy and radiation therapy have not been reported to be effective. the extent of the surgery is dependent on the area involved. single mammary tumors should be surgically removed with -cm lateral margins or margins wide enough for complete resection. deep margins may include removing sections of abdominal fascia or musculature en bloc with mammary tumor. multiple mammary tumors should be removed via regional or unilateral chain mastectomies. bilateral, staged mastectomies are reserved for more aggressive tumors. there is insufficient evidence at this time to recommend routine complete unilateral or bilateral chain mastectomies. at the time of surgery, axillary lymph nodes are removed only if enlarged or positive on cytology for metastasis. sorenmo et al. ( ) provide a thorough review of canine mammary gland neoplasia. research complications treatment of early-stage or low-grade mammary tumors may be rewarding, allowing dogs to continue on study. if removed early enough, malignant masses could yield the same results. all dogs should be monitored regularly for recurrence and new mammary tumors. beagles are subject to many of the inherited and/ or congenital disorders that affect dogs in general. in a reference table on the congenital defects of dogs (hoskins, ) , disorders for which beagles are specifically mentioned include brachyury (short tail), spina bifida, pulmonic stenosis, cleft palate-cleft lip complex, deafness, cataracts, glaucoma, microphthalmos, optic nerve hypoplasia, retinal dysplasia, tapetal hypoplasia, factor vii deficiency, pyruvate kinase deficiency, pancreatic hypoplasia, epilepsy, gm gangliosidosis, globoid cell leukodystrophy, xx sex reversal, and cutaneous asthenia (ehlers-danlos syndrome). other defects observed include cryptorchidism, monorchidism, limb deformity, inguinal hernia, diaphragmatic hernia, hydrocephaly, and fetal anasarca. each of these other congenital defects occurred at less than . % incidence. etiology benign prostatic hyperplasia (bph) is an age-related condition in intact male dogs. the hyperplasia of prostatic glandular tissue is a response to the presence of both testosterone and estrogen. clinical signs bph is often subclinical. straining to defecate (tenesmus) may be seen because the enlarged gland impinges on the rectum. urethral discharge (yellow to red) and hematuria can also be presenting clinical signs. epizootiology and transmission bph typically affects older dogs (> years), although glandular hyperplasia begins as early as years of age. approximately % of inact male dogs will develop bph by years of age (smith, ) . pathologic findings in the early stages of bph, there is hyperplasia of the prostatic glandular tissue. this is in contrast to human bph, which is primarily stromal in origin. eventually, the hyperplasia tends to be cystic, with the cysts containing a clear to yellow fluid. the prostate becomes more vascular with a honeycomb appearance (resulting in hematuria or hemorrhagic urethral discharge), and bph may be accompanied by mild chronic inflammation. pathogenesis bph occurs in older intact male dogs because increased production of estrogens (estrone and estradiol), combined with decreased secretion of androgens, sensitizes prostatic androgen receptors to dihydrotestosterone. the presence of estrogens may also increase the number of androgen receptors, and hyperplastic prostate glands also have an increased ability to metabolize testosterone to α-dihydrotestosterone (kustritz and klausner, ) mediating bph. diagnosis and differential diagnosis bph is diagnosed in cases of nonpainful symmetrical swelling of the prostate gland in intact male dogs, with normal hematologic profiles and urinalysis that may be characterized by hemorrhage. a prostatic biopsy can be performed to confirm diagnosis. differential diagnoses include squamous metaplasia of the prostate, para-prostatic cysts, bacterial prostatitis, prostatic abscessation, and prostatic neoplasia (primarily adenocarcinoma). these differential diagnoses also increase in frequency with age and, except for squamous metaplasia, can also occur in castrated dogs. as such, these conditions do not necessarily abate or resolve with castration. prevention castration is the primary means for prevention of benign prostatic hyperplasia. treatment the first and foremost treatment for bph is castration. in pure cases of bph, castration results in involution of the prostate gland detectable by rectal palpation within - days. for most dogs in research studies, this is a viable option to rapidly improve the animal's condition. the alternative to castration is hormonal therapy, primarily with estrogens. this may be applicable in cases where semen collection is necessary from a valuable breeding male (e.g., genetic diseases). if the research study concerns steroidal hormone functions, then neither the condition nor the treatment is compatible. finasteride, a synthetic α-reductase inhibitor, has been used in dogs to limit the metabolism of testosterone to α-dihydrotestosterone. treatment at daily doses of . - . mg/kg orally for weeks was shown to reduce prostatic diameter and volume without affecting testicular spermatogenesis (sirinarumitr et al., ) . upon discontinuation of finasteride, the prostate generally returns to its pretreatment size within several months (smith, ) . gonadotropin-releasing hormone analogs such as desorelin inhibit production of testosterone and estrogen via negative feedback on the hypothalamus-pituitary axis. this is available in a sustained release subcutaneous implant, which has demonstrated efficacy in reducing prostatic size in dogs (junaidi et al., ) . however, medical therapy has not shown to be as advantageous as castration. research complications bph can cause complications to steroidal hormone studies, in that the condition may be indicative of abnormal steroidal hormone metabolism, and neither castration nor estrogen therapy is compatible with study continuation. the development of tenesmus as a clinical sign may also affect studies of colorectal or anal function. research model older dogs with benign protastic hypertrophy are used in research to evaluate the use of ultrasonic histotripsy as a precise nonsurgical urethralsparing alternative to prostate surgery (lake et al., ; hall et al., ; schade et al., ) . etiology juvenile polyarteritis syndrome (jps), also known as steroid-responsive meningitis-arteritis, is a painful disorder seen in young beagles (occasionally reported in other breeds) caused by a systemic necrotizing vasculitis. the cause of the vasculitis has not been established but appears to have an autoimmune-mediated component and may have a hereditary predisposition. clinical signs clinical signs of jps include fever, anorexia, lethargy, and reluctance to move the head and neck. the dogs tend to have a hunched posture and/ or an extended head and neck. most dogs seem to be in pain when touched, especially in the neck region. neurological examination may reveal proprioceptive deficits, paresis, or paralysis. the syndrome typically has a course of remissions and relapses characterized by - days of illness and - weeks of remission (scott-moncrieff et al., ) . there may be a component of this condition that is subclinical, given that vasculitis has been diagnosed postmortem in beagles that had no presenting signs. epizootiology and transmission jps typically affects young beagles ( - months), with no sex predilection. jps has been reported in other breeds including sibling welsh springer spaniels (caswell and nykamp, ) . pathologic findings on gross necropsy, foci of hemorrhage can be seen in the coronary grooves of the heart, cranial mediastinum, and cervical spinal cord meninges (snyder et al., ) . local lymph nodes may be enlarged and hemorrhagic. histologically, necrotizing vasculitis and perivasculitis of small to mediumsized arteries are seen. these lesions are most noticeable where gross lesions are observed, but they may be seen in other visceral locations. arterial fibrinoid necrosis leading to thyroid gland hemorrhage and inflammation was also reported (peace et al., ) . the perivasculitis often results in nodules of inflammatory cells that eccentrically surround the arteries. the cellular composition of these nodules is predominantly neutrophils, but it can also consist of lymphocytes, plasma cells, or macrophages (snyder et al., ) . fibrinous thrombosis of the affected arteries is also seen. a subclinical vasculitis has also been diagnosed in beagles post mortem; it is not known whether this subclinical condition is a different disorder or part of a jps continuum. this subclinical vasculitis often affects the coronary arteries (with or without other sites). pathogenesis the initiating factors for jps are unknown. it was once presumed to be a reaction to test compounds by laboratory beagles, but this may have been coincident to the fact that the beagle is the breed most often affected with jps. immune mediation of jps is strongly suspected, because the clinical signs have a cyclic nature and respond to treatment with corticosteroids, and the affected dogs have elevated α -globulin fractions and abnormal immunologic responses. there may be hereditary predisposition, given that pedigree analysis has indicated that the offspring of certain sires are more likely to be affected, and breeding of two affected dogs resulted in one in seven affected pups (scott-moncrieff et al., ) . diagnosis and differential diagnosis differential diagnoses include encephalitis, meningitis, injury or degeneration of the cervical vertebrae or disks, and arthritis. in the research facility, the disorder may be readily confused with complications secondary to the experimental procedure, or with postsurgical pain. beagles with jps that were in an orthopedic research study were evaluated for postsurgical complications and skeletal abnormalities prior to the postmortem diagnosis of systemic vasculitis (authors' personal experience). prevention and control no prevention and control measures are known at this time. treatment clinical signs can be abated by administration of corticosteroids. prednisone administered orally at . mg/kg, q h, was associated with rapid relief of clinical symptoms. maintenance of treatment at an alternate-day regimen of . - . mg/kg was shown to relieve symptoms for several months. however, withdrawal of corticosteroid therapy led to the return of clinical illness within weeks. research complications because of the potentially severe clinical signs and the need for immunosuppressive treatment, jps is often incompatible with use of the animal as a research subject. it is unknown whether subclinical necrotizing vasculitis causes sufficient aberrations to measurably alter immunologic responses. etiology interdigital cysts are chronic inflammatory lesions (not true cysts) that develop in the webbing between the toes. the cause for most interdigital cysts is usually not identified unless a foreign body is present. bacteria may be isolated from the site, but the lesions may also be sterile (hence the synonym 'sterile pyogranuloma complex'). clinical signs dogs with interdigital cysts are usually lame on the affected foot, with licking and chewing at the interdigital space. exudation may be noticed at the site of the lesion. the lesion appears as a cutaneous ulcer, usually beneath matted hair, with possible development of sinus tracts and purulent exudate. epizootiology and transmission interdigital cysts are common in a variety of canine breeds, including german shepherds. beagles have been affected in the research setting. interdigital cysts usually occur in the third and fourth interdigital spaces (bellah, ) . a retrospective study of beagles housed in a research industry setting, linked development of interdigital cysts to body codition score, age, location of cyst, and type of caging, and may result from chronic interdigital dermatitis (kovacs et al., ) . pathologic findings histopathologically, interdigital cysts are sites of chronic inflammation, typically described as pyogranulomatous. pathogenesis initial development of the cysts is unknown, except for those cases in which a foreign body can be identified. diagnosis and differential diagnosis bacterial culture swabs and radiographs should be taken of the cysts to rule out bacterial infection and radiopaque foreign bodies or bony lesions, respectively. a biopsy should be taken if neoplasia is suspected. treatment if a foreign body is associated with the lesion, then removal is the first order of treatment. if biopsy of the site provides a diagnosis of sterile pyogranuloma complex, then systemic corticosteroid therapy (e.g., prednisolone at mg/kg q h) can be initiated and then tapered once the lesion heals. interdigital cysts that are refractory to medical therapy require surgical removal. excision includes the removal of the lesion and the interdigital web, and a two-layer closure of the adjacent skin and soft tissues is recommended (bellah, ) . the foot should be put in a padded bandage and a tape hobble placed around the toes to reduce tension when the foot is weight-bearing. the prognosis for idiopathic interdigital cysts is guarded, because the cysts tend to recur (bellah, ) . research complications research complications from the cysts are minimal, unless the dogs need to be weight-bearing for biomechanic or orthopedic studies. treatment with systemic steroids could be contraindicated with some experimental designs. etiology 'cherry eye' is a commonly used slang term for hyperplasia and/or prolapse of the gland of the nictitating membrane (third eyelid). this is not considered a congenital anomaly, but there is breed disposition for this condition, including beagles. a specific etiology is not known. clinical signs the glandular tissue of the nictitating membrane protrudes beyond the membrane's edge and appears as a reddish mass in the ventromedial aspect of the orbit. excessive tearing to mucoid discharge can result, and severe cases can be associated with corneal erosion. pathologic findings typically, the glandular tissue is hyperplastic, possibly with inflammation. rarely is the tissue neoplastic. pathogenesis prolapse of the gland may be a result of a congenital weakness of the connective tissue band between the gland and the cartilage of the third eyelid (helper, ) . prevention hyperplasia of the third eyelid cannot be prevented, but dogs that develop this condition unilaterally should have the other eye evaluated for potential glandular prolapse. preventative surgical measures might be warranted. treatment corticosteroid treatment (topical or systemic) can be used to try to reduce the glandular swelling. however, surgical reduction or excision of the affected gland is typically required to resolve the condition. in the reduction procedure, the prolapsed gland is sutured to fibrous tissue deep to the fornix of the conjunctiva (helper, ). if reduction is not possible (as with deformed nictitating cartilage) or is unsuccessful, removal of the gland can be performed. such excision is fairly straightforward and can be done without removal of the nictitating membrane itself. the gland of the third eyelid is important in tear production; although the rest of the lacrimal glands should be sufficient for adequate tear production, keratoconjunctivitis sicca is a possible consequence after removal of the gland of the nictitating membrane. research complications in most cases, research complications would be minimal, especially if treated adequately. either the presence of the hyperplastic gland or its removal might compromise ophthalmologic studies. antimicrobial resistance profiles and mechanisms of resistance in campylobacter jejuni isolates from pets life span and cancer mortality in the beagle dog and human studies of distribution and recurrence of helicobacter spp. gastric mucosa of dogs after triple therapy plasma von willebrand factor concentration and thyroid function in dogs catheter-related infections in long-term catheterized dogs. observations on pathogenesis, diagnostic methods, and antibiotic lock technique aaha nutritional assessment guidelines for dogs and cats open-and closed-formula laboratory animal diets and their importance to research comparison of the accuracy of two ultrasonographic measurements in predicting the parturition date in the bitch dog thyroiditis: occurrence and similarity to hashimoto's struma surgical management of specific skin disorders bordetella and mycoplasma respiratory infections in dogs and cats associations between lymphocytic thyroiditis, hypothyroidism, and thyroid neoplasia in beagles diagnostic exercise: peracute death in a research dog insecticide and acaricide molecules and/ or combinations to prevent pet infestation by ectoparasites neurologic manifestations associated with hypothyroidism in four dogs veterinary surgery: small animal neoplasms of the skin and subcutaneous tissues in dogs and cats neoplasia of the skin and mammary glands of dogs and cats pancreatic adenocarcinoma in two grey collie dogs with cyclic hematopoiesis variation in age at death of dogs of different sexes and breeds comparison of campylobacter carriage rates in diarrheic and healthy pet animals advances in dietary management of obesity in dogs and cats effect of amount and type of dietary fiber on food intake in energy-restricted dogs effect of level and source of dietary fiber on food intake in the dog an outbreak of fatal hemorrhagic pneumonia caused by streptococcus equi subsp. zooepidemicus in shelter dogs molecular characterization of canine parvovirus strains in argentina: detection of the pathogenic variant cpv c in vaccinated dogs external parasites: identification and control orthopedic coaptation devices and small-animal prosthetics enterohepatic helicobacter spp. in colonic biopsies of dogs: molecular, histopathological and immunohistochemical investigations intradural vasculitis and hemorrhage in full sibling welsh springer spaniels respiratory disease in kennelled dogs: serological responses to bordetella bronchiseptica lipopolysaccharide laboratory animal medicine do not correlate with bacterial isolation or clinical respiratory symptoms lymphoma: which chemotherapy protocol and why? detection of humoral antibody to the transmissible venereal tumor of the dog laboratory animal management: dogs reproductive cycles of the domestic bitch hereditary canine spinal muscular atrophy: an animal model of motor neuron disease. can evaluation of the helicobacteraceae in the oral cavity of dogs management of septicemia in rhesus monkeys with chronic indwelling catheters clinical and virological findings in pups naturally infected by canine parvovirus type glu- mutant eradication of helicobacter spp. by using medicated diet in mice deficient in functional natural killer cells and complement factor d client information series: canine demodicosis client information series: fleas and flea allergy dermatitis management of the burn wound burn trauma chlorine dioxide sterilization of implanted right atrial catheters in rabbits current concepts in the management of helicobacter associated gastritis discordant s and s rrna gene phylogenies for the genus helicobacter: implications for phylogenetic inference and systematics use of narcotic antagonists to modify stereotypic selflicking, self-chewing, and scratching behavior in dogs epidemiology of canine and feline tumors epizootiologic characteristics of canine and feline leukemia and lymphoma evaluation of the ovicidal cctivity of lufenuron and spinosad on fleas' eggs from treated dogs enteric coccidiosis the respiratory system the association of american feed control officials dog and cat food nutrient profiles: substantiation of nutritional adequacy of complete and balanced pet foods in the united states study of obesity in dogs visiting veterinary practices in the united kingdom pathological prognostic factors in breast cancer. i. the value of histological grade in breast cancer: experience from a large study with long-term follow-up utility of fdg-pet scanning in lymphoma by who classification principles of treatment for canine lymphoma miller's anatomy of the dog update on diagnosis of canine hypothyroidism immunohistochemical and histochemical stains for differentiating canine cutaneous round cell tumors the laboratory canine canine conjunctival mast cell tumors: a retrospective study canine cutaneous epitheliotropic t-cell lymphoma: a review canine infectious respiratory disease helicobacter-associated gastric disease in ferrets, dogs, and cats enteric bacterial infections hemorrhagic streptococcal pneumonia in newly procured research dogs association between canine malignant lymphoma, living in industrial areas, and use of chemicals by dog owners reproductive patterns in the domestic dog-a retrospective study of the drever breed the dog as a research subject a review of canine pseudocyesis leptospirosis surgical treatment of an elbow hygroma utilizing microvascular free muscle transfer in a newfoundland bacterial diseases immunoprophylaxis leptospirosis gastric helicobacters in domestic animals and nonhuman primates and their significance for human health non-helicobacter pylori helicobacter species in the human gastric mucosa: a proposal to introduce the terms h. heilmannii sensu lato and sensu stricto diseases of the small intestine histotripsy of the prostate: dose effects in a chronic canine model flea control failure? myths and realities small animal clinical nutrition operating room emergencies shock evaluation of the sensitivity and specificity of diagnostic criteria for sepsis in dogs pulmonary parenchymal disease canine thyroid neoplasms: epidemiologic features magrane's canine ophthalmology helicobacter-like organisms: histopathological examination of gastric biopsies from dogs and cats current veterinary therapy x: small animal practice congenital defects of the dog gastric and duodenal ulcers in dogs with mastocytoma complications in the use of indwelling vascular catheters in laboratory animals helicobacter infection diseases of the large intestine pregnancy management in the bitch tracheal collapse. diagnosis and medical and surgical treatment hygroma of the elbow in dogs thermal injuries joint working group on refinement factors contributing to the contamination of peripheral intravenous catheters in dogs and cats diversity in bacterium-host interactions within the species helicobacter heilmannii sensu stricto morphological study of the effects of the gnrh superagonist deslorelin on the canine testis and prostate gland five-year longitudinal study on limited food consumption and development of osteoarthritis in coxofemoral joints of dogs cvt update: interpretation of endocrine diagnostic test results for adrenal and thyroid disease etiopathogenesis of canine hypothyroidism maintenance energy requirement of dogs: what is the correct value for the calculation of metabolic body weight in dogs? outbreak and control of haemorrhagic pneumonia due to streptococcus equi subspecies zooepidemicus in dogs kirk's current veterinary therapy xii: small animal practice an emerging pulmonary haemorrhagic syndrome in dogs: similar to the human leptospiral pulmonary haemorrhagic syndrome? tarsal joint contracture in dogs with golden retriever muscular dystrophy an epidemiological study of interdigital cysts in a research beagle colony value of the ( )c-urea breath test for detection of gastric helicobacter spp. infection in dogs undergoing endoscopic examination pathogenesis of helicobacter pylori infection prostatic diseases semen collection in the dog accuracy of canine parturition date prediction using fetal measurements obtained by ultrasonography chronic catheterization of the intestines and portal vein for absorption experimentation in beagle dogs evaluation of weight loss protocols for dogs problems in wound healing associated with chemotherapy and radiation therapy histotripsy: minimally invasive technology for prostatic tissue ablation in an in vivo canine model fdg-pet imaging in canine lymphoma and cutaneous mast cell tumor comparison of fertility data from vaginal vs intrauterine insemination of frozenthawed dog semen: a retrospective study withrow & macewen's small animal clinical oncology estimation of gestational age and assessment of canine fetal maturation using radiology and ultrasonography: a review effects of four preparations of . % chlorhexidine diacetate on wound healing in dogs the prediction of parturition date in canine pregnancy clustering of activating mutations in c-kit's juxtamembrane coding region in canine mast cell neoplasms transmissible venereal tumors kirk's current veterinary therapy : small animal practice canine lymphoma and lymphoid leukemias the staging and treatment of multicentric highgrade lymphoma in dogs: a review of recent developments and future prospects association between waste management and cancer in companion animals tick paralysis in north america and australia thyroid gland and arterial lesions of beagles with familial hypothyroidism and hyperlipoproteinemia bacterial gastroenteritis in dogs and cats: more common than you think enteropathogenic bacteria in dogs and cats: diagnosis, epidemiology, treatment, and control dermatologic aspects of tick bites and tick-transmitted diseases a chronic access port model for direct delivery of drugs into the intestine of conscious dogs mast cells and canine mast cell tumours: a review etiologic study of upper respiratory infections of household dogs effect of early enteral nutrition on intestinal permeability, intestinal protein loss, and outcome in dogs with severe parvoviral enteritis determination of strain variability of microsporum canis to disinfectants cutaneous fungal infections diagnosis of neoplasia tumors of the mammary gland transmissible dog cancer genome reveals the origin and history of an ancient cell lineage clonal origin and evolution of a transmissible cancer notice regarding nih plan to transition from use of usda class b dogs to other legal sources (not-od- - ) guide for the care and use of laboratory animals surgical closure of elbow hygroma in the dog colitis and colon cancer in waspdeficient mice require helicobacter species tumors of the genital system practical laboratory methods for the diagnosis of dermatologic diseases animals and animal products, subchapter a, parts , , and comparison of three skin preparation techniques in the dog comparison of three skin preparation techniques in the dog. part : clinical trial in dogs manual of clinical behavioral medicine for dogs and cats. mosby-year book identification of and screening for human helicobacter cinaedi infections and carriers via nested pcr identification of three novel superantigen-encoding genes in streptococcus equi subsp. zooepidemicus, szef, szen, and szep hypothyroidism in dogs: cases ( - ) plasma von willebrand factor antigen concentration in dogs with hypothyroidism plasma von willebrand factor antigen concentration and buccal bleeding time in dogs with experimental hypothyroidism canine cutaneous mast cell tumor: morphologic grading and survival time in dogs atlas of small animal wound management and reconstructive surgery what's your diagnosis? fever and leukocytosis in a young beagle. canine juvenile polyarteritis syndrome (beagle pain syndrome) a clonal outbreak of acute fatal hemorrhagic pneumonia in intensively housed (shelter) dogs caused by streptococcus equi subsp. zooepidemicus thyroid diseases urogenital emergencies emergency procedures for the small animal veterinarian prognostic significance of morphological subtypes in canine malignant lymphomas during chemotherapy streptococcus zooepidemicus: an emerging canine pathogen characterization of pneumonia due to streptococcus equi subsp. zooepidemicus in dogs tumors of the skin and soft tissue aspiration-induced lung injury origins and evolution of a transmissible cancer canine mast cell tumors express stem cell factor receptor arterial and venous blood gas analyses dogs and cats as laboratory animals hypocretin levels in sporadic and familial cases of canine narcolepsy comparison of giardia diagnostic tests in diagnosis of naturally acquired canine chronic subclinical giardiasis effects of chlorhexidine diacetate and povidone-iodine on wound healing in dogs genetic evidence for an east asian origin of domestic dogs urethral-sparing histotripsy of the prostate in a canine model factors influencing canine mammary cancer development and postsurgical survival how to treat common parasites safely muller and kirk's small animal dermatology systemic necrotizing vasculitis in nine young beagles thomson's special veterinary pathology, second ed. mosby-year book thyroid and parathyroid glands diseases of the small bowel canine infectious tracheobronchitis (kennel cough complex) diseases of the intestines the use of ultrasonography for pregnancy diagnosis in the bitch cytologic examination of fine-needle aspirates from mammary gland tumors in the dog: diagnostic accuracy with comparison to histopathology and association with postoperative outcome effects of finasteride on size of the prostate gland and semen quality in dogs with benign prostatic hypertrophy canine prostatic disease: a review of anatomy, pathology, diagnosis, and treatment pathologic features of naturally occurring juvenile polyarteritis in beagle dogs development, anatomy, histology, lymphatic drainage, clinical features, and cell differentiation markers of canine mammary gland neoplasms withrow & macewen's small animal clinical oncology nutrient requirements of dogs and cats (nutrient requirements of domestic animals) trauma to the skin and subcutaneous tissues of dogs and cats chronic problem wounds of dog limbs acvim small animal consensus statement on leptospirosis: diagnosis, epidemiology, treatment, and prevention lumbosacral stenosis in dogs mammary neoplasia in a closed beagle colony complete mitochondrial genomes of ancient canids suggest a european origin of deomestic dogs artificial insemination in canids: a useful tool in breeding and conservation artificial insemination with frozen semen in dogs: a retrospective study of years using a non-surgical approach manual of canine and feline cardiology comparative evaluation of agar dilution and broth microdilution methods for antibiotic susceptibility testing of helicobacter cinaedi thyroiditis in a group of laboratory dogs: a study of beagles obesity-related metabolic dysfunction in dogs: a comparison with human metabolic syndrome pro-inflammatory properties and neutrophil activation by helicobacter pylori urease of agriculture, animal and plant health inspection service annual report animal usage by fiscal year. available from: <www leptospirosis in dogs: a review with emphasis on clinical aspects thomson's special veterinary pathology, second ed. mosby-year book endocrinology of pregnancy in the dog: a review immunoblot analysis as an alternative method to diagnose enterohepatic helicobacter infections management of superficial skin wounds psychodermatosis colony multiplex pcr assay for identification and differentiation of campylobacter jejuni, c. coli, c. lari, c. upsaliensis, and c. fetus subsp. fetus the role of c-kit in tumorigenesis: evaluation in canine cutaneous mast cell tumors aaha canine vaccination guidelines canine mast cell tumours: a review of the pathogenesis, clinical features, pathology and treatment serum concentrations of thyroxine and , , ′-triiodothyronine before and after intravenous or intramuscular thyrotropin administration in dogs surgical treatment of specific skin disorders naltrexone for treatment of acral lick dermatitits in dogs use of ultrasound in the measurement of subcutaneous fat and prediction of total body fat in dogs mammal species of the world: a taxonomic and geographic reference withrow & macewen's small animal clinical oncology the authors thank dr. bambi jasmin of marshall farms for contributions on preventive health practices for class a dogs. key: cord- - ksfpaf authors: nan title: proceedings of the th european paediatric rheumatology congress: part : virtual. - september date: - - journal: pediatr rheumatol online j doi: . /s - - - sha: doc_id: cord_uid: ksfpaf nan introduction: juvenile idiopathic arthritis (jia) represents the most common pediatric chronic rheumatic disease. children with jia present an increased risk of infections, due to the immune-regulatory effects of disease modifying antirheumatic drugs (dmards); many of these infections are vaccine-preventable. nevertheless, suboptimal vaccinations rates are reported in children with jia. objectives: to evaluate vaccination coverage in a population of children with jia and to describe the prevalence of the adverse events following immunization (aefis) in our cohort. methods: a single-centre retrospective study was conducted by reviewing medical records of all jia patients, diagnosed according to ilar criteria, admitted to the pediatric rheumatology unit of university of naples federico ii from january to december . parents were asked to provide the vaccinations records in form of the vaccination booklet. the occurrence of aefis was explored by telephone interviews. introduction: intrarticular corticosteroid injections (iaci) are widely used in the management of patients with juvenile idiopathic arthritis (jia). general anesthesia can be avoided in case of a small number of joints to inject or in older children. however, pain and anxiety may reduce the patient compliance to iaci, and may compromise the accuracy of the procedure. in order to overcame such problems, the use of appropriate methods of pain and anxiety control is advisable. objectives: to assess the effectiveness and satisfaction of patients undergoing iaci with the use of topical numbing agent or under minimal sedation. methods: patients with jia who underwent an iaci of up to joints were recruited. depending on age and number of joints to treat, a group of patients (group a) were injected with the application minutes prior the procedure of a topical numbing agent (prilocaine+lidocaine) to the skin over the injection site. another group of patients (group b) were treated under minimal sedation (ketorolac/tramadol or morphine + midazolam). the physician was asked to record the degree of motion and pain of the patient during the procedure and the patient (or parents for patients aged less than years) was asked to report the degree of pain and satisfaction on a visual analogue scale (vas) from to . results: twenty-seven patients were enrolled for a total of procedures, and of them in group a and b, respectively. the median age at the procedure was years for group a and years for group b. for group a median pain scores for patients, parents and physicians were , and . , respectively. in patients of group b who underwent the iaci under ketorolac/tramadol the median pain scores for patients, parents and physicians were , . and . , whereas in patients treated with morphine median pain scores were , and , respectively. overall, we found that pain as reported by the patient/parent were higher with increase in the number of sites injected (and, consequently, duration of procedure) and age of patient. amount of motion during procedures was overall negligible. the majority of patients/parents was satisfied for the procedures. only patients treated with midazolam had psychomotor agitation during the iaci. conclusion: iaci in a small number of sites without the use of general anesthesia is well tolerated by patients. the level of pain perceived from patients is irrespective of the power of the painkiller used, but seems to correlate with the duration of the procedures. it is possible that, in the paediatric age, the psychoemotional component seems to be decisive, with a progressive loss of tolerance with the increase in the number of injected joints. for gc-ms analysis of the steroid hormone metabolites age and sexmatched healthy controls were matched to each patient. patients were excluded if they were treated with corticosteroids in the preceding months. results: of the metabolites measured, were significantly lower in jia patients before the etanercept treatment compared to the healthy control group. one day after the injection only metabolites were still significantly lower in the jia patients and all the other metabolites normalized and were similar to the control group. urine metabolite ratios reflecting cyp and β-hsd enzymatic activity indicate that these two enzyme activities were lower in jia patients. the slowest recoveries noted were for metabolites of dheas and oh pregnenolone. conclusion: prior to etanercept treatment almost all urine adrenal metabolites were significantly lower mainly due to the active inflammatory process. immediately after the treatment many metabolites raised to normal values as in the control group. the two adrenal enzymes that were found to be affected in jir are cyp and β-hsd . blocking tn alpha immediately restore adrenal function in jia. introduction: patients with juvenile idiopathic arthritis (jia) receive adalimumab treatment. adalimumab is a monoclonal antibody that blocks tnf-α and is structurally and functionally similar to human igg . nevertheless, there are reports of the development of anti-drug antibodies. the production of these antibodies may be associated with treatment failures (a decrease in the effectiveness of therapy or drug inefficiency that developed over time) and hypersensitivity reactions. to our knowledge, there is currently limited information on the availability of adalimumab antibodies (aaa) in patients with jia. objectives: to evaluate the prevalence rate and the clinical significance of aaa in patients with jia on adalimumab treatment. methods: patients with jia were examined, of whom had the oligoarticular form of the disease, of them with uveitis, and patients had the polyarticular form of the disease, of them with uveitis. among them, there were ( %) girls and ( %) boys. the mean age was . ± . years; the mean disease duration was . ± . years. patients received adalimumab (at least year before the study) with concomitant administration of methotrexate (mtx) or adalimumab only - children who did not receive mtx for at least months prior to the study as a result of either adverse events of mtx administration ( patients) or permanent drug remission ( patients). before starting adalimumab therapy, all participants were treated with mtx. the mean duration of adalimumab treatment for these patients was . ± . years. the serum aaa level of antibodies was determined using the enzyme immunoassay (eia) method. this method determines both free and bound antibodies to adalimumab at reference values less than au/ml. a and was used every weeks for months. the values were presented as mean ± standard deviation. data processing and analysis were carried out using pearson's chi-squared test and spearman's correlation test. results: ( %) of the patients enrolled in the study had aaapositive results. the mean aaa level in positive patients was . ± . au/ml. further disease relapses tended to occur significantly more often in aaa-positive patients than in aaa-negative ones (χ = . , p = . ). thus, of ( . %) aaa-positive children had at least exacerbation of the disease within months, compared with of ( . %) in aaa-negative ones. out of ( . %) aaapositives did not take mtx for at least months compared to out of ( . %) in aaa-negative ones. thus, aaas are found to be significantly more frequent without concomitant administration of mtx in the treatment of jia (χ = . , p = . ). there were no observed adverse events or side effects during adalimumab therapy. no significant correlation was found between the presence of aaa and sex, introduction: advances on molecular medicine, illumination of the cytokine network and the immune pathways shed light on the etiopathogenesis for a better understanding of juvenile idiopathic arthritis (jia). however, the fact that the course of the disease differs individually strongly suggests the effect of external factors. objectives: the current study was undertaken to evaluate sociodemographic and sociocultural features, parent behavior, the gestation and breastfeeding period, nutritional status of early childhood in our patients with jia, and to determine their relationship with disease activity, damage index, remission time, and relapse rate. methods: the study was conducted with a face-to-face questionnaire method with the parents of patients with jia and healthy children. the medical patient records were reviewed. juvenile arthritis disease activity score (jadas) , wallace clinical inactive disease criteria, juvenile arthritis damage index (jadi), and relapse rates were used to assess the general medical condition of each patient. results: the median age of jia patients (n = ) was ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) , with a female ratio of , %. age at disease onset was ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) years. the first remission time was ( - ) months. the patients were evaluated according to disease subtypes and treatment modalities. there was no difference in the duration of breastfeeding according to the distribution of the subtypes (p = , ). when the breastfed and formula-fed patients were compared, there was a marginally significant difference in terms of first remission time (p = , ), whereas there was a significant difference in relapse rate in patients who introduced to cow milk early (< months) (p = , ). the early risk factors and their relationship with the disease are presented in table . both breastfeeding durations and maternal literacy levels showed a significant difference in terms of relapse rates (p = , ; p= , , respectively). there was no significant difference in breastfeeding durations and gestational risks between the patients and the healthy group (p = , ; p= , ), respectively. however, the smoking rate among family members was significantly higher in the patient group (p = , ). conclusion: in patients with juvenile idiopathic arthritis, breastfeeding rate and duration did not differ when compared to healthy controls. however, breastfeeding duration, cow's milk commence age, and maternal literacy appeared to be relevant to the relapse rates. going to preschool both influence the remission time and relapse rate. these findings suggest a role for parental attitude and nutritional status during early childhood in the course of jia. none declared introduction: immunogenicity and low trough concentrations have been associated with adalimumab treatment failure in several studies of paediatric inflammatory diseases, indicating the possible value of therapeutic drug monitoring (tdm). adalimumab efficacy may be improved by changing dose or treatment intervals based on drug concentrations. however, lack of standardization, assay heterogeneity, and paucity of research hinder the implementation of tdm in clinical practice. objectives: to assess the relationship of trough concentrations, immunogenicity and adalimumab response in paediatric patients with jia. methods: monocentric cohort study of patients ≤ years with jia treated with adalimumab due to active arthritis. clinical data and plasma samples were collected during routine follow-up. adalimumab trough concentrations were measured by liquid chromatographytandem mass spectrometry (lc-ms/ms). anti-adalimumab antibodies were measured in samples with trough concentrations < mg/l. disease activity was evaluated using the clinical juvenile arthritis disease activity score with joint count (cjadas ). response to adalimumab was defined as at least % reduction of disease activity within months of therapy followed by clinical inactive disease or minimal disease activity after months. the latter was defined as cjadas ≤ . and ≤ . , for oligoarthritis and polyarthritis, respectively, or an active joint count equal to zero when cjadas was unavailable. results: adalimumab trough samples were available from jia patients. although there was no significant difference in median adalimumab dose, trough concentrations were significantly lower in patients with secondary failure compared to primary failure or an adequate adalimumab response (p-values < . ). in addition, there were samples with trough concentrations < mg/l, in the group with secondary failure and in the group with adequate adalimumab response (table ) . conclusion: adalimumab trough concentrations were significantly lower in jia patients with secondary failure compared to primary failure or an adequate response to adalimumab. anti-adalimumab antibodies were present in out of samples with trough concentrations < mg/l. adalimumab trough concentration measurements may identify jia patients that would benefit from increased doses or shorter treatment intervals. in addition, jia patients with primary failure and adequate adalimumab trough concentrations may respond better to biologic agents with other therapeutic targets. although biologic agents have improved disease outcome of patients with jia, concentration measurements using reliable and cost-effective methods, such as lc-ms/ms, could further improve efficacy of biologic agents and guide treat-to-target strategies. introduction: most studies of physical fitness (pf) in juvenile idiopathic arthritis (jia) have shown decreased levels of maximal oxygen consumption (vo max) compared to healthy peers. in jia, boys have higher pf-levels than girls and younger children have higher levels than adolescents, congruently with data of healthy peers. previously, we have shown that more than half of jia-patients had below normative average of vo max. however, monitoring physical activity (pa) using accelerometry, % of boys and % of girls with jia fulfilled the recommendations of who of ≥ hour of pa per day, which was comparable to normative values ( %/ %). moreover, patients reporting engagement more than hours per week in club-sports exceeded accelerometry values of healthy peers. objectives: to explore the association between pf and specific sport habits in to -year-old jia-patients, related to gender, bmi, disease activity, and pain, and comparing the most fit quartile (q ) of patients (respectively boys and girls) to the least fit quartile (q ). methods: sixty patients with jia performed an indirect ergometertest of vo max (watt max test) and answered the physical activity and sport questionnaire (pasq). objective pa-monitoring for one week was conducted using the gt m accelerometer. cut-offs for moderate-high and high intensity pa were set to > and > counts per minute, respectively. disease activity was assessed with the jadas- , current pain and worst pain last week were measured on visual analogue scales (vas) and in a one-week pain diary using the faces pain scale-revised (fps-r). results: girls with jia (n= ) had lower mean pf than the boys (n= ) ( . ± . / . ± . ml/kg/min), being below normative values, respectively. in both genders the most fit boys and girls (q ; . - / . - ) had average to well-above normative average pf. the least fit boys (q ; . - . ) all had pf-levels well-below normative average. in girls q -levels ( . - . ) were well-below to below normative average. we found significant differences between most fit (q ) and least fit (q ) patients regarding patient´s global wellbeing (p= . ) and pain diary (p= . ). these differences were not significant when separating genders, though differences were more pronounced in girls. the least fit girls (q ) had significantly higher disease activity (jadas- ) than the most fit girls (q )(p= . ). the most fit boys and girls (q ) engaged equally in high intensity sports (soccer: / ; / , handball: / ; / , gymnastics: / ; / , rowing: / ; / ). however, more boys than girls played soccer ( / ; / ), whereas more girls preferred sports of lower intensity (riding: / ; / ). eight of boys in soccer and boys in gymnastics or rowing had below average to well-above normative average of pf (q +q : . - ). three girls in gymnastics, girls in soccer, and girls in handball were in q ( . - ) with levels of average to well-above average pf. the third girl in soccer was in q ( - . ) with levels of well-below to below normative average. none of the riding girls were in q and only was in q ( . - . ) (below to average normative pf). comparing accelerometer-monitored values of pa-intensity in girls with low (q ) and high (q ) pf, pavalues of q were significantly lower than in q . the same tendency was observed in boys, but not to significance. conclusion: our results are in accordance with most other studies of pf in jia, adding to the knowledge of gender-specific differences in pf and type and behavior in sport activities. it emphasizes the need of regular pf-testing and guidance in high intensity pa and sport in order to improve pf and avoid the risks of inactivity and lifestyle diseases in jia. pg/ml), which also showed the highest the frequency of detection of its increase. it was absent in sjia ( . ± . pg/ml). the highest values of il- r ( . ± pg/ml) were in the middle age group. the data obtained suggest the compensatory value of increasing il- r and the simultaneous initiation of inflammatory and anti-inflammatory processes during exacerbation of jia. assessment of the ratios of stimulating and inhibiting cytokines showed in patients with uveitis, the ratio of ifn-γ/il- β ( . ± . ) was higher than with other jia (from . ± . in ojia to . ± . in pjia) and ifn-γ/il- r ( . ± . versus from . ± . in ojia to . ± . in sjia). an increase of il- β/il- r ratio was characteristic only for sjia ( . ± . ). all of these ratios increased with disease activity (r= . - . ) & they did not reflect the unpleasant course of the disease. methods: in this multicenter, case-control study, fecal samples were collected from children with jia, with of these samples collected from untreated children ( of whom were treatment-naïve children). samples from children with jia were collected during treatment with mtx as single treatment and samples from children during treatment with etn. of those children, four were treated with etn as single treatment and nine had a combination of etn and mtx. we compared children on single treatment with mtx with untreated children ( treatment-naïve), and children on treatment with etn (nine in combination with mtx) with untreated children ( treatment-naïve). we also did pairwise comparisons of samples taken before any medication was given (n = ) and samples taken during ongoing treatment with mtx (n = ) or etn (n = , four in combination with mtx). the microbiota was characterized by sequencing amplicons from the v and v regions of the s rrna gene. alpha diversity of the fecal samples was measured using the chao- index and the shannon diversity index. to compare these indices between treated children and untreated children, we used a logistic regression model with age at sampling as a covariate. for pairwise analyses, we used the wilcoxon signed-rank test. to analyze the community composition of the microbiota, principal coordinate analysis (pcoa) plots based on bray-curtis distances were generated for visual comparisons, and analysis of similarity (anosim) was used to test for differences. analyses for relative abundances of taxa were performed at three taxonomic levels (phyla, families, and genera), and logistic regression with age as a covariate was used for calculations of differences between treated and untreated children, while the wilcoxon signedrank test was used for pairwise comparisons. significance was set to p < . and corrections for multiple comparisons were made using the benjamini-hochberg method. results: analyses showed no significant differences in α-diversity between children treated with mtx or etn and untreated children, and pairwise comparisons of samples before and during treatment with mtx or etn also showed no differences. pcoa plots for children treated with mtx or etn, in comparison with untreated children, did not show any clustering. anosim showed no significant differences between treated and untreated children. pcoa plots were also made for the pairwise comparisons of children sampled before and during treatment, and according to that analysis the community compositions of microbiota did not change in any uniform way during treatment with either mtx or etn. furthermor, analyses of relative abundances of specific taxa did not reveal any significant results in any of the comparisons, after adjustment for multiple analyses. conclusion: treatment with mtx or etn did not alter the composition of fecal microbiota in children with jia. introduction: juvenile idiopathic arthritis (jia) is the most common rheumatic disease in childhood and an important cause of shortterm and long-term disability if patients are not treated appropriately. by definition, jia clinically presents with peripheral joint inflammation of unknown origin, persisting for at least six consecutive weeks and starting before the age of years. the predominant subtypes, i.e. oligoarticular (oligo) and polyarticular (poly) jia, have long been assumed autoimmune diseases caused by dysregulation of the adaptive immune system, with a central role for autoreactive t cells belonging to the th and th lineages and autoantigens that may include aggrecan, fibrillin, matrix metalloproteinase (mmp)- and heat shock proteins. nevertheless, the original t cell-centered hypothesis has been challenged since it does not cover nor completely explain the full spectrum of immune-pathological phenomena observed in patients. lien.desomer@uzleuven.b objectives: emerging evidence suggests a potentially important role for neutrophils in jia pathogenesis. here, we investigated extensively the phenotypical features of neutrophils present in the peripheral blood and inflamed joints of jia patients. methods: synovial fluids and parallel blood samples from patients with oligo-or polyjia and blood samples from healthy children were collected. multicolor flow cytometry panels allowed for in-depth phenotypical analysis of neutrophils, focusing on the surface expression of adhesion molecules, activation and maturation markers, chemoattractant-and toll-like receptors. multiplex technology was exploited to quantify pro-and anti-inflammatory cytokines in plasma and synovial fluids. results: the vast majority of synovial fluid neutrophils displayed a strongly activated, hypersegmented phenotype with decreased lselectin (cd l) expression and increased numbers of nuclear lobes, upregulation of adhesion molecules cd b, cd b and cd and downregulation of chemokine receptors cxcr / . an elevated percentage of cxcr -expressing aged neutrophils was detected in synovial fluids from patients. strikingly, significant percentages of synovial fluid neutrophils showed a profound upregulation of atypical neutrophil markers, including cxcr , icam- and hla-dr. conclusion: our data indicate that neutrophils present in inflamed joints of jia patients are strongly activated cells with elevated proinflammatory and antigen presenting potential. this detailed molecular analysis supports the notion that a complex intertwining between these innate immune cells and adaptive immune events drives jia. none declared the main factors, associated with incomplete vaccination againts measels, parotitis, rubella and diphtheria in juvenile idiopathic arthritis patients n. lyubimova , i. objectives: the aim of our study was to evaluate the rate and the main factors of incomplete vaccination against measels,parotitis, rubella (mmr) and diphtheria in jia patients. methods: in the present study were included data jia( boys and girls)aged from to years,who received scheduled vaccination before the age of years and before jia onset against measles,parotitis,diphtheria and rubella.incomplete vaccination means the reduced number of vaccine to age.in all patients the ig g anti-vaccine antibodies levels were detected with elisa.jia categories were:oligoarthritis - ,polyarthritis - ,systemic- and enthesitisrelated arthritis- .data presented with median and %> % results: incomplete vaccination against mmr was in ( %)diphtheria in ( %) of the jia patients. the main differences in the studied groups are in the table.there were no differences in sex,jia categories and treatment, except biologics compare to complete and complete vaccination in all vaccines.no differences in antimeasels(p= . ),antiparotitis (p= . ) and anti-rubella(p= . )vaccination between complete and incomplete vaccination group.number of patients with protective level of anti-vaccine antibodies was similar, except parotitis( % vs . %, p= . ).the anti-diphtheria antibodies igg level was lower in the patients with incomplete vaccination group ( . iu/ml [ %ci: . ; . ] vs . [ %ci: . ; . ], p= . )as well as number of patients with protective level( % vs %, p= . ). in the multiple regression model only jia onset age(p= . )and methotrexate treatment duration(p= . ) were predictors of incomplete vaccination against mmr and methotrexate treatment duration(p= . ) and biologic treatment(p= . ) for diphtheria incomplete vaccination.incomplete mmr vaccination influence on the maintenance of the protective anti-parotitis level(p= . )in regression model.in correlation analysis the number of vaccination influences on anti-diphtheria antibodies level(p= . )and number of patients with protective level of anti-diphtheria antibodies(p= . ). the main predictors in logistic regression for incomplete vaccination for mmr were:onset age< years(or= . conclusion: younger onset of jia age, longer duration of jia and methotrexate treatment, biologics and more than biologics are the main predictors of incomplete vaccination againt mmr and diphtheria. introduction: the prevalence of autoimmune thyroid disorders (aitd) has been reported to be higher in patients with juvenile idiopathic arthritis (jia) in comparison to the general population. nevertheless, there is a lack of studies investigating risk factors for aitd development in children with jia. objectives: to investigate the co-occurrence of jia and autoimmune thyroiditis in southern italy and to identify potential predisposing factors to anti-thyroid antibodies (ata) positivity in a jia population. methods: a single-centre retrospective study was conducted. all jia patients admitted to the pediatric rheumatology unit of the university of naples federico ii, from january to december , tested for ata at least once and with a minimum of -months follow-up, were included. for each patient, demographic, clinical and laboratory data were extracted from clinical charts. differences between patients affected by jia with or without ata were analyzed. results: three hundred thirty jia patients ( females; median age . years, iqr . - . ) were included in study. median age at jia onset was years (iqr: . - . ). twenty-three patients [ % ( % ci . - . )] presented ata positivity. twenty-one of them ( . %) were females. anti-thyroperoxidase was positive in / patients ( . %) while patients presented anti-thyroglobulin positivity ( . %). both antibodies were present in / ( . %). patients showed the typical ultrasound findings of autoimmune thyroiditis, resulting in a prevalence of hashimoto's thyroiditis of . % ( % ci . - . ) in our cohort. three female patients developed subclinical hypothyroidism, whereas one male patient presented subclinical hyperthyroidism. the remaining patients were euthyroid. no statistically significant difference was observed in regard to age of jia onset, follow-up duration and jia subtype between the patients with or without ata. the proportion of females was marginally significantly higher (p= . ) in the group with ata positivity compared to children without thyroid antibodies ( . % vs . %, respectively). . % of patients with ata showed ana positivity compared to . % of patients without ata (p= . ). family history for aitd was significantly higher in children with thyroid antibodies positivity (p= . ). anti-tnf-alpha inhibitors were administered in only children ( %) with thyroid antibodies before their detection compared to . % of patients without thyroid antibodies (p= . ). multivariate regression analysis showed that patients with a family history for aitd were about four times more likely to develop ata (or . , % ci . - . , p= . ) and confirmed that ata positivity is less likely to occur in patients undergone anti-tnf-alpha therapy (or . , % ci . - . , p= . ). conclusion: a high prevalence of ata positivity and hashimoto's thyroiditis in patients with jia was found in our wide southern italian cohort. as expected, a positive family history of aitd was found to be associated with a higher risk to ata development during the follow-up. this finding supports the usefulness of an active screening for aitd in jia children, in particular in patients with relatives affected by thyroid disorders. notably, patients treated with tnf-alpha inhibitors resulted less likely to develop thyroid antibodies. further studies are needed to investigate the effect of anti-tnf-alpha therapy on thyroid autoimmunity in jia. introduction: the knee is considered by far the joint most frequently affected at jia onset. nonetheless, jia onset may present with unusual musculoskeletal involvement, eventually leading to a delay in the diagnosis and treatment. objectives: to identify the type and number of musculoskeletal sites affected at jia onset in consecutive patients seen at the study center in an years period. methods: records of patients with new diagnosis of jia from june to may available information in the medical history and standardized joint assessment at diagnosis, were retrospectively reviewed. systemic jia subtype according to ilar classification criteria were excluded. demographic and clinical features, including the type and number of joints at disease onset and diagnosis, were registered. data were analyzed through descriptive statistics. results: of a total of caucasian patients included in the study ( . % females), patients ( . %) had oligoarthritis, ( . %) rf-negative polyarthritis, ( . %) rf-positive polyarthritis, ( . %) psoriatic arthritis, ( . %) enthesitis-related arthritis (era). antinuclear antibody (ana) were positive in patients ( . %). the median age at onset was . years (iqr . - . ). at diagnosis ( . %) patients had only active joint, ( . %) had - active joints, ( . %) had ≥ . as expected the knee, the tibiotalar and the wrist were the most frequently affected joints ( . %, . %, . %, respectively); cervical spine was involved only in patients with polyarthritis (n= ). notably, of patients with monoarthritis at diagnosis presented with large joints involvement, among which n= isolated elbow and n= isolated wrist, and with small joints involvement (table ) . no sufficient data were available regarding the involvement of tendons and bursae, since the standard joint assessment form did not include them. nonetheless, additional patients, not included in the sample analysis, had isolated tenosynovitis involvement at diagnosis (n= both-sided ulnar extensor tendons; n= isolated tenosynovitis of the flexor digiti proprius; n= tenosynovitis of flexors digiti proprii). conclusion: our study confirms the knee, the tibiotalar and the wrist as the most frequently affected joints at jia diagnosis. on the other hand, musculoskeletal sites, such as small joints of hands and feet, the hip and the shoulder, usually involved in polyarticular jia, can be the site of disease presentation in oligo-and also mono-articular jia. further, jia may present with isolated tendon involvement. our results foster not to delay jia diagnosis in persistent synovitis occurring in infrequent joints and to include musculoskeletal sites, other than joints, in the standard articular evaluation. this could be realized by merging clinical and imaging (i.e. ultrasound) musculoskeletal examinations in the same assessment. none declared introduction: treatment response in jia is currently viewed as a binary outcome: response or non-response. however, jia is a heterogeneous disease and it is likely that different, identifiable subgroups of children and young people (cyp) may demonstrate different patterns of disease following treatment. identifying these response subgroups can assist the tailoring of stratified treatment approaches in jia. objectives: to identify subgroups of cyp defined by different trajectories of juvenile arthritis disease activity score (jadas) components following methotrexate (mtx) initiation for jia. methods: mtx-naïve cyp with jia were selected if enrolled prior to january in the bspar etanercept cohort register or the biologics for children with rheumatic diseases study at point of starting mtx. jadas components (active joint count, physician's global assessment (pga, - cm), parental global evaluation (pge, - cm) and standardised esr ( - ) were calculated based on data collected in the year following mtx initiation. multivariate group-based trajectory models were used to explore mtx response clusters across the different jadas components, which were log p transformed for analysis. optimal models were selected based on a combination of model fit (bic, relative entropy, average posterior probabilities), parsimony and clinical plausibility. clinical and demographic characteristics and achievement of acr pedi / by six months were compared across identified groups. results: of cyp selected, the majority were female ( %) and of white ethnicity ( %), with rf-negative jia the most common disease category ( %). six subgroups of cyp were identified with differing patterns of disease activity following mtx initiation. two groups improved across all jadas components: fast improvers ( %), and slow improvers ( %). persistent pga ( %), and persistent pge ( %) groups maintained one persistent disease feature but otherwise improved. one group relapsed ( %) and a final group had persistent disease overall ( %). there were no differences in active joint counts at mtx initiation between subgroups and all ilar categories were represented across each subgroup. however, cyp in persistent disease and slow improver groups had higher chaq, pga and pge scores at mtx initiation. those with persistent disease were also older at mtx initiation. the majority of cyp fulfilled acr pedi response (> % across every group). acr pedi achievement was low at months for slow improvers ( %) and high in the relapse group ( %). between % and % achieved acr pedi response in groups with persistent disease in one jadas component. we identify different patterns of disease activity within cyp initiating mtx, suggesting a simple responder/non-responder analysis at a set point may be over-simplistic. commonly used response measures did not adequately describe these heterogeneous response patterns. understanding both clinical factors associated with, and biological mechanisms underpinning, these subgroups would aid stratified medicine in jia. introduction: despite modern treatment and improved disease control, pain is the most common complaint in juvenile idiopathic arthritis (jia). knowledge about pain thresholds and pain sensitivity among young adults with jia is sparse. objectives: to study pressure pain thresholds (ppts) in young adults with jia, years after disease onset compared with controls. methods: consecutive newly diagnosed children with jia and a disease onset between - from central norway, were included in this prospective population-based long-term follow-up study. children with onset - were part of the nordic jia cohort , . age-and sex-matched controls were drawn from the national population register of norway. inactive disease and remission were defined according to wallace , . at the follow-up between - , data from a clinical examination and blood tests were included in addition to an investigator-blinded quantification of ppts. a digital algometer was used to manually apply pressure three times with an even rate at the upper and lower limb. ppts from jia and controls, and from subgroups of jia defined by disease status, were compared with multilevel models in stata. results: among the participants with jia, % were female, median age was . (iqr . - . ) years, median disease duration was . (iqr . - . ) years, % had an oligoarticular disease (persistent or extended), and % were in remission off medication. in the control group, % were female and median age was . (iqr . - . ) years. results from the multilevel regression model showed significantly lower ppts among participants with jia compared to controls (table ). in the jia group, participants with inactive disease had lower ppts than both jia in remission off medication and jia with active disease ( table ). the results were consistent for both upper and lower limb. conclusion: in this long-term follow-up study of young adults with jia, we found significantly lower ppts compared to controls. this may indicate that young adults with jia have altered pain sensitivity possibly due to accumulated earlier pain experiences. introduction: juvenile idiopathic arthritis (jia) represents the most common chronic rheumatic disease in childhood. non-steroidal antiinflammatory drugs (nsaids) and intra-articular steroids are the first line treatment for jia. systemic steroids, disease modifying antirheumatic drugs (dmards) and biologic drugs are used in children with severe disease. it is not possible at onset of disease to predict when a child can suspend pharmacological treatment, so children affected from jia have to continue pharmacological treatment for several months or years. anecdotal reports showed that rarely jia could present renal involvement due to uncontrolled inflammation or to long exposure to drugs. objectives: because no cohort studies investigating renal injury in children with jia are available, we designed this kind of study in our population. methods: we retrospectively evaluated patients suffering from jia. jia diagnosis was made according to ilar criteria, treatment was assigned with acr recommendations. for each patient we recorded the type and the duration of pharmacological treatment and the presence of renal injury. renal injury was defined by the presence of hypertension (systolic and/or diastolic blood pressure > th percentile for age, sex and height), proteinuria (persistentconfirmation within months-urinary protein/creatinine ratio> . mg/mg for children < years old and > . introduction: juvenile idiopathic arthritis (jia) is a pediatric rheumatic disease with partially unknown etiology and pathogenesis. neutrophils are the most common immune cell present in synovial fluid from inflamed joints in oligoarticular jia, but the role of neutrophils in the immunopathogenesis of oligoarticular jia has not been investigated. objectives: to characterize neutrophil phenotypes and effector functions in the circulation and in the inflamed joint during active arthritis in children with oligoarticular jia. methods: paired samples of blood and synovial fluid from children with oligoarticular jia were investigated regarding surface markers, phagocytic ability and oxidative burst. healthy blood neutrophils exposed to cell-free jia synovial fluid and healthy oral cavity neutrophils were studied as controls for synovial fluid exposure and transmigration respectively. results: synovial neutrophils had a shifted phenotype, characterized by high surface levels of neutrophil activation markers cd b and cd b, and mannose receptor cd and decreased levels of adhesion molecule cd l compared to circulating neutrophils. in comparison to oral cavity neutrophils, synovial neutrophils had higher levels of cd b and a different overall phenotype, suggesting that the phenotype shift in synovial compared to circulating neutrophils is not dependent on transmigration alone. jia synovial fluid in itself induced activation of healthy blood neutrophils, measured as increased cd b levels. synovial fluid neutrophils had impaired ability to phagocytose opsonized e. coli and to produce oxygen radicals upon neutrophil activation with phorbol-myristateacetate (pma) compared to circulating neutrophils. the impaired effector functions in synovial neutrophils was not dependent on the synovial fluid alone, as addition of cell-free synovial fluid to blood neutrophils did not alter phagocytosis and oxidative burst. conclusion: jia synovial fluid neutrophils are activated, have a "polarized" phenotype and impaired effector functions compared to neutrophils in the circulation. this study will help bridge the current knowledge-gap regarding the role of neutrophils in the immunopathogenesis in oligoarticular jia. methods: a case report is described. data was extracted from the medical chart of the patient and a literature review was undertaken. results: a -year-old girl was transferred to our tertiary center after being admitted for prolonged intermittent fevers, abdominal pain, fatigue and polyarthralgias. on examination, there was symmetrical proximal muscle weakness, a vasculitic lower limb rash, facial erythema with eyelid edema (fig. ) and oral mucositis. initial laboratory exams revealed pancytopenia, high muscle enzymes, increased erythrocyte sedimentation rate with moderately elevated reactive c-protein, and hypocomplementemia. she also had non-nephrotic proteinuria, without hematuria.further investigations showed a positive direct antiglobulin test, antinuclear antibodies, antidouble-stranded dna, anti-mi and anti-ku. serositis (pericardial and pleural effusions, ascitis) and hepatosplenomegaly were present. lower limb mri documented diffuse muscle edema. the diagnosis of an overlap syndrome of jsle and iim was established. while being treated for concomitant bacteremia, the patient became ill-appearing, with persistent fevers, worsened cytopenias, low fibrinogen and high ferritin and triglycerides, and a macrophage activation syndrome (mas) diagnosis was assumed. the patient received antibiotics and intravenous immunoglobulin, followed by methylprednisolone pulses, iv cyclosporine (cyc), hydroxychloroquine and supportive therapy with progressive improvement. due to hypertension (possibly related to cyc) and persistent proteinuria a renal biopsy was performed showing class iv lupus nephritis. after achieving clinical stability, cyc was switched to mycophenolate mofetil as an induction treatment, which is ongoing. conclusion: imm with sle os is uncommon, and has seldom been described in children. in addition to fulfilling sle criteria, our patient had clinical, laboratory and imagiologic evidence of imm. the presence of myositis specific antibodies (especially anti-mi ) further supports the diagnosis of an os rather than an atypical presentation of a lupus myopathy. juvenile dermatomyositis appears to be the imm subtype -it is associated with anti-mi , and mild heliotrope and eyelid edema are compatible. facial rash sparing the nasolabial folds is more suggestive of sle. mas is a rare but life-threatening condition that should be suspected in rheumatologic conditions and might be triggered by infections or disease flares. its identification may be particularly challenging at presentation, especially in sle where cytopenias are common. the reported prevalence in adult sle ranges from . % to . %; disease-specific criteria have been proposed. mas has occasionally been described in iim. in a patient with a predisposing condition, persistent fevers and illappearance must always prompt a mas workup, since early diagnosis and treatment are paramount. due to an early referral to a pediatric rheumatology center, the patient received a prompt diagnosis and treatment, which probably improved her prognosis. results: four of the five patients were female ( %) and all aged between and years. four of them had calcinosis at the time of diagnosis, although they may have had symptoms for to months prior to diagnosis. skin involvement was severe requiring multiple systemic and topical therapeutic agents in four out of the five patients -significantly more affected than the muscles. one patient had amyopathic subtype with normal childhood myositis assessment score (cmas) throughout. none of them had cardiac involvement. all had weakly positive anti-nuclear antibodies (ana); but were negative for myositis antibodies except the patient with most severe skin involvement and calcinosis (patient ), who was positive for anti-tif gamma antibodies. two of the three patients with calcinosis at onset had cyclophosphamide as the second line agent (chosen due to calcinosis) following systemic corticosteroids with complete resolution of the lesions after six cycles at mg/m . one patient responded to infliximab, which failed to work after months, following which cyclophosphamide was tried with good response. the other two patients were given cyclophosphamide after they failed to respond to rituximab, which did work for muscle disease. one patient had recurrent episodes of calcinosis needing surgical curettage despite initial response to cyclophosphamide and later ivig. introduction: systemic juvenile idiopathic arthritis (sjia) is a unique form of childhood arthritis. according to current understanding sjia is primarily driven by innate immune mechanisms at disease onset, but can progress towards chronic destructive arthritis, which can involve t cellular immunity. for yet incompletely understood reasons, sjia can be complicated by macrophage activation syndrome (mas), a severe hyperinflammatory condition characterized by a catastrophic cytokine storm resulting in multiple organ failure and high mortality. objectives: the sjia/mas working party (wp) aims to promote knowledge and international multidisciplinary collaboration among experts in the field of mas and sjia and to foster translational research in order to improve the care and outcome of these patients methods: currently pres members participate to the mas/sjia wp. the wp arranges an annual meeting during the pres congress, open to all members activities. the mas/sjia wp core team frequently report about ongoing activities by email. results: several studies are currently ongoing. a project aimed to establish and validate a risk score for mas in sjia patients using routine laboratory parameters of disease activity and severity has already completed the construction phase. recently, building of a validation cohort comprising data form patients from paediatric rheumatologic centers has been accomplished and is awaiting analysis (claudia bracaglia). a second project focused on mas patients with systemic thrombotic microangiopathy (tma) has just completed the collection of patients with mas and tma from centers in countries and results will soon be published (francesca minoia). furthermore, the mas/sjia wp participated in the data collection phase of a project on the development of new criteria for primary hlh (jan-inge henter and annacarin horne introduction: hemophagocytic lymphohistiocytosis (hlh) is an immunological disorder characterized by clinical signs and symptoms of severe uncontrolled inflammation, due to massive release of inflammatory cytokines. a delay in diagnosis is common, and is one of the factors that determine the poor outcome. hlh is classified into primary (phlh) and secondary (shlh). it is important to differentiate between the two as management differs. objectives: to describe the clinical and laboratory profile of hlh in infancy. methods: the electronic case files of children (age< year) diagnosed with hlh at the aims, kochi, kerala, between january and december , was retrospectively reviewed and described. results: eight infants, with age range . months to months, were clinically diagnosed with hlh. all were immunised and had normal development for age. none had a family history suggestive of hlh. third degree consanguinity was present in parents of patient no. and second degree for patient no. . duration of symptoms before presentation ranged from days to days. duration of follow up with us ranged from days to days, for those who expired. all, eight of them, had fever, anemia, thrombocytopenia, hyperferritinemia, transaminitis, raised ldh and crp. lymphadenopathy was present only in patient no. . before starting specific treatment patient no. had pseudomonas sepsis, patient no. had roseomonas gilardii infection; patient no. and were igm cmv positive but their pcr was negative. both of them had received prior blood transfusion. before making a definitive diagnosis of hlh patients were treated for puo, sepsis ? cause and acute liver failure. there was a delay in diagnosis for all patients except patient no. . all of them were treated with hlh protocol with modification according to clinical status of the patient. later, broad spectrum antibiotics, antifungals and antivirals were used for all. anakinra was tried for patient no. . five patients (phlh) succumbed to sepsis and mods and three (one phlh and two shlh) are continuing follow up. hsct was not done in any of them. other clinical features are shown in table . conclusion: making a timely diagnosis of hlh is difficult. differentiating phlh from shlh is very important as the management differs. genetic testing should be done for all infants with hlh. negative genetic study doesn't rule out phlh. the only curative treatment for phlh is hsct. shlh infants, once their primary condition is treated, can have normal survival. hyperbilirubinemia, splenomegaly, neutropenia, hepatomegaly, tissue hemophagocytes and hypertriglyceridemia were more common in phlh. health, kolkata diagnosed as having mas, admitted between july and april was tabulated and retrospectively analyzed . objectives: to evaluate the clinical features, laboratory findings and outcomes in pediatric mas, assess the response to different pharmacological therapies, and finally to identify possible factors associated with an unfavourable outcome. methods: the data of patients diagnosed with mas over the study period was analyzed for the clinical and laboratory features, treatment details, response to therapy and outcome. results: patients were diagnosed as having mas. primary illness was sjia in ( %), sle in ( %) and kawasaki disease (kd) in ( %). all had fever with varying degrees of multi systemic involvement. hyperferritinemia was universally present. in the absence of anakinra in india, pulse methylprednisolone with cyclosporine was used for treating the majority. patients ( . %) expired. patients on biologics and steroids can present with a silent mas which may be difficult to diagnose. conclusion: mas is a near fatal complication with protean manifestations and multi organ dysfunction. hyperferritinemia is characteristic, higher values being associated with increased mortality. patients resistant to steroids and cyclosporine had a poor prognosis. early recognition with aggresive management forms the backbone of a successful outcome as reflected by improved prognosis over successive years. late presentations with multiorgan dysfunction are associated with the poorest outcomes. methods: case report's description results: a two-year-old boy presented with one month history of fever associated with limping gait, cervical lymphadenopathy and skin rash. laboratory tests showed elevation of inflammatory markers and ferritin. by exclusion criteria, sjia was diagnosed and steroid therapy started. after a soft tissue bacterial infection, fever relapsed and laboratory tests were consistent with mas (day ): hb . g/dl, plt /mm ; fdp ug/l, crp mg/l, ferritin ug/l. high doses intravenous metilprednisolone and oral cyclosporin a (csa) were started. on day he presented a systemic capillary leak syndrome and acute myocarditis. he was admitted into the pediatric intensive care unit (picu) where intravenous immunoglobulin and subcutaneous anakinra (ana) were added. on day , due to an introduction: sjögren's syndrome is a systemic autoimmune disease characterized by dry syndrome and lymphocytic infiltration of the exocrine and extraglandular glands. pulmonary involvement in primary sjögren's syndrome occurs in - % of patients, with very heterogeneous manifestations, and occasionally as an initial mani-festation¹. diffuse interstitial lung involvement is one of the most characteristic pulmonary manifestations and the most frequent subtypes in lung biopsy are interstitial lymphocytic pneumonia and nonspecific interstitial pneumonia². objectives: -year-old girl presented to our hospital because of bilateral interstitial involvement with ground glass areas in lower lobes of both lungs on thorax and abdominal ct scan after for kidney stones follow-up. the patient had grade mmrc dyspnoea and dry cough but denied having symptoms of arthralgia or arthritis, photosensitivity, oral and genital ulcers, raynaud's phenomenon or episodes of dry mucosa. she had no history of autoimmune disease nor family antecedents of any autoimmune disease. a physical examination disclosed no finger clubbing or swollen superficial lymph nodes but indicated crackles on pulmonary auscultation. laboratory work showed elevated acute phase reactants, positive rheumatoid factor, positive antinuclear antibodies ( / ), positive cytoplasmic antineutrophil antibodies ( / ) and igg and iga hypergammaglobulinemia. an examination for autoantibodies were negative for anti-ss-a, anti-ss-b, anti jo- , anticentromere and anti-scl- antibodies. iontophoresis with pilocarpine and -minute walk test was also normal. pulmonary function tests demonstrated a mild restrictive impairment and a reduced percent diffusion capacity for carbon monoxide of %. fibreoptic bronchoscopy showed acute inflammation in bronchial mucosa. flow cytometry of bronchoalveolar lavage and cytology showed lymphocytosis with a % of cd and % of cd lymphocytes in bronchoalveolar lavage fluid. finally, a transbronchial lung biopsy lead to a definitive diagnosis, showing mixed interstitial inflammation and lymphocytic follicular hyperplasia with formation of germinal centers, suggestive of a lymphoid interstitial pneumonia of unreleased autoimmune etiology. throughout time, the patient reported progression of her symptoms with increasing dyspnoea, persistent dry cough, xerostomia and arthralgia. schirmer and rose bengal dye test were negative, and a salivary gland biopsy showed interstitial plasmacytosis and no igg plasma cells expression which suggested sjogren's disease. a high resolution computerized axial tomography was requested, suggesting organizing pneumonia in the context of sjogren's disease. methods: several studies indicate that lung involvement in sjögren is more frequent in advanced stages of the disease and rarely as an initial manifestation. sjögren's syndrome in paediatric age is rare and the subtype of secondary sjogren's is the most common. the course is longer, and the symptoms are more heterogeneous than in adulthood . the diagnosis in children is delayed, because children less frequently report dryness and frequently present with extraglandular clinical features suggestive of other autoimmune diseases. a systematic review on primary sjögren's syndrome in male and paediatric population reported a . % of pulmonary involvement in paediatric patients. pulmonary involvement is associated with an increase in the mortality of patients with sjögren's, therefore, it is essential to periodically monitor patients with respiratory symptoms, making an early diagnosis and treatment of the disease. results: -conclusion: we present a case of a patient with childhood sjögren's disease with atypical onset of disease with lung involvement. introduction: sarcoidosis is a multi-system disorder. little is known about its pathogenesis. in children, the early onset sarcoidosis phenotype including blau syndrome is more often seen. , the diagnosis of sarcoidosis is confirmed by demonstrating a typical non-caseating granuloma on a biopsy specimen. other granulomatous diseases should be excluded, in particular mycobacterial infections, crohn's disease and immunodeficiencies. the clinical presentation may vary depending on the organs involved and the age of the patient. , objectives: we are reporting the case of a boy with a presentation of bone sarcoidosis at a young age. this is a rare phenotype in children. methods: clinical details were retrospectively collated using routine clinical records. confirmation of diagnosis was confirmed with bone biopsy. results: a year old non-identical twin boy of ghanaian descent born in the uk had a slowly growing, painless frontal bone mass which started to develop from months of age. he was developmentally normal, with no history of fever, rashes or joint pains. examination findings revealed frontal bossing while the remainder of the musculoskeletal examination was normal. there was no evidence of rashes, hepatosplenomegaly and ocular examination was normal. the patient was initially referred for neurosurgical review with suspected fibrous dysplasia, after an initial mri scan of the head revealed abnormal marrow signal and expansion of the frontal bone, with no soft tissue swelling. however, the ct scan of the calvarium was not suggestive of fibrous dysplasia. consequently, bone biopsy was performed demonstrating inflammation with granuloma formation. he was referred to infectious diseases and rheumatology. there was no travel history and no tb contact. quantiferon tb was negative. infectious work-up was negative especially for mycobacterial infections. rheumatology work-up identified on skeletal survey another bone location: a well-defined lytic lesion in the right distal fibula that was biopsied. infection cultures and pcr were negative. histopathology identified fibrous tissue and poorly formed granulomas. laboratory investigations revealed a mild microcytic anaemia with iron deficiency and eosinophilia. he had normal serum calcium and vitamin d and his esr was mm/hr. ana, anca and rheumatoid factor were negative, and complement c and c were normal. his serum angiotensin converting enzyme (ace) level was raised at nmol/ ml/min (normal < nmol/ml/min). investigations revealed mild renal impairment with normal urinary tests including normal calcium, protein and tubular proteins. ultrasound of the kidneys was normal. chest x-ray was normal. lung function was performed and was normal. dlco couldn't be performed due to low lung volume. vascular and inflammation genetic panel identified a variant in the nemo gene. functional studies excluded nemo deficiency and patient did not display any of the clinical features. however, a pattern of dysregulated t cells response was identified. he was treated with oral steroids and methotrexate. the oral steroids were successfully weaned off. he has been successfully treated with methotrexate mg s/c to initially stabilise disease with no bone growth, and had no significant side effects. repeat mri years later showed increased burden of disease with other newly affected sites however, including the right femoral diaphysis and signal changes in the left tibial metaphysis. based on the mri and increasing musculoskeletal pain, decision was made to escalate to anti-tnf (adalimumab) with good clinical response. conclusion: bone sarcoidoisis is rare in children but this should be considered in the differential diagnoses when granulomatous inflammation is identified on histopathology. response to steroids and methotrexate is usually good but some patients will need escalation to anti-tnf. the most worrisome non-rheumatic condition causing persistent night pain in children which closely mimics arthritis is malignancy , . it is vital to pick up subtle clues at an early stage especially in absence of hematological manifestations , organomegaly and lymphadenopathy. to reveal early clinical clues in pediatric patients with predominant musculoskeletal (msk) night pains who were initially diagnosed as suffering from some form of chronic arthritis but ultimately turned out to be affected by malignancy. methods i gathered a data of five pediatric patients fulfilling above mentioned criteria who were seen at dev children's hospital between january and march . it included demographics, clinical presentation and laboratory results. all above cases reemphasize the need for an extremely detailed history pertaining to characteristics of pain & pattern recognition in pediatric rheumatology. prolonged fever , persistent msk night pain, persistent limp, upper limb and hip joint involvement which is unlikely for jia at onset are proven to be the earliest subtle clues which should not be missed. other constitutional symptoms, respiratory, cardiovascular, ophthalmologic or osteoarticular involvement were absent. growth was unaffected. auditory tests were normal. systemic antibiotic treatment and local steroids were ineffective. laboratory findings were unremarkable, with only mild elevation of esr ( mm/ st hr). ana and anca were absent in repeat meausrements ( months intervals). cardiovascular disease was excluded. abdominal us was normal. on the basis of relapsing bilateral auricular chondritis and confirmatory histological findings revealing inflamed cartilage from the pinna of the ear with chondrocyte degeneration, perichondrial infiltrates of lymphocytes, plasma and polymorphonuclear cells and replacement of cartilage with fibrous tissue perivascular infiltrates of polymorphonuclear cells and lymphocytes, relapsing polychondritis was diagnosed. one month nsaids trial, pending histology results was ineffective. methotrexate sc and steroids mg/kg/d gradually tapered over a -month period were given with significant improvement of auricular inflammation and normalization of markers of inflammation. auricular chondritis worsened after steroid withdrawal and adalimumab was added to treatment with significant improvement of auricular inflammation in months. in the following months auricular chondritis relapsed during uris with mild elevation of esr ( mm st hr) and crp ( mg/l). after months of treatment, in an effort to prolong the intervals of adalimumab administration, bilateral auricular chondritis relapsed. after months of mtx and months of adalimumab administration inflammation was put in complete remission. the following year no flares or involvement of other systems were observed, under methotrexate and adalimumab treatment. conclusion: in this patient isolated auricular relapsing polychondritis was unresponsive to nsaids. steroids and methotrexate greatly improved inflammation but did not induce complete remission. complete remission was achieved by addition of adalimumab to methotrexate treatment, which also allowed for steroids discontinuation. none declared first ever single center study revealing spectrum of rheumatic diseases in children from an indian state of gujarat d. b. pandya, on behalf of dr mehul mitra, pankaj buch, sonal shah, there is very limited information and awareness about pediatric rheumatic and immunodeficiency diseases amongst primary physicians , , in gujarat and to make this matter even worse, we are not having a single exclusive pediatric rheumatology and immunology centre for a population of around million. to guesstimate a status of children with rheumatic and immunodeficiency diseases in gujarat and spectrum of these diseases at dev children's hospital. methods i gathered a retrospective data of patients who attended dev children's hospital between january and january . out of these, children with confirmed diagnosis of inflammatory rheumatic diseases and suspected primary immunodeficiencies were included. patients with non-inflammatory musculoskeletal(msk) pains and non-rheumatic diseases causing msk pains were excluded. my collected data included referral details, demographics, clinical presentation, laboratory results and diagnosis. majority of the cases were referred by pediatricians, orthopedicians, hemato-oncologist and general physicians. main reasons for referral were joint involvement , undiagnosed fever , multisystem disease and elevated inflammatory markers. many physicians had put a diagnosis like rheumatoid/rheumatic arthritis, autoimmune disease or connective tissue disease. almost % of patients had been evaluated with rf, aso titer, ana and joint imaging irrespective of clinical pattern by their primary physicians before referral. fever , msk involvement, extreme fatigue, constitutional symptoms, skin and mucosal involvement were prominent complaints noted by me. family history of rheumatic, primary immunodeficiency (pid) or consanguinity was found in / of patients. anemia of chronic disease, elevated esr and thrombocytosis were almost universal laboratory findings in our cohort. rheumatic diseases in children are not anymore rare but due to lack of expertise and awareness , these children are not getting diagnosed. many cases were advised unnecessary rheumatological investigations even before referral. results: a -year-old female patient was referred to the rheumatology clinic at our hospital with a previous history of fever of °c ( . ºc), loss of appetite, and acute polyarthritis of wrist, knees, and ankles. at that time, laboratory exams revealed a hemoglobin of . g/dl, c reactive protein . mg/l, and antistreptolysin o titers of ui/ml (normal range < ui/ml. clinical symptoms were relieved only after using nsaids. after months, the patient returned to our hospital with a -month history of weight loss and claudication related to pain and daily morning stiffness ( minutes) on her right ankle. new laboratory findings demonstrated positive antinuclear antibodies : , negative rheumatoid factor, and alpha- -acid glycoprotein of mg/dl (normal range: - mg/dl). clinical signs suggestive of chronic arthritis with exuberant swelling of the ankles were observed on physical examination (figure a). she was screened for tuberculosis (tb) and had a positive ( mm) tuberculin skin test (figure b). chest ct revealed infiltrative soft tissue mass in the posterior mediastinum, with homogeneous contrast enhancement (figure c). magnetic resonance imaging of both ankles was performed and demonstrated bilateral and symmetrical tibiotalar arthritis and prominent tenosynovitis of extensors, flexors, and fibularis tendons (figure d). right ankle synovial biopsy revealed no granulomas and joint fluid culture was negative for mycobacterium tuberculosis, confirming reactive arthritis (poncet's) and tenosynovitis, that may follow mycobacterial infection with no infective agent in the joints. conclusion: to our knowledge, there is no report of poncet's disease associated with inflammatory tenosynovitis, showing the particularity of this case. the patient's symptoms resolved after two months of anti-tb therapy. introduction: cacp is characterized by congenital or early-onset camptodactyly (usually bilateral); non-inflammatory arthropathy (more frequently in the wrists, knees, ankles, elbows, and hips); coxa vara (reduction of the angle between the neck and shaft of the femur); and non-inflammatory pericardial effusion (a late manifestation, less frequently reported). recognizing the radiological aspects of this syndrome and differentiating it from jia is crucial since cacp has no effective treatment and jia is usually treated with nsaids and methotrexate ( , ) . objectives: to report a rare case of cacp syndrome mimicking jia. methods: case report and literature review. results: a -year-old male patient presented with arthropathy characterized by painless progressive swelling and restricted movement of the hands, hips, knees, and ankles since the first year of life. he had a family history of camptodactyly from his paternal grandfather. on physical examination, symmetric camptodactyly of the hands and feet was observed (a). he had no history of rash or weight loss and inflammatory markers were unremarkable. the echocardiogram was normal. the pelvic radiograph showed a widening of the joint space and bilateral coxa vara. magnetic resonance imaging (mri) of the hips (b) and knees (c) was performed and depicted large joint effusions (arrows, b and c) with normal synovial thickness and mild synovial enhancement in all joints, without bone marrow edema-like signal. a synovial biopsy of the knee was performed and revealed mild synovial hyperplasia without inflammatory cells. the patient was diagnosed with camptodactyly-arthropathy-coxa vara-pericarditis syndrome (cacp -omim ), a recently described genetic disorder with no gender predominance identified to date ( ). conclusion: an important differential diagnosis of cacp is juvenile idiopathic arthritis (jia), a painful inflammatory chronic arthritis that can cause not only joint effusions due to synovial inflammation, but arthritis was the most frequent extraglandular manifestation. renal tubular acidosis represented the typical expression of renal involvement ( cases). neuromyelitis optica and aseptic meningoencephalitis ( and cases, respectively) were the most typical neurologic manifestations. two cases of interstitial lung disease and one of pulmonary hypertension were reported. almost all patients had autoantibodies, mostly ana ( / patients) and anti-ssa/ro ( / patients). the schirmer test was performed in less than half of the patients, of whom % tested positive. a positive result of minor salivary biopsy was reported in / cases with available data. juvenile idiopathic arthritis was the most frequently associated disease, followed by systemic lupus erythematosus ( and cases, respectively). no significant differences between patients with or without parotitis were found except that patients with parotitis showed increased levels of crp more frequently than those without it (p= . ). patients with anti-ssa/ro had more frequently a positive schirmer test (p= . ). the presence of rf was significantly associated with dry mouth (p= . ), arthritis (p= . ), and rash (p= . ). a positive minor salivary biopsy was more common in children with dry eyes than in those without this clinical feature (p= . ). arthritis was more frequent in patients with other diseases than in those with primary ss (p= . ). we further investigated ss features according to the age groups (≤ years, - years, ≥ years). parotid involvement was inversely proportional to the age and occurred more frequently in younger patients ( % of those ≤ years; p= . ). interestingly, the rate of anti-ssa/ro positivity increased with age ( % of those ≥ years; p= . ). conclusion: even though parotitis was the most frequently reported feature, a wide range of clinical manifestations in children with ss has been reported so far. a better knowledge of css features will help to pave the way for the development of css specific diagnostic criteria. none declared introduction: pachydermodactyly (pdd) is a rare benign fibromatosis, characterized by progressive painless swelling of soft tissue of proximal interphalangeal (pip) joints without inflammation signs. generally pdd affects pip joints of the fingers, rarely of the thumb. the involvement is typically symmetrical, in few cases unilateral. it usually occurs more frequently in young males. etiology is unknown, but it arises from mechanical stimulation of periarticular skin (i.e repetitive rubbing, interlacing, and cracking of fingers). pdd has to be considered in the differential diagnosis of arthritis (i.e. juvenile idiopathic arthritis, jia) and many syndromes (i.e. progressive pseudorheumatoid dysplasia). prognosis is good with cessation of mechanical stimulation the recurrent paroxysmal appearance of inflammatory lumps (local erythematous tender swellings, which partially respond to antiinflammatory agents), accompanied by elevated inflammatory markers during flares, suggest that fop may be an autoinflammatory disease. the episodic formation of bone, often following a trivial injury, suggests that innate immune-related triggers induce tissue transformation through the bmp pathway. moreover, interleukin- β (il- β), a well-known mediator of the innate immune system, has been linked to ho and mineralization in mesenchymal stem cell cultures derived from human bone marrow. we hypothesized that treating fop patients with anti-il- agents could help ameliorate the progression of this devastating disease. we report our experience treating two fop patients with anakinra and canakinumab. objectives: to decrease the frequency of fop paroxysms, and/or limit the symptoms and extent of residual lesions, by using anti-il- agents. methods: patients' data and blood il- levels were analyzed to characterize the efficacy of anti-il- treatments in ameliorating the natural progression of fop. results: a . year old boy and a year old girl were diagnosed with fop, both clinically and genetically (the typical r h mutation was found). various treatments, including high-dose corticosteroids, pamidronate infusions, celecoxib, monteleukast and sirolimus, did not change the course of the disease. both patients are receiving canakinumab (the male patient was initially treated with anakinra). the male patient has been treated for over years. flare rate was markedly reduced from one new lump every days to approximately one every days ( figure ). the lumps involved in almost all of these flares are the same: at the left scapular base and within the sternocleidomastoid muscle. the female patient has been treated for a year, and has not experienced any ho flares during canakinumab treatment. temporarily withholding canakinumab in both patients, led to serious flares weeks after the last dose. notably, while undetectable levels of il- β (< . pg/ml) were found in the three plasma samples obtained from the male patient during treatment with anakinra or canakinumab, high levels (up to . pg/ml, about -fold higher compared to average levels measured in healthy controls) were found in his plasma samples collected during the flare ( figure ). in contrast, il- and il- plasma levels, measured before, during and after withholding treatment, were comparable or slightly higher than those observed in healthy controls ( figure a , b). conclusion: we report here, for the first time, that anti-il- agents were found efficacious in treating two fop patients. we also found markedly increased il- β levels during flares, which normalized following the treatment. we suggest a role for il- β in the pathogenesis of this disease. although it is too soon to conclude whether fop may be included under the umbrella of auto-inflammatory syndromes, anti-il- agents can be effective in ameliorating the natural progression of fop. introduction: musculoskeletal symptoms are one of the common reasons for applying to rheumatology departments in general practice . although inflammatory causes are generally considered in the foreground, it is known that non-inflammatory causes including genetic diseases may also be responsible. the absence of signs of inflammation (morning stiffness, redness, tenderness) and normal inflammatory markers in laboratory findings may support nonrheumatologic diseases . objectives: to present genetic disorders that can mimic rheumatologic symptoms and to answer when genetic diseases should be considered in the differential diagnosis in patients presenting with rheumatological complaints. methods: we retrospectively evaluated patients who applied to hacettepe university pediatric rheumatology department with musculoskeletal compliants between january and december and had been consulted to genetics departmant. the rate and degree of consanguinity, clinical diagnosis, indication for consultation, accompanying musculoskeletal and other findings had been recorded. the diagnosis of genetic diseases were based on physical examination, radiological evaluations and genetic analysis. results: a total of patients, boys ( . %), with a mean age . ± . years were included in the study. the rate of consanguinity was . %. the most frequent referral to the genetic department was the presence of skeletal anomalies (n: ) such as camptodactyly, clinodactyly, and bone shortness accompanying joint findings. other causes include short stature (n: ), joint deformity (n: ), joint hyperlaxicity (n: ), dysmorphic findings such as atypic facial appearance (n: ), accompanying diseases that may be part of a syndrome (n: ), genetic diagnosis suspicion according to the results of radiological examination (n: ) and joint findings without clinical and laboratory signs of inflammation (n: ). distribution of joint involvement in patients with genetic disease were hands, knees, and hips respectively. in the laboratory evaluation of patients presenting with joint swelling and arthralgia, acute phase reactants (erythrocyte sedimentation rate and c-reactive protein concentrations) were within normal reference values. one third of the patients ( . %) had a final diagnosis of a genetic disease. the diagnoses of these patients were as follows; cacp (camptodactyly, arthropathy, coxa vara deformity and pericarditis) syndrome (n: ), trichorhinophalangeal syndrome (n: ), progressive pseudoromatoid dysplasia (n: ), lig syndrome (n: ), m syndrome (n: ), h syndrome (n: ), spencd (spondyloenchondrodysplasia, n: ), and nonspecific connective tissue disease (n: ). conclusion: genetic syndromes with musculoskeletal findings are often unrecognized and misdiagnosed as rheumatologic diseases leading to unnecessary procedures and treatments. summarizing the genetic diagnosis spectrum that can be detected in these patients will increase the awareness of physicians. results: according to the results of observation, the disease was more common in the age group of - years ( %), to a lesser extent among children in the group of - years ( %), less often in the group of - years ( %). when examining infectious agents, zoonotic infection was detected in % (listeria monozytogenes, yersinia enterocolitica). clinical course of nodular erythema in this group was characterized by an expressed activity of the inflammatory process with multiple elements in the lower and upper extremities, joint syndrome, increased esr to ± . mm per hour, crp ± . mg\l. the disease was preceded by an episode of acute infection with an increase in body temperature, intoxication, in some cases with short-term intestinal syndrome, pharyngitis. the rashes were persistent and recurrent, with a slow regression of laboratory activity. streptococcal etiology of nodular erythema was detected in % of cases. there was an increase in esr to ± . mm per hour, crp ± . mg/l, a significant increase in antistreptolysin on average ± % iu / ml. with an increase in individual cases to iu/ml. in % of cases, erythema nodosum developed after an intestinal infection. among the pathogens were identified sh. disenteria, e. coli, yersinia enterocolitica, enterovirus. the disease was characterized by moderate activity, a good response to etiological therapy and a short course of nsaids . an interesting fact was the development of nodular erythema in % of cases caused by the epstein-barr virus in groups of children from to years and - years. they had clinic picture with normothermia, no symptoms of intoxication, periodically occurring elements of nodular erythema on the shins, no blood changes. therapy aimed at eliminating the virus gave a positive result and did not require specific anti-rheumatic therapy. in % of cases, the etiology of nodular erythema was not defined. the clinical course of nodular erythema in children depends on the infectious agent that was the trigger of the pathological process. the higher activity and duration of the disease is caused by zoonotic infection, which requires more active antiinflammatory therapy with corticosteroids, which may be associated with the activation of autoimmunity. this group of children was taken for further observation as a group at risk of developing systemic connective tissue disease. changes in the etiological structure of nodular erythema and treatment tactics require further study. introduction: sjögren syndrome (ss) is a chronic autoimmune disorder characterized by inflammation of the lacrimal and salivary glands leading to oral and ocular dryness. childhood ss is rare and poorly defined and underdiagnosed owing to the lack of childspecific diagnostic or classification criteria. objectives: the purpose of this study is to describe cases with pediatric ss in order to better clarify the characteristics of the disease in the pediatric age. methods: we retrospectively reviewed medical records of patients (pts) with pediatric ss referring to three italian pediatric rheumatology centers. due to lack of childhood validated ss-specific criteria, physician diagnosis was the only inclusion criteria. results: we collected data on pts ( females). the mean age of disease onset is . yrs (median . , range - ). the mean age of diagnosis is . (median . , range - ). the follow up period varied from . to . yrs (mean . , median . ). the most common manifestations were articular involvement (mainly with arthralgia) ( / pts) and parotid/salivary glands swelling ( / pts). xerostomia and xerophthalmia were found in / pts and in / respectively. vaginal dryness was reported only by one pt. fever and fatigue occurred in / and / pts respectively. we also recorded cases of circulating immune complexes manifestations in pts, purpura (n= ) and glomerulonephritis (n= ). we observed an endocrine involvement in pts ( metabolic syndrome, autoimmune thyroiditis). abdominal pain was found in / pts. all pts were positive for autoantibodies (positivity for ana or anti-ssa or anti-ssb or fr) at presentation. rf test results were available in pts, all positive. positive ana (titer> / ) and anti-ssa were present in / pts and in / respectively. hypergammaglobulinemia (range , - . g/dl) was found in / pts ( na). abnormal schirmer test was observed in the half of cases ( / ). minor salivary gland biopsy was performed in pts resulting in histological evidence of focal lymphocytic sialadenitis in / . sonographic evaluation of salivary glands was abnormal in all of the patients ( / ). with regard to treatment, / pts received corticosteroids and eight were also treated with one or more dmards such a hydroxychloroquine (n= ), methotrexate (n= ), azathioprine (n= ), leflunomide (n= ). biological therapy was used in patients for systemic involvement: received belimumab and then rituximab, while the other patients received rituximab. conclusion: xerostomia and keratoconjunctivitis sicca were not common in our series while recurrent parotid swellings were more frequent than what reported in adults. pediatric recurrent parotitis should increase the suspicion for sjögren syndrome. current diagnostic criteria for ss do not include parotitis and therefore, the incidence of ss may be under-recognized in childhood. the disease is not always benign and patients with severe course may need second line treatment including immunosuppressant and biologics. introduction: improving our understanding of pediatric rheumatological (pr) patient population is crucial for pediatric rheumatologists to know rheumatic disease epidemiology and to raise awareness leading to early detection. we didn't find studies of pr disorders presenting in the first year of life. objectives: the aim of this study is to assess the prevalence of pr disorders with onset in the first year of life. methods: we retrospectively studied patients observed in our pediatric rheumatology unit between january st of and december st of . we defined acute (< weeks), subacute (≥ and < weeks) and chronic (≥ weeks). results: a total of patients were observed in years. diseases' onset occurred in the first decade of life in patients ( %) and in the first year of life in ( , %). among the latest group, chronic inflammation was the most frequent group of diagnosis ( %), followed by recurrent inflammation ( %), acute inflammation ( %), infection ( %), infiltrative/ degenerative disorders ( %) and subacute inflammation ( %). the remaining patients ( %) were diagnosed with other disorders classified as miscellaneous. among chronic inflammation group, patients were diagnosed with juvenile idiopathic arthritis ( systemic); had neonatal lupus and one patient had polyarteritis nodosa. among recurrent inflammation group, patients were later diagnosed with pfapa (periodic fever, aphthous stomatitis, pharyngitis and adenitis), were diagnosed with behçet disease and had an autoinflammatory disorder. acute vasculitis was diagnosed in patients ( kawasaki disease and acute hemorrhagic edema of infancy). among infectious diseases group, there were two cases of congenital syphilis with arthritis and two cases of osteomyelitis secondary to bcg vaccination. conclusion: rheumatological diseases presenting in the first year of life are not exceptional. although many patients didn't have a definitive diagnosis at the beginning of the symptoms, many of them were later diagnosed with rheumatic disorders, mostly chronic inflammation ( %), which requires early diagnosis, specific treatment and long-term follow-up. rheumatic diseases must be considered as differential diagnosis in the first year of life in order to avoid delayed intervention and long term disabilities and sequelae. ( ), on the other side measles-induced mas has rarely been reported ( ). objectives: we present the case of a child known to have sjia in remission, who presented a measles primary infection and a secondary kd complicated by mas. methods: a years old girl, not fully vaccinated and known to have sjia in remission under methotrexate, presented for frequent high grade fever of days duration associated with flat flash red spots on the face and trunk as well as the palms and soles. a koplik's spot was identified. conjunctivitis and coryza were also present. initial viral serology, including measles, returned negative. fever persisted and on day , edema of both hands and feet appeared with bilateral cervical adenopathy, erythematous tonsils, gingivitis, cracked lips and hepatomegaly was noted. all cultures were negative and chest x-ray was normal. inflammatory markers rose up. viral serology was repeated and measles igm came back positive. cardiac ultrasound ruled out coronary aneurism and the ophthalmic exam showed no uveitis. kd criteria were met and g/kg of intravenous immunoglobulins (ivig) were administered. after hours of clinical improvement, fever reappeared and the patient returned to be ill looking although the rash regressed. we noted high ferritine( ng/ml) together with low c , decrease in platelets( x /ml) and elevation of hepatic enzymes, ldh and cpk, without increase in the inflammatory biomarkers. mas was suspected and a bone marrow aspirate showed the presence of mild macrophage hemophagocytosis. antibodies for lupus and auto-immune myositis were all negative. steroids were given, fever disappeared, and spectacular clinical and biological improvements were objected. weeks later, desquamation of all extremities was noted. sars-cov- was not investigated because historically this case presented year earlier than the pandemic. results: we hereby report, for the first time, kd and mas triggered by measles infection in a child with sjia in remission. the exact mechanism involved in kd-induced mas and measles-induced mas has not yet been defined but a defective immune response is suspected ( ). conclusion: significant similarities and overlap between measles, kd, sjia and mas make an early diagnosis very challenging ( )( ). the recent covid pandemic emphasizes how a viral illness can be responsible of kd and sometimes degenerating in mas. we report this clinical case as an example of a systemic inflammatory syndrome (sis) taking place after a viral infection to measles. in the era of covid pandemic and secondary sis in children, an additional challenge is present in regions lacking measles vaccine coverage. none declared the musculoskeletal manifestations of scurvy: a diagnostic challenge for the rheumatologist p was a -year-old boy, with autism spectrum disorder, malnutrition and severe food selectivity, admitted to our unit for refusal to bear weight and bruises in lower limbs. the auxological evaluation showed a strongly dystrophic aspect. coagulation profile and main organ function markers were normal. at nutritional biochemical parameters evaluation, iron and vitamin c deficiencies were detected (vitamin c: μmol/l). oral vitamin c therapy was started, with prompt clinical response. p was a -year-old boy with autism spectrum disorder, admitted to our unit for lameness and difficulty in walking for a month. at clinical examination, a mottled skin at lower limbs was noted. joint examination was normal. auxological parameters and main blood tests were adequate for age. given the presence of food selectivity, he underwent serum vitamin c dosage ( μmol/l); hence he started oral vitamin c therapy, with rapid clinical improvement. p was a years old boy who was referred for coxalgia and fever. at clinical examination, pale skin, gingival hyperemia, and pain in mobilization of the left hip were present. microcytic anemia was detected, but main organ and inflammatory markers were normal. no evidence of infection was present. x-ray of femur and knee showed morpho-structural alteration of the distal metaphysis bilaterally. a low intake of fruit and vegetables was reported; hence, dosage of vitamin c was performed, resulting reduced ( . μmol/l). he started vitamin c oral therapy with clinical response. p was a -year-old girl with behavioral disorder and intellectual disability, admitted for fever and right knee swelling which appeared two days after a right leg burning. c-reactive protein and esr were elevated and ultrasound exam confirmed intra-articular knee effusion. suspecting a septic arthritis, antibiotic therapy was started with laboratory normalization and partial clinical improvement. considering the persistence of knee swelling after nine days of intravenous antibiotic therapy, the presence of gingival hyperemia and history of food selectivity, vitamin c dosage was practiced ( μmol/l). oral vitamin c was administered with complete clinical resolution. conclusion: although scurvy is considered a disease of the past, it still occurs nowadays. food selectivity associated to autism is a major risk factor for vitamin c deficiency in childhood. rheumatologists should take into account the diagnosis of scurvy in the diagnostic approach of musculoskeletal disorders in children, especially when development disorders are present. . %), juvenile dermatomyositis (n= ), sarcoidosis (n= ), granulomatous polyangiitis (gpa) (n= ), sting-associated vasculopathy with onset in infancy (savi) (n= ), and oligoarticular jia (n= ). respiratory symptoms were present in ( . %) patients at the time of primary diagnosis. in other patients, the time period between the diagnosis of the rheumatic disease and the onset of the respiratory symptoms ranged from to years. cough, the most common symptom, was present in ( . %) patients. six patients manifested with cough and sputum. six ( . %) patients had shortness of breath and one patient had hemoptysis. on the physical examination of one patient, rales and clubbing were detected. high resonance computerized tomography (hrct) was performed in all patients. hrct findings were as follows; lymphadenopathy in patients ( . %), ground glass appearance in patients ( . %), consolidation in one patient, pleural effusion in one patient, pulmonary nodule in patients ( . %), fibrosis in one patient, cystic lesions in patients ( . %), septal thickening in patients ( . %), bronchiectasis in one patient, and reverse halo sign in one patient. in echocardiographic examination, only one patient had pulmonary hypertension. three patients underwent open lung biopsy, and diagnosis was made with pathological examination of the lung tissue. of these three patients, two ( . %) had lymphocytic interstitial pneumonia (lip), and one patient had chronic inflammation and focal fibrosis. infectious lung disease was not detected in any patient. ten patients ( . %) had interstitial lung disease associated with rheumatic disease, one patient had pulmonary hemorrhage, one patient had pulmonary involvement of gpa, one patient had pulmonary involvement of sarcoidosis. there was no statistically significant difference between the first and last spirometry and dlco values during the follow-up period. mortality was . % ( / ) in this cohort. active disease was significantly associated with abnormal tc, hdl, and tg levels (p= . *), (p= . *) and (p= . *) respectively. multivariate analysis of the factors affecting abnormal cholesterol level revealed that sle is a significant predictor of abnormal cholesterol level . presence of jsle increase risk of abnormal cholesterol times more than cases without jsle. the overall percent predicted was %. active disease is a significant risk factor for abnormal tg with increased risk of abnormal tg by . among cases with active disease than cases with inactive disease. the overall percent predicted was . %. conclusion: children with rheumatic diseases showed significant lipid profile abnormalities. abnormal tc, hdl and tg are significantly associated with active disease. presence of jsle increase risk of abnormal cholesterol. active disease is a significant risk factor for abnormal tg. therefore, lipid levels should be monitored regularly and managed in patients with paediatric rheumatic diseases to minimize the longterm risk of cvd. methods: non-experimental, cross-sectional and descriptive study. a confidential survey was conducted online, aimed at residents and attendings who deal with musculoskeletal pain. were addressed with the definitions of arthralgia, arthritis, myalgia, allodynia and hyperesthesia (between five to seven options) with only one correct answer. correct definitions: arthralgia (pain localized to the joint or periarticular structures, as a only manifestation); arthritis (criterion one or criterion two: -joint swelling or intra-articular effusion / -limitation of joint mobilization associated with at least one of the following: a) pain b) tenderness c) swelling d) heat); myialgia (pain with muscular origin or referred to muscle, regardless of its etiology); allodynia (pain resulting from usually non-painful stimulus); hyperesthesia (coexistence of allodynia plus hyperalgesia -exaggerated responses to tactile and thermal nociceptive and nonnociceptive stimuli the association of pure red cell aplasia (prca) with thymoma led to the discovery of the autoimmune mechanisms involved in the pathogenesis of this rare disease. till date many adult case reports have revealed a strong link between prca and autoimmune diseases, endocrine disorders, rheumatic diseases, autoinflammation and immune dysregulation. [ ] [ ] [ ] [ ] [ ] objectives to stimulate a search for the genetic and immunological roots for a . years old girl with syndromic face, pure red cell aplasia, type diabetes and polyarthritis. methods this is a story of a . years old girl with pure red cell aplasia, type diabetes and polyarthritis. she was normal till months of age. at the age of months, she was diagnosed with type diabetes. she was evaluated by her paediatrician in view of generalized hypotonia, deformed pinna, low set ears, midfacial hypoplasia, blue sclera, umbilical hernia and retracted eyelids. she had multiple episodes of seizures during next few months. to me, she was presented with one year history of polyarthritis with severe pallor requiring frequent blood transfusions. family history was inconclusive. musculoskeletal examination showed polyarthritis involving right knee, bilateral ankles, fingers and toes. further examination revealed haemolytic facies and hepatosplenomegaly. i was not able to make out any facial dysmorphism mentioned earlier by her paediatrician. results: table conclusion early age of onset, pure red cell aplasia, autoimmune and endocrine manifestations with some doubtful facial dysmorphism inspired me to suspect some known or unknown immune dysregulation syndrome in this child. genetic analysis would be the best possible option in this scenario if financial condition permits. introduction: galactosialidosis (gs) is a rare inherited lysosomal storage disorder (lsd) which is characterized by a defect in the lysosomal glycoprotein catabolism. here we report, for the first time, a case of a child affected by gs who presented with recurrent episodes of extensive joint inflammation in both knees. knowledge on gs related inflammatory joint pathology is lacking, which hampers evaluation of possible mechanisms that could give an explanation for the significant arthritic joint abnormalities as observed in our patient. objectives: the aim of this study is to describe the clinical presentation as well as the laboratory, radiologic and microscopic features of this extremely rare presentation of gs. furthermore, we conduct a literature review on lsd's complicated by arthritis in order to evaluate potential mechanisms that could explain the extensive inflammatory joint swelling observed in our patient. methods: in this study we present a -year-old turkish boy who was diagnosed with gs (late infantile form) at months of age. from the age of years, the boy presented with episodes of inflammatory joint pathology of the knee. informed consent was obtained. alongside the case report, a literature review using medline was conducted. an extensive list of known lsd's was combined with the terms: "arthritis", "joint inflammation", "synovitis" and "synovial inflammation". cases in which joint inflammation was based on a probable cause other than the underlying lsd were excluded. results: in the present case, owing to comprehensive examinations (i.e. laboratory tests, imaging and microscopic examination) multiple possible causes for the recurrent inflammatory joint pathology could be rejected (i.e. no signs of infectious arthritis, reactive arthritis, osteoarthritis, arthritis secondary to a malignancy or crystal induced arthritis). a diagnosis which could explain the clinical picture is the jia subtype: ana negative oligo-articular jia. however, microscopic examination showed numerous foamy macrophages with extensive vacuolization in the synovial tissue of the inflamed joint, which is not associated with jia. given the evidence of storage products within the macrophages of the inflamed synovial tissue and no conclusive diagnosis, gs itself should be considered as the primary cause for the recurrent arthritis. an in-depth literature review using medline for data on inflammatory joint pathology in lsd's showed that lsd subtypes (i.e. fabry disease, farber lipogranulomatosis, gaucher disease type , mucopolysaccharidosis ix, a-mannosidosis, fucosidosis and cystinosis) could present with disease related arthritis. multiple potential arthritic mechanisms secondary to storage product accumulation in lsd's have been described, such as: dysregulation of innate immunity and increased upregulation of numerous pro-inflammatory proteins. conclusion: given the evidence of storage products within macrophages of the inflamed synovial tissue and the absence of other etiological clues, our hypothesis is that gs itself is the primary cause for the inflammatory joint pathology in our patient. although, gs cannot be linked directly to joint inflammation, lysosomal defects have been associated to pro-inflammatory effects that possibly could result in arthritic disease. future identification of other patients with gs is required to support the hypothesis of an arthritic clinical phenotype of gs and to assess underlying pathophysiology. introduction: joint pain (jp) is a relatively common complaint among children and adolescents. a painful joint in children for many years continues to maintain the status of the most common symptom of juvenile arthritis. however this symptom should not always be interpreted as a manifestation of rheumatic diseases. objectives: the aim of current review is to debate of the structure in children with the chief complaint of jp. methods: we retrospectively analysed our series of children which attending outpatient department with complaint about pain lasting longer than two months in one or more joints. the clinical, instrumental and laboratory pictures were collected. special attention was paid to certain aspect of medical complaints, a complete and accurate history and physical examination. different categories as possible etiologies of jp in children were systematize and detailed. results: all children were divided into several groups based on their anatomical and physiological characteristics of osteoarticular system: the first group consisted of children under - years old, the second group - children - years old, the third group - children over years old. research suggests that more preschool children were experience bilateral lower extremity pain by "post-walk genesis" due to natural hypermobility, immaturity of sensory innervation of the joints and imbalance of the leg muscles (e.g. growing pains). the second most common cause of jp was associated with intra -or postinfectious factor (viral, streptococcal and chronic focal of infection). the frequency of juvenile arthritis and other rheumatic diseases in children of this age group did not exceed %. special attention was paid to fever, chills, malaise, nightpain and constitutional symptoms with changes in blood lab tests to exclude osteomyelitis (inc specific cause), malignancies manifestation and other bone tumors (less %). the most common causes of joint pain of school-age children were hypermobility syndrome and enthesopathy (primary, secondary). secondary enthesopathy were result of changes in nutrition, rapid growth and excessive exercise. also enthesopathy were manifestation of endocrine, gastrointestinal or infectious diseases. the proportion of children with the onset of chronic inflammatory arthropathy also did not exceed %. hypermobility child's syndrome was characterized by harmless pain (inc low back pain), linked to physical activity (less morning stiffness). over the past decade, we've seen a gradual increase in the number of children ( % were girls) with knee pain by diagnosed patellofemoral and mediopatellar plica syndromes, patellar tendinitis or idiopathic cause. in most cases children was complicated by syndrome of increased anxiety. the share of true chronic inflammatory arthropathies, including spondylitis, in children of this age group did not exceed %. fibromyalgia were diagnosed less %. introduction: a significant part of patients in rheumatologist's practice is children and teenagers with complaints of pain. the further volume of examination and the choice of treatment course depends on the capability of the rheumatologist to define the inflammatory and non-inflammatory genesis of pain. that makes the problem of differential diagnosis very important. objectives: to conduct a comparative analysis of patients with a principal pain complaint to determine if there are significant differences in the groups with the inflammatory and noninflammatory pain genesis. methods: the retrospective study included children who consulted a rheumatologist in the outpatient clinic in the period - without preliminary selection (n = ). of them there were selected children with principal pain complaint (n = ). according to the diagnosis, the children were divided into groups: those who have inflammatory genesis of pain (a, n = ) and those with noninflammatory genesis of pain (b, n = ). the group a included children with such diagnoses as: reactive, poststreptococcal and juvenile idiopathic arthritides. the group b included children with arthralgia, chronic pain syndrome, orthopedic pathology, fibromyalgia. results: . groups a and b differ in the average age of the first complaints onset (t-criterion for equality of means) with a high degree of statistical significance (group a = , years; group b = , years; p = . ). which means that in group a more often than in group b first complaints appear in the age between to while in group b more often than in group a it happens in the age between to . . there was a statistically significant difference in the means between groups a and b in time between the onset of first complaints and the first visit to a rheumatologist (p = . ) also in favor of this conclusion speaks the fact that in group a the number of visits to a rheumatologist in the same year when the first complaints appear is almost times higher than in group b. % of cases in group a consulted the rheumatologist the same year when the first complaints appeared in comparison to group b where only % of patients did the same. below is the table with distribution of cases by the number of years between the first complaints onset and the first visit to a rheumatologist in both groups: conclusion: in children with arthritides, the first pain complaints appear at an earlier age (an average of . ), and in group b (an average of . ). patients with arthritis more often visit a rheumatologist earlier (within year after the first complaints) than those with non-inflammatory genesis of pain complaints. the most common cause of recurrent musculoskeletal pain is growing pain (gp) in children. differential from rheumatic diseases could be challenging in some cases since there are no diagnostic criteria for gp. objectives: to analyze gp characteristics in a large cohort of patients in comparison with other non-inflammatory and inflammatory diseases causing limb pain, and to simplify the gp's diagnosis process by using machine learning (ml) techniques. methods: this is a multicenter cross-sectional study. introduction: it is a well-known fact that the period of intensive growth in children is associated with the processes of active bone mass accumulation and coincides with them in time. one of the most distinctive indicators of an increase in the disease incidence among children for the recent decade (+ , %) can be found in the skeletal disorders resulting from disrupted calcium metabolism and vitamin d deficit. the latter is widespread in ukraine as it is observed in % of schoolers. objectives: establish the specifics of the structural and functional status of the bone tissue in children during the growth spurt, taking account of the degree of vitamin d sufficiency. methods: the examination covered children aged - who were divided into three groups depending on the presence of the growth spurt (gs) and its intensity: group - children who had become - cm taller for the year in question; group - children who had become taller by cm or more, group - children who had experienced no growth spurt. inclusion criteria were the following: no chronic somatic or endocrine pathologies, no musculoskeletal disorders or mineral homeostasis disruptions; physical exertion corresponding to their age; the children had not been taking any complexes of vitamins and minerals, including vitamin d for months before the examination. conclusion: children aged - showed deficiency of vitamin d reaching % which had no correlation with the presence or intensity of the growth spurt. in children who experienced growth spurt, a reduced bmd proved more frequent and correlated with the spurt intensity, however, it did not depend on sufficiency of vitamin d . therefore, during the growth spurt, disrupted mineralization of the bone tissue was influenced not only by the vitamin d deficit but also by the correlation between the bone tissue mineralization rate and intensity of growth in the children. methods: a self-reported question online survey on qol of patients with sjia and aosd was developed by the non-profit organizations, the autoinflammatory alliance, kaisz/vaisz, enca and sjia foundation in english and translated to dutch. respondents were recruited by convenience sampling through online social media posts. data on flares, triggers, family history, and correlation of symptoms with labs were collected in addition to detailed information on qol during and in-between flares. results: between and , there were responses; were from parents of children with sjia, from adults with sjia, and from adults with aosd. interestingly, adults (whether diagnosed with sjia or aosd) were more likely to report pain, fatigue, joint swelling or arthritis, nausea & vomiting, and diarrhea during flares than children. adults were also more likely to describe flares >one month. % of patients reported being "greatly" or "severely" limited during flares. between flares, % reported being "greatly" or "severely" limited while % were "somewhat" limited. % felt their condition affected their studies, job, and career, including % of children with sjia, % of adults with sjia, and % with aosd. respondents were asked open-ended questions regarding their experience with disease flares and impact on their lives, and specifically how sjia and aosd affected work, career and schooling. responses regarding the disease experience were classified into theme areas: ) experience with disease onset and process of diagnosis; ) health care access, quality, and drug safety concerns; ) physical impact of the disease including pain and chronic fatigue; ) social impact of the disease; ) mental health and emotional impact of the disease; ) impact on work, career, and employment; and ) broad impact on life and lifestyle. responses regarding effect on work, career, and schooling were categorized into theme areas: ) physical impact negatively influencing school/work productivity; ) lost work and wages, including unemployment and needing disability benefits, and parents missing work to care for the child; and ) the socialemotional impact as well as negative effects on mental health. about half of patients regardless of age reported the name sjia did not represent well the disease, specifically that it did not emphasize the systemic symptoms, and that the disease gets confused with other types of arthritis. adult patients with sjia did not like to have juvenile in the name. conclusion: children and adults with sjia and aosd report high levels of qol limitation and effect on school, work, and career, both during and between flares. our qualitative data emphasizes the importance of multidimensional evaluation of disease with ongoing input from the patients, which will provide a foundation for asking more relevant research questions to foster better care and improve qol. results: in total participants were included in the study : juvenile idiopathic arthritis (jia) patients, and their parents. the mean age of the patients was . ± . years. significant differences were found between patients and healthy children in such hrqol survey categories like "autonomy" and "financial resources" (p < . ). although quality of life in children's with juvenile idiopathic arthritis was lower than in healthy children in hrqol survey category "self perception" (p < . ). after analyzing data no significantly differences were found between patients and parents' assessment scores in hrqol survey categories (p > . ). conclusion: juvenile idiopathic arthritis has a moderate negative influence on hrqol survey categories "self perception", "autonomy" and "financial resources" (p < . ) according kidscreen- queationnaire. introduction: juvenile dermatomyositis (jdm) is often first identified by parents and carers as the red facial rash develops. the rash can progress and lead to young people being misdiagnosed with eczema, scarlet fever or psoriasis. however, over time the obvious signs of jdm can become "invisible" as treatment calms the rashes and masks the outward signs of jdm, until a flare occurs, when the rashes can be a marker for disease activity or progression. as part of a larger study, children around the united kingdom were asked to discuss their views on whether they wanted people to be able to see their jdm. objectives: to understand the implications for children and young people from having a disease that has visible and invisible phases and whether they want others to see their jdm, or not. methods: children and young people around the united kingdom who were already consented and enrolled into the uk juvenile dermatomyositis cohort and biomarker study were asked to complete a bespoke questionnaire. there was a mix of open and closed questions, and it was administered in paper format to all children and young people between the ages of and years of age for self-completion, either on the paper forms, or via a secure web-based software system. the questionnaires were administered at the end of . numeric data were described and qualitative data were analysed using standard content analysis. results: questionnaire packs were sent out, with ( %) being returned. of these could not be used due to practical reasons, such as only demographic data being completed, which left a sample of . ( %) of the who responded said other people could not see their jdm, with only ( %) saying it was visible and ( %) saying they did not know if others can see it. did not respond to the question as said their jdm has gone away. they were then asked whether it was a good or bad thing for others to be able to see their jdm or for others not to be able to see it. young people left comments as to why it was a good thing, left comments as to why it was a bad thing and left comments to why they said don't know, table presents the top ranking response for the three multichoice answers. conclusion: this study has highlighted the disparity between young people wanting others to see their jdm so that they gain more understanding and empathy from those around them, but equally, wanting their jdm to be invisible, so that they feel the same as their peers. whilst many paediatric rheumatic conditions are in fact invisible, our data illustrate that jdm often gives children and young people a taste of both visible and invisible phases of disease activity. as one young person said "it's not good, nor badit's good that it's invisible sometimes so i can blend in without the disabled stereotype. however, sometimes it needs to be seen so i can be understood and not challenged". disclosure of interest: none declared multidimensional assessment report (j-fimar) which includes comprehensive patient self-report questionnaire and numerical rating scales to measure pain, fatigue, headache, sleep quality, physical function, psychological state, health-related quality of life, satisfaction with illness course. the j-fimar has been devised according to the outcome measure in rheumatology (omeract) guidelines. discriminant ability of the multidimensional tool was evaluated by testing it in a control group including healthy controls and patients affected by active juvenile idiopathic arthritis (jia). the psychosocial consequences of chronic pain were evaluated by using the children depression index (cdi) and the multidimensional anxiety scale for children (masc). the objective sleep quality was measured by overnight polysomnography. results: table shows characteristics and the most represented somatic symptoms in our cohort of jfs patients at the study enter. polysomnography was performed in patients with sleep disturbance; / ( . %) showed an electroencephalographic pattern of alpha wave intrusion in slow wave sleep (sws). the presence of objective sleep disorders was significantly correlated to cdi score rs - , (p≤ , ) and masc , (p= , ). from november to april j-fimar was completed by jfs patients (f ( . %), median age . years [ . - . ], median disease duration . years [ . - . ]) in visits. all patients filled out the questionnaire in a short time (< minutes) and considered it simple and easy to understand. jfs patients showed significantly higher score for pain, fatigue, poor physical function and measure of psychological distress than healthy controls and jia patients (p< . for each item). conclusion: jfs patients presented significantly higher pain experience, functional disability, and impaired quality of life than patients with active jia. a relevant percentage of jfs patients experience sleep disturbances, which were correlated with mood and anxiety disorders. our multidimensional tool was feasible and able to quantify global jfs severity. this multidimensional tool, by measuring the main domains affected by the disease, could be promising to individualize treatment strategy and to test its efficacy. disclosure of interest: none declared introduction: fatigue is a subjective state of overwhelming, sustained exhaustion and decreased physical and mental capacity, which is not relieved by rest. fatigue is the most common complaint in children and teens with an autoinflammatory disease, besides the disease related flares. the purpose for this study was to show that fatigue is a serious issue for children and young people with autoinflammatory diseases. we hypothesized that age, gender and/ or the type of autoinflammatory disease could have differing effects on the fatigue experience. objectives: we aimed to investigate fatigue in children and young people (cyp) with autoinflammatory disease, including how this affected them on a daily basis. methods: cyp with autoinflammatory diseases were invited to complete an online survey, providing details about their fatigue and how it affected them. the survey was developed by the non-profit organizations autoinflammatory alliance and kaisz/vaisz, in english. respondents were recruited by convenience sampling through online social media posts. data on age, gender and disease were collected in addition to information on their experience of fatigue on school and social interaction. a total of cyp (age range - years) with an autoinflammatory disease responded to the survey ( % female). results: the majority of respondents ( %) reported experiencing both mental and physical fatigue. respondents were asked how much their fatigue affected them, on a scale of to ; overall, the mean fatigue score was . . however, young people aged or over reported a significantly higher impact than those aged - years (mean . , p= . ). different autoinflammatory diseases were surveyed: crmo %, caps %, pfapa % also unclassified said (usaid) with %. in the open-response portion of the survey, % of respondents reported that fatigue was physical, as well as mental, in their experience. most ( %) reported that someone had doubted their fatigue in the past; % had found their teachers had doubted them, % had friends who doubted them, and % reported that they felt their doctors had doubted them. children and young people also felt a number of activities made their fatigue worse (table ) ." conclusion: cyp with autoinflammatory diseases experience physical and mental fatigue. health professionals and teachers should listen to patients reporting fatigue, validate their experience, and help find ways to support them. identifying resources to help the patients with fatigue, and referrals to therapy and mental health resources as needed may help the patients to better cope and manage their chronic disease. further studies will include patient engagement in designing questionnaires about all aspects of life and autoinflammatory disease will help our understanding of these complex conditions and how they affect patients. introduction: scleromyositis is the most common overlap syndrome but is rarely observed in childhood. this disorder involves two different autoimmune diseases: systemic scleroderma (ssc) and polymyositis (pm). objectives: to describe the clinical course of a ssc/pm syndrome in a young girl. methods: case report results: an -year-old female was admitted to the neurological unit of our hospital for creatine phosphokinase (cpk) increase and hypertransaminasemia associated to sporadic episodes of right calf pain. familiarity for muscular dystrophy was reported in the maternal branch. muscle tone and trophism were preserved at initial neurological evaluation. laboratory investigation confirmed increased muscle enzyme levels, including cpk (x ) (ck-mm . %, ck-mb . %), aldolase (x ), cardiac troponin (x ) and myoglobin (x ). suspecting a primary muscle disease, she underwent a total body stir-mri which showed a diffuse edema of gluteus medius bilaterally and a muscle biopsy revealing a marked muscle damage with dystrophic aspects and normality of the tested proteins. a genetic extended panel for congenital myopathies resulted negative. after months, a new clinical examination showed the occurrence of general skin induration, sclerodactyly and tightening of the face skin. appearance of dysphagia was also reported, and muscle enzyme increase persisted. in suspicion of an ssc/pm overlap syndrome, she was referred to our unit. nailfold capillaroscopy showed capillary dilatation and branching, megacapillaries and diffuse microhemorrhages. reduction of esophageal contractions amplitude and hypotensive lower esophageal sphincter pressure were observed at esophageal manometry test. high-resolution ct of lungs and pulmonary function testing were normal. skin biopsy showed sclerodermiform findings. immunological studies revealed a positivity of antinuclear antibody ( : ) and anti-ku. anti-pm-scl resulted negative. an oral corticosteroid therapy (prednisone, . mg/kg/day) was started in association with subcutaneous methotrexate ( mg/m /week) and intravenous immunoglobulins (ivig) ( gr/kg every two weeks). improvement of skin manifestation, joint mobility, as well as normalization of serum cpk levels were observed. over months, prednisone and ivig were slowly discontinued up to the ongoing dosage of . /mg/day and gr/kg every weeks, respectively. mtx is still ongoing at the same dosage. conclusion: the diagnosis of overlap connective tissue disease syndromes may be challenging in pediatric age. different symptoms may be prevalent at different stages throughout the course of the disease. in our patient, a localized myositis preceded the ss onset by about four months. even though the use of high dose of corticosteroids is associated to a higher incidence of renal crisis in patients with css, a combined therapy with high doses of oral steroids, ivig and mtx was safe and effective in skin, muscle and joint symptoms in our patient. results: a total of images were obtained from healthy children included in the study and capillary measurements were made. capillary density was significantly higher in group than in groups and . arterial width was significantly lower in group as compared to group and , and in group as compared to group . apical loop width and capillary distance were significantly lower in group compared to group and and . there was no significant difference between the age groups in terms of capillary length and venous width. there was no difference between the groups in terms of capillary morphology. in total image evaluations, capillary tortuosity was < % in . %, and > % in . %, and capillary crossing were < % in . % and> % in . %. while the enlarged capillary was . % and the avascular area was . %, capillary branching, capillary meandering, microhemorrhage, and giant capillary were not detected in any case. there was a good level of agreement between the researchers, as cases with capillaries were evaluated with a good level of agreement (table ) . conclusion: this is the first study to evaluate capillary morphology in healthy turkish children. this study also adds that some special forms such as enlarged capillary and avascular area, which is always named as pathological in adult age, can be seen in healthy children. these data will be guiding in capillaroscopic studies in various patient groups, particularly in children with collagen vascular diseases. methods: patients with jia were tested for hla-b . they were divided into groups: ) hla-b positive and ) hla-b negative. results: patients ( , %) were hla-b positive and all of them are fulfilled the eular criteria of entesitis-related arthritis (era). the group consists of patients ( . %). there's no statistical difference between both groups in active joint count, ana-positivity and uveitis frequency, the rate of use methotrexate and time before biologics. no difference in axial cervical spine ( . %) vs ( . %) (p= . ) and sacroiliac joints ( . %) vs / ( . %) (p= . ) involvement was observed. hla b (+) patients often received pulse therapy with methylprednisolone due to increased inflammatory activity and severe arthritis ( % vs . %, p= . ). other parameters are listed in table . conclusion: patients with hla-b positivity were characterized by male predominance, more often hip involvement, higher laboratory activity and the need for more frequent use biologics. the rate of axial involvement wasn't different in hla-b positive and negative patients, that needs further study and creating more accurate classification criteria for jsa. disclosure of interest: none declared introduction: although gut is increasingly recognized as origin and/or target of inflammation in adult onset spondyloarthritis (spa), the incidence of gut involvement in juvenile spa (jspa) patients is still largely unknown, mostly due to the lack of reliable non-invasive tests. objectives: we performed a cross-sectional study of fecal calprotectin (fcal), a surrogate marker of gut inflammation, in patients with jspa, other forms of juvenile idiopathic arthritis (jia) and noninflammatory (ni) conditions. methods: fcal was measured by commercially available assay in stool samples of enthesitis related (era), psoriatic (psa) and patients with other jia subtypes (oligo-and poly-articular) who fulfilled ilar criteria, as well as in children with ni causes of musculoskeletal pain (ni-msd), regardless of the gastrointestinal (gi) symptoms (table ). fcal was compared among different groups of patients and correlated with demographic data, clinical characteristics, treatment modalities and disease activity measured by jspada. the values were also dichotomized to < mg/kg, - mg/kg, and > mg/kg, which was regarded as normal, slightly increased and increased, respectively. ileocolonoscopy was performed in one patient. our study has shown that fcal levels are significantly higher in era patients compared to other jia (p= . ) and/or ni-msd (p= . ) patients. moreover, almost a third of patients with era had levels of fcal above the range regarded as normal, which adds to the number of evidences for a gut inflammation in this particular type of jia. besides, the fcal levels were higher in those with axial involvement, which further suppots the association of gut and axial inflammation in children with era. although endoscopy remains a gold standard for the diagnosis of gut inflammation, fcal can help to select children with era who might benefit from this invasive procedure, regardless of the gi symptoms, as shown in one patient with the highest fcal concentration in our study. moreover, fcal levels seems not to be influenced by disease characteristic and/or concomitant therapy intake. therefore, fcal should be a part of diagnostic workup in children with any type of jia, but most importantly in those with era. evaluate potential predictor variables of magnetic resonance imaging (mri) sij remission methods: retrospective review of prospectively collected data. we included patients with era (according to ilar criteria) continuously treated with anti-tnf agents for ≥ months who had at least two mris of the sacroiliac joints performed before starting anti-tnf therapy (baseline) and during the follow up ( > months after anti-tnf treatment). si joints were examined using t -weighted images, t fastsuppressed and short-tau inversión recovery. the sparcc-sis was scored by two pediatric radiologists. sparcc-sis assessed the presence, depth and intensity of bone marrow edema (bme) on consecutive six slices in the iliac and sacrum bones . scoring is composed by: bme ( - ), bm intensity ( - ), bm depth ( - introduction: several paediatric patients manifest conditions commonly misdiagnosed as spider bites, which however, can include other arthropods bites; bacterial, viral, and mycotic infections; vasculitis; dermatological diseases; miscellaneous conditions as drug reactions, chemical injuries. objectives: in italy, spiders which are likely to be associated with severe toxin mediated tissue damage are uncommon, especially in urban zones. however, a minor trauma may be a precipitating factor for pyoderma gangrenosum particularly over the legs, in association with inflammatory bowel disease, haematologic diseases and juvenile idiopathic arthritis (jia). methods: we describe a -years old boy with pyoderma gangrenosum complicated spider bite in association with systemic jia (sjia). the patient was in clinical remission after the start of the sjia, occurred two months before, still treated with tapering doses of steroids and canakinumab, with the normalization of inflammatory parameters (crp, esr, saa, ferritin) and clinical manifestations. only a mild arthritis of the knee persisted and for this reason he was still treated with steroids. furthermore, he developed hyperglycemia, requiring insulin treatment. the first dermatological manifestation which he referred was a red dot of the leg skin. in a few days, the erythema enlarged, involving an area of x cm, with oedema, pain, and blisters, evolving in a necrotic lesion, with purulent exudate, surrounded by a haemorrhagic zone. results: haematological controls revealed neutrophilic leucocytosis, increased crp and procalcitonin. he started treatment with intra venous administration of teicoplanin plus ceftriaxone, with no resolution of the clinical manifestations and the reduction of leukocytosis, crp, procalcitonin. a culture swab was performed and was positive for pseudomonas aeruginosa, confirmed by pcr on the culture. he started ciprofloxacin and surgical curettage of the lesion, with the resolution of the lesion and the normalization of biochemical parameters. conclusion: the aspect of the lesion and its evolution were evocative of a spider bite suggested by anamnestic records, complicated by a pyoderma gangrenosum secondary to pseudomonas aeruginosa. the underlying disease, the immune suppressive treatment, with steroids and biological drugs, the hyperglycaemic pattern of the patient allowed the severe evolution of the spider bite. children in treatment with immune suppressive and/or biologic drugs are at high risk of infections. skin lesions, as arthropods bites, can be a facility for superinfection, with possible haematological and systemic diffusion. the strict application of the ilar requirement for the presence of documented arthritis for the diagnosis of sjia, early in the disease course, may result in unnecessary delays in initiating appropriate treatment. in preliminary printo classification criteria for sjia, this mandatory requirement of documented arthritis has been modified. to measure performance of preliminary printo classification criteria for sjia in our indian cohort. methods i gathered a data of seven sjia patients who attended dev children's hospital between jan and jan . my data included demographics,clinical presentation, laboratory parameters and outcome of these patients. all these patients were diagnosed at an early stage by clinical judgement irrespective of fulfilment of ilar criteria. i applied preliminary printo classification criteria for all. average age of selected children ( girls and boys) was . years. conclusion a preliminary printo classification criteria for sjia has been validated in our cohort. there are many raised inflammatory markers in most of these patients other than wbc count. these markers should be considered to be added in supportive laboratory criteria to be more specific towards the diagnosis. it is important to add pid in exclusion list especially in a case of sjia with mas at onset. trial registration identifying number leningrad's regional children' two patient stopped treatment within months from therapy start: due to primary inefficiency ( ) and allergic reaction ( ). five ( / ) patients were-co-administered with cdmards, other with oral gc, and subjects had been previously exposed to other biologic drugs. whole patients stopped therapy due to secondary inefficiency: patients were switched on toc, other children were switched on eta ( ) introduction: systemic juvenile idiopathic arthritis (sjia) is a rare, complex auto-inflammatory disease with significant morbidity including fever, rash, serositis and articular problems. with the availability of interleukin- (il- ) and il- inhibitor treatment, morbidity has significantly reduced and the outcome for sjia patients has improved. however, differences in access to care and differences in treatment strategies between countries in and outside of europe remain a concern. objectives: the single hub and access point for paediatric rheumatology in europe (share) consortium aimed to develop best practices for paediatric rheumatic diseases in order to decrease differences in care between european countries. here, we present the final results of the literature review and a series of consensus meetings on defining overarching, diagnostic and therapeutic recommendations for diagnosis and treatment of sjia. methods: the share methodology has been previously published, including the use of the eular standardized operating procedure for developing best practice recommendations. as per these guidelines, a methodologist provided supervision during the process and consensus meetings. conclusion: hscore seems to perform slightly better than ms-score for the diagnosis of mas in our cohort. early inhibition of il- is discussed to play an important role in the disease course of sjia . assuming that pretreatment with other dmards leads to a later start of therapy with canakinumab, this analysis evaluates the effectiveness of canakinumab as first-line vs. second-line dmard. to evaluate the effectiveness of canakinumab as first used biological dmard in sjia compared to canakinumab in sjia-patients pretreated with other dmards. methods sjia-patients documented in the german biologic registry for pediatric rheumatology (biker), who were exposed to canakinumab, were identified. for the first-line (fl) group dmard naïve patients were selected, prior treatment with corticosteroids and/or nsaids was allowed. patients receiving any dmard prior to canakinumab entered the second-line (sl) group. both groups were compared in a retrospective intention-to-treat-analysis. effectiveness canakinumab treatment showed good effectiveness in sjia both as first-and second-line dmard. after months the use of canakinumab as first-line dmard is associated with higher response rates compared to second-line use. our data support the hypothesis that early treatment with canakinumab is associated with good therapeutical response and a positive effect on the disease course of sjia. results: a total of children ( girls) with sle were identified. median age of symptom onset and diagnosis was years(range - years) and years respectively. the presenting manifestations were fever( ), oral ulcers( ), alopecia( ), malar rash( ), photosensitivity( ), renal involvement ( ), seizures( ) and gastrointestinal complaints ( ) apart from some unusual manifestations of isolated peripheral arthritis( ), isolated bilateral pleural effusion( ), macrophage activation syndrome( ). laboratory investigations: hemogram revealed anemia in children and thrombocytopenia in . urine examination showed nephrotic range proteinuria in child and subnephrotic proteinuria in . microscopic hematuria was noted in pateints. renal function tests were deranged in cases. ana, anti dsdna positivity and hypocomplimentemia were present in all. renal biopsy was done in patients, had class iv, one class iii and one had class v lupus nephritis. all patients were initiated on hydroxychloroquine and photoprotection. children with renal involvement were given pulse methylprednisolone followed by tapering doses of oral prednisolone and intravenous, monthly cyclophosphamide. azathioprine was used as maintenance therapy in all. subcutaneous weekly methotrexate was used in patients. one child (mas) died during disease course. disease continues to be in remission in rest. conclusion: we found a significant female preponderance in our study group. renal involvement was the commonest presentation. some unusual presentations were also seen. early recognition of sle is critical for timely initiation of appropriate treatment. this is the first report of a cohort of pediatric sle from this part of india. introduction: autoantibodies in ahai may be igg/igm/iga. ahai can be divided into primary or secondary (e.g. sle, lymphoproliferative diseases, infections, medications). it is also classified based on the temperature at which the antibody reacts to erythrocytes, and can be warm (igg or iga) or cold (igm or c ). in warm ahai, the antibodies react at temperatures ≥ ºc, not activating the complement system and not undergoing agglutination in vitro. in cold ahai, antibodies react at temperatures below ºc, activating the complement system with in vitro agglutination.mixed aiha (warm and cold) is rare and occurs in < % of aiha cases and can occur at any age, but is extremely rare in children. the prevalence of the mixed form is less than / , , patients with ahai. objectives: to report a rare case of mixed ahai and idiopathic intracranial hypertension(iih) in a -years old female patient with a previous diagnosis of sle and aps. methods: case report and literature review. results: a -years old female adolescent previously diagnosed with sle/aps since was in remission on hydroxychloroquine( mg);azathioprine( mg);aspirin( mg);vitamind ( . iu);calcium( g), and sunscreen. in april , she had a relapse presenting with fatigue, myositis, headache, hypocomplementemia, and severe autoimmune hemolytic anemia (hb of g/dl) (sledai- k= points). mixed ahai was diagnosed base on a direct/indirect coombs test / +;directantiglobulintesting showing anti-iga(weak),anti-igm( +/ +),anti-igg( +/ +),anti-c c(weak),anti-c d ( +/ +);igg / subclasses with a reaction of : ( +/ +);an eleven cell antibody panel positive revealing a cold and warm antibody, and adsorption technique revealing a cold and warm autoantibody. chest ct showed bibasilar subsegmental atelectasis, head ct/mri was normal and lp showed a high opening pressure of cmh o with a normal cell count. after the procedure, the patient reported improvement in the pain and was diagnosed with iih. the patient was screened for secondary causes for ahai (table ) due to the unusual mixed type pattern and serology was positive for chlamydia trachomatis (igm) and mycoplasma pneumoniae (indeterminate-igm/positive-igg) suggesting a recent infectious trigger causing reactivation of the underlying disease with a probable cross-reactivity. the patient treated with -days of clarithromycin. before the infectious screening came back negative, ahai was treated with a single dose of ivig( g/kg) and then, with -days of methylprednisolone( g/day). azathioprine was replaced by mycophenolate mofetil. due to headache recurrence, acetazolamide( mg/day) was started, and the patient referred no pain. the patient was discharged with a resolution of the symptoms. objectives: to our knowledge, the association of gbs and bbe has been described in adults only. methods: we here describe a child presenting at sle disease-onset with an overlap of peripheral (gbs) and central (bbe) nervous system manifestations, highlighting the possible association between these two entities in children. results: an -year-old healthy girl presented with acute ataxia, ophtalmoparesis and altered level of consciousness, rapidly followed by areflexia, facial paresis, swallowing difficulties, sensory deficits, paresis in all four limbs and respiratory insufficiency. these symptoms were accompanied by pleuro-pericardial serositis, proteinuria and hypertension. immunological investigations revealed the presence of positive ana and ds-dna antibodies. the renal biopsy showed a stage iii lupus nephritis. hence, the clinical, laboratory findings and biopsy report led to the diagnosis of psle. brain and spine mri did not show any abnormalities; diffuse slowing compatible with nonspecific encephalopathy was seen on eeg. nerve conduction studies (ncs) confirmed the clinical suspicion of acute polyradiculoneuropathy with proximal interruption of motor nerve conduction, compatible with guillain-barré-like syndrome. csf analysis (performed twice) remained normal. the patient was treated with glucocorticoids, intravenous immunoglobulins, cyclophosphamide as well as plasmapheresis. the neurological and physical symptoms improved gradually with complete neurological recovery four months after onset. conclusion: overlapping forms of bbe/gbs have never been described in association to sle in children. our patient's presentation and evolution fulfilled the criteria for such an overlap, occurring at psle onset. although sle and bbe/gbs are rare entities, our case suggests that there may be a common underlying immune background. this association should be recognized early for rapid and appropriate treatment initiation. infantile antiphospholipid antibody syndrome: acquired and de novo apl appearance in four infants t. giani , g. ferrara , a. mauro , r. cimaz introduction: antiphospholipid syndrome (aps) is a rare condition in the neonatal age. in most cases it is considered a passively acquired autoimmune disease, due to a transplacental passage of maternal antiphospholipid antibodies (apl). exceedingly unusual is the de novo production of apl in newborns and infants. objectives: to describe four infants who developed an early brain stroke with increased and persistent levels of apl, even after six months of life. methods: we reviewed the clinical charts of four such infants, followed from diagnosis up to two years after the disappearance of apl. conclusion: common characteristics of these four children are the development of brain stroke and the increased and persistent apl levels even after six months of life. this opens the window on a gray zone related to the origin of these antibodies (maternal or neonatal) and on their role in the pathogenesis of the infantile brain stroke. patients had over % of their monitoring completed but only had over %. aspects of monitoring that were more time intensive or were required less regularly were most frequently overlooked. there was a statistically significant increase in the percentage of completed monitoring in those patients for whom the lupus checklist was used compared to patients where a checklist was not used (p= . ). conclusion: there is significant room for improvement in the monitoring of these patients with jsle in the rheumatology clinic. this audit illustrates that more diligent use of the lupus checklist and an overall improvement in sustained use of the checklist will help to improve monitoring of these patients. evidence suggests that checklists are underutilised in medicine and wider implementation of this simple tool could improve patient outcomes. , , interventions such as in person or electronic reminders, or audits with feedback to physicians could improve usage over time. the application of the lupus checklist or a similar document in other paediatric clinics is important for comprehensive monitoring of a condition as complex as jsle and has the potential to prevent ongoing damage and medication toxicity in this high-risk population. juvenile onset and this cluster have may more severe kidney, neuropsychiatric or hematological involvement. objectives: the aim of this study was to assess the clinical and laboratory characteristics, disease activity, and treatment response of patients with juvenile sle (jsle). methods: this is a retrospective study involving patients between july and january . the data of patients diagnosed with jsle and followed up for a minimum of months, were collected. the sledai- k scores at initiation and at the follow-up ( st, rd, th, and th months of treatment) were examined. the sledai- k score was considered to be ≤ , for disease remission status. results: a total of children were included in to the study. the female/male ratio was . / and the median age of the patients at the diagnosis was (iqr: . - . ) years. the median follow-up of patients was (iqr: - ) month. four of the patients were diagnosed with monogenic sle. two siblings were diagnosed with c deficiency and two were diagnosed with familial chilblain lupus. the most common clinical findings were found musculoskeletal complaints ( . %), malar rash ( %), oral ulcers ( . %), and fever ( . %), respectively in over all the group. the frequency of involvement of the system and organs was as follows; mucocutaneous . %, musculoskeletal . %, renal . %, hematological . %, serous membranes . %, neuropsychiatric . %, respectively. all patients had anti-nuclear antibody positivity, while . % had anti-ds dna, . % had anti-sm and . % had antiphospholipid antibody positivity. while all patients received hydroxychloroquine treatment, . % of the patients were received were mycophenolate mofetil, . % were azathioprine, . % cyclophosphamide, . % methotrexate and . % were rituximab. the median sledai- k score was (iqr: - . ) at admission, besides it was found to (iqr: - ), (iqr: - ), (iqr: - ) in the st, th and th months of treatment, respectively. while % of the patients had active disease at admission, . % at months, . % at months and . % at months still had active disease (sledai- k > ). patients with initially high sledai- k scores had significantly lower remission rates in the first month (p= . ). it was observed that patients with high sledai- k scores in admission were more resistant to conventional immunosuppressive treatments and the use of rituximab was more frequent in these patients. at least one major organ (renal, hematological, neurological) were affected in % of patients. the remission rate of these patients at months was found significantly decreased compared to the others (p < . ). renal biopsy was performed in patients ( . %). of them had type lupus nephritis (ln), had type , had type , and had type . it was observed that patients with renal involvement were the group that reached remission latest. conclusion: the presence of high initial sledai- k scores and the major organ involvement have poor predictive value to achieve inactive disease. a two year old girl of consanguineous parents presented to hospital at months of age with fever and erythematous macular rash on her cheeks which spread to her nose, chin, and ears. the rash started a month prior, and progressed over her entire body. a skin swab grew staphylococcus aureus but the rash didn't respond to topical antibiotics. review of systems was unremarkable except for longstanding oral thrush and diaper rash. birth and family history were unremarkable. on exam she had a diffuse, erythematous, morbilliform eruption over her face and body. she had facial swelling, orbital edema and vasculitic oral ulcers. she had leukopenia mainly neutropenia, low hemoglobin, with normal platelets. her liver enzymes and erythrocyte sedimentation rate (esr) were high while c-reactive protein, immunoglobulins, c and c were normal. cultures were negative, however she was positive for adenovirus, mycoplasma and ebv (ebv load was iu/ml ). autoimmune hepatitis work up was negative. the direct coombs test, antinuclear antibodies ( : ), ro, rnp and smd were positive. ch came low as well as c q level of mg/dl (normal range - mg/dl). lymphocyte subsets showed reduced cd and nk cells. bone marrow aspiration showed active marrow. skin biopsy showed chronic non-specific inflammation (immunofluorescence and electron microscopy were not available). echocardiogram showed dilatation of the left coronaries. she was treated with intravenous immunoglobulin (ivig) for kawasaki disease with no improvement. therefore pulse steroid mg/kg followed by mg/kg was initiated. her rash, facial swelling and abnormal blood counts improved dramatically. whole exome sequence showed homozygous variant c. g>t p.g c at the c qa gene. while tapering steroids she flared so subcutaneous methotrexate was started. unfortunately, she continued to have rash, leukopenia and high liver enzymes, so treatment was switched to mycophenolate mofetil and hydroxychloroquine. however she did not improve and started to have recurrent bacterial and viral infections that included cellulitis, gastroenteritis and upper respiratory tract infection. we started her on regular ivig, which helped with infections and allowed for weaning of steroids. however she developed alopecia and lower limb spasticity with delayed walking. mri brain and spine was normal. upon reanalysis of the wes, two other homozygous mutations at kif c and apg were identified and associated with spastic paraplegia, but reported as variants of unknown significant. fresh frozen plasma (ffp) transfusions were started, initially weekly, then every two weeks and subsequently every four weeks. the rash disappeared, leukopenia and esr improved and we were able to discontinue steroids conclusion: early-onset sle with a severe course of disease raises the possibility of a genetic etiology. we are reporting, for the first time, a rare missense mutation g>t in exon of the c qa gene that resulted in an amino acid substitution that is pathogenic. interestingly, she had other mutations associated with neurological manifestation that never reported together before and altered her phenotype. she has responded well to ffp as has been reported in a few case reports results: a total of psle under the age of years were included, % (n = ) were males. the overall mean age at diagnosis was . ± . years and median disease duration was . ( - ) years. huv was diagnosed in . % (n = ) of psle cohort. psle with uv were more likely to be males ( % vs %; p < . ), diagnosed at a younger age ( . vs . years; p < . ), have a family history of sle ( % vs %; p = . ) and have conjunctivitis more frequently ( % vs . %; p < . ) than psle without uv. psle with uv were also less likely to have cns involvement ( . % vs %; p = . ) and hematological manifestations such as leukopenia ( . % vs %; p = . ) and thrombocytopenia ( . % vs %; p = . ). in addition, psle with uv were more likely to be associated with low c complement count ( % vs %; p < . ) and positive cytoplasmic anca ( % vs %; p = . ).however, the psle with uv cohort were less likely to be associated with ana ( % vs %; p = . ), dsdna ( % vs %; p = . ) and perinuclear anti-neutrophil cytoplasmic antibodies ( % vs %; p = . ). conclusion: we report a high occurrence of huv in psle cohort ( . %) associated with unique demographic, clinical features and laboratory features. the debate regarding whether huv is a rare subset or unusual type of sle, or is a separate entity altogether, continues. however, the overlap in clinical, laboratory and genetic mutation supports the notion that huv and sle fall into the same spectrum of autoimmune disease with similar disease pathogenesis. however, further studies are needed to reach clear conclusions regarding the relationship between huv and sle. introduction: the last decade has brought a lot to the approaches to the diagnosis and treatment of juvenile arthritis. in russia, the actualization of the problem of diagnosis and treatment of jia required the development of federal standards, which provide the most detailed algorithms for medical care, both at the stage of inpatient and outpatient care. in the regions of the russian federation, the effective use of these documents required a whole range of additional educated activities, both with students of medical universities, as well as with the medical and nursing community, in addition, a set of work was carried out to create a regional regulatory framework. in the total biological therapy pool, % of patients receive tnf-alpha inhibitors, antibodies to il- receive % of patients, antibodies to il- - , %. it is worth noting that when using biological agents in % of cases, the criterion of an inactive disease was achieved by - months, which was characterized by the absence of acute inflammatory symptoms, normalization of esr and crp. monitoring of patients with jia receiving biological agents required the conduct of a number of educational activities for medical personnel, the creation of an additional methodological base. for further training of young specialists at the regional medical university, a program of an additional educational course in pediatric rheumatology was developed and introduced. a regional patient organization was established and also required a set of information activities by the medical community. conclusion: in the saratov region of the russian federation, about % of patients with jia receive biological therapy, which corresponds to the average indicators according to the literature. in the structure of the biological drugs used, the group of tnf-alpha inhibitors is preserved - %. the introduction of modern methods of treatment using biological agents in jia has significantly increased the effectiveness of treatment, but it required the organization of additional information support for medical personnel. disclosure of interest: none declared introduction: immunogenicity and development of anti-drug antibodies have been associated with treatment failure and adverse events during biologic treatment. anti-drug antibodies (adas) have been reported in % of juvenile idiopathic arthritis patients treated with adalimumab. however, their role in reducing adalimumab efficacy is still debated due to conflicting results. no study has been directed toward identification of neutralizing adas in paediatric rheumatic disorders. objectives: aim of our study was to detect adas, along with their clinical relevance, using a new theranostic peptide-base assay in a cohort of children with inflammatory chronic diseases on adalimumab treatment. methods: six candidate adalimumab derived peptide antigens (hc-cdr , hc cdr , hc cdr , lc cdr , lc cdr , lc cdr ) have been developed and optimized to be tested. their performance has been compared with commercial elisa kit and a spr-based optical assay (biacore®). assays have been performed in sera of a cohort of children receiving adalimumab due to an inflammatory chronic disease. mean age, disease duration, concomitant treatment with methotrexate (mtx), ana positivity, disease activity parameters and scores at the time of ada determination have been recorded. chisquare, and fisher exact test were used to compare data. pearson's and spearman's correlation tests were used to determine correlation coefficients for entered variables. results: eighteen ( f, median age . , range . - , yrs) patients were enrolled: affected by juvenile idiopathic arthritis, of whom complicated by jia -associated chronic uveitis, and patients affected by chronic idiopathic uveitis. peptide assay revealed adas in children, biacore in , commercial elisa in . of note, we found total concordance among the tests just in patients. no significant correlation has been proven among the ada determinations. biacore and elisa determination showed significant concordance (r s : . , p< . ). the presence of hc cdr and lc cdr resulted significantly correlated with disease activity (r s : . , p< . ), and, inversely, with disease remission on treatment (r s = - . , p< . ). no patient experienced severe adverse events and no correlation with adas has been revealed conclusion: in chronic rheumatic disorders, novel reliable methods are urgently required to guide clinical decision and support decisions about switching within or between drugs in refractory children. the different methods, since based on different antigenic probes, detect different antibody populations. the present peptide-based assays might contribute to identify neutralizing adas in patients treated with adalimumab. further validation in larger cohort is required. introduction: non-bacterial multifocal osteomyelitis (nbo) is a rare polygenic autoinflammatory disease, which is difficult to diagnose and treat. because of combination of bone lesions with arthritis and/ or axial skeleton damage in most cases the diagnosis of juvenile idiopathic arthritis (jia) or juvenile ankylosing spondylitis (jas) may be establish as a concurrent diagnosis, so this allows to legal use of biologics (ba) for the treatment. objectives: to analyze the single center experience of clinical and laboratory features of multifocal nbo in patients (pts) who were treated by ba for the last years. methods: the study involved a retrospective cohort of multifocal nbo pts treated by different ba in our clinic from to . all of them underwent standard rheumatological examination. in order to examine all localizations of the bone damage, a scintigraphy and/ or "whole body" mri scan was performed. results: among the whole group of pts with nbo (n= ) we identified pts treated by ba (tnf-inhibitors only). the majority were girls (n= , %). age at disease onset was . years in average (me . range . - . ). for legal reason of ba administration, we classified our patients according to rheumatological features as jia or jas. pts had jia ( girls), pts had jas ( girls). among pts had oligoarthritis ( %), had polyarthritis of low limbs (hip, knee, ankle). axial involvement was represented by active erosive sacroiliitis with deep bone marrow edema on mri scan in pts ( %), active spondylitis of several bodies in thoracic spinein ; erosive arthritis with partial ankyloses of facet joints of neck in pts, multiple syndesmophytes in girl. we found that definite axial lesions in nbo developed in very young children (in y.old at minimum), much earlier than in "idiopathic" jas. hla b was presented in pts ( %), pts had ana in high titer (all of those hla b -negative). the pts had bone lesions in different parts of skeleton: vertebral bodies - pts, clavicle - , sternum, ribs - , extremities bones, metaphysic mostly (tibial, fibular - pts), sacroiliac region - pts. extraskeletal manifestations were observed in pts, one in each condition -uveitis, psoriasis pustulosus, acnae conglobate. in a girl with very severe course of disease, not responded to any therapy nbo was combined with familial mediterranean fever. high level of laboratory activity were detected before biologics in pts ( %): esr acceleration up to mm/h, increase of crp up to mg/l. treatment included nsaids (all), methotrexate ( pts), sulfasalazine ( pts, but it was withdrawn in all pts), bisphosphonates ( pt), prednisolone ( pts). because of high activity of nbo with appearance of new bone lesions and persistent arthritis tnf inhibitors were administrated: etanercept in pts, adalimumab - ( as first line, second line), golimumab - . at the start of ba the average age was . years (range . - . ); mean disease duration was , years (range . - . ). there were cases of withdrawals. due to inefficacy etanercept was switched to adalimumab. disease activity decreasing was reached in the most of the patients ( from ). among them pts developed the whole remission with resolving of active arthritis and bone marrow edema spots. skin lesions (psoriasis pustulosis and acnae conglobate) were significantly improved. there were no adverse events during the tnf therapy. conclusion: our experience of the therapy with tnf inhibitors in patients with high nbo activity has shown that this is a good and safe therapeutic option that is expected to prevent progression and bone destruction. . ae were reported for . % of patients, most within to hours after the first or second injection: flu-like symptoms ( . %), hypocalcaemia ( . %) and hypophosphatemia ( %). underweight patients (body mass index < . kg/m²) accounted for % of hypocalcaemia. the frequency of all the ae not significantly decreased with the reduction of the first dose. only one serious hyponatremia occurred corresponding to a patient with renal failure before treatment. conclusion: our results were similar to those previously published: bisphosphonates are safe for osteoporosis in children. in the literature, sae are very rare in children, being limited to anecdotal osteopetrosis in cases of higher doses and long-term treatment, and delayed bone healing. anecdotal osteonecrosis of the jaw in adults has never been described in children. the use of bisphosphonates beforehand requires dietary measures (vitamin d and calcium supplementation). furthers systematic collection on efficacy and safety parameters for each bisphosphonates drug should confirm these data. introduction: the use of biosimilars in rheumatology has increased significantly over the last years and has resulted in considerable cost savings. objectives: to assess the effectiveness and tolerability of the adalimumab biosimilar abp in patients with jia. methods: a database of patients prescribed adalimumab in our service has been screened to identify patients with jia, who switched from the originator to the biosimilar. only patients who had a clinical review since they had started the biosimilar were included. a paired-samples t-test was conducted to compare the number of active joints at the clinic appointment before and after the initiation of the biosimilar treatment. the frequency and type of side effects, the clinical response and the number of patients who switched back to the originator have been collected. results: sixty-one patients who switched to the biosimilar abp between february and february were included. they were comprised of enthesitis-related arthritis (era), polyarthritis, oligoarthritis, psoriatic and systemic jia patients. their baseline characteristics and outcomes are summarised in table. the mean duration of follow-up after the switch to biosimilar was months (range - ). eleven patients ( %) reported side effects; the most common side effect (n= , . %) was injection site reactions and the remaining consisted of anaphylaxis, druginduced lupus, dizziness and bone pain, respectively. seven patients ( . %) reverted to the adalimumab originator, as a result of side effects, because of ineffectiveness and one patient for both reasons. in addition, patients were changed to a different biologic, one patient due to allergy to both the originator and biosimilar and the other two patients had active disease on the originator and biosimilar adalimumab. two patients stopped the biosimilar and remained off any biologic, in the first case this was due to a side effect and in the second case it was patient's choice. on the whole, . % of patients had remained on abp at their last visit. there was no significant difference in the active joint count before the biosimilar was started (mean . +/- . ) and after the switch (mean . +/- . ), (p= . ). introduction: golimumab (gol) is approved for polyarticular juvenile idiopathic arthritis (pjia) in patients of ≥ years but long-term safety data are limited. objectives: prospective monitoring of long-term safety and effectiveness of gol in routine care using the biker-registry. methods: baseline demographics, clinical characteristics, disease activity and safety parameters were compared to a contemporary : matched control cohort using alternative tnf inhibitors or methotrexate without exposure to a biologic. efficacy outcomes were jadas , joint counts and functional status. safety assessments were based on adverse events (ae) reports. results: in this ongoing study, pts initiating gol were matched to with alternative tnfi and biologic-naïve pts. pts starting gol had a longer disease duration (p< . ) and use of gol was significantly more often second line ( . % vs . %, p< . ) and thus disease activity was lower at baseline. pts in the gol cohort used less corticosteroids, otherwise patients were comparable with pts treated with other tnfi (table ). in gol treated ps a marked clinical response was noted at months and beyond, indicating the effectiveness of gol in the treatment of pjia. a significant decrease of the mean jadas . to . (p= . ) after months of treatment was observed, as well as jia acr / / / response rates of / / / %. jadas remission and minimal disease activity was observed in % and . % after months and in % and % after months of treatment. rates of ae, sae and infectious ae were comparable in the gol cohort ( . / py, . / py and . / py), the alternative tnfi cohort ( . / py, . / py and . / py) and the mtx only cohort ( . / py, . / py and . / py). sae reported in the gol cohort were flares of uveitis and of jia (each ) and fibromyalgia syndrome ( ) . sae reported in the alternative tnf cohort was two serious infections (both influenza), one knee ligament injury, one flare of arthritis and one hyperventilation . no case of pregnancy, malignancy or death was reported. conclusion: golimumab seems an effective in treatment of pjia. tolerability was acceptable and comparable to alternative tnfi or mtx. recruitment to the project is ongoing. disclosure of interest none declared introduction: methotrexate (mtx) is one of the most commonly used disease-modifying anti-rheumatic drug in rheumatology practice. it has some side effects that can impair quality of life. the most common of them is associated with the gastrointestinal tract. objectives: the aim of the study is to evaluate and compare the frequency of methotrexate intolerance in adult and pediatric patients. methods: patients with rheumatologic diseases followed in hacettepe university pediatric rheumatology and rheumatology departments who used oral or parenteral methotrexate for at least months were included in the study. methotrexate intolerance was assessed using 'methotrexate intolerance severity score (miss) questionnaire. the miss questionnaire consisted of parts: abdominal pain, nausea, vomiting, fatigue and behavioral symptoms. the patients scored the severity of each symptom separately; : no symptoms, : mild symptoms, : moderate symptoms, : severe symptoms. a total score of or more was defined as mtx intolerance. visual analogue scale (vas) ranging from cm to cm was performed to each patient concurrently with the miss questionnaire. in the pediatric patient group, miss questionnaire and vas assessment were applied to both patients and families. results: a total of patients, of whom were children, enrolled in the study. the mean age for children and adults were . (± . ) and . (± . ) respectively. the most frequent diagnosis of patients was juvenile idiopathic arthritis ( . %) in children and rheumatoid arthritis in adults ( . %). the mean mtx dose in adults and pediatric group was . (± ) mg vs . (± . ) mg (p: . ). the prevalence of mtx intolerance in children and adults were . % (n: ) and . % (n: ) respectively. the mean miss score in the pediatric group was higher compared with the adults ( . ± . vs . ± . , p< . ). similarly, the mean vas scores were higher in pediatric group ( . ± . vs . ± . (p< . )). there was a strong correlation between miss and vas scores between family and child evaluations (p < . , r = . / p < . , r = . ). abdominal pain, nausea, vomiting and behavioral symptoms were observed more frequently in children compared to adults. results: ( %) out of patients were diagnosed with psoriasis denovo. one patient was treated with ada (a girl with undifferentiated arthritis who had positive hla-b , anf and family history of psoriasis -her grandmother had psoriasis), patients were treated with eta (both female, one patient had undifferentiated arthritis, the other had enthesitis-related arthritis; both patients had positive hla -b and anf negative). patients achieved significant improvement after changing tnfalpha inhibitor ( -ada, -eta), patient (was treated with eta) had significant improvement after discontinuation of biological therapy. conclusion: this single-center observational study demonstrates the possibility of developing psoriasis de-novo in patients with jia receiving tnf-alpha inhibitors. although more extensive research is needed, our data suggest that discontinuing the tnf-alpha inhibitor or switching to another tnfalpha inhibitor in patients with psoriasis de-novo should be considered as a treatment strategy in such cases. objectives: long-term surveillance of patients newly initiating toc treatment for at least years compared to a cohort of patients newly initiating a comparator biologic using the biker-registry. methods: baseline demographics, clinical characteristics and disease activity, efficacy and safety parameters were compared. efficacy outcomes were jadas , joint counts and functional status safety was assessed by adverse events (ae) reports. results: patients with matched controls have been recruited. patients starting on toc were older at treatment start ( . vs. . years (y); p< . ) and had a longer disease duration (p< . ). toc was significantly more often a second line biologic (p< . ). baseline jadas ( +/- vs +/- ), chaq-di ( . +/- . vs . +/- , ), esr +/- mm/h vs. +/- mm/h and active joint counts ( +/- vs. +/- ) were comparable. upon toc a substantial response with a significant reduction in jadas from . to . (p< . ) after months of treatment was observed. there were no significant differences between patients from the toc cohort and their matched controls in the jia acr / / / criteria, jadas , jadas remission and minimal disease activity was reached by comparable numbers (toc % and %; control cohort % and %). the total number of ae was comparable (toc cohort n= ae; ( / py); control cohort n= ; ( / py; rr . ; %ci . - . ). more serious ae (sae) were reported with toc. serious infections were documented at lower frequency with toc. uveitis events were documented at significantly higher frequency with tnf inhibitors most likely due to a selection bias (table ) . sae with toc were depression (n= ) in with suicidal intent, exacerbation of jia (n= ), septic arthritis, gastrointestinal infection, abdominal pain, colitis, paronychia and fracture. sae in the control cohort were depression, osteomyelitis, gastrointestinal infection and disease flare. no significant differences regarding cytopenias and elevated transaminases were observed. no gastrointestinal perforation, no vascular events and no deaths occurred. conclusion: toc was effective and comparable to treatment with alternative biologics. tolerability was acceptable. as toc was given as a second-line biologic in the vast majority of patients comparisons between the cohorts have to be interpreted carefully. observation is ongoing. conclusion: in this retrospective cohort study in pediatric patients on rtx-treatment, we found undetectable low drug levels in adapositive patients, indicative for their neutralizing capacity. consequently, the lack of b-cel depletion leads to reduced treatment efficacy. patients with sle seem more susceptible to develop ada. if ada are detected, continuation of treatment seems non-effective and changing medication is advised. certainly when considering that, in this study, anaphylactic reactions only occurred in ada-positive patients. none declared objectives: the aim of this study was to evaluate retrospectively the long-term efficacy and safety of adalimumab in patients with jiaassociated uveitis. methods: we have retrospectively analysed nineteen jia patiens data with associated uveitis from our centre registry between and , treated with adalimumab after failure of treatment with corticosteroids and metotrexate. demografic data and blood samples were collected at different time points while uveitis activity was evaluated by slit-lamp biomicroscopy. adverse events were recorded. results: registry records provided years follow up of jia patients data with associated uveitis. eleven patients were females ( . %) diagnosed as oligo/extended oligoarticular jia while eight ( . %) were males diagnosed as enthesitis related arthritis (era). before adalimumab was prescribed, all patients were previously treated with metotrexate during . years in avarage dose of mg/ m weekly. the mean uveitis duration, before adalimumab administration was months. ten years long follow up period have showed that there were no new relapsis of uveitis while patients were receiving adalimumab and metotrexate. all of our patients were able to gradually tapper and stop treatment with topical steroids two months after adalimumab commencing. seven patients were able to stop biological treatment after . years of adalimumab usage. uveitis relapsed three monts after the adalimumab discontinuation only in one patient. two patient were lost to follow up during the transitional period. no serious adverse events were recorded. conclusion: during the long term follow up period adalimumab have shown good efficacy and safety profile in jia patients with active inflammatory ocular disease. introduction: post-streptococcal syndrome is a systemic immunemediated complication of beta-haemolytic streptococci infection, mostly seen as post-streptococcal arthritis, rheumatic fever or glomerulonephritis. uveitis is an uncommon manifestation of this syndrome. objectives: case report methods: case report results: a previously healthy -year-old female was admitted at the emergency department with prolonged fever, arthritis and red eye. she had a -month history of febrile episodes every two weeks, with axillary temperature ranging from , to ºc. migratory arthralgia affecting both knees and tibiotarsal joints showed up two months after the fever onset and worsened in the previous week, with refusal to walk. non-painful bilateral red eye for several weeks was mentioned. other symptoms were absent. recent infections were denied and family history was irrelevant. physical examination revealed lower limb muscular atrophy, knees pain and impaired function and bilateral tibiotarsal arthritis with inability to walk. ophthalmological observation showed a bilateral non-granulomatous anterior uveitis. sequential laboratory work up revealed a maximum eritrocitary sedimentation rate of mm/h, maximum c-reactive protein of , mg/dl, microcytic hypochromic anemia, positive antistreptolysin o titer (asot) (initial result of that increased to in weeks and later decreased to ) and negative anti-nuclear antibodies. cardiac involvement was excluded. the diagnosis of rheumatic fever with concomitant poststreptococcal uveitis was assumed and the patient was treated with oral and topical ophthalmic corticosteroids with prompt clinical resolution of fever, acute polyarthritis and uveitis. no relapse occurred in a -year follow-up. conclusion: juvenile idiopathic arthritis (jia) is the most common cause of uveitis in childhood. although our patient clinical course could initially raise the possibility of systemic jia (sjia), the criteria that define this entity weren't all present and clinical and laboratory findings were more supportive of rheumatic fever. besides, uveitis occurs exceptionally in sjia, which turned this diagnosis even less reasonable. in our rheumatology unit, among patients diagnosed with jia in years, had uveitis. however, in the group of patients with sjia only one had ocular involvement, a boy with isolated vitritis. post-streptococcal uveitis (psu) typically presents as bilateral, non-granulomatous anterior uveitis, as described in this case. as streptococcal infection is very common among children and many patients may experience subclinical infection. psu should be considered in all patients with uveitis along with positive asot and negative routine investigations for other causes. although psu has been described in literature, to the best of our knowledge, this is the first reported case of concomitant rheumatic fever and psu. . ada was first tapered to every weeks by % of the responders and then to every weeks by % before discontinuing. fewer respondents used or tapered ifx, toc or aba. around % tapered the interval and % tapered the dose and interval for aba, % for toc and % ifx there were differences in the duration of tapering prior to discontinuation of specific medications. for ada it was months in %, months in % ,and months in %. for ifx it was months in %, months in %, and months in %. for toc it was % after weeks, % after weeks and % after weeks. for aba i.v. it was % after weeks, and % after weeks. if combination therapy was used, % tapered the bdmard first, % csdmard first, and % both simultaneously. conclusion: this is the first survey to describe "real world" medication tapering and discontinuation practices of pediatric rheumatologists and ophthalmologists globally. most physicians start to taper medication after months of remission on medication and discontinue after the to months of tapering. we would like to thank all the participating colleagues, who took time to fill out our surve introduction: jia-associated uveitis (jia-u) occurs in - % of children with juvenile idiopathic arthritis (jia) and typically asymptomatic, and sight-threatening complications occur in % of children, (i.e. cataracts, vision loss). frequent ophthalmic examinations are important for early diagnosis and monitoring of uveitis activity. even after uveitis is controlled, risk of disease exacerbation still exists. therefore, frequent ophthalmic screening and monitoring is important for detection and management of jia-associated uveitis (jia-u). s proteins, cytokines, and chemokines detected in aqueous humor of patients with uveitis are also detected in tears. biomarker discovery using tears is promising since collection is noninvasive, feasible, well-tolerated, and close to the target organ. objectives: we aim to determine if s proteins, cytokines, and chemokines levels differ in tears of children with jia and jia-u and in children with jia-u by uveitis activity. methods: tears were collected using schirmer strips from children ≥ years old with oligo-or polyarticular rf negative jia with (jia-u) and without uveitis (jia-no-u), and in children with jia-u at time of active and inactive eye disease. activity was defined by standardization of uveitis nomenclature (sun) criteria. active uveitis was anterior chamber inflammation grade ≥ . + cells. s a , a , and a were measured by elisa, and il- , il- , ip- , mcp- , rant es, and sicam- by luminex assays. biomarker levels were compared in children with ) jia-no-u (n= ) to active jia-u (n= ), and ) jia-u (n= ) at time of active and inactive uveitis. results: children with jia-no-u and jia-u were matched by jia subtype and arthritis activity. they had primarily oligoarticular jia ( %), active arthritis ( %), and were on systemic medication ( %). at time of active uveitis, % had grade . +, and % had + and mean interval between time of active and inactive disease was months. we found that levels of biomarkers in tears of children with jia-no-u compared to active jia-u were similar. although not statistically significant, levels of s a (mean difference , pg/ml [ % ci - to , ], p= . ) and sicam- ( pg/ml [ % ci - to , ], p= . ) were higher when uveitis was active compared to inactive. conclusion: our results suggest that s a and sicam- are potential biomarkers of uveitis activity in jia-u, but not uveitis diagnosis. thus, neutrophils may play a role in the pathogenesis of anterior uveitis which has been reported in an animal model of acute anterior uveitis. identifying biomarkers using tears provides a noninvasive and objective method of monitoring uveitis. limitations are our heterogeneous cohort that varied by arthritis severity and immunosuppression, and minimally active uveitis. we were underpowered to detect statistically significant differences and continue to collect tears prospectively in children with jia-u with goal of n= . despite low uveitis activity, we were still able to detect differences. further studies in larger and diverse cohorts are necessary to assess the role of s a and sicam- in jia-u. objectives: to report an extremely rare presentation of gpa in a year old with acute digital ischemia. a year old boy, with a background of poorly controlled type diabetes and hypothyroidism, initially presented to hospital unwell with diabetic ketoacidosis. treatment was initiated promptly with good response. furthermore, he was found to have weight loss, productive cough and hearing loss over the past months. he was haemodynamically stable, but very pale and cachectic. he had reduced air entry and crackles on the right. there was hypertonia and clonus in his lower limbs. blood tests showed microcytic hypochromic anaemia (hb g/l), normal white cell count, thrombocytosis and raised inflammatory markers (crp mg/l and esr mm/hr). his chest x-ray showed enlargement of the right hilum with consolidation/ atelectasis extending into the middle and lower lobes. mri scans of head and spine were normal apart from fluid opacification in the paranasal sinuses. he was screened for infections including tuberculosis and started on intravenous antibiotics. on day , he developed painful bluish discolouration of his left hand, particularly his thumb, index and middle fingers. his left radial and brachial pulses weren't palpable. a heparin infusion was started. a doppler scan showed occlusion of radial and ulnar arteries proximal to the wrist with no clear thrombus. he had a ct thoracic aorta with contrast which showed proximal left radial artery occlusion and distal ulnar artery occlusion with no evidence of proximal embolic source or vasculitis. it showed multiple perihilar masses (lymph nodes) in the right lung and peripheral parenchymal masses in both lungs, suggestive of atypical infection or connective tissue disease. blood tests still showed raised inflammatory markers(crp mg/l, esr mm/hr and platelets /l). an autoantibody screen showed positive anca with strongly positive anti pr (> u/ml); other autoantibodies, including ana, ds dna and anti-phospholipid antibodies, were negative. he developed further ischaemia with bluish, painful discoloration of his right foot, especially right great toe, with a weakly palpable dorsalis pedis pulse. doppler scan revealed occlusion/narrowing of the posterior tibial artery cm proximal to the ankle. following vascular team advice, he was started on ilioprost infusion to aid reperfusion of the extremities involved, with good results. based on clinical and lab features of systemic inflammation, evidence of upper airway involvement(bilateral conductive hearing loss and sinusitis on mri scan), parenchymal lesions on ct chest and strong pr positivity, a diagnosis of gpa was made. results: our patient responded well to therapy including multiple pulses of high dose methylprednisolone and cyclophosphamide, with improvement of all organs involved and no further digital ischemia. conclusion: although gpa is very rare in children, it is associated with high morbidity and mortality. many studies show that the spectrum of paediatric gpa is not vastly different from adults, except for higher gender bias towards female, more constitutional and musculoskeletal symptoms and higher risk of subglottic stenosis. although there are a handful of case reports of digital ischaemia in adults with gpa, to our knowledge this is the first case report of acute digital ischaemia in paediatric gpa. early diagnosis and prompt treatment with a multidisciplinary team approach is paramount for good outcome. introduction: adenosine deaminase- deficiency (dada ) is a monogenic vasculitis syndrome whose presentation ranges from recurrent fevers and livedo reticularis to systemic vasculitis, hematologic and immunologic abnormalities, and early-onset stroke. it is characterized by biallelic loss-of-function mutations in the encoding gene of ada protein and low levels of ada enzymatic activity in the peripheral blood. the genotype and phenotype features of dada has a wide spectrum. treatment with anti-tnf inhibitors is effective in controlling vascular inflammation and reducing strokes. objectives: to describe two sisters with different presentations of dada and a deletion mutation on exon of the ada gene. methods: medical data was used to describe the clinical manifestations of two siblings. parental informed consent was obtained. results: patient : a -year-old female had presented with fever, rash, arthralgia, hepatosplenomegaly, and coombs positive autoimmune hemolytic anemia (aiha) at the age of years. she had been followed with a suspected diagnosis of systemic lupus erythematosus (sle) and steroids, azathioprine, mycophenolate mofetil had been used. her ana and complement levels were normal. because of unmet classification criteria of sle, genetic testing had been done, and no mutation found in the ada gene. cranial mr and mr angiography was normal. she was referred to our clinic after . years of the first manifestation. physical examination revealed raynaud phenomenon on both hands and feet, livedo reticularis, arthritis, and splenomegaly. laboratory tests indicated an increase in acute phase reactants, cd , cd , and switched memory b cell lymphopenia, and hypogammaglobulinemia. because of prolonged fevers, a thorax ct was obtained and aneurisms of the renal artery were seen. abdominal ct angiography indicated multiple aneurysms of both renal, intercostal, and hepatic arteries. repeated genetic analysis of the ada gene showed a homozygous deletion mutation on exon . she has been followed on anti-tnf and iv immunoglobulin without severe symptoms for a year. patient : the older sister had been followed with a diagnosis of familial mediterranean fever with e q heterozygous mutation because of recurrent fever, abdominal pain, erysipelas-like erythema, elevated acute phase reactants, and splenomegaly. she did not have any other cutaneous or systemic findings. because of parental consanguinity, the ada gene was analyzed and a homozygous deletion mutation on exon was found. she has been followed without any symptoms after anti-tnf treatment. throat swab was negative. abdomen ultrasound showed bowel wall thickening, testis ultrasound was normal. hsp diagnosis was confirmed. methylprednisolone iv was administered for three days, then oral prednisone was started. purpuric lesions, abdominal pain persisted, so we decided to add mmf ( mg/ m /day) and prednisone was tapered in a month. results: thanks to mmf vasculitis lesions and abdominal symptoms disappeared in few days. mmf was continued for a month, tapered in months. there was no evidence of relapse in a months follow up. conclusion: these cases suggest that mmf may be useful to induce and maintain remission of recurrent hsp with gastrointestinal involvement. multicenter clinical trials with long-term follow up to confirm the efficacy of mmf in the treatment of hsp with gastrointestinal involvement are needed. introduction: henoch-schönlein purpura (hsp), the most common childhood vasculitis. cholecystitis is extremely rare in patients with hsp. this is the first case of a libyan child presenting with hsp complicated by calculus cholecystitis hsp nephritis. objectives: our aim is to present an unusual case of gall bladder involvement in an -year-old libyan female affected by hsp. methods: a case reports study results: : we report an unusual case of gall bladder involvement in an -year-old libyan female with hsp. she was referred to a rheumatology clinic due to hsp with chronic calculus cholecystitis and distended small bowel with fluid-like fecal material with no evidence of intussusception on an abdominal ultrasound. the patient had a one-month history of abdominal pain, purpuric lesion on lower limbs and swelling in both feet. she was admitted times to another hospital before being referred to the rheumatology clinic. an abdominal sonography revealed a distended small bowel with fluid-like fecal material with no evidence of intussusception and chronic calculus cholecystitis; they treated her with urosdoxycholic acid tab at mg per day and ibuprofen syrup. then referred to our rheumatology clinic. after days, she showed a purpuric rash over her lower extremities, mainly over her thighs and buttocks, microscopic hematuria, no arthritis, no fever, no abdominal pain; her blood pressure was normal at \ mmhg, and she had normal laboratory tests (cbc, wbc . , hgb . , platelets esr ml\hour, crp mg\dl was negative, c was mg\dl within normal range - mg\dl, c was . mg\dl within normal range - , anca, ana, as well antidsdna ab yielded negative, antistreptolysin-o (aso) titer was todd , lft included total bilirubin , direct , indirect gpt,got, u, creatinine ) except urine routine showed mild microscopic hematuria rbc hpf , protein was nil ) urine for pro-tein disclosure of interest none declared p correlation of serum neopterin levels with disease activity and moneta division of rheumatology, irccs, ospedale pediatrico bambino gesù, roma; university of genova a multinational study of thrombotic microangiopathy in macrophage syndrome clinical impact of a targeted next-generation sequencing gene panel for autoinflammation and vasculitis laboratory biomarkers to facilitate differential diagnosis between measles and kawasaki disease in a pediatric emergency room: a retrospective study a rare case of measles-associated hemophagocytic lymphohistiocytosis in an infant. cureus children's interstitial and diffuse lung disease respiratory complications of the rheumatological diseases in childhood on behalf of dr nishant dharsandiya and dr j.p. keshrani paediatric rheumatology & immunology, dev children's hospital arthritis care res (hoboken) disclosure of interest: none declared development and initial validation of the ms score for diagnosis of macrophage activation syndrome in systemic juvenile idiopathic arthritis development and validation of the hscore, a score for the diagnosis of reactive hemophagocytic syndrome double-blind, placebo-controlled study of anakinra in pediatric and adult patients with still's disease l. schanberg , p. nigrovic duke children's hospital & health center, durham; boston children's hospital, boston; children's mercy kansas city, kansas city; university of alabama at birmingham, birmingham; nationwide children's hospital, columbus; university of iowa hospitals and clinics children and adolescents with sle: not just little adults severe disease presentation and poor outcomes among pediatric systemic lupus erythematosus patients in south africa the checklist manifesto: how to get things right clinical review: checklists -translating evidence into practice the who surgical safety checklist: a review pehlivanoğlu p gastrointestinal henoch-schönlein purpura treated with mycophenolate mofetil: description of two case reports venous vessel wall thickness in lower extremity is increased in male patients with behcet's disease increased vein wall thickness in behçet disease polyarteritis nodosa: a contemporary overview eular / printo / pres criteria for henoch -schönlein purpura , childhood polyarteritis nodosa , childhood wegener granulomatosis and childhood takayasu arteritis : ankara six patients were treated with canakinumab and patients with anakinra. conclusion: it is known that excessive production of il- β can cause inflammatory bone loss and abnormality. vitamin d deficiency and osteopenia/ osteoporosis may cause additional musculoskeletal problems besides arthritis and joint destruction in caps. we think that ca metabolism and bone mineral density measurements should be a part of routine controls in patients with caps. disclosure of interest none declared ab clinical and genetic features of patients with periodic syndrome associated with mutation of the tumor necrosis factor receptor gene and juvenile arthritis having mutations in tnfrsf a gene m active arthritis in / , it was poly in , oligo in . when assessing the clinical symptoms and laboratory activity of patients with jia, it was revealed that in the onset of the disease, systemic manifestations were observed in / : fever in / , rash in / , hepatosplenomegaly in / , pneumonitis in / , carditis in / and lymphadenopathy in / . high laboratory activity was recorded in / . active arthritis in / , it was polys in , oligo in . in all % of patients, the nucleotide variants of the tnfrsf a gene were identified in the study. / of patients were diagnosed with traps. the most frequent heterozygous variant of tnfrsf a gene with nucleotide substitution of c. g>a was found in / of patients, in / of patients it was found homozygous variant with nucleotide substitution of c. g>a, in / of children it was found heterozygous variant with deletion of c. _ del. all of these variants are pathogenic. / of patients were diagnosed with ja: juvenile arthritis with a systemic onset was in / , paucarticular arthritis was in / , in / it was poly rf-and in / it was psoriatic arthritis. it is worth noting to note that in / a heterozygous version of the tnfrsf a gene was detected with a nucleotide substitution c. g> a, however, considering the absence of clinical manifestations of autoinflammatory disease and active articular syndrome in these patients, children were diagnosed with ja. in addition dvoryakovskaya: none declared, a. mamutova speaker bureau of: novartis, k. isayeva: none declared, r. denisova speaker bureau of: novartis covid- and relapsing kawasaki disease: a case report during the pandemia m. c. maggio ab introduction: the pandemia of covid- remains a global health alarm with high incidence of lethality, especially in older age groups who suffer from underlying medical conditions. however, children are less likely to manifest severe conditions. objectives: covid- was correlated to a higher incidence and a suspected increased risk of kawasaki disease (kd) in children anamnestic records revealed a previous kd, without coronary artery lesions (cal), year before. results: he was treated with antibiotics, intravenous infusion of immunoglobulins (ivig) ( gr/kg), acetylsalicylic acid (asa) ( mg/kg in doses/day) and reached defervescence into days. echocardiography excluded cal. the nasopharyngeal swab for sars-cov- was doubt. the second throat swab done the day after ivig infusion, was negative; however, the third nasopharyngeal swab for sars-cov- , done days after ivig infusion, was positive. chest x-ray showed a significant lung interstitial thickening. il- levels were < . pg/ml (n.v. < . pg/ml). he continued treatment with antibiotics, asa ( mg/kg/day), with the progressive resolution of the clinical symptoms and of the normalization of laboratory findings. conclusion: the peculiar outcome of the patient is the correlation of covid- with kd, recently reported as associated. kd is considered as a multifactorial autoinflammatory disease, induced by a cytokine hypersecretion with a systemic vasculitis. covid- is considered a cytokine storm syndrome, with a severe systemic vasculitis. sars-cov- infection could be the trigger that could lead to hyperinflammation of kd. the ivig infusion could explain the transient negative swab for sars-cov- , with the successive positive relieve lasting days, and the normal levels of il- , detected after ivig infusion. relapsing kd is rare ( . - . %); in our patient this event could be triggered by the documented sars-cov- infection. disclosure of interest none declared disclosure of interest none declared ab spectrum of systemic inflammatory syndrome in children during covid pandemic in india d. b. pandya, on behalf of dr haresh dobariya pediatric rheumatology & immunology, dev children's hospital ab rituximab for treatment of resistant paediatric mctd v. paisal, s. compeyrot-lacassagne paediatric rheumatology the diagnosis and classification of of mixed connective tissue disease mixed connective tissue disease in children -case series the value of rituximab treatment in primary sjögren's syndrome juvenile idiopathic arthritis a multifaceted approach is essential for robust rehabilitation m methods: in a retrospective study children ( % girls) aged median (iqr) , ( , - , ) years with oligoarticular onset jia without extra-articular manifestations (oligo-ja) who did not received dmards were monitored. all children were met ilar criteria. ttriamcinolone acetonide (ta) was administered intra-articular at a dose of - mg with an injection interval of - - months which was depended on the activity of the disease. the maximum allowable number of consecutive isolated intra-articular injections (is-iai) was - . a total of active joints were injected with ta: knees - injections, ankles - injections. all children were divided into two groups: active / inactive arthritis based on the effectiveness of local corticosteroid treatment. the average follow-up was and physicians' assessment of jia disease activity efficacy is-iai of ta was no associated significantly with number of active joint of onset oligo-ja, cjadas , serum level of crp mg/ml, esr mm/h, il pg/ml and tnf-α pg/ml, titer of anf. the mean inflamed synovial fluid of il levels abstracts from conferences and relevant studies were added. rcts were included if (i) patients were aged ≤ years, (ii) patients had a previous defined pediatric rheumatic diagnosis and (iii) rct met predefined outcomes. studies were excluded in case of (i) observational or single arm study or (ii) sample size ≤ patients. study design, location, duration, treatment, population, sample size, age criteria, gender, concomitant treatments and primary outcome was extracted. results: out of screened references, references reporting unique rcts in pird. all rcts reported efficacy while / rcts provided safety outcomes and / rcts provided pk data. ten of reviewed bdmards are approved for pirds by the food and drug administration (fda). of these, seven had ≤ rcts. the most common intervention was tnf inhibitors ( %) treatment with intravenous immunoglobulin (ivig) significantly reduces the risk of caas. however, up to % of cases are ivig resistant with a higher risk of cardiovascular complications. currently several second-line treatments are available for refractory kd. nonetheless, the existing literature is still unable to identify which treatment is the most effective. recent studies suggest that a il- receptor antagonist (anakinra) may be an effective therapy in refractory kd. objectives: we report the case of a year-old boy diagnosed with kd refractory to conventional treatment, who developed giant caas successfully treated with subcutaneous (sc) anakinra. methods: case report. results: a year-old boy was referred to our pediatric rheumatology unit days after the onset of a typical refractory kd. he had been previously treated at a local hospital with two doses of ivig ( g/kg), infused respectively and days after the onset of the fever. afterwards, given the persisting fever, doses of pulse intravenous (iv) methylprednisolone (mpdn mg/kg/day) have been used for days followed by oral prednisone ( mg/kg/day). treatment with acetylsalicylic acid ( mg/kg/day q h) was also started. following a transient defervescence the day after the first iv pulse mpdn, fever relapsed and the echocardiography showed caas of left main coronary artery (lmca), left anterior descending (lad) and right coronary artery (rca) rationale and study design for a phase i/iia trial of anakinra in children with kawasaki disease and early coronary artery abnormalities (the anakid trial) the use of interleukin receptor antagonist (anakinra) in kawasaki disease: a retrospective cases series there are few reports of acute kidney injury (aki) in kd, defined as serum creatinine level elevation to more than . times of baseline level. objectives: to describe the case of kawasaki disease complicated by aki methods: a -year-old female was admitted to our rheumatology unit with persistent fever ( days), widespread polymorphous exanthema, change in lips and in oral mucosa. family history was unremarkable. she had no chronic underlying disease nor history of previous hospitalization. at admission, she appeared stable. body temperature was . °c, o saturation was % in ambient area, blood pressure was / mm hg, heart rate was bpm, respiratory rate was breaths per minute. on examination she presented widespread polymorphous exanthema, changes in lips and in oral mucosa, cervical lymphadenopathy and bilateral conjunctival injection. results: exams revealed: white blood cells /μl, hb . g/dl, platelets . /μl, albumin . g/dl, serum sodium meq/l, serum chloride meq/l. transaminases were in normal range. creatinine was . mg/dl disclosure of interest none declared ab paediatric extra-pulmonary large vessel arteritis, a forme fruste of pediatric behcet's disease? we presented two siblings from a consanguineous marriage with different clinical presentations of dada . further, we emphasize that genetic testing should be repeated in the presence of clinical suspicion. introduction: there are several scoring systems developed in japan that are clinically used to stratify high risk kd patients and thus identify the ones that may benefit from early adjunctive therapy. there are increasing reports from all over the world on poor performance of these scores in other ethnic populations. objectives: the aim of our study was to evaluate the kobayashi, egami, sano and kawamura scores in our population which is homogenous caucasian. methods: hospital database was retrospectively searched for code m . of the international classification of diseases, th revision, clinical modification code: mucocutaneous lymph node syndrome [kawasaki] , over the period from january to december . all patients who were seen in this period for the first time for complete or incomplete kawasaki disease, as defined by the american heart association, were included. we applied ivig resistance prediction scores (kobayashi, sano, egami and kawamura scores) to our cohort. only patients who received g/ kg ivig within the first days of the disease were included in this analysis. the scores of prediction models were calculated for each patient and patients were assigned to high-or low-risk group accordingly. results: during the study period a total of children were diagnosed with kd ( . % males, median age . years). all of them were caucasian except one child who was biracial (caucasian and african american). among them, children were hospitalized in the acute phase of the disease and children were seen in the subacute phase of the disease. children were followed-up for at least one year to evaluate persistent coronary artery aneurysms (caa), which were observed in ( . %) patients. among them, were not treated with ivig and received ivig after days of illness. patients were treated with ivig within first days of illness and were included in the calculation of ivig resistance prediction scores. ( . %) were ivig resistant. sensitivity of kobayashi, sano, egami and kawamura scores were . , . , . and . , respectively. specificity of those scores were . , . , . and . , respectively. we found no difference in demographic or clinical characteristics between ivig resistant and ivig responsive patients. patients with ivig resistance had significantly higher alt (p = . ), neutrophil-to-lymphocyte ratio (p = . ) and lower serum sodium (p = . ). conclusion: by applying the japanese scores to our population, we were able to identify most of the low-risk, but missed many of the high-risk patients. our results are consistent with caucasi n based population studies available to date. introduction: varicella zoster virus (vzv) related arterial ischemic stroke (ais) has been described in literature in pediatric age. however, the long-term course of post-vzv vasculopathy need to be inquired: clear information about prevalence of recurrence and severity of clinical outcome are lacking, even if a favorable evolution was initially described, and therapeutic protocols are not currently standardized. objectives: we aimed to describe the clinical, laboratory and neuroradiologic features of children affected by ais due to post-vzv referred to our institute and to present our experience in their therapeutic management. methods: we selected pediatric patients ( females) with ais and a cns confirmed vzv reactivation and/or with a vzv history in the previous months. other causes of pediatric stroke (systemic disease, cardiac disease, trauma, major thrombophilia) were excluded. clinical, neuroimaging, laboratory and treatment data were reviewed, focusing on pediatric score outcome measure (psom) and executive functions final outcome. results: average age of ais onset, vzv primary infection and interval between infection and ais were: years mo (range: year and mo- years and months), years and months (range months- . years), and months (range days- months), respectively. the ais involved the nucleo-capsular region in cases, the cerebral cortex in cases, the thalamus in cases, and the pons in subjects. seventeen patients had inflammatory focal cerebral arteriopathy (ifca). virological confirmation (vzv-dna or anti-vzv igg in the cerebrospinal fluid) was obtained in patients. three patients were treated with trombectomy and one with rtpa. thirteen patients were treated with antiviral agents associated with steroids in cases, with different administration schedules. only in one case steroid treatment was given without association with antiviral agents. one patient received a short course of steroid and antiviral treatment at the time of the stroke and then a more prolonged course after six months at the time of the virological diagnosis. prophylactic antiaggregants were administered to all patients. mean follow-up was years and months (range mo - years) ; ifca was persistent in cases and transient in subjects. four patients presented a recurrence of post vzv arteriopathy, two of them presenting new stroke events. twelve patients presented a variable motor deficit at last follow up. the mean psom score of the cohort at the last visit was (range - ). executive functions were evaluated at last follow up in twelve patients, showing no deficit in seven patients, a mild deficit in two patients and a severe deficit in the last three. conclusion: albeit a favourable evolution was initially described, our experience suggests that vzv-related ais may result in persistent fca and significant neurological impairment in the majority of cases. therapeutic approach, particularly involving steroid administration, still need to be validated. introduction: iga vasculitis/ henoch schönlein purpura (igav/hsp) is the most common vasculitis of childhood and renal involvement is the most serious long-term complication. a better understanding of the pathophysiology of the progression to kidney disease is required for better treatment to be achieved and current biomarkers of ig a vasculitis with nephritis (igavn) lack the predictive value. objectives: in this study, an untargeted metabolomics approach was performed to reveal the underlying molecular mechanism of disease pathogenesis and to find potential biomarkers of plasma samples from patients with igav and igavn.methods: igav was diagnosed according to the ankara criteria in ( ). forty-five patients, including active igav patients (h), igavn (n), and age-and gender-matched healthy controls (c), were enrolled in the study. plasma samples from subjects were collected on the same day of igav(hsp) diagnosis and before steroid or other immunosuppressive treatment initiated. this study has utilized liquid chromatography-mass spectrometry (lc-ms/ q-tof) to investigate the alterations in plasma metabolomic profiles. three separate pools, health controls, active igav , and igavn were created. peak picking, grouping, and comparison parts were performed (metabolite profiling) via xcms (https://xcmsonline.scripps.edu/) software. results: totally peaks were detected for group h, n and c. among them peaks were found to be statistically significant and reliable (p< . ) and of these peaks were found to be changed (fold change > . ) between the groups c and h. on the other hand, peaks were found to be changed (fold change > . ) between the groups h and n. the number of the peaks on the intersection of the peaks found to be changed between the groups (c and h) and (h and n) was . based on putative identification results, peaks were matched with metabolites. we found an up-regulated level of dhap( : ), prostaglandin d /i , methyltetrahydrofolic acid, porphobilinogen and n-acetyl- -o-acetylneuraminic acid/n-acetyl- -o-acetylneuraminic acid, -aminopentanamide / -aminopentanoic acid, glycocholic acid, saccharopine, n -succinyl-l-ornithine, gamma tocopherol, and galactosylsphingosine /glucosylsphingosine in igav patients. in conclusion, we have identified a number of metabolites that may be associated with the pathogenesis of igav. we also suggest that dhap ( : ), prostaglandin d /i , porphobilinogen, -methyltetrahydrofolic acid and n-acetyl- -oacetylneuraminic acid/n-acetyl- -o-acetylneuraminic acid may serve as biomarkers for predicting kidney disease since they were increased only in the patients who developed renal involvement at follow-up. children were divided into four groups: those with jia who didn't receive mtx yet (group ); those who received mtx less than one gram during whole treatment (group ); those who received mtx from to grams (group ); children, received more than grams of mtx (group ). the autoimmune inflammatory process in jia can cause formation of pathological changes in the liver, even before the start of treatment. it is confirmed by a statistically significant correlation of bfgf level in st group with liver steatosis according to ultrasound examination (r = . ) and the level of c-reactive protein (r = . ). this indicates a close relationship between the intensity of the inflammatory process and collagen synthesis activation, which can further provoke liver fibrosis. alterative processes in the liver associated with autoimmune inflammation, as evidenced by the presence of a positive correlation between the level of alt and bfgf (r = . ). upon reaching mtx dose gram and grams, it is possible that compensatory processes in the liver are triggered, as evidenced by the negative correlation between the content of bfgf and hgf (r = - . ).conclusion: the use of modern markers with routine laboratory and instrumental studies is appropriate for the timely determination of the risks of developing irreversible pathological changes in the liver during jia treatment with mtx. objectives: the aim of our study is to evaluate the efficacy of (iag) injections in hip in children with (jia) and to assess the factors predicting the improvement of this management. methods: this is a retrospective study, between and , including patients with jia diagnosed according to the ilar criteria. the socio-demographic data were collected as well as the parameters of the disease. the activity was evaluated by jadas. the functional impact was assessed by the lequesne score. the treatments taken have been specified as well as the infiltrations received. the improvement after infiltration was assessed by jadas and lequesne score.results: fourteen patients were included, with mean age . + . . the mean age at the onset of symptoms was + . [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] . subtypes of jia according to the ilar were: enthesitis-related arthritis in cases, seropositive polyarticular jia in cases, seronegative polyarticular jia in cases, oligoarticular jia in cases and juvenile psoriatic arthritis in one case. all the patients had hip arthritis, inaugural in % of the cases. of these, . % had a flexion deformity and lower limb inequality. the average lequesne index was . + . . the treatments taken were methotrexate in . % of the cases, sulfasalazine in . % of the cases, and the combination of the two in . % of the cases. eleven patients underwent hip infiltration, and three of them required more than one. eighty one percent improved thereafter. the number of infiltrations was not statistically associated with the lequesne index (p = . ). improvement after infiltration was negatively associated with the prior existence of an inequality of the lower limbs (p = . ). the existence of a flexion deformity was not associated with good results after infiltration (p = . , r=- , ). ten patients ( %) among those who had an infiltration did not have to resort to surgery. conclusion: iag injection is an adjunct therapy in aji with hip involvement offering a good results and delay surgery in the majority of cases. the presence of lower limb inequality is associated with less improvement of iag. conclusion: synovial rice bodies are rarely described in juvenile idiopathic arthritis, even less at disease onset. their presence has not been associated to a worse disease prognosis or joint outcome but awareness of the existence of this particular form of intraarticular loose bodies may encourage the clinician to use lower gauge needle during arthrocentesis procedure; this can prevent arthroscopy, as occurred in our case . arthroscopy may be necessary in some cases to achieve full drainage of the joint. in our series the duration of arthritis correlated with the size of rice bodies and the number and agressiveness of procedures needed to evacuate them. objectives: we described a case of liver involvement in sle presenting with emphasis on the differential diagnosis with autoimmune hepatitis. methods: case report study results: : an -year-old female patient was referred to the rheumatology clinic with complaints icteric sclera for months anorexia, malaise, pain in the both knees, ankles joints and both wrists accompanied by swelling, and remarkable motion limitations. laboratory revealed t bilirubin . mainly direct . with elevated liver enzymes got , gpt , alkp , high glutamyl transpeptidase u\l her wbc . hgb , ptl , except very high esr ml\hr, crp was positive mg\dl, viral screen (hcv, hbsag, hiv) was normal, serology tests ana was positive with high titer , anti ds-dna ab was positive , anti-sm was negative, anti lkm antibodies negative, anti smooth muscle ab negative soluble liver antigen were negative, antimitohondrial ab( m ,m ,m ). ultrasound abdomen revealed mild enlarged spleen, abnormal diffused increased liver echogenicity with early stage of liver cirrhosis treated her by fresh frozen plasma times, vit k mg once\ day then was referred to rheumatology clinic regarding her serology tests & developed arthritis of her joints suspected psle! she was performed liver biopsy showed lesions necrotic inflammatory portal and lobular severe in eosinophilic polynuclear with cirrhosis evoking a syndrome of overlap associating a primary biliary cirrhosis and an autoimmune hepatitis. laboratory data revealed liver dysfunction and liver biopsy suggesting autoimmune hepatitis, and she underwent treatment for hepatitis (prednisolone with azathioprine), urosdoxycholic acid with fat-soluble vitamins k, d&a, e. however, with the elimination of jaundice and decreased hepatic enzyme levels, the prednisolone dose was tapered within months and stopped before they were referred to rheumatology clinic. on her review of systems, she has malar rash, generalized fatigability. on physical examination, we found malar rash, levidoreticularis of her skin, swelling and limitation of movement in the knees, ankles, wrists joints. there was hepatosplenomegaly. laboratory data revealed liver treatment for hepatitis, ana still high titer : , antids dan positive with titer iu\ml, antisma was negative .wbc . , hgb . , plt , esr ml\hr, her ultrasound abdomen: revealed slightly heterogeneous liver with coarse echotexture without focal lesion with liver span cm.these paraclinical results together with the clinical findings strongly suggested systemic lupus erythematosus (sle) as the definitive diagnosis. indeed, in this case, aih was associated with sle, prednisolone orally for months, after that dose was tapered and continued, rapid clinical improvement in arthritis, malaise, and general condition. azathioprine was continued. in addition, daily hydroxycholoquine sulfate overlapping of sle and aih should be suspected when aih patients present with a malar or other skin rash. the prompt diagnosis and adjustment of further treatment plans can improve disease outcomes and prevent liver disease progression. introduction: juvenile systemic lupus erythematosus (sle) is a chronic autoimmune disease characterized by multi-visceral involvement with an unpredictable prognosis. the diagnosis is usually made in young women aged between to years, however, it can affect people at any age and it is classified as a juvenile illness when it starts before the age of . objectives: we are reporting the epidemical, clinical, therapeutical and evolutional characteristics of a series done in the pediatric pole in setif with girls and boy. methods: the average age of onset is years. the average time limits of the diagnosis is months. the clinical features is done with cutaneous, articular manifestations and fever respectively in % % and % of the cases ,followed by kidney damage in % of the cases , the cardiac, pulmonary and ophthalmological participations are reported with low percentage. haematological involvement was detected in % of the patients and the inflammatory syndrome was almost constant. a positive titer of anti-nuclear antibodies and anti-dna is objectified, as well as a reduction in the complement rate. antibodies anti gp and anti cardiolopine are positive in % of cases. kidney damage was diagnosed in % of the cases , and only one case of overlap syndrome with dermatomyosits was reported. concerning the neurological form it was present in only one addolecent girl ,and only one case of familial lupus.results: the diagnosis is based on the classification of the american college of rheumatology (acr) revised on and the new criteria slicc"systemic lupus international collaborating clinics" . the clinical characteristics of our series relies on global data of literature with the predominance of cutaneous and articular involvement. with however some specific characteristics which are individualized by a more advanced age of onset, years on average in our study versus years and years, the rarity of familial forms ( case), a lower percentage of kidney damage ( % versus % and %).the therapeutic management was based on corticosteroid therapy and hydroxychloroquine in the majority of cases, the use of immunosuppressants has been reserved for severe forms. conclusion: lupus is an autoimmune disease with protean clinical manifestations, the prognosis of which is dominated by renal, neurological and thrombotic disorders. cortisonic treatments and immunosuppressants have significantly improved the prognosis for life . trial registration identifying number: lupus is an autoimmune disease with protean clinical manifestations, the prognosis of which is dominated by renal, neurological and thrombotic disorders. cortisonic treatments and immunosuppressants have significantly improved the prognosis for life . onset of inactive and active oligo-ja were not significantly differ. the analysis revealed a correlation between a short phase of beneficial effect after is-iai of ta and risk of activity disease (with an inactive phase of arthritis less than months, the risk activity was or = . , p < . ; with an inactive phase less than months -or = . , p < . ). rtx was administered to patients who had received high-dose cs with - dmards; in all cases combined pulse therapy cs № - was preliminarily used. rtx mg № was applied after mo- y from the debut of the disease. in all cases, its use led to clinical improvement after - mo with normalization of laboratory activity indicators, in cases a decrease in the level of b cells to - . in μl was noted ( with agammaglobulinemia). after months patients had severe infectious complications, of them ended fatally. another patients had a second stroke. the st patient survived, had a kidney allotransplantation, there is no disease activity. the nd patient, in connection with the development of the demyelinating process of cns, attempted to continue therapy using golimumab with ivig. it led to an increase in the infectious syndrome, therefore, we decided to refrain from continuing with itnf as well. the patient died after years from the administration of rtx due to the progression of neurological disorders. cases with auto-inflammatory syndromes were: chronic infantile neurologic cutaneous and articular syndrome received tcz; it was unsuccessful (hyperthermia and rash persisted, eye lesions progressed, there were no increase in height), later switched to anakinra. family mediterranean fever, received adalimumab (ada). the -year-course of ada leaded to the disappearance of articular and abdominal syndrome while maintaining persistent increased levels of esr and crp and periodic fever. the use of tcz in patients with ssd was more successful. the first patient received it subcutaneously for year, cs&dmards ( were used) had already been canceled, lung and kidney lesions were contained, blood pressure normalized, escsg-ai decreased from to , mrss decreased from to . in the second case, the patient received tcz for months i/v, decrease of escsg-ai . to , mrss to were noted, the dose of cs was halved, he also continued treatment with cyclophosphamide. we introduce a -year-old girl patient who has been admitted to our clinic with suspicion of an erythema nodosum. she had painful subcutaneous nodules for weeks, especially on the lower extremities and her face. macroscopically, central necrotizing skin rashes could be seen. she had frank arthritis of both knee and ankle joints. the comprehensive serological diagnosis (including hepatitis serology and anti-streptolysin titer) were normal except for a slight increase in crp , mg/dl and esr mm/h. the patient also complained of abdominal pain and bloody stools. calprotectin was μg/g. a gastro-coloscopy revealed a small mariske and a minimal inflammation of the ileocecal valve, without signs of vasculitis or chronic bowel disease. a skin biopsy revealed leukocytoclastic vasculitis of the small arteries. angiography of the intestinal arteries was rejected by the family. initially we started a treatment with methylprednisolone pulses followed by oral prednisolone. the patient showed a very good response with quick resolution of the skin symptoms and abdominal pain. the medication could be quickly tapered and discontinued at full remission after one month results: pan is classified as a cutaneous pan (cpan) when there are exclusive skin manifestations, besides arthralgia or arthritis. a systemic pan must be diagnosed with the involvement of internal organs. however, cutaneous pan may evolve into systemic pan. in our patient, the skin and joints were primarily affected. if the existing gastrointestinal complaints are part of a systemic pan or chronic bowel disease could not be cleared yet, due to refusal of further investigations. conclusion: cpan must be considered as a suspected diagnosis in patients with necrotizing skin nodules. as transition of the cutaneous into the systemic form cannot be predicted regular monitoring is mandatory. introduction: prevalence of behcet's disease in children is not known, but is probably very low. extra-pulmonary large vessel arteritis in these cases is even rarer as a presenting manifestation. objectives: to report two cases of paediatric extrapulmonary large vessel arteritis with a 'behcet like disease'. methods: we present case reports of two cases who presented to paediatric rheumatology opd to our department. ms. f, a year old girl was referred to us with history of short duration of fever, generalized lymphadenopathy, neutrophilic leucocytosis, thrombocytosis, hyperglobulinemia and high inflammatory markers. on detailed history and examination she was found to have a healed palatal ulcer and her maternal aunt was found to have a history of recurrent oral ulcer, genital ulcer and enthesitis. patient's montoux test was positive but the gene expert for mtb was negative. md-ct showed a circumferential thickening of aorta, subclavian and bilateral renal artery with stenosis at origin of both renal arteries indicating a vasculitis. few necrotic nodes were also noted in lungs. lymph node biopsy suggested a reactive hyperplasia. tissue typing showed presence of hla b , b . she improved clinically with oral prednisolone and mycophenolate mofetil and had no recurrence till her recent follow up visit. second case, master fkn an year old child was referred to us with a background of week history of fever, non migratory arthritis, raised inflammatory markers and a symptomatic severe aortic regurgitation with pandiastolic flow reversal on d echo. his evaluation showed negative montoux, normal igg levels and hla b b on tissue typing. his aortic wall thickness resolved with mg/kg oral prednisolone and mycofenolate mofetil. results: both these cases have features similar to behcet's disease. these cases do not fulfil isg, icbd or icbd criteria for pediatric behcet's disease. however, the aortitis and other clinical features responded well to the treatment in both cases.conclusion: paediatric case with extra-pulmonary large vessel arteritis that do not meet criteria for behcet's disease but have specific clinical or laboratory features do respond well to immunosuppression. therefore, after ruling out other causes of the large vessel vasculitis, a possibility of form fruste of behcet's disease should be under consideration. publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. these abstracts have been published as part of pediatric rheumatology, volume , supplement , : proceedings of the th european paediatric rheumatology congress (pres ). the full contents of the supplement are available at https://ped-rheum. biomedcentral.com/articles/supplements/volume- -supplement- . please note that this is part of . key: cord- -hxhlhb m authors: van der gronde, toon; los, leontien; herremans, arnoud; oosting, ronald; zorzanelli, rafaela; pieters, toine title: toward a new model of understanding, preventing, and treating adolescent depression focusing on exhaustion and stress date: - - journal: front psychiatry doi: . /fpsyt. . sha: doc_id: cord_uid: hxhlhb m objective: adolescent depression is a heterogeneous disorder, with a wide variety of symptoms and inconsistent treatment response, and is not completely understood. a dysregulated stress system is a consistent finding, however, and exhaustion is a consistent trait in adolescent patients. the aim of this paper is to critically assess current hypotheses in adolescent depression research and reframe causes and treatment approaches. methods: a mixed-method approach involved a review based on publications from pubmed, embase and psycinfo, and two exemplary adolescent cases. results: both cases show a spiral of stress and exhaustion, but with a different profile of symptoms and coping mechanisms. reframing both cases from the perspective of coping behavior, searching for the sources of experienced stress and exhaustion, showed coping similarities. this proved essential in the successful personalized treatment and recovery process. in combination with recent evidence, both cases support the functional reframing of depression as the outcome of a stress- and exhaustion-related spiralling mechanism. conclusions: we propose to open up a symptom-based, mood-centered view to a model in which adolescent depression is framed as a consecutive failure of stress coping mechanisms and chronic exhaustion. addressing exhaustion and coping primarily as a treatment strategy in adolescents and young adults might work in synergy with existing treatments and improve overall outcomes. this perspective warrants further investigation. major depressive disorder (mdd) is the leading cause of disability worldwide ( ) , with to % of patients proceeding to suicide ( , ) , and a substantive disease burden for adolescents and young adults ( ) ( ) ( ) . depression is a heterogeneous group of brain disorders with varied contextualized origins, complex genetics and a neurobiology that is not completely understood. the etiology is not elucidated, and particularly for adolescents there is an evidence gap ( , , ) . the serendipitous discovery of first the tri-and tetracyclic antidepressants (tcas) and later the stress-modulating serotonin reuptake inhibitors (ssris) led successively to the catecholamine and monoamine hypotheses of depression ( ) . in later years, reduced adult neurogenesis and changes in structural and functional neuronal plasticity have been linked to the onset and treatment opportunities of major depression ( , ) . genetic research has shown that there is not a single genetic cause for depression, and all known genetic factors combined only explain a limited percentage of the variance in clinical outcomes ( , ) . the estimated heritability of depression is %- %, indicating %- % is explained by other factors, such as adverse life experiences ( , ) . researchers have turned to epigenetics to develop new forms of genetic and pharmacological modeling, in an effort to describe the etiology of depression better ( ) . despite many years of research by numerous investigators both in academia and industry, psychoactive targeted therapeutics with controllable and specific effects on the brain microcircuitry and chemistry did not and probably will not materialize due to the complex nature of mental disorders ( ) . in order to open up our thinking about mdd we take up the challenge to reframe depression, specifically focusing on adolescents. we note that within the current framework depression is diagnosed based on the presence of a series of mood-related symptoms and their effect on daily functioning. the seven most commonly used interviews and self-report questionnaires together describe a heterogenous group of symptoms, such as either high or low appetite, more or less sleep than usual, and a feeling of sadness ( ) . this causes differences in diagnosis based on which scale is used ( ) . the widely varying patterns in which these symptoms often present themselves ( , ) , and the high occurrence of several comorbidities, such as anxiety, psychosis, and autism spectrum disorder, indicate that depression is not a homogenous disease, but a continuous, heterogeneous group of disorders associated with a wide variety of different risk factors ( , , ( ) ( ) ( ) ( ) . combined with the lack of understanding of the etiology of adolescent depression, the large variation of presentation and treatment approaches is the main driver for us to try to reframe the concept of mdd in adolescent patients. we also aim to explain why responses to treatment vary substantially and why older age is a consistent and important risk factor for a poorer mdd course ( ) ( ) ( ) ( ) . we will take a new perspective toward mdd by focusing on stress and the depressive mood related to development in adolescence. this yields a promise for novel therapeutic approaches and potential breakthroughs in depression research, treatment and prevention. a mixed method approach was used involving clinical investigation of adolescent case reports and a narrative review. pubmed, embase, and psychinfo were searched for relevant publications, with select additions of recent findings based on collective suggestions of the authors. to make sure the patient perspective is not lost when critically assessing the current framework and new possibilities, two case reports were included. written informed consent was obtained from both subjects for the case reports. many findings in depression research have failed the scientific test of replication. for example, the volume of the amygdala of depressed patients has been found to be increased ( ) in some studies, and decreased in others ( ) . patients with melancholic depression, a subtype based on symptoms, were thought to respond better to tcas than atypical patients (hence the name) ( , , , ) , but other researchers could not replicate this finding ( ) ( ) ( ) ( ) . plasma levels of leptin, which reduces appetite, has been found higher in melancholic patients ( ) , or higher in atypical patients ( ) . finally, childhood trauma and/or abuse is more common in melancholic than in atypical patients ( ) , or vice versa ( ). one consistent finding, however, is a dysregulated stress system in depressed patients ( ) ( ) ( ) ( ) . in approximately % of depressed patients a dysfunction of the hypothalamicpituitary-adrenal (hpa) axis is detected, mainly hyperactivity ( , ) . also a disruption of the diurnal variation of cortisol is commonly seen ( , ) . unfortunately, after decades of research efforts this finding has not resulted in a stress-targeted treatment option or a clinical test to predict treatment response ( , ) , and it remains debated whether hpa-axis dysregulation is a cause or a consequence of depression. this does provide an important insight: depression is at least partially the result of stress and a differential dysregulation in the stress system is an important trait ( ) . the stressor may be in the past (e.g. childhood maltreatment or trauma) ( , ), or acutely (e.g. dealing with new life events). the initial response of people to stress is typically a coping mechanism aimed at exerting control over the stressor either by avoiding, reducing or predicting its occurrence. examples of such efforts are the canceling of obligations or disengagement from social interaction ( ) . the hpa axis exerts a fundamental role regulating both internal as external stimuli, integrating the physiopathological and behavioral dimensions of stress. we postulate that depression is the result of a failure of coping mechanisms to control the stressors and a differential dysregulation in the stress system. the accumulation of stressful events, and the eventual failure of coping mechanisms to deal with the stress, can lead to exhaustion and depressive behavior. preclinical experiments already hinted at a relation between the effectiveness of coping behavior, the effort involved and feedback on the development of gastric ulcers. although coping efforts were effective, ulcers still developed when coping took more effort and less feedback was offered ( , ) . preclinical evidence indicated that chronic exposure to relatively mild stressors which rats can adapt to relatively easily (e.g. tilting the cage at a slight angle, emptying a water bottle in the cage, introducing new bedding material), ultimately resulted in the development of anhedonia ( ) . the chronic character of having to cope with mild stressful events over and over again, and the lack of control over stressors, was sufficient for depressive symptoms to develop ( ) . in a forced swimming test, rats who were dosed with psilocybin developed the coping technique of floating faster than other rats, indicating a window of behavioral flexibility ( ) . ketamine displayed the opposite effect, with more mobility ( ) . we hypothesize that depressive behavior, specifically anhedonia and withdrawal, and the consequent loss of interest and enjoyment in usual activities, is an evolutionary mechanism to guard the organism against the exhaustion that may results from excessive or chronic coping behavior. as such, depressive behavior is both an expression of psychological pressure and a physiological precaution. this substantiates the entanglement of psychological and physiological factors in mdd. stress response mechanisms can change the allocation of metabolic resources in a stressful situation, where that is needed. similarly, depression could be the expression of a forced change in allocation of attention. depressed patients are known to ruminate, or continually analyze their problems and relive their memories ( ) . anhedonia can be interpreted as a way to secure mental resources, by reducing the interest in distractions ( , ) . depression can be seen as an exaggerated social navigating coping mechanism, caused by an accumulation of stress and a spiral of unsuccessful adaptive behaviors which leads to exhaustion. by entering a depressive mode, the organism aims to guard itself from exhaustion. the challenge is to interfere with this mood-affecting spiralling mechanism (see figure ) to prevent depression from developing. dealing with stress and potential exhaustion, as opposed to dealing with the symptoms of depression, could prove to be an effective treatment approach. there is currently only limited evidence-based rationale for choosing one treatment over another for an individual patient ( , ( ) ( ) ( ) , with no differentiated approach for adolescents or adults ( , ) . even defining depression subtypes based on symptoms has not helped ( ). despite guidelines and evidence-based interventions, treatment is still primarily based on trial and error ( , ) , and primarily aimed at improving mood. yet, between one third ( ) to half ( , ) of adult patients show no response to weeks of first line treatment with antidepressant drugs, and are advised to try a different antidepressant. further, one third of all patients never reach a response after four lines of antidepressant treatment ( ) . the current therapeutic shortcomings are the consequences of our lack of knowledge of causes, the underlying neurobiology and chemistry ( ) , and risk factors that contribute to the onset and maintenance of depression. as a consequence, the treatment paradigms are oversimplified with little attention for preventive measures ( ) . when albert hofmann, who first synthesized lysergic acid diethylamide (lsd), came in contact with it himself in , he noted the hallucinogenic properties. in it was first marketed as a therapeutic drug. in the s, timothy leary was the first to start experimenting with psilocybin combined with psychotherapy ( ). in the s and s, lsd and psilocybin were tested in several small-scale clinical trials for anxiety, depression and addiction ( , ) . in response to increased recreational use, international legislation was introduced as part of the "war on drugs," which brought an abrupt end to clinical research with these and similar substances in the s ( , , , ) . in the last two decades, clinical trials with psychedelics have started to take place again ( ) . a brief overview of the indications these psychedelics have been investigated for post- is indicated in table ( , , ) . new insights in the complex etiology of depression might be offered by findings with the use of psychedelics for treatment-resistant depression ( , ) . several psychedelics have shown to help depressive patients in a limited number of studies with small number of patients. the classic psychedelics, compounds such as lsd, psilocybin, and ayahuasca, have diverse pharmacological profiles, including robust effects on the serotonergic system ( , , , ) . a psychedelic not acting on the serotonergic system is the dissociative anesthetic ketamine, which in subanesthetic doses acts as an antagonist on the n-methyl-d-aspartate (nmda) receptor, a type of glutamate receptor ( , , , ) . esketamine, the s-enantiomer of ketamine, has been approved by the food and drug administration (fda) for treatment-resistant depression ( ) , but ketamine has been and continues to be used offlabel to treat depression too ( ) . this highlights that serotonergic activity, or even a mono-aminergic activity, is not required for the antidepressant effect of a psychedelic compound, further stressing the need for abandoning the old hypotheses. these hallucinogens, and the chemically related entactogen , -methylenedioxymethamphetamine (mdma) may have a place in offering a positive experience to break the self-sustaining depressive state and allowing for introspection during psychotherapy to process stressful life-time experiences as a form of reverse medical engineering ( ) . from a psychological point of view, psychedelics work through a different mechanism than classic antidepressants. instead of the elevation of mood and the reduction of anxiety, psychedelic drugs induce a profound temporary positive experience (e.g. a mystical or religious sensation). this positive experience allows for the temporary disintegration of existing networks, which in turn facilitates reprocessing of past emotions and introspection ( ) . in turn, this improves the capacity to cope with stress ( ) . also, the use of a psychedelic in combination with a psychotherapeutic process could have long-term effects, counteracting the effect of a negative experience and disrupting the negative and "downward spiralling" compulsive thinking ( ) . in this article we move away from mood improvement as a primary target ( , ) . we offer an alternative integrated approach for the treatment of adolescent and young adult depression by focusing on stress factors and exhaustion reduction, seeing anhedonia and withdrawal as an evolutionary coping mechanism. this integrates approaches such as the social navigation hypothesis of watson and andrews ( ) with cognitive bias ( ) and selye's biological stress ( , ) . with this approach we take a functional perspective, and focus on the function the depressive state provides to the adolescent patient and how it develops. this perspective is instrumental for tailormade treatment strategies. we will discuss these insights on the basis of two adolescent patient reports. mood disorders have been shown to be progressive, with patients developing more complex psychopathologies over time ( , ) . approximately % of patients retrospectively state that their first depressive episode occurred before the age of ( , ) ; another report states % experience that before the age of ( ) . this further highlights the progressive nature of depression and the need for early intervention. a -year-old caucasian woman was referred by her own general practitioner to the department of adolescent psychiatry and addiction prevention for binge drinking and daily use of marijuana. the intake together with her parents showed that the patient already had a history of moderate depression and an eating disorder, anorectic of the purging type with moderate severity. no abnormalities were reported regarding appearance, behavior, eye contact, and rapport orientation and cognition [intelligence quotient (iq) of ]. however, she regularly suffered from suicidal thoughts and a low ability to experience pleasure. though she had no concrete suicide plans, in gloomy periods she showed risky behavior, like crossing a busy road without looking. she usually performed well in school, despite occasional lags in attendance, which were compensated with short periods of active study. her mother had a history of mdd. at the department of adolescent psychiatry and addiction prevention, we classified the addiction behavior as mild. but we also established a comorbid psychiatric and substance-use disorder profile. thus, we chose for an integrated treatment for comorbidity that has been found to be consistently superior ( ) . effective treatment for comorbid conditions combines different therapeutic modalities, i.e. psychotherapy [e.g. motivational interviewing (mi), cognitive behavioral therapy (cbt)], pharmacotherapy (e.g. antidepressants), and family therapy. using combinations of different modalities typically increases therapeutic effect by exerting a synergistic impact on symptoms ( ) . with mi, the patient was motivated to choose a first educationrelated treatment goal. this was to prevent school dropout at all cost. we started cbt to control her marihuana and alcohol abuse and prevent school dropout. we added medication in order to try to stabilize her mood with fluoxetine, an ssri, which might also modulate stress. the medication initially seemed to have some effect but after two months there was a sharp mood drop, increased suicidality and aggravation of eating disorder symptoms. eventually she had a body mass index of kg/m . the eating problems were mapped and analysed by an eating disorder specialist. the latter used a problem-solving approach and focused on both directive counseling and emotional support. the eating disorder specialist also advised to choose a medication with low risks of weight gain. the psychiatrist changed the medication to citalopram. subsequently, the treatment team focused on teaching the patient how to cope with stressful situations and the associated anxiety. the stress appeared to be mainly caused by a feeling of lack of control. the patient turned out to have a high intelligence and learning ability, but also felt that she had no control over her learning process. she had not sufficiently developed social learning strategies in her early school years. in addition, there appeared to be an issue of individuation and separation problems. these problems got worse because it was almost impossible for her parents to let her develop in her own way due to the stress they had over her suicidal thoughts, drug use, and worsening physical condition due to bad eating habits. we decided on an additional family counseling approach to address these issues. the integrated treatment modality approach proved effective. she developed a realistic idea of what caused her stress, how she reacted situationally and improved her awareness that she tends to have control over everything. her parents were involved in helping her developing control coping skills and checking on achievements. because of this insight, she succeeded in maintaining her diet less strictly and experimenting with behaving differently without alcohol or drugs. her parents saw that she was doing better and were able to release her a bit more. this increased her sense of control and provided enough space to further discover what goals she wanted to achieve. in the process her mood and her ability to experience pleasure improved significantly. she successfully passed her school exams and proceeded to university. a -year old caucasian girl was referred by her own general practitioner after a suicide attempt with symptoms of sadness, anxiety, and obsessive-compulsive behavior. the intake was together with her parents. she was struggling in school, despite her very supportive family. no drug abuse or other psychiatric symptoms were found. she told the counselor she tried hard, but felt that she could not keep up in school; it was never good enough, no matter how hard she tried. the counselor estimated that the school level was appropriate for the level of intelligence of the patient. she had periods when her self-esteem was very low. during these periods she spent hours on her appearance, focusing on her hair and makeup. her hair fell out as a result of these sessions. she could not stop herself, and always ended with self-harm. this in turn lowered her self-esteem and increased the experienced stress. she was locked in a downward spiral. gradually her mood disorder worsened and made her passive. she no longer wanted to go to school and meet friends, but passed hours in front of the mirror. she attempted to end her life. we hypothesized on the basis of the girl's stress complaints that she felt school, parents, and friends expected too much of her. after a neuropsychological assessment the testing showed that she had a disharmonic intelligence profile with an iq of approximately (using the wechsler intelligence scale for children-iii ( ) ), inconsistent at all factor levels. we classified a mild intellectual developmental disorder in the conceptual and practical domain, which explained the structural struggle with the standard school curriculum instructions. we educated parents and school on how instructions might fit in better with her learning abilities and style. her preferred method of learning new things was being shown how to do it, as opposed to having it explained to her. this led to significant stress reduction and positive school experiences. in the process her self-esteem improved, the experienced stress decreased, and her mood improved. cbt was adjusted to her learning style and was used to reduce her obsessive-compulsive behavior. though both case reports show a different profile of symptoms and coping mechanisms, in both cases a downward spiral of stress, coping behavior, and exhaustion are central. both patients described themselves as rarely feeling relaxed and as struggling to fulfill their daily tasks. after several years of chronic stress, a period followed in which they felt constantly exhausted. the first patient coped with stressful situations through aberrant food intake behavior, suicidal thoughts, and mood swings. she overcompensated this restrictive behavior with recreational drug abuse. the second patient developed compulsory behavior, stress, and suicidal thoughts and overcompensated leading to self-harm. in the current framework both cases would be viewed as different and based on their symptomatology ask for different treatments. reframing both cases, from the perspective of coping behavior, searching for the origin and sources of the experienced stress and exhaustion and coping with stressful situations, showed stress coping similarities between the two cases and proved an essential part of the personalized treatment and recovery process. both cases support the added clinical value of the functional reframing of depression as the outcome of a mood-affecting stress and exhaustion related spiralling mechanism. the adolescent cases presented here are good examples of how depression can be managed by relearning effective coping behavior. this prevents patients from reverting to a depressive state in order to cope with the life stressors. in more severe and chronic cases, patients suffering from difficult-to-treat or treatment resistant mdd, patients are in a deep depressive state and are not capable of learning new coping behaviors. we envision that in such situations more radical medical interventions are needed to first elevate patients from the depressive state into a state where learning new and effective coping strategies can take place. in these situations, psychedelics (e.g. ketamine) have proven to be effective to temporarily draw people out of a deep depressive state. with the support of followup medication and adequate psychological guidance, the patients may then develop effective coping strategies. as this is a narrative review, and not a formal systematic review, caution needs to be used when interpreting this data. select literature sources have been added based on informal searches, so contradicting studies may have been missed. similarly, the two cases were selected for their exemplary stories, not because they are typical. as such, this paper aims to provide new insights and direction for future treatments, not a definitive answer on how to improve treatment. after the spanish flu of , many infected patients developed post-viral fatigue in the following months and years. on top of that, the randomness of who was infected and who died as a result led to learned helplessness, which caused anhedonia and other depressive symptoms ( ) . the recent pandemic of the novel coronavirus, severe acute respiratory syndrome coronavirus [sars-cov- , previously known as -ncov ( )], has overwhelmed healthcare facilities with the high need for acute care. this puts a large psychological toll on the entire population, with high levels of stress ( ) . next to the risk of the many life events that can be expected in these situations, coping behavior-such as avoiding conflict, or searching social support-is often limited due to confinements that are put in place to prevent further spread. furthermore, the lockdown situation and mass isolation at home in many countries may increase the risk of domestic violence and divorces. this could all lead to a rise in trauma-related stress disorders in the months and years to come. breaking a vicious cycle of stress, inadequate coping behavior and exhaustion with a holistic view, and possibly with psychedelic-supported psychotherapy, might help treat the many psychiatric patients that can be expected. reframing depression and shifting clinical practice to a more comprehensive and integrated look at the individual experience of a patient, including all causes for stress, pressure, and exhaustion, might be more helpful in developing promising treatment strategies. also, treatment practices that take into account preventive mental health interventions, and that focus on stress, exhaustion, and coping strategies, could have a significant and lasting impact on many patients struggling with depression. the perspective of stress, coping, and exhaustion provides the therapist with another treatment approach that can work in synergy with the existing arsenal of therapeutic approaches, making the therapist more effective. increased focus is needed on support programs to help individuals develop functional coping mechanisms to deal with pressure, before more serious coping mechanisms develop in the form of withdrawal from stressful situations, compulsory behavior, or frequently occasional use of recreational drugs ( ) . our intuition is that during successful treatment patients experience small successes of effective coping and re-live the rewarding properties of such experiences. reliving experiences could repair the damaged reward mechanisms and diminishes the experienced anxiety and stress which then might subsequently drive and sustain further recovery ( ) . psychedelics may offer help in breaking free from the existing cognitive bias, by facilitating introspection, re-living of past experiences, and development of new coping mechanisms. effective treatment strategies for adolescent and young adult depression should combine different therapeutic modalities and focus on exhaustion and sources of stress. using a combination of treatment modalities could increase therapeutic effectiveness by improving the pace of learning new coping behaviors, exerting a synergistic impact on the developmental perspective, and breaking the downward spiral of stress and exhaustion, which eventually leads to a reduction of the depression symptoms. this might also help for other related mental disorders in adolescents and young adults where exhaustion and stress are central, such as burnout syndrome ( ) . but similarly, post-traumatic stress disorder, autism spectrum disorder, and generalized anxiety disorder are related to stress ( , ( ) ( ) ( ) . these disorders could also benefit from the reframing of the concept of mood and stress. we would like to offer this integrated and multidisciplinary perspective as a consideration for the development of new multimodal treatment approaches for mdd and other related psychiatric disorders. all datasets generated for this study are included in the article/ supplementary material. written informed consent was 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research with psychedelic drugs social support, dysfunctional coping, and community reintegration as predictors of ptsd among human trafficking survivors coping strategies and mental health outcomes of conflict-affected persons in the republic of georgia reviewing the potential of psychedelics for the treatment of ptsd we would like to thank prof dr. eric vermetten, prof. dr. claudi bockting, and the reviewers for their feedback on this paper, and the patients who consented to have their history described for the case reports. furthermore, we would like to thank cassandra nemzoff for her english manuscript correction services. in conflict of interest: during the late stage development of this manuscript, tg accepted a position in oncology at astrazeneca. astrazeneca had no role in any aspect of this paper. key: cord- - gwrpu authors: berth, sarah h.; lloyd, thomas e. title: secondary causes of myositis date: - - journal: curr treat options neurol doi: . /s - - - sha: doc_id: cord_uid: gwrpu purpose of review: the purpose of this paper is to comprehensively evaluate secondary causes of inflammatory myopathies (myositis) and to review treatment options. recent findings: this review highlights recent advancements in our understanding of known causes of myositis, including newer drugs that may cause myositis such as checkpoint inhibitors and viruses such as influenza, hiv, and sars-cov . we also discuss treatment for malignancy-associated myositis and overlap myositis, thought to be a separate entity from other rheumatologic diseases. summary: infections, drugs, rheumatologic diseases, and malignancies are important causes of myositis and are important to diagnose as they may have specific therapies beyond immunomodulatory therapy. the term "myositis" is often used interchangeably with "idiopathic inflammatory myopathy" (iim), referring to primary autoimmune diseases of muscle including dermatomyositis, inclusion body myositis (ibm), antisynthetase syndrome, and necrotizing autoimmune myopathy [ ] [ ] [ ] [ ] [ ] [ ] . however, there are also known causes of inflammatory myopathies which must be considered in the evaluation of patients with acute or subacute myopathy, including infections, drugs, mixed connective tissue disease, and malignancies. furthermore, while polymyositis is classically included in iims, most cases are now thought to either be early ibm or secondary to another disease such as those covered here. as several excellent recent reviews have covered treatment of iim [ , ••, ] , this review will focus on known, or secondary, causes of myositis. infectious myositis can occur with bacterial, viral, fungal, or parasitic infections. bacterial myositis, which is typically focal, can occur via hematogenous spread (pyomyositis) or via spread from contiguous infection or trauma [ ] . while a range of bacteria can cause pyomyositis, the most common is staphylococcus aureus, which causes up to % of cases in tropical regions and up to % in the usa [ , ] . the most common cause of bacterial myositis not due to hematogenous spread is streptococcus, whereas myositis in the setting of trauma is typically due to polymicrobial infection [ ] . viral myositis is most commonly caused by influenza and enterovirus but can be caused by many different classes of viruses [ ] , and clinical presentations range from myalgias to focal myositis to rhabdomyolysis. myalgias are typically an initial presenting symptom of influenza, whereas myositis usually follows days of illness and is marked by pain and swelling. in progression to rhabdomyolysis, muscle pain and weakness typically become diffuse and are accompanied by a marked increase in serum creatine kinase (ck) enzyme level and myoglobinuria. a recent retrospective case study from wuhan on neurologic complications of sars-cov- indicates that infectious myositis may also be a complication of sars-cov- , as close to % of patients had muscle injury as defined by the presence of myalgias and ck units per liter (u/l) [ •] . typically, viral myositis is treated symptomatically and resolves within days. an exception to this is hiv-associated myositis which presents with both proximal and distal weakness progressing over weeks to months that clinically and pathologically overlaps with inclusion body myositis (ibm) [ • ]. finally, fungal and parasitic infections have been reported to cause myositis. fungal myositis is rare and usually occurs in immunocompromised hosts, whereas parasitic myositis occurs in endemic regions; the most common causes include trichinella, taenia solium, and toxoplasma gondii [ ] . medications have also been linked to myositis. statins commonly cause myalgias, but are also rarely associated with an autoimmune necrotizing myopat h y a n d a u t o a n t i b o d i e s t o -h y d r o x y - methylglutaryl-coenzyme a reductase (hmgcr) [ ] . most ( %) patients with anti-hmgcr myositis were previously exposed to statins [ ] , though anti-hmgcr myositis can also present in statin-naïve patients. immune checkpoint inhibitors (ici) are a class of drugs recently developed for cancer treatment, for which myositis has been recognized as an immune-related adverse event. myositis in these patients can occur along with other autoimmune syndromes, most commonly myasthenia gravis or myocarditis [ ] . myositis typically occurs early in the course of treatment, with one study showing median onset days after initiation of ici [ ] . other medications that have been linked to myositis include penicillamine [ , ] , interferon beta [ ] , and tnfα inhibitors [ ] . in this era of covid- , it is important to note that chloroquine and hydroxychloroquine, used to treat or prevent sars-cov- , can cause a progressive myopathy characterized by autophagic vesicles [ •] . myositis has also been associated with connective tissue diseases, including systemic sclerosis, systemic lupus erythematosus (sle), mixed connective tissue disease, and sjögren's syndrome. recent studies suggest that myositis in patients with systemic sclerosis confers a worse prognosis than those without myositis [ , ] , suggesting that overlap myositis should guide treatment decisions in these patients. finally, myositis can also be secondary to underlying malignancy. autoimmune necrotizing myopathy, dermatomyositis, and polymyositis have all been associated with malignancies [ , ] . risk of malignancy is highest in the year prior to and following diagnosis [ ] [ ] [ ] [ ] [ ] [ ] [ ] , and it is associated with older age [ , , ] , male sex [ ] , cutaneous necrosis [ , ] , rapid onset of disease [ ] , high inflammatory markers [ , ] , and resistance to treatment [ ] . in dermatomyositis, the presence of nxp- and tif- γ antibodies are also associated with an increased risk of malignancy [ ] . of note, myositis can be a rare feature of chronic graft versus host disease (cgvhd), a complication of allogeneic stem cell transplantations [ ] [ ] [ ] . for an overview of commonly used medications to treat myositis, see table . while these are the most common medications used to treat both primary (iim) and secondary causes, this is not a comprehensive list, and the use of these and other medications is discussed in detail elsewhere [ ] [ ] [ ] . for viral infectious myositis, patients are treated with hydration, rest, and analgesics, and symptoms usually resolve within days [ ] . for hivassociated myositis, one study of patients showed patients treated with immunosuppressive medications had improvement in proximal weakness despite the progression of distal weakness, though it is unclear if this improvement may be due to the natural progression of disease [ •] . in this case series, several patients improved with initial treatment of prednisone transitioned to steroid-sparing agents such as mycophenolate or azathioprine. in our opinion, it is reasonable to initiate a trial of immunosuppressive therapy in hivassociated myositis with consultation of an infectious disease physician. treatment of bacterial, fungal, or parasitic myositis will require antibacterial, antifungal, or antihelminthic therapy, respectively [ ] . for patients with anti-hmgcr antibodies, cessation of statin therapy is important [ ] . for patients that require cholesterol-lowering medication, proprotein convertase subtilisin/kexin type (pcsk ) can be considered, as these medications were shown to be safe in a case series of patients with hmgcr antibodypositive necrotizing myopathies [ ] . in rare mild cases, further treatment beyond statin cessation may not be necessary [ ] . for immune treatment, expert consensus recommends initial treatment with steroids (oral steroids at mg/kg/day or iv steroids . - g/day for - days) with initiation of azathioprine, methotrexate, mycophenolate, or intravenous immunoglobulin (ivig) [ ] . ivig monotherapy may be considered in patients with comorbidities that could be worsened with steroids, such as diabetes mellitus or osteoporosis [ ] . in refractory or relapsing patients, rituximab may be considered [ , , ] . expert guidelines recommend the treatment of ici-associated myositis tailored to severity [ ••] . for mild weakness without ck elevation, patients may be offered analgesia, and ici may be continued with careful monitoring of ck. for mild or moderate weakness with ck elevation, it is recommended for icis to be held, and prednisone can be initiated at . - mg/kg. these cases may require permanent discontinuation. for severe weakness limiting activities of daily living, cessation of ici and referral to a neurologist or rheumatologist with expertise in managing myositis are recommended. in this case, patients can be treated with - mg/kg prednisone (use higher dose if weakness is severely limiting mobility or if there is dysphagia or cardiac or respiratory involvement), with consideration of plasmapheresis or ivig treatment. if there is no improvement in - weeks, transition to immunosuppression therapy such as azathioprine, methotrexate, or mycophenolate may be considered. with myocardial involvement, it is recommended that icis be permanently discontinued [ ••] . it is unclear if rechallenge of severe ici-associated myositis with ici is safe, although one report examining two patients re-challenged or months after myositis resolution did not see a reoccurrence of ici-associated myositis [ ] . in a systematic review of ici-associated neuromuscular complications, of ici-associated myositis patients improved with immunosuppression [ ] . for myositis related to penicillamine, tnfα inhibitors, and interferon beta therapy, cessation of these medications led to improvement in symptoms [ , , ] . caution is recommended with re-challenge of penicillamine and tnfα inhibitors, as re-challenge has been reported to be associated with relapse for both penicillamine-associated myositis [ , ] and tnfα inhibitor-associated myositis [ , ] . there is limited data for treatment of overlap myositis, but the general principle is to use immunosuppression therapy that also targets the associated rheumatic disease. systemic sclerosis is the most common rheumatologic disease that overlaps with myositis [ , ] . although there is limited data for immunosuppressive treatment, our center prefers to start with a steroid-sparing agent such as mycophenolate which is commonly used to treat systemic sclerosis, as glucocorticoid treatment is a risk factor for renal crisis [ ] . for myositis associated with systemic lupus erythematosus (sle), patients typically respond well to glucocorticoid treatment; resistant myositis can be treated with additional immunosuppression such as methotrexate [ , ] . ivig is usually avoided in patients with systemic lupus erythematosus with antiphospholipid antibodies due to the risk of thromboses. in myositis associated with mixed connective tissue disease, known to respond well to steroids, treatment with increased doses of glucocorticoids usually provides a good response [ ] . rheumatoid arthritis rarely is associated with myositis [ ] , and myositis is usually initially treated with glucocorticoids with consideration of transition to steroid-sparing agents [ ]. sjogren's syndrome is rarely associated with inclusion body myositis (ibm) [ , ] . although ibm is refractory to treatment [ ] [ ] [ ] , patients with ibm and sjogren's syndrome have been reported to respond to treatment with immunosuppression [ , , , ] . thus, it is our practice to treat sjogren's syndrome patients with new diagnosis of ibm with immunosuppression, starting with prednisone mg/kg/day for - months. if patients respond to glucocorticoids, we initiate steroid-sparing agents such as methotrexate or azathioprine for a trial period while tapering glucocorticoids. steroid-sparing agents are selected due to side effect profile (table ) [ ] . however, in our clinical experience, we have seen little response to immunosuppression in these patients. when myositis is discovered to be associated with malignancy, a guiding principle is to treat the underlying malignancy, which in some cases has been shown to cure myositis [ ] [ ] [ ] [ ] . however, this should not preclude the treatment of myositis with immunosuppression. corticosteroids and ivig are commonly used to avoid side effects and interactions with chemotherapeutic agents. curr treat options neurol ( ) : glucocorticoid treatment should be coordinated around possible surgery, since glucocorticoids can delay wound healing. prognosis tends to be worse than in idiopathic inflammatory myositis, but depends on the treatment of the underlying malignancy [ , ] . in a study examining polymyositis in the setting of cgvhd, patients were treated with either prednisone monotherapy or a combination of prednisone with either azathioprine or cyclosporine, and all showed improvement [ ] . another case series of three patients with dermatomyositis-associated cgvhd showed improvement with immunosuppression via combination treatment of corticosteroids, tacrolimus, rituximab, mycophenolate mofetil, and/or ivig [ ] . given these results, we recommend steroids with additional immunosuppressive agents if necessary for cgvhd-associated myositis. we recommend that all patients with myositis be evaluated by a physical therapist that specializes in neuromuscular disease to develop an exercise program. exercise in myositis has been shown to be safe and effective at improving endurance and strength [ ] [ ] [ ] [ ] . patients with polymyositis or dermatomyositis that underwent intensive aerobic exercise combined with resistance training in a randomized controlled trial have improved muscle function, quality of life, and possible reduced disease activity [ ] . in fact, a subset of dermatomyositis and polymyositis patients undergoing resistance training showed decreased disease activity [ ] . a recent randomized, singleblinded crossover trial examining aerobic training with exercise bicycles showed safety and improved aerobic capacity in patients with inclusion body myositis, providing class ii evidence for aerobic training improving cardiopulmonary fitness [ ] . we recommend combined aerobic and strength training [ ] , with avoidance of high-impact and eccentric exercises. additionally, passive range of motion exercises is useful for extremely weak muscles to prevent contractures. physical therapists should also work with patients to prevent falls and evaluate patients for assistive devices for ambulation. we recommend referring patients with dysphagia to speech therapy for a swallow evaluation. oropharyngeal dysphagia may be addressed with diet modifications and head positioning maneuvers. for refractory dysphagia, patients may require percutaneous endoscopic gastrostomy to maintain nutrition. attention has turned to using rituximab for refractory myositis, for which several studies have shown positive effects for patients with myositis or necrotizing myopathies [ , [ ] [ ] [ ] . a randomized, double-blind placebo-controlled trial examining rituximab in myositis did not reach its primary endpoint, but most patients had clinical improvement [ •] . these studies support an offlabel use for rituximab in patients with refractory myositis, although additional rigorous studies are needed to evaluate its effectiveness. several new medications for iim are currently undergoing clinical trials. if they are found to be effective, further evaluation in treatment of secondary causes of myositis will be warranted. some of the most promising ones are commented on below. abatacept is a fusion protein of f c region of igg and ctla- designed to prevent t cell activation that is currently fda-approved to treat rheumatoid arthritis. there have been case reports of abatacept successfully used to treat refractory overlap myositis [ ] and refractory ici-associated myositis [ ] . a pilot study of patients with refractory dermatomyositis or polymyositis using abatacept found that almost half of their patients showed reduced disease activity and improved muscle performance after treatment for months [ ] , and there is now a phase iii, randomized, double-blind trial to further evaluate abatacept for myositis treatment (clinicaltrials.gov identifier: nct ). jak inhibitors, designed to prevent interferon-induced activation of cytokine receptors, have also been tested in pilot studies for refractory dermatomyositis with promising results, including improved weakness and skin lesions [ ] [ ] [ ] . the jak inhibitor tofacitinib is under investigation in the open-label pilot stir trial (clinicaltrials.gov identifier: nct ). another drug currently under investigation is tocilizumab, a monoclonal antibody directed against interleukin . a case report found normalization of ck in two patients with refractory polymyositis treated with tocilizumab [ ] , and another showed improvement of both arthritis and weakness in a patient with overlap myositis with rheumatoid arthritis [ ] . a randomized controlled phase ii trial is underway examining tocilizumab treatment of myositis patients (clinicaltrials.gov identifier: nct ). secondary myositis has several underlying triggers. here, we have highlighted myositis in the setting of infections, medications, systemic rheumatologic disease, and malignancies. a careful history and workup will detect these underlying causes, for which treatment can be modified accordingly. severe and persistent cases of secondary myositis require an integrated approach of treating the underlying systemic cause, immunosuppression, and physical therapy. inclusion body myositis: clinical features and pathogenesis th enmc international workshop: clinico-sero-pathological classification of immune-mediated necrotizing myopathies zandvoort, the netherlands, - october th enmc international workshop: classification of dermatomyositis skeletal muscle involvement in antisynthetase syndrome evaluation and construction of 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anti-pd- monoclonal antibodies: systematic review immune checkpoint inhibitorrelated myositis and myocarditis in patients with cancer penicillamine induced polymyositis and dermatomyositis dermatomyositis induced by drug therapy: a review of case reports severe dermatomyositis triggered by interferon beta- a therapy and associated with enhanced type i interferon signaling dermatomyositis induced by anti-tumor necrosis factor in a patient with juvenile idiopathic arthritis this study describes clinical and pathological features of hydroxychloroquine-induced vacuolar myopathy patients with systemic sclerosis/polymyositis overlap have a worse survival rate than patients without it disease progression in systemic sclerosis-overlap syndrome is significantly different from limited and diffuse cutaneous systemic sclerosis high risk of cancer in autoimmune necrotizing myopathies: usefulness of myositis specific antibody idiopathic inflammatory myopathies and malignancy: a comprehensive review 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a systematic review and meta-analysis clinical and biological factors predictive of malignancy in dermatomyositis most patients with cancerassociated dermatomyositis have antibodies to nuclear matrix protein nxp- or transcription intermediary factor gamma national institutes of health consensus development project on criteria for clinical trials in chronic graft-versus-host disease: i. the diagnosis and staging working group report polymyositis as a manifestation of chronic graft-versus-host disease dermatomyositislike muscle pathology in patients with chronic graftversus-host disease vaccinations for rheumatoid arthritis azathioprine: drug information methotrexate: drug information mycophenolate motefil (cellcept) and mycophenolate sodium (myfortic): drug information immune globulin (intravenous, subcutaneous, and intramuscular): drug information therapeutic apheresis (plasma exchange or cytapheresis): indications and technology. uptodate therapeutic apheresis (plasma exchange or cytapharesis): complications. uptodate anti-hmgcr myopathy this is a comprehensive review of anti-hmgcr myopathy use of proprotein convertase subtilisin/kexin type inhibitors in statin-associated immune-mediated necrotizing myopathy: a case series intravenous immune globulin for statin-triggered autoimmune myopathy rituximab in the treatment of refractory anti-hmgcr immune-mediated necrotizing myopathy treatment and outcomes in necrotising autoimmune myopathy: an australian perspective management of immune-related adverse events in patients treated with immune checkpoint inhibitor therapy this paper provides expert guidelines on treatment of icimyositis immune checkpoint inhibitor rechallenge in patients with immune-related myositis d-penicillamine-induced polymyositis in patients with rheumatoid arthritis. arthritis rheum penicillamineinduced polymyositis-dermatomyositis anti-tumor necrosis factor inhibitor therapy-induced dermatomyositis and fasciitis prevalence of other connective 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sjogren syndrome associated with inflammatory muscle diseases management of inclusion body myositis successful treatment of dermatomyositis associated with adenocarcinoma of the prostate after radical prostatectomy successful cure of dermatomyositis after treatment of nonseminomatous testicular cancer dermatomyositis and malignancy. a multicenter cooperative study prostate cancer underlying acute, definitive dermatomyositis: successful treatment with radical perineal prostatectomy cancerassociated myositis: clinical features and prognostic signs sporadic inclusion body myositis: pilot study on the effects of a home exercise program on muscle function, histopathology and inflammatory reaction improvement in aerobic capacity after an exercise program in sporadic inclusion body myositis exercise in inflammatory myopathies, including inclusion body myositis safety and efficacy of strength training in patients with sporadic inclusion body myositis improvement in health and possible reduction in disease activity using endurance exercise in patients with established polymyositis and dermatomyositis: a multicenter randomized controlled trial with a -year open extension followup benefits of intensive resistance training in patients with chronic polymyositis or dermatomyositis community exercise is feasible for neuromuscular diseases and can improve aerobic capacity rituximab in the treatment of inflammatory myopathies: a review rituximab therapy for myopathy associated with anti-signal recognition particle antibodies: a case series longitudinal course of disease in a large cohort of myositis patients with autoantibodies recognizing the signal recognition particle rituximab in the treatment of refractory adult and juvenile dermatomyositis and adult polymyositis: a randomized, placebophase trial although this study did not meet its primary endpoint, % patients with refractory dermatomyositis or polymyositis met definition of improvement abatacept as a successful therapy for myositis-a case-based review abatacept for severe immune checkpoint inhibitor-associated myocarditis abatacept in the treatment of adult dermatomyositis and polymyositis: a randomised, phase iib treatment delayed-start trial jak inhibitor improves type i interferon induced damage: proof of concept in dermatomyositis tofacitinib citrate for refractory cutaneous dermatomyositis: an alternative treatment a case of refractory dermatomyositis responsive to tofacitinib. semin arthritis rheum therapeutic effect of tocilizumab on two patients with polymyositis. rheumatology (oxford) a case of overlap syndrome successfully treated with tocilizumab: a hopeful treatment strategy for refractory dermatomyositis? publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations the authors would like to thank dr. andrew mammen for his careful review of the manuscript, and dr. lisa christopher-stine, dr. christopher mecoli, dr. eleni tiniakou, dr. brittany adler, dr. jemima albayda, and dr. julie paik for feedback on table . key: cord- -mh uh b authors: boloori, alireza; arnetz, bengt b.; viens, frederi; maiti, taps; arnetz, judith e. title: misalignment of stakeholder incentives in the opioid crisis date: - - journal: int j environ res public health doi: . /ijerph sha: doc_id: cord_uid: mh uh b the current opioid epidemic has killed more than , americans over the past two decades. despite the magnitude of the crisis, little is known to what degree the misalignment of incentives among stakeholders due to competing interests has contributed to the current situation. in this study, we explore evidence in the literature for the working hypothesis that misalignment rooted in the cost, quality, or access to care can be a significant contributor to the opioid epidemic. the review identified several problems that can contribute to incentive misalignment by compromising the triple aims (cost, quality, and access) in this epidemic. some of these issues include the inefficacy of conventional payment mechanisms in providing incentives for providers, practice guidelines in pain management that are not easily implementable across different medical specialties, barriers in adopting multi-modal pain management strategies, low capacity of providers/treatments to address opioid/substance use disorders, the complexity of addressing the co-occurrence of chronic pain and opioid use disorders, and patients’ non-adherence to opioid substitution treatments. in discussing these issues, we also shed light on factors that can facilitate the alignment of incentives among stakeholders to effectively address the current crisis. from to , the total number of drug-related deaths in the u.s. increased from , to , . among them, opioid analgesics have contributed the most, from to , , a . % increase [ ] . this dramatic change has contributed to a substantial drop in the average life expectancy in the u.s. for consecutive years, particularly among men [ , ] . a myriad of factors have been attributed to the opioid crisis. these include: • regulations on reimbursement policies, such as the hospital consumer assessment of healthcare providers and systems (hcahps) survey, which partially rewards healthcare systems and providers when patients score high on pain management experience of care, thus making providers more inclined towards opioid analgesics [ ] ; • lack of a comprehensive multi-modal pain management strategy [ ] ; • barriers in adopting treatments for opioid /substance use disorders [ ] ; • efforts that have influenced downplaying the negative impacts of opioids, such as marketing by pharmaceutical companies and professional associations promoting opioids [ ] or pain being declared as the fifth vital sign [ ] ; • regarding the novel coronavirus (covid- ) pandemic, we note that second-order effects have been reported on the opioid crisis; e.g., an increase in rates of opioid use disorders [ ] and opioid use in intensive care units during mechanical ventilation [ ] . to address the opioid crisis, many remediation actions and policies have been implemented. for example, the centers for disease control and prevention (cdc) have proposed a set of guidelines for prescribing opioids for chronic pain conditions [ ] , with the main focus being on avoiding such medications to the greatest possible extent. as of october , the centers for medicare and medicaid services (cms) removed pain management questions from the hcahps survey [ ] . although the pain management measure in the survey accounts for a small portion of medicare's reimbursements/incentives paid to hospitals, it may have incentivized providers to prescribe opioid medications [ ] . these actions have been part of a concerted effort to curb the prescription of opioids [ ] . as reported by the national institute on drug abuse [ ] , the number of deaths in the u.s. caused by prescription opioids dropped from , in to , in . despite this decrease, limiting opioid prescriptions may already have had other repercussions, such as a dramatic increase in deaths from synthetic opioids (e.g., fentanyl), from , to , during the same period [ ] . based on these premises, we pose that one of the main issues that contributes to the opioid crisis is the absence of a systemic perspective where (dis)incentives of various stakeholders are taken into consideration in promoting patients' health and safety. it is imperative to understand the incentive misalignment from a system perspective if we are to effectively combat the epidemic. to this end, we pursue the following objectives in this review: ( ) we evaluate evidence in the extant literature surrounding factors that can potentially cause misalignment among stakeholders by compromising either cost, quality, or access to care in this epidemic and ( ) identify efforts and strategies that may contribute to alleviating such misalignments. we conducted a literature review by addressing and summarizing potential sources of incentives' misalignment and their impacts on the opioid crisis [ ] . in conducting this review, we searched two databases: medline (pubmed) and web of science. for our search mechanism, we identified three main categories based on the type of medication originating the epidemic, the type of problem/objective we attempt to address in this review, and the type of stakeholders involved along with some of their strategies. for these categories, we also used a series of search terms. these categories are represented as follows, respectively: • category : "opioid". • category : "alignment", "misalignment", "align", "misaligned", and "incentive". • category : "stakeholder", ("societal planner", "payer", "insurer", "insurance", or "coverage"), ("payment", "reimbursement", "fee-for-service", "capitation", "capitated", "pay-for-performance", "bundled payment", "accountable care", or "value-based"), ("provider", "physician", or "hospital"), "patient", ("employer" or "employment"), ("pharmaceutical" or "drug"), ("pharmacologic", "non-pharmacologic", or "nonpharmacologic"), ("barrier" or "facilitator"), and ("contingent" or "contingency"). to search key terms/words in the title, abstract, or main body of studies, we then used a combination of categories - . for example, one option is the combination of "opioid", "alignment", and ("provider" or "physician" or "hospital"). the timeline for our search encompassed studies published (online) between january and december . only studies published in english were included. of note, to account for the sheer number of references in the literature, we limit the number of databases to two, our search timeline, and the number of search terms for category . from a total of articles identified, our review resulted in studies (see figure ). among the original articles that we identified, we sequentially filtered out by screening of titles, due to duplicate references in our two databases, by screening of abstracts, and by full article review. in reviewing the studies, we noted that factors and dynamics that typically cause misalignment can be dichotomized into two stages, depending on whether or not a patient has been diagnosed with (or is in danger of) opioid/substance use disorder (oud/sud). our review identified five categories of stakeholder misalignment prior to oud onset and two sources of misalignment subsequent to oud (table ). in sections . and . , we separately discuss the literature for each of these prevention and intervention stages, respectively. in table , we also present a summary of these studies along with types of stakeholders, sources of misalignment addressed, and number and date ranges of studies published under each topic. to this end, we note that the vast majority of papers have been published within - (the second half of our search timeline). in table , we provide the glossary of some terms used commonly throughout the paper. an entity who plays a role in navigating a healthcare-related problem, e.g., payer, provider, patient, employer, pharmaceutical company, etc. an interest for a stakeholder, e.g., monetary (revenue), health-related (quality of life), political (implications of a proposed healthcare bill), organizational (e.g., integrity and power issues), or behavioral (e.g., psychological factors). a condition caused by competing and/or conflicting interests between two or more stakeholders resulting in either an increase in the cost of care, a reduction in the quality of care, or less access to care. alignment a condition where devising mechanisms among stakeholders can either lower the cost, improve the quality, or enhance the access to care. this is a relative notion in that a "complete" alignment may not be attainable in reality. fee-for-service a payment mechanism where a provider is separately reimbursed for every service delivered to a patient. a payment mechanism where a provider is reimbursed per patient per time period. pay-for-performance the general class of payment mechanisms where the provider(s) is reimbursed based on the quality of care delivered to patients. some examples include "bundled payment" and "accountable care". bundled payment a payment mechanism where a bundled payment is paid to a group of providers per patients per episode of care. accountable care a payment mechanism where a group of providers shares benefits/savings (upon high-quality delivery of care) or is penalized in reimbursements otherwise. managed care health insurance plans that provide care for enrollees at lowered cost. different types include health maintenance organizations, preferred provider organizations, and point of service. care fragmentation care that is delivered to a patient via multiple providers while there is little to no coordination between providers. there is evidence that outcomes such as inappropriate prescribing of opioids and diagnosed opioid misuse are more prevalent among fee-for-service (ffs) enrollees compared to patients with other health insurance plans like managed care [ , ] . this is in part due to the fact that payment mechanisms, such as ffs and capitation, would not incentivize providers to allocate more resources (e.g., time) to properly evaluating pain conditions [ ] . hence, they could prompt providers to prioritize opioid medications over non-opioid or non-pharmacologic treatments [ ] [ ] [ ] [ ] . on the other hand, incentivizing providers may not necessarily yield the most desirable outcomes. for example, incentivizing based on patient's satisfaction/experience of care might have propelled providers to opioid prescription [ , [ ] [ ] [ ] . for other instances where considering monetary incentives for providers has resulted in mixed outcomes, see [ , ] . the literature has raised three issues with existing guidelines for opioid prescription, particularly the cdc guidelines [ ] : • providers do not have a clear idea about how to easily implement these guidelines in their practices or there exist uncertainties surrounding the impact of the recommendations on patient pain levels, particularly in the presence of comorbidities [ ] . across different specialties/medical conditions, (i) there is no consensus among providers in selecting optimal treatments, and (ii) there are various perspectives on how opioids are deemed appropriate, resulting in many of the providers not aligning with the guidelines and/or significant variations among them in opioid prescription [ ] [ ] [ ] . on a similar note, emergency departments (eds) are shown to be more aligned with the cdc guidelines than non-eds [ ] . • even for the same medical condition, there is substantial variation in opioid prescription among providers. this can be a direct consequence of the issue raised under the first item in this list [ , ] . furthermore, regarding the system structure, we note the dual drug benefit use among veterans affairs (va) and medicare part d enrollees, where about % of va enrollees who use opioids are reported to also obtain opioid prescription from dual sources [ , ] . non-opioid pharmacological (e.g., acetaminophen and nonsteroidal anti-inflammatory drugs) and non-pharmacological treatments (e.g., physical therapy, chiropractic, acupuncture, relaxation techniques, etc.) are not only shown to be associated with lower rates of opioid prescription and misuse [ - ], but reported to be as effective as opioids in managing pain conditions, especially chronic conditions [ - ]. as another medium, cannabis use or legalizing it in many u.s. states has been shown to be associated with lower rates of opioid prescriptions [ - ]. however, there is also evidence that using cannabis may not completely replace opioids in addressing pain complications [ ] . that said, despite patients' willingness to be engaged with alternative non-opioid treatments and healthcare organizations (e.g., va) that have already started adopting such treatments [ , ] , there are barriers in their uptake such as high cost, poor reimbursements to providers under payment mechanisms such as ffs, lack of coverage for some treatments such as acupuncture and psychological interventions, skepticism of patients towards these treatments once they have started taking opioids, and nonadherence to these treatments in the long term among patients with chronic pain [ , [ ] [ ] [ ] [ ] . numerous efforts have been reported to reduce the prescribing of opioids and/or incidence of oud/sud. these include the implementation of prescription drug monitoring programs [ , ] , statewide medicaid program initiatives such as coordinated care organizations [ ] [ ] [ ] , educational outreach and academic detailing for providers [ ] [ ] [ ] , advances in medicine/surgery that lower post-surgical dependence on narcotics [ , ] , the fentanyl patch-for-patch program [ ] , pharmacy consult intervention [ ] , quality measure development and/or quality improvement [ ] , using data analytics to predict the risk of overdose [ ] , and schedule change of opioid analgesics [ ] . other initiatives have been reported to be less successful in this regard; for example, the adoption of controlled substance laws, which are reported to not be associated with lowering the prescription of opioids or overdose incidence among disabled medicare beneficiaries [ ] . in pain management, the misalignment between physicians and patients on treatment goals is reported to adversely impact pain management outcomes, mainly because patients' first objective is typically to reduce pain intensity, while providers' first priorities are to enhance functioning and diminish medication side effects [ ] . it has also been reported that pain management quality may be associated with the quality of the physician-patient interaction, and this is impacted by factors like provider experience and knowledge, proper prioritization of discussing pain severity among provider's activities, and providers' past unpleasant encounters with patients [ ] . when patients are at risk for or diagnosed with oud/sud, interventions center on harm reduction programs, including medication assisted treatment (mat) and opioid substitution programs-both benefiting from medications such as methadone, naltrexone, buprenorphine, and naloxone, syringe access/exchange programs, and other initiatives such as screening, brief intervention, and referral to treatment [ ] [ ] [ ] [ ] . despite their efficacy, the majority of people suffering from oud/sud lack access to treatments [ ] . therefore, the literature has mainly focused on barriers and facilitators to adopting these medications. we present these studies in sections . . and . . . induced by the healthcare system: the barriers include lack of full or proper insurance coverage (e.g., in the california medicaid program, naloxone is covered as an ffs medication, and managed care plans like capitation do not cover the drug), high costs of medications, limited number of providers/counselors resulting in a dearth of programs or long waiting lists, a low percentage of licensed physicians having a secured waiver that is required to provide mat or the majority of counties lacking a treatment-waivered physician, insufficient education among pharmacists (this can be resolved by educational materials through improved fda-approved formulations), the short-term period of opioid substitution programs, and bureaucratic requirements for program entry/enrollment [ , [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] . induced by providers and patients: the barriers include competing time for providers' limited practice time, preventing them from allocating enough time to properly evaluate patients' risk of oud/sud, lack of interest in treating oud/sud, care fragmentation and distrust in the quality of care between pcps and specialists, stigma surrounding the use of these treatments among patients and providers, provider's stigma in dealing with oud/sud patients, being less receptive to patients' treatment preferences (magnifying the importance of shared decision-making and physician-patient interaction), and nurses having low motivation/role support in working with patients [ , , , [ ] [ ] [ ] [ ] . patients also deem transportation/mobility as a barrier in seeking treatments, especially in rural settings [ ] . in addition, patients' demographic and physiological characteristics (e.g., male gender, minority race, history of opioid overdose, and hepatitis c) are shown to be associated with a higher likelihood of abrupt discontinuation of treatments [ ] . expanding capacity of treatments and providers: adequate monetary incentives and reimbursement for providers, reducing regulatory burdens, providers' education, private insurance coverage, and utilizing state subsidies are reported to impact the successful recruitment of providers [ ] [ ] [ ] . real-world instances of initiatives include the substance abuse and mental health services administration and health resources and services administration (samhsa-hrsa) joint project on expanding the use of medications in safety-net settings [ ] , samhsa's addiction technology transfer center network [ ] , cvs pharmacy providing naloxone without prescriptions in most states [ ] , california implementing a state-wide hub-and-spoke model to improve access to oud treatments [ ] , improving the rate of follow-up treatments among medicaid enrollees in pennsylvania by offering incentives to providers [ ] , and the supportact expanding medicare coverage to include bundled payment for treatments [ ] . by contrast, in the first three year implementation of global payment and accountable care by blue cross blue shield of massachusetts, no significant impact on using treatments was observed [ ] . improving treatment adherence and program retention: to improve retention in treatment programs or increase the number of days of opioid/drug abstinence, initiatives have included contingency management and financial incentives for patients [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] (see [ ] for a review). challenges associated with these initiatives include the use of monetary incentives to buy drugs [ , ] and diversion or misuse of methadone and buprenorphine [ , ] . goods-based incentives may lower such risks; however, they impose higher operational costs [ ] . in addition, counselors may exhibit resistance towards contingency management and financial incentives, which could necessitate educational outreach and training [ ] . as other initiatives have been demonstrated to yield positive outcomes, one can refer to syringe access/exchange programs [ , , ] and the use of technology such as therapy observation via a mobile application [ ] [ ] [ ] . role of employers: employment rates among drug-dependent people are far lower than average rates for the u.s. population [ ] . to this end, employers are deemed effective sources for establishing reinforcement strategies for drug abstinence and treatment adherence [ ] . tools, such as employment-based behavioral reinforcement and vocational problem-solving training, are reported to positively impact employment rates, opioid abstinence, and treatment adherence among opioid-dependent workers [ ] [ ] [ ] [ ] [ ] . there is also evidence that employers who have educated workers and monitored opioid use among them, expanded capacity on oud/sud treatments, and limited opioid availability via modified health plans have observed little to no negative impact on their productivity levels [ ] . furthermore, the roles of employers along with the government and work associations in addressing oud/sud and providing treatments for workers were discussed in [ ] . this review highlights the misalignment of incentives across stakeholders as an important, but, to date, often overlooked contributor to the ongoing opioid epidemic. in this review, we identified various conditions, surrounding the roles of stakeholders, that have contributed to misaligned incentives by compromising the cost, quality, or access to care in the opioid crisis. prior to experiencing oud/sud (the prevention stage), misalignment typically occurs between: • payers, providers, and patients due to conventional payment mechanisms such as ffs and capitation, lack of proper insurance coverage for multi-modal pain management, and system structures such as dual drug benefit programs for va and medicare part d enrollees resulting in care fragmentation; • policy makers and providers due to guidelines that are not easily translatable for implementation in practice; • providers and patients due to lack of shared decision making on treatments, which is also common in the intervention stage. all of the studies characterized as prior to the development of the patient's oud/sud (prevention) and related to multi-modal pain management and initiatives for opioid prescription concerned all three potential misalignment sources, i.e., cost, quality, and access. none of the five prevention categories encompassed all of the stakeholder categories identified by our search, although the majority concerned payers, providers, and patients. after experiencing oud/sud (the intervention stage), misalignment typically exists between: • payers, providers, and patients due to lack of proper insurance coverage for oud/sud treatments, the limited number of providers for prescribing treatments, and lack of effective incentives and reimbursements for providers; • pharmaceutical companies, payers, and patients due to the high cost of medications; • providers (pcps and specialists) due to care fragmentation and lack of proper guidelines to streamline pathways for patients. in contrast to the studies categorized as the prevention phase, those related to barriers and facilitators of adopting treatments after development of the patient's oud/sud (intervention phase) all involved misalignment related to cost, quality, and access. although we have not carried out a formal systematic literature review, we would like to point out that, overall, many of the studies, including those driving changes in practice guidelines and reimbursement or confirming/purporting disincentive mechanisms, are of a moderate quality. furthermore, the majority of studies analyzed in this review have been published within - (the second half of our search timeline). therefore, the results presented here are less impacted by some of the developments in the early s (e.g., unregulated marketing strategies of pharmaceutical companies) [ ] . nevertheless, our findings support the hypothesis that misaligned incentives play a significant role in the opioid epidemic. that said, they would not solely explain the totality of the current opioid crisis, in that efforts to aligning incentives among stakeholders may not always alleviate this crisis or, while improving one aspect, could worsen another dimension in this epidemic. for example, ineffective performance-based payment mechanisms do not necessarily promote quality of care in pain management, such as those utilizing patients' satisfaction scores or experience of care. perhaps, this is one of the reasons that mechanisms like bundled payments are becoming more common in pain management among both cms and private insurance companies [ ] . as another example, we note that many initiatives aimed at curbing the supply of opioids have not addressed how patients in dire pain conditions have been impacted [ ] . therefore, we stipulate that any effort that fails to account for both ends of the spectrum (e.g., valuing the risk of oud/sud while downplaying the risk of un-/under-treated pain) will likely fail in alleviating the opioid crisis thoroughly. in addition to the foregoing issues, there are other factors that have received little to no attention in the literature, and accounting for them in incentive mechanisms can yield more impactful outcomes: ( ) the co-occurrence of oud/sud and chronic pain can impose pressure on providers due to multi-layered and complex treatment requirements, lack of patient improvement for either condition, and care fragmentation caused by ineffective pain management referrals [ ] . ( ) guidelines that promote curbing the supply of opioids may have unintended consequences such as the increase in the number of deaths caused by fentanyl misuse. in the presence of conflicting interests, one can investigate how facilitating aligning incentives can contribute to remedying such effects. ( ) stigma and discrimination against people with concurrent oud/sud and mental health disorders can stymie an effective care delivery process [ ] . ( ) although incurred medical expenditures for oud/sud would be higher than that for under-treated pain [ ] , employers' cost of lost productivity would not be much different, because their employees could miss work due to both oud/sud and unrelieved pain [ , ] . hence, the role of employers should not be limited to expanding access to oud/sud treatments. indeed, employers' contribution to employment-based insurance coverage would impact the availability of treatment options and the cost of prescription drugs [ ] , which, in turn, affects pain management outcomes. ( ) strategies like contingency management, aimed at improving oud/sud treatment adherence and retention in opioid substitution programs, have been reported to be effective only in the short term (due to financial/resource limitations), and their efficacy over the long term is yet to be investigated [ ] . ( ) the timing of initiating oud/sud treatments is a deciding factor in their success. however, patients at higher risk may not be always easy to identify. to address this, one can benefit from points of access to patients to potentially initiating treatments. these include ed visit/hospital admission [ ] [ ] [ ] [ ] [ ] and incarceration [ ] [ ] [ ] [ ] [ ] [ ] [ ] . employing techniques like screening, brief intervention, and referral to treatment (sbirt) can also be helpful in this regard [ ] . ( ) behaviors like opioid injections can increase the risks of hiv and hepatitis c virus (hcv) infection. the co-occurrence of these conditions could make patients more vulnerable against the risks of oud/sud, and hence, extra care should be taken when dealing with such instances [ ] [ ] [ ] [ ] [ ] . ( ) as a result of opioid consumption ramping up during the covid- pandemic [ , ] , the long-term rates of oud/sud can be impacted as well, which can inevitably aggravate misaligned incentives. in addition to the avenues discussed thus far, this is another stream that warrants further investigation and knowledge production. our review has some limitations. first, even though we cover a wide range of topics associated with misaligned incentives, our method for including articles may prevent us from generalizing our findings across the whole opioid epidemic. second, we did not conduct a systematic literature review, and hence, caution should be exercised with respect to the quality of reviewed articles or recommendations made with respect to mechanisms that trigger misaligned incentives among stakeholders. third, in many of the studies reviewed, we construed the notion of misaligned incentives by exploring evidence on the main driving factor behind this misalignment: triple aims (cost, quality, or access) being compromised in the epidemic. this may be related to lack of empirical evidence where such misalignments are brought further to the center of attention. this could warrant investigations by conducting survey analyses among all parties involved (e.g., payers, providers, patients, etc.). fourth, although our objective in this paper was to review the literature for evidence of misalignment, we did not quantify this notion (e.g.: how much misalignment is acceptable?). this is another avenue that is worth investigation for future research. our review sheds light on a body of literature suggesting several factors that can stir misaligned incentives between various stakeholders in the opioid epidemic. we further summarize these factors by whether or not a patient has been diagnosed with oud/sud yet. along with potential challenges, we also address opportunities and strategies that have been shown to be successful in contributing to mitigating the epidemic. of note, 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national trends in hepatitis c infection by opioid use disorder status among pregnant women at delivery hospitalization-united states key: cord- - r s authors: farhoudian, ali; baldacchino, alexander; clark, nicolas; gerra, gilberto; ekhtiari, hamed; dom, geert; mokri, azarakhsh; sadeghi, mandana; nematollahi, pardis; demasi, maryanne; schütz, christian g.; hash-emian, seyed mohammadreza; tabarsi, payam; galea-singer, susanna; carrà, giuseppe; clausen, thomas; kouimtsidis, christos; tolomeo, serenella; radfar, seyed ramin; razaghi, emran mohammad title: covid- and substance use disorders: recommendations to a comprehensive healthcare response. an international society of addiction medicine practice and policy interest group position paper date: - - journal: basic clin neurosci doi: . /bcn. .covid . sha: doc_id: cord_uid: r s coronavirus disease (covid- ) is escalating all over the world and has higher morbidities and mortalities in certain vulnerable populations. people who use drugs (pwud) are a marginalized and stigmatized group with weaker immunity responses, vulnerability to stress, poor health conditions, high-risk behaviors, and lower access to health care services. these conditions put them at a higher risk of covid- infection and its complications. in this paper, an international group of experts on addiction medicine, infectious diseases, and disaster psychiatry explore the possible raised concerns in this issue and provide recommendations to manage the comorbidity of covid- and substance use disorder (sud). oronavirus disease (covid- ) is a new member of the coronavirus family that infect humans . it first emerged in the wuhan region of china in november (lai shih, ko, tang, & hsueh, ) . by march , the world health organization (who) assessed the global situation of covid- as a pandemic. patients with cardiovascular diseases, chronic respiratory diseases, people aged or older, and males have a higher risk of mortality than the rest of the population huang et al., ; wang et al., ) . frequently reported clinical symptoms at the onset of the disease include pyrexia ( %- %), cough ( %- %), myalgia or fatigue ( %- %), and shortness of breath ( %) huang et al., ; wang et al., ) . sore throat and, less commonly, sputum production, headache, hemoptysis, and diarrhea have also been reported (chan et al., ) . in more severe cases, covid- can cause pneumonia, severe and acute respiratory syndrome, and sometimes ( %- % of all infected cases) death (world health organization, b) . currently, the medications used for severe cases of covid- include chloroquine phosphate (gao, tian, & yang, ) , hydroxychloroquine sulfate (javadi et al., ) , lopinavir/ritonavir (li & de clercq, ; lim et al., ) , oseltamivir (li & de clercq, ; vetter, eckerle, & kaiser, ) , and ribavirin (li & de clercq, ) . but none have been approved by regulatory authorities for use against covid- . the most common strategies, as advised by who, include preventative measures such as quarantine and limitations of movement in infected areas (hellewell et al., ; wu, leung, & leung, ) , interruption of human-to-human transmission, early identification and isolation, providing appropriate care for patients, identifying and reducing transmission from the animal source, and minimizing the social and economic impact through the new coronavirus created a complex situation for all sections of the communities around the world. health care providers are in the frontline of intervening to stop the spread of covid- . meantime people who use drugs (pwud) are at increased risk during this pandemic since they are a stigmatized and marginalized populations. health service providers who are providing different needs for pwud in treatment and/or harm reduction settings should always keep themselves safe with using standard ppe based on the who recommendations. additionally pwuds live in crowded locations and so screening and early identification of covid- patients are important to break the cycle of transmission. it is recommended that protocols for opioid substitution therapy modify with complete adherence to patients' safety regarding both opioid drug risks and covid- infections. it is important to have in mind that different stages of ost needs different approaches. pwuds are more vulnerable to stress and other mental health problems. this makes psychological interventions such as cognitive-behavioral therapy and other modalities very important to have for pwuds during these difficult and challenging times to assist and sustain treatment. medical conditions such as respiratory illness, renal insufficiency, chronic pain and cardiovascular disorders are also important medical conditions that should be addressed appropriately among pwuds with covid- . health service providers in both fields of addiction treatment and covid- treatment and prevention systems should be aware regarding special situations arising in the overlap of drug use and covid- illness. march, april , vol , num [covid- ] farhoudian, a., et al. ( ) . covid- and substance use disorders. bcn, ( ), - . multispectral partnerships (world health organization, a). bai and colleagues mentioned some covid- transmission from asymptomatic patients as a challenge for preventive activities (bai et al., ) . in most countries, people who use drugs (pwud) are stigmatized and marginalized population with lower access to healthcare. they suffer from poorer health, weaker immune function, chronic infections, various issues with respiratory, cardiovascular, and metabolic systems, as well as a range of psychiatric comorbidities (ahern, stuber, & galea, ; stuber, galea, ahern, blaney, & fuller, ) . pwud are a marginalized group who experience high rates of morbidities, three to five times higher compared to the general population (o'connell, ) . cheung et al. estimated that the risk of death among young pwud homeless women in toronto is to times higher than their housed counterparts (bohnert & ilgen, ; fernandez-quintana et al., ) . substance use imposes different health problems, which may complicate superimposed infection with co-vid- . for instance, chronic high alcohol consumption significantly increases the risk of acute respiratory distress syndrome (mccarthy et al., ) . during the h n epidemic, a history of opium inhalation had been identified as a risk factor for admission to an intensive care unit (icu) with confirmed h n (tabarsi et al., ) . additionally, it is essential to understand how pwud differently perceive danger and risk-taking behaviors during an epidemic, making them more risk averse (manfredi & d'onofrio, ; rhodes, ) . pwud have a higher rate of smoking and different studies estimated the current smoking rate of more than % among them (duan et al., ; sutherland et al., ; weinberger, gbedemah, & goodwin, ) . several studies found smoking a significant risk factor for middle east respiratory syndrome (mers) transdmission (alraddadi et al., ; nam, park, ki, yeon, kim, & kim, ; sherbini iskandrani, kharaba, khalid, abduljawad, & hamdan, ) . a literature review did not reveal even one article focusing on substance use disorder (sud) and covid- . therefore, a group of international experts on addiction medicine, infectious diseases, and disaster management teamed up to explore the comorbidity of covid- infection with substance use disorder and identify the necessary recommendations for health service providers and policymakers in this situation. although the majority of covid- infections are mild, the number of severe cases in a pandemic has the potential to overwhelm any healthcare system. consequently, health authorities may be required to repurpose health services and facilities away from pwud. when such an incident occurs, a business continuity protocol will cover several contingency measures so that organizations supporting pwud will continue to provide their essential services. a response to both covid- and drug use involves government, different sectors of the community and health authorities (who director-general's opening remarks at the media briefing on covid- on march , ) to implement evidence-based prevention programs as well as engaging different stakeholders for policy coordination (volkow, poznyak, saxena, gerra, & unodc-who informal international scientific network, ) . generally, drug use prohibition and criminalization approaches result in higher stigmatization and discrimination against pwud (boyd & macpherson, vancouver area network of drug users, ; santos da silveira, andrade de tostes, wan, ronzani, & corrigan, ) . this approach puts pwud at a higher risk of viral transmission. governments, health authorities, and other relevant stakeholders should identify the provision of services for pwud as essential services to support a comprehensive and proactive response to the challenges that covid places on this population, especially when they are under treatment (ekhtiari et al., ). pwud have poor access to health services due to stigma and discrimination (ahern, stuber, & galea, ; salamat, hegarty, & patton, ) . they are among the pervasive hard-to-reach populations. for example, studies show that drug use is one of the significant barriers to taking the influenza vaccine (bryant et al., ; kong, chu, & giles, ) . many homeless pwud communities live in crowded groups in shelters and or shooting galleries with no or minimal air conditioning facilities. additionally, poor hygiene, risky behaviors such as sharing drug-using paraphernalia and intoxication put pwud at higher risk of covid- infection. one of the other risk factors for pwud and people who inject drugs (pwid) is their weaker immune system due to a range of factors. these factors include long-term/high-dose administration of opioid drugs (liang, liu, chen, ji, & li, ; sacerdote, franchi, gerra, leccese, panerai, & somaini, ) , malnutrition (haber, demirkol, lange, & murnion, ; vila et al., ) , homelessness (haber et al., ) , and longterm alcohol and methamphetamine use (nelson, zhang, bagby, happel, & raasch, ; roy et al., ) . despite lacking evidence for introducing hiv as a risk factor for covid- (british hiv association, ), there are some concerns regarding the access to treatment services for people living with hiv/aids (plwha) and their adherence to antiretroviral therapy (dadkha, mohammadi, & mozafari, ) . this situation could finally increase the rate of mortality among plwha. on the other hand, respiratory infections among pwud are common and, in many cases, do not present with recognized symptoms of these diseases (dimassi & rushton, ; bradley drummond et al., ; gordon & lowy, ) . tuberculosis is another respiratory infection that is more common among pwud (perlman, salomon, perkins, yancovitz, paone, & jarlais, ) even in high-income countries heuvelings et al., ) . care providers are at the front line of any outbreak response. they are not only at the risk of infection but are also prone to burnout and psychological distress. in a study conducted on frontline staff involved in the severe acute respiratory syndrome (sars) epidemic, it was found that they had high levels of burnout, psychological distress, and posttraumatic stress (maunder et al., ) . this situation is compounded with evidence that counselors and therapists for pwud are well-known as having a higher rate of burnout (vilardaga et al., ) during usual practice. staff working in harm reduction settings, where most of the health service providers are peer groups, should be adequately supported. this support should prevent cross-viral exposure, psychological distress (hashemian et al., ; lancee, maunder, & goldbloom, ) , psychiatric disorders (tang, pan, yuan, & zha, ; , discrimination (gilchrist et al., ) , and physical and psychological violence (world health organization, b). concerns regarding infection and the above mentioned stressful events may affect their effectiveness in an outbreak (abolfotouh, alqarni, al-ghamdi, salam, al-assiri, & balkh, ) . all staff should have access to personal protection equipment (ppe). they should perform hand hygiene frequently, use alcohol-based hand rub/gels if their hands are not visibly soiled or with soap and water when they are visibly soiled. they must keep at least one meter distance from affected individuals, wear a medical mask when in the same room with an affected individual, and dispose of the material immediately after use. they should clean their hands immediately after contact with respiratory secretions, cover the nose and mouth with a flexed elbow or disposable tissue when coughing and sneezing, and refrain from touching eyes, nose, or mouth with potentially contaminated hands (world health organization, b). also, they must avoid close contact with anyone that has fever or cough (world health organization, b) and finally improve airflow in living space by opening windows as much as possible (world health organization, b). self-isolation of individual staff is paramount if there are signs of an infection (heymann & shindo, ; world health organization, a) . pwud staff still need to retain their crucial role at a distance either through digital technology or phone and continue their pwud management and treatment plan, such as the provision of daily ost medication (tschakovsky, ). there is no convincing evidence that the paraphernalia and devices for drug use are the primary sources of virus transmissions in the latest epidemics of coronaviruses (alagaili, briese, amor, mohammed, & lipkin, ) . however, as the main source of viral transmission has been defined to occur through the droplets, it makes sense to advise pwud populations to avoid sharing cigarettes, pipes , water pipes and hookahs, and so on (knishkowy & amitai, ; munckhof, konstantinos, wamsley, mortlock, & gilpi, ) . one should continue providing clean needle and syringes and 'take-home' naloxone (thn) when appropriate. infected patients are most virulent during the prodromal period. in the case of being mobile and carrying on usual activities, they play an essential part in spreading the infection to the other parts of the community (heymann & shindo, ). in such conditions, it is imperative to have an effective mechanism for the active and rapid detection of signs and symptoms and patient's isolation (hellewell et al., ; shamaei et al., ) . during the h n pandemic in , one of the risk factors for death or admission at intensive care units was a delay in diagnosis (tabarsi et al., ) . early detection in pwud can be difficult as covid- symptoms could be confused with a withdrawal syndrome (dimassi & rushton, ; bradley drummond et al., ; gordon & lowy, ) . it is highly recommended that a mechanism be implemented for the frequent screen-ing of covid- in pwud within harm reduction and treatment settings (salamat, hegarty, & patton, ; van olphen, eliason, freudenberg, & barnes, ). any pandemic affects illicit drug distribution networks (rahimi movaghar, farhoudian, rad goodarzi, sharifi, yunesian, & mohammadi, ) . sometimes this situation persuades pwud to seek treatment services for help, but usually, they switch to a more hazardous consumption. the iranian covid pandemic generated the highest incidence of mortality secondary to methanol toxicity (at least dead from drinking toxic alcohol in iran after coronavirus cure rumor, ; tainted alcohol claims more lives than coronavirus in khuzestan province, iran, ). however, opioid substitution therapy (ost) provision of controlled medication has become the main focus of the continuity plans around pwud to make sure that such provision is not interrupted during the covid- lockdown strategies (being imposed by several governments). any close personal contact may be harmful and risky for covid- transmission. methadone syrup and buprenorphine tablets or film are often provided to pwud after bringing out their blister packs. despite no evidence, this action might increase the chance of viral transmission by exposing both staff and pwud. it is recommended that dispensing clinics be trained to handle the process of tablet delivery with minimum hand contact. take-home doses of medications can be provided for more extended periods in situations of quarantine, selfisolation, or lockdown and health service disruptions. the maximum time for take-home doses of drugs is recommended when the dose and social situation are stable. treatment seeking individuals should be adequately informed about the changes in the practice, and they should receive appropriate support in case of uncertainty and concerns. however, decisions should be taken on a case by case basis. in summary, individuals under buprenorphine maintenance treatment (bmt) can receive accelerated take-home doses after two weeks of initiation. in particular, the people can receive this protocol who are at least on mg methadone or mg daily buprenorphine and have no signs of withdrawal symptoms, do not experience craving (mokri, ekhtiari, edalati, & ganjgahi, ) , are abstinent based on self-reporting, and provide negative toxicological tests. this condition should be reviewed every days if the individuals provided with take-home doses are not showing the stability mentioned above. buprenorphine take-home doses are probably safer than methadone take-home doses. if the person is in isolation and unable to pick up their medication personally, it can be delivered to their homes, or they can authorize someone else to collect the medication. opioid substitution therapy (ost) is among a category of treatment modalities that is normally considered to need regular and frequent supervision of patients, especially early in treatment. it is recommended that a more flexible ost program needs to be taken into account during the covid pandemic . given the safety profile of buprenorphine, it would seem to be the preferred substitution treatment for individuals who want to initiate treatments. it is faster and safer (maremmani & gerra, ) to reach an effective maintenance dose of buprenorphine compared to methadone, in fact it can be done on the first day of treatment. some of the medications under consideration for the treatment of covid- can significantly inhibit and/or stimulate methadone metabolism, puting patients at the risk of withdrawal or toxicity (lüthi, huttner, speck, & muelle, ; winton & twilla, ) . methadone specifically in high doses may prolong qt interval and cause fatal arrhythmias (krantz, lewkowiez, hays, woodroffe, robertson, & mehle, ) . possible cardiomyopathy in infected patients may increase the chance of torsade's de pointes arrhythmia (lüthi et al., ) and, particularly if combined with chloroquine which also prolongs the qt interval. withdrawal symptoms from buprenorphine are milder than that of methadone in case of interruption to the supply of medication, at least in the short term. where available, the long acting (monthly) subcutaneous injections are an alternative to providing take home doses. even transdermal buprenorphine should be considered where no other alternatives exist. multiple patches can be given simultaneously if necessary to achieve a therapeutic dose for opioid dependence treatment. additionally, benzodiazepine prescription for myalgia or stressful circumstances due to covid- may also increase the risk of toxicity during methadone mainte-nance treatment (mmt). during the pandemic period, it is more likely that individuals with drug use disorders or those who are in treatment seek out benzodiazepines or other tranquillizers (dorn, yzermans, & van der zee, ; fassaert et al., ) . benzodiazepines misuse may mask signs and symptoms of covid- infection and could escalate respiratory distress. patients are at a higher risk of methadone overdose in the initial stabilization period of methadone prescription (cornish, macleod, strang, vickerman, & hickman, ; degenhardt, randall, hall, law, butler, & burns, ) . for mmt patients, the authors do not recommend relaxing the methadone dose protocol at this phase of treatment however they do suggest avoiding unnecessary visits and rigor, on a case by case basis. if accelerated induction is necessary, an additional dose of - mg can be followed by a further dose if someone has been observed hours after their initial methadone dose. if they are still experiencing withdrawal at this time, they can safely be given a further dose. for buprenorphine, individuals can be rapidly inducted to optimal maintenance doses ( - mg daily). clinicians should consider increasing the dose if the individuals are still experiencing daily cravings, ongoing opioid use, or opioid withdrawal. however, clinicians should be sensitized in the differentiation between withdrawal syndromes, including myalgia, insomnia, sweating, fatigue, and nausea with signs and symptoms of viral covid- infection. pupil size is the best guide to distinguish opioid withdrawal from the symptoms of covid- as this infection does not affect pupil size. it should be possible to see pupil size even with video consultations. although the prescription period of anti-viral treatment is usually less than two weeks and the induction of hepatic metabolic enzymes takes more than the regular time for antiretroviral therapy (art) prescription, the clinicians should be careful about the changes of methadone level in these patients during and more specifically after termination or discharge of the treatment for co-vid- . change from split doses to multiple daily doses is a strategy in patients who receive antiviral therapy. as a result of the induction of methadone metabolism, some patients may need a mild increase in their previous methadone dosage after a few days of initiating antiviral treatment. for buprenorphine, double doses can be given every other day for people who are not considered safe to receive take-home doses. in exceptional situations, some patients on mmt or bmt fulfill the criteria for completion of their ost. termination is a stressful process (berger & smith, ) and needs close supervision and constant consultation. besides, the emotional distress associated with opioid withdrawal may increase the risk of suicidal ideation. termination of mmt and bmt increases the stress, so more attendance at treatment centers are needed, and it is not recommended during the covid- epidemic. some people who use opioids may wish to cease their opioid use during the outbreak, either due to reduced availability of opioids or the difficulty accessing treatment services. the most straightforward approach to detoxification, if available, would be single high dose buprenorphine. doses ranging from to mg have been used for this purpose (ahmadi, jahromi, ghahremani, & london, ) . alternative approaches include clonidine or a combination of symptomatic medications (world health organization, ). individuals with moderate to severe signs of cov-id- infection need medications consisting of a cocktail of art, antimicrobials, and analgesics. these medications may interfere with urine or saliva test results. for instance, quinolones (e.g. moxifloxacin, lomefloxacin, norfloxacin, ofloxacin, ciprofloxacin), rifampin, tolmetin (a non-steroidal anti-inflammatory drug) may yield a false-positive result in opiates urine drug screening (reisfield, goldberger, & bertholf, ). chloroquine demic, the clinicians should assess the benefits of the urinary or saliva testing at this critical circumstance, especially as this will potentially increase unnecessary risks due to close contacts. in this pandemic, it seems that information is spreading more extensively and rapidly in comparison to the sars outbreak in . however, this condition may result in a worsening of public fear, panic, and distress. social isolation may also make individuals susceptible to more psychological distress. consequent economic depression after a pandemic also causes uncertainty and threats to future welfare (strong, ) . the unpredictable future is exacerbated by myths and misinformation that are often driven by fake news and public misunderstanding (bao, sun, meng, shi, & lu, ) . some patients will experience grief over the loss of loved ones. the relationship between adverse life events and brain stress systems have a prominent role in addiction disease (koob, (koob, , (koob, , . pwud are much more vulnerable to stress and crisis followed by lapse and relapse to ex-drug users (goeders, ; koob et al., ; milidvojevic & sinha, ; somaini et al., ) . as a result of stressful events and disasters, mental health problems emerge or exacerbate (farhoudian, hajebi, bahramnejad, & katz, ; farhoudian, rahimi movaghar, rad goodarzi, younesian, & mohammad, ) . in such circumstances, healthy individuals may start drug use (farhoudian et al., ; somaini et al., ) , and several patients may relapse into their previous drug use and start their high-risk behaviors (brandon, vidrine, & litvin, ; farhoudian et al., ; rahimi movaghar, et al., ) . anxiety, worry, depression, irritability, and anger in pwud should be considered as a prodromal sign of lapse or relapse into a new episode of drug use. psychosocial interventions are a vital element in the treatment of pwud, especially in people using stimulants and having mental problems (de crescenzo et al., ) . in this period, internet-based psychotherapy is highly recommended as a replacement. internet consultation, including phone calls, video chat, and short messages, have great potential to make psychological assessment and treatment more cost-effective. computer-assisted therapy appears to be as effective as a face-toface treatment for treating anxiety disorders and depression (taylor & luce, ) . although it requires some equipment and knowledge, it offers a good alternative for more isolated locations, which is relevant in this pandemic. negative emotional states, including fear, anxiety, and boredom, as well as social withdrawal and or isolation, are the main emotions that patients will experience during the covid- pandemic. cbt has been recognized as one of the most beneficial interventions for pwud (lee & rawson, ) . stress reduction as a technique of cbt, either alone or in combination with pharmacotherapies, may prove beneficial in increasing quality of life and reducing cravings and promoting abstinence in clients seeking treatment for sud (goeders, ) . clinicians should help their patients to identify, manage, and reduce their negative emotional states associated with relapse and apply techniques of behavioral activation compatible with specific circumstances of each patient. coping skills training and crisis intervention are the most common types of cbt interventions to be recommended. matrix model is a multi-element package of therapeutic strategies to produce an integrated outpatient treatment experience (rawson & mccann, ; rawson et al., ) . treatment is delivered in an intensive outpatient program primarily in structured group sessions targeting the necessary skills. it is recommended that the meetings could be held individually instead of group format, hoping to lessen the risk of covid- infection. the recommended parts based on the manual (services among iranian people living with hiv and aids: a qualitative study, ) for the period of covid pandemic include: . rp : taking care of yourself; . rp : emotional triggers; . rp : recognizing stress; . rp : reducing stress; . rp : acceptance; . rp : coping with feelings and depression; . rp elective c: recreational activities. incentive-based treatment approaches (i.e. contingency management [cm] ) are effective interventions in reducing addictive behaviors in pwud (ainscough, mcneill, strang, calder, & brose, ; benishek et al., ; lee & rawson, ; messina, farabee, & rawson, ; rawson et al., ) . evidence also supports the cm beneficial effect on the treatment of these individuals targeting infectious disease control (herrmann , matusiewicz, stitzer, higgins, sigmon, & heil, ) . to take advantage of cm in the prevention of cov-id- , the desired behaviors (e.g. washing hands every hour, cleaning hands, etc.) and their scores or prizes (e.g. take-home doses) should be clearly defined and inserted into the list, just like other desired behaviors (e.g. negative urine test). perceived social support from relatives and friends is a major predictor for retention in treatment for pwud shirinbayan, rafiey, vejdani roshan, narenjiha, & farhoudian, ) and the main factor of psychological resilience to disaster (radfar, nematollahi, & arasteh, ; rodriguez-llanes, vos, & guha-sapir, ) . considering the importance of family support, clinicians are advised to engage family and care providers more than ever during the pandemic. attracting other sources of social support such as guaranteed wages and an increase in social security payments will help the individual to pass this period with a better outcome. opioids such as methadone are respiratory depressants, and tolerance develops very slowly and incompletely. when patients under mmt acquire covid- , they should be more closely monitored for both worsening respiratory functions and methadone toxicity. abrupt cessation of methadone must be avoided because anxiety and agitation due to withdrawal syndrome may induce or worsen cardiorespiratory complications (friedman, kamel, perez, & hamada, ; kienbaum, thurauf, michel, scherbaum, gastpar, & peters,, ) . the prevalence of kidney impairment in hospitalized covid- patients is high, and renal insufficiency increases the risk for in-hospital deaths (cheng et al., ) . studies indicate that heroin users, especially pwid, suffer from nephropathy (cunningham, brentjens, zielezny, andres, & venuto, ; do sameiro faria, sampaio, faria, & carvalho, ; may, helderman, eigenbrodt, & silva, ) . other studies confirm that individuals using amphetamine (ginsberg, ertzman, & schmidt-nowara, ; rifkin, ) , cocaine (merigian & roberts, ; norris et al., ; sharff, ) , alcohol (de marchi, cecchin, basile, bertotti, nardini, & bartoli, ; perneger, whelton, puddey, & klag, ) , and potent cannabis (abodunde, nakda, nweke, & veera, ; gudsoorkar & perez jr, ) are more likely to suffer from renal failure. it might be logically concluded that people with a history of drug consumption are more prone to contract renal insufficiency when they are infected to covid- ; however, there is not any revealing evidence so far. evidence suggests that renal insufficiency does not affect the metabolism of methadone in mmt patients (murtagh, chai, donohoe, edmonds, & higginson, ) . despite this issue, patients in acute renal failure due to covid- should be monitored for signs of methadone toxicity because of other reasons for renal insufficiency. heart diseases increase the risk factors of death due to covid- to % in affected individuals with hypertension, . % in diabetics, and . % in patients with other cardiovascular diseases (murtagh et al., ) . individuals with a history of alcohol or drug use are more likely to have cardiac pathology. excessive alcohol consumption (fabrizio & regan, ; mirijello et al., ) , amphetamine (giv, ; o'neill et al., ) , heroin (routsi et al., ) , and cocaine (barton duell, ) are all associated with the increased risk of cardiac pathology. contracting covid- sometimes can result in moderate to severe pain including myalgia, sore throat, and headache that requires pain management. it is recommended that acute pain in pwid with covid- is managed in consultation with pain or addiction specialists. people who use opioids regularly will require additional opioids for the management of pain (athanasos, smith, white, somogyi, bochner, & ling, ; doverty et al., ) . buprenorphine as a high-affinity partial agonist of mu-receptors has an analgesic effect in divided doses, but stops effecting other opioid analgesics and hinders acute pain management in case of necessity (harrington & zaydfudim, ) . in this case, buprenorphine can be ceased and opioid analgesics used or buprenorphine can be continued and non-opioid medications such as clonidine, pregabalin/gabapentin and ketamine can be used (goel et al., ) . health services will need to rapidly adapt to the cov-id- situation. they will need to establish a mechanism of making decisions quickly and under stress, to identifying the essential services to be continued, to develop new mechanisms of patient flow (including screening, batching and referral), to redistribute staff from non-essential roles, and maintaining the continuity of essential supplies (communications, ) . to reduce the risk of transmission, it is generally recommended that nonessential services close, or make their services available by telephone or on-line. when face-to-face services are required, some modifications may need to be made to the service system, for the identification of cases, the protection of staff, the reduction of transmission, and to ensure the continuity of essential services (interim guidline for healthcare facilities, ). when health services remain open in a pandemic, they should first invite all visitors to wash their hands before they touch anything. then they should screen all new visitors with whatever sars-cov- screening mechanism is appropriate for the local conditions. this may include a combination of temperature (where possible measured with a non-touch thermometer), clinical symptoms (cough, shortness of breath, sore throat), and epidemiological criteria (recent travel, contact with cases, health care worker). where, possible, patients meeting the testing criteria should be tested on-site and then directed to isolate themselves awaiting the results. for testing and any subsequent clinical interaction, staff should wear personal protective equipment (ppe) to protect themselves from transmission. if the client is coughing, it is preferable they should also wear a surgical mask (world health organization, c). transmission is through to be mostly via droplet spread when people who are infected sneeze, cough or talk. staff and patients should wash their hands frequently and be careful what they touch. surfaces should be cleaned after they have potentially contaminated. depending on the availability of ppe and the risk in the local community, it may be appropriate for staff to wear masks and gloves, or even gowns and eye protection. patients with symptoms should wear a mask to prevent transmission through cough and sneezing. patients can be divided into three risk groups, those with confirmed sars-cov- virus, patients who meet criteria for testing awaiting test results, and other patients with differing levels of ppe depending on the availability of ppe. preferably, patients with different risk levels should be treated in different parts of the health service. staff and patients should keep a distance from each other (world health organization, c). in addition to providing ost, services should take the opportunity to encourage cessation of smoking by prescription of nrt, and by the distribution of naloxone and overdose resuscitation. in preparation of staff members being sick or isolated awaiting test results, each staff member involved in ost treatment should have at least one other staff member who can continue their role if they are sick. where possible, staff may separate into different teams who have even less contact, so that if one person is sick then the risk of all needing to isolate themselves is reduced (guide on business continuity planning for covid- , february, ). pwud are a marginalized hard-to-reach population living in crowded groups with lower access to healthcare. they usually suffer from poorer health, weaker immune function, chronic infections, as well as various issues with physical and psychiatric comorbidities. consequently, they have a higher risk of contracting co-vid- and its transmission and casualties. we believe that substance use and covid- have a complicated relationship with each other. in summary, we suggest the following items: health authorities should develop and apply specific strategies for pwud for early covid- identification and patient isolation, interrupting transmission, providing appropriate care, attending medical issues, and minimizing negative social impact. health authorities are responsible for providing adequate healthcare for pwuds. they may be required to repurpose and reorient health services through a business continuity team. this team implements evidence-based programs and makes decisions on how the organizations will continue to provide their services. also, they make sure that all ost patients have adequate access to their opioid drugs. treatment sectors should provide essential requirements, as well as software and programs tailored to their own clients' needs. staff may also teach the patients the hygiene rules, self-monitoring for signs of illness, and rapid reporting of the disease in case of occurrence. a mechanism for frequently screening for signs and symptoms of infection should be established. internet and mobile-based social media communications should be considered as the first-line approaches for education and appropriate interventions. opioid users face increased challenges; some concerns are about their take-home doses and repetitive visits that make it impossible for them to stay at home. this pandemic could be considered as an extraordinary circumstance; the clinicians should facilitate ost protocol for clinically stable patients and cancel all group-based interventions or therapies. healthcare workers in substance use treatment facilities are also facing a higher risk of infection, burnout, distress, psychiatric disorders, discrimination, and violence. the essential right for each service provider, no matter a peer group or professional service provider, is to be safe and secure, in both physical and mental health aspects. misinformation, social isolation, ensuing economic depression, and possible grief reactions may result in exacerbation of public fear, panic, and distress that can be followed by lapse and relapse in ex-drug users. stress reduction, crisis interventions, coping skills training, motivational interviewing, and tailored and modified relapse prevention interventions, modification in contingency-based management for rewarding virus transmission preventive behaviours, attracting family support, managing patients' vocational problems are the main helpful psychosocial interventions. in this period, internet-based psychotherapy and phone counseling are highly recommended. there are many medical considerations regarding pwud that other physicians in charge of the management of co-vid- treatment should keep in their minds. clinicians should be careful in the differentiation between withdrawal signs and symptoms and those of covid- infection. pwud may have different clinical manifestations due to various etiologies. healthcare providers should consider different possible manifestations and, more importantly, avoid any type of medical stigma or discrimination against pwud. pwud regularly self-medicate their physical and mental problems with drugs, which may mask critical covid- symptoms. a number of drug-drug interactions between substance of use, addiction treatment medications, and covid- medications must be considered in terms of toxicity, withdrawal, and exacerbation of fatal side effects. there is also a possible overlap of pathological laboratory results of the cbc and liver enzymes in pwud and people with covid- infection. histories of renal failure, cardiovascular and metabolic diseases are more likely to emerge in pwud that put them at higher risk of morbidity and mortality after contracting covid- pain management in pwud, specifically opioid users and patients under ost, has some complexity, which calls for the involvement of joint expertise. the study has been conducted with no funds from external sources. original idea, wrote initial topics and headlines, and the first draft: ali farhoudian and seyed ramin radfar; participated in the literature review, writing, editing, and revision of the report and reached consensus on the conclusion: all authors. the authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. we are immensely grateful to dr. richard rawson, professor at integrated substance abuse programs, university of california, los angeles, and dr. richard schottenfeld, senior research scientist at yale school of medicine, for their comments during the process of writing the manuscript. the views expressed are those of the author (s) and not necessarily dr. richard rawson and or dr. richard schottenfeld. authors also respectfully dedicate the article to the souls of all healthcare providers who lost their precious lives in the fight against covid- . cannabinoid 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with acute respiratory distress syndrome. the lancet respiratory medicine cocaine use disorder is associated with changes in th /th /th cytokines and lymphocytes subsets a novel coronavirus from patients with pneumonia in china covid- in wuhan: immediate psychological impact on health workers. medrxiv coronavirus disease (covid- ): a perspective from china key: cord- -c d nk x authors: mikasa, keiichi; aoki, nobuki; aoki, yosuke; abe, shuichi; iwata, satoshi; ouchi, kazunobu; kasahara, kei; kadota, junichi; kishida, naoki; kobayashi, osamu; sakata, hiroshi; seki, masahumi; tsukada, hiroki; tokue, yutaka; nakamura-uchiyama, fukumi; higa, futoshi; maeda, koichi; yanagihara, katsunori; yoshida, koichiro title: jaid/jsc guidelines for the treatment of respiratory infectious diseases: the japanese association for infectious diseases/japanese society of chemotherapy – the jaid/jsc guide to clinical management of infectious disease/guideline-preparing committee respiratory infectious disease wg date: - - journal: journal of infection and chemotherapy doi: . /j.jiac. . . sha: doc_id: cord_uid: c d nk x nan the japanese association for infectious diseases (jaid) and japanese society of chemotherapy (jsc) announced the "guide for the use of antimicrobial drugs" in and the "guidelines for the use of antimicrobial drugs" in . subsequently, the "the jaid/ jsc guide to clinical management of infectious diseases " was published. with its revision, guidelines were newly prepared. concerning respiratory infectious diseases, in japan, the japanese respiratory society published guidelines for the management of community-acquired pneumonia, hospital-acquired pneumonia, respiratory tract infection, and -/nursing and healthcare-associated pneumonia. furthermore, the japanese society of pediatric pulmonology and japanese society for pediatric infectious diseases announced the "guidelines for the management of respiratory infectious diseases in children in japan". internationally, many guidelines, including those established by the american thoracic society and infectious diseases society of america, have been published from various countries. thereafter, clinical research on respiratory infectious diseases has advanced, leading to the accumulation of many outcomes regarding epidemiology, clinical diagnosis, and treatment. however, the types of microorganisms that cause respiratory infectious diseases have increased with the number of resistant bacteria. in addition, conditions have also varied with causative microorganisms through the recent compromised host's severe status. the place of treatment varies: from the outpatient clinic to the icu. physicians responsible for treatment also vary: practitioners, hospital doctors, pulmonologists, emergency physicians, board certified member of jaid, japanese antimicrobial chemotherapy physician. there are a large number of options of antimicrobial drugs that are available, including new drugs; therapeutic strategies are confused. on the other hand, recently, the entity of pk-pd has been commonly recognized, and the importance of scientifically using antimicrobial drugs has been emphasized. in addition, the japanese society of chemotherapy established a system for antimicrobial chemotherapy-certified physicians, and promoted the widespread, adequate use of antimicrobial drugs. based on these, the two societies prepared the jaid/jsc guidelines for the treatment of respiratory infectious diseases. if specific treatment guidelines can be presented, this may contribute to an improvement in the treatment responses of respiratory infectious diseases, a reduction in health expenditure, and the prevention of resistant bacteria. the guidelines were prepared based on the ebm so that they reflected the management of respiratory infectious diseases in japan and covered all such diseases in adults and children. to prepare the guidelines, a committee was established in , and a draft was published on homepage based on an approval from the boards of directors at the two societies through a review-based consensus. opinions were collected from the two societies' members. in japan, there have been no such guidelines covering respiratory infectious diseases. in the future, with further advances in research, the contents of the guidelines must be revised. however, we successfully provided treatment guidelines that are the most advanced at present. the guidelines were prepared for all clinicians to understand the treatment of respiratory infectious diseases and manage them with antimicrobial drugs adequately. they do not limit treatment by individual physicians or affect their rights to select it. the guidelines may be commonly applied for respiratory infectious disease management/research/education in japan, improving the quality of respiratory infectious disease management, preventing an increase in the number of resistant bacteria, and contributing to national health. we hope that the guidelines will be utilized by a large number of clinicians in respiratory infectious disease management. lastly, we thank the committee members and secretariat staff for their cooperation. . descriptions on the recommendation grade and evidence level . definition of firstand second-choice drugs . precautions -in this article, with respect to the administration method (especially doses) of antimicrobial drugs, they are recommended based on sufficient doses. considering the products adopted at each medical institution, antibiograms, severity, underlying disease, age, and presence or absence of organ disorder, the dose should be increased or decreased if necessary. -the spectra of third-generation cephems for intravenous injection, ctx and ctrx, are similar, but ctx, which is excreted in the kidney, should be primarily used when liver dysfunction is present, and ctrx, which is excreted in bile, should be primarily used when renal dysfunction is present. -as quinolones exhibit antitubercular actions, patients with pulmonary tuberculosis should be excluded for use. . a list of antimicrobial drug abbreviations and doses for neonates are presented at the end of this volume. . . community-acquired pneumonia . . . empiric therapy ---executive summary---patient with bacterial pneumonia should be treated primarily with high-dose penicillin (aii). in elderly patients and those with underlying lung diseases, the use of respiratory quinolones may be considered positively (bii). in case of atypical pneumonia, a macrolide or tetracycline is the first choice. respiratory quinolones should be reserved as alternative drugs (bii), but may be used depending on local circumstances about drug resistance (ciii). in case of whether pneumonia or atypical pneumonia dose not diagnose, comobination with high-dose penicillin and a macrolide or tetracycline should be attempted first (bii). respiratory quinolones should be reserved as alternative drugs (bii). in severer cases requiring treatment in the icu, a macrolide or new quinolone should be used aggressively in combination with a broad spectrum b-lactam such as high-dose penicillin from the beginning of treatment (aii). ---explanation---community-acquired pneumonia refers to hospital-acquired pneumonia that develops h or more after admission or pneumonia that develops in healthy adults on social activities other than medical practice-/nursing-associated pneumonia [ e ] . as signs and symptoms, cough, sputum, thoracic pain, and dyspnea appear, and this disease acutely occurs with systemic symptoms such as fever and general malaise [ e ] . however, these symptoms are not marked in some elderly patients. furthermore, atypical pneumonia including mycoplasma is characterized by a small amount of sputum, and can be differentiated (tables and ) [ , ] . concerning examination, gram staining and culture of sputum are used to identify causative microorganisms and select subsequent treatment strategies [ , ] (aii). kits for rapid diagnosis with urine or nasal swab are also used for auxiliary diagnosis [ , ] (aii). a blood test shows inflammatory findings such as leukocytosis and an increase in the crp level, facilitating a certain assessment of the disease [ , ] . on thoracic imaging, consolidation or a ground glasslike shadow is observed [ e ] (ii). when patients are in an immunosuppressive state related to an underlying disease, a causative microorganism test should be performed, considering the possibility of opportunistic infection [ e , , ] (a). in elderly patients, aspiration pneumonia is frequently observed, and the management of this disorder is necessary (refer to the section " . aspiration pneumonia" on page. ). in the presence of renal dysfunction, the type and dose of an antimicrobial drug must be carefully selected [ , ] (aii). bacterial pneumonia should be differentiated from atypical pneumonia in accordance with "the jrs guidelines for the management of community-acquired pneumonia in adults in " (edited by the committee to prepare guidelines regarding respiratory infectious diseases, japanese respiratory society) (tables and ) [ ] . although legionella pneumonia is routinely classified as atypical pneumonia, various types of atypical pneumonia do not include legionella pneumonia in this differentiation method. a. bacterial pneumonia ( ) outpatient treatment bacterial pneumonia is primarily caused by sterptococcus pneumoniae, haemophilus influenzae, and moraxella catarrhalis [ e , , ] (ii). basically, these types of pneumonia should be treated by orally administering high-dose penicillin [ e ] (aii). in japan, macrolide-resistant s. pneumoniae is detected in most cases; therefore, macrolides are not recommended as the first choice, differing form those in europe and the united states [ , , , , ] (aii). for outpatient treatment, b-lactamase inhibitorcontaining penicillin is commonly used. therapy with cva/ampc or sbtpc ( tablets/ e times a day) is recommended with respect to the efficacy and suppression of resistant bacteria [ , , ] (aii). however, such high-dose prescriptions are not always accepted by health insurance system in japan, and the following prescriptions (examples) should also be considered. in elderly patients or those with underlying lung diseases such as copd/old pulmonary tuberculosis, the use of respiratory quinolones should be considered positively from the perspective of the effects on penicillin-resistant pneumococcus and tissue transfer [ , , ] (bii). however, many new quinolones also have antimicrobial activities against mycobacterium tuberculosis; therefore, the presence or absence of active tuberculosis must be strictly checked before administration [ ] (aii). ( ) hospital treatment for hospital treatment, injection is primarily used. however, basic concepts for drug selection are similar to those at the outpatient clinic. considering s. pneumoniae, h. influenzae, and m. catarrhalis, high-dose penicillin or cephems, which are effective for these microorganisms, should be selected [ e ] (aii). if more potent treatment is required, respiratory quinolone injection should be used [ , ] (bii). ---drugs to be recommended---( ) outpatient treatment a first choices -cva/ampc, oral ( / mg), tablets/ e times a day -sbtpc, oral ( mg), tablets/ e times a day * concerning cva/ampc and sbtpc, up to mg of ampc or up to mg of abpc are approved dosage in japan. combination therapy with ampc (oral preparation) should also be considered. [example] cva/ampc, oral ( / mg), tablet/ times a day þ ampc, oral ( mg), tablet/ times a day <> second choices -lvfx, oral, mg/once a day -grnx, oral, mg/once a day -stfx, oral, mg/ e times a day -mflx, oral, mg/once a day -tflx, oral, mg/twice a day ( ) hospital treatment a first choices -sbt/abpc, intravenous drip, g/ e times a day -ctx, intravenous drip, e g/ e times a day -ctrx, intravenous drip, g/once a day or g/twice a day <> second choice -lvfx, intravenous drip, mg/once a day b. atypical pneumonia ( ) outpatient treatment atypical pneumonia is primarily caused by mycoplasma pneumoniae, chlamydophila pneumoniae, and legionella pneumophila [ e , , , , ] (ii). the oral administration of a macrolide or tetracycline is the first choice [ , , , ] (aii). to suppress resistant bacteria, respiratory quinolones should be reserved as alternative drugs [ , , , , ] (bii). however, recently, the appearance of macrolideresistant m. pneumoniae in adults has raised an issue in japan. respiratory quinolones must be used as the first choice depending on local circumstances about drug resistance [ ] (ciii). ( ) hospital treatment for hospital treatment, injection is primarily used. however, basic concepts for drug selection are similar to those at the outpatient clinic. if more potent treatment is required, new quinolone injection should be used [ e , , , ] (bii). ---drugs to be recommended---( ) outpatient treatment a first choices -azm sustained-release preparation, oral, g/single dose -cam, oral, mg/twice a day -mino, oral, mg twice a day <> second choices -lvfx, oral, mg/once a day -grnx, oral, mg/once a day -stfx, oral, mg/ e times a day -mflx, oral, mg/once a day table items used to differentiate between bacterial and atypical pneumonia [ ] . . under years of age . no or minor underlying diseases . stubborn cough . poor chest auscultatory findings . no sputum, or no identified aetiological agent by rapid diagnosis . a peripheral white blood cell count below , /ml table criteria for differentiation [ ] . in cases using the items in -tflx, oral, mg/twice a day ( ) hospital treatment -azm, intravenous drip, mg/once a day -mino, intravenous drip, mg/twice a day -lvfx, intravenous drip, mg/once a day -cpfx, intravenous drip, mg/twice a day. -pzfx, intravenous drip, to mg/twice a day c. cases in which whether the disease is bacterial pneumonia or atypical pneumonia is unclear ( ) outpatient treatment in this case, combination therapy with high-dose penicillin and a macrolide or tetracycline should be selected as the first choice to cover both bacterial and atypical pneumonia [ e , , , , , ] (bii). as respiratory quinolones cover both bacterial and atypical pneumonia, they are convenient, but should be reserved as alternative drugs from the perspective of suppression of resistant bacteria [ e , , , , ] (bii). however, in elderly patients or those with underlying lung diseases such as copd/old pulmonary tuberculosis, the use of respiratory quinolones should be considered positively from the perspective of the effects on penicillin-resistant pneumococcus and tissue transfer [ , , ] (bii). recently, the appearance of macrolideresistant m. pneumoniae in adults has raised an issue. respiratory quinolones may be used as the first choice depending on local circumstances about drug resistance [ ] (ciii). ( ) hospital treatment for hospital treatment, injection is primarily used. however, basic concepts for drug selection are similar to those at the outpatient clinic. if more potent treatment is required, new quinolone injection should be used [ e , , ] (bii). ( ) severer cases requiring treatment in the icu in severer cases requiring treatment in the icu, s. pneumoniae should be initially considered, and a macrolide or new quinolone should be used aggressively in combination with a broad spectrum b-lactam such as high-dose penicillin from the beginning of treatment primarily to cover latent atypical bacteria (in particular, when l. pneumophila is not covered, the condition may become fatal) [ e , , , ] (aii). in particular, combination therapy with a macrolide is recommended from immunological aspects to suppress excessive inflammation related to cytokines [ ] (cii). as the possibility that causative microorganisms may be enteric bacteria including esbl-producing bacteria cannot be ruled out, carbapenem injection should be used as a first-choice drug in patients with a background factor for which esbl-producing bacteria are frequently detected [ , ] (bii). the sensitivity of a urinary antigen kit to s. pneumoniae and legionella spp. is approximately %. therefore, even when the patient is negative for these bacteria in the initial phase, the possibility of pneumonia related to these bacteria should not be ruled out [ e , , ] (ii). ---drugs to be recommended---( ) outpatient treatment a first choices -cva/ampc, oral ( / mg), tablets/ e times a day -sbtpc, oral ( mg), tablets/ e times a day * concerning cva/ampc and sbtpc, up to mg of ampc or up to mg of abpc are approved dosage in japan. combination therapy with ampc (oral preparation) should also be considered. [example] cva/ampc, oral ( / mg), tablet/ times a day þ ampc, oral ( mg), tablet/ times a day þ one of the followings: -azm sustained-release preparation, oral, g/single dose -cam, oral, mg/twice a day -mino, oral, mg/twice a day <> second choices -lvfx, oral, mg/once a day -grnx, oral, mg/once a day -stfx, oral, mg/ e times a day -mflx, oral, mg/once a day -tflx, oral, mg/twice a day ( ) hospital treatment a first choices -sbt/abpc, intravenous drip, g/ e times a day -ctx, intravenous drip, e g/ e times a day -ctrx, intravenous drip, g/once a day or g/twice a day þ one of the followings: -azm, intravenous drip, mg/once a day -mino, intravenous drip, mg/twice a day -cam, oral, mg/twice a day <> second choices -lvfx, intravenous drip, mg/once a day -pzfx, intravenous drip, to mg/twice a day ( ) severer cases requiring treatment in the icu -taz/pipc, intravenous drip, . g/ e times a day -ipm/cs, intravenous drip, . e g/ e times a day -mepm, intravenous drip, g/ e times a day -bipm, intravenous drip, . e . g/ e times a day -drpm, intravenous drip, . e g/ times a day þ one of the followings: -azm, intravenous drip, mg/once a day -lvfx, intravenous drip, mg/once a day -cpfx, intravenous drip, mg/twice a day -pzfx, intravenous drip, to mg/twice a day -mino, intravenous drip, mg/twice a day ---executive summary----when causative microorganisms are identified based on the results of microbial examination of good-quality sputum, blood culture, and urinary antigen (s. pneumoniae, l. pneumophila) tests and drug susceptibility testing of the causative agents, definitive therapy should be performed if possible [ , ] (biii). -the place of treatment and drugs should be selected in accordance with the severity of the disease [ , ] (aii). -antimicrobial drugs should be selected in reference to the susceptibility of isolated bacteria to antimicrobial drugs or a drugsusceptibility tendency in the area [ , , , ] when these data are available (aii). -the administration period of an antimicrobial drug is determined in accordance with the improvement of symptoms and laboratory data, with a target of e days [ , ] (biii). -when the patient is infected with l. pneumophila or c. pneumoniae, the optimal administration period is about days [ ] (biv). a. streptococcus pneumoniae -the clinical and laboratory standards institute (clsi) has established higher criteria for breakpoints for penicillin susceptibility on the administration of parenteral antimicrobial drugs for s. pneumoniae infections other than meningitis [ ] , based on the following findings: patients with severe pneumonia due to s. pneumoniae with a low pcg susceptibility (mic: . e mg/ml) showed no difference in responses to pcg and outcome [ , ] (ii). for the treatment of pneumococcal pneumonia, the dose of penicillin should be increased [ , ] (a). -in japan, most s. pneumoniae isolates are macrolide resistant [ , ] . -respiratory quinolones have potent anti-pneumococcal activities (iii). the clinical effects of such quinolones are similar to those of high-dose ampc [ ] (ii). -in japan, quinolone-resistant s. pneumoniae is detected in e % of the isolates [ ] . as quinolone resistance may be readily induced by point mutations of dna gyrase or topoisomerase genes [ ] , quinolones must be used adequately (aiii). b. haemophilus influenzae -the abpc-resistant mechanism of h. influenzae involves blactamase production and/or pbp mutation. previously, blactamase production was primarily involved, but, recently, pbp mutation-mediated b-lactamase-negative abpc-resistant (blnar) strains have been increasingly detected. abpcresistant strains with both b-lactamase production and pbp mutation are classified as b-lactamase-positive cva/abpcresistant (blpacr) strains. -according to a national survey in japan, ( . %) and ( . %) of h. influenzae strains were blnar and b-lactamase-producing strains, respectively [ ] . -blnar strains are also resistant to firstand secondgeneration cephems. -pipc exhibits an antimicrobial activity against blnar strains. however, it is ineffective for blpacr strains. c. klebsiella spp., escherichia coli, proteus spp. -the proportion of extended spectrum b-lactamase (esbl)producing bacteria has slightly increased among isolates from respiratory samples. -according to a national survey in japan, esbl-producing bacteria account for . e . % of respiratory sample-derived klebsiella spp. strains [ , ] . -most esbl-producing strains are simultaneously resistant to quinolones [ ] . antimicrobials should be selected according to the drug susceptibility of isolated bacteria. -in japan, carbapenemase-producing strains are extremely rare. d. mycoplasma pneumoniae -in the field of pediatrics, the detection rate of macrolideresistant m. pneumoniae has markedly increased. in adults, that of macrolide-resistant m. pneumoniae also increase [ , ] . -tetracyclines exhibit potent clinical effects on macrolideresistant m. pneumoniae [ ] . -respiratory quinolones have good activities against m. pneumoniae [ , ] . e. legionella spp. -it should be noted that pneumonia related to legionella spp. other than l. pneumophila sg cannot be diagnosed using legionella urinary antigen testing. -as neither b-lactams nor aminoglycosides have antimicrobial activities against legionella spp., which proliferates within host cells, they are clinically ineffective. -quinolones, macrolides, and tetracyclines have been confirmed to exhibit clinical effects on legionella spp. previously, em was the first choice for this infection, but many recent studies have showed the clinical efficacies of lvfx and azm [ , ] . -rfp is effective when combined with em. the combination of em and rfp is useful. a study suggested the effects of combination therapy with lvfx and a macrolide [ ] (ciii). -although there are no marked differences in antimicrobial drug susceptibility among legionella spp., clinical reviews to verify this are limited [ ] . f. chlamydophila pneumoniae -only a few studies have supported the clinical effects of antimicrobial drugs against c. pneumoniae pulmonary infections. -tetracyclines, macrolides, and quinolones may be effective. these drugs are recommended primarily based on the results of basic studies [ , ] . g. staphylococcus aureus -with respect to staphylococcus aureus in japan, there has been an increase in the number of methicillin-resistant strains even in patients with community-acquired pneumonia. in particular, recently, municipal-onset-type mrsa (ca-mrsa) with panton-valentine-leucocidine (pvl) has been detected in japan, raising an issue [ ] . -in cases of mssa infection (bacteremia), the clinical effects of cez are superior to those of vcm [ ] . -as the susceptibility of mrsa to oral antimicrobial drugs differs among isolates, drugs should be selected according to its drug susceptibility results. h. streptococcus spp. -among various types of streptococcus, the streptococcus anginosus group is frequently detected, and characterized by strong abscess-forming features [ ] . streptococcus pyogenes and streptococcus agalactiae may also cause pneumonia. the former may lead to serious pulmonary infection [ ] (v). -there is no penicillin resistance, but macrolide resistance is observed at a low frequency [ ] . -the anti-streptococcus activities of quinolones vary. among quinolones, grnx, mflx, and stfx have relatively potent antimicrobial activities [ , ] . i. moraxella catarrhalis -the number of b-lactamaseproducing strains has increased since the 's. currently, most strains produce b-lactamase [ , ] . b-lactamase produced by m. catarrhalis decomposes penicillin. -in japan, macrolide-or quinolone-resistance have not been reported [ ] . j. anaerobes -most anaerobes that cause pneumonia exist in the oral cavity. peptostreptococcus spp., prevotella spp., and fusobacterium spp. are involved. mixed infection with microaerophilic streptococci is often observed. -in many cases, infection with anaerobes may be associated with aspiration. -most oral anaerobes (prevotella spp., fusobacterium spp., and porphyromonas spp.) are susceptible to combination drugs consisting of penicillin and a b-lactamase inhibitor, cldm and mnz [ ] . k. pseudomonas aeruginosa -in patients with chronic respiratory tract infection, pseudomonas aeruginosa colonizes in the airway, and may cause community-acquired pneumonia [ ] . -as the susceptibility of p. aeruginosa to antimicrobial drugs differs among clinical isolates, drugs should be selected according to its drug susceptibility results. ---drugs to be recommended----the drug susceptibility of each clinical isolate should be classified in accordance with the clsi criteria [ ] . -establishment of prescriptions recommended in this article * antimicrobials have been approved for specific diseases and specific causative agents by japanese ministry of health and welfare. the approvals are based on the results of clinical studies with good clinical practice. as a general rule, the recommendations in this section refer to this (aii). however, recent trends in drug susceptibility are also considered. * the recent drug susceptibility results of the nationwide studies in japan were referred [ , ] . * the recommendations without the approvals by japanese ministry are graded by evidence levels. [ -when the susceptibility of identified causative microorganisms is clarified, or after the treatment responsiveness is evaluated, whether or not de-escalation is possible should be reviewed [ e ] (aii). ---explanation---definition: hospital-acquired pneumonia is defined as "pneumonia that newly develops h or more after admission". in many cases, treatment is difficult due to unfavorable patient conditions such as the presence of an underlying disease, immune capacity, and general condition [ e ]. laboratory findings: patients meeting of items, fever, an abnormal leukocyte count, and purulent secretes, in addition to the appearance of an abnormal shadow of the chest should be diagnosed with hospital-acquired pneumonia [ e ]. ) ventilator-associated pneumonia (vap): vap refers to pneumonia that newly develops h or more after endotracheal intubation/ventilator initiation. its onset within e days after endotracheal intubation is classified as early-type, and its subsequent onset as late-type [ , , , ] . ) hospital-acquired pneumonia other than vap: several types of hospital-acquired pneumonia other than vap include ( ) immunodeficiency (for example, neutropenia during anticancer therapy, cell-mediated immunodeficiency related to the administration of steroids or immunosuppressive drugs) and ( ) aspiration pneumonia including latent aspiration (refer to the section " . aspiration pneumonia" on page ). appropriate management and selection of antimicrobial drugs in accordance with individual conditions are necessary [ ] . with respect to microorganisms that are expected, refer to the section " . hospital-acquired pneumonia--- . . empiric therapy: cases in which gram staining is available" (p. ). ---drugs to be recommended--a. cases in which there is no risk of resistant bacteria antimicrobial drugs should be selected, targeting streptococcus pneumoniae, h. influenzae, and klebsiella spp. as causative microorganisms [ e ] (biii). although it is difficult to estimate/identify causative microorganisms using sputum samples, bacteria that are not isolated/cultured from goodquality sputum may not be causative microorganisms. if resistant bacteria such as mrsa and p. aeruginosa are not detected on sputum culture and there is no deterioration of clinical symptoms, an initial drug should be continued [ ] (biii). in patients in whom aspiration episodes are clear, those in whom oral hygiene is not maintained, or those with consciousness disorder, drugs with anti-anaerobe activities should be selected, considering the involvement of anaerobes [ ] (biii). if an adequate antimicrobial drug is administered, the treatment period may be e days, excluding mrsa and p. aeruginosa [ , ] (bii). a first choices -sbt/abpc, intravenous drip, g/ e times a day -ctx, intravenous drip, e g/ times a day -ctrx, intravenous drip, g/once a day or g/twice a day * if the involvement of anaerobes is suspected, sbt/abpc should be selected. <> second choice -lvfx, intravenous drip, mg/once a day (as its antimicrobial activity against anaerobes is weak, monotherapy with this drug should be avoided in patients with aspiration pneumonia.). b. cases in which there is a risk of multi-drug-resistant bacteria (table ) [ ] to cover multi-drug-resistant bacteria including p. aeruginosa, broad-spectrum antimicrobial drugs with anti-p. aeruginosa activities should be selected [ e ] (aiii). considering the frequency of esbl in each institution, carbapenems should be considered even when enteric bacteria, including klebsiella spp. and escherichia coli, are suspected (biv). if p. aeruginosa is not isolated on good-quality sputum culture, a treatment option should be de-escalated to drugs for cases in which there is no risk of resistant bacteria [ e ] (aii). if aspiration is suspected, or if the involvement of grampositive bacteria is suggested, combination therapy with cldm must be considered (biv). if there is a risk of mrsa carrier (table ) , combination therapy with anti-mrsa drugs should also be considered. the mean administration period of antimicrobial drugs with respect to causative bacteria in patients with an improvement was approximately days. however, that for resistant bacteria such as p. aeruginosa and mrsa was approximately days [ ] (bii). if appropriate antimicrobial drugs can be administered after clarifying causative bacteria, a treatment period of approximately days is recommended [ , , ] (bii). a first choices -taz/pipc, intravenous drip, . g/ e times a day -ipm/cs, intravenous drip, . g/ times a day or g/ times a day -mepm, intravenous drip, g/ times a day -drpm, intravenous drip, . e g/ times a day -bipm, intravenous drip, . e . g/ e times a day <> second choices -cfpm, intravenous drip, e g/ e times a day -cpfx, intravenous drip, mg/twice a day -pzfx, intravenous drip, to mg/twice a day if the involvement of anaerobes is suspected, one of the following options should be combined with one of the above regimens: -cldm, intravenous drip, mg/ e times a day -sbt/abpc, intravenous drip, g/ e times a day c. severe cases one of the following options must be combined with one of the regimens for cases in which there is a risk of multi-drugresistant bacteria. when comparing the results between patients undergoing appropriate and inappropriate treatments, the prognosis of the latter was significantly poorer [ , ] (bii). however, a study reported that the prognosis in a group with compliance with recommended drug selection was significantly poorer than in a non-compliance group in patients in whom infection with drug-resistant bacteria in the icu was suspected even among those in whom the etiology was bacteriologically investigated [ ] (bii). therefore, it must be considered that, even when resistant bacteria are etiologically involved, the administration of an appropriate antimicrobial drug that covers them does not always improve the prognosis. -taz/pipc, intravenous drip, . g/ e times a day -ipm/cs, intravenous drip, . g/ times a day or g/ times a day -mepm, intravenous drip, g/ times a day -drpm, intravenous drip, . e g/ times a day -bipm, intravenous drip, . e . g/ e times a day one of the following options should be combined with one of the above regimens: should be estimated based on the results of the clinical microbiological culture (cmc: gram staining and culture) of a lower airway sample immediately before the start of treatment, and not based on bacteria isolated on active surveillance culture (asc), which was conducted as a strategy to prevent/ control infection prior to onset [ ] . -microorganisms that cause pneumonia or (colonization of) the lower airway should be estimated based on the presence or absence of neutrophils or phagocytosis (excluding those patients with neutropenia or functional impairment of neutrophil) [ ] (bii). ---explanation---[gram staining] diagnostic accuracy of hospital-acquired pneumonia is improved by confirming neutrophils and bacterial cells using gram staining of airway samples. this observation has also been confirmed through an increase in the likelihood ratio of hospital-acquired pneumonia in patients with a clinical pulmonary infection score (cpis) of points or higher [ ] . as bacteria isolated from the lower airways of inpatients are common colonizers in many cases, gram staining is also useful for discerning colonization from infection by evaluating the presence or absence of neutrophil and phagocytosis. therefore, it is desirable to combine bacterial culture with gram staining [ , e ] . antimicrobial-drug selection based on gram staining findings leads to appropriate empiric therapy in two-thirds of patients with hospital-acquired pneumonia, and it can be continued as definitive therapy in many cases [ ] . if there are no bacterial cells on gram staining of lower airway sample in whom an antimicrobial regimen was not changed within the past h, it is unlikely that the focus of infection/inflammation is within the lungs (lower airway) [ ] . in this case, the possibility of pneumonia mimic, such as pleural effusion, atelectasis, and pulmonary edema, is suggested if the lung field opacity still remains in chest x-ray. if there is no other infectious focus, the discontinuation of an antimicrobial drug may be warranted [ , , ] . a study has reported that the culture results of asc performed as a strategy of routine infection control measure prior to the development of nosocomial pneumonia accurately predicted the causative pathogen in only % of cases [ ] . therefore, it is necessary to submit airway samples for clinical microbiological culture (cmc) immediately before the start of presumptive treatment. [causative microorganisms and their origin] microorganisms that cause hospital-acquired pneumonia are derived from the oropharynx, airway (including the nasal cavity and nasal sinus), digestive tract, and environment. gastrointestinal tract-derived causative microorganisms are enteric bacteria (primarily, klebsiella spp., e. coli and others such as proteus spp., enterobacter spp., serratia spp., morganella spp., and citrobacter spp.). those derived from the upper airway include s. pneumoniae, h. influenzae, moraxella catarrhalis, s. aureus (namely methicillin sensitive strain), and oral anaerobes. those derived from the environment include methicillin-sensitive s. aureus, pseudomonas spp., acinetobacter spp., and stenotrophomonas spp. [ , , , ] . as the above bacteria derived from the airway and gastrointestinal tract basically exert strong virulence to the airway, they can be considered a core pathogen group of hospital-acquired pneumonia. their potential for developing airway inflammatory response is generally believed stronger than those caused by environmental pathogen [ , ] . table risk factors for multi-drug-resistant bacteria. . previous use of antimicrobial drugs within days . interval of days or more from admission . admission from an area/hospital in which resistant bacteria are frequent . immunosuppressive state or treatment table risk factors for carrying mrsa [ ] . conditions under which anti-mrsa drug therapy should be considered (including gram stain) mrsa---" (p. ). ( ) diplococcus consisting of a pair of two cocci (gpdc: grampositive diplococci) s. pneumoniae should initially be suspected. enterococcus is also a gpdc in microscopic appearance, but is basically considered a non-pulmonary pathogen [ ] . <> cases in which there have been no previous treatment with antimicrobial drugs or risks of penicillin-resistant pneumococcus -pcg, intravenous drip, , , to , , units/ e times a day -abpc, intravenous drip, g/ e times a day <> cases in which previous treatment with antimicrobial drugs or a risk of prsp is present -ctrx, intravenous drip, g/twice a day or g/once a day -ctx, intravenous drip, e g/ e times a day -lvfx, intravenous drip, mg/once a day -vcm, intravenous drip, g/twice a day (tdm should be conducted so that a trough is e mg/ml [ ] .) ( ) gram-positive coccus in either short or long chain (gpc in chain) aor b-hemolytic streptococci is indicated. -pcg, intravenous drip, , , to , , units/ e times a day -abpc, intravenous drip, g/ e times a day ( ) gram-positive bacillus with a rod-like morphology (gpr: gram-positive rod) corynebacterium spp. may be indicated. -vcm, intravenous drip, g/twice a day (tdm should be conducted so that a trough is e mg/ml [ ] .) c. gram-negative bacteria ---executive summary----when gram-negative bacteria are observed, h. influenzae, m. catarrhalis, enterobacteriaceae, p. aeruginosa, acinetobacter spp., and stenotrophomonas spp. may be indicated [ e , , ] (bii). -it is difficult to estimate the type of bacteria based on the morphology on gram staining in comparison with grampositive bacteria. -gram-negative bacteria frequently detected as causative microorganisms include enteric bacteria and p. aeruginosa. -it is encouraged important to recognize the basic antimicrobial drug susceptibility pattern of each type (group) of bacteria to make sure that the empiric antimicrobial therapy is appropriate (table ). ---drugs to be recommended--- ( ) cases of early-onset hospital-acquired pneumonia in which there have been no previous administration of antimicrobial drugs or risk of resistant bacteria aero-respiratory pathogen, such as h. influenzae and m. catarrhalis, and enteric bacteria, such as klebsiella spp., are indicated. -sbt/abpc, intravenous drip, g/ e times a day -ctrx, intravenous drip, g/twice a day or g/once a day -ctx, intravenous drip, e g/ e times a day -lvfx, intravenous drip, mg/once a day ( ) cases of late-onset hospital-acquired pneumonia or ventilator-associated pneumonia in which the risk of resistant bacteria is high an antimicrobial drug with anti-pseudomonal activity that targets non-glucose-fermentative gram-negative rod should be administered [ , , ] -to treat polymicrobial infection, the administration of an antimicrobial drug with an activity against obligate anaerobe is not always necessary [ , ] . -in non-severe cases, the administration of antimicrobial agents with anti-mrsa activity may be withheld in the initial phase even when staphylococcus-like bacterial cells are observed [ ] . ---explanation---when several types of bacteria differing in gram staining and morphology are observed, the condition is commonly interpreted as aspiration pneumonia, suggesting the involvement of anaerobes. however, the number of hospital-acquired pneumonia (including vap) caused by anaerobes have been reported relatively smaller than generally anticipated. [ ] , polymicrobial infection does not always require the prompt antimicrobial therapy that covers anaerobes. even though when aspiration pneumonia is suspected, sbt/abpc is frequently prescribed assuming anaerobic infection, which actually works good on many occasions, it has to be acknowledged that sbt/abpc exert good antimicrobial activity not solely against anaerobes, but also aero-enteric pathogen of pneumonia such as streptococcus pneumonia, oral streptococci, h. influenzae, m. catarrhalis, and klebsiella pneumonia. inpatients are often exposed to gram-negative bacteria residing in the hospital environment. furthermore, there are many opportunities to undergo antimicrobial drug therapy that affects the indigenous microflora. for such reasons, gram-negative bacillus (enteric bacteria or p. aeruginosa) frequently colonize within the oropharyngeal region of the elderly patients or long-term bedbound patients, many of whom need airway suctioning or have tracheostomy that may serve as portal of entry of environmental pathogen. oropharyngeal microflora primarily consisting of these gram-negative bacteria can be aspirated into the airway after surgery requiring sedation or anesthesia, or during or after endoscopic examination [ , , ] . briefly, anaerobes may be an occasional pathoen in polymicrobial infection as seen on gram staining of patients with suspected aspiration pneumonia, but s. pneumoniae, h. influenzae, s. aureus, klebsiella spp., p. aeruginosa, and acinetobacter spp. are more commonly involved in many cases, being similar to the microorganisms that are thought to be the major pathogen of hospital-acquired pneumonia. this is in contrast with the community-onset aspiration pneumonia, represented by lung abscess, in that anaerobes are primarily involved [ , ] . anaerobes involved in hospital-acquired pneumonia include facultative anaerobic a-hemolytic streptococci in the oral cavity and obligate anaerobes. oral obligate anaerobes include grampositive coccus (peptostreptococcus sp.), gram-negative coccus (veillonella sp.), and gram-negative bacillus "oral pigmented" bacteroides (bacteroides melaninogenicus), prevotella sp., porphyromonas sp., and fusobacterium sp.). many of these types of bacteria are susceptible to b-lactams that do not contain a b-lactamase inhibitor, new quinolones, macrolides, and tetracyclines. therefore, patients with hospital-acquired pneumonia may be basically treated by standard empiric therapy for hospital-acquired pneumonia even when aspiration pneumonia related to several types of bacteria is suspected [ ] . ---drugs to be recommended---( ) cases in which it is not necessary to consider the involvement of multi-drug-resistant bacteria, or early hospitalacquired pneumonia the involvement of oral streptococcus, oral anaerobes, s. pneumoniae, h. influenzae, and enteric bacteria should be considered. -sbt/abpc, intravenous drip, g/ e times a day -ctrx, intravenous drip, g/once a day or g/twice a day -ctx, intravenous drip, e g/ e times a day -lvfx, intravenous drip, mg/once a day ( ) late-onset hospital-acquired pneumonia or cases in which there is a risk of multi-drug-resistant bacteria in addition to the above pathogens, the involvement of non-glucose-fermentative gram negative bacteria or esblproducing enteric bacteria must be considered. -cfpm, intravenous drip, e g/ e times a day -czop, intravenous drip, e g/ e times a day -taz/pipc, intravenous drip, . g/ e times a day table basic susceptibility of various pathogen groups to antimicrobial drugs. ---explanation---if drug susceptibility test is not conducted for some reasons after the identification of causative microorganisms, an antimicrobial drug should be selected with reference to the susceptibility pattern (local sensitivity) of the identified bacteria at each institution. if the local sensitivity is not obtained, a drug should be selected based on the basic susceptibility of various pathogens to antimicrobial drugs (table ) [ ] . in the treatment of hospital-acquired pneumonia, the duration of antimicrobial therapy generally tends to be longer than required for the following reasons: opacity on chest x-ray often remains for reasons other than pneumonia even after the start of antimicrobial drug treatment; and there may be a large number of latent nonpneumonia (or non-infectious-disease) factors that may cause increase in body temperature or crp level in inpatients [ ] . however, if appropriate antimicrobial drug treatment is performed, it is possible to complete treatment in week [ ] . in strains such as enterobacter spp., serratia spp., citrobacter spp., and morganella spp. (table gnr b ), the expression of intrinsic antimicrobial-drugresistance genes encoded in chromosome genes is induced during antimicrobial drug treatment, a phenomenon which is basically rarely seen in e. coli, klebsiella spp., h. influenzae, and m. catarrhalis (table gnr a ) ( table ) [ , , ] . therefore, if adequately chosen treatment parameters are improved, antimicrobial treatment could be completed with careful follow up of patients' condition. although it is useful to recognize these pathogens, abbreviated as space (serratia, pseudomonas, acinetobacter, citrobacter, and enterobacter), as a representative microorganism group that causes hospital-acquired pneumonia, the space group is essentially a common colonizer. therefore it is important to bear in mind that antimicrobial drug is not always indicated upon the isolation of space to avoid selection of antimicrobial resistant bacteria related to unnecessary or long-term antimicrobial therapy [ , ] . lzd should be selected [ , ] (ai). the therapeutic efficacy of lzd is similar to those of glycopeptides [ , ] . the penetration of lzd into the alveolar epitheliumlining fluid and intra-alveolar sputum is more favorable. therefore, use of lzd should be encouraged in cases of restricted sputum expectoration, such as vap [ ] (bii). exclusive use of a single drug may accelerate the acquisition of resistance to the agent [ e ] (ci). as dap is inactivated by pulmonary surfactants, its use should be avoided for mrsa pneumonia. -glycopeptides should be selected as first-line drug for pneumonia caused by corynebacterium sp [ ] (aii). ---explanation---there is no significant difference in the therapeutic efficacy for mrsa pneumonia between glycopeptides and lzd. several studies reported that the overall clinical efficacy of lzd, including the incidence of side effects, was superior to vcm in patients with hospital-acquired pneumonia caused by mrsa [ , ] . however, since the dosing of vcm in these studies have been considered suboptimal, further study is needed [ , ] . some investigators have recommended that, when mrsa is susceptible to cldm or mino on a susceptibility test, lzd, a protein synthesis inhibitor should be administered given the possible involvement of the panton-valentine leukocidin [ , ] . if a prompt improvement is achieved by the intravenous drip of lzd mg q h, or if the patient's condition is not critical, switch from the intravenous administration to an oral preparation of lzd, which shows high bioavailability [ ] , is encouraged. as dap is inactivated by pulmonary surfactants, it should not be used to treat mrsa pneumonia. this may not apply to the treatment of septic pulmonary embolism [ ] . ---drugs to be recommended---( ) mrsa a first choices -vcm, intravenous drip, g/twice a day -teic, intravenous drip, mg for the first days/ twice a day for loading, mg/once a day from day * tdm should be conducted so that the trough levels of vcm and teic range from to mg/ml [ ] . -lzd, intravenous drip or oral administration, mg/ twice a day <> second choices -abk, intravenous drip, mg/once a day (a trough level was established as mg/ml using tdm.) -st combination drug (smx at mg/tmp at mg), oral administration, tablets/twice a day or intravenous drip, mg/twice a day -cldm, intravenous drip, mg/ e times a day (the results of drug susceptibility testing must be confirmed). [non-extended-spectrum b-lactamase (esbl)-producing bacteria] ( ) hospital treatment " (p. ). ( ) e. coli, klebsiella spp., proteus mirabilis (esbl-producing bacteria) refer to the section " . community-acquired pneumonia--- . . definitive therapy--- [ ] klebsiella spp. [esbl-producing bacteria] ( ) hospital treatment" (p. ). ( ) enterobacter spp., serratia spp., citrobacter spp., morganella spp., proteus vulgaris a third-generation cephems or quinolones should be administered [ , , ] (aii). -ctrx, intravenous drip, g/once a day or g/twice a day -ctx, intravenous drip, e g/ e times a day -lvfx, intravenous drip, mg/once a day -cpfx, intravenous drip, mg/twice a day -pzfx, intravenous drip, mg/twice a day <> if a strain is estimated to constantly express cephalosporinase (highly resistant to b-lactamase inhibitorcontaining b-lactams, oxyimino [¼ rd generation] cephalosporin and cephamycin, through plasmid genes) on an antimicrobial drug susceptibility test, fourthgeneration cephems or carbapenems should be administered. -cfpm, intravenous drip, e g/ times a day -czop, intravenous drip, e g/ times a day -mepm, intravenous drip, g/ times a day -drpm, intravenous drip, . e g/ times a day ( ) p. aeruginosa anti-pseudomonal penicillins, third-generation or later cephems, carbapenems, or new quinolones should be administered [ , ] refer to the section " . community-acquired pneumonia--- . . definitive therapy--- [ ] h. influenza (abpcsusceptible), [ ] h. influenza (b-lactamase-producing), [ ] h. influenza (b-lactamase-negative ampicillin-resistant (blnar), and [ ] h. influenza (b-lactamase-positive amoxicillin clavulanate-resistant (blpacr)" (p. e ). ---explanation---according to some investigators, enteric bacteria are classified into types: sensitive, gram-negative rods, such as e. coli, klebsiella pneumoniae, and p. mirabilis, which are susceptible to first-generation cephalosporin, and resistant, gram-negative rods, such as enterobacter spp., serratia spp., and citrobacter spp., which show an intrinsic or inducible resistance to third-generation cephalosporin through chromosomal ampc genes [ , , ] . in addition, the number of extended spectrum of b-lactamase (esbl)-producing strains of e. coli, klebsiella, and proteus sp. that are resistant to all cephalosporin has increased. among resistant gnrs, such as enterobacter spp., strains that constantly produce ampctype b-lactamase (cephalosporinase) (plasmid type) must also be considered [ , ] . concerning non-fermentative bacteria, their intrinsic susceptibility to antimicrobial agents differs among p. aeruginosa, stenotrophomonas spp., and acinetobacter spp. a study indicated that, in patients with p. aeruginosa pneumonia, monotherapy with a new quinolone might show unfavorable bacteria-eradicating effects or lead to recrudescence [ ] . in some patients, combination therapy with a b-lactam (pipc, caz, cfpm, or carbapenems), which has an anti-pseudomonal activity, and aminoglycoside or new quinolone may be considered [ , , ] . most strains of stenotrophomonas spp. are susceptible to mino or an st combination drug. m. catarrhalis and acinetobacter spp. are the frequent types of gram-negative coccus detected in patients with early and late hospital-acquired pneumonia, respectively. many strains of the former produce b-lactamase. the latter is a gnr existing in the hospital environment, and may be resistant to many antimicrobial drugs. however, in japan, the multi-drug resistance of this type of bacteria has not widely distributed. carbapenems and new quinolones should be selected. however, the vast majority of acinetobaccter strains are susceptible to sbt/abpc. in particular, sbt has an antimicrobial activity against this type of bacteria, and their susceptibility to sbt/abpc should routinely be confirmed. primary test drugs for an antimicrobial susceptibility of this type of bacteria (drugs appropriate for a routine examination panel) are sbt/abpc, caz, ipm/cs, mepm, gm, tob, lvfx, and cpfx [ ] . pan-sensitive strains of h. influenzae are b-lactamase (bl)-negative, abpc-sensitive (blnas) strains. however, there are various resistance patterns: bl-producing, abpcresistant (blpar), bl-negative, abpc-resistant (blnar), and bl-producing, ampc/cva-resistant (blpacr) strains. blnas strains can be treated with abpc, but sbt/abpc therapy is required to control blpar strains. the administration of ctrx or new quinolones is necessary for blnar or blpacr. a randomized-controlled trial with multivariate analysis has shown that factors for favorable bacteriological effects included the absence of p. aeruginosa-related pneumonia (< . ), a higher body weight (< . ), a low apache ii score (severity) ( . ), and cpfx therapy ( . ) [ ] . conditions suggesting the use of new quinolones include allergy to b-lactams, the presence of or concern for nephropathy (an aminoglycoside cannot be combined with a b-lactam), necessity of covering obligate intracellular pathogen, or situations in which switching to an oral preparation is indicated [ ] . an in vitro study indicated that the alveolar epithelial lining fluid (elf) concentration of lvfx reached as high as its serum concentration. furthermore, a prospective open-label study reported that switching of intravenous drip to oral administration decreased the elf concentration, but it was within the range at which many pathogens are deemed sensitive based on the cumulative data of minimum inhibitory concentrations for causative microorganisms [ ] . ---executive summary----nursing and healthcare-associated pneumonia (nhcap) is a category independently defined in japan based on medical circumstances. -the attending physician proposes a treatment category (groups a to d) by evaluating what treatment is necessary as the most important item based on the patient's and his/her family's will ( fig. ) [ ] . -risk factors for resistant bacteria are categorized into two items, and initial treatment options are recommended, assuming target causative microorganisms (civ). -in patients in whom the general condition is unfavorable due to complications or in terminal-stage patients, initial treatment options are recommended considering side effects from the perspective of innocent properties (civ). -in group d, in which intensive care is required, combination therapy with broad-spectrum (involving resistant bacteria and legionella) and potent antimicrobial drugs is recommended (bi). ---explanation--- in , the japanese respiratory society issued the "guidelines for the management of nursing and healthcare-associated pneumonia (nhcap)" [ ] , considering medical circumstances in japan with reference to the entity of healthcare-associated pneumonia (hcap) proposed in the untied states [ ] . the definition of nhcap is shown in table . as this committee has no objection to the entity itself, the selection of drugs will be explained based on evidence to avoid duplications with the above guidelines. the mortality rate and frequency of resistant bacteria in patients with nhcap are intermediate between community-acquired pneumonia (cap) and hospital-acquired pneumonia (hap). however, nhcap may be primarily regarded as being similar to geriatric pneumonia [ , ] . there is no fact that the rate at which resistant bacteria are isolated increases with severity [ ] . even when pneumonia is not severe, the host's activities of daily living (adl) and an underlying disease/immunodeficiency reduce the prognosis in many cases [ ] . as this type of pneumonia develops in a variety of uneven populations, it is difficult to simply determine severity classification. therefore, considering various conditions, the entity of "treatment category", involving the ethical aspects of geriatric care, was introduced based on evaluation by the attending physician who knows the patient well ( fig. ). frequent basic conditions or concomitant diseases for nhcap in japan include an advanced age, central nervous diseases, aspiration, a reduction in adl, and tubal feeding. their factors are aspiration pneumonia itself or risk factors, and hcap in japan may overlap with aspiration pneumonia [ ] . on the other hand, in nhcap patients, mrsa, p. aeruginosa, and anaerobes are more frequently isolated in comparison with cap patients. it is necessary to switch therapeutic strategies, considering these causative microorganisms. refer to the next section " . aspiration pneumonia" (p. ). [type and frequency of causative microorganisms] concerning causative microorganisms in nhcap patients, resistant bacteria are frequently detected, differing from cap patients. however, with respect to microorganisms that cause hcap, the distribution and frequency of streptococcus pneumoniae and h. influenzae, which are frequently isolated in cap patients, as well as mrsa, p. aeruginosa, and gram-negative bacillus, which are frequently detected in hap patients, differ among countries, areas, and institutions due to their variety (iii). concerning causative microorganisms, a study reported that there was no marked difference between nhcap and cap [ ] . on the other hand, a study in the united states indicated that s. aureus was frequently detected [ ] , and another study in italy, where the rapid aging of society is advanced, as described for japan, reported that aspiration pneumonia, h. influenzae, s. aureus, and gram-negative bacillus were more frequent than in patients with cap [ ] . as a result, the rate of resistant bacteria increased, and inappropriate antimicrobial drugs were selected in a high proportion of patients. in addition, the mortality rate was higher than in cap patients, suggesting the association between the two factors. representative causative microorganisms with respect to the presence or absence of risk factors for resistant bacteria are presented in table [ ] . of these, resistant bacteria, which are not targeted in cap patients, were isolated in approximately %. however, the value was lower than in hap patients. this is a current status of japan (iii). however, we must consider that patients in whom isolated bacteria are unclear account for approximately %, with the involvement of aspiration as a background factor [ ] . in addition to bacteria commonly isolated in cap patients, the frequency of enteric bacteria and anaerobes has increased [ ] . [rules of antimicrobial drug therapy] risk factors for resistant bacteria in nhcap patients include "the previous use of antimicrobial drugs for days or more within days" and "tubal feeding" ( [ ] . risk factors for involvement by drug-resistant pathogens. -if no antibiotic therapy in the preceding days or current tube feeding, the patient can be assumed to have no risk of involvement by drug-resistant pathogens. -however, if past medical history indicates isolation of mrsa, the patient should be assumed to have risk of involvement by mrsa. * ) inappropriate when aspiration pneumonia is suspected, because it has insufficient activity against anaerobic bacteria. * ) because of insufficient activity against anaerobic bacteria, when used to treat suspected aspiration pneumonia, it should be used in combination with an antibiotic that has activity against anaerobic bacteria (e.g., mnz, cldm, sbt/abpc). definition of nhcap [ ] . . pneumonia diagnosed in a resident of an extended care facility or nursing home . pneumonia diagnosed in a person who has been discharged from a hospital within the preceding days . pneumonia diagnosed in an elderly or disable d person who is receiving nursing care . pneumonia diagnosed in a person who is receiving regular endovascular treatment as an outpatient (dialysis, antibiotic therapy, chemotherapy, immunosuppressant therapy) standards for nursing care patients whose performance statues is ps (capable of only limited self-care, confined to bed or a chair more than % of their waking hours) or more. item incudes patients on psychiatric wards. not isolated in those who had made favorable daily life activities without a history of antimicrobial drug therapy [ ] . another study indicated that tubal feeding was an independent risk factor for infection with p. aeruginosa (odds ratio: . ) [ ] (ii). this is the reason why treatment category c was established in the guidelines. briefly, patients who do not meet the above two items are regarded as having no risk factor for resistant bacteria, and assigned to group b. patients meeting or items or those in whom mrsa was previously isolated are assigned to group c. respective drugs to be recommended were separately established. patients in whom outpatient treatment is considered to be appropriate are assigned to group a, and those in whom the attending physician considers ventilator or icu management necessary to group d. drugs to be recommended were added, and a treatment category algorithm ( fig. ) [ ] was prepared. concerning hcap treatment in europe and the united states, there is a gap between drugs used in clinical practice and those recommended in guidelines [ ] (ii). therefore, treatment category-based empiric therapy in japan may be acceptable in clinical practice; future investigation is necessary. there is no evidence regarding the administration period of antimicrobial drugs. an administration period of e days, which is routinely adopted in the highest percentage of patients, is appropriate (biv). when administering antimicrobial drugs for a longer period, equivalent-spectrum antimicrobial drugs should be selected, or de-escalation of antimicrobial drugs should be performed. in this case, fever, crp, and leukocyte counts are often used as indices of the treatment response. in cases of aspiration pneumonia in which aspiration recurs during treatment despite the efficacy of antimicrobial drugs, it is necessary to evaluate whether the effects of antimicrobial drugs are not obtained or recurrence occurs. ---drugs to be recommended--a. empiric therapy ( fig. ) [ ] ( ) cases in which there is no risk of resistant bacteria and outpatient treatment is performed (group a) according to a study, chlamydophila spp. and m. pneumoniae accounted for . and . % of patients in whom the type of microorganisms that cause nhcap was clarified in japan, respectively [ ] . the results suggested that chlamydophila spp. is a target of treatment, as described for cap. therefore, in group a, combination therapy with a b-lactam and macrolide or monotherapy with a respiratory quinolone should be performed (bii). in group d, an anti-p. aeruginosa drug should be combined with cpfx, pzfx, or azm for injection, considering legionella or chlamydophila spp. pneumonia. however, concerning combination therapy with a macrolide (cii) in patients without "severe pneumonia requiring intensive care", as described below, the evidence level is not always high from the perspectives of medical economics, side effects, and resistant bacteria [ ] . some studies examined the mortality rate with respect to the presence or absence of treatment covering atypical pathogens, and reported that the mortality rate was significantly lower in the presence of such treatment [ ] . a recent meta-analysis also showed a difference [ ] . respiratory quinolones were established as an option (bii) based on many references describing that their effects are similar to or more potent than those of combination therapy with a b-lactam and macrolide. however, this must be further examined, considering factors such as severity and the presence or absence of concomitant sepsis [ ] . furthermore, the prevalence of penicillinresistant pneumococcus, which has been internationally emphasized as an issue, and macrolide-resistant pneumococcus, which has been markedly observed in japan, was also a background factor for establishing respiratory quinolones as an option [ ] . the previous use of antimicrobial drugs, which is often observed in patients with nhcap, is considered to be a risk factor for resistant pneumococcus [ ] . a study reported that penicillin or em resistance in hcap patients was more advanced than in cap patients [ ] . a study indicated that the efficacy of oral therapy with lvfx was similar to that of ctrx injection therapy in patients with cap [ ] . another study reported that, among patients with non-severe hcap, oral lvfx was useful in those with no description of causative microorganisms [ ] . however, when aspiration pneumonia is suspected, grnx or mflx should be selected, because the effects of lvfx on anaerobes are weak. furthermore, several studies suggested the usefulness of mflx, which is not influenced by the kidney function and does not require dose regulation, in elderly patients with nhcap [ , ] . as treatment is completed with a single, high dose, compliance is favorable. azm sustained-release preparations [ e ], which simultaneously cover bacteria and atypical pathogens, and stfx, which shows a favorable mic for anaerobes, may also be recommended [ ] . a first choices -cva/ampc, oral ( / mg), tablets/ e times a day -sbtpc, oral ( mg), tablets/ e times a day table risk factors for involvement by drug-resistant pathogens a in nhcap [ ] . history of antibiotic therapy for or more days in the preceding days current tube feeding the risk of mrsa should be taken into account whenever there is past history of mrsa isolation. when attempting to predict the isolation of drug-resistant pathogens based on the presence of these risk factors, it should be borne in mind that their sensitivity and negative predictive value are high, but their specificity and positive predictive value are low. a drug-resistant pathogens include pseudomonas aeruginosa, mrsa, acinetobacter, esbl-producing enteric bacteria, and stenotrophomonas maltophilia. table possible pathogens isolated from nhcap patients [ ] . when an nhcap patient has no risk factors for involvement by drug-resistant pathogens pneumococcus mssa gram-negative enteric bacteria (including klebsiella and e. coli) haemophilus influenzae oral streptococci atypical pathogens (particularly chlamydophila) when an nhcap patient has a risk factor for involvement by drug-resistant pathogens (the following will be considered in addition to the above-mentioned pathogens) pseudomonas aeruginosa mrsa acinetobacter esbl-producing enteric bacteria þ one of the followings: -azm sustained-release preparation, oral, g/single dose -cam, oral, mg/twice a day <> second choices -mflx, oral, mg/once a day -grnx, oral, mg/once a day -stfx, oral, mg/l to times a day or -ctrx * , intravenous drip, g/once a day or g/twice a day -ctx * , intravenous drip, e g/ e times a day þ one of the followings: -azm sustained-release preparation, oral, g/single dose -cam, oral, mg/twice a day * ) as the antimicrobial activity of the drug against anaerobes is insufficient, it is inappropriate under a tentative diagnosis of aspiration pneumonia. ( ) cases in which there is no risk of resistant bacteria and hospital treatment is performed (group b) in this category, we recommend monotherapy from the perspectives of causative microorganisms resembling those for cap and side effect-based "innocent properties". a study reported that initial treatment with narrow-spectrum antimicrobial drugs did not always lead to a poor prognosis [ ] . in particular, according to two articles [ , ] , it is not necessary to consider resistant bacteria in hcap patients in whom causative microorganisms are unclear; treatment in accordance with cap treatment is sufficient (bii). however, an advanced age, central nervous diseases, aspiration, and a reduction in adl are the clinical characteristics of aspiration pneumonia. the condition of nhcap in japan overlaps with aspiration pneumonia [ ] . therefore, in group b, to which patients admitted for the first time, with no recent use of antimicrobial drugs, correspond, antimicrobial therapy with b-lactamase inhibitor-containing penicillins is appropriate, as described for cap. however, when aspiration pneumonia is suspected, ctrx and lvfx should be avoided (biv). for the management of enteric bacteria, candidate drugs for group b, papm/bp, may be selected. actually, it is not necessary to consider p. aeruginosa in patients with cap or non-icu hap. a study indicated that ertapenem, which is not effective for p. aeruginosa, was useful [ ] , as demonstrated for papm/bp. however, another study reported that the widespread use of ertapenem induced the cross resistance of p. aeruginosa to other carbapenems; the use of papm/bp alone should be avoided [ ] (biv). in elderly persons, with a high risk of aspiration, who are repeatedly admitted and discharged, klebsiella is often involved. taz/pipc is more useful according to a study [ ] (bii). in patients in whom gram-negative bacillus is detected on gram staining of sputum or those in whom the involvement of enteric bacteria is suspected, papm/bp or taz/pipc should be selected (biv). -sbt/abpc, intravenous drip, g/ e times a day -ctrx * , intravenous drip, g/once a day or g/twice a day -ctx * , intravenous drip, e g/ e times a day -lvfx * , intravenous drip, mg/once a day -papm/bp, intravenous drip, . e g/ e times a day * ) as the antimicrobial activity of the drug against anaerobes is insufficient, it is inappropriate under a tentative diagnosis of aspiration pneumonia. ( ) cases in which there is a risk of resistant bacteria and hospital treatment is performed (group c) the target microorganisms include p. aeruginosa, mrsa, and acinetobacter spp. in addition to frequent microorganisms that cause respiratory infection [ , , , ] . as antimicrobial drugs, taz/pipc, with an antimicrobial activity against p. aeruginosa, fourth-generation cephems, carbapenems, and quinolones (cpfx, pzfx) are recommended. taz/ pipc exhibits effects similar to those of ipm/cs and mepm in patients with nursing and healthcare-associated pneumonia [ ] (bii). pzfx also has an antimicrobial activity against s. pneumoniae when used at a high dose ( g/day). when pneumonia related to atypical pathogens such as chlamydophila spp. is suggested, quinolones should be selected. as the antimicrobial activities of fourth-generation cephems and quinolones against anaerobes are weak, these drugs should be combined with mnz, cldm, or sbt/abpc. recently, the resistance of the bacteroides fragilis group to cldm has advanced [ ] . therefore, in europe and the united states, mnz is selected as a first-choice antimicrobial drug against anaerobes. however, the rate at which the b. fragilis group is involved in oral anaerobes is low, and combination therapy with cldm may be selected [ , ] . therefore, for combination therapy with fourth-generation cephems, we recommend the two drugs. when there is a risk of mrsa, such as previous admission, they should be combined with vcm, teic, or lzd. if there is no abscess formation, abk is also effective. a first choices -taz/pipc, intravenous drip, . g/ e times a day -ipm/cs, intravenous drip, . e g/ e times a day -mepm, intravenous drip, g/ e times a day -drpm, intravenous drip, . e g/ times a day <> second choices -cfpm* , intravenous drip, e g/ e times a day -cpr * , intravenous drip, e g/ e times a day þ one of the followings: -cldm, intravenous drip, mg/ e times a day -mnz, intravenous drip, mg/ times a day or -cpfx * , intravenous drip, mg/twice a day -pzfx * , intravenous drip, mg/twice a day þ one of the followings: -cldm, intravenous drip, mg/ e times a day -sbt/abpc, intravenous drip, g/ e times a day *in addition to the above drugs, if mrsa infection is suspected, antimicrobial drugs should be added in accordance with the section "mrsa pneumonia". * ) as the antimicrobial activity of the drug against anaerobes is insufficient, it should be combined with a drug with an antimicrobial activity against anaerobes (mnz, cldm, or sbt/abpc) under a tentative diagnosis of aspiration pneumonia. ( ) severe cases requiring intensive care (group d) to cover l. pneumophila and atypical pathogens, which are rare as causative microorganisms but may cause severe conditions, group-c antimicrobial drugs should be combined with cpfx, pzfx, or azm injection (bi). concerning the usefulness of combination therapy with a b-lactam and macrolide injection for severe pneumonia, evidence has been accumulated [ ] . a study indicated that, in severe community-acquired pneumonia patients with sepsis or requiring icu management, combination therapy with a blactam and macrolide led to a more favorable prognosis compared to that with a quinolone (i), suggesting that antiinflammatory actions are involved in the mechanism [ ] . in addition, another study reported that, among pneumonia patients with acute pulmonary disorder, both the ventilator withdrawal and survival rates in a macrolide-treated group were higher than in a non-macrolide-treated group [ ] (i). several meta-analyses also support them [ , ] . a first choices -taz/pipc, intravenous drip, . g/ e times a day -ipm/cs, intravenous drip, . e g/ e times a day -mepm, intravenous drip, g/ e times a day -drpm, intravenous drip, . e g/ times a day þ one of the followings: -cpfx * , intravenous drip, mg/twice a day -pzfx * , intravenous drip, mg/twice a day -azm, intravenous drip, mg/once a day <> second choices -cfpm * , intravenous drip, e g/ e times a day -cpr * , intravenous drip, e g/ e times a day þ one of the followings: -cldm, intravenous drip, mg/ e times a day -mnz, intravenous drip, mg/ times a day þ one of the followings: -cpfx * , intravenous drip, mg/twice a day -pzfx * , intravenous drip, mg/twice a day -azm, intravenous drip, mg/once a day in addition to the above drugs, *if mrsa infection is suspected, antimicrobial drugs should be added in accordance with the section "mrsa pneumonia". * ) as the antimicrobial activity of the drug against anaerobes is insufficient, it should be combined with a drug with an antimicrobial activity against anaerobes (mnz, cldm, or sbt/abpc) under a tentative diagnosis of aspiration pneumonia. antimicrobial drugs against identified causative microorganisms should be selected in accordance with the section " . hospital-acquired pneumonia" (p. ). ---executive summary----as oral indigenous bacteria, including anaerobes, cause aspiration pneumonia, b-lactamase inhibitor-containing penicillins are appropriate (bii). -in cases of nosocomial onset, it is necessary to cover gramnegative bacillus, including p. aeruginosa. -in cases of severe ventilator-associated pneumonia (vap), the selection of broad-spectrum antimicrobial drugs or combination therapy with them should not be hesitated (ai). -the detection rate of esbl-producing gram-negative bacillus has increased, and antimicrobial drugs should be carefully selected. -it is important to prevent subclinical aspiration through oral care and the prevention of gastroesophageal reflux, such as head lifting (bii). -to prevent aspiration pneumonia, it is also important to improve the nutritional status and avoid the overuse of sleeping pills/ sedatives (bii). ---explanation---[characteristic and classification of diseases] aspiration pneumonia occurs with a background factor, dysphagia, which is frequently observed in the presence of a reduction in adl or systemic functions, especially cerebrovascular disorder. its onset is associated with dietary ingestion in elderly persons [ ] . currently, aspiration pneumonia is accurately defined only in the guidelines for the management of hospitalacquired pneumonia (hap) in adults, which were prepared by the japanese respiratory society [ ] . the guidelines present conditions that may cause dysphagia, which were proposed by the japanese study group on aspiration pulmonary disease (table , modified) [ ] . in our guidelines, we primarily explain antimicrobial drugs to be selected for patients with such conditions. the above definition is also adopted in the guidelines for the management of nursing and healthcare-associated pneumonia (nhcap) [ ] . in elderly persons admitted to long-term care beds or nursing homes, risk factors include dysphagia and tubal feeding according to international data on pneumonia that develops in nursing homes [ e ]. in japan, frequent underlying diseases in patients with nhcap also include central nervous diseases and dementia, which are closely associated with aspiration. the proportion of patients after percutaneous endoscopic gastrostomy (peg) is high [ ] . however, among various types of community-acquired pneumonia, a diagnosis of aspiration pneumonia is made based on onset factor-based classification, and is not equal to nhcap diagnosed primarily based on the place of onset or grade of nursing. according to data in spain, aspiration pneumonia accounts for . % of patients with healthcareassociated pneumonia (hcap) requiring admission. this percentage was markedly higher than in those with communityacquired pneumonia (cap) requiring admission ( . %), but corresponded to no more than / [ ] . on the other hand, a multicenter cooperative study involving inpatients with pneumonia in japan, where the rapid aging of society is advanced, reported that . % of patients who were admitted with cap had aspiration pneumonia. even in patients with cap, which is not classified as nhcap, the involvement of aspiration cannot be ignored [ ] . furthermore, the study indicated the involvement of aspiration in . % of patients, aged over years, with cap/ hap [ ] . in the future, the significance of distinguishing aspiration pneumonia among patients with nhcap or hap and changing therapeutic strategies should be examined. however, nhcap more markedly affects adl compared to cap, and the aspect of elderly pneumonia is emphasized; it may be significant to positively diagnose aspiration pneumonia and establish therapeutic strategies different from those for cap [ ] . concerning hap, a reduction in the immune function is a background factor. hap has two aspects: pneumonia with a high risk of resistant bacteria and that in which central nervous diseaserelated aspiration is involved. in the guidelines for the management of hospital-acquired pneumonia in adults, which were prepared by the japanese respiratory society, mendelson syndrome and vap are categorized as a group, and classifications, involving diffuse deglutition-related bronchiolitis, in which there are no findings of pneumonia, are proposed. in addition, a flow chart for diagnosis is presented [ ] (fig. ) . with respect to the condition and treatment of vap, refer to a review described by chastre et al. [ ] management other than antimicrobial drug therapy should also be considered, and bundle (table )-based prevention should be performed [ ] (aii). [type and frequency of causative microorganisms] streptococcus pneumoniae, s. aureus, and enterobacteriacae have been reported. a study indicated that k. pneumoniae was frequent [ ] . the involvement of oral indigenous bacteria, such as streptococcus anginosus group. and anaerobes, has been suggested [ , ] . in cases of nosocomial onset, gram-negative bacillus, including p. aeruginosa, must also be considered. concerning e. coli, klebsiella spp., and proteus spp., the number of esbl-producing strains may increase in the future. [rules of antimicrobial drug therapy] if appropriate antimicrobial drug therapy is not selected under a diagnosis of aspiration-related pneumonia, insufficient treatment may lead to a fatal condition, or excessive treatment may increase the number of resistant bacteria, showing negative effects. there may be differences in options for empiric therapy between patients with vap (most patients show severe conditions) and those with diffuse deglutition-related bronchiolitis, in whom the start of treatment is not accelerated. on the other hand, approaches to prevent pneumonia after aspiration or avoid aspiration are important. oral care, head lifting, and improvement in the nutritional status must be considered, and the overuse of sleeping pills/ sedatives should be avoided (bii). the best option for standard-type aspiration pneumonia is an antimicrobial drug that exists an antimicrobial activity against both aerobes and anaerobes. sbt/abpc and taz/pipc are effective for anaerobes frequently isolated in the respiratory system, such as fusobacterium spp., prevotella spp., and peptostreptococcus spp. [ , ] . as the resistance rates of these types of bacteria to the two regimens are low, these regimens are also recommended as first choices in the guidelines established by the japanese association for anaerobic infection research [ ] . however, a study reported that the previous administration of antimicrobial drugs and adl were correlated with the frequency of enterobacteriacae-or p. aeruginosa-related pneumonia [ ] . a retrospective study involving patients with aspiration pneumonia showed that the frequency of k. pneumoniae-related pneumonia was % [ ] . based on these studies, drugs to be selected should be changed in accordance with the previous administration of antimicrobial chemotherapeutic drugs in patients admitted to general or medical wards. among patients with hospital-acquired pneumonia, broad-spectrum drugs should be selected in those with severe aspiration pneumonia or vap (bii). when causative microorganisms are identified and an improvement in the condition is achieved, de-escalation should be performed. ---drugs to be recommended--a. empiric therapy ➀ no risk of resistant bacteria drugs with potent antimicrobial activities against oral anaerobes are presented. however, no article has provided high-level evidence regarding aspiration pneumonia. as the following drugs affect the intestinal flora, antimicrobial drugassociated diarrhea may occur. if symptom improvement is delayed, patients must be promptly admitted, and drip table conditions that may cause dysphagia [ ] [ ] . bundles for the prevention of ventilator-associated pneumonia. ( ) upper body lifting the head should be lifted at e . ( ) discontinuation of sedatives a sedative should be discontinued once a day to evaluate whether or not extubation is possible. ( in addition to the above items, methods to prevent aspiration pneumonia include oral care, the administration of drugs that improve the deglutition function, such as ace inhibitors and cilostazol, improvement in the nutritional status, eating/swallowing rehabilitation, and anti-pneumococcus vaccination. infusion therapy should be performed (outpatient treatment should not be prolonged). ( ) outpatient treatment a first choices -cva/ampc, oral ( / mg), tablets/ e times a day -sbtpc, oral ( mg), tablets/ e times a day <> second choices -mflx, oral, mg/once a day -stfx, oral, mg/ e times a day -grnx, oral, mg/once a day ( ) hospital treatment when a diagnosis of aspiration pneumonia is made, sbt/abpc is most frequently used in japan [ ] . kaneko et al. reported that the sensitivity of oral anaerobes that may cause aspiration pneumonia, such as peptostreptococcus spp., prevotella spp., and fusobacterium spp., to sbt/abpc was %, similar to that to taz/pipc [ ] . the effects of cldm on aspiration pneumonia or a pulmonary abscess are similar to those of sbt/abpc (bi) [ ] . sbt/abpc and cldm showed similar effects and tolerance on aspiration pneumonia ( . and . %, respectively) [ ] . oral anaerobes, excluding bacteroides spp., are still susceptible to cldm. a randomized clinical trial (rct) indicated that cldm was more potent than cephems [ ] . a first choice -sbt/abpc, intravenous drip, g/ e times a day <> second choice -cldm, intravenous drip, mg/ e times a day ➁ cases in which there is a risk of resistant bacteria or severe cases in cases in which there is a risk of resistant bacteria or severe cases, drugs should be selected in accordance with options for group c for nhcap. tubal feeding is a risk factor for aspiration, and is also a risk factor for resistant bacteria [ ] . when the involvement of enterobacteriacae, such as k. pneumoniae and e. coli, is suggested, empiric therapy should be selected in accordance with cases in which there is a risk of resistant bacteria [ ] . in japan, the proportion of esbl-producing bacteria on sputum culture in patients with respiratory infectious diseases is % or less [ ] , but the number of esbl-producing bacteria has slightly increased; this must be considered in the future [ , ] . a study reported that the clinical effects of taz/pipc on non-esblproducing k. pneumoniae were more potent than those of sbt/abpc; caution is needed [ ] . it must be considered that, in cases of aspiration pneumonia classified as hcap, enterobacteriacae is isolated at a frequency that cannot be ignored. concerning aspiration pneumonia that occurs in hospitals, some reviews proposed that antimicrobial drugs should be selected, regarding the condition as hospitalacquired pneumonia; empiric therapy may be selected in accordance with the guidelines for the management of hospital-acquired pneumonia, which were published by the japanese respiratory society [ , ] . according to a study, bipm, which does not cause kidney dysfunction in elderly patients, is also effective (civ); therefore, it is presented as an option for cases in which there is a risk of resistant bacteria [ ] . the mortality rate in patients with vap is high. if causative microorganisms cannot be initially covered, the mortality rate may increase [ ] . therefore, drugs should be selected, regarding the condition as severe aspiration pneumonia. three studies reported that, in a group in which taz/pipc was selected as a drug to be combined with aminoglycosides for vap treatment, the mortality rate was lower than in a group in which caz was selected [ e ]. in particular, when pneumonia was caused by p. aeruginosa, the clinical effects of taz/pipc were more potent than those of ipm/cs (bii). for monotherapy, information on the culture of protected specimen brush (psb) samples or broncho-alveolar lavage (bal) fluid is strongly recommended [ , ] . on the other hand, an observational study indicated that threedrug therapy (two anti-p. aeruginosa drugs þ an anti-mrsa drug) deteriorated the prognosis; an rct should be conducted in the future [ ] . therefore, if there is a risk of resistant bacteria, at least broad-spectrum antimicrobial drugs must be used for empiric therapy. however, assuming causative microorganisms with reference to gram staining reactions, minimum necessary antimicrobial drugs should be selected based on local factors (antimicrobial drug susceptibility pattern of each type of bacteria in each hospital). recently, the entity of ventilator-associated tracheobronchitis (vat) was proposed, and the disadvantages of aggressive treatment have been discussed [ ] . in a multicenter cooperative study, patients with vat, which occurred in the icu, were divided into two groups with and without antimicrobial drug therapy, and the results were compared. in the former, the incidence of vap was significantly lower, and the mechanical ventilation-free period was significantly longer. in addition, the icu mortality rate was significantly lower. on the other hand, there was no significant difference in the appearance of resistant bacteria between the two groups [ ] . a first choices -taz/pipc, intravenous drip, . g/ e times a day -ipm/cs, intravenous drip, . e g/ e times a day -mepm, intravenous drip, g/ e times a day -drpm, intravenous drip, . e g/ times a day -bipm, intravenous drip, . e . g/ e times a day <> second choices -cfpm, intravenous drip, e g/ e times a day -cpr, intravenous drip, e g/ e times a day þ one of the followings: -cldm, intravenous drip, mg/ e times a day -mnz, intravenous drip, mg/ times a day or -lvfx, intravenous drip, mg/once a day -cpfx, intravenous drip, mg/twice a day -pzfx, intravenous drip, to mg/twice a day þ one of the followings: -cldm, intravenous drip, mg/ e times a day -mnz, intravenous drip, mg/ times a day -sbt/abpc, intravenous drip, . e g/ e times a day *if mrsa infection is suspected, antimicrobial drugs should be administered in accordance with the section "mrsa pneumonia" in addition to the above drugs. [administration period of antimicrobial drugs] it is recommended that the treatment period of hospitalacquired pneumonia should be e days. however, the treatment period should be days in patients with pneumonia related to non-glucose-fermenting bacteria such as p. aeruginosa [ ] (bii). concerning vap, a study reported that there was no difference in the clinical effects between and days [ ] . to control identified causative microorganisms, antimicrobial drugs should be selected in accordance with the section "hospital-acquired pneumonia". if mrsa infection is suspected, antimicrobial drugs should be selected in accordance with the section "mrsa pneumonia". (bii). -in severe or refractory cases in which the efficacy of initial treatment is not sufficient, combination therapy with an antifungal drug should also be considered [ e ] (bii). -as the effects of combination therapy with an azole and amph-b preparation antagonize in some strains, a combination of these drugs should be avoided [ ] (aiii). -for the target treatment of this disease, an antifungal drug of which the class is different from that of a drug used for preventive administration should be used (biii). ---explanation---[characteristics of the disease] -symptoms: this disease develops in severe immunocompromised hosts such as patients received chemotherapy for leukemia or hematopoietic stem cell/organ transplantation. symptoms such as fever that does not respond to broadspectrum antimicrobial drugs, cough, dyspnea, sputum, and bloody sputum/hemoptysis are observed. -laboratory findings: chest x-ray shows an infiltrative shadow (typically, a wedge shadow involving the pleura as the base). on thoracic ct, infiltrative and nodular shadows (with a halo sign in some cases) are observed. in the recovery phase of neutrophils, an air crescent sign is noted. an increase in the inflammatory marker such as the crp level, aspergillus galactomannan antigen-positive reactions, and an increase in the ( / )-b-d-glucan level are useful for diagnosis. however, neither the sensitivity nor specificity is sufficient. the results should be carefully evaluated. -causative microorganisms: aspergillus fumigatus is frequently detected, but, recently, an increase in the number of patients with non-fumigatus aspergillus-related ipa has been indicated. -specific condition: lesions are sometimes formed in the nasal sinus and brain; caution is needed. -early diagnosis: early treatment is important for successful treatment for this disease. ---drugs to be recommended---a study reported that, in a group in which vrcz was used for the initial treatment of ipa, the results of treatment were more favorable than in a group in which d-amph was used [ ] . furthermore, another study indicated that therapy with l-amb at mg/kg/day was safer than that at mg/kg/ day, although there was no significant difference in the clinical efficacy [ ] . cpfg, mcfg, and itcz also have anti-aspergillus activities, and can be used. it is important to consider different strategies in accordance with the appearance of the host's allergy or adverse events and interactions with drugs used to treat an underlying disease. b. chronic progressive pulmonary aspergillosis (cppa) ---executive summary----in japan, various disease types such as aspergilloma with infiltration and enlargement of an existing cavity are included. cppa includes various diseases such as chronic necrotizing pulmonary aspergillosis (cnpa), chronic cavitary pulmonary aspergillosis (ccpa), and chronic fibrosing pulmonary aspergillosis (cfpa). it refers to a series of syndrome for which the administration of antifungal drugs is essential. -treatment should be started with injection. if symptoms and findings are stabilized, injection should be switched to oral drugs. -initial treatment with mcfg or cpfg should be performed [ , ] (ai). -initial treatment with itcz, vrcz, or l-amb can also be selected in accordance with the host's underlying disease or drugs used to treat the underlying disease. -for maintenance therapy, itcz and vrcz oral preparations are recommended (aiii). ---explanation---[characteristics of the disease] -symptoms: this disease develops in hosts with organic diseases such as a cavity or cystic disease of the lung or bronchus. symptoms such as fever, sputum, bloody sputum/ hemoptysis, and dyspnea are observed. -laboratory findings: chest x-ray and ct show an infiltrative shadow, enlargement of a cavity, thickening of the cavity wall/pleura, and a niveau in the cavity. there is an increase in the crp level in many patients. most patients are positive for anti-aspergillus precipitating antibody. neither aspergillus galactomannan antigen nor b-d-glucan is a clue to diagnosis. -causative microorganisms: a. fumigatus is frequently detected. non-fumigatus aspergillus-related cppa is also often observed. ---drugs to be recommended---a clinical study in japan indicated that there was no marked difference in the efficacy of treatment between mcfg-and vrcz-treated groups, whereas mcfg was safer [ ] . another study reported that there was no difference in treatment results between mcfg and cpfg [ ] . in the phase of severe symptoms such as fever and bloody sputum, treatment should be started using these injections. -pulmonary aspergilloma is classified into two types: simple and complex aspergilloma based on the grade of difficulty in resection. the former refers to aspergilloma formation in a focus with a thin wall, such as a cyst, without accessory lesions at the periphery. the latter refers to aspergilloma formation in a cavity derived from a strongly destructed existing structure of the lung, such as old pulmonary tuberculosis and bronchiectasis, with marked destructive lesions or pleural adhesion at the periphery of the cavity. ---drugs to be recommended---resection should be selected as a first choice. when resection is impossible, medical treatment can be considered. in preparation, such as l-amb, and -fc should be performed for weeks or more. subsequently, treatment should be continued using flcz or f-flcz. -in japan, cryptococcus gattii infection has also been reported. if possible, causative fungus must be isolated/identified. ---explanation---[characteristics of the disease] -symptoms: this disease is often asymptomatic, and is detected on a health checkup in many cases. -laboratory findings: chest x-ray and ct show solitary or multiple nodular and infiltrative shadows. -some cavities are observed in a lot of cases. there is no enhancement of the inflammatory marker in many cases, but glucuronoxylomannan antigen-positive reactions are detected. -causative microorganisms: this disease is caused by cryptococcus neoformans. recently, infection with c. gattii has been reported in vancouver, canada and the north area of the west coast of the united states of america; caution is needed. -c. gattii is primarily distributed in the tropical and subtropical zones. infection in humans has been considered to be rare. however, since , patients infected with c. gattii have been reported in the pacific coast of north america. even healthy adults are infected with c. gattii, and the mortality rate is high. ---drugs to be recommended---although there is no evidence regarding pulmonary cryptococcosis, flcz tablets, which have a potent activity against cryptococcus, are frequently selected when the patient's condition is stable in the absence of an underlying disease. azoles other than this drug can also be selected. [ ] (aii). -if the lesion is localized, resection should be considered. -combination therapy with an iron chelating agent and l-amb should be avoided [ ] (ai). ---explanation--- recently, an increase in the incidence of infection with cunninghamella has also been indicated. -specific condition: nasal/brain-type, dermal, and disseminated zygomycosis is observed. ---drugs to be recommended---currently, only amph preparations may be clinically useful for treating zygomycosis among antifungal drugs that are available in clinical practice in japan. as high-dose therapy must be started as early as possible, not d-amph but l-amb should be selected. -l-amb, intravenous drip, mg/kg/once a day precautions for the use of antifungal drugs (confirm the package inserts.) ➀ vrcz vision disorder, liver dysfunction, and neurological/ mental adverse events may occur. combination therapy with rfp, rbt, efavirenz, ritonavir, carbamazepine, long-acting barbiturate, pimozide, quinidine sulfate, ergot alkaloid, or triazolam is contraindicated. this drug is also contraindicated for pregnant women. as a rule, it is contraindicated for patients with a ccr of < ml/ min (injection only). as the blood concentration of vrcz may vary, tdm should be conducted. in patients with mild to moderate liver dysfunction, the dose should be regulated. ➁ itcz hepatopathy and congestive heart failure may occur. combination therapy with pimozide, quinidine, bepridil, simvastatin, triazolam, azelnidipine, ergotamine, nisoldipine, dihydroergotamine, vardenafil, eplerenone, blonanserin, sildenafil, tadalafil, aliskiren, dabigatran(itcz oral only), rivaroxaban, ergometrine, or methylergometrine is contraindicated. this drug is contraindicated for patients with severe liver diseases, pregnant women. patients with a ccr of < ml/min are also contraindicated (injection only). ➂ flcz hepatopathy and a prolongation of qt may occur. combination therapy with triazolam, ergotamine, dihydroergotamine, quinidine, or pimozide is contraindicated. this drug is also contraindicated for pregnant women. ➃ f-flcz combination therapy with triazolam, ergotamine, dihydroergotamine, quinidine, or pimozide is contraindicated. this drug is also contraindicated for pregnant women. ➄ l-amb adverse events such as nephropathy, hypopotassiumemia, and fever may occur. this drug is contraindicated during leukocyte transfusion. ➅ cpfg this drug is safe, but hepatopathy may occur. caution is needed for combination therapy with cyclosporin, tacrolimus, rfp, efavirenz, nevirapine, phenytoin, dexamethasone, or carbamazepine. ➆ mcfg this drug is safe, but hepatopathy may occur. ➇ -fc anorexia and myelopathy may occur. combination therapy with tegafur-/gimeracil-/oteracil potassium-containing drugs is contraindicated. even after the discontinuation of tegafur-/gimeracil-/oteracil potassium-containing drugs, combination therapy should be avoided within days. this drug is also contraindicated for pregnant women. ---drugs to be recommended---st combination drugs are used as a gold standard of pcp treatment. however, there have been a large number of patients in whom treatment was discontinued due to their side effects. recently, atovaquone also became available in japan as a second-choice drug. in patients with mild pcp, atovaquone tablets were as effective as st combination drugs. in those with moderate pcp, st combination drugs were more effective, but there was no significant difference due to a small number of subjects. in atovaquone-treated patients, the incidence of adverse events for which administration was discontinued was lower than in st combination drug-treated patients, suggesting that the tolerance is high [ ] . the administration period should be days in hivinfected patients and days in non-hiv-infected patients. a target daily dose of trimethoprim should be e mg/kg. -st combination drug, oral, to tablets/ times a day -st combination drug, intravenous drip, e mg as trimethoprim/ times a day (infused over e h) <> second choices -pentamidine, intravenous drip, mg/kg/once a day (infused over e h) -atovaquone oral suspension, ml ( mg as atovaquone)/twice a day for days (orally administered after meals) * adjuvant therapy in patients with a pao of < mmhg or a-ado of > mmhg in room air, one of the above drugs should be combined with a corticosteroid from the start of treatment. however, the dose may be reduced or administration may be discontinued in the early phase in accordance with symptoms. when the respiratory state is extremely unfavorable, pulse therapy should also be considered. prednisolone days e : oral, e mg/twice a day days e : oral, e mg/twice a day days e : oral, . e mg/twice a day ---precautions for each drug---(confirm the package inserts.) ➀ st combination drug (baktar tablets) fever, exanthema, digestive symptoms, hepatopathy, nephropathy, and blood disorder may occur. this drug may interact with methotrexate, sulfadoxine, pyrimethamine, diaphenylsulfone, sulfonyl amide/sulfonylurea oral drugs for diabetes, warfarin, phenytoin, cyclosporin, zidovudine, digoxin, tricyclic antidepressants, and lamivudine. this drug is contraindicated for neonates, low-birthweight infants, pregnant women, and patients with g- -pd deficiency. in patients with renal dysfunction, dose reduction must be considered. side effects such as hypoglycemia, hypotension, nephropathy, taste disorder, numbness of the tongue/lips, ventricular arrhythmia, exanthema, and fever may occur. combination therapy with zalcitabine, pfa, or amiodarone is contraindicated. this drug is contraindicated for patients with severe ventilatory disturbance. ➂ atovaquone nausea/vomiting, exanthema, and diarrhea may occur. this drug should be carefully administered to patients with severe kidney or liver dysfunction. this drug may interact with rfp, rbt, tetracycline, metoclopramide, zidovudine, acetaminophen, benzodiazepines, aciclovir, opioid analgesic drugs, cephalosporin antibiotics, antidiarrheal drugs/laxatives, and indinavir. h. cytomegalovirus (cmv) pneumonia ---executive summary----in the field of transplantation, preemptive treatment with gcv should be conducted through cmv antigenemia test monitoring. -the efficacy of preemptive treatment with vgcv or pfa is similar to that of gcv. -if a diagnosis of cmv pneumonia is made, treatment with gcv should be promptly started [ ] (aii). -vgcv and pfa are recognized as alternative drugs for gcv [ , ] (bii). -combination therapy with an antiviral drug and high-dose immunoglobulin should be performed [ ] (aiii). ---explanation--- ---antimicrobial drugs to be recommended---a first-choice drug for cmv pneumonia treatment is gcv, which has been frequently used. pfa has been used to treat cmv infection in aids patients, but experience on its use is limited in patients after hematopoietic stem cell transplantation. ( ) initial administration a first choice -gcv, intravenous drip, mg/kg (over h or more)/ every h for e weeks þ anti-cmv high-titer gamma globulin, intravenous drip, . e g/once a day for the first days <> second choices -pfa, intravenous drip, mg/kg (over h or more)/ times a day, every h for e weeks or more þ anti-cmv high-titer gamma globulin, intravenous drip, . e g/once a day for the first days or -pfa, intravenous drip, mg/kg (over h or more)/ twice a day, every h for e weeks or more þ anti-cmv high-titer gamma globulin, intravenous drip, . e g/once a day for the first days ( ) maintenance administration a first choices -gcv, intravenous drip, mg/kg (over h or more)/once a day, days a week or -gcv, intravenous drip, mg/kg (over h or more)/once a day, days a week * this regimen should be completed after confirming the disappearance of clinical symptoms and negative reactions on two consecutive cmv antigenemia tests. <> second choice -pfa, intravenous drip, e mg/kg (over h or more)/once a day (in clinical practice in japan, there have been few case reports on once-a-day administration at mg/ kg as maintenance therapy. a dose exceeding mg/ kg should be avoided. for administration at mg/kg, twice-a-day administration at mg/kg is commonly selected.) * this regimen should be completed after confirming the disappearance of clinical symptoms and negative reactions on two consecutive cmv antigenemia tests. ---precautions for each drug---(confirm the package inserts.) ➀ gcv severe leukopenia, neutropenia, anemia, thrombopenia, pancytopenia, aplastic anemia, and bone marrow suppression may occur. an animal experiment showed that this drug induced transient or irreversible spermatogenic dysfunction and reduced fertility. in humans, this drug may cause spermatogenic dysfunction. an animal experiment demonstrated the teratogenicity, mutagenicity, and carcinogenicity of this drug. in the presence of renal hypofunction, it is necessary to regulate the dose. this drug is contraindicated for patients with marked bone marrow suppression (neutrophil count: < /mm or platelet count: < , /mm ) and pregnant women. it may interact with didanosine, zidovudine, ipm/cs, bone marrow-suppressing and kidney function-affecting drugs, zalcitabine, st combination drugs, cyclosporin, probenecid, and mycophenolate mofetil. ➁ vgcv this is a prodrug of gcv. ➂ pfa acute renal failure, shock, heart failure, thrombophlebitis, and convulsion may occur. it is necessary to regulate the dose in accordance with the kidney function. combination therapy with pentamidine is contraindicated. this drug is contraindicated for patients with a ccr of < . ml/min/kg. ---executive summary---for the treatment of community-acquired pneumonia in children, antimicrobial drugs should be selected, considering age and severity. ---explanation--- patients with acute respiratory infectious disease symptoms, such as fever, nasal discharge, pharyngeal pain, and cough, and the appearance of a new infiltrative shadow in the lung on imaging examinations such as chest x-ray and ct are regarded as having pneumonia [ ] . in patients with pneumonia, thoracic auscultation findings often include accessory murmurs and the attenuation of respiratory sounds. most patients with respiratory infectious diseases consult hospitals with fever and cough. the lesion site of the airway is estimated based on symptoms and physical findings (fig. ) [ ] . in addition to thoracic findings, it is necessary to check the presence or absence of dyspnea signs, such as tachypnea, nasal alar breathing, retractive breathing, shoulder breathing, orthopnea, groaning, and cyanosis. to consider the need of antimicrobial-drug administration and options of antimicrobial drugs, pneumonia is classified into three types: bacterial, viral, and atypical pneumonia based on causative microorganisms [ ] . [type and frequency of causative microorganisms] microorganisms that cause childhood community-acquired pneumonia differ among ages. according to the data on investigation of causative microorganisms based on lavage sputum culture in japan, bacterial and viral pneumonia is frequent in infants/children aged year or younger. in those aged e years, the incidences of bacterial, viral, and atypical pneumonia are similar. in those aged over years, the incidence of atypical pneumonia is the highest [ ] (fig. ) insufficient. however, a review reported similar findings [ ] ( table ) [ ] . in children, it is not easy to investigate causative microorganisms. in institutions in which it is impossible to investigate causative microorganisms, treatment must be performed based on the statistical frequency of causative microorganisms described below. however, in those in which investigation is possible, the etiology should be investigated if possible. [rules of antimicrobial drug therapy] it is important to improve the efficacy of treatment by accurately predicting causative microorganisms and selecting an appropriate antimicrobial drug and its administration method. whether or not an antimicrobial drug should be indicated must be comprehensively evaluated by differentiating bacterial, viral, and atypical pneumonia with reference to age, severity, clinical symptoms, physical findings, laboratory data, and x-ray findings [ ] . as a rule, a single antimicrobial drug should be selected. when the type of microorganisms that caused pneumonia is identified, an antimicrobial drug should be selected through de-escalation, considering drug susceptibility and pharmacokinetics. [clinical symptoms, physical findings] wet cough and tachypnea are frequently observed in children with bacterial pneumonia. the proportion of labored breathingfree patients is high in children with mycoplasma pneumonia [ , ] . auscultation findings include intermittent accessory murmurs (rales) regardless of the type of pneumonia. in children with mycoplasma pneumonia, the proportion of those in whom auscultation findings are not marked is significantly higher than in other groups. in children with chlamydia pneumonia, fever is mild, and cough is protracted. thus, clinical symptoms and physical findings show characteristics related to causative microorganisms, but it is difficult to identify causative microorganisms based on clinical symptoms and physical findings alone in individual patients [ e ] . concerning laboratory findings on admission in children with bacterial and viral pneumonia, there are significant differences in the leukocyte count, crp level, and erythrocyte sedimentation rate between the two groups (p < . ). however, measurements overlapping in about one-third of patients are presented [ ] (fig. ) . briefly, it is impossible to accurately differentiate bacterial from viral pneumonia based on inflammatory responses reflected by the leukocyte count, crp level, and erythrocyte sedimentation rate. mycoplasma pneumonia is characterized by increases in the crp level and erythrocyte sedimentation rate, but many patients show normal leukocyte counts or a slight decrease in this parameter. furthermore, it is difficult to differentiate mycoplasma from viral pneumonia based on laboratory data [ ] . [chest x-ray] chest x-ray findings show characteristics related to causative microorganisms to some degree, but it is difficult to identify causative microorganisms in individual patients [ ] . it is important to evaluate the severity of pneumonia, for selecting outpatient or hospital treatment and reviewing the necessity of antimicrobial drugs and route of administration (oral or intravenous). the classification of severity in the guidelines for the management of respiratory infectious diseases in children in japan is presented [ ] (table ) . causative microorganisms with respect to age in children with community-acquired pneumonia [ ] . the severity classification of childhood pneumonia has not been reached in japan or internationally. this should be examined in the future. [standards for outpatient/hospital treatment] as a rule, outpatient treatment should be performed in mildstatus patients evaluated according to the severity classification, and hospital treatment in mild-status patients with dehydration. in addition, it is necessary to determine admission when outpatient treatment does not lead to an improvement in symptoms or considering social adaptation [ ] (table ) . [initial antimicrobial drug therapy] when examining children with pneumonia, treatment must be started without any precise information about causative microorganism in many cases. basically, empiric therapy should be performed, considering the severity of pneumonia and causative microorganisms. -the type of causative microorganisms depends on age and severity. therefore, the necessity of antimicrobial drugs should be examined, and selected, considering age and severity. in addition, bacterial, viral, or atypical pneumonia should be differentiated, and comprehensively evaluated in reference to clinical symptoms, physical findings, laboratory findings, and xray findings [ ] . in particular, acute bronchitis/pneumonia related to intermediately susceptible h. influenzae (mic: mg/ml) can be managed with oral ampc or abpc intravenous injection therapies [ ] . recently, the number of abpc-susceptible strains has annually decreased [ , ] . the proportion of blnar strains (mic: mg/ table age-related distribution of microorganisms that cause pneumonia in children [ ] . immediately after birth to . inflammatory response on admission in children with pneumonia [ ] . ml or more) has increased, raising an issue with respect to drug selection. when the involvement of blnar strains is suspected, high-dose ampc or new oral cephems may be necessary at outpatient clinics [ ] . the efficacy of outpatient antimicrobial drugs for blnar strains, which will increase in the future, should be carefully monitored. concerning hospital treatment, the clinical effects of abpc intravenous injection for e days until the results of a susceptibility test were clarified were investigated, and approximately % of patients responded to this therapy. there was no exacerbation in any patient [ ] . in non-responders or patients in whom clinical effects are insufficient, it is necessary to switch the antimicrobial drug. pipc, ctx, and ctrx have stable antimicrobial activities. when reviewing the clinical effects of pipc on childhood bronchopulmonary infection, the response rate was %; the results were satisfactory [ ] . -concerning treatment for m. catarrhalis pneumonia, m. catarrhalis produces b-lactamase. however, when examining the clinical course, ampc is effective [ , ] . this is because the enzymatic activity of b-lactamase produced by m. catarrhalis is low [ ] . (table ) . [evaluation of the treatment response and administration period] the administration period of antimicrobial drugs is shown in table [ ] . classification of the severity of community-acquired pneumonia in children [ ] . moderate severe . increases in the number of resistant strains of s. pneumoniae and h. influenzae derived from respiratory infectious diseases [ ] . to treat community-acquired pneumonia, antimicrobial drugs should be administered for e days. the treatment response should be evaluated after e days. in children, disease progression is often prompt, and the first evaluation should be performed after days in younger and severe-status children, and not after days [ ] . if an improvement in clinical symptoms or laboratory data is achieved, the same antimicrobial drug should be continued until an appropriate antimicrobial drug and drug susceptibility are clarified. with respect to the administration period of antimicrobial drugs, factors such as the type of causative microorganisms and patient background differ among individual patients; therefore, it is difficult to establish standardized criteria. as m. pneumoniae and c. pneumoniae slowly proliferate, the treatment period is prolonged (table ). in patients infected with general bacteria, the administration of antimicrobial drugs can be discontinued days after pyretolysis [ ] . however, further antimicrobial drug therapy is necessary to treat s. aureus pneumonia. [management for non-responders to antimicrobial drugs] when there are no therapeutic effects of antimicrobial drugs on pneumonia, whether or not a diagnosis of pneumonia is correct should be initially investigated [ ] . the possibility of diseases other than pneumonia, with a pneumonia-like shadow, must be reviewed (table ). if it can be ruled out, whether or not the expected type of pathogenic microorganisms is correct should be examined. if the type of causative microorganisms is the same as expected, the possibility of resistant microorganisms should be considered. new therapeutic strategies should be devised carefully and promptly. when the condition further exacerbates despite treatment switching, additional examination should be conducted. [ ] . concepts regarding the diagnosis and treatment of childhood mycoplasma pneumonia [ ] . . as it is often difficult to make a diagnosis of mycoplasma pneumoniae infection based on serum antibody titer-positive findings in the acute stage alone, the mycoplasma pneumoniae nucleic acid identification test (lamp method) should be conducted to make a definitive diagnosis in the acute stage. . as first-choice drugs for mycoplasma pneumonia, macrolides should be used. . the effects of macrolides can be evaluated based on pyretolysis within e days after administration. . to treat pneumonia that does not respond to macrolides, the administration of tosufloxacin or tetracyclines should be considered if necessary. however, as a rule, tetracyclines are contraindicated for children aged years or younger. . these antimicrobial drugs should be administered in accordance with administration periods recommended for individual drugs. . in patients with severe pneumonia, systemic steroid therapy must be considered. however, easy steroid administration should be avoided. however, mycoplasma pneumoniae is not included in bacterial types for which this preparation may be indicated. ---drugs to be recommended--- a first choices ) cases in which there is no risk of resistant bacteria -ampc, oral, e mg/kg/ times a day -sbtpc, oral, mg/kg/ times a day -cdtr-pi, oral, mg/kg/ times a day -cfpn-pi, oral, mg/kg/ times a day -cftm-pi, oral, mg/kg/ times a day ) cases in which infection with resistant bacteria is suspected i) two years or younger, ii) pretreatment with an antimicrobial drug (within weeks), iii) concomitant development of otitis media, iv) history of pneumonia/repeated otitis media -ampc, oral, e mg/kg/ times a day -cva/ampc ( : preparation), oral, . mg/ kg/twice a day -cdtr-pi, oral, mg/kg/ times a day -cfpn-pi, oral, mg/kg/ times a day -cftm-pi, oral, mg/kg/ times a day ) cases in which onset/recurrence/recrudescence is observed despite previous treatment ) -tbpm-pi, oral, e mg/kg/twice a day -tflx, oral, mg/kg/twice a day <> second choices -azm, oral, mg/kg/once a day for days -cam, oral, . mg/kg/twice a day ( ) admission (moderate, general ward) a first choices -abpc, intravenous injection or drip, mg/kg/ times a day -pipc, intravenous injection or drip, mg/kg/ times a day -sbt/abpc, intravenous injection or drip, mg/kg/ times a day * when m. pneumoniae, chlamydia trachomatis, or c. pneumoniae infection is strongly suspected, one of the above regimens should be combined with a macrolide [with respect to the administration method/ dose, refer to the section "➁ six years or older---( ) outpatient clinic (mild)".]. <> second choices -ctx, intravenous injection or drip, mg/kg/ times a day -ctrx, intravenous injection or drip, e mg/kg/ once to twice a day ( e mg/kg/day) ( ) admission (severe, icu) -papm/bp, intravenous drip, mg/kg/ times a day -mepm, intravenous drip, mg/kg/ times a day -taz/pipc, intravenous drip, . mg/kg/ times a day * when legionellosis cannot be ruled out, one of the above regimens should be combined with a macrolide [with respect to the administration method/dose, refer to the section "➁ six years or older---( ) admission (moderate, general ward)".]. ➁ six years or older ( ) outpatient clinic (mild) a first choices -azm, oral, mg/kg/once a day for days -cam, oral, . mg/kg/twice a day <> second choices -ampc, oral, e mg/kg/ times a day -sbtpc, oral, mg/kg/ times a day -cdtr-pi, oral, mg/kg/ times a day -cfpn-pi, oral, mg/kg/ times a day -cftm-pi, oral, mg/kg/ times a day -mino, oral, e mg/kg/twice a day (in children aged years or younger, the use of this drug is limited to those in whom other drugs cannot be used or nonresponders to other drugs.) ( a first choices ) cases in which bacterial pneumonia is suspected -abpc, intravenous injection or drip, mg/kg/ times a day -pipc, intravenous injection or drip, mg/kg/ times a day -sbt/abpc, intravenous injection or drip, mg/ kg/ times a day -ctx, intravenous injection or drip, mg/kg/ times a day -ctrx, intravenous injection or drip, e mg/ kg/once to twice a day ( e mg/kg/day) ) cases in which atypical pneumonia is suspected -azm, oral, mg/kg/once a day for days -cam, oral, . mg/kg/twice a day -em, intravenous drip, mg/kg/ e times a day -mino, oral or intravenous drip, e mg/kg/twice a day (in children aged years or younger, the use of this drug is limited to those in whom other drugs cannot be used or non-responders to other drugs.) ) cases in which it is impossible to differentiate bacterial from atypical pneumonia one drug each should be selected from choices ) and ), and combined. -em, oral, e mg/kg/ times a day -azm, oral, mg/kg/once a day for days -cam, oral, . mg/kg/twice a day -em, intravenous drip, mg/kg/ e times a day -mino, oral or intravenous drip, e mg/kg/twice a day (in children aged years or younger, the use of this drug is limited to those in whom other drugs cannot be used or non-responders to other drugs.) ---executive summary---for the treatment of hospital-acquired pneumonia in children, antimicrobial drugs should be selected, considering severity and the involvement of resistant bacteria. empiric therapy should be started by combining two drugs if necessary, considering various resistant microorganisms, differing from that for communityacquired pneumonia (biii). hospital-acquired pneumonia is defined as pneumonia that newly develops h or more after admission. ventilator-associated pneumonia is defined as pneumonia that develops h or more after endotracheal intubation [ ] . these conditions may become severe due to an underlying disease, reduced immune capacity, or the deterioration of the general condition, and are caused by drugresistant microorganisms in many cases; treatment is difficult in most cases. not only microorganisms acquired in the community but also those existing in the hospital environment cause hospital-acquired pneumonia in children, as reported in the adult field. bacteria that cause community-acquired pneumonia (s. pneumoniae, h. influenzae), enteric bacteria (e. coli, k. pneumoniae), s. aureus, non-glucose-fermenting bacteria, such as p. aeruginosa, and acinetobacter spp., and anaerobes cause hospital-acquired pneumonia [ ] . in addition, not only general bacteria but also fungus and viruses sometimes cause hospital-acquired pneumonia in patients with immunodeficiency. among patients with nosocomial infection, causative microorganisms differ, and drug-resistant microorganisms are involved in many cases. in children, it is not easy to investigate causative microorganisms, but, if drug susceptibility is clarified, it contributes to successful treatment. therefore, lavage or aspiration sputum culture should be conducted to investigate the etiology, if possible [ , ] . [rules of antimicrobial drug therapy] basically, empiric therapy should be performed, considering the severity of pneumonia, an underlying disease, and causative microorganisms. in particular, the involvement of drug-resistant microorganisms, such as mrsa, extended-spectrum b-lactamase (esbl)-producing bacteria, and multi-drug-resistant p. aeruginosa (mdrp), must always be considered for treatment. empiric therapy should be started by combining two drugs if necessary, considering various resistant microorganisms, differing from that for community-acquired pneumonia [ ] . as the state of resistant bacteria differs among institutions, antimicrobial drug options should be customized based on records on antimicrobial drug susceptibility (antibiograms) at each institution. a consensus regarding the administration period of antimicrobial drugs has not been reached. with respect to the administration period of antimicrobial drugs, factors such as the type of causative microorganisms and patient background differ among individual patients with nosocomial infection; therefore, it is difficult to establish standardized criteria. however, when complications such as severe immunodeficiency, pulmonary suppuration, lung abscess, and pleuritis are absent, antimicrobial drugs should be administered for days after pyretolysis ( e days) [ ] . considering an underlying disease or the immune state, flexible management must be performed. in children, disease progression is often prompt, and the first evaluation should be performed after days in younger and severe-status children, and not after days [ ] . if an improvement in clinical symptoms or laboratory data is achieved, the same antimicrobial drug should be continued until an appropriate antimicrobial drug and drug susceptibility are clarified. when the type of microorganisms that caused pneumonia is identified, a target-focused antimicrobial drug should be selected through de-escalation, considering drug susceptibility and pharmacokinetics [ ] . concerning multi-drug-resistant microorganisms, it is important to promote standard preventive strategies and those to control nosocomial infection, such as the prevention of droplet/contact infection, thoroughly. furthermore, oral care and devised postures (if there is no medical contraindication, the head should be lifted at e .) are necessary to prevent vap [ ] . in this article, the classification of severity (table , p. ) in the guidelines for the management of respiratory infectious diseases in children in japan was used [ ] (refer to the section " . pneumonia (children), . community-acquired pneumonia".). ---drugs to be recommended--- a first choices -caz, intravenous injection or drip, mg/kg/ times a day -czop, intravenous injection or drip, mg/kg/ e times a day -cpr, intravenous injection or drip, mg/kg/ e times a day if necessary, one of the above regimens should be combined with one of the following drugs: ) cases in which anaerobe infection is suspected (such as aspiration pneumonia) -cldm, intravenous drip, in children with immunodeficiency-/blood disease-related pneumonia, antimicrobial drugs should be selected, considering an underlying disease, the grade of immunodeficiency, and involvement of various causative microorganisms. initial antimicrobial drug therapy should be started by combining two drugs if necessary, considering various causative microorganisms, differing from that for community-acquired pneumonia (biii). [characteristics and classification of the disease] as immunodeficiency-/blood disease-related pneumonia in children often develops in hospitals, it has the characteristics of hospital-acquired pneumonia in many cases. it may become severe due to the patient's unfavorable conditions, such as an underlying disease, reduced immune capacity, and the deterioration of the general condition. even non-pathogenic microorganisms may cause pneumonia in many cases. furthermore, drug-resistant microorganisms often cause pneumonia; treatment is difficult in many cases [ , ] . to achieve multidisciplinary, comprehensive treatment to save children, it is necessary to cooperate with other special fields. [type and frequency of causative microorganisms] not only microorganisms acquired in the community in the presence of various immunodeficiency states but also nonpathogenic microorganisms existing in the hospital environment cause immunodeficiency-/blood disease-related pneumonia in children. bacteria that cause community-acquired pneumonia (s. pneumoniae, h. influenzae), enteric bacteria (e. coli, k. pneumoniae), s. aureus, non-glucose-fermenting bacteria, such as p. aeruginosa, and acinetobacter spp., and anaerobes cause this type of pneumonia. in addition, not only general bacteria but also fungus and viruses often cause this type of pneumonia. furthermore, drugresistant microorganisms are involved in many cases, as indicated for hospital-acquired pneumonia [ , ] . [type of immunodeficiency, causative microorganisms to be monitored, and precautions for diagnosis] ➀ humoral immunodeficiency: as bacterial opsonization and complement activation are affected, patients with humoral immunodeficiency are prone to be infected with general bacteria. among immunodeficiency patients with hyper-igm-emia, pneumocystis pneumonia should be considered in those with conditions related to cd ligand abnormalities. ➁ cellular immunodeficiency: in addition to infection with general bacteria, infection with intracellular parasitic bacteria, fungus, or protozoa may become severe, and be protracted. as the differentiation and induction of b and killer t cells by cd -positive lymphocytes are affected, the eradication of virus-infected cells is inhibited (table ) [ ] . ➂ neutrophil abnormalities: neutrophil abnormalities are classified into two types: neutropenia and neutrophil functional disorders. patients with a peripheral blood absolute neutrophil count (anc) of < /ml or those in whom the anc is estimated to reach < /ml within h are regarded as having neutropenia [ ] . of these, the risk is higher in patients with an anc of /ml or less in whom the period is estimated to exceed days. many patients with neutropenia do not show purulent sputum or abnormal findings on chest x-ray even in the presence of pneumonia. therefore, when fever persists, thoracic ct should be performed in the early stage. all microorganisms including general bacteria (gram-positive bacteria, gramnegative bacteria), fungus, and viruses may cause pneumonia. in particular, in addition to neutropenia early after homologous hematopoietic stem cell transplantation, infection-prone features associated with humoral/cellular immunodeficiency related to the administration of immunosuppressives persist over a long period. furthermore, the concomitant development of acute/chronic graft-versus-host disease (gvhd) is a risk factor for the onset of pneumonia. in addition, non-infectious pulmonary disorder related to drugs/radiation for pretreatment may occur, and it is important to differentiate it from infectious diseases (fig. ) [ , ] . a representative neutrophil functional disorder, chronic granulomatosis, induces active oxygen production disorder of neutrophils, affecting bactericidal actions. therefore, patients with this disorder are prone to be infected with non-h o -producing catalase-positive bacteria (s. aureus, k. pneumoniae, e. coli, candida spp., aspergillus spp.). ➃ complement deficiency: patients with complement deficiency are prone to be infected with bacteria with capsules, such as s. pneumoniae, h. influenzae (capsule strains), and neisseria meningitidis [ ] . in children, it is not easy to investigate causative microorganisms, but, if drug susceptibility is clarified, it contributes to successful treatment. therefore, various cultures should be conducted to investigate the etiology, if possible. in addition, testing of various antigens, such as urinary s. pneumoniae/legionella antigens, b-dglucan, aspergillus antigen, cryptococcus antigen, candida antigen, and cytomegalovirus antigen, and tests using nucleic acid amplification methods, such as the pcr method, should be utilized, if possible. [rules of antimicrobial drug therapy] initial antimicrobial drug therapy should be performed, considering the severity of pneumonia and an underlying disease. for the treatment of immunodeficiency-/blood disease-related pneumonia in children, antimicrobial drug therapy should also be basically selected, considering causative microorganisms. as described for nosocomial infection, the involvement of drugresistant microorganisms, such as mrsa, extended-spectrum blactamase (esbl)-producing bacteria, and multi-drug-resistant p. aeruginosa (mdrp), must always be considered for treatment. initial antimicrobial drug therapy should be started by combining two drugs, if necessary, considering various resistant microorganisms, differing from that for community-acquired pneumonia [ , ] . as the state of resistant bacteria differs among institutions, antimicrobial drug options should be customized based on records on antimicrobial drug susceptibility (antibiograms) at each institution. a consensus regarding the administration period of antimicrobial drugs has not been reached. with respect to the administration period of antimicrobial drugs, factors such as the type of causative microorganisms and patient background differ among individual patients with nosocomial infection; therefore, it is difficult to establish standardized criteria. in children, disease progression is often prompt, and the first evaluation should be performed after days in younger and severe-status children, and not after days. if an improvement in clinical symptoms or laboratory data is achieved, the same antimicrobial drug should be continued until an appropriate antimicrobial drug and drug susceptibility are clarified. when the type of microorganisms that caused pneumonia is identified, a target-focused antimicrobial drug should be selected through de-escalation, considering drug susceptibility and pharmacokinetics [ ] . monitoring culture of the airway is useful for treating immunodeficiency-/blood disease-related pneumonia in children [ ] . general preventive methods are presented in table [ ] . in addition, long-term low-dose macrolide therapy or the intermittent administration of b-lactams to prevent p. aeruginosa fixation is effective in some patients with chronic bronchitis [ , ] . in those with chronic granulomatosis, the oral administration of itcz ( e mg/kg/day, maximum: mg/day) or subcutaneous injection of ifn-g ( , domestic standard units/m , e times a week) is useful for preventing infection [ ] . in this article, the classification of severity (table , p. ) in the guidelines for the management of respiratory infectious diseases in children in japan was used (refer to the section " . pneumonia (children), . community-acquired pneumonia".). ---drugs to be recommended--- ( ) pneumonia related to mild immunodeficiency in the initial phase after admission -sbt/abpc, intravenous injection or drip, mg/kg/ e times a day -ctx, intravenous injection or drip, mg/kg/ e times a day -ctrx, intravenous injection or drip, mg/kg/twice a day ( ) pneumonia related to moderate/severe immunodeficiency -caz, intravenous injection or drip, mg/kg/ e times a day -czop, intravenous injection or drip, mg/kg/ e times a day -cpr, intravenous injection or drip, mg/kg/ e times a day in severe cases, -papm/bp, intravenous drip, mg/kg/ times a day -mepm, intravenous drip, mg/kg/ times a day -drpm, intravenous drip, mg/kg/ times a day -taz/pipc, intravenous drip, . mg/kg/ times a day -vcm, intravenous drip, mg/kg/ times a day -abk, intravenous drip, e mg/kg/once a day -teic, intravenous drip, mg/kg/every h, times, subsequently: e mg/kg/once a day when there is no response, -amk, intravenous drip, e . mg/kg/twice a day -tob, intravenous drip, . mg/kg/ times a day if necessary, an antifungal drug (mcfg) and st combination drug should be additionally administered. when aspergillus infection is suspected, treatment should be started with vrcz or l-amb instead of mcfg. in patients with cellular immunodeficiency, one of the above drugs should be combined with mcfg and an st combination drug in the early stage. in those with neutrophil abnormalities, one of the above drugs should be combined with mcfg in the early stage. when legionellosis cannot be ruled out in the severest cases, one of the above regimens should be combined with a macrolide (with respect to the administration method/dose, refer to the section " . community-acquired pneumonia---➁ six years or older---( ) admission (moderate, general ward)" (p. ).). in the presence of gcv resistance, the intravenous drip of pfa (foscarnet), mg/kg/ times a day should be performed. ---executive summary---in the treatment of neonatal pneumonia, antimicrobial drugs should be selected after differentiating congenital from acquired pneumonia. initial antimicrobial drug therapy should be started by combining two drugs, regarding the condition as severe systemic infection and considering various causative microorganisms. the administration method and dose should be selected based on the age (days) and birth weight (biii). [characteristics and classification of the disease] the incidence of neonatal pneumonia is not high. according to sakata, pneumonia occurred in only ( . %) of approximately , neonates who were admitted during a -year period [ ] . neonatal pneumonia is frequently observed as a portion of systemic infection represented by sepsis, and not as a single condition. it is classified into two types: congenital and acquired pneumonia [ ] . in most cases, neonatal pneumonia does not cause any typical symptoms such as fever or cough in comparison with infantile/ childhood pneumonia. the neonatal protective capacity against infection is physiologically immature, often leading to a severe condition. in the neonatal phase, artificial respiration management is performed in many cases, and ventilator-associated pneumonia (vap) is frequently observed [ e ]. in addition, many neonates are admitted to the neonatal intensive care unit (nicu) for a long period; therefore, the incidence of nosocomial infection is high. [type and frequency of causative microorganisms] several types of congenital pneumonia include transplacental infection, intrauterine infection related to aspiration of infected amniotic fluid on premature rupture, and birth canal infection with vaginal discharge on delivery. these types of congenital pneumonia are primarily caused by various viruses (cytomegalovirus, herpes simplex virus), bacteria (streptococcus agalactiae (gbs), e. coli, listeria monocytogenes), chlamydia, and fungus. the clinical onset of perinatal pneumonia is frequently observed immediately to days after birth [ ] . postnatal pneumonia usually develops weeks or more after birth. it is caused by viruses and bacteria. viral infection may occur when rs virus, parainfluenza virus, or adenovirus prevails in the ward. however, it rarely leads to the onset of pneumonia. frequent causative bacteria include s. aureus, e. coli, p. aeruginosa, acinetobacter spp., enterobacter spp., and legionella spp., which exist in the environment. these often cause nosocomial infection [ ] . in premature babies, gram staining of tracheal aspirate samples is useful for selecting antimicrobial drugs to be administered in the initial phase [ ] . in children, it is not easy to investigate causative microorganisms, but, if drug susceptibility is clarified, it contributes to successful treatment. therefore, blood or bronchial lavage fluid culture should be conducted to investigate the etiology, if possible. [rules of antimicrobial drug therapy] as many neonates have systemic infection in an immunodeficiency state, the same administration method and dose as selected for the treatment of sepsis should be used [ ] . therefore, the severity of pneumonia is not considered. when bacterial pneumonia is suspected, combination therapy with abpc and ctx is commonly selected as initial treatment. considering l. monocytogenes infection, combination therapy with abpc is recommended. after causative microorganisms are identified, antimicrobial drugs should be selected with reference to their drug susceptibility. in cases of vap, antimicrobial drug options should be customized based on records on the drug susceptibility (antibiograms) of microorganisms that cause nosocomial infection at each institution. in neonates, there are marked age-related differences in the pharmacokinetics of antimicrobial drugs; therefore, these drugs must be carefully administered in the neonatal phase. concretely, the same dose as established in the field of pediatrics should be used, and the administration interval should be prolonged in accordance with age [ ] . in cases of severe asphyxia or acute renal failure, the administration interval must be further prolonged. it should be shortened with an improvement in the kidney function [ e ] . a consensus regarding the administration period of antimicrobial drugs has not been reached. however, the standard administration period is days. with respect to the administration method/dose, refer to the section "xi. doses for neonates". in neonates, disease progression is often prompt, and the treatment response should be evaluated after days, and not after days. if an improvement in clinical symptoms or laboratory data is achieved, the same antimicrobial drug should be continued until an appropriate antimicrobial drug and drug susceptibility are clarified. when the type of microorganisms that caused pneumonia is identified, a target-focused antimicrobial drug should be selected through de-escalation, considering drug susceptibility and pharmacokinetics [ ] . ---drugs to be recommended--- ---executive summary----pyothorax refers to a condition in which pus accumulates in the thoracic cavity. usually, pleural effusion puncture is performed, and a diagnosis of pyothorax is made based on the results of various examinations, such as (macroscopic) purulent pleural effusion, microorganisms detected on gram staining or culture of pleural effusion, or pleural effusion ph: < . (biii). -in patients with acute pyothorax related to community-acquired pneumonia, treatment should be performed in accordance with that for community-acquired pneumonia, considering microorganisms that cause community-acquired pneumonia, such as streptococcus pneumoniae (biii). -in patients with slowly progressing pyothorax, mixed infection with oral aerobes/anaerobes is frequently observed. combination therapy with pcg or abpc and cldm or mnz, which show anti-anaerobe activities, or therapy with a single antimicrobial drug with an anti-anaerobe activity, such as sbt/abpc, should be selected (biii). -when there is a risk of multi-drug-resistant bacteria, monotherapy with a carbapenem, combination therapy with a fourthgeneration cephalosporin and cldm or mnz, and combination therapy with a quinolone and cldm or mnz should be considered, assuming esbl-producing enteric bacteria, resistant p. aeruginosa, anaerobes, and acinetobacter (biii). -if the results of culture/susceptibility tests are clarified, antimicrobial drugs should be changed in accordance with them (aiii). -the penetration of aminoglycosides to the thoracic cavity is poor, and their activities reduce when the ph is low. therefore, the use of aminoglycosides should be avoided as a rule (biii). -if a diagnosis of pyothorax is made, the administration of an appropriate antimicrobial drug should be started, and drainage must be performed (aii). if possible, the attending physician should consult a surgeon in the early stage (aiii). -in some patients with marked pleural thickening or multilocular pleural effusion, thoracoscopic debridement is necessary (biii). in addition, a fibrinolytic drug, such as streptokinase, is administered through a thoracic drain, or surgical interventions such as thoracotomy or decortication is performed in some cases (biii). ---explanation--- [diagnosis] -pyothorax is defined as a condition in which pus accumulates in the thoracic cavity, but this definition has no diagnostic objectivity. for this reason, usually, pleural effusion puncture is performed, and a diagnosis of pyothorax is made based on the results of various examinations, such as (macroscopic) purulent pleural effusion, microorganisms detected on gram staining or culture of pleural effusion, or pleural effusion ph: < . [ , ] . [causative microorganisms] -pleural effusion appears in e % of patients with bacterial pneumonia, but leads to pyothorax in . e %. other etiological factors for pyothorax include surgery, trauma, and esophageal perforation. -microorganisms that cause pyothorax depend on its etiology and course. in the presence of bacterial pneumonia, pyothorax is caused by the same microorganisms as caused bacterial pneumonia. furthermore, acute pyothorax is frequently caused by s. pneumoniae and s. aureus. however, in many patients with chronic pyothorax, mixed infection primarily with anaerobes is involved. among anaerobes, fusobacterium spp. (especially fusobacterium nucleatum), prevotella spp., peptostreptococcus spp., and bacteroides spp. are frequently detected [ e ]. according to recent studies, the detection rate of the streptococcus anginosus group is high [ , ] . -in many cases, pyothorax with a relatively slow course is associated with m. tuberculosis. it must be considered that pulmonary lesions do not always concurrently exist with tuberculous pleuritis. [treatment] -no randomized comparative study regarding antimicrobial drug treatment for pyothorax has been conducted. an antimicrobial drug with an activity against microorganisms expected or obtained on culture should be selected and administered. in acuteonset patients in whom there is no risk of resistant bacteria, for example, those with pyothorax accompanying communityacquired pneumonia, antimicrobial drugs such as pcg and abpc should be initially selected, considering s. pneumoniae. these drugs simultaneously cover fusobacterium, peptostreptococcus, and the viridans streptococcus group. however, prevotella and bacteroides produce b-lactamase; therefore, when the results of culture are not obtained, combination therapy with antimicrobial drugs with activities against anaerobes, such as cldm and mnz, or therapy with such a single drug, such as sbt/abpc, should be selected. -when there is a risk of multi-drug-resistant bacteria, monotherapy with a carbapenem should be selected as a first choice, assuming esbl-producing enteric bacteria, resistant p. aeruginosa, and acinetobacter. a fourth-generation cephalosporin should be combined with cldm, or a quinolone should be combined with cldm or sbt/abpc. -if the results of culture/susceptibility tests are clarified, antimicrobial drugs should be changed in accordance with them. however, the culture of anaerobes is difficult, or is not conducted in some cases. therefore, this should be confirmed to the laboratory. when only one type of bacteria are detected on a culture test despite several types of bacteria detected on gram staining of pleural effusion, anaerobes must also be considered. -the penetration of aminoglycosides to the thoracic cavity is poor, and their activities reduce when the ph is low. therefore, for pyothorax treatment, the use of aminoglycosides should be generally avoided [ e ]. [treatment period] -the pyothorax treatment period has not been established. however, when pneumonia promptly responds to treatment and thoracic drainage is successfully achieved in patients with pneumonia-related pyothorax, a treatment period of e days is required. in patients in whom drainage is unsuccessful, those with marked pleural thickening, or those with encapsulated/septum-like pyothorax, a treatment period of about weeks is often required. [treatments other than antimicrobial drug therapy] -after a diagnosis of pyothorax is made, the administration of an appropriate antimicrobial drug should be promptly started, and drainage is necessary. when the pleural fluid is purulent and viscous in the absence of a multilocular pattern, chest-tube insertion is routinely performed. the position of insertion should be confirmed using thoracic ct within h after insertion. wozniak et al. performed multivariate analysis involving patients with pyothorax and indicated that failure in the first drainage was strongly correlated with mortality, suggesting the necessity of early consultation with surgeons [ ] . -in some patients with marked pleural thickening or multilocular pleural effusion, thoracoscopic debridement is necessary. in addition, a fibrinolytic drug, such as streptokinase, is administered through a thoracic drain, or surgerical interventions such as thoracotomy or decortication is performed in some cases [ ] . ---drugs to be recommended--- a first choice -sbt/abpc, intravenous drip, g/ e times a day <> second choices -pcg, intravenous drip, , , to , , units/ times a day -abpc, intravenous drip, g/ e times a day þ one of the followings: -cldm, intravenous drip, mg/ e times a day -mnz, intravenous drip, mg/ times a day ➁ cases in which there is a risk of multi-drug-resistant bacteria a first choices -taz/pipc, intravenous drip, . g/ e times a day -ipm/cs, intravenous drip, . e g/ e times a day -mepm, intravenous drip, g/ e times a day -drpm, intravenous drip, . e g/ times a day <> second choices (i) -cfpm, intravenous drip, e g/ e times a day -czop, intravenous drip, e g/ e times a day -cpr, intravenous drip, e g/ e times a day þ one of the followings: -cldm, intravenous drip, mg/ e times a day -mnz, intravenous drip, mg/ times a day <> second choices (ii) -lvfx, intravenous drip, mg/once a day -cpfx, intravenous drip, mg/twice a day -pzfx, intravenous drip, to mg/twice a day þ one of the followings: -cldm, intravenous drip, mg/ e times a day -sbt/abpc, intravenous drip, g/ e times a day -mnz, intravenous drip, mg/ times a day * with respect to the risk of multi-drug-resistant bacteria, refer to the section " . hospital-acquired pneumonia" table (p. ). * in particular, mrsa infection must be considered in patients with nosocomial onset or the previous administration of antimicrobial drugs. when staphylococcus infection is suspected on gram staining of pleural effusion, an anti-mrsa drug should be used as an empiric therapy. if mssa is identified as causative bacteria, deescalation should be performed. . definitive therapy -antimicrobial drugs against causative microorganisms identified should be selected in accordance with the section " . ---executive summary---for the treatment of pyothorax in children, antimicrobial drugs should be administered after investigating the etiology using thoracentesis or blood culture, if possible. in addition to antimicrobial drug therapy, treatment for retention fluid (pleural effusion drainage, continuous drainage) must also be considered (biii). [characteristics and classification of the disease] pleuritis refers to inflammation of the pleura. fluid (pleural effusion) is retained in the pleural cavity. pleuritis is classified into types: fibrinous (dry) pleuritis, exudative (wet) pleuritis, and purulent pleuritis (pyothorax) based on conditions [ ] . on auscultation, the attenuation of respiratory sounds, as well as pleural friction rubs, are heard. percussion dullness is noted. in the chronic stage, localized pleural thickening in various shapes is observed. when pus is obtained on thoracentesis, a definitive diagnosis of pyothorax is made. when the protein level in nonpurulent pleural effusion is high, tuberculous pleuritis should be differentiated [ ] . [type and frequency of causative microorganisms] previously, pyothorax was associated with s. aureus in many cases. however, recently, such cases have been rare. according to data form a national survey in the former half of the 's, there were only a few patients with s. pneumoniae-or anaeroberelated pyothorax [ ] . in many cases, pleuritis follows m. pneumoniae-or virus-related pneumonia. decubitus-view imaging shows the retention of pleural effusion in approximately % of patients with mycoplasma pneumonia [ ] . if the drug susceptibility of causative microorganisms is clarified, it contributes to successful treatment. therefore, pleural effusion obtained by thoracentesis should be cultured to investigate the etiology, if possible. when bacterial infection-related pyothorax is suspected, the intravenous injection or drip of sbt/abpc, ctx, or ctrx should be selected in community-onset patients without an underlying disease. on the other hand, combination therapy with sbt/abpc (intravenous injection or drip) and cldm (intravenous drip) or carbapenem therapy (intravenous drip) should be started in those with an underlying disease or nosocomial onset, considering s. pneumoniae, anaerobes, h. influenzae, and s. aureus [ ] . based on the gram staining reactions of pleural effusion, causative microorganisms should be estimated, and antimicrobial drugs must be reviewed. if necessary, tuberculosis should also be investigated. the administration period of antimicrobial drugs must be longer than that for pneumonia. as the type of causative microorganisms, patient background, and state of retention-fluid drainage differ among individual patients, it is difficult to establish standardized criteria. however, target administration periods for s. pyogenes (gas)-, s. pneumoniae-, and s. aureus-related pyothorax are , , and days or more, respectively. the treatment response should be evaluated e days after the start of administration. if an improvement in clinical symptoms or laboratory data is achieved, the same antimicrobial drug should be continued until causative microorganisms and their drug susceptibility are clarified. when the type of microorganisms that caused pneumonia is identified, a targetfocused antimicrobial drug should be selected through deescalation, considering drug susceptibility and pharmacokinetics [ ] . for the treatment of pyothorax, treatment for retention fluid (pleural effusion drainage) is also a basic procedure in addition to antimicrobial drug therapy. if necessary, continuous drainage should be performed (table ) [ ] . if pleural thickening leads to underexpanded lung, decortication should be indicated. the widespread application of thoracoscopic surgery has facilitated minimally invasive surgery [ ] . ---drugs to be recommended--- ( ) community onset (without an underlying disease) -sbt/abpc, intravenous injection or drip, mg/kg/ times a day -ctx, intravenous injection or drip, mg/kg/ e times a day -ctrx, intravenous injection or drip, mg/kg/twice a day ( ) community-acquired infection (with an underlying disease), nosocomial onset -cldm, intravenous drip, mg/kg/ times a day þ -sbt/abpc, intravenous injection or drip, mg/kg/ times a day or one of the following drugs alone should be administered: -taz/pipc, intravenous drip, . mg/kg/ times a day -papm/bp, intravenous drip, mg/kg/ times a day -mepm, intravenous drip, mg/kg/ times a day -drpm, intravenous drip, mg/kg/ times a day . definitive therapy refer to the section " . community-acquired pneumonia--- . . definitive therapy" (p. ) or " . hospital-acquired pneumonia--- . . definitive therapy" (p. ). table indications for continuous drainage [ ] . ➀ cases in which pleural effusion obtained on thoracentesis is purulent ➁ cases in which clinical effects are not achieved by antimicrobial drug therapy alone (within h) ➂ cases in which retention fluid affects the respiratory function ---executive summary----as initial treatment, four drugs (inh, rfp, and pza þ eb or sm) should be administered for months. subsequently, as a rule, standard treatment (a), in which two drugs, inh and rfp, are administered for months, should be performed as maintenance treatment (ai). -when pza cannot be used for initial treatment for some reason, inh, rfp, and eb or sm, should be administered for months as initial treatment. subsequently, standard treatment (b), in which two drugs, inh and rfp, are administered for months, should be performed as maintenance treatment (aii). -in patients in whom chest x-ray shows a cavity on initial consultation to during initial treatment and the septum culture is still positive at the completion of initial treatment, maintenance treatment should be prolonged over months. in addition, the prolongation of maintenance treatment should also be considered in patients with severe tuberculosis, such as military tuberculosis and tuberculosis of the central nervous system, those with immune depression, and those with relapse of tuberculosis (aii). -for the treatment of latent tuberculosis infection, inh should be administered for or months (ai). when m. tuberculosis, as the source of infection, is resistant to inh, or when the oral administration of inh is difficult due to side effects, rfp should be used as a second-choice drug for or months (ai). ---explanation--- [ , ] . in particular, this method is named "standard treatment (a)" in the guidelines for the management of tuberculosis in in japan. in this article, this name is also used. -the secondary assessment of a study examining the efficacy of rifapentine and inh showed that factors for unsuccessful treatment/recurrence included a cavity on chest x-ray at the start of treatment and positive findings on culture at the completion of initial treatment for months [ ] . similarly, when the treatment period was extended from to months in patients with silicotuberculosis, in whom the unsuccessful treatment/recurrence rates are high, the recurrence rate decreased from to %. therefore, various guidelines recommend that maintenance treatment should be prolonged over months in patients with a cavity and those showing positive findings on septum culture at the completion of initial treatment [ , ] . -in , combs et al. compared the results of treatment between a group treated with inh, rfp, and pza for months and, then, with inh and rfp for months and that treated with inh and rfp for months, and reported that the efficacy and incidence of side effects were similar [ ] . based on such a study, the following regimen is recommended as standard treatment (b) in the guidelines for the management of tuberculosis in in japan: when pza cannot be used for some reason, inh, rfp, and eb or sm, are administered for the first months, and, subsequently, two drugs, inh and rfp, are administered for months. -patients who are infected with m. tuberculosis, but do not develop tuberculosis are regarded as having latent tuberculosis infection (ltbi). inh administration for ltbi decreases the incidence of tuberculosis by e % [ ] . previously, this was called preventive therapy, but is currently termed ltbi treatment. the decrease in the incidence of tuberculosis is correlated with compliance with inh, and more marked preventive effects may be achieved when compliance is higher [ e ]. in a study involving inh administration to ltbi patients with an old shadow on chest x-ray, this therapy inhibited the onset of tuberculosis in and % of patients treated for and months, respectively (there was no significant difference between the two groups) [ ] . based on the data, some studies recommended that the period of standard inh administration for ltbi should be months [ e ]. however, a consensus regarding an effective administration period ( or months) has not been reached from various aspects including the efficacy, compliance, expenses, and incidence of side effects. actually, the administration period should be determined based on compliance and the incidence of side effects. -in ltbi treatment, rfp should be used for or months as an alternative drug when the oral administration of inh is impossible for some reason. the preventive effects of rfp on the onset of tuberculosis in ltbi patients may be similar to those of inh. furthermore, the incidence of liver dysfunction is lower than that related to inh [ e ]. however, for the use of rfp, drug interactions must be considered. ---drugs to be recommended---a first choice -inh, oral, mg/kg/once a day (maximum: mg/ day) þ rfp, oral, mg/kg/once a day (maximum: mg/ day, orally administered before meals as a rule) þ pza, oral, mg/kg/once a day (maximum: mg/day) þ eb, oral, mg/kg/once a day (maximum: mg/day) or sm, intramuscular injection, mg/kg/once a day (maximum: mg/day)/ e times a week. * the above drugs should be administered for months, and, subsequently, two drugs, inh and rfp, should be administered for months. <> second choice -inh, oral, mg/kg/once a day (maximum: mg/ day) þ rfp, oral, mg/kg/once a day (maximum: mg/ day, orally administered before meals as a rule) þ eb, oral, mg/kg/once a day (maximum: mg/day) or sm, intramuscular injection, mg/kg/once a day (maximum: mg/day)/ e times a week. * the above drugs should be administered for months, and, subsequently, two drugs, inh and rfp, should be administered for months. [ ] . in japan, tanaka et al. conducted combination therapy with cam ( mg/kg) and eb/rfp/km in patients, and indicated that . % of those who underwent initial treatment became negative for mac [ ] . concerning cam, many studies have reported a correlation between the in vitro drug susceptibility and treatment response [ e ]. furthermore, a study indicated that azm was as effective as cam [ ] . -rbt, which was published in the drug price in nhi scheme in japan in , was also approved for tuberculosis and non-tuberculous mycobacterium infection, including pulmonary mac infection. the drug interactions of rbt are less marked than those of rfp, and rbt is used as a first-choice drug for disseminated mac infection in hiv-infected patients [ ] . on the other hand, rbt induces side effects such as uveitis. in elderly patients, in whom pulmonary mac infection frequently develops, various side effects, such as gastrointestinal disorder, make long-term therapy difficult [ ] . in addition, no study has indicated that rbt is more effective than rfp for pulmonary mac infection in non-hiv-infected patients. therefore, rfp should be selected as a first-choice drug for pulmonary mac infection in non-hiv-infected patients. -kobashi et al. divided patients with pulmonary mac infection into two groups: a group treated with cam, rfp, eb, and sm (intramuscularly injected at mg/kg times a week for months) and a group treated with saline, and conducted a randomized, double-blind, comparative study [ ] . in the sm-treated group, the rate at which the culture of sputum became negative was higher than in the salinetreated group ( . vs. . %, respectively). there has been no high-quality study demonstrating the usefulness of combination therapy with aminoglycosides other than their study. however, various guidelines recommend that combination therapy with sm, amk, or km should be performed for e months in the initial phase of treatment in patients with a cavity or severe nodular/bronchodilatation type infection based on experience [ , , ] . guidelines in the united states recommend sm or amk, and comment that no study has showed which of two drugs, sm and amk, is more effective, although sm has been more frequently used [ ] . in japan, sm or km is recommended [ ] . -based on the results of these studies, the non-tuberculous mycobacterium infection control committee, japanese society for tuberculosis recommends the following doses and administration methods for chemotherapy for pulmonary mac infection in the "opinions regarding chemotherapy for pulmonary non-tuberculous mycobacterium infection---revision in ": rfp: mg/kg (up to mg)/day, once a day, eb: mg/kg (up to mg)/day, once a day, cam: e mg/day ( e mg/kg), once a day or two divided doses ( mg: two divided doses), and sm or km: mg/kg or less (up to mg), intramuscularly injected or times a week [ ] . -a cooperative statement on non-tuberculous mycobacterium infection by the american thoracic society/infectious diseases society of america recommends therapy with cam at to mg/day or azm at mg/day, eb at mg/kg/day, and rfp at mg/kg/day (up to mg) for patients with a cavity or severe nodular/bronchodilatation type infection. in addition, it is recommended that combination therapy with sm or amk ( e mg/kg, e times a week, patients aged over years: mg or less) for e months in the initial phase should be considered [ , ] . -the treatment period is established as about year after the culture becomes negative in the above guidelines, but this is not based on evidence. in the guidelines for the management of non-tuberculous mycobacterium infection, which were published by the british thoracic society, the treatment period of pulmonary mac infection is established as years. in the future, an optimal treatment period should be investigated. ---drugs to be recommended----cam, oral, mg/ times a day or mg/twice a day þ rfp, oral, mg/kg/once a day (maximum: mg/ day, orally administered before meals as a rule) þ eb, oral, mg/kg/once a day (maximum: mg/day) * severe-status patients and those with cavity-type lesions in addition to the above regimen, the intramuscular injection of sm or km should be added. abscessus is sometimes susceptible to lzd, tgc (tigecycline), and ketolides, but it is unclear whether there is a correlation between the drug susceptibility and clinical effects [ , ] . -combination therapy with cam and several intravenous antimicrobial drugs (amk, cfx, and ipm/cs) may control the symptoms and progression of pulmonary infection with m. abscessus [ , ] . however, actually, hospitalization is required to administer these intravenous antimicrobials, and the administration period is limited to e months. subsequently, treatment with oral drugs is performed, but cam is the only reliable oral drug, as described above. on the other hand, monotherapy with cam should be avoided from the perspective of resistance induction. although some studies reported combination therapy with lzd or quinolones, its efficacy has not been established. -based on such a background, a combination of surgical resection of the lesion and combination chemotherapy is the only treatment that is expected to achieve the complete cure of pulmonary infection with m. abscessus in which the lesion is localized [ , , ] . ---drugs to be recommended--- a first choice based on the results of a drug susceptibility test, the following antimicrobial drugs should be combined: -cam, oral, mg/ times a day or mg/twice a day þ amk, intravenous drip, mg/kg/once a day þ ipm/cs, intravenous drip, . g/ times a day or g/ times a day * surgery must be considered. the treatment period should be at least months after culture becomes negative. ---executive summary----for the treatment of childhood tuberculosis, several drugs should be combined, and administered for a specific period (aii). -for the treatment of non-tuberculous mycobacterium infection, several drugs should be combined, and administered for a specific period. however, mycobacterium often resists treatment. if there is no treatment response, surgery must be considered (ciii). ---explanation--- [characteristics and classification of the disease] in japan, tuberculosis is still an important infectious disease. when encountering patients with chronic infection who do not respond to general antimicrobial drugs, tuberculosis should be considered for differential diagnosis. mycobacteria that can be cultured are classified into two types: m. tuberculosis complex and non-tuberculous mycobacteria (ntm) [ ] . m. tuberculosis is a major type of m. tuberculosis complex, and has a strong infectivity from humans to humans. childhood tuberculosis is classified into two types based on age [ ] . briefly, primary tuberculosis represented by hilar lymph node tuberculosis and meningitis, which develop following primary infection, is characteristic of infants and children. the interval from infection until onset is short, and the morbidity rate is high. in addition, this disease may lead to a severe condition. pulmonary/hilar lymph node tuberculosis in infants and children is asymptomatic, or the general condition is favorable even in the presence of fever or cough in many cases. when primary tuberculosis is detected based on dyspnea or an unfavorable general condition in addition to fever or cough, many infants/children have military tuberculosis or meningitis. on the other hand, secondary tuberculosis with a cavity lesion or nodular shadow in the lung field is frequent in junior high school students or older. symptoms such as cough, sputum, fever, and thoracic pain are often observed. in most children, the source of infection can be clarified through detailed peripheral contact screening at the time of onset. usually, the source of infection is clarified in / to / of children. it is often their fathers/mothers or grandfathers/grandmothers [ e ]. as childhood tuberculosis does not form a cavity in the lung field, the m. tuberculosis level in the focus is lower than in adults. in many cases, it is difficult to bacteriologically or histologically make a definitive diagnosis in comparison with adult tuberculosis. usually, it is possible to make a definitive diagnosis by comprehensively evaluating epidemiological/clinical information such as opportunities for the source of infection to contact with tuberculosis patients, tuberculin reaction-or quantiferon tb (qft)-based verification of infection, imaging findings suggestive of tuberculosis, such as chest x-ray findings, verification of m. tuberculosis from sputum or gastric juice, and individuals' resistance including the grade of bcg vaccination-acquired immunity and age, as well as by considering treatment responses in some cases. qft is a very useful testing method to quantitatively measure ifn-g and diagnose tuberculosis infection without being influenced by bcg. however, assessment in infants/children should be further examined in the future [ ] . when a definitive diagnosis of pulmonary tuberculosis cannot be made based on chest x-ray findings alone, thoracic ct, which facilitates the detailed evaluation of the presence or absence and extent of tuberculous lesions, is useful for diagnosis. furthermore, imaging findings of tuberculosis do not change in a short period in many cases. non-tuberculous mycobacterium belongs to mycobacterium, the same category as reported for m. tuberculosis. therefore, it is often detected as a mycobacterium-positive smear of sputum, that is, gaffky's positive reaction. initially, some patients are regarded as having infectious tuberculosis, and admitted to a tuberculosis ward. symptoms and imaging findings are also similar between nontuberculous mycobacterium-and m. tuberculosis-infected patients. unless detected bacteria are identified, or unless either gene is detected using the nucleic acid amplification method, it is difficult to differentiate the two types of bacteria. however, it is important to recognize that tuberculosis and non-tuberculous mycobacterium infection are different diseases [ , ] . the most important point is that non-tuberculous mycobacterium infection does not transmit from humans to humans, differing from tuberculosis, an infectious disease in humans. therefore, it is not necessary to isolate the patient, and, as a rule, patients requiring admission should be managed in a general ward. as there are no public hygieneassociated problems, it is not necessary to submit a report to a health center. [type and frequency of causative microorganisms] in japan, the number of patients with childhood tuberculosis has markedly decreased. the number of newly registered patients with tuberculosis decreased from , ( ) to ( ) in children aged e years [ e ]. however, a decrease in the incidence of smear-positive pulmonary tuberculosis, which is important as the source of infection, is not marked in great urban areas. we cannot conclude that the opportunity of infection in children is favorably decreasing; caution is needed. the number of patients who newly develop non-tuberculous mycobacterium infection in japan is estimated to be approximately . in the adult field, it accounts for about / of that of patients who newly develop tuberculosis. however, it is relatively low in children. approximately % of patients with non-tuberculous mycobacterium infection are infected with m. avium complex (m. avium and mycoboterium intracellulare, pulmonary mac infection), and approximately % are infected with m. cansasii. [rules of antimicrobial drug therapy] -the characteristics of antitubercular chemotherapy in children are that children are tolerable to a relatively high dose per body weight in comparison with adults with respect to pharmacokinetics, and that the incidence of side effects is low [ ] . in the pediatric field, -month treatment with inh, rfp, and pza for childhood pulmonary tuberculosis is internationally selected as standard chemotherapy: three drugs, inh, rfp, and pza, are administered every day for the first months, and inh and rfp every day for the subsequent months. when drug resistance is suspected, these drugs should be combined with sm or eb in the initial phase until the results of a resistance test are clarified. in patients with secondary tuberculosis, -drug combination therapy with inh, rfp, pza, and sm (or eb) should be initially performed. in addition, as a rule, follow-up must be continued for years after the completion of treatment [ e ]. on the other hand, drug resistance, referral to another hospital, and discontinued treatment are present among patients who drop out of treatment, although the number of such patients is small. it is necessary to support the resistance and continuation of treatment. in particular, recently, the number of patients in whom it is difficult to continue treatment has increased. potent compliance support must be considered in connection with direct observed therapy (dot) by health centers and welfare activities [ ] . side effects during treatment include liver dysfunction. however, if the maximum ast or alt levels are approximately , administration should be carefully continued without discontinuing treatment. if these levels exceed , treatment should be transiently discontinued, and additional administration at a low dose should be conducted after confirming the normalization of the liver function. the dose should be gradually increased. liver dysfunction requiring a change of treatment is not frequent. furthermore, there is an increase in the serum uric acid level, but continuous treatment leads to normalization. there have been few patients with arthralgia. -prevention of tuberculosis: to prevent the onset of tuberculosis in uninfected persons, bcg vaccination should be performed. concerning its efficacy, a consensus regarding its potent preventive effects on severe disseminated tuberculosis, such as tuberculous meningitis and military tuberculosis, has been reached. considering the importance of tuberculous meningitis prevention, bcg vaccination in the early phase of infancy ( e months after birth, or earlier in accordance with the state of peripheral tuberculosis prevalence) is still necessary in japan [ ] . -treatment for latent tuberculosis: to prevent the onset of tuberculosis in persons with a history of tuberculosis, treatment for latent tuberculosis (conventional chemoprevention) should be conducted. a large-scale controlled study reported that inh therapy decreased the incidence of tuberculosis by approximately e %. for drug administration, the risk of tuberculosis onset should be concretely and flexibly evaluated based on the tuberculin reaction, opportunity of infection, age, and state of bcg vaccination in individual patients [ ] . -treatment for non-tuberculous mycobacterium infection: nontuberculous mycobacterium infection is refractory despite combination therapy with antitubercular drugs. in particular, there is no evidence regarding treatment in children [ ] . the effects of monotherapy are weak, and monotherapy with cam may lead to the appearance of cam-resistant bacteria within a few months [ ] ; therefore, this therapy should be avoided. the responses of m. kansasii to antitubercular drugs are relatively favorable, and cure may be achieved. however, pulmonary mac infection is often resistant to treatment. if there is no response, surgery must be considered. recurrence after the completion of treatment is also often observed. ---drugs to be recommended--- * as the administration period is longer than that for tuberculosis patients, the development of vision disorder should be considered even at these doses. * if there is no response, surgery must be considered. ---explanation---acute bronchitis is characterized by cough that persists for days or more. in most cases, cough persists for e weeks, but spontaneously subsides [ , ] . sputum is present in some cases, but is absent in others. sputum may be purulent even when viral infection is etiologically involved. neither chest x-ray nor ct shows the appearance of a new abnormal shadow, differing from pneumonia. viruses . there is no evidence that infection with other bacteria directly causes acute bronchitis in adults without an underlying disease [ ] . however, in a study using the transtracheal aspiration method in japan, h. influenzae, s. pneumoniae, and m. catarrhalis were primarily isolated in patients diagnosed with bacterial acute bronchitis in the absence of a chronic lower respiratory infectious disease as an underlying disease [ ] . in cases of pertussis, cough persists particularly over a long period, and paroxysmal coughing, inspiratory whooping, and vomiting after coughing may occur [ ] . acute bronchitis caused by m. pneumoniae also induces severe, persistent cough. in cases of influenza, fever, headache, general malaise, and arthralgia are observed. furthermore, acute viral bronchitis may lead to acute bacterial exacerbation in patients with chronic respiratory lesions as underlying diseases; fever and an increase in the amount of purulent sputum are observed. as a rule, when an underlying disease or complication is absent, the routine administration of antimicrobial drugs for acute bronchitis is not recommended [ , ] . to control symptoms such as cough, symptomatic therapy should be performed if necessary. on the other hand, antimicrobial drug treatment with macrolides is indicated for patients with pertussis. treatment after the catarrhal period does not reduce the degree or duration of cough, but antimicrobial drugs are necessary to prevent infection to peripheral persons [ , ] . when performing antimicrobial drug treatment for acute bronchitis caused by m. pneumoniae or c. pneumoniae, macrolides should be selected as first-choice drugs. however, an increase in macrolide-resistant m. pneumoniae must be considered [ ] . in cases of influenza, anti-influenza therapy should be conducted within h after onset [ ] . in patients with underlying diseases or elderly persons with complications, bacterial (e.g., s. pneumoniae) infection may occur following viral infection, although this is not frequent in healthy adults. when acute bronchitis related to bacterial infection, including secondary infection, is strongly suspected based on cough/sputum, fever, leukocytosis, or findings suggestive of the presence of causative microorganisms on gram staining of sputum despite the absence of a new infiltrative shadow on chest x-ray, antimicrobial drug treatment is considered in accordance with treatment for community-acquired bacterial pneumonia [ , ] . ---drugs to be recommended--- when there are no complications such as chronic respiratory diseases, the administration of antimicrobial drugs for acute bronchitis are not recommended as a rule (with respect to the selection of antimicrobial drugs for acute bronchitis complicated by chronic respiratory diseases with secondary bacterial infection, refer to the section " . miller & jones classification of purulent sputum. m : saliva, complete mucous sputum m : mucous sputum containing a small volume of purulent sputum p : sputum in which the purulent area comprises / or smaller p : sputum in which the purulent area comprises / to / p : sputum in which the purulent area comprises / or greater fever and shortness of breath, in addition to bacterial infection-related respiratory symptoms, such as increases in the frequency of cough, volume of purulent sputum, and degree of purulence, from the chronic, stable conditions of underlying diseases, such as copd, bronchiectasis, and old pulmonary tuberculosis. concerning laboratory data, inflammatory responses involving the leukocyte count and crp level are enhanced, and pao is often reduced on blood gas analysis. [imaging findings] imaging findings are necessary to differentiate chronic respiratory disease-related airway infection from pneumonia. the absence of a shadow must be confirmed. ct should also be performed to evaluate underlying diseases such as pulmonary emphysema and bronchiectasis. [estimation of causative microorganisms and gram staining] it is possible to collect sputum in many patients. gram staining is useful for predicting causative microorganisms or differentiating respiratory tract infection in the presence of chronic respiratory disease from persistent infection. according to a study, the tone of sputum suggests the presence of pathogenic microorganisms rather than the degree of purulence; macroscopic examination is also necessary [ ] . sputum involves much information, and is the most important sample. samples should be collected before the administration of antimicrobial drugs. those collected on waking-up early in the morning are ideal. to evaluate the degree of sputum purulence, the miller & jones classification [ ] (table ) is used, but, if samples are evaluated as p or higher, causative microorganisms may be predicted using gram staining. on gram staining, an area where the number of inflammatory cells is large should be initially searched at a low magnification, and detailed observation should be conducted at a high magnification. before the administration of antimicrobial drugs, sputum should always be submitted for a susceptibility test. as causative microorganisms, h. influenzae, p. aeruginosa, m. catarrhalis, and s. pneumoniae are frequently detected. persistent infection with p. aeruginosa is often observed, but it must be differentiated from acute exacerbation based on clinical symptoms and laboratory data. in addition, s. aureus and k. pneumoniae should be considered [ ] . the involvement of atypical pathogens such as c. pneumoniae or mixed infection with viruses and bacteria must also be considered. [treatment] the purpose of treatment is to reduce clinical symptoms, prevent recurrence, prolong the interval until subsequent exacerbation, and inhibit lung tissue damage. the administration of appropriate antimicrobial drugs relieves clinical symptoms, and maintains the respiratory function [ ] . on the other hand, inappropriate antimicrobial drugs may deteriorate the prognosis, inducing recurrence. in japan, the resistance of s. pneumoniae and h. influenzae to macrolides and b-lactams is advanced [ , ] . several studies have reported that new quinolones are more useful than b-lactams [ , e ] . respiratory quinolones have potent antimicrobial activities against all types of causative microorganisms, and against resistant bacteria [ e ]. concerning the administration period, a study indicated that the efficacy of administration for days was similar to that for days, and that the former was safer than the latter. the administration period should be shortened [ ] . ---drugs to be recommended--a. empiric therapy internationally, some studies have supported the usefulness of b-lactams [ , ] . however, in japan, the resistance of s. pneumoniae and h. influenzae to macrolides and b-lactams is advanced, and p. aeruginosa is also sometimes isolated. therefore, the use of b-lactams and macrolides is limited to patients without risk factors. an international comparative study reported that the efficacy of azm sustained-release preparations was similar to that of new quinolones [ ] . however, in japan, the long-term administration of macrolides is performed in many patients; therefore, circumstances differ. beta-lactamase-producing strains are detected in approximately e % of h. influenzae strains. beta-lactamasenegative, ampicillin-resistant (blnar) strains account for approximately %. therefore, when drug susceptibility is unclear, new quinolones should be selected as first-choice oral antimicrobial drugs. if drug susceptibility is clarified, they should be switched to effective and narrow-spectrum drugs. as injection, penicillins should be initially selected, followed by b-lactamase inhibitor-containing penicillins, carbapenems, and new quinolones. ➁ m. catarrhalis beta-lactamase-producing strains account for % of m. catarrhalis strains. as oral antimicrobial drugs, macrolides should be initially selected, followed by b-lactamase inhibitor-containing penicillins, second-/third-generation cephems, and new quinolones. as injection, b-lactamase inhibitor-containing penicillins, second-/third-generation cephems, new quinolones, or carbapenems should be selected. ➂ p. aeruginosa as oral drugs, new quinolones should be selected. as injection, anti-p. aeruginosa penicillins, cephems, monobactums, carbapenems, or new quinolones should be selected. as the drug susceptibility of this type of bacteria markedly differs among strains, drugs should be selected based on the results of culture tests. ➃ s. pneumoniae as oral drugs, penicillins should be initially selected, followed by new quinolones. in patients with a risk of resistant bacteria, respiratory quinolones such as lvfx and grnx should be selected. as injection, penicillins or ctrx should be selected, but carbapenems must be considered in severestatus patients. ---explanation---[characteristics/classification of the disease] dpb is a chronic inflammatory disease of the respiratory tract, which is frequently observed in east asians including japanese. there is no gender difference, and this disease frequently develops in persons aged e years. it is often detected in patients with a history of chronic sinusitis or in those with the concomitant development of chronic sinusitis. this disease is classified as the category of sinobronchial syndrome. [symptoms] the most typical symptoms of dpb are persistent cough and purulent sputum. symptoms such as exertional shortness of breath and dyspnea appear in accordance with disease progression. in patients with a complication of chronic sinusitis, purulent nasal discharge and nasal obstruction are observed. chest x-ray shows pulmonary overexpansion or a diffuse scattered nodular shadow. thoracic hrct reveals a diffuse centrilobular nodular shadow. furthermore, obstructive respiratory dysfunction, hypoxemia, and an increase in the cold agglutinin value ( -fold or more on the hemagglutination method) are observed. [type and frequency of causative microorganisms] in patients with dpb, persistent respiratory tract infection with h. influenzae, s. pneumoniae, or m. catarrhalis is often observed. however, the incidence of persistent infection with p. aeruginosa increases with progression. [long-term macrolide therapy] previously, the prognosis of dpb was unfavorable; respiratory failure gradually progressed through repeated acute exacerbation related to respiratory tract infection, leading to a fatal outcome; however, the prognosis of dpb has been markedly improved since long-term macrolide therapy with low-dose administration of em or other -membered ring macrolides was established [ e ]. early diagnosis/treatment have facilitated the complete cure of dpb. therefore, if once a diagnosis of dpb is made, long-term macrolide therapy should be started promptly. ---drugs to be recommended---➀ persistent infection -the oral administration of em at e mg/day should be continued for months to be evaluated its clinical effects [ ] . -in many cases, an improvement in symptoms (such as a decrease in the volume of sputum) will be achieved within e months after the start of administration. -in addition, an improvement in imaging findings or the respiratory function will be achieved after e months of treatment. croup syndrome is characterized by acute laryngeal stenosisassociated respiratory disturbance such as barking cough, hoarseness, and inspiratory stridor. most lesions involve not only the larynx but also the trachea/bronchus. this disease is sometimes called laryngotracheobronchitis [ ] . etiological factors are classified into two types: infectious and non-infectious (allergy-/ foreign body-related) factors [ , ] . the incidence of infectious croup syndrome is high in infants/children aged monthse years [ , ] . [type and frequency of causative microorganisms] croup syndrome is primarily caused by viruses. parainfluenza virus type is the most common virus [ ] . in addition, parainfluenza virus type / , influenza a/b virus, rs virus, human metapneumovirus, coronavirus, adenovirus, and measles virus are relatively frequently isolated [ , ] . [rules of antimicrobial drug therapy] in most cases, croup syndrome is caused by viruses, and antimicrobial drugs are not necessary. therefore, no study has evaluated the efficacy of antimicrobial drugs in patients with croup syndrome. there are no treatment guidelines regarding croup syndrome in which antimicrobial drugs are recommended [ , ] . ---executive summary---bronchiolitis is caused by viruses, and the administration of antimicrobial drugs is not necessary (ai). ---explanation--- bronchiolitis is an acute, inflammatory, obstructive disease involving the bronchiole. narrowing of the bronchiolar lumen related to mucosal epithelial injury, inflammatory-cell infiltration, interstitial edema, or an increase in mucus secretion causes air trapping in the peripheral respiratory tract, leading to obstructive respiratory disorder. this disease frequently develops in children aged years or younger. however, infants aged months or younger account for % or more [ ] . [type and frequency of causative microorganisms] bronchiolitis is primarily caused by viruses. rs virus accounts for e %. in addition, parainfluenza virus, human metapneumovirus, adenovirus, and influenza virus are relatively frequently isolated [ e ]. [rules of antimicrobial drug therapy] in most cases, bronchiolitis is caused by viruses, and antimicrobial drugs are not necessary. basic treatment is symptomatic therapy. in double-blind comparative studies involving abpc and non-treated groups [ ] , azm and non-treated groups [ ] , and abpc intravenous injection/oral em and non-treated groups [ ] , respectively, there were no significant differences in the admission period or symptom improvement. however, a small-scale doubleblind comparative study reported that the interval until recovery in the cam-treated group was shorter than in the non-treated group [ ] . according to another study, the incidence of secondary bacterial infection during the course of rs virus-related bronchiolitis was . %, and there was no difference between antimicrobial drug-treated and non-treated groups [ ] . therefore, it is not necessary to administer antimicrobial drugs to children with bronchiolitis for routine treatment or the prevention of secondary bacterial infection. however, follow-up must be carefully continued during the course of bronchiolitis. when a diagnosis of secondary bacterial infection-related pneumonia or otitis media is made, antimicrobial drug therapy should be started. ---executive summary---bacterial tracheitis is a bacterial disease with the rapid progression of dyspnea. if symptoms are progressive, antimicrobial drugs should be used even when a definitive diagnosis is not made (aiii). ---explanation--- fever and croup syndrome-like cough/stridor initially appear, and respiratory disorder rapidly progresses, but there is no specific posture, salivation, or dysphagia, which are characteristic of acute epiglottitis. a definitive diagnosis can be made based on characteristic clinical features and purulent secretion in the respiratory tract. in some cases, a lateral view of the larynx on x-ray shows stenosis below the larynx [ ] . this disease frequently develops in children aged e years [ ] . [type and frequency of causative microorganisms] s. aureus-related tracheitis accounts for approximately %, followed by that related to m. catarrhalis, h. influenzae, streptococcus pneumoniae, and streptococcus pyogenes [ e ]. mixed infection with viruses and bacteria is frequent, and parainfluenza virus type i [ ] and influenza a virus [ ] are often detected. [rules of antimicrobial drug therapy] antimicrobial drugs should be intravenously administered for the following reasons: this disease rapidly progresses, and oral administration is difficult in many cases. as empiric therapy, combination therapy with vcm, which may be effective for infection with s. aureus (including mrsa), and third-generation cephems (ctrx, ctx), which have potent antimicrobial activities against m. catarrhalis, h. influenzae, s. pneumoniae, and s. pyogenes, should be performed. the administration period is e days [ ] . ---drugs to be recommended---refer to the section " . pneumonia (children)---drugs to be recommended . definitive therapy---" (p. ). ---executive summary---acute bronchitis is primarily caused by viruses, and the necessity of antimicrobial drug administration is low (ai). when acute bronchitis is caused by m. pneumoniae, c. pneumoniae, or b. pertussis, antimicrobial drugs should be administered if necessary (aiii). secondary infection with s. pneumoniae or h. influenzae may occur, although its incidence is unclear. therefore, when there is no improvement, the administration of antimicrobial drugs should be considered (aiii). ---explanation---[characteristics and classification of the disease] bronchitis causes symptoms such as cough, fever, and general malaise. various causative microorganisms induce inflammation of the epithelial tracheobronchial tissue, leading to the onset of bronchitis. clinically, there are no special findings on auscultation, or only rough respiratory sounds (intermittent accessory murmurs) are heard. chest x-ray does not also show any marked infiltrative shadow. usually, patients in whom the interval after onset is less than weeks are regarded as having acute bronchitis [ ] . however, bronchitis diagnosed in japan slightly differs from that in europe and the united states. the latter primarily causes persistent cough. in japan, patients in whom there are no findings on chest x-ray despite clinical signs of pneumonia or those in whom chest x-ray is not performed are often diagnosed with bronchitis; the disease entity must be arranged. [type and frequency of causative microorganisms] viruses, such as rhinovirus, influenza virus, rs virus, adenovirus, parainfluenza virus, human metapneumovirus, and human bocavirus, account for % of causative microorganisms. m. pneumoniae, c. pneumoniae, and b. pertussis also cause bronchitis, although such cases are relatively rare [ , ] . [rules of antimicrobial drug therapy] acute bronchitis is primarily caused by viruses, and the administration of antimicrobial drugs is not necessary. a metaanalysis compared adults to whom antimicrobial drugs were administered for bronchitis treatment with non-treated adults, and indicated that there was no difference in the efficacy [ ] . few reports on clinical studies involving children have been published, and the scale is small; objective data are insufficient, but no study has reported that antimicrobial drugs are effective [ e ]. however, if secondary bacterial infection following viral infection causes fever, purulent sputum, leukocytosis, or an increase in the crp level, antimicrobial drugs should be administered, considering s. pneumoniae and h. influenzae. other indications for antimicrobial drug administration include m. pneumoniae-, c. pneumoniae-, or b. pertussis-related bronchitis with protracted cough. as m. pneumoniae-or c. pneumoniae-related bronchitis tends to show spontaneous cure, the administration of antimicrobial drugs is not always necessary, but the necessity of administration should be evaluated, considering the severity of symptoms and course (with respect to indications and administration methods, refer to the section " . pneumonia (children)".). first-choice drugs for m. pneumoniae-, c. pneumoniae-, or b. pertussis-related bronchitis are macrolides. in patients with b. pertussis-related bronchitis, antimicrobial drugs relieve symptoms only during the catarrhal period, but, if b. pertussis-related bronchitis is suspected based on clinical symptoms, previous vaccination, lymphocyte-predominant leukocytosis, an anti-pt antibody titer, and lamp findings, antimicrobial drugs should be used. however, -membered ring macrolides are ineffective for b. pertussis-related bronchitis. symptoms are similar to those of pneumonia, but, when chest x-ray does not show any abnormalities, or, when it is impossible to strictly differentiate bronchitis from pneumonia due to difficulty in chest x-ray, treatment should be performed in accordance with pneumonia. ---drugs to be recommended--- secondary bacterial infection after viral infection (cases in which fever, purulent sputum, leukocytosis, or an increase in the crp level is observed) a first choices -ampc, oral, e mg/kg/ times a day -sbtpc, oral, mg/kg/ times a day -cdtr-pi, oral, mg/kg/ times a day -cfpn-pi, oral, mg/kg/ times a day -cftm-pi, oral, mg/kg/ times a day <> second choices -azm, oral, mg/kg/once a day, days -cam, oral, . mg/kg/twice a day . definitive therapy ➀ b. pertussis -em, oral, e mg/kg/ times a day -cam, oral, . mg/kg/twice a day -azm, oral, mg/kg/once a day, days ➁ m. pneumoniae ▪ macrolide-sensitive strains -em, oral, e mg/kg/ times a day -azm, oral, mg/kg/once a day, days -cam, oral, . mg/kg/twice a day ▪ macrolide-resistant strains -mino, oral or intravenous drip, e mg/kg/twice a day (in children aged years or younger, the use of this drug is limited to those in whom other drugs cannot be used or non-responders.) -tflx, oral, mg/kg/twice a day (administration is limited to children aged years or younger in whom mino cannot be used.) ➂ chlamydia (c. pneumoniae, c. psittaci, c. trachomatis) -em, oral, e mg/kg/ times a day -azm, oral, mg/kg/once a day, days -cam, oral, . mg/kg/twice a day . influenza ---executive summary----both m protein inhibitors and neuraminidase inhibitors (nais) are commercially available as anti-influenza drugs as of july . -influenza viruses a (h n ) and a (h n ) pdm (seasonal influenza) have been reported to be resistant to amantadine, an m protein inhibitor which can be used in japan. the use of this drug as an anti-influenza drug should be avoided for a while [ , ] . -during the influenza outbreak period, anti-influenza therapy should be promptly started based on a clinical diagnosis even when patients with influenza-like symptoms show negative results on a rapid diagnosis kits (because influenza cannot be completely ruled out) [ ] (ai). -nais significantly improve influenza survival, and nai administration within days after onset significantly reduces the rate at which the condition becomes severe [ , ] (ai). -currently, the following nais can be selected in japan. during the outbreak period, an appropriate drug should be selected based on the patient background and latest information on a prevalent influenza strain: -oseltamivir (oral), efficacy: a (h n ) pdm , a (h n ), b, resistance: h y mutant -zanamivir (inhalation), efficacy: type a/b -laninamivir (inhalation), efficacy: type a/b -peramivir (intravenous drip), efficacy: type a/b ---drugs to be recommended---there is no meta-analysis of anti-influenza drugs other than oseltamivir and zanamivir as of july . however, it has been shown that the early introduction of anti-influenza therapy for influenza significantly inhibits not only the mortality and admission rates but also the incidences of influenza-associated pneumonia, otitis media, and ischemic heart disease in comparison with symptomatic therapy. nais such as laninamivir and peramivir have also been confirmed to be as effective as oseltamivir at the time of development [ ] (ai). <>outpatient treatment -oseltamivir, oral, mg/twice a day, days (as a rule, administration to children/adolescents aged e years should be avoided.) -zanamivir, inhalation, mg/twice a day, days -laninamivir, inhalation, mg/single dose -peramivir, intravenous drip, mg/single dose <>hospital treatment ➀ patients with severe, life-threatening influenza in patients with severe, life-threatening influenza requiring admission, respiratory failure or encephalopathy is present. in either case, the complication must be treated, but, as a rule, nais should be introduced within h after the onset of influenza to obtain their effects. -oseltamivir, oral, mg/twice a day, days (as a rule, administration to children/adolescents aged e years should be avoided.) -peramivir, intravenous drip, mg/single dose (this drug can be repeatedly administered every day in accordance with symptoms.) ➁ non-life-threatening influenza patients with pneumonia -oseltamivir, oral, mg/twice a day, days (as a rule, administration to children/adolescents aged e years should be avoided.) -peramivir, intravenous drip, mg ( mg for patients in whom the condition may become severe)/single dose (this drug can be repeatedly administered every day in accordance with symptoms.) ➂ non-life-threatening influenza patients without pneumonia -oseltamivir, oral, mg/twice a day, days (as a rule, administration to children/adolescents aged e years should be avoided.) -zanamivir, inhalation, mg/twice a day, days -laninamivir, inhalation, mg/single dose -peramivir, intravenous drip, mg/single dose (this drug can be repeatedly administered every day in accordance with symptoms.) * patients with a (h n ) -basic treatment is the early administration of anti-influenza drugs [ ] . -according to an article, there were no significant differences in the viral level or mortality rate days after the start of administration between double-and standard-dose oseltamivir therapies [ ] . however, treatment was not started within h after onset in all patients in the article. ---executive summary---influenza is caused by influenza virus. antimicrobial drugs are not necessary. it is recommended that neuraminidase inhibitors should be administered within h after onset (ai). if pneumonia or otitis media occurs through secondary bacterial infection, the administration of antimicrobial drugs must be considered (biii). ---explanation---[characteristics and classification of the disease] influenza often appears with sudden fever and shivering/ headache/general malaise/muscular pain/dry cough, followed by marked respiratory or digestive symptoms. in underlying diseasefree children, recovery is achieved after e days [ , ] . however, during the outbreak period, even underlying disease-free children are often admitted with serious symptoms such as encephalopathy, myocarditis, and pneumonia requiring artificial respiration. although the outbreak period is from december until march every year, outbreaks are observed in the summer in some areas [ , ] . [type and frequency of causative microorganisms] since influenza a (h n ) pdm prevailed in , the outbreaks of types of influenza, a (h n ) pdm , a (h n ), and b, have been repeated. their incidences differ among years. [rules of antimicrobial drug therapy] no antimicrobial drug is indicated for influenza. it is recommended that neuraminidase inhibitors should be administered within h after onset [ ] . the doses of neuraminidase inhibitors approved in japan are presented in table . during the course of influenza, bacterial infection such as pneumonia and otitis media may occur. previously, the incidence of secondary bacterial infection in children exceeded % [ ] , but it has been % or less since neuraminidase inhibitors were developed [ , ] . however, bacterial infection is observed in e % of severe-status patients requiring intensive care [ , ] . streptococcus pneumoniae, s. aureus, and h. influenzae are frequently detected as causative microorganisms [ , , , ] . no study has demonstrated that the prophylactic administration of antimicrobial drugs at the onset of influenza prevents secondary bacterial infection. among children with influenza, antimicrobial drug therapy should be considered in those in whom signs of pneumonia or otitis media do not subside despite the administration of a neuraminidase inhibitor. . parasitic diseases of the respiratory system ---executive summary----parasitic diseases are widely distributed throughout the world. in addition to domestic infection, japanese travelers may be infected in overseas endemic areas. furthermore, parasitic diseases always considered in foreign patients from endemic areas [ ] (biv). -when peripheral blood eosinophilia is observed in addition to respiratory symptoms and abnormal findings of the chest imaging, examinations should be performed to differentiate parasitic diseases [ ] (biv). -parasitic diseases of the respiratory system are caused by paragonimus spp., ascaris lumbricoides, ancylostoma duodenale, necator americanus, strongyloides stercoralis, toxocara canis, toxocara cati, wuchereria bancrofti, brugia malayi, or dirofilaria immitis. -there are two major diagnostic tests for parasitic diseases: ( ) detection of parasite eggs or larvae in sputum or stools, and ( ) detection of parasite-specific antibodies using serum or pleural effusion samples (immunodiagnosis). -an anti-parasite antibody screening test against species of parasite is commercially available; paragonimus spp., strongyloides sp., t. canis, d. immitis, ascaris suum, anisakis simplex, gnathostoma spp., fasciola hepatica, clonorchis sinensis, spirometra erinaceieuropaei, and cysticercus cellulosae. -diagnosis/treatment consultations regarding parasitic diseases by the japanese society of parasitology are available (as of ). refer to the homepage (http://jsp.tm.nagasaki-u.ac.jp). ---explanation----paragonimus spp. several paragonimus species are known to cause human infection. paragonimus westermani and p. miyazakii are distributed in japan. infection occurs through the consumption of freshwater crabs (intermediate host: eriocheir japonica, e. sinensis, geothelphusa dehaani) or wild boars (paratenic host:sus scrofa) contaminated with metacercaria (infective larvae) as a raw or insufficiently cooked food [ ] . typical symptoms are cough, sputum, thoracic pain, and exertional dyspnea. in patients with such symptoms, the presence of peripheral blood eosinophilia suggests this disease. in many cases, a diagnosis is made based on the peripheral blood eosinophilia, a history taking of food and table standard doses of neuraminidase inhibitors in children. oseltamivir a oral mg/kg, twice a day, days (the use of this drug should be avoided in children/adolescents aged e years.) zanamivir b inhalation mg, twice a day, days laninamivir inhalation years or older: mg years or younger: mg, single dose peramivir intravenous drip mg/kg, once a day a the preventive administration of this drug at mg/kg (once a day) for days was approved, but is not covered by health insurance. b the preventive administration of this drug at mg (once a day) for days was approved, but is not covered by health insurance. immunodiagnosis. some of paragonimiasis patients are asymptomatic, and the presence of lung lesions is detected on a health checkup. extrapulmonary paragonimiasis such as cutaneous and cerebral paragonimiasis are classically known form of the ectopic infection with paragonimus spp. in cases of cutaneous paragonimiasis, a slowly moving nodular lesion in the subcutaneous tissue is a characteristic symptom. the worms may migrate through mediastinal soft tissues to the brain, causing eosinophilic meningitis or cerebral paragonimiasis in some cases [ ] . since paragonimus spp. is widely distributed around the world, japanese travel to endemic area such as china, korea, thailand, and philippines possible to infect with paragonimus spp. as well as foreign patients from endemic areas, this disease always is considered when a patient has respiratory symptoms and/or lung lesions with eosinophilia [ ] . chest x-ray findings vary: not only pulmonary parenchymal lesions, such as nodular (±cavity formation) and infiltrative shadows, but also pleural lesions, such as the retention of pleural effusion and pneumothorax, are sometimes observed [ ] . many patients show peripheral blood eosinophilia and/or elevated serum total ige. immunodiagnosis to detect parasite-specific antibody has been proven as the most useful and reliable tool. not only patient's serum but also pleural effusion could examine by immunological test. commercially available anti-parasite antibody screening test is including paragomimus spp. in japan, egg-detection rate among paragonimiasis patients nowadays is low; for example . % in sputum and . % in balf [ ] , . % in bronchoscopic aspirate [ , ] . after a definitive diagnosis is made, oral treatment should be started. the type of treatment to be selected, outpatient or hospital treatment, depends on the patient's general condition. however, usually, outpatient treatment is possible. in patients having pleural effusion, pleural fluid must be extensively drained off before starting chemotherapy [ ] (biii). in patients with chronically encapsulated pleural effusion, surgery is required [ ] (ciii). ---drugs to be recommended---a first choice (same dose for adults and children) -praziquantel, oral, mg/kg/ times a day, e days [ ] (aiii) -a. lumbricoides, a. duodenale, n. americanus the larvae of these parasites pass through the lung in the human body, causing asthma-or pneumonia-like symptoms such as transient fever, cough, and dyspnea. on chest x-ray, transient nodular/infiltrative shadows are observed. many patients show peripheral blood eosinophilia and/or elevated serum total ige. previously, the condition was called loffler syndrome. currently, it is classified as simple pulmonary eosinophilia in the category of pie syndrome [ ] . symptoms appear e weeks after the oral ingestion of a. lumbricoides embryonated eggs. the latency period of percutaneous infection with n. americanus larvae or percutaneous/oral infection with a. duodenale larvae is approximately days. larvae appeared in the small intestine penetrate the intestinal wall, enter the portal vein, migrate through liver to heart/lung. larvae penetrate the human skin transfer to the lung with blood flow. then these larvae migrate up the bronchi and trachea, over the epiglottis, down the esophagus/stomach, and reach the small intestine. in the intestine the larvae develop into mature adults [ ] . simple pulmonary eosinophilia related to parasites spontaneously resolved in a few weeks. in many cases, a definitive diagnosis is made based on parasite eggs detected on a stool examination, although larvae are sometimes detected in sputum [ ] . ---drugs to be recommended---a first choice (same dose for adults and children) -pyrantel pamoate, oral, mg/kg/single-dose administration * dry syrup for children is available. * this drug is effective for adult worms in the intestinal tract, but not for larvae migrating in the human body. therefore, a stool examination should be performed weeks after oral administration. if parasite eggs are detected, additional administration should be conducted. <> second choices (same dose for adults and children) -albendazol, oral, mg/single-dose administration -mebendazole, oral, mg/twice a day, days, or mg/single-dose administration -ivermectin, oral, e mg/kg/single-dose administration (after fasting) -s. stercoralis in japan, s. stercoralis is distributed in nansei islands, chain of islands extending from southwestern kyushu to northern taiwan. there are few young persons newly infected with s. stercoralis, but the incidence of infection is high in elderly persons [ ] . internationally, s. stercoralis is widely distributed in tropical/subtropical areas. not only domestic infection but also japanese travel to endemic area possible to infect with this parasite. foreign patients from endemic areas, strongyloidiasis always considered when a patient has respiratory symptoms and/or lung lesions with eosinophilia. s. stercoralis percutaneously infects humans. larvae penetrate the human skin transfer to the lung with blood flow. then these larvae migrate up the bronchi and trachea, over the epiglottis, down the esophagus/stomach, and reach the small intestine. in the intestine the larvae develop into mature adults. parasite eggs delivered by adults are hatched while descending the intestinal tract, and larvae excreted in stools. some larvae developed to infective form again invade/transfer through the mucosa around the anus, maintaining a life cycle in the human body. such a mode of infection is termed autoinfection. with the transfer of larvae to the lung, asthma-or pneumonia-like symptoms, such as transient fever, cough, and dyspnea, appear, as indicated for simple pulmonary eosinophilia related to a. lumbricoides, a. duodenale, or n. americanus. on chest x-ray, transient nodular/infiltrative shadows are observed. many patients show peripheral blood eosinophilia and/or an increase in the total ige level. in immunocompromised patients, suppressing the cellmediated immunity such as atl patients, hiv/aids patients, those receiving immunosuppressive drugs, the number of s. stercoralis increases through acceleration of autoinfection, and larvae are disseminated in various organs, leading to a severe condition (disseminated strongyloidiasis). in such cases, stridor, bloody sputum, tachypnea, protein-losing gastroenteritis, ileus, and mobile exanthema are observed. furthermore, severe pneumonia related to enteric bacteria disseminated with larvae, lung abscess, or bacterial meningitis concomitantly occurs [ ] . a diagnosis is made based on s. stercoralis larvae detected in stools/sputum. immunological diagnosis is also useful [ ] . ---drugs to be recommended---a first choice (same dose for adults and children) -ivermectin, oral, mg/kg/single-dose administration (after fasting), additional administration at the same dose after weeks (ai) * repeated administration must be considered in cases of disseminated strongyloidiasis [ ] . * a study reported that transrectal or percutaneous administration was useful in patients in whom oral administration was difficult due to digestive symptoms [ ] . <> second choice (same dose for adults and children) -albendazol, oral, mg/twice a day, days (bi) -t. canis, t. cati infection to humans occurs through the oral ingestion of the embryonated eggs of t. canis or t. cati [ ] . it also occurs through the consumption of beef/chicken liver or meat contaminated with larvae as a raw or insufficiently heated food. this is considered to be a dominant route of infection in japan [ ] . as humans are not definitive host for t. canis and t. cati, they do not become adults in the human body [ ] . larvae invading the human body transfer to various organs with blood flow through the intestinal mucosa. target organs are the lung, liver, eyes, and central nervous system including spinal cord. toxocariasis is a typical larva migrans. lesions are often observed in the lung/liver (visceral larva migrans). there are few symptoms, or nonspecific symptoms are present. in many cases, a diagnosis is made based on peripheral blood eosinophilia and multiple nodular shadows of the lung or liver on ct. ocular or central nervous symptoms appear in some patients. it is impossible to make a diagnosis on a stool examination due to larva migrans. immunological diagnosis is useful. after a definitive diagnosis is made, treatment should be started. when visceral larva migrans is asymptomatic, follow-up may be continued. ---drugs to be recommended---a first choice (same dose for adults and children) -albendazol, oral, mg/kg/ or times a day, e weeks [ ] (biii) * this drug should be taken with meals for days. a -day period of discontinuation should be established and then restarted drug if required. <> second choices (same dose for adults and children) -albendazol, oral, mg/twice a day, days [ ] (biii) -mebendazole, oral, e mg/twice a day, days [ ] (ciii) -w. bancrofti, b. malayi w. bancrofti and b. malayi are called lymphatic filaria. infection occurs when these parasites are transmitted to humans through mosquitoes. the pathogenesis of lymphatic filariasis is relate to structural and functional abnormality of lymphatic channels induced by parasitized adult worms. infection with w. bancrofti is characterized by febrile attacks, lymphedema/elephantiasis, hydrocele, and chyluria. in patients infected with b. malayi, neither hydrocele nor chyluria is observed, and lymphedema of the lower limbs/ elephantiasis are localized in the lower thighs. microfilaria produced by adult worms is not pathogenic, but rarely induces allergic reactions in the lung, contributing to tropical pulmonary eosinophilia (tpe) [ ] . this condition shows a chronic course, differing from simple pulmonary eosinophilia. cough, dyspnea, and stridor with exacerbation at night are observed. fever, malaise, and weight loss are noted in some patients. on chest x-ray, bilateral reticular nodular lesions are detected. peripheral blood eosinophilia and an increase in the anti-filaria antibody titer are observed. in case of tpe, no microfilaria is detected [ ] . if treatment is not performed, the condition may gradually exacerbate. it is important to adequately make a diagnosis for the differentiation of this disease. in the world, , , persons are infected with lymphatic filaria, but tpe occurs in less than . % of these. the risk of this disease in travelers is unclear, and most patients consist of foreign persons from endemic areas [ ] . ---drugs to be recommended---a first choice (same dose for adults and children) -diethylcarbamazine, mg/kg/ times a day, days * in cases of malayan filariasis, marked side effects, such as digestive symptoms, fever, lymphangitis/ lymphadenitis, and orchitis/epididymitis, may appear. therefore, a half dose ( mg/kg) should be administered times a day for days [ ] . -d. immitis d. immitis parasitize in the dog right ventricle and pulmonary artery, where mature female worms produce microfilaria that circulate in peripheral blood. infection to humans is mediated by microfilaria-ingesting mosquitoes. d. immitis larvae in human subcutaneous tissue inserted by mosquito bite, some larvae migrate to the heart and die. dead worms produce infarcts then they lodge in pulmonary vessels. there are few symptoms [ ] . in patients with symptoms, thoracic pain, cough, bloody sputum, stridor, and fever have been reported. typical chest x-ray findings include solitary coin lesions. in many cases, an abnormal shadow of the chest x-ray is indicated on a health checkup, and d. immitis infection is pathologically diagnosed from a tissue specimen extirpated under a tentative diagnosis of lung cancer. at this point, peripheral blood eosinophilia is rarely observed [ ] . ---drugs to be recommended (same dose for adults and children)----as a diagnosis is made using pathological specimens in many patients, oral treatment is not 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infections, with a focus on the per-pathogen bacteriologic response in infections caused by streptococcus pneumoniae and haemophilus influenzae: a pooled analysis of seven clinical trials role of oral extended-spectrum cephems in the treatment of acute exacerbation of chronic bronchitis efficacy and safety of -day azithromycin versus -day moxifloxacin for the treatment of acute bacterial exacerbations of chronic bronchitis final draft report of the treatment guideline of dpb. diffuse lung disease study group, scientific research specific disease study business by the ministry of health, labour and welfare. study report in macrolides for diffuse panbronchiolitis study regarding the clinical efficacy of long-term therapy with low-dose erythromycin for diffuse panbronchiolitis long-term therapeutic effects of erythromycin and newquinolone antibacterial agents on diffuse panbronchiolitis longterm low-dose administration of erythromycin to patients with diffuse panbronchiolitis report by 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judicious use of antimicrobial agents high levels of adamantane resistance among a (h n ) viruses and interim guidelines for use of anti-viral agentseunited states, d influenza season update: drug susceptibility of swineorigin influenza a (h n ) viruses accuracy of rapid influenza diagnostic tests. a meta-analysis critically ill patients with influenza a (h n ) in mexico enteric absorption and pharmaco-kinetics of oseltamivir in critically ill patients with pandemic (h n ) influenza antivials for treatment of influenza. a systemic review and meta-analysis of observation studies influenza committee of the japanese association for infectious diseases, proposal by the japanese association for infectious diseases effect of double dose oseltamivir on clinical and virological outcomes in children and adults admitted to hospital with severe influenza: double -blind randomised controlled trial influenza viruses feigin and cherry's textbook of pediatric infectious diseases ameican academy of 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paragonimiasis: experimental and clinical experience with praziquantel in korea parasitic infections of the lung:a guide for the respiratory physician current status of strongyloides infection in okinawa pulmonary strongyloidiasis: the varied clinical presentations non-oral treatment with ivermectin for disseminated strongyloidiasis how common is human toxocariasis? towards standardizing our knowledge toxocariasis in japan lessons from eight cases of adult pulmonary toxocariasis :abridged republication thiabendazole vs. albendazole in treatment of toxocariasis: a clinical trial a case of adult hepatic toxocariasis tropical pulmonary eosinophilia: a case series in a setting of nonendemicity study group regarding the establishment of medical management by appropriate treatment with rare-disease drugs for imported tropical diseases/parasitosis. guidelines for drug therapy for parasitosis. study group regarding drugs for tropical diseases drug to be contraindicated for combination therapy: rfp precautions for combination therapy: decrease in the blood concentration: dexamethasone, phenytoin, carbamazepine, chloroquine increase in the blood concentration: cimetidine ➁ pyrantel pamoate patients can take this drug regardless of meals. there are few side effects. ➂ albendazol this drug should be taken with meals for days. a day period of discontinuation should be established and then restarted drug if required.as liver dysfunction is frequently observed, caution is needed during the administration period. bone marrow suppression and stevens-johnson syndrome must also be considered.precautions for combination therapy: decrease in the blood concentration: ritonavir, phenytoin, carbamazepine, phenobarbital increase in the blood concentration: praziquantel ➃ mebendazolealthough this drug has been used in few children, the same dose as established for adults is used. in children weighing kg or less, a half dose should be used. this drug is contraindicated for pregnant women or those who may be pregnant. combination therapy with cimetidine may increase the blood concentration of mebendazole. combination therapy with metronidazole may cause toxic epidermal necrolysis (ten) and stevens-johnson syndrome. after fasting, this drug should be taken with water. the incidence of side effects is low, but nausea/vomiting and mild hepatic disorder are sometimes observed. the safety of this drug in pregnant women or children weighing less than kg has not been established. to these patients, this drug should be administered only when its therapeutic advantage is considered to exceed its risk. ➅ diethylcarbamazine as side effects, fever, lymphangitis/lymphadenitis, and orchitis/epididymitis, which result from anti-parasitic actions, are observed in addition to abdominal discomfort, nausea, and abdominal pain. the safety of this drug in pregnant women has not been established. upper row: dose (mg/kg), lower row: frequency of administration per day key: cord- - qdrshz authors: scully, crispian title: respiratory medicine date: - - journal: scully's medical problems in dentistry doi: . /b - - - - . - sha: doc_id: cord_uid: qdrshz ●. upper respiratory infections are commonplace, especially in young people, and are often contagious; ●. lower respiratory infections are often contagious and some are potentially fatal; ●. asthma is common and may be life-threatening; ●. chronic obstructive pulmonary disease is common and disabling; ●. tuberculosis worldwide is an important infection, affecting people with hiv/aids or malnutrition particularly; ●. lung cancer is common and usually has a poor prognosis. • upper respiratory infections are commonplace, especially in young people, and are often contagious the respiratory tract consists of the upper respiratory tract (urtnose, paranasal sinuses, pharynx and larynx; discussed in ch. ) and the lower respiratory tract (lrt): the respiratory airways (trachea, bronchi and bronchioles) and lungs (respiratory bronchioles, alveolar ducts, alveolar sacs and alveoli), discussed in this chapter. protective mechanisms in the respiratory tracts include a mucociliary lining. particles or pathogens are trapped in the mucus and driven by ciliary action (the ciliary elevator) to the pharynx. mucociliary trans port declines with age but any effect on clinical infection has not been proved. lymphoid tissues of the waldeyer ring (adenoids, palatine and lingual tonsils) are important in developing an immune response to pathogens. however, the best respiratory defence mechanism is the cough reflex, the components of which include cough receptors, affer ent nerves, the cough centre, and efferent nerves and effector muscles. impairment of any of these -as may be seen in older patients or those with conditions associated with lowered consciousness (e.g. sedative use and neurological disease) -can weaken protection. dysphagia or impaired oesophageal motility may exacerbate the tendency to aspi rate foreign material. the alveolar defence mechanisms include mac rophages, immunocytes, surfactant, phospholipids, immunoglobulin g (igg), ige, secretory iga, complement components and factor b; many immune defects manifest with recurrent respiratory infections. lung function is vital to gas exchange -the blood absorbs oxygen and releases carbon dioxide. normal gas exchange requires adequate alveolar ventilation, normal ventilation/blood flow relationships and adequate alveolar-capillary membrane surface area. breathing (ven tilation) depends on respiratory drive, which reacts to the respiratory load. this process requires work and results in gas exchange. oxygen is transported in combination with haemoglobin in erythro cytes and a small amount dissolved in plasma. the oxyhaemoglobin dissociation curve is sigmoidal; once the oxygen saturation falls below %, the amount of o transported to the tissues and brain falls rapidly. high temperatures, acidosis, raised co and raised , diphosphoglycerate ( , dpg) levels encourage oxygen offloading, whereas fetal haemoglobin and carboxyhaemoglobin have the con trary effect. chronic hypoxaemia (e.g. at high altitudes) stimulates release of erythropoietin from the kidneys, with a rise in red cell pro duction, and raised , dpg. athletes have abused erythropoietin to gain competitive advantage (ch. ). the most common lrt disorders are asthma and chronic obstructive pulmonary disease (copd). respiratory disorders are common, and are often caused or aggravated by tobacco smoking. they may significantly affect general anaesthesia (ga) and conscious sedation (cs), since they are often a contraindica tion to use of benzodiazepines, opioids, ga agents and other respira tory depressants. impaired gas exchange leads to laboured breathing and can cause significant incapacity. features include cough, sputum production, wheeze, dyspnoea, chest pain, cyanosis, fingerclubbing ( fig. . ) , use of accessory muscles of respiration with indrawing of the intercostal spaces (hyperinflation), and abnormalities in chest shape, movements, respiratory rate and breath sounds. cough may be a feature of any respiratory problem but, if chronic, may herald serious disease -for example, copd, cancer or infec tion such as tuberculosis. mucoid or mucopurulent sputum is often a feature ( fig. . ); purulent sputum indicates acute bronchitis, bronchiectasis or lung abscess. blood (haemoptysis) or bloodstained sputum, though common in acute infections (especially in preexisting copd), bronchiectasis and pulmonary embolism, may herald an even more serious condition -for example, possibly one due to carcinoma or tuberculosis. wheezing is caused by airways obstruction and is a typical sign of asthma or copd. breathlessness (dyspnoea) is distress ing, and may be caused by respiratory or cardiovascular disease, or by anaemia, and is particularly ominous if it persists at rest. excessive resistive load, such as in asthma, copd and cystic fibro sis, impairs airflow. elastic load increases because of, for example, interstitial fibrosis, muscle paralysis and obesity. diagnosis of respiratory disorders is from the clinical features sup ported by imaging (especially chest radiography). spiral computed tomography (ct) can now scan the lungs in a quick - second breathhold and therefore, instead of producing a stack of individual ct slices, which may be misaligned due to patient movement or breathing in between slices, provides highresolution three dimensional images. respiratory function tests can measure individual components of the respiratory process. spirometry is the basic screening test for assess ing mechanical load problems, the quantification involving determi nation of the vital capacity (vc) -slow vital capacity (svc) and/or forced vital capacity (fvc) -and the speed of maximal expiratory flow (mef; fig. . ). in health, about % of a normalsized vc is expelled in second (fev ). the peak flow meter, which measures the peak expiratory flow rate (pefr; the earliest portion of forced expiration), is a simple measure of airflow obstruction, when the fev is a much smaller fraction of the vc. in lung restriction, the diminished vc can be mostly expelled in about second. serial meas urements (e.g. in asthma) provide valuable information about disease progress. the reversibility of airways obstruction is usually assessed by spirometry before and after use of a bronchodilator agent. arterial blood gas analysis yields considerable information about gas exchange efficiency. arterial hypoxaemia in adults is defined as pao below . kpa breathing room air, although it is not usually treated as clinically important unless below kpa, when oxygen saturation will be % or less (table . ). arterial carbon dioxide tension (paco ) is used as an inversely pro portional index of 'effective' alveolar ventilation. hence, a high paco is taken to indicate poor alveolar ventilation. alveolar hypoventila tion (raised paco ) with a normal ph probably represents a primary ventilatory change present long enough for renal mechanisms to compensate, as in chronic ventilatory failure. ventilation/blood flow relationships are most simply assessed by considering the size of the difference between the amounts of oxygen and carbon dioxide in the blood and in the air; the differences are small if the lungs are work ing efficiently. disparity between ventilation/blood flow ratios results in abnormally wide differences -and then alveolar-arterial po and arterial-alveolar pco gradients will be abnormal. alveolar capillary surface area is assessed by measuring the uptake of carbon monoxide -usually abnormal in diffuse interstitial inflam matory and fibrotic processes and in emphysema. assessing bronchial reactivity and the exercise response can help evaluate breathlessness. simple exercise testing provides information about overall fitness and the appropriateness of cardiorespiratory responses. radionuclide lung scanning, blood gas analysis and sputum cytology or culture are sometimes needed in addition. management can include oxygen administration by mask or nasal cannula (figs . and . ) . lrt disorders can cause significant incapacity and are often a con traindication to ga, and even to cs. asthma is common, affecting - % of the overall population; it is on the increase, particularly in childhood, with a frequency of up to % in some highincome countries. asthma usually begins in childhood or early adult life; about half the patients with asthma develop it before age years. bronchial hyperreactivity causes reversible airway obstruction from smooth muscle constriction (bronchospasm), mucosal oedema and mucus hypersecretion. there are two main types, extrinsic (allergic) and intrinsic asthma (table . ). extrinsic (allergic) asthma, the main childhood type, may be pre cipitated by allergens in animal dander, feathers or hair, drugs (e.g. nonsteroidal antiinflammatory drugs [nsaids] and some antibiot ics), food (e.g. eggs, fish, fruit, milk, nuts), house dust (mite allergens) or moulds. patients frequently have or develop other allergic diseases, such as eczema, hay fever and drug sensitivities. extrinsic asthma is associated with ige overproduction on allergen exposure, and release of mast cell mediators (histamine, leukotrienes, prostaglandins, bradykinin and platelet activating factor), which cause bronchospasm and oedema. about % of asthmatic children lose their asthma or improve by adulthood. intrinsic asthma is usually of adult onset and not aller gic, but appears rather to be related to mast cell instability and airway hyperresponsivity. triggers include emotional stress, gastro oesophageal reflux or vagally mediated responses. either type of asthma can be triggered by: infections (especially viral, mycoplasmal or fungal); irritating fumes (e.g. traffic or cigarette smoke); exercise (possibly due to cold air); weather changes; emotional stress; foods (e.g. nuts, shellfish, strawberries or milk) or additives (such as tartrazine); and drugs (e.g. aspirin and other nsaids, beta blockers and angiotensinconverting enzyme inhibitors [aceis]). in wellcontrolled patients with asthma, clinical features may be absent. during an asthmatic episode, symptoms may include dysp noea, cough and paroxysmal expiratory wheeziness with laboured expiration. the frequency and severity of attacks vary widely between individuals (table . ). patients may become distressed, anxious and tachycardic, have reduced chest expansion and be using accessory respiratory muscles to increase their ventilatory effort. nasal polyps are common, especially in aspirinsensitive asthmatics. children with asthma initially suffer from repeated 'colds' with cough, malaise and fever, often at night. asthma is typically diagnosed when the patient has more than one of the following -wheeze, cough, difficulty breathing and chest tightness -particularly if these are frequent and recurrent; are worse at night and in the early morning; occur in response to, or are worse after, exercise or other triggers, such as exposure to pets, cold or damp air, or with emotions or laughter; or occur without an association with colds. there is often: ■ a personal history of atopic disorder ■ a family history of atopic disorder and/or asthma ■ widespread wheeze, heard on chest auscultation ■ a history of improvement in symptoms or lung function in response to adequate therapy. a prolonged asthmatic attack, which is refractory to treatment, may lead to lifethreatening status asthmaticus (persisting for more than hours). failure of the patient to complete a sentence, indrawing of the intercostal muscles, a rapid pulse, a silent chest and signs of exhaustion are suggestive of impending respiratory arrest. diagnosis of asthma is from the clinical history and presentation, based on recognizing a characteristic pattern of episodic symptoms in the absence of an alternative explanation. investigations include a chest radiograph (to exclude other diagnoses, such as a pneumo thorax), spirometry (serial pefr), skin tests and blood examination (usually eosinophilia, raised total ige and specific ige antibody concentrations, which may help identify allergens). occasionally, a histamine or methacholine challenge is used if the diagnosis is unclear. in children with an intermediate probability of asthma, who can perform spirometry and have evidence of airways obstruction, assess the change in fev or pefr in response to an inhaled bronchodilator (reversibility) and/or the response to a trial of treatment for a speci fied period; if there is significant reversibility, or if a treatment trial is beneficial, a diagnosis of asthma is probable. management includes patient education, smoking cessation advice, avoidance of identifiable irritants and allergens, and use of drugs. home use of peak flow meters allows patients to monitor progress and detect any deterioration that may require urgent modification of treatment. treatment should be based on the amount by which peak flow is reduced (a pefr diary should be kept). drugs used for asthma management (table . ) include oxygen, shortacting β agonists (sabas; such as salbutamol), corticosteroids, leukotriene receptor antagonists and omalizumab (a recombinant humanized monoclonal antiige antibody that reduces the antigen specific ige). inhaled longacting β agonists (labas) may be needed ( fig. . ). deaths from asthma are usually a result of failure to recognize dete rioration or reluctance to use corticosteroids. other factors that have been studied include: ■ air pollution -there is an association between air pollution and aggravation of existing asthma ■ allergen avoidance -there is no consistent evidence of benefit ■ breast-feeding -there is evidence of a protective effect in relation to early asthma ■ electrolytes -there is no consistent evidence of benefit ■ fish oils and fatty acid -there is no consistent evidence of benefit ■ house dust mites -measures to reduce the numbers of house dust mites do not affect asthma severity ■ immunotherapy -allergenspecific immunotherapy is beneficial in allergic asthma ■ microbial exposure -there is insufficient evidence to indicate that the use of probiotics in pregnancy reduces the incidence of childhood asthma ■ modified milk formulae -there is no consistent evidence of benefit pets -there are no controlled trials on the benefits of removing pets from the home ■ tobacco -exposure to cigarette smoke adversely affects quality of life, lung function, need for rescue medications and longterm control with inhaled steroids. there is an association between maternal smoking and an increased risk of infant wheeze ■ weight reduction -there is an association between increasing body mass index and symptoms of asthma. elective dental care should be deferred in severe asthmatics until they are in a better phase; this can be advised by the patient's general practitioner. asthmatic patients should be asked to bring their usual medica tion with them when coming for dental treatment. local anaesthe sia (la) is best used; occasional patients may react to the sulphites present as preservatives in vasoconstrictorcontaining la, so it may be better, where possible, to avoid solutions containing vasoconstric tor. adrenaline (epinephrine) may theoretically enhance the risk of arrhythmias with betaagonists and is contraindicated in patients using theophylline, as it may precipitate arrhythmias. relative analgesia with nitrous oxide and oxygen is preferable to intravenous sedation and gives more immediate control. sedatives in general are better avoided as, in an acute asthmatic attack, even ben zodiazepines can precipitate respiratory failure. ga is best avoided, as it may be complicated by hypoxia and hyper capnia, which can cause pulmonary oedema even if cardiac function is normal, and cardiac failure if there is cardiac disease. the risk of post operative lung collapse or pneumothorax is also increased. halothane or, better, enflurane, isoflurane, desflurane and sevoflurane are the preferred anaesthetics, but ketamine may be useful in children. allergy to penicillin may be more frequent in asthmatics. drugs to be avoided, since they may precipitate an asthmatic attack (see later), include those listed in box . . acute asthmatic attacks may also occasionally be precipitated by anxiety; it is important to attempt to lessen fear of dental treatment by gentle handling and reassurance. even routine dental treatment can trigger a clinically significant decline in lung function in approximately % of asthmatics. acute asthmatic attacks are usually selflimiting or respond to the patient's usual medication, such as a betaagonist inhaler, but status asthmaticus is a potentially fatal emergency (ch. ). there may be complications caused by the antiasthmatic drugs (table . ). gastrooesophageal reflux is not uncommon, with occasional tooth erosion. periodontal inflammation is greater in asthmatics than in those without respiratory disease. persons using steroid inhalers may develop oropharyngeal candidosis or, occasionally, angina bullosa haemorrhagica. guidelines on the management of asthma may be found at: http://www.sign.ac.uk/guidelines/fulltext/ /index.html, http:// www.nice.org.uk/guidance/qualitystandards/indevelopment/asthma. jsp and http://www.britthoracic.org.uk/portals/ /guidelines/ asthmaguidelines/qrg % .pdf (all accessed september ). churg-strauss syndrome (css) is a rare, potentially fatal, systemic vasculitis similar to polyarteritis nodosa (pan), characterized by severe asthmalike attacks with peripheral eosinophilia, and intravas cular and extravascular granuloma formation with eosinophil infiltra tion and skin lesions in %. cardiopulmonary involvement is the main cause of death. css is diagnosed if at least of the criteria listed in box . are positive. the year survival of untreated css is %. combination treatment with cyclophosphamide and prednisolone (prednisone) provides a year survival of %. management problems relating to patients with css may include res piratory impairment and corticosteroid treatment (ch. ). chronic obstructive pulmonary disease (copd; chronic obstructive airways disease, coad) is a common, chronic, slowly progressive, irre versible disease (most frequently a combination of chronic bronchitis and emphysema), characterized by breathlessness and wheeze (airways obstruction), cough and sputum. chronic bronchitis is defined as the excessive production of mucus and persistent cough with sputum production, daily for more than months in a year over more than consecutive years. it leads to production of excessive, viscous mucus, which is ineffectively cleared from the airway, obstructs and stag nates, and becomes infected, usually with streptococcus pneumoniae, moraxella catarrhalis and haemophilus influenzae. patchy areas of alveolar collapse can result. emphysema is dilatation of air spaces dis tal to the terminal bronchioles with destruction of alveoli, reducing the alveolar surface area available for respiratory exchange. copd is now the preferred term for conditions with airflow obstruction because of a combination of airway and parenchymal damage; patients were previ ously diagnosed as having chronic bronchitis or emphysema. copd is characterized by airflow obstruction -defined as an fev / fvc ratio reduced to less than . . if fev is % or more, a diagno sis of copd should only be made if there are respiratory symptoms (e.g. dyspnoea or cough). the airflow obstruction is not fully revers ible, does not change significantly over months, and is usually progres sive in the long term. the most important causes of copd include cigarette smoking, environmental pollution, dusts, chemicals or occupational exposures to various substances. exposure to smoke from home cooking or heating fuels may contribute. deficiency of the antiproteolytic enzyme alpha antitrypsin is a rare cause of emphysema. there is often significant airflow obstruction before the person is aware of it and so copd typically remains undiagnosed until patients are in their fifties. differentiation from asthma is important (table . ). a diagnosis of copd should be considered in patients over the age of who have a risk factor (e.g. smoking) and exertional breath lessness, chronic cough, regular sputum production, frequent winter 'bronchitis' or wheeze. clinical judgment is based on history, physical examination, confirmation of airflow obstruction using spirometry (postbronchodilator spirometry) and assessment of the severity of dyspnoea (tables . and . ). copd is characterized by breathlessness and wheeze (airways obstruction), cough and an early morning mucoid sputum production. to investigate symptoms that seem disproportionate to spirometric impairment progressive dyspnoea, low oxygen saturation, carbon dioxide accumu lation (hypercapnia) and metabolic acidosis mean that patients may ultimately become dyspnoeic at rest ('respiratory cripples'), especially when recumbent (orthopnoea), and eventually develop respiratory failure, pulmonary hypertension, right ventricular hypertrophy and rightsided heart failure (cor pulmonale). two clinical patterns of copd are recognized: ■ 'pink puffers' -patients with emphysema who manage to maintain normal blood gases by hyperventilation, and are always breathless but not cyanosed; rather they are pink from vasodilatation ■ 'blue bloaters' -patients with chronic bronchitis who lose their co drive, fail to maintain adequate ventilation and become both hypercapnic and hypoxic with central cyanosis, cor pulmonale and oedema (for these patients, the respiratory drive is from the low po and thus oxygen administration is contraindicated) (table . ). the diagnosis of copd is based upon clinical history and presen tation. investigations include a chest radiograph (which may show hyperinflated lung fields with loss of vascular markings); arterial blood gases (which should be measured if pulse oximetry shows oxygen satu ration less than %); spirometry; and lung function tests. fev is reduced in all cases (fev of less than % signifies severe copd) and the flow-volume curve shows a typical pattern, with reduced flow rates at mid and lowerlung volumes. a ratio of fev :fvc of less than % confirms airways obstruction. patients with copd and their family should be educated about the disease, and about required lifestyle changes and medication. nondrug therapy includes: stopping smoking (nicotine replacement therapy or bupropion may help); exercise by pulmonary rehabilitationof proven benefit; weight loss (improves exercise tolerance); and vaccination (pneumococcal and influenza vaccines). drug therapy includes shortacting bronchodilators (anticholinergic drugs [ipra tropium bromide]) and β agonists (salbutamol) to treat the reversible component of airway disease; corticosteroids (inhaled or systemic); and antibiotics (amoxicillin, trimethoprim or tetracycline). mucolytics, such as carbocisteine, reduce acute exacerbations by almost onethird. longterm oxygen therapy (ltot) reduces mortality. people with stable copd who remain breathless or have exacerba tions, despite using shortacting bronchodilators, should be offered the following as maintenance therapy: ■ if fev is % of predicted or more: use either a longacting β agonist (laba) or longacting muscarinic antagonist (lama). ■ if fev is less than % predicted: either a laba with an inhaled corticosteroid (ics) in a combination inhaler, or a lama. offer a lama in addition to a laba plus ics to people with copd who remain breathless or have exacerbations, despite taking laba plus ics, irrespective of their fev . provide pulmonary rehabilitation for all who need it; noninvasive ventilation (niv) is the treatment of choice for persistent hyper capnic ventilatory failure during exacerbations not responding to medical therapy. the frequency of exacerbations should be reduced by appropriate use of inhaled corticosteroids and bronchodilators, and vaccinations. bronchodilators (shortacting β agonists [saba] and shortacting muscarinic antagonists [sama]) should be the initial empirical treat ment for the relief of breathlessness and exercise limitation. ics have potential adverse effects (including nonfatal pneumonia) in people with copd. offer a oncedaily lama in preference to fourtimes daily sama to people with stable copd who remain breathless or have exacerbations, despite using shortacting bronchodilators as required, and in whom a decision has been made to commence regular maintenance bronchodilator therapy with a muscarinic antagonist (see above). most patients -whatever their age -are able to acquire and main tain an adequate inhaler technique. bronchodilators are usually best administered using a handheld inhaler device (including a spacer device if appropriate). patients with distressing or disabling dyspnoea, despite maximal therapy using inhalers, should be considered for nebulizer therapy. they should be offered a choice between a face mask and a mouth piece to administer their nebulized therapy, unless the drug specifically requires a mouthpiece (for example, anticholinergic drugs). some patients with advanced copd may require maintenance oral corticosteroids when these cannot be withdrawn following an exacer bation. these individuals should be monitored for the development of osteoporosis and given appropriate prophylaxis. theophylline should only be used after a trial of saba and laba, and only to those who are unable to use inhaled therapy, as there is a need to monitor plasma levels and interactions. the dose of theo phylline prescribed should be reduced at the time of an exacerbation if macrolide or fluoroquinolone antibiotics (or other drugs known to interact) are given. there is insufficient evidence to recommend prophylactic antibiotic therapy in the management of stable copd. mucolytic drug therapy should be considered in patients with a chronic cough productive of sputum. if patients remain symptomatic on monotherapy, their treatment should be intensified by combining therapies from different drug classes, such as: ■ β agonist and theophylline ■ anticholinergic and theophylline. inappropriate oxygen therapy in people with copd may depress respiration. ltot is indicated in patients with copd who have a pao of less than . kpa when sta ble, or a pao greater than . kpa and less than kpa when stable, and one of: secondary polycythaemia, nocturnal hypoxaemia (oxygen saturation of arterial blood [sao ] of less than % for more than % of the time), peripheral oedema or pulmonary hypertension. to reap the benefits of ltot, patients should breathe supplemental oxygen for at least hours per day. to ensure that all those eligible for ltot are identified, pulse oximetry should be available in all health care settings. the assessment of patients for ltot should comprise the measurement of arterial blood gases on two occasions at least weeks apart in patients who have a confident diagnosis of copd, who are receiving optimum medical management and whose copd is stable. patients should be warned about the risks of fire and explosion and told not to smoke when using oxygen. ambulatory oxygen therapy should be considered in patients on ltot who wish to continue oxygen therapy outside the home, and who have exercise desaturation, are shown to have an improvement in exercise capacity and/or dyspnoea with oxy gen, and are motivated to use oxygen. adequately treated patients with chronic hypercapnic respiratory failure who have required assisted ventilation during an exacerbation, or who are hypercapnic or acidotic on ltot, should be referred to a specialist centre for consideration of longterm niv. advanced emphysema is occasionally treated with sur gery -excision of large acquired bullae or, rarely, lung transplantation. patients with copd who need dental care can be classified as follows: ■ patients at low risk -experience dyspnoea on effort but have normal blood gas levels. these patients can receive all dental treatment with minor modifications. ■ patients at moderate risk -experience dyspnoea on effort, are chronically treated with bronchodilators or recently with corticosteroids, and pao lowered. a medical consultation is advised to determine the level of control of the disease before any dental treatment. ■ patients at high risk -have symptomatic copd that may be end stage and poorly responsive to treatment. with these patients, a medical consultation is essential before any dental treatment is carried out. patients with copd are best treated in an upright position at midmorning or early afternoon, since they may become increasingly dyspnoeic if laid supine. it may be difficult to use a rubber dam, as some patients are mouthbreathers and not able to tolerate the additional obstruction. la is preferred for dental treatment, but bilateral mandibular or palatal injections should be avoided. patients with copd should be given relative analgesia only if absolutely necessary, and only in hospital after full preoperative assessment. cs with diazepam and midazolam should not be used, as benzodiazepines are respiratory depressants. patients should be given ga only if absolutely necessary, and intravenous barbiturates are contraindicated. secretions reduce airway patency and, if lightly anaesthetized, the patient may cough and contaminate other areas of the lung. postoperative respiratory complications are more prevalent in patients with preexisting lung diseases, especially after prolonged operations and if there has been no preoperative preparation. the most important single factor in preoperative care is cessation of smok ing for at least week preoperatively. respiratory infections must also be eradicated; sputum should first be sent for culture and sensitivity, but antimicrobials such as amoxicillin should be started without await ing results. the medical management of copd should be optimized prior to surgery. the ultimate clinical decision about whether or not to proceed with surgery should rest with a consultant anaesthetist and consultant surgeon, taking account of comorbidities, functional status of the patient and necessity for the surgery. composite assessment tools, such as the american society of anesthesiologists (asa) scoring system, and not just lung function, are the best criteria for the assessment of patients with copd before surgery. those taking corticosteroids should be treated with appropri ate precautions (ch. ). interactions of theophylline with other drugs, such as adrenaline (epinephrine), erythromycin, clindamycin, azithro mycin, clarithromycin or ciprofloxacin, may result in dangerously high levels of theophylline. ipratropium can cause dry mouth. guidelines for the management of copd may be found at: http:// publications.nice.org.uk/chronicobstructivepulmonarydisease cg (accessed september ). respiratory viruses usually spread by touch or airborne transmission and the very small particles ( - . micrometres) can avoid the upper respiratory tract defences and the mucociliary elevator to reach the lung alveoli. a range of viruses can cause lower respiratory tract infections (lrtis ; table . ). some viruses (e.g. influenza and respiratory syncytial) can spread from the upper to the lower respira tory tract via infection of the respiratory epithelium and can lead to bacterial superinfection and pneumonitis (pneumonia). mycoplasmal (atypical) pneumonia and tuberculosis (tb) may be direct infections. epidemics of a potentially fatal severe acute respiratory syndrome (sars) have been caused by a coronavirus that originated in china and spread worldwide; h n bird influenza also arose as an epidemic; and a similar epidemic, but of swine influenza (h n ), emanated from mexico (see later). bacterial infections, such as pneumonia or lung abscess, can also result from material aspirated into the lungs, and are usually unilat eral. those who aspirate more than others have, as a result, more frequent lrti and this is seen in alcohol and other drug abusers, as well as comatose patients. exogenous penetration and contamination of the lung can result from trauma (e.g. a stab wound or road traffic accident) or surgery. entamoeba histolytica can occasionally cause pneumonia -by direct extension from an amoebic liver abscess (table . ). patients with endocarditis, or septic pelvic or jugular thrombo phlebitis, may experience lrti acquired haematogenously and then it is often bilateral. immunocompromised persons (e.g. those with human immunode ficiency virus/acquired immune deficiency syndrome [hiv/aids] and transplant recipients) and people with bronchiectasis or cystic fibrosis are also susceptible to respiratory infections by a range of opportun istic microbes. pneumocystis jiroveci (p. carinii), for example, is a com mon cause of potentially fatal pneumonia in immunocompromised patients -especially those with hiv/aids (chs and ). clinical features of lrti vary according to the part of the respiratory tract mainly affected: ■ bronchiolitis causes rapid respiration, wheezing, fever and dyspnoea -but is restricted mainly to infants. ■ bronchitis causes cough, wheezing and sometimes dyspnoea. ■ pneumonia causes cough, fever, rapid respiration, breathlessness, chest pain, dyspnoea and shivering. antimicrobial therapy is indicated, particularly for pneumonia. antivirals have not been highly effective. oxygen may be needed. pneumococcal vaccine is indicated for older people. the majority of lrtis are severe illnesses, and are contraindications to all but emergency dental treatment. ga is hazardous and absolutely contraindicated. dental treatment should be deferred until recovery, or be limited to pain relief. influenza is mainly a communitybased infection transmitted in house holds and communities. healthcareassociated influenza infections can arise in any healthcare setting, most commonly when influenza is also circulating in the community. influenza is a contagious disease caused by influenza virus types a, b or c. type a has two main subtypes (h n and h n ); it causes most of the widespread influenza epidemics and can occasionally be fatal. type b viruses generally cause regional outbreaks of moderate severity, and type c viruses are of minor significance. a person can spread influenza starting day before they feel sick and for another - days after symptoms start. influenza can be pre vented or ameliorated by vaccination each autumn; this is especially indicated for older people and those with cardiorespiratory disease. influenza attacks virtually the whole respiratory tract; symptoms appear suddenly after - days and include fever, sore throat, nasal congestion, headache, tiredness, dry cough and muscle pains (myalgia). most people recover in - weeks but infection can be lifethreatening, mainly because primary influenzal viral pneumonia can lead to sec ondary bacterial pneumonia or can exacerbate underlying conditions (e.g. pulmonary or cardiac disease). the old and very young, and those with chronic disorders, are more likely to suffer complications, such as pneumonia, bronchitis, sinusitis or otitis media. influenza has also been followed by depression, encephalopathy, myocarditis, myositis, pericarditis, reye syndrome and transverse myelitis. rest, maintenance of fluid intake, analgesics, antipyretics, and avoid ance of alcohol and tobacco help relieve symptoms. aspirin must never be given to children under the age of years who have 'flulike symptoms, and particularly fever, as this can cause reye syndrome. zanamivir (an antiviral that works against influenza types a and b) can shorten the symptoms by approximately day, if treatment is started during the first days of illness. other antiviral drugs include amantadine, oseltamivir and rimantadine; they may be helpful but their use is restricted mainly to immunocompromised persons, since they can cause adverse effects. influenza can be a severe contagious illness so all but emergency den tal treatment should be deferred until recovery. ga is hazardous and absolutely contraindicated. influenza type a subtype h n can cause an illness known as 'avian influenza' or 'bird 'flu' in birds, humans and many other animal spe cies. hpai a(h n ) -'highly pathogenic avian influenza virus of type a of subtype h n ' -is the causative agent and is enzootic in many bird populations, especially in southeast asia. it has spread globally and resulted in the deaths of over people and the slaughter of mil lions of chickens. a vaccine that could provide protection (prepandrix) has been cleared for use in the european union. h n is a more recent emergent infection, similar in many respects. swine influenza is common in pigs in the midwestern united states, mexico, canada, south america, europe (including the uk, sweden and italy), kenya, china, taiwan, japan and other parts of eastern asia. transmission of swine influenza virus from pigs to humans is not com mon, but can produce symptoms similar to those of influenza. a outbreak in humans ('swine 'flu') was due to an apparently new strain of h n arising from a reassortment produced from strains of human, avian and swine viruses. it can pass from human to human. antiviral agents such as oseltamivir may help. vaccines are now available. an outbreak of a lifethreatening febrile respiratory infection appeared in , originating from guangdong, china, and was named severe acute respiratory syndrome (sars). caused by a newly recognized coronavirus (sarsassociated coronavirus, sarscov), sars spread via close contact to many countries across the world. according to the world health organization, people worldwide became sick with sars during the course of the first recognized outbreak and died. the incubation period of - days is followed by a high fever (above . °c), malaise, headache and myalgia. some people also experience mild upper respiratory symptoms and, after - days, lower respiratory signs -a dry cough and dyspnoea, potentially progressing to hypox aemia. sars can cause a pneumonia with a mortality approaching %, particularly in older or immunocompromised people. artificial ventilation has been needed in - % of cases. antiviral agents, such as oseltamivir or ribavirin, may help. inactivated vaccines, virally and bacterially vectored vaccines, recombinant protein and dna vaccines, as well as attenuated vaccines, are under development. sars is a severe illness, and all but emergency dental treatment should be deferred until recovery. ga is hazardous and absolutely contraindicated. for all contact with suspect sars patients, careful hand hygiene is important, including handwashing with soap and water; if hands are not visibly soiled, alcoholbased handrubs may be used as an alternative to handwashing. if a suspected sars patient is admitted to hospital, infection control personnel should be notified immediately. infection control measures (www.cdc.gov/ncidod/hip/iso lat/isolat.htm; accessed september ) should include standard precautions (e.g. hand hygiene): healthcare personnel should wear eye protection for all patient contact; contact precautions (e.g. gown and gloves for contact with the patient or their environment); and airborne precautions (e.g. an isolation room with negative pressure relative to the surrounding area and use of an n filtering disposable respirator for persons entering the room). pneumonia is classed as 'primary' if it occurs in a previously healthy individual, and is usually lobar; it is called 'secondary' if it follows some other disorder, such as previous viral respiratory infections, aspir ation of foreign material, lung disease (bronchiectasis or carcinoma), depressed immunity (e.g. alcoholism or immunosuppression), or aspir ation of oral bacteria ( pneumonia causes cough, fever, rapid respiration, breathlessness, chest pain, dyspnoea and shivering. complications can include lung abscess or empyema (pus in pleural cavity). it is important to avoid alcohol and tobacco, but use analgesics and antipyretics to relieve the symptoms. broadspectrum antimicrobi als given promptly and empirically usually include a macrolide (azithromycin, clarithromycin or erythromycin), quinolone (moxiflox acin, gatifloxacin or levofloxacin), or doxycycline for outpatients. for in patients, cefuroxime or ceftriaxone plus a macrolide is used. prophylaxis includes immunization against influenza and pneumococci. pneumonia is a severe illness and all but emergency dental treatment should be deferred until recovery. ga is hazardous and absolutely contraindicated. ventilatorassociated pneumonia (vap) is discussed later. legionellosis is a bacterial respiratory infection caused by one of the family legionellaceae, gramnegative aerobic bacilli, ubiquitous in water and soil but particularly preferring warm aquatic environments. the term legionnaire's disease was coined as a result of an outbreak of the previously unrecognized respiratory disease in an american legion meeting in philadelphia in , but it is now recognized worldwide, many infections being contracted during travel abroad, particularly to spain, turkey and some other mediterranean areas. legionella bacteria can be found in natural freshwater environments, usually in insufficient numbers to cause disease. legionella grow best in warm water, as in hot tubs, cooling towers, hot water tanks, large plumbing systems, or the airconditioning systems of large buildings. though there are over legionellaceae, most infections are caused by legionella pneumophila. disease is contracted by inhalation of contaminated mist or vapour, mainly (approximately %) through aerosolization of infected water in airconditioning systems, hotwater systems, humidifiers, nebulizers, showers and spa pools. outbreaks have mostly been linked to aerosol sources in the community, cruise ships and hotels, with the most likely sources being whirlpool spas, air conditioning units in large buildings, potable (drinking) water systems, and water used for bathing. risk factors include: ■ exposure to: recent travel with an overnight stay outside of the home (outbreaks of travelassociated legionellosis are infrequently identified but more than % of cases are thought to be associated with recent travel) whirlpool spas recent repairs or maintenance work on domestic plumbing ■ systemic illhealth: alcohol use chronic kidney disease diabetes immune defects liver disease malignancy smoking. illness mainly affects males over , smokers, heavy drinkers, older people and the immunocompromised. also vulnerable are travellers, especially middleaged and older tourists, and conference or business groups, possibly because of tiredness or age. many young people have been exposed to infection and become seropositive, but remained healthy. there is no evidence of persontoperson transmission of legionellosis. legionellosis manifests as one of two clinical syndromes (table . ). legionnaire's disease is typically a lobular type of pneumonia, which can be fatal but is fortunately rare; infection can range from discrete patches of inflammation and consolidation to involvement of whole lobes. pontiac fever is milder and usually subsides rapidly, often with out treatment. people who should be tested for legionnaire's disease include those with pneumonia in the following groups: because legionella is commonly found in the environment, clinical isolates are necessary to interpret the findings of an environmental investigation. diagnosis can be by rapid urine molecular testing for l. pneumophila antigen, and culture of respiratory secretions on selective media. sensitivity and specificity of the diagnostic tests are shown in table . . pontiac fever is a selflimited illness; most cases recover within week and few benefit from antibiotic treatment. overall mortality in legionnaire's disease may be as high as %, and over % in older people and up to % in the immunocompromised. erythromycin is standard treatment; cephalosporin is an alternative. legionella species are present in roughly twothirds of potable water samples collected from domestic and institutional taps and drinking fountains, and from a similar percentage of dental units, but water from these dental units often has higher bacterial concentrations (ch. ). there are reports of legionella infections in dental unit water lines, and antibodies and occasionally frank infection demonstrated in dental staff; at least one patient appears to have contracted and died from infection emanating from a dental practice. prevention is crucial, involving (ch. general aspects tuberculosis (tb) , an infection caused by mycobacteria, affects approxi mately onethird of the world's population ( . billion people); it is a major global health problem, some million people dying from it annu ally. tb disproportionately affects the poorest persons in both high income and developing countries. in highincome countries, most human tb arises from mycobacterium tuberculosis, transmitted from person to person through the air. tb usually affects the lungs initially (pulmonary tb) but can also involve brain, kidneys, spine and other parts. from victorian times to about the second world war, mycobacterium bovis infection from infected cows' milk (bovine or btb) was a major cause of morbidity and mortality; it was clinically and pathologically indistin guishable from infection caused by m. tuberculosis. cattletesting and a slaughter programme became compulsory in and, by the s, the incidence of tb in cattle had been substantially reduced. tuberculosis from m. bovis in cows' milk was virtually eliminated in highincome countries by the tuberculin testing of cattle and pasteurization of milk. in the developing world, many cattle still have tb, and btb is still seen. btb has also increased in highincome countries over the last two dec ades and an infection rate of up to % in badgers -and transmission to cattle -may explain this. tb is not spread by touch or by drinking glasses, dishes, sheets or clothing. it is usually transmitted by infected sputum, typically from close contacts such as family members, but is unlikely to be transmit ted between normal social contacts. tb can present an occupational risk to healthcare professionals, including dental staff. one outbreak of drugresistant tb in new york involved at least patients, most of whom contracted tb in one of hospitals; nearly % of the patients were also hivpositive, and most were young males of hispanic or african heritage. tb has been transmitted between pas sengers during longhaul airline flights. the risk of transmitting tb though air circulation is now low because the highefficiency particu late air (hepa) filters on newer commercial aircraft are of the same type as those used in hospital respiratory isolation rooms; indeed, the number of times air is cleaned each hour exceeds the recommendation for hospital isolation rooms. subsaharan africa has the highest rates of active tb per capita, driven primarily by the hiv epidemic. the absolute number of cases is highest in asia, with india and china having the great est burden of disease globally. in the usa and most western european countries, the majority of cases occur in foreignborn residents and recent immigrants from countries in which tubercu losis is endemic. immunocompromised people -such as diabetics and severely immuno deficient patients, like those with hiv/aids (about % of south africans with hiv/aids also have tb) -and patients in prisons or institutions are at risk. tb also mainly affects medically neglected persons, such as vagrants, alcoholics, intravenous drug abusers or older homeless people. the main groups at increased risk for infection therefore include people who are resourcepoor or immunoincompetent, especially: tb in developing countries is particularly widespread and is increasing, the highest rises in incidence being in southeast asia, subsaharan africa and eastern europe. in highincome countries, the incidence is also rising, probably because of worsening social deprivation, homelessness, immigration, hiv infection and intra venous drug abuse. it is now as common in london as in the devel oping world, and is seen especially in immigrants, such as those from the indian subcontinent, africa and south asia. this increase appears to be a result of the development of tb disease in individu als who may have been infected for some time and of new infections acquired in the uk, or as a result of travel to other countries where tb is common. london accounted for the highest proportion of cases in the uk in ( %), followed by the west midlands region ( %); % of these were born outside the uk and mainly originated from south asia and subsaharan africa. in , there was a rise in the number of tb cases compared to , as well as an increase in drug resistance. more information on tb, including statistics, can be found at: http:// www.hpa.org.uk/publications/infectiousdiseases/tuberculosis/ and http://www.tbfacts.org/tbstatistics.html (both accessed september ). initial infection with tb is usually subclinical. about % of those infected develop overt disease; of these, half will manifest within years (primary tb), while the remainder will develop postprimary disease. inhaled mycobacteria may cause subpleural lesions (primary lesion) and lesions in the regional lymph nodes (primary complex). body defences usually localize the mycobacteria, though these remain viable; infected persons are not obviously ill and are unlikely to know they are infected (latent ; table . ). latent tb infection (ltbi) usu ally becomes active only after many years, if body defences become weakened (box . ). however, active tb can develop shortly after mycobacteria enter the body, if body defences are impaired such as in ageing, drug or alcohol abuse, or hiv/aids. also, in massive infec tions, acute active tb can result, typically causing a chronic productive cough, haemoptysis, weight loss, night sweats and fever. erythema nodosum may be associated. extrapulmonary tb is less common; it may appear as glandular involvement in the neck or elsewhere, and is less infectious than pulmonary tb. lymph node tb may lead to lymphadenopathy, caseation of the nodes and pressure symptoms -for example, on the bronchi. postprimary tb follows reactivation of an old primary pulmonary lesion and results in features ranging from a chronic fibrotic lesion to fulminating tuberculous pneumonia. the pulmonary lesions may extend and lead to a pleural effusion. reactivation or progression of primary tb may also result in widespread haematogenous dissemina tion of mycobacteria -'miliary tb'. multiple lesions may involve the central nervous system, bones, joints, and cardiovascular, gastrointes tinal and genitourinary systems. clinical presentation in tb is thus variable, depending on the extent of spread and the organs involved. as it frequently passes unrecog nized for so long, the mortality is high. similar illnesses to tb may also be caused by atypical (nontuber culous) mycobacteria, such as m. avium complex (mac; see below). the diagnosis of tb is suggested by the history and confirmed by physical examination, a massively raised erythrocyte sedimentation rate (esr), positive tuberculin skin tests (tsts; mantoux or heaf test for a delayed hypersensitivity reaction to protein from m. tuberculosis [purified protein derivative; ppd]) and chest imaging. hypersensitivity develops with - weeks of infection and can be detected by conversion of the tst from negative to positive, but tsts are neither % sensi tive nor specific. a positive mantoux reaction indicates previous immu nization (bcg; bacille calmette-guérin -live attenuated m. bovis) or current infection -not necessarily disease. chest radiography may show scarring and hilar lymphadenopathy. computed tomography (ct) may show areas of calcification or highlight a tuberculous abscess. smears and culture of sputum, blood, laryngeal swabs, bronchoalveolar lavage, gastric aspirates or pleural fluid may be tested for mycobacteria. polymerase chain reaction (pcr) techniques have greatly acceler ated the diagnosis and speciation, though ziehl-neelsen, auramine or rhodamine microbial stains are still used. the mycobacteria growth indicator tube (mgit) system gives results as early as - days. blood assay for m. tuberculosis (bamt) may be positive by interferongamma release assay (igra). some % of people over years have a positive igra. the igra can be used in place of (but not in addition to) tst. igras measure the immune reactivity to m. tuberculosis. white blood cells from most persons that have been infected with m. tuberculosis will release interferongamma (ifnγ) when mixed with m. tuberculosis antigens. a positive test result sug gests that m. tuberculosis infection is likely; a negative result suggests that infection is unlikely. latent infection (ltbi) can be diagnosed with either a tuberculin skin test or an igra (more specific). igra gives a result within hours and should be used biological therapy is given, such as for rheumatoid arthritis or inflammatory bowel disease. prior bcg vacci nation does not cause a falsepositive igra test result. more informa tion on the igra is available at: http://www.cdc.gov/tb/publications/ factsheets/testing/igra.htm (accessed september ). active tb is diagnosed by sputum microscopy and culture in liquid medium with subsequent drugsusceptibility testing. nucleic acid people who should be tested for tb include those who have symp toms, those who have had close daytoday contact with active tb disease (family member, friend or coworker), those who have hiv infection or aids, those with lowered immunity, those who are required to for employment or school, and those about to be treated with biological agents. the top priority of tb control programmes is to identify and give complete treatment to all patients with active disease. tb is a notifi able disease and contact tracing is an important aspect of limiting spread. treatment with antibiotics is indicated for people who are sick with tb, those infected but not sick, and those who are close contacts of infectious tb cases. treatment for 'symptomatic sputumpositive' patients, which should be instituted as soon as possible, is combination chemotherapy, usually isoniazid plus rifampicin plus pyrazinamide or ethambutol for months, with continuation of daily isoniazid and rifampicin for a further months. treatment for 'asymptomatic' patients who are believed to have been infected by contacts, but are not unwell, includes isoniazid for months or isoniazid and rifampicin for months. rifapentine is a longacting rifampicin used once weekly. fluoroquinolones (moxifloxacin) may also act against tb. there may be resistance to one or more than one antibiotic. currently, given the potential risk of drugresistant tb being present, treatment is usually started with isoniazid, rifampicin, pyrazinamide and ethambutol (or a quinolone such as gatifloxacin or moxifloxacin) for months, then isoniazid and rifampicin for months. all antituberculous drugs (table . ) have potentially serious adverse effects and require careful monitoring. if patient compliance is considered to be poor, directly observed therapy (dot), where drugs are dispensed by and taken in the presence of a healthcare profes sional, may be indicated. new drugs are on the horizon. immunization using bcg is advocated for schoolchildren, highrisk individuals and healthcare professionals -although its efficacy has been questioned. new vaccines are in development. chemoprophylaxis with isoniazid and rifampicin is indicated in a number of situations (box . ) . tb can become resistant to the drugs used to treat it particularly when the drugs are misused or mismanaged. this may occur, for example, when: in some developing countries, approximately % of cases are multi ple antibioticresistant; this is termed multidrugresistant tuberculosis (mdrtb); in the uk, only a small minority currently fall into this category but the number of cases is increasing. mdrtb is defined as resistance to rifampicin and isoniazid; it may be atypical in presenta tion and the infection disseminates. more than % of people with tb worldwide have mdrtb, and eastern europe has a high prevalence. mdrtb is seen mainly in people with hiv/aids and in hiv/aids and in africans. bedaquiline, is a new antitubercular agent the first active agent against tuberculosis to be registered since . extensively drugresistant tuberculosis (xdrtb) is a rare type of mdrtb, not only resistant to isoniazid and rifampin, but also to any fluoroquinolone and at least one of three injectable secondline drugs (i.e. amikacin, kanamycin, or capreomycin). xdrtb is of special concern for immunocompromised people (e.g. with hiv/aids), who are more likely to develop tb, and have a higher risk of death if they do develop it. xdrtb is most often encountered in people from eastern europe, russia and africa. it has been transmitted in healthcare facilities and is now seen worldwide. it is essentially untreatable, though capreomycin has been used effectively to treat mdrtb in hivpositive individuals. totally drugresistant tb was reported initially in - in india, iran and italy; it is spreading, despite denials, and is most disquieting. chronic ulcers, usually on the tongue dorsum, are the main oral manifestation of tb. they result from coughing of infected sputum from pulmonary tb, including in hivinfected persons with tb, but are rare and such cases (usually middleaged males) may result from neglect of symptoms or default from treatment. occasionally, the diagnosis is made from biopsy of an ulcer after granulomas are seen microscopically. acidfast bacilli are rarely seen in oral biopsies, even with the help of special stains, so unfixed material should also be sent for culture if possible. tuberculous cervical lymphadenopathy is the next most common form of the infection and is particularly com mon among those from south asia. most tb lymphadenitis is pain less, with several enlarged, matted nodes, but systemic symptoms are present only in a minority and only about % have pulmonary mani festations on radiography (fig. . ) . diagnosis relies on tuberculin testing, which can be positive in both tuberculous and non tuberculous mycobacterial cervical lymphadenitis. any person with lymphadenop athy and recent conversion from a negative to positive tuberculin test should be suspected of having mycobacterial infection, and this should prompt biopsy (e.g. fineneedle aspiration biopsy) for culture or histo logical confirmation. pcr will improve diagnosis, as culture must wait - weeks for a result. oral complications of antitubercular therapy are rare, but rifabutin and rifampicin can cause red saliva. pulmonary tb is of high infectivity, as shown by cases of tuber culous infection of extraction sockets and cervical lymphadenitis in patients treated by an infected member of staff at a dental clinic. dental staff who themselves were hivpositive, working in a dental clinic for hivinfected persons in new york, have died from tb con tracted occupationally. transmission of mdrtb between two dental workers may have occurred in an hiv dental clinic. infection control is thus important, so staff with tb are usually precluded from their occupation until treated. management of a patient with tb depends upon the level of poten tial infectivity (table . ) . patients with open pulmonary tb are con tagious, and dental treatment is thus best deferred until the infection has been treated. treatment with appropriate drugs for weeks drasti cally reduces the infectivity of patients with pulmonary tb. if patients with open pulmonary tb must be given dental treatment, special pre cautions should be used to prevent the release of mycobacteria into the air, to remove any that are present and to stop their inhalation by other persons. reduction of splatter and aerosols, by minimizing cough ing and avoiding ultrasonic instruments, and use of a rubber dam, are important. improved ventilation, ultraviolet germicidal light, new masks and personal respirators, and other personal protective devices, such as hepa filters, are indicated ( fig. . ) . mycobacteria are very resistant to disinfectants, so that heat sterilization must be used. la is safe and satisfactory. relative analgesia is contraindicated because of the risk of contamination of the apparatus. ga is also contraindicated for dental treatment because of the risk of contamina tion of the anaesthetic apparatus and because of impaired pulmonary function. aminoglycosides, such as streptomycin, enhance the activity of some neuromuscular blocking drugs and in large doses may alone cause a myasthenic syndrome. possible drug interactions are shown in table . . other factors, such as alcoholism or intravenous drug use (ch. ), hepatitis (ch. ) or hiv disease (ch. ), may also influence dental management. mycobacteria other than tuberculosis (mott) are widely distributed in water, soil, animals and humans, and rarely cause disease. severe mott infections have been seen, however, in individuals predisposed because of defects in the interleukin (il ) and interferongamma (ifngamma) pathways. mycobacterium abscessus, a bacterium found in water, soil and dust, has been known to contaminate medications and products, including medical devices. healthcareassociated m. abscessus can cause a vari ety of infections, usually of the skin, but it can also cause lung infec tions in persons with various chronic lung diseases and is increasingly recognized as an opportunistic pathogen in cystic fibrosis (cf) patients persontoperson transmission of atypical mycobacteria is not important in acquisition of infection, except for skin infections. on rare occasions, mott skin infections have followed tattooing with contaminated tattoo inks. many people become infected with and har bour mott in their respiratory secretions without any symptoms or evidence of disease. individuals with respiratory disease from mott do not readily infect others and, therefore, do not need to be isolated. mott are generally not infectious to others. infection with m. abscessus is usually caused by injections of con taminated substances or by invasive medical procedures employing contaminated equipment or material. infection can also occur after accidental injury where the wound is contaminated by soil. there is very little risk of transmission from person to person. mac complex, m. scrofulaceum and m. kansasii are possible causes of tuberculous cervical lymphadenitis. mac may also infect the lungs (similar to tb), skin or lymph nodes. lung disease is also caused occasionally by m. kansasii, mainly in middleaged and older persons with underlying chronic lung conditions. m. fortuitum and m. chelonae may cause skin and wound infections and abscesses, frequently associated with trauma or surgery. m. marinum may cause 'swimming pool granuloma', a nodular lesion that may ulcerate, usually on an extremity. m. ulcerans may produce chronic ulcerative skin lesions, usually of an extremity. m. abscessus skin infections present with swollen and/ or painful areas that are usually red, warm and tender to the touch, and which can also develop into boils or pustules. other features of m. abscessus infection are fever, chills, muscle aches and malaise. cervical lymphadenitis due to mac, m. scrofulaceum and m. kansasii may affect otherwise healthy young children, most commonly pre school females who have unilateral cervical lymphadenopathy, typically in the submandibular or jugulodigastric nodes, and they may form a 'cold abscess'. mott is the usual cause in children under years but tb is more common in older patients. absence of fever or tuber culosis, a positive tuberculin test and failed response to conventional antimicrobials are highly suggestive of mott, but definitive diagnosis is by smear, culture or pcr of biopsy material obtained by fineneedle aspiration or removal of nodes. treatment is based on results of laboratory testing, which should identify the appropriate antibiotic. preventive treatment of close contacts of persons with disease caused by mott is not needed. most mott are resistant to standard antitubercular medication and, though it is possible that clarithromycin or clofazimine may have some effect, excision of affected nodes is the usual recommended therapy. water from dental units may contain mott species; mycobacterial proliferation in biofilms may explain the extent of this contamination (ch. ). aspiration syndromes are conditions in which foreign substances are inhaled into the lungs and which can have consequences ranging from asphyxia to infection and lung abscess. dental restorations or frag ments of teeth, plaque, gastric contents and other materials may be aspirated, especially if material enters the pharynx, and particularly if the cough reflex is impaired for any reason. most commonly, aspiration syndromes involve oral or gastric contents associated with gastrooesophageal reflux disease (gord), swallowing dysfunction (ch. ), neurological disorders and structural abnormalities, such as a pharyngeal pouch. cricopharyngeal dys function involves cricopharyngeal muscle spasm or achalasia of the superior oesophageal sphincter, and can be seen in infants who have a normal sucking reflex but have incoordination during swallowing, pos sibly secondary to delayed development or cerebral palsy. anatomical disorders, such as cleft palate, pharyngeal pouch, oesophageal atresia, tracheooesophageal fistula, duodenal obstruction or malrotation, and motility disorders, such as achalasia, may have an aspiration risk. infirm older patients are also at risk of aspiration, especially if they are bedbound or have neurological disorders. isolated superior laryngeal nerve damage, vocal cord paralysis, cerebral palsy, muscular dystrophy and riley-day syndrome (familial dysautonomia) are all associated with increased risk of aspiration. ventilatorassociated pneumonia (vap), as defined by the centers for disease control and prevention (cdc), is present when the chest radiograph shows new or progressive infiltrate, consolidation, cavitation or pleural effusion in conjunction with either new onset of purulent sputum or change in character of sputum, and an organism isolated from blood, or the isolation of an aetiological agent from a specimen obtained via suction aspiration through an endotracheal or tracheostomy tube. the major route for acquiring endemic vap is oropharyngeal colo nization by endogenous flora or by exogenously acquired pathogens from intensive care units. vap is the most commonly reported health careacquired infection in patients receiving mechanical ventilation, with prevalence rates consistently in the - % range. mortality rates in vap are at least double those in patients without vap, ranging from % to % when the infection is caused by a multidrugresistant gramnegative pathogen. the healthcare infection control practices advisory committee of the cdc has developed guidelines for the prevention of vap. these include strategies aimed at preventing aspiration of contaminated oral or gastric material (e.g. raising the head of the bed and draining subglottic secretions), and interventions to alter bacterial coloniza tion of stomach (e.g. stress ulcer prophylaxis and selective digestive decontamination) and mouth. oral hygiene, suctioning and the provi sion of moisture to lips and oral mucosa, plus toothbrushing, may be important in prevention of vap. there are also strategies for manag ing ventilator circuits (e.g. replacement of ventilator circuits, use of closed rather than open suction, and use of heat moisture exchange as opposed to heated circuit technology). lung abscess is a localized infection leading to cavitation and necro sis. while some cases result from aspiration of foreign material, most develop from pneumonia caused by infection with staph. aureus or klebsiella pneumoniae. bronchial obstruction by carcinoma is another important cause. symptoms resemble those of suppurative pneumonia. there is a risk of infection spreading locally or leading, via septicaemia, to a brain abscess. diagnosis rests mainly on the chest radiograph, which may sometimes show cavitation or a fluid level. antimicrobial chemotherapy, postural drainage and relief by bronchoscopy of any obstruction are indicated. a wellrecognized cause of lung abscess is inhalation of a tooth or fragment, a restoration or rarely, an endodontic instrument. when undertaking endodontics or cementing restorations, such as inlays or crowns, a rubber dam or other protective device should always be used to avoid the danger of inhalation. lung abscesses may also result from aspiration of oral bacteria, particularly anaerobes, especially in infirm older patients or those who are intubated. the other main dangers in dentistry are with ga, particularly if an inadequate throat pack has been used. patients who inhale tooth frag ments or dental instruments must have chest radiographs (lateral and posteroanterior) and, if necessary, bronchoscopy. loeffler syndrome appears to be an allergic reaction, usually to the parasitic worm ascaris lumbricoides, or drugs such as sulphonamides. it manifests with pulmonary infiltrates (and abnormal chest radio graph) and eosinophilia (eosinophilic pneumonia). the disease usually clears spontaneously. sarcoidosis, so named because skin lesions resembled a sarcoma, is a multisystem granulomatous disorder, seen most commonly in young adult females in northern europe, especially in people of african heritage. the aetiology is unclear but propionibacterium acnes and p. granulosum have been implicated and associations have been reported with exposure to inorganic particles, insecticides, moulds and occupations such as firefighting and metalworking. serum sam ples contain antibodies directed against mycobacterium tuberculosis antigens. sarcoidosis is associated with hladrb and dqb , and a butyrophilinlike (btnl ) gene on chromosome . thelper (th ) cells release il and ifnγ, and augment macrophage tumour necrosis factor alpha (tnfα) release. cd regulatory t cells cause a limited impairment of cellmediated immune responses (partial anergy) but no obvious special susceptibility to infection. sarcoidosis affects the thorax in %, but has protean manifestations and can involve virtually any tissue (table . ). sarcoid most typi cally causes löfgren syndrome (fever, bilateral hilar lymphadenopathy, arthralgia and erythema nodosum, especially around the ankles; figs . and . ). other common presentations may include pulmonary infiltration and impaired respiratory efficiency, with cough and dyspnoea in severe cases, or acute uveitis, which can progress to blindness. susceptibility to lymphomas has been suggested but not confirmed. because of its vague and protean manifestations, sarcoidosis is under diagnosed. in the presence of suggestive clinical features, helpful investigations include: chest radiography (enlarged hilar lymph nodes); raised serum angiotensinconverting enzyme (sace ; table . ) in acute disease (this is insensitive, nonspecific and a poor guide to therapy); positive gallium citrate or gadolinium or positron emis sion tomography (pet) scans; labial salivary gland or transbronchial biopsy (for histological evidence of noncaseating epithelioid cell granulomas) -except in löfgren syndrome, which is a classical clini cal diagnosis. fdeoxyglucose pet is helpful in identifying sites for biopsy. nonspecific findings may include mild anaemia, leukopenia, eosinophilia, hypergammaglobulinaemia, raised esr and low serum albumin. hypercalcaemia is common because of extrarenal produc tion of active vitamin d and can result in renal damage. alkaline phosphatase, 'nucleotidase, lysozyme and adenosine deaminase levels are raised in hepatic sarcoidosis. evidence of impaired delayed hypersensitivity reactions to some antigens may be useful. kveim skin tests are not now used. half the patients with sarcoidosis remit within years and about % remit by years. patients with only minor symptoms usually need no treatment but corticosteroids, sometimes with azathioprine, methotrexate, tetracyclines, hydroxychloroquine, infliximab or etaner cept, are given if there is active organ disease (ocular disease, progres sive lung disease, hypercalcaemia or cerebral involvement). biopsy of the minor salivary glands frequently shows noncaseating granulomas and association with other features of sarcoidosis, par ticularly hilar lymphadenopathy. this is an important diagnostic find ing that may obviate more invasive procedures. sarcoidosis can involve any of the oral tissues but has a predilection for salivary glands. asymptomatic swelling of the parotid glands or cervical nodes, and less frequently the lips, may accompany systemic disease. superficial or deepseated red submucosal nodules may develop intraorally and on the lips. nontender, wellcircumscribed, brownishred or violaceous nodules with superficial ulceration have also been reported. the oral and lip lesions may occasionally precede systemic involvement. there is enlargement of the major salivary glands in about % of cases; some have xerostomia, and the association of salivary and lacri mal gland enlargement with fever and uveitis is known as uveoparotid fever (heerfordt syndrome). salivary swelling may also be seen with out other features of heerfordt syndrome. the salivary gland swellings usually resolve on treatment of sarcoidosis but this may take up to years. facial palsy and other cranial neuropathies may be seen. there is also an association with sjögren syndrome, when ssa and ssb serum autoantibodies are found. rarely there is an association of thyroiditis with addison disease, sjögren syndrome and sarcoidosis (tass syndrome). there is a group of patients who have histologi cal features of sarcoid in one or more sites in the mouth, such as the gingivae, but no systemic manifestations. a few of these patients may ultimately develop other more or less systematized disease but the majority probably have isolated lesions. such cases, where no exog enous cause for the granulomatous reaction can be found, are regarded as having 'sarcoidlike' reactions (orofacial granulomatosis) and treat ment is unnecessary. however, patients should be kept under observa tion for as long as possible. management of patients with systemic sarcoidosis may include con sideration of respiratory impairment, uveitis and visual impairment, renal disease, jaundice or corticosteroid treatment. la is safe and satisfactory. cs is contraindicated if there is any res piratory impairment. ga should only be given in hospital. lung cancer is the most common cancer in highincome countries in males and most frequently affects adult urban cigarettesmokers. bronchogenic carcinoma accounts for % of all primary lung cancer and has also become increasingly common in women (because of increased tobacco use), to the extent that the mortality rate for the two sexes has become almost equal. metastases from cancers elsewhere are also frequently found in the lungs. recurrent cough, haemoptysis, dyspnoea, chest pain and recurrent chest infections are the predominant features. local infiltration may cause pleural effusion, lesions of the cervical sympathetic chain (horner syndrome), brachial neuritis, recurrent laryngeal nerve palsy or obstruction of the superior vena cava with facial cyanosis and oedema (superior vena cava syndrome). there are many nonmetastatic extrapulmonary effects of bron chogenic (or other) carcinomas -for example, weight loss, anorexia, fingerclubbing, neuromyopathies, thromboses (thrombophlebitis migrans), muscle weakness, various skin manifestations and ectopic hormone production (of antidiuretic hormone, adrenocorticotropic hormone, parathyroid hormone and thyroidstimulating hormone). metastases from bronchogenic cancer are common and typically form in the brain (which may manifest with headache, epilepsy, hemi plegia or visual disturbances), liver (hepatomegaly, jaundice or ascites) or bone (pain, swelling or pathological fracture). the diagnosis is based on history and physical examination, supported by radiography, ct and magnetic resonance imaging (mri), sputum cytology, bronchoscopy and biopsy. spiral ct appears to detect tumours at an early stage. the overall year survival rate is only %. radiotherapy is the most common treatment. only some % of patients are suitable for surgery but, even then, the year survival is only about %. chemotherapy has been disappointing, except in smallcell carcinomas. dental treatment under la should be uncomplicated. cs should preferably be avoided. ga is a matter for specialist management in hospital, as patients often have impaired respiratory function, espe cially after lobectomy or pneumonectomy. this, along with any muscle weakness (myasthenic syndrome, eaton-lambert syndrome) that can make the patient unduly sensitive to the action of muscle relaxants, makes ga hazardous. oral cancer may be associated with lung cancer, and vice versa, or develop at a later stage (ch. ). such synchronous or metachronous primary tumours must always be ruled out. metastases can occasionally affect the orofacial region and cause enlargement of the lower cervical lymph nodes, epulislike softtissue swellings or labial hypoaesthesia or paraesthesia in the jaw. soft palate pigmentation is a rare early oral manifestation. lung cancer is a fairly common cause of death in dental techni cians, but it is unknown whether this is due to smoking alone or to dust inhalation. cystic fibrosis (cf) is one of the most common fatal hereditary dis orders. inherited as an autosomal recessive trait, with an incidence of about in births, it is the most common inherited error of metabolism and is seen mainly in people of european descent. the gene responsible is on chromosome q. cf is caused by defects in the cystic fibrosis transmembrane conductance regulator (cftr), a protein that appears to be part of a cyclic adenosine monophosphate (camp)regulated chloride channel, regulating cl − and na + transport across epithelial membranes, and ion channels and intracellular fluid flow in sweat, digestive and mucus glands. the basic defect in cf is abnormal chloride ion transport across the cell membrane of nearly all exocrine glands. the blockage of salt and water movement into and out of cells results in the cells that line the lungs, pancreas and other organs producing abnormally thick, sticky mucus that can obstruct the airways and various glands, especially in the respiratory tract and pancreas. involved glands (lungs, pancreas, intestinal glands, intrahepatic bile ducts, gallbladder, submaxillary and sweat glands) may become obstructed by this viscid or solid eosino philic material. recurrent respiratory infections result in a persistent productive cough and bronchiectasis, with the lungs becoming infected with a variety of organisms including staph. aureus, haemophilus influenzae, pseudomonas aeruginosa, strep. pneumoniae, burkholderia cepacia, and sometimes mycoses or mycobacteria. mycobacterium abscessus is a nontuberculous mycobacterium increasingly recognized as an opportunistic pathogen in cf patients. viral infections, such as mea sles, can have severe sequelae. pancreatic duct obstruction leads to pancreatic insufficiency, with malabsorption and bulky, frequent, foulsmelling, fatty stools. gallstones, diabetes, cirrhosis and pancreatitis may result. sinusitis is very common. growth is frequently stunted. the mutations can also cause con genital bilateral absence of the vas deferens, so fertility is impaired in most males with cf. in women, fertility may be impaired by viscid cervical secretions, but many women have carried pregnancies to term. most patients have a high concentration of sodium in their sweat (also reflected in the saliva); a sweat test showing sodium and chloride values of more than mmol/l is considered positive, between and mmol/l equivocal, and less than mmol/l negative. physiotherapy and postural drainage are crucially important. clearance of sputum is helped by water aerosols and bronchodila tors (terbutaline or salbutamol), but mucolytics such as carbocisteine, methyl cysteine and dornase alfa are of questionable effectiveness. treatment with ivacaftor, a cftr potentiator, improves chloride transport through the ion channel. amoxicillin and flucloxacillin are effective prophylactic antimicrobi als and may be given by aerosol. vaccination against measles, whoop ing cough and influenza is important. a low fat intake, adequate vitamins and oral pancreatic enzyme replacement (pancreatin) are also necessary. doublelung or heart-lung transplantation may eventually become necessary. sinusitis is very common; most cf patients have recurrent sinusitis and nasal polyps. the major salivary glands may enlarge and hyposali vation sometimes occurs. the lowfat, highcarbohydrate diet and dry mouth may predispose to caries. enamel hypoplasia and black stain may be seen, and both dental development and eruption are delayed. tetracycline staining of the teeth was common but should rarely be seen now. pancreatin may cause oral ulceration if held in the mouth. la is satisfactory but cs is usually contraindicated because of poor respiratory function. ga is contraindicated if respiratory function is poor. lung disease, such as bronchiectasis, liver disease and diabetes, may complicate treatment. bronchiectasis is dilatation and distortion of the bronchi. causes include: ■ congenital defects, which should be considered in all patients include cystic fibrosis, kartagener syndrome, alpha antitrypsin deficiency, collagen defects (e.g. marfan syndrome) there is no identifiable underlying cause in about % of adults and % of children. the damaged and dilated bronchi lose their ciliated epithelium and therefore mucus tends to pool, causing recurrent lrtis, typically with strep. pneumoniae, haemophilus influenzae or pseudomonas aeruginosa. overproduction of sputum, which is purulent during exacerbations, a cough (especially during exercise or when lying down) and finger clubbing are typical features, with recurrent episodes of bronchitis, pneumonia and pleurisy. haemoptysis is not uncommon. in advanced bronchiectasis, chest pain, dyspnoea, cyanosis and respiratory failure may develop. complications may include cerebral abscess and amyloid disease. chest radiography and pulmonary function tests are required. high resolution ct (hrct) is useful. postural drainage is important. antimicrobials, such as amoxicillin, cephalosporins or ciprofloxacin, are given for acute exacerbations and for longterm maintenance treatment. ga should be avoided where possible and is contraindicated in acute phases. workers exposed to airborne particles may develop pulmonary disease (pneumoconiosis), which ranges from benign (e.g. siderosis) to malig nant, as in mesothelioma from asbestosis (see appendix . ), but any pneumoconiosis can cause significant incapacity. ga may be contraindicated; the physician should be contacted before treatment. berylliosis may be a hazard in some dental technical laboratories, when lung cancer is more frequent. respiratory complications following surgical operations under ga include segmental or lobar pulmonary collapse and infection. they are more common after abdominal surgery or if there is preexistent respiratory disease or smoking (see also ch. ), and can be signifi cantly reduced by smoking cessation, preoperative physiotherapy and bronchodilators, such as salbutamol. if postoperative pulmonary infection develops, sputum should be sent for culture, and physiotherapy and antibiotics should be given. the common microbial causes are strep. pneumoniae and haemophilus influenza; in this case, suitable antibiotics include amoxicillin and erythromycin. hospital infections may include other microorganisms, such as mrsa, klebsiella, pseudomonas and other gramnegative bacteria. inhalation (aspiration) of gastric contents can cause pulmonary oedema and may be fatal (mendelson syndrome); it is most likely if a ga is given to a patient who has a stomach that is not empty, has a hiatus hernia or is in the last trimester of pregnancy. prevention is by ensuring the stomach is empty preoperatively; if it is not, an anaes thetist should pass an endotracheal tube. antacids or an h receptor blocker, such as cimetidine or ranitidine, may be given by mouth pre operatively to lower gastric acidity. if gastric contents are aspirated, the pharynx and larynx must be carefully sucked out. systemic corticosteroids have been recommended but probably do not reduce the mortality. respiratory distress in premature infants may be caused by immaturity of surfactantproducing cells, when the alveoli fail to expand fully; this necessitates endotracheal intubation for many weeks. it may, in turn, result in midface hypoplasia, palatal grooving or clefting, or defects in the primary dentition. the same oral effects may be seen with prolonged use of orogastric feeding tubes. the degree to which subsequent growth corrects these deformations is currently unknown, though the palatal grooves typically regress by the age of years. using soft endotracheal tubes does not obviate this problem and, at present, the best means of avoiding palatal grooving appears to be the use of an intraoral acrylic plate to stabilize the tube and protect the palate. acute respiratory distress syndrome (ards) is a sequel to several types of pulmonary injury and some infections, including those with oral viridans streptococci. patients with endstage pulmonary disease are considered for potential transplantation, usually using a lung from a braindead organ donor. a combination of ciclosporin, azathioprine and glucocorticoids is usu ally given for lifelong immunosuppression to prevent a tcell, alloim mune rejection response. inhaled nitric oxide modulates pulmonary vascular tone via smooth muscle relaxation and can improve ventilation/perfusion matching and oxygenation in diseased lungs. early graft failure following lung transplantation has been described by various investi gators as reimplantation oedema, reperfusion oedema, primary graft failure or allograft dysfunction. pathologically, this entity is diffuse alveolar damage. see also chapter . a meticulous presurgery oral assessment is required and dental treatment must be undertaken with particular attention to establishing optimal oral hygiene and eradicating sources of potential infection. dental treatment should be completed before surgery. for months after surgery, elective dental care is best deferred. if surgical treat ment is needed during that period, antibiotic prophylaxis is probably warranted. cardiopulmonary transplantation (heart and lung transplantation) is the simultaneous surgical replacement of the heart and lungs in patients with endstage cardiac and pulmonary disease, with organs from a cadaveric donor. all transplant recipients require lifelong immunosuppression to pre vent a tcell, alloimmune rejection response. see also chapter . a meticulous presurgery oral assessment is required and dental treatment must be undertaken with particular attention to establishing optimal oral hygiene and eradicating sources of potential infection. dental treatment should be completed before surgery. for months after surgery, elective dental care is best deferred. if surgical treat ment is needed during that period, antibiotic prophylaxis is probably warranted. national institutes of health: national institute of allergy and infectious diseases healthcare infection control practices advisory committee guideline for the prevention of healthcare associated pneumonia nosocomial pneumonia: state of the science extensively drugresistant tuberculosis as a cause of death in patients coinfected with tuberculosis and hiv in a rural area of south africa a review of the possible role of oral and dental colonization on the occurrence of health careassociated pneumonia: underappreciated risk and a call for interventions reducing ventilatorassociated pneumonia through advanced oraldental care: a month study apic infection control and applied epidemiology: principles and practice sepp. ventilatorassociated pneumonia and oral care: a successful quality improvement project guidelines for preventing the transmission of mycobacterium tuberculosis in healthcare settings a randomized trial of dental brushing for preventing ventilatorassociated pneumonia pneumonia associated with a dental unit waterline the pathogenesis of ventilatorassociated pneumonia: its relevance to developing effective strategies for prevention aspects of human disease chronic obstructive pulmonary disease (copd) aspects of human disease in vitro antibacterial activities of oral care products against ventilatorassociated pneumonia pathogens the impact of a simple, lowcost oral care protocol on ventilatorassociated pneumonia rates in a surgical intensive care unit intermittent suction of oral secretions before each positional change may reduce ventilatorassociated pneumonia: a pilot study current trends and newer concepts on diagnosis, management and prevention of respiratory tract infections key: cord- - kudq h authors: hahn, austin m.; adams, zachary w.; chapman, jason; mccart, michael r.; sheidow, ashli j.; de arellano, michael a.; danielson, carla kmett title: risk reduction through family therapy (rrft): protocol of a randomized controlled efficacy trial of an integrative treatment for co-occurring substance use problems and posttraumatic stress disorder symptoms in adolescents who have experienced interpersonal violence and other traumatic events date: - - journal: contemp clin trials doi: . /j.cct. . sha: doc_id: cord_uid: kudq h decades of research demonstrate that childhood exposure to traumatic events, particularly interpersonal violence experiences (ipv; sexual abuse, physical abuse, witnessing violence), increases risk for negative behavioral and emotional outcomes, including substance use problems (sup) and posttraumatic stress disorder (ptsd). despite this well-established link—including empirical support for shared etiological and functional connections between sup and ptsd –the field has been void of a gold standard treatment for adolescent populations. to address this gap, our team recently completed a large randomized controlled trial to evaluate the efficacy of risk reduction through family therapy (rrft), an integrative and exposure-based risk-reduction and treatment approach for adolescents who have experienced ipv and other traumatic events. the purpose of this paper is to provide a detailed description of the design and methods of this rct designed to reduce sup, ptsd symptoms, and related risk behaviors, with outcomes measured from pre-treatment through months post-entry. specifically, the recruitment and sampling procedures, assessment measures and methods, description of the intervention, and planned statistical approaches to evaluating the full range of outcomes are detailed. clinical and research implications of this work are also discussed. interpersonal violence experiences (ipv; sexual abuse, physical abuse, witnessing violence) and other forms of traumatic events (e.g., traumatic grief, disasters, accidents involving injury) during childhood serve as strong and consistent predictors of substance use problems (sup) [ ] [ ] [ ] [ ] [ ] , posttraumatic stress disorder (ptsd) [ ] , depression [ ] , and risky sexual behaviors [ , ] during adolescence and adulthood [ , ] . evidence-based treatments have been developed and evaluated for treating pediatric ptsd and depression among adolescents who have experienced ipv and other traumatic events through individual, office-based approaches [ ] . trauma focused-cognitive behavioral therapy (tf-cbt) [ ] , an exposure-based treatment that teaches youth and caregivers skills for managing trauma-related behavioral and emotional problems, is the most widely-disseminated pediatric trauma-focused, evidence-based treatment, with an abundance of rcts to support its safety, efficacy, and effectiveness with trauma-related mental health concerns [ , ] . existing treatments for adolescent sup emphasize teaching youth new cognitive and behavioral skills for responding to internal and external substance use cues and often involve the caregiver in establishing contingencies for achieving and maintaining substance use reductions (e.g., cbt, motivational enhancement therapy with cbt, multisystemic therapy [mst], contingency management, etc.) [ ] . among youth who have experienced ipv and other traumatic events, substance use may result from feelings of distress in relation to trauma cues and expectancies that using substances will help the young person cope with such distress. long-standing, siloed approached to treatments for sup versus https://doi.org/ . /j.cct. . received february ; received in revised form april mental health problems has resulted in a fragmented set of treatment offerings wherein interventions for substance using populations rarely address common co-occurring mental health disorders, such as ptsd, despite the fact that they may be functionally related [ , ] . prior to the current trial, only two small pilot rcts (n's < ) had been published to evaluate integrated approaches to treatment of cooccurring sup and ptsd among adolescents [ , ] . although both pilot studies supported the feasibility of integrated approaches, only one found significant main effects for both sup and ptsd [ ] . neither study was adequately powered to establish efficacy, leaving the field without a gold standard treatment for this vulnerable population. risk reduction through family therapy (rrft) [ , ] is an integrative, exposure-based treatment approach for adolescents who have experienced ipv and other traumatic events. to address the need for an empirically-supported psychosocial therapy for adolescents with cooccurring sup and ptsd, our team recently completed the first large, sufficiently powered randomized controlled efficacy trial of rrft, focusing on the sup and ptsd outcomes [ ] . while a concise overview of the methods specific to those outcomes are included in the published paper, it does not provide a full description of the recruitment and sampling procedures, assessment measures and methods, description of the intervention, and planned statistical approaches to evaluating the full range of outcomes. thus, the current paper describes the full protocol of this nih-funded stage ii rct designed to evaluate the efficacy of rrft in comparison to treatment as usual in reducing sup, ptsd, hiv sexual risk behavior, and putative risk mechanisms (e.g., emotion regulation, parenting) among a sample of adolescents who had experienced ipv and other traumatic events who were treated in a "real world" setting. a stage ii rct was conducted to examine the efficacy of rrft in comparison to treatment as usual in reducing sup, ptsd, and related problems (e.g., hiv sexual risk behaviors) when delivered in a community-based mental health treatment setting under the supervision of the treatment developer. beyond serving as the first large rct to date to address the long-standing question of efficacy of an integrative treatment targeting co-occurring sup and ptsd for adolescents, the study aimed to improve clinical practice by offering: ) a more efficient alternative to the current compartmentalized approach to treatment of this population (which often involves referrals to multiple agencies) [ ] ; and ) a risk-reduction option for youth at elevated risk for developing substance abuse and related mental health problems in the future, but who may or may not meet diagnostic thresholds. a sample of adolescents with current sup and ptsd symptoms was recruited between december -january . each participant and a designated caregiver completed a structured clinical interview and standardized questionnaires at five timepoints: pre-treatment (baseline), three months post-baseline, six months post-baseline, months post-baseline, and months post-baseline. the first five cases enrolled into the study were assigned to the rrft clinicians as pilot cases to practice implementation of the treatment and were not entered into the rct. families entering the study after the pilot cases (n = ) were assigned to either an experimental condition or a control condition. one hundred twenty-four cases were urn randomized to condition (described below in detail) and of these cases were not randomized bur rather assigned to a specific condition either because they had a sibling already enrolled in the study (and a family could not receive both treatments due to contamination factors) (n = ) or because of case load issues (e.g., if therapists in the control condition were on a wait list and the rrft clinician had several open slots, it was preferable not to have the participant wait to receive treatment and thus were assigned to rrft or vice versa) (n = ). see consort diagram (insert figure here) . participants randomized to the experimental condition were assigned to a therapist who was trained and supervised in rrft. participants randomized to the control condition received treatment as usual (tau). these treatment conditions are described in greater detail below (see interventions). the final sample in the rct consisted of adolescents who met the following inclusion criteria: ) aged to years; ) reported at least one memorable experience of ipv (other traumatic events were permitted and included-but ipv was required); ) reported current non-tobacco substance use as defined by at least one substance using day in the past days; and ) reported five or more ptsd symptoms. youth were excluded from the current study if they: ) were previously identified as having a pervasive developmental disability or moderate to severe mental retardation; ) were actively suicidal or homicidal; or ) reported active psychotic disorder. statistical power was estimated for the difference between rrft and tau in change from baseline to each follow-up assessment. using g*power [ ] , the design effect formula was used to calculate the effective number of independent observations provided by each pair of measurements [ ] . results showed that at an alpha of . and with independent observations from participants, the study was adequately powered (i.e., power = . ) to detect a small-to-medium effect of f = . for the between-group differences in change. youth were primarily recruited through two local child advocacy centers (cacs). cacs provide victims of child maltreatment with a variety of services, including forensic interviewing, medical examination, advocacy, and outpatient mental health treatment. cacs are among the most common entry points to community services for abused children, and ipv victims make up~ % of the cases seen at cacs nationally (www.cac-sc.org). cacs are mandated by their accreditation standards to provide mental health treatment for abused children or have strong referral relationships with professionals and organizations that do. while use of community-based therapists required the investigative team to create more extensive training and supervision protocols than a trial conducted at the academic medical center, it provided a realistic evaluation and promoted future transportability and dissemination [ ] . as part of routine care, all adolescents who presented to the cacs for evaluation and/or treatment underwent a semi-structured intake assessment to determine traumatic event history, trauma-related symptoms, and appropriateness for outpatient care. findings were then used to determine study eligibility. eligible youths and their families were informed about the study and referred to research study staff for further screening and potential enrollment. research staff confirmed youth used non-tobacco substances (alcohol and/or drugs) at least once in the past days using the timeline followback (tlfb) [ ] and the presence of five or more ptsd symptoms using the global appraisal of individual needs (gain) [ ] . adolescents who met these criteria and their caregivers were then asked to provide written consent/assent for recruitment into the study, sign a release of information (allowing for chart reviews), and schedule the pre-treatment assessment. all consent procedures were approved by the medical university of south carolina institutional review board (irb). an adaptive randomization procedure, known as urn randomization, was used to balance potentially confounding variables among the participants randomized to each condition [ ] . this approach to randomization reduces pre-treatment variability between groups on these factors. the urn randomization procedure was implemented using an adaptation of the microsoft access application grand [ ] and was set up by the study statistician (jc). to keep assessors blind to condition, participants were urn randomized to the rrft or tau conditions by a trained cac staff member (not a study clinician) using this program immediately following completion the baseline assessment. specifically, once the research assistant screened and consented a new participant entering the study, she or he provided the necessary information to the cac staff member to enter into the urn to produce the condition assignment. specifically, condition assignment was balanced based on pre-treatment ptsds severity (score on ucla-ptsd-ri [ ] [ ] [ ] ≥ ), frequency of pretreatment substance use (≥ substance using days over past days); and the gender of the adolescent. once the condition was identified, the cac staff member informed the pi and the tau supervisor of the condition assignment. the pi (for rrft assignment) or the tau supervisor (for tau assignment) would then determine therapist assignment (based on case load and participant schedule match) and then inform the clinician about the new client. treatment for participants in both the rrft and tau conditions was provided by master's level clinicians ( clinicians in the rrft condition and clinicians in the tau condition) housed at the two cac settings. all of the clinicians were female and white. clinician effort dedicated to treating study participants across both conditions were covered by the grant. all cac clinicians had previous training in trauma-focused treatments, but no prior training in substance use treatment. rrft clinicians completed intensive formal training in rrft and received weekly supervision from the developer of rrft, while tau clinicians completed gold-standard training in tf-cbt and received weekly supervision from an experienced clinician with expertise in tf-cbt. each clinician was assigned to one treatment condition exclusively. for all cases in this study, effort for clinicians in both conditions was covered by the grant funding which supported the study, and treatment was provided at no cost participants and their families. rrft is an adaptation and integration of preexisting empiricallysupported, cognitive-behavioral interventions and principles designed to address the adolescent behavioral health problems targeted here including: tf-cbt [ ] , multisystemic therapy [ ] [ ] , and empirically-supported psychoeducation strategies for prevention of highrisk sexual behaviors [ ] and sexual revictimization [ ] . based on the integration of these models, the rrft manual outlines seven treatment components: ( ) psychoeducation and engagement, ( ) family communication, ( ) substance abuse, ( ) coping, ( ) ptsd, ( ) healthy dating and sexual decision making, and ( ) revictimization and risk reduction. several theoretical models underpin rrft intervention strategies. first, the rrft treatment model draws upon ecological theory [ ] by assessing and targeting the web of social influences (e.g., family, peer, community) that promote risk (e.g., substance using peers) [ ] and resiliency (e.g., family activities) [ ] for substance use and related risk behaviors at each level of an adolescent's ecology. for example, the youth and caregivers work with the therapist to determine what maintaining factors ("drivers") contribute to a given risk behavior at each level of their ecology (e.g., substance use as a coping strategy; low parental monitoring; substance-using peers) and how those drivers can be modified to reduce substance use and promote emotional resilience (e.g., teach positive coping skills, involve other family members or neighbors for monitoring, connect the youth with structured activities that provide a forum for meeting non-using peers). second, mowrer's two-factor theory [ ] is applied in rrft, as therapists aim to extinguish distress and fear that an adolescent who has experienced ipv and other traumatic events has paired with memories and cues of the trauma. according to this theory, fear is acquired through a classical conditioning process by which the individual pairs a neutral stimulus (e.g., the dark; a certain word/smell) with a stimulus that invokes a fear response (e.g., sexual assault) -such that the neutral stimulus elicits the fear/distress response in the absence of the feared stimulus. change occurs through exposure therapy, as individuals can reduce a fear response during exposure to the feared stimuli without the feared aversive consequences. based on its adaptation from tf-cbt, rrft includes gradual exposure therapy to address ptsd symptoms via the development of a detailed written or verbal account of the ipv experiences and other traumatic events. as part of this exposure-based trauma narrative work, cognitive-behavioral therapy also is involved, where the therapist helps adolescents identify and replace inaccurate and/or unhelpful beliefs that they have developed in relation to the traumatic events (e.g., "i am damaged goods"; "the abuse was my fault"; "i am unlovable"; "being high is the only way to deal with what happened.") skill-building in the area of coping (e.g., emotional reactivity) is an important preamble to the exposure work and is accomplished by teaching distress tolerance and relaxation skills. third, the connection between substance use and trauma-related symptoms can be conceptualized in the context of negative reinforcement theory [ ] , which posits that escape and avoidance of negative affect (in this case, trauma-related distress) is an important motive for substance use. sometimes referred to as the "self-medicating hypothesis," a decrease in trauma-related substance use is thought to occur with improvement of self-regulation deficits [ ] , such as emotional reactivity. the coping and ptsd components of rrft focus on improving such skills-with a particular focus on reducing emotional suppression and empowering the youth with safe, healthy, prosocial skills to withstand distress and negative affect. rrft is individualized in that the different needs, strengths, preferences, and developmental factors of each adolescent and family are incorporated into case conceptualization and tailored treatment planning. the rrft manual provides suggested language in introducing and teaching specific skills, session activities, and therapy homework ideas. the order in which the components (table ) are administered is determined by needs of the youth/family and is based on severity of the problems. the rrft protocol is typically administered through weekly, - min individual sessions. when feasible and applicable, brief joint family sessions are also conducted. therapists are encouraged to engage in brief phone or sms/text check-ins with families between sessions to promote treatment engagement, particularly when new skills have been taught or during times of family crisis. duration of treatment is not fixed in rrft; rather, treatment is ended when the youth and family's goals have been met. treatment progress is tracked systematically with standardized tools (questionnaires, urine drug screens) as well as ongoing updates to the functional assessment of risk and protective factors. although pharmacological interventions were not implemented as part of this trial, participants were not prohibited or discouraged from pursuing medication from outside providers. adolescents assigned to the tau condition received the standard treatment that a ipv victim would typically receive at the cac where the trial took place. at the study site, tau clinicians had completed gold-standard training in tf-cbt (i.e., -day in person clinical training workshop, approximately months of follow-up consultation calls delivered by experienced national tf-cbt trainers) and received on-going weekly supervision in tf-cbt. in addition to treatment that is typically offered at the cacs, tau included capacity to refer to other agencies in the community (e.g., group therapy for substance use problems), which was documented in their charts. tau has been utilized as a comparison condition for several behavioral treatment evaluations involving adolescent substance abuse [ ] or trauma [ ] . the primary reason tau was selected for the control condition was that no "standard of care" exists for co-occurring substance use problems and ptsd among adolescents. alternative comparison conditions were considered, including evidence-based substance use treatment only, evidence-based ptsd treatment only, and waitlist control. these approaches were deemed insufficient because they would effectively result in withholding treatment for known problems in participants. a pre-defined course of parallel or sequential treatments for each presenting problem (i.e., delivered as separate treatments, likely by separate providers and possibly in separate clinics) was also considered but deemed unnecessarily burdensome for participants. thus, given the ethical need to provide treatment to the control group (adolescents with current substance use and clinically significant ptsd symptoms) and a deficiency of information regarding how to address the heterogeneous clinical needs of this population, tau was selected as the most appropriate comparison condition for this study. the frequency and nature of services provided was closely monitored and recorded using several strategies. first, a comprehensive chart review was conducted of the therapy session notes across both conditions, where study staff recorded information regarding characteristics of each session (e.g., duration of session, who participated in the therapy session, focus of session, and contact in between sessions), as well as whether outside for referrals were made (for the tau condition). second, all therapy sessions across both conditions were audio-taped to measure therapist adherence to rrft and to characterize tau. the audio recordings of % of sessions across both conditions ( sessions total) were coded by raters trained to > % inter-rater reliability. tapes were coded using the family therapy scale from the therapy procedures checklist [ ] , which is an assessment of techniques used in session (e.g., improving family communication patterns), and an rrft therapist adherence measure (rrft-tam) [ ] . the rrft-tam was developed using guidelines from the standards for educational and psychological testing [ ] and accompanying rasch methods [ ] . because rrft represents an integration of tf-cbt for ptsd and mst for sup, the rrft-tam was designed to capture key features of those models. finally, caregivers also completed the services assessment for child and adolescent [ ] at the final assessment point to report on a wide range of services that had been accessed over the course of participation in the study. both the control and experimental groups were assessed at five timepoints: pre-treatment (t ), months post-baseline (t ); months post-baseline (t ); months post-baseline (t ); and months postbaseline (t ) by a highly trained research assistant who was blind to condition. assessment time points were anchored to study entry/baseline assessment rather than treatment completion due to variable duration of treatment. the full assessment battery lasted approximately h (see table for research instruments). several strategies were employed to maximize retention. first, to establish a long-term collaborative relationship with families, assessments were scheduled at the family's convenience, contacts were as friendly and personalized as possible, and families were reimbursed for their participation in each assessment session. second, at consent, we requested up to eight phone numbers of the caregivers' and adolescents' best friends, closest relatives, and places of employment to facilitate contact each time the family is assessed; we also asked if participants had plans to change their place of residence. third, we received consent to reach the adolescents (and caregivers as applicable) through text messaging and social media in addition to phone and mail. fourth, direct contact with the families helped to maintain the cohort, as all families were tracked monthly for therapist adherence and school placement reports. when possible, participants were followed by the research assistant responsible for the initial research interview, which promoted rapport and a sense of involvement. the research assistant administered the assessment battery in each family's home or at the cac, based on the participant's preference and availability. to compensate for their time, families were paid $ for completing the intake interview and $ for each subsequent assessment. data from all timepoints were collected on all families who were randomized into the study, even if they dropped out of treatment. the statistical analyses will follow intention-to-treat methods, with youth and caregivers included in the randomly assigned condition independently of their participation in the clinical intervention. the data are structured with five repeated measurements (level- ) nested within participants (level- ). to address this, the primary statistical models will be implemented as mixed-effects regression models [ ] , with continuous outcomes analyzed according to a normal sampling distribution and discrete outcomes analyzed using bernoulli (dichotomous), negative binomial (count), or ordinal (ordered categories) sampling distributions. primary outcomes focus on substance using days and ptsd symptom severity, with secondary outcomes targeting marijuana use and marijuana using days, alcohol use and alcohol using days, and polysubstance use (i.e., the use of at least two different substances). sexual risk behaviors, as measured by the sexual risk behavior scale [ ] , are secondary outcomes that will be evaluated as well. to model change over time, polynomials and/or time-related indicators will be entered at the level of repeated measurements. for instance, by including linear and quadratic polynomials, the model would estimate an instantaneous rate of change that, over time, can slow down or speed up. alternatively, more basic formulations, such as the use of dummy-coded indicators for the post-baseline assessments, could test for change between baseline and each subsequent assessment occasion. the effect of rrft will be tested using a dummy-coded indicator for intervention condition ( = tau, = rrft), which will be entered at participant-level along with cross-level interactions between condition and the level- time term(s). significance testing will be based on the wald test (i.e., β/se), and tests that are not directly provided by this formulation (e.g., the significance of within-group change for rrft) will be obtained using planned contrasts. a number of potential control variables will be considered. for instance, at level- , an indicator may be included for treatment status at each measurement occasion. this would test for an overall shift in the level of the outcome [ ] socioeconomic data, and family composition ac chart review of information from intake interview semi-structured interview to assess lifetime history of ipv and ipv incident characteristics [ ] a c substance use and abuse timeline followback (tlfb) [ ] type, quantity, and frequency of non-tobacco substance use over past days a urine drug screens [ ] the urine toxicology screen to validate tlfb self-report a diagnostic interview schedule for children (c-disc) [ ] diagnosis of axis i disorders ac substance use risk and protective factors family environment scale (fes) [ ] cohesion and conflict subscales; social and environmental characteristics of families ac bad friends subscale [ ] youth's peer relations ac alabama parenting questionnaire (apq) [ ] parenting practices across the following domains: corporal [ ] severity of depressive symptoms a sexual risk behavior scale [ ] severity of risky sexual behaviors (e.g., condom use) a other trauma-related treatment targets and mechanisms emotion regulation questionnaire (erq) [ ] tendency to regulate emotions in two ways: ( ) cognitive reappraisal and ( ) expressive suppression a upps-r-c child version [ ] impulsivity traits a hopelessness scale for children (hsc) [ ] current level of hopelessness a child attributional style questionnaire -revised (casq) [ ] causal explanations for positive and negative events. a treatment assessment rrft therapist adherence measure (rrft-tam) [ ] content & skills that were addressed (and not addressed) at each session n/a a therapy procedures checklist [ ] techniques used in each session based on those from the most commonly used youth interventions (e.g., cbt) n/a a services assessment for child and adolescent (saca) [ ] interview to assess any additional services (e.g., church counseling, inpatient hospitalizations) that had been accessed over the course of participation in the study c client satisfaction questionnaire- [ ] consumer satisfaction with treatment ac chart reviews see description above in control condition: treatment as usual. n/a note. a/c denotes person completing the assessment a = adolescent, c = caregiver. a n/a indicates measure was used for coding of therapy session tapes across both conditions, as described below. trajectory following the end of treatment. likewise, at level- , variables may be included to control for participant demographic variables (e.g., age, sex, race) and/or indicators of treatment intensity (e.g., duration, frequency). the models will be implemented using supermix [ ] or similar software for mixed-effects regression models. the objective of this paper was to describe the rationale and methods for a recently completed nida-funded stage ii rct to rigorously evaluate the efficacy of rrft, an integrative and exposure-based treatment approach for adolescents who had experienced ipv and other traumatic events, in comparison to treatment as usual. this study was conducted to address a significant gap in the field with regard to integrative treatment for co-occurring sup, ptsd, and related problems (e.g., hiv sexual risk behavior) among adolescents. that is, although significant progress has been made in treating trauma-related psychopathology among adolescents and in treating sup among adolescents independently, significantly less is known about treatment of sup and ptsd in an integrative fashion among adolescents who have experienced ipv and other traumatic events. research with trauma-exposed adults suggests that integrated approaches to the treatment of comorbid ptsd and sup are safe and efficacious [ , , ] . however, a review noted that few studies examining integrated approaches to sup and ptsd have included sufficient follow-up assessments [ ] . given that post-treatment substance use relapse rates are high, including among youth [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] , assessments that extend to the year following treatment are critical in determining whether gains are indeed maintained after treatment. a substantial strength of the stage ii trial was that it included -and month post baseline assessments to determine if indeed rrft was successful in targeting long-term improvements in sup and ptsd symptoms, as well as sexual risk behaviors. another strength of the stage ii trial is that it evaluated the safety and efficacy of an exposure-based, integrative approach to treatment of these co-occurring problems. exposure-based approaches (i.e., intentionally approaching and recalling specific thoughts, feelings, memories, and cues of traumatic event experiences) have strong empirical support for the treatment of ptsd among adults [ ] and youth [ , ] . integrated intervention approaches for ptsd and sup that do not incorporate exposure have had less robust findings [ , ] . the stage ii builds upon the prior research completed with rrft. prior to the stage ii study, a stage ia feasibility trial [ ] and a stage ib pilot rct [ ] evaluating rrft have been completed. the stage i work resulted in a treatment manual, a clinician training protocol, and a quality assurance system. the results from these prior studies were promising, indicating that rrft can be readily learned and implemented with fidelity, and that it can lead to improvements in drug use, drug use-related risk and protective factors, ptsd symptoms, and hiv sexual risk behaviors. the first outcome paper for the current trial indicates that the results hold true for sup and ptsd symptoms. numerous other strengths of the stage ii rct design are noteworthy. first, this study focuses on a 'real world' population of adolescents-where the focus was on heterogeneous symptoms (e.g., current substance use, ptsd symptoms), rather than requiring meeting full diagnostic criteria (e.g., severe substance use disorder + ptsd diagnosis). this ensures the study results will generalize to a broader population of youth who are highly vulnerable for the wide range of negative sequelae that can follow ipv and other traumatic event experiences. the multi-faceted clinical needs of this population call for an innovative solution to bridge the gap between early intervention and treatment, resulting in an inclusive risk-reduction approach with the potential for a wider-spread impact. second, establishing an integrative treatment option for this population directly addresses issues related to client burden (having to navigate separate, parallel or sequential treatments for sup and ptsd delivered by different therapists in different settings) and clinician preferences [ ] to have tools to address the multi-faceted problems most representative of their clients. third, the stage ii trial affords a unique opportunity to pursue mechanisms of action research, which can direct improvements to treatment models and inform important next steps in this line of research. as noted in the methods, we assessed several empirically-informed skills specifically targeted in rrft (e.g., emotional regulation; parenting) that may lead to improvements in sup and ptsd. next steps with the study will involve evaluation of the sexual risk behavior outcomes and the putative targets of treatment as mechanisms of action. the details provided in this protocol paper allow for a complete picture of the study design, as well as promote opportunities for reproducibility in future clinical trials that may be designed to evaluate other treatment options for adolescents who have experienced trauma and engage in high risk behavior. this may be 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use problems and ptsd among adolescents: a randomized controlled trial adolescent substance use following a deadly u.s. tornado outbreak: a population-based study of , families key: cord- - hiuzkvz authors: maspero, cinzia; abate, andrea; cavagnetto, davide; el morsi, mohamed; fama, andrea; farronato, marco title: available technologies, applications and benefits of teleorthodontics. a literature review and possible applications during the covid- pandemic date: - - journal: j clin med doi: . /jcm sha: doc_id: cord_uid: hiuzkvz background: covid- spread rapidly throughout the world from china. this infection is highly contagiousness, has a high morbidity, and is capable of evolving into a potentially lethal form of interstitial pneumonia. numerous countries shut-down various activities that were considered “not essential.” dental treatment was in this category and, at the time of writing, only non-deferrable emergencies are still allowed in many countries. therefore, follow-up visits of ongoing active therapies (e.g., orthodontic treatment) must be handled taking special precautions. this literature review aims at reducing in-office appointments by providing an overview of the technologies available and their reliability in the long-distance monitoring of patients, i.e., teledentistry. methods: a literature review was made according to preferred reporting items for systematic reviews and meta-analyses protocols (prisma-p) guidelines. randomized clinical trials, cross sectional, observational, and case-control studies were evaluated with the mixed methods appraisal tool for quality assessment and study limitations. results: a primary search found articles, / were excluded as non-relevant on the basis of: the abstract, title, study design, bias, and/or lack of relevance. twelve articles were included in the qualitative analysis. conclusions: teleorthodontics can manage most emergencies, reassuring and following patients remotely. the aim set by dental teleassistance was met as it reduced patients’ office visits whilst maintaining regular monitoring, without compromising the results. although our preliminary findings should be further investigated to objectively evaluate the efficacy, cost-effectiveness, and long-term results, we are confident that teleassistance in orthodontics will have a role to play in the near future. a new type of coronavirus initially named novel coronavirus pneumonia (ncp) and later renamed new corona virus ( -ncov or covid- ) spread rapidly from china to the world from december . it is the seventh coronavirus known to spillover to humans [ ] . this viral infection is of great concern due to its high contagiousness and morbidity, as well as its ability to evolve into a potentially lethal form of interstitial pneumonia and its possible evolution into a potentially lethal form of interstitial pneumonia [ ] . preventive hygiene measures such as social distancing, quarantine, and isolation have been taken to limit its diffusion in most countries to different extent [ ] . on january , the world health organization (who) stated that covid- constituted a public health emergency of international relevance [ ] . the national health committee keeps receiving an ever-increasing number of confirmed, suspected, and fatal cases reported from all over the world. to date, they are still carrying out world surveillance. there was an estimated human-to-human healthcare-related transmission of about % at the beginning of the outbreak [ ] . many health care workers got and still are getting infected [ ] . government and healthcare services have put on their thinking hats to re-organize triage services in an attempt to reduce nosocomial infection by covid [ ] . this task is particularly arduous as transmission is mainly through droplets and numerous subjects may be asymptomatic and/or in the incubation period. dental clinics belong to a high-risk category as infection can be facilitated during dental maneuvers that generate droplets, including restorative procedures, professional hygiene sessions, etc., or whilst patients are in the waiting room [ ] . therefore, strict and effective hygiene protocols for infection control are urgently needed for dental practices to reduce dental practitioners' and patients' risk to get infected. the use of appropriate personal protective equipment (ppe) is pivotal in avoiding cross infection during clinical practice between patients and healthcare workers and the adoption of adequate decontamination measures can help to reduce the risks. although it has also currently been suggested that dental clinics limit their practice only to not deferrable emergencies, this is not always possible. some ongoing treatment such as orthodontic therapies and/or critical situations, like conditions that must be identified in the early stages and treated immediately to avoid more serious outcomes, require timely follow-up appointments. indeed, continuous monitoring by the orthodontist is a must in orthodontic treatment so as to evaluate the efficacy and/or any undesirable effects [ , ] . however, some periodic visits are not strictly necessary and others could be delayed by instructing the patient how to make simple changes to the appliance, for example by indicating which teeth to put the intraoral elastics on or how many activations to perform on the central screw of a rapid palatal expander. at the time of writing, despite huge investments and research efforts, the current pandemic is still under investigation as are the best preventive measures to be adopted in individual fields. however, we are of the opinion that avoiding unnecessary follow-up appointments whilst maintaining the monitoring of treatment outcomes and current health status would be of great interest and importance for healthcare providers. recently, an innovative approach has been proposed in the medical field. although it was originally developed to provide healthcare services in remote areas, it may well be of use in managing healthcare services in this unprecedented emergency situation, i.e., telemedicine. the world health organization (who) defines telemedicine as the use of telecommunications and virtual technologies to provide healthcare outside of traditional healthcare facilities [ ] . in more detail, telemedicine is a set of technologies, especially information and communication technologies (ict), specifically aimed at providing healthcare services from a distance to lessen the need for contact between the patient and the healthcare provider [ , ] secure communication of medical information, notes, sounds, pictures, or any other form of data necessary are required to prevent, or to diagnose pathologies, and therefore, to treat and to monitor patients [ ] . moreover, telemedicine is not only able to facilitate communication and interaction between the healthcare provider and the patient, but also between the providers themselves. indeed, it can, to a certain extent, remove geographical and temporal barriers, bridging gaps in the dishomogeneous distribution of the healthcare offer. therefore, it can provide care for more people, enabling them to benefit from healthcare services, especially those who live in remote areas and/or have poorly developed healthcare facilities. it can simplify online transmission of diagnostic tests and reduce waiting lists for consultations through an enhanced organization of appointments [ ] [ ] [ ] . this makes these technologies a great resource in optimizing and reducing in-office visits and does not compromise necessary check-ups. treatment progress and efficacy can be monitored in this time of social distancing, which will most likely be prolonged into the year to come as the international scientific community has declared that a definitive cure and/or vaccine is not yet available as research is still ongoing. nowadays, telemedicine is becoming more and more widespread in the fields of oncology, cardiology, pediatrics, psychiatry, psychology, radiology, pneumology, dermatology, neurology, orthopedics, ophthalmology, and dentistry [ ] . although teleassistance in dentistry is far from new, it seems that its advantages in orthodontics have not yet been fully explored and is used on a limited scale. indeed, there are some reviews on teledentistry in general but none on teleorthodontics as most articles about teleorthodontics are relatively new. as no reviews have yet been carried out on the efficacy of teleassistance in orthodontics as a way to manage patients at a distance, we would like to report on the evidence available as to the possibility of implementing new technologies in teleassistance, generally known by teleorthodontics to help during the covid- pandemic to remotely monitor patients' conditions. this topic is far from new, however, few studies have been reported, there is need for exploratory research for a better understanding. given the above, a non-systematic literature review was performed [ ] . the electronic literature was searched using the following databases: medline, pubmed, embase, cochrane library, ebm reviews, web of science, ovid, and google scholar. the search was mainly based on five terms, i.e., teledentistry, teleorthodontics, virtual assistance, tele assistance, and telemedicine. embase and pubmed were searched respectively using also the terms embase subject headings (emtree) and medical subject heading (mesh). the endnote software reference manager (version x × . , thomson reuters, released september , toronto, on, canada) was used/adopted to store/archive and view/analyze retrieved references studies. the research refers to the preferred reporting items for systematic reviews and meta-analyses (prisma-p) [ , ] . grey literature was also searched, but no data met the inclusion criteria. a hand search for relevant studies in the selected bibliography was also performed. studies involving new or already existing devices and software for teleassistance in orthodontics were included. service provided, type of intervention, clinical outcomes, efficacy and efficiency of assessed methods, and possible time saving compared to traditional methods were evaluated. the following study designs were included: observational studies, longitudinal studies, prospective studies, case-control studies, systematic and narrative reviews, and clinical trials. given the state of technology and its rapid evolution, the search was limited to papers published over the previous years. studies in a language other than english or on application areas unrelated to orthodontics were excluded. articles with a poor methodology description lacking at least two of the following were excluded: study design, sample size, hardware utilized, software installed. letters to the editor, short communications, and all other publications not subjected to the peer review process were also excluded. considering the variety of study designs in the articles included, mixed methods appraisal tool (mmat) was used for quality assessment [ ] . the score of each article was calculated by dividing the criteria that were considered satisfied by ( % by criterion, % if all criteria were considered satisfied). the use of this system is compatible with a literature review that analyzes different research methodologies, as reported by whittemore [ ] . two of the authors of this study (a.f and m.e.m) read the titles of the retrieved articles independently to ensure they met the eligibility criteria. if in doubt, the abstracts were read and the same method was applied. a final selection was then made by an independent evaluation of the full text of aforementioned papers before inclusion. any disagreement between the assessors was resolved by their discussing the full texts. the studies selected according to eligibility criteria are reported in the evidence table (table ). one reviewer (a.f) extracted data from the full-texts and the other (m.e.m), independently verified the extracted data. data extraction included: journal and year of publication, study design, clinical outcomes, and the conclusions of the research. the description of the included studies is reported in table . teleassistance in dentistry is a new and powerful tool that makes for effective communication between the care provider and patient and between the providers themselves. the study stated that these technologies can be of significant help in treating orthodontic emergencies. mmat score %. the sample is not representative of the target population. observations taken from this pilot study through the assessment of treatment planning and comparison between patients' opinion about traditional dental examinations (face to face) and teleorthodontics showed that the treatment planning was influenced by the diagnosis of the observer. however, the consultation system satisfied both the clinician and the patient. the study concluded that in-office assessment of a rapid maxillary expander can be successfully substituted with teleorthodontics (dm software). mmat score %. this paper presents a small sample size due to several dropouts. the sample was selected from a pool of patients attending a single hospital and, therefore, the conclusions cannot be extended to a private setting. teleorthodontics is a useful tool to manage emergencies, and monitor patients at a distance using whatsapp. mmat score %. the study is based on personal experience. no patients were analyzed, no results were evidenced due to the differences in the design of the selected studies, understandable given the heterogeneity of what was taken into account, it was not deemed fit to apply common methods for evaluation of the risk of bias. there was a low or absent overall risk of bias as to data description but high risk of bias for the efficacy analysis of such a technology. all considered papers had high or unknown selection bias and reference standards. moreover, as this is a novel topic, to the best of our knowledge, no validated protocol has yet been reported. due to the heterogeneity of study designs and the technological tools assessed, it was not possible to carry out a meta-analysis of the data. therefore, a thematic investigation was made, targeting the main topics that were analyzed in the selected papers. no other limitations appear to be present, as the review was carried out according to the prisma-p guidelines. initially articles were found. the primary search retrieved articles, net of elimination of duplicates (n = ). a total of articles were then deemed irrelevant after screening the abstract, the title, or the study design and were therefore excluded. twenty records were screened from the database and another articles were excluded due to bias. twelve studies were read in extenso and were included in the qualitative analysis. the summary of the studies that met the inclusion criteria is shown in table . the prisma flow chart reports the search methodology ( figure ). five studies assessed the benefits of teleassistance in orthodontics for the management of patients at a distance. they all stated that teleorthodontics has the potential to provide significant and determinant help even if further investigation is deemed necessary [ ] [ ] [ ] [ ] [ ] . five papers evaluated the efficacy and reliability of orthodontic teleassistance in the diagnosis treatment and follow-up of patients [ ] [ ] [ ] [ ] [ ] . five studies assessed the benefits of teleassistance in orthodontics for the management of patients at a distance. they all stated that teleorthodontics has the potential to provide significant and determinant help even if further investigation is deemed necessary [ ] [ ] [ ] [ ] [ ] . five papers evaluated the efficacy and reliability of orthodontic teleassistance in the diagnosis treatment and follow-up of patients [ ] [ ] [ ] [ ] [ ] . one study endorsed the use of teleorthodontics for remote patient management [ ] . one study evaluated which of the available it technologies would allegedly be used in the near future for remote patient management [ ] . all the included studies agreed on the advantages of introducing teleorthodontics into clinical practice. taking into consideration the included studies, one was not analyzed by mmat, as this system is not suitable for non-empirical studies such as reviews and theoretical papers [ ] . a total of studies were analyzed by mmat, nine of them were quantitative, two qualitative, and no studies used mixed methods. all the papers that were included were rated equal to or above % (average score . %) according to the mixed method assessment tool and were therefore included. table presents a detailed summary of each of the studies included. one study endorsed the use of teleorthodontics for remote patient management [ ] . one study evaluated which of the available it technologies would allegedly be used in the near future for remote patient management [ ] . all the included studies agreed on the advantages of introducing teleorthodontics into clinical practice. taking into consideration the included studies, one was not analyzed by mmat, as this system is not suitable for non-empirical studies such as reviews and theoretical papers [ ] . a total of studies were analyzed by mmat, nine of them were quantitative, two qualitative, and no studies used mixed methods. all the papers that were included were rated equal to or above % (average score . %) according to the mixed method assessment tool and were therefore included. table presents a detailed summary of each of the studies included. currently, available technologies that can be used in teleorthodontics are: high-speed internet connection, digital videos and photographs, smartphones, and websites. a review by costa et al. [ ] . emphasized that peer-to-peer communication services (msn, skype, etc.) can be helpful in patient management but that they are not sufficiently reliable by themselves, since they are products of big companies, they may be subjected to unpredictable changes. the authors of the aforementioned review thus recommend using websites instead, as they are easier to use and require no installation. in order to minimize problems involving safety, the same authors recommend using anti-virus and/or firewalls and adopt only sites with valid digital certification and end-to-end data encryption [ ] . whatsapp messenger seems to be the most widely used communication tool according to available literature [ ] . maintaining periodic virtual contacts, while it is impossible to do otherwise, is a valuable tool to build and maintain a positive patient-clinician relationship and a valuable therapeutic allegiance [ ] . digital technology in imaging and impression taking, that is now commonplace in most dental practices, is a powerful tool for the orthodontist to access, analyze and, if need be, communicate with patients, colleagues, and/or dental technicians. the widespread diffusion of smart phones among doctors and patients led to the development of a new option. [ , ] indeed, an application for smartphones that allows remote monitoring of orthodontic patients using an algorithm of artificial intelligence, has recently been developed. this application is called dental monitoring tm (dm) [ ] . its purpose is to provide a precise record of the patient's occlusion with the integrated phone camera. dm was designed to carry out orthodontic follow-up at a distance. it tracks tooth movement through a d reconstruction of an intraoral movie taken with the smartphone camera and specific cheek retractors. the patients themselves make a video that is processed into a scan by dm tm . therefore, orthodontists can perform real-time monitoring of treatment outcomes anywhere and anytime. this smartphone application (android, ios) was originally designed to provide access to orthodontic treatment for people living in places with limited access, to improve comfort and fruibility of the service for people who have busy schedules or travel frequently for work. similarly, patients who are on orthodontic treatment during the covid pandemic period can benefit tremendously from remote monitoring, avoiding unnecessary follow-up appointments. patient monitoring through this simple software may also improve treatment efficacy by avoiding late detections of problems such as debonded brackets, broken ligatures, non-tracking aligners, and are therefore able to solve the problem in the early stage [ ] . a review on the benefits of teledentistry published in , which considered only papers with high quality assessment scores, stated that not only is teledentistry potentially an effective tool for patient management, but it also has a positive economic impact on the dental profession. this review also pointed out that there is a rapid increase in the number of publications as to the efficacy of teledentistry, especially in oral medicine, periodontics, pediatric dentistry, and orthodontics [ ] . however, due to the lack of conclusive evidence and the different methods (outcomes, assessment methods, main goal, etc.) they adopted, the findings cannot be generalized. other papers evaluate teleorthodontics as a means of performing initial examinations and report that there was no disagreement between in-office assessment and remote assessment through clinical photographs as to diagnosis and treatment planning [ , ] . they demonstrated that teleorthodontics reduced costs and provided treatment access to a wider range of persons able to benefit from specialist treatment at a distance, without compromising the quality of care [ , , ] . a study by favero et al. reported how new technologies applied to orthodontics allowed for remote management of several common orthodontic questions that would have otherwise necessitated in-office treatment: e.g., ligature displacement, discomfort from the appliance, cheek irritation [ ] . a preliminary study by hansa et al. [ ] . evaluated whether the use of remote monitoring, carried out with dm tm software, is able to reduce the number of in-office visits compared to the traditional appointment management. the same study used a questionnaire to assessed patients' attitude towards the use of a remote monitoring software during treatment the patients who had remote monitoring had fewer in-office appointments: . in average during the -month follow-up taken into consideration. this means that over a -year treatment period, an average of . in-office appointments could be avoided by the use of dm software. most patients classified the application as user-friendly (easy or very easy) ( %) and ( %) thought it was useful for their treatment. the questionnaire revealed that most patients using dm had the sensation of enhanced communication with their dentist and better convenience. however, this study [ ] provides only preliminary results and, as do other studies, suggests that if the whole treatment period were to be considered instead of just months, more precise information on the effects of teleorthodontics could be obtained. some studies analyzed the benefits of teleassistance in orthodontics and reported their utility in periodic check-ups for those in retention to make an early identification of problems and immediately book in-office appointments, thus maintaining a good doctor-patient relationship and a good level of surveillance over finished cases, without taking up the dentists' and patients' time unnecessarily [ ] . several studies have described teleorthodontics as an effective tool that allows the orthodontist to maintain treatment control in situations where the patient cannot go to the clinic [ ] . these results are in agreement with data reported by berndt et al. [ ] . the authors provided evidence of the viability of teleorthodontics during interceptive treatment. other studies have shown that the use of new patient monitoring technologies has enabled dental professionals to enhance the quality of treatment provided to their patients, as reported by mandall and stephens [ , ] . these authors stated that teledentistry is an effective way to identify appropriate referrals and that teledentistry may well increase treatment efficacy [ ] . dunbar et al. compared the reproducibility of treatment planning performed on digital records, clinical examinations, and standard records. the paper also considered patients' opinion of in-office visits and teleassistance [ ] . it showed that that % of the observers were influenced by the type of records used to decide which treatment was more appropriate. the agreement between doctors was higher on standard records than on digital ones. the authors of this study concluded that it is possible to save money, time, and avoid the need to go to the dental office for a consultation [ ] . bradley et al. also made favorable comments about this system [ ] . the attitudes toward teleassistance in orthodontics, and in general, dentistry by respective dental care professionals, was investigated in several studies which confirmed it was as an effective alternative to in-office visits for several routine procedures and to make consultations more accessible to dentists and patients [ , ] . mandall concluded that teleassistance in dentistry is a reliable tool, enabling the screening of new patients and therefore, that it was of substantial help in lowering incorrect referral rates and reduced the waiting list for fist consultations [ ] . morris et al. [ ] stated that three dimensional impressions taken with dental monitoring software do not differ greatly to those taken with an intraoral scanner (iteroelement, align technology, santa clara, ca, usa). there was a clinically insignificant mean difference of . mm between the digital models generated with dental monitoring and intraoral scans, suggesting and therefore judging it clinically insignificant [ ] . heather et al. [ ] evaluated the reliability and accuracy of dm. they assessed intercanine and intermolar distances during rapid maxillary expansion (rme) on dm scans and on digital models taken at in-office follow-up appointments. the paper reported a slightly higher margin of error for dm scans compared to digital model at the molar level. however, in-office and dm measurements differed by less than . mm. therefore, the author of this study concluded that, as long as dm scans are of acceptable quality, they can be reliable in the formulation of clinical decisions. the reliability of dm in the evaluation of rapid palatal expansion treatment, compliance and satisfaction were also studied by kuriakose et al. [ ] , who was in agreement with the aforementioned claims. that is, dm was able to make a remote assessment of the condition of posterior crossbite. no significant difference was noted in intermolar width between dm, digital model, or intraoral examination. on the basis of these data, it seems that in-office control of maxillary expansion can be substituted by teleassistance with dm software [ ] . bernd et al. [ ] stated that facial orthopedic treatments can be delivered by sufficiently trained general dentists through remote supervision of an orthodontist using teleassistance technology. this may well make a significant improvement in conditions of malocclusion in children, who for various reasons, cannot be treated in-office by an orthodontist. even if most patients treated with phase i orthodontics usually require a phase ii treatment cycle, malocclusion is far less complex and is, therefore, easily managed. the ever more powerful capacity of modern computers has led to a continuous development of innovative technologies. indeed, currently, various branches of medicine and dentistry are benefiting from the advances provided by new technologies for the diagnosis and treatment of several pathologies. teledentistry is the part of telemedicine that deals with the application of ict to dental care. moreover, teledentistry and dental video phoning allow colleagues to readily exchange information. it can also become a cutting-edge screening system able to reduce patients' waiting time for specialist advice. as long as it is correctly set up, it is capable of improving service and working conditions and may even reduce costs [ ] . teleorthodontics generally refers to any orthodontic care delivered through information technology. a common and relevant example could be that of colleagues being able to discuss the digital records of clinical cases over the internet and to exchange advice and share experience. the first studies on teleorthodontics date back to the early s [ , ] . a remarkable example that yielded promising results was a paper investigating the possibility to deliver orthodontic treatments through the remote real-time supervision of an orthodontic specialist for general dentists so as to reach patients with limited access to orthodontic care [ , ] . another useful application is remote retention check-up by sending images rather than physically going to the dentist [ ] . however, most likely, we shall have to wait for yet another decade before teleorthodontics becomes a viable option as technological and cultural obstacles still have to be overcome. in recent years, the number of patients who wish to undergo orthodontic treatment requiring fewer in-office visits, while at the same time allowing the specialist to maintain control over the progress of their treatment, has grown. teleorthodontics as a mean to further reduce unnecessary journeys to the orthodontic practice while maintaining control over treatment is allegedly one of the main reasons teleorthodontics has gained ground over the past few years. the development of clear aligners and lingual custom prescription brackets with robotic multi-wires has significantly reduced chair-side time and in-office visits [ , ] . as a rule, aligners or wires are changed during in-office visits at pre-established appointments that have been made on the basis of personal experience and common knowledge of an approximated time span for the wire to have exhausted its biological efficacy. however, a one size fits all approach is not always ideal, as average values do not take into account a patient's individual biological response. teleorthodontics allows for tailor-made scheduled in-office visits though remote monitoring, promoting a more productive workflow. these procedures are capable of reducing chair time and improving patient convenience. as reported in the results of our review, it appears that the most promising technology for teleassistance in orthodontics is dental monitoring tm (dm). this is based on three integrated platforms: a smartphone application that takes the patient through correct record taking; a software that adopts an algorithm that quantifies individual tooth movements (less than . • for mesiodistal angulation and faciolingual inclination, and rotation) and an internet-based interface where the dentist can check patients' updates as soon as they are uploaded and interact with the patient. alerts can be set at certain thresholds to receive warnings should an emergency condition arise, e.g., debonded brackets, gingival issues depending on poor hygiene, non-tracking aligners, and so forth and/or for specific treatment objectives. all images recorded by the software are available on the clinician's platform. physicians can take advantage of in-office photos (baseline and interim photos) as reference to better understand changes. the software allows four possible monitoring levels, i.e., the number of photos per period of time. routine pre-treatment monitoring requires one picture every couple of months. the monitoring of active treatment requires one or two photos per week (for aligners and the other therapies respectively). the monitoring of the retaining phase has a more complex picture timing scheme: once weekly for a month, then once monthly for six months, followed by once every couple of months. the last possibility is known as dm go live, which is for use in aligner therapy, where pictures are taken once weekly and the patient is informed whether to keep the same aligner or to proceed to the next one. although expectations are promising, teleassistance in orthodontics could have some limitations. forwarding scans each days may become a nuisance and frustrating for the patient as they may sometimes need to be taken again. moreover, the reduction in the time spent visiting the patient in person may deteriorate the patient-doctor relationship. therefore, consent and education are needed for the patient to begin a similar path in order to build a positive and strong therapeutic allegiance [ ] . during the pandemic outbreak, orthodontists had to significantly reduce, and in certain cases, suspend follow-up visits of patients currently under active treatments. we can therefore say that the use of applications for monitoring orthodontic therapy could be an effective solution to continue to keep deferrable orthodontic patients under control during the closure of dental practice due to covid and to reduce unnecessary in-office appointments. the italian society of orthodontics (sido) has recently published the recommended guidelines on the management of orthodontic patients during the covid- outbreak. orthodontic emergencies are unpredictable issues caused by orthodontic appliances that provoke pain or discomfort, thus requiring urgent dental care [ ] . orthodontic emergencies should be faced using a stepwise approach. the first recommended approach should be virtual assistance through photographic documentation or a video call. it is important to perform a preliminary triage to distinguish situations that require in-office treatment rather than those that are remotely manageable. unlike other dental questions, orthodontic problems like traumatic injuries of teeth and periodontal structures, abscesses, etc., have a lower degree of severity and often do not necessitate in-office care to be solved. the most common orthodontic emergencies are related to the detachment of one or a few brackets and acute stinging of the lips and the oral mucosa caused by orthodontic wire or scraping brackets. many of these problems can be readily solved at home with less stress for patients' families, saving time for both patients and dentists alike. since they are not true emergencies, they can, more often than not, be easily resolved by providing the patient with simple instructions during a video call or with typed messages after photographic documentation of the problem, describing the intraoral condition. it has been suggested that dental caregivers become familiar with the potential social networks and modern web-based communication platforms have, thanks to the possibility of making a precise evaluation of indications and contraindications [ , ] . patients should continue ongoing therapies, but should also be video checked periodically. dental professionals and their team must select the number of eligible patients and organize this procedure [ ] . in all other cases, it is advisable to contact each individual patient in therapy actively in order to give specific indications and it is recommended to make telephone appointments with patients - weeks apart to carry out a further check-up or fix an appointment in the studio, if strictly necessary [ ] . patients must be reassured and periodically checked, in particular if they have discomfort or problems related to their orthodontic appliance. it is important to emphasize that not only must emergencies be managed by the orthodontist, but also all other patients with both mobile and fixed appliances. teleorthodontics relies on information technology and telecommunications and allows for various types of orthodontic follow-up visits at a distance. therefore, it is of fundamental importance to be able to avail oneself of teleorthodontics for the constant monitoring of all patients should the orthodontic practice be shut-down and/or visits significantly limited. the professional, thanks to special devices, can check a patient's real situation remotely and compare it with the digital setups previously made, especially in the case of treatments with lingual orthodontics and aligners [ ] . based on the revised articles, new information technology improved the management of orthodontic patients, and in numerous cases, allowed for their remote management. teleorthodontics has the potential to improve patient management and reduce treatment costs. this review does have some limitations. one such limitation is the fact that the studies included had only a fair scoring in mmat. moreover, although most papers reported a positive attitude towards teleorthodontics, a publication bias may be present since all papers reported one or more positive outcomes for accuracy and/or efficacy and some papers are technical reports or pilot studies. only a limited number of papers made a controlled comparison of teleassistance in orthodontics with traditional methods. many included studies focused on the evaluation of efficacy rather than the effectiveness of teleorthodontics. it would be of great importance to evaluate the appropriateness of teleassistance in orthodontics by assessing clinical outcomes and costs/template details the sections that can be used in a manuscript. this review found a growing number of studies sustaining the efficacy of teleassistance in orthodontics. the advent of a large number of technological innovations over the past few years in dental and in orthodontic practices has allowed for substantial improvement. the covid- pandemic will surely have long-term effects on patient management as it seems unlikely there will be any definitive treatment or vaccines available in the near future. this condition will require a different organization of dental appointments for several months to come and remote patient management could be efficiently carried out using instant messaging platforms to deliver healthcare consultancies. we believe that teleassistance in orthodontics should be considered a welcome resource, as it is able to successfully manage many dental emergencies, to reassure and follow patients at a distance without exposing them and/or dental practitioners to unnecessary risks. moreover, most case issues can be promptly solved without the patients coming to the orthodontist office by communicating with photos and/or videos, saving both the patient's and clinician's valuable time. the aim of teleorthodontics is fulfilled by reducing unnecessary follow-up visits while maintaining regular monitoring, thus not jeopardizing expected results. the potential of teleorthodontics is virtually endless; remote consultations could be carried out across the globe without the obstacles of distances or of scheduling appointments. this kind of approach could be of great help in the management of all dentofacial orthopedic removable appliances and of orthodontic treatments that need little in-office maintenance, such as some clear aligner therapies. even though in-office visits are still required for many dental and orthodontic procedures, teleorthodontics opens up open new horizons in the treatment and follow-up of many patients. nevertheless, currently, most studies report only pilot studies and evaluate short-term results of teleassistance in orthodontics. therefore, there is limited evidence and the study designs differ, as do the interventions and endpoints assessed in the papers included, meaning that our findings cannot be strictly generalized. however, although we are of the opinion that further studies with higher levels of evidence are needed to objectively evaluate efficacy, cost-effectiveness, and long-term results, we are confident that teleassistance in orthodontics will have a role to play in the future. technological advances have substantially changed dentistry. in orthodontics, software like dental monitoring, which is capable of providing web-based platforms for sharing health data [ ] between patients and doctors, may allow orthodontists to closely monitor their patients' status, reducing in-office visits and delivering more patient-centered treatment. the aim of teleassistance in orthodontics is to reduce unnecessary in-office visits and improving monitoring and early treatment of problems that may jeopardize the desired final outcome. teleassistance in orthodontics may allow for remote consultations that can be carried out wherever without the need for the patient to be anywhere near the office. the downside of teleorthodontics is the reduced time to develop and maintain a positive relationship between doctor and patient [ , ] . dunbar [ ] reported in a feasibility study that % of patients thought that in-office consultation was extremely important, and most patients preferred it to teleorthodontics assistance. another important consideration are the points of law regarding patient confidentiality that may be in danger because of digital communication of sensible data over the internet [ ] . the quality of the doctor-patient relationship is particularly important should the treatment have complications or if outcomes are deemed unacceptable. malpractice lawsuits may increase if patients feel they are not receiving treatment of a satisfying quality. moreover, teleassistance in orthodontics and patients' confidentiality issues are more complicated in orthodontics because patients are often minors. therefore, the teleorthodontics we are implementing during the covid pandemic should not be seen in the future as a new treatment option for patients looking for cheaper and aesthetic alternatives to traditional orthodontics, as dental and orthodontic care should not be reduced to a simple question of "commodity" [ ] . as already reported by hansa et al. [ ] , orthodontists are still a little doubtful about treatment at a distance because of the possibility of limiting their patient base and due to the risk patients may face. it is the authors' opinion that, in the future, teleassistance in orthodontics will be helpful to maintain high standards of care while reducing unnecessary in-office visits in order to improve rather than reduce the quality of the service already provided by conventional orthodontics. a pneumonia outbreak associated with a new coronavirus of probable bat origin a novel coronavirus from patients with pneumonia in china the novel coronavirus originating in wuhan, china: challenges for global health governance china coronavirus: who declares international emergency as death toll exceeds clinical characteristics of hospitalized patients with novel coronavirus-infected pneumonia in wuhan, china dentistry and coronavirus (covid- )-moral decision-making treatment of dental dilacerations comparison of the dental and skeletal effects of two different rapid palatal expansion appliances for the correction of the maxillary asymmetric transverse discrepancies opportunities and developments in member states: report on the second global survey on ehealth telemedicine: a new horizon in public health in india applications of teledentistry: a literature review and update telemedicina linee di indirizzo nazionali addressing health disparities in rural communities using telehealth telemedicine: a guide to assessing telecommunications for health care chapter : executive summary prática clínica baseada em evidências na Área da saúde proposal: a mixed methods appraisal tool for systematic mixed studies reviews the integrative review: updated methodology using teledentistry to provide interceptive orthodontic services to disadvantaged children a systematic review of the research evidence for the benefits of teledentistry communication through telemedicine: home teleassistance in orthodontics tele-orthodontics": concept, scope and applications teledentistry for screening new patient orthodontic referrals. part : a randomised controlled trial accuracy of dental monitoring d digital dental models using photograph and video mode the influence of using digital diagnostic information on orthodontic treatment planning-a pilot study accuracy of a smartphone-based orthodontic treatment-monitoring application: a pilot study the assessment of rapid palatal expansion using a remote monitoring software profiling the interest of general dental practitioners in west yorkshire in using teledentistry to obtain advice from orthodontic consultants management of orthodontic emergencies during -ncov teleortodontia: ferramenta de auxílio à prática clínica e à educação continuada implementation and evaluation of a low-cost telemedicine station in the remote ecuadorian rainforest the world of orthodontic apps. apos trends orthod up in the air: orthodontic technology unplugged! apos trends orthod dental care: virtual consultations and remote monitoring a systematic review of clinical outcomes, utilization and costs remote patient monitoring via non-invasive digital technologies: a systematic review do-it-yourself orthodontics, and remote treatment monitoring attitudes of uk consultants to teledentistry as a means of providing orthodontic advice to dental practitioners and their patients effectiveness and efficiency of a cad/cam orthodontic bracket system efficacy of clear aligners in controlling orthodontic tooth movement: a systematic review considerazioni sull'uso di whatsapp nella comunicazione e relazione medico-paziente whatsapp in clinical practice: a literature review transverse dental and dental arch depth dimensions in the mixed dentition in a skeletal sample from the th to the th century and norwegian children and norwegian sami children of today everything in its place! " apos trends orthod showing you care: an empathetic approach to doctor-patient communication being as good as your dumbest competitor? this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license the authors thank barbara wade, contract professor at the university of torino, for her linguistic advice. the authors declare no conflict of interest. key: cord- -f p yaw authors: wang, hao; sikora, per; rutgersson, carolin; lindh, magnus; brodin, tomas; björlenius, berndt; larsson, d.g. joakim; norder, heléne title: differential removal of human pathogenic viruses from sewage by conventional and ozone treatments date: - - journal: int j hyg environ health doi: . /j.ijheh. . . sha: doc_id: cord_uid: f p yaw sewage contains a mixed ecosystem of diverse sets of microorganisms, including human pathogenic viruses. little is known about how conventional as well as advanced treatments of sewage, such as ozonation, reduce the environmental spread of viruses. analyses for viruses were therefore conducted for three weeks in influent, after conventional treatment, after additional ozonation, and after passing an open dam system at a full-scale treatment plant in knivsta, sweden. viruses were concentrated by adsorption to a positively charged filter, from which they were eluted and pelleted by ultracentrifugation, with a recovery of about %. ion torrent sequencing was used to analyze influent, leading to the identification of at least viral species, most of which belonged to families with some having unclear classification. real-time pcr was used to test for human-related viruses in inlet, conventionally treated, and ozone-treated sewage and outlet waters. the viruses identified in influent and further analyzed were adenovirus, norovirus, sapovirus, parechovirus, hepatitis e virus, astrovirus, pecovirus, picobirnavirus, parvovirus, and gokushovirus. conventional treatment reduced viral concentrations by one to four log , with the exception of adenovirus and parvovirus, for which the removal was less efficient. ozone treatment led to a further reduction by one to two log , but less for adenovirus. this study showed that the amount of all viruses was reduced by conventional sewage treatment. further ozonation reduced the amounts of several viruses to undetectable levels, indicating that this is a promising technique for reducing the transmission of many pathogenic human viruses. pathogenic human and animal viruses found in aquatic environments are usually shed from feces (enteric viruses), urine, and respiratory secretions from the infected host and enter into sewage water. the human viruses belong to different viral families. the most common viruses that are widely dispersed in sewage around the world include hepatitis a virus, hepatitis e virus, rotavirus, adenovirus, norovirus, astrovirus, parvovirus, coronavirus, poliovirus, and other enteroviruses (hellmer et al., ; laverick et al., ; lodder and de roda husman, ) . not only human enteric viruses and animal pathogens, but also other viruses can be found in waters contaminated with sewage (bosch, ; cantalupo et al., ) . if the pathogens are not removed in the treatment plants, they will be released into natural watersheds where many of them can persist for long periods (fong and lipp, ; kotwal and cannon, ) . new hosts might be infected with these viruses through direct contact with contaminated water or by drinking it or by eating animals such as mollusks that have filtered and concentrated viruses from sewage-contaminated water (nenonen et al., ) . in most western wastewater treatment plants, raw sewage is treated with combined mechanical, biological, and chemical processes such as screening, flocculation, sedimentation, and filtration. gross pollutants and most organic and inorganic solids are removed during these steps. the effluent is thereafter either discharged into a receiving water system or reused for other purposes. little is known, however, about the efficiency of removal of human viral pathogens from sewage by conventional treatment. several studies have shown that such treatments t are efficient for the reduction of the parasites giardia and cryptosporium and for bacteria but have little effect on adenoviruses and enteroviruses (li et al., ; ottoson et al., a; rodriguez-manzano et al., ) . additional disinfection after conventional treatment is applied in some treatment plants to further remove pathogens, such as treatment with peracetic acid, chlorination, and ultraviolet irradiation (das, ; kitis, ) . these treatments are efficient for inactivating and removing bacteria and protozoa, but not for most enteric viruses (freese and nozaic, ; shannon et al., ) . ozone treatment is an alternative for removing microcontaminants in sewage because ozone is an extremely reactive oxidant and thereby a powerful disinfectant. it has been used for disinfection of drinking water in europe since (rice et al., ) and has also been installed in some sewage treatment plants (oh et al., ; rakness et al., ) . the disinfecting ability of ozone treatment has been shown to be efficient for bacteria and parasites in clean water (kim et al., ; peeters et al., ) , and this treatment also has been shown to reduce the concentrations of enteric viruses and bacteriophages (burleson et al., ; kim et al., ) . however, the ability of ozonation to inactivate pathogens in wastewater might be hampered due to the high contents of organic materials in sewage (burleson et al., ) . one mechanism for reducing viable viruses in water by ozone treatment is assumed to be due to a conformation change of the viral capsid proteins by oxidation that either destroys the capsid or suppresses the virus/host cell receptor binding by changing the viral capsid proteins (shannon et al., ) . previous studies conducted in wastewater treatment plants have shown that ozone disinfection might be highly efficient in inactivating bacteria and bacteriophages after conventional sewage treatments (kim et al., ; tyrrell et al., ) , but knowledge regarding its effect for reducing human enteric viruses is relatively scarce. we used next-generation sequencing (ngs) technology and realtime pcr to investigate the efficiency of virus removal in sewage by conventional treatment and to evaluate the effect of additional ozone treatment at a full-scale pilot plant in sweden. the investigated sewage treatment plant in knivsta, which is situated km north of stockholm, sweden, uses traditional activated sludge treatment and receives primarily household waste from up to , population equivalents with a hydraulic design flow of m / h. the initial treatment is mechanical with two parallel screens and an aerated grit chamber. the subsequent biological treatment includes activated sludge and reactors with carriers of active biofilms, and this is followed by a chemical treatment step where ferric chloride is added prior to the sewage entering the two final parallel sedimentation basins. before release into the recipient river (knivstaån), the effluent passes through a pond for the removal of phosphorus-containing fine particles. in an additional ozonation step treating the entire wastewater flow was added at the end of this process line. the full-scale ozonation step is divided into two parallel lines with a total maximum capacity of m effluent wastewater per hour. the ozonation step includes lifting pumps, the production of ozone in generator units, the injection of ozone by static mixers, contact tanks, and final contact filters. each line contains two lifting centrifugal pumps (apex isf c, bristol, uk), one static mixer (nr mixer, statiflo international ltd, uk), one m stain-less steel contact tank with m water depth and two compartments, one ozone destructor for off-gas (primozone, sweden), and two contact filters with a total area of m filled with m light-expanded clay aggregates (leca, saint-gobain linköping, sweden) for potential stripping or quenching of ozone residues in ozonated wastewater. the ozone is produced from evaporated liquid oxygen with > . % o (yarapraxair, sweden) diluted to % o by addition of air in an ozone generator with a maximum production capacity of . kg o /h (gm , primozone, sweden). an ozone dose of around mg/l is added to the effluent wastewater through static mixers that transfer more than % of the added ozone to the wastewater. most of the ozone reacts or degrades rapidly after the addition to the wastewater. analysis of the water samples in the inlets and outlets of the contact tanks show ozone concentrations of - mg o /l and . - . mg o /l respectively. to verify that adequate amounts of ozone are transferred, the removal of pharmaceutical residues was calculated based on frequent inlet and outlet samples, and the results showed a typical removal efficiency for an ozone dose of - mg o /l, which is also reported in other studies and is related to total organic carbon (toc) concentrations (beijer et al., ) . the hydraulic retention time in the contact tanks was on average min and the minimum and maximum retention time was and min, respectively, during the period of ozonation that began in august and ended in february . the wastewater chemistry as well as effects on the recipient river were studied in parallel research projects before, during, and after the ozonation trial. for the present study, flow-proportional h composite samples of influent ( l per sample), effluent ( l), effluent after ozonation ( l), and effluent after the dam (outlet; l) were collected on three occasions in (november until december (week ); december until december (week ); and december until december (week / )), with time adjustment for the flow rate to represent the "same" water. all samples were cooled during sampling and then frozen at − °c until further processing. the water samples were first centrifuged at × g for min before filtration twice through nano-ceram cartridge filters (argonide, sanford, florida, usa) at an average flow rate of . l/min. the viruses were electrostatically attached to the filter from which they were eluted by ml of . m phosphate buffer containing . m glycine (ph . ). the eluate was collected, and the ph was adjusted to . by the addition of m hcl. the eluate was thereafter filtered through a . / . μm sartobran capsule filter (sartorius, göttingen, germany) to remove remaining debris and most bacteria. the filtrate was then ultracentrifugated in eight tubes at , rpm for h at °c. the pellet in each tube was resuspended in μl mm tris-hcl (ph . ) overnight, pooled, and stored at − °c until analysis. a fixed amount of human mastadenovirus (hadv- ) was added to . l raw sewage, and the sewage was concentrated by the method above. one milliliter of unconcentrated water and one ml from each concentration step was collected and analyzed for adenovirus by quantitative real-time pcr (qpcr) and isolation on cell culture. nucleic acids in the water samples were extracted from μl concentrated sample using the qiagen dna blood and tissue kit (qiagen, hilden, germany) according to the manufacturer's instructions. qpcr for adenovirus was performed in a μl reaction mix containing μl extracted nucleic acids, × universal dna master mix (thermofisher, waltham, ma, usa), . μm of forward and reverse primer, and . μm of probe (table s ). the cycling conditions were °c for min and °c for min followed by two-step cycling times at °c for s and °c for min on an abi fast real-time pcr system (applied biosystems, foster city, ca, usa). for isolation of hadv- on cell cultures, μl of -fold serial dilutions ( / to / , ) in eaglés minimal essential medium (mem, gibco, waltham, ma, usa) from each concentration step were inoculated in duplicate into wells in -well plates (thermofisher) containing confluent monolayers of a cells. the plates were incubated at °c in an atmosphere of % co for h, after which the medium containing virus was removed from each well, followed by addition of μl mem containing % fetal calf serum and % l-glutamine (gibco). the plates were incubated at °c in % co and were examined for cytopathogenic effects daily for days. . . . nuclease treatment of the dissolved pellets from the three concentrated incoming sewage samples before nucleic acid extraction, μl of the dissolved pellet was treated with u benzonase nuclease (sigma-aldrich, st. louis, mo, usa) and . mm mgcl (applied biosystems, foster city, ca, usa) and incubated at °c for h. thereafter edta was added to a final concentration of mm to inhibit the nuclease activity. dna was extracted from μl of each treated sample using the qiaamp dna mini kit (qiagen, hilden, germany), and rna was extracted from the remaining μl of each sample using the rneasy plus mini kit (qiagen, hilden, germany). the rna was reverse transcribed into cdna in a μl reaction mix containing . μl extracted rna, . μg random hexamer primers (roche diagnostics, indianapolis, in, usa), . mm dntp (sigma-aldrich), × first strand buffer (invitrogen, waltham, ma usa), mm dithiothreitol (invitrogen), u rnaseout (invitrogen), and u superscript iii reverse transcriptase (invitrogen). the synthesis was performed at °c for min followed by °c for min, and the cdna was stored at − °c until further amplification. extracted dna and cdna samples were amplified by nested pcr in triplicate. briefly, touch-up gradient pcr using primers sisp and sis (table s ) was used as the first-round amplification in a μl reaction mix containing . μl template, × taq buffer (applied biosystems), mm mgcl (applied biosystems), . mm dntp (sigma-aldrich), u taq dna polymerase (roche diagnostics), and . μm of each primer. the pcr reaction was performed for one cycle at °c for min, followed by cycles touch-up pcr with °c for s and °c for s ( °c increase per cycle), followed by cycles of °c for s, °c for s, and °c for min, and with a min final extension at °c. five microliters of the first-round pcr product were further amplified with the primers sisp and sis (table s ) in a μl reaction mix containing × taq buffer (applied biosystems), mm mgcl (applied biosystems), . mm dntp (sigma-aldrich), u taq dna polymerase (roche diagnostics), and . μm of each primer. the pcr was performed with an initial denaturation at °c for min followed by cycles of °c for s, °c for s, and °c for min, and with a min final extension at °c. the triplicates were pooled, and the pcr products were visualized by . % agarose gel electrophoresis. before library building for next-generation sequencing (ngs), the majority of the amplified products were sheared into - bp fragments by sonication using a bioruptor sonication device (diagenode, seraing, belgium). the pcr products from each sample were pooled and thereafter aliquoted into five tubes each with μl product. one aliquot was not sonicated, while the four other aliquots were sonicated for , , , and cycles, respectively (each cycle was one minute with s sonication and s without sonication). after sonication, the five aliquots were pooled, and the products were visualized by . % agarose gel electrophoresis. libraries were built from the fragmented pcr products by using the ion plus fragment library kit on an ab library builder system (thermofisher, waltham, ma usa) according to manufacturer's protocol. the newly built libraries were amplified for eight cycles and purified with ampure xp beads (beckman coulter, brea, ca, usa). samples were then further size selected to about bp by using a pippin prep (sage science, beverly, ma, usa). the recovered materials were analyzed using the agilent high sensitivity d screentape system on a tapestation (agilent, santa clara, ca, usa). the dna concentration was thereafter estimated using an ion quantitation kit (thermofisher). the libraries were diluted and pooled to reach a final concentration of pm. template preparation and chip loading was performed on the ion chef instrument using the ion pgm™ hi-q™ view chef kit according to the manual (thermofisher). an ion chip (thermofisher) was used, and sequencing was conducted on an ion torrent pgm with an ion pgm hi-q view sequencing kit (thermofisher). the sequence data obtained was automatically trimmed by the ion torrent suite software (thermofisher), and the resulting bam files were imported into clc genomic workbench . . (qiagen, hilden, germany) for analysis. the pipeline for viral identification is illustrated in supplemental figure a . low-quality reads, reads below bp, and the primer sequences were removed. the sequences were mapped to a human hg reference genome using stringent criteria, with length fraction set at . and similarity fraction set at . . the mapped reads were discarded, while unmapped reads were assembled de novo using the built-in clc de novo assembler with a word size of and a minimal contig size of bp. the contigs obtained from the de novo assembly and singleton reads longer than bp were blasted against the ncbi genbank non-redundant nucleotide database (nr/nt) using blastn and a cut-off with an e-value of − for significant hits. after blast, contigs and singletons that satisfied an e-value < − and an hsp length > bp were selected, and viral hits among them were used for further analysis. primers and probes for selected viruses related to human diseases were designed and used to verify the results obtained by ngs (table a ) and to determine the prevalence of these viruses after conventional treatment and ozone treatment. the most common viruses identified were human feces pecovirus, picobirnavirus, parvovirus, parvoviruslike virus, adenovirus genotype , astrovirus , and gokushovirus. three microliters of extracted nucleic acids from the samples were analyzed by qpcr in a μl reaction mixture containing × reaction mix (invitrogen), u rnaseout™ (invitrogen), . μl superscript ® iii/platinum ® taq mix (invitrogen), and . μm of each primer, and . μm of probe. the qpcrs for astrovirus and picobirnavirus were performed with initial reverse transcription at °c for min and °c for min. the qpcr was performed for cycles of °c for s and °c for min for most viruses, but with extension at °c for adenovirus and °c for gokushovirus and astrovirus . the qpcrs were performed in a fast real-time pcr system (applied biosystems), and all samples were analyzed in duplicate. the four concentrated water samples (incoming sewage, conventionally treated, ozone treated, and outlet water) from each of the three weeks were also analyzed by qpcr for common enteric viruses (adenovirus, astrovirus, hepatitis a virus, hepatitis e virus, norovirus gi, norovirus gii, norovirus giv, parechovirus, sapovirus, aichivirus, mengovirus, torovirus, enterovirus, and rotavirus). all primers and probes used for the detection are listed in table a . the method and conditions for the qpcr were as previously described (hellmer et al., ) . the qpcrs were performed on a fast real-time pcr system (applied biosystems), and all samples were tested in duplicate. a puc plasmid containing all viral target regions was synthesized by genescript (genescript usa inc. nj, usa), and ten-fold serial dilutions were used as the positive control in all qpcr analyses. the ct values of the samples were relative to the ct values from the dilutions of the plasmid containing the virus sequences being analyzed, and from this the numbers of viral genomes per milliliter were estimated. these values were also compared to estimated amounts of viral genomes by assuming a perfect qpcr detecting one genome by using the formula: (ct value of the sample) = − . × log genomes/ml + . the number of estimated viral genomes was not adjusted to the estimated recovery in any of the analyzed waters, but was used directly to compare the reduction of viruses by the different treatments. nested pcr was used to amplify the hexon protein-coding region of adenovirus. the μl reaction mix contained μl extracted dna, × taq buffer (applied biosystems), . mm mgcl (applied biosystems), . mm dntp (sigma-aldrich), . μm of forward and reverse primers (advf st and advr st; table s ), and u taq dna polymerase (roche diagnostics). the pcr was initiated at °c for min, followed by cycles at °c for s, °c for s, and °c for min, and a min final extension at °c. five microliters of the pcr product from the first-round amplification were used as the template for nested pcr as described above but with different forward and reverse primers (advf nd, advr nd; table s ). the fragments were purified using a qiaquick pcr purification kit (qiagen) according to the manufacturer's protocol, and the purified amplicons were sent for sequencing to gatc biotech, constance, germany. the sequences obtained were analyzed in the seqman pro program in the dnastar program package version . . (dnastar inc., madison, wi, usa). the sequences were aligned with the corresponding region of the hexon gene of adenovirus sequences representing all human mastadenovirus types obtained from genbank. evolutionary distances were calculated using the hasegawa-kishino-yano (hky) algorithm in the dnadist program in the phylip package version . (felsenstein, a; felsenstein, b) with transition/transversion ratio of . and gamma correction with alpha . . phylogenetic trees were constructed using the unweighted pair-group method using arithmetic averages (upgma) and the neighbor-joining method in the neighbor program of the phylip package. the trees were visualized with the program treeview, version . . (page, ) . the added adenovirus could be detected by qpcr and isolation on cell cultures in all concentrations steps (table ). the raw sewage water was concentrated about times (from . l to . ml) with this technique, and the adenovirus was concentrated about times, indicating a recovery of % (table ). the treatment of the pellet with nucleases before nucleic acid extraction did not significantly change the efficiency of the concentration procedure. by isolation on cell culture, it could be shown that most adenoviruses were viable, and the viruses from the final ultracentrifugation pellet could be detected up to a dilution of − , indicating a % efficiency for the technique. however, when the pelleted samples treated with nuclease were isolated on cell culture, viruses could only be detected in a − dilution, which would indicate % recovery similar to the qpcr (table ) . by ngs sequencing, , to , reads were obtained after quality control for each of the three concentrated incoming sewages (table ) . after de novo assembly, to , contigs and singletons were obtained. between and sequences were homologous to different viruses and could be classified into viral families, corresponding to about . % to . % of all contigs obtained (table ). in all, viruses belonging to different families were identified (table a ) . bacteriophages from the families of inoviridae, microviridae, myoviridae, podoviridae, and siphoviridae accounted for the largest proportion of the identified viruses. sequences similar to gokushovirus, a member of microviridae, were abundant and accounted for more than % of all viral sequences in one sample. apart from bacteriophages, viruses infecting plants, vertebrates, invertebrates, and protists were also identified. although there were fewer sequences similar to viruses that could infect vertebrates than bacteriophages, they had a high diversity and belonged to nine of the viral families. plant-related viruses, including tombusviridae, virgaviridae, alphaflexiviridae, betaflexiviridae, partitiviridae, and tymoviridae, were also widely distributed in the samples. sequences similar to a number of viruses related to human diseases were also detected. as shown in table , sequences representing some common viral families, such as adenoviridae, astroviridae, papillomaviridae, parvoviridae, and picobirnaviridae were found. contigs longer than bp identified human adenovirus f, serotype in samples qpcr was used for identification of common human enteric viruses in influent, treated sewage, ozone-treated effluents, and after passing an open dam system. three of these viruses (adenovirus, norovirus gii, and astrovirus) were detected in samples from the influent and after treatment at % to % reduced concentrations, with adenovirus being the least affected (table , fig. ). an additional four viruses (norovirus gi, sapovirus, parechovirus, and hepatitis e virus) were only detected in the inlet samples with concentrations reduced to undetectable levels after conventional treatment. based on the obtained ngs sequences, new qpcr primers and probes were designed to detect seven selected viruses related to humans in the incoming sewage, including human feces pecovirus, picobirnavirus, parvovirus, parvovirus-like virus, adenovirus type , astrovirus type , and gokushovirus (table ). for these viruses the reduction of viral genomes after the conventional treatment ranged from . % for gokushovirus to - % for parvovirus and parvovirus-like virus during weeks and / (table ). the reduction was higher, %, for parvovirus during week . ozone treatment of conventionally treated effluent lowered the amount of viruses further to undetectable levels for pecovirus, picobirnavirus, parvovirus-like virus, and gokushovirus for all three weeks. this treatment reduced the adenovirus concentration by % to %, norovirus gii by % to %, and astrovirus and parvovirus by % to % (tables and ). despite not being detected after ozone treatment, several of these viruses were found in the outlet water after the dams, as were parvovirus during weeks and and parvoviruslike virus, astrovirus , pecovirus, and adenovirus during week . for these viruses, the amount of virus identified in the outlet water was between % and % of that identified in the conventionally treated sewage samples (tables and ) . it was possible to amplify and sequence a partial region of the adenovirus hexon gene in all water samples except for the outlet samples from weeks and / . the sequence obtained for the ozone-treated sample in week could not be analyzed because it contained multiple sequences. phylogenetic analysis was performed for the remaining nine sequences and revealed that six belonged to species f and two to species a, and for the ozone-treated sample in week the species could not be determined, but it was found on the same branch as species f strains in the phylogenetic tree (fig. ) . the strains were divergent from each other, and the most similar strains were from conventionally treated sewage from weeks and within species f and were found on the same branch as the strains in the incoming and ozone-treated samples from week / (fig. ) . in this study we demonstrated a high diversity of viruses in incoming sewage. human-related viruses were strongly reduced by conventional treatment of the sewage, and the elimination of several of these was achieved by additional ozone treatment. other studies have previously shown reduction of parasitic protozoa, bacteria, and phages by conventional treatment of sewage (ottoson et al., a; tyrrell et al., ) , but little was known regarding the reduction of human enteric viruses (montazeri et al., ; ottoson et al., b,c) or their sensitivity to ozonation of sewage. while ozonation is already recognized as a promising technology for removing microcontaminants, such as pharmaceuticals, in sewage (beijer et al., ) , the additional benefit of reducing risks for the spread of human pathogenic viruses via table real-time pcr for seven of the viruses identified by ngs and the estimated numbers of genomes of these viruses per milliliter of water in untreated and treated sewage samples from three weeks in , where k numbers indicate internal sample numbers. virus week week week contaminated waters should be considered as well. the conventional treatment of sewage eliminated or reduced the amount of most viruses detected in inlet sewage in this study, but it was less efficient for parvovirus and adenovirus. additional ozone treatment lowered the amount further, for some viruses to undetectable levels. this result is in line with other studies that demonstrated a reduction of enteroviruses and f + coliphages by more than . and . log with ozone disinfection of wastewater effluents (xu et al., ) . because there is a relatively high quantity of suspended solids and organic materials in secondary effluent after conventional treatment that could affect the ozone treatment efficiency, we do not know if an increased amount of ozone or longer ozone treatment time would have reduced the amounts of viruses even further. however, in this study some viruses that were undetectable in the ozone-treated samples reoccurred in the outlet water, including parvovirus, norovirus gii, human feces pecovirus, parvovirus-like virus, gokushovirus, and hadv-f , although the amounts were significantly lower compared with raw sewage. the reason for the identification of viruses in the outlet after the dam system despite the fact that they were not detected by qpcr after ozonation is unclear, but two circumstances identified during the evaluation of the operation of the treatment plant might explain these findings. during week , the protective sieves for the lifting pumps in the ozonation step were partly clogged with large particles released by high hydraulic flow in the treatment plant leading to by-pass of % of the conventionally treated wastewater directly to the dam. in week / , the concentration of suspended solids in the conventionally treated wastewater was mg ss/l, which was % higher than in samples from week and week that contained mg ss/l. this might have allowed some of these viruses to escape the ozone treatment and to reappear in the dams. additional explanations could be that our attempts to follow the "same" water based on the flow through the treatment plant had been disrupted and that the waters analyzed from the outlet of the dams were not the same as the ozonized waters. another reason might be that the viruses were present in amounts too low to be detected in the ozonized water by qpcr. larger amounts of water might be needed to determine if these viruses were also present in the waters after ozone treatment, and further studies are also needed to determine the impact of the ozone treatment on these viruses. adenoviruses are resistant to uv disinfection (baxter carole et al., ; and were also rather insensitive to the ozone treatment used in this study. in clean water, human mastadenovirus f (hadv-f ) has been shown to be more resistant to ozone treatment than feline calicivirus, which is often used as a surrogate for noroviruses (thurston-enriquez et al., ) . in the present study, the dominant strains of adenovirus varied, both between the differently treated waters and within the sample groups. there were different hadv-f and hadv-f strains in all inlet sewage samples, while in one ozone-treated sample a divergent type f strain dominated and in some of the treated waters there were type a strains. a somewhat similar finding was also obtained by fernandez-cassi and co-workers (fernandez-cassi et al., ) . the pattern observed in this study suggests that there was a complex composition comprising multiple adenovirus types in the raw sewage, and these might have varying degrees of sensitivity to the conventional processing and ozone treatment. however, we do not know if these viruses are viable after the ozone treatment, and the oxidization might have changed the conformation of the viral head protein and thereby inhibited viral-host binding (shannon et al., ) . because the amount of viral genomes decreased significantly after the ozonation, the treatment might not only change the conformation of the viral capsids, but might also destroy or open the capsid of some viruses and thereby release the viral genomes into the water where nucleases are present. further studies are needed on ozonation of water containing adenovirus types that are easy to isolate on cell cultures in order to identify the viability of the viruses after treatment. the high diversity of viruses identified in the inlet sewage in this study is in agreement with a previous study on sewage where known viruses representing taxonomic families, as well as a large number of novel viruses, were identified (cantalupo et al., ) , confirming that raw sewage contains a vast and diverse viral pool. the identified viruses could infect bacteria, plants, vertebrates, invertebrates, and protists, with bacteriophages contributing the largest proportion. the bacteriophage gokushovirus, which primarily targets chlamydia, bdellovibrio, and spiroplasma (labonte et al., ) , accounted for most viral reads in all samples. this virus has been shown to be widespread in global environmental samples, especially in aquatic ecosystems (hopkins et al., ; labonte et al., ) , and can be used as a potential viral indicator for treatment efficacy in different waters. human disease-related viruses, which can cause diarrhea, respiratory diseases, conjunctivitis, meningoencephalitis, and infantile gastroenteritis (fong et al., ; nguyen et al., ) were also identified. some of these that might cause gastroenteritis, such as human picobirnavirus and human feces pecovirus (giordano et al., ; phan et al., ; phan et al., ) , were widely detected in the sewage samples but are usually not tested for at hospital laboratories. to understand their importance for public health, more enteric viruses identified in environmental samples should be incorporated into the routine monitoring of patients with gastroenteritis. there were also other human pathogenic viruses detected in the sewage during the whole study period, including hpv, which might cause warts, papilloma, and malignant tumors. other recent studies have also identified multiple types of hpv, including the oncogenic high-risk hpv , in raw sewage (bibby and peccia, ; cantalupo et al., ; la rosa et al., ) . the presence of this virus in large amounts in aquatic environments has caused concern about its potential for waterborne transmissions, which might cause anogenic or oral hpv infections even among people who have not been sexually active (fratini et al., ) ; however, further research into its transmission by the waterborne route is still needed. when comparing the results obtained with real-time pcr and ngs, only adenovirus and astrovirus could be identified by ngs data, and sequences corresponding to sapovirus, norovirus, and parechovirus were not found even though these viruses could be identified with realtime pcr. this might be due to their low quantity in sewage. most of the viruses detected by ngs had about one to two log higher viral genome concentrations than the overlooked viruses, indicating that ngs has some limitations when dealing with complex environmental samples and might underestimate the number of different viruses if the number reads are not high enough to exhaustively probe the sample. the concentration efficiency of about % used in this study might also have influenced the amount of viruses identified. however, this efficiency is comparable to that obtained by other concentration methods (cashdollar et al., ; fout et al., ; hellmer et al., ; ikner et al., ) . by using adsorption to charged filters, hadv- , which was used for the evaluation of this technique, has previously been used in another study with a recovery of about %, while the recovery was % to % for enteroviruses (ikner et al., ) . the low recovery of adenovirus might be due to its surface capsid structure and electrostatic charge, which might facilitate the entrapment of these viruses in the charged filters and hamper their elution from the filters (gibbons et al., ; shi et al., ) . hadv- was used in this study as an indicator of the effectiveness of the method because it could easily be detected by both qpcr and isolation on cell cultures and was shown to be viable in all concentration steps used. this method might therefore have a higher concentration efficiency for other viruses than adenovirus and thus should also be analyzed for other viruses that can be isolated on cell culture. this work expands our knowledge of the possible use of ozone treatment to eliminate viruses from water. the ability of ozonation to reduce the transmission risks of human pathogens might therefore be considered when decisions are taken as to whether it is worthwhile to install advanced sewage treatments to remove microcontaminants and bacterial pathogens. it should be acknowledged that in addition to the apparent advantages, ozonation also come with a cost, and high ozone doses in particular can sometimes lead to the formation of compounds that can negatively affect aquatic life (samuelsson et al., ) . further studies are needed to determine the most efficient methods, including different ozonation procedures, for viral elimination in sewage and whether these pathogens in treated waters are viable and can spread. the elimination of human pathogens is imperative in order to prevent waterborne viruses from re-entering into the environment and thus reduce the potential risk they pose to public health. inactivation of adenovirus types , , and in drinking water by uv light, free chlorine, and monochloramine inactivation of adenovirus types , , and in drinking water by uv light free chlorine, and monochloramine removal of pharmaceuticals and unspecified 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data associated with this article can be found, in the online version, at https://doi.org/ . /j.ijheh. . . . key: cord- -d za hi authors: kapepula, paulin m.; kabengele, jimmy k.; kingombe, micheline; van bambeke, françoise; tulkens, paul m.; sadiki kishabongo, antoine; decloedt, eric; zumla, adam; tiberi, simon; suleman, fatima; tshilolo, léon; muyembe-tamfum, jean-jacques; zumla, alimuddin; nachega, jean b. title: artemisia spp. derivatives for covid- treatment: anecdotal use, political hype, treatment potential, challenges, and road map to randomized clinical trials date: - - journal: am j trop med hyg doi: . /ajtmh. - sha: doc_id: cord_uid: d za hi the world is currently facing a novel covid- pandemic caused by sars-cov- that, as of july , , has caused a reported , , cases and , deaths. to date, only two treatments, remdesivir and dexamethasone, have demonstrated clinical efficacy through randomized controlled trials (rcts) in seriously ill patients. the search for new or repurposed drugs for treatment of covid- continues. we have witnessed anecdotal use of herbal medicines, including artemisia spp. extracts, in low-income countries, and exaggerated claims of their efficacies that are not evidence based, with subsequent political controversy. these events highlight the urgent need for further research on herbal compounds to evaluate efficacy through rcts, and, when efficacious compounds are identified, to establish the active ingredients, develop formulations and dosing, and define pharmacokinetics, toxicology, and safety to enable drug development. derivatives from the herb artemisia annua have been used as traditional medicine over centuries for the treatment of fevers, malaria, and respiratory tract infections. we review the bioactive compounds, pharmacological and immunological effects, and traditional uses for artemisia spp. derivatives, and discuss the challenges and controversies surrounding current efforts and the scientific road map to advance them to prevent or treat covid- . the unprecedented covid- pandemic caused by the novel zoonotic pathogen of humans, sars-cov- , has, as of july , , caused , deaths of , , confirmed cases reported by the who. although covid- commonly presents as a severe respiratory tract illness, it causes multisystem disease, and deaths have been attributed to cytokine storm, acute respiratory distress syndrome (ards), and excessive aberrant immunological responses. of several recent and ongoing treatment intervention trials, only two randomized controlled trials have to date demonstrated benefits of specific therapies. one study indicated that hospitalized covid- patients who received remdesivir had a % faster time to recovery than those who received placebo. another trial reported that dexamethasone reduced mortality by one-third in seriously ill patients requiring respiratory support. of note, dexamethasone was previously shown to be effective in the treatment of ards. among other drugs initially considered of promise, trials of chloroquine or hydroxycholoroquine plus lopinavir/ritonavir with or without azithromycin have shown no reduction in mortality in hospitalized patients. despite limited success in finding effective treatments months after the first appearance of sars-cov- as a new human pathogen, the desperate quest for new and repurposed drugs to reduce the morbidity and mortality of covid- continues. the anecdotal use of artemisia spp. extracts for covid- treatment in low-income countries has led to exaggerated and unproven claims of its efficacy in the absence of a scientific basis or results from clinical trials. this highlights the urgent need for further research on herbal compounds to evaluate efficacy through controlled trials, and for efficacious compounds, to establish the active ingredients, develop formulations and dosing, and define pharmacokinetics, toxicology, and safety to enable drug development. we discuss the bioactive compounds, pharmacological and immunological effects, and traditional uses for artemisia spp. derivatives, and discuss the challenges and controversies surrounding current efforts to advance them for potential use to prevent or treat covid- . traditional herb-and plant-derived medicinal products are being used and trialed for the treatment of covid- in china. , among many, derivatives from the herb artemisia annua (figure ) have been used as traditional medicine over centuries for the treatment of fevers, malaria, and respiratory tract infections. the "sweet wormwood" plant contains artemisinin (figure ), a medicine developed during the cultural revolution in china. the nobel prize in physiology or medicine was awarded to professor youyou tu for her key contributions to its discovery. the who recommends artemisinin-based combination therapies (acts) as first-line treatments for uncomplicated plasmodium falciparum malaria. results of a small clinical study from china of artesunate, a hemi-synthetic derivative of artemisinin (figure ), for the treatment of covid- reported that artesunate was associated with shorter duration of covid- symptoms ( . ± . versus . ± . days) and hospital stays ( . ± . versus . ± . ) than standard of care. table shows the concentrations of artemisinin and artesunate that can be achieved in the plasma of patients receiving conventional doses of these drugs, and the concentrations needed to inhibit the replication of other viruses or the inflammatory response in vitro. these data suggest that artesunate may offer both antiviral and anti-inflammatory effects at clinically achievable concentrations. , , in april , an herbal tonic derived from a. annua extracts by the madagascar institute of applied research and branded "covid-organics" was launched. covid-organics has been promoted as a cure for covid- . however, reliable pharmacological and efficacy data are lacking, and there is concern that its widespread use for covid- could result in reduced access to effective medicines as well as possible selection of p. falciparum resistance to acts by exposing patients to suboptimal concentrations of artemisinin when malaria cases are misdiagnosed as covid- . of note, the content of artemisinin in a. annua is about %, which means that g of plant material is needed to obtain the equivalent of a -mg therapeutic dose of artemisinin, if considering a % extraction. furthermore, the typical concentration of artemisinin in infusions is around mg/l; l must be ingested to absorb the antimalarial therapeutic dose, which is not feasible. therefore, to avoid the promotion of unproven remedies in this climate of uncertainty and fear, it is important that research into traditional medicinal plants and their derivatives be conducted properly. artemisia annua is an annual herbaceous plant of the asteraceae family native to asia and eastern europe ( figure ). as a. annua is the source for leading whoapproved antimalarials, seed varieties have been adapted by breeding for lower latitudes, and cultivation has been successfully achieved in many tropical countries. artemisia annua is a source of many biologically active compounds, , with more than compounds isolated and identified, including at least monoterpenes, sesquiterpenes, triterpenoids and steroids, flavonoids, seven coumarins, and four aromatic and nine aliphatic compounds. it naturally produces and stores artemisinin in the glandular trichomes on its leaves, stems, and flowers. sesquiterpenes, caryophyllene oxide, caryophyllene, farnesene, and germacrene d are the most abundant chemicals identified in the essential oil of the fruits. artemisinin is a sesquiterpene lactone, containing an unusual endoperoxide group (figure ) which is believed to be responsible for its antimalarial activity. artemisia annua extracts are said to contain antiinflammatory, antioxidant, and antimicrobial substances, and to show antiviral activity. [ ] [ ] [ ] the flavonoids casticin and chrysosplenol d, extracted from a. annua, suppressed the expression of inflammatory mediators through the regulation of nf-κb and c-jun in a murine macrophage cell line, suggesting that these components might be useful in the treatment of inflammatory and infectious disorders. the water-soluble fraction of a. annua, after the extraction of artemisinin, was shown to regulate the expression of proinflammatory cytokines, matrix metalloproteinases, and nf-κb; promote cell cycle arrest; drive reactive oxygen species production; and induce bak or bax-dependent or independent apoptosis. artemisia annua extracts significantly inhibited cytopathy caused by sars-cov strain bj and showed activity against sars-cov- in vero-e cell-based cytopathic effect screening. since the beginning of the covid- pandemic, formulations of a. annua have been used in africa and china for covid- prevention and treatment. in the drc, herbal formulations have been used for the prevention and treatment of covid- by fumigation, infusion, or decoction. it is important to emphasize that there are no controlled data supporting the use of any of these, and their efficacy for covid- is unknown. arguably, natural product research is only relevant to the development of new drugs as a first step to identifying specific molecules with activity. teas cannot function as drugs meeting international standards, as their components are unknown and not standardized. advancing traditional medicines will require identification of active components of plant extracts, methods to yield purified compounds, and determination of compound pharmacology including studies of biological activity, bioavailability, absorption, distribution, metabolism, excretion, and toxicity properties of each molecule. for evaluation of the antiviral effects of herbal formulations, the screening system should meet all requirements of any good assay, including validity, lack of ambiguity, accuracy, reproducibility, simplicity, and reasonable cost. because these requirements are better met by in vitro screening, in vitro bioassays must be used to guide the isolation of active compounds from plant extracts. the antiviral activities of the pure compounds must then be confirmed at a later stage by in vivo assays in appropriate animal models. the who acknowledges that the quantity and quality of safety and efficacy data on traditional medicines are far from sufficient to meet the criteria needed to support their use. the reasons for the lack of research data include inadequate healthcare policies and a lack of accepted research methodology for evaluating traditional medicines. , , at a time when countries are consumed by their own national interests and agendas, the world is looking to natural products to provide readily available, affordable treatments. a cure or treatment for covid- derived from locally grown herbs and plants remains a viable option for some countries and communities. however, to develop drugs rather than crude preparations of herbs and plants, the specific pharmacologically active components need to be isolated, verified through proper pharmacological evaluation, and then possibly optimized through modern (hemi) synthesis strategies before being developed according to rigorous international guidelines for drug development. however, repurposing of available plant-based drugs, for example, artesunate, offers a potential time-and cost-saving approach. indeed, investigators from saudi arabia have registered a placebo-controlled trial (www.clinicaltrials.gov identifier: nct ) to evaluate the efficacy of artesunate in adults with mild symptoms of covid- . as the world desperately searches for new treatments to reduce rates of severe morbidity and mortality from covid- , the promotion of new drug discovery building on extracts from traditional medicinal plants should be encouraged. the anecdotal and unproven use of a. annua for covid- following claims from politicians and others in low-income countries highlights the need for hard data to establish the active ingredients; develop formulations and dosing; define the pharmacokinetics, toxicology, and safety; and evaluate efficacy through controlled trials. coronavirus disease (covid- ) situation report nih clinical trial shows remdesivir accelerates recovery from advanced covid- . press release low-cost dexamethasone reduces death by up to one third in hospitalised patients with severe respiratory complications of covid- . recovery trial press release dexamethasone treatment for the acute respiratory distress syndrome: a multicentre, randomised controlled trial no clinical benefit from use of hydroxychloroquine in hospitalised patients with covid- . press release pay attention to situation of sars-cov- and tcm advantages in treatment of novel coronavirus infection traditional chinese medicine for covid- treatment anti-malarial drug, artemisinin and its derivatives for the treatment of respiratory diseases the effect of malaria control on plasmodium falciparum in africa between guidelines for the treatment of malaria the antiviral activities of artemisinin and artesunate artemisinin inhibits the replication of flaviviruses by promoting the type i interferon production the content of artemisinin in the artemisia annua tea infusion artemisia annua as a traditional herbal antimalarial flavonoids from artemisia annua l. as antioxidants and their potential synergism with artemisinin against malaria and cancer secondary metabolites of artemisia annua and their biological activity chromatographic fingerprint artemisinin chemical research dried leaf artemisia annua improves bioavailability of artemisinin via cytochrome p inhibition and enhances artemisinin efficacy downstream essential oil of artemisia annua l.: an extraordinary component with numerous antimicrobial properties. evid based complement alternat med anti-inflammatory, antioxidant and antimicrobial effects of artemisinin extracts from artemisia annua l antiviral evaluation of herbal drugs. quality control and evaluation of herbal drugs occurrence of some antiviral sterols in artemisia annua flavonoids casticin and chrysosplenol d from artemisia annua l. inhibit inflammation in vitro and in vivo identification of natural compounds with antiviral activities against sars-associated coronavirus a review on identification of antiviral potential medicinal plant compounds against with covid- coronavirus (covid- ): a protocol for prevention and treatment (covalyse ® ) the complexity of medicinal plants: the traditional artemisia annua formulation, current status and future perspectives who supports scientifically-proven traditional medicine authors' addresses: paulin m. kapepula and jimmy k. kabengele, key: cord- -stgx h authors: Ürün, yüksel; hussain, syed a.; bakouny, ziad; castellano, daniel; kılıçkap, saadettin; morgan, gilberto; mckay, rana r.; pels, kevin; schmidt, andrew; doroshow, deborah b.; schütz, fábio; albiges, laurence; lopes, gilberto; catto, james w. f.; peters, solange; choueiri, toni k. title: survey of the impact of covid- on oncologists’ decision making in cancer date: - - journal: jco glob oncol doi: . /go. . sha: doc_id: cord_uid: stgx h purpose: to understand readiness measures taken by oncologists to protect patients and health care workers from the novel coronavirus (covid- ) and how their clinical decision making was influenced by the pandemic. methods: an online survey was conducted between march and april , . results: a total of oncologists from countries participated. the median age was years (range, - years), and the majority were male ( %). at the time of the survey, nearly all participants self-reported an outbreak in their country ( . %). personal protective equipment was available to all participants, of which surgical mask was the most common (n = ; %). telemedicine, in the form of phone or video encounters, was common and implemented by % (n = ). testing patients with cancer for covid- via reverse transcriptase polymerase chain reaction before systemic treatment was not routinely implemented: % reported no routine testing, % performed testing in selected patients, and % performed systematic testing in all patients. the most significant factors influencing an oncologist’s decision making regarding choice of systemic therapy included patient age and comorbidities ( % and %, respectively). although hormonal treatments and tyrosine kinase inhibitors were considered to be relatively safe, cytotoxic chemotherapy and immune therapies were perceived as being less safe or unsafe by participants. the vast majority of participants stated that during the pandemic they would use less chemotherapy, immune checkpoint inhibitors, and steroids. although treatment in neoadjuvant, adjuvant, and first-line metastatic disease was less affected, most of the participants stated that they would be more hesitant to recommend second- or third-line therapies in metastatic disease. conclusion: decision making by oncologists has been significantly influenced by the ongoing covid- pandemic. the severe acute respiratory syndrome coronavirus (sars-cov- ) viral pandemic has affected nearly all sectors of health care globally. , as of june , , . . million people have been diagnosed with the novel coronavirus (covid- ) , and , have died as a result of the disease worldwide. covid- has had a large and negative impact on cancer treatment and research. , there is significant concern that the pandemic could lead to adverse outcomes related to other preexisting conditions, including cancer. this concern is driven by the potential for delayed presentation, diagnosis, and/or treatment that could emanate from patient avoidance of hospital visits, doctors' assumptions about the risk/benefit ratio of every intervention, as well as health care resource reallocation to patients with covid- . [ ] [ ] [ ] [ ] [ ] [ ] [ ] in addition, covid- has already had an impact on cancer research. patients with cancer are considered to be at increased risk from covid- -related complications because of treatment-related immunosuppression, increased comorbidities, and the underlying malignancy itself. , [ ] [ ] [ ] [ ] [ ] [ ] [ ] in addition, they may be more likely to contract covid- secondary to frequent contact with the health system and a high-risk environment for covid transmission. , organizations such as the european society for medical oncology (esmo), asco, the national comprehensive cancer network, and the american association for cancer research (aacr) have published guidelines regarding the precautions and treatment modifications during the pandemic. - we must carefully weigh the uncertainty from the additional risk of infection versus benefit from treatment. although we still ignore the specific vulnerability resulting from various oncological scenarios as well as the variety of anticancer strategies, we do not have adequate knowledge on the long-term impact of current changes in oncologic practice. [ ] [ ] [ ] in this international, web-based survey, oncologists were asked about pandemic-related changes in their clinical practices and personal measures taken to protect their own physical well-being in response to the covid- pandemic. we conducted a global survey of medical oncologists. respondents were contacted through differing distribution channels, including direct e-mail and social media networks such as twitter and oncology-specific groups on facebook. the survey was conducted between march and april , . data collected included demographics, country, practice setting, and years of experience. in addition, the survey tool included questions regarding attitudes of medical oncologists around patient risk factors (age, performance status, comorbidities), administration of types of antineoplastic therapy (cytotoxic therapy, targeted therapy, immunotherapy), and use of therapy in differing settings (neoadjuvant, adjuvant v metastatic). the question "do you perform covid- rt-pcr test before the treatment" was added to the questionnaire on april , . all the data in this survey are collected anonymously, with no personal information (apart from their name and publicly available contact details). the full survey can be accessed at: https://docs.google.com/forms/d/e/ faipqlserbtv bi ml w cfuh cjtljwgpp jp jbp s qc hfz f sa/viewform. the frequencies of all categorical data were calculated. bar plots and stacked bar plots were used to visualize the data. all statistical analyses were carried out using spss version . (ssps, chicago, il). a total of oncologists from countries participated in the survey, and % of responses were received between april and april , . the median age of the participants was years (range, - years), and the majority were male ( %). at the time of the survey, almost all participants stated that there was an outbreak in their country ( . %). most of the participants practiced at a university or academic center ( %) and have . years of experience in practice ( % ; tables and ) . overall, % of participants cared for ≥ patients daily during the pandemic, and % saw ≥ patients. the use of telemedicine among the participants was quite common ( %). all participants stated that they were consistently using personal protective equipment (ppe), of which surgical mask ( %), gloves ( %), and glasses ( %) were most frequently used. n mask usage rate was found to be % (fig ) . because the question "do you perform covid- rt-pcr test before the treatment" was added to the questionnaire after the initial inception of the questionnaire, only answers were received. although % stated that they did not perform routine testing, % stated that they performed reverse-transcriptase polymerase chain reaction (rt-pcr) tests in selected patients and % in all patients. when asked about factors affecting treatment decision making, participants stated patient age and concomitant diseases were influential factors ( % and %, respectively; fig ) . regarding perceptions about the safety of antineoplastic therapy, hormonal treatments and tyrosine kinase inhibitors (tkis) were considered to be relatively safe, but cytotoxic chemotherapy and immune therapies context key objective does covid- influence the decision-making process of oncologists? knowledge generated in this international survey including oncologists from countries, the most commonly used personal protective equipment was the surgical mask. telemedicine is being increasingly used. the most significant factors influencing an oncologist's decision making regarding the determination of treatment were patient age and comorbidities. hormonal treatments and tyrosine kinase inhibitors were considered to be relatively safe, but cytotoxic and immune therapies were perceived as being less safe or unsafe by respondents. likewise, neoadjuvant, adjuvant, and first-line metastatic disease was less affected, but most of the participants stated that they would be more reluctant to recommend second-or third-line therapies in the metastatic setting relevance during the pandemic, the decision-making process of oncologists is significantly affected. international collaboration and prospective studies are critical in providing a stronger evidentiary basis for making these decisions. impact of covid- on oncologists' decision making in cancer were considered less safe or unsafe (fig ) . most participants stated that during the pandemic they would use less chemotherapy, anti-ctla- antibody, anti-pd- or pd-l antibodies, and corticosteroids. however, participants did not express alterations in prescribing patterns for hormonal therapies, tkis, and bone-modifying agents (fig ) . a total of % of the participants stated that they would use granulocyte colony-stimulating factor (g-csf) more frequently. in general, the decision to reduce use across all therapy categories was expressed by participants. the degree of therapy reductions was less pronounced for use of therapy in the neoadjuvant and adjuvant setting. second-and thirdline treatment use for metastatic disease was dramatically reduced across survey participants ( fig ) . we asked participants whether they would modify systemic treatment dosing, schedules, and context of use (figs and ). no significant differences in demographic, preventive, or practice-related data were seen among participants of different nationalities. the covid- pandemic has resulted in changes in the delivery of cancer care. , , , , , [ ] [ ] [ ] since its emergence, covid- has rapidly crossed all borders and affected health care networks globally. health care systems and medical professionals have been propelled to respond to the evolving and complex situation, with some of them being rapidly overwhelmed by a sudden high number of cases requiring health care resource reallocation. given early data suggesting that patients with cancer may be at substantially higher risk of covid- -related complications, medical oncologists face unique challenges in continuing to meet the needs of both patients and staff during this unprecedented pandemic. this survey provides important context of the readiness measures and perceptions of medical oncologists during the initial stages of the pandemic. our results demonstrate that, although oncologists are trying to continue treating their patients on the basis of guidelines, despite the lack of evidence regarding covid- -related risk at the time of this study, they have made important modifications in usual practice. although neoadjuvant and adjuvant treatments in curative settings are less affected, a decrease in treatment of metastatic disease is expected based on our survey. hormonal treatments are generally considered safer, and there is no anticipated change in delivery of these therapies. on the other hand, there is no consensus about the safety of monoclonal antibodies and immunotherapies among oncologists surveyed. although most recent data suggest that giving immune checkpoint inhibitors (icis) to covid- -positive patients with cancer is safe, , , it is highly probable that the oncological community has acted with caution and reserve regarding initiation or maintenance of such treatments during the last months, potentially affecting patient outcomes. telemedicine has been implemented at a low rate over the decade, but it has become increasingly useful while mobility is reduced and social distancing is mandated for pandemic control. , in our survey, % of the participants stated that they used telemedicine in some form yes, all patients ( ) use of g-csf more than before ( ) no change ( ) note. data are presented as % (no.) or median (range). abbreviations: g-csf, granulocyte colony-stimulating factor; rt-pcr, reversetranscriptase polymerase chain reaction. a n = responses available for this variable.Ü rün et al during this pandemic. however, the adaptation of the legal infrastructure and reimbursement systems for telemedicine are still ongoing. in addition, it is necessary to keep in mind some difficulties. limited use of phones, smartphones, or internet access may be a barrier, especially in rural areas, as well as for elderly patients. we will need to develop strategies to overcome these issues with care delivery. sars-cov- is a highly transmissible virus, and health care professionals have been at the forefront of workers with the highest risk of infection. recently, the infectious diseases society of america published a guideline on ppe that should be used for the protection of health care workers. the vast majority of survey participants stated that they used surgical masks. although only % of respondents described using n masks, the survey did not capture the proportion of respondents who had access to n masks while caring for patients known to have covid- , which is recommended, especially while doing invasive procedures such as intubation, bronchoscopy, and any airway-related manipulations. unfortunately, severe shortages of ppe globally have created significant challenges. , a significant proportion of patients with covid- are asymptomatic, increasing the risk of recommending active cancer treatment during the pandemic. [ ] [ ] [ ] furthermore, the pcr-based test used for the diagnosis of covid- is currently of suboptimal accuracy; in some cases where radiologic covid- is considered, the pcr test may be negative. however, there is no recommendation as to whether routine pcr testing should be required. testing availability and defining populations in which screening tests should be performed for asymptomatic patients and diagnostic tests for symptomatic patients remains a challenge globally. also, developing workflows to operationalize testing in a safe manner for patients and health care works will be critical in mitigating viral spread. the case fatality rate increases in the elderly population and in patients with comorbidities such as diabetes mellitus, hypertension, and cancer. , , , , , [ ] [ ] [ ] however, current data regarding cancer and covid- remain elusive. in a recent meta-analysis by desai et al, the overall pooled prevalence of cancer in patients with covid- was . %, suggesting at least a doubling of the risk compared with the general population. given the heterogeneity present among oncology patients, population-based estimates may not estimate an individual's risk. when making treatment decisions in patients with cancer, oncologists consider a patient's age, performance status, and concomitant diseases, among many factors. this individualized approach will be central to carefully evaluating the risk/benefit profile of anticancer treatments during the pandemic. in our study, % of participants stated that age would affect their treatment decisions, and % stated that the presence of concomitant diseases would do so. considered together, age, eastern cooperative oncology group (ecog) performance status ≥ , or the presence of chronic obstructive pulmonary disease (copd) influenced . % of the participants' treatment decisions. conventionally, curative cancer treatment often involves neoadjuvant and/or adjuvant systemic treatment. although there is a modest decrease in the use of neoadjuvant therapy compared with the prepandemic period-which may correspond to a delay from some surgical interventions during the pandemic-and a marked % reduction in adjuvant treatment use, treatment practices are being carried out with relative preservation of dose density and intensity in the curative setting. for patients with metastatic disease, % of the participants stated that they would offer first-line treatment less frequently, and in case of systemic treatments, % of the participants stated that they would decrease the number of cycles of chemotherapy to be given. during the pandemic, it is perceived as essential to administer curative treatments as much as possible. however, in the case of treatment regimens for which the incremental benefits are low and the risk of infection is high, such as second-and third-line therapy for metastatic disease, it sounds more reasonable to colleagues to curtail use to maximize survival in a patient population that may be more debilitated at baseline. largely, these decisions are highly individualizing. it has become a priority to discuss and refine the multiplicity of parameters for decision making within our community as well as with the patients. the magnitude of expected clinical benefit should be evaluated for each intervention. although some groups have attempted to develop standardized guidelines, these are not evidence based, given the unprecedented nature of the pandemic. such evidence-based statements will need multivariable analyses of extremely large numbers of patients with cancer. interestingly, hormonal treatments are generally considered safe. because there are sex differences in susceptibility and vulnerability to covid- , several hypotheses related to the androgen pathway have been proposed. two different studies suggest that the use of antiandrogens may be protective for covid- in patients with prostate cancer. , in this survey, a significant part of the participants ( %) stated that they considered hormonal treatments safe. immunotherapy has rapidly become part of the standard treatment protocols for many cancers, including melanoma, lung, kidney, and bladder. however, icis can cause severe immune-mediated toxicity, such as pneumonitis, colitis, hepatitis, and endocrine disorders. because management of ici toxicity rarely requires the use of immunosuppressive steroids, we see some reluctance among clinicians to prescribe icis during the covid- pandemic. there is concern that icis can increase the severity of the disease because of their immunomodulatory properties. although almost half of the participants were reticent about whether they were safe or not, one-third of them stated that they did not think it was safe. however, there is currently paucity of data regarding icis and covid- . the aacr national meeting featured covid- and cancer special sessions. data presented by barlesi et al from patients with cancer and covid- who were treated at gustave roussy showed that an ecog performance status . , hematologic malignancies, and chemotherapy within the past months were associated with worse outcomes; however, immunotherapy or targeted agents in the past months did not associate with the deterioration of the covid- clinical course. in contrast to this study, in the study, being . years of age and undergoing treatment with icis within days were predictors for hospitalization and severe disease. however, in a recent study, which was also from mskcc, including patients with covid- and lung cancer, pd- blockade was not associated with the severity of covid- . the us food and drug administration has approved doses of nivolumab administered every weeks and pembrolizumab every weeks. this will be more convenient in terms of reducing the frequency of patients coming to the hospital. in the study presented by zhang et al, having cancer treatment in the last days was found to be associated with a more serious clinical course of covid- . in the follow-up of patients who received icis, only patient had covid- , and their clinical course was mild. in another recently published large cohort study from china, hematologic malignancy, lung cancer, or metastatic cancer (stage iv) were associated with increased frequency of severe events. there were no differences regarding the severity of covid- between patients with nonmetastatic cancer and patients without cancer. the first results of the teravolt (thoracic cancers international covid- collaboration) were also presented during aacr . data from patients with thoracic cancer were examined, revealing that the presence of copd was associated with hospitalization and multiple comorbidities associated with hospitalization and death risk. however, tumor type and cancer therapy did not affect survival. in our survey, % of oncologists stated that they used more g-csf than before. using g-csf can protect patients from hospitalization through reducing the risk of neutropenic fever. patients who required intensive care unit admission because of covid- showed a higher percentage of gm-csf+ cd + t cells, suggesting excessive activation of the immune response by g-csf may promote our study has several limitations. the limited number and format of questions does not provide an in-depth quantitative analysis of some common clinical practices. however, we expected the brevity would increase response rate and reliability. in addition, we cannot confirm that all participants were medical oncologists, and although conducted globally, the survey does not evenly represent all countries this report serves as a pilot study to learn general approaches and immediate reactions of oncologists at this point in the covid- pandemic and to identify difficulties and uncertainties in clinical decision making that would benefit from clearer guidance on the basis of reliable data. many uncertainties exist with regard to covid- and infection in patients with cancer. the risk/benefit ratio of the decisions we make and the expected benefit of everything we do have become essential arguments and limiting factors at the time of covid- . counterintuitively, the absolute benefit of an adjuvant therapy can sometimes be modest in a curative setting, while it can be major in some metastatic cancers where the palliative versus curative impact of immunotherapy can be disputed. ongoing research is essential to improve our understanding of the disease and optimize health care delivery strategies for patients with cancer. this survey provides an important context to assess current physician readiness and attitudes about care delivery during the pandemic. the covid- pandemic has affected, and continues to affect, both patients and oncologists in a variety of ways. as in all oncological practice, it is critical that each patient be evaluated on an individual basis, and the risk/benefit ratio of any proposed therapy must be evaluated by a patient's treating oncologist. although esmo and asco have published general guidelines to oncological practice, it is impossible to provide recommendations for each clinical scenario. for this reason, it is more important than ever that colleagues continue to systematically discuss their patients in tumor board settings. in addition, it is essential that the oncology community gather comprehensive, rigorous data to further improve the clinical decision-making process during this unprecedented moment. the covid- and cancer consortium, a multicenter, voluntary registry collecting and examining data on risk factors and outcomes of patients with cancer who develop covid- , will play an important role in understanding how baseline characteristics and systemic treatment modalities affect the risk of severe covid- . , we hope, as our experience, collaboration, and knowledge sharing improve, that we will be able to more effectively manage this outbreak with more evidencebased interventions and treatments. exelixis (inst) adaptimmune (inst), bms (inst), gsk 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of pd- blockade on severity of covid- in patients with lung cancers covid- and health care's digital revolution virtually perfect? telemedicine for covid- airborne or droplet precautions for health workers treating covid- ? sars-cov- infection in health care covid- in south korea-challenges of subclinical manifestations transmission of -ncov infection from an asymptomatic contact in germany substantial undocumented infection facilitates the rapid dissemination of novel coronavirus (sars-cov- ) false-negative of rt-pcr and prolonged nucleic acid conversion in covid- : rather than recurrence controversies about covid- and anticancer treatment with immune checkpoint inhibitors clinical characteristics of patients who died of coronavirus disease in china risks from deferring treatment for genitourinary cancers: a collaborative review to aid triage and management during the covid- pandemic covid- and cancer: lessons from a pooled meta-analysis androgen-deprivation therapies for prostate cancer and risk of infection by sars-cov- : a population-based study (n = ) impact of anti-androgenic therapies on covid- : an observational study in male population from a covid- regional centre of lombardy (italy) treatment of the immune-related adverse effects of immune checkpoint inhibitors: a review determinants of severity in cancer patients with covid- illness pathogenic t cells and inflammatory monocytes incite inflammatory storm in severe covid- patients ethics and resource scarcity: asco recommendations for the oncology community during the covid pandemic crowdsourcing a crisis response for covid- in oncology we thank all health care professionals working in this difficult pandemic period, risking their own lives. we also thank all the physicians who participated in the global survey and shared their opinions about their daily practices. key: cord- - g sjnl authors: nabil, ahmed; uto, koichiro; elshemy, mohamed m.; soliman, reham; hassan, ayman a.; ebara, mitsuhiro; shiha, gamal title: current coronavirus (sars-cov- ) epidemiological, diagnostic and therapeutic approaches: an updated review until june date: - - journal: excli j doi: . /excli - sha: doc_id: cord_uid: g sjnl coronaviruses are a group of enveloped viruses with non-segmented, single-stranded, and positive-sense rna genomes. in december , an outbreak of coronavirus disease (covid- ) caused by the novel severe acute respiratory syndrome coronavirus (sars-cov- ), in wuhan city, china. the world health organization (who) declared the coronavirus outbreak as a global pandemic in march . fever, dry cough and fatigue are found in the vast majority of all covid- cases. early diagnosis, treatment and future prevention are keys to covid- management. currently, the unmet need to develop cost-effective point-of-contact test kits and efficient laboratory techniques for confirmation of covid- infection has powered a new frontier of diagnostic innovation. no proven effective therapies or vaccines for sars-cov- currently exist. the rapidly increasing research regarding covid- virology provides a significant number of potential drug targets. remdesivir may be the most promising therapy up till now. on may , , gilead sciences, announced that the u.s. food and drug administration (fda) has granted emergency use authorization (eua) for the investigational remdesivir as a potential antiviral for covid- treatment. on may , , gilead sciences, announced that the japanese ministry of health, labour and welfare (mhlw) has granted regulatory approval of veklury® (remdesivir) as a treatment for sars-cov- infection, the virus that causes covid- acute respiratory syndrome, under an exceptional approval pathway. also, corticosteroids are recommended for severe cases only to suppress the immune response and reduce symptoms, but not for mild and moderate patients where they are associated with a high-risk side effect. based on the currently published evidence, we tried to highlight different diagnostic approaches, side effects and therapeutic agents that could help physicians in the frontlines. in december , a novel coronavirus, sars-cov- , was identified as the pathogen causing coronavirus disease in wuhan, china. on march , , the world health organization declared covid- as a global pandemic (whitworth, ) . covid- is an enveloped, positivesense, single-stranded rna virus that belongs to the beta-cov genus, which also includes sars-cov and mers-cov. it shares % nucleotide identity with bat sars-like covzxc and % identity with human sars-cov (chan et al., a) . covid- is transmitted by inhalation or contact with infected droplets. the incubation period for covid- is on average, - days, but can be up to days. during this period, also known as the "presymptomatic" period, some infected persons can be contagious, from - days before symptom onset (wei et al., ) . the clinical manifestations of covid- varied from asymptomatic carrier status, acute respiratory disease (ard) and pneumonia. the prevalence of asymptomatic cases is significant ( - % of all infections) and is defined as individuals with positive viral nucleic acid tests but without any covid- symptoms. most people with covid- develop only mild ( %) or moderate ( %) disease, approximately % develop a severe disease that requires hospitalization and oxygen support, and % have a critical disease with complications such as respiratory failure, acute respiratory distress syndrome (ards), sepsis and septic shock, thromboembolism, and/or multiorgan failure, including acute kidney injury and cardiac injury (cdc, b) older age, co-morbidities such as diabetes, hypertension, cardiac disease, chronic lung disease, cancer and bmi > kg/m have been reported as risk factors for severe disease and death (cdc, a) . wang and colleagues ( a) reported that there are common signs and symptoms that % of the patients have felt including fever ( . %), fatigue ( . %), dry cough ( . %), anorexia ( . %), myalgia ( . %), dyspnea ( . %) and for the most common comorbidities are hypertension ( . %) and cardiovascular disease ( . %). symptoms may develop days to weeks following exposure to the virus (cdc, b). according to wu and mcgoogan ( ) , among , sars-cov- cases reported to the chinese center for disease control and prevention (ccdc), % were mild (mild or absent pneumonia), % were severe (dyspnea, hypoxia, > % lung involvement within - days), % were critical (respiratory failure, shock, multiorgan dysfunction), and . % were fatal. symptoms in children with infection appear to be uncommon, although some children with severe covid- have been reported (cdc, a) . based on currently available information and clinical expertise, risk factors for severe covid- include older adults ≥ years as well as people of all ages with chronic lung disease or moderate to severe asthma, serious heart conditions, diabetes, severe obesity, chronic kidney disease, liver disease and immunocompromised people (cdc, a). upon infection with covid- , it binds to the host cell's angiotensin-converting enzyme (ace ) receptors which commonly expressed on the epithelial cells of alveoli, trachea, bronchi, and bronchial serous glands of the respiratory tract. then the virus enters and replicates in these cells (liu et al., ) . the newly developed virions are then released and infect new target cells. unfortunately, there is no specific antiviral treatment or vaccine recommended for covid- that is currently available. according to the european centre for disease prevention and control (ecdc), since december and as of june , , , cases of covid- have been reported including, most cases in america (n = ) were reported from the united states ( , , ), brazil ( , ) and peru ( , ) , followed by europe (n = , , ): most cases were reported in russia ( , ), united kingdom ( , ) and spain ( , ) , asia (n = ): most cases were in india ( , ), iran ( , ) and turkey ( , ), africa (n = ): most cases were in south africa ( , ), egypt ( , ), nigeria ( , ), oceania (n = ): most cases were in australia ( , ), new zealand ( , ) and guam ( ) ( figure ), including , deaths, most deaths in america (n = , ) were reported from the united states ( , ), brazil ( , ) and mexico ( , ) , followed by europe (n = ): most deaths were in united kingdom ( , ), italy ( , ) and france ( , ), asia (n = ): most deaths were in india ( , ), iran ( , ) and turkey ( , ), africa (n = ): most deaths were in egypt ( , ), south africa ( , ) and algeria ( ), oceania (n = ): most deaths were in australia ( ), new zealand ( ) and guam ( ) (ecdc, ). the countries that beat covid- were divided into three groups as follows: countries beating covid- : green plots (figure ), countries that are nearly there: yellow plots ( figure ) and countries that need to take action: red plots (figure ) . these plots adjusted for each country to better show the data. the vertical axis is plotted in arbitrary units, to easily compare the shapes of the curves (endcoronavirus, ). the diagnosis of covid- mainly depends on the demonstration of the virus in respiratory secretions by special molecular tests. common laboratory findings include normal/ low white cell counts with elevated c-reactive protein (crp). the computerized tomographic chest scan is usually abnormal even in those with no symptoms or mild disease (singhal, ) . in addition to laboratory testing capacity and reagent shortages, the rapidly growing sars cov pandemic has encouraged many diagnostic manufacturers to develop and sell fast and easy-to-use equipment to facilitate testing outside the laboratory (who, a). currently, there are two main categories commercially available for covid- tests. the first category includes molecular assays for detection of sars-cov- viral rna using polymerase chain reaction (pcr)-based methods. the second category includes serological and immunological assays that largely depend on detecting antibodies produced by individuals as a result of exposure to the virus or on the detection of antigenic proteins in infected individuals. it is necessary to ensure that these two categories of tests serve overlapping purposes in the management of the sars-cov- pandemic (carter et al., ) . current covid- diagnostic tools and techniques are shown in table and a diagnostic model for covid- in figure . symptomatic treatment and oxygen therapies represent the major treatment interventions for patients with severe infection. mechanical ventilation may be necessary in cases of respiratory failure refractory to oxygen therapy, whereas hemodynamic support is essential for managing septic shock (cascella et al., ) . to the best of our knowledge, different therapeutic approaches have been evaluated against covid- in vivo, vitro and in clinical trials. many of these therapies had a great impact on clinical recovery. current covid- therapies are shown in table . both sars and sars-cov- invade the cell through the ace receptor. sars-cov reduces ace expression, causing an imbalance between the ace/ang ii/at r axis and the ace /ang ( - )/mas receptor axis. a novel therapeutic strategy for hypertension targets the ace/ang ii/at r axis. angiotensin-converting enzyme inhibitors (aceis) and agents acting on the renin-angiotensin system (aras) inhibit the ace/ang ii/at r pathway in addition to modulation of the ace /ang ( - )/mas receptor pathway. covid- patients observed to have a dysfunction in the renin-angiotensin system (ras). it was also noticed that acei/angiotensin-receptor blockers (arb) had the potential to decrease the viral load, regulate immune function and inhibit inflammatory responses. mscs transplantation improved the outcome of covid- patients. these findings may be due to regulating inflammatory response and promoting tissue repair and regeneration, where mesenchymal stem cells are blank cells that can differentiate into most cellular types in addition to their paracrine fashion of cytokines and growth factors that dampen inflammation and cell death. leng et al., tocilizumab well-known recombinant humanized anti-human interleukin- receptor monoclonal antibody that is mainly used for rheumatoid arthritis patients. in covid- infection, a massive number of t-lymphocytes and mononuclear macrophages are activated, emitting different cytokines such as interleukin- (il- ), which binds to the il- receptor on its target cells, causing the cytokine storm and severe inflammatory responses in most organs including lungs, liver, kidney and other tissues and organs. tocilizumab can specifically bind soluble interleukin- receptor (sil- r) and membrane-bound interleukin- receptor (mil- r) and inhibits their signal transduction. human monoclonal antibody coronavirus neutralizing antibodies target the viral trimeric spike (s) glycoproteins that exist on the viral surface and mediate viral entry into the host cells. li et al., baricitinib most viruses invade cells through receptor-mediated endocytosis. ace is the receptor that covid- uses to infect lung cells. ace is a cell surface protein that distributed many cells including kidney, blood vessels, heart, and, especially, lung at alveolar epithelial cells. at cells are mainly prone to viral infection. one of the known regulators of endocytosis is the ap -associated protein kinase (aak ). disruption of aak might, in turn, interrupt the passage of the virus into cells and also the intracellular assembly of virus particles. baricitinib with therapeutic dosage ( mg or mg once daily) is sufficient to inhibit aak . covid- recovered patients' convalescent plasma covid- recovered patients' convalescent plasma contains a huge quantity of covid- monoclonal antibodies. so, direct administration of covid- recovered patients' convalescent plasma might suppress viremia. several studies showed a shorter hospital stay and lower mortality rate in convalescent plasma-treated patients than those who were not treated with it. chen et al., nelfinavir was recommended to be used as a potential therapy for covid- through inhibition of its main protease using an integrative approach combining molecular docking, homology modeling and binding free energy calculation. regulation of interferon production the dna sensor cyclic gmp-amp synthase (cgas), anaplastic lymphoma kinase (alk) and stimulator of interferon genes (sting) were suggested to be potential therapeutic effective targets preventing the cytokine storm during covid- infection. hucmscs have shown significant tissue repair and immunomodulation with a low immunogenic effect that makes these cells very ideal candidates for the allogenic adoptive transfer therapy. hucmscs were also suggested to be a potential treatment for h n infectioninduced acute lung injury. covid- showed a similar inflammatory cytokine profile to that of h n . liang et al., cd-sace inclusion compounds the main receptors for sars-cov and sars-cov- are ace soluble ace (sace ) retaining ace enzyme activity in addition to binding sars-cov s-protein. so sace can inhibit sars-cov infected cells. since sars-cov and sars-cov- infection mechanisms are the same, sace can inhibit the infection of sars-cov- . to improve the water solubility of sace , the formation of a complex between cd and sace would be effective and enables it to meet drug atomization inhalation requirements. sun et al., b favipiravir (avigan®) favipiravir is a pyrazine carboxamide broad-spectrum antiviral drug that has been approved in japan for influenza treatment. it is a prodrug that is phosphorylated and ribosylated intracellularly to form its active metabolite (favipiravir ibofuranosyl - ′-triphosphate) that acts as a competitive inhibitor for viral purine nucleosides in addition to inhibition of rna-dependent rna polymerase (rdrp) of rna viruses. finally, it interferes with viral replication. du and chen, ivermectin fda-approved for parasitic infections treatment. caly et al. reported that ivermectin has the potential to inhibit covid- in vitro by interfering with the nuclear import of host and viral proteins, where its single treatment was able to cause ~ -fold reduction in covid- virus after h in cell culture model. orally bioavailable prodrug (β-d-n -hydroxycytidine- '-isopropyl ester) has been reported to improve pulmonary function and reduces covid- titer through induction of transition mutation frequency in viral rna causing lethal mutagenesis of covid- . sheahan et al., atazanavir atazanavir inhibits the activity of covid- essential protease, causing a decline of viral replication in addition to its ability to stop the cytokine storm-associated mediator releasing. so, it acts both as an anti-inflammatory and antiviral candidate. fintelman-rodrigues et al., it has a protective effect on lung tissue by inhibiting nf-κb expression in lung tissues, inhibition of il- and tnf-alpha as proinflammatory cytokines and induction of anti-inflammatory cytokine il- . hadadi et al., ribavirin it is a guanosine analog that interferes with rna and dna virus's replication through interference with viral polymerases and interference with rna capping. it was shown to have limited value for the treatment of covid- as monotherapy with high cytotoxicity but when used in combination with other agents it provided the best chance for clinical efficacy. graci and cameron, ; sanders et al., corticosteroids corticosteroids are mainly used for decreasing the host inflammatory responses into the lungs which may lead to acute lung injury and acute respiratory distress syndrome (ards) but corticosteroids may have adverse effects, including delayed viral clearance and the high risk of secondary infection. moreover, direct evidence for corticosteroids in the treatment of covid- is limited. russell et al., lianhuaqingwen (anti-viral and anti-inflammatory) traditional chinese medicine that has been previously used for influenza treatment with broad-spectrum anti-influenza effects. lianhuaqingwen was found to inhibit covid- replication in vitro with a significant reduction in pro-inflammatory cytokines (tnf-α, il- , ccl- /mcp- and cxcl- /ip- ). anticoagulant treatment low molecular weight heparin appears to be associated with better prognosis in severe covid- patients meeting sic criteria or with markedly elevated d-dimer. an interventional clinical trial on participants in xijing hospital showed that the early use of aspirin in covid- patients, which has the effects of inhibiting virus replication, anti-platelet aggregation, anti-inflammatory and anti-lung injury, is expected to reduce the incidence of severe and critical patients, shortens the length of hospital duration and reduces the incidence of cardiovascular complications. tang et al., ; clinicaltrials.gov, despite the approved beneficial effects of these therapeutic approaches, recent studies concluded that most of these candidate's administration has a toxic effect in overdoses, causing common and severe adverse effects including nausea, pruritus, arrhythmias, hypoglycemia, anemia, jaundice, hyper-lipidemia, electrolyte abnormalities, acute renal injury, hematological disorders, hyperuricemia, neuropsychiatric effects and various drug-drug interactions. chloroquine (cq) interferes with ventricular repolarization that increases the risk of torsades de pointes (tdp) and may cause sudden cardiac death (ursing et al., ) , also it causes neuropsychiatric manifestations in-cluding confusion agitation, psychosis, mania, hallucinations, paranoia, suicidal ideation, depression, insomnia and catatonia (aneja et al., ) as well as severe hypoglycemia (el-solia et al., ) . moreover, cq has severe immunological mediated adverse effects including drug reaction with eosinophilia and systemic symptoms (dress) (girijala et al., ) , stevens-johnson syndrome (leckie and rees, ) and toxic epidermal necrolysis (cameron et al., ) . lopinavir/ritonavir (lpv/r) combination has been reported to have gastrointestinal disorders, so in some sars-cov- patients, the treatment was stopped due to these severe side events (owa and owa, ) . notwithstanding the minimal side effects of teicoplanin, it may cause thrombocytopenia in some treated cases (terol et al., ) . a recent clinical trial regarding remdesivir with severe covid- patients concluded that adverse events including hypokalemia, constipation, hypoalbuminemia, anemia, jaundice, hyperlipidemia, liver enzyme elevation and thrombocytopenia were reported (wang et al., c ). an exploratory randomized controlled trial assessing the efficacy and safety of arbidol in covid- patients reported that patients had adverse events including diarrhea, nausea and loss of appetite (eikenberry et al., ) , also hypotension, acute renal injury, teratogenicity, hypersensitivity, electrolyte abnormalities, fatigue, diarrhea, weakness, anemia and chest pain are the most common risk factors during treatment of covid- patients using inhibitors of the renin-angiotensin system (ingraham et al., ) . zhang and colleagues ( ) reported that intravenous transplantation of wharton's jelly derived mesenchymal stem cells (hwjcs) was safe and effective especially, in covid- critical severe cases. regarding tocilizumab that was used as a treatment for severe covid- cases, it may cause serious adverse reactions, like intestinal perforation, candidiasis and lipid metabolism abnormalities (tao et al., ) . fda has approved convalescent plasma therapy in covid- critical patients, but up till now, only three studies with small sample size reported effectiveness and safety so more clinical trials are needed to ensure both safety and efficacy (bloch et al., ) . otherwise direct-acting antivirals (daas) demonstrated, a safe therapeutic approach with common side effects including fatigue, headache, nausea and neuropsychiatric symptoms (medeiros et al., ) . concerning using of favipiravir (avigan®) as a treatment for covid- patients, it was reported that favipiravir elevates plasma uric acid, so this finding should be considered in hyperuricemia, gout and kidney impairment patients (mishima et al., ) . despite the beneficial effect of corticosteroids with covid- patients, they are associated with a high risk of death, side effects like bacterial infections and hypokalemia so they are not recommended for mild and moderate covid- patients, but they should be used in severe cases only to suppress the immune response and reduce symptoms . glucose- -phosphate dehydrogenase (g pd) deficiency is one of the most common human enzymatic disorders affecting around million people worldwide (luzzatto and arese, ). decreased g pd production results in low levels of nadph and reduced glutathione stimulating hemolytic anemia which is characterized by oxidative stress and red blood cell lysis (francis et al., ) . the risk of hemolytic anemia should be considered during chloroquine/hydroxy chloroquine (cq/hcq) therapy of patients with g pd deficiency (mohammad et al., ) . beauverd and colleagues ( ) reported that sars-cov- infection can enhance severe acute hemolysis in patients with g pddeficiency, and cq/hcq can worsen this crisis. during the treatment of sars-cov- , it is important to carefully monitor potential hemolytic effects of cq/hcq in g pd deficiency cases. if a decline in hemoglobin levels during the first days of cq/hcq treatment is observed, the treatment should be stopped. hemolysis usually is reversible after finishing therapy with cq/hcq (de franceschi et al., ) . also, kapoor and kapoor ( ) warned of the use of cq because of the risk of hematological disorders in patients with g pd deficiency. in contrast, both (youngster et al. ; beutler ) concluded that cq or hcq mono-therapies are safe also in g pd deficient cases. afra and colleagues ( ) reported that infections might be the most common causes of hemolysis in g pd deficient patients. thus, sars-cov- patients may show significant hemolysis even before cq or hcq administration. finally, sars-cov- treatment using cq or hcq, especially in areas with high g pd deficiency prevalence, should alert medical staff to this possible harmful effect. the us food and drug administration warned of cardiotoxicity caused by hydroxychloroquine and mentioned g pd as a baseline test before the onset of hydroxychloroquine treatment (fda, ) . moreover, in july the who discontinued clinical trials with hydroxychloroquine and lopinavir/ritonavir treatment arms for covid- (who, b), where both therapies produced little and no reduction in the mortality of hospitalized sars-cov- cases when compared to standard of care. finally, covid- pandemic is a highly infectious disease caused by the novel coronavirus sars-cov- that can be transmitted through droplets and close contact and repre-sents a global public health crisis. fever, fatigue and dry coughs are the most common signs and symptoms of covid- . due to rapid transmission, countries around the world should increase attention to disease surveillance systems. spr gold nanoparticlebased biosensors may be a promising diagnostic technique as it had high sensitivity, selectivity, reliability, portability, is rapid and cheap, but this method is an indirect method, where it detects antibody, so developing of spr biosensor to detect covid- itself still is a great challenge. no proven effective therapies or vaccines for sars-cov- currently exist. the most promising therapy up till now maybe remdesivir, also we recommend corticosteroids therapy for severe cases only to suppress the immune response and reduce symptoms, but not for mild and moderate patients where they are associated with high-risk side effects. g pd should be considered as a baseline test for starting cq or hcq treatment protocol to avoid its possible hemolytic effect. we should further strive to develop specific medications, support the research and development of vaccines, and also decrease morbidity and death of sars-cov- to preserve the population. ahmed doubtful 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important lessons from the coronavirus disease (covid- ) outbreak in china: summary of a report of cases from the chinese center for disease control and prevention effective treatment of severe covid- patients with tocilizumab nelfinavir was predicted to be a potential inhibitor of -ncov main protease by an integrative approach combining homology modelling, molecular docking and binding free energy calculation the effect of corticosteroid treatment on patients with coronavirus infection: a systematic review and meta-analysis medications and glucose- -phosphate dehydrogenase deficiency intravenous infusion of human umbilical cord wharton's jelly-derived mesenchymal stem cells as a potential treatment for patients with covid- pneumonia protease inhibitors targeting coronavirus and filovirus entry all authors express their great gratitude for researchers, physicians, nurses, health care technicians and all co-workers in the frontlines in egypt, japan and any spot of the globe who spend their life during fighting this the authors declare that they have no conflict of interest. key: cord- -jx ws b authors: gong, yuan; guan, li; jin, zhu; chen, shixiong; xiang, guangming; gao, baoan title: effects of methylprednisolone use on viral genomic nucleic acid negative conversion and ct imaging lesion absorption in covid‐ patients under years old date: - - journal: j med virol doi: . /jmv. sha: doc_id: cord_uid: jx ws b the use of corticosteroids has been controversial in viral pneumonia. in most cases, application of methylprednisolone in severe and critical viral pneumonia patients can quickly alleviate the symptoms of dyspnea and prevent disease progression. however, some scholars have confirmed that corticosteroids delayed the body's clearance of the virus. in our retrospective non‐randomised study, patients under years old and diagnosed with coronavirus disease (covid‐ ) were included, according to given methylprednisolone treatment (n = ) or not (n = ), they were separated into groups. by comparing the clinical data we concluded that corticosteroids therapy can effectively release covid‐ symptoms such as persistent fever and difficult breathing, improve oxygenation and prevent disease progression. however, it can prolong the negative conversion of nucleic acids. this article is protected by copyright. all rights reserved. in yi chang city, hu bei province, the first outbreak of covid- commenced on january in the yichang third people's hospital. with persons becoming infected and the increasing number of covid- patients, the medical resources of the yichang third people's hospital were in short supply. in this case, jiangnan district of yichang central people's hospital has been put into use urgently, and nearly percent of covid- confirmed patients in yichang have been treated in our hospital. until date, this highly contagious respiratory disease has caused infections worldwide, countries have found confirmed patients until april [ ] . unfortunately, there is no specific drug for this disease at present. as one of the drugs for the treatment of interstitial pneumonia, corticosteroid have been studied in many epidemic viral pneumonia. arabi ym et al [ ] found that corticosteroid therapy can relieve respiratory symptoms in middle east respiratory syndrome (mers) patients, and this treatment was not related to mortality, but related to mers coronavirus rna clearance replacement. peiris js et al [ ] reported that corticosteroid treatment in early stage of severe acute respiratory syndrome (sars) was associated with a higher subsequent plasma viral load. christian b [ ] analyze the clinical impact of corticosteroids therapy on h n influenza-related ards patients and found no beneficial effect. during the progression of viral pneumonia, an outbreak of inflammation may cause acute respiratory distress syndrome (ards). despite the controversial role of corticosteroids, they are often used as a supportive approach to minimize inflammatory response in viral pneumonia [ , ] .as a type of corticosteroids, methylprednisolone is widely used in clinic because of its large distribution, high concentration and long retention time in alveolar epithelial cells [ ] . however, there is fierce debate about whether corticosteroids slow down the clearance of coronaviruses [ ] and increase the chance of opportunistic infections [ ] , but still the use of corticosteroids seems to be indispensable in the treatment of with severe and especially critical covid- patients [ ] [ ] [ ] . a retrospective comparison study was performed on covid- patients under years old who were admitted between january and february . regardless of whether the patient has a positive nucleic acid test result before hospital admission, we re-tested the nasopharyngeal swabs for covid- on the first day of admission. all of them were diagnosed by positive result of real-time fluorescent rt-pcr detection of nasopharyngeal swabs, of which patients who had persistent high fever (body temperature> ℃) for three consecutive days, or progress in ct imaging within days (that is, the number of affected lung segments increased by %, or the range of the original affected lung segments increased by %) or with hypoxia and difficulty breathing were treated with methylprednisolone, the initial dose was calculated based on their body weight ( - mg/kg/d) [ ] and gradually halved every days, the total treating course range from to days. in addition, all the patients have received antiviral therapy ( mg of arbidol three times a day, mg/ mg of lopinavir and ritonavir twice daily) for - days. in the end, all these patients recovered smoothly and were discharged according to the standard, that is, the symptoms were significantly relieved, the ct imaging lesions were obviously absorbed, and the two consecutive nucleic acid detection were negative. most importantly, there was no death. based on whether they were treated with methylprednisolone or not, they were divided into two groups, the basic information and disease typology are described in the table below: ct images of days before and after treatment in those groups were compared. good ct imaging lung lesion absorption is defined as: the number of affected pulmonary segments is reduced by half, or the ct density of the lesion is significantly reduced. the time of viral nucleic acid negative conversion is calculated as the time interval between two consecutive negative detections of new coronavirus nucleic acid and the onset of illness (table ). statistical analyses were performed using the spss . (ibm, usa). data were shown as mean values ± standard deviation (sd). two-tailed student's t-test was used to compare the two groups of means in this study, p values were ≤ % at a rest state; arterial partial pressure of oxygen (pao )/oxygen concentration (fio ) ≤ mmhg. patients with > % lesions progression within to hours in lung imaging should be treated as severe cases. critical: meeting any of the following criteria: occurrence of respiratory failure requiring mechanical ventilation; presence of shock; other organ failure that requires monitoring and treatment in the icu. critical cases are further divided into early, middle and late stages according to the oxygenation index and compliance of respiratory system [ ] . determined to measure the significance. p values < . were considered extremely significant (expressed as ***), < . were considered very significant (expressed as **), < . were considered significant (expressed as *), ≥ . were considered not significant (abbreviated as n.s). we compared the changes of ct imaging at days before and after treatment, and found out that most lung lesions were presented as follows: ground glass opacity, cloudy, interstitial changes and fibrous stripes, consolidation (figure ). after days of antiviral treatment, cases in the non-methylprednisolone treatment group completely absorbed the lung lesion on ct image, cases partially absorbed the lung lesion ( figure a and b) . in the methylprednisolone treatment group, compared with ct image days before antiviral and methylprednisolone treatment, cases completely absorbed the lung lesion on ct image, cases partially absorbed the lung lesion, and cases enlarged the lung lesion ( figure c and d) . however, there was no statistical difference in the total number of pulmonary segments with lesion before and after days of treatment in both groups. the time that needed for viral nucleic acid negative conversion in the non-methylprednisolone treatment group ( . ± . ) was shorter than that in the methylprednisolone treatment group ( . ± . , p = . ). patients in the methylprednisolone treatment group developed hypoxia before treatment (ie, the percentage of finger oxygen saturation without oxygen inhalation was less than or equal to %). however, after these patients were discharged and isolated for days, the blood oxygen saturation returned to normal levels ( figure ). covid- is an animal-derived virus [ ] , bats may be the host of the virus and intermediate hosts may include pangolins [ ] . to date, cases of covid- diagnosed patients in yichang city, hubei province have been treated in our hospital. these patients range from . to years old, and there is no significant difference between the male and female ratios, which indicates that covid- is susceptible to all the population with no obvious gender differences and can cause disease at all ages. unfortunately, there are still no specific drug to treat covid- at present. according to the diagnosis and treatment guideline issued by the chinese national health council on march , , corticosteroids are recommended for severe, especially critically ill patients [ ] , which can effectively alleviate the symptoms of patients such as dyspnea and high fever, but also can prevent patients from rapid progress in lung imaging. however, due to the well-known reasons, corticosteroids are highly controversial in the treatment of viral pneumonia. some scholars believe that corticosteroids can slow down the clearance of the virus [ ] , and long-term use of corticosteroids will also cause a series of such as opportunistic fungal infection, femoral head necrosis, etc [ ] . in our study, we found that the time required for nucleic acid negative conversion in the corticosteroids treatment group was longer than that in the non-corticosteroids treatment group, which is consistent with the opinion that the use of corticosteroids can slow down the clearance of the virus [ , , ] . but more importantly, although the proportion of severe and critical typology patients in the methylprednisolone treatment group is higher than that in the non-methylprednisolone treatment group, the percentage of good ct imaging lung lesion absorption in methylprednisolone treatment group ( . %) is comparable to that in the non-corticosteroids treatment group ( %), and oxygen-deficiency of the hypoxic patients are gradually improved in the corticosteroids treatment group. despite the fact that two severe patients in methylprednisolone treatment group had larger lung lesions after days treatment, they did not turn into critical cases and both of them recovered and successfully discharged with no complications. based on the result of retrospective analysis of clinical data, we concluded that corticosteroids are a safe and effective treatment for covid- . in the early stage of the disease, the use of corticosteroids may affect the clearance of the virus, but in the period of rapid disease progression, the use of corticosteroids can inhibit the further deterioration of the disease and create opportunities for treatment. from the perspective of the treatment for critical and severe patients in our hospital, corticosteroids plays a very important role in saving patients' lives and rapidly suppressing the progress of the disease. considering that the majority typology of covid- patients under years old are moderate typology, the use of corticosteroids requires individualized selection. corticosteroids need to be used promptly when disease progression changes rapidly and may develop into severe or critical cases. if there is insufficient evidence, it is best to avoid the use of corticosteroids, as nucleic acid negative transformation takes longer after treatment, which may be due to slower virus removal. this study have limitations because it was not a randomized study and also just the patients under years old and just one type of corticosteroids were included in the study, due to the urgency, there are difficulties in carrying out a rigorous large-scale clinical trial. although corticosteroids therapy is widely controversial in viral pneumonia, it is safe and effective in clinical applications. therefore, larger randomized studies are needed to confirm our preliminary results. corticosteroid therapy for critically ill patients with middle east respiratory syndrome effects of early corticosteroid treatment on plasma sars-associated coronavirus rna concentrations in adult patients early corticosteroids in severe influenza a/h n pneumonia and acute respiratory distress syndrome. american journal of respiratory and critical care medicine glucocorticoid treatment of suspected organizing pneumonia after h n infection: a case report defining the role of glucocorticoids in inflammation glucocorticoid attenuates acute lung injury through induction of type macrophage optimization of dexamethasone administration for maintaining global transduction efficacy of adeno-associated virus serotype prevention and management of glucocorticoid-induced side effects: a comprehensive review: infectious complications and vaccination recommendations the use of anti-inflammatory drugs in the treatment of people with severe coronavirus disease (covid- ): the perspectives of clinical immunologists from china potential benefits of precise corticosteroids therapy for severe -ncov pneumonia efficacy and safety of corticosteroids in covid- based on evidence for covid- , other coronavirus infections, influenza, community-acquired pneumonia and acute respiratory distress syndrome: a systematic review and meta-analysis cross-species transmission of the newly identified coronavirus -ncov viral metagenomics revealed sendai virus and coronavirus infection of malayan pangolins (manis javanica) clinical features and short-term outcomes of patients with sars in the greater toronto area the authors declare that they have no competing financial interests. yuan gong, zhu jin collected and analyzed the data, and prepared the manuscript. shixiong chen contributed to the collecting and interpretation of radiological materials. guangming xiang, li guan were involved in the patient management and organization work. baoan gao designed the study and reviewed the manuscript. key: cord- -nie n b authors: day, m.a.; ehde, d.m.; burns, j.; ward, l.c.; friedly, j.l.; thorn, b.e.; ciol, m.a.; mendoza, e.; chan, j.f.; battalio, s.; borckardt, j.; jensen, m.p. title: a randomized trial to examine the mechanisms of cognitive, behavioral and mindfulness-based psychosocial treatments for chronic pain: study protocol date: - - journal: contemp clin trials doi: . /j.cct. . sha: doc_id: cord_uid: nie n b this randomized trial will evaluate the mechanisms of three chronic pain treatments: cognitive therapy (ct), mindfulness meditation (mm), and activation skills (as). we will determine the extent to which late-treatment improvement in primary outcome (pain interference) is predicted by early-treatment changes in cognitive content, cognitive process, and/or activity level. the shared versus specific role of these mechanisms across the three treatments will be evaluated during treatment (primary aim), and immediately post-treatment to examine relapse mechanisms (secondary aim). we will enroll individuals with chronic pain (with low back pain as a primary or secondary condition), with projected to complete the study. participants will be randomly assigned to eight, . h telehealth group sessions of ct, mm, or as. mechanisms and outcomes will be assessed twice daily during -week baseline, -week treatment period, and -week post-treatment epoch via random cue-elicited ecological momentary assessment (ema); activity level will be monitored during these time epochs via daily monitoring with actigraph technology. the primary outcome will be measured by the promis -item pain interference scale. structural equation modeling (sem) will be used to test the primary aims. this study is pre-registered on clinicaltrials.gov (identifier: nct ). this study will determine the temporal sequence of lagged mediation effects to evaluate rates of change in outcome as a function of change in mediators. the findings will provide an empirical basis for enhancing and streamlining psychosocial chronic pain interventions. further, results will guide future efforts towards optimizing maintenance of gains to effectively reduce relapse risk. chronic pain is debilitating, pervasive, and costly [ , ] . a number of interventions have demonstrated efficacy [ ] [ ] [ ] for chronic pain management, including chronic low back pain (clbp): ( ) cognitive therapy (ct); ( ) mindfulness meditation (mm); and ( ) activation skills (as) [ , ] . each of these approaches has a unique theoretical rationale underpinning its application. ct teaches patients to notice maladaptive thoughts and their influence on pain, and targets these for change. thus, changing what people think (i.e., cognitive content) to more adaptive thoughts is a focus of ct [ ] . mm encourages patients to disengage from automatic thinking and to mindfully place attention on different perceptive experiences [ ] . mm therefore targets how people think (i.e., cognitive process). as targets reductions in maladaptive pain behaviors and uses reinforcement principles to increase well behaviors. hence, what people do (i.e., behavior) is targeted in as [ ] . understanding the mechanisms of psychosocial pain treatments has been identified as critical [ , ] . while equivalent efficacy is typically obtained on average when active treatments are compared, e.g., [ , ] the theories underlying specific treatments argue that effects of different treatments work through unique mechanisms. it is also possible that these unique mechanisms underlie post-treatment changes. however, minimal research has examined whether ct, mm, and as engender benefit via their specific theorized pathwaysthe specific mechanism modelor if benefit is obtained via a combination of shared pathwaysthe shared mechanism model [ ] [ ] [ ] . if a mechanism factor plays a causal role in outcome, change in that factor must precede change in outcome [ ] . actigraphy and ecological momentary assessment (ema) are repeated measures methodologies ideally suited to assess such mechanism relations in real-time [ ] . ema technology affords the capacity to disentangle temporal precedence of mechanism-outcome changes. these data will allow us to determine, for the first time, the timing of changes in mechanism variables during treatment, the effects of these changes on subsequent changes in outcome variables, and the extent to which these changes and effects are specific to, versus shared across, the three treatment conditions. the purpose of this randomized trial is to identify the mechanisms of ct, mm, and as for chronic pain, with low back pain experienced as a primary or secondary condition. given past research showing equivalent efficacy for active treatments, we hypothesize no significant group level outcome differences. e.g., , however, we do hypothesize individual variability in treatment response and maintenance of gains. identify the mechanisms of ct, mm, and as. we will determine the extent to which late-treatment improvement in pain interference is predicted by early-treatment changes in three primary mechanism variables: cognitive content (i.e., catastrophizing), cognitive process (i.e., mindful non-judgment), and/or activity level (i.e., actigraph "activity counts"). hypothesis a. early treatment changes in mechanisms will be significantly associated with late treatment improvement in pain interference. hypothesis b. the shared mechanisms model hypothesizes that if the mechanisms are shared, there would be small, non-significant betweentreatment differences in early mechanism changes. hypothesis c. the specific mechanisms model hypothesizes that if changes in mechanisms are specific to ct, mm, and as, then treatment condition will have a significant effect on early changes in the mechanisms, which will then be associated with subsequent outcome change. we will evaluate the post-treatment mechanisms that explain relapse (i.e., return to baseline levelsor worseon pain interference), maintenance, and continued gains associated with these treatments. the shared (hypothesis a) and specific (hypothesis b) mechanism models will be applied to test post-treatment mechanisms. in this study, we will use a -group parallel ( : : ), single-blind design (see fig. ). we will recruit and enroll individuals with chronic pain, with a low back pain problem experienced as a primary or secondary pain condition in the past -months. participants will be randomly assigned to eight, . h, group zoom videoconference sessions of ct, mm, or as. mechanism and outcome variables will be assessed twice daily during the -week baseline, -week treatment period, and -week post-treatment epoch via random cue-elicited ema; physical activity level will be monitored during these time epochs via daily monitoring using actigraph technology. follow-up assessments of mechanism and outcome variables will be conducted at -and months post-treatment. the primary endpoint for the primary study aim (aim ) is the post-treatment pain interference score, operationalized as an average of pain interference ratings made on the twice-daily diaries during the first four days after treatment. the endpoint for the secondary study aim (aim ) is the post-treatment score at days follow-up, as operationalized as the average of pain interference ratings on the diaries from the final four days of the immediate post-treatment follow-up period. all study procedures were piloted and developed in preliminary work by the investigative team. specifically germane to this proposal, we have conducted numerous clinical trials examining psychological interventions based on the techniques investigated in this study for clbp and other pain conditions [ ] [ ] [ ] [ ] , including telehealth assessment and treatment delivery [ ] [ ] [ ] [ ] [ ] . we have also published multiple studies examining treatment mechanisms and have a great deal of experience in implementing ema, with compliance rates exceeding % [ , , , . this study is pre-registered on clinicaltrials.gov (identifier: nct ). the trial protocol follows standard protocol items: recommendations for interventional trials (spirit) guidelines [ ] . informed consent will be obtained from all participants prior to enrollment. potential participants (n = enrolled for n = completers; see power analysis below) will be identified via diagnostic codes in the uw medicine medical records. recruitment will also occur via other strategies, including posting flyers in the relevant pain and rehabilitation clinics, clinician referrals, announcements on the hospitals-wide electronic reader boards and national recruitment strategies, including social media. study inclusion criteria include: ( ) age ≥ years; ( ) endorse having low back pain as a primary or secondary pain problem in the past months; ( ) meet criteria for having a chronic pain problem (≥ months, with pain experienced on ≥ % of days in the past months) [ ] ; ( ) average intensity of chronic pain ≥ on a -point scale for most days of the previous months; ( ) chronic pain interference for general activities ≥ on a -point scale for the past months; ( ) able to read, speak, and understand english to comprehend the worksheets, measures, and interventions implemented; ( ) if currently taking analgesic or psychotropic medication, medications must have been stabilized for ≥ weeks prior to this study; and ( ) availability of a telephone, webcam, and microphone through computer or telephone, as well as daily internet access. exclusion criteria include: ( ) primary pain condition is headache; ( ) severe cognitive impairment; ( ) current alcohol or substance dependence; ( ) active malignancy (e.g., cancer not in remission), terminal illnesses, or serious medical conditions that may interfere with either study participation or with receiving potential treatment benefits (e.g., severe lupus); ( ) inability to walk at least yards, which would limit the ability of participants to benefit from the activation skills intervention; ( ) significant pain from a recent surgery or injury; ( ) pain condition for which surgery has been recommended and is planned; ( ) any planned surgery, procedure, or hospitalization that may conflict with or otherwise influence participation in the study; ( ) currently or recently receiving other psychosocial treatments for any pain condition (as this may influence these treatment results); ( ) current or past participation in a uw department of rehabilitation medicine research study with treatment components that may overlap those in the current study; ( ) current or history of diagnosis of primary psychotic or major the exploratory aims of the study are not described in detail herein, due to space limitations. these exploratory tests will include: ( ) evaluating the moderators of response per the limit, activate, and enhance (lae) moderation model from pre-to post-treatment (i.e., to test individual differences in treatment response), as well as moderators of change from pre-treatment to followup (i.e., to test individual differences related to maintenance of gains); ( ) utilizing the actigraph and ema data to explore the nature of the time course of micro-level changes in mechanisms and outcomes during and following treatment; ( ) effects related to secondary outcomes (e.g., pain intensity) and nonspecific mechanisms (e.g., therapeutic alliance), as well as changes at -and month follow-up. thought disorder within the past years; ( ) psychiatric hospitalization within the past months; ( ) psychiatric or behavioral conditions in which symptoms were unstable or severe within the past months; ( ) any psychiatric or behavioral issues as noted in the medical record or disclosed/observed during self-report screening that would indicate participant may be inappropriate in a group setting; and ( ) presenting symptoms at the time of screening that would interfere with participation, specifically active suicidal or homicidal ideation with intent to harm oneself or others, or active delusional or psychotic thinking. assignment to one of the three groups will be accomplished using a covariate-adaptive randomization scheme. we will use a procedure proposed by pocock and simon, with the objective of balancing the covariate in the marginal distributions [ ] . the covariates for the covariate-adaptive randomization will be sex, baseline pain interference score (mild/moderate or severe, as assessed via the -item roland-morris disability scale [ ] with cutoff for severe being a score of ≥ ), and low back pain type (primary or secondary pain). participants will be offered eight . selected based on our successful application of these format specifications in prior clinical trials, which have evaluated eight session, groupdelivered treatment programs, and programs with session duration length of . h (both in person and via telehealth). e.g., [ , , , , ] . during their study participation, all participants will continue to receive their usual medical, psychiatric, and psychotherapeutic care. clinicians will be expected to follow closely the treatment manuals to ensure all scheduled material is covered, and to ensure the consistency and replicability of treatment. in all three treatment conditions, group sessions will be conducted via the online, hipaa-compliant zoom videoconferencing platform (https://zoom.us/). zoom videoconferences allow participants to see and hear each other, and also allow screen sharing, giving clinicians the opportunity to display visual information (e.g., powerpoint slides) during sessions. all participants will receive a treatment workbook specific to their treatment allocation to refer to during the group sessions as well as additional content to read between sessions. in all conditions, home practice activities will be assigned to build skills in the coping techniques taught in sessions. cognitive-restructuring techniques will be used to help patients recognize the relationships between thoughts and the connection between thoughts with feelings, behaviors and pain [ ] . these techniques will help patients: identify negative or unrealistic automatic thoughts; evaluate automatic thoughts for accuracy, identify sources of distorted thoughts, recognize the connection between automatic thoughts and emotional/physical shifts; challenge negative, distorted automatic thoughts via "weighing the evidence"; develop new realistic alternative cognitive appraisals; and practice applying new appraisals and beliefs. participants will receive training in mindfulness meditation, specifically vipassana, which is the form of meditation typically implemented in mindfulness research [ ] . with this technique, the emphasis is placed upon developing focused attention on an object of awareness, e.g., the breath. this focus is then expanded to include a more open, non-judgmental monitoring of any sensory, emotional, or cognitive events. a standard script will be used by the clinician as a guide. the clinician will however lead the practice "from within," in the sense that they will not simply just "read" the scripts, but will use their own language to guide the meditation taking into account his/her own experiences (for example, when describing sounds in the virtual room). participants will be seated in a comfortable yet alert position. a guided inquiry of the participant's experiences will follow each in-person exercise, and will also be implemented in relation to discussing participant's at-home practice. participants will be educated about the role of inactivity and behavioral avoidance in chronic pain and functioning [ ] . they will learn how to be aware of the activities they avoid because of pain, and how to set effective goals so that, step by step, they can start being more active and resume some activities they enjoyed in the past but are currently avoiding. explanation and practice of a set of specific skillsincluding appropriate pacing skillsto facilitate an increase in appropriate activity level will be provided. the sessions will be conducted by a postdoctoral psychology fellow or licensed psychologist (the "clinician") with at least two years of clinical experience, including experience working within the context of chronic pain treatment. the clinicians will be trained and supervised by the investigators who have considerable experience in the study treatments. during training, clinicians will be assigned reading materials [ ] [ ] [ ] and will complete three, -h treatment workshops led by the investigators; all therapists will be trained in, and will deliver, all three treatments. mm therapists will be strongly encouraged to engage in their own personal practice of mindfulness, including discussions around how this personal practice is important for being able to respond genuinely and to have insight into the processes of meditation. clinicians will also be trained in the use of motivational interviewing (mi) for enhancing motivation to engage in treatment, including reading miller and rollnick's text [ ] , and engaging in at least h of mi instruction and practice. clinicians will also receive training in group leadership techniques, including strategies for enhancing group cohesion. the clinicians will be provided with a detailed treatment manual and protocol, and will be provided with regularly scheduled supervision. adherence and fidelity will be monitored using session audio recordings. masters-level or above clinicians supervised by the investigators will review a random selection of % of the recordings ( randomly selected sessions per group) to ensure procedures are followed. delivery quality and protocol adherence criteria will be developed for each session, adapted from the ct adherence and competence scale [ ] and the mindfulness-based ct-adherence appropriateness and quality scale [ ] . corrective feedback will be provided to the clinician during supervision; didactics and role plays to correct "drift" will be implemented if needed. we will implement a number of strategies to maximize participant retention. for example, across cohorts, sessions will be offered at different times on a recurrent basis (e.g., a morning session cohort will be offered, and then in the next cohort an evening session will be offered), giving participants scheduling flexibility; however, once a participant commences treatment, a participant cannot change groups/clinicians. we will track session attendance and reasons for missed sessions. reasons for attrition will be assessed for participants who withdraw. clinician-rated participant engagement will be assessed following each session for each participant [ ] . enactment of treatment-specific skills will be assessed by homework practice, assessed via ema. to minimize possible missed extended surveys, ema, and actigraph data, we will provide financial incentives. the descriptive, primary and secondary outcome variables, covariates (variables to control for in planned analyses if needed), and mechanism (mediator and moderator) variables for this study are listed in table . specific measures by time point are provided in table . assessments will be undertaken via a combination of extended telephone assessments and ema monitoring. participants will have the option to complete the ema surveys via smart phone, tablet, laptop, or desktop computer. the cue-elicited emas will be administered via software programmed to randomly alert participants daily within two pre-set -min blocks (via notifications for smart phone users and email messages for tablet, laptop, or desktop users) to complete the ema surveys in the morning and evening. all participants will be given predetermined options for the morning and evening blocks for receiving surveys: for example, - am and pm, - am and pm, or - am and pm. notification cues to complete the emas will be administered during a randomly selected time within these blocks. the number of items for each measure in the emas was selected on the basis of content validity, factor loadings established during initial measure development and validation studies, brevity, and pilot data. building on this, the minimum number of items was then selected that achieved at least good internal consistency reliability (α ≥ . ) for the mechanism variables and excellent reliability (α ≥ . ) for the primary outcome variable of pain interference in our pilot data. the actigraph will be worn throughout all ema phases. all outcome measures will be administered by staff blind to group allocation. due to space limitations, here we provide only a brief description of the planned analyses. readers interested in more details can find them on clinicaltrials.gov (identifier: nct ). only analyses planned to address the primary study aims are described here. briefly, we plan to test the primary study hypotheses using a -wave structural equation modeling (sem) approach. we will first calculate slope coefficients representing the linear change in each outcome and mechanism variable during the first two weeks of treatment (early treatment) and second two weeks of treatment (late treatment), using regression. see fig. for the data time points included in these calculations. we will then enter these variables, along with control variables and variables representing treatment condition in a series of sem models. the model depicted in fig. represents the initial model we plan to test for the catastrophizing mechanism variable, providing that it evidences at least a small effect size for change over time for at least one treatment condition during the first two weeks of treatment. however, the model will be simplified (by removing treatment condition as a predictor, and the paths associated with treatment condition) if nonsignificant between treatment condition effects are found for change during the early treatment phase. up to two additional sem models will also be tested, with non-judgment and activity level as the mechanism variables. in these models, the a and a coefficients represent the treatment ″- ″ of investigator-developed qualitative items the gold standard for assessment of movement (i.e., what people actually do) in the real world is actigraph technology, which is why we elected to use this assessment approach in this trial. that this mechanism is not measured via self-report like the primary hypothesized mechanisms of the other two conditions is a potential methodological confound that was considered. hence, to address this, we elected to also concurrently administer a self-report measure of what people do (i.e., godin, and self-reported amount of time spent sitting). this will allow us to test whether the findings differ as a function of form of assessment (i.e., self-report versus objective assessment). condition effect (two dummy ivs) on early change in the mechanism variable being examined. the b coefficient in this model represents the effect of early treatment change in the mechanism variable on subsequent late treatment change in outcome. a significant b coefficient would support hypothesis a for that mechanism variable. significant a or a coefficients, indicating between-treatment condition differences in early changes in mechanism variables, would support hypothesis c (the specific mechanisms model). post-hoc analyses would then be performed to determine which treatment resulted in greater changes in the mechanism variable being examined. if both the a and a coefficients are not statistically significant, this would be consistent with hypothesis b (i.e., the shared mechanisms model) for that mechanism variable. we will conduct six primary statistical tests (described above) to test the primary aim for three mechanism variables, in order to better understand the effects of the treatments on pain interference. data from prior researchincluding means and standard deviationssupports the anticipated medium to large effects of ( ) the causal effects of the treatments on the mechanism variables [ , [ ] [ ] [ ] , ( ) the association between the mechanism variables and pain interference [ ] [ ] [ ] , as well as ( ) the mechanism paths that we propose to test [ , , ] , which form the basis of our assumptions for the power analyses. although we were unable to identify any studies that examined the effect sizes associated with any of these treatments on behavioral activity, as a group these studies are consistent with our assumptions that ct, mm, and as treatments have medium to strong effects on key mechanism variables. assuming at least medium effects (i.e., rs ≥ . and/or ds ≥ . ) [ ] we then computed the sample sizes needed to detect significant effects for the planned primary analyses, using the benjamini-hochberg procedure to control for alpha inflation in these analyses [ ] . the sample sizes needed to detect significant effects for each of these analyses is presented in table , using the tests for the three direct mediation effects of the mechanism variables for three of these analyses, and a test for the three treatment condition x mediation (representing moderated mediation) effects for the other three analyses, assuming at least medium effects for each of these effects. sample size estimates needed to detect the primary mediation effects were conducted based on the joint significance method of testing mediated effects, using the powmedr program in r version . . statistical software with the following assumptions: ( ) alpha levels consistent with the benjamini-hochberg procedure (see table ); ( ) power of . ; and ( ) at least medium effects. power calculations for the interaction (mediated moderation) analyses were conducted using g*power with the same assumptions. thus, by employing the analytic models experiment-wise, and by integrating treatment-condition into the model(s) as an interaction effect (rather than running separate analyses for each treatment condition), we will be able to take advantage of the power afforded by running the entire sample of participants (n = ) through the planned tests. this, combined with the less stringent benjamini-hochberg type-i error adjustment, has left us well-powered to detect the hypothesized effects if they exist. that said, we plan to enroll participants with a goal of obtaining complete data for participants (n = per condition). this study was reviewed and approved by the uw human subjects division. an independent data safety monitoring committee (dsmc) comprised of an occupational therapist (chair), biostatistician, and physical therapist with experience in treating clbp has been appointed. the dsmc will monitor safety of participants throughout all phases of the trial. per uw human subjects division guidelines, we will monitor for and track possible adverse events (aes) throughout the study. reviewing and reporting of aes to the dsmc, the uw irb, and nccih will be undertaken in accordance with requirements. this study will be stopped prior to its completion if: ( ) one of the interventions is associated with adverse effects that call into question the safety of the intervention; ( ) any new information becomes available during the trial that necessitates stopping the trial; or ( ) other situations occur that warrant stopping the trial. this study is designed to isolate the effects of coping skills typically taught in integrated, multi-modal treatments (i.e., cbt, mbis) to determine their specific role in chronic pain management. testing the mediators of these specific pain techniques -ct, mm, and aswill identify if theorized mechanisms are unique to a specific treatment or are shared, trans-therapy mechanisms. results of this study will determine the relative importance of targeting change in what people think, how people think, or what people do in relation to chronic pain management. identification of treatment mediators will bring order and parsimony to psychotherapeutic theory [ , ] . research has underscored the problem of patients relapsing back to baseline levels of pain/function following psychosocial pain interventions, with relapses found in as little as one month following treatment [ , ] . thus, the time period immediately post-treatment might be critical. this study will examine the mechanisms that possibly precede continued improvement, maintenance, and relapse in the one month immediately post-treatment, and will investigate how these factors may relate to longer-term (i.e., -and -month) outcomes. although some prior research has used ema or actigraphy to evaluate treatment outcomes, e.g., , to the best of our knowledge, this study will be the first to utilize both actigraphy and ema during pain treatment and during the critical month following administration of treatment to evaluate mechanisms. in planned secondary analyses, this methodological advancement of the inclusion of actigraphy and ema will afford the capacity to determine precisely ( ) when and how sudden gains might occur, ( ) how long it takes for "slow and steady" gains to become meaningful and what processes underlie these gains, ( ) the earliest point at which it is possible to conclusively determine that the treatment is not well suited to a given individual and that an alternative approach should be offered, and ( ) the processes and temporal sequence underlying post-treatment relapse, maintenance, and continued gain. these findings could lead to streamlined interventions and informed relapse-prevention approaches that distill the most critical change factors into an efficient and cost-effective treatment package. recruitment started in august . the trial is underway; it is expected to be completed may . research reported in this manuscript was supported by the national center for complementary and integrative health of the national institutes of health under the award number r at . the content is solely the responsibility of the authors and does not necessarily represent the official views of the national institutes of health. the authors have no conflicts of interest to report. a cost utility analysis of interdisciplinary early intervention versus treatment as usual for high risk acute low back pain patients mindfulness meditation for the treatment of chronic low back pain in older adults: a randomized controlled pilot study efficacy and effectiveness of cognitive behaviour therapy for chronic pain: progress and some challenges meditation programs for psychological stress and well-being: a systematic review and meta-analysis pain and behavioral medicine: a cognitive-behavioral perspective full catastrophe living: usinf the wisdom of your body and mind to face stress mindfulness-based 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therapeutic strategies for critically ill patients with covid- date: - - journal: ann intensive care doi: . /s - - -z sha: doc_id: cord_uid: hmsknon since the novel coronavirus disease (covid- ) outbreak originated from wuhan, hubei province, china, at the end of , it has become a clinical threat to the general population worldwide. among people infected with the novel coronavirus ( -ncov), the intensive management of the critically ill patients in intensive care unit (icu) needs substantial medical resource. in the present article, we have summarized the promising drugs, adjunctive agents, respiratory supportive strategies, as well as circulation management, multiple organ function monitoring and appropriate nutritional strategies for the treatment of covid- in the icu based on the previous experience of treating other viral infections and influenza. these treatments are referable before the vaccine and specific drugs are available for covid- . in late december , a group of patients with pneumonia of unknown cause were confirmed to be infected with a novel coronavirus ( -ncov) in wuhan, china. the -ncov has now infected tens of thousands of people in china and has spread rapidly around the globe [ ] . the world health organization (who) has declared coronavirus disease (covid- ) as a public health emergency of international concern and released interim guidelines on patient management [ ] . due to the severity and the spreading of covid- (novel coronavirus pneumonia, ncp), the chinese government and the medical institutions have executed strict strategies to control the influence of this epidemic [ ] . until the end of february, the epidemic has been controlled to a great extent nationally. in wuhan, the situation tends to be stable while a high proportion of critically ill patients are still under treatment of intensive care. coronaviruses (covs) are enveloped viruses with a single positive-stranded rna genome (~ - kb in length). covs mainly cause respiratory tract infections and some strains have high infectivity and mortality as well as heavy damage on public health, such as severe acute respiratory syndrome (sars) and middle east respiratory syndrome (mers). the -ncov is a β-cov of group b with over % similarity in genetic sequence with sars-ncov [ , ] . the latest version of diagnosis and treatment plan pointed out that the main transmission route is droplet transmission and close contact transmission. in addition, there are risks of airborne spread of -ncov during aerosol-generating medical procedures in specific circumstances [ , ] . for the positive nucleic acid in oropharyngeal swabs. asymptomatic cases also have the risk, although weak, of transmission. respiratory viral infection can cause severe illness, especially in the elderly and persons with co-morbidities [ ] . according to the latest version of diagnosis and treatment guidelines, confirmed cases infected with -ncov are classified to have severe illness once complying with one of the following symptoms: ( ) anhelation, respiratory rate ≥ times/min; ( ) oxygen saturation at rest ≤ %; ( ) pao /fio ≤ mmhg; and classified to be the critical/life-threatening illness once complying with one of the following symptoms: ( ) respiratory failure, mechanical ventilation needed; ( ) shock; ( ) other organ dysfunction syndrome and requirement of intensive care unit admission. the progress of the severe illness with covid- is usually rapid and there is no clear separation between the severe illness and the critical illness. therefore, patients of these two classes are combined to be the critical illness, which is helpful for health care workers to diagnose and treat patients with intensive care and resources at the early stage of the critical illness. the diagnostic evidences for icu admission according to the previous experience in the treatment of sars include old age (> years old), presence of co-morbidities (particularly, diabetes mellitus, hepatic or cardiac disease), and elevated lactate dehydrogenase levels on admission to hospitals [ , ] . -ncov invades through the respiratory mucosa and infects other cells, inducing cytokine storm systemically [ ] . some patients may progress rapidly with ards, disseminated intravascular coagulation (dic), septic shock, and eventually multiple organ failure [ ] . therefore, early identification and timely treatment of critical cases is of crucial importance. evidence-based therapy and supportive care in icu is the mainstay for the management of severe and life-threatening illness of covid- . the severe and critical illnesses with covid- should be treated in icu in the hospital with nosocomial infection control. strict volume management, multi-organ function evaluation, critical care of the nutritional assessment/appropriate nutritional support are essential for these patients in icu. in addition, attention should be paid to bedbound patients to prevent deep vein thrombosis. at present, there is no antiviral treatment with confirmed effectiveness for covid- . available drug options that come from the clinical experience of treating sars, mers and other previous influenza virus have been used for the treatment of covid- patients. although these antiviral drugs are promising in the treatment of covid- , it should be kept in mind that: ( ) the adverse effects of the drugs need to be monitored in clinic, ( ) the effects of these drugs on critically ill patients still need to be clarified, ( ) the potential mutation of the coronavirus may lead to the drug resistance of the virus. nucleoside analogs have a broad-spectrum antiviral effect via the mechanisms of lethal mutagenesis, chain termination, and inhibition of nucleotide biosynthesis. fabiravir and ribavirin are representative drugs of nucleoside analogs and exhibit the antiviral effect by inhibiting nucleotide biosynthesis. it has been demonstrated that the combination of fabiravir and oseltamivir in the treatment of severe influenza may accelerate clinical recovery than oseltamivir alone [ ] . in addition, it has been reported that the combination of ribavirin and interferon alpha (ifn-⍺) significantly reduced the -day mortality of critically ill patients infected with mers, although the -day mortality was not affected [ ] . ribavirin and ifn-⍺ were also used in the treatment for sars. however, ribavirin might have side effects such as anemia and liver injury, and ifn-⍺ may not improve the patients' outcome [ ] . therefore, the use of ribavirin and ifn-⍺ in the treatment of covid- needs to be further elucidated by clinical studies. lopinavir/ritonavir is a protease inhibitor in the treatment of hiv infection. lopinavir/ritonavir showed the antiviral activity by inhibiting the replication of coronavirus in vitro. it has been reported that the combination of lopinavir/ritonavir with ribavirin could lower the risk of ards compared with ribavirin alone [ ] . most recently, the randomized clinical trial of lopinavir/ritonavir ( mg/ mg, twice-daily for days) in the treatment of covid- by cao et al. has shown that in hospitalized adult patients with severe covid- , no beneficial effect was observed with lopinavir/ritonavir treatment compared with standard care group [ ] . the adverse effects of lopinavir/ritonavir treatment include anorexia, nausea, abdominal discomfort, diarrhea, or acute gastritis. moreover, the risk of hepatic injury, pancreatitis, more severe cutaneous eruptions, as well as the drug interactions due to cyp a inhibition has been observed in the clinical trial, which arouses concern about the use of higher or prolonged dose regimens for outcome improvement [ ] . in addition, serious complications such as acute kidney injury and secondary infection were fewer than in those not receiving treatment. future trials with severe illness might help to elucidate the possibility of benefit of lopinavir/ritonavir treatment. remdesivir (gs- ) is a new nucleoside analog and has been recognized as a potential and promising antiviral drug against a wide array of rna viruses, including sars/mers-cov. it is currently under clinical development for the treatment of ebola virus infection [ ] . remdesivir potentially inhibits the rna-dependent rna polymerase from mers-cov, reduces virus replication, decreases the virus titer in mouse lungs infected with mers-cov, and improves the lung tissue damage [ , ] . the antiviral activity of remdesivir and ifn-beta was found to be superior to that of the combination of lopinavir/ritonavir and ifn-beta against mers-cov [ ] . a randomized, controlled trial has reported that the prolonged use of remdesivir in the treatment of ebola virus disease (evd) is safe [ ] , and no adverse events have been observed [ ] . as a candidate drug that has not been approved, information about the side effects of remdesivir has not been reported yet. at present, two randomized, controlled, double-blind clinical trials are ongoing to evaluate the efficacy and safety of remdesivir ( mg loading dose on day , followed by mg i.v. once-daily maintenance dose for days) in hospitalized patients with mild/moderate or severe covid- respiratory disease [ , ] . the results of these clinical trials may open the window for effective antiviral therapy for such an epidemic infectious disease. arbidol is a small indole-derivative molecule and is approved for the prophylaxis and treatment of influenza and other respiratory viral infections [ ] . it also showed inhibitory activity against other viruses, enveloped or not, responsible for emerging or globally prevalent infectious diseases such as hepatitis b and c [ ] . in addition, arbidol has been reported to have antiviral activity against the pathogen of sars, and the effect of arbidol mesylate-a derivative of arbidol, was almost five times higher than arbidol in reducing the reproduction of sars in cells in vitro [ ] . it has been claimed that arbidol was effective against -ncov in vitro [ ] . a randomized multicenter controlled clinical trial of arbidol in patients with -ncov is in progress in china [ ] . it is known that angiotensin-converting enzyme- (ace ) as a membrane protein is a functional receptor of sars-cov and it can facilitate virus entry into the cells by binding to the spike (s) protein of the virus, which mediates the fusion of viral and host membranes [ ] [ ] [ ] . therefore, it may be of importance to block the binding of s protein to ace to treat viral infection, such as sars-cov [ ] . chloroquine is a -aminoquinoline known since , the sulfate and phosphate salts of which have both been commercialized as widely used antimalarial and autoimmune disease drugs. chloroquine also shows broad-spectrum antiviral effects [ ] . it was found to be a potent inhibitor of sars-cov infection due to its inhibitory effect on ace [ ] . it has been demonstrated that -ncov enter the epithelial cells of oral mucosa via the essential receptor ace [ ] , and chloroquine can function at both entry and post-entry stages of -ncov infection [ ] . besides the antiviral activity, chloroquine has an immune-modulating activity, which may synergistically enhance its antiviral effect in vivo. recently, wang et al. have demonstrated that chloroquine is highly effective in the control of -ncov infection in vitro and is suggested to be assessed in human patients suffering from covid- [ ] . in addition, the results from more than covid- patients have indicated that chloroquine phosphate is superior to the control treatment in inhibiting the exacerbation of pneumonia, improving lung imaging, promoting virus negative conversion, and shortening the disease course [ ] . however, attention should be paid to the potential detrimental effects of chloroquine observed in previous attempts to treat viral diseases. at present, the clinical trials to evaluate the efficacy and safety of chloroquine in the treatment of covid- is ongoing [ ] . the use of chloroquine in the treatment of covid- should refer to the most recent announcements if any. in addition, hydroxychloroquine is a -aminoquinoline derivative antimalarial drug. hydroxychloroquine is an immunosuppressive drug with mature clinical application in the treatment of rheumatic immune diseases such as rheumatoid arthritis and systemic lupus erythematosus [ , ] . it has been found to be more potent than chloroquine in inhibiting -ncov in vitro. hydroxychloroquine sulfate mg given twice daily for day, followed by mg twice daily for another days is recommended in the treatment covid- [ ] . at present, the clinical evaluation of hydroxychloroquine in the treatment of covid- is in progress [ ] , which might shortly provide preliminary results about the effectiveness of hydroxychloroquine. patients with pneumonia, especially in severe condition, may encounter with co-infection or cross-infection of bacterial pathogens, for instance staphylococcus aureus, during medical treatment in the hospital. considering the high incidence of bacterial infection for critically ill patients with covid- , it is essential to test the kinetics of procalcitonin (pct) and c-reaction protein (crp) in covid- patients for timely diagnosis and intervention of bacterial infection. according to the recent ats/idsa clinical practice guidelines, besides antiviral treatment for patients with viral-infected pneumonia, clinicians should empirically give antibacterial therapy to patients that initially have severe diseases (extensive pneumonia, respiratory failure, hypotension, and fever), or deteriorate after initial improvement, or fail to improve after to days of antiviral treatment [ ] . thus, antibiotic treatment is recommended in the treatment of covid- patients based on the evidence of bacterial infection. the blind and inappropriate use of antibiotics, especially the broad-spectrum antibiotics, should be avoided. immune disorders have been observed in the treatment of patients with covid- . the virus infection activates the immune cells, leading to cytokine storm which is associated with disease severity [ ] . on the other hand, the critical illness with covid- mainly affect elders or people with chronic diseases, some of whom have very low number of lymphocytes, especially cd + t cells, implying deficiency of immune system. therefore, to modulate the immune responses, a variety of pharmacologic agents have been proposed [ , ] . the use of corticosteroids in the treatment of ards is controversial. observational data in sars suggest that immunomodulation with regimens of high-dose methylprednisolone might be helpful in modulating inflammatory responses and lung damage [ , ] . on the other hand, other studies showed that use of steroids is associated with increased risk for bacterial infection, increased mortality, and even antiviral resistance in influenza-associated pneumonia or ards [ ] [ ] [ ] [ ] . moreover, multiple studies have reported that corticosteroid treatment is associated with delayed viral shedding in hospitalized patients without significant change in -day mortality [ ] [ ] [ ] . corticosteroid therapy in patients with mers was shown to be not associated with a difference in mortality, but associated with delayed mers coronavirus rna clearance [ ] .the early use of parenteral glucocorticoids therapy for fever reduction and pneumonia prevention has been shown to increase the risk for critical disease or death from h n infection [ ] . the currently limited clinical research does not support the use of corticosteroids in the treatment of ards in covid- patients to improve the outcome of patients. the who recommended that corticosteroids should not be used in the treatment of viral pneumonia or ards. there is no convincing proof for the therapeutic benefits of corticosteroids in the treatment of covid- , which still need to be demonstrated in clinical research. thymosin alpha- is a thymic peptide hormone with significant benefits in restoring the homeostasis of the host immune system [ ] . it is chemically synthesized and used in diseases with impaired immune system [ ] . it has been reported that the low lymphocyte count is associated with the poor prognosis of septic patients. the use of thymosin alpha- therapy in combination with conventional medical therapies was effective in improving clinical outcomes and reducing mortality in severe sepsis [ ] . in addition, thymosin alpha- can enhance the immune responses of sars patients and help to limit the spreading of sars [ ] . therefore, although there is no clinical evidence showing the beneficial effects of thymosin alpha- in covid- , it has been recommended to be used for some patients to enhance cellular immunity for the resistance of viral infection. cyclosporine a is widely used in transplantation and autoimmune disorders due to its immunosuppressive effect. cyclophilin a as a key member of immunophilins is the cellular receptor for cyclosporine a [ ] . the inhibition of cyclophilins by cyclosporine a could block the replication of coronavirus, including sars-cov [ ] . therefore, non-immunosuppressive derivatives of cyclosporine a might serve as broad-range cov inhibitors applicable against emerging virus like -ncov, which still needs to be confirmed by clinical studies in the future. there are two types of interferons (ifns), type i ifns and type ii ifns. it has been demonstrated that type i ifns can inhibit the replication of both sars and mers-cov [ , ] . kuri et al. have reported that ifn transcription was blocked in tissue cells infected with sars-cov and cells infected with sars-cov were able to partially restore their innate immune responsiveness to sars-cov after priming with small amounts of ifns [ ] . moreover, in patients with severe mers-cov infection, the combination of ifn-alpha- a with ribavirin was shown to improve survival [ ] . recently, the combination of remdesivir and ifn-beta was shown to have significant antiviral activity [ ] . intravenous gammaglobulin is considered as the safest immunomodulating drug available for the treatment of severe infection and sepsis. it has high titers of neutralizing antibodies against broad-spectrum virus, bacteria, and other pathogens, and can modulate the host immune responses in several ways. however, a large-scale multicenter randomized placebo-controlled trial did not show improved survival with intravenous gammaglobulin in severe sepsis [ ] . moreover, a cochrane review showed that intravenous gammaglobulin did not reduce the mortality of septic patients [ ] . therefore, there is no convincing argument to recommend intravenous gammaglobulin in the treatment of -ncov. one of the most important mechanism underlying the deterioration of covid- is cytokine storm characterized by elevated levels of il , ifn-and other cytokines, which will lead to ards or even multiple organ failure [ ] . tocilizumab is a recombinant humanized monoclonal antibody binding to il receptor and inhibiting its signal transduction. tocilizumab has been used in the treatment for rheumatoid arthritis (ra) [ ] . moreover, tocilizumab has been reported to be effective against cytokine release syndrome induced by car-t cell infusion against b cell acute lymphoblastic leukemia [ ] . in diagnosis and treatment guidelines of ncp (trial version . ) [ ] , tocilizumab is recommended for the immunotherapy of patients with extensive lung lesions and severe cases that show an increased level of il in laboratory testing. the efficacy of tocilizumab in covid- patients still needs to be investigated. in , chinese traditional medicine was used to prevent and treat sars [ ] . in , during the pandemic of h n influenza, the traditional chinese medicine of china issued a chinese traditional medicine prevention program, which included several chinese herbal medicine formulae for the prevention of infection of adults and children. shufengjiedu capsules and lianhuaqingwen capsules have also played a role in the prevention and treatment of new respiratory infectious diseases such as influenza a (h n ) [ , ] . some studies have confirmed that yupingfeng powder has antiviral, antiinflammatory and immunoregulatory effects [ ] . a multicenter, large-scale, randomized trial found that yinqiao powder plus another heat-clearing formula could reduce time for fever resolution in patients with the h n influenza virus infection [ ] . it is suggested that high-risk populations exposed to covid- patients, including medical staff, family members, and other people who are in close contact with covid- patients, as well as residents living in covid- outbreak areas, might benefit from taking chinese traditional medicine formulae for prevention. however, the efficacy and safety of these chinese traditional medicine formulae in covid- need to be further confirmed by clinical trials. the convalescent plasma derived from the patients with antibodies against -ncov can be effective in reducing the mortality rate of critically ill patients with infectious disease [ ] . convalescent plasma has been found to have an immunotherapeutic potential for the treatment of mers, sars and ebola virus disease [ ] [ ] [ ] . the explanation for the efficacy of convalescent plasma therapy is that antibodies from convalescent plasma might suppress viremia via free viral clearance, blockade of new infection, as well as the acceleration of infected cell clearance [ ] . in addition, the use of high-titer mers serum from camel could significantly improve the histology of lung damage and increase the clearance of mers-cov in mice [ ] . moreover, the use of convalescent plasma or serum was also suggested by who under blood regulators network when vaccines and antiviral drug was unavailable for an emerging virus. evidence shows that convalescent plasma therapy is not associated with the occurrence of severe adverse events [ ] . convalescent plasma, if available, can be used for the treatment of critically ill patients with covid- after the evaluation of the valence of antibody. it is worthwhile to test the efficacy and safety of convalescent plasma transfusion in covid- patients. a meta-analysis showed that among patients with -ncov infection, the incidence of ards is approximately % [ ] . moreover, between % to % of patients admitted to icu have hypoxemia/or development of respiratory exhaustion [ ] . therefore, timely and effective respiratory support can contribute to reduce complications and improve the survival of such critically ill patients. oxygen therapy, high-flow nasal cannula, and non-invasive ventilation may reduce the need of endotracheal intubation and decrease ventilator-associated complications and mortality. however, several studies have reported that the failure of non-invasive ventilation was up to % in which invasive ventilation was ultimately required in the treatment of severe influenza a (h n ) in canada [ ] . non-invasive ventilation may be effective and safe for some patients, whereas it might increase virus transmission to health care workers because of risk for infected aerosol generation. therefore, for the treatment of -ncov, non-invasive ventilation may be used in selected patients in early stages with milder acute hypoxemic respiratory failure [ ] . while for critically ill patients, the effectiveness of transitionally oxygen therapy, such as respiratory status and oxygen index (po / fio ), needs to be closely monitored and it should be switched to mechanical ventilation when necessary. high-flow nasal cannula has emerged as an alternative to non-invasive ventilation to prevent intubation and reduce mortality in patients with acute hypoxemic respiratory failure [ ] . high-flow nasal cannula has been reported to significantly reduce -day mortality of community-acquired pneumonia compared with standard oxygen or non-invasive ventilation [ ] . hui et al. have shown that the breath dispersion distance is limited therefore lowering the risk of air transmission. however, the loose connection of the cannula with nasal obstruction can significantly increase the dispersion distance [ ] . wearing masks (particularly n ) can effectively reduce the breath dispersion distance during high-flow nasal ventilation to prevent nosocomial transmission [ , ] . in addition, high-flow nasal cannula might increase virus transmission risk due to aerosol generation. therefore, staff protection of health care workers is critical. mechanical ventilation for patients with severe ards should be managed with lung-protective strategies to minimize ventilator-associated lung injury and to improve survival. the approach to minimize ventilatorassociated lung injury and to improve survival includes: ventilation with low tidal volumes ( to ml/kg of predicted body weight), targeting plateau pressure (< cmh o) [ ] , and minimizing the inspired oxygen concentration to decrease oxygen toxicity. high positive endexpiratory pressure (peep) can reduce the need for high fio by improving gas exchange and lung compliance, whereas too high peep may lead to lung overdistension and hemodynamic instability. optimal peep which can be titrated by pressure-volume curve, oxygenation, stress index, electrical impedance tomography (eit), ultrasound, and some other clinical parameters is associated with improved survival rate among severe ards patients [ ] . lung recruitment needs to be evaluated for mechanically ventilated patients when uncorrectable hypoxemia occurs, and lung recruitment should be executed for patients whose lungs can restore aeration. ct, eit, ultrasound, and other bedside techniques should be used to evaluate lung recruitability before lung recruitment. for critically ill patients managed with mechanical ventilation, excessive spontaneous breathing due to stretching may lead to lung injury. therefore, neuromuscular relaxant may be used to control the spontaneous breathing and protect the lung. prone positioning ventilation is a technique that often improves oxygenation in ards, possibly through improvements in ventilation-perfusion matching, the uniformity of ventilation, and gravity-related atelectasis. prone ventilation was used in mechanically ventilated sars patients without enough data to draw any conclusion with regard to its efficacy [ ] . although prone ventilation showed no improvement in survival or organ dysfunction overall, it might be beneficial for patients with severe ards. a multicenter rct demonstrated that early application of prone positioning in patients with severe ards resulted in decreased mortality [ ] . in addition, the use of prone positioning in patients with h n influenza-induced severe ards was shown to be related with improved oxygenation, sustained after returning to a supine position, and with decreased carbon dioxide retention [ ] . generally speaking, prone positioning ventilation for no less than h daily is a relatively safe procedure that rarely worsens a patient's respiratory status. it can be thus recommended for the treatment of -ncov-induced severe ards. ecmo has become the important life-support strategy for the standardized treatment of ards patients. ecmo should be considered as early as possible when the lung recruitment and prone positioning ventilation show to be ineffective. observational studies have reported that patients with ards induced by h n influenza showed lower hospital mortality with transfer to an ecmo center compared with matched non-ecmo-supported patients [ ] . the use of ecmo also showed survival benefit in patients with severe mers [ ] . ecmo tends to improve patient outcomes when used among those with limited organ failures and good pre-morbid functional status [ ] . substantial proportion of critically ill patients with covid- appear to have developed cardiac arrhythmias or shock [ ] , and may need ecmo support. however, for those who will develop septic shock or refractory multiple organ failure, ecmo is not suggested due to its less benefit. ecmo is a resource-intensive, highly specialized and expensive form of life support with potential for significant complications such as hemorrhage and nosocomial infection. therefore, the use of ecmo should be strictly limited in the treatment of covid- . moreover, since the number of critically ill patients is still increasing and the resource of ecmo is finite, judgment is needed to decide when ecmo may be worthwhile and when it may not. support with ecmo is supposed to be for the most critically ill patients in regions with extensive resources for this therapy [ ] . for patients with ards, restrictive and timely fluid resuscitation is associated with better oxygenation and lower mortality. aggressive fluid administration may worsen oxygenation and ventricular dysfunction, which may result in longer duration of mechanical ventilation and even mortality. therefore, it is necessary to assess fluid responsiveness and to evaluate ventricular function during fluid resuscitation. conservative fluid administration while maintaining adequate mean arterial pressure and organ perfusion with the appropriate use of diuretics and vasopressors is of importance [ ] . according to the latest epidemiological report, the incidence for the critically ill patients to develop multiple organ dysfunction syndrome is up to % [ ] . covid- may be combined with other organ injuries, including liver injury, cardiac dysfunction, coagulopathy, which may need the routine functional support for critically ill patients in icu. moreover, all the critically ill patients with covid- admitted into icu have negative nitrogen balance and malnutrition [ , ] , which has been considered as a contributing factor to the emergence of viral infectious diseases. therefore, appropriate nutritional strategy is pivotal for the treatment of critical illnesses when necessary. there are no specific antiviral drugs or vaccines for -ncov at present. therefore, it is important to enhance the host immune response against the infection with -ncov. all of the drug options are based on the experience treating sars, mers or some other previous influenza viruses. the efficacy of existing drugs as well as adjunctive pharmacologic interventions in the treatment of critical ill patients with covid- warrants further verification in clinical research. to completely stop the epidemic spreading of covid- , a vaccine for -ncov is urgently needed. besides enhancing the host immune responses against viral infection, appropriately respiratory supportive strategies, monitoring and support of multiple organ function, modulating the immune status and inflammatory responses individually, as well as the prophylaxis and treatment of complications are all important guarantee for the recovery of critically ill patients with covid- . for a better understanding of this novel virus, more research needs to be done to get optimal strategies for the treatment of covid- . a novel coronavirus from 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publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations the authors would like to express their appreciation for all of the health care workers and other hospital staff for their efforts in combating the outbreak of covid- . all the authors have participated in literature retrieval and viewpoint discussion. ll and rl have written this article under the supervision of dc and jl. all authors read and approved the final manuscript. not applicable. not applicable. not applicable. the authors declare that they agree for the publication of this article. the authors declare that they have no competing interests. key: cord- -j kg qf authors: jones, samuel l.; blikslager, anthony t. title: disorders of the gastrointestinal system date: - - journal: equine internal medicine doi: . /b - - - / - sha: doc_id: cord_uid: j kg qf nan however, the abdominal wall is too rigid to allow effective palpation of intraabdominal structures. abdominal auscultation is particularly useful for assessing the motility of the large intestine. progressive motility of the small intestine, conversely, is difficult to distinguish by auscultation from nonprogressive motility. the distinct character of the borborygmi produced during propulsive contractions of the cecum and ascending colon allow evaluation of the frequency and strength of retropulsion and propulsion. propulsive contractions of the cecum and ventral colon occur every to minutes and give rise to prolonged rushing sounds heard over long segments of intestine. retropulsive sounds presumably are similar to propulsive sounds, but they occur less frequently. the distinction of propulsion from retropulsion is not important clinically because both types of contractions signify normal motility. inter-and intrahaustral mixing contractions produce nonspecific sounds of fluid and ingesta movement that are difficult to distinguish from other borborygmi, such as small intestinal contractions or spasmodic contractions. auscultation over the right flank and proceeding along the caudal edge of the costal margin toward the xiphoid allows evaluation of the cecal borborygmi. auscultation over a similar area on the left side allows evaluation of the pelvic flexure and ascending colon. typical progressive borborygmi heard every to minutes on both sides of the abdomen indicate normal motility of the cecum and ascending colon. less frequent progressive sounds may indicate a pathologic condition of the large intestine or may result from anorexia, nervousness (sympathetic tone), or pharmacologic inhibition of examination of patients with disease of the gastrointestinal tract must include evaluation of the metabolic and cardiovascular status of the patient, because acute conditions of the proximal or distal intestinal tract have the potential to lead to endotoxemia and sepsis. examination of the cardiovascular system (heart, peripheral pulse, and mucous membranes), lungs, and abdomen is essential to detect clinical signs of systemic inflammation from endotoxemia, coagulation disorders, dehydration, ileus, shock, and other abnormalities resulting from injury to the small or large intestine. chapter . covers clinical signs of systemic inflammation from endotoxemia and sepsis. one performs the physical examination of the abdomen primarily by auscultation, transabdominal ballottement, and transrectal palpation. abdominal distention often indicates distention of the large intestine; however, small intestinal distention also can cause visible abdominal distention if a large proportion of the small intestine is involved. one can perform abdominal palpation in neonatal foals; after several weeks of age, motility (i.e., α -adrenergic agonists such as xylazine). [ ] [ ] [ ] absolute absence of any auscultable borborygmi suggests abnormal motility and indicates ileus resulting from a serious pathologic condition but is not specific to any segment of the intestine. , if borborygmi are audible but progressive sounds are not detectable, determining whether a significant abnormality exists is difficult. borborygmi heard more frequently than normal may result from increased motility following feeding; from excessive stimulation from irritation, distention, or inflammation; or after administration of parasympathomimetic drugs such as neostigmine. large intestinal motility increases in the early stages of intestinal distention regardless of the site. mild inflammation or irritation of the large intestinal mucosa also can stimulate motility. parasympathomimetic drugs stimulate contractions and auscultable borborygmi in the large intestine; however, an increase in parasympathetic tone may result in segmental contractions, which actually inhibit progressive motility. one can detect sand or gravel in the large intestinal ingesta by auscultation behind the xiphoid process. one can hear sand or gravel particles grinding together during progressive contractions of the ascending colon. the presence of sand in the ingesta becomes clinically detectable by auscultation or fecal sedimentation before the amount of sand is enough to produce clinical signs of pain or irritation (diarrhea). if progressive contractions are audible without hearing sand sounds, clinically important quantities of sand likely are not present. if the frequency of progressive contractions is low or absent, detecting sand by auscultation is difficult. percussion of the abdomen during auscultation can reveal gas in the large intestine. the characteristic ping produced by simultaneous digital percussion and auscultation over a gas-filled viscus often is associated with abnormal accumulation of gas under pressure. this technique is particularly useful in foals, ponies, and miniature horses because of the limitations of palpation per rectum. one can use transabdominal ballottement to detect large, firm masses or an abnormal volume of peritoneal fluid. the usefulness of this technique is usually limited to animals too small to palpate per rectum. one can detect soft tissue masses or fetuses by bumping the structures with a hand or fist. if excessive peritoneal fluid is present, one can generate a fluid wave by ballottement; however, this technique is not as useful in horses older than weeks because the abdominal wall is rigid. transrectal palpation is the most specific physical examination technique for investigation of intestinal disease and is particularly valuable when evaluating obstructive diseases. , the primary objectives of transrectal palpation are to assess the size, consistency, and position of the segments of the large intestine; to determine the presence of any small intestinal distention; and to detect intraabdominal masses. evaluation of the wall thickness and texture and the mesenteric structures (blood and lymphatic vessels and lymph nodes) also may aid in diagnosis of large intestinal disease. the interpretation of transrectal palpation findings in light of clinical signs and laboratory results is an important diagnostic aid for developing appropriate treatment strategies for intestinal diseases manifested by abdominal pain. enlargement of one or more segments of large intestine detected by transrectal palpation provides evidence of obstruction at or distal to the enlarged segment. by systematically evaluating each segment, one may determine the site of obstruction. obstruction of the pelvic flexure, for instance, results in enlargement of the pelvic flexure and ventral colon, but the dorsal and descending colons are of normal size. enlargement of a segment of the large intestine usually is accompanied by abnormal consistency of the contents. one may distinguish accumulation of gas, fluid, or ingesta and may detect foreign bodies in palpable segments. accumulation of gas and fluid infers complete and acute obstruction, whereas accumulation of ingesta infers chronic and incomplete obstruction. accumulation of fluid usually indicates ileus. one must evaluate the consistency of the contents in light of the size of the segment; ingesta in the ventral colon of a dehydrated patient may be firm, but the size of the ventral colon will be normal. conversely, if the ingesta is firm because of a distal obstruction, the ventral colon will be enlarged. displacement of a segment of the large intestine may create an obstruction detectable by enlargement of the segment and accumulation of gas and fluid, even if the site of obstruction is not palpable. torsion of the ascending colon at the sternal and diaphragmatic flexures results in acute accumulation of gas and fluid proximal to the torsion, causing distention of the left dorsal and ventral colons. depending on the degree of torsion, the position of the ventral and dorsal colons may not be significantly abnormal. displacement of a segment of large intestine often results in incomplete obstruction, and the diagnosis relies solely on detection of the displaced segment in an abnormal position. the position of the displaced segment may not be palpable, and the diagnosis then relies on the inability to find the segment in a normal position. one must take care to ensure that the segment that appears to be displaced is not in a normal position but has become too small to palpate from a decrease in the volume of ingesta. the cecum, right dorsal and ventral colons, pelvic flexure, and descending colon are palpable in most horses. one should palpate the nephrosplenic space to detect the presence of intestine, usually pelvic flexure, entrapped within the ligament. small intestine is not normally palpable in the horse. distention is an indicator of ileus with gas or fluid retention, usually following a strangulating or nonstrangulating obstruction. strangulating obstructions result from conditions such as volvulus or torsion, lipoma, or entrapments. such conditions often are accompanied by severe pain, dehydration, peritoneal fluid changes, and a varying degree of gastric fluid accumulation. the small intestine in these cases is turgid and firm on palpation. one should assess the mesentery and wall thickness as for large intestinal disorders. careful palpation of the inguinal rings in stallions with small intestinal distention is crucial for determining inguinal herniation. evaluation of the wall thickness and mesenteric vessels can reveal venous congestion (mural edema and enlarged blood and lymphatic vessels) or inflammation (mural edema with normal vessels). disruption of arterial blood flow does not cause venous congestion, but the arterial pulse is not detectable. mesenteric tears may not be palpable, but the entrapped ischemic intestinal segment may be thickened with edema. one may detect acute or chronic inflammation with cellular infiltration of the intestinal wall as thickening of the wall without edema and also may note enlargement of mesenteric lymph nodes. one should interpret abnormalities in the wall or vessels in light of the size, consistency, and position of the segment of intestine and the clinical signs. several conditions involving small intestinal strangulating lesions do not necessarily cause abnormal rectal examination findings until the disease has been present for an extended time. these conditions include diaphragmatic herniae and epiploic foramen entrapments. peritoneal fluid analysis may be normal in these cases as well because the fluid is trapped in the thorax or in the cranial abdomen. surgery is usually necessary for diagnosis. nonstrangulating causes of small intestinal distention can be divided further into intraluminal and extraluminal obstructions. ileal impactions are probably the most common cause of intraluminal obstructions, and on rare occasions one can palpate the impaction in the upper right quadrant, near the ileocecal opening. intraluminal masses caused by lymphoma, eosinophilic enteritis, foreign bodies or ascarid impactions often lead to small intestinal distention and are usually indistinguishable from one another based on palpation alone. small intestine in these cases can be moderately to severely distended, depending on the degree of obstruction. extraluminal obstructions include abdominal masses, abscesses or tumors, and large colon displacement. one always should palpate the rest of the abdomen carefully to help rule out these causes. some cases of small intestinal distention result from a physiologic rather than a mechanical obstruction. ileus may result postoperatively or following inflammatory diseases of the bowel (proximal enteritis) or peritoneal cavity (peritonitis). the bowel is usually mildly to moderately distended and almost always is accompanied by significant amounts of accumulated gastric fluid. the small colon is easily distinguishable by the presence of normal fecal balls and an antimesenteric band. in cases of impaction of the small colon, a long, hard, tubelike structure is present in the caudal abdomen, and the band is palpable along the length. fluid stool is often present in the rectum in these cases, as is tenesmus. one can detect and carefully evaluate rectal tears by palpation. one can detect mural masses in palpable segments of intestine or mesentery; however, if a mass causes obstruction, one can detect the result of the obstruction in proximal segments of intestine even if the mass is unreachable. palpation of the mesenteric vessels may reveal thickening and thrombosis, which can lead to ischemia or infarction. one can perform visual inspection of the mucosa of the rectum and descending colon with a speculum or flexible endoscope and also can evaluate rectal tears or perforations, mural masses, strictures, or mucosal inflammation. one also can perform guided biopsy of the mucosa or masses. the obvious limitations are the amount of fecal material interfering with the examination and the distance of the lesion of interest from the anus. these techniques offer little advantage over palpation in many cases unless the patient is too small to palpate. examination of the oral cavity in cases of dysphagia or weight loss is a necessary part of the physical examination. one should adequately sedate the horse and should use a full-mouth speculum to allow palpation and visualization of all parts of the oral cavity. one should examine the area for abnormal dentition, foreign bodies, fractures, abscesses, and ulceration. the presence of fluid accumulation in the stomach indicates a decrease or absence in propulsive motions of the small intestine or obstruction of gastric outflow. decreased small intestinal motility may result from a functional or mechanical blockage. masses, feed impactions, or strictures in the pylorus or in the proximal duodenum may obstruct gastric outflow. one routinely assesses fluid accumulation in the stomach by siphoning off the gastric contents with a nasogastric tube and examining the fluid for amount, color, and any particular odor. normal fluid is green and may contain foamy saliva. the volume obtained by gastric lavage is usually less than l. large volumes of fluid (> to l) accumulate in the stomach of horses with proximal enteritis, and the fluid is foul smelling and often has an orange to yellow discoloration. if one suspects proximal enteritis, one can submit the fluid for culture and gram staining. salmonella sp. and clostridium sp. have been cultured in some cases. patients with postoperative ileus also frequently accumulate large amounts of gastric fluid. horses with section . examination for disorders of the gastrointestinal tract strangulating obstructions or luminal obstructions often accumulate moderate amounts of gastric fluid, but the amount is generally less than in horses with proximal enteritis or postoperative ileus. hemorrhage in the gastric fluid usually indicates devitalized small intestine, stomach wall, or severe gastric ulceration. fluid with large amounts of food material often indicates a gastric impaction, and one should lavage the stomach until obtaining no more ingesta. horses and foals with chronic gastric ulceration in the glandular mucosa of the stomach or in the duodenum may develop strictures and have fluid accumulate in the stomach. endoscopy or contrast radiography aids in diagnosing gastric outflow obstruction. evaluation of the hemogram is essential when one assesses conditions of the gastrointestinal tract. however, hematologic alterations associated with diseases of the gastrointestinal tract are often nonspecific, reflecting systemic response to inflammation, endotoxemia, or sepsis. neutrophilic leukocytosis and normochromic, normocytic anemia with or without hyperfibrinogenemia commonly are associated with chronic inflammatory conditions of the intestine. anemia from chronic blood loss occurs infrequently in adult horses because of the large iron stores and high concentrations of iron in their diet; usually anemia follows chronic inflammation, as do alterations in the leukon and plasma fibrinogen concentrations. plasma protein concentrations vary depending on gastrointestinal losses of albumin and globulin and elevation of globulin concentration from antigenic stimulation. protein-losing enteropathies may manifest predominantly as a hypoalbuminemia or may have a concurrent hypoglobulinemia. immunoglobulin quantification can be useful in selected cases; immunosuppression with low immunoglobulin m concentration has been shown to occur in some cases of lymphosarcoma. parasitic infections, especially strongylosis, may be characterized by elevated serum immunoglobulin g(t) concentration. significant alterations of the hemogram do not accompany acute disease of the intestine unless severe inflammation, dehydration, endotoxemia, or sepsis is present. during the early stages of endotoxemia, elevations in circulating concentrations of inflammatory mediators, epinephrine, and cortisol produce characteristic changes in the hemogram. leukopenia, with neutropenia and a left shift, toxic changes in the neutrophil cytoplasm, and lymphopenia occur commonly. hemoconcentration and hyperfibrinogenemia are also common. thrombocytopenia and other coagulopathies are also features of endotoxemia. indeed, thrombocytopenia may be the earliest indicator of sepsis. endotoxemia and circulating mediators of inflammation activate the coagulation cascade, causing a hypercoagulable state that can lead to consumption of coagulation factors and coagulation defects manifested as elevated prothrombin time, partial thromboplastin time, fibrin degradation products, and bleeding time, and reduced activity of antithrombin iii. [ ] [ ] [ ] neutrophilic leukocytosis occurs during the later stages of endotoxemia. the most common serum biochemical abnormalities with diseases of the large or small intestine are electrolyte imbalances. serum calcium concentrations are often low with strangulating obstructions and acute inflammatory diseases. inflammation of the mucosa can disrupt electrolyte fluxes severely. diarrhea or gastric reflux greatly exacerbates the loss of sodium, potassium, calcium, magnesium and bicarbonate. ischemia of the intestine causing hypoxia and cellular damage may be reflected by an elevated serum phosphate concentration resulting from phosphate leakage from damaged cells. ischemia and cellular hypoxia in any segment of the intestine also causes a shift in energy metabolism to anaerobic glycolysis, resulting in increased production of lactate and elevated serum lactate concentration. reduced perfusion of peripheral tissues from hypotensive shock and intestinal ischemia can cause elevations in serum lactate. however, obstruction of the intestine during ischemia may result in absorption of lactate from the lumen. , anion gap is an indirect measurement of organic acid production during states of tissue hypoxia and is a reasonable estimate of serum lactate concentration. metabolic acidosis may accompany lactic acidemia, but an inconsistent association exists between the two, especially when mixed acid-base imbalances are present. , elevations of hepatic enzymes, specifically γ-glutamyltransferase, may occur with large colon displacements, duodenal strictures, or anterior enteritis. relative polycythemia from hemoconcentration or splenic contraction and changes in red blood cell deformability from hypoxia or hypocalcemia may increase blood viscosity. blood viscosity increases in patients with acute obstructive disease. hyperviscosity reduces perfusion of capillary beds, thereby exacerbating ischemia and tissue hypoxia. hyperviscosity is one manifestation (along with lactic acidemia, coagulopathies, and clinical signs of shock) of the pathophysiologic events that take place during acute inflammatory or vascular injury to the large intestine. laboratory tests designed to reflect the systemic effects of endotoxemia, ischemia, sepsis, and shock are important to design therapeutic strategies, and monitor response to therapy. abdominocentesis and analysis of peritoneal fluid (pf) is a diagnostic technique performed on many patients with disease of the gastrointestinal tract. one can quantitate cytologic examination of pf; white blood cell and red blood cell counts; protein, fibrinogen, lactate, phosphate, and glucose concentrations; lactate dehydrogenase, creatine kinase, and alkaline phosphatase activity; and ph. the results of pf analysis may help establish a specific diagnosis but more importantly may reflect inflammatory, vascular, or ischemic injury to the intestine requiring surgical intervention. pf reflects a sequence of events that takes place during acute vascular injury to the intestine. the pf protein concentration first increases, followed by an increase in the red blood cell count and fibrinogen concentration. a transudative process resulting from vascular congestion and increased endothelial permeability allows small macromolecules (albumin) to escape into the pf, followed by larger macromolecules (globulin and fibrinogen), and finally diapedesis of cells (red blood cells, then white blood cells). , if ischemic inflammation of the intestine and visceral peritonitis occur, an exudative process ensues. severe inflammation of the intestine and visceral peritoneum causes large quantities of protein and white blood cells, primarily neutrophils, to escape into the pf. as damage to the bowel progresses, the protein concentration and red blood cell and white blood cell counts continue to rise. as the degree of irreversible damage to the intestine increases, the pf characteristics become more exudative. , eventually, bacteria begin to translocate across the intestinal wall and appear in the pf as the mucosal barrier breaks down. neutrophils predominate, and their cytoplasm becomes granulated, and döhle bodies often are visible. if perforation occurs, bacteria and particles of ingesta appear in the pf, and the neutrophils become degenerate, that is, pyknotic, with karyorrhexis, karyolysis, and smudge cells. elevated pf protein concentration is a sensitive indicator of early inflammation, whereas elevated red blood cell counts in the presence of normal white blood cell counts suggest vascular damage without significant tissue ischemia. elevation of the white blood cell count usually indicates severe tissue inflammation or intestinal injury. the gross color of the pf can be helpful in detecting injury and necrosis of the intestine. a serosanguinous appearance indicates vascular injury, whereas orange or brown-red indicates necrosis with the release of pigments such as hemosiderin. serial samples of pf are most useful in determining the nature and extent of damage to the intestine, but in many cases of ischemia, irreversible tissue damage has occurred by the time pf abnormalities appear. tissue hypoxia and ischemia cause a rapid elevation of pf lactate dehydrogenase, creatine kinase, and alkaline phosphatase activity and lactate concentration. , , phosphate concentration increases when cellular disruption occurs. pf enzyme activities, phosphate, and lactate concentration increase faster and higher than serum activities. [ ] [ ] [ ] pf ph and glucose concentration tend to decrease during intestinal ischemia, but not as low as in septic peritonitis. although biochemical alterations may provide early indicators of intestinal ischemia and necrosis, they are nonspecific and offer no advantage over conventional methods of pf analysis in many cases. pf alkaline phosphatase has been shown to arise predominantly from degenerating white blood cells, and elevations of other enzyme activities may occur with many inflammatory diseases. thus the specificity of many tests run on pf is questionable. however, in selected cases in which conventional pf analysis and physical examination do not provide sufficient information to develop a treatment plan, biochemical analysis of the pf may be useful. cytologically examined cells of the pf may reflect chronic inflammatory conditions of the large intestine, especially eosinophilic or lymphocytic processes. infectious and inflammatory conditions often cause increases in the neutrophil count and may be indistinguishable unless bacteria are visible. one also may detect neoplastic diseases by pf examination. chronic infection and inflammation may be associated with elevated pf protein and fibrinogen concentrations. culture of pf usually is required to distinguish bacterial infections from noninfectious inflammation unless bacteria are visible on cytologic examination. however, culture of pf is often unrewarding because factors that are found in inflammatory pf inhibit bacterial growth, and leukocytes phagocytose many bacteria in the pf. decreases in pf glucose concentrations (< mg/dl) and ph (< . ) are early indicators of a septic process. the glucose concentration and ph in the pf should approximately equal the blood glucose concentration and ph. a pf fibrinogen concentration greater than mg/dl also indicates bacterial infection. gross examination of the feces can provide information about digestion and transit time in the large intestine. large fiber particles in the feces represent poor mastication or poor digestion in the large intestine. small, mucuscovered, hard fecal balls indicate prolonged transit through the descending colon, whereas increased fluidity implies decreased transit time. feces containing sand or gravel are not necessarily abnormal. however, a significant amount of sand implies that large quantities are present in the colon. frank blood indicates substantial bleeding into the distal colon (right dorsal colon and/or small colon) from mucosal damage. laboratory analysis of the feces is performed frequently in cases of diarrhea. fecal cytologic examination and tests for occult blood detect mucosal inflammation, section . examination for disorders of the gastrointestinal tract erosion, or ulceration. severe inflammatory diseases in human beings, invasive bacterial infections in particular, have been shown to increase the shedding of leukocytes in the feces. a higher percentage of horses with salmonellosis and diarrhea have fecal leukocyte counts greater than cells per high power field than horses with negative fecal cultures for salmonella. these results suggest that high fecal leukocyte counts indicate salmonellosis in horses with diarrhea. however, the specificity of this test is probably low. low fecal leukocyte counts do not rule out salmonellosis. fecal occult blood tests detect blood in the feces, presumably from erosion or ulceration of the mucosa, but do not distinguish the source of the blood. large volumes of blood ( to l) given by nasogastric tube were required to produce a positive test for occult blood in the feces, but the amount of blood originating from the large intestine required to produce a positive test is unknown. a positive test implies significant hemorrhage into the gastrointestinal tract. newer, more sensitive tests detect not only occult blood but also degraded blood and may be useful to determine the site and quantity of blood loss. a positive test implies significant hemorrhage into the gastrointestinal tract. bacteriologic examination of the fecal flora has been used to quantitate specific bacterial species in the feces of horses with diarrhea. quantitation of clostridial species may be beneficial in diagnosing clostridial infection of the large intestine. tests to detect clostridial toxins in intestinal contents or feces are important to determine whether clostridia cultured from the feces are causing disease. the most common bacterial pathogens isolated from the feces of horses are salmonella and clostridium. the number of salmonella organisms isolated from the feces of horses with clinical salmonellosis is usually higher than from horses with asymptomatic infections. however, the volume of feces in many cases of acute diarrhea is high, and the concentration of salmonella organisms may be lower than would be expected, accounting for many false-negative fecal cultures. the sensitivity of fecal cultures for detecting salmonella infection may be as low as %. culture of five consecutive daily fecal samples is recommended to increase the sensitivity of the test. because salmonellae are intracellular organisms, culture of rectal scrapings or a rectal biopsy sample, along with fecal material, may increase the sensitivity of culture for detecting salmonella infection to %. one can perform a polymerase chain reaction assay on fecal samples to detect dna from salmonella sp. the polymerase chain reaction test is more sensitive than culture and is frequently positive in clinically normal horses that continuously shed small amounts of bacteria. polymerase chain reaction or immunologic tests also may detect clostridium perfringens and c. difficile exotoxins in the feces. qualitative fecal examination is a technique to detect nematode and cestode ova, protozoan oocysts, parasitic larvae, and protozoan trophozoites. a direct smear of fecal material is a rapid method to screen feces for ova and oocysts, to detect parasite larvae and trophozoites, and to observe motility of ciliates and parasite larvae. fecal flotation is a more sensitive technique for isolating and detecting ova and oocysts because the eggs are concentrated from the sample. zinc sulfate and sucrose solutions are often used to concentrate less dense ova and oocysts. zinc sulfate produces less distortion of trophozoites and larvae than sucrose solutions. fecal sedimentation is particularly appropriate for ciliates, giardia, and trichomonads. quantitative techniques such as the cornell-mcmaster method allow one to estimate the number of eggs per gram of feces and are most appropriate in monitoring parasite control programs. survey radiography of the normal esophagus is usually unrewarding but may be useful in horses with esophageal obstructions to determine the extent and location of the obstruction. one may detect foreign bodies or soft tissue masses, and in cases of esophageal rupture, one may see free air and ingesta in the tissues surrounding the esophagus and may observe pneumomediastinum. thoracic radiographs may be necessary to detect intrathoracic esophageal obstructions, megaesophagus, or cranial mediastinal masses causing extraluminal obstruction. one may use barium swallows or double-contrast esophagrams after resolution of the obstruction to determine whether a stricture or diverticulum or other underlying disorder is present. barium sulfate is the usual contrast medium and can be administered orally via a dose syringe or by nasogastric tube ( to ml of a % barium sulfate suspension or barium paste). oral administration is preferred for evaluation of swallowing and lesions in the proximal esophagus. administration of contrast using a nasogastric tube (preferably cuffed) allows for delivery of larger volumes of barium (up to ml) but should be performed without sedation if possible. one can follow administration of contrast material with air insufflation to create a double-contrast effect. if one suspects a rupture of the esophagus or if the likelihood of aspiration of the contrast material is high, one should use iodinated organic compounds in an aqueous solution as contrast material. contrast radiography may be the most definitive method for the diagnosis of primary megaesophagus or other functional disorders such as autonomic dysautonomia (grass sickness) affecting the esophagus. one should take care when interpreting esophageal radiographs if the horse is sedated. acepromazine or detomidine administration causes esophageal dilation in normal horses, especially after passage of a nasogastric tube. radiography of the adult equine abdomen is an effective technique in detecting radiodense material in the large intestine, such as enteroliths, sand, and metallic objects. , one survey demonstrated that radiography has . % sensitivity and . % specificity for diagnosing enterolithiasis. radiography also can be a useful tool for detecting sand accumulation in the colon that causes diarrhea or impactions ( figure . - ) and for monitoring resolution in medically treated horses. the large size and density of the adult abdomen precludes evaluation of soft tissue structures because the detail and contrast of the radiographs are usually poor. one is more likely to obtain diagnostically useful abdominal radiographs from small ponies and miniature horses than from full-size adult horses. accumulation of gas is visible on radiographs of adult horses, but distinguishing normal intestinal gas from obstruction is often difficult. horses should be fasted for to hours to reduce the amount of ingesta in the large intestine before radiography. abdominal radiography is more useful in foals than in adult horses. radiographs are more detailed and contrast can be good. radiographic evidence of gas distention in the large intestine may indicate large intestinal obstruction, and radiographic signs of displacement are often diagnostic. one may diagnose impactions, intussusceptions, foreign bodies, and other disorders with the aid of radiography. functional ileus may be difficult to distinguish from mechanical obstruction. , administration of contrast (barium sulfate % at ml/kg) via nasogastric tube increases the diagnostic capabilities of radiography. gastric ulceration also is recognizable with contrast radiography in the foal, although this is not as accurate a method as endoscopy. contrast administered retrograde via a -f foley catheter inserted into the rectum at a dose of up to ml/kg has excellent potential for diagnosing disorders of the small colon, transverse colon, and large colon in foals. ultrasonographic evaluation of the abdomen can add valuable information in cases of acute or chronic gastrointestinal disease. examination of the adult horse requires a . -to . -mhz transducer at minimum. one may use sector, linear, or curved linear transducers. clipping of the hair over the area to be examined, along with the application of isopropyl alcohol and ultrasound coupling gel, enhances evaluation. to evaluate the abdomen adequately, one must know the anatomic location and normal appearance of the individual organs. in the left cranial abdomen, one can assess the greater curvature of the stomach between the eleventh and thirteenth intercostal space, and one can use the spleen and the large splenic vein as landmarks. cases of gastric dilation from gas or impaction appear as an enlargement of the viewing area to cover greater than five rib spaces. one also can evaluate the stomach for intramural or extramural masses such as abscesses or for squamous cell carcinoma. the lesser curvature is not routinely visible. assessment of the small intestine should include evaluation for changes in thickness, motility, location, and visibility. one may find small intestinal loops easily in the left lower quadrant of the abdomen, but these normally are visible in other locations. one can visualize the duodenum consistently on the right side of the abdomen deep to the liver in the tenth to twelfth intercostal space or deep to the right kidney at the fifteenth to sixteenth intercostal space. mural thickening (> mm) may occur in cases of infiltrative or proliferative diseases, postoperative cases, enteritis, and paralytic or mechanical ileus. thickening of the small intestinal wall in foals, with or without the presence of gas shadows within the wall, should raise suspicions of clostridial enteritis. one can assess motility by monitoring a specific area for contractions over time. ultrasonography is an accurate method of distinguishing strangulating versus nonstrangulating disorders of the small intestine. strangulated small intestine has thicker small intestinal walls and larger intestinal diameter than in nonstrangulating disorders. strangulating lesions have decreased motility in the incarcerated segments with normal motility elsewhere. cases of paralytic ileus or nonstrangulating obstruction have a diffusely decreased peristalsis, but not to the degree observed with strangulating lesions. , one may diagnose some specific lesions of the small intestinal tract using ultrasonography. one may see ascarids in foals in cases of ascarid impaction and epiploic foramen entrapments as edematous loops of small intestine found in the right cranial abdomen. one may note small intestinal intussusceptions as targetlike lesions when viewed in cross sections. the presence of bowel loops, stomach, or liver in the thoracic cavity indicates the presence of herniation through the diaphragm and should be confirmed using radiography or surgical exploration. evaluation of the large intestine may be difficult because of the large amounts of gas within the lumen. however, certain disorders are readily identifiable via ultrasonography. one can assess the nephrosplenic ligament area for bowel entrapment in the left paralumbar fossa. in cases of entrapment, the spleen will be pulled away from the body wall and fluid or gas shadows will be observable dorsal to the spleen, obscuring the kidney, which is normally adjacent and abaxial to the spleen. small colon, small intestine, or pneumoperitoneum also may produce a gas shadow and obscure the kidney from view. sand impactions may appear as hyperechoic bands on the ventral abdominal wall. one may see ileocecal and cecocolic intussusceptions in the upper right paralumbar fossa. in cases of colitis, large, fluid-filled colons may be visible with or without intramural edema. one can find the right dorsal colon consistently abaxial to the liver, within the right thirteenth to fifteenth intercostal space and may be thickened (> mm) in cases of right dorsal colitis. evaluation of the abdomen always should include assessment of the peritoneal space for any evidence of an increased amount of pf or increased cellularity of the fluid as indicated by an increase in echogenicity. ultrasonography also can be useful in determining the ideal location for abdominocentesis. one also should evaluate the liver, kidneys, and spleen. one may detect choleliths, nephroliths, masses, abscesses, or enlargement of any of these organs. abscesses or tumors not associated with visceral organs may be difficult to visualize and interpret via ultrasonography. although more commonly used to diagnose lameness and musculoskeletal problems, nuclear scintigraphy has several uses for evaluation of the gastrointestinal tract. scintigraphy is now available at most universities and many private referral hospitals. one must use proper isolation protocols and waste disposal techniques strictly. the procedure requires special gamma cameras and the injection of radioactive materials into the bloodstream. one can use one of two methods: injection of technetium- m methylene diphosphonate ( m tc-mdp) directly into the blood or injection of m tc-labeled leukocytes. labeling of leukocytes involves aseptically collecting heparinized blood samples, isolating the buffy coat, and mixing those leukocytes with a radioactive dye ( m tc hexamethylpropyleneamine oxime, or m tc-hmpao) in vitro. one then reinjects the labeled leukocytes and obtains images. the principle of nuclear scintigraphy then lies in increased uptake of the dye or the white blood cells into areas of inflammation. one of the most common uses of nuclear scintigraphy in evaluating the gastrointestinal tract is diagnosis of dental disease. scintigraphy using m tc-mdp proved to be more sensitive in cases of dental disease than was radiography. scintigraphy was slightly less specific, however, and therefore should be used with radiography or computed tomography for ultimate accuracy. scintigraphy using radiolabeled white blood cells can support a diagnosis of right dorsal colitis in the horse. images taken of the abdomen hours after injection showed an increased linear uptake of leukocytes in the region of the right dorsal colon in horses with right dorsal colitis compared with normal horses. this technique also may prove useful for diagnosing intraabdominal abscesses in the horse. other uses of nuclear scintigraphy include evaluation of metastasis of abdominal tumors to bony areas, assessment of biliary kinetics, and determination of gastric emptying times. [ ] [ ] [ ] endoscopy endoscopic examination of the gastrointestinal tract begins with evaluation of the pharyngeal area by examination for any signs of collapse or dysfunction. one should evaluate the ability of the horse to swallow. the floor of the pharynx should be clean and free of feed material and foreign bodies. one can examine the oral cavity with the horse under heavy sedation or anesthesia and with the help of a full-mouth speculum. one can examine the teeth for any irregularities, obvious cavities, sharp points, or hooks and the hard and soft palpate for completeness and any evidence of ulceration, masses, or foreign bodies. one should use a -m flexible fiberoptic endoscope to examine the esophagus, which is accomplished best by passing the endoscope into the stomach and viewing the esophagus as one withdraws the endoscope while dilating the lumen with air. the esophageal mucosa normally should be a glistening, light pink color. ulceration can occur with cases of choke, reflux esophagitis or in horses that have had an indwelling nasogastric tube. erosions may be punctate, linear, or circumferential. one should evaluate carefully for any ulcers to ensure that no areas of perforation through the entire thickness of the esophageal wall exist. distinguishing normal peristaltic contractions from areas of stricture requires observation of the area and its motility over time. one also may note diverticula as outpouchings of the mucosa, sometimes associated with a stricture distally. megaesophagus, although rare, appears as a generalized dilation of the esophagus. one may detect food or foreign body impactions of the esophagus via endoscopy. one always should reevaluate the esophagus after removing any obstruction to detect the presence of complications (ulceration, rupture) or initiating causes (strictures, diverticula, and masses). a -m flexible endoscope also allows examination of the stomach. the horse should be fasted for at least hours before endoscopy. one can examine the cardia and fundus easily, as well as the margo plicatus. the squamous mucosa should resemble the esophageal mucosa. the glandular mucosa should be glistening red and may have a reticulated pattern. one should carefully examine for evidence of ulceration or masses. one can obtain transendoscopic biopsy material easily from esophageal, pharyngeal, or gastric masses, and because the biopsy size will be small, one should take several samples for histopathologic examination. pharmacologic agents (bethanechol) to empty the stomach and provide complete visualization of the entire fundic region, the pylorus, and the duodenum may be useful. for a complete description of gastroscopy and evaluation of gastric and gastroduodenal ulceration, please refer to chapter . . d-glucose or d-xylose absorption tests are useful in determining malabsorption of carbohydrates from the small intestine in horses. the protocol for absorption tests using either carbohydrate is similar. the horse should be fasted for to hours before testing. increased periods of fasting actually have been shown to decrease absorption of d-xylose and interfere with results. one administers a dosage of . to g/kg of d-glucose or d-xylose via a nasogastric tube. administration of sedatives may increase the blood glucose levels falsely and interfere with gastrointestinal transit times. one then collects blood samples to measure glucose or xylose concentrations at , , , , , , , , and minutes after administration. one may take additional samples up to hours after dosing if the results are questionable. one should measure glucose in blood samples collected with sodium fluoride as an anticoagulant and measure xylose in samples collected in heparinized plasma. a normal d-glucose absorption test, also known as an oral glucose tolerance test, should have a peak between and minutes, and this peak should be greater than % above the resting glucose value. complete malabsorption is defined as a peak less than % above the resting levels, and partial malabsorption is defined as a peak between % and % above the resting level. one must keep in mind that gastric emptying, gastrointestinal transit time, length of fasting, cellular uptake and metabolism, and endocrine function influence glucose absorption curves. malabsorption demonstrated by the oral glucose tolerance test is sensitive but not specific. diseases that may cause a lowered or delayed peak include infiltrative lymphosarcoma, inflammatory bowel disease (lymphocytic-plasmacytic or eosinophilic), cyathostomiasis, chronic colitis (salmonella sp.), multisystemic eosinophilic epitheliotropic disease, food allergies, and small intestinal bacterial overgrowth. d-xylose absorption tests have some advantages over the oral glucose tolerance test because xylose is not metabolized in the small intestinal mucosa and insulin does not influence its absorption. gastric and intestinal motility, intraluminal bacterial overgrowth, and renal function still influence xylose absorption, because the kidneys clear xylose. the other main drawback to d-xylose is that it is generally available only in research settings. however, xylose measurements are available at most major universities. a normal d-xylose absorption curve should peak between and mg/dl at to minutes after dosing. decreased xylose absorption can occur in horses with inflammatory bowel disease, lymphosarcoma, multisystemic eosinophilic epitheliotropic disease, cyathostomiasis, extensive small intestinal resections, and any cause of villous atrophy. maldigestion is a common occurrence in foals with diarrhea. bacteria (especially clostridium sp.) and viruses (especially rotavirus or coronavirus) may invade and destroy the villous epithelial cells that manufacture lactase and other disaccharidases, resulting in an inability to digest lactose. in this case, continued ingestion of the mare's milk may cause an osmotic diarrhea, which may exacerbate the underlying enterocolitis. one can perform lactose tolerance testing to assess the degree of maldigestion. one administers d-lactose at g/kg as a % solution via nasogastric tube and measures glucose concentrations in the blood at , , , , , , , , and minutes. a normal curve shows doubling of glucose levels compared with baseline by minutes after administration. accurate measurement of gastric emptying can be difficult to assess. several methods are currently available. multiple diagnostic imaging techniques have been used to study gastric emptying times. one can use contrast radiography to assess gastric emptying in foals. in the normal foal, barium remains in the stomach for varying amounts of time, but a significant amount should be gone within hours. gastric emptying of solid, nondigestible, radiopaque markers also has been used in adult horses and ponies, but the results were variable and unpredictable even in the normal horse. nuclear scintigraphy is used commonly in human beings to measure gastric emptying and can be used in horses where available. this technique requires oral administration of m tc pentenate ( mci), and serial images taken of the cranial abdomen. the tracer is usually not visible minutes after administration in normal horses. alternatively, if nuclear scintigraphy is not available, one can use acetaminophen absorption testing as an indirect determination of gastric emptying. , one performs this test by administering mg/kg of acetaminophen orally and measuring subsequent blood values and calculating the time to reach maximum serum concentrations and the absorption constant. in human beings, the proximal small intestine absorbs almost all of the acetaminophen. the median time to reach peak plasma levels using acetaminophen absorption in horses was . minutes. one often requires histopathologic examination of tissues from the intestine to diagnose chronic inflammatory, infiltrative, or neoplastic conditions, and such examination can be useful in evaluating the extent of injury after obstruction or ischemia. rectal mucosal biopsies are easy to collect with few complications. however, to collect a full-thickness biopsy of the intestine requires a surgical approach (flank or ventral midline approach). laparoscopy offers a safer technique to observe the large intestine and other abdominal structures. one can obtain biopsies of masses, lymph nodes, mesentery, or intestinal serosa via laparoscopy and mucosal biopsies of the upper gastrointestinal tract via endoscopy. other diagnostics, specifically laparoscopy and computed tomography, are available but require specialized equipment and personnel with specific training. flexible or rigid endoscopes used for laparoscopic evaluation of the abdomen allow for visualization of visceral organs and potentially for collection of biopsy material from masses or organs. full-thickness biopsies of the intestines are not routinely possible through the laparoscope and usually require flank or ventral midline laparotomy. the laparoscopic procedure can be done in the standing or recumbent horse. advantages of this technique over a flank or ventral midline celiotomy include smaller incisions, less healing time, and less procedure time. disadvantages include the large amount of equipment needed, skill involved, and the limitation as a diagnostic modality, rather than a treatment. clinical applications of diagnostic laparoscopy include rectal tears, percutaneous abscess drainage, assessment of adhesions, displacements, and integrity of the serosa of various bowel segments, and biopsy of abdominal masses. computed tomography scans are available at several universities across the country. they have been used frequently to evaluate dental disease and may be useful in evaluating tumors and masses of the head, larynx, pharynx, and proximal esophagus. computed tomography also has promise for evaluating abdominal disorders in foals. most equipment can accommodate up to lb. restrictions to computed tomography as a diagnostic aid include expense, availability, expertise, and weight and size limitation. permeability increases, cells are recruited rapidly into the tissue, plasma protein cascades are activated, and a myriad of soluble products are released that coordinate the response, trigger innate and adaptive immunity, and mobilize reparative elements. although the cellular and vascular response and the secreted mediators of inflammation are important for killing pathogens and limiting invasion of injured tissues by commensal organisms, they can be damaging to host cells and proteins if not tightly regulated. thus if the inciting stimulus is not eliminated quickly, the inflammatory response itself causes significant tissue injury. the mechanism regulating inflammation has been the focus of much research to identify therapeutic targets to modulate the damage to host tissues during many gastrointestinal diseases. recent work has provided some of the molecular and cellular details of this complex physiology and has led to novel therapeutic strategies for treating inflammation. the gastrointestinal epithelium interfaces with a luminal environment inhabited by potentially hostile microbial organisms. the epithelium presents a physical barrier to invasion by the flora of the gastrointestinal tract, consisting of the apical cellular membrane, intercellular tight junctions the permeability of which is highly regulated, and a secreted layer of mucus. breaching of the mucosal barrier by invading pathogens generates potent soluble and neural signals that initiate an inflammatory response. conceptually, the epithelium can be thought of as a sensory organ detecting pathogen invasion to trigger an appropriate host defense and reparative response. noninfectious mucosal injury or invasion of epithelial cells by pathogenic organisms such as salmonella activates synthesis of proinflammatory chemokines (chemoattractants) by epithelial cells and triggers a robust influx of neutrophils into the tissue within hours of the damage. of the chemoattractants produced by epithelium, interleukin- (il- ) has a particularly important role in initiating inflammation by recruiting neutrophils from blood [ ] [ ] [ ] and regulating neutrophil migration through tissue matrix adjacent to epithelium. , bacteriaderived formylated chemotactic peptides also act as potent chemoattractants that are fully capable of stimulating a robust inflammatory response in the intestine if the epithelial barrier permits the diffusion of the peptides across the mucosa. epithelial cells activated during infection produce cytokines such as tumor necrosis factor α (tnf-α), arachidonic acid metabolites, and other proinflammatory mediators that activate recruited leukocytes. bacterial products, particularly lipopolysaccharide and other cell wall components, are potent activators of leukocytes recruited into the tissue. once the inflammatory response has been initiated, tnf-α, il- β, and other proinflammatory products of neutrophils, monocytes, mast cells, and epithelial cells amplify the inflammatory response. the enteric nervous system has a key role in sensing and regulating inflammatory responses in the intestine. for example, clostridium difficile toxin a activates a neural pathway that triggers mast cell degranulation and neutrophil influx into the tissue. , blockade of this neural pathway is sufficient to abolish the profound inflammatory response induced by toxin a and many of the effects of toxin a on enterocyte secretion. other pathogens and immune-mediated hypersensitivity reactions similarly stimulate inflammation by mechanisms that involve the enteric nervous system. thus the epithelium interacts in a highly complex manner with the intestinal milieu, the enteric nervous system, and inflammatory cells to regulate the tissue response to injury and infection. resident macrophages located in the lamina propria, submucosa, and intestinal lymphoid organs are among the first cells beyond the epithelium to respond to infection or injury. macrophages are activated by bacterial products via pattern recognition receptors and begin to produce proinflammatory molecules important for recruiting and activating neutrophils and monocytes. pattern recognition receptors recognize microbial products ranging from lipopolysaccharide to peptidoglycan and even cpg-containing bacterial dna and signal the invasion by pathogens. of the pattern recognition receptors, the lipopolysaccharide receptor complex is perhaps the best defined. lipopolysaccharide activates macrophages via the cd -toll-like receptor complex to initiate transcription of the inflammatory cytokines tnf-α and il- β, which synergize with lipopolysaccharide to amplify the macrophage response. lipopolysaccharide, particularly in concert with inflammatory cytokines, stimulates macrophages to produce copious amounts of nitric oxide, which is microbicidal and vasoactive. nitric oxide and other nitrogen radicals react with reactive oxygen intermediates (rois) to produce some of the most toxic molecules of the host defense system: the peroxynitrites. il- is produced as well to recruit neutrophils. as the response progresses, other inflammatory mediators, particularly the arachidonic acid-derived lipids, are produced. these lipids have potent vasoactive effects and are important stimuli of endothelial cells, neutrophils, and platelets. four important changes occur in the intestinal vasculature during inflammation: . alteration of blood flow . increased vascular permeability . increased adhesiveness of endothelial cells, leukocytes, and platelets . exposure of the basement membrane and activation of the complement, contact, and coagulation cascades a wide range of mediators alters blood flow during intestinal tract inflammation, from gasses such as nitric oxide (a major vasodilator of the intestinal vasculature) to lipids (prostaglandins, leukotrienes, thromboxanes, and platelet-activating factor), cytokines, bradykinin, histamine, and others. the major sources for these mediators include activated leukocytes, endothelial cells, epithelial cells, and fibroblasts. the primary determinant of blood flow early in inflammation is vascular caliber, which initially decreases in arterioles, but then quickly changes to vasodilation coincident with opening of new capillary beds, increasing net blood flow. the increase in blood flow is short lived, for the viscosity of the blood increases because of fluid loss and tissue edema through leaky capillaries. leukocyte margination, platelet adhesion to endothelial cells and exposed matrix, and areas of coagulation protein accumulation further decrease local circulation. inflammatory mediator actions on the endothelial cells initially increase vascular permeability. histamine, leukotrienes, platelet-activating factor, prostaglandins, bradykinin, and other mediators stimulate endothelial cell contraction, and interendothelial gaps form. , this stage of increased vascular permeability is readily reversible. concurrently, mediators such as the cytokines tnf-α and il- β induce a structural reorganization of the interendothelial junctions, resulting in frank discontinuities in the endothelial monolayer. cytokines also stimulate endothelial cells to express adhesion molecules that support adhesion of leukocytes and platelets, leading to the next and perhaps most devastating event. leukocytes (primarily neutrophils) and platelets adhere to exposed basement membranes and activated endothelial cells. adherent neutrophils and platelets then are exposed to the mediators of inflammation present in the surrounding milieu, which activates the cells to release oxidants and proteases (particularly elastase) that injure the endothelium and have the potential to cause irreparable harm to the microvasculature. [ ] [ ] [ ] marginated neutrophils begin to transmigrate between endothelial cells (as described in later sections), and if their numbers section . pathophysiology of gastrointestinal inflammation are large enough, they disrupt the integrity of the interendothelial junctions, worsening the vascular leakage. conceptually, these stages of enhanced vascular permeability can be thought of as a mechanism to allow plasma proteins to enter the tissues and to potentiate the critical influx of leukocytes into tissues. however, if not regulated precisely, alterations in hydrostatic and oncotic forces and irreversible damage to the vascular bed may have devastating consequences. moreover, inappropriate activation of plasma protein cascades and leukocytes by activated endothelium and exposed matrix proteins can contribute to systemic inflammation (systemic inflammatory response syndrome; see chapter . for more information) characterized by hypotension, generalized vascular leak syndrome, and multiorgan dysfunction, which may be fatal. phosphodiesterase inhibitors reduce endothelial permeability in ischemia-reperfusion injury and other models of inflammation-induced vascular leakage , by increasing endothelial tight junction integrity and thus may be a viable therapeutic strategy to prevent or reduce the permeability alterations associated with inflammation. endothelial cells respond to products of activated epithelial cells and macrophages in the intestinal tissue to recruit cells and humoral mediators of inflammation into the tissue. activated endothelial cells display a range of molecules critical for neutrophil and platelet adhesion. intercellular permeability increases to expose basement membrane proteins that trigger humoral defense systems (complement, coagulation, and contact system cascades) and to provide access for these macromolecules to the tissue. endothelial cells are an important source of inflammatory mediators that amplify the response and vasoactive substances (particularly nitric oxide) that alter blood flow. infection or injury to the gastrointestinal mucosa causes an influx of leukocytes from the blood that lay the foundation of the inflammatory response. neutrophils, being the first to arrive during inflammation, have a dominant role in the acute response. within minutes, neutrophils are recruited into the tissue where they are activated to release products that not only are proinflammatory and lethal to pathogens but also may damage host cells and tissues. not surprisingly, much attention has been paid to the role of neutrophils in the pathophysiology of many inflammatory conditions. neutrophil depletion is protective in many models of gastrointestinal inflammatory disease. of interest to clinicians, blockade of neutrophil migration into inflamed tissues prevents many of the pathophysiologic events associated with infectious enteritis, ischemia-reperfusion injury, and other gastrointestinal diseases. , [ ] [ ] [ ] [ ] [ ] neutrophil transendothelial migration is a multistep process that is temporally and spatially regulated and has a degree of cell type specificity ( figure . - ) . the predominant sites of neutrophil transendothelial migration are in the postcapillary venules and, in some tissues, the capillaries. endothelial cells in these vessels respond to cytokines and other soluble signals by expressing molecules that promote neutrophil adhesion and transmigration, including selectins and counterreceptors for integrins. as neutrophils flow through these vessels, they are first tethered to activated endothelium. tethering is mediated by selectin molecules expressed on neutrophils (l-selectin) and on activated endothelial cells (p-and e-selectins) that bind to p-selectin glycoprotein ligand- (psgl- ), e-selectin ligand- (esl- ), and other mucin counterreceptors. , tethering functions to increase the exposure of the neutrophil to activating chemokines presented on the surface of the endothelial cells. stimulation of neutrophils by il- and other chemokines activates the second step of transendothelial migration. chemokine binding to their receptors on the neutrophil generates signals that activate the binding of integrin adhesion receptors to their ligands, called intracellular adhesion molecules or vascular cell adhesion molecules expressed on endothelial cells in inflamed mucosa. integrin ligation to cellular adhesion molecules arrests the tethered neutrophils, resulting in firm adhesion to the endothelium. of the integrins expressed on neutrophils, the β integrins have a particularly important role in transendothelial migration. calves and human beings with a disorder known as leukocyte adhesion deficiency illustrate the requirement for β integrinmediated adhesion in neutrophil function. leukocyte adhesion deficiency results from an autosomal recessive trait causing the lack of the β integrin expression. the neutrophils from these individuals cannot migrate into most tissues and do not function normally, resulting in poor tissue healing and profound susceptibility to infection, especially at epithelial barriers. , other integrins also have a role in transendothelial migration. β integrins mediate transendothelial migration in some cells and seem to be particularly important for mediating emigration of monocytes into many tissues. following this firm adhesion step, neutrophils migrate through the endothelium along a chemotactic gradient of il- and other chemoattractants such as leukotriene b . , , neutrophils migrate across the endothelial monolayer at intercellular junctions via a mechanism involving a series of integrin-ligand interactions mediated by β and β integrins and other adhesion molecules that is generally capable of maintaining the integrity of the endothelial barrier. however, massive flux of neutrophils through the endothelium alters endothelial tight junctions and injures the basement membrane, resulting in increased endothelial permeability to molecules as large as plasma proteins and even endothelial cell detachment from the basement membrane. , nonintegrin molecules such as platelet/endothelial cell adhesion molecules (pecams) also are involved in transendothelial migration of neutrophils. homotypic binding of pecams on adjacent endothelial cells form part of the intercellular junction. neutrophils express an integrin of the β family that can bind pecam, and via sequential binding of β integrins to pecam, the neutrophil can , and other proinflammatory mediators. endothelial cells stimulated by inflammatory mediators produce chemoattractants (such as il- ) and display adhesion molecules that promote neutrophil emigration. the three steps of neutrophil (polymorphonuclear [pmn]) emigrationcapture/rolling (mediated by selectins), adhesion (mediated by β integrins), and transendothelial migration (mediated by integrins and platelet/endothelial cellular adhesion molecule [pecam])-occur on activated endothelium. chemoattractant molecules, such as il- trigger neutrophil emigration. in inflamed tissues, cytokines (il- β and tnf-α) and a variety of other proinflammatory mediators stimulate the neutrophil oxidase complex to produce reactive oxygen intermediates (rois; o and h o and their derivatives). activated neutrophils degranulate to release proteases and other hydrolases, cationic peptides (defensins), myeloperoxidase, and other products into the tissue. activated neutrophils synthesize a variety of inflammatory mediators, including prostaglandins (pge ) that modulate the inflammatory response. the products of activated neutrophils (rois, proteases, and mediators) stimulate epithelial secretion and alter tight junction permeability, promoting diarrhea. neutrophils eventually migrate across the infected epithelium by a mechanism that involves integrins, disrupting tight junction integrity and increasing permeability to bacterial products, thus exacerbating the inflammatory response. "unzip" the intercellular junction and migrate through, closing it behind itself. a key feature of neutrophils and other leukocytes is the requirement for integrin-mediated adhesion to extracellular matrix proteins (ecms) or other cells to achieve an optimal effector phenotype. critical components of the ecms in inflamed tissues include fibronectin, fibrinogen, and vitronectin, deposited in tissues as a result of plasma leakage and by synthesis of new proteins by stromal cells and resident macrophages in response to inflammatory mediator activation. the changing composition of the matrix proteins deposited in tissues during inflammation serves as a clue as to the nature of the tissue environment for recruited inflammatory cells as they become activated. individual gene expression studies have demonstrated that adhesion to matrix proteins induces the expression of cytokines and chemokines and their receptors, arachidonic acid-derived lipid mediator synthases, metalloproteinases, growth factors, transcription factors, and other genes that influence the differentiation and activation of inflammatory cells. roi production, phagocytosis, degranulation, and other effector functions stimulated by inflammatory mediators and bacterial products are optimal only when neutrophils adhere to the ecms. adhesion to distinct ecm proteins selectively activates signaling pathways and gene expression of neutrophils, monocytes, and other leukocytes with differing abilities to promote certain functions such that the composition of ecms in many ways controls the development of the ultimate effector phenotype. thus integrin-mediated adhesion provides a mechanism by which neutrophils and other leukocytes can sense the complex tissue environment and respond appropriately. of the activators of neutrophils at sites of inflammation, complement (c -opsonized particles), cytokines (tnf-α and il- β), platelet-activating factor, immune complexes, and bacterial products are among the most potent stimuli. other mediators produced during inflammation may modify neutrophil activity, particularly formylated bacterial peptides, chemokines, complement fragments (c a), leukotriene b , and prostaglandins. activated neutrophils are highly phagocytic; produce large amounts of rois; degranulate to release myeloperoxidase, cationic antimicrobial peptides (defensins), serine proteases (mainly elastase), and metalloproteinases; and secrete inflammatory mediators (tnf-α, il- β, prostaglandins, leukotrienes, and others) (see figure . - ). mast cells strategically reside in mucosal tissues, including the submucosa and lamina propria of the gastrointestinal tract, and constitute a crucial first line of defense at epithelial barriers. however, they are also important effector cells of the pathophysiology of inflammatory gastrointestinal diseases. experimental depletion of mast cells, genetic deficiency in the development of mast cells, or pharmacologic stabilization of mast cells to prevent degranulation have a protective effect in a variety of models of gastrointestinal inflammatory disease, including dextran-or trinitrobenzenesulfonic acid-induced colitis, , ischemia-reperfusion injury, , and immediate hypersensitivity responses. mast cells are activated by a wide variety of microbial products and host-derived mediators. among the activators of mast cells the so-called anaphylatoxins (complement fragments c a, c a, and c a), are potent stimuli causing release of mediators of inflammation. in addition, mast cells are the primary effector cells of immunoglobulin e-mediated anaphylaxis (type i hypersensitivity reactions) by virtue of their high affinity receptors for immunoglobulin e. cross-linking of receptor-bound immunoglobulin e on mast cell surface by antigens (i.e., food antigens) causes rapid degranulation, resulting in the explosive release of granule contents. neural pathways in the intestine also regulate mast cells. mast cells respond to enteric pathogen invasion via neural reflexes that stimulate the release of inflammatory mediators. activated mast cells release preformed histamine, -hydroxytryptamine, proteases, heparin, and cytokines from granules. activation also stimulates de novo synthesis of a range of inflammatory mediators, including prostaglandins, platelet-activating factor, and leukotrienes. transcription of a number of peptide mediators, such as the cytokines tnf-α and il- β among many others, also increases on stimulation of mast cells. mast cell products have profound effects on the vasculature, increasing endothelial permeability and causing vasodilation. moreover, mast cell-derived mediators greatly enhance epithelial secretion by a mechanism that activates neural pathways of epithelial secretion and directly stimulates epithelial cells. mast cell products significantly alter intestinal motility, generally increasing transit and expulsion of intestinal contents. mast cell-derived leukotrienes and tnf-α also have a crucial role in host defense against bacterial pathogens, acting to recruit and activate neutrophils. , mast cells have a newly identified role in host defense and inflammatory responses to bacterial pathogens, which in part is caused by the release of proinflammatory mediators during bacterial infection, which is critical for recruiting and activating other innate host defense cells such as neutrophils. however, mast cells are also phagocytic, have microbicidal properties, and can act as antigen-presenting cells to the adaptive immune system. although accumulating evidence was establishing the role of mast cells in innate immunity, a seminal study that unconditionally identified the importance of mast cells in host defense demonstrated that mast cell-deficient w/ w v mice have impaired responses to gram-negative bacterial peritonitis, resulting in a significant increase in mortality. the role for mast cells in host protective responses appears to be as a sensor of bacterial invasion. unlike immunoglobulin e-mediated responses, bacterial products seem to elicit a highly regulated and selective response from mast cells. the complement cascade is a fundamental part of the inflammatory response. activation of the complement cascade by immune complexes (classical pathway) or by bacteria or bacterial products, polysaccharides, viruses, fungi, or host cells (alternative pathway) results in the deposition of complement proteins on the activating surface and the release of soluble proteolytic fragments of several complement components. in particular, activation of either pathway results in the deposition of various fragments of the complement protein c , which are potent activators of neutrophils and monocytes. opsonization of particles with c fragments constitutes a major mechanism of target recognition and phagocyte activation. during the activation of the complement cascade culminating in deposition of c , soluble fragments of c (c a), c (c a), and c (c a) are liberated. these fragments, termed anaphylatoxins, have potent effects on tissues and cells during inflammation. perhaps most notably, anaphylatoxins are chemotactic for neutrophils (particularly c a), activate neutrophil and mast cell degranulation, and stimulate roi release from neutrophils. the termination of the complement cascade results in the formation of a membrane attack complex in membranes at the site of complement activation, and if this occurs on host cells such as endothelium, it may cause irreversible cell injury. although the primary source of complement is plasma, epithelial cells of the gastrointestinal tract also produce c , suggesting that local production and activation of the complement cascade during inflammation occurs in intestinal tissues. clearly, if the regulatory mechanisms of the complement cascade fail, then the inflammatory response may be inappropriate and tissue injury can occur. the role of complement in gastrointestinal inflammation has been most studied extensively in models of ischemia-reperfusion injury. activation of the complement cascades has a major role in altered endothelial and epithelial permeability in these models. several lines of evidence support the importance of complement in intestinal injury. mice deficient in c or c are protected against ischemia-reperfusion injury. moreover, administration of monoclonal antibodies against c reduced local and remote injury and inflammation during intestinal reperfusion injury in a rat model. administration of a soluble form of complement receptor , a regulatory protein that halts the complement cascade by dissociating c and c on host cell membranes, reduced mucosal permeability, neutrophil influx, and leukotriene b production during ischemia-reperfusion injury in rats and mice. , although neutrophils and mast cells mediate many of the pathophysiologic effects of the complement cascade, the membrane attack complex may have a primary role in altered vascular permeability during ischemia-reperfusion injury. four components initiate the contact system of coagulation: hageman factor (hf), prekallikrein, factor xi, and high-molecular-weight kininogen. hf is a large plasma glycoprotein that binds avidly to negatively charged surfaces. bacterial cell walls, vascular basement membranes, heparin, glycosaminoglycans, and other negatively charged surfaces in the intestine capture hf and the other three important initiators of the contact system in a large multimolecular complex. of the surfaces that bind hf, the extracellular matrix is a potent activator of the contact system. once bound, hf is converted to hf-α, which cleaves prekallikrein to kallikrein and factor xi to factor xia. the ultimate result is further cleavage of hf by kallikrein and triggering of the contact system cascade, activation of intrinsic coagulation by factor xia, activation of the alternative pathway by hf, and proteolytic cleavage of high-molecular-weight kininogen by kallikrein, releasing biologically active kinins. the products of the contact system, particularly bradykinin, have several important biologic properties that drive many of the vascular and leukocytic responses during inflammation. bradykinin induces endothelial cell contracture and intracellular tight junction alterations that increase vascular permeability to fluid and macromolecules. bradykinin also affects vascular smooth muscle contracture, resulting in vasoconstriction or vasodilation depending on the location. bradykinin also increases intestinal motility, enhances chloride secretion by the intestinal mucosa, and intensifies gastrointestinal pain. in neutrophils, kinins stimulate the release of many inflammatory mediators, including cytokines, prostaglandins, leukotrienes, and rois. kallikrein cleaves c to release c a, a potent chemotactic factor for neutrophils, and thus has a role in recruiting and activating inflammatory leukocytes. the plasma kallikrein-bradykinin system is activated in a variety of acute and chronic inflammatory diseases of the gastrointestinal tract. , recent evidence has demonstrated that blockade of the pathophysiologic effects of bradykinin has clinical applications. oral or intravenous administration of the bradykinin receptor antagonist icatibant reduces the clinical signs, onset of diarrhea, and many of the histopathologic changes in experimental models of colitis in mice. inhibition of kallikrein by oral administration of p attenuated the intestinal inflammation, clinical score, and systemic manifestations in a model of chronic granulomatous enterocolitis. thus the contact system is a viable therapeutic target for inflammatory diseases of the intestine. changes in blood flow to the mucosa and other regions of the intestine that reduce perfusion of the tissues can potentiate the initial damage caused by infection or injury. for example, reperfusion of ischemic tissues is associated with platelet and neutrophil clumping in the small vessels of the mucosa, which can impede blood flow. platelets are activated and adhere to exposed basement membrane and activated endothelial cells and provide a surface for leukocyte adhesion. the accumulation of platelets and leukocytes can reduce vessel diameter and blood flow significantly while potentiating local coagulation and thrombus formation. soluble mediators released by activated leukocytes and endothelial cells also affect blood flow. histamine and the vasoactive lipids derived from arachidonic acid (leukotrienes, prostaglandins, thromboxane, prostacycline, and platelet-activating factor) have a prominent role in regulating local perfusion during inflammation and also may have systemic effects on blood flow. procoagulant mediators released by inflammatory cells in response to the inflammatory process (i.e., tissue factor produced by macrophages or endothelial cells), exposed basement membrane proteins, and bacterial components can trigger the contact system and the coagulation and complement cascades, the products of which affect blood flow. nitric oxide, whether produced by endothelial cells or leukocytes (macrophages), is a potent regulator of blood flow and has a significant role in the control of perfusion during inflammation. many of the mediators that affect perfusion also affect endothelial permeability, altering osmotic and hydrostatic balance and tissue edema. in extreme cases, local and systemic coagulopathies initiated by vascular injury and absorption of microbial products and inflammatory mediators induce a hypercoagulable state, leading to microthrombus formation, which can reduce blood flow, or macrothrombus formation, which causes tissue infarction. the cellular mediators of inflammation have the potential to inflict severe injury to intestinal tissues. neutrophils have an important role in the pathophysiology of many intestinal diseases, including ischemia-reperfusion injury, , infectious enterocolitis, [ ] [ ] [ ] nonsteroidal antiinflammatory drug-induced mucosal ulceration, and others. depletion of neutrophils, blockade of their emigration into tissues, or inhibition of neutrophil activation reduce the severity of these and other inflammatory diseases. thus many antiinflammatory therapies are emerging that specifically target neutrophil adhesion, migration, and activation. migration of neutrophils through endothelium during emigration into inflamed tissues is remarkable in that the permeability of the endothelial monolayer is preserved under most circumstances. however, a limit exists above which neutrophil migration alters the permeability characteristics of the endothelium. the effect is in part physical in that mere movement of large numbers of neutrophils through the endothelium is sufficient to disrupt the tight junctions mechanically and is caused in part by toxic products of neutrophils that damage endothelial cells and basement membranes. , serine proteases (particularly elastase) and metalloproteinases released by degranulating neutrophils destroy tissue matrix proteins and cell-surface proteins that make up endothelial intercellular junctions. these degradative enzymes are particularly damaging to basement membranes and the cellular barriers of the endothelium, thus contributing to vascular permeability (and local tissue edema) and thrombosis. the permeability may be affected to the extent that not only water but macromolecules (albumin, matrix proteins, complement, etc.) leak into the interstitium. blockade of neutrophil adhesion to endothelium with anti-β integrin antibodies has a sparing effect on the microvasculature in experimental intestinal ischemiareperfusion injury, reducing the alterations in vascular permeability and histopathologic evidence of microvascular damage. similar to the endothelium of inflamed tissues, massive neutrophil transmigration occurs across the epithelium in response to infection or injury. neutrophil transepithelial migration increases epithelial permeability by disrupting tight junctions. like the endothelium, neutrophils disrupt the epithelial barrier mechanically as they migrate through (see figure . - ). proteases, particularly elastase, degrade basement membrane components and tight junction proteins. products of activated neutrophils (tnf-α and interferon-γ) increase tight junction permeability by direct effects on the enterocytes. prostaglandins released by activated neutrophils stimulate epithelial secretion, thus contributing to diarrhea. subepithelial accumulation of neutrophils can lead to deadhesion of the epithelial cells from the basement membrane and mild to severe ulceration. the physiologic results of the effects of neutrophils and their products on the epithelial barrier include protein-losing enteropathy and absorption of bacterial cell wall constituents, which potentiates the local and systemic inflammatory responses. neutrophils in inflamed tissues stimulated by potent host-derived activators (such as il- β and tnf-α) and bacterial products (lipopolysaccharide) release copious amounts of rois (see figure . - ). although these oxygen and oxyhalide radicals are important for killing pathogens, they are also potentially toxic to epithelial and endothelial cells and matrix proteins. reactive nitrogen intermediates produced primarily by macrophages during inflammation combine with rois to form peroxynitrites, which are particularly toxic. in addition to injury to mucosal tissues, rois also have an as yet ill-defined role in recruiting and activating neutrophils, thereby potentiating the inflammatory response. in support of the role of rois in inflammatory diseases of the gastrointestinal tract, administration of inhibitors of roi production or pharmacologic roi scavengers can be protective in many models of reperfusion injury or enterocolitis. many therapies are aimed at inhibiting neutrophil activation and effector functions in tissues have been evaluated for use in intestinal diseases. phosphodiesterase inhibitors, by causing cyclic adenosine monophosphate accumulation in neutrophils, are antiinflammatory by virtue of their ability to suppress neutrophil activation and roi production. new phosphodiesterase inhibitors selective for the predominant neutrophil isoform of phosphodiesterase hold promise for use in many inflammatory diseases. subepithelial mast cells also have an important role in altering epithelial permeability in inflamed intestine. during the intestinal hypersensitivity response, subepithelial mast cell release of mast cell protease ii by degranulation increases epithelial permeability via an effect on tight junctions. , , this alteration in tight junction permeability results in enhanced transepithelial flux of macromolecules, including proteins and bacterial products. cytokines released by mast cells and phagocytes also regulate tight junction permeability. interleukin- , a product of mast cells and macrophages, increases epithelial permeability. moreover, tnf-α and interferon-γ, products of many inflammatory cells, synergistically increase tight junction permeability. acute equine colitis causes rapid, severe debilitation and death in horses (more than % of untreated horses die or require euthanasia). since , several reports have described a number of different acute diarrheal conditions in the horse that appear to share a common characteristic clinical presentation. - diarrhea associated with acute equine colitis occurs sporadically, is highly fatal, and is characterized by intraluminal sequestration of fluid, moderate to severe colic (abdominal pain), and profuse watery diarrhea with resultant endotoxemia, leukopenia, and hypovolemia. , , the condition can affect adult horses of all ages but usually occurs in horses between and years of age. disease onset is sudden with a rapid progression and often is preceded by a stressful event. a definitive diagnosis is made in only about % to % of cases. , most ante-and postmortem diagnostic tests remain speculative. treatment of the condition in horses is costly because of the massive fluid therapy required. currently, no curative treatment is available for acute colitis in horses, human beings, or other mammals. treatment regimens provide rehydration, electrolyte and plasma protein replacement, mitigation of the effects of circulating endotoxin, and antimicrobial therapy when indicated. attempts during the past years to develop appropriate treatments (i.e., vaccines or pharmacologic agents) have been hampered by the unavailability of acceptable equine models and have been unsuccessful because of the complex pathophysiology of the intestinal epithelium. although the mechanisms responsible for the fluid losses are not known, inflammatory cells may play an integral role because this condition is characterized by large numbers of granulocytes infiltrating the large intestinal mucosa. [ ] [ ] [ ] [ ] [ ] equine cecal and colonic tissues collected during the acute stages of experimentally induced acute equine colitis (equine ehrlichial colitis, lincomycin with and without clostridium spp. inoculation, nonsteroidal antiinflammatory drug administration) reveal the presence of numerous neutrophils and eosinophils in the lamina propria and submucosa. , , , granulocytederived reactive oxygen intermediates are crucial to antimicrobial defenses in the gut and stimulate chloride and water secretion by interactions with enterocytes. , normal equine intestinal tissue is unique compared with that in most other mammalian species for a preponderance of eosinophils located in the intestinal mucosa and submucosa. , production of reactive oxygen intermediates by stimulated phagocytic granulocytes following mucosal barrier disruption may be responsible for the massive fluid secretory response that occurs during the early stages of acute equine colitis. colitis refers to inflammation and mucosal injury of the colon and cecum (typhlocolitis) that may occur in response to a number of causes. , the cause of the colonic injury may be well-defined such as in naturally occurring infectious or experimentally induced colitis. however, many cases of human and animal diarrhea have a speculative or unknown diagnosis or no diagnosis. , , irrespective of the underlying or initiating cause of colonic injury, the colon apparently has a limited repertoire of responses to damage because most forms of colitis demonstrate similarities in histopathologic appearance and clinical presentation. various degrees of mucosal erosion and ulceration, submucosal/mucosal edema, goblet cell depletion, and presence of an inflammatory cellular infiltrate within the mucosa and submucosa are common to many types of human and animal colitis. , [ ] [ ] [ ] characteristic clinical manifestations include intraluminal fluid sequestration, abdominal discomfort, hypovolemia, and most often profuse, watery diarrhea. large bowel diarrhea results from abnormal fluid and ion transport by cecal and colonic mucosa. loss of fluid by the large intestine can result from malabsorptive or hypersecretory processes and is often a combination of the two. colonic secretory processes are a function of the crypt epithelium, whereas absorptive processes are limited to surface epithelial cells. under normal baseline conditions, an underlying secretion by crypt epithelium is masked by a greater rate of surface epithelial cell absorption. abnormal forces influencing the rates of secretion and absorption can result in massive, uncontrolled secretion and malabsorption by large intestinal mucosal epithelial cells, leading to rapid dehydration and death. , two intracellular processes control colonic secretion: the cyclic nucleotide (cyclic adenosine monophosphate [camp] and cyclic guanosine monophosphate [cgmp]) and the calcium system. , agents may activate adenyl cyclase (vasoactive intestinal peptide, prostaglandin e [pge ]) or guanyl cyclase (bacterial enterotoxins) and induce increases in camp or cgmp, respectively. this reaction causes phosphorylation of specific protein kinases that induce the actual apical and basolateral membrane transport events. increases in intracellular free calcium may arise from cyclic nucleotide-dependent release of stored calcium within the cell or from increased calcium entry across the cell membrane. , calcium may act through calmodulin, which then can activate membranephosphorylating protein kinases. at least four central systems control intestinal secretion: ( ) the hormonal system, ( ) the enteric nervous system, ( ) bacterial enterotoxins, and ( ) the immune system. , hormonal control of colonic electrolyte transport is exerted primarily through the renin-angiotensinaldosterone axis. , the enteric nervous system controls transport through three separate components: ( ) extrinsic nerves of the parasympathetic and sympathetic pathways; ( ) intrinsic ganglia and nerves, secreting a variety of neurotransmitters including peptides; and ( ) neuroendocrine cells (intraepithelial lymphocytes) that reside in the epithelium and release messengers onto the epithelial cells in a paracrine manner. , [ ] [ ] [ ] [ ] many bacterial enterotoxins can induce intestinal secretion by camp or cgmp signal transduction. bacterial enterotoxins can stimulate enteric neurons, providing evidence for interaction between two controlling systems. preformed inflammatory mediators such as histamine, serotonin, or adenosine and newly synthesized mediators such as prostaglandins, leukotrienes, platelet-activating factor, various cytokines, the inducible form of nitric oxide, and reactive oxygen metabolites can initiate intestinal secretion by directly stimulating the enterocyte and by acting on enteric nerves indirectly to induce neurotransmitter-mediator intestinal secretion. for instance, when added to the t colonic cell line, the known mast cell mediators histamine, adenosine, and pgd induce chloride secretion. [ ] [ ] [ ] prostaglandins of the e and f series can cause an increase in chloride secretion in intact tissue and isolated colonic cells. [ ] [ ] [ ] leukotrienes, platelet-activating factor, and a number of cytokines have been shown to have no effect on t cell secretion but have a significant effect on electrolyte transport in intact tissue, suggesting that intermediate cell types may be involved in these secretory responses. [ ] [ ] [ ] the epithelial cell chloride secretory response occurs via prostaglandin-and adenosine-mediated increases in cellular camp, whereas histamine acts by h receptor induction of phosphatidylinositol turnover, production of inositol triphosphate, and mobilization of intracellular calcium stores. , lipoxygenase products (leukotrienes) are capable of activating a colonic secretory response and do not appear to involve the cyclic nucleotides or calcium ions. phagocyte-derived reactive oxygen mediators (roms) can induce colonic electrolyte secretion in vitro, suggesting that oxidants may contribute directly to the diarrhea associated with colitis. [ ] [ ] [ ] [ ] [ ] reactive oxygen species initiate the secretory response by increasing cellular camp or stimulating mesenchymal release of pge or prostacyclin, which in turn stimulates the epithelial cell or enteric neuron, respectively. [ ] [ ] [ ] [ ] [ ] [ ] sodium nitroprusside, an exogenous source of nitric oxide, stimulated an increase in chloride secretion in rat colon that was mediated by cyclooxygenase products and enteric neurons. table . - summarizes inflammatory mediator-induced epithelial cell chloride secretion. acute colitis rarely develops by a simple cause or effect phenomenon but is influenced by many extrinsic and intrinsic host and microorganism factors. inflammatory mediators released from mast cells and monocytic or granulocytic phagocytes cause intestinal chloride and water secretion and inhibit neutral sodium and chloride absorption. , , inflammatory cells, particularly the phagocytic granulocytes, play an important role in mucosal pathophysiology in cases of colitis. , large numbers of these cells are observed on histopathologic examination of tissues from human and animal cases of colitis. products of cell activation stimulate direct and indirect secretory responses in intestinal cells and tissues. [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] products of phagocyte secretion may amplify the inflammatory signal or have effects on other target cells in intestine such as enterocytes and smooth muscle cells (table . - ). the nadph-oxidase system of phagocytes (neutrophils, eosinophils, monocytes/macrophages) is a potent inducer of superoxide radicals used as a host defense mechanism to kill invading microorganisms. , during inappropriate stimulation such as inflammation, trauma, or ischemia followed by reperfusion, increased levels of toxic oxygen species are produced, causing damage to host tissues. engagement of any of several receptor and nonreceptor types including phagocytosis mediators, chemotactic agents, various cytokines, and microbial products can stimulate phagocytes. resident phagocytes or those recruited to colonic mucosa early in the disease process are considered to augment mechanisms causing fluid and electrolyte secretory processes, a so-called amplification process. , activation of the respiratory burst results in the production and release of large amounts of superoxide anion (o − ) and h o . , in addition to these roms, activated phagocytes secrete peroxidase enzyme (myeloperoxidase from neutrophils and eosinophil peroxidase from eosinophils) into the extracellular space. the peroxidases catalyze the oxidation of clby h o to yield hocl, the active ingredient in household bleach products. the peroxidase-h o -halide system is the most cytotoxic system of the phagocytes; hocl is to times more toxic than o or h o . hocl is a nonspecific oxidizing and chlorinating agent that reacts rapidly with a variety of biologic compounds including dna, sulfhydryls, nucleotides, amino acids, and other nitrogen-containing compounds. hocl reacts rapidly with primary amines (rnh ) to produce the cytotoxic n-chloramines (rnhcl). the mechanisms by which hocl and rnhcl damage cells and tissue remain speculative, but possibilities include direct sulfhydryl oxidation, hemoprotein inactivation, protein and amino acid degradation, and inactivation of metabolic cofactors of dna. peroxidase-derived oxidants have been shown to degrade hyaluronic acid and collagen. in addition, luminal perfusion of specific roms increased mucosal permeability and serosal application caused increases in clsecretion in vitro. tissue myeloperoxidase activity, an index of tissue granulocyte infiltration, is used clinically and experimentally to assess degree of intestinal inflammation. , myeloperoxidase activity is elevated in acute flare-ups of human inflammatory bowel disease and various animal models of acute colitis. [ ] [ ] [ ] [ ] [ ] the acute inflammatory response in these conditions is characterized predominantly by neutrophils, the predominant source of myeloperoxidase activity. however, this assay measures total hemoprotein peroxidase, which includes monocyte and eosinophil peroxidase in addition to neutrophils. moreover, levels of peroxidase activity in equine circulating eosinophils are greater than in circulating neutrophils, and this may apply to resident tissue eosinophils as well. arachidonic acid metabolites are thought to play a role in intestinal inflammation in diarrheal disease. , , elevated levels of these intermediate metabolites have been demonstrated in natural disease and experimental models of colitis and appear to parallel increases in roms in inflamed intestine. addition of h o or hocl to rat colonic tissue in ussing chambers has been shown to induce pge release and active clsecretion. , prostaglandins can stimulate increases in clsecretion in intact intestinal tissue , , and in isolated colonic t cells. , interactions between roms and mesenchymal release of pge /pgi may be relevant to the mechanisms producing the diarrheic condition. fibroblasts co-cultured or juxtaposed to colonic t cells greatly increased the clsecretory response to h o in vitro through the release of pge . in addition, equine colonic mucosa has an increased sensitivity to endogenously released prostaglandin by exhibiting a significant secretory response under in vitro conditions. endotoxin, the lipopolysaccharide component of the outer cell wall of gram-negative bacteria, is present in large quantities in the large intestine of healthy horses. , endotoxins are released into the immediate surroundings when gram-negative bacteria undergo rapid proliferation or die. , the intact bowel forms an effective barrier to the transport of significant amounts of these highly antigenic toxins, but the diseased gut absorbs these macromolecules in large amounts, causing the subsequent adverse systemic effects that are often life threatening. disruption of the intestinal barrier (i.e., ischemia, trauma, inflammatory conditions) overwhelms the capacity of the liver to clear endotoxins, and systemic endotoxemia ensues. endotoxins have been shown to be potent activators of the inflammatory process, stimulating the production and release of numerous cytokines by activated macrophages and other immunocytes. in vitro studies suggest that endotoxin activates phagocytic granulocytes to secrete roms, increase release of lysozymes, and enhance the migratory response to chemotactic stimuli. prostacyclin and thromboxane a mediate hemodynamic dysfunction, and lipoxygenase products may induce tissue ischemia. the cytokine interleukin- causes a febrile response and initiates the acute phase response. tumor necrosis factor contributes to many of the abnormal physiologic responses, particularly hemostatic functions that potentiate coagulopathy. additional mediators include interleukin- , platelet-activating factor, procoagulant mediators, and various other speculated substances. endotoxins trigger mucosal immune cells and subsequent release of inflammatory mediators in cases of colitis. the first report of experimentally induced endotoxemia described clinical signs and hematologic findings that closely paralleled those reported for severe colitis in horses. studies in which endotoxin was administered intravenously in human beings and laboratory animals caused significant dose-related gastrointestinal changes, ranging from mild diarrhea to bloody, watery diarrhea. , in vitro studies on the effects of endotoxin on intestinal water and electrolyte transport in adult male rats showed a significant decrease in net colonic sodium absorption and increased colonic permeability. in animal models of protein energy deficiency, endotoxin-induced mortality increased compared with that of well-nourished control animals. endotoxin depresses lymphocyte responses to specific mitogens. thus the adverse effects of malnutrition and endotoxin are mutually aggravating. the importance of a normal immune system to the defense of the mucosal surface of the gastrointestinal tract is evident in the immunosuppressed state. primary immunodeficiencies affecting the gastrointestinal tract are well documented. [ ] [ ] [ ] common agammaglobulinemia is the most frequently reported gastrointestinal disease and causes b cell deficiency-associated giardiasis. interestingly, selective immunoglobulin a (iga) deficiency rarely results in intestinal disease because of a speculated increase in mucosal igm response. however, combined iga and igm deficiencies with a higher incidence of intestinal disease occur. a selective deficiency of secretory iga has been associated with intestinal candidiasis. certain mucosal pathogens may enhance their pathogenicity by producing iga proteases. defects in cell-mediated immunity are associated most commonly with intractable diarrhea, and organisms frequently involved include salmonella spp., escherichia coli, and shigella spp. acquired immunodeficiency or immunosuppression in adults can result from infectious diseases (particularly viral), nutritional deficiencies, aging phenomenon, and drugs (corticosteroids, azathioprine, cyclophosphamide). nutrition is a critical determinant of immunocompetence and risk of illness. , impaired systemic and mucosal immunity contribute to an increased frequency and severity of intestinal infections observed in cases of undernourishment. abnormalities occur in cell-mediated immunity, complement system, phagocytic function, mucosal secretory antibody response, and antibody affinity. morbidity caused by diarrheal disease is increased particularly among individuals with stunted growth rate because of malnourishment. the critical role of several vitamins and minerals in immunocompetence has been substantiated in animals deprived of one dietary element and findings in human patients with single-nutrient deficiency. tables . - and . - summarize nutritional-related immune system abnormalities. in summary, nutritional deficiency can cause increased colonization of the intestine with microorganisms, alter the symbiotic characteristics of resident intestinal bacterial populations, and impair defenses of the gastrointestinal tract, allowing increased risk of systemic spread of infection and absorption of macromolecules (in particular, endotoxin). indigenous microflora greatly impede colonization of the gastrointestinal mucosa by pathogenic organisms. the ability of a potential pathogen to initiate an infection depends on its ability to breach the mucosal epithelial barrier. one mechanism by which the normal flora inhibit establishment of pathogens is by preventing adherence of the pathogen to mucosal cells by occupying the site or by stearic hindrance. [ ] [ ] [ ] [ ] resident microbes also produce byproducts such as antibacterial factors that allow symbiosis rather than competition between them. another hindrance mechanism is production of volatile fatty acids by normal microbial digestive processes to create an environment that is toxic to many bacterial populations, particularly the enterobacteriaceae. disturbances in motility patterns occur during inflammatory diseases of the colon, but the role of motility alterations in the pathogenesis of diarrhea remains unclear. invasive bacteria cause characteristic motor patterns in the colon consisting of rapid bursts of motor activity that appear to decrease transit time through the large intestine. the result is reduced clearance of bacteria from the large intestine, which may contribute to the virulence of the organism. absorption of endotoxin and the release of inflammatory mediators such as prostaglandins disrupts the motility patterns of the large intestine, resulting in less coordinated contractions, and may contribute to the alterations in motility seen with invasive bacteria. although the effect of endotoxin and prostaglandins on transit time is not profound, the disruption of coordinated activity may play a role in causing diarrhea. thorough mixing and prolonged retention time of ingesta are important not only in microbial digestion of nutrients but also in absorption of microbial byproducts and fluid. , the ingesta is viscous and therefore must be mixed to bring luminal ingesta in contact with the mucosa for absorption. in addition, poor mixing increases the thickness of the unstirred layer, decreasing contact of ingesta with the mucosa and decreasing absorption. , progressive motility must be present, however, if a diarrheal state is to occur. , ileus may be accompanied by increased fluid in the lumen of the large intestine, pyridoxine, folic acid, impairs cell-mediated immunity and vitamin c, vitamin e reduces antibody response. vitamin b decreases lymphocyte stimulation response to specific mitogens. zinc deficiency affects humoral and cell-mediated immunity. iron inhibits bacterial multiplication. copper depresses antibody response. needed by neutrophils and lymphocytes for optimal function, which may be related to myeloperoxidase and ribonucleotidyl reductase deficiencies. but without progressive motility the fluid is not passed. frequently, acute colitis causes a period of ileus characterized by scant stool. diarrhea is apparent only when motility returns and the ingesta is passed. increased progressive motility has been suggested to cause diarrhea by decreasing transit time and is thought to play a role in irritant catharsis and in the mechanism of action of some laxatives. irritation and distention increase motility and may well decrease transit time, but increased secretion also is thought to contribute to diarrhea caused by these substances. one should direct the clinical investigation of malabsorption at ascertaining and trying to localize the source of the abnormality. in medical practice, impairment of one or more phases of the digestion and absorption of dietary constituents may precipitate clinical signs that are associated primarily with carbohydrate, protein, or fat malabsorption. this level of differentiation is not possible in the horse because of the herbivorous diet and the contribution of large intestinal functions. in human and small animal medicine, disturbances in digestive processes especially from exocrine pancreatic insufficiency or reduced intestinal bile salt concentration are principal determinants of many clinical malabsorption syndromes. the rarity of pancreatic problems in horses and the herbivorous diet makes maldigestion less of a concern and difficult to pursue diagnostically. nevertheless, maldigestion undoubtedly contributes to chronic weight loss conditions in horses, which may be significant with severe infiltrative disease of the small intestine with partial to total villous atrophy and flattened mucosa. impairment of digestive processes may exacerbate diarrhea in the suckling foal through reduced intestinal bile salt concentrations from hepatic or ileal dysfunction. malabsorption is not synonymous with diarrhea, although diarrhea may be a feature. adult horses rarely exhibit diarrhea with small intestinal problems unless large intestinal involvement is concomitant. chronic diarrhea is predominantly a large intestinal disorder that reflects an overload of water and electrolytes and thus may be considered a state of impaired absorption. primary small intestinal disease is more likely to occur in neonates and young foals. for example, acquired small intestinal brush border lactase deficiency may result in increased lactose fermentation in the large intestine and induction of osmotic diarrhea. box . - lists conditions that have been or potentially could be associated with malabsorption syndromes and maldigestion in the horse. malabsorption in horses has no pathognomonic clinical syndrome. case recognition derives from the robust investigation of horses with chronic wasting. prevalence is unknown. no strict case definition exists, even for chronic wasting. interest generated by unusual clinical test results and their related pathologic findings has stimulated publication of reports of cases considered as malabsorption in horses. pathologic description of the predominant cellular infiltrate and the pattern of intestinal distribution have resulted in the classification of many conditions as representing examples of chronic inflammatory bowel disease (cibd) (see box . - ), drawing analogies from human medicine. in the affected animal, coexistent enteric protein loss reflecting changes in mucosal integrity from extensive infiltration and inflammation in the intestinal tract is likely to be more debilitating than the malabsorption. the principal concern of the owner is the weight loss and poor condition of the horse. many clinical examination findings, except for body condition, may appear within normal limits. investigation of the weight loss, together with the clinical pathologic findings, helps to eliminate other more commonly encountered causes of wasting. box . - lists clinical signs that may be associated with malabsorption syndromes. no characteristic clinical pathologic profile of malabsorption exists. findings relate to the stage of the underlying disease process and intercurrent problems. the syndrome tends to cause anemia (normocytic, normochromic) and neutrophilia. hemolytic or macrocytic anemia and thrombocytopenia have been observed in alimentary lymphosarcoma. lymphocytosis (leukemia) rarely is encountered. eosinophilia is uncommon even with suspected immune-mediated conditions and widespread tissue eosinophilia. many animals are hypoalbuminemic and hypoproteinemic; horses with alimentary lymphosarcoma may exhibit hyperproteinemia and hypergammaglobulinemia. serum or plasma may be lipemic. the clinician may find elevated hepatic and biliary tract enzymes (γ-glutamyltransferase and alkaline phosphatase) in multisystemic conditions; for example, eosinophilic granulomatosis (multisystemic eosinophilic epitheliotropic disease; eg [meed]). abdominocentesis has been of diagnostic value in several alimentary lymphosarcoma cases, but rarely in the granulomatous conditions. ultrasonographic examination of the abdomen can yield infomation on intestinal distention, wall thickness, and unexplained masses detected on rectal palpation. rectal biopsy is easy to perform and may provide an indication of cellular infiltration that could be present at more proximal locations. however, pathologists examine few equine rectal samples, and the interpretation is frequently equivocal. adoption of standardized grading or classification would improve the diagnostic value. a proposed classification system was based on a retrospective study of rectal biopsies from horses ages to years with clinical signs of intestinal disease. necropsy results were studied from horses. biopsy specimens ( horses) and necropsy rectal tissue ( horses) from horses ages to years served as controls. simple proctitis, the presence of neutrophils in the crypt or surface epithelium, was an abnormal finding compared with mild scattered neutrophil infiltration in controls. simple proctitis was found in association with malignant lymphoma and other inflammatory disorders. inflammatory bowel disease was diagnosed from rectal biopsy specimens in of eg (meed) cases and of granulomatous enteritis cases confirmed at necropsy. rectal biopsy aided diagnosis for of horses in a series of lymphocytic-plasmacytic enterocolitis cases. eosinophils were demonstrated on impression smears of rectal mucosal biopsies from of horses with eosinophilic enterocolitis. skin biopsies or ultrasound-guided biopsies of liver, lymph node, or lung may reveal evidence of multisystemic disease. one can obtain intestinal and lymph node biopsies via a standing laparotomy. exploratory laparotomy facilitates rigorous inspection of the gastrointestinal tract and associated organs to obtain multiple biopsies from intestinal sites and lymph nodes. the procedure may provide a diagnosis, enabling one to make decisions on potential treatment and management options. cost and potential postoperative complications may limit surgical procedures for diagnosis. laparoscopy may provide an alternative means to facilitate biopsy of certain tissues. however, one should consider surgical exploration as an option early in the process rather than as a last resort. the noninvasive breath hydrogen test used to assess carbohydrate malabsorption in human beings has not proved reliable in equine studies. intestinal function tests can provide a practical and inexpensive means to assess the absorptive capability of the small intestine. for clinical practice purposes this is limited to carbohydrate absorption. abnormality of carbohydrate absorption has become an important precept on which to base a diagnosis of malabsorption in the horse. however, results of the oral glucose tolerance test (ogtt) or d-xylose absorption test require cautious interpretation. pathologic changes in the mucosa and submucosa must be extensive and widely distributed to greatly affect the peak plasma concentration and shape of the curve. the tests are easy to perform in practice and require a baseline blood sample predosing and further samples for up to hours after administration of the solution. many commercial laboratories conduct glucose and xylose assays. the immediate dietary history, gastric emptying rate, intestinal transit, age, and hormonal effects of the horse influence glucose peak and curve shape. higher glucose peaks are recorded from healthy animals eating grass or hay than from those eating concentrates. recent appetite or the level of cachexia may affect test results. maximum plasma glucose level (> % baseline) is reached by minutes in healthy animals given g glucose per kilogram body mass as a % solution. , break points below which the probability increases of carbohydrate malabsorption associated with intestinal morphology changes have been proposed. a referral population of mature horses with chronic weight loss was divided into three groups based on ogtt results to determine if any concurrence with the morphologic diagnoses existed. group (n = ) had a normal ogtt (peak glucose concentration at minutes > % baseline) and contained animals that had normal small intestinal morphology, and a few with large intestinal lesions. group (n = ) had partial malabsorption and included horses with small intestinal infiltrative disease that allowed some glucose uptake. diagnoses included lymphosarcoma, villous atrophy, granulomatous enteritis and eg (meed). seven horses had normal small intestinal histologic findings. peak glucose concentrations were less than % and greater than % of baseline at minutes. seventeen horses in the group had large intestinal pathologic conditions. group horses (n = ) had total malabsorption; the peak concentration at minutes was less than % above baseline. these horses had severe infiltration throughout most of the small intestine that was attributed predominantly to lymphosarcoma or granulomatous enteritis. however, the test is far from definitive; one cannot assume a flat curve indicates malabsorption and a poor prognosis. two horses with chronic weight loss initially diagnosed with malabsorption based on flat ogtt curves subsequently showed more normal ogtt responses. full-thickness intestinal biopsies were unremarkable. one horse had an elevated serum immunoglobulin e to oat allergen. oats and oat straw were removed from access. dexamethasone was given on a tapered protocol, and a repeat ogtt was normal at months. the other horse received oral probiotics to counter suspected small intestinal bacterial overgrowth, was clinically normal in months, and had an improved ogtt with a minute peak. therefore malabsorption, as defined by an absorption test and weight loss, may occur in the horse without significant morphologic changes in the intestine, and the condition may be transient. demonstration of carbohydrate malabsorption in of horses with chronic diarrhea showed poor diagnostic sensitivity for small intestinal involvement. impaired glucose absorption was recorded in horses with predominantly large intestinal problems, cyathostomiasis, chronic colitis, alimentary lymphosarcoma, and meed. although prior dietary history influences peak plasma xylose concentration, xylose is not confounded by hormonal effects or mucosal metabolism. gastric emptying rate, intestinal motility, intraluminal bacterial overgrowth, and renal clearance do affect curve shape. healthy mares not fed for up to hours had flatter curves and a slower decrease in plasma xylose than when deprived for to hours. hence recent appetite or the level of cachexia may influence test results. abnormal d-xylose absorption represented by a flat curve or delayed absorption is considered indicative of significant jejunal disease and has been observed with most examples of cibd, parasitism, and idiopathic villous atrophy. , ponies may have lower peak d-xylose concentrations at and minutes than horses, although the range of peak values at the test dosage ( . g d-xylose per kilogram body mass in a % solution) is wide. potentially diagnostic discriminatory cut off points for peak plasma xylose concentrations have not been determined. abnormal absorption curves have been detected in the absence of small intestinal histologic changes, and interpretation is clouded further by findings from small intestinal resection studies in healthy ponies. nine ponies with % distal small intestinal resection and four shamoperated controls were placed on interval feeding for weeks and then turned out to pasture until months after surgery. grazing was supplemented by twice daily (meal feeding) concentrate rations. all ponies gained weight and were clinically normal, and none developed diarrhea. however, the mean peak xylose concentration at minutes declined progressively (at monthly intervals) over the study period in the resection group to % of that of controls. lack of clinical malabsorption was attributed to adaptation of the residual % of healthy small intestine and of large intestinal function. bacterial overgrowth in the small bowel remnant from refluxed cecal contents (resected ponies had ileocecal valve bypass) may have contributed to the abnormal xylose assimilation. by contrast, xylose absorption decreased over months, associated with substantial weight loss, lethargy, and diarrhea, in an earlier study of extensive (≥ %) small intestinal resection in ponies. an important difference was the feeding pattern; those ponies received pelleted feed twice daily for the entire month follow-up period. consequently, horses with suspected malabsorption may adapt to an interval feeding regimen. the critical factor could be the availability of sufficient unaffected or minimally affected small intestine and large intestinal functional capacity. the outcome for animals with small intestinal disease and some unknown degree of large intestinal pathologic dysfunction may be less successful than shown in the experimental study. abnormal xylose absorption reverted to normal following days of corticosteroid therapy in an adult thoroughbred gelding with a -week history of weight loss and diarrhea for weeks; peak xylose concentration at minutes was within normal limits and the horse had gained weight. d-xylose absorption was abnormal in an adult standardbred gelding with a -month history of poor performance, weight loss, intermittent fever, mesenteric lymphadenopathy, elevated fibrinogen, and decreased albumin and globulin levels. multiple fullthickness small intestinal biopsies revealed evidence of granulomatous enteritis. the horse received antibiotics postoperatively and then corticosteroids parenterally for to months. after weeks, peak plasma xylose had increased, although absorption was delayed. five months after cessation of corticosteroid therapy, the horse had regained weight and was bright and alert, and d-xylose absorption was normal. diagnostic predictions were made retrospectively by examining d-xylose absorption in horses with granulomatous enteritis compared with those with eg. peak xylose concentrations were much lower in horses with granulomatous enteritis than those with eg, whereas in eg the absorption curve shifted to the right with the peak occurring at minutes. the small intestine is affected predominantly in granulomatous enteritis with extensive villous atrophy and more diffuse lesions in the large intestine, whereas in eg (meed) the large intestine is more involved. hence, the extent and distribution of pathologic changes in the small and large intestines may influence xylose absorption test results. the chronic wasting horse with suspected malabsorption and probable enteric protein loss has at best a guarded to poor prognosis. prognosis may be improved through early and aggressive investigation to achieve a diagnosis, and perhaps assess the stage in the natural progression of the disorder. the owner may elect euthanasia of the animal or may be willing to determine whether the condition can be improved. in the short term, intravenous infusion of plasma or colloids, with or without fluids and electrolytes, may be necessary to stabilize the condition. prognosis is much worse for the horse that is inappetent. prolonged intensive total parenteral nutrition and/or oral alimentation may not be a realistic course of action. the overall therapeutic and management plan can prove to be expensive. the owner must be cognizant from the start that the outcome may not be altered, even after protracted therapy. one cannot make predictions for outcome of therapy without meaningful data because only a few case reports of successful responses with long-term follow up exist. some level of digestive and absorptive capability remains in the diseased small intestine. interval feeding of small quantities of food may be beneficial if the horse continues to eat, and particularly for animals with ravenous appetites that seem able to maintain their reduced state of body condition without further losses. diet should include feeds with a high fiber content to favor large intestinal fermentation, including grass hay and access to pasture complemented by commercial high-fiber rations based on beet pulp and soybean hulls. energy intake can be increased through feeding high-energy dense fats that provide . times more calories than carbohydrates. most affected horses should tolerate high fat ( % to %) processed feeds containing vegetable oils or rice bran (up to % of the concentrate mix, equivalent to % vegetable oil) to achieve the higher-fat composition. changeover to a higher-fat concentrate should be gradual. even in healthy animals that can eat up to % added fat, appetite may decrease as the percentage increases, and fecal consistency may change. clearly, the objective for the horse with suspected malabsorption is to sustain, and preferably increase, dietary intake, value, and efficiency. the owner of an affected horse must be prepared to experiment with feeds, must be patient, and must keep records. no standard procedure exists. exposure to a feed component may contribute to the problem as an allergen eliciting a hypersensitivity reaction. identifying the potential allergen through immunologic testing or by stepwise removal and outcome assessment over a longer period may be difficult. the clinician should give immunosuppressive drugs early in the process. immunosuppressive agents have produced the most promising responses to ameliorate the effects of conditions associated with malabsorption, particularly cibd. short-duration, and in some cases more prolonged and sustained, improvements in body condition, weight gain, demeanor, energy and activity levels have occurred following corticosteroid administration. one should start treatment as early as possible. one should follow initial parenteral (intramuscular or intravenous) loading doses of dexamethasone (sodium phosphate) with a series of depot injections, or orally administered prednisolone or prednisone, on a tapered dose protocol over a period of months. interval low-dose therapy may be necessary if clinical signs return after treatment ends. one uses the lowest dose to control the clinical signs for alternate-day therapy. clinical benefits far outweigh concerns over potential adverse effects. chemotherapeutic agents such as vincristine, cytosine, cyclophosphamide, and hydroxyurea have been tried in a few cases of cibd or lymphosarcoma with no apparent success, probably related to the advanced stage of the disease when treatment was initiated and the dose selected. resection of a segment of intestine that is edematous, hemorrhagic, or constricted is an option in localized forms of cibd, , particularly if gross changes are not discernible in adjacent or distant parts of the intestinal tract, that is, malabsorption is not a feature. long-term outcome has been favorable. removal of a substantial proportion of the diseased small intestine may be indicated in a horse with malabsorption, considering that resection of % distal small intestine was performed in healthy animals without inducing adverse effects. however, because pathologic changes may exist in normalappearing small or large intestine that is not resected or biopsied, the prognosis remains guarded. two young horses with granulomatous enteritis had the thickened terminal small intestine resected with positive outcomes; one survived months, the other has a follow up extending more than years. anthony t. blikslager to gain an appreciation of the mechanisms whereby the mucosa is injured and subsequently repaired, one must understand how the integrity of the mucosa is regulated physiologically. regulation of mucosal integrity is referred to as mucosal barrier function, which is vital because it prevents bacteria and associated toxins from gaining access to subepithelial tissues and the circulation. however, the mucosa has two conflicting functions: it must serve as a protective barrier and continue to absorb solutes necessary to maintain well-being of the host. this conflict is most notable at the intercellular (paracellular) space, which allows passage of select solutes and water, - but which does not admit large molecules, including bacterial toxins. the paracellular space is regulated almost exclusively by the tight junction, which is the interepithelial junction at the apical-most aspect of the paracellular space. although these tight junctions originally were viewed as inert cellular adhesion sites, what has become clear in recent years is that tight junction permeability depends on tissue-specific molecular structure and is regulated by a complex array of intracellular proteins and the cytoskeleton. tight junctions consist of a group of transmembrane proteins that interdigitate from adjacent cells. although occludin originally was thought to be the predominant tight junction transmembrane protein, a group of proteins termed claudins appear to be more critical. these transmembrane proteins interact with the cytoskeleton via a series of intracellular proteins, including zonula occludens , , and ; cingulin; and others. in addition, local regulatory proteins such as the small guanosine triphosphatase-rho are also critical to tight junction function. in general the relative contractile state of the actin cytoskeleton determines the degree to which tight junctions are open or closed, but the complexities of regulation of this process are understood poorly. , the most sensitive measure of mucosal barrier function is transepithelial electric resistance, which is measured by mounting mucosa in an ex vivo system called an ussing chamber, because this measurement is largely a reflection of the permeability of mucosa to ions. , ions may follow one of two routes when traversing epithelium: transcellular and paracellular. because cell membranes have a resistance to passive flow of ions . to log units greater than that of the epithelium as a whole, measurements of transepithelial resistance largely reflect the resistance of the paracellular space, and in particular the tight junctions that regulate paracellular flow of ions. because tight junctions differ in structure from different portions of the mucosa, measurements of transepithelial resistance reflect the net resistance of epithelium of variable permeability within a given tissue. for example, tight junctions in the intestinal glandular structures called crypts are leakier than those in the surface epithelium because of fewer and less organized tight junction strands. , conversely, surface epithelium has a greater number of well-organized tight junction strands that result in epithelium with a high resistance. this correlates well with the absorptive function of epithelium located on the mucosal surface and the secretory function of crypt epithelium. structure of tight junctions also varies with the segment of intestine. for example, tight junctions have more strands in the ileum than in the jejunum, which is reflected by a higher transepithelial resistance in the ileum. the stomach has four regions based on the type of mucosal lining (in an orad to aborad order): nonglandular stratified squamous epithelium, cardiac epithelium, proper gastric mucosa, and pyloric mucosa. stratified squamous epithelium has distinct differences in terms of barrier function compared with the remainder of the gastrointestinal tract. this epithelium has baseline transepithelial resistance measurements of approximately to Ω/cm , which is an order of magnitude higher than the adjacent cardiac mucosa. , thus the stratified squamous mucosa is exceptionally impermeable. this in effect is the only mechanism this mucosa has to defend itself against injury. the stratified squamous epithelium consists of four layers: the outer stratum corneum, stratum transitionale, stratum spinosum, and the basal stratum germinativum. however, not all layers contribute equally to barrier function, the barrier being composed mostly of interepithelial tight junctions in the stratum corneum and mucosubstances secreted by the stratum spinosum. , the relative impermeability of stratified squamous mucosa can be demonstrated by the effects of hcl on this type of epithelium in vitro, which has little effect until it reaches a ph of . or lower. thus although most of the literature on equine ulceration pertains to the effects of hcl and inhibitors of hcl secretion, [ ] [ ] [ ] [ ] other factors may be critical to the development of gastric ulcer disease. the site of hcl secretion (proper gastric mucosa) also is protected from so-called back-diffusion of h + by a high transepithelial electric resistance (compared with cardiac mucosa), but a number of other critical mechanisms also exist to prevent acid injury. the gastric mucosa secretes mucus and bicarbonate, which together form a hco --containing gel that titrates acid before it reaches the lumen. , the mucus layer is formed principally by glycoproteins (mucins) secreted by goblet cells but also includes other gastric secretions and sloughed epithelial cells. mucins consist of core peptides with a series of densely packed o-linked polysaccharide side chains that, once secreted, become hydrated and form a viscoelastic gel. however, the mucus layer does not form an absolute barrier to back-diffusion of acid. thus for acid that does back-diffuse into the gastric mucosa, epithelial na + /h + exchangers are capable of expelling h + once the cell reaches a critical ph. recent studies have renewed interest in the protective mechanisms of mucus because of the discovery of a group of compounds secreted by goblet cells called trefoil peptides. the name of these peptides is derived from a highly conserved cloverleaf structural motif, which confers substantial resistance to degradation by proteases including pepsin. three members of this group are known, ps , sp, and intestinal trefoil factor, the latter of which is secreted solely by goblet cells in the small and large intestine. ps and sp are secreted by goblet cells within the stomach and are believed to intercalate with mucus glycoproteins, possibly contributing to the barrier properties of mucus. these peptides also play a critical role in repair of injured mucosa. an additional mucosal function that serves to reduce the level of injury is adaptive cytoprotection, wherein application of topical irritants to gastric mucosa results in subsequent protection of mucosa in response to repeated exposure to damaging agents. for example, pretreatment with % ethanol protected against mucosal damage in response to subsequent application of absolute ethanol, and this effect was abolished by treatment with the cyclooxygenase inhibitor indomethacin. the cytoprotective effect of prostaglandins has been demonstrated directly in studies in which preadministration of prostaglandins protected gastric mucosa from damage by agents such as concentrated hcl and hypertonic saline. prostaglandins appear to be cytoprotective in the stomach at doses less than those used to inhibit gastric acid secretion, ruling out a simple antacid mechanism. although not fully characterized, cytoprotection has been attributed in part to prostaglandin-stimulated mucus production. an associated beneficial effect of prostaglandins is the increased production of bicarbonate, which is trapped within mucus on the surface of the mucosa. , interestingly, prostaglandin e (pge ) appears to lose its cytoprotective activity in the presence of the mucolytic agent n-acetylcysteine. attention also has been directed at enhanced mucosal blood flow as a potential mechanism for prostaglandin-mediated cytoprotection. for example, pretreatment with pgi protected against ethanol-induced mucosal damage as a result of increased mucosal blood flow. although pge , which is also cytoprotective, does not increase blood flow, it may prevent vascular stasis associated with irritant-induced vascular damage resulting from inhibition of neutrophil adherence to damaged endothelium. sensory nerves also have been implicated in cytoprotective mechanisms. these nerves are distributed throughout gastrointestinal mucosa. as an example of their importance in mucosal cytoprotection, pretreatment of newborn rats with capsaicin (to which sensory nerves are sensitive) renders the mature rats more susceptible to gastric injury. alternatively, use of a low dose of capsaicin, which stimulates rather than destroys sensory nerves, protects gastric mucosa against injurious agents. , sensory nerves contain neuropeptides such as calcitonin-gene-related peptide (cgrp) and substance p, which may play a protective role via vascular mechanisms. for instance, cgrp stimulates increased gastric blood flow, which is theorized to reduce injury in much the same way as prostaglandins do. in fact, recent studies suggest that the roles of prostaglandins and cgrp in gastric cytoprotection are intertwined intimately. in particular, pgi is believed to sensitize sensory nerves following treatment with a mild irritant, with resultant increases in cgrp release and mucosal flow. similar studies have shown that antagonists of cgrp inhibit the cytoprotective action of pge . another neural mediator, nitric oxide, also has been implicated in adaptive cytoprotection. interestingly, nitric oxide has a number of actions that are similar to those of prostaglandins, including maintenance of mucosal blood flow. regulation of barrier function in the intestine is not as well characterized as that of the stomach, although mechanisms of barrier function, including secretion of mucus and regulation of mucosal blood flow, are presumed to be similar. the proximal duodenum also has to protect itself from acid damage as it receives gastric contents, and this involves secretion of mucus and bicarbonate in much the same way as the stomach. one other mechanism that helps the stomach and the intestine to maintain mucosal barrier function is the speed with which the mucosa repairs. thus for a defect to develop in the mucosal barrier, injurious factors have to outpace mucosal recovery. such recovery initially involves epithelial migration across denuded regions of basement membrane (restitution), a process so rapid that epithelial defects may be resurfaced within minutes. for example, in bile salt-injured colon, denuded surface mucosa was covered completely by restitution. in the small intestine, villi greatly amplify the surface area of the mucosal luminal surface, which in turn takes far longer to resurface with restituting epithelium once it has become denuded. however, intestinal villi are able to reduce the denuded surface area considerably by extensively contracting. these mechanisms are described in detail under mechanisms of gastrointestinal mucosal repair. although the stratified squamous epithelium is relatively impermeable to hcl, a number of factors can enhance the damaging effects of hcl in this epithelium. in particular, bile salts and short-chain fatty acids are capable of breaking down the squamous epithelial barrier at an acid ph, thereby exposing deep layers to hcl, with subsequent development of ulceration. , high concentrations of short-chain fatty acids normally exist within the equine stomach because of microbial fermentation. these weak acids penetrate squamous mucosa and appear to damage na + transport activity principally located in the stratum germinativum. bile salts also may be present in the proximal stomach because of reflux from the duodenum. although such reflux has a high ph, bile salts appear to adhere to stratified squamous epithelium, becoming lipid soluble and triggering damage once the ph falls below . diet and management (e.g., periods of fasting) also play crucial roles in the development of conditions conducive to gastric ulceration. typically, a ph gradation in horses exists from proximal to distal compartments of the stomach, with the lowest ph values in the distal stomach. however, fasting disrupts this stratification such that low ph values may be recorded in the proximal stomach. fasting conditions also increase the concentration of duodenal contents within the proximal stomach, particularly bile. proper gastric mucosa is exposed to injurious agents, including pepsin, bile, and acid. parietal cells in the horse secrete acid constantly as an adaptation to near-continuous intake of roughage, but the enterochromaffin-like cells within the proper gastric mucosa and g and d cells within the pyloric mucosa tightly regulate acid secretion. histamine released by enterochromaffin-like cells amplifies acid secretion and interacts with h receptors on parietal cells and g cells, which release the prosecretory hormone gastrin. a combination of histamine and gastrin can have a synergistic effect on parietal cell gastric secretion, because these mediators have distinct receptors and second messengers. however, d cells are sensitive to an acidic environment and release somatostatin, which inhibits acid secretion. nonetheless, gastric mucosa may be exposed to acid for prolonged periods of time, particularly in horses that are extensively meal fed and that do not have the benefit of roughage, which tends to buffer stomach contents. , aside from peptic ulceration induced by combinations of acid and pepsin, research in human medicine has revealed the tremendous importance of helicobacter pylori in inducing ulceration. infection with this organism has the effect of raising gastric ph because of disruption of gastric glands and also induces an inflammatory reaction that causes damage. however, little evidence to date indicates that this organism is involved in gastric ulcers in horses. in the absence of a known role for infectious agents in gastric ulceration in animals, ulceration likely develops from injurious factors similar to those found in the proximal stomach, including gastric acid and bile. however, some factors that are important to induction of squamous epithelial ulceration may not be important in development of proper gastric mucosal ulceration. for example, feed deprivation and intensive training reproducibly induce squamous epithelial ulceration in horses but have little effect on proper gastric mucosa in horses. gastric acid likely plays a key role, whereas other factors such as nonsteroidal antiinflammatory drugs (nsaids) serve to reduce gastric defense mechanisms. in particular, inhibition of prostaglandin production reduces mucus and bicarbonate secretion while also reducing gastric mucosal blood flow. some of the nsaids also have a topical irritant effect, although this appears to be of minor significance because the route of administration (oral or parenteral) seems to have little influence on development of ulceration. the source of prostaglandins responsible for gastric protection originally was assumed to be cyclooxygenase (cox- ), because this isoform is expressed constitutively in gastric mucosa, whereas cox- is not expressed in the stomach unless induced by inflammatory mediators. however, mice in which the cox- gene has been knocked out fail to develop spontaneous gastric lesions, possibly because of compensatory increases in prostaglandin production by cox- . this concept agrees with recent data indicating that inhibition of both cox isoforms is required to induce gastric ulceration. from a clinical perspective this data indicate that drugs selective for cox- or cox- may be less ulcerogenic in the horse. because cox- elaborates prostaglandins induced by inflammatory stimuli, selective inhibitors of cox- may be particularly useful because of their ability to serve as antiinflammatory agents that are less ulcerogenic. the most notable cause of intestinal mucosal injury in horses, particularly those suffering from colic, is ischemia. initially, that a reduction in gastrointestinal blood supply leads to mucosal injury seems intuitive. however, the anatomy of the gastrointestinal tract and the differing structure of the intestinal mucosa at various anatomic locations have a significant influence on the extent of mucosal injury. furthermore, ischemic injury may be induced by several different mechanisms, including occlusion of arterial supply by a thrombus, strangulation of intestinal vasculature, and generalized reduction in blood flow associated with various shock states. in addition, a number of seemingly distinct mechanisms of intestinal injury, such as intestinal distention, also trigger mucosal injury via an ischemic mechanism. finally, reperfusion injury also may influence the extent of mucosal injury following an ischemic episode and has been proposed as a potential site of therapeutic intervention. , thus understanding the mechanisms of ischemia-reperfusion injury is critical to developing an understanding of the severity of various clinical conditions and beginning to formulate a therapeutic approach to diseases characterized by this devastating form of injury. the intestinal circulation is capable of closely regulating blood flow during periods of low systemic perfusion pressure. , in particular, local regulation of resistance vessels within the microvasculature is particularly prominent, whereby metabolic end products of adenosine triphosphate (atp) result in continued dilation of resistance vessels despite reductions in systemic arterial pressure. dilation results in continued perfusion of gastrointestinal tissues during the early stages of shock, while other organs such as skeletal muscle undergo massive shunting of blood resulting from increased constriction of resistance vessels. the reasons for these differences in regulation are not entirely clear but may relate to the high level of energy required to fuel the intestinal mucosa and the serious systemic effects of breaches in the mucosal barrier. however, as blood flow falls below a critical level, regulatory systems are no longer effective and oxygen uptake by the gastrointestinal tissue decreases, culminating in tissue damage. the tip of the villus is the most susceptible region affected by hypoxia in the equine small intestine, largely because of the countercurrent exchange mechanism of blood flow in the small intestinal villus. this countercurrent exchange mechanism is attributable to the vascular architecture, which consists of a central arteriole that courses up the core of the villus, arborizes at the tip, and is drained by venules coursing down the periphery of the villus. as oxygenated blood flows into the central arteriole, oxygen tends to diffuse across to the adjacent venules, which flow in the opposite direction. this series of events takes place along the length of the villus, resulting in a tip of the villus that is hypoxic even under normal conditions. furthermore, reduced blood flow as occurs in shock exacerbates the countercurrent exchange of oxygen, and the tip becomes absolutely hypoxic. this mechanism might explain why the small intestinal mucosa is more susceptible to ischemic injury, compared with the colon, which has no villi. for example, the duration required to produce severe morphologic damage to the equine colon is approximately % longer than in the small intestine. intestinal mucosal epithelium is susceptible to hypoxia because of the high level of energy required to fuel the na + /k + -atpase that directly or indirectly regulates ion and nutrient flux. the first biochemical event to occur during hypoxia is a loss of oxidative phosphorylation. the resulting diminished atp concentration causes failure of the energy-dependent na + /k + -atpase resulting in accumulation of sodium, and subsequently intracellular water. the ph of the cytosol drops as lactic acid and inorganic phosphates accumulate from anaerobic glycolysis. the falling ph damages cell membranes, including lysosomal membranes, resulting in the release and activation of lysosomal enzymes into the cytosol, further damaging cellular membranes. damage to the cell membrane allows the accumulation of high concentrations of calcium in the cytosol, which activates calciumdependent degradative enzymes. these events result in cytoplasmic blebbing of the basal membrane with subsequent detachment of cells from the underlying basement membrane. recent studies on epithelial injury during ischemia suggest that most epithelial cells undergo programmed cell death (apoptosis) during ischemia and reperfusion rather than necrosis, allowing retention of reusable components of irreversibly injured cells. in one study, % of detached epithelium during small intestinal ischemia and reperfusion underwent apoptosis. although the most obvious result of apoptosis is loss of surface epithelium, a number of cells on the lower portion of the villus (in the small intestine) and cells within the crypts also may undergo apoptosis that only may become evident up to hours following reperfusion of ischemic tissue. morphologic changes observed in ischemic-injured small intestinal mucosa follow a similar sequence regardless of whether ischemia alone or ischemia and reperfusion induce injury (table . - ). initially, epithelium separates from the underlying basement membrane, forming a fluid-filled space termed grüenhagen's space ( figure . - ). the mechanism of fluid accumulation in this space is not understood entirely but may result from continued epithelial absorption of nacl and water before it has detached fully from neighboring epithelial cells. this fluid accumulation likely exacerbates epithelial separation from the basement membrane. subsequently, epithelium progressively sloughs from the tip of the villus toward the crypts, which are the last component of the intestinal mucosa to become injured. [ ] [ ] [ ] injury of crypts likely relates to the vascular architecture, because crypts receive a blood supply separate from the vasculature involved in the villous countercurrent exchange mechanism. the early morphologic changes observed in the equine large colon during ischemia are different from those described in the equine small intestine because of the lack of intestinal villi. however, as might be expected, the more superficially located surface cells are sloughed before those in crypts. , the orderly progression of tissue injury has been used by one group of investigators to predict accurately the survival of horses with large colon volvulus. the researchers took biopsies from the pelvic flexure, which has been shown previously to reflect mucosal changes along the length of the colon accurately, and examined them histologically for the width of the crypts and intercrypt interstitial space. they expressed the latter measurements as a ratio of interstitium to crypt width (i:c) and defined nonviable colon as that which has greater than % loss of crypt and an i:c ratio greater than . using this methodology, researchers correctly predicted survival in % of horses. because of the dramatic decline in strongylus vulgarisinduced colic, which was associated frequently with infarction of intestinal arterial blood supply, most ischemic lesions are associated with strangulating obstruction. therefore considering mechanisms of ischemic injury in horses with naturally occurring strangulating lesions is important. the majority of experimental work has assessed complete ischemia (complete occlusion of the arterial blood supply) or low-flow ischemia (during which arterial blood flow is reduced). , however, during intestinal strangulation, a disparity between the degree of occlusion of the veins and arteries occurs whereby veins are occluded before arteries because of differences in compliance of vascular walls. thus strangulating lesions are typically hemorrhagic (hemorrhagic strangulating obstruction) as the arteries continue to supply blood to tissues that have little or no venous drainage. the result is ischemic injury, as previously outlined, but also a tremendous congestion of the tissues. such hemorrhagic congestion has two opposing effects: it disrupts tissue architecture, including the mucosa and its epithelium, and continues to provide oxygenated blood to the tissues during much of the ischemic episode. in contrast, when strangulation results in sudden cessation of arterial blood flow (ischemic strangulating obstruction), tissues appear pale, and the mucosa rapidly degenerates because of a complete lack of oxygenated blood. because intestine that may look nonviable (dark red) may in fact have less mucosal injury than that of ischemic strangulated intestine. an additional consideration in clinical strangulating obstruction is the degree of ischemia that intestinal distention may induce. for example, experimental distention ( cm of h o for hours) and decompression ( hours) of jejunum resulted in a significant increase in microvascular permeability and a significant decrease in tissue oxygenation similar to that which would be expected with low-flow ischemia. , in particular, microscopic evaluation of vasculature revealed capillary endothelial cell damage and local edema formation. this data suggest that distended intestine proximal to an obstruction may undergo mucosal injury despite its normal appearance. indeed, in one study, intraluminal pressures greater than cm h o in naturally occurring cases of colic correlated with a poor prognosis for survival. although that reperfusion of ischemic tissues results in exacerbation of mucosal injury recently has been taken for granted, one should remember that mechanisms underlying intestinal reperfusion injury have been defined largely in laboratory animals under specific conditions. [ ] [ ] [ ] [ ] [ ] however, studies on reperfusion injury in horses have had some conflicting results. , , the conflict may be attributable to the way in which the studies have been performed. in particular, the type of ischemia used in most laboratory animal studies has been low-flow ischemia (in which the blood flow typically is reduced to % of baseline flow), whereas studies in horses have used a number of different ischemic models, including various types of strangulating obstruction. although strangulating obstruction is of great clinical relevance, this type of ischemic insult is less likely to develop reperfusion injury. , , conversely, low-flow ischemia appears to prime tissues for subsequent injury once the tissue is reperfused, and considerable evidence supports the presence of reperfusion injury in horses following low-flow ischemia. , , , nonetheless, lowflow ischemia may not be a common clinical entity. in addition to the type of ischemia, other factors are involved in priming tissues for reperfusion injury, including species and anatomic-specific variation in oxidant enzyme and neutrophil levels ( table . - ). for example, the foal appears to have low levels of small intestinal xanthine oxidase, an enzyme that has been shown to play a critical role in triggering reperfusion injury in laboratory animals, , , whereas adult levels are much greater, particularly in the proximal small intestine. in addition, horses appear to have low numbers of resident neutrophils in the intestinal mucosa, and this population of neutrophils (rather than those recruited from the circulation) appears to be most critical for induction of reperfusion injury. however, studies demonstrating reperfusion injury in the equine colon following low-flow ischemia have shown significant accumulation of neutrophils within the mucosa. therefore a complete understanding of mechanisms of neutrophilic infiltration and the mechanisms whereby they damage tissue requires further study. reperfusion injury is initiated during ischemia when the enzyme xanthine dehydrogenase is converted to xanthine oxidase and when its substrate, hypoxanthine, accumulates simultaneously because of atp use ( figure . - ). , however, little xanthine oxidase activity occurs during ischemia, because oxygen is required as an electron acceptor. during reperfusion, xanthine oxidase rapidly degrades hypoxanthine in the presence of oxygen, producing the superoxide radical as a by-product. the superoxide radical contributes to oxidative tissue damage and, most importantly, activates neutrophil chemoattractants. , thus inhibition of xanthine oxidase in feline studies of intestinal ischemiareperfusion injury prevents infiltration of neutrophils and subsequent mucosal injury. , however, inhibition of xanthine oxidase has had no effect on ischemiareperfusion injury in equine small intestine and colon, suggesting that reperfusion injury is simply a continuation of injury initiated during ischemia, as suggested in some equine studies, or that the classic reperfusion injury pathway is activated by alternate sources of reactive oxygen metabolites. the latter has been suggested by studies in feline models of ischemia-reperfusion injury in which the source of a significant proportion of reactive oxygen metabolites is unknown and is independent of xanthine oxidase and neutrophils. a veterinary review of the pathogenesis of intestinal reperfusion injury in the horse suggested the concept of a therapeutic window wherein treatment of reperfusion injury would be beneficial. the basis of this concept is that certain conditions exist under which ischemic injury is minimal and that tissues are damaged severely during reperfusion. thus under conditions of low-flow ischemia, little injury is demonstrated during hours of ischemia, but remarkable injury occurs during hour of reperfusion. [ ] [ ] [ ] however, a therapeutic window may not exist under conditions of strangulating obstruction in which severe injury occurs during ischemia and minimal injury occurs during reperfusion. this in turn greatly reduces clinicians' ability to ameliorate ischemiareperfusion injury with treatments such as antioxidants at the time of reperfusion. mechanisms of gastric repair depend greatly on the extent of injury. for instance, superficial erosions can be covered rapidly by migration of epithelium adjacent to the wound; a process termed epithelial restitution. however, ulceration (full-thickness disruption of mucosa and penetration of the muscularis mucosa) requires repair of submucosal vasculature and extracellular matrix. the formation of granulation tissue initiates repair and supplies connective tissue elements and microvasculature necessary for mucosal reconstruction. connective tissue elements include proliferating fibroblasts that accompany newly produced capillaries that form from proliferating endothelium. recent studies indicate that nitric oxide is critical to both processes, , which likely explains the reparative properties of nitric oxide in the stomach. once an adequate granulation bed has formed, newly proliferated epithelium at the edge of the wound begins to migrate across the wound. in addition, gastric glands at the base of the ulcer begin to bud and migrate across the granulation bed in a tubular fashion. repairing epithelium expresses epidermal growth factor, which appears to facilitate these processes. in addition, a mucoid cap facilitates these events and retains reparative factors and serum adjacent to the wound bed. once the ulcer crater has been filled with granulation tissue and the wound has been reepithelialized, the subepithelial tissue remodels by altering the type and amount of collagen. despite the remodeling process, ulcers tend to recur at sites of previous ulceration, and the concern is that this remodeling can result in excessive deposition of collagen and fibrosis. reparative mechanisms are similar in the intestine, except that in the small intestine, mucosal villi contribute to mucosal repair. once intestinal epithelium is disrupted, two events occur almost immediately to reduce the size of the denuded portion of the villus: contraction of the villus and epithelial restitution ( figure . - ). for example, in porcine ileum subjected to hours of ischemia, villi were % of their former height and % of the denuded villous surface area was covered in flattened epithelium within hours. enteric nerves appear to regulate villous contraction, because inhibition of enteric nerve conduction prevents villous shortening following injury. the contractile component of the villus is a network of myofibroblasts distributed throughout the lamina propria of the villus and along the central lacteal. inhibition of villous contraction results in retarded epithelial repair because of the larger denuded surface that remains to be covered by migrating epithelium compared with similarly injured villi that have contracted. pge also has been implicated in regulating villous contraction, because application of pge resulted in villous contraction when perfused through normal rat ileum. as villi contract, assuming the basement membrane is intact, epithelium from the margins of the wound migrates centripetally to resurface toward the tip of the villus. the process of restitution is similar in denuded colonic mucosa, except that it may proceed more rapidly because of the lack of villi. epithelial restitution is solely a migratory event that does not depend on provision of new enterocytes by proliferation. cellular migration is initiated by extension of cellular lamellipodia that receive signals from the basement membrane via integrins. intracellular signaling converges on the actin cytoskeleton, which is responsible for movement of lamellipodia. specific components of the basement membrane appear to be critical to the migratory process. for example, application of antibodies to collagen types iii and iv, which are important components of intestinal mucosal basement membrane, impeded epithelial restitution. , other elements of the basement membrane, including proteoglycans, hyaluronic acid and noncollagenous proteins such as fibronectin and laminin also may provide important signals. these subepithelial matrix components that facilitate restitution may form the basis for clinical treatments designed to speed up the repair process, analogous to administration of matrix components to horses with articular cartilage damage. although epithelial restitution results in gross closure of previously denuded regions of gastrointestinal mucosa, closure of interepithelial spaces ultimately is required to restore normal epithelial barrier resistance. because the tight junction is principally responsible for regulating the permeability of the interepithelial space, repair and closure of this structure likely is critical to restore intestinal barrier function. recent research indicates that prostaglandins play a vital role in recovery of tight junction resistance, indicating that administration of nonselective cox inhibitors to horses with colic, particularly those recovering from strangulating obstruction, may be deleterious. therefore judicious use of nsaids is appropriate until more selective drugs that allow continued production of reparative prostaglandins are available for use in horse. after restoration of the epithelial barrier, the epithelium must reestablish normal mucosal architecture to allow normal gut absorptive and digestive function. in porcine ileum subjected to hours of ischemia, the epithelial barrier was restored within hours, but villi were contracted and covered in epithelium with a squamous appearance. restoration of normal villous architecture required another days. newly proliferated crypt epithelium replaces the flattened villous epithelium that characterizes restitution. under normal circumstances the dividing stem cells, of which the base of each mucosal crypt has approximately four, form new enterocytes. newly divided enterocytes migrate from the crypt onto the villus. during migration, enterocytes differentiate and acquire specific absorptive and digestive functions. fully differentiated enterocytes reside on the upper third of the villus for to days and then are sloughed into the intestinal lumen. this process accelerates during mucosal repair and requires increased proliferative rates. a variety of locally available gut-derived factors, including luminal nutrients, polyamines, and growth factors, may stimulate increased proliferation within to hours. the return of the normal leaflike shape of the villus occurs following the appearance of normal columnar epithelium. although prostaglandins have been implicated in mucosal cytoprotective function, few studies have assessed their importance in mucosal repair. one study implicated prostaglandins in growth factor-stimulated restitution, but a more prominent role of prostaglandins in mucosal repair is their ability to close interepithelial tight junctions. , , for instance, ischemic-injured small intestine rapidly recovers barrier function (as measured in vitro as transepithelial resistance) in the presence of pgi and pge , despite the fact that these prostanoids had little effect on villous contraction and epithelial restitution. however, electron microscopic examination of tissues reveals dilation of tight junctions in tissues treated with nsaids, whereas those additionally treated with prostaglandins have closely apposed tight junctions (figures . - and . - ). prostaglandins stimulate closure of tight junctions via the second messengers cyclic adenosine monophosphate and ca + , which interestingly were among the first mediators found to modulate tight junction permeability. , such tight junction closure is of importance to patients with intestinal injury that are treated with nsaids, because reduced prostaglandin levels may result in increased intestinal permeability. for example, in a study on ischemic-injured porcine ileum, treatment with the nsaid indomethacin resulted in a significant increase in intestinal permeability to inulin and lipopolysaccharide compared with tissues that were treated additionally with pgi and pge . section . pathophysiology of mucosal injury and repair a b figure . - ultrastructural appearance of repairing ischemic-injured mucosa. a, restituting epithelium hours following a -hour ischemic episode in the presence of the nonselective cyclooxygenase inhibitor indomethacin. dilation of the interepithelial space and the apical tight junction (arrows) correlates with a leaky intestinal barrier, b, similar restituting epithelium had been treated additionally with prostaglandins e and i . the close apposition of the tight junction (arrows) and the interepithelial space correlate with normalization of intestinal barrier function. -cm bar = µm. the process of restitution absolutely depends on a group of compounds called polyamines. , the rate-limiting enzyme in the formation of the polyamines spermine, spermidine, and putrescine is ornithine decarboxylase. in rats with stress-induced duodenal ulcers, systemic administration of the ornithine decarboxylase inhibitor α-difluoromethylornithine significantly reduced polyamine levels and greatly reduced epithelial restitution. furthermore, intragastric treatment of these same rats with putrescine, spermidine, and spermine prevented the delayed mucosal repair induced by α-difluoromethylornithine. interestingly, gastric tissue levels of ornithine decarboxylase increased in rats with stress-induced gastric ulcers, suggesting that tissue injury enhances polyamine production, which may contribute to the normal rapid rate of epithelial restitution. the mechanisms whereby polyamines stimulate epithelial restitution are not clear. mccormack, wang, viar, et al. hypothesized that polyamines increase transglutaminase activity, an enzyme that catalyzes the cross-linking of cytoskeletal and basement membrane proteins. further investigation of the role of polyamines in iec- cell migration showed that depletion of polyamines resulted in disruption of the cytoskeleton and reduced the physical extension of lamellipodia. more recent studies have clarified this pathway. in particular, polyamines have been shown to regulate cytoskeletal cellular migration via activation of the small guanosine triphosphatase-rho-a by elevating intracellular ca + levels. these elevations in ca + result from polyamine regulation of expression of voltagegated k + channels and altered membrane electric potential. polyamines also play a role in the normal physiologic regulation of crypt cell proliferation and differentiation. , polyamines are produced by fully differentiated enterocytes at the tip of the villus and may reach the crypt within sloughed luminal epithelium or via local villous circulation. following intestinal injury, polyamines appear to stimulate enhanced proliferation by increasing the expression of protooncogenes, which control the cell cycle. the mechanism whereby polyamines influence gene expression likely relates to the cationic nature of these compounds, which may influence the tertiary structure of negatively charged dna and rna. locally produced growth factors-including epidermal growth factor (egf), transforming growth factor α (tgf-α), tgf-β, and hepatocyte growth factor-have the ability to modulate mucosal recovery. the most important of these growth factors in early mucosal repair events is tgf-β, which is a potent stimulus of epithelial restitution and modulator of the extracellular matrix. neutralization of tgf-β retards epithelial migration in vitro, and tgf-β apparently may serve as a point of convergence for mediators of restitution, because neutralizing tgf-β also inhibits the effects of other peptides. however, tgf-β paradoxically inhibits epithelial proliferation, thereby reducing the supply of new enterocytes for mucosal repair. conversely, egf, produced by the salivary glands and duodenal brunner's glands, and the related tgf-α, produced by small intestinal enterocytes, are potent stimulants of enterocyte proliferation. these growth factors share approximately % of their amino acid structure, bind to the same receptor on the basolateral surface of enterocytes, and are not related to tgf-β. the physiologic role of egf is difficult to discern because it is present in the intestinal lumen, with no apparent access to its basally located receptor. however, egf has been proposed to act as a "surveillance agent" that gains access to its receptor during epithelial injury (when the egf receptor likely would be exposed) to stimulate proliferation. tgf-α presumably has a similar role, but it is present in greater concentrations in the small intestine because it is produced by differentiated villous enterocytes. the mature peptide is cleaved from the extracellular component of the transmembrane tgf-α precursor and released into the lumen. another group of proreparative peptides produced within the gastrointestinal tract are the trefoil peptides. under physiologic conditions, trefoil peptides are secreted by mucus-producing cells at distinct anatomic sites. for example, gastric epithelium produces the trefoil peptide ps , whereas the small and large intestine mucosa produce intestinal trefoil peptide. however, any of the trefoil peptides may be upregulated within repairing epithelium regardless of anatomic site. , in addition, trefoil peptides have the ability to induce their own expression, amplifying the level of these reparative factors at sites of mucosal repair. trefoil peptides are the most potent stimulants of epithelial migration in vitro, and their effects are independent of growth factors, including tgf-β. however, recent evidence suggests that egf receptor activation is required for induction of ps and another of the trefoil peptides, termed spasmolytic peptide, in gastric epithelium in vitro. the importance of trefoil peptides to the mucosal repair response in vivo is illustrated by gene knockout studies, in which mice deficient in intestinal trefoil factor have greatly reduced ability to repair intestinal injury. in fact, detergent-induced mucosal injury was lethal because of a lack of restitution compared with wild-type mice that fully recovered from similar mucosal injury. the fact that administration of intestinal trefoil factor restored restitution has important therapeutic implications. the mechanism whereby trefoil peptides stimulate epithelial migration is yet to be characterized fully but appears to involve translocation of the adherens junction protein e-cadherin, thereby allowing cells to become untethered from neighboring cells. the principal metabolic fuel of enterocytes is glutamine and of colonocytes, butyrate. however, recent studies suggest that glutamine and butyrate have more specific proliferative actions aside from their role as nutrients. for example, in the piglet ipec-j enterocyte cell line, glutamine enhanced gene transcription by increasing mitogen-activated protein kinase activity. , similarly, butyrate stimulated mucosal growth following colonic infusion in the rat. because of such growth-promoting actions, glutamine was shown to prevent intestinal mucosal atrophy and dysfunction that accompanies starvation , and long-term total parental nutrition. , additionally, glutamine improves function of transplanted small intestine , and protects intestinal mucosa from injury if administered before chemotherapy and radiation therapy. , intestinal nutrients also may synergize with other proliferative agents. for example, administration of glutamine and tgf-α to porcine ileum that had been subjected to hours of ischemia resulted in a synergistic increase in mitogen-activated protein kinase activity, enterocyte proliferation, and villous surface area. although concern has arisen that such early return to normal surface area may result in dysfunctional mucosal digestive and absorptive function because of resurfacing denuded mucosa with immature epithelium, nutrients and growth factors also appear to promote early differentiation. in the case of glutamine and tgf-α restoration of postischemic small intestine, rapid recovery of digestive enzymes also was documented. effective gastrointestinal motility involves a complex interaction between the enteric nervous system, muscular wall, and luminal contents. additional factors that influence the net transit of digesta include gravity, the volume and viscosity of the contents, and pressure gradients created by simultaneous contraction and relaxation of adjacent segments of bowel. casual use of the term intestinal motility in veterinary medicine often underestimates the complexity of the processes involved in the transit of intestinal contents. this is particularly true when the term is used to describe the frequency and or intensity of intestinal sounds, or borborygmi. the existence of borborygmi does not always equate with progressive movement of intestinal contents. disruption to normal motility occurs commonly in horses for a variety of reasons. examples of diseases in which altered motility may be present include gastroduodenal ulceration, intraluminal obstruction or impaction, excessive wall distention, strangulating obstructions, peritonitis, and inflammatory bowel diseases such as duodenitis proximal jejunits or colitis. ineffective intestinal motility is also a feature of several neonatal diseases, including prematurity, systemic sepsis, and perinatal asphyxia. certain parasitic infections, electrolyte derangements, and endotoxemia can modify digesta transit in horses of all ages. general anesthesia and specific sedatives, such as xylazine, romifidine, or detomidine, also disturb motility. the inhibition of propulsive bowel activity usually is referred to as ileus. ileus is ascribed most frequently to the condition that occurs after laparotomy and is termed simple or uncomplicated postoperative ileus (poi). the term complicated or paralytic ileus describes intestinal motility disturbed for longer periods after surgery. poi in horses is associated most commonly with surgery of the small intestine, particularly after resection and anastomosis, , is a common complication of small intestinal surgery, and can have a negative effect on short-term postoperative survival. , motility dysfunction likely is present in all horses after laparotomy, but many are affected subclinically and require minimal or no specific intervention. in symptomatic animals, clinical signs are apparent shortly after recovery and include colic, tachycardia, dehydration, decreased borborygmi and fecal output, and sequestration of fluid within the stomach. rectal examination and ultrasound reveal small intestinal distention with rare or absent wall movement. the severity and duration of intestinal stasis varies, lasting from minutes to days. a specific motility disorder involving the cecum or ileocecocolic region occurs sporadically in horses. [ ] [ ] [ ] the condition most commonly occurs after general anesthesia and extraabdominal surgery, particularly orthopedic and upper airway procedures, and therefore often is categorized as a form of poi. anecdotally, horses at greatest risk are young male performance animals. other cases occur spontaneously, often in animals with painful primary conditions such as uveitis or septic tenosynovitis. the syndrome is frustrating in that clinical signs are often subtle unless cecal perforation has occurred. in horses with a cecal emptying defect after anesthesia, overt signs are usually apparent to days after the procedure. the earliest detectable signs include depression and a reduction in feed intake and fecal output. ineffective emptying results in overfilling of the cecum with moist contents, which is manifest by signs of mild to moderate colic. if the condition is recognized late or untreated, the cecum may rupture and result in fatal peritonitis. the inherent rhythmicity of electric activity in the intestine is controlled by the interstitial cells of cajal, specialized cells that are electrically coupled to myocytes via gap junctions. these cells are responsible for generating and propagating slow-wave activity and may be critically involved in a range of motility disorders. the enteric nervous system primarily controls and coordinates intestinal contraction. a combination of central and autonomic innervation influences events, but contraction does not require external neural input. the parasympathetic supply to the gastrointestinal tract is via the vagus and pelvic nerves, and the sympathetic supply is through postganglionic fibers of the cranial and caudal mesenteric plexuses. a complex network of interneurons within each plexus integrates and amplifies neural input; the intensity and frequency of resultant smooth muscle contractions are proportional to the amount of sympathetic and parasympathetic input. additional binding sites for a number of other endogenous chemicals, including dopamine, motilin, and serotonin exist within the enteric nervous system and on smooth muscle cells. acetylcholine is the dominant excitatory neurotransmitter in the gastrointestinal tract and exerts its action through muscurinic type receptors on smooth muscle cells. sympathetic fibers innervating the gastrointestinal tract are adrenergic, postganglionic fibers with cell bodies located in the prevertebral ganglia. activation of α adrenergic receptors on cholinergic neurons within enteric ganglia inhibits the release of acetylcholine and therefore reduces intestinal contraction. β -, β -, and β-atypical receptors are directly inhibitory to the intestinal smooth muscle. inhibitory nonadrenergic, noncholinergic neurotransmitters include adenosine triphosphate, vasoactive intestinal peptide, and nitric oxide. , these neurotransmitters are critical for mediating descending inhibition during peristalsis and receptive relaxation. substance p is a nonadrenergic, noncholinergic neurotransmitter that may be involved in contraction of the large colon. , the rate and force of intestinal contractions along the small intestine and large colon of the horse are important determinants of intestinal motility; of even greater importance to the net propulsion of digesta are the cyclical patterns of contractile activity. these patterns are known as the small intestinal and colonic migrating motility (or myoelectric) complexes (mmcs). , the colonic complex usually originates in the right ventral colon and variably traverses the ascending and descending colons. many of these complexes are related temporally to a specialized motility event of the ileum, the migrating action potential complex. local inflammation within the intestinal muscularis and inhibitory neural events are important initiators of intestinal ileus. , intestinal inflammation not only is important in primary intestinal diseases in horses, such as duodenitis-proximal jejunitis and colitis but also is induced after simple intestinal handling during laparotomy. experimental data from other species suggests that handling of the small or large intestine at the time of surgery activates resident macrophages with resultant increased expression of p-selectin and intercellular adhesion molecule on endothelial cells within the vasculature of the muscularis. the upregulation of associated ligands on leukocytes leads to sequential "sticking and rolling," followed by neutrophil migration into the interstitium. the subsequent release of neutrophil products interferes with cell signaling and results in reduced intensity of smooth muscle contraction. furthermore, the inflamed intestine fails to contract normally in response to putative prokinetic agents. another key factor in the development of intestinal stasis after inflammation is the local overproduction of nitric oxide caused by the upregulation of inducible nitric oxide synthase (inos) by resident macrophages. nitric oxide is a key inhibitory neurotransmitter of the nonadrenergic, noncholinergic system. nitric oxide synthase inhibition has been a pharmacologic target in the treatment of experimental ileus. the inhibitory effects of α -agonists such as xylazine and detomidine on cecal and large colon motility are well described. [ ] [ ] [ ] [ ] [ ] [ ] intravenously administered xylazine inhibits cecal and large colon motility for to minutes without seriously disrupting small intestinal myoelectric activity, and detomidine can reduce large intestinal myoelectric activity for up to hours. the α -antagonist yohimbine has a weak but positive effect on cecal emptying in normal ponies, suggesting that normal motility is under constant α -adrenergic tone. atropine is a postganglionic blocking agent that binds to muscarinic receptors. when administered at . mg/kg, atropine inhibits individual small intestinal, cecal, and colonic contractions for about minutes but supresses small intestinal and colonic migrating complexes for up to hours. neural reflexes also may mediate inhibition of motility associated with peritoneal inflammation. , the afferent segment is composed partly of capsaicin-sensitive visceral afferent c fibers that terminate in the dorsal horn of the spinal cord, where they can activate inhibitory sympathetic fibers or synapse directly on the sympathetic ganglia. consequently, the efferent limb of the reflex expresses increased sympathetic outflow, primarily mediated through stimulation of α -adrenoreceptors, and inhibition of acetylcholine release, which provides the rationale for α -blockade in treating ileus. intraluminal infusion of capsaicin before abdominal surgery ameliorated the severity of poi in experimental rats. this finding highlights the importance of visceral afferent fibers in the development of poi. ileus also can occur in association with intestinal obstruction or displacement. mild to moderate distention of the bowel, such as that occurring in the early stages of an intraluminal obstruction, evokes an increase in local contractile activity. , excessive distention results in inhibition of motility within the distended segment of bowel. intestinal stasis is not always detrimental and under certain conditions may be protective. endotoxemia is a clinical feature of many diseases of the equine gastrointestinal tract, and endotoxins independently can exert a negative effect on intestinal motility and transit. a variety of mediators likely are involved, but activation of α -adrenoreceptors and production of prostanoids appear to be important, for pretreatment with yohimbine or nonsteroidal antiinflammatory drugs (nsaids; phenylbutazone or flunixin), respectively, ameliorates the inhibitory effects of experimental endotoxin infusion. , endotoxin infusion induced an inflammatory response in the intestine of rats that mimicked the response induced by handling during laparotomy. the similarity of the responses were highlighted in a recent study that demonstrated that prior exposure of the muscularis to endotoxin protected the intestine from the effects of manipulation. the pathophysiology of cecal emptying defect is not known. this syndrome may best mimic poi in human beings and generally is considered a large intestinal disorder. an important difference in horses is that laparotomy is a rare predisposing factor, and most cases occur in horses undergoing routine extraabdominal surgical procedures. general anesthesia itself is a potent inhibitor of gastrointestinal motility in horses, but these effects are short-lived and reversible within hours of anesthetic withdrawal. the return of normal motility in horses after experimental ileus was most delayed in the cecum, suggesting that this may be a common site of ileus in horses. a link between routine postoperative medications, such as phenylbutazone and aminoglycoside antibiotics, has been suspected but not established. an inhibitory effect of nsaids on large colon contractility has been demonstrated using in vitro techniques. primary sympathetic overstimulation could be involved, for many of the affected animals are young, male horses or animals with painful diseases. the duration of surgery influences the development of small intestinal poi, but not cecal emptying dysfunction. , technique may have a weak influence on small intestinal poi after jejunojejunostomy. the duration of intestinal ileus was shorter in animals that received a sideto-side stapled anastomosis than those that had a hand sewn end-to-end procedure. the duration of ileus after stapled end-to-end anastomosis was not different from that after either procedure. reported risk factors for the development of poi in horses include age (> years), small intestinal resection and anastomosis, breed (arabians had a greatest risk than other breeds), and duration of surgery. interestingly, performing a pelvic flexure enterotomy and emptying the colon had a protective effect against poi. the diagnosis of ileus is based on history and physical examination findings. important tests include determination of pulse rate and rhythm, auscultation and percussion of the abdomen, rectal palpation, and passage of a nasogastric tube. a complete blood count with fibrinogen estimation and cytologic analysis of peritoneal fluid may improve the accuracy of diagnosis. affected animals may be colicky because of accumulation of fluid in the upper gastrointestinal tract (classical poi) or cecal contents (cecal emptying defect). decompression of the stomach is important diagnostically and therapeutically in horses with poi after small intestinal surgery. failure to relieve pain with gastric decompression could point toward mechanical obstruction, severe inflammation of the intestine, or peritonitis. most animals with ileus are depressed and have reduced fecal output and intestinal borborygmi. one should interpret intestinal sounds with caution, however, because the presence of borborygmi does not always equate to progressive intestinal motility and merely may reflect local, nonpropagated contractions. rectal palpation findings in cases of persistent poi or duodenitis-proximal jejunitis are usually nonspecific but may reveal dilated, fluid-filled loops of small intestine. the clinician occasionally can palpate roughened peritoneal surfaces if peritonitis is present. one can palpate cecal distention with digesta in horses with advanced cecal dysfunction. distinguishing functional ileus from mechanical obstruction is important and can be difficult, but horses with mechanical obstruction typically have sustained high volumes of gastric reflux that vary little over time. the management of intestinal ileus depends on the segment of gastrointestinal tract involved. therapy for ileus of the proximal gastrointestinal tract involves a combination of gastric decompression, fluid and electrolyte therapy, and antiinflammatory drug therapy. electrolyte therapy is critical, particularly for maintaining adequate extracellular concentrations of potassium, calcium, and magnesium. calculation of the volume of fluid to be administered should include maintenance requirements ( to ml/kg/day) plus an estimate of losses, especially those lost through gastric decompression. one should consider parenteral provision of calories when feed has been withheld for more than hours, particularly after the horse has had surgery. a combination of amino acids and dextrose with or without lipids effectively provides these calories. hand walking also may provide some benefit to these animals but is not likely to have a direct effect on intestinal motility. one should avoid drugs that may impair normal intestinal motility, including the anticholinergics such as atropine and opiate receptor agonists such as morphine and meperidine. butorphanol appears to have little or no adverse effect on small or large intestinal motility. , one should use α -agonists sparingly because of their inhibitory effects on large intestinal motility. fluid therapy is the key component in managing cecal emptying defect, usually in combination with lubricants or laxatives, such as mineral oil or magnesium sulfate, and with careful use of antiinflammatory drugs. horses with primary cecal impaction or impaction caused by an emptying defect frequently require surgery to prevent fatal rupture. the surgical management of these cases is controversial and may include typhlotomy alone, typhlotomy with a bypass procedure such as ileocolic or jejunocolic anastomosis, or a bypass without typhlotomy. most horses that undergo simple typhlotomy have an uneventful recovery, although a small number experience impaction again and require a second laparotomy. experimental and anecdotal evidence provides a strong rationale for using antiinflammatory drugs to prevent and treat gastrointestinal ileus, particularly in animals that may have endotoxemia. flunixin meglumine is used widely in equine practice as an analgesic and antiinflammatory agent, and it ameliorates many of the adverse systemic effects of endotoxin, particularly those on the cardiovascular system. a potential negative effect of nsaids on large intestinal contractility has been suggested. broad-spectrum antimicrobials are indicated when one suspects sepsis or for the compromised immune system, as in cases of moderate to severe endotoxemia. theoretical concerns have been raised regarding the use of aminoglycoside antibiotics in animals with ileus. high concentrations of aminoglycoside antimicrobials inhibited intestinal contractions in exposed sections of intestine in vitro, but this inhibitory effect is unlikely to occur at clinically relevant doses. motility-enhancing drugs have been advocated to treat gastrointestinal ileus. unfortunately, information directly pertinent to horses is limited and must be extrapolated cautiously from that of other species because of the differences in intestinal anatomy and physiology. prokinetic drugs potentially can shorten the length of hospitalization, thereby reducing the cost of treatment and the number of potential complications such as weight loss, thrombophlebitis, and laminitis. experimental evidence indicates that prokinetic drugs can minimize the development of postoperative abdominal adhesions. most prokinetic drugs require a healthy gut wall to enhance intestinal contraction. therefore one should not assume that many of these drugs would be effective in the presence of an inflammatory injury such as that which can occur after intestinal manipulation at surgery or that associated with duodenitis-proximal jejunitis. bethanechol is a parasympathomimetic agent that acts at the level of the myenteric plexus and directly on intestinal smooth cells through muscarinic receptors. bethanechol is a synthetic ester of acetylcholine and is not degraded by anticholinesterase. bethanechol has cholinergic side effects, including abdominal discomfort, sweating, and salivation, although these are minimal when the drug is administered at . mg/kg body mass subcutaneously or orally. bethanechol has efficacy in diseases that involve abnormal gastric emptying and delayed small intestinal transit and has been shown to increase gastric contractility and hasten the emptying of liquid and solid phase markers from the stomach of normal horses. [ ] [ ] bethanechol also increases the strength and duration of wall contractions in the cecum and right ventral colon and consequently speeds up cecal emptying. neostigmine increases receptor levels of acetylcholine by inhibiting cholinesterase. the drug ( . to . mg/kg intravenously) promotes cecal and colonic contractile activity and hastens the emptying of radiolabeled markers from the cecum. neostigmine has been used to manage small intestinal ileus, but it significantly delayed the emptying of -mm beads from the stomach of normal adult horses. metoclopramide acts principally as a -hydroxytryptamine -receptor ( ht- ) agonist and ht- -receptor antagonist. in contrast to newer generation benzamides, metoclopramide is also an antagonist at dopamine (da ) and (da ) receptors. antagonism of prejunctional da receptors facilitates acetylcholine release and smooth muscle contraction. metoclopramide crosses the blood-brain barrier, where its antagonist properties on central da receptors can result in extrapyramidal signs, including seizure. these signs were responsible for poor acceptance of the drug in equine practice. most investigators have failed to demonstrate significant effects of metoclopramide in experimental animals, but constant intravenous infusion ( . mg/kg/hr) in a population of postoperative horses significantly decreased the volume and duration of gastric reflux over control and intermittent drug infusion groups. infusion was well tolerated and appeared to be superior to intermittent infusion or no treatment at all. cisapride is a second-generation benzamide that acts as a ht- agonist and ht- receptor antagonist but is without antidopaminergic action. stimulation of ht- receptors within the enteric nervous system enhances release of acetylcholine from the myenteric plexus. several reports suggest the efficacy of cisapride in managing intestinal disease in horses, including the resolution of persistent large colon impaction, treatment of equine grass sickness, and as a preventative for poi in horses after small intestinal surgery ( . mg/kg body mass intramuscularly during the postoperative period). [ ] [ ] [ ] [ ] the horse erratically absorbs tablets administered rectally, but a method for preparing a parenteral form of the drug from tablets has been described. cisapride has the potential to cause adverse cardiac side effects mediated through blockage of the rapid component of the delayed rectifier potassium current that include lengthening of the qt interval and development of torsades de pointes, a potentially fatal arrhythmia. these adverse effects have resulted in withdrawal of the drug in the united states. domperidone acts as a competitive antagonist at peripheral da receptors. the drug is a therapeutic agent ( . mg/kg/day) for mares grazing endophyte-infected tall fescue, principally because of drug-enhanced prolactin release. the potential prokinetic effects of domperidone have not been studied extensively in horses, but a modest efficacy of domperidone ( . mg/kg intravenously) has been demonstrated in experimental ileus in two ponies. erythromycin is a direct motilin receptor agonist on smooth muscle cells and also may act within the enteric nervous system to facilitate the release of acetylcholine and motilin. erythromycin enhances gastric emptying in normal horses but has a more pronounced effect on the hindgut. , erythromycin lactobionate ( . mg/kg intravenously) hastens cecal emptying in normal animals and induces colonic mmc-like activity across the colon. administration often is associated with defecation and abdominal discomfort. the drug may help prevent cecal impaction in horses after anesthesia, although its effectiveness on cecal motility in the immediate postoperative period may be reduced. high doses, constant infusion, or prolonged use of erythromycin induces receptor downregulation and inhibition of activity. erythromycin can induce diarrhea in adults, therefore one should avoid dosing over many days. naloxone ( . mg/kg intravenously) induces contractile activity in the cecum and left colon. defecation commonly follows administration of naloxone within to minutes. α -adrenoreceptor antagonists such as yohimbine or tolazoline counteract increased sympathetic outflow in response to nociceptive stimulation. yohimbine infusion ( µg/kg) also may attenuate the negative effects of endotoxin on motility. intravenous infusion of lidocaine may suppress primary afferent neurons, thereby limiting reflex efferent inhibition of motility. an infusion dose of to mg/min over to hours has been recommended for horses. lidocaine infusion is associated with reversible side effects that include muscle fasciculations, ataxia, and seizure. consequently, the rate of infusion requires close monitoring. katharina l. lohmann, michelle henry barton endotoxemia is defined as the presence of endotoxin in the bloodstream. most often, however, the term is used to refer to the associated clinical manifestations caused by an overshooting inflammatory reaction. in its pathophysiologic consequences the innate immune response to endotoxin (lipopolysaccharide) is similar to the response to other stimuli; for example, overwhelming bacterial infection, viral infection, or severe trauma. the term systemic inflammatory response syndrome therefore was introduced to describe a general systemic inflammatory process independent of cause. sepsis is defined as the "systemic inflammatory response to infection," and septic shock as "sepsis-induced hypotension, persisting despite adequate fluid resuscitation, along with the presence of hypoperfusion abnormalities or organ dysfunction." according to these definitions the diagnosis of sepsis requires documentation of infection by culture in addition to two or more of the following findings: hypo-or hyperthermia, tachycardia, tachypnea or hypocapnia, and leukocytosis, leukopenia, or an increased proportion of immature leukocyte forms. organ failure is a common sequela of endotoxic or septic shock, and the term multiple organ dysfunction syndrome describes insufficiency of two or more organ systems, as evident by clinical or clinicopathologic changes. in horses one should include the laminae of the feet in the list of organs susceptible to failure. german scientist richard pfeiffer ( - ), in working with vibrio cholerae, first described endotoxin as a toxin "closely attached to, and probably integral of, the bacterial body." he observed this toxin to be distinct from the actively secreted, heat-labile, and proteinaceous bacterial exotoxins. endotoxin later was found to be a heat-stable lipopolysaccharide structure, and the terms endotoxin and lipopolysaccharide now are used interchangeably. lipopolysaccharide is a major structural cell wall component of all gram-negative bacteria, including noninfectious species (figure . - ). with to × molecules per cell, lipopolysaccharide makes up about % of the outer layer of the outer cell membrane and is a key functional molecule for the bacterial outer membrane, serving as a permeability barrier against external noxious agents. the lipopolysaccharide molecule consists of four domains, which are essential for the virulence of gram-negative bacteria. three of the domains (inner core, outer core and o-specific chain) represent the hydrophilic polysaccharide portion of the molecule, whereas the lipid a portion represents the hydrophobic lipid portion ( figure . - ). combined, these domains confer the overall amphiphilic properties of the molecule that lead to the formation of micellar aggregates in aqueous solutions. o-specific chains (also called o-antigen polysaccharides or o-chains) are characteristic of any given type of lipopolysaccharide and show enormous structural variability between bacterial serotypes. o-chains are synthesized by addition of preformed oligosaccharide blocks to a growing polymer chain and therefore have a repetitive structure. o-specific chains determine part of the immunospecificity of bacterial cells and, on interaction with the host immune system, serve as antigens for the production of species-specific antibodies. o-specific chains are further responsible for the smooth appearance of gram-negative bacterial colonies on culture plates, and lipopolysaccharide molecules containing an o-chain are termed smooth lipopolysaccharide. the inner (lipid a-proximal) and outer (o-chainproximal) core oligosaccharide portion is more conserved between different strains of gram-negative bacteria than the o-specific chain. the core of all lipopolysaccharide molecules contains the unusual sugar kdo ( -deoxy-dmanno-oct- -ulopyranosonic acid), which links the core region to the lipid a molecule. synthesis of a minimal core is essential for the survival of bacteria, and the smallest naturally occurring lipopolysaccharide structure consists of lipid a and kdo. in contrast to the s-form colonies, colonies of gram-negative bacteria with lipopolysaccharide molecules that lack the o-specific chain but contain a core region show a rough appearance on culture plates. rough lipopolysaccharide molecules are denoted further as ra, rb, etc. to indicate the length of the core region. in re-lipopolysaccharide (also called deep rough lipopolysaccharide), the core region is reduced to a kdo residue. remutants often are used to raise antibodies against the core region in an attempt to provide cross-protection against a variety of bacterial species. the lipid a portion serves to anchor the lipopolysaccharide molecule in the bacterial outer membrane and has been identified as the toxic principle of lipopolysaccharide, and its structure is highly conserved among gramnegative bacteria. the common structure shared by lipid a molecules is a , '-bisphosphorylated β , -linked d-glucosamine disaccharide backbone (lipid a backbone), which is acylated by up to six fatty acids. figure . - shows the acylation pattern for escherichia coli lipopolysaccharide. variation in the lipid a structure between gramnegative bacteria affects the number, length, and position of fatty acids and the backbone structure and the substitution of phosphate by other polar groups. according to its nature as a structural cell wall component, the presence of endotoxin implies the presence of gram-negative bacteria as a source. depending on the nature of the underlying disease, these bacteria may circulate in the bloodstream in their intact form (i.e., bacteremia), may be confined to a localized infectious process, or may be part of the endogenous bacterial flora colonizing the gastrointestinal tract. in any of these scenarios, endotoxin molecules are released as a by-product of bacterial growth and in large numbers on bacterial cell death. common infectious conditions associated with endotoxemia in horses include neonatal gram-negative sepsis, bacterial pneumonia and pleuropneumonia, endometritis, peritonitis, and infectious colitis with bacteria such as salmonella spp., that are not part of the normal intestinal flora. in one study, for example, endotoxin was detectable in plasma of % of foals evaluated for presumed sepsis. the term translocation describes entry of endogenous bacteria and bacterial products from the gastrointestinal tract into tissues and the systemic circulation. the natural intestinal flora of horses consists mainly of gramnegative, anaerobic bacteria, and thus large amounts of endotoxin normally exist in the lumen of the equine intestinal tract. even in health, small amounts of endotoxin cross the intact mucosal barrier and reach the portal circulation and the liver. these molecules are cleared, however, by the mononuclear phagocytic system in the liver and only lead to a localized and restricted activation of the host immune system. for endotoxin translocation to become detrimental, excessive amounts have to cross the intestinal barrier and overwhelm the mononuclear phagocytic system or the capacity of the liver to detoxify lipopolysaccharide must be compromised. the latter may be a concern in conditions such as hepatitis, cholangiohepatitis, or portosystemic shunting of blood. permeability of the intestinal mucosal barrier frequently increases in cases of acute gastrointestinal disease. colic patients are prime candidates to development endotoxemia, and plasma endotoxin was detectable in % to % of colic patients on admission. , a higher percentage of horses tested positive for endotoxin when only patients presented for surgical intervention were evaluated. aside from gastrointestinal rupture, increased permeability to intact bacteria or free endotoxin molecules is thought to be associated most commonly with ischemic insults such as strangulating obstruction and bowel infarction, severe inflammation as in proximal enteritis and colitis, bacterial overgrowth, and intraluminal acidosis, which occurs with grain overload. , one study, however, found no difference in plasma endotoxin detection between disease groups, therefore emphasizing the fact that any disease of the abdominal cavity can induce endotoxemia in horses. in the same study, endotoxin was approximately times more likely to be detected in peritoneal fluid as opposed to plasma samples. similarly, higher cytokine concentrations have been measured in peritoneal fluid than in plasma. the likely explanation for these findings is a local inflammatory response in the peritoneal cavity elicited by translocated bacteria and/or lipopolysaccharide molecules before their absorption into the systemic circulation. although certainly the most important factor in horses, conditions other than gastrointestinal disease may result in translocation of endotoxin and bacteria. in experimental studies using laboratory animals, entry of gutassociated bacteria into the lymphatic system was demonstrated after hypovolemic shock, burn injuries, trauma, malnutrition, and starvation. [ ] [ ] [ ] furthermore, endotoxin itself caused bacterial translocation into mesenteric lymph nodes after intraperitoneal administration to mice. these findings have received much attention in the literature concerning human patients because they serve to explain cases of endotoxic shock in the absence of demonstrable bacterial infection. one should keep in mind the possibility of translocation when evaluating cases of presumed systemic inflammatory response syndrome in horses, in which one cannot demonstrate bacterial infection or gastrointestinal disease. endotoxin translocation also may be associated with strenuous exercise, which results in reduced splanchnic blood flow, hypoxemia, and a higher body temperature. in fit racehorses a significantly increased mean plasma lipopolysaccharide concentration was found after racing, whereas antilipopolysaccharide immunoglobulin g levels were decreased. fit horses showed significantly higher antilipopolysaccharide immunoglobulin g concentrations at rest than sedentary controls, suggesting leakage of small amounts of endotoxin from the intestinal lumen during training and racing. the clinical significance of these findings requires further investigation. the initiating event in the pathophysiology of endotoxemia is the activation of lipopolysaccharideresponsive cells by endotoxin, resulting in altered cellular functions and increased expression of inflammatory mediators. immune cells such as macrophages, which are the first to encounter endotoxin, respond to minute amounts of lipopolysaccharide, which usually allows them to eliminate gram-negative bacteria and free lipopolysaccharide molecules efficiently. an important factor in the exquisite sensitivity to lipopolysaccharide is the presence of lipopolysaccharide-binding protein (lbp). lbp is an approximately -kd plasma glycoprotein synthesized by hepatocytes and belongs to the group of acute phase proteins. under the control of inflammatory agents and cytokines, lbp concentration in plasma increases approximately -fold within hours of an inflammatory stimulus. the main function of lbp is to transfer lipopolysaccharide to endotoxin-responsive cells, which include mononuclear phagocytes, neutrophils, lymphocytes, and endothelial cells. the importance of a highly sensitive response to lipopolysaccharide for protection against gram-negative bacterial infection is demonstrated in experiments using lbp "knock-out" mice (mice that lack the lbp gene and are therefore unable to synthesize lbp). although these animals are resistant to the effects of isolated lipopolysaccharide, they are unable to control bacterial infection and rapidly succumb. despite its crucial importance for an effective host defense, lbp is not essential for lipopolysaccharide-receptor interaction per se, because high concentrations of lipopolysaccharide can activate cells in the absence of lbp. aside from its role as a catalyst of cellular activation by lipopolysaccharide, lbp has opsonizing activity and participates in the phagocytosis of lipopolysaccharide by macrophages and neutrophils. , although phagocytosis of lipopolysaccharide is receptor dependent, it appears to be uncoupled from intracellular signaling events and occurs in the absence of cell activation. lbp further catalyzes transfer of lipopolysaccharide to lipoproteins such as high-density lipoprotein, which neutralizes lipopolysaccharide activity. this detoxifying effect may become important when large amounts of lipopolysaccharide are present. a protective effect of lbp against lipopolysaccharide challenge and infection has been demonstrated in a murine model. the most important lipopolysaccharide receptors known to date are cluster differentiation antigen (cd ) and toll-like receptor (tlr ). both are classified as pattern recognition receptors, which means that they recognize lipopolysaccharide as a pattern common to all gram-negative bacteria. cd is a -kd protein that in its membrane-bound form (mcd ) is inserted into the cell membrane via a glycosylphosphatidyl-inositol anchor. cd is expressed primarily on monocytes and tissue macrophages and to a lesser extent on neutrophils. cd also is found in a free, or soluble, form (scd ) that can bind to cell types lacking cd , such as endothelial cells, and make them lipopolysaccharide-responsive. in addition to this proinflammatory effect, high concentrations of scd can sequester and neutralize lipopolysaccharide. the amount of circulating scd greatly increases during inflammation, which makes it a useful marker of acute and chronic inflammation. although cd is known to be crucial for cellular activation, it cannot transmit signals to the inside of the cell because it lacks a transmembrane domain. the missing link between cd and the cytosolic environment is a toll-like receptor in association with a molecule named md- . the name toll-like receptor stems from the homology of the mammalian receptor with a receptor type in drosophila (toll) that is important for dorsoventral orientation and immune responses in the fly. a number of toll-like receptors have been identified in mammalian species so far, but tlr appears to be the receptor subtype most important for lipopolysaccharide signaling. the importance of cd and tlr in the cellular response to lipopolysaccharide has been demonstrated in a number of experiments. mice deficient in cd are incapable of mounting a normal inflammatory response to lipopolysaccharide, whereas mutation or deletion of the gene encoding for tlr causes lipopolysaccharide hyporesponsiveness. [ ] [ ] [ ] after binding of lipopolysaccharide to cellular receptors, a multitude of signaling events takes place within the cell and results in the alterations of cellular metabolism known as cell activation. signaling pathways are characterized by sequential phosphorylation and thereby activation of enzymatic activities. a typical end result of intracellular signaling is the activation of transcription factors; for example, proteins that bind to dna and promote gene transcription. translational mechanisms are activated in a similar manner. among the bestcharacterized pathways in endotoxin-induced cell signaling are the mitogen-activated protein kinase (mapk) pathways and the activation of transcription factor nuclear factor κb (nfκb) (figure . - ) . , in the nfκb pathway the intracellular domain of tlr associates with the adapter protein myeloid differentiation factor and recruits interleukin- receptor-associated kinase to the complex. activation of interleukin- receptor-associated kinase, tumor necrosis factor receptor-associated factor, nfκb-inducing kinase, and iκb-kinase follow, and lastly, iκb is phosphorylated. iκb is an inhibitor protein complex that sequesters and inactivates nfκb in the cytoplasm. on phosphorylation, iκb is ubiquinated and degraded, and nfκb is translocated to the nucleus where it unfolds its activity. nfκb is a dimeric protein complex with several isoforms of which the p /p heterodimer is the most important inducible complex in mammals. proteins of importance for the pathogenesis of septic shock, the genes of which contain promoter elements for nfκb, include cytokines, inducible nitric oxide synthase, and cyclooxygenase (cox- ). three groups of mapks known to be crucially important for lipopolysaccharide-induced signal transduction are extracellular signal-regulated kinase, c-jun-terminal kinase, and p . final effects of signaling through mapk pathways include the activation of several transcription factors, translation initiation factors, and cytosolic enzymes such as phospholipase a , as well as an increase in the expression of adhesion molecules on the cell surface. despite the characterization of seemingly separate pathways, one should recognize that interaction and synergy between pathways is likely to occur. for example, simultaneous activation of p , c-jun-terminal kinase, and extracellular signal-regulated kinase results in much higher levels of tumor necrosis factor (tnf) reporter expression than activation of a single pathway. , aside from the mechanisms described here, pathways involving atypical protein kinase c , and receptor-independent integration of lipopolysaccharide into the cell membrane and ceramide-like second messenger activity of lipopolysaccharide have been proposed. additional pathways are likely to be uncovered in the ongoing investigation of intracellular signaling mechanisms and their in vivo significance. although endotoxin can exert some direct effects, cytokines are a primary mediator of lipopolysaccharide effects. cytokines are glycoprotein molecules that regulate inflammatory and immune responses by acting as a signal between cells. cytokines of major interest in the pathogenesis of endotoxemia include tnf, the interleukins, chemokines, and growth factors such as granulocyte-monocyte colony-stimulating factor. tnf is thought of as the most "proximal" cytokine released in response to lipopolysaccharide. studies corroborate this by showing that administration of recombinant tnf mimics the effects of lipopolysaccharide, and that antibodies directed against tnf protect against the lethal effects of endotoxin. increased plasma activity of tnf is associated with increased mortality in equine patients with acute gastrointestinal disease and in septic neonates. despite being a structurally diverse group of proteins, cytokines share several characteristics that allow them to execute their complex functions in the inflammatory response. any individual cytokine generally is produced by several different cell types, can act on different cell types, and has multiple effects on any given cell. furthermore, cytokine effects are redundant, meaning that different cytokines can share the same effect. in endotoxemia, this is particularly true for the effects of interleukin- (il- ) and tnf. many of the biologic activities of cytokines in vivo result from synergistic or antagonistic actions involving two or more cytokines. within itself the cytokine response is highly regulated: cytokines induce or suppress synthesis of other cytokines including their own (feedback regulation), regulate expression of cytokine receptors, and regulate cytokine activities. additional regulatory mechanisms include the release of specific cytokine inhibitors such as soluble il- and tnf-α receptors, cytokine receptor antagonists such as il- receptor antagonist, and antiinflammatory cytokines including il- , il- , il- , and transforming growth factor β. glucocorticoids also are produced increasingly in response to endotoxin and inhibit the production of cytokines. during a controlled inflammatory response, therefore, cytokine secretion is a selflimited event, whereas excessive stimulation of cytokine release can lead to the perpetuation of the inflammatory response even after the initial stimulus has been removed. conversely, the compensatory antiinflammatory reaction can become severe enough to cause anergy of the immune system and increased susceptibility to infection, which has been termed the compensatory antiinflammatory response syndrome. overall, excessive and unbalanced stimulation of the immune system therefore may result in predominantly proinflammatory (systemic inflammatory response syndrome), antiinflammatory (compensatory antiinflammatory response syndrome), or combined (mixed antagonist response syndrome) responses. interestingly, tolerance to endotoxin develops after repeated exposure to lipopolysaccharide. tolerance can be demonstrated in vitro and in vivo and encompasses decreased production of cytokines and a diminished clinical response. , mechanisms that likely are responsible for the development of endotoxin tolerance include receptor downregulation and inhibition of intracellular signaling pathways. , cytokines such as tnf are important mediators in the development of endotoxin tolerance. the development of endotoxin tolerance in horses has been reported. , aside from cytokines, a number of other molecules function as inflammatory mediators in the pathogenesis of endotoxemia, the synthesis and release of which are stimulated by endotoxin and by cytokines. these mediators include the arachidonic acid metabolites or prostanoids, platelet-activating factor (paf), oxygenderived free radicals, nitric oxide (no), histamine, kinins, and complement components. table . - summarizes the origins, targets, and effects of the most important inflammatory mediators involved in the pathogenesis of endotoxemia. figure . - shows the pathways of arachidonic acid metabolism by cox and lipoxygenase. cox products are the prostaglandins (pgs), prostacyclin (pgi ) and thromboxanes, and the lipoxygenase produces the leukotrienes. the innate immune response to lipopolysaccharide is an efficient defense mechanism that provides maintenance of homeostasis and therefore health in the face of an almost continuous exposure to microorganisms and their products. detrimental consequences of this immune response only occur if excessive and uncontrolled mediator output results in endothelial damage, neutrophil-mediated tissue damage, and uncontrolled activation of the coagulation and fibrinolytic cascades and the complement system. ultimately, the combination of these events culminates in cardiovascular instability, impaired hemostasis, organ failure, shock, and death. the following discussion addresses the various pathophysiologic events in the development of endotoxemia and shock and the role of inflammatory mediators. normal endothelium plays an important role in regulating blood pressure and regional tissue perfusion and provides an anticoagulant surface. endothelial dysfunction and damage result in a decreased responsiveness to vasoactive agents (vasoplegia), increased vascular permeability, and a tendency for clot formation in the microvasculature. if the basement membrane and underlying matrix are compromised, further microvascular hemorrhage can occur. endothelial cell damage is primarily neutrophilmediated. more specifically, damage is caused by oxygen-derived free radicals, which are produced within endothelial cells via reactions involving neutrophil-derived elastase and hydrogen peroxide molecules, endothelial cell enzymes such as xanthine oxidase, and endothelial cytosolic iron. the hypochloric anion radical (ho˙) is thought to be responsible most directly for endothelial cell cytotoxicity. no˙produced by constitutively expressed nitric oxide synthase in endothelial cells may afford protection from oxygen radical-induced endothelial cell damage. no is able to scavenge superoxide radicals and react with them to form peroxynitrite. variations in the ability to produce no may explain why vascular beds in different organs vary in their susceptibility to neutrophilmediated damage. excessive production of no by an inducible form of nitric oxide synthase (i nos), however, contributes to tissue damage, and increased peroxynitrite concentrations may be responsible in part for paf-induced increases in vascular permeability. in addition to oxygen-derived free radicals, activated neutrophils release matrix metalloproteinases, which contribute to tissue damage. vascular endothelial cells are further susceptible to direct effects of various cytokines, most prominently tnf-α and il- . these cytokines are thought to cause damage via the induction of cox activity and production of prostanoids and through generation of free radicals. neutrophil activation by lipopolysaccharide and cytokines results in stimulation of phagocytosis and the respiratory burst, release of lysosomal enzymes and inflammatory mediators, and expression of adhesion molecules. perhaps the single most specific clinicopathologic indicator of endotoxemia is pronounced neutropenia, which temporally correlates with peak plasma concentrations of tnf. neutropenia is caused primarily by margination of neutrophils in the vasculature, whereas significant loss through active migration into peripheral tissues likely is limited to the presence of a localized source of infection. margination is made possible by adhesion molecules on endothelial cells and leukocytes that interact and allow sticking of leukocytes to the endothelial lining of blood vessels. endotoxin or cytokines such as tnf and il- can initiate expression of adhesion molecules. subsequent transmigration of cells into tissue spaces is aided by the production of leukocyte collagenase, which allows enzymatic destruction of the vascular basement membrane. margination and transmigration of neutrophils occurs in three phases. , in the first phase of tethering and rolling, endothelial cells are stimulated to express p-selectin and e-selectin, which bind to p-selectin glycoprotein ligand- and sialylated lewis-x-like structures on leukocytes, respectively. whereas p-selectin is stored preformed in weibel-palade bodies of endothelial cells, e-selectin is expressed only following stimulation by cytokines. additionally, constitutively expressed l-selectin on neutrophils can bind to endothelial glycoproteins and glycolipids. during the second phase, firm adhesion is mediated by binding of neutrophil integrins (lfa- and mac- , also known as cd a/cd and cd b/cd ) to intercellular adhesion molecule (an immunoglobulin structure) on endothelial cells. although integrins are expressed constitutively on the leukocyte surface, activation signals are necessary to induce a high-affinity state and interaction with the endothelial surface. transmigration finally requires the expression of yet another adhesion molecule, namely platelet/endothelial cell adhesion molecule , which is located at the intercellular junction of endothelial cells. chemotactic factors including activated complement factor c a and the cxc chemokines control transmigration. the latter group includes il- , which is expressed by endothelial cells in response to activation. rebound neutrophilia, which is observed frequently following episodes of endotoxemia, is caused by neutrophil release from the bone marrow reserve pool and by stimulation of myeloid cell proliferation via granulocyte-macrophage colony-stimulating factor and is mediated primarily by tnf and il- . in health, coagulation and fibrinolysis underlie stringent control mechanisms that allow appropriate clot formation and their resolution. coagulopathies frequently are observed in horses with colic , , and foals with sepsis and are likely attributable to endotoxemia. disseminated intravascular coagulation (dic) results from a widespread activation of the coagulation and fibrinolytic systems and failure of their control mechanisms. ultimately, this leads to disseminated fibrin deposition in the microvasculature, consumption of platelets and clotting factors, and accumulation of fibrin degradation products (fdps). depending on the underlying disease process and the impairment of the systems, dic can manifest as a diffuse thrombotic syndrome leading to ischemic organ failure, a fibrinolytic syndrome with uncontrolled hemorrhage, or a combination of both. a procoagulant state in which one can detect clinicopathologic abnormalities precedes dic. activation of the coagulation cascade culminates in the cleavage of fibrinogen to fibrin by the serine protease thrombin. thrombin deposition on endothelial cell surfaces leads to platelet adherence and their activation by surface-bound paf. the intrinsic and extrinsic arms of the coagulation cascade are activated in endotoxemia. the intrinsic pathway is initiated by activation of coagulation factor xii (hageman factor), prekallikrein, and highmolecular-weight kininogen, which compose the contact system. although direct activation of coagulation factor xii by endotoxin has been demonstrated, the extrinsic pathway likely is more important for the development of coagulopathy in endotoxemia and sepsis. activation of the extrinsic pathway depends on the interaction of coagulation factor vii with tissue factor, which is the only coagulation factor not constitutively present in blood. tissue factor is present in subendothelial tissues and is exposed on vascular injury but also is expressed on endothelial cells and mononuclear phagocytes in response to lipopolysaccharide. , increased expression of monocyte tissue factor (also described as increased procoagulant activity) was found to be associated significantly with coagulopathy and poor prognosis in horses with colic. furthermore, lipopolysaccharide-induced tissue factor expression by equine peritoneal macrophages may be associated with the development of intraabdominal adhesions. regulatory mechanisms of the coagulation cascade include tissue factor pathway inhibitor, antithrombin iii (at iii), and the protein c system. protein c acts as an anticoagulant by inactivating clotting factors v and viii and promotes fibrinolysis by inactivating plasminogen activator inhibitor (pai). protein c activation by thrombin-thrombomodulin complexes is important for the anticoagulative properties of normal endothelium, and downregulation of endothelial thrombomodulin expression by tnf and il- and decreased expression of at iii and tissue factor pathway inhibitor by damaged endothelial cells contribute to the procoagulant state in endotoxemia and sepsis. [ ] [ ] [ ] in addition, activation of vascular endothelial cells leads to a loss of prostacyclin and no production and an increased release of thromboxane a (txa ). as a result, platelets are stimulated to aggregate and release txa and paf, thereby further promoting clot formation. the crucial step in the fibrinolytic cascade is the conversion of plasminogen to plasmin, a fibrin-degrading enzyme. tissue-type (tpa) and urokinase-type (upa) plasminogen activator are the major initiators of fibrinolysis, whereas pai and α -antiplasmin are the main regulatory components. , tnf and il- have been shown to induce the release of upa and tpa and the synthesis of pai. activation of fibrinolysis leads to consumption of α -antiplasmin and accumulation of fdps, which if present in high concentrations can interfere with platelet aggregation, fibrin polymerization, and thrombin formation and can promote bleeding. additionally, fdps mediate an increase in vascular permeability. lipopolysaccharide infusion in rabbits and human beings resulted in an early increase in plasma tpa activity, followed by a later profound rise in pai activity and fall in tpa activity. increased plasma pai concentrations also were found in horses with colic compared with controls. , thus although fibrinolysis may compensate initially for accelerated coagulation, its subsequent inhibition contributes to clot formation. activation of the complement system in endotoxemia occurs via the alternative pathway through interaction with lipopolysaccharide. increased concentrations of plasmin and kallikrein (caused by activation of the fibrinolytic and contact system) further promote this pathway by directly activating complement factors c a and c a. aside from being key molecules in the complement cascade, c a and c a are anaphylatoxins and cause an increase in vascular permeability via mast cell degranulation. c a further activates the lipoxygenase pathway in neutrophils and monocytes, acts as a chemotaxin for leukocytes and monocytes, and promotes neutrophil adhesion to endothelial cells. in response to acute inflammation, synthesis and secretion of a number of proteins called the acute phase proteins increases in hepatocytes, whereas synthesis of albumin decreases. the primary function of this acute phase response may be to suppress and contain inflammatory responses. il- and il- are the most important cytokines that induce the acute phase response, which typically begins within a few hours of the insult and subsides within to hours, unless the initiating cause persists. in horses, fibrinogen (the most commonly evaluated), haptoglobin, transferrin, ferritin, ceruloplasmin, coagulation factor viii:c, serum amyloid a protein, c-reactive protein, α -acid glycoprotein, and phospholipase a are considered part of the acute phase response. one must consider the effect of acute inflammation on the serum concentration of several coagulation factors when evaluating coagulation profiles. serum fibrinogen concentration is determined primarily by the acute phase response, although fibrinogen is consumed increasingly on activation of the clotting cascade. shock is characterized by a loss of homeostasis attributable to breakdown of hemodynamic control mechanisms, decreases in cardiac output and the effective circulating volume, and inadequate perfusion of vital organs. shock caused by endotoxemia is classified as distributive shock and is largely initiated by vascular dysfunction in the periphery. peripheral vascular beds are of major importance for the regulation of local tissue perfusion and affect systemic blood pressure by regulating total peripheral resistance. normally, vascular smooth muscle tone is regulated by endothelin- (vasoconstriction), no, and prostacyclin (vasodilation) released from vascular endothelial cells. as mentioned before, detrimental effects of no are attributable to induction of i nos in macrophages and other cell types, rather than endothelialderived no. peripheral vasomotor effects of endotoxin manifest as vasodilation and vasoplegia and are mediated by pgi , no, and mediators such as bradykinin. widespread vasodilation leads to vascular blood pooling, decentralization of blood flow, decreased venous return, and in effect decreased effective circulating volume and cardiac output. compensatory responses in the form of an initial hyperdynamic phase include tachycardia, increased cardiac output and central venous pressure, pulmonary hypertension, peripheral vasoconstriction, and increased peripheral vascular resistance. , , the early vasoconstrictive phase corresponds to an increased serum concentration of txa , but additional vasoconstrictors such as arginine vasopressin, angiotensin ii, serotonin, endothelin, and norepinephrine likely are implicated in the pathogenesis of shock and organ failure. with progression of disease, the animal enters a stage of decompensated shock and progressive systemic hypotension, which correspond to increased plasma concentrations of prostacyclin, pge and bradykinin. , inadequate blood flow and oxygen delivery to tissues caused by hypotension is confounded by direct myocardial suppression via no, increased vascular permeability, intravascular microthrombosis, and impaired tissue oxygen extraction and results in progressive metabolic acidosis and inhibition of normal cellular metabolism. quantification of endotoxin in plasma samples is possible. the limulus amebocyte lysate assay is an activity assay based on the endotoxin-sensitive hemolymph coagulation cascade in the horseshoe crab limulus polyphemus. in limulus this reaction is thought to be a defense mechanism against gram-negative infection. although frequently used as a research tool, the assay is not convenient enough to become a routine clinical test. the clinician therefore must appreciate the primary disease processes associated with a high risk of endotoxemia and rely on clinical signs and clinicopathologic data to achieve a diagnosis. in some cases, endotoxemia may be the first indication of disease or may be the most overt of otherwise subtle clinical manifestations. with colitis or proximal enteritis, for example, one may detect signs of endotoxemia before the development of colic, diarrhea, or gastric reflux, which more specifically indicate the nature of the primary illness. diseases such as peritonitis or pleuritis, however, may show nonspecific clinical findings including fever, anorexia, and depression. findings such as neutropenia, which indicate endotoxemia, should urge the clinician to search for a septic process. in vivo experiments in horses clearly show that many of the clinical signs associated with acute gastrointestinal disease and sepsis are attributable to the activities of lipopolysaccharide and cytokines such as tnf. on administration of sublethal doses of lipopolysaccharide the clinical response can be divided into the early hyperdynamic and the later hypodynamic or shock phases. clinical signs during the first phase, which begins within to minutes after lipopolysaccharide administration, include anorexia, yawning, sweating, depression, evidence of abdominal discomfort, muscle fasciculation, and recumbency. heart and respiratory rates increase, and decreased borborygmi suggest ileus. hyperemia of the mucous membranes and an accelerated capillary refill time indicate the hyperdynamic state. if one administers large amounts of lipopolysaccharide or if exposure is ongoing, depression worsens progressively, anorexia persists, and feces develop diarrheic character. signs of colic typically abate after the initial stage. fever develops as a result of direct action of tnf on the thermoregulatory center and il- -induced local production of pge in or near the hypothalamus. , because of compromised peripheral perfusion, mucous membrane color changes to brick red or purple, a dark "toxic" line appears, and capillary refill time is prolonged. inadequate peripheral perfusion and compromised organ function finally characterize the hypodynamic shock phase. body temperature may become subnormal and the skin, especially on extremities, is cool to the touch. the arterial pulse weakens and venous fill is decreased. vascular endothelial damage and increased capillary permeability result in a muddy mucous membrane color and diffuse scleral reddening. hemostatic abnormalities can manifest in the form of thrombosis, such as of the jugular vein, or increased bleeding tendency with mucosal petechiation or ecchymoses and prolonged bleeding from venipuncture sites. bleeding also may occur in spontaneous epistaxis or prolonged hemorrhage after nasogastric intubation. additional clinical signs typically reflect the development of organ failure. renal failure and laminitis appear to be common complications of endotoxemia in horses. renal failure results from ischemic cortical necrosis and acute tubular necrosis caused by coagulopathy-induced afferent arteriolar obstruction. clinical signs may include oliguria, anuria, or hematuria caused by renal infarction. laminitis may lead to lameness, increased digital arterial pulsation, increased warmth of the hoof wall, and sensitivity to hoof tester pressure. other signs of organ failure include icterus, anorexia and depression caused by liver failure, tachypnea and dyspnea caused by pulmonary failure, colic and bleeding caused by ischemia-induced gastrointestinal ulceration and abnormal motility patterns, and persistent tachycardia or cardiac arrhythmia in cases of cardiac failure. in pregnant mares, fetal death and abortion can occur because of increased production of pgf α and decreased serum progesterone concentrations. , alterations in the hemogram and serum biochemical profile are nonspecific and mainly reflect the underlying disease process and the occurrence of organ failure. leukopenia caused by neutropenia may be the most specific indicator of acute bacterial sepsis or endotoxemia. in prolonged cases, an increased proportion of immature neutrophil forms (bands) and toxic changes are observable. toxic changes resulting from neutrophil activation include vacuolation, cytoplasmic granulation, basophilic cytoplasm, and döhle's bodies. because neutropenia occurs early in the development of endotoxemia, it also may be a useful parameter for monitoring horses at risk. on recovery, neutropenia typically is followed by a pronounced rebound neutrophilia. an elevated hematocrit and total serum protein concentration are evidence of dehydration; however, splenic contraction caused by increased sympathetic stimulation and protein losses also influence these parameters. a normal or only slightly decreased serum protein and albumin concentration in the face of an elevated hematocrit and clinical signs of dehydration should alert the clinician to the possibility of protein loss. hypoproteinemia and hypoalbuminemia can occur because of loss via the gastrointestinal or urinary tract or with pleural or peritoneal cavity effusion. increased vascular permeability and edema formation contribute to hypoproteinemia. serum electrolyte abnormalities primarily depend on the nature and duration of underlying disease processes and need to be evaluated individually. common sources of electrolyte loss are gastrointestinal secretions, urine, and sweat; however, severe effusion into body cavities may contribute. in anorexic patients, lack of dietary intake is a confounding factor that warrants consideration. in human patients, gram-negative sepsis frequently is associated with hypocalcemia, more specifically a decrease in serum ionized calcium concentration. endotoxin is thought to be a causative factor, and proposed mechanisms include acquired parathyroid gland insufficiency, dietary vitamin d deficiency, impaired calcium mobilization, and renal α-hydroxylase insufficiency leading to decreased , -hydroxylation of vitamin d. hypocalcemia in septic human patients was found to be associated with hypotension and poor outcome. in horses with surgically managed gastrointestinal disease, decreased serum ionized calcium concentration was a common finding and was most severe in patients with strangulating or nonstrangulating infarctions. in some horses, ionized calcium concentration decreased further throughout surgery. treatment with calcium gluconate resulted in normalization of serum ionized calcium concentrations in all cases. septic neonatal patients are frequently hypoglycemic. aside from decreased oral intake and generally increased metabolism, glucose use by the infecting bacteria, inhibition of gluconeogenesis by endotoxin, and insulinlike activity produced by macrophages are responsible for hypoglycemia. interestingly, experimental endotoxin administration results in transient hyperglycemia in adult horses, whereas profound hypoglycemia occurs in foals. one should evaluate coagulation parameters if coagulopathy is suspected. the most significant changes can be expected with severe inflammatory disease such as colitis, , devitalized intestine as with strangulating obstruction, , and with increased duration of disease. in horses with acute gastrointestinal disease, coagulation profiles were considered normal in only horses. although coagulation times may be shortened during the procoagulant state, commonly observed abnormalities with developing dic include an increased concentration of fdps and soluble fibrin monomer, prolonged prothrombin time indicative of factor vii consumption, prolonged activated partial thromboplastin time indicative of factor viii:c and ix consumption, prolonged thrombin time, decreased at iii activity, thrombocytopenia, and decreased protein c and plasminogen activities. fibrinogen concentration frequently increases and reflects the acute phase response rather than coagulation abnormalities. some clinicians make a diagnosis of dic if three or more coagulation parameters (specifically at iii, fdps, platelet count, prothrombin time, and activated partial thromboplastin time) are abnormal, whereas others require overt clinical signs of hemorrhage and concomitant thrombosis in addition to classic laboratory findings. the prognostic value of coagulation parameters has been evaluated. , , overall, persistence or worsening of abnormalities in the face of treatment appears to be more indicative of poor outcome than alterations in any specific parameter. in one study, decreased serum at iii concentration was the parameter most commonly associated with fatal outcome in mature horses with colic. one should further evaluate the serum biochemical profile regarding compromise or failure of specific organ systems. increases in serum creatinine and urea nitrogen concentration can have prerenal, renal, or postrenal causes. in cases of endotoxemia and sepsis, prerenal azotemia caused by dehydration and decreased renal blood flow and renal azotemia caused by organ failure are most likely to occur. one can use urine specific gravity and the response to fluid therapy to differentiate renal from prerenal causes of azotemia. although ideally one should perform urinalysis before initiating fluid therapy, one should never delay treatment to obtain a sample and instead should use the first available urine sample. with prerenal azotemia, urine specific gravity is increased, urinalysis is normal in other respects, and azotemia resolves with adequate fluid therapy. azotemia in the face of normal or decreased urine specific gravity, however, indicates compromised renal function. depending on the extent of renal damage, proteinuria and hematuria also may be present. bacteriuria and an elevated urine leukocyte count may occur if urinary tract infection is the underlying cause for the development of endotoxemia. in these cases, urine culture and sensitivity testing are indicated to aid appropriate antimicrobial therapy. increased serum activity of liver enzymes (aspartate aminotransferase, γ-glutamyltransferase, sorbitol dehydrogenase, alkaline phosphatase) are common in endotoxemic patients; however, liver failure caused by endotoxemia is rare. sorbitol dehydrogenase is the most liver-specific of the enzymes and a sensitive indicator of acute hepatocellular necrosis; however, sorbitol is unstable and routine assays may not be available. one should evaluate liver enzymes and function tests (serum indirect and direct bilirubin concentration, serum bile acids and blood ammonia) in cases of prolonged and profound depression to rule out hepatoencephalopathy. one should evaluate arterial blood gases in patients with primary respiratory disease or with clinical evidence of respiratory failure and in profoundly depressed, recumbent patients, especially neonates. hypoxemia observed in response to endotoxin infusion is thought to be caused by an increase in ventilation-perfusion mismatch rather than pulmonary edema as occurs in human patients with acute respiratory distress syndrome. the lung is not a major shock organ in horses; however, pulmonary edema may occur in patients with associated sepsis or complications such as dic. the ideal treatment for endotoxemia is prevention. if one possibly can recognize and closely monitor patients at risk, one can provide treatment proactively and may reverse the effects of endotoxin before the inflammatory response has developed a dynamic of its own. unfortunately, endotoxemia can develop rapidly, and horses are exquisitely sensitive to the effects of endotoxin; therefore, many equine patients are not evaluated until reaching more severe stages of endotoxemia or shock. prognosis and patient outcome then frequently depend on the severity of complications associated with endotoxemia. treatment of endotoxemia involves multiple aspects, and the following strategies have been proposed : • inhibition of endotoxin release into the circulation • scavenging of lipopolysaccharide molecules to prevent direct effects and interaction with inflammatory cells • inhibition of cellular activation by lipopolysaccharide • inhibition of mediator synthesis • interference with the effects of inflammatory mediators • general supportive care in addition, complications such as renal failure, one also must address liver failure, cardiac failure, laminitis, and abortion in pregnant mares. when evaluating reports concerning the efficacy of any one treatment, one should keep in mind differences in underlying disease processes and the complexity of the inflammatory cascade. a "one for all" treatment most likely will not be found, and similarly, any one treatment can only address one or few pathophysiologic aspects of endotoxemia. understanding the rationale for different treatment strategies is important to be able to tailor treatment to the needs of the patient. inhibition of endotoxin release requires identification and removal of its source. therefore whenever endotoxemia is evident, the clinician should strive to reach a diagnosis of the underlying disease and ascertain whether ischemic or inflamed bowel or a gram-negative septic process is present. aside from history, physical examination, and routine laboratory tests, evaluation may include exploratory laparotomy in colic patients, roentgenologic and ultrasonographic evaluation of the pleural and peritoneal cavity and organs, ultrasonographic evaluation of umbilical remnants in neonatal foals, evaluation of passive transfer and calculation of a sepsis score in foals, and repeated culturing of blood or other specimens. if one suspects an infectious process, one should pursue identification of the responsible microorganisms and their antimicrobial sensitivity spectrum; however, one should not delay treatment to obtain culture results. specimen containers with removal devices for antimicrobials are available and are useful in cases for which one has initiated treatment before specimen collection. once one reaches a diagnosis, one must take appropriate measures to correct the primary disease process. examples are removal of devitalized sections of bowel or infected umbilical remnants, drainage of infected pleural or peritoneal fluid, and gastric lavage followed by administration of mineral oil and/or activated charcoal in cases of grain overload to prevent further absorption of endotoxin. one must address any septic process with appropriate antimicrobial therapy. initially, broad-spectrum coverage of the most likely organisms is recommended; one then should specify therapy according to results of culture and sensitivity testing. sepsis in foals is caused predominantly by gram-negative organisms, of which e. coli, actinobacillus spp., klebsiella spp., salmonella spp. and pasteurella spp. frequently are identified. the reader is referred to other texts for review of general principles of antimicrobial therapy. regarding endotoxemia specifically, antimicrobial therapy has been suggested to increase the amount of circulating endotoxin by inducing endotoxin release on cell death of gram-negative bacteria. a recent in vitro study compared endotoxin release and inflammatory mediator activity between antimicrobials commonly used to treat e. coli septicemia in foals and specifically evaluated amikacin, ampicillin, amikacin plus ampicillin, ceftiofur, and imipenem. although these antimicrobials showed no difference in the ability to kill bacteria, amikacin and the amikacin/ampicillin combination resulted in the lowest and ceftiofur in the greatest release of endotoxin. endotoxin release appeared to be dose-dependent in that lesser amounts were released at higher antimicrobial concentrations. based on these results and clinical experience, combining antimicrobial therapy with endotoxin-binding agents such as polymyxin b may be beneficial, especially when using β-lactam antimicrobials. antimicrobials frequently are given perioperatively to colic patients to lower the risk of peritonitis, incisional infection, and generalized sepsis and endotoxemia. because antimicrobial therapy has been implicated in the development of colitis, the duration of treatment should be minimal. unless evidence of sepsis, such as fever or changes in the leukogram, is present, perioperative administration of antimicrobials should not exceed a to hours. conversely, antimicrobial therapy frequently is used in cases of infectious colitis to treat the inciting cause and to prevent sepsis from translocation of bacteria. endotoxin typically has a short plasma half-life and is removed rapidly by mononuclear phagocytes or neutralized by binding to serum proteins and lipoproteins. many conditions responsible for the development of endotoxemia in horses, however, are associated with an ongoing release of endotoxin. examples include severe gastrointestinal inflammation as in proximal enteritis or colitis, grain overload, or uncontrolled sepsis. therapy directed against endotoxin itself may be able to interrupt the continuous activation of the inflammatory cascade in these cases. further benefits of antiendotoxin treatment may be derived if large amounts of endotoxin have been released before the inciting cause can be addressed. an important consideration regarding the efficacy of immunotherapy is the region of the lipopolysaccharide molecule against which antibodies are raised. the o-chain of lipopolysaccharide acts as a potent antigen on infection with gram-negative bacteria ; however, antibodies directed against the o-chain are serotype specific and cannot afford significant cross-protection against heterologous bacterial strains. the core and lipid a region, both of which show a much higher degree of homology between lipopolysaccharide derived from different bacterial strains, offer a more promising target for immunotherapy. active immunization against endotoxin has been reported for horses. vaccination with a bacterin/ toxoid vaccine prepared from rough mutants of salmonella typhimurium or s. enteritidis protected horses against homologous and heterologous endotoxin challenge , and carbohydrate overload. despite these encouraging results and the current availability of a vaccine for use in horses (endovac-equi, immvac inc., columbus, missouri), active immunization against endotoxin does not appear to be a common practice. in comparison, passive immunization with antilipopolysaccharide antibodies is used widely. rough bacterial mutants, most commonly j of e. coli o :b and s. minnesota re , are used to immunize donor horses and subsequently prepare serum or plasma products. proposed mechanisms of action after binding of the antibodies to lipopolysaccharide include steric blockade of lipid a interaction with cellular receptors and enhanced bacterial clearance by opsonization. [ ] [ ] [ ] studies concerning the efficacy of antibody administration in equine patients vary in their results. beneficial effects have been described in experimental models of endotoxemia, acute gastrointestinal disease, and neonates with sepsis, , [ ] [ ] [ ] whereas in other studies, antibodies failed to protect foals and horses against endotoxin effects. - furthermore, administration of a s. typhimurium antiserum to foals was associated with an increased respiratory rate and higher serum activities of il- and tnf. various equine serum and plasma products are currently commercially available. an antiserum raised against the lipopolysaccharide-core of s. typhimurium (endoserum) is available for administration to endotoxemic horses at a recommended dose of . ml/kg body mass. diluting the serum ten-to twentyfold in crystalloid intravenous solutions, administering it slowly over to hours, and monitoring the patient for adverse reactions is advisable. although the product is marketed for use in foals with failure of passive transfer, adverse effects have been reported, and one should use caution when administering it to neonates. plasma from donors inoculated with j (e. coli) and s. typhimurium (re mutant) is available under a restricted license (polymune-j, vet dynamics, inc., san louis obispo, california). the manufacturer recommends administration of at least to l in cases of endotoxemia. in addition, hyperimmune plasma, which has a guaranteed minimum immunoglobulin g content but does not contain specific antiendotoxin antibodies (hi-gamm equi, lake immunogenics, inc., ontario, new york; polymune and polymune-plus, vet dynamics, inc.), is marketed for treatment of failure of passive transfer, and many clinicians use it to treat endotoxemia and sepsis. in addition to antibodies and protein, plasma contains active constituents such as complement components, fibronectin, clotting factors, and at iii and therefore may be particularly useful in patients with endotoxemia-induced coagulopathy. volumes of to ml/kg body mass of hyperimmune plasma have been recommended for use in endotoxemic patients. , polymyxin b polymyxin b is a cationic polypeptide antibiotic that binds to the anionic lipid a portion of lipopolysaccharide and neutralizes its endotoxin capacity. at dosages required for antimicrobial activity, polymyxin b carries the risk of respiratory paralysis and ototoxic, nephrotoxic, and neurotoxic side effects; however, a much lower dose is required for endotoxin-binding activity. the effects of polymyxin b in horses have been evaluated in different experimental models. , , in an in vivo study in foals, treatment with polymyxin b at a dosage of u/kg body mass before infusion with s. typhimurium lipopolysaccharide resulted in significantly less severe elevations of body temperature, respiratory rate, and serum activities of tnf and il- compared with untreated controls. similarly, polymyxin b treatment of adult horses given endotoxin significantly ameliorated clinical signs and decreased plasma tnf activity. in the latter study, benefits of treatment were also evident at lower dosages of polymyxin b ( and u/kg body mass) and administration of polymyxin b hour after the start of endotoxin infusion. conversely, polymyxin b failed to ameliorate clinical signs of endotoxemia or prevent the development of coagulopathy, acidosis, lameness, and shock in experimental carbohydrate overload. side effects suggestive of neurotoxicity appeared after repeated administration of mg/kg body mass ( , u/kg) and in milder form, . mg/kg body mass ( , u/kg) polymyxin b. nephrotoxicity was not observed. currently, use of polymyxin b in equine patients is recommended at dosages of to u/kg body mass every to hours. one should initiate treatment as early in the disease process as possible, because the beneficial effects of lipopolysaccharide scavenging are limited to the first to hours after the onset of endotoxemia, before tolerance develops. side effects in the form of neuromuscular blockade and apnea, which necessitate slow infusion of the drug in human patients, have not been observed in horses. one therefore can administer the entire dose as a slow bolus. if one uses polymyxin b in horses with hypovolemia, dehydration, or azotemia, one should attempt to improve peripheral tissue perfusion, minimize the polymyxin b dose, and closely monitor patients for nephrotoxicity. close monitoring is also important if one administers medications such as aminoglycoside antibiotics, which share a similar spectrum of potential side effects, concurrently. azotemic neonates have been reported to be more susceptible to the nephrotoxic effects of polymyxin b than adult horses. in an attempt to decrease the risk for adverse effects while preserving lipopolysaccharide-neutralizing ability, a conjugate of polymyxin b with dextran has been developed. in conjugated form, polymyxin b is prevented from extravasation into tissues, where it exerts toxic effects by interaction with cell membranes. in addition, conjugation increases the residence time of polymyxin b in the circulation and therefore should prolong the antiendotoxic effect. the polymyxin b-dextran combination was evaluated at a total dose of mg/kg body mass of polymyxin b in . g/kg body mass dextran given minutes before administration of endotoxin in horses. treatment was found to block the development of tachycardia, tachypnea, fever, and neutropenia completely and to prevent increases in serum concentrations of tnf, il- , txb (a txa metabolite), and the prostacyclin metabolite -keto-pgf α . although mild adverse effects in the form of tachypnea, sweating, and increased systolic blood pressure were observed, these were transient and could be prevented by pretreatment with ketoprofen. the polymyxin b-dextran combination is not commercially available at this time. natural endotoxin-binding proteins such as lbp, lipoproteins, and scd have been evaluated experimentally. results of these studies are controversial, and detrimental effects occurred in some cases. a protein receiving much attention regarding potential therapeutic efficacy is the bactericidal permeability-increasing protein (bpi). this protein is structurally similar to lbp but is expressed exclusively in myeloid precursors of polymorphonuclear leukocytes. bpi is stored in primary granules of mature neutrophils and during inflammation is expressed on their cell membranes and secreted into the extracellular environment. bpi has an even higher affinity for lipopolysaccharide than lbp and shows antibacterial activity specific for gram-negative bacteria. binding of bpi to the gram-negative bacterial membrane results in growth arrest and is an important factor in the antibacterial activity of intact neutrophils. furthermore, bpi binding disrupts normal membrane organization and makes bacteria more susceptible to hydrophobic substances, including antimicrobials. experimentally, recombinant bpi has been shown to protect against the toxic and lethal effects of isolated lipopolysaccharide and intact gram-negative bacteria, and clinical trials in human patients show promising results concerning its therapeutic use. the biology and potential use of bpi in horses has not been evaluated. treatments aimed at inhibiting lipopolysaccharide interaction with cells or turning off intracellular signaling pathways are under investigation. nontoxic lipopolysaccharide or lipid a structures can act as endotoxin antagonists, if they competitively inhibit binding to lbp or cellular receptors or inhibit cellular activation by other mechanisms. of the potential antagonists that have been evaluated experimentally, lipopolysaccharide and lipid a from the phototrophic bacterium rhodobacter sphaeroides, and a synthetic compound (e ) the structure of which is based on r. sphaeroides lipopolysaccharide, have been most promising. [ ] [ ] [ ] [ ] [ ] unfortunately, species differences exist regarding cellular response to these structures, and r. sphaeroides lipopolysaccharide acts as a potent inducer of cytokine expression in equine cells. based on results of receptor transfection studies in other species, , tlr is likely responsible for this phenotypic variation. additional compounds including lipopolysaccharide derived from nitrogen-fixing plant bacteria of the species rhizobium are being evaluated to reveal further insight into structural requirements for endotoxin antagonists in horses. nonsteroidal antiinflammatory drugs (nsaids) are probably the most commonly used drugs to treat endotoxemia. the rationale for their use is inhibition of prostaglandin endoperoxide h synthase, that is, cox, and thereby inhibition of prostanoid production (see figure . - ). additional beneficial effects may include scavenging of oxygen-derived free radicals and iron chelation; however, side effects may occur at dosages required to achieve these effects. prostanoids have been identified as important mediators in the inflammatory response in a number of studies, and inhibition of their synthesis is associated with beneficial effects. two cox isoforms are recognized: constitutively expressed cox- and inducible cox- . upregulation of cox- expression results from various proinflammatory stimuli, including lipopolysaccharide, tnf-α, and il- . constitutively expressed cox products are likely important for maintenance of homeostasis, whereas increased production of prostanoids by cox- is thought to be responsible for detrimental effects during inflammation and shock. research has focused on the development of selective cox- inhibitors; however, none of these products are currently available for use in horses. in horses the most commonly used nsaid to treat endotoxemia is flunixin meglumine. beneficial effects of flunixin meglumine have been described in experimental models of endotoxemia [ ] [ ] [ ] and in clinical cases. in equine colic patients, treatment with flunixin meglumine before exploratory surgery resulted in reduced plasma concentrations of txb and pge and had a favorable effect on cardiovascular parameters. flunixin meglumine was shown further to maintain cardiac output and systemic arterial blood pressure, improve blood flow to vital organs, reduce pulmonary endothelial damage, and improve survival on endotoxin challenge. [ ] [ ] [ ] [ ] nsaid use in horses carries the risk of side effects, most importantly the development of gastrointestinal ulceration and renal papillary necrosis (renal crest necrosis). in a study comparing the side effects of flunixin meglumine ( . mg/kg body mass), phenylbutazone ( . mg/kg body mass), and ketoprofen ( . mg/kg body mass) given times daily for days, lesions of the gastric glandular mucosa occurred most commonly. phenylbutazone resulted in the most severe side effects, which included small intestinal edema, erosions, and ulcers in the large colon and decreased serum albumin concentration. renal crest necrosis occurred more frequently in horses treated with phenylbutazone but also occurred with flunixin meglumine treatment. despite the higher risk of side effects, use of phenylbutazone has been suggested for certain cases. in colic patients, phenylbutazone may provide analgesia and ameliorate endotoxin-induced ileus without masking cardiovascular effects of endotoxin, which are used to determine the necessity of surgical exploration. for similar reasons and to minimize side effects a reduced dose of flunixin meglumine ( . mg/kg body mass) has been suggested and is used widely in horses. at this dosage, flunixin meglumine was shown to inhibit eicosanoid synthesis efficiently in an in vivo model of endotoxemia. reduction of clinical signs, however, was dose dependent, and therefore one should choose the appropriate dose based on the circumstances of each case. ketoprofen has been suggested to have superior effects because of a proposed dual inhibitory effect on cox and lipoxygenase and may carry a decreased risk of side effects compared with flunixin meglumine and phenylbutazone. a comparison of cytokine and eicosanoid production by lipopolysaccharide-stimulated isolated monocytes in vitro, however, showed no significant difference between horses pretreated with flunixin meglumine ( . mg/kg body mass) or ketoprofen ( . mg/kg body mass), respectively. eltenac has been evaluated in an experimental endotoxemia model in horses. given minutes before lipopolysaccharide infusion, eltenac at a dose of . mg/kg protected against changes in clinical, hemodynamic, and hematologic parameters and blunted the lipopolysaccharide-induced rise in plasma cytokine concentrations in comparison with controls. some parameters, however, including heart rate, leukocyte count, lactate concentration, and plasma tnf activity, were not improved. ibuprofen may have beneficial effects superior to the other nsaids, because it may be possible to achieve tissue concentrations safely that allow iron chelation to occur. according to a study in healthy foals, dosages of ibuprofen up to mg/kg every hours can be given safely for up to days. the use of corticosteroids for antiinflammatory therapy in sepsis and endotoxemia has been controversial in human and equine patients, and beneficial effects superior to the ones achieved by nsaids have not been demonstrated consistently overall. corticosteroids inhibit the activity of phospholipase a and the release of arachidonic acid from cell membrane phospholipids, as well as the production of tnf, il- , and il- in response to a lipopolysaccharide stimulus. experimentally, beneficial effects of dexamethasone in equine endotoxemia have been demonstrated. , to inhibit tnf production by equine peritoneal macrophages, however, the required concentration of dexamethasone was high and corresponded to an in vivo dosage (approximately mg/kg body mass) greatly exceeding current recommendations. although single doses of corticosteroids are unlikely to carry a disproportionate risk of side effects, one should consider the suggested association of laminitis with corticosteroid use in horses. in cases of sepsis, further immunosuppressive effects could be detrimental. in human patients with certain types of septic shock, dysfunction of the hypothalamic-pituitary-adrenal axis has been recognized and successfully treated with hydrocortisone replacement therapy. use of corticosteroids for this indication has not been evaluated in horses. pentoxifylline, a methylxanthine derivative and phosphodiesterase inhibitor, has been suggested for use in endotoxemia because of its effects on neutrophil function and its ability to inhibit the production of various cytokines, interferons, and thromboplastin. decreased production of tnf, il- , txb , and thromboplastin in response to endotoxin was shown in an equine ex vivo model. in horses given endotoxin followed by treatment with pentoxifylline ( . mg/kg body mass followed by continuous infusion of mg/kg/hr for hours), however, only minimal beneficial effects were observed. treatment significantly improved body temperature, respiratory rate, and whole blood recalcification time, but no effect was observed regarding heart rate, blood pressure, leukocyte count, plasma fibrinogen concentration, and serum cytokine concentrations. the conclusion was that benefits of treatment with pentoxifylline might be restricted to administration of high bolus doses or continuous infusion early in the pathophysiologic process. in an in vivo endotoxemia model in horses, combination of pentoxifylline ( mg/kg body mass) and flunixin meglumine ( . mg/kg body mass) was found to have greater benefit than each treatment on its own. the currently recommended dosage for oral administration of pentoxifylline is mg/kg every hours. because of its rheologic properties, that is, the ability to increase erythrocyte deformability and microvascular blood flow, pentoxifylline may be particularly useful in endotoxemic patients showing evidence of laminitis. an intravenous preparation of pentoxifylline is not commercially available. dimethyl sulfoxide (dmso) is used frequently in an attempt to scavenge oxygen-derived radicals. the treatment may be most appropriate in cases of ischemia-induced intestinal damage and associated reperfusion injury. however, dmso failed to show beneficial effects in an experimental model of intestinal ischemia when administered on reperfusion of the ischemic intestine. dmso at the commonly used dose of g/kg body mass was shown to increase mucosal loss after ischemia and reperfusion of the large colon, and hence a reduced dose of . g/kg body mass has been proposed for cases of intestinal ischemia. for intravenous administration, dmso needs to be diluted in polyionic solutions to a concentration not exceeding %. oral administration of a % to % solution via nasogastric intubation is also possible. aside from dmso the xanthine oxidase inhibitor allopurinol has been suggested as a treatment to prevent oxygen radical-induced tissue damage. during periods of ischemia, tissue xanthine dehydrogenase is converted to xanthine oxidase, which on reperfusion catalyzes the generation of superoxide radicals. , evaluation in horses showed beneficial effects of mg allopurinol per kilogram body mass administered hours before endotoxin challenge. in another study, mucosal damage attributable to oxygen-derived free radicals was not attenuated by allopurinol in an experimental ischemia-reperfusion model. lidocaine given intravenously has been suggested as an antiinflammatory, analgesic, and prokinetic agent, and some clinicians use it to treat colic and laminitis in horses. in an experimental endotoxemia model in rabbits, lidocaine was found to inhibit hemodynamic and cytokine responses to endotoxin profoundly if given immediately following lipopolysaccharide infusion. use of lidocaine therefore may have additional merit in endotoxemic patients. a common regimen for lidocaine use in horses is administration of an initial bolus ( . mg/kg body mass) section . endotoxemia followed by continuous infusion at a rate of . mg/ kg/min. one should monitor patients for toxic neurologic effects associated with a lidocaine overdose. high concentrations of ω- fatty acids can alter the phospholipid composition of cellular membranes toward a decreased ratio of ω- to ω- and thereby can affect membrane functions such as phagocytosis, receptor binding, and activities of membrane-bound enzymes. most importantly for the treatment of endotoxemia, ω- fatty acid incorporation into cell membranes decreases the availability of arachidonic acid (an ω- fatty acid) for eicosanoid synthesis and provides alternative substrates. metabolism of ω- fatty acids via the cox and lipoxygenase pathway leads to the production of -series prostaglandins and -series leukotrienes, which have less biologic activity than their -series and -series counterparts derived from arachidonic acid. aside from these mechanisms, ω- fatty acids prevent lipopolysaccharideinduced upregulation of cd in monocytic cells and therefore may be able to block transmembrane signaling of lipopolysaccharide. cells from horses given linseed oil (high in ω- fatty acids) for weeks before blood collection showed significantly decreased expression of procoagulant activity, txb , and tnf in response to lipopolysaccharide stimulation. , in an in vivo experimental model of endotoxemia in horses, treatment resulted in prolonged activated partial thromboplastin time and whole blood recalcification time, suggesting an anticoagulant effect; however, a significant beneficial effect on clinical response and serum eicosanoid concentrations was not observed. because dietary addition of ω- fatty acids requires several weeks of treatment, intravenous infusion was evaluated and shown to alter the composition of cell membrane phospholipids rapidly. further evaluation of this treatment for use in horses is necessary before dosage recommendations can be made. monoclonal and polyclonal antibodies against equine tnf have been evaluated. [ ] [ ] [ ] administration of a monoclonal antibody preparation before lipopolysaccharide infusion resulted in significantly reduced plasma tnf-activity, improved clinical abnormality scores, lower heart rate, and higher leukocyte count compared with controls. furthermore, plasma concentrations of lactate and -keto-pgf α were reduced significantly, whereas txa production was not affected. in another study, administration of a rabbit polyclonal antibody against recombinant human tnf was unable to improve clinical and hematologic parameters when given shortly ( minutes) after lipopolysaccharide infusion, although inhibition of tnf activity was present in vitro. , findings in horses are in agreement with studies in other species and suggest that beneficial effects of tnf inhibition may be limited to administration before lipopolysaccharide exposure. widespread clinical use therefore is unlikely to become feasible. clinical trials in human patients have not shown significant benefits of tnf antibody treatment. , the effects of selective paf receptor antagonists have been evaluated. paf is implicated in the development of systemic hypotension, lipopolysaccharide-induced platelet aggregation, ileus, and increased vascular permeability and may mediate recruitment of leukocytes to inflamed tissues. , a study in horses using the paf receptor antagonist sri - before lipopolysaccharide infusion showed significant decreases in heart rate and shorter elevation of lactate concentrations in response to the treatment. although not statistically significant, additional beneficial effects included delayed onset of fever, a shortened period of neutropenia, and reduced maximal platelet aggregation. whenever possible, the clinician should correct volume and electrolyte deficits, or at least improve them, before anesthetizing a patient for a surgical procedure. for initial resuscitation, polyionic solutions such as lactated ringer's solution given at rates of to ml/kg/hr are appropriate. patients with severe hypovolemia and shock may require higher fluid volumes. a viable alternative to large-volume resuscitation with isotonic fluids is the use of small volumes of hypertonic solutions, which transiently raise plasma osmolality, thereby causing a fluid shift from the interstitial space into the vasculature and rapidly restoring circulating volume. hypertonic saline solution ( . % sodium chloride) is the most commonly used hypertonic solution and has been shown to have beneficial effects in endotoxemic horses. a dose of ml/kg is recommended, which one should give as a bolus infusion over to minutes, followed by administration of an isotonic solution to restore total body fluid volume. one should use hypertonic saline with caution in patients with sodium and/or chloride derangements and should monitor serum electrolyte concentrations in the case of repeated administration. improvement of the cardiovascular status in response to fluid therapy is indicated by normalization of heart rate, mucous membrane color, and capillary refill time. failure of urination to occur despite appropriate fluid resuscitation should result in critical evaluation of renal function. once one has stabilized the patient, one should choose a maintenance fluid rate to maintain adequate hydration and plasma volume. for adult horses, the maintenance fluid rate is approximately ml/kg/hr, whereas neonatal foals that are not nursing may require larger volumes ( ml/kg/hr). one should monitor fluid administration carefully in endotoxemic patients, because lowered plasma oncotic pressure caused by hypoproteinemia along with an increased vascular permeability increase the risk of tissue edema formation. furthermore, a rapid increase in total body fluid volume may be detrimental in patients with compromised cardiac and peripheral vasomotor function and may increase the severity of vascular pooling in peripheral organs. in these patients, hypertonic saline or colloids may be more appropriate means of stabilization than large volumes of crystalloid solutions. plasma is an ideal colloid and should be administered to maintain a serum total protein concentration above . g/dl. to raise plasma protein concentration and colloid osmotic pressure significantly, however, horses often require large volumes of plasma ( to l or more in a -kg horse), and one should consider alternative colloids. furthermore, high-molecular-weight polymers are thought to provide superior oncotic effects in cases of sepsis and endotoxemia, when vascular permeability is increased. hetastarch, or hydroxyethyl starch, (hespan) is commercially available as a % solution in . % sodium chloride. hetastarch molecules have very high molecular weight, and degradation must occur before renal excretion. these properties result in a longer plasma half-life and prolonged oncotic effects compared with other colloids; persistence of the oncotic effect for hours was found in hypoproteinemic horses. a dosage of to ml/kg given by slow intravenous infusion along with an equal or greater volume of crystalloid fluids is recommended. , in human patients, prolonged activated partial thromboplastin time, decreased factor viii activity, and decreased serum fibrinogen concentration have been described in association with hetastarch use. in the limited number of equine studies, bleeding times were not affected , ; however, one should monitor patients treated with hetastarch for coagulopathy. one should base correction of serum electrolyte concentrations on the results of laboratory evaluation. ideally, one should evaluate serum electrolyte concentrations of patients receiving fluid therapy daily. one should take ongoing losses and lack of dietary intake into account, especially when serum concentrations, as in the case of potassium, poorly reflect total body electrolyte stores. potassium supplementation is recommended in patients experiencing prolonged (greater than hours) periods of anorexia. one can add calcium in the form of calcium gluconate, which is available as a % solution. based on a study in healthy horses, rates of administration for calcium gluconate in the range of . to . mg/kg/min are recommended, and as a guideline, one should administer . to ml/kg body mass per day of a % solution. one can add potassium in the form of potassium chloride or potassium gluconate to intravenous solutions at a dose of to meq/l given at a maintenance rate. administration of potassium should not exceed a rate of . to meq/kg/hr. metabolic acidosis in endotoxic shock is attributable to lactic acidemia and inadequate tissue perfusion. acid-base balance often improves considerably after fluid resuscitation (preferably with alkalinizing solutions such as lactated ringer's solution) alone; however, additional sodium bicarbonate may be required in cases in which serum bicarbonate concentration remains below meq/l. for adult horses, the bicarbonate deficit (in meq hco ) is calculated as . × body mass (kg) × base deficit, whereas for foals one should use a factor of . . as a general rule, one should administer half the required amount as a bolus followed by the remaining half over to hours. because endotoxemia is a dynamic process and losses are ongoing, one should reevaluate acid-base status at least once daily. foals with sepsis are frequently hypoglycemic, and % dextrose solutions are useful as initial resuscitation fluids. one should reduce the glucose concentration of intravenous solutions according to the blood glucose concentration to avoid prolonged hyperglycemia. administration of hyperimmune plasma ( to ml/kg body mass) is highly recommended in foals with evidence of partial or complete failure of passive transfer. one should consider positive inotropic and vasomotor agents in patients with persistently inadequate tissue perfusion. lower dosages of dopamine ( . to µg/kg/min) result in vasodilation of the renal, mesenteric, coronary, and intracerebral vasculature via dopaminergic effects, whereas higher dosages (up to µg/kg/min) also exert stimulation of β -adrenergic receptors, resulting in increased myocardial contractility and heart rate. dobutamine is a direct β -adrenergic agonist and does not appear to have significant vasodilator properties. dosages for dobutamine of to µg/kg/min as continuous intravenous infusion have been recommended for use in horses. in addition, norepinephrine was evaluated in hypotensive critically ill foals that were refractory to the effects of dopamine and dobutamine. at dosages up to . µg/kg/min administered concurrently with dobutamine, six out of seven foals showed an increase in mean arterial pressure, and all foals had increased urine output. because of the risk of cardiac side effects, close monitoring of heart rate and rhythm should accompany infusion of inotropes. indirect blood pressure measurements using a tail cuff may be used to monitor the effects of treatment. more frequently than overt thrombosis or bleeding attributable to dic, hemostatic abnormalities occur in the form of alterations in the coagulation profile. a procoagulant state with shortened bleeding times or prolonged bleeding times caused by consumption of clotting factors may be evident. one should address abnormalities in the coagulation profile as early as possible but especially if they persist more than hours after initiation of therapy. because of the complex interactions of coagulation and fibrinolysis during endotoxemia, one should combine anticoagulant therapy with the administration of fresh frozen plasma to replace clotting and fibrinolytic factors. heparin acts as an anticoagulant by activation of at iii and subsequent inhibition of thrombin, release of tissue factor pathway inhibitor from endothelial cells, and inhibition of platelet aggregation. because endogenous at iii levels frequently are decreased in patients with coagulopathy, addition of heparin to fresh frozen plasma may be the most effective route of administration. an initial dose of iu/kg body mass followed by to iu/kg body mass times daily has been recommended. anemia caused by erythrocyte agglutination occurs in some patients during therapy with unfractionated heparin , but typically resolves within hours if therapy is discontinued. because of the risk of microthrombosis associated with erythrocyte agglutination, use of low-molecular-weight heparin ( iu/kg body mass subcutaneously every hours) has been recommended but may be cost-prohibitive. one may give aspirin orally ( to mg/kg body mass, every hours), which irreversibly inhibits platelet cox activity, to inhibit platelet aggregation and microthrombosis. platelet hyperaggregability has been implicated in the pathogenesis of carbohydrate-induced laminitis, and heparin and aspirin have been recommended to prevent development of laminitis. in an in vitro study, however, aspirin did not inhibit endotoxin-induced platelet aggregation. luteolysis caused by increased concentrations of pgf α leads to pregnancy loss in endotoxemic mares before day of pregnancy. daily administration of altrenogest (regu-mate, hoechst-roussel agri-vet, somerville, new jersey) at a dose of mg orally consistently prevented fetal loss in mares if administered until day of pregnancy. treatment with flunixin meglumine, by blockade of pgf α release, also may contribute to the maintenance of pregnancy in endotoxemic mares. the pathogenesis of fetal loss and abortion caused by endotoxemia, surgery, or systemic disease later in gestation is not understood completely. proposed mechanisms include direct effects on the fetus, placental function, or placental progesterone production. the pathophysiology of laminitis caused by endotoxemia is understood incompletely; however, decreased digital blood flow , and intravascular microthrombosis have been implicated. decreased no production by vascular endothelial cells in response to endotoxin has been suggested as a mechanism for vasoconstriction and decreased blood flow ; however, use of no donors remains controversial. maintenance of adequate peripheral perfusion and anticoagulant and antiinflammatory therapy may be helpful in preventing and treating laminitis caused by endotoxemia. although the innate immune response to endotoxin (lipopolysaccharide) is crucially important for the preservation of homeostasis and health, large amounts of endotoxin can evoke an excessive and uncontrolled inflammatory response and result in a dysfunction of hemostatic and circulatory control mechanisms, loss of vascular integrity, and finally tissue damage. conditions commonly associated with the development of endotoxemia in horses are acute gastrointestinal diseases, especially of ischemic and severe inflammatory nature, and localized or generalized infections. although measuring endotoxin concentrations in equine plasma is possible, this is not feasible in a clinical setting, and one typically reaches a diagnosis of endotoxemia based on clinical signs and clinicopathologic data. successful treatment of endotoxemia requires resolution of the primary disease process in addition to neutralization of circulating endotoxin, interference with the activities of inflammatory mediators, and general supportive care. newer treatments, such as blockade of endotoxin-interaction with cells or interruption of cell signaling pathways, are under investigation. possible sequelae of endotoxemia include dic, multiple organ failure, circulatory failure, and death. frequently, the outcome of conditions associated with endotoxemia in horses depends on the severity of associated complications; for example, renal compromise, laminitis, and abortion. resting state the lateral margins of the vesicle, that is, the buccal mucosa, are in close contact with the cheek teeth. caudally, the external space communicates with the pharynx through the aditus pharyngis. the mucous membrane of the mouth is continuous at the margin of the lips with the skin and during life is chiefly pink but can be more or less pigmented, depending on the skin color and the breed type. the lips are two muscular membranous folds that unite at angles close to the first cheek teeth. each lip presents an outer and an inner surface. the upper lip has a shallow median furrow (philtrum); the lower lip has a rounded prominence or chin (mentum). the internal surface is covered with a thick mucous membrane that contains small, pitted surfaces that are the openings of the ducts of the labial glands. small folds of the mucous membrane called the frenula labii pass from the lips to the gum. the free border of the lip is dense and bears short, stiff hairs. the arteries of the mouth are derived from the maxillary, mandibular, labial, and sphenopalatine arteries of the major palatine artery. the veins drain chiefly to the lingual facial vein. sensory nerves originate from the trigeminal nerve (cranial nerve v) and the motor nerves from the facial nerve (vii). the cheeks spread back from the lips and form both sides of the mouth and are attached to the alveolar borders of the bones of the jaws. the cheeks are composed of skin and muscular and glandular layers and then the internal mucous membrane. the skin is thin and pliable. in contrast, the oral mucous membrane is dense and in many areas of the oral cavity is attached firmly to the periosteum so that construction of oral mucosal flaps can be achieved only by horizontal division of the periosteal attachment. such a feature is important in reconstructive techniques applied to the oral cavity. the blood supply to the cheeks comes from the facial and buccal arteries and the sensory nerves from the trigeminal and motor nerves from the facial nerve. the hard palate (palatum durum) is bounded rostrally and laterally by the alveolar arches and is continuous with the soft palate caudally. the hard palate has a central raphe that divides the surface into two equal portions. the word mouth is used commonly to signify the first part of the alimentary canal or the entrance to it. the mouth is bounded laterally by the cheeks, dorsally by the palate, and ventrally by the body of the mandible and by the mylohyoideus muscles. the caudal margin is the soft palate. the mouth of the horse is long and cylindric, and when the lips are closed, the contained structures almost fill the cavity. a small space remains between the root of the tongue and the epiglottis and is termed the oropharynx. the cavity of the mouth is subdivided into sections by the teeth. the space external to the teeth and enclosed by the lips is termed the vesicle of the mouth, and in the enter the nose from the glands of the vomeronasal duct. to what extent these secretions aid in pheromone reception is not known. that portion of the palatine mucosa immediately behind the incisor teeth frequently is swollen (lampas) during eruption of the permanent teeth. this swelling is physiologic and not pathologic. the tongue is situated on the floor of the mouth between the bodies of the mandible and is supported by the sling formed by the mylohyoideus muscles. the root of the tongue is attached to the hyoid bone, soft palate, and pharynx. the upper surface and the rostral portion of the tongue are free; the body of the tongue has three surfaces. the apex of the tongue is spatulate and has a rounded border. the mucous membrane adheres intimately to the adjacent structure and on the dorsum is dense and thick. the lingual and sublingual arteries supply the tongue from the linguofacial trunk and matching veins. the linguofacial trunk drains into the linguofacial vein. the lingual muscles are innervated by the hypoglossal nerve (xii) and the sensory supply is from the lingual and glossopharyngeal (ix) nerves. the formula for the deciduous teeth of the horse is times i - c - p - for a total of . the permanent dental formula is times i - c - p - or p - m - for a total of or . in the mare the canine teeth are usually small or do not erupt, hence reducing the number to or . the first premolar tooth (wolf tooth) is often absent and has been reported as occurring in only % of the upper dentition of thoroughbred horses. the teeth of the horse are complex in shape and are compounded of different materials (dentin, cementum, and enamel). they function as grinding blades to masticate and macerate cellulose food in the important first stage of the digestive process. the cheek teeth in the horse are a well-documented feature of the evolution of equus caballus. the first incisor is present at birth or the first week of life. the second incisor erupts at to weeks of age; the third incisor, at to months of age; the first and second premolars, at birth to weeks of age; and the third premolar, months of age. the eruption times for the permanent teeth are as follows: first incisor, / years of age; second incisor, / years of age; third incisor, / years of age; the canine tooth, to years of age; the first premolar (wolf tooth), to months of age; the second premolar, / years of age; the third premolar, years of age; the fourth premolar, years of age; the first molar, to months of age; the second molar, years of age; and the third molar, / to years of age. this eruption sequence clearly indicates that the eruption of the second and third permanent premolar teeth give the potential for dental impaction. the modern horse has six incisor teeth in each jaw that are placed close together so that the labile edges form a semicircle. the occlusal surface has a deep enamel invagination (infundibulum) that is filled only partially with cementum. as the incisor teeth wear, a characteristic pattern forms in which the infundibulum is surrounded by rings of enamel, dentin, enamel, and crown cementum in a concentric pattern. each incisor tooth tapers from a broad crown to a narrow root so that as the midportion of the incisor is exposed to wear, the cross-sectional diameters are about equal; that is, at years of age, the central incisor tooth of the horse has an occlusal surface that is an equilateral triangle. observations on the state of eruption, the angles of incidence of the incisor teeth, and the pattern of the occlusal surfaces are used as guides for aging of horses. the canine teeth are simple teeth without complex crowns and are curved. the crown is compressed and is smooth on its labial aspect but carries two ridges on its lingual aspect. no occlusal contact occurs between the upper and lower canine teeth. when erupted, the six cheek teeth of the horse function as a single unit in the mastication of food. each arcade consists of three premolar and three molar teeth. the maxillary arcade is slightly curved, and the teeth have a square occlusal surface. the occlusal surfaces of the mandibular teeth are more oblong, and each arcade is straighter. the horse is anisognathic, that is, the distance between the mandibular teeth is narrower (one-third) than the distance between the upper cheek teeth. this anatomic arrangement affects the inclination of the dental arcade as the jaws slide across each other in the food preparation process. the unworn upper cheek tooth presents a surface with two undulating and narrow ridges, one of which is lateral and the other medial. on the rostral and lingual side of the medial style is an extra hillock. the central portion of these surfaces is indented by two depressions that are comparable with, but much deeper than, the infundibula of the incisor teeth. when the teeth have been subjected to wear, the enamel that closed the ridges is worn through and the underlying dentin appears on the surface. thus after a time the chewing surface displays a complicated pattern that may be likened to the outline of an ornate letter b, the upright stroke of the b being on the lingual aspect. dentin supports the enamel internally, cementum supports the enamel lakes, and the peripheral cementum fills in the spaces between the teeth so that all six teeth may function as a single unit, that is, the dental arcade. transverse ridges cross each tooth so that the whole maxillary arcade consists of a serrated edge. the serrations are formed so that a valley is present at the area of contact with adjacent teeth. these serrations match fitting serrations on the mandibular arcade. the true roots of the cheek teeth are short compared with the total length of the tooth. cheek teeth have three roots: two small lateral roots and one large medial root. by custom, that portion of the crown embedded within the dental alveolus is referred to as the reserve crown, and the term root is confined to that area of the tooth that is comparatively short and enamel free. wear on the tooth gradually exposes the reserve crown, and the roots lengthen. in an adult -lb horse the maxillary cheek teeth are between . and . cm in length. dental wear accounts for erosion and loss of tooth substance at a rate of mm/yr. the pulp chambers of the teeth are also complex. the incisors and canines have a single pulp chamber. the mandibular cheek teeth have two roots and two separate pulp chambers. the maxillary cheek teeth, although they have three roots, have in fact five pulp chambers. as occlusal wear proceeds, deposition of secondary dentin within the pulp chambers protects the chambers (e.g., the dental star, medial to the infundibulum on the incisor teeth). in the mandibular cheek teeth the transverse folding of the enamel anlage (during morphogenesis of the tooth) does not take place, and the occlusal surface is a simple surface of central dentin surrounded by enamel. each tooth then is conformed to a single arcade by the presence of peripheral crown cementum. the oral cavity and oropharynx are subject to a variety of diseases. however, many conditions affecting the first portion of the alimentary system produce the same clinical signs, regardless of their cause. the clinical signs may include inappetance or reluctance to eat, pain on eating or swallowing, oral swelling, oral discharge, and fetid breath. affected animals may show some interest in food but hesitate to eat it. salivation may be excessive and may be contaminated with purulent exudate or blood. the occurrence of bruxism (i.e., grinding of teeth) can indicate discomfort in other areas of the alimentary tract; for example, bruxism and frothing oral saliva are characteristic features of gastric ulceration in the horse. the clinician needs to be aware that considerable weight loss can occur rapidly with inability to feed and swallow. diseases that result in denervation of the pharynx and inappropriate swallowing can have the complication of inhalation pneumonia. after a complete physical examination and ascertaining the history, the clinician should approach examination of the mouth systematically in all cases. one can examine a considerable portion of the mouth and teeth from the outside by palpation of the structures through the folds of the cheek. most horses allow an oral examination without sedation or the use of an oral speculum. in many cases, however, one best achieves the detailed oral examination by sedation and the use of an oral speculum and a light source. one should irrigate the mouth to wash out retained food material so as to be able to inspect and palpate the lips, cheeks, teeth, and gums. the classic signs of dental disease in the horse include difficulty and slowness in feeding, together with a progressive unthriftiness and loss of body condition. in some instances, the horse may quid, that is, it may drop poorly masticated food boluses from the mouth, and halitosis may be obvious. additional problems reported by owners include bitting and riding problems and headshaking or head shyness. facial or mandibular swelling may occur. nasal discharge can result from dental disease associated with maxillary sinus empyema. mandibular fistulae frequently are caused by lower cheek tooth apical infections. some correlation exists between the age of the animal and clinical signs (table . - ). ancillary aids for a complete examination of the oral cavity of the horse may include radiology, endoscopic examination, fluoroscopy, biopsy, and culture. one should take care always during endoscopic evaluation of the oral cavity using a flexible endoscope. the author recommends sedation and the use of an oral speculum to prevent inadvertent mastication of the endoscope. if one uses general anesthesia as part of the diagnostic workup, then endoscopic evaluation of the oral cavity is much easier. in selected cases, advanced imaging technologies such as computed tomography, magnetic resonance imaging, or nuclear scintigraphy may be beneficial. the lips of the horse are mobile and prehensile. in many ways they function like the tip of the elephant's trunk in that they test, manipulate, and sample the environment for potential nutritive value. consequently, loss of motor function (e.g., facial palsy) affects the efficiency of the prehensile system. the lips grasp food in grazing or browsing, and the incisor teeth section the food. with mastication and lubrication with saliva, the bolus of food forms and is manipulated from side to side across the mouth, assisted by the tight cheeks of the horse and the palatine ridges. swallowing begins as the food bolus contacts the base of the tongue and the pharyngeal walls. during swallowing, the soft palate elevates to close the nasopharynx, the base of the tongue elevates, and the hyoid bone and the larynx move rostrally following contraction of the hyoid muscles. during this process, the rima glottidis closes and the epiglottis tilts dorsally and caudally to protect the airway so that food is swept through lateral food channels around the sides of the larynx into the laryngoesophagus. fluoroscopic studies in nursing foals in the dorsoventral view showed that contact occurs between the lateral food channels in the midline so that in outline the food bolus achieves a bow tie shape. dysphagia is defined as a difficulty or inability to swallow. anatomic classifications for dysphagia include prepharyngeal, pharyngeal, and esophageal (postpharyngeal) dysphagias. the site of the cause for dysphagia influences the clinical signs. prepharyngeal dysphagia is characterized by dropping food (quidding) or water from the mouth, reluctance to chew, hypersalivation, or abnormalities in prehension. pharyngeal and esophageal dysphagias are characterized by coughing; nasal discharge containing saliva, water, or food material; gagging; anxiousness; and neck extension during attempts to swallow. the following section describes esophageal dysphagia in more detail. causes of dysphagia can be divided into four types: painful, muscular, neurologic, or obstructive (table . - ). pain and obstruction cause dysphagia by interfering with the mechanics of prehension, bolus formation and transfer to the pharynx, and deglutition. muscular and neurologic causes of dysphagia impede prehension and swallowing by affecting the motor function of the lingual or buccal musculature, muscles of mastication (temporal and masseters), and pharyngeal and cranial esophageal muscles. sensory loss to the lips, buccal mucous membranes, pharynx, or tongue also may cause dysphagia. neurologic causes of dysphagia may affect the forebrain, brainstem, or peripheral nerves that control prehension (cranial nerves vm, vs, vii, and xii), transfer of the food bolus to the pharynx (cranial nerves vs and xii) and swallowing (cranial nerves ix and x). diagnosis of the cause of dysphagia is based on physical examination including a careful oral examination, neurologic examination, clinical signs, and endoscopy of the pharynx, esophagus, and guttural pouches. radiology may be useful to assess the bony structures of the head and throat. ultrasonography is valuable for examining the retropharyngeal space and esophagus to detect and evaluate masses. one may detect pharyngeal or esophageal causes of dysphagia with routine endoscopic examination or with contrast radiography. although one also can use endoscopy to assess deglutition, one must remember that sedation adversely affects the deglutition mechanism. one may assess deglutition using fluoroscopy or manometry, but these techniques require specialized equipment. specific diagnostic procedures for nonalimentary causes of dysphagia are covered elsewhere in this text (see chapter ). specific treatments aimed at resolving the underlying disorder causing dysphagia are discussed in detail elsewhere. one should avoid feeding roughage with long fiber length (hay or grass) to most horses with dysphagia. dietary modifications that promote swallowing such as feeding slurries made from complete pelleted feeds may be sufficient to manage some cases of partial dysphagia. one must take care to prevent or avoid aspiration pneumonia in horses with pharyngeal or esophageal dysphagia. one can manage foals by feeding mare's milk or a suitable substitute through a nasogastric tube. one also may administer pellet slurries or formulated liquid diets via nasogastric tubes to older horses. prolonged nutritional management of dysphagic horses may require extraoral feeding using a tube placed through an esophagostomy. formulated pelleted diets are often easy to administer through a tube as slurry and are balanced to meet the nutritional requirements for healthy horses. one must feed sufficient quantities to deliver adequate calories ( to mcal/day for a -kg horse). adjustments may be necessary for horses that are cachectic or have extra metabolic demand (such as pregnancy). adding corn oil to the ration ( cup every or hours) is a common method of increasing fed calories. liquid diets also have been used for enteral feeding but may not be tolerated as well as pelleted diets. regardless of the method of nutritional management, one must monitor and replace salivary losses of electrolytes. saliva contains high concentrations of na, k, and cl. a group of ponies with experimental esophagostomies and a horse with esophageal squamous cell carcinoma were fed a complete pelleted diet through esophagostomy tubes but developed metabolic acidosis, hyponatremia, and hypochloremia apparently because of salivary losses. surprisingly, salivary losses of potassium did not result in hypokalemia in these cases, presumably because of replacement in the diet. however, if the diet is deficient in potassium, hypokalemia may result. one often can accomplish electrolyte replacement by adding nacl and kcl to the diet. one can maintain horses for months with frequent feedings through an esophagostomy tube. parenteral nutrition (total or partial) may be useful in the short term but is not often feasible for long-term management. tooth eruption is a complex phenomenon involving the interplay of dental morphogenesis and those vascular forces responsible for creating the eruption pathway. these changes are responsible for osteitis and bone remodeling within the maxilla and mandible. young horses frequently show symmetric bony swelling resulting from these eruption cysts. in some cases, additional clinical signs of nasal obstruction with respiratory stridor or nasal discharges may be apparent. pathologic problems associated with maleruption include a variety of dental diseases. oral trauma can displace or damage erupting teeth or the permanent tooth buds. as a result, teeth may be displaced and erupt in abnormal positions or may have abnormal shapes. supernumerary teeth, incisors and molars, can develop, as well as palatal displacement of impacted teeth (maxillary p - , or third cheek tooth). in almost all of these conditions some form of surgical treatment is necessary. significant evidence from the location of apical osteitis in diseased teeth (table . - ) confirms that dental impaction is a major cause of dental disease in the horse. in a series of extracted teeth, were p - or p - (cheek tooth or , respectively). early observations had indicated that the first molar (m , or cheek tooth ) was the most commonly diseased tooth, and an "open infundibulum" in this tooth has been suggested as the cause. studies on cementogenesis of the maxillary cheek teeth have shown, however, that in fact most maxillary cheek teeth have a greater or lesser degree of hypoplasia of cementum within the enamel lakes and that this "lesion" rarely expands into the pulp. the central infundibular hole is the site of its vascular supply to the unerupted cement lake. on those occasions in which cases one can use apicoectomy and retrograde endodontic techniques to save the diseased tooth. one must take care, however, in selection of patients. in most cases of apical osteitis in the horse that result from dental impaction, immature root structures make achieving an apical seal of the exposed pulp difficult. gingival hyperemia and inflammation occur during the eruption of the permanent teeth and are common causes of a sore mouth in young horses (particularly -year-olds as the first dental caps loosen). such periodontal changes usually resolve as the permanent dental arcade is established. during normal mastication, the shearing forces generated by the occlusal contact of the cheek teeth essentially clean the teeth of plaque and effectively inhibit deposition of dental calculus. wherever occlusal contact is ineffective, periodontal changes and calculus buildup occur; for example, the deposition of calculus on the canine teeth of mature geldings and stallions is common. routine dental prophylaxis forms an important component of maintaining normal occlusal contact, and for this reason one should remove arcade irregularities that result in enamel point formation on the buccal edges of the maxillary cheek teeth and the lingual edges of the mandibular cheek teeth. one should remove these edges annually in horses that are at grass and twice yearly in young horses, aged horses, and stabled horses. horses at grass have been shown to have a greater range of occlusal contact and therefore better periodontal hygiene than stabled horses. in stabled horses the range of occlusal contact is narrower and the formation of enamel points occurs more frequently with subsequent buccal ulceration and the initiation of a cycle of altered occlusal contact and hence irregular arcade formation. this process leads to severe forms of periodontal disease and wave mouth formation. periodontal disease occurs with abnormal occlusal contact and initiation of the cycle of irregular wear and abnormal contact. such changes progress to loss of alveolar bone, gross periodontal sepsis, and loss of tooth support. in this sense periodontal disease truly is the scourge of the equine mouth and results in tooth loss. palatine clefts may result from an inherited defect and are caused by failure of the transverse palatal folds to fuse in the oral cavity. harelip accompanies few palatine clefts in the horse. the degree of palatine clefting depends on the stage at which interruption in the fusion of the part ii disorders of specific body systems caries of cementum occurs, that is, secondary inflammatory disease and acid necrosis of the cementum, apical osteitis may develop. pulpitis is key to the pathogenesis of dental decay in the horse. the initiation of inflammatory pulp changes may be a sequela to dental impaction or dental caries or may result from fracture of a tooth. if the onset of the inflammatory process is slow, then formation of secondary dentin within the pulp chambers may protect the pulp and the tooth. secondary dentin formation occurs from stimulation of odontoblasts within the pulp chamber. such changes are the normal process of protection during dental wear and attrition as crown substances wear away and the reserve crown comes into wear. in acute disease, however, this defense mechanism is ineffective, and the changes that occur and that are sequelae to pulpitis reflect the location of each affected tooth. for example, pulpitis and apical osteitis of the third mandibular cheek tooth most commonly results in the development of a mandibular dental fistula. pulpitis of the third maxillary cheek tooth, however, results in an inflammatory disease within the rostral maxillary sinus and in development of chronic maxillary sinus empyema (figure . - ) . oblique radiographs greatly assist the diagnosis of dental decay by demonstrating sinus tract formation, sequestration of bone, mandibular osteitis, hyperplasia of cementum, and new bone formation (so-called alveolar periosteitis). the management of dental decay in the horse usually involves surgical extraction of the diseased tooth. in some palatopalatal folds occurs. toxic or teratogenic effects are documented in other species, but little data are available in the horse. in recent years, treatment for repair of uncomplicated palatine defects has been recommended but prognosis is generally poor because of the considerable nursing care required and the high incidence of surgical failures. one should emphasize early surgery and the use of mandibular symphysiotomy in affording surgical exposure. the combination of mandibular symphysiotomy and transhyoid pharyngotomy to approach the caudal margins of the soft palate affords surgical access, and one can construct mucosal flaps to repair the defects. however, the incidence of surgical breakdown is high, and healing by first intention is the exception rather than the rule. a recent surgical report documented the successful closure of a median cleft of the lower lip and mandible in a donkey. foals born with a severely deviated premaxilla and palate have a wry nose. one can achieve surgical correction of the deviated premaxilla by submucosal division of the premaxilla across the nose at the line of the first cheek tooth. circumstantial evidence indicates that such a defect has a genetic cause, and the defect occurs most frequently in the arabian breed. other developmental abnormalities are subepiglottic cysts resulting from cystic distortion of remnants of the thyroglossal duct, which may cause dyspnea and choking in foals. surgical removal of these cysts results in normal function. the most significant developmental defect of dental origin is a maxilla that is longer than the mandible, that is, the horse is parrot-mouthed. an overbite of cm in the incisor arcade may be present in a horse with a mismatch of less than cm between the first upper and lower cheek teeth. parrot mouth and monkey or sow mouth are thought to be inherited conditions. some correction of minor incisor malocclusion occurs up to years of age. recognition and detection of parrot mouth are important in the examination of potential breeding stock. surgical attempts to inhibit overgrowth of the premaxilla by wiring or by the application of dental bite plate procedures have been documented in recent years. as has been indicated, the horse is by nature a curious animal and uses its lips as a means of exploring a variety of objects. wounds of the lips, incisive bone, and the mandibular incisor area occur commonly in the horse and usually result from the horse getting the lips, jaw, or teeth caught in feeding buckets, in fence posts, or in halters or having a segment of tongue encircled with hair in tail chewing. as the horse panics and pulls away from its oral entrapment, considerable trauma can occur to the lips, teeth, and gums. most wounds repair satisfactorily, provided one finds them early and observes the basic principles of wound hygiene, excision of necrotic tissue, and wound closure. one must ensure that oral mucosal defects are closed and that effective oral seals are made before external wounds are closed. in some cases, offering specially constructed diets or even feeding the horse by nasogastric tube or esophagostomy during the healing processes may be necessary. foreign body penetration of the tongue, cheek, or palate has been reported in grazing and browsing horses and in particular in horses that have certain hay sources that contain desiccated barley awns or yellow bristle grass. other plant material and grass awns also occasionally may penetrate the tongue, gingiva, or cheek, causing inflammation or abscesses. ulcerative stomatitis also results from the toxicity of phenylbutazone therapy. vesicular stomatitis is a highly contagious viral blistering disease described in more detail elsewhere. treatment of glossitis and stomatitis primarily aims at removing the inciting cause. actinobacillus lignieresii, the causative agent of actinobacillosis, has been isolated and identified from ulcers on the free border of the soft palate and oral and laryngeal granulomata. the bacterium also was reported in a sublingual caruncle in a horse with a greatly swollen tongue. therapy with ml of % sodium iodide and g of ampicillin every to hours effected a clinical cure. saliva is important for lubricating and softening food material. the horse has paired parotid, mandibular, and polystomatic sublingual salivary glands. the parotid gland is the largest of the salivary glands in the horse and is situated in the space between the ramus of the mandible and the wing of the atlas. the parotid duct is formed at the ventral part of the gland near the facial crest by the union of three or four smaller ducts. the duct leaves the gland above the linguofacial vein, crosses the tendon of the sternocephalicus muscle, and enters the mouth obliquely in the cheek opposite the third upper cheek tooth. the parotic duct orifice is small, but some dilation of the duct and a circular mucous fold (the parotid papillae) exist at this point. the mandibular gland is smaller than the parotid gland and extends from the atlantal fossa to the basihyoid bone. for the most part, the mandibular gland is covered by the parotid gland and by the lower jaw. the mandibular duct is formed by union of a number of small duct radicles that emerge along the concave edge of the gland and run rostral to the border of the mouth opposite the canine tooth. the orifice is at the end of a sublingual caruncle. the mandibular gland possesses serous, mucous, and mixed alveolar glandular components. the parotid gland is a compound alveolar serous gland. the parotid salivary gland can secrete saliva to yield rates of ml/min, and a total daily parotid secretion can be as much as l in a -kg horse. parotid secretion only occurs during mastication, and administration of atropine or anesthesia of the oral mucosa can block secretion. parotid saliva is hypotonic compared with plasma, but at high rates of flow, concentrations of sodium, chloride, and bicarbonate ions increase. parotid saliva of the horse has a high concentration of calcium, and occasionally calculi (sialoliths) form within the duct radicles of the parotid salivary gland. congenital parotid duct atresia, acquired stricture from trauma to the duct, or obstruction by plant material (sticks or foxtails and other seeds) also may occur. the clinical signs of sialolithiasis or other forms of ductule obstruction include a fluid swelling in the form of a mucocele proximal to the stone and occasionally inflammation of the parotid gland. ultrasonography is useful to diagnose salivary mucoceles and to detect foreign bodies or sialoliths. measurement of electrolyte concentrations in aspirates from suspected mucoceles might be helpful to distinguish them from hematomas. salivary potassium and calcium concentrations are higher than plasma. treatment may require surgical removal of the stone or plant material in the case of sialolithiasis or foreign body obstructions. other causes of obstruction may require resection of the affected portion of the duct or chemical ablation of the gland. primary sialoadenitis is unusual but can occur in one or both glands. the condition is painful and may be associated with a fever and anorexia. secondary sialoadenitis is more common and usually is associated with trauma. infectious sialoadenitis from corynebacterium pseudotuberculosis or other bacterial pathogens also may occur. diagnosis is by physical examination and by finding an enlarged edematous parotid gland tissue on ultrasonographic examination. culture and cytologic examination of aspirates may be useful for diagnostic purposes. treatment in usually palliative, consisting of nonsteroidal antiinflammatory drugs. appropriate antibiotic therapy is indicated as directed by culture and sensitivity results. chemical irritation, glossitis, stomatitis, or other causes of prepharyngeal dysphagia cause ptyalism or excessive salivation in horses. specific therapy for the ptyalism usually is not required as long as salivary losses are not excessive, resulting in dehydration and electrolyte imbalances. ingestion of the fungal toxin slaframine also causes hypersalivation in horses. the fungus rhizoctonia leguminicola, which produces slaframine, causes black patch disease in red clover. slaframine is a parasympathomimetic compound that stimulates exocrine secretion in the parotid gland. slaframine toxicosis most commonly occurs in the spring or early summer and rarely requires treatment other than removal from the pasture. mowing removes the source in most cases because regrowth in pastures often has less fungal contamination. . the esophagus has no digestive or absorptive functions and serves as a conduit to the stomach for food, water, and salivary secretions. the esophageal mucosa is a keratinized stratified squamous epithelium. the submucosa contains elastic fibers that contribute to the longitudinal folds of the esophagus and confer elasticity to the esophageal wall. a transition occurs in the muscle type composing the tunica muscularis from striated skeletal muscle in the proximal two thirds of the esophagus to smooth muscle in the distal third. in the proximal esophagus the skeletal muscle layers spiral across one another at angles. within the smooth muscle layers of the distal esophagus the outer layer becomes more longitudinal, whereas the inner layer thickens and becomes circular. the wall of the terminal esophagus can be to cm thick. deep cervical fascia, pleura, and peritoneum contribute to the thin fibrous tunica adventitia of the esophagus. motor innervation to the striated skeletal muscle of the esophagus includes the pharyngeal and esophageal branches of the vagus nerve, which originate in the nucleus ambiguus of the medulla oblongata. parasympathetic fibers of the vagus nerve supply the smooth muscle of the distal esophagus. sympathetic innervation of the esophagus is minimal. passage of ingesta through the esophagus can be considered part of the swallowing process, which consists of oral, pharyngeal, and esophageal stages. the oral stage is voluntary and involves transport of the food bolus from the mouth into the oropharynx. during the involuntary pharyngeal stage the food bolus is forced through the momentarily relaxed upper esophageal sphincter by simultaneous contractions of the pharyngeal muscles. in the esophageal phase of swallowing the upper esophageal sphincter closes immediately, the lower esophageal sphincter opens, and esophageal peristalsis propels the bolus into the stomach. unlike a food bolus, liquids do not require peristalsis to reach the lower esophageal sphincter and may precede the food bolus during swallowing. the upper esophageal sphincter prevents esophagopharyngeal reflux during swallowing and air distention of the esophagus during inspiration. upper esophageal pressure increases in response to pressure from a food bolus and to increased intraluminal acidity, as would occur with gastroesophageal reflux. the lower esophageal sphincter is a smooth muscle located at the gastroesophageal junction that is morphologically ill defined but forms an effective functional barrier. normally the lower esophageal sphincter is closed in response to gastric distention to restrict gastroesophageal reflux. relaxation of the lower esophageal sphincter permits passage of ingested material from the esophagus to the stomach. distention of the stomach with ingesta mechanically constricts the lower esophageal sphincter. gastric distention also triggers a the esophagus is a musculomembranous tube that originates from the pharynx dorsal to the larynx and terminates at the cardia of the stomach. in adult thoroughbred horses the esophagus is approximately cm long. the cervical portion is approximately cm long; the thoracic portion, approximately cm long; and the short abdominal portion, only approximately cm long. the cervical esophagus generally lies dorsal and to the left of the trachea in the cervical region. in the thorax the esophagus courses through the mediastinum lying dorsal to the trachea and crosses to the right of the aortic arch dorsal to the heart base. impactions. intramural causes of esophageal obstruction include tumors (squamous cell carcinoma), strictures, diverticula, and cysts. [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] mediastinal or cervical masses (tumors or abscesses) may cause extramural obstructions. congenital anomalies are covered in detail later. the clinician must perform a thorough physical examination, including complete oral and neurologic examination, to help rule out causes of dysphagia and nasal discharge other than esophageal obstruction. the clinical signs associated with esophageal obstructions are related primarily to regurgitation of food, water, and saliva caused by esophageal (postpharyngeal) dysphagia. horses with esophageal obstruction are often anxious and stand with their neck extended. one may note gagging or retching, particularly with acute proximal obstructions. bilateral frothy nasal discharge containing saliva, water, and food material; coughing; odynophagia; and ptyalism are characteristic clinical signs, the severity of which varies with the degree and location of the obstruction. distention in the jugular furrow may be evident at the site of obstruction. one may observe other clinical signs related to regurgitation of saliva, water, and food material, such as dehydration, electrolyte or acid-base imbalances, weight loss, and aspiration pneumonia. in extreme cases, pressure necrosis from the impaction or trauma to the esophagus may cause esophageal rupture. if the rupture is in the cervical esophagus, crepitus or cellulitis may be evident along with signs of systemic inflammation. thoracic auscultation is important to determine whether aspiration pneumonia is present. intrathoracic esophageal rupture may result in pleuritis and its associated clinical signs. passage of a nasogastric tube is an effective way to detect and localize an obstruction but provides little information about the nature of the obstruction or the condition of the esophagus. the most direct method for diagnosis of esophageal obstructions is endoscopic examination. most cases of esophageal obstruction occur at sites of natural narrowing of the esophageal lumen, such as the cervical esophagus, the thoracic inlet, base of the heart, or the terminal esophagus, thus one may need an endoscope longer than m for complete evaluation. endoscopic evaluation is useful before relief of an impaction to localize the obstruction and to investigate the nature of the impaction if one suspects a foreign body. foreign bodies may be retrievable via transendoscopic tethering. one can obtain critical diagnostic and prognostic information following resolution of the impaction. assessing the affected esophagus for mucosal ulceration, rupture, masses, strictures, diverticula, and signs of functional abnormalities is important (figure . - ) . ultrasonography of the cervical region is useful not only to confirm a cervical esophageal impaction but also part ii disorders of specific body systems vagal reflex that increases lower esophageal sphincter tone, a safety mechanism against gastroesophageal reflux. the mechanical and vagal mechanisms that promote lower esophageal sphincter tone prevent spontaneous decompression of the stomach, which along with a lack of a vomiting reflex in the horse, increases the risk of gastric rupture during episodes of severe distention. esophageal obstruction has many causes (table . - ) and most often is manifested clinically by impaction of food material and resulting esophageal dysphagia. esophageal obstruction may be caused by primary impactions (simple choke) of roughage, particularly leafy alfalfa hay, coarse grass hay, bedding, and even grass. prior esophageal trauma or poor mastication caused by dental abnormalities may predispose horses to primary esophageal impaction. wolfing or gulping food may precipitate primary impactions, particularly if the horse is exhausted or mildly dehydrated after a long ride or is weakened from chronic debilitation. impactions also may result from disorders that physically impede the passage of food material and fluid by narrowing the luminal diameter, reduce the compliance of the esophageal wall, or alter the conformation of the esophageal wall such that food material accumulates in a pocket or diverticulum. foreign bodies, intra-or extramural masses, or acquired or congenital anomalies cause these so-called secondary to provide critical information about the location and extent of the impaction and esophageal wall thickness and integrity. ultrasonography may provide information about the cause. radiographic assessment of the esophagus can confirm the presence of esophageal obstruction in cases in which one cannot view the affected area adequately using endoscopy. one can detect impacted food material in the esophagus by a typical granular pattern and often can observe gas accumulation proximal to the obstruction. air or barium contrast radiographic studies are most useful for evaluating the esophagus following relief of the impaction if one suspects a stricture. one often can detect esophageal dilation, diverticula, rupture, functional disorder (megaesophagus), or luminal narrowing caused by extraluminal compression more easily using contrast radiographic studies instead of endoscopy ( figure . - ). - one should take care when interpreting radiographic studies in sedated horses, particularly after passage of a nasogastric tube or other esophageal manipulations that may contribute to esophageal dilation. the primary goal of treatment for esophageal impaction is to relieve the obstruction. parenteral administration of acepromazine ( . mg/kg intravenously), xylazine ( . to . mg/kg intravenously) or detomidine ( . to . mg/kg intravenously), oxytocin ( . to . iu/kg intramuscularly), and/or esophageal instillation of lidocaine ( to ml of % lidocaine) may reduce esophageal spasms caused by pain or may decrease esophageal tone. [ ] [ ] [ ] [ ] some clinicians advocate parasympatholytic drugs such as atropine ( . mg/kg intravenously) to reduce salivary secretions and lessen the risk of aspiration. however, undesirable effects of atropine including excessive drying of the impaction and inhibition of distal gastrointestinal motility may preclude its use. resolution of an impaction may require physical dispersal of the material. one can use a nasogastric tube to displace the impacted material along with external massage if the obstruction is in the cervical region. often, carefully lavaging the esophagus with water via an uncuffed or a cuffed nasogastric tube while the head is lowered is necessary to aid in breaking up the impaction. some clinicians advocate a dual tube method whereby a tube is placed through each nasal passage into the esophagus for ingress and egress of the lavage fluid. because of the risk of aspiration of water and food material, esophageal lavage sometimes is done under general anesthesia with a cuffed nasotracheal tube. in refractory cases, intravenous administration of isotonic fluid containing . % nacl and kcl ( to meq/l) for hours at a rate of to ml/kg/ day along with esophageal relaxants such as oxytocin may promote hydration and softening of the impaction and help prevent or alleviate any electrolyte or acid-base imbalances resulting from salivary losses of chloride, sodium, and potassium. one should note that the effects of oxytocin on esophageal tone occur in the proximal two thirds of the esophagus and may not be effective for mucosa has recovered as assessed by endoscopy, one can feed the horse soft food (moistened pellets and bran mashes). one can return the patient gradually to a highquality roughage diet over to days, depending on the degree of esophageal damage induced by the impaction and the nature of any underlying disease. the prognosis for survival is good ( %), but some horses may require permanent dietary modification if persistent chronic obstruction is a problem. aspiration pneumonia and perforation are potential complications of severe or prolonged esophageal obstructions. if aspiration is suspected, administration of broad-spectrum antibiotics that are effective against gram-positive and gram-negative organisms, including metronidazole ( mg/kg orally every hours) for anaerobes is advisable. a subsequent section describes treatment of esophageal perforation or rupture. esophagitis refers to a clinical syndrome of esophageal inflammation that may or may not be ulcerative. the major protective mechanisms of the esophageal mucosa include salivary and food material buffers, normal peristaltic motility, and the barrier formed by the gastroesophageal sphincter. reflux esophagitis is caused by repeated episodes of gastric fluid regurgitation into the distal esophagus and subsequent chemical injury to the mucosa ( figure distal obstructions. , rarely, esophageal obstruction ultimately may require esophagotomy to relieve the impaction. one must enforce strict restriction of food and water, including access to bedding material, until the obstruction is resolved and the esophagus has regained function. systemic effects of dysphagia associated with esophageal impaction include dehydration, hyponatremia, hypochloremia, and metabolic alkalosis from prolonged loss of salivary free water and electrolytes. if the duration of a complete esophageal obstruction is hours or longer, one should correct dehydration and electrolyte and acid-base imbalances. one can restore fluid and electrolyte balance with oral electrolyte solutions if the patient is less than % to % dehydrated and the esophageal obstruction is resolved. horses that are greater than % to % dehydrated or those that have a refractory obstruction or moderate to severe electrolyte imbalances may require intravenous fluid therapy with solutions containing . % nacl and kcl ( to meq/l). one should perform esophageal endoscopy after relief of the impaction to determine whether any complications of the impaction have developed or if a primary cause of the obstruction is present. endoscopic examination is critical to determine the postobstruction treatment plan and for follow-up evaluation of esophageal healing. one should reevaluate the horse every to weeks following resolution of the impaction if one notes esophageal dilation or mucosal injury. additional evaluation via radiography may be warranted to assess motility and transit times. dilation proximal to the site of obstruction, mucosal injury from trauma, stricture formation, formation of a diverticulum, megaesophagus, and esophagitis are sequelae to esophageal obstruction that predispose patients to reobstruction. the rate of reobstruction may be as high as %. depending on the duration of the obstruction and the degree of trauma or dilation, the risk of reobstruction is high for to hours or longer, thus one should withhold food for at least to hours after resolution of the obstruction. sucralfate ( mg/kg orally every hours) may hasten healing if esophageal ulceration is evident, but the efficacy of sucralfate for this purpose is not established. some clinicians suggest that administration of a nonsteroidal antiinflammatory drug (nsaid) such as flunixin meglumine ( mg/kg orally or intravenously every hours) or phenylbutazone ( to mg/kg orally or intravenously every to hours) for to weeks after resolution of the impaction may reduce the development of strictures. judicious use of nsaids is recommended to prevent nsaid-induced worsening of esophageal mucosal injury. one should avoid orally administered nsaids if esophagitis is present. after to hours or when the esophageal duodenal strictures caused by chronic ulceration commonly have reflux esophagitis. diagnosis requires endoscopic examination of the esophagus. one may note diffuse, patchy, linear, or coalescing erosion or ulcerations (see figures . - and . - ). one also may observe significant edema or hyperemia. determining whether an underlying disease, such as infection, neoplasia, esophageal strictures, or diverticula, is present is important. in addition, one must examine the stomach to determine whether the esophagitis is associated with gastritis, gastric obstruction, or gastric ulcer disease. contrast radiography may be helpful to detect esophageal ulceration and is useful to assess esophageal motility and transit time. the principles of therapy for reflux esophagitis include control of gastric acidity, mucosal protection, and correction of any underlying disorder contributing to gastroesophageal reflux. reduction of gastric acid production with h histamine receptor blockers such as ranitidine or proton pump antagonists such as omeprazole is critical for resolution of the esophagitis. some clinicians advocate using sucralfate to promote healing of ulcerated esophageal mucosa. however, the ability of sucralfate to bind ulcerated esophageal mucosa is not proven, nor is the efficacy of sucralfate for hastening esophageal ulcer healing. horses with reflux esophagitis following delayed gastric outflow caused by gastroduodenal ulcer disease, gastric paresis, or proximal enteritis may benefit from prokinetic drugs that act on the proximal gastrointestinal tract. metoclopramide ( . to . mg/kg subcutaneously every to hours) reduces gastroesophageal reflux by increasing lower esophageal sphincter tone, gastric emptying, and gastroduodenal coordination. one should exercise caution when giving metoclopramide to horses because they are prone to extrapyramidal neurologic side effects of the drug. cholinergic drugs such as bethanechol ( . to . mg/kg subcutaneously every to hours or . to . mg/kg orally every to hours) may improve gastric emptying and are effective for treating reflux esophagitis. for esophagitis from trauma or pressure injury after esophageal impaction, judicious use of nsaids may be warranted to reduce esophageal inflammation and pain. dietary modification may be necessary for patients with esophagitis, depending on the degree of ulceration or if motility is impaired. one should feed horses with mild esophagitis frequent small meals of moistened pellets and fresh grass. severe esophagitis may necessitate withholding food and complete esophageal rest for several days. although the prognosis for esophagitis is good in the absence of underlying disease, the risk of esophagus is delayed, such as in functional disorders of the esophagus. like ulceration of the squamous portion of the stomach in horses, gastric acid and bile salt chemical injury is a major mechanism of esophageal squamous epithelial ulceration. , reflux esophagitis may occur along with gastric ulcer disease, motility disorders, increased gastric volume from gastric outflow obstructions, gastric paresis, intestinal ileus, or impaired lower esophageal sphincter function. , other causes of esophagitis in horses include trauma (foreign bodies, food impactions, nasogastric tubes), infection (mural abscesses), or chemical injury (pharmaceuticals, cantharidin) ( figure . - ). [ ] [ ] [ ] [ ] the clinical signs of esophagitis are nonspecific and similar to esophageal obstruction and gastric ulcer diseases. gagging or discomfort when swallowing may be evident, and hypersalivation and bruxism are signs of esophageal pain. esophageal (postpharyngeal) dysphagia may be evident. one may note partial or complete anorexia such that horses with chronic esophagitis may have significant weight loss. esophageal hypomotility dysfunction caused by the inflammatory process may result in esophageal impaction. clinical signs of underlying diseases that predispose to esophagitis may predominate or mask the signs of esophagitis. horses with gastrointestinal motility disorders such as proximal enteritis or gastric outflow obstruction are at a high risk of developing reflux esophagitis because of the presence of gastric acid and bile salts in the fluid reflux. foals with gastric, pyloric, or stricture formation is high if severe circumferential or coalescing ulcerations are present. esophagitis from severe trauma or infection may be prone to stricture formation. motility dysfunction of the equine esophagus is caused most commonly by hypomotility resulting in esophageal dilation (ectasia) or megaesophagus. although megaesophagus in horses most commonly is acquired, reports indicate idiopathic megaesophagus in young horses may be congenital. [ ] [ ] [ ] [ ] acquired megaesophagus in horses may be a consequence of chronic or recurrent esophageal obstruction. , esophageal impactions of a short duration cause a proximal dilation of the esophagus that is generally reversible. however, if the duration of the obstruction is long enough, the motility of the esophagus proximal to the site of obstruction may be impaired permanently. other causes of acquired megaesophagus include extraesophageal obstruction by tumors or abscesses, pleuropneumonia, and vascular ring anomalies. , acquired megaesophagus also may result from neurologic, neuromuscular, and muscular disorders. neurologic diseases that cause vagal neuropathy-such as equine protozoal myeloencephalitis, equine herpesvirus myeloencephalitis, and idiopathic vagal neuropathy-have been associated with megaesophagus in horses. pleuropneumonia may be associated with a vagal neuropathy resulting in megaesophagus. megaesophagus is an early sign of equine dysautonomia and may be observable in patients with botulism. myasthenia gravis is a well-known cause of megaesophagus in nonequine species but has not been reported in horses. also in other species, electrolyte disorders, cachexia, primary myopathies, myositis, and addison's disease may affect esophageal motility but have not been associated with megaesophagus in horses. one can induce iatrogenic megaesophagus by the α adrenergic agonist detomidine, but this is transient and reversible. , nonetheless, the use of this drug may complicate clinical evaluation of esophageal motility. esophageal inflammation, particularly reflux esophagitis, may affect motility and cause megaesophagus. however, because esophageal hypomotility affects the tone and function of the lower esophageal sphincter, reflux esophagitis also may be a complication of a primary functional disorder. thus assessing esophageal motility in horses with esophagitis that is not responding appropriately to treatment is important. along with a complete physical examination one should include a careful neurologic examination to help rule out primary neurologic causes of megaesophagus. because esophageal hypomotility is a functional obstruction, the clinical signs of esophageal hypomotility or megaesophagus are similar to esophageal obstruction. unlike mechanical obstruction the onset of clinical signs is insidious rather than acute. the clinical signs include those associated with esophageal dysphagia. , , [ ] [ ] [ ] [ ] the cervical esophagus may be dilated enough to be evident externally. weight loss is a common sign. signs attributable to an underlying disease may be evident. diagnosis of esophageal hypomotility requires transit studies. one can measure the transit time of a bolus from the cervical esophagus to the stomach by fluoroscopy or contrast radiography. , other signs of esophageal hypomotility and megaesophagus include pooling of contrast material and an absence of peristaltic constrictions. , , , endoscopy may reveal a dilated esophagus and an absence of peristaltic waves. , one may observe evidence of underlying disease causing obstruction or esophageal dilation. , one should evaluate the esophagus for evidence of esophagitis that is causing esophageal motility dysfunction or is a result of impaired esophageal clearance of gastric fluid. esophageal manometry may be useful to document abnormal postdeglutition contraction pressures, contraction time, and propagation times but is not often available for routine clinical application. , one should perform other diagnostic tests such as a complete blood count and chemistry to help determine a possible underlying cause. cerebral spinal fluid analysis may be indicated to rule out neurologic disorders. specialized testing such as electromyography to detect neuromuscular disorders may also be indicated. treatment of esophageal hypomotility or megaesophagus should aim at treating the underlying cause. dietary modification should aim at improving esophageal transit of food. one should feed the horse slurries of pellets, and feeding from an elevated position to promote transit may be beneficial. metoclopramide or bethanechol may benefit patients with reflux esophagitis associated with megaesophagus by increasing lower esophageal tone, gastric emptying, and reducing gastroesophageal reflux. the prognosis depends on the underlying cause and the degree of dilation. although many cases of megaesophagus associated with reflux esophagitis respond well to treatment, many other forms of megaesophagus including congenital megaesophagus have a poor prognosis. strictures most commonly are caused by pressure necrosis from esophageal impactions that induce circumferential erosion or ulceration of the esophageal mucosa, although esophageal injury caused by oral administration of corrosive medicinal agents and trauma to the neck may also result in stricture formation. congenital strictures also have been reported. strictures caused by mucosal and submucosal trauma are termed esophageal webs or rings. strictures may also originate in the muscular layers and adventitia of the esophagus (mural strictures) or in all of the layers of the esophagus (annular stenosis). , horses with these lesions have a presentation similar to those with simple obstructions, because strictures result in partial obstruction and impaction of food material in the lumen. one can detect esophageal webs or rings with endoscopy (see figure . - ), whereas identification of mural strictures or annular stenosis may require a double-contrast esophogram (see figure . - ). in a retrospective study of horses with esophageal stricture following simple obstruction, maximal reduction in esophageal lumen diameter occurred within days of the esophageal obstruction. although surgery has been used to relieve such strictures, initial medical management is warranted because strictures may resolve with conservative therapy, and the esophagus continues to remodel for up to days following ulceration. in one report, seven horses with esophageal obstruction-induced stricture were treated conservatively by feeding a slurry diet and administering antiinflammatory and antimicrobial medications, and five of seven were clinically normal within days. one of the five successfully treated horses had a -cm area of circumferential ulceration, suggesting that the potential exists for extensive mucosal injury to resolve without permanent stricture formation. if resolution of strictures within days is insufficient, one should investigate other methods to increase esophageal diameter. bougienage has been used successfully in small animal patients and human beings. the technique involves passage of a tubular dilatable instrument down the esophagus and stretching of the stricture. one may perform the technique by passing a nasogastric tube with an inflatable cuff. however, one has to perform the procedure frequently to have any success, and horses do not tolerate it well. alternatively, a number of surgical techniques have been used to resolve strictures, including resection and anastomosis, , temporary esophagostomy with fenestration of the stricture, esophagomyotomy for strictures of the muscularis and adventitia, , or patch grafting with local musculature. however, such surgeries are fraught with complications, largely because of the propensity of the traumatized esophagus to restricture. , the esophagus lacks a serosal layer and does not rapidly form a fibrin seal as does the remainder of the intestinal tract, so anastomoses tend to leak. in addition, tension on the esophagus during swallowing and movement of the neck impairs healing of anastomoses. , in spite of these difficulties, the long-term prognosis for horses with chronic esophageal strictures treated surgically is better than for those treated nonsurgically. two types of diverticula are traction (true) diverticula and pulsion (false) diverticula. traction diverticula result from wounding and subsequent contraction of periesophageal tissues, with resultant tenting of the wall of the esophagus. pulsion diverticula arise from protrusion of esophageal mucosa through defects in the muscular wall of the esophagus and usually result from trauma or acute changes in intraluminal pressure. traction diverticula appear as a dilation with a broad neck on contrast esophagography, whereas pulsion diverticula typically have a flask shape with a small neck on an esophagram (see figure . - ). , although traction diverticula are usually asymptomatic and of little clinical significance, pulsion diverticula may fill with feed material, ultimately leading to esophageal obstruction. [ ] [ ] [ ] a movable mass in the midcervical region may be noticeable before onset of complete obstruction. pulsion diverticula may be corrected surgically by inverting or resecting prolapsed mucosa and closing the defect in the wall of the esophagus. , , inversion of excessive mucosa may reduce the diameter of the esophageal lumen and predispose horses to esophageal obstruction and therefore should be reserved for small diverticula. congenital disorders of the esophagus are rare. reported congenital abnormalities include congenital stenosis, persistent right aortic arch, esophageal duplication cysts, [ ] [ ] [ ] intramural inclusion cysts, , and idiopathic megaesophagus. , , in the one report of congenital stenosis, double-contrast radiography revealed concentric narrowing of the thoracic esophagus in the absence of any vascular abnormalities at the base of the heart. successful treatment included having the foal stand with the forelimbs elevated off the ground following each feeding. persistent right aortic arch is a congenital anomaly in which the right fourth aortic arch becomes the definitive aorta instead of the left aortic arch, which results in constriction of the esophagus by the ligamentum arteriosum as it extends between the anomalous right aorta and the left pulmonary artery. clinical signs may include those associated with esophageal (postpharyngeal) dysphagia, drooling, and distention of the cervical esophagus resulting from partial obstruction of the thoracic esophagus. , endoscopic examination typically reveals dilation of the esophagus cranial to the obstruction section . esophageal diseases with evidence of diffuse esophagitis. successful surgical treatment of persistent right aortic arch has been reported in one foal. esophageal duplication cysts and intramural inclusion cysts cause typical signs of esophageal obstruction, including salivation, esophageal dysphagia, and swelling of the cervical esophagus as the cysts enlarge. , , such signs can make them difficult to differentiate from other forms of esophageal obstruction (choke). endoscopic examination may reveal compression of the esophageal lumen and communication with the esophageal lumen if it exists. ultrasonographic examination may be the most useful method of antemortem diagnosis if the cyst is in the cervical esophagus. examination of an aspirate of the mass may aid in the diagnosis by revealing the presence of keratinized squamous cells. , surgical treatments have included complete surgical resection and surgical marsupialization. , , the latter appears to be more successful and results in fewer complications. , complications of surgical resection have included laryngeal hemiplegia following surgical trauma to the recurrent laryngeal nerve in the region of the esophagus and esophageal fistula formation. perforation typically occurs in the cervical region in response to external trauma, necrosis of the esophageal wall caused by a food impaction, or rupture of an esophageal lesion such as an impacted diverticulum. the esophagus is particularly vulnerable to external trauma in the distal third of the neck because only a thin layer of muscle covers it at this point. iatrogenic perforation may occur in response to excessive force with a stomach tube against an obstruction or a compromised region of the esophagus. esophageal perforations may be open or closed and tend to cause extensive cellulitis and necrosis of tissues surrounding the wound because of drainage of saliva and feed material within fascial planes. systemic inflammation associated with endotoxemia from septic cellulitis may occur. closed perforations of the esophagus are particularly troublesome because food material, water, saliva, and air may migrate to the mediastinum and pleural space via fascial planes. , because of the leakage of air into the tissues surrounding the rupture, extensive subcutaneous and fascial emphysema frequently develops and is usually evident clinically and on cervical radiographs. pneumomediastinum and pneumothorax are potentially fatal complications of esophageal ruptures. treatment should include converting closed perforations to open perforations if possible, extensive debridement and lavage of affected tissues, broadspectrum antibiotics, tetanus prophylaxis, and esophageal rest. the clinician may achieve the latter by placing a feeding tube into the esophagus via the wound. alternatively, one may place a nasogastric tube using a small tube ( -f diameter) . for open perforations, once the wound has granulated and contracted to a small size, one may attempt peroral feeding. extensive loss of saliva via esophageal wounds may lead to hyponatremia and hypochloremia. in addition, transient metabolic acidosis occurs because of salivary bicarbonate loss, followed by progressive metabolic alkalosis. although reports of esophageal wounds healing well by second intention exist, healing takes a prolonged time. in addition, some perforations never completely heal and form permanent esophagocutaneous fistulae that may require surgical correction. the development of esophageal strictures is not common because wounds are usually linear and not circumferential. however, traction diverticula may develop. other complications of esophageal wounds include horner's syndrome and left laryngeal hemiplegia. in a retrospective study on esophageal disorders, only of horses with esophageal perforations survived long-term ; in a report of esophageal trauma following nasogastric intubation, of horses were euthanized. the prognosis is therefore poor in horses with esophageal perforations, largely because of the extent of cellulitis, tissue necrosis, shock, and local wound complications. specialized endoscopic equipment allowing visual inspection of the entire adult equine stomach has become increasingly available to veterinarians in academia and private practice. thus gastric disease in horses recently section . diseases of the stomach has gained increasing awareness among veterinarians, owners, and trainers. peptic ulcer disease is defined as erosions or ulcers of any portion of the gastrointestinal tract normally exposed to acid. mucosal damage can include inflammation, erosion (disruption of the superficial mucosa), or ulceration (penetration of the submucosa). in severe cases, fullthickness ulceration can occur, resulting in perforation. the proximal (orad) portion of the equine stomach is lined by stratified squamous mucosa similar to the esophageal lining. the distal (aborad) portion of the stomach is lined with glandular mucosa, and the distinct junction between the two regions is deemed the margo plicatus. ulceration can occur in either or both gastric regions, although different clinical syndromes and pathophysiologic mechanisms apply. as a result, the broad term equine gastric ulcer syndrome (egus) has been used to encompass the wide array of associated clinical syndromes. egus develops in horses of all ages and continues to be of major clinical and economical importance. the prevalence of gastric ulceration has been reported for a variety of breeds and types of horses; however, most current data involve thoroughbreds in race training. the prevalence of squamous ulceration in horses in race training varies from % to % - and can be as high as % when limited to animals actively racing. in a survey of active show horses, % had gastric ulceration, with only horse having ulceration of the glandular fundus. in one large retrospective study ( adult horses from to ) evaluating incidence of gastric ulceration identified at necropsy, an overall prevalence of . % was found. the highest prevalence was found in thoroughbreds (including arabians) and standardbred trotters, and cold-blooded horses were affected significantly less. lesions were located most commonly in the squamous mucosa along the margo plicatus, followed by the glandular body, proximal squamous mucosa, and antrum. many studies investigating prevalence of gastric ulceration do not differentiate between squamous and glandular lesions or evaluate only squamous disease. in a recent study in which the gastric antrum and pylorus were evaluated in horses in a hospital setting, % had antral or pyloric erosions or ulcerations, % had squamous mucosal lesions, and % had lesions involving the glandular body. a correlation between the presence or severity of squamous disease and antral/pyloric disease was not identified. the reported prevalence of gastric ulceration in foals varies from % to %. [ ] [ ] [ ] an imbalance between inciting and protective factors in the mucosal environment can result in ulcer formation. , the major intrinsic factors promoting ulcer formation include hydrochloric acid, bile acids, and pepsin, with hydrochloric acid being the predominant factor. various intrinsic factors protect against ulcer formation such as the mucus-bicarbonate layer, maintenance of adequate mucosal blood flow, mucosal prostaglandin e and epidermal growth factor production, and gastroduodenal motility. in human beings, extrinsic ulcerogenic factors include nonsteroidal antiinflammatory drugs, helicobacter pylori, stress, changes in diet, or gastrointestinal disorders, especially those resulting in delayed gastric emptying. in human neonates, physiologic stress associated with a major primary illness seems to be associated strongly with gastric ulcers. many of the other factors mentioned previously are believed to be important in horses, but clear evidence of an infectious agent has not yet been identified in horses or foals with egus. , recently, the possibility of helicobacter infection in horses has reemerged with the identification of polymerase chain reaction products from urel, a protongated urea channel unique to gastric-dwelling helicobacter species, in the squamous epithelium of three horses, two of which had squamous erosions. the specific factors involved in injury and the protective mechanisms vary between regions of the proximal gastrointestinal tract. the pathophysiology of squamous mucosal ulceration in the horse appears similar to that in gastroesophageal reflux disease in human beings and ulceration of the nonglandular mucosa in pigs. excess acid exposure is the predominant mechanism responsible for squamous mucosal ulceration, although many details remain unclear. hydrochloric acid is secreted by parietal cells in the gastric glands via a hydrogen-potassium adenosine triphosphatase (h + ,k + -atpase) pump on the luminal side. horses secrete acid continuously, and measured ph of equine gastric contents varies from less than to greater than depending on the dietary state of the horse (fed or fasted). , a protocol of repeated -hour periods of fasting and feeding has been shown to induce squamous erosion and ulceration. because this protocol results in periods of prolonged gastric acidity (ph < . ) and because concurrent administration of the histamine (h ) receptor antagonist ranitidine reduces lesion severity, the protocol supports the role of acid exposure in the pathogenesis of squamous ulcer disease. several peptides can stimulate or inhibit parietal cell secretion of acid. the predominant stimuli for hydrochloric acid secretion are gastrin, histamine, and acetylcholine via the vagus nerve. g cells release gastrin within the antral mucosa, whereas mast cells and enterochromaffin-like cells release histamine in the gastric gland. histamine binds to type receptors on the parietal cell membrane, causing an increase in cyclic adenosine monophosphate and resulting in phosphorylation of enzymes that activate the proton pump. gastrin and acetylcholine can act via calcium-mediated intracellular pathways and also stimulate histamine release directly. isolated equine parietal cells respond maximally to histamine stimulation and only minimally to carbachol and pentagastrin. gastrin release is controlled primarily by gastrin-releasing peptide, which is stimulated by gastric distention and increased luminal ph, but the interaction between gastrin and histamine has not been elucidated fully in the horse. somatostatin, released by fundic and antral d cells, is the primary inhibitor of gastric acid secretion by parietal cells. the inhibitory effect of somatostatin is primarily paracrine, but plasma levels of somatostatin negatively correlate with gastric luminal acidity. epidermal growth factor, a peptide produced in saliva, also inhibits gastric acid secretion. foals can produce significant amounts of gastric acid by the second day of life, with consistent periods of acidity (ph < . ) in clinically normal animals. , in one study, foals tended to have a high gastric ph at day of age, but in a study of critically ill foals, some foals demonstrated periods of gastric acidity on the first day of life. suckling was associated with an immediate rise in gastric ph, whereas periods of rest in which foals did not suck for more than minutes were associated with prolonged periods of acidity. whereas premature human infants are capable of gastric acid production at weeks of gestation, only of premature foals demonstrated an acidic ph recording in a study of gastric ph profiles in critically ill foals. however, multiple factors likely were involved in critically ill foals of this study, and the true ontogeny of gastric acid production in foals is currently unknown. equine squamous mucosa is thin at birth but becomes hyperplastic and parakeratotic within days. the parallel between decreasing ph and proliferation of squamous epithelium correlates with that observed in other species. the combination of a thin gastric epithelium with a high acid output may leave neonatal foals susceptible to ulcer formation at a young age. in addition, one must remember the difference in normal appearance of the squamous mucosa when interpreting gastric endoscopy in a neonatal population. in esophageal squamous mucosa, intercellular tight junctions and bicarbonate secretion are the major factors involved in protection against acid injury in other species, although squamous bicarbonate secretion had not been documented in the horse. [ ] [ ] [ ] the principal barrier is a glycoconjugate substance secreted by cells in the stratum spinosum, with a contribution from the tight junctions in the stratum corneum. this barrier function is considered weak at best, and thus a functioning lower esophageal sphincter, normal salivary flow, and salivary mucins contribute to the prevention of acid injury in human gastroesophageal reflux disease. in horses a mechanical barrier like the lower esophageal sphincter is not available to protect the gastric squamous mucosa from acid exposure. the normal gastric fill line rests just below the cardia, so only the squamous mucosa along the lesser curvature adjacent to the margo plicatus should receive exposure to acidic gastric contents regularly. not surprisingly, this correlates with the most common location of squamous mucosal ulceration. bile salts and pepsin have been implicated as contributing factors to ulcer disease in many species. in rabbit esophageal mucosa, bile salt absorption occurs and is correlated directly with mucosal barrier disruption. the unconjugated bile salts cholate and deoxycholate have a pk a (negative logarithm of the ionization constant of an acid) of and . , respectively, and therefore cannot remain in solution and cause mucosal damage in the presence of acid. alternatively, the conjugated bile salt taurocholate (pk a . ) can cause mucosal injury in the ionized salt form at ph or the un-ionized acid form at ph to . in the pig, bile salts or acid alone cause squamous mucosal damage, whereas a combination of the two result in extensive damage in vitro. in the horse a similar synergistically damaging effect was found with the addition of bile salts and acid (ph . ) to stratified squamous mucosa in vitro in one study. in addition, the investigators were able to document levels of bile salts and acid sufficient to cause mucosal damage in gastric contents within hours of feed deprivation. this is not surprising, given that duodenogastric reflux occurs normally in the horse. in a separate in vitro study of equine squamous mucosa, prolonged exposure to acid alone (ph . ) had a damaging effect, and synergism with exposure to a combination of acid and pepsin or taurocholate was not found. the lack of synergism likely is caused by the lower ph used in this study and stresses the importance of acid exposure in squamous ulcer disease. pepsinogens are secreted primarily by chief cells, although secretion by neck cells, cardiac glands, and antral pyloric glands also occurs. in an acidic environment (ph < . ), pepsinogen is converted to the active pepsin. although the proteolytic activity of pepsin normally is directed toward dietary protein, it also can act on the gastric mucosa. thus acid remains the major contributing factor to squamous mucosal damage, although other factors such as pepsin and bile salts may play an important role as well in the initiation or perpetuation of disease. several mechanisms help protect the glandular mucosa from acid injury. the mucus-bicarbonate layer serves to titrate h + ion from the gastric lumen to co and h o. cellular restitution and prostaglandins of the e series, which enhance mucosal blood flow and secretion of mucus and bicarbonate in the glandular mucosa have not been documented in squamous epithelium. , of these mechanisms, mucosal blood flow is likely the most important contributor to overall gastric mucosal health. nitric oxide is a key regulator of mucosal blood flow and prostaglandin synthesis and thus may play a role in mucosal protection. dietary factors also have been implicated in ulcer disease. horses in race training have a high incidence of gastric ulceration and frequently are fed high-concentrate, low-roughage diets. in one study, higher volatile fatty acid (acetic, propionic, and isovaleric acid) concentrations, higher gastric juice ph, and lower number and severity of nonglandular ulceration were documented after feeding an alfalfa hay-grain diet compared with a bromegrass hay diet. however, many factors differed between the diets, such as digestible energy, bulk, crude protein, and mineral content (especially calcium). thus dietary factors represent an important area of further investigation in the pathophysiology of egus, particularly squamous ulceration. the pathophysiologic correlation between exercise and squamous ulcer disease has not yet been defined despite the high prevalence of ulceration in performance horses. preliminary work suggests that gastric compression occurs during treadmill exercise, presumably because of an increase in intraabdominal pressure. such contracture could result in increased acid exposure to the squamous mucosa by raising the fill line of gastric contents. further studies in this laboratory have provided support for this theory by demonstrating a high ph in the proximal stomach, immediately distal to the lower esophageal sphincter, during resting conditions that decreases during treadmill exercise (m. lorenzo-figueras and a.m. merritt, personal communication, ) . risk factors associated with gastric ulceration include gender and age, and the reported prevalence of gastric ulcers has increased over time. in one study, ulcers were found more commonly in stallions, and the prevalence of gastric ulceration decreased with age, independent of gender, although this trend was only significant in the population of standardbred trotters. interestingly, the frequency of gastric ulceration increased from less than % before to approximately % after . in a study of thoroughbred horses in race training, an increase in squamous ulcer severity was noted in horses years old or older and in those horses that had raced. in the same study, severity of glandular lesions did not change between examinations, and age (> years) was the only factor associated with glandular lesion severity. several studies have failed to document a correlation between nonsteroidal antiinflammatory drug (nsaid) administration and naturally occurring ulcer disease. , , , , however, nsaid administration is a well-known cause of gastric ulceration under experimental conditions. [ ] [ ] [ ] [ ] [ ] nsaid-related ulceration typically is described as predominantly glandular, although nonglandular ulceration also can occur by a mechanism that has not yet been characterized fully. nsaids cause a decrease in prostaglandin e synthesis because of inhibition of the cyclooxygenase pathway. therefore a resultant decrease in glandular mucosal protection, most notably via decreased mucosal blood flow and mucus production, is the most likely mechanism of action. in one study, however, phenylbutazone administration resulted in ulceration of the glandular mucosa at the pyloric antrum but did not alter mucosal prostaglandin e concentration significantly. clinical signs typically associated with gastric ulceration in foals include poor appetite, diarrhea, and colic. many foals probably never exhibit clinical signs, and some do not exhibit clinical signs until ulceration is severe or fatal perforation has occurred. glandular ulceration typically is considered the most clinically significant type of disease in this population. the physiologic stress of a concurrent illness has been associated with gastric ulceration in foals. retrospectively, ( %) of foals up to days of age with a clinical disorder were found to have lesions in the gastric glandular mucosa, and prospectively ( %) of foals up to days of age with a clinical disorder had glandular ulceration. by contrast, only % to % of clinically normal foals examined in endoscopic surveys had lesions observed in the gastric glandular mucosa. , critically ill neonatal foals can have a greatly different ph profile compared with that in clinically normal foals, potentially because of alterations in gastric motility and acid secretion. gastric ulceration was not identified in any animals at necropsy in that study; however, ulceration has been documented in a similar population. thus factors other than acid exposure, most notably mucosal blood flow, may play an important role in the stressrelated ulceration in neonates. subjectively, gastric ulceration and rupture in the hospitalized neonatal population occurs less commonly now than in previous reports. advances in overall neonatal care, especially supportive care, likely have contributed to this decline. in suckling foals less than days old, lesions typically originate in the squamous mucosa adjacent to the margo plicatus along the greater curvature. such lesions can occur in foals as young as days of age and have been observed in % of foals less than days old. histologic examination of these lesions has revealed disruption of the epithelial layers of the mucosa and a neutrophilic infiltration. another phenomenon that occurs in young foals is the shedding, or desquamation, of squamous epithelium, which appears as flakes or sheets of epithelium. desquamation occurs without ulceration in up to % of foals less than days of age, and this process typically is not associated with clinical signs. , , in older foals, lesions become more prevalent in the squamous mucosa, particularly along the lesser curvature. lesions also are found in the squamous mucosa of the fundus and adjacent to the margo plicatus. these lesions can be severe and often are associated with clinical signs such as diarrhea, poor appetite, and poor growth and body condition. diarrhea is the most frequent sign in symptomatic foals with squamous mucosal lesions and is associated with more diffuse erosion or ulceration of the squamous mucosa than that which occurs in asymptomatic foals. in some foals, poor growth, rough hair coat, a potbelly appearance, or all of those occur along with moderate to severe squamous mucosal ulceration. in horses with severe or diffuse squamous ulceration, bruxism or colic may occur. gastroduodenal ulcer disease occurs almost exclusively in suckling and early weanling foals. clinical signs of duodenal ulceration are similar to those described for gastric ulceration (bruxism, colic, salivation, diarrhea), but the consequences are often more severe. lesions occur primarily in the proximal duodenum and range from diffuse inflammation to severe ulceration. foals with duodenal ulceration often have delayed gastric emptying and may have gastroesophageal reflux. complications can include gastric or duodenal rupture, duodenal stricture, and ascending cholangitis. severe squamous and esophageal ulceration and aspiration pneumonia can occur following gastroesophageal reflux. , [ ] [ ] [ ] [ ] the gastroduodenal ulcer disease syndrome can occur in outbreaks and most commonly is identified in intensive breeding operations. the cause of duodenal lesions in foals is not known. one theory is that the problem begins with diffuse duodenal inflammation that can coalesce down to a focal area of ulceration (g.d. lester and a.m. merritt, personal communication, ) . a temporal relationship between gastroduodenal ulcer disease and rotaviral diarrhea has been suggested, but an infectious cause remains unproven. although lesion location and severity associated with rotaviral infection varies among species, duodenal ulceration has not been reported. clinical signs attributable to egus in older horses vary and classically include anorexia and chronic or intermittent colic of varying severity. many horses with endoscopic evidence of disease may appear to be clinically normal or have vague signs that include decreased consumption of concentrates, postprandial episodes of colic, poor performance or failure to train up to expectations, poorquality hair coat, and decreased condition or failure to thrive. diarrhea typically is not associated with gastric ulceration in adult horses, although ulceration can occur concurrently with other causes of diarrhea. horses actively racing are more likely to have squamous ulceration than those solely in training. lesions occur predominantly in the squamous mucosa, particularly adjacent to the margo plicatus ( figure . - ) . in more severe cases, lesions can extend dorsally into the squamous fundus. clinically relevant lesions typically affect a greater portion of the squamous mucosa and can be deep enough to cause bleeding. however, bleeding from ulcers in the gastric squamous mucosa typically is not associated with anemia or hypoproteinemia. according to a recent study, the incidence of glandular lesions, particularly within the pyloric region, may be higher than previously reported, which emphasizes the importance of a thorough endoscopic examination and proper documentation of lesion location when reporting or discussing egus, especially the differentiation between squamous and glandular disease. although one may suspect a diagnosis of egus based on clinical signs and response to treatment, the only current method of confirmation is via gastroendoscopy, which one can perform easily in the standing horse or foal with mild sedation. in adult horses a -m endoscope allows for visual inspection of the entire stomach, pylorus, and proximal duodenum. shorter scopes permit examination of the gastric body and fundus, but not the pyloric antrum in most cases. one should use an endoscope with a maximum external diameter of mm for neonatal foals. numerous scoring systems for lesion severity have been described, but a recent consensus has been published by the equine gastric ulcer council (table . - ). duodenal ulceration can be difficult to confirm. duodenoscopy is the most specific means of diagnosis, although the procedure is more difficult than gastroscopy. additionally, an endoscope at least cm in length is needed for foals up to to months old, and a longer endoscope usually is required for older animals. diffuse reddening or inflammation may be the only recognizable lesion in cases of early duodenal disease. excessive enterogastric reflux of bile through the pylorus suggests duodenal dysfunction. however, the pylorus frequently appears open, and some degree of enterogastric reflux is common under normal conditions. ulceration at the pylorus or pyloric antrum also suggests the presence of a duodenal lesion. if one can perform gastroendoscopy, but not duodenoscopy, the severity of lesions, particularly in the glandular mucosa and in the squamous mucosa of the lesser curvature dorsal to the pyloric antrum, usually will be severe when duodenal ulcers are present. multiple pharmacologic treatments have been suggested for treating egus. because acid has been implicated as the most important pathophysiologic component of squamous ulcer disease, most antiulcer therapy centers on suppression or neutralization of gastric acid. severity and location of gastric lesions and severity and duration of clinical signs, as well as medication cost, can play a role in the therapeutic management of egus (table . - ). if gastroendoscopy is unavailable, some guidelines to therapy can be used, but the efficacy of the treatment is based on clinical signs, which are often vague or nonspecific. signs of colic or diarrhea that result from gastric ulcers often resolve within hours. one can note improvements in appetite, bodily condition, and attitude within to weeks. if one does not observe improvement in clinical signs, treatment has not been effective or gastric ulceration was not the primary problem. the principal therapeutic options for ulcer treatment include h antagonists (cimetidine, ranitidine, famotidine, nizatidine), proton pump blockers (omeprazole, pantoprazole, rabeprazole, esomeprazole), the mucosal adherent sucralfate, and antacids. the h antagonists suppress hydrochloric acid secretion through competitive inhibition of the parietal cell histamine receptor that can be overcome partially with exogenous pentagastrin. use of h antagonists has been successful in raising gastric ph and resolving gastric lesions in foals and adult horses. , , clinical and experimental evidence has demonstrated greater individual variability with lower dosages of h antagonists. thus dosage recommendations are based on levels necessary to increase gastric ph and promote ulcer healing in a majority of horses. commonly recommended dosages are to mg/kg orally every hours or . mg/kg intravenously every hours for cimetidine and . mg/kg orally every hours or . to mg/kg intravenously every hours for ranitidine. famotidine has been used less extensively in the horse, but a dose of to mg/kg/day has been recommended. because gastric perforation caused by glandular ulcer disease has been reported in hospitalized neonates, many clinicians routinely use prophylactic antiulcer therapy in this population. although clinically normal foals respond predictably to ranitidine, sick neonates have shown variability in ph response to intravenously administered ranitidine, with a much shorter duration of action and in some cases no noticeable response. thus currently used dosing schedules for hospitalized foals may be inadequate. because some critically ill foals have a predominantly alkaline gastric ph profile and because gastric acidity may be protective against bacterial translocation in neonates, the need for prophylactic ulcer therapy is controversial. in critically ill human neonates, intravenous administration of ranitidine raises gastric ph and gastric bacterial colonization but does not increase the risk of sepsis. in a retrospective study of hospitalized foals less than days of age, no difference in the frequency of gastric ulceration at necropsy was found between those foals that received prophylactic treatment for gastric ulcers and those that did not. because the study was retrospective, specific details regarding lesion location and severity were not available; however, none of the foals in the study died because of gastric ulcer disease. h antagonist therapy should continue for to days, but complete ulcer healing may take to days. if an animal is kept in race training during therapy, clinical signs may resolve but the lesions may not. currently, cimetidine and ranitidine are available in injectable, tablet, and liquid forms. famotidine and nizatidine are available in tablets. proton pump inhibitors block secretion of h + at the parietal cell membrane by irreversibly binding to the h + ,k + -atpase proton pump of the cell. these agents have a prolonged antisecretory effect, which allows for once-daily dosing. omeprazole, the first proton pump inhibitor to be developed, is the only currently approved agent for the treatment of egus. several studies have documented the safety of orally administered omeprazole in foals and adult horses. , omeprazole has demonstrated efficacy in the healing of nsaid-induced ulcers in horses and in naturally occurring cases of egus. , more importantly, omeprazole has been shown to eliminate or reduce the severity of gastric ulcers in thoroughbreds maintained in race training. the available equine preparation of omeprazole (gastrogard, merial, ltd., duluth, georgia) is recommended at a dose of mg/kg orally every hours. initial reports suggested that to days of omeprazole therapy were necessary to achieve maximum acid suppression; however, an increase in gastric ph and a decrease in acid output are evident to hours after omeprazole paste administration. after initial treatment ( days), treatment with or mg/kg every hours has been shown to decrease or prevent the recurrence of disease in animals maintained in training. the powder form of omeprazole degrades rapidly in an acidic environment, thus one must use an enteric-coated capsule (as used in the human preparation) or a specially formulated paste (such as gastrogard) to allow delivery of the active drug to the small intestine for absorption. many compounding pharmacies prepare omeprazole in liquid or paste formulation for use in horses, but their efficacy has not been evaluated to date. other proton pump inhibitors have been developed recently for use in human beings, including rabeprazole, lansoprazole, esomeprazole, and pantoprazole. in gastroesophageal reflux disease treatment in human beings, esomeprazole has demonstrated a higher rate of healing at and weeks compared with omeprazole, but rabeprazole, lansoprazole, and pantoprazole have similar efficacy. an intravenous formulation of pantoprazole recently became available commercially and may prove beneficial for patients in need of antiulcer therapy that cannot be treated orally. research regarding the pharmacokinetics and efficacy of other proton pump inhibitors in horses is not currently available. sucralfate is effective in treating peptic ulcers and preventing stress-induced ulcers in human beings. the mechanism of action likely involves adherence to ulcerated mucosa, stimulation of mucus secretion, enhanced prostaglandin e synthesis, and increased concentration of growth factor at the site of ulceration, although the prostaglandin effects may not play an important role in ulcer healing. these are factors relevant to glandular mucosa, and the efficacy of sucralfate in treating ulcers in the equine gastric squamous mucosa remains undetermined. sucralfate may be effective in preventing stress-induced ulcers in neonatal foals, because these occur in the glandular mucosa, although no clinical evidence directly supports this concept. in human beings, sucralfate provides protection against stress-induced ulcers with a decreased risk of pathogenic gastric colonization. one should give sucralfate at a dosage of to mg/kg every to hours. the efficacy of sucralfate in an alkaline ph is controversial but appears likely. [ ] [ ] [ ] moreover, at the time of administration of an section . diseases of the stomach h antagonist, the gastric ph likely will have returned to an acidic ph since the last dosage and will remain so for to minutes depending on the route of administration; thus one likely can administer the agents simultaneously if so desired. the use of antacids to treat gastric ulcers has not been examined critically in the horse. research in horses has shown that g aluminum hydroxide per g magnesium hydroxide results in an increase in gastric ph above for approximately hours. thus although antacids may be useful for treating ulcers in horses, a dose of approximately to ml at least every hours is necessary for a standard adult horse. the use of synthetic prostaglandin e analogs, such as misoprostol, has been effective in treating gastric and duodenal ulcers in human beings, and the proposed mechanism of action involves inhibition of gastric acid secretion and mucosal cytoprotection. frequently reported adverse effects of intestinal cramping and diarrhea in human beings have precluded the use of misoprostol in horses. one should consider prokinetic drugs in foals with duodenal disease and gastroesophageal reflux and when one suspects delayed gastric emptying without a physical obstruction. the cholinergic drug bethanechol has been shown to increase the rate of gastric emptying in horses. in cases of acute gastric atony, bethanechol . to . mg/kg administered subcutaneously every to hours has been effective in promoting gastric motility and emptying, followed by oral maintenance dosages of . to . mg/kg to times daily. adverse effects can include diarrhea, inappetance, salivation, and colic, but at the dosages stated, adverse effects have been infrequent and mild. a complete review of ileus and prokinetic therapy is available in chapter . . for foals with severe gastroduodenal ulcer disease that have developed duodenal stricture, surgical therapy is necessary. , these animals require a serious financial commitment because intensive perioperative medical therapy is critical for a successful outcome. even with surgical therapy, these foals often warrant a guarded prognosis. pyloric stenosis is a structural resistance to gastric outflow. congenital pyloric stenosis has been reported in foals and one yearling and results from hypertrophy of the pyloric musculature. [ ] [ ] [ ] acquired pyloric stenosis can result from neoplasia or duodenal ulceration. [ ] [ ] [ ] [ ] clinical signs depend on the degree of obstruction and include abdominal pain, salivation, and teeth grinding. complete or near complete obstruction can result in gastric reflux and reflux esophagitis. in foals with congenital pyloric hypertrophy, clinical signs may begin with the consumption of solid feed. in foals one can make a presumptive diagnosis via gastric endoscopy and radiography (plain and contrast studies). depending on the cause and severity of disease, gastric endoscopy may provide a presumptive diagnosis in the adult horse. measurement of gastric emptying can aid the diagnosis. several methods of measurement are currently available, including nuclear scintigraphy, acetaminophen absorption, and postconsumption [ c] octanoic acid blood or breath testing. , , exploratory laparotomy shows a distended stomach and thickened pylorus accompanied by a relatively empty intestinal tract. if complete obstruction is not present, medical therapy with a prokinetic such as bethanechol can increase the rate of gastric emptying. phenylbutazone and cisapride also have been shown to attenuate the delay in gastric emptying caused by endotoxin administration. , surgical repair is necessary for definitive treatment of complete or near-complete obstruction and consists of gastroenterostomy or pyloroplasty. , gastric dilation can be classified as primary, secondary, or idiopathic. causes of primary gastric dilation include gastric impaction, grain engorgement, excessive water intake after exercise, aerophagia, and parasitism. , secondary gastric dilation occurs more commonly and can result from primary intestinal ileus or small or large intestinal obstruction. time to development of gastric reflux is proportional to the distance to the intestinal segment involved, with duodenal obstruction resulting in reflux within hours. clinical signs of gastric dilation include those associated with acute colic and in severe cases, ingesta appearing at the nares. associated laboratory abnormalities include hemoconcentration, hypokalemia, and hypochloremia. the most common reported cause of gastric rupture in horses varies between reports. in a retrospective study of horses, gastric rupture occurred most commonly as a secondary phenomenon ( %), usually because of small intestinal obstruction, with primary gastric dilation and idiopathic rupture occurring almost equally ( % and %, respectively). in another retrospective study of horses in combination with a search of the veterinary medical database (vmdb), % of the gastric rupture cases were classified as idiopathic. risk factors for gastric rupture include feeding grass hay, not feeding grain, gelding, and a nonautomatic water source. , nasogastric intubation does not preclude the possibility of gastric rupture, and the amount of reflux obtained before rupture varies greatly. because these reports were retrospective, one cannot rule out confounding factors with certainty. regardless of the initiating cause, gastric rupture usually occurs along the greater curvature. in horses with rupture caused by gastric dilation, tears in the seromuscular layer are frequently larger than the corresponding tears in the mucosal layer, indicating that the seromuscularis likely weakens and tears before the mucosa. , in contrast, horses with gastric rupture following gastric ulceration usually demonstrate full-thickness tears of equal size in all layers. gastric rupture is usually fatal because of widespread contamination of the peritoneal cavity, septic peritonitis, and septic shock. initial clinical signs vary with the primary disease; however, when rupture occurs, a previously painful animal can exhibit signs of relief. subsequent signs are consistent with peritonitis and shock, including tachypnea, tachycardia, sweating, and muscle fasciculations. surgical repair is thus limited but has been reported for partial-thickness tears, and in one case of a combined tear of the mucosa and muscularis with only a focal serosal tear, a full-thickness repair was performed with a favorable outcome. gastric impaction can result in acute or chronic signs of colic in the horse. although a specific cause is not always evident, ingestion of coarse roughage (straw bedding, poor-quality forage), foreign objects (rubber fencing material), and feed that may swell after ingestion or improper mastication (persimmon seeds, mesquite beans, wheat, barley, sugar beet pulp) have been implicated. possible predisposing factors include poor dentition, poor mastication and rapid consumption of feedstuffs, and inadequate water consumption. clinical signs can vary from anorexia and weight loss to those consistent with severe abdominal pain. in severe cases, spontaneous reflux may occur, with gastric contents visible at the nares. in cases of acute severe abdominal pain, one often makes a diagnosis during exploratory celiotomy. in animals not exhibiting signs of colic warranting surgical intervention, an endoscopic finding of a full stomach after a normally adequate fast ( to hours) often can confirm the diagnosis. abdominal radiographs are reserved for smaller horses and ponies. in addition to pain management, specific treatment consists of gastric lavage via nasogastric intubation or massage and injection of fluid to soften the impaction during laparotomy. [ ] [ ] [ ] nonulcerative gastritis rarely occurs in the horse; however, a single case of emphysematous gastritis caused by clostridium perfringens has been reported. mimic that of a strangulating or nonstrangulating small intestinal obstruction, so distinguishing between the two syndromes is important because appropriate treatment of small intestinal obstruction usually requires surgical intervention. studies suggest that the survival rate for horses with dpj that endured surgical exploratory laparotomy was poor compared with those treated medically, although differences in disease severity may have accounted for the results in these early reports. , the clinical syndrome of dpj was well described in the s, and although recognized by its classical presentation, varying degrees of focal intestinal and systemic illness may occur. - dpj usually occurs alone but can occur along with gastritis, ileitis, typhlitis, and or colitis. typical pathologic findings in horses with dpj include involvement of the duodenum and usually the proximal jejunum. the ileum and large colon usually are determined to be grossly normal. gastric distention is a common finding and is thought to be caused by hypersecretory mechanisms in the proximal small intestine and a functional ileus of affected enteric segments. the small intestine may be to cm in diameter because of fluid distention with malodorous, red to brown-red intralumenal fluid accumulation. duodenal (and jejunal) serosal surfaces may have varying degrees and distribution of bright-red to dark-red petechial and ecchymotic hemorrhages and yellow to white streaks. the enteric mucosal surfaces are usually hyperemic and have varying degrees of petechiation and ulceration. microscopically, the most severe lesions have been located in the duodenum and proximal jejunum but may extend proximally to the gastric mucosa and aborally to the large intestinal mucosa and submucosa. microscopic lesions consist of varying degrees of mucosal and submucosal hyperemia and edema. more severe lesions include villus degeneration with necrosis and more severely, sloughing of villous epithelium. the lamina propria, mucosa, and submucosa may have varying degrees of granulocyte infiltration (predominantly neutrophils), and the muscular layers and serosal surfaces contain small hemorrhages. proximal small intestinal serosal fibrinopurulent exudate is a common finding in the more severe cases; therefore the term hemorrhagic fibrinonecrotic duodenitis-proximal jejunitis has been suggested as a more descriptive name for this syndrome. horses with dpj often have evidence of multiple organ involvement such as hepatic changes including congestion and varying degrees of biliary duct hyperplasia. additional systemic involvement likely is caused by endotoxin absorption, metabolic imbalances such as acidemia, and circulatory changes. the cause of this syndrome remains an enigma (much like the cause of other inflammatory conditions affecting the intestinal tract). several microorganisms have been implicated as playing a role in triggering dpj, including clostridium spp., salmonella spp., and some mycotoxins, but efforts to reproduce the syndrome experimentally have been futile. a recent dietary change with an abrupt increase in dietary concentrate level has been suggested to predispose a horse to developing dpj because of intraluminal microbial imbalances. two intracellular processes control intestinal secretion, the cyclic nucleotide (cyclic adenosine monophosphate and cyclic guanosine monophosphate) and the calcium systems. agents (inflammatory mediators, microorganisms, toxic agents) can activate adenyl cyclase (vasoactive intestinal peptide, prostaglandin e ) or guanyl cyclase (bacterial enterotoxins) and induce increases in cyclic adenosine monophosphate and cyclic guanosine monophosphate, respectively. this reaction causes phosphorylation of specific protein kinases, which induce the actual mucosal membrane transport events. increases in intracellular free calcium may arise from cyclic nucleotidedependent release of stored calcium within the cell or from increased calcium entry across the cell membrane. calcium may act through calmodulin, which then can activate membrane-phosphorylating protein kinases. the net effect is increased movement of sodium and chloride into the mucosal cell from the interstitium, with secretion of sodium and chloride into the intestinal lumen. water follows the directional flux of sodium and chloride through highly permeable intercellular spaces. several bacterial toxins and endogenous mediators can cause active secretion and contribute to a synergistic mucosal secretory response. passive secretion of protein-rich fluid into the lumen occurs following damage to the mucosal epithelium, capillary endothelium, and submucosal inflammation in the proximal small intestine. the clinically relevant events that result from active and passive fluid secretion are proximal small intestinal distention and nasogastric reflux, dehydration, and circulatory shock. the concentration of protein in the peritoneal fluid from horses with dpj is usually higher than in horses with small intestinal obstruction. a disproportionate increase in total protein concentration relative to nucleated cell count occurs probably by leakage of blood or plasma into the peritoneal cavity without a significant stimulus for leukocyte chemotaxis. suggested mechanisms for increased abdominal fluid protein concentration include serositis associated with inflamed intestine and small intestinal distention causing passive congestion and increased capillary hydrostatic pressure of visceral peritoneal vessels. small intestinal ileus is another hallmark sign of dpj and the pathophysiology is complicated, involving primary and secondary dysfunction of the central, autonomic, and enteric nervous systems and their purported roles in governing intestinal motility. primary role-players in dpj-associated ileus include peritoneal inflammation, inflammatory cell migration/activation within the muscularis, small intestinal mechanical distention, and effects of endotoxin absorption. the use of prokinetic agents for treating ileus and gastric/small intestinal distention in horses with dpj is becoming more common, but veterinarians should realize that a potential restriction on their use is the need for normal intestinal integrity. in spite of that, one may use motility modifiers judiciously. the veterinarian has the challenge of differentiating horses with dpj from horses with small intestinal obstructive lesions so as to avoid surgical intervention (table . - ). horses with dpj typically show signs of acute abdominal pain initially, and then after gastric decompression, volume replacement, and analgesic therapy, the colic signs subside, but signs of lethargy and malaise become more apparent. in contrast, horses with obstructive lesions of the small intestine usually show signs of abdominal pain until the affected viscus is repaired via surgical intervention or the viscus ruptures. another differentiating characteristic is the large volume (> to l with each decompressive effort) of nasogastric reflux that is often malodorous and orange-brown or red-brown. dpj-affected horses have moderate to severe small intestinal distention palpated on rectal examination, temperature of . °to . °c ( . °to . °f), dehydration, brick-red mucous membranes, lethargy and absent borborygmi, prolonged capillary refill time, tachycardia (> beats/min), and tachypnea. although the signs of abdominal pain usually resolve after gastric decompression, most horses remain severely lethargic. without periodic removal of the fluid that accumulates in the proximal intestinal tract, signs of abdominal pain usually recur. horses with dpj often require gastric decompression at -hour intervals, with to l of fluid recovered each time. nasogastric tubes left in place for long periods of time cause varying degrees of pharyngitis, laryngitis, and esophagitis. typical clinical laboratory findings include an increased packed cell volume and total plasma protein reflective of volume depletion, a metabolic acidosis (with elevated anion gap) in longstanding or severe cases, an increased peritoneal fluid protein concentration (often > . g/dl), and a mild to moderate elevation of the peritoneal white blood cell count, although the count usually is less than , cells per microliter. , the peritoneal fluid is usually yellow and turbid, but in severe cases diapedesis occurs resulting in a serosanguinous color. the white blood cell count in the peripheral blood may be normal, decreased, or increased. in addition, hyponatremia, hypochloremia, hypokalemia, and acid-base alterations (elevated anion gap) are often evident. the loss of enteric bicarbonate through evacuation of enterogastric reflux and poor tissue perfusion from hypovolemia can lead to metabolic acidosis. one makes a definitive diagnosis of dpj in most cases by gross examination of the duodenum and proximal jejunum at surgery or at necropsy. some equine practitioners have observed an apparent geographic relationship in the incidence and severity of the syndrome, with more cases occurring in the southeastern united states. horses with dpj appear to share a common characteristic clinical presentation, and the mechanisms leading to electrolyte imbalances, fluid loss, ileus, and endotoxemia and septicemia are similar. treatment regimens are supportive and aim at plasma volume replacement (usually in the form of crystalloid fluid replacement), analgesia and antiinflammatory therapy, gastric decompression, antiendotoxin therapy, antimicrobial therapy if indicated, nutritional support, and nursing care. one should institute aggressive intravenous polyionic fluid therapy immediately in a horse with dpj. one should calculate the total fluid deficit based on clinical assessment of dehydration (e.g., for % or moderate dehydration, . × kg body mass = l) and should administer replacement fluids rapidly (up to to l per hour per -kg adult horse). administering intravenous hypertonic saline ( %) may be useful to treat hypovolemic shock in horses with severe circulatory shock. the use of to l of hypertonic saline ( % nacl) improved systemic blood pressure and cardiac output in horses with hemorrhagic shock and in a model of equine endotoxemia. if one chooses this treatment option, intravenous administration of replacement isotonic fluids must follow immediately to maintain tissue integrity. one should not allow horses with significant volumes of gastric reflux to ingest foodstuffs or liquids orally. once one has administered replacement fluids and the horse is well hydrated, one should administer maintenance fluid amounts, which may be as high as ml/kg/day. unfortunately, the intravenous fluid therapy itself may accelerate the flux of fluid from the vasculature into the intestinal lumen because of a reduction in intravascular oncotic pressure and an increased capillary perfusion pressure, which can result in an increased volume of gastrointestinal reflux. however, the veterinarian should not consider reducing the volume of intravenous fluid therapy because excessive fluid losses continue to occur. one should monitor plasma protein concentration, overall hydration, and the volume of reflux and then determine the rate of intravenous fluid administration. during the initial hours of therapy, even aggressive intravenous fluid administration results in only moderate clinical improvement. the clinical response, as evidenced by improved hydration status, decreased nasogastric reflux, improved attitude, and improvement in values reflecting kidney function (decreased blood urea nitrogen and creatinine), correlates with improvement of intestinal damage. horses with dpj that continue to reflux large volumes of enterogastric fluid frequently for more than to hours most likely will experience protein loss from the inflamed and disrupted intestinal mucosal barrier and from systemic protein catabolism. decreased colloid oncotic pressure leads to decreased effective circulating fluid volume and edema. total plasma protein may decline to below g/dl and the albumin may decrease to below . g/dl. fresh or thawed frozen plasma is ideal for replacement of functional proteins. one should consider treatment with intravenous plasma therapy or a combination of plasma and synthetic colloid (e.g., synthetic amylopectin) as soon as one sees evidence of a consistent decline in total plasma protein or albumin (< . g/dl) or if the horse is developing dependent edema. fresh plasma (preferred) or fresh frozen plasma is the treatment of choice if coagulation disorders accompany protein loss. an average-size horse ( kg) requires to l of plasma (albumin . g/dl) or synthetic colloid to improve plasma oncotic pressure. administration of additional aliquots of to l of a balanced colloidal solution may be necessary if the dpj crisis continues. in addition to albumin (the major colloid component), plasma contains other components that provide overall systemic support (e.g., fibronectins, complement inhibitors, elastase and proteinase inhibitors, antithrombin iii). one may administer a % solution of hydroxyethyl starch (hetastarch ( %), abbott laboratories, north chicago, illinois), a synthetic colloid, at to ml/kg. because of the large size of the starch molecules, this solution is an effective plasma volume expander, resulting in sustained dosedependent decreases in packed cell volume and plasma protein concentration with increased oncotic pressure. the cost of an appropriate amount of commercial plasma or synthetic colloid solution for treatment of adult horses with dpj may be prohibitive but can be life-saving. horses with enteritis frequently absorb large amounts of endotoxin from the disrupted intestinal mucosal barrier, therefore putting these horses at a high risk for laminitis. one should monitor digital pulses every to hours until systemic signs of enteritis have abated (fever, leukopenia, etc.). treatment to combat endotoxemia is critical, and several therapeutic approaches are available. choice of treatment options is based on severity of disease, renal function, hydration status, and economics. the reader is referred to chapter . for a thorough discussion of endotoxemia pathophysiology, treatment, and prevention. nonsteroidal antiinflammatory drugs are the most frequently used group of drugs for treatment of abdominal pain in horses (flunixin meglumine . mg/kg intravenously every hours or phenylbutazone . mg/kg orally or intravenously every hours). the clinician must weigh the benefit of the analgesic effect of nonsteroidal antiinflammatory drugs with the possibility of further damage to the intestine by potentially blocking the protective effects of intestinal mucosal prostaglandins. one should consider other classes of drugs for treating colic associated with dpj. butorphanol (torbugesic; an opioid analgesic) at . to . mg/kg with detomidine (dormosedan; an α-agonist) at . to . mg/kg given intramuscularly every to hours is a useful combination that has minimal effects on gastrointestinal motility. because clostridium spp. are suspected as a causative agent of dpj, penicillin often is administered to affected horses. however, one should consider broad-spectrum antimicrobial coverage for horses with dpj. one can add an aminoglycoside (gentamicin, amikacin) or thirdgeneration cephalosporin (ceftiofur [naxcel], upjohn co., kalamazoo, michigan) to the penicillin therapy, keeping in mind the potential adverse effects of these drugs on renal function. effective antisecretory medications targeting the equine small intestine have not been identified. one should consider the nutritional needs of horses with dpj. most horses have a total body protein loss from cachexia and a protein-losing enteropathy. total parenteral nutrition may be indicated in horses that remain anorectic for more than to days. parenterally administered solutions containing glucose, balanced amino acid solutions, lipid emulsions, balanced electrolyte and trace minerals, and vitamins have been administered to adult horses with small intestinal ileus or enterocolitis. based on a small number of horses, this therapy has proved promising in terms of minimizing protein losses and decreasing the duration of illness. providing for part of the nutritional requirements of the horse ( to , kcal/day) is possible with glucose-amino acid solutions, which are of moderate cost. one may suppose reasonably that providing nutritional support to an anorectic, severely ill horse will facilitate the healing process and even shorten the duration of illness. thus the overall cost of providing parenteral nutritional supplementation to horses with dpj may well be offset by quicker recovery and diminished requirements for other, expensive treatments. normal (healthy) intestine is necessary for optimum performance of prokinetic agents in horses. many motilitymodifying agents likely are ineffective in cases of dpj. however, some benefit may come of the judicious use of prokinetic agents in inflammatory conditions of the equine intestine, particularly if the agent provides additional effects such as analgesia. for example, lidocaine infusion has several actions that may be beneficial in the treatment of ileus, including suppression of primary afferent firing, antiinflammatory properties, an observed analgesic effect, and direct stimulation of smooth muscle. an infusion dose of to mg/min over to hours has been recommended. the reader is referred to chapters . and . for a complete description of motility modifying agents. medical therapy is sufficient in most cases of dpj, but in those cases in which the horse continues to produce copious enterogastric reflux, one may consider surgery as an option. refractory cases have been observed to improve with surgical intervention; however, some horses with refractory dpj have been observed to recover with supportive medical care alone even after days of refluxing large amounts of fluid every to hours (personal observation). the decision of when to intervene surgically often is difficult. one may elect surgery to determine the extent of gross pathologic condition and intestinal distention and to perform intestinal bypass so as to direct enterogastric reflux toward the cecum and colon, where the fluid can be reabsorbed. allen and clark have described two approaches for surgical therapy in such cases. a standing right flank laparotomy with resection of the last rib has been used to approach the duodenum and cecal base. using this approach, one makes a small stoma between the duodenum and cecum using a handsewn . -to . -cm side-to-side anastomosis. the stoma may act as a shunt to decompress the proximal small intestine and deliver the small intestinal fluid to the cecum for reabsorption. following recovery, the stoma likely will close. when a veterinarian is confronted with a horse exhibiting abdominal discomfort, with small intestinal distention palpable per rectum, and greater than l of gastric reflux, the veterinarian should recommend referral of the horse to a facility capable of performing abdominal surgery. the chance that such a horse has an intestinal obstruction is too great to decide to treat it as if it may have dpj. surgery on such horses is not unusual, even though dpj is possible, to rule out an obstruction. at present, the survival of horses with dpj that undergo surgery is much greater than previously described, and certainly greater than that of horses with small intestinal obstruction that do not have surgery. horses with dpj that receive appropriate therapy have a reasonably good chance of making a full recovery. horses that continue to have frequent episodes of voluminous nasogastric reflux and systemic signs of endotoxemia and septicemia have a poorer prognosis for recovery. frequent complications of dpj include laminitis, thrombophlebitis, and weight loss. the clinical signs of chronic wasting and poor body condition, although nonspecific for a diagnosis of malabsorption antemortem, can be attributed to proliferative or inflammatory intestinal disorders, often collectively referred to as chronic inflammatory bowel diseases. clinical signs include alimentary lymphosarcoma, granulomatous enteritis, multisystemic eosinophilic epitheliotropic disease (meed), and lymphocyticplasmacytic enterocolitis-conditions affecting young and adult horses. proliferative enterocolitis, a transmissible disease of foals to months of age characterized by significant small intestinal pathologic changes, will be included in this group. however, several other primarily small intestinal conditions described from a morphologic perspective, such as chronic postinfarctive inflammation and mycobacterial infections, will not be discussed. in addition, a single case of aa amyloid-associated gastroenteropathy in an -year-old morgan stallion that had evidence of severe malabsorption based on poor d-xylose absorption is included. for comparative purposes, table . - lists the clinical and clinicopathologic features of the diseases, and tables . - and . - present the gross morphologic and histopathologic findings, respectively. the extent of small intestinal disease is the key to determine whether one can demonstrate malabsorption based on abnormal carbohydrate absorption. as described in chapter . , this is not an all-or-nothing situation. in the same animal the staging of the pathologic changes differs in different regions of the small and large intestines, thus influencing severity of clinical signs and absorption findings. furthermore, the extent of pathologic changes in different animals with ultimately the same morphologic diagnosis affects absorption studies and progress of the disease. early diagnosis remains a challenge, and even multiple intestinal biopsies taken at exploratory laparotomy may prove unhelpful. by contrast, intestinal infiltration with the predominant cell types can be found in grossly normal appearing intestinal tissue. alimentary lymphosarcoma of the horse may represent a primary neoplasia of the gut associated lymphoid tissue with significant cellular infiltration of the small intestine and associated lymph nodes with minimal large intestinal or systemic involvement. case series and pathology reports indicate that young horses to years of age primarily are affected, although the age range can be broad. [ ] [ ] [ ] no breed or sex predilection exists. prevalence is unknown. despite the progressive nature of lymphomata, onset of clinical signs can be rapid and the animal may become acutely ill. as with all adult cases of chronic inflammatory bowel disease, antemortem diagnosis is by a process of exclusion and usually is confirmed post mortem. frequently, the horse has anemia, thrombocytopenia, neutrophilia or neutropenia, hypoalbuminemia, normal serum protein or hyperproteinemia, and hypergammaglobulinemia. lymphocytosis is rare. one may palpate intraabdominal masses, mainly enlarged mesenteric lymph nodes, rectally. abdominocentesis has been of diagnostic value. carbohydrate absorption tests usually reveal partial to total malabsorption indicative of the severely reduced surface area resulting from significant villous atrophy and the extensive mucosal or transmural infiltration. rectal biopsy has aided diagnosis. early confirmation of a suspected diagnosis necessitates exploratory laparotomy to obtain multiple intestinal and lymph node biopsies. in the future, markers of cancer cells may become available and may be cost-effective to aid diagnosis. prognosis is poor. natural progress of the disease is unknown. most horses are presented in an advanced state of disease. immunosuppressive drugs or chemotherapy may afford temporary improvement. however, outcome is unaffected. the chronic wasting condition granulomatous enteritis was first described in ; of horses were young standardbreds. most affected horses are to years of age. case reports from many countries revealed a predominance of standardbred over thoroughbred horses by three to one. , some of the standardbreds were related, implicating a genetic predisposition. prevalence is low. the condition is sporadic and has an insidious onset, and the course can be protracted. significant diagnostic features include anemia, slight increases or decreases in white blood cell counts, hypoalbuminemia, normal serum protein or hypoproteinemia, occasional increases in serum alkaline phosphatase activity, normal serum γ-glutamyltransferase activity, and enlarged mesenteric lymph nodes on rectal palpation. reduced carbohydrate absorption to the level of partial to total malabsorption is reported frequently, consistent with the severe morphologic changes throughout the small intestine. one can attribute the low proportion of horses exhibiting diarrhea , to the preferential distribution of inflammatory infiltration in the small intestine, with lesser involvement of the large intestine. rectal biopsy can be a useful aid to diagnosis. treatment of horses with granulomatous enteritis with a variety of drugs, particularly corticosteroids, has not affected the outcome except in the short term. one successful response has been reported. prolonged corticosteroid administration produced clinical remission in a -year-old standardbred gelding based on improvement in clinical signs and in d-xylose absorption. five months after cessation of approximately months therapy, d-xylose absorption was normal and the horse was bright, alert, and resumed a level of athletic performance. parenteral administration of dexamethasone sodium phosphate was tapered to achieve a minimal effective dose to reduce intestinal inflammation and abolish clinical signs. adverse effects were not reported. the outcome of this single case is encouraging. surgery may be indicated if the disease is localized. two young horses underwent resection of the thickened terminal small intestine to confirm a diagnosis and provide a means of treatment; one horse died months after surgery, and the other has remained clinically normal for at least years. the cause of granulomatous enteritis is unknown. several infectious agents have been implicated, including mycobacterium avium. the condition may represent a granulomatous hypersensitivity reaction. immunemediated responses to dietary, parasitic, or bacterial antigens may be important initiating factors. recently, six cases purported to represent granulomatous enteritis were linked to environmental contamination with aluminum. although the case definition was flawed and problems existed with the data and interpretation, the report nevertheless raised the possibility that a toxicologic basis may exist for some equine inflammatory bowel disorders. lumen from parasitic, bacterial, or dietary sources. infectious agents have not been identified. , widespread use of the avermectins has tended to reduce parasite loads and composition to favor small strongyles (cyathostomes). eosinophilia is a feature of parasitism in the equine intestinal tract, although nematodes rarely have been identified in any lesions of meed. , however, failure to detect larval structures in these lesions may be attributable to chronicity of the disease and destruction of the parasites in tissue. biopsies of the rectal mucosa or of the skin, liver, intestinal tract, and lymph nodes may assist in diagnosis. treatment has been attempted with a variety of drugs, including antibiotics, corticosteroids, and anthelmintics with larvicidal activity. immediate improvement has not been borne out in the long term. prognosis is poor. the clinical objective is to reach a tentative diagnosis early in the course of the disease for intervention to be more than transient. unlike the other conditions (see table . - ), meed has definitive liver and pancreatic involvement, and thus maldigestion may make a significant contribution to the wasting disease. for example, the lowered albumin and protein could result in part from impaired pancreatic enzyme digestion, and the effects of inflammatory lesions in the liver and ileum may decrease bile salt concentrations. the morphologic findings in lymphocytic-plasmacytic enterocolitis reflect the predominant infiltrative cellular elements of this rarely encountered condition. a retrospective study of horses provided the information presented in the tables. no specific clinical or clinicopathologic features differentiate this condition antemortem from other inflammatory diseases of adult horses. carbohydrate absorption was abnormal or delayed in of horses, consistent with the predominance of small intestinal pathologic changes. rectal biopsies were abnormal in of horses, two of which were reported as having lymphocytic-plasmacytic proctitis. prognosis is poor. treatment has been unsuccessful, probably because of the advanced nature of the condition at the beginning of treatment. proliferative enteropathy has not been associated with abnormal carbohydrate absorption based on three horses subjected to carbohydrate absorption tests. however, the florid mucosal lesions in the jejunum and ileum undoubtedly contribute to impaired digestive function and potential malabsorption of vitamins, minerals, and amino acids in the distal small intestine. the condition meed encompasses disorders characterized by a predominant eosinophilic infiltrate in the gastrointestinal tract, associated lymph nodes, liver, pancreas, skin, and other structures and accompanied by some degree of malabsorption and enteric protein loss. the disorders include chronic eosinophilic gastroenteritis, eosinophilic granulomatosis, chronic eosinophilic dermatitis, and probably basophilic enterocolitis. the condition differs from idiopathic eosinophilic enterocolitis, in which segmental lesions in the small or large intestine induce signs of colic requiring surgical intervention , without evidence of malabsorption or multisystem involvement. although prevalence is low, meed appears to be more common than granulomatous enteritis based on the accumulated published reports and personal experience in australia and the united states. most affected horses are to years of age, and standardbreds and thoroughbred are reported to predominate. the condition is sporadic and has an insidious onset, and the course is protracted with a duration of to months. diarrhea is common in contrast to granulomatous enteritis. severe skin lesions with exudative dermatitis and ulcerative coronitis are prominent and frequently are the principal reason for veterinary attention being sought. despite extensive tissue eosinophilia, systemic eosinophilia is rare. hematologic values are usually unremarkable. notable features include hypoalbuminemia and normal serum protein or hypoproteinemia, and because of liver involvement, serum γ-glutamyltransferase and alkaline phosphatase activities may be increased. most reports of carbohydrate absorption test findings (glucose or d-xylose) indicate retarded absorption and a reduced or normal peak concentration delayed to at least minutes. one can interpret this pattern as the existence of sufficient small intestinal absorptive capacity to enable moderate absorption with possibly delayed gastric emptying or ileocecal ejection. morphologic changes are less pronounced in the small intestine than in the large intestine, and small intestinal lesions predominate segmentally in the proximal duodenum and distal ileum. furthermore, significant hyperkeratosis of the fundic region may contribute to gastric muscle contractile disruption. diarrhea can be a consequence of the severe segmental or multifocal granulomatous lesions in the large intestine with mucosal and transmural thickening and extensive ulceration. abundant fibrosis is a feature of all affected tissues (see table . - ). the cause of meed is unknown and could represent a chronic ongoing immediate hypersensitivity reaction against undefined antigens ingested or excreted into the affects foals to months of age, particularly those that have been weaned recently. the disease is caused by lawsonia intracellulare, an obligate intracellular bacterium found in the cytoplasm of proliferative crypt epithelial cells of the intestine. the condition in a foal was described first as intestinal adenomatosis, because of similarity to the swine disorder of the same name. later, molecular studies showed that intestines from an affected foal contained l. intracellulare sequences as determined by polymerase chain reaction analysis and confirmed by southern blot hybridization. recently, studies of a cluster of affected foals on three breeding farms in canada provided much information on the clinical syndrome, laboratory investigations, and response to treatment. two of the three farms bred arabians, hence a demographic predominance of arabian foals exists. clinical signs included depression, rapid and significant weight loss, edema, diarrhea, and colic. poor body condition, a rough hair coat, and potbelly appearance were common findings. other problems often were concurrent, including respiratory tract infection, dermatitis, intestinal parasitism, and gastric ulceration. significant laboratory findings were anemia, transient leucocytosis, hypoalbuminemia, hypoproteinemia, and elevated serum creatine kinase concentrations. diagnosis was confirmed by identifying characteristic intracellular bacteria within the apical cytoplasm of proliferating crypt epithelial cells using silver stains and by results of polymerase chain reaction analysis and immunohistochemical testing. antemortem diagnosis relied on clinical signs, hypoproteinemia, and exclusion of common enteric infections. one can confirm diagnosis in live animals by fecal polymerase chain reaction analysis (positive in of foals tested) and serologic testing; foals with proliferative enteropathy were evaluated serologically and had antibodies against lawsonia intracellulare. treatment is effective. most foals received erythromycin estolate ( to mg/kg per os every to hours), alone or with rifampin ( to mg/kg per os every hours) for to weeks. foals frequently needed supportive therapy at the outset for stabilization. response to therapy has been excellent. rapid improvement in clinical signs even within hours preceded the rise in plasma protein concentration. the source of the infection was undetermined. no apparent link existed between the three farms and a swine operation or solid and liquid waste disposal on pasture. however, one cannot exclude airborne spread of dried fecal material over distances. comparisons of epidemiologic findings from the swine disease indicated that overcrowding, feed changes, antibiotic usage, and mixing and transportation were potential risk factors at two of the farms. recent weaning appeared to be a key element in the pathogenesis. samuel l. jones acute diarrhea caused by colitis in adult or young horses is a potentially life-threatening disorder of a variety of causes (table . - ) characterized by hypersecretion of fluid, motility disturbances, altered microbial flora in the colon, and an impaired mucosal barrier caused by direct injury or inflammation. many of the clinical and clinicopathologic features are similar regardless of the cause. severe dehydration with profound electrolyte abnormalities is common, as is systemic inflammation from absorption of endotoxin or other bacterial products through the compromised mucosa. gastrointestinal protein loss may result in reduced colloid oncotic pressure from hypoproteinemia, leading to tissue edema. colitis is a highly catabolic disorder, and weight loss may be rapid and severe. some cases of colitis may be complicated by extensive mucosal ulceration, serosal inflammation, or mural ischemia/infarction extending from the inflammation or resulting from coagulopathies. thus diagnostic measures aimed at determining the cause necessarily must be accompanied by clinical and laboratory assessment of hydration, electrolyte and acid-base balance, plasma protein concentration and colloid oncotic pressure, organ function, and evaluation of the degree of systemic inflammation and of the integrity of the intestinal wall. although therapeutic strategies are similar for many causes of colitis, consisting primarily of control of local and systemic inflammation, maintenance of fluid and electrolyte balance, promotion of tissue perfusion, replacement of plasma protein, preservation of colloid oncotic pressure, promotion of mucosal repair, restoration of the microbial ecology of the colon, and nutritional management, some causes of acute colitis have specific therapies aimed at eliminating the cause. a variety of infectious organisms has been identified as causes of acute colitis in adult horses. the clinical syndromes associated with these infections are indistinguishable in most horses. however, appropriate diagnostic tests including fecal bacterial culture, fecal bacterial toxin analysis, pcr, and/or serology may identify specific infectious organisms. salmonella is a genus of gram-negative facultatively anaerobic bacteria that are common gastrointestinal pathogens in horses. many serotypes of salmonella have been reported to infect horses, but those classified in group b appear to be associated more commonly with disease than those in other groups. group b includes s. typhimurium and s. agona, two of the species most frequently isolated from horses. - s. typhimurium is the most pathogenic serotype in horses and is associated with a higher case fatality rate than other species of salmonella. the number of horses that are infected inapparently with and actively shed salmonella in their feces has been reported to be as high as % to %, but actual prevalence of salmonella-shedding in the general horse population is likely to be much lower, less than % to %. horses shedding salmonellae are a potential source of infection to susceptible horses, , as are environmental reservoirs. [ ] [ ] [ ] for these reasons, salmonellosis is one of the most common nosocomial diseases in horses. nosocomial salmonellosis significantly affects morbidity and mortality in hospitalized horses. the emergence of multidrug resistance in equine salmonella isolates has been a cause of concern because of the importance of salmonellosis as a nosocomial disease and because salmonella represents a significant zoonotic pathogen. , [ ] [ ] [ ] the virulence of the bacteria varies tremendously with serotype and even among strains of the same serotype in part because of the important role of host susceptibility in the pathogenicity of particular organisms. the infective dose is generally millions of organisms inoculated orally, but various environmental and host factors can reduce the infective dose to a few thousand or even hundreds of organisms. [ ] [ ] [ ] environmental factors or stresses that increase susceptibility to salmonella infection are not well defined, but high ambient temperature, for example, is known to increase the prevalence of salmonellosis in horses greatly. indeed, the peak incidence of salmonellosis in horses occurs in late summer and fall. , , other environmental and host factors that increase the risk of salmonella infection include transportation, antibiotic administration, gastrointestinal surgery, general anesthesia, preexisting gastrointestinal disease, change in diet, and immunosuppression. , , host factors that restrict gastrointestinal colonization and invasion by pathogens include gastric ph, commensal gastrointestinal flora, gastrointestinal motility, the mucosal barrier and mucosal immunity. , gastric acidity is an important defense mechanism preventing live organisms from reaching the intestine. altering the gastric ph with histamine receptor antagonists, for example, may increase susceptibility to infection. gastrointestinal flora inhibits the proliferation and colonization of salmonella by secreting bacteriocins, short-chain fatty acids, and other substances that are toxic to salmonella. in addition, elements of the normal flora compete for nutrients and space, especially on the mucosa. being predominantly anaerobic, the normal flora maintain a low oxidationreduction potential in the environment of the large intestine, which inhibits the growth of many bacterial pathogens. the importance of normal host gastrointestinal ecology is illustrated by the fact that disturbances of the colonic flora with antibiotics, changes in feed, ileus, or other underlying gastrointestinal disease greatly increase the susceptibility of the host to infection by salmonella, often resulting in serious disease. the immune status of the host may be one of the most important factors determining not only the susceptibility to salmonella infections but also the degree of invasion and subsequent outcome of the infection. local immunity, such as mucosal antibody secretion and enterocyte-derived cationic peptides, prevents colonization of the mucosa. , , opsonizing antibodies and activation of the complement cascade are important in fighting systemic invasion by salmonella by increasing the efficiency of phagocytosis and by direct bactericidal activity. humoral immunity, however, is often ineffective in preventing disease and dissemination once invasion occurs and salmonella has established in its intracellular niche. following invasion, salmonella is capable of surviving and multiplying within macrophages, rendering humoral (noncellular) immune systems ineffective. , specific cellular immunity may be the most effective defense mechanism in the host arsenal against dissemination and systemic infection by salmonella. , oral inoculation with small numbers of virulent organisms may induce protective immunity in horses and calves, but the duration of the immunity is not known. , oral and parenteral vaccines using killed or attenuated organisms and bacterial products have been promising but are effective only against homologous organisms and are usually not cross-protective among different serogroups. [ ] [ ] [ ] in adult horses, salmonella primarily infects the cecum and proximal colon, causing enterocolitis, and the ability to disseminate beyond the intestine and cause enteric fever is limited. in foals, however, salmonellosis often is associated with septicemia. the ability of salmonella to cause enterocolitis depends on the ability of the bacteria to invade the gastrointestinal mucosa. , invasion of the gastrointestinal mucosa occurs preferentially through specialized enterocytes called m cells that overlay intestinal lymphoid tissues such as peyer's patches in nonequine species. a variety of enteric pathogens exploit m cells during infection of intestinal tissue. invasion of the epithelium occurs by self-induced uptake via the apical membrane of the m cell, often killing the cell in the process. salmonellae then invade neighboring cells via the basolateral membrane, eventually spreading the destruction of the epithelium beyond the principle area of attack. virulent salmonellae have a well-developed invasion mechanism involving generation of an apparatus called a type iii secretory system that enables virulence gene products to be injected directly into enterocytes. virulence proteins injected by salmonellae into enterocytes engage the cellular machinery and induce the cell to engulf the bacteria by macropinocytosis. salmonella virulence gene products also induce enterocyte chloride and fluid secretion and upregulate enterocyte transcription of inflammatory cytokines (tumor necrosis factor α and interleukin- β) and chemokines that trigger a mucosal inflammatory response. , , after salmonellae invade the mucosa, they are phagocytosed quickly by macrophages and dendritic cells in the lamina propria and lymphoid tissues. the ability of salmonellae to disseminate systemically and cause enteric fever is associated with the ability to survive and proliferate in macrophages. indeed, phagocytes have an important role in dissemination of the pathogen to blood, lymph nodes, liver, and spleen. most salmonellae in the blood and tissues of infected animals that are competent to cause enteric fever are within phagocytic cells. in adult horses with salmonellosis, dissemination appears to be limited to the intestine and mesenteric lymph nodes, and salmonella rarely is cultured from blood. however, in foals and in some adults, salmonella causes an enteric feverlike disease with dissemination to mesenteric lymph nodes, liver, spleen, and blood. salmonella organisms require specific virulence gene clusters encoded on the chromosome or on plasmids for intracellular survival in macrophages. some of these genes are sensors that signal the bacteria that it has entered an intracellular environment and turn on genes required for intracellular survival. others, like invasion genes, are transported from the bacteria and injected into macrophage cytosol by a type iii secretory system to prevent phagosome/lysosome fusion and subvert other essential macrophage killing mechanisms. salmonellae also possess multiple genes that confer resistance to reactive oxygen and nitrogen metabolites, perhaps the most lethal antimicrobial mechanisms of macrophages. diarrhea associated with salmonellosis has multiple causes. a salmonella cytotoxin inhibits protein synthesis in mucosal cells, causing morphologic damage and altered permeability. virulent salmonellae also produce an enterotoxin similar to the heat-labile toxin (lt) produced by escherichia coli. , the enterotoxin contributes to but is not required in the pathogenesis of diarrhea. , salmonella enterotoxin increases secretion of chloride and water by colonic mucosal cells in many species, including horses, by increasing intracellular cyclic adenosine monophosphate concentrations. the ability of virulent salmonellae to cause diarrhea appears to be associated most closely with the ability to invade enterocytes and to trigger an inflammatory reaction in the intestinal tissue. , gene products injected into enterocyte cytosol by the type iii secretory system of invading salmonellae stimulate chloride and fluid secretion. salmonella invasion of enterocytes is also a potent activator of inflammatory chemokine and cytokine production, resulting in the recruitment of leukocytes, particularly neutrophils, and activation of resident macrophages and mast cells. products of these activated leukocytes, including prostaglandins, leukotrienes, reactive oxygen metabolites, and histamine, are potent stimulators of chloride secretion in the colon of many species. , [ ] [ ] [ ] the enteric nervous system integrates the diverse processes of pathogen recognition, triggering of the inflammatory response, and induction of enterocyte fluid secretion. many of the inflammatory mediators studied stimulate colonic secretion by prostaglandin-dependent mechanisms, resulting in increased intracellular cyclic adenosine monophosphate or calcium concentrations or both in mucosal cells. in addition, these mediators and the enteric nervous system may stimulate secretion by prostaglandin-independent mechanisms, inhibit sodium and water absorption, cause motility disturbances, and potentiate tissue injury, all of which enhance the pathogenicity and dissemination of salmonella and contribute to the pathogenesis of diarrhea. , neutrophils recruited to the mucosa by signals generated by the infected enterocytes physically contribute to mucosal injury by producing a variety of products that are lethal to pathogens but are also toxic to host cells. , moreover, neutrophils attracted to infected epithelial cells accumulate beneath the monolayer, lifting it off the basement membrane in sheets. neutrophils also migrate across the epithelial monolayer in potentially massive numbers. transepithelial migration of neutrophils increases the permeability to macromolecules, bacterial products, and even bacteria. potentially massive losses of electrolytes, water, and protein can occur depending on bacterial and host factors. perhaps most devastatingly, mucosal injury and altered permeability allow systemic absorption of bacterial products and dissemination of bacteria, resulting in systemic inflammatory responses such as occur with endotoxemia and septicemia. four syndromes of salmonella infection have been described clinically and reproduced experimentally in horses: ( ) inapparent infections with latent or active carrier states; ( ) depression, fever, anorexia, and neutropenia without diarrhea or colic; ( ) fulminant or peracute enterocolitis with diarrhea; and ( ) septicemia (enteric fever) with or without diarrhea. inapparent infections can be activated to clinical disease in compromised horses, such as horses with colic or horses being treated with antibiotics, causing mild to severe enterocolitis. in addition, latent infections (nonshedding) can become active infections (shedding) under certain conditions, such as transportation stress and antibiotic treatment. horses with depression, anorexia, fever, and neutropenia without diarrhea generally have a good prognosis and recover in several days without specific treatment. the septicemic form is restricted mostly to neonatal foals and is uncommon in adult horses. this discussion focuses on acute enterocolitis. acute enterocolitis is characterized by severe fibrinonecrotic typhlocolitis, with interstitial edema and variable degrees of intramural vascular thrombosis that may progress to infarction. severe ulceration of the large intestinal mucosa may occur with serosal ecchymoses and congestion. the earliest signs of enterocolitis are usually fever and anorexia. , signs of colic may be apparent early in the course of the disease, especially if ileus is present. clinical signs of endotoxemia are common and range from fever, elevated heart and respiratory rates, poor peripheral perfusion, and ileus to fulminant and rapidly progressive signs of endotoxemic shock. oral mucous membranes are often pale with perigingival hyperemia (a toxic rim) but may be brick red or cyanotic, with prolonged capillary refill time. one may note weakness, muscle fasciculations, cold extremities, and other signs suggestive of hypotensive shock; synchronous diaphragmatic flutter; abdominal pain; and significant metabolic and electrolyte abnormalities in severe cases of enterocolitis. one also may note signs of mild dehydration before diarrhea is apparent. once diarrhea is evident, dehydration may become severe rapidly. occasionally, horses die peracutely, without developing diarrhea. diarrhea may not be apparent for several days but usually occurs by to hours after the fever begins. , the duration of the diarrhea may be days to weeks. the character of the first diarrheal feces is usually watery with particles of roughage but may become fluid rapidly without solid material. finding frank blood and fibrin in the feces is unusual. the volume of feces is often large, with frequent defecation. one may note straining or signs of colic when the patient is defecating, and rectal prolapse may occur occasionally. persistent straining and rectal prolapse may be a sign of colonic infarction. abdominal borborygmi are often absent early in the course of the disease because of ileus but become evident later, usually when diarrhea begins. fluid and gas sounds are commonly audible, but normal progressive motility is less frequently audible than normally. transrectal palpation may reveal edematous rectal mucosa and colon and fluid-filled colon and cecum. one may obtain gastric reflux, especially early in the course when ileus is evident. hematologic abnormalities early in the course of the disease include moderate to severe neutropenia, lymphopenia, and leukopenia, a mild to moderate left shift, and toxic changes in the neutrophils. , thrombocytopenia, moderate to severe hemoconcentration, and hyperfibrinogenemia are also common. neutropenia is an early but nonspecific indicator of salmonellosis, often occurring concurrently with the onset of fever. later in the course of disease, one may see neutrophilic leukocytosis, indicating recovery. a degenerative left shift, with metamyelocytes and myelocytes in the peripheral blood, is a poor prognostic sign. serum biochemical analysis may reveal azotemia, elevations in serum sorbitol dehydrogenase and γglutamine aminotransferase activity, and elevated serum lactic acid concentration. azotemia is often prerenal, but acute hemodynamic renal failure may occur in severely dehydrated, endotoxemic, or septicemic patients. indeed, elevation of creatinine concentration is a poor prognostic indicator in horses with acute colitis. hemodynamic renal disease may be complicated by toxic injury caused by administration of nephrotoxic drugs. hyponatremia may also contribute to prerenal azotemia. elevations in hepatocellular enzymes are usually mild and reflect damage to the hepatocytes from absorbed toxins such as endotoxin and from poor perfusion caused by hypotensive shock or dehydration. lactic acidemia may be present, reflecting poor tissue perfusion. plasma protein rapidly drops as protein is lost in the gastrointestinal tract, causing moderate to severe hypoalbuminemia and hypoglobulinemia. peripheral or organ edema (vascular leak syndrome) may occur if hypoproteinemia is severe, coupled with increases in endothelial permeability induced by systemic inflammation. hypokalemia, hyponatremia, hypochloridemia, and hypocalcemia are common electrolyte abnormalities in patients with enterocolitis. metabolic acidosis also may be present. coagulopathies, such as decreased antithrombin iii activity and disseminated intravascular coagulation, may occur. urinalysis may reveal isosthenuria, proteinuria, hematuria, cylindruria, and glucosuria if hemodynamic or toxic renal injury is present. the number of leukocytes in the feces usually is elevated, and occult blood may be detectable. peritoneal fluid is usually normal except when severe mural inflammation or colonic infarction occurs. routine detection of salmonellae in feces involves five daily cultures of large samples ( to g) of feces using enrichment techniques. , , however, the sensitivity of fecal culture can be as low as % to %, even if one cultures several fecal samples collected daily. concurrent culture of rectal biopsy specimens and feces increases the sensitivity of culture techniques to % to %. currently, the polymerase chain reaction (pcr) is the most sensitive and rapid test for detecting salmonella in feces. a single pcr test applied early in the course of disease is a more sensitive test for the presence of salmonella than repeated fecal cultures. , detection of salmonellae in feces does not prove a diagnosis of salmonellosis, but the positive predictive value of a positive pcr or culture results is high in horses with compatible clinical signs. culture of peripheral blood may allow isolation of the organism if bacteremia or septicemia is present, but blood cultures are not a sensitive test for salmonellosis in adult horses. although foals are more likely than adults to become septicemic, culture of blood is recommended in all cases with signs suggestive of septicemia. increased numbers of fecal leukocytes suggest an invasive process in the colon but are not specific for salmonellosis. early in the course of the disease, dehydration, electrolyte and acid-base imbalances, endotoxemia, and sepsis may be life threatening. aggressive treatment during the acute stages to replace fluids lost in the diarrhea and to control sepsis and endotoxemia is often effective in controlling the primary disease. weight loss and hypoproteinemia are often severe. complications such as multiorgan dysfunction, vascular leak syndrome with peripheral and organ edema, laminitis, acute renal failure, venous thrombosis and septic phlebitis, irreversible protein-losing enteropathy or chronic malabsorption, pulmonary aspergillosis, and gastrointestinal infarction can occur. in many instances, horses recover from acute salmonellosis with aggressive treatment, only to succumb to complications of the disease, partially explaining the high fatality rate of equine salmonellosis compared with human salmonellosis. chronic, mild to moderate diarrhea occasionally occurs in horses after a bout of severe salmonellosis, usually with protein-losing enteropathy. if the chronic diarrhea persists beyond to weeks after the onset of signs, the prognosis for recovery is poor. potomac horse fever (equine monocytic ehrlichiosis) is caused by the obligate intracellular rickettsial organism neorickettsia risticii. [ ] [ ] [ ] [ ] the disease is most common from late summer to early fall, with a peak incidence in july and august. potomac horse fever was described first in the northeast but since has been diagnosed in most areas of the continental united states, with a particularly high prevalence in the northeast and midwest. the geographic distribution is characterized by a significantly higher percentage of cases found along waterways and rivers. , the disease occurs sporadically, temporally and geographically, and can affect any age group of horses. the case fatality rate is % to %. transmission of n. risticii has been reproduced experimentally by oral, intramuscular, intradermal, subcutaneous, and intravenous routes. , however, the natural route of infection has remained a mystery until recently. the epidemiologic data, the fact that many other rickettsial diseases are transmitted by insect vectors, and the finding that the disease can be transmitted via whole blood have implicated insect vectors in the natural transmission of the organism. attempts to transmit the disease experimentally with ticks (dermacentor variablis) or biting flies (stomoxys calcitrans) have been unsuccessful. , recently, n. risticii has been found to infect virgulate cercariae larval stages of trematodes that use operculate freshwater snails (juga spp.) as part of their life cycle in northern california. infected virgulate cercariae have been identified in aquatic snails collected in other parts of the country as well. virgulate cercariae are part of the life cycle of trematodes that are common parasites of many species and use freshwater snails and aquatic insects as intermediate hosts. although the trematode species infected with n. risticii remains to be identified definitively, at least two species are considered potential vectors. during the trematode life cycle, aquatic snails release large numbers of infected cercariae into water, where they seek their next intermediate host. infected metacercaria have been identified in a variety of aquatic insects. preliminary studies suggest that n. risticii in fact may be transmitted via ingestion of mature caddis flies containing infected metacercariae. possibly horses are infected by drinking water containing infected cercaria released from snails or by ingesting infected metacercariae in other aquatic insects. the number of pcr-positive snails in endemic regions corresponds to the seasonal incidence of potomac horse fever and may be as high as %. the pathogenesis of n. risticii is not understood completely. the organism infects and survives in monocytes and monocyte-derived leukocytes and can be found in blood monocytes during natural infections, but the sequence of events resulting in enterocolitis remains speculative. the organism appears first to infect blood monocytes in experimentally infected horses, which may be the vehicle of organ infection. , however, in naturally infected horses, whether leukocytes of monocytic lineage or epithelial cells are infected first is unclear. the target organ is the gastrointestinal mucosa, with the most severe lesions found in the large intestine. , infection of human colonic cells in vitro does not cause major cytopathologic effects for several days. disruption of the microvilli in the region of the plasma membrane where sodium chloride channels are located has been observed in human colonic cell cultures. infection in horses is associated with variable degrees of morphologic damage. , mild morphologic damage and mononuclear cell infiltration of the lamina propria occur early during the infection, but fibrinous, necrotizing typhlocolitis with severe mucosal ulceration and inflammation of the lamina propria may occur later in the disease. vasculitis and intravascular coagulation are consistent features in the large intestine, with perivascular edema. one can observe n. risticii in mucosal cells and macrophages and mast cells of the lamina propria. , n. risticii can survive and multiply in macrophages by inhibiting the production of reactive oxygen intermediates and by avoiding lysosomal digestion by blocking phagosome-lysosome fusion. [ ] [ ] [ ] evidence of impaired sodium chloride absorption in the colon has been suggested to contribute to diarrhea in infected horses and may be related to destruction of the enterocyte membrane structure in the region of sodium chloride channels. , direct injury to the mucosa by n. risticii and colonic inflammation are likely to be prominent features leading to diarrhea, especially later in the disease. fluid, protein, and electrolyte loss likely is caused by mucosal injury and effects on enterocyte fluid secretion caused by the inflammatory response. like other inflammatory conditions of the colon, systemic inflammation caused by absorption of bacteria and bacterial products is a potential complication of n. risticii infections if mucosal injury is severe, which contributes to the clinical signs seen during the disease. n. risticii infection is clinically similar to other forms of enterocolitis and is characterized by anorexia, depression, and fever. , , experimental infections produce a biphasic fever occurring to days apart. decreased gastrointestinal motility, manifested as reduced borborygmi, occurs during the early stages before the onset of diarrhea. diarrhea occurs in % of cases and occurs days after the second fever episode during experimental infections. , the diarrhea can be moderate to severe and dehydrating. ileus can develop at any stage of the disease and can cause signs of moderate to severe colic. systemic signs of endotoxemia, shock, and peripheral edema may occur and are similar to those described for salmonellosis. experimental and natural infection with n. risticii can cause abortion of infected fetuses in pregnant mares. , laminitis is a complication in % to % of naturally occurring cases and is often severe. other complications include protein-losing enteropathy, thrombosis, and renal failure, as described for salmonellosis. hematologic abnormalities reflect endotoxemia, dehydration, and sepsis and are essentially identical to those described for salmonellosis. neutropenia with a left shift is a consistent feature and occurs concurrently with or soon after the onset of diarrhea. thrombocytopenia is common and often severe. neutrophilic leukocytosis occurs later in the course of the disease. hyperfibrinogenemia is usually more pronounced than that with salmonellosis. serum electrolyte, acid-base, and biochemical abnormalities are also similar to those described for salmonellosis. coagulopathies are common during n. risticii infection and reflect activation of coagulation pathways. disseminated intravascular coagulation is common and may be related to the high frequency of laminitis associated with n. risticii infection. one cannot base diagnosis of n. risticii infection solely on clinical signs because the disease is clinically similar to other forms of enterocolitis. however, in endemic areas, acute colitis is likely to be caused by n. risiticii, and thus the clinical signs of acute inflammatory colitis in fact may have a high predictive value. serologic evidence of infection, such as rising antibody titers to n. risticii detected by indirect immunofluorescence or enzymelinked immunosorbent assay in paired serum samples may be helpful in establishing a diagnosis. , one should take care when interpreting the indirect immunofluorescence serologic test for n. risticii because the test appears to have a high false-positive rate. culture of the organism from blood is possible but is difficult and is generally useful only in the research laboratory. recently developed polymerase chain pcr tests for n. risticii dna are rapid, highly sensitive (as sensitive as culture), and specific for n. risticii infection and can be applied to blood or feces. [ ] [ ] [ ] prevention prevention of the disease by reducing exposure to the causative organism is difficult because the mode of transmission is not known. a killed vaccine has been developed that is effective in preventing clinical illness other than fever in % of experimentally challenged horses using the vaccine strain. however, field studies suggest the vaccine has limited benefit for prevention or decreasing the severity of natural infection. vaccine failures have been attributed to strain differences in antigenicity or to poor antibody responses to the vaccine. , clostridiosis is an important cause of acute enterocolitis in foals and adult horses. clostridium perfringens and c. difficile are associated most commonly with intestinal clostridiosis in horses, but other clostridial species, including c. septicum, c. cadaveris, and c. sordellii also have been isolated from horses with enterocolitis. [ ] [ ] [ ] [ ] [ ] [ ] in horses of all ages, clostridial enterocolitis appears to be a common antibiotic-associated and nosocomial cause of enterocolitis. , , however, clostridiosis in neonatal foals is a distinct clinical entity and is discussed in more detail elsewhere. this chapter focuses on adult intestinal clostridiosis. clostridia are obligate anaerobic to aerotolerant spore-forming gram-positive rods that are ubiquitous in the environment in the spore form. clostridia are elements of the normal flora of horses of all ages and are among the first bacteria acquired after birth. however, clostridia inhabiting the gastrointestinal tract normally are found in low numbers and do not produce enterotoxins. clostridiosis is associated with an increase in the number of a particular species of clostridia in the gastrointestinal tract and, perhaps most importantly, exotoxin production. although the conditions resulting in exotoxin production are not understood fully, several factors increase clostridial numbers in the gastrointestinal tract. dietary factors are known to affect the numbers of clostridium species shed in the horse feces. experimental induction of colic increases fecal shedding of clostridium species in the absence of diarrhea. antibiotics, particularly administered orally or recycled via the enterohepatic system, are well documented to increase the recovery of clostridia colony-forming units (cfus) in equine feces and may result in clinical clostridiosis. , , [ ] [ ] [ ] [ ] indeed, clostridiosis associated with c. perfringens or c. difficile is likely to be the most important cause of antibiotic-induced enterocolitis in the horse. clostridium perfringens c. perfringens is made up of many genetically distinct strains of variable virulence that produce one or more of a large group of exotoxins. the pattern of exotoxin production is used to classify c. perfringens into five types, a, b, c, d, and e. c. perfringens type a is the most common clostridium isolate from healthy horses of all ages and adults and foals with diarrhea worldwide. c. perfringens types a, b, c, and d have been associated with hemorrhagic enteritis in foals less than days of age, with type c being the most common cause in north america. the primary toxin produced by c. perfringens type a is α-toxin (phospholipase c), which interferes with glucose uptake and energy production and activates arachidonic acid metabolism and signaling pathways in enterocytes. oral administration of α-toxin does not cause tissue necrosis but causes increased secretion by small intestinal mucosal cells in human beings. , the β-toxin of types b and c is a cytotoxin that causes enterocyte necrosis, ulceration, and ultimately severe intestinal inflammation and hemorrhage. a novel toxin designated β may also have a role in c. perfringens enterocolitis. the biologic activity of the β -toxin is similar to β-toxin, but β -toxin is not related to β-toxin in sequence. the β -toxin was prevalent in two groups of horses with acute enterocolitis but not in healthy horses. the β -toxin appears to be associated predominantly with c. perfringens that would have been classified otherwise as type a but that in fact may represent a previously undescribed type. virulent strains of c. perfringens type a and to a lesser extent type c also may produce enterotoxin. enterotoxin is a cytotoxin that inserts into cell membranes to form pores, which alter permeability to water and macromolecules and ultimately lead to cellular necrosis. massive desquamation of the intestinal mucosa resulting from enterotoxin cytotoxicity triggers an inflammatory response, intestinal edema, mural hemorrhage, and systemic inflammation. enterotoxin also alters tight junction integrity, resulting in increased paracellular permeability by a noncytotoxic mechanism. clostridium difficile c. difficile produces several toxins, but only two, toxin a and toxin b have been studied in detail. toxin b is a potent cytotoxin in vitro, but its role in enterocolitis is less clear than the role of toxin a. toxin b does not induce fluid secretion, inflammation, or characteristic alterations in intestinal morphology. c. difficile induces an inflammatory response with hypersecretory diarrhea that is induced in large part by the enterotoxin toxin a. toxin a induces neutrophil influx into intestinal tissue, mast cell degranulation, and secretion of prostaglandins, histamine, cytokines, and -hydroxytryptamine by these activated leukocytes. , the products of neutrophils and mast cells have a prominent role in the vasodilatory and secretory responses in the intestine during c. difficile infection. the enteric nervous system is central to the induction of intestinal inflammation and mucosal secretion by toxin a. a model for toxin a-induced secretory diarrhea has emerged in which toxin a stimulates substance p-containing afferent sensory nerve fibers, which in turn stimulate mast cell degranulation, recruitment and activation of polymorphonuclear leukocytes, and vasodilation. [ ] [ ] [ ] toxin a-induced stimulation of enterocyte secretion can occur via secretomotor neuronal stimulation by substance p-containing sensory neurons or products of mast cells and polymorphonuclear leukocytes. neural blockade or depletion of substance p abolishes mast cell degranulation, polymorphonuclear leukocyte influx, and enterocyte secretion. how toxin a triggers the sensory component of the enteric nervous system is not known yet, but toxin a-induced necrosis of enterocytes likely exposes afferent neurons to the noxious milieu of the intestinal contents. equine intestinal clostridiosis is clinically similar to other forms of acute enterocolitis in horses. , although the clinical course is usually acute, peracute colitis with rapid death may occur. occasionally, a milder, more prolonged clinical course occurs. one may note fever, anorexia, and depression before the onset of gastrointestinal signs, but more commonly no prodromal signs are apparent. signs of endotoxemia and shock may accompany acute signs of colic and severe, dehydrating diarrhea. diarrhea may not be profuse but is usually dark and foul smelling. like the clinical signs, hematologic and serum biochemical abnormalities are similar to those associated with other forms of enterocolitis and reflect fluid, protein, and electrolyte loss and systemic inflammation from endotoxemia. neutropenia, leukopenia, and hemoconcentration are common. hypoproteinemia may be profound. one often may note hyponatremia, hypokalemia, hypochloremia, hypocalcemia, and a mixed prerenal/renal azotemia, as well as metabolic acidosis and coagulopathies. serum concentrations of hepatocellular enzymes such as sorbitol dehydrogenase may be elevated, and liver function may be reduced. preliminary diagnosis of equine intestinal clostridiosis caused by c. perfringens is based on the isolation of greater than cfus of c. perfringens type a per gram of feces from patients with diarrhea and signs suggestive of toxemia. similar criteria are used to screen human patients for c. perfringens type a infection. normal horses shed fewer than cfus/g of feces, and usually horses with intestinal clostridiosis shed greater than × cfus/g. , however, identification of increased numbers of clostridium organisms in the feces does not prove infection. detection of c. perfringens toxins in feces or intestinal contents in horses with increased numbers of fecal cfus and clinical signs of enterocolitis is more conclusive evidence of an enterotoxigenic infection than culture alone. immunoassays are available that are primarily designed to detect c. perfringens enterotoxin. however, the reliability (specificity) of some immunoassays for diagnosis of c. perfringens infection has come into question. recently, pcr multiplex and gene probe assays have been developed to detect the major lethal toxins in isolates or fecal samples to determine the pattern or toxin production and are currently the preferred methods of detection. [ ] [ ] [ ] as for c. perfringens, diagnosis of c. difficile infection consists of culture of the organism from feces and identification of toxins in the feces. bacterial culture of c. difficile may be difficult and may be an insensitive test in horses. [ ] [ ] detection may require enrichment techniques and culture of multiple fecal samples. , detection of toxins a and b in feces is regarded as the preferred test for diagnosis of c. difficile infection in human beings. commercial enzyme-linked immunosorbent assays are available for toxins a and b that are specific and appear to be more sensitive than a single culture for identifying c. difficile infection in adult horses. , one also may induce toxin production by c. difficile isolates. sensitive pcr methods also have been developed for application to fecal samples and isolates to detect the genes for toxins a and b. proliferative enteropathy is a chronic hyperplastic disorder of the small intestine and has been described in a variety of mammalian and avian species. , the only causative agent identified to date that induces proliferative enteropathy is the obligate intracellular pathogen lawsonia intracellulare. , the pig is the most frequently naturally affected species. however, the reports of equine proliferative enteropathy associated with l. intracellulare have increased in recent years. [ ] [ ] [ ] [ ] the relatedness of the strains of l. intracellulare causing proliferative enteropathy in pigs and horses or even among other affected species is not known. no host restriction is apparent because hamsters and other rodents can be infected with porcine strains of l. intracellulare. before the year , reports of proliferative enteropathy in the literature describing isolated cases were sporadic. [ ] [ ] [ ] however, since , outbreaks on breeding farms have been documented on farms in canada, suggesting that a new strain has emerged. the mode of infection is fecal-oral, and infected animals can shed large numbers of organisms in feces. affected animals shedding the organism in the feces serve as a source of infection for herdmates. possibly nonequine species serve as reservoirs contributing to outbreaks on horse farms. factors that increase the risk of proliferative enteropathy in pigs include overcrowding, ration changes, transport, and weaning. , like pigs, horses are affected as weanlings. factors associated with weaning and other stresses may affect immunity and increase susceptibility to infection. the incubation period is to weeks in nonequine species and is presumed to be similar in horses. experimental l. intracellulare infection produces characteristic pathologic lesions in pigs and hamsters that are identical to lesions in horses with proliferative enteropathy. , a profound hyperplasia of the mucosa predominantly caused by proliferation of crypt epithelium and crypt hyperplasia is induced locally in infected islands of tissue and eventually extends to the entire distal jejunum and ileum. l. intracellulare preferentially infects proliferating cells, thus the tropism for the crypt epithelium. infected cells proliferate far more rapidly than uninfected cells, suggesting that l. intracellulare directly induced the proliferative response. however, the molecular basis for the enhanced proliferation is not known. l. intracellulare penetrates epithelial cells in a membrane-bound vesicle but eventually escapes the vacuole and is found free in the cytoplasm concentrated at the apical pole of the cell. the gross pathologic lesions found in equine proliferative enteropathy are characteristic. [ ] [ ] [ ] [ ] lesions may be segmental and typically are found in the ileum and terminal jejunum in horses. however, lesions also may affect the duodenum. severe mucosal hypertrophy often occurs but may wane during the chronic stages of the disease. the mucosa may become corrugated with focal erosions or ulcers. one often can identify submucosal edema easily on cut sections of affected segments. moderate to severe crypt hyperplasia with atrophy of the intestinal villi is a consistent feature. the hyperplastic crypts are branched and may herniate into the submucosa. necrosis, edema of the submucosal and lamina propria, hemorrhage, mononuclear inflammation and muscular hypertrophy have been reported in affected intestinal segments but are not consistent. special stains such as silver stain are required to detect intracellular organisms. the organisms are curved or comma-shaped rods found clustered in the apical cytoplasm of hyperplastic crypt epithelium. the proliferative response of the intestinal mucosa alters absorption of nutrients and fluid secretion by disrupting the architecture of the villi and by altering the maturation of epithelial cells into absorptive cells, accounting for the secretory diarrhea and often severe weight loss. , the combined effects of the inflammatory part ii disorders of specific body systems response and malabsorption may account for the protein-losing enteropathy. proliferative enteritis most commonly affects weanling foals ages to months. the clinical signs of proliferative enteropathy include ill thrift, weight loss, peripheral edema, diarrhea, and colic. [ ] [ ] [ ] [ ] the diarrhea is usually in the form of soft feces but may be profuse and watery. some foals with mild diarrhea have black, tarry feces. secondary complications such as gastric ulceration, bronchopneumonia, or parasitism may occur concurrently with the proliferative enteropathy. clinicopathologic features include mild to moderate anemia, moderate to severe hypoalbuminemia (often < g/dl), hypoglobulinemia, neutrophilic leukocytosis, and hyperfibrinogenemia. creatine kinase activities may be elevated in affected foals. prerenal azotemia and electrolyte imbalances such as hyponatremia may be associated with diarrhea. peritoneal fluid analysis is usually unremarkable. ultrasonographic examination of the small intestine often reveals significant thickening of the intestinal wall ( figure . - ). intestinal edema may be evident as a hypoechoic appearance to one or more layers of the intestinal wall. methods for antemortem diagnosis include serologic analysis of l. intracellulare antibodies and pcr analysis of feces. serologic analysis using an indirect immunofluorescent antibody test may be the most useful single test available. the pcr test is specific but the sensitivity may be low. by the time clinical signs appear, % of pigs are serologically positive for anti-lawsonia intracellulare immunoglobulin g (igg). in contrast, only % of pigs had positive fecal pcr tests. of the seven foals tested in an outbreak of equine proliferative enteropathy, four foals with confirmed disease and three with suspected proliferative enteropathy had serologic titers against l. intracellulare of : or greater. in contrast, serum samples collected from foals before the outbreak were negative for l. intracellulare antibodies. fecal pcr for l. intracellulare was positive in of foals tested, and half of the serologically positive foals had negative fecal pcr tests. many clinicians combine serologic analysis with fecal pcr testing to increase the sensitivity and specificity of these diagnostic methods. isolation and culture of the organism requires cell culture techniques that are not widely available. thus no practical method exists for culturing the organism from feces or tissues that is available for clinical use. definitive diagnosis requires histopathologic examination of affected tissues. diagnosis is based on typical histopathologic findings of mucosal hypertrophy and submucosal edema and identification of small, curved, rod-shaped intracellular bacteria at the apical pole of epithelial cells in affected segments of intestine. special stains such as warthin-starry silver stain are required to detect the bacteria in histopathologic specimens. pcr analysis of affected intestinal tissue is a specific test for the presence of l. intracellulare and, unlike fecal pcr analysis, appears to be sensitive. strongyle infections in horses are caused by two groups of nematodes: large and small strongyles (see the section cyathostomiasis). large strongyles that are pathogenic in horses include strongylus vulgaris, s. edentatus, and s. equinus. of these species, s. vulgaris is by far the most important cause of disease in the large intestine and in fact is the most pathogenic parasitic infection in horses. s. vulgaris infection in horses is manifested clinically by two forms: acute and chronic disease. the age and resistance of the host, the infective dose, and the size and function of the affected arteries influence the type and degree of disease that occurs. sudden ingestion of large numbers of infective larvae by a naïve host causes acute strongylosis, whereas ingestion of fewer infective larvae over a long period of time by an older, more resistant host causes chronic strongylosis. acute strongylosis is more likely to cause colic than diarrhea and may be rapidly fatal. chronic strongylosis tends to cause debilitation and signs of colic but may also cause diarrhea. diarrhea associated with acute strongylosis occurs within several days of infection and is likely to be caused by migration of the larvae through the intestinal wall. fourth-stage larvae migrate through the mucosa and submucosa into the arterioles of the intestine, causing mural edema, hemorrhage, and infiltration with inflammatory cells into the intestinal wall. , increased secretion and decreased absorption of fluid and electrolytes, stimulated by inflammatory mediators such as prostaglandins and histamine, may play a role in the diarrhea induced by s. vulgaris. interstitial edema and damage to the interstitial matrix and mucosa may result from inflammation and migration of the parasites, causing increased secretion of fluid and albumin loss. abnormal gastrointestinal motility also may play a role in the development of diarrhea. migration of larvae through the intestinal wall early in the course of infection affects myoelectric activity and motility in the large intestine and may affect retention of ingesta and absorption of fluid. , the cause of death in acute strongylosis has not been addressed but may be related to massive migration through the vasculature, causing thrombosis with ischemia and infarction of the intestine. chronic strongylosis causes typical verminous arteritis and is associated more commonly with natural infections in horses than with acute strongylosis. lesions of the large intestinal vasculature caused by migration of larvae through the intima are characterized by thrombus formation, narrowing of the arterial lumen, fibrosis, and thickening of the arterial wall. , embolization may occur, causing acute segmental infarction of the large intestine, but more commonly reduced blood flow without embolization causes ischemia and occasionally infarction. , postmortem examination of horses with colonic infarction failed to reveal embolization as the cause in most cases. reduced blood flow in the tissues of the intestine usually results from narrowing of the arterial lumen by the thrombus and formation of microthrombi at sites independent of the parasites. release of vasoconstrictive inflammatory mediators such as leukotrienes from platelets, neutrophils, and eosinophils and elaboration of parasitic antigens or toxins may cause vasoconstriction and ischemia. horses with experimental strongylosis were found to have a % reduction of blood flow in the colonic vasculature. clearly, reduced blood flow is an important effect of chronic strongylosis, but the relationship between blood flow and diarrhea is unclear. disrupted motility resulting from ischemia may lead to diarrhea by reducing the retention of ingesta and absorption of fluid. acute infarction and mucosal ulceration have been found to cause severe chronic diarrhea in naturally infected horses. release of inflammatory mediators such as prostaglandins, histamine, and kinins from inflammatory cells associated with thrombi and inflamed intestine also may affect secretion, absorption, and motility, leading to diarrhea. the clinical signs of acute strongylosis caused by s. vulgaris infection are characterized by depression, moderate to severe colic, and fever. diarrhea is less often a feature of acute strongylosis than is colic. most cases of acute strongylosis occur in young, naïve horses that are introduced to an infested environment or are inoculated experimentally with infective larvae. this form of strongylosis often is not recognized naturally. chronic strongylosis, however, occurs most commonly as a natural syndrome. weight loss or poor weight gain; chronic, intermittent colic; fever; poor appetite; and diarrhea are frequent signs. , diarrhea may be profuse and watery, or the feces may be soft but of normal volume. transrectal palpation may reveal thickening and fremitus in the cranial mesenteric artery. young horses are most commonly affected, but older horses also may be affected. horses with acute infarction or large intestinal ulceration following chronic strongylosis may have signs of severe abdominal pain, sepsis, and endotoxemia, and profuse, watery diarrhea is common. hematologic abnormalities associated with strongylosis include neutrophilic leukocytosis and eosinophilia. [ ] [ ] [ ] neutrophilia appears to be an early event during the course of the disease, and eosinophilia tends to appear later. , hyperfibrinogenemia also may occur, especially later in the course of the disease. serum αand β-globulin and igg(t) concentrations are characteristically elevated. [ ] [ ] [ ] horses with chronic ulcerative colitis following strongylosis may exhibit severe hypoalbuminemia. peritoneal fluid analysis may reveal an elevated protein concentration and eosinophilia. , tentative diagnosis is based on clinical signs, hematologic abnormalities, and peritoneal fluid analysis. elevated serum αand β-globulin concentrations and igg(t) concentration support the diagnosis. fecal analysis may reveal strongyle eggs, but fecal egg counts are often unreliable because nonpatent larvae cause the disease. appropriate preventive measures are important in controlling this disease, including management procedures such as preventing overcrowding, reducing exposure of susceptible individuals, and instituting proper deworming schedules. ivermectin is the preferred anthelmintic used to control strongylosis in horses. monitoring fecal egg counts as a means of evaluating the efficacy of parasite control measures is recommended. infection with small strongyles (cyathostomiasis) is well recognized as a cause of diarrhea and large intestinal disease in horses of all ages. [ ] [ ] [ ] [ ] [ ] [ ] clinical disease is caused by intramural larval stages. the cyathostome life cycle requires migration by fourth-stage larvae through the mucosa of the large intestine and may include a period of hypobiosis during which the larvae remain encysted within the mucosal layer of the large intestine. after a period of hypobiosis the larvae emerge in response to a largely unknown stimulus. most cases occur when larval emergence takes place, classically in the late winter and spring in the northern temperate zones when larvae are expected to emerge and in the late fall or winter months in the southeastern united states and subtropical regions. sudden emergence of encysted larvae causes the mucosal injury, ulceration, and inflammatory reaction responsible in large part for the clinical disease. , however, migration of the larvae as they penetrate the mucosa affects motility patterns and can cause inflammation that may contribute to diarrhea. chronic, eosinophilic, granulomatous colitis and diarrhea with histopathologic evidence of hypobiotic cyathostome larvae in the large intestine have been reported in two horses during a period in which emergence of larvae would not be expected to occur (early winter). natural emergence of cyathostome larvae causes fibrinous inflammation of the large intestine, focal necrosis, mural hemorrhage, and ulceration of the large intestinal mucosa, which even may result in bleeding into the lumen. mild to moderate eosinophilic and mononuclear inflammation of the lamina propria occurs, and moderate to severe interstitial edema frequently occurs. , colonic inflammation and interstitial edema may contribute to the diarrhea, along with the loss of the mucosal barrier, by causing increased active and passive secretion of fluid, electrolytes, and protein. protein loss is often significant, resulting in profound hypoalbuminemia and interstitial edema of skin and other organs. chronic, granulomatous colitis has been reported to occur in response to encysted larvae and may cause diarrhea by increased secretion following granulomatous inflammation or disruption of the interstitium by granulomatous infiltration. administration of an anthelmintic to horses with a heavy load of encysted larvae also may cause rapid larval death and acute and often severe inflammation similar to natural emergence. cyathostomiasis may be the most commonly identified cause of chronic diarrhea in the horse. [ ] [ ] [ ] however, an acute syndrome also has been associated with cyathostomiasis. clinical signs of cyathostomiasis are characterized by moderate to severe weight loss or poor weight gain, ill thrift, ventral edema, intermittent fever, and intermittent, mild colic. acute onset of diarrhea is typically profuse and progresses to chronic diarrhea that is often mild, is the consistency of bovine feces, and may be intermittent. [ ] [ ] [ ] [ ] [ ] [ ] appetite is usually normal, but affected horses occasionally have a ravenous appetite. transrectal palpation usually does not reveal any abnormalities. cyathostomiasis may affect any age of horse, and clinical signs are more common during periods of emergence of larvae, corresponding to late winter and spring in northern temperate zones. the deworming history may appear to be adequate. neutrophilic leukocytosis is typically evident, but the white blood cell count may be normal. [ ] [ ] [ ] [ ] [ ] [ ] profound hypoalbuminemia is a characteristic feature of cyathostomiasis, manifested clinically by ventral edema. plasma αand β-globulin concentrations may be elevated, which can result in a normal total plasma protein concentration in spite of hypoalbuminemia. [ ] [ ] [ ] the serum igg(t) concentration, however, has been reported to be normal, which may help distinguish cyathostomiasis from s. vulgaris infection. , , in addition, peritoneal fluid analysis does not usually reveal any abnormalities, in contrast to horses with s. vulgaris infection. fecal analysis may be unrewarding because the infection is often not patent when clinical signs are apparent. measurement of plasma fructosamine may provide a measure of protein catabolism or protein loss in the absence of hypoalbuminemia. plasma fructosamine concentrations are significantly lower in horses with experimental cyathostomiasis than in normal controls, , suggesting that this test may be a useful diagnostic tool. however, the test has not yet been validated in naturally occurring cases, and neither the specificity nor the sensitivity is known. rectal scrapings or rectal mucosal biopsies may reveal evidence of cyathostome larvae. , definitive diagnosis usually requires microscopic examination of biopsy specimens of the cecum and ascending colon, collected by laparotomy. examination of biopsy specimens collected from the small intestine is recommended to rule out other causes of weight loss and diarrhea. one should include appropriate diagnostic tests, such as culture of feces for pathogenic bacteria, in the workup to rule out other causes. preventive measures are appropriate for other horses on premises known to have a problem with cyathostomiasis, particularly frequent deworming (every weeks) during times of high infectivity (spring and summer in the north and fall, winter, and early spring in the south) to eliminate parasites before they become patent. because of high levels of resistance to benzimidazoles, avermectins (ivermectin or moxidectin) are the drugs of choice. [ ] [ ] [ ] resistance to ivermectin has been demonstrated, but the prevalence of ivermectin resistance appears to remain low. although daily pyrantel pamoate administration also has been reported to reduce worm burdens and pasture infectivity in young and mature horses effectively, cyathostome resistance has been reported and is a concern for the use of this drug as a routine preventive anthelmintic. , diarrhea in adult horses may also occur secondary to administration of antimicrobial or antiinflammatory medications or after ingestion of toxic compounds. affected horses exhibit clinical signs that may be indistinguishable from signs exhibited by horses with diarrhea of infectious etiology. antibiotic-associated diarrhea has been reported in many species, including horses. certain antibiotics-such as trimethoprim-sulfonamide combinations, erythromycin, penicillins, tetracyclines, clindamycin, and lincomycinare associated with naturally occurring and experimental enterocolitis syndromes in horses. , [ ] [ ] [ ] [ ] in some cases, such as with trimethoprim-sulfonamide combinations, the geographic incidence of antibiotic-associated diarrhea appears to differ considerably. clostridium perfringens, c. difficile, and salmonella spp. are apparently the most common causes of antibioticassociated diarrhea in horses. outbreaks of c. difficile have been reported in hospitalized horses being treated with antibiotics. , in sweden, accidental erythromycin ingestion has been associated with c. difficile enterocolitis in mares in which their foals were being treated for rhodococcus equi. , , interestingly, this phenomenon has not been reported in other areas of the world. foals being treated with erythromycin are at a higher risk for diarrhea than foals being treated with other antibiotics. tetracycline administration has been shown to be associated with an increase in the numbers of gram-negative enteric bacteria and c. perfringens in the feces of horses and reactivation of salmonellosis and prolongation of fecal shedding of salmonella. , the most common mechanism by which antibiotics cause diarrhea is by disrupting the gastrointestinal flora. the normal large intestinal flora, comprised of mainly obligate anaerobes and streptococci, protects the host from pathogenic bacteria by colonization resistance. ecologic factors play an important role in colonization resistance. for example, surface bacteria in the large intestine interact with receptors on the mucosal cells, facilitating adherence to the mucosa. , in doing so, the normal organisms compete more successfully for this important niche. competition for space and nutrients is an important means of preventing colonization and proliferation of pathogenic bacteria. in addition, anaerobic bacteria produce short-chain fatty acids (scfas) and other metabolites that are toxic to facultative anaerobic bacteria, especially in the conditions of the large intestine. , , organisms of the normal flora also produce bacteriocins that inhibit growth of potential pathogens. antibiotics that deplete the population of obligate anaerobes and streptococci efficiently decrease colonization resistance. production of fatty acids diminishes, thus reducing competition for space and nutrients. as a result, gram-negative enteric bacteria such as salmonella are able to proliferate. in addition, pathogenic anaerobes normally found in low numbers can proliferate. antibiotic-resistant strains of bacteria, especially gram-negative enteric bacteria and possibly clostridia, may be selected by antibiotic administration, allowing proliferation of pathogenic bacteria resistant to many antibiotics. obligate anaerobic commensal organisms, perhaps the most critical group of microbes for maintaining colonization resistance, are usually susceptible to macrolides, tetracyclines, β-lactams, and lincosamides, perhaps explaining the high incidence of diarrhea associated with the administration of these antibiotics. in addition to reduction of colonization resistance, depletion of the normal anaerobic microbial population in the intestine decreases carbohydrate fermentation and production of scfas, which contributes to the pathogenesis of antibiotic-associated diarrhea by decreasing absorption of sodium and water by the colonic mucosa. ampicillin decreases colonic fermentation of carbohydrates in human beings. human patients with antibioticassociated diarrhea have greatly impaired colonic fermentation and low production of scfas. erythromycin, ampicillin, or metronidazole treatment is associated with decreased production of scfas in patients with and without diarrhea. absorption of sodium and water is stimulated by absorption of scfas in the equine colon, suggesting that reduction of colonic scfa content by antibiotic-induced depletion of anaerobic flora has similar effects in horses as in human beings. broad-spectrum antibiotics exert a more profound effect on the gastrointestinal flora than narrow-spectrum antibiotics. antibiotics administered orally, especially those that are poorly absorbed, are more likely to cause diarrhea than are parenterally administered antibiotics. for instance, clindamycin is less likely to cause diarrhea in human beings when administered intravenously than when administered orally. antibiotics with extensive enterohepatic circulation, such as tetracyclines and erythromycin, are excreted in high concentrations in the bile and are associated more commonly with diarrhea than antibiotics that do not undergo enterohepatic circulation. antibiotics may cause diarrhea by means other than by disrupting the normal flora. direct toxic effects may play a role in producing irritation, increasing secretion, and disrupting motility patterns. tetracyclines are irritating to the gastrointestinal mucosa and may cause inflammation and increase secretion. erythromycin has been shown to interact with smooth muscle cells, stimulating gastrointestinal motility. , normal peristalsis plays an important role in suppressing the population size of potentially pathogenic bacteria. normally, bacteria that are prevented from adhering to the mucosa by colonization resistance are swept aborally by peristalsis and are excreted in the feces. disruption of normal motility patterns may prevent clearance of pathogenic bacteria, contributing to the colonization of mucosal surfaces. diarrhea induced by antibiotics usually occurs within days of antibiotic administration or can occur several days after cessation of antibiotic treatment. the clinical syndrome of antibiotic-associated diarrhea can vary from mild diarrhea to fulminant enterocolitis with severe diarrhea. mild cases of diarrhea are common, especially in foals receiving erythromycin, trimethoprim-sulfonamide combinations, or rifampin. , mild cases of diarrhea are usually not clinically significant. however, acute, severe enterocolitis can occur in all ages of horses receiving antibiotics and can be life threatening. clinical signs are identical to other causes of acute enterocolitis. severe, dehydrating diarrhea, endotoxemia, sepsis, and shock may occur. hemoconcentration, neutropenia, hypoproteinemia, and electrolyte and acid-base imbalances are common. severe hyponatremia may occur in foals with antibiotic-associated diarrhea, especially if trimethoprimsulfonamide and rifampin combinations are the cause. more detailed descriptions of the clinical and laboratory findings were given previously. diagnosis is presumptive, because definitive diagnosis of antibiotic-associated diarrhea is impossible. fecal culture and pcr testing may reveal salmonella or clostridium infection. toxicity resulting from nonsteroidal antiinflammatory drug (nsaid) administration has been well documented in several species, including horses. [ ] [ ] [ ] [ ] [ ] [ ] [ ] in horses and human beings, nsaid toxicity is manifested by renal and gastrointestinal disease. elderly human patients are more susceptible to nsaid toxicity, but the effects of age on nsaid toxicity in horses are less well defined. foals are considered to be more susceptible than adult horses to gastrointestinal disease following nsaid administration, and ponies may be more susceptible than horses. all nsaids are capable of inducing gastrointestinal and renal damage at toxic concentrations, and the toxicity is not significantly different among products. aspirin is potentially more toxic than other nsaids because it irreversibly inactivates cyclooxygenase by acetylation, whereas other nsaids reversibly inhibit cyclooxygenase. however, phenylbutazone is the drug most commonly reported to cause toxicity in horses, perhaps because of its widespread use by veterinarians and horse owners. phenylbutazone toxicity in horses is characterized by mucosal ulceration throughout the gastrointestinal tract, oral ulceration, renal papillary necrosis, vasculopathy, thrombosis, and protein-losing enteropathy with hypoalbuminemia. [ ] [ ] [ ] this discussion focuses on the toxic effects of nsaids on the large intestine but necessarily includes elements of upper gastrointestinal and renal disease. horses with large intestinal disease resulting from nsaid toxicity generally are receiving inappropriately large doses. the dosage regimen recommended for phenylbutazone ( . mg/kg twice in day and then . mg/kg twice daily) is considered to be safe. experimental studies in horses, however, have shown toxicity to occur when greater than the recommended dosage ( . mg/kg/day) is administered for several days. , in most reported cases of phenylbutazone toxicosis horses were receiving higher than recommended dosages. , , regardless, administration of phenylbutazone at the recommended dosage has been reported to cause a significant decrease in plasma protein concentration and gastrointestinal disease. , moreover, signs of nsaid toxicity have been reported in normovolemic horses treated with appropriate doses of phenylbutazone. , dehydration, sepsis, and endotoxemia exacerbate the renal and gastrointestinal toxicity of nsaids. clearly, the margin of safety is narrow for phenylbutazone and probably for other nsaids used in horses as well. gastrointestinal disease induced by nsaids is manifested by mucosal ulceration, inflammation, bleeding, and protein-losing enteropathy. , , , in addition to direct effects on the mucosal barrier, nsaid administration has been shown to cause an acute relapse of preexisting colonic inflammatory disease and worsen colonic inflammation in human beings. , , whether this occurs in horses is not clear. the mechanism by which nsaids induce mucosal damage is probably multifactorial. direct irritation may play a role in oral and gastric irritation and ulceration; however, parenteral administration of nsaids produces oral and gastric ulceration as well. inhibition of prostaglandin synthesis by inhibition of cyclooxygenase (the constitutive cox) and cyclooxygenase (the inducible cox) appears to be the most important mechanism of mucosal injury. prostaglandins, particularly pge and pgi , are critical for mucosal health. , pge has been shown to increase mucosal blood flow; increase secretion of mucus, water, and bicarbonate; increase mucosal cell turnover rate and migration; stimulate adenyl cyclase activity; and exert other protective effects in the gastric mucosa of several species. , , perhaps most importantly, pge and pgi have a role in maintaining epithelial tight junction integrity, which is indispensable for mucosal barrier function and repair after mucosal injury. in spite of the overwhelming amount of information about the role of prostaglandins in maintaining the mucosal barrier in other species and clear clinical and experimental evidence that nsaids injure the equine colonic mucosa, the role of prostaglandins in mucosal protection in the equine colon is not yet well defined. inhibition of cox- and cox- in equine colonic mucosa with flunixin meglumine resulted in reduced electric resistance of the mucosa and increased permeability to macromolecules in vitro (a.t. blikslager and s.l. jones, ) , suggesting that flunixin treatment disrupts the epithelial tight junctions in the equine colon. mucosal changes were correlated with a profound inhibition of pge and pgi concentrations in the treated tissues. in other studies, administration of a pge analog prevented the gastrointestinal manifestations of phenylbutazone toxicosis in ponies. recent development of nsaids specific for cox- have greatly reduced the frequency and severity of gastrointestinal side effects in human beings taking nsaids for chronic musculoskeletal conditions. thus cox- -specific nsaids hold promise for use in horses to treat arthritis and reduce the incidence of toxicity. for example, the cox- -specific inhibitor etodolac was less harmful to equine colonic mucosa than flunixin meglumine in vitro (a.t. blikslager and s.l. jones, ) . moreover, etodolac was significantly more permissive than flunixin for recovery of the mucosa in equine ischemic-injured intestinal tissues, and in fact, recovery was no different than control tissues. however, their use is at present limited because the specificity of the so-called cox- selective inhibitors and their efficacy as analgesics have not been demonstrated in the horse. nsaid-induced mucosal injury is associated with a significant inflammatory response to microbial products exposed to the lamina propria. this inflammation exacerbates mucosal dysfunction and injury associated with nsaid toxicity. for example, depletion of neutrophils or blockade of neutrophil influx into gastrointestinal tissues or inhibition of neutrophil activation and release of toxic products prevents many of the pathophysiologic effects of nsaid toxicity in the gastrointestinal tract. [ ] [ ] [ ] [ ] the inflammatory response alone may result in moderate to severe gastrointestinal ulceration, mural vascular thrombosis and edema, fluid secretion, protein-losing enteropathy, and mucosal hemorrhage. nsaid colitis manifests as two clinical syndromes: right dorsal colitis (rdc) and generalized nsaid toxicity. rdc is an ulcerative disorder isolated to the right dorsal segment of the large intestine. , , the most prominent clinical signs of rdc are anorexia, lethargy, and colic. anorexia, depression, diarrhea, fever, and signs of section . inflammatory diseases of the gastrointestinal tract causing diarrhea endotoxemia also may be features. if the rdc is chronic, weight loss, intermittent colic, lethargy, anorexia, and ventral edema are common clinical signs, along with soft and unformed feces. severe ulceration of the right dorsal colonic mucosa results in proteinlosing enteropathy and significant hypoproteinemia attributable mainly to hypoalbuminemia. hypoproteinemia may be severe enough to cause peripheral (usually ventral) edema.in some cases, one may note dehydration, electrolyte abnormalities, neutropenia or anemia, azotemia, and biochemical abnormalities if the ulceration and diarrhea are severe or if systemic inflammation is present. clinical signs of generalized nsaid toxicity may vary from mild diarrhea with no systemic signs to severe dehydrating diarrhea with anorexia, fever, depression, peripheral edema, oral ulceration, and colic. , , clinical signs of systemic inflammation caused by endotoxemia may occur, manifested as poor peripheral perfusion, tachycardia, tachypnea, weakness, trembling, and cyanotic or hyperemic oral mucous membranes. hematuria or oliguria may be present if renal involvement is present. complications associated with other forms of severe enterocolitis, such as laminitis, thrombophlebitis, and severe weight loss, may occur. hematologic abnormalities of generalized nsaid toxicity are nonspecific and include neutropenia with a left shift or leukocytosis and hemoconcentration. serum biochemical analysis is characterized by profound hypoproteinemia, hyponatremia, and metabolic acidosis. , hypocalcemia, hypokalemia, hypochloremia, and elevated hepatocellular enzyme activities also may occur. hypoproteinemia may occur without signs of diarrhea. azotemia may be prerenal from dehydration but frequently is caused by renal failure resulting from a combination of hemodynamic and toxic renal injury. urinalysis frequently reveals hematuria, proteinuria, cylindruria, and isosthenuria. fecal occult blood is frequently detectable. diagnosis of either form of nsaid colitis is often presumptive, with a history of overdose of nsaids being strong evidence of nsaid toxicity. but as discussed earlier, toxicity may occur with dosage regimens that are not considered inappropriate, particularly if the horse experiences a concurrent period of dehydration. one can use ultrasonographic examination of the right dorsal colon to confirm a diagnosis of rdc, but the sensitivity of this method is questionable. ultrasonography ( . -to -mhz transducer at the right twelfth to fifteenth intercostal spaces below the margin of the lung axial to the liver) may reveal a thickened right dorsal colon (> . cm) and evidence of colonic edema in horses with rdc. however, the sensitivity of this method of diagnosis is questionable. one can use nuclear scintigraphy of horses after infusion with technetium -labeled white blood cells to document inflammation of the right dorsal colon. diagnosis of rdc may require one to perform laparotomy or laparoscopic examination of the right dorsal colon. one must rule out other causes of enterocolitis, such as salmonellosis, potomac horse fever, clostridiosis, and antibiotic-associated diarrhea. cantharidin is the toxic principle found in beetles of the genus epicauta, commonly known as blister beetles. [ ] [ ] [ ] ingestion of the beetles in contaminated alfalfa hay causes release of the toxin from the tissues of the beetle and absorption through the gastrointestinal tract. transcutaneous absorption may occur but appears to be rare in horses. blister beetles feed on the flowers of alfalfa and may be incorporated into processed alfalfa hay if the hay is cut and processed simultaneously, as by crimping. [ ] [ ] [ ] the beetles often swarm, and one may find large numbers of beetles in small portions of hay. the lethal dose of cantharidin is less than mg/kg, but the concentration of cantharidin varies from species to species of blister beetles and between sexes. , as many as to as few as to beetles may be lethal. usually, only one or a few horses fed contaminated hay ingest beetles because the beetles are concentrated in a small portion of the hay. however, outbreaks involving many horses on a farm have occurred. most cases occur in texas and oklahoma, but horses in other states may be affected as well, especially if hay is imported from states where blister beetles are common. peak incidence is in late summer and fall. the fatality rate may be % or greater, , but if the patient survives several days, recovery is probable. cantharidin is absorbed from the gastrointestinal tract and excreted via the kidney. cantharidin is a potent irritant, causing acantholysis and vesicle formation when applied topically. , , the chemical is thought to disrupt oxidative metabolism in the mitochondria, causing mitochondrial swelling, plasma membrane damage, and changes in membrane permeability. the mucosa of the gastrointestinal tract is affected most commonly in horses because they ingest the toxin. cell swelling and necrosis occur, resulting in mucosal ulceration. oral, esophageal, gastric, and small and large intestinal ulceration have been observed in natural and experimental canthariasis. , , severe fibrinous to pseudomembranous inflammation and submucosal edema of the intestine also have been reported. diarrhea probably results from the severe ulceration and inflammation of the large intestine, causing increased secretion of water, electrolytes, and protein and decreased absorption of fluid. large volumes of fluid and protein are lost in the gastrointestinal tract, causing hemoconcentration and profound hypoalbuminemia in some cases. , , cystitis and myocarditis occur in natural and experimentally produced cases of cantharidin toxicity. , , cystitis occurs because renal excretion of cantharidin results in high concentrations in urine. occasionally, hemorrhagic cystitis may occur, with hematuria or frank hemorrhage into the bladder. the cause of the myocarditis and myocardial necrosis is unknown but also may be a direct effect of the toxin on the myocardium. elevated plasma creatine kinase activity often occurs and has been postulated to arise from the damaged myocardium. , horses have a characteristically stiff gait, but histopathologic evidence of skeletal muscle injury that explains the elevated plasma creatine kinase activity has not been observed. the kidneys are often pale, swollen, and moist, with occasional infarcts. hypocalcemia and hypomagnesemia are biochemical features of cantharidin toxicity in horses that have not been explained. , , hypocalcemia may occur from hypoalbuminemia, but the ionized calcium concentration often is decreased along with the total calcium concentration, indicating that hypoalbuminemia is not responsible for the hypocalcemia. in addition, clinical signs of hypocalcemia, such as synchronous diaphragmatic flutter, are often associated with hypocalcemia from cantharidin toxicity. hypocalcemia associated with hypoalbuminemia alone does not produce clinical signs. cantharidin toxicity can cause a range of clinical signs from mild depression and abdominal discomfort to fulminant signs of toxemia and rapid death, depending on the ingested dose of toxin. most commonly, clinical signs include depression, sweating, irritability, abdominal pain, elevated heart and respiratory rates, fever, polyuria, polydypsia, and profuse diarrhea. , , blood is rarely visible in the feces. affected horses frequently posture to urinate; indeed, stranguria and pollakiuria are characteristic of cantharidin toxicity. signs of hypocalcemia include synchronous diaphragmatic flutter and tremors. a stiff and stilted gait may be evident. one may note neurologic signs such as head pressing, swaying, and disorientation. signs of systemic inflammation from endotoxemia may be apparent in severe cases. some horses develop severe depression and toxemia and may die within hours after ingestion of cantharidin without developing diarrhea. , hematologic abnormalities include hemoconcentration and neutrophilic leukocytosis. occasionally, neutropenia and leukopenia may accompany endotoxemia. serum biochemical analysis usually reveals elevated creatine kinase activity, hypocalcemia, and hypoalbuminemia. , biochemical abnormalities include hypocalcemia (ionized and total calcium concentrations), hypomagnesemia, and azotemia. , , urine specific gravity is characteristically in the hyposthenuric range. , microscopic hematuria and mild proteinuria may be evident. fecal occult blood is often present, but hematochezia is unusual. one can make a tentative diagnosis based on clinical signs and the finding of blister beetles in the hay. determining the species of the insects may be necessary to estimate the amount of cantharidin ingested. all species of epicauta contain cantharidin, but some have small amounts. definitive diagnosis requires the measurement of the cantharidin concentration in gastric or intestinal contents and urine. , measurement of cantharidin concentration in the beetles is often done but is not necessary. arsenic toxicosis is an unusual cause of diarrhea in horses, resulting from ingestion of arsenic-containing herbicides, insecticides, and other pest control products contaminating water or roughage used as a food source. the toxicity of arsenic depends on the valence of the element. , arsenate may be reduced to arsenite in mammalian systems, and arsenite is thought to be more toxic than arsenate and less rapidly excreted in urine. arsenate and arsenite uncouple oxidative phosphorylation, leading to breakdown of energy metabolism in the cells of many tissues. widespread cellular injury and death occur rapidly during acute arsenic toxicosis. multiorgan failure usually results. in fact, cardiomyopathy and pulmonary disease are common causes of death in human beings. damage to the large intestine is probably caused in part by direct cellular toxicity and corrosion by the compound. however, vasculitis is a hallmark of the disease in human beings and horses and is thought to be the most important mechanism of large intestinal disease in human beings. , acute hemorrhagic colitis is a feature of arsenic toxicosis, with severe mural edema and mucosal ulceration. profuse, hemorrhagic diarrhea and abdominal pain result. chronic arsenic toxicity can occur but appears to be rare in horses. acute depression, weakness, abdominal pain, hemorrhagic diarrhea, and shock are characteristic of acute arsenic toxicosis in horses. death may occur before diarrhea is evident. initial clinical signs may be difficult to distinguish from other peracute forms of colitis and are related to endotoxic shock, metabolic disturbances, and dehydration. later, cardiac arrhythmias, pulmonary edema, acute renal failure, and neurologic deficits (ataxia and stupor) may develop. one may observe anuria or polyuria. hemolytic anemia caused by preferential binding of arsenic compounds to red blood cells is a feature of arsenic poisoning in human beings. hematologic abnormalities may be apparent after the peracute stages from injury to bone marrow cells and ongoing hemolysis. leukopenia and thrombocytopenia have been described in human patients. serum biochemical analysis may reveal azotemia, hepatocellular enzyme activities higher than generally attributed to endotoxemia, and elevated creatine kinase activity. urine specific gravity may be in the isosthenuric range, with hematuria, cylindruria, and proteinuria evident by urinalysis. diagnosis may be possible by measuring blood and urine arsenic concentration, but these tests may not be diagnostic. postmortem diagnosis is by measuring the arsenic concentration in liver and kidney samples. history of exposure and clinical signs remain the primary means of diagnosis. other disorders associated with diarrhea in adult horses include anaphylaxis, carbohydrate overload, and sand enteropathy. careful evaluation of history, environment, and management will assist the clinician in arriving at an accurate diagnosis. severe intestinal anaphylaxis is a syndrome in horses characterized by peracute, rapidly fatal colitis. the severe syndrome is clinically and pathologically similar to other known causes of peracute colitis, such as salmonellosis, clostridiosis, and antibiotic-associated diarrhea. some cases are less severe and manifest as mild to moderate diarrhea or colic. an ige-mediated type i hypersensitivity or an ige-independent anaphylactoid reaction can produce the syndrome of intestinal anaphylaxis. , local gastrointestinal exposure to a food, environmental contaminant, drug, or other allergen usually induces intestinal anaphylaxis, , but anaphylaxis also may occur with systemic exposure to an allergen. [ ] [ ] [ ] [ ] massive mast cell degranulation, secretion of inflammatory mediators, and activation of enteric neural reflexes in the intestine causes profound alterations in blood flow, increased vascular permeability and interstitial edema, recruitment of neutrophils, altered motility, mucosal injury, absorption of microbial products, and mucosal hypersecretion. [ ] [ ] [ ] [ ] [ ] systemic signs may be caused by the anaphylactic reaction or may be associated with systemic inflammation triggered by microbial products (endotoxin) absorbed through the injured and hyperpermeable mucosa. intestinal anaphylaxis in horses may be a peracute, fulminant enterocolitis with endotoxemia that may be fatal. , this form is characterized by severe intramural edema and hemorrhagic inflammation of the large intestine, often producing submucosal thickening on the order of many centimeters. vascular thrombosis may be widespread with mucosal and serosal petechia and ecchymoses. less severe forms of intestinal anaphylaxis may manifest as patchy areas of intestinal edema and congestion. diarrhea results from intestinal inflammation initiated by the type i hypersensitivity response. many of the mediators of type i hypersensitivity, such as histamine and -hydroxytryptamine, have well-documented stimulatory effects on mucosal secretory activity, vascular and epithelial permeability, and motility [ ] [ ] [ ] in the intestine. systemic inflammation from endotoxemia may be overwhelming once the mucosal barrier breaks down. infarction of intestinal segments and other organs may occur from intravascular coagulation. ileus, abdominal distention, and moderate to severe abdominal pain may result from motility disturbances and infarction of the large intestine. the clinical signs are similar to those described for other forms of peracute colitis. however, the severity may vary, manifesting as colic or moderate diarrhea. characteristically, severe shock, signs of systemic inflammation from endotoxemia, and severe metabolic disturbances are observable. , heart and respiratory rates may be elevated greatly, with other signs of cardiovascular collapse such as weak and thready peripheral pulses and peripheral vasoconstriction. however, peripheral vasodilation may occur later in the course of disease. dark red, muddy, or cyanotic mucous membranes with a prolonged capillary refill time signify sepsis. borborygmi are usually absent, and abdominal tympany may be heard on percussion, following ileus. moderate to severe colic may accompany ileus. severe diarrhea may occur, but death may occur before diarrhea is evident. multiorgan failure from disseminated intravascular coagulation is not unusual. rapid onset of weakness, staggering, and trembling commonly precedes death. the syndrome may cause death in to hours. hematologic abnormalities include severe neutropenia and leukopenia, thrombocytopenia, and hemoconcentration. serum biochemical alterations include hyponatremia, hypokalemia, hypocalcemia, and severe metabolic acidosis. blood urea nitrogen and creatinine may be elevated from prerenal or renal azotemia. if acute renal failure accompanies the colitis, hyperkalemia may result. hepatocellular enzyme activity may be elevated in the serum from endotoxemia. severe coagulopathies are common, resulting in prolonged coagulation times, elevated fibrinogen, decreased antithrombin iii activity, and elevated plasma concentration of fibrin degradation products. analysis of peritoneal fluid may be valuable because infarction of the large intestine is not unusual. protein concentration and the white blood cell count may be elevated. red blood cell counts are less likely to be elevated, because infarction and not strangulation of the intestine occurs. diagnosis is based on clinical signs, postmortem findings, and exclusion of other causes. cultures and toxicologic analysis of fecal samples and gastrointestinal tissues fail to demonstrate a clear cause. other diagnostic tests are also inconclusive. if an antigen is suspected as the trigger of the anaphylaxis, a prausnitz-küstner passive cutaneous anaphylaxis sensitization test can confirm the presence of antigen-specific ige in the patient serum. overeating of soluble carbohydrates, especially so-called hot grains such as corn, overwhelms the digestive capability of the small intestine, resulting in a high percentage of the soluble carbohydrates entering the large intestine. the amount of soluble carbohydrates that produce diarrhea varies according to the previous dietary history of the individual. horses fed diets higher in soluble carbohydrates are more resistant to the deleterious effects of carbohydrate overload. gradual accommodation to a diet high in carbohydrates can be accomplished over several weeks. however, horses fed an unusually large amount of grains or other form of soluble carbohydrates often develop diarrhea and may, depending on the amount ingested, develop severe colitis, systemic inflammation from endotoxemia, metabolic acidosis, and laminitis. [ ] [ ] [ ] [ ] the pathogenesis of colitis from carbohydrate overload is caused primarily by the toxic effects on the microbial flora in the large intestine. a sudden delivery of soluble carbohydrates to the large intestine causes rapid fermentation by gram-positive lactic acid-producing bacteria and a sudden increase in organic acid production. the cecal ph rapidly decreases, and the lactic acid concentration rapidly increases. rapid organic acid production overwhelms the buffering capacity of the large intestine not only by directly depleting the buffers found in the contents but also by reducing the efficiency of buffer secretion. bicarbonate secretion is linked to absorption of volatile fatty acids, which are produced in low amounts by fermentation of soluble carbohydrates. the contents of the large intestine become profoundly acidic, resulting in unfavorable conditions for the microbial flora. lactic acid-producing bacteria flourish, while the gram-negative bacteria, especially the enterobacteriaceae, are killed in large numbers by the acids. large quantities of endotoxin are released from the dying bacteria. the osmotic load from the lactic acid produced in the large intestine is an important factor in the development of diarrhea because organic acids such as lactic acid are absorbed poorly. mild cases of carbohydrate overload may result purely from osmotic diarrhea. in more severe cases, the acidic contents of the large intestine are toxic to the mucosa, causing necrosis of the mucosal tissues, similar to that occurring in ruminal acidosis. mucosal ulceration allows absorption of large quantities of endotoxin and lactic acid produced by the massive die-off of acid-intolerant microbes and fermentation of soluble carbohydrates, normally poorly absorbed by intact mucosa. systemic inflammation from endotoxemia may be overwhelming, and profound metabolic acidosis may occur. secretory diarrhea caused by the direct effects of acid luminal contents on the mucosa, as well as the effects of inflammatory mediators on enterocyte secretion, worsens the acidosis and dehydration. systemic inflammation from endotoxemia, along with intestinal inflammation, adversely affects intestinal motility, and ileus develops. ileus and gas production from fermentation of the carbohydrates may cause severe distention of the large intestine and signs of abdominal pain. laminitis is a frequent complication of endotoxemia and lactic acidosis. in fact, carbohydrate overload is used to induce laminitis as an experimental model because of the consistency of the laminitis produced. [ ] [ ] [ ] clinical signs of colitis from carbohydrate overload can vary according to the amount of carbohydrates ingested and accommodation of the flora to a high-carbohydrate diet. mild cases may result in a transient osmotic diarrhea with no systemic effects. more severe cases are characterized by signs similar to those described for other forms of colitis, including abdominal pain, moderate to severe diarrhea, and dehydration. signs of endotoxemia and sepsis are frequently present in severe cases. elevated heart and respiratory rates are common, with peripheral vasoconstriction early in the disease, followed by peripheral vasodilation as the disease progresses. depression may be profound from metabolic acidosis and endotoxemia. abdominal auscultation and percussion may reveal ileus and intestinal tympany. nasogastric intubation may yield significant gastric acidic reflux. one may note particles of grain in the gastric reflux and the feces, if grain overload is the source of the carbohydrate overload. laminitis may complicate mild and severe cases of carbohydrate overload, especially if the animal has had previous bouts of laminitis. hematologic abnormalities include neutropenia and leukopenia. severe dehydration may result in profound hemoconcentration. protein loss later in the course of disease may result in hypoproteinemia. serum biochemical abnormalities include azotemia, elevated hepatocellular enzyme activity, hyponatremia, and hypokalemia. severe hypocalcemia and metabolic acidosis are characteristic of the disease. serum lactate concentrations are elevated in the absence of evidence of intestinal strangulation or infarction. peritoneal fluid analysis often reveals no abnormalities. sand enteropathy is described in more detail under the heading of obstructive diseases, because acute obstruction is often associated with abnormally large amounts of sand in the large intestine. however, chronic sand-induced diarrhea is a distinct syndrome that can occur at any age from abnormal accumulation of sand in the large intestine. , chronic diarrhea and signs of colic may occur without obstruction. the pathogenesis of sand accumulation in individual horses, other than simple ingestion of large quantities, is unclear. presumably the sand causes irritation and may disrupt motility, leading to diarrhea. the diarrhea is usually not severe and dehydrating and may be intermittent. weight loss is characteristic and can be severe in some cases. complications may occur such as peritonitis and acute obstruction. diagnosis usually is based on finding abnormal amounts of sand in the feces. because sand-induced chronic diarrhea is associated primarily with sand accumulation in the ventral colon, auscultation of the ventral abdomen immediately behind the xiphoid process may reveal characteristic sand sounds. this technique is only sensitive if peristalsis is present. ultrasonography also may be useful to identify sand in the ventral colon but is not useful to quantitate the amount of sand. occasionally, radiography may be required to detect sand in the colon. the principles of therapy of acute diarrhea from colitis are similar regardless of the cause and include replacement of fluid and electrolyte losses, control of colonic inflammation and reduction of fluid secretion, promotion of mucosal repair, control of endotoxemia and sepsis, and reestablishment of normal flora. this section focuses on a review the principles of therapy with references to specific therapies for particular causes as they arise. replacement of fluid and electrolyte losses is of primary concern in treating horses with salmonellosis. depending on the severity of the disease, fluid losses may be minimal or massive. one can administer fluid and electrolytes orally or intravenously. some horses with mild to moderate diarrhea may maintain hydration and electrolyte balance by consuming water and electrolytes voluntarily. freshwater and water containing electrolytes should be available in all cases. in many instances, periodic nasogastric intubation and administration of water and electrolytes via the tube may be sufficient to maintain hydration. in more severe cases, one can maintain indwelling nasogastric tubes and can administer up to to l of fluid by the tube every to minutes, if ileus is not evident. however, intravenous administration of fluids is preferred in most cases, requiring significant quantities of fluid to replace and maintain hydration and electrolyte balance. for patients with severe diarrhea to require large volumes ( to l/day) of intravenous fluids to maintain hydration is not unusual. frequent monitoring of packed cell volume, serum electrolyte concentration, venous blood gases or total serum carbon dioxide, blood urea nitrogen and creatinine, urine protein and cytologic findings, and body weight is important to monitor hydration, electrolyte and acid-base balance, and renal function. isotonic sodium chloride or lactated ringer's solution frequently is used to restore and maintain fluid and electrolyte balance. one can add potassium chloride to the fluids and administer it at a rate up to . to . meq/ kg/hr. generally, a rate of less than . meq/kg/hr is used. hypertonic nacl solutions ( to l of % to % nacl) have been used in horses that are severely hyponatremic (< meq/dl). one should not administer hypertonic solutions to severely dehydrated horses, but such solutions have been used clinically without complication and with considerable beneficial effect in patients with endotoxemia. the beneficial effects of hypertonic nacl are short-lived ( to minutes). one should administer isotonic solutions concurrently or immediately following administration of hypertonic nacl solutions. isotonic ( . %) or hypertonic ( . %) sodium bicarbonate solutions are used to correct metabolic acidosis. prolonged administration of sodium-containing fluids may promote diuresis and renal water loss or accumulation of peripheral edema and should be used conservatively when one notes a free water loss. administration of isotonic dextrose ( %) or . % dextrose/ . % nacl solutions may be beneficial when free water loss (sodium excess) is evident. many horses with acute colitis are concurrently hypoproteinemic because of gastrointestinal losses and are absorbing bacterial products that induce a systemic inflammatory response. thus plasma oncotic pressures are abnormally low in the face of increased vascular permeability. interstitial edema formation is a clinical problem in these patients and contributes to organ dysfunction. crystalloid fluids, although critical for replacing water and electrolyte losses from diarrhea, actually may contribute to a drop in plasma oncotic pressure because of hemodilution. , administration of colloid solutions are important for volume expansion and to maintain plasma oncotic pressures, which improve tissue perfusion and oxygenation and organ function in hypovolemic, hypotensive, and hypoproteinemic patients with or without systemic inflammatory response syndrome. colloids are more effective than crystalloid fluids at expanding plasma volume and thus require smaller volumes. moreover, the effect of colloid volume expansion is longer lasting than crystalloid fluid volume expansion, because colloids are retained in the vasculature better. , natural colloids, such as plasma and purified albumin are used commonly. in addition to its beneficial colloidal properties, plasma harvested from donor horses immunized with rough mutants of escherichia coli (j ) or salmonella typhimurium may have other benefits for treatment of endotoxemia from gastrointestinal disease. , the horse may require large volumes ( to l/day) to increase and maintain plasma protein concentration significantly. synthetic colloids such as dextrans, starches, or polymerized hemoglobin are also available for use in the horse. hetastarch ( to ml/kg of a % solution) increases colloidal oncotic pressures for up to hours in hypoproteinemic horses and has beneficial effects on cardiac output and other cardiorespiratory parameters, vascular permeability, interstitial fluid content, and tissue perfusion in models of hypoproteinemia and systemic inflammatory response syndrome. when one administers synthetic or even natural colloids, monitoring plasma oncotic pressure may be more relevant than monitoring plasma protein concentrations as a means of assessing the need for plasma or other colloid administration. hetastarch may prolong bleeding times by altering von willebrand's factor function; thus one should use this synthetic colloid cautiously in horses with suspected coagulopathies, active hemorrhage, or other bleeding problems. control of colonic inflammation and secretion is a difficult and poorly studied aspect of equine acute colitis. the role of inflammation and mediators such as prostaglandins as causes of fluid loss is well known for salmonella and clostridium infections. cox inhibitors (nsaids) have antisecretory effects in the equine colon and in models of salmonellosis that appear to extend to clinical management of salmonellosis. , , [ ] [ ] [ ] indeed, nsaids commonly are administered to horses with salmonellosis. however, prostaglandins such as pge and pgi are also cytoprotective to gastrointestinal mucosa and critical for mucosal repair. the doses of nsaids used pharmacologically to inhibit colonic inflammation and secretion in fact may be detrimental to the mucosa if not used judiciously. nsaids have been shown to exacerbate colonic inflammation in human beings with inflammatory colitis, impede mucosal healing in several models of mucosal injury, and have well-documented detrimental effects on colonic mucosa in horses. , , in addition to toxicity to the colonic mucosa, gastric ulceration is not unusual in horses with enterocolitis and may be related to treatment with nsaids. in addition to nsaids, other drugs occasionally are used as antiinflammatory or antisecretory therapy. metronidazole has beneficial effects in experimental models of gastrointestinal inflammation, including nsaid toxicity and may be useful for treating horses with colitis, but evidence supporting its use is lacking. bismuth subsalicylate solutions administered orally often are used to decrease inflammation and secretion in the colon. in adult horses the volume of solution necessary to be beneficial is large ( to l every to hours). often the solution is administered twice daily instead of to times daily. if one does not achieve a beneficial effect within to days of treatment, one should discontinue administration of bismuth subsalicylate solution. one can administer the treatment more frequently in foals, and clinical improvement occurs more often in foals than in adult horses. in light of the role of reactive oxygen metabolites in colonic inflammation, free radical scavengers have been advocated to reduce the effects of these molecules. sulfasalazine metabolites have been shown to reduce reactive oxygen metabolite-induced colonic inflammation in other species, and sulfasalazine has been used to treat chronic inflammatory disease in horses but has not been used to treat acute colitis. the only free radical scavenger used commonly in horses with colitis is dimethyl sulfoxide, which at a dosage of . to . g/kg intravenously every to hours in a % solution has been used in clinical cases of colitis, but evidence of efficacy has not been established. systemic inflammatory response syndrome associated with endotoxemia frequently occurs in patients with salmonellosis. the principles of therapy for endotoxemia are covered in detail elsewhere in this chapter. oral administration of activated charcoal and mineral oil is used commonly to reduce absorption of endotoxin in horses with colitis. low doses of nsaids (such as flunixin meglumine at . to . mg/kg intravenously every to hours) inhibit eicosanoid synthesis induced by endotoxin. in addition, administration of nsaids prevents laminitis from endotoxemia, a devastating complication of salmonellosis. one must remember that prostaglandins are important for mucosal healing and may worsen mucosal injury in colitis. although the benefits of low doses of nsaids administered to horses with systemic inflammatory response syndrome are believed to outweigh the risks of worsening gastrointestinal damage, judicious use is recommended. sucralfate ( mg/kg orally every hours) has been advocated to aid in healing the colonic mucosa, but the efficacy in the large intestine is questionable. misoprostol ( µg/kg orally to times daily) and other synthetic pge analogs have been shown in several species including horses to enhance mucosal healing in the intestine and promote recovery in experimental models of colitis. misoprostol may be particularly useful for treating nsaid toxicity, the generalized form or rdc. however, the efficacy of misoprostil for hastening mucosal healing is clinically unproven in equine colitis. the primary drawbacks of prostaglandin analogs such as misoprostol are the side effects of the drug, including abdominal cramping, diarrhea, sweating, and abortion in pregnant mares. one can add psyllium mucilloid to the diet ( tablespoons once or twice daily) to increase the production of scfas in the colon. amylase-resistant fermentable fiber such as psyllium is hydrolyzed by colonic bacteria to scfas such as butyrate, which represent a major energy source for colonocytes. butyrate and other scfas hasten epithelial maturation and stimulate salt (and thus fluid) absorption in the colon, improve the clinical course of ulcerative colitis, and hasten colon healing. psyllium is itself a source of butyrate in the colon and also promotes the movement of amylase sensitive carbohydrates into the distal colon, which then are fermented to scfas. thus psyllium is thought to be clinically useful for promoting mucosal healing in colitis. many horses with salmonellosis or other forms of colitis have mild to severe signs of abdominal pain from gas and fluid distention of the colon, colonic ischemia, or infarction. one can accomplish analgesia with nsaids such as flunixin, but the potential for worsening mucosal injury or nephrotoxicity may prevent the use of analgesic doses, especially in horses with suspected nsaid toxicity. newer nsaids that specifically target cox- (the inducible cox) but have little activity against cox- (the constitutive cox) may be useful analgesics that spare the gastrointestinal mucosa. for example, etodolac ( to mg/kg intravenously or orally once daily) has analgesic properties in horses and may spare the intestinal mucosa from the detrimental effects associated with nonselective cox inhibitors (a.t. blikslager, personal communication, ) . however, the specificity for cox- in horses is unproven. thus avoiding the use of any nsaids in horses with rdc or other forms of nsaid toxicity is advisable. xylazine or detomidine may provide temporary relief of pain. butorphanol is a useful analgesic that one can administer intramuscularly ( . mg/kg every hours) or as a continuous infusion. an infusion of . µg/kg/hr in isotonic crystalloid fluid such as lactated ringer's solution has been suggested. continuous lidocaine infusions ( . mg/kg intravenous loading dose administered slowly over minutes and followed by mg/kg/hr infusion in isotonic crystalloid fluids) can provide profound visceral analgesia and may have added prokinetic benefits if ileus is present. broad-spectrum antibiotic treatment often is recommended in neutropenic horses or horses with signs of septicemia. neutropenia is associated with an increased risk of septicemia and septic complications such as septic phlebitis and infection of surgical site. septicemia is a potentially life-threatening complication of enterocolitis and may be caused directly by salmonella, clostridium, other invasive enteric bacteria, or indirectly by toxic injury to the colonic mucosa that breaks down the barrier to luminal microbes. neutropenia possibly may weaken host defenses enough to render horses susceptible to organisms that breach the mucosal barrier. although most attempts to culture bacteria from the blood of adult horses with colitis fail to isolate organisms, no detailed studies have been undertaken to determine the prevalence of bacteremia or septicemia in these patients. disseminated aspergillosis has been reported in horses as a complication of acute colitis, demonstrating the potential for systemic infections with rarely pathogenic organisms stemming from colonic mucosal injury in the face of potential immunosuppression from neutropenia. , broad-spectrum antibiotics lessen septic complications in human patients. however, evidence supporting this principle in horses with colitis is lacking. treatment with antibiotics is controversial in horses with salmonellosis and is not thought to alter the course of the enterocolitis. antibiotics directly targeted at the salmonella are reserved for patients with the enteric fever (septicemia) form of salmonellosis, documented with positive blood cultures. lipid-soluble antibiotics are suited ideally for salmonella infections, because the bacteria persist intracellularly. trimethoprim-sulfadiazine or other potentiated sulfa drugs, enrofloxacin, and chloramphenicol are preferred antibiotics for the enteric fever form of salmonellosis for this reason. as with other causes of enterocolitis, the use of antibiotics for equine monocytic ehrlichiosis is controversial. fear of inducing salmonellosis or other forms of antibiotic-induced diarrhea and the difficulty of diagnosing the disease early have caused most authors to recommend judicious use of antibiotics. however, in patients with a high suspicion of neorickettsia risticii infection, treatment with antibiotics often is indicated before definitive diagnosis. lipid-soluble drugs are desirable because the organism can live within cells. oxytetracycline ( . mg/kg intravenously every hours), doxycycline ( mg/kg orally every hours), trimethoprim-sulfadiazine ( mg/kg trimethoprim orally or intravenously every to hours and mg/kg sulfadiazine every to hours), or erythromycinrifampin ( mg/kg and mg/kg, respectively, orally every hours) have been used effectively to treat clinical cases. , [ ] [ ] [ ] the tetracyclines appear to be the most effective antibiotics for treatment of potomac horse fever. treatment is most successful if initiated before the onset of diarrhea. , clostridiosis if one has administered antibiotics since the onset of enterocolitis, one should discontinue administration as soon as possible. specific treatment with metronidazole ( to mg/kg orally every hours) is effective for treating clostridiosis in human beings and appears to be effective in horses. , metronidazole resistance in clinical isolates of clostridium difficile has been reported in one outbreak but appears to be rare in most human and equine cases. metronidazole-resistant isolates were sensitive to vancomycin, which may be effective for treating clinical cases if one suspects metronidazole resistance. however, metronidazole remains the treatment of choice. some authors describe the off-label use of c. perfringens type c antitoxin in cases of neonatal clostridiosis, described in more detail elsewhere. antitoxin preparations generally are not advocated for use in adult horses with clostridiosis. lawsonia intracellulare is susceptible to a variety of antibiotics in vitro, including chlortetracycline, erythromycin, penicillin, difloxacin, and ampicillin. lipid-soluble antibiotics with a large volume of distribution usually are chosen to treat proliferative enteropathy because l. intracellulare is an intracellular organism. erythromycin estolate ( to mg/kg orally every to hours) alone or with rifampin ( mg/kg orally every hours) is the most commonly reported efficacious treatment for proliferative enteropathy. chloramphenicol ( mg/kg orally every hours) has also been reported to be effective if erythromycin worsens the diarrhea. anecdotal reports suggest that oxytetracycline and doxycycline also may be effective. supportive care including maintenance of hydration and electrolyte balance and plasma or colloid administration to increase colloid oncotic pressure in hypoalbuminemic patients is also indicated. one should treat affected foals until clinical signs, hypoproteinemia, and ultrasonographic evidence of intestinal thickening resolve. the prognosis depends on the duration of the disease and the degree of fibrosis and destruction of the intestinal architecture. hypercoagulability is a common complication of enterocolitis, associated with systemic inflammation from endotoxemia. administration of heparin ( to iu/kg subcutaneously or intravenously every to hours) may prevent thrombosis in these patients, provided antithrombin iii concentrations are adequate in the plasma. concentrated sources of antithrombin iii are not available for use in horses, but whole plasma may provide an important source. treatment with heparin is thought to decrease thrombosis, especially of the jugular vein, a serious complication of salmonellosis. low-dose aspirin treatment ( mg/kg orally every to hours) along with heparin treatment may provide added benefit by irreversibly inhibiting platelet function. heparin and aspirin may have protective effects on the digital lamina. , heparin also may enhance the phagocytic activity of the reticuloendothelial system by enhancing the efficiency of opsonins such as fibronectin and immunoglobulin, thereby stimulating phagocytosis of products of coagulation and possibly other particles, including bacteria. , maintenance of the bacterial flora and antagonism of pathogenic bacteria such as salmonella in the gastrointestinal tract are important defense mechanisms preventing colonization by pathogenic bacteria. the use of probiotic preparations containing beneficial bacteria has been shown to prevent colonization of pathogenic bacteria, including salmonella, in poultry. little work has been done to investigate the efficacy of these products in preventing salmonellosis in horses, but ongoing studies may provide important information. probiotic and other preparations designed to restore normal flora to the gastrointestinal tract, such as fecal suspensions, sour milk, and yogurt, have been used clinically to shorten the course of salmonellosis, with variable results. therefore prevention of infection by using probiotic agents and other means is important. exposure of susceptible horses to salmonella should be avoided, but the task is difficult, especially because asymptomatic infections are common and the bacteria are ubiquitous in the environment. prophylactic use of probiotic preparations, judicious use of antibiotics in susceptible horses, control of environmental conditions such as temperature, and restricted exposure to pathogenic bacteria are important for control of salmonellosis. because altered large intestinal flora appears to play an important role in the pathogenesis of equine intestinal clostridiosis or any antibiotic-associated diarrhea, probiotic preparations have been advocated to treat affected horses. sour milk, a product containing lactose-producing streptococcus species, appears to improve the clinical course greatly in horses suspected of having clostridium perfringens type a infection. sour milk may benefit the patient by altering the flora and antagonizing enterotoxigenic c. perfringens type a but also is reported to be bactericidal against c. perfringens type a. preparations of saccharomyces boulardi are effective for reducing diarrhea and the frequency of c. difficile recurrence in human beings. however, whether relapse is a problem in horses with c. difficile colitis is not clear. lactobacillus preparations have a protective effect in human beings and decrease the severity and duration of antibioticassociated diarrhea. , however, evidence of their clinical usefulness in horses is lacking. good nursing care and adequate nutrition are vital to the treatment of horses with salmonellosis. salmonellosis is a severely catabolic disease, increasing caloric requirements greatly. normal intake of roughage to provide energy may be inadequate; however, one should avoid feeding of grains to prevent carbohydrate overload. dietary management usually consists of restricting or eliminating long-stem roughage (hay) from the diet and feeding exclusively a complete pelleted diet (at least % dietary fiber). the rationale behind this recommendation is to reduce the mechanical load on the colon. frequent meals ( to times a day) are recommended. one can add corn oil ( cup every to hours) to the pellets to increase the caloric intake without adding roughage or grain. one should note that if a horse with colitis refuses to eat pelleted feed, then one should feed good-quality grass hay. in anorectic or severely catabolic patients, enteral and parenteral nutrition (total and partial) has been used successfully to provide calories and nutritional support. strongylus vulgaris infection requires treatment of the migrating parasite larvae and the lesions produced by the parasite. fenbendazole ( mg/kg orally every hours for days or mg/kg orally every hours for days) and ivermectin ( mg/kg orally) are effective in killing fourth-stage larvae. other anthelmintics also may be part ii disorders of specific body systems effective when given at higher doses than those required to kill adult worms. the efficacy of these anthelmintics against larvae within thrombi is not known. thrombolytic and antithrombotic therapy has been advocated in horses with suspected strongylosis. , heparin ( to iu intravenously or subcutaneously every to hours) is often administered as an anticoagulant. aspirin ( to mg/kg orally every to hours) is usually combined with heparin to inhibit platelet adhesion. aspirin also may inhibit release of platelet products such as thromboxane that affect the motility of the large intestine. low-molecular-weight dextrans have been advocated as antithrombotics that act by inhibiting platelet function and coagulation. , the clinical efficacy of dextran administration appears to be good, but no controlled studies have been performed. anthelmintic administration is usually the only treatment necessary for mild to moderate cases of cyathostomiasis treated early in the course of the disease (within to weeks of onset). fenbendazole is effective against many larval stages, but resistance is increasing. although the reported efficacy of ivermectin varies against certain stages, one study reported an overall efficacy of %. currently, fenbendazole ( . to mg/kg orally every hours for days) followed on day by ivermectin ( mg/kg orally) is the most commonly advocated treatment regimen. , moxidectin ( µg/kg orally once daily) also may be effective against adults and l and l larval stages and may be useful for treating cyathostomiasis. antiinflammatory therapy also may be beneficial, especially in severe or refractory cases. nsaid administration may have limited value, but dexamethasone appears to be efficacious in refractory cases when used with larvicidal anthelmintics. , pretreatment with dexamethasone or prednisolone is indicated before anthelmintic administration if heavy larval loads are suspected to prevent an acute exacerbation of the disease by rapid death of encysted larvae. bismuth subsalicylate often is administered orally as an antisecretory agent in young animals. supportive care may be necessary in severe cases, particularly if hypoproteinemia is severe. horses occasionally require administration of intravenous crystalloid fluids and plasma or other colloids. proper nutritional support is also important. supportive care is the most important principle of therapy for cantharidin toxicity. intravenous fluid administration; maintenance of electrolyte balance, especially calcium; and prevention of further renal and urinary tract damage is important. , diuresis by intravenous fluid administration is often sufficient to prevent renal failure. furosemide often is administered after rehydration of the patient to further promote diuresis and to decrease the concentration of the toxin in the urine, which may ameliorate some of the effects on the urinary tract mucosa. diuresis also has been suggested to increase clearance of the toxin, but no evidence for this has been found. judicious use of nsaids may be necessary to control abdominal pain but should be reserved until the patient is rehydrated and renal failure has been ruled out. cantharidin is lipid-soluble; therefore oral administration of mineral oil may prevent further absorption of the toxin. activated charcoal often is administered with the mineral oil. to reduce arsenic absorption, one should initiate administration of cathartics such as mineral oil and magnesium sulfate slurries and activated charcoal by nasogastric tube immediately. chelation therapy with sodium thiosulfate to g in ml of water orally and dimercaprol (bal) mg/kg intramuscularly every hours is indicated. dimercaprol is a specific antidote for trivalent arsenicals, but its efficacy in horses is questionable. intravenous fluid administration may help treat shock, replace fluid lost in feces, and promote diuresis but should be monitored carefully because pulmonary edema is a frequent complication. the horse may require more specific treatment of renal, cardiac, pulmonary, or neurologic disease. treatment of intestinal anaphylaxis is in principle similar to treatment of other forms of colitis but is often unsuccessful because of the rapidly progressive nature of the syndrome. inclusion of heparin in intravenous fluids ( to iu/kg intravenously every to hours) may help prevent vascular thrombosis. administration of hypertonic saline solutions or colloids may prove to be useful during initial periods of shock. early treatment with prednisolone succinate ( to mg/kg intravenously) or dexamethasone ( . to . mg/kg intravenously) may be essential for successful treatment. mild cases of carbohydrate overload may not require treatment other than exclusion of grains from the diet for several days to weeks and gradual reintroduction of grain into the diet later if the horse needs the extra energy. patients showing signs of colic or diarrhea without other systemic signs may benefit from administration of mineral oil, charcoal, and fluids via nasogastric tube. one also may lavage residual carbohydrates from the stomach with the nasogastric tube. nsaids such as phenylbutazone ( . to . mg/kg/day intravenously) or flunixin meglumine ( mg/kg intravenously every hours) often are administered to prevent laminitis. phenoxybenzamine and heparin given before the onset of laminitis may prevent or decrease the severity of laminitis. , more severe cases with dehydrating diarrhea, systemic signs of endotoxemia, or metabolic acidosis require intravenous fluid support to maintain water, electrolyte, and acid-base balance in addition to the previously mentioned treatments. large amounts of bicarbonatecontaining solutions may be required. one should take care when administering hypertonic bicarbonate solutions, because many patients already may be hyperosmotic from lactic acidemia. isotonic sodium bicarbonate . % may be useful in the hyperosmotic patient. careful attention to calcium balance is also important, because severe hypocalcemia may occur. one should institute aggressive therapy for systemic inflammation from endotoxemia. one should administer broad-spectrum antibiotics intravenously to combat bacteremia and septicemia, which frequently complicate colitis induced by carbohydrate overload. in extreme cases, especially if the patient has ingested a large quantity of grain, surgical removal of the grain from the large intestine may be indicated, especially if one can accomplish surgery before the onset of severe clinical signs. however, administration of oral cathartics, such as magnesium sulfate slurries or mineral oil, or a combination of these, is often sufficient to clear the carbohydrates from the large intestine before fermentation, mucosal damage, and absorption of endotoxin and lactic acid occur. oral administration of activated charcoal may prevent absorption of endotoxin by binding the molecules in the lumen of the bowel. in any case, one should discontinue feeding of the source of the soluble carbohydrates, such as grains. one should feed the horse low-carbohydrate and low-protein roughage such as grass or oat hays until the microbial flora recovers. oral administration of probiotic preparations containing lactobacillus is contraindicated; however, other sources of normal equine large intestinal microbial flora, such as fecal extracts from normal feces, may be useful to reintroduce appropriate microorganisms. complications from laminitis and sepsis are common and often cause death. treatment of sand enteropathy requires removal of the sand from the gastrointestinal tract using psyllium products and magnesium sulfate slurries administered orally. analgesics may be required initially to relieve pain and stimulate appetite. a diet high in roughage often stimulates further passage of sand. treatment may require several weeks to remove as much sand as possible. prevention of the disease is important, and recurrence is not unusual. lumen results in clinical signs similar to those of simple obstruction, occlusion of the blood supply results in a more rapid deterioration of the intestinal mucosa and subsequent onset of endotoxemic shock. although a great deal of interest in the relevance and treatment of intestinal reperfusion injury has arisen recently, - the lesion that develops during strangulation is often severe, leaving little viable bowel for further injury during reperfusion. although extensive lengths of strangulated small intestine may be resected, strangulation of the large colon presents a much greater treatment dilemma because strangulated intestine usually extends beyond the limits of surgical resection. therefore horses with large intestinal strangulation often recover with extensive intestinal injury left in place. thus subtle degrees of reperfusion injury may be important in horses with large colon disease, warranting further work in this area in an attempt to reduce mortality. strangulating obstruction may be divided into hemorrhagic and ischemic forms. , hemorrhagic strangulating obstruction, which is most common, involves initial occlusion of veins before occlusion of arteries because of the greater stiffness of arterial walls. this lesion is characterized by a darkened appearance to affected bowel and increased thickness as blood is pumped into the lesion. ischemic strangulating obstruction occurs if the intestine is twisted tightly enough to occlude arteries and veins simultaneously. in the case of the colon, such strangulation has been suggested to be determined by how much ingesta is in the colon, because intestinal contents may prevent the intestine from twisting tightly. tissue involved in ischemic strangulating obstruction appears pale and of normal or reduced thickness because of a complete lack of blood flow ( figure . - ). bowel peripheral to strangulating lesions also may become injured because of distention, which reduces mural blood flow once it reaches critical levels. furthermore, as this intestine is decompressed, it also may undergo reperfusion injury. [ ] [ ] [ ] small intestinal strangulation horses with small intestinal strangulating obstruction typically have moderate to severe signs of abdominal pain that are only intermittently responsive to analgesic medications. during the latter stages of the disease process, horses may become profoundly depressed rather than painful as affected intestine necroses. horses have progressive signs of endotoxemia, including congested mucous membranes, delayed capillary refill time, and an elevated heart rate (> beats/min in most cases). in addition, one typically obtains reflux following passage of a stomach tube, and one usually can detect loops of distended small intestine on rectal palpation of the abdomen. however, these latter findings vary depending on the duration and location of the obstruction. for example, horses with ileal obstructions tend to reflux later in the course of the disease process than horses with a jejunal obstruction. furthermore, a horse that has an entrapment of small intestine in the epiploic foramen may not have palpable loops of small intestine because of the cranial location of these structures. abdominocentesis can provide critical information on the integrity of the intestine and is indicated in horses in which one suspects strangulation of the small intestine. a horse that has signs compatible with a small intestinal obstruction and additionally has serosanguinous abdominal fluid with an elevated protein level (> . mg/dl) is likely to require surgery, although one must differentiate these a b figure . - ischemic strangulating obstruction of the small colon by a mesenteric lipoma. a, the lipoma (arrow) has encircled a segment of small colon tightly. b, following resection of the lipoma, a pale area of strangulated small colon clearly is demarcated (arrows), the appearance of which is consistent with ischemic strangulating obstruction. cases from proximal enteritis. in general, horses with small intestinal strangulation show continued signs of abdominal pain, whereas horses with proximal enteritis tend to be depressed after initial episodes of mild abdominal pain. in addition, horses with small intestinal strangulation continue to deteriorate clinically despite appropriate medical therapy and will likely begin to show an increased white blood cell count (> , cells/µl) in the abdominal fluid as the duration of strangulation increases. however, cases occur in which the differentiation between small intestinal strangulation and proximal enteritis is not clear, at which point one may elect surgery rather than risking delay of abdominal exploration of a horse with a potential strangulating lesion. the prognosis for survival in horses with small intestinal strangulating lesions is generally lower than for most forms of colic. however, recent studies indicate that in excess of % of horses with small intestinal strangulating lesions are discharged from the hospital. nonetheless, veterinarians should warn owners that the long-term survival rates are reduced substantially to below %, in part because of long-term complications such as adhesions. , in addition, the prognosis is particularly low for some forms of strangulation, including entrapment of small intestine within a mesenteric rent. the epiploic foramen is a potential opening (because the walls of the foramen are usually in contact) to the omental bursa located within the right cranial quadrant of the abdomen. the foramen thus is bounded dorsally by the caudate process of the liver and caudal vena cava and ventrally by the pancreas, hepatoduodenal ligament, and portal vein. intestine may enter the foramen from the visceral surface of the liver toward the right body wall or the opposite direction. studies differ as to which is the most common form. , in the case of entrapments that enter the foramen in a left-to-right direction, the omental bursa ruptures as the intestine migrates through the epiploic foramen, which may contribute to intraabdominal hemorrhage often seen with this condition. clinical signs include acute onset of severe colic with examination findings compatible with small intestinal obstruction. the condition tends to be more prevalent in older horses, possibly because of enlargement of the epiploic foramen as the right lobe of the liver undergoes ageassociated atrophy. however, the disease also has been recognized in foals as young as months of age. one makes a definitive diagnosis at surgery, although ultrasonographic findings of distended loops of edematous small intestine adjacent to the right middle body wall suggest epiploic foramen entrapment. in general, thickened, amotile intestine on ultrasonographic examination is highly predictive for small intestinal strangulating obstruction. small intestine entrapped in the epiploic foramen may be limited to a portion of the intestinal wall (parietal hernia), and the large colon may become entrapped within the epiploic foramen. in treating epiploic foramen entrapment, one must not enlarge the epiploic foramen by blunt force or with a sharp instrument, because rupture of the vena cava or portal vein and fatal hemorrhage may occur. prognosis has improved substantially over the last decade, with current short-term survival rates (discharge from the hospital) ranging from % to %. preoperative abdominocentesis has been found consistently to be the most predictive test of postoperative survival. , lipomata form between the leaves of the mesentery as horses age and develop mesenteric stalks as the weight of the lipoma tugs on the mesentery. the stalk of the lipoma subsequently may wrap around a loop of small intestine or small colon causing strangulation. one should suspect strangulating lipomata in aged (> years old) geldings with acute colic referable to the small intestinal tract. , ponies also appear to be at risk of developing disease, suggesting alterations in fat metabolism may predispose certain horses to development of mesenteric lipomata. one usually makes the diagnosis at surgery, although on rare occasions one can palpate a lipoma per rectum. treatment involves surgical resection of the lipoma and strangulated bowel, although strangulated intestine is not always nonviable. studies indicate that approximately % to % of horses are discharged from the hospital following surgical treatment. a volvulus is a twist along the axis of the mesentery, whereas torsion is a twist along the longitudinal axis of the intestine. small intestinal volvulus theoretically is initiated by a change in local peristalsis or the occurrence of a lesion around which the intestine and its mesentery may twist (such as an ascarid impaction). volvulus is reportedly one of the most commonly diagnosed causes of small intestinal obstruction in foals. , the theory is that young foals may be at risk of small intestinal volvulus because of changing feed habits and adaptation to a bulkier adult diet. onset of acute, severe colic, a distended abdomen, and radiographic evidence of multiple loops of distended small intestine in a young foal suggest small intestinal volvulus. however, one cannot differentiate volvulus from other causes of small intestinal obstruction preoperatively. in adult horses, volvulus frequently occurs in association with another disease process, during which small intestinal obstruction results in distention and subsequent rotation of the small intestine around the root of the mesentery. although any segment of the small intestine may be involved, the distal jejunum and ileum are affected most frequently because of their longer mesenteries. one makes the diagnosis at surgery by palpating a twist at the origin of the cranial mesenteric artery. treatment includes resection of devitalized bowel, which may not be an option because of the extent of small intestinal involvement (similar to large colon volvulus). prognosis is based on the extent of small intestine involved and its appearance following surgical correction of the lesion. in general, horses with greater than % of the small intestine devitalized are considered to have a grave prognosis. a number of structures, when torn, may incarcerate a segment of intestine (typically the small intestine), including intestinal mesentery, the gastrosplenic ligament, the broad ligament, and the cecocolic ligament. horses with such incarcerations have signs typical of a horse with strangulating small intestine, including moderate to severe signs of abdominal pain, endotoxemia, absent gastrointestinal sounds, distended small intestine on per rectal palpation, nasogastric reflux, and serosanguinous abdominal fluid. however, the prognosis for many of these horses appears to be lower than for horses with other types of small intestinal strangulations. for example, in horses with small intestine entrapped in a mesenteric rent, only of horses were discharged from the hospital, and only of horses for which follow-up information was available survived long term (> months). poor outcome may result from the difficulty in unentrapping incarcerated intestine, the degree of hemorrhage, and the length of intestine affected. inguinal herniae are more common in standardbred and tennessee walking horses that tend to have congenitally large inguinal canals. inguinal herniae also may occur in neonatal foals but differ from herniae in mature horses in that they are typically nonstrangulating. the nature of the hernia (direct versus indirect) is based on the integrity of the parietal vaginal tunic. in horses in which the bowel remains within the parietal vaginal tunic, the hernia is referred to as indirect, because strictly speaking the bowel remains within the peritoneal cavity. direct herniae are those in which strangulated bowel ruptures through the parietal vaginal tunic and occupies a subcutaneous location. these direct herniae most commonly occur in foals and should be suspected when a congenital inguinal hernia is associated with colic, swelling that extends from the inguinal region or the prepuce, and intestine that may be palpated subcutaneously. , although most congenital indirect inguinal herniae resolve with repeated manual reduction or application of a diaper, surgical intervention is recommended for congenial direct herniae. historical findings in horses with strangulating inguinal herniae include acute onset of colic in a stallion that recently had been used for breeding. a cardinal sign of inguinal herniation is a cool, enlarged testicle on one side of the scrotum (figure . - ). , however, inguinal herniae also have been reported in geldings. one also can detect inguinal herniae on rectal palpation, and one can use manipulation of herniated bowel per rectum to reduce a hernia, but this is generally not recommended because of the risk of rectal tears. in many cases, the short segment of herniated intestine greatly improves in appearance after reduction and in some cases can be left unresected. the affected testicle will be congested because of vascular compromise within the spermatic cord, and although the testicle may remain viable, resection generally is recommended. the prognosis in adult horses is good, with up to % of horses surviving to months. horses that have been treated for inguinal herniae may be used for breeding. in these horses, the remaining testicle will have increased sperm production, although an increased number of sperm abnormalities will be noticeable following surgery because of edema and increased temperature of the scrotum. although umbilical herniae are common in foals, strangulation of herniated bowel is rare. in one study, of ( %) horses with umbilical herniae had incarcerated intestine. clinical signs include a warm, swollen, firm, and painful hernia sac associated with signs of colic. the affected segment of bowel is usually small intestine, but herniation of cecum or large colon also has been reported. in rare cases, one may find a hernia that involves only part of the intestinal wall, called a richter's hernia. in foals that have a richter's hernia, an enterocutaneous fistula may develop. in one study, of foals with strangulating umbilical herniae survived to discharge, although at least died of long-term complications. an intussusception involves a segment of bowel (intussusceptum) that invaginates into an adjacent aboral segment of bowel (intussuscipiens). the reason for such invagination is not always clear but may involve a lesion at the leading edge of the intussusception, including small masses, foreign bodies, or parasites. in particular, tapeworms (anoplocephala perfoliata) have been implicated. ileocecal intussusceptions are the most common intestinal intussusceptions in the horse and typically affect young animals. in one study evaluating cases of ileocecal intussusception, the median age of the horses was year old. acute ileocecal intussusceptions are those in which the horses has a duration of colic of less than hours and involve variable lengths of intestine that ranged in one study from to cm long. in acute cases the involved segment of ileum typically has a compromised blood supply. chronic ileocecal intussusceptions typically involve short segments of ileum (up to cm long), and the ileal blood supply is frequently intact. abdominocentesis results vary because strangulated bowel is contained within the adjacent bowel. obstruction of the small intestine often is evident, including nasogastric reflux and multiple distended loops of small intestine on rectal palpation. horses with chronic ileocecal intussusceptions have mild, intermittent colic, often without evidence of small intestinal obstruction. in one study, a mass was palpated in the region of the cecal base in approximately % of cases. transabdominal ultrasound may be helpful in discerning the nature of the mass. the intussusception has a characteristic target appearance on cross section. other segments of the small intestine also may be intussuscepted, including the jejunum (figure . - ) . in one study of jejunojejunal intussusceptions, the length of bowel involved ranged from . to . m. attempts to reduce intussusceptions at surgery are usually futile because of intramural swelling of affected bowel. one should resect jejunojejunal intussusceptions. for acute ileocecal intussusceptions, one should transect the small intestine as far distally as possible and perform a jejunocecal anastomosis. in horses with particularly long intussusceptions (up to m has been reported), one may attempt an intracecal resection. for horses with chronic ileocecal intussusceptions, one should perform a jejunocecal bypass without small intestinal transection. the prognosis is good for horses with chronic ileocecal intussusceptions and guarded to poor for horses with acute ileocecal intussusceptions, depending on the length of bowel involved. herniation of intestine through a rent in the diaphragm is rare in the horse and may involve any segment of bowel, although small intestine is herniated most frequently. diaphragmatic rents may be congenital or acquired, but acquired herniae are more common. congenital rents may result from incomplete fusion of any of the four embryonic components of the diaphragm: pleuroperitoneal membranes, transverse septum, and esophageal mesentery. in addition, abdominal compression of the foal at parturition may result in a congenital hernia. acquired herniae are presumed to result from trauma to the chest or a sudden increase in intraabdominal pressure, such as might occur during parturition, distention of the abdomen, a sudden fall, or strenuous exercise. herniae have been found in a number of different locations, although large congenital herniae are typically present at the ventral most aspect of the diaphragm, and most acquired herniae are located at the junction of the muscular and tendinous portions of the diaphragm. a peritoneopericardial hernia has been documented in at least one horse. figure . - jejunojejunal intussusception in a horse presented for colic. the intussusceptum has become ischemic because of invagination of intestine and its mesenteric blood supply into the intussuscipiens. clinical signs usually are associated with intestinal obstruction rather than respiratory embarrassment. however, careful auscultation may reveal an area of decreased lung sounds associated with obstructed intestine and increased fluid within the chest cavity. such signs may prompt thoracic radiography or ultrasound, both of which one can use to make a diagnosis. auscultation also may reveal thoracic intestinal sounds, but differentiating these from sounds referred from the abdomen typically is not possible. in one report, two of three horses diagnosed with small intestinal strangulation by diaphragmatic hernia had respiratory acidemia attributable to decreased ventilation. treatment of horses with diaphragmatic hernia is fraught with complications because of the need to reduce and resect strangulated bowel and the need to repair the defect in the diaphragm. , because dorsal defects in the diaphragm are among the common forms of diaphragmatic defect, closing the diaphragmatic hernia via the approach used for abdominal exploration may not be possible. however, because herniation is likely to recur, scheduling a second surgery using an appropriate approach to resolve the diaphragmatic defect is appropriate. horses with large colon volvulus have rapid onset of severe, unrelenting abdominal pain, most often in postpartum broodmares. once the large colon strangulates (≥ -degree volvulus), gas distention is significant, leading to gross distention of the abdomen, compromised respiration as the distended bowel presses up against the diaphragm, and visceral pooling of blood as the caudal vena cava is compressed. horses with this condition are frequently refractory even to the most potent of analgesics. these horses may prefer to lie in dorsal recumbency, presumably to take weight off the strangulated colon. an abbreviated physical examination is warranted in these cases, because the time elapsed from the onset of strangulation to surgical correction is critical. under experimental conditions, the colon is irreversibly damaged within to hours of a -degree volvulus of the entire colon. despite severe pain and hypovolemia, horses may have a paradoxically low heart rate, possibly related to increased vagal tone. in addition, results of abdominocentesis often do not indicate the degree of colonic compromise , and in many cases are not worth attempting because of extreme colonic distention. palpation per rectum reveals severe gas distention of the large colon, often restricting access to the abdomen beyond the pelvic brim. one may make the diagnosis tentatively based on signalment, severity of pain, and degree of distention. at surgery, the volvulus typically is located at the mesenteric attachment of the colon to the dorsal body wall and the most common direction of the twist is dorsomedial using the right ventral colon as a reference point. however, the colon may twist in the opposite direction, twist greater than degrees (up to degrees has been reported) or twist at the level of the diaphragmatic and sternal flexures. in all cases, one should decompress the colon as much as possible, and in many cases a colonic evacuation via a pelvic flexure enterotomy greatly aids correction of the volvulus. one must determine after correction of the volvulus whether the colon has been injured irreversibly and should base the determination on mucosal color and bleeding (if an enterotomy has been performed), palpation of a pulse in the colonic arteries, serosal color, and appearance of muscular motility. if one judges the colon to be damaged irreversibly, one can consider the feasibility of a large colon resection. although % of the colon can be resected (that part of the colon distal to the level of the cecocolic fold), damage from the volvulus usually exceeds that which can be resected. in these cases, surgeons may elect to resect as much damaged bowel as possible or may advise euthanasia. the prognosis is guarded to poor because of the rapid onset of this disease. in one study the survival rate was %. in a more recent report the survival rate was % for horses with -degree volvulus of the large colon compared with % for horses with -degree volvulus. however, one study in central kentucky documented a high success rate, possibly because of early recognition of the disease and the proximity of the hospital to the surgical caseload. postoperative complications include hypovolemic and endotoxic shock, extensive loss of circulating protein, disseminated intravascular coagulation, and laminitis. in addition, large colon volvulus has a propensity to recur. although one study documented a recurrence rate of less than %, some authors believe recurrence may be as high as %. therefore one should consider methods to prevent recurrence in patients at risk of recurrence, particularly broodmares that tend to suffer from the disease recurrently during the foaling season. , the most common intussusceptions of the large intestine are cecocecal and cecocolic intussusceptions. , both are likely attributable to the same disease process, with variable inversion of the cecum. these conditions doughnut-shaped prolapse of rectal mucosa and submucosa. type ii prolapses involve full-thickness rectal tissue, whereas type iii prolapses additionally have invagination of small colon into the rectum. type iv prolapses involve intussusception of proximal rectum or small colon through the anus in the absence of prolapse of tissue at the mucocutaneous junction at the anus. one can differentiate type iv from other forms of prolapse by their appearance and a palpable trench between prolapsed tissue and the anus. type i prolapses occur most frequently in horses with diarrhea, in which the rectal mucosa becomes irritated and protrudes intermittently during episodes of tenesmus. if tenesmus persists, rectal mucosa can remain prolapsed. rectal mucosa rapidly becomes congested and edematous under these conditions, which one should treat with osmotic agents such as glycerin or magnesium sulfate and by massaging and reducing the prolapse. a purse-string suture may be required to keep the mucosa inside the rectum. topical application of lidocaine solution or jelly, epidural anesthesia, and sedation may help reduce tenesmus that incites and exacerbates rectal prolapse. one can apply similar treatments to type ii rectal prolapses. however, these more severe prolapses may not be reducible without surgical resection of mucosa and submucosa from the prolapsed bowel. , type iii and iv rectal prolapses are more serious injuries because of involvement of small colon. in horses with type iii prolapses, one should perform an abdominocentesis to determine if injured small colon has resulted in peritonitis. one should reduce the small colon component manually if possible, although prolapsed rectal tissue typically requires mucosal/ submucosal resection. one should perform surgical exploration of the abdomen to determine the status of the small colon, although one can use serial abdominocenteses in lieu of surgery to detect progressive necrosis of bowel. type iv prolapses occur most commonly in horses with dystocia. these prolapses are almost always fatal because of stretching and tearing of mesenteric vasculature, with subsequent infarction of affected bowel. therefore euthanasia usually is warranted tend to occur in young horses ( % were less than years old in one study) and may be associated with intestinal tapeworms. horses show highly variable clinical signs, including acute severe colic, intermittent pain over a number of days, or chronic weight loss. these variable presentations likely relate to the degree to which the cecum has intussuscepted. initially, the cecal tip inverts, creating a cecocecal intussusception, which does not obstruct flow of ingesta. as the intussusception progresses, the cecum inverts into the right ventral colon (cecocolic intussusception), obstructs flow of ingesta, and often causes severe colic. the cause of abdominal pain is often difficult to differentiate in these cases, although detecting a mass on the right side of the abdomen by per rectal palpation or ultrasound examination sometimes is possible. , treatment involves manual surgical reduction by retracting the intussusceptum directly or via an enterotomy in the right ventral colon. however, a number of cases occur in which one cannot reduce the cecum readily because of severe thickening or in which surgical procedures result in fatal contamination. for example, one report stated that of horses were euthanized in the perioperative period because of complications, and another report stated that of horses were euthanized before or during surgery. the latter included all of the horses with chronic disease because of irreversible changes to the cecum. however, one recent report on cecocolic intussusceptions indicated that seven of eight horses that underwent right ventral colon enterotomy and cecal resection survived long-term, suggesting that continued improvements in surgical techniques may improve the prognosis. colocolic intussusceptions are rare but have been reported to affect the pelvic flexure and the left colons. [ ] [ ] [ ] [ ] although the condition is reported to be more common in young horses, - the condition may affect older horses. clinical findings may include a palpable mass on the left side of the abdomen. ultrasonography also may be useful. treatment requires manual reduction of the intussusception at surgery, , or resection of affected bowel. because the left colons may be exteriorized extensively and manipulated at surgery, - the prognosis is fair. rectal prolapse may occur following any disease that causes tenesmus, including diarrhea, rectal neoplasia, and parasitism, or prolapse can occur following elevations in intraabdominal pressure during parturition or episodes of coughing. , rectal prolapses are classified into four categories (table . - ) based on the extent of tissue prolapsed and the severity. type i rectal prolapse is most common and is characterized by a intussusception of rectum and poor small colon through the anus based on physical examination findings. however, confirmation of severe small colonic injury requires abdominal exploration via a midline approach or laparoscopy. a horse with compromised small colon conceivably could undergo a colostomy of the proximal small colon, but the compromised small colon typically necroses beyond that which can be resected via a midline abdominal approach. nonstrangulating infarction occurs following cranial mesenteric arteritis caused by migration of strongylus vulgaris and has become a rare disorder since the advent of broad-spectrum anthelmintics. although thromboemboli have been implicated in the pathogenesis of this disease, careful dissection of naturally occurring lesions has not revealed the presence of thrombi at the site of intestinal infarctions in most cases. these findings suggest that vasospasm plays an important role in this disease. clinical signs vary greatly depending on the extent to which arterial flow is reduced and the segment of intestine affected. any segment of intestine supplied by the cranial mesenteric artery or one of its major branches may be affected, but the distal small intestine and large colon are more commonly involved. no clinical variables exist that one can use to differentiate this disease from strangulating obstruction reliably. in some cases, massive infarction results in acute, severe colic. occasionally, one may detect an abnormal mass and fremitus on palpation of the root of the cranial mesenteric artery per rectum. one should consider this disease a differential diagnosis in horses with a history of inadequate anthelmintic treatment and the presence of intermittent colic that is difficult to localize. although one should perform fecal parasite egg counts, they are not indicative of the degree of parasitic infestation. in addition to routine treatment of colic, dehydration, and endotoxemia, medical treatment may include aspirin ( mg/kg every hours) to decrease thrombosis. definitive diagnosis requires surgical exploration. however, these cases are difficult to treat because of the patchy distribution of the lesions and the possibility of lesions extending beyond the limits of surgical resection. in addition, further infarction may occur following surgery. the prognosis is fair for horses with intermittent mild episodes of colic that may be amenable to medical therapy but is poor in horses that require surgical intervention. , surgical exploration of a horse with on-going intestinal injury exacerbates shock induced largely by endotoxin traversing damaged mucosa, and this in turn correlates with mortality. the initial clinical step in the workup of horses with colic is taking a thorough history. however, one may have to delay taking a complete history until after the physical examination and initial treatment, because management of abdominal pain may take precedence. if possible, one should obtain the vital components of the history before examination and treatment: the duration and severity of colic symptoms, analgesics already administered, and a history of any adverse drug reactions. the two most critical factors from a history that would support a decision to explore a horse with colic surgically are the duration of signs and the extent of pain. one deduces the latter from asking the owner about the presence and frequency of pawing, looking at the flanks, rolling, repeatedly going down and getting back up, posturing as if to lie down or urinate, among other clinical evidence of pain. table . - lists other important components of the history one should obtain to try to ascertain why colic has occurred. just as the history necessarily may need to be brief to allow rapid treatment of colic, so the clinician must be able to alter the extent of the physical examination to treat the horse in a timely fashion. the most critical examination finding is the heart rate of the horse, because it provides an excellent assessment of the cardiovascular status of the horse. the heart rate is likely the single most reliable predictor of the need for surgery and survival. , because analgesics can alter the heart rate dramatically, if possible, one should obtain the heart rate before administering analgesics. other components of the examination are designed specifically to gather information about the cardiopulmonary status of the horse (quality of the pulse, mucous membrane color, capillary refill time, respiratory rate, and full auscultation of the chest), and the nature of the intestinal obstruction (auscultation of gastrointestinal sounds, per rectal palpation of the abdomen, and presence of nasogastric reflux). although classic presentations exist for horses with obstructions of the small or large intestine (table . clinical management of colic is distinctly different from management of many other clinical syndromes because the initial focus is often not on defining the definitive diagnosis but rather on deciding whether a horse requires surgical exploration. therefore the clinician must collect historical, physical examination, and clinicopathologic information and make a decision whether these findings warrant medical management or whether to perform surgical exploration of the abdomen because of a suspected obstructive or ischemic lesion. for example, one may examine a horse with signs of severe abdominal pain, poor cardiovascular status, and abdominal distention that may be compatible with an extensive list of differential diagnoses but that more importantly indicate the need for abdominal exploration to minimize the extent of intestinal injury. the speed with which one can make this clinical decision has a tremendous effect on the well-being of the patient, , because delaying gastric fluid accumulation because of direct compression of the small intestine by distended colon or via tension on the duodenocolic ligament. the most useful diagnostic test for determining the type of intestinal obstruction is rectal palpation of the abdomen. however, one can reach only approximately one third of the abdomen via the rectum, and this percentage may be substantially less in large horses or heavily pregnant horses. nonetheless, attempting to determine the type of obstruction present (small intestine versus large intestine, and simple obstruction versus strangulating obstruction) is worthwhile; this information directly affects prognosis. in one study, interns and residents at a veterinary teaching hospital were able to predict the type of lesion with a specificity exceeding %. findings from palpation are helpful in educating the client about the potential findings in surgery and the likelihood of survival for the horse. before considering how to manage signs of colic, one should remember that such signs are poorly localized. therefore although colic is most frequently associated with intestinal disease, one should consider dysfunction of other organ systems, including urinary obstruction, , biliary obstruction, uterine torsion or tears, , ovarian artery hemorrhage, and neurologic disease as differential diagnoses. however, the duration and severity of colic the most immediately useful clinicopathologic information in horses with colic are the packed cell volume and total protein, because one can use them to substantiate clinical estimates of dehydration and they correlate strongly with prognosis. , a serum biochemical profile is useful for assessing electrolyte imbalances, tissue perfusion (anion gap or lactate), and kidney and liver function. one can use serum biochemical or blood gas analysis to assess acid-base status. horses with colic most frequently show evidence of metabolic acidosis associated with poor tissue perfusion caused by hypovolemia or endotoxemia, but one may note other abnormalities such as metabolic alkalosis in association with extensive loss or sequestration of stomach chloride. metabolic acidosis has been investigated further in horses with colic by measuring blood lactate, although this test is not offered routinely in many laboratories. lactate levels also have been inferred from measurement of the anion gap, although one study noted that lactate in horses with colic did not account for the entire anion gap. lactate levels and anion gap closely correlate with prognosis for survival. , , other key components of assessment of the horse with colic are abdominocentesis and complete blood count. the total white blood cell count and differential can provide crucial evidence of systemic inflammation associated with endotoxemia stemming from colic attributable to colitis (leukopenia, neutropenia, and a left shift) rather than an obstruction (highly variable complete blood count findings). peritoneal fluid may be helpful in determining the integrity of the intestine. specifically, as the intestine becomes progressively devitalized, the peritoneal fluid becomes serosanguinous as red blood cells leak into the abdomen, followed by an elevation in the total protein (> . g/dl) and progressive increases in total nucleated cell count (> , cells/µl). however, these findings do not always correlate well with the condition of the intestine, particularly in horses with large colon volvulus. for example, in a study of horses with large colon volvulus, the average total protein ( . g/dl) and total nucleated cell count ( cells/µl) were normal despite the fact that only % with a -degree volvulus survived. , these measures may appear normal because the development of severe mucosal injury following large colon volvulus is rapid and may not allow enough time for protein and leukocytes to equilibrate with the abdominal fluid. investigators have taken all the variables routinely assessed during evaluation of horses for colic and have attempted to develop models to predict accurately the need for surgery and the prognosis for life. [ ] [ ] [ ] [ ] none of these predictor models has taken the place of clinical decision making, although these studies have added part ii disorders of specific body systems signs are excellent predictors of whether a horse requires surgical exploration of the abdomen. in fact, refractory pain supersedes all other predictors of the need for surgery in the colic patient. once signs of colic have been recognized and categorized as to their severity, rapidly and effectively relieving the pain is critical for the well-being of the horse and to reduce the owner's anxiety. in addition, pain is best managed before it becomes severe. several classes of analgesics are readily available to treat horses with colic (table . - ), including α -agonists (xylazine, detomidine), opiates (butorphanol), and nonsteroidal antiinflammatory drugs (nsaids, such as flunixin meglumine). although much of this information is familiar to most practitioners, several principles deserve emphasis. the short-duration drugs xylazine and butorphanol, which provide analgesia for to minutes, allow the veterinarian to determine if pain is recurrent within the time period of the typical examination. in contrast, flunixin meglumine is not as potent as an analgesic but has a much longer duration of action. to avoid deleterious effects on gastrointestinal mucosa and the kidneys, one should not administer flunixin meglumine more frequently than recommended. , the recent discovery of two isoforms of cyclooxygenase (cox), the enzyme inhibited by nsaids, has resulted in discovery of drugs that can more selectively inhibit proinflammatory cox- while permitting continued constitutive production of prostanoids. such specificity may be advantageous in horses with colic, particularly when one considers recent evidence of reduced intestinal recovery from an ischemic event with flunixin compared with a drug that is more selective for cox- . one should reserve the α agonist detomidine for horses with severe, unrelenting pain because of its tremendous potency. in addition, one should remember that α -agonists reduce the heart rate associated with a transient increase in blood pressure, , thereby reducing the predictive value of the heart rate and pulse pressure. tremendously to understanding of the importance of some prognostic factors, particularly those reflecting cardiovascular function. simple obstruction involves intestinal obstruction of the lumen without obstruction of vascular flow. however, because a tremendous volume of fluid enters the small intestinal lumen daily, , the obstructed intestine tends to become distended, which in turn may reduce mural blood flow. ultimately, such distention may result in necrosis of tissues, particularly in the immediate vicinity of the obstruction. few are the causes of simple obstruction in the small intestine, and the incidence of these obstructions is low (approximately % of all referred horses in one large hospital-based study). however, in some geographic regions, this type of obstruction is prevalent. for example, in the southeastern united states, ileal impactions are common. ileal impactions most commonly occur in adult horses in the southeastern united states. although feeding of coastal bermuda hay has been implicated in the regional distribution of the disease, separating geographic location from regional hay sources as risk factors has been difficult. nonetheless, feeding coastal bermuda hay likely places horses at risk of ileal impaction, particularly if the coarse fiber content of the hay is high. furthermore, sudden changes in feed from an alternate type of hay to coastal bermuda hay likely places a horse at risk of ileal impaction. studies in england have revealed tapeworm infection as another important risk factor for ileal impaction. based on risk analysis, the data suggested that in excess of % of the ileal impaction cases studied were associated with serologic or fecal evidence of tapeworm infection. because of the poor sensitivity of fecal analysis for tapeworms, proudman and trees have developed a serologic test (enzyme-linked immunosorbent assay) with a sensitivity of approximately % and a specificity of %. clinical signs of horses with ileal impaction are typical for a horse with small intestinal obstruction, including onset of moderate to severe colic and loops of distended small intestine palpable per rectum as the condition progresses. because the ileum is the distal most aspect of the small intestinal tract, nasogastric reflux may take a considerable time to develop and is found in approximately % of horses requiring surgical correction of impacted ileum. , one usually makes the diagnosis at surgery, although on occasion one may palpate an impacted ileum per rectum. multiple loops of distended small intestine frequently make the impaction difficult to palpate. ileal impactions may resolve with medical treatment but frequently require surgical intervention ( figure . - ) . at surgery, one can infuse fluids directly figure . - appearance of roundworms that have been retrieved within the nasogastric reflux from a foal with an ascarid impaction. the large size of these ascarids (bar = cm) contributes to the risk of impaction following sudden kills of these parasites by broad-spectrum anthelmintics. into the mass, allowing the surgeon to breakdown the impaction. the surgeon may include dioctyl sodium sulfosuccinate in the infused fluid to aid in disruption of the mass. extensive small intestinal distention and intraoperative manipulation of the ileum may lead to postoperative ileus, but recent studies indicate that this complication is less frequent as the duration of disease before admission decreases. recent studies indicate that the prognosis for survival is good. , ileal hypertrophy is a disorder in which the muscular layers (circular and longitudinal) of the ileum hypertrophy for unknown reasons (idiopathic) or following an incomplete or functional obstruction. for idiopathic cases, proposed mechanisms include parasympathetic neural dysfunction resulting in chronically increased muscle tone and subsequent hypertrophy of the muscular layers of the ileal wall. such neural dysfunction possibly could result from parasite migration. alternative hypotheses include chronic increases in the muscular tone of the ileocecal valve, leading to muscular hypertrophy of the ileum as it contracts against a partially occluded ileocecal valve. the jejunum also may be hypertrophied, alone or with the ileum. clinical signs include chronic intermittent colic as the ileum hypertrophies and gradually narrows the lumen diameter. in one study, partial anorexia and chronic weight loss ( to months) were documented in % of the horses, most likely because of intermittent colic and reduced appetite. because hypertrophy does not affect the ileal mucosa, no reason exists to believe that these horses experience malabsorption of nutrients. one usually makes the diagnosis at surgery, although one may palpate the hypertophied ileum per rectum in some cases. for treatment, one performs an ileocecal or jejunocecal anastomosis to bypass the hypertrophied ileum. without surgical bypass, intermittent colic persists and the thickened ileum ultimately may rupture. the prognosis is fair with surgical treatment. secondary ileal hypertrophy is most commonly notable in horses that previously have had colic surgery and that may have a partial or functional obstruction at an anastomotic site. for example, in one case report, a horse developed ileal hypertrophy after surgical correction of an ileocecal intussusception. ileal hypertrophy also was noted in a horse with cecal impaction in which an ileocolic anastomosis was oriented incorrectly. horses are typically re-presented for recurrence of colic in these cases. surgical therapy is directed at addressing the cause of small intestinal obstruction and resecting hypertrophied intestine. meckel's diverticulum is an embryonic remnant of the vitelloumbilical duct, which fails to atrophy completely and becomes a blind pouch projecting from the antimesenteric border of the ileum. , however, similar diverticula also have been noted in the jejunum. these diverticula may become impacted, resulting in partial luminal obstruction, or may wrap around an adjacent segment of intestine, causing strangulation. occasionally, an associated mesodiverticular band may course from the diverticulum to the umbilical remnant and serve as a point around which small intestine may become strangulated. mesodiverticular bands also may originate from the embryonic ventral mesentery and attach to the antimesenteric surface of the bowel, thereby forming a potential space within which intestine may become entrapped. clinical signs range from chronic colic for an impacted meckel's diverticulum to acute severe colic for intestine strangulated by a mesodiverticular band. one makes the diagnosis at surgery, and treatment requires resection of the diverticulum and any associated bands. the prognosis is good for horses with simple impaction of a meckel's diverticulum and is guarded for horses with an associated small intestinal strangulation. adhesions of one segment of bowel to another or of a segment of intestine to other organs and the body wall most typically occur following abdominal surgery and may be clinically silent, cause chronic colic attributable to partial obstruction, or result in acute obstruction. these differing clinical syndromes are attributable to the type of adhesions that develop. for example, a fibrous adhesion that does not by itself obstruct the intestinal lumen might serve as the pivot point for a volvulus, whereas an adhesion between adjacent segments of the intestinal tract may create a hairpin turn that causes chronic partial obstruction. the number of adhesions that develop also may vary greatly from horse to horse. some horses may develop a single adhesion adjacent to an anastomotic site or a discrete segment of injured intestine, whereas other horses may develop diffuse adhesions involving multiple segments of intestine, likely because of widespread inflammation of the peritoneum at the time of the original surgery. the mechanism whereby adhesions develop is complex but likely involves initial injury to the serosa initiated by intestinal ischemia, reperfusion injury, and luminal distention. importantly, such injury involves infiltration of neutrophils into the serosa accompanied by loss of mesothelial cells. in one study assessing the margins of resected small intestine, extensive neutrophil infiltration was documented in the serosa, particularly in the proximal resection margin that had been distended before correction of a variety of strangulating lesions. regions of serosal injury and inflammation subsequently undergo reparative events similar to any wound, including local production of fibrin, de novo synthesis of collagen by infiltrating fibroblasts, and ultimately maturation and remodeling of fibrous tissue. unfortunately, during this process, fibrin may result in injured intestinal surfaces adhering to adjacent injured bowel or an adjacent organ. once a fibrinous adhesion has developed, new collagen synthesis may result in a permanent fibrous adhesion. alternatively, proteases released by local phagocytes may lyse fibrinous exudate, thereby reversing the adhesive process. thus one can view formation of adhesions as an imbalance of fibrin deposition and fibrinolysis. prevention of adhesions depends on inhibition of the mechanisms involved in adhesion formation, including reduction of serosal injury with early intervention and good surgical technique, reduction of inflammation by administration of antiinflammatory medications, physical separation of inflamed serosal surfaces (e.g., carboxymethylcellulose and hyaluronan), [ ] [ ] [ ] and pharmacologic modulation of fibrinous adhesion formation (e.g., heparin). in addition, early return of motility in the small intestine after surgery may reduce contact time between inflamed surfaces of intestine, thereby reducing the chances of adhesion formation. horses at greatest risk of developing adhesions after colic surgery appear to be those that have small intestinal disease. , in one study of horses undergoing surgical correction of small intestinal obstruction, % developed a surgical lesion associated with adhesions. foals appear to have an increased incidence of adhesions compared with mature horses regardless of the nature of the abdominal surgery. one study indicated that % of foals developed lesions attributable to adhesions regardless of the type of initial surgery. studies conflict as to whether the degree of surgical intervention influences adhesion formation, but in one study, horses that require enterotomy or resection and anastomosis were at greatest risk of developing adhesions. as an indication of the importance of postoperative adhesion formation, adhesions were among the most common reasons for repeat laparotomy in postoperative colic patients. , clinical signs of horses with adhesions vary greatly depending on whether the adhesion is causing partial obstruction or complete luminal obstruction or involves intestinal vasculature. adhesions would be an important differential diagnosis for intermittent colic in the postoperative period, particularly if such colic was not relieved by nasogastric decompression of the stomach. continued intermittent colic should prompt abdominocentesis to determine if septic peritonitis is present, which may contribute to adhesion formation. placement of a large bore drain and peritoneal lavage ( figure surgery should prompt immediate nasogastric intubation to decompress the stomach. treatment should include attempts at obtaining reflux from the horse at frequent intervals rather than relying on passive flow of reflux. in addition, administration of intravenous fluids should account for the maintenance requirement ( ml/kg/day, about l/hr in the average horse) and fluid losses via reflux. in practice, this requires frequent monitoring of packed cell volume and total protein to ensure that the horse remains well hydrated. although concerns have arisen that overhydrating horses may contribute to increased nasogastric reflux, keeping horses well-hydrated to avoid hypovolemic shock is critical. additionally, one should monitor electrolytes frequently, particularly considering their potential role in smooth muscle contraction and nerve excitability. because of the important role of inflammation in postoperative ileus, including elaboration of cox- -produced prostanoids, administration of nsaids is indicated. nsaid administration is particularly necessary if postoperative ileus is associated with endotoxemia, because lipopolysaccharide-induced prostanoid production disrupts propulsive motility in horses. , interestingly, phenylbutazone is more effective than flunixin meglumine at reducing the deleterious actions of lipopolysaccharide on intestinal motility. however, one should use caution when administering nsaids to patients with postoperative ileus in light of research suggesting that complete inhibition of prostanoid production can alter motility patterns in normal equine intestine. the advent of selective cox- inhibitors may provide optimal antiinflammatory treatment in the future. other treatments aimed at specifically modulating intestinal motility include lidocaine (bolus of . mg/kg followed by . mg/kg/min for hours), erythromycin ( . to . mg/kg slow intravenous infusion in l saline every hours), and metoclopramide ( . mg/kg/hr). , , the mechanism of lidocaine is presumed to be inhibition of sensory nerve activity within the wall of the intestine, thereby reducing reflex sympathetic inhibitory activity. in addition, intravenously administered lidocaine appears to be an effective analgesic. thus an important feature of intravenous lidocaine therapy may be to control postoperative pain-induced reduction of gastrointestinal motility and mucosal secretory activity. metoclopramide may stimulate intestinal motility by several mechanisms, including dopamine receptor blockade, cholinergic stimulation, and adrenergic blockade. although metoclopramide has been shown to be beneficial for reversing postoperative ileus in clinical patients and research animals, it has central nervous system excitatory side effects in the horse that make its use difficult. nonetheless, administration of metoclopramide to horses with postoperative ileus resulted in elect repeat laparotomy or laparoscopy. in one study of adhesions, % of repeat laparotomies were performed within days, suggesting that surgical colic attributable to adhesions typically occurs within months of an initial surgical procedure. unfortunately, the prognosis for horses with colic attributable to adhesions is low, with only % of horses in one study surviving from adhesion-induced colic. the definition of ileus is intestinal obstruction, including physical and functional obstructions. however, in veterinary medicine, the term typically is used to designate a lack of progressive aboral propulsion of ingesta resulting in functional obstruction. one typically bases the diagnosis of postoperative ileus on the presence of excessive gastric fluid accumulation (reflected as excessive nasogastric reflux). postoperative ileus may occur following any abdominal exploratory procedure. however, horses undergoing surgery for strangulating small intestinal lesions or small intestinal obstructive lesions such as an ileal impaction are at greatest risk. recently, the syndrome of postoperative ileus in horses has been broadened to include those horses that may have delayed transit of ingesta through the large intestine following surgery. this large intestinal ileus may follow any type of surgery, particularly horses that have had orthopedic surgery, and is characterized by reduced fecal output (fewer than three piles of manure per day) rather than excessive nasogastric reflux. however, horses with excessive nasogastric reflux are unlikely to have normal fecal output, so the distinction between these two manifestations of ileus is not absolute. mechanisms involved in precipitating postoperative ileus characterized by small intestinal dysfunction likely involve local inflammation, reduced coordination of progressive motility, and increased sympathetic tone. a recent series of studies in the rat has shown that surgical manipulation of intestine results in delayed transit time associated with infiltration of neutrophils into intestinal longitudinal muscle [ ] [ ] [ ] and upregulation of inducible nitric oxide synthase and cox- . the mechanisms in the horse may be similar in that extensive manipulation of the intestine resulted in abnormal intestinal motility in ponies, and prostanoids and nitric oxide alter or reduce intestinal motility in horses. [ ] [ ] [ ] clinical signs of postoperative ileus following colic surgery include evidence of abdominal pain, increased heart rate, reduced gastrointestinal sounds, and reflux of gastric fluid via a nasogastric tube. of these signs, heart rate is critical because it appears to be a more sensitive indicator of pain in the postoperative period than overt evidence of colic. therefore a sudden increase in the heart rate of a postoperative patient following colic a significantly reduced duration of reflux and shorter postoperative hospital stays compared with horses not receiving this drug. in the same study, constant infusion of metoclopramide was superior to intermittent infusion. recent in vitro studies indicate that metoclopramide effectively increases smooth muscle contractile activity throughout the small intestine. similarly, the motilin agonist erythromycin had stimulatory effects on equine small intestine, although the results were not uniform throughout the small intestine. erythromycin stimulates contractile activity in the longitudinal muscle of the pyloric antrum but inhibits contractile activity in circular smooth muscle in this segment of the gastrointestinal tract. the latter may be attributable to activation of motilin receptors on inhibitory nerves and may result in enhanced gastric emptying. in vivo studies on erythromycin confirmed the stimulatory action of this drug on the distal small intestine and indicated this drug also stimulates contractile activity in the cecum and pelvic flexure. however, the stimulation depends on the temporal association with surgery. erythromycin stimulated contractile activity in the postoperative period in the ileum and pelvic flexure but not the cecum, suggesting this drug may be useful for treating select cases of postoperative ileus. for horses with presumed ileus of the large colon, signs included reduced fecal output (fewer than three piles of manure per day), reduced gastrointestinal sounds, variable presence of colic, and on occasion a palpable impaction of the cecum or large colon. risk factors for this syndrome include orthopedic surgery, length of the operative period, and most importantly inadequate treatment with phenylbutazone, presumably resulting from insufficient control of postoperative pain. although treatment of large colon impaction in the postoperative period typically is uncomplicated, onset of cecal impaction is fatal in many cases because of the difficulty in recognizing horses that have cecal dysfunction. therefore one should pay close attention to fecal production and optimal analgesic treatment in any horse following an orthopedic procedure. other painful procedures, including ophthalmologic procedures, also likely place horses at risk of developing ileus of the large intestine. simple obstructions of the large intestine such as impaction tend to have a more gradual onset than those of the small intestine, although horses may become acutely and severely painful with some forms of colon displacement. in fact, some of these cases mimic and may progress toward large colon volvulus. medical therapy is frequently successful in correcting large colon impactions. however, cecal impactions present much more of a dilemma because of the greater propensity of this organ to rupture, the relative difficulty of surgically manipulating the cecum, and the onset of cecal dysfunction that may prevent the cecum from emptying following surgical resolution of impaction. cecal impaction may be divided into two syndromes: primary cecal impactions that result from excessive accumulation of ingesta in the cecum and secondary cecal impactions that develop while a horse is being treated for a separate problem. , although primary impactions typically consist of impacted, relatively dry fecal material and secondary cecal impactions tend to have fluid contents, considerable overlap exists between the two syndromes, and one must approach each case carefully. in horses with primary cecal impactions, onset of abdominal pain occurs over a number of days, reminiscent of the development of a large colon impaction. one should differentiate cecal impactions from large colon impactions on the basis of rectal palpation findings. cecal impactions have a propensity to rupture before the development of severe abdominal pain or systemic deterioration and therefore must be monitored closely. secondary cecal impactions typically develop following unrelated surgical procedures that result in postoperative pain (particularly orthopedic surgeries). secondary cecal impactions may be even more difficult to detect because one may attribute postoperative depression and decreased fecal output to the operative procedure rather than to colic. by the time horses with secondary cecal impactions show noticeable signs of colic, the cecum may be close to rupture. in many cases, no signs of impending rupture are evident. therefore all horses that undergo surgeries in which considerable postoperative pain may develop should have feed intake and manure production closely monitored. a recent study indicated that horses that produce fewer than three piles of manure daily in the postoperative period are at risk of developing a large intestinal impaction. furthermore, horses that underwent prolonged (> hour) orthopedic surgery that received inadequate treatment with phenylbutazone were at considerable risk of reduced postoperative fecal output. these results are in contrast to statements indicating that nsaids may place horses at risk of impaction, statements that appear to be based largely on clinical impressions rather than on risk analysis. the diagnosis of primary cecal impaction is based on palpation of a firm, impacted cecum per rectum. in some cases, cecal impactions may be difficult to differentiate from large colon impactions. however, careful palpation reveals the inability to move the hand completely dorsal to the impacted viscus because of the attachment of the cecum to the dorsal body wall. treatment for horses with primary cecal impactions may include initial medical therapy, including aggressive administration of intravenous fluids and judicious use of analgesics. however, if the cecum is distended grossly or if medical therapy hasno effect within a reasonable period of time, surgical evacuation of the cecum via a typhlotomy is indicated. in addition, performing an ileocolostomy to bypass the cecum is advisable, because postoperative cecal motility dysfunction with recurrence of the impaction is common. , in horses that develop secondary cecal impactions, diagnosis is based on palpation of a greatly distended cecum filled with semifluid intestinal contents. the nature of the contents likely is related to the more rapid progression of this disease compared with primary cecal impaction. one should not delay surgery because of the risk of cecal rupture. however, if the cecum appears healthy following typhlotomy and evacuation, bypass of the cecum is not as critical as it is for primary impactions as long as one can control the inciting cause of the impaction (such as orthopedic pain). the prognosis is guarded for surgical treatment of all cecal impactions because of the potential for the cecum to rupture during prolonged medical treatment or during surgical manipulation, the possibility of abdominal contamination during surgery, and the extensive surgical procedures required. in a recent report, seven of nine horses for which cecal impaction was treated by typhlotomy and ileocolostomy or jejunocolostomy lived long term. however, a separate report indicated that all horses with cecal impaction following another disease process had cecal rupture without any signs of impending rupture. ingesta impactions of the large colon occur at sites of anatomic reductions in luminal diameter, particularly the pelvic flexure and the right dorsal colon. although a number of risk factors have been reported, most have not been proved. however, a sudden restriction in exercise associated with musculoskeletal injury appears frequently to be associated with onset of impaction. another consideration is equine feeding regimens, which usually entail twice daily feeding of concentrate. such regimens are associated with large fluxes of fluid into and out of the colon, associated with readily fermentable carbohydrate in the colon and subsequent increases in serum aldosterone, respectively. one may prevent these fluid fluxes, which may cause dehydration of ingesta during aldosterone-stimulated net fluid flux out of the colon, with frequent small feedings. amitraz, an acaricide associated with clinical cases of colon impaction, can induce impaction of the ascending colon. , this effect may provide some clues as to the pathogenesis of large colon impaction. in particular, amitraz appears to alter pelvic flexure pacemaker activity, resulting in uncoordinated motility patterns between the left ventral and left dorsal colon and excessive retention of ingesta. absorption of water from the ingesta increases with retention time, dehydrates the contents of the colon, and results in impaction. conceivably, parasite migration in the region of a pacemaker may have a similar action. other factors implicated in large colon impaction include limited exercise, poor dentition, coarse roughage, or dehydration. clinical signs of large colon impaction include slow onset of mild to moderate colic. fecal production decreases, and the feces are often hard, dry, and mucuscovered because of delayed transit time. the heart rate may be elevated mildly during episodes of pain but is often normal. signs of abdominal pain are typically well controlled with administration of analgesics but become increasingly more severe and refractory if the impaction does not resolve. the diagnosis is based on palpation of a firm mass in the large colon per rectum. however, one may underestimate the extent of the impaction by rectal palpation alone because much of the colon is out of reach. adjacent colon may be distended if the impaction has resulted in complete obstruction. one should attempt initial medical treatment. administration of analgesics (e.g., flunixin meglumine at . to . mg/kg intravenously every to hours; butorphanol at . to . mg/kg intramuscularly every to hours; or xylazine at . to . mg/kg intravenously as needed) controls intermittent abdominal pain. administration of oral laxatives such as mineral oil ( to l by nasogastric tube every to hours) and the anionic surfactant dioctyl sodium sulfosuccinate ( to g/ kg diluted in to l of water by nasogastric tube every to hours) are used commonly to soften the impaction. saline cathartics such as magnesium sulfate ( . mg/kg in to l by nasogastric tube) also may be useful. one should not permit access to feed. for impactions that persist, one should institute aggressive oral and intravenous fluid therapy ( to times the maintenance fluid requirement). if the impaction remains unresolved, the horse becomes uncontrollably painful, or extensive gas distention of the colon occurs, surgery is indicated. in addition, one can monitor abdominal fluid serially to determine the onset of intestinal compromise. at surgery, one evacuates the contents of the colon via a pelvic flexure enterotomy. the prognosis is good for those horses in which impactions resolve medically ( % long-term survival in one study) and fair in horses that require surgical intervention ( % long-term survival in the same study). enteroliths are mineralized masses typically composed of magnesium ammonium phosphate (struvite). however, magnesium vivianite also has been identified in enteroliths, along with variable quantities of sodium, sulfur, potassium, and calcium. the formation of magnesiumbased minerals is puzzling because of the relative abundance of calcium in colonic fluids, which would favor the formation of calcium phosphates (apatite) rather than struvite. however, elevated dietary intake of magnesium and protein may play a role. many horses that develop enteroliths are located in california and are fed a diet consisting mainly of alfalfa hay. analysis of this hay has revealed a concentration of magnesium approximately times the daily requirements of the horse. furthermore, the high protein concentration in alfalfa hay may contribute to calculi formation by increasing the ammonia nitrogen load in the large intestine. enteroliths most commonly form around a nucleus of silicon dioxide (a flintlike stone), but nidi have included ingested nails, rope, and hair. enteroliths usually are found in the right dorsal and transverse colons. although enterolithiasis has a wide geographic distribution, horses in california have the highest incidence. in one california study, horses with enterolithiasis represented % of the surgical colic population, and arabians, morgans, american saddlebreds, and donkeys were at greatest risk of this disease. in a study of enterolithiasis in texas, risk factors also included feeding of alfalfa hay and arabian breed. however, in that study, miniature horses were also at risk. horses with enteroliths are rarely under years old, although an enterolith in an -month-old miniature horse has been reported recently. enterolithiasis is characterized by episodic, mild to moderate, intermittent abdominal pain. progressive anorexia and depression may develop. the amount of pain depends on the degree of obstruction and amount of distention. partial luminal obstruction allows the passage of scant, pasty feces. heart rate varies and depends on the degree of pain. in some cases, an enterolith is forced into the small colon, where it causes acute small colon obstruction. one may diagnose enteroliths by abdominal radiography or at surgery. on rare occasions, one may palpate an enterolith per rectum, particularly if it is present in the distal small colon. in general, these cases require surgery, although enteroliths being retrieved per rectum have been reported. in fact in one study, % of horses presented for treatment of enterolithiasis had a history of passing an enterolith in the feces. however, enteroliths typically are located in the right dorsal colon, transverse colon, or small colon. at surgery, one gently pushes the enterolith toward a pelvic flexure enterotomy, but removal frequently requires a separate right dorsal colon enterotomy to prevent rupture of the colon. following removal of an enterolith, one must conduct further exploration to determine if other enteroliths are present. solitary enteroliths are usually round, whereas multiple enteroliths have flat sides. the prognosis is good ( % -year survival in one study of cases), unless the colon ruptures during removal of an enterolith. in one recent study, rupture occurred in % of cases. sand impactions are common in horses with access to sandy soils, particularly horses eating feed placed on the ground. some horses, especially foals, deliberately eat sand. fine sand tends to accumulate in the ventral colon, whereas coarse sand may accumulate in the dorsal colon. , however, individual differences in colonic function may contribute to accumulation of sand, because some horses can clear consumed sand, whereas others cannot. distention from the impaction itself, or gas proximal to the impaction, causes abdominal pain. in addition, sand may trigger diarrhea, presumably because of irritation of the colonic mucosa. in horses with sand impactions, clinical signs are similar to those of horses with large colon impactions. one may find sand in the feces, and auscultation of the ventral abdomen may reveal sounds of sand moving within the large colon. however, unlike sand-induced diarrhea, one may not hear sand impactions easily because of the lack of colonic motility. to determine the presence of fecal sand, one places several fecal balls in a rectal palpation sleeve or other container, which subsequently is filled with water. if sand is present, it accumulates at the bottom of the container. in addition, one may detect mineral opacity within the colon on abdominal radiographs, particularly in foals, ponies, and small horses. abdominal paracentesis typically yields normal fluid and poses some risk because large quantities of sand in the ventral colon make inadvertent perforation of the colon more likely. peritoneal fluid is often normal but may have an elevated protein concentration. initially, medical therapy is warranted. administration of psyllium hydrophilic mucilloid ( . to . kg/ kg in to l of water by stomach tube) may facilitate passage of sand. one should administer the solution rapidly because it will form a viscous gel. an alternative method of administration is to mix psyllium with l of mineral oil, which will not form a gel and can be pumped through a nasogastric tube easily. one then pumps to l of water through the tube. the psyllium separates from the oil phase and mixes with the water, forming a gel within the gastrointestinal tract. psyllium is thought to act by stimulating motility or by agglutinating the sand. however, a recent experimental study failed to show a benefit of this treatment for clearing sand from the colons of otherwise normal horses. if a severe impaction is present, one should not give the psyllium until softening the impaction by administrating intravenous or oral fluids and other laxatives. perforation is a potential complication in horses with sand impactions because the sand stretches and irritates the intestinal wall and causes inflammation. therefore if colic becomes intractable, one should perform surgical evacuation of the large colon. the prognosis is generally good. , displacement of the ascending colon is a common cause of large intestinal obstruction. the ascending colon is freely movable except for the right dorsal and ventral colons. contact with adjacent viscera and the abdominal wall tends to inhibit movement of the ascending colon from a normal position; however, accumulation of gas and fluid or ingesta may cause the colon to migrate. feeding practices, including feeding of large concentrate meals, likely plays a role in initiating displacement of the large colon. large concentrate meals increase the rate of passage of ingesta, allowing a greater percentage of soluble carbohydrates to reach the large intestine, which in turn increases the rate of fermentation and the amount of gas and volatile fatty acids produced. the production of large amounts of volatile fatty acids stimulates the secretion of large volumes of fluid into the colon. the association between feeding concentrate and development of displacements of the large colon is illustrated by studies indicating that ascending colon displacement is more prevalent in horses fed a highconcentrate, low-roughage diet. abnormal motility patterns of the ascending colon also have been suggested to contribute to the development of colonic displacement. feeding stimulates colonic motility via the gastrocolic reflex, but large meals may alter normal motility patterns and concurrently allow rapid accumulation of gas and fluid from fermentation. , migration of parasite larvae (strongyles) through the intestinal wall also has been shown to alter colonic motility patterns. other experimental studies also have shown that strongylus vulgaris infection results in reduced blood flow to segments of the large intestine without necessarily causing infarction. electric activity of the colon and cecocolic junction increases after infection with s. vulgaris and cyathostome larvae, probably reflecting a direct effect of migration through the intestine and an early response to reduced blood flow. displacements of the ascending colon generally are divided into three types: left dorsal displacement, right dorsal displacement, and retroflexion. left dorsal displacement is characterized by entrapment of the ascending colon in the renosplenic space. the colon often is twisted degrees such that the left ventral colon is situated in a dorsal position relative to the left dorsal colon. the entrapped portion may be only the pelvic flexure or may involve a large portion of the ascending colon, with the pelvic flexure situated near the diaphragm. the colon may become entrapped by migrating dorsally between the left abdominal wall and the spleen or may migrate in a caudodorsal direction over the nephrosplenic ligament. occasionally, one can palpate the ascending colon between the spleen and abdominal wall, lending support to the first mechanism of displacement. gastric distention is thought to predispose horses to left dorsal displacement of the ascending colon by displacing the spleen medially, allowing the colon room to migrate along the abdominal wall. right dorsal displacement begins by movement of the colon cranially, medial (medial flexion) or lateral (lateral flexion) to the cecum. according to one author, the proportion of right dorsal displacements with medial versus lateral flexion is approximately : . in either case the pelvic flexure ends up adjacent to the diaphragm. retroflexion of the ascending colon occurs by movement of the pelvic flexure cranially without movement of the sternal or diaphragmatic flexures. displacement of the ascending colon partially obstructs the lumen, resulting in accumulation of gas or ingesta and causing distention. secretion of fluid in response may exacerbate the distention. tension and stretch of the visceral wall is an important source of the pain associated with colonic displacement. tension on mesenteric attachments and the root of the mesentery by the enlarged colon also may cause pain. ischemia rarely is associated with nonstrangulating displacement of the colon. however, vascular congestion and edema often occur in the displaced segments of colon, resulting from increased hydrostatic pressure from reduced venous outflow. morphologic damage to the tissues is usually minor. clinically, displacement of the ascending colon is characterized by intermittent signs of mild to moderate abdominal pain of acute onset. however, one also may note an insidious onset of colic. one may note dehydration if the duration of the displacement is prolonged. the heart rate may be elevated during periods of abdominal pain but is often normal. abdominal distention may be present if the colon is enlarged by gas, fluid, or ingesta. fecal production is reduced because progressive motility of the large intestine is absent. one often diagnoses left dorsal displacements by palpation per rectum. one can feel the left ventral colon in a dorsal position; it often is filled with gas. one can trace the ascending colon to the nephrosplenic space, and the spleen may be displaced medially. alternatively, one can reach a tentative diagnosis using abdominal ultrasonography. the spleen is visible on the left side of the abdomen, but the gasdistended bowel obscures the left kidney. evaluation of this technique indicates that false positives occur in few instances, although false negatives occasionally may occur. a definitive diagnosis therefore may require surgery. right dorsal displacements are characterized by the presence of the distended ventral colon running across the pelvic inlet and may be felt between the cecum and the body wall if a lateral flexion is present. the pelvic flexure is usually not palpable. retroflexion of the ascending colon may produce a palpable kink in the colon. if the displaced colons are not distended by gas in the instance of right dorsal displacement and retroflexion, the ascending colon may not be palpable and is conspicuous by its absence from a normal position. peritoneal fluid may increase in amount, but the color, protein concentration, and white blood cell count are usually normal. however, as the displaced segment becomes edematous, fluid leaking through the serosa into the peritoneal fluid increases the protein concentration. surgical correction of colon displacement is the most effective means of resolving this disorder. however, nonsurgical intervention has been successful in select cases of nephrosplenic entrapment of the large colon. [ ] [ ] [ ] before attempting such manipulations, the clinician must be certain of a diagnosis. one anesthetizes the horse and places it in right lateral recumbency, rotates the horse up to dorsal recumbency, rocking it back and forth for to minutes, and then rolls the horse down into left lateral recumbency. one should palpate the nephrosplenic space per rectum to determine whether the entrapment has been relieved before recovering the horse from anesthesia. one may administer phenylephrine ( - µg/kg/min over minutes) to decrease the size of the spleen. more recently, phenylephrine has been used successfully with to minutes of exercise to reduce nephrosplenic entrapments in four of six horses. the authors suggested that the technique be used on horses with mild to moderate colonic distention, particularly when financial constraints are severe. a number of cases occur in which nonsurgical interventions do not correct the problem and others in which nonsurgical manipulations correct the entrapment but result in large colon volvulus or displacement. one should take horses in such condition to surgery promptly. the prognosis for horses with large colon displacement is good. in one study on horses with nephrosplenic entrapment of the large colon, survival exceeded %. the horse, particularly young horses, may ingest foreign material that can cause obstruction, such as bedding, rope, plastic, fence material, and feedbags. these foreign bodies may result in impaction with ingesta and distention of the intestine, typically in the transverse or descending colon. young horses usually are affected. in one study the obstructing mass could be palpated per rectum in three of six horses. fecaliths are common in ponies, miniature horses, and foals. older horses with poor dentition also may be predisposed to fecaliths because of the inability to masticate fibrous feed material fully. fecaliths commonly cause obstruction in the descending colon and may cause tenesmus. other clinical signs are similar to those of enterolithiasis. abdominal radiography may be useful in smaller patients to identify the obstruction, especially if gas distention around the foreign body or fecalith provides contrast. the horse usually requires surgical treatment. mural masses such as abscesses, tumors (adenocarcinoma, lymphosarcoma), granulomata, and hematomas ( figure . - ) can cause luminal obstruction and impaction, typically in older horses. impaction may result from obstruction of the lumen or impaired motility in the segment of intestine with the mass. abscesses may originate from the lumen of the intestine or may extend from the mesentery or mesenteric lymph nodes. intramural hematomas form most commonly in the descending colon and cause acute abdominal pain. once the acute pain from the hematoma subsides, impaction proximal to the hematoma develops because of impaired motility through the affected portion of the colon. trauma, ulceration of the mucosa, and parasitic damage are speculated causes of intramural hematomas. , stricture of the large intestine occurs when fibrous tissue forms in a circular pattern around or within the intestine, reducing the luminal diameter and the ability of the wall to stretch. strictures may be congenital or may follow peritonitis, previous abdominal surgery, or inflammatory bowel disease. in a report of horses with inflammatory bowel disease, horses had strictures, four of which were in the small intestine and two of which were in the large colon. clinical signs vary according to the degree of luminal obstruction. partial obstruction and impaction tend to produce mild to moderate abdominal pain of insidious onset. mural hematomas tend to produce signs of acute abdominal pain. , per rectal palpation of the abdomen may reveal the presence of a mass or simply the impacted segment but not the mass itself. one may note fever, weight loss, and anorexia if an abscess or tumor is the cause. an elevated white blood cell count; hyperfibrinogenemia; hyperglobulinemia; or normocytic, normochromic anemia may occur with abscesses or tumors. peritoneal fluid may reflect the cause of the mass. tumor cells may occur infrequently. one may note evidence of inflammation with bacteria if the cause of colic is an abscess or granuloma, in which case one should culture the fluid. hematomas may cause hemorrhage into the peritoneal fluid. treatment usually requires surgical resection of the mass. one may treat abscesses with appropriate antibiotics if the impaction can be resolved medically with oral or intravenous analgesics and laxatives. streptococcus spp, actinomyces pyogenes, corynebacterium pseudotuberculosis, rhodococcus equi, anaerobic bacteria, and gram-negative enteric organisms commonly are involved in abscesses. atresia of a segment of the colon is a rare congenital abnormality in horses. the heritability and causes of the condition are unknown. one potential mechanism for development of the lesion is intestinal ischemia during fetal life, which results in necrosis of a segment of intestine. clinical signs include a failure to pass meconium and colic within the first to hours of life. secondary abdominal distention results from complete intestinal obstruction, and abdominal radiographs may reveal gas-distended colon. one makes the diagnosis at surgery. any portion of the colon may be absent, but the distal segment of the large colon or the proximal small colon usually is affected most severely. if sufficient tissue is present, one may attempt anastomosis to the proximal blind end of the colon. the prognosis depends on which segment of the colon is absent but is usually poor because of an absence of distal colon. neoplasia in the alimentary tract of the horse is uncommon. primary and metastatic neoplasia can affect multiple locations within the oral cavity and gastrointestinal tract (boxes . - and . - ). neoplasia is not limited to older horses. the average age of horses with squamous cell carcinoma is . to . years. , the alimentary form of lymphoma occurs most commonly in horses less than years of age. identification of benign versus malignant tumors is imperative to justify treatment and predict survival. clinical signs associated with alimentary neoplasia are related to the tumor location. clinical signs of oral neoplasia can include enlargement or ulceration of the mandible or maxilla. neoplasia of the tongue results in weight loss, quidding, prepharyngeal dysphagia, halitosis, and nasal discharge containing feed material if the oropharynx is involved. [ ] [ ] [ ] tumors of the esophagus cause signs typical of esophageal dysphagia, ptyalism, choke, intermittent colic, fever, weight loss, and halitosis. , , gastric neoplasia can be associated with abnormal chewing and swallowing behavior, anorexia, weight loss, chronic intermittent colic, abdominal distention, and intermittent fever. abdominal neoplasia has been implicated in % of horses with intermittent or chronic colic. , altered stool character, weight loss, ventral edema, and recurrent fever have been associated with intestinal neoplasia. acute signs of abdominal discomfort can occur in intestinal obstructions from malignant and benign neoplastic disease. paraneoplastic syndromes may occur in the horse. the most common syndromes are cancer cachexia, ectopic hormone production, anemia, leukocytosis, thrombocytopenia, hypergammaglobulinemia, fever, and neurologic abnormalities. horses with cancer cachexia have profound weight loss despite adequate consumption of calories. diagnosis of alimentary neoplasia can be challenging. data collected from a complete blood count, biochemistry panel, and urinalysis may support the diagnosis of neoplasia but rarely confirms it. normocytic normochromic anemia indicates chronic disease and is the most likely cause of anemia associated with neoplasia. blood loss anemia (via gastrointestinal tract) and immune-mediated hemolytic anemia (lymphoma) are less frequent causes of anemia associated with abdominal neoplasia. peripheral eosinophilia has been reported in association with multisystemic eosinophilic, epitheliotropic disease with lymphoma. leukocytosis and hyperfibrinogenemia are common findings. serum chemistry can confirm hypoalbuminemia caused by inflammation of the bowel wall. hyperglobulinemia can be characterized with serum electrophoresis, which is nonspecific and can reveal chronic inflammation. a few cases of lymphoma have been identified with monoclonal hypergammaglobulinemia. ectopic hormone production may result in hypercalcemia (calcium > mg/dl), which is associated with alimentary neoplasia such as lymphoma, multiple myeloma, carcinomata, and ameloblastoma. , hypoglycemia (blood glucose < mg/dl) can occur with neoplasia of the pancreas or liver. rectal examination may detect an abdominal mass, thickening of the intestinal wall, lymph node enlargement, or a gritty texture in horses with carcinomatosis. rectal biopsy can reveal lymphoma in some cases. fecal occult blood test is nonspecific for neoplastic disease but can reveal blood loss through the gastrointestinal tract. occasionally, abdominocentesis can identify neoplasia if the tumor exfoliates cells into the abdomen. one can diagnose squamous cell carcinoma, adenocarcinoma, and mesothelioma from peritoneal fluid. , , , characterization of peritoneal fluid as an inflammatory exudate or modified transudate without any neoplastic cells present is common. cytologic analysis of peritoneal fluid samples collected by abdominocentesis accurately predicted the presence of neoplasia in of cases in one study. cytologic examination of two or more peritoneal fluid samples increases the sensitivity of this test for detecting abdominal neoplasia. measurement of peritoneal fluid glucose concentration and ph is valuable to differentiate inflammation in the peritoneum caused by neoplasia from bacterial peritonitis. abdominal neoplasia typically is associated with peritoneal glucose concentrations similar to blood and ph higher than . . d-xylose absorption tests can reveal malabsorptive diseases that include lymphoma. , immunoglobulin m deficiency is associated with lymphoma in some young adult horses, but the prevalence of immunoglobulin m deficiency in horses with lymphoma and the value of measuring serum immunoglobulin m concentrations for the diagnosis of lymphoma have not been evaluated. dna cell cycle analysis of suspect neoplastic cells has been used to detect lymphoma in equine patients confirmed with the disease. this method of evaluating fluid or tissues aspirates may increase the accuracy for diagnosing neoplasia in the future. a complete evaluation of the oral cavity may include using a full-mouth speculum, radiographs, and endoscopy of the pharynx. evaluation of the esophagus and stomach with a -m endoscope can reveal intralumenal masses. pleuroscopy has been used to obtain biopsy samples of extralumenal masses surrounding the esophagus. contrast radiography can assist in the diagnosis of neoplasia within the wall or outside of the esophagus. , ultrasonography of the stomach, small intestine, cecum, and large colon is useful in detecting intestinal wall thickness, abdominal masses, and excessive peritoneal fluid. identification of neoplasia in the liver, kidney or spleen may support metastasis to other parts of the gastrointestinal tract or lymph nodes. laparoscopy and exploratory laparotomy often are required to obtain a final diagnosis. lymphoma is the most common neoplasia in the horse and has been divided into four categories. this section covers only the intestinal/alimentary form. in the past, lymphoma has been called lymphosarcoma, but the preferred term by oncologists is lymphoma because no benign form of this disease exists. lymphoma originates from lymphoid tissue and predominantly affects the small intestine and intestinal lymph nodes. chronic weight loss from malabsorption, intermittent colic, and fever are the most common clinical findings. , chronic diarrhea has been reported in some cases. paraneoplastic pruritus and alopecia have been identified in one case of diffuse lymphoma. one generally does not note peripheral lymphadenopathy, but one may palpate enlargement of the intestinal lymph nodes on rectal examination. large colon resection for treatment of lymphoma in horses has increased short-term survival in two horses. chemotherapy in two mares that were pregnant extended their lives long enough to foal normally. long-term prognosis for intestinal lymphoma is poor. squamous cell carcinoma (scc) is a malignant tumor of the gastrointestinal epithelium. scc is the second most common neoplasia in the horse and is the most common oral neoplasia. however, the incidence of scc is rare. , , in the oral cavity scc may affect the lips, tongue, hard palate, pharynx, and mucosa. , treatment for scc in the oral cavity may involve surgical resection, iridium- brachytherapy, -fluorouracil, or intralesional cisplatin. , [ ] [ ] [ ] the prognosis for survival is good if complete removal of the tumor is possible. metastasis beyond the regional lymph nodes is rare for oral scc. squamous cell carcinoma is the most common tumor of the stomach and esophagus , and can invade these areas and metastasize to the lymph nodes and lungs. abnormal masses were palpated on rectal examination in four of five cases of gastric scc. treatment by surgical resection is not possible in most cases and the horses die or are euthanized. adenocarcinoma is a malignant tumor that can occur in the small intestine, cecum, and large colon. the tumor arises from the glandular crypts of the gastrointestinal tract and has been reported in middle-aged and older horses. metastasis to the lymph nodes, liver, and lungs can occur. intestinal adenocarcinoma has been reported to metastasize to the bone and was diagnosed using nuclear scintigraphy following injection of technetium- m hydroxymethylene diphosphate. , no reports of successful surgical resection have been published. leiomyosarcoma is a malignant tumor of the smooth muscle lining the gastrointestinal tract and has been reported in the stomach, small intestine, and rectum. , , , , in one case report, gastroscopy could not identify the mural mass in the stomach that was found during exploratory surgery. another report describes a favorable outcome for surgical resection of a leiomyosarcoma that was protruding from the anal sphincter in a -year-old quarter horse. prognosis for survival is favorable if surgical resection is possible. leiomyoma is a benign tumor of the smooth muscle of the gastrointestinal tract that can occur in the stomach, small intestine, and small colon. , clinical signs are consistent with intestinal obstruction. surgical resection and anastomosis of the affected portion of the intestine have been performed without complications. lipoma is a benign tumor that occurs in older horses ( to years) and arises from mesenteric adipocytes. the tumor grows on a stalk that wraps around the intestine, causing a strangulating lesion manifested clinically by acute obstructive colic. intestinal injury caused by pedunculated lipomata may occur in the small intestine, small colon, and rectum. long-term survival with surgical resection and anastomosis of the affected segment has been reported to be % to %. , oral neoplasia oral cavity neoplasia may involve the dental tissue (odontogenic tumors), bone (osteogenic tumors), or soft tissues (see box . - ). ameloblastoma occurs in horses greater than years old and mainly affects the mandible. ameloblastic odontoma affects younger horses and usually involves the maxilla. both are benign but locally invasive. radiographs may distinguish the difference between an ameloblastoma (radiolucent lesion) and ameloblastic odontoma (radiolucent lesion with partially mineralized density). the best treatment option is surgical resection and radiation therapy regardless of the type. juvenile mandibular ossifying fibroma occurs in the rostral mandible of young horses between the ages of months and years. the fibroma may cause significant distortion of the bone. with early diagnosis and surgical excision of the mass, the horse has a good prognosis. melanomas, sarcoids, and oral papilloma occur on the mouth and lips. melanomas rarely metastasize, but they commonly are found in the parotid salivary glands and lymph nodes. sarcoids are the most common skin tumor that can involve the mouth. ulcerations of the buccal mucosa are difficult to treat. intralesional cisplatin, cryosurgery, radiation, and laser excision have been tried with limited success. equine papilloma virus is responsible for the common skin wart found on the lips and muzzle of young horses. these lesions are usually selflimiting but may be removed successfully by cryosurgery or excision. a number of detailed and informative reviews are available describing the anatomy, physiology, and pathophysiology of the equine peritoneum. [ ] [ ] [ ] [ ] [ ] the peritoneum consists of a single layer of mesothelial cells lining the peritoneal cavity and serosal surfaces of the intraabdominal viscera. the mesothelial lining of the diaphragm, abdominal walls, and pelvic cavity is termed parietal peritoneum. the visceral peritoneum includes the serosal surfaces of the intraabdominal organs. the parietal and visceral portions of the peritoneum are contiguous with each other through the omentum, mesenteries, and ligaments. caudally, the peritoneum reflects over the surfaces of the pelvic organs (portions of the urogenital tract and rectum), excluding them from the peritoneal space, and thus much of the pelvic cavity and contents are described as retroperitoneal. the peritoneal space communicates with the lumen of the uterus (and thus the external environment) via the fallopian tubes in females. in males the peritoneum forms a true blind sac. the vascular supply and nervous innervation of the visceral peritoneum are supplied by the splanchnic vessels and visceral autonomic nerves, respectively. branches of the intercostal, lumbar, and iliac arteries supply the parietal peritoneum, and the phrenic and intercostal nerves provide nervous innervation. the clinical relevance is that inflammation of the parietal peritoneum is perceived as somatic pain, resulting in a splinted abdominal wall, pain on external palpation, and reluctance to move. visceral pain is mediated by small type c sensory fibers, which are believed to be stimulated by bowel distention, smooth muscle spasms, tension on the mesentery, and ischemia. the peritoneal lining functions as a semipermeable barrier to the diffusion of water and low-molecular weight solutes between the blood and the abdominal cavity. the peritoneum secretes a serous fluid that lubricates the abdominal cavity, inhibits adhesion formation, and has minor antibacterial properties. , macrophages, mast cells, mesothelial cells, and lymphocytes provide immune function within the peritoneum. , peritoneal macrophages impart antibacterial activity via complement receptors, phagocytic activity, interaction with t lymphocytes, neutrophil chemotaxis, and fibroblast activation. the peritoneal surface maintains a high level of fibrinolytic activity through the production of plasminogen activators by mesothelial cells. this function, together with the lubricant properties of the peritoneal fluid, helps to maintain gliding surfaces within the peritoneum and prevent adhesion formation. in quadrupeds, peritoneal fluid produced by the mesothelium tends to move ventrally and cranially, aided largely by diaphragmatic movement. peritoneal fluid, waste products, and foreign material (including bacteria) exit the peritoneal cavity to enter the lymphatic system through diffusely distributed subendothelial pores or via the large diaphragmatic stomata, depending on particle size. large molecules and particles greater than approximately , mw (such as bacteria) exit through the diaphragmatic stomata and ultimately enter the thoracic duct. peritonitis is inflammation of the mesothelial lining of the peritoneal cavity and is characterized by desquamation and transformation of mesothelial cells; chemotaxis of neutrophils; release of several soluble mediators of inflammation; exudation of serum, fibrin, and protein into the peritoneal cavity; and depression of fibrinolytic activity. peritonitis occurs in association with a variety of disorders that result in mechanical, chemical, or infectious insult to the peritoneal lining. [ ] [ ] [ ] [ ] any process resulting in disruption or irritation of the peritoneal lining, inflammation or infection of abdominal organs, or compromise of the intestinal wall can result in peritonitis (box . - ). common mechanical injuries include blunt or perforating trauma to the abdominal wall, breeding and foaling accidents, and abdominal surgery. a variety of traumatic insults of iatrogenic origin can cause peritonitis, such as the pathogenesis of peritonitis as a series of stages, as reviewed and described by trent, is useful. the contamination stage, lasting to hours, involves introduction of bacteria into the peritoneum and initiation of the acute inflammatory response previously described. if the organisms are not eliminated and infection is established, the process evolves to the stage of acute diffuse peritonitis. although the overall movement of contaminants is toward the diaphragmatic stomata and into the thoracic duct, the nature of the peritoneal circulation is such that regardless of the location of the initial contamination, bacteria spread throughout the peritoneum within several hours. the stage of acute diffuse peritonitis lasts up to days. the inflammatory response persists and escalates with continued exudation of proteinaceous fluid and influx of inflammatory cells. offending organisms are delivered to the lymphatic system and may be eliminated by the immune system. organisms, however, may gain access to the systemic circulation in sufficient numbers to result in clinically relevant septicemia. in human beings and laboratory animals having undergone polymicrobial contamination of the peritoneum, the organisms causing septicemia at this stage are usually coliforms, e. coli in particular. this stage of the disease process has the highest mortality because of the effects of severe peritoneal inflammation, endotoxemia, and septicemia. if the animal survives this stage but fails to eliminate the infection in the peritoneal cavity, the disease enters a transitional phase referred to as the acute adhesive (or localizing) stage. this stage occupies a time frame of perhaps to days after the initial insult. neutrophils are still active, macrophages are increasing in numbers, and fibrin aggregates are being organized or lysed. in human beings and laboratory animals, selective reduction and synergism continue such that anaerobes and gram-negative aerobes predominate. if infection persists beyond this point, organization of fibrin proceeds and organisms become isolated from host defenses. at this point, the disease process enters the stage of chronic abscessation. this stage can begin as early as days after inoculation and persists indefinitely. clinical signs of peritonitis depend on the primary disease process, the duration of the problem, and the extent of peritoneal inflammation. localized peritonitis may have few or no systemic manifestations, whereas severe localized or generalized peritonitis often is accompanied by severe toxemia or septicemia or both. septic peritonitis usually causes more severe clinical signs because of the inflammatory mediators released in response to bacterial toxins and because of the presence of endotoxin when gram-negative organisms are involved. most clinical signs are nonspecific and include fever, depression, inappetance, decreased borborygmi, and dehydration. additional signs, reported in horses (ages months to years) with peritonitis, were colic, ileus, weight loss, and diarrhea. horses with peracute peritonitis, as occurs with rupture of the bowel or rectal tear, have severe toxemia, weakness, depression or severe colic, tachycardia, tachypnea, and circulatory failure. fever may not be present depending on the degree of shock. typical clinical findings include sweating, pawing, muscle fasciculations, weak peripheral pulses, red to purple mucous membranes, prolonged capillary refill time, and decreased skin elasticity. parietal pain, characterized by reluctance to move, splinting of the abdominal wall, and sensitivity to external abdominal pressure occur in some acute cases. urination or defecation may be painful for the horse, and urine and fecal retention may be evident on rectal examination. palpation of the abdomen externally may elicit flinching, aversion movements, or groaning. with extensive abdominal fecal contamination, rectal examination may reveal a gritty feeling of the serosal and parietal surface of the peritoneum because of fibrin deposition and a dry texture of the peritoneum. in horses with more chronic peritonitis, rectal examination findings can include pain on palpation of fibrinous or fibrous adhesions, intestinal impaction or distention following ileus and dehydration, an abdominal mass (abscess or neoplasia), or an impression of bowel floating in fluid. in many cases, one can detect no abnormalities on rectal examination. horses with localized, subacute, or chronic peritonitis may have signs of chronic or intermittent colic, depression, anorexia, weight loss, intermittent fever, ventral edema, exercise intolerance, decreased or absent intestinal sounds, and mild dehydration. heart rate and respiratory rate may be normal. fecal output may be normal; however, horses with chronic diarrhea and weight loss have been reported. foals with peritonitis usually exhibit signs of colic (acute or chronic) and are febrile, depressed, and inappetant. in some foals with primary peritonitis, pleural effusion occurs. in young foals, peritonitis can cause rapid metabolic deterioration, and determination and correction of the primary problem requires immediate attention. in older foals, peritonitis may occur insidiously, as occurs following s. equi or r. equi infections. clinicopathologic abnormalities vary depending on the time of onset and severity of peritonitis. horses with acute, septic peritonitis can have leukopenia, hemoconcentration, metabolic acidemia, azotemia, and electrolyte imbalances reflective of systemic inflammation from endotoxemia and hypovolemia. horses with peritonitis of a few days' duration may have leukocytosis and hyperfibrinogenemia. plasma protein levels vary depending on the hydration status, degree of exudation into the peritoneum, and type of underlying problem. in chronic peritonitis, hyperproteinemia with hyperglobulinemia may be present. neonates with uroperitoneum caused by urinary bladder rupture or urachal disease tend to develop azotemia, hyponatremia, hypochloremia, hyperkalemia, and acidosis. foals with peritonitis following septicemia, severe enterocolitis, severe meconium impaction, intussusception, small intestinal volvulus, gastric or duodenal rupture, or ascarid impactions usually have clinicopathologic findings reflective of systemic inflammation, such as inflammatory leukogram or leukopenia, hemoconcentration, and acidosis. chronic abscessation, as occurs in foals with r. equi and streptococcal infections, results in clinicopathologic findings reflecting chronic inflammation (anemia, hyperfibrinogenemia, hyperglobulinemia). abnormalities in the composition of peritoneal fluid occur with peritoneal inflammation, and peritoneal fluid analysis is principal to the diagnosis of peritonitis. one collects peritoneal fluid through puncture of the abdomen on the ventral midline. one should clip and prepare an area aseptically. usually, the lowest point of the abdomen, to cm caudal to the xiphoid cartilage, is prepared for puncture; although in some cases one may perform paracentesis more caudally, particularly when one suspects a specific area of sequestered fluid or abscessation. in addition, one may choose a site to the right of midline in an attempt to avoid the spleen. one can perform peritoneal puncture using a / -inch, -gauge needle or, following local anesthesia and a stab incision with a no. scalpel blade, using a sterile cannula. one collects fluid by gravity flow and should collect fluid in a tube containing anticoagulant, preferably edta for cytologic examination, and in a sterile tube without anticoagulant for visual inspection and, if desired, for culture. one should fill the edta tube to half its volume, because the edta will alter the refractive index of the fluid, resulting in a falsely elevated value for total solids when one collects only a small volume and tests it with a refractometer. one should evaluate peritoneal fluid routinely as to color, turbidity, total protein, white blood cell (wbc) count and differential, and the presence of bacteria as determined by gram stain. normal peritoneal fluid is clear and straw-colored and does not coagulate spontaneously. peritoneal fluid becomes turbid when increased numbers of white blood cells and concentration of protein are present. pink or red fluid indicates free hemoglobin or hemorrhage. blood introduced into the peritoneal fluid iatrogenically in some cases may be differentiated from blood from internal hemorrhage based on the presence of platelets and hematocrit. fluid with iatrogenic blood contamination contains platelets, whereas fluid with blood following internal hemorrhage or diapedesis often does not have platelets. blood contamination resulting from splenic puncture often results in the packed cell volume of the sample being greater than that of the blood. large volumes of dark brown or green fluid with a fetid odor obtained from several sites strongly suggest bowel rupture, but one should perform cytologic examination for confirmation. the distribution of polymorphonuclear and mononuclear cells varies widely, and one should interpret the results of cell counts and differentials as supporting a number of disorders rather than a specific diagnosis. normal equine peritoneal fluid contains fewer than nucleated cells per microliter. , wbc counts in acute peritonitis (> , /µl) are reported to be higher than those in chronic peritonitis ( , to , /µl) [ ] [ ] [ ] ; however, this is not always the case, and the wbc count depends most on the cause of the peritonitis. the wbc level does not always correlate with severity of peritonitis or the prognosis. the peritoneal fluid wbc count can be greater than , /µl following enterocentesis, with no clinical signs or problem. conversely, peritoneal wbc counts of fewer than , /µl may be found in foals or horses with intraabdominal abscesses. the peritoneal wbc count can increase to greater than , /µl following celiotomy and can be higher if an enterotomy is done. postoperatively, the wbc count normally continues to decline and returns to near normal by to days. failure of the wbc count to decrease suggests peritonitis resulting from a postoperative complication. finally, peritoneal fluid wbc counts greater than , /µl indicate severe focal or generalized peritoneal sepsis. the distribution of polymorphonuclear and mononuclear cells varies in normal peritoneal fluid, , but polymorphonuclear cells usually predominate. with acute peritonitis, polymorphonuclear cells typically increase to a greater degree than mononuclear cells, but this depends on the cause. in horses that have bowel disease accompanied by endotoxemia, the number of peritoneal mononuclear cells increases, as does transformation of mesothelial cells to macrophages. in chronic cases, one easily may mistake transforming mesothelial cells for neoplastic cells, which can make diagnosis difficult, particularly when the presenting problem is compatible with a neoplastic process. in such cases, consultation with a clinical pathologist regarding cytologic findings is prudent. factor, and interleukin- have been measured in the peritoneal fluid of horses with abdominal disorders, but the diagnostic and prognostic implications of the presence or absence of these enzymes and analytes is limited. [ ] [ ] [ ] one should submit peritoneal fluid samples in appropriate media (port-a-cul vial, bbl microbiology system) for aerobic and anaerobic cultures in an attempt to identify the pathogenic organism(s). obligate anaerobic bacteria such as bacteroides are difficult to culture, because one must collect, transport, and culture the sample under strict anaerobic conditions. frequently, bacterial cultures are negative when bacteria are present in peritoneal fluid. to enhance recovery of bacteria, one can inoculate peritoneal fluid into blood culture medium (septi-chek columbia, hoffmann-laroche inc., nutley, new jersey), and if the horse has received antimicrobial treatment, one first should pass fluid through an antimicrobial removal device (a.r.d., becton dickinson & co., cockeysville, maryland). early and aggressive therapy is required if treatment of peritonitis is to be successful. the goals of treatment are to resolve the primary problem, minimize the inflammatory response, and prevent long-term complications. in the acute phase, one gives primary consideration to the arrest of endotoxic, septic, or hypovolemic shock; correction of metabolic and electrolyte abnormalities and dehydration; and management of pain. in the absence of blood gas and electrolyte determinations, adequate volumes of a balanced electrolyte solution are required to correct dehydration and support the cardiovascular system. if the plasma protein concentration of the horse is less than . g/dl, one should consider administration of plasma or synthetic colloids. one should administer flunixin meglumine (banamine) for its local and systemic antiinflammatory effects. dosages vary depending on the severity of peritonitis, degree of toxemia, severity of pain, and hydration status of the horse and range from . mg/kg intramuscularly or intravenously every to hours to . mg/kg intramuscularly or intravenously every hours. the higher dosage provides greater visceral analgesia, whereas the lower dosage is effective in modifying the effects of experimental endotoxemia. in addition to analgesic and general antiinflammatory effect, flunixin meglumine may be effective in retarding adhesion formation when administered early in the acute, diffuse stage of septic peritonitis. heparin therapy has been recommended to prevent adhesion formation and to render bacteria more susceptible to cellular and noncellular clearing mechanisms. in experimental models using laboratory animals, normal peritoneal fluid protein concentration is less than . g/dl. protein levels between . g/dl and . g/dl can be difficult to interpret, but one should consider levels greater than . g/dl to be elevated abnormally. fibrinogen concentration increases with inflammation, and levels greater than mg/dl in the peritoneal fluid suggest that an acute inflammatory process is present. fibrinogen content will also increase from blood contamination. the presence of free and phagocytosed bacteria in peritoneal fluid indicates generalized suppuration, abscessation, or compromised bowel. if one observes numerous microorganisms of mixed types free in the peritoneal fluid or if one observes plant material, massive bacterial contamination of the abdomen following bowel rupture likely has occurred. the presence of toxic or degenerate neutrophils and bacteria within polymorphonuclear cells helps to distinguish peritoneal fluid from intestinal contents in such cases. enterocentesis yields discolored fluid containing mixed microorganisms and plant material and that is largely devoid of white blood cells. bacterial contamination of a sample can occur during collection of the sample, and iatrogenic contamination of a sample can result in free and intracellular bacteria in peritoneal fluid, particularly if processing is delayed. in such cases the bacterial numbers are few and the neutrophils appear healthy. in some cases of gastrointestinal perforation the luminal material, inflammatory cells, and protein may be sequestered by the omentum and further contained by fibrinous adhesions. abdominal fluid obtained via standard ventral paracentesis may have low cellularity and protein content but large numbers of mixed bacteria indicating bowel rupture. examples include gastric rupture along the greater curvature of the stomach between the omental layers (omental bursa) and perforated gastric or duodenal ulcers in foals. correlating all cytologic findings with clinical and clinicopathologic findings is important for interpreting the results of peritoneal fluid cytologic examination. biochemical analysis of peritoneal fluid may be useful in detecting sepsis when cytologic examination and culture are negative or otherwise unavailable. in a prospective study by van hoogmoed, rodger, spier, et al., peritoneal fluid ph and glucose concentrations from horses with septic peritonitis were significantly lower than horses with nonseptic peritonitis and healthy horses. peritoneal fluid ph less than . , glucose less than mg/dl, and fibrinogen concentration greater than mg/dl were considered highly predictive of septic peritonitis. serum to peritoneal glucose concentration differences of greater than mg/dl was considered the most diagnostically useful test for septic peritonitis in the study. increased activities of alkaline phosphatase, lactic dehydrogenase, creatine kinase, aspartate aminotransferase, tumor necrosis heparin therapy was associated with decreased adhesions in septic peritonitis. heparin has not yet been demonstrated clearly to have similar efficacy in horses, although it may. suggested dosages range from to iu subcutaneously every hours for hours to to iu/kg subcutaneously every hours. one should note that heparin induces red blood cell aggregation in horses, which may adversely affect capillary blood flow. one should initiate antimicrobial therapy after making a diagnosis of peritonitis and before the results of peritoneal culture are available, because isolating an organism may take several days and often culture fails to isolate the organism(s). intravenous administration of antimicrobials is preferred over oral or intramuscular routes in acute, diffuse, septic peritonitis because more reliable levels of drug are achieved in the tissues and peritoneal fluid than otherwise would be obtained in horses with hypovolemia or decreased intestinal motility. the combination of a β-lactam antibiotic with an aminoglycoside is appropriate in most circumstances and certainly in the acute diffuse stage of septic peritonitis. these drugs act synergistically to provide a broad spectrum of activity against a variety of gram-positive and gramnegative aerobic and anaerobic bacteria. potassium penicillin ( , to , iu/kg intravenously every hours) combined with gentamicin ( . mg/kg every hours) is an appropriate regimen. in most cases, peritonitis will have resulted from bowel contamination, and thus one should presume a mixed infection with gram-negative aerobic bacteria and gram-positive and gram-negative anaerobic bacteria. one also should presume the same in many cases of traumatic peritonitis, as occurs with foreign body puncture, breeding trauma, or foaling trauma. therefore a strong possibility exists of infection involving penicillin resistant bacteroides fragilis, so that adding metronidazole ( mg/kg orally every to hours) to the regimen is prudent. combination therapy with β-lactam and aminoglycoside antibiotics (and metronidazole when indicated) is a standard and generally effective protocol. one can modify this antimicrobial regimen when culture and antimicrobial sensitivity results become available. aminoglycosides and nonsteroidal antiinflammatory drugs have the potential to induce acute renal tubular damage, particularly when dehydration and decreased renal perfusion are present. therefore adequately rehydrating the patient and ensuring that renal function is intact before initiating treatment with these drugs are important. furthermore, maintaining hydration and monitoring renal function during the course of treatment are important. monitoring serum creatinine concentration; performing serial uninalysis observing for pigment, red blood cells; and casts; determining the ratio of γ-glutamyltransferase to creatinine in the urine; and therapeutic drug monitoring of aminoglycoside levels are useful in this regard. sodium ampicillin and ceftiofur sodium are β-lactam antibiotics that may be useful in combination therapy. these drugs have an extended gram-negative spectrum compared with penicillin. however, as a third-generation cephalosporin, ceftiofur is less effective against anaerobes than penicillin. one also may consider ceftiofur, trimethoprim-potentiated sulfonamides, amikacin, and enrofloxacin for treatment of gram-negative infection based on culture and sensitivity results. enrofloxacin is a quinolone drug with excellent activity against gramnegative pathogens, including pseudomonas, and also can be effective against resistant staphylococci (personal observation). such staphylococci may be involved in infections caused by traumatic puncture of the abdominal wall. enrofloxacin has a variety of potential toxic effects, including cartilage damage in young growing animals. however, a recent study concluded the drug was safe when administered to adult horses intravenously at mg/kg every hours for weeks. one probably should avoid using the drug in young, growing animals until the issue of cartilage damage is resolved. administration of enrofloxacin to horses constitutes off-label usage. one should treat horses with acute, diffuse, septic peritonitis with antibiotics until the white blood cell count, plasma fibrinogen, and abdominal fluid analysis are normal. in horses that respond to therapy, this process takes a variable amount of time depending on the offending organisms and stage of disease at the time treatment is initiated. horses with abdominal abscessation resulting from polymicrobial infection may require many months of antibiotic treatment. abdominal abscesses caused by streptococci and corynebacterium pseudotuberculosis also may require long-term treatment (weeks to months). long-term antibiotic treatment generally necessitates the use of oral antibiotics, and the options are limited. trimethoprim-potentiated sulfonamides are administered orally and are effective against a variety of gram-positive and gram-negative organisms, although some streptococci are resistant. metronidazole is an orally administered drug effective against anaerobic bacteria, as previously discussed. other orally administered antimicrobials one may consider for long-term use include doxycycline (broad spectrum), erythromycin (gram-positive spectrum), and enrofloxacin (mostly gram-negative spectrum). importantly, rifampin, when used with other drugs, can be effective in penetrating and resolving abscesses. combination therapy with erythromycin and rifampin is the standard treatment for rhodococcus equi infection in foals. peritonitis caused by actinobacillus equuli usually is manifested as a diffuse, supporative peritoneal exudate. the same is true for some cases involving streptococci (personal observation). these infections generally respond well to combination therapy with penicillin and gentamicin. if streptococci are involved as the sole pathogen, then penicillin alone should be effective. streptococci potentially can be involved in mixed, synergistic peritoneal infections in horses. drainage or lavage of the peritoneal cavity may be of benefit in removing toxic bacterial by-products and products of inflammatory cells. high numbers of inflammatory cells and release of their mediators can persist even after the primary stimulus of the inflammatory response has resolved. infusing large volumes of isotonic, warmed fluid into the peritoneal cavity also dilutes the inflammatory mediators, possibly reducing their deleterious effects. when successful, peritoneal lavage decreases the peritoneal fluid wbc count and total protein, potentially reflecting a decrease in diffuse inflammation. the benefits of peritoneal lavage are controversial, and a positive effect may be more likely during the acute, diffuse stage of disease. , some studies suggest peritoneal lavage, along with heparin therapy, may reduce the incidence of adhesions. one should perform peritoneal drainage and lavage using a drain of no less than f diameter. foley-type catheters can be used, but "mushroom" drains provide a larger area for fluid to enter the drain. two approaches to peritoneal lavage are ( ) retrograde irrigation through a ventrally placed ingress-egress drain and ( ) placement of ingress catheter(s) in the paralumbar fossa(e) for infusion of fluids, with a drain placed ventrally for removal of infused fluid. one must recognize that thorough peritoneal lavage can be achieved only via ventral midline laparotomy. complications associated with the use of abdominal drains or repeated peritoneal penetration to drain fluid include retrograde infection, local irritation, pneumoperitoneum, and subcutaneous seepage around the drain and resultant cellulitis. if the patient is hypovolemic or hypoproteinemic, one should consider volume replacement and administration of plasma before removing large quantities of fluid from the abdomen. in horses with suspected parasite involvement, such as verminous arteritis, one should give larvicidal doses of an anthelmintic once the condition of the horse is stabilized. ivermectin, fenbendazole, and thiabendazole have been recommended as larvacidal therapies. visualization of auscultation sounds of the large intestine small intestinal betagalactosidase activity in the horse rectal biopsy diagnosis in horses with clinical signs of intestinal disorders: a retrospective study of cases equine lymphocyticplasmacytic enterocolitis: a retrospective study of cases eosinophilic enterocolitis and dermatitis in two horses breath hydrogen measurements in ponies: a preliminary study the oral glucose tolerance test in the horse small intestinal malabsorption in the horse: an assessment of the specificity of the oral glucose tolerance test transient glucose malabsorption in two horses: fact or artifact? chronic diarrhoea in adult horses: a review of referred cases effect of food deprivation on d-xylose absorption test results in mares malabsorption syndromes in the horse the diagnostic value of the d-xylose absorption test in horses with unexplained chronic weight loss small intestinal malabsorption in horses effects of extensive small intestinal resection in the pony effects of extensive resection of the small intestine in the pony clinical remission of granulomatous enteritis in a standardbred gelding following long term dexamethasone administration clinical and pathophysiological features of granulomatous enteritis and eosinophilic granulomatosis in the horse inflammatory bowel disease in horses: cases segmental eosinophilic colitis: a review of cases chronic idiopathic inflammatory bowel diseases of the horse section . malabsorption syndromes and maldigestion: pathophysiology, assessment, management, and outcome references of critical care medicine consensus conference: definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis sisson and grossman's the anatomy of domestic animals observational study of "urine testing" in the horse and donkey stallion oral examination and diagnosis: management of oral disease fluoroscopic investigations of swallowing in the horse esophageal dysfunction in a weanling thoroughbred cervical esophagostomy to permit extraoral feeding of the horse use of a liquid diet as the sole source of nutrition in six dysphagic horses and as a dietary supplement in seven hypophagic horses acid-base and electrolyte alterations associated with salivary loss in the pony dysphagia caused by squamous cell carcinoma in 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prostaglandin e on motility of the equine gut in vitro investigation of the effect of prostaglandins and nonsteroidal antiinflammatory drugs on contractile activity of the equine smooth muscle of the dorsal colon, ventral colon, and pelvic flexure evaluation of nitric oxide as an inhibitory neurotransmitter in the equine ventral colon prostanoid production via cox- as a causative mechanism of rodent postoperative ileus the action of low dose endotoxin on equine bowel motility sir frederick hobday memorial lecture: all wind and water-some progress in the study of equine gut motility antagonism of endotoxin-induced disruption of equine bowel motility by flunixin and phenylbutazone cyclooxygenase inhibitors in equine practice in vitro effects of erythromycin, lidocaine, and metoclopramide on smooth muscle from the pyloric antrum, proximal portion of the duodenum, and middle portion of the jejunum of horses efficacy of metoclopramide for treatment of ileus in horses following small 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surgical treatment of sand colic in equids: cases ( - ) surgical treatment of sand colic: results in horses diarrhea associated with sand in the gastrointestinal tract of horses abdominal auscultation in the detection of experimentally induced gastrointestinal sand accumulation failure of psyllium mucilloid to hasten evaluation of sand from the equine large intestine nonstrangulated colonic displacement in horses functions of the equine large intestine and their interrelationship in disease comparisons of age, breed, history and management in horses with colic motor functions of the intestine the effect of strongylus vulgaris larvae on equine intestinal myoelectrical activity displacement of the large colon reversal of colonic net absorption to net secretion with increased intraluminal pressure use of ultrasound in horses for diagnosis of left dorsal displacement of the large colon and monitoring its nonsurgical correction renosplenic entrapment of the large colon in horses: cases renosplenic entrapment of the large colon in horses: cases further experiences with non-surgical correction of nephrosplenic entrapment of the left colon in the horse effect of phenylephrine on hemodynamics and splenic dimensions in horses displacement of the large colon associated with nonsurgical correction of large-colon entrapment in the renosplenic space in a mare foreign body obstruction of the small colon in six horses fecalith impaction in four miniature foals obstruction of the small colon by intramural haematoma in three horses submucosal haematoma as a cause of obstruction of the small colon in the horse: a review of four cases inflammatory bowel disease in horses: cases intestinal atresia in horses clinical survey of tumours and tumourlike lesions in horses in south east queensland abdominal neoplasia (excluding urogenital tract) clinical manifestation of squamous cell carcinoma in horses lymphoma (lymphosarcoma) in horses oral and dental tumors in equine denistry t cell-rich b cell lymphosarcoma in the tongue of a horse multiple myeloma in a horse rhabdomyosarcoma of the tongue in a horse paraneoplastic bullous stomatitis in a horse gastric squamous cell carcinoma in three horses use of esophagoscopy in the diagnosis of esophageal squamous cell carcinoma in a horse gastric hyperplastic polyp in a horse gastric leiomyosarcoma in a horse multisystemic, eosinophilic, epitheliotropic disease with intestinal lymphosarcoma in a horse an immunohistochemical study of equine b-cell lymphoma squamous cell carcinoma of the equine stomach: a report of five cases six cases of squamous cell carcinoma of the stomach of the horse small intestinal adenocarcinoma in a horse ganglioneuroma as a cause of small intestinal obstruction in the horse: a case report intestinal carcinoid in a mare: an etiologic consideration for chronic colic in horses leiomyoma of the small intestine in a horse jejunal intussusception associated with leiomyoma in an aged horse duodenal leiomyoma associated with colic in a two-year-old horse leiomyosarcoma of the duodenum in two horses pedunculated lipomas as a cause of intestinal obstruction in horses: cases ( - ) clinical aspects of lymphosarcoma in the horse: a clinical report of cases multiple peripheral nerve sheath tumors in the small intestine of a horse equine adenocarcinomas of the large intestine with osseous metaplasia intestinal myxosarcoma in a thoroughbred mare gastrointestinal stromal tumors of the equine cecum colonic adenocarcinoma with osseous metaplasia in a horse intestinal adenocarcinoma causing recurrent colic in the horse equine colonic lipomatosis large colon resection for treatment of lymphosarcoma in two horses colic in a mare caused by a colonic neurofibroma small colon intussusception associated with an intralumenal leiomyoma in a pony leiomyoma of the small colon in a horse an analysis of cases of intestinal obstruction caused by pedunculated lipomas rectal leiomyosarcoma in a horse strangulation of the rectum of a horse by the pedicle of a mesenteric lipoma rectal biopsy diagnosis in horses with clinical signs of intestinal disorders: a retrospective study of cases standing rectal and tail surgery disseminated peritoneal leiomyomatosis in a horse ascites as a result of peritoneal mesotheliomas in a horse a case of peritoneal mesothelioma in a thoroughbred mare omental fibrosarcoma in a horse neoplasia of the mouth and surrounding structure pleuroscopic diagnosis of gastroesophageal squamous cell carcinoma in a horse recurrent esophageal obstruction due to squamous cell carcinoma in a horse chronic colic in the mature horse: a retrospective review of cases recurrent colic in the mature horse: a retrospective review of cases paraneoplastic syndromes lymphosarcoma and associated immune-mediated hemolytic anemia and thrombocytopenia in horses differentiation of chronic lymphocytic leukemia in the horse: a report of two cases hypercalcemia associated with malignancy in a horse adenocarcinoma of intestinal origin in a horse: diagnosis by abdominocentesis and laparoscopy differentiation between intra-abdominal neoplasms and abscesses in horses, using clinical and laboratory data: cases ( - ) malabsorption in the horse associated with alimentary lymphosarcoma immunodeficiency associated with lymphosarcoma in a horse flow cytometric methods to diagnose selected equine immune-mediated disorders pleural effusion associated with squamous cell carcinoma of the stomach of a horse use of diagnostic ultrasonography in horses with signs of acute abdominal pain the indications for equine laparotomy: an analysis of cases equine lymphosarcoma diarrhoea in the horse as a result of alimentary lymphosarcoma paraneoplastic pruritus and alopecia in a horse with diffuse lymphoma lymphoma in the horse. proceedings of the twelfth annual meeting of the american college of veterinary internal medicine squamous cell carcinoma of the pharyngeal wall in a horse squamous cell carcinoma of the oral, pharyngeal and nasal mucosa in the horse treatment of superficial ulcerative squamous cell carcinoma in three horses with topical -fluorouracil intratumoral chemotherapy with cisplatin in oily emulsion in horses excision of oral squamous cell carcinoma in a horse extensive resection and anastomosis of the descending (small) colon in a mare following strangulation by a mesenteric lipoma section . peritonitis references . hosgood g: peritonitis. . a review of the pathophysiology and diagnosis the peritoneum and peritoneal cavity large animal internal medicine diseases of the peritoneum and mesentery equine internal medicine peritonitis associated with actinobacillus equuli in horses: cases veterinary gastroenterology peritonitis and other intra-abdominal infection antibiotic susceptibility of bacterial pathogens from horses peritonitis in horses: cases biologic reactions to endotoxin effect of dietary alpha-linoleic acid on equine monocyte procoagulant activity and eicosanoid synthesis review of cases of peritonitis in the horse reference values for equine peritoneal fluid diagnostic cytology in the equine species: overview of effusions (peritoneal, pleural, and synovial joint) and transtracheal wash effects of enterocentesis on peritoneal fluid constituents in the horse internal abdominal abscesses in the horse: a study of cases equine peritoneal fluid analysis following celiotomy analysis of equine peritoneal fluid evaluation of peritoneal fluid ph, glucose concentration, and lactate dehydrogenase activity for detection of septic peritonitis in horses tumor necrosis factor and interleukin- activity and endotoxin concentration in peritoneal fluid and blood of horses with acute abdominal disease low dose flunixin meglumine: effects on eicosanoid production and clinical signs induced by experimental endotoxemia in horses heparin in the treatment of experimental peritonitis erythrocyte agglutination associated with heparin treatment in three horses therapeutic strategies involving antimicrobial treatment of large animals with peritonitis effect of long-term administration of injectable enrofloxacin solution on physical and musculoskeletal variables in adult horses peritoneal lavage in the horse pharmacologic principles therapeutic drug monitoring: a tool for rational drug therapy. proceedings of the seventh american college of veterinary internal medicine forum toxicity of quinolones although a number of potential causes of peritonitis exist, sepsis is a common and serious complication, and the identification and control of bacterial sepsis is critical for a successful outcome. bowel leakage (as well as external trauma) results in contamination of the peritoneum with large numbers of many types of bacteria. the intestinal tract contains a mixed population of bacteria, and the quantity of bacteria and prevalence of anaerobic species increase in the distal segments. [ ] [ ] [ ] [ ] [ ] [ ] [ ] there are approximately × anaerobic and × aerobic bacteria per milliliter of cecal and colonic fluid, thus the potential for bacterial contamination of the peritoneum is great. high mortality is associated with contamination from the lower bowel because of the large numbers of bacteria present. hirsch and jang reported isolation of an infective agent from equine peritoneal fluid in approximately % of attempts. obligate anaerobic bacteria were cultured most frequently, followed by members of the enterobacteriaceae family (escherichia coli). penicillin-resistant bacteroides fragilis was isolated from % to % of cases. in another study in which bacteria were identified in equine abdominal fluid by cytologic examination or culture, e. coli was the organism most commonly isolated. in human beings and laboratory animals the well-established fact is that despite the variety of organisms initially introduced subsequent to these events, established infections are characterized by only a few types of bacteria, which are often gram-negative aerobes and anaerobic bacteria. this selectivity occurs through the processes of selective reduction of bacterial populations and bacterial synergism. a well-known example of synergism in human beings and laboratory animals is peritonitis involving e. coli and b. fragilus. the presence of each organism is beneficial to the survival of the other, and each is important in the overall pathogenesis of the disease. e. coli is associated with septicemia and early mortality, whereas b. fragilis infection tends to result in chronic abscessation with delayed morbidity and mortality. some evidence suggests that in horses, in addition to coliforms and anaerobes, streptococci and perhaps c. psuedotuberculosis may survive selective reduction and participate in synergistic infection following polymicrobial contamination.biologic events resulting from contamination of the abdomen or injury to the mesothelial cells have been described [ ] [ ] [ ] [ ] and include release of catecholamines, histamine, and serotonin from peritoneal mast cells; vasodilation and hyperemia; increase in peritoneal vascular permeability; secretion of protein-rich fluid into the peritoneum; transformation of mesothelial cells into macrophages; and influx of polymorphonuclear cells, humoral opsonins, natural antibodies, and serum complement into the peritoneal cavity. additionally, depression of the peritoneal fibrinolytic activity, fibrin deposits on the peritoneal surface, and sympathetic-mediated ileus of the gastrointestinal tract can occur.these processes benefit the animal by confining contamination and infection, and indeed, with clean, minimally invasive procedures such as enterocentesis or trocharization, this is effective. however, with greater severity of peritoneal contamination or irritation, these processes are magnified and become deleterious, resulting in problems such as hypovolemia, hypoproteinemia, ileus with resultant bowel distention, ischemia of the bowel wall with subsequent absorption of bacteria and toxins, and ultimately adhesion and abscess formation. additionally, systemic responses to bacterial toxins, particularly lipopolysaccharide, , can compromise the metabolic condition of the patient further. equine peritoneal macrophages release several mediators when exposed to bacterial lipopolysaccharide, undoubtedly an important component of septic peritonitis.pathologic description of peritonitis includes origin (primary or secondary), onset (peracute, acute, chronic), distribution (localized versus diffuse), and presence of bacteria (septic versus nonseptic). , clinically, viewing key: cord- -uxp kg authors: goodarzi, pedram; mahdavi, farzad; mirzaei, rasoul; hasanvand, hamze; sholeh, mohammad; zamani, farhad; sohrabi, masodreza; tabibzadeh, alireza; jeda, ali salimi; niya, mohammad hadi karbalaie; keyvani, hossein; karampoor, sajad title: coronavirus disease (covid- ): immunological approaches and emerging pharmacologic treatments date: - - journal: int immunopharmacol doi: . /j.intimp. . sha: doc_id: cord_uid: uxp kg the sars-cov- virus is an etiological agent of pandemic covid- , which spreads rapidly worldwide. no proven effective therapies currently exist for this virus, and efforts to develop antiviral strategies for the treatment of covid- are underway. the rapidly increasing understanding of sars-cov- virology provides a notable number of possible immunological procedures and drug targets. however, gaps remain in our understanding of the pathogenesis of covid- . in this review, we describe the latest information in the context of immunological approaches and emerging current antiviral strategies for covid- treatment. in december , many severe respiratory diseases accompanied by pneumonia appeared in wuhan, hubei province, china, with unknown etiology [ ] [ ] [ ] . sequencing examination on lower respiratory tract specimens showed a novel coronavirus named novel coronavirus ( -ncov) [ ] [ ] [ ] [ ] [ ] . data from genome sequencing of sars-cov- assist the researchers in approving diagnostic examination, epidemiologic tracking, and advancement of preventive and curative strategies [ ] . the clinical sign of covid- has a wide range from moderate, self-restraint respiratory tract illness to acute progressive pneumonia, multi-organ collapse, and death [ , ] . up to the present, there were no licensed therapies for the therapy of -ncov infection. after the rise of the sars-cov- in , screening of licensed drugs for the therapy of sars led to the identification of some drugs (as reviewed by vijayanand and colleagues) [ ] , such as protease inhibitors, nucleoside analogs, intravenous immunoglobulins, convalescent sera, tumor necrosis factor-alpha blockers, interferons, traditional chinese medicines, and glycyrrhizin. this virus causes sars in humans [ ] . there are no confirmed efficacious treatments for the however, researchers made much effort to develop antiviral strategies for the treatment of covid- . this review will describe the current evidence on significant proposed, repurposed, or experimental therapies for covid- and present a summary of contemporary clinical experience and treatment guidelines for this new pandemic sars-cov- . antibodies are an essential part of host immune reactions to viral infection. due to their unique maturation process, antibodies can emerge extremely particular to viral antigens [ ] . the first use of immunoglobulins (antibodies) as a therapy opportunity for viral diseases can be hunted back to the beginning th century, using sera of infected people, who had improved from the same condition [ , ] . this natural therapy regimen ( serum therapy), was slowly replaced by immunoglobulins purified from merged sera, intravenous immune globulin (ivig) [ ] . notwithstanding the achievement of both serum therapeutics and ivig, no meaningful advancement was made to produce antibodies as therapeutics. the hybridoma technique was continuously launched, facilitating the separation of monoclonal antibodies (mabs) from immunized mice in [ ] . various approaches have been established since the mid- s for the effective separation of mabs toward viruses of human and animal sources [ ] . to date, there are no confirmed vaccines or therapeutic medications that are special to covid- . preventing monoclonal antibodies (mabs), owing to their fantastic antigen specificity, is among the most suitable nominees for compensating viral infection [ ] . hence, recognizing and cloning of mabs that can accurately target viral superficies proteins to hinder the viral entrance to host cells is an acceptable strategy for blocking and handling covid- , mainly when effective vaccines and therapeutics medications are unavailable in the outbreak of the covid- pandemic [ ] . mabs targeting exposed positions on viral outside proteins are frequently identified as hopeful classes of drugs toward infectious disorders and have conferred therapeutic potency for numerous types of viruses [ , ] . neutralizing antibodies produced against coronavirus mainly target the spike (s) glycoproteins outside the viral envelope that mediates entrance into host cells. the s protein is composed of two functional subunits, which involve cell binding (s subunit) and s subunit, which includes membrane fusion. s subunit the main target of the humoral immune system, that potent neutralizing antibodies often produced against it [ ] [ ] [ ] [ ] [ ] [ ] . a recent report by wang et al. has shown that human mabs can neutralize both sars-cov- and sars-cov in cell culture [ ] . another report demonstrated that chen and colleagues separated two human mabs employing sars-cov- rbd-specific memory b cells separated from healed cases with covid- . these two mabs could especially attach to sars-cov- rbd, block the interplay within sars-cov- rbd and the hace receptor, and lead to potent neutralization of sars-cov- s protein pseudotyped virus infection. before-mentioned human anti-sars-cov- rbd-ace blocking mabs are initially described and endure transcendent hope to be employed as specific preventive and therapeutic tools toward underway sars-cov- pandemic [ ] . this knowledge suggests that mabs have a promising approach for tackling the covid- pandemic. the results of using mabs are still premature, and future studies will shed light on the feasibility of this type of biological therapy for patients with covid- ( figure) (table) . the sera separated to form recovered patients from the infectious disease called convalescent plasma, which has been employed to prevent and treat various infectious illnesses for longer than one century. antibodies exist in immune or convalescent plasma, intercede their curative effects through multiple mechanisms. the antibody can attach to a given infectious agent by compensating its infectivity directly. another mechanism that antibody may also contribute to its therapeutic effect includes complement activation, phagocytosis, and antibody-dependent cellular cytotoxicity. non-neutralizing antibodies attach to the infectious agent but do not intervene with their capacity to replicate in-vitro systems may also participate in prevention and expedite the rehabilitation process [ , ] . across the previous two decades, convalescent plasma therapy has been successfully employed to manage sars, mers, and the h n pandemic with competent potency and safety [ ] [ ] [ ] [ ] . a meta-analysis of investigations of sars-cov and severe influenza virus infection explained a statistically meaningful decline in the pooled odds of fatality following treatment with convalescent plasma, contrasted with placebo or no treatment [ ] . however, convalescent plasma treatment was unable to considerably enhance the durability of the ebola virus infection, presumably due to the lack of data on neutralizing antibody titration for stratified examination [ ] . because the virological and clinical features share similarities between sars-cov- , mers, and sars-cov- , convalescent plasma treatment might be a confident strategy choice for covid- saving [ ] . patients who have healed from covid- with a huge neutralizing antibody concentration may be a precious donor reservoir of convalescent plasma. it is worth mentioning that there are potential safety concerns on convalescent plasma therapy, including transmitting other infectious agents and a pathological event called antibodydependent enhancement (ade) [ ] . ade attributes to a means of how antibodies increasing throughout a previous infection exacerbate clinical severity as an outcome of disease with a distinct viral serotype. this event is famed for some viruses, prominently the dengue virus [ ] . although, in convalescent serum trials, attention, and alertness to recognize any enhanced infection, evidence will be demanded. in a recent report published in china, researchers revealed that in % of patients, one dose of convalescent plasma ( ml) was well-tolerated and significantly increased or maintained neutralizing antibodies at high levels, resulting in the disappearance of viremia within a week. it can also modulate multiple parameters compared to pre-transfusion, including decreased c-reactive protein and increased lymphocyte numbers. besides, convalescent plasma therapy in seven cases who had the former viremia led to the disappearance of viremia (undetectable viral load). another finding that study was that convalescent plasma treatment was well-tolerated and conceivably improved the clinical symptoms, thereby neutralizing viremia in patients with severe covid- . finally, the authors of this study believe that further investigations are wanted to define the optimal dose and clinical benefits of convalescent plasma therapy [ ] . future studies should analyze the efficiency of convalescent plasma treatment in many patients, and the potential risk of this therapeutic method must be deeply assessed (figure) (table) . the increasing knowledge is regarding covid- pathogenesis has supported the role of excess inflammatory mediators in patients with covid- . patients' pathological characteristics with covid- include capillary leakage of liquid and entrance of inflammatory cells, including t cells, neutrophils, and macrophages [ ] , referring a function for chemokines and cytokines targeting vascular endothelium. the concentration of pro-inflammatory cytokines, including il- , il- , tnf-α, and ifn-γ, are elevated in the blood of cases infected with covid- [ , ] . recent studies report different cytokine profiles in patients with severe covid- [ , [ ] [ ] [ ] [ ] [ ] [ ] . in a study carried out by huang and colleagues have revealed the higher concentration of il- , il- , il- , tnf, g-csf, ip- ; cxcl , mcp- (ccl ) and mip- a (ccl ), but not il- , in cases hospitalized in the intensive care unit (icu) contrasted with non-icu patients ( ). another study confirmed that during acute covid- disease, some pro-inflammatory cytokines such as il- β, il- ra, il- r, il- , il- (cxcl ), il- , ifn-γ, gm-csf elevated [ , , , ] . in recent exciting research, the concentration of some cytokines/ chemokines, including il- , il- , ifnγ, tnf, and ip- in icu patients with covid- , have been higher than mild to moderate non-icu patients [ , [ ] [ ] [ ] . various strategies, including global targeting of the inflammation or compensating a single crucial inflammatory marker, are applied to cope with cytokine storm in covid- . between key cytokines, il- has drawn significant attention levels, and antibodies that hinder the il- receptor (il- antagonist, tocilizumab, and sarilumab) are now following phase / clinical trials for the possible therapy of covid- [ ] . another hopeful strategy is targeting ifn-γ, which has been remarked by beginning a clinical trial for jak-stat inhibitor (ruxolitinib) for managing covid- severity [ ] . tnf works upstream of il- , and anti-tnf treatments earlier revealed protecting impacts in deadly sars-cov disease [ ] . a recent report by cavalli et al. have shown that the efficacy of anakinra (human interleukin- receptor antagonist protein) was notably higher in subjects with covid- contrasted with those who received standard treatment for three weeks, led to decreased levels of serum crp, improved respiratory function ( % vs. %), increased survival rate ( % vs. %). however, the study results demonstrated that bacteremia's risk was elevated in cases receiving anakinra than those receiving standard treatment [ ] . although there is no particular antiviral medicine for covid- , knowledge of cytokine storm mechanisms can help to speculate possible therapeutic interventions ( figure) (table) [ ] . it is alleged that corticosteroid treatment is not supported for viral pneumonia [ ] . investigations have revealed that the use of systemic corticosteroids for patients with sars-cov and mers-cov was correlated with a higher fatality rate than patients under standard treatment [ , ] . the same finding was described in cases with influenza virus-associated pneumonia [ ] . in a study performed by matsuyama et al. [ ] , they utilized the nasal administration of corticosteroids for patients infected with coronaviruses. they indicated that in the cell culture models, the inhaled form of corticosteroids, such as ciclesonide, could be useful for the treatment of coronaviruses. ciclesonide exerts antiviral and anti-inflammatory activity in in-vitro models [ ] . furthermore, there are some open clinical trials for the therapeutic assessment of methylprednisolone on covid- patients [ ] . a systematic review study carried out by tahvildari and colleagues [ ] , shows that at least six different published studies on the effect of corticosteroids on covid- patients. also, wu et al. [ ] indicated that the use of corticosteroids for patients with covid- who developed ards could lead to a better outcome and reduce the mortality rate. these results indicate the necessity of checking the clinical conditions of covid- patients before prescribing corticosteroids. finally, recently, a case report study from japan shows that orally inhaled ciclesonide alleviates the local inflammation in the lung of patients with covid- pneumonia and inhibits the propagation of the virus by antiviral activity [ ] . further studies are required to unravel the precise mechanism of corticosteroids in the exacerbation of patients with covid- ( figure) (table) . mesenchymal stem cells (mscs) are a subset of non-hematopoietic adult stem cells, readily isolated from various tissues. they show immunoregulatory activity and could be employed for the tissue repair process as they secrete paracrine factors [ ] . cell-based therapy, remarkably stem cell therapeutics, has become an encouraging remedial field, in which many perceive possibilities to cure deadly and inflammatory disorders [ , ] . notwithstanding the notable progress of stem cell-based treatment, immunogenicity, poor cell source, and moral problems are deemed the main therapeutic approach restrictions. among these, mscs have drawn much attention due to origin potential, a high reproduction speed, having a low invasive method, and free of moral problems. there is an extreme advantage in applying msc treatment in contrast with other approaches [ ] . the results indicate that following covid- infection may start suppressing immune overactivity in the human body. in patients infected with sars-cov- , the immune system generates massive volumes of inflammatory factors, prompting cytokine storm in which the immune cells produce an extreme amount of cytokines and chemokines [ ] . herein, it is the opening of the msc therapy strategy in the treatment of covid- patients. msc cure can limit the storm release of cytokines by the immune system and raise endogenous restoration by regenerative features of stem cells [ ] . recently, some countries, such as china, the usa, iran, and various other countries, have launched msc therapy, and some reports are currently available in the published literature. mscs, working their immunomodulatory features and their differentiation capacity, can inhibit lung tissue loss by hindering the cytokine storm and restoration and regeneration of damaged tissues [ ] . a recent study carried by chen and co-workers indicated that the use of mscs notably improves the survival proportion of h n -induced ards and provides a philosophical background for treating h n -induced ards preclinical research and clinical research. because h n and covid- share similar complications and are associated with multi-organ collapse, msc-based treatment could be a feasible option for the treatment of covid- [ ] . in the same way, a recent case-report study showed that the adoptive transfer therapy of human umbilical cord blood derived-mesenchymal stem cells (hucmscs) to a chinese female patient afflicted with acute covid syndromes improved her laboratory tests and ct images [ ] . before receiving any treatments, the percentage of her neutrophils was increased to . % while the number of lymphocytes was decreased to . %. she was operated with antiviral medications, including lopinavir/ritonavir, ifn-α, and oseltamivir, also the intravenous dose of moxifloxacin, xuebijing, methylprednisolone, and immunoglobulins. the case was also curbed to non-invasive mechanical ventilation to expedite breathing and decrease muscle weakness due to weak oxygenation. as the vital symptoms exacerbate, the case was treated with hucmscs solely and with α thymosin × cells per three times. the study results explained that following the second injection, serum albumin, crp, alt, and ast were steadily diminished, and other important symptoms were enhanced. after that, the patient was discharged from the ventilator and capable of walking, and the number of neutrophils and white blood cells returned to the baseline levels. most importantly, the abundance of cd +, cd +, and cd + t cells was significantly enhanced. also, the qualitative outcomes of ct images following the second and third doses of hucmscs revealed that pneumonia was attenuated. after two days of the third injection, the patient was rescued from the icu, and most of the vital symptoms and clinical laboratory parameters returned to the standard ranges. the outcomes recommended that hucmscs could be an excellent strategy choice alone or in combination with other immunomodulatory tools for covid- patients [ ] . a recent study performed in china in cooperation with the united states recruited seven cases with covid pneumonia from january to february . patients experienced mscs transplantation, and their clinical signs were consecutively checked for days. the study demonstrated that the transplantation of hucmscs led to a marked decrease in the level of pro-inflammatory cytokines and a substantial improvement in clinical symptoms without any significant adverse effects [ ] . the pulmonary function, along with the seven patients' clinical symptoms, were significantly improved after two days of transplantation. the number of peripheral lymphocytes also increased, while crp concentration was diminished after the treatment. additionally, the number of hyperactive cytokine-secreting immune cells, namely cxcr +cd +, cxcr +cd +, and cxcr + nk cells was remarkably lowered within - days after transplantation of hucmscs. moreover, the frequency of cd +cd c+cd b mid regulatory dc cell population was significantly elevated. the level of tnf-α was significantly reduced, while il- was raised in the hucmscs-treated group contrasted with the placebo control group. besides, the gene expression characterization explained that ace and tmprss genes are not expressed in hucmscs, implying that the coronavirus would not infect these cells. hence, the intravenous transplantation of hucmscs is seemingly safe and efficient for the treatment of cases with covid- pneumonia, notably those in critically severe conditions [ ] . as multiple clinical trials are launched worldwide, we should not have to wait long to determine if mscs are a viable and valid treatment choice for severe covid- . considering the need for mitigating the prevailing covid- pandemic, with superiority to manage fatality as low as possible, the judgment that msc is reliable and can invert severe critical disease with high power is an invention designing a completely novel biological procedure that needs to be developed urgently (figure) (table) . chloroquine and hcq are both known as antimalarial drugs. clinical studies introduced these two drugs as a possible choice for covid- treatment due to having in-vitro antiviral and antiinflammatory properties [ ] [ ] [ ] [ ] . several studies suggested that chloroquine could improve the radiological and virological features of covid- [ ] . chloroquine is a reliable and effective drug for covid- in some preclinical trials [ ] and other studies [ ] . in this regard, smith et al. [ ] indicated that cardiac arrhythmia is a significant side effect of chloroquine. in the matter of hydroxychloroquine, reports are controversial [ , , ] . in a study conducted by shamshirian et al. [ ] , there was no potential clinical efficacy in prescribing hcq. simultaneously, the in-vitro anti-sars-cov- activity of this particular drug seems to be more than chloroquine [ , ] . fortunately, there are currently several clinical trials being conducted on these drugs [ ] . also, regardless of the solo practice for these drugs, gautret, and colleagues [ ] suggested a combination of hcq and azithromycin as an effective treatment for decreasing the viral load in patients with covid- . another aspect of these drugs is the possibility of using them in different conditions such as pregnancy. a majority of studies conducted on hcq did not reflect any serious concerns, and this drug seems to be safe for pregnant women [ ] . besides, as mentioned by lother et al. [ ] , clinical trials for the assessment of medicines as post-exposure prophylaxis could be helpful. a recent report noted that the severity of covid in patients treated with hcq was higher than those not receiving this medication. also, the report showed that there was no meaningful correlation within the use of hcq and intubation or mortality [ ] . besides, another report demonstrated that amongst cases hospitalized in metropolitan new york with covid- , practice with hcq, azithromycin, or both, matched with neither medication, was not meaningfully correlated with variations in an in-hospital fatality. however, the analysis of these conclusions may be restricted by the observational study [ ] . the recent study also indicated that hcq did not substantially decrease symptom severity in outpatients with early, mild covid- [ ] . at the same time, another study performed by mitjà and colleagues indicated that hcq in patients with mild covid- has no benefit beyond routine care [ ] . moreover, arshad and co-workers [ ] showed that in patients with covid- treated with hcq alone and combined with azithromycin, it was correlated with a decline in covid- associated mortality. comprehensive systematic review and meta-analysis studies and clinical trials in this field are urgently needed ( figure) (table) . ace (angiotensin-converting enzyme- ) is a transmembrane enzyme expressed on the exterior of epithelial cells in the many organs such as lungs, arteries, heart, kidney, and intestines [ , ] . recently, the new coronavirus is responsible for pandemic covid- , sars-cov- is thought to be mainly or exclusively bound to ace [ , ] . the molecular interplay among ace and spike has been created [ , ] , and manufactured compounds or antibodies, interfering with the interplay of ace , and the viral spike protein could be produced. another therapeutic approach is the use of soluble ace as a virus scavenger and neutralizer. soluble ace formed by a proteolytic splitting of the membrane anchor is ordinarily located in the plasma; however, its concentration is shallow. an increase in the availability of soluble ace at tissue positions would change the rivalry with membrane-bound ace toward the soluble form, leading to the repression of viral entry into the cells. it is also expected that this approach would preserve tissue ace [ , ] . a new study has recently shown that the recombinant form of ace reduces the infection and viral growth in cell culture and organoids by acting as a decoy for sars-cov- [ ] . this study showed that by adding a genetically altered variant of ace , termed human recombinant soluble angiotensin-converting enzyme (hrsace ), the entry of covid- into the lung epithelial cells was halted. in this study, the results of cell culture indicated that hrsace decreased the load of sars-cov- by , - , times [ ] . the authors also used the blood vessels and kidney organoids to explain that sars-cov- could directly contaminate and propagate in these tissues, suggesting a potential agent of multi-organ collapse and cardiovascular damages as a result of covid- . the augmentation of hrsace , too, diminished the infectivity of sars-cov- in these organoids [ ] . in engineered models of the human blood artery and kidney organoids developed from human stem cells, it was confirmed that it could straight contaminate and replicate itself in these tissues. these findings provide crucial information about the pathogenesis of covid- and explain the reason for multi-organ collapse and cardiovascular injuries. in this engineered human tissues, hrsace also diminished the viral load of sars-cov- . the researchers highlighted that their experiment has only tested the drug efficacy through the initial stages of sars-cov- infection. further investigation would be demanded to determine the fidelity of this recombinant therapy for later stages of the disease (figure) ( table) . the prescription of ribavirin for the therapy of coronaviruses returns to sars-cov and mers-cov. reports indicated that this antiviral agent's administration did not show promising results for the treatment of sars-cov [ ] . meanwhile, ribavirin antiviral activity was addressed in in-vitro studies in a dose-dependent manner [ , ] . on the other hand, a group of studies demonstrated a beneficial role of ribavirin in the treatment of mers-cov [ ] . simultaneously, some investigations showed that the combination of ribavirin and interferon was unsuccessful in treating mers-cov [ ] . there is limited knowledge about the efficiency of ribavirin in the amelioration of covid- [ ] . a study conducted by elfiky et al. [ ] , using bioinformatics approaches, favipiravir (also known as t- ) is an antiviral drug that selectively and robustly hinders the rna-dependent rna polymerase (rdrp) of rna viruses, was licensed in in japan to cure pandemic influenza virus diseases [ ] . interestingly, despite its anti-influenza virus activity, this molecule can also halt the replication of an extensive range of rna viruses (e.g., flaviviruses, alphaviruses, filoviruses, noroviruses, arenaviruses, bunyaviruses, and other rna viruses) [ ] . regarding the emergence of sars-cov- , it is urgently essential to recognize active antiviral [ ] . they indicated that patients receiving favipiravir showed improved chest imaging, faster decreased viral load, and fewer adverse effects than the control group [ ] . another study performed by chen et al. compared the efficacy of favipiravir versus arbidol [ ] . they showed that the clinical recovery rate on day seven and the degree of auxiliary oxygen treatment or non-invasive mechanical ventilation did not significantly vary within the favipiravir-and arbidol-treated groups. besides, the current study demonstrated that favipiravir significantly enhanced the latency to relief for fevers. also, adverse effects caused by favipiravir were mild and manageable [ ] . these preliminary clinical results provide useful information about therapeutic options for sars-cov- infection (figure) ( table) . remdesivir (gs- ) is a prodrug (nucleotide) with extensive antiviral action toward viruses from distinct genera in-vitro [ ] . it also has therapeutic effects on nonhuman primate models of deadly ebola and nipah virus contaminations [ , ] . investigations conducted on epithelial cells from human airway explained that remdesivir additionally hinders replicating an extensive range of coronaviruses, including mers-cov [ ] . moreover, some reports indicated that remdesivir has robust action toward sars-cov- in-vitro [ , ] . a recent investigation performed on rhesus macaques contaminated with sars-cov- noted that the treatment with a -day regimen of iv remdesivir launched hours following virus inoculation was correlated with some therapeutic outcomes (lower disease severity rates, less pulmonary infiltrates, lower virus titers in bronchoalveolar lavage samples) contrasted with the control animals. of note, remdesivir medication did not diminish the viral load or the titer of the virus in the nasopharynx or rectal swabs compared to the control of vehicle control [ ] . various clinical trials are currently being performed in the us, china, and other countries. a recent clinical trial in hospitalized patients with severe covid- in china showed that remdesivir treatment was not correlated with a decline in hospitalized patients' recovery period. the results indicated that patients receiving remdesivir had a lower period of hospital stay than those receiving placebo ( vs. days); however, such a reduction in hospital stay period was not statistically significant. also, the continuation of invasive mechanical ventilation was more concise (but not statistically meaningful) in the remdesivir-treated group, and only a tiny percentage of patients ( . %) underwent invasive mechanical ventilation at the time of reception. remdesivir did not significantly reduce the viral load of sars-cov- in nasopharyngeal, oropharyngeal, and sputum specimens. remdesivir was stopped in patients ( %) because of adverse effects [ ] . however, a phase iii randomized, open-label trial performed on hospitalized patients with severe covid- showed that the disease severity was lower in patients who received remdesivir within days after the onset of clinical symptoms compared with those treated after days of the manifestation of clinical signs [ ] . notably, patients treated with remdesivir had a more short recovery period than those treated with placebo. also, the mortality rate in remdesivir-treated patients ( . %) was lower than patients receiving a placebo. however, the difference in mortality rate within the two groups was not statistically meaningful [ ] . another clinical trial has been recently established in the us, china, and other countries to explore the efficacy of remdesivir in improving patients with covid- (table ) . further clinical trials are wanted to determine the effect of remdesivir on patients with covid- (figure) ( table) . ivermectin is an fda-licensed drug that has a broad spectrum of antiparasitic activity [ ] . studies have shown that this drug exerts antiviral action toward an extensive range of viruses invitro [ ] [ ] [ ] [ ] . it has been designated that ivermectin hinders the interplay within the human immunodeficiency virus- (hiv- ) integrase protein (in) and importin (imp) α/β heterodimer accountable for the nuclear import of in [ ] . ivermectin has, too, been demonstrated to impede nuclear import and hiv- replication [ ] . also, ivermectin suppresses explicitly the activity of the ns helicase enzyme, required for the replication of flaviviruses [ ] . in the same way, ivermectin inhibits the replication of dengue virus type (denv- ) in aedes albopictus [ ] . another study indicated that ivermectin prevents the interaction between denv and ns with its nuclear transporter importin α/β in-vitro and make effort protection toward denv - [ ] . ivermectin is thought to be effective against sars-cov- , the virus which causes pandemic covid- [ ] . it has been reported that ivermectin can reduce the replication of sars-cov- when added to the cell culture h post-infection. besides, ivermectin can diminish the viral load by ~ folds, whiting h post-infection [ ] . the next critical step is to examine dosing regimens that mimic the currently recommended use of ivermectin in humans [ ] . a current phase iii clinical trial in thailand showed that ivermectin was safe but did not perform any clinical advantage when used for dengue viruses. however, studies recommended that dosing regimens might be improved and expanded, depending on pharmacokinetic analyses [ ] . although denv differs from sars-cov- , the design of future clinical trials should be revisited to provide valuable information about the efficacy of this drug on covid- . current studies hold great promise for the prescription of ivermectin as a possible antiviral therapy against sars-cov- ( figure) (table) . β-d-n -hydroxycytidine is a ribonucleoside analog called eidd- , an orally bioavailable prodrug by wide range antiviral action toward multiple independent rna viruses, which includes influenza, ebola, coronaviruses, and veev [ ] [ ] [ ] [ ] . currently, there are no specific licensed therapeutics for sars-cov- . recently, an interesting study indicated the efficacy of eidd- against covid- in human cells and mice [ ] . eidd- is an orally bioavailable drug that its mechanism of action is similar to remdesivir. these drugs can mimic the function of infections caused by other types of coronaviruses [ ] . clinical trials seem to be needed to investigate the probable applicability of eidd- in the clinic against pandemic covid- ( figure) (table) . lopinavir and ritonavir are the hiv- fda approved drugs, which inhibitors of the hiv protease. this anti-protease activity seems to be active on the sars-cov- protease, either. lopinavir and ritonavir could induce adverse effects, such as qt prolongation, and must be carefully prescribed for patients with liver-associated diseases [ ] . several clinical trials conducted on the combinatory use of lopinavir/ritonavir was more pronounced in patients with covid- than other therapeutic regimens [ , ] . one study also showed that the combination of lopinavir/ritonavir and arbidol (an antiviral agent against rna viruses) did not significantly protect covid- in patients [ ] . meanwhile, zhu and colleagues [ ] demonstrated that arbidol monotherapy was more effective than the use of lopinavir/ritonavir and arbidol. besides, an in-vitro study performed on lopinavir did not exhibit any direct antiviral activity against sars-cov- [ ] . regardless of these findings, the administration of lopinavir/ritonavir seems beneficial on sars-cov and mers-cov only when used at the early stage of infection [ ] . in conclusion, it seems hard to introduce the lopinavir/ritonavir as a treatment option for covid- , but further clinical trials are warranted to elucidate the effectiveness of these drugs (figure) ( table) . there is progressing proof that cases with severe covid- promote a hypercoagulable status, which has been correlated with weak outcomes such as increased respiratory malfunction, severe respiratory distress syndrome, or mortality [ ] [ ] [ ] [ ] [ ] [ ] [ ] . the initial treatment with anticoagulation drugs in patients with severe covid- infection may diminish the risk of thrombotic complexities and promote clinical consequences [ , , , , ] this increasing evidence urged researchers to focus on the potential applicability of using anticoagulating agents for covid- . heparin is an anticoagulant agent possessing potential benefits beyond anticoagulant activity. it has been shown that heparin decreases coronary thrombosis, pulmonary emboli, and microvascular ischemia. besides, it has anti-inflammatory and antiviral properties, enabling this compound to lower the degree of lung inflammation and improving oxygenation [ ] . a new retrospective report by tang et al. confirmed that anticoagulant therapy is correlated with a diminished mortality percentage in covid- patients with coagulopathy. also, the results recommend that patients with severe covid- disease or considerably elevated levels of d-dimer (> x uln) may have declined fatality when they receive preventive doses of heparin. researchers also proposed that anticoagulant treatment seems to be correlated with a more favorable prediction in severe covid- patients engaging sepsis-induced coagulopathy (sic) standards extended d-dimer [ ] . however, prospective studies are demanded to validate these conclusions because the current retrospective study has limited data ( figure) (table) . rates that humanity has experienced in the st century after the pandemic influenza outbreak of . although the gaps remain in our understanding of the pathogenesis covid- , the velocity and mass of antiviral strategies began to examine possible medicines for covid- to highlight both the demand and capacity to provide high-quality data even amid a pandemic. probably the best plan for fighting with the sars-cov- is an effective vaccine, which prompts the immune system to produce antibodies against viral proteins or t cells that can eliminate infected cells. however, vaccine development is slower than the spread of the epidemic; therefore, the clinically useful candidate drugs would be necessary and urgent for the treatment of patients with covid- . among the immunological approaches, cp therapy might be a trusting approach choice for covid- saving; however, future investigations should examine the efficacy of cp treatment in many patients, and the potential risk of this therapeutic approach must be profoundly evaluated. besides, many clinical trials are underway across the world; however, currently, no therapies have been shown useful to date for covid- , or some drugs such as remdesivir have a limited benefit in patients with covid . there are no conflicts to declare. this work was supported by the iran university of medical sciences. in vero cells hydroxychloroquine was found to be more potent than chloroquine to inhibit sars-cov- [ , ] hcq could significantly shorten ttcr and promote the absorption of pneumonia [ ] hcq significantly associated with viral load reduction/disappearance in covid- patients and its effect is reinforced by azithromycin [ ] hcq no effect on intubation or death in patients with covid- [ ] hcq did not substantially reduce symptom severity in outpatients with early, mild covid- [ ] . hcq has no benefit in patients with mild covid- [ ] . hcq with or without azithromycin was not significantly associated with differences in inhospital mortality [ ] hcq alone or with azithromycin in patients with covid- was associated with a decline in covid- associated mortality [ ] . chloroquine phosphate inhibit the fusion of the virus to the cell membrane by modulation of the endosomal ph in vitro activity against sars-cov- in infected vero e cells reported; some evidence it may block infection in vero e cells exposed to sars-cov- [ , , ] clinical experience in treating pts with covid- accumulating; reports of possible clinical benefits, including decrease in viral load and duration of illness [ , , ] favipiravir (fpv) rna polymerase inhibitor in vitro evidence of activity against sars-cov- in infected vero e cells reported with high concentrations of the drug [ , , ] fpv significantly improved the latency to relief for pyrexia and cough [ ] fpv in patients with covid- led to decrease of viral load and significant improvement in 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cytokine production a trial of lopinavir-ritonavir in adults hospitalized with severe covid- arbidol combined with lpv/r versus lpv/r alone against corona virus disease : a retrospective cohort study anticoagulant treatment is associated with decreased mortality in severe coronavirus disease patients with coagulopathy in vero e cells remdesivir inhibits sars-cov- replication [ , ] remdesivir was not associated with statistically significant clinical benefits [ ] clinical improvement was observed in % of severe covid- patients treated with remdesivir in a cohort study [ ] remdesivir was associated with shortened recovery time and decreased rate of mortality in patients with covid- versus the placebo group [ inhibition of viral entry into the cell in vitro hrsace had a dose dependent effect of viral growth of sars-cov- and was able to reduce it by a factor of , to , in cell cultures [ ] currently no known published data regarding efficacy or safety in the treatment of covid- ivermectin inhibiting impα/β which mediated nuclear import of viral proteins in some human and animal viruses.in vitro activity against some human and animal viruses in vitro evidence of activity against sars-cov- in infected vero-hslam cells reported with high concentrations of the drug [ ] currently no known published data regarding efficacy or safety in the treatment of covid- key: cord- -ffgo gl authors: bertsimas, d.; borenstein, a.; mingardi, l.; nohadani, o.; orfanoudaki, a.; stellato, b.; wiberg, h.; sarin, p.; varelmann, d.; estrada, v.; macaya, c.; nunez gil, i. title: personalized prescription of acei/arbs for hypertensive covid- patients date: - - journal: nan doi: . / . . . sha: doc_id: cord_uid: ffgo gl the covid- pandemic has prompted an international effort to develop and repurpose medications and procedures to effectively combat the disease. several groups have focused on the potential treatment utility of angiotensin-converting-enzyme inhibitors (aceis) and angiotensin-receptor blockers (arbs) for hypertensive covid- patients, with inconclusive evidence thus far. we couple electronic medical record (emr) and registry data of , patients from spain, italy, germany, ecuador, and the us with a machine learning framework to personalize the prescription of aceis and arbs to hypertensive covid- patients. our approach leverages clinical and demographic information to identify hospitalized individuals whose probability of mortality or morbidity can decrease by prescribing this class of drugs. in particular, the algorithm proposes increasing acei/arbs prescriptions for patients with cardiovascular disease and decreasing prescriptions for those with low oxygen saturation at admission. we show that personalized recommendations can improve patient outcomes by . % compared to the standard of care when applied to external populations. we develop an interactive interface for our algorithm, providing physicians with an actionable tool to easily assess treatment alternatives and inform clinical decisions. this work offers the first personalized recommendation system to accurately evaluate the efficacy and risks of prescribing aceis and arbs to hypertensive covid- patients. since its emergence in december , the covid- pandemic has put an enormous strain on healthcare systems around the world. as of october , , more than million cases have been reported globally, with a death toll greater than . million [ ] . patients who have developed severe acute respiratory syndrome coronavirus (sars-cov- ) infection exhibit a wide range of clinical responses, from being asymptomatic to being critically ill [ ] . given the heterogeneity of clinical manifestations of the disease, it is of critical importance to be able to understand how patients will respond to various potential treatments [ ] . there is still limited evidence from randomized controlled trials (rcts) to recommend specific anti-sars-cov- treatment for patients with a suspected or confirmed covid- infection. a preliminary report from the recovery collaborative group demonstrates that the use of dexamethasone for covid- patients receiving either invasive mechanical ventilation or oxygen alone can result in lower mortality [ ] . among antivirals, remdesivir is the only drug which has shown promising results and recently received fda approval; in a relatively small cohort of patients hospitalized for severe covid- , clinical improvement was observed in % of the participants [ ] . in separate multi-center studies, it was shown that remdesivir can lead to faster clinical improvement in adults who were hospitalized with covid- and had evidence of lower respiratory tract infection [ , ] . there is controversy regarding the effects of chloroquine and hydroxychloroquine [ , , ] . a wide range of other therapies are continuously being evaluated, including corticosteroids, other antiviral agents (lopinavir, ritonavir), antibodies, and convalescent plasma transfusion [ ] . ace inhibitors (aceis) and angiotensin-receptor blockers (arbs) have gained attention regarding their potential benefits and harms to covid- patients. aceis and arbs are two medications commonly used to treat high blood pressure. they work on the same biochemical pathway in the body to treat hypertension, but at different spots. initially, there was concern regarding a potential increased risk to covid- patients taking acei/arbs due to the drugs' biological mechanisms. sars-cov- attacks human cells by binding its viral spike protein to the membrane-bound form of the monocarboxypeptidase angiotensin-converting enzyme (ace ) [ ] . aceis and arbs directly act on the renin angiotensin aldosterone system, raising speculation that ace inhibitors and arbs might be harmful in patients with the disease [ ] . however, multiple clinical investigations from various countries showed that neither aceis nor arbs were associated with an increased risk of in-hospital death or severe covid- [ , , , , ] . to the contrary, among hospitalized patients with covid- and coexisting hypertension, inpatient use of acei/arbs was associated with lower risk of all-cause mortality [ ] . the effects of acei/arbs for hypertensive covid- patients are therefore not well-understood, and there is no consensus on appropriate uses of these drugs [ ] . personalized or precision medicine aims at providing answers to these types of questions [ ] . this emerging field is expected to radically transform medical care and public health, uncovering prevention and treatment programs more closely targeted to the individual patient [ ] . machine learning (ml) and analytics play a major role in this endeavor [ ] . by leveraging large datasets, these techniques can generate insights and derive decision rules by processing information that exceed the capacity of the human brain [ ] . thus, they are able to exploit data patterns at the individual level to determine the effect of a treatment or the projected risk of mortality/morbidity. our objective is to develop a model that determines whether a treatment t can reduce the risk of mortality/morbidity for an individual patient. we include in our dataset n observations of the {(x i , y i , z i )} n i= , where x i ∈ r p are the features of the ith observation, z i ∈ [t, c] is the assigned treatment or control, and y i ∈ r is the corresponding outcome of interest. we let y(c) be the potential outcome resulting from the assignment of the control and y(t ) of the treatment. this problem lies at the core of the causal inference literature. rubin [ ] set its foundation by proposing the potential outcomes framework which assumes that patients are prescribed a treatment via a probabilistic assignment mechanism. under this framework, the causal effect of a treatment t is measured by the difference in the potential outcomes y(t ) − y(c). the fundamental challenge of this problem is that for any given patient, only one of the potential outcomes is observed [ , ] . as a result, causal inference methodologies usually focus on estimating the aggregated treatment effect, studying its impact on an entire population rather than at the individual level. personalized medicine calls for more individualized approaches that leverage patient-level characteristics to evaluate treatment efficacy for each patient in isolation. since machine learning estimates a binary or continuous outcome of interest from large, high-dimensional datasets, a common approach involves training separate prediction models for the treatment and the control group, and recommending the alternative with the best outcome [ , ] . this technique is referred in the literature as "regress and compare" [ ] . bertsimas et al. [ ] showed how this framework can be extended for the management of diabetes by applying the k-nearest neighbors method. while a useful and intuitive framework, "regress and compare" has received criticism as it can be subject to prediction errors and biases associated with the specific classification or regression algorithm. more advanced machine learning approaches are focused on tree-based methods that involve recursive partitioning [ ] , causal trees [ ] , causal forests [ ] , and optimal prescriptive trees [ ] . recently, a machine learning based framework was proposed to identify the best therapy for patients with coronary artery disease [ ] . the authors created a series of regression models for several treatment alternatives to predict the time from diagnosis to a potential heart attack or a stroke. it extends the classical "regress and compare" approach by aggregating an ensemble of ml models, making it more robust to individual method biases. the algorithm recommends the therapy with the best expected outcome through a voting mechanism that considers the predictions from each of the regression models. we build upon this framework and adapt it to the specific challenges posed by covid- . in this paper, we propose a machine learning-based approach for personalized prescription of acei/arbs for hospitalized hypertensive patients with covid- . we leverage emr and registry data of , patients from spain, italy, germany, ecuador, and the us to provide accurate predictions of expected mortality and morbidity. we then propose individualized treatment decisions by applying the voting scheme that was introduced by bertsimas et al. [ ] ; we combine multiple binary classification models to identify whether there is a potential benefit from prescribing this class of drugs based on a patient's characteristics. the main contributions of this work can be summarized as follows: -we combine emr data with an international registry to create a diverse dataset from multiple clinical centers. we present a unified dataset from hospitals of five distinct countries, encompassing demographics, pre-admission comorbidities and medications, vitals at admission, laboratory test results, and inpatient medications. -we develop binary classification models to predict mortality and morbidity during hospital admission under treatment alternatives. -we utilize an ensemble analytical framework, that has been previously applied to personalize treatments for coronary artery disease and hypertension [ , ] , to evaluate the effectiveness of acei/arbs at the individual level. -we discover specific patient populations who benefit most from this class of drugs, such as patients with cardiovascular disease, as well as those who may suffer from these prescriptions, like patients with low oxygen saturation at admission. we provide clinical insights that validate findings from the medical literature, and propose new hypotheses for further investigation. -we provide a dynamic online application with a userfriendly interface of the predictive models and the resulting prescriptions for use by clinical providers. we propose a machine learning approach to the problem of personalizing treatments. a patient's prescription is generated based on individualized risk scores under each treatment alternative. we leverage clinical data from , patients across international institutions to train our models. one ensemble of various machine learning models is trained to predict mortality/morbidity risk with acei/arbs, and another ensemble is trained to predict the risk when patients are not given acei/arbs. we then employ a voting scheme to aggregate the risk scores of the individual methods and give a final prescription and estimated benefit of treatment. an overview of the approach is illustrated in figure . this study utilizes patient data from hospitals across five countries: spain, italy, ecuador, germany, and the united states. depending on the institution, data is sourced either from a standardized covid- specific registry or from electronic medical records. the data is separated into a derivation cohort, which is used to train the machine learning models, and a validation cohort, which is used to test the models on unseen populations. the derivation cohort is comprised of data from , hypertensive patients from hope registry's hospitals in spain and from hm hospitals, also in spain is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint match treated and untreated populations based on clinical features and other treatments. train several binary classification models to predict patient risk under treatment alternatives. fig. : an overview of the machine learning approach to prescription personalization. [ ] . the validation cohort consists of data from patients diagnosed with hypertension from the following organizations and geographic locations: hope (italy, germany, ecuador), asst cremona (northern italy), and brigham and women's hospital (massachusetts, united states). the study population includes adult patients with a hypertension diagnosis who were admitted to the hospital with confirmed severe acute respiratory syndrome coronavirus (sars-cov- ) infection by polymerase chain reaction testing of nasopharyngeal samples. hypertension was identified using diagnosis codes from a patient's medical record or from patient history available in the registry, as accepted in their respective medical centers or attending medical teams; this is detailed further in the appendix. a description and details of the collaborating organizations, as well as the time horizon of admissions for each organization's study population, can be found in table . dataset features include demographics, pre-admission comorbidities and medications, vitals at admissions, laboratory test results, and inpatient medications. in total, we compile features, which are summarized in supplemental tables - . comorbidities are derived from the international classification of diseases (icd), th and th revision, using codes of hospital discharges. medications are extracted from the anatomical therapeutic chemical (atc) classification system. we record the earliest laboratory test results obtained within the hospital admission and include both binary measurements (e.g., d-dimer ≥ . mg/l) and continuous measurements (e.g., creatinine in mg/dl). we also collect information on patient mortality, as well as inpatient development of specific morbidities during hospitalization, including: sepsis, acute renal failure, heart failure, and embolic event. the outcome of interest is the occurrence of mortality or morbidity during hospital admission. missing values are imputed using multivariate imputation by chained equations (mice) (details can be found in the appendix) [ ] . we exclude all features that are not present for at least % of the observations. as opposed to data obtained from a randomized controlled trial (rct), for which treatment assignment is random, the data in our study is observational in nature. given that we aim to determine the effect of a treatment on the probability of mortality and morbidity for a patient, we must consider that individuals taking a specific treatment may differ from those that are not taking the treatment in terms of their baseline, or pre-treatment, characteristics. such characteristics may affect both treatment assignment and mortality/morbidity risk and may, therefore, confound our treatment effect estimates. we also recognize that the medications that we are investigating were not used in isolation and were often administered in combination with other medications; this, too, may bias our treatment effect estimates. in order to mitigate bias introduced by confounding variables, we use matching techniques prior to training our machine learning models. matching is a method that can be used to control for confounding in observational studies. the motiva-. cc-by . international license it is made available under a perpetuity. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted november , . tion of the technique is to find groups of treated and non-treated individuals whose pre-treatment characteristics are similar, and to then create models using only these individuals. by minimizing the differences in pretreatment characteristics, we become more confident that the outcome estimates can be attributed to differences in the treatment assignment rather than to preexisting differences between the individuals in the treated and non-treated group. we evaluate our matching procedure based on how balanced pre-specified covariates are between our treated and non-treated groups. balance is measured by comparing the pairwise absolute standardized mean differences in covariates. groups is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted november , . are considered well-balanced if their standardized mean differences are below . . for our matching procedure, we aim to find populations of patients in each treatment group that ( ) have similar baseline characteristics and ( ) have similar medications as part of their additional treatments. to study of the effect of acei/arbs on patient mortality, we first identify all of the patients that were given either aceis or arbs during their hospital stay. we then use cardinality matching [ ] to identify the most similar cohort of non-acei/arb recipients to this group, as measured by a set of important pre-treatment and other treatment features. the final dataset we use to predict patient mortality consists of the acei/arbs treatment group along with the matched dataset from the non-acei/arbs treatment patient group. using the matched datasets, two sets of models are constructed to predict a patient's risk of mortality/morbidity, as defined in section . . one set of models is trained on patients who were given acei/arbs, and the other on patients who were not given acei/arbs. the matching process aims to equalize the baseline characteristics of the populations to better isolate the effect of acei/arbs between the two sets of models. for each treatment, we train six binary classification models to predict a patient's risk of mortality/morbidity. the machine learning methods we utilize are: random forests [ ] , classification and regression trees [ ] , optimal classification trees [ ] , gradient boosted decision trees [ ] , quadratic discriminant analysis [ ] , and gaussian naïve bayes [ ] . these models take diverse approaches to classification tasks and involve tradeoffs in their interpretability, handling of nonlinear relationships, and computational complexity. further details on the training procedures and parameter tuning employed for these models are available in the appendix. algorithms were trained using python . . and julia . . through scikit-learn [ ] , xgboost [ ] , and the interpretable ai [ ] packages. the primary metric of performance for the classification models is area under the roc curve (auc), which measures a model's ability to discriminate between high and low risk patients. although the predictive models are not the final output of our framework, this evaluation is important to verify that the individual models provide high quality predictions. we apply the shapley additive explanations (shap) to identify the most important risk drivers for each learner under both treatment alternatives [ , ] . we use the shap python package [ ] , leveraging the tree explainer for the xgboost, classification and regression trees, and random forests algorithms and the kernel explainer for the logistic regression, quadratic discriminant analysis, and gaussian naive bayes classifiers. the shap methodology approximates any nonlinear prediction model with a linear model around the patient prediction. the coefficients of the linear approximation are called shap values. they are computed for each observation by introducing every feature separately and comparing the model output risk. we calculate the absolute mean shap value for all the independent covariates using the testing set. we report the ones with the greatest impact on the prediction task. each algorithm is used to train two separate models: one model with acei/arbs and one without acei/arbs. for a given patient and algorithm, the models yield a prediction for the patients mortality/morbidity risk with acei/arbs,ŷ y , and without acei/arbs,ŷ n . the algorithm recommends acei/arbs if administering the treatment is predicted to have a reduction of at least % in the probability of mortality/morbidity. namely, treatment with acei/arbs is suggested if: the improvement threshold is intended to reduce unnecessary prescriptions: if the patient's predicted risk is nearly identical under both treatment alternatives, we do not recommend treatment. the threshold of % was chosen based on tradeoffs between treatment effectiveness and number of prescriptions; this is further explored in the appendix. the six ml algorithms yield six "votes" for whether or not to recommend acei/arbs. the final prescription aggregates the votes. if there is majority consensus (i.e. if at least four methods agree on the optimal treatment), the majority choice is selected. in the case of ties (i.e. three methods vote for acei/arbs and the other three vote against it), we consider the auc of the individual methods as a way of measuring the credibility of the votes. we select the treatment option which has a higher average auc for the methods that voted for it. in other words, in the case of a tie between the treatments, we follow the treatment selected by the most credible methods. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint an effective treatment prescription scheme should improve outcomes compared to the current standard of practice. since our outcome of interest is a patient's mortality/morbidity, good prescriptions would decrease the incidence rate. prescription evaluation is a wellrecognized problem due to the lack of counterfactuals; we only have data on the treatment received by a patient, and we cannot know what their outcome would have been under the other treatment option. we must therefore estimate the counterfactuals to evaluate the quality of our prescriptions, and we can leverage the predictive models for this task. we perform this assessment in several ways: prescription effectiveness the effectiveness of the prescription scheme can be estimated by comparing the actual event rate to the average predicted risk under our prescription scheme. for a given patient, we can compute their predicted risk under a treatment as the average probability among the methods that voted for the treatment; for example, if acei/arbs are selected by four methods, the predicted probability with treatment would be the averages of these four methods' predictions. letŷ ip denote patient i's predicted probability of mortality/morbidity under the recommended treatment, and y i ∈ { , } indicate the true outcome. then the prescription effectiveness (pe) is defined as: if the raw mortality/morbidity rate is %, for example, and the average probability of mortality/morbidity is % under the prescription scheme, then the pe equals - . . we adjust the calculation of this metric to include only cases for which the algorithmic recommendation differs to the doctors' prescription at the standard of care. thus, observations of patients whose medication did not change were not included. note that a negative number indicates an improvement in mortality/morbidity. when applying the prescription algorithm to external populations with significantly different mortality/morbidity rates, the pe metric may require recalibration. pe compares the baseline mortality/morbidity rate to the average probability of the proposed treatments. if a new population has a much higher event rate than the training population, the predicted probabilities may be systematically low; the opposite is true if the new population has a much lower incidence rate. we take a simple rescaling approach to adjust the probabilities proportionally to the incidence rates. denoting the outcome rate on the training population asȳ t rain , we can construct a calibration factor c = n n i= y ī y t rain if the new population has a higher incidence rate, this factor will be greater than , meaning that we scale up the projected probabilities. if the new population has a lower incidence rate, then c < and the probabilities will be scaled down. the calibrated pe (cpe) is then given by: other sophisticated calibration schemes exist, but this metric has an appeal of not requiring access to data and outcomes for the full external population. for example, if we are applying the method to a new hospital, we only need to know the baseline mortality/morbidity to recalibrate our probabilities. we also note that by using a constant scaling factor, we preserve the ordering of the probabilities; this, therefore, does not affect the prescription decisions or the auc of the models. prescription robustness while pe and cpe are highly intuitive metrics, they can also be biased in their estimates of the outcome probability under the prescription scheme since the predictions are taken from methods that also determine the prescription. in the binary classification setting, these metrics involve data of different types as they compare the discrete outcomes with continuous probabilities. prescription robustness (pr) takes a more objective view: it uses a single ml method to evaluate both the outcome probability under the standard of care (given treatments) and the probability under the prescription. for example, pr with respect to cart would be computed as: are the cart models' predicted outcomes under the proposed treatment (p) and true treatment (t), respectively. pr is calculated for each of the six candidate methods, and the range across the methods is reported. we report the proportion of our prescriptions that match the true treatment decisions. for example, if out of patients, of our treatment recommendations are consistent with the treatment decision, then the agreement rate would be %. we note however that given the rapid evolution of the . cc-by . international license it is made available under a perpetuity. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted november , . ; https://doi.org/ . / . . . doi: medrxiv preprint pandemic and shifting treatment protocols, the true treatments do not necessarily reflect a consistent treatment strategy. while the agreement rate is informative, the goal of the prescriptive algorithm is to improve upon the current standard of care and thus a high agreement rate is not necessarily desirable. prescription auc we also report the auc of the risk probabilities for our prescriptions compared to the true outcomes. we can only compare the probabilities and outcomes for the patients whose treatment prescriptions agree with their true treatments, since we do not have the counterfactual outcomes. for example, if the agreement rate is %, the auc of our prescriptions can only be compared for the % of patients with agreement. this metric does not assess the prescription benefit, but rather the quality of our predictions under the prescription algorithm. in this section, we present the results of our analysis from the predictive and prescriptive components of this study. in section . , we provide information regarding the final dataset and describe the impact of the matching process. section . focuses on the predictive performance of the binary classification models trained to predict mortality/morbidity risk. section . outlines the quantitative results of the proposed prescription mechanism. section . summarizes the online interface that was developed to communicate the output of the algorithm to the clinical audience. the derivation cohort contains , observations of patients receiving acei/arbs and , records that are not prescribed the specific class of drugs. following the method described in section . , we identify optimal matches for the treatment group and restrict our cohort to an equally balanced set of , cases. we select the features for matching through a t−hypothesis test, identifying the variables that are most significant in differentiating those who experienced the outcome of interest and those who did not. thus, we selected patient features and also included all available covariates related to other administered treatments, including hydroxychloroquine, antivirals (lopinavir and ritonavir), corticosteroids, anticoagulants, and interferons. we achieve pairwise balance between two groups below . for all covariates considered. figure provides an illustration of the matching results. in supplementary table s , we summarize the pre-treatment variables before and after the matching procedure. a descriptive summary of each treatment group's clinical features and outcomes, for both the derivation and validation groups, is shown in table . after matching, the derivation cohort has an even split of patients with and without acei/arbs. the validation cohort has total patients, of which ( . %) receive acei/arbs. the aucs for the six individual binary classification algorithms for both the acei/arbs and non-acei/arbs models are shown in table . we report the average aucs on the training and testing splits of the derivation population, as well as the external validation population. in general, the models for predicting outcomes without acei/arbs have higher performance on the test and validation set than those for patients treated with acei/arbs. random forests and xgboost are the highest performing methods overall, although nearly all methods demonstrate aucs above . across all cohorts, and above . in most cases. a summary of the predictive models and their feature importance is shown in table . our analysis reveals that the key predictors of mortality and morbidity are common between the two treatment groups. abnormal creatinine levels, white blood cell count, and hemoglobin are identified in both groups as the most significant lab values. age and low oxygen saturation are also identified within the top five predictors of risk. these biomarkers have been identified in other retrospective analysis of mortality outcomes of covid- [ , , ] . in accordance with the medical literature [ ] , lymphocyte count is also found as an important feature in both models. there are a few less significant variables in each cohort that are distinct between the two groups. platelets were found to only be a significant risk predictor for acei/arbs, while blood sodium and temperature only appeared in the no ace/arbs cohort. table shows the results of the prescription voting scheme on the training, testing, and validation populations for an improvement threshold of . %. . is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted november , . prescription rate decreases from the % seen in practice in the training and testing data due to the matching procedure. in the raw validation data, we see an increase in the prescription rate from the observed . % of covid- patients who received acei/arbs at these sites. the pe metric indicates a reduction in mortality and morbidity rate of . % on the validation set, a notable reduction from the baseline mortality/morbidity rates seen in practice. when calibrating for the incidence rates in the testing and validation populations, the cpe decreases from the pe but still demonstrates a reduction in average risk. the pe metric indicates a slight increase in the mortality/morbidity probability on the test set (- . %). when evaluating the given vs. recommended treatments using each of the individual ml algorithms as the ground truth, we see a benefit ranging from . % to . % on the test set and . % to . % on the validation set. thus, we see a benefit even in the most pessimistic estimates. we observe that the pe metric can be worse than even the most pessimistic pr estimate; this is due to the fact that pe compares probabilities to the event rate, versus directly comparing probabilities. while both are useful, pr provides a more consistent basis for evaluation. the match rate is . % on the testing set and . % on the validation set. the predictions of mortality/morbidity under our prescriptions have an auc of . % on the testing set and . % on the validation set, demonstrating strong discriminative ability for risk in cases where the predictions match the true treatment decisions. figure compares the proposed prescription frequencies to the true treatment decisions administered in practice on the validation data, broken down by various clinical features. these figures offer insight into how our prescriptions differ from current practice and how the treatment patterns change for specific clinical characteristics. our results generally propose to increase the prescription rate in the validation data, which treated . % of patients with acei/arbs in practice. the prescription rate increases by . % for patients with heart . cc-by . international license it is made available under a perpetuity. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted november , . ; https://doi.org/ . / . . . doi: medrxiv preprint is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted november , . ; our goal is to provide clinicians with a readily available and actionable tool that can communicate the algorithm recommendations. for this reason, we have developed an online application that can directly inform the decision making process of physicians using the proposed models. through this application (accessible at: https://www.covidanalytics.io/treatments), practitioners can enter new patient data at hospital admission, obtain individualized estimations of mortality/morbidity risk and evaluate the effectiveness of acei/arbs for their own patients. figure displays the user interface of the web application. in this study, we compiled emr and registry data from five different countries to create predictive and prescriptive models for covid- patients. we demonstrate that accurate analytical models can help physicians assess the potential benefit of acei/arbs for hypertensive patients in practice. to the best of our knowledge, this constitutes the first personalized prescription algorithm for covid- patients that has been validated in an international cohort of patients. we place particular emphasis on essential components of causal inference by applying matching methods to confirm common baseline characteristics between both treatment groups, establishing similar baseline risk between the two populations. we combine six well-established binary . cc-by . international license it is made available under a perpetuity. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted november , . classification techniques to predict in-hospital mortality and morbidity. we combine these models on an individual basis, using a voting scheme to assess whether the prescription of acei/arbs can reduce the probability of a hypertensive patient experiencing an adverse event during hospital admission. we apply detailed quantitative evaluation metrics to assess the recommendations' effectiveness and robustness. we demonstrate through various metrics that the application of our framework can lead to improved patient outcomes relative to the standard of care. figure offers insight into how our proposed treatment scheme agrees with and differs from what was observed in the data, as measured by the prescription rates. our algorithm recommends an increase in the overall number of prescriptions of acei/arbs. this includes suggestions to hypertensive patients who were not originally prescribed this line of therapy as well as patients who were already prescribed this class of drugs. a benefit of personalization is also the identification of patients for whom getting this regimen might be detrimental. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint fig. : visualization of the online algorithm user interface. figure (a) shows that the algorithm recommends a higher acei/arb prescription rate for patients with heart disease. this could be highly impactful given the prevalence and potential consequences of cardiovascular disease in severe covid- cases [ , ] . in particular, we note that the algorithm identifies a significantly higher proportion of patients with atrial fibrillation who would benefit from this class of drugs. this finding is in line with the hypothesis that this comorbidity in combination with covid- can lead to severe complications [ ] , and potentially extends previous findings suggesting a benefit of acei/arbs in relation to atrial fibrillation [ ] . the proposed personalized treatment allocation identifies a potential subgroup of hypertensive patients for which acei/arb prescriptions may be detrimental. figure (d) highlights that the prescription rate should be lowered amongst patients with low oxygen based on the mortality/morbidity outcome. oxygen saturation has been commonly used as a reference metric to potentially identify respiratory complications due to covid- . this finding provides an interesting direction for future clinical research. our prescription scheme proposes an increase in prescription rates across all age groups, as indicated in figure (e). the algorithm proposes the most significant increase in prescription rates for the youngest cohort below years of age. other clinical criteria for acei/arbs cannot be confirmed by our study due to our outcome of interest. for example, ace inhibitors are known to be risky for women who may become pregnant due to potential birth defects, [ ] yet our prescription scheme proposes a higher prescription rate for women (figure (g) ). this is not surprising, because such an effect would not be captured in our mortality/morbidity outcome. these external factors demonstrate the need for clinical expertise; while this tool can facilitate treatment decisions, it must be considered in the broader context of a patient's care. . cc-by . international license it is made available under a perpetuity. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted november , . ; https://doi.org/ . / . . . doi: medrxiv preprint finally, we note that our criteria for prescription is an improvement of at least . % in predicted mortality/morbidity during hospitalization. thus, the reduction does not necessarily imply that acei/arbs are harmful to the remaining patients; the effect could be neutral. the raw predicted probabilities for a patient under each treatment alternative can be assessed in more detail on an individual basis. this can assist clinicians by quantifying the effect of acei/arbs on the specific outcome of interest, mortality/morbidity from covid- , which can then be traded off against other external concerns such as chronic hypertension treatment for. there are several limitations to this study. we consider the effect of acei/arbs in isolation, rather than in combination with other treatments. this assumes that the effect of other treatments is independent from the effect of acei/arbs. this is consistent with existing literature, in which covid- treatments have generally been considered separately rather than as combination regimens. however, there is potential to consider treatment strategies more holistically as drug combinations. the methodology presented in this work could be easily extended to the case of multiple treatments: rather than training models for the treated and untreated group, as done here, models could be trained for n treatment groups, and the same prescription and voting scheme could be followed to choose between the n alternatives. this was impractical in the current study given the scope of the available data, as the sample sizes become much smaller when dividing the population by treatment combination, but this could be considered in future work as larger datasets become available. all of the data included in the derivation and validation cohorts were collected between february to may . as a result, our investigation carries the limitations associated with the design of observational studies. moreover, we would like to highlight that the outcome prevalence seems to be dependent on the relative timing of the pandemic curve. hence, confounding factors such as the degree of congestion in the hospital systems, or changes in the clinical protocols and the use of other drugs might have affected the observed mortality and morbidity rates. additionally, there is a tradeoff between obtaining detailed clinical data and curating large datasets. in order to leverage a broad international cohort of patients, we were unable to use granular data that was only available for subgroups of patients. as a result, we used binary indicators with predefined cutoff values for many clinical features. if raw lab readings were available, we could gain further insight into these features and identify data-driven risk cutoffs. finally, we note that these results are not causal and do not isolate the effect of acei/arbs in patient outcomes. however, given the time and cost involved in implementing an rct, we believe that this study adds value. our study provides insight into potential subpopulations with maximal benefit from acei/arbs that can guide future clinical studies. our approach provides promising evidence for the the benefit of individualizing acei/arbs for hypertensive covid- patients. using machine learning, we are able to identify patients who would benefit the most by receiving this type of medication. our framework highlights the potential effect of this class of drugs for hypertensive patients or cases admitted with low oxygen saturation. by personalizing the drug prescription process, the proposed framework improves patient outcomes and avoids unnecessary drug prescriptions that would have limited efficacy. in the future, the algorithm could be integrated in practice into existing emr systems to generate dynamically personalized treatment recommendations. our data-driven approach invites further testing using datasets from other hospitals or other types of treatment. our work is a key step toward a fully patient-centered approach to covid- management and the utilization of existing treatments to reduce its toll on public health. identification of causal effects using instrumental variables recursive partitioning for heterogeneous causal effects ) 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position document of the working group on pharmacology and drug therapy of the esc the epidemiology and pathogenesis of coronavirus disease (covid- ) outbreak clinical predictors of mortality due to covid- based on an analysis of data of patients from wuhan estimating causal effects of treatments in randomized and nonrandomized studies on the application of probability theory to agricultural experiments. essay on principles. section .] comment: neyman ( ) and causal inference in experiments and observational studies should atrial fibrillation be considered a cardiovascular risk factor for a worse prognosis in covid- patients? pharmacologic treatments for coronavirus disease (covid- ): a review a multivariate analysis of genomic polymorphisms: prediction of clinical outcome to -fu/oxaliplatin combination chemotherapy in refractory colorectal cancer estimation and inference of heterogeneous treatment effects using random forests good or bad: application of raas inhibitors in covid- patients with cardiovascular comorbidities remdesivir in adults with severe covid- : a randomised, double-blind, placebo-controlled, multicentre trial who ( ) who coronavirus disease (covid- ) dashboard the epidemiology, diagnosis and treatment of covid- american association for artificial intelligence association of inpatient use of angiotensin-converting enzyme inhibitors and angiotensin ii receptor blockers with mortality among patients with hypertension hospitalized with covid- designmatch: matched samples that are balanced and representative by design acknowledgements the authors wish to thank travis ziegler for his help in creating the online interface of the algorithm. we would like to thank the clinical team from azienda socio-sanitaria territoriale di cremona (asst cremona) and hm hospitals for collecting their electronic health records, creating a covid- dataset, and providing us with access to it. the authors are also grateful to the hope collaboration for compiling a comprehensive registry from multiple countries and centers and sharing it with us. key: cord- -iswxlbhb authors: bastier, p l; aisenberg, n; durand, f; lestang, p; abedipour, d; de santerre, o gallet; couloigner, v; bequignon, e title: treatment of sleep apnea by ent specialists during the covid- pandemic date: - - journal: eur ann otorhinolaryngol head neck dis doi: . /j.anorl. . . sha: doc_id: cord_uid: iswxlbhb abstract the treatment of sleep disorders has been strongly impacted by the covid- pandemic. when the lockdown is over, resumption of usual patient care will require precautions to limit the risk of contamination for patients and caregivers. in this document, the french association of otorhinolaryngology and sleep disorders (afsorl) and the french society of otorhinolaryngology (sforl) put forward a summary of the measures for continuing the treatment of sleep apnoea syndrome in these new practice conditions. emphasis is placed on teleconsultation, methods of nocturnal sleep studies, the conditions for treatment by continuous positive airway pressure (cpap) ventilation, and the postponement of more invasive treatments. the implementation of lockdown measures and the massive surge in patients suffering from serious forms of covid- infections has led to a reorganisation of healthcare in many countries around the world. the focus has shifted to emergency treatment and the postponement of non-priority treatments. if obstructive sleep apnea syndrome (osas) is not considered to be an immediately lifethreatening pathology, its consequences can be serious, especially in the presence of specific comorbidities or high-risk occupations. considering the high prevalence of sleep-disordered breathing in the general population, the structures dedicated to the care of patients with osas are likely to be rapidly overwhelmed once the lockdown measures are lifted. in their latest recommendations regarding this period of the pandemic, the french regional health agencies (ars) have advocated for a progressive resumption of screening and diagnosis activities in order to avoid any delay in treatment. these recommendations apply to sleep apnoea syndrome, among others. afsorl and sforl created this document to provide a practical framework for ent specialists to allow them to continue treating patients suffering from sleep disorders after the end of the lockdown. the principles on which it is based are the continuation of treatment, prioritising treatment according to severity criteria, and the protection of patients and caregivers from possible viral transmission. these recommendations may change depending on the health situation. teleconsultation by phone or dedicated video platform is preferred for an initial consultation concerning sleep disorders. the patient can prepare for this consultation by filling out online or paper questionnaires sent to them beforehand. the clinical examination can be conducted after the sleep recording, except where the consultation raises suspicion of a differential diagnosis whose treatment would require a rapid management (tumour of the upper airways). in this case, prevention measures must be applied: appropriate personal protective equipment, fitting out the practice and waiting room, disinfection after every patient. the initiation of a cpap treatment without having carried out a recording beforehand can be discussed in the event of a significant clinical probability of osas with severe symptoms (https://aasm.org/covid- -resources/covid- -mitigation-strategies-sleep-clinics-labs). a request for treatment form with a motivation letter can be sent to the social security institution. the conduct of the clinical examination before the initiation of treatment of a patient suffering from osa must be delayed in the absence of severe symptoms. if the treatment must be implemented rapidly, this examination will be conducted with the strengthened protection measures laid out in the recommendations issued by the french society of otorhinolaryngology (sforl) [ ] . there is no indication to treat patients suffering from simple snoring during the covid- pandemic. sleep endoscopy under sedation is not advised during the covid- pandemic as it generally applies to patients presenting with mild to moderate osas and asking for surgery. it is possible to implement treatment with a mandibular advancement device (mad) during the covid- pandemic. the caregiver protection rules put forward by sforl [ ] . the patient's covid status must be determined before the procedure. if surgery was eventually avoided, the benefit/risk ratio between the initiation of symptomatic treatment with cpap, with possible risks of domestic contaminations, and no therapy, is to be discussed on a case by case basis. it is not advised to initiate a myofunctional therapy for osas in the current context of covid- pandemic. thus, the international society of oral, facial and lingual physical therapy has recommended the closure of physical therapy practices and stated that this type of treatments is not a priority during the current epidemic, as they generally apply to mild forms of osas (https://siklomf.fr/). however, a decree issued by the french government on april, , , allows for rehabilitation exercises via teleconsultation, including those for the rehabilitation of respiratory diseases (obstructive, restrictive or mixed) and of maxillofacial disorders apart from facial paralysis (https://www.service-public.fr/particuliers/actualites/a ). in all cases and particularly for patients presenting with a mild or moderate osas whose treatment by surgery, mad or cpap must be postponed until after the pandemic, additional non-invasive treatments may be proposed, and individual health practices should be recommended, such as positional therapy in the event of positional osas, weight loss, limiting the consumption of alcohol and the use of sedatives, medical treatment of nasal obstruction (https://aasm.org/covid- resources/covid- -mitigation-strategies-sleep-clinics-labs). patients with daytime sleepiness should also be advised to avoid high-risk activities such as car-driving or activities with significant risks of accident. there is currently no scientific data regarding the dangers of cpap therapy in the current context of covid- pandemic. however, the intentional air leaks around the mask and the high positive air flows delivered by the machine may contribute to spreading sars-cov- in the patient's environment and exposing those close to them. opinions regarding indications and modalities of cpap therapy during the current pandemic were not consensual [ , ] . therefore, on march, , , the french language respiratory society (splf) issued national recommendations on this subject (http://splf.fr/wp-content/uploads/ / /apnee-du-sommeil-covid_ - .pdf). according to those, cpap treatment should be limited to severe forms of osas in the current context of covid- pandemic. this treatment should be done at home as often as possible through a service provider in compliance with the protective rules. any patient, even asymptomatic, should be considered as possibly infected with sars-cov- and contagious. additionally, even in the rare cases where a patient had a negative pcr testing just before the initiation of cpap therapy, there is no guarantee that he will not become infected while he or she is still on this treatment. thus, the same precautions should apply to all patients. due to the risk of aerosolization, in-laboratory, initiation of cpap or split-night study are not advised. explanations for putting on and adjusting the mask can be given while staying at a distance of at least one meter from the patient, or through explanatory videos if necessary. telemonitoring is preferred for the initial set-up, with additional equipment sent by post and explanations given by phone or video after it has been received. the cpap machine should not be used near the patient's family or friends. if possible, he or she should remain alone in the bedroom where the cpap treatment is performed. if it impossible for the spouse or partner to sleep in a separate room page of j o u r n a l p r e -p r o o f and especially if he or she suffers from comorbidities at risk of severe complications from covid- , a temporary discontinuation of the treatment might be discussed with the physician in charge of the osas treatment. the equipment must be cleaned as per the standard procedures laid out by the manufacturers. the bedroom's surfaces must be cleaned and ventilated by opening windows regularly. the patient must wash their hands before and after handling the equipment, and every time they return to and leave their bedroom. in patients infected with sars-cov- , coughing can make the cpap machine difficult to tolerate. additionally, once their symptoms have disappeared, the cpap machine must be sealed in a plastic bag for days before being reused. the machine must be carefully cleaned to ensure the absence of any live virus and a new tubing and new mask must be used (request these from the service provider). a recent study demonstrated the persistence of the virus on plastic up to hours after its application [ ] . in the event of a confirmed or suspected covid- infection in a hospitalised patient, cpap therapy should be discontinued while awaiting the covid- diagnostic test results. if the infection is confirmed, before resuming the treatment, the cpap mask and tubing should be modified following the recommendations issued by the "ventilation and oxygen therapy" (gav) task force of splf (http://splf.fr/wp-content/uploads/ / /les-procedures-du-gavo -protectionvirale -maj avril .pdf). if it is impossible to follow these recommendations, discontinuing the treatment during the epidemic might be necessary. teleconsultation monitoring is advised for all modes of treatment, facilitated by service provider and/or manufacturer websites for cpap treatment. sleep studies to control the efficiency of newly installed mad must be delayed until the end of the pandemic. monitoring will focused primarily on clinical symptoms during this period (day-time sleepiness, sleep quality, snoring, arousals). the authors declare that they have no competing interest. ent consultation in the context of covid- pandemic eur ann otorhinolaryngol head neck dis case for continuing community niv and cpap during the covid- epidemic covid- : community cpap and niv should be stopped unless medically necessary to support life aerosol and surface stability of hcov- (sars-cov- ) compared to sars-cov- key: cord- -mbv vb r authors: jean, shio-shin; hsueh, po-ren title: old and re-purposed drugs for the treatment of covid- date: - - journal: expert review of anti-infective therapy doi: . / . . sha: doc_id: cord_uid: mbv vb r introduction: the coronavirus disease (covid- ) caused by the novel severe acute respiratory syndrome coronavirus (sars-cov- ) has developed since december . it has caused a global pandemic with more than three hundred thousand case fatalities. however, apart from supportive care by respirators, no standard medical therapy is validated. areas covered: this paper presents old drugs with potential in vitro efficacy against sars-cov- . the in vitro database, adverse effects, and potential toxicities of these drugs are reviewed regarding their feasibility of clinical prescription for the treatment of patients with covid- . to obtain convincing recommendations, we referred to opinions from the us national institute of health regarding drugs repurposed for covid- therapy. expert opinion: although strong evidence of well-designed randomized controlled studies regarding covid- therapy is presently lacking, remdesivir, teicoplanin, hydroxychloroquine (not in combination with azithromycin), and ivermectin might be effective antiviral drugs and are deemed promising candidates for controlling sars-cov- . in addition, tocilizumab might be considered as the supplementary treatment for covid- patients with cytokine release syndrome. in future, clinical trials regarding a combination of potentially effective drugs against sars-cov- need to be conducted to establish the optimal regimen for the treatment of patients with moderate-to-severe covid- . since december , wuhan city (the capital city of hubei province, china) experienced a major outbreak caused by the severe acute respiratory syndrome coronavirus (sars-cov- ) [ , ] . owing to its high transmission potential, the sars-cov- infection has become a global public health menace [ ] . according to the covid- research information published in the pubmed database, fever ( - %), cough ( - %), dyspnea ( - %) and myalgia ( - %) were the most prevalent manifestations among patients with covid- . elevation of serum aspartate aminotransferase, creatine kinase, creatinine, and c-reactive protein levels were more frequently seen in the complicated covid- patients than the uncomplicated group, while a normal serum procalcitonin concentration was noticed among most covid- patients [ , ] . additionally, . % of covid- patients required the hospitalization at intensive care units, . % presented with acute respiratory distress syndrome (ards), . % had shock, and . % of hospitalized patients had fatal outcomes. the pandemic caused by covid- has brought a huge burden to healthcare facilities for many countries, especially in patients with comorbidities [ ] . unfortunately, standard treatment against covid- is currently lacking. in addition to developing new treatment options (such as immunotherapies and host-directed therapies), scientists worldwide continue to simultaneously explore the efficacy of existing drugs against sars-cov- . this article summarizes old drugs that could be potentially re-purposed for covid- treatment. remdesivir, which targets the viral rna-dependent rna polymerase (rdrp) and induces premature termination of viral rna transcription [ ] , is considered as the most promising drug against sars-cov- [ , ] . initially, uncertainties regarding the adverse effects (such as nausea, vomiting, rectal hemorrhage, and hepatic toxicity) and clinical efficacy of remdesivir were reported in the clinical treatment of covid- [ ] . an important study reported the outcomes of the hospitalized patients ( in the us, in europe or canada, and in japan) who were treated with compassionate-use remdesivir for severe covid- recently [ ] . among these patients, patients ( . %) received mechanical ventilation and ( . %) underwent extracorporeal membrane oxygenation prior to initiation of remdesivir treatment. all these patients received a -day course of remdesivir administered intravenously, consisting of mg on day and followed by mg daily for the remaining days of treatment. the overall mortality was . %. of note, clinical improvement was observed in ( %) patients, and the abnormality of hepatic function was the most frequent adverse effect ( %), followed by diarrhea ( %), skin rash ( %), acute kidney injury ( %), etc. limitations of this study included the small size of the cohort, no viral load data collections at baseline and follow-up periods, and the lack of a randomized control group [ ] . ongoing randomized controlled trials for evaluating the clinical efficacy of remdesivir is absolutely needed. the other rdrp inhibitor favipiravir is known to be active in vitro against oseltamivir-resistant influenza a, b, and c viruses [ ] . although favipiravir has been reported to significantly shorten the duration of clinical recovery for covid- patients by cai et al., who published their investigational results in engineering, this article has been temporarily withdrawn. in spite of unfavorable pharmacokinetic (pk) profile and no conclusive data regarding its efficacy in the treatment of covid- , favipiravir was approved for marketing in the treatment of covid- patients in china in march . ribavirin, a guanosine analogue, is an antiviral drug that has been used to treat several viral infections, including hepatitis c virus and respiratory syncytial virus (rsv). it was recommended for covid- treatment by the national health commission and state administration of traditional chinese medicine in the th edition of their report, 'novel coronavirus pneumonia diagnosis and treatment plan' [ ] . the in vitro antiviral activity of ribavirin against sars-cov, however, was estimated at concentrations up to μg/ml [ ] . the regimen of lopinavir/ritonavir (see as follows) plus ribavirin was also shown to be effective against sars-cov in patients and in tissue culture [ ] ; however, its clinical efficacy is currently unproven. for the orthocoronavirinae family, protease inhibitors (pi) are used to target papain-like protease and c-like protease [ ] . among the pis that inhibit the coronavirus, the antiviral activity of lpv against mers-cov is controversial in the tissue culture model [ ] . notably, treatment with lpv/rtv alone ( / mg administered orally twice daily for days; chinese clinical trial register number, chictr ) failed to demonstrate clinical improvement and reduction of viral rna load compared to standard care alone in patients with severe sars-cov- [ ] . the other pi darunavir, which has been extensively used for the treatment of hiv infection in both naïve and experienced subjects, has been shown to have promising potential against sars-cov- in vitro; nevertheless, this drug needs to be further investigated (http://www.sd. chinanews.com/ / / / .html). because of their unfavorable pk profiles and negative clinical trial data, however, the us national institute of health (nih) consensus treatment guidelines panel recommended against the use of lpv/rtv and other human immunodeficiency virus (hiv) pis alone in treatment of covid- in april, [ ] . chloroquine is an important drug in the treatment of malaria and autoimmune diseases (such as rheumatoid arthritis [ra] and lupus erythematosus). additionally, chloroquine was shown to increase endosomal ph, which eliminates an important prerequisite for virus/cell fusion and interferes with the glycosylation of the cellular receptors of sars-cov [ ] . notably, hydroxychloroquine has been shown to be significantly more potent than chloroquine in vitro (ec values, . and . μm, respectively); additionally, there are fewer concerns regarding drug-drug interactions for hydroxychloroquine than for chloroquine. consequently, despite conflicting opinions [ ] , hydroxychloroquine has been recently proposed as having the ability to control cytokine storms and shorten the clinical recovery time among critically ill sars-cov- -infected patients [ , ] . recently, hydroxychloroquine sulfate was approved by the us centers for disease control and prevention for emergent use in treating adolescent or adult patients (body weight ≥ kg) with severe covid- on march . according to data from physiologically based pharmacokinetic models, a loading dose of mg twice daily of hydroxychloroquine sulfate, which is followed by a maintenance dose of mg twice daily for days, has demonstrated significant superiority ( days in advance) to chloroquine phosphate ( mg twice daily, -fold higher than that used in malaria treatment) in inhibiting sars-cov- in vitro [ ] . additionally, the cardiac toxicity might temper the enthusiasm for the widespread use of chloroquine in the treatment of covid- . it is noteworthy that one randomized controlled trial in wuhan, china validates the clinical superiority of hydroxychloroquine ( mg twice daily for days) over the control group in significantly shortening recovery time [ ] . according to one notable study, azithromycin ( mg on day , followed by mg per day on days - ) was shown to significantly reinforce the efficacy of hydroxychloroquine ( mg thrice daily for days) in the treatment of patients with severe covid- . the positive clinical outcome in these covid- patients is attributed to the excellent efficiency of virus elimination after administration of this combination regimen [ ] . consequently, hydroxychloroquine in combination with azithromycin might be deemed a promising alternative to remdesivir in the treatment of patients with sars-cov- infection. nevertheless, the warning on qtc prolongation caused by this combination regimen should be cautiously considered. despite excellent efficacy on a small group of patients with covid- , the us nih consensus treatment guidelines panel recommended against the use of this combination regimen in the treatment of covid- due to its cardiac toxicity [ ] . tocilizumab is a monoclonal antibody employed in treatment of ra exacerbation. it was originally designed to inhibit the binding of il- to its receptors for alleviating cytokine release syndrome. tocilizumab is currently being investigated in a randomized, double-blind phase trial for its clinical efficacy and safety in patients with covid- compared to placebo plus standard care in the us [ ] . recently, in china, an open label, non-controlled study (clinicaltrials.gov identifier: nct ) investigated the efficacy of tocilizumab for reducing oxygen requirement. although no control group was included in that study, the preliminary report shows a promising potential for tocilizumab on the basis of the outcome in the covid- patients, who had mild-to-moderate ards and received a single intravenous dose of mg tocilizumab [ ] . the efficacy of a janus kinase inhibitor ruxolitinib, which was originally used in the treatment of intermediate-or high-risk myelofibrosis, is currently being evaluated in a phase trial for the treatment of patients with covid- -associated cytokine storm [ , ] . despite a theoretically promising role in alleviating cytokine release storm, the us nih consensus treatment guidelines panel recommended against use of the janus kinase inhibitors in the treatment of covid- presently due to their broad immunosuppressive effects [ ] . teicoplanin was demonstrated to potently prevent the entry of ebola, mers, and sars envelope pseudotyped viruses into the cytoplasm, as well as exhibit an inhibitory effect on transcription-and replication-competent virus-like particles in the low micromolar range (ic , nm) [ ] . mechanistic investigations showed that teicoplanin specifically inhibits the activities of the host cell's cathepsin l and cathepsin b, responsible for cleaving the viral glycoprotein and allowing the exposure of the receptor-binding domain of its core genome and its subsequent release into the cytoplasm of the host cells (i.e., the late endosomal pathway) [ , ] . although the clinical efficacy of teicoplanin against sars-cov- is not proven presently, these studies indicate the potential role of teicoplanin as a novel inhibitor against cathepsin l-dependent viruses. apart from teicoplanin, lipoglycopeptides (dalbavancin, oritavancin, and telavancin) are also considered as potentially repurposable drugs for covid- treatment [ ] . ivermectin is an fda-approved broad-spectrum anti-parasitic (helminths, scabies, etc) agent. it is usually administered with a single dose of μg/kg orally [ ] . of note, it has been shown to boost human immunity (including enhancement of production of il- and other cytokines, activation of superoxide anion production, and augmentation of lymphocyte response to mitogens) [ ] . originally, ivermectin was identified as an inhibitor of the interaction between the hiv- integrase protein (in) and α/β heterodimer of the importin, which is responsible for in nuclear import [ ] , thus inhibiting hiv replication. additionally, ivermectin has also been demonstrated to effectively control infections caused by several other rna viruses (such as dengue, influenza, rsv, and rabies) [ ] . its broad-spectrum antiviral activity was considered to be related to the reliance of multiple rna viruses on impα/β during infection [ ] . caly et al. recently demonstrated that a single-dose treatment with ivermectin induced an approximately -fold reduction in the viral rna of sars-cov- at h in a vero-hslam cell culture model [ ] . the therapeutic potential of this drug against human covid- is currently being evaluated. although severe adverse effects about potentiation of the gabaergic synaptic transmission (depression, ataxia), and psychosis, confusion, seizure were occasionally reported in few patients with diseases other than onchocerciasis [ ] , the conventional dose (≤ μg/kg) of ivermectin is considered to be as a safe regimen in human therapy [ ] . the neurokinin- (nk- ) receptor, encoded by the tacr gene, is the main receptor for substance p. numerous insults, including multiple viral infections, likely facilitate the interaction between substance p and nk- receptor, resulting in serious lung parenchymal injury through neuro-inflammatory processes [ ] . recently, us food and drug administration (fda) approved the phase , double-blind odyssey study (clinicaltrials.gov identifier: nct , initiated on april ) to investigate the efficacy and safety of tradipitant at a dosage of mg orally twice daily for the treatment of inflammatory lung injury following critical covid- infection [ ] . among sars patients, a group treated with inhaled nitric oxide experienced a reversal of pulmonary hypertension, thereby exhibiting a significant improvement in hypoxia and requiring a shorter duration of ventilatory support, compared to the matched control group [ ] . nevertheless, the society of critical care medicine recommends against its routine use for patients with covid- pneumonia unless they are refractory to other strategies [ ]. the ace within the lower respiratory tract is the primary target of the sars-cov- infection [ ] . sars-cov- and sars-cov can effectively utilize the ace receptors expressed on the epithelial cells of the lung, intestine and kidney for human invasion [ ] . therefore, despite conflicting opinions [ ] , a cautious administration of ace inhibitors or arb might be advised for covid- patients [ ] . interestingly, a high ace activity is observed in association with reduced severity of ards among patients with lower respiratory tract infection caused by rsv [ ] . fedson et al. observed that statins target the host response to infection (endothelial dysfunction) rather than the virus itself and suggested that combination therapy with arb and statins might accelerate a return to homeostasis, allowing patients to recover on their own [ ] . despite abovementioned benefits, the us nih consensus treatment guidelines panel recommended against routine addition of this combination regimen in covid- treatment [ ] . we are fighting an indefinite battle against a dangerous and highly contagious virus with significantly higher spread potential than sars-cov. as stated in the aforementioned paragraphs, most drugs that are being considered for covid- therapy are under scrupulous investigations to assess their adverse effects as well as efficacy against sars-cov- . several medicines have been withdrawn because of adverse reactions after showing clinical promise [ ] . presently, no drug or specific therapy against sars-cov- is formally recommended by the us fda. till date, except for supportive management, covid- is 'essentially untreatable' [ , ] . nevertheless, among the numerous drugs with potentially good in vitro efficacy against sars-cov- , we identified some that have been validated to have acceptable safety as well as favorable pharmacokinetic profiles in human therapy. apart from remdesivir that was shown to have acceptable clinical efficacy against moderate-to-severe covid- and acceptable side effects, the potential antiviral drugs that are likely useful in the treatment of patients with mild-to-moderate covid- included hydroxychloroquine, teicoplanin, and ivermectin. moreover, among the anti-il- receptor monoclonal antibodies under evaluation regarding the efficacy of improvement in oxygenation function of lung parenchyma and cytokine storm in covid- patients with moderate ards, tocilizumab probably has a better effect than others. however, the immunosuppression induced by tocilizumab is a cause for concern as many patients with covid- likely have leukopenia or lymphopenia. in fact, despite the current unproven clinical efficacy through stringent trials, a combination of the abovementioned useful drugs ought to be carefully considered to combat sars-cov- . in future, we sincerely hope that effective vaccines and documented drug regimens specifically targeting sars-cov- can be developed to authentically prevent covid- and cure critically ill covid- patients as soon as possible. this study was not funded. the authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed. peer reviewers on this manuscript have no 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patients with covid- associated cytokine storm teicoplanin inhibits ebola pseudovirus infection in cell culture glycopeptide antibiotics potently inhibit cathepsin l in the late endosome/lysosome and block the entry of ebola virus, middle east respiratory syndrome coronavirus (mers-cov), and severe acute respiratory syndrome coronavirus (sars-cov) •• an important study issuing the in vitro efficacy of teicoplanin on sars-cov and mers-cov teicoplanin: an alternative drug for the treatment of coronavirus covid- ? the pharmacokinetics and interactions of ivermectin in humans-a mini-review immunomodulatory effect of various anti-parasitics: a review an alphascreen®-based assay for high-throughput screening for specific inhibitors of nuclear import the fda-approved drug ivermectin inhibits the replication of sars-cov- in vitro issuing an important finding, validated by us fda, about the in vitro efficacy of ivermectin on reducing sars-cov- loading nuclear trafficking of proteins from rna viruses: potential target for antivirals? serious neurological adverse events after ivermectin-do they occur beyond the indication of onchocerciasis? • a detailed study addressing the potentially adverse effects about ivermectin treatment on patients with scabies, many helminth infestations safety of high-dose ivermectin: a systematic review and meta-analysis exploring the safe dose of ivermectin in human treatment double-blind, placebo-controlled study to investigate the efficacy of tradipitant in treating inflammatory lung injury and improving clinical outcomes associated with severe or critical covid- . (clinicaltrials.gov nct ) inhalation of nitric oxide in the treatment of severe acute respiratory syndrome: a rescue trial in beijing society of critical care medicine treating the host response to emerging virus diseases: lessons learned from sepsis, pneumonia, influenza and ebola hiding in plain sight: an approach to treating patients with severe covid- infection treatment options for covid- : the reality and challenges issuing many potentially effective drugs against sars-cov- and other practical therapies in treatment of critical covid- in detail key: cord- -sfyagtl authors: von euler, h; stråhle, k; thörne, a; yongqing, g title: cell proliferation and apoptosis in rat mammary cancer after electrochemical treatment (echt) date: - - journal: bioelectrochemistry doi: . /j.bioelechem. . . sha: doc_id: cord_uid: sfyagtl abstract background: several authors have recently reported encouraging results from electrochemical treatment (echt) in malignant tumours. however, echt is not established and mechanisms are not completely understood. in vivo studies were conducted to evaluate the toxic changes and effectiveness of echt on an animal tumour model. methods: tumours were induced by injecting cells from the r ac rat mammary tumour cell line clone d subcutaneously, in female fischer rats. echt was conducted by inserting a platinum electrode into the tumours. the positive and negative control groups were subjected to the same conditions but without current. the rats were kept for , or days post-treatment. three hours prior to euthanasia an i.p. injection of bromodioxyuridine (brdu) was given. the rats were euthanized, the lesions extirpated and samples were collected for histopathological, and immunohistochemical examination. results: significant changes in cell proliferation rate were seen both in the cathode and anode regions. apoptosis were induced in the anodic treated area outside the primary necrosis, detected with the tunel method. discussion: the results suggest that secondary cell destruction was caused by necrosis with cathodic echt and apoptosis or necrosis with anodic echt. electrochemical treatment (echt) of tumours has been used for more than a hundred years [ ] . although treated with great concern, during the last years many encouraging reports have been published where authors report of tumour destruction in a vide range of tumour models like subcutaneous sarcomas [ ] , melanomas [ ] , intramuscular implanted hepatomas [ ] , subcutaneous lewis lung carcinoma [ ] and most recently in liver tumours [ , ] . electrolysis is a simple technique using a direct current passed through a conductive medium between a pair of electrodes, measured in coulombs ( c = a  s). at the cathode (negative electrode) sodium hydroxide and hydrogen gas are liberated, whereas at the anode (positive electrode), hydrochloric acid, oxygen, and chlorine gas are produced [ , ] . the resulting ph change, the anode becomes acidic relative to the basic environment surrounding the cathode, causes a localised parenchymal necrosis [ , ] . the electric field causes a flux of interstitial water, electro-osmosis, from the anode towards the cathode, since the water molecules act like a dipole. consequently, the tissue surrounding the anode dehydrates while oedema is obtained around the cathode [ , ] . charged substances, dissolved or suspended in tissue, migrate in the electric field and accumulation of ions and charged tissue constituents are obtained at certain and different locations in the electric field. the electric field influences the ion exchange across the cell membranes. hence, the transmembrane potential is altered and thereby the conditions, e.g. for many essential enzyme-regulated reactions [ , ] . there is a negligible thermal effect [ ] . the clinical introduction of echt has been hindered by uncertainness regarding dose planning and mechanisms of destruction. in professor nordenström reported results from the treatment of lung tumours in patients [ ] . many of these patients were, for various reasons, unsuitable for surgical, radiotherapeutic or chemotherapeutic treatment. regression was obtained in out of tumours and no signs of re-growth were detected after a - year follow-up period. among the side effects, nordenström noticed slight fevers and local pain during the treatment. from the early s until today more than patients have been treated with echt in china [ ] . the results have been presented in a number of publications and at several conferences and have been thoroughly reviewed, for example by nilsson et al. [ ] . despite the vast experiences from china and recent clinical experimental studies in australia [ ] echt is still not established and obviously endorse the need for further investigation concerning e.g. destructive mechanisms. here we present a suitable experimental model to evaluate the mechanism and effectiveness of low-level direct current therapy in mammary carcinoma in rat, with the r ac mammary carcinoma model, first described by hilf et al. [ ] . in a previous work we were able to identify, in vitro, the effect of a ph gradient on the tumour cell line used in the animal model [ ] . the aim of this study was to see if similar results regarding cell morphology, proliferation and induction of apoptosis could be achieved after echt in vivo and if any differences between the electrode polarity, coulomb given and duration after treatment could be detected. in addition it was investigated if an indication of destructive efficacy could be obtained. the animal experiments conformed fully to the swedish animal ethical committee's code s / . the inoculation model was performed as earlier described by sapino et al. [ ] with some slight modifications. the r ac rat mammary tumour cell line (clone-d; kindly provided by prof. g. bussolati, university of turin, italy) was cultured in rpmi with glutamax i medium (gibcok, invitrogen, stockholm, sweden) supplemented with % heat-inactivated foetal bovine serum and plated in tissue culture flasks (falcon plastics, los angeles, ca) in a humidified jc, % co incubator. when the cells reached approximately % confluence, they were collected by trypsin-edta treatment. briefly the cellsheet was rinsed once with ca + -and mg + -free pbs and incubated for approximately min at jc in the presence of fresh trypsin-edta. after incubation the cells were suspended in rpmi for injection. viability was determined for harvested cell batches using the trypan blue exclusion dye method. all cells used for this study showed > % viability. tumours were induced by injecting . ml ( . - .  cells) r ac rat mammary tumour clone d subcutaneously into the shaved left and right region cm caudal to the scapula in rats weighing - g. before the tumour model was commenced a test inoculation preformed at the the national veterinary institute (sva, uppsala, sweden) on spf rats had proven that the clone d were free from the following viruses; murine poliovirus/ theiler's encephalomyelitis virus (tev), reovirus type , hantaan virus, parainfluenza virus type (pmv- )-sendai, pneumonia virus of mice (pvm), rat coronavirus and parvovirus/kilham rat viruses (krv). the procedure of subcutaneous implantation was performed under aseptic conditions. the animals were divided into two dose categories ( or c; c = a s) with a follow up period after treatment of , or days. each group consisted of four rats. moreover, nine positive controls (tumour cells inoculated and electrodes inserted but no electric treatment; three rats for each time period) and three negative controls; one for each time period (as for pos controls but only rpmi injected) were included in the study, making the total number of rats . animals were kept under defined flora conditions in our animal facility. they were allowed food and water ad libidum. tumours size measurements were made using a digital vernier calliper. the three longest, orthogonal diameters (a, b and c) were registered. tumour volume was calculated using the formula (pabc/ ). tumours were allowed to grow for approximately days, which resulted in nodules that had a mean volume f sd of f mm . tumours were elevated above the skin and easily measured with a digital vernier calliper (guanglu, taizhou, china). the rats were treated under general anaesthesia using midazolam (dormicumr, roche, stockholm) . mg/ml and fentanylfluanisone (hypnormr, janssen animal health, buckinghamshire, uk) diluted : , which was injected i.p. . ml/ g [ ] . after induction, one half of the initial dose was iterated every min. a heating gel pillow was placed underneath the animal to avoid hypothermia. two identical string shaped electrodes made of pt:ir ( : ), with a diameter of . mm, were used throughout the experiments. the string was electrically insulated using teflonr, despite the active electrode, mm long. before each use, the electrodes were disinfected in % ethanol. the electrodes were placed in the left and right tumour, through a small cutaneous incision and were held firmly by a supporting gantry. the electrodes were inserted in a caudal-cranial direction with the rats in ventral recumbency lying on their chest. in all procedures, the electrode on the animal's right was made anodic. the electrode spacing varied between and mm. direct current was passed through the electrodes by means of a constant-current power supply, consisting of a potentiostat (wenking lt , germany) coupled to an adjustable resistance. the current and voltage were continually monitored with multimeters ( d metexrinstru-instruments, korea), and data was recorded on a palm pilot iiixer (palm, santa clara, ca, usa) using the accompanying software (quickoffice, cutting edge software, usa). to avoid muscle twitching, linear current ramps with a length of min were used to reach the current level ( ma) and before turning off at the end of the treatment. the total coulomb was continually calculated and the treatment was interrupted when a total dose of or c had been delivered. the applied voltage automatically varied in the range of - v throughout the treatment, since the equipment was designed to maintain a constant current. after echt, rats were returned to the animal housing facility. the rats were wrapped in heat insulating towels and housed separately when waking up, to optimise postoperative recovery and to prevent cannibalising one another's tumours; later on four rats were housed per cage. during the first h postoperatively the rats received two i.p. injections of buprenorphine (temgesicr, schering-plough ab, stockholm, sweden) . mg/kg to sustain accurate analgesia. tumour wounds were inspected daily. after treatment the animals' status was continuously examined. h prior to euthanasia the rats were given an i.p. injection of -bromo- v-deoxyuridine (brdu) mg/ kg, dissolved in sterile, . % sodium chloride. the rats were euthanized by administering ml napentobarbital . % i.p., the lesions extirpated and samples were collected for histopathological and immunohistochemical examination. sample buffer used was % phosphate buffered formaldehyde. the tissue was examined in a light microscope (nikon eclipse e ) after staining with haematoxylin eosin according to routine procedures. for investigation of potential distant metastases, tissue from liver, spleen and lungs were examined. for the immunohistochemical quantification of cellproliferation the s-phase marker brdu (thymidine analogue) was used. after dewaxing the paraffin sections in xylene and rehydrated in ethanol according to standard procedures, the slides were rinsed and kept in tbs for at least min. the glasses were place in a beaker with . m citrate buffer ph ( . ), heated to boiling point in a microwave oven and then kept boiling for min. the buffer and tissue sections were cooled down to room temperature during min in cold water. to block endogenous peroxidase activity the sections were incubated with . % h o solved in methanol for min in rt. the sections were rinsed in tap water and subsequently with tbs  min. to improve antibody penetration the sections were treated with . % protease in tbs for exactly min in rt, followed by careful rinsing with tbs for min. to block unspecific binding the sections were incubated with % bsa-tbs for min, then covered with the primary antibody (mouse anti-brdu, dako, glostrup, denmark) for h in rt. after careful washing, the secondary antibody (rabbit anti-mouse biotinylated, dako) was applied to the sections and incubated for min before it was removed with tbs. thereafter the avidine -biotin -complex /hrp (dako) was added and rinsed off after min, followed by dab (diaminobenzidine, sigma) staining for min. counterstaining with hematoxylin (mayer, merck) for min was performed according to conventional procedures. finally, the sections were rinsed in tap water for approximately min. dehydration and mounting followed standard routines. the labelling index (li), the ratio of brdu positive cells and the total amount of cells, was quantified by light microscopy. seventy high power fields were examined in each section. the counting started at the border of the primary destruction caused by heavily ph changes [ ] , in this paper called the border of destruction and moved out towards untreated tumour tissue in a sunray pattern, with the electrode as the centre. the cumulative incidence of brdu labelled cells was determined for each of the ten high power fields, called zones, counted (fig. ). in the positive control the counting started at the border of the central necrosis, spontaneously formed in the tumour. for the immunohistochemical detection and quantification of apoptosis (programmed cell death) at single cell level, based on labelling of dna strand breaks (tunel technology) the in situ cell death detection kit, pod (roche diagnostics, mannheim, germany) was used. the formalin-fixed tissue sections were dewaxed and transferred into pbs. after incubation with proteinase k ag/ml in mm tris -hcl for min in jc the slides were rinsed in pbs  min, followed by blocking the endogenous peroxidase activity with % h o in methanol for min in rt. after additional rinsing in pbs  min the slides fig. . average tumour size after echt compared to untreated control. in the beginning the anodic treatment gives rise to an immediate decrease in tumour volume due to dehydration. at day the initial tumour volume and the one after treatment is the same for the control. hence, the difference in volume becomes . there is an illusionary prominent increase in ''tumour volume'' immediately after echt at the cathode due to the formation of oedema (electro-osmosis). error bars are showing the standard deviation (sd), which is the percentage increase/decrease from start of the experiment (e.g. day ) until termination ( , or days after echt). were incubated in permeabilisation solution . % triton x- (sigma) in . % sodium citrate (merck) for min in jc. after rinsing in pbs at rt, al of tunel reaction mixture was added on the section and incubated for min at jc in a humidified atmosphere in the dark. after rinsing the slides in pbs, samples were analysed in a fluorescence microscope (leica tcs nt arkr laser confocal microscope). for light microscope analysis al converter-pod was added on the samples followed by incubation in a humidified chamber for min at jc. after rinsing slides in pbs, al dab-substrate solution (roche diagnostics) was added. a final min incubation at rt followed. after the last rinse with pbs the slides were counterstained with haematoxylin (merck) and mounted according to standard routines. subsequently analysis in a light microscope (nikon eclipse e with a sony ccd color video camera) was performed. tumour volumes were expressed as mean f standard deviation (sd). data were analysed as a mixed model according to littell et al. [ ] using the individual animal as a random factor. time and anode, cathode or none were used as fixed factors. the procedure mixed in the sas package was used for the analysis [ ] . a p-value of less than . was considered statistically significant. the comparison of the proliferation rate, with immunohistochemistry, between the therapeutic and the control group was statistically analysed with the student's t-test. a p-value of less than . was considered statistically significant. fig. . chart showing the cumulative incidence of tumour cells in s-phase from the border of destruction and out towards ''normal'' tumour tissue. note that the cell proliferation is significantly decreased even far from the actual echt destruction, suggesting that additional impact on tumour proliferation is achieved, apart from the primary necrosis. initially ( d) the decrease in cell proliferation rate is more prominent close to the border of destruction, due to toxic impact from the produced hydrochloric acid, oxygen, and chlorine gas (anode) or sodium hydroxide (cathode; not shown). further away from the necrotic area it becomes higher than for the d group. error bars are showing the standard deviation (sd). the initial volumes of tumours were f mm . the difference (percentage) between the tumour volume initially and after , and days post treatment, respectively, were assessed by means of comparing the mean difference for each treatment group, divided with the initially determined tumour volume. hence, the variation in initial tumour volume, between groups, could be neglected (fig. ) . after the echt was supplied to tumours, it was observed that the volumes initially decreased at the anode and increased at the cathode when compared with the control. only one rat went into complete remission (anode c, d). the tumour sloughed off days after echt. in the rest a significant decrease (both anode and cathode) in tumour progression compared to untreated control was achieved. significant tumour responses were found in the anode c d and c d, when compared to the corresponding cathodic treatments as well as the controls. tumour cells were easily identified on hematoxylin and eosin sections by their basophilic properties and polymorph appearance. the tumours were well delimited and did seldom attach to underlying muscles. tumour samples, positive control and treated (anode) are shown in fig. . microscopic examination of the control group indicated that the mammary tumours that developed showed the characteristics, described in detail by papotti et al. [ ] , of a high differentiated solid adenocarcinoma with minor central necroses. the necrosis surrounding the positive electrode was coagulative in nature with preservation of the architectural contours. in contrast, the necrotic areas surrounding the negative electrode exhibited liquefaction and almost complete effacement of tissue architecture (not shown). due to the subtotal tumour destructive dose, in all cases except the complete remission described earlier, necroses and reparative tissue were found alongside remnants of vital tumour conglomerates. the necrotic areas occurred mostly as coagulation necroses in organization, interspersed with connective tissue. the necrotic area was sharply demarcated from the adjacent tumour. several necroses were partially encased in vital tumour tissue. distant metastases were not detected in any of the inoculated rats following macroscopic as well as microscopic examination of lung, spleen and liver tissue. this confirms the findings of a former study by sapino et al. [ ] . there was a significant decrease in cell proliferation both at the anode and cathode compared to the positive control. the labelling index (li) was almost constant from the border of destruction and further out in less affected tumour tissue. an example of this is shown for animals killed days after echt (fig. ) . the positive control can be compared to the significantly decreased brdu labelling for both anode (not shown) and cathode treatments (fig. ) . cell proliferation was significantly impaired far from the macroscopic as well as microscopic visible border of destruction. initially ( d) the proliferation rate was significantly decreased close to the border of destruction, for both c and c, compared to the d and d post echt groups (all groups not shown). further out from the necrotic area the d-group had a higher li instead, compared to the other treatments. c ( d) is included in fig. . the spontaneous amount of apoptosis in the r ac rat mammary tumour cell line is very low in vitro [ ] . after echt an induction of apoptosis was found in the anodic treated areas at the border of destruction compared to both the untreated control as well as the cathode groups. in fluorescence microscope (fig. ) the light green stained nuclei express the presence of cleaved genomic dna that during apoptosis have yield doublestranded, low molecular weight dna fragments (mono-and oligonucleosomes) as well as single strand breaks (''nicks'') in high molecular weight dna. labelling free v-oh termini with modified nucleotides in an enzymatic reaction can identify those dna strand breaks. in the cathode treatments very necrotic material was found close to the destruction zone and almost no intact nuclei were considered as being apoptotic. in the controls the general frequency of apoptosis was investigated, especially at the border of the spontaneous central necrosis/necroses. occasionally, clusters of positive stained cells were found, but the overall amount of apoptosis was low. in the light microscope the findings in the fluorescence microscope were confirmed (fig. ). this subtotal tumour destruction trial was carried out to investigate the possible biological features of echt on mammary carcinomas and not being a treatment modality for dose -response calculations. hence, the dose could be sustained at a low level, minimising the postoperative trauma and patient discomfort. despite the large variation in initial tumour size and small number of animals, it was possible to prove a statistical difference between the untreated control and the rats that underwent echt, even if this was not the primary aim of this study. the single electrode configuration also made it possible to separately examine the different polarities' influence on the tumour, still working in the same individual. as we believe that the ph alterations during echt is the major reason for tissue destruction we have recently presented a paper where the r ac rat mammary tumour clone d was investigated in vitro [ ] . in this study tumour cells were exposed to a ph gradient similar to that of echt and after a variable period of recovering in normal medium investigations were carried out concerning viability (mtttest), morphological observation in phase contrast microscope and light microscope, nucleotide analogue incorporation (brdu), caspase- activity measurement and detection of dna fragmentation by an agarose gel electrophoresis. in this study cell proliferation was significantly impaired, both in acidic and alkaline milieu. more interesting however was the fact that apoptosis was induced only in strong acidic environment and that the cell morphology distinctly resembles the features seen in in vivo experiments with echt. since the induction of apoptosis is concentrated to the border of destruction at the anode the most probable mechanism is the acidification that occurs. this is also supported by the in vitro study described above. interestingly the cell proliferation rate was reduced significantly in the whole tumour, both for the anodic and cathodic treatment, suggesting that secondary mechanisms such as the inflammatory response, tumour ischemic anoxia and radical formations also impair the tumour progression after echt. hence, the treatment had a significant effect on tumour cells proliferation far from the evidently destroyed area. very few studies with echt have separated the two electrodes and studied the different impact on the cell damage. in this trial an excellent possibility to study this was achieved. the information could be useful if it is known that a specific tumour is more prone to resist, or susceptible to undergo, apoptosis. the choice of tumour may influence the treatment outcome and could possibly explain why different studies have claimed either the anode or the cathode as being more efficacious. the direction of the intracellular ph (ph i ) change (acidification or alkalisation) as well as the level of the change depends on the extracellular (ph e ). it is well known that acute extracellular acidification acidifies the intracellular environment, thereby perturb the cell proliferation [ ] . low ph e results in low ph i because of increased h + entry. intracellular acidification correlates well with dna digestion, and acidic cells show apoptotic morphology [ ] . it has also been shown that acid endonuclease can be responsible for the dna cleavage seen in apoptotic neutrophils [ ] . thus, acidification is a potential signal for the final, irreversible stages of cell death. the destructive mechanism in higher ph is that alkalic condition directly destroy various enzyme and structure proteins and result in inactivation of function or protein denaturation. intracellular alkalisation increases the inward calcium current and the resultant increase of intracellular ca + [ ] . the initiating event in necrosis leads to an influx of water and extracellular ions. intracellular organelles, most notably the mitochondria, and eventually the entire cell, swell and rupture, the structure of the relatively unchanged dna is randomly degraded. echt perturbs blood perfusion in treated tumours and thus leads to growth retardation [ , ] . it is also described that echt causes micro thrombi that eventually lead to ischemic injury [ , ] . it is however not clear if there is any difference between electrode polarities, considering micro thrombi formation and hypoxic lesions, although some reports claim a slightly stronger impact at the anode [ , ] . apoptosis is triggered by a hypoxic environment [ , ] . thus, it is easy to assume that the apoptosis found in this study is due to ischemic injury. however, it is hard to explain why there is such a difference between the anodic and cathodic treatments. furthermore, the results in the previous described in vitro study support the hypothesis that low ph induces apoptosis, whereas high ph induce necrosis [ ] . taking these two studies together they indicate that the echt of r ac cells and exposition of low ph in vitro exhibit several features of apoptosis including chromatin condensation, dna fragmentation, tunel labelling and activation of caspases. the observations in the animal model can certainly be a combination of both acidic milieu and hypoxia, although most likely with low ph as the predominating factor. the development of different echt treatment modalities is getting increasing interest in the western world. basic investigations of the cellular behaviour in both normal and neoplastic tissue are good complements to the large-scale models and long terms studies of the safety effects of electrochemical treatment that recently have been published [ , , ] . the introduction of echt as a complement in the treatment of tumours in humans as well as companion animals can soon be anticipated. a complete treatise on electricity in theory and practice biophysical approach toward tumor regression in mice inhibition of experimental tumor growth in hamsters by small direct currents effect of applied dc currents on experimental tumor growth in rats electrochemical modification of tumor growth in mice electrolytic treatment of colorectal liver tumour deposits in a rat model: a technique with potential for patients with unresectable liver tumours local treatment of hepatic metastases with low-level direct electric current: experimental results electrolyte destruction of lung tissue. electrochemical aspects biologically closed electric circuits: clinical, experimental and theoretical evidence for an additional circulatory system development of a dose-planning method for electrochemical treatment of tumors. a study of mammary tissue in healthy female cd-rats, electro-magnetobiol liver electrolysis: ph can reliably monitor the extent of hepatic ablation in pigs electrochemical treatment of tumors (ect): electroosmotic dewatering (eod) as the primary mechanism, drying technol modified cell proliferation due to electrical currents tumor treatment by direct electric current -tumor temperature and ph, electrode material and configuration electrochemical treatment of lung cancer reviewelectrochemical treatment of tumours electrolytic ablation as an adjunct to liver resection: experimental studies of predictability and safety effect of actinomycin d on estrogen-induced changes in enzymes and nucleic acids of r ac mammary tumors, uteri, and mammary glands cellular toxicity induced by different ph levels on the r ac rat mammary tumour cell line. an in vitro model for investigation of the tumour destructive properties of electrochemical treatment of tumours tumor types derived from epithelial and myoepithelial cell lines of r ac rat mammary carcinoma anaesthesia of animals for biomedical research sas system for mixed models dual secretory and myoepithelial differentiation in the transplantable r ac rat mammary carcinoma, virchows arch acidic environment causes apoptosis by increasing caspase activity etoposide-induced apoptosis in human hl- cells is associated with intracellular acidification the acid deoxyribonuclease of neutrophils: a possible participant in apoptosis-associated genome destruction the effects of changing intracellular ph on calcium and potassium currents in smooth muscle cells from the guinea-pig ureter tumor treatment by direct electric current. tumor perfusion changes blood perfusion of subcutaneous tumours in mice following the application of low-level direct electric current lowlevel direct electrical current therapy for hepatic metastases: i. preclinical studies on normal liver experimental study of electrolysis-induced hepatic necrosis caspases in ischaemic brain injury and neurodegenerative disease oxygen deprivation induced cell death: an update the safety of electrolytically induced hepatic necrosis in a pig model a new treatment for unresectable liver tumours: long-term studies of electrolytic lesions in the pig liver professor lennart eriksson and associate professor jerker olsson, at the department of microbiology, pathology and immunology, division of pathology, huddinge university hospital, are acknowledged for being scientific advisors and for histopathological consultation.ulf olsson, associate professor, department of biometry and informatics, slu, uppsala, is acknowledged for statistical consultation.this work was in part financially supported by the agria-insurance company stockholm, sweden. key: cord- -cxjnczwv authors: ormerod, a.d.; white, m.i.; shah, s.a.a.; benjamin, n. title: molluscum contagiosum effectively treated with a topical acidified nitrite, nitric oxide liberating cream date: - - journal: br j dermatol doi: . /j. - . . .x sha: doc_id: cord_uid: cxjnczwv a double‐blind, group‐sequential clinical trial of acidified nitrite was performed to demonstrate the efficacy of this nitric oxide donor in treating molluscum contagiosum. subjects received either % sodium nitrite co‐applied with % salicylic acid under occlusion, or identical cream with % salicylic acid, omitting sodium nitrite. active and control treatment groups were well matched for the number and duration of lesions and made a similar number of applications. we found a % cure rate in the active treatment group and % cure with control treatment (p = · ). the mean time to cure was · months. staining of the skin and irritation were frequent side‐effects but did not prevent successful treatment. molluscum contagiosum and are related to orthopox and parapox viruses and share some homology with vaccinia. , nitric oxide (no) has been shown to have antiviral effects in dna, rna, enveloped and encapsidated viruses. , it reduces replication of herpes simplex type , vaccinia and the orthopox ectromelia virus, murine coronavirus and in vitro, but not in vivo, has antiviral properties for avian reovirus infection. not all viruses are inhibited by no, e.g. tickborne encephalitis virus is resistant to its effects. we have previously described the use of acidified nitrite cream as an no donor to treat dermatophyte infections and now show the effectiveness of this topical treatment in molluscum contagiosum. within keratinocytes, the molluscum virion colonies are isolated in a unique sac which provides an immunologically privileged environment for replication. lesions lack a t-cell and killer cell infiltrate, reflecting absence of a host response. this may result from the expression of epitopes on the molluscum bodies mimicking those normally found on the surface of macrophages. current therapies include physical destruction, manual extrusion, liquid nitrogen therapy and curettage, all of which are painful, although pain can be reduced by lidocaine/prilocaine (emla) cream. , the pain of these therapies is important, as most patients are under years old. there are few well conducted clinical trials of therapy for molluscum, although povidone iodine and % salicylic acid was effective in one such trial and % podophyllotoxin in another. interestingly, the latter trial showed only a % response rate over months with placebo therapy, demonstrating the slow rate of spontaneous resolution. the infection can be severe in patients with human immunodeficiency virus (hiv)induced immunosuppression, where disfiguring facial lesions are a therapeutic problem. in some such patients, resolution with the antiviral cidofovir has been noted when coincidentally given for cytomegalovirus infection. as we could not estimate the size of the effect of this therapy, we chose a double-blind, group-sequential design in which subjects were randomized to receive either % sodium nitrite co-applied with % salicylic acid under occlusion, or identical cream with % salicylic acid but omitting sodium nitrite, as a control. children under year of age, pregnant or lactating women, an unco-operative child or mother, and those on immunosuppressive drugs or known to have hiv infection, were excluded. lesions on the face were q british association of dermatologists excluded because of potential stinging or staining of the skin. subjects were asked to apply the treatment to each individual lesion every night and record the treatment in a diary. wherever possible, occlusion with cling film or light adhesive tape was suggested, but certain body sites and widely distributed lesions often precluded occlusion. statistical analysis was on an intention-to-treat basis. repeated x analyses (pearson's, spss statistical package) were scheduled after , , , and patients completed, with a prospective stopping rule for p , ´ , ´ , ´ , ´ and ´ on successive analyses. completion was defined as months, or when the patient was cured or dropped out, if sooner. at least month of treatment was necessary to be valid for efficacy. the log rank test was used to assess differences in cure rate over time, with the last evaluable status carried forward for drop-outs. the median age of subjects was years and interquartile range years. twenty-two were girls and eight boys. the infection had a mean^sd duration of ´ ^ ´ months. no significant difference was found between the active treatment and control groups in the number of lesions per patient or duration of these lesions (table ) . cure was significantly greater with no treatment after patients completed therapy, with % cure in the active treatment group and % cure with control treatment ( table ) (x with yates' correction p = ´ , fisher's exact test p , ´ ), and the mean time to cure^sd was ´ ^ ´ months. a kaplan±meier plot (fig. ) demonstrates the rate of cure over time and was analysed by the log rank test. this showed a significant difference in the survival curves, with cure being greater in the active group (p , ´ ). four of patients stopped the active treatment because of irritation and lack of efficacy, and two further patients who cleared complained of significant irritation. similar irritation occurred in four of the controls. lack of efficacy was the primary reason for stopping treatment in of controls. brown staining was recorded in six subjects with active treatment but not in controls. patients were not disturbed by this, as there was improvement in the lesions. subjects dropped out of the study evenly in both active and control groups, including subjects that were cured. five active and four control subjects dropped out after month, six in each group dropped out after months, and five active and four control subjects completed months. the mean^sd number of treatments in the active treatment group was ^ compared with ^ in the control group. this confirms that the control group did not fail to clear because of early withdrawal. although instructed to apply the treatment nightly, on average it was only applied every second night. this was because treatment was fiddly and time-consuming or, where there was irritation, treatment was omitted for a few days. no other systemic or other adverse events were noted. acidified nitrite cream is an effective therapy for this distressing condition and, unlike physical treatments, is painless. irritation was the main reason for stopping the therapy in the four non-responders to active therapy. although staining of the skin was common in the active treatment group, it only occurred in six of . it is unlikely to have led to bias, as the end-point of cure of all lesions is an objective and specific end-point. staining did not put patients off continuing the treatment, which was done by motivated parents, and could be overcome by reformulating the acidified nitrite, substituting a reducing acid for the salicylic acid. molluscum is more common in subjects with eczema, and tends to induce eczematization of the surrounding skin. , some such patients tolerate this poorly, but the addition of topical steroids or use of an alternate day schedule has helped other patients. applying creams under occlusion leads to displacement on to perilesional skin. a more viscous and occlusive formulation with applicators may be more successful. adhesive tape can also be used and left in place to protect perilesional skin. no has specific antiviral effects at levels below those toxic to host cells, by inhibiting viral replication. it probably acts on several targets by inhibiting rna synthesis, dna replication, early and late viral protein synthesis and by nitrosylating viral structural proteins. we have shown that higher concentrations of no from nitrite and ascorbic acid are immunopotentiating. we showed that no caused lymphocyte, macrophage and neutrophil infiltration, expression of the adhesion molecules intercellular adhesion molecule- and vascular cell adhesion molecule- and migration of antigen-presenting cells. we also showed an increase in p . it is therefore possible that no acts through dna toxicity to infected cells, promoting apoptotic cell death. we have successfully treated genital lesions of molluscum contagiosum and extensive lesions in two subjects with hiv infection. the immunosuppressed patients took longer to clear, suggesting that immunopotentiation contributes to the successful clearance of the virus. sequence analysis of a molluscum contagiosum virus dna region which includes the gene encoding protein kinase and other genes with unique organization similarity in genome organization between molluscum contagiosum virus (mcv) and vaccinia virus (vv): identification of mcv homologues of the vv genes for protein kinase , structural protein vp , rna polymerase kda subunit and beta-hydroxysteroid dehydrogenase the antiviral role of nitric oxide does nitric oxide play a critical role in viral infections? evidence for an antiviral effect of nitric oxide, inhibition of herpes simplex type replication inhibition of viral replication by interferon gamma induced nitric oxide synthase disassociation between the in vitro and in vivo effects of nitric oxide on a neurotropic murine coronavirus an antiviral effect of nitric oxide: inhibition of reovirus replication nitric oxide and viral infection: no antiviral activity against a flavivirus in vitro, and evidence for contribution to pathogenesis in experimental infection in vivo a randomised trial of acidified nitrite cream in the treatment of tinea pedis demonstration of a unique viral structure: the molluscum viral colony sac lack of host cellular immune response in eruptive molluscum contagiosum molluscum contagiosum in childrenÐevidence based treatment curettage of molluscum contagiosum in children: analgesia by topical application of a lidocaine/prilocaine cream (emla) molluscum contagiosum treated with iodine solution and salicylic acid plaster topical . % and . % podophyllotoxin cream for self-treatment of molluscum contagiosum in males. a placebo-controlled, double-blind study facial and perioral molluscum contagiosum in patients with hiv infection. a report of eight cases resolution of recalcitrant molluscum contagiosum virus lesions in human immunodeficiency virus-infected patients treated with cidofovir monitoring trial progress the association of molluscum contagiosum and infantile eczema eczema and molluscum contagiosum the inflammatory and cytotoxic effects of nitric oxide releasing cream on normal skin key: cord- -nljd ok authors: gordon, jennifer l.; balsom, ashley a. title: the psychological impact of fertility treatment suspensions during the covid- pandemic date: - - journal: plos one doi: . /journal.pone. sha: doc_id: cord_uid: nljd ok purpose: to examine the psychological impact of fertility treatment suspensions resulting from the covid- pandemic and to clarify psychosocial predictors of better or worse mental health. methods: women from canada and the united states (ages – years) whose fertility treatments had been cancelled were recruited via social media. participants completed a battery of questionnaires assessing depressive symptoms, perceived mental health impact, and change in quality of life related to treatment suspensions. potential predictors of psychological outcomes were also examined, including several personality traits, aspects of social support, illness cognitions, and coping strategies. results: % of respondents endorsed clinical levels of depressive symptoms. on a -point scale, participants endorsed a significant decline in overall quality of life (m(sd) = - . ( . ), p < . ) as well as a significant decline in mental health related to treatment suspensions on a scale from - to + (m(sd) = - . ( . ), p < . ). several psychosocial variables were found to positively influence these outcomes: lower levels of defensive pessimism (r = -. , p < . ), greater infertility acceptance (r = . , p < . ), better quality social support (r = . , p < . ), more social support seeking (r = . , p < . ) and less avoidance of infertility reminders (r = -. , p = . ). conclusion: fertility treatment suspensions have had a considerable negative impact on women’s mental health and quality of life. however, these findings point to several protective psychosocial factors that can be fostered in the future to help women cope. one in six reproductive-aged couples experience infertility, defined as being unable to achieve pregnancy despite � months of focused attempts to conceive [ ] . although male and female-factor infertility are equally prevalent, women generally bear the brunt of infertilityrelated burden: even in cases of male-factor infertility, treatments such as intrauterine insemination (iui) or in vitro fertilization (ivf) require that women attend near-daily ultrasounds, self-inject gonadotropins, and undergo invasive and painful procedures. women also carry a disproportionate share of the psychological burden associated with infertility, with infertile women consistently reporting lower self-esteem, more depression and anxiety, and lower life satisfaction, than their male partners [ ] . studies of women presenting for the evaluation of infertility in a tertiary care setting suggest that approximately - % of these women experience clinically significant depression or anxiety [ ] [ ] [ ] [ ] . in fact, quality of life and levels of depression and anxiety among women undergoing fertility treatments are indistinguishable from those of individuals undergoing cancer treatments and cardiac rehab following a heart attack [ ] . on march th , , the american society of reproductive medicine and the canadian fertility and andrology society announced their recommendations to immediately suspend all in-person fertility treatments throughout canada and the u.s. indefinitely due to the covid- pandemic [ , ] . these recommendations included delaying the start of new treatment cycles but also, in many cases, abandoning treatment cycles that had already begun. while perhaps the right decision given the circumstances, this was devastating news for thousands of couples: unsurprisingly, one early survey of patients at a new york city fertility clinic found that % of patients reported being "very" to "extremely" upset over the cancellation of fertility cycles [ ] . however, to our knowledge, there have been no studies examining the mental health impacts of fertility treatment suspensions. this was therefore the purpose of the current investigation. furthermore, the current study aimed to clarify predictors of better or worse mental health during this challenging time. women from across canada and the united states were recruited to participate in the current online study via advertising on social media. to qualify, women had to report having had their fertility treatments suspended due to the covid- pandemic and that their treatments had not yet resumed. individuals were compensated with a $ . amazon e-gift card for their participation. the consent form for this study consisted of the first page of the survey-all participants provided consent by clicking on the "accept" button and continuing to the survey itself. the study was reviewed and approved by the university of regina research ethics board. the study was advertised on facebook between april th and june th , . the study ad instructed prospective participants to message the research team if they were interested. a member of the team then verified their eligibility to participate. if deemed eligible, they were provided with a link and password to access an online survey using qualtrics survey software. any diagnoses known to contribute to their infertility and to report which treatments had been suspended due to the pandemic. patient health questionnaire- (phq- ). the phq- [ ] consists of items based on dsm-iv criteria for diagnosing depressive disorders and is capable of determining both disorder presence and severity. items are scored on a -point likert scale ranging from (not at all) to (nearly every day), which indicates the degree participants have been bothered by the listed problems in the past weeks (total scores ranging from - ). in the current study, internal consistency was found to be α = . . an internal consistency above . suggests that the items of a scale are sufficiently correlated as to suggest that they measure the same general construct. intolerance of uncertainty scale short form- (ius- ). the ius- [ ] includes items on a -point scale ranging from (not at all characteristic of me) to (entirely characteristic of me). the questionnaire features three subscales: inhibitory anxiety, prospective anxiety, and a total score. in the current study, internal consistency was found to be α = . . revised life orientation test (lot-r). the lot-r [ ] is a -item questionnaire focusing on pessimism and optimism. the lot-r is on a -point scale ranging from (strongly disagree) to (strongly agree). of the -items, items contribute to an overall optimism score and are filler questions. in the current study, internal consistency was found to be α = . . revised defensive pessimism questionnaire (dpq-r). the dpq-r [ ] is a -item questionnaire focusing on defensive pessimism. the dpq-r is on a -point likert scale for a maximum total score of . in the current study, internal consistency was found to be α = . . illness cognition questionnaire (icq). the icq [ ] is an -item questionnaire with responses on a -point scale from "not at all" to "completely". for the purposes of this study, the words "my illness" were replaced with "my infertility. this measure has a three-factor structure, these factors being "helplessness" (e.g. my infertility controls my life"), "acceptance" (e.g. "i have learned to live with my infertility"), and "perceived benefits" (e.g. "i have learned a great deal from my infertility". infertility coping questionnaire. this questionnaire (s file) was developed by our research team because a comprehensive infertility-specific coping questionnaire was not deemed to exist. its creation was based on a careful review of all existing infertility-specific coping questionnaires. it began as a list of items, which was reduced to items after redundant items were removed, in collaboration with our patient-advisors. these items were retained to represent each of the following subscales: ) avoidance, ) active coping, ) find meaning, ) defensive pessimism, ) optimism, ) seek social support, ) behavioral engagement. responses are on a -point scale from "not at all" to "always". its internal consistency in the current study was found to be α = . . indicators of social support. participants were asked to indicate the number of people, apart from their romantic partner, with whom they speak openly about their infertility. they were also asked to rate, on a -point scale from 'very unhelpful' to 'very helpful', the degree to which their partner and the degree to which others have helped them cope with the suspension of fertility treatments. psychosocial impact of treatment suspensions. participants were asked to rate on a scale from - (very negative impact) to + (very positive impact), the extent to which their mental health had been impacted by treatment suspensions. they were also asked to rate the extent to which their mental health had been impacted by the other components of the pandemic (e.g. worries about the virus, living with restrictions on daily activities, unemployment, financial difficulties). quality of life before and after the pandemic. a -item quality of life measure [ ] asked participants to answer the following question: "taking everything in your life into account, please rate your overall quality of life on the following -point scale. one ( ) means life is very distressing; it's hard to imagine how it could get much worse. seven ( ) means life is great; it's hard to imagine how it could get much better. four ( ) means life is so-so, neither good nor bad." they were asked to answer this question twice: first, with the present in mind and second, thinking about their state in the month leading up to treatment suspensions. all analyses were conducted using sas . . the two primary outcomes for this study were change in quality of life rating (from before treatment suspensions) and mental health impact ratings. the wilcoxon signed rank test, a non-parametric test that does not require data to be normally distributed, was used to assess whether change in quality of life and mental health impact were significantly different from . spearman correlations, also a non-parametric test that does not require normally-distributed data, were used to examine the relationship between indicators of social support, personality traits, aspects of illness cognition, and coping strategies, on these two outcomes. for both illness cognitions and coping strategies, an additional linear regression analysis using proc glm was conducted including all cognitions or coping factors as predictors within the same model to clarify their independent effects. these were repeated after log-transforming both change in quality of life rating and mental health impact ratings to improve normality of these dependent variables, both of which were leftskewed (towards the negative end of the scale). power calculations were carried out in g � power. setting alpha at . , this study had % power to detect a correlation coefficient of . , which we judged to be the smallest clinically significant effect that we would want to be powered to detect. a total of women contacted us through facebook with interest in the study. thirty-eight participants did not pursue the conversation past an initial explanation of the study and were deemed ineligible to participate. finally, participants were removed from all analyses because the survey took less than minutes to complete, raising questions about the validity of responses. thus, participants were remaining for the current analysis. table reports the demographic and reproductive health characteristics of these women. participant ages ranged from to years and time spent trying to conceive ranged from to months. more than half of the participants had had an ivf cycle cancelled and approximately one third were in the midst of iui. % of the participants were ages - and % were aged or older. table summarizes the median psychosocial variables assessed in the study. median depressive symptoms were quite high based on the patient history questionnaire, with over half of the sample scoring above the clinical cut-off of . there was a statistically significant decline in self-reported quality of life of . / following the suspension of fertility treatments (s( ) = - , p < . ). when rating the mental health impact of treatment suspensions on a scale other % patient history questionnaire- score (/ ; = clinical cut-off) . median mental health impact of other pandemic components (- to + ) - . ( . ) mean # of confidants about infertility . ( . ) % from - (very negative impact) to + (very positive impact), respondents endorsed a median score of - . , which is significantly different from (s( ) = - , p < . ) (fig ) . overall, % of respondents reported that treatment suspensions had had a negative impact on mental health. baseline characteristics. neither age, years of education, annual income, nor the number of children a woman had were correlated with either change in quality of life or perceived mental health impact (p >. ). however, the length of time a woman had been trying to conceive was associated with a greater negative perceived mental health impact (r( ) = -. , p = . ) of treatment suspensions. personality traits. table depicts the correlation between three personality traits (trait optimism, defensive pessimism, and intolerance of uncertainty) that were considered potentially relevant under the current circumstances, in relation to the overall change in quality of life and the mental health impact attributed to fertility treatment suspensions. with regards to the psychological impact of fertility treatment suspensions during the covid- pandemic personality traits, defensive pessimism was related to a greater negative change in overall quality of life as well as a greater negative mental health impact of treatment suspensions. neither trait optimism nor intolerance of uncertainty were significantly related to any outcomes (p >. ). infertility-related cognitions. greater acceptance was associated with a more positive change in overall quality of life and lesser mental health impact attributed to treatment suspensions (table ) . furthermore, greater benefit-finding was associated with a smaller mental health impact of treatment suspensions while helplessness was associated with a greater negative mental health impact of treatment suspensions. however, when all three illness cognition factors were included in the same regression model as three simultaneous predictors of quality of life change, only acceptance was a significant predictor of treatment suspensions (β(se) = . ( . ), p < . ) while helplessness (β(se) = . ( . ), p = . ) and benefit-finding (β(se) = . ( . ), p = . ) were not. the same pattern was seen when examining the impact of illness cognitions on perceived mental health impact: acceptance was a significant predictor (β(se) = . ( . ), p < . ) while helplessness (β(se) = . ( . ), p = . ) and benefit-finding (β(se) = . ( . ), p = . ) were not. these results remained unchanged when quality of life change and mental health impact were log-transformed to improve normality of the dependent variable. coping strategies. the internal consistency of each of the seven subscales was examined. in instances where it was below . , items were removed to improve it. this resulted in items being removed. the remaining items are included in table . the internal consistency of the psychological impact of fertility treatment suspensions during the covid- pandemic the final subscales are as follows: ) avoidance, α = . , ) active coping, α = . , ) finding meaning, α = . , ) defensive pessimism, α = . , ) optimism, α = . , ) seek social support, α = . , and ) behavioural engagement, α = . . as shown in table , spearman correlations revealed that seeking social support was correlated with a more favourable change in quality of life and that engaging in less avoidance was associated with a more favourable change in mental health. when all seven coping factors were included in the same regression model, seeking social support remained the only factor predicting change in quality of life: specifically, a -point increase in mean item endorsement was associated with a . -point increase in quality of life (β(se) = . ( . ), p = . ). avoidance remained predictive of a greater negative mental health impact (β(sem) = - . ( ), p = . ). however, optimism emerged as predictive of a more favourable mental health impact of treatment suspensions (β(sem) = . ( . ), p = . ). the other coping factors were not significant predictors (p > . ). these results remained unchanged when quality of life change and mental health impact were log-transformed. sensitivity analyses: predictors of the mental health impact of other pandemic aspects. on a scale from - to + , participants were asked to reflect on the extent to which their mental health had been impacted by aspects of the covid- pandemic that were unrelated to their fertility treatments being cancelled (e.g. activity restrictions, social isolation, financial hardship, job loss). of the variables listed in table , defensive pessimism (r( ) = -. , p = . ), infertility acceptance (r( ) = . , p = . ), and infertility benefit-finding (r ( ) = . , p = . ) were weakly correlated with this outcome. the current study sought to examine the mental health impact of fertility treatment suspensions resulting from the covid- pandemic. furthermore, it sought to explore the psychosocial predictors of this psychological impact. overall, results suggest that the mental health impact of treatment suspensions is substantial: indeed, over % of respondents reported clinically significant depressive symptoms, a rate that is considerably higher than typical rates observed in this population, which hover closer to % (nelson, shindel, naughton, ohebshalom, & mulhall, ; volgsten et al., ) . similarly, over % of respondents endorsed a "- " or worse on a scale from - to + to reflect the mental health impact that treatment suspensions have had. these findings mirror a survey of patients at a new york city fertility clinic finding that % reported being "very" to "extremely" upset over treatment cancellations [ ] . however, the current study extends these findings by conducting a more detailed assessment seek information or advice that can help me achieve pregnancy take time to understand, identify, or express my feelings try to find meaning in my experience try to grow as a person as a result of this experience accept the situation as it is decide that i don't care prepare myself for the worst tell myself that it would be for the best if i didn't get pregnant tell myself that having biological children is not important believe that everything will work out stay optimistic that my efforts will be successful fantasize about how things might turn out believe that i will feel better in time try to find humor where i can seek social support seek emotional support professionals (e.g., counsellor, doctor) seek emotional support from friends or loved ones seek emotional support on the internet (e.g., blogs, chatrooms) seek emotional support from others with similar experience practice self-care (e.g., meditation, watch movie) of the mental health impact of treatment suspensions, as well as factors moderating this impact. several variables were found to moderate the psychological impact of treatment suspensions. perhaps unsurprisingly, women who had been trying to conceive for a longer time reported a greater negative mental health effect of treatment suspensions. furthermore, while the number of confidants a person had was unrelated to the impact of treatment suspensions, women who reported better emotional support from their partner and others also reported a smaller negative mental health impact. this is consistent with prior research finding that better quality social support is associated with lower infertility-related distress [ ] . it is noteworthy that the mean number of reported confidants was very small and that only % of respondents reported that their confidants were at least "somewhat" helpful in their efforts to cope with fertility treatment suspensions. women found their partners to be somewhat more helpful, however, as % were rated as at least "somewhat" helpful. furthermore, only % of women endorsed seeking social support from friends and loved ones at least "often". overall, these findings suggest that quality social support is beneficial for women who are struggling with the stresses of infertility but that this is not available to most women. this is consistent with research finding that unsupportive social interactions are commonly reported by women struggling with infertility and that these interactions predict greater distress [ , ] . thus, interventions aimed at improving the quality of the social support that they receive from others may be beneficial for this population. for example, a recent pilot study [ ] found that couples experiencing infertility benefited greatly from sessions of interpersonal therapy, a therapeutic approach that is primarily focused on improving the quality of one's interpersonal relationships. furthermore, in this study, interpersonal therapy was found to result in significantly better outcomes when compared to brief supportive therapy. with regards to personality traits, defensive pessimism was associated with a greater decline in quality of life, as well as a greater negative mental health impact of fertility treatment suspensions. defensive pessimism is the tendency to, in times of uncertainty, focus on potential negative outcomes and have low expectations in an effort to avoid disappointment [ , ] . although this approach may prove useful in motivating an individual to take steps toward avoiding an unwanted outcome under certain circumstances (spencer & norem, ) , our findings suggest that it is maladaptive in the context of the largely uncontrollable condition of infertility. spearman correlations revealed that greater acceptance and benefit-finding were associated with a lesser mental health impact of fertility treatment suspensions while greater helplessness was associated with a greater negative impact. however, in a regression model including all three infertility-related cognitions as predictors simultaneously, only acceptance was found to be a significant predictor. the importance of illness acceptance-that is, the extent to which an individual changes their focus from the elimination of their illness to living as well as possible with their illness-has been shown to be a strong predictor of wellbeing among those living with chronic pain [ ] [ ] [ ] . consistent with this, meta-analytic evidence suggests that acceptance and commitment therapy (act) [ ] , which aims to foster greater illness acceptance and reduce illness-related avoidance, is an effective intervention for chronic pain [ ] . to our knowledge, only one case study has documented the use of act for infertility-related distress [ ] , with promising effects. with regards to coping strategies, seeking social support and endorsing greater optimism were associated with better outcomes. in contrast, avoidance of infertility reminders was associated with worse outcomes. this latter finding is consistent with prior research finding that the endorsement of an avoidant coping style has been associated with worse psychological outcomes in the context of infertility [ ] [ ] [ ] [ ] . furthermore, in one of the few existing longitudinal studies of coping and psychological outcomes in infertility, the avoidance of reminders and thoughts concerning one's infertility was found to be a mediator between baseline vulnerability for psychopathology and -month distress levels [ ] . interventions targeting avoidance as a coping strategy, such as acceptance and commitment therapy, may be well-suited for infertility-related distress. although avoidance is often a clinical target in cognitive behavioural therapy, most studies that have applied this treatment approach to infertility have not directly targeted infertility-related avoidance [ , ] . the current study findings should be interpreted in light of some limitations. first, it is a cross-sectional investigation, providing only a snapshot of the interrelationships between psychosocial factors and infertility-related distress in the context of the covid- pandemic. the sample size was somewhat limited and is also not guaranteed to be representative of all women under similar circumstances-potentially, more distressed women were compelled to complete the survey as it appeared on their facebook feed. nonetheless, it provides some valuable insights into the emotional challenges that the covid- pandemic has introduced in the lives of women struggling with infertility. furthermore, it points to several targets for future interventions specifically targeting infertility-related distress. in summary, the current study suggests that the suspension of fertility treatments have had a significant negative impact on women's mental health and quality of life. low defensive pessimism, high-quality social support, greater infertility acceptance, and less use of avoidance, were all found to be protective factors against the negative effects of treatment suspensions on wellbeing. these findings suggest that additional mental health resources are likely to be needed in this population; they also suggest that infertility-specific psychological interventions should target social support, infertility acceptance, and infertility-related avoidance. supporting information s file. the infertility coping questionnaire, developed by the research team for the purposes of this study. 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patients with chronic pain: empirical evidence and reappraisal a prospective analysis of acceptance of pain and values-based action in patients with chronic pain. health psychology acceptance and commitment therapy: altering the verbal support for experiential avoidance acceptance and commitment therapy versus traditional cognitive behavioral therapy: a systematic review and meta-analysis of current empirical evidence. international journal of psychology and psychological therapy using acceptance and commitment therapy to treat infertility stress the psychological well-being of infertile women after a failed ivf attempt: the effects of coping counselling in infertility: individual, couple and group interventions. patient education and counseling gender differences in how men and women who are referred for ivf cope with infertility stress resilience and social support promote posttraumatic growth of women with infertility: the mediating role of positive coping psychosocial vulnerability, resilience resources, and coping with infertility: a longitudinal model of adjustment to primary ovarian insufficiency treatment of depression and anxiety in infertile women: cognitive behavioral therapy versus fluoxetine psychotherapy for infertility: a cognitive-behavioral approach for couples we thank tianna sauer for her help with data collection. conceptualization: jennifer l. gordon, ashley a. balsom. key: cord- -vgjz ts authors: nan title: th international congress of the european association for endoscopic surgery (eaes) sevilla, spain, – june date: - - journal: surg endosc doi: . /s - - -x sha: doc_id: cord_uid: vgjz ts nan laparoscopic cholecystectomy is one of the most commonly performed operations worldwide. bile duct injury (bdi) is a rare but very serious complication of the procedure, with a significant impact on quality of life and overall survival. the high frequency of bdi with laparoscopic cholecystectomy was first considered to be a consequence of the initial learning curve of the surgeon, but it later became clear that the primary cause of bdi is misinterpretation of biliary anatomy. intraoperative cholangiography (ioc) has been advised by many authors as the technique reduces the risk of bdi. however, the procedure has inherent limitations and is therefore reserved for select cases. fluorescent cholangiography using indocyanine green(icg) is a novel approach, which offers real-time intraoperative imaging of the biliary anatomy. a comparative study was contacted by administering icg intravenously or intrabiliary during the operation. forty patients scheduled to undergo an elective lap. cholecystectomy were randomly divided in two groups: in group a icg was administered in a dose . mg in ml solution intravenously hour before surgery. in group b icg was injected intrabiliary in a . mg/ml solution mixed with the patient's bile. also, we observed and analysed the following parameters, liver function, b.m.i, asa score and possible complications, before and after operation. results: group a. intravenous icg was administered in patients. there was no any reaction and the extrahepatic biliary anatomy was identified well. there was no bdi or any complication related to the procedure. group b. icg was injected intrabiliary in patients during the laparoscopic procedure. in all but one patient the extrahepatic biliary tree was delineated very well. in one patient part of icg solution was injected into the gallbladder wall and this resulted in a partially confusing image. there was no bdi and no postoperative complication conclusions: fluorescence cholangiography can be used during laparoscopic cholecystectomy to obtain fluorescence images of the bile ducts following intrabiliary injection during the operation orintravenous injection h before the procedure. the later technique is more easy to perform and does not require catheterization of the biliary tree. endoscopia digestiva chirurgica, policlinico universitario ''a. gemelli'', rome, italy; ihu, strasbourg, france; camma group, icube, university of strasbourg, cnrs, ihu strasbourg, strasbourg, france; ircad, strasbourg, france; digestive and endocrine surgery, nouvel hopital civil, university of strasbourg, strasbourg, france; digestive and endocrine surgery, ihu-strasbourg, strasbourg, france aim: surgical societies are united in promoting the critical view of safety(cvs) during laparoscopic cholecystectomy(lc). nonetheless, reports have shown a discrepancy between the operative reports and the correct application of cvs, which may explain the stability of bile duct injury rates. therefore, surgeons and computer scientists at our institution are developing a machine-learning algorithm to automatize cvs assessment. however, the lack of a consistent cvs video assessment framework limits the ability to generate data to train the artificial intelligence. here we describe and test a method for cvs evaluation in videos. method: between march and july , consecutive videos of lc performed at nouvel hospital civil(strasbourg, france) were recorded. two independent reviewers assessed the achievement of cvs in the s video sequences preceding clipping of cystic duct and artery. in addition to the 'doublet view' method, a 'binary' video evaluation method was tested: each of the criteria composing the cvs( structures entering the gallbladder, clearance of the hepatocystic triangle and lower part of the cystic plate) was classified as achieved or not. if the criteria were met, then the cvs was considered achieved. inter-rater agreement for cvs and for each of the criteria was evaluated. results: twenty-two videos( fundus first and partial lc, and broken videos) were excluded from the cvs analysis. cvs elements were assessable in all but one s videos sequences( . %). after mediation, cvs was achieved in / ( . %) of lc. the cystic plate was identified in only . % of videos. inter-rater agreement using the doublet view vs. the binary method was as follows: . %(? = . ) vs. . %(? = . ) for cvs achievement, . %(? = . ) vs. . %(? = . ) for the structures, . %(? = . ) vs. . %(? = . ) for the hepatocystic triangle and . %(? = . ) vs. . %(? = . ) for the cystic plate ( fig. ) . conclusions: reliable cvs assessment is crucial to generate consistent data for machine-learning algorithms aiming at decreasing bile duct injury after cholecystectomy. our binary cvs video assessment method showed higher inter-rater reliability than the doublet view, originally described for assessment of photos. further studies are on going to validate the cvs assessment in videos and support our initial results. surg endosc ( ) the vital role of surgeries in healthcare requires a constant attention for improvement. surgical process modeling is an innovative and rather recently introduced approach for tackling the issues in nowadays complex surgeries, involving complex logistics, much technology, and large teams. surgical process modeling allows for evaluating the introduction of new technologies and tools prior to the actual development and is beneficial in optimization of the treatment planning and treatment performance in operating room. in this study, we first discuss the concepts associated with surgical process modeling, aiming to clarify them and to promote their use in future studies. next, we apply these concepts to analyze the procedure of challenging interventions, minimally invasive liver treatment (milt) methods, with the ultimate goal of improving and optimizing the treatment procedure. the procedure model of current treatment activities and planning of various milt methods and the associated techniques, are analyzed and combined into a generic procedure model of milt, which provides a firm foundation for qualitative and quantitative analysis of different milt procedures. the generic procedure model is validated by data from erasmus medical center (rotterdam, the netherlands) and oslo university hospital (oslo, norway) . the proposed procedure model is designed to be a basis for improvement of the procedure and to determine how and where the new technologies can be best, effectively and efficiently, employed in the clinical practices prior to and/or during actual development of the new technologies for milt. as a conclusion, the current work illuminates the importance of surgical process modeling for improving different aspects of treatment procedures and provides an overview of various modeling strategies that can be used to establish surgical process models. the generic procedure model of various milt methods, including laparoscopic liver resection, laparoscopic liver ablation and percutaneous ablation, is introduced and validated which is a basis for introduction of the optimized procedure model of milt objective: to determine the most appropriate time to start total laparoscopic living donor right hepatectomy (tldrh) based on the experience with laparoscopic liver resection (llr). summary background data accumulation of experience in llr is essential before starting tldrh to ensure donor safety. methods: we retrospectively reviewed data of and consecutive patients who underwent llr and donor hepatectomy, respectively, between and . operative outcomes of laparoscopic major hepatectomy (lmh) were compared between two periods based on tldrh introduction (phase i - vs phase ii . learning curve of llr was evaluated using the cumulative sum (cusum) method to determine the optimal time of tldrh introduction. conclusion: accumulating an experience of at least lmh cases is needed in low-volume lt centers before starting tldrh to ensure donor safety. introduction: the number of surgical adverse events is still too high. an important number of these adverse events occur within the operating room (or) and are in fact preventable. in order to reduce adverse events in the or, we simply need to know what went well and what can be done better. the aim of this study was to analyze and debrief a predefined selection of surgical procedures, with the use of an operating room 'black box', to identify commonly observed safety threats and resilience support events. methods: in the period - , predefined gastro-intestinal laparoscopic cases were recorded by the or black box'. the postoperative surgical team assessment record (star) questionnaire was used. the recordings were analyzed by specifically trained raters, using the systems engineering initiative for patient safety (seips) model of work system and patient safety to identify relevant safety threat and resilience support events. qualitative data analysis was used to identify the most commonly discussed events during the team debriefings. results: in only . % (n = ) of times or team members, when asked direct following surgery, indicated that they had noticed aberrations (n = ) during the case. a mean number of . (sd . ) relevant positive and negative events (e.i. aberrations) per surgical procedure were identified using the black box performance report. on average, . (sd . ) of events identified by the black box were rated as safety threats. most events discussed during the team debriefings were related to communication. conclusion: these results once again highlighting the importance of clear and closed-loop communication in the operating room. theatre staff underestimated the number of aberrations occurring in the or, when asked to retrieve from memory. postoperative structured team debriefing may be important for resolving incorrect assumptions between operating team members to avoid future unnecessary miscommunication. background: the eaes has recently published an intraoperative adverse event classification to assist the direct measurement and routine reporting of minimal access surgery interventions. we aimed to explore the clinically validity and reliability of the classification. methods: a prospective evaluation utilising case videos and clinical data from a completed multi-centre laparoscopic total mesorectal excision surgery randomised controlled trial was performed (isrctn ). enacted adverse events identified with the observational clinical human reliability analysis technique were graded with the eaes classification by two blinded, independent assessors. test-retest reliability was explored using grades previously applied during the development of the classification with intraclass correlation co-efficients calculated. clinical validity was assessed using -day morbidity events, the clavien-dindo classification and the highest eaes grade per case. results: laparoscopic cases ( h of surgery) contained error events which were all successfully categorised. excellent inter-rater and test-retest reliability was seen (icc . , % ci . - . , p \ . and icc . , % ci . - . , p \ . respectively. % of patients experienced post-operative morbidity (median event, range [ ] [ ] [ ] [ ] [ ] [ ] . labelling analysed cases by their highest eaes classification grade gave % grade , % grade and % grade procedures. % of grade cases developed a morbidity event, but this significantly increased in grade and operations ( % and %, p = . ). the number of complications and highest recorded clavien-dindo grade increased with each additional grade ( . ± . vs. . ± . vs. . ± . , p = . and median vs. vs. , p = . respectively). anastomotic leak and re-operation were correctly captured by the allocated eaes grade ( . % vs. . % vs. %, p \ . and % vs. % vs. %, p \ . respectively). there was a significant rise in length of stay observed with increasing eaes grade (median vs. vs. days, p \ . ). conclusion: in the context of major laparoscopic surgery, the eaes intraoperative adverse classification is seen to be a clinically valid and reliable assessment method. psychological medicine, nuhs, singapore, singapore aims: neurobiological feedback in surgical training could translate to better educational outcomes such as measures of learning curve. the variation in brain activation of medical students when performing laparoscopic tasks before and after a training workshop is not properly studied before and we planned to do this using functional near infrared spectroscopy (fnirs) which is a non-invasive optical brain imaging tool that measures cortical oxygenation change which is used as a marker of pre-frontal cortex activity (pfca). methods: this randomised controlled trial examined the pfc activity differences in two groups of novice medical students during the acquisition of basic laparoscopic tasks. 'trained-group' had standerdised oneto-one training on the tasks, while the 'untrained-group' had no prior trainining and was just shown a video of the tasks. the pfca was measured pre and post intervention using a portable fnirs device. primary outcome was the difference in the pfca pre and post intervention. secondary outcomes were the differences in pfca between the tasks and between the sexes. results: trained and untrained medical students with an equal sex distribution and a comparable age distribution were invovlved in the study. all students were right handed. trained group had a significantly attenuated pfca in the 'precision-cutting' (p = . ) and 'suture-insertion' (p = . ) tasks compared to the untrained group. subgroup analysis based on sex revealed significant attenuation in pfca in trained females compared to untrained females across of the laparoscopic tasks: 'pegstransfer' (p = . ), 'precision-cutting' (p = . ), 'suture-insertion' (p = . ). no significant pfca attenuation was found in male students who underwent training compared to untrained males. conclusion: a standardised laparoscopic training workshop promoted greater pfca attenuation in female medical students compared to males. this suggests that female and male students respond differently to the same instructional approach. these results may have implications for surgical training and education such as a greater focus on one to one surgical training for female students and use of pfca attenuation as a form of neurobiological feedback as a measure of learning curve in surgical training. robot assisted versus laparoscopic advanced suturing learning curve e. leijte , i. de blaauw , c. rosman , s.m.b.i. botden surgery, radboudumc, nijmegen, the netherlands; pediatric surgery, radboudumc, nijmegen, the netherlands aims: compared to conventional laparoscopy, robot assisted surgery is expected to have most potential in difficult areas and demanding technical skills as minimally invasive suturing. this study was performed to identify the differences in the learning curves of laparoscopic versus robot assisted advanced suturing method: novice participants, with the knowledge of basic surgical procedures, were recruited and performed three suturing tasks on the eosim laparoscopic augmented reality simulator or the robotix robot assisted virtual reality simulator. each participant performed an intracorporeal suturing, tilted plane needle transfer and anastomosis needle transfer task. to complete the learning curve, all tasks were repeated for maximal twenty repetitions or until a plateau was reached three consecutive times. clinical relevant and comparable parameters regarding time (seconds), movements and safety were recorded. intracorporeal suturing was used to visualize and compare the learning curves between the groups. results: forty-six participants completed the learning curve, of which laparoscopically and robot assisted. when comparing the suture time, the plateau was reached much faster in the robot assisted group ( - repetitions) than the laparoscopic group ( ) ( ) ( ) repetitions) as shown in figure . there was a significant difference in 'time per suture', during the whole learning curve with median values of versus (first knot), versus (fifth) and and (eighteenth), all with a p \ . . however, the parameter 'adequate surgical knot' was reached earlier in the laparoscopic group than in the robot assisted group. first: % versus %, fifth: % versus %, and eighteenth: % versus %. when assessing the 'needle out of view' parameter, the robot assisted group scored a median of . and . s during the first, respectively eighteenth knot, and the laparoscopic participants had their instruments out of view for and s during the first respectively eighteenth knot. conclusion: the learning curve of minimally invasive suturing can be reduced with the use of robot assisted surgery, with a specific reduction in operation time. the rate of adequate knots seemed to remain lower in robot assisted surgery, although this could be due to the virtual reality aspect of the simulator. introduction: endoscopic sleeve gastroplasty (esg) is a novel promising bariatric endoscopy treatment. gastric volume reduction and delayed gastric emptying are the mechanisms driving weight loss. however, little is known about the factors influencing the effectiveness of weight loss overtime. the present study aims at evaluating the correlation between endoscopic suture appearance and excess weight loss (ewl%) at and months follow up. patients and methods: all patients who underwent follow-up endoscopy at and months after esg were included. esgs were classified in groups according to endoscopic appearance of the gastric sutures: optimal (group ) when all stitches were in place and tights; suboptimal (group ) when one or more stiches were displaced; loose (group ) when all the sutures were completely disrupted. bmi at enrollment and ewl% at and months were recorded and compared to the endoscopic appearance. results: a total of patients were included in the analysis. at months, ( . %) patients had an optimal esg, ( . %) had a suboptimal sleeve and ( . %) had complete sutures failure. bmi at enrollment and ewl% were respectively . ± . and . ± . % for group , . ± . and . ± . % for group and . ± . and . % ± . % for group . twenty five patients had months egds: ( %) presented an intact esg and were classified in group , ( %) in group and ( %) in group . twelve months ewl% was respectively . ± . %, . ± . and ± . %. initial bmi significantly correlated with suture status at both (rho - . ; p \ . ) and months (rho - . ; p = . ) follow-up. furthermore, the sutures' appearance itself correlated with ewl% at both time points (rho ? . ; p = . and rho . ; p = . respectively). conclusion: our preliminary results show that the aspect of the endoscopic suture has a significantly impact on ewl% at and months after esg. furthermore, bmi at enrollment seems to predict endoscopic suture duration overtime. larger studies and longer follow-up are needed to further validate our preliminary findings. background and aim: endoscopic sleeve gastroplasty(esg) is a relatively novel endoscopic procedure that reduces the gastric lumen with proven less complications and less months weight loss compared to laparoscopic sleeve gastroplasty (lsg) . at present there are no studies investigating the role of multidisciplinary approach in esg. the aims of the present study were to evaluate the role of multidisciplinary assessment(ma) prior esg, weight loss outcomes, quality of live improvements and adverse events. material and methods: from may to may all patients that underwent esg were retrospectively evaluated from a prospective database. until september before esg only psychiatric evaluation was requested, while after this date we adopted the guidelines of the italian society for obesity surgery and all patients were evaluated on a multidisciplinary fashion prior esg. the multidisciplinary team was composed by:gastroenterologist, surgeon, psychiatrist, endocrinologist and dietitian. patients were divided in two groups:group were patients with esg before ma and group were patients with esg after ma. we compared this two groups in terms of weight loss outcomes, quality of live improvements and adverse events. quality of live was measured with the bariatric analysis and reporting outcome system(baros).all procedures were done with the apollo overstitch suturing system(apollo endosurgery) and a double channel gastroscope olympus tgif- (olympus japan).all procedures were done in general anesthesia and with insufflation of co . all patients had ambulatory visit t , and months after esg and weight loss outcomes were measured in terms of excess weight loss (%ewl),the total body weight loss (%tbwl) and baros scale were assessed. statistical analysis was done with chi-square test and \ . value was considered significant. results: patients were identified ( female; mean age . , range - ) . mean bmi at inclusion was . (range . - . ). mean %ewl and %tbwl at months was . and . respectively (table ) .non procedure related complications were observed. comparing the two groups there was significant(p \ . ) difference in terms of %ewl and %tbwl (table ) ,with better results in group . there was also a significant improvement in the baros scale in the patients in group . conclusions: ma before esg has a fundamental role in terms of better procedure outcomes for both weight loss and quality of live in obese patients. gastroenterology, hadassah medical center, jerusalem, israel, israel aims: the over-the-scope clip (ovesco) is a novel endoscopic tool that enables non-surgical management of gastrointestinal defects. the aim of this study was to report our experience with ovesco for patients with staple line leaks following laparoscopic sleeve gastrectomy (lsg). methods: a prospectively maintained irb-approved institutional database was queried for all patients treated with ovesco for staple line leaks following lsg from to . primary outcome was complete resolution of leak following ovesco as defined by return to complete oral nutrition and no evidence of leak on imaging. secondary outcome was the number of additional endoscopic or surgical procedures needed following ovesco. results: twenty-five patients ( males, females) were treated with ovesco for staple line leaks following lsg. the median age was years (range - ), and mean body mass index was kg/m . nine patients ( %) were referred from an outside hospital. the median time from index operation to leak diagnosis and from leak diagnosis to ovesco was days (range - ), and days (range - ), respectively. all patients had upper staple-line leaks near the gastroesophageal junction. initial treatment included antibiotics- patients; computed tomography guided drainage and antibiotics- patients; and laparoscopic drainage- patients. ovesco led to final resolution of leak in patients ( %) within days of clip deployment (range - ). leaks which persisted following ovesco were eventually resolved with a combination of ovesco and stent- patients ( %), total gastrectomy and esophago-jejunostomy- patients ( %), and endoscopic suturing- patient ( %). one mortality was noted in a patient who suffered multiorgan failure. the number of additional endoscopic sessions ranged from to (median ). no procedure related complications were noted. all patients were treated with total parenteral nutrition and the total length of stay was days (range - ). conclusions: despite its low success rate, ovesco should be part of the bariatric surgeon's non-surgical armamentarium in treating staple line leaks following lsg. r. bademci , r. vilallonga , p. alberti , r. renato , c. yuhamy , s.s. cordero , l. posadas general surgery, istanbul medipol üniversitesi, istanbul, turkey; bariatric surgery, vall d'hebron, barcelona, spain background: in cases of morbid obesity, treatment is generally applied as either a surgical or endoscopic approach. the number of primary obesity surgery endolumenal (pose) procedures is increasing but the reliability and effectiveness is unclear as yet. the aim of this study was to present a series of cases that required revision surgery due to pose failure and to reveal possible alternative surgeries. materials and methods: a retrospective comparison was made of the data of obese patients with pose failure and conversion to surgical procedures between and in respect of operation, medical illness and bmi results. results: the patients comprised % females, % males with a mean age of . ± . years and mean follow-up period of . ± . months. on average, patients lost . ± . kg, with an average excess weight loss of . %. conclusion: no firm conclusions can be drawn from such a small group. although sg seems to be a safe procedure and should be considered as the first technique to be applied following pose failure, it is possible to perform gastric bypass on patients with this endoscopic precursor. introduction: the population of post bariatric surgery patients is rapidly increasing worldwide. due to the altered anatomy post roux-en-y gastric bypass (rygb), conventional endoscopic management for choledocholithiasis is challenging. these patients are now commonly managed by means of a laparoscopic assisted ercp. although effective, this requires significant resource utilization and potential morbidity related to the need for surgical intervention. we present our preliminary experience with a purely percutaneous management of choledocholithiasis in bariatric patients post-rygb. methods: a retrospective single center review identified five patients with choledocholithiasis after bariatric rygb who underwent percutaneous cbd access and treatment by interventional radiology. four patients underwent percutaneous transhepatic cbd access while one patient underwent percutaneous trans-cholecystic cbd access. in three of the five patients conscious sedation alone was sufficient to perform the procedure. results: all patients had radiologically confirmed choledocholithiasis and were clinically symptomatic prior to intervention. the biliary tree was successfully accessed percutaneously and cleared in all five patients. in the four patients where a percutaneous transhepatic access was utilized, three patients required only fluoroscopic balloon sphincterplasty and sweep of the cbd to clear the ductal stones, while the fourth required percutaneous cholangioscopy assisted lithotripsy for clearance. in the fifth patient with non-dilated intrahepatic bile ducts a trans-cholecystistic approach into the cbd was utilized with percutaneous cholangioscopic assistance to clear the ductal stones. all procedures were completed successfully with no post procedure complications. conclusion: percutaneous clearance of cbd stones in bariatric patients presents a minimally invasive alternative to current surgical practice. the use of conscious sedation and the purely percutaneous approach may potentially reduce morbidity and resource utilization for this increasingly common clinical scenario. laparoscopic narbona-arnau procedure to control the gerd after lsg- years results of a prospective study i.c. hutopila, c. copaescu background: after the laparoscopic sleeve gastrectomy (lsg) alone or associated with calibration of the esophageal hiatus, for some patients the reflux symptoms worsen postoperatively due to development of a hiatal hernia (hh) or due to the recurrence of the hh previously repaired. for these situations, when the conservative treatment fails, are proposed some surgical solutions, one of them cardiopexy with teres ligament-narbona arnau. objective: is to establish a standardized laparoscopic technique for cardiopexy using the teres ligament (narbona arnau technique) and to analyze the procedure's outcomes. methods: the study was performed in a bariatric and metabolic center of excellence-ponderas academic hospital. all the patients undergoing narbona arnau procedure to control gerd after lsg since were included and prospectively analyzed. the selection criteria included lsg patients, presenting hh and symptomatic gerd. preoperative investigations were upper gastrointestinal endoscopy, radiological contrast study, ph-metry, computed tomography with oral contrast. results: patients were included into the study. gerd and hh were preoperatively documented in all the cases. one patient was excluded after years of follow up after being converted to a laparoscopic roux-en-y gastric bypass, for intense relux symptoms. no incidents during surgery. for cases laparoscopic narbona arnau technique was performed concurrent with re-sleeve gastrectomy and gastric curvature plication. without postoperative complications. postoperative follow-up at months, , and years, the percentage of patients without gerd symptoms and free of treatment with ppis was , %, , %, , %, respectively . %. at years postoperatively the upper gi endoscopy showed remission/ improvement of the degree of esophagitis for patients. for the same period of follow-up, the ph-metry highlighted a normal value of demeester score for . % o patients (all the patients had preoperatively high de meester scores). no objective signs of hiatal hernia recurrence at imagistic investigations and upper gastrointestinal endoscopy were encountered. conclusions: complete preoperative evaluation is mandatory for choosing the optimal intervention. laparoscopic narbona arnau technique after lsg is proved to be a good option for the treatment of symptomic gerd, but further studies with high-volume patients are necessary. introduction: the aim of this study was to investigate the influence of baseline glycated hemoglobin level (hba c) level in bariatric patients on postoperative outcomes. we found scarce of clinical data regarding influence of baseline hba c on bariatric surgeries postoperative morbidity and readmission what was inspiration to conduct this multicenter retrospective study. methods and procedures: retrospective cohort study analyzed patients who underwent laparoscopic: sleeve gastrectomy (sg), roux-en-y gastric bypass (rygb) or mini-gastric bypass (mgb) for morbid obesity in seven referral bariatric centers. patients were divided into groups depending on preoperative hba c : hba c \ . %; . - . % and c . %. primary endpoints: influence of hba c level on perioperative ( -days) and postoperative ( -months) morbidity rates, operation time, length of hospital stay (los) and readmission rate. results: study group included , % females and % males. median age was ( - ) years. median hba c was . ( . - . ). hba c \ . % was present in % patients, hba c . - . % in %, and hba c c . % in %. percentage of male patients increased in groups from % in hba c \ . % to % in hba c c . % significantly. same tendency through groups we observed in case of bmi and age. uncontrolled diabetes (hba c c . %) was present in . % patients, while . % patients were not on antidiabetic medications despite having hba c c . %. median operative time in patients was significantly longer than in hba c \ . % and hba c . - . %. -days morbidity rate was . % and did not differ groups significantly, as -months morbidity rate (excl. -days) of . % . los did not differ groups significantly. patients having hba c in range of . - . % and with hba c c . % did not have significantly increased odds for perioperative morbidity, -months postoperative morbidity as compared with those with hba c \ . %. patients with hba c c . % had increased or for prolonged los as compared to those with hba c \ . % (or . ; % ci . - . ). hba c did not influence or for readmissions. patients with baseline hba c c % had significantly increased chances for hospital readmission (or . , % ci . - . ). conclusion: baseline level of hba c did not influence chance for perioperative morbidity, -months postoperative morbidity and prolonged los. patients with hba c c % have increased chance for hospital readmissions. surg endosc ( ) :s -s introduction: surgical resection is crucial for curative treatment of rectal cancer. through improvements in treatment and minimally invasive techniques, -year survival improved to over % of patients. the most recently introduced surgical technique is robotic-assisted surgery (ras). ras and conventional laparoscopy (cl) seem equally effective in terms oncological control. however, ras possibly provides further advantages e.g. d vision or the endowrist function, which have the potential to maximize the precision of surgery and thus has benefits for functional outcomes such as sexual function as well continence. therefore, the aim of this systematic review and meta-analysis was to compare functional outcomes of cl and ras for rectal cancer. materials and methods: this review was done according to the prisma and amstar guidelines andregistered with prosper-o(crd ). the search was planned with the pico criteria and conducted on medline (via pubmed), web of science and central. two independent reviewers first screened titles and abstracts and then eligible full-texts. inclusion criteria were original studies, comparative studies for cl vs. ras for rectal cancer as well as reporting of functional outcomes. quality assessment was done with the newcastle-ottawa-scale for non-randomized studies and the cochrane tool to assess risk of bias for randomized trials. results: the search retrieved hits, of which studies with patients met inclusion criteria. preliminary results yielded a lower rate of urinary retention for ras (odds ratio (or)[ %-confidence interval (ci)] . [ . , . ] ) while there were no differences for ileus (or[ci]: . [ . , . ] ). erectile function (iief) showed no differences after (mean difference (md)[ci] . [- . , . ] , (md[ci] . [- . , . ] ) and months (md[ci] . [- . , . ] ). in terms of urinary problems (ipss) there were no differences postoperative (md[ci] - . [- . , . ]) and month postoperative md[ci] - . [- . , . ] ), but advantages for the cl group after months md[ci] - . [- . , - . ] ). discussion: ras and cl seem to provide similar functional outcomes after rectal cancer surgery. however, the results need to be interpreted carefully as none of the studies had any functional outcome defined as primary endpoint. future studies should evaluate both surgical approaches in terms of functional outcomes and should be appropriately powered. methods: from april to november , laparoscopic right colectomy with intracorporeal anastomosis were performed in our surgical department. all patients in both groups were perioperatively managed using an eras pathway. seventy-two patients had the enterotomy closed with a single layer running suture of filbloc tm (assut europe). these patients were matched with patients who underwent intracorporeal right colectomy with enterotomy closed with a 'hybrid' double layer technique (first layer interrupted stitches in maxon tm - (covidien), second layer using a running suture in pds tm .intraoperative variables, anastomotic leak rate, morbidity and mortality rates were analyzed. results: the two groups were homogeneous with respect to demographics, body mass index (bmi), american surgical association score (asa) as well as for tumor stage. in the barbed group, median operating time was . min vs . min in the hybrid group (p = . ). anastomotic leak occurred in ( . %) patients in the hybrid vs ( . %) patients in the barbed group (p = . ) all patients required a reoperation. intraoperative findings at shows in ( . %) cases in the hybrid group a leak at the enterotomy closure, while an intact staler access was observed in both patients in the barbed group. no difference was observed with respect to non-infectious complications between the two groups (p = . ). patients in the hybrid group experienced a longer hospital stay when compared to the barbed group (p = . ). a re-admission occurred in the hybrid due an intraabdominal collection, while no re-admission was observed in the barbed group. no patient died in the postoperative period. conclusion: our results shows that the use of knotless barbed suture for enterotomy closure after laparoscopic intracorporeal right colectomy is safe, reproducible and associated with shorter operative time. aims: the accurate measurement and staging of rectal cancer, in particular the distal margin of low rectal tumours, is of paramount importance to optimise oncological surgical resection whilst preserving function. it is well recognised that the lower the tumour, the greater the technical challenges, operative time and the possibility of a temporary or permanent stoma. accurate localisation of the tumour is also essential to assist the multi-disciplinary team when considering neo-adjuvant chemoradiotherapy (crtx). the objective was to compare tumour height as reported on magnetic resonance imaging (mri) with endoscopic measurement. methods: a retrospective analysis of rectal tumour heights on pre-operative endoscopy and mri in patients undergoing radical colorectal surgery with curative intent over years from january . rectal tumours were identified as within cm of the anal verge (av). all mri measurements were reported by one of two specialist gastrointestinal radiologists. measurements were taken from the lowermost point of the tumour to the av. endoscopic measurements were as recorded by endoscopists including rectal surgeons, general surgeons, gastroenterologists and a clinical nurse specialist endoscopist. results: records of eighty one patients with histologically confirmed rectal adenocarcinoma were reviewed. median age was years ( to ). twenty three patients had or more endoscopies. on mri the median tumour height from the av was . cm ( . - cm) . on endoscopy the median tumour height was cm ( - cm) . on comparing endoscopy with mri, the median difference was cm ( - cm) . for over a third of patients ( %) tumours were lower on mri than endoscopy, median difference . cm ( . - cm) . only rectal surgeons documented tumour height in relation to the rectal folds. the majority of the repeat endoscopies were performed by surgeons to locate tumours more accurately pre-surgery. on no occasion was it documented whether the tumour had been measured during insertion or withdrawal of the endoscope. conclusions: precise localisation of rectal tumours is imperative to plan complex surgery and give informed counsel to patients. this study demonstrates the urgent need for a standardised protocol for all endoscopists to use while recording the distal extent of rectal tumours. objectives: the aim of the present rct was to compare the incidence of genitourinary (gu) dysfunction after elective laparoscopic low anterior rectal resection and total mesorectal excision (lar ? tme) with high or low ligation (ll) of the inferior mesenteric artery (ima). secondary aims included the incidence of anastomotic leakage and oncological outcomes. background: the criterion standard surgical approach for rectal cancer is lar ? tme. the level of artery ligation remains an issue related to functional outcome, anastomotic leak rate, and oncological adequacy. retrospective studies failed to provide strong evidence in favor of one particular vascular approach and the specific impact on gu function is poorly understood. methods: between june and december , patients who underwent elective laparoscopic lar ? tme in italian nonacademic hospitals were randomized to high ligation (hl) or ll of ima after meeting the inclusion criteria. gu function was evaluated using a standardized survey and uroflowmetric examination. the trial was registered under the clinicaltrials.gov identifier nct . results: a total of patients were randomized to hl (n ) or ll (n ). gu function was impaired in both groups after surgery. ll group reported better continence and less obstructive urinary symptoms and improved quality of life at months postoperative. sexual function was better in the ll group compared to hl group at months. urinated volume, maximum urinary flow, and flow time were significantly (p \ . ) in favour of the ll group at and months from surgery. ultrasound measured post void residual volume and average urinary flow were significantly (p \ . ) better in the ll group at months postoperatively. time of flow worsened in both groups at months compared to baseline. there was no difference in anastomotic leak rate ( . % hl vs . % ll). there were no differences in terms of blood loss, surgica l times, postoperative complications, and initial oncological outcomes between groups. conclusions: ll of the ima in lar ? tme results in better gu function preservation without affecting initial oncological outcomes. hl does not seem to increase the anastomotic leak rate. introduction: robotic single-site cholecystectomy (rssc) has been known to have some advantages such as reducing stress of the surgeon compared to single incision laparoscopic cholecystectomy (silc). however, there are few studies comparing the perioperative outcomes of these two operative methods. patient and methods: between march and february , rssc and silc were performed for benign gallbladder disease in our center. propensity score matching was performed to control variables including sex, age, body mass indes (bmi), diagnosis, american society of anesthesiologist (asa) score and cohorts were selected among the silc group through : matching. the perioperative data of these patients were analyzed retrospectively. the diagnosis was classified into acute cholecystitis, chronic cholecystitis, and gallbladder polyp. results: patient demographics between the two groups were evenly matched. total operation time including docking time was slightly longer in rssc group ( . min vs. . min, p \ . ), but real working time except the docking or set-up was shorter in rssc group ( . min vs. . min, p \ . ). conversion to additional robotic arm or additional port was frequent in silc group ( vs. cases, p = . ). intraoperative bile spillage rate ( . % vs. . %, p = . ) and postoperative hospital stay ( . days vs. . days, p = . ) were comparable in both group. conclusion: both surgical procedures performed safely. but the rssc demonstrated the better performance of the operation with shorter working time and the advantage of overcoming unexpected difficulties during the surgery with low conversion rate compared to silc. even though laparoscopic cholecystectomy(lc) is the gold standard procedure for cholelithiasis, patients are still suffering from various causes of pain. one of main causes is high pressure by pneumoperitoneum which makes peritoneal stretching and diaphragmatic irritation. however, there are few well-designed studies for evaluating pneumoperitoneum. therefore, we conducted a study to compare the postoperative pain after lc at serial different pressure methods. a prospective randomised double blind study was done in patients with benign gallbladder disease. they were divided into groups. each patients underwent lc with different pneumoperitoneum method; group a: far-low ( - mmhg), goup b: low ( - mmhg) and group c: standard pressure ( - mmhg). three groups were compared for pain intensity, duration, analgesic requirement and complications. post-operative pain score was significantly least in far-low pressure group as compared to low or standard pressure group during late periods ( , h). but, there were no pain score difference between far-low and low groups during early period ( , , , h) even though scores of standard group were significant higher than those of low group. number of patients requiring rescue analgesic doses and intraoperative complications were not significantly different among groups. this study demonstrates reducing the pressure of pneumoperitoneum results in reduction in intensity of post-operative pain. this study also shows that low pressure technique is safe with comparable rate of intraoperative complications. however, in immediate postoperative period, there is limitaton of pain relief after low pressure surgery. therefore, there may need new alternatives for pain. background and aim: anatomical hepatectomy with the glissonian approach is widely accepted as an important technique to ensure surgical safety and curability of the carcinoma. however, the histomorphological structure of the hepatic connective tissue is not sufficiently understood by surgeons. this study aimed to clarify the hepatic connective tissue structure using modern tissue imaging and analytical techniques. materials and methods: in total stained thin slices were loaded onto the computer and were reconstructed as dimages and analyzed. results: when the liver capsule enters the liver at the hepatic hilum, it becomes a sheath which envelops the portal pedicle. the hepatocytes in a row that constitute the periportal limiting plate at the edge of the hepatic lobule are firmly supported by the framework of the reticular fiber. the hepatic lobule and the portal area are in contact via the periportal space of mall. the framework of the limiting plate plays a role of a capsule of hepatic lobule (proper hepatic capsule) on the side in contact with the portal area. the binding site between the hepatic capsule and proper hepatic capsule (ppbs) is loose binding and is a layer that is easy to apply to surgical procedures. in order to enter between the liver capsule which became the sheath of the portal pedicle and the proper hepatic capsule at the hepatic hilum, the liver capsule must be dissected to reach the surface of the proper hepatic capsule. then, on the one hand, the portal pedicle is firmly gripped and pulled, on the other hand, the hepatic parenchyma covered by the proper hepatic capsule is pushed to expand between the portal pedicle and the liver parenchyma. at this time, the portal area (glisson's sheath) branched from the sheath of the portal pedicle into the gap of the hepatic lobule breaks like a string. with this dissecting plane, dissecting layer can reach to the next branch of the portal pedicle without entering into the portal pedicle or liver parenchyma. conclusion: understanding the connective tissue constituting the liver and conducting surgery turns the laparoscopic systematic hepatectomy into a standardized procedure. background: postoperative pancreatic fistula (popf) is the primary contributor to morbidity after distal pancreatectomy (dp). to date, no techniques used for the transection and closure of the pancreatic stump showed a clear superiority over the others. this study aimed to compare the rate of popf after pancreatic transection conducted with the reinforced stapler (rs) and ultrasonic dissector (ud) following dp. method: consecutive patients underwent dp from to were retrospectively reviewed. we included dps where pancreatic transection was performed by rs or ud and excluded dps extended to the pancreas head. to overcome the absence of randomization, we conducted a propensity matching analysis according to risk factors for popf. results: overall, patients met the inclusion criteria. the rs was employed in patients and ud in cases. after the one-to-one propensity matching, patients were selected from each group. the matched rs and ud cohort have no differences in baselines characteristics except for the mini-invasive approach, that was more common in the ud group ( % vs. %, p = . ). overall, patients ( %) developed a popf, a grade b ( %) and ( %) a grade c. in the rs group the rate of popf was % (n = ) and the ud group % (n = ) with a p \ . . conclusion: the results of this study suggest that the use of rs for pancreatic transection, reduces the risk of postoperative pancreatic fistula. a randomized trial is needed to confirm these preliminary data. aim: this study compares clinical and cost outcomes of robot-assisted single port and open longitudinal pancreaticojejunostomy (rlpj and olpj) for chronic pancreatitis. single incision mis needs more manual skills than conventional multiport operation. the advantage of better operation course is d vision and dedicate instrument. this paper aims to evaluate the feasibility and safety of the robot-assisted single incision with single port platform for chronic pancreatitis. materials and methods: clinical and cost data were retrospectively compared between open and ralpj. we collected patients since july, to september, . the patient was supinely placed in reverse trendelenburg position. the assistant surgeon was located between patient's legs. under general anesthesia a trans-umbilical . cm skin incision was made. a single incision advanced access platform with lagis port, glove portÒ (nelis, s. korea) and gelpoint combined with the da vinci si and xi surgical system (intuitive surgical, sunnyvale, ca, usa) pure or plus one was performed. the three arms, no. , no. , and da vinci scope, were in dwelled through the glove portÒ. pneumoperitoneum of mmhg was established through the port. a rigid -degree up scope was used during operation. results: twenty-one patients underwent lpj: open and ralpj. no robot-assisted cases converted to open were noted. patients undergoing ralpj had less intraoperative blood loss, a shorter surgical length of stay, less postoperative pain and lower medication costs. operation supply cost was higher in the ralpj group. no obvious difference in hospitalization cost was found. conclusions: versus the open approach, ralpj performed for chronic pancreatitis shortens hospitalization, less postoperative pain and reduces medication costs; hospitalization costs are equivalent. a higher operative cost for ralpj is mitigated by a shorter hospitalization and less pain control. robotassisted puestow procedure using single port platform is feasible and safe method. the total procedures by da vinci robotic system are safe and easily performed in highly selected patients. general surgery, hospital universitario infanta sofia, madrid, spain; general surgery, hospìtal quirón la luz, madrid, spain aims: the concomitant presence of abdominal wall midline hernias and diastasis recti is frequent. diastasis recti might be a risk factor not only for having but for recurrence of midline hernias. most open surgical procedures not consider the treatment of both pathologies, nor laparoscopic most spread out approaches. the author presents a novel endoscopic, extraperitoneal and retromuscular hernioplasty technique and its preliminary results. methods: a serie of patients is presented. a ct abdominal wall study is performed preoperatively. they all presented abdominal wall midline hernias in presence of a [ . cm concomitant diastasis recti. there were females and males. a totally endoscopic, extraperitoneal and retromuscular repair was performed, that included a midline anatomic restoration, tension-free hernia gap closure, omphaloplasty and skin treatment, if needed in every case. the tension-free massive-meshed hernioplasty included a bilateral totally endoscopic posterior components separation when needed. no drainages were used. all procedures included a bladder catheterization. results: all patient were dispatched within a period under h. no reoperations were needed in postoperative period. postoperative pain was measured by an eva scale. % of the patients have no pain medication after - h dispatching from hospital. % of the patients have a skin suffusion or hematoma. a male patient presented a temporary abdominal asymmetry due to a unilateral posterior component added to his technique. the mean following-up is to months ( - months) . no recurrence was observed. conclusions: preliminary results demonstrate this new approach to be a safe, feasible and a reproductible procedure. the 'terra' novel technique could provide of a new minimally invasive approach to abdominal wall midline hernias repair in the presence of a diastasis recti. only time and new results can predict the spreading out of this 'third way'. results: this study comprised males and females. mean age was years (range - years) and mean body mass index was . gh and mh were found intraoperatively in and cases respectively. mean operative time for all hernias (gh/mh) was min (range - min); min for gh (range - min); and min for mh (range - min). in . % of cases, hernia operative measurement was larger than preoperative size, especially in cases of incisional hernias ( . %). in . % of cases, laparoscopy found additional abdominal wall defects previously undetected by physical examination and by us-and/or ct-scan. a composite mesh and a non-composite mesh (up to cm in size) were used in . % and . % of cases respectively. the ethicon securestrap?? absorbable fixation device straps for sm fixation were employed in . % of cases. mean length of hospital stay was . days. mean follow-up time was months (range - months). in our study, there was one early (\ days) postoperative seroma ( . %), plus one late, small ( cm) symptomless recurrence, but neither needed reoperation. conclusion: the sutureless sm technique facilitates intra-abdominal introduction, as well as the handling and fixation of large/very large meshes. this new approach is safe and fast, even in cases of gh/mh repair. aims: any ventral hernia (vh) combined with rectus muscle separation (rms) must be repaired along with repairing the rms, otherwise there is a high risk for hernia recurrence. open rms repair is vast and traumatic surgery and laparoscopy is not effective. at a new era of repairing abdominal wall hernia by assisted endoscopy started with wolfgang reinhold's milos procedure. these procedures are somewhat complexed and real reconstruction of the linea alba (la) was limited, which done better by ferdinand koeckerling's elar technique. we perfected the elar technique to be fully endoscopic with wide mesh fusing to the muscles immediately by fibrin glue: extended endoscopic hernia & linea alba reconstruction glue (eehlarglue), achieving a low traumatic mis for vh and rms with excellent surgical and cosmetic results. methods: our eehlarglue is a totally endoscopic based technique used since . penetrating with optiview trocar and co pressure to the anterior rectus sheet (ars) level is followed by an extensive endoscopic dissection of the sub-cutaneous fat tissue from the ars. three trocars are inserted at the supra-pubic line enabling the dissection up to the xiphoid and costal margins laterally. any hernia sac is dissected, and the content reduced back to the abdominal cavity. relaxing incisions of the ars are performed longitudinally in the lateral aspect. the la is reconstructed by running two layers of non-absorbable sutures from xiphoid to pubis. a light mesh x cm is applied over the repair and the mesh is fused immediately to the muscles by fibrin glue. results: patients underwent the eehlarglue with follow up of months. all had significant rms of - - cm combined with primary or recurrent vh. recovery was smooth with - days of simple analgesics and return to regular activity within - days. no one had recurrent vh, but two males had limited rms and two early cases seroma formation. conclusions: our eehlarglue enables endoscopic vh repair and la reconstruction with extrastrength received by immediate mesh fusion to muscles with fibrin glue. thus, achieving low traumatic mis, easy recovering and very effective results-a perfect solution for patients with vh combined with rms. results: twelve blinded prospective rcts were used. when compared to tep repair, tapp repair has comparable seroma formation rates (chi = . ; (p = . ); ci - . , . ; i = %) and post-op pain at h (chi = . ; (p = . ); ci - . , . ; i = %). however, tep repair is associated with a significantly shorter operative time (chi = . ; (p = . );ci . , . ; i = %), post-op pain at hour (chi = . ; (p = . ); . , . ; i = %) and shorter hospital stay (chi = . ; (p = . ); ci . , . ; i = %). conclusion: tep is significantly better than tapp repair with regards to operative time, post-op pain at h and hospital stay. there is no significant difference with regards to post-op pain at h and seroma formation. background: primary hyperhidrosis (ph) is a neurological condition characterized by excessive sweating most often of the face, palms or axillae . palmar hyperhidrosis is treated through sympathetic chain clipping or transection .we aiming to compare the efficacy and results obtained with both techniques. patients and methods: sixty four patients underwent of sympathetic procedures from march to february . the patients were categorized into two groups: right sided transection sympathectomy and left sided clipping . patients were evaluated to compare the rates of success, satisfaction, compensatory sweating and recurrence either with transection or clipping of the t andt ganglion .mean follow up was ? _ months. results: sixty four patients males and females undergoing electro-coagulation sympathectomy on the right side and clipping on the left side. with mean age was years (range to years). all patients had balanced demographic data . no statistical difference between the two groups according rate of success. compensatory sweating was observed in patients ( . %) overall with cases of severe unsatisfied compensatory sweating. recurrence was reported in one case with transection and cases in clipping. satisfaction was occurred in cases in transection group and cases in clipping group .pnumothorax was occurred in cases in transection group compared to one case in clipping. no gustatory sweating and over dryness were reported in both groups. conclusion: both thoracoscopic sympathetic transection and clipping of t t ganglion are safe and effective procedure in palmar hyperhidosis treatment. with no differences regarding recurrence rate,satisfaction and incidence compensatory sweating. keywords: thoracoscopic sympathectomy,palmar hyperhidrosis, clipping, compensatory hyperhidrosis. introduction: primary ventral hernias and ventral incisional hernias pose a challenge for surgeons throughout the ages. even though minimally invasive surgery and hernia repair have evolved rapidly, there is no standardized method that adequately decreases postoperative complications. hybrid hernia repair is a surgical repair, which has not been adopted widely. it combines both a laparoscopic and open component allowing sac excision, primary defect repair as well as laparoscopic mesh insertion. aims: to evaluate the short-term and long-term outcomes of hernia recurrence for patients undergoing hybrid ventral repair (hvr) for the treatment of primary and incisional ventral hernias. methods: between october- and june- , hybrid vhr was performed in -patients at st mary's hospital, imperial college london. the medical records of these patients were reviewed retrospectively for demographics, comorbidities, prior surgeries, body mass index (bmi), hernial defects, hybrid technique used; mesh selection, operative time, complications and recurrences over a -year follow-up. results: twenty-four patients who underwent hybrid vhr were included with surgery performed by two surgeons. the mean age is -years with a mean bmi of . kg/m . % had incisional hernias and % had primary hernias. the number of hernia defects ranged from to , with the average mesh size used was x cm. extensive adhesionolysis was performed in % of patients. -day postoperative complications; patients developed post-operative seroma, paralytic ileus in , pain control in and urinary retention in patient. there were no conversions to open procedures. the mean length of hospital stay was -days. none of the patients developed chronic pain and only one recurrence over the -year follow-up period. conclusions: the hybrid technique for vhr is safe and feasible, and has important benefits over an open or purely laparoscopic approach, including a low rate of seroma formation, chronic pain and fiveyear hernia recurrence. future investigation may include randomized controlled trials, to fully evaluate the benefits of hybrid vhr, with careful assessment of patient-centred end-points including quality of life and postoperative pain. surgery, medical faculty-university of tetove, tetove, macedonia; general medicine, medical faculty-university of tetove, tetove, macedonia; anestesiology, medical faculty-university of tetove, tetove, macedonia; surgery, clinical hospital-tetove, tetove, macedonia laparoscopic cholecystectomy is widely used operative technique and it's characterized with less postoperative hospitalization and side effects. duration of the hospitalization after laparoscopic surgery depends on several factors of which pain and physical weakness are the most important. dexamethasone is well known; not only for its anti inflammatory effects but at the same time for analgesic and antiemetic effects, although the mechanism of this effects are not clarified yet. objectives: the aim of our study is the evaluation of analgesic effect of dexamethasone on reducing postoperative pain after laparoscopic surgery. patients and methods: in this study, patients aged - years old undergoing laparoscopic surgery, were classified into two groups, patients in each group. the first group were treated with a intravenous injection of mg dexamethasone preoperatively and another dose the next day after operation. the second group received a intravenous injection of normal saline. we evaluated the dose of consumed analgesics and antiemetic's drug during the first h in both groups. results: according to our experience results the total dose of tramadol in a postoperative period in dexamethasone receiving group was smaller than in normal saline group. measure of postoperative pain was assessed using the paper-based vas scale. our result shows that the intensity of post operative pain in a period during first h, after surgery in a group of patients treated with dexamethasone was lower compared with the group of patients treated with normal saline. nausea and vomiting during the first h was significantly lower in the dexamethasone group than in the normal saline group. surgery, hospital quiron sagrado corazon, sevilla, spain; surgery, hospital virgen macarena, sevilla, spain; surgery, hospital virgen del rocio sevilla, sevilla, spain aims: closing the defect (cd) during laparoscopic ventral hernia repair (lvhr) could be related to a reduction of seroma formation or bulging (hernia mesh) compared to conventional lvhr. but tension of the midline may contribute for some authors to a higher incidence of pain, recurrence in medium size defects and suggest to perform a component separation (cs) for restoring the midline in medium-large defects.we have developed a new technique for restoring the midline in medium ventral hernias (lira technique) and weanalyzed our results in terms of pain and recurrence compared to our conventional cd series (ccd). methods: we conducted a prospective controlled study of lvhr with ccd from january to december and a prospective controlled study performing lira technique from january to january . we analyzed and compared both techniques in medium size defects ( - cms) in terms of postoperative pain ( , days, , months and year) using a visual analogue scale (vas), bulging (return to prior distance among rectus muscles with the mesh in the sac in ct that didn't need surgical treatment)and recurrence (by physical examination and tomography). results: ccd was performed in patients (mean age was . ± . years old and mean bmi was . ± . kg/m ) and lira technique in patients (mean age was . ± . years old and mean bmi was . ± . kg/m ). the mean average follow-up in both series was year. mean average vas in ccd was . ± . ( day), . ± . ( days) . ± . ( month) . ± . ( months ) and at year. in lira series vas was . ± ( h) . ± . ( days), . ± . ( month), ( months) and ( year) . there are cases of bulging in ccd series and recurrence. bulging and recurrence were absent in lira series. conclusions: lira technique might be a safe procedure in medium size defects for restoring the midline in lvhr, and could be related to a lower pain rate compared to ccd with no recurrence or bulging. surg endosc ( ) :s -s background: the desire of pediatric surgeon to reduce incision related morbidity and pain while achieving good cosmetic results has recently led to the introduction of single incision pediatric endo-surgery [sipes] and needlescopic surgery. intracorporeal suturing and knot tying during sipes remains challenging. the aim of this study is to introduce a novel and simple technique for intracorporeal suturing of the pediatric inguinal hernia after needlescopic disconnection of hernia sac using just needles rather than laparoscopic instruments. it is an imitation of the principles of sewing machine. methods: the first author discussed the idea of the technique with the co-authors and a demonstration was done on a silicon pad before application of the technique on children with congenital inguinal hernia [cih] for peritoneum closure after needlescopic disconnection of the hernia sac. the main outcome measurements were; feasibility of the technique, knot quality, suture placement accuracy, performance and suturing time and recurrence rate. results: the sutures were snugly applied to the ridges of silicon pad with good approximation and the knot was firmly tightened in all experiments. after applying and mastering the technique on a silicon pad, we shifted to use it on children with hernia defect. all operations were completed by the needlescopic technique without the need for insertion of any laparoscopic instruments. the time required for suturing of the peritoneum around internal inguinal ring [iir] and knot tying, decreased considerably from min s in the first operation to less than min after the fifth operation and stabilized at approximately minute s. no major intraoperative complication and no recurrence. the primary end-point was to compare clinical outcome as well as cost effectiveness study between both groups. results: a total of patients were enrolled ( of them underwent tapp and olr). drop out occurred in cases ( of tapp and of olr group). patient characteristics were statistically similar between the groups. tapp procedure had less early post-operative pain (p = . ), a shorter length of stay (p = . ) and less postoperative complications (p = . ) when compared with the olr approach. a slightly higher recurrence rate in the tapp group was found. additionally, there is a trend towards a higher postoperative quality of life and less chronic pain in the tapp group. conclusions: tapp procedure for bilateral inguinal hernia effectively reduces early postoperative pain, hospital stay and postoperative complications. cannizzaro hospital, catania, italy aim: the purpose of this study was to evaluate the long-term results in terms of safety and efficacy of a new technique to repair incisional ventral hernias with a self-gripping mesh, after a mean follow-up period of months. methods: a retrospective, single-centre study was performed from june to june . all patients undergoing elective incisional ventral hernia repair were included. hernias were diagnosed based on clinical examination at the outpatient clinic. in case of doubtful diagnosis, ct-scan was used to confirm the diagnosis. the component separation technique and, when needed, tar were performed. the self-gripping mesh was placed in sublay position (overlap cm) with the self-gripping surface face down. in all cases drainage tubes were placed in retromuscular and supraaponeurotic position. the following characteristics were collected: age, sex, body mass index (bmi), smoking, comorbidities, number of previous surgical operations, defect size (ehs classification), mesh size, postoperative complications, duration of follow-up. all patients were interviewed by telephone every six months. when patients complained recurrence or other symptoms, visits were organized and when there was the doubt of recurrence a ct-scan was performed. results: a total of patients were included in this study, males, mean age was years. % of patients had bmi [ , smokers and diabetics were respectively % and %. the mean defect size was cm . component separation technique was associated with tar in patients. in cases the size of mesh was cm, while in patients the size of mesh was cm and in cases this was cm. in the other patients the mesh sizes were tailored to defect dimensions. subcutaneous seromas occurred in patients, they were treated conservatively in cases and with percutaneous punction in cases. long-term follow-up demonstrated recurrences in one case, while in another one ct-scan revealed a bulging. no cases of mesh infection, pain or sensation of mesh. conclusions: this study with a mean follow-up period of months demonstrated that the use of self-gripping mesh in sublay position is safe and effective to treat incisional ventral hernias. aim: morgagni hernias present technical challenges. the laparoscopic approach was described at first in , however, as they are uncommon in adult life and, little data exist on the optimal method of surgical management. this study purpose was to analyse a method for laparoscopic repair of morgagni giant hernias using laparoscopic primary closure. methods: this case series describes a method of laparoscopic morgagni hernia repair using primary closure. in all patients a laparoscopic transabdominal approach was used. the content of the hernia was reduced into the abdomen and the diaphragmatic defect was closed with a running laparoscopic suture using a self-fixating suture. clips were placed at the edges of the suture to secure the pledged sutures to both the anterior and posterior fascia. demographic data as age, gender and bmi were collected. operative data (operative time, rate of conversion, blood loss) and post-operative data (short and long term complications, length of hospital stay, need of readmission and reoperation) were recorded. results: retrospectively collected data about patients were analysed. there were ( . %) male and ( . %) females. the median bmi was . ± . kg/m . median operative time was ± min. there were no intraoperative complications nor conversion to open surgery. patients began a fluid diet on the first post-operative day and were discharged after a median hospital stay of ± . days. in a median follow up of months we did not observe any recurrences. conclusions: transabdominal laparoscopic approach with primary closure of the diaphragmatic defect is a viable approach for repair of morgagni hernia. in our experience, the use of laparoscopic transabdominal suture fixed to the fascia allowed the closure of the defect laparoscopically with minimal tension on the repairs. can we predict the success of the laparoscopic approach in the adhesive small bowel obstruction? c. tellez marques, e. sebastian valverde, e. membrilla fernandez, l. grande posa, i. poves prim general surgery, parc de salut mar-hospital del mar, barcelona, spain aims: the laparoscopic approach in the acute adhesive small bowel obstruction and internal hernias (asbo) has shown superior to laparotomy in terms of morbidity and hospital stay. especially, in patients who present simple adhesions or internal hernias. according to this, the aim of the study is to determine those preoperative factors associated with simple adhesions and internal hernias, and consequently, improve the success of the laparoscopic approach in asbo methods: a retrospective study of patients who underwent urgent surgery for asbo was conducted from january to may . we compare preoperative variables between single adhesions and internal hernias vs complex adhesions. a p value \ . was considered statistically significant. results: we analysed patients who underwent surgery for asbo, ( %) by laparoscopy and ( %) by laparotomy. conversion rate in laparoscopy was . %. . % of patients presented a single adhesion or internal hernia; and . % were considered complex adhesions. sex and age did not correlate with the type of adhesions. previous surgery (p \ . ), number of previous surgeries (p \ . ), asa (p \ . ) and previous abdominal wall mesh (p = . ) were significantly associated with complex adhesions. laparoscopy as the only surgical history was significantly associated with simple adhesions (p = . ). only appendectomy (p = . ) or supramesocolic (p = . ) previous surgeries tended to present single adhesions but it did not reach statistical significance. the need for intestinal resection was not related to the type of adhesions (p = . ). there was a significant correlation between the findings in the ct (computed tomography) and the type of adhesion found (p = . ). signs of ischaemia on ct were related to the need for intestinal resection (p \ . ). in the multivariate analysis, the number of previous surgeries, asa and ct scan findings were identified as independent factors related to the type of adhesion. conclusions: according to our study, a lower number of previous surgeries, asa i-ii and internal hernia in the ct scan are associated with single adhesions and internal hernias. patient selection is a key factor for the success of laparoscopic approach in asbo. aims: there aims of this study were: (i) to compare england with the united states in the utilisation of minimal access surgery (mas) and in-hospital mortality from four common abdominal surgical emergencies (appendicitis, incarcerated or strangulated abdominal hernia, small or large bowel perforation and peptic ulcer perforation). (ii) within england to evaluate the influence of mas upon in-hospital and long-term mortality. methods: between and , the rate of mas and in-hospital mortality for four abdominal surgical emergencies were compared between the united states and england. univariate and multivariate analyses were performed to adjust for underlying differences in baseline patient demographics. results: , admissions in england for four abdominal surgical emergencies were compared to an estimated , , admissions in the united states. after adjustment for patient demographics, mas was used less commonly england for three conditions; appendicitis (odds ratio (or) . , % ci . - . ), abdominal hernia (or . , ) and small or large bowel perforation (or . , ). in-hospital mortality in multivariate analysis, was increased in england compared to the united states for three conditions; abdominal hernia (or . , % ci . - . ), small or large bowel perforation (or . , ) and peptic ulcer perforation (or . , % ci . - . ). in england, after adjustment for patient demographics, open surgery was associated with increased in-hospital mortality for three conditions; abdominal hernia (or . , % ci . - . ), small or large bowel perforation (or . , % ci . - . ) and peptic ulcer perforation (or . , . similarly open surgery was associated with increased long-term mortality for three conditions; abdominal hernia (hr . , % ci . - . ) , small or large bowel perforation (hr . , % ci . - . ) and peptic ulcer perforation (hr . , % ci . - . ). conclusions: minimal access surgery was used less commonly and inhospital mortality was increased in england compared to the united states for common abdominal surgical conditions. given the benefits of mas shown in this large study, strategies to enhance adoption of mas in emergency conditions in england need to be optimised and include appropriate patient selection and improved surgeon mas training and experience. surg endosc ( ) :s -s background: in the treatment of inguinal hernias, there is little hard evidence concerning the economic reimbursement in the diagnosis-related-group (drg) era. factors that affect whether a hospital may earn or lose financially depending on open or laparoscopic approach is still underexplored. the aim of this study is to provide a reliable analysis of in-hospital costs and reimbursements in inguinal hernia surgery. methods: this retrospective study analysed the -year experience in inguinal hernia repair in patients undergoing open lichtenstein (ol), laparoscopic totally extraperitoneal unilateral (utep) or bilateral (btep) hernia repair. demographics, results, costs and drg-based reimbursements were recorded and analysed. results: during the study period, patients underwent ol, patients utep and patients btep. the average total cost amounted to eur in ol, eur in utep and eur in btep groups (p \ . *). the hospital reimbursement amounted to eur, eur and eur in the ol, utep and btep groups respectively (p \ . *). finally, the mean hospital earnings were eur, eur and - eur for each patient in ol, utep and btep respectively (p \ . *). conclusions: in-hospital costs were higher in utep and btep as compared to ol. the drg-based reimbursement provided adequate compensation for patients with unilateral inguinal hernia, whereas hospital earnings were profitable in ol group only, and led an overall financial loss in the btep group. surgeons should be conscious that clinical advantages of the laparoscopic approach are not adequately compensated for, from an economic point of view. aims: umbilical hernias are common anatomical defects in swine which become a suitable model for surgical training and research in the field of surgical meshes. the aim of this study was to develop a surgical protocol for a successful laparoscopic implantation of stem cell-coated surgical meshes. methods: large white pigs, weighing - kg and with congenital abdominal hernia were anesthetized for the surgical procedures. non absorbable polypropylene surgical meshes were coated with fibrin glue (fg) (control group) or with fg admixed with porcine bone marrowderived mesenchymal stem cells (fg/bm-mscs). approximation of hernia's borders was performed by intracorporeal suture. the meshes were carefully rolled inside the trocar for laparoscopic implantation. the surgical implantation was performed by laparoscopy using helicoidal staples. laparoscopic inspections and biopsies of the tissue surrounding the mesh were performed at , and days post-implantation. at day , the animals were euthanized and macroscopically evaluated. ultrasonography was used at day , , and to evaluate the size of the hernia. the biopsies were then processed for the histological analysis. results: ultrasonography demonstrated that the mean size of umbilical hernias before mesh implantation was . ± . cm. a decrease in hernia mean size was observed at day and . the laparoscopic procedures allowed a successful mesh implantation in all animals. in most of cases, the implantation site did not show excessive inflammation or tissue adhesions. but one animal showed hernia maintenance. one animal had peritoneal and implant-site infection. foreign body reaction was noted in the histological analysis, although no significant difference was found between the control, and bm-msc group. conclusions: the anatomical similarities between humans and pigs in umbilical hernias make this animal model useful to: i) improve minimally invasive surgical procedures for hernia treatment; ii) evaluate new surgical meshes, and iii) introducing stem cell therapy to hernia surgical repair. the laparoscopic approach is efficient and safe for the implantation of stem cellcoated meshes. gene and protein expression analysis are required to evaluate the molecular changes between the conventional and the stem cell surgical approach. aims: fluorescence angiography with indocyanine green (icg) is used as a marker in the assessment of tissue perfusion, being more frequently used in colorectal procedures. this technology has shown to be a good technique to reduce complications related to vascular supply to the anastomosis. in esophagogastric procedures blood supply to the gastric pouch, jejunum and esophagus could be evaluated by icg fluorescence imaging. it could be also used in bariatric surgery to evaluated the anastomoses, during gastric bypass, and blood supply to the gastroesophageal junction and the angle of his during sleeve gastrectomy. methods: we have collected data during gastric resection due to adenocarcinoma and bariatric procedures that were performed by the same surgeon, using icg fluorescence to evaluate blood supply. the icg was infused before performing the anastomosis in order to evaluate the need to change the transaction line (tl). we analyzed those cases in which the tl was changed and the number of leaks in those cases that we changed this line. results: all the cases were performed by laparoscopic approach: subtotal gastrectomy (sg), total gastrectomy (tg), gastric sleeve (gs) and gastric bypass. there were no changes regarding the tl before performing the anastomosis in any of the four types of procedures (sg, tg, gs, gb). in the analyzed data there is anastomotic leak in one sg procedure ( . %). conclusions: icg fluorescence angiography could be helpful in assessing blood supply during gastrointestinal anastomosis, although we have not find an influence in the results during bariatric and gastric procedures. however, we do not have the sufficient evidence to determine the value of this technology in this entities, being needed more volume and data to improve the significance of the results. aims: hyperspectral imaging (hsi) combines a spectrometer with a camera to analyze the tissues' optical properties in a broad wavelength range, without the need for a contrast agent. it provides extensive real-time information about tissue physiology, including oxygen saturation (sto ). fluorescence-based enhanced reality (fler) is a software solution providing a dynamic, quantitative analysis of the signal evolution of a systemically administered fluorophore, during fluorescence angiography (fa) . the aim of this study was to compare the performance of hsi and fler to assess bowel perfusion, in a porcine, non-survival model of bowel ischemia. methods: in pigs, an ischemic small bowel segment was created and imaged after hour of ischemia. the imaging modalities were applied sequentially to the same area.hsi was performed first, to acquire the sto spectra, by means of the tivita tm system (diaspective vision, pepelow, germany), which provides a spectral range of - nm and a nm resolution. subsequently, fa was performed using a nir-capable laparoscopic camera (d-light p, karl storz, germany), after intravenous injection of . mg/kg of indocyanine green (icg; infracyanine, serb, paris, france). the fluorescence flow was recorded during s, then the slope of the fluorescence flow was analyzed using a proprietary software to obtain a virtual perfusion cartography. the virtual cartography was overlaid onto real-time images to obtain the enhanced reality effect. ten adjacent regions of interest (rois) were selected from hsi datasets and were superimposed to fler-generated cartographies using a custom plug-in software function, allowing for a quantitative comparison of both imaging modalities. hsi was repeated after icg injection. results: the r correlation coefficient between hsi-sto and the fler slope was . . at control hsi after icg injection, the correlation coefficient dropped significantly (r . ). the interference of icg on hsi imaging was clearly identified in the spectral curves. conclusion: sto given by hsi provided results comparable to those obtained with fler in our bowel ischemia model, without the need to inject a contrast agent. icg interferes with hsi datasets, disrupting sto values. surgical treatment is one of the most effective options for treatment of giant hiatal hernia. laparoscopic approach became is a 'gold standard' over the time demonstrating all advantages of minimally invasive techniques over the open procedures. however the utility of robotic operations still remains controversial. aim of the study: evaluate the initial experience of robotic fundoplication in compare to laparoscopic procedures. materials and methods: since the january till the december of thirty operations were operated on. mean age was . ( - ), among them ( %) were female and ( %) were males. mean bmi was . ( . - . ) . laparoscopic procedures were performed in patients ( st group), robotic procedures with davinci system were performed in patients of the second group. nissen fundoplication modified was performed in patients, toupet fundoplication was used for patients. results: the median operative time in laparoscopic group was min, in robotic group- , min. there were no statistical differences between two groups (p = . ). blood loss was minimal in both groups. mean postoperative hospital stay was . days ( - days) in the st group and , days ( - days) in the second. there were no statistical differences between two groups (p = . ). postoperative course was uneventful in all patients of both groups. surgical stress response is associated with systemic inflammatory syndrome, sepsis, multiorgan dysfunction syndrome. robotic assisted surgery has been introduced to overcome the limitations of conventional laparoscopy. this technique has potential advantages over laparoscopy, such as increased dexterity, three-dimensional view, and a magnified view of the operative field. these advantages could result in limited intra-abdominal trauma and hence in attenuated surgical stress response over conventional laparoscopy. aims: this study aimed to synthesize data on the effect of robot assisted surgery on surgical stress response. methods: electronic databases were searched with the search terms 'surgical stress', 'stress response', 'oxidative stress', 'robotic assisted surgery', 'c-reactive protein', 'interleukin ', 'interleukin ','cortisol',;'oxidative stress markers', 'antioxidants', 'antioxidant status', 'mda', 'glutathione', 'cortisol', 'acute phase response' up to and including march . results: one hundred forty studies were identified and their title and abstract were reviewed. one randomized controlled trial, six non randomized comparative studies, one experimental study and one case report met inclusion criteria. data were discordant. one prospective trial concluded that cortisol and il- were lower in laparoscopic assisted distal gastrectomy compared with robot assisted distal gastrectomy in another study comparing robotic assisted laparoscopic radical prostatectomy with open radical prostatectomy based on plasma measurements of il- , il- a and c-reactive protein, it was demonstrated that robotic assisted laparoscopic radical prostatectomy induces lower tissue trauma than open radical prostatectomy. in another study, it was reported reduced expression of genes associated with surgical stress response in patients treated with robotically assisted radical prostatectomy compared with patients treated with open prostatectomy. the case report concerned a case of polymyalgia rheumatic after robotic assisted laparoscopic prostatectomy. the experimental trial demonstrated that cortisol and substance p were significantly higher with open thoracic approach versus robot assisted thoracoscopic oesophageal surgery. conclusion: further research is needed to elucidate the effect of robotic surgery on surgical stress, based on a well standardized protocol for the measurement of surgical stress response. purpose: tissue compression is essential to prepare the tissue for proper staple formation. this study evaluates the risk factors of compression injury on the circular stapling line in vitro. methods: to reproduce the artificial bowel wall, a collagen plate was prepared by mixing collagen extracted from porcine with glycerin. artificial collagen plates with mm and mm in the thickness were made for dry and healthy condition and immersed plates in the tap water for min to make wet and edematous condition. circular stapler (cdh a, ethicon, usa) was applied in the collagen plates (dry and wet condition) and optimal compressions. compression line was evaluated for compression injury score. risk factors for excessive compressions and unacceptable injury were analyzed. results: in the dry condition, optimal compression didn't cause unacceptable injury. in the wet condition, excessive compressions were occurred in . % with optimal approximation. unacceptable injury was significantly different in proper and excessive compression cases as . % and . %, respectively. on the univariate analysis, thickness ( mm), wet condition, proximal side, maximal compression, and excessive compression were associated with unacceptable injury. on the multivariate analysis using logistic regression model, excessive compression was significant independent factor to cause tissue injury (p \ . ) and this significance was also proved in the optimal compression group (p = . ). background: minimal invasive appendectomy gained much popularity due to its better cosmoses, early recovery and less wound site infections. single incision laparoscopic appendectomy (sila) has many disadvantages such as, long operative time, bad ergonomics, surgical site infections, high conversion rate and port site hernia. needlescopic appendectomy (na) using mediflexÒ facial closure needle expected to be more superior over sila. here in we compare our results of needlescopic appendectomy with single-incision one. material and methods: one hundred and twenty patients with acute non complicated appendicitis were randomly assigned to na and sila children for each group during the period between january to october . the main outcome measurements included, demographics, operative time, intraoperative complication, conversion rate, post-operative hospital stay, surgical site infection, port site hernia and cosmetic results. results: a total of children underwent appendectomy. there were children who underwent na and children who underwent sila. there were no difference in age ( . vs . years, p = . ), weight ( . vs . kg, p = . ) and hospital stay ( . vs . days, p = . ) between the two groups. there were no intraoperative complication during the two surgical approaches. operative time for na group is significantly shorter than single incision group ( . vs . min, p = . ). no single case of conversion in na group and cases needed conversion in sila group. seven cases of sila showed surgical site infection. cases of sila group presented with port site hernia. the na group was superior as regard ergonomics. the two groups showed equal excellent cosmetic results. conclusion: needles scopic appendectomy and sila are comparable as regard cosmetic results and hospital stay. na proved to be safe, applicable, repetitive and superior over sila as regard better ergonomics, less operative time, absence of surgical site infection and port site hernia. aims: to objectively analyze the surgical performance and surgeon's ergonomics in the use of a novel flexible laparoscopic instrument during intracorporeal suture, and compare it with the use of a conventional laparoscopic needle holder. methods: three experienced laparoscopic surgeons performed five laparoscopic sutures on an organic tissue using the novel flexible instrument (flexdexÒ) and five sutures using a conventional needle holder with axial handle. the new device is based on a mechanical design with no electrical components, which transfers the surgeon's hand, wrist, and arm movements to the instrument tip in an intuitive manner. the use of the instruments was organized in a random fashion. prior to the study, participants conducted a -minute training session with the new flexible instrument. execution time and quality of the suture were assessed for each repetition. besides, flexion and radioulnar deviation of the wrist were recorded using an electrogoniometer (biopac systems, inc.) attached to the surgeon's hand and forearm. the intensity of the forearm's muscle activation was also analyzed by means of a myo armband (thalmic labs). results: surgeons required more time to perform the intracorporeal suture using the novel laparoscopic instrument ( . ± . s vs. . ± . s; p \ . ), but the quality of the suture was similar with both instruments. the wrist flexion ( . ± . °vs . ± . °; p \ . ) and wrist ulnar deviation ( . ± . °vs . ± . °; p \ . ) were significantly lower when using the flexible instrument. during the suturing tasks, the use of flexdexÒ instrument led to a higher muscular activation of the flexor ( . ± . vs . ± . rms; p \ . ) and extensor ( . ± . vs . ± . rms; p \ . ) muscle groups of the forearm. conclusions: the presented novel instrument allows surgeons to perform robotic-like laparoscopic suturing. we believe that with a longer training period surgeons could potentially reduce surgical times with this device. the preliminary results of this study suggest that the use of this new instrument provides a quality of the suture similar to that obtained with a conventional laparoscopic needle holder and an ergonomically more adequate wrist posture. aims: the intraoperative real-time evaluation of tissue perfusion is one key element for successful visceral surgery. traditionally, tissue evaluation is performed visually by surgeons. newer devices for objective quantification have in majority been based on the application of the fluorescent dye indocyanin green (icg). a novel method derived from geographic research is hyperspectral imaging (hsi). the aim of this study was the evaluation of hsi as a promising method for the evaluation of tissue perfusion and its implementation in the evaluation of the gastric conduit during esophagectomy in a porcine model. methods: the hsi camera records a dimensional data cube from a dimensional surgical situs obtaining wavelengths between and nm. the absorption at different wavelengths is tissue-specific and influenced by the amount of oxygenated haemoglobin and other pigments. a software calculates different indices in real-time including oxygen saturation. a porcine model (n = ) is used for esophagectomy with gastric conduit formation. ischemia is induced artificially by magnets simulating staplers. different shapes of the gastric conduit and anastomosis formation are evaluated for perfusion metrics in order to obtain recommendations for the optimal formation of esophagogastrostomy. conclusion: hsi is a promising method for intraoperative evaluation of tissue perfusion that does not require application or injection of any agents. the preliminary results in this study showed that the gastric conduit receives its main blood supply from the gastroepiploic arteries and not via the mucosa. further results from the current evaluations enable formation of an optimized gastric tube and esophagogastrostomy in esophagectomy. surg endosc ( ) pediatric surgery, al azhar university, giza, egypt; pediatric surgery, beni suef university, beni suef, egypt background: varicocele is one of the most common causes of infertility. many surgical interventions are used for varicocele ligation including open and conventional laparoscopic multiport or single incision techniques. the aim of the study is to present a new needlescopic lymphatic sparing varicocele ligation using mediflexÒ facial closure needle and gauge vascular access cannula. material and methods: twenty-two male children with bilateral varicocele of grade ii-iii. all children were counseled by clinical examination, doppler ultrasonography, abdominal ultrasonography, and routine laboratory investigations. testicular lymphatics were delineated by subcutaneous injection of / cm methylene blue in anterior wall of the scrotum min prior to surgery. the testicular vessels (both vein and artery) were ligated one cm above the deep inguinal ring using two mediflex needles with preservation of lympatics. the main outcome measurements included; operative time, hospitalization, testicular atrophy, hydrocele formation, recurrence of varicocele and intra or postoperative complication. results: a total of twenty-two male children with grade ii-iii varicocele subjected to needlescopic lymphatic sparing technique. twenty one were bilateral. background and aims: even if the clinical outcomes of robotic rectal resections are under investigation, the related robotic costs have not yet been well addressed, and the differences between the robotic rectal resection costs and the laparoscopic approach are still not well known. we have therefore performed a prospective comparative study of robotic rectal resections (rrr) and laparoscopic rectal resections (lrr) performed at our centre with the aim to evaluate the cost-effective outcomes of robotic versus laparoscopic surgery. study design: this is an observational, comparative prospective non-randomized study which includes patients that underwent laparoscopic and robotic rectal resection reaching a minimum of months of follow up from february to march , at the sanchinarro university hospital, madrid. an independent company performed the financial analysis and fixed costs were excluded. outcome parameters included surgical and post-operative costs, quality adjusted life years (qaly), and incremental cost per qaly gained or the incremental cost effectiveness ratio (icer). the primary end-point was to compare clinical outcome as well as cost effectiveness study between both groups. results: a total of rrr and lrr were included. the mean operative time was significantly lower in the lrr approach ( versus min; p = . ). the main pre-operative data, overall morbidity, hospital stay and oncological outcomes were similar in both groups, except for the readmission rate (rrr: . %, lrr: . %;p = . ).the mean operative costs were higher for rrr ( . versus . €; p = . ); however, the mean overall costs were similar ( . € for rrr and . € for the llr; p = . ). mean qalys at year for rrr group ( . ) was higher than that associated with lrr ( . ) (p = . ). at a willingness-to-pay threshold of , € and , €, there was a . % and . % probability that rrr group was cost-effective relative to lrr approach. conclusion: this study provides data of cost-effectiveness differences between rrr and lrr approach showing a benefit for the rrr aim: the efforts were aimed to the introduction of novel surgical technologies to overcome the intrinsic anatomical and technical constraints of rectal surgery. this was the case of the introduction into the clinical practice of laparoscopy and later on of robotic surgery for rectal surgery. however, whether robotic surgery is actually superior to laparoscopy is still debated. the aim of this study was to compare d laparoscopy and robotic surgery for rectal cancer on technical and oncological outcomes. methods: this was a single-center, prospective, randomized controlled trial. all patients more than years of age undergoing elective surgery for rectal cancer situated from to cm from the anal verge were included. patients undergoing abdominal perineal amputation and/or with t and/or m tumours were excluded. patients were randomized before surgery into two arms: arms a ( d laparoscopy) and arm b (robotic), and gave their consensus to the study. demographic data, data regarding the tumour, operative and post-operative data were collected. patients with a follow up shorter than months were excluded as well. results: twenty patients were enrolled in arm a and in arm b in the period time of one year. patients' population of the arms was homogeneous as concerns demographic characteristics and stage of the disease. robot-assisted rectal resection results in comparable operative time ( . vs min; p = . ). the conversion rate was significantly lower for arm b ( vs p = . ). postoperative morbidity was comparable between groups. hospital stay was comparable but time required to resolve post-operative ileus was shorter in arm b ( . vs . days, p = . ). overall survival and disease-free survival were comparable between arms ( . % vs . %, p = . , and . % vs . %, p = . , respectively) conclusions: d laparoscopy and robotic surgery are two viable options for rectal surgery. robotic surgery can add some in terms of post-operative outcomes and ergonomics. aim: currently, robotic surgery for rectal cancer is a surgical operation that is being performed worldwide. we also introduced robotic surgery in . however, after robotic surgery, we observed a rise in creatinine kinase (ck), which is unlikely to happen in other surgeries. we studied the postoperative complications of rectal cancer patients who underwent either robotic surgery or laparoscopy during the same period of time. methods: from january to november , patients underwent surgery using robotassisted rectal resection (da vinci si cases and xi cases) and patients underwent laparoscopic rectal resection. in this study, abdominoperineal resection, intersphincteric resection, and lateral lymph node dissection were excluded. result: the operation time for the robotic surgery group was significantly longer than that for the laparoscopic group ( min vs. min; p \ . ). the ck value of the robotic surgery group on pod was significantly higher than that of the laparoscopic group ( iu/l vs. iu/l; p \ . ). in addition, one case of compartment syndrome was observed in the laparoscopic group. there were no significant differences in age, body mass index, intraoperative bleeding, tumor invasion depth, urination disorder, or postoperative hospital stay. in robotic surgery, it is considered that the increase in ck value is caused by the extended operation time, contact of the patient's cart with the left thigh of the patient, and the extra force applied to the abdominal wall caused by the displacement of the remote center. conclusion: in robotic surgery, it is suggested that the measurement of postoperative ck value is important. therefore, an attempt to shorten the operation time and paying attention to the surgical field are necessary to improve the outcomes. aims: anastomotic leak remains as one of the most important and life threatening post-operative complications in colorectal surgery. this complication has important consequences, both acute and long term, longer hospital stay, re-intervention, and increased morbidity and mortality. among all different circumstances that have been related to this entity, blood supply is an important factor that might have influence. fluorescence with indocyanine-green (icg) is used as a marker in the assessment of tissue perfusion in colorectal surgery which might reduce the numbers of leaks. methods: a multicenter analysis of the experience of centers in spain is collected in order to assess the value of icg in colorectal anastomosis. colorectal procedures were performed using icg to evaluate vascular supply in the anastomosis. icg was infused before performing the anastomosis analyzing the number of cases in which the transection line (tl) was changed. we also analyzed the number of leaks in those cases that we changed this line. results: out of the cases performed, cases were performed by open surgery, by laparoscopy, by single-port and with transanal total mesorectal excision(tatme). the following procedures were performed: right colonic resection(rc), splenic flexure partial resection(sf), left colonic resection(lc), subtotal colectomy(sc), total colectomy(tc), hartman reversal surgery(hr), low anterior resection with partial mesorectal-escision(lar) and ultra low anterior resection with total mesorectal-escision(ular). leak rate(lr) was . % ( . %rc, . %lc, . %sc, . %lar, . %ular). overall lr was . % in colonic surgery and . % in rectal surgery. the tl was changed due to icg in . % of the cases ( . %rc, . %sf, . %lc, % tc, . % lar, . % ular), being . % in colonic resection and . % in rectal resection. the relation between leaks and the cases in which the tl was changed, were % ( . %rc, %lc, . %ular). conclusion: icg fluorescence may play a role in anastomotic tissue perfusion assessment. the lr after colorectal surgery might decrease using icg to detect the proper tl before to perform the anastomosis. however, we do not have the sufficient evidence to determine that the changing transaction line can lead to avoid leaks. surg endosc ( ) aims: to analyse the value of postoperative day crp as an early predictor of safe discharge in robotic rectal cancer surgery. methods: a retrospective analysis was performed, including patients who had undergone robotic total mesorectal excision (tme) in a single centre over a -year period (may -september . patients who had a permanent stoma (abdominperineal resections or hartmann's procedure) were exluded from the study, leaving patients for further analysis. as the los is currently used as a performance tool in assessing outcomes in colorectal surgery (with a cut-off established at days), we compared the crp values in these groups. results: fourty one percent of patients were discharged home within days. they had an earlier peak of crp on postoperative day (pod) (median . , ) . the group of patients that were discharge home after days ( %) had a crp peak on pod (median , ). on pod , the group of patients that went home within days had a lower crp ( - -vs. - -) compared to the group of patients that were discharge after days, p = . ). conclusions: a crp peak on pod in robotic tme can predict an early and safe discharge (los within days). background: purposelateral pelvic lymph node dissection (lpnd) is suggested to treat suspected lymph node metastasis in pelvic side-wall in patients with rectal cancer who underwent preoperative chemoradiotherapy (crt). however, technical difficulties make it possible that lateral pelvic lymph nodes (lpns) are not dissected completely and, thus, remained in the narrow pelvis. near-infrared fluorescence imaging (fi)-guided surgery is expected to help visualization and complete excision of nonvisible lymph nodes during cancer surgery. this study aimed to evaluate the efficacy of fi using indocyamine green (icg) to identify lpns during robotic lpnd. methods: rectal cancer patients who were suspected lpn metastasis and had received preoperative crt were prospectively enrolled. icg in a dose of . mg was injected around tumor preoperatively. all procedures were performed with a totally robotic approach. after completing lpnd, fi was checked again for identifying remained lpns and resecting them completely. results: the lpns were successfully detected in ( . %) of the patients. however, after accounting for eight cases, having finished adjusting icg injection, the lpns were successfully detected in ( . %) of patients. the fi-guided lpnd group (n = ) showed similar mean operative time for unilateral pelvic dissection and complication rate, compared to patients who underwent conventional robotic lpnd (n = ). however, the mean number of unilateral harvested lpns was . in the fi-guided lpnd group, which was greater than the mean of . in the conventional group. lpn metastasis was identified in % of the fi-guided lpnd group, which was higher than that of the conventional group, . %. conclusion: fi-guided lpnd identifies lymph nodes in pelvic side-wall with great reliability. this contributes to increased number of lpns yield compared to conventional robotic lpnd. this technique should be considered to dissect them completely by preventing subsequent missing of nonvisible lpns. aims: to compare the medium-term oncological outcomes of laparoscopic total mesorectal excision (l-tme) vs. robotic total mesorectal excision (r-tme) for rectal cancer. methods: a retrospective analysis was performed including patients who underwent l-tme or r-tme resection between - . patients with disease stage iv at diagnosis or r resection were excluded. patients were initially included, and cases of r-tme were matched based on age, gender, stage and time of follow-up with an equal number of patientswho underwent l-tme. we compared -year disease free survival (dfs) and overall survival (os). in adittion, a multivariate analysis was performed in order to idenfity independent prognostic factors for -year dfs and os. results: pathological outcomes were similar between groups. however, major complications were lower in the robotic group ( . % vs. . %, p = . ), highlighting the anastomotic leakage rate, which was . % in the r-tme vs. . % in the l-tme group (p = . ). overall, the -year dfs rate was % in the laparoscopic group and % in the robotic group (p = . ). the -year os rate was % in the l-tme groups and % in the r-tme group (p = . ). for disease stage iii, -year dfs was significantly higher in the r-tme group. os was also significantly superior in the robotic group for every stage, reaching % in the stage iii. in the multivariate analysis, r-tme was a significant positive prognostic factor for distant metastasis (or . %ci . , . , p = . ) and os (or . %ci . , . , p = . ). conclusions: r-tme for rectal cancer can achieve better oncological outcomes compared to l-tme, especially in stage iii rectal cancers. the robotic approach has demonstrated to be a significant positive prognostic factor for local recurrence and overall survival, due to the better postoperative outcomes. however, a longer follow-up period is needed to confirm the oncologic findings. university hospital for visceral surgery, university of oldenburg, oldenburg, germany; bremen spatial cognition center, university of bremen, bremen, germany aims: in clinical settings, realistic assessment of one's own abilities can enhance performance and promote patient safety, especially in surgical residents, who inevitably have to acquire skills during real surgery. this study thus implemented the global assessment of laparoscopic skills (goals) questionnaire with the aim to explore divergences between resident self-evaluation and specialist's evaluation on laparoscopic performance, as a first step to implement the goals questionnaire as a tool for constructive and objective feedback. methods: between july and october , seven residents from the university hospital for visceral surgery at the pius-hospital oldenburg participated in this study. at the end of every laparoscopic operation where the resident acted as the primary surgeon, the resident and the supervising surgeon independently evaluated the resident's operative performance using the goals questionnaire. the five dimensions evaluated were depth perception, bimanual dexterity, efficiency, tissue handling and autonomy. a cumulative goals-score (with being the highest possible score) was calculated for n = laparoscopic operations. resident's year of training, the level of case difficulty and the type of laparoscopic procedure performed was also analysed. results: residents overestimated their laparoscopic abilities in . % of the operations (goals-scores: residents: median = , mean = . ; specialists: median = , mean = . ; p \ . ). residents in the first three years of surgical training were more likely to overestimate their performance (residents: median = . , mean = . ; specialists: median = , mean = . ; p \ . ) than those with more than three years of surgical experience (residents: median = , mean = . ; specialists: median = , mean = . ; p = . ). goals score differences did not depend on case difficulty and laparoscopic procedure. conclusions: surgical residents tend to overestimate their intraoperative laparoscopic performance when compared to specialist evaluation. overestimation was found to depend on one's own laparoscopic experience and seem to disappear with gained expertise. these results signify the importance of individually adapted training and the greater need for objective feedback for surgical residents. this approach could in return increase the skill acquisition rate of the resident and in return contribute towards enhancing patient safety. introduction: the delivery of safe surgical care is dependent of various, complex and interrelated factors. substantial data exist regarding the impact of training in human factor skills on surgical outcomes. however, except for the standardized time-out process, the best way to go about improving these skills remains unclear. the aim of this study was to gain more insights in the theatre staff's perception of human factors and their importance on surgical outcome in the operating theatre. methods: the surgical team assessment record (star) questionnaire was used to study the role of human factors, such as communication, situational awareness and organization, contributing to surgical team performance. the self-assessment questionnaire was filled out by the theatre staff, directly after the surgical procedure. conditional logistic regression was used to identify the impact of the role in the operating theatre on the yes versus no answers. results: some questionnaires were completed. the theatre staff rated their team's performance with a median of (iqr . , -point likert scale). the surgical fellows (n = ) rated their personal factors significantly lower compared to the rest of the operating team (median versus , p-value \ . ). the staff surgeon (n = ) indicated significantly more often that there were many distractions ( . %, yes n = ) and noticed aberrations ( . %, yes n = ) during the surgical procedure (pvalue \ . ) when compared to the rest of the operating team. most aberrations reported by the surgeons were related to technical performance. conclusions: human factors play an important role in the surgical environment. situational awareness may be less developed in members of operating teams, compared to the surgeon of that team. further work is needed to elucidate the impact of human factor skills on team performance. a team-based approach to safety interventions is recommended. future studies should determine what type of aberrations and distractions are most relevant and valuable to embark on with team training. dept. of digestive surgery, school of medicine, tokushima university, tokushima, japan; dept. of digestive surgery, tokushima university, tokushima, japan background: the qualitative evaluation for laparoscopic training of medical students was performed using rubric evaluation, and weak points in conjunction with the lack of anatomical knowledge were derived. to conquer these weak points, virtual reality (vr) ? augmented reality (ar) training for understanding of regional anatomy was investigated. materials and methods: one hundred and six students in th grade of tokushima univ. participated basic laparoscopic task training (gummy band ligation, beads transfer, delivery of beads, gauze excision) with training box and sham laparoscopic cholecystectomy with virtual simulator. rubric evaluation, as qualitative evaluation, which includes the evaluation standards for each maneuver were performed before and after basic task training and sham operation. the group which self-evaluation was higher in a rubric evaluation was investigated. the d image of vessels and bile duct obtained from mdct of real patient was projected in reality space with microsoft hololens. training of ar image using hololens was performed for understanding of regional anatomy. after training of regional anatomy with hololens, sham laparoscopic cholecystectomy was performed again, and quality of procedure was evaluated by rubric. anatomical questions were. results: rubric evaluation in basic task training showed no difference between self-evaluation and evaluation by tutor before and after practice. in sham laparoscopic cholecystectomy, several students showed higher score than tutor, especially in part of extension of operation field by elevation of the gall bladder, exposure of triangle of calot, and exposure of cystic duct. after ar training, all students showed high score in questions related regional anatomy during operation. especially, rubric evaluation of students who showed high self-evaluation in sham operation showed same score with tutor. conclusions: as rubric evaluation showed weak points of detailed parts of maneuver, and vr ? ar was useful for understanding details of regional anatomy for laparoscopic training. background: the eaes has recently published an intraoperative adverse event classification to aid reporting of minimally access surgery events. this includes capture of non-consequential errors. we aimed to investigate the clinical impact of these apparent 'near miss' events. methods: case videos and clinical data from a completed multi-centre laparoscopic total mesorectal excision randomised controlled trial was utilised (isrctn ). the eaes classification was applied by two blinded assessors to all enacted adverse events identified on video analysis using the observational clinical human reliability analysis technique. the total number of grade (non-consequential) errors were compared with the number and nature of day morbidity events (graded with the clavien-dindo system) and length of stay. results: cases ( h of surgery) contained error events of which ( . %) were classified as eaes grade (median per case, interquartile range - , range - ). there were significantly more inconsequential errors recorded in patients that developed any early morbidity event than those who had an uneventful post-operative recovery (median . (iqr - ) vs. ( - ), p = . ). a stepwise increase in the sum of eaes grade errors is seen for each additional day morbidity event reported ( . vs. vs. vs. , p = . ) and the highest clavien-dindo grade experienced ( vs. vs. vs. . p = . ). positive correlation is observed between the sum of eaes grade a errors and length of post-operative stay (r s = . , p = . ). conclusion: in the context of major laparoscopic surgery, near misses are commonplace and correlate with surgical outcomes. this may represent a novel surrogate assessment method for intraoperative performance. aims: diagnostic laparoscopy (dl) is an under-utilised procedure that can replace non-therapeutic exploratory laparotomies in many contexts. to date, no validated education programme for dl exists. this study seeks to evaluate the feasibility, acceptability and face, content, construct validity of the laplat curriculum (laparoscopic learning for abdominal trauma; a simulationbased curriculum for trauma dl). this is in addition to the development of a novel d-printed bench-top model for abdominal inspection. methods: this prospective and observational pilot study involved novice medical students and junior doctors. surgeons from the uk and international (n = ) were involved in a two stage delphi-process to determine the components of the training course which were used to formulate a final curriculum. in the absence of an adequate model for abdominal inspection, a novel dprinted abdominal inspection model was designed and produced. after an introductory familiarisation session as well as pre-course cognitive lectures, the novices performed tasks on a virtual reality and bench-top simulator with repetitions of each in a half-day session. outcome measures for construct validity were total time to complete task, accuracy, percentage of horizon maintained and economy of movement. face and content validity as well as acceptability was evaluated by a qualitative and quantitative survey. results: face, content and construct validity as well as acceptability was established. face validity was demonstrated in all components of the course (including pre-course cognitive content and technical tasks) in addition to content validity. all also met an acceptability threshold of / on a -point likert scale. one-way anova tests demonstrated construct validity in all tasks (p \ . ) with learning curves in reducing time observed. using a performance improvement metric, one-way anova tests showed similar rates of improvement per participant between most tasks (p [ . ). the course was rated overall mean . / (± . ). conclusion: this pilot study has demonstrated the feasibility, acceptability and face, content and construct validity of the laplat curriculum as well of the novel d-printed abdominal inspection model. randomised controlled trials are needed to establish higher-quality evidence, as part of a wider curriculum with transfer needed to the clinical environment. surgery, regional institute of gastroenterology and hepatology, cluj-napoca, romania; anesthesiology-surgical propedeutics, university of agricultural sciences and veterinary medicine, cluj-napoca, romania; radiology, regional institute of gastroenterology and hepatology, cluj-napoca, romania; urology, training and research center, prof. dr. sergiu duca, cluj-napoca, romania; general surgery, training and research center, prof. dr. sergiu duca, cluj-napoca, romania aims: to evaluate the benefits of systematical use of ex vivoliver model and ct imaging in the planning process for swine laparoscopic liver resections done by residents during training programs. methods: twenty four general surgery residents were equally divided into two groups: first one which performed laparoscopic liver resections without planning stage and the second one which systematically used anatomical data from a swine liver model and interactive ct scans d reconstructions. the planning stage included an interactive tutorial for establishing the strategy for the next resection followed by performing open liver dissection and the same resection on an ex vivoswine model. a total of twelve models were used during this step. afterwards, laparoscopic procedures were performed on sixteen anesthetized domestic pigs, two swine for every team, composed of three residents. both groups were part of a dedicated and continuous training program and used the same 'step by step' protocol for resections. results: the average time for imagistic planning was . min and for open dissection and resection was . min. all teams successfully completed the interventions and followed the standardized protocol without trainers' interventions and with no conversions. the second group obtained better results regarding the time needed for completion and blood loss. also, when the planning stage was applied the resection was more accurate and less functional parenchyma was removed. the 'warming up' by adding the imagistic and anatomical data to the core protocol offer more clarity before laparoscopic liver resections. this also makes an upgrade for our 'step by step' protocol and provides sufficient data to admit this planning stage as mandatory for laparoscopic liver resection on swine during a training program. introduction: submucosal tunnel endoscopic resections (ster) had been increasingly performed for treatment of gastric subepithelial tumors. one of the limitations for ster is the risk of incomplete tumor resection due to close dissection and bridging of tumor capsule. endoscopic full thickness resection (eftr) allowed complete resection of the tumor with margins to prevent recurrence. this study aimed to review the techniques and outcomes of eftr for treatment of gastric subepithelial tumors. method: patients who received endoscopic resection for gastric subepithelial tumors were recruited. the gastric subepithelial tumors were considered eligible for endoscopic resection with size \ mm. all patients received preoperative assessments including eus and ct scan to define the extend of tumors and the proportion of extra and intralumenal components. all the procedures were performed under general anesthesia with co insufflation. eftr started after injection with mucosal incision up to % of tumor circumference, followed by submucosal dissection to identify tumor margin. further dissection was performed using esd devices. after adequate exposure of lateral margins, incision into muscularis propria was performed to achieve full thickness resection. luminal defects were closed by either clips, clip-loop crown method or overstitch suturing. results: from to , patients received eftr for gastric subepithelial tumors. the mean age was . years, and were male. the gist were located at greater curvature ( ), cardia ( ) , lesser curve ( ) and antrum ( ) . the mean size was . mm ( - mm) . most of the eftr were performed in operation theatre while two were done at endoscopy. the mean hospital stay was . days, and mean operative time was min ( - mins). there was no conversion to laparoscopy. closure of luminal defect were performed mostly with clips ( ), followed by overstitch ( ) and clip and loop crown closure ( ) . most patients resumed full diet on day , and all the pathologies confirmed gist tumors with clear resection margins. conclusion: endoscopic full thickness resection is technically feasible and safe procedure for treatment of gastric gist. future research should focus on refining the techniques of eftr and closure of the defect. next generation endoscopic intervention (project engine), osaka university, suita, japan; gastroenterological surgery, osaka university, suita, japan; research & development, -d matrix, ltd., chiyoda-ku, tokyo, japan; research & development, fuso pharmaceutical industries, ltd., cyuou-ku, osaka, japan background: hemostatic peptides have received increased attention. self-assembling peptides (tdms) comprise synthetic amphipathic peptides that immediately react to changes in ph and/or inorganic salts to transform into a gelatinous state. since tdms do not carry a risk of infection, their clinical application as new hemostatic agent is expected to increase. the first generation of these peptides (tdm- ) is currently used as a hemostatic agent in europe. however, tdm- exhibits slow gel-formation and low retention capabilities on tissue surfaces. the second generation (tdm- ) was therefore developed to encourage faster gel-formation and better tissuesealing capabilities, and we subsequently verified its usefulness and increased performance relative to tdm- in preclinical open surgery. aim: the aim of this study was to verify the efficacy of tdm- in terms of its hemostatic effect in endoscopic surgery. materials and methods: evaluation of the hemostatic effect in endoscopic surgery (animal study) was performed using eight female ( kg) pigs in spine position. following systemic heparinization, we established a bleeding model by utilizing flexible endoscopic grasping forceps on the anterior wall of the stomach and duodenum. in the hemostasis method, an endoscope with a distal hood was brought into contact with the bleeding point, and ml tdm- was applied to the wound. after tdm- gelation, the endoscope was removed, and the acute hemostatic effect (after min) was confirmed. histologic evaluation was subsequently performed on resected specimens. results: in the endoscopic bleeding model, of the cases ( . %) showed complete hemostatic effects on the anterior wall of the stomach, whereas on the anterior wall of the duodenum, of cases ( %) showed complete hemostatic effects. moreover, none of the gels were displaced from the anterior walls of the stomach and duodenum, and histologic evaluation confirmed no infiltration of inflammatory cells. the new self-assembling peptide (tdm- ) displayed improved hemostatic effects relative to the previous generation (tdm- ) in endoscopic surgery. tdm- had potential usefulness for upper gastrointestinal bleeding. our future work will assess its usefulness for laparoscopic surgery. objective: indocyanine green (icg) is a dye used in medicine since the mid- s for different applications in ophthalmology, cardiology and hepatobiliary surgery; thanks to its selective hepatic uptake and biliary excretion, it can be used to evaluate hepatic function in patients scheduled for hepatic resection surgery. the aim of this study is to evaluate the efficacy and the feasibility of icg guided surgery in the intra-operative localization of liver tumors, comparing the pre-operative radiological aspect, the intra-operative visualization and the post-operative histopathological features of the tumors. materials and methods: icg was intravenously injected for a routine liver function test (limonÒ) in patients who underwent hepatic resection surgery for primitive and secondary liver tumors in the period between november and september . for each patient was performed an intraoperative visualization of the stain both in vivo and ex vivo, using a nearinfrared imaging system. all the images were recorded. results: a correct differentiation between liver parenchyma and tumor area was obtained in . % of cases. five patients were not evaluable due to widespread uptake or complete absence of uptake; it was probably the first cases enrolled in the study for which we were not able to set doses and timing of administration of icg. in patients in which the method had been feasible, we observed a prevalence of nodular pattern in patients with hepatocellular carcinoma ( %) and a predominance of rim pattern in both cholangiocarcinoma ( %) and metastasis ( %). furthermore, in patients with hccs well-intermediate differentiated (g -g ) was found predominantly a nodular pattern ( . %), whereas in poorly differentiated ones was prevalent a rim appearance ( %). regarding radiological correlations, the only one patient who presented an atypical radiological feature in pre-operative evaluation, showed a lesion with no icg captation in intra-operative visualization. conclusions: icg fluorescence imaging is a safe, minimally invasive and quite inexpensive method, that can be easily administered for routine evaluation of pre-operative liver function. it can be a useful support tool in the intra-operative detection of liver tumors, especially in laparoscopic surgery where it is not possible to directly touch the tissue. surgery, bundang cha medical center, seongnam-si, korea; surgery, severance hospital, seoul, korea; surgery, nhimc ilsan hospital, ilsan, korea; surgery, seoul national university bundang hospital, seongnam, korea; surgery, asan medical center, seoul, korea backgrounds & aims: robotic surgical system had been widely accepted in various surgical field with the expectations of overcoming the limitation of laparoscopic surgery. however, robotic liver resection had not generalized, so far. thus, this study aimed to evaluate the feasibility and safety of robotic major liver resection by prospective multicenter study. methods: from july to december , five surgeons who were novice in robotic liver resection but experienced a lot in open and laparoscopic liver resection in five tertiary hospitals performed cases of robotic major anatomical liver resection. perioperative patient's clinical data and surgical data were prospectively collected. results: cases of left hemihepatectomy, case of extended left hemihepatectomy, cases of right hemihepatectomy, cases of right anterior sectionectomy, cases of right posterior sectionectomy, and one cases of central bisectionectomy were performed. the most common indications were hepatocellular carcinoma for cases following intrahepatic cholangiocellular carcinomas for cases, liver metastases for cases, sarcoma for case, intraductal papillary neoplasms for cases, mucinous cystic neoplasm for case, hemangioma for case, and intrahepatic duct stones for cases. surgical resection margins for all tumor cases were negative. total average operation time was . ± . min and estimated intraoperative blood loss was . ± . ml (minimal to ml). in terms of severe surgical complication, there were cases of postoperative fluid collection treated with drainage and one case of bile leakage treated with percutaneous trans-hepatic biliary drainage. only one case out of cases was converted to the conventional open left hemihepatectomy because of bleeding. conclusions: in this study, robotic anatomic major liver resection might be safely performed even by robotic beginners but advanced open and laparoscopic liver surgeons. surgical technique: with the patient at °on right lateral decubitus, access is gained through the path of the percutaneous drainage catheter after opening of the aponeuroses of the oblique and transverse muscles of the abdomen. a mm laparoscopic trocar is inserted and a cavity is created with pneumoretroperitoneum at mmhg. it is accessed with an optic of °and mm, and the work space is extended with aspiration and hydrodissection. with mm grippers, the necrotic material is removed, washed and drained. a two light silicone probe is left, one light for drainage and another one for washing. results: the mean age was . background: minimally invasive surgery has achieved worldwide acceptance in various fields, however, pancreatic surgery remains one of the most challenging abdominal procedures. in fact, the indication for robotic surgery in pancreatic disease has been controversial. the present study aimed to assess the safety and feasibility of robotic pancreatic resection. methods: we retrospectively reviewed our experience of robotic pancreatic resection done in sanchinarro university hospital. clinicopathologic characteristics, and perioperative and postoperative outcomes were recorded and analyzed. aim: this work aims to study the contact pressure between the moving capsule and a synthetic small intestine in order to provide design guidance for prototyping the self-propelled capsule robot for small-bowel endoscopy. method: since small-bowel peristalsis consists of peristaltic contraction and wave distension, the contacts between the capsule and the small intestine are multimodal. we consider three contact cases for the capsule robot. case : the capsule moves on a flat small intestinal surface; case : the capsule moves in a collapsed intestine with a flat surface support; and case : the capsule moves in a surrounded small intestine. by considering these three contact cases, experimental testing and finite element analysis (fea) were conducted by measuring the contact pressure between the small intestine and the capsule. introduction: traditional laparoscopic instruments have limited degrees of freedom and are not ergonomic. this results in severe limitations in performing complex, and even simple tasks in surgery, limiting many surgeons from performing a variety of minimally invasive procedures. handx tm is a hand-held, electromechanical smart instrument with robot-like features. the instrument is composed of a sophisticated user interface that enables unrestricted hand movement, and a novel, motor driven articulating tool that is controlled by the interface. the instrument is . mm in diameter, lightweight, and can be easily moved between laparoscopic trocars and perform complex motions in the surgical field. after the regulatory process was completed we have tested the device clinically through a structured, approved, clinical trial. materials and methods: after irb approval patients were recruited to the trial. we have included a variety of procedures that require suturing and complex tissue manipulation. two experiences surgeons performed all procedures. after completing each procedure the surgeons completed a detailed standard usability (sus) questionnaire. results: procedures were completed successfully without complications or device malfunction. there were female and male patients with an average bmi of . procedures performed were right hemicolectomis with intra-corporeal anastomosis, paraesophageal hernia repairs and fundoplication, diagnostic laparoscopies, tapp procedures, ventral hernias with fascial suturing, and laparoscopic cholecystectomies. the average performance score was . / . the results suggest that the handx device is safe and easy to use and may offer a simple solution for enhancing minimal invasive surgery capabilities and possibly reduce conversion rates while maintaining current standard surgery flow.the handx could potentially extend the surgeon's abilities to access hard to reach anatomy and perform complex maneuvers and present a cost-effective alternative to large console-based robotic systems. objective: endoscopic submucosal dissection (esd) has become widely accepted treatment for rectum neuroendocrine neoplasm. the aim of this study is to evaluate the safety and efficacy of esd with dental floss-assisted suspension traction for rectal neuroendocrine neoplasm. methods: we retrospectively reviewed the medical records of the patients, who underwent esd for rectum neuroendocrine neoplasm at endoscopy center of zhongshan hospital, fudan university. the data of operation time, r resection and adverse events were collected analyzed.in dfs-esd group: after the mucosa was partly incised along the marker dots, the next step was to construct traction device, similar to others in esd, with dental floss and hemoclip. the dental floss was tied to any arm of the metallic clip. the hemoclip was attached onto the incised mucosa, another hemoclip was attached onto normal mucosa opposite to the lesion in the same way. the submucosa was clearly exposed with the traction of dental floss and the resection could proceed. results: patients were enrolled in the study. there were patients treated by esd with dental floss-assisted suspension traction and patients treated by conventional esd. the average tumor size was ( . ± . )cm in both group. the operation time was . ± . min in conventional esd group and ( . ± . ) min in dfs-esd group (t = . , p = . ). according to pathological grading about rectal neuroendocrine neoplasm, there were grade (g ) and grade (g ) in conventional esd group while grade (g ) and grade (g ) in dfs-esd group (? = . , p = . ). among cases in this study, all the basal resection margins were negative, the en blot resection rate was % and the curative resection rate was %. however, pathological results showed tumor tissue close to the burning margin in cases of conventional esd group and in cases of dfs-esd group (? = . , p = . ). conclusions: esd with dental floss-assisted suspension traction for rectum neuroendocrine neoplasm can assist exposing tumor borders, provide good vision during the procedure and offer clearer anatomic structure, so as to simplify operation, reduce operation time and ensure the negative basal margin. it is especially suitable to be promoted in primary hospitals. surg endosc ( ) aims: force feedback and assessment provides detailed insight into tissue manipulation skills. the aim of this study is to evaluate learning curves for basic laparoscopic skills based of force and motion learning curve patterns. morevover, we aimed to detect the favourable time span for this curriculum for each individual trainee. methods: in this prospective cohort study, first year surgical residents participated in a three week at home training course. a mobile box training was equipped with forcesense system for objective force, motion and time based assessment. the system provides seventeen unique metrics. the training goal was set by the mean score of proficient laparoscopic surgeons. each repetition was captured and made available for analyses. continuous force feedback was provided during training. curve fitting was used to estimate the learning curve plateau and the number of repetitions needed to approach the plateau phase and to reach proficiency level. finally, a comparisson between novices and experts was executed. results: a total of attempts, executed by residents were captured and analyzed. significant improvement of motion analysis parameters (e.g. path length and time) was observed for all training tasks, except for the fifth tasks. tissue manipulation skills (i.e. maximum and mean applied force) significantly improved by training tasks , and . learning curve analysis revealed various shapes and lengths of the individual learning curves. a large range in learning curve plateaus was found between trainees and between tasks. each trainee managed to accomplish the preset goals within three weeks. conclusion: force-and motion based assessment provides insight into both tissue manipulation and instrument handling skills. when combined in learning curve analysis, these parameters effectively show progression towards proficiency for each individual trainee over time. we emphasize the variation in learning curves between trainees. therefore, we recommend individually tailored courses provided with objective force-and motion-based learning curve tracking. aims: the posterior retroperitoneoscopic adrenal access represents a challenge in orientation and working space creation.the aim of this experimental acute study was to evaluate the impact of computer-assisted quantitative fluorescence imaging on adrenal gland identification and perfusion assessment in the posterior retroperitoneoscopic approach. methods: six pigs underwent synchronous (n = ) or sequential (n = ) bilateral posterior retroperitoneoscopic adrenalectomy (pra, n = ). fluorescence imaging was obtained via intravenous administration of ml of indocyanine green (icg) using two near-infrared camera systems. fluorescence-based visualization of adrenal glands before vascular division (n = ), after main vascular pedicle ligation (negative control, n = ) or after adrenal division (n = ) was followed by completion adrenalectomy. one of the animals had undergone icg injection h previously, during another study. the dynamic evolution of fluorescence signal intensity over time was recorded and analyzed using a proprietary software. the computed color-coded perfusion cartography was superimposed onto real-time images obtained by corresponding left (l) and right (r) camera systems. the slope of fluorescence signal intensity evolution over time in the regions of interest (roi) served to assess adrenal perfusion by means of quantitative fluorescence signal analysis. results: in the retroperitoneum, the adrenal glands were promptly highlighted after primary intravenous icg administration or showed an increase in fluorescence signal intensity upon reinjection (both glands in a recovery pig and one gland in the sequential approach). after left adrenal main vascular pedicle ligation, the gland displayed low perfusion (blue; rois a -a in figure ), while a weak fluorescence signal after completion adrenalectomy suggests perfusion via collateral vessels. with intact vascular supply, the caudal segment of the right adrenal (a ) gland showed a significantly higher perfusion rate (red) than the ischemic cranial segment (a ). quantitative analysis of logarithmic fluorescence intensity showed a statistically significant difference between perfused and ischemic zones (p = . ) allowing to assess gland vascularity. kidneys (k) and adrenal glands showed distinct perfusion curves ( figure ). conclusions: prior to dissection, fluorescence imaging allows to easily discriminate the adrenal gland from surrounding retroperitoneal structures. during adrenal gland surgery, icg injection complemented by a computer-assisted quantitative analysis helps to distinguish between wellperfused and low-perfused segments. giant adrenal tumors:technical considerations and surgical outcome a. giordano, g. alemanno, c. bergamini, p. prosperi, v. iacopini, a. dibella, a. valeri sod chirurgia d'urgenza, aou careggi, firenze, italy objectives: giant adrenal tumors are tumors with size more than cm. these are rare cancer associated with malignancy in % of cases. the size of these tumors is an important topic in literature because of their higher probability of malignancy and possible technical limitations of laparoscopic approach. we report our center's experience on laparoscopic adrenalectomy. materials and methods: in the last ten years we performed about adrenalectomies for benign and malignant adrenal tumors. of these were giant tumors. the medium size was . cm ( - cm). tumors were on the left adrenal gland and on the right. there were women and men, the average age was ( - years). of these cancers were laparoscopically removed and with open approach. cases of open conversion. results: betweenn the tumors laparoscopically removed we recorded cases of carcinoma, endothelial cysts, adenomas ( with aldosterone and with cortisol hypersecretion), myelolipomas, pheochromocytomas and metastases from lung carcinoma. the surgical outcomes in these patients were optimal in terms of good pain control and hospital stay (median days). the average time of the intervention was min with very low blood less ( ml). no postoperative complications were recorded. the removal of the adrenal gland necessitated or trocars. in the dissection and resection phases we always used radiofrequency scalpel. the follow up after and months didn't show local recurrences. conclusions: laparoscopic adrenalectomy offers significant advantages over the open approach. the size of these tumors is still at the center of debate for the choice of the technique. the tumor size is only a predictive parameter of possible malignancy. the laparoscopic approach is a safe and feasible method in terms of surgical and oncological outcomes also for the giant adrenal tumors, only if performed by expert surgeons and in high-volume centers. vascular or adjacent organs infiltration is a contraindication to the laparoscopic approach. aims: adrenal gland size greater than cm is considered a contraindication to laparoscopic adrenalectomy (la). aim of the present case-control study is to compare the surgical outcomes in patients undergoing la for adrenal gland measuring = cm versus = . cm in diameter. methods: from january to august , las were performed in the two authors' centers which follow an identical treatment protocol. eighty-one patients with an adrenal gland size = cm (intervention group) were included in the study. based on body mass index (bmi) class [ kg/m ) , lesion side (right or left), surgical technique (anterior transperitoneal for right and left-sided lesions, anterior transperitoneal submesocolic for left-sided lesions) and lesion type (conn-cushing, pheocromocytoma, primary adrenal cancer or metastases, other type of lesion), patients with an adrenal gland lesion measuring = . cm in diameter were included (control group) and paired to the intervention group. results: comparing the intervention and control groups, statistically significant differences were observed in mean lesion size ( conclusions: the only significant difference between the two groups was the operative time which was longer in the intervention group. conversion and complication rates were also higher in the intervention group but the difference was not statistically significant. based on the present data, adrenal gland size measuring more than cm in diameter is not a contraindication to a laparoscopic approach. ; and orthopaedics and urologists for the remaining . %.the costs from these claims, differed from to % of the total damage burden per year. the review of medical charts of claims related to laparoscopic gynaecologic surgery showed that % of claims were filed for visceral and/or vascular injuries ( % bowel injuries, % ureter). % of the injuries were entry-related. a delay in diagnosing injuries was the primary reason for financial compensation. conclusion: evaluating and learning from complications and claims will improve medical health care. in contrast to overall trends and developments considering medical claims, claims concerning laparoscopic surgery decreased, possible due to a rising learning curve. considering laparoscopic surgery, extra caution is required at moment of entry and the early recognising complications and at pre-operative counselling from patients. the aim of the study was to determine indications and contraindications for laparoscopic splenectomy in abdominal trauma patients and to analyze results of the operations. patients and methods: the study involved patients with spleen injury grade iii who were admitted in our institute in the years of - . the patients were divided on two groups. laparoscopic splenectomy was performed in patients (group i) and 'traditional' splenectomy was carried out in patients (group ii). there was no difference in the demographic data and trauma severity between the two groups.non-invasive investigations, such as laboratory investigations, serial abdominal ultrasound examinations (us), x-ray in multiple views and computed tomography (ct) had been performed before the decision about necessity of an operation was made. results: patients after laparoscopic operations had better recovering conditions compare to patients with the same injury after 'traditional' splenectomy. neither surgery related complications no mortalities were registered in both groups. laparoscopic splenectomy was more timeconsuming operation than 'traditional' splenectomy. we suggest that as experience of laparoscopic splenectomy is gained the operation time will be reduced. conclusion: laparoscopic splenectomy is a safe feasible operation in patients with spleen injury. the operation is indicated in patients with spleen laceration more than cm of parenchymal depth with moderate continuing bleeding or expanding hematoma and contraindicated in patients with hemodynamic instability and high bleeding rate (more than ml/h on serial us examinations). the isolated hydatid disease of the spleen is a quite rare condition, liver and lungs being the most common locations. the treatment requires usually splenectomy, open or laparoscopic. there are few reports in the literature describing a spleen-preserving type of surgery. we present a case of a female patient, y.o., with a large cystic lesion of the spleen, cm in diameter. lab tests and ct scan confirmed that is a hydatid cyst. after albendazole treatment and vaccination the patient was referred to us for surgical treatment. the procedure was performed under general anesthesia and laparoscopic approach was performed with the intention to preserve the spleen. after the cyst was identified and adhesiolysis was done, the area was isolated from the rest of the abdominal cavity with sponges with a betadine solution in order to prevent contamination. a needle aspiration of the cyst allowed the evacuation of ml of purulent content, an indicator of a dead cyst. betadine solution was injected into the lesion. laparoscopic excision of the cyst was performed using advanced electrocoagulation devices and the spleen removal was not deemed necessary. two drainage tubes were placed in the remnant cavity. an abdominal ultrasound was performed in the third postoperative day and no collections were identified. the postoperative outcome was uneventful; the patient was discharged in the th postoperative day. the conclusion is that in selected cases, with the cyst located in the anterior part of the spleen, with proper equipment and experienced laparoscopic teams, the cyst can be successfully treated without splenectomy. deep neuromuscular block was induced with rocuronium . mg/kg. in group , forty patients were enrolled for reversal of profound neuromuscular block during thyroid surgery (sugammadex mg/kg, after identification of vagus nerve). in group , thirty-five patients were enrolled profound neuromuscular block during thyroid surgery(without reversal of nmbd). tof-watch acceleromyograph was recorded in response to adductor pollicis muscle for ulnar nerve stimulation in patients with both groups; recovery was defined as a train-of-four (tof) ratio = . .to prevent laryngeal nerve injury during the surgical procedures, all patients were neurophysiologically detected using ionm. results: the total duration of surgery was higher in group than group ( . ± . , . ± . ;p \ . ). the mean time to recovery of the tof ratio to . was higher in group than group ( . ± . , . ± . ; p \ . ). the mean duration of vagus reverse (v : , milisecond) was higher in group than in group ( . ± . , . ± . ; p \ . ). no significant difference was found between left and right v -v and r -r values in group following nerve monitoring, whereas in group , a significant difference was found between left v -v , left r -r and right v -v values ( introduction: oeosphagogastric oncology trials have often lacked robust methods of monitoring and surgical quality assurance (sqa), leading to difficulty in interpretation of trial results. this study aims to assess expert opinion regarding challenges to sqa in oncology trials and potential mitigating strategies. method: a purposive international cohort of expert stakeholders with experience in oncology trials were recruited including: surgeons; oncologists; trial methodologists, and; trial managers. semi-structured interviews were thematically analysed using grounded theory. spss was utilised to assess differences between trial stakeholders' opinions. results: emergent themes were identified and consensus themes emerged on qualitative analysis of stakeholder responses. key consensus challenges to implementation of sqa in oncology trials included: insufficient resources; limitations of surgical volume in centre selection; differing oncological beliefs and resistance to change adoption; overly prescriptive protocols and standardisation contributing to difficulty in surgeon recruitment; and cultural factors leading to difficulties in providing and receiving feedback. seminal consensus mitigating strategies to overcome challenges to sqa in oncology trials included: trial centre selection according to case volume (n = , %); requirement for specific centre attributes for inclusion in trials including specialist centre designation and participation in national audit (n = , %); consideration for surgeons learning curve in surgeon selection (n = , %); flexible standardisation of trial operating (n = , %); operation manual utilisation to aid standardisation of surgical interventions (n = , %); case monitoring using video (n = , %) or photographs (n = , %); direct intraoperative observation by an expert (n = , %), and; histopathological assessment of resected specimens (n = , %). other methods of monitoring surgical quality advocated included: recording post-operative outcomes; lymph node yield; case report forms; and real time data monitoring (n = , %). oncologists were significantly more likely to state the importance of standardisation of surgery in oncology trials (p \ . ), and trial methodologists significantly more likely to advocate consideration of surgeons' learning curve in surgeon selection (p \ . ). conclusion: surveying international expert stakeholder opinion revealed a wide variety of perceived challenges across all domains of surgical quality assurance. proposed mitigating solutions require consensus opinion to formulate a framework to aid design of sqa measures within future oncology trials. research group did not register a single case of ega leakage while patients in control group (? \ , ). had the leakage which was stopped by means of 'endovac' system. there were cases of esophagus postoperative strictures which developed months after the surgery in the research group which was less than in the control group which saw cases of strictures of ega (? \ , ). months after surgery, the number of post-operative strictures increased in both groups, but was lower in the research group and amounted to cases in the research group and cases in the control group (? \ , ). there were cases of esophagus postoperative strictures which developed months after the surgery in the research group which was less than in the control group which saw cases of strictures of ega (? \ , ). neither of the groups had any cases of post-operative mortality. purpose: to investigate the prognostic effects and risk factors of the omission and delay of postoperative chemotherapy of ii/iii gastric cancer (gc), with the goal of providing a reference for interventions of related departments. methods: the clinicopathological data of patients undergoing radical gastrectomy for ii/iii gc were collected and retrospectively analyzed. we defined the chemotherapy delayed until more than days after radical gastrectomy and the complete omission of chemotherapy as unacceptable chemotherapy initiation (uac group), while the chemotherapy conducted within days of radical gastrectomy was defined as acceptable chemotherapy initiation (ac group). the survival between the two groups was compared, and the trends and risk factors of uac were analyzed. results: the total number of patients who underwent totally laparoscopic distal gastrectomy with uncut roux-en-y and delta shaped billroth-i anastomosis was and , respectively. the mean reconstruction time was longer in uncut roux-en-y than in delta shaped billroth-i, ( . ± . vs. . ± . min, p \ . ). the uncut roux-en-y was used more cartridge than delta shaped billroth-i anastomosis ( . ± . vs. . ± . , p \ . ). however there was no significant differences in operation time, estimate blood loss, number of retrieved lymph node and postoperative course between reconstruction methods. postoperative complications more than clavien-dindo grade iiia occurred in cases ( . %) of postoperative early complications and cases ( . %) of late complications. the endoscopic findings showed excellent short and long-term outcomes in terms of very low incidence of bile reflux and reflux-induced remnant gastritis in uncut roux-en-y compared with delta shaped billroth-i anastomosis. conclusions: uncut roux-en-y gastrojejunostomy was a useful reconstruction method with totally laparoscopic distal gastrectomy for cancer, especially for diverting enteral contents from the remnant stomach and preventing remnant gastritis. therefore, it is recommended for young patients with early stage disease who have a long time to live after distal gastrectomy for cancer. operative technique: the seromuscular layer above the tumor is dissected, while the mucosa is kept unbroken. when seromuscular layer is dissected all around the tumor, the full layer is lifted, and the mucosa is stretched. the mucosa is then transected with a stapling device to execute fullthickness resection of the specimen. finally, the seromuscular defect is repaired by hand-sewn suture. results: since december , clean-net has been performed in patients with gastric smts. all tumors were resected en-blocwithout rupture. the average operation time ranged from to min with an average of . min. the postoperative course was uneventful. microscopically the surgical margin was tumor-negative (r resection) in all cases. the margin width was small with an average of . mm ± . . conclusions: clean-net is a useful option in the laparoscopic surgical treatment of gastric smt, when excessive sacrifice of the healthy gastric wall surrounding the endophytic tumor should be avoided. background: the type of fundoplication-complete or partial is still controversial for the surgical treatment of gerd. laparoscopic toupet ( wrap) fundoplication has less post op dysphagia and gas bloating compared to nissen fundoplication ( wrap) and is advised to be the procedure of choice when esophageal manometry findings are abnormal, however it is considered by some less effective and more difficult to perform. the aim of this research was to determine in the functionality and efficacy of the different types of fundoplication. methods: explanted pigs stomachs weighing - kg were studied. two different studies of the les were performed: distensibility and failure point (occurrence of reflux according to volume added to the stomach). for both studies we first disrupted the lower esophageal sphincter using a rigiflex tm dilating balloon. we then performed three different fundoplications-nissen, toupet, dor and measured the distensibility of the egj after each fundoplication. the failure point was determined following each fundoplication type. results: we used pig stomachs for the distensibility study and pig stomachs for the failure point study. there was no statistically significant difference between the nissen and toupet fundoplications when distensibility was measured, however the egj was more distensible following dor fundoplication (p = . for nissen, . for toupet). when the failure point was measured, nissen fundoplication was significantly more effective than toupet, and toupet was significantly more effective than dor (p = . ,p = . respectively) conclusions: we studied the differences between the mechanical effects on the egj following three different fundoplications, encompassing , , and of the esophagus. we demonstrated that there is a significant difference between dor fundoplication and nissen/toupet when distensibility was measured. there was no difference in the distensibility of the egj following a or wrap. there was, however a significant difference of effectiveness between all three fundoplications. these findings suggest that the and fundoplications have similar functionality while the wrap mechanically prevents possible reflux and support proponents of toupet fundoplication rather than nissen due to the similar functional results while decreasing the post op dysphagia and gas bloating complications. surg endosc ( ) aim: to describe patients undergoing surgical treatment of incident gastro-oesophageal reflux disease and the use of anti-reflux treatment in a danish population-based cohort. methods: all adult danes - undergoing upper endoscopy and receiving a diagnosis of gerd within days were identified. patients with previously diagnosed gerd, peptic ulcer-disease, barrett's oesophagus or cancer of the gastrointestinal tract were excluded. in this study, only patients undergoing anti-reflux surgery within two years of gerd-diagnosis were subsequently included. age, sex, charlson comorbidity index (cci), anti-reflux surgery (primary and re-operative) and endoscopic dilatation were identified using the danish national patient registry. mortality was identified using the national civil registry. pharmacological treatment of gerd (proton pump inhibitors, h \ su \/su-blockers and other prescription anti-reflux drugs) as well as use of nonsteroid anti-inflammatory drugs (nsaid) and anti-thrombotic treatment were identified using thethe danish national prescription registry. all data was linked on an individual level using the unique identification number that all danish citizen are assigned to at birth or first immigration. results: a total of first-time fundoplications were performed, hereof . % performed laparoscopically (n = ) and . % performed using open technique (n = ). at one-year followup, . % (n = ) had undergone endoscopic dilatation and . % (n = ) had undergone reoperation. the -day mortality was \ . %. patients had a median age of years ( - years) and were predominately male ( . %-n = ). a total of . % had cci (n = ). diagnoses were gerd with esophagitis ( . %-n = ), gerd without esophagitis ( . %, n = ) and gerd without specification ( . %, n = ). before initial endoscopy, , % (n = ) used at least one type of anti-reflux drug, dropping to . % (n = ) in the year after anti-reflux surgery. however, even when censoring patients with barrett's esophagus or peptic ulcer disease after initial endoscopy and patients undergoing concomitant treatment with nsaids or antithrombotic drugs, . % still used at least one type of anti-reflux drug after surgery. conclusion: in this population-based study, anti-reflux surgery was safe and lowered the use of pharmacological treatment. however, even when adjusting for competing reasons for use of antireflux drugs, . % used at least one type of anti-reflux drug one year after surgery. the new approach to perform nissen fundiplication m. paranyak, v. grubnyk surgery, odessa national medical university, odessa, ukraine nearly % of patients who undergo laparoscopic anti-reflux surgery at long-term follow-up need for surgical reintervention mostly because of hiatal hernia (hh) recurrence, wrap migration or disruption. purpose: the aim of our prospective study was to evaluate and compare several technics of wrap fixation and determine whether modified nissen fundoplication(mnf) reduce failure rate in the long term follow up. materials and methods: this was a prospective, randomized, controlled trial. from november to october one hundred and thirty-eight gerd patients who underwent anti-reflux surgery were divided into two groups. excluded criteria for our study ware diagnosed hiatal hernia (hh) type iii. in the i group which include patients we performed the following manipulations: nf was supplemented with suturing wrap to the diaphragmatic crura ( patients) on each side using two non-absorbable stitches. such technique permit us to create more symmetrical wrap. in case of weak conditions of crura or short esophagus ( patients) fundoplication wrap was sutured to the body of stomach using two non-absorbable stitches on each side. control group ( patients) underwent classic nissen fundoplication (nf) without wrap fixation. all patients were assessed before and after surgery using validated symptoms and quality of life (gerd-hrql) questionnaires, -h impedance-ph monitoring and barium-swallow. results: baseline characteristics were similar between groups. there were no conversion to open procedure or mortality. mean hospitalization was . days ± . days. at , months (range -- ) of followup, the overall rate of complications after mnf was , % ( hh reccurence) and nf , % ( hh reccurence, slipped wrap). patient in mnf group show significant improvement in gerd-hrql score, from . ± . (preoperatively) to . ± . (postoperatively) (p? \ ? . ). complete ppi independence was achieved in %. in the ii group of patients mean gerd-hrql score decline from . ± . (preoperatively) to . ± . (postoperatively), postoperative ppi treatment was necessary in %. conclusions: according to our study mnf minimized risk of slipped wrap and intrathoracic migration of the wrap and can make positive impact on reducing the failure rate of laparoscopic anti-reflux surgery. aims: comparative evidence across laparoscopic antireflux procedures does not exist. aim of this project was to identify direct comparative evidence between laparoscopic antireflux procedures and synthesize evidence using network meta-analytical methods. methods: the databases of medline, amed, central, opengrey were interrogated. pairwise meta-analyses for each pair of interventions using a random-effects model and network metaanalysis in stata was performed using the mvmetacommand and self-programmed stata routines. differences between direct and indirect evidence were explored by comparing direct and indirect estimates though computing the inconsistency factor within each closed loop of evidence. the ranking probabilities for all treatments of being at each possible rank for each intervention were computed using the mvmetacommand in stata. a hierarchy of the competing interventions was obtained using rankograms. quality of evidence was assessed using grade-nma and the cinema application. results: forty-three publications reporting on randomized trials and some patients were identified. the network of treatments formed a closed loop between °, °and anterior °; and star network between °and other treatments; and between anterior °and other treatments. laparoscopic °, °, anterior °and anterior °were equally effective in the control of heartburn and this was supported by low quality of evidence according to grade-nma. the odds for dysphagia were lower for anterior °(high quality evidence), anterior °( moderate quality evidence), °(moderate quality evidence) and proton-pump inhibitors (moderate quality evidence) compared to °. the odds for gas-bloat were lower for °and anterior °compared to °(low quality evidence). the odds for regurgitation, morbidity and reoperation were similar across treatments, albeit these were associated with very low quality evidence. anterior °had a % probability of being the best treatment in terms of dysphagia. conclusion: under consideration of treatment effect estimates, evidence quality as assessed with grade-nma and other parameters, anterior °, anterior °and °should be preferred over °. further research needs to focus on the comparison between °and °/ °. aims: we have recently demonstrated that the tension of crural closure can be reliably measured intraoperatively (alsgbi conference december ). the aims of this study were to further characterise tension at the diaphragmatic hiatus from our prospective pilot study of patients. methods: a prospective analysis was performed of patients undergoing laparoscopic hiatal hernia repair between april and december . patients underwent crural tension measurement intra-operatively. patients had a pre-operative ct scan of the abdomen within one-year of surgery. hiatal surface area (hsa) was measured intraoperatively and a sauter-fh universal digital force gauge was used to measure the tension of crural closure during cruroplasty. outcome measures included the mean tension of the crural closure and the presence of muscle splitting during the cruroplasty. results: for all patients, the mean crural tension measurement was . n and the mean hsa was mm . pre-operative ct was positively correlated with post-dissection intra-operative hsa (r = . , p = . ), however, strength of association was weak (r = . ) and ct consistently overestimated the size of hiatal defect intra-operatively (mean of differences mm , p = . ). crural tension was positively correlated with age (r = . , p = . ), hiatal height (r = . , p \ . ), hiatal width (r = . , p \ . ) and hsa (r = . , p \ . ). crural tension was correlated to the hiatal width to height ratio to assess the shape of defect and there was positive correlation (r = . , p = . ). tension was calculated for the posterior and anterior halves of the suture cruroplasty. anterior tension was significantly higher when compared to posterior tension ( . n vs . n, p \ . ) . patients had evidence of muscle splitting during the cruroplasty. the group with muscle splitting were significantly older ( vs , p = . ), had larger hsa ( mm vs mm , p \ . ) and higher crural tension ( . n vs . n, p \ . ). the lowest observed mean crural closure tension causing muscle splitting was . n. conclusion: there is now a possibility to optimise this operation with objective measures years after it was first described. initial findings suggest that crural closure up to * n could be the permissible tension threshold for suture cruroplasty and higher tension may benefit from the use of mesh reinforcement. background: endoscopic submucosal dissection (esd) and endoscopic full thickness resection (eftr) are advanced endoscopic techniques which can be time consuming using traditional endoscopic instruments. a new endosurgery platform, designed by fortimedix surgical, was developed featuring flexible articulating instruments to use in combination with a standard flexible endoscope. the platform is intended to perform endoscopic cutting, dissecting, and hemostasis. aim: evaluate feasibility of the platform in the upper gi-tract. project description: the platform was tested in a dry esophageal model as well as a second series with a porcine esophagus and stomach. the system has an external docking station affixed to the operative table to stabilize both flexible instruments for the right and left hand of the surgeon. at the tip of the endoscope, a cap containing instrument lumens is attached to allow advancing and removing the flexible instruments. the endoscope with the cap and instrument lumens attached is advanced via an overtube with outer diameter . mm. in the first series, flexibility and range of motion of the endeffectors was assessed. additionally, the ability to advance the instruments to the intraluminal target area from the docking station and along the scope was evaluated. in the second series, the functional capabilities of the system and instruments were evaluated in a porcine model. preliminary results: : in the dry model, the platform was adequately deployed to the target then range of motion was tested as well as cutting and grasping gastric wall with instrumetn triangulation achieved. the grasping forceps provided enough force to pull the mucosal wall and expose the dissection plane. in the pig model, the distal esophagus and stomach could successfully be accessed and platform deployed. esd was performed using newly designed flexible articulating scissors, dissection-hook, and graspers with good triangulation and sufficient grasping force with traction/counter-traction. the new fortimedix surgical endo-surgery platform applied to a standard flexible endoscope is feasible to perform esd. future studies are planned to determine learning curve and compare it to traditional endoscopic instruments. background: in laparoscopic surgery, we usually observe the organs in the same direction to avoid a mirror-image situation. therefore, we are unable to recognize how far the dissection has proceeded on the other side of the target organs or lesions, especially when the plane of dissection is under the mesentery or organs. this becomes a problem not to understand how far the dissection has progressed and how much more dissection is needed. aim: to solve this problem, we developed a laparoscopic device with tip illumination. project description: the device is configured by the long and narrow part made of polycarbonate resin and a battery-powered light-emitting diode to illuminate the tip by shining light through the polycarbonate resin. during the surgery, the tip of the device is inserted into the deepest part of the dissection area, and the transmitted light indicates how far the dissection has progressed. the tip of the device has a prism structure and light is emitted in a direction perpendicular to its axis. tip position can thus be more clearly identified even with insertion in the same direction as the laparoscopic view. to verify the utility of this instrument, laparoscopic surgeries were performed in a porcine model and cadavers. preliminary results: we performed some laparoscopic surgery such as the medial-to-lateral approach to the white line of the left side of the descending colon for sigmoidectomy, dissection of the posterior surface of the pancreas to the upper edge of the pancreatic body or splenic artery for distal pancreatectomy, and the separation of the anterior surface of the inferior vena cava from the liver to the area between the right and middle hepatic vein for right hepatectomy. we quickly and easily identified the deepest part of the dissection area even if identification had been difficult using other techniques such as placing gauze in the deepest position, inserting forceps into the dissection area or simply depending on the experience of the operator. background: recent advancements within surgery have seen artificial intelligence transform traditional approaches. robotic assistive devices have demonstrated particular success, as safe and cost effective, and are widely supported via industry and local government as a step closer to the future standard of practice. an example of seamless and touchless robotic assistive technology is based on touchless and interactive eye tracker glasses worn by the surgical team thereby enabling the team to perform wider surgical tasks, more efficiently and reduced human error. we introduce a perceptually-enabled, smart operating room (smart-or) based on a novel real-time framework for theatre-wide d gaze localisation in a mobile fashion. this framework enables dynamic gaze based user interaction with a robotic scrub nurse to facilitate meaningful practical integration of human and technology intra-opertively. aims: we tested participant acceptability of a novel robotic scrub nurse during simulated surgery. project description: surgeons performed segmental resection of pig colon and handsewn end-to-end anastomosis while wearing eye-tracking glasses to select surgical instruments on a screen. the robotic scrub nurse(rn) picked up and transferred the instrument to the surgeon. the study compared human nurse(hn) vs rn. gaze-screen interaction was based on a d gaze framework we developed with synergy of conventional wearable eye-tracking, motion capture system and fixed in space rgb-d cameras for real-time d reconstruction of the environment. nasa-tlx and van der laan's technology acceptance questionnaires were collected and analysed using anova. preliminary results: overall, teams of surgeons(st) and scrub nurses(sn) participated. nasa tlx feedback for st and sn revealed no significant difference between in mental, physical or temporal demand. importantly, st and sn reported no significant difference in task overall performance. st reported more significant frustration with rn vs hn. van der laan's scores showed positive usefulness and satisfaction scores in using the rn platform. overall, all outcomes were more positive by sn vs rn. conclusions: this is the first platform of its kind. overall, quantitative and qualitative feedback was positive. the source of frustration has been understood and we believe it can be improved by appropriately modifying robot behaviour. importantly,there was no difference on perception of performance. background: endoscopic tumor resections in the gi tract may be facilitated by more advanced instruments for dissecting and suturing. we have focused on developing an endoscopic suturing technique using a standard flexible pediatric endoscope with new, flexible instruments allowing for complex end-effector movements. aim: perform flexible endoscopic suturing using a standard flexible scope in the gi tract project description: a standard flexible pediatric endoscope and a standard gastroscope were used for testing the new technique. via an overtube, the endoscope and newly designed fortimedix surgical flexible instruments (needle holder; grasper) with a diameter of mm were inserted into the esophagus. suture training was performed in an experimental setting in a box in the dry lab and porcine model . the flexible needle holder was advanced into the esophagus next to the scope, and a suture of the esophageal wall was performed, followed by extracorporeal knot-tying with knots. the test series consisted of training with both resident trainees and surgeons to evaluate the learning curve. each participant performed sutures on the box model and in the pig-esophagus. feasibility, duration of the different steps, and handling problems were documented. preliminary results: test series (box training on esophago-gastric explant) with prototype showed good feasibility. suturing was possible in out of attempts. median duration for single bite: min ( - ); knot-tying: min ( ) ( ) ( ) ( ) ( ) ( ) ( ) . test series (training in pig-model) with prototype showed improved feasibility with better flexibility of instrument shaft: median duration of double bite: min ( - ); knottying: min ( ) ( ) ( ) ( ) ( ) , overall duration intraluminal esophageal double bite suture and closing with knots: median duration: min ( - ). the new flexible endosuture instruments seem feasible to use and perform dependable intraluminal sutures. the training period and learning curve is short and the objective is to apply this system clinically for closure of perforations and fistulas. school of mechanical and aerospace engineering, nanyang technological university, singapore, singapore; general surgery, national university hospital, singapore, singapore; gastroenterology, national university hospital, singapore, singapore; surgery, chinese university of hong kong, hong kong, hong kong background: ideally, endoscopic suturing should mimic surgical closure as the latter is stronger than most endoscopic closure devices. however, endoscopic suturing is challenging due to the confined endoluminal space and lack of dexterity of current endoscopic instruments. we have developed a novel robotic suturing device to overcome these problems. aim: this animal study aims to demonstrate the feasibility of this device in closing perforations. method: the trial was conducted on an anaesthetized live pig. a double-channel colonoscope was first inserted into the rectum. following saline lift, a mm submucosal incision was created in the rectum to simulate a perforation. the robotic suturing device and grasper were inserted into the two colonoscope channels, allowing the endoscope to remain in position for tool exchanges or needle reloading. both the effectors were intuitively tele-operated by the user via a robotic master console. this robotic suturing device manipulated a curved, double-point needle (with a cm - vicryl suture) to penetrate tissues at desired orientations. the needle could be switched between both jaws of the device through a locking mechanism. this facilitated passing the needle through tissues to form stitches or through suture loops to form surgical knots. the articulated joints and five degrees of freedom allowed dexterous steering to reach targets and triangulation with other tools in a confined space. the robotic grasper facilitated handling of tissue and suture. result: a total of four running stitches were performed and secured with a surgical knot by passing the needle through suture loops. the suture was cut and the needle was removed by the robotic grasper through the channel. min and min were required to stitch and tie the knot respectively. there was no complication. conclusion: our novel endoscopic robotic device can suture perforations resulting from complex endoscopic procedures. as our suturing method is similar to laparoscopic and robotic suturing, closure using our device is expected to be as strong as a surgical through-and-through closure. when developed further, this device can be used to close full-thickness resection sites and orifices in transluminal endoscopic surgery. modelling a collaborative robot with the ieee sdc standard for combined focused ultrasound and radiation therapy j. berger, m. unger, l. landgraf, a. melzer medical faculty, university hospital leipzig, innovation center computer assisted surgery, leipzig, germany background: surgical robotics require a smooth integration into the operating room (or) . for this propose the ieee sdc(service-oriented device connectivity) standard has been developed in the or.net project. in preparation for a combined focused ultrasound and radiation therapy (fus-rt) we have shown concepts and evaluations to position ultrasound and interventional devices with collaborative kuka arms. however, the safe and intraoperative cooperation with multiple different or-devices (e.g. an irradiation unit) requires a more sophisticated exchange of the robot's information and functionality. aim: to realize a safe clinical integration, the aim of this work is to implement and evaluate a dynamic connection between the kuka robots and other devices using the vendor-independent sdc communication standard. project description: a kuka lbr iiwa r robot (kuka ag, germany) was modeled inside the sdc standard for medical device communication. the interconnection with other devices was implemented and evaluated on a mobile platform to position a clarius l wireless ultrasound transducer (clarius mobile health corp, canada). all necessary information of the robot was represented in the medical device description of the sdc standard to be shared via network. for each joint of the robot arm the position, torque, stiffness, damping, velocity and functional-states were represented, resulting in a total of parameters. the software was implemented in c ?? on a standard pc accessing the kuka controller cabinet with ros (robot operating system) via ethernet. the accessibility of each parameter, as well as activation commands for planning and movement were tested with an sdc-consumer application. preliminary results: the sdc-provider functionality of the robot was successfully implemented, allowing for dynamic changes of the robot state during interventions. all appliances (sdc standard compatible) in the robots network can react to state changes and send movement and planning commands to the robot via activations. after testing, % of the defined parameters are safely accessible. implementing the medical device communication for the kuka robot enables its integration into any networked operation room that supports the sdc standard. it is, therefore, ready to be set up and evaluated for the application of fus-rt in a clinical environment. background: assessment of perfusion of the left colon with fluorescence during anterior resections for cancer changes surgical decisions in up to % of cases. use of fluorescence has been shown to be associated with lower leak rates, and improved short-and long-term outcomes with reduced costs. given the high incidence of colorectal cancer, fluorescence-guided perfusion assessment could be of great importance in contemporary surgical practice. however, there is currently no standardisation of this technique which represents a significant limitation to widespread adoption. aim: to standardise fluorescence-guided perfusion assessment in rectal anterior resection through a computer vision algorithm. project description: videos were collected by a single surgeon in a referral centre for colorectal cancer treatment. perfusion assessment was used before proximal colon division to identify the best location for transection. a bolus of indocyanine green was injected intravenously and a near-infrared camera used to assess perfusion through fluorescence. photographs of fluorescent imaging of the colon were analysed using a non-supervised learning algorithm called 'k-means clustering'. the first step was to digitally subtract all background pixels, leaving only the area of interest of the colon. this area was then subsegmented into 'clusters' corresponding to perfused and nonperfused areas. a mathematical model was applied based on the sub-clusters centres to select the area for transection with optimal perfusion of the proximal colon. preliminary results: representative images of proximal colon under perfusion assessment were presented to expert surgeons. the optimal point for transection was selected based on their clinical judgement on previously delimited areas indicated by random letters. this was compared with the results from the automated segmentation using the algorithm ( fig. ). the area identified for section by the algorithm included the area selected by the expert surgeons in . - % of test cases. these results need to be further validated due to high risk of overfitting. next steps include the collection of multicentre data with a standardised fluorescence perfusion assessment. after robust training, the algorithm will be validated on real-time clinical data to ensure improved outcomes for patients, which is our ultimate goal. background: endoscopic submucosal dissection (esd) is a flexible endoscopic technique that allows for an en bloc removal of lesions of the gastrointestinal (gi) tract. these procedures are typically time consuming due to the difficult control of the tools, and they often require around min for removing lesions, that can reach - cm in diameter. the probability of intestinal perforation exceeds % and the hemorrhage risk ranges from . % to . %. a flexible robotic endoscope may offer a solution to overcome these limitations, by improving the degrees of freedom (dof) and operational efficiency. aim: within this clinical panorama, the aim of this project is presenting the development of a novel miniaturized robotic device to be coupled to the tip of a traditional endoscope for the surgical dissection of gi neoplasms. project description: the robotic platform consists of the miniaturized robot, the actuator housing (hereafter called external platform), the control unit and the master console (i.e.,two geomagic touch phantom) to allow the user driving and control (figure a ). during the operation, one surgeon stands close to the patient to maneuver the endoscope for exploring the gi tract and reaching the target area. another surgeon operates the miniaturized robot through the master console, carrying out the surgical procedure. the robot has been designed to be coupled to the tip of traditional flexible endoscopes of . mm in diameter. it exploits the flexibility of the endoscope for navigation through the intestine and integrates two-active robotic arms (i.e.,cautery and gripper) extending the dofs, and thus enhancing the efficiency during complex tasks such as manipulation and surgical tissue dissection. furthermore, the endoscope provides the optical system for visual feedback and one working channels for conventional instruments. preliminary results: firstly, a mock-up that faithfully reproduces the miniaturized robot has been realized using a d printer machine (projet mjp , d system, inc.) to verify the feasibility of the design solution. after verifying the potentiality of the d printed prototype, a final device, with the same features (i.e.,dof and geometry) of the d printed prototype, has been designed, fabricated and assembled ( figure b ). background: virtual and augmented reality has been widely used in many fields mainly for entertainment purposes. we think that it could be beneficial to use augmented reality in medical practice. aim: the aim of this study was to evaluate usefulness of d holographic images of patients anatomy displayed using augmented reality goggles during endovascular aortic repair (evar). project description: one of the major challenges during endovascular procedures is working on two dimentional x-ray images of three dimentional vascular anatomy. using d holograms of patients anatomy could be beneficial during the evar procedure and could make the orientation in vascular anatomy easier for surgeon. we performed two endovascular aortic repairs with the assists of microsoft hololens -smart glasses using augmented reality. we used carna life application created by polish company medapp. it was one of the first use of holograms during vascular procedures in the world (second and third stent-graft implantation using holographic imaging in the world). results: two patients with abdominal aortic aneurysms, -years old male and -years old female, were operated on. holograms of patient's anatomy made from preoperative angio ct scans by polish company medapp were displayed during the procedures using microsoft hololens. holograms could be displayed in any place and configuration using augmented reality, which means that the images did not interfere with the surgeon's field of vision. microsoft hololens use voice commends which permits the surgeon staying sterile. stent-graft implantations were successful. both patients were discharged three days after the procedure and the hospitalization was uneventful. seeing precise patient's vascular anatomy reconstructions in three dimention certainly helped us to navigate in a vascular tree. we believe that in the future this technology would enable to reduce the operation time and need for radiation. background: interaction with electronically controlled operating room (or) systems embedded in modern surgical environments is everyday practice for surgeons performing minimally invasive surgery (mis). while there is a non-sterile operating nurse available in the or, capable of interacting with these systems upon request by the surgeon, this indirect control is mostly slow, prone for error and disrupting surgical workflow. facing an unanticipated and unwanted outcome may cause distress emotions. distress emotions are undesirable when performing surgery, since they may impact available cognitive workload. furthermore, they may result in negative communication, hampering or-team empowerment and effective leadership. both factors are known to negatively influence quality and safety in the or. aim: the aim of the tedtrial is to investigate what setup best enables surgeons to interact with the endoscopic operating room setup during surgical procedures. as a result, disruptions of workflow, delays and errors may be reduced. outcome parameters will be objectified using medical data recorder (mdr) derived output and biometric analysis using hexoskinÓ. subjective evaluation of outcome parameters is done using questionnaires. project description: the tedcubeÓ system is a plug-and-play device enabling wearable sensors to act as a wireless alternative for a regular computer mouse, therefore enabling direct hands-free and sterile control of the or. the study is an observational trial with three different arms: intervention group ) direct interaction by surgeon with or environment using tedcubeÓ and myo tm armband, intervention group ) direct interaction of surgeon with or environment using tedcubeÓ and plantronicsÓ wireless microphone headset. the third arm is the control group using indirect interaction of surgeon with or environment using third-person computer interaction. main endpoint of study is the number of workflow disruptions due to the operation of laparoscopic or equipment. secondary endpoints are error rate, delay, team communication, subjectively reported frustration and satisfaction with the system and objectively measured stress as symptom of frustration and anger as distress emotions. preliminary results: primary and secondary endpoints of study are compared among groups. it is anticipated that reduction of miscommunication, error and delay may result in a reduction of distress emotions. trial start is expected q . anticipating the automated intraoperative tissue recognition: intraoperative tissue classification using hyperspectral imaging and machine background: iatrogenic injuries may occur despite a sound expertise in surgical anatomy. hyperspectral imaging (hsi) is an emerging optical method, combining the use of a camera system with a spectrometer. hsi analyzes optical properties of tissues and acquires d data sets with two spatial dimensions (x, y) and one spectral dimension (?). the data sets contain information about tissue physiology, composition, and perfusion. those spectral features coupled with machine learning algorithms might allow for automatic tissue recognition. aim: assessing the ability of an hsi-based machine learning to discriminate the hyperspectral features of different tissues during neck and abdominal surgical procedures. methods and procedures: fourteen pigs underwent laparotomy (n = ) or neck dissection (n = ). twenty data sets were acquired in vivo from abdominal organs and from neck structures by means of a customized hyperspectral camera (diaspective vision, germany). different anatomical structures were manually outlined by a surgeon using an image manipulation software (gimp). each pixel contained a hyperspectral curve and each curve was composed of bands (from to nm with a nm resolution). the curves were normalized using the standard normal variate method. a logistic regression machine learning (ml) algorithm was used to train the model to discriminate tissues, based on the hsi spectral features. the efficacy of the prediction model was tested using the k-fold (k = ) cross-validation. results: a large number of tissue-related hyperspectral curves could be extracted ( thyroid, vagal nerve, fatty tissue, cartilage, carotid artery, muscle, carotid vein, portal vein, biliary tract, gallbladder, hepatic artery, pancreas, duodenum, abdominal adipose tissue). the algorithm used min to 'learn' all data sets, and prediction was provided as an immediate output. overall, prediction accuracy was and % for neck and abdominal structures respectively. in particular, biliary ducts could be identified with a % accuracy and the vagal nerve with an % accuracy (see figure for details). background: a gaze-controlled robotic endoscope is innovative technology with myriad potential applications in the rapidly advancing field of flexible endoscopy. improvements to the current flexible device to allow examination of the gastrointestinal tract whilst minimising procedural discomfort and complications are desirable. aim: to use a gaze contingent framework to manipulate a flexible endoscope through a simulated upper gastrointestinal tract (ugit) model. description: a flexible gastroscope (karl storz pks) was attached to a ur axis robotic arm (universal robots), mounted onto a rail and placed on top of a surgical table. two cogwheel shaped dials were d printed and placed onto the up/down and left/right wheels on the head of the gastroscope ( figure ). robotization of these controls was achieved by using two motors (dynamixel rx- f) to steer the distal tip. this system allows users to operate a robotised flexible endoscope using gaze control. gaze interaction with the screen was based on a d gaze framework we developed with the synergy of conventional wearable eye-tracking, motion capture system and fixed in space rgb-d cameras for d reconstruction of the environment. users are able to control endoscope movements without handling the device. the distal tip of the gastroscope was controlled using eye gaze technology. the ur robot was used to enable shaft rotation (initiated by fixed head movements) and linear movements were triggered using a joystick handle (up for forward movement, down for endoscope withdrawal). pause and retroflexion of the endoscope are achieved by moving the joystick left and right respectively. users were asked to navigate an endoscope through an ugit model (chamberlain group) simulating a diagnostic gastroscopy using gaze control and targeting ten points scattered through the stomach. results: four expert endoscopists and one novice used gaze control to successfully navigate a gastroscope through a simulated ugit. all were able to intubate the oesophagus and accurately locate ten targets placed in the fundus, body, antrum and pylorus of the stomach. conclusion: gaze control endoscopy is a feasible concept. it allows ergonomic, user-friendly and intuitive control whilst maintaining the benefits of a flexible endoscope. background: image-guided needle biopsies and histopathological evaluation are the gold standard for the diagnosis of liver neoplasms. most often, however, these are reserved for suspicious, but not diagnostic, situations. radiomic may help to characterize tumor biology by correlating imaging features with relevant tumor-biology information. features derived from radiomic analysis may provide complementary information to support clinical decisions, especially in situations where tissue analysis cannot be performed or is inconclusive. aim: the goal of our technology is to exploit computational capabilities for image analysis in order to identify radiomic features useful for characterizing liver lesions and to identify relevant information related to patient prognosis. project description: patients derived from an internal database and patients randomly extracted from the cancer archive liver dataset were included in this study. lesions were extracted from those volumes using expert annotations ( secondary vs primary; well differentiated vs non-well differentiated). lesions were then split into training and testing sets. first order statistical features were computed and a lasso regression step was performed to reduce the number of features. both logistic regression and random forest models were built using cross-validation to predict the target classes on the test set. preliminary results: only features namely the energy and the volume of the lesion were sufficient, when combined in either model, to predict the differentiation grade on the test set with an f -score of . (± . ). we are currently working on the addition of higher order statistical features to the analysis in order to differentiate primary from metastatic tumors and identify complementary features that may assist clinical decisions in patients with inconclusive hepatic lesions. objective of the technology or deviceideally, the use of medical simulators could provide trainees with initial background information about indications for procedures, endoscopic technique, and early hands-on training experience that could shorten the initial critical learning curve. rationale for using ex vivo models is that in the beginning of the learning curve, the most important issue is having an initial exposure to the basic movements and maneuvers. our objective of is to create a stomach model from renewable polymer, which would closely simulate normal human stomach with gastric pathology for endoscopic diagnostic or interventional skill acquisition/evaluation. description of the technology and method of its use or application stomach model is based in several steps; the first one is in the in-silicodesign of the overall shape, after that we d print the positive two halves of it. the interior detail is obtained shaping the d printer parts with ceramic putty. once concluded, this elaborated part will serve as a template in order to build injection bleeding moulds. in the injection bleeding moulding a mesh is placed between layers in order to provide structural attachment points as stiches or several pathological models that will be incorporated after the casting process. we have developed for these instance polyp moulds, fistulae structures in order to attach endoscopic clamps. the two halves are closed once the pathological models are placed inside via a thermic-fusing and stitching creating a leak proof stomach model. preliminary results if available: our models were evaluated by international experts in ircar/ihu france in interventional endoscopy course and were favorable accepting for next trails in these prestigious institutions. conclusions: future directionsa new endoscopic training model of stomach was made and will be evaluated and validated for feasibility in mastering diagnostic and interventional endoscopic skills. clinical trials will be necessary to compare the ability of the simulator to perform training compared with traditional methods of training in endoscopic procedures. background: endoscopes are the eye of surgeons in minimally invasive surgery (mis). conventional endoscopes are mostly chopstick-like and are steered by the assistant. this limits the field of view and results in issues such as endoscope-instrument fencing, surgeon-assistant coordination. existing robotic endoscope holder enables solo-surgery, however endoscope remains blocking the instrument movement and impairs the operational safety. flexible endoscope such as the endoeye provides angulation at the tip and could enlarge the field of view. however, its steering the view is much more complex compared to the rigid endoscope. aim: to provide an intuitive robotic flexible endoscope with enhanced safety. project description: in this work, we present a robotic flexible endoscope for mis with enhanced safety. in the proof-of-concept system, it contains a flexible endoscope module and a robot manipulator. the endoscope contains a proximal rigid shaft and a distal flexible bending section. it is installed onto the patient side manipulator (psm) of the da vinci research kit (dvrk). visual servoing is adopted to achieve autonomous instruments tracking. during the tracking process, movements of the manipulator as well as the endoscope are minimized to save space for the operation and avoid instrument-endoscope fencing. the endoscope could also be controlled by the surgeon. a foot pedal is used to switch between the tracking-mode and control-mode. preliminary results: a prototype was developed and tested experimentally. in tracking a volume of * * mm , the spaces required by the flexible endoscope are . % (inside the trocar) and . % (outside the trocar) of that occupied by the rigid endoscope. evaluation with the fls tasks involved subjects. all of the participants completed the tasks under the tracking-mode without failure. in the ex-vivo test with porcine stomach, the endoscope successfully guided the detection, dissection and knotting autonomously. background: fluorescence imaging allows to visualize deep-seated anatomical structures, using a deeper tissue penetration of near-infrared (nir) compared to visible light. the most commonly used fluorescent substance, indocyanine green (icg), is not naturally excreted by the urinary system and requires retrograde stent placement and injection. lighted catheters have been proposed to help visualise the ureter. fluorescent dye-coated ureteral catheters could well represent a more effective and less expensive solution. icg is unsuitable for coating materials. aim: to develop a stable fluorescent coating for catheters to be used intraoperatively, working in the same nir window as icg, to facilitate its use with clinically available systems. project description: the coating was developed based on poly(methyl methacrylate) (pmma), a biocompatible polymer, and on specifically designed fluorescent dyes exhibiting icg-like optical properties. three nir dyes (substances a, b, and c) were tested in order to find the optimal one, in terms of fluorescence signal intensity, and were compared to icg in a polymer form and to an icg-based reference card (green balance tm ). the fluorescent coating was applied onto common ureteral stent materials: hydrophilic-coated ultrathaneÒ, silicone-coated latex, and pvc. the coating process involved cycles of immersion into the respective dyes blended in pmma polymer (icg, substances a, b, and c), followed by a drying phase. the various tubes were partly inserted into a porcine ureter, next to the icg-based reference card. images were taken in white light and nir modes using the d-light p camera system (karl storz), at a fixed camera-to-target distance. the fluorescence signal intensity was measured for the different regions of interest (each material/coating combination inside and outside of the ureter, reference card) using proprietary software and normalised against the reference card. preliminary results: the signal intensity was significantly higher for all new substances as compared to icg. substance a showed the strongest fluorescence signal intensity among the tested coatings in all tested conditions and materials and was identified as the ideal candidate to undergo further evaluation and in vivo testing. background: endoscopic resection(er) of early gastric cancers provides tremendous patient advantages. however, post-resection findings of deeper sub-mucosal(sm) and/or lympho-vascular invasion can necessitate a second, surgical intervention. we propose that pre-resection evaluation of the submucosal architecture under the tumour can provide critical information for staging and operative planning. we evaluate three techniques to assess the submucosal architecture underlying the gastric mucosa in a pig model. aim: to evaluate three needle-based methods of evaluating the sm before er. project description: acute pigs were used. a simulation of sub-mucosal tumours (endoscopically and eus visible bleb) by injecting the sm with cc of undyed nac. a linear eus was use for all procedures. the tumours were marked and labelled according to geography. methodology: after creating the tumours, anterior lesions were evaluated using the following g needle-based modalities: confocal microscopy(cm) using the through-the-needle cellvizio (mauna-kea) system; mini-biopsy(mb) using the micro-biopsy forceps moray (us endoscopy) and fine-needle biopsy(fnb). results: cm examinations were video recorded in all a positions. submucosal vascular visualisation was possible in all cases, excellent in / . mb was performed in lesions with a total of biopsies obtained from each lesion (total = ). fnb was performed once in the anterior lesions and twice in the posterior lesions with different needle brands. therefore, there was a total of biopsies collected. passes were performed in each biopsy (total = ). each pass constituted - insertion/withdrawal movements combined with fanning, slow pull technique, no suction and suction ( - cc air negative pressure) to collect the material. all material were sent to an animal anatomo-pathologist blinded to the acquisition method. mean time of confocal examination was min sec ( ' ' '- ' '') . mbtook a mean time of min and fnb was a mean of min for each biopsy. cm identified different patterns of vessels in relation to the probe position (superficial/reticular, middle cross-roads or deep/longitudinal). conclusion: eus-fnb, cm and mb are three potential methods to assess the sub-mucosal space underlying the gastric mucosa. cm offered the most architectural information but required more time to perform. these method's may have a role in better staging patients for appropriate er. background: the overall and disease-free survival of patients with rectal cancer is dependant on its staging, and adequate selection of the treatment strategy. mri has a proven efficacy in rectal cancer local staging and recognition of the adverse prognostic features. however, it can be difficult to utilise it as a navigation tool for surgeons, as it represents a complex three-dimensional pelvic space with a series of individual two-dimensional images. d image reconstruction has been successfully adopted in other surgical fields to overcome these limitations. aim: our primary aim is to develop a bespoke automated generation of patient-specific d pelvic models, which will improve surgical planning and navigation, patient interaction and surgical education. true-size, rotatable d models will offer a more realistic three-dimensional representation of the surgical space and its complex relationships, allowing for a more confident surgical rehearsal and potentially better utilisation of minimally invasive techniques in rectal cancer management. our secondary aim is to develop a large multipurpose database of the d models of male and female pelvis in health and in the disease. project description: our multidisciplinary team consists of colorectal surgeons, radiologists specialising in pelvic mri imaging and computer scientists. virtual d pelvic models are generated based on standard d dicom mri images routinely used for rectal cancer staging, which guarantees the high fidelity of cancer delineation. segmentation of the pelvic anatomy is performed with the use of itk-snap, an open-access, multi-platform software. machine learning technology is then employed to automate the d model generation, making it time-efficient, allowing for its clinical application. preliminary results: in the initial stage, using the manual segmentation, we have created ten models of normal male and female pelvic anatomy. a good inter-rater agreement level was found, which proves reproducibility of the approach applied. various machine learning algorithms are being explored to fully automate the process of d model generation, which will allow for their use in clinical practice and in development of the d colorectal database. the technology will be further implemented in creation of dynamic models of functional pelvic floor disorders. surgery, toho university omori medical center, tokyo, japan; surgery, neuchâtel hospital, neuch tel, switzerland background: laparoscopic gastrojejunostomies are time-consuming and require a specific training. alternatively, sutureless anastomosis can be achieved by means of endoscopically delivered magnetic rings. objective of the study: assessing the feasibility and reproducibility of an endo-laparoscopic gastrojejunostomy technique, using magnets coated with a fluorescent biocompatible polymer. methods and procedures: four pigs ( acute, survival models) and one cadaver were included in this study. the anastomotic device was composed of two magnetic rings ( x x mm; attraction force newton), each one attached to a cm long thread. the distal ring was inserted endoscopically into the first duodenum, and the extremity of the thread was clipped to the gastric mucosa. twenty-four hours later, a two-port laparoscopy ( mm, mm) was performed, using a near-infrared (nir) laparoscope (d-light-p; karl storz). the magnet's position in the jejunum was detected thanks to the transluminal fluorescence of the dye. magnetic interaction with the metallic tip of the laparoscopic grasper allowed to catch the ring and bring the bowel loop to the future anastomotic site on the gastric wall. simultaneously, the proximal magnet was delivered to the gastroesophageal junction using a flexible endoscope. the magnet was carefully advanced into the stomach allowing precise connection with the distal ring. in one cadaver the procedure was repeated. the sole variation was that, in order to reach the second jejunal loop, the distal magnet was placed using a gastroscope inserted through a transgastric port. in two acute animals, the distal magnetic ring was introduced into the jejunum via an enterotomy. the anastomotic procedure (from the distal magnet detection via fluorescence to the magnetic connection using a hybrid approach) was reiterated times. survival animals were followedup for days and underwent control endoscopies and ct-scans. results: the procedure was easy to standardize and reproducible, with a mean anastomotic procedure time of . ± . min. there were no technical problems and magnetic connection could be precisely directed in all cases, at both the anterior and posterior gastric wall. no complications occurred during the survival period and the anastomoses were patent by day . transluminal fluorescence allowed for a rapid detection of the magnet. colorectal cancer is the fourth most common cancer in high-income countries counting [ . deaths worldwide. survival rate reaches % in case of early diagnosis, falling down to % in case of advanced stage. conventional colonoscopy screening is limited by invasiveness, pain and often need of sedation. wireless capsule endoscopy enables inspection without discomfort, but passive locomotion often leads to incomplete and/or false negative results. the european endoo project (grant agreement ) aims to develop a novel system that overcomes most of the drawbacks of conventional colonoscopy, maintaining accurate and reliable diagnosis and therapy. the system is composed of an active robotic platform that magnetically drives a soft-tethered capsule; magnetic guidance is achieved through the magnetic localization of the capsule in combination with a closed-loop control that maintains an optimal and safe link between the capsule and the magnetic end-effector. a stereoscopic camera is integrated in the capsule for enhanced diagnosis though d reconstruction and automated detection of lesions/pathologies. the different modules of the endoo medical platform are illustrated in the figures. the robotic guidance systemconsists of an anthropomorphic manipulator that controls the capsule through an external permanent magnet. the robot, positioned on a dedicated trolley, is equipped with sensors for performing safe human-robot collaboration. the medical workstationincorporates: screens, buttons and pedals for visualization and command initiation, a joystick for system teleoperation and a back-end for fluidic control and data communication. the soft-tethered capsuleembeds an internal permanent magnet, magnetic sensors, an accelerometer, white and infrared illumination and an hd stereoscopic vision system with two wide-angle customized optics. a controller serves as the main control unitfor performing real-time communication and closed-loop control of the robot, localization system, capsule and physician commands. the synergistic cooperation of academic, industrial and clinical partners within the project allowed to develop and validate the system in in-vitro \/i [ , exvivoand preliminary cadaver sessions, performing comparisons with state-ofthe-art commercial colonoscopes. in conclusion, the endoo medical platform provides: reduced procedural pressures, user-friendly procedures, similar functionalities and performances of commercial devices, comparable procedural times and considerably lower costs with a new painless approach. background: this study is aimed at the comparison of the process of manual and robotic-assisted positioning of the electrode performing radiofrequency ablation with the usage of multifunctional robot-assisted surgical platform. under the control of the surgical navigation system. the main hypothesis of this experiment was that the use of a collaborative manipulator will allow to position the active part of the electrode relative to the center of the tumor more accurately and from the first attempt. we also check the stability of the electrode's velocity during insertion and consider some advantages in ergonomics using the robotic manipulator. methods: sphere-shaped tumor phantoms measuring mm in diameter were filled with contrast and inserted in cow livers. livers were used for the robotic experiment and an equal quantity for manual. the livers were encased in silicone phantoms. analysis of ct data gave the opportunity to find the entry and the target point for each tumor phantom. this data was loaded into the surgical navigation system that was used to track and record the position of the rf-electrode during the operation for further analysis. results: standard deviation of points from the programmed linear trajectory totaled in the average . mm for the robotic experiment and . mm for the manual operation with a maximum deviation of . mm and . mm respectively. standard deviation from the target point was . mm for the collaborative method and . mm for manual method. the average velocity was . mm/s for the manipulator and . mm/s for the manual method, but the standard deviation of the velocity relative to the value of the average velocity was . mm/s and . mm/s respectively.thus, in two criteria out of three, the manipulator is superior to the surgeon, and equality is established in one. surgeons also noticed advantages in ergonomics performing the procedure using the manipulator. conclusions: this experiment was produced as part of the work on the developing of the robotic multifunctional surgical complex. we can confirm the potential advantages of using robotic manipulators for minimally invasive surgery in case of collaborative practice for cancer treatment. surg endosc ( ) background and aims: laparoscopy has reduced tactile feedback compared to open surgery. in neuropsychological literature there is increasing evidence that visual and haptic information converge to form a mental representation of an object. through the combination of these inputs, this representation is believed to be more refined and robust. we investigated whether tactile exploration of a lifelike anatomical object before executing a laparoscopic action on this object in a laparoscopic box trainer improves performance of this action. description: a randomized prospective cohort study with two groups (a ? b) of ten laparoscopically naïve medical students was conducted. we compared the groups for baseline characteristics and performance, using a basic laparoscopic task (post and sleeve). to investigate the effect of haptic exploration, students performed ten repetitions of a laparoscopic needle action on a lifelike silicone caecum model (applied medical, rancho santa margerita, usa). group a did a pre-test visual exploration of the model. in group b manual exploration of the anatomical model was added to the visual exploration before executing the task. the box trainer was equipped with the forcesense tm (medishield, delft, the netherlands) system for skill assessment using objective force, motion and time parameters. results: baseline characteristics and-laparoscopic performance were comparable (p [ , ) . performances of trials on the anatomical model were captured and parameter outcomes were compared between groups. significantly less force (maximal force, maximal impulse, mean force and force volume) was exerted by the 'touch' group (p \ . ) (fig. ). this group also completed the task with less distance travelled by the instruments (p \ , ). there was no significant difference in time needed to complete the task (p = , ). conclusion: this study showed that, when performing a laparoscopic task on an anatomical model, pre-task haptic exploration of the model results in the use of significantly less force and less movement. adding haptic exploration to a laparoscopic training curriculum could therefore result in more efficient and more refined learning of laparoscopic actions. this, in turn, could lead to better, quicker and safer performance of laparoscopic operations. . esophagogastroscopy was performed before gabe and -week post-procedure assessing gastric abnormalities. weight and fasting plasma ghrelin were obtained at baseline, -, -, -and -months post-index procedure. after months, the sham group was unblinded and received gabe. both gabe and sham crossover to gabe groups were followed for months and received lifestyle therapy (behavioral-diet education). preliminary results: gabe was successful in all patients with no serious complications. significant, progressive weight loss was observed at and maintained at months. ghrelin in gabe group decreased by % ( . pg/ml) compared to baseline and months levels. weight-loss was approximately . % greater in the gabe group versus sham at months ( table ) . itt = intent-to-treat, pp = per-protocol analysis preformed using independent-sample t-test and à paired-sample t-test conclusions: gabe using eles is safe, accompanied by significant and so far maintainable weight loss. gabe using the eles demonstrated a reduction in ghrelin levels. aims: transanal total mesorectal excision (tatme) is the latest colorectal approach that continues to be in the spotlight. this study aims to describe the technique in depth by identifying and understanding technical advantages, errors and adverse events. methods: detailed video analysis using observational clinical human reliability analysis (ochra) was completed on clinical tatme cases performed by international surgeons. error frequency and error pathways leading to adverse events were described. tatme expert surgeons were interviewed and engaged in a workshop to elicit error-reducing mechanisms. results: overall technical errors and adverse events per procedure on average occurred ± . (range -- ) and ± . (range - ) times respectively. inadequate insufflation and poor camera optics were the most frequent set-up problems. instrument handling errors consisted most commonly of excessive grasper movement during the pursestring phase ( times total), inappropriate force applied ( times) with the energy device during the rectotomy, inappropriate force with the grasper ( times) and excessive movement with the energy device ( times) during tme dissection. incorrect dissection planes were created during tme dissection mostly due to insufficient retraction ( times) which didn't allow adequate exposure of the tissue planes. the most frequently occurring consequence was bleeding (mean: times per procedure). rectal perforation ( cases), vaginal wall injury ( cases), and prostatic injury ( cases) were also recorded. adverse events regularly occurred as a result of poor set-up/exposure, inappropriate retraction and/or instrument movement and incorrect plane surgery. error-reducing mechanisms and 'technical tips' describe specific steps and actions, both set-up/equipmentrelated and technique-related, that aim to prevent errors from occurring and avoid adverse consequences. ochra and individual feedback with error-reducing mechanisms developed by this study have been implemented into the national training programme for tatme. conclusion: tatme is an advanced complex procedure during which technical errors and their consequences are not infrequent. tatme requires knowledge of anatomy 'bottom-up', familiarity with its specialised equipment and technical skill working in a narrow space. appropriate structured training and mentorship are therefore recommended. surg endosc ( ) objective: insufficient vascular supply is one of the main causes of anastomotic leak in colorectal surgery. icg has been shown to provide information on tissue perfusion, identifying a well-perfused location for colonic and rectal transections and thus possibly reducing the leak rate. objective of this study is to evaluate the usefulness of intraoperative assessment of anastomotic perfusion using intraoperative indocyanine-green dye (icg) angiography in patients undergoing left-sided colon or rectal resection with colorectal anastomosis. methods: this randomized trial involved patients undergoing laparoscopic left-sided colon and rectal resection randomized : to intraoperative icg or to subjective visual evaluation of the bowel perfusion without icg (clinicaltrials.gov nct ). the primary aim was to assess whether icg angiography could lead to a reduction in anastomotic leak rate. secondary outcomes were possible changes in the surgical strategy and postoperative morbidity. results: after randomization, patients were excluded. accordingly, patients were included in the analysis; in the study group, and in the control group. icg angiography showed insufficient perfusion of the colic stump, which led to extended bowel resection, in cases ( %). an anastomotic leak developed in patients ( %) in the control group and in patients ( %) in the study group (p = n.s.). conclusion: intraoperative icg fluorescent angiography can effectively assess vascularization of the colic stump and anastomosis in patients undergoing colorectal resection. this method led to further proximal bowel resection in cases, however its role in reducing anastomotic leak rate should be studied in further research. endoscopic sleeve gastroplasty (esg) is a promising endoscopic bariatric procedure carried out with the application of transmural sutures resulting in a gastric reduction and gastric shortening. sutures are placed in u shape fashion, from the incisura to the fundus, which is preserved, using an over the endoscope suturing platform (overstitch, apollo endosurgery, austin, texas, usa). the choice of right lankmarks for suturing the gastric wall is extremely important for the efficacy and safety of the procedure. flexible endoscopy suffers from little anatomical reference points. correct spatial relation to precisely target the insertion of the helix device used for retraction and correct orientation of the full thickhness tissue bite require a good undrestanding of the anatomy of the stomach and sourrounding organs including vascular structures that could be inadvertently injured (left lobe of the liver, gallbladder, spleen, short gastric vessels, pancreas, transverse colon). surgeons by training can 'see' the anatomy beyond the gastric wall and undrestand whether they work in a safe layer or whether an underlying structure should be spared. this video illustrates all the potential risks realted with a wrong chioce of endoscopic landmarks when performing esg with respect to gastric and abdominal anatomy. introduction: central bisectionectomy, anterior sectionectomy, and posterior sectionectomy are technically demanding procedures in minimally invasive approach because of difficult expoure and extensive parenchymal transection planes. with limited robotic instruments including absence of cusa, these procedures have been rarely perfomed by robotic approach. method: consecutive robotic central bisectionectomy, anterior sectionectomy, and posterior sectionectomy were performed. patients were all males and were , , and -years-old, respectively. pathologic diagnoses were all hepatocellular carcinomas of each . , . , and . cm diameter. operative settings were identical for the three kinds of procedure. the patients were placed in supine with a reverse trendelenburg and right side elevation. umbilical -mm camera port, three -mm ports and additional -mm assistant port were used. glissonian approach and icg fluorescence image clearly demarcated the resection planes. parenchymal transection was performed using the maryland bipolar dissector and harmonic scalpel. the rubber band self-retraction method and third arm of robot system helped for stable and excellent exposure of surgical planes result: there were no conversions to laparoscopic or open surgery. the operative time was , , and min and estimated intraoperative blood loss was , , and ml. the pathologic surgical margin was . , . , and . cm. the length of stay after surgery was , , and days and there were no postoperative complications. conclusion: robotic central bisectionectomy, anterior sectionectomy, and posterior sectionectomy are still demanding procedures with long operative time. however, these procedures could be performed safely in regard to short-term perioperative outcomes. robot surgical system provided several benefits for anatomical hepatectomies including a stable and excellent operative field and clear surgical planes. suprapubic hernias (less than cm above the pubic arch in the midline) require important anatomical knowledge because of complexity of their repair and low incidence, by approximately % of all hernias. the problem to repair this type of hernias is that inferior margin of the defect is very close to pubic symphysis, consequently, mesh overlap is often inadequate. treatment of suprapubic hernias is controversial because of limited evidence in the literatura. this video shows the case of a -year-old female patient with suprapubic hernia with a defect of x cm. we performed a laparoscopic repair with a bilateral peritoneal flap of the groin region (as it is perfromed during tapp) for proper view of the pubic symphysis, cooper's ligaments, epigastric and major vessels, nerves and meticulous dissection the space of retzius. the defect was repaired by reconstructing the middle line with a running sutures. subsequently, titanium helical tacks were used to fix the mesh to the pubis and cooper and following the double-crown technique having special attention when fixing the mesh near to inguinal chanal, due to the possibility of causing chronic pain. the peritoneal flap was fixed over the mesh with abdsorbable fixation devices and seal with fibrin glue. laparoscopic repair of suprapubic hernias can be considered as the first option in treatment, because it endeavors to join the advantages of a minimally invasive approach and it is associated to low recurrence. the main advantages are that allows a proper visualization the anatomy and a proper fixation of the mesh. background and aim: thoracoscopic esophagectomy has been performed for two decades and becomes widely spread. we evaluate our cases who undergone the thoracoscopic esophagectomy and consider the future prospective of this operation.transient recurrent laryngeal nerve palsy after lymphadenectomy in this surgery is not rare and induces not only hoarseness but also aspiration or pneumoniae. new method to avoid this complication is desired. patients and methods: patients who received thoracoscopic esophagectomy in our institute from march to october were enrolled and studied retrospectively. operative indication is an all of the clinically resectable cases including with a neoadjuvant treatment or definitive chemoradiotherapy before surgery. overall survival rate of the patients with thoracoscopic approach and with thoracotomy until was analyzed. long term outcome of the patients with thoracoscopic esophagectomy was compared to the result from comprehensive registry of esophageal cancer in japan. short term results of the perioperative parameters were analyzed between left lateral decubitus position and prone position.we had introduced intraoperative nerve monitoring system for prone esophagectomy from . results: there was no significant differences of the survival rate between thoracoscopic group and thoracotomy group based on pathological stage. year survival without neoadjuvant treatment was . % (pstagei), . %(pstageiia), . %(pstageiib), . %(pstageiii), respectively. year survival rate of cstageii and iii with neoadjuvant chemotherapy was . % and year survival rate of the salvage esophagectomy after failure of definitive chemoradiotherapy was . %. every outcomes are as good as any reported results in esophagectomy. in the comparison of the lateral position with the prone position, total blood loss was significantly lower in prone position. inflammatory response after surgery was improved more rapidly in prone group, therefore, prone position is recommended as a minimally invasive procedure for thoracoscopic esophagectomy. transient recurrent laryngeal nerve palsy was observed % of patients. conclusion: thoracoscopic esophagectomy will develop further as a standard operation for esophageal cancer. nerve monitoring is useful for detecting recurrent nerve and avoiding nerve injury. background: laparoscopic total mesorectal excision (tme), in a wide female pelvis is usually technically easier than in a narrow male pelvis. however, this is not always the case, as the uterus and adnexae may obscure the views and hinder safe dissection, especially in obese patients. techniques such as graspers through additional ports or suspension with sutures through the broad ligament may potentially cause injury or need additional ports/assistants. aim: we present a novel technique using a self-retaining gynaecological uterine manipulator to improve access during deep pelvic laparoscopic surgery in female patients. technical tip: the operation is commenced in the standard manner for a laparoscopic rectal excision. once pelvic dissection is commenced, whenever it is felt that uterine retraction would be advantageous (depending on the level of the rectal tumour, size of the uterus and ovaries, obesity etc.) a self-retaining uterine manipulator (as shown in the video) is used. the tip of this disposable device is introduced into the uterus after dilatation of the uterine cervix. once the balloon at the tip has been inflated, the instrument is secure and hence there is no need for active manipulation by an assistant. the shaft can be rotated to allow anteversion/retroversion of the uterus to varying degrees as required to aid dissection. as the video depicts clearly, it acts as a self-retaining retractor for the uterus and is removed at the end of the operation. though the procedure is being demonstrated by a gynaecologist in the video, the instrument is quite easy to insert and some of our colorectal team have been trained as well. conclusion: the self-retaining uterine manipulator is an efficient tool for uterine retraction in laparoscopic rectal surgery and we have been using it routinely in tme in females for the past years, with no complications. this was previously published as a technical tip in the journal of minimal access surgerybut has never been submitted for peer review as a video. the authors present a video of two clinical cases treated by trans-axillary endoscopic approach. methods: a years-old male and a -year-old male presented with intermittent dysphagia and frequent reflux (class ii of lahey). one had a history of recurrent respiratory infections. the disease was characterized by oesophagogastroscopy (egd) and oesophagogram. trans-axillary approach with areolar port. step-by-step as follows: (i) dissection anteriorly to the pectoralis major muscle (ii) isolation of the anterior border of sternocleidomastoid muscle (iii) omohyoid muscle's isolation (iv) identification of the thyroid's upper pole (v) zd isolation (vi) myotomy of the cricopharyngeal muscle (vii) zd's resection with stapler and its withdrawn with sac. results: both cases progressed without complications. complete local recovery was verified in both cases one month after the procedure. conclusion: this technique seems feasible and reproducible, allowing zd diverticulectomy with a better cosmetic result and perhaps lower surgical site infections (ssi). in the authors' knowledge, this approach to dz has never been published. background: gastric leak occurs in - % of patients who undergo roux-en y gastric bypass (rygb) for morbid obesity. the pathophysiology may be related to gastric ischemia, fistula, or ulcer.gastric leak is a severe complication of gastric bypass (gbp) that is associated with significant morbidity and mortality. fistula may have several clinical impacts, depending on patientrelated factors, fistula characteristics, onset time, and therapy proposal. abdominal drainage, gastrostomy, and revisional surgery constitute the traditional approaches to dehiscence and fistula closure, with variable results. methods: we present a video of a clinical case of -year-old lady with body mass index of kg/m who underwent roux-en-y gastric bypass and h later presentedtaquicardia and right cuadrantum pain. the ctscan inform a apical leak at the gastric pouch level. the video shows the relevant aspects of a revisional surgery and the key points to drain the fistula and close de defect laparoscopically. results: after monts, the patient achieved succesful results, defined as a stabel clinical situation with image evidence of gastric fistula remision. conclusions: gastric bypass (gbp) is one of the most efficient bariatric interventions in morbidly obese patients. the most severe risk of this procedure seems to be the staple line leak, and the management of this complication can be very arduous. without any guidelines it is very difficult to determine the right procedure addressing the staple line leak after gbp. laparoscopic sleeve gastrectomy (lsg) has become the most commonly performed operation worldwide as a primary bariatric/metabolic procedure. however, conversion to other surgical procedures such as roux-en-y gastric bypass (rygb) or one anastomosis gastric bypass (oagb) have been described as treatment options for inadequate weight loss after lsg and unresolved co-morbidities or complications such as leak, stricture, and severe gastroesophageal reflux disease (gerd). we present two clinical cases of weight regain and severe gerd and dysphagia, which account for the main indications to reversal of lsg to either oagb or rygb. aims: we show in the video the surgical technique that we perform by laparoscopic aproach, in order to construct a roux-en-y polipropilene banded gastric bypass lrygb-b. methods: we are performing this procedures within a prospective randomized trial that is design to compare the long term results of lrygb-b versus the standard laparoscopic roux-en-y gastric bypass.the video shows our technique in a case of a years old female with a bmi of kg/m . first we create a vertical gastric pouch of about - ml, and a polypropylene mesh ( x mm) is placed - mm proximal to the anastomosis around the gastric pouch, with the help of a laparoscopic band retractor. after that a cm roux-en-y limb is constructed in an antegastric antecolic fashion, been the lenght of the biliary limb cm. a mm gastroyeyunal anastomosis is performed with a linear stapler, and the enterotomy and gastrostomy are closed with a / barbed running sutures. jejunojejunostomy anastomosis is constructed in similar fashion, but with a lenght of - mm. the petersen space and the mesenteric defect are closed with polipropilene / sutures. results: patients has been operated following this technique, and there has been no complications related to the polipropilene band. (the ramdomized prospective trial is still ongoing). conclusions:the video shows a reproductible easy way to perform a lrygb-b using a polipropilene mesh. introduction: a -year old female patient presented at our clinic two years after initial rouxen-y gastric bypass. she had had a preoperative bmi of , and had a significant weight loss which resulted in a bmi of , at two years postoperatively. she currently suffered from severe dumping with glycaemia levels dropping to mg/dl. pharmacological treatment with metformine, sandostatine and acarbose did not yield any results. on top of these problems she felt less restriction, could eat large portions and had gained kg in the last three months. objective: the usual approach for severe dumping-related hypoglycemia would be to undo the gastric bypass. this patient however was extremely anxious to regain weight, so we sought other options. we assumed that by adding more restriction and slowing down the emptying of the gastric pouch we could alleviate some-if not all-of the dumping related symptoms and prevent further weight regain. methods: in this video we present the banding of a gastric pouch for severe dumping after rouxen-y gastric bypass. results: although unconventional, the banding of the pouch yielded excellent results. the slower pouch emptying and reduced portions resulted in a near complete remission of all symptoms. as an additional benefit we found a slight weight loss of four kilograms six weeks postoperatively. conclusion: the usual treatment of severe dumping-related hypoglycemia would be an undo of the gastric bypass. in this case however the patient was extremely anxious to regain weight, being very pleased with the results her gastric bypass had yielded. in agreement with both the patient and treating endocrinologist we attempted a different approach. the slower pouch emptying and increased restriction offered another way to alleviate the dumping and deep hypoglycemia while concomitantly resulting in weight maintenance. aim: the aim of this video is to present a novel surgical technique to avoid stent migration after endoscopic placement in patients with leakage subsequent to laparoscopic sleeve gastrectomy (lsg) . methods: this video shows the case of a patient (bmi , kg/m ) who developed an upper gastric leakage days after lsg. a ct scan showed a small leakage at the eg junction complicated by intra-abdominal abscess. a ct guided percutaneous drainage of the abscess was performed. a stent placement was attempted endoscopically three times and failed for migration. we decided to place laparoscopically a non adjustable gastric ring (nagr) around the stomach, in order to avoid stent migration.first of all the stent is replaced endoscopically in order to cover the fistula tract. the patient is placed in a half sitting position and the pneumoperitoneum was obtained using a veress needle in left subcostal space. a port technique is used as in standard laparoscopic sleeve gastrectomy.the procedure starts with the mobilization of adhesions, the fistula is identified in the upper part of the tubule.the gastric tubule is isolated and the lesser omentum is opened. the blunt needle at the tip of the ring is passed retrogastrically, a tourniquet can be useful is the positioning turn out to be difficult. the nagr is then closed over the gastric tubule containing the stent. a drain is finally placed. results: the stent was removed after weeks. a gastrointestinal ct scan with oral contrast showed a complete resolution of leakage. after months the patient was in a good condition with bmi , kg/m . the stent was endoscopically removed after weeks. a gastrointestinal ct scan with oral contrast showed a complete resolution of the leakage. after months the patient was in a good condition with bmi , kg/m . conclusions: this new technique is feasible and effective, as shown in this video; however the nagr can lead to complications, so a strict follow up is needed and if any complication appears, should be considered to remove laparoscopically the ring. introduction: in this case, we will discuss the case of a year old male patient who underwent a laparoscopic cruraplasty and gastric plication resulting in a weight loss of kg. other medical history reported insulin-dependent diabetes, reflux esophagitis and sleeping apnea with cpap. two years after gastric plication the patient presented with passage problems, gastro-esophageal reflux and epigastric pain. to this end a swallow test was performed revealing a large fundus with a restricted passage of contrast. due to the persistent complaints and the abnormal findings on barium swallow a surgical re-intervention was needed. objectives: despite the current bmi of and the age of the patient, conversion from a gastric plication to a roux-en-y gastric bypass was performed. several other surgical options were considered, including an undo of the gastric plication or a dilatation with a resizing of the fundus. methods: in the video we describe the laparoscopic approach for a conversion of a gastric plication to a roux-en-y gastric bypass. results: at months follow-up the patient showed a weight loss of kg and the resolution of his earlier symptoms. the patient had a normal oral intake without any gastro-esophageal reflux or epigastric pain. conclusion: after a gastric plication, partial loosening of the sutures and stenosis are both wellknown complications. as presented in the video, it is apparent that a laparoscopic undoing of gastric plication is not as straightforward as it seems. firm adhesions between folds can compromise the procedure and inhibit a complete separation of the tissues. we believe that in these cases the best surgical approach is to convert to a roux-en-y gastric bypass. laparoscopic sleeve gastrectomy (lsg) is a relatively new surgical approach in the weight loss surgeon's armamentarium. in literature there is a consensus about the importance of mobilizing completely the gastric fundus before transection. the resg (revised sleeve gastrectomyresleeve) may be a valid option for failure of primary lsg. we focused the attention on the consequences that can have an incomplete resection of gastric fundus during an operation of sleeve gastrectomy and how they can be solved by the repetition of this procedure. a sleeve gastrectomy was performed in an obese -year-old woman (bmi = ). three days after the operation, an upper gi x-ray with gastrografin did not show any abnormalities. three months after the surgical procedure, the woman referred frequent episodes of vomiting and a significant weight loss ( kilos). an upper gi x-ray with gastrografin demonstrated the presence of multiple communicating cavities of the gastric fundus. the esophagogastroduodenoscopy (egd) showed that the gastric tube close to the esophagogastric junction was separated from a recess ( - cm in diameter) by an incomplete septum. a severe hypokalemia and consequent ecg abnormalities were treated with intravenous infusion of potassium. then, we performed a laparoscopic operation. the gastric tube was completely released along the suture line of the previous operation and, especially, the posterior surface of the upper part until the left crus of diaphragm became evident. under the guide of the bougie, the recess was removed. results: the clinical course was regular, and the patient was discharged on third post-operative day after an upper gi x-ray with gastrografin which demonstrated the absence of leakage and a normal gastric tube. after year, the patient was very satisfied with the operation. conclusions: the complete mobilization of the gastric fundus allows to see clearly which part should be resected to obtain an adequate gastric tube and facilitate a correct placement of the stapler. in our experience, in patients with a residual fundus, an upper gi x-ray with gastrografin and an egd are needed to exclude the presence of stenosis. then, a resleeve gastrectomy is an efficient and safe procedure to treat this post-lsg complication. weight regain is one of the main problems in bariatric surgery. we have many surgical option but when we evaluate patients with long follow up and bmi of superobese patient before the first surgery, the weight recidivism can arrive up to - % at years.in most cases the first surgery is a restrictive procedure, and in many cases sleeve gastrectomy.here we present a case of weight regain after laparotomic super-magenstrasse (that we consider like a sleeve gastrectomy except for remnant removal) with a big incisional hernia. after a complete multidisciplinary re-evaluation we decided to perform an oagb (one anastomosis gastric bypass) but in this case we decided to create a functional exclusion to the duodenal transit by positioning a minimizer ring. this solution is effective in food diversion and guarantee gastric and duodenal endoscopic exploration in case of need. we think that this technique can represent an option to take in account for selected cases. at the end of bariatric procedure we perform a laparoscopic repair of incisional hernia with mesh in the hope to avoid future surgery and post operative small intestine herniation. patient rejected additional bariatric procedures and in fact she has gained kg two years later (bmi . ). conclusions: lagb gastric erosion is uncommon ( . - %) . intraoperative (such as perigastric approach) and patient related factors (smoking, alcohol…) have been described as risk factors. the most frequent clinical presentation is weight loss failure; band and port issues (such as infection) are also frequent. erosion is infrequent to present as an acute event (\ %: peritonitis, abscess…) or asymptomatically (\ %). diagnosis is mostly performed under upper endoscopy. the most common therapeutic technique is removal of the band (by endoscopy or surgery), repair of the stomach, if needed, and band replacement (at least three months later). some authors have performed immediate replacement but the incidence of recurrent erosion seems to be higher. other options are lagb removal alone or conversion to different bariatric procedure. for endoscopic removal, it has been advised to wait until the band buckle is in the stomach and is sometimes very difficult. replacement of the band is not associated with weight regain. she reports years of evolution presenting moderate intensity heartburn that was exacerbated during the night as well as submit occasional rejurgutation. the intensity of the symptoms is attenuated by maintaining a diet without irritants and improving feeding times. denies hematochezia, unintentional reduction of weight, dysphagia or early satiety. the patient has suffered from obesity since childhood, after pregnancy she had progressive weight gain and difficulty in controlling blood sugar, so she is scheduled a gastric bypass roux-en-y . preoperative endoscopy was performed, evidencing submucosal tumor in the gastroesophageal junction at of the dentary arch, approximately cm in diameter. an endoscopic ultrasound was performed, demonstrating subepithelial lesion of the gastroesophageal junction, hypoechoic, with well-defined borders, pseudobilobulated, . cm x . cm, and dependent on the external muscular layer. a fine needle aspiration is performed in which spindle cells are identified, leiomyoma is likely diagnosed. it is programmed for laparoscopic resection of submucosal gastric tumor, gastric bypass and laparoscopic cholecystectomy. a tumor at the level of the gastro esophageal junction of approximately . cm is identified in the surgery, which can be resected by laparoscopy without complications. the patient is discharged after days of postoperative stay. the final histopathological result: leiomyoma of . cm with free edges. cd (-) gog (-) caldesmon (?)s (?). background: fifty percent of patients who have undergone gastric bypass, posterior reversal and sleeve gastrectomy and finally complete hiatoplasty presents symptomatic gastroesophageal reflux disease. surgical reinforcement of the lower esophageal sphincter is necessary to prevent acid reflux. here, we describe ligamentum teres cardiopexy, a surgical technique that reinforces the lower esophageal sphincter and restores its competence with a new valve, in patients with previous conversion of sleeve gastrectomy to gastric bypass and hiatal hernia repair. methods: we present the surgical techhnique performed to a patient with initial gastric bypass who underwent sleeve gasterctomy for hipoglycemias and hiatoplastia for severe gerd. persistent gerd requested to undergo ligamentum teres cardiopexy. in this procedure, the ligamentum teres is released from its umbilical connection and the hernia reduced by manual traction, freeing the last - cm of esophagus in the abdomen. the distal ligamentum teres is fixed with one stitch to the apex of the angle of his, one at the gastroesophageal junction, and one joining the gastric fundus to the esophagus. the remainder of the ligamentum teres is fixed over itself with four to six stitches, forming a necktie cardiopexy. the procedure concludes with diaphragmatic crus closure. results: after months, the patient achieved successful results, defined as resolution of gerd, no protonpump inhibitor (ppi) use, and manometry measurement over mmhg after surgery. conclusions: ligamentum teres cardiopexy combined with closure of the gastric crus is a late alternative treatment for gastroesophageal reflux disease in patients with previous sleeve gastrectomy and hiatal hernia. general surgery, ponderas academic hospital, bucharest, romania introduction: as metabolic surgery techniques evolve during the years, we have to face more and more patients with complications ands uboptimal results after the older/initial procedures. vertical banded gastroplasty(vbg) is one of those procedures that gain momentum during the initial experience in bariatric surgery, but has proven to have dissapointing results and a lot of complications, nowadays surgeons having to deal with difficult revisional operations. aim in this video: we want to present from our experience the difficulties encountered during the revisional surgery, rouxen y gastric bypass (rygbp)aftervbg, and the tips and tricks that will make this a safer and easier procedure. objective: after thorough preoperative assessment and a review of the literature multiple treatment options were considered. the procedure of choice ended up being a laparoscopic adjustable gastric banding, with the objective to achieve optimal weight loss with the lowest risk for complications. methods: in this video we present the placement of an adjustable gastric banding in a patient with a cirrhotic liver and portal hypertension and the possible pitfalls. results: postoperatively there were no complications and patient had a satisfying weight loss both months and year postoperatively. in a short review of the literature we've found that bariatric surgery is feasible in patients with portal hypertension as long as the patient is not decompensated or has bleeding varices. conclusion: cirrhosis and portal hypertension are no absolute contraindication for banding, sleeve or rny gastric bypass as long as the patient is not decompensated or has bleeding varices. the type of surgery is dependent on patient and surgeon-related factors. the aim should be to achieve optimal weight loss with the lowest possible surgical risk in this type of patients. surg endosc ( ) :s -s introduction: in this case, we will discuss on a year old female patient who had undergone a laparoscopic nissen fundoplication years ago due to gerd grade b. because of morbid obesity a n-sleeve gastrectomy was performed year ago resulting in a weight loss of kg. at presentation she had regained all the lost weight, resulting in a bmi of , . the patient history also reported insulin-dependent diabetes and obstructive sleep apnea with cpap. gastroscopy was performed showing a large residual fundus but no esophagitis. on the subsequent upper gi series a relatively wide sleeve with an intact nissen-collar was detected. objectives: a laparoscopic conversion to a roux-en-y gastric bypass was performed. other potential surgical treatment options are a sadi procedure or a sleeve gastrectomy with transit bipartition (santoro procedure). methods: in the video we describe the laparoscopic approach for a conversion of a n-sleeve to a roux-en-y gastric bypass. results: at month follow-up the patient presented with a weight loss of kg. the patient had good restriction on oral intake and did not have any reflux-related symptoms or complaints. conclusion: conversion from a n-sleeve to a roux-en-y gastric bypass is a challenging procedure. the largest pitfall during the creation of the gastric pouch is to staple a double fold of the nissen fundoplication. we believe that in these rare cases of weight regain after n-sleeve, the best surgical approach is to convert to a roux-en-y gastric bypass. four years later, in , a laparoscopic conversion to roux-en-y gastric bypass was performed because of weight regain. she now presents with satisfactory and stable weight loss over the last few years. she was recently diagnosed with a brca- mutation for which she underwent a bilateral ovarectomy and mastectomy. the patient's brother was also diagnosed with this mutation and died of pancreatic cancer at the age of . genetic counseling advised a twoyearly follow-up because of an increased risk up to % of developing pancreatic cancer. control gastroscopy showed a normal esophagus and gastric pouch. control ct scan revealed hypertrophic stomach creases in the excluded stomach. these results prompted a laparoscopy-assisted gastroscopy of the excluded stomach which uncovered hypertrophic stomach glands and intestinal metaplasia on biopsy. methods: in this video we demonstrate the laparoscopic approach for complex revisional bariatric surgery. conversion from rny gastric bypass to a sleeve gastrectomy in a patient who already underwent a vbg. the focus of the video is on a manual gastro-gastrostomy with partial gastrectomy of the fundus and part of the stomach where the old vbg-band was placed. results: after , months follow-up the patient had no complaints and a stable weight. upper gi series shows a normal passage of contrast through the sleeve gastrectomy. conclusion: endoscopic surveillance of the remnant stomach and echo-endoscopy of the pancreas is no longer possible after rny gastric bypass. in cases where the need for such a surveillance arises after a rny bypass a patient-tailored approach is necessary. in our patient a laparoscopic conversion from a rny gastric bypass to a sleeve gastrectomy was performed. this approach keeps the patient's wish for weight loss intact while enabling further surveillance through natural-orifice endoscopy. a -year-old morbidly obese japanese woman with a body mass index of kg/m suddenly complained of swallowing difficulty months after laparoscopic roux en y gastric bypass surgery with retro-colic roux limb route. an internal hernia of the defect of the transverse mesocolon was suspected by computed tomography, and emergency intervention was performed. the surgery revealed no internal hernia. however, strong inflammation and adhesion were observed between the transverse mesocolon and the retrocolicroux limb. in addition, the roux limb on the oral side of the adhesion site was dilated and bent.the adhesion between the transverse mesocolon and the flexed roux limb was dissected, linearized and re-fixedby suturing to the transverse mesocolon. however, since the difficulty of oral intake persisted re-do surgery was performed again. after resecting the roux limb involved in the severe inflammation, a 'new' roux limb was lifted to the cephalad via the ante-colic route. finally, the gastric pouch and roux limb were re-anastomosed with - absorbable sutures in an interrupted full thickness single layer manner. in the present case, we experienced difficulty with both adhesiolysis and determining the accurate target line to resect at the 'old' gastrojejunostomy. however, blocking the blood flow of the 'old' roux limb facilitated the accurate recognition of the target line. esofagogástrica, cirugía general y ap digestivo, hospital regional universitario de málaga, malaga, spain; hepatobiliopancreática, hospital regional universitario de málaga, malaga, spain introduction: marginal ulcer is one a serious complications after a bariatric gastric bypass. tobacco, non-steroidal anti-inflammatory drugs (nsaids) and helicobacter pylori (hp) infection are known risk factors. methods: we present a -year-old women operated years before of bariatric surgery with a gastrojejunal (gy) bypass technique due to intraoperative dehiscence of the staple line after attempting a vertical gastrectomy (sleeve). she has persistent vomiting and epigastralgia from months after the intervention, affecting his quality of life. upper gastrointestinal endoscopy (uge) was performed, describing an ulcer in the gy anastomosis. she started hp eradication treatment, treatment with proton pump inhibitors (ppis), tobacco and nsaids were discontinued, but she had slight improvement. after months the uge was made again, which show peptic esophagitis and marginal ulcers. the plasma gastrin level was normal. due to the persistence of symptoms despite conservative treatment, we decided reoperation by laparoscopy. we found herniated bowel in petersen space, which were reduced and the space was closed. we proceeded to truncal vagotomy. the gy anastomosis was resected ( fig. ) and performed again. finally, we perform antrectomy. the pathological anatomy showed ulceration. she was diacharged home on the th postoperative day without any complications. results: a marginal ulcer after bariatric surgery appears in the jejunal mucosa of the g-y anastomosis. the symptoms are epigastric pain, nausea and vomiting. acid, tobacco, nsaids and hp infection has an important role in their development \ sup [ . \/sup [ the first treatment is medical, discarding out the risk factors, but if it is not effective, it will be surgical, resecting the previous anastomosis. the usefulness of vagotomy is debatable, but the percentage of success increases. in our case, we perform antrectomy to avoid retained antrum syndrome. the hernia through petersen space is a cause of intestinal obstruction and abdominal pain as the case presents. although we believe that the symptoms were mainly caused by the marginal ulcer, the internal hernia was probably a symptomatic cause. conclusion: the treatment of a marginal ulcer is medical, eliminating the risk factors, but if it is not effective, the surgery is indicated. results: bowel's measurements and confection of the gastric pouch are identical in both cases. in the first case, intestinal anastomosis is performed in the inframesocolic compartment once small bowel has been divided. in the second case, such union is made next to the gastrojejunal anastomosis with the bowel uncut, making the section once no leakage has been found conclusions: laparoscopic roux-en-y gastric bypass is currently considered one of the technique of choice in the surgical treatment of morbid obesity. there are variations and alternatives for its realization. to know them can allow to individualize the technique to each type of patient. we present a clinical case of a year old female. she had a vertical banded gastroplasty procedure (in another clinic) years ago with an initial weight loss of kg in a period of months. she was seen at our clinic because she was suffering from dysphagia to solids and general diffuse abdominal pain for the last month. at physical exam we found a bmi of and nothing else called our attention. we did an upper gi endoscopy and egd transit; we concluded that a gastric bypass would offer her the best results. therefore, we converted her vertical banded gastroplasty into a gastric bypass laparoscopically. she had an uneventful postoperative period and was discharged home without complications. aims: sadis emerged as a modification of biliopancreatic diversion with duodeno-ileal switch (bpdds) in which after sleeve gastrectomy (sg), the duodenum is anastomosed to an ileal loop in a billroth-ii fashion. sadis has promising outcomes for weight loss and comorbidity resolution in morbidly obese patients avoiding the high morbidity of biliopancreatic diversion with duodenal switch. clinical case: -year-old patient, subjected to bariatric surgery two years ago, including a sleeve gastrectomy (sg). despite this operation and dietary and hygienic modifications, the patient gained weight in recent months, reaching a bmi of kg/m and an overweight of kg. an endoscopy was carried out on her, which provided evidence of a gastric remnant of moderate size with flexible tissue, normal peristalsis, and fast disposal speed. the case was discussed in a joint session, leading to the decision to apply revision surgery. the decision was taken to apply sadis, a novel technique that had never been used before in andalucia. the rate of weight re-gain after the use of classical techniques such as sleeve gastrectomy (sg) or the roux-en-y gastric bypass (rybg) is considerable high. revision surgery due to weight re-gain is necessary in many of these cases. sadis emerged as a simplified alternative to the use of bpdds as revision surgery following a gv due to weight re-gain with good short-term results, in terms of both weight control and comorbidity control. since only one anastomosis needs to be applied, chirurgical time diminishes, as well as the rate of surgery-related complications. moreover, it could be used, through laparoscopy, for patients who have undergone previous, complex abdominal surgery. conclusion: sadis showed a promising short-term weight loss outcome and comorbidity resolution rate but long-term data are missing and there is currently a high level of technical variability. on the other hand, further studies are required to measure its cost-effectiveness compared to the currently popular bariatric procedures, sg and rygb. aims: the lps sleeve gastrectomy is the most common bariatric surgery technique because it has a low surgical complexity and acceptable weight loss results. however, - % of patients present with an insufficient weight loss, weight regnances, reflux or dysphagia. in these cases, it is recommended to perform a second bariatric surgery to combine a component of malabsorption such as gastric bypass or duodenal switch. the video describes the technique of a laparoscopic biliopancreatic diversion with duodenal switch with a previous laparoscopic sleeve. the objective is to describe the safety of the technique and the subsequent success of it. methods: a -year-old female patient presented morbid obesity with a bmi of after performing a laparoscopic sleeve gastrectomy in . initially, she presented a percentage of excess weight loss of %, reaching a bmi of after two years of follow-up. after this, she suffered a reganancia of all the weight lost despite diet and exercise, presenting a bmi . a study was made with tegd where no complications of the previous surgery or symptoms of gastroesophagical reflux or dysphagia were observed. the lps duodenal switch is proposed in the obesity unit committee in , without immediate postsurgical complications. the patient presented a favorable postoperative period and was discharged three days postoperatively. results: at the present time, the patient has achieved a % excess weight loss and has a bmi of . . presents good oral tolerance with stools a day without urgency. it doesn't present protein deficioncies. vitamin deficiencies are orally supplemented. the lps duodenal switch is a technique that can be performed after a sleeve gastrectomy safely in cases of insufficient weight loss or weight reganancia. the patients presented a greater weight loss after the duodenal switch than after the gastric bypass, observing a lost of excess weight of % compared to %. the differences being statistically significant. weight regain after gastric bypass is a challenging problem. a number of revisional surgical options have been reported. this is a case of a year-old woman years after lrygb. her initial bmi was , lowest after surgery- , at presentation- . the video shows a robotassisted laparoscopic conversion of rygb to loop duodenal switch. the roux limb is transected and dissected to the gastrojejunostomy. the gastrojejunostomy is resected and the gastric pouch is recreated over a bougie. the gastric blood suply is confirmed with icg. a gastro-gastrostomy is created to restore gastric continuity and a sleeve gastrectomy is performed. the duodenum is devided and a duodeno-ileostomy is created cm from the ileocecal valve. the remaining roux limb is resected. the patient recovered uneventfully. conversion of rygb to loop duodenal switch requires creation of as little as two anastomoses, in comparison to standard ds, which requires four. it is a safe option for patients with weight regain after lrygb. methods: irb approval and informed consent have been obtained. a dissection is conducted to separate the descending mesocolon of the gerota's plan from the medial aspect to the peritoneal lining to the left parietal gutter. the peritoneal layer is incised parallel to the vessel and close to the colonic wall. the dissection is continued anteriorly up to reach the resected parietal gutter. a passage into the mesentery of the upper rectum is created for the allocation of the stapler and the dissection of the rectum. these maneuvers permit to straighten the mesentery simplifying the identification and cutting of the sigmoid arteries. a caudal-to-cranial dissection of the mesentery is performed from the sectioned rectum to the proximal descending colon by a sealed envelope device. it can be very useful to mobilize the colon in any direction: laterally, medially, or upward. the dissection is performed along the course of the vessel up to the proximal colon, with progressive sectioning of the sigmoid arterial branches. the specimen is extracted by a pfannenstiel incision. the anastomosis is performed transanally with a circular stapler according to knight-griffin technique. results: we performed a laparoscopic segmental colectomy using this approach for patients with benign sigmoid lesions: diverticulitis, flat polypoid lesions (no lift-up sign), and bowel endometriosis. the mean operative time and blood loss were . ± . min and ± ml, respectively. there were not a single conversion to open surgery and no any leakage or stricture. only cases of intraluminal bleeding and case of wound infection (treated conservatively) were observed. conclusion: we consider this approach to be safe and useful for segmental colectomy to be performed sectioning the sigmoid artery close to the colonic wall. aims: to show a clinical case with a video of a patient was operated for colon cancer in hepatic angle by a single suprapubic incision (ssilrh). methods: a -year-old male assessed for abdominal pain and weight loss. on physical examination: a painful mass was detected in the upper right quadrant. the colonoscopy revealed an ulcerated lesion in the hepatic angle and the biopsy revealed a moderately differentiated adenocarcinoma. in the abdominal ct a mass of x cm was observed (figure). the patient was operated with ssilrh technique, as shown in the attached video. results: the patient was placed in the supine position and with the legs separated. the surgeon is placed between the patient's legs. a transverse incision of the skin was made in the middle line of . cm to cm above the pubis. the underlying fascia was divided transversely, the rectus abdominal muscle was exposed, a purse-string suture placed in the fascia. an mm reusable trocar was inserted for the chamber, a mm reusable flexible trocar was placed at the o'clock position and another trocar was placed at the o'clock position. the ileocecal valve was released from the peritoneal parietal foil, as well as the mesocolon right by a lateral to medial approach to the second portion of the duodenum. the hepatic angle was also dissected from lateral to medial. for the anastomosis, the mm trocar was replaced with a mm trocar and a stapler was placed. a mm °chamber was inserted through the mm flexible trocar. the small intestine was divided as well as the proximal transverse colon with endogia. an intracorporeal ileocolic anastomosis was performed. the piece was removed through the suprapubic incision. he was discharged after days without complications. the histological studies confirmed a differentiated adenocarcinoma of x x cm. the surgical margins were free, without infiltrated lymph nodes ( / ) with stage pt n . the ssilrh technique allows a complete resection of the mesocolon and complies with the oncological principles. they can present with abdominal pain, nausea, acute abdomen, symptoms of intestinal obstruction or asymptomatic with incidental diagnosis. their diagnosis can be difficult. the objective is to demonstrate the safety and efficacy of the laparoscopic approach in this infrequent pathology. material and methods: we present a video of the surgical intervention of a -year-old patient, with functional dyspepsia, with a casual diagnosis of a pseudocystic mass of the right colon after performing a ct scan: giant diverticulum of the hepatic colon angle with fecaloid content inside it under tension the patient goes to the emergency room for acute abdominal pain, pending colonoscopy, antibiotic treatment is established, and a laparoscopic approach is decided upon after the patient's evolution. results: intervention: complete laparoscopic approach, trocars. large size tumor in the right colon, diverticular in appearance, with stony content inside, with locoregional adenopathies, oncological radical right hemicolectomy, manual intracorporeal anastomosis, correct postoperative, hospital discharge. on the th day. definitive pathological anatomy: giant diverticula on areas of intense mucosal ulceration, free edges. conclusion: the laparoscopic approach of the symptomatic diverticula of the right colon is safe and effective. introduction: minimally invasive transanal surgery (tamis) is a surgical technique whose established indications are the complete exeresis of rectal polyps that are not resectable endoscopically or early rectal neoplasms with good prognosis criteria. transanal devices with gel platform facilitate dissection in this field. however, one of the drawbacks of this approach is the oscillation of the right nerve, which hinders dissection and prolongs the surgical time. material and methods: we present the case of a patient with a central depression neoformation, located cm from the anal margin in the posterior aspect of the rectum in a male patient. the lesion occupies % of the circumference and was considered unresectable endoscopically. the endoscopic biopsies showed a tubulovillous adenoma with moderate dysplasia. results: an exeresis of full thickness of the rectal wall is performed, with subsequent suture of the defect. we show in the video the use of a glove interposed in the pneumoperitoneum gum to maintain the stability of the neumorectum and the technique of dissection and suture, as well as the stability of the neumorectum with this technique throughout the procedure. the use of a glove as a reservoir to stabilize the nemorectum is an economical and easy-to-use method that can safely replace extra devices. aims: endometriosis is a gynecologic disorder defined by the presence of endometrial glands and stroma outside the uterine cavity. deep infiltrating endometriosis (die) invades mm to the retroperitoneum of the pelvic sidewalls, the rectovaginal septum, or the muscularis of the bowel, bladder or ureters. the rectum is being the most common bowel site of involvement. for symptomatic die, medical therapy should always be the first-line treatment. therefore, a minimally invasive approach using laparoscopy is considered the gold standard option and challenging aiming at complete disease excision. also, there are several advantages of natural orifice specimen extraction when compared with abdominal incision that may directly impact the postoperative results of these young patients. methods: we report a case of a -year-old female with a -month history of chronic pelvic pain, dyschezia and rectal bleeding. these symptoms were refractory to hormonal, antispasmodic and opioid therapy. magnetic resonance imaging reported a nodule x cm invading the rectal wall cm to the dentate lane. we performed a laparoscopy and we found the nodule at the uterine posterior wall invading the rectal anterior wall. the nodule was invading into the rectum in a large area so we proceeded with segmental resection and added hysterectomy and salpinguectomy because it was the preference of the patient. the anastomosis was created intracorporeally and the specimen was removed through the vagina performing in this way a totally laparoscopic procedure with natural orifice specimen extraction. results: the total operative time was h, the postoperative stay was uneventful and the patient was discharged on day four. the pathological report showed an endometrioma cm length predominantly involving colonic muscularis propria. conclusion: laparoscopic surgery is a safe and feasible approach for the surgical management of deep infiltrating endometriosis of the rectum and the gold standard for female young patients that often need multiple surgeries. in addition natural orifice specimen extraction avoids potential complications of abdominal incisions. week-day surgery, university, sapienza, ospedale sant'andrea, rome, italy; urology, clinica mater dei, rome, italy aims: we describe a case of a patient affected by a mass in the left kidney and a diverticular stenosis of the sigma. methods: a years old woman complained abdominal pain in the left flank of the abdomen and in the left iliac fossa radiated to the hypogastrium, with fever and no passing flatus. contrast enhanced computer tomography scan (ct-scan) showed a cm mass of the superior pole in the left kidney and a colonic diverticulitis with thickness of the wall and a microperforation of the sigma. she underwent to medical therapy with resolution of the diverticulitis. after weeks a laparoscopic nefrectomy and sigmoidectomy was planned. patient was positioned on the right flank. this position was kept for both the procedures. we performed four trocar accesses along the left subcostal region and a periombelical incision for the specimen extraction. results: post-operative course was uneventful. patient was discharged in post-operative day. istopathological exam showed a renal cell carcinoma confined to kidney with no positive lymph nodes and a diverticular stenosis of the sigma. laparoscopy allowed to perform two fine procedures in a critical situation using few trocar incisions and obtaining good results. background: hartmann procedure consists in a sigmoidectomy followed by a terminal colostomy. stoma is associated with complications and suboptimal quality of life, so the restoration of colonic continuity should be at least considered in any case. open restoration has been associated with significant morbidity and mortality. many authors have described the advantages of laparoscopic hartmann reversal. we want to go a step further showing our experience using a combined laparoscopic and transanal approach in an attempt to improve the surgical technique in a patient with previous abdominal surgeries and a rectovaginal fistulae. methods: the transanal and laparoscopic team work simultaneously. by the abdominal approach a pericolostomic incision is made, the distal affected colon is resected and a purse string suture is performed around the anvil of the eea mm single-use stapler with . mm staples (autosuture, covidien). a mm umbilical trocar is located for a °camera and a gelport laparoscopic system (applied medical) with two mm trocars is introduced through the colostomy wound. hard pelvic adhesiolysis was performed and splenic flexure was also mobilized.the gelpoint path transanal access platform (applied medical) is introduced through the anal canal with three trocars in a triangle position. the proximal rectum and mesorectum are dissected until the peritoneal reflexion. the previous stapler line with the resected tissue is then exteriorized throught the anus. the distal rectum is prepared with a circumferential purse string suture. the vaginal defect was sutured transanally. the proximal colon and the anvil are extracted through the rectal stump and connected to the circular stapler, performing an end-to-end anastomosis. results: the total operative time was h. the postoperative stay was uneventful and the patient was discharged on day . conclusions: as in patients with rectal cancer, dissection of the stump in hartmann reversal procedure may be better and associated with shorter operative time. as with any new surgical procedure, it is probably too early to draw conclusions but nowadays transanal combined with laparoscopic approach seems to be a safe and feasible technique to perform a hartmann reversal, especially in challenging cases. intravenous and endoluminal contrast enhanced ct revealed the presence of a large retroperitoneal fluid and gas collection, due to diverticular perforation, extended from pelvis to iliac bifurcation, involving the left urether. no hydrosoluble contrast media leakage or massive pnuemoperitoneum were present. after an initial conservative treatment without significant improvement an emergency laparoscopic left colectomy with primary anastomosis and laparoscopic retroperitoneal collection drainage was performed. the laparoscopic approach was very challenging due to the obesity of the patient and the presence of the abscess. the patient was discharged on pod after requiring re-intervention for dehiscence of the left iliac mini-laparotomy on pod . conclusion: diverticular perforation in obese patients adds a further challenge to its laparoscopic treatment and deserves an aggressive surgical approach since its outbreak. although intracorporeal anastomosis has been demonstrated to be safe and effective after right colectomy, limited data are available about its efficacy after left colectomy for colon cancer located in splenic flexure. there are few studies comparing patients who underwent laparoscopic left colectomy with intracorporeal anastomosis or with extracorporeal anastomosis. anyway literature shows that there is no significant difference between intracorporeal anastomosis and extracorporeal anastomosis about oncological result. as for right hemicolectomy, intracorporeal anastomosis seems to show a trend towards a faster recovery after surgery due to the shorter time to flatus and lower post-operative pain expressed in the mean vas scale. laparoscopic left colectomy with intracorporeal anastomosis is associated with a lower rate of post-operative complications as for right colectomy. literature results could suggest that a complete laparoscopic approach could be considered a safe method to perform laparoscopic left colectomy with the advantage of a guaranteed faster recovery after surgery. as usual further randomized clinical trials are needed to obtain a more definitive conclusion. we show a video of a years old patient with a pure splenic flexure colon cancer who underwent to a laparoscopic left hemicolectomy with intracorporeal anastomosis. case presentation: here we describe a case of a year old asthmatic and hypertensive lady with an asa score of iii who presented to emergency after a right knee replacement with a four day history of lower abdominal pain. she was septic upon arrival to the resuscitation roomimmediately prompting the hospital's local septic management protocol. a ct scan of her abdomen showed a rectosigmoid perforation with free intra-abdominal air and fluid. the patient underwent laparoscopic hartmann's procedure within h of admission. after an uneventful postoperative recovery the patient was discharged home after a total of days of hospitalisation. she was followed up at surgical outpatients with no adverse events over the course of the subsequent months. conclusion: this case exhibits the feasibility of laparoscopic hartmann's procedure as a surgical modality for hinchey stage iv diverticulitis. the positive outcome supports the claim that for experienced surgeons laparoscopic hartmann's procedure remains a safe and viable option for elderly comorbid patients in the emergency setting. introduction: mesenteric cysts are a very infrequent pathology, they usually present an anodyne clinic, and their diagnosis is reached casually. objectives: to demonstrate the safety and efficacy of the laparoscopic approach, in cases with intra-abdominal cysts of benign etiology, using material with mini-instruments, reducing surgical aggression, maintaining its safety and efficacy.material and method: clinical case: a -year-old man with no personal history of interest. in the last two months he presented episodes of pain in the right hypochondrium, exploration without findings, us-ct scan: a cystic tumor of cm. in hepatic colon angle compatible with uncomplicated benign mesenteric cyst, tumor markers and normal colonoscopy. evidence of interest is exposed. given the evolution it is decided tto. elective surgical. result: intervention: laparoscopic approach, trocars, two of . mm, optics of mm °, benign cystic tumor, with colloid content of more than cm. of diameter in antimesenteric border of colon, which is not possible to separate, mobilization and resection is carried out by endo-gia, including a portion of the colonic wall, appendectomy, extraction in a pocket. good postoperative course, alt to nd day. definitive ap: mesenteric cyst, absence of malignancy. the laparoscopic approach is a valid and effective alternative in cases of benign intra-abdominal cystic pathology, the use of mini instruments reduces surgical aggression, favoring the recovery of the patient. male, yr, wuth doblue post-operative coloanal stenosi and women, with ultralow rectal neoplatis stenosis ( cm from anla verge). both patients were discharge ater days from prosthesis positionins without pain and complications. the first patient, with protection ileostomy, showed fecal incontinence before the operation and was performed prosthesis positioning because rectal losses of infected material and fever. fecal incontinence was showed also after procedure but he had not fever. second patient, yr, with ultralow rectal tumor, after prosthesis positioning was submitted to radiotherapy and she decided for not to be operated and she survives after months in ful well-being. conclusion: endoscopic prosthesis positioning is a consolidated procedure for treatment of bowel obstruction. this study demonstrated that this procedure is safe and this kind of prosthesis is suitable for correct positioning. results: we present a case of a years old man with faecal occult blood test positivity that was diagnosed by colonoscopy of a villous lesion at cm of anal verge. biopsies were taken showing a tubulovillous adenoma with high grade dysplasia. a rectal mri was done showing the lesion fixed to the postero-lateral left side of the lumen at cm of anal verge. no pathological lymph nodes were reported. extension study was negative. the case was presented in multidisciplinary committee agreeing in local excision. in october the procedure was done without incidents. the patient was placed in lithotomic position finding a lesion occupying of the lumen. resection was done without incidents and posterior suture with continuous barbed sutures. he presented an uneventful recovery being the patient discharged in rd postoperative day. definitive pathological findings showed a ptis with negative margins. after three months of followup the patient remains with good functional results and waiting for the first endoscopic revision. conclusions: tamis is a safe and feasible technique with low morbidity that gives us an alternative for early rectal cancer or big rectal lesions much less invasive than techniques used until now. complete mesocolon excision and d lymphadenectomy are two fundamental points in the oncological surgery of right colon cancer. most of the adenopathic recurrences of colon neoplasia in tumors located in the hepatic angle and the ascending colon are located near the head of the pancreas and the vascular axis of the superior mesenteric vein due to an alleged incomplete dissection. we present a case of right colon neoplasia where we performed a laparoscopic right hemicolectomy associated with a d lymphadenectomy. we use medial to lateral dissection of the mesocolon focused on the dissection of the superior mesenteric vein with the identification of ileocolic vascularization, right colic vessels and henle's trunk. this approach is safe and facilitates a correct resection of the mesocolon, which is approached following the embryological plans and a vascular ligature near the bifurcation. the performance of an extended lymphadenectomy allows a wider resection of the mesocolon and the excision of a greater number of lymph nodes, all of which can contribute to a greater survival. the efficacy of pc treatment is related with a properly preoperative imaging diagnosis of the disease, but the poor sensitivity for identifying small peritoneal metastasis are the major obstacle to achieve a complete resection and that leads to peritoneal recurrence. imageguided surgery using icg, could represent an advance in the detection of small peritoneal nodules. there are only a few clinical studies that have analyzed the role of icg for the staging of pc, specially from ccr, and nearly in all of them the selected approach were exploratory laparotomy. this study presents a laparoscopy case, as a non-invasive way of cs in selected patients with limited pc. a new category, tis, was created for low-grade appendiceal mucinous neoplasms (lamns) that invade or push into the muscularis propia by ajcc cancer staging th ed. management of these tumors depends on stage and histology. traditionally, laparotomy was the most recommended approach, however, if laparoscopy is safe, it could be used. the laparoscopic appendectomy should be done with 'not touch' technique and a radical approach has been recently proposed for its treatment. the laparoscopic radical appendectomy should start by exploring complete abdominal cavity. grasping of appendix should not be done. complete resection of mesoappendix is obligated. cequectomy with stapled endogia is necessary. the specimen must be extracted in an endobag. methods: we report a case of a year-old female patient with a personal history of three caesarean sections. this patient was studied due to chronic abdominal pain. a computerized axial tomography was performed, showing an appendix increased in size and a thick wall. the colonoscopy evidence a lesion that protrudes from appendiceal base which is biopsied. results: a laparoscopic way was used and large and width appendiceal was viewed ( x cm). furthermore, a rounded right anexial tumor was also found. a radical not touch laparoscopic appendectomy with stapled cequectomy was done. the intraoperative study was mucinous appendiceal tumor without serose affection. the final result was ptisnx (lamn) without resection margins affected. after h of admission, the patient is discharged without incidents. conclusion(s): minimally invasive surgery in lamns is possible if it is performed with enough experience, following specific rules and tips to manage this tumors. a correct follow-up should be carried out using tumor markers and computer tomography (ct). introduction: resection of both benign and malignant colovesical fistulae can be particularly challenging and carry with it specific surgical considerations. often there is a large inflammatory mass sat within a narrow pelvis, limiting specimen mobility and consequently access to dissection plains. additionally, with the underlying inflammatory process, the ureters may be displaced anatomically and be at risk of injury. aim: to demonstrate a streamlined and reproducible approach to the laparoscopic management of both benign and malignant colovesical fistula, with specific emphasis on the different modalities for bladder repair. method: the following method portrays an overall technique which is adapted dependant on the clinical scenario and specific intra-operative findings: approach to abdominal cavity in standard fashion.identification of right ureter.poster-medial mobilisation of the mass to facilitate delivery out of the pelvis followed by visualisation of the left ureter on the medial and lateral sides before division of the fistula.division of the fistula in benign disease or resection of the bladder dome in malignant disease.transverse laparoscopically sympathetic suprapubic skin incision.vertical incision through linea alba to deliver bulky specimen.intra/extracorporeal repair of bladder dome. results: all of the considered cases were successfully completed with a laparoscopic approach, irrespective of the malignant status of the disease in question. conclusion: both benign and malignant colovesical fistula disease can make the laparoscopic approach to resection challenging, especially when encountering a bulky mass in a narrow male pelvis. the stepwise and streamlined approach considered here can help facilitate successful and safe laparoscopic completion without the necessity to convert to open. background: primary neoplasms of the retrorectal space are very rare. they are located in anatomically difficult area to be addressed, hence a complete evaluation of the lesion is required to determine the extent of resection and the appropriate surgical approach, which include posterior, abdominal and combined abdominoperineal, depending on the characteristics of the lesion. objective: to show a combined laparoscopic abdominoperineal approach of retrorectal tumor. method: we present a video of a combined laparoscopic abdominoperineal resection of a lowlying retrorectal tumor in a -year-old female without prior abdominal surgery. conclusion: retrorectal tumors are infrequent. their anatomical location can make difficult the surgical approach. preoperative imaging can provide useful information for surgical planning. in the recent years, minimally invasive surgical approach has been proposed. laparoscopic approach is feasible and safe, but it is important to select adequately the patients. background: adult intussusception is a rare clinical event representing only - % of all bowel obstruction cases and % of all intussusceptions and the occurrence of adult intussusception due to colonic cancer is even more rare. aim: we present this case of malignant colo-colic intussusception and literature review to increase the awareness of the incidence of colocolic intussusception due to colonic cancer. case report and literature review: our patient is a years old female was admitted to our hospital due to central abdominal pain, cea level of , she was further investigated with ct scan of the abdomen and pelvis which raised the suspicion of mid transverse colon intussusception due to large polypoid lesion. she was further assessed with urgent colonoscopy which confirmed mid transverse colon tumour with biopsies confirmed adenocarcinoma. laparoscopic extended right hemicolectomy with lymph node dissection was performed. upon laparoscopic exploration it was found that the colocolic intussusception was evident as described on the ct scan and as clearly shown on the video. histologically, the transverse colon carcinoma was a moderately differentiated adenocarcinoma, with no lymph node involvement ' out lymph nodes', tnm staging of pt pn pm and r resection. intussusceptions of the colon in adult are frequently found in the ileocecal portion or sigmoidal colon but rarely in the transverse colon. only two cases of adult intussusception of the transverse colon caused by colonic cancer have been reported. overall cases on literature review reported showing colo-colic intussusception due to colonic malignancy. conclusion: colo-colic intussusception due to colorectal cancer is a rare clinical event, however it should be included in the differential diagnosis of colonic obstruction. laparoscopic surgery is safe in malignant colocolic intussusception. aims: single-incision laparoscopic colectomy (silc) aims to achieve better cosmetic outcomes, less pain, and faster recovery compared to multi-port laparoscopic colectomy, but it also has several limitations, especially the technical difficulties. we report our experience with singleincision robotic right hemicolectomy via video presentation. methods: we arranged robotic-assisted single-incision right hemicolectomy for a -year-old female patient with ascending colon tumor. the operation was performed with gloveport singleport device and a three-arm da vinci robotic surgical system through a small midline umbilical incision. colectomy was proceeded by a medial-to-lateral approach along with one or two accessory instruments for maintaining sufficient bowel traction or surgical field exposure. after vessel ligation, complete colon mobilization and right side omentum division, the robotic arms were undocked to perform anastomosis extracorporeally. results: the operation was performed successfully without drainage tube placement. the total operative time was min. the bowel movement returned on post-operative day ,and the patient tolerated normal soft diet on post-operative day . she was hospitalized for days after operation. the pathology report revealed colon adenocarcinoma (t n m , tumor size . cm), and lymph nodes were harvested. conclusions: single-incision robotic colectomy (sirc) approach seems feasible and safe in treatment of ascending colon cancer. this surgical option provides less pain and wound scar for the patient. moreover, it also achieves further benefits for the surgical procedures compared to silc. reasons being, first, it has better instruments flexibility and precision with endo-wrist, as well as less instruments clashing. second, the improved camera stability achieved through the use of the robotic arm is unattainable through manual hand-controlled methods. third, roboticassisted approach gives us an ergonomic environment, which enables the operator to control the arms while sitting by the console, and also to reassign them whenever they cross each other or block the surgical view. in spite of the advantages above, we still need to sincerely consider each patient's situation for proper management. recently, indocyanine green (icg) fluorescence has been introduced in laparoscopic colorectal surgery to provide detailed anatomical information.the aim of our study is the application of icg imaging during laparoscopic colorectal resections: to identify sentinel lymph node, for studying its prognostic value on nodal status, to facilitate vascular dissection when vascular anatomy of the tumor site is unclear and to assess anastomotic perfusion to reduce the risk of anastomotic leak. after tumor identification ml of icg solution ( . mg/kg) is subserosal peritumoral injected. a full hd image s camera, switching to nir mode, in about min displays fluorescence: the sln is identified and the sln biopsy (slnb) is performed.when tumor is in difficult site, as hepatic or splenic flexure, ml of icg solution ( , mg/kg) is intravenous injected. in about - s a real-time angiography of tumor area is obtained; on this guide, vascular dissection and pedicle ligation is performed.after anastomosis, another ml of icg solution is injected to confirm anastomotic perfusion. if there is an ischemic area, a new anastomosis is performed. from november , patients were enrolled: left colectomy, right colectomy, transverse resections, and resections of splenic flexure. in ten cases, intraoperative angiography led to the identification of vascular anatomy. in two cases the anastomotic perfusion wasn't good and the surgical strategy was changed. four postoperative complications occurred, of which one anastomotic leak, due to a mechanical problem. from november , patients were enrolled to perform the slnb: right colectomy, left colectomy, transverse resection and splenic flexure resections. the sln was identified in cases. cases were found to be n to the conventional examination and were subjected to ultrastaging. icg-enhanced fluorescence imaging is a safe, cheap and effective tool to increase visualization during surgery. it's recommended to reduce the incidence of anastomotic leak, to facilitate the assessment of vascularization in order to perform oncological resections, and to perform the slnb to study its clinical role on nodal status and for the sln ultrastaging in order to identify the micrometastases. background: surgical emptying of lateral pelvic lymph nodes (llnd) is a strategy used differently when compared the approaches to rectal cancer in the west and eastern countries. there is evidence that = mm lymph nodes in lateral compartment should be removed, even in the setting of neoadjuvant chemoradiation. minimally invasive surgery with nerve-sparing technique and sharp dissection with minimal bleeding may help overcome the significant complexity of the procedure that may have been a technical obstacle to implementation in the past. the standardization of the technique may help implementation with shorter learning curves and excellent surgical outcomes. methods: a -year-old male with distal rectal cancer underwent neoadjuvant crt for a mrt cn m mremvi ? mrcrm ? disease. there was one left obturator node of mm prior to crt. following weeks of crt completion, the patient underwent tatme for the primary disease followed by left lateral node dissection by laparoscopy. results: the present video illustrates the most relevant surgical steps to perform lateral node dissection. the procedure has been didactically divided into steps. the left ureter is identified and retracted using a vessel loop (step ). identification of the common iliac vein and dissection with subsequent identification of psoas and internal obturator muscles (step ). identification and dissection of accessory vessels. ( step ) identification of obturator nerve and obturator vessels (step ). blunt dissection of obturator nerve (step ). identification and ligation of obturatory vessels. (step ) umbilical artery is skeletonized to allow identification and clearance of fatty tissue along superior vesical arteries, internal iiliac artery/vein, inferior vesical artery and internal pudendal artery (step ). postoperative course was uneventful. conclusion: standardization of lateral-node dissection for rectal cancer has paramount importance. laparoscopic lateral-node dissection for rectal cancer provides optimal anatomical view and allows safe dissection of the nodes of interest. aims: the aim of this video is to describe our technique using fluorescence to assess the lymph flow to ensure a complete mesocolic excision and central vascular ligation in order to provide expertise to contribute to the standardization of this new tool. methods: laparoscopic right colectomy with total excision of the mesocolon was proposed in all cases. for the detection of lymph flow, we injected indocyanine green dye ( milliliter of milligrams dye dilution in milliliter of distilled water) into the subserosal to submucosal layer around the tumor at point with a -gauge injection laparoscopically after trocar insertion, and observed the lymph flow using a near-infrared system (visera elite ii, olympus) after injection. we also performed a total mesocolic excision with central vascular ligation in the region where the lymph flow was fluorescently observed. results: ( %) patients were included. no intraoperative or postoperative complications presented. no adverse effects were reported due to the infusion of indocyanine green. the lymph flow was visualized intraoperatively in a satisfactory way helping the surgeon in decision making to determine an appropriate separation line of the mesentery. the section line of the mesocolon was modified in ( %) case based on the findings obtained by fluorescence. the mean operative time was ( ) min. the morphometric laboratory data of the specimens to audit the correct complete mesocolic excision were satisfactory according to the oncological standards. conclusion: fluorescence lymphography during colorectal surgery was feasible and reproducible with a minimum of added complexity. fluorescence-guided surgery may be a helpful technique for determining an appropriate total mesocolic excision in colon neoplasms. aims: this video shows our technique for complete mesocolic excision (cme) during right colectomy for cancer. methods: in this video, a years old patient underwent a laparoscopic right colectomy with cme for a cancer of the ascending colon diagnosed with a colonoscopy performed after positivity to fecal occult blood test (fobt). after ct scan staging we obtained d printed models to clarify patient's vascular anatomy. patient was placed in supine position, trocars were inserted in left quadrants as for standard right colectomy. cme is performed by sharp dissection between the visceral fascia that covers the posterior lay of the mesocolon and the parietal fascia that covers the retroperitoneum (toldt's fascia). the ileo-colic vessels are used as landmark to identify the right anterior surface of the superior mesenteric vessels. with a caudo-cranial approach, the mesocolon is sharply dissected and the root of tributaries venous is ligated, up to the inferior margin of the pancreas. the gastro-colic trunk is dissected out with ligation of the right colic vein, while the gastroepiploic vein is preserved (harvesting the sixth group lymph node). the pancreas-duodenum fascial plane is entered and all the lymphoid tissue around the vessel surface is harvested. procedure is completed with ileo-transverse intracorporeal stapled anastomosis. results: in our experience, between april and december , laparoscopic right hemicolectomies with cme were performed. we had no major intraoperative vascular lesions. no patients needed intraoperative blood transfusion. compared to our series of standard right colectomies we did not notice any significant difference in post-operative complications. the follow-up is too short to demonstrate if the cme approach has a better oncological outcome compared to standard right colectomy. conclusions: laparoscopic cme is feasible, although it requires a higher expertise level of surgical know-how. the quality of evidence is limited and does not consistently support the superiority of cme as compared to standard right colectomy. better data are needed before cme can be recommended as the standard of care for colon cancer resections. h. bando gastroenterological surgery, ishikawa prefectural central hospital, kanazawa, japan aim: in case of right-sided transverse colon cancers, it is necessary to dissect the lymph nodes around the root o f the middle colic vessels. but in this area there are dangerous organs, for example : pancreatic head, duodenum, and gastrocolic trunk. it is the point of our technique that we resect the accessory right colic vein and middle colic vein, and then dissect pancreas head and duodenum at early step of the operation. method: we perform the operation by five trocars. the first step is to transect the great omentum, and confirm the lower edge of pancreas.there are much adhesion between mesocolon of transverse colon and stomach, great omentum. it is very important to dissect the adhesion accurately. secondly, the mesocolon is incised at lower edge of pancreas. it is possible to detect the lower edge of pancreas in obese people. the anterior surface of superior mesenteric vein is exposed. the accessory right colic and middle colic vein are resected. and then front face of surgical trunk, pancreas, and duodenum is dissected caudally as possible. the superior mesentery artery is resected below the mesocolon after flip up of transverse colon. this approach is safe and feasible, because the dangerous organs are handled by direct vision. by that, extraction of intestine is easy from small incision. afer flip up of transverse colon, the mesenteric of ileum is incised. the root of ileocecal vessels is exposed and these are resected. the peritoneum of the front of superior mesenteric artery is incised, and the lymph nodes around the surgical trunk are dissected. this dissected area is easily connected with the one done beforehand. uniquely we resect the mesocolon and major omentum from the root of dissected vessels to resected side of transverse colon. and then right-side colon is dissected medial approach. conclusion: we dissect the dangerous organs in advance. that prevent major injury of them. background: good visualisation of the operative field is a fundamental requirement for safe laparoscopic colorectal surgery. over the past years of the senior author's experience, camera systems have evolved from single to three chip, high definition (hd) and most recently, the k system. in parallel, the rest of the infrastructure such as cables, processors, monitors etc. have also undergone improvements, resulting in improved image quality. aim/methods: we present a video of a case of laparoscopic total mesorectal excision (tme), performed with strict adherence to our previously published 'stepwise approach to laparoscopic colorectal surgery' which places particular emphasis on safety aspects. tme was performed in a year old male patient with history of previous abdominal as well as robotic prostatic surgery. the procedure was filmed with all components including the camera head, cables, processing unit, screens as well as the recording/mixing decks being k. multiple external k cameras were also used. live transmission to a remote audience as part of our masterclass was achieved using appropriate bandwidth and projection on to k screens. results: feedback from the operating team as well as from the live audience was that the image quality was far superior to hd systems. the k system accorded a degree of clarity well beyond usual expectations. the depth of field also appeared to be different initially, but within a few minutes of starting the procedure and acclimatisation, the effects were appreciable. the clarity of the image which showed the fine details of the dissection planes and anatomical landmarks as well as the vibrancy of the vasculature gave a distinct three-dimensional effect to the picture. this excellent visualisation added one more layer of safety and complemented our stepwise approach for a successful procedure. conclusion: the laparoscopic k system, in our practice, proved to bea beneficial visualisation tool to enhance the accuracy of dissection. vital structures appeared to be more vivid and clearer with dissection planes being more easily apparent. in our opinion the laparoscopic k system when combined with a systematic approach enhances safety, especially in complex laparoscopic colorectal surgery. accumulating evidence suggests that laparoscopic surgery for colon cancer has feasibility and efficacy equal to or over conventional laparotomy. for cases with pasthistory of laparotomy, especially history of colon resection, however, there is almost no evidence for laparoscopic recolectomy for metachronous colon cancer. since , we have been used submucosal local injection of indocyanine green (icg) around primary colorectal cancer by using intraoperative endoscopy, and complete mescolic excision (cme) have been convincingly carried out, which was clarified by completely resected icg positive area. although evidence on the oncological efficacy of icg guided surgery has not yet been clarified, since it can be easily judged whether cme is performed clearly, it is considered that icg guided surgery for primary colon cancer is useful for education. recently, we are applying this to ensure convincing cme for patients with colorectal cancer who had a history of colic resection. the representative case is as follows. a -year-old female was diagnosed as advanced sigmoid colon cancer, and laparoscopic sigmoidectomy with high tie of the inferior mesenteric artery was performed years ago. then she was diagnosed as the metachronous descending colon cancer. the feeding artery of the new tumor should be the left colic artery, however, the left colic artery was already resected and genuine feeding artery was not identified by preoperative examination. by injecting icg into submucosa endoscopically during operation, it was clearly observed that the lymphatic flow from the tumor was directed to the inlet portion of the inferior mesenteric vein (imv). re-cme was performed by ligating the inlet of imv. intraoperative icg was also useful for clarifying the borderline for adhesion detachment of pastoperation between the mesentery and retroperitoneum (figure) . interestingly, icg flow in the mesentery direct to of the anus side was disrupted clearly at the past anastomotic site. we believe that laparoscopic surgery under icg guidance is potential useful tool that can confirm evidence to date more intuitively in real time. further studies, ideally randomized controlled trials, are required for define the oncological usefulness of icg guided surgery for re-do colectomy. the operation movie will be presented at the meeting. background: laparoscopic lateral pelvic node dissection (llpnd) is a minimally invasive alternative to open surgical therapy for advanced low rectal cancer patients. in this video, we demonstrate the technique of llpnd for rectal cancer patients with suspicion of lln metastases after neoadjuvant chemo-radiation. methods: the principle of this approach is en bloc resection with bilateral peritoneum. the peritoneum is incised lateral to the ureter following the line between external and internal iliac vessels. in the next step, llpnd dissection of the regional lymph node and high ligation of inferior mesenteric vessels were performed. a contralateral llpnd was performed in the same manner as a mirrored technique. after extracting the specimen, an end-to-end double-stapled circular anastomosis was performed. results: the procedure was done safely without any complications.the surgical duration was mins, and the blood loss was ml. the number of harvested lateral pelvic lymph nodes was . the tnm stage was ypt an m . conclusion: this approach enables extended resection during lymph node dissection, allowing autonomic nerve preservation. it is maybe a helpful approach in the treatment of locally advanced rectal cancer with a lateral lymph node metastasis. aims: the aim is to present an inspection method where the anastomosis vascularity is testing simultaneously using the indocyanine green fluorescent angiography intraluminal and intraperitoneal. methods: sixty-five year old female patient underwent standard laparoscopic-assisted low anterior rectal resection for rectal carcinoma. the proximal end of the bowel and the stump of the distal rectum were checked using near-infrared fluorescence imaging with d-light camera. after making sure of adequate perfusion of the bowel, the end-to-end stapled anastomosis was performed under the laparoscopic visualisation. the d-port proctoscope was inserted into the anus. the second icg injection was administered. the perfusion of the anastomosis in transabdominal way and viability of the mucosa in transanal way was evaluated with two d-light cameras simultaneously. the anastomosis was determined cm from the anal verge. an air-water leak and tension of the bowel tests were performed. after evaluation of anastomosis viability with fluorescence imaging, after negative air-water leak and tensions testing, the decision was made by surgeon not to perform preventive ileostomy. results: the patient had no complains for the first three days postoperatively. nevertheless, crp level was growing and was . mg/l on the second postoperative day, and . mg/l on the th postoperative day. the patient complained of the pain in the right iliac area and below symphysis on the th postoperative day. the abdominal and pelvis computed tomography scan with oral contrast was performed which denied our thoughts about the anastomotic leakage. intravenous cefuroxime and metronidazole antibiotics were prescribed. the crp level was . mg/l on the th postoperative day. the patient was discharged on the th postoperative day without preventive ileostomy. conclusion: using the original, standardized colorectal anastomosis inspection method we can determine which patient doesn't need the preventive ileostomy after low colorectal anastomosis. the important causes of anastomotic leak are local ischemia and staple line defect. the purpose of this study was to investigate the combination of methods aimed to reduce the risk of anastomotic leak after anterior resections for rectal cancer. methods: we retrospectively analyzed perioperative outcomes of the first patients, who underwent modified laparoscopic anterior resection with partial mesorectal excision for rectal cancer without preventive stomy. operative technique was modified and included routine preservation of the left colic artery (fig )(aimed to improve anastomotic blood supply), manual suture invagination of the 'dog ears' (fig ) (aimed to reduce the risk of staple line defects), transperineal pelvic drainage and pelvic peritoneum reconstruction (aimed to reduce the risk of reoperation in case of leakage). anastomotic leak rate, reoperation rate, left colic artery preservation rate, additional operative time (time required for left colic artery preservation, 'dog ears' invagination and pelvic peritoneum reconstruction), blood loss, morbidity and mortality were analyzed. results: ( . %) patient developed an asymptomatic leakage, which was managed conservatively. there was no postoperative mortality and no reoperations. median additional operative time was min for the first procedures and min for the last procedures. left colic artery preservation was successful in ( . %) patients. median blood loss was ml. conclusions: additional techniques used in our modification of laparoscopic anterior resection are safe and may lead to improved perioperative outcomes. however, they are associated with increased operative time, which may be reduced with a better learning curve. introduction: parastomal hernias are a significant cause of post abdominal ostomy morbidity with an overall life-time incidence exceeding %. the complications can range from a bulge resulting in stoma bag leakage, to life threatening bowel obstruction. the prevent-trial sought to determine if prophylactic utilisation of polypropylene mesh would decrease the incidence of parastomal hernias, with initial results demonstrating that it was safe to use in permanent end stomas. aim: to demonstrate a reproducible and streamlined technique for laparoscopic parastomal hernia repair with intraperitoneal funnel mesh, and assess the outcomes with the clavien-dindo (cd) classification tool. method: parastomal hernia repairs ( colostomy, ileostomy) were considered, with the following approach adopted for each: swab sutured in stoma orifice to prevent wound contamination.sharp dissection of the stoma using parachute technique.stoma end refreshed followed by change of gloves and instruments.lateral stay sutures placed to tighten sheath later on.pneumoperitoneum temporarily created to assess/divide adhesions.funnel mesh placed in-situ, orientated in the optimal intraabdominal position, and sutured to the peri-colic fat to prevent slip.medial suture placed to narrow the sheath further.pneumoperitoneum re-created and mesh fixed in place with double crown laparoscopic tacks.redundant portion of end stoma excised and stoma formed. results: at median follow up of months: no recurrence.no reported symptoms of pain or decreased stoma functionality.one superficial wound infection treated with drainage at bedside (cd = grade ) conclusion: laparoscopic parastomal hernia repair with intraperitoneal funnel mesh for permanent end stomas yielded good outcomes in our patient cohort. a streamlined and reproducible approach ensures that the technique can be adopted for both prophylactic, primary and recurrent repair. parastomal hernias are common and can be associated with significant morbidity. when taking this into account, in conjunction with the recommendations of the initial results of the prevent-trial, one may consider prophylactic utilisation of a mesh in patients receiving a permanent end stoma. general surgery, rambam medical center, haifa, israel year old, female patient referred to our institution with common bile duct stricture, caused by iatrogenic injury during laparoscopic cholecystectomy. during last year, patient suffered from recurrent episodes of ascending cholangitis. recently, she underwent ercp and severe stricture of middle cbd was diagnosed. plastic stent was inserted through the cbd. mrcp also showed severe stricture of cbd with dilatation of biliary tree, proximal to the stricture. due to severe and resistant (did not resolved by recurrent dilatation) structure of middle cbd, she was referred to operation. patient underwent da vinci robot-assisted excision of the cbd stricture, hepaticojejunostomy and extracorporeal jejunojejunostomy of roux-an-y limb. total operating time was min. day three after operation patient started regular diet and was discharged home on day four. final pathology has shoved part of cbd with severe inflammation. aims: extrahepatic biliary duct resection for the treatment of bismuth i and ii stage klatskin tumor is the standard surgical technique [ ] . methods: a years old patient present at emergency room (er) with right upper abdominal pain with an elevation of the inflammatory markers at the blood exams and fever. the patient was submitted to a computer tomography (ct) that shows a tumor involving the lower tract of the principal bile duct. an endoscopic retrograde cholangio pancreatography (ercp) with biopsy (intraductal papillary neoplasm of the bile duct,ipnb with high-grade dysplasia) and stent placement was performed. considering the good general conditions of the patient and an absence of vascular and nodal invasion at the preoperative imaging, a minimally invasive surgical resection of the biliary tract with cholecystectomy was performed. results: a four port laparoscopic biliary tract resection with cholecystectomy was performed with lymphadenectomy of the hepatic hilum. no vascular or liver infiltration was found. the hepatic hilum was completely skeletonized. the resection of the biliary duct was performed with adequate free margin. a biliary reconstruction with roux-en-y technique was performed and a fully laparoscopic hepatico-jejunal anastomosis was done. and abdominal retro anastomotic drain was placed. the operative time was min. the postoperative course was complicated by a low rate biliary leakage that was treated conservatively. the patient was discharged at post operative day in good general conditions. the histological examination revealed a moderately differentiated in situ cholangiocarcinoma of the principal bile duct with the involving of the cystic duct with free resection margin (pt bn r ). conclusions: laparoscopic resection of the biliary tract is a challenging procedure that allows, in expert hands, to achieve in selected cases negative pathological margin, complete linfonode retrieval and entero-biliary bypass. injury to the extrahepatic bile duct during bile duct or hepatic surgery can be reduced by better real-time visualization. recently, indocyanine green (icg) fluorescence imaging has been used in laparoscopic hepatobiliary surgery. we applied icg fluorescence imaging in patient with huge hepatic cyst which severely deviated extrahepatic bile duct. the patient had received laparoscopic cholecystectomy and huge hepatic cyst stuck firmly with peri-hepatic structures including bile duct. icg fluorescence imaging correctly identified the common hepatic duct and remnant cystic duct and allowed for more meticulous and easier dissection. therefore, icg fluorescence imaging may guide a safe and accurate dissection and excision in hepatobiliary surgery. results: total patients who underwent ercp were , and . percent ( cases) had a first failed ercp and of then were unsuccesfull in the second intent of ercp. intrahospitalary stay was more than days in the percent, in the . percent was to days, with and average of days. conclusions: before, during or after lcbde, ercp remains the gold standard for manegement of choledocolitiasis confirmed by clinics, laboratory and imagenology. lcbde is a very good option that requires experience and specific skills, and especialized equipment. in years the rate of sucess in our hospital was . % and there were no posoperatory complications such as: biliar peritonitis, pancreatitis or liver abscess. aims: easier intraoperative recognition of the biliary anatomy may be accomplished by using near-infrared (nir) fluorescence imaging after an injection of indocyanine green (icg). neither radiological support nor additional intervention such as opening the cystic or common bile duct is required, making it an easy and real-time technique to use during surgery. the aim of this video is to describe our experience in fluorescence-guided cholangiography in different clinical situations. methods: intravenous injection of icg is used to illuminate extrahepatic biliary anatomy. however, the simultaneous enhacement of liver parenchyma can disturb the visualization of clinical details. the key is in the used dose of icg, the route of administration and the time since its infusion. in the first case, a scheduled cholecystectomy is shown in which a dose ( ml of mg dye dilution in ml of distilled water) administered intravenously h before the intervention was used. the second case shows an urgent cholecystectomy in which the dose ( ml of mg dye dilution in ml of distilled water) was administered intragallbladder during surgery. all patients underwent laparoscopic cholecystectomy with traditional four-port technique. all procedures were performed using a -degree mm laparoscope with nir imaging capability (visera elite ii, olympus). results: there were no intraoperative or postoperative complications. there was no increase in operative time due to the use of icg. in the first case, a clear identification of the cystic duct and the main bile duct was obtained thanks to the biliary excretion of the icg and the intravenous clearance. in the second case, the identification of the cystic duct, the main bile duct and the cystic artery occurred due to the intravesicular absorption of icg. conclusion: fluorescence-guided cholecystectomy clarifies the dissection plane. it can be considered to increase the safety of laparoscopic cholecystectomy. being aware of the doses, times and possible routes of administration is basic to universalize the technique and give it utility in different scenarios. introduction: mirizzi syndrome type is an uncommon cause of obstructive jaundice caused by an inflammatory response to an impacted gallstone in hartmann's pouch or the cystic duct with a resultant cholecystocholedochal fistula. the obstructive biochemical changes can be caused by direct extrinsic compression from the impacted gall stone or from the fibrosis caused by advanced chronic cholecystitis, or for the established fistula. objective: we present a case of a mirizzi type syndrome with choledocholithiasis which was solved by laparoscopy approach. material and methods: a -year-old female patient with no past medical history. the history of present illness begans with the presence of icteric dye since the last days; she received symptomatic treatment with poor improvement. a liver and biliary tract ultrasound was performed with report of a mm coledochus, mm wall gallbladder. then an endoscopic retrograde clolangiopancreatography was performed with successful endoscopic sphincterotomy and removal of gallstones. but the patient jaundice persisted after the procedure. the patient underwent cholecystectomy and laparoscopic common bile duct exploration, where the findings were a mirizzi type according to the csendez classification, chronic cholecistitis and choledocholithiasis. results: in this laparoscopic approach we performed a partial cholecystectomy, bile duct exploration with removal of residual gallstones. the closure of the choledocotomy was performed with simple knots using vycril . . a subhepatic drainage was left. the patient showed adequate clinical evolution. after days the patient was discharged. conclusions: it is important to properly identify the anatomy at the time of surgery to avoid injury of the common bile duct. operative treatment of mirizzi syndrome type includes either laparoscopic or open subtotal cholecystectomy or placement of a t-tube or choledocoplasty. near-infrared fluorescent cholangiography (nirf-c) is an innovative intra-operative imaging technique that allows a real-time enhanced visualization of the extrahepatic biliary tree by fluorescence. thanks to the development of laparoscopes/endoscopes with light sources emitting infrared frequencies, it is possible to visualize anatomical structures (vessels, ureters, bile ducts, etc.) through the luminous intensity of substances (fluorescein, blue of methylene, indocyanine green) which are injected into the patient. this technology may be considered as an important teaching tool for laparoscopic surgery, especially for young surgeons in their surgical learning curve and it could lead to reduce the risk of iatrogenic bile duct injuries during laparoscopic cholecystectomy. the following video is characterized by a series of intra-operative images of biliary anatomy by fluorescence, having an important educational interest, while also detecting anatomical variations of the cystic duct. a. umezawa, minimally invasive surgery center, yotsuya medical cube, tokyo, japan aims: laparoscopic cholecystectomy(lap-c) for cholecystolithiasis has become standard. however, serious bile duct injury has been reported as a complication. repeated colic and chronic inflammation in cholecystolithiasis lead to the so-called difficult gallbladder conditions, such as dense fibrosis and scarring of the tissue. dissection of calot's triangle includes the risk of bile duct injury. critical view of safety (cvs) is the most well-known land mark for safe cholecystectomy. in the revised tokyo guidelines (tg ), important land marks and bailout procedures had been proposed. those are for the difficult gallbladder which are not able to achieve cvs. methods land marks: baseline of segment of the liver and sulcus rouvier should be confirmed. the gallbladder wall itself is also useful landmark. bailout procedure: when the dissection of calot's triangle is considered impossible, bailout procedures should be considered. subtotal cholecystectomy which leave the neck is one of option. the fundus first technique is another approach. however, because fundus first technique has a possibility of leading to serious bile duct injury, it should stop by the neck. in this video, first case shows the importance of landmarks from near miss cases of misidentified injuries. second case shows bailout procedure, subtotal cholecystectomy with fundus first technique. result: in the atrophic gallbladder (case , near miss), it is liable to misidentify the junction of common bile duct as the gallbladder neck. the neck and common hepatic duct were lifted together easily. with confirming the landmark, misidentification was corrected and bile duct injury was avoided.in the case , since the calot's triangle was obscured due to repeated cholecystitis, dissection of gallbladder was performed from the bottom to the neck, and was excised with the cervical portion remained. the remaining neck was reconstituted.in each case, intraoperative cholangiography was performed, and it was confirmed that there was no bile duct injury. without postoperative complications, those patients were discharged pod as usual lap-c. conclusion: during lap-c for difficult gallbladder, the most annoying part is bile duct injury. confirming landmarks and switching bailout procedures can be contributory to avoid bile duct injury and to achieve safe lap-c. aims: choledocholithiasis is an important cause of morbidity and is present in about % of patients submitted a cholecystectomy. his treatment should be done in the same operative time, avoiding the morbidity and hospitalization time and costs of multiple procedures.the transcystic approach is preferable to prevent morbidity associated to choledochotomy.large stones can preclude this procedure. the use of laser lithotripsy to stone fragmentation is an option to provide transcystic extraction. methods: we present a video of laparoscopic transcystic common bile duct (cbd) exploration for choledocholithiasis. results: female patient, years old with a previous hospitalization for acute cholangitis with choledocholitiasis.submitted to laparoscopic cholecystectomy with intraoperative cholangiography that showed the presence of stone in distal cbd with cm size. the use of holmium laser lithotripsy made the stone fragmentation and provided his extraction by transcystic route using a basket.the patient was discharged at th postoperative day, with no complications. conclusion: the use of laser lithotripsy for large cbd stones is safe and effective, making possible the transcystic approach and preventing the choledochotomy morbidity. surg endosc ( ) :s -s gallbladder adenocarcinoma is rare and extremely aggressive. its' incidence is higher in elder females and its progression is rapid and silent with a dismal prognosis if diagnosed at advanced stages. we present the case of a years-old female with dyspeptic complaints. the abdominal ultrasound revealed a cm solid lesion of the gallbladder suspect for malignancy. the ct confirmed the presence of a vegetant mass on the free border of the gallbladder fundus with x mm. we performed a radical cholecystectomy with lymphadenectomy and liver bed excision. the post-operative period was complicated with a urinary tract infection, with full recovery after antimicrobial treatment. the histological sample revealed an adenocarcinoma of the gallbladder (t bn m ) and the patient remains asymptomatic and tumour free months after the surgery. gallbladder cancer treatment depends of the stage and clinical presentation of the disease. complete surgical excision is the only curative treatment and should include a limited hepatectomy and portal pedicle lymphadenectomy. laparoscopic surgery might be an option in early stages, although it is challenging and requires both expertise in hepato-biliary and laparoscopic surgery. seen at the emergency room for a two month history of abdominal pain associated with jaundice. she is evaluated by the surgical team and diagnosed with acute cholecystitis and moderate risk for choledocholithiasis. the initial surgical plan was cholecystectomy with intraoperative cholangiogram. during surgery, firm adhesions are found from the gallbladder to omentum. friable tissue with edema and easy bleeding. difficulty is encountered during the dissection of calots'triangle. an intraoperative cholangiogram is done through hartmans'pouch without identifying correctly the biliary tract. therefore, an endoscopic retrograde cholangiopancreatography (ercp) is done to visualize the correct anatomy. during the ercp, a stenotic common hepatic duct is found and no stones are visualized. a biliary endoprosthesis is placed. she is discharged asymptomatic. a month later, the patient is back in the emergency room with abdominal pain. after an abdominal ct scan, we found that the endoprosthesis had migrated to the th portion of the duodenum. a second ercp is done and this time we found a big stone ( . - cm) aims: when training in the residency you watch your teacher perform laparoscopic cholecystectomy with ease, and even yourself perform several steps. but as a young surgeon, when confronted with a patient with acute cholecystitis, you're filled with emotions, and you do not know where to start the gallbladder dissection. the aim of this presentation is to show to young surgeons that you can, and must achieve, critical view of safety when performing laparoscopic cholecystectomy for acute cholecystitis. methods: we present the case of a years old female patient, bmi of . , who presented with a grade ii (moderate) acute cholecystitis. following tokyo guidelines, we initiated antibiotics and general supportive care, but without clinical improvement. the patient was proposed for laparoscopic cholecystectomy. results: at initial exploration we identified a cm long gallbladder, with a thick wall, difficult to manipulate. we opted for an anterograde cholecystectomy, in our opinion the best option in acute cholecystitis. the dissection was started with hook electrocautery and then continued with a combination of blunt dissection with the aspirator and with the hook. when reaching the pedicle, blunt dissection was used in order to appreciate the anatomy of the cystic duct and cystic artery. after correct identification of these structures they ware clipped and cut. a drainage tub was then placed, and the abdomen deflated. conclusion(s): as a young surgeon, when dealing with acute you must maintain your calm, and try to achieve critical view of safety before transecting the cystic duct and cystic artery. this can be achieved with a combination of blunt and sharp dissection, keeping your camera clean and with a good collaboration with the assisting surgeon. conclusions: here, an easy and reproducible method is described for future macroscopic analysis by the surgeon following a cholecystectomy. in addition, we depict several frequent macroscopic abnormalities in order to provide surgical colleagues with some cases of abnormal macroscopic gallbladders. the left hepatectomy is a demanding and difficult procedure, still limited to reference centers. the caudal approach and exposure of the middle hepatic vein is a reliable way to achieve a safely and reproductible left hepatectomy. with this technique, exposing the middle hepatic vein, we believe that we can perform a safe and feasible laparoscopic left hepatectomy increasing the quality of this hepatectomy. we present a -year-old woman with an intrahepatic and common bile ductlithiasiswhich was previously submitted to an ercp. with an unsolved intrahepatic lithiasis the patient was proposed to alaparoscopic left hepatectomy. the minimally invasive approach for alpps in a patient with a large hepatocellular carcinoma in a liver with severe steatosis is shown. during the first stage a partial alpps is performed. pve is performed in postoperative day one. after days from the first stage both liver volume and function (by hida scan) are re-assessed. right hepatectomy (second stage of alpps) is then conducted by laparoscopic aproach. hepato-bilio-pancreatic, centro hospitalar são joão, porto, portugal a year old woman with a previous history of anxiety and catheter ablation to treat heart arrhythmias, was studied for for multiple pancreatic cysts incidentally discovered on a routine ultrasound. an mri was performed showing multiple cystic tumors throughout the pancreas, the largest of which was mm. this led to a suspicion of multi-focal, side-branch intraductal papillary mucinous neoplasm (ipmn), with minimal dilatation of the main pancreatic duct. an echo endoscopy was subsequently performed indicating probable multifocal ipmn. a fna was carried out during this procedure, with aspiration of cystic content which was sent for cea analysis and cytology. cytology was compatible with mucinous neoplasm with mild atypia and cea u/ml. a splenic preserving total laparoscopic pancreatoduodenectomy was proposed. the procedure was uneventful and the patient was discharged on the th post-operative day. pathology revealeded a mm ipmn, with severe dysplasia and foci of microinvasive ductal adenocarcinoma of mm-pt n r . indocyanine green immunofluorescence guided laparoscopic partial hepatectomy y. tai obtaining negative tumor margin during laparoscopic hepatectomy has always been a very challenging topic for surgeons in that the surgeons are not able to palpate the tumor during laparoscopic surgery. although intraabdominal echo is available, but it demands great experiences and skills. with the guidance of icg immunofluorescence, surgeons can avoid failure of not obtaining enough negative margins nor resect too much healthy liver. icg is often used to estimate the liver function prior to hepatectomy traditionally. it binds to plasma protein and has a peak absorbance at nm and emits fluorescence with a wavelength of approximately nm. icg is preferentially retained in or around biliary malignancies due to impaired biliary excretion of hepatocytes in the affected area. we performed icg immunofluorescence guided laparoscopic partial hepatectomy on a years old male who suffers from hcc located at segment and . icg was injected days prior to the operation day. while evaluation of liver is performed, it also allowed us to use a high-end laparoscopic camera system equipped with integrated filters for detection of near-infrared fluorescence. during the surgery, we were able to clearly locate the borders of malignancies through the use of integrated filters combine with icg injection. the pathology study also confirmed that the adequate tumor free margin ([ . cm) were obtained in both tumors and the patient's condition was stable as well. icg immunofluorescence guidance enables surgeons to obtain optimum result in tumor resection through laparoscopic surgery. it also has the ability to detect bile leakage. with the use of icg immuofluorescence, surgeons will have higher chances to achieve adequate negative margins. background: parenchymal sparing hepatic resection has the advantage of preserving valuable tissue in chemotherapy-treated livers, assuring an adequate future remnant volume without compromising long-term survival. moreover, the laparoscopic approach offers the decreased postoperative morbidity of minimally invasive surgery. whenever technically feasible, this kind of procedure should be considered a suitable alternative to the classic major hepatectomy for the treatment of multiple colorectal liver metastases. methods: -year old male with a previous history of laparoscopic sigmoidectomy in november for a pt n m sigmoid adenocarcinoma. a control scanner three years later showed liver metastases in segments v, viii, ii and caudate lobe. after chemotherapy (xelox), control mri and pet scans showed a good response. he was proposed for a laparoscopic parenchymal-sparing liver resection. results: total operative time was h and min with no intraoperative complications. patient presented a right atelectasis as the only postoperative complication and was resolved with respiratory therapy. he was discharged in days. pathology report showed that lesions on segment v and viii had no viable tumor ( % fibrosis) and lesions on segment ii and caudate lobe had moderately differentiated adenocarcinoma. margins were free in all the lesions. after a month follow up, the patient has no recurrence and normal liver function tests. conclusion: minimally invasive liver resection is possible in patients with multiple bilobar liver metastases and allows to perform parenchymalsparing surgery safely. difficult localization of lesions such as the caudate lobe are not a contraindication for this type of surgery. laparoscopic approach for perihilar cholangiocarcinoma is still poorly reported in the literature due to technical challenges secondary to the combination of major hepatectomy, lymphadenectomy and biliary confluence resection. despite this, in selected cases it can be a good option to provide a short term benefit to patients. the video reports the case of a perihilar cholangiocarcinoma with involvement of left bile duct and therefore requiring left hepatectomy. komagome hospital, bunkyo-ku,tokyo, japan aims: segmentectomy is an anatomic liver resection, in which the tertiary branches of the glissonean pedicles are selectively transected. however, the branching pattern of the tertiary branches varies depending on the case, particularly in segment (s ) and segment (s ). the extrahepatic approach to the glissonean pedicle from the hepatic hilum is very difficult depending on the branching pattern. furthermore, the distance of exposing the secondary branches that are to be preserved becomes longer, and there is an increased risk of biliary leakage and delayed biliary stricture due to excessive traction in laparoscopic surgery. therefore, laparoscopic s and s segmentectomy are considered technically difficult. we standardized the intrahepatic glissonean pedicle approach for laparoscopic s and s segmentectomy. methods: we standardized the intrahepatic glissonean pedicle approach for laparoscopic s and s segmentectomy. we identify the targeted glissonean pedicle intrahepatically after the parenchymal transection along the major hepatic vein or its branch running on the intersegmental plane, referring to the preoperative simulation by d imaging. (a)s segmentectomy; after the mobilization of the right lobe, the glissonean pedicles of s (g ) can be approached from the dorsal side by transecting the parenchyma between the ivc and the right hepatic vein. after the division of the g , the parenchyma is transected along the demarcation line and the rhv from the root side to the peripheral side. (b)s segmentectomy; first, the parenchyma is transected along the middle hepatic vein (mhv) from the root side to the peripheral. g is typically detected on the right dorsal side of the mhv. after the division of the g , the liver parenchyma is transected along the demarcation line and the rhv from the root side to the peripheral side. results: we have experienced cases of laparoscopic s segmentectomy and cases of laparoscopic s segmentectomy. conclusion: our approach to the g and the g is safe and very useful. laparoscopic anatomical segmentectomy of right anterior section is technically demanding because it is difficult to dissect the deep tertiary branches of right anterior portal pedicle (rapp). we present three cases of laparoscopic anatomical segmentectomy using the extrafascial and transfissural approach: ) anatomical resection of segment , ) anatomical resection of the ventral area ) anatomical resection of segment dorsal area. the extrafascial and transfissural approach means that the liver parenchyma along the fissure lines is opened, then the surgeon can confirm the glissonean pedicles and territory directly. the extrafascial and transfissural approach in laparoscopic anatomical segmentectomy of right anterior section is feasible and effective because this technique can easily be approached to the deep tertiary branches of rapp. repeated liver resection has significant role in patients with recurrent hepatocellular carcinoma (hcc) in several situations. laparoscopic redo surgery is becoming safer along with advance in surgical technique. we have performed laparoscopic re-resection for limited intrahepatic hcc recurrence. the aim of the present study was to investigate its significance comparing with first laparoscopic liver resections. subjects: patients with limited intrahepatic hcc recurrence after open hepatectomy underwent laparoscopic liver re-resection (n = ). methods: adhesion between abdominal wall and visceral organs was carefully divided, after the first laparoscopic port was safely inserted. adhesion between diaphragm and liver surface or between previous liver cut surface and colon or duodenum was also minimally dissected. approach to the glisson's pedicles at the hepatic hilum was often difficult due to previous surgical procedure, thus pringle's maneuver was generally applied. dissection of hepatic parenchyma approaching to the target glisson's branch was often preceded under the ultrasound-guidance. liver resection was performed using lcs, biclamp, and cusa using intermittent block of the hepatic inflow. operation time, intraoperative bleeding, morbidity, mortality, and postoperative hospital stay were compared with those in patients who underwent first laparoscopic liver resection during the same period (n = ). results: operation time was significantly longer in the re-resection group, possibly due to the adhesiolysis. meanwhile, no significant difference was detected in intraoperative bleeding, morbidity, mortality and postoperative hospital stay between the first and the redo surgeries. methods: the donor was a -year-old gentleman who decided to donate part of his liver to his wife suffering from viral liver cirrhosis and hepatocellular carcinoma. his bmi was . kg/m and the preoperatively estimated donor's right liver volume was ml, representing . % of his entire liver. with the recipient's weight of kg, the graft to recipient weight ratio (grwr) was . %. the liver had classic hilar anatomy except that the right posterior intrahepatic duct seperately joined to the left main hepatic duct. after isolation and clamping of right hepatic artery and portal vein, indocyanine green of . mg was injected intravenously. results: the total operation time was min and the estimated blood loss was ml without transfusion. indocyanine green fluorescence image clearly demonstrated the anatomical demarcation between the lobes and visualized the running of the biliary tree. his postoperative course was uneventful and discharged postoperative day . conclusion: real-time indocyanine green fluorescence image may be particularly helpful to delineate anatomical surgical plane and to determine the appropriate division point of hepatic duct during laparoscopic living donor hepatectomy. surg endosc ( ) the correct management of intraoperative volemic status is essential in laparoscopic liver resection in order to control bleeding and to perform even complex procedures with a good profile of safety. central venous pressure is not really reliable in laparoscopy, due to presence of the pneumoperitoneum and patient position. monitoring of haemodynamic parameters via vigileo system is a minimally invasive method to control stroke volume variation, cardiac output, cardiac index and oxygen delivery in order to optimize the anaesthesiological management by controlling venous bleeding and avoiding tissutal ischemia. introduction: non-hydatid liver cysts represent a heterogeneous group of disorders that differ in their etiology, prevalence and clinical manifestations.within them, the simple hepatic cyst is the most frequent.the majority of simple cysts are an incidental finding during the performance of an imaging test for another unrelated cause and few of them are symptomatic or are associated with complications, and surgery is not necessary in most of them. described various therapeutic approaches so far there is no consensus about the optimal treatment of simple symptomatic, complicated or growth-showing liver cysts during its follow-up. currently the laparoscopic approach is widely used for the management of cysts hepatic, with results similar to open surgery but with the advantages of laparoscopy. objectives: to demonstrate the safety and efficacy of the laparoscopic approach in the approximation of complicated simple hepatic cysts.material and method: clinical case: a -year-old female patient with a history of: giant hiatus hernia intervention with laparoscopic nissen, fibromyalgia, previous ischemic colitis. hospital admission due to pneumonia and right pleural effusion with us: simple cyst x x mm in segment v hepatic, with dilatation of biliary radicals adjacent to the cyst, distended gallbladder with irregular walls in the hepatic side. ct: cystic lesion in segment iv-v of the liver, which has increased in size, with small microabcesses adjacencies to the lesion, thickening of the gallbladder wall, to assess cholecystitis. antibiotic treatment is established with good evolution, deciding surgery. results: intervention: complete laparoscopic approach, trocars, edematous cholecystitis, large retroyuxta vesicular cyst,with thickened walls with serous content. cholecystectomy maintaining the cyst wall, puncturing and taking samples for cytology and biochemistry of the contents, resection of the cyst wall, partial flare of its internal surface, negative intraoperative biopsy, epipoplasty, with drainage placement.correct postoperative course.pathological anatomy: simple biliary cyst with negative cytology, ck ?, ck -, calretina-. conclusion: the treatment of choice of complicated simple hepatic cysts is laparoscopic.we recommend performing an intraoperative biopsy of all resected liver cysts to confirm its nature,we propose cyst enucleation as the best surgical treatment. objective: the objective of the following case is to present a patient with symptomatic polycystic liver disease, which was solved by laparoscopy approach and the management of its complications. material and methods: the case reported is about a years old female patient with abdominal pain in upper right quadrant associated to asthenia, adynamia and hyporexia. ct scan reported heterogeneous liver with multiple ovoid images with regular edges defined which the biggest one measure x x mm with volume of cc on segment and , which comprises stomach, and the other one in segment with a volume of cc and others small sized located in segment , and b. results: in this laparoscopic approach, we performed a cyst unroofing of the two biggest cysts as well as cholecystectomy because of firm and lax adhesions. the patient evolved with fever in the th day postsurgical day and biliary leaking in a volume of cc in hrs. an ercp (endoscopic retrograde cholangiopancreatography) was asked for that was carried out by finding leak at the intrahepatic biliary duct therefore; esphinterotomy with placement of plastic endoprotesis was performed. the patient evolved without complication and was discharged at the th day. conclusions: only symptomatic polycystic liver disease needs to be treated. the choice of treatment is not yet standardized, for voluminous cysts the unroofing ideally by laparoscopy is the gold standard and the ercp is the elected treatment when the biliary leak appears as a complication. introduction: laparoscopic liver resection (llr) for tumors located in the posterosuperior segments of the liver (segments (s) or ) is a challenging procedure. especially, llr for s is difficult because the access of instruments is limited, bleeding control is not feasible, major llr is sometimes required, and obtaining sufficient resection margin is not easy. to overcome this obstacles, we performed llr in s with a lateral approach using intercostal trocars. to obtain competent resection margin, llr through right hepatic vein (rhv) first approach was performed for . cm mass located near the rhv in a year old female. case: after full mobilization of right liver including all short hepatic veins and caudate lobe, rotate the whole liver completely to the left side to approach to the root of rhv. one intercostal trocar was inserted to access the lesion. parenchymal transection started from the confluence of hepatic vein and then, followed along rhv with ligating several small branches from rhv. resection margin was demarcated after localization using laparoscopic ultrasonography. after completion of parenchymal dissection using cusa and ultrasonic shears, hemostatic agents were applied and drain was inserted. operation time and estimated blood loss were mins and ml. the patient was discharged without any complication on postoperative day . final pathological assessment confirmed clear resection margin (safety margin : . cm). conclusion: laparoscopic s segmentectomy with hepatic vein first approach technique is safe and recommended to obtain better resection margin. aims: simple liver cysts are the most common cystic lesions of the liver. most are diagnosed casually in image tests such as ultrasound or computerized tomography, most of which are asymptomatic and do not require treatment. in symptomatic patients (abdominal distension with palpable mass, abdominal pain, dyspnea, jaundice, etc.) the clinical manifestations are usually due to the growth of the cysts or the compression of neighboring structures. liver function tests are usually not altered. intracystic complications occur in less than % of cases and malignancy is exceptional. in this video, we present the case of a symptomatic patient with polycystic liver disease including a large size hepatic cyst. material and methods: -year-old woman with a personal history of arterial hypertension, saos, partial hysterectomy due to endometrial cancer, who was referred to our department complaining of supraumbilical pain and abdominal distension with palpable mases. abdominal ultrasound showed cholelithiasis and multiple simple hepatic cysts. in ct scan, multiple hepatic cysts were found, the largest one of about cm of larger diameter. echinococcus granulosus serology test was negative. there was also no evidence of cancer disease in pet scan. results: a laparoscopic approach was performed with four trocars, three of mm and a hasson trocar inserted thought a umbilical small incisional hernia. aspiration and wide unroofing of the large size cyst and smaller accessible ones was done. the patient also underwent cholecystectomy with intraoperative cholangiography and umbilical eventroplasty. the patient recovered uneventfully and is asymptomatic one year after surgery. conclusion: simple liver cysts rarely require treatment. in some cases, especially in large, complicated and symptomatic simple liver cysts, surgery is indicated. laparoscopic fenestration treatment is the best choice. aims: liver resection is the preferable initial treatment option for solitary or limited multifocal hepatocellular carcinomas. surgical indications for laparoscopic liver resection (llr) are the most important consideration, like liver function, tumor size (diameter less than cm) and location (easy technical access like in the left lateral section or on the surface of the inferior region). partial liver resection or left lateral sectionectomy are the typical procedures for such tumors and are considered the best way to begin llr. with accumulating experience and technical advancement, llr has been performed for tumors larger than cm and for others locations. some requirements to perform llr are to have experience in liver surgery and laparoscopic also, adequate technology and intraoperative ultrasound. methods: a -year-old male smoker, ex-parenteral drug users with chronic hcv liver disease child-a stage. he is diagnosed with a single lesion of cm in segment iii of the liver, biopsied twice without conclusive diagnosis and with a three-phase ct suggestive of hepatocarcinoma li-rads with data of portal hypertension (pht) and mild ascites. after the study is commented on tumor committee deciding surgical intervention. results: a laparoscopic resection of segment iii was performed with trocars. liver is explored by intraoperative laparoscopic ultrasound. vascular control was performed using the pringle technique. liver transection was done with sonostar until identification of intraparenchymal segment iii vascularization, which is sectioned with endogia ( mm) with seamguard. after the resection, we perform hemostasis control with electrocoagulation and hemostatic material. intraoperative bleeding of ml. favorable postoperative evolution, high on the th postoperative day. ap: cm trabecular hepatocarcinoma moderately differentiated pt b, r resection. conclusions: llr allows major liver resections with low morbidity and mortality and the advantages of laparoscopic surgery. an efficient learning curve can be achieved by a parallel evolution of procedures and indications (according to modified bclc staging system and treatment strategy). studies suggest that llr results in less blood loss, shorter postoperative hospital stays, lower abdominal wall trauma and lower incidences of ascites accumulation and postoperative liver failure. with respect to oncological considerations, tumor margins are adequately maintained during llr. v. drakopoulos, s. voulgaris, i. iliadis, k. botsakis, p. trakosari, v. vougas st department of surgery and transplantation unit, district general hospital of athens « evangelismos » , athens, greece introduction: laparoscopic surgery is gaining acceptance in the treatment of liver metastasis. laparoscopic treatment of liver metastasis often presents technical difficulties and requires an extensive learning curve. material-method: we present the case of a year old woman presented with a liver metastasis in section of the liver. the patient had been submitted to a laparoscopic low posterior resection in february . patient underwent laparoscopic left lateral hepatectomy, with the use of three trocars (umbilical mm, and two in the midclavicular line bilaterally.) left lateral hepatectomy was conducted with the use of a linear stapler. the postoperative period was uncomplicated and the patient remains in good condition three months after surgery. conclusion: laparoscopic approach seems to be safe for treatment of liver metastasis, offering better surgical field view and less postoperative complications. year survival rate after laparoscopic hepatectomy is compared to the open approach. general surgery, chang gung memorial hospital kaohsiung division, kaohsiung, taiwan purpose: laparoscopic hepatectomy is a quickly growing method for liver tumor because of modern technology. but for the ihd thrombosis, it is still technique dependent. the video was tried to share our experience for special case. material and method: one y/o female patient suffered from fever episode and image show s cm hcc with right anterior ihd obstruction r/o tumor thrombosis, hilum ln enlargement, double right portal vein, hilum adhesion with duodenum, no ascites . lab data : no-b, no-c child a, afp , icg clearance rate . %, plt . heart, lung function exam normal. the laparoscopic right total hepatectomy and hilum ln dissection was conducted. results: laparoscopic approached was performed. the hilum ln dissection was done with vessel and bile duct isolation. hilum ln frozen show negative malignancy. hemi-vessel control was done with resecting the vessel. right hepatectomy was done with preserving middle hepatic vein. the right anterior and posterior ihd was opened and tumor thrombosis was removed from right anterior ihd carefully. the stump of ihd was closed by suture separately. the total op time was min with cc blood loss. post op minimsl bile leakage was found in the drain at day . the patient discharged at day with drain. conclusions: laparoscopic hepatectomy may be a feasible method for hcc even with ihd tumor thrombosis. surg endosc ( ) introduction: the progressive laparoscopic learning in gastric surgery and the great development of instruments and laparoscopic material that facilitates the realization of advanced procedures, has led to an increase in the use of laparoscopy in the treatment of gastric cancer. material and methods: we present the case of a -year-old man without amc with a history of ischemic heart disease who enters our surgery department for cholangitis secondary to choledocholithiasis. ercp is requested during his admission that describes a gastric lesion from which a biopsy is taken, making it impossible to access vater papilla to perform sphincterotomy and lithiasis extraction due to the existence of duodenal diverticula. the result of pathological anatomy of the gastric lesion was compatible with adenocarcinoma. negative extension study. the clinical case is presented in a committee of multidisciplinary tumors and it is decided to perform surgical intervention of both pathologies. a subtotal gastrectomy was performed with a roux-en-y reconstruction. surgical time of min. choledochotomy was performed with lithiasis extraction, as well as intraoperative exploration of the bile duct and main conduits by means of a choledochoscope. results: income of days, with a clavien ii. the definitive pathological anatomy was an ai stage with a total of isolated nodes without evidence of neoplasia in any of them, therefore it does not require adjuvant treatment. the patient is asymptomatic, with nutritional supplementation with follow-up in ccee of surgery. conclusions: in our case, there were no serious postoperative complications when performing gastric resection and bile duct exploration with drainage of the same. from the oncological point of view, the number of lymph nodes extracted and the surgical margins are similar to those obtained in patients in whom we perform open surgery; therefore, although it is a single clinical case, laparoscopy in expert surgeons is a safe and effective technique. the puestow procedure was initially proposed to alleviate the pain in patients with chronic pancreatitis and dilated wirsung duct. its objective is to provide an efficient drainage of the pancreatic fluids and, in the meantime, to preserve the pancreatic tissue and minimize the risk of endocrine and exocrine pancreatic insufficiency. aims: to describe the particular technical aspects and the efficacy of totally laparoscopic puestow procedure in patients with cystic duodenal dystrophy. methods: a years old patient presenting diffuse epigastric pain, vomiting and weight loss was diagnosed at endoscopic ultrasound and biopsy with cystic duodenal dystrophy. a conservative treatment was decided with octreotide and opioids. however, due to the persistence of symptoms surgery was performed. results: due to the association of a dilated wirsung duct, the patient was submitted to a puestow procedure. the surgical procedure was completed in a minimally invasive manner; after dissecting the anterior surface of the pancreas an intraoperative ultrasound was performed in order to identify the wirsung duct. therefore, the pancreatic parenchyma was transected along the wirsung duct, a totally laparoscopic pancreato-jejunostomy on roux en y limb being performed. the early postoperative outcome was uneventful, the patient being discharged in the sixth postoperative day. at one month and six months follow up the need for opioid treatment significantly diminished. a kinking of the enteral anastomosis required a laparoscopic intervention one year after with a very good evolution after. conclusions: totally laparoscopic puestow procedure seems to be a safe and efficient method in order to treat symptomatic patients with cystic duodenal dystrophy in whom a dilated wirsung duct is present. aims: the approach to the intraductal papillary mucinous neoplasm (ipmn) is various, from a radiological follow-up with magnetic resonance (rm) to the surgical treatment with a pancreatic resection [ ] . the surgical approach is various and depends on the localization of the lesion and on the surgical skills [ ] . methods: a years old patient was admitted at the chi possy-saint germain-en-laye with an acute pancreatitis. at the ecoendoscopy was found a pancreatic cystic at the junction of the pancreatic body and tail with a wirusng diameter of mm. a second episode of acute pancreatitis occurred a few months later. after that episode the patient was submitted to a computer tomography (ct) that found a cystic lesion of cm with an increasing dilatation of the wirsung duct. the serum ca - was ui/ml. a laparoscopic sils distal pancreatectomy with spleen conservation was performed. results: a trans-umbilical incision was performed with the positioning of the gelpoint sils platform with the placement of trocars. a distal pancreatectomy with a spleen preservation and without a standard linfadenectomy was performed. the pancreatic stump was closed with an endo-gia mm with seamguard device. any drain was placed. the post-operative course was uneventfull. a ct scan was performed in …. post-operative day which didn't show collections. the patient was discharged in -…… post'operative day. the histological examination shows an ipmn with low grade dysplasia. no invasive carcinomatoses cells were found. the distal pancreatic sils resection with spleen conservation is a feasible and safe technique that combine all the advantages of the minimally invasive laparoscopic approach with the esthetic advantages of the sils approach. pancreato-duodenectomy is a complex surgery, requiring several anastomoses to reconstruct the digestive tract. due to its technical complexity, the laparoscopic approach is not yet the goldstandard and there remains some controversy about its oncological safety. worldwide experience is limited, and its safety and effectiveness are yet under evaluation.we present the clinical case of a years-old woman with a prior history of epilepsy. she was studied due to painless obstructive jaundice and a cm pancreatic head tumour was diagnosed on imaging, causing cbd and wirsung channels' dilatation. the tumour was considered locally resectable and she was proposed for a radical pancreato-duodenectomy.we present the main steps of the surgery including the oncological resection with lymphatic basin clearance and totally laparoscopic reconstruction.the post-operative was uneventful, and the histologic sample revealed a ductal adenocarcinoma (t ) with an r resection and / lymph nodes invaded. although technically demanding, laparoscopic pancreato-duodenectomy is safe and effective requiring teams with experience both in pancreato-biliary and laparoscopic surgery. chronic pancreatitis is characterized by a progressive pancreatic fibrosis with loss of endocrine and exocrine function. one of its main symptoms is debilitating pain. surgical drainage of a dilated pancreatic duct is an option to consider in cases of refractory pain. longitudinal pancreato-jejunostomy allows an effective decompression of the pancreatic channel and a significant improvement in the quality of life. we present the clinical case of a years-old lady with a prior history of gallstones. she was treated for an acute pancreatitis in may , followed by recurrent relapses of pain and enzymatic elevation. she required opioid use for partial pain control and a significant kg decrease on body weight due to 'fear of eating'. the endo-ultrasonography and the mri revealed a chronic pancreatitis with an mm wirsung duct with ductal stones and an atrophic body and tail. we proposed a laparoscopic longitudinal pancreato-jejunostomy. the surgery was performed with trocars, with the surgeon on the right side of the patient. we performed a trans-mesocolic cm pancreato-jejunostomy. the post-operative was uneventful, and the patient was discharged on the th post-operative day, asymptomatic. laparoscopic longitudinal pancreato-jejunostomy, although effective is a technically demanding surgery but brings the benefits of a minimally invasive approach. background: preservation of spleen in distal pancreatectomy is also useful from the maintenance of platelets and the prevention of overwhelming post splenectomy infection. we have performed laparoscopic spleen preservation distal pancreatectomy: lspdp to benign and low-grade tumors of the pancreatic body tail. the aim of this study was to report our surgical experience with the method of svp: splenic vessel preservation and wt: warshaw technique of lspdp, describe our techniques with videos. method: there are three points of our surgical technique. , precede pancreatic dissection, improve the mobility of the pancreas. , confirming the courses of splenic artery and classified them into two major types. , preserving the left gastro-epiploic vessels and short gastric vessels.the postoperative cases of lspdp which performed from april to september was retrospectively studied. result: of consecutive patients were performed lspdp at our institute, were svp and were wt. ages, gender and bmi were similar for two groups. there were no significant differences in operative time, blood loss and length of stay after surgery. comparing pathological finings, wt was associated with a slightly large tumor lesion (median mm vs. . , p = . ). among the median observation period of months, splenic infarction was observed in case in svp and cases in wt. however, they were focal splenic infarctions, they did not need surgery or drainage. there were no cases in which late onset of splenic artery occlusion or esophageal / gastric varices. conculusion: after performing lspd, the function of the spleen was good in all cases. both svp and wt were safe and feasible procedures. this is the case of a -years-old lady presenting with recurrent abdominal intractable pain she has been suffering from for the last years. msct revealed pancreatic calcifications from mm to - mm and dilatation of the main pancreatic duct in the body of the pancreas up to mm. the patient underwent laparoscopic local resection of the head of the pancreas combined with longitudinal roux-en-y pancreaticojejunostomy-a technique known as frey's procedure. it is recognized as an effective therapeutic option for the surgical treatment of patients with persistent pain caused by chronic pancreatitis.after performing the posterior wall of the pancreaticojejunal anastomosis we've faced an intraoperative complication such as volvulus of the roux limb causing serious ischemia of the limb. we were forced to remove all previous sutures in order to untwist the roux limb, thereafter the pancreaticojejunostomy was started anew.the purpose of this video is to demonstrate that frey's procedure can be performed in a minimally invasive fashion, which provides all the well-known advantages of this approach. we demonstrate that even such serious intraoperative complication as volvulus of the roux limb can be managed without conversion. our center has an experience of over laparoscopic frey's procedures, however this is the first case where we encountered with such complication and we believe this is an experience worth sharing.yet we would like to underline that this approach should be used by highly skilled minimally invasive surgeons experienced in intracorporeal suturing which is the most challenging stage in frey's procedure. v. tomulescu, i. hutopila, c. copaescu spleen preserving distal pancreatectomy (spdp) is commonly applied in patients with benign or low-grade malignant tumors in the body and tail of the pancreas. two surgical techniques for spdp have been described. the first technique was described by kimura (spleen preserving distal pancreatectomy with splenic vessel preservation-spdp-svp) and preserves the main splenic artery and vein and excises the tail of the pancreas and those small, short vascular connections to the body;the second technique was described by warshaw and involves resection of the splenic vein and artery before distal pancreatectomy, and conservation of theshort spleno-colic and gastric vessels to keep normal blood flow for the spleen (spleen-preserving distal pancreatectomy with splenic vessel resection-spdp-svr). we present the case of a years old female with / mm tumor of the pancreatic tail on ultrasonography. ct scan confirmed the tumor and endoscopic ultrasonography with fna have shown a solid pseudopapillary tumor. due to the low grade malignancy we have decided to perform a laparoscopic spleen preserving distal pancreatectomy with splenic vessels preservation (lspdp-svp). for lspdp-svp the difficulty is related with the splenic vessels dissection and manipulation. primary dissection and control of main trunk of splenic artery and vein will help to quickly control bleeding during vascular rupture in small vessels dissection. optimal stapling of any tissue requires an adequate tissue compression time to allow elongation of the tissue being compressed, smooth firing of the instrument, consistent staple line formation balanced against the risk of increased tissue tearing and excessive tensile strength. this is why, for pancreatic division, we prefer choosing a cartridge loaded with higher staplers. the pancreatic stump transection line is evaluated for bleeding and when it is needed, hemostatic clips are applied. histology report confirmed a solid pseudopapillary tumor t nomxl v r at this moment with month good follow up. in conclusion lspdp-svp is safe, reproductible and demonstrated very good outcomes when certain indications are respected. surg endosc ( ) aim: advances in minimally invasive surgery has permitted to perform complex techniques by this approach, being the laparoscopic duodenopancreatectomy (lpd) one of these. the aim of this communication is to present a surgical technique video for a complete laparoscopic pd, showing the most important steps of the resective and reconstructive phase, with the anastomosis realized completely by laparoscopy. methods: a surgical technique video is presented showing the main steps for the lpd and a complete laparoscopic reconstruction with an hepaticojejunostomy, duct-to-mucosa pancreatic-jejunostomy and a gastrojejunostomy. results: an years old woman with past medial history of arteria hypertension, dyslipidemia, type ii diabetes mellitus and a breast cancer treated in with lumpectomy and axillary lymphadenectomy plus radiotherapy, recently diagnosed of and adenocarcinoma of the head of the pancreas. the ct scan showed a neoplasia localized in the head of the pancreas without extension to other organs. a laparoscopic pd was indicated after a multidisciplinary committee evaluation. a supraumibical hasson trocar was used for the pneumoperitoneum, three mm trocars and two mm trocars were used. lpd was performed. the resective phase was done following the conventional steps of the open whipple procedure and for the reconstructive phase, a child limb was used for a termino-lateral hepatico-jejunostomy with an absorbable / monofilament; a duct-to-mucosa pancreatic-jejunostomy with an absorbable / monofilament and finally a latero-lateral mechanical gastro-jejunostomy was performed. surgical time was min. postoperative course without complications and the patient was discharged on the th postoperative day. definitive anatomopathological exam: intraductal tubulopapilar neoplasia, x x mm, with wide high grade epithelial dysplasia. free margins. ptisn ( / ). conclusion: laparoscopic pd is a feasible procedure with a high technical requirement which should be performed in specialized centres with high experience in hepatobiliary surgery and in advanced laparoscopic procedures, because of its high morbidity and mortality. conclusions: robotic assistance in whipple may overcome limitations of laparoscopy and offer a minimaly invasive approach to this procedure potentially resulting in lower blood loss and less morbidity. we need further prospective randomized trials in order to determine the exact role of robotics in pancreatic surgery. aims: distal pancreatectomy is the standard curative treatment for symptomatic benign, premalignant, and malignant disease of the pancreatic body and tail. the most obvious benefits of a laparoscopic approach to distal pancreatectomy include earlier recovery and shorter hospital stay. spleen-preserving distal pancreatectomy should be attempted in case of benign disease. laparoscopic spleen-preserving distal pancreatectomy (lspdp) is expected to be less invasive than laparoscopic distal pancreatectomy with splenectomy. however, there are few reports regarding the details of the procedure for lspdp, and its safety remains unclear. this study aimed to evaluate the feasibility and safety of lspdp. methods: retrospective analysis of surgery treatment of patients was made. lspdp was conducted in the period from to in the department of laparoscopy surgery of state institution o.shalimov national institute of surgery and transplantology. the average age was : . years, the body mass index (bmi) was . ± . results: laparoscopic distal pancreatectomys was performed in % of cases, were attempted in female and male patients. postoperative pathological examinations revealed cases of serous cystadenoma in the body and tail of the pancreas, case of serous oligocystic adenoma, case of mucinous cystadenoma, case of neuroendocrine tumor (insulinoma), and case of solidpseudopapillary neoplasm. complications related to the surgery were like acute pancreatitis with -fold increase normal plasma amylase confirmed by ct- cases, fluid collection- cases, pancreatic fistula (grade a)- cases. the operation time was . min, (range - min) blood loss of . g (range - g), mean hospital stay was . days (range - days). conversion to laparotomy was in case. mortality was . conclusion: laparoscopic spleen-preserving distal pancreatectomy is minimally invasive, safe, and feasible for the management of benign pancreatic tail tumors, with the advantages of earlier recovery and less morbidity from complications. aims: a pancreatic pseudocyst is an encapsulated, mature fluid collection occurring withing the pancreas that have a well-defined wall minimal or no necrosis secondary to pancreatic injury and mediated by the enzimatic and inflammatory disruption of pancreatic tissue. it is a common complication of acute and chronic pancreatitis. we present the case of a pancreatic pseudocyst located within the body of the pancreas due to recurrent necrotic pancreatitis. the objective of this video is to show the minimally invasive surgical approach of this entity. methods: a -year-old man without medical history was admitted to hospital in the digestive service on times for acute necrotizing pancreatitis. after study in which is evidenced cholelithiasis and pseudocyst in pancreatic body of cm maximum diameter and formation of two peripancreatic collections without signs of superinfection, cholecystectomy is indicated. magnetic control cholangiography was performed after surgery and it showed an increase in the size of the pancreatic pseudocyst, suspecting wirsung's duct disruption. therefore, endoscopic retrograde cholangiopancreatography (ercp) was performed by placing a plastic pancreatic prosthesis and performing a sphincterotomy. after hospital discharge, the patient is re-admitted due to recurrent abdominal pain without analytical alteration. tc abdominal observed an increase in the pseudocyst from to cm. this case was discussed in a multidisciplinary committee and surgical intervention was decided. results: laparoscopic approach is decided and four trocars were placed. initially, a gastrostomy was performed with liquid outlet. an aspiration of the liquid and quistogastrostomy with mm endogia was made. the patient progresses favorably, being high on the tenth postoperative day, without complications. conclusions: almost every pancreatic pseudocyst improves spontaneously and needs no specific treatment. draining is indicated when secondary symptoms to compression, complications or rapidly enlarging are found. depending on the complexity of the pseudocyst, its communication with wirsung's duct and the existence of ductal injury, it may perform a percutaneous, endoscopic or surgical drainage. the goal of pancreatic debridement is to excise all dead and devitalized pancreatic and peripancreatic tissue while preserving viable functioning pancreas, controlling resultant pancreatic fistulas, and limiting extraneous organ damage. only the surgical procedure is definitive. case: a y old male presents with intermittent low retrosternal pain and progressive dyspnea with exercise since a couple of months. cardiac investigation was negative and gastroscopy showed a grade b esophagitis. he was treated medically but with only partial response. on a thoraco-abdominal cat-scan the diagnosis of a left sided bochdaleks' hernia was made. the hernia includes the left kidney (with blood vessels and ureter), transverse colon and small intestine which are positioned in the left lower thoracic cavity with the left lung considerably compressed. method: given the clear correlation between the patients' complaints and these anatomical findings, he was referred to our service of abdominal surgery. we performed a laparoscopy with the patient in lithotomy position and the surgeon between the legs. the patient was tilted to his right side. mobilization of the spleen was necessary to gain maximal access to the hernia. we were able to reduce all the herniated content, freed the margins of the defect, reduced the hernia sac and repositioned the kidney intra-abdominally. the defect was manually closed with non-resolvable stitches and covered with a mesh which was secured with tackers. result: postoperatively the patient recovered well with adequate pain relief and pulmonary support. he could leave the hospital after days. control cat-scan on day postoperatively shows an intact lining of the diaphragm with normal positioning of the intra-abdominal organs. on follow-up weeks after surgery the patient had regained normal activities and was symptom free. conclusion: a symptomatic left sided bochdaleks' hernia in adults with an ectopic intrathoracic kidney is extremely rare. we hereby state that, during a laparoscopic repair, the kidney can also be safely reduced, which has almost never been described in literature yet, enhancing pulmonary recovery, improving access for mesh placement and thus diminishing recurrence rate. aims: large incisional hernias repair involves an actual problem for surgeons to face. anterior component separation has been an important method allowing to close the fascia defects without tension while also having underlay mesh reinforcement.therefore, we present a case of incisional hernia reparation performing endoscopic anterior component separation with advantages compared with open approach. method: we present the case of a -year-old woman, bmi kg/m , with previous laparoscopic gastric sleeve and posterior reintervention using open approach. the patient presented a cm size incisional hernia m w . a ct scan was performed, confirming a midline incisional hernia containing colon, with an herniary defect of cm. full minimal invasive abdominal wall repair was proposed. a cm size incision was made in left iliac region to reach the aponeurosis of external oblique muscle. we placed a balloon trocar and subcutaneous pneumo-dissection with mmhg pressure was performed; then, we placed a mm trocar in left lumbar space. the aponeurosis of external oblique muscle was incised and anterior component separation from inguinal to subcostal area was achieved. an extensive intermuscular dissection was performed to achieve complete midline closure. we performed the same procedure on the right side. then, with laparoscopic approach using v-loc n° suture, we completely closed the midline. eventually, we placed a x cm ptfe-c mesh fixed with a double crown of tackers and fibrin glue. results: postoperatory course was uneventful and the patient was discharged h after surgery without any remarkable event during his postoperative stay. the patient has been followed up for months without any complication or recurrence in ct scan, confirming the correct minimally invasive reconstruction of the abdominal wall. conclusions: trends in abdominal wall reconstruction and complex-hernia repairs have advanced rapidly in recent years. the goal is to perform a complete abdominal wall repair with no tension in midline incisional hernias. endoscopic anterior component separation and laparoscopic eventroplasty with closure of the defect, leads to a complete wall reconstruction without tension and avoids drawbacks due to primary close defect in those patients with herniary defects wider than cm. aims: endoscopic technique is a valid and safe approach for the treatment of abdominal wall defects. to combine the advantages of complete endoscopic extraperitoneal surgery with those of sublay mesh repair we propose totally endoscopic sublay anterior repair (tesar), a safe and feasible approach for the treatment of ventral and incisional midline hernias. methods: from may to september patients were referred to our unit for clinical and radiological diagnosis of midline ventral or incisional hernia and selected for tesar. exclusion criteria were: complicated ventral or incisional hernia (i.e. incarcerated hernia), maximum defect width [ cm, contraindications to general anesthesia. the procedure consisted of suprapubic access with trocars, complete endoscopic pre-aponeurotic dissection, isolation and reduction of the hernial sac, bilateral incision of the medial rims of recti aponeurosis and dissection of retromuscular plane to create the retromuscular space, sublay non-absorbable mesh positioning and anterior aponeurosis reconstruction. one drain was always placed in the retromuscular space and one drain in the subcutaneous space. results: all procedures were completed with endoscopic approach, with no conversion to laparoscopy or open surgery. no intraoperative complications were registered. total mean operative time was ± . min. no post-operative major complications were registered. only one subcutaneous seroma was registered ( . %), and treated conservatively. the mean postoperative stay was . ± . days. at post-discharge clinical checkups drains were checked and removed when indicated. no wound complications nor recurrence were registered to date. cosmetic and functional results were successful in all patients. conclusions: tesar is a safe and feasible technique for the extra-peritoneal sublay repair of ventral hernias with totally endoscopic approach. it provides accurate hernia repair with good outcomes in terms of resolution of symptoms and post-operative complications. r. mizuno, m. kondo backgrounds: abdominal incisional hernia is found in more than % after abdominal surgery, and risk factors such as wound infection, obesity, elderly, high abdominal pressure are pointed out. laparoscopic hernia repair using intraperitoneal onlay mesh (standard ipom) is becoming widespread in japan since the insurance release in , and our hospital is actively working on it. recently, ipom plus procedure which also carries out fascia suture in addition to laparoscopic mesh placement has been introduced. aims: we report the clinical results of laparoscopic abdominal incisional hernia repair in our hospital. methods: we performed hernia repairs using a mesh for cases from january to september . of these, cases were standard ipom and cases were ipom plus. there was no significant difference in the patient background such as gender, age, bmi, etc, and in the intraoperative findings such as hernia orifice diameters and adhesions. surgical time, postoperative hospital stay, and the rate of complications such as seroma, mesh bulging, postoperative pain, hernia recurrence were compared and examined between the two groups. results: as a result, in ipom plus group, the operation time was longer and the incidence rate of postoperative pain was higher, but the incidence of mesh bulging was significantly lower. also, in some cases since , the ' u reverse stitch method ' is used as an ingenuity of fascia suture in ipom plus. conclusions: laparoscopic abdominal incisional hernia repair has the advantage of being able to reliably confirm the hernia orifice from the intraperitoneal side?it is excellent in the identification of the fragile part of the abdominal wall and in the visibility of the restoration range. with regard to the ipom plus procedure which has been introduced in the last few years, although the operation time is extended, it has usefulness such as reduction of mesh bulging. from the viewpoint of cosmetic surgery, usage of ipom plus will increase in the future. introduction: incisional hernia is one of the most common complications after abdominal surgery. several methods have been introduced, and yet, there is no consensus on the best method of repair. we present a novel method for hernia repair which uses the retromuscular sublay mesh repair through a single incision at the pubic area to improve cosmesis. methods: medical records of patients who underwent single-port retrorectal incisional hernia repair from may to december were reviewed. patients were placed in supine position and a cm incision was made in the pubic area below the panty line. a flap is made upwards until the defect is found and bilateral rectus sheathes are dissected. a mesh is then placed between the posterior rectus sheath and the muscle. results: a total of patients with midline incisional hernia underwent single-port retro-rectal incisional hernia repair. mean age was . ± . years with an average bmi of . ± . . all the patients had midline hernia defect with an average of . ± . cm. mean operation time was . ± . min and estimate blood loss was . ± . ml. there was no postoperative complication, and ( %) patients were discharged on the day of surgery. conclusion: the single-port retrorectal incisional hernia repair is safe and effective while providing good cosmesis to selected patients with incisional hernia. aims: closing hernia defect during laparoscopic hernia repair is a vast extended technique nowadays. however, this technique is associated with mesh placemnt intraabdominally in contact by the abdominal content. nowadays there is a trend to recontruct the midline and to avoid a mesh intraabdominally in those cases suitable for it, as a new step forward of minimally invasive abdominal wall reconstruction. laparoscopic sublay approach with retromuscular placement of a mesh without mechanical fixation after reconstruction the linea alba migth be considered an option in primary hernias of the midline. methods: we present a case of a year old male with an umbilcal hernia of centimeter in diameter associated with rectus diastasis. a laparoscopic approach was performed, using one and two millimeter trocars placed on the left flank. the first step was to open the lateral side of the posterior fascia of the left rectus muscles, dissecting the retromuscular plane until we reach the linea alba getting into the preperitoneal space where the sac was diseected preserving the integrity of the peritoneum. the contralateral posterior fascia was also dissected all the way to the semilunaris line. the midline was closed, including th hernia defect, using a running double loop suture (maxon-loopÒ). a self gripping mesh (progripÒ) is placed in the retromuscular space in a sublay position ( cm long, cm wide). last, we close the fascia of the left rectus muscle using a barbed suture (v-locÒ). results: surgical time was min, being discharged of the hospital on postoperative day . pain was controlled with conventional analgesia and no postoperative complications, nor seroma was detected. conclusions: sublay approach for ventral hernia can provide a midline reconstruction, reestablishing abdominal function and avoiding the use of intraabdominal meshes and traumatic fixation, decreasing postoperative complications and pain. aims: lumbar hernia is one of the rare cases that most surgeons are not exposed to. hence the diagnosis can be easily missed. this is often related to previous surgery as lumbotomies or primary in the superior lumbar triangle. this leads to delay in the treatment causing increased morbidity. we report a case of adquired lumbar hernia in a middle-aged woman repaired by laparoscopic approach. methods: a years old woman with surgical history of a myelomeningocele surgery by posterior approach over years ago, a laparoscopic left nephrectomy years ago with a left colostomy due to a left colon injury during this procedure. a hartmann reversal by laparoscopic approach months later. patient showed a large lumbar mass over cms in the left lumbar region and a large scar near to spinal cord. it was soft in consistency, reducible and expansible on coughing and straining with defined borders. computerized tomography showed a large defect in the superior lumbar fascia over cms in the grynfeltt-lesshaft triangle with the left colon inside. results: patient was placed in a full lateral decubitus position. in order to optimize exposure, a lumbar roll was placed under the lumbar region. a capnoperitoneum ( - mmhg) was built up. one mm and two mm trocars were used and positioned in the left mid axillary line. a optic was used. adhesions were removed and toldt fascia was opened in order to expose the hernia defect bounded by quadrates lumborum, erector spinae muscles, rib and serratus. hernia content was carefully extracted from the sac using a ligasure maryland (covidien medtronic-usa). hernia defect was measured and an intraperitoneal mesh (dinamesh-ipom feg textiltechnik mbh, aachen, germany) was positioned and sutured by tackers to the margins included the bone. patient was discharged in h with a low pain rate and without complications. there is not recurrence in months follow-up. conclusion: laparoscopy might be a safe and feasible approach for repairing lumbar hernias, either primary or adquired, with a low rate of pain and complications s surg endosc ( ) after pneumoperitoneum is done, three mm trocars are placed on the left flank. the defect is delimited by drawing it over the skin of the patient with aid of an intramuscular needle and intraabdominal vision. posterior fascia is opened longitudinally at its medial edge and the retromuscular space is dissected. the arcuate line of douglas and the epigastric vessels are identified. from this point, transversus abdominis fascia is sectioned cranially cm medial to the semilunar line, preserving the neuro-vascular pedicles that reach the rectus abdominis laterally. at supraumbilical level, transversus abdominis fibers advance behind rectus abdominis, so they need to be sectioned to access to the space below the ribs. lateral dissection of this space enables a tensionfree closure at midline. once the procedure is repeated on the contralateral side using two mm and one mm trocars on the right flank, a continuous suture of the posterior fascia is performed with a barbed suture. the anterior fascia is closed with a slowly-absorbable monofilament loop-type suture. finally, a double-layer polypropylene mesh is placed at retromuscular level without any suture and fibrin glue is applied. results: the patient was discharged hous after surgery. no recurrence has been presented to the moment. conclusions: the section of the aponeurotic plane from the arcuate line of douglas enables a more accurate dissection of the retrotransversus plane without sectioning its fibers except for its cranial end, preserving the innervation and vascularization of the abdominal wall. this technical modification aims to simplify a complex laparoscopic procedure allowing its estandarization. aims: the authors present a video with their standardized laparoscopic ventral hernia intraperitoneal mesh (ipom) hernioplasty procedure but introducing a novel laparoscopic technique for tension releasing while hernia gap closure and midline anatomical restoration. methods: a years old male patient with a bmi presents a symptomatic ventral hernia recurrence after a sigma colic cancer open surgery. a ct scan study showed a cm transverse diameter midline ventral hernia. a laparoscopic ipom hernia repair procedure is performed using mm instruments and a mm camera. when checking tension while midline restoration suturing, we decide to add a tension-releasing maneuver: a totally laparoscopic transverse abdomini muscle release (taltar). this maneuver allow right rectus posterior sheath to advance some distance to the midline, in order to provide a tension-free midline closure. a double-faced ready-to visceral contact mesh is now placed and fixed. case and technical details are shown in the video. results: the patient was discharged from hospital within a period of h with a rate in a eva acute pain visual scale. in a year follow-up, there has no been an anatomical or clinical recurrence. no chronic pain, anatomical recurrence, lateral asymmetry, umbilical or abdominal wall complications have been reported with this technique. conclusions: depending on the patient characteristics, anatomical hernia factors and surgeon mini invasive experience, a taltar maneuver could be a safe and feasible option for releasing tension when midline anatomical laparoscopic closure. more studies are needed in order to standardized this approach. aims: when primary ventral hernia and simultaneous diastasis recti are diagnosed, there is no consensus among the international surgical community on the surgical treatment regarding indications or surgical technique. however, if diastasis recti is symptomatic of or is associated with midline hernias, the corrective surgery of both pathologies at the same time could be the most recommended option. when we only correct the herniary defect, we risk performing a reparation on an anatomically weak tissue, so the rate of hernia recurrence may increase. we propose a minimally invasive access using totally endoscopic retromuscular hernioplasty. by developing this technique, several advantages are provided, such as no peritoneal opening without intraabdominal access, no mesh fixation needed and simultaneous solving of both pathologies. method: we present the case of a -year-old man, with bmi kg/m and no previous medical history complaining of ventral hernia with associated recti diastasis. a cm size umbilical hernia was diagnosed with a cm size supraumbilical diastasis recti associated. full endoscopy retromuscular hernioplasty was proposed. a cm size incision was made in left hypocondrium, openned the anterior rectus sheath and retracted the rectus muscle. we placed a balloon trocar and open the homolateral retromuscular space after placing two mm trocars in left lumbar space and epigastric position. we crossed-over the linea alba and achieve contralateral retromuscular space. after this step, the hernia sac was reduced and we extended the dissection cm caudal to the hernia ring. both medial posterior rectus sheaths were sutured with running barbed suture n° and a x cm size light-weight, big pore, polipropilene mesh was placed in retromuscular space and unrolled properly with enough overlap. a drain was placed and the anterior rectus sheath incision was closed. results: the patient was discharged h after surgery without remarkable events during his postoperative stay. he has been followed up for months remaining asymptomatic. conclusions: totally endoscopic retromuscular ventral hernia repair in men with umbilical hernia and diastasis recti associated, is feasible and reproducible procedure with several advantages compared to traditional laparoscopic ipom in terms of pain and mesh position. aims: parastomal hernia (ph) is one of the most frequent long-term complications of stoma formation, occurring in %- % of patients. surgical treatment for parastomal hernia is the only cure but a fairly difficult field with a recurrence rate ranging from % to % of cases. due to its advantages, the number of laparoscopic mesh repairs for parastomal hernia has gradually increased over the past decade. according to this common complication, we report a case of laparoscopic reparation of ph using the sugarbaker technique. method: we present the case of a -year-old patient with surgical antecedent of laparoscopic low anterior resection due to rectal cancer, presenting in postoperative period an anastomosis leakage with severe peritonitis was identified and a laparotomy with end colostomy was performed. the postoperative course was uneventful. during the follow-up the patient showed a centimetres size paraestomal hernia, being a m w incisional hernia confirmed with ct scan.the patient underwent full laparoscopic hernia repair, performing a sugarbaker technique, exposing parastomal hernia completely to measure the hernia ring size ( centimetres) and the midline associated defect ( centimetres). a x cm size ptfe-c was selected to allow a -cm overlap over two defects. results: using this approach, the bowel loop was pushed into the abdominal wall and appropriate place between the mesh edge and the abdominal wall is left to allow the bowel loop to pass through. postoperatory course was uneventful and the patient was discharged h after surgery without any remarkable event during his postoperative stay. he has been followed up for months without realizing any clinical signs or alterations in ct scan. compared with traditional open surgical repairs, laparoscopic repair has certain advantages including its safe operation, postoperative rapid recovery, fewer complications, and lower recurrence rate. however, it still faces challenges regarding parastomal hernia treatment, and there is a need to improve existing surgical techniques. aims: nowadays, the principal disadvantages of laparoscopic approach in hernia repair are the use of intraabdominal meshes and traumatic fixation. first, intraabdominal meshes involve the contact of the prosthesis with the intestinal loops with the consequent risk of adhesion and fistula. also, using helicoidal sutures in prosthetic fixation produces adhesions to the tackers and a non-negligible incidence of chronic pain. when it comes to lead to better results, placing the mesh in retromuscular space avoids the drawback of contact with the loops, and using self-fixation meshes may decrease the rate of acute and chronic pain. accordind to this facts, we present a case of laparoscopic ventral hernia repair with transabdominal retromuscular mesh placement without traumatic fixation. methods: we present a -year-old patient with a cm diameter hernia showed in preoperative ct scan, m w , with diastasis recti associated. the patient underwent laparoscopic surgery using transabdominal retromuscular route. one mm and two mm trocar were placed in left flank. the posterior rectus sheath on the left side is opened starting cms far from the left egde of the defect. once the retromuscular space is dissected, the hernia ring is dissected and the hernia sac reduced, we continue with the dissection in retromuscular space on the side. craniocaudal dissection is achieved cm distal to the defect margins. the hernia defect with the anterior rectus sheath and the diastasis recti were closed using v-loc running suture. self-adhesive mesh was subsequently placed. the mesh should be overlap cm from the margins of the defect, covering the defect widely, with grips facing upwards. finally, we closed the posterior rectus sheath with peritoneum on the left side with v-loc running suture. results: the postoperative course was uneventful and the patient was discharged h after the surgery. after months of follow-up no clinical or radiological recurrence was showed. conclusions: the combination of laparoscopic approach, retromuscular mesh placement and the use of self-fixation meshes, seems to be an actual useful solution, combining the advantages of each item and avoiding the use of intraabdominal meshes and helicoidal sutures. aims: laparoscopic ventral hernia repair has clear advantages over open repair, including less post-operative pain and earlier return to normal activity. however, a prolonged surgeon learning curve is necessary to perform this technique effectively. robot assistance may improve outcomes of minimally invasive ventral hernia repair with improved three-dimensional visualization and enhanced dexterity with articulating instrumentation. we report a case of robotic rives-stoppa epigastric hernia repair in order to demonstrate the feasibility of the robotic approach. methods & results: a -year-old man came to our attention for the presence of a palpable mass in the epigastric region. the abdominal ct scan showed the presence of an epigastric hernia with herniation of omental content, and the presence of diastasis recti. the patient was then submitted to a rives-stoppa robotic hernia repair under general anesthesia. the da vinci-si surgical system (intuitive surgical inc., sunnyvale, ca, usa) was brought into position over the head of the patient and docked after placement of the ports. three trocars were placed in the hypogastric region along the transtubercular line. a fourth trocar was placed in the left iliac fossa and used by the assistant. the operation started with an extended adhesiolysis and hernia reduction. then, the retromuscolar dissection began by incising the posterior sheath starting from cm above the pubic symphysis. an extended dissection of the rives space was performed to create a correct housing for the mesh. the hernia defect and the diastasis recti were closed using a - absorbable barbed suture. a phasix st tm mesh (bard inc./davol inc., warwick, ri) was positioned in the retromuscular plane, and was anchored with absorbable sutures and glue. the midline incision was closed using a - absorbable barbed suture. the operative time was minute. the postoperative period was uneventful, and the patient was discharged home on the second post-operative day. conclusions: robotic rives-stoppa ventral hernia repair is feasible, safe, and effective when a standardized approach is performed. whether robotics may improve the outcomes of minimally invasive ventral hernia repairs, including lower recurrence rates, decreased post-operative pain, or shorter surgeons' learning curve, will require careful prospective investigation. aims: the authors present a video with a left chronic bochdaleck hernia classical hernioplasty repair but performing a mini invasive thoracoscopic approach and mm instruments. methods: a years old female patient come to hospital due to chronic left dorsolumbar pain. a ct scan study showed a chronic left diaphragmatic bochdaleck hernia. a lateral right decubitus thoracoscopic repair is performed using mm instruments and a mm camera. case and technical details are shown in the video. results: the patient was discharged from hospital within a period of h with no pain and a clean chest x-ray. in a year time follow-up, not an anatomical or clinical recurrence has been reported. neither chronic pain or respiratory complications happened, with in this period of time. conclusions: depending on the patient characteristics, anatomical factors and surgeon mini invasive experience, left bochdaleck hernia mini invasive thoracoscopic hernioplasty repair using mm instruments could be a safe and feasible option. more studies are needed in order to standardized this approach. surg endosc ( ) abdominal wall surgery has expanded exponentially in the last decade. many techniques have been developed, mainly in minimally invasive surgery. laparoscopic ventral and incisional hernia repair (lvihr) has become a common procedure because of its feasibility and safety but unfortunately, it is not free of complications. chronic postoperative pain and bleeding are frequent complications, prolonging hospital stay and altering quality of life of the patients. absorbable or non-absorbable tacks are the usual method of mesh fixation and sometimes combined with transfascial sutures to secure the mesh. these mechanical fixations pierce the abdominal wall causing nerve or vessel injuries. some studies showed no differences between absorbable tacks, non-absorbable tacks or transfascial sutures concerning postoperative remarkably high pain. some authors consider that a non-penetrating fixation of the mesh getting an effective mesh-abdominal wall interface will reduce significantly the postoperative pain after a laparoscopic ventral hernia repair. tissue glues are used in different medical treatments and also have been used successfully for extra peritoneal mesh fixation in laparoscopic inguinal hernia repair, open ventral hernia repair but not so in laparoscopic ventral hernia repair in spite of good results published in the literature. cyanoacrylate and its derivatives are 'synthetic glues' and classified as medical devices with stronger adherent properties than fibrin glues. experimental studies have reported good results compared with suture fixationand also tissue toxicity doesn't lead to an increased foreign body reaction. some authors have studied the use of cyanoacrylate in laparoscopic inguinal hernia repair but unfortunately, clinical trial reports in ventral and incisional hernia repair were not found in the literature because the lacking of experimental studies that guarantee the safety of intra-abdominal mesh fixation and the interaction of the glue with the intra-abdominal tissue. our group developed an experimental study demonstrating the feasibility, safety and effectiveness of the cyanoacrylate using for intraperitoneal mesh fixation and after this conclusion, started a clinical study. this video shows the methodology for laparoscopic mesh fixation with only glue in our first cases. aims: small epigastric hernias, associated or not with the rectus abdominis diastasis, and small umbilical hernias are common in middle-aged women, particularly with past history of pregnancy. the aim of this video is to illustrate a new extraperitoneal approach to these clinical situations. methods: patients between the ages of and years old, with epigastric hernia orifice up to cm, with or without associated umbilical hernia (up to cm), were chosen for this procedure. the surgery begins with a vertical umbilical incision for the umbilical hernia's correction, and dissection of the pre-aponeurotic plane. two mm trocars (mini-laparoscopy instruments) are introduced at both flanks to enlarge the pre-aponeurotic plane towards the xiphoid appendix. in this way epigastric hernial defects are isolated. the surgery proceeds with defect suturing with braded suture, midline invagination and mesh placement if necessary. results: all patients had an eventful post-operative period and were discharged home at postoperative day . the aesthetic and functional results are optimal conclusion: for selected cases with high aesthetic motivation this technique seems to be feasible and with optimal cosmetic results. this technique allows the mesh placement both in-lay and onlay, protecting it from surgical site infections often present at the classical approac bochdalek hernia is a rare entity in adults. fewer than have been reported in medical literature, the majority of which were incidentally diagnosed. as such, the optimal repair of a symptomatic hernia is unknown. we present a case of adult bochdalek hernia repair. methods: a -year-old obese male patient with a years of chronic dry cough and left lung opacity in chest x-ray. a large posterior and lateral bochdalek hernia with herniation of intestinal loops and fat to the left hemithorax was seen in chest and upper abdominal ct scan. the hernia extended to mid-thorax, caused significant atelectasis of left lung. eighteen months later, due to appearance of chest and abdominal pain following a recent motor vehicle accident, a repeat chest ct was done and a slight enlargement of the hernia was shown. results: the patient was operated laparoscopically, positioned in a semi-right lateral decubitus with double lung intubation. a large left posterior and lateral diaphragmatic hernia which contained transverse and descending colon with omental fat was seen. they were pulled in to the intraperitoneal space carefully. the defect was measured to be * cm. it was reduced to * cm by suturing with a non-absorbable v-loc suture . advancing the camera to the thoracic cavity showed the left lung to be severely atelectatic. after selective recruitment lung was well expanded. a symbotex composite cm mesh was fixed to the defect area by suturs and laparoscopic tacker. the operation and post-operative course were uneventful. chest x-ray demonstrated the bowel below the diaphragm. the patient was discharged on pod . at -month follow-up, chest x-ray was normal. objective: to demonstrate the safety and efficacy of the standardized laparoscopic approach in the treatment of large parastomal hernia. currently, this approach is recognized as the one of choice in parastomal hernia pathology, being controversial which is the best technique of choice: keyhole vs sugarbaker. material and method: clinical case: a -year-old woman with a history of laparoscopic abdominoperineal amputation due to rectal neoplasia (pt n ), a year ago, with symptomatic parastomal hernia with incarceration episodes and inflamation changes in the stomal orifice.tac: large hernia parastomal with intestinal content inside. surgical treatment is decided. result intervention: complete laparoscopic approach, right lateral partial decubitus, trocars, dissection of the hernia defect and reduction of the content, partial mobilization of the pre-stomal colon, with bleeding at the level of the vascular origin, requiring careful hemostasis to avoid ischemia of the colostomy, herniorrhaphy with stitches with extracorporeal knotting, placement of polypropylene/pvdf mesh,fixed with irreabsorbable tackers with administration of biological glue at the edges of the mesh. correct postoperative, discharge at the rd day. asymptomatic and without hernia recurrence at one year of follow-up. conclusions: the technique of sugarbaker using a laparoscopic approach is a safe and effective alternative in the treatment of parstomal hernias. objetives: laparoscopic ventral hernia repair provides advantages in term of low infection rates and postoperatory stay when is compared with open repair. trends in laparoscopic abdominal wall surgery is to complete defect closure without tension in midline. closing the defect in ventral hernias wider than - cms creates high tension in midline and postoperatory pain. it's proposed different techniques to solve this drawback. laparoscopic posterior component separation makes the defects closure easier with no tension and placing the mesh extraperitoneally. methods: years old woman with previous total hysterectomy, a m m w midline incisional hernia was clinically diagnosed and confirmed with ct scan. full laparoscopic abdominal wall repair with defect closure was proposed. trocars in left side were placed and posterior rectus sheath right side in the defect margin is freed. once the lateral edge of the rectus sheath is reached, the posterior rectus sheath is incised, dividing the posterior aponeurotic sheath of the internal oblique muscle. this allows access to the plane between the internal oblique and the transversus abdominis muscles. it's is made the same steps in the left side with trocar on the right flank. the posterior rectus sheath both side is reapproximated in the midline and cms polipropilene mesh is placed and unfolded properly. it's fixed using cyanocrilate glue. one drain is left in retromuscular position and mm trocar wounds are sutured. results: postoperatory course was uneventful. hospital stay h. the drain was removed in day after surgery. after months follow-up no complication or recurrence were identified. methods: this video will show the evidence of gangrenous jejunal segment due to superior mesenteric vein thrombosis in a patient with history of breast ca on hormonal treatment.in this video, the gangrenous segment was resected and primary anastomosis was done using endogia mm. results: a second look after h revealed to be negative for any further ischemic bowel. conclusion: therefore, laparoscopy in acute abdomen is diagnostic and for treatment. introduction: gastric pseudo-volvulation is a rare entity of paraesophageal hernia that is characterized by migration of the stomach into the posterior mediastinum. this clinical-radiological picture has severe complications so in certain cases should be operated urgently. another small group of patients are asymptomatic, although the current literature recommends their regulated surgical intervention. we present a gastric pseudo-volvulation in the mediastinum, with a laparoscopic approach, showing that by systematizing the surgery, it is possible to perform this type of intervention with relative ease and safety material and methods: we present a video of an urgent laparoscopic approach in a female patient of years with a personal history of hypertension, smoking and dyslipidemia. with a hiatus hernia diagnosed more than ten years ago. he went to the emergency department due to significant symptoms of heartburn and reflux, as well as incoerctable vomiting and difficulty feeding one week of evolution. a simple abdomen and postero-anterior chest radiograph was performed, showing a paraesophageal hiatus hernia with almost the entire stomach included in the mediastinum. a thoraco-abdominal axial tomography corroborated giant hiatus hernia with pseudovolvulation and incarceration data. urgent intervention was decided by laparoscopic approach in which hiatus hernia reduction and esophageal abdominalization were performed. closure of pillars and reinforcement with bioabsorbable mesh. gastric and gastropexy toupet of anterior face to anterior peritoneum of abdominal wall. results: the patient had a post-operative h without incident, discharged with a crushed diet. the follow-up and evolution has been acceptable without notable complications. conclusion: the laparoscopic approach, in extreme cases of paraesophageal hiatus hernia with incarceration of the stomach and pseudovolvulation of it, is a correct, safe and effective alternative in experienced groups. surg endosc ( ) case report of incarcerated hiatal hernia. years old female was admited to the hospital due to severe chest pain and vomiting for about six h. physical examination and lab test showed no abberations. chest xray revaled incarcerated stomach above the diaphragm. she was rushed to the or. laporoscopic approach was used, the stomach was removed from the chest and nissen fundoplication was performed. day after surgery patient was asymptomatic, got full oral diet. she was discharged on postoperative day two, without a need of any analgetics. gastroduodenoscopy was performed weeks after surgery and showed proper image of oesophagus, stomach and duodenum, neither signs of hiatal hernia nor inflamation were present. laparoscopic approach is good way to treat incarcerated hiatal hernias and is related with shorter lenght of stay, lesser postoperative pain and better patient comfort. and it should be procedure of choice in this kind of cases. she was operated open technique using a cm long incision in right iliac fossa and the appendix was phlegmonous. the patient began feeling bad from the second day postoperative having temperature over °c, pain and increasing crp. the general condition worsened the next day when the temperature went up till . °c, extreme generalized pain and crp: . the ct abdomen control indicates signs for generalized peritonitis and rises the suspicion for a forgotten large gauze. the patient is operated using laparoscopy technique: identifying and taking out the foreign body, doing adhesiolises, extensive lavage and in the end inserting one drain in douglas. the video is presenting what king of special graspers can be used but also tips and tricks when speaking about identifying the anatomy but also dissection in acute and inflamed environment. postoperatively the patient began to feel better and in the th day was released home. conclusion: this case illustrates that even after open surgery, laparoscopy is a viable solution with the condition that there is available experience in minimally invasive surgery. introduction: foreign bodies can enter inside the human body by different mechanisms such as ingestion, aspiration, trauma or in some cases due to medical procedures. they are potentially life-threatening events, the diagnosis could be challenging and its management depends on their location. case report: a -year-old male was referred to our hospital due to chronic abdominal pain. he had cholelithiasis, medical history of acute pericarditis and past surgical history of left adrenalectomy, left nephrectomy, distal pancreatectomy and colon resection due to an adrenal adenocarcinoma (stage t n m ).abdominal radiograph showed a foreign body in the left lower quadrant of the abdomen, as an incidental finding. this was not detected in ct scans during ten years of oncology follow-up. ct scan revealed an extraintestinal metallic curved object in the right lower quadrant. this finding was not related to any surgical intervention or trauma. diagnostic laparoscopy was performed: the foreign body seemed to be a guidewire, it was included into the omentum and almost stuck to the abdominal wall. the guidewire was reached and carefully extracted through a mm trocar without any evidence of intra-abdominal organ injury. then an elective cholecystectomy was also performed due to his medical history of symptomatic cholelithiasis.the procedure lasted min. the hospital discharge was on the third postoperative day and no complication was registered. conclusion: is extremely rare to discover a guidewire that had migrated into the peritoneal space without abdominal injuries.this case report demonstrates the technical feasibility, safety and minimal postoperative morbidity associated with minimal invasive laparoscopic removal. aims: the authors present a video with their standardized laparoscopic groin hernia transabdominal preperitoneal hernioplasty (tap) procedure but using mm instruments and mm camera approach. methods: a years old male patient with a bmi presents a symptomatic bilateral groin hernia for months. us study showed an indirect bilateral inguinal hernia. a laparoscopic tap hernia repair procedure is performed using mm instruments and a mm camera. a selfgripping mesh preperitoneal hernioplasty and peritoneal flap barbed-sutured hermetic closure was performed. case and technical details are shown in the video. results: the patient was discharged from hospital within a period of h with a rate in a eva acute pain visual scale. in a year follow-up, there has no been an anatomical or clinical recurrence. no chronic pain, anatomical recurrence, umbilical or abdominal wall complications have been reported with in this period of time. conclusions: depending on the patient characteristics, anatomical factors and surgeon mini invasive experience, a laparoscopic bilateral hernia repair using mm instruments, could be a safe and feasible option. more studies are needed in order to standardized this approach. results: during tapp approach a direct hernia relapse was identified, the previous mesh was included on preperitoneal space and some non-absorbable sutures to inguinal ligament were identified. stitches and nearly total mesh removal (only the part surrounding cord elements was left in place) were performed. x heavyweight polypropylene mesh was employed fixed with gubran Ò and the flap was closed with running sutures. patient was discharged uneventfully the same day. seven months later he did not need analgesics and had no physical impairment. conclusions: post inguinal hernia repair chronic pain can be severe and disabling, and is becoming more prevalent. the origin is complex and meshes and sutures could play a role. the management is multimodal and demanding. for refractory patients, surgery may be an option. laparoscopic, open and mixed approaches have been employed. they usually combine mesh removal and substitution (often in different planes) and groin nerve therapies. nowadays, triple neurectomy seems to be the most effective treatment (more than % pain relief). generally, removal of mesh alone does not lead to lasting pain relief or has worse outcomes compared with associated neurectomy. introduction: mesh repair of inguinal hernia is sometimes followed by adverse effects such as mesh migration, chronic groin pain or recurrence. removal of the mesh is necessary in selected cases. we affront this cases by tapp intervention. methods: we present a video with two intreventions of inguinal recurrent hernia by laparoscopy (tapp). we remar the points to decide explant the mesh or not to explant. the conditions to decide the explant were the proximity to the main vessels in inguinal area (espigastric and femoral vessels) and the plication of the mesh. results: and conclusion as we show in the video, the explant of the mesh is only conditioned by the plicature of the mesh for its migration and recurrence, accompanied usually with pain. we don't remove any time the mesh or the plug if it is in the triangle of doom with firm adhesions to the main vessels. we cover the previous mesh with a new ligthweigth d mesh and closing at the end the preitoneum over the new reparation. introduction: tep technique isn't a controversial area in surgical practice for inguinal hernias anymore, but a fully accepted method. the use of general anesthesia has been the mainstay of laparoscopic hernia repair, but epidural anesthesia is not a contradiction to properly selected patients. material-method: the approach of the extraperitoneal area achieved without use of a dilation balloon, but via the indroduction of the camera and the dissection of the regional structures. trocars ports were used: a mm trocar through the umbilicus for the camera, exactly as in sils (single incision laparoscopic surgery), another one mm is placed in the midline between the umbilicus and pubis, the last mm trocar is placed in the midclavicular line ipsilateral with the hernia. the key for every operation was the tension free technique with placement and fixation of a mesh x cm. in / cases the mesh was placed with tacks on the inside of the inferior epigastric artery-vein complex. all patients were dismissed from the hospital in h, no drain was placed and no major postoperative complications took place. conclusion: tep is a demanding technique with serious learning curve. the use of a dilation balloon for insertion in the extraperitoneal area is not prerequisite. tep is an appropriate method both for first appearing and recurrent inguinal hernias. epiduralanesthesia instead of general anesthesia is no a contradiction for properly selected patients. aims: the aim of this study was to investigate the effects of preperitoneal carbon-dioxide (co ) insufflation during tapp (transabdominal preperitoneal) repair. materials and methods: male patients with inguinal hernia were include in our study. we obtain laparoscopic access at the umbilicus and introduce mm port. two mm working ports are placed lateral. diagnostic laparoscopy of the entire abdomen is necessary to rule out other pathology or contraindications for surgery. using aspiration needle we insuflate carbon-dioxide ( mmhg) preperitoneal at the level of anterior superior iliac spine while decrease abdominal gas pressure to mmhg. same procedure is made lateral to the umbilical artery. results: we found that preperitoneal carbon-dioxide (co ) insufflation during tapp facilitate the future parietalisation and even can reduce operating time in future improvements of the technique. there were no intraoperative complications related to this procedure. we did not found any potential risk of the technique when is use by trained surgeons. aims: laparoscopic inguinal hernia repairs (lihr) are performed more and more frequently because they offer some advantages; however, we cannot forget their specific complications. lihr are associated sometimes with peritoneal tears that can lead to bowel obstruction. we present two cases of bowel obstruction related to peritoneal defects post tapp procedure and review peritoneal closure, bowel obstruction and options to repair defects. a year-old male was scheduled for tapp due to bilateral relapse. two x tio mesh tm fixed with securestrapÒ, employed also for peritoneal flap closure, were employed. three days later he was readmitted with bowel obstruction with ct suggesting 'adhesions'. a year-old male had bilateral tapp in another centre. seven days later he presented with bowel obstruction. ct showed metallic tackers and suggested 'adhesions' results: first case: after four days of conservative treatment failure, a revisional laparoscopy showed ileum herniation through a peritoneal defect and firm adhesions to the mesh. bowel was labouriously separated and the peritoneal defect closed with two running sutures. he was discharged on the \ sup [ th \/sup [ postoperative day and three years later he is asymptomatic. second: after two days of conservative treatment failure, on laparoscopy, ileum was filmy adhered to polipropilene mesh through a big defect on flap closure. defect was closed with interrupted sutures. as tears persisted, an omental flap was created to cover the area. patient was discharged on the th day and continues asymptomatic three years later. conclusions: lihr bowel obstructions can be divided in adhesive disease and herniation. herniation can be early (through peritoneal defects) or late (trocar site). international guidelines recommends a thorough closure of peritoneal incision or bigger tears (grade b). the closure can be achieved with staples, tacks, running suture, or glue. these last two methods are more time-consuming but less painful. running suture seems to be the best, due to its low costs, tightness and low pain but sometimes can be technically difficult. low intra-abdominal pressures (= mmhg) facilitate suturing. when a herniation appears, careful bowel management is needed and running sutures are recommended. if tears persist, an omental flap can be useful. aims: application of a single port robotic platform to perform an entirely transanal tatme/ tata. methods: the following video demonstrates how a totally transanal proctosigmoidectomy is performed using a novel, single port (sp) robotic platform was used to carry out a totally transanal proctosigmoidectomy, single port robotic tatme/tata. a -year-old female patient with a clinical t n b rectal cancer at the cm level, status post neoadjuvant chemoradiotherapy ( cgy, xeloda) is presented. shown here is the open transanal dissection followed by docking of the sp robot, implementation of the single port instruments (fenestrated bipolar forceps, cadier, scissors, camera, clip applier) through a gelpoint path to complete a totally transanal proctosigmoidectomy including transanal tatme, ima/imv transection, splenic flexure release, and left colonic mobilization, loop ileostomy, and handsewn coloanal anastomosis. results: blood loss was cc. pathology demonstrated a moderately differentiated, rectal adenocarcinoma. the total mesorectal excision was complete (grade ), margins were negative, and all lymph nodes were negative for metastatic carcinoma. the patient was discharged on postoperative day after an uncomplicated hospital course. there was no postoperative morbidity or mortality. conclusions: application of the single port robot to transanal tatme/tata (sprtatme) is presented here. while much work remains to be done to validate the sp robot's safety, this first demonstration of a totally transanal tatme/tata establishes its feasibility and utility. this single port platform stands to greatly expand the application of natural orifice transluminal endoscopic surgery (notes). as shown, the sp robot offers more than sufficient visualization, technical control, and adequate reach to perform such an operation. we present an exciting new avenue by which to complete operations in an entirely transanal fashion, which are classically performed via a combined transanal and transabdominal approach. methods: this video shows the utilization of a new robotic platform to perform transanal endoluminal microsurgery, rtem. presented here is a year old woman with a recurrent rectal adenoma at the cm level, status post a previous tem resection in october . demonstrated is the utilization of the sp robot through a gelpoint path in order to perform a partial fullthickness and full-thickness resection. the robot is introduced through a mm in diameter cannula via a four-channel face-plate. the instruments' two-jointed mobility at the elbows and wrists as well as the novel navigation system are well demonstrated. the docking of the sp robot, utilization of the dissecting devices, and closure of the defect is shown. results: sprtem was performed with a blood loss of cc, and the patient was discharged on postoperative day . there was no postoperative morbidity, mortality, or moderate/severe pain. pathology showed tubular adenoma with low-grade dysplasia in a non-fragmented specimen with negative margins circumferentially. conclusion: initial experience using the sp robot for rtem is demonstrated here. the robot provides wonderful visualization and operative control to the surgeon. articulation of the robot's wrists and arms have the potential to facilitate technical aspects of the procedure. rtem stands as an exciting development in the field of transanal endoluminal surgery. introduction: the application of robotic approach in the esophageal surgical field is in its first phase. the microsuturing and microdissection capabilites of the robotic system can potentially overcome the traditional limitation of the laparoscopic surgery thus enhancing the indications of minimally invasive surgery. methods: we have performed a retrospective analysis of our prospectively maintained database that included patients who underwent robotic-assisted esophagectomy for malignant disease between and . results: ten out of sixteen patients had squamous cell carcinoma meanwhile six had adenocarcinoma. ten mckeown's and six ivor lewis were performed. the mean operative time was min ( - ) and the median blood loss was ml ( - ). no patients required conversion nor intraoperative transfusion. the morbidity rate was / ( . %) : a transitory laryngeal nerve paresis, a pneumotorax and pneumonia. the mean hospital stay was (range - ) days. an r resection rate of . % was achieved with a mean lymph node yield of ( - ). the -year disease free survival was . %, wheres the the -year overall survival was . %. conclusions: robotic assisted minimally invasive esophagectomy (ramie) is safe and feasible, it offers promising results while preserving a good oncology adequacy. this video shows our technique for the treatment of an esophageal diverticolum using a robotic left sided transthoracic approach, followed by a heller myotomy and dor fundoplication using a transabdominal approach. our case is a year old male, who suffered from severe dysphagia, halitosis and gastric reflux who on endoscopic and radiological investigations was found to have low grade and a cm wide esophageal diverticulum, cm from the lower esophageal sphincter. initially conservative management was attempted, however following poor compliance and the persistance of symptoms after year of therapy, surgical intervention was indicated. the operation was performed using the minimally invasive robotic system of the davinci siÒ, starting with the thorax time. the patient is positioned in left side decubitus. the camera-trocar is insert in the thorax via the fifth intercostal space the, two mm and one mm robotic trocars are added. the lung is liberated from pleural adhesions and the esophagus is then prepared exposing the diverticulum which is successfully removed with an endo-giaÒ. the esophageal muscle fibers, near the suture line is reinforced with separated vicryl stitches and the resected piece is extracted via endo-bag. a fr thoracic drainage tube is then placed and the trocar accesses repaired. the patient is the put in supine position with a °anti-trendelemburg angle. three robotic trocars (two mm and one mm) are placed and the robot docking is made from the patient left shoulder. the lesser omentum is divided to visualize and prepare the gastric-esophageal junction (gej) sparing the vagus nerve. the heller myotomy is then performed for cm over the gej and cm under it. the mucosal integrity is assured via laparoscopic and contemporary gastroscopic view. the gastric fundus is attached to the distal esophagus completing the dor fundoplication. post-operative care comprehends the removal of the thoracic drainage during the first post-operative day, the pain management and the progressive realimentation. the hospitalized period lasts day and the patient was dismissed without complications occurred. the uniportal video assisted lung lobectomies gained popularity all over the world during the last years. the technique is safely applied for peripheral pulmonary lesions, under cm, but more and more complex cases are being approached while the indications continue to evolve. our aim is to present the particular aspects of this technique in an -year-old female patient with a giant bullous lesion located in the lower lobe of the right lung. the preoperative work-up for this case is presented and commented. a multidisciplinary surgical team consisting of thoracic and pediatric surgeons was involved. a single . cm length incision in the fourth intercostal space was used for the access. due to the fact that the lesion involved almost the entire lobe and the margins were very close to the hilum, we have decided and performed a right lower lobectomy. dissection and stapling were quite difficult. all the anatomical structures had small dimensions, forcing us to perform an 'artery first approach' in a very narrow space. no complications during or after surgery were encountered. the patient was discharged after four days and she went to school on the sixth day. histopathological examination showed that the lesion was a type ccam (congenital cystic adenomatoid malformation). conclussion: the uniportal video assisted lung lobectomy was safety applied for a giant bullous lesion of the right lung. aim: dunbar syndrome, celiac trunk (ct) compression syndrome, caused by median arcuateligament is a rarely diagnosed disease because of its nonspecific symptoms, which cause adelay in the correct diagnosis. the aim of the study was to demonstrate the usefulness andadvantages of laparoscopic approach in the treatment of dunbar syndrome. methods: we performed laparoscopic release of ct in the department of general, minimallyinvasive and elderly surgery in olsztyn in . all of three patients suffered from severepain of abdominal cavity before the surgery. results: in two cases, there were a complete remission of the symptoms. in one case, there was animprovement. all patients reported relief of symptoms in the first days after the operation.there were no postoperative complications. conclusions: the laparoscopic treatment of dunbar seems to be safe and feasible procedure. thelaparoscopic surgery alone can often eliminate discomfort, while angioplasty and stentimplantation are no longer necessary. introduction: the advances in robotic surgery have permitted the application of such technology to various surgical fields, one of the last of these being hernia surgery. we present a case video of the treatment of a dual-hernia using a robotic retromuscular ventral hernia repair(rrvhr) using the davinci siÒ robotic system. the case report demonstrates the evolution of the trans-abdominal robotic umbilical prosthetic (tarup) in that it utilises a 'double docking' technique to allow the positioning of a large retromuscular mesh. methodology: our patient is a -year-old male who presented with chronic epigastric pain. the abdominal ct confirmed two abdominal wall hernias; an epigastric and supra-umbilical hernia with visceral contents and wall defect diameter of cm and . cm, respectively. using the minimally invasive robotic system of the davinci siÒ we adapted the well known retromuscular mesh technique. the operation was initially intraperitoneal with access to the retromuscular preperitoneale space using a right sided longitudinal incision.(as per standard tarup technique). we proceed with the dissection of the retro-muscular space until the left lateral edges of the rectus sheath, creating a preperitoneal space for the placement of a specifically modified ultrapro polypro-leneÒ x cm mesh. following this we repositioned the davinci siÒ in a symmetrical manner, with ports placed in the retromuscular space. the mesh is positioned and the peritneum subsequently closed with a v-lock sutureÒ. finally we opted for a negative pressure jackson-pratt drain, inserted preperitoneally. results: the patient was discharged on the nd post-operative day without complication follow up continued until months post operatively during which the patient remained asymptomatic, without signs for hernia recurrance . conclusion: the technique highlighted in our video demonstrates the utility of the robotic system in hernia repair. specifically the approach proved a success as it facilites the placement of the mesh totally extra-peritoneally with closure of the posteriore sheath without tension. the added advantages are that the port-sites are distant from the mesh thus reducing infective risk. additionally this technique allows the treatment of large peritoneal defects. surg endosc ( ) aim: to analyse the performance of a robotic fellow during a robotic total mesorectal excision (tme) at the end of the fellowship, and subsequently compare it with their mentor. methods: the fellow is exposed to robotic colorectal lists per week. during the fellowship, assessment of performance is recorded in a structured proforma covering aspects of autonomy, tissue handling and dissection. at the end of the fellowship, areview of cases performed by the fellow and the mentor was carried out in a blindly manner (video footage). results: robotic tme training was divided into modules in order of complexity and the trainee had to achieve sequential proficiency in each module, before progression. docking of davinci robotic system. inferior mesenteric artery exposure and ligation, development of medial to lateral plane and inferior mesenteric vein division. left colonic and splenic flexure mobilization. pancreas identification. rectal dissection (tme). qualitative assessments were recorded by the mentor; the fellow was 'able to perform with verbal help' most of the steps from early on. by the end of the fellowship, all steps were performed in a similar manner in terms of quality and oncological integrity when compared with the mentor. conclusions: at completion ofan advanced robotic colorectal fellowship, high quality trainees can perform every step of the tme dissection in a similar manner with the trainer, when assessed blindly, without compromising oncological integrity. aims: to find safe and simple method in robotic rectal low anterior resection with low tie arterial ligation and lymph node dissection around the root of inferior mesenteric artery. methods: we performed robotic rectal low anterior resection (rlar) by davinci si system in eight patients with rectal cancer. we applied low tie arterial ligation, just caudally to the origin of the left colic artery in all cases. during the procedure, we used tilepro function of davinci si system which enabled to display two other visual informations through external inputs under the normal -dimensional surgeon console view. preoperative d-ct vessel branching simulation video and intra-operative real time ultra sound navigation view were displayed simultaneously under normal operative camera view in the surgeon console. results: left colic artery preservation was completely done in all cases. the mean time to find and expose the left colic artery from the first incision in sigmoid mesentery was min, which was drastically shorter than conventional method. this method needed lesser mobilization of inferior mesenteric artery (ima), and may be less invasive to autonomic nerve around the root of ima which is very important for ejaculation function. conclusion: robotic rectal low anterior resection with low tie arterial ligation was performed safely and in short time, using tilepro intra-operative navigation method. preoperative d-ct vessel branching simulation video and intra-operative real time ultra sound navigation view were very useful in the procedure. we present the method in video. nerve sparing tme and pelvic neuroanatomy for colorectal surgeons p. tejedor, f. sagias, j.s. khan aim: to describe the critical points in which the pelvic nerves can be damaged during a total mesorectal excision (tme) for rectal cancer and the benefits of robotic surgery for identifying these points. methods: there are critical points regarding pelvic neuroanatomy: superior hypogastric plexus (shp): located in front of l -s . the ganglionic sympathetic fibres form the right and left sympathetic trunk, travel along the anterior surface of the aorta and coalesce in the shp at the level of the inferior mesenteric artery (ima). superior hypogastric nerves: they take an anterolateral course into the pelvis. there is an avascular 'holy plane' around the rectum between these two nerves. inferior hypogastric plexus (ihp): lies over the posterolateral pelvis, almost parallel to the internal iliac arteries. this can be identified at the lower end of the rectum. neurovascular bundles(of walsh): in front of the denonvillier's fascia, at and o'clock position. they are responsible for erectile function. results: lack of knowledge or identification of key structures at these points can lead to increased risk of nerve damage and translate into poor functional outcomes. the ima is dissected up to the origin from aorta and here the shp can be seen. care is taken to avoid any damage to these structures. the tme plane is found at the back of ima as the inner most dissectible layer between mesorectum pelvic fascia. right and left superior hypogastric nerves are identified. dissection is carried out posteriorly, laterally and anteriorly. ihp is identified at the lower third of the rectum, when the dissection is about to reach the pelvic floor. care should be taken in not to go too far lateral and damage this plexus. in the anterior dissection, plane is carried in front of the denonvilliers' fascia. the neurovascular bundles can be seen at and o'clock position and the surgeon has to be careful to stay inside that plane in order to avoid damage. conclusions: the precise dissection in robotic surgery results in minimal tissue damage and better visualization and preservation of the pelvic nerves. aims: to describe and evaluate new contributions and eventual advantages of icg fluorescence to perform an icg guided bilateral pelvic lymph node dissection in a patient who underwent low-anterior-resection for rectal carcinoma. we also present the basic steps to avoid ileostomy during rectal surgery in which icg and ghost ileostomy play an important role. methods: a -year-old male patient was referred to our hospital due to abdominal pain and significant changes in usual bowel habits.colonoscopy showed a no obstructing cm middle rectal mass, which was reported as an adenocarcinoma.ct scan and mri revealed a mm polyp in the anterior rectal wall which was located cm from the anal verge. it was involving mucosa and sub-mucosa with muscularis propia invasion. no pathological lymphadenopathies or hepatic metastatic disease were found (stage t n ).a laparoscopic ultra-low-anterior resection plus icg lateral lymphadenectomy with total mesorectal excision was performed. a complete splenic flexure mobilization was performed to achieve a safe tension-free anastomosis. transection line of the proximal rectum was checked after icg intravenous injection. icg was injected around the tumor by inserting an anoscope, just before the surgery. after the dissection of the rectum, lateral lymphadenectomy was performed assisted by icg. an end-to-side anastomosis was made. and a vascular loop was passed around the terminal ileum to create a ghost ileostomy.the procedure lasted min. reactive protein c was monitored to identify an initial leak. the patient was discharge in postoperative day and no complication was detected. results: pathological exam reported a rectal adenocarcinoma. pelvic lymphadenectomy results were: negative nodes, negative nodes and negative nodes from right lymph node dissection, left lymph node dissection and rectosigmoid resection specimen respectively. no metastatic disease was found (stage t n m ). conclusions: in our experience, icg fluorescence imaging system offers important contributions to rectal surgery furthermore than evaluating vascular supply to the anastomosis. lymphatic mapping of the lateral lymph nodes and avoiding ileostomy could be a potential important use in the future. larger studies and more specific evaluations are needed to confirm its role in colorectal surgery and to find its limitations. background: robotic surgery for colorectal cancer is an emerging technique. potential benefits as compared to conventional laparoscopic surgery have been demonstrated. innovative robotic technologies have helped surgeons overcome many technical difficulties of conventional laparoscopic surgery such as hand-eye coordination, a two-dimensional view, and a restricted range of motion. robotic-assisted surgery was established as a new approach to minimally invasive surgery, overcoming these limitations. the following video shows a total robotic sigmoidectomy step by step on the basis of ourexperience. intervention: a -year-old male patient with no previous medical historyand a colon adenocarcinoma, cm from the anal verge, no distant metastases. it was decided to perform a robotic sigmoidectomy. target anatomywas located andwe proceededto the exposure of the mesenteric vessels from medial to lateral. a cautery wasused to open the peritoneum,up to the origin of the inferior mesenteric artery, and caudally past the sacral promontory.the vessels weretransected by ligasuretm. we performedthe complete release of the colon taking care to avoid injury to retroperitoneal structures. we usedligasuretm to section the mesocolon in order to prepare the transection of the proximal colon. indocyanine green was used to check the correct vascularization. an endogia tristapletm was used to divide the colon. subsequently, we sectioned the rectumand extracted the specimen through itwith no need to make any auxiliary incisions. we introduced the anvil of the suture device to perform the anastomosis. we sectionedand close the rectum with an endogia tristapletm. finally we opened the proximal colon to introduce the anvil,making a pursestring to fix it and create a side to end anastomosis. outcome: the surgery took min. the patient started oral intake h after surgery and left the hospital on the rd postoperative day. pathological examination ruled out a colon adenocarcinoma pt n . conclusion: total robotic sigmoidectomy is safe and feasible and can be a procedure of choice to achieve a good surgical qualityand avoid assistance incisions in patients with colon cancer. surg endosc ( ) with more and more data now advocating wait and watch policy for these patients which require close radiological and endoscopic follow-up but unfortunately around % of them have regrowth of tumour which will require surgical intervention. the use of robot for cancer resections is becoming more frequent especially in narrow spaces like in an obese male pelvis. the reason being better -dimensional views, more angulation of the instruments and exclusion of tremors, which in turn leads to better dissection and preservation of hypogastric nerves. in this video, we present a robotic low anterior resection for rectal re-growth in an obese -years old male patient. he was offered neoadjuvant chemoradiotherapy after discussion in mdt. he had an complete response with chemoradiotherapy and was decided to offer him watch and wait regime. unfortunately, he developed rectal re-growth in the first year of his follow up. imaging showed t lesion with no distant metastasis and was later confirmed on histology as well. after mdt discussion he was offered robotic low anterior resection. the video starts by showing the clinicopathological features of patient including his radiological and endoscopic images. robotic port sites are shown. the edited video starts with rectal dissection after ligation of inferior mesenteric artery and vein with emphasis on narrow pelvis and preservation of hypogastric nerves, seminal vesicles and intact presacral fascia. postoperative histology was ypt no and patient was discharged home after days with no postoperative complications. background: minimally invasive surgery for colon resection has improved patient outcome, however a minilaparotomy still is necessary to extract the specimen. this report describes a new approach that combine laparoscopic parellel overlap stapling left colectomy with natural orifice specimen extraction surgery, with the aim to minimize abdominal wall trauma. method: laparoscopic left colectomy for malignant diesease was performed using a standard five-port technique. after releasing the left colon via laparoscopy, divide the proximal and distal of specimen with -echelon, and put distal sigmoid colon and proximal transverse colon together. open sigmoid colon cm apart from distal margin, and incise transverse colon at proximal margin. take transverse colon and sigmoid colon side-to-side anastomosis via -echelon. incise posterior vaginal fornix to get into the abdominal cavity and extract specimen through vaginal. outcome parameters such as complications, conversions, operative time, postoperative recovery, and postoperative pain were prospectively recorded in a database. results: surgery was performed for patients with left-colonic carcinoma. no perioperative complications or conversions occurred. the median operating time was min. the median visual analogue scale score of postoperative pain was , and of patients needed analgesia on postoperative day . the median postoperative hospital stay was days. for malignancies, tissue margins were oncologically adequate, the averge number of harvested lymph nodes were . . the -week follow-up period was uneventful. conclusion: the described technique, a combination of laparoscopic parellel overlap stapling and natural orifice surgery, has the potential to avoid incision-related morbidity of the minilaparotomy in laparoscopic left colon resections. background: open surgical skills training has been well established over centuries, however, there are some significant differences in laparoscopic surgical skills training. it is an obvious advantage that the trainee and the trainer have the same view; however, some of the hurdles include the differences in tactile feedback, hand eye co-ordination, spatial awareness, depth perception and maximizing assistance. aim: we present a video highlighting some of the key challenges faced in laparoscopic colorectal surgical training, show-casing our systematic, structured approach. our approach: we have developed a structured approach starting with junior surgical trainees and progressing through to consultant level as per the levels below: level : attend courses/ workshops level : master camera work level : contra-lateral assisting level : intermediate level trainee-start operating with trainer scrubbed. the trainer is an additional member of the scrub team and stands on the same side as the trainee (does not replace any assistant) level : advanced level trainee-gradual progression from level . trainer un-scrubbed but standing next to the monitor throughout the procedure. level : trainer in theatre but out of sight of the trainee, with little interference level : progression to trainer-once proficiency is achieved at level / , the trainee is trained to become a trainer, for the junior and intermediate level trainees. within each level the complexity of the procedure increases as the trainee progresses through the level. junior trainees (years - of surgical training) are taken through levels - , intermediate (middle years of training) level or and advanced (last - years) up to levels . this way of training allows multiple members of the team to be trained simultaneously in every case. each operating list is preceded by team briefings where the role of every member of the team is clearly identified and followed by individual and collective feedback. conclusion: this training ladder proved very successful through the years. the feedback from trainees at all stages has been consistently positive. several trainees who have progressed to independent consultant practice, in the uk and abroad, are adopting this approach in their practice. introduction: despite the potential microsuturing capabilities of the robotic surgery, most of the esofago-jejunostomy after robotic total gastrectomy are still performed extracorporeal or through mechanical staplers. this can increase the cost of the procedure, the risk related to a improper functioning of the stapler. methods: we reviewed our prospectively maintained database analyzing patients from april to september , who underwent robotic total gastrectomy with hand-sewn esophagojejunostomy for gastric cancer. results: a total of patients were included in the study. the mean estimated blood loss was ml ( - ). the overall operative time was min ( - ). length of hospital stay was days ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . no conversion was necessary nor anastomotic leakage occurred. the morbidity rate was / ( . %) and included a subhepatic abscess and wound infection trough pfannenstiel incision. a r resection rate was achieved in all cases. the mean of lymph node yield was ( - ). the -year disease free survival was %, the -year overall survival . %. the robotic-assisted hand-sewn esophago-jejunostomy is a safe and no time-consuming technique. it avoids the complication related to the stapler firing and it offers cosmetic benefit to the patient in terms of extraction site. introduction: colorectal endoscopic submucosal dissection (esd) is increasingly practiced for treatment of early colorectal neoplasia. however, colorectal esd is difficult to perform due to lack of retraction as well as instability especially over hepatic flexure. dilumen eip is an external flexible sheath introduced during colonoscopy to stabilize environment for esd. this video demonstrated the use of dilumen eip for performance of colonic esd at the ascending colon method and results: this is a years old lady who received screening colonoscopy and found a mm lateral spreading tumor (lst) type iia lesion at ascending colon distal to ileocecal valve. under general anesthesia, patient received colonic esd using dilumen eip. due to significant looping, the dilumen device was introduced with the techniques of double balloon enteroscopy. after identification of the lst, the balloon in the front would be deployed to the proximal to the lesion while both balloons would be insufflated and created a stable environment. the esd procedure started after submucosal injection with normal saline in mix with indigocarmine, epinephrine and hyaluronate. mucosal incision was performed over the anal side of the lesion, and after adequate submucosal dissection, clips were applied to attach the mucosal flap to the sleeve of proximal balloon and achieved retraction. the submucosa was adequately exposed for dissection using dual knife jet. this enhanced submucosal dissection especially at one area with significant fibrosis. after the procedure, complete closure of the mucosal defect was performed by clips and assisted by the front balloon. the pathology confirmed intramucosal adenocarcinoma with clear resection margins. discussion: the dilumen eip device stabilized the environment within the colon with the double balloon and provide adequate retraction for performance of colorectal esd. surgery, kobe city medical center general hospital, kobe, japan background: robotic surgery has been widely spread all over the world, but robotic gastrectomy is not common and difficult because of complex anatomy and wide-ranging operation fields. in addition, it had been performed only under a few high-volume centers for reasons of the limitation of national health insurance in japan, which means medical expenses not covered by insurance. the situation was changed from this april, so we started robotic gastrectomy to reduce complications more rather than laparoscopic gastrectomy. we report results and aim to present the methods in detail using da vinci si surgical system. methods: we place five trocars, one is umbilical endoscopy port, and other four ports are placed at the reverse trapezoid, almost fan-shaped. using the arm number , the organ can be lifted up so that sharp lymphadenectomy is able to be done by almost a scissor as the arm number while applying the countertraction by the arm number . in order to achieve a clear and bloodless lymphnode dissection while maintaining the oncological safety, we think not only the ultrasonic coagulating scissor but also the electrocautery of the scissor is very essential in robotic surgery. less postoperative complication such as pancreatic fistula or pancreatitis might be derived from robotic surgery because we can avoid pressing the pancreas during the suprapancreatic dissection of lymph nodes. the billroth i reconstruction can be performed using da vinci endowrist stapler under stable and inflexible surgical fields without needing help of surgical assistant. results: from october to december , patients with gastric cancer were operated robotic gastrectomy, included total gastrectomy. there was no conversion to open surgery and no conversion to other procedures derived from intraoperative complications, and the overall operation time is gradually decreasing from the th case. we are now on the way of learning curve shortening operation time, but robotic gastrectomy is no less safer and adequate than laparoscopic surgery. we will show our robotic procedures including lymphadenectomy around subpyloric and suprapancreatic area, and reconstruction with several important points in our video purpose: this report describes the benefits and drawbacks in the use of a novel articulating device (artisential), which has a multi-degree wrist freedom like the davinci endowrist, in performing complete single-port d lymph node dissection (lnd) in single-incision distal gastrectomy (sidg). methods: the artisential was used in performing sidg with d lnd for patients with advanced gastric cancer. all operations were performed by a single surgeon using a threedimensional camera and a passive scope holder in place of a scopist. the artisential was used mainly in the sb and suprapancreatic lnd, an area that is relatively far from the single port. in certain cases when the pancreas needed to be pushed down, such as obese male patients, the intraabdominal organ retractor was used to lift the tissue and the artisential to push the pancreas. operative results and short-term outcome were analyzed. results: twelve patients underwent the procedure without any intraoperative events, conversion to conventional laparoscopy, or surgery-related complications including postoperative pancreatic fistula. all patients underwent single port d lnd by complete exposure of the portal and splenic vein. mean operation time was . ± . mins. and mean number of retrieved lymph nodes was . ± . . the artisential was found to be useful in grasping the tissues behind the pancreas and the major arteries throughout most of the lnd. the articulating motion also allowed the narrow single-port field of view to be clearly seen without the instrument body obstructing the camera. conclusion: the use of artisential in sidg appears feasible and reproducible, and is mandatory in performing a complete d lnd in sidg. the video shows a case of laterally spreading tumour of the rectum with preoperative benign histology, paris classification -is g (granular type), ut n eus stage, kudo type iv, nice type . the neoplasm measured x cm, and extended from to cm from the anal verge, mainly located on the posterior wall. according to our local policy the indication was a transanal full-thickness excision. this was performed with the medrobotics flexÒ robotic system, used here for the first time outside the united states.the system technology utilizes an articulated multi-linked scope that can be steered along non-linear, circuitous paths in a way that is not possible with traditional, straight scopes. the maneuverability of the scope is derived from its numerous mechanical linkages with concentric mechanisms. this enables surgeons to perform minimally-invasive procedures in places that were previously difficult, or impossible, to reach. with the flexÒ robotic system, surgeons can operate through a single access site and direct the scope to the surgical target. once positioned, the scope can become rigid, forming a stable surgical platform from which the surgeon can pass flexible surgical instruments. the system includes on-board d hd visualization. the flexÒ robotic system contains two working channels to accept a number of different surgical and interventional instruments including monopolar and bipolar electrodes, scissors and graspers for tissue manipulation.the video shows the introduction of the dedicated rectoscope, the connection of the flexible robot, and the way to operate the device performing a full-thickness excision, including suturing of the rectal defect by means of two running sutures by a v-lock / thread. while illustrating the technique the authors will comment pros and cons of the use of the device. background: hepatobiliary procedures using a minimally invasive approachare demanding, especially in major hepatectomies. the use of da vinci surgical system allows to overcome some of the kinematics limitations of the direct manual laparoscopy maintaining the potential advantages of a minimally invasive approach . we herein present a case of left hepatectomy and local lymphadenectomy for hepatocellular carcinoma, carried out with the use of the da vinci xi. methodology: a -years old man with a long-lasting hbv chronic infection and ct scan and mri finding of a -cm solid neoplasia of the left hepatic lobe and gallbladder stones, was operated with the da vinci xi platform. the patient was placed in a supine position, with °anti-trendelenburg inclination. the trocars were positioned according with the intuitive indication for the upper quadrants surgery. results: the procedure was successfully completed in min.at first, an intraoperative us scan with the use of tile-pro technology was done to determinate the tumor extension. the hepatic parenchyma transaction and the local lymphadenectomy were performed with monopolar scissors and bipolar grasps. the left hepatic vein section was performed with an endoscopic vascular stapler. there were no surgical complications or need for conversion to laparoscopy or laparotomy. the post-operative course was uneventful and the patient was discharged days after surgery. conclusion: the da vinci xi can facilitate some technically demanding procedures and ultimately widen the range of application of minimally invasive surgery such as hepatic surgery. besides the well-known advantages provided by robotic surgery on d imaging, increased range of motion and augmented surgical dexterity, one of the most interesting and innovative features of robotic technology is the digitalization of the operative view; furthermore the tile-pro multiinput display allows the surgeon a d view of the operative field along with the ultrasound exam for a precise understanding of anatomy and vascularity and of tumor location. during the last few years, robotic surgery as well, as the latest innovation of minimally invasive procedures, takes its position in this particular field with the benefits of overcoming the limitations of conventional laparoscopy. our aim is to demonstrate the advantages of robotic surgery in procedures of hepatectomies, on occasion of a robotic hepatectomy performed by our team. methods: we present video fragments of a robotic left lateral hepatectomy procedure in an elderly female patient with a symptomatic gigantic haemangioma of the left hepatic lobe. we emphasize on the technical aspects and the advantages that the surgeon gains applying the robotic techniques in such procedures. results: the procedure was completed with minimal blood loss and the patient presented an uncomplicated post-operative course, with discharge on the third postoperative day, minimal need of analgesics and full recovery. conclusions: the excellent three-dimensional and high quality visualization that the robotic system offers, combined with the flexibility and the accuracy of the robotic instruments (especially on suturing), provide to the surgeon an important aid, in order to avoid serious complications, such as intraoperative bleeding and post-operative bile leaks. the restriction of the limitations of conventional laparoscopy is far more beneficial and promising for the evolution and the future of minimal invasive liver surgery. aims: the new da vinci xi surgical cart allows multi-quadrant and complex surgical interventions in a minimally invasive fashion. we present a case of robotic appleby left pancreatectomy using this platform and its specific operating bed. methods: a -years old woman with ct scan finding of a -mm hypo-vascular neoplasm of the pancreas body underwent surgery with the use of the new da vinci xi with four arms upper quadrants trocar' disposition. results: the procedure was successfully completed in min. the pancreatic body was mobilized in order to expose the portal-mesenteric axis. the gland was transected using a robotic endo-stapler as well as the splenic vein. after evaluating the patency of collateral circles with intra-operative ultrasound, the common hepatic artery and the celiac artery were transected. then we increased the right tilted position and the neoplasia was detached from the gastric body by a tangential gastric resection using the robotic endo-stapler. finally, the operation was accomplished with the transection of the posterior attachment of the spleen and the pancreatic tail. no conversion or intra-operative complications were recorded. the post-operative course was uneventful and the patient was discharged days after surgery. the da vinci xi with its specific tools helps in performing challenging procedures such as appleby operation for locally advanced pancreatic cancer. in our experience, the robotic endo-stapler permits the operating surgeon to directly control the transaction phase whereas the specific operating bed allows to perform minimally invasive multi-quadrant surgery and to obtain a better exposition of the operating field. results: the whipple procedure was successfully completed in min. thanks to the dvtm the patient's position changed during the intervention to improve the exposure, with the instruments left inside the abdomen and without undocking the robot. the dissection of the pancreatic head from the portal vein and the section of the retroportal lamina were performed with the use of the endowrist vessel sealer device. a personal modified end-to-side pancreatojejunostomy was carried out, with / prolene and gore-tex double layer suture. no intra-operative complications occurred and no conversions to laparoscopy or laparotomy were required. the postoperative course was uneventful. conclusions: the use of the new fully wristed vessel sealer extend makes easier difficult maneuvers such as the fine dissection of the pancreatic head from the portal vein and the section of the retroportal lamina, enabling an optimized approach for vessels sealing and cutting and tissue bundles. moreover, the dvtm allows patient's movements without undocking the system or removing instruments from the abdomen, enhancing the surgical workflow. background: necrotizing pancreatitis is a devastating illness which can develop in up to % of patients who suffer from pancreatitis. it carries great morbidity with an associated mortality rate between to %. many of these patients require drainage of fluid collections to treat sequela related to pain, per-os tolerance, and source control of sepsis if infected. the step-up approach to treatment of this disease has trended towards minimally invasive techniques, considering the morbidity of open debridement. as such, many centers have implemented the use of transgastric debridement via endoscopic cystogastrostomy. this technique, while effective in draining fluid and particulate necrotic tissue, has difficulty in resection of large necrotic tissue, due to instrument and anatomic limitations. current endoscopic accessories designed for polypectomy or foreign body extraction, for example, are not optimal for performing necrosectomy. to overcome this obstacle, additional access sites can be utilized to assist debridement. we describe the first laparoscopic assisted transgastric endoscopic necrosectomy through a percutaneous gastrostomy in a year old male with infected pancreatic necrosis secondary to biliary pancreatitis. aim: to investigate the feasibility of utilizing gastrostomy access to assist in debridement during endoscopic necrosectomy. methods: the patient previously underwent an open necrosectomy and gastrostomy tube placement for acute emphysematous pancreatitis. post-operatively, there was a persistent and enlarging cm infected walled-off necrosis (won). therefore, endoscopic cystogastrostomy was performed using a lumen-apposing metal stent. results: frank pus was evacuated. initial endoscopic necrosectomy was technically challenging due to the large volume of solid necrotic tissue. repeat endoscopic debridement utilized a surgical laparoscopic grasper via the gastrostomy site to aide solid debris extraction (video). this allowed for complete necrosectomy and resolution of the won. the patient did well and was discharged subsequently. conclusion: this is another emerging minimally invasive technique in the step-up approach for debridement and drainage of won. the use of the gastrostomy as a utility port for accessory instruments not only enhanced the technical aspects of the procedure but increased its efficacy as well. further experience is needed to validate the utility and reproducibility of this technique. objective: the presentation of the minimally invasive surgical approach for pancreatic necrosectomy guided by videoretroperitoneoscopy or var (video assisted retroperitoneoscopic), established in our center, as one of the option of the step-up approach treatment for acute necrotizing pancreatitis (anp) methods: the placement of the patient on the operating table should be in decubitus, with right lateral inclination, at - °on the horizontal surface. the pancreatic cell is approached using the drainage catheter previously placed by radiological control (ultrasound or ct) as a guide, which will allow access to the cavity with safety. an incision of - cm is made around the previously placed catheter, crossing the subcutaneous cellular tissue and muscular fascias, dissolving the musculature. it continues in a blunt dissection, until a loss of resistance is appreciated which generally coincides with the outflow of necrotic or purulent material. once the retroperitoneal cell is accessed, a mm trocar is placed and a pneumoretroperitoneum is performed. the -mm trocar allows the joint use of a mm and °optic and the surgical material that allows debridement and cleaning. the aspiration and hydrodissection of the necrotic material, and the extraction of the solid component of the necrosis are proceeded. once the collection is drained and the necrotic material removed, a wash and drain system is placed, like a -way foley type probe. conclusions: in conclusion, the var is an alternative surgical technique, valid and reproducible in the treatment of anp, which offers comparable results and even superior, in some series, to those of open surgery, with satisfactory results in terms of morbidity and postoperative mortality. aim: lung subsegmentectomy is suitable for small and deep, non-palpable lung nodules. since it is difficult to intraoperatively detect the arteries, veins and bronchi of the subsegment, as well as the intersubsegmental borders, complete video-assisted thoracic surgery (vats) for lung subsegmentectomy is challenging. we use preoperative three dimensional ct to detect the arteries, veins and bronchi of the subsegment before conducting complete vats subsegmentectomy, and perform intraoperative bronchoscopy to detect the bronchi and intersubsegmental borders. i would like to describe our experience of complete vats combined subsegmentectomy for a non-palpable lung nodule. methods and results: the patient was a -year-old woman. during health screening, a small groundglass opacity was observed in her right lung on chest ct. the nodule was mm in diameter and was located in s b (horizontal subsegment of the posterior segment) near s (the anterior segment). we preoperatively diagnosed the lesion as well-differentiated adenocarcinoma, and planned combined subsegmentectomy for s b and s a (lateral subsegment of the anterior segment) of the right upper pulmonary lobe. before the operation, the locations of vessels were confirmed by three-dimensional ct angiography. video-assisted thoracoscopic surgery was performed using four ports: two cm ports in the th intercostal space in the post-axillary line and in the angulus inferior scapulae line for the operator, a cm port in the th intercostal space in the mid-axillary line for the assistant, and a cm port for the camera in the th intercostal space in the mid-axillary line. the cm port was also used for removal of the resected specimen. intraoperative bronchoscopy was used for detecting the subsegmental bronchi. she was diagnosed with primary lung cancer (adenocarcinoma in situ, nonmucinous) postoperatively. the tumor was pathologically graded as tisn m . no tumor recurrence has been noted in follow-up of twenty two months. conclusions: the combination of preoperative three-dimensional ct angiography, intraoperative bronchoscopy and complete video-assisted thoracoscopic surgery can be used for performing lung combined subsegmentectomy. aims: minimally invasive surgery is increasingly widespread for the diagnosis and treatment of abdominal pathology. laparoscopy is a diagnostic resource for those cases in which mass biopsy is not approachable through image-guided puncture, and is often therapeutic in the same act. it avoids the morbidity and mortality associated with laparotomy, favoring the early treatment of malignant processes. methods: we present a case of a year old male who was incidentally diagnosed with an oval-shaped pelvic mass in the right lateral wall of the pelvis, adjacent to the vascular bundle of the right external iliac at its origin( centimeter), without sign of infiltration of surrounding structures. no other pathological findings on the abdominal computerized tomography and magnetic resonance imaging were found. due to its localization, it was not accessible to percutaneous biopsy. the first diagnostic impression was a benign tumor of the nerve sheath (schwannoma), without being able to rule out other diagnostic possibilities. to provide a definitive diagnosis the patient was subjected to an elective laparoscopic resection of the tumor. surgical procedure was performed using a millimiter and two millimeter, umbilicus for the optical system and operative on hypogastrium and left iliac fossa respectively. acleavage plan between the tumorand rightiliac vesselswas found. the exeresis of the masswas achieved, and it was extracted using an endo-bagÒ through the umbilical port site. a drain was put in the surgical bed. results: the patient had a short, uneventful post-operative course, being discharged on postoperative day . pathological examination revealed a lymphatic node with metastasis of poorly differentiated carcinoma, with suspected urothelial lineage. cystoscopy was performed with the finding of a centimeter lesion on the right ureteral orifice with calcifications on the surface. biopsies were taken, confirming the bladder origin of the tumor. conclusions: both diagnostic and therapeutic laparoscopy is useful on pelvic masses because of the direct vision into this narrow anatomical space, especially in obese patients, providinga detailed view that makes easier to isolate and spear the anatomical structures surrounding the tumor, minimizing the risk of tumor rupture and bleeding. surg endosc ( ) aim: indocyanine green (icg)-enhanced fluorescence has been introduced initially in laparoscopic surgery to provide detailed anatomical information during laparoscopic cholecystectomy and to evaluate vascular supply to garantee correct anastomotic perfussion in order to reduce the risk of anastomotic leak. the uses of icg are increasing, specially in hepatic and oncological surgery in order to identify centinel lymph node and lymphatic mapping.we propose the use of icg imaging during complex laparoscopic colorectal resection in cases presenting ureter obstruction, to prevent iatrogenic ureteral injury. methods: we present a case of a year old female previously diagnosed of pelvic endometriosis with severe pain and symptoms related with episodes of pseudo-occlusion .a colonoscopy was performed finding sigmoid cancer in an area of endometriosis in a narrow colon with difficulties to perform a complete colonoscopy that could be related to the process of pseudo-occlusion. the biopsy was informed as an adenocarcinoma.the ct-scan showed a dilatated left ureter in an area next to the sigmoid colon.we propose a preoperative strategy with a bilateral double j stent insertion, finding a ureter obstruction caused by the endometriosis.icg was injected through the ureteral catheter, guiding us during the surgery to avoid a iatrogenic ureteral injury. results: a laparoscopic left colectomy was performed. the icg allows us to follow the ureter during the surgery, disecting the colon properly from the area attached to the ureter. the prestenotic area of the ureter was marked dilatated up to two centimeters allowing the icg to identify it from the anatomic structures of the areas and guarateeing that there was not spill of icg out of the ureter avoiding a postoperative leak of urine. conclussions: when tumors, or another entities like endometriosis, produce a ureteral occlusion, icg could be injected through a j stent, allowing us to identify and to avoid an injury.icg fluorescence imaging is a safe, cheap, and effective tool to increase visualization during surgery, offering additional information of the anatomy in colorectal surgery. in this video we are going to show three cases of the robotic treatment of splenic artery aneurism and the evolution of the technology that we relied on for the preoperative planning and intraoperative navigation. our preoperative evaluation evolved from a tridimensional virtual reconstruction with augmented reality to patient specific anatomical d printed models, initially made of rigid materials and afterwards made of malleable materials, in order to reproduce hollow anatomical structures such as vessels, feasible to simulate the planned surgical plan. the choice of a robotic approach, in selected cases, allowed to restore the continuity of the splenic artery after the exclusion or excision of the aneurism, in order to preserve the spleen. aims: tumor-induced osteomalacia (tio) is a rare paraneoplastic syndrome in which patients presents bone pain, fractures and muscle weakness caused by the fibroblast growth factor (fgf- ), a phosphate and vitamin d-regulating hormone. in tio, fgf- is secreted by mesenchymal tumors that are usually benign but small and difficult to locate. when medical treatment is unsuccessful, surgical treatment is indicated and conclusive.this video shows our technique for tio surgical treatment guided by indocyanine green (icg) fluorescent angiography. methods: the patient is an -years-old woman with tio confirmed by blood sampling of fgf- , gallium- pet/ct scan and abdominal ct scan which identified a highly vascularized mm nodule in the mesentery along the ileo-colic vascular axis.the patient was scheduled for a diagnostic laparoscopy with tio removal.the patient was placed in supine position. three trocars were introduced in the left quadrants. identified the last ileal loop, following ileo-colic vessels, a small mesenteric bulge was found. the icg fluorescent angiography confirmed the localization of the ipervascularised nodule and helped to define its edges. the nodule was removed through monopolar energy and the hemostasis was optimized through bipolar energy. the specimen was extracted through an endobag using one of the trocar access. results: the postoperative course was uneventful and the patient was discharged on postoperative day . histopathological examination showed an extrasurrenalic paraganglioma. conclusion: tio are often difficult to locate for surgical removal. icg fluorescent angiography allows to facilitate tio localization and removal. the minimally invasive technique decreases perioperative morbidity and mortality. laparoscopic removal guided by icg angiography should be considered when tio needs to be removed and is difficult to locate. aim: this video shows our technique to perform laparoscopic resection of a voluminous left paraaortic paraganglioma. methods: the patient is a -years-old man with a recent medical history offever, lumbar pain and haematuria.abdomen ct scan, performed during admission at emergency department, revealed a x cm left paraaortic retroperitoneal mass with pseudo-aneurysm. after procedure of angiographic embolization (with spermatic artery sparing), the patient was scheduled for a laparoscopic resection of paraaortic tumor. the patient was placed in the right flank position. three trocars ( mm) in the abdominal midline and one trocar in left hypocondrium were placed. at initial examination of the abdominal cavity, voluminous left paraaortic mass arising in the contest of left mesocolon was found, dislocating posteriorly kidney vessels. the parietal peritoneum was divided and the paraaortic lesion was dissected on the aortic plane from medial to lateral and from down to up, preserving the inferior mesenteric vessels; the mobilization was carried on to splenic vein. the vessels, supplying the mass and arising directly from aorta, was isolated and taped with vascular clips. on the inferior margin of the lesion a large vessel, probably connected with previously embolized pseudoaneurysm, was dissected with vascular linear stapler. the mobilization was completed through difficult dissection from aortic plane and mesocolic posterior surface. the colonic perfusion was verified with fluorescence angiography. specimen was extracted through an endobag.a drain was left in pelvis. postoperative day .histopathological examination showed a morphological and immunoistochemical pattern for benign paraganglioma. conclusion: laparoscopic resection of paraaortic paragangliomas is feasible by skilled surgeon. the minimally invasive technique decreases perioperative morbidity and mortality. careful preoperative planning and surgeon's experience with vascular dissection and visceral mobilization are mandatory for a good outcome. aims: posterior retroperitoneal endoscopic approach has been considered for many years as a very complex and unsafe surgical technique. often attributed to a difficult location and visualization of retroperitoneal structures. in addition, surgeons were forced to work in a small and easily altered space due to discontinuous flow with constant changes of the retroperitoneal vision. lately this approach is emerging thanks to technological advances, mainly better visualization laparoscopic cameras and high definition screens, as well as continuous flow insufflators of co , maintaining stable and smoke-free cavity uninterruptedly. methods: it shows a management of a potentially serious complication and the reproducibility of the technique through the retroperitoneal approach. results: to operate with high pressure of neumoretroperitoneum allows to contain the hemorrhage and to value with relative serenity and security, the best surgical option to repair said injury being laborious due to the reduced workspace. conclusions: the posterior or retroperitoneal approach is feasible, safe and fast. although the possibility of injuring the vena cava in right adrenalectomy remains one of the most serious and feared complications. as shown in the video, posterior retroperitoneal endoscopic approach allows repair of vascular injury correctly and safely. methods: four patients undergoing adrenalectomy, two of them with right adrenal pathology and two left. minimally invasive access, endoscopic approach, is exposed in all of them. results: in the first two surgeries, right gland is shown. initially, transabdominal approach, which requires mobilization and separation of the liver to access the retroperitoneal space and subsequent proceed to adrenal extirpation. later, right retroperitoneal approach is observed, with a meticulous sealing of the adrenal vein prior to complete the dissection of the gland, despite the small cavity created by co . in the second part, both left adrenal approaches are exposed. transabdominal pathway is necessary to mobilize left colon and spleen to access a narrow space above the upper edge of the pancreas to locate adrenal gland. this is very different in posterior adrenal approach. conclusions: posterior or retroperitoneal approach is feasible and safe, allowing access to adrenal glands, located in retroperitoneal space, without across peritoneal cavity and its disadvantages. colon and small intestine mobilization is not necessary, with a lower rate of intestinal lesions and postoperative ileus. in the same way, liver or spleen mobilization is avoided. aims: when performing a laparoscopic adrenalectomy, especially in the setting of pheochromocytoma, one of the most important steps is to gain control of the adrenal vein early on in the procedure before great manipulation of the adrenal gland. we present the case of a year old female with episodic headaches and tachycardia and severe uncontrolled hypertension, found to have elevated plasma and urine metanephrines with ct scan localizing a . cm right sided adrenal nodule. the patient was prepared preoperatively with phenoxybenzamine until mildly orthostatic with dry mucous membranes and was taken for laparoscopic right adrenalectomy. methods: after positioning our patient in left lateral decubitus, ports were placed inferior to the costal margin. the right lobe of the liver was mobilized and retracted cephalad and the ivc was exposed. careful and meticulous dissection was carried up the ivc, however no main adrenal vein was encountered. the adrenal gland was then dissected circumferentially and was removed in an endoscopic retrieval bag. there was no difficulty in hemostasis and the patient was deemed to be hemostatic prior to withdrawal of the ports and extubation. results: our patient had no issues with hemodynamic stability and her blood pressure was within normal ranges during and following the case. her hemoglobin was stable postoperatively with . immediately post op and . on discharge. her pre-op hemoglobin was . . conclusions: our video demonstrates a right adrenal gland that was congenitally missing a main adrenal vein. it is very possible that small venous branches were taken with dissection however we believe this report to be important to note in the literature for surgeons performing adrenalectomy. surg endosc ( ) aims: adrenal cysts are the most frequently identified adrenal cysts, although they are a rare entity. typically they are presented by abdominal pain or palpable mass, but nowadays, cystic lesions of the adrenal gland are more often discovered incidentally by radiologic studies. adrenal cysts have an extensive differential diagnoses, which makes a difficult definitive diagnosis and a difficulty in later management. the management of an adrenal cyst can be summarized in three fundamental pillars: discard the functional status of the cyst, evaluation of eventual malignancy by images, and avoid possible complications (hemorrhage, infection), especially in large cysts . methods: clinical case: a -year-old male patient, with no history, studied for nonspecific pain in the right hypochondrium, without other accompanying symptoms. an abdominal ultrasound was performed, a cystic lesion in hcd without being able to identify the origin was seen. complementary explorations of interest are shown (ct), the biochemical study discards functionality of the lesion, negative serology for hydatidosis. the minimally invasive approach is the gold standard in the surgical treatment of adrenal pathology, so a laparoscopic approach is proposed for this patient. aims: endometriosis is a high incidence disease (approximately % of women) with a large impact on women's quality of life and fertility. endometriosis nodules surgical treatment is necessary every time there is evidence of active disease. the aim of this video is to present a minimally invasive technique for the resection of an endometriosis nodule from the abdominal wall. methods: a -years-old woman, with past history of endometriosis and a c-section, presents at the office with a palpable nodule at the rectus abdominis left lateral border, close to the umbilical scar. she had complaints of exuberant catamenial pain and magnetic resonance imaging (mri) showed a mm nodule compatible with endometriosis depot. this technique uses trocars ( ? mm) placed at the pfannenstiel scar. stepby-step as follows: (i) dissection of the pre-aponeurotic plane and isolation of the lesion (ii) lesion excision and its removal with sac (iii) closure of the aponeurotic defect braded suture. results: the post-operative period was uneventful and the patient was discharged home at post-operative day one. the aesthetic result was excellent and the patient was asymptomatic one month after the procedure. conclusion: endometriosis of the abdominal wall is related to previous c-section, is a rare event (incidence . - . %) and usually located in the subcutaneous fat underlying the scar. the presence of nodules in the depth of the muscle is much uncommon and particularly in this clinical case, the nodule was located cm cephalad from the previous pfannenstiel scar. this technique seems easy and reproducible in the authors' opinio. aims: general surgeons often face gynecological pathological findings, either along with other abdominal pathology, or as primitive cases that need laparoscopic expertise. with this particular presentation, our goal is to demonstrate the essential laparoscopic skills and the basic operative strategy that a general surgeon should be familiar with, in order to manage such cases. the presentation is made on occasion of a woman with multiple uterine fibromatosis of the pelvis, who was treated by our team. methods: we present video fragments of the laparoscopic excisional procedure for multiple uterine fibromyomatosis of the pelvis, highlighting the proper strategy in order to conclude the operation effectively and uneventfully, in a minimally invasive fashion. results: patients with multiple, large or other complex forms of uterine or pelvic fibromas can effectively be treated with a minimally invasive approach, with minimal blood loss, very fast recovery and minimal postoperative pain and complications. % of pregnancies require emergency surgery for a non obstetric indication, including acute appendicitis, cholecystitis, adnexal torsion, choledoco-lytiasis, hernias, intestinal obstructions, oncologic pathology or other less frequent indications. laparoscopic approach is the preffered surgical option for the patologies presented above. aims: to present the technical particularities and to analyze the outcomes of the emergency operations in pregnant women operated in hospital. method: a retrospective study including all the pregnant women operated in our hospital between - was performed. the preoperative workup and the surgical indication was discussed by a multidisciplinary medical team. the anesthesic and the obstetrical risk and their management was evaluated and specifically planned for each patient. the intraoperative and post-operative outcomes were recorded. results: patients with gestational age between weeks and weeks who underwent emergency laparoscopic procedures were included in the study. out of the cases we have performed appedectomies, cholecystectomies, adnexal torsions. with a min mean operating time, we had no major intraoperative complications; the technical challenges are presented and discussed. the hospital stay was , days ( - days). no major complications were associated with the laparoscopic approach in these cohort. one pre-term labour in a weeks gestational patient was post-operatively encountered. conclusion: laparoscopic surgery can be the first option for pregnant woman with non obstetrical surgical emergencies; challenges in diagnostic, management and surgical techniques of the multidisciplinary team are expected. the objective of this presentation is to demonstrate step by step the technique to the oncologic surgeon and gynaecologist in training, including some tips and pitfalls. this is a laparoscopic transperitoneal approach in a woman with advanced cervical cancer (figo ib ) that will be treated with exclusive radio-chemotherapy. the purpose of the laparoscopic lumbo-aortic lymph node staging is to define the irradiation field. in this indication false negative in pet ct ranges from to % (depending of the existence of pelvic fixation or not). the limits of this lymphadenectomy are: both ureters as the lateral limit of the dissection, iliac bifurcation as the caudal limit and renal veins as the cranial one. since the tumour is cervical and not ovarian, both ovarian veins are not resected. in the pathologic report, lymph nodes were examined free of cancer spread. the patient have had a radio-chemotherapy with restriction of the irradiation field on the pelvis. lymphocele is a frequent complication that only sometimes needs treatment ranging from dietary changing to percutaneous drainage. if conversion to laparotomy for bleeding this technique loose its benefice but this is a rare complication. this technique is feasible and safe but requires advanced laparoscopic skills. objectives: although extremely rare, isolated splenic metastases are being increasingly diagnosed due to the improvement of imaging, survival times, and surveillance of oncologic patients. this video alerts to the growing diagnostic dilemma with primary lesions of the spleen, particularly in patients with history of cancer, and reviews the laparoscopic splenectomy 'step-by-step'. case-report: -year-old male patient diagnosed with rectal cancer (g adenocarcinoma at cm of the anal verge) after a colonoscopy for rectal bleeding. thoracic and abdominal ctscan and pelvicmri, showed a ct n lesion, without distant metastases, except for a mm suspicious splenic lesion. cea- . ng/ml. after neoadjuvant therapy, a complete response was verified at the th week post-crt with a stable splenic lesion, and a 'watch-and-wait' program was initiated with no evidence of disease at the rd month. pet-ctscan did not show active metabolic features, despite an increase in the splenic lesion. in mdt, elective laparoscopic splenectomy was proposed and afterwards performed uneventfully. with the patient in semi-right lateral tilt, we approached the spleen inferiorly by dividing the splenocolic ligament. then we continued upwards, dividing the gastrosplenic ligament and exposing the splenic hilum, which was then carefully dissected, clipped and divided. finally the splenorenal ligament was divided and the spleen was extracted within an endobag, through a small pfannenstiel incision. pathologic report revealed a splenic lymphangioma. the patient is currently under a 'watch and wait' protocol surveillance with no signs of regrowth or relapse disease after year and months of follow-up. conclusion: one out of five colorectal carcinomas are metastatic at their presentation. isolated metastases to sites other than liver, lung or axial skeleton, are extremely rare, but can be found in the spleen. although the rare splenic secondary involvement is usually associated with breast, lung, melanoma, and gynecologic malignancies, if we consider solitary splenic metastases, colorectal and ovarian carcinomas are important sources. also, imaging including percutaneous biopsy, is frequently insufficient to clarify the nature of splenic lesions. for all these reasons, the decision-making process about this issue can be a true challenge, and will probably end up with laparoscopic splenectomy. therefore, surgeons must be familiarized with a standardized technique. sarcoidosis is a multisystem disease of unknown etiology characterized by the formation of noncaseating granulomas. sarcoidosis should be considered in the differential diagnosis of lymphoid disease. indications for diagnostic splenectomy includes a suspicion of a neoplasic process. the less invasive laparoscopic approach is the gold standard. case report: a -year-old female was referred to a general surgery department to complete a study to rule out lymphoid neoplasia. followed by hematology for cytopenias. biopsy of bone marrow and adenopathies were negative for lymphoid process. patient presented ct with multiple solid ( - mm) lesions in spleen, in thorax showed no pathological changes. laparoscopic splenectomy was performed. access with optical trocar, in mammary line. triangle -mm trocars after pneumo under vision. section with ligasure of gastroesplenic ligament with short vessels and phrenic-splenic ligament. identification and preservation of pancreatic tail. section of splenic vessels at hilar level (branches) with ligasure. lower pole release. release of posterior part with gerota and diaphragm. incision by aid helps in bag without fragmenting. review of hemostasis, extraction of trocars under direct vision. intraoperative findings: spleen with normal external appearance, not megalic. postoperative evolution: satisfactory. first hours without incidents and with analytical control without anemization. tolerance and mobilization starts without incidents. the histopathology report shows granulomas formed by epithelioid histiocytes with the presence of multinucleated giant cells of the foreign body type, in some perisinusoidal granulomas the giant cells with the presence of asteroid bodies in their interior. the material has been revised with the extension of special studies. conclusion epithelioid granulomatosis, non-necrotizing, which suggests sarcoidosis. the procedure lasted min. the hospital discharge was on the next postoperative day and no complication was registered. conclusion: splenectomy can be performed in a classic way, but at present the less invasive laparoscopic approach is the gold standard. indications for splenectomy include splenic tumours of unknown origin, suspicion of a neoplastic process, and splenomegaly. sarcoidosis should be considered in the differential diagnosis for lymphoid disease. postoperative pathological examination confirms the diagnosis. week-day surgery, university, sapienza, ospedale sant'andrea, rome, italy aims: we describe an interesting case of a female patient affected by a suspected echinococcus granulosus large cyst of the spleen. methods: a years old woman complained abdominal pain and a sense of gravity in the upper left abdominal quadrant. computed tomography scan(ct-scan) showed a centimetre (cm) cyst of the spleen with thickness of the wall and contrast enhancement uptake referred to an echinococcus granulosus cyst. the sierological blood test assessment, antigens and antybody markes, for echinococcus granulosus infection was negative. a laparoscopic procedure was planned. the patient was positioned on the right flank, four trocars were inserted along the left subcostal region of the abdomen: one millimetre (mm) trocar for camera, one mm for the assistant, and two of mm for instruments. a periombelical minilaparotomy was performed for the specimen extraction. results: post-operative course was uneventful. patient was discharged in third post-operative day. istopathological exam showed a simple epithelial cyst of the spleen. conclusions: laparoscopy is safe and feaseable in case of large cyst of spleen in condition of unclear nature of the cyst. laparoscopy permits to explore the abdominal cavity and to assess the cyst characteristics in a lack overlap between the radiological exam and blood test examination. surg endosc ( ) we describe laparoscopic splenectomy for recurrent splenic cyst after laparoscopic marsupialization and partial resection of splenic cyst. the patient was a -year-old woman with abdominal discomfort and with a -cm palpable mass in the left upper and inferior quadrant. she undergone years ago in another country a laparoscopic operation for splenic cyst. abdominal computer tomography revealed a cystic lesion of the spleen with concomitant huge splenomegaly. serology and oncological marker were negative. we performed laparoscopic splenectomy for the recurrent splenic cyst. the operation took min. histologic examination of the resected spleen revealed a chronic hematoma. the patient had no abdominal symptoms during months of follow-up. postoperative long term follow-up and examination by ultrasound or computed tomography is required after surgical treatment for splenic cyst to exclude the possibility of recurrence after spleen-preserving surgery. hand-assisted surgery is a recognized technique that combines the advantages of laparoscopic approach with the tactile feedback of the laparotomic one. it proved beneficial especially for the treatment of megaspleens due to lymphoma localization, thanks to safer handling of splenic vessels, major bleeding control and more effective detachment of superior splenic pole from the diaphragmatic dome. here we show an hand-assisted splenectomy for megaspleen reaching the omolateral anterosuperior iliac spine due to lymphoproliferative disease, in which the hand, inserted through a right subcostal minilaparotomy, was very useful during the dissecting manoeuvres, the splenic artery recognition and ligation and the isolation of the superior pole of the spleen from the gastric fundus and diaphragm. in any case of huge spleens, the specimen bagging is very difficult to perform in a pure laparoscopic way, not to mention the inexistence of capable endobag; besides, a minilaparotomy would be necessary for the spleen extraction. hand-assisted approach allow to overcome this not underestimable technical difficulty, reducing operative time with similar aesthetic and functional results to that of laparoscopic approach. aim: the evolution of technology and its application to the minimally invasive surgery of the thyroid gland offers new surgical techniques, like the transaxillary approach. this new procedure is still being implemented in our environment and has recently begun to be incorporated into our surgical practice. the objective of this case is to explain step by step how to carry out a right transaxillary endoscopic thyroidectomy and emphasize in the most relevant tips to take into account. also, current indications and limitations of this technique will be addressed. methods: a -year-old woman is referred for evaluation of a right thyroid nodule without any associated symptomatology. the blood test shows normal thyroid profile. cervical ultrasound is performed identifying a . cm single right nodule with well-defined edges and presence of peripheral vascularization. no other nodules are identified. fine needle aspiracion (fna) of the nodule describes a bethesda iii. after evaluation, a right transaxillary endoscopic thyroidectomy was performed. results: dissection begins in the subcutaneous plane above the pectoralis major muscle until identification of the sternocleidomastoid muscle. dissection continues towards the prethyroid muscles in order to perform a lateral approach of the thyroid gland. section of the upper pole allows better exposure of the recurrent laryngeal nerve (rln) which is being monitored intermittenly. identification and preservation of the parathyroid glands is the next step. surgery is completed with the section of the inferior pole of the thyroid along with the istmus. the postoperative period was uneventful and patient was discharged at h after surgery. final pathology revealed a cm nodule without malignancy. conclusion: surgical treatment of the thyroid gland by transaxillary approach may be indicated in previously selected patients with benign pathology, offering the advantages from minimally invasive techniques (shorter recovery time, shorter incision length, etc.). further research is required to make a better assessment of the minimally invasive approaches in thyroid surgery. we present the video of a thoracoscopic esophageal leiomyomaenucleation. it has been widely demonstratedthe advantages of theminimally invasive approach in surgery. esophageal thoracoscopic surgery has been suggested as an alternative to open procedures, presenting less surgical trauma, lower risk of bleeding, less postoperative pain, lower wound infection and lower pulmonary morbidity, showing similar oncologic outcomes. although leiomyomas are the most commonof benign tumors of the esophagus, they are relatively rare, presenting an incidence of - per . autopsy series. in our case, the patient was diagnosed of leiomyoma located at the medium third of the esophagus. he referred a history of months of dysphagia for solid and liquids and retrosternal pain. the complementary studies were esophagoscopy, esophagography, ct and endoscopic ultrasonography. the patient was operated by a thoracoscopy approach using ports. it was completed the enucleation of the tumor following the closure of the muscular layer. methylene blue test confirmed no leaks. the patient was discharged on third day postoperative developing no incidences. pathology report: leiomyoma cm size, actin and desmin positive; s- , cd and cd negative. we want to demonstrate the advantages of a minimally invasive approach in this kind of pathology. aims: this video shows our technique to perform thoracoscopic enucleation of large esophageal leiomyoma. methods: the patient is a -years-old woman with a six months history of progressively worsening dysphagia. chest ct scan revealed a cm lesion of middle esophagus with extrinsic compression of mucosa and no increased fdg uptake on fdg-pet scan. barium swallow study showed a lateral deviation of thoracic esophagus due to extrinsic compression. endoscopic ultrasound confirmed the suspicion of esophageal leiomyoma. patient was scheduled for a thoracoscopic enucleation of esophageal tumor. she was placed in prone position and one-lung ventilation was employed. three trocars were placed in intercostals spaces on right hemithorax. azygos vein was identified and transected between vascular clips. esophagus was circumpherentially isolated from mediastinal structures. after myotomy, the lesion was dissected from submucosal-mucosal layer. since air leak test excluded injury of internal layer, muscular layer was closed with a continuous suture. the specimen was extracted through an endobag. a drain was left in place. results: the postoperative course was uneventful and the patient was discharged on postoperative day . final pathological examination confirmed esophageal leiomyoma. conclusion: thoracoscopic surgery in prone position allows removal of large esophageal tumor with several advantages. the minimally invasive technique decreases perioperative morbidity and mortality. introduction: spontaneous esophageal perforation is life threatening disease and requires emergent surgical treatment. recently, the efficacy of minimally-invasive surgery such as laparoscopic and thoracoscopic surgery for esophageal perforation has been reported. we report a novel technique of minimallyinvasive abdominal and left thoracic approach (malta) for spontaneous esophageal perforation. case presentation: -year-old male, who had been under hemodialysis due to iga nephropathy, complained of chest pain after vomiting several times. since the ct scan showed left hydropneumothorax and pneumomediastinum, and the gastrografin study demonstrated extravasation from left side of esophagus, we diagnosed him with the spontaneous esophageal perforation and planed emergent surgery. the patient was placed in the reverse trendelenburg position, and the legs were split, with the left side of the upper body lifted in order to perform thoracoscopy and laparoscopy simultaneously. first, we explored the thoracic cavity through a mm port in the left th intercostal space and added other ports. we identified the rupture site mm in size on the left wall of the lower esophagus and sutured the mucosa and the muscle layer with a running suture respectively. we covered the perforation section with pericardium fat and irrigated the cavity with physiological saline. then transferred to the abdominal cavity, no contamination was found in the abdominal cavity. a feeding tube was inserted into stomach through the round ligament of the liver and the operation was completed. the total operative time was min and the amount of intraoperative bleeding was ml including pleural effusion. postoperatively, the patient experienced left empyema pleurae but no other severe complications and was discharged on postoperative day . conclusion: we experienced a rare case of spontaneous esophageal perforation of a patient under hemodialysis. malta is an effective procedure for emergent esophageal operation because of great visual field of the chest and abdominal cavity without expanding contamination. introduction: digestive caustic injury is associated with high morbidity and mortality with stenosis in the long term. surgical treatment involves resection of the esophagus and reconstruction with the stomach, colon or jejunum. coloplasty provides several advantages but its vascularization is complex and involves anastomosis. classically, vascular assessment was achieved by palpation through laparotomy and color evaluation. indocyanine green (icg) allows a minimally invasive intraoperative angiography in real time. methods: a -year-old female with medical history of caustic ingestion and subsequent esophagogastric stenosis, carrier of feeding jejunostomy. . thoracoscopy (prone position): dissection of the esophagus from the hiatus to the upper thoracic inlet. . laparoscopy: patient in the supine position, placement of five trocars. total non-oncological gastrectomy, post-pyloric section of the duodenum and omentectomy were completed. mobilization of the righ, transverse and descending colon. measurement of the transverse colon with a tape (distance from the neck and the esophageal hiatus). individualization of the righ, middle (with its branches) and left colic arteries and placement of clamps at the right colic, right branch of the middle colic and left colic arteries. cc of icg were injected allowing for an assessment of the colon vascularization. section of the right branch of the middle colic artery. proximal section of the ascending and distal colon near the splenic angle, preserving the marginal arch. silk point to join the staple line of the descending colon and the pylorys. side-to-side mechanical antiperistaltic anastomosis between the distal endo of the coloplasty and the jejunum. finally an anastomosis between the ascending and descending side-to-side mechanical anastomosis using an assistance incision in the left flank was performed. . cervical dissection: extraction of the surgical especimen under laparoscopic control. vascular assessment with icg is performed before and after the side-to-side anastomosis is performed. results: there were no intraoperative complications. the patient was discharged on postoperative day . discussion: we describe the first case of total minimally invasive colonic interposition with icg assessment of the vascularization. this technique, although technically demanding, avoids the drawbacks of the open surgery and allows for a precise assessment of the vascularization of the graft. surg endosc ( ) introduction: large pedunculated fibrovascular polyps are uncommon, mostly benign, intraluminal massess, usually located in the upper esophageal tract. most frequent reported clinical manifestation is dysphagia, followed by regurgitation, chest pain and intestinal bleeding. ct scan, and mri are the key in the diagnostic work-up revealing a sausage-shaped intraluminal mass. endoscopy with ultrasonography and biopsy add important information for the diagnosis and pedicle location. surgical excision is deemed due to potentially life-threating complication related to airway obstruction. the most frequent polyp resection is performed through cervical esophagotomy or by direct esophagectomy. however, this approach is related to a high morbidity and mortality rate. in the last years, few excisions have been reported by a endoscopical approach with a lower post operative complication. material and methods: this video shows the surgical steps of a trans-oral endoscopic surgical resection of a giant ( cm) pedunculated polyp in a year old man. the procedure was performed under general anesthesia. a flexible endoscope probe was used and the distal end of the polyp was extracted through the oral cavity with a loop. the endo-gia stapler was used to cut the base of polyp and finally removed. the anatomo-pathological study confirmed the diagnostic of a fibrovascular polyp with no evidence of malignancy. results and conclusions: the patient had an uneventful recovery with no recurrency at years of follow up. this minimally invasive approach is a safe and feasible procedure to treat large esophageal fibrovascular polyps avoiding the complications related to more aggresive procedure. introduction: leiomyomas are the most common mesenchymal tumors affecting the esophagus and they usually grow in the mid to distal third of it. they tend to be asymptomatic, but sometimes they can grow to enormous size and produce dysphagia. case report: -year-old male asymptomatic patient was referred to our hospital due to an incidental finding. ct scan revealed a x mm rounded submucosal tumor on the dorsal side of the lower third of the esophagus. upper gastrointestinal endoscopy revealed a cystic lesion in the lower esophagus cm from the incisor teeth, with normal overlying mucosa. an endoscopic-ultrasound-guided fine-needle-aspiration of the mass was performed, which was reported as a likely leiomyoma.conservative treatment was performed, no growth was detected during eleven years of follow-up. but it became symptomatic, the patient complained of progressive dysphagia caused by compression so surgical resection was decided.laparoscopic enucleation of esophageal leiomyoma was performed. the tumor was reached by transhiatal dissection. a careful dissection of the mass was performed, preserving the vagal branches. an intraoperative endoscopy was performed to verify the integrity of esophageal mucosa and that the tumor was completely resected. the muscular layer was sutured after enucleation using absorbable suture material and the hiatus was closed with non-absorbable suture material. a dor fundoplication was also performed. a swallow test with a water-soluble contrast was obtained on postoperative day one. no pathological findings were found so the patient was asked to drink.histopathological exam revealed a tumor measuring mm mm mm consistent with leiomyoma.the procedure lasted min. the hospital discharge was on the third postoperative day and no complication was registered. conclusion: surgical excision is the mainstay of treatment and is recommended for symptomatic leiomyomas and those greater than cm. this case report demonstrates the technical feasibility, safety and minimal postoperative morbidity associated with minimal invasive esophageal surgery. introduction: total esophagectomy by means of minimally invasive surgery has proven to be a valid and effective alternative for performing this procedure. however, this procedure is not implemented in most centers. objective: demonstrate the technique of a total esophagectomy by endoscopic surgery for a benign esophageal stenosis. material and methods: clinical case: a -year-old female patient diagnosed with double esophageal peptic stenosis, treated on several occasions with endoscopic dilation by digestive, showing in the last endoscopy: severe esophagitis with stenosis impassable to cms. additional tests of interest are exposed. resolved: intervention: right thoracoscopy in prone position, dissection and complete mobilization of the thoracic esophagus, section of the azygos vein, pleural drainage. laparoscopic time, trocars, gastrolysis respecting the right gastroepiploic vessels, broad kocher until the cava is identified, vascular section of the vessels left gastric, full mobilization of the stomach, subxiphoid minilaparotomy, beginning of the cervical time with dissection of the cervical esophagus, section and fixation of this to a tube, externalization of the piece by abdominal route, creation of the gastric tubular with successive loads of gia, ascending posterior mediastinal plasty with manual esophago-tubular anastomosis, with placement of drainages and feeding jejunostomy. right operative with radiological control with gastrografin on the th day, discharge from hospital on the th day. asymptomatic one year after surgery, with radiological control without alterations. conclusions: the approach of esophageal peptic stenosis with minimally invasive surgery is safe and effective, adding the advantages inherent to this type of technique. (figs. , ) , showing a cystic lesion in the gastric submucosa with a well defined, medial and superior to the lesser curvature of the stomach with exophytic growth. it causes extrinsic compression of the cardia in the gastric body. within the differential diagnosis are gastric duplication cysts or gastrointestinal stromal tumor. a biopsy was taken, discarding the presence of neoplastic cells. finally, a study of digestive transit showed extrinsic compression at the cardial level, which causes difficulty in passing contrast. a laparoscopic approach was performed beginning with the dissection of the abdominal esophagus. the presence of a cystic lesion on the anterior face of the abdominal esophagus was identified (figs. , ) . we proceeded to the complete resection of cyst. the surgery was completed with °f undoplication anterior dor. the patient went home on the rd day without incident. results: duplication cysts are congenital malformations of the gastrointestinal tract contiguous with the esophagus, which can communicate with the esophageal lumen. most are diagnosed in childhood, but when it is diagnosed in adults, they used to be symptomatics. it is more frequent in men. although the pathogenic mechanism is unknown, it is caused by an anomaly during embryonic development. they are located in the thoracic esophagus, at the level of the lower and posterior mediastinum and, less frequently, in the abdominal esophagus, as in our case. they can give digestive symptoms(epigastralgia, vomiting) or respiratory symptoms. the diagnosis is made with eda, ct, and ecoendoscopy of choice, although it may be incidental. the treatment of choice in symptomatic patients is complete resection or cystic enucleation. in asymptomatic surgical is not defined, because it can cause complications, and, malignization due to degeneration is very infrequent. conclusion: the most of duplication cysts are diagnosed in childhood, although it's more frequent in adults to be symptomatic. surgical treatment can cure this disease. however, the choice between these becomes difficult in young patients, where the low incidence does not allow get series of long patients and decisions must be based on results achieved in adults. objetivos: to demonstrate the safety and efficacy of the laparoscopic approach in this infrequent pathology, pointing out the importance of having standardized the procedure to achieve better results. material and methods: case report: a -year-old man with progressive dysphagia until almost complete afagia, with clinical, endoscopic, radiological and manometric diagnosis,compatible with typical primary achalasia. chagas negative serology,we show the complementary studies of interest.dilatation is not performed, preoperative symptomatic treatment with calcium channel inhibitors. intervention: laparoscopic approach, trocars, aberrant left hepatic artery with signs of severe esophagitis,opening of the gastroesplenic-hepatic ligament, no retroesophageal window, dissection of the hiatus and inferior mediastinal, preservation and mobilization of the left hepatic artery and the anterior vagus,meticulous disection of the cardia,standardized myotomy: first proximal cms. with adequate simultaneous traction of both edges of the myotomy, then distal myotomy including - cm, including selectively the distal oblique fibers of les, tutorization with fouché and methylene blue to confirm good step and absence of leakage, dor-type funduplication, pts on each side, fixed to both pillars, hiatalmediastinal drainage. egd on the st day of normal po, dischargeat rd day, asymptomatic and with normal radiological control at year of age. conclusions: laparoscopic mh should be the first therapeutic option, in patients with primary achalasia, even in young patients. the length of myotomy, especially distal to ueg is one of the most important aspects of surgery, most authors (pellegrini) recommend that the myotomy extend - cm in the stomach, even up to cm below the ueg to achieve an effective disruption of the eei.the standardization of the procedure is fundamental to increase safety and effectiveness in these more complex cases. aims: the surgical treatment of giant hiatal hernias is a complex and demanding procedure, not only in terms of performing the operation in a minimally invasive abdominal fashion by avoiding thoracic approaches, but also concerning the management of large hiatal defects which contribute to high recurrence rates. our aim is to present our surgical technique for the reconstruction of such hiatal hernias, exploiting the benefits of the robotic approach and also to highlight the technical aspects of non-absorbable mesh placement in order to bridge effectively the hiatal defects. methods: we present video fragments from a procedures selected from a series of cases of robotic reconstruction of giant hiatal hernias performed by our team, in which a non-absorbable meshes were utilized to restore the hiatal gap. we emphasize on the clear benefits of robotic surgery in these cases and on the strategy of how to avoid high recurrence rates. results: all of our patients, who underwent reconstruction of giant hiatal hernias with this particular technique, experienced very good early post-operative results, very short hospital stay and no recurrence in a -month follow-up. conclusions: the robotic approach for the treatment of large hiatal hernias offers great advantages to both surgeons and patients, by eliminating the restrictions of conventional laparoscopic surgery, minimizing intra-operative incidents and post-operative complications. large hiatal defects are very effectively closed with the use of advanced suturing techniques and non-absorbable meshes in a tension-free bridging fashion. aims: mckeown esophagectomy is commonly used for invasive esophageal carcinoma. as the morbidity and mortality rates for esophagectomy are persistently high, minimally invasive esophagectomy in prone position is expected to reduce respiratory postoperative complications. there is still limited experience for the use of minimally invasive approaches in patients undergoing surgery after neoadjuvant chemoradiation and many concerns about the feasibility, safety, and oncological outcomes of these procedures are still present. methods: we present the case of a -year-old female with a middle third esophageal squamous cell carcinoma, who received neoadjuvant chemoradiation. she underwent laparoscopic and thoracoscopic (prone position) mckeown esophagectomy with hand-sewn esophagogastric anastomosis through a left lateral cervical incision. results: the operation was completed successfully, with no conversion to open surgery. the operative time was h with minimal blood loss and the patient was fed on day and discharged on day post-op. r resection was achieved and the number of total harvested lymph nodes was ( positive nodes, n ). conclusions: minimally invasive mckeown esophagectomy in patients with esophageal cancer and prior chemoradiation is feasible and safe procedure with acceptable oncological outcomes. results: preliminary results demonstrated that minimally invasive ivor-lewis esophagectomy procedure, provided of a better postoperative pain control and less respiratory complications. in order to standarise our procedure, the video shows how three different types of esophagogastric anastomosis are performed, depending on the patient characteristics, anatomical factors and safety and comfort for the surgeon: manual termino-terminal, mechanical termino-terminal and mechanical latero-lateral. conclusions: in our way to standardization, we are still looking for the best type of anastomosis, even though, we find out that, manually performed anastomosis are easier to performed, when the section in esophagus is lower, involving medium and inferior third. in the other hand, mechanical termino-terminal anastomosis seemed to be an ideal option for upper sections. more studies are needed in order to standardized one anastomosis, for all cases. because esophagectomy with radical lymphadenectomy is highly invasive, thoracoscopic esophagectomy (te) is attracting attention as a less invasive procedure. we first performed te with the left decubitus position in . in we developed a hybrid of the prone and left lateral decubitus positions for te, and a total of patients underwent te with a hybrid position . we introduced te with a hybrid position for the following three reasons: ( ) mobilization and lymphadenectomy around the middle and lower esophagus are easier in the prone position. thanks to artificial pneumothorax and the gravity, the middle and lower mediastinum are opened, and which give us good surgical field. ( ) lymphadenectomy along the left recurrent laryngeal nerve (rln) is more reliable and precise when performed in the left lateral decubitus position. we can dissect lymph node around the rln higher position in the upper mediastinum. ( ) unexpected events requiring conversion to thoracotomy (e.g., massive bleeding, injury of other organs, dense intrathoracic adhesion, resection of adjacent organs) are easier to deal with in the left lateral decubitus position. the patient is fixed on the operating table with the semi-prone position and we can easily change patient positions from the left lateral decubitus position to the prone position and vice versa using rotation system of the operation table. the upper mediastinal procedure including lymphadenectomy along the right and left rln is performed with the patient in the left lateral decubitus position, while the middle and lower mediastinal procedures are performed with the patient in the prone position with artificial pneumothorax ( mmhg). theabdominal procedures wereperformed by hand-assisted laparoscopic surgery (hals) and gastric tube reconstruction through aposterior mediastinal route was performed as a standard surgical procedure in our institution. the magnifying effect of thoracoscope enables us to perform more precise surgery and preserve nerve and vessels, and a hybrid position is thought to be feasible and effective methods. ivor lewis esophago-gastrectomy is a standard procedure for the treatment of distal esophageal cancer. among the years, the surgical community standardized the mininvasive abdominal phase. the thoracic phase is much more complex because usually all surgeons get in trouble in the phase of esophago-gastric anastomosis. in fact, is still very difficult and tricky to perform a mechanical circular anastomosis due to problems with the correct handling of the circular stapler through the minitoracotomy and is also difficult to place the anvyl in the proximal esophagus. the linear anastomosis (side-to-side) is a little bit easier but not so effective as the circular anastomosis in terms of leak rate. we think that robotic approach with its endowrist can allow us to overcome these limits and that a tailored double layer hand sewn esophago-gastric anastomosis could be the right choice. we treated patients with this approach and they were all uneventful in the post operative period except for a case of chylothorax we treated successfully with lipiodol injection in inguinal lymphnodes. we need more cases to analyze the technique in terms of leak rate and major complications but we think this is a promising and cost-effective procedure for robotic approach. aim: anastomotic leakage is one of the most dreaded complication after esophagectomy. indocyanine-green near-infrared angiography (nir-icga) intraoperative use has been recently introduced for visceral perfusion evaluation. in this video we present our technique for gastric conduit fashioning according to the nir-icga blood supply evaluation in a total minimallyinvasive ivor-lewis esophagectomy. methods: a years-old man affected by a siewert adenocarcinoma (ct , n , m ) underwent a preoperative neoadjuvant treatment according to cross protocol. at restaging ct-scan no more pathologic nodes were evident (ct , n , m ). the patient was submitted to a total minimally-invasive ivor-lewis esophagectomy. surgical procedure: after pneumoperitoneum induction and trocars insertion, the lesser omentum was opened and a lymphadenectomy at stations a, , , and performed. the esophagus was dissected at diaphragmatic hiatus with lymphadenectomy at station , and . the larger omentum was opened along the right gastroepiploic arcade, that was preserved, the short gastric vessels divided and gastric fundus mobilized. by evaluating the presence of an intense fluorescence at nir-icga, a tailored partial tubulization of the stomach was performed with multiple linear stapler firing. a right thoracoscopy was performed through trocars. the azygos vein ligated and divided. the mediastinal pleura was opened and the esophagus was dissected entirely with an en-bloc excision of nodes at stations , and . nodes at stations , , and were removed separately. the esophagus was sectioned above the azygos vein level and a purse-string fashioned. the cardia and the gastric tube were pulled up and a minithoracotomy performed. a new nir-icga was repeated to verify the good blood supply and tailor the site of anastomosis on a well perfused area. the stomach was opened and a circular stapler inserted. after the end-to-side esophago-gastric anastomosis fashioning, the tubulization was completed by linear stapler firing and the specimen removed. results: the post-operative course was uneventful and the pathologic examination revealed a cardial adenocarcinoma (ypt ,n , r ). conclusions: nir-icga is an interesting and easy-to use tool for surgeons. nevertheless in literature is still not clear which is the best parameter to measure the blood supply. large studied are needed. aim: uses and application of indocyanine green (icg) fluorescence in the field of surgery are growing exponentially. the safety and feasibility of its usage has been proven in several areas and various pathologies of surgery and surgeons are starting to incorporate it into their common practice. however, there are still several aspects to define regarding this technology. we present different uses of icg in the specific area of esophageal cancer. methods: we used icg fluorescence at different moments of a two-field minimally invasive esophagectomy. first of all, peritumoral injection of icg may offer a lymphatic mapping, both in the abdominal phase of the surgery and the thoracic one, improving lymph node dissection by allowing a more targeted and less morbid approach that includes all relevant nodal stations. at the moment of the gastric section, intravenous injection provides assessment of gastric conduit perfusion, therefore optimizing the construction of the graft to avoid the inclusion of poorly perfused areas that may increase the risk of leak of the anastomosis. besides that, the esophagogastric anastomosis can be tested in the thoracic phase of the operation in order to check an adequate perfusion and prevent further complications. results: we consider that icg fluorescence is a promising technology that could be easily introduced in the surgical routine of the esophageal surgeon as an instrument to assess the anastomosis perfusion. icg is also feasible in detecting lymph node drainage from the esophagus, although its technique of application needs to be defined. conclusions: icg fluorescence has opened a new world of possibilities in all the different surgical specialties. its use in the esophagectomy is safe, simple and feasible. in a near future, its application to esophageal cancer surgery could improve survival by predicting and preventing anastomotic leak and guiding in a tailored lymphadenectomy. further research is needed to demonstrate these promising applications. introduction: the oesophagectomy is currently still mandatory in the curative treatment of the malignant oesphagic pathology. this procedure is defined by important morbidity and mortality. the minimally invasive approach aims to reduce the complications without repercussion on the oncological outcomes, however it's not exempt from them being a demanding surgical technique like it is. aim: we present the video of three complications after a three-stage oesophagectomy (mckeown-like) with the thoracic stage via thoracoscopy and the minimally invasive surgical solution for both of them. methods: all three cases represent a three-stage oesophagectomy for malignant esophageal pathology. the first one was a -year-old male who suffered an intraoperative left main bronchus injury. the second case was a -year-old male with no intraoperative complications whatsoever. nonetheless, on the second postoperative day, milky drainage started to appear through the thoracic tube. the third and final case represents an intraoperative hemorrhage, which is the most common complication of this kind of surgery. results: the first case was diagnosed and treated intraoperatively with the use of an adhesive matrix. during the postoperative period the patient showed no further complications. the second case was a chylothorax, diagnosed on the second postoperative day. it was treated initially with conservative measures. due to bad evolution, he underwent surgery on the tenth postoperative day. we can see how we ligated the stump of the thoracic duct in the original surgery and then how we repaired the unexpected leak. after the second surgery, the patient was discharged on the sixth day. the last patient was also diagnosed and treated intraoperatively successfully, with no repercussion whatsoever in the postoperative time. conclusions: the minimally invasive surgery has many advantages in the upper gastrointestinal field. it is a demanding technique, so it is important to be able to treat the complications that may arise with this approach. surg endosc ( ) aims: the use of icg fluorescence is incrising in surgery, mainly as a test of vascular supply in colonic anastomoses. during the last years, other potential uses have been described, such as the identification of the sentinel lymph node and lymphatic mapping in oncological surgery. these advances could allow a better staging in order to decide the most appropriate treatment to each patient. gastric cancer is one of the fields where this could play a key role in the near future. we present a case of a patient who underwent a laparoscopic total gastrectomy with icg-guided d lymphadenectomy, where a personalized lymphatic mapping was performed. methods: a -year-old male patient underwent gastroscopy for gastric discomfort, and a gastric carcinoma was detected at the greater curvature of gastric body. endoscopic biopsy was informed as diffuse type gastric adenocarcinoma. the preoperative staging was completed with echoendoscopy and ct-scan (t bn m ). we decided to perform a laparoscopic total gastrectomy with icg-guided lymphadenectomy. the preoperative day, a gastroscopy was performed to inject . mg of icg in four submucosal areas around the tumor. results: intraoperatively, the lymphatic mapping marked by icg was checked, allowing the identification of the territory of drainage of the tumor to lymph nodes at the lesser curvature, the greater curvature and the splenic artery. a d lymphadenectomy and a total laparoscopic gastrectomy with roux-en-y reconstruction was performed. during the lymphadenectomy, we were able to observe marked lymph nodes in territory , and also observed that the paraaortic lymph node behind the celiac trunk did not become green and the lymphadenectomy at this area was not continued. the patient presented no postoperative complications, and was discharged on the seventh postoperative day. the histological results showed a diffuse type gastric adenocarcinoma pt n and isolated lymph nodes, being one of them possitive (corresponding to the adenopathy marked at the greater curvature). conclusions: lymphatic icg-mapping in gastric cancer is a potential revolutionary advance that could ensure a correct lymphadenectomy, avoiding lymph node understaging. it is necessary to continue carrying out studies that will allow developing protocols to define appropriate lymphadenectomy based on icg-mapping. introduction: petersen's hernia is one of severe postoperative complication after gastrectomy, which may result in massive resection of small intestine. it is considered an essential proscedure to close the petersen's defect for all cases after such reconstruction after gastrectomy as roux-en y method. we report a case of petersen's hernia after radical gastrectomy, which was repaired laparoscopically. patient: the patient was -year-old male, who underwent laparoscopic distal gastrectomy for gastric cancer (d lymph node dissection followed by roux-en-y reconstruction) two years ago. the closure of petersen's defect was not performed in the initial operation. he was aware of abdominal pain and visited emergency unit in our hospital. abdominal ct scan showed internal hernia of petersen's hernia. surgical procedure: in laparoscopic examination, dilation of small intestinal and mastoid ascites was observed. massive small intestine including y-limb entered into petersen's defect from left to right side. we carefully pulled through the small intestine and confirmed absence of ischemic change in the whole small intestine. then the petersen's defect was closed by continuous suturing with - non-absorbable barbed suture. results: the operation time was min and the estimated blood loss was ml. oral intake was started from the next day of the operation. there was no postoperative complication. the patient was discharged on the th postoperative day. conclusion: we could safely perform laparoscopic repair for petersen's hernia. regarding technical points in the procedure, it is important to judge the direction of the small intestine into the petersen's defect, to manage the dilated small intestine gently, and to close the petersen's defect by laparoscopic suturing. introduction: in this case we present a -year old male with a history of morbid obesity, sleep apnea and psychiatric affliction including alcohol and nicotine abuse. in he underwent a laparoscopic roux-en-y gastric bypass. the results were satisfactory, with no complications post-surgery, and a steady weight loss over time (pre: kg, post: kg). in november , he presented with complaints of dysphagia and weight loss ( kg in months). laryngoscopic examination by the otorhinolaryngologist was negative. he was referred to gastro-enterology for gastroscopy. biopsies showed a mildly differentiated adenocarcinoma of the gastro-esophageal junction with submucosal invasion. objective: after negative staging assessment, multiple treatment options were considered. the route of choice ended up being a laparoscopic radical gastrectomy with esophago-jejunostomy, with the objective to achieve optimal oncological results. methods: the procedure is demonstrated in this video. the gastric pouch as well as the remnant stomach, greater and lesser omentum were resected laparoscopically. due to the invasion of the carcinoma into the distal esophagus, a segment of the esophagus was resected as well. following anatomopathological examination on frozen section, the resection margins were reported malignancy free. results: postoperatively, there were no complications. ct scan with contrast showed no signs of leakage. anatomopathological examination confirmed the tumor to be a mildly invasive and poorly differentiated adenocarcinoma with local signet-ring cell differentiation (pt bn ). there was no need for adjuvant therapy. oral intake was sound. conclusion: adenocarcinomas of the gastric pouch are rarely seen following gastric bypass. this patient presented with complaints of dysphagia, and an adenocarcinoma was diagnosed. consequently, the patient had a total gastrectomy at our hospital. the surgery was performed laparoscopically, and was executed with success. to conclude, it is feasible to treat adenocarcinomas after gastric bypass laparoscopically via total gastrectomy and omentectomy. year old, female patient presented with upper abdominal discomfort and microcitic anemia. an ulcerative lesion was found on gastroscopy examination in body of the stomach (near the grate curvature). biopsy was done and pathology result showed poorly differentiated adenocarcinoma. chest computed tomography (ct) was without any significant findings. abdominal ct showed the lesion in stomach without enlargement of regional lymph nodes. her blood laboratory examinations were within normal limits, including serum cea. patient underwent laparoscopic total gastrectomy with modified d lymphadenectomy and roux-en-y esophagojejunostomy. total operating time (ort) was min. three days after operation, patient has developed none st elevated mi and respiratory failure. she was intubated. on day after operation she was extubated, on day patient started regular diet and was discharged home on day . final pathology result confirmed poorly differentiated adenocarcinoma of the stomach. this video shows our favourite technique for laparoscopic d subtotal gastrectomy. we usually perform the procedure with or trocars; after the coloepiploic detachment we perform the gastric transection first! this manoeuvre provides a perfect view for the lymphadenectomy. at the end of our dissection we transect the duodenum with seamguard reinforcement. before going on with the reconstructive phase, we prepare the roux en 'y' with double loop technique, usually without dividing the mesentery. then we remove the specimen through a periumbilical - cm minilaparotomy; we think it's important anyway to check margins and distance from the tumor before going on with the reconstructive phase. from the same minilaparotomy we retrieve the prepared limb for roux en y and we perform a side to side mechanical linear anastomosis outside.then we proceed with performing the anastomosis between the gastric pouch and the alimentary limb by laparoscopy. we like very much this technique for the increased exposition of tissues during lymphadenectomy. laparoscopic roux en 'y' d surg endosc ( ) a body-tc was performed in which axillary, mediastinal adenopathies and images suggestive of hepatic metastases were identified. the biopsy confirms a gastrointestinal stromal tumor. the case discussed in a multidisciplinary committee and the pet-ct study was completed, subcardial gist t n m was diagnosed. neoadyuvance was decided with imatinib for one month and surgery was performed using a laparoscopic approach. the approach was performed with trocars ( mm supraumbilical, two mm subcostal left and right, mm subxifoid and mm left flank). gastrectomy was performed with d lymphadenectomy following the oncological principles of subcardial tumors. the piece was removed in a bag by extending the mm port to mini-laparotomy. esophagogastric anastomosis was performed by hand assisted circular mechanical suture. methylene blue test was carried out. no nasogastric tube left, but drainage tutoring the esophagogastric anastomosis was left. results: the postoperative evolution was favorable. oral tolerance without incidents at fourth postoperative day. the patient was discharged without incidences on the seventh postoperative day. the pathological study of the piece was reported as subcardial gastrointestinal stromal tumor cm with respected surgical margins and lymph nodes free of malignancy, postoperative diagnosis of t n m . one month after surgery, the patient has adequate oral tolerance. she does not report gastroesophageal reflux and at months remains asymptomatic and with good evolution. conclusions: laparoscopic proximal gastrectomy is a technique that is not currently used but can be performed through a laparoscopic approach. it is a safe technique with good clinical and oncological results, especially in the early gastric cancer and gastrointestinal stromal tumors. however, long-term studies are necessary. laparoscopic gastrectomy is a perfectly safe option nowadays for the treatment of gastric cancer. every year the percentage of the laparoscopic approach is rising not only in the east but also in the west. we present a case of a year old female patient with a gastric tumor of the antrum-g adenocarcinoma with a ct n m staging. we perform a subtotal laparoscopic gastrectomy with a d lymphadenectomy and roux-en-y anastomosis. the patient begin clear liquids on the first post operative day and was discharged on the th. the final anatomopathological result of the specimen was a adenocarcinoma (g )-pt n . there were nodes resected all negative. the case was discussed in multidisciplinary team and was decided for clinical follow up with no further treatments. the patient was evaluated one month after surgery with no complaints and will continue the follow up. upper gi surgery, university of verona, verona, italy laparoscopic endoscopic cooperative surgery is an option in medium size submucosal cancers invading the muscular layer, mainly in border area were wedge resections are nor feasible.in this video we report a case of prepiloric gist treated with news technique (nonexposed endoscopic wall-inversion surgery).we think that this technique is feasible and safe and should be considered a valid option with a view to preserving the organ. aim: laparoscopic wedge resection or partial resection is a safe and feasible stomach preserving approach to gastric submucosal tumors (smt) such as gastrointestinal tumors (gist), and it has been widely performed recently. however, it should not be applied to the tumors at cardia in order to avoid stenosis or disruption of anti-reflux mechanism. we have introduced percutaneous endoscopic intragastric surgery (peigs) for smt at cardia since to preserve function of cardia. we will report the tips, techniques, and clinical result of our peigs. methods: from september to august , seven patients with smt at cardia underwent peigs in our hospital. we insert the mm port at umbilicus and investigate the abdominal cavity at first. then the incision is extended to . cm and lap-protector tm is equipped with the site to perform mini-laparotomy. using peroralendoscopy, a stomach was insufflatedand incision is made at an anterior wall of gastric body under direct vision. additional lap-protector tm is placed into the stomach so that the stomach is fixed on the abdominal wall. it enables us to keep direct access to gastric lumen and stable operative field. ez access tm is attatched on lap-protector tm , and intragastric operation is started. subsequently, two trocars are inserted using funada's gastropexy instrument. tumor is dissected by using energy devices, avoiding injury of capsule of the tumor. the defect of the gastric wall is closed by intragastric suturing. we should take particular care not to damage egj during the suturing, inserting peroral endoscopy in and out. results: the mean operation time was ( - ) min and the amount of intraoperative bleeding was . ( . - . ) ml. the maximum diameter of tumors was ( - ) mm. one case was low risk gist and otherwise were leiomyoma. the postoperative course was uneventful in all cases, without leakage or stenosis. total hospital stay was ( . - ) days. no patient had symptoms of esophagitis. conclusions: peigs for smt at gastric cardia is a feasible and safe approach, preserving function of cardia. our procedure achieves great stability and excellent visualization during the operation, which may have led to the fine surgical results. laparoscopic lymphadenectomyin gastric cancer is considered a feasible and safe procedure. data on the compliance of lymphadenectomy in the various lymph node stations is not yet well understood; moreover it is not clear if there are particular conditions relate to the patients impairing the oncological results. this video reports the use of the icg for the lymph node dissection of station number in a case of obese patient and a case of a cirrhotic patient. fist patient, m.a., was a year old man with distal cancer ct n and a bmi. second patient, t.d., was a year old man with distal cancer ct n and a alcoholic cirrhosis child b . in both cases, intraoperative endoscopy was performed to min before the onset of lymph node dissection. . mg of icg was injected into the submucosal layer in quadrants of the primary tumor. a laparoscopic subtotal gastrectomy was conduced with d lymphadenectomy. lymph note navigation were analyzed by novadaqÒ detector. using navigation system we removed the n basin. in both cases dissection were effective and pancreatic surface were easily detectable. number of lymph nodes retrieved was in the case of obese patient and in the case of cirrhotic patient. pathological tnm were pt n ( / n ?) in the first case and pt n ( / n ?) in the second. no n ? metastases were detected in n station for both cases. no pancreatic fistula was recorded. icg lymph node navigation system should be considered a valid support for the surgeon for completion of a correct lymphadenectomy in surgical challenging cases. aims: morgagni hernia is the rarest of congenital diaphragmatic hernias ( - %). its presentation is rare in adults and its finding is usually incidental. it was first described by giovanni b. morgagni in . it is located in the anterior region of the diaphragm. it is caused by a congenital defect in the fusion of the transverse septum of the diaphragm and the costal arches. the need for surgery depends on the presentation, it is recommended early repair before the development of complications. classically, the surgical approach was thoracotomy or laparotomy. currently, the tendency is to use a minimally invasive approach, which has shown good results, lower morbidity and faster recovery. the need to repair the defect with a mesh is controversial, recommended when it is not possible to close the defect without tension. the objective of this video is to demonstrate the safety and efficacy of the laparoscopic approach for the repair of this type of hernia, as well as the different types of mesh that can be used. aims: the treatment of the non-metastatic gastro intestinal stromal tumour (gist) is the surgical resection [ ] . the duodenal gastro-intestinal stromal tumour (gist) is a relatively rare clinical entity. from all the resected gist, only % are duodenal [ ] . the clinical presentation could vary from the most common acute gastro intestinal (gi) bleeding, chronic anaemia, but also acute abdomen caused by tumour rupture and intestinal obstruction. methods: a years old patient present at the emergency department of the chi poissy-st germain-en-laye (paris, france) with acute gastrointestinal bleeding. at the laboratory exams the haemoglobin was . g/ dl. the patient perform a computer tomography (ct) which shows two hyper vascularised lesion at the th duodenum; this lesions has an intra and extraluminare growing. the ct scan didn't show any other abdominal lesions. the patient were submitted to a minimally invasive surgical operation with the multiport laparoscopic technique. results: the resection of the th and th duodenum and of the first centimetre of jejunum was performed with a four trocar laparoscopic technique. a latero-lateral duodeno-jejunal mechanical anastomosis was performed. the operative time was min. the patient start with oral alimentation on the third post-operative day after a ct scan with oral contrast that was negative for anastomotic dehiscence and collections. the post-operative course was globally uneventful and the patient was discharged at fifth post-operative day without complications. the histological examination shows a low risk gist, cd positive and with a ki- inferior of % (classification tnm th edition pt aims: gastric volvulus are a rare condition that sometimes represent a diagnostic challenge for surgeons. here we present the video of a recent case of a gastric volvulus in our area that was treated with a minimal invasive approach. methods: we report the case of a -year-old woman who was admitted in the emergency room (er) with epigastric transfixing pain and impossibility to vomit that had started h prior to the admission. the physical exam showed good vital signs, and her abdomen was soft, with a tendency to tenderness with palpation in the epigastrium without guarding or rigidity. her lab tests were normal and the conventional radiology showed a double gastric bubble. we run an urgent computed tomography scan (ct scan) and a upper gastrointestinal (gi) endoscopy that showed a big type ii hiatal hernia that was complicated with a gastric volvulus. results: first, a nasogastric (ng) tube was placed for decompression of the stomach at the time when the endoscopy was made. the patient experienced a great improvement of the pain with that initial measure and remained stable. after almost a day of appropriate resuscitation, she underwent urgent surgery: we performed a hernia reduction, resection of the hernia sac, hiatal closure and a gastropexy and nissen fundoplication. the patient suffered no complications in the immediate postoperative time and was discharged after six days. conclusion: gastric volvulus are an uncommon emergency that we need to keep in mind. a simple abdomen x-ray can be very helpful, given that the double gastric bubble sign is a typical sign of this condition. it's always mandatory to perform an upper gi endoscopy in order to get to the diagnose and place a ng tube promptly. the surgery can be safely delayed in stable patients with no signs of ischemia, and a laparoscopic approach is associated with a shorter hospital stay and good long-term outcomes in this kind of patients. aims: during laparoscopic treatment of hiatal hernias the dissection can be complicated, but even more so the closure of the pillars, especially in giant hiatus hernias with a large defect. the use of prosthesis is controversial due to the lack of long-term studies and the possibility of secondary complications. the aim of this video is to demonstrate the safety of mesh hiatoplasty in hiatus hernia surgery. methods: we present the case of a -year-old woman with hypertension, hypothyroidism and right hemicolectomy for neoplasia years ago. the patient presented with malnutrition, with a weight loss of kg in the last months. a gastroscopy was performed in which a large hiatus hernia, that caused gastric volvulation, was shown. the upper gastrointestinal oral contrast study revealed esophageal tertiary waves and good passage to the gastric chamber, with an organoaxial volvulation of the stomach that was completely included in the thoracic cavity. results: through a five trocar laparoscopic approach, a large paraesophageal type iv hiatal hernia ( cm hiatal orifice) with complete herniation of the stomach and greater omentum to the mediastinum was observed. after reduction of the hernia content, complete dissection with partial resection of the sac was performed. an extended mediastinal dissection of the esophagus, with descent of the esophagogastric junction until achieving an abdominal esophagus of - cm, was carried out. after posterior and anterior phrenorrhaphy with nonabsorbable sutures, dislacement of the right pillar without diagragmatic opening was evidenced. it was decided to reinforce the hiatorraphy using a c shape composite mesh fixed with nonabsorbable sutures. the procedure was completed with a nissen-type fundoplication. postoperative course was uneventful and the patient remains without hernia recurrence months after the intervention. conclusion: prosthetic reinforcement in hiatal hernia repair can be a very useful resource in large hiatal defects in which a stress-free hiatus closure cannot be achieved. however, its use must be individualized according to the characteristics of the patient, the quality of the tissues involved and the result of simple hiatorraphy. aims: heller myotomy is an advanced laparoscopic surgical technique for the treatment of achalasia, a rare disease in which long time is needed to achieve the learning curve. surgical simulation, using animal models with an anatomy similar to humans, could help improving surgeon performance in a shorter time. the aim of our video is to show an ex-vivo and in-vivo animal model for heller myotomy training. methods: a cadaveric porcine model was developed using a tissue block including the esophagus and the stomach, without the diaphragm, mounted in a physical laparoscopic simulator. training procedures were also performed in an in vivo porcine model. experiments were carried out in the ' jesús usón' minimally invasive surgery centre in cáceres. results: the surgical technique is described step by step, first in the esophagus-stomach ex-vivo model and later in the live animal model. conclusion: surgical simulation using cadaveric an live animals offers a realistic representation, allows training in a safe environment, and can be very useful for advanced laparoscopic training in low incidence pathologies. introduction: esophagic perforation is one of the least frequent complications after laparoscopic nissen fundoplication, but it remains one of the most dreaded because of its morbidity and mortality rates and its technically difficult reparation. aims: to present how the authors dealt with an iatrogenic esophagus perforation post laparoscopic nissen fundoplication. methods: the authors report the clinical case of a -year-old woman who underwent a laparoscopic nissen fundoplication because of a symptomatic large hiatus hernia in a different hospital. the second postoperative day and after resuming oral intake, she presented respiratory and hemodynamic instability. she needed a chest tube that drained purulent content. the patient was referred to our hospital for clinical management. an urgent ct scan with oral contrast was performed without showing any leakage. results: in spite of the results, as the patient was unstable, she underwent an emergent diagnostic laparoscopy. it was found a small anterior esophagus perforation with right mediastinic collection. a running suture of the perforation was carried out and the nissen fundoplication was converted to a dör fundoplication. the operative time was min. she went to the intensive care unit for ten days. five days after the surgery, she was given methylene blue with no exteriorization through the drainages. as postoperative morbidity, she suffered from a right pneumonia and a thoracic collection that was treated by thoracic surgeons. the patient was finally discharged on the th postoperative day. she did well at home. she attended follow-ups without clinical reflux or any other particular condition. conclusions: esophagic perforation is a life-threatening complication that can be managed laparoscopically if it is detected soon after surgery and an expertise is available. surgical treatment of achalasia fails in - % of patients. the most frequent responsible cause is a previous incomplete myotomy, followed by fibrosis and aspects related with antireflux procedure. revisional surgery can represent a greater difficulty and a challenge. in this video we show revisional surgeries after heller's myotomy with dor fundoplication for achalasia. all cases presented a recurrence of the symptomatology and a revisional surgery was proposed. surgeries were characterized by the presence of a herniation of the previous fundoplication, fibrosis around the prior myotomy and/or the formation of a pseudodiverticulum. we show the steps followed and the aspects to consider during the dissection. these cases demonstrate that laparoscopic reoperation for achalasia is feasible, even after open surgery. aims: upside-down stomach (uds) is a rare type of large paraoesophageal hernia, characterized by migration of the entire or large parts of the stomach into the posterior mediastinum. uds is associated with severe complications like strangulation or volvulus development, possibly leading to acute gastric outlet obstruction and incarceration. surgical repair is the only curative treatment option and therefore recommended for these patients. standard procedure includes a hiatoplasty followed by an anti-reflux procedure. in a variety of studies, the use of mesh proved to be superior with respect to reduction of anatomical recurrences. methods: a -year old woman presented to us with reflux symptoms, dysphagia, dyspnea and tachyarrhythmias. she reported a weight loss of kg in the last months. ct scan and esophagogastroscopy showed a large paraoesophageal hernia, measuring approximately cm, with intrathoracic uds. results: we performed a laparoscopic hernia repair with dissection of the hernia sac from the posterior mediastinum, tension-free intrabdominal reposition of stomach and distal esophagus and hiatoplasty with biologic mesh (tutomesh tm ) augmentation. finally, a toupet fundoplication was performed to recreate the antireflux valve. in consequence of pronounced adhesions, a lesion of the muscularis of the distal esophagus occurred during surgery. the esophageal mucosa was unaffected. we treated the lesion laparoscopically with a simple interrupted suture (vicryl tm - ). an intraoperative patent blue v leak test did not identify any leaks. the recovery was uneventful. the patient was discharged on day after surgery and was free of symptoms in her follow-ups. conclusions: patients with large hiatal hernias and uds can be treated successfully and effectively with laparoscopic mesh repair. intraoperative complications can be handled laparoscopically in a safe manner. iatoplasty followed by nissen fundoplication represent the gold standard treatment of hiatal hernia; however it has been reported high hernia recurrence rate, especially in case of giant hiatal defects. in order to reduce recurrence rate, various techniques of hiatoplasty reinforcement have been implemented, such as prosthetic materials apposition. however, in literature have been reported various mesh complications such as esophageal and proximal stomach erosion and late esophageal perforation after ischemia, especially in case of synthetic non absorbable materials.in this video we are going to show the repair of a huge hiatal hernia by hiatoplasty and positioning of an absorbable biosynthetic 'bio a' mesh which is replaced by connective soft tissue over six months, therefore decresing complications and recurrence rate.as usual, we start with the mobilization of gastric fundus and isolation of diaphragmatic pillars by sectioning the aderences between them and herniated viscera. we proceed then with intrabdominal esophagus mobilization and higher mediastinal dissection in order to obtain an adequate esophageal lenght. after the exposition of the hiatus, we approximate the pillars with some non absorbable stitches and we reinforce the hiatus positioning a 'u' shaped bio a mesh over the esophagus, simply fixed to crura with single stitches. then we go on performing nissen fundoplication.the use of this prosthetic material appears to be cost-effective; first series in literature show very low complication rate and less recurrences of hiatal hernia than hiatoplasty without reinforcement. this video demonstrates the technique of laparoscopic identification and complete dissection of the sac of a totally intrathoracic stomach. identification of the sac is performed centrally by scoring the peritoneum overlying the arch of the diaphragmatic hiatus. the inferior edge is retracted and series of blunt dissection is undertaken. once the areolar tissue of the avascular plan is visualized; a raytec sponge is placed and advanced cephalad to expose the extra-saccular space. this raytec is kept in place to allow carbon dioxide to infiltrate and further delineate the anatomy. we then proceed with dissection at the left crus and right crus. complete reduction of the stomach can be achieved without grasping it. this can be performed by applying caudal retraction on the sac. this maneuver exposes the plane outside the sac. this space is divided into two compartments (right and left) separated by a septum which indicates the proximal extent of the sac. this plane is avascular and blunt dissection can easily free the hernia sac from the mediastinal structures and the pleura. this was followed by excision of the sac and hiatal repair which is reinforced with bioabsorbable mesh. the proximal short gastric vessels were then divided and a standard toupet fundoplication was performed. v -upper gi-reflux-achalasia introduction-objectives: the mixed giant hiatus hernias with paraesophageal component are hernias of difficult surgical correction, the laparoscopic approach of these implies a greater experience of the surgical team, given the complexity involved in its management, being the recurrence a complication that neither the use of meshes in this surgery has been able to avoid. in very high-risk patients, the gastric anterior pexy (boerema) may be an alternative to treat or alleviate the symptoms of these large hiatal hernias, although the frequency of recurrence with this technique is very high. material and methods. objective: the objective of the following case is to present a patient with type- hiatal hernia, barrett's esophagus without dysplasia and situs inversus. method: a laparoscopic partial fundoplication was performed on a -year-old male patient with a history of situs inversus totalis, who was seen in our general surgery service presenting a clinical history of retrosternal pain, heartburn and regurgitation. an endoscopy was performed, which reported hiatal hernia type and incompetence of lower esophageal sphincter, with squamocolumnar junction biopsies with report of barrett's esophagus without dysplasia. results: surgical time was programmed, for toupet type fundoplication; there were lax adhesions from omentum to wall, the lax hiatus and already known situs inversus. partial funcuplication was performed, with the usual technique adapted for structural anatomical abnormality, postoperative course without complications, oral initiation at the next day, drainage penrose type was set draining just a little serohematic liquid, diet was progressed and patient was discharged on the third postoperative day without complications. conclusion: situs inversus is the mirror image of situs solitus, which presents subdivision in situs inversus totalis, which is the most usual form, characterized by the mirror location of the intraabdominal and thoracic organs including the heart; in the case presented, the patient was referred with situs inversus and barrett's esophagus, performing laparoscopic fundoplication. the gold standard of surgical management is laparoscopic in benign esophageal pathology. gastroesophageal reflux disease (gerd) is a condition that reduces the quality of life and can causedisorders associated with acid reflux, such as bronchial asthma, barrett's esophagus and esophagealadenocarcinoma. gerd is often caused by existing of hiatal hernia. in rare instances gerd is associatedwith type iv hiatal hernias in which the part of stomach and other organs migrate into mediastinum.nowadays this condition can cause problems for some surgeons.patient was a -year-old man. he was diagnosed with hiatal hernia in . the condition had beenhaving asymptomatic course until . patient takes omeprazole mg for years. he startedexperiencing chest pains when inhaled and dyspnoea in june . co-morbidities were: arterialhypertension, chronic obstructive pulmonary disease (copd) and obesity (body mass index was . kg/m ). the posterior mediastinum contained the part of stomach, large bowel and small bowelaccording to chest roentgenography. sizes of esophageal hiatus were mm. in our clinical centerwas performed laparoscopic removal of hernia, cruroraphy, mesh repair of the esophageal hiatus andnissen fundoplication in july. during the surgery stomach, the part of small intestine, greatomentum and transverse colon were relocated into abdominal cavity. after cruroraphy, repair of theesophageal hiatus with prolene mesh was performed. the patient was in intensive care during h.total enteral feeding was initiated on second day. patients had been discharged within days aftersurgery. patient was re-examined by a surgeon in september , there were no signs of a reccurence.this case report shows an efficiency and feasibility of the laparoscopic approach to the treatment gerdassotiated with a large defect in the phrenoesophageal membrane, allowing other organs, such as colon,great omentum and small intestine to enter the hernia sac. aims: the authors present a video with their standardized laparoscopic hiatal hernia repair and anti-reflux nissen procedure but using mm instruments and mm camera approach. methods: a years old female patient with a bmi presents a symptomatic gastro esophageal reflux disease (gerd) for years. manometry and ph-metry showed a lack of esophageal motor disorders and a severe acid pattern with a . demeester score. panendoscopy study showed a cm hiatal hernia and a los angeles-grade esophagitis. she decided not to go with ppi treatment anymore. a laparoscopic hiatal hernia repair and standardized nissen procedure is performed using mm instruments and a mm camera. case and technical details are shown in the video. results: the patient was discharged from hospital within a period of h with a rate in a eva acute pain visual scale. in a year follow-up, there has no been an anatomical or clinical recurrence. no chronic dysphagia, anatomical recurrence or abdominal wall complications have been reported with in this period of time. conclusions: depending on the patient characteristics, anatomical factors and surgeon mini invasive experience, hiatal hernia and anti-reflux mini invasive standardized repair using mm instruments, could be a safe and feasible option. more studies are needed in order to standardized this approach. background and aims: parastomal herniation a very frequent complication in stoma patients. in isolated parastomal hernias (type i or iii)* a laparoscopic sugarbaker repair with intraperitoneal mesh is our preferred technique. if a concomitant incisional hernia is present (type ii or iii)* we currently opt for a retromuscular mesh repair as described by pauli. we adopted a minimal invasive approach using the robotic platform. methods: we performed a robot-assisted laparoscopic pauli repair for a wide incisional henria needing component separation and a small parastomal hernia (type ii)*. a non-slit retromuscular mesh was placed after a bilateral tar (transversus abdominus release) and lateralization of the colon. results: the operation was performed robot-assisted laparoscopically with x trocars without the need to convert to an open procedure. the procedure lasted min. the patient was discharged from the hospital on post-operative day three. one month after the repair our patient presented with a parastomal skin infection for which she received surgical cleaning and wound dressing. ct scan three months postoperative shows good positioning of the mesh with a reinforced abdominal wall. conclusions: the modified sugarbaker repair in parastomal herniation is feasible following a pauli approach (retromuscular mesh positioning) completely laparoscopic, albeit robotically assisted. short-term follow up is promising. long-term postoperative follow-up in these patients is needed. methods: case presentation results: a -year-old caucasian female patient was admitted on emergency due to a progressive alteration of her physical condition and weigh loss, caused by intermitent and intense epigastric pain and vomisments. symptomes occurred several years prior to admittance, but used to be mild and rare. during the last months, the described episodes became more intense, lasted longer and occurred more frequently. percutaneous ultrasound raised the suspicion, while thoraco-abdominal ct revealed an enormous intrathoracic morgagni hernia and gastric volvulus inside the hernial sack. after a careful preoperative preparation (restoring of the nutritional and hydric inballances, amelioration of respiratory parameters), laproscopy confirmed the diagnosis; we gently reintegrated the herniated organs from the thoracic hernia into the abdominal cavity (small bowel, large omentum, transverse-doloco-colon, and thisted stomach); a laparoscopic exploration of the hernial cavity was followed by a thorough hemostasis. do to patient's frailty, we decided to leave the hernial sack in situ. surgical direct repair of the defect technique was done by using extracorporeally tied separate sutures through separate skin incisions. the postoperative outcome was completelly uneventful; patient was discharged on postoperative day . barium contrast at mounths followup showed a slight esophageal diskynesia, but normal gastroduodenal passage; due to aerocolia, the normal position of the transverse colon could be confirmed aswell; no signs of reccurrence where detected. conclusions: although very rare, a morgagni hernia should be suspected and included in the differential diagnosis of patinets with dispeptic syndrome and epigastric/thoracic symptomes. thoraco-abdominal ctscanning is the imagistic technique of choice. laparoscopic approach became the gold standard, being far mora addvantageous as compared to laparotomy or thoracoscopy. direct suture with extracorporeally separate sutures through separate skin incisions was chosen for being less time consuming; for the same resons, the hernial sack was left in situ, with no consequences so far. aims: the giant fibrovascular polyp is one of the rarest benign lesions of the oesophagus. the most common locations of origin are the upper oesophagus or crico-pharyngeal region. the lesion is more common in elderly population, particularly men. symptoms include dysphagia, odynophagia. management options include surgical resection or endoscopic removal with endoloop. we aim to demonstrate the optimal management of these rare lesions using an endoscopic approach. method: we demonstrated the management of -year old patient with a giant oesophageal polyp, excised by minimally invasive endoscopic resection. the patient was placed in supine position and tracheal intubation was performed under general anaesthetic before an endoscopic approach was taken. the oesophago-duodenoscopy visualised a cresenteric shaped lumen due to an intraluminal mass occupying two thirds of the oesophageal diameter. the procedure was a multidisciplinary approach with the upper gi surgical and gastroenterology consultants. the polyp stalk was located in the oesophagus at the level of t and an endoloop was manipulated to surround the polyp. the polyp was then separated from the stalk by cauterisation and resected from the patient. the stalk was then injected with adrenaline to prevent haemorrhage. results: the excised specimen was a cm polyp with stalk originating from the t -t level. histology confirmed diagnostic suspicions of a benign pedunculated fibrovascular polyp. the polyp was covered by non-keratinising squamous epithelium with a discoloured tip demonstrating ulceration. there was no evidence of dysplasia or neoplastic process. the video shows a case of laterally spreading tumour of the rectum with preoperative benign histology, paris classification -is g (granular type), ut n eus stage, kudo type iv, nice type . the neoplasm measured x cm, and extended from to cm from the anal verge, mainly located on the posterior wall. according to our local policy the indication was a transanal full-thickness excision. this was performed with the medrobotics flexÒ robotic system, used here for the first time outside the united states. the system technology utilizes an articulated multi-linked scope that can be steered along nonlinear, circuitous paths in a way that is not possible with traditional, straight scopes. the maneuverability of the scope is derived from its numerous mechanical linkages with concentric mechanisms. this enables surgeons to perform minimally-invasive procedures in places that were previously difficult, or impossible, to reach. with the flexÒ robotic system, surgeons can operate through a single access site and direct the scope to the surgical target. once positioned, the scope can become rigid, forming a stable surgical platform from which the surgeon can pass flexible surgical instruments. the system includes on-board d hd visualization. the flexÒ robotic system contains two working channels to accept a number of different surgical and interventional instruments including monopolar and bipolar electrodes, scissors and graspers for tissue manipulation. the video shows the introduction of the dedicated rectoscope, the connection of the flexible robot, and the way to operate the device performing a full-thickness excision, including suturing of the rectal defect by means of two running sutures by a v-lock / thread. while illustrating the technique the authors will comment pros and cons of the use of the device. surg endosc ( ) the video shows the use of a barbed suture of novel concept. this first prototype thread developed together with assut europe (roma, italy) is characterised by a bidirectional / barbed suture, of cm length overall, with two needles mm in diameter, and circumference. in order to fix the thread to the tissue, on the exact midline of the thread a small ( mm) ball of the same material of the thread is fused with heat. this button as the entire thread is made of polydioxanone, a monofilament material for long-term absorption, self-retaining. this small advancement offera a consistent advancement in endorectal surgery helping in making transverse wound closures as easy as never before. the first stitch is placed on the transverse midline of the rectal wall defect, this way approximating proximal and distal edges. the button keeps the thread under tension allowing the completion of a running suture towards one of the two lateral ends of the would. when the first end is reached the needle is cut and the other needle is grabbed in order to perform the other half of the running suture keeping the right tension on the thread, with no risk of lumen stenosis. the two lateral ends of the suture are self-blocked passing them through the last stitch. no need for clips, knotting or buttonholes to pass through. while illustrating the technique the authors will comment pros and cons of the use of the device. background: the usefulness of robotic surgery has been largely reported; however, there are not enough reports on gist's treatment. the aim of this study is to report a single center experience on gastric gist's robotic resection. gastrointestinal stromal tumor (gists) are the most common mesenchymal tumors (overall incidence - % of all gastrointestinal malignant tumor). they are most frequently located into the stomach. complete surgical resection still remains crucial for patients with gists. in cases of difficult localization of tumor (e.g. posterior wall, his angle) and bigger tumor (more than cm in diameter), there still exist apparent difficulty and limitation to conduct laparoscopic resection. robotic assistance provides wide movements of its arms and was recognized particularly useful in case of difficult tumor localization, especially for those positioned at the posterior side of the stomach wall or around the lesser curvature. methods: six consecutive patients were analyzed focusing on safety (conversion/complications rate; hospital stay), oncological (margin resection, recurrence rate) and feasibility (operative time, technical tip and tricks) profile of robotic approach. results: the mean operative time was ± min, the mean hospital stay ± days. conversion rate was nihil. no intra and post-operative (mean follow-up months) complications were registered. in all cases, the resections were classified as r . conclusions: our experience supports the usefulness of robotic system in case of gist located at anatomically difficult gastric portion, such as lesser curvature or fundus close to gej, confirming the excellent oncological outcomes ( % r ) and the encouraging safety profile ( %). regarding the operative time our data are similar or better as compared to those reported by the previous literatures and didn't differ by the most recent published data for laparoscopic gastric resection. the anatomical hand-sewn reconstruction performed by precise hand-sewn suture instead of the usage of mechanical staplers represents a real great advantages of robotic resection. in our series, no patients suffered from stenosis or leakage after operation. background: we describe the use of a different suture from those historically used in the elaboration of a widely spread surgical technique such as the nissen fundoplication, for the treatment of pathological gastroesophageal reflux or symptomatic hiatal hernias. in our unit we have implemented the use of / irreabsorbable barbed suture to close the diaphragmatic pillars and the °fundoplication with the same continues suture. aim: the objetive of the use of the irreabsorbable barbed suture in the nissen fundoplication is to shorten the surgical times, which would achieve benefits for the patient and the institution, increasing the number of ambulant patients and the number of patients to be operated the same surgical session. objective: the goal of the present study was to demonstrate that intraoperative icg fluorescent imaging is a safe technique that can be used in laparoscopy establishing the exact location of the lymphocele and reducing intraoperative risks. method: fifty milligrams of icg dissolved in ml of saline solution was injected via percutaneous drainage placed into the lymphocele to decompress transplanted kidneys weeks before a laparoscopic lymphocele marsupialization procedure. results: during the first exploratory laparoscopy, in the flank and right iliac fossa, near the renal grafts, fluorescence was identified in raised areas that were the internal side of the lymphocele lobes. the lymphocele wall was dissected and ml of serous fluid was aspirated after puncturing. a cm breach was then made in the cyst wall using the ultracision harmonic scalpel (ethicon us). afterwards, a pedicle of the omentum in the lymphocele core was interfered with and fixed by stitches. conclusions: laparoscopic surgery seems to be the preferred surgical option for the treatment of primary symptomatic lymphocele after kidney transplantation. intraoperative icg fluorescent imaging is a safe technique to establish the exact location of the lymphocele and reduces the risk of damaging urinary structures during surgery. conclusions: this method proved safe and risk-free, easily reproducible and without the need for a different toolkit than the one of a modern operating theatre. the preliminary analysis shows a strong correlation between the perfusional data so far obtained and the early outcome of the graft. thus opening the way to further analysis aimed to a future better management of post-operative immunosuppressant and support therapy. these results are quite encouraging, even if our study is at an initial stage. conclusions: results show a persistent dread across specialities regarding ai. rather than be seen as threat, ai should be embraced by clinicians as it will ease the ever-increasing daily workload faced. this will enable clinicians to focus their skills on patient centred activities, interventional procedures and development. despite current regulatory hurdles, ai implementation in medicine is unavoidable. this coming revolution presents a unique opportunity for endoscopist and radiologist to refocus their expertise in novel areas. project description: from february to july a three-armed proof of concept study was conducted at three hospitals, in three groups of patients; recurrent ventral hernia, aortic aneurysm, and healthy controls. patients were measured once at the outpatient clinic using an electronic nose based on three metal oxide sensors. measurement data were compressed to low-dimensional vectors using a tucker like algorithm, and used to train an artificial neural network (ann) to provide a classification between patients (? ) and healthy controls (- ). preliminary resultsa total of patients (hernia n = , aneurysm n = ) and controls were included in the study. based on receiver operating curve (roc) analysis, the ann could differentiate between recurrent hernia patients and controls with the following details: area under the curve (auc) . , sensitivity . , specificity . . aortic aneurysm patients and healthy controls could be differentiated with an auc of . , sensitivity of . , and specificity of . . the aeonoseÒ enose can reliably distinguish patients with weak collagen (recurrent hernia and aortic aneurysm patients) from healthy controls. validation of these results in a prospective cohort study is required before clinical application of the device. background: laparoscopic and endoscopic cooperative surgery (lecs) has been performed gastric submucosal tumor (smt) or duodenal tumor. although minimally invasive surgery using thoracoscopy has been the usual approach for esophageal smt, the treatment method combined thoracoscopy and endoscopy has not been established. in addition, submucosal endoscopic tumor resection (set) for esophageal smt was reported using the technique of submucosal tunnel. aim and project description: we planned to resect large esophageal smt located in the upper or middle thoracic esophagus by a combined endoscopic and thoracoscopic approach. because set is only recommended for tumors up to mm in size owing to the limited submucosal space available and the left thoracic approach is restricted by the aortic arch and the trachea. preliminary results (case presentation): a -year-old woman was diagnosed with a benign schwannoma of length mm originated from either the submucosal or the muscular layer of the middle thoracic esophagus by endoscopic ultrasonography, enhanced computed tomography, and ultrasound-guided fine-needle aspiration biopsy. since the tumor had increased in the years and she had a symptom of dysphagia, we planned to resect it by a combined endoscopic and thoracoscopic approach. on endoscopy in the supine position, a submucosal tunnel was created mm proximal to the cranial edge of the tumor, and its only oral end was dissected from the mucosal and muscular layers. this was followed by the resection of the entire tumor by left-sided thoracoscopic procedure in the prone position. endoscopic mucosal closure was achieved by using clips. no postoperative complications were observed. large benign esophageal tumors can be safely excised with minimally invasive surgery by using a combination of endoscopy and thoracoscopy. background: haemorrhage remains a major cause of morbidity and death in all surgical specialties. in laparoscopic surgery. relatively small amounts of blood can obscure the view of the operative field and increase the risk of injury to surrounding structures. excessive bleeding often leads to longer hospital stays, increased healthcare service utilisation, and higher healthcare costs, among other negative consequences. aim: the aim of this study was to analyse the feasibility of purastatÒ, a new synthetic haemostatic device, made of self-assembling peptides in laparoscopic colorectal surgery. project description: this was a prospective observational non-randomised study. consecutive patients undergoing laparoscopic colorectal surgery were enrolled. informed consent was obtained from all patients inclusion criteria was the need employ a secondary method of haemostasis when traditional methods such as conventional pressure or utilization of energy devices to control the bleeding were either insufficient or not recommended/ appropriate due to proximity to ureter, pelvic/sacral veins and other important structure. preliminary results: twenty patients were enrolled ( males ( %) and ( %) females). mean age was years (± , years). all patients were undergoing elective laparoscopic colorectal cancer surgery ( right hemicolectomy, sigmoid colectomy, anterior resection). we utilised mls of purastatÒ in all patients. the mean area of application was , cm (± . cm ) with the amount of purastatÒ needed per centimetre being . mls. the mean time to apply the product was secs (± s), whereas the mean time to achieve haemostasis was , secs (± . s). there were no post operative complications in this cohort of patients. mean operative time overall was min (± . min). none of the patients experienced delayed post-operative bleeding and the mean hospital stay was days (± . ). in conclusion, according to the purpose of this preliminary study, we have demonstrated that purastatÒ can be easily used in laparoscopic surgery and it is a safe, effective haemostatic agent. this is a feasibility study and additional controlled studies would be useful in the future. during last three years the laparoscopic method of surgery in the presence of common bile duct stones was carried out. after performance of intraoperative cholangiography and visualization of stones in the common bile duct laparoscopic, choledochotomy and bile duct stones extraction was undertaken in patients, using flexible choledochoscopy control. in all patients with gallbladder stones was then performed laparoscopic cholecystectomy. results: laparoendoscopic intervention on common bile duct was successfully performed in patients ( . %) and the operation was completed by common bile duct drainage by kehr. in patients due to technical difficulties conversion to open surgery was carried out. postoperative morbidity in the form of bile leakage were diagnosed in patients ( . %). in three cases they stopped spontaneously in - days after the operation. patients were operated on repeatedly and additional suturing on choledocholithiasis was carried out. postoperative mortality was . %. the death of the patient of years was caused by acute cardiovascular failure. institute for image guided surgery, ihu-strasbourg, strasbourg, france; hepato-digestif, nouvel hôpital civil, strasbourg, france; image guided surgery, nouvel hôpital civil, strasbourg, france; gastroenterology, chu-besancon, besancon, france; gastroenterology, chu-lyon, lyon, france; gastroenterology, clinic de trocadero, paris, france background: eus is difficult to learn and has a steep learning curve. therapeutic eus (teus) is even more so. simulators, ex-vivo models and phantoms are the most common current teaching modalities but are felt by many to be unsatisfactory for high-level training. aim: we designed a training curriculum for teus that uses high-fidelity animal models and present a validation study performed by teus experts. project description: different simulated pathologies were created in each of acute pigs. teus experts performed therapeutic procedures in two or more animals over two days. each intervention was evaluated simultaneously using a structured survey by an non-expert observer. data included demographics and procedure details as well as likert-scale evaluation of the quality, realism and education utility of the simulations. global evaluation of the experience was captured from the experts as written comments. all data was consurrently registered and subsequently analysed by two blinded surgical educators. methodology: three types of models were created using surgical access: -tumors (injection of types of hydrogel), -retro-gastric collections ( - cm long intestinal loops filled with oatmeal, oil-water and gel), -obstructions (bile duct and ureteral ligations days prior to experience). gastric, pancreatic and liver tumor models were used for fna and fnb practice. retrogastric fluid collections and choledochal/ureteral obstructions were used for cyst gastrostomy, hepaticogastrostomy, gallbladder drainage and kidney drainage. results: experts age: - , median intervention time min , total of interventions evaluated, overall quality of experience: ( %) ranked - (excellent), ( %) from - (good), ( %) from - (poor), / procedures were successfully completed. models were rated good to excellent quality ( - ) in ( %), poor quality in ( %). for % ( ) of the interventions the model was considered not good enough to be repeated (solid retrogastric tumor and peripheral hepatic lesion). conclusion: high-fidelity live animal models with simulated pathologies are considered to be excellent training tools by experts and may provide a better learning experience for teus. surg endosc ( ) in our short videos, we present scenarios in which this technology helped: to distinguish a significantly dilated cystic duct from the cbd, to identify an anterior cystic artery in the contest of acute inflammation, to identify a luksha duct, to exclude a leak after endoloops positioning on cystic duct. intra-operative augmented visualisation of biliary anatomy with indocyanine green cholangiography is an essential technology tool with the potential to extend the hour window of safety for emergency cholecystectomies, with significant logistics benefits. introduction: endoscopic resection of subcardial polyps has its limitations; especially when it is necessary to dry out the entire gastric wall. uniportal intragastric surgery is a good alternative for the exeresis of subcardial premalignant lesions with gastric preservation. patient and method: we present a video with two cases. technique: we perform a laparoscopy to explore the entire abdominal cavity, then we open a . cm hole in the great curvature; a cm incision is made in left hypochondrium and the uniportal device is placed inside de stomach. we inject serum in the submucosa with a endoscopic needle. when submucosa is completely separated from muscular lay; a submucosal exeresis can be made; but when there is not a complete separation after injection, then we perform a entire wall resection with a cm circular margin. if a complete wall resection is made, then we close the defect with a barbed suture. results: case : years old male with a , cm subcardial polyp, preoperative biopsy was informed as severe dysplasia. in the laparoscopy we saw an unknown lesion in the great curvature that looked like a gist. we placed the uniportal device intragastric and proceed to the submucosal serum injection. as the submucosal lay was completely separated from muscular, then we performed a submucosal exeresis. we close the gastrotomy and made the resection of the great curvature lesion with endostapler. the pathological analysis confirmed the severe dysplasia in subcardial lesion and gist in the great curvature lesion. patient was discharged with no complications after days. case : years old male with a cm subcardial polyp. preoperative ecoendoscopy suggested a muscular layer infiltration but only severe dysplasia was found in the previous biospsy. laparoscopy did not found more lesions, and uniportal intragastric device was placed. a complete wall resection was made, and the defect was closed with manual barbed suture. pathologyst confirmed severe dysplasia and unaffected margin. patient was discharged with no complications after days. conclusion: uniportal intragastric surgery is feasible and safe and may be useful for subcardial premalignant lesions when endoscopic resection is very difficult or not feasible. introduction: the role of icg in bariatric surgery is still unclear. knowing the lack of perfusion in the gastric pouch could be of great interest in revisional surgeries; but the question remains: is the current icg technology reliable enough to make intraoperative decisions in bariatric surgery? methods: we have carried out a check of tissue perfusion with icg fluorescence in several cases of primary and revisional bariatric surgery. a solution of , mg/kg was injected intravenously and icg fluorescence was performed. we looked for the correct staining of the entire gastric pouch and the intestinal loop trying to rule out areas of tissue ischemia. results: the cases in which the test was performed showed a minimal delay of - s between the intestinal loop stain and the pouch. a correct staining was observed in all but one case shown in the video. is the case of a years-old male patient who was operated years earlier in another center; at that time he underwent a sleeve gastrectomy. we evaluated the patient for persistent gastroesofhageal reflux of years of evolution with esophagitis. we offered revisional surgery to perform gastric bypass and hiatal closure. fundus was dilated so a funduplasty was performed instead of using endostappler in the vertical side of the pouch. manual anastomosis gastric bypass was performed. when the icg test was performed, a corner of the pouch does not stain green (an area of , cm) . so the decision was to resect that part and redo the anastomosis or wait and see. it was decided not to resect and the patient was discharged two days later with no complications and good outcome with a months follow up. conclusion: icg fluorescence may be useful in bariatric surgery in the future but more evidence is needed of its usefulness in making intraoperative decisions. background: lymph node status is one of the key prognostic factors in patients with colorectal cancer, and remains the most important selection criteria for adjuvant chemotherapy. it is believed that at least % of node negative patients will suffer disease recurrence within the first years after surgery. this may be due to understaging of lymph node status. sentinel lymph node mapping is widely used for staging of breast cancer and melanoma, with injection of colloid tc and isosulfan blue (ib). however, indocyanine green (icg) fluorescence guidance is a new technical approach to this issue, with promising results for detection of aberrant lymphatic drainage outside of the planned resection. the icg lymphography has the advantage of offering a good visualization of the lymphatic channels but there are problems in order to identify the lymphatic nodes. aim: the objective of the experimental study is to investigate the possibility to detect the sentinel lymph nodes after the injection of different solutions with indocyanine green in the subserosal colonic layer in the pig. project description: twelve female large white pigs were operated with laparosocpic approach and spies optic filter (karl storz, germany). indocyanine green was injected in the subserosa of the colonic wall ( ml at points). lymphatic flow was observed at - - - - and min, searching for the migration of the icg by the lymphatic channels and its introduction in the sentinel nodes. preliminary results. the identification of the sentinel nodes is very difficult with the solution of icg-sterile water. with this technique we can see the lympjatic channels but not the lymphatic nodes. the adition of % human albumin as a transporter of the icg is very helpful for the correct identifiaction of the lymphatic channels at - - min and the correct visualization of the lymphatic nodes at min after the bowel injection. addition of other transporters like dextran solutions may be helpful too but the time to the correct visualization is longer. there was significant difference among the three groups as regards postoperative les and postoperative ph metery.the incidence of persistent dysphagia was significantly higher in the group i. postoperative gerd symptoms were significantly higher in group iii ( . %. p \ . ). recurrent achalasia was significantly higher in group i ( patients . %, patients in group ii ( . %) and nil in group iii (p \ . ). in conclusion: longer myotomy on the gastric side ([ . cm) ensures complete division of the les with better outcomes in term of resolution of dysphagia but may be associated with higher postoperative gerd. therefore, a myotomy length of . to . cm on the gastric side provides a balance between relieve of dysphagia and development of postoperative gerd. c/t scan of his abdomen revealed a large groin hernia with signs of small bowel obstruction and collapsed distal bowel. emergency theatre was organised for this patient with anaesthetic assessment prior to his surgery. initial plan of local exploration with possibility of small resection was changed once he was under full anaesthetic with muscle relaxation. his abdominal girth provided an opportunity to utilise laparoscopic intervention as an initial approach. laparoscopy with degree lens revealed moderately distended loops of small bowel and a large omental mass along with a loop of small bowel incarcerated in right direct inguinal hernia site. background: robotically assisted surgery is a rapidly developing modality of minimally invasive surgery with proven advantages in the management of cancer. despite its increasing prevalence, there is still an ongoing debate regarding its future role in colorectal surgery. while the prospective randomised multi-centre studies provide research evidence for its potential efficacy, an assessment of its effectiveness and realistic outcomes in everyday clinical practice can add an important perspective to this discussion. the international robotic colorectal registry will allow to compile and pool the international robotic colorectal experience. aims: the aim of the international robotic colorectal registry is to monitor the safety and outcomes, as well as the quality of specimen of robotically assisted colorectal surgery for malignant and benign diseases of the colon and rectum. the primary endpoint is a composite oncological failure. the secondary endpoints include anastomotic leak, resection margin involvement, conversion rate, operative time, post-operative -day morbidity and mortality, long term oncological outcomes, quality of life, functional outcomes and cost-effectiveness. project description: the international robotic colorectal registry is a multicentre web-based, online secure database. the registry has been awarded an ethical approval by a relevant national committee. all surgeons performing robotic or robotically-assisted surgery are invited to participate. the data collected includes patient demographics, cancer characteristics, operative details, histology of the specimen, wound healing, post-operative therapy, readmission, quality of life and functional (bowel, urinary and sexual) outcomes. all the sensitive patient information is encrypted before its introduction into the database. preliminary results: so far, twenty robotic colorectal centres have joined the international robotic colorectal registry. the preliminary results will be published once patients have been enrolled. univariate and multivariate analyses will be performed to identify possible risk factors for poor outcome.the possibility to record open, laparoscopic or other minimally invasive colorectal procedures will facilitate comparison of the outcomes of the robotically assisted surgery and other modalities. the registry will also allow each surgeon enrolled to monitor their skill progression and outcomes over the time. results will be published in surgical literature and presented internationally. background: gastric outlet obstruction (goo) due to benign strictures is an uncommon surgical entity today. this paucity relates to the decrease in its aetiological factors in the modern era as well as to advances in both prevention and medical as well as endoscopic treatments of such condition. the most common of causes relating to peptic ulcer disease, has been subdued for decades with quality acid control medications. on the other hand advances in gastroscopic dilatations skimmed even more the frequency of these cases from arriving to surgical intervention. aim: this presentation gives an update on the standing of this pathology and its surgical management today. it will also shed a light on our early experience in this condition at the royal hospital of muscat in oman. project description: a case series of all patients with goo, who were surgically managed between and results: there were a total of patients, males and females. the cause of obstruction was peptic ulcer disease in , corrosive injury in , iatrogenic perforation in and idiopathic hypertrophic stenosis in . emergency presentation was seen in . management included jaboulay pylorpolasty in , resection in (distal gastrectomy in , total gastrectomy in ) or a bypass (gastrojejunostomy) in . in of the above, the procedure was done by laparoscopy. post operatively, temporary gastric paresis delayed recovery in , however all symptoms resolved in . there were no recurrences at minimum of years of follow up. in spite of advances in medications and gastroscopy interventions, we still seem to identify this condition within our population. although infrequent, they demand awareness from surgeons since they could be managed successfully, especially laparoscopically, with minimal morbidities and early recovery. the introduction of advanced laparoscopy to the unit's setup in recent years, made such option feasible with satisfactory and durable outcomes. background: gists of the upper gi are found mainly in the stomach ( - % of cases) and small intestine ( %). duodenal gists however, comprise a smaller subset with a frequency of to %. the optimal surgical procedure for duodenal gist is still evolving. since wide margins and extensive lymphadenectomy are not required, restrain from more radical resections in this area would be a valid option. aim: this is a video case report of a patient with a gist involving the third part of the duodenum treated by laparoscopic lateral duodenectomy and end-side roux-en-y duodenojejunostomy case report: years lady presented with recurrent mid abdominal postprandial pain with anorexia, nausea and occasional vomiting an ultrasound showed well defined hypoechoic mass of . . cm at the right para-aortic region . ct scan defined the mass as retroperitoneal, intimately related to the pancreas uncinate process and the third part of duodenum with no clear cleavage line between them. an mri endorsed the diagnosis of gist of the duodenum. she was operated upon through a laparoscopic lateral duodenectomy including the gist at the third part of the duodenum. a frozen section confirmed the clear margins . reconstruction was done by a roux-en-y duodenojejunostomy with the alimentary limb taken cm from the dj flexure. she had an uneventful post operative recovery and was discharged well. the histology confirmed a low grade gist tumour hence no further treatment was needed. at follow up six months later, she was doing well and gaining weight. conclusion: complex anatomy of the pancreatico-duodenal area makes conserving the duodenum for tumours rather than a major resection a challenging option. in our case however, with the disease in the third part being of a moderate size, a lateral duodenal wall resection including the mass was possible rather than a segmental resection. this procedure could be an ideal choice for benign, moderate sized tumours in the third and fourth part of the duodenum. background: during laparoscopic colectomy, laparoscopic lymph node dissection and extracorporeal intestinal anastomosis is commonly performed. an umbilical incision of - cm and wide-range mobilization of the intestinal tract is required for extracorporeal anastomosis. previously, we introduced intracorporeal overlap anastomosis in june as a minimally invasive treatment. here, we report its short-term outcomes. aim: we retrospectively compared the surgical outcomes of cases of extracorporeal anastomosis and cases of intracorporeal anastomosis, all of which were performed between june to may . procedures: after lymph node dissection and sufficient mobilization of the intestinal tract, the proximal and distal intestines were resected perpendicularly to the intestinal tract with a -mm linear stapler. the anastomosis was performed after the specimen was extracted from an umbilical incision. the opposite sides of the mesenteric margin cm from the staple line of the one intestinal tract, and cm from the staple line of the other intestinal tract, were marked, and then the respective intestinal tract was positioned to join the opposite mesenteric sides together. an insertion hole was made in the intestinal tract at the marked site. side-to-side anastomosis with a linear stapler was performed, and then the insertion hole was closed with a linear stapler after several temporary sutures. preliminary results: in the extracorporeal anastomosis group, the mean operation time, blood loss, and post-operative days were min, ml, and . days, respectively. furthermore, there were three intraoperative cases of bleeding ( . %), and two postoperative cases of lymphorrhea ( . %) that occurred. however, in the intracorporeal overlap anastomosis group, the mean operation time, blood loss, and post-operative days were min, ml, and . days, respectively. additionally, there were no cases of intraoperative complications, and only one postoperative case of lymphorrhea ( . %). conclusion: intracorporeal overlap anastomosis in laparoscopic colectomy is safe and feasible, and can be used as a minimally invasive treatment. nowadays d-printing it's not a new technology any more but with an exponential developing. there are beliefs that in % of everything that will be produced will be d-printed. in medical field this technology knows the same exponential developing. first used in orthopedics and maxilo-facial surgery now d-printind is used in many other fields for different reasons, like preoperative training models, surgical special instruments, in medical education, etc.. liver surgery is in continuous developing and this is the reason why we need experimental liver model for training and testing. a best liver experimental model should heave liver consistency, to be flexible, to heave the same ultrasound feedback, to be cheap and easy to be reproduced. this is why we developed a liver experimental model made of gelatin by a simple recipe, using a dprinted mold, created after a human liver ct-scan. first was made the segmentation of the liver. after segmentation we create the d virtual liver model and the negative image of the liver, which was used for creation of the pieces of the liver mold, with connections between them and a hole on the top to pour the gelatin solution. ( ) ethical concerns on learning and training with real patients and substitutives such as animals, and ( ) reconciling time devoted to learning with clinical practice, considering the european work time directives. simulation in medical education is and has been the preferred route to address both pedagogical needs. virtual simulation has proven to be a valid tool for training; however, current systems restrict usage to tasks and modules offered, without possibility of personalization. we present the minimally invasive surgery simulator scenario editor (mis-sim) an environment where users can create, edit and run virtual reality tasks designed for medical training. the environment features an editor allowing users to develop learning tasks, defining its learning objectives and task goals in an easy way. a first proof of concept has been implemented for surgical training and training activities (demostrators and short courses) have been carried out in three european sites: spain, the netherlands and hungary. during training activities, different exercises have been created and uploaded to the contents' database. trained technical skills include handeye and bimanual coordination, instrument handling and pulling. preliminary results with users have shown mis-sim training potential, although some functionalities should be made easier. personalization has been highlighted as the key added value of mis-sim with respect to the current competitions in the market: the ability for target users to use virtual reality based learning tools while remaining in complete control of the learning process. mis-sim aspires to break the barrier between vr and medical education by empowering users to create their own tasks. with mis-sim teachers/course creators and learners (healthcare professionals & future healthcare professionals) will benefit from an innovative tool to ( ) create personalised medical learning contents tailored to preferred learning styles, allowing the creation of individualize learning paths; ( ) improve the efficiency of training by focusing on the training needs of the learners and ( ) share and sell vr-based didactic contents. c. tiu , p. sánchez-gonzález , m. chmarra , d. gutiérrez , c. guzmán-garcía , l. sánchez-peralta , g. wéber , f. sánchez-margallo , b. pagador , j. dankelman aims: currently surgical training is largely based on the improvement of technology enhanced learning solutions. the progress of engineering and the diversification of training facilities outside the operating theater results in an even greater contribution of technology in the future. the main reasons to encourage these changes are increased efficiency of simulators and directly increased patient's safety. the goal assumed by the easier project is to develop multi-skill, online platforms for minimally invasive surgical (mis) procedures-based on common pedagogical principles with reference value in a multinational space. the platform will allow the connection of external assets (such as simulators) to centralize all training data from residents. this work presents the milestones of the project during its first year of life. methods: the consortium's activity started with a knowledge elicitation process organizing brainstorms and workshops including experts in mis and interventional techniques, from spain, romania and hungary. this experience led to the formulation of a questionnaire that was implemented online and sent via email to surgeons and residents from the participating countries. results: accumulated experience was used to define the pedagogical needs of the platform. the pedagogical needs form the starting point for defining the technical requirements and specifications. based on them, the design of the platform has been achieved, including its architecture and communication protocol between external assets design, facilitated by the use of state of art educational standards. discussions and conclusions: next steps include the implementation of the easier platform, as well as the definition of cases studies selected by the clinical partners in spain, romania and hungary to solve applications of the platform dedicated to cholecystectomy, lumbar puncture and arthroscopy. a pedagogical model, built by the experience of the consortium, is being used to guide instructional design of the course. finally, results will be validated in a multi-center validation study.the easier project will create a training platform with reference value for european surgery. the structure of the consortium, based on the confluence between collectives with clinical, technological and pedagogical experience, will generate a complex learning tool in surgery embodying technology-based training systems with clinical experience. background: the treatment of groin hernia is an important part of our daily surgical activity. aim: we proposed to evaluate outcomes of the laparoscopic trans abdominal pre peritoneal treatment (tapp) of the groin hernia. project description : one hundred and fifty patients who underwent a tapp for a groin hernia were included in a retrospective study between january and november . results: the gender ratio was . the average age was , years. twenty percent of patients had a history of abdominal surgery. the operative indication was a unilateral hernia in % of cases, associated with an umbilical hernia in % of cases, a recurrent groin hernia in % of cases and a bilateral inguinal hernia in % of cases. the conversion rate was . %. the hernias were classified according to the ehs classification in l type in % of cases, l in % of cases, l in % of cases, m %, l r in % of cases and f r in % of cases. a contralateral inguinal hernia was discovered in % of patients. a polypropylene mesh x cm was fixed by a stapling in % of cases and by a suture in % of the cases. the average operation time was min. the hospital stay average was , day. an antalgic treatment was prescribed in % of patients. the average time to return to normal physical activity was days. a postoperative seroma was noted in % of patients. no cases of mesh suppuration were noted. chronic pain was noted in two patients. no recurrence was noted with an average follow-up of months. conclusion: laparoscopic treatment of the groin hernia by tapp had good results concerning the postoperative pain, early recovery of physical activity and aesthetic damage. a larger setback is needed in our study to evaluate the recidivism rate. background: surgeon's training in ultrasound is viewed and understood differently in different parts of the world. if in united states the need for surgeons' training was accepted and taken over by the american college of surgeons, in europe the practice is completely different from one country to another, from one city to another, from one department to another within the same premises hospital. in some european countries, surgeons currently use ultrasound for diagnosis-especially in urgency, for follow-up, intraoperative, or as guidance for many surgical gestures. during this time, access to ultrasound of other surgical specialties-gynecology, urology, ophthalmology-is considered natural. material and method: once the decision to initiate an ultrasound course for surgeons was taken, a team of experts with technical or clinical expertise in ultrasound was organized. at the initiative of the technology commission, the courses were to be organized at the eaes congresses or others communication events endorsed by eaes. starting from the importance of each ultrasound application in surgery, it was decided to develop different modules to solve different training needs. at this time, the course offered at seville covers the capitols like abdominal ultrasound, guided punctures and trauma. a module dedicated to intraoperative ultrasound is under construction and will be available in november . the course has a skill abilities dominant character, two thirds of it being thought of as a hands-on application on stationary, classical ultrasounds with large screens and also on small size wireless actual devices. results: after his debut in frankfurt in , the course was resumed in london and in bucharest, twice. in this process, new modules and better teamwork skills have been developed. the participants' satisfaction quizzes, coming from all continents, were really encouraging. for the intraoperative ultrasound module the team approach is unique. students will have the opportunity to practice on live animals both laparoscopic and open abdominal procedures conclusions: the ultrasound for surgeons course initiated by eaeas was received with interest. the team will seek to inspect the real needs of training surgeons in this field and will complement and diversify the current platform surg endosc ( ) preliminary results: a total of procedures ( - , ± . ) were carried out in patients. the indications included acute ( leaks following esophageal resection, rupture of the strictured anastomosis following pneumatic dilatation) and chronic conditions (esophagopleurobronchial and gastropleurobronchial fistulas following the resection of esophageal diverticulum and sleeve gastrectomy). the initiation of the therapy was in , and day in case of acute conditions, and after years of the duration of the unsuccessful therapy in chronic cases. the successful closure was observed in patients, patient passed from mods and ards. in case, the initiation of evac was provided as a combined surgical and endoscopic intervention (ct proven distant intraabdominal abscesses). in chronic cases, was discontinued due to the haemophagocytic syndrome of unknown etiology, in the second one, success in reduction of the lesion and symptomatology with long term duration was observed following just applications of evac, despite minimal remanent leakage. the success is to our experience linked to early initiation of the therapy and presumes complex intensive care. the future investigation should specify the timing including preemptive use of evac and the combination of evac with other endoscopic, interventional and surgical therapeutic modalities. the aim of this feasible study is to investigate complete robotic esophagectomy with total mediastinal lymph node dissection (retm) only by the robotic arms. methods: the patient is placed hemi-prone position with one lung ventilation by blocking balloon tube under general anesthesia. the robotic trocar for st arm of da vinci xi surgical system is placed in the th intercostal space (ics) on the scapular line, the trocar of nd arm is placed in the th ics on the posterior axillary line, rd arm trocar is placed in the th ics on the middle axillary line, th robotic arm trocar is placed rd ics on the middle axillary line, and assistant trocar only for taking in and out of gauze is placed in the th ics on the middle axillary line. on the upper mediastinal lymph node dissection, robotic camera exchanges from nd to rd robotic arm to close and identify anatomical structures. esophagectomy with lymph node dissection starts from middle and lower mediastinum to upper mediastinum including along bilateral recurrent laryngeal nerves. all procedure perform under close-up view along the robotic enhanced anatomy to preserve organ functions. background: complete stenosis of the duodenal lumen secondary to a surgical suture in the treatment of a duodenal ulcer is a rare complication. the usual surgical resolution corresponds to a gastrojejunostomy associated or not, to an antrectomy with vagotomy, as a treatment for the peptic disease. the endoscopic resolution of this complication requires the use of complex maneuvers and specific therapeutic instruments. aim: to describe the endoscopic resolution of iatrogenic occlusion after raffia of perforated duodenal ulcer. description: a -year-old man was admitted to the emergency service for four days of pain and abdominal distension associated with abundant retention vomiting. performed ten days ago of a perforated duodenal ulcer, in which manual raffia was performed in two planes and drainage. abdomen and pelvis ct showed great distension and diffuse thickening of the gastric wall. the endoscopy showed abundant gastric retention content, pylorus, and bulb edema, and complete closure of the duodenal lumen, secondary to suture material; it was possible to count three suture threads. with a tipped papillotome and electrocautery, all the suture threads were sectioned, identifying a filiform opening through which a hydrophilic guide is inserted under fluoroscopy until it is sure to overcome the stenosis; we dilated the trajectory with a dilator of mm in diameter and cm in length. with a contrast medium, we observed an adequate trajectory and installed a partially covered duodenal metal stent (hanaro stent) of cm in length by mm in diameter in order to sustain the dilation. he was sent to home with inhibitors of the proton pump. after two weeks, the stent was removed, without complications. he was controlled two weeks after withdrawal, and, with pharmacotherapy, the patient was asymptomatic, making a normal life. conclusion: in this case, the result was positive. satisfactory results can prevent major surgery, which reduces the risk and possible complications. a new range of non-invasive medical tools with a remarkable improvement on the existing market. a manual laparoscopy, with the important novelty of having a bending head with a high degree of movement. this head can get multiple spatial positions to work in surgery and is very easy to use, with the same scissors thimble who controls it, so its performance and learning is very simple and intuitive. the tools can be easily reusable and they can be cleaned and sterilized by ordinary methods, very ergonomic and lightweight . the generic type models we initially have developed are focused in general surgery, but gradually we will develop new applications and different heads for specific medical conditions such as arthroscopy, laryngoscopy, otolaryngology, ophthalmology, orthopedics . its operation is simple and functional, simply moving the scissors thimbles, where they have a dual role, combining the head tilt and the action of opening and closing of this is achieved.the design of this tool allows us to work with some degrees of unparalleled freedom from the existing tools. our instruments replicate the movements of the robot with a simple handheld mechanical instrument, our philosophy is to position our instruments in between a long empty field between the surgeon and the robot. the tip of our instruments are providing the surgeons with angulations impossible to reach with the traditional instruments unless applying huge movements from the hands of the surgeon. we consider that this devices will have a very fast acceptance from the market as this robotic type movements can be managed by the surgeon through the traditional mm trocars, without the need to change to a new surgical technique, just with the traditional method and a very brief training. background: diverticula of the middle thoracic esophagus are infrequent, its etiology may be secondary to traction or pulsion mechanisms. when the etiology is a mechanism of pulsion, they are associated with esophageal motor disorders and its prevalence is estimated between . % and . % of the population . they are rarely symptomatic and the diagnostic is usually incidental. the most common symptoms are episodes of food impaction, chest pain or bronchoaspiration.diverticulectomy and esophageal myomectomy by minimally invasive approach is the treatment of choice in those with large size or associated symptoms. aim: to describe a clinical case of esophageal diverticulum solved by minimally invasive surgery approach. clinical case description: a -year-old patient with a history of epilepsy and hypothyroidism consulted for atypical chest pain and dysphagia to liquids and solids. a study with esophagogastroduodenoscopy was performed: cm from the dental arch, a large wide-mouth diverticulum was identified. we complete the study with an esophagram with barium: voluminous diverticulum in the right lateral face of the middle esophageal and a thoracic ct scan showing esophageal diverticulum located in the carina, from . x . cm to cm from the esophagogastric junction. due to the suspicion of associated motor disorder, high resolution manometry was performed showing a significant motor disorder with alteration of peristalsis and exit obstruction with incomplete relaxation of the inferior sphincter and superior hypertonic sphincter. preliminary results: the patient underwent surgery: diverticulectomy and complete esophageal myotomy by thoracoscopy minimall invasive approach. the patient evolved favorably and was discharged after days with a previus control esophagram without pathological findings. currently, it remains asymptomatic months after surgery. , rectus muscles are re-approximated from xiphoid to pubis using laparoscopic running self-locking, pds sutures to restore anatomy and physiologic function of the abdominal wall. unlike the standard access to the abdominal cavity executed with lateral access, the lap-t technique is performed through sopra-pubic aesthetic approaches, using one mm and one mm bariatric ( cm) instruments laterally, and one mm camera in the middle.the entire procedure is performed in gas-less laparoscopy, with laryngeal mask and intra-peritoneal liquid anesthesia. the repair is consolidated placing an intra-peritoneal semi-absorbable mesh. preliminary results: in all cases abdominal functioning was successfully restored; no higher pain related to the continuous laparoscopic suturing has been reported compared to bridge ipom laparoscopic repair, while allowing for a more physiologic outcome and a stronger repair. the use of miniaturized instruments allowed for minimal tissue trauma and accurate surgical gestures; the tiny trocar sites did not require skin suturing and might reduce the risk of trocar hernias. no intra operative bleeding, no seroma formation, chronic pain, nor mesh infection have been recorded. % follow up at months, % at months with no recurrences observed. the lap-t technique allowed for a sound and anatomic reconstruction, reduced trauma, faster recovery and more satisfactory aesthetic results. surg endosc ( ) background: anastomotic leakage is a serious complication, associated with significant morbidity and mortality. one possible cause of anastomotic leakage is insufficient vascular supply. markers of sufficient perfusion include pink color of the bowel wall, visible peristalsis, palpable pulsations and bleeding from the marginal arteries. these signs are subjective and may be misinterpreted even by experienced surgeons. aim: the assessment of bowel perfusion with the use of indocyanine-green fluorescence angiography might be helpful in decreasing the number of anastomotic leaks. project description: we report a case report of a middle-aged patient without significant medical history who was treated by transanal total mesorectal excision (tatme) for rectal carcinoma. the patient underwent neoadjuvant treatment with radiochemotherapy. during the surgical procedure, indocyanine-green fluorescence angiography showed adequate perfusion of the bowel. the postoperative phase was uneventful and the patient was discharged home on the th postoperative day. preliminary results: indocyanine-green fluorescence angiography is a safe, cost-effective and feasible tool for assessment of tissue perfusion during colorectal resections. background: to properly learn how to perform a laparoscopic suture, along with safe tissue handling, applying an appropriate magnitude of the force on the tissue is essential. for this reason, it is fundamental to investigate and validate if training with real-time visual force feedback improves the suturing performance of laparoscopic novice surgeons. capturing all of the forces applied in laparoscopic in surgery in an unobtrusive way has been difficult in the past. sensor has supplied a novel force-sensing film (forcefilm) that can detect all of the forces applied with laparoscopic instruments without changing the surgical workflow or operation of the instruments. aim: to evaluate the effect of visual force feedback on surgical performance, applied force and surgeon's ergonomics during training of laparoscopic suturing using the sensor technology (sensor medical laboratories ltd.). methods: twenty novice laparoscopic surgeons participate in this study. they perform a laparoscopic suture on an ex vivo stomach tissue from a pig. participants are assigned, in a random fashion, to either group that receives visual force feedback (a) or the control group (b) without visual force feedback. five training trials (t -t ) are carried out in order to assess the learning curve. in addition, an evaluation pretest (t ) and posttest (t ), without visual force feedback but recording the force applied, will be performed after the training trials. the applied force on the tissue and visual force feedback of each instrument are provided by means of the sensor technology. it accurately measures the forces exerted on the tissue from the instrument tip and wirelessly communicates the force information to the surgeon via visual force-feedback. during each trial, several parameters are evaluated such as execution time, applied force, surgical performance, and mental and physical workload. preliminary results: laparoscopic training using visual force feedback leads to an improvement of suturing skills with a reduction of the applied force and therefore providing a potentially positive effect on patient outcomes and surgeon's ergonomics. background: hiatal hernia is a frequent disorder, characterized by a protrusion of any abdominal structure other than the esophagus into the thoracic cavity through a widening of the diaphragmatic hiatus. current anatomic classification is mainly based on the location of the gastroesophageal junction and the presence of a true hernial sac, differentiating sliding from paraesophageal hernias. there is no solid evidence to support an association between gastric carcinogenesis and peh. however, chronic reflux is considered as one of the strongest risk factors of developing adenocarcinoma of the esophagus and proximal stomach. aim: herein, we report a case of an -year-old caucasian female with dysphagia, regurgitation and heartburn accompanied by an iron deficiency anemia, a remarkable total body weight loss and recurrent lower respiratory tract infections due to microaspirations. subsequent work-up with ct, upper endoscopy and barium esophagram confirmed the presence of synchronous distal gastric adenocarcinoma and a giant paraesophageal hernia with complete intrathoracic stomach. after mdt discussion and keeping in mind the patient's age and comorbidity, a d laparoscopic distal gastrectomy with a synchronous hernia reduction with posterior cruropexy was scheduled. project description: the patient was placed in a supine position, five thoracoscopic ports were introduced, and a diagnostic laparoscopy of the abdominal cavity was performed. the stomach was identified through the dilated hiatus into the left thorax. the hernia sac was dissected away from mediastinal structures, then excised to untwist the stomach. after reduction of the stomach to abdominal cavity, a total d ? gastrectomy with a roux-en-y reconstruction was performed. maintenance of optimal vision during minimally invasive surgery is crucial to maintaining operative awareness, efficiency and safety. hampered vision is commonly caused by laparoscopic lens fogging (llf) and lens condensation which has prompted the development of various antifogging fluids and warming devices. numerous tricks have been proposed to overcome this issue, such as heating the scope into a sterile thermos flask filled with hot water, or using one of the commercially available antifogging solutions. however, whether one method is superior to another remains elusive. as most surgeons know, none of these tips are totally efficient, as they don't treat the cause: the temperature difference. taking into account this need, we have developed ehs (endoscopy heater system), a thermoadjustable system by microcontroller, which is implemented in the manufacturing process of the rigid endoscope focused on laparoscopy. the technology enables the self-modulation of the temperature of the endoscope within the different conditions during the surgery, avoiding the % of laparoscopic fogging. with the adoption of ehs surgeons get a clear field of vision avoiding continues repetitions of extraction and insertion of the endoscope in the body during the intervention. in this way the risks of the patients are reduced with a more efficient and shorter duration procedure. ehs also represents an alternative that meets sustainability criteria by reducing energy costs and eliminating much of the waste currently generated by this procedure. therefore, this innovation will disrupt the laparoscopic device market by enhancing safety and effectiveness without introducing new components that could complicate surgical procedures. case report: we presented the case of a year old women with chronic coloenteric fistula. conservative treatment was unsuccessful. the orifice was then closed with two subsequent clips, and the patient recovered well. to our knowledge, this is the first successful case of coloenteric fistula treatment with ovesco discussion: ovesco system is a technique that enables the closure of gastrointestinal defects (perforation sites, leaks, fistulas) . after the system application, the patient can be treated at home as was the case with our patient. a successful closure of the leak or fistula is possible when no extraluminal abscess is present. in our case, we had a cavity (previous sinus or abscess) that drained into the small bowel, thereby forming the coloenteric fistula. this allowed us to succeed with a fistula closure, as the cavity could drain into the small bowel conclusions: looking through the reports, one notes that the success rate of the otsc system procedure for insufficiency of anastomosis or colorectal fistula was - %, but only nine successful reports of chronic colorectal fistula were found). a % success rate is reported if the clip is placed within a week of occurrence of the leak . on considering the financial side, clips could reduce costs and time of hospitalization and avoid patients having to undergo a surgical repair . the major advantage of ovesco clips seems to be their ability to grasp more tissue compared to the standard clips and their strong grip on the wound margins because of their sharpened teeth. the drawback of the clips in fistula sealing is their incomplete grasp when the tissue is fibrotic. most authors agree that ovesco is not very appropriate for fistulas larger than - mm. inguinal hernia repair is one of the most performed interventions in minimally invasive surgery. in this opportunity we report a new technique through the use of innovative devices such as the robotic clamp and magnetic deviceswith this technique and thanks to the magnetized devices and the robotic clamp we have demonstrated to reduce the surgical time between - min as well as to optimize the ergonomics of the surgeon.we explain the technique with a demostrative video and exposition of the devices that are necessary for make it.with this new technique we get a greater capacity of mabiobra for dissection of the peritoneum and later a greater facility for the suture of the same in the repair of the inguinal hernia. a motorized and computerized laparoscopic tool that can be customized to the specific surgeon and procedure a. szold aim: surgeons have different levels of skill and use instruments for different tasks, but laparoscopic instrument are commonly simple mechanical instruments that allow limited degrees of motion, and the same instruments are used regardless of the surgeon or the task. robotized articulating instruments so far have added degrees of freedom, but perform in a standard way for all users and procedures. technology: human xtensions has developed a \ u[hand-held \/u [ motorized smart laparoscopic instrument, that was recently introduced in human procedures. the device has several features that enable to customize it to the user and procedure. the degrees of freedom can be reduced from to , the scale of rotation motion has options that can control both speed and range of rotation, a feature especially useful for the variable types of suturing tasks. results: the variable features were tested in different procedures requiring suturing and grasping. the combination of all optional settings made the instrument customizable to the different skill levels of the surgeons. as such, it enabled to control the complexity of the device and take the surgeon through the learning curve until full control of all features was achieved. in addition, the combination of different controls was used for performing specific tasks requiring different levels of maneuverability. in september , the results of a bomss survey regarding the routine use of pre-operative bariatric surgery were published. they found that % of units surveyed considered routine preoperative ogd completely unnecessary. as part of newly launching bariatric services in a single isolated centre we protocoled that all bariatric patients had to undergo pre-operative ogd, including a clo test, and reviewed if the ogd findings had influenced our surgical choice of operation and any necessary treatment before surgery. all patients embarking on the bariatric programme since its launch in jan to sept were included and had an ogd. the results of these ogds and all the clo tests were reviewed. these ogds were all performed by a single consultant to minimise any potential subjective differences. of the patients, ( %) tested clo positive of which had normal findings on ogd. patients had a hiatus hernia, gastritis, oesophagitis, gastritis and oesophagitis, had other findings e.g. ulcers, polyps' or nodules. the positive clo patients underwent eradication of h pylori. studies have shown that this is a treatable and preventable cause of gastritis/ gastric cancers and potential surgical complications causing prolonged hospital stay in % of patients. knowing about the presence of a hiatus hernia prior to surgery also contributed to the surgical planning, including allowing time for the concurrent correction of the hiatus hernia in the operation. all patients with demonstrable oesophagitis ( %) had their operative choice changed to roux en y gastric bypass thus aiming to prevent post-operative reflux which would have been exacerbated had they undergone a sleeve gastrectomy instead. carrying out a pre-operative ogd had a significant impact in operative choice and additional treatment before surgery and therefore should be advised in all patients. general surgery department, ahievran university, kirsehir, turkey the majority of fatalities worldwide in people under the age of years are caused by trauma . blunt mechanisms account for . to . %of injuries [ ] [ ] [ ] [ ] ,with the abdomen being affected in . to . % of all traumatic injuries. this case contribute to the literature: a patient with sleeve gastrectomy has distorted anatomy at duodenogastric junction, if has bat,her/his small bowel perforation(sbp) will occur on more distal segment. this a unique case before unpublished. years old female who had sleeve gastrectomy years ago presented to emergency department sustained blunt abdominal trauma (bat). when she arrived pyschical exam (pe) revealed an abdominal guarding, tenderness, normal vital signs but those increased h later. wbc values also increased h later. hb was normal.fast showed in cm thickness fluid early in douglas pauch (dp), mm in supravesical, mm diameter in dp h later. abdominal ct: mm diameter fluid in interloop, dp free air at th h from the accident. a diagnostic laparoscopy(dl) was done with diagnossed acute abdomen.there were a sbr-located cm from treitz, intraperioneal fibrin deposits and fluid-repaired with a primary suture.the patient discharged on days without any event. repeat ct scans are recommended for patients with initial suspected bowel injury. we could not do this; cause ct exam could taken in rush hours only but we did repeatly pe that peritoneal iritation signs increased,resulted a dl,surgical therapy. according to the literature; dl may be a good treatment option in these patients, to reduce morbidity or mortality, time to surgery has been emphasized. long interval between presentation and surgery was found to be associated with complications. very few reports of isolated jejunal transection following blunt abdominal trauma have been published in literature. the literature mentioned; the patients with sbp are hemodinamically stable on arrival to the hospital like our case are, a rupture of the jejunum was seen just distal to the duodenal-jejunal flexure but there were a perforation cm below treitz ligament and caused me to think the patient had sleeve gastrectomy and some brid around gastric and duodenal proximal jejunal part of intestines and also caused a new descended treitz ligament. normally external forces across to spine produce a blast effect on small bowel between treitz and ileocolic ligament. introduction: sasi bypass is a novel metabolic/bariatric surgery operation based on minigastric bypass and santoro's operation.it can be offered for patients with weight regain after sleeve gastrectomy. sleeve gastrectomy (sg)is a commonly performed bariatric procedure.weight regain following sg is a significant issue.yet,the understanding of this phenomenon is still unclear.rates of regain ranged from . % at years to . % at years.sasi bypass was an option for some candidates having sg done years back and failed to achieve the required weight loss or having weight regain.in sasi bypass, resleeve gastrectomy of the dilated gastric pouch is done followed by a side to side gastro-ileal anastomosis. the aim of this study is to report the clinical results and the outcomes of sasi bypass as a therapeutic option for patients with weight regain after sg methods: we conducted a retrospective study for morbidly obese patients having history of sg done more than years back and failed to achieve and/or to maintain the required bmi. exclusion criteria:patients with recent history of laparotomy(less than months). procedure was done at sidra hospital in kuwait from november to november . using ports, resleeve gastrectomy was performed over fr bougie tube starting cm above the pylorus then gastro-ileal anastomosis (side to side)was performed cm above the pyloric ring to an ileal loop counted cm from the ileocaecal valve. data was collected from the patients including:weight loss progress,laboratory full results. discussion and results: during the study period: morbidly obese patients with a mean bmi of ± kg/m were evaluated. -%ewl(excess weight loss)reached % at one year. -diabetes was cured in the known diabetic patients (type )within months,and the one known type diabetic patient had better control and less insulin daily doses(results were guided by glycated haemoglobin results every months). follow up laboratory results were normal in % of patients (all were kept on regular vitamins and proteins supplementation)-one patient had postoperative leak(day )from the anastomotic line that was treated conservatively. conclusion: sasi bypass is a promising operation that offers a good weight loss for morbidly obese patients having weight regain after sg conclusions: our study demonstrates a good agreement between the degree of liver steatosis and monocytes fat accumulation as well as between plin levels in liver and circulating monocytes. this suggests that ectopic fat deposition is a generalized feature of insulin resistance in obesity. sg reverses monocyte fat accumulation and restores insulin signalling, which correlates well with insulin sensitivity. moreover, circulating mmp levels significantly dropped after sg suggesting that the state of generalized inflammation characterizing obesity normalizes. her stomach stapled,a foreign tube like body was seen on cut surface of the stomach.the foreign body seen in dissected stomach wall is the tube is in placed a gastric banding insuflation tube.a laparatomy was made and the tube is extracted her stomach sutured primarily,nasogastric decompression,peritoneal drainage was made.her peritoneum was drained.she has a septic condition, leave in icu for a long period.her general status being well and discharged from hospital in days.we learn after the operation not before;she had a gastric adjustable banding and extraction the gastric band, but the tube of gastric band is not removed. alkhaffaf et al present a case of fistulation of the lagb tubing into the jejunum a review of the published data to identify the salient learning points with this and similar rare complications fistulation from lagb tubing is a rare complication that tends to follow removal of an infected port. the clinical presentation is nonspecific, rendering the preoperative diagnosis difficult. the tube and band can be removed laparoscopically, with closure of the small bowel fistula site. securing the tubing to the abdominal wall fascia after intentional detachment from the port might reduce the incidence of this complication.katherine j et al report a late and rare complication of a small bowel obstruction in a -year-old woman from an lagb placed for years. although not a common complication, one that could easily see the safety record of lagb patients tarnished if this small subgroup of patients is not acted upon promptly by emergency departments' unfamiliar lagb surgery. in our case we already made esophagogastroduodenoscopy before operation, ofcourse take past medical history from the patient.the patient hide past operation (gastric banding and removing band and port but leaving insuflation tube). ). there was no difference in the two groups regarding follow-up rate. basic demographics were the same, and other long-term results were similar between the groups. regression models for both post-op complications and failure as defined by baros score did not show that gender is a risk factor. discussion and conclusions: in our study, revisional sleeve surgery were similar. we did not see any significant difference in post-op complications, success of the operation as defined by baros, or subjective feeling of the patients. we do believe that gender-specific outcomes should be taken into consideration in optimizing patient selection and preoperative patient counseling, and that in the case of a sleeve post a band gender is not a risk factor for complication or failure of the procedure. objective: the internal hernia is a rare but a potentially fatal complication of laparoscopic roux-en-y gastric bypass (lrygb). the aims of this study are: ( ) to determine the impact of mesenteric defects closure on the incidence of internal hernia after lrygb; ( ) to determine the symptoms, characteristics and management of internal hernias after lrygb. the median interval between lrygb and reoperation was months in group a and months in group b. the median percentage of excess weight loss (%ewl) was % vs %, respectively (p = . ). the median percentage of total weight loss (%twl) was % vs %, respectively (p = ns). patients, % ( in group a), were admitted to the emergency room with acute abdomen pain. a ct scan was performed in patients, %, and showed signs of occlusion in all cases. the most common symptoms were abdominal pain and vomiting. the surgery was performed using laparoscopy in patients, %, and using laparotomy or conversion in patients, %. conclusions: the closure of mesenteric defects during lrygb is recommended because it is associated with a significant reduction in the incidence of internal hernia. our study intends to analyze the long term results of sleeve gastrectomies performed by d laparoscopic approach. materials and methods: a prospective cohort study was conducted to perform gastric sleeve for morbid abesity. all surgeries were performed by the same surgeon over a period of two years. the operating surgeon is a senior most laparoscopic surgeon with vast experience in laparoscopic surgery. during two years period, cases were operated using d laparoscopy system. scientific calculation was done using spss release . windows software. results: patients, female ( %) and male ( %), with median age of . ± . ( - ) the excess weight lost (ewl) was % in the first year, % in the second, % in the third, % in the fourth, % for the fith year, % for the sixth and % for the seventh. postoperative complications were stenosis of the sleeve always located in the incisura and treated with endoscopic dilatation except one that required conversion to oagb. three leakages, all of them reoperated with drainage and introducing prosthesis by endoscopy in the same act. we have never had a postoperative bleeding of the sleeve. conclusions: d gastric sleeve laparoscopy is a safe and feasible technique for morbid obesity and related pathologies. the ewl is correct in long time. complications are rare but is necessary to have a good level of suspicious in order to a rapid solution. the worst complication is the leak of the sleeve. the oversewn of the gastric section is a good technique to avoid this complication. surg endosc ( ) aims: leak is one of the common complications of laparoscopic sleeve gastrectomy that result prolongation of hospital stay, morbidity and even mortality. methods: i report new approach for the treatment of leaks presented to me post laparoscopic sleeve gastrectomy with laparoscopic roux en y bypass to the leak site at the level of gastroesophageal area. this new approach is possible and feasible, and avoids stenting due to high failure rate, prolonged hospitalization and saves life of patients. results: all leaks healed days from surgery due to well vascularized small intestinal patch, except for leaks that healed after weeks of conservative treatment. aims: analyse the effect of one anastomosis (mini) gastric bypass (mgb/oagb) in the treatment of gastro-esophageal reflux in patients previously submitted to laparoscopic sleeve gastrectomy (sg). methods: a retrospective analysis was performed on the data of patients who underwent mgb/ oagb after a previous sg at policlinico san marco, italy, from january to june . a total of patients, female and males ( % f/ % m) underwent mgb/oagb after sg, due to the development of significant gastro-esophageal reflux disease (gerd), refractory to proton pump inhibitors (ppi), detected with the gerd questionnaire (gerd-q) and esophagogastroduodenoscopy (egds). in three patients ( %) a weight regain was also observed (mean bmi . kg/m , range . kg/m - . kg/m ). mean patients age was . ( - years old). before sg none of the patients had declared symptoms of gerd or was subjected to a therapy with ppi, preoperative egds did not show signs of esophagitis. mean bmi of the patients who developed gerd without weight regain was . kg/m ( kg/m - . kg/m ) at the time of surgery, with a medium ewl% of % ( . - . %). patients were treated unsuccessfully with ppi for at least six months before programming revisional surgery. mean gerd-q score was . results: after mgb/oagb, with a mean follow up of months ( - months), mean bmi was . kg/m and gerd-q score was . however, five patients out of ( %) developed an anastomotic ulcer or a grade c esophagitis. we did not observe any post-operative immediate complication nor any death. conclusion: mgb/oagb is a simple, effective and safe surgical procedure for patients who underwent a previous sg and who developed gerd, with satisfactory results in the short and medium post-operative time, even if there is still concern regarding the complications linked to biliary reflux. v.s. kyosev aims: laparoscopic adjustable gastric band (lagb) was one of the common techniques in bariatric surgery worldwide. the advantages included the possibility of regulation, ease of placement, acceptable weight loss and low rate of perioperative complications. a late complication of lagb is penetration of the gatric band through the gastric wall and migration into the lumen of the stomach. hereby, we present three cases of gastric band migration following lagb. methods: from to we observed cases of gastric band migration in between and years after lagb placement. the patients were hospitalized in surgical department complaining of sudden sharp epigastric pain, nausea and vomiting, with symptoms onset in the last few days. all patients underwent abdominal ultrasound examination, x-ray investigation of the abdomen with oral contrast administration, fibrogastroscopy. in cases the imaging studies revealed gastric band migration into the stomach's lumen and in case-obstruction of the jejunum by the gastric band. all patients underwent laparoscopic surgery. results: two of the patients underwent gastrotomy, extraction of the gastric band and roux-and y-gatric bypass. the patient with jejunal obstruction underwent laparoscopic enterotomy, extraction of the gastric band and cholecystectomy due to concomitant cholecystitis. two of the patients had no additional perioperative complications and were discharged at the th postoperative day. one patient developed fever, left pleural effusion and partial insufficiency of the gastrointestinal anastomosis in the early postoperative period without the need of surgical treatment. the patient was discharged on th postoperative day. all patients were prescribed a diet and monthly blood test of ion balance. conclusions: lagb was one of the most common treatment methods due to the epidemic spread of morbid obesity in western countries. detailed knowledge on possible lagb complications is essential for the treatment of these patients. the diagnosis of lagb complications is often delayed due to its relative rarity and nonspecific clinical manifestations, but in most of the cases it requires emergency surgery for management of life-threatening conditions. results: there was conversion in patients (short mesentery of the small intestine). such postoperative complication like anastomotic leak in patient ( . %) and staple line bleeding in patient ( . %), which was managed laparoscopically. compensation for type diabetes was achieved in ( %) patients, improvement was recorded in ( . %), dyslipidemia in ( . %) and ( . %) patients, arterial hypertension in ( . %) and ( %) patients respectively, what led to metabolic syndrome resolution in ( %) patients. the liquid is allowed to take after day. average postoperative hospitalization- . ± . days. %ewl for months %. conclusions: laparoscopic mini gastric bypass is an effective method of surgical correction of body weight and metabolic disorders in patients with morbid obesity and allows to receive an adequate and stable correction of arterial hypertension, lipid and carbohydrate metabolism, which are components of a metabolic syndrome. introduction: over time laparoscopic sleeve gastrectomy lsg has become the most popular bariatric operation worldwide. a critical step during lsg is ensuring sleeve-size consistency. gastrisail device (gastric positioning system) is a three in one surgical device replacing the standard bougie used in lsg for the application of suction, decompression and to serve as a sizing guide for gastric sleeve creation. the aim of this study is to evaluate the possible merits of gastrisail device in lsg over the standard laparoscopic sleeve gastrectomy. methods: a prospective study of patients randomly divided into two groups: group a composed of twenty patients who undergo lsg with the use of gastrisail and group b composed of twenty patients who undergo lsg with the standard bougie without the use of gastrisail comparing both according to operative time, consistent sleeve formation, delineation and visualization, intraoperative and post-operative complication rates, the lenght of hospital stay,gastric pouch design and percentage of excess weight loss (%ewl). results: regarding intraoperative time, the mean time was . ± . and . ± . for group a and b respectively,while no patients in group b had consistent sleeve formation, patients ( %) had consistent sleeve formation. delineation and visualization were accomplished in % of group a patients, was not accomplished at all in group b patients. the alignment of the stomach was reached in patients in group a but no patients at all in group b, the mean of hospital stay was . ± . and . ± . for group a and b respectively, the smaller tube design illustrated by gastrograffin x-ray at rd post-operative day was accomplished in patients ( %) and patients ( %) in group a and b respectively. there was no significant difference in %ewl in both groups. conclusion: the use of gastrisail device is superior to the standard lsg in consistent sleeve formation, visualization, delineation and good alignment and accomplishment of a small tube design while no significant difference in %ewl. bariatric surgery has spread all over the world. since japan has few patients with morbid obesity compared with western countries, it has been implemented only in limited facilities. however, bariatric surgery in japan is rapidly spreading recently, and many facilities are about to install bariatric surgery. effects of bariatric surgery are known to last for a long time, but some cases require reoperation which is called revision surgery due to late complications or rebound. because of thick subcutaneous and visceral fat, open surgeries are not even always a good solution to make surgery easier in morbid obese patients and all procedures must be completed laparoscopically. therefore, especially in revision surgery, the incidence of complications tends to be increased. as the number of bariatric cases to be increased in japan, cases requiring revision surgery is likely to increase. in revision surgery, it is necessary to select the procedure according to patient condition, and it is necessary to familiar well with those procedures. we will present cases that underwent revision surgery in our department and show the clinical outcome. we have done four revision surgeries after sleeve gastrectomy so far. operative indications are mid-gastric stenosis and rebounding disease. for stenosis cases, we performed roux-en y gastric bypass with distal stomach resection, and for rebounding cases, we performed re-sleeve gastrectomy with duodenal-jejunal bypass. average interval from initial operation to revision surgery is months in rebounding cases, and months in stenosis cases. duration of operation was min in average, and mean estimated blood loss was ml. no postoperative mortality was observed. in rebounding cases, excess bmi loss at year after surgery was . % in average, and both cases achieve diabetes remission at year. one cases of mid-gastric stenosis required a nutritional support with formula diet temporally. in particular after sleeve gastrectomy, revising to roux-en y gastric bypass, re-sleeve gastrectomy, and adding the duodenal-jejunal bypass will be the main techniques. along with an increase of bariatric surgery in japan, it is necessary to acquire sufficient knowledge and skills to carry out revision surgery. methods: we present the case of a year old woman who underwent lsg after lagb removal and lgcp. the patient underwent preoperative endoscopy and barium swallow, with no sign of stomach perforation or erosion. we emphasize that the patient, had undergone three operations of gastric band placement, gastric band removal and gastric plication before sleeve gastrectomy. however, a successful lsg was achieved. results: no severe postoperative complications were mentioned. conclusion: weight loss in the first year was % of the excess weight.sleeve gastrectomy after gastric band removal and gastric plication, for morbid obesity seems to be safe and efficient, especially in casesof absence of gastric erosion. surg endosc ( ) department of surgery, patients were observed with serious septic complications many years after gastric banding operation. we detected a female dominance ( female, male) in patients with a mean age of . years. the leading symptoms were: dysphagia, upper abdominal tenderness and pain, spontaneous fistula formation, fever, masked septic signs, bowel and urinary obstruction. patients underwent video-endoscopy, chest and abdominal ct (computed tomography), fistulography and cystoscopy. results: in still morbid obese patients, laparoscopic procedures were performed with a conversion rate of %: atypic gastric and cardia resection in cases, gastric suture in cases, small bowel resection and suture in - cases. in one case, fistulectomy, abscess evacuation and combined urinary bladder suture and drainage were carried out. the duration of the surgeries were over h with minimal blood loss (\ ml). the foreign bodies were completely removed in every case. intraoperative complication was not occurred. early physiotherapy were promoted, oral feeding were gradually built up from the th postoperativ day depending on the type of the operation. early postoperative complications included recurrent fistula formation (n = ) and wound infection (n = ). all the fistulas were closed after conservative treatment. average hospital stay was days, regular check-ups were held on the rd, th and th months of follow up. conclusion: gastric banding is the most common, routine and safe technique for the treatment of morbid obesity. the development of late, severe septic complications draws attention to the crucial importance of follow up. the surgical management of these patients is recommended in specialized centers in regard to difficult operative conditions and atypic treatment options. aims: single anastomosis duodeno-ileal bypass with sleeve gastrectomy (sadi-s) has been proposed as an alternative to biliopancreatic diversion with duodenal switch (bpd-ds) in order to maintain the outcome of the original procedure simplifying the technical complexity and to avoid potential complications. moreover, it potentially represents the more natural second step bariatric procedure after sleeve gastrectomy (sg). we aimed to report the initial experience with sadi-s of our high volume bariatric center. methods: retrospective analysis of patients who underwent bariatric procedure between july and november was conducted. the primary aim was the evaluation of the safety of sadi-s, defined as the rate of postoperative complications. the secondary endpoint was the bariatric efficacy of the procedure, defined as percentage excess weight loss (%ewl). results: among patients who underwent bariatric procedures at our institution ( . %) patients were scheduled for sadi-s. all patients had multiple comorbidities. initial indication for sadi-s was failed sg in patients (median pre-sg bmi . kg/m \ sup [ \/sup [ ; median months after initial operation respectively) and primary procedure in patients (median pre-operative bmi . kg/m ). the surgical procedure was accomplished with robotic-assisted approach in cases (median operative time min) and with laparoscopic trocars standard approach in the remaining cases (median operative time min). the duodeno-ileal anastomosis was fashioned using a double layer hand-sewn running sutures. no patients showed early post-operative complications, the median postoperative stay was days. at a mean follow up of months the median %ewl was . . to date no patients experienced surgical. one patient develop wernicke encephalopathy months after surgery, but he was non-compliant to multivitamin supplementation. conclusions: at least in a high volume bariatric center sadi-s, both as second step after sg and as primary surgical option, seems to be a safe and effective bariatric metabolic procedure based on solid physiopathologic principles. on the other hand, longer follow-up is necessary to support the use of this procedure as a better alternative to bpd-ds. m.r. elkeleny , a. abo khozima git and bariatric surgery, faculty of medicine, alexandria university, alexandria, egypt; git surgery department, faculty of medicine,alexandria university, alexandria, egypt four bariatric cases . female patient with intragastric balloon, minor leak from the balloon leading to ballon migration to the jejunum;hance, small bowel obstruction occured. emergency diagnostic laparoscopy was done, enterotomy and extraction of the balloon, direct repair of enterotomy and balloon extraction through mm port site. . male patient presented after days of lsg with small bowel obstruction due to entrapment of small bowel loop through one of the port sites;therefor, emergency laparoscopy was done with reduction of the herniated segment and closure of the port site. . female patient presented with stricture of the ogj after re-sleeve gastrectomy managed by balloon dilatation which recur after weeks .she was managed by expandable metallic stent for weeks with good response and the stent was removed. . -year-old male patient presented with sever peripheral neuropathy following months after sleeve gastrectomy, and the patient was getting worse; thus, he used wheel chair. he has been making good progress on vitamin b complex injections. the aim of our study was to compare histopathological findings of gastric specimens to preoperative clinical symptoms and to conclude about the need for ugi endoscopy as a routine prior to surgery. methods: the last two years, morbid obese patients were selected to undergo laparoscopic sleeve gastrectomy (lsg) in our institution. for the needs of our study, all of them had ugi endoscopy and were reviewed for upper gi symptoms. histopathological reports obtained according to our protocol, after surgery. results: gastric histology from specimens revealed: no findings in / patients ( . %), gastritis in / patients ( . %) and focuses of incomplete intestinal metaplasia without dysplasia in / patients( . %). finally, two minor leiomyomas with low cellular proliferation rate were fully excised in a patient's specimen. there was no inconsistency between preoperative symptoms and gastric histology, while leiomyomas found were no reported to ugi endoscopy due to size. conclusions: some of the patients with clinical features of food intolerance, gastroesophageal reflux disease, and peptic ulcer disease had finally findings in histopathology of their stomachs. history of helicobacter pylori infection implements a raised incidence of mucosa pathology as well. because only one case revealed carrying significant pathology (leiomyomas), we consider that is safe to proceed with surgery in an otherwise asymptomatic patient based on his previous medical records and blood tests. aims: splenic abscess following laparoscopic sleeve gastrectomy (lsg) is a rarely seen complication. the aim of our study was to present a case of splenic abscess in a morbid obese patient who underwent lsg. as the main concern in these cases is leakage from the staple line, we present our diagnostic and treatment approach. methods: a -year-old, female morbid obese patient (bmi . kg/m ), without any predisposing risk factors, underwent elective lsg in our department. following an uneventful course, she was discharged at the nd postoperative day. however, at the th postoperative day, she readmitted to our unit with high temperature of . o c, left upper quadrant tenderness and leukocytosis. contrast computed tomography (ct) revealed an abscess at the upper pole of the spleen , cm in maximum diameter, without leakage from the staple line. results: the patient was treated with broad-spectrum antibiotics and radiological percutaneous drainage of the abscess. although there was a partial clinical improvement, a week later, a new ct scan revealed the continuous presence of the abscess. despite the stable general condition of the patient a laparoscopic splenectomy was performed and a gradual recovery was followed. the presence of splenic abscess without splenic trauma or leakage from the gastric staple line, is an extremely rare complication and only a few cases have been previously reported. the cause has not yet clarified, but the proposed mechanism involves infarction of the spleen, due to vascular compromise and subsequent infection. most of the reported splenic abscesses were diagnosed during the late postoperative period. in our report we present a case of early onset, hence highlighting the need of clinical awareness for early diagnosis and treatment. introduction: obese surgical patients with obstructive sleep apnea (osa) have a higher risk of peri-and postoperative desaturations and subsequent morbidity and mortality. currently, the best perioperative management of patients without known osa remains unclear. although routine osa screening has been advocated, sleep studies are costly and time consuming. we hypothesized that bariatric patients can be safely monitored on a surgical ward by continuous postoperative pulse oximetry without preoperative screening for osa. objectives: to evaluate outcomes of continuous postoperative pulse oximetry without preoperative osa-screening, and to compare the results to outcomes of patients with osa and continuous positive airway pressure (cpap) treatment. methods: all patients who underwent bariatric surgery between and were included in this single-center retrospective cohort study. all patients were postoperatively monitored with continuous pulse oximetry on the surgical ward. patients with less than two documented saturation measurements were excluded. patient files were reviewed for osa diagnosis, cpap usage and perioperative details. primary outcomes were -day complication rates, intensive care unit admissions due to cardiopulmonary causes and postoperative desaturations of spo \ %. secondary outcomes were icu admissions following all causes, length of stay and rates of reoperation and readmission. results: in total, patients were included. patients ( %) were preoperatively diagnosed with osa, ( . %) were cpap users. complications occurred in . % of patients without osa and in . % with osa(p = . ). desaturations were documented in . % and % (p \ . ), respectively. in both groups, patient was admitted postoperatively to the icu for cardiopulmonary causes that could be related to osa (p = . ). both recovered without further complications. icu admissions, regardless of cause, occurred in . % of patients without osa and in . % with osa(p \ . ). no significant difference between groups was observed in complications based on clavien dindo classification, length of stay, reoperation-and readmissions-rates. conclusions: these findings suggest that continuous postoperative pulse oximetry without preoperative osa-screening is a safe perioperative management strategy for bariatric surgical patients. future studies are needed to assess cost-effectiveness of pulse oximetry vs. routine preoperative osa-screening in a prospective clinical setting. background: the pathology of colon is one of the most pressing and socially significant problems of modern health care, because it leads to reduction of the working population employed in manufacturing, in some cases to disability and reduced quality of life. mini invasive surgery of the colon has a great advantage: speed recovery, shorter hospital stay and better cosmetic results, the quickest return of patients to work. as a result, mini invasive endovideosurgery is firmly established in clinical practice of coloproctology. objective: the choice of optimal surgical method for treatment of colostasis, achievement of favorable outcomes of treatment. introduction: laparoscopic roux-en-y gastric bypass (rygb) is one of the most important bariatric surgical procedures performed worldwide and it can produce an important loss of weight with reversal of metabolic disorders like diabetes and dyslipidemia. even though it has good results, some complications occur after gastric bypass. a rare but serious complication of rygb is the so-called postprandial hyperinsulinemic hypoglycemia. its prevalence has been estimated less than % of cases and its pathophysiology remains unclear. methods: the aim is to present a case series of reversal surgery in patients with severe hiperinsulinemic hypoglycemia after rygbp in the hospital general universitari de la vall d'hebron. unit of endocrine-metabolic and bariatric surgery (eac-bs center of excellence for bariatric and metabolic surgery by ifso). it is a retrospective analysis of a prospective database same surgical team. we present in this study, the main features of those patients. results: between and , patients underwent a laparoscopic reversal procedure to normal anatomy and age mean was year ( years to years). mean preoperative body mass index (bmi) was . kg/m (range - . kg/m ) and were women. all patients presented hypoglycemia symptoms years after and the longest was years after the procedure. the first step of the standard approach was a laparoscopic reversal to normal anatomy with resection of the alimentary rygb limb in cases. a concomitant sleeve-like gastrectomy (sg) was added. four patients presented postoperative complications: gastrogastric anastomosis leak ( ) introduction: laparoscopic sleeve gastrectomy is the most performed bariatric procedure, but complications might interfere with patient's long-term evolution based on its compliance and tolerance, surgical attitude and unpredictable evolution. materials: we present the case of a female obese patient, with type ii diabetes mellitus and blood hypertension, with multiple, sequential bariatric minimally-invasive interventions: sleeve gastrectomy in complicated by postoperative acute gastric dilation and mediogastric stenosis, reoperated for viscerolysis and cholecystectomy, with endoscopic gastric dilations, initially converted to functional one anastomosis gastric bypass ( cm limb), with a non-adjustable gastric ring positioned instead of stapled division. the last operation was complicated months after by persistent biliary gastro-esophageal reflux, chronic abdominal pain, and gas bloat syndrome. in the patient underwent conversion to laparoscopic r-en-y gastric bypass, with gastro-enteral anastomosis resection, band removal and viscerolysis. results: conversion to r-en-y was complicated by biliary leakage post-viscerolysis, treated with laparoscopic approach in the \ sup [ th \/sup [ po day. after multiple surgical and endoscopic interventions, the patient presents short-term favorable outcomes, with no reflux or abdominal pain, with further weight loss and diabetes improvement. conclusion: bariatric surgery has unpredictable evolution in same cases, and conversion to r-en-y seems to be the best solution. lgcp is widely used in developing countries due to its lower cost and good results. material and methods: we performed in our department lgcp for morbid obesity. excess weight loss (%ewl) was % at month after surgery and % at one year. in cases revision surgery was needed for different complications and in cases for inadequate weight loss or weight regain after month follow up. in cases we performed sleeve gastrectomy (in cases after taking down the plication) and in cases we performed a re-plication in one row. results: the rate of revision surgery was % overall and % for inadequate weight loss (excess weight loss \ %) or weight regain. major complications occurred only in one patient (leak with abscess) but it was solved by laparoscopy. minor complications as vomiting and nausea appeared in patients ( %) and were solved with medication. after one year follow up %ewl in these cases was %. conclusions: revision surgery after lgcp is possible. a new plication or sg was the option in our series with good results. further studies are needed to evaluate the use of lgcp in the armamentarium of bariatric surgery. background: roux-en-y gastric bypass (rygb) is one of the most commonly performed bariatric procedures around the world.however, rygb it sometimes carries the risk of rarebut serious long-term complications such as malnutrition and liver failure. we report a case of laparoscopic reversal of rygb. methods: in march , a laparoscopic rygb was performed for a -year-old female without comorbidities and with a bmi of kg/m . all laboratory test results at the preoperative evaluation were within the normal range. abdominal ultrasound revealed moderate hepatic steatosis and oral endoscopy a hiatal hernia with grade b esophagitis. one year later, patient experienced an important weight loss of kg (from to kg) with a bmi of kg/m . however, patient presented general weakness, abdominal pain, ascitis lower extremitiy edema, anemia, progressive caloric and protein malnutrition, vitamin (a, d), mineral (copper) and folic acid deficiencies, nonalcoholic steatohepatitis (nash) and liver function was progressive worsening. results: a laparoscopic reversal of gastric bypass was performed. the operation was successfully performed via laparoscopy. operating time was min. postoperative was uneventful and patient discharge home at day . hepatic biopsy revealed nash with steatohepatitis of % (fibrosis f - / ). eight months after reversal of gastric bypass, patient has improved her clinical situation (no asthenia), maintains of weight ( kg) and has improved her nutritional status and liver function parameters. conclusion: laparoscopic reversal of rygb is technically feasible and might be performed safely after thorough preoperative evaluation in carefully selected patients with malnutrition and liver failure. conclusion: laparoscopic sleeve gastrectomy it's a safety obesity procedure before major abdominal hernia repair. it's a minimally invasively technique with an absence of anastomoses. these factors prevent fewer complications, without using the small bowel, and skin problems and allow resolution of obesity-associated co-morbidities. body weight loss after surgery may be an opportunity to repair the severe loss of domain incisional hernia. bibliography borbély, y., zerkowski, j., altmeier, j., eschenburg, a., kröll, d. and nett, p. general surgery, benhazi medical center, benghazi, libia, general surgery, royal bahrain hospital, manama, bahrain obesity is a worldwide epidemic with an increasing incidence trends and as a consequence obesity related health problems become priority to healthcare authorities in all the countries. laparoscopic gastric plication is an emergent restrictive procedure which claimed to be low cost because they do not need staplers and carries less complications as compared to laparoscopic sleeve gastrectomy. we present here a years female who was operated for morbid obesity four months back where she underwent laparoscopic gastric plication with no immediate post operative complication and her wight loss was adequate. two days before presentation to our emergency department she started to complains of sever attacks or upper abdominal pain and vomiting.clinical examination was unremarkable apart of abdominal tenderness in left upper abdomen. all blood routine were normal and all inflammatory markers were within normal range.ct abdomen showed large cystic lesion around the greater gastric curvature containing fluid and raised possibility of collection. patient was admitted to hospital, in despite of medical treatment her pain persists and necessitate immediate laparoscopic exploration. gastro-gastric hernia at the greater curvature through loosen ethibond suture that was used to plicate the stomach in the previous surgery. we released the suture to liberate the strangulated stomach which is not gangrenous. re-plication was not possible because of the extensive gastric wall edema and as preoperative discussion with the patient she refused conversion to sleeve gastrectomy no intervention was done. post surgery patient was free of symptoms and tolerating oral diet and discharged home on third post operative day with no complications. gastro-gastric herniation could progress to gastric wall gangrene which will result in high morbidity and even mortality. high index of suspicion is required to diagnose the condition . preoperative patient counseling is important to explore the surgical options if deemed necessary to convert to another bariatric procedure. k. chouillard, a. d'alessandro, l. chahine background: bariatric surgery is the best available, long-term treatment for morbid obesity. currently, laparoscopic sleeve gastrectomy (sg) is the most commonly performed bariatric procedure in france. despite its safety and efficacy, long-term complications of sg are not rare including gastro-esophageal reflux disease (gerfd), twisting, stenosis, insufficient weight loss, and weight regain. the goal of this study was to analyze the pattern and short-term results of surgical revision in patients with sg. methods: revisional bariatric surgery, regardless of its motivation, was always a multidisciplinary decision after clinical, biological, endoscopic, and radiological assessment. patients who had revisional surgery after sg were retrospectively identified and subsequently divided in subgroups according to preoperative body mass index ( we aim to present the management and the particular aspects of the surgical technique in a gastrobronchial fistula after gastric sleeve . the mean time between intervention and diagnosis is . - . months. methods: between and , laparoscopic gastric sleeve resections were performed in our bariatric center. we had one case of gastrobronchial fistula associated with an inferior lobe abscess of the left lung, diagnosed months after the gastric sleeve. the patient was subject for medical treatment for h, than a laparoscopic intervention was performed in order to drain the lung abscess and the gastric fistula and to place a feeding jejunostomy. . months after this intervention ( . months after gastric sleeve) a laparoscopic roux-en-y fistulojejunostomy was performed. the evolution was monitorized with blood tests, upper gi contrast series and ct scans. results: the surgical drainage of the lung abscess, along with the antibiotherapy, controlled the infection and allowed the lung cavity to reduce in size, and thus the drainage tubes introduced in the thorax through the diaphragmatic orifice were retracted progressively. also, the feeding jejunostomy allowed a proper nutrition for the patient with a good recovery. however, . months after the drainage intervention, the gastric fistula was not healed, and a decision to interrupt the communication with the lung cavity was made, by creating a laparoscopic fistulojejunostomy. after this, the evolution was favorable, with the healing of the lung cavity, oral feeding was permitted and the jejunostomy was suppressed. conclusions: the treatment of the gastrobronchial fistula is complex (medical, endoscopic or surgical), phased and long lasting until healing. surgery was our initial choice for treatment due to the existence of the lung abscess, which needed to be drained. key words: gastrobronchial fistula, lung abscess, laparoscopy, fistulojejunostomy s.i. filip, i. hutopila, c. copaescu introduction: leakage remains one of the most dreadful complications in metabolic surgery. the main cause of leakage is poor tissue oxygenation due to inadequate vascular perfusion. the study of intraoperative tissue perfusion in real time due to icg enhanced fluorescence could provide valuable information for the surgeon in order to prevent postoperative fistula. aim: to present our experience in using icg enhanced fluorescence in laparoscopic bariatric surgery material and method: in cases of gastric sleeve, cases of gastric bypass and in cases of revisional surgery or redo cases we used intraoperative icg mediated fluorescence to assure the optimal vascularization of the involved tissues. in our video we present intraoperative aspects before and after using icg in different cases. results: in all cases of primary gastric sleeve and gastric bypass with intraoperative use of icg we did not encounter inadequate perfusion. in one case of redo gastric bypass after failed vertical banded gastroplasty for morbid obesity despite intraoperative laparoscopic normal aspect of the gastro-jejunal anastomosis, icg mediated fluorescence allowed to identify an unexpected ischemic anastomosis and we could prevent consecutive postoperative leakage. discussion: presented cases are discussed and result with referral to literature is made. conclusion: intraoperative use of icg is a valuable tool in assessing the perfusion of the tissues and provide essential information for the surgeon in order to avoid postoperative leakage. , including patients, hemostasis with clips has been performed in all cases. however, among these cases nine patients required reoperation for early postoperative bleeding. in five cases a bleeding source from the stapled line was identified while in cases no identifiable source was found. during the second period ( to present) patients were submitted to bariatric surgery and hemostasis was performed by over sewing with a running suture. among these cases reoperation for postoperative bleeding was needed in cases ( . %), but no bleeding from the staple line being encountered ( %). the difference has statistical significance. no significant complications related to the use of this type of reinforcement were encountered. conclusions: over sewing the gastric stapled line in bariatric surgery is superior to hemostatic clip application in preventing the postoperative bleeding from the stapled line postoperative bleeding. a protocol of active search of the bleeders during the bariatric procedure should be implemented and respected in all the cases. gastroenterological surgery, saitama medical university international medical center, hidaka-shi, saitama, japan intestinal endometriosis is a rare disease which is associated with about to % of patients with endometriosis, and it is favorable to the rectum and sigmoid colon. here we report cases (shown in the table) underwent laparoscopic resection for intestinal endometriosis. there were no postoperative complications in all cases, and all patient was discharged on - \ sup [ th \/sup [ postoperative day. before the operation, of patients were diagnosing intestinal endometriosis, and it was difficult to preoperatively diagnose. among them, the symptoms at the time of menstruation were clear was one case. in case of submucosal tumor, preoperative diagnosis seems difficult. additional image examination at menstruation may be useful for diagnosis. d dissection was performed for case , , because malignant disease could not be denied as a preoperative diagnosis. of them were strongly doubted endometriosis in surgical findings. in intestinal endometriosis surgery, pelvic adhesions and fibrosis are often advanced. in the sigmoidectomy, the average operation time was min and the blood loss was ml. in the rectal resection, the average operation time was min and the blood loss was ml. in case and , pelvic adhesion was severe, residual rectum could not be straightened, and side to side anastomosis was performed. in intestinal endometriosis surgery, intestinal anastomosis method should be considered flexibly. conclusion: laparoscopic surgery for intestinal endometriosis was safe, but technically difficult because of fibrosis and adhesion. it is important to accurately diagnose from clinical symptoms and image also intraoperative findings. anastomotic method should be decided according to the case. aim: the aim of the study was to identify and highlight some of the complications one can encounter in bariatric surgery-specific-sleeve gastrectomy and discuss the therapeutic options one has at his disposal. methods: the study was retrospective. we identified a number of patients which had a sleeve gastrectomy done in our clinic for a year period. of these had important surgical complications encountered during the surgery or in postoperative care. results: the group included patients, with an average bmi of [ kg / m . average hospital stay was days, with an average of . days which increased to days when fistulas were encountered. the most frequent surgical complications were bleeding from the gastric suture ( ) and gastric fistula ( cases). other complications encountered were wound hematoma. surgery was required in of the cases of bleeding and of the fistula cases required reintervention. one case was resolved with endoscopic stenting. conclusions: laparoscopic gastrectomy is considered a safe procedure with good results for the patient. although complications are rare they pose a series of technical difficulties for the surgeon due to the weight of the patient and frequent comorbidities which come with obesity. a thorough understanding of the symptoms and good follow-up ensures the best results. aims: to achieve additional weight loss or to resolve band-related problems, a laparoscopic adjustable gastric banding (lagb) can be converted to a laparoscopic roux-en-y gastric bypass (rygb). there is limited data on the feasibility and safety of routinely performing a single-step conversion. we assessed the efficacy of this revisional approach in a large cohort of patients operated in a high-volume bariatric institution. to the best of our knowledge this series represents the largest single-center study on conversion from lagb to rygb methods: between october and december , a total of patients who underwent lagb removal with rygb were identified from a prospectively collected database. in all cases, a single-stage conversion procedure was planned. the feasibility of this approach and peri-operative outcomes of these patients were evaluated and analyzed. results: a single-step approach was successfully achieved in ( . %) of the patients. during the study period, there was a significant increase in performing the conversion from lagb to rygb single-staged. no mortality or anastomotic leakage was observed in both groups. only patients ( . %) had a -d complication: most commonly hemorrhage (n? = ? / ), with no significant difference between the groups. conclusion: converting a lagb to rygb can be performed with a very low morbidity and zero-mortality in a high-volume revisional bariatric center. with increasing experience and full standardization of the conversion, the vast majority of operations can be performed as a single-stage procedure. only a migrated band remains a formal contraindication for a one-step approach. surg endosc ( ) . six months after surgery the mean hrql score, was ( - ) in patients underwent to lsg and . ( - ) in patients underwent lgb. twelve months after surgery the mean postoperative questionnaire score was ( - ) in patients who underwent lsg. at ph-manometry the mean percentage time of acid reflux in orthostatism was . (range - . ) and in clinostatism . (range . - . ). the mean demeester score at the distal electrode was . ( . - . ). conclusions: in asymptomatic patients, complete gerd evaluation before bariatric surgery allows better selection of surgical procedure, to reduce the postoperative occurrence of severe or de novo gerd. postoperative gerd evaluation provides useful data regarding the impact of lsg on gastroesophageal reflux. a larger patient sample size is required. aims: vertical calibrated gastrectomy (usually know as gastric sleeve) as unique technique gives better results than the roux y bypass in terms of improvement of anthropometric measures, reduces comorbidities and has a lower rate of postsurgical complications, with an improvement of quality of life. material and methods: an observational, longitudinal, retrospective and comparative study with patients, aged - years,during a period of years. everyone must comply with the protocol of the unit. demographics of the population and the anthropometric data will be measured in the presurgical consultation, the month and the year after the surgery: weight, height, bmi, weight loss percentage,bmi percentage and percentage of excess weight lost. we took data on the cardiovascular risk by the framingham score. the quality of life is measured by baros scale. mayor comorbidities are hypertension, diabetes, dyslipidemia. complications will be measured in absolute frequencies. for de statistical study, we apply type t student or chi square being statistically significant p equal to or less than . . results: there was not statistically significant difference between the techniques of surgery month (p = , ), but they were evident to the year of the same (p . ). not gender or age differences were apparent. mayor complications did not appear in gastrectomy (no leaks), highlighting the number of bleeds with this surgical technique. the bypass there were two leaks. there was no statistically significant difference in cardiovascular risk (p = , ) between the two techniques. there was a more significant decrease in number of comorbidities in gastrectomy against the bypass, with a total disappearance of patients with dyslipidemia. there were no statistically significant differences in baros score, although it was higher in gastrectomy. conclusions:-the vertical gastrectomy as unique technique can be considered superior in the short term, as well as safe, according to the aec quality parameter. we think it will be necessary to continue their studies into the medium-long term. aims: analyze the impact of different bariatric surgeries technics in carbohydrate metabolism and pancreatic beta cell population of none obese adult wistar rats. methods: we used twenty healthy not obese adult wistar rats divided in five groups randomly assigned. each with n = . the control groups were divided into fasting control (f) and sham (surgical control). the surgical groups were separated into vertical gastrectomy (gs), % resection of the middle small bowel (ri ) and gastric bypass (gb). in each group was assessment: beta cell mass modifications, pancreatic islets histomorphometry, proliferation, apoptosis and neogenesis in beta-cell pancreatic population; intraperitoneal glucose test tolerance, body weight and food intake. statistical analysis as evaluated using mann whitney test. results: the malabsorptive and restrictive group have a significantly smaller increase weight than the control groups. the intraperitoneal tolerance glucose test reports incremental glucose area under curve (auc) was significantly higher in the malabsorptive group and lower in the restrictive group compare to the control groups during the second (p \ . ) and third (p \ . ) month of the study. the beta-cell mass was significantly higher in the ri group compared with control groups respectively. there was a significantly increased number of beta-cell per pancreatic insulin positive area in gs and gb. proliferation was significantly increased in ri and gb group, and significantly decreased in sg compared. there was no significantly difference during apoptosis assessment among surgical and control groups. in neogenesis differences between groups were assessed qualitatively by the presence pdx - expression, being higher in rygb. the endocrine pancreas in our model is altered by the anatomical and functional conditions arising from surgical techniques. carbohydrate metabolism conditions are affected by temporary adaptive processes due to surgical alternatives. there is a hyperplasia and hypertrophy of the beta cells in surgeries with a malabsorptive component, as well as greater neogenesis. these results could explain part of the existing relationship between the enteropancreatic axis and the existing incretins. m. buza, c. copaescu introduction: nowadays, we have high volumes of obese patients for whom surgery is the answer, but unfortunately the psychological evaluation has no standard recomandation in preoperative evaluation of bariatric patients. it is argued that surgery success, in addition to the operation itself, relies on behavioral changes and that one of the goals of the preoperative assessment is to prepare the patient for the postoperative period, aiming to optimize surgical results. aim: although no formal standard exists in the literature, there is growing recognition of the important elements to be addressed and the appropriate means for collecting the necessary data to determine psychological readiness for these procedures. methods: information regarding the components of the clinical interview and the specific measures used for psychological testing are discussed. given the limited data on predicting success after surgery, determining psychological contraindications for surgery is addressed. additionally, the multiple functions served by the psychologist during this assessment procedure are highlighted along with the value of this procedure in the patients' preparation for surgery as well as the postoperative follow-up. in our center of excelence for bariatric and metabolic surgery (coe) we introduced since a mandatory pre-and postoperative psychological evaluation for all patients addressing the metabolic program. results: psychological evaluation of patients before bariatric surgery is a critical step, not only to identify contraindications for surgery, but also-and more so-to better understand their motivation, readiness, behavioral challenges, and emotional factors that may impact their coping and adjustment through surgery and the associated lifestyle changes. postoperative follow-up is necessary. the psychological evaluation of the patient undergoing bariatric surgery is an invaluable piece of the larger pre-and post-surgical assessment, aiming better results in the short and long term after bariatric surgery. introduction: a mesenteric cyst is defined as a benign abdominal tumors that is located in the mesentery of the gastrointestinal tract, identified in * of , hospital admissions. mesenteric chylous cysts are rare pathologic entities that often present with unspecific symptoms. the preoperative diagnosis requires all the common abdominal imaging techniques. usually the correct diagnosis may be made only at the operation stage or during the histological examination. all mesenteric cyst should be resected in order to avoid their complications, complete surgical resection is recommended and curative in the majority of cases with a low risk of local recurrence. the laparoscopic approach is the gold standard in the treatment of intraabdominal mesenteric chylous cyst. laparoscopic resection provides less pain, shorter hospital stay, and early recovery for the patient. case report: we report a case of -year-old saudi woman who presented to our clinic complaining of upper abdominal pain and mass in the epigastrium for one week, no history of nausea, vomiting, or recent changes in bowel habits. her medical and family histories were clear and she had never had any abdominal interventions. abdominal palpation revealed a smooth-surfaced mass palpable in the left upper quadrant, ultrasonography and with computed tomography of the abdomen revealed an approximately mm unilocular cyst closely related to the mesentery in the left side of upper abdomen not related to the pancreas .the cyst was excised by laparoscopy complete surgical excision to avoid recurrence within healthy borders, it is contained milky white fluid. the histopathological findings were chronic inflamed mesenteric cyst. a review of the literature considering this rare entity was also performed to evaluate our treatment strategy. conclusion: mesenteric chylous cysts represent a diagnostic challenge and they should be considered when a physician encounters an intraabdominal mass. usually the correct diagnosis may be made only at the operation stage or during the histological examination. the treatment of choice is the complete surgical excision that can be safely performed by laparoscopy. surg endosc ( ) background: diverticulum of appendix is relatively rare, and appendiceal diverticulitis was reported to have a higher risk of perforation than appendicitis. in the us and europe, because of the high risk of perforation, preventive appendectomy is recommended to appendiceal diverticulosis, even if the patient has no abdominal pain. methods: we retrospectively reviewed the records of post-operative patients, who were diagnosed appendicitis or appendiceal diverticulitis on the pathological findings in our institution from january to october . all patients were performed computed tomography (ct) before operation. patients underwent laparoscopic surgery, including appendectomy, cecal resection, ileocecal resection and right hemicolectomy, while patients underwent open surgery. total of cases of appendiceal diverticulitis were analyzed in our study. result: patients had abdominal pain before surgery. patients were diagnosed appendiceal diverticulitis by preoperative ct. all patients underwent laparoscopic surgery ( appendectomy, cecal resection, and ileocecal resection). on the pathological findings, perforation of appendix was found in patients and the pseudo type of diverticula with no muscle layer was found in all patients. patients with appendicitis were treated surgically during the same period. among them, a perforation of appendix was found in cases. the perforation rate was . %. on the other hand, the perforation rate of appendiceal diverticulitis was . % in our study. conclusion: the perforation rate of appendiceal diverticulitis was higher than of appendicitis in our study. for the examination of the treatment strategy, including preventive appendectomy, the accumulation of more cases will be expected. case presentation: a -year-old man was referred to our hospital with right lower quadrant abdominal pain for days. his fever was . °c. his white blood cell count was , / ll, and c-reactive protein level was . mg/dl. ct revealed multiple diverticula of cecum and appendix. micro-abscess and free air were found around appendix. we diagnosed this case as appendiceal diverticulitis and laparoscopic appendectomy was performed. a perforation was found in resected appendix. microscopic study revealed a pseudo-diverticulum. the inflammation of appendix was stronger in serous membrane side than in mucosa side. this finding accorded with appendiceal diverticulitis. introduction: in order to reduce the abdominal trauma and the length of scar incisions (also during laparoscopic surgery) many approaches during the last decade has been proposed, such as single access laparoscopic surgery (sals). the aim of our paper was to update the data of our previous paper with a greater cohort of patients and a longer follow-up, also showing the single access laparoscopic left colectomy (salc) technique in particular with inferior mesenteric artery preservation imap (valdoni's technique). materials and methods: we made a retrospective analysis from october and october of all patients who underwent a sals approach for colorectal disease in the department of general and mininvasive surgery of san camillo hospital of trento. statistical analysis was performed using ibm spss statistics . continuous data were expressed as mean ± standard deviation (sd). categorical data were expressed as absolute number and percentage. the results are presented as -tailed values with statistical significance if p values \ . results: from october until october , salc for colorectal surgery were performed in our unit. of this , were for left colectomy. in cases we performed an imap. the salc with imap were performed only in case of benign disease. the mean operative time was . ± . . only one intraoperative complication were recorded, that was a splenic capsule tear, resolved with apposition of fibrillar haemostats. according to clavien dindo classification there were in particular grade ii complications, a bleeding solved with blood transfusion and one pancreatitis solved with medical therapy; grade iiia complications that was anastomotic bleeding solved endoscopically (the two complications raised in patients with imap) and iiib complications due to anastomotic leakage which needed reoperation. the mean length of incision was . ± . cm. logistic regression did not show any correlation between imap and any complications. conclusion: in conclusion, salc is a safe but very challenging technique which need a longer learning curve than the conventional laparoscopic one. in laparoscopic colectomy, also, imap seems to be safe and effective without correlation with post-operative complications also if performed in single access laparoscopic approach. aims: to describe an infrequent anatomical variation that can give rise to diagnostic and therapeutic difficulties. methods: patient with ivermark syndrome (situs ambiguus and polysplenia) with acute appendicitis and bibliographic review results: a -year-old male who consulted for flank and right hypochondrium pain of h of evolution, associated with nausea without vomiting, no fever noir other symptoms. to the physical examination good general condition. painful to palpation selectively on the flank and right hypochondrium, with involuntary defense and positive decompression at this level. the signs of rovsing and psoas were negatives. in the analytical performed leukocytes of , with neutrophils in % and rpc (reactive protein c) in mg/l. abdominal ct (computed tomograph): cecum and the ilio-cecal valve were visualized at the subhepatic level with tubular structure on the side and seemed to correspond to the cecal appendix which is increased in size ( mm), with findings suggestive of acute appendicitis. sigma and descending colon located in right hemiabdomen. second per duodenal portion located anterior to the superior mesenteric artery. superior mesenteric vein located to the left of the superior mesenteric artery, rotating around it, (radiological signs compatible with intestinal malrotation). no free fluid collections nor pneumoperitoneum. laparoscopic appendectomy on phlegmonous acute appendicitis without incidents. correct post-operative course, being discharged at h; the pathological anatomy was reported as acute appendicitis in phlegmonous. conclusions: ivermark syndrome is a genetic alteration with a multifactorial inheritance pattern, characterized by an alteration in the situation of the mesenteric vessels, which leads to abnormal rotation of the intestine during the embryonic period and alteration of the situation of different intra-abdominal organs, without a specific pattern that is pathognomonic, is associated with congenital heart anomalies between and %. reaching adulthood only between and % of them. a case of acute appendicitis is presented in a patient with this anomaly, which can lead to diagnostic and therapeutic difficulties due to the anatomical variations involved. abdominal tomography is the image method that provides the best performance for the diagnosis of acute pathologies in this type of patients. background: the clinical manifestations which occur in relation to decompression during scuba diving are variable. mild symptoms have often been reported in gastrointestinal tract. this is one of the severe cases with gastrointestinal barotrauma. ischemic colitis caused by air embolism very rare, therefore it is to be reported and discussed. case presentation: a -year-old man visited our emergency room with diffuse abdominal pain and bloody diarrhea days ago. the patient was a skilled diver who took seafood through diving for years. two days before presenting, the patient had severe abdominal pain just after diving for h at a depth of meters. he was immediately transferred to a local hospital for hyperbaric oxygen therapy, but there was no improvement with the symptom. abdomen ct angiography showed terminal ileal, ascending, sigmoid colonic and rectal decreased enhancement with wall thickening. sigmoidoscopy showed diffuse huge ulcerative lesions and ischemic changes on mid rectum and sigmoid colon. emergent subtotal colectomy and temporary loop ileostomy were done, and pathologic findings revealed diffuse mural infarct with serosal abscess formation in whole colon and transmural infarct in terminal ileum. conclusion: surgical approach could be one of the treatment options, though it depends on severity of the symptoms and the patients' conditions. colonic lipomas are extremely uncommon benign tumours, with an incidence ranging between . % and . %. although they are most frequently asymptomatic, when colonic lipomas are [ ?cm, they may present symptoms such as constipation, abdominal pain or rectal bleeding. most colonic lipomas typically occur in middle aged women and are located in the ascending colon and the caecum, while occurrence in other parts of the colon and rectum is rare. in this case report, we describe a lipoma that caused descendent bowel intussusception. a -year-old male presented with longstanding history of constipation. personal history of interest included active smoker, hypertension, hypercholesterolemia, psoriasis with joint affectation and reiter syndrome. he had had no previous surgery. he attended the emergency services on th july with a two-day bowel obstruction, without fever or nausea, being attended by our surgical emergency unit. he had been assessed during the previous months by gastroenterology, with a colonoscopy that showed a cm submucosal lesion that partially occluded descendent bowel, with inconclusive biopsy. an abdominal contrast-enhanced computed tomography (ct) was performed, confirming a welldefined mass located in splenic flexure of descendent bowel, conditioning a large bowel intussusception, nevertheless with no obstructive acute signs. the surgery was scheduled a few weeks later, performing a laparoscopic segmental resection with primary anastomosis including oncologic margins. the patient evolved satisfactorily in the postoperative period and was discharged six days after the surgery without any complications. likewise, he was monitored on a regular basis at our outpatient department and was free of symptoms at the -month follow-up visit. the histological analysis revealed a cm ulcerated lipoma affecting % of bowel circumference. the molecular study, using fluorescent in situ hybridation (fish) showed no mdm gene amplification. laparoscopic segmental resection of the large bowel is a safe and feasible technique for the treatment of large bowel intussusception caused by a colonic lipoma. the complete removal of the lipoma will condition the prognosis. furthermore, in the future, endoscopic surgery using colonoscopy could be employed when having a certain preoperative diagnosis of lipoma. surg endosc ( ) introduction: acute appendicitis is one of the most common abdominal surgical emergency, the diagnosis of which mostly relies on conventional methods such as physical examination and blood tests. the use of ultrasonography and ct abdomen aids in more precise diagnosis especially in patients with atypical presentation or in elderly. aim: this study aims to evaluate the ability of the neutrophil/lymphocyte ratio (nlr), platelet/lymphocyte ratio (plr) and mean platelet volume (mpv) in predicting the diagnosis of acute appendicitis. methods: retrospective analysis of prospectivly maintained data of all patients ( ) admitted with acute appendicitis to the emergency department at a tertiary hospital in the middle east between january till september . medical records and database of patients,who had appendicectomy for clinically and radiologically proven appendicitis, were reviewed. the retrieved data included patient's demographic and laboratory values of white blood cells (wbc), neutrophil (n), lymphocyte (l), and platelet (p) along with their ratios for comparison. results: spss version was used for tabulating the data. the recommended cutoff value of the nlr, plr and mpv in predicting the diagnosis of acute appendicitis was decided by using receiver operating characteristic (roc) curve analyses. at least for nlr, the confidence interval (ci) was . which is percentage of the positive values, since the confidence limit was between to %. our results showed that the laboratory parameters were fairly significant since the confidence interval was . in predicting the diagnosis in our population. conclusion: although appendicitis is a clinical diagnosis but laboratory parameters specially nlr, plr and mpv can be used as an adjunct in the diagnosis of acute appendicitis. literature is scarce concerning the validity of such parameters in our part of the world and prospective randomized controlled trials are needed to prove the efficacy of such rationale. objective: tumors of the cecal appendix represent a subset of colonic neoplasms whose early diagnosis is a real clinical challenge. correspond to . % of all gastrointestinal tumors and their prognosis depends on the type of injury, being the most frequent variety the carcinoid type. appendix involvement in endometriosis is rare, accounting for % of all endometriosis cases, and sometimes mimicking cecal tumors. methods: a -year-old woman with a history of hypothyroidism due to autoimmune thyroiditis and atrophic gastritis with gastric neuroendocrine tumors resected by endoscopy that in the digestive unit reviews, tac with double contrast was requested, showing a lobulated lesion in the cecum adjacent to the ileocecal valve, with contrast enhancement of approximately mm, suggestive of tumor. the colonoscopy evidenced a protruding appendicular osteum with inflammatory aspect that was biopsied. the pathological anatomy of the biopsy reports chronic congestive colitis with edema of the own blade and minimal acute activity, with moderate local eosinophilia.the case was presented in the multidisciplinary oncology committee and it is decided, due to the patient's background, to perform surgery on the lesion. laparoscopic right hemicolectomy was performed, with extracorporeal latero-lateral mechanical anastomosis with endogia signiaÒ mm. results: the patient evolves favorably, with good oral tolerance and depositional habit. she is sent home at the sixth postoperative day. the pathological anatomy reports tumor injury in the appendicular ostium compatible with endometriosis at the base of the cecal appendix implantation, ruling out malignant tumor pathology. conclusions: gastrointestinal tract endometriosis represents - % of cases, being most frequently located in the rectal-sigmoid region. appendix involvement in endometriosis is rare, accounting - % of all endometriosis cases and presents a preoperative diagnostic challenge, because sometimes mimicking a carcinoid cecal tumor. in our case, due to the patient's history, we assumed that the cecal lesion was a carcinoid tumor, so we performed a laparoscopic right colectomy, but if we had known that it was an endometriosis, we could have performed an appendectomy, although in both cases the laparoscopic approach gives us some benefits compared to the open approach aims: the natural history and predictive factors associated with chronic anastomotic complications have not been clearly studied. the aim of this study was to evaluated the predictive factors related to chronic anastomotic complications methods: from january to december , a total of patients who underwent anastomotic leakage were enrolled in this study. all patients underwent anterior resection with or without defunctioning stoma due to colorectal cancer. the patients received follow-up by clinical examination and abdominopelvic computed tomography (ct). they underwent a follow-up ct every months for the first year and then every months for the next years after that. complicated group (cg) underwent chronic anastomotic complications. normal group (ng) didn't underwent chronic anastomotic complications like stricture, fistula, chronic sinus, etc. results: there were no significant differences in gender, age, preoperative chemoradiotherapy and operation type between two groups. low rectum lesion and defunctioning stoma at the time of primary surgery were more frequent in cg (p = . , . ). there were no significant differences in type of anastomotic leakage, international leakage grade and ct findings at the time of diagnosis of anastomotic leakage. however, abnormal ct findings at the time of month were more frequent in cg group (p \ . ). in multivariate analysis, abnormal ct finding at the th months was only significant factor related to chronic anastomotic complications. conclusions: abnormal ct findings at the th month associated with prediction of chronic anastomotic complications. aims: acute appendicitis is the most common cause of acute abdomen requiring surgical intervention in the world. nowadays, standard treatment of acute appendicitis involves a surgical approach, eitherlaparoscopic or open.the purpose of the present study is to evaluate the safety of a discharge within less than h after performing appendectomy as a result of an uncomplicated acute appendicitis. conclusions: patients who undergo appendectomy (open or laparoscopic) for acute uncomplicated appendicitis, without surgical incidents and an adequate social/family network, can be discharged in less than h without a higher risk of post-operative complications or readmissions than patients with longer postoperative stays. it will be necessary to conduct more prospective studies with higher level of evidence that could corroborate our results. aims: median arcuate ligament syndrome (mals), also known as the celiac axis compression syndrome, is a rare condition caused by to the compression of the celiac trunk and the nerves located in this area (celiac plexus) by the median arcuate ligament. it is believed that mals is caused by the median arcuate ligament compression of the celiac plexus nerves over the celiac trunk, but another probably cause may be the lack of blood flow to the organs supplied by the celiac artery, however, this theory is controversial. the first clinical sign of mals is the apparition of postprandial abdominal pain in the upper abdomen. this typical pain forces patients to avoid eating, which can lead to loss weight (often more than pounds). other associated symptoms may include nausea, diarrhea, vomiting and delayed gastric emptying (a delay in food moving from the stomach into the small intestine). in relation to this uncommon condition, we present a clinical case of laparoscopic management of mals. methods: we present a -year-old patient with complaints of recurrent epigastric pain, postprandial vomiting and loss weight. blood tests and gastroscopy were performed to help ruling out more common causes of his symptoms, such as gastroesophageal reflux disease (gerd), gastritis or gastroparesis. as a part of the differential diagnosis, mals was suspected and a mesenteric doppler ultrasound was ordered to check blood flow through the celiac trunk and evaluate a possible compression of the celiac plexus. also, an angio-ct scan was also performed to confirm the diagnosis. once the mals was diagnosed, we decided to perform a laparoscopic approach as definitive surgical procedure. results: the patient was discharged h after surgery with no remarkable events during his postoperative stay. he has been followed up during months, remaining asymptomatic. conclusions: laparoscopic approach in mals offers a superior visualization during the surgery and involves lower morbidity in compare to open approach, which makes it an optimal treatment for this condition. aim: pilonidal sinus is a common disease with annoying and often painful symptoms. traditional surgical techniques for its treatment are characterized by either intense postoperative pain and prolonged wound-healing periods (wide resection, marsupialization) or unsatisfying aesthetic results (advancement or rhomboid flaps). 'endoscopic pilonidal sinus treatment' (epsit) is a new minimally invasive technique which utilises the meinero scope, primarily designed for the endoscopic treatment of complex perianal fistulas in a technique known as vaaft. we present our experience and outcomes in three treatment centers in northern greece. methods: between july and november we treated patients with pilonidal sinus using the epsit technique. the mean age of patients was , and % of them were male. patients were treated in the acute phase with the presence of pilonidal abscess. all operations were performed by two laparoendoscopic surgeons specifically trained in the technique. most patients were treated on a day-case basis. postoperative wound care included daily tract irrigation with ml of saline for a total of days. results: there were no immediate postoperative complications. medium postoperative pain was . on a vas scale. % of patients were discharged on the same day, patients remained in hospital for one day mainly due to social reasons. return to daily activities was immediate. in a maximum follow-up of months we observed recurrences. conclusions: epsit is a promising minimally invasive technique for the treatment of pilonidal sinus. what makes it mostly attractive is the minimal amount of postoperative pain, the excellent cosmetic result and the fast recovery with return to daily activities. introduction: isolated acute chylous peritonitis is a rare event. when presented as an acute abdomen warranting surgical intervention, it is often difficult to determine the cause pre-operatively. here, we report a case of acute chylous peritonitis due to meckel's diverticulitis presented with the clinical features suggestive of acute appendicitis. presentation of the case: a -year-old female presented with abdominal pain and clinical features consistent with acute appendicitis underwent diagnostic laparoscopy. she was found to have four-quadrant chylous peritonitis and ileus caused by an inflamed meckel's diverticulum adhered underneath a loop of small bowel and mesentery leaking chyle. after uneventful postoperative recovery, she was discharged at post-operative day two with oral antibiotics and was advised to take a low-fat diet. aims: perforated diverticulitis with purulent peritonitis (hinchey iii) has traditionally been treated with surgery including colon resection and stoma (hartmann procedure) with considerable postoperative morbidity and mortality. laparoscopic lavage has been suggested as a less invasive surgical treatment. methods: a -year-old woman with a -day history of abdominal discomfort exacerbed during the last h. ct scan showed neumoperitoneum accompanied by free fluid and a cm collection adjacent to descending colon showing diverticula suggestive of covert perforation. after h of non-response to medical treatment, associated with the impossibility of percutaneous drainage through interposition of intestinal loops, colon and lumbar vessels, urgent surgical intervention is decided. results: laparoscopic lavage of all quadrants was performed with saline, l or more, of body temperature, until clear fluid was returned. two non-suction j-pratt drains were placed. intravenous antibiotics were continued for a minimum of h, then oral antibiotics were continued for week. oral fluids were commenced on the first postoperative day and solids were subsequently introduced, depending on clinical progress. conclusion: laparoscopic management is reasonable alternative to the traditional open resection for hinchey grade ii-iii perforated diverticulitis with generalized peritonitis. this approach has a low mortality rate despite patient co-morbidity and disease severity. benefits include stoma avoidance and minimal wound infection. subsequent elective resection is probably unnecessary and readmission in the medium term is uncommon. background: constipation and fecal incontinence are common annoying complications after pull through procedures for hirschsprung disease (hsd). many causes could be the etiology of these problems. perineal descent syndrome could be the major hidden cause of these complications. the aim of this study is to evaluate the role of perineal descent syndrome in the development of post pull through constipation and fecal incontinence in addition to evaluate the role of laparoscopic rectopexy for treatment of these problems. \ b[patient and methods: \/b [ patients treated with pull through for hsd over the period of five years. out of the patients presented with constipation and fecal incontinence. patients with constipation and patients with fecal incontinence. rectal exam, anorectal manomety, defecography, contrast enema, rectal biopsy, emg, proctoscopy and endorectal ultrasound were performed to all patients. patients with stricture, missed aganglionic segment, injured internal anal sphincter, and loss of the sensory mucosa above the dentate line were excluded from the study. anterior wall rectopexy was performed for anterior wall rectocele. posterior wall rectocele was treated by retro rectal mesh rectopexy. emg is repeated weeks and months after surgery. outcome measurements included constipation, fecal incontinence and pudendal nerve latency. results: cases of post pull through constipation and fecal incontinence. patients with constipation and patients with fecal incontinence. patients with stricture, patients with missed aganglionic segment, patients with loss of anal sensory sensation and patients with injured anal sphincter were excluded from the study. defecography showed patients with anterior rectocele ( males and females) and patients with posterior rectocele ( males and females). the patients mean age . ± . years . emg showed prolonged pudendal nerve conduction in all cases. anterior wall and retro rectal rectopexy were performed laparoscopically without complications. constipation was resolved in all patients after surgery. all patients showed fully control in defecation. pudendal nerve latency decreased in all patients. conclusion: perineal descent syndrome proved to be a major hidden cause of post pull-through constipation and fecal incontinence. laparoscopic rectopexy showed a good solution of these complications. cystic lymphangioma is a rare entity. the surgical indication is determined by the size and symptomatology, and consists of the complete exeresis of the tumor. the laparoscopic approach is feasible in these cases, allowing a broad visualization of the anatomy, accessibility to the retroperitoneum in the context of a minimally invasive approach and a better recovery of the patient, without providing an increase in morbidity compared to the conventional. in this way we defend as a technique of choice laparoscopic surgery against these rare tumors for the general surgeon in the abdominal cavity, betting on a minimally invasive surgery. aims: laparoscopicposterior sutured rectopexy is one of the accepted treatment options for fullthickness rectal prolapse. recently, reduced port surgery(rps) has beenan emerging concept that, compared with conventional multiple port surgery (mps), yields reduced postoperative pain and improved cosmesis. the aim of the study is to evaluate the feasibility and safety of rps for fullthickness rectal prolapse. methods: rps was performed by single-incision plus one puncture, using internal organ retractor(ior) to secure operative field. straining one ior by - strings in - directions makes it possible to retract the internal organs three-dimensionally. this multi-directional flexible retraction could secure good operative field. from to , patients (rps: cases, mrs: cases) underwent laparoscopicposterior suture rectopexyfor total rectal prolapse. shortterm outcomes were compared between the two procedures. results: there was no significant difference between rps and mps in median operative time ( vs . min, respectively, p [ . ). the median blood loss volume was not significantly different between rps and mps groups ( . vs . ml, p \ . ). the duration of median hospital stay after surgery was not significantly different between two groups ( . vs days, respectively, p [ . ). the frequency of complications after surgery were not different between them. conclusions: reduced port lap-rectopexy can be a good therapeutic option for total rectal prolapse. a prospective, randomized, controlled trial should be conducted to confirm the superiority of this procedure over mps. the piccolo project proposes a new compact, hybrid and multimodal photonics endoscope based on optical coherence tomography (oct) and multi-photon tomography (mpt) combined with novel red-flag fluorescence technology for in vivo diagnosis and clinical decision support. for its development it includes different phases of validation. within this framework, the present study has as main objective: to characterize a model of rat colonic hyperplasia, which will be used for the development and validation of the previously mentioned endoscopic technology. secondary objectives: procure the reproducibility of the model chosen and determine the optimal time, after induction of the model. material and methods: animals (rattus norvegicus), wistar, males and females \ -yearold, randomly distributed. group (n = ): by laparotomy, a non-resorbable suture (silk / ), not stenosing, is placed through the wall of the colon. group (n = ): by endoscopy, a . mm long segment of a polymeric catheter is inserted, which is fixed to the wall of the colon by means of a suture. group (n = ): by means of endoscopy, a self-expanding and uncoated metallic stent are placed in the colon. group (n = ): a superficial laser resection of the colonic mucosa is performed by endoscopy. group (n = ): as an extension of the most optimal model. weekly, the animals were anesthetized again to perform a colonoscopy, which determined the degree of mucosal growth in descending colon and colonic biopsies were extracted weekly ( weeks). results: group . growth around the sutures after the second follow-up, diagnosed as hyperplastic polyps after a histopathological analysis. aim: the role of laparoscopy in the management of generalized appendicular peritonitis is controversial. this is due mainly to the lack of scientific data. through this study and a laborious bibliography research, we proposed to report our experience in terms of postoperative results, in the laparoscopic treatment of generalized appendicular peritonitis and to try to identify the risk factors associated with the occurrence of global morbidity and conclude on the feasibility of this technique in its treatment. methods: we conducted a retrospective study including all cases of generalized appendicular peritonitis managed laparoscopically, in the general surgery department of charles nicolle hospital between january and december . results: we identified patients. the mean age was . years. one fifth of the cases required a midline conversion ( . %). the mean operative time was . ± , min. the overall morbidity rate was % including surgical complications. there were no deaths. in uni-variate analysis, comorbidity, crp [ mg /l, operative time exceeding min and midline conversion were significantly associated with postoperative morbidity. co-morbidity, diabetes, asa score [ , delay of consultation [ days, intra-abdominal abscess and operative time exceeding min were significantly associated with medical complications. the univariate analysis also revealed that crp [ mg /l and midline conversion were predictive of surgical complications.the multivariate analysis identified the midline conversion as the only independent factor significantly associated with post operative morbidity (odds ratio = . , % confidence interval [ . - . ] ). conclusion: based on our results, it appears reasonable to continue the laparoscopic management of diffuse appendicular peritonitis. however, enhance this technique is basic in order to reduce midline conversion rate and to shorten operative time, which can lead to post operative complications. aims: currently, acute appendicitis is the most common surgical emergency. laparoscopic appendectomy is the usual procedure to treat acute appendicitis. the aim of this study is to evaluate the safety of electrocoagulation in the treatment of mesoappendix in laparoscopic appendectomy. methods: we have retrospectively studied a prospective database of operated patients of appendecectomy in emergency surgery unit. we have reviewed laparoscopic appendectomies from june st, to december st, . the mesoappendix was electrocoagulated in every laparoscopic appendectomy. the statistical analyses has been done with spss . version. results: our group consists of patients of which . % were male and . % were female. the average age was . years with a standard deviation of . % and p was . years. the most common total stay was day ( patients). the usual post-operative stay was one day ( ). we classified the diagnosis in complicated apendicitis ( patients) and no complicated apendicitis ( patients). the conversion rate was . % ( ). the main surgical complications were: surgical wound infection ( . %); intraabdominal abscess ( . %); and bleeding ( %). only one of the patients that suffered bleeding had complicated appendicitis. the medical complications were catheter sepsis ( . %); respiratory infection ( . %); cardiologicals ( , %); and paralytic ileus ( . %). the treatment of mesoappendix with electrocoagulation is safe and effective since the complications rate is very low. even so, it would be necessary to conduct more prospectives randomized studies in order to get enough evidence about the treatment of mesoappendix with monopolar electrocoagulation. introduction: the difficulty of resection of the rectum is determined by its anatomical relationships, intimately in contact with the bladder, seminal vesicles, prostate and urethra in the case of the male, vagina in the woman and nerve structures that will give defecatory, genital and urinary functionality. this structure creates a big impediment due to problems of visualization and difficult dissection, in such a way that conventional surgical techniques instigates a series of complications derived from this difficulty. we propose a new approach in rectal surgery in patients with inflammatory bowel disease. material and methods: a -year-old man with a history of ulcerative colitis developed a severe acute outbreak refractory to treatment. a total laparoscopic colectomy with a terminal ileostomy was performed in . in he was notified for reconstruction. we evidenced a rectal stump of about cm with signs of inflammatory disease at the mucosal level. a transanal proctectomy was performed with confection of 'j-pouch' and ileoanal anastomosis about cm from the anal margin by laparoscopy. the postoperative courses favorably, being discharged on the sixth day. currently in follow-up in digestive and general surgery, he is asymptomatic and he has an optimum level of quality of life valued by the sf- weeks after the intervention. conclusions: our service introduces the transanal approach to the performance of proctectomy in cases of inflammatory disease, a technique that provides clear advantages by improving visualization and the identification of anatomical structures. in this way, a safe dissection of the pelvis is achieved, adjusted to the serosa of the rectum, with preservation of the mesorectum and the hypogastric plexus, and with the consequent improvement of the genital and urinary function. the result is an equally safe surgery, which implies little increase in operative time and with better and shorter postoperative recovery.the conservation of the pelvic innervation avoids disorders of ejaculation, vaginal lubrication and bladder and rectal motility. the transanal approach for the performance of proctectomy provides benefits in terms of the preservation of the hypogastric plexus, minimizing the anatomical difficulties involved in rectal surgery and maintaining urinary and sexual function. aims: to evaluate the feasibility and outcomes of laparoscopic appendicectomies in both simple and complicated appendicitis, given the increasing trend towards a laparoscopic approach in the last four decades for the treatment of acute appendicitis. we present data from a district general hospital over a -year period. methods: we retrospectively analysed a single consultant's continually updated database of laparoscopic appendicectomies between / / and / / ( months). patient demographics, investigations, intraoperative findings and postoperative outcomes were recorded and analysed. complicated appendicitis was defined as the formation of appendiceal mass or abscess with or without perforation and peritonitis. results: cases of laparoscopic appendicectomies were identified during the specified period. the median patient age was (range - years). true positive rates for uss and ct were % and %, respectively. the rate of negative appendicectomies was %. transanal minimally invasive surgery (tamis) has been used for the treatment of rectal neoplasms such us benign polyps and early rectal cancer. when the tumour is located in the upper rectum or close to the rectosigmoid junction, this approach may be technically dificcult.we present a video of a tamis resection of a large polyp located cm from the anal verge. after properative examination and ct and mri were performed, the patient was prepared for surgery, and a trasnanal minimally invasive surgery was proposed.resection of the polyp was performed with the aim of an endogia and conventional laparoscopic materials. total resection of the polyp with free margin was possible. the postoperative pathology report confirmed a high grade displasia villo-tubular adenoma with a lesion free margin. tamis resection of tumours located above the rectosigmoid junction may be a safe and feasible technique in selected patients. aims: pelvic organ prolapse (pop) is a very relevant problem for women's quality of life and has a prevalence of about % defined by symptoms and up to % when established by physical examination. nowadays, sacrorectopexy for posterior pop and sacrocolpopexy for apical pop are considered the gold standard techniques. recently, we have seen that laparoscopic lateral suspension is a feasible procedure for apical pop, obtaining a success rate higher than % at one year. these results are similar to what we can achieve with sacrocolpopexy. methods: we herein present the case of a -year-old woman with apical and posterior pop, this was provoking an important impact on her quality of life, with obstructive defecation (needing digitations) and urinary incontinence. we proposed sacrorectopexy for her posterior pop and laparoscopic lateral suspension for her apical pop. in the video we can see how we perform a ventral mesh sacrorectopexy, following d'hoore technique; and a laparoscopic lateral suspension with preperitoneal dissection, following the technique described by the team headed by dubuisson and veit-rubin. we used laparoscopic ports ( , , . and . mm). results: patient was discharged home on the second postoperative day and has not had any sign of recurrence or extrusion after more than two years of follow-up. in addition, she has not suffered lower urinary tract symptoms, constipation or pain. conclusions: we present a case in which we have carried out a laparoscopic lateral suspension instead of a sacrocolpopexy for an apical pop, obtaining good short-term and long-term results. we consider it is very soon to assess this technique's efficacy and it has to be validated in studies with larger source of patients. nevertheless, we think this procedure might become an excellent alternative to sacrocolpopexy for apical pop. aims: laparoscopy is a minimally invasive approach with low morbidity. the aim is to show the usefulness of the laparoscopic approach for massive intra-abdominal abscesses, which it is controversial. we report three patients who underwent emergency laparoscopy for peritonitis or massive intra-abdominal abscesses not amenable to percutaneous approach that were suspected to be caused by acute diverticulitis. methods: all patients had diagnosis of acute diverticulitis (hinchey ii-iii grade) with pelvic abscesses situated between sigma and bladder or diffuse peritonitis. the patients with hinchey ii grade had failed conservative management with antibiotics. they underwent emergency laparoscopy under general anaesthesia, with three abdominal ports. intra-abdominal abscess cavities were exposed and the purulent exudate was sampled and aspirated. copious irrigation was performed under direct vision and thorough examination without other findings. the procedure was completed laparoscopically in all cases. results: all patients had favourable evolution. one of them had a properly drained faecal fistula which changed to a purulent fistula on the twentieth postoperative day. this patient underwent laparoscopic left colectomy three months later because he had have a new episode of acute diverticulitis. other two cases showed very good clinical evolution, without evidence of fistula in postoperative period and they were complete asymptomatic one month later. conclusion: in our experience laparoscopic drainage is a feasible, safe, and effective for the treatment of pelvic abscesses and diffuse peritonitis secondary to acute diverticulitis. n. pinheiro, a. ziegler introduction: solitary rectal ulcer syndrome (susr) is characterized as a rare disease whose pathophysiology remains uncertain. it was first described in by cruveilhier and his clinicopathological feature was reported in by mandigan and morson, where he is associated with defective disorders, internal rectal prolapse, and psychological changes. according to works about % of the patients are asymptomatic. when symptomatic the diagnosis can be made through physical examination, clinical history and, often, confirmed by endoscopy with biopsies. treatment depends on the severity of the symptoms and the existence of associated rectal prolapse. according to the literature, conventional surgical options include local excision, rectal mucosectomy, retopexy, and segmental colonic resection. rolato: a -year-old male complaining of anal bleeding at bowel movements years ago. he performed, several times, conservative treatment, but without improvement. he sought proctological care and underwent colonoscopy, in which he showed an ulcerated lesion on the anterior wall of the distal rectum. new investigation with videodefecogram revealed colorectal intussusception with associated mucosal prolapse, being considered the factor causing the ulcer. elected by the sacropromontofixação. evoluiu with improvement of anal bleeding, mucorrhea and anal discomfort. after a proctological examination, which was normal, a control colonoscopy performed after months of surgery revealed rectal mucosa, with residual scarring and disappearance of the submucosal nodule present in the initial examination. reassessed after months, the patient is asymptomatic. conclusion: rectal solitary ulcer whose causal factor was a colorectal prolapse (intussusception) with mucosal exteriorization through the anal canal, which was individually treated with sacropromontofixation. j.p. mali, p.j. mentula, a.k. leppäniemi, v.j. sallinen approximately - % of patients diagnosed with colonic diverticulitis have an intra-abdominal abscess as a complication. abscess diameter of - cm is generally accepted as a cut-off determining the choice of treatment between antibiotics alone and percutaneous drainage. the aim of this study was to analyze the treatment choices and outcomes of patients with diverticular abscesses. this was a retrospective cohort study which was conducted in helsinki university hospital, an academic teaching hospital functioning as secondary and tertiary referral center. patients with computer tomography-verified acute left-side colonic diverticulitis with intra-abdominal abscess were collected from a database containing all patients treated for colonic diverticulitis in our institution during - . altogether, suitable patients were included in analyses. those treated primarily with percutaneous drainage or antibiotics alone ( and patients, respectively) were further compared in regards to treatment results. the main measured outcomes were need of emergency surgery and -day mortality. abscesses under mm were mostly treated with antibiotics alone with high success rate ( out of , %). in abscesses over mm, the use of emergency surgery increased and use of antibiotics alone decreased with increasing abscess size, but the proportion of successful drainage remained at - % regardless of abscess size (figure ). there were no differences in failure rate, -day mortality, need of emergency surgery, permanent stoma, recurrence, or length of stay in patients treated with percutaneous drainage versus antibiotics alone, even when groups were adjusted for potential confounders. white blood cell count = . * /l, abscess diameter = mm, and corticosteroid medication were independent risk factors for failure of treatment with antibiotics alone. patients without these risk factor had % and patients with one risk factor had % success with antibiotics alone. percutaneous drainage as treatment for large abscess does not seem to be superior to treatment with only antibiotics. majority of patients with abscesses over mm in diameter undergo surgery as primary intervention. introduction: even today, 'chronic appendicitis' is a clinical term that is not widely accepted nor well documented amongst the medical community. its etiology is the presence of a mass (e.g. fecal mass, hyperplasia of lymphatic tissue, etc.) that continuously and partially obstructs appendix lumen. it is presented as a low intensity, intermittent, with exacerbations and remissions, abdominal pain that is located at the right iliac region. the pain lasts up to several months and it is usually underestimated by the patient. its diagnosis is based on imaging examination. appendectomy is the treatment of choice for chronic appendicitis. the operation is challenging for the surgeon who has to cope with an intensively inflamed area around the appendix without the ease of access to that area. purpose: to present our laparoscopic approach to a chronic appendicitis case and to review the literature. case report: a -year-old woman is hospitalized due to chronic appendicitis. the patient was treated conservatively with the use of intravenous antibiotics in two separate hospital admissions dated and months back respectively. eight weeks after the last exacerbation, she underwent a laparoscopic appendectomy. results: even though the procedure was planned six months after the first episode, the laparoscopy revealed a severe inflammation of the appendix, which was extended to the caecum and the surrounding preperitoneal tissues. although the difficultness of the operation it was completed successfully laparoscopically. the histological examination confirmed without any doubt the existence of 'chronic appendicitis'. the patient was discharged uneventfully the third postoperative day. conclusions: chronic appendicitis is an existing clinical entity that the surgeon may come through during his career. in the hands of experienced laparoscopic surgeon, the laparoscopic approach is feasible and safe. introduction: ventriculo-peritoneal shunting (vps) used in the treatment for hydrocephalus is associated with several complications.the exact cause of such extrusion is not known. visceral perforation is an unusual but serious complication with consequeces such as peritonitis, meningitis or encephalitis. management involves prompt removal of shunt, intravenous antibiotics, an adequate recovery gap so that cerebrospinal fluid culture is sterile and then followed by shunt replacement on opposite side. aim: multidisciplinary approach of extrusion of vps through anus by laparoscopic and external ventricular drainage. case exposure: a -year-old woman had a vps inserted year ago after excision of gangliocytoma due to lhermitte-duclos disease. she was admitted in the emergency department without symptos after trans-anal protrusion of vps catheter. the neurological and abdominal evaluation was normal. laboratory tests did not reveal disorders and abdominal ct-scan suggested perforation, itshowed the insertion of the end of the catheter in sigma, without pneumoperitoneum or intraabdominal free fluid. cranial ct-scan did no describe sings of hydrocephalus. the patient underwent an emergencysurgical intervention. first of all, antibiotic therapy was initiated and neurosurgery's team was performed an external ventricular drain and they disconnected the proximal catheter side. after that, an exploratory laparoscopy was performed. it revealed a microperforation and collection beside to an appendix' base due to the proximity with the catheter. additionally, the catheter was freed from adhesions at the point of entry into the colon and after careful dissectionwe release the vps from colon with a . cm transmural trajectory at the sigmoid level. no free fluid was seen and rest of the bowel appeared normal. the distal end was removed through the anus and the proximal end through a laparoscopic port. we performed a laparoscopic segmental cecum resection and an extracorporeal colo-colonic anastomosis was performed for a mini-pfannestiel laparotomy of assistance. there were no complications in the postoperative period, being discharge on the th day. conclusion: the multidisciplinary approach and the laparoscopic support in the diagnosis and treatment of patients with colon perforation caused bay vps catheter is a feasible and safe option in third level centers. background: acute appendicitis continues to be the most common source of complicated intraabdominal infection worldwide. the high incidence of postoperative complications and dissatisfaction with the results of treatment in cases of complicated appendicitis and peritonitis gave the reason for conducting this study. aim: to evaluate the effect of different laparoscopic trocars position in case of laparoscopic appendectomy for diffuse appendicular peritonitis for the incidence of postoperative complications methods: the results of laparoscopic treatment of patients with acute appendicitis complicated by diffuse peritonitis were analyzed. the first group consisted of ( %) patients operated by triangulation access (type trocar placement according sages guidelines for laparoscopic appendectomy (sages qla). the second group consisted of ( %) patients operated by sectorisation access (type sages qla). postoperative complications were classified by clavien-dindo classification. results: the duration of the operation for the analyzed groups was . ± . vs . ± . min. there were no deaths among this group of patients. the incidence of postoperative complications for both group was . %. postoperative complications in the triangulation and sectorisation group were % and . % respectively (p . ). clavien-dindo iiib complications were noted in . % (n- ) patients and presented with intra-abdominal abscesses (iaa). all patients with iaa were operated in sectorisation group. conclusion: sectorisation trocar placement increases the incidence of intra-abdominal complications for laparoscopic appendectomy for diffuse appendicular peritonitis. introduction: the diverticular disease of the colon is a chronic entity with a variety of abdominal symptoms that can present with recurrent episodes of acute diverticulitis (ad). the prevalence of diverticulosis is not influenced by gender and increases with age, which, according to the increase in life expectancy, explains the accumulation of cases in western countries. the classic diagnostic-therapeutic algorithm of the disease is it has been based on the hinchey classification, the use of antibiotics and the intervention of hartmann (ih) at the acute time and elective colectomy in the multirecurrent cases. the use of laparoscopy with washing and drainage is actualymore extended in cases with peritonitis. objectives: to demonstrate the safety and efficacy of the laparoscopic approach, in cases with diverticular disease complicated by severe inflammatory plastron with 'covered' perforation, with several recurrent episodes. material and method: case report: a -year-old man with ap-diverticulitis years ago with complete resolution and normal control colonoscopy. he presents in the last two months three compatible episodes of acute diverticulitis, exploration with plastron-mass in hypogastrium without defense, tac-marked thickening of a segment of cms. of medium sigma, collection not drainable in mesosigma, of cm, which loses the plane of cleavage with loops of thin neighbors with a linear tract that suggests fistulization. evidence of interest is exposed. given the evolution, it is decided surgical elective treatment. result intervention: preoperative ureteral double catheterization, laparoscopic approach, is exposed by video, rectosigmoid resection by diverticular plastron, with negative io biopsy, mechanical colorectal anastomosis. good postoperative course, discaharge at th day. defini-tive ap: perforated diverticulitis, absence of malignancy. the laparoscopic approach is a valid and effective alternative in cases of complex and severe diverticular disease. aim: tamis resection has been described for the treatment of rectal neoplasms, wether benign or early malignant tumours. since tamis appearance, many different indications have been reported.we aim to show an special indication as seen in this video of a tamis resolution of a rectal stenosis non treatable by endoscopy. method: we present a video of a female patient, previously treated for a large rectal adenoma treated by trasnanal apporach, with a postoperative sepsis which required lateral colostomy and trasanal drainage. after surgery, the patient suffered from a rectal stenosis which couldn' t be solved by endoscopy, so the patient was sent back for a surgical treatment.we decided to performed a trasnanal apporach by tamis and a long and circunferiential stenosis around cm from the anal verge was seen.we performed a rectotomy by electrocautery in the posterior rectal wall until the perirectal fat was seen and the stenosis was passed. a dilatation with a foley catether was also performed. results: postoperative course was uneventful and after months she was prepared for colostomy closure with no complications and remains asymptomatic nowadays. conclusion: tamis approach of rectal stenosis may be a safe and feasible technique in selected cases if conservative treatments fail. iatrogenic endoscopic colon perforation it is a severe, but rare complication of colonoscopy. the incidence of this complication is estimated to be . - . % for diagnostic colonoscopies and . - % for therapeutic colonoscopies. the management of these complications depends on the size of the lesion,the time elapsed between the lesions were produced and diagnostic of the lesions and associated pathology. the treatment can be consevative,endoscopic or surgical(clasic/ laparoscopic) in our sevice in last years we treated cases with iatrogenic colon perforation after diagnostic colonoscopies. all lesions were at sigma level. one case was admission in our service at days after a diagnostic colonoscopy.the pacient was operated clasic,in emergency,we found a fecaloid peritonitis,a perforation at sigma level.we made a colostomy, lavage, drainage but the pacient died after days. in cases we made the operation at maximum h after the lesion was diagnosticated by the endoscopist(directly visualisation).we didn't made radiologic investigation.the pacients were operated laparoscopic,we made suture,lavage,drainage. evolutions of the pacients were good. conclusion: iatrogenic colonic perfortion are rare,but severe complication. laparoscopic surgery can be a choice in treatment of this complication introduction: complicated diverticulitis with fistula is responsible for about % of surgical procedures in diverticular disease and is commonly found in patients with diverticulitis of the sigmoid colon. colovesical fistulas are the most frequent ( %), with highest incidence in males. only a third of these patients have a history of diverticulitis. in most cases, treatment is surgical, and colectomy is performed, whether or not in association with vesical recession. case report: year old male with pneumaturia and fecaluria for the preceding months. the colonoscopy identified a diverticulitis of the sigmoid colon and the subsequent pelvic mri suggested a colovesical fistula. the cystoscopy was not able to identify any fistulous opening, but a double j catheter was placed in the left ureter, as surgical treatment had been proposed. a subsequently abdominal pain motivated a preoperative ctscan which revealed a pneumoretroperitoneum and a fluid collection near the left ureteral tract. the multidisciplinary team on the case decided to perform a percutaneous nephrostomy, followed by an exploratory laparoscopy. the fistula tract was identified and a laparoscopic sigmoidectomy with partial cystectomy was performed, as well as a ureterorenoscopy (with double j replacement). there were no intra or postoperative complications, and the patologic repport had no signs of malignancy. video of the surgical procedure is presented. conclusion: a laparoscopic approach to complicated diverticulitis with colovesical fistula is safe and effective when performed by experienced colorectal surgeons. introduction: diverticular disease is characterized by its high prevalence, being one of the most frequent causes for hospital admission when it comes to gastrointestinal pathology. even though it is more frequent in older patients, there has been an increase in incidence amongst lower age groups. the approach to the disease has also suffered changes in the last few years, showcasing a tendency for less invasive options, deferring elective surgery to later in the course of the disease. this study examines the therapeutic approach to diverticular disease in our hospital. methods: retrospective analysis of demographic data, therapeutic options and surgical outcomes in patients admitted for diverticular disease between january and june . results: patients(n = )were included in the study: ( %)were male and ( %) were female, with an average age of years. patients( %) underwent medical treatment, with surgery reserved for the remaining patients, of which were emergencies, with the other being elective( %).about % of patients were only admitted once, %were admitted twice and % had or more episodes. for the single-admission group, the most common treatment was medical( %of cases), as was the case for the group with or more episodes(in which %of cases were subjected to medical treatment). in the patient group with episodes, %were submitted for surgery, most of which elective.as far as the surgically operated group is concerned, no statistically significant differences were found with regards to patient sex. age, however, was significantly greater for the group that underwent emergency surgery vs that submitted to elective ( . years vs . years,p \ . ).the most common procedure overall was colic recession, with hartmann's operation standing out as the most frequent for the emergency surgery group. length of hospital stay was again higher for the emergency group (vs elective; vs ,p \ . ),as well as the morbidity rate. no statistically significant differences were found with regards to mortality rate. conclusion: knowledge of the natural history of diverticular disease led to changes in the approach to treatment, with a tendency to adopt a less aggressive therapeutic. despite controversy around aspects such as selection of patients for elective surgery, among others, it is key to the approach to diverticular disease that existing recommendations are taken into account, treatment is individualized and outcomes are closely monitored. surg endosc ( ) aims: the objective of this analysis is to establish if there is differences after the procedure of laparoscopy appendicectomy comparing the use of endoloop (el) vs. endostapler (es) in complicated and non-complicated acute appendicitis. methods: we performed a retrospective analysis of a prospective database of patients from february to june . we divided the patients in two groups: depending on that the procedure of the appendicectomy was with endoloop or endostapler. the groups were created selecting patients in order to be homogeneous as to perforation appendix rate, thus a propensity score was performed for sex, age and perforation rate. an univariant analysis was carried out in regard to the differences in the use of el vs es in the apparition of abdominal complication, as well as hemorrhage, ileo, surgical wound infection, collection, reintervention or hospital readmission.qualitative variables were expressed in terms of absolute frequencies and percentages and mean values and standard deviation were used to express quantitative variables. introduction: intramural haematomas can develop anywhere within any the gastrointestinal tract . these are most frequently associated with blunt trauma above the level of the sigmoid colon and very rarely occur in the rectum . spontaneous, non-traumatic haematomas are a rare clinical condition usually secondary to haematological blood disorders or anticoagulant therapy . case summary: a -year old gentleman presented to the emergency department with a day history of worsening lower abdominal pain and bloody stool. he presented twice within the previous week with worsening, generalised abdominal pain. the patient had been taking regular aspirin and clopidogrel following insertion of coronary artery stents. on clinical examination, he was guarding with a distended, generally tender lower abdomen but all observations were stable, afebrile. an initial computer tomography of the abdomen reported pneumoperitoneum with haemorrhagic ascites; a differential diagnosis being perforated sigmoid colon with a large localised haematoma. the patient underwent an emergency laparotomy and hartmann's procedure (appendicectomy, sigmoid colostomy and rectal stump). he recovered well with no significant post-operative complications. histology reported the rectal perforation macroscopically associated with an opened haematoma and no evidence of malignancy. the appendix shows reactive appendicitis with serousal inflammation background: ulcerative colitis (uc) is one of the risk factor of developing sporadic colorectal cancer. approximately % of uc patients develop an acute attack of severe colitis, and % of these patients require colectomy. one third of the patients will not respond to steroid therapy. thus, a long-term follow-up has been recommended. case report: we reported a single case of completed years follow of colorectal cancer related ulcerative colitis on years old female patient undergoing emergency operation ( staged total colectomy and j-pouch ileo-rectal anastomosis) after year no responsed of medical treatment before, presenting with bloody diarrhea and anemia. there was no post operative complication reported. pathologic finding was early adeno carcinoma, closed follow up was done each year and for another five years later, no progression of the disease was found in this period and the patients has good quality of life after this procedures. is becoming a standard and feasible surgical method worldwide. % of patients with crohn's disease (cd) and % patients with ulcerative colitis (uc) will require an operation during their life. over the last decade, there have been many studies documenting the safety and feasibility of the laparoscopic approach for ibd in well-selected patients. methods: patients with a cd with the tight stenosis in the distal ileum and/or ileo-colon or various colon and rectum stenosis, patients with uc with ineffective medical therapy, steroid dependence or dysplasia underwent the lcs. from to , ileocolic resections, hemicolectomies, subtotal colectomies and restorative proctocolectomies with ileopouchanal anastomosis were performed either totally laparoscopically or laparoscopically assisted (n = ).the average time of the procedure was min ( - min), average blood loss ml ( - ml) and the conversion to laparotomy was in . %. average return time of the bowel function was . days ( - days) and the average hospital stay was . days ( - days). complications occurred in patients ( . %). cases of the early ileus due to adhesions, cases of the anastomotic bleeding threated conservatively, case of the instrumental perforation of the small bowel, cases of the incisional hernia in minilaparotomy and wound infections occurred. conclusion: in well-selected patients with ibd, thanks to superior short-and long-term outcomes, the laparoscopic approach should be considered a safe and effective method when performed by experienced surgeons. supported by mo . aim: over % of patients with crohn's disease (cd) will require a surgical resection within years of their diagnosis and one quarter will have another resection for disease recurrence. laparoscopy should by preferred approach in surgery in cd due to reduced morbidity, faster recovery time, shorter hospital stay and reduction in adhesions and hernial formation. methods: patients with cd with the tight stenosis in the distal ileum and/or ileo-colon or various colon stenosis were indicated for the laparoscopy. from january to november we performed ileocolic resections, hemicolectomies and subtotal colectomies either totally laparoscopically or laparoscopically assisted. the average time of the procedure was min ( - min). the average return time of the bowel function was . days ( - days) and the hospital stay was from to days. complications occurred in patients ( . %) . in cases early ileus developed due to adhesions, in case was anastomotic bleeding threated conservatively, the incisional hernia in minilaparotomy occurred in cases and wound infections occurred. conclusion: minimally invasive surgery is becoming a gold standard in cd. it is safe and feasible in well-selected patients thanks to short-and long-term outcomes. laparoscopic approach for recurrent disease is still in debate. supported by mo . aim: the aim of the study was to observe when laparoscopy is avoided when treating surgical complications of crohn disease. methods: we did a retrospective study which included all of the patients diagnosed and operated in our clinic for complications of crohn disease during a period of years. results: we identified a number of patients operated for complications of crohn disease. of these were operated by minimally invasive procedures. we observed that laparoscopy was avoided in the case of intestinal fistulas (p = , ). also when sepsis associated the surgical complication-laparoscopy was avoided (p = , ). age under years represented another factor to avoid laparoscopy (p = , ). conclusions: although laparoscopy offers numerous advantages careful selection of the patients is of utmost importance so the safety of the procedure can be ensured. retroperitoneal sarcoma represents approximately - % of all sarcomas and less than . % of all neoplasia. radiotherapy and chemotherapy still do not represent valid therapeutic alternatives; therefore radical surgery remains the only valid option. complete surgical resection is the only potential curative treatment modality for retroperitoneal sarcomas. the ability of complete resection of a retroperitoneal sarcoma with tumor grading remains the most important predictor of local recurrence and disease-specific survival. hypoglycemia is a rare but potentially lifethreatening presentation of soft tissue tumors the etiology of hypoglycemia may be difficult to diagnose, assays for insulin-like activity (ila) were found to be high in the extract of tumor tissue, while insulin was not detected in significant concentration neither in the same extract nor in his serum. the most likely mechanism of hypoglycemia appears to be production of insulin like substance and increased utilization of glucose by the tumor. laparoscopic surgery represents an alternative technique for radical resection of such tumors rather than traditional surgery. only few cases of retroperitoneal tumors resected laparoscopically were reported in the literature. we report a rare case of years old male presented to ed unconscious due to hypoglycemia.he was resuscitated and admitted for further investigations. hypoglycemic attack recurred again during the same evening of admission. initial investigations were within normal except for serum glucose mg/dl ( . mmol/l). his tsh, glucagon & cortisol levels were within normal, insulin and c-peptide levels were undetectable. only hypokalemia ( . meq/l). he tested negative for the anti-insulin antibodies. his abdominal ultrasound as well as his ct scans showed the presence of a large retroperitoneal tumor ( cm cm cm) with a heterogeneous contrast effect. a glucose supplement was required to maintain the plasma glucose level within normal limits during which complete resection of the tumor which was performed laparoscopically. diagnosis of such hypoglycemia inducing retroperitoneal fibrosarcoma represents great challenge especially when patients presents only with hypoglycemia and no other abdominal symptoms, management using minimal invasive technique to resect and remove such tumors from the retroperitoneal region shows superiority in recovery and limitation of complications when done by experienced surgeons. solitary fibrous tumor (sft) is a rare fibroblastic mesenchymal neoplasm, tipically arising from the pleura, less frequently from other anatomic sites. sft is an indolent neoplasm, but it have been described cases of greater aggressiveness in terms of local recurrences and more rarelly of distant metastases. among the various extrapleural sites, intrabdominal, retroperitoneal localization is the most common site, followed by the pelvis soft tissues and parenchymatous organs. the most common clinical finding of intraabdominal localization is a palpable mass, and the pain is the most frequently associated symptom. the diagnosis is performed by imaging, but the histological as well as immunohistochemistry characterization of the lesion is the latest goal. furthermore, histological features are used to attempt to identify the patient with a hight risk of malignant evolution of the tumor. the gold standard treatment is surgical approach, meanwhile there are no evidences about the efficacy of any adjuvant treatment. we present the case of a -year-old man affected by symptomatic tfs arising from mesosigma treated by surgical radical excision. finally, we propose a review of the literature of last decade. background: laparoscopic right hemicolectomy involves making an additional incision to remove the specimen and perform the anastomosis. recently, natural orifice specimen extraction surgery (noses) has been reported as an alternative approach without any additional incisions or extensions, may lead to better outcomes compared to conventional laparoscopic right hemicolectomy. in this video, we aimed to evaluate the safety and feasibility of noses for laparoscopic right hemicolectomy. methods: we describe the technique with transvaginal specimen extraction and d lymph node dissection in laparoscopic right hemicolectomy by this video. we performed intracorporeal anastomosis combined with a transvaginal route of specimen extraction after medial-to-lateral mobilization. transverse transvaginal posterior colpotomy was performed under aid with visualization. the specimen was pulled into the sterilized plastic bag, passed transvaginally. the vaginal incision was then closed with a running suture. results: the operation time was min and the hospital stay was days. an excellent postoperative recovery was demonstrated and has shown future potential for less incision. the pathologic tnm stage is t n m . conclusions: this video has shown that laparoscopic right hemicolectomy with the noses technique is feasible and safe for selected cases. the long-term benefits of this procedure need to be more evaluated. recently, indocyanine green (icg) fluorescence has been introduced in laparoscopic colorectal surgery to provide detailed anatomical information.the aim of our study is the application of icg imaging during laparoscopic colorectal resections: to identify the sentinel lymph node (sln) to search micrometastases that can be missed with the conventional pathological exam, and to assess anastomotic perfusion to reduce the risk of anastomotic leak. after tumor identification ml of icg solution ( . mg/kg) is subserosal peritumoral injected. a full hd image s camera, switching to nir mode, in about min displays fluorescence: the sln is identified and the sln biopsy (slnb) is performed.after the transection ml of icg solution is injected to confirm the stumps perfusion. if there is an ischemic area, a new resection is performed.after the anastomosis is performed, another bolus of icg is intravenous injected to confirm the anastomotic perfusion.when the sentinel node is negative for cancer metastases by conventional histological examination, ultrastaging is performed by serial sections. when no micrometastases are identified on these sections, immunohistochemical techniques are applied. from november , patients were enrolled: left colectomy, right colectomy, transverse resections, and splenic flexure resections. in two cases, one left colectomy and one right colectomy, the anastomotic perfusion wasn't good and the surgical strategy was changed. four postoperative complications occurred, of which one anastomotic leak, due to a mechanical problem. from november , patients were enrolled to perform the slnb: right colectomy, left colectomy, transverse resection and splenic flexure resections. the sln was identified in cases. cases were found to be n to the conventional examination and were subjected to ultrastaging. the serial sections showed micrometastases in two cases. in the other cases the immunohistochemistry was performed but the exam is still in progress. icg-enhanced fluorescence imaging is a safe, cheap and effective tool to increase visualization during surgery. it's recommended to assess the anastomotic perfusion in order to reduce the incidence of anastomotic leak, and to perform the slnb for the sln ultrastaging in order to identify micrometastases. methods: for the last years, tem was performed on patients' with early rectal cancer. there were women and nine men, age to . localization of tumors was - cm from anus. mean size of tumors was . cm. full thickness excision was performed in all patient with suturing of mucosa. during follow-up in three patients' metastasis in lymph nodes of mesorectum were detected. all of these patients were re-operated: laparoscopic colectomy with total mesorectal excision (tme) was done. for the last year in patients with early stage rectal cancer we used indocyanine green (icg) with fluorescent imaging for mapping sentinel lymph node. icg was injected in four quadrants to submucosa around the tumor. during the laparoscopy, sln was detected and removed with morphological examination. results: among nine patients in patients, sln was negative. tem was performed in these patients with good results. after - months no recurrence or metastasis were detected in these patients. in two patients with positive sn laparoscopic tme was performed with low colorectal anastomosis. anastomotic complication was occurred in one patient. conclusion: tem procedure is highly effective in selected group of patients with early rectal cancer. mapping and examination of sln can clarify indication for the tem in the patients with early rectal cancer. purpose: laparoscopic surgery for colorectal cancer provides better short-term benefits and similar long-term outcomes compared with conventional open surgery. unlike minimally invasive surgery, natural orifice specimen extraction (nose) can provide additional advantages by reducing morbidity and postoperative pain related to the surgical extraction site. this study aimed to evaluate the efficacy and safety of a nose procedure using needlescopic instruments for colon cancer surgery. methods: between november and february , patients underwent laparoscopic nose using needlescopic instruments. the first port for the camera was placed at the umbilicus. a -mm or -mm port was inserted in the right lower quadrant. a -mm or -mm port was inserted in the right upper quadrant. individual needlescopic forceps for the assistant were inserted into left upper and lower quadrant ports. thus, a total of ports were placed. the superior rectal artery and inferior mesenteric vein were ligated with clips, and colonic mobilization was performed using a medial to lateral approach. after rectal stump irrigation, the distal rectum was transected using an endoscopic linear stapler. the proximal colon and associated mesentery were transected. after the rectal stump was opened, a wound retractor was pulled through the anus and inserted in the rectal lumen. the resected specimen was transanally extracted through this route. an anvil was intracorporeally attached to the proximal colon, and the open rectal stump was reclosed using an endoscopic linear stapler; colorectal anastomosis was then performed using a double-stapling technique. results: of the patients, were male and were female, with a median age of years ( - years). median body mass index was . . the tumor site was in the sigmoid colon in patients and rectosigmoid colon in patients. median operative time was min and blood loss was ml. there was no conversion to open surgery. no postoperative complication was observed. median postoperative hospital stay was days ( - days). conclusions: nose surgery using needlescopic forceps is an easily performed type of reducedport surgery with a conventional port arrangement. this procedure is feasible for the selected patients. introduction: splenic flexure colon cancer accompanying obstruction is usually managed stent insertion as a bridge to surgery and left hemicolectomy, or subtotal colectomy. however, stent insertion can fail more often than in sigmoid colon because it requires longer colonoscopic approach in the circumstance of impossible bowel preperation. although subtotal colectomy has advantage in the aspect that it is -stage treatment, it needs open surgery in most cases, right colon has to be sacrificed without oncologic neccesity, and preoperative staging and evaluation can be insufficient. despite colostomy is reluctant procedure when considering quality of life, in splenic flexure colon cancer obstruction, we can obtain prompt stabilization of patient state, suffient time to preoperative staging and evaluation, and also we can achieve minimally invasive surgery by using colostomy site as mini-laparotomy and close colostomy before discharge. colostomy site, tumor location, and minilaparotomy site for next radical surgery have to be considered comprehensively before making colostomy incision. colostomy site has to be appropriate as mini-laparitomy site for feasibility of laparoscopic left hemicolectomy and the colostomy has to be included in the specimen with caution to prevent unneccessary lengthening of the specimen. we experienced cases which were treated succefully in this strategy and report them. result: temperary loop transverse colostomy and laparoscopic left hemicolectomy via colostomy site in splenic flexure colon cancer obstruction has advantage of quick stabilization of patient's status, suffient preoperative staging and evaluation, achieving minimally invasive surgery, and also rapid colostomy closure before discharge. our tatme procedure for locally advanced low rectal cancer following chemoradiotherapy y. nakamoto , r. okamoto , f. kimura , h. yanagi , t. nakajima , h. yoshie , n. yamanaka surgery, meiwa hospital, nishinomiya, japan, surgery, yoshie clinic, itami, japan background: short-course chemoradiotherapy using hyper-fractionation method (scrt; gy/ fraction/ days ? s- or xeloda) is performed to secure circumferential resection margin (crm) due to tumor shrinkage, reduction of cancer cells with viability, reduction of radiation hazard for resectable locally advanced lower rectal cancer (more t or n ). the patient underwent radical surgery after one month of scrt. for more locally advanced lower rectal cancer (t or n ), induction chemotherapy is performed before scrt. for patients with poor efficacy of chemotherapy, we also do normal fraction gy radiotherapy. methods: we introduced tatme from last august, and cases were performed so far. in all cases temporary stoma has been constructed, and intersphincter resection (isr) is based on partial isr avoiding total isr considering postoperative anal function. if possible, colonic j-pouch is added, and pelvic floor repair may be added for esr cases and older people. at first one team preceded with the anal operation and shifted to the abdominal procedure, now it is done with two teams with the advantage of getting good visual field from both sides when there is difficulty identifying the right dissecting layer. tatme is very useful in cases such as large tumor, obesity, and narrow pelvis. furthermore, when it is difficult to identify the dissecting layer by scarring after crt, it is more possible to control the crm/drm of cancer. results: cases of isr, case of apr, case of tpe were performed, and in of these cases lateral lymph node dissection was also performed (one side , both sides ). postoperative complications were anastomotic leakage, pelvic floor infection, perineum infection, and bowel obstruction. conclusions: tatme for locally advanced lower rectal cancer is useful even after chemotherapy and scrt. background: although many studies have demonstrated similar perioperative outcomes for single-incision laparoscopic surgery (sils) and conventional laparoscopic surgery (cls) for colon cancer, few have directly compared the costs of them. we aimed to compare costs between sils and cls for colon cancer. methods: we analyzed the clinical outcomes and overall hospital costs of patients who underwent laparoscopic surgery for colon cancer from july to september at severance hospital; were used for analysis after propensity score matching. the total hospital charge, including fees for the operation, anesthesia, preoperative diagnosis, and postoperative management was analyzed. results: the total hospital charges were similar in both groups ($ . vs. $ . , p = . ). however, the patients' total hospital bill was higher in the sils group than in the cls group ($ . vs. $ . , p \ . ) mainly due to the difference of the cost of access devices. there was no difference in the additional costs associated with readmission due to late complications between the two groups ($ . vs. $ . , p = . ). conclusions: sils for colon cancer yielded similar costs as well as perioperative and long-term outcomes compared with cls. therefore, sils can be considered a reasonable treatment option for colon cancer for selective patients. aims: technology improvements in medicine allow the development of new minimally invasive approaches. despite every single advantage of these new devices they also can cause technical problems and difficulties for the surgical team. well known from last few years-laparoscopic assisted transanal total mesorectal excision for distal rectal cancer is perfect example for a quite new procedure, based on the combination of forgotten old surgical principles and technology advances. the aim of the study is to analyze the rate of technical problems during the procedure and to measure the impact of them on the operative time. methods: we conducted prospective observational study related to technical problems during the procedure. for the period between september and november in the department of endoscopic endocrine surgery and coloproctolgy at military medical academy-sofia have been performed laparoscopic assisted transanal total mesorectal excisions. we used standard local preoperative work up and postoperative care protocols. we defined technical problem as intraoperative event different from complication leading to delay in operative time. every technical problem during the procedure was recorded and time for resolving the problem was measured in seconds. results: overall technical problems occurred in of the cases. most of them were related to the insufficient smoke evacuation during the cases. the second most common technical problem were the excessive rectal stump spasms during the procedure-this complication occurred in of the patients. mean delay of the procedure related to technical problems is min. in our series we experienced only one intraoperative complication which was specimen perforation during the dissection. three complications occurred in postoperative period-two urinary retentions and one perianastomotic abscess, without need of reoperation. conclusion: technical problems during the procedure can be source of delay in operative time. correct use of devices in operating room is the key to reduce technical issues. technical problems can increase the rate of intraoperative near miss events and complications during the transanal total mesorectal excision. surg endosc ( ) aims: anastomotic leak after rectal cancer surgery constitutes a severe complication associated with poorer oncologic outcome and quality of life. preoperative assessment of the risk for anastomotic leak is a key component of surgical planning, including the opportunity of creating a defunctioning stoma. methods: studies on rectal cancer surgery published between and were systematically reviewed according to the preferred reporting items for systematic reviews and meta-analyses of individual participant data (prisma-ipd) guidelines. with the aim to generate a score for anastomotic leak, all available per-operative covariates were used as independent factors in a logistic regression model with anastomotic leak as dependent variable. a receiver operating characteristic curve (roc) analysis was generated. we selected as threshold the value that allowed a missing rate of anastomotic leak \ %. the predictive power of the previously selected cut-off was validated in an independent set of patients. results: twenty-six centers provided individual data on patients. with a threshold value of the roc corresponding to . in the training set, the area under the roc curve (auc) was . (p \ . ). sensitivity and specificity of the model's probability [ . to identify anastomotic leak were . % and . %, respectively. accuracy of the threshold value was confirmed in the validation set with . % of sensitivity and . % specificity. conclusions: we trust that, with further refinement using prospective data, this nomogram based on preoperative risk factors may assist surgeons in decision making. the score is now available online (http://www.real-score.org). in ( . %) cases laparoscopic interventions were performed in patients with diverticular colon disease. in the group of patients with colorectal cancer localization of the tumor in the right parts was observed in ( %) patients, in the left-in ( %), in the rectum- ( %). results: in the adenocarcinoma of the sigmoid colon, performed a left laparoscopic hemicolectomy ( cases) and resection of the sigmoid colon ( ). was executed high clipping and intersection of the lower mesenteric vessels, aorto-iliac lymphatic dissection. in the standard scope, lymph node dissection was performed with removal and testing of not less than epi-, para-and mesocolical lymph nodes (max ). the average length of the laparoscopic stage is ± min. laparoscopic right hemicolectomy ( cases) was performed in accordance with the principles of cvl (central vascular ligation) and cme (complete mesocolic excision). intracorporal ileotransversoanastomosis was formed by a semimanual method with endogia universal and v-lock suture material. the average length of the laparoscopic stage was ± min, the open phase was ± . in the tumor of the lower and middle ampullary parts of the rectum ( cases) after neoadjuvant chemoradiotherapy, was executed a laparoscopic total mesorectumectomy. conclusions: the use of minimally invasive technologies in colorectal surgery provides a complete revising of the abdominal organs, adequate scope of resection and lymph nodes dissection in surgical interventions. background: it is thought that complete mesocolic excision (cme) improves the oncologic outcomes for colon cancer. but, precise mesenteric mobilization from retroperitoneum and safe ligations at the origins of central vessels are considered to be technically difficult in single port surgery(sps). to resolve this problem, we utilize retro-mesenteric medial approach for right side colon cancer. herein, we introduce this technique and assess its outcomes. operative procedure: the multi-trocar platform is placed in the umbilical site. d laparosopy is inserted from one of this channels. the surgeon manipulates instruments via the other channels. st step: right colonic mesentery is mobilized medial to lateral from the head of the pancreas and retroperitoneum along the embryonic plane. nd step: the origins of ileocolic and right colic vessels are divided and central lymph node dissection is achieved. rd step: hepatic flexure is taken down from cranial. and right lateral attachment is dissected away and cme is achieved. th step: specimen is extracted and anastomosis is performed using a functional end to end anastomosis extracorporealy. results: from april to december , consecutive patients underwent sps-cme with right side colon cancer. there were in stage i, in stage ii, in stage iii and in stage iv. the mean operative time was min. the mean estimated blood loss was ml. there was no conversion to open surgery. additional port was placed in patients ( . %). intraoperative bleeding was occurred in patient. anastomotic leakage was observed in patient ( . %), intestinal obstruction ( . %) and wound infection in ( . %). conclusion: these results suggest that retro-mesenteric medial approach in single port surgery with right side colon cancer is useful and safe technique. aims: this multicenter, randomized controlled trial (simple trial) aimed to investigate the quality of life (qol) and patient satisfaction of single port laparoscopic surgery (spls) for colon cancer, compared with multiport laparoscopic surgery (mpls). methods: patients with histologically diagnosed adenocarcinoma in cecum, ascending and sigmoid colon were eligible for this trial. eligible patients were randomly assigned to the spls or mpls group at a ratio of : . qol was measured with the eortc qlq-c third edition (korean version) preoperatively and postoperatively at month , , and . in addition, patient satisfaction was surveyed with a five-point questionnaire at postoperative month. to exclude the impact of adjuvant chemotherapy on qol, subgroup analysis for patients with or without adjuvant chemotherapy were carried out. (clincaltrials.gov identifier: nct ) results: total patients were randomly allocated into the spls group (n = ) and mpls group (n = ). in total patients, global health status and five functional scale steadily increased and nine symptom scales also gradually improved over time. but, nausea/ vomiting and appetite loss temporally deteriorated at postoperative month. pain score was significantly worse in the mpls group ( . in the spls group vs. . in the mpls, p = . ) at postoperative month and appetite loss score was significantly worse in the spls group ( . vs . , p = . ) at postoperative month. except for that domains, all the other items of qol between groups were not different until postoperative months. patient satisfaction was significantly higher regarding the operation (p = . ) and the abdominal wound (p = . ) in the spls group. in patients without adjuvant chemotherapy, some items of qol (global health status, physical functioning, role functioning, emotional functioning, fatigue and pain) were significantly better in the spls group at postoperative month. since postoperative month, all of qol domains (except pain score) were similar between groups. conclusion: although postoperative pain was temporarily better in the spls, most of qol domain were similar between the spls and the mpls group until postoperative month. in patients without adjuvant chemotherapy, spls showed better outcomes in some of functional scales and symptom scores at postoperative month. coloproctological surgery, juntendo university, tokyo, japan; gastroenterological surgery, juntendo university, tokyo, japan introduction: laparoscopic surgery causes less postoperative pain compared with pain after laparotomic surgery, and its low invasiveness should be considered for pain control. we have previously controlled postoperative pain by epidural anesthesia. in this study we compared postoperative multimodal analgesia centering on acetaminophen in patients who underwent laparoscopic colorectal cancer surgery with the conventional method. subjects: the subjects were patients who underwent laparoscopic colorectal cancer surgery between january and june . surgery was performed under epidural anesthesia in patients and multimodal analgesia in : periodic acetaminophen administration ? transverse abdominis plane (tap) block in , periodic acetaminophen administration ? local anesthesia of the wound in , and periodic acetaminophen administration ? intravenous patient-controlled analgesia (ivpca) in . the operating roomoccupying time, postoperative pain (nrs), frequency of taking analgesics as needed, and postoperative nausea were investigated for days after surgery and the duration of urethral catheter placement and postoperative intestinal movement were investigated in the epidural anesthesia and multimodal analgesia groups. results: while the time from entering the operating room to initiation of surgery was significantly shorter, the time from completion of surgery to leaving the room was significantly longer in the multimodal analgesia group. there was no difference in the operating room-occupying time. the frequency of postoperative pain was significantly lower in the multimodal analgesia group on postoperative day (pod) . the frequency of taking analgesics as needed was significantly lower in the multimodal analgesia group on pod , , and . no significant difference was noted in the duration (number of days) of urethral catheter placement or postoperative nausea between the groups. regarding postoperative intestinal movement, discharge of gas occurred significantly earlier in the epidural anesthesia group. the total number of incidents of complications in the epidural anesthesia group was . discussion: in laparoscopic colorectal cancer surgery, the effect of multimodal analgesia centering on periodic administration of acetaminophen without epidural anesthesia for postoperative analgesia was sufficient compared with the effectiveness of epidural anesthesia. this approach to analgesia may be useful because none of the potential complications of epidural anesthesia occur. surg endosc ( ) in the last years the application of new technologies like d vision or virtual reality have provided to surgeons the possibility of establish a preoperative surgical plan of each surgery and of each patient. these advances are specially useful in minimally invasive colorectal surgery due to the variability in location, anatomical relationship with other organs and vascular variants of these type of surgeries. the aim of our work is to built a digital -dimensional virtual model of the colorectal ct scan imagen of patients with colorectal cancer. the virtual models are obtained from the preoperative ct scan. the ct scans that we use to this work are general electric healthcare revolution gsiÒ and siemens somatom perspective Ò and the size of each image is mm. a medical software let us build a reconstruction of colorectal digital images where a radiologist has marked the exact image of the tumor so we obtain a d reconstruction which can provide an enhanced understanding of crucial anatomical details like the exact location of the tumor and the relationship with other organs and structures of the patient which can be selectively displayed or hidden. this information has an important applicability into clinical practice since it lets surgeons estimate the colorectal anatomy, tumor size and relationships, providing key landmarks to choose the most appropiate surgery, the best trocar location and a safer dissection specially in some cases whose location can change the kind of surgery radically. we present some cases where virtual models were crucial for the preoperative and intraoperative surgical plan, showing the potential interest of these d reconstructions in colorectal surgery. in conclusion the ct scan colorrectal image reconstruction can provide an enhanced understanding of crucial anatomical details of the colon and tumor location and relations which could contribute to choose the best surgical option and to improve safety in colorectal surgery. background: anastomotic leakage (al) after colorectal procedures are a common surgical experience and represents a significant burden both for patients and surgeons. the incidence of al has been reported to vary between . % to up to %, with rates for the colon and rectum of - % and - %, respectively. they, not only add to potential postoperative patient morbidities and to overall costs of postoperative patient care, but also are considered a quality indicator in colorectal surgery. aim: we aimed to evaluate the clinical burden associated with anastomotic leaks following colorectal surgery. methods: we conducted a retrospective analysis of colorectal patients who underwent conventional or laparoscopic colorectal surgery for colorectal cancer (crc), from january st, to december st, in a single colorectal centre (centro hospitalar de leiria). patient demographics, intraoperative and postoperative aspects were collected and analysed. all statistical analysis will be conducted using stata software (statacorp lp). results: in our cohort of pts, developed a clinical al ( . %), mostly males ( %), with an average age of ± . . male gender and conversion were independent risk factors. the group with al had a higher lohs ( . days vs, . -p \ . ). out of al have been detected after the discharge. the mean diagnostic day was the eighth, and mode estimated at day . when compared with a control group, wcc, eosinophils and crp were statistically significant different in al group, at day and . conclusion: in the present study, no statistically significant risk factors for al in crc surgery were detected, except for male gender and conversion. clinical methods and biomarkers were useful for early diagnosis. technology combined with experience and common sense may be the embodiment of the clinical method. conclusions: our regional screening program has significantly improved early diagnosis and quickened surgical treatment of crc. thanks to this, we obtained an earlier stage at diagnosis, a less invasive surgical approach, and a lower rate of complications and emergency surgery need were obtained also with an improvement in both os and dfs. introduction: surgeons are increasingly being faced with the problem of treating elderly colon cancer patients. we evaluated the outcome of silc in patients of over years with colon cancer with a propensity score matched comparison to assess its perioperative and long-term oncological outcomes. methods: this retrospective cohort study analyzed our experience with silc for colon cancer over years. eighty-seven patients of over years with colon cancer who electively underwent silc were included in this study (elderly group). eighty-seven patients were then chosen out of a collective of patients less than years old in a propensity score matched design (younger group). short-term clinical outcomes in both groups were compared and verified its long-term oncological outcome. results: american society of anesthesiologists score and post-operative complication rate were significantly higher in elderly group. however, the other short-term clinical outcomes including post-operative hospital stay were equivalent in two groups. the rates of -year cancer specific survival were . % in elderly group and . % in younger group, respectively, and the -year overall survival rates were . % and . %, respectively. no significant differences were seen between two groups. conclusions: our initial experiences suggested the oncological and clinical safety of silc in patients of over years with colon cancer. however, further studies are needed to demonstrate the advantages of this procedure compared to conventional laparoscopic colectomy. aim: some clinical trials have reported the safety and efficacy of laparoscopic colectomy for colon cancer. on the other hand, transverse colon cancer was excluded in these trials because of the difficulty of laparoscopic colectomy for transverse colon cancer. in this presentation, we report the tips for laparoscopic colectomy for transverse colon cancer. tips: in our department, transverse colon cancers has been resected by laparoscopically so far. to complete cvl and cme, lymph nodes around middle colic artery should be resected, however many important structure, duodenum, pancreas, superior mesenteric vein (smv) and so on, may be obstacles. this is most difficult point for this surgery. our surgery is as follows. mobilization of ileum and ascending mesocolon from caudal sideconfirm duodenum and pancreasexpose smv and ligation root of ileocecal artery and veindissect lymph nodes around smv and ligation of middle colic artery and accessary right colic veinconfirm pancreas from caudate side of transverse mesocolon and incise the peritoneum along the caudal side of the pancreasdissect lymph nodes sufficiently by dissection from both side of transverse mesocolonmost important point. to dissect lymph nodes safely, confirmation from both side of transverse mesocolon is necessary and dissection should be performed along important structure, smv, pancreas and so on. introduction: we have developed and previously reported single-incision plus one port laparoscopic anterior resection of the rectum (sils ? -ar) as a reduced port surgery in which we can utilize the incision for drainage as an additional access route for laparoscopic procedures including the transection the lower rectum. a consecutive experience from its introduction of sils ? -ar for rectal cancer is reviewed, and its -year oncological outcomes are evaluated retrospectively. methods: one hundred and forty-one patients ( female) with a mean age of . years adopted the sils ? procedure for rectal cancer. a lap protector (lp) was inserted through a . cm transumbilical incision; an ez-access was mounted to the lp and three -mm ports were placed. a -mm port was inserted in the right lower quadrant. results: one hundred and thirty-six patients ( . %) completed with sila ? -ar. the tumor locations in the rectosigmoid, rectum above the peritoneal reflection (ra), and rectum below (rb) were , and , respectively. the median follow-up interval was months. aims: colovesical fistulae came from inflammatory disease or cancer and do have a significant morbidity. the most common location is the sigmoid colon and the most common aetiology is diverticulitis. the treatment of choice is a surgical procedure. the aim was studying compare laparoscopic approach in patients diagnosed by benign (diverticulitis) and malignant (colon adenocarcinoma) colovesical fistulae. methods: from january to march all characteristics of surgical patients with diverticular and colon adenocarcinoma colovesical fistulae were reviewed. patient details (sex, age, symptoms, diagnosis, medical history and anaesthetic risk), surgical approach, hospital stay and complications were recorded. both groups were compared with significance level set at p \ . . results: nine laparoscopic ( %) and open approaches ( %) in diverticular colovesical fistulae were performed, with a conversion rate of %. the procedure done was sigmoidectomy. there were also performed laparoscopic ( %) and open approaches ( %) in colon adenocarcinoma colovesical fistulae. the procedures done were sigmoidectomy, pelvic exenteration, left colectomy, low anterior resection and loop colostomy. comparison between the two groups didn't show significant differences in characteristics but did show significant differences regarding the approach, with more cases performed by open approach in colon adenocarcinoma colovesical fistulae (p = . ). conversion rate didn't show significant differences. patients diagnosed for malignant colovesical fistulae had more complications, cases ( %), ( %) i-ii and ( %) iii-iv-v according to clavien dindo classification, manifesting significant differences (p = . ). laparoscopic approach didn't show significant differences regarding complications. conclusions: generally, surgical approach with colonic resection and partial or total cystectomy is the treatment of choice in colovesical fistulae, although vesical resection can be avoided if it is suspected benign aetiology. whenever laparoscopic approach is performed by experienced surgeons, is feasible in colovesical fistulae and the morbidity and mortality numbers are acceptable. laparoscopic approach allows the advantages of a minimally invasive treatment but implies clinical trials to stablish stronger evidence. aims: laparoscopic right hemicolectomy became the standard of care for treating cecum, ascending and proximal transverse colon cancer in many center. most centers use multiport laparoscopic colectomy with extracorporeal resection and anastomosis (mce). single-incision laparoscopic colectomy with intracorporeal resection and extracorporeal (sci) remains controversial. the aim of the present study is to compare these two techniques using propensity matching analysis. methods: this study analyzed patients who underwent laparoscopic right hemicolectomy including mce surgeries and sci surgeries from december to december . short-term outcomes were recorded. postoperative pain was evaluated using a visual analogue scale (vas) and postoperative analgesic use as outcome measure. results: the length of skin incision in the sci group was significantly shorter than in the mce group: median (range) ( - ) cm verses ( - ) cm (p \ . ). the vas score after surgery was significantly less in srhi than in mrhe. significantly fewer patients required analgesia after srhi after surgery. there were no significant differences in operative time, intraoperative blood loss, the number of lymph nodes removed and postoperative courses between the groups. the cost effectiveness was significantly cheaper in srhi than in mrhe. conclusions: sci for right colon cancer is safe and technically feasible. sci reduces the length of skin incision and postoperative pain compared with conventional mce. aim: this study was designed to clarify the utility of laparoscopic surgery for advanced lower rectal cancer after neoadjuvant chemoradiotherapy (ncrt). patients and methods: we investigated -year disease-free survival rate, operative outcomes and recurrence risk factor in patients with lower rectal cancer (ct - , n - ) who underwent laparoscopic surgery after ncrt from to december in kitasato university hospital. results: of patients, patients underwent low anterior resection (lar), patients underwent intersphincteric resection (isr) and abdominoperineal resection (apr). there were anastomotic leakage, and urinary disorder and sexual dysfunction. ypcr rate was . %, but patients ( . %) had recurrence ( liver, lung and lymph node and local recurrence; there is some overlapping). ypt and lymph node metastasis were detected as a recurrent risk factor. the -year relapse-free survival rate (rfs) was . % and the -year overall survival rate (os) was %. conclusion: in this examination, ypt and lymph node metastasis were risk factor for recurrence. the operative outcomes, -year rfs and the -year os are relatively good results. we will conduct further follow-up, and it is necessary to investigate a long term prognosis. laparoscopic surgery is warranted for rectal cancer after ncrt. surg endosc ( ) introduction: synchronous colorectal neoplasia presents an incidence ranges from % and %. classically its surgical treatment consisted in the realisation of a subtotal colectomy (stc), however, several authors have proposed that in certain occasions the realisation of two segmental resections with two anastomoses was not accompanied by an increased risk of anastomotic failure. the objective of this study was to compare the feasibility and safety of the laparoscopic approach of synchronous colorectal neoplasia using two different techniques: stc versus two segmental resections with two anastomoses. methods: we retrospectively reviewed the clinical data of patients over years of age who underwent colorectal surgery between and at a single center. we included patients with a synchronous colorectal neoplasia who underwent laparoscopic surgery, either stc or double resection (dr). results: a total of patients met the inclusion criteria. mainly males ( %) with an average age of years, with a scale of the american association of anesthesiologists superior to ii in % and with an average body mass index of kg / m . the mean operative time was min in the dr and min in the stc, the stc resulted in a higher conversion rate ( % vs %) and intraoperative bleeding ( % vs %), in addition to a postoperative period with more complications, only % of the patients undergoing stc didn't present any complication while % of the patients with a dr didn't present any complication. % of the stc presented anastomotic failure and only % of the dr. the mean hospital stay was days in the dr and . in the stc. in the dr, an average of cm of colon was resected with an average of . lymph nodes, while in the stc, cm of colon was resected with an average of . resected nodes. conclusions: the double resection with two anastomosis is a less aggressive surgery, with fewer complications and a shorter hospital stay, providing similar oncological results. there were no differences in morbidity, re-operations or hospital stay. regarding tumor stage there were no differences between the three groups. as for the resected nodes, we found a mean of in stc, in lc and sr with no statistical difference. there were no differences in the affected nodes among groups. in our patients we didn't find differences in the recurrences rate or in the distant metastases rate.the average follow-up was months (range: - ), with no differences in overall survival. conclusion: segmental resection of splenic flexure neoplasias is safe and feasible, with no differences in morbidity or in the oncological outcomes compared with more aggressive surgeries. introduction: the evaluation of perfusion in colorectal anastomosis is still a field of study and progress for the development of new modalities that allow reducing the ratio of dehiscence or anastomotic leakage (al) in said surgery. our objective with this work is to highlight the utility of indocyanine green (icg) in the said evaluation after colo-rectal surgery. methods: we present a series of cases of colorectal surgery (benign and malignant disease) intervened in the period between and . the population sample has been homogenized according to age criteria, risk factors and comorbidity. a retrospective database has been developed with the spss v. software for the evaluation of the results obtained. the primary outcome measure was al rate with at least month of follow-up. results: a significant reduction in the incidence of al was observed in patients who underwent colo-rectal surgery (p = . ). low al rates were shown in rectal cancer surgery (p = . ). there was no significant decrease in the al rate when colorectal procedures for benign and malignant disease were combined. conclusions: the use of the image by fluorescence with indocyanine green is a safe, reproducible and relatively simple method with which to evaluate the perfusion of the colorectal anastomosis as well as reduce the rate of anastomotic leak in the postoperative period. large well-designed randomized control trials are needed to provide evidence for its routine use in colorectal surgery. introduction: currently colonoscopy is the gold standard investigation for colonic evaluation. although caecal intubation is one of its quality indicators, it is not attained in up to % of cases. this remains a significant concern. limited data are available on the follow-up of patients with incomplete colonoscopy. aims: to assess colonoscopy completion rate, the reasons for incomplete colonoscopy, and the methods used to complete colonic evaluations after incomplete colonoscopy. methods: we performed a retrospective study of incomplete colonoscopies in our unit over a one year period ( ) these results compare favorably with published data. few statistically significant differences between groups suggest varying modalities of treatment broadly result in similar qol. this data highlights a need for well-delivered support programmes for specific issues, for example stoma care and sexual dysfunction. future studies will need to include a baseline questionnaire to truly measure the impact of surgery and measure quality in an increasingly elderly and comorbid population. splenic flexure cancer (sfc), comprising the tumours raised in the distal transverse colon and proximal descendingcolon, accountfor to %of all surgically treated colorectal cancers.in cme forsfc, dissection of both the transverse and descending mesocolon must be considered. however, the use of laparoscopic surgery as a curative treatment for sfc, has never been investigated in adequate controlled trials, because of difficulty in deciding on the appropriate operative procedure, as well as technical difficulties with laparoscopic lymph node dissection. the aim of this multicenter study is to evaluate the oncologic effectiveness of laparoscopic segmental resection with cme with for cancer located at the splenic flexure. we performed a retrospective analysis of all cases of sfc treated with a laparoscopic segmental resection with cme in five different institution. intra and post operative were evaluated. patientes were evaluated, the mean operative time was . ± . min. a total of ( . %) conversions occurred, due to splenic artery lesion, one for difficult adesyolisis and three due to locally advanced tumour. recurrence was observed in ( . %) patients. there was a significant association between disease stage and recurrence (p \ . ) with a higher proportion of stage iv patients in the recurrence group ( . % vs . %). at days follow-up no mortalitywere recorded.during a median follow-up of months (range - ), deaths occurred (all of them for disease progression). keplan mayer curves showed a compareble suvival with other colo-rectal cancer. in conclusion, laparoscopic segmental resection with cme and cvl seems to be an oncologically safe and effective procedure for treatment of sfc. it may be regarded as the standard surgical method for elective management of this disease. in the future, more tailored patient-and tumor-specific segmental resection might be achieved with the use of routine lymph node road mapping. it is very important to establish a minimum number of lymph nodes to analyse for a correct staging. it has been established as . the treatment of colorectal cancer is essentially surgical. the review of the medical literature indicates that laparoscopic colorectal surgery is a safe procedure that has not found significant differences in the survival rate from open surgery. aim: the aim of our study is to compare the outcomes of laparoscopic and open resection for colorectal cancer surgery evaluating lymph node assessment. methods: the patients were collected in our hospital during the period from / / to / / and the number of lymph nodes obtained in lymphadenectomy has been studied comparing the laparoscopic and laparotomy approaches. results: interventions were performed. were laparotomic, were laparoscopic and converted laparoscopic (fig ) . the average number of nodes found in these interventions was , . nowadays, the recommendations to obtain a proper lymphadenectomy is to find more than lymph nodes. analysing our procedures, surgeries had obtained a good lymphadenectomy. according to the approach, , % of the interventions ( ) are laparotomy, , % ( ) are laparoscopic procedures and , % ( ) are by reconverted laparotomy (figure ). the average number of lymph nodes isolated was similar. laparotomy approach found , nodes while , nodes were found in laparoscopy. converted laparoscopy found , ( figure ). conclusion: the treatment of colorectal cancer is essentially surgical. today, there are a lot of studies that support that laparoscopic surgery has a survival rate similar to laparotomy surgery. according to our study, the data collected indicates that the number of isolated lymph nodes in both approaches is very similar. to sump up, laparoscopic colorectal surgery is safe and has demonstrated oncological adequacy comparable to open approach and better short-term outcomes due to a less invasive approach. background: laparoscopic low anterior resection highlights the advantages of laparoscopic surgery (better surgical field, less bloodloss, less postoperativepain, better cosmeticresult). defunctioning ileostomy prevents anastomotic leakage in low rectal cancers, butincreases morbidity, degrades thequality of life and requires a second surgery for its closure. method: in the last months we performed laparoscopic low anterior resections for rectal cancer, whithout performing any protectiveileostomy, afterchecking the anastomosis intraoperatively( men, women. average age: years). the typical placement of trocars included one supraumbilical mm trocar, two right sided mm trocars in the midclavicular line, one mm in the left midclavicular line and one mm trocar in the suprapubic midline which is also used for specimen removal, after a cm transverse extension of the incision. we present themain stages of the procedure (dissection andmesorectal excision, division of the rectum with linear stapler using the 'chinese hat-parnex' technique, creation of an end-to-end intracorporeal anastomosisusing circular stapler under direct laparoscopic vision). results: no major postoperative complication was observed. the mean operative time was min ( - ) and free surgical margins were achieved. in one case a conversion to open surgery occured. the average length of hospital stay was days ( - ). conclusions: the laparoscopic approach facilitates access to the middle and lower rectum, total mesorectal excision and avoidance of ileostomy if possible. it is a demanding operation with extended learning curve, and requires adequate experience in laparoscopic surgery and colorectal surgical oncology. background: in colorectal cancer, local excision is an attractive treatment option, but additional resection is considered when lymph node metastasis(lnm) is expected at high rate. in lower rectal cancer, advanced surgery techniques are required, so it is often difficult to make judgments. the aim of the current study is to assess the reliability of laparoscopic surgery for submucosally invasive rectal adenocarcinoma (pt ) analyzing short-term outcomes and long-term survival. method: this cohort study analyzed patients who underwent laparoscopic rectal resection for submucosally invasive rectal adenocarcinoma (pt ). conversion rate and functional and oncologic outcomes were analyzed. data on long-term results and survival were evaluated. result: surgical procedure was low anterior resection / intersphincteric resection / abdominoperineal resection: / / , and conversion to open surgery was needed for ( . %) patients. sphincter-preserving procedures were performed in ( . %) patients. there were no perioperative mortalities and positive resection margin. the mean length of hospital stay was . days. complications beyond clavien-dindo grade iii occurred in ( . %) patients,the anastomotic leakage rate was . % ( / ). the positive lymph node metastasis rate was . % ( / ). high tumor budding (p = . ), lymphatic invasion (p \ . ), and mucinous /poor histological differentiation (p = . ) were significantly associated with lymph node metastasis on univariate analysis. on multivariate analysis, only lymphatic invasion was associated with lymph node metastasis (p \ . ).the median follow-up time was months (range, - months), recurrence free survival rates was . % ( / ). conculusion: the outcomes of this study suggest that laparoscopic surgery can be used for safe and radical resection of submucosally invasive rectal adenocarcinoma (pt )?and the absence of lymphatic invasion, budding, and mucinous /poor histological differentiation are each associated with low risk of lnm. risk stratification models integrating these factors need to be investigated further. conclusions: this study highlights the complex nature of sarcopenia, as well as its common incidence. minimally invasive surgery had a higher incidence of sarcopenia than that of open surgery when both were performed within an enhanced recovery setting. despite colorectal patients being a typically well-nourished cohort at low risk of complications, there may well be benefit from interventional strategies such as perioperative immunonutrition or pre-habilitation to reduce the incidence of this poor prognostic indicator. backgrounds: urinary dysfunction is frequently observed after rectal resection and justifies urinary drainage. the concept of enhanced recovery after surgery (eras) has been widely spread from the early s. however, the optimal duration of postoperative urinary drainage is unknown. aims: the aim of this study was to comprehend short-term outcome of early removal of urinary catheter after robotic rectal surgery (rrs). patients and methods: (patients) the data of consecutive patients who underwent rrs at two hospitals between april and november were retrospectively reviewed. the main indication of rrs was the patients who need rectal mobilization with autonomic nerve preservation regardless of benign or malignant disease. perioperative management: none of the patients received epidural anesthesia for postoperative analgesia. our basic principle was to remove urinary catheter on postoperative day (pod) . after removal of urinary catheter, trans-urethral catheterization (tuc) was performed in the following situations: ) no autonomous urination over h after removal ) the decrease in urine volume (\ ml/ hr) ) the appearance of subjective symptoms like abdominal distension. when tuc was required even once, residual urine volume was measured with ultrasonic examination device since then. results: twenty seven male and female were included. the median age of patients and bmi were years old and . kg/m , respectively. the surgical procedures included anterior resection (n = ), intersphincteric resection (n = ), abdominoperineal resection (n = ), hartmann's procedure (n = ), and total coloproctectomy (n = ). only one patient received lateral pelvic lymph node dissection. urinary catheter was removed on pod in cases ( . %), on pod in cases ( . %). although tuc was needed in three cases ( . %) immediately after removal, tuc was no longer needed within three days in all three patients. late dysuria was observed in two cases ( . %), and bladder overdistension was suspected in these two cases. conclusions: our study showed that urinary catheter could be safely removed on pod after rrs. however, careful follow-up observation to avoid bladder overdistension is essential after removal. introduction: intersphincterian low rectal resection is a valid alternative to lower rectal cancers located at about - cm from the anus. methods: we present cases from our personal experience for tumors localized - cm from the anus. of them required preoperative radiochemotherapy. in cases, abdominal surgery was performed laparoscopic, having the surgical specimen extracted transanal. lone star device was used for the perineal procedure in all cases. cases required a manually, separate wires anastomosis; the others cases benefited from mechanical anastomosis performed endoanal with - mm circular stapler. we performed complete mesorectum excision in all cases, ligation at the origin of inferior mesenteric artery, complete mobilization of left splenic flexure and lateral protective ileostomy. all pacients underwent inspection rectoscopy before transit reintegration, and cases were reintegrated over a period of - weeks, except for cases which developed a colo-anal fistula, that closed under conservative treatment over a period of - months. results: there were no postoperative anal incontinence. in one case, a relative anal stenosis occured, which required endoscopic dilation. there was case of tumor recurrence and required abdominoperineal resection. conclusion: literature data sustain a - / ratio for very low rectal resection versus rectum amputation. the limit resection under the tumor is accepted as . cm. very good functional results by considering oncological principles, is a sustainable argument for choosing this kind of procedure as an alternative of rectum amputation. in the few studies conducted on crcs, the reported rate of sln micro-metastases is up to - %. the aim of this ongoing prospective study is to assess the predictability of the ex-vivo nirf sln mapping and of the research of micrometastases in nnd crc patients to propose adjuvant chemotherapy. materials and methods: fifty-eight patients undergoing standard oncological crc laparoscopic resection have been prospectively enrolled in two centre. as previously described by the authors, the intact surgical specimen was extracted and opened longitudinally and ml of indocyanine green (icg; mg/ml) was injected submucosally at four corners around the tumor in order to identify the lymphatic pathway and the slns. each sln presenting as negative at conventional histological analysis, was further investigated with ultrastaging techniques including serial sectioning and additional immunohistochemistry, in order to detect the presence of micrometastases. results: thirty patients were n ? , and were nnd. overall, a total of lymph nodes were retrieved. a total of sln were identified (mean . per case) and of those were nnd. after ultrastaging investigations, micrometastatic cases were found in nnd patients. the patients were so upstaged to n . sln located deeper in the mesenteric and mesorectal fat could easily be identified by nirf (even after nchrt). conclusions: in our preliminary series, the ex-vivo nirf sln mapping rightly predicts the status of loco-regional nodes, as confirmed by the histological investigations. the micrometastases' identification let selected patients to undergo the adjuvant treatment with the aim to reduce the risk of recurrence. ( / ) in lateral node positive group and . % ( / ) in lateral node negative group. four of local recurrence were lateral lymph node recurrence. two patients recurred the other lateral side of previous lpl, then they were laparoscopically resected and no recurrence ( , months). two patients recurred the same side after lpl were not curable because of liver metastasis and extensive invasion to the common iliac vessels. conclusion: selective lpl for rectal cancer was safe and good local control for lateral lymph node positive patients. also curable local recurrence resection was possible for non-treated lateral lymph node recurrence. intestinal malrotation is an embriologic anomaly generally discovered in the first months of life due to bowel obstruction. adult presentation is rare and its association with colon cancer is far more rare. we report a case of a years old man affected by asymptomatic intestinal malrotation incidentally found during an abdominal computed tomography (ct) performed for retroperitoneal colonic perforation in a patient with an endoscopically diagnosed aenocarcinoma of the caecum and a large polyp of the descending colon. preoperative vascular anatomic study allowed us to plan a laparoscopic approach safely also with adequate lymphoadenectomy. the abdominal cavity was entered throught a right flank mm optical trocar on the transverse umbilical line. three additional mm trocars were placed in right iliac fossa, right and left hypocondrium respectively. exploratory laparoscopy confirmed midgut malrotation and a fresh flogistic area at the descending colon perforation site. caecum and ascending colon were on midline and attached due to adhesions to sacral promontory. ileocolic artery (ica), middle colic artery (mca) and ima were selectively ligated but not at their origins due to aberrant anatomy. laparoscopic subtotal colectomy with intracorporeal stapled ileosigmoid anastomosis were carried out (endogia mm, double layer / polyglicolic acid suturing of the breech). the anisoperistaltic nature of the anastomosis is due to the disposition of the mesenterium which did not allow an isoperistalting orientation of the two resected stumps. the specimen was extracted throught a pfannestiel incision. the postoperative course was complicated by intestinal obstruction conservatively treated with slow bowel function's restoration. the patient was discharged from the hospital in th postoperative day. unexpectedly specimen histology revealed two villous adenomas with high grade dysplasia. lymphnodes were retrieved from the specimen (ptisn ). to date our case is the only fully laparoscopic colonic resection reported in literature in malrotation as well as the first intracorporeal stapled ileo-sigmoid anastomosis for such disease. the median hospital stay was days. in-hospital mortality was nil. the overall morbidity was %. the median length of follow-up was months. conclusions: our preliminary results suggest that robotic-assisted surgery for colorectal cancer can be carried out safely and according to oncological principles. robotic surgery is advantageous for both surgeons (in that it facilitates dissection in a narrow pelvis) and patients (in that it affords a very good quality of life via the preservation of sexual and urinary function in the vast majority of patients and it has low morbidity and good midterm oncological outcomes). in rectal cancer surgery, the robotic approach is a promising alternative and is expected to overcome the low penetration rate of laparoscopy in this field. aims: postoperative inflammation have been reported as one of the independent prognostic factors in several types of malignancies.the aim of this study is to clarify the impact of laparoscopic approach on postoperative inflammatory status after surgery for colorectal cancer, and to analyze the association between postoperative inflammation and prognosis in patients with colorectal cancer. methods: a total of patients with stage l-lll colorectal cancer (crc) who underwent curative surgery were retrospectively analyzed. the maximum crp value measured between the times of surgical resection and discharge was defined as 'max crp'. the optimal cut-off value of max crp that best predicts rfs was determined to be mg/dl by the minimum p-value approach. methods: trainees working in this firm were responsible for data collection. patients who underwent emergency surgery during the calendar year of had the following details collected-the presence or absence of a complication in the -day post-operative period, the type of complication and description of complication along with the grade of the complication (see fig. .) . patients who underwent intermediate to major surgery were followed up at outpatients and were specifically asked for the occurrence of complications from the point of discharge up until the outpatient appointment. with one centralised national hospital-the people who were discharged and subsequently experienced considerable or major complications invariably represented back to hospital via the a&e department. results: a total of emergency surgeries were performed by this surgical firm in , % of these being done laparoscopically. of these cases- patients experienced post-operative complications within the first days after their procedure. this equated to a complication rate of . %. the most common complications were abdominal pain, nausea & vomiting, and wound infection. there were complications for each of these categories. post-operative bleeding occurred in cases with fistulas or leak of an anastomosis occurring in cases. death of a patient occurred in instances once as a result of post-operative bleeding from the site of anastomosis after a whipple's procedure, the nd occurred subsequent to post-operative bleeding from a peptic ulcer and in the rd case occurred in an instance of faecal peritonitis as a result of anastomotic failure after a roux-en-y bypass for a patient with pancreatic malignancy. conclusion: the davien-clindo classification proved to be simple, efficient and useful in analysing post-operative outcomes. the results indicate that despite the emergency setting & elderly cohort of patients-minimally invasive surgery proved to be a safe and viable option. conclusions: in this prospective study, we observed greater rates of detection of adenomas among endoscopists. screening colonoscopy on symptomatic and/or high risk group for crc is valuable in early detection and the prevention of crc. large sample size and long period of screening colonoscopy was needed. limitation of our study was the small sample size and no use of high detention endoscopy. results: the mean intraoperative blood loss volume was significantly less in the lap group than in the open group ( vs. ml, respectively, p \ . ). the mean operative time was not significantly different between the lap group and the open group ( vs min, respectively, p = . ). the incidence of severe postoperative complication (grade or higher in the clavien-dindo classification) was lower in the lap group ( / ( %) vs / ( %), respectively). the mean postoperative hospital stay was significantly shorter in the lap group than that in the open group ( vs. days, respectively, p = . ). conclusions: lap-tpe can be a safe and feasible procedure. background: amyloid light chain (al) amyloidosis is a rare protein deposition disorder with an incidence ranging between - cases per million people. it can present insidiously with localized or multisystem symptoms and usually occurs later in life. prognosis is poor as al typically presents at an advanced stage. intestinal pseudo-obstruction is a rarely reported complication of al amyloidosis. here we report a case of al amyloidosis which was identified during surgery for intestinal pseudo-obstruction. case presentation: a year old male presented to the emergency department with a month history of abdominal pain and distension, as well as marked swelling of his lower limbs. this had worsened in the previous weeks and he had developed intermittent diarrhoea. ct showed ileitis with marked dilation of the proximal small bowel. laparatomy revealed small bowel that was grossly distended that rapidly developed multiple petechiae and subsequent haematomas upon handling. two days later a repeat laparotomy was performed and . m of ishaemic small bowel was resected. histology showed amyloid deposition with positive congo red staining. subsequent cardiac events led to an echo being performed that showed concentric left ventricular hypertrophy attributed to amyloid deposition within the myocardium. free serum light chain ratio was sent and confirmed the diagnosis of al amyloidosis. he has recently been started on a treatment regimen consisting of cyclophosphamide and dexamethasone. discussion: systemic al amyloidosis frequently involves the gastrointestinal tract, typically presenting with chronic diarrhoea and associated malabsorption. only case presenting with pseudo-obstruction has been reported in the literature. al amyloidosis presents insidiously with non-specific symptoms depending on which organs are affected. treatment aims to prevent further deposition of protein within the organs. prognosis is determined by the organs that are affected and the extent of protein deposition within them. cardiac involvement holds the worst prognosis ultimately causing sudden cardiac death. the mainstays of management are early identification and treatment implementation to prevent protein build up and subsequent organ failure. conclusion: a diagnosis of amyloidosis should be considered in patients with intestinal pseudo-obstruction to expedite the diagnosis of al amyloidosis and improve survival. aim: in the management of locally advanced rectal cancer (larc), the achievement of a complete total mesorectal excision (tme) with clear resection margins was demonstrated to be the main predictor of overall and disease-free survival. predicting surgical difficulty in larc patients may be of particular importance to choose the best surgical approach. this study proposes a mri-based score to identify preoperatively larc patients with a high risk of having a difficult surgery. methods: this is a retrospective study based on the european mri and rectal cancer surgery (eumarcs) database, including patients with mid-low larc who were treated with neoadjuvant chemoradiation therapy and laparoscopic tme with primary anastomosis. data on pre-treatment and restaging through magnetic resonance imaging were available for all patients. surgical difficulty was defined as high or low grade taking in to account operative (e.g. duration of surgery), and postoperative factors (e.g. hospital stay). score accuracy was evaluated by estimating sensitivity, specificity and area under the receiver operating characteristics curve (aroc). results: seventeen ( . %) of larc patients were graded as high surgical difficulty. the eumarcs score was developed using the following significant predictors of surgical difficulty: bmi [ , interspinous distance \ . mm, ymrtstage = t b, and male sex. the score ranged from to . the cut-off score to best differentiate patients with a high probability of difficult surgery was = points. this cut-off value showed the best balance in sensitivity and specificity. the eumarcs score demonstrated high accuracy (aroc: . ) conclusions: the eumarcs score was found to be sensitive and specific in predicting surgical difficulty in larc patients who were candidate for laparoscopic tme. the score has the advantage of considering patient and cancer related characteristics that can be all assessed preoperatively and it can be useful in the decision making process. this score has not yet been externally validated. background: recently published two non-inferiority randomised control trials has raised questions on laparoscopic surgery for rectal cancer, showing lower quality pathological specimens to those achieved using an open technique. locally advanced rectal cancers add to the level of difficulty for laparoscopy approach. our study was aimed to assess feasibility of laparoscopic rectal surgery, comparing short term outcomes, quality of surgical specimen, morbidity and mortality, between propensity score match groups of locally advanced and early rectal cancers. methods: prospectively acquired data from consecutive patients undergoing laparoscopic surgery for rectal cancer at the minimally invasive colorectal unit in united kingdom between and . locally advanced rectal tumours were identified as t b or t with pre-operative mri scans. all the patients were operated by the same team and the procedures were performed laparoscopically. : propensity score matching was performed to create a perfect match in terms of tumour height. results: total of laparoscopic rectal resections were performed during the study period, out of which patients had locally advanced (la) disease and were propensity-score matched for tumour height with non-locally advanced (nla) patients. median operative time was higher for the la surgery group ( min vs min p = . ). however, conversion to open surgery (p = . ), readmission (p = . ), re-operation (p = . ), clinical anastomotic leak (p = . ) and -day mortality rates (p = . ) were all equivalent between the two groups. r resection was achieved in % of la group as compare to % of nla group (p = . ). conclusion: this study demonstrate that standardised approach to laparoscopy is safe and feasible in locally advanced rectal cancers. comparable post-operative short-term clinical and pathological outcomes were seen between la and nla groups. aims: the application of colorectal cancer screening programs, has showed a decrease in recurrence and mortality. for this reason, these programs are being implemented at a national level in the different spanish regions, as has happened in our community.to present the initial short-term results on the morbidity of the immediate postoperative period to days of colon cancer, mortality and hospital stay after the implementation of a screening program in our center. methods: a retrospective study was performed. patients aged between and years were included in the study, diagnosed with colon cancer. they underwent minimally invasive surgery, in most cases, with any type of colonic resection, from january to december . all patients were diagnosed, conventionally or through a screening program, the latter according to the plan implemented in our community. the sample was divided into two groups of patients according to the way of being diagnosed (group si screening = patients, group no screening = patients) and they were compared according different variables: dependent factors of the patient, factor of type colon cancer, factors of colon cancer resection and follow-up. results: both groups were comparable in all study variables. regarding the variables included in the follow-up, no statistically significant differences were found in terms of postoperative mortality-clavien-dindo v. however we found differences statistically significant in postoperative morbidity (p = . ) and in its classification according to clavien dindo i-iv (p = . ). the complications analyzed independently, such as anastomotic dehiscence (p = . ) or postoperative ileus (p = . ), have also presented significant differences, unlike surgical wound infection (p = . ). conclusion: at our center, the application of the screening program has not influenced in the initial stage of colon cancer or its surgical approach. however, we have found a lower overall morbidity rate and minor complications, justified by a lower incidence of anastomotic dehiscence and postoperative ileus. background: colorectal carcinoma is one of the most common malignancies. surgery is the only definitive method to achieve cure for this illness and can be performed via an open or a laparoscopic approach. the pros and cons of each approach have been discussed extensively, with the oncologic efficiency of the laparoscopic approach being one of the leading topics. objective: the aim of this study was to establish oncological non-inferiority of the laparoscopic approach to colorectal cancer. primary outcome measure was defined as number of harvested lymph nodes. secondary outcome measures were medium-term disease free and overall survival as well as length of hospital stay, time to oral feeding and short-and long-term complication rate. methods: this was a single center retrospective chart review. all consecutive patients who underwent colon or rectal resection due to colorectal carcinoma at hadassah medical center between the years - were included. patients who were operated on for recurrent disease or who had metastatic disease at the time of surgery were excluded. patients were divided into three groups according to the surgical approach: laparoscopic, open or converted. medium-term oncological outcomes were the same for all groups. time to oral feeding, length of hospital stay, short-and long-term complication rate were all significantly improved in the laparoscopic group. conclusions: we were unable to prove non-inferiority of the laparoscopic approach regarding the number of harvested lymph nodes. however, all surgical approaches yielded a high number of harvested lymph nodes which is most probably oncologically sufficient, as reflected by the non-existent difference in medium-term oncological follow up. this study supports previous studies showing the superiority of the laparoscopic approach regarding short term recovery and overall complications rates. aims: two non-inferiority randomised control trials have questioned the utility of laparoscopic surgery for rectal cancer by failing to prove that pathological markers of high quality surgery are equivalent to those achieved by open technique. we intend to present short and long-term postoperative outcomes from the largest single surgeon series of consecutive patients undergoing laparoscopic tme for rectal cancer. we describe the standardised laparoscopic technique developed by the principal surgeon, and the short-term outcomes from three surgeons who were trained in and subsequently adopted the same approach. methods: prospectively acquired data from consecutive patients undergoing surgery for rectal cancer by the principal surgeon (ap) at the minimally invasive colorectal unit in portsmouth between and were analysed along with data acquired between and from surgeons (tq,nf,ah) at three further international centres. end-points were overall and diseasefree survival at years, and early post-operative clinical and pathological outcomes. results: consecutive patients underwent laparoscopic tme surgery by the principal surgeon (ap). at years overall survival was . % (dukes' a = . %; b = . %; c = . %); disease-free survival was . % (dukes' a = . %; b = . %; c = . %). post-operative length of stay, lymph node harvest, mean operating time, rate of conversion, incomplete resection, major morbidity and day mortality were not significantly different between the principal surgeon and those he had trained when subsequently in independent practices. conclusion: laparoscopic tme produces excellent long-term survival outcomes for patients with rectal cancer. a standardised approach has the potential to improve outcomes by setting bench-marks for surgical quality, and providing a step-by-step method for surgical training. results: analysis of association of tumor location (sigmoid, right or left colon), operation time, blood loss, extraction site, type of surgical sutures used for wound closure with postoperative complications or specimen quality either did not show significant correlation or could not be conducted due to data nature. unexpectedly, a significant difference was demonstrated between two surgical teams in terms of hernias. majority of cases- ( . %) were performed by surgeon (s ), surgeon (s ) operated on ( . %) patients, nevertheless minilaparotomy closure was usually performed by junior members of the team. conversion rate was . % for s and . % for s (p = . ). operation time and blood loss were smaller in s group compared to s ( . ± . min vs . ± . min, p = . and . ± . ml vs . ± . ml, p = . respectively). specimen quality and early postoperative complications did not differ. postoperative hernia rate was . % for s and . % for s (p = , ). both surgeons used the same specimen extraction sites and materials for wound closure. hernias were more frequent after vertical minilaparotomy- % ( of patients), and in converted patients , % ( of patients), compared to , % ( of ) in transverse minilaparotomy group. there was no association of hernias and wound infections. conclusions: our study demonstrates, that besides consultant dependent surgical surrogates, steps which are often performed by other members of surgical team (such as wound closure) may contribute to complication rate as well. more thorough supervision of wound closure may be needed. aims: laparoscopic complete mesocolic excision (cme) right hemicolectomy is considered a demanding procedure and it is actually adopted in few centers from the west. the aim of the present study is to analyze the safety of laparoscopic cme right hemicolectomy and to compare its short-term results with standard right hemicolectomy in a single western center. methods: prospectively collected data from patients who underwent laparoscopic cme right hemicolectomy between june and november were retrospectively analyzed (cme group) and compared with data from patients submitted to standard laparoscopic right hemicolectomy between april and november (s group). results: no differences were observed between the cme and the standard right hemicolectomy groups in terms of clinical characteristics. in the cme group, . % of patients were = years old, . % of patients were asa class , . % of patients had = comorbidities, . % of patients had bmi [ and . % of patients had = previous abdominal surgeries. no differences were observed in terms of duration of surgery ( ± min vs. ± min; p = . ) and intraoperative complications ( . % vs. . %; p = . ) between cme and s groups; mean blood loss was lower in the cme group ( . ± . ml vs . ± . ml, p = . ). the percentage of overall ( . % vs. . %; p = . ) and severe (clavien-dindo = ) complications ( . % vs. . %; p = . ), redo surgery ( . % vs. . %; p = . ) and readmission ( . % vs. . %; p = . ) was comparable between cme group and s group. a significant difference was observed in the length of specimen ( ± mm vs. ± mm; p \ . ) as well as in the length of proximal ( ± mm vs. ± mm; p = . ) and distal margins ( ± mm vs. ± mm; p = . ) in favor of the cme group. the number of lymph nodes harvested was slightly higher in the cme group ( . ± . vs. . ± . ; p = . ) as it was for the percentage of cases with less than retrieved lymph nodes ( . % vs. . %; p = . ), although these differences did not reach statistical significance. conclusions: this study represents one of the few western experiences demonstrating the safety of laparoscopic cme right hemicolectomy. cme technique showed good short-term results and better quality specimens when compared with the standard procedure. aim and background: peritoneal dissemination of colorectal cancer (pc) makes the complete resection of cancer lesions impossible. in such cases, multidisciplinary therapy is essential with mainly chemotherapy. preoperative diagnosis of pc is usually uncertain by ct or mri image. for diagnosis of pc needs surgical materials with laparotomy. but the laparotomy and resection of pc with general anesthesia tends to make impossible for immediate chemotherapy. less invasive diagnosis of pc is necessary and expected.endocytoscopy (ec) makes the histological diagnosis with precise images gained by high magnification (x ). as a preliminary examination, ec diagnosis for resected specimens of pc were evaluated. methods: two cases of pc diagnosed in operation were evaluated. under general anesthesia, laparotomy was conducted. peritoneal dissemination lesions obviously diagnosed as pc were resected. immediately the lesions were stained by methylene blue solution for to s. ec observation was done according ec classification ) and ecv classification ). results: in two cases, ec observation was successfully done. images of dilated surface microvessels of a nonhomogeneous caliber or arrangement were observed in nbi ec corresponding to ec-v . histopathological diagnosis of resected specimens was metastatic colorectal carcinoma in peritoneum in both cases. conclusions: histological diagnosis for pc is gained by ec with resected specimen. as the result of this investigation, ec examination via camera port in laparoscopic operation might be possible for diagnosis for pc of colorectal cancer in vivo. aims: the aim of this presentation is to demonstrate and analyze surgical complications, arising during laparoscopic colorectal resections for cancer and to analyze the reasons of adverse events. methods: we demonstrate videos from our surgeries, where different types of complications occurred and share our classification of types of mistakes, that may lead to intraoperative complications and ways to prevent them. results: we divide mistakes in laparoscopic colorectal resections into two large groups-'false strategy' and 'dangerous techniques'. the first includes poor diagnosis, too extensive or insufficient extent of surgery and improper enthusiasm in using platforms. prevention of first type mistakes is in thorough training and peer-review of each consultant practice. second type of mistakes includes two subtypes : 'faulty habits'-use of unsafe techniques (blind port insertion, poor vascular exposure prior to clipping, not obtaining 'critical views', unsafe use of energy and stapling devices etc.) and 'failure in a certain case'-when despite correct general approach a complication occurred (misinterpretation of fascial layers or vessels). prevention of 'faulty habits' lies in supervised training in high volume colorectal departments including dedicated surgical devices training. to avoid 'failure in a certain case' standardization of surgical procedure is essential, as the most efficient way to prevent this type of mistake is 'pattern recognition'ability of a surgeon to compare the picture he sees during a procedure with a 'standard' view, he used to have during previously performed standard surgeries-this is apparentely impossible when every procedure is done differently. regular reviews of own surgeries recording and other surgeons' procedures may also fascilitate pattern formation. in case a complication occurres we use the four step course of action: preservation of the view, temporary control, decision on conversion, permanent control. conclusion: as popularity of laparoscopic colorectal resections is growing rapidly the number of intraoperative compliactions is increasing as well. we demonstrate videos of complications and our approach to classification of possible mistakes. systematic aproach to reasons, underlying certain mistakes helps to produce a strategy to reduce intraoperative complication rate. introduction: the drains placement inside the abdominal cavity has traditionally been carried out to evacuate hematic remains or postoperative collections. there is no scientific evidence of the prophylactic use of drainage in elective colorectal cancer (ccr) surgery to avoid anastomotic complications or other complications. however, it is traditionally used. when the anastomotic leak is produced, it is generally agreed that drainage system should be used for therapeutic purposes. aims: the aim of this study is to evaluate the effectiveness of the use of prophylactic drainage in elective surgery of ccr. we would check if they avoided the appearance of complications, and if they are useful when the anastomotic leak appears. methods and results: we analyzed the data collected in our hospital from / / to / / . we studied the number and type of interventions in which prophylactic drainages were placed, the appearance of anastomotic complications and if these drains were effective. interventions were performed during this period of time. % of these procedures had used prophylactic drainage ( interventions). this percentage was up to % in patients who have performed a left colon surgery as a sigmoidectomy or rectal procedure. during this period, there were cases of anastomotic leakage. in all of them had been placed drainage but only of them were effective. conclusions: we have seen that prophylactic drainage is a common practice independently of the location of the anastomosis. the last multimodal rehabilitation guidelines recommended the nonuse of drains systematically above the peritoneal reflection with a high level of scientific evidence. they cause discomfort to the patient and delay early mobilization. however, it may be useful to use drains in the first h of a pelvic floor procedure. there is not enough evidence to show sistematic drainage after colorectal anastomosis prevents complications of the anastomosis or other complications. aims: colonic cancers of the splenic flexure is uncommon and associated with poor prognosis. several studies were published aimed to identify the optimal surgical option for the best oncological outcomes. however, whether an extended colectomy or a segmental resection is required is still controversial. the aim of this study is to analyse the outcome of the two different approaches through the experience of a single centre. materials and methods: retrospective data of consecutive patients with diagnosis of colonic cancer situated at the splenic flexure of our department between and were analysed. based on type of surgical procedure, patients were enrolled in arm a (segmental resection) and arm b (extended resection). arm a patients were treated with segmental resections with a wide mobilisation of the transverse and descending colon and ligation of the left colic artery, sparing the middle colic artery and the inferior mesenteric artery. functional lateral to lateral anastomosis was performed extracorporeally. arm b patients were treated with more extended colectomies, both associated with central vascular ligation. results: out of patients included, were allocated in arm a and in arm b. patients' population of the arms was homogeneous as concerns demographic characteristics and stage of the disease. operative time was comparable ( , min vs min, p = , ). the length of the specimen was significantly shorter in arms a ( , vs , , p = , ) . the number of harvested lymphnodes did not differ between the two groups ( , vs p = , )postoperative short term complications was comparable in both arms ( vs , p = , ). no postoperative mortality was observed. overall -year survival and disease free survival rates were similar in arm a and b ( . % vs . %, p = , and , % vs , %, p = , ). hospital stay was similar in the two groups (p = , ). conclusions: despite a shorter length of surgical specimen after limited resections, postoperative complications, lymph node harvest, and survival were comparable in both.in our opinion the extracorporeal anastomosis is functional to both the achievement of a cleaner operative field and a better control of the resection margins. incidence of neuroendocrine tumours in the rectal area has increased in recent years.before the onset of minimally invasive colorectal surgery, these lesion had to be treated by a more radical technique when not suitable for endoscopic resection.selection of the cases is mandatory in order to achieve good results not only surgical, but also oncological. we present our series of neuroendocrine tumoirs treated by tamis approach, including technical aspects, deffect closure techniques and data regarding pathological findings.all cases were low grade carcinoid tumours. resection with free margin was obtained in all cases. defect closure was performed in all cases. the tumours were settled , and cm form the anal verge. postoperative course was uneventful, ann no adyuvant therapy was needed.tamis apporach for rectal neuroendocrine tumours is a safe and feasible technique. proper selection of the cases is mandatory in order to achieve good results. surg endosc ( ) aim: to assess the safety and efficacy of single layer of barbed vs double layer 'hybrid' (interrupted and running) suture for the closure of anastomotic stapler access enterotomy after laparoscopic right colectomy with intracorporeal anastomosis. methods: from april to november , laparoscopic right colectomy with intracorporeal anastomosis were performed in our surgical department. all patients in both groups were perioperatively managed using an eras pathway. seventy-two patients had the enterotomy closed with a single layer running suture of filbloc tm (assut europe). these patients were matched with patients who underwent intracorporeal right colectomy with enterotomy closed with a 'hybrid' double layer technique (first layer interrupted stitches in maxon tm - (covidien), second layer using a running suture in pds tm - (ethicon). intraoperative variables, anastomotic leak rate, morbidity and mortality rates were analyzed. results: the two groups were homogeneous with respect to demographics, body mass index (bmi), american surgical association score (asa) as well as for tumor stage. in the barbed group, median operating time was . min vs . min in the hybrid group (p = . ). anastomotic leak occurred in ( . %) patients in the hybrid vs ( . %) patients in the barbed group (p = . ). all patients required a reoperation. intraoperative findings show in ( . %) cases in the hybrid group a leak at the enterotomy closure, while an intact staler access was observed in both patients in the barbed group. no difference was observed with respect to noninfectious complications between the two groups (p = . ). patients in the hybrid group experienced a longer hospital stay when compared to the barbed group (p = . ). a re-admission occurred in the hybrid due an intraabdominal collection, while no re-admission was observed in the barbed group. no patient died in the postoperative period. aims: lymph node status is one of the key prognostic factors in patients with colorectal cancer, and remains the most important selection criteria for adjuvant chemotherapy. it is believed that at least % of node negative patients will suffer disease recurrence within the first years after surgery. this may be due to understaging lymph node status. sentinel lymph node mapping is widely used for staging of breast cancer and melanoma, with injection of colloid tc and isosulfan blue (ib). however, indocyanine green (icg) fluorescence guidance is a new technical approach to this issue, with promising results as it is not influenced by body mass index or lymphatic invasion. intraoperative fluorescence icg navigation also aims for detection of aberrant lymphatic drainage outside the planned resection. the icg lymphography has the advantage of offering a good visualization of the lymphatic channels but there are problems to identify the lymphatic nodes. our objective with this study is to rate the use of the intraoperative lymphogram in cases of elective colorectal surgery to evaluate if there were changes in the surgical attitude regarding the performance of lymphadenectomy. methods: indocyanine green was injected into the submucosal layer around the tumor at points with?a -gauge localized injection before lymph node dissection and the lymph flow was observed at , and min after injection, using a near-infrared camera system. in addition, a complete mesocolic excision with central vascular ligation guided the region where the lymph flow was observed to be fluorescent. the following table summarizes the procedures carried out as well as the lymphadenectomy performed before and after the use of icg. in brief, after the application of intraoperative icg it was observed that in % of patients additional lymph nodes were obtained after the expansion of the surgical plan, moreover % affected lymph nodes were spotted after the expansion of the surgical plan. conclusions: intraoperative real-time visualization of the lymph flow using indocyanine green fluorescence imaging during laparoscopic colon cancer surgery is feasible and a helpful technique for lymph node mapping which may lead to intraoperative changes in lymphadenectomy. tamis resection of rectal tumours has proven to be a sefe and feasible technique, specially for lesion located in the mid and low rectum.when the tumour is located in the upper rectum, and specially near the colorectal junction, tamis resection may be more difficult, not only due to technical aspects, but also due to the risk of a free perforation, specially when a full thickness resection is performed.we present our results of tamis resections of lesions located around the colorectal junction. four resections where performed with the aim of an endostpaler in order to achieve full resection without the risk of a free colonic perforation.in cases, an abdominal combined laparoscopic exploration was made, in order to help and assure proper resection of the lesion as well as avoiding intraoperative complications.distance from the anal verge ranged from to cm.postoperative course was uneventful in all cases, and a complete specimen resection was obtained in all cases.tamis resection of tumours located in the rectosigmoid junction may be a safe and feasible technique in selected patients. methods: between january to april , patients with diagnosis of right colon adenocarcinomas underwent right hemicolectomies. the data was analysed for patients demographic, histology, type of surgical approach, intraoperative details (length of surgical procedure, blood loss, blood transfusion, conversion rate) and short-term post-operative outcomes including complications. introduction: postoperative ischemic colitis is a life-threatening vascular gastrointestinal condition, that mainly occurs after cardiovascular surgery. we present a surprising case following a laparoscopic rectum resection. case report: a -year-old diabetic patient with upper rectal adenocarcinoma undergoing laparoscopic anterior rectal resection (partial mesorectum excision) and mechanical anastomosis following chemotherapy / radiotherapy. after h postsurgery he presented abdominal pain, distension and fever. on adominal computed tomography (ct) scan (contrast enema) no anastomotic leakage (al) finfings were revealed. neither digital palpation nor proctosigmoidoscopy ( th day) showed al signs. the patient clinical situation improve with conservative treatment (antibiotics, digestive rest …), c-reactive protein levels decreased and the blood cultures were negative. on the th day he was discharged presenting semiliquid stools. eight days later he needed hospital readmission: air and feculent/purulent discharge from the previos abdominal drainage orifice. ct scan: no evidence of dehiscense found although rectum and sigmoid colon distention and an image of a 'large fecaloma' were observable. on the th day of hospitalization he expulsed a large malodorous segment of tissue with necrotic asppearance (image) through the anus with surprising histologic features: 'complete-thickness necrotic colonic wall'. further rectosigmoidoscopy: complete anastomosis, signs of ischemic colitis proximate to the anastomosis and a fistulous orifice. surprisingly, the patient progressed favorably, being discharged the th day for ambulatory control with a low debit enterocutaneous fistula. histopathological diagnosis: ypt n m . follow up: the fistula discharge quantity increased maintaining diarrheal stools through anus along with persistent anemia and malnutrition. a exploratory laparotomy was schedule. fistulous tract towards a small stenotic segment of colon inmediately proximal to the colorectal anastomosis was identify and resected. finally a terminal colostomy was performed. subsequent postoperative without incidents. currently the patient is asymptomatic. comments: it seems indisputable that a colon segment, proximal to the anastomosis, was necrosed and expelled through a colorectal anastomosis. the mechanism seems inexplicable to us. it is even more disconcerting that there was no disruption of the anastomosis. objectives: fluorescence-guided surgery has emerged as a new imaging modality to improve the detection of liver and lymph node metastasis in colorectal cancer. in right-sided colon cancer, the standard lymphadenectomy should reach the ileocolic vessels and the right branch of the middle colic vessels. the purpose of this study is to perform an objective estimation of lymphatic drainage and metastatic lymphonodes in right-sided colon carcinoma through indocyanine green (icg) lymphography. methods: patients with right-sided colon adenocarcinoma were included, excluding those in stage iv, t and those who underwent urgent surgery. cc of icg peritumoral were injected using a peripheral intravenous catheter at the beginning of the intervention. the lymphatic drainage mapping of the tumor was identified. lymphadenectomy of the ileocolic vessels and right branch of the middle colic vessels was performed extending it to the left branch and origin of middle colic vessels if it was shown in the mapping. results: patients were included. the average age was . in patients the tumor was located in the ascending colon and in patients in the hepatic angle. in patients, the mapping showed lymphatic drainage to ileocolic vessels and right branch of the middle colic vessels. in patients ( %) it showed drainage to the left branch and origin of the middle colic artery, therefore extended lymphadenectomy was performed at that level. in patients, the postoperative period was uneventful. patient presented infection of the surgical wound and another patient developed a cm perianastomotic collection treated with percutaneous drainage. the anatomopathological report showed nodal metastasis in of the patients ( %) in whom lymphatic drainage was observed in the territory of the middle colic vessels with icg. these patients presented the tumor in the hepatic angle. therefore, of the patients with right-sided colon carcinoma ( %) presented nodal metastasis in the territory of the middle colic vessels. conclusions: fluorescent lymphography may improve the results of lymphadenectomy in colon cancer. in patients with tumors of the hepatic angle, lymphadenectomy extended to the left branch and origin of middle colic vessels, could be an adequate alternative. introduction: over the last decade, the common principles of surgical treatment in colon surgery are central vascular ligation (cvl) and complete mesocolic excision (cme). however, the superior mesenteric vessels anatomy, while performing the right colectomy is characterized by wide variability, which can lead to complications, especially during minimally invasive surgical intervention. objective. the purpose of this study is describing vascular variations around the superior mesenteric artery and vein-middle colic, right colic and ileocolic vessels, henle trunk in the laparoscopic right colectomy. materials and methods: the study was held in the 'dobrobut' clinic and o. o. bohomolets national medical university, department of general surgery (kyiv, ukraine) during the - period. patients were included to the study, females ( . %), males ( . %) in the average age of , ± , years. all the patients underwent the laparoscopic right colectomy (cme ? cvl) with d lymph node dissection. recorded video materials from each laparoscopic right colectomy were analyzed during the study. results: ileocolic vessels were the most stable. there were typical anatomical position in all cases. . % of cases, ileocolic vein was identified anteriorly to the ileocolic artery, while . % being posteriorly. right colic vein was absent in . % of cases. right colic vein drainage was to henle trunk and inferior mesenteric vein in . % and . % respectively. the right colic artery was present in % of patients, it's origin was superior mesenteric artery in . % and . % the middle colic artery. the middle colic vein was present and drained to superior mesenteric vein in % of cases. same as the middle colic artery with the superior mesenteric artery origin. henle trunk was present in . %, gastro-pancreato-colic trunk in . % of cases gastro-pancreatic trunk in . %, gastro-colic in . %. conclusions: knowing the options of surgical vessels anatomy, while performing the right colectomy, altogether with surgeons preparation, using the ct-scan data can reduce the risk of iatrogenic damage and complications risks. introduction: the enhanced recovery after surgery (eras) protocol was designed to accelerate convalescence, reduce morbidity and shorten the length of hospital stay (los). one of its major interventions is balanced perioperative fluid therapy. the impact of this single intervention on short-term outcomes is widely discuss. aim: the aim of this study was to assess the impact of perioperative fluid therapy on short-term outcomes. material and methods: the analysis included consecutive prospectively registered patients operated laparoscopically for colorectal cancer between november and january . patients were divided into two groups: balanced (= ml) or unbalanced ([ ml) perioperative fluid therapy. all patients were treated according to eras protocol. study outcomes were: recovery parameters, morbidity rate, los, -day readmission rate. results: group consisted of and group of patients. there were no statistically significant differences between the groups in terms of demographic and operative parameters. morbidity was lower in group ( . % vs . %, p = . ). patients in group were discharged home earlier than in group ( vs days, p \ . ). moreover, we observed differences in recovery parameters between the groups: tolerance of an oral diet on the st postoperative day ( % vs. %, p = . ) and patient mobilization on the day of surgery ( % vs. %, p = . ). -day readmission rate was lower in group ( . % vs. %, p = . ). conclusion: a balanced perioperative fluid therapy on the day of surgery may be associated with faster convalescence, lower morbidity rate, shorter los and lower -day readmission rate. methods: a retrospective analysis was performed including patients who underwent lcs or ocs for cancer treated as emergency in a single centre between and . patients who underwent palliative surgery were excluded. lcs were : propensity score-matched based on pposum and stage of disease with ocs. short-term outcomes included oncological quality, length of hospital stay (los) and postoperative mortality. for long-term outcomes, -year overall and disease free survival (os and dfs) rates were analyzed. results: during the study period, a total of emergency colorectal resections were performed. of them, % (n = ) were coloniccancers. lcs were matched to an equal number of ocs.median age was ( ) years and % were females. median follow-up was ( ) months. the majority of resections were right hemicolectomies ( %), followed by sigmoid resections ( %) and subtotal colectomies ( %). operative time ( ( ) background: total mesorectal excision (tme) offers the best reported rates for local recurrence and survival in patients with rectal cancer. our series from a single high-volume center, assessed the feasibility, safety and long-term oncologic adequacy of laparoscopic total mesorectal excision methods: we reviewed the prospective database of consecutive unselected patients undergoing laparoscopic tme for rectal cancer between and at the department of general surgery, onze-lieve-vrouwziekenhuis hospital (olv), campus aalst, belgium. the objective of the present study was to evaluate the effectiveness of laparoscopic tme, with an emphasis on perioperative variables and long-term oncological outcomes. results: pts with mid and distal rectal cancer up to cm from the anal verge had laparoscopic tme resection. patients ( . %) underwent a sphincter-preserving surgery and the remaining patients ( . %) had an abdominoperineal resection. end-to-end anastomoses: pts ( %), j-colonic pouch: pts ( % introduction: the rica clinical pathway (intensified recovery in abdominal surgery), also called surgical multimodal rehabilitation, is the application of a series of perioperative measures and strategies in those patients who are going to undergo a surgical procedure with the objective of reducing secondary stress to the surgical intervention. in this way, we achieve a better recovery of the patient and significantly reduce complications and morbidity. objective: s to analyze, through our database of patients undergoing crc, the percentage of postoperative ileuses and the following quality indicators: the postsurgical hospital stay, the anastomotic leak, and the infection of the surgical site. to check if the implantation of the rica pathway has meant an improvement in our postoperative hospital stay and with that, a lower sanitary cost. methods and results: we analyzed the data collected from those patients who underwent ccr in our hospital between / / and / / , during which time we implemented the rica clinical pathway. the average hospital stay was days. of the patients, . % presented anastomotic leak, . % infection of the surgical wound and . % paralytic ileus. we have verified how the average hospital stay increases with the appearance of anastomotic leak ( . days), infection of the surgical wound ( . days) and paralytic ileus ( . days). when we divided this -month period into two halves to see the impact of the implantation of the clinical pathway, we obtained the following results: the post-surgical hospital stay in the period from / / to / / was . . the stay from / / to / / was . . the implantation of the rica clinical pathway is providing us with important advantages in our clinical practice, with greater postoperative comfort and an improvement in our quality indicators, such as the decrease in the average hospital stay of our patients. on the other hand, after starting its implementation we have encountered the resistance to change clinical habits and the one that requires a multidisciplinary participation, so adherence to this is being progressive, and requires periodic audits to reinforce and consolidate our achievements, and identify our points of improvement. however, tem has not yet achieved widespread use. recently, transanal minimally invasive surgery (tamis) using single-port surgery devices has been reported. initially facilitated by existing single-port surgery devices, two platforms for transanal access, the gelpoint Ò path (applied medical, rancho santa margarita, ca, usa) and the sils tm port. the gelpoint Ò path is the only platform to be specifically designed for tamis y tatme. objetive: in the present study, usesa gelpoint Ò path was performed in patients with lower rectal neplasms. results: complete full-thickness excision was performed in all cases of tamis and free margins over rectal cancer. on two cases no neoplasm was visualizad. the patient characteristics, operative techniques and operative outcomes were evaluated. the mean age of the patients was . years (range - ). the mean operating time were min (range - ). patients was selsted for tatme, for tamis and two patients for evaluation and biopsy if was necesary. additional transabdominal rectal resection was not performed, and adjuvant chemoradiotherapy was performed in all cases. tamis using a gelpoint Ò path was revealed to be easy and safe to perform. although only a small number of cases were treated, and the operation was demonstrated to be sufficiently feasible. conclusion: gelpoint path is a good tool for colorectal surgery in tatme, tamis and evalluation of anastomoses or de novo lesions introduction: several improvements in rectal cancer treatment, in the last decades, resulted in a markedly increased survival. nevertheless, surgery remains the prevalent treatment and to % of operated patients experience some kind of functional abnormalities. as nowadays we acknowledge the importance to focus not only on survival rates but also on quality of life, we craved for a precise, reproducible, simple, clear and user-friendly tool for evaluating bowel function in rectal cancer patients after sphincter saving operation. therefore, we performed a thorough translation with cultural adaptation of the patient reported outcome tool, low anterior resection syndrome (lars) score, to the portuguese language (lars-pt) and population. methods: according to the current international recommendations, we designed this study encompassing three main phases: (i) cultural and linguistic validation to european portuguese; (ii) feasibility and reliability tests of the version obtained in the previous phase; and (iii) validity tests to produce a final version. the questionnaire was completed by patients from six portuguese colorectal cancer units, and completed it twice. results: the portuguese version of lars score showed high construct validity. regarding the test-retest, the global intraclass correlation showed very strong test-retest reliability. looking at all five items, only items and presented a moderate correlation. lars score was able to discriminate symptoms showing worse quality of life in patients submitted to preoperative radio and chemotherapy. conclusion: lars questionnaire has been properly translated into european portuguese, demonstrating high construct validity and reliability. this is a precise, reproducible, simple, clear and user-friendly tool for evaluating bowel function in rectal cancer patients after sphincter saving operation. therefore, his sistematic use should be implemented. oesophagectomy is the mainstay of curative treatment for oesophageal cancer and post-oesophagectomy diaphragmatic hernia (podh) represents a potentially life-threatening surgical complication characterized by an underestimated occurrence rate and unknown related risk factors. this study analyses the experience of two tertiary designated centers in order to evaluate key elements concerning development and treatment of podh. a cohort of consecutive patients affected by a clinically resectable oesophageal cancer (any t, any n and m ) underwent ivor-lewis oesophagectomy between march and april according to three different approaches: totally open incision procedure (oilo), hybrid (hilo) and totally mininvasive to esophagectomy (milo). all population was retrospectively observed in the context of a postoperative calendarised follow-up in order to record the incidence and postrepair results of podh. patients underwent ivor-lewis oesophagectomy for cancer and ( . %) developed podh within a median follow-up period of months ( - ). surgical repair was generally applied by the mean of laparoscopic cruroplasty ( %) with a conversion rate of %. postoperative morbidity did not include early recurrences but exclusively cardio-pulmonary complications ( patients) with one case of respiratory failure leading to death. the discharge was reached after a median hospital stay of days ( - ) while recurrences ( %) occurred over a median followup period of . months. a wide univariate analysis identified statistically significant associations between podh occurrence and the administration of preoperative chemoradiotherapy, the complete pathological response (cpr) and a lymph node harvest (lnh) larger than stations (p-value of . , . and . respectively). the strong influence of an extended lnh was confirmed by the multivariable analyses ( . ) along with cpr which should however be considered as longer survival-related bias. the minimally invasive surgery and the neoadjuvant chemoradiotherapy represent a considerable part of multimodal treatment for oesophageal cancer presenting a not statistically significant association with podh development while a lnh including more than nodes resulted to be an independent risk factor mirroring the extent of surgical demolition in oesophagectomy. l. barbulescu aim: to asses the safety and effectiveness of robotic total meso-rectal excision vs laparoscopic total meso-rectal excision and to analyse the primary outcomes. methods: the operative, post-operative and oncological outcomes were evaluated to assess the effectiveness of both techniques of tme. in our center were performed robotic rectal resections and laparoscopic resections from january to present. results: the rtme was associated with longer operation time, early bowel movements, lower risk of conversion and shorter hospitalization. the statistical equivalence was seen between rtme and ltme for non-oncological variables like blood loss, morbidity and reintervention risk. the oncological variables such as number of harvested nodes and positive circumferential resection margin risk were also comparable in both groups. the length of distal resection margins was similar in both groups. conclusion: rtme in patients with rectal cancer was associated with a lower rate of conversion and less incidence of urinary retention. the operative time in rtme was significantly longer than in ltme. the initial oncological and function outcomes of rtme seem to be equivalent with ltme. c. athanasiou aims: two randomized controlled trials failed to show non-inferiority of the laparoscopic total mesorectal excision (ltme) compared to open. ltme becomes particularly challenging in low rectal cancers and in narrow pelves. many surgeons report that robotic tme (rtme) may be beneficial in that setting. our aim was to systematically review the literature and compare the pathologic outcomes of open, laparoscopic and robotic tme for rectal cancer methods: medline, embase, scopus, cochrane library and web of knowledge databases were searched for randomized controlled trials (rct) reporting patholologic outcomes of open, laparoscopic or robotic tme with no language restriction. our primary outcome was quality of tme on macroscopic assessment of the specimen. secondary outcomes included positive circumferential resection margin, distance to radial margin, number of lymph nodes and positive radial margin. the included studies were quality assessed and the jadad score was reported. the grade approach was used to rate the certainty of each network estimate. results: fourteen rcts were included in our study. seven rcts compared the otme to the ltme, six compared the ltme and rtme and one study the otme to the rtme. no statistical significant difference was found in quality of tme when the the ltme was compared to the otme or = . ( . , , ) or the rtme or = . ( . , . ) . no difference was found in pcrm for the laparoscopic or = . ( . , . ) or the robotic approach or = . ( . , . ) when compared to open. distance to radial margin and number or lymph nodes didn't differ between the groups. conclusions: no significant advantage on pathologic specimen quality has been found with the robotic approach. the ltme doesn't seem to compromise the quality of the specimen. h. samura , j. arakaki , k. sugata , y. hori , y. nagamine , f. kohagura , h. motonari , s. kameyama , t. ishimine division of digestive and general surgery, urasoe general hospital, okinawa, japan; department of surgery, urasoe general hospital, okinawa, japan colorectal cancer often invade adjacent organs and it is known that prognosis improves with resection of the involved organ. we report our experience of invaded adjacent organ resection, which include seminal vesicle, uterine and bilateral appendages, posterior wall of the vagina and bladder wall. method: although the range of resection is predicted by image study preoperatively, at the time of operation, it was decided by palpation with a forceps. each operation is evaluated by operation time, blood loss, blood transfusion volume, postoperative complication, postoperative hospital stay, and short term prognosis. result: resection cases of seminal vesicle, posterior vaginal wall, uterine and bilateral appendages and bladder wall were , , and , respectively. the results are shown in the order of seminal vesicle / vaginal posterior wall / uterine / bladder. median age was , , and years old. the median operation time was , , , min, the median blood loss was , , , ml, and only one case of uterine and bilateral appendages resection required the blood transfusion. the average postoperative hospital stay was , , , days. nine cases have postoperative complication, that include delayed wound healing, anastomotic leakage and rectovesical fistula, postoperative ileus, chyle ascites and neurogenic blodder. all of those were improved with conservative treatment. the mean hospital stay in complication cases was days ( - ) and ( - ) days without complications. the median observation period was days ( - ), and there was no local recurrence. all of the case of stage iv were dead. there was no local recurrence and all patient without stage iv are alive, it seems that the resection range was sufficient. conclusion: even with adjacent organ invasion colorectal cancer, it was possible to determine the resection line by palpation with laparoscopic forceps manipulation, and possible to resect margin free of cancer. laparoscopic low rectal resection with/without diverting ileostomy p. ihnát, m. tesar, p. ostruszka, p. gunková, p. vávra background: the construction of diverting ileostomy (di) is recommended to avoid septic complications of anastomotic leakage. the aim of our study was to assess the benefits and risks of di constructed during laparoscopic low anterior resection (lar). methods: retrospective clinical cohort study was conducted in university hospital ostrava, czech republic. all patients undergoing laparoscopic lar with tme because of rectal cancer within a -year study period were assessed for study eligibility. results: a total of patients ( patients without di, patients with di) after laparoscopic lar were enrolled into the study and underwent analysis. both study subgroups were comparable in terms of demographic and clinical features. postoperative -day morbidity was significantly lower in patients without di ( . % vs. . %, p = . ). anastomotic leakage frequency was higher in patients without di ( . % vs. . %, p = . ); surgical intervention was necessary in . % of patients without di. stoma-related complications were noted in . % of patients with di; some patients had more than one complication. surgical intervention because of stoma-related complications was needed in patients ( . %). distinctive complications of di laparoscopic construction (small bowel obstruction due to di semi-rotation around its longitudinal axis) was noted in patients ( . %). mean stoma period (interval between lar and di reversal) was more than months in our study; only . % of patients were reversed without delay (= months). postoperative morbidity after di reversal was . %; re-laparotomy was needed in . % of patients. conclusions: despite benefits of di in protecting low rectal anastomosis, ileostomy construction remains fraught with many stoma-related complications and long stoma periods associated with significantly decreased quality of life. aims: single port laparoscopic is a minimally invasive surgical technique that joint the cosmetic advantages with the well recognized benefits of the standard laparoscopic approach [ ] . we describe a laparoscopic single port hartmann reversal in a patient by the use of the umbilical colostomy site for surgical access [ ] . methods: a years old patient was submitted to a laparoscopic single port hartmann procedure with an trans-umbilical colostomy for a recurrent sigmoid volvulus that was treated at the beginning by endoscopic de-rotation. after three months the patient was reevaluated for a hartmann reversal with a laparoscopic single port technique. after routine skin preparation and laparoscopic setup, the colostomy is mobilized from its mucocutaneous border, and the anvil of a circular stapler is secured to the distal lumen. by the use of a gelpoint system with trocars, the intra-abdominal adhesiolisis in performed. the splenic flexure is mobilized to achieve a sufficient mobilization of the left colon that allows the fashion of a tension free anastomosis. the rectal stump is mobilized to the mid rectum, starting from the posterior mesorectal fascia around to the anterior rectal wall. a tension-free colorectal anastomosis is secured with a standard circular mm stapling device inserted transanally. the colostomy wound is closed. the operative time was min. results: the postoperative course was uneventful, the patient was discharged at forth postoperative day, oral intake started on postoperative day three. conclusions: single port laparoscopic hartmann reversal thought the umbilical stoma site is a minimally invasive surgical option that is safe in selected patients and offer the best cosmetic results. [ the progressive evolution of surgical techniques and oncologic protocols on rectal cancer disease facilitates surgeons to challenge the skills for anus preservation in low rectal cancer surgery. the laparoscopic surgery is already one of the best ways to reach the pelvic floor and to try procedures, which were previously difficult to apply through open surgery. the anastomotic leakage has particularly high occurrence if the anastomosis is performed in the anal or distal rectum area. it is evident that although the fecal diversion does not decrease post operatory mortality, it significantly reduce the risk of anastomotic leak and the risk of a second major surgery when the leak occur. diverting stomas are low-risk procedures from a technical point of view, but they potentially expose the patients to postoperative morbidity, impacting the patients' quality of life. it is not easy to decide whether the fecal diversion is needed or not. this decision must be made on a case to case basis, trying to apply the stomas only when they are really needed. we report our initial experience by living a transmesenterial cotton loop around the pre terminal ileum which extremities are turned out usually through the lateral trocar wound in laparoscopy or by applying a dedicated mini incision in open surgery. the purpose is to perform (in case of suspected fistula), a mini invasive diverting procedure, by widening the loop wound and by pulling up the ileum in a lateral loop ileostomy. we applied this procedure to consecutive patients with low colorectal anastomosis and in two of them we performed a lateral loop ileostomy with good results. we believe this can be an alternative that needs to be standardized. purpose: sarcoidosis is a chronic, multisystem inflammatory disorder with unknown aetiology characterised by noncaseating granulomas within involved organs. gallbladder involvement in sarcoidosis is extremely rare and literature review revealed only reported cases to date. in this paper, we present a case of gallbladder associated sarcoidosis. method: a -year-old lady was known to the clinic for regular surveillance of liver steatosis and incidental gallbladder polyps. the largest polyp was mm at presentation in and has grown to mm in . in view of worsening symptoms of biliary colic and growing polyps, a laparoscopic cholecystectomy was performed. results: laparoscopic cholecystectomy was unremarkable and specimens of the gallbladder and lymph nodes were sent for histology. histological examination revealed chronic cholecystitis with polypoid cholesterolosis of the gallbladder and noncaseating granulomata within a lymph node, which strongly suggest sarcoidosis. conclusion: in conclusion, we report a case of incidental finding of gallbladder sarcoidosis over the course of treatment of biliary colic and symptomatic gallbladder polyps. therefore, the definitive treatment for patients with symptomatic gallbladder sarcoidosis is a cholecystectomy. the surgical management of cholelithiasis can be associated with significant morbidities. despite the relatively low incidence of bile duct injuries during laparoscopic cholecystectomy, the total number is large due to the high frequency of the operation. the subtotal cholecystectomy with its variants is a well known bailout strategy to the surgical community. however, there is no agreement on when and how to perform these procedures. indeed, the majority of surgeons will adopt these solutions when there is a struggle to identify the critical view of safety. this struggle results increases the risk of injuries. we hypothesize that a primary intent gall bladder lithotomy and disconnection (glad) when the dissection of the gb pedicle is anticipated difficult dissection is a safe and feasible strategic option. methods: out patients elevtively admitted to aberdeen univesity hospital with gall stone disease between march and november , consecutive patients were operated with glad procedure based on intraoperative criteria. the primary outcome was the operative time. secondary outcomes were length of hospital stay, the criteria to do this procedure will be explained, the outcomes will be listed. indocyanine green is a molecule that becomes fluorescent when excited struck with light of a specific wavelength in the infrared spectrum (nir-infrared), allowing the visualization of anatomical structures in which it has accumulated. the aim of the study is the application of icg enhanced fluorescence in laparoscopic cholecystectomy in order to identify the anatomy of the biliary tract, to reduce the risk of iatrogenic lesions and the conversion rate. the study involves laparoscopic cholecystectomy for cholecystitis and gallstones of main biliary tract. the evening before the surgery, a vial of icg ( mg) diluted in ml of saline solution was intravenous injected. during the procedure, after opening the calot triangle, switching to the nir mode on the camera, the anatomy of the biliary tract and in particular of the main biliary tract is visualized. the cystic duct and cystic artery are isolated, their section between clips is cut and the cholecystectomy is performed. from january patients were enrolled: cases of acute cholecystitis, cases of gallstones of main biliary tract, undergoing preoperative ercp. in cases of cholecystitis, the angiography allowed the visualization of the main biliary tract. in one case, an abnormal course of the cystic duct was identified. in two cases of gallstones of common bile duct, it favoured the visualization of the biliary tract anatomy. all cases were completed with laparoscopic technique. there were no intra-and post-operative complications. icg-enhanced fluorescence is a safe, effective, cheap and rapid tool that can also be applied in small hospitals with no need for training. its use does not extend the time of surgery and allows the visualization of the anatomy of the biliary tract, especially in situations where it can be altered by reducing the conversion rate and potentially the risk of iatrogenic lesions of the main biliary tract. case presentation: patient is a year old female with no significant past medical or surgical history presented to the emergency department with a day history of worsening sharp right upper quadrant pain with associated nausea, vomiting, and po intolerance. the pain started a few months prior, however it was self-limited with diet modifications. an ultrasound demonstrated a contracted gallbladder with a mm gallbladder wall. white blood cell count was within normal limits and total bilirubin was slightly elevated to . mg/dl. no palpable mass was noted on physical exam. an mr cholangiopancreatography was performed which demonstrated a dilated gallbladder measuring . x . cm, a severely thickened gallbladder with a small intramural collection and multiple gallstones. the patient proceeded with a laparoscopic cholecystectomy. intraoperatively, the omentum was densely adhered to the gallbladder and needle decompression of the gallbladder was unsuccessful due to the wall thickness. the gallbladder was subsequently removed without any complications. patient's remaining hospital course was uncomplicated. surgical pathology returned demonstrating acute on chronic cholecystitis. discussion: cholecystomegaly or 'giant gallbladder' disease is a rare pathology encountered in the surgical world. there have been few reported cases, most of which occurred in the elderly ([ years). kuznetsov et al. defined an enlarged gallbladder to have a volume of - cc and a giant gallbladder as exceeding cc (the average weight of the liver). the etiology remains unknown, however certain factors exist to allow the gallbladder to reach this size without life-threatening sequela. preoperative imaging, such as mr cholangiopancreatography, is important to differentiate biliary pathology and delineate anatomy. removal of the gallbladder is recommended to prevent the development of complications like cholangitis or bowel obstruction. the cause of cholecystomegaly still remains uncertain and warrants further research. the management and treatment remains similar to acute cholecystitis. aims: mini-laparoscopic cholecysectomy (mlc) is considered to be the best variant of minimizing surgical trauma and improving cosmesis in laparoscopic cholecystectomy. the most challenging techniqual step of mlc is clipping the cystic duct. it may be impossible or unsafe when diameter of cystic duct exceeds mm, which is common in severe chronic colecystitis or acure cholecystits. there is very limited data in the literature about the use of mlc in acute cholecystits. the aim of study was to access the first results of new technique of mlc. methods: five women with the mean age of years ( - ) underwent mlc. the st -mm troacar was inserted in the umbilicus and used for the camera and removal of the gallbladder. the nd -mm troacar was inserted in subxyphoidal area and used for the main working instruments, including medium-large polymer clip-applier (hem-o-lok type). the rd and th -mm troacars were placed in right subcostal area and used for mini-graspers (karl storz). in initial procedures we used conventional -mm clip-applier with adopted medium-large titanium clips. to improve safety, we aplied -mm hem-o-lok type clip-applier for the last patient with acute cholecystitis. in this case the diameter of cystic duct was , mm. the clipping was performed successfully. the -mm drain was placed via subcostal troacar incision. also, in this case we applied original technique of removal of the bladder using wound retraction instrument (karl storz). results: in all the cases there were no intra-or postoperative complications. the mean duration of procedures was min ( - min). the postoperative stay was days in every patient. the patients estimated their pain on postop day as 'almost absent' and cosmethic results mo postop as 'exellent'. conclusions: . new technique of mlc alowed to perform the clipping of cystic duct safely, which is essential in acute calculous cholecystitis. was conducted in department of surgery lumhs jamshoro. all the patients having age = year of age, either gender presented with history of abdominal pain, nausea and vomiting and were diagnosed as cholelithiasis included in the study and were planned either for mini-laparoscopic cholecystectomy and conventional laparoscopic cholecystectomy were explored for outcome while the patients with empyema gallbladder, gangrene, mucocele gallbladder and adhesions were excluded from the study. results: during one year study period, total five hundred patients were diagnosed as cholelithiasis with means age . ± . (sd). of five hundred, ( . %) were underwent for mini-laparoscopic cholecystectomy with ( . %) were males and ( . %) were females. the outcome were measured as postoperative pain (vas) . ± . , size of wound (umbilical mm, epigastrium mm and subcostal mm), excellent cosmetic results, mean ± sd for hospital stay (hrs) and operative time (minutes) was . ± . and . ± . , early return to work ( . %), minor oozing ( . %), port size hernia ( . %). remaining ( . %) were underwent for conventional laparoscopic cholecystectomy with ( . %) were males and ( . %) were females. the outcome were measured as postoperative pain (vas) . ± . , size of wound (umbilical mm, epigastrium mm and subcostal mm), mean ± sd for hospital stay (hrs) and operative time (minutes) was . ± . and . ± . , early return to work ( . %), port size hernia ( . %) along with zero ( %) mortality. conclusion: it has been concluded that mini-laparoscopic cholecystectomy is superior and feasible than conventional laparoscopic cholecystectomy and has decreased early postoperative incisional pain, avoided late incisional discomfort and safe procedure with nearly scarless wounds with superior cosmetic effect especially for young female patients. objective: to determine the outcome of immediate versus late laparoscopic cholecystectomy in acute cholecystitis at tertiary care hospital hyderabad / jamshoro sindh pakistan patients and methods: the descriptive case series study of one year ( - ) was conducted in department of surgery lumhs jamshoro. all the patients having age = year of age, either gender presented with history of abdominal pain, nausea and vomiting and were diagnosed as acute cholecystitis (cholillthiasis) included in the study and were planned for laparoscopic cholecystectomy and were explored for outcome as immediate (within h) and late components ([ weeks). the frequency and percentage was calculated for categorical variables and mean ± sd was calculated for numerical variables. as this was descriptive case series so there was no any statistical test of significance was applied. results: during one year study period, total one hundred patients were diagnosed as acute cholecystitis with means age . ± . (sd). of one hundred, % were females and % were males. the immediate outcome reported as tissue fragile %, pancreatitis %, slipage of ligature of cystic duct %, empyema gallbladder %, mucocele % and gangrenous gallbladder % while the late outcome reported as adhesions %, cholecystoduodenal fistula and mirizzi syndrome % and %, gallstone ileus %, perforated gallbladder % and cholidochiolithiasis % while the mean ± sd for hospital stay (days) in immediate as . ± . while in late outcome (days) during acute cholecystitis . ± . and after surgery ( weeks later) as . ± . respectively. conclusion: it has been concluded that early lc for acute cholecystitis with cholelithiasis is safe, low cost and feasible intervention and offering the additional benefit of shorter hospital stay and reduce the economical burden. surg endosc ( ) :s -s general surgery, chang gung memorial hospital kaohsiung division, kaohsiung, taiwan background: the treatment of common bile duct (cbd) stones is challenging while unclear hepatic hilum anatomy especial experience of previous laparotomy. a minimally-invasive approach choledocholithotomy is feasible, but can be difficult and converted for the unclear anatomy of the biliary tree. near-infrared (nir) cholangiography by systemic administration of indocyanine green (icg) can enhance the visualization of the biliary tree anatomy but is limited by the high intensity of background fluorescence signal coming from the liver. nir fluorescence cholecysto-cholangiography by direct biliary tree administration of the icg can enhance the biliary tree without background noise signal. we created the nir cholangiography via different route according to patient situation : systemic circulation or biliary tree injection to see the feasibility of those application. material and method: ten patients who suffered from obstructive jaundice due to cbd stone and patients received percutaneous biliary tree drainage as first treatment and patients received endoscopic biliary tree drainage. those patients received laparoscopic choledocholithotomy as definite treatment after acute infection phase. patients received biliary tree icg injection via drain tube and patients by systemic injection. visualization and fluorescence patterns around cbd was recorded. results: in our series, one patient received previous gastrectomy and patients had previous biliary tree surgery. background: laparoscopic cholecystectomy (lc) has become the gold standard for the treatment of gallstone disease. multiple studies have confirmed its safety, lc at index admission is still not widely practiced in ireland. we present our experience in performing index cholecystectomy at cuh after the start of acute care surgery program in may . aim: the aim of this study is to determine the safety of laparoscopic cholecystectomy at index admission, complications,re-admissions, and los. methods: electronic records, theatre records and imaging reports were searched to enroll all patients who underwent lc for gallstone disease at index admission from may to october . patient demographics, indication for surgery, postoperative complications, readmission and conversion rate were recorded.in addition timings of mrcp and ercp, imaging findings, and los were also noted. results: a total of patients underwent lc during the study period. median age was years ( - ). male to female ratio was : . . ( %) patients had acute cholecystitis, ( %)had acute biliary pancreatitis, ( . %)biliary colic and ( . %) had cholecystitis with signs of cbd obstruction. ( . %)patients had obstructive jaundice and one with adenomyomatosis. patients ( %) had preop mrcp while ( %) underwent pre-op ercp. all except patients undergoing ercp had preprocedure mrcp. patients had pre-op cholangiograms. in terms of complications, ( . %) patients had bile leak and one( . %) had re-operation. one patient had the post-op hematoma which was drained percutaneously, one patient had procedure abandoned because of bradycardia upon induction of anesthesia. there was no common bile duct injury, no conversion to open and no days mortality was reported. the average length of hospital stay has been days. ( to days). conclusions: laparoscopic cholecystectomy at index admission for cholecystitis, choledocholithiasis, and biliary pancreatitis, has been a safe and feasible treatment option in our hospital. a safe practice can be ensured by adherence to a care pathway and a multidisciplinary, consultant-led service. index cholecystectomy service can be provided safely across the country to prevent diseaserelated morbidity and multiple re-admissions in patients awaiting interval surgery. when to use the two-stage surgery to treat choledocholithiasis: the size aims: the treatment of choledocholithiasis has been provided by various of studies worldwide. the most common accepted minimal invasive treatment was two-stage treatment using endoscopic retrograde cholangiopancreatography before or after laparoscopic cholecystectomy(ercp ? lc), and one-stage treatment with laparoscopic exploration of the common bile duct(lcbde). in fact, despite several large studies have been published in recent years, the debate for the ideal treatment of choledocholithiasis is way from being concluded. we aim to find the proper treatment option for the patients with variable sizes of choledocholithiasis. methods: we retrospectively analyzed patients who underwent treatments for cholidocholithiasis in our institute between january , and july , . the patients who received either ercp and lc in the same admission, and the patient who received lcbde, irrespective of trans-cystic(ltcbde), or choledochotomy(lcd), were included. the data was analyzed with chi-square test and mann-whitney u test. results: the stone size of the ercp ? lc group is significantly smaller than the lcbde group. we further analyzed the ercp failure case, and the group of stone size [= . mm has a significantly higher rate of procedure failure. the failure rate is increasing with the stone size. conclusions: both the treatment of lcbde and ercp ? lc have similar safety and success rate, and the rate of residual stone was also similar in both group. however, the failure rate for ercp is significantly increased when stone size is larger than . mm in this study. aims: the xanthogranulomatous cholecystitis (xc) is a rare entity that can cause doubt in the choice of surgical treatment, because of differential diagnosis with gallbladder carcinoma (gc). methods: a -year-old patient presented acute abdominal pain in the right upper quadrant, nausea and low-grade fever with signs of peritonitis. he had elevated pcr, leukocytosis with neutrophilia. abdominal ultrasound showed an acute xanthogranulomatous cholecystitis. a laparoscopic cholecystectomy was decided but it was converted to open surgery due to the difficulty in the dissection, with fundus embedded in the hepatic bed and intraoperative finding of hilar adenopathic conglomerate .the postoperative period was torpid, with abdominal pain, jaundice, elevated bilirubin and enzymes of cholestasis. postoperative abdominal tomography showed injury in the iv segment of the liver suggestive of neoplasia. metastatic adenopathic conglomerate at the hepatic hilum caused extrinsic biliary obstruction with hepatic failure later so an internal-external drain was placed in the bile duct. the patient was died a week later. the pathological anatomy reported a stage four of gc. results: xc is a rare, non-neoplastic, inflammatory and destructive entity of the gallbladder wall, considered a variant of chronic lithiasic cholecystitis. it may be due to extravasation of bile or ulceration of the mucosa, causing an inflammatory reaction and fibrosis, with xanthomatous cells. the prevalence is to % in the resected gallbladders. it is more frequent in - years oldfemales. its clinical presentation does not have specific characteristics that differ from cholelithiasis, except for the weight loss. radiologically it is characterized by nodular thickening and increased attenuation of the vesicular wall with signs of cholecystitis, indistinguishable from a vc. the xanthogranulomatous inflammatory foci infiltrate the hepatic parenchyma, having an invasive behavior; hence, it mimics a neoplastic disease. the confusion in diagnostic and the risk of gc (up to %) makes treatment contentious. conclusions: the xc can simulate an advanced gc that sometimes makes us wonder if we should perform a radical surgical treatment; when presented in an emergency situation, our therapeutic decision can focus on solving the acute problem and be conditioned by the patient's general condition. single port transumbilical laparoscopic surgery (sptls) is a techinque that has been around for about years. although the enthusiasm for this type of surgery seems to have diminished in recent years it is expected to rise considering the recent development of sophisticated devices for its execution . we report retrospectively our year experience with procedures performed by sptls technique. in a private practice setting in mexico city. procedures include cholecystectomy ( ), appendectomy ( ), inguinal hernia tapp and tep ( ), hiatus and esophageal ( ) , sleeve gastrectomy ( ), colon ( ), gyn ( ) . different access platforms were employed. we explain our selection criteria for the application of the technique and describe the evolution of the instruments employed during the past years, from laparoscopic conventional to curved and bendable; regular scopes to extra long telescopes with different angles. or time, top bleeding, conversion rate, the need to employ an extra trocar, complications, pathology reports, scheduled or urgent kind of surgery and length of hospital stay were recorded from the beggining; patients variables such as bmi, asa status, tep risk, satisfaction with the procedure and other were recorded . we describe the evolution of our technique, and our learning curve with cholecystectomies. we compare our group of sptls transvaginal assisted laparoscopic hysterectomy (tvalh) patients vs tvalh multiport patients. we explain the feasibilty, and efficiency of the procedure in our hands compared to other series. background: in japan, the severity of acute cholecystitis(ac) is assessed by the severity classification of the tokyo guidelines (tg ). the value of c-reactive protein (crp) is not included in the severity classification criteria. the first line treatment, according to tg , for mild (grade i) to moderate (grade ) ac is laparoscopic cholecystectomy, but laparoscopic surgery may not be feasible in some cases due to adhesion or local inflammation of the gall bladder. aim: the aim of this study is to assess the effect of crp on the open conversion rate in laparoscopic cholecystectomy for acute cholecystitis.method: we conducted a retrospective study. patients who were diagnosed with ac and treated with emergent laparoscopic cholecystectomy between june and may in our institution are included. we set the cutoff value for crp at mg/dl and compared the open conversion rate. secondary endpoints are amount of bleeding, operation time, post-operative course (peak in body temperature and inflammatory markers) and the frequency of complications according to the clavien-dindo classification. results: out of patients had a crp value greater than or equal to mg/dl. the median crp values for the crp \ group and crp = group were . and . , respectively. the open conversion rate of the crp = group was significantly higher than that of the crp \ group ( / , / , p = . ). the most common reason for these conversions was local adhesion ( / ) . there were no differences in the amount of bleeding, operation time, post-operative course, and frequency of complications with clavien-dindo grade ii or higher. background: reports about clinical value of fluorescent cholangiography using indocyanine green (icg) during single-incision laparoscopic cholecystectomy (silc) were increasing. we report clinical value and pitfalls of fluorescent cholangiography during silc for the patients with the infraportal type of the right posterior bile duct. methods: our silc procedure utilized the sils-port with an additional -mm forceps through the umbilical incision. before silc, ml of icg ( . mg) was administrated by intravenous injection. for fluorescent cholangiography, icg fluorescent laparoscope system was used. results: we performed fluorescent cholangiography during silc in patients with the infraportal type of the right posterior bile duct. all procedures were completed successfully. the interval from the injection of icg to the first obtained fluorescent cholangiography before the dissection of calot's triangle ranged from to min. detectability of infraportal type of the right posterior bile duct before dissection in claot's triangle was . % (n = ) and that during dissection in calot's triangle was . % (n = ). the infraportal type of the right posterior bile duct could be identified under fluorescent cholangiography only when it joined into the common hepatic duct. conclusions: utilization of fluorescent cholangiography can lead silc to safe even for the patients with the infraportal type of the right posterior bile duct. its benefit is emphasized when the infraportal type of the right posterior bile duct joins into the common hepatic duct. aims: due to the development of laparoscopic surgery and the progress made in surgical treatment ofhydrocephalus, surgeons may come across patients with ventriculoperitoneal (vp) shunt, as candidates for laparoscopic procedures. according to this fact, we report a case of an unusual complication of laparoscopy surgery that can appear in this kind of patients. methods: we present a case of a -year-old man with medical history of normotensive hydrocephalus with vp shunt, that came to the emergency room complaining of abdominal pain and fever since two days. blood test showed an elevation of infection parameters and inflammatory markers, and the ultrasound study revealed an emphysematous cholecystitis. therefore, we decide to carry out an emergency laparoscopic cholecistectomy. the patient did not present any adverse event during the surgery or the immediate postoperative period, being discharged the third postoperative day and evaluated ambulatory one month after the surgery with no complications. two months after surgery, the patient returned to the emergency room presenting alteration in consciousness and fever. results: during the study of the pacient, an abdominal ct was performed, showing a complete section of the vp shunt in the subcutaneus space of the upper abdominal wall and intraperitoneal migration of the remaining catheter. the patient was transferred to neurosurgery to carry out an emergent replacement of the ventriculoperitoneal shunt. after surgery and intravenous antibiotic treatment, the patient evolved favourably and was discharged a few days later. conclusions: the rate of serious complications associated with a laparoscopic approach is overall low and up to % of them occur during the abdominal access for camera or port placement and may not be recognized until postoperative period. vp shunts should not be a contraindication for laparoscopic surgery. however, laparoscopy approach must be carry out with good anesthetic and monitoring facilities and taking several previous considerations, such as verifying the proper functioning of the vp shunt, identifying the path of the catheter within the abdominal wall to avoid inadvertent damage to the catheter during trocar placement and ensuring that the intraperitoneal portion of the catheter is not twisted or obstructed prior to decompression of the abdomen. surg endosc ( ) introduction: since advantages of robotic surgery is being more emphasized, robotic cholecystectomy (rc) cases are increasing. ajou group had introduced a method called which technique places the trocars transversally on the bikini line and it makes cosmesis and pain beneficial. however, rc with low incision port has several limitations. therefore, we changed port placement which may be a one of safe tehniques for rc. method: this study retrospectively reviewed data for patients who received rc with port changing method (rcpc, n = ) and rc with low incision port (rcli, n = ) from february -february and surgical variables were analyzed. results: patients in both groups had similar demographic features and indications for surgery. the rcpc group required no conversions to conventional robotic surgery and no additional operation, whereas the rcli group had one incisional hernia ( . %) and two bowel perforation ( . %) cases. length of stay ( . ± . vs. . ± . days, respectively; p = . ) did not significantly differ between the rcpc and scli groups. however, the rcpc group had shorter operative time ( . ± . vs. . ± . min; p = . ) than the rcli group, although the parameters mentioned above were not statistically significant. conclusion: robotic cholecystectomy with bikini line incision has some limitations even though it has cosmetic benefits. whereas robotic surgery with changing port method is one of safe and feasible procedures for performing robotic cholecystectomy. also nothing more to say that it gains cosmesis effect and escapes complications. mini surgery, odessa medical university, odessa, ukraine the aim of the study was to optimize the diagnostic and therapeutic tactics for yatrogenic injuries of the extrahepatic bile ducts. methods: patients were examined. typical manifestations were jaundice, cholangitis, biliary peritonitis, external biliary fistula, subhepatic abscess.cholecystectomy main cause of damage.a visual, manual and x-ray examination of the hepato-choledochus and cholangioscopy were performed. ultrasound, endoscopic retrograde cholangiopancreatography, fistuloholangiography or percutaneous transhepatic cholangiography play a leading role in diagnosing. the results: high damage to the bile duct was detected in . % of patients, low-in . %.percutaneous transhepatic drainage under ultrasound control was performed in . % of patients.emergency laparotomy, sanation of the abdominal cavity and external drainage of the bile ducts were performed with bile peritonitis. recovery operations produced . % of patients. reconstructive interventions were performed in . % of patients after - weeks after the first stage. the covery operations were successful in . % of patients. . % of the sick had complications in the form of biloma. a scar stricture formed in . % of patients after - months. patient underwent recanalization of the stricture zone with a dilatation balloon through interchangeable transhepatic drainage. balloon dilatation was performed retrogradely through the large duodenal papilla in patients. deaths in the postoperative period was not observed. conclusions: the surgical team should be strengthened by an experienced surgeon when intraoperative diagnosis of yatrogenic damage to the bile ducts.the operation should be completed by external drainage of the bile duct and the abdominal cavity in the absence of an experienced specialist.recovery operations are shown only with lateral injury of the ducts.the patient must be sent to a specialized institution for radical surgical treatment after stabilization of his general condition. aim of the study sub-hepatic bile collections, biloma and hematoma are rare complications and we present our experience in treatment this complications. material and methods: from laparoscopic cholecystectomy performed in our clinic, three patients (two women and one men) to whom it was performed laparoscopic cholecystectomy, came back two weeks later after they were released from the hospital because of epigastric discomfort, fever and nausea. results: clinical examination after rehospitalization showed tenderness in the epigastrium and right subcostal region. in all patients were measured high levels of leukocytosis and crp . an ultrasound examination of the abdomen revealed a large hypoechoic collection in the sub hepatic space, after the abdominal ct scan was performed, the density of the collection did not indicate the presence of blood in two patients. percutaneous drainage of the collection in both patients was realized under us guidance and - fr catheter was inserted in the sub hepatic region. in the first patient cc of bile-stained liquid, and in the second patient cc of biliary liquid was drained. in a third patient h after surgery signs of significant hypotension and limited tenderness at the right subcostal region occurred. a complete blood count (cbc) showed a decrease in the level of haemoglobin to . g%. ultrasound examination revealed a fluid collection in the sub hepatic space, which is also confirmed by computed tomography. laparotomy was performed and the large sub hepatic hematoma was evacuated. after that the fr abdominal drain was inserted into the sub hepatic space. the postoperative course of all three patients was not complicated. conclusion: sub hepatic biloma and hematoma are rare complications of laparoscopic cholecystectomy, while early diagnosis followed by percutaneous drainage or open laparotomy is the only way to resolve these complications. ( ), hemoperitoneum . % ( ) . the average number of days of hospitalization was . days. there was no mortality at days. conclusion: in the emergency setting the rendezvous technique has an adequate success rate of cannulation and clearence of the bile duct, an acceptable surgical time, few complications, these being more frequent in those patients with inflammation of the gallbladder and without associated mortality at days. there is a need for controlled randomized studies with a greater number of patients recruited and follow-up to determine the usefulness of this technique. intraoperative cholangiography could serve as a fundamental solution to avoid the bile duct injury during laparoscopic cholecystectomy. however, it is difficult to identify the cystic duct to which the contrast catheter should be inserted in cases with high degrees of adhesion around the calot's triangle. in these cases, it is not possible to conduct cholangiography from the cystic duct. for these types of cases, intraoperative cholecystography may serve as an option. however, since the bladder is a bag-like organ that expands when liquids are entered, directly inserting a contrast dye into the bladder would make the bladder itself expand, which makes it impossible for to maintain enough pressure in the contrast dye to flow into the cystic duct, extrahepatic bile duct, and intrahepatic bile duct. also, since it is difficult to control leakage of the contrast dye from the catheter insertion site, it is not possible to obtain enough images to sufficiently understand the anatomical characteristics of the bile duct in many cases. therefore, cholecystography is not generally recognized as a method to be used during surgery. in our facility, we insert the contrast catheter through the bladder after stretching the gallbladder neck as much as possible, hold the gallbladder neck with a removable intestinal clamp, and then apply the contrast dye to the bile duct. through this method, it is possible to insert enough contrast dye into the cystic duct, extrahepatic bile duct, and intrahepatic bile duct to understand the anatomical characteristics of the bile duct, allowing us to obtain appropriate images of the biliary tract. because this method uses equipment that is highly versatile, we believe that it is inexpensive and convenient. during this presentation, we will also conduct a case presentation of the methods of bladder contrasting that we utilize in our facility during laparoscopic cholecystectomy. introduction: retrieval of a thick walled gallbladder during a difficult laparoscopic cholecystectomy (lc) for an acute or chronic calculous cholecystitis can be exasperating. it increases operative time and often necessitates enlargement of mm port to deliver the specimen. the 'in-situ cholecystotomy', which we wish to call the 'delhi maneuver' is very helpful in improving the ergonomics of specimen retrieval, saves time and conserves cosmesis. patients & methods: one hundred and ten patients of acute or chronic calculous cholecystitis were placed randomly in groups. a disposable transparent plastic bag was used in all cases to retrieve the gallbladder specimen through the - mm port using a rampley's sponge holding forceps. retrieval was done using conventional technique in patients (group b). the delhi maneuver was used in the remaining patients (group a). it involved cutting the gall bladder inside the plastic bag in a certain fashion, delivering the gallstones in the bag, and removal of gallbladder preceding the stones. the retrieval time, number of insertions of sponge holder, any rupture of plastic bag as well as the number of cases needing port enlargement were noted. results: the average time taken by delhi maneuver (group a) was min as compared to was min by conventional method (group b). the number of insertions of sponge holder ranged from - in group a (mean ) and - in group b (mean ). four patients needed port enlargement in group a ( %) while patients needed enlargement in group b ( . %). there were incidences of bag rupture in group a ( %) and in group b ( %). the delhi maneuver improved the ease and speed of specimen extraction at laparoscopic cholecystectomy for thick walled gallbladders. it also decreased the need for port enlargement for specimen retrieval. the bile duct injuries are a very complex desease to confront, the inciian managment is to clasificate the injury and to identifie the mechamism of the injury. it's important for the optimal heal of the patient to have a multidisciplinary approach including internal medicine, surgery, endoscopy and interventional radiology specialists. the laparoscopic cholecystectomy responsible for %- % of them.this is a retrospective study on the incidence, classification and management of bile duct injuries in a private sector hospital in monterrey nl. mexico. in this study, bile duct injuries were identified in years of experience in a single center. were categorized using the strasberg classification. variables were evaluated such as type of injury, mechanism of injury, hospital stay, if the surgery was scheduled or of emergency, the moment in which the surgeon evidenced the injury, the way in which the surgeon became aware of the injury performed. the type of management that was given to this lesion was also studied and the days of intrahospital stay and the number of reinterventions or procedures performed were compared.the average age of the patients was years, patients belonged to the female sex, although there were lesions of all kinds in this work, there was a greater incidence in strasberg type a lesions, which represented % of the lesions. the most common diagnosis presented was cholecystolithiasis. in surgeries the evidence and repair of the bile duct was in the same intervention aims: bile leak is a rare but recognised complication after laparoscopic cholecystectomy. this usually occurs after a difficult procedure complicated by adhesions, unusual anatomy or if the surgeon is inexperienced or unfamiliar with the anatomy. this video aims to demonstrate the laparoscopic diagnosis and treatment of this complication particularly for surgical trainees. methods: we report a case of significant bile leak occurring soon after a straightforward laparoscopic cholecystectomy due to very short cystic duct (cd). the procedure was carried out uneventfully but the cd was clipped flush with the bile duct. the patient was discharged on the day of surgery feeling well but readmitted with abdominal pain h later. results: after readmission the patient underwent a ct demonstrating only a small amount of fluid suggestive of a small collection. she was treated conservatively but suddenly deteriorated and a repeat ct confirmed significant intraperitoneal fluid. a diagnostic laparoscopy was carried out urgently confirming a cd stump bile leak where the clips had sloughed off causing the leak. two litres of bile was aspirated with copious irrigation and a latex t-tube inserted into the cbd. patient made a full and rapid recovery. conclusions: this is a rare complication and learning opportunities for trainees are therefore infrequent. this video demonstrates a successful laparoscopic approach to management of postoperative bile leak showing t-tube insertion technique and highlighting the need for careful cd closure techniques during laparoscopic cholecystectomy when the duct is very short. about - % of bile duct stones could not be extracted using conventional endoscopic techniques (baloon, sphincterotomy). there is lower success rate in elderly patients; among the biggest challenges are intrahepatic stones, size of stone is large, etc. aims: to present the case of a recurrent intrahepatic lithiasis and its management using spyglass choledochoscopy.to expose, other cases and the main outcome and complications of other difficult cases of bile duct stones that solvedusing this choledochoscope vs. the traditional one and the beneffits. we present a case of years old male who presented with cholangitis caused by an intrahepatic stone that required multiple sessions of endoscopic retrograde cholangiopancreatography with spyglass for clearance. one year later, he presented again with cholangitis, that required another session of spyglass lithotripsy and cholecistectomy. conclusions: besides ercp, there are different approaches to treat difficult bile duct stones, as transhepatic percutaneous drainage, surgical techniques, or other endoscopic techniques (doubleballoon, enteroscopy). ercp and sphincterotomy are the first step of endoscopic treatment with more than % of success rate, and a low mortality and morbility rate; other steps include some lithotripsy techniques, or the use of biliary stent as a bridge before definite treatment. spyglass is a visualization & intervention system used when common ercp has been unsuccessful, and it is first line for better and direct image of biliary ducts, with °range of motion, with multiple advantages like the concomitant use of lithotripsy devices. aims: the number of elderly people has increased, because of the strong association between age and gallstone disease, both prevalence and incidence of this disease are increasing. this presentation aims to review our current management options of octogenerian patients with acute cholecystitis. methods: we retrospectively analyzed octogenerian patients who were admitted to the our hospital with the diagnosis of acute cholecystitis between january and october . the patients were initially allocated to four different treatment groups as follows: immediate surgery, delayed surgery, medical treatment and cholecystostomy. differences in the outcomes between the treatment groups were evaluated. results: there were males ( . %) and females ( . %) with a mean age of . years (range - years). the patients had different co-morbid diseases, especially hypertension ( , . %) cardiovascular disease ( , . %) and diabetes mellitus ( methods: a retrospective observational study where were analyzed patients older than years who underwent urgent surgery for ac who fulfilled an indication for surgery according to tokyo guidelines . the type of cholecystitis, stay and postoperative complications, the type of intervention, the conversion rate, the need for reoperation and re-admissions in patients older than years were analyzed and compared with those of patients operated on for cholecystitis younger than years. outcomes: a total of patients were registered, older than years ( %) and younger ( %). in cases, cholecystitis were complicated ( . %), cases older than years ( . %) and in cases younger than years ( . %). the approach was laparoscopic in % of the cases older than years, with a conversion rate of . %, not finding statistically significant differences with younger than years ( % laparoscopies with . % of conversions). % of patients older than years had some type of postoperative complication, not finding statistically significant differences in patient younger than years ( %); being the most frequent complication the intrabdomintal abscess ( . % of patients [ years, and . % of those \ years = '' span = '' [ being not statistically significant with % ci. any patient older than years required re-entry after discharge, compared to patients younger than years who were re-entered, not being statistically significant; and any patient older than years required reintervention, while it was necessary to reoperate patients younger than years ( %), being not statistically significant. mortality was very low, finding case in older than years ( . %) and case in younger ( . %), not obtaining statistically significant differences. the postoperative stay in patients younger than years of age has a median of days and in older than years a median of days, not finding statistically significant differences with % ci conclusions: laparoscopic cholecystectomy is safe and effective in the treatment of elderly patients with (ac), there being no differences with younger patients. introduction: significant bile leak is an uncommon but serious complication of laparoscopic cholecystectomy. our study aims to evaluate the efficacy of relaparoscopy in treating symptomatic bile leak and biloma formation. material and methods: patients presenting with postoperative bile leak after different operations on extrahepatic biliary tree from january to december were reviewed retrospectively (in total, , laparoscopic surgical interventions were performed for the period under study). the sites of bile leaks were the cystic duct stump in thirty seven patients, the bile ducts of luschka in fifty two, liver beds in cases after hepatectomy, in had small injury of cbd, and seven patients with tubular stenosis of the common bile duct. results: three main approaches of mini-invasive treatment of bile leakage was used: ( ) percutaneous puncture with or without drain under ct-scan or ultrasound guidance in patients; ( ) endoscopic management in patients (in patients ( . %) were managed with ercp alone and fifteen ( . %) were treated with a percutaneous intervention followed by ercp. endobiliary stent placement was performed after es in patients and without es in twenty seven patients ( ) relaparoscopy has been performed in patients, in cases of biliary peritonitis. conclusions: relaparoscopy was the ultimate method of treating postoperative complications of laparoscopic surgery in . % of patients. in general, this method, as well as laparoscopic intervention, is highly effective in the diagnosis and correction of postoperative complications, with minimal surgical trauma for the patient, with great therapeutic effect and subsequent rapid social rehabilitation of patients. introduction: laparoscopic operations have already become routine, even for pancreatoduodenectomy for periampular cancer. for unresectable cases, endoscopic bibliary stenting or hepaticojejunostomy are usually used. these methods are quite expensive and may be accompanied by complications. materials and methods: laparoscopic cholecystogastroanastomosis was performed in patients with unresectable periampullary cancer. there were females and men and average age was , . the indications for surgery in all patients was unresectable periampullary cancer and biliary hypertension with preserved patency of the cystic duct. the level of bilirubinemia ranged from to lmol/l (the average level was , lmol/l). we used -port technique. optical trocar was placed in the right iliac region, one mm above the navel and one mm in the right hypochondrium after punction gallblaber and aspiration of bile, we cut the apex of the gallbladder and gastric antrum up to . cm and performed cholecystogastroanastomosis with barbed-suture v-loc. results: we had not conversion to open surgery. the average operation time was min. postoperative stay was average days and on median follow-up of month. post-operatively, there were no major morbidity and nil mortality. we had cases of leakage of bile through drainage for up to - days, which spontaneously stopped. all patients showed a decrease in the level of bilirubinemia. patients were later radical operated (pancreatoduodenectomy), while they did not have such phenomena as cholangitis, pancreatitis, inflammation of the hepatoduodenal ligament elements, which we often observe after endoscopic biliary stenting. conclusions: laparoscopic cholecystogastroanastomosis is safe, effective and feasible for patients with periampular cancer and obstructive jaundice. aims: surgeons with the expertise and resources to perform laparoscopic common bile duct exploration often prefer the 'one stage approach' over endoscopic retrograde cholangio-pancreatography (ercp) for the management of common bile duct (cbd) stones. this case series aims to evaluate the effectiveness of lcbde in a single benign upper gastrointestinal (gi) unit. methods: all patients with suspected and confirmed pre-operatively cbd stones who underwent a lcbde between january and october were included. lcbde was performed on the basis of pre-operative suspicion of cbd stone confirmed by intra-operative imaging. results: patients with confirmed choledocolithiasis had lcbde during this time period. the indications for lcbde were deranged liver function tests, dilated cbd or confirmed stones on preoperative imaging. median age was (range - ), % of whom were female. % of patients had confirmed cbd stones pre-op. % of cases were performed as emergencies and conversion rate to open was . %. choledocotomy was performed in % of cases. in % of these t-tube was left in situ. transcystic approach was used in the remaining %. despite positive intraoperative imaging no stones were found on cbd exploration in cases ( %). in patients stones were unable to be cleared with lcbde. the overall morbidity was %. % of patients had gallstone related complications. overall mortality was % (due to bile leak). / patients required re-intervention with re-look laparoscopy (n = ) or ercp (n = ). patients re-presented within months with cbd stones. overall median length of stay was days. conclusions: our case series demonstrates that lcbde is an effective and safe treatment for choledocolithiasis in both the elective and emergency settings. complication rates are comparable with therapeutic ercp ( % specific complications) followed by laparascopic cholecystectomy ( % day morbidity). the variability in anatomic location of subvesical bile ducts puts them in danger during hepato-biliary operations. its prevalence varies between % and %. the origin and drainage of these ducts were limited mainly to the right lobe of the liver, but great variation could be seen. some authors think of them as small bile ducts that drain directly into the body of the gallbladder; others consider them to be networks of miniscule bile ducts between the liver capsule and the gallbladder. recent studies suggest that clinically relevant bile leaks complicate approximately . - . % of cholecystectomies. injury to a subvesical duct is one of the most common causes of cholecystectomy associated bile leak and occurs as often as major bile duct injuries and leaks from the cystic duct stump. indeed, recent studies suggest that about % of clinically relevant bile leaks are caused by inadvertent injury to a subvesical bile duct. there are four types of subvesical bile ducts, including ( ) superficial variations of segmental and sectorial bile ducts, ( ) superficial or intercommunicating accessory bile ducts, ( ) hepaticocholecystic ducts, and ( ) aberrant bile ducts.we present a case of year old patient who developed a coleperitoneum after a routine daycase colecystectomy due to the inadvertent injury of a hepatocholecystic duct. a superior comprehension of ductal anatomy is essential in preventing and managing operative injury to the subvesical ducts, although some times is unavoidable. nowadays, the diagnosis of liver cancer is primarily radiological, as recommended by the principal international societies. in doubtful cases or due to the clinician needs, diagnostic evaluations can eventually be completed with a liver biopsy. the goal is to perform the examination, or the examinations, that guarantee the most elevated sensibility and specificity levels being as little invasive as possible. nevertheless, even using the best radiological tools, the diagnosis is not certain, due both to device limitations and radiology experience. recently, various diagnostic algorithms have been proposed, relating with contrast enhancement characteristics, different radiological techniques, blood examinations and cross evaluations from different radiologists. one of the most recent algorithm purposed is liver imaging reporting and data system (li-rads), that evaluates ct and mri imaging to classify hepatic lesions in different diagnostic categories, in order to perform a better and more precise diagnosis of hcc or other liver benign or malignant lesion. through a retrospective study, we evaluated and compared preoperative imaging and post-operative histological reports. results reveal that li-rads routine use increases hcc diagnosis up to %. background: we previously developed a modified difficulty scoring system (dss-ihd) of laparoscopic liver resection (llr) for patients with intrahepatic duct (ihd) stone. we validated dss-ihd in patients who underwent llr for hepatolithiasis. methods: dss-ihd was based on the extent of liver resection ( to ), stone location ( to ),atrophy of liver parenchyma ( to ), ductal stricture \ cm from the bifurcation ( to ), and combined choledochoscopic examination for remnant ihd ( to ). results: the dss-ihd ranged from to and divided to -level groups of low group (score * ; n = ), intermediate group ( objective: improving the surgical treatment of patients with cholangiogenic abscesses of the liver through the application of minimally invasive technologies. material and method: in the presented study presented results of treatment of patients with biliary liver abscesses. surgical interventions for hepatic abscesses were performed simultaneously with the elimination of the primary pathological process of the biliary system, which caused the occurrence of cholangitis, or in the near future (up to days) after biliary drainage drainage. among patients with biliary liver abscesses, treated with minimally invasive methods, revealed abscesses of the right hepatic lobe, -abscesses of the left hepatic lobe, -abscesses and right and left hepatic lobes. single abscesses were detected in patients, and in -two or more abscesses. in terms of liver abscesses, more than cm were detected in patients, more than cm in patients. drainage of the biliary tract was carried out endoscopically transpapillary and (if the endoscopic approach was unsuccessful) with transcutaneous transhepatic approach. results: drainage under ultrasound guidance was performed on patients with solitary and patients with two or more cholangiogenic abscesses of the liver. laparoscopic interventions were performed on patients. among the patients operated on using minimally invasive technologies, occurred complications ( . %). patient died due to the development of biliary sepsis ( . %). conclusion: percutaneous drainage of liver abscesses under ultrasound control is appropriate not only for single abscesses, but also for their larger number, which has many advantages over other interventions. it was proved possibility of simultaneous drainage of liver abscess and bile duct. percutaneous drainage of the liver abscess, drainage of the biliary tract and laparoscopic surgical intervention are complementary aspects in the treatment of liver abscesses of biliary origin. after laparoscopy residual calculus can be removed endoscopically in more favorable conditions after stabilization of the patient's condition is achieved and the infection-associated disorders are eliminated. in case of localization of abscesses in the marginal segments of the liver, laparoscopic atypical resection of the liver with an abscess is most desirable. general surgery, rambam medical center, haifa, israel background: recently robotic surgery has emerged as one of the most promising surgical advances. despite its worldwide acceptance in many different surgical specialties, the use of robotic assistance in the field of hepatobiliary (hbp) surgery remains relatively unexplored. our study presents single institution's initial experience of robotic assisted surgery for treatment of benign hepatobiliary pathologies. methods: a retrospective analysis of a prospectively maintained database on clinical outcomes was performed for consecutive patients that underwent robotic assisted surgery for benign hbp disease at rambam medical center during - . results: there were robotic assisted surgical procedures performed for benign hbp pathologies during the study period. there were anatomical robotic liver resections for symptomatic hemangiomas, cases of giant liver cyst, robotic assisted surgery for type i choledochal cyst, case of benign (iatrogenic) common bile duct (cbd) stricture, cases of robotic (cbd) exploration due to large intra choledochal stones and cases of cholecystectomy for cholelithiasis. the median postoperative hospital stays for all procedures were . days (range - days). general morbidity (minor) was %. there was no mortality in our series. conclusion: robotic surgery is feasible and can be safely performed in patients with different benign hbp pathologies. further evaluation with clinical trials is required to validate it's real benefits. most liver cysts are asymptomatic and tend to have a benign clinical course. however, symptomatic or complicated liver cysts sometimes require surgical intervention. needle aspiration is safe and can be the lease invasive procedure, this procedure is however associated with a high failure rate and rapid recurrence. surgical approach is the crucial and provides definitive treatment for such cysts. thirteen cases were nominated from shonan kamakura general hospital between january and december . mean age and body mass index (bmi) were . and . , respectively. all patients have had any complaint such as upper abdominal pain, dyspnea, and fever. two cases were clinically diagnosed as the infectious cyst and serum crp was elevated before surgery. additional cholecystectomy was planned for one case of chronic cholecystitis with gallbladder stones. all cases were prompted the reduced port surgery (rps) and cases were performed rps with trans-vaginal approach (hybrid notes) and case was chosen in single port surgery. cyst unroofing was performed for all cases. mean operation time and blood loss of all cases were . min. and . ml, respectively. no surgical complication has been occurred in all cases, an infectious cyst case was however required additional drainage for infectious control after surgery. although statistic difference was not shown, fewer blood loss and shorter hospital stay was seen in non-infectious cases, compared to laparotomy cases. mean hospital stay after surgery of whole cases, non-infectious cases, infectious cases was . , . , . days, respectively . no recurrence of any symptom was shown in any cases in observation period ( - days) . laparoscopic unroofing is the definitive treatment for the complicated or symptomatic liver cyst. however, for the infectious cyst, infection control such as intensive drainage and/or administration of antibiotic before surgery may be needed to avoid additional treatment, leading to longer hospital stay. laparoscopic unroofing of liver cyst can be the first choice for symptomatic or complicated liver cyst. also, reduced port surgery can be nominated to achieve less invasiveness. introducction: laparoscopic liver resection (llr) has been increasing since it was first reported in . three international expert consensus conferences on llr surgery were held in louisville, ky, usa, in , morioka, japan in and southampton, uk, in . while most initial minimally invasive liver resections were typically done for benign lesions in anterior o left segments, llr is currently being applied for major anatomic resections, malignancy, cirrhosis and liver donor hepatectomy. clinical case report: this is a -year-old male patient with a history of hta and liver cirrhosis due to hepatitis b virus. hepatocarcinoma is diagnosed in liver segment vi with a size of cm . in the digestive study the patient presents a child a stage, meld \ , without signs of portal hypertension. complete analytical with normal afp and cea . markers. after presentation of the patient in a multidisciplinary committee and being a stadium according to the early bclc classification, laparoscopic surgery with segment vi resection was decided. discussion: laparoscopic liver resection is becoming widely accepted for the treatment of hepatocellular carcinoma. liver resection is a first-line option in very early and early-stage disease. many meta-analysis have shown that llr is better than open liver resection in terms of short-term outcomes for patients with child-pugh a cirrhosis, solitary tumors, and minor resections. in the long-term setting, the results demonstrate that a minimally invasive approach is comparable to an open approach in terms of overall. in conclusion, the current evidence conclude than llrs for hcc are safe and may be considered a standard practice in specific settings. results: there were women ( %) and men ( %). the age of patients ranged from to years. the patients underwent complex examination including abdominal ultrasound, esophagogastroduodenoscopy, and some of them underwent ct (computed tomography). all patients in the first stage were performed antegrade external drainage of biliary tracts with x-rays of the biliary tracts, and specifying the level and extent of the block.total miniinvasive interventions were hold. two patients in connection with the uncoupling of equity ducts were performed antegrade bilobar stenting with preliminary split external bile release.there were complications after carried out interventions in cases, which were associated with dislocation of holangiostomic drainage in patients ( . %); with acute cholecystitis in patient ( . %); with hydrothorax in patients ( . %); perihepatic biloma in case ( . %). patient ( . %) had a recurrence of obstructive jaundice due to germination of endobiliary stent in the late period after stenting. lethal outcome appeared in patient. conclusions: ultrasound examination allows us to determine the level of obstruction of the biliary tract, to substantiate the tactical position in the application of mini-invasive technologies. antegrade miniinvasive technologies in the treatment of tumor lesions of the proximal bile ducts allow timely and effectively stop biliary hypertension and to determine further treatment strategy. acknowledgements this study was supported by the russian science foundation under project ? - - . background: repeat hepatectomy is an effective treatment, with long-term surgical outcomes for recurrent hcc and colorectal liver metastasis(crlm). however, the efficacy of a minimally invasive surgical approach for recurrent liver tumor is not yet confirmed. the purpose of this study is to examine the efficacy of laparoscopic repeat hepatectomy(lrh) compared with open repeat hepatectomy(orh) for recurrent liver tumor. we retrospectively analyzed the clinicopathological features and short-term surgical outcomes between lrh and orh. methods: from to , patients with liver cancer underwent repeat hepatectomy. of those patients, patients underwent partial hepatectomy, patients were undergone laparoscopically, and patients underwent open hepatectomy. we compared the clinicopathological and surgical parameters in the lrh group with those in the orh group. results: there were no significant differences in patients' gender, age, viral infection status, child-pugh classification, tumor size, tumor number, and tumor location in the two groups. the operative times were similar, but blood loss was significantly lower in lrh group ( vs. ml, p \ . ). the postoperative hospital stay was significantly shorter in the lrh group ( . vs. . days, p = . ). postoperative complications(cd = a) were observed only in the orh group, with a complication rate of . %. conclusions: we demonstrate that lrh reduces blood loss and postoperative complications compared with orh. lrh might be a feasible and effective procedure for the selected patients. background: the liver is the most common site of metastatic disease with up - % of all cancers having the potentiality for sending liver metastasis during the disease. consequently, increasing value for surgical resection of hepatic deposits of different types of cancers, the need for accurate evaluation of the extent of hepatic metastasis was established for choosing the most suitable patients for surgery and in planning the extent of hepatic resection. the aim of this work is to evaluate the role of intra-operative ultrasound in the detection of hepatic deposits in intra-abdominal malignancies with special emphasis on its accuracy, sensitivity, specificity. patients and method: this study was carried out on thirty patients who were admitted to the gastrointestinal surgery unit, main alexandria university hospital with intra-abdominal malignancies for whom elective open surgical intervention was recommended in the period from st of september till the th of march . results: in the present study consisted of males ( . %) and females ( . %). their mean age at admission was . ± . years. six of the included patients ( %) were found to have hepatic lesions by using ious including the four cases ( . %) already detected by preoperative imaging. two cases ( . %) were newly discovered in the operative room by using ious. conclusion: the current study has proved that ious demonstrates superior lesion detection over the various non-invasive preoperative imaging modalities causing significant impact on change of the planned surgical strategy laparoscopic approach to the liver has become an integral part of surgery. two consecutive international consensus meeting recommends major hepatectomy has been on the expert hands. tumors located in the right posterior section are considered to be difficult for laparoscopic resection. patients and methods: since , until , cnuhh has been performing laparoscopic hepatectomies including major hepatectomies. among major ones, there are rh, lh, rps, ch, and as. we analyze data on patient demographics, tumor characteristics, operative date, and posterior outcome retrospectively. results: during - , laparoscopic rps were performed. the diagnosis were hcc in and crlm in patients. median operative time was min, and median blood loss was ml. no blood transfusion was occurred. median tumor size was mm, and median resection margin was . mm. six of the patients ( %) were cirrhotic on pathology. there was no conversion and was no postoperative mortality. median hospital stay was . days. conclusion: laparoscopic rps is known challenging procecedure. strict preoperative planning and operative procedure is mandatory. even though it should be performed by the experienced hands both on hepatic surgery and laparoscopic skill, it can be an good option for treatment of the tumor locating over right posterior section. purpose: previously we developed a new sponge (named endoractor) as an organ retraction device in laparoscopic surgery in and have reported that it is useful in various surgical procedures including rectal surgery we confirmed that it is also useful in laparoscopic radiofrequency ablation of the liver in terms of pulling and protecting organ, so we report it materials and methods: a case is an -year-old female with liver cirrhosis. she had primary hepatocellular carcinoma in s lesion with a diameter of . cm very close to the inferior vena cava and middle hepatic vein root and in s lesion with a diameter of . cm we thought she could not put up with hepatic resection because of her poor hepatic reserve capacity. and we could not expect treatment effect by embolization therapy since contrast effect was poor. so we decided to select ablation therapy in the puncture and ablation of the s tumor, since there was concern about the thermal damage of the middle hepatic vein and the cooling effect by the inferior vena cava, we would dissect the right coronary mesentery sufficiently and pull the liver apart from the inferior vena cava and the middle hepatic vein as much as possible using our endoractor also, in the puncture and ablation of the s tumor, it was feared that the stomach would be thermally damaged, so we would place endoclactor between the liver and the stomach to protect the stomach results: when ablating the s tumor, we could pull the liver securely without slipping, so we did not cause thermal damage to the middle hepatic vein. and there was no cooling effect by the inferior vena cava, so we could obtain sufficient cautery margin. in ablation of s tumor, we were able to puncture by stabilizing the lateral segment of the liver on our endoractor, and avoid thermal damage of the stomach conclusion: it seems possible to perform safe and reliable puncture and ablation by using our endoractor as well in laparoscopic radiofrequency ablation surg endosc ( ) surgical reinterventions in patients with complicated hepatic hydatid cysts usually occur as a result of diagnostic or technical failures during the initial procedure. according to recent studies, the most common complication after liver hydatid cyst surgery is local sepsis at the residual cavity and long-term biliary leak. we report the case of a -year-old male with a history of liver hydatid disease four years before the current episode, admitted in our surgical department for intense upper right quadrant pain. abdominal ultrasonography, ct and mri scans revealed three cysts in the gastrosplenic ligament, in liver segments vii-viii, and ii-iii respectively, sized between and cm. the intraoperative aspect during laparoscopy was strongly suggestive for liver hydatid disease. laparoscopic fenestration with tunneling for the hepatic cyst in segment viii, partial cystectomy in the left liver lobe and ideal cystectomy in the gastrosplenic ligament were performed. postoperatively, the patient displayed a constant biliary drainage output of - ml from the cavity remnant in the segment viii. conservative therapy for external biliary fistula and concomitant treatment with albendazole for months were initiated. evolution was slowly favorable with decreased biliary drainage to ml two months after surgery and complete symptom resolution five months after hospital discharge. aims: this study aimed to evaluate the effectiveness of fluorescence imaging with indocyanine green (icg) during laparoscopic deroofing of hepatic cysts. methods: this was a single-center, case-control study. we included patients who underwent laparoscopic deroofing between november and october . imaging with and without icg fluorescence was performed in (icg group) and (non-icg group) patients, respectively. icg was intravenously administered between min and . h before surgery. we performed a standard laparoscopic procedure. we detected a thin bile duct on the hepatic cyst on using intraoperative icg fluorescence imaging. we adjusted the resection line of the cyst wall and ligated the bile duct at the point at which it crossed the resection line. data on age, sex, cyst size, resected cyst size, operative time, estimated blood loss, post-operative hospital stay, complications, and recurrence were compared between the groups. results: the mean cyst size was ± . and ± . mm, the mean resected cyst size was ± . and ± . mm, and the mean operative time was . ± . and ± . min in the icg and non-icg groups, respectively. using icg fluorescence imaging, the bile duct was detected on the cyst wall in patients ( %). all surgeries were completed laparoscopically, and no post-operative complications occurred in either group. recurrence of the hepatic cyst occurred in one patient ( %) of the non-icg group. conclusions: fluorescence imaging with icg is used widely in hepatobiliary surgery for intraoperative identification of biliary and vascular anatomies. this method does not require complicated techniques or instruments. icg fluorescence imaging may facilitate the prevention of intra-or post-operative complications, such as biliary leakage, in laparoscopic surgery. in this study, icg fluorescence imaging was found to be effective in detecting the bile duct on the cyst wall intraoperatively, allowing for wider resection of the cyst and avoiding inadvertent injury. our study suggests that wider resection of the cyst wall might prevent recurrence of hepatic and that icg fluorescence imaging could ensure procedural safety. abdominal ct showed: large hepatic cyst ( x , x cm size), with no malignity signs, that occupies practically the whole right liver, causing subsegmentary atelectasis of the middle lobe, superior and inferior cava vein compression, and displacement of right kidney, pancreas and right atrial. due to breath involvement, a percutaneous drainage is performed achieving clinical improvement and reduction of the size of the injury. the patient was released but a cyst superinfection occurred; once this problem was solved, the drainage was removed. results: in light of the complication, surgical treatment was decided, which confirmed the large cyst located in right posterior hepatic segments with tight diaphragmatic adhesions. we carried out the cyst evacuation and a wide laparoscopic resection of the cyst walls, until the posterior area of the cava vein, combining supra and infrahepatic access. the patient was released on the sixth postoperative day and continues asymptomatic. conclusions: simple cysts can be approached in a no surgical way (punction-aspiration with/ without sclerosing products injections) or in a surgical way (cyst wall fenestrations, cystectomy or liver resections). a conservative treatment will obtain symptomatic relief but with a high risk of recurring. recurrence is the main drawback of unroofing. cystectomy is the better option but may be too complicated depending on the cyst's location. to our patient, we carried out a wide laparoscopic unroofing (even though its posterior localization) to minimize recurrence possibilities. in conclusion, laparoscopic resection of the cyst wall is a simple and effective approach in symptomatic or complicated cases. background: single-incision laparoscopic surgery or laparoendoscopic single-site surgery is emerging as an alternative to conventional multiple-incision laparoscopic surgery. it has a potential benefit of less postoperative pain and faster recovery compared with conventional multiple-incision laparoscopic surgery. single-incision laparoscopic hepatectomy (silh) has been reported in only a few small series and the majority were minor resections. case report: a y/o male patient is a case of chronic viral hepatitis b and early cirrhosis of liver. two atypical hepatocellular carcinomas (up to . cm in diameter) located at the junctions of segments & and segments & were impressed by liver magnetic resonance imaging (mri). we performed single-incision laparoscopic anatomical hepatic resection of the right posterior section via a -cm transverse incision on the right middle abdominal wall. inflow control was carried out with an extra-glissonian approach before parenchymal transection. the glissonean pedicles of segments and were divided by linear staplers respectively as well as a major branch of the right hepatic vein in segment . the operative time was min and the estimated blood loss was ml. the pathologic examination revealed two foci of hepatocyte dysplasia with a safe margin of cm. the patient was discharged eight days after the surgery uneventfully. conclusion: single-incision laparoscopic anatomical right posterior sectionectomy is feasible and safe by experienced laparoscopic surgeons. it provides a fast recovery but needs a long operative time. the mortality in the patient with liver cirrhosis is very high. the aim of this work was to decrease mortality and morbidity by using endoscopic local heamostasis and laparoscopic operations, in the patients with bleeding from cirrhosis by variceal bleeding. methods and material: we observed patients with cirrhosis complicated by variceal bleeding during years. there were patients with child phue a, ones with child phue b, ones with child phue c. all the patients were performed prolonged endoscopic heamostasis with conservative therapy. the main methods that we used were the ligation in cases, sealing in cases, sclerotherapy in cases. in cases we couldn't stop the bleeding with band ligation method and introduce the danis stents into esophagus and stopped the bleeding successfully. to prevent the re-bleeding we performed the laparoscopic dissection the abdominal part of esophagus with suturing the venous vessels, coagulations and dissection of short gastric vessels between stomach and spleen, clipping the left gastric artery and vein in the patients. in patients we performed laparoscopical suturing the variceal veins by introducing the laparoscopic trocars into the stomach. in cases with varices vien of stomach, with non-effective local endoscopic heamostasis we performed laparoscopic resection the fundal part of stomach. results: endoscopic local heamostasis were successful (in %) in cases. the relapse of bleeding were in patients. patients died. there was no mortality after laparoscopic operations. there were cases for trocar wounds infection, cases of subphrenic abscess. goals: the advance of laparoscopic surgery also includes the more complex procedures of abdominal surgery such as those affecting the liver and pancreas. there are multiple indications that laparoscopy has in hepatobiliopancreatic surgery, both in benign and malignant pathologies. material and methods: we present the video of a -year-old male patient with a history of right hemicolectomy due to disease-free intestinal lymphoma who, in the control analysis by his attending physician, detects the elevation of tumor markers. an extension study was started showing a hepatic lesion in the caudate lobe with a pathological anatomy suggestive of hepatocarcinoma and an adenopathy suspicious for malignancy adjacent to the right renal vein. the clinical case is presented in a multidisciplinary tumor committee and it is decided to perform surgery. a laparoscopic caudate lobe resection was performed, previously performing intraoperative ultrasound and a lymphadenectomy of the portal territory, vena cava and exeresis of adenopathy of the right renal vein. introduction: major vascular complications during laparoscopic surgery occur approximately in one in cases, but mortality rate can reach - %. most major vascular injuries lead to conversion to laparotomy but successful laparoscopic repair is also possible. simulation training improves laparoscopic performance and possibly reduces surgeons mental strain. materials & methods: during two editions of advanced laparoscopic training course participants had a task to control a major vessel damage (damage). before the task an educational video explaining the methods of obtaining haemostasis was shown. the algorithm of the 'damage' task was as follows: without previous preparation a cm injury of a major vessel was done with l-hook electrocautery. after the injury participants were free to control the damage the way they wanted. heart rate of the participants was measured with an ear electrode. measurements were carried out times-before the injury, immediately after, and afterwards obtaining vessel control. after participants were interviewed for their feelings after the 'damage' task. results: there were vessel injuries in animals. one animal died during the 'damage' task min after desuflation due to relapse of bleeding. there was no conversion to open procedure. temporary vessel control was obtained with different methods. all participants used vicryl . or pds ii . suture for final hemostatic purposes. heart rate of the participants before injury were - ± . bpm, immediately after the injury it rose to - ± . bpm, and after obtaining vessel control were in the range - ± . bpm. a statistically significant difference was found between the ratio of the first and second hr measurement (p = . , t = - . ), and second compared to the third (p = . , t = . ) measurement. participants judged their experience on a -point scale ( - was not helpful at all; -was extremely educative). the educational value of the task received points in cases and points in one case. conclusion: participants feel stress during major vessel bleeding even in animal model, and this stress can result in a serious intraoperative mental strain and significantly increase heart rate. participants found the 'damage' task very useful for their daily practice. the aim of study was to improve the results of treatment of patients with hepatic echinococcal cysts by using of argon plasma coagulation. methods: the analysis of treatment results of patients was put into the basis of this study. it was ( . %) men and ( . %) women in total. an average age of them was . ± . years. the main difference between groups was a way of liver parenchyma coagulation in order to make reliable hemostasis. in main group the final stage of surgical intervention on liver was argon plasma coagulation. it was performed to ( . %) patients. alternatively, monopolar coagulation was performed to ( . %) patients (comparison group). results: in main group in the . % cases pericystectomy was conducted. the resecting surgeries was performed to . % cases. in comparison group was conducted in . % cases. in early postoperative period in main group the complications were observed in . % of cases. the same parameter was . % in comparison group. it led to relaparomies. the forming of external biliary fistulas was observed in ( . %) patients in main group and in ( . %) patients in comparison group. however, all the fistulas have closed spontaneously on th- th day in both groups. hernias of abdominal wall and peritoneal adhesions that manifested by intestinal obstruction of different degree were considered as complications of late postoperative period. these values were % and . % in main group versus % and . % in comparison group, respectively. the resection of hepatic echinococcal cysts with further application of argon plasma coagulation on the cyst bed was accompanied by complications quantity decrease in patients that underwent surgery in early as well as in late postoperative period. in this case more positive dynamics of functional liver values improvements was observed. aims: indocyanine green (icg) fluorescence imaging has been reported as a reliable and safe navigation tool in laparoscopic hepatectomy. however, the factors affecting the sensitivity of tumor detection with icg fluorescence imaging is relatively unclear. the aim of the present study is to analyze the factors of successful icg fluorescence in laparoscopic hepatectomy. methods: this is a retrospective single-center study. this study population consisted of laparoscopic hepatectomies from january to november undertaken at kurashiki central hospital. we excluded patients whose tumors were located more than mm from the liver surface, those who did not receive icg fluorescence imaging, and those who were not injected with icg dye ( . mg/kg) intravenously within days of surgery. the pinpoint endoscopic fluorescence imaging system was used to detect the tumor location. we evaluated the relationship between successful fluorescence and the timing of injecting icg before operation, tumor size, icg r , liver damage and bmi. results: following exclusion, patients were eligible for analysis. among the tumors resected, icg fluorescence imaging detected tumors ( . %), including hepatocellular carcinomas and liver metastases. icg fluorescence imaging detected all tumors in the patients injected with icg to days before hepatectomies . icg fluorescence imaging detected all tumors which were more than mm in diameter. there was no relationship between indocyanine green fluorescence with icg r , liver damage and bmi. conclusions: the injection of icg to days before operation and a tumor size of more than mm can be factors in successful fluorescence in laparoscopic hepatectomy. introduction: cysts in the liver have a wide variety of aetiologies. it is important to characterize the cystic lesion before treating it. the simple cyst has a low prevalence and is more frequent in women. fenestration is a useful option for the treatment of simple cysts in selected patients. case presentation: a -year-old woman was referred to our hospital with a one-year history of intermittent, right upper quadrant pain, with no other associated symptoms. computed tomography and magnetic resonance imaging showed a large cyst ( , x , cm) in the right of the liver. the cyst presented lobulated morphology, smooth edges and well delimited. there were other smaller cysts in the left lobe. hepatic function in blood analysis was normal. biomarkers, tumor markers and hepatitis virus markers were negative. outpatient follow-up and symptomatic treatment of pain was decided. after six months of follow-up, the pain persisted, so surgical treatment was proposed. a laparoscopic fenestration was performed, widely resecting the free wall of the cyst. there was no evidence of a connection to the bile duct. there were no complications. on days she was discharged. discussion: some giant hepatics cysts become symptomatic due to mass effect. persistence of pain is an indication of surgical treatment. laparoscopic fenestration is an alternative for the management of simple hepatic cysts. aim: laparoscopic liver resection for malignant pathology such as colorectal cancer metastases has been a matter of discussion for several groups in the last years. it has been proposed as a safe and feasible treatment but subjects like short and long term outcomes and oncologic results have not been adequately assessed. methods: we performed an observacional retrospective study of patients undergoing laparoscopic liver resection for colorectal metastases in our center. from november to november a total of patients underwent laparoscopic liver resection. data for resection margin, hepatic and extrahepatic recurrence and both disease free survival and overal survival were collected. patients were discussed in a multidisciplinary group with oncologist, radioterapic oncologist and surgeons. the surgical procedures were perfomed by the same team in all the cases to minimize bias. results: a total of patients ( . %) were non resectable at the time of surgery.the mean overall survival was months with a maximum of months. we got a mean of disease free survival in our patients of . months. the hepatic recurrence was %, most of them in high risk patients, and from this group . % underwent a new liver resection. major complications took place in patients ( . %) two biliar leaks, one bowel perforation, two hepatic failure, one evisceration and three respiratory insufficiency needing urgent surgery in three of the cases. mean hospital stay was . days. a mean of days of this stay were in an intensive care unit. conclusions: laparoscopic liver resection for colorectal liver metastases could be a feasible technique when perfomed by trained surgeons. it improves the postoperatory recovery with a reduction of hospital stay and less postoperatory pain without increasing the development of major complications or mortality in the first days after surgery. we got good oncological results that have been improving with the experience acquisition of the surgical team. aged to underwent surgery for cirrhosis with massive refractory ascites child c ( - ), without obvious signs of hepatic encephalopathy. major etiological factors were: viral hepatitis c ( patients ( . %)), b ( patients ( . %)), b ? d ( patients ( . %)), toxicity ( patients ( , %) ). to prevent possible bleeding at the first stage, endoscopic filling of esophageal varices with fibrin glue was performed in patients ( . %). after testing the effectiveness of varices filling, in the following - days decompression surgery of thoracic lymphatic duct was performed under local anesthesia to improve lymphatic drainage from liver and abdominal organs. simultaneously, laparoscopic sanitation of abdominal cavity was performed, with complete evacuation of ascites fluid, rinsing and drainage. fractional post-surgery rinsing was repeated daily for - days towards removing peritoneum edema and improving its absorptive properties. results evaluation was performed , and months after surgery, based on criteria of liver reserves and ascites volume. results: post-surgery mortality from liver failure was . % ( patients) . other patients died of the same cause the following - months. annual survival rate was . %. complete ascites regression over - months after surgery was noted in patients ( . %), significant regression and stabilization in ( . %), moderate regression with need for periodic decompressive laparocentesis in cases. in all patients, functional liver reserves and life quality significantly improved. conclusions: the use of the given technique of refractory ascites correction, in patients with depleted liver cirrhosis, by laparoscopic sanitation with post-surgery fractional rinsing of abdominal cavity, with simultaneous decompression of thoracic lymphatic duct showed very high efficiency and deserves establishment as a clinical practice. t. urade, hepato-biliary-pancreatic surgery, kobe university, kobe, japan aim: anatomical liver resections guided by a demarcation line after portal staining or inflow clamping of the target territory were established as essential methods for the curative treatment of hepatocellular carcinoma (hcc) and then subsequently applied to other malignancies. however, laparoscopic anatomical liver resection (lalr) is much more difficult to reproduce these procedures and to confirm demarcation of the hepatic segment visually on the monitor. recently, laparoscopic fluorescence imaging system has been used as a tool for real-time intraoperative navigation in llr. the aim of this study is to demonstrate how to perform lalr using indocyanine green (icg) fluorescence imaging. methods: three patients underwent pure lalr using icg fluorescence imaging. the following operative procedures were performed: partial liver resection for hcc, segmentectomy for liver metastasis and right anterior sectionectomy for hcc. in all patients, preoperative d simulation images from dynamic ct were reconstructed using a d workstation to decide on cutting points of the glissonean branches. after mobilization of the liver, intraoperative ultrasonography was performed to identify the location of the tumor and glissonean pedicles corresponding to the tumor-bearing hepatic region. we dissected or transected the hepatic parenchyma to encircle the glissonean pedicles. after clamping or closure of them, . mg of icg was injected intravenously to identify the boundaries of the hepatic segments under near-infrared light. parenchymal transection was started according to the demarcation on the liver surface. the lateral aspect of the parenchymal transection was carried out based on the demarcation between non-fluorescing and fluorescing liver parenchyma as far as possible. results: in all the cases, demarcation lines on the liver surface could be visualized clearly after injection of icg. in addition, boundaries of cone units, segments and sections could be recognized to some extent because the tumor-bearing hepatic region became non-fluorescing parenchyma during parenchymal transection. these procedures were completed successfully, and the postoperative courses were almost uneventful. aim: sintrahepatic cholangiocarcinoma is the second most common primary liver cancer after hepatocellular carcinoma (hcc). although the laparoscopic approach of these tumours is not frequent due to its complexity, it is performed increasingly by hepatic surgeons.traditionally, the abdominal surgery in cirrhotic patients has been reserved to selected cases secondary to the high rate of complications. the advance on the treatment of the hcc on liver cirrhosis and the higher safety when performed by laparoscopic approach has encourage some surgeons to extend surgery to child b-c or portal hypertension patients. methods: we present a male of years old, diagnosed in of liver cirrhosis accompanied with portal hypertension. on mri in was found a solid lesion of mm located on segment ii hepatic. biopsy confirmed the diagnostic of intrahepatic cholangiocarcinoma. after a liver function evaluation (child c, meld ), an hepatic chemoembolization was performed. sequentially ct scans indicated a complete radiologic response. after years of follow up, mri showed a recurrence of mm between segment ii and iii of the liver.on multidisciplinary committee liver resection was decided due to suitable liver function and low aggressiveness of the tumour. a laparoscopic left lobe liver resection was performed. sonastarÒ and ligasure tm were used to perform the liver transection and endo gia tm for portal and hepatic veins sections. the surgery develop was complicated due to trend to bleeding that finally was achieve through cauterization. results: early after the surgery, the patient presented a haematic debt through the drain of cc accompanied of hypotension, therefore an emergent surgery was indicated. an exploratory laparoscopy was performed finding hemoperitoneum and diffuse bleeding of the liver surface that was controlled. the patient had a proper recovery and was discharged on the th day post-surgery. the analysis of the specimen showed a . cm cholangiocarcinoma with a . cm margin of resection. conclusion: there is an augmented risk of complications on liver resection of cirrhotic patients with portal hypertension. the laparoscopic approach allows to reduce potential complications, despite bleeding continuous to jeopardize this surgery, this option could be proposed on selected patients. introduction: accessory spleen itself is found in approximately % to % of the population. most ( %) are located near the splenic hilum but intrapancreatic accessory spleens (ipas) are the second most frequent location ( . %) of accessory spleens. in adults, ipas are clinically silent. they may become clinically important because of their radiographic similar appearence of cancer. intrapancreatic accessory spleen is a rare cause of pancreatic pseudotumors and is located in the pancreatic tail in approximately % to %. ipas can be difficult to differentiate radiologically from hypervascular pancreatic tumors such as pancreatic endocrine neoplasms because theycan share a similar enhancement pattern. as a result, most of the reported cases of ipas have been diagnosedonly after distal pancreatectomy was completed. material and methods: we present the case of a -year-old male patient with a history of large vessel vasculitis followed-up for rheumatology, which showed a pancreatic nodule in a control ct so he was referred to digestive for study. an echoendoscopy was performed. it showed, at the level of the tail, in the third distal, a lesion of x mm, hypoechoic, with rounded morphology and well-defined edges that can not be biopsied given the absence of adequate window for the realization of fine needle aspiration biopsy (fnab). based on these radiographic findings, the differential diagnosis included a pancreatic endocrine tumor. due to the high suspicion of malignancy and the absence of biopsy, he was referred to general surgery for scheduled surgery. a laparoscopic corporocaudal pancreatectomy was performed without incidents and the definitive histology showed an intrapancreatic accessory spleen in the pancreatic tail that excluded the presence of cancer. conclusion: intrapanceratic accesory spleen is a challenging diagnosis to make and it should be included in the differential diagnosis of pancreatic neoplasm. its early identification precludes surgical resection. however, the preoperative diagnosis of ipasmay be difficult, and distal pancreatectomy is a safe and relatively simple operation, most of the reported cases of ipas being diagnosed correctly only after surgery there are various options for treating pps. this paper describes our tailored and methodological approach to laparoscopic drainage of pancreatic pseudocysts based on an anatomical classification. methods: we adopted the laparoscopic approach in patients who had pps requiring surgical drainage. the laparoscopic method had been decided according to preoperative computed tomography (ct) and intraoperative findings. the results shown represent median (range). the aim of this work was to decrease mortality and morbidity in patients with combined trauma. methods and material: for years patients were brought to our clinic with combined trauma. everybody was performed ct and ultrasound examination. patients were performed open laparatomic operation due to massive liver rupture, spleen rupture and massive trauma of bowels, pancreas and kidney with massive bleeding. in circumstances we didn't found the trauma of the abdominal organs and the massive abdominal bleeding after ct observation. those patients were cured conservatively. in circumstances with combined trauma after ct examination we performed laparoscopic operation. in circumstances from the patients, who we started laparoscopic operation in, we conversed to laparotomy, due to massive liver rupture, and trauma spleen and hollow organs. in those circumstances we performed urgent laparotomies with suture ligation of bleeding points, suturing of liver and hollow organs and drainage of abdomen cavity. results: we performed laparoscopic operation in patients. in circumstances with trauma of liver we performed laparoscopic electro coagulation and argon-plasma coagulation. in circumstances with trauma of liver we performed electro coagulation with packing the omenture to its surface. in circumstances with trauma of spleen we performed argon plasma coagulation and used fibrin glue. after laparotomic operations mortality were in circumstances, morbidity were in patients. after laparoscopic operation mortality were in circumstances of severe combined trauma with multiple abdominal trauma and morbidity in patients. conclusion: laparoscopic operations in patients with combined trauma decrease mortality and morbility. aims: in laparoscopic distal pancreatectomy, getting away liver and stomach from the surface of the pancreas is sometimes difficult. when we separate the pancreatic body from the retroperitoneum, we must not injure the pancreas to prevent breaking a tumor. when we cut the dorsal side of the spleen from the retroperitoneum, we rarely cut into the spleen accidentally. based on our experiences, we gradually explored a set of procedural operation steps to resolve these problems. our three-step maneuver simplifies the procedure and improves the efficiency and safety of laparoscopic distal pancreatectomy. methods: as the first step, to get away the liver we sutured the round ligament of liver and crus of the diaphragm using - pds and the both ends were tugged form the outside of the body through both side of the xiphoid process. and the stomach was hung from the outside using two nylon thread like a bridge, so we could see the surface of the pancreas body with a good view. the second step was a rolling up maneuver of the pancreas. when we separate the pancreatic body and tail from the retroperitoneum, we rolled the pancreas with gauze for use in laparoscopic surgery and lifted the gauze up in only one assistant's forceps. then we could find the correct line for dissection clearly. the last step was a hanging maneuver of the spleen. when we cut the dorsal side of the spleen from the retroperitoneum, we hanged the hilum of spleen with cotton tape. with this technique we could find easily the correct line to dissect. results: the operation time was h and min and the estimated blood loss was a little. we did not injure the tumor or spleen in this operation. the patient recovered uneventfully after short hospitalization. conclusion: our three-step maneuver can be effective to perform laparoscopic distal pancreatectomy. about - % of patients with pancreatic collections will develop walled off necrosis, with an associated - % mortality. there are multiple options for intervention and drainage, usually the outcomes after endoscopic drainage are related with the nature of the collections. aims: to evaluate and present the rol of endoscopy in pseudocyst and walled off necrosis treatment, and favorable outcomes. methods and results: we present a case of a years old male, who presented biliary pancreatitis treated with cholecystectomy and transoperative cholangiogram weeks ago. he continued with persistent abdominal pain; his ct scan showed a big walled off necrosis; he was taken to surgery for an endoscopy-assisted laparoscopic cystogastrostomy with necrosectomy, he was discharged days po. conclusions: the step-up management of walled off necrosis has proven to be a better option than conventional surgical or endoscopical techniques alone; by reducing complications and mortality vs conventional necrosectomy. the use of endoscopic treatments reduce the pro-inflamatory response. drainage of walled off necrosis can be done by a transpapilar or transmural endoscopic apporach each one with its own advantages. some authors avoid the use of endoscopy in walled off necrosis because of a higher rate of complications, re-interventions and a greater lenght hospital stay. in our experience, we have achieved excellent results with this combined technique. nearest and long- patients underwent chemotherapy after electroporation procedure. day mortality was . % (n = ) in electroporation group. it was found that erreversible electroporation improved local recurrence-free survival ( and months, respectively, p = . ) and distant recurrence free survival ( and months, respectively, p = . ) . overall survival was and months, respectively (p = . ). conclusion: irreversible electroporation of locally advanced pancreatic cancer is safe. four month chemotherapy followed by surgical procedure is associated with good local response and better overall survival compared with chemotherapy alone. these data will be validated in further multicenter study. introduction: pancreatic pseudocysts are the most frequent complication of acute or chronic pancreatitis. usually asymptomatic, they can be managed conservative or, in case of complications, by several methods, endoscopic, percutaneous or by surgery. material and method: we present the case of a years old patient known with an episode of acute pancreatitis five years ago, who was hospitalised now for an upper gastrointestinal bleeding with hematemesis. the upper endoscopy showed a subcardial bulking with an erosion of the posterior gastric wall, with signs of recent bleeding, managed by clipping. patient work-up showed a cm pancreatic pseudocyst at endoscopic ultrasound. taking into consideration the history of the patient, the size and the complication of the cyst, the patient was proposed for a drainage intervention. results: a minimally invasive approach was decided. using ultrasonography guidance, a posterior gastrotomy was performed with the cystotome, establishing the comunication with the pancreatic pseudocyst. dilatation of the path with mm cre baloon, with partial evacuation of turbid liquid. the drainage consisted in pigtail fr plastic stents. the patient was discharged the following day in a good health condition.the endoscopic ultrasound control at weeks showed complete resolution of the pancreatic cyst and was followed by stent removal. the endoscopic drainage of the pancreatic pseudocyst represents the first treatment option as an alternative to the surgical intervention, being minimally invasive, with low risk and fast recovery. clinical case report: a -year-old man was admitted to the hospital with a diagnosis of severe acute pancreatitis and multi-organ failure. during the first month patient has in uci and non invasive procedures were attempted: enteral feeding by a nasoduodenal tube was started and antibiotics were administered to control sepsis. on day , percutaneous drainage was performed for large retroperitoneal abscess. on days, endoscopic transgastric necrosectomy was performed and the left collection was resolved. due to the multi-organ failure persistence and the evidence of size increase of the right retroperitoneal collection, a vard was decided.the right collection was accessed following the previously pigtail catheter. a mm trocar was placed to create retro-pneumoperitoneum with a pressure between - mmhg. a trocar of mmhg was placed, purulent content was aspirated and a debridement was performed. irrigation and aspirate was performed with normal saline and povidone-iodine solution. drainage was used to perform washes with physiological saline and urokinase.on days, the ct confirmed collection resolution. on days he was discharged. after months, the patient is in good clinical condition. discussion: drainage of the retroperitoneal abscesses via laparotomy is highly invasive and risky. vard enables radical necrosectomy and drainage less invasively. in this patient, the complete resolution of the right collection is obtained with retroperitoneal debridement without complications. we conclude that careful retroperitoneal necrosectomy is a valid alternative for the management of right collections. aims: in this study we analyze laparoscopic approach for hepatocellular carcinoma in order to clarify iwe can take advantage in some outcomes as complications, postoperative recovery or long-term survival outcomes. methods: a retrospective case consecutive study has been taken analyzing: age, sex, body max index, comorbidity, surgical extension and tumor size. the outcomes analyzed were: operation time, intraoperative blood loss, blood transfusion, postoperative morbidity and mortality, intensive care stay, hospital stay, tumor size, r resection, conversion rate, early reintervention, disease-free survival rate, overall survival rate results: in this study patients were analyzed males and females with ages between and years (mean age ) and diverse comorbidities: arterial high pressure ( / ; %), diabetes ( / ; , %) ; dislipemy ( / ; , %) , hepatophaty measured as liver cirrhosis ( / ; , %). all of them underwent laparoscopic liver surgery, in cases non-anatomical resection was performed while in the other a segmentectomy was performed. in cases the laparoscopic was strict, in and assistance incision was needed. operative time was - min (mean: min). blood loss mean was , g/dl and only intraoperative transfusion were needed. massive blood loss was reported in case. postoperative medical complications were observed: hepatic failure and renal insufficiency and in case we observed a postoperative hemorrhage that needed an urgent reintervention. the mean of intensive care stay was day and hospital stay was . days. about oncological outcomes r resection was achieve in / ( %), r in / ( %). at years / cases were free disease, dead by progression of disease and dead by other causes. aim: the purpose of this study is to analyze our initial experience with laparoscopic duodenopancreatic resection. introduction: laparoscopic procedures have advanced to represent the new gold standard in many surgical fields. laparoscopic pancreatoduodenectomy and laparoscopic distal pancreatectomy(ldp) are advocated to improved perioperative outcomes, including decreased blood loss, shorter length of stay, reduced postoperative pain and expedited time to functional recovery. however, the indication to minimally invasive approach for pancreatic surgery is often benign or low grade malignances. material and method. the steps of ldp procedures are similar to the open procedure. we perform destructive part of procedure totally laparoscopically and we prefer to do reconstructive part of procedure using hand-assisted techniques. for the period - , we have been perform pd, ( %) we have done with laparoscopic approach. ( %) of patients were operated totally laparoscopic and ( %) of patients were operated by handassisted techniques. results: a significantly higher conversion rate was encountered when lc was done - weeks after es, as compared to week after ercp. it is estimated that pancreatitis after ercp affects roughly three to percent of patients and many endoscopists quote a post-ercp pancreatitis rate of - %. however, - % is probably a more realistic answer for the majority of ercp endoscopists. wise endoscopists inform their patients that there is a spectrum of post ercp pancreatitis severity, from mild ([ % of cases) to severe ( - % of cases). in mild forms, pancreatitis after ercp may resolve itself. conclusion: endoscopic retrograde cholangiopancreatography is a procedure used to diagnose and treat disorders involving the pancreatic and bile ducts. acute pancreatitis is the most common and feared complication of endoscopic retrograde cholangiopancreatography. the assumption is that the duration of the laparoscopic method is longer, but on the other hand the patient have better wound healing and fewer possibility of developing postoperative hernia . the postoperative period is much more simple due to the significantly shorter hospitalization and the faster recovery, and according to patients the level of pain is much smaller as well. however the oncology results are the same. introduction: spiegel hernias are a rare, representing only between . % and % of all abdominal wall hernias. due to its location, below the spiegel line, its diagnosis requires a high index of suspicion. the physical examination only detects % of the spiegel hernias and, in many occasions, imaging tests are necessary for the diagnosis. goals: our objective is to describe the case of an urgent laparoscopic repair of a case of high grade bowel obstruction secondary to a spiegel hernia. material and methods: we present the case of a -year-old male patient with no medical history that comes to the emergency department of our center due to an eight hour evolution of abdominal discomfort associated with nausea without vomiting or other symptoms. the patient was afebrile and hemodynamically stable at all time. on physical examination, the abdomen is soft and depressible, painful on the left flank where a tumor compatible with spiegel's hernia is palpable. in the blood count there is no leukocytosis nor alteration of inflammatory parameters. an abdominal computed tomography (ct) scan was requested from the emergency department which demonstrated a high-grade small bowel obstruction caused by an entrapped loop of distal jejunum conditioned by a left-sided spiegel hernia. given the situation, an informed consent was obtained, and the patient was taken to the operating room for emergency laparoscopic repair. we performed a laparoscopic hernioplasty with ventralpatch mesh between oblique major and transverse and primary closure of defect in continuous suture. after this, the evolution of the patient is favorable, with good oral tolerance and re-establishment of intestinal transit, being able to be discharged h after surgery. the spiegel hernia is a rare entity that requires a high index of suspicion for its diagnosis. despite the limited evidence published in the literature on the laparoscopic repair of incarcerated spiegel hernias, the studies published so far suggest that the laparoscopic repair is a valid alternative to the classic approach when it is performed by a well-trained laparoscopic surgeon. introduction: repair of lateral abdominal wall hernias (both primary and incisional) can be challenging due to the complexity of anatomy, issues with fixation and the low incidence of such cases. a good understanding of abdominal wall and retroperitoneal anatomy, coupled with proficient laparoscopic technique is essential for successful repair via the minimally invasive approach. methods: a retrospective review of a prospectively maintained database was performed to identify patients with lateral abdominal wall hernias who underwent laparoscopic repair from january to july . results: patients with hernias were identified ( primary, incisional). mean patient age was (range - ) and mean bmi was . kg/m (range . - . ). according to ehs classification, the incisional hernia defects were located at subcostal (l , n = ), flank (l , n = ), iliac (l , n = ) and lumbar (l , n = ) regions. background: it is commonly admitted that laparoscopic surgery has the advantage of abdominal wall preservation. however, the increased use of laparoscopy has resulted in certain complications specifically associated with the laparoscopic approach, such as trocar-site incisional hernia. until today, it is not finally clarified 'patient-dependent' factors contributing to the occurrence of postoperative hernia after laparoscopic abdominal surgery. methods: between and , patients were operated due to trocar-site incisional hernia in one surgical centre. 'the patient-depending' factors which caused postoperative trocar site incisional hernia data was collected and retrospectivily analysed. results: port site incisional hernia occurred in % ( patients) after the use of trocars with mm or larger diameter. the presence of metabolic syndrome was the decisive factor in the development of postoperative incisional hernia in % ( patients). in % ( patients) the postoperative hernia occurred on the background of a long cough symptoms caused by chronic obstructive pulmonary diseases. the cause of postoperative hernia in % ( patients) of patients was the condition of lifting a one-time severity or heavy physical work. in % ( patients) of postoperative patients hernia developed due to prolonged constipation of chronic inflammatory colon diseases. conclusions: thus, when the aponeurosis of the trocars is adequately closed, the reason of the occurrence of postoperative hernias was caused by patient-dependent factors which increase intra-abdominal pressure. for this method, small midline incision cm in length - cm away from hernia orifice was carried out initially. dissection of intraperitoneal adhesion was carried out by sils with sils device. subsequently after closure of initial laparotomy unilateral anterior rectus sheath was incised from the same incision and dissection of retro-rectus space up to preperitoneal space was done under laparoscopic vision. dissecting the other side was carried out by same fashion. initial dissection of linea alba could be done by open surgery from initial incision. further dissection of linea alba, retro-rectus space, and hernia orifice was carried out by sils. defect closure of anterior and posterior rectus sheath using barbed suture was also done by sils and self-grip mesh was inserted. additional trocar to assist retro-rectus dissection, defect closure, and decompression of intraperitoneal cavity was inserted as required. aims: the laparo-endocsopic approach of inguinal hernia contiue to bring many clarifications concerning inter-parieto-peritoneal space of this region through in vivo exploration, obtained by magnification by means of specific optic intrumentation. our study aimed to revalue the in vivo fascias, to establish their embryological correspondences and to reunite the variable nomenclature existing in the classical anatomy of this region. these observations find their applicability in tapp and tep hernia procedures, as the old anatomical descriptions are no longer operative. methods: we have tried to identify the structures that delimit the anatomical regions of retzius and bogros in recording of tapp procedures performed on men, on the right side, for small indirect hernias on patintes with clear view of the structures. additional, a review of literature on this subject has been performed through a search in the detabases according to the following keywords: bogros space, retzius space, preperitoneal approach, urogenital fascia. results: retzius and bogros are the medial and lateral compartments of the inter-parietalperitoneal space, located between the transversal fascia and the parietal peritoneum. these narrow, virtual spaces are best highlighted today with the help of insufflation techniques during laparo-endoscopic procedures. a competent and careful dissection confirms a 'deep and superficial' stratification, highlighting embryonic relics derived from the uro-genital fascia: urinaryprevesical fascia and spermatic fascia. in addition, the real retzius space is located previously and the real bogros space is located behind this strcuture. the confluence area of the two spaces is a critical point of laparo-endoscopic dissection, its non-recognition may 'wander' the dissection. conclusions: literature data in this topic reflects a certain terminological confusion using general terms such as 'preperitoneal tissue' or 'arreolar tissue' to denote what we consider to be the urogenital fascia or its prologations. the data obtained were synthesized in several drawings and diagrams very useful in training surgeons to use tapp / tep techniques. aim: spigelian hernia containing epiploic appendage is really rare entity. in this paper, we present a very rare case of spigelian hernia involving epiploic appendage performed laparoscopic hernia repair. case report: a -year-old woman presented to the emergency department with sudden onset abdominal pain in the left lower quadrant. on physical examination, she had a small, palpable tender mass in the left lower abdominal quadrant. temperature and white blood cell count were normal. an inflamed epiploic appendage with an oval shape, a fatty core, and a central thin hyperdense line in the hernia sac was detected on abdominal computed tomography. its intraabdominal relationship with the normal wall of the sigmoid colon was well appreciated (figure a, b) . diagnostic laparoscopy was performed. (figure ) adhesions between the sac and epiploic appendage are released using sharp dissection. a peritoneal flap is then created (figure ). laparoscopic tapp repair was used without closing the defect (figure ) . the patient was discharged on th days uneventfully. aims: morgagni's hernia is an in infrequent, congenital, anterior or retrosternal diaphragmatic defect. the right side is the most frequently affected, up to % of cases. it represents between and % of congenital diaphragmatic hernias. in childhood, they usually attend asymptomatically or with respiratory symptoms. up to % are diagnosed in adulthood, incidentally or after gastrointestinal obstruction debut. the treatment is surgery, which can be by laparoscopic or open approach.we present a case of laparoscopic approach with intra-abdominal mesh placement of giant morgagni's hernia diagnosed in senile age. methods: -year-old woman with a history of advanced alzheimer's dementia, partially dependent in daily life activities and institutionalized who consulted for intermittent episodes of oral diet intolerance associated with vomits of one month of evolution. abdominal examination was anodine. chest radiograph revealed a right lower lung field mass with fluid collected. thoracoabdominal scan showed small bilateral pleural effusion and large, right anterolateral morgagni's hernia, which contains dilated segment of transverse colon and greater omentum . results: laparoscopic approach was performed. hernia was reduced and hernia sac was removed. the defect was repaired with a dual-component (absorbable and non absorbable) mesh anchored with intracorporeal suture. patient recovered and was discharged days after surgery. conclusion: laparoscopic approach for morgagni's hernia reapir is secure and offers the advantages of less post-opertive pain, faster recovery and short postopatory stay. introduction: recently, laparoscopic operations for ileus are increasing. we have undergone laparoscopic operation to adhesive ileus with umbilicar incision at the beginning. the umbilicar incision at the beginning makes it possible to secure the laparoscopic field by peeling the adhesion under direct view, and makes it easy to repair damage to the intestinal tract. surgical procedure: at first, the umbilicus - cm incision was made and peeled the adhesion as much as possible under direct vision. secondly, ez access was set and inserted one mm port, therefore laparoscopic operation was performed with or pieces of mm ports. when the repair or resection of small intestinal due to damage is necessary, it is pulled out through the ez access. objective: to investigate the possibility of problems of laparoscopic ileus operation to adhesion ileus by umbilicar incision at the beginning. introduction: small bowel obstruction (sbo) during pregnancy is a rare condition with an incidence of . - . % and in around % of cases it is most caused by adhesions from previous abdominal surgery. other diagnosis, such as, hernias, malignancy, volvulus or intussusception are extremely rare. when sbo occurs in pregnancy, it carries a significant risk to mother and fetus. its diagnosis of can be difficult to make as symptoms are often attributed mistakenly to the pregnancy. goals: a case report of congenital bowel obstruction during the second trimester of pregnancy handled by laparoscopy. material and methods: we report the case of a year old woman with a history of chronic lung disease, pregnant because in vitro fertilization ( ? weeks) who attended the emergency department with abdominal pain and bloating accompanied by nausea and vomiting for two days. on physical examination she showed a distended, soft, depressible and painful abdomen without peritonism. laboratory tests were normal. a nasogastric tube was placed with generous output fecaloid intestinal contents. abdominal ultrasound by expert radiologists in abdomen showed a moderate amount of free abdominal fluid with normal uterus moderate and sbo to the ileum because of intestinal adhesion. this results were confirmed with an magnetic resonance imaging (mri). results: the patient was operated by laparoscopic approach with three trocars. the main problem was discovered. we founded a congenital adhesion which conditionated the obstructive syndrome. postoperative recovery was uneventful and the patient was discharged h after surgery. conclusion: the non-obstetrical acute abdomen in pregnant patient is a reality that occurs in one of every pregnancies. its diagnosis in more difficult than in nonpregnant patients requiring or high index of suspicion. the laparoscopic approach of acute abdomen during pregnancy is a valid and safe option, even in the early hours after diagnosis of bowel obstruction when it is performed by a well-trained laparoscopic surgeon. aim: intestinal malrotation (im) without midgut volvulus in adults is a rare clinical entity, which is the result of an incomplete rotation of the small bowel during embryogenesis, due to the nonlysis of the ladd bands. these ligaments spread between the duodenum and caecum and do not allow the gastrointestinal tract to take its normal position into the peritoneal cavity. im appears in to - newborns and is usually asymptomatic. diagnosis is usually made in the first month, and presents with findings of an acute abdomen, small bowel ileus and volvulus. im in adults is a rare entity. most of the times it is asymptomatic, but it can cause chronic abdominal discomfort and constipation. we present the laparoscopic management of an adult patient with intestinal malrotation. methods: our patient, a year old female, presented to the emergency room with a -month history of abdominal pain and nausea. all blood tests were normal. an abdominal mri showed intestinal malrotation without volvulus. due to persisting symptoms, she underwent a diagnostic laparoscopy with complete lysis of the ladd bands. the only unusual finding was a slight oedema of the duodenum. results: her symptoms settled postoperatively and she was discharged on the nd postoperative day. since her discharge, she has not developed any similar abdominal pains or complaints. conclusions: symptomatic intestinal malrotation in adults is an unusual clinical entity, but it is definitely one of the differential diagnoses we need to consider in case of chronic abdominal symptoms. the management consists of the division of the ladd bands, and this procedure can be performed safely with laparoscopy. many small intestinal obstructions are due to adhesions after laparotomy, but small bowel obstructions without history of open surgery is relatively few. in diagnostic imaging such as preoperative ct examination, the cause is diagnosed to some extent, but details are sometimes unknown unless operative observation is actually made. in many institutions, laparoscopic surgery is also actively introduced into the operation to relieve bowel obstruction, and its effectiveness is beginning to be recognized. we examined the usefulness of laparoscopic surgery for patients with small bowel obstruction without history of laparotomy from experience in our hospital. aim: from december to october , we searched cases of laparoscopic surgery for a small bowel obstruction without previous laparotomy at our hospital, and clinical findings, surgical results, and postoperative course were examined. results: there were ten cases. eight men and two women. the median age was years ( - yrs.) . reasons for intestinal obstruction were adhesions cases, internal hernia cases, persimmon stones case, small intestine tumor case. four cases of adhesions were emergency surgery. there were cases of emergency surgery and waiting surgery. five laparoscopic operations were completed and five cases during laparotomy transition. the median surgical operation time was min ( - min), and the median bleeding amount was g ( - g). there was no fatal case after operation, only one complications of ileus. the median length of hospital stay was days ( - days) . conclusion: laparoscopic surgery for intestinal obstruction with no history of laparotomy was thought to be a safe and effective procedure. although the transition to laparotomy would be higher in case of emergency, but there was no case of large incisional laparotomy. conclusions: laparoscopic surgery for sbo reduces postoperative complications and contributes to shortening the postoperative hospital stay and to decreasing the rate of recurrences, although it is a retrospective study, which is a safe and a useful approach. furthermore, first episode of sbo without previous operation seems to be an appropriate indication for laparoscopic surgery. background: postoperative adhesion after abdominal surgery may cause intestinal obstruction, chronic pain, or female infertility, which constitutes the major problems after surgery. adhesion formation are reported to be reduced by laparoscopic surgery and the use of anti-adhesion barriers. seprafilm composed of sodium hyaluronate carboxymethylcellulose bioresorbable membrane has been widely used to date, especially in open surgery. the characteristics of seprafilm, which is easily stick when wet, conversely brittle when dry cause it difficult to deliver into the abdominal cavity via the small incision in laparoscopic surgery. therefore, seprafilm is not much used in laparoscopic surgery. although various methods of insertion of seprafilm have been reported, some need special devices, or some acquire skill. methods: we adopted the pre-moistening technique for the replacement of seprafilm in consecutive cases of laparoscopic gastrointestinal surgery. a sheet of seprafilm was cut into equal pieces. to soften the sheets, one of the pieces was placed on a folded wet gauze until it became naturally curled then it was reversed, and the same procedure was repeated. softened sheet is easily to deliver into the abdominal cavity via a small incision by pushing with digital finger. moistened sheet expands naturally in the abdominal cavity. one or two pieces were needed to cover the incision. this process took only a few minutes. results: in all cases, the sheets were successfully introduced into the abdomen and spread widely enough to cover the incision. there have been no adverse effects, no postoperative complications, or gastrointestinal obstruction due to adhesion in the observation period of median two years. conclusions: short term outcomes were good after applying this technique. however, to record the incidents of intestinal obstruction and chronic pain, over years observation is indispensable. long term follow-up studies are required to clarify the usefulness of the anti-adhesive barrier in gastrointestinal surgery. b. east, rd department of surgery, motol faculty hospital, prague, czech republic aim: since when the ipom acronym was used for the first time our views at intraperitoneal mesh positioning has changed several times. despite growing evidence on its possible long term consequences it is still preferred method at some centres for large number of patients. the aim of this study is to point out the pitfalls of this method but also show that ipom is a good technique but only for highly selected cohort of patients. methods: this is a review of the literature focusing on the indications and complications of ipom pointing out controversies among the published articles over last two decades. some mesh material characteristics are being discussed as they are basic for understanding this complex and highly sensitive issue. results: a wide range on indications of ipom from little umbilical to large incisional hernias is advocated by many. however, some opinion leaders promoting this technique as universal and ideal for everyone just few years ago are advising to avoid it if possible lately. a necessary overlap has also been questioned recently. despite improving anti-adhesion barriers and methods of fixation in may a surgical mesh has become classified as risk class iii by the eu parliament and council on medical devices hoping to prevent physiomesh like incidents in the future. the need for post market registries and long term follow up is obvious. conclusion: us as surgeons implant a mesh in our patients and therefore we should be aware of its possible long term effects. no mesh on the market has a long term safety evidence especially in the intraperitoneal space. ipom is a good technique but possess a significant risk of long life complications and therefore should be spared only for those unfit for other methods of repair, patients with too high mesh infection risk, obese or older patients. introduction: acute appendicitis in elderly patients is relatively uncommon and could represent an underlying neoplasm. hence patients over the age of are often referred for a follow-up colonoscopy after management of acute appendicitis. the current routine use of computed tomography (ct) scans in the evaluation of suspected acute appendicitis in elderly patients prior to surgery coupled with intra-operative findings at laparoscopy question the role of follow-up colonoscopy for these patients. aims: to determine the role and optimal timing of colonoscopy in early detection of colorectal neoplasia after treatment of acute appendicitis in elderly patients. methods: all patients aged years and above with confirmed appendicitis admitted to our hospital during the period / / to / / were included. follow-up colonoscopy, diagnosis of colorectal neoplasia and its location in this patient cohort was evaluated. results: number of people aged and above in olol who had appendectomies from the dates / / to / / = . out of them / ( %) had full colonoscopy within years of the appendectomy.of them of the colonoscopies done were maleand were females. / ( %) of these colonoscopies were completely normal. colonoscopy identified colorectal carcinoma in ascending colon ( . %). other pathologies identified included: benign polyp ( %), polyp with low grade dysplasia ( %) and others ( . %) (lymphocytic colitis, ulcerative colitis, medication related ulceration, diverticulosis, melanosis coli, haemorrhoids). conclusions: in elderly patients above years of age: there may be an increased risk of colorectal cancer after acute appendicitis. only % of this patient cohort underwent colonoscopy after appendectomy. the current recommendations suggest the need for follow-up colonoscopy in elderly patients post acute appendicitis. further studies are needed to decide whether routine colonoscopy is indicated after acute appendicitis patients over years. introduction: it is generally accepted that the main aetiology of appendicitis is obstruction due to appendicoliths in adults and lymphoid hyperplasia in children. in contrast, incidental appendicoliths have been reported to occur in up to % of the asymptomatic population. controversy still exists regarding the association of appendicolith and appendicitis. is the appendicolith a causative factor or merely an incidental finding? aims: to determine the association between the presence of appendicolith and acute appendicitis (perforated or non-perforated) vs healthy appendix. methods: we collected the data retrospectively from the electronic records of all appendicectomies performed between january and december in our institution. data collected included: age, sex, appendix histology and the presence of appendicolith. interval or incidental appendicectomies were excluded from this study. we analysed the data using spss software version . results: during the study period appendectomies were performed (males: , females: , age range: - years). cases were histologically confirmed cases of acute appendicitis and of these, were perforated. a normal appendix was identified in cases. the remaining cases were due to chronic appendicitis, sub-acute appendicitis, lymphoid hyperplasia, parasitic infestation, and neoplasm. appendicolith was found in cases, of which were found in a normal appendix and were found in an inflamed appendix. out of the cases of appendicolith with normal appendix: cases were aged between and years old, cases were aged between and years old and case was aged between and years old. out of cases of appendicolith with acute appendicitis, cases were aged between and years old, cases were aged between and years old and case was aged over . conclusions: appendicolith may merely be an incidental finding and is not the primary cause of appendicitis. no significant correlation between gangrenous/perforated appendicitis and the presence of appendicolith. contrary to popular belief appendicoliths are more common in paediatric appendicitis than in adult cases. further research is recommended. over the last years, patient satisfaction surveys have gained increased popularity. nowadays, respect for patients' needs is central to our health care system. hospitals use patient satisfaction surveys to assess quality of care. many hospitals routinely survey patient satisfaction but relatively little data has been published. our acute surgical assessment unit operates from am to pm monday to friday and in its first year saw surgical patients, of whom were discharged and were admitted to the hospital for further management. aims: to assess the levels of satisfaction of patients attending asau at our lady of lourdes hospital. methods: a random sample of patients seen in the asau was surveyed to determine their level of satisfaction and the experience they had whilst attending asau. a novel self-reported patient satisfaction questionnaire was developed and used to assess patients' opinion regarding the treatment they received, the doctor's explanation of their condition, the waiting time and the service in asau. also the questionnaire encouraged patients to suggest improvements to the service. aim: sintestinal obstruction is a very common cause of presentation to an emergency department. the most common cause in patients with prior abdominal surgery are adhesions, but the list of differential diagnosis is large. internal hernia is a very rare cause of obstruction, with a reported incidence of between . and . %. the herniation related with broad ligament defects is even more uncommon. methods: we report the case of a -years-old woman with antecedents of liver transplant, tubal ligation and appendectomy. the patient was admitted refering abdominal pain in the epigastrium of h duration, accompanied by nausea and vomiting. on physical examination, abdomen was depressible, tender in the right low quadrant, without evidence of peritoneal irritation. laboratory studies were normal except for an elevated leukocyte count with a left shift. computed tomography (ct) revealed dilated small bowel loops with a transition point in right lower quadrant. radiological diagnosis was intestinal obstruction, with fibrous adhesion as the most probably aetiology. management was conservative at the beginning, with intravenous hydration, nasogastric tube and administration of gastrografin (diatrizoate) without a good response. results: at h, an exploratory laparoscopy was perform, finding dilatation of small bowel loops and a cm defect in the right broad ligament in which a segment of ileum was herniated. ileal segment was liberated without evidence of ischemia. the hernial defect was closed by laparoscopy with simple silk stitches. the postoperative course was excellent, tolerating oral feeding next morning. the patient was discharged h after surgery. conclusions: internal hernias of the broad ligament are an extremely rare cause of intestinal obstruction, but must be added to the differential diagnosis for female patients due to the risk of intestinal strangulation and perforation. even if clinical and radiological diagnose is difficult, ct is the best tool to delineate the cause and location of the obstruction. laparoscopy allows reduction of the hernia and closure of the defect with minimal invasiveness. because of that, the laparoscopic approach of bowel obstruction should be considered as the first choice if there is the suspicion of an internal hernia, without signs of necrosis or perforation. the laparoscopic approach is a safe and effective tool in the management of postoperative complications. it is well tolerated in critically ill patients and avoids respiratory and wound related morbidity associated with laparotomy. it also reduces diagnostic delay and a considerable number of unnecessary laparotomies, with a high resolution rate and minimal morbidity. it thus represents a valid and necessary alternative in surgeon's armamentarium. in the management algorithm of our institution we always choose the laparoscopic technique as the fisrt tool in case a reoperation is necessary. , small bowel obstruction ( . % vs . %), and colorectal cancer obstruction ( . % vs . %) was found higher for acs unit group, and also progressively higher during the last years. conclusion: according to our study, laparoscopic approach in abdominal emergencies shows an upward trend, and surgeons from acs units seem to have higher rates of laparoscopy than general surgeons in emergency procedures. background: incarcerated and strangulated hernias present a major problem in emergency medicine. there is scarce data about the role of laparoscopy in the management of these patients. laparoscopic repair offers the benefits of the ability to survey the incarcerated organ and to evaluate its viability, apart from the obvious advantages of laparoscopic surgery. the use of mesh repair in these emergent operations is also a major concern, due to the un-sterile conditions in which they are performed. objective: to evaluate the safety and short-term efficacy of laparoscopic emergent repair of incarcerated hernias. methods: retrospective review of prospectively collected data of all the patients who underwent emergent laparoscopy due to an incarcerated hernia between november and october . results: during the study period, patients underwent emergent laparoscopy due to incarcerated hernias ( females, males). had incarcerated inguinal hernias, and had incarcerated umbilical hernias. mean age was . . all inguinal hernias were repaired in the tapp approach, and using an absorbable mesh. all umbilical hernias were repaired using the ipom approach. patients had bowel obstruction, had incarcerated omentum, and one patient had incarcerated urinary bladder. patients underwent resection of an ischemic organ ( bowel, urinary bladder, omentum). mean hospital los was . days. during the follow up period there were no mortalities, and no recurrences. one patient had a wound infection that resolved with antibiotics. conclusion: laparoscopic emergent repair of incarcerated hernias is a safe and feasible approach. further studies with longer follow up time need to be conducted, in order to evaluate the added benefit of the laparoscopic approach. gibraltar is a small overseas british territory with a residential population of approximately , inhabitants, that increases up to , daily due to incoming tourists and cross-frontier workers. as a geographically isolated center we have to provide a varied service including emergency surgery, and elective operating such as colectomies, gastrectomy's etc. one of the challenges faced is the limited stock of red blood cell (rbc) units within gibraltar and reliance on platelets (plt) from across the border from spain. given the immanent brexit we need to prepare for the challenges we will face in these times of political and distribution uncertainty. a prospective audit of all blood use within gibraltar was carried out over months. the number and type of units requested, the number of units given, the speciality, location and indication for requests was recorded. introduction: the use of laparoscopic surgery in abdominal emergencies, such as in trauma, has had a slow acceptance. the advantages with this approach include less postoperative pain, faster recovery, quicker return to everyday activities, and fewer complications. we have collected the cases and indications of laparoscopy in abdominal trauma in the main hospitals in the andalusian capitals and compared with the national registry material and methods: a total of patients who underwent laparoscopic surgery in the main hospitals of seville, cordoba, malaga, cadiz, huelva, jaen, granada and almeria were analyzed. they have been compared with the traumas archived nationally by the spanish association of surgeons taking into account age, sex, score of the american society of anesthesiologists, hemodynamic stability and mechanism of injury. the intra and postoperative variables were compared between groups. results: at the national level, the main cause of abdominal trauma were traffic accidents, therefore, it was the patients who had a greater number of laparoscopies ( . %), followed by stab wounds ( , %) and run over ( . %). in our series, the average age of the patients is years and % are male. only eco-fast was performed in % of the patients, being positive in . % of the cases. as they were stable patients, in % of the cases a tac was possible. in our data, % of the laparoscopies were performed for therapeutic purposes as well as being diagnostic, thus avoiding a posterior laparotomy. conclusion: slaparoscopic surgery for abdominal trauma, either blunt or penetrating, is safe and technically feasible in hemodynamically stable patients. we found that laparoscopic surgery was associated with shorter operative time, lower estimated blood loss and faster return to normal diet. based on our findings we establish the indications of laparoscopy in these patients aims: submucosal aneurysm of small intestine is extremely rare, but its rapture can be lifethreatening. due to the unstable hemodynamics and unknown site of bleeding, emergency laparotomy has been widely performed for the rupture. we will present case reports and show the strategy for minimally invasive treatment for ruptured aneurysm. methods: we experienced two cases of ruptured submucosal aneurysm resected by laparoscopic surgery. case is a -year-old male who was taken to our er with massive hematochezia. ct showed arterial bleeding in the small intestine and angiography revealed bleeding from the ilial artery. selective embolization using gelatin sponge and micro coil was performed and hemostasis was obtained. video capsule endoscopy found the hemispheric elevated lesion with protrusion at the top in the ileum. using balloon assisted enteroscopy, the site of aneurysm was marked with injecting india ink, which allows surgeons to accurately and easily identify the part of small intestine with aneurysm. subsequently, a single incisional laparoscopic assisted partial ileectomy was performed for the purpose of definitive diagnosis and preventing re-bleeding. the ileum with aneurysm was easily identified in laparoscopic exploration owing to the marking, and it was taken out from the incision to perform resection. case is a -year-old female who was transferred to our emergency department with sudden onset of massive melena. ct and angiography were perfomed, and bleeding from the rd jejunal artery were confirmed. subsequently, therapeutic embolization was performed in the same way as case . enteroscopy revealed submucosal elevation similar to case in the jejunum. we carried out endoscopic tattooing, followed by single incisional laparoscopic assisted partial jejunectomy. results: the operative time in case and case were min and min, respectively, and the amount of blood loss was both ml. the postoperative course was uneventful in both cases. case was discharged on the postoperative day , and case was on postoperative day . conclusions: our experience indicates that ruptured submucosal aneurysm of the small intestine can be effectively managed by a laparoscopic surgery with combination of therapeutic embolization and enteroscopic evaluation, which is safe and minimally invasive. background: laparoscopic bilateral inguinal hernia repair may be completed with one large selffixating mesh crossing the midline in front of the bladder. no studies have investigated in detail whether preperitoneal mesh placement induces temporary or more lasting urinary symptoms. methods: urinary and hernia related symptoms were evaluated preoperatively and postoperatively at , and months in patients using the iciq-mluts questionnaire and eurahs-qol score. results: voiding symptoms and bother scores were unchanged at or months, but there was significant improvement at months compared with preoperative findings (symptoms p \ . ; bother score p \ . ). incontinence symptoms improved at month (p \ . ) but not at or months, with a bother score significantly improved at month (p \ . ) and months (p \ . ). diurnal and nocturnal frequency did not change significantly postoperatively, but months nocturnal bother score was decreased (p \ . ). eurahs-qol scores showed significant improvement in all domains for all measurements compared to previous measurements. postoperative symptoms were improved at months, compared with preoperative pain scores (- . ), restriction of activity (- . ) and cosmetic scores (- . ) these findings were statistically significantly (p \ . ). at months, there were no patients with severe discomfort (score = ) for any of domains. no recurrences were diagnosed with % clinical follow-up at months. conclusion: placing a large preperitoneal self-fixating mesh for bilateral groin hernia repair did not cause new urinary symptoms and demonstrated significant improvement in voiding symptoms at months. incontinence and nocturnal bother score were significantly improved. introduction: tep/tapp hernia repair is an increasingly widely used surgical methods for minimally invasive treatment of inguinal hernia. tep advantages to tapp are noincision of the parietal peritoneal sheet, therefore no need for its recovery-sewing or sticking at the end of the procedure, and no need for attachment of the prosthetic mesh to the structures of the anterior abdominal wall, which results in a reduction in the financial cost of operation.various types of meshes with different characteristics are used, depending on the surgeon's preferences.the aim of this study is to highlight mesh-related postoperative complications, which can be serious and life-threatening. material and methods: a retrospective cohort study of cases of unilateral or bilateral tep and tapp hernia repair performed at the university hospital for the period - with a study of early and late postoperative complications potentially causally related to the implanted prosthetic mesh and methods of their treatment. results: for a -year period tapp ( bilateral) and tep ( bilateral) have been performed. three complications (clavien-dindo iva, ivb and v) were found, of which were early postoperative (up to pod)-one in tapp- pod small bowel adhesive ileus due to suture dehyscense of the peritoneal sheet and adhesion of a bowel loop to the surface of polypropylene mesh.one in tep- pod-a large preperitoneal hematoma with haemorrhagic shock at years old female in anticoagulant therapy-an open revision of the preperitoneal space and definitive haemostasis; followed in pod established bladder lesion from erosion from the edge of self-locking polypropylene mesh. suture and drainage performed, but the patient died of decompensation of concomitant diseases. a late complication- months after bilateral tep-erosion of soft polypropylene mesh of sigma (probable undetectable lesion of the peritoneum) with faecal peritonitis-hartmann procedure with laparostoma followed by restitution but persistent chroniosepsis with established abscess in retzii. months after-revision with abscess incision and extraction of infected meshes. discussion: use of biologic meshes is quite expensive, however synthetic non-resorbable meshes implanted in preperitoneal layout is a prerequisite for specific severe postoperative complications. inguinal hernia repair is one of the most performed procedure all over the world, with more than million procedures performed each year, it represents one of the top three most performed procedures. the lichtenstein procedure is one of the first procedures that a young trainee in general surgery learn, not only for its reproducibility and for the great numbers of procedures that could be done in each department, but also because during inguinal hernia repair the trainee learn a lot of skills which are the basis of major surgical interventions. the surgeon's performance for any procedure could be evaluated by way of established learning curves that can predict the minimum number of procedures required to reach the same intra and post-operative outcomes as an experienced surgeon performing the same technique. the aim of our multicentre study was to analyse how many cases are required to stabilize operating time (ot) and intra and post-operative complication rates over the course of the learning curve period for a lichtenstein procedure. from january to december all lichtenstein procedures from four different institutions were recorded in a prospective maintained computer database. the results of the first consecutive procedures performed by three different trainees (group a; group b; group c) were compared with the same numbers of procedures by two senior surgeons of the same institutions (group e, group f). cusum analysis was performed to evaluate the achieving of learning curve. no differences in terms of biometric and hernia type were recorded between the five groups. cusum analysis showed that the trainees achieve the learning curve between the - procedures. no intra or post-opertive complications were recorded during the training period.in conclusion after our analysis we found that at least procedures are needed for the trainees to achieve the learning curve for lichtenstein procedures. background: since its first description in the s, the total extraperitoneal (tep) technique has established itself as a popular endoscopic method for the repair of inguinal hernias. the tep repair is generally viewed as a technically-demanding procedure requiring adequate experience to minimize and handle complications. in this case report, we describe an uncommon complication of urethral injury, which was successfully repaired laparoscopically. case report: mr r is a year old gentleman with no significant past medical history who presents to the department of general surgery, tan tock seng hospital, with a two-month history of a reducible right inguinal hernia, associated with some tenderness. an ultrasonography confirmed the diagnosis of a fat-containing indirect right inguinal hernia. in view of persistent pain, mr r was counseled for a laparoscopic repair of his right inguinal hernia. as mr r was able to empty his bladder just prior to surgery, no urinary indwelling catheter (idc) was inserted. an infra-umbilical incision was made to access the posterior rectus sheath and a balloon was used to bluntly dissect the pre-peritoneal plane. on inspection of the operating field, persistent pooling of blood was noted in the retropubic space. careful inspection revealed a defect in a tubular structure just inferior to the bladder neck. an idc was inserted, which confirmed a . cm defect in the pre-prostatic urethra. decision was made for primary repair using absorbable sutures in two layers. the bladder was subsequently filled via the idc, which did not reveal any leak. we then completed the right inguinal hernia repair using a mesh. mr r made an uneventful recovery and was discharged on post-operative day with instructions to keep the idc in-situ for two weeks. the idc was removed after two weeks and a micturating cystourethrogram was performed, which showed no filling defects along the urethra and no contrast leaks. discussion: though uncommon, urethral injuries can be a complication of laparoscopic tep repair. the key to managing these complications is in the early identification of such injuries intra-operatively. with early recognition and careful assessment, such complications can be managed laparoscopically with minimal post-operative morbidity. aim: the purpose of this study is to report surgical technique and outcome of hybrid tapp procedure (a combination of tapp and ipom) for inguinal hernia patients complicated with preperitoneal space adhesion. methods: hybrid tapp procedure is applied if peritoneal dissection or closure of the peritoneum is difficult due to severe adhesion. the peritoneum should be dissected as much as possible. for the site where adequate dissection was achieved, the collagen mesh is placed outside the peritoneum. in the part where dissection was difficult it is placed inside the peritoneal cavity. in order to prevent mesh migration, the mesh should be directly fixed to the cooper's ligament with a tacker. for this purpose, the peritoneum around the cooper's ligament must be well-dissected, even if it is strongly adhered, so that the ligament can be exposed. the crucial points in the hybrid tapp procedure are fixation of the mesh and prevention of the bowel herniation into the preperitoneal space. at the site where peritoneal dissection is possible, the mesh is directly fixed on the fascia using a tacker. if it is difficult, the mesh is placed in the peritoneal cavity and fixed over the peritoneum. if there is a risk of migration along with peritoneum, transcutaneous full-thickness fixation can be performed using non-absorbable sutures. the preperitoneal space should be closed tightly as soon as possible in order to prevent the bowel herniation into the preperitoneal space. at closure of the preperitoneal space, the peritoneum is fixed on the collagen mesh using non-absorbable sutures. objective: show a tapp approach using a self-fixating mesh( x cm. progrip tm laparoscopic self-fixating mesh, medtronic) with bipolar peritoneal defect sealing, avoiding the use of tackers and performing an easy and sutureless peritoneal closure. material and methods: years old male, asa ii, medical history of beta-latacm allergy, high blood pressure, dyslipidemia and bilateral knee surgery. diagnosed of bilateral inguinal hernia at consultation due to inguinal disconfort. surgical site infection prophylaxis with iv vancomycin. balanced general anesthesia. supine decubitus position with shoulder supporting to allow a forced trendelemburg. degree optical device with trocars disposition: one mm umbilical trocar and mm trocar in both flanks, same distance and height to umbilical trocar. peritoneal opening and flap creation with monopolar energy, blunt maneuvers and pneumoperitoneum dissection. anatomical landmarks identification(cooper's ligament, epigastric and iliac vessels, hernia defect and spermatic cord elements). reduction of hernia sac content(pseudosac in this case, direct hernia) and complete peritoneal dissection to achive a correct mesh placing. mesh is folded in parts(one inferior part, two superior parts) in vertical axis outside the abdomen to facilitate the posterior intraabdominal maneuvers. introduction: into abdominal cavity with grasping forceps and correct unfolding mesh assesment: medially(pubic bone), caudal(cooper's ligament) cranial(more than cm of hernia defect/ deep inguinal ring) and lateral(anterior superior iliac spine). finally, we use a bipolar forceps to close de peritoneal defect. in order to facilitate this step, its necessary to decrease pneumoperitoneum pressure and to use the grasping forceps to bring together both peritoneal flap edges prior to bipolar energy sealing. results: min. surgical procedure. h hospital discharge, no complications. routine outpatient follow up(week, month, months and month later) with an epididymitis episode months after surgery(treated with oral ciprofloxacin). conclusions:-this procedure is an easy implementation technique once the intraabdominal mesh unfolding procedure control is reached.-the use of a self-fixating mesh avoid the use of tackers and its potential disadvantages(e.g. increasing postoperative pain).-bipolar peritoneal sealing offers a quick, easy, cheap and safe peritoneal closure, avoiding the contact of the mesh with the viscera in the same manner. results: we performed procedures within patients. the average age was years. twenty six percent of hernias were bilateral, , % were inguinoscrotal and % in the right side. the median asa score was . the conversion rate was , %. the average duration of the procedure was , min min. overall morbidity was %. there were seromas ( , %) . on -year follow-up, one recurrence ( , %) was found and chronic postoperative pain in one case . we had no mortality. in the univariate analysis, male sex, inguinoscrotal hernias, hernias classified as nyhus a were significantly associated with overall postoperative morbidity. a chronic obstructive pulmonary disease was the only variable significantly associated with the occurrence of medical complications. conclusion: given these results, the tapp technique is a good alternative in the treatment of groin hernias. however, enhancing this approach is essential to reduce the operating time and the postoperative outcomes. introduction: studies have emphasized the impact of a strong safety culture on patient outcomes. consequently, many interventions focus on improving the safety culture, of which teamwork and safety climate are important ingredients. it is known that differences in culture and safety attitudes may also impact teamwork. implementations of safety interventions, such as a ' black box', are dependent upon these differences. the aim of this study was to assess the safety culture at the operating theatre complex, along with the theatre staff's attitude towards a specific quality improvement intervention, a black box in the operating room as a tool for structured team debriefing. methods: the validated dutch version of the hospital survey on patient safety culture was administered to all healthcare professionals working in the operating room complex at one academic medical centre. this survey was supplemented with questions regarding the use of a 'black box', a medical data recorder in the operating room, to measure the staff's attitude towards this quality improvement tool and its potential contribution to patient safety. aims: the aim of the study was to compare two methods of treatment of dunbar syndrome: thelaparoscopic release of median arcuate ligament alone and the hybrid method consisting ofsurgery and percutaneous stent implantation to celiac trunk. methods: we performed laparoscopic release of ct in the department of general, mini-mallyinvasive and elderly surgery in olsztyn in - . all of patients suffered from severepain of abdominal cavity before the surgery. three patients underwent doppler percutaneousangioplasty of the ct with stent implantation one month after the laparoscopy. results: all patients reported relief of symptoms in the first days after the operation. in two cases fromboth groups, there were a complete remission of the symptoms. in one case respectively,there was an improvement. there were no postoperative complications. the results of both methods do not show the differences therefore the surgery alone seems tobe a safe and feasible procedure. it increases the comfort of the patient and brings theopportunity for normal functioning. the method of wedge resection of lungs in patients with limited forms of chemo-resistant pulmonary tuberculosis is developed. in order to evaluate the efficacy, patients underwent surgery (the main group). for comparison, the data on similar operations in patients, made according to the traditional method (with the help of a cardboard weaving machine yo- ) were selected. compared the duration of the stage of resection itself, the frequency of need for additional hemostasis of the parenchyma sutures, the degree of deformation of the pulmonary tissue in the seam area, the frequency of postoperative complications and reoperations, the duration of postoperative inpatient treatment. the developed method, in comparison with the traditional one, has the following advantages: simultaneously leak proofness and hemostasis with minimal electrothermal damage to tissues are provided and there is no need for additional hemostasis, there are no negative effects of manual stitching of parenchyma of lung with abandonment of foreign material, a significant reduction in the duration of wedge resection of the lung from . to . min, a decrease in the number of postoperative pulmonary-pleural complications is achieved by . % and caused by them reoperations-by . %, shortening the duration of postoperative inpatient period of treatment from . to . days. introduction/aims: laparoscopy is a diagnostic and therapeutic resource that is largely used in elective gastrointestinal surgery due to its well-known advantages over the classic open approach. nevertheless, there is still some discussion about its application in emergency surgery. our aim is to analize the use of the laparoscopic approach by the members of the surgical emergency unit from our medical center. methods: a descriptive research based on the data of patients who required emergency surgery, that was performed by the members of the surgical emergency unit of a spanish hospital between november and may , was conducted. these data were analyzed according the pathology that motivated the surgical procedure and the chosen form of surgical approach (open versus laparoscopic). results: out of the patients in whom emergency surgery was performed, suffered from a pathology that actually allowed the laparoscopic treatment. laparoscopy was used in . % of these patients. according to pathology, the most common were acute appendicitis and cholecystitis, in which the laparoscopic approach was used, respectively, in % and % of the cases. regarding other less frequent pathologies, such as gastroduodenal perforation, bowel obstruction, diverticulitis and pancreatitis, laparoscopy had a less significant role. according to the year, a general tendency to increase the use of the laparoscopic approach was found, most notably in the cases of acute appendicitis and cholecystitis (with rates above % in ). conclusions: despite our positive results in the terms of the implementation of the laparoscopic approach in emergency surgery, there is still room for improvement, especially in regards of the less common pathologies. furtheremore, additional studies are needed in order to identify the factors that have had an effect, in favour or detriment, in the development of emergency laparoscopy in our center. aims: laparoscopic surgery, which produces small scars, has become widespread. when performing surgery through small laparoscopic incisions, a surgeon manipulates tools inserted into the abdomen through ports. for minimally invasive accurate procedure, the port as the pivot point should be stabilized on the abdominal wall. however, these laparoscopic incisions are loaded while manipulation because it is difficult for the port to be fixed on. thus, it is necessary for the patient friendly manipulation to be fixed the port mechanically. we developed a new pivot restraint device (prd) attached to a trocar for guiding the tool. the purpose of this study is to evaluate both of reducing the operating time and the load of the port with the prd experimentally. methods: the prd uses gimbal mechanism for two rotating axes and a linear guide mechanism for the insertion axis though into the forceps. in the experiment, the left hand forceps with or without the prd and the right hand forceps without the prd were set on the training box. the box had a measuring system created with a pressure sensitive sensor for the continuous force (resolution . n, fps) applied to abdominal wall fulcrum. the experiment task was performed as following three steps. ( ) the surgeon lifted the g weight for s at the initial position using the right hand forceps. ( ) the weight was transferred from the right hand forceps to the left hand forceps, and held for s. ( ) the weight was moved to the predetermined position, held for s, and returned to the initial position. the surgeons were five endoscopic specialists and five non-specialists. the operating time and the time ratio exceeded n for the left hand forceps were measured. two grouped datasets with or without the prd were compared using two-sided t-test. results: the prd was associated with both of reducing the operating time ( . s vs. . s; p \ . ), and the load of the port ( . % vs. . %; p \ . ) at the statistical analysis. conclusion: the prd could be used for reducing the operating time and the load of the port in minimally invasive accurate procedure. background: pathophysiological changes during laparoscopic surgery and positive pressure pneumoperitoneum (pp) may include (beside cardiovascular changes) elevated intra-thoracic as well as intracranial pressures. however, the possibility of physiological and functional cerebral impairment under pp is still debated. aim: to study the effects of pp on brain activity during different modes of anesthesia and ventilation during laparoscopic cholecystectomy (lc). patients and methods: thirty patients undergoing elective lc were divided to those who were ventilated by intermittent positive pressure ventilation (ippv, pt.) and by high frequency jet ventilation (hfjv, pt.). in those under hfjv we used total intravenous anesthesia (tiva). in those under ippv we either used inhalational anesthesia or tiva. intra-ocular pressures were detected in both eyes, trans-cranial doppler was used to measure the changes in flow of the middle cerebral artery, and cerebral oxygenation (o saturation) was measured too. each parameter was detected during anesthesia before surgery, several times during surgery under pp and after co evacuation. a novel computerized signal analysis by a continuous recording through a single electrode was done to explore cerebral cognitive activity during surgery. results: all surgeries went uneventful and without complications, pp was set to mmhg, and each patient was positioned in a degree anti-trendelenburg posture. cerebral perfusion and oxygenation were not changed significantly during pp. intra-ocular pressures decreased during anesthesia and increased during pp, but to a lesser extent under tiva. however, pressures during pp did not exceed pre-surgical values. we did not observe changes in cognitive brain activity during pp, although enhanced cerebral activity was seen under hfjv. conclusions: increased intra-abdominal pressure during laparoscopic surgery was not accompanied by decreased cerebral functions, maybe due to cerebral circulatory auto-regulation. changes in cerebral cognitive functions under hfjv might be explained either by the different cerebral effects of tiva in comparison to inhalational anesthesia, or due to dissimilar hemodynamic changes during hfjv. aims: gallstone ileus (gi) is a rare complication of cholelithiasis and accounts for . - % of small bowel obstructions. intermittent and non-specific presentation often results in late diagnosis. the triad of rigler is pathognomonic (pneumobilia, small bowel obstruction and ectopic gallstones), so an image test is usually mandatory in order to assure the diagnose. our aim is to expose our experience regarding this topic to show that a minimally invasive approach is feasible in selected cases. methods: since january we treated cases of gi, of whom ( %) underwent laparoscopic surgery. in all cases a ct was made to reach diagnosis. enterolithotomy alone is our preferred procedure for the resolution of this pathology. here we present a descriptive analysis of our data in those cases where a laparoscopic treatment was attempted. epidemiological variables, surgical technique, postoperative complications, days until hospital discharge, recurrence, etc. has been collected. results: % of patients were female( ) and % male ( ). mean age was . size of gallstones varied from to mm and ct located them all in the ileum. two conversions to open surgery were made ( %), in one case because the gallstone could not be found and in the other case due to the need of an intestinal resection. in two cases ( %) la aparoscopic-assisted surgery was performed using a pfannestiel incision for the gallstone extraction and enterorrhaphy. only one case was total laparoscopic approach ( %). two cases needed an intestinal resection and anastomosis, one of them was complicated with a leak that needed reintervention. there were two cases of recurrence during the follow-up time. hospital stay varied from to days, mean of days. conclusion: the widespread use of ct facilitates early diagnosis with high sensitivity detecting rigler's triad. a totally laparoscopic procedure might be ideal for patients specially with solitary stones even though a laparoscopic-assisted approach is an easier technique for surgeons with less experience in laparoscopic surgery. although experience in minimally invasive surgical treatment of gi is still developing, it may be recommended in selected cases and experienced hands. introduction: most of surgical interventions in hospitals in the world, where laparoscope is used, it is common that the vision inside the human body is constantly interrupted by fogging in laparoscope tip. the laparoscope fogging is caused by the difference of temperatures between the optic tip and the abdominal cavity. material and method: we replaces the traditional laparoscope for the ehs (endoscope heater system) with resistance between the internal and external tube that maintains the temperature of laparoscope at ( - °celsius) without modifying the external architecture of traditional laparoscope. results: ehs does not generates any waste like other anti-fog systems, like liquids, plastics covers or electric heater. reduces intervention time, can keep same instruments or accessories for the intervention. all of the above means a saving of resources with have a positive environmental impact. conclusions: the discomfort transmitted by surgeons about the fogging in laparoscopy tip make success of the product and it will replace the current laparoscope which is fogged. aim: synchronous locally-advanced low rectal cancer and prostate adenocarcinoma represent a rare condition and a challenging situation for colorectal surgeons and urologists. the simultaneous resection of both adenocarcinomas after long-course chemoradiation therapy combines two major surgical procedures associated with a potentially increased postoperative morbidity. in the other hand, simultaneous resections minimize the risk of difficult dissections, which are expected if the two procedures are scheduled sequentially. in the past decade, robotic-assisted minimally-invasive surgical techniques have been increasingly used to treat both rectal and prostatic malignancies. especially in case of prostatic malignancy, the robotic approach is considered the treatment of choice because it is associated with significantly lower blood loss and transfusion rate, and much greater functional outcomes compared to laparoscopy. methods: we present the case of a -year-old male patient (bmi: . ) diagnosed with a histologically proven locally-advanced rectal adenocarcinoma (ct an ) located at cm from the anal verge and concurrent histologically proven prostatic adenocarcinoma [gleason score of ( ? )] located in the postero-basal right lobe. the preoperative total-body computed tomography (ct) scan showed no evidence of metastatic disease. after discussion in a multidisciplinary meeting, the patient received a long-course neoadjuvant chemoradiation therapy (ncrt). at the restaging positron emission tomography / magnetic resonance imaging (pet-mri), the rectal lesion was classified as ymrt n . preoperatively, the surgical difficulty was assessed as high, based on the calculation of the eumarcs score (equal to / ). moreover, due to the high-risk status of the prostate cancer (gleason ), it was decided not to preserve the neuro-vescular bundles during the radical prostatectomy. results: the patient was operated on after weeks from completion of ncrt by using the da vinci robot system si with a single docking approach, as previously described, in order to address both cancers. conclusions: this video shows the main surgical steps of the simultaneous robotic resection of the low rectal adenocarcinoma first, of the prostatic carcinoma then, and the mechanical colo-anal anastomosis followed by drain positioning and ileostomy. this video demonstrates the perioperative safety and feasibility of the minimally invasive robotic approach in case of extended and challenging oncologic resections. general surgery, rambam medical center, haifa, israel year old, male patient presented with melena, without abdominal pain, nausea or vomiting. patient underwent colonoscopy and tumor was found in ascending colon (near the hepatic flexure). biopsy from the tumor has showed moderately differentiated adenocarcinoma. his blood laboratory examinations were within normal limits except of hgb level- . . cea and cea - were normal. abdominal computed tomography was normal . patient underwent da vinci robot-assisted right hemicolectomy with extracorporeal anastomosis. total operating time was min. three days after operation patient started regular diet and was discharged home on day four. final pathology result confirmed diagnosis of moderately differentiated adenocarcinoma. introduction: one of the goals of colorectal surgery is to decrease the number of leaks once an anastomosis has been performed. this life-threating entity after elective surgery has been related to the clinical history of the patients, the location of the tumor and to technical reasons, specially due to tension in the anastomosis or to lack of vascularization. tension could be identified during surgery, while vascular supply is evaluated by the surgeons based on a subjective analysis of the color of the colon/ileum. fluorescence tries to make these subjective parameter more objective in order to avoid an anastomosis with lack of vascularization, decreasing the numbers of leaks related to this factor. patients and method: the study presents a quasi-experimental analysis made from january to october in two hundred and eighty-five patients who underwent elective colerectal surgery, performing either a colo-rectal, ileo-rectal or intracorporeal ileo-colic anastomosis. vascular supply was eveluated using indocianyne green (icg) in one hundred and forty-five patients, while one hundred and forty subjects were operated in a previous period without using this technology, being considered the control group. the number of time that the attitude changed and the number of leaks were collected. results: out of the cases performed, were right colectomies (rc), left colectomies (lc) and rectal excision (re). in % the transection line was changed ( , % in rc, , % in lc and , % in rr) . in comparison with the control group, the icg group had a significantly less indicence of anastomotic leak compared to the control group ( , % vs. , %, p = , ), lower rate of terminal stoma after reoperation ( , % vs. , %, p = , ), a shorter length of hospital stay ( days vs. days, p = , respectively), and a low morbidity and mortality. conclusions: the rate of leaks after colorectal surgery decrease using icg to detect the proper transsection line before to perform the anastomosis in comparison with control group. these findings might influence in the final results although it is necessary in the future to find a system that provides greater objectivity by quantifying icg. aims: anastomotic leaks continue being one of the most important complications when a colorectal surgery is performed. this complication is usually related to the level and type of resection, the patient clinical history and surgical technique, where tension and vascular supply are the most important. indocyanine green (icg) fluorescence angiography seems to be helpful in order to evaluate the vascularization at the resection margins. methods: we have collected data on colorectal procedures that were performed by the same surgeon using icg fluorescence angiography to evaluate vascular supply to the anastomosis. in order to asses in which of the different type of colorectal procedure has more value to be used, we analyzed the type of surgical procedure, the percentage change in the resection margin and the number of anastomotic leaks (al). results: all of the cases were performed by laparoscopic approach: left colonic resection (lc), right colonic resection (rc), splenic flexure partial resection (sf), low anterior resection with partial mesorectal escision (lar), ultra low anterior resection with total mesorectal escision (ular) and total colectomy (tc). there was a change of transection line (ctl) in lc ( , %), rc ( %), sf ( , %) and ( , %) in rectal anastomosis (lar, ular and tc). as far as al we found: lc ( , %), rc ( %) and , % in rectal procedures. lc, sf and rectal procedure showed more ctl and less al, while rc showed less ctl and more al. conclusion: icg fluorescence angiography as an additional tool to try to reduce the anastomtic leak rate seems to have more value in the procedures that involve the left colon and the rectum, since that is where we have observed the greatest number of ctl, this could be explained by the riolan's arcade and the variability of the vascular anatomy. however, it seems that this is a line of research should continue developing with longer and larger studies, so in that way we can have more significant results. retrorectal tumors ara rare and often found incidentally. the majority of retrorectal tumours are benign, but they have potential for malignant transformation and therefore should be resected when found. a case of a -year-old female patient with a retrorectal tumor is showed. the tumor was found incidentally on ct scan of the abdomen for evaluation of non specific right side abdominal pain. a mri was also performed and imaging was informed as a probably congenital retrorectal tumor (tailgut cyst) there was no evidence of involvement or invasion of other structures the tumor was palpable at rectal examination. a transanal minimally invasive surgery (tamis) approach was proposed. preoperative preparation was done with a full mechanical and oral antibiotic bowel preparation. preoperative parenteral antibiotics werw administred. under general anesthesia, lithotomy position. the contour of the tumor is not visible due to the small size. palpation of tumor and placement of clips to lolocate was done. placement of gel point path and rectal insufflation. a longitudinal incision was made to the posterior left side of rectal wall. the insufflation of the perirectal extraperitoneal space allowe for excellent exposure of the tumor. the tumor was disected with ligasure. then the tumor was extracted transanally.the proctotomy was closed in a single layer with reabsorbible monofilament continuous suture (pds). no complications after the procedure. the patient was discharged at days. discusion: traditionally, the retrorectal tumors have been resected using a posterior parasacrococcygeal approach, an abdominal approach or a combined abdominal and posterior approach. with the advent of minimally invasive surgery, laparoscopyc approach has been described too. however, tamis approach is feasible, with low pain, morbidity, fester recovery and excellent cosmetic (no scare) results. it can be accomplished using standard laparoscopic equipment, with transanal access. we think that perhaps it could be the gold standar approach for this tumors. aimes: robotic-assisted laparoscopic surgery (rals) is a promising advanced technology that can overcome the inherent limitations of conventional laparoscopic surgery (cls). its advantage includes free-moving multijoint forceps, a motion scaling function, high-quality three-dimensional imaging, and stable camera work by an operator. this study aimed to clarify the short-term outcomes of rals for rectal tumors. methods: this study group comprised patients who underwent rals for rectal tumors (cancer in patients and gastrointestinal stromal tumor in patient), excluding ones with distant metastasis from november through december . the clinicopathological findings and short-term outcomes in rectal tumors were analyzed. results: the median operative time was min ( - ). the median console time was min with a median blood loss was ml ( - ). conversion rate was . % ( / ). the median postoperative hospital stay was days ( - ). patients ( . %) had postoperative complications. patients ( . %) had lymph nodes metastases. the mean harvested lymph node was . . the r resection rate was % ( / ). conclusions: these results suggest that rals for rectal tumors is safe and feasible, and the perioperative outcomes are acceptable. introduction: anastomotic healing defects are a feared complication which might have a fatal impact on the patient. fundamental conditions for proper anastomotic healing include sufficient blood supply. fluorescent angiography using indocyanine green in the spectrum of near infrared light facilitates the monitoring of tissue perfusion during a surgery. aim: a presentation of the results of our non-randomized study in which we assessed prospectively obtained data from a perioperative assessment of anastomosis perfusion by fluorescent angiography using indocyanine green during robotic rectal cancer surgery. method: thirty patients with rectal cancer, who underwent a robotic resection with primary anastomosis, were consecutively included in the study between april , and june , . the study included patients facing a least invasive surgery with a guaranteed payment by a health insurance company. during the surgery, we monitored and assessed the quality of the perfusion of the resection line of the sigmoid colon and subsequent anastomosis by means of fluorescent angiography using indocyanine green in the spectrum of near infrared light. the data were obtained prospectively and subsequently analyzed. results: between april , and june , , we consecutively included rectal cancer patients in the project: men and women. monitoring of the perfusion of the resection line and anastomosis was successful in all cases and perfusion quality was satisfactory across the sample. perfusion insufficiency requiring a change in the resection line level or anastomosis adjustments was not detected with any patient. in two cases ( . %) of tme, we gave up the planned protective ileostomy owing to quality perfusion of the anastomosis. one patient ( . %) suffered from defective anastomosis healing without clinical symptomatology (type a). we found no technical complications related to fluorescent angiography or undesirable effects due to the application of indocyanine green. conclusion: even though we did not register insufficient perfusion in our sample and hence we did not have to change the resection line level or adjust the anastomosis, we may state that fluorescent angiography performed by an experienced colorectal surgeon may potentially reduce the frequency of complications linked to defective anastomosis healing.supported by mo aims: the aim of our study is to demonstrate whether robotic surgery has any influence on the reduction of complications in the aged population undergoing rectal cancer. methods: we performed a retrospective analysis of a prospective database of patients who underwent robotic surgery for rectal cancer. we divided our population in groups: under year old, between and year old and above year old. we recorded complications in each group intra and post procedure. qualitative variables were expressed in terms of absolute frequencies and percentages and mean values and standard deviation were used to express quantitative variables. the analysis of data was applying fisher's exact test or chi-squared test for qualitative variables and variance analysis or student'-t test for quantitative variables. statistically significant values of p \ . underwent multivariate logistic regression analysis. results: the present study included patients ( males).seventy seven patients were under year old, patients were between and year old and patients were above year old. the analysis showed conversion rates of . %, . %, . %, and complication rate of . %, . %, and . % in each group. univariate analysis showed no differences between the three groups. nevertheless, there were statistical differences from bmi, asa and neoadjuvant therapy. in multivariant analysis only neoadjuvant therapy was significant. conclusions: robotic approach do not decrease complications in elderly population. introduction: it has been described the advantages of total transanal mesorectal excision (tatme), with better visualization and access to the lower rectum. we use this access whith the gel point path device, to repair a rectovaginal fistula with stenosis of low rectal anastomosis in two patients, that would be difficult by conventional abdominal approach method: we show our surgical technique for repair a rectovaginal fistula with stenosis of low rectal anastomosis in two female patients operated due to rectal neoplasia. one of the patients underwent prior chemo-radiotheratpy. rectoscopy and image test was performed at the patients prior the intervention. no recurrence signs are recorded at mri.we describe the operation technique: a new anterior rectal resection was performed with a combined transanal (gel point path) and abdominal minimally invasive approach. redo anastomosis whith eea stappler was performed, vaginal repair and epiploplasty. the intervention was especially laborious due to the fibrous tissue. pathology: fistulous path without tumor infiltration in the two patients. at two months, a opaque enema show permeability and absence of leaks in the two patients. the ileostomy was closed at three months. discusion: we believe that transanal access through the gel point path can be a good option for rectovaginal fistula and stenosis of low rectal anastomosis, allowing a better visualization and acces, and making more easy a very difficult intervention. introduction: tamis or transanal minimally invasive surgery for polyp resection has increased fame for several situations in which adenomas with or without dysplasia cannot be removed with conventional colonoscopy. in this video we show the step by step technique performed with the da vinci xi system. material and methods: in this video we show the setting and the location of the patient-side cart and the arms to perform the resection of polyps in different patients and how to develope the procedure. results: after placing the patient-side cart the arms are connected to ports and the camera, double fenestrated grasper and scissors are connected to the arms through a transanal gel-port device. a line is described around the polyp with monopolar energy to determine the place of the dissection. the scissor is exchanged by a robotic harmonic wrist instrument and the complete dissection is performed. the wound is closed using a robotic needle holder and a suture. results: transanal robotic surgery could be safely performed after a standardized technique is stablished. aims: robotic rectal cancer surgery has demonstrated to obtain at least the same results than laparoscopic surgery. however, robotic surgery is associated with high rates of costs, specially when conversion to opened surgery occurs. the goal of this study is to create a predictor nomogram of conversions for robotic rectal cancer surgery. methods: we performed a retrospective analysis of a prospective database of patients who underwent robotic surgery for rectal cancer from october to november . we performed a bivariant analysis and detected the variables which were related with the conversion: body mass index (bmi) and the t. we divided the patients of the population in two groups depends on obesity (bmi of kg/m ) and on t (t - /t - ). we registered conversions in each group calculating the pretest risk. we performed likelihood index (lr ?/-) for under and above kg/m of bmi, adding in a second step the lr of t; obtaining the prediction index for four groups by using a standardize nomogram. results: the present study included patients ( males). were under bmi of kg/m and above. regarding t, were with a tumor of t - and with t - . the analysis showed a conversion rate of the statistical sample of %. univariant analysis showed significative differences in the bmi (p = . ) and t (p = . ). a nomogram was performed; as regards the bmi, the positive likelihood index in the group of bmi [ a prediction index of conversion of % (lr ? , ) and in bmi \ the prediction index of conversion is % (lr- , ). adding the t group data, for bmi [ and t - the conversion prediction rate is . % (lr- , ); for bmi [ and t - the conversion prediction is % (lr ? , ). bmi \ and t - the conversion prediction is % (lr- , ); imc \ and t - , the conversion prediction is %. conclusion: a standardize nomogram with the variable bmi and t facilitates the selection of patients for robotic surgery in rectal cancer avoiding conversion to open surgery. background: d-laparoscopy is proven to improve performance in dry laboratory settings, especially for novice surgeons due to better depth perception. however, the benefits for experienced laparoscopic surgeons are still discussed. aim: the aim of this study is to compare the results of right hemicolectomy (rc) using a conventional ( d hd) laparoscopic system with rc performed using a d laparoscopic system in terms of duration, complications and results. material and methods: from all laparoscopic right hemicolectomies performed in our clinic we selected all procedures performed by the same team of consultant surgeons using the same technique and divided them in groups. the study group comprised of all patients operated using our d einstein vision . system; all other patients which were operated using our standard wolf hd laparoscopy system comprised the control group. all patients were retrospectively analyzed in terms of patients characteristic, or time, duration of operation, intra-and postoperative complications, length of hospitalization, pain score, necessity of analgesics and number of lymph nodes retrived. risk factors for complications (bmi, smoker, diabetes, copd, bph) were also registered. results: there were patients included in the study group, while the control group comprised of patients. mean operation time in the study group was . min in the study group, while mean or time was . min. mean operation time in the control group was . min, while mean or time . min. one reintervention was noted in the control group and two in the the study group; no conversion to open surgery was noted. there were no significant differences regarding patient characteristics, pain score, wound complications, hernia rate, length of hospitalization or number of lymph nodes removed. conclusions: there were no significant differences regarding the outcome of rc using d laparoscopy; total or time was significantly higher in the study group due to the time needed to set up the d-laparoscopy unit. this is biased by the fact that the d system needs to be set up manually while the conventional hd system is integrated in the or. also, there was no significant difference in complication rate. background/purpose: robotic approach can be a treatment option for patients with pelvic recurrence after primary resection for rectal cancer. however, data regarding patient selection, complication rates, and oncologic outcomes are rarely reported. we aimed to present initial experience and to evaluate feasibility, safety, and oncologic outcomes of robotic salvage surgery for recurrent rectal cancer. methods: ten patients who underwent robotic salvage surgery for local recurrence at the anastomotic site, lateral pelvic side-wall, or lateral pelvic lymph nodes (lpns) were retrospectively evaluated from a prospectively maintained database. results: two patients underwent pelvic mass excision with en bloc resection of anastomosis and redo-anastomosis, and eight patients underwent lateral pelvic lymph node dissection (lpnd) for lpn metastasis; one of these eight patient underwent additional en bloc resection of anastomosis. all patients achieved r resection. the median operation time was min and the median estimated blood loss was ml. there were no conversions. as for intraoperative complications, one patient experienced ureter injury during lpnd because the metastatic lpn was closely abutting to the ureter. the median hospital stay was days. in six patients who underwent lpnd, the median number of harvested lymph nodes was (range - ) and the median number of metastatic lymph nodes was (range - ). with median follow-up months, one patient developed lung and pelvic recurrence at months after salvage operation and seven patients remained in disease-free state at the last follow-up. conclusion: initial experience of robotic salvage surgery for pelvic recurrence in rectal cancer indicated that it is safe and feasible. therefore, the robotic approach can be considered as a treatment option for the treatment of local recurrence in selected patients. introduction: there is uncertainty regarding the effects of simulated patient death. several reports showed increased cognitive load and poorer learning outcomes, and others increased performance without causing stress to learners. we have not found any report studying the impact of animal death in the simulation lab. methods: this was an observational cohort study to assess the emotional and cognitive load of surgeons who experienced animal death in the simulation lab. seventy-four faculty and residents from different surgical specialties training minimally invasive surgery participated in the study. one cohort consisted of surgeons whose animal died during surgery, and the other by those whose animal survived. emotions were assessed using the scale for mood assessment and cognitive load with nasa task load index. results: twenty percent of participants experienced mortality while training anti-reflux surgery ( cases) and other procedures ( cases). causes of death included intraoperative pneumothorax (n = ), hemorrhage (n = ), and cardiac dysrhythmias (n = ). participants exposed to animal death had higher levels of sadness and anxiety, and lower levels of happiness (p [ . ). cognitive load was slightly higher in the exposed cohort (p [ . ). conclusions: these findings suggest that mortality in the animal lab do not have a significant effect on cognitive workload and emotions of surgeons training complex laparoscopic procedures. introduction: the visuospatial profiles of expert laparoscopic surgeons remain unaccounted in the current literature for as the influence of visuospatial ability on laparoscopic learning has mainly been investigated in medical students or novice surgeons and using simulators as means of performance measurement. such knowledge is critical, as without understanding how clinical experience may impact visuospatial processes in surgeons, we hinder our efforts to utilize the available knowledge to support surgical education for the future. this study is aiming to explore the development and influence of visuospatial processes on intraoperative laparoscopic learning. method: the study reports the interim baseline results from the ongoing longitudinal study throughout a -year period of training on laparoscopic surgery. data from surgeons including residents undergoing training were captured and compared to specialists who are working in departments of general and visceral surgery at two large hospitals. the mean experience of the surgical residents was years. the mean laparoscopic experience among the senior surgeons is years, with each surgeon performing an average of laparoscopic procedures per week. visuospatial ability was tested using mental rotation test (mrt), guay visualization of views tests (gvvt), spatial perspective taking and spatial orientation test (ptost) and pictorial surface orientation (picsor). spearman correlation coefficient was used in this study with a p-value of significance at \ . . results: senior surgeons have an overall good visuospatial profile, in the sense that they performed close to optimum on all measurement scales. the spearman rho revealed a significant correlation between scores on gvvt and picsor (r = . , p = . ) and between ptost and picsor (r = -. , p = . ). a significant correlation between years of laparoscopic experience and ptost score was also observed (r = . , p = . ). when comparing residents and senior surgeons, no significant difference on the mrt was observed (m = . , sd = . ), nor between baseline scores of senior surgeons and resident surgeons on all tests. conclusion: the results of this study carry important clinical and theoretical implications, as the results hint towards the idea that intraoperative laparoscopic experience lends little to no influence over the development of visuospatial ability. learning models and laparoscopic technical skills, how to adapt each case to improve objectives: according to da. kolb learning is the result of how people perceive and then process what they have perceived. the aim of this study is to identify the personal characteristics of learning in of the participants in a course of laparoscopic technical skills according to the styles described by kolb. methods: between june and november , participants performed a h course distributed over five consecutive days performing laparoscopic manual intestinal anastomosis in endotrainer. they all filled in kolb's learning style test adapted to spanish. the anastomoses were performed in 'ex-vivo' swine intestines. in each anastomosis we evaluated the quality at the end and execution time. the test and quality variables were analyzed through statistical studies. results: in our study, % of the participants were women and % wew men. %were staff surgeons and % were resident. the median age among residents was years and among the staff years. the most frequent learning model in the sample studied was converging ( %). the predominant model among women was assimilating ( %), which, however, represented only % in men. in men, converging model was predominant ( %). among the staff, the most frequent model was diverging ( %). adaptation style prevailed among residents ( %), being rare among the staff ( %). the mean time of the anastomosis was min for both the adapter model and the assimilator, min, for the convergent and divergent models. the quality of the anastomosis performed by each participant was % for the adapter model, % for the assimilator model, % for the convergent model and % for the divergent model. the predominant style in our study was convergent. among women, the most frequent model was assimilator wheras in men it was the least frequent. in the residents, the most frequent model was adapter however, it was very rare in adjuncts. among residents we do not find divergent styles. the highest quality of the anastomosis was achieved by those who worked with an assimilating style. knowing previously the training style we can individualize the teaching methodology in order to improve competences. aims: assess whether laparoscopic appendicectomies (la) are a superior option to open appendicectomies (oa). specifically, comparing the time taken, complication rates and whether it is more appropriate to perform an la overnight, as opposed to oa. finally, to find out how a range of outcomes differs between different grades of surgeon. methods: an information request was sent to the clinical coding department to derive patient identification numbers for all appendicectomies over a ten-month period ( total surgeries). these numbers were then inputted into the hospital information system where the electronic operation note is present, and specific outcomes were derived and analysed. results: % of operations were oa and % were la. mean la times for consultants, sas and spr were . , and min respectively and oa , and min respectively. their respective conversion rates were %, % and %. oa had a complication rate of . %, la was . %. conclusion: oa are performed more than la. spr doctors had the slowest completion times for la but the lowest conversion rates. sas doctors had the fastest completion times for la and oa but higher conversion. la takes longer than oa but has lower complication rates; key factors when performing at night. key statement: laparoscopic appendicectomies require more surgeon-hours and have the potential to be converted to open, however the rates of complications and serious complications are significantly lower. background: paper based resources have been the standard sources for information for centuries. however, more and more people (patients and staff alike) are looking online for information. while the internet often provides excellent resources, there is often conflicting and confusing material of doubtful veracity. trainee staff and patients/carers should be able to access reliable resources whenever and wherever they are. the aim of this project was to create a high-quality resource fulfilling these needs. aim: we present a video demonstrating our integrated colorectal education website ( http://www.colorectaleducation.com/). our approach: high quality health care provision requires highly trained staff as well as wellinformed patients. information resources for these two groups are usually accessible from different repositories. our integrated website provides a common platform for all those involved in colorectal surgery, to use, learn and reflect on. users are directed to separate sections for patients and colorectal professionals. multiple disclaimers prevent patients accidentally stumbling across clinical/ operative information, whilst providing access to those who wish to do so. trainees struggle with balancing their educational needs with their service commitments. this website gives them the opportunity to view detailed operative training videos on the go. many of videos are chapter based allowing them to stop and re-start with ease. modules are also available for nurses providing them access to relevant educational material. the modular design of the website allows us to build upon it with more topics planned to be added over the next eighteen months. the resource also has detailed chapterised videos for patients due to undergo various colorectal procedures. all have been approved by a multi-professional panel including patients and are designed to provide information, offer support and to allay any anxiety. videos with the care pathway and previous patients' experiences are accessible on demand. conclusion: on demand information has now become the norm with the use of smart phones/ tablets. this website provides patients, surgical trainees and other healthcare professionals access to information and education in a clear and reliable format anywhere in the world. colorectal education, on demand and just a click away! objective: in the last decade the growing interest in robotic surgery is evident as shown by several published articles. the aim of the present study is to evaluate the main outcome of a single center experience and to describe the organizational system we have progressively established in our center in order to improve the development of robotic program in all surgical area. materials and methods: we report a case series of patients who underwent robot-assisted surgery at sanchinarro university hospital since the beginning of the program (october ) until november main patient demographic characteristics, type of surgery, peri and postoperative data and follow-up were evaluated. results: a total of robotic procedures were performed for a total of patients. the prevalence of malignant disease was %. a total of pancreatic surgery were performes; liver resections (mean operating time: min); gastrectomy (mean operating time min); esophagectomy (mean operating time: min); colorectal resections ( rectal resections, sigmoidectomy hemicolectomies right, left colectomy) (mean operating time: min); nissen procedures (mean operating time: min), esofagheous myomectomy for achalasia (operating time: min); adrenalectomy (mean operating time: min); three biliary surgery for benign desease, splenectomy. eight partial resection of the duodenum, one yeyunal resection, one mesenteric cyst resection and retroperitoneal tumor have been performed. conversion rate was %, total morbidity have been %. there has been no peri and postoperative mortality up to days after surgery. the average hospital stay and intensive care were respectively days (range - days) and . days (range - days). conclusions: the organizational model defined in our center is facilitating the constant and progressive development of the robotic program. a broad and flexible availability of the robotic system, a progressive increase of young surgeons joining this technology as well as the institutional and departmental economical effort are the points with which the robotic system may increase its development in a surgical department. aims: endoscopic surgery has been widespread in the field of general surgery. however, in japan, there is no standard program for endoscopic surgery training, and its competency has not been considered for the acquisition of board certified surgeon. the purpose of this survey was to investigate the current situation of endoscopic surgery training and autonomy of young surgeons for endoscopic surgery in japan. methods: the survey was planned to target general surgery members of the japan society for endoscopic surgery (jses) who was post graduate year or less. after approval by the ethics committee of jses, the request for the participating in survey was mailed to object members. questionnaire responses were available in print or online media. the contents of the questionnaire consisted of items, about the conditions of endoscopic surgical training, experienced case number, and the self-assessment of autonomy from to point by zwisch scale in specific procedures of endoscopic surgery. results: the total response rate was . % ( / ). sixty five answers were excluded due to inadequate response and answers were analyzed. of the questionnaire respondents, % were male and % were female. the ratio of board certified surgeon was %. although % of the teaching hospitals had simulators for basic training of endoscopic surgery and % of the respondents practiced basic skill of endoscopic surgery, only % teaching hospitals had specific training programs for endoscopic surgery. the surgeons who operated cases of laparoscopic appendectomy and inguinal hernia repair and cases of laparoscopic cholecystectomy, right hemicolectomy and sigmoidectomy, felt confident to perform each procedure independently. regarding with laparoscopic rectal resection and gastrectomy, even though the surgeons who had cases of experience, they didn't had confidence to perform those procedures independently. conclusions: this study is the first national survey to investigate the status of endoscopic surgery training in japan and the autonomy of young surgeons for endoscopic surgery. in order to develop a training system for not only basic skills but also advanced procedures of endoscopic surgery, cooperation of each teaching hospital, academic surgical society, medical specialty board is necessary. currently there is a debate about what is the most optimal work schedule for residents of general surgery, it is important to respect the free time of residents to avoid burnout, however it is also important have enough exposition to clinical cases that allow a satisfactory development in the clinical practice. this becomes even more important when we talk about the learning of surgical skills. this is where the laparoscopic simulation industry opens a large area of opportunity, for a reasonable price it is possible to practice basic laparoscopic skills without compromising patient safety. this is a pilot study that was carried out during the period from january to june , in a public hospital in monterrey, nl, mexico, the composition between the execution of the standardized exercises of the fls (fundamental laparoscopic surgery) in an endoscopic simulator was performed to residents of general surgery (from first to fifth year) hrs before being on call vs these same residents post call. a series of questions was asked to each resident in each measurement, so in this way they answered the same questions twice, then a comparison of the results of both questionnaires was made. the results of the exercises were assessed and rated by the same person using the criteria established in the fls for the scores of each exercise and for the final grade. an average age of years was obtained, measurements were taken of residents of which are male and female. on average, the residents before be on call performed the exercises with h of having slept while the post call performed the exercises with . h of having slept, the residents before be on call had on average . h without sleep while the post call had h without sleep. the average number of hours worked per week is h, measured by the time in and out of the hospital. in this study, conclusive results were obtained regarding the null relationship of sleep deprivation with the performance of laparoscopic skills in surgical residents. aim: 'precision cutting' is one of skills tasks of the fundamentals of laparoscopic surgery (fls) program, which is cutting a circle on a piece of gauze under laparoscope and assessed by completing time (maximum time limit: s). there is no definition of quality of the final product. the aim of this study is to develop an assessment tool of laparoscopic precision cutting and test its reliability. method: an assessment tool of laparoscopic precision cutting was developed with four items based on completion, degree of deformation, degree of being pulled, and overall appearance of the final product of laparoscopic precision cutting by experts' meetings. the scale of each item was points likert scale. a descriptive sheet with a legend and a text description for each scale (fig) was attached for assessors' reference. for our high school entry medical students, they gained hands-on experiences of laparoscopic skills first time by attending a -hour course at minimally invasive surgery training center, national taiwan university hospital (ntuh). we invited students to participate this study after this training. we collected participants' final products of ' precision cutting' station and assessed them by using this assessment tool. this study was proved by institutional review board, ntuh (irb no: rinb). results: students were enrolled between february to june . two non-medical assessors and a senior surgeon were invited to assess the products. the mean score and cronbach' s alpha value of each item were as followed: completion . ± . , . ; degree of deformation . ± . , . ; degree of being pulled . ± . , . ; and overall appearance . ± . , . . conclusions: in summary, we successfully developed an assessment tool for laparoscopic 'precision cutting' and showed its reliability. the tool could provide qualitative descriptions for objective feedbacks. validating this tool in a large scale is undergoing. purpose: to evaluate whether the participants who experienced this scenario could recall an interventional scenario for testing trainees' situational awareness and intra-operative decision making when they participated this training again. methods: we designed an iodm training course for junior surgical trainees and nurses by using live pigs since sep . in the first simulation, we created an interventional scenario and then provided an educational session. a researcher disconnected the ekg monitor on purpose for creating a scenario that the pig would lose vital signs when the team nearly finished a diagnostic laparoscopy. if the team did not aware the situation after . min, a researcher would remind the team (fig). we used a new developed assessment tool of iodm and an assessment tool for nontechnical skills for surgeons (notss) for self-evaluations and objective assessments. we also discussed with them about their reactions while encountering this interventional scenario. results: between sep to june , teams participated this training and experienced this interventional scenario. fourteen nd year surgical trainees have experienced it before. only one participant ( %) recalled it and made a quick decision while encountering this interventional scenario again. the results of iodm assessment and notss did not show statistical difference comparing their self-assessments in the first and second year. based on the analysis of the discussions, most of them remembered this this interventional scenario and reminded themselves to react it properly before the simulation. however, when they were the primary surgeon of diagnostic laparoscopy, they focused on performing this procedure and tutoring their junior trainee. they had no capacity in their brain to notice the change of vital signs. in addition, although they increased their situation awareness in clinical settings after the st time iodm training, they did not show this ability in the simulation. conclusions: recalling of an interventional scenario for testing situational awareness of surgical trainees was very poor ( / , %) among the nd year surgical trainees. qualitative analysis of discussions showed their brain capacities were occupied by performing new procedures and tutoring others. how to enhance trainees' situational awareness should be addressed. aims: a well-designed learning curve is essential to measure the progress of surgical abilities. learning curves are very important to test the skills of trainees. however, there are still no welldefined criteria for developing good learning curves. as a result, many authors use subjective evaluation criteria. the purpose of this review is to analyse this field of surgical education and to identify the key criteria for good learning curves. methods: learning curves were investigated in the field of laparoscopic and robotic minimally invasive surgery. surgery of appendectomy, cholecystectomy, cholectomy, inguinal hernia repair and gastrectomy were considered. the type of surgery, the year of publication, the design of the study, the surgeon's experience (resident, young or senior), the surgical technique, the number of patients involved in the study and the suggested learning curve by the different studies were taken into account. in the selection of articles, more importance was given to those based on the activity of young surgeons or residents. results: the literature analysis showed conflicting results. the different learning curves for the same surgery may be due to the different evaluation criteria considered. only a few studies investigate the learning curves of young surgeons and residents. conclusions: the data available in the literature on learning curves are contradictory. several factors need to be evaluated in order to create more accurate learning curves. we suggest the introduction of checklists with a score for each parameter to be examined, in order to develop more objective and standardized learning curves. aim: the uk training programme for transanal total mesorectal excision (tatme) has completed its first round of training. the study aim was to design a reporting platform that provided trainees with video-assisted feedback in a clear, concise and useful manner to support their training. methods: an established method of video analysis called observational clinical human reliability analysis (ochra) was used to assess the surgical performance of the trainees during their clinical tatme cases. a reporting form for the ochra results was designed identifying areas of difficulties in each procedure and providing error reduction mechanisms. this was piloted during the national training programme for tatme in the uk. results: the ochra reporting form underwent three modifications before the content and format was agreed upon. the final version is divided into three sections: a. case details, b. ochra findings, and c. suggested error-reducing mechanisms. for part b the tatme procedure was divided into four phases of the operation: . pursestring, . rectotomy, . tme dissection, and . connected phase when the abdominal and transanal teams work together synchronously. for each phase, ochra findings described the most frequently occurring technical inaccuracies/errors, number of consequential errors/adverse events and the most frequent and serious consequences encountered. suggested error-reducing mechanisms in part c were developed and established by an expert workshop and individual interviews with international surgeons experienced in tatme.trainee and mentor feedback stated that the reporting form had a clear format, easy to follow and understand. the error-reducing mechanisms were particularly useful and allowed the trainee to focus on improving specific technical aspects in their subsequent cases. conclusion: video analysis using ochra can provide a wealth of information on surgical performance, especially for trainees at the start of their learning curve. as an exploratory study, validation of the reporting platform is required; however, its potential to offer detailed, individualised feedback to enhance training is promising. laparoscopic pelvic surgery training program-using a new concept d-printed versatile pelvi-trainer r.c. elisei , f. graur , c. popa , e. mois , l. furcea , n. al hajjar general surgery, bistrita emergency county hospital, bistrita, romania; general surgery, regional institute of gastroenterology and hepathology ,,prof. o. fodor,,, cluj-napoca, romania pelvic laparoscopic surgery (rectal, urological, or gynecological laparoscopic surgery) is an advanced surgery which require advanced skills, not easy to acquire. there are a lot of training programs for advanced laparoscopic skills but many of them are not affordable for most of surgery residents in eastern europe, where the training programs are far behind from those in western europe. because of that those training programs need to be improved and optimized. in the european union we want equal and high skilled surgeons. this is why we designed a new concept of pelvi-trainer, a versatile one in order to offer the residents the possibility to achieve advanced laparoscopic skills like perfect coordination, precise movements, ability to cut and suture after a well defined route, all of them in the pelvis tight space. we d-printed this pelvitrainer which has multiple characteristics: cheap and easy to produce, easy to be used, versatile because offer the possibility to achieve the skills named above, and many others, but also to train on real ex vivo animal rectum (suine model). we also believe that with a proper training a medical student and a young surgery resident are able to achieve the same skills like experienced surgery residents or specialists. in order to demonstrate that we need a study to compare the time to perform or more exercises in this new concept pelvi-trainer by the medical students, young and experienced residents and surgery specialists. what we want to achieve with this training program project is to have more and more skilled surgeons in advanced laparoscopy and an equal laparoscopic surgery training all over the country, close to the level of training in the western europe. also we want this training program to make a standardization of the pelvic laparoscopic surgery training first in our country and then in other countries if possible. aims: the objective of this systematic review is to provide an evidence-based overview of the different components of laparoscopic training curricula, emphasizing the value of objective forcebased assessment and how this in implemented in modern laparoscopic training. methods: bibliographic databases of pubmed and embase were searched till april to identify studies reporting on evidence-based laparoscopic skills training. abstracts of retrieved studies were reviewed by two authors independently and those meeting the inclusion criteria were selected for full-text review. results: the search yielded a total of individual records. a total of articles were included. the articles were divided into nine different categories, which include 'metrics', 'benchmark criteria', 'measurement systems', 'timetable', 'training modalities', 'camera settings', 'training tasks', 'serious gaming', and 'competition'. a descriptive analysis of the data is provided. motion analysis parameters, such and path length and time are frequently validated and used for assessment. the results of validation studies on tissue manipulation parameters, such as maximum force and mean force show proved their discriminating power between different levels of proficiency. however, implementation of these metrics remain restrained. conclusions: numerous studies on laparoscopic skills training have been conducted over the years. nevertheless, no consensus is reached towards the use of objective assessment tools. although the value of validated metrics is described well, implementation of objective metrics is limited. we recommend to consider objective force-and motion metrics for feedback and assessment during laparoscopic skills training. surgery, regional institute of gastroenterology and hepatology, cluj-napoca, romania; anesthesiology, university of agricultural sciences and veterinary medicine, cluj-napoca, romania; radiology, regional institute of gastroenterology and hepatology, cluj-napoca, romania aims: the aim of the study was to create a new easy learning method of swine liver anatomy for residents in training. based on human liver surgical anatomy we put 'face to face' the similar structures and also the differences using ex vivo porcine models and ct reconstructions from live pigs. methods: having in mind the human liver anatomy, in the first stage we used data obtained from dissection of twelve porcine liver models to create an anatomical pattern, which summarized the most important surgical information. in the second stage, anatomical data obtained from ct scans of twelve living anesthetized pigs were analyzed. the ct reconstructions and volumetry data were added to the gross anatomy pattern to create a more complex learning module. results: the residents established the most frequent description of swine liver anatomy by putting together the information from ex vivo model dissection. the liver parenchyma is divided into four main anatomic lobes: left lateral, left medial, right medial and right lateral. all those lobes are connected only in the posterior part, which allows a very good separation between them by deep fissures. just as in humans, we found eight distinct segments with independent vascularization and biliary drainage. portal vein has a specific 's' shape; in most cases hepatic artery was found like a trifurcation and extrahepatic biliary tree has a very thin wall. in the right hemi-liver, the inferior vena cava passes through the liver parenchyma. most frequent, we found five hepatic veins which are running completely intraparenchymal. the imagistic data offered a very useful d reconstruction with anatomical positions of the vascular-biliary tree and liver segmentation and gave us the possibility to create practical scenarios for resections. perhaps the most important information was to discover and see the section plan and to calculate the volume of the remaining liver after resection. conclusions: the anatomical-imagistic pattern based on \ i[ex vivo \/i [ model disections combined with imagistic data offers a unique mindset before intervention. the concept 'human \ i[vs \/i [ swine' to create an easy method of learning for residents in training can be applied to swine liver anatomy. the learning of surgery is traditionally based on the behaviourist model . goals are set, standards of care fixed, with regular assessments of the level achieved. the teacher exercises control over the student, imposing rules and models, supported by 'reinforcing' actions (reward or punishment). the theory of skinner's program of education, from , is reflected in surgical learning. it foresees a gradual progression by level of difficulty, following a transmission-imitation model . these theories seem currently outdated to face the new challenges of medicine and surgery and to keep up with technological developments. bruner, one of the theorists of the constructivist model, proposed in a method of collaborative learning between those who teach and those who learn. the goal of the method was to improve strategic problem solving. the comparison between various perspectives (between teacher and student), allowed the learner to better absorb knowledge and improve critical thinking. in kapur published on the theory of 'productive failure'. this model makes the error of a single person useful for all his colleagues, privileges the practice of theoretical knowledge, contextualised learning as opposed to abstract learning, and 'guided' practice compared to a 'guided' theory. bruner and kapur's systems favour creativity, critical analysis of a problems origin, and the practical use of knowledge. they represent a hypothesis of learning, based on constructive discussion and a continuos 'give-take' feedback system. in order to put these new models into practice in the clinical context, one may hypothesise and propose the adoption of a formal discussion of clinical cases that are complicated or difficult. thereby making the theoretical lessons more collaborative, intuitive and inclusive. in the surgical field, one could adapt such a concept to surgery simulation, virtual reality and anatomical models. aim: large hiatal hernias have a surgical indication when the patients suffering disabling symptoms such as anaemia, dyspnea, chest pain, gastric reflux. several studies showed that in the case of large hernias the placement of a prosthesis was safe and could protect against recurrence. mini-invasive surgery is the preferred approach for hiatal hernia repair and anti-reflux procedure and the toupet fundoplication has been shown to be the best surgical technique for the hiatal hernias repair.the laparoscopic approach is currently the surgical gold standard but is burdened by technical difficulties especially in the case of large hiatal hernias. the robotic system is designed to overcome some technical difficulties of laparoscopy and the studies available in literature report the safety and effectiveness of the robotic approach in complex hiatal hernias repair. methods: we present the case of a grade iv hiatal hernia treated with a robotic approach in a years old woman (bmi: kg/m ). the medical history consisted of a road accident with a probable mechanism of deceleration, three years before. the patient had been suffering from dyspnea for three years. due to the recent discovery of an anaemia, the patient was subjected to an endoscopic examination with the identification of a voluminous grade iv hiatal hernia. a subsequent computed tomography (ct) scan showed also the partial herniation of the transverse colon. results: the patient underwent to surgery by using the da vinci robot system siÒ (intuitive surgical, sunnyvale, usa) with a single docking approach. the surgery consisted in the liberation of the hernial sac, the placement of a goretex prosthesis and the packaging of a toupet fundoplicatio. the surgery was performed without complication. conclusions: the robotic approach in the hiatal hernia surgery seems to be a valid alternative to laparoscopy, especially in complex cases. the surgical ability in robotic surgery is of paramount importance. general thoracic surgery, kawasaki municipal hospital, tokyo, japan aim: video-assisted thoracoscopic surgery (vats) with carbon dioxide (co ) for mediastinal surgery is known to improve the visualization of medaistinal space. we report our experiences with two cases that underwent vats thymectomy using co insufflation under the one-lung ventilation general anesthesia by double lumen tube. methods: the instruments that were used for vats thymectomy were only the -mm -degree rigid thoracoscope, maryland jaw energy device, cotton made-dissectors, and straight endoscopic grasping forceps. they were used through sealed ports designed for laparoscopic surgery. lowpressure co insufflation set at mmhg were used for compression of surround tissue of mediastinal tumor during the releasing procedure. results: the patients were an -year-old male and a -year-old female. thoracoscope with the mmhg co insufflation provides excellent visualization of the medaistinal space and operation could be done smoothly without any hemodynamic compromise. their pathological diagnoses were thymic cancer and thymoma, type b . the operative times were min and min. the postoperative courses were uneventful and the patients were discharged on day th and rd . conclusion: we have just begun to routinely use co insufflation for mediastinal tomorectomy and present our early experiences of successful vats thymectomy by utilizing co \ su \/su insufflation. aims: this retrospective study aims to evaluate the feasibility of single-incision thoracoscopic surgery (sits) for primary spontaneous pneumothorax (psp), using a novel multichannel port (x gateÒ). methods: between october and november , ten patients who underwent sits using x gateÒ. nine patients were male and was female, with mean age of . ± . years old. a . cm incision is placed in the middle axillary line on the th or th intercostal space, depending on the lesions. postoperative outcomes of these patients were compared with those of patients with psp who underwent conventional three-port video-assisted thoracic surgery (vats). results: there were no conversions from sits to vats. mean operative time of sits group was significantly shorter than that of three-port vats group ( . ± . min vs . ± . min, p = . ). mean number of staplers used in surgery was . ( ) ( ) ( ) ( ) in sits group and ( ) ( ) ( ) ( ) ( ) in vats group (p = . ). mean duration of postoperative drainage was also shorter in sits group ( . ± days vs . ± . days, p = . ). no recurrence and wound infection were observed in sits group. conclusion: sits using x gateÒ is feasible when performed for selected patients with psp. x gateÒ provides good visualization of intrapleural space and esthetic outcomes, as well as a superb maneuverability by decreasing mutual interference of surgical instruments. although conventional three-port vats for psp is well established, sits using x gateÒ can be a permissible alternative. further examinations are required to evaluate efficacy of sits using x gateÒ. aims: haemorrhage remains a leading cause of potentially preventable death in trauma. in particular non-compressible torso haemorrhage is approximated to cause - % of mortality in civilian trauma patients with otherwise survivable injuries and % in war setting. we performed a literature review to assess the potential for using endovascular stenting in traumatic venous injuries and explore the evidence of their efficacy and safety with different venous injury patterns. methods: systematic online search of pubmed performed using key words'endovascular stent', 'venous injury', trauma, penetrating, blunt, abdominal and pelvic. inclusion criteria included all studies that explored the use of endovascular stents following traumatic abdominopelvic venous injuries. english language studies were used. results were presented according to prisma guidelines. results: of the studies generated by the search,there were only four case reports in the literature documenting the use of endovascular stents in traumatic venous injuries dating back to and most recently . the four cases included three retrohepatic ivc injuries, two secondary to blunt trauma and one penetrating; whilst the final case a blunt injury at the ilio-caval bifurcation. all four cases reported successful deployment of stents via the femoral or internal jugular veins, with subsequent resolution of haemorrhage. length of time taken for stent insertion ranged from to min. three of four patients made full recoveries and discharged from hospital, with one patient subsequently dying of a brain injury independent of the successful venous stent insertion. no complications were reported at up to months follow up in remaining cases including stent leak, stenosis or migration. conclusion: endovascular venous stents have been used successfully in managing complex abdominopelvic traumatic venous injuries. in particular retrohepatic venous injuries refractory to hepatic packing and vessel embolization, which are not amenable to direct surgical repair due to anatomical location. however before endovascular stenting can be added to the arsenal of interventional radiologists for abdomino-pelvic trauma, further development of stents custom made for venous injuries as well as prospective studies examining their long term safety and outcomes is needed. tracheal papilloma is a rare neoplasm growing from the tracheal or bronchial epithelium and has no specific clinical presentations. this is a -year-old female who complained of progressive dyspnea for about months. physical examination was unremarkable and the there was no abnormal finding by the chest plain film. chest computed tomography was arranged and revealed a mass lesion located at the tracheal lumen with more than % luminal obstruction. we used fiberoptic bronchoscopy to evaluate the airway and found a mass lesion with pedicle originated from the posterior tracheal wall. cryotherapy was considered for the tumor mass removing to establish a patent airway. the pathologic report revealed tracheal papillomatosis without any malignant component. dyspnea was immediately improved and the patient chose closely observation after the bronchoscopic cryotherapy. aims: recent advances in laparoscopic surgery, both in techniques and instrumentation material, have led to the emergence of innovative technological fields, among which robotic surgery stands out.one of the handicaps of this surgery is its high cost as well as the long learning curve. in this stage a new tool arises, the flexdex semi robotic arm, which combines the precision and the range of movements of robotic surgery with the greater availability, simplicity of use and learning of conventional laparoscopic surgery.the objective of this study is to evaluate the efficacy and safety of the flexdex device in different laparoscopic procedures. methods: flexdex's is a three-axis gimbal technological device integrated in a conventional laparoscopic instrument that translates the surgeon's hand, wrist, and arm movements from outside the patient into corresponding movements of an end-effector inside the patient's body.the greater accessibility provided by the flexdex allows the surgeon to perform sutures in areas of difficult access where mobility with conventional laparoscopic instruments is not optimal. the comfort of the surgeon remains fundamental in any type of surgery, even more when we are in anatomical locations with complex access, especially for the realization of sutures. here is where surgical innovation instruments such as flexdex provides ergonomic comfort for the surgeon and improves the patient's safety, especially in high-risk situations, such as when performing anastomosis. results: we present a prospective series of laparoscopic procedures carried out by the same surgical team being the initial experience in our environment in the use of the flexdex semi robotic arm for the realization of complex anatomical sutures.this is a case series of patients to whom different surgical techniques requiring manual suture have been performed. these being tapp procedures, nissen-type fundoplicature and reinforcements of colorectal anastomosis. it is important to note that in none of the cases complications were recorded conclusions: flexdex can provide an excellent alternative to the robotic systems in complex surgical procedures, offering surgeons the precision and control they desire while maintaining the balance of cost, outcome and patient benefit. background: a new single-port device (fsis-flexible-single-incision-surgery) is presented. this new platform has three working channels, two for rigid instruments and one for the flexible endoscope. the channel for flexible instruments offers a pneumatic sealing to avoid the air's leak of the cavity (abdomen, rectum, vagina) . in this study the preclinical data are shown testing the feasibility and safety for laparo-endoscopic instruments. methods: experimental evaluation of feasibility and safety in two stages. in the first stage a working channel with pneumatic sealing was tested in simulators to use a flexible endoscope. in the second stage (animal model) the single incision device that makes possible to use laparoscopic instruments and flexible endoscopes was tested. the measured variables were: time of the procedure, co employed, adverse intraoperative events, grip's losing, losing of pneumatic sealing, feasibility and safety of the procedure for the surgeon. results: the hysterectomy and double adnexectomy was done with a median time of . min. the median of the co consumption was . litres. only in one case ( . %) the surgeon had problems with the abdominal navigation of the endoscope that was easily solved. the grip's lose wasn't a major problem. the median size of the skin incision was . cm. the median surgeon' score for the feasibility was and for the safety was . . conclusions: the surgeons considered that the use of the device was very feasible and safe. the fsis-device is a universal platform for single-incision-surgery for surgeons and gastroenterologists and for abdominal, rectal and vaginal access. aim: despite the near-infrared fluorescence (nirf) via the intravenous administration of indocyanine green (icg) improves the visualisation of the cystic duct (cd) and the extrahepatic biliary tract (ebt), the back fluorescence of the liver reduces the signal-to-noise ratio.we have modified the technique of nirf cholecystocholangiography with intragallbladder icg injection by using the arrow-karlan tm balloon cholangiography catheter instead of the purse string at the gallbladder's fundus. this procedure allows a high rate of visualisation of the ebt, with few cases of icg leakage.aim: of this study is to confirm the feasibility of this different technique and to analyse the icg spillage from the gallbladder and to identify the ebt. methods: we enrolled nine patients undergoing laparoscopic cholecystectomy for cholelithiasis. the gallbladder was perforated with the cholangiogram catheter, the balloon inflated with . ml of saline and tightened. the bile was drained and the icg bolus injected. a titanium clip was the placed on the catheter strict closely to the gallbladder in order to prevent the catheter dislocation. results: the cd and the ebt were visible before dissection in / and / patients respectively. after dissection the cd was visible in all the patients and the ebt again in / patients. there was only one icg spillage due to a tardive positioning of the clip. in a case of inflamed gallbladder this technique helped in the identification of the dissection plane. conclusions: our preliminary results of this ongoing study confirm the feasibility of this different approach as a possible alternative to the purse string and a good visualisation of ebt. introduction: robotic-assisted surgery is a promising technique for overcoming the limitations of laparoscopic surgery, especially with regards to complex and advanced surgical procedures. here, we describe the establishment and implementation of our robotic upper gastrointestinal (gi) and hepato-pancreato-biliary (hpb) surgery program within our center of excellence for minimally invasive surgery as well as the first-year results. method: robotic-assisted surgery was performed using the davinci xi surgical system tm and performed by two surgeons specialized in minimally invasive surgery (db and tk). our robotic surgery program of upper gi and hpb surgery was established in three steps: ( ) first, surgical procedures with easier degree of difficulty were performed robotically, including cholecystectomy, minor gastric resections and fundoplications. ( ) then, pancreatic distal resections, enucleations, adrenalectomies and atypical liver resections were robotically performed, as procedures with moderate degree of difficulty. ( ) finally, advanced and highly complex procedures were performed, including right hemihepatectomy, complex pancreatic head resections (including portal vein resections), total gastrectomy and esophagectomy. data collected from july till july were retrospectively analyzed with regard to conversion rate, morbidity (clavien dindo grade £ ) and mortality. results: within the first year, a total of robotic assisted upper gi and hpb resections were performed. the first step of establishing our robotic surgical program included eight procedures. here, conversion rate, morbidity and mortality were %. within the second step of establishment procedures were performed. conversion rate, morbidity and mortality were %, % and %. the last step included of advanced and highly complex procedures. these procedures resulted in a conversion rate of %, % morbidity and % mortality. conclusion: our stepwise approach enables a safe implementation of a robotic surgical program for upper gi and hpb surgery with low morbidity and no mortality even for highly complex procedures. however, highly complex procedures required a high conversion rate, which might be caused by the early stage of experience. the standard surgical procedure of choledochal cyst is a complete excision of the cyst with rouxen-y hepaticojejunostomy and laparoscopic surgery had been increasingly used. this is still a challenging way to perform anastomosis due to the small diameter of bile duct and the possibility of bile leak or stricture. robotic system can overcome the shortcomings of laparoscopy with providing three-dimensional view, magnification, and articulated instruments. from jan to dec , patients underwent robotic cyst excision and hepaticojejunostomy by single surgeon. we reviewed the clinical data and compared with laparoscopic outcomes of early (from to ) and late (from to ) group, retrospectively. patients of robotic series were all female with mean age . years and bmi . . the mean size of cyst was . . cm, and todani type ia , ic and iva , respectively. total trocars were used with robotic working arm and assist and camera. the mean operative time . ± . min, and it was similar with late laparoscopic group ( ± . min) and significantly shorter than early group ( ± . min).there were no open conversion in robotic and late laparoscopic group, however, the early laparoscopic group involved % of conversion rates. the hospital length was ± . days in robotic group, and it was similar with late group ( ± . ) and more shorter than early group ( . ± . ). in robotic series, postoperative complications occurred patients. one case included cholangitis which was resolved after conservative treatment. bile leakage was developed in patient, and treated with drain that inserted intraoperatively. last cases showed incisional hernia at postoperative months, and was corrected by laparoscopic herniorrahphy. complications (n = ) in late laparoscopic group included hepaticojejunostomy stricture and stone, bleeding of jejunal branch, portal vein thromobosis, acute pancreatitis, and adhesive ileus. there were no mortaility case in any groups.robotic surgery of choledochal cyst is a safe and feasible option with short-term results that are comparable to laparoscopic approach. general surgery, sanchinarro university hospital, madrid, spain background: the incidental detection of benign to low-grade malignant small pancreatic neoplasms increased in the last decades. the surgical management of these patients is still under debate. the aim of this paper is to evaluate the safety and feasibility of robotic enucleations. methods: we retrospectively reviewed our prospectively databases from november . demographics, pathological characteristics, perioperative outcome, and medium-term follow-up of patients who underwent robotic pancreatic enucleations were collected. results: patients were included. the mean age of the patients was years ( - ). the median body mass index was ( - ). ten lesions were located in the pancreatic head, in the pancreatic body, in the pancreatic tail. operative time was min (range - ), no intraoperative transfusion were needed and in one patient conversion to open approach was needed. in three patients grade b pancreatic fistula occurred. the mean postoperative stay was , days. conclusions: robotic enucleation is a feasible and safe approach, with low incidence of morbidity. the results of surgical treatment of patients with pulmonary tuberculosis were evaluated depending on the prevalence of the tuberculosis process and the type of surgical intervention used. according to the results of the questionnaire, people operated on pulmonary tuberculosis in the period from to years ago, the frequency of cases of tuberculosis reactivation, the complicated course of the remote postoperative period, as well as the mortality and causes of lethal outcomes were assessed. it was found that after sublobular resection and lobectomy, treatment failure was noted at . %, relapse of tuberculosis- . %, pleural empyema- . %, bronchial fistula- . %, cardiovascular insufficiency-in . % operated. the mortality rate was . % with a total clinical efficacy of . %. after combined resection and bylobectomy, treatment failure was noted at . %, relapse of tuberculosis- . %, pleural empyema- . %, bronchial fistulae- . %, cardiovascular failure- . % operated. the mortality rate was . % with a total clinical efficacy of . %. after pneumonectomy, treatment failure was noted at . %, relapse of tuberculosis- . %, pleural empyema- . %, bronchial fistulae- . %, cardiovascular failure- . % operated. the mortality rate was . % with a total clinical efficacy of . %. robotic reduced-port splenectomy using single-site platform j.h. lee background: in the era of minimal invasive surgery, single incision laparoscopic splenectomy can offer some advantages compared to conventional laparoscopic splenectomy. but it requires expertise in minimally invasive techniques due to technical difficulties. the da vinci robotic reduced-port splenectomy using single-site platform permits greater freedom of movement and higher levels of accuracy than previous laparoscopic surgery through two small incisions. methods: we performed a retrospective review of all patients who underwent robotic reduced-port splenectomy using single-site platform at our institution between january, and november, . one cm periumbilical incision was made for glove port insertion and the other incision was made at left side of abdomen for additional mm port insertion.the surgical technique is much same as open procedure. short gastric artery was ligated, firstly. splenic artery and vein were ligated individually. during the surgery, any stapling device was not used. vessel sealer was used for hemostasis and mobilization of spleen. a specimen was removed through umbilical port site within lap-bag. result: eight patients ( female and male) with median age of . years underwent robotic reducedport splenectomy using single-site platform (one case with combined robotic cholecystectomy for gall bladder stones without additional trocar). the indications were; hematological disease (n = ), splenic mass (benign n = , malignant n = ). preoperatively measured spleen size was ranged . cm to cm (mean cm). there were no intraoperative complications and open conversion. mean operative time was min. (range - min) including docking (mean min) and console time (mean min) mean blood loss was under ml. mean hospital stay was . days after surgery. one patient underwent oral anticoagulation therapy only for portal vein thromobisis without any symptoms, and thromobisis was resolved at month follow-up ct scan. there were no clavien-dindo class iii or above postoperative complication. conclusions: robotic reduced-port splenectomy using single-site platform seems to be feasible and effective. it seems to overcome certain limits of previous robotic or conventional single-site laparoscopic splenectomy and single-site only robotic splenectomy. we think mm additional port allows to use endo-wrist da vinci instruments such as vessel sealer which enhances dissection efficiency andsafety of procedures. aims: inguinal lymph node dissection carries an important risk of post-operative complications, mainly related with wound complications and long term lymphedema. the minimally invasive approach aims to reduce the morbidity of this procedure, avoiding the traditional groin incision but still allowing a full access to the lymph node basin. the authors aimed to describe their videoassisted inguinal lymph node dissection (vilnd) cases, comparing the surgical outcomes with a sample of open inguinal lymph node dissection (oilnd) cases. methods: we performed a retrospective descriptive study that compared the data from patients submitted to vilnd since (the year in which this technique was first performed in our institution) with the patients submitted to oilnd in and . gynaecologic and urologic malignancies were excluded. the statistical analysis was performed using spssv Ó, with a p value \ . indicating statistical significance. results: a total of cases of inguinal lymph node dissection were analysed, . % of which vilnd (none of them requiring conversion to the open approach). melanoma was the primary tumour in % of patients. the vilnd and oilnd groups had no statistically significant difference between them regarding age, body mass index, smoking status or the reason for lymph node dissection-clinically detected lymph node vs. positive sentinel node biopsy. the mean of isolated lymph nodes in the vilnd ( . ) and oilnd ( . ) groups was also not statistically different (p = . ). there was no difference in the rate of post-operative seroma, wound dehiscence or lymphedema. the rate of surgical site infections was higher in the oilnd group- % vs. . % during post-operative hospital admission (p = . ); . % vs. . % after discharge (p = . ). conclusions: in our population of patients we conclude that the main advantage of the videoassisted approach regarding surgical morbidity lies in the reduction of the infection rate, as the published literature also confirms. the equivalent number of lymph nodes retrieved in both groups points toward the oncological safety of the minimally invasive procedure, that we hope to study further in the future after a longer follow up period. objectives: to evaluate the clinical feasibility of tumor localization technique with radio-frequency identification (rfid) clip marker methods: we developed the proto-type rfid integrated endoscopic clip (rfid-clip) and probe to detect it on serosa surface during the laparoscopic surgery. a pig weighing kg was used as the specimen for the in-vivo test. endoscopist performed the application of the rfid-clip on porcine gastric mucosa. after then, the surgeon tried to find the location of rfid-clip using the detection probe and marked with the electrocautery. after the gastrectomy with cm margin (each to proximal and distal), we confirmed the prediction of rfid-clip location and accuracy of resection. results: rfid-clip location was detected and recorded on the exact site of clip application. detection range was very short and we confirmed there are almost no differences between actual clip location and our prediction. this result might arise from using the low-frequency rfid tag to increase the accuracy through reduction of the range. however, some rfid-clip were not detected because of the issue of clipping trouble, not rfid tag. conclusions: this is a basic study to evaluate the clinical usefulness and feasibility of the new localizing technique. we confirmed the possibilities of this system and it could be the helpful option to provide the information of exact location for the minimally invasive surgery or early gastrointestinal tumors. background: the advantages of laparoscopic posterior retroperitoneal adrenalectomy (lpra) have been described in the literature. the aim of this study was to compare the clinical outcomes of lpra and robotic posterior retroperitoneal adrenalectomy (rpra) and determine the differences that could affect the outcomes. methods: we retrospectively analyzed adrenalectomy cases at asan medical center from to . there were lpra and rpra cases, and their clinicopathological features and surgical outcomes were compared. results: in lpra, there was a positive relationship between operation time and male gender, early period of experience, adrenal tumor size, and pheochromocytoma. in rpra, adrenal tumor size and pheochromocytoma were the only factors affecting the operation time. when the adrenal tumor size was = . cm, the operation time of lpra was shorter than that of rpra (p = . ). when the tumor size was [ . cm, there was no significant difference in the operation time of lpra and rpra (p = . ). conclusions: rpra is a feasible and technically safe approach for benign adrenal diseases. the use of rpra could benefit patients with large tumors and provide comfort by overcoming the factors contributing to a longer operation time in the laparoscopic technique. methods: twenty years experience at the american university of beirut medical center for laparoscopic adrenalectomy. a total of cases were done laparoscopically with no conversion and minimal complication. the average operative time is mins.the video will show the various steps used for lap redo (lt) adrenalectomy for a cm pheochromocytoma using the lateral position and through trocars. attempt to remove the pheochromocytoma in iraque was complicated by cardiac arrest treated successfully and patient referred to the american university of beirut medical center. results: patient had smooth postoperative course following laparoscopic adrenalectomy and patient discharged days later with no complications. conclusions: even large adrenal masses can be completed laparoscopically in advanced experienced centers in laparoscopy. surg endosc ( ) aims: the adrenocortical of uncertain malignancy neoplasm is a spectrum of classification for adrenal tumors whose histopathological diagnosis is uncertain. clinical case: we present a year old patient with constitutional syndrome and severe hypercortisolism and hypokalemia reason why she was admitted to icu for episodes of ventricular fibrillation. no other medical history of interest except refractory hypertension to treatment. the tc showed a left adrenal mass of . . cm with microcalcifications, areas of necrosis and hemorrhage, no infiltrating, without disease to distance. the surgery was a laparoscopic left adrenalectomy with no evidence of infiltration and no lymph nodes. the histopathology lesion presented a dense proliferation cellular of cortical type, with incomplete fibrous, without vascular or capsular invasion, with a % ki ; positivity vimentin and cd . all epithelial markers, were negative. all this leads to the diagnosis of a neoplasm of uncertain malignancy potential adrenocortical. during the postoperative period, the patient presents a crisis of adrenal insufficiency that was treated with intravenous replenishment corticoidea and later orally with good clinical response. discussion: the adrenal carcinoma has a low incidence ( . %), incidence peak around the years, the most frequent is the mixed secretory. they are - % of the adrenal incidentalomas. it is usually presented to the diagnosis as a locally advanced tumor with metastases (to liver, lung, retroperitoneal ganglia and bone). may present clinically due to hormonal hyperproduction; or be non-functioning tumors. the adrenal carcinoma poses a great difficulty at the time of the diagnosis pathological, and includes as differential diagnosis to other abdominal tumors. the distinction between corticoadrenal adenoma and adrenal carcinoma is sometimes difficult, so it has been defined a spectrum of intermediate category called adrenocortical neoplasm of intermediate or uncertain malignancy. it is obtained with the weiss criteria, being necessary at least of them for confirm the diagnosis of adrenal carcinoma. this category has a low risk of local recurrence or metastasis, but it needs a narrow follow-up. conclusion: adrenal carcinoma of uncertain malignancy implies a new category in those tumors of difficult classification. aims: multiple endocrine neoplasia type (men ) is an autosomal dominant disorder with an estimated prevalence of per , in the general population. among patients suspected to have a pheochromocytoma, the diagnosis is rarely confirmed and only % is presented bilaterally. we present bilateral laparoscopic adrenalectomy in patients with men . method: a -year-old woman with a family history of medullary thyroid cancer and breast cancer. personal history: hypertension, medullary thyroid cancer, breast cancer, laparoscopic cholecystectomy. appendectomy. after a study by endocrinology and suspicion of bilateral pheochromocytoma, discussing the case in a multidisciplinary committee, bilateral adrenalectomy was decided by laparoscopic approach. selective alpha- -adrenergic blocking agent (doxazosin) were utilized before surgery. under general anesthesia left adrenalectomy was performed first in right lateral decubitus position. mmhg pneumoperitoneum was started with the verres needle and trocars ( mm umbilical, mm subxifoid and mm left subcostal).once dissection was completed the gland was placed in a plastic bag and extracted through one of the trocars incisions, then the position of the patient was changed to left lateral decubitus for the right adrenal approach. another right subcostal mm trocar was used. adhesiolysis of previous cholecystectomy was performed to right adrenal approach. adrenal veins were divided between metallic clips.no drainage was employed. results: the procedures were successfully performed without conversion. surgical time was min and hospital stay was days. had a clinical reversion with control of blood pressure monitored by endocrinology conclusions: currently, the laparoscopic approach is the technique of choice for the management of adrenal pathology.lateral decubitus transperitoneal approach is the procedure of choice in most cases. bilateral laparoscopic synchronous adrenalectomy is feasible and safe with good results as in our patient. traditionally the treatment of hyperparathyroidism for patients with familial hyperparathyroidism was subtotal parathyroidectomy or total parathyroidectomy and auto transplantation. in the era of minimally invasive parathyroidectomy, the removal of only abnormal glands guided by preoperative localizing studies has been suggested. aims: this systematic review aimed to investigate the role of focused minimally invasive parathyroidectomy in the treatment of patients with familial hyperparathyroidism. methods: electronic databases were searched with the search terms 'men i', 'familial hyperparathyroidism', 'men a','hyperparathyroidism-jaw tumor syndrome', 'parathyroidectomy', 'minimally invasive ', for the time period up to and including december . full publications, including clinical trials randomized or not, retrospective studies, case series, case reports that provided relevant data met inclusion criteria. results: thirty five possibly relevant studies were identified. abstracts were reviewed and fifteen articles were excluded. twenty studies, that met inclusion criteria were retrieved in full text and included in the systematic review, including three retrospective cohort studies i.e. two presenting data on meni associated hyperparathyroidism and the third study on familial hyperparathyroidism and seventeen small case series or case reports. the two retrospective studies on meni hyperparathyroidism included patients treated either with focused minimally invasive parathyroidectomy or with the conventional approach. these studies presented conflicting data with one supporting and the other negating the focused minimally invasive parathyroidectomy due to the failure of localization studies to identify enlarged parathyroid glands in a great number of patients. conclusion: undoubtedly, the idea of minimally invasive parathyroidectomy in patients with hereditary and familial hyperparathyroidism is interesting. this idea is especially challenging in the case of meni. existing data suggest that focused mimimally invasive parathyroidectomy is feasible under the condition of exact preoperative localization studies. the main advantage of this approach is the minimization of the risk of postoperative hypoparathyroidism. however, data are limited and further research is needed before valid conclusions can be drawn on the suitability of this approach. objective: resection of pheochromocytomas is a challenging procedure due to hemodynamic lability, tumor vascularity and malignant potential.given the technical challenges for resection of large pheochromocytomas, there were hesitations about using the laparoscopic approach for these tumors during the first decade of laparoscopic surgery. however, improvement in imaging modalities,better pharmacological preparation,advances in anaesthesia and laparoscopic surgery rendered laparoscopic surgery for pheochromocytomas safe and efficient. our aim was to evaluate surgical outcomes in patients with pheochromocytoma and to validate the role of laparoscopic surgery in the treatment of these tumors. design: a total of procedures for pheochromocytoma were performed between january -september . the preoperative diagnosis, operative details, complications, length of hospital stay, morbidity and follow up were retrieved from the hospital records of patients who underwent adrenalectomies for benign and malignant adrenal tumors in the same period. preoperative localization was established in all patients with computerized tomography (ct) or magnetic resonance imaging (mri), while iodine - -metaiodobenzyguanidine(mibg) scan was reserved for ambiguous cases where paraganglioma or metastatic disease was suspected. endocrinological evaluation and complete adrenal dynamic testing were performed to determine whether the tumor was functional or not. results: eighty-seven tumors were removed from patients. one patient with meniia underwent bilateral resection of pheochromocytomas in two stages. tumor size in laparoscopic procedures ranged from . cm to . cm (mean . cm). forty-three patients had benign disease, potentially malignant (based on pass), malignant with metastasis. eight were in the context of a familial syndrome. sixty -eight patients underwent laparoscopic adrenalectomy, patients had open approach from the start for recurrent pheochromocytoma or large benign tumor, patient had open approach due to inoperable malignant pheochromocytoma and patients had conversions from laparoscopic to open procedure. nine patients received sodium nitroprusside intraoperatively to treat hypertension. one patient developed pulmonary embolism, and succumbed month later. there were no recurrences for the benign tumors during the follow-up period. conclusions: laparoscopic resection of pheochromocytomas despite its increased level of difficulty compared to that of other adrenal tumors, is a safe and effective procedure. aim: the concept 'large' in transperitoneal lateral laparosopic adrenalectomy (tlla) has been evolving along time, ranging from to - cm depending on different authors. on the other hand, some authors discourage laparoscopic surgery in larger tumors due to the increased risk of malignancy in those larger than - cm, referring to malignancy in out of or cases. paragangliomas are rare tumors originated in extra-adrenal chromaffin cells, with an incidence of - cases per million inhabitants. they can appear in any location between neck and pelvis. sympathetic paragangliomas are usually functional and catecholamines producers. we present a movie of surgical intervention of a -year-old patient who, in study for refractory hypertension, presented paraganglioma producing norepinephrine, whose approach was performed laparoscopically. -year-old woman studied by nephrology for refractory hypertension. on physical examination, only obesity standed out. in blood exams, levels of normetanephrine were observed in plasma of pg/ml and aldosterone pg/ml. abdominal scintigraphy was performed in which there was no evidence of increased activity at adrenal level. abdominal ct shows retroperitoneal extra-adrenal tumor of inter-aortocava location immediately below renal vessels with dimensions of . . cm. after preparation, she was operated. laparoscopic access was performed under exhaustive monitoring. an heterogeneous, polylobulated tumor of cm, located interaortocava, intimately adhered to left renal vascular pedicle, was observed. a cattell-braash and kocher maneuver was performed, with exposure of inferior cava and aorta to iliac bifurcation. complete tumor excision was performed after clipping arterial and venous tributary branches. after the operation, the pacient presented favorable evolution being discharge on the second postoperative day with good control of blood pressure levels. laparoscopic approach of retroperitoneal paragangliomas is a safe technique, which allows minimally invasive access, with consequent improvement in postoperative results. the exact location of lesions and their relationships with surrounding structures, as well as their functional behavior, are very important when considering the best therapeutic strategy for these patients. we present the case of a -year-old obese male patient referred for adrenalectomy after being diagnosed with left adrenal incidentaloma. abdominal mri showed a . / . / . left adrenal mass with normal hormonal levels. after preoperative workup, the patient underwent standard laparoscopic adrenalectomy. the lateral to medial dissection and mobilization of the spleen and pancreatic tail was difficult due to the abundance of peritoneal and pararenal fat. the anatomy was peculiar: the bulky pancreatic tail was located well inferior to the splenic hilum and was visible throughout the intervention and the spleen was quite elongated-long axis = cm. the exposure of the adrenal gland was therefore cumbersome. the operating time was min and blood loss ml. the abdominal drainage was maintained for h. before discharge the patient underwent a control abdominal us examination that only showed a thin line of left pleural fluid. the patient was readmitted days after discharge for chest pain, fever ( . °c) and malaise with no abdominal signs. the emergency ct scan diagnosed left basal pneumonia with minimal pleural effusion and a / cm fluid collection between the spleen and diaphragm while the blood test showed leukocytosis. the patient was treated for pneumonia with an apparent clinical benefit for three days and lowered white cell count but his condition worsened during the forth day. repeat abdominal us demonstrated that the abdominal collection increased in size therefore the patient underwent emergency surgery. during laparoscopic exploration, the collection was unveiled as being pancreatic juice (more than times the normal serum levels of lipase and amylase). after thorough lavage, two drainage tubes were positioned in the left subphrenic space. the postoperative course was uneventful under antibiotic treatment for pneumonia and pancreatic antisecretory medication. the patient was discharged after days with minimal pancreatic drainage and the drainage tube was extracted after more days. the aim of the study was to develop the algorithm and the choice of the method of endoscopic treatment of a combined pathology of uterine leiomyoma and adenomyosis depending on the reproductive plans. methods: the study involved patients with a combined pathology of uterine leiomyoma and adenomyosis. indications for conservative myomectomy were: the size of the uterus is more than weeks. pregnancy; multiple leuomatous nodes and adenomyotic foci up to cm in size; hemorrhagic and pain syndromes, anemia, compression of the adjacent organs; suspected node malfunction; submucous leiomyoma deforming the uterine cavity with foci of adenomyosis; subserous, cervical isthus nodes and foci of adenomyosis; the presence of endometrial hyperplasia, tumors of uterine appendages; growth rate of uterine leiomyoma more than weeks pregnancy for the year; the growth of uterine leiomyoma on the background of drug treatment; infertility associated with leiomyoma and uterine adenomyosis.the laparoscopic myomectomy of the subserous node on the 'leg' with a size of more than cm and nodes of more than cm of intramural location is shown with an interest in preserving the organ.the hysterectomy is indicated for women after years of age who insist on hysterectomy, with a combination of uterine leiomyoma with atypical endometrial hyperplasia. results: the conservative myomectomy and removal of adenomyotic foci were performed in ( . %) patients: from hysteroscopic access- , vaginal access- , laparoscopic access- , abdominal access- in the presence of reproductive plans.the hysteroscopic myomectomy was performed in ( . %) patients, hysterectomy in ( . %) patients: from laparoscopic access- , from vaginal access- , from abdominal access- in the absence of reproductive plans. conclusions: the choice of surgical treatment of uterine leiomyoma and adenomyosis depends on the reproductive plans of the woman and the severity of the lesion.the laparoscopic method of treating a combined pathology of uterine leiomyoma and adenomyosis in the presence and absence of reproductive plans is a priority for women. surgery, policlinico ,,paolo giaccone,,, palermo, italy background: breast cancer in females represents the most frequent neoplasm in all age groups. the risk of getting breast cancer (mc) increases with age. the brca and the brca genes (tumor-suppressor genes, autosomal dominant transmission at high penetrance) alone justify from % to % of cases of hereditary breast cancer. methods: from january to june we have analyzed patients with brca mutation. all patients had in common a genetic mutation of brca or brca tumor suppressor genes. results: the frequency of germline mutation on brca ( patients: %) was identical to brca gene ( patients: %). of the analyzed patients were women ( . % of patients) brca and brca , and men ( . %) all with brca mutation. conclusions: prophylactic surgery must be seen as a way to put the patient in the condition to implement the most appropriate treatment. further studies will be necessary to support the validity of prophylactic surgery in patients with mutations in brca and brca genes. introduction: laparoscopic hysterectomy is a safe surgical technique for removing the uterus with or without including the ovaries and fallopian tubes. laparoscopic surgery of endometrial cancer is a safe method, with the mean time of recovery being two days only. material-method: the case of a yr old woman with metrorrhagia and anaemia (ht , %) due to adenocarcinoma of the endometrius is presented. the patient underwent a laparoscopic hysterectomy and oophorectomy. trocar ports were used during the procedure (a mm transumbilical port, similar to the port used in single incision laparoscopic operations, two mm ports at the level of the anterior superior iliac spines, and a mm port in the middle of the imaginary line between the pubic symphisis and the umbilicus). the uterine vessels and the uterine ligaments were ligated and dissected by using a thermal energy source. the patient's postoperavite course was uneventful. the patient continues to be in good condition, months post-surgery. conclusion: laparoscopic hysterectomy seems to be a safe method for addressing endometrial cancer, as it offers the surgeon a better surgical field, is tissue friendly and causes fewer postoperative complications. it is considered to be a less traumatic operative method, as due to zooming in the picture there is greater accuracy in handling the tissue, and blood loss is minimal. m. shahin background: hysterectomy is one of the most frequently performed surgical procedure. though there are three approaches in hysterectomy (open, vaginal and laparoscopic), still there are controversies regarding the optimal route for performing it. methods: this prospective comparative study included obese patients subjected for panhysterectomy as a treatment. the forty-two patients were allocated into two groups: group (a) subjected to laparoscopic pan-hysterectomy, group (b) subjected to open pan-hysterectomy. results: there was significant difference between the two groups regarding mean operative time, blood loss, analgesic requirements and hospital stay, while no significant difference regarding intra-operative complications. conclusions: laparoscopic hysterectomy in obese patients has emerged as a viable, safe and better alternative to open hysterectomy amongst appropriately trained surgeons. general: endometriosis in the inguinal region is rare. the usual presentation is that of a woman in the reproductive age group. it accounts for . - . % of patients affected by endometriosis. the groin swelling is usually slow growing, painful with exacerbations during menses. the incidence of inguinal endometriosis on the right side is - % as compared to the left. aim: to present our laparoscopic approach for the treatment of the diagnostic dilemma. case presentation: a -year-old woman presented with a palpable mass in the right groin. the swelling was associated with a dull aching pain. the patient was suffering from increasing pain over the swelling during menstruation. she had undergone cesarean section some years ago and the scar had healed by primary intention. mri scan revealed a nodular hypoechoic lesion at the level of the internal inguinal ring with the absence of vascular flow around the lesion. results: since inguinal endometriosis was in the differential diagnosis and it may be associated with pelvic or intraperitoneal endometriosis, a laparoscopic approach was decided. the procedure was successfully completed laparoscopically following the transabdominal preperitoneal approach. the endometriosis was found, after dissecting the internal inguinal ring, firmly adhered to the round ligament. it was excised en bloc with the round ligament. a preperitoneal polypropylene mesh was inserted to protect for future inguinal hernias due to extensive dissection at the level of the internal inguinal ring. no intraperitoneal endometriosis was appreciated. histopathology revealed endometriosis of the round ligament. the patient was uneventfully discharged the next day. on follow up the patient was asymptomatic. conclusions: round ligament endometriosis is a rare entity. it is a disease of specific interest to the physician. it can be confused with an inguinal hernia and thereby pose a diagnostic dilemma. we recommend considering endometriosis in the differential diagnosis of groin swellings in women. the transabdominal preperitoneal approach is feasible and safe in the hands of an advanced laparoscopic surgeon. introduction: sentinel node biopsy is the newest accepted method for surgical staging of early stage endometrial and cervical cancer. aim: to evaluate the role of the technique of indocyanine green (icg) identification of the sentinel lymph nodes in cases of early endometrial cancer. material and method: five patients with early endometrial and cervical cancer were introduced in a prospective study. icg was locally injected during the laparoscopic exploration. novadac pinpoint near to red technology was used. guided biopsies were performed into the marked sentinel nodes and histological results were evaluated. results: sentinel lymph nodes were easily identified by using icg and near-infrared technology. technical details are described. no associated complication was encountered. conclusion: sln mapping using icg in uterine cancers is demonstrated as an effective and safe procedure. laparascopic extraction of an intraperitoneal gossypiboma following c/s and a retroperitoneal gossypiboma following pyeloplasty n. ozlem general surgery department, ahievran university, kirsehir, turkey gossypibomas are forgatten foreign bodies,iatrogenic.their symptoms are different where they are. they extracted with laparotomy in the past but now we can some article mentioned their extraction was made with laparoscopy. case : y o female has abdominal pain after c/s for . years. a gossypiboma was extracted with laparoscopy above umblicus.a superficial surgical site infection existed,drained,subsided. case : yo m had a pyleoplasty operation years ago.a gossypiboma was extracted with retroperitonescopy,no postoperative event. basibuyuk et al reported retroperionescopic extraction of a gossypiboma from single port in first time.althoug every effort taken the incidence of foreign body detected in the body is about . - . %.they are most frequently localized in the intraabdominal cavity followed by tracheobronchial area,pleural cavity,pararenal area,vagina,spinal chord, neck, femur,breast,bladder,pancreas,and they may cause local irritation,and infection.tactile sense is absent in laparoscopy. all radiologic examinations(usg ct pet mri etc) be used to detect.we used usg ct.in the end laparoscopy make the diagnosis and remove gossypibomas in our cases with less postoperative pain and cosmosis. justo et al the computerized tomography (ct) scan is the most useful method for diagnosis; however, sometimes the preoperative diagnosis remains uncertain even after the imaging exam. in that case, laparoscopy arises as a valuable diagnostic tool, as well as a prompt treatment option. concerning gossypiboma, prevention is preferred rather than treatment. notwithstanding, there is no highly reliable prevention system. counting sponges is a method based on staff communication during the surgery with only % sensibility. routine surgical postoperative x-ray (spox) constitutes an early detection system, but the need to incorporate a radiopaque marker and to expose the whole surgical field to maximize its efficacy limits its use. more recently, electronic dispositives based on barcode detection and other technological adjuncts for counting sponges are being developed. none of these prevention systems are reliable when used alone. our education and research clinic was a state hospital before. no surgeon followed above instruction.but now we use all. multiple procedures and surgical teams, long operations and non-elective operations are the evidenced risk factors.c/s operation was learned full opened of ostium of cervix of the patient. urology, japan, nagoya, japan aims: some scoring systems have been suggested to standardize the renal tumor characteristics. among them, renal score is widely used in partial nephrectomy. whereas diameter-axis-polar (dap) score was developed to be more significantly related with postoperative renal function. our study compared dap score with renal score in robotic partial nephrectomy (rpn) outcomes. methods: records of patients who underwent rpn at nagoya daini red cross hospital between april to october were analyzed retrospectively. those include three oncocytomas. accordingly, we calculated the estimated glomerular filtration rate (egfr) just before rpn and month postoperatively in patients. we compared two nephrometry scores with warm ischemic time and change in egfr. results: in our institution, four surgeons performed rpn. according to dap score, patients were high, were middle and were low. according to renal score, were high, were middle and were low. the median warm ischemic time was min ( - ). the median egfr decreased from . ( . - . ) to . ( . - . ) ml/min/ . m . there were no significant differences in warm ischemic time and percentage change in egfr between renal score groups (p = . and . ) but significant differences between dap score groups (p \ . and p \ . ). univariate and multivariate analyses were used to identify factors influencing postoperative renal function. that confirmed that dap score was independent poor predictors of change in egfr after rpn. conclusions: dap score is simpler estimate system than renal score. our study suggested that dap score is a useful scoring system for preoperative evaluation of renal tumor for rpn. further investigation is needed to better understand preoperative dap score. aims: retroperitoneal primary tumors comprise a great variety of neoplasm with different histological typologies, with insidious clinical symptoms and little specificity in most cases. its diagnosis is established through imaging tests and anatomopathological study is needed so complete surgical resection is the treatment of choice. the aim of the video is to demonstrate the safety and efficacy of the minimally invasive approach in patients with retroperitoneal lesions. methods: a -year-old female patient who, in the course of an abdominal pain at the right iliac fossa suspected of possible acute appendicitis, is diagnosed with a right retroperitoneal tumor, compatible with primary neurogenic tumor on a ct. radiographic imaging is a key component of the evaluation of a patient with a retroperitoneal mass, a ct scan is necessary to evaluate the primary site as well as to rule out metastatic disease. after complete biochemical study, nonfunctioning tumor is determined. the study is completed with mri where the lesion is located below the right kidney, in front of the right psoas muscle and lateral to the inferior vena cava, and without contact with these structures. ??it is in intimate contact with the ovarian vein. the complementary tests and iconography of interest of the case are exposed. surgical intervention is proposed with a laparoscopic approach. results: full minimally invasive approach in left lateral decubitus position: trocars-lateral laparoscopic transabdominal approach. laparoscopic liberation of the right colon, kocher maneuver until the inferior vena cava is visualized, identification of a tumor of approximately cm in the right infrarenal region, lateral to the right ureter, which includes the gonadal vessels. resection of the tumor in block with margins previous dissection and clipping of the proximal and distal gonadal vessels with ligasureÒ. the patient presented a successful postoperative recovery, being discharged h after the intervention. definitive result of the specimen: leiomyosarcoma, grade of the fnclcc with negative margin. the laparoscopic approach is a safe and effective technique in the approximation of retroperitoneal tumors, a radical oncological criterion is always needed with correct margins of resection especially in those of uncertain etiology. we started endoscopic thyroidectomy using the lifting method in and have developed single incision endoscopic thyroidectomy (siet) via chest (c-) or axillary incision (a-) by our original retractor since . we created a new approach in . recently, we have applied this method to parathyroid surgery. in this study, we present our method and results in parathyroid surgery with regard to surgical outcome and patients' complaints. method: endoscopic parathyroidectomy of c-siet was performed in patients with hyperparathyroidism (primary , secondary ) in new approach (mean age , male female ). single parathyroid adenoma was diagnosed using ultrasonic device, preoperatively. the patient is placed in a supine position with the neck extended. mm vertical incision is made in anterior chest. flexible endoscope (olympus co. japan) is used through mm trocar detached the retractor. in new approach, the parathyroid and thyroid are exposed through the avascular space between sternal head and clavicular head of sternocleidomastoid muscle. both of the skin and sternal head are lifted up by our original retractor (takasago medical co. japan). parathyroid adenoma behind the thyroid is resected using an ultrasonic scalpel. i would like to present our c-siet procedure. results: no scars in the neck were left in all cases. benign and hemi lateral parathyroid adenoma sized from mm to mm (mean: . mm) were operated. mean operation time is min. in new approach. there was no complication. parathyroid hormone levels decreased in all patients immediately after operation. conclusion: it is a little possible to make recurrent nerve palsy in this approach. new approach is useful to operate and make the working space wider without stress to find out of parathyroid adenoma. our original retractor can be introduced easily in most hospital, because it is not so expensive. most of women satisfied cosmetic results because of hidden scars. objectives: radiofrequency ablation (rfa) is a novel and developing technique for the treatment of parathyroid hyperplasia/adenoma in the context of secondary hyperparathyroidism (hpt) to chronic kidney disease (ckd) and there is little literature on the subject. the purpose of this study is to determine its usefulness by contributing a case carried out in our hospital. methods: we selected a case of secondary htp in a patient of years old with ckd who presented a parathyroid adenoma detected clearly by ultrasound scanning. the patient was dismissed for surgery due to high surgical risk due to his comorbidities. rfa of a right inferior parathiroid adenoma was performed. intact parathyroid hormone (ipth) was measured before arf and min after de procedure, calcium and phosphorus were measured the day after. the treatment was considered effective if ipth levels decreased at least % min after rfa and calcium levels decreased the day after. results: ipth level before rfa was pg/ml. ipth level after min of rfa was pg/ ml, this meant a % reduction (normal values - pg/ml). calcium levels were from . at the baseline to . the day after (normal values . - . mg/dl) and phosphorus from . to . mg/dl (normal values . - . mg/dl). the patient presented dysphonia as a complication that improved with corticosteroid therapy. we are currently waiting for the next analytical controls at , and months after the proceidure. conclusions: rfa of parathiroid adenomas for treating secondary hpt in patients with ckd is feasible in selected patients. this treatment may reduce the morbidity that surgery supposes, it is developed in an outpatient regime avoiding hospital admission and this contributes to a reduction of health costs. however, a longer follow-up is necessary to verify the good results in our case. splenectomy is one of the treatment strategy for advanced portal hypertension due to liver cirrhosis. after splenectomy, thrombocytopenia is dramatically ameliorated, and liver function parameters have also been improved in several clinical settings. however, the mechanism underlying such a phenomenon remains unclear. the aims of the present study was to analyze histological changes of the liver after splenectomy in human, and to speculate the underlying mechanism. subjects and methods: cirrhotic patients with hepatocellular carcinoma (hcc) who had undergone laparoscopic splenectomy prior ( weeks- months) to hepatic resection were analyzed (n = ). non-tumorous liver specimens obtained at hepatectomy were histologically investigated. liver tissues from cirrhotic hcc patients who underwent only hepatectomy were used as controls (n = ). results: after splenectomy, significant leukocytosis, especially increase in monocytes, was observed in addition to thrombocytosis. in the non-cancerous liver tissues, many round-shaped cd -positive macrophages accumulated after splenectomy, while this phenomenon was merely observed in patients without splenectomy. the macrophages were cd ? (m marker) and cd -cd ? , suggesting their anti-fibrotic population. the accumulated macrophages existed around fibrous scar as well as ck ? epcam ? cells spreading out from the ductular reactions (dr). as a result, the number of ki -positive hepatocytes significantly increased after splenectomy. the amount of platelets detected in the liver did not change even after splenectomy. finally, remarked attenuation of the established liver fibrosis was detected after relatively long duration. the accumulated macrophages expressed metalloproteinase (mmp)- and fibroblast growth factor (fgf)- , suggesting these molecules may possibly participate in resolution of established fibrosis and hepatocyte proliferation. conclusion: splenectomy in cirrhotic patients with portal hypertension ameliorate liver fibrosis, and stimulate liver regeneration. the mechanism possibly include hepatic accumulation of anti-fibrotic cd -positive macrophages and stimulation of dr-derived ck ? epcam ? progenitor-like cells. in patients with advanced splenic fibrosis, splenectomy could be a feasible therapeutic modality. the paper tries to establish the role and the opportunity of using laparoscopy in regard with abdominal contusions, as well as its indications or contraindications, combined in a therapeutic algorithm. we analyzed two groups of patients with abdominal contusions divided over two -year periods, - ( patients) and - ( patients) respectively. we have separated the two periods because starting from we have established a strategy for dealing with cases of abdominal contusions where we included diagnostic and / or therapeutic laparoscopy and nonoperative management. the investigation was done by fast echography, ct scan, simple abdominal radiography, peritoneal lavage puncture, and sometimes arteriography. in the second period we determined the diagnostic and therapeutic laparoscopy indications: suspicion of hollow or parenchymal organ injury, or mesentery injury, the presence of hemoperitoneum or fluid in the peritoneal cavity in a stable patient without major hemorrhage, apparent with unique injuries, without immediate vital risk and without other associated severe trauma. we have associated in this last period the nonoperative management for patients with grade and lesions of parenchymal organs that do not have fluid in the peritoneum, or only a very discreet quantity. in the first period, all patients were treated by classic surgery, resulting in unnecessary laparotomies where no visceral lesions were revealed. in the second period, we applied non-operative management to patients out of , patients with grade and splenic injuries, and patients with grade and hepatic lesions. diagnostic laparoscopy was performed in cases, in of them without evidence of lesions, and in other cases of grade lesions no therapeutic action was required. therapeutic laparoscopy was required for one case of splenectomy and one of hepatorrhaphy. diagnostic laparoscopy is useful in abdominal contusions, if certain indications are followed and in selected patients. in our study, with the introduction of modern therapeutic strategies, unnecessary laparotomies were completely avoided, some lesions being even treated by laparoscopy. the new algorithm introduced allowed % of patients to avoid laparotomy. aims: about cases of splenic hamartoma have been described in the literature since it was first described by rokitansky in , it is a rare benign tumor. it is usually a casual finding in laparotomies or autopsies. they are usually asymptomatic, but there are few symptomatic splenic hamartomas and they can be associated with haematological alterations, being in some cases associated with spontaneous splenic rupture and acute abdomen, two thirds of them have multiple tumors. there are no specific data that allow the preoperative diagnosis of this entity, which is performed after the anatomopathological study of the surgical specimen, which must be extracted entirely, this together with the size of the spleen makes the laparoscopic approach difficult. the aim of this video is to demonstrate the surgical technique of a complete laparoscopic approach for this type of lesions, without the need for assistance laparotomies (handport). methods: clinical case: a -year-old man admitted to internal medicine due to fever and left lumbar pain. additional explorations of interest are discussed, including: thrombopenia of probable peripheral origin secondary hypersplenism (fna of bone marrow), ct: splenomegaly with splenic masses, which deform the splenic contour, compatible with atypical hemangiomas, without being able to discard other vascular splenic tumors. results: complete semi-laparoscopic approach, trocars, multilobulated splenomegaly ( x cm.), mechanical vascular section, complete bag extraction after minilaparotomy on the left flank. the patient presented a successful postoperative recovery, being discharged on the th po day. abdominal ultrasound at st week with portal vein thrombosis, which resolves after treatment with heparin. definitive result of the specimen: multiple splenic hamartoma. asymptomatic one year after surgery. the laparoscopic approach is a valid and effective alternative to splenic benign tumor lesions. the size does not contraindicate this type of approach, although the complete extraction of the spleen is recommended for its pathologic study. we recommend eco-doppler control per week, given the risk of portal thrombosis with an existing laparoscopic post-splenectomy. objectives: splenic cysts are a rare entity, currently described between - cases in literature. a female patient's case is hereby presented, giant splenic cyst treated by conservative laparoscopic surgery obtaining good results. method: years old female, without any relevant medical history, examined after abdominal pain on the left hypochondriac region, nausea, postprandial swelling and mass sensation. after exploration the presence of such mass was ratified, the rest of exploration found no relevant findings, no record of previous traumatism nor any other relevant incidence. diagnosis was made through ultrasound and computerized tomography, the existence of a big splenic cyst is confirmed, cm by cm, on the superior section of the spleen, negative results after parasitism test, normal haemogram, coagulation and biochemistry levels. patient was intervened using laparoscopic surgery, performing the deroofing technique on the cyst (two liters of orangey amber serous liquid that was sent for analysis) as well as extirpation of superior wall of the cyst, which was sent to pathological anatomy, a saline solution was used to cleanse the cavity, omentum and drainage were then set in place. results: patient evolved satisfactorily, hospital discharge and drainage withdrawal after h. regular check-ups, after and months, patient presents no symptoms nor recurrence. pathological anatomy confirmed primary splenic cyst and the extracted liquid as cystic. conclusion: splenic cysts are primary ( %) or secondary ( %). diagnosis is performed through imagery tests, cat scan the being standard test used. regarding her treatment there is no clear consensus, due to the fact that up to a few years ago, complete splenectomy was the recommended treatment, techniques with preservation of the spleen are currently being widely recommended through laparoscopy in literature. among the conservative techniques percutaneous aspiration, with or without the injection of a sclerosing agent, partial splenectomy, marsupialisation, cystectomy, decapsulation, unroofing or fenestration can be found. the main issue is recurrence rates. few cases of primary giant splenic cysts treated by laparoscopic decapsulation can be found in literature, this treatment being simple and quick to perform, resenting a recurrence rate lower than other techniques such as aspiration and marsupialization. introduction: technology's progress and its application in the minimally invasive surgery of the thyroid gland offers us new surgical approache's like the transaxillary approach. this new technic still unusual in our environment and has recently begun to be incorporated into our surgical practice. the objective of this case is to explain step by step how to carry out a right transaxillary thyroidectomy and emphasize in the most relevant tips to take into account. also we going to review the main limitations we observed so far. statement of the case: we present the case of a -year-old woman referred for evaluation of a left thyroid nodule without associated symptomatology. the blood test shows normal thyroid profile. cervical ultrasound is performed identifying a . cm single right nodule with welldefined edges and presence of peripheral vascularization . no other nodules are identified. fna of the nodule describes a bethesda iii. after evaluation we decide to perform a left transaxillary thyroidectomy. discussion: surgical treatment of the thyroid gland by transaxillary approach may be indicated in previously selected patients, offering the advantages from minimally invasive techniques (shorter recovery time, shorter incision length, etc.). surely, more evidence and experiencie is required to make a better assessment of minimally invasive approaches in thyroid surgery. surgery, taipi city hospital, yan-ming branch., taipei, taiwan; surgery, taipei city hospital, taipei, taiwan the first endoscopic thyroidectomy was performed in using a cervical approach. since then, various remote-access method, have been developed for thyroid surgery to avoid scarring of the neck. trans axillary approach(taa),bilateral axillo-breast approach(baba),and retroauricular approach(raa) are common in use. the main benefit of these procedure is that there are no visible scar that is one of the drawbacks of conventional kocher's incision. however,these methods require more dissection and longer operation time than conventional thyroidectomy transoral thyroidectomy(tovet) is a new approach and has become popular in recent years, however,most surgeons peformed a single procedure because of the limited patients and the learning periods sine ,more than cases were performed,patients received endoscopic thyroidectomy(et) procedure at our hospital. we compare the surgical procedure of bilateral axillo-breast approach(baba) with transoral vestiblar approach(tovet) in our hospital both performed by one single surgeon .the surgen has expended eaqual amounts of time with these two procedures. the patient seletion process,operation time, operation procedure and approach,learnig experience, consmetic effect,onaologic consideration and surgical outcome were discussed yhroughly. presenting a case of a thyroid metastasis from an ovarian carcinoma, we conducted a review of the literature without finding similar reported cases. case: a -year-old woman consults for progressive asthenia, weight loss and ascites. abdominal ct finds a conglomerate in the pelvis involving the ovaries and peritoneal implants, the largest up to cm. an omental epigastric lesion biopsy and paracentesis is performed resulting in adenocarcinoma and omental metastasis from ovarian neoplasm, associated with ca of . patient starts neoadjuvant therapy with carboplatin-paclitaxel. in image controls there is a favorable response. three months later, intervention was carried out; laparotomy hysterectomy ? double anexectomy ? omentectomy ? appendectomy ? pelvic and paraaortic lymphadenectomy.the anatomopathological study shows a low-differentiated endometrioid carcinoma, omentum infiltration and absence of metastatic lymphatic involvement. while getting the maintenance treatment with bevacizumab the patient presented symptoms of arthritis and hypercalcemia was detected ( . ) with pth . a gammagraphy was performed and an increased uptake area was detected in the lower pole of rtl, suggestive of a parathyroid adenoma. we initially proposed the possibility of performing radiofrequency ablation but in a previous thyroid ultrasound we visualize nodular lesions in rtl compatible with adenoma and a mass in the superior mediastinum that seems to correspond the area of greatest uptake in the gammagraphy so finally the procedure is dismissed and surgery is proposed. during the intervention we found a hard consistency nodule in the inferior pole rtl and lymphadenopathies of hard consistency in right vi area that are sent for intraoperative anatomopathological study with the result of adenocarcinoma metastasis without identifying origin. a total thyroidectomy, parathyroidectomy and central ganglion drainage is performed with the result of a parathyroid adenoma, lymphatic invasion of ovarian-grade latent carcinoma and extensive vascular permeation by carcinoma of the thyroid. the patient maintains oncological treatment with carboplatin-caelix. in the last follow-up, the pth and calcemia remains normal. conclussion: although some cases of neoplasic thyroid involvement associated with struma ovarii have been published, no cases similar to the one described are found, neither in our experience, which is why it is an exceptional case. the aim of the study was to evaluate the effectiveness of the use of embolization of the splenic artery in order to prevent portal bleeding. methods: the study included patients, who had esophageal varices bleeding, which developed as a result of decompensated cirrhosis of the liver of various etiologies of classes b and c according to child-pugh. patients were divided into groups. the main group included ( . %) patients who underwent endoscopic ligating of bleeding varix and in order to prevent recurrence of bleedingembolization of the splenic artery with gianturco coils. the comparison group consisted of ( . %) patients who received only drug therapy. to assess the effectiveness of the treatment, the patient's condition was monitored for months. results: the average age of patients in the comparison group was . ± . years. using only drug therapy, we stopped bleeding in ( . %) patients. in all cases, at the end of treatment, we received an improvement in clinical and laboratory parameters. ( . %) patients died. the duration of treatment was . ± . days. the average age of patients in main group was . ± . years. performing endoscopic ligation of bleeding varices, we stopped bleeding in ( . %) patients. in all cases, at the end of treatment, we received an improvement in clinical and laboratory parameters. ( . %) patients died. the duration of treatment was . ± . days. a statistical analysis of mortality and duration of treatment revealed a significant difference (p \ . ) between the groups in both indicators. after splenic artery embolization in all cases managed to achieve a reduction in blood flow of - %. after months among patients in the comparison group, bleeding relapse occurred in ( . %) cases. in the main group, this indicator was . % ( patients). the indicator in the main group was significantly (p \ . ) different from the same indicator in the comparison group. conclusion: performing embolization of the splenic artery in patients after endoscopic hemostasis of variceal bleeding allows to reduce the pressure in the portal system, which in turn leads to a decrease in the frequency of bleeding recurrences. thoracoscopic esophagectomy for aortoesophageal fistula y. ebihara, t. shichinohe, y. kurashima, s. murakami, surgery ii, hokkaido university, sapporo, japan background: aortoesophageal fistula (aef) is an uncommon but one of highly fatal conditions. there are surgical, endoscopic and interventional radiological treatment options, however, definitive treatment is the surgical intervention. video-assisted thoracoscopic surgery (vats) has been gradually accepted as a substitution for thoracotomy to reduce the invasiveness of the surgery as radical surgery for esophageal cancer. we aimed to evaluate a feasibility of vatsesophagectomy (vats-e) for aef in this study. introduction: achalasia is the most common motility disorder of the esophagus. heller's cardiomyotomy associated with a antireflux technique is the treatment of choice in patients with this disease; however, a small group of patients could present a recurrence of the symptoms being necesary a new surgery, what is an important challenge for most of the surgeons. we report the case of recurrence after a laparoscopic miotomy and dor fundoplication as a paradigm for the appropiate management in this kind of patients. methods: a years old female, who underwent a previous miotomy and a dor fundoplication in due to an achalasia.six years after surgery, the patient showed epigastric pain and dysphagia. the study of the patient was performed with: barium swalow, phmetry, manometry, ct-scan and mri showing a recurrence of her disease.the patient was transfered to our center where she underwent a new surgery.the key points of the new surgery includes the next steps: dissection of the previous adhesions, dissection of the dor's partial fundoplication, avoid dissection of the anterior esophageal wall at the leve lof the hiatus (the area of previous myotomy) in order to avoid perforation of the esophagus, lateral and posterior dissection of the distal esophagus, lateral myotomy at the rigth wall of the esophagus and a toupet's funduplicatury. all of thisis procedures are done under intraoperative endoscopy in order to confirm a good passage to the estmach and to identify a perforationic supervision. results: following theseis steps several patients have been operated in our center with excellent results. in all of these cases, including the patiente presented previously, the symptoms have dissapeared. conclusions: achalasia is a rare motility disorder of the esophagus, being recurrences an important challenge for surgeons. a great proper therapeutic strategy using the different diagnostic exams and the supervison by a group of experts in this kind of entity are the basis in order to obtain good results in these situations. aims: re-do fundoplication is usually performed for recurrent reflux symptoms due to wrap failure or recurrent hiatus hernia. conversely, persistent dysphagia may occur early due to tight wrap/crural repair which should be avoided by good surgical technique. a small group of patients however may suffer progressive dysphagia due to weakening motility (especially in older patients), fibrosis of the wrap or a combination of the two. this video demonstrates the successful treatment of this problem with a laparoscopic conversion from nissen to posterior toupet fundoplication. a year old man underwent an uncomplicated laparoscopic nissen fundoplication in with complete resolution of reflux symptoms. he re-presented years later, still free of reflux but suffering progressive dysphagia and troublesome regurgitation. investigations demonstrated intact wrap and no mechanical obstruction, but confirmed low-amplitude peristalsis. a trial endoscopic dilatation improved symptoms for days before recurrence, suggesting likely wrap fibrosis (which would reduce elasticity and impede passage of food bolus), justifying consideration for a conversion from nissen to toupet. results: this video demonstrates the expected adhesions between fundoplication and inferior surface of left lobe liver, mobilisation and division of the nissen fundoplication, and reconstitution of a posterior toupet fundoplication. the patient made a good recovery and was discharged the following day. three-and six-month follow-up confirmed complete resolution of symptoms with no recurrence of reflux. conclusion: laparoscopic re-do surgery for late-onset progressive dysphagia is a safe and viable option. patients must be thoroughly investigated and carefully selected for an appropriately tailored procedure. they should also be advised of the increased risks associated with re-do surgery. the anatomy can be unpredictably distorted by variable adhesions and this operation should therefore only be performed by laparoscopic surgeons experienced in both primary and re-do fundoplication. methods: i report unusual iatrogenic injury of cervical esophagus that resulted with complete resection post total thyroidectomy for papillary ca of thyroid patient presented days post surgery to our center. the video will show the steps used to treat this unusual complication by neck exploration, laparoscopic trans hiatal esophagectomy with creation of gastric tube with preservation of the right gastroepiploic artery and the neck anastomosis between the cervical esophagus and stomach. were open and minimally invasive esophagectomies. of the patients, were for squamous cell carcinoma, were adenocarcinoma and were of other histological diagnosis such as gastrointestinal stromal tumor and schwannoma. the median length of stay for patients who underwent minimally invasive esophagectomies was days ( to days) while the median length of stay for patients who underwent open esophagectomies was days ( to days). the minimally invasive group had a shorter icu stay of day. for day morbidity, the minimally invasive esophagectomy group had patients who encountered anastomotic leaks, with post operative pneumonia while the open esophagectomy group had patient with anastomotic leak, patient with post operative stricture and patient with delayed gastric emptying. there were mortalities in the minimally invasive group while there were no mortalities in the open group. conclusion: our data show that patients who underwent minimally invasive esophagectomies had a shorter duration of hospitalization with similar perioperative morbidity rates. minimally invasive esophagectomy is a viable surgical option for a select group of patients. aims: there has been an increasing tendency towards minimally invasive surgery for esophageal cancer. our aim was to evaluate the results of the thoracoscopic approach (ta) and compare them with the ones of open approach (oa) at our institution. methods: retrospective review of all patients who underwent esophagectomy due to esophageal cancer (adenocarcinoma or squamous cell) between and were included. patients with siewert iii tumors and those who didn't need a thoracic approach were excluded. results: during the study period were performed esophagectomies, through ta. in . % of these, the abdominal stage was done by laparoscopy. when comparing ta versus oa, there were no statistically significant differences in the baseline characteristics of the two groups (mean age, median body mass index, ecog performance status, asa score, smoking status, diabetes mellitus, pulmonary disease, histologic type, clinical staging and neoadjuvant chemo and radiotherapy). regarding outcomes, there were no significant differences in need of intraoperative transfusion, median intraoperative blood loss, operative time and length of stay. although not significant, in ta group there was a tendency for higher overall morbidity ( . % versus . %, p = . ); major morbidity-ctcae - ( . % versus . %, p = . ); anastomotic leak ( . % versus . %, p = . ) and re-intervention rate ( . % versus %, p = . ). on the other hand, in ta group there was a tendency (although not significant) towards lower rate of respiratory complications ( . % versus . %, p = . ), lower rate of r margins ( . % versus . %, p = . ) and higher median of lymph nodes removed ( versus , p = . ). conclusions: in our series, outcomes of ta were similar to oa, with a tendency towards lower respiratory complications, lower rate of r margins and higher number of lymph nodes removed in ta group. the impact of these findings in survival remains to be seen. the tendency towards higher morbidity may be related to the learning curve, since this were the first cases performed at our center. background: esophagectomy is a surgical procedureburdened by a high morbidity rate. the effect of minimally invasive (mi) approach on elderly patients is still not clear. aim: of this study was to analyze the impact of mi approach on post-operative course according to the patient age. methods: a consecutive series of patients underwent to elective oncological esophagectomy between and . all data were entered into a prospective database. patients submitted to -flield or trans-hiatal esophagectomywere excluded andonly ivor-lewisopen, hybrid or totally minimally invasive esophagectomywere. patients were stratified according to age in groups:group a(= years) patients, group b ([ and \ years) and group c (were = years) .clinical and pathological factors influencing surgical outcome were evaluated. complications were classified according to clavien-dindo (cd). results: as expected outcomes worsened with patients age(cd = b: . % group a, % group b and % group c. p = . ), mortality ( % group a, % group b and . % group c. p = . ) and length of stay ( days group a, days group b and days group c. p = . ).a statistically significant higher incidence of anastomosticleaks was observed among patients submitted to totally mi esophagectomy in group c vs a and b that were respectively , %, % and %. major respiratory complications were not statistically different among these three sub-group. conclusions: old age has a significant impact on outcomes afteresophagectomy. in this subset of patients a mi approachcould also increasepostoperative morbidity. elderly patients should be carefully selected before to be submitted to mi esophagectomy. introduction: esophagectomy is a major surgical procedure with morbidity and mortality related to the patient's condition, stage of the disease, complementary treatments, and surgical experience. minimally invasive esophagectomy (mie) may lead to a reduction in perioperative morbidity and mortality with very good quality of life. material and method: we present the experience of the center of excellence in esophageal surgery regarding totally mie through thoracolaparoscopic modified mckeown three-stage approach followed by esophageal reconstruction by gastric intrathoracic pull-up and cervical esophagogastric anastomosis used for the treatment of thoracic esophageal cancer. results: in the last years, mie was performed initial, in our clinic with extracorporeal preparation of the gastric conduit with reduced lung complications and hospital stay. we introduced the totally minimally invasive esophagectomy with laparoscopic-assisted feeding jejunostomy using a d high definition camera. operative times were: thoracic- min, abdominal- min and cervical- min with a total of min. the augmented d high definition image provided an excellent visual field, that allowed an accurate identification of dissection plans and extensive periesophageal and perigastric lymphadenectomy. the short-term outcomes of the totally minimally invasive esophagectomy procedure were very encouraging with early feeding on jejunostomy and the control of cervical anastomosis was usually performed in the th day postoperative and the patients were discharged in the th day postoperative without any symptomatology. at the first and third-month follow-up was not reported any major complications. the long-term oncological results are being evaluated. conclusions: the totally minimally invasive approach using advanced technology of endoscopic surgery allowed for these patients a simple postoperative evolution, no major complications, and a good recovery after an extensive surgery. the solid experience in open esophageal surgery of the upper gastrointestinal surgeons provides a fast learning curve of complex minimally invasive surgical procedures with reduced perioperative morbidity. long-term follow-up should confirm the results from the literature regarding the survival, which is expected to be for these patients at least equivalent with outcomes after open esophagectomy. introduction: esophageal fistulas, benign or malignant, represent a real challenge for the surgeons and gastroenterologists, regarding the treatment and the outcome. in these cases, endoscopic treatment is the first line approach, being less invasive and sometimes avoiding the need for surgery. this includes clips, stents, glue and even suture. material and method: we have analyzed esophageal fistulas in patients with benign or malignant pathology, diagnosed and treated in the first months of . the management of this complication included a self-expandable esophageal metallic stent. we have evaluated the diagnosis, the surgical intervention, the timing until the development of the leak, the localization and management of the fistula. results: were postoperative leaks and spontaneous esophageal fistulas. the localization was cervical in one case, thoracic in cases and abdominal in cases. for the postoperative fistulas, in patients the treatment included at least one surgical reintervention with lavage and drainage, beside the insertion of an esophageal metallic stent. in the other cases, endoscopic treatment and antibiotic therapy was enough. in cases, the stent migrated needing repositioning. days mortality was %, both patients from postoperative group. conclusions: esophageal fistulas represent a severe complication, usually in patients already immunocompromised. endoscopic management, including self expandable esophageal metallic stent, can be the main approach, by stopping the contamination and by permitting the early per oral feeding. disadvantages include the possibility of migration and the need of removal after - weeks. methods: five hundreds and one patients with esophageal cancer who underwent mie from to at our department were eligible. we considered the risk factors of complications of pneumonia, anastomotic leakage, and hoarseness after surgery, and the risk factors of difficulty of surgery. results: the risk factors of postoperative complications in univariate analysis were more than years old (odds ratio: . , p = . ), more than ii in asa-ps (odds: . , p \ . ), more than g of bleeding (odds: . , p = . ), more than min. of operation time (odds: . , p \ . ), and colon reconstruction (odds: . , p = . ). the one in multivatiate analysis was more than ii in asa-ps (odds: . , p = . ). the risk factors of much bleeding were colon reconstruction (odds: . , p \ . ), and more than of lymph node dissection (odds: . , p = . ). the risk factors of long operation time without cervical lymph node dissection were neo-adjuvant therapy (odds: . , p \ . ), more than of lymph node dissection (odds: . , p = . ), and colon reconstruction (odds: . , p \ . ). the ones with cervical lymph node dissection were more than pstage iii (odds: . , p \ . ) and more than of lymph node dissection (odds: . , p = . ). conclusions: considering those risk factors, we should perform perioperative management more carefully. method: sa -year-old man with a tobacco and alcoholic habit was suspended for years, under treatment for arterial hypertension, who consults for a logical dysphagia of months of evolution. he is diagnosed of stenosing esophageal distal third epidermoid carcinoma txn m . it is decided to place a prosthesis that is effective and subsequent neoadjuvant qt-rt, after weeks of its completion the surgery is performed. results: the surgery is performed in times, initially by laparoscopy. the esophageal hiatus and the greater curvature are dissected preserving the right gastroepiploic, and lymphadenectomy of the celiac trunk with pedicle section of the left gastric. gastric plasty is performed with a section of lesser curvature towards fundus. it is continued by thoracoscopy. a section of the azygos vein is performed, dissection of the esophageal middle and lower third and lymphadenectomy. gastric plasty is promoted, proximal esophagus section and latero-lateral intrathoracic gastro-oesophageal anastomosis. the anatomopathological study reports ypt and pn with / adenopathies, and disease-free surgical margins. he was discharged without complications on the th day and did not require re-entry. conclusions: ivor-lewis endoscopic surgery is safe and meets oncological criteria in selected patients with distal esophageal neoplasia and performed by an experienced esophagogastric unit. background: the rates of thoracoscopic esophagectomy performed in the prone and left lateral decubitus positions are similar in japan. we retrospectively reviewed short term outcomes of thoracoscopic esophagectomy for esophageal cancer performed in the left lateral decubitus position under artificial pneumothorax by co insufflation in a single institution. this study aimed to evaluate the feasibility of applying this procedure. methods: between july and december , patients with esophageal cancer underwent thoracoscopic esophagectomy in the left lateral decubitus position under artificial pneumothorax by co insufflation. the thoracic procedure is performed as follows:the lymph nodes around the right recurrent laryngeal nerve are dissected. on the cranial side, the lymph node dissection is advanced to the level of the inferior thyroid artery. then, the assistant rotates the trachea toward the ventral side, and the lymph nodes around the left recurrent laryngeal nerve are dissected. the middle and inferior mediastinal lymph nodes are dissected including supradiaphragmatic lymph nodes and the dorsal lymph nodes around the thoracic descending aorta. then, the esophagus is transected using an automatic suture device. finally, the tracheal bifurcation area lymph nodes are dissected. we retrospectively analyzed these patients. results: the completion rate of thoracoscopic esophagectomy was . %, and the procedure was converted to thoracotomy in five patients, due to hemorrhage,severe adhesion. the mean intrathoracic operative time, intrathoracic blood loss, and number of dissected mediastinal lymph nodes were . min, . ml, and . , respectively. postoperative complications included pneumonia ( . %), anastomotic leakage ( . %), and recurrent nerve paralysis ( . %). postoperative ( d) mortality was / ( . %) due to ards and nomi, respectively. conclusions: standardization of the procedure for thoracoscopic esophagectomy in the left lateral decubitus position under artificial pneumothorax by co insufflation, with a standardized clinical pathway for perioperative care led to favorable surgical outcomes. introduction: recently thoracoscopic surgery has become widespread even in chest procedure in thoracic esophageal cancer surgery. as an advantage of minimally invasive esophagectomy, it is possible to perform sophisticated procedures due to its magnified visual effects. on the other hand, short-term perioperative safety and oncological safety are still unclear. in cases where abnormal anatomy or comorbidity in the thoracic cavity is observed, it is thought that it is necessary to carry out thoracic surgery which ensures safety while keeping in mind the transition to transthoracic surgery. here, we report on esophageal resection of the thoracic esophageal cancer accompanied by a mm saccular aneurysm inside the aortic arch. patient: a -year-old man visited a nearby doctor with a chief complaint of discomfort during swallowing. upper gastrointestinal endoscopy examined middle cervical esophageal cancer and received referral to our hospital. ct revealed a mm saccular aneurysm inside the descending aorta in contact with the thoracic esophagus. preoperative diagnosis was middle thoracic esophageal cancer; -iic ct bn m stageia (uicc th). we performed thoracoscopic esophagectomy and lymph node dissection as curative surgery. the anterior surface of the aorta was exposed from the lower mediastinum and descended ascendingly, reaching the lower end of the saccular anus at the head level of the lower pulmonary vein. peeling off the esophagus dorsal side along the margin of the saccular sac and performing esophageal resection. conclusion: we reported thoracoscopic esophageal resection for thoracic esophageal cancer with chest descending aortic saccular aneurysm. thoracoscopic surgery, which can fully exploit close magnification effect, seemed to be useful for anatomically disqualified cases. introduction: anastomotic leakage from oesophagojejunal (oj) anastomosis after total gastrectomy is associated with a high morbidity and mortality rate. leakage rates reported vary between ?% and ?% but lack of consensus in management. in the past, it often required surgical intervention or radiologically abscess drainage that will keep patients fasted with external drain for a long duration. recently, variable endoscopic options-oesophageal stents, clips, fibrin glue and endoluminal vacuum therapy had been introduced with variable outcomes. here, we presented a case of oj anastomotic leak management with combination innovative endoluminal and radiologically technique to insert double pig-tailed catheter. aim: to introduce the feasibility of double pig-tailed catheter for drainage and management of oj anastomosis leak. a year old man presented with two months history of dysphagia. upper endoscopy (ogd) showed suspicious cardio-oesophageal lesion. histology biopsy confirmed with adenocarcinoma. ct-scan of thorax, abdomen and pelvic showed irregular thickening at cardiooesophageal junction with regional lymphadenopathy. no distant metastases. he underwent uneventful d total gastrectomy. on th post-operative day, patient had spike fever and newly developed atrial fibrillation. urgent ct-thorax, abdomen and pelvis with oral omnipaque. it showed lower mediastinal gas-containing fluid adjacent to oj anastomosis within the left retrocrural space suspicious for leak. ogd evaluation showed pin-hole oj leak. guidewire inserted via endoscopy into left retrocural space under radiologically guidance. double pig-tail fr cm subsequently inserted via seldinger approach over guide wire. the proximal end of pig-tail pushed into left retrocural space and distal end positioned into efferent jejunal limb with crocodile jaw through endoscope. diluted contrast injected and passed down to efferent limb with minimal leak. outcome: after double pig-tail insertion, patient started on clear feed on st day post-insertion. one week later, he was started on full feed. repeat upper endoscopy and stent removal done two weeks later. contrast injection showed small blind ended sinus tract from anastomosis toward left pleural space without obvious leak. conclusion: radio-endoscopic is a novel minimally invasive technique that allows insertion of double pig-tailed internal drainage to control oj anastomosis leak. it allows early enteral nutritional feeding and avoid external drainage. background: the number of gastric cancer (gc) survivors, especially long-term survivors, is increasing. how best to evaluate the diseasespecific survival (dss) of gc survivors over time is unclear. we aimed to assess changes in the conditional survival of patients with gc after curative intend gastrectomy and the evolution of the impact of well-known risk factors. methods: clinicopathological data from , patients who underwent curative intend resection for gc at four specialized centres (three in china and one in italy) and from the surveillance, epidemiology, and end results (seer) database were retrospectively analysed. changes in the patients' -year conditional disease-specific survival (cs ) were analysed. we used time-dependent cox regression to analyse which variables had long-term effects on dss and devised an accurate, dynamic dss predictive model based on the length of survival. results: the median follow-up time was months, and disease-specific death occurred in , cases ( . %). the dss of the patients after surgery was dynamic, and most of the disease-specific deaths occurred within the first years after surgery. based on -, -, -, -and -year survivorships, the cs of the population increased gradually from % to . %, . %, . %, . %, and . %, respectively. subgroup analysis showed that the cs of patients who had poor prognostic factors initially demonstrated the greatest increase in postoperative survival time (e.g., n b: . %- . %, ? . % vs. n : . %- . %, ? . %). time-dependent cox regression analysis showed the following predictor variables constantly affecting dss: age, the number of examined lymph nodes, t stage, n stage and site (p all \ . , years after gastrectomy). the influence of prognostic factors on dss and cs changed dramatically over time. based on data from several large global centres, we developed an effective model for predicting the dss of gc patients based on the length of survival time. this model can provide personalized long-term follow-up strategies for patients. methods: we retrospectively analyzed clinicopathological data for rgc patients who underwent radical gastrectomy from centers. the prognosis prediction performances of the ajcc th and ajcc th tnm staging systems and the trm staging system for rgc patients were evaluated. web-based prediction models based on independent prognostic factors were developed to predict the survival of the rgc patients. external validation was performed using a cohort of chinese patients. result: the mean number of retrieved lymph nodes was . , and in . % of patients, the number was = . the predictive abilities of the ajcc th and trm staging systems were no better than those of the ajcc th staging system (c-index: ajcc th vs. ajcc th vs. trm, . vs. . vs. . ; p [ . ). within each staging system, the survival of the two adjacent stages was not well discriminated (p [ . ). multivariate analysis showed that age, tumor size, t stage and n stage were independent prognostic factors for overall survival (os), disease-specific survival (dss) and disease-specific survival (dfs). based on the above variables, we developed web-based prediction models, the huang os model, the huang dss model and the huang dfs model, which were superior to the ajcc th staging system in their discriminatory ability (cindex), predictive homogeneity (likelihood ratio chi-square), predictive accuracy (aic, bic), and model stability (time-dependent roc curves). the stratified analysis showed that regardless of whether more or fewer than lymph nodes were retrieved, the predictive performances of the web-based prediction models were still better than those of the other three staging systems. a decision curve analysis showed that the huang model provided better net benefits than the other three staging systems. external validation showed predictable accuracies of . , . and . , respectively, in predicting os, dss and dfs. conclusion: the ajcc tnm staging system and the trm staging system did not enable good distinction among the rgc patients. we have developed and validated visual web-based prediction models that are superior to these staging systems. objective: to perform competing risk analysis and evaluate cancer-and noncancer-specific mortality in patients with gastric cancer after radical surgery. methods: a total of patients from our department (as training set) and a total of patients from the surveillance, epidemiology, and end results (seer) database (as validation set) were enrolled in the study. the cumulative incidence of cancer and noncancer-specific mortality was determined by univariate and multivariate competing risk analysis. results: the five-year cancer-and noncancer-specific cumulative incidence of death (cid) in the training set were . % and . %, respectively, which were significantly lower than that in the validation set ( . % and . %, respectively). multivariable analysis showed that age, tumor site, tumor size and ptnm stage were independent predictors of gastric cancer-specific mortality and overall survival, whereas age was an independent predictor of gastric noncancer-specific mortality. noncancer-specific cid surpassed cancer-specific cid for ptnm stage i patients after approximately years of surgery, but never for stage ii and iii patients. moreover, for stage i patients, the time point when noncancer-specific cid surpassed cancer-specific cid become earlier as age increasing, with only . years after surgery for patients more than years of age. conclusions: age is an independent predictor of gastric cancer-and noncancer specific mortality and overall survival for patients after radical surgery. for patients with stage i gastric cancer, noncancer-specific mortality is a significant competing event, with an increasing impact as age increases. aim: of the study was to analyse the possibility of function preserving gastrectomy based on the sentinel lymph node (sln) concept. methods: during last years in two clinics odessa national medical university we used mapping procedures in the patients with early gastric cancer. there were men and women, age to years, mean age . ± . years. blue dye was injected into quadrants of the submucosal layer surrounding the primary lesion using an endoscopic puncture needle in patients. blue lymphatic vessels and blue-stained lymph nodes can be identified by laparoscopy within min. of the blue dye injection. we used . % indocyanine green in patients, which we injected by intraoperative endoscopy. new technology indocyanine green (icg) fluorescent imaging was used for sln mapping in this patients. results: amany patients, in which we used blue dye for mapping sln, positive sln was in patients, negative-in patients. in all patients distal gastrectomy (dg) was performed with d lymphdissection. from patients with negative sln in patients metastasis in other lymph nodes were detected.among patients in whom we used icg fluorescent mapping positive sln were detected in patients. laparoscopic-assisted distal gastrectomy with d lymph node dissection was performed in these patients. in patients with negative sln partial wedge resection was performed in patients, segmental pylorus preserving gastrectomy was performed in patients. during follow-up period from to months no recurrences or metastasis were detected in these group of patients. qol in this group of patients was much better, than in patients with conventional distal gastrectomy. conclusions: icg fluorescent method is highly effective for detection of sln. in the patients with early gastric cancer function preserving gastrectomy based on sln navigation may be promising strategy to achieve better results. laparoscopic procedure taking advantage of robotic gastrectomy for gastric cancer to prevent pancreatic fistula gastrointestinal surgery and surgical oncology, ehime university, toon-city, japan backgrounds and aims: analysis of japanese national clinical database (ncd) showed that laparoscopic gastrectomy(lg) had rather increased pancreatic fistula (pf) compared with open gastrectomy. on the other hand, last year, multicenter collaborative research result of robotic gastric cancer surgery(rg)was shown that the complications including pf were significantly decreased as compared with lg. in this study, we have employed a new easy to use device in lg to minimize pf during suprapancreatic lymph nodes dissection requiring pancreatic retraction and compared with conventional lg and rg. materials and methods: internal organ retractor (aesculapÒ) to grasp the gastropancreatic fold and the suprapancreatic peritoneum to imitate davinci's forceps was guided with a thread outside the body. patients(jan. * nov. ) were divided into three groups as follows, group lg- (n = ), lg using the standard devices, group lg- (n = ), lg using organ retractor, group rg (n = ). amylase value in drain(d-amylase) and the volume in drainage, intraoperative bleeding, postoperative hospital stay, incidence of cd (] grade iii) were compared among three groups. results: data are indicated as lg- /lg- /rg(mean ± sd), respectively. on the day and third day after surgery, d-amylase were ± / ± / ± and ± / ± , ± (iu/l). d-amylase was significantly lower in lg- and rg group than in lg- the day after surgery. the operation time was significantly longer in rg, ± / ± / ± (min). bleeding volume and hospital stay did not differ among groups. pancreatic fistula (cd ] grade iii)was observed only in lg- group at (%) . discussion: pf(grade]cdiii), which may lead to mortality, occurred in lg- group. a significant elevation of d-amylase on the st postoperative day was prevented in lg- just like rg, which seemed to lead to prevent pf afterwards. the multijoint forceps is known to be an advantage of rg but it cannot be reproduced by lg using a linear forceps. however, another advantage such as vertical grasping and lifting of the gastropancreatic fold at rest could be mimicked by lg using this device, which seemed to enable a safe lymph node dissection and lead to reduce the pancreatic damage. conclusion: this inexpensive and easy to use method taking the advantage of rg seems to reduce surgeon's fatigue and tissue damage(pf). the study presents comparison of perioperative outcome between different surgical approaches for gastric adenocarcinoma (ac). methods: retrospective cohort of patients that underwent gastrectomy for (ac) at rambam hospital during - . patients data was collected based on demographic characteristics, bmi, operating room time (ort), number of lymph nodes (ln), length of hospitalization (loh), and perioperative complications. results: study population included patients after total gastrectomies, of them robotic and partial gastrectomies, of them robotic. age, gender and bmi were similar between patients who underwent any type of procedures. median length of hospitalization (loh) for robotic total gastrectomy was . days and it was significantly shorter than both laparoscopic total gastrectomy (ltg) . days (p = . ) and open total gastrectomy (otg) . days (p \ . ). similar significant differences in (loh) between the groups were observed among patients who underwent partial gastrectomy, but the comparison between robotic and laparoscopic procedures was limited due to small numbers of (lpg). median(ort) was significantly longer among robotic gastrectomies compared to open, the difference was min in total gastrectomy group and min in partial gastrectomy group (p \ . for both differences), but the difference in(ort) between laparoscopic and robotic procedures were smaller and non-significant. the number of dissected (ln) was similar between the procedures in total gasrectomies. in partial gastrectomies, the number of dissected (ln) was even higher among both laparoscopic and robotic gastrectomies compared to open (p \ . ).) conclusions: robotic total and partial gastrectomies for gastric (ac) are associated with oncologically adequate lymphadenectomy and faster patient recovery, but longer ort. objectives: during esophagojejunostomy using a circular stapler after latg, placement of the anvil head via the transabdominal approach proved difficult. the authors report on a method modified for laparoscopy-assisted, esophagojejunostomy performed by placing the pretilted anvil head(orvil) via the transoral approach. methods: between january and november , esophagojejunostomy was performed using orvil in patients after latg. the anesthesiologist introduced the anvil while observing its passage through the pharynx. during the anastomosis, we kept the jejunum fixed in position with a silicone band lig-a-loops, thereby preventing the intestine from slipping off the shaft of the stapler. results: esophagojejunostomy using the orvil was achieved successfully in all patients. no other complications, such as hypopharyngeal perforation and/or esophageal mucosal injury, occurred during passage. the postoperative complications of anastomosis were leakage in two patients and stenosis in patients, in whom mild relief was achieved using a bougie. conclusions: esophagojejunostomy using the orvil is a simple and safe technique. gastrointestinal tract surgery, fukushima medical university, fukushima-shi, japan; surgery, ohara general hospital, fukushima-shi, japan background: juvenile polyposis of the stomach is a very rare disease, and its malignant potential has been reported previously and total gastrectomy has been recommended as a standard treatment. recently, the usefulness of laparoscopic surgery for this case has been reported, however this type of surgery is thought that maintaining the surgical space is difficult because of distended and thickening stomach. case presentation: eight years ago, a -year-old woman who had no family history of gastrointestinal polyposis had been diagnosed with gastric polyposis and polyp-related anemia and received twice endoscopic submucosal dissection to early gastric cancer in another hospital. she had received an annual upper gastrointestinal endoscopy and she had taken iron supplements for anemia caused from the occasional bleeding from the polyps. however, the number of the polyps had increased over time. because she had a loss of appetite, she admitted to our hospital. enhanced computed tomography showed gastric wall thickening and multiple gastric polyps without lymphadenopathy or distant metastasis. colonoscopy showed no specific findings. she was diagnosed as the juvenile polyposis of the stomach, and she received laparoscopic total gastrectomy with roux-en y esophagojejunostomy. in operative findings, although there were the excessive distention and congestion of the stomach, standard laparoscopic surgery could be performed. the resected specimen revealed multiple variously sized polyps throughout the stomach except for lesser curvature and fundus and the histopathological examination revealed that all polyps were hyperplastic polyps without containing cancer. she was discharged on postoperative day . we successfully performed laparoscopic surgery to treat a rare case of juvenile gastric polyposis. introduction: we report a novel technique for combined use of laparo and thoracoscopy for faradvanced adenocarcinoma of esophagogastric junction (aeg). case presentation: a 's years old man presented with far-advanced aeg. an esophagogastroduodenoscopy revealed a type lesion with the entire circumference around esophagogastric junction (egj). contrast radiography revealed a severe stenosis in the egj and wall irregularity from egj to cardia. computed tomography revealed a stenosis of egj, suspected invasion into the left side diaphragm and some lymph nodes metastases at the abdomen. we diagnosed siewert type ii aeg (ct an m , cstage iiia : japanese classification of gastric carcinoma ver. ). surgical technique :the patient was placed in the reverse-trendelenburg position with the left upper body lifted and legs spread, under general anesthesia. the tumor was huge, exposed from the serous membrane and invaded the left crus. first we performed from laparoscopic proximal gastrectomy using five ports. then, three ports were added in the th, th, and th intercostal spaces with the patient in the same body position, and performed thoracoscopic lower esophagectomy under artificial pneumothorax with intrathoracic pressure of - mmhg, which allows the ventilation of both lungs. the lower esophagus was resected under the thoracoscopic view to ensure an adequate margin. following this resection, intrathoracic esophagojejunostomy was performed by using the laparo-and thoracoscopic techniques. the operative time was min, and the blood loss was g. he was discharged on the th day after the operation without any postoperative morbidity. the histopathological diagnosis was pt bn am , p , pstage iv. after adjuvant chemotherapy with capecitabine and oxaliplatin, ramcilumab monotherapy is undertaken now. ct revealed solitary lung metastasis in months after the operation. conclusion: malta for locally advanced aeg invading the surroundings could be performed safely. introduction: despite being the pioneer in laparoscopic surgery, europe did not have similar surgical experience compared to east asia due to decreased exposure to gastric cancer. several studies on minimally invasive gastrectomy for gastric cancer have been conducted in europe. however, some of them did not analyse total gastrectomy as a distinct entity combining both distal and total gastrectomies; moreover, most of them do not provide data on full five-year follow up for each patient. baltic countries stand in between east and west in terms of gastric cancer incidence: incidence rate per , is . in united kingdom, . in lithuania and . in japan. this exposure to gastric cancer provides unique opportunity to investigate the role of laparoscopic gastrectomy. therefore, a case-control study was designed to evaluate laparoscopic (ltg) versus open total gastrectomy (otg), comparing short-term surgical and long-term oncologic outcomes. surgery, jeju national university, school of medicine, jeju, korea; surgery, chosun university, school of medicine, gwangju, korea objective: although mcv (mean corpuscular volume) levels are known to be associated with the prognosis of various diseases, few study investigated mcv as prognostic factor after gastric cancer surgery. the aim of this study is to address the prognostic value of mcv in gastric cancer who underwent curative gastric cancer surgery. methods: patients (june -december ) with stage i, ii, and iii cancer were consecutively included in this study. all patients underwent curative gastric cancer surgery including subtotal gastrectomy or total gastrectomy. overall survival (os), disease-free survival (dfs) and postoperative complications rate were compared between mcv [ group and = group. results: of all patients, the mean mcv was fl (normal range, to fl). the dfs was significantly higher in the high-mcv ([ ) than low-mcv group(= ) (p \ . ) group. there was no significant difference in postoperative complications when compared with clavien-dindo scale. the survival rate of the high mcv group was higher but there was no significant difference. conclusions: mcv may be a predictive factor after gastric cancer surgery. unlike previous studies, patients with low mcv group showed lower dfs. more research is needed on the significance of mcv in variety of disease. methods: and materials. for years we observed cases with gist of stomach and duodenum. seven patients were brought to clinic with the bleeding and two patients were brought to clinic with vomiting and compensate stenosis. in all circumstances we done the ct, mrt and endoscopic examinations of stomach and duodenum with biopsy . in two circumstances we performed endoscopic operation. in one circumstance we successfully take off the gist from the duodenum endoscopically. during the operation we use the endoscopic instruments. in another circumstances,after endoscopic excision the tumor appear the bleeding which was stopped by endoscopic local heamostasis, by putting clipps on the vessels. in circumstances the tumors were in stomach. in circumstances we performed laparoscopic wedge resection the tumors by staplers. in circumstances when the tumor was very big and situated in the fundus of stomach, we performed laparoscopic resection of the fundal part of stomach by using laparoscopic staplers and 'liga sure' sealing. in circumstance we took off the tumor by putting laparoscopic trocars inside the stomach for instruments and for visualization tumor. after excision the tumor and took it of the stomach we sutured the holes in the stomach. we have no mortality after laparoscopic operation. there were no malignisation in all circumstances. we have cases morbidity. in circumstance the bleeding from the stomach that was stopped endoscopically. in circumstance there was wound infection. the aim of the study to decrease the morbidity in the patients with perforated ulcers of the stomach and duodenum. we observed patients with perforated ulcers of stomach and duodenum. women were , men were . average age about years. patients had perforation ulcer of stomach and duodenum. patients had perforations with bleeding. all patients were divided in two groups. the first groups patient operated laporocopically, in the second group patients operated traditionally. results: there were no mortality in the group that operated laparoscopically. in the group that were operated traditionally one patient died after rebleeding. the average stay in hospital in the group that were operated laporoscopically about days. in the groups with traditional operations, were about days. the morbidity in the first group were in cases. pneumonia in cases, suppuration of the troacar points were in cases. in the second group pneumonia were in cases, suppuration of the operation wound were in cases, subdiaphragmatic abscess was in cases. conclusion: laporoscopic operation in during treatment decrease the mortality, morbidity and hospital staying in the patients the perforated ulcer of stomach and duodenum . of the patients of the third group ( . %) were operated about ulcer rebleeding in the hospital, and ( . %)-about the profuse bleeding ulcer. noonr patient had recurrent bleeding. the average treatment time for patients in group was . ± . days. conclusions: the development of hemorrhagic shock in patients with peptic ulcer bleeding significantly increases the risk of rebleeding and mortality. the application of endoscopic hemostasis allows to reduce the risk of rebleeding and mortality compared with conservative antiulcer therapy. surgical treatment can achieve reliable hemostasis, but accompanied by higher mortality and longer duration of hospital treatment. tan tock seng hospital is second largest hospital in singapore. it is affiliated to two medical schools in singapore and it is a training hospital for both undergraduates and postgraduates. minimally invasive surgery for both benign and malignant diseases of upper gastrointestinal tract becomes more and more popular nowadays. in our department, all the residents have to view the step by step instructional videos of mininally invasive surgeries before they can assist in the cases or perform on their own under the supervision of consultant surgeons. the viewing of the instructional videos help them with better understanding of the procedures. the viewing of videos help them with the importance of steps, standardization of steps. with the help of instructional video, they can not only assist better in the surgery but also reduce the learning curve when they start doing the procedure themselves after the graduation from the residency programme. this is the step by step instructional video of laparoscopic repair of perforated duodena ulcer for surgeons-in-training rotated to our department. in general duplication cysts are rare developmental congenital disorders of the gi tract. three morphological criteria should be met in order to confirm the pathological diagnosis: . they should be attached to the stomach's wall and should be the continuation of it, . at least one of the muscle layers of the stomach's wall should be included and .it should have normal gastric mucosa. the treatment is either enucleation or partial gastrectomy. aim: present our minimally invasive approach to a rare prepyloric submucosal cystic lesion causing gastric outlet obstruction. case report: a -year-old female with vomiting, weight loss and in bad general condition was diagnosed after a full work-up (blood tests, endoscopies, eus, ct and mri) with a submucosal cystic tumor. this cyst first was thought to be a duplication cyst. since the patient was young, our intention was to offer the least invasive surgical technique in order to spare gastrectomy and billroth anastomosis. results: the procedure was completed laparoscopically with enucleation of the cyst through a gastrotomy on the anterior wall of the stomach. after the enucleation of the cyst the gastric mucosa was sutured back and then the gastrotomy was closed with continuous sutures. the result of the pathological report confirmed a rare case of a heterotopic pancreatic cystic lesion. the postoperative course of the patient was uneventful and was discharged with instruction for her diet the th postoperative day. the patient months post-operative has no symptoms. conclusion: in such benign conditions and especially in young patients, gastrectomies could be avoided if possible and give their place to less invasive approaches in order to reduce lifelong risks and morbidity. trangastric enucleation of the cyst although a demanding approach is safe and could be considered as a 'gentler' technique with reduced morbidity. background: pancreatoduodenectomy is considered to be very invasive for early superficial duodenal tumors (sdts), which have a lower risk of lymph node metastasis. partial duodenal resection with endoscopic submucosal dissection for sdts is an attractive technique but it is associated with a high risk of complications. the full-thickness resection of the duodenum wall including laparoscopic and endoscopic cooperative surgery has risk of spreading tumor cells and digestive juices into the abdominal cavity. we have developed novel technique for sdts to decrease the risk of exposure to abdominal cavity of tumor cells and digestive juices, called nonexposed duodenum laparoscopic and endoscopic cooperative surgery (neo-dlecs). aim: the aim of this study is to evaluate the feasibility and safety of neo-dlecs for sdts. surgical procedure: the attachment of the transverse mesocolon was freed from the head of the pancreas and retroperitoneal tissues under laparoscopy. the duodenum and the head of the pancreas were mobilized from the retroperitoneum using the kocher maneuver. a standard esd was performed for the sdt using endoscope. the serosa of the esd ulcer bed was reinforced using the laparoscopic hand-sewn suturing technique in the seromuscular layer around the resected area. after completing the procedure, the endoscope was inserted and passed over the resected area to confirm that there was no stenosis or leakage. methods: ten consecutive patients with sdt underwent neo-dlecs in our institute between march and march . the clinicopathological features of the patients and surgical outcomes were prospectively collected and retrospectively analyzed. results: pathological diagnosis was adenocarcinoma for six patients, adenoma for three patients, and neuroendocrine tumor grade for one patient. the median tumor size was ( - ) mm. the median operative time was . ( - ) min. the median blood loss was ( - ) g. there were no conversions to open surgery in this series. intraoperative perforation was found in two cases during the esd procedure. however, all perforations were closed and reinforced using hand-sewn sutures. no postoperative complications were above grade in the clavien-dindo classification system. conclusions: neo-dlecs is safe and feasible and can be an option for surgical sdt resection. aims: wilkie's syndrome is caused by the entrapment of the rd part of the duodenum between the aorta and the superior mesenteric artery (sma). surgery is indicated for chronic cases and failure of conservative management, being reported a laparoscopic duodenojejunostomy as a minimally invasive option. methods: all cases treated by laparoscopic duodenojejunostomy in our centre because of chronic wilkie's syndrome were recorded. results: females and male underwent a laparoscopic duodenojejunostomy, with a mean age of years (range - ). all patients presented abdominal pain, and weight loss was identified in most of them. a reduced aortomesenteric angle measured by ct scan was the key for the diagnosis (mean angle . degrees, range - ). conventional laparoscopic approach was performed in two patients, the other two patients underwent a sils port approach. mean time of surgery was . min (range - ) and length of stay was days (range - ). after a mean follow-up of . months (range - ), patients improved their symptoms. conclusions: surgery is the mainstay in complicated or refractory cases of sma. laparoscopic duodenojejunostomy has the advantages of the laparoscopic approach (including rapid recovery time, reduced post-operative pain and shorter hospital stay) and it is feasible, safe and effective. in mexico in , gastric cancer represented the rd cause of death; it may manifest in a variety of histologic, anatomic, and genetic patterns, which influences the surgical approach. until now gastrectomy with curative intent is the only treatment that offers potential cure in gastric cancer. in recent years, laparoscopy has emerged as an important modality in the surgical management. in multiple trials no significant difference in recurrence, long-term survival and disease-free survival was observed when compared to the standard open gastrectomy. we present the case of a year old man. with a smoking history of pack years, suspended years earlier. he presented unspecific upper gastrointestinal symptoms; an upper endoscopy was made observing a suspicious depressed lesion of cm located in the greater curvature between the body and the antrum, the biopsy resulted in a poorly diferentiated signet-ring cell carcinoma of the stomach. an endoscopic ultrasound and a thoracoabdominal ct scan showed no evidence of enlarged adenopaties or metastatic disease. initially a diagnostic laparoscopy was made, there was no evidence of carcinomatosis, nor free intraperitoneal fluid; so the greater omentum was dissected towards the splenic and hepatic flexure; a d lymph node dissection was performed, and a subtotal gastrectomy with reconstruction of roux en y was done; intraoperative endoscopy was done to identify the lesion, so adequate margins could be obtained. the patient had a good post operative evolution and was discharged home at th day tolerating oral intake. minimally invasive techniques have proved equivalency of oncologic results when compared to the conventional approach; these techniques are becoming the preferred approach in the treatment of well-selected patients with gastric cancer and have a role in definitive staging, curative resection, and lymphadenectomy. appropriate selection of patients and optimal technical approach are paramount for good outcomes. most data of laparoscopic gastrectomy come from eastern countries, where the prevalence is higher; however western experience is growing along with evolution and development in surgical instruments and new technology. wilkie syndrome is a rare cause of high intestinal obstruction, resulting from the compression of the duodenum between the abdominal aorta and the superior mesenteric artery. the main symptoms are nausea and vomiting, weight loss, early satiety, abdominal distension and epigastric pain. historically, the barium study and arteriography were the diagnostic tests used; more recently the angiotac has shown greater sensitivity. the diagnostic criteria are: dilated duodenum, duodenal compression by the superior mesenteric artery and aortomesenteric angle less than degrees. patients with an acute condition usually respond to conservative treatment (decompression, correction of hydroelectrolyte alterations, nutritional support…). however, those with chronic symptoms usually require surgery preferably with laparoscopic approaches of duodenojejunostomy or the strong's procedure. the strong procedure mobilizes the duodenum by dividing the ligament of treitz. once the duodenal-jejunal junction is mobilized, the duodenum is positioned to the right of the superior mesenteric artery and it is preferred because it provides less morbidity due of the maintaining of the integrity of the gastrointestinal tract, but it has a failure rate of %. gastrojejunostomy allows gastric decompression, but does not relieve duodenal compression, so digestive symptoms may persist, leading to the appearance of a blind loop syndrome or recurrent peptic ulcers. on the other hand, the duodenojejunostomy, which according to some series may be the procedure of choice, may obtain a success rate higher than %. we advocate to initiate the surgical approach with the strong procedure and if it fails to perform to a duodenojejunostomy. during this procedure, gastro-esophageal reflux was evaluated and assigned to severe, moderate and slight category. if the reflux was observed slightly up to cervical esophagus, the case was assigned to moderate category. if the reflux was observed intensely up to cervical esophagus, the position was returned to head high position for the safety and the case was assigned to severe category. the anti-reflux surgery was considered in the moderate and severe categories. results: we have performed laparoscopic nissen procedure in cases. the outcome was assessed by reflux test performed on - postoperative day, and the results showed the reflux was disappeared in every cases. median follow-up period of this study was months ( - months) . in cases ( . %) ppi was restarted before months after the anti-reflux surgery. in cases ( . %) ppi was restarted after the anti-reflux surgery during the whole follow-up period of this study. the bmi of the patients had no relationship to the needed restart of ppi. to evaluate the degree of esophagitis objectively before and after the anti-reflux surgery we designed 'the esophagitis score'. in this scoring method, a number from - was assigned according to the degree of esophagitis along with the la classification. the results of the study have shown that the reflux esophagitis was improved obviously after the anti-reflux surgery even in the ppi restarted group (p \ . ). discussion: to extract the gerd patients who really need anti-reflux surgery is important. reflux test is feasible because of its convenience and visual effects for the patients. the results of the laparoscopic nissen fundoplication were good. background: laparoscopic paraesophageal hernia repair with fundoplication has become more and more popular nowadays due to less morbdity and mortality with shorter length of hospital stay. discussion: tan tock seng hospital is the second largest hospital in singapore. it is affiliated to two medical schools in singapore and it is a training hospital for both undergraduates and postgraduates. in our department, all the residents have to view the step by step instructional videos of mininally invasive surgeries before they can assist in the cases or perform on their own under the supervision of consultant surgeons. the viewing of the instructional videos help them understand the procedures better. the videos can also help them recognize the important steps and standardized safe approach. with the help of instructional video, they can not only assist better in the surgery but also reduce the learning curve when they start performing the procedure themselves during their training period. this is the step by step instructional video of laparoscopic paraesophageal hernia repair with fundoplication for surgeons-in-training who are posted to our department. conclusion: the step by step instructional video on laparoscopic paraesophageal hernia repair with fundoplication can help the surgeons in training reduce their learning curve and improve their surgical skills so that they can perform the procedure safely. the human immunodeficiency virus (hiv) is a neurotropic virus. there have been reports of patients with hiv who have esophageal motility problems, sometimes associated with opportunistic infections. the absence of contractility is defined as a major motility disorder according to the chicago v . classification, which is characterized by normal esophagogastric union relaxation and % peristalsis failure. we present the case of a -year-old male patient with a history of acquired immunodeficiency on treatment with efavirenz, emtricitabine and tenofovir. he presented progressive dysphagia, gastroesophageal reflux and pyrosis of months of evolution. physical examination showed no alterations. upper endoscopy is done reporting a normal esophagus and diffuse chronic gastritis. the esophagogram reported inadequate esophageal motility with contrast stasis and a delayed emptying. the esophageal manometry reported an upper esophageal sphincter with high resting pressure. the middle and distal esophagus showed absence of peristalsis with a pan-esophageal pressurization pattern. the lower esophageal sphincter presented normal resting pressure and borderline relaxation ( %). the integrated relaxation pressure was less than mmhg. the diagnostic impression was absence of contractility (chicago classification v . ).medical management was initiated with inhibitors of the proton pump, isosorbide dinitrate and injections of botulinum toxin without success. it was decided to program the patient for a heller myotomy with toupet fundoplication. a trans-surgical endoscopy revealed a complete myotomy with no leakage or obstruction. the patient went home on the second postoperative day tolerating a solid diet.heller myotomy by laparoscopy with partial fundoplication is safe in the treatment of patients with hiv and esophageal motility disorders, reporting a mortality of . %. the effect of endoscopic treatments prior to surgery is controversy aims: epiphrenic diverticulum represents an infrequent entity and it is usually associated with esophageal motility disorders, such as achalasia, distal esophageal spasm, nutcracker esophagus or hypertensive lower esophageal sphincter. nowadays, epiphrenic diverticulectomy, esophageal myotomy and partial fundoplication is the gold standard technique; although it supposes a challenging procedure and it may provoke lots of complications. approach for diverticulectomy usually depends on the distance from the upper border of the diverticulum's neck to gastroesophageal junction, considering that thoracoscopy should be carried out when this distance is more than cm. methods: we presentthecase of a -year-old male patient, with a bodymass index of anda medical history of diabetes, smoking and alcoholism. his symptoms were mainly regurgitation and dysphagia. upper endoscopy showed esophageal dilatation and the presence of a diverticulum with its neck cm over the gastroesophageal junction. ct scan confirmed these findings and manometry showed achalasia. in the video we can see how we perform a laparoscopic diverticulectomy with esophageal myotomy and dor fundoplication. results: patient was discharged home on the second postoperative day with no complication. after more than two years of follow-up, he has not suffered regurgitation, heartburn, dysphagia or chest pain. conclusions: we present a case with an epiphrenic diverticulum secondary to achalasia in which we performed a laparoscopic diverticulectomy, esophageal myotomy and dor fundoplication. some authors suggest that the correction of the underlying motility disorder is the key in the management of these patients and they do not recommend concomitant diverticulectomy for all cases. however, we consider that the complete procedure, adding diverticulectomy, supposes the gold standard and it is feasible to perform for teams which are skilled in esophageal and gastric laparoscopic surgery, despite its high morbidity rates. purpose: a laparoscopic wedge resection for a gastric submucosal tumor closed to gastroesophageal junction or involved to gastroesophageal junction is technically challenging and more aggressive compared with tumors in other sites of the stomach. a gastroesophageal reflux disease would be more prevalent after laparoscopic wedge resection of a gastric submucosal tumor in gastroesophageal junction because of the destruction to low esophageal sphincter. we hypothesized that a prophylactic anti-reflux surgery after this surgery would be less prevalent the gastroesophageal reflux disease (gerd) and more improve the quality of life of the patients. the aim of this study is to analyze our experience with prophylactic anti-reflux surgery after laparoscopic wedge resection for a gastric submucosal tumor of gastroesophageal junction materials and methods: we retrospectively collected data from patients who diagnosed with submucosal tumor of near the gastroesophageal junction underwent laparoscopic wedge resection between january and december . the patients were divided into groups according to operation with prophylactic anti-reflux surgery (group a) and without one (group b). results: there were no difference in the frequency of the preoperative gerd symptoms between the groups, whereas postoperative gerd symptoms and postoperative use of acid suppressive medications were more frequent in the group b (p = . , p = . ). however, there were no differences in the follow-up endoscopic findings in terms of reflux esophagitis and hill's grade between the groups. in group a, postoperative mean low esophageal sphincter (les) pressure was . ± . . the les pressure was dropped until mmhg in the only one patient. however, there was no reflux symptom in this patient. conclusions: the prophylactic anti-reflux surgery after laparoscopic gastric wedge resection of gastroesophageal junction is an effective method of prevent gastroesophageal reflux symptoms. background: the most critical obstacle is a pancreatic leakage(pl). the most cause of pl might be an activation of pancreatic juice by the mixing of pancreatic juice and intestinal fluid because of the anastomosis technique, the difference of anastomosis between pancreatic duct and caliber of jejunum, and the topple of jejunal mucosa. aim: in this study, we devised the new anastomotic method of pancreato-jejunostomy, so called ' pancreatic stent sliding guide' (pssg) method using a pancreatic duct stent. we would like to demonstrate its method and results. (operative procedure) the cases of hybrid laparoscopic pancreatico-duodenectomies (pd) were done by shuriken-shaped umbilicoplasty with pssg. the pancreatic duct stent, which is fit for a diameter of pancreatic duct, is used for the direct puncture without any incineration. the aims of direct puncture are both the avoidance of the enlargement of anastomotic opening and disturbance of blood flow. the contralateral of anastomotic opening is also punctured and the stent is pulled out of the jejunum. the - pds with the needles at both ends is used for anastomotic thread. firstly, the eversion anastomosis of posterior wall is done by sliding the needle on the stent. and then the anastomosis of anterior wall is done by the same way. the stent of contralateral side is cut and the hole is closed. materials and methods: the cased of pancreato-jejunostomy by pssg method were done by february . the average of patient's age was y.o. the disease of patients were pancreatic cancer (n = ), bile duct cancer (n = ), and papilla vater cancer(n = ). the pancreatic leakage by the isgpf were grade : ,a: ,b: ,c: respectively. in the same periods, we underwent the more ten cases of open pd by pssg method. the pl were only one case of grade a and there were none of clinical pl. conclusion: our new device of pancreato-jejunostomy by pssg might be very effective for the decrease of pl from the view point of machanisms of pl even for laparoscopic pd. year old, male patient presented with upper abdominal discomfort and pain, without nausea, vomiting or weight loss. an sub mucosal lesion was found on endoscopy examination in first part of the duodenum. endoscopic ultrasound has showed . cm sub mucosal lesion in first part of duodenum (anterior wall and close to pylorus). cytology examination from the lesion has showed neuroendocrine tumor. computed tomography of abdomen and chest were normal. his blood laboratory examinations were within normal limits. patient underwent da vinci robotic partial gastrectomy with intra corporeal billroth ii gastrojejunostomy. total operating time (ort) was min. three day after operation patient started regular diet and was discharged home on day fife. final pathology report confirmed diagnosis of carcinoid tumor with ki less than %. surg endosc ( ) :s -s p -robotics & new techniques-education integrated education for colorectal disease-a digital solution for a digital age united kingdom aims: surgical plume has problem in poor visibility of the operative field, inclusion of harmful chemical substances, and biological risk. it is desirable that plume should be removed appropriately to minimize these risks. we assessed whether these problems can be solved by using commercialized evacuator semi-quantification of residual chemicals in the abdominal cavity: was performed using industrial smoke tester by aspirating the intra-abdominal plume onto filter papers and digitizing the stains. ( ) detection of dna in the exhausted gas from the evacuator: the hepa filter, which was interposed at the inlet or outlet of the evacuator, was analyzed using pcr method to detect any dna derived from porcine tissues. results: ( ) laparoscopic visualization: judgement score were . vs. . for ec and . vs. . for us (evacuator: on vs. off, both p \ . ), indicating the visualization was significantly better in the use of the evacuator on both devices general surgery, royo villanova hospital general surgery minimally invasive surgery centre, jesús usón minimally invasive surgery centre methods: i report my experience at the american university of beirut medical center for laparoscopic adrenalectomy cases, left adrenalectomy and cases for right adrenalectomy. three out of the series are large adrenal of cm, and all of these were completed laparoscopically.the video will show the steps of this procedure.a large rt. adrenal mass measuring cm, wt. gm was removed laparoscopically using trocar techniques. the lateral position facilitated the exposure and ease of dissection. the mass was removed by extending one of the trocar site with muscle splitting using endocatch mm. results: patient was discharged home days after surgery. the operative time was hour. pathology revealed carcinoma with no involvement of the capsule or vascular invasion patients (male: n = ; female: n = ) underwent minimally invasive adrenalectomy (tp: n = ; rp: n = ) at our institute. mean patient age was . years ( - years). besides comparing operative (intraoperative blood loss, previous abdominal surgeries, conversion rate, operative time, tumor size) and perioperative factors (time of hospitalization, time to oral intake, histology, postoperative complications) in each group, perioperative outcomes of a learning curve (lc)-the first procedures in both groups-was also analyzed in terms of tumor size, significantly larger lesions were removed with tp (tp: . ± . mm vs rp: . ± . mm; p = . ). the number of asa (american society of anesthesiologists) ii patients were significantly higher in the tp group while there were significantly more asa iii patients in the rp group conversions ) showed no significant difference. the analysis of lc showed a significant difference in previous abdominal surgeries min vs rp: . ± . min; p = . ] all favoring the tp approach. conclusion: both methods proved to be feasible and safe in terms of minimally invasive adrenalectomy. based on our own experience the tp approach resulted in improved operative time and conversion rates to demonstrate the safety and efficacy of the laparoscopic approach in the treatment of large splenomegaly. currently, this approach is recognized as the one of choice in benign splenic pathology, being controversial in the face of a massive splenomegaly or neoplastic pathology. material and method: clinical case: a -year-old man followed in the dept. of internal medicine for a hepatosplenomegaly of probable lymphoproliferative origin. additional explorations of interest are provided. result: intervention: complete laparoscopic approach, right lateral partial decubitus, massive splenomegaly, ? cm, splenuncle of - cm that is resected, section of short vessels, dissection of the splenic hilum, vascular section with endogias, splenectomy with full extraction in a pocket through reduced laparotomy in the left flank for anatomopathological study the aim of this video is to demonstrate the safety and efficacy of the laparoscopic approach in the treatment of large splenomegaly. currently, this approach is recognized as the one of choice in benign splenic pathology, being controversial in the case of a massive splenomegaly or neoplastic pathology it can transform into adenocarcinoma. patients and methods: between and we performed laparoscopic nissen fundoplication (lars) in cases of gerd. in cases of gerd patients be was proved by endoscopy and histological examination. the demeester score was higher ( . versus . , p \ . ), and bile re?ux was measured more frequently among the be patients on the other hand during the . years long endoscopic follow up early barrett carcinoma developed in patients, . months after the lars. both patients underwent a limited surgical resection of the distal esophagus and esophagogastric junction, regional lymphadenectomy, and reconstruction by interposition of an isoperistaltic jejunal segment. there were no complication. histological examination was shown pt n stage disease in both cases. oncological follow up was months long ( . y) and both patients are still disease free. conclusions: although lars can affect regression in a part of be patients, progression to adenenocarcinoma can also occur. endoscopic surveillance is important in the case of be to recognize early cancer, to perform limited surgical resection with low morbidity and long overall-and disease free survival gastric cancer development a nomogram for predicting the conditional probability of survival after d lymphadenectomy for gastric cancer this study aimed to devise a nomogram to predict the conditional probability of cancer-specific survival (cpcs) in gastric cancer (gc) patients after gastrectomy with d lymphadenectomy. methods: clinicopathological data for , gc patients who underwent d lymphadenectomy in a large-volume eastern institution (the training cohort) were analysed. cancer-specific survival (css) was predicted using cox regression models. a conditional survival nomogram was constructed to predict cpcs at and years post-gastrectomy. two external validations were performed using a cohort of , chinese patients and a cohort of italian patients. results: in the training cohort, the -year cpcs was . % immediately post-gastrectomy and increased to . %, . %, . % and . % at , , and years post-gastrectomy, respectively. multivariate cox regression analyses showed that age; tumour site, size and invasion depth; numbers of examined and metastatic lymph nodes; and surgical margins were independent prognostic factors of cancer-specific survival (all p \ . ) and formed the nomogram predictor variables. internal validation showed that the conditional nomogram exhibited good discrimination ability at and years post-gastrectomy (concordance index, . and . , respectively) gastric cancer does non-compliance in lymph node dissection affect oncological efficacy in gastric cancer patients undergoing radical gastrectomy? univariate and multivariate analyses revealed that non-compliance was an independent risk factor for os. logistic regression analysis demonstrated that the extent of gastrectomy, primary tumour site, history of intraperitoneal surgery, bmi and open gastrectomy were independent preoperative predictive factors for non-compliance. cox analysis demonstrated that age, pt, pn, and the extent of gastrectomy independently affected os in patients with noncomplaint lymphadenectomy. however, os was significantly better in the compliant group than in the non-compliant group regardless of the recommendation for chemotherapy. stratified analysis demonstrated that os was significantly better in chemotherapy patients than in patients without chemotherapy and stage ii patients (pt n /n m and pt n m ) in whom chemotherapy was not recommended. conclusion: non-compliance is an independent risk factor after radical gastrectomy for gc we prospectively collected and retrospectively analysed the medical records of patients with proximal gc who underwent lspsd. the data were split / , with one group used for model development and the other for validation testing. results: of the patients enrolled in this study, ( . %) required laparoscopic haemostasis treatment. a multivariate analysis determined the following preoperative adverse risk factors for the model group: gender, preoperative n stage, and terminal branches of the splenic artery (spa), and we developed a scoring system based on these findings. each of these factors contributed point to the risk score. the intraoperative laparoscopy hemostasis rates were . , . , . , and . % for the low-, intermediate-, high-, and extremely high-risk categories, respectively. there were statistically significant differences among groups (p \ . ). with the increase in risk, both blood loss volume (blv) and operative time (min) of lspsd increased significantly (p \ . ).the area under the receiver operating characteristic curve for the score of intraoperative laparoscopic haemostasis was . . the observed and predicted incidence rates for intraoperative laparoscopic haemostasis were parallel in the validation set. conclusions: this simple we compared the survival of src patients with that of tubular adenocarcinoma patients according to bmi. results: the -year survival of src was significantly worse than that of wmd (p \ . ) but superior to that of pd (p \ . ). bmi-stratified analysis showed that in the high-bmi group, the prognosis of src was similar to that of wmd (p [ . ) and better than that of pd (p \ . ). in normal-bmi patients, src had a worse prognosis than wmd (p \ . ) but a more favorable prognosis than pd (p \ . ). src among low-bmi patients displayed much poorer survival than did both wmd (p \ . ) and pd (p = . ). multivariate analysis indicated that the risk of death was lowest for src patients with a high bmi and highest for src patients with a low bmi baseline characteristics were compared in a -patient rspshl cohort and a -patient lspshl cohort. one-to-four propensity score matching was performed to determine between-group differences. result: in total, patients were matched, including patients who underwent rspshl and who underwent lspshl. no significant differences in baseline characteristics were observed between these groups after matching. significant differences in total operative time, estimated blood loss (ebl), splenic hilar blood loss (shbl), splenic hilar dissection time (shdt), and splenic trunk dissection time were detected between these groups (all p \ . ). furthermore, no significant differences were evident between rspshl and lspshl in the overall noncompliance rate of lymph node (ln) dissection ( the highest body temperature within week after operation was used to establish diagnostic thresholds for high body temperature and low body temperature, which was obtained by x-tile software. the study used cox regression to analyze the influence of high body temperature on -year dfs. results: a total of patients were included in the analysis. the diagnostic threshold for high body temperature was defined as °c; patients with a high postoperative body temperature were allocated to the high temperature group (htg), while another patients were allocated to the low temperature group (ltg) cao department of gastric surgery, fujian medical university union hospital, fuzhou, china background: laparoscopic surgery for remnant gastric cancer third step: baring of the right side of the esophagus. fourth step: exposure of left gastroepiploic vessels and lns dissection in the splenic hilar area. fifth step: baring of the left side of the esophagus. the above procedure was performed for rgc patients with stage ct - an /? disease. results: there was no conversion to open surgery. mean operation time was . ± . min, mean blood loss was . ± . ml, and mean times to first flatus p -upper gi-gastric cancer a novel prognosis prediction model after gastrectomy for remnant gastric cancer: development and validation using international multicenter databases fuzhou, china; department of gastrointestinal surgery the model calibration was accurate in predicting -year survival. dca showed that the model has a greater benefit. the results were also confirmed by bootstrap internal validation. in external validation, c-statistics and dca showed good prognostic performance in patient datasets from participating institutions. moreover, we verified reliability of the model in an analysis of patients with different eln counts p -upper gi-gastric cancer a novel abdominal negative pressure lavage-drainage system for anastomotic leakage after r resection for gastric cancer while risk of gastric cancer for ppi users was higher than non-ppi users when duration between - year, = year, = year and = year. the risk of gastric cancer when duration = year(rr = . )and duration = year(rr = . )are higher than risk of gastric cancer when duration between - year (rr = . ). according to location subgroups meta-analysis,risk of non-cardiac gastric cancer for ppi users higher than non-ppi users conclusion: based on a systematic review with meta-analysis, we found the correlation between long-term use of ppi and the risk of gastric cancer and long-term use of ppi may increase the risk of non-cardiac gastric cancer when duration = year p -upper gi-gastric cancer age-adjusted charlson comorbidity index (acci) is a significant factor for predicting survival results: there were patients included in the analysis. the high-acci and low-acci groups had significant differences in preoperative abdominal surgery history, asa grade, tumor size, tumor stage, histologic type, age and comorbidity (all p \ . ). the incidence of postoperative complications was . % in the high-acci group and was significantly higher than that in the low-acci group (p = . ). the overall survival rate (os) and cancer-specific survival (css) rate in the low-acci group were both higher than those in the high-acci group (p \ . ). univariate and multivariate analyses showed that the acci was an independent risk factor for os and css (p \ . ). furthermore, a combination of the tnm staging system and acci showed a trend toward higher prognostic value and higher auc for os and css than the tnm staging system alone (p \ . ). conclusions: the acci was an we aimed to investigate the clinicopathological features and prognosis of patients with mgc and the impact of postoperative adjuvant chemotherapy on long-term survival. methods: the clinical and pathological data of patients diagnosed with gastric adenocarcinoma and undergoing radical gastrectomy from stratified analysis showed that, in advanced gastric cancer (agc), the -year os rates of mgc without adjuvant chemotherapy and sgc without adjuvant chemotherapy were . % and . %, respectively, with a statistically significant difference (p = . ). the -year os rates of advanced mgc after adjuvant chemotherapy and of advanced sgc after adjuvant chemotherapy were . % and . %, respectively, and the difference was not statistically significant (p = . ). the -year os rate of advanced mgc after adjuvant chemotherapy was significantly higher than that of patients without adjuvant chemotherapy ( . % vs. . %, p = . ). conclusions: mgc is a poor prognostic factor after radical gastrectomy for gastric cancer background: whether the tumor-node-metastasis (tnm) staging system is suitable for patients with node-negative gc is still controversial. the modified staging system established by rpa showed good prognostic performance in a variety of cancers. the application of rpa has not been reported in the prognostic prediction of gc. methods: node-negative gc patients who underwent radical resection at fujian medical university union hospital (n = ) and sun yat-sen university cancer center (n = ) with an at least -year follow-up information were selected as the training set. rpa was used to develop a modified staging system. patients from the surveillance, epidemiology, and end results databases (n = ) were selected as the external validation set. results: the -year overall survival (os) rates of patients with th ajcc-tnm stage ia-iiia in the training set were ia %, ib %, iia %, iib % and iiia %. multivariate analysis (mva) showed that larger tumor size, older age, and deeper depth of invasion were independent risk factors for os in patients with node-negative gc (all p \ . ). patients were reclassified into rpa i, rpa ii, rpa iii, and rpa iv stage based on rpa, the -year os rates were %, %, %, and %, respectively, with significantly difference (p \ . ). two-step mva showed that the rpa staging system was an independent predictor for os (p \ . ) were retrospectively collected. patients were classified into two groups according to bmi of \ kg/m ( patients; high bmi group) and = kg/ m ( patients; low bmi group). for these patients, clinicopathological variables were analyzed using propensity score matching to mitigate the selection bias: sex, age, asa physical states, clinical stage, laparoscopy-assisted total gastrectomy (latg) or totally laparoscopic total gastrectomy (tltg), d lymph node dissection, combined resection of other organs, method of anastomosis, jejunal pouch reconstruction. the surgical results and postoperative outcomes were compared and examined between the two groups. results: a total of patients were matched for the analysis. contrary to our expectations, there were no differences in the surgical results about operative time and estimated blood loss (low bmi . ± . min, high bmi . ± . min; p = . , low bmi . ± . g, high bmi . ± . g; p = . , respectively). furthermore, there was no significant difference in postoperative outcome of complication (clavian-dindo [ iiia) and the length of postoperative hospital stays (low bmi cases, high bmi cases baiocchi general surgery, university of brescia-spedali civili, brescia, italy background and aim: recently indocyanine green (icg) was introduced in clinical practice as a fluorescent tracer. the use of icg for sentinel lymph node (ln) mapping was investigated in lots of fields such as breast methods: we conduced a single center prospective trial. we included patients with gastric cancer candidate to surgery. icg was injected intraoperative or the day before surgery, via submucosal or subserosal. total or subtotal gastrectomy was performed open, laparoscopic or video-assisted access. during gastric cancer standard lymphadenectomy we studied lymphatic flow and ln bright in vivo and ex vivo japan introduction: in japan, the number of elderly patients with gastric cancer has been increasing in correlation with the increase in average age of the population. the aim of this study is to assess the safety and efficacy of laparoscopic gastrectomy for cancer in elderly patients compared with the short-term outcome in the nonelderly. method: we reviewed patients who underwent laparoscopic gastrectomy (dital gastrectomy,proximal gastrectomy,total gastrectomy)between ).the incidence of advanced cancer(stageiior more)was higher in elderly patients there were no significant differences in the operating time,blood loss and postoperative hospital stay. there were no significant differences in the incidence of postoperative morbidity. conclusion: in elderly patients, there was a tendency of reduction surgery being selected according to individual condition, but there was no significant difference in the short-term outcome.hence,we conclude that laparoscopic gastrectomy is indicated even in elderly patients. p -upper gi-gastric cancer improved technique of vacuum therapy and carried out ltg . a patient factor (the gender, the age and bmi), an operation factor (operation time, the bleeding amount, lymph node dissection and conjurer), a coincidence related complication (clavien dindo classification, sutural insufficiency of grade more than , anastomotic stricture, anastomotic region bleeding and reflux esophagitis) and the post-operatively length of stay were considered . result: cs crowd met cases ( . %) and ls cluster ( . %) cases. years old of age medians ( - ), men and women were examples ( . %), examples ( . %) and bmi median . ( . - . ) by a patient factor, and a significant difference didn't admit by two groups for days, the post-operatively average length of stay was days by ls group by cs group. conclusion: operation time was short for a coincidence by linear stapler more than a coincidence by circular stapler in comparison of an esophagoenterostomy way in ltg on the day before the operation, we endoscopically clipped several points located cm proximal to the tumor edge to cover about half of the tumor. after lymph node dissection, we incised the stomach with an endoscopic linear stapling device,including the previously placed clips. reconstruction was performed in all patients who underwent billroth i or roux-en-y procedures. result: no complications were observed during pre-operative endoscopic clipping or intraoperatively p -upper gi-gastric cancer small intestinal tumors after laparoscopic surgery in our hospital small intestinal tumors are rarely observed, accounting for about - % (malignant cases: - %) of all gastrointestinal tumors. therefore, occasionally, their diagnoses can be difficult. however, recently, capsule and balloon endoscopes have been widely employed were examined regarding patient backgrounds, diagnostic methods, pathological findings, postoperative courses, and prognoses. results: the subjects consisted of males and females, with a mean age of years. their chief complaints were black stools the median distance from the treitz ligament or bauhin valve was cm ( - ) postoperative complications were abdominal abscess ( cases; . %) and surgical site infection (ssi), hemorrhage, and paralytic ileus ( case each; . %). pathological diagnoses were lymphoma metastatic small intestinal tumor ( cases; . %), and granuloma, lipoma, peutz-jeghers polyp, clear cell sarcoma, malignant mesothelioma, and ectopic pancreas most patients were diagnosed in bleeding, complicated by anemia and black stools. however, as most tumors were relatively close to the treitz ligament and bauhin valve, almost a half could be diagnosed with a small intestine endoscope before surgery patients were classified as popf and no-popf according to their grade b or c popf status. popf was diagnosed according to international study group of pancreatic fistula (isgpf) criteria or clinical findings. patient characteristics, intraoperative parameters, electrosurgical device type, pathological findings, and early postoperative outcomes were compared. electrosurgical devices were classified asthunderbeat (tb) or laparosonic coagulating shears (lcs) based on energy sources. results: eighteen patients developed grade b or c popf. among them, ( . %) and ( . %) were diagnosed with popf according to isgpf criteria and clinical findings ), operation time (p = . ) and electrosurgical device type (p = . ) were significant risk factors for popf following lag ) and tb device (or, . ; % ci ) were independent risk factors for popf following lag. conclusions: operation time and tb use significantly affect the risk of popf and should be considered in future clinical studies. p -upper gi-gastric cancer feasibility and nutritional benefits of double flap with no-knife stapler reconstruction after laparoscopic proximal gastrectomy for gastric cancer were analyzed. receiver operating characteristic curves were generated, and by calculating the areas under the curve(auc) and the c-index, the discriminative ability of crps during different periods were compared, including pre-crp, postoperative days , , and postoperative maximum crp (post-crp max ). a decision curve analysis was performed to evaluate the clinical utility. result: ultimately, patients were included this study and the median follow-up time was ( - ) months. for postoperative recurrence, the auc and c-index of pre-crp were . and . , respectively, significantly higher than the other crps, all p \ . . among = ''''''the = '''' post-crps = '''' post-crp = '''' sub = similar findings were observed for overall survival. conclusion: both pre-crp and post-crp max , cheap and easily obtained, are independent predictors of recurrence for gc. act significantly prolonged the rfs for stage ii/iii gc patients with high-prep p -upper gi-gastric cancer robot-assisted gastroduodenal surgery: a single center experience robot-assisted gastroduodenal surgery (ras) was introduced to overcome the technical limitations of conventional laparoscopy. it provides a d-amplified view to the surgeons and an increased ability to control the operative field by manipulating optics, as well as enhanced mobility and precision of instruments. the aim of the present study is to evaluate the main outcome of a single center experience in gastroduodenal robotic surgery. materials and methods: we report a case series of patients who underwent robot-assisted gastroduodenal surgery at sanchinarro university hospital between conclusions: robot-assisted gastroduodenal surgery is a safe and feasible technique in experienced centers with advanced robotic skills. in the literature, there are only few reports of robotic assisted gastroduodenal resection. further studies are necessary to better confirme our results. p -upper gi-gastric cancer atypical methods: retrospective review of ogd reports before and after the introduction of the new guidelines. inclusion criteria: all elective ogds. exclusion criteria: emergency ogds and elective therapeutic ogds. data recorded: patient demographics, endoscopist, indication, number of photos, anatomical site photographed, pathology identified and whether pathology photographed or not. results: ogds reviewed, before the guidelines (group ) and afterwards (group ). the most common indication was reflux ( %) in group and anaemia ( %) in group clinical utility of systematic pre treatment staging laparoscopic exploration methods: all locally advanced gastric adenocarcinoma managed in surgical oncological unit between st january and th november were prospectively enrolled in the study. in the absence of emergency surgery or preoperative contraindications, all patients with curative intent underwent either preoperative chemotherapy followed by surgical exploration in the intent of curative gastrectomy (g)or systematic pretreatment laparoscopic exploration (l) benkabbou surgical department the patient background (age, gender, bmi) and c-stage of the preoperative factor were matched using propensity score matching method, and the surgical results were compared and examined. results: thirty rg groups matched rag cases. the operation time (rag / lg) was significantly longer in the rag group as . ± . min / . ± . min (p \ . ). amount of blood loss was not significantly different each other; ml / ml (p = . ). pathologically t a case was involved in cases in rag and cases in lg. the extent of lymph node dissection (d ? / d ) was / cases in both groups conclusions: rag in our clinical experiences can be safely introduced and short-term results are comparable to those of lg. verification of superiority of robotic surgery including long-term results seems to influence the future of robotic surgery conclusions: totally laparoscopic gastrectomy is feasible method in terms of surgical outcomes. furthermore, totally laparoscopic total gastrectomy is not technically difficult in advanced gastric cancer such as early gastric cancer and safety method. key words: gastrectomy, reconstruction, laparoscopic surgery, stomach neoplasm aims: meckel's diverticulum (md) is one of the most common congenital anomalies of the small intestine caused by an obliteration defect of omphalomesenteric duct. the objective of this study was to review surgical treatment and clinical outcomes of md, and evaluate the safety and feasibility of minimal invasive surgery (mis) in md. methods: we performed a retrospective analysis of medical record for patients who underwent meckel's diverticulectomy at six hallym-university-affiliated hospitals between d), as well as the average of drainage stay. patients who underwent laparoscopic repair required significantly less parenteral analgesics than the open group.the mean postoperative stay was significantly shorter for laparoscopic group (mean, . d) than the open one.morbidity of medical and surgical complication was higher in open groups ( vs ). the most common complication in both groups was medical complication.more case of pneumonia was occurred in open groups compared to laparoscopic groups methods: a retrospective study using our prospective database was designed to analyse all the resected md in our centre. epidemiological data, clinical setting, diagnostic test and histological results were reported. results: md was resected in patients, males and females, with a mean age of . years ( . - . ). in cases, a laparoscopic approach was chosen. eighty-seven percent of the patients had a presurgical imaging test (ultrasounds, ct-scan or meckel's scan) background: perforated peptic ulcer (ppu) is a substantial health problem with significant postoperative morbidity up to % and mortality up to % worldwide. aims: this study aimed to estimate the sensitivity scoring systems for prognosis morbidity of patients operated for ppu with diffuse peritonitis. methods: a total of patients were underwent emergency repair for ppu with diffuse peritonitis in pirogov russian national research medical university's surgical clinics during - years. different scoring systems used to predict outcome in ppu patients were identified: boey score, peptic ulcer perforation (pulp) score, asa, mannheim peritonitis index (mpi), world society of emergency surgery sepsis severity score (wses score). to quantify the strength of the concatenation of prognostic score and morbidity we use odds ratio (or) with % ci ), respectively. pulp score and asa score have good prognostic value in relation to morbidity, but less than boey, mpi and wses sss. patients with pulp [ had or with % ci of p -upper gi-gastroduodenal diseases gastrostomy tube placed by laparoscopy as a new therapeutic option for continuous intestinal infusion treatment with levodopa/ carbidopa we present year outcomes of our initial consecutive patient cohort. methods: patients were identified in a prospectively maintained irb-approved database ( - ). post-operative eckardt scores and a -point validated system questionnaires were obtained via telephone interviews one patient required reoperation for failed myotomy. the mean eckardt score at years was . (± . ), with all fourteen patients having an eckardt score \ . all patients reported significant improvement in their quality of life. classic gerd symptoms (heartburn and regurgitation) were present in ( . %) patients. proton-pump inhibitors are being used by % of with patients with excellent symptom control. seven patients returned for a repeat egd (median . yrs) with patients having normal anatomy and having la grade a esophagitis ( patient on ppi). barrett's esophagus was not detected. conclusion: long-term results from our early experience with lhm are excellent and durable with only one patient requiring re-intervention in years until recently the esophagectomy was the only choice in treatment of patients with end-stage achalasia. developing of minimally invasive techniques such as a laparoscopic heller miotomy and peroral endoscopic myotomy (poem) allowed to use them as a treatment options. aim: to present an experience of treatment of patents with end-stage cardiac achalasia. materials and methods: since . till the laparoscopic heller myotomy was performed in , and esophagectomies were performed in patients with failed previously myotomy made in other clinics. gastric tube was used to replace the esophagus in patients underwent esophagectomy after skeletization of crura posteriorly to esophagus, two separated rectangular patches of parietene progrip mesh (covidien) measuring x . - cm were attached to the posterior surfaces of the crura. the patches were fixated themselves due to special hooks. than continious twodirections suture was placed through both crura along with the patches using self-gripping v-loc - suture (covidien). the same suture was used for construction of nissen fundoplication wrap . cm long. aditional anchoring stich through the wrap and esophageal wall was placed using ti-cron - suture (covidien). d laparoscopy was used while suturing using richard wolf epic system. results: all the procedures were performed successfully. there were no cases of bleeding from the suturing points either from the crura and the fundus wall. there were no crural dehiscence while suturing, even if the distance between crura was more than cm. the mean duration of suturing facilitated by d laparoscopy was min (range, - min) for crural repair, and min (range, - min) for fundoplication. there were no excessive postoperative pain in all the patients. there were no disphagia month postop in every patient. conclusions: . the new technique of posterior buttress of crural repair using small patches of parietene progrip mesh and v-loc suture showed feasibility and safety. . the use of d in such case most commonly manifested symptoms are cough, sore throat, hoarseness, dysphonia, globus and only % patients with lpr have typical gerd symptoms. also ppi therapy are less effective in patients with lpr in comparison with patients which have typical features of gerd. purpose: to compare the outcomes between surgical treatment and conservative therapy in patients with laryngopharyngeal reflux. materials and methods: for the period chesarev faculty surgery # , federal state autonomous educational institution of higher education i.m. sechen, moscow, russia p -upper gi-reflux-achalasia a case of a primary parahiatal hernia associated with a type i hiatal hernia emergency county hospital parahiatal hernia is a rare disease that occurs when an abdominal organ protrudes through an opening adjacent to an anatomically intact esophageal hiatus. the herniated organ is usually the stomach, although cases of omental and colonic herniation exist we report the case of a -year-old woman which accused epigastric pain, starting years prior, pseudo-angina, heartburn and bloating. based on imagistic findings the patient was diagnosed with a parahiatal hernia and an associated type i hiatal hernia. patient underwent surgery and a cm diameter defect in the diaphragm lateral to the left crus was discovered, through which - % of the stomach had herniated. the hiatal orifice was slightly enlarged but anatomically intact, with an associated small sliding hiatal hernia. we performed closure of the defect, hiatoplasty and a floppy-nissen fundoplication pneumatic dilation with mm balloon was performed under general anesthesia. radiological contrast control and endoscopy reevaluation revealed a perforation just above the squamo-columnar junction. a minimally invasive approach was decided. an fully covered esophageal stent was inserted. radiological control after days reveals left pleurisy and migration of the stent. the same day was performed an endoscopic repositioning of the stent with clip fixation. left pleural puncture was performed and clear fluid was extracted. the condition of the patient got worse and she was transferred on icu ( . ). we performed left pleurostomy and initial exploratory laparoscopy-no intraperitoneal lesions. due to difficult transhiatal access to the inferior mediastinum the surgery was converted to open-perisophageal mediastinal abscess was found, evacuated and drainage and jejunostomy were performed. after a week, the patient presented progressive altered condition, febrile syndrome. thoraco-abdominal ct-scan showed left pleural effusions. left pleurostomy was performed, with extraction of fetid fluid. continuous lavage was instituted. on st of august, the pleurostomy tube drained gastric content, and the clinical examination revealed signs of generalized peritonitis. laparotomy was performed with lavage, drainage and posterior decompression gastrostomy. results: postoperative evolution was favorable, with the suppression of pleural drainage in . and discharge in . with alimentation exclusive on jejunostomy. one month later, she had normal clinical and radiological examination evaluation of efficacy was performed with reflux symptom index (rsi) specific for extraesophageal symptoms, subjective satisfaction and occurrence of dysphagia and gas-bloat syndrome. a rsi score [ was considered as pathological. results: rsi significantly decreased after surgery ( and msa as compared with total fundoplication; , % of patients were satisfied with surgery: a comparison between techniques showed superiority of msa objective: to demonstrate the efficacy of hiatorraphy without the use of meshes in thegiant paraesophageal hiatus hernia, as well as the standardization of our technique, with thetechnical steps that we make successively. material and method: clinical cases: -year-old man,with symptomatic hiatal hernia with progressive intolerance and dysnea. egd: the stomach rotated in a giant hiatal hernia.gastroscopy not completed due to endoscope loop formation within giant hiatal hernia with gastric volvulation. ct: large hiatal hernia,combined volvulation (axial axial mesenteric organ), the stomach in a right subpulmonary situation. results: intervention: laparoscopic approach.hh of large paraesophageal size,double organoaxial-and-mesenteric volvular component,gastric walls very thickened and adhered to the mediastinum.reduction of all content and the sac,is adhered to the pleura, extended med-iastinal esophageal disection, up to vein pulmonary and get enough abdominal esophagus and rule out the presence of an short esophagus,posterior-anterior and left tutorized modified hiatorraphy with stitches in ''u'' with non-absorbable suture on teflon reinforcement patches.nissen fixed to both pillars, intramediastinal drainage.egd at the st day with esophageal stenosis due to inflamation of the nissen, resolved with medical treatment. dischage at th day.asymptomatic and without radiological recurrence after months of follow-up. conclusions: in giant and paraesophageal hiatus hernias, modified primary hiatorraphy together with mediastinal esophageal dissection extended can be an effective and safe alternative, and can be advised as a technical gesture prior to a collis nissen and-or placement of a hiatal-hiatoplasty mesh united states of america aim/background: prescribed opioids for pain control have been implicated as major contributors to addiction through their illicit use. efforts to reduce opioid prescriptions and measure their impact on outcomes are novel. we analyzed how patient outcomes are affected with reduced opioid prescriptions following laparoscopic foregut surgery narcr: %), length of hospital stay (narcs: . days vs. narcr: . days), -day readmission rates (narcs: % vs. narcr: %) and perioperative complication rates. additionally, no significant qol outcome differences between the groups were reported at one month postoperatively. conclusion: our study supports reducing opioid prescriptions as a strategy to counter illicit drug use and addiction patients who underwent paraesophageal hernia repair at a tertiary referral center were analyzed retrospectively. demographic data, asa classification, characteristics of peh, onset of symptom, dysphagia severity score, characteristics of fundoplication (partial vs. total; laparotomy vs. laparoscopy; emergency vs. elective) and surgical outcome (length of stay, complication and -day mortality) were recorded and reviewed. results: patients were included; % were female (mean age of . years old and mean body mass index of . ). mean onset of symptom was . weeks after peh repair, dysphagia severity scores were changed . from . . conclusion: in our series, the dysphagia severity scores reduced after surgery upper gi surgery, the catholic university of korea mary's hospital, incheon city, korea p -upper gi-gastric cancer general surgery biopsy from the mass has showed poorly differentiated signet ring cell adenocarcinoma. chest computed tomography revealed mm thoracic aortic aneurism. abdominal computed tomography showed mm infra renal aortic aneurism and no evidence of metastatic disease general surgery year old, female patient presented with upper abdominal pain, weight loss ( kg during last three month), without nausea or vomiting biopsy was done and pathology result showed intestinal type, her -negative adenocarcinoma of the stomach. chest and abdominal computed tomography (ct) were normal. endoscopic ultrasound (eus) revealed cm lesion with invasion to the muscularis propria (mp) she was treated by neo adjuvant chemotherapy ( cycles carboplatine ? fu). patient underwent laparoscopic partial gastrectomy with modified d lymphadenectomy and billroth ii gastrojejunostomy. total operating time (ort) was min. three day after operation patient started regular diet and was discharged home on day fife. final pathology result confirmed intestinal type, modified differentiated adenocarcinoma of the stomach economou st surgical department general, visceral and transplant surgery, section minimally invasive surgery, heidelberg university hospital, heidelberg, germany; department of surgery, iuliu hatieganu university, cluj-napoca, romania; general and visceral surgery, klinikum mittelbaden, baden-baden, germany surgery, toyonaka municipal hospital, toyonaka city, osaka, japan; gastroenterological surgery, osaka university, osaka, japan; next generation endoscopic intervention, osaka university, osaka, japan aims: uncomplicated healing of anastomoses in colorectal surgery is the basis for early adjuvant oncology therapy. the basis for proper healing is good blood flow. we use by robotic surgery foor control the firefly by intuitive. since january , icg has used for blood flow in laparoscopic bowel surgery for the d-light system of storz. method: use of icg wants to accurately determine the resection line for free colon operations based on good blood circulation. we use icg pulse in two batches and color detection using d light from storz to verify blood flow. the first dose is given after the skeletalisation of the intestines intraabdominally and the second after the colic anastomosis to verify its vitality. results: in the period under review we performed laparoscopic operations on the free colon, % of the operations were elective. we had . % leakage across the set, however, in the subset of elective operations, we had only a leak of . %. conclusion: in an unselected set of colorectal operations, leakage was . %, but only . for elective operations. in our group there was a clear effect of using icg in elective laparoscopic resections with an intracorporal anastomosis, the effect was not shown in others, probably due to leakage were factors other than blood flow. objective: right hemicoloctomy (rhce) is the first choice in treating the right colon cancer. complete mesocolic excision with extended lymph node dissection at the roots of superior mesenteric artery (sma) branches enables removal of all lymphatic tissue and prevents local recurrence. previously variability of sma branches was demonstrated. the aim of presented study was to compare the distribution of sma branches in two ethnically different cohorts methods: preoperativect scans with vascular d reconstruction were assessed in patients ( - years) from russia and patients ( - years) from turkey with right colon cancer operated in - . the distribution of ileocolic artery (ica), right colic artery (rca) and middle colic artery (mca) was investigated. results: ica and mca could be found on ct scans in all patients, whereas rca had significantly different distribution between patient cohorts: it was visible in ( %) of turkish patients and only in ( %) of russian patients (p = . ). conclusion: these results suggest that there might be ethnical differences in sma branches distribution. in turkish patients all named sma branches ate visible on ct scans in %, whereas in russian patients only in %. the majority of patients from russia don't have rca. ica and mca could be found in all patients regardless ethnicity. knowing the variant of sma branching before the operation can help plan extended lymph node dissection. the national training programme in laparoscopic colorectal surgery (s-micras-lapserb) in serbia was set up to introduce standardized and structured training in laparoscopic colorectal surgery. method: an assessment based structured training programme (lapserb) started in . series of hands on supervised workshops were conducted for four different hospitals using the structured training by single trainer. this study aims at retrospective analysis of prospectively collected data for patients undergoing colorectal resections. we look at short-term clinical and pathological outcome of patients within laparoscopic colorectal resections performed in national training program. results: during the period november until november , laparoscopic colorectal resection was performed in ( male and female) patients. mean age of patients was . ( - ). the most common indication was colorectal cancer ( patients, . %), ( . %) patients were operated due to the colorectal polyps not suitable for endoscopic resection and ( . %) was operated due to ibd. there were ( . %) right colonic, ( . %) left colonic /tme and ( . %) other resections. average number of lymph node harvested in patients with colorectal carcinoma was . . there were / ( . %) r resections mean duration of hospital stay was . days ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . postoperative complications were encountered in / patients ( . %). overall, mortality rate was . % ( / ). conclusions: this study demonstrates successful and safe adoption of laparoscopic technique for colorectal resections. short term clinical and pathological outcomes are compared to published data and shows wider adoption at the national level. standardization of operative technique and structured training remains the key in success. introduction: femal adnexal tumor of probable wolffian origin (fatwo) was first described in . it is a tumor of mesonephiris wolffian duct origin. fatwo is rare tumor which is usualle benign. in the literature has been reported cases and only cases of recurrent disease. next rare tumor in pelvic localisation is sex cord-gonadal stromal tumor of sertoli cells. methods: we present case report of women who presented metastatic fatwo with duplicity of sertoli tumor. results: -year old women underwent years ago exstirpation of tumor in the left broad ligament. histologically there was rare benign fatwo. this year was indicated adnexectomy at gynecology department. during the operation was done bilateral adnexectomy and discovered tumor of anterior wall on upper rectum. microscopic examination showed sertoli tumor on the left ovary. afterward we completed next examinations. colonoscopy without any abnormality. on ct scan was tumor cm without contact to rectum wall, without distant metastasis. the same was described on rectal ultrasonography-normal wall of rectum, tumor probably from uterus. at diagnostic laparoscopy was tumor mass cm, with necrosis arising from anterior wall of the rectum. next small metastasis on pelvic peritoneum. we performed debulking of this big tumor and metastasectomy, there was no infiltration to muscularis propria of the rectum. patient did not have any postoperativ complications. microscopic examination of the rectal tumor and small peritoneal metastasis showed metastatic fatwo. after weeks she underwent laparoscopic second look operation. there were small metastasis on pelvis peritoneum. we removed two biggest metastasis and the rest was destroyed wit j plazma. microscopic examination showed in this metastasis sertoli tumor. conclusion: our patient has metastatic fatwo and sertoli tumor. fatwo is so rare, that in the literaure is not enough information for observation or adjuvant therapy. in one case was described imatinib mesylae (gleevec) therapy with good results. surgeons must be ready to meet new diagnosis. bochdalek hernia is a type of congenital diaphragmatic hernia. in most cases, it is diagnosed during the neonatal period. we present a case of laparoscopically treated congenital bochdalek hernia that led to jejunal strangulation in an adult . case: an fifty eight year old obese(bmi = . ) female admitted for gradually worsening right flank pain, vomiting and respiratory distress for one day. there was no trauma history to chest or abdomen. the past medical history were old cva, well controlled hypertension and dm. she was hemodynamically stable. her right flank was very tender. there was no abdominal distension. initial cbc tests showed leukocytosis ( , /ul) , but electrolytes were normal. chest pa revealed right side diaphragmatic hernia. there was poorly enhanced, herniated small bowel in the right hemithorax on chest ct scan. the patient was taken for emergency operation. on laparoscopy, the normal liver was displaced leftward because of herniated bowel. there was incarcerated jejunum and omentum which could not be reduced. so we widened a cm sized posterolateral diaphragmatic defect first, and then we could reduce the strangulated jejunum( cm in length) and omentum. there was no hernial sac. the defect was closed with -o prolene. finally, the strangulated jejunum was resected and anastomosed extracorporeally. the hospital progress of the patient was not eventful. on post-operative day , the patient was allowed soft diet. the patient was discharged on post-operative day without any complication. conclusion: congenital diaphragmatic hernia is an uncommon condition in adults, but you should keep in mind the diaphragmatic hernia as a cause of intestinal obstruction and respiratory distress in an adult. prompt surgical intervention is required to a favorable outcome. laparoscopic repair of bochdalek hernia is a good management option. aims: intestinal obstruction is one of the most frequent abdominal conditions in the emergency department (ed). up to % of patients having undergone a laparotomy will have an episode throughout their lives, of which % up to % will respond to conservative management. the laparoscopic approach is widely accepted and supported by the studies published up todate. it is recommended in patients with suspected single band, who have less than one previous laparotomy and less than h of clinical evolution. our objective is to validate in our experience that these premises are the appropriate ones in the election of candidates for a minimally invasive approach. methods: we present a series of cases admitted with symptoms compatible with adhesive intestinal obstruction in the ed of a third level hospital during months. all patients underwent abdominal ct to rule out the possible causes of obstruction. emergency surgery was indicated because of failure of a conservative medical treatment or for the findings of the complementary tests. results: a initial laparoscopic approach was performed in the patients, with a conversion rate of % of the cases (resection and anastomosis was required in patients, due to loop suffering or intestinal tumor not seen in the ct). among the patients who required laparotomy, % had more han h of clinical evolution before de surgery and % had free fluid in the tc. as surgical complications: intestinal perforations were produced secondary to the manipulation. there was recurrences of obstruction in the following months. conclusion: the laparoscopic approach is feasible in selected cases and experienced hands. acording to our results it is recommended to perform it in only in patients with less than h evolution and with a single band image in the ct without free fluid. the intestine should be explored avoiding the manipulation of the most extensive loops to prevent complications and keep in mind the possible conversion to laparotomy in case of complications. aim: the aim of the study was to evaluate whether physiologic and operative severity score for the enumeration of mortality and morbidity (possum) is useful to predict the risk of complications in patients older than years. methods: we performed a retrospective study of patients older than years old diagnosed with acute abdomen who were admitted to the department of general, minimally invasive and elderly surgery in olsztyn between may and october . results: the most common disagnosis was ileus. the mortality rate in surgery department was %.after relocation to the intensive care unit, the overall mortality rate was . %. the patients who died a short time after surgery had mortality rates greater than % and morbidity rates greater than % according to possum. conclusions: this study shows that possum seems to be a valuable scale to predict the risk of death after surgery in older patients. patients with higher mortality and morbidity scores should be very carefully selected for surgery. aims: diaphragmatic hernia in adulthood is rare. the most common causes are blunt and penetrating trauma. we present an intraoperative video of the laparoscopic repair of an adult onset, non-traumatic, diaphragmatic hernia in a patient with splenomegaly. method: a year old woman was referred to upper gastrointestinal surgery with epigastric burning and pain in the left side of her chest, radiating to the left shoulder, for one year. there was no recent or distant history of trauma. she has a past medical history of treated hepatitis c, cirrhotic liver disease, splenomegaly, thrombocytopenia and iron deficiency anaemia. gastroscopy was interpreted as a fundal diverticulum. ct abdomen/pelvis with intravenous (iv) contrast showed this to be a left diaphragmatic defect with herniated stomach causing a volvulus, which lay immediately above an enlarged spleen. a ct three years prior to this showed no diaphragmatic hernia. the patient had some symptomatic relief with a proton pump inhibitor and oral antacids, however due to her persistent symptoms surgery was undertaken. the patient had laparoscopic repair of the diaphragmatic hernia. ports were as follows: mm umbilical, mm left upper quadrant, mm right upper quadrant, mm left iliac fossa. a left posterior diaphragmatic defect was found, just above the enlarged spleen, containing the incarcerated fundus of the stomach. the hernia was reduced by gradual dissection of the sac. a cm nonabsorbable polypropylene mesh (proceed) was used to cover the defect a cm margin. this was tacked in place with protack. a single french robinson drain was left in situ. results: the procedure was uncomplicated. oral diet was introduced on post-operative day and the drain was removed and patient discharged on day . there were no post-operative complications. conclusions: the video shows an effective dissection of a left sided diaphragmatic hernia and mesh repair, overcoming multiple technical challenges secondary to splenomegaly and portal hypertension. aims: creating laparoscopic anastomosis is a challenging surgical skill with high clinical relevance. to assure efficient training and enhanced learning curves, constructive and objective feedback is essential. currently there is no appropriate instrument to assess the surgical performance while creating laparoscopic anastomosis. the aim of this study is to develop and validate the anastomosis-objective structured assessment of technical skill (a-osats) score. methods: to obtain an international expert consensus for a procedure specific checklist (psc) for laparoscopic anastomosis, a modified delphi survey with an integrated analytic hierarchy process is currently being performed. each a-osats sub step is assigned a specific weight to determine its importance to the final outcome of the anastomosis. to validate the a-osats score, a laparoscopic side-to-side small bowl anastomosis with a linear stapler and hand-sewn closure of the enterotomy was chosen and is performed by surgeons with varying degrees of laparoscopic experience on a live porcine model. all performances are recorded and rated twice using the a-osats by two blinded experts. results: the final a-osats score includes a weighted psc developed by the modified delphi survey and the already validated global rating scale of previously published osats scores. four key steps (bowel placement, creation of enterotomies, stapling, closure of enterotomy) and sub steps, as well as their definitions, were established during the delphi survey. to validate the a-osats, surgeons ( experts, intermediates, novices) have participated in the study so far. preliminary results showed significant differences between all three levels of laparoscopic experience (novices: . ± . ; intermediates: . ± . , experts: . ± . ; p \ . ) for the overall a-osats score as well as the psc itself (novices: . ± . , intermediates: . ± . , experts: . ± . ; p = . ). conclusions: the a-osats is a weighted score that objectively assesses surgical skill during the creation of laparoscopic anastomosis. preliminary results confirm construct validity of the proposed score. furthermore, by offering the possibility to differentiate single aspects during the procedure, the a-osats allows focused feedback to enhance one's performance. minor changes in weights are expected after the last round of the delphi survey. interand intrarater reliability will be assessed after final inclusion of all participants.aims: to apply augmented reality technology from three-dimensional colon models as preoperative planning method in colorectal surgery. method: from three-dimensional anatomical models of the colon we have developed holograms of augmented reality. the models were obtained from ct images (siemens somatom perspective Ò) with abdominal image cuts with mm thick. the recovery of the images was in dicom format and the processing to achieve the three-dimensional reconstruction was performed with the programs osirixÒ and horosÒ, which made a complete segmentation of the colon surface, and a modification of the image density. in this way models d were obtained of the isolated colon, and in relationship with the bone structure. the application colon d ar was designed (increased hyper experience-visualizer with slam technology) creating a hologram of augmented reality to scale : from each three dimensional model to make a projection of it on the abdomen of the patient by modifying the position in height of the reconstruction, using the bone pelvis as anatomic reference point to calibrate the placement of the hologram. results: in the preliminary phase (from october to december ) holograms of augmented reality were developed in patients with colorectal cancer (right colon, left colon, transverse colon and rectum) to complement the radiological reconstruction with the virtual model. in the application phase (from january ) the holograms developed are going to be applied as a method to improve preoperative study. conclusions: three dimensional reconstruction of the tumor in the preoperative plan of colorrectal surgery combined with hyperreality technology allows to develop models of augmented reality in order to improve colon anatomy knowledge and to plan the surgical technique.aims: laparoscopic adrenalectomy has become the standard of care for most adrenal masses. we report a case of laparoscopic adrenalectomy for left adrenal adenoma. methods: we present the case of a -year-old caucasian female patient with an asymptomatic, left-sided adenoma, that was incidentally detected during abdominal ultrasound. no headaches, palpitations, tachycardia, tremor, dizziness or vomiting were reported. pre-operative blood tests confirmed that the tumor was a non-secreting one and a ct-scan revealed a . . cm left adrenal mass. laparoscopic surgical excision was proposed. the patient was placed in semilateral right-sided decubitus position. four trocars ( epigastric- mm & subcostals- mm & mm) were used, without the use of a liver retractor. the adrenal vessels were clipped not only with the standard laparoscopic clips, but also with the hem-o-lok ligation system. results: the operation lasted for h with minimal blood loss. the patient's post-operative course was uneventful and she was finally discharged four days post-operatively. histology report ensured that it was adenoma of the adrenal cortex. aims: since the first laparoscopic adrenalectomy in (gagner), the laparoscopic lateral transabdominal approach has proved to be the one of choice. it provides an easy anatomical orientation, overall the technique is similar to other traditional laparoscopic procedures. on the other hand, the posterior retroperitoneoscopic adrenalectomy (pra), described in (waltz), has proven to be a safe technique and effective for the surgical management of several adrenal pathologies. the advantages include direct access to the adrenal gland, without the need for visceral mobilization or lysis of adhesions from previous abdominal operations and the ability to perform a bilateral adrenalectomy without repositioning the patient. currently there is controversy about which is the approach of choice, having to take into account the learning curve necessary for the retroperitoneal approach and the reduced number of patients with adrenal pathology subsidiary of surgical management. the objetive is to demonstrate the safety and efficacy of the standardized laparoscopic approach of the left adrenal gland with trocars for selected cases. methods: clinical case: -year-old man, resistant hypertension despite concurrent use of three antihypertensive agents, with biochemical and radiological diagnosis of left adrenal adenoma with primary hyperaldosteronism. demonstrative video of the technical steps in a standardized way that we propose for laparoscopic left adrenalectomy only using trocars. results: full laparoscopic surgical approach in right lateral decubitus position: trocars-lateral transabdominal approach. steps: . laparoscopic liberation of the splenic flexure of the colon for the colo-spleen-pancreato-gastric en block mobilization until identification of the left pillar, . dissection of the medial border of the gland, identification of left renal and diaphragmatic vein, as well as the adrenal vein which is dissected and clipped, . dissection of the lateral edge of the adrenal gland, . lower pole dissection of the gland completing the resection with ligasureÒ. the patient presented a successful postoperative recovery, being discharged h after the intervention. asymptomatic, the patient does not need antihypertensive drugs at year follow-up. conclusion(s): the standardization of the procedure allows reducing the number of trocars, maintaining the safety and effectiveness of the minimally invasive approach. aims: cortical-sparing adrenalectomy is a suitable treatment for hereditary and sporadic bilateral pheochromocytoma, in cases of low risk of malignancy, to reduce the possibility of adrenal insufficiency assuming the chance of local recurrence. the aim of the study is to analyze the functional results of partial adrenalectomy by retroperitoneal endoscopic approach in singleadrenal patients or patients requiring bilateral adrenalectomy. methods: prospective study between january and october including pheochromocytoma patients diagnosed with low risk of malignant mutations. all patients agreed to be included in the study. experienced endocrine surgeons who have been trained in minimally invasive endocrine surgery performed the procedure using the same surgical technique. demographic variables and clinical characteristics were collected, subsequently carrying out the descriptive analysis of the data. results: a total of eight patients were registered, five associated with men type syndrome and three in the context of vhl syndrome. retroperitoneoscopic resection was performed without laparoscopic or open conversion and no postoperative complications; the average hospital stay was . days. preservation of the functional cortex without corticosteroids was achieved in ( . %) of out cases with a follow-up of . ± months. today, these seven patients have a preserved adrenal function without hormone replacement. conclusions: cortical-sparing adrenalectomy by the retroperitoneal endoscopic approach, in expert hands, is safe and feasible for the treatment of hereditary and sporadic pheochromocytoma in a context of low malignancy, making it possible to avoid the need for corticoid replacement in most cases. biomedical sciences, university of west attica, athens, greece partial adrenalectomy has been suggested for patients benign adrenal tumors especially in the case of hereditary syndromes, like multiple endocrine neoplasia type , von hippel-lindau disease and neurofibromatosis type i. aims: this systematic review aimed to investigate the role of partial adrenalectomy in the treatment of hereditary pheochromocytoma. methods: electronic databases were searched with the search terms 'men ii', 'von hippel lindau', 'neurofibromatosis', 'laparoscopic partial adrenalectomy', 'robotic assisted partial adrenalectomy' for the time period up to and including december . full publications, including clinical trials randomized or not, retrospective studies, case series, case reports that provided relevant data met inclusion criteria results: thirty five possibly relevant studies were identified. abstracts were reviewed and fourteen articles were excluded as they were review articles or articles presenting data on open partial adrenalectomy. twenty one studies, that met inclusion criteria were retrieved in full text and included in the systematic review. eight studies presented data on partial adrenalectomy in patients with von hippel lindau including two case series with median follow up ranging from to . years and six case reports. thirteen studies presented data on partial adrenalectomy in patients with men ii, including two case series and eleven case reports. recurrence rate was estimated at about % for pheochromocytoma. overall steroid dependence rate was estimated at %. conclusion: minimally invasive partial adrenalectomy is a therapeutic option especially in patients with heritable pheochromocytoma, given that tumors are often bilateral, tumors are commonly benign and severe morbidity and mortality may be associated with life-long steroid replacement therapy such as the possibly lethal addisonian crisis . however, data are limited, follow up is not standardized and not appropriately reported and rcts are difficult to be done due to the rarity of the disease. a multinational registry on the short term and long term outcomes of partial adrenalectomy in hereditary pheochromocytoma would be a significant source of knowledge. results: patients were operated on after an average of months with complaints. in both groups, the leading symptoms were severe dysphagia and severe regurgitation. no intraoperative complication was detected. in the transoral group, one patient had to be reoperated on for bleeding, another patient developed pneumonia in the transcervical group. the average duration of the surgeries ( . vs. min, p \ , ), the time to oral feeding ( . vs. . days, p \ , ) and the mean hospital stay ( . vs. . days, p \ , ) were significantly shorter in the transoral group than the transcervical group. patients were completely symptomless postoperatively. after transcervical treatment, complaints were developed in cases (moderate dysphagia and hoarseness). after transoral surgery, recurrent symptoms were observed in patients, had to be reoperated transcervically due to severe regurgitation. conclusion: transoral stapler diverticulostomy is a fast procedure and offers short hospital stay especially in comorbid, aged patients and intermedium diverticulum size. in the long term, some of the patients may require reintervention due to persistent regurgitation. the transcervical approach has higher perioperative morbidity, which can be performed in patients with less than cm or large diverticulum size. aims: complex hiatal hernias, either implicating large hiatal defects or concerning cases of recurrence, often need apart from the primary closure of the hiatal gap, the re-enforcement of the crura with the use of meshes. our aim is to demonstrate the surgical technique for the on-lay placement of the absorbable mesh (phasix tm st mesh /bard) in challenging cases, presenting both the laparoscopic and the robotic approach. methods: we present video fragments from procedures of laparoscopic and robotic reconstruction of complex hiatal hernias, performed by our team, in which an absorbable mesh was utilized in an on-lay fashion. results: patients having undergone a minimally invasive surgical approach (laparoscopic or robotic) for the treatment of complex hiatal hernias with the use of an absorbable mesh, had an uneventful post-operative course and very short hospital stay and recovery time. the -month follow up revealed no recurrences or late complications. conclusions: treating complex cases of hiatal hernias with a minimally invasive approach can be proven quite challenging, with high recurrences and possible complications rate. a proper surgical technique, either laparoscopic or better (based in our primary experience) robotic, by experienced surgical teams and the use of meshes with the right strategy, minimizes the complications, offers all the benefits of minimally invasive surgery and reduces the recurrence rates. aims: several flexible endoscopic techniques for symptomatic zenker's diverticulum have been developed during the last decade. thulium laser has limited tissue penetration and may decrease the risk of perforation. this study reports the first use of thulium laser through flexible endoscopy for cricopharyngeal (cp) myotomy. aims were safety and efficacy of flexible endoscopic thulium laser myotomy and quality of life (qol) changes after treatment. methods: a retrospective review of a prospectively collected database of patients who underwent thulium laser septum division for symptomatic zenker's diverticulum was done. demographic data, presenting symptoms, diverticulum characteristics, and intraoperative data were analyzed. functional outcome swallowing scale (foss) and m.d. anderson dysphagia inventory (mdadi) questionnaires were administered to determine severity of dysphagia and its effect on qol, both preoperatively and during follow-up visits. all the operations were carried out under general anesthesia. a continuous laser configuration and an emissionpower of w was used in non-contact mode. once the mucosa was opened, the fibers of the cricopharyngeal muscle were divided until the buccopharyngeal fascia was visibile. results: between march and september , patients ( males) underwent flexible endoscopic cp myotomy with thulium laser. mean age was ± . , mostly males ( . %). seven patients ( . %) presented with recurrent diverticulum after previous transoral or open treatment. mean diverticulum size was . ± . cm. preoperative main symptoms were dysphagia ( . %), regurgitation ( . %), and cough ( . %). foss score was = in patients ( . %). mean mdadi global and composite score were . ± . and . ± . . complete division of the septum was achieved in all patients. mean hospital stay was . ± . days. there was only one perforation treated conservatively. no -days mortality was observed. at median follow-up of months, foss was = in ( . %) patient and mdadi global and composite score were . ± . and . ± . . all main symptoms were significantly reduced and qol significantly increased. conclusions: flexible endoscopic approach with thulium laser is a safe and effective treatment option for zenker's diverticulum either as a primary treatment or as a rescue therapy. objective: this study sought to explore prognostic factors for patients with borrmann type iv gastric cancer and to establish a predictive model for survival benefit of postoperative adjuvant chemotherapy in such patients. method: this study reviewed the clinical data of patients who underwent curative surgery at fujian medical university union hospital from to for borrmann type iv gastric cancer using a prospective database. cox regression analyses were performed to identify prognostic factors that formed the basis for a nomogram and risk groups. establishment of risk groups to identify patients with borrmann type iv gastric cancer who would benefit from adjuvant chemotherapy. results: patients who underwent r resection were included in this study.multivariate analysis showed that bmi, tumour differentiation, pt stage, pn stage, and asa score were independent prognostic factors. patients in the act-group had longer os than patients in the sagroup, although the p-value for this difference was marginally above the threshold for statistical significance ( . % vs. . %, p = . ). stratified analysis showed that there was no significant difference in os between the act-group and the sa-group for each ajcc stage (stage ii: . % vs. . %, p = . ; stage iii: . % vs. . %, p = . ).a nomogram was established based on these independent risk factors, and nomogram scores were used to divide all patients into a high-risk group (score [ ), an intermediate-risk group ( \ score = ) and a low-risk group (score = ).further stratified analysis based on ajcc stage showed that the -year survival rate was higher in the adjuvant chemotherapy group than in the surgery alone group for low-and intermediate-risk patients in each ajcc stage, while high-risk patients in stage iii did not significantly differ. objective: this study sought to explore the prognostic factors for smoking patients with gastric cancer and to establish a predictive model for the survival benefit of postoperative adjuvant chemotherapy in such patients. methods: we studied patients who were diagnosed from september to september at union hospital of fujian medical university. cox regression analyses were performed to identify prognostic factors. the kaplan-meier method was used to assess the effect of smoking history on the benefit of adjuvant chemotherapy after gastric cancer surgery. a decision tree algorithm was used to identify smoking patients who benefited from postoperative adjuvant chemotherapy. results: the median follow-up time for the whole group was . months, and the average age of all the included patients was . years.multivariate analysis showed that age (p \ . ), bmi (p \ . ), degree of tumor cell differentiation (p \ . ), and ajcc stage (p \ . ) were independent risk factors for the prognosis of smoking patients. based on these independent risk factors, a decision tree model for the benefit of adjuvant chemotherapy for smokers with gastric cancer was established, and the smoking patients were divided into the low-risk patients . %), medium-risk patients ( - year os, . %) and high-risk patients ( - year os, . %) (p \ . ). conclusion: cigarette smoking may reduce the efficacy of adjuvant chemotherapy after gastric cancer surgery. our decision tree model is simple and effective for identifying smokers who would benefit from adjuvant chemotherapy. objective: our study investigated the effect of lymph node (ln) noncompliance on the longterm prognosis of patients after laparoscopic total gastrectomy (ltg) and explored the risk factors of ln noncompliance. methods: the clinicopathological data of gastric cancer (gc) patients who underwent ltg with d lymphadenectomy from june to december were prospectively collected and retrospectively analyzed. the effects of ln noncompliance on the long-term prognosis of patients with gc after ltg were explored. results: the overall ln noncompliance rate was . %. ln noncompliance was significantly correlated with age, bmi, asa score, tumor size, macroscopic tumor type and tnm staging (p values \ . ). the survival rate of patients after ltg with ln compliance was significantly superior to that of patients with ln noncompliance (p = . ). the stratified analysis of tnm stage indicated that there was no difference between the os of stage i patients with ln compliance and those with ln noncompliance; os of stage ii/iii patients with ln compliance was significantly better than that of those with ln noncompliance. cox regression analyses showed that ln noncompliance was an independent risk factor for os. logistic regression analysis showed that high bmi ([ kg/m ) was an independent risk factor for preoperative prediction of ln noncompliance in cstage ii/iii patients. compared with patients with a low bmi (bmi \ kg/m ), those with a high bmi were more likely to show ln noncompliance during surgery, especially during the dissections of # , # a and # a ln stations. conclusion: ln noncompliance was an independent risk factor for poor prognosis in patients with advanced gastric cancer (agc) after ltg. patients with high bmi were more likely to have ln noncompliance, especially during the dissections of # , # a and # a ln stations. ln tracing was recommended for these patients to reduce the rate of ln noncompliance. aim: to study the differences in pathology, survival, and recurrence between special remnant gastric cancer (srgc) and nonspecial rgc (nrgc). method: a total of rgc patients were analyzed in hospitals in china from january to july .we compared the -year overall survival (os) disease-free survival (dfs) rates and used two-step regression explore the influence of the rgc categories on patient outcomes. results: all of the patients divided into srgc group (group s) (n = ) and nrgc group (group n) (n = ). the r resection rate and lymph node (ln) dissection number of group s were significantly higher than group n (p \ . ). the difference in -year os was not significant (p = . ), but the -year dfs of group s was worse than group n (p = . ). twostep multivariate analyses showed nrgc was an independent risk factor for poor dfs. of the patients who had undergone r resection, patients ( . %),suffered recurrence, and the recurrence rate of group s was significantly higher than group n (p = . ), moreover, the ln recurrence rate of group s was significantly higher than group n (p = . ). cox regression analysis showed that age, ca level, n stage and category of rgc were independent risk factors for rgc recurrence. conclusion: srgc has a higher r resection rate and ln dissection number than nrgc, but among patients who had undergone radical gastrectomy, srgc patients had worse dfs and a higher tendency for ln recurrence; thus, they should be treated differently in the clinic. objective: the aim of this study was to report our institution's experience with a novel abdominal negative pressure lavage-drainage system (anplds) for anastomotic leakage (al) after radical gastrectomy (rg) for gastric cancer (gc). background: al is a severe complication associated with high morbidity and mortality after rg for gc. the optimal creation of drainage in al patients after rg remains controversial. methods: the study enrolled patients who underwent r resection for gc at our institution between and . anplds was routinely used for patients with al after january . al rates and postoperative outcome were compared before and after the anplds therapy. we used multivariate analyses to evaluate clinicopathological and perioperative factors for associations with al and failure-to-rescue (ftr) after al. results: al occurred in patients ( / , %), leading to deaths. the al rate was similar before ( - , period ) and after ( - , period ) the implementation of anplds ( . % vs . %, p = . ). age and malnourished were independently associated with al. the ftr rate and abdominal bleeding rate after al occurred were respectively . % and . % for the entire period, but compared with period , it significantly decreased at period ( . % vs . %, p = . ; . % vs . %, p = . , respectively). what's more, only anplds therapy was an independent protective factor for ftr after al. conclusion: our experience demonstrates that anplds is feasible and cost-effective for the management of al after rg for gc. objective: to apply the principles of the 'metro-ticket' paradigm to develop a novel tnm staging system (ntnm) for gastric cancer (gc). background: the 'metro-ticket' prognostic tool for hepatocellular carcinoma has been proven to predict outcome, but a similar concept has not been investigated for gc. methods: the ntnm considered the distance from the origin on a cartesian plane incorporating the pn (x-axis) and pt (y-axis) stages. gc patients undergoing radical resection at fujian medical university union hospital (fmuuh) (n = ) were included. the ntnm was validated using external cohorts from the sun yat-sen university cancer center (sysucc) (n = ) and surveillance, epidemiology, and end results (seer) (n = ) databases. results: ntnm classes with the same distance from the origin have same stage; the stage increases with this distance. among all patients, . % (n = ) were restaged in the ntnm compared with the th edition of the ajcc-tnm classification; . % (n = ) were downstaged in the ntnm compared with the th edition. the ntnm provides significant survival differences between stages (all p \ . ). the survival difference between stages ib and iia was especially large for the ntnm (p \ . ) compared to the th and th editions (p = . ). the concordance index and hazard ratio increased successively with the ntnm stage. similar findings were observed in both external cohorts. conclusion: compared with the ajcc-tnm classification, the 'metro-ticket' ntnm for gc is easier to remember and provides some improvements; therefore, the ntnm may be considered for adoption in future editions of the ajcc-tnm classification. objective: to investigate the prognostic value of complete blood count (cbc)-based biomarkers for patients with resectable gastric cancer (gc). methods: patients with gc who underwent curative resection between december to december were included. estimated area under the curve (auc) and multivariate cox regression models were used to identify the best cbc-based biomarker. time-dependent receiver operating characteristics (t-roc) analysis was used to compare the prognostic impact. results: based on multivariate analysis, the lymphocyte-monocyte ratio (lmr) and hemoglobin (hb) level were the independent prognostic factors (both p \ . ). based on the lmr and hb level, we established the cbc-based inflammatory score (cbcs). higher cbcs was associated with older age, female sex, higher american society of anesthesiologists (asa) score, proximal tumor location, larger tumor size, later stage and vascular involvement (all p \ . ). univariate analyses showed that higher cbcs was also associated with poorer overall survival (os), which was consistent in each stage (all p \ . ). multivariate analysis revealed that the cbcs was a significant independent biomarker (p \ . ). furthermore, t-roc curve of the cbcs was superior to that of the prognostic nutritional index (pni), systemic immune-inflammation index (sii), modified glasgow prognostic score (mgps) and c-reactive protein/albumin ratio (crp/ alb) throughout the observation period. conclusion: preoperative lmr and hb were optimal cbc-based biomarkers for predicting os in gc patients after curative resection. based on the lmr and hb, we developed a novel and easily obtainable prognostic score called the cbcs, which may improve the prediction of clinical outcomes. purpose: the aim of this study was to evaluate the prognostic value of the eighth ajcc tnm staging classification for patients with gastric cancer who had already survived for years. patients and methods: patients who underwent radical gastrectomy at a large eastern center were considered. the prognostic value of staging systems were assessed and compared. additional external validation was performed using a dataset from the surveillance, epidemiology, and end result (seer) database. results: the -year overall survival (os) rate for patients in the training set was . %. with the prolongation of the survival time after surgery, the -year os improved significantly (p \ . ). however, there were no significant differences in survival curves among patients who have survived years after surgery. the auc and c of the eighth ajcc classification for predicting of -year os decreased gradually after surgery and appeared stable after years. for patients who survived years after surgery, we constructed a new tnm staging system (ntnm) according to the survival curves of t stage and n stage. a -step multivariate analysis showed that ntnm, age and sex were independent prognostic factors. the ntnm demonstrated superior prognostic stratification, with higher c-statistic and likelihood ratio chi-square scores and lower aic values than those of the ajcc classification. similar results were observed in the external validation set. conclusion: the ntnm predicted an additional survival more accurately than did the ajcc classification for patients who have survived years after surgery; this may guide decisions regarding surveillance. objective: to investigate the relationship between preoperative sarcopenia and systemic inflammation and evaluate the prognostic impact of these factors on patients with resectable gastric cancer (gc). methods: patients with gc who underwent radical gastrectomy between december and december were included. a multivariate cox regression analysis was performed to identify the prognostic factors. a novel prognostic score (slmr) was developed based on preoperative sarcopenia and the lymphocyte-monocyte ratio (lmr), and its prognostic value was evaluated. results: in total, patients with resectable gc were included in the study. on multivariate analysis, preoperative sarcopenia and the lmr were shown to be independent prognostic factors (both p \ . ). a low lmr was an independent predictor from sarcopenia (p \ . ). based on preoperative sarcopenia and the lmr, we established the slmr. an elevated slmr was associated with older age, higher asa scores, larger tumor size, advanced stages and vascular invasion (all p \ . ). multivariate analysis revealed that the slmr was a significant independent predictor (p \ . ). we incorporated the slmr into a prognostic model that included tumor size and tnm stage and generated a nomogram, which accurately predicted -and -year survival for gc patients. objective: to explore whether adjuvant chemotherapy is still needed in patients aged less than years with pt n - and pt / n gastric cancer. methods: multi-center cohort data of patients with gastric cancer who underwent radical gastrectomy were analyzed. kaplan-meier curves and cox regression were used to analyze the relationships between chemotherapy and prognosis. additionally, nomograms to predict the benefit of chemotherapy were established. results: in total, , patients with pt n - and pt / n gastric cancer were included. patients ( . %) were aged \ years. the -year overall survival (os) was not significantly different between the \ years of age group and = years of age group ( . % vs. . %, respectively; p = . ). lymph node (ln) metastases (hr . ; p = . ) and ln dissection number \ (hr . ; p \ . ) were independent risk factors for the os of patients aged \ years. adjuvant chemotherapy did not improve the -year os for patients aged \ years with pt n - and pt / n gastric cancer (p = . ). however, chemotherapy showed a significant benefit (p = . ) when there were ln metastases and/or ln dissection number was \ . two nomograms were constructed, and the calculated difference was the potential benefit of adjuvant chemotherapy for the patients aged \ years. conclusions: ln metastases and ln dissection number \ were independent prognostic risk factors of patients aged \ years with pt n - and pt / n gastric cancer. patients with these risk factors may benefit from the addition of adjuvant chemotherapy. objective: the choice of reconstruction after distal gastrectomy remains controversial. we have performed roux-en-y (r-y) method after laparoscopic distal gastrectomy(ldg) as a standard since , but we have performed billroth ii (b-ii) method in an increasing number of cases, depending on the patient. we retrospectively investigated the outcomes of patients with b-ii method after laparoscopic distal gastrectomy in our hospital. methods: patients who underwent b-ii and r-y reconstruction after ldg from january to december were included. the patient characteristics, surgical outcomes, and postoperative outcomes between the procedures were retrospectively analyzed. we also compared extend of gastritis on endoscopy and loss of body weight after surgery at year. results: b-ii / r-y : / . b-ii was selected in the elderly patients with poor asa-ps (p \ . ). in surgical outcomes, operative time was shorter for b-ii than r-y (p \ . ), and blood loss was also smaller (p = . ). in postoperative outcomes, there were significant differences in complications (?grade ) (b-ii vs. r-y: . vs. . %, p = . ) and length of stay (b-ii vs. r-y: median . vs. -day, p \ . ). there was significant difference in presence of gastritis between b-ii ( . %) and r-y ( . %) (p \ . ), but no significant difference in loss of body weight (p = . ). conclusion: b-ii reconstruction may be an adequate procedure for high-risk cases because of its shorter operative time and the absence of severe complications. background: numerous studies have shown that the short-term efficacy of three-dimensional ( d) laparoscopic radical gastrectomy (lg) is comparable to that of two-dimensional ( d)-lg. whether d-lg affects the recurrence pattern after surgery has not been investigated. using data from a prospective clinical trial, the present study compares the recurrence patterns between d-lg and d-lg. methods: from january to april , a total of patients were recruited for the clinical trial (nct ). the recurrence types, the first recurrence time and recurrence-free survival (rfs) were compared between the two groups. multivariate analyses of factors associated with rfs were performed to identify whether d-lg affects the recurrence patterns. results: ultimately, patients were analyzed ( in the d-lg group and in the d-lg group), and there were no differences in the clinicopathological data between the two groups. distant metastasis was the most common type of recurrence. there were no significant differences between the two groups in the recurrence types, the first recurrence time or rfs (all p [ . ). according to the th american joint committee on cancer tumor-node-metastasis (tnm) staging system, both groups were stratified into pathological (p) i, ii, and iii stages. the stratified analysis showed that there were no statistically significant differences in rfs between the d group and the d group among patients in each subgroup (all p [ . ). the multivariate analysis of rfs showed that pathological tnm (ptnm) stage and lymphovascular invasion were independent risk factors (all p \ . ). the multivariate analysis of post-recurrence survival (prs) showed that adjuvant chemotherapy was an independent protective factor (p = . ). conclusions: distant metastasis was the most common type of recurrence after lg. the postoperative recurrence patterns, rfs and prs after d-lg were similar to those after d-lg. purpose: the aim of this study is to evaluate the efficacy of delta-shaped anastomosis compared to circular stapler anastomosis in laparoscopic distal gastrectomy with billroth i reconstruction (ladg-bi). method: this is a single-center randomized controlled study. eligibility criteria included histologically proven gastric adenocarcinoma in the lower third of the stomach, clinical stage i tumor. patients were preoperatively randomized to circular stapler anastomosis or delta-shaped anastomosis. the primary endpoint is the number of analgesics use during days after surgery. we compared the surgical outcomes of the two groups. postoperative qol was evaluated using the postgastrectomy syndrome assessment scale- . this trial was registered at the umin clinical trials registry as umin . results: between december and september , patients (delta-shaped anastomosis , circular stapler anastomosis ) were enrolled. there was no difference in the number of analgesics use during day after surgery (median : delta-shaped anastomosis vs. : circular stapler anastomosis, p = . ). there was no difference in the overall proportion with in-hospital grade ii-iiib surgical complications ( %: delta-shaped anastomosis, %: circular stapler anastomosis). there was no operation-related death in either arm. regarding postoperative qol evaluated month after surgery, diarrhea subscale was significantly worse in delta-shaped anastomosis than in circular stapler anastomosis. conclusion: we did not demonstrate the advantage of delta-shaped anastomosis in terms of postoperative pain. since delta-shaped anastomosis tended to cause postoperative abdominal symptoms related to diarrhea, we should carefully apply the delta-shaped anastomosis to ladg. introduction: the use of a three-dimensional( d) camera for laparoscopic surgery has been reported in literature. however, there are only few comparative studies demonstrating its benefits, and no reports on the application of d vision to single-incision laparoscopic surgery. this study aims to compare d vision to the previous two-dimensional( d) system in solo single-incision laparoscopic distal gastrectomy(sidg). methods: medical charts of gastric cancer patients who underwent solo sidg from february to december were retrospectively reviewed. patients were grouped into either d group or d group depending on the type of camera used. all the operations were performed by a single surgeon using a flexible camera(olympus, japan), fixed onto a passive scope holder without the use of a scopist or an assistant. operative data, postoperative outcome, and early complication were analyzed. results: ninety had their operations under d vision and used the d scope. in both groups, there was no difference in age, body mass index, staging, and other demographic or histopathologic criteria. operative time was significantly faster in the d group( . ± . vs. . ± . mins., p = . ) and ebl was also less( . ± . vs. . ± . ml, p = . ). patients in the d group started small fluid diet faster( . ± . vs. . ± . postoperative days, p = . ), and were discharged faster( . ± . vs. . ± . postoperative days, p = . ). early complication was also less in the d group( . % vs. . %) but there was no statistical significance(p = . ). conclusion: the use of the d camera improves operative outcome and hospital stay in patients undergoing solo sidg. the frequency of anastomotic leakage after gastrectomyreaches - %. at the same time, mortality in this group of patients reaches %, and the use of aggressive methods of surgical treatment for the treatment of anastomotic leakage increases the mortality rate from to %. since , vacuum-assisted closure has been used to treat anastomotic leakage of various localizations. the essence of this method is based on the creating a local negative pressure, which is transmitted to the drip cavity through a special porous spongy system. the negative pressure created in the closed cavity, allows you to remove exudate, helps to reduce tissue swelling, improvesmicrocirculation, which in turn contributes to the development of granulations and wound healing with separation of the fistulous course. failures in using the method of vacuum therapy in anastomotic leakage are associated with the great difficulty of delivering a polyurethane sponge with a drainage tube to the leakage zone. in this regard, we have developed an improved method of endoscopic local vacuum therapy, in which the delivery of a polyurethane sponge was carried out with the help of a thread through a pharyngeal ring, a leakage zone and brought out through a drainage tube. this technique has been successfully used in the treatment of four patients with anastomotic leakage after operations on the upper part of the digestive tract. for complete healing of the cavity of the leakage and defect of the organ wall, it took , , and sessions of replacing the vac system, respectively (average . ± . ). there were no complications during the endoscopic local vacuum therapy. when the control endoscopic studies after months after the completion of the treatment at the site of defects of the seams of the anastomoses formed tender scar tissue without signs of narrowing of the organ. aims: enhanced recovery after surgery pathways are safe and effective for patients undergoing gastrectomy. this study aimed to identify perioperative factors influencing the adherence to the protocol, the postoperative course, and the consequent length of stay. methods: between and , patients were referred to our institution for gastric cancer. among these, patients underwent atypical gastric resection and were excluded from this analysis. were assigned to either total or distal gastrectomy and represent the study population. all patients were managed with a standardised perioperative pathway according to eras principles. according to data from the literature and based on our clinical experience, patients with optimal adherence to eras protocol may fit the criteria for discharge within ninth postoperative day, that was considered our ideal threshold for hospital discharge. data were retrospectively collected and analysed from a prospectively maintained database. statistical analyses were performed using spss version for macintosh. the v test, with a significance level of . , was used to investigate the association between the outcome and perioperative categorical variables. when parametric assumptions were met, student's two-tailed t-test was used to compare the means of continuous variables; otherwise, the mann-whitney test was performed. a significance level of . was chosen. logistic binary regression with a backward selection procedure and selection criteria of p-value \ . were exploited to determine significant predictors. results: preoperative, intraoperative and early postoperative variables were considered. among all, multivariate regression analysis revealed that incomplete preoperative immunonutrition, failure to extubate the patient at the end of surgery, intraoperative crystalloids infusions [ ml and blood transfusion [ ml, surgery duration [ min, and failure to mobilise patients within h from surgery were associated with delayed discharge. the logistic regression model was statistically significant (p \ . ) and correctly classified . % of cases. sensitivity and specificity were . % and . %, respectively. conclusions: results seem to be clinically rational and focus the attention on the importance of some perioperative clinical issues for the management of postoperative course. these variables could be considered as clinical goals to be reached in order to get an early discharge. objectives: the purpose of this study is to confirm the safety of laparoscopic gastrectomy with intraperitoneal cisplatin administration as a treatment for advanced gastric cancer with potential for peritoneal seeding. methods: from july to august , patients with advanced gastric cancer who underwent ip chemotherapy after diagnostic laparoscopy were retrospectively studied. all patients underwent laparoscopic gastrectomy with ip chemotherapy or ip chemotherapy alone after a diagnostic laparoscopy. gastrectomy was performed for palliative purposes even with seeding. results: the average age of the patients was years. eight patients ( . %) had preop chemotherapy. curative resection (r ) was performed in patients ( . %). in diagnostic laparoscopy, cytology was performed in patients ( . %) and cy was ( . %). peritoneal metastasis was detected in patients ( . %). of the total cohort, the year os rate was . % and the median survival time was months. in the case of stage iiib and below, the -year os rate was %, but it was % in stage iiic-iv group. when the r resection group and the r - resection group were compared, the -year os rates were . % and . %, respectively. hematological toxicity such as neutropenia was not seen in all patients. the mean hospital stay was . days and adjuvant chemotherapy was performed in patients ( . %). background: radical proximal gastrectomy (pg) and lymph nodes dissection are indicated for selected gastric cancers at the upper third of the stomach. with the advent of laparoscopic surgeries, more and more pg were performed by laparoscopic apporaches. in the past years, our team has accomplished and reported the oncological outcome of laparoscopic distal gastrectomies in cases of clinical stage i gastric cancer in taiwan. through the evolution of surgical trechniques and team work, we have cruised the learning curve of laparoscopic gastrectomy and reconstruction. materials and methods: in this report,we would like to present our surgical experience of laparoscopic proximal gastrectomy for gastric cancer patients. from to , pateints with gastric cancer underwent laparoscopic gastrectomies by the same surgical team at the national taiwan university. among them,six consecutive pateints (male:female = : ) with gastric adenocarcinoma of the upper stomach underwent laparoscopic pg in . the demographics, dissection, reconstruction methods and peri-operative outcome are presented. all six patients tolerated the procedure well, onepatient had mild anastomotic stenosis and improved with one session of endoscopic dilatation. one patient needed temporary proton pump inhibitor for controlloing acid reflux. four of the patients were pathological stage i, and the rest two pateint were stage iia and iiia disease. there was no tumor recurrence until now. summary: laparoscopic proximal gastrectomy is technically safe for treating upper third gastric cancers. the long term oncological outcome deserve further observation. introduction: open gastrectomy (og) has long been the preferred surgical approach worldwide for treatment of gastric cancer (gc). nowadays, several randomized, prospective trials have confirmed improvements in postoperative outcomes for laparoscopic gastrectomy (lg) compared to open procedures, with similar oncologic outcomes. however, most part of these studies comes from the eastern countries. material and methods: a prospective non randomized study was conducted with all patients operated of gc at ramón y cajal university hospital from january to december . over patients enrolled, patients underwent lg and og. textbook outcome was defined as the percentage of patients who underwent a complete tumour resection with at least lymph nodes in the resected specimen and an uneventful postoperative course, without hospital readmission. results: a textbook outcome was achieved in . % of patients operated of gc. the outcome parameter 'no severe postoperative complication' had the greatest negative impact on the textbook outcome. a statistically higher number of patients with early cancer ( % vs. . %) and subtotal gastrectomy ( . % vs. . %) were found in the laparoscopic group. no statistically differences were found between open and laparoscopic approach regarding operating time, rate of microscopic margin positivity, hospital stay, number of retrieved lymph nodes, complications, reinterventions, mortality and readmissions. no statistical differences in textbook outcome were found between both groups ( . % vs. %; p = . ). conclusions: laparoscopic gastrectomy for treatment of gastric cancer seems to be safe and feasible with similar textbook outcomes compared to open gastrectomy. introduction: laparoscopic surgery has been increasing for treatment of gastric cancer. however, standardization of this minimally invasive approach has not been reached yet because of its technical difficulties and the concern about oncological safety. the aim of the study was to analyze the outcomes of our learning curve in this complex surgical technique. material and methods: the first consecutive cases of laparoscopic gastrectomy (lg) performed at our hospital from november to february were enrolled. patients were divided into two groups based on the period they were operated. training phase (tp) was considered between and ( cases) and more-developed phase (mdp) between and ( cases). conversion, lymphadenectomy and retrieved lymph nodes (ln), hospital length of stay, mean operative time, complications, reintervention and mortality rates were compared between the two phases of learning curve. results: the number of retrieved ln was higher in the mdp ( ± , vs. , ± , ; p = , ). furthermore, we have also found less complications ( , % vs. , %; p = , ), a decreased reintervention rate ( , % vs. , %; p = , ) and overall mortality ( , % vs. %; p = , ) in the mdp. there were no significant differences in conversion rate, mean operative time, and hospital length of stay between phases. conclusion: although we consider that our learning curve is not completed yet because the average of monitored parameters have not reached a steady state, the improvement on surgical parameters and postoperative course in the last two years have showed our results are near to the best results published in the literature. aims: lymph node (ln) dissection proves to be essential for oncological gastrectomy, given that the presence of ln metastases is very high, even for early gastric cancer ( . % for t a and . % for t b). this way, d dissection for advanced gastric cancer and d ? for early gastric cancer are the gold standard procedures. some teams are using indocyanine green (icg) lymphography to improve their ln dissections, claiming that this technique facilitates the harvesting of small fluorescent ln that, otherwise, would be difficult to identify by conventional laparoscopic methods. methods: we herein present the case of a -year-old man with a t b distal gastric cancer. endoscopic ultrasound discarded the presence of metastatic ln and ct scan showed no distant metastases. icg was administrated endoscopically the day before the surgery, an amount of mg was injected along the submucosal layer around the tumour. in the video we can see how we perform a laparoscopic distal gastrectomy with d ? ln dissection and roux-en-y reconstruction. icg lymphography helped us to complete our expected ln harvesting, especially for groups (infrapyloric) and (left gastric artery). thanks to this technique, we could resect ln that we might have obviate during a usual laparoscopic procedure. results: patient was discharged home on the sixth postoperative day without complications and with adequate oral tolerance. conclusions: we present a case in which we have performed a laparoscopic distal gastrectomy with d ? dissection and roux-en-y reconstruction. we used icg lymphography to help us to improve our ln harvesting. although it is soon to assess if this technique may increase the number of retrieved ln and in which stations might be more useful, we consider this is a harmless method that may help gastric teams to complete their expected ln dissections. introduction: gastrointestinal stromal tumor (gist) represents around . % to % of gastrointestinal neoplasms, with the mesenchymal tumor being more frequent than the digestive one.the gist can be produced from the esophagus to the anus, at any point, being the stomach of ( to %) and the small intestine ( to %) more frequent sites.it is characterized by the expression of the tyrosine kinase growth factor receptor,cd ,differentiating it from other mesenchymal tumors,which do not express it.it is accepted that its origin corresponds to the interstitial cells of ramón y cajal,which act as a pacemaker for intestinal motility.they are very heterogeneous tumors, which vary in size,morphology and biological behavior,being neoplasms with uncertain malignant potential.the incidence is between the fourth and sixth decades,being the distribution by gender similar. clinical case: female patient of years,who goes to the general surgery service,as interconsultation,after a veda,by dyspepsia.it is reported stomach:ceiling mucosa without alterations,at the level of the greater curvature is seen a tumor of cm,hard to the touch with the biopsy forceps,slightly irregular covered with mucosa of normal appearance. computed tomography: stomach body:rounded image of nodular aspect which does not present heterogeneous enhancement after administration intravenous iodine contrast extending to peritoneal region, measures x x mm liver:hypodense image without heterogeneous enhancement adjacent to this,a mm rounded image that is suggested to be studied with nmr. gadolinium nmr liver hypodense image with well-defined limits without heterogeneous enhancement of cystic aspect. gastric roof,heterogeneous formation,which enhances with gadolinium mmx m-mx mm,having to discard a gist. surgical technique laparoscopic partial gastrectomy. pathological anatomy and immunohistochemistry . cm injury with net edges.uncertain malignant fusocellular nodule, cd ??? actin-dog ??? s -no mitosis or invasion of the mucosa is observed. conclusion: a case of stomach gist is presented,which,the main symptom was dyspepsia,being the clinical presentation very variable,in relation to the place in which it is located. there is fletcher criteria for the risk of malignancy,this being less than . cm,very low risk,less than cm, the patient evolved favorably,without surgical complications.aims: to present the surgical procedure of resection of the lesser gastric curvature and its pedicle with laparoscopic surgery, fulfilling oncological criteria, carried out in the general surgery service of the hospital of torrecárdenas. methods: an -year-old man with prostate cancer treated with complete hormonal block and epoc, who consults for rectal bleeding of week of evolution. it is diagnosed of gist in gastric lesser curvature, x x cm, very vascularized and infiltrates the wall producing marked imprint on the fundus. it is tributary of left gastric artery. precise blood transfusion and presents hemodynamic stability, is decided surgical resection scheduled. results: the surgery is performed by laparoscopy, with a tumor of approximately cm, which is dependent on the lesser curvature. the esophageal hiatus and the lesser curvature are dissected with section of the left gastric pedicle. atypical gastrectomy of the lesser curvature including gist, making a gastric sleeve dependent on the greater curvature. the anatomopathological study reports pt pn with lymph nodes without adenopathies, and disease-free surgical margins. he was discharged without complications on the th day and did not require re-entry. conclusions: the laparoscopy surgery for atypical gastrectomy of lesser curvature is safe and meets oncological criteria in selected patients and performed by an experienced esophagogastric unit. aims: to present the surgical procedure of total gastrectomy with d lymphadenectomy with laparoscopic surgery, fulfilling oncological criteria, carried out in the general surgery service of the hospital of torrecárdenas. methods: a -year-old male with a tobacco habit who consults due to epigastric pain and constitutional syndrome of months of evolution. it is diagnosed of gastric adenocarcinoma t n m . neoadjuvant qt is decided, after weeks of its completion, scheduled surgery is performed. results: the surgery is performed by laparoscopy, showing a stenosing tumor in at gastric antrum of approximately cm. dissection of the greater curvature with section of the right gastroepiploic at its birth and duodenal section is performed. dissection of the lesser curvature with d lymphadenectomy, section of the pedicle of the left gastric and the distal esophagus. the transit is restored with latero-lateral esophageal-jejunal anastomosis and jejunojejunostomy. the anatomopathological study reports ypt a and pn with / adenopathies, and disease-free surgical margins. he was discharged without complications on the th day and did not require reentry. conclusions: the laparoscopy surgery for total gastrectomy with complete d lymphadenectomy is safe and meets oncological criteria in selected patients and performed by an experienced esophagogastric unit. background: in gastric cancer surgery, to secure surgical margin, it is necessary to accurately judge the position of the tumor. however, with conventional marking clips, it is difficult to identify the exact location of the tumor during laparoscopic surgery. purpose: we investigate whether icg (indocyanine green) fluorescence navigation method is effective and safe for determination of cutting line in laparoscopic gastrectomy. patients and methods: subjects underwent laparoscopic gastrectomy (including robot-assisted surgery) based on the icg method for gastric cancer in the period from april to december . the day before surgery, icg diluted times ( . ml of reagent ? . ml of distilled water) was injected at cm from the tumor edge and . ml at the four submucosal layers around. then clip to the same part. gastrectomy based on standard surgery is performed, and the position of the tumor and spread of icg are confirmed by icg fluorescence navigation during operation, and a cutting line is determined. the extent of icg from the tumor is again measured with the excised specimen and compared with the pathological margin. results: among the patients who underwent intraoperative pathological examination, they were negative in all cases except one. the spread of icg was . cm on average, and considering the marking position ( cm) from the tumor edge, securing of . cm or more was possible. the operation time was . ± . min and the estimated bleeding loss was . ± . ml. conclusion: laparoscopic gastrectomy with icg method can evaluate tumor position and spread easily and in real time during operation and it was effective for determining the cutting line in laparoscopic gastrectomy. epstein-barr virus (ebv) has been known as one of causal virus of gastric cancer. ebv-related gastric cancer considered to be about % of the entire gastric cancer, and it is rare that ebvrelated gastric cancer has multiple lesions. the patient was years old female. she was diagnosed with upper gastrointestinal endoscopy with lesion in the lower major stomach body, lower anterior wall of the stomach body, rear wall in the middle part of the stomach, rear wall in the middle part of the stomach, and lesser curvature of the stomach angle, as a result of biopsy, adenocarcinoma was observed from the former four. the patient underwent a robot-assisted total gastrectomy. adding a newly found lesion, the histopathological diagnosis was pt b in the lower major stomach body, pt b in the lower anterior wall of the stomach body, pt b on rear wall in the middle part of the stomach, pt b on rear wall in the middle part of the stomach, and pt a in lesser stomach body, pn , pstageia. pathological examination results showed that the four lesions were positive for tumor cells in eber in situ hybridization and were considered to be ebv-related gastric cancers. she was discharged on the th day after the operation without any postoperative morbidities.there has been no sign of recurrence without postoperative therapy for months. results: a -year-old female with no medical history of interest or allergies to medications, who consulted for palpable mass at mesogastric level to the left of the midline associated with abdominal pain of - months of evolution, without concomitants or relationship with the intake, valsalva or physical efforts, without change in the depositional habit or toxic syndrome. the abdominal ct (computed tomography) revealed a cystic mass in jejunum mesentery, defined edges, about cm in diameter and that does not capture contrast; likewise, there is no ascites, retroperitoneal adenopathies or other intra-abdominal or pelvic masses, radiology recommends completing the study with abdominal mri (magnetic resonance imaging) that informs of possible lymphangioma at the level of the jejune mesentery. surgical exeresis was decided, which was carried out by laparoscopic approach, with emptying of the lesion and enucleation of the lesion without incidents, the postoperative evolution was favorable being discharged at h. the pathological anatomy reported fibro-adipose tissue with presence of lymphatic dilatations associated with a cystic lesion without epithelial lining, with serous fluid and abundant macrophagic reaction compatible with mesenteric lymphangioma. conclusions: the mesenteric cyst is a rare pathology with an incidence ranging from / , to / , , predominating in the fourth decade of life. it is defined as any cystic lesion in the mesentery, and is subdivided according to its origin into lymphatic, mesothelial, urogenital, dermoid, and enteric and pseudocysts. most of the time they are asymptomatic although they can (as in our case) present with abdominal pain and even produce complications such as intestinal obstruction, volvulus, intracystic hemorrhage, infection, rupture, and even malignant transformation. for the diagnosis, the palpation can be of great help, showing mass of well-defined limits and partially mobile. the imaging test of choice is abdominal ultrasound / abdominal ct, supplemented by magnetic resonance imaging. the recommended treatment is surgical exeresis, considering laparoscopy as the first option; if it is complete, it can be considered as a curative treatment. purpose: gastrostomy(og) is an alternative method for nutrition support, especial for the patients with oral-esophagus route obstruction or dysfunction. the most operation were conducted by young surgeon or residents. laparoscopic gastrostomy(lg) was a new coming procedure and the skillful suture techniques were needed. the most the residents can't be qualified for this operation. we designed the method for laparoscopic gastrostomy to provide the traning opportunity of suture skill training and guarantee the patient's safety. material and method: laparoscopic gastrostomy procedure was done with two mm trocar. the lower body of stomach was chose. four point around gastrostomy wound were chose for subcutaneous fixation. the straight needle with - prolene was inserted into peritoneal cavity from upper point, then punctured the sero-muscular layer of stomach. the needle was retrieved out from the same point by guidance of gauge needle. the same way was used for other three points. one purse string around gastrostomy was created by one hand suture method and fastened by köckerling knot tier after insertion of fr foley tube. finally, the peritonization was finished by hand tie externally and knot were keep in subcutaneous layer material-method: we present the case of a year old woman who presented with melena, hematemesis, anemia (ht . %) and being haemodynamically unstable. after the stabilization of the patient, a gastroscopic examination followed, where it revealed a tumor of the fundus (adenocarcinoma). the patient was submitted to laparoscopic total gastrectomy and oesophagojejunal anastomosis, omega type (o), and intestinal anastomosis braun, with the usage of trocars (umbilical mm as inserted in laparoscopic surgery of a single incision, and two mm in the midclavicular line bilaterally). the oesophagojejunal anastomosis was conducted with the use of a linear stapler for the posterior wall and the convergence of the anterior wall with laparoscopic sutures in two layers. patient remains in well condition, months after the operation. conclusion: laparoscopic approach seems to be safe for treatment of gastric cancer of the fundus and of the gastroesophangeal junction, as it offers better surgical field view and less postoperative complications. the restoration of the continuity of the gastrointestinal tube with anastomosis of w type is considered safe alternative to the classic roux-en-y anastomosis. git and bariatric surgery, faculty of medicine, alexandria university, alexandria, egypt; git surgery, faculty of medicine, alexandria, egypt background: superior mesenteric artery syndrome is best described as compression of the third part of duodenum by the superior mesenteric artery, resulting in obstruction. the study of this rare medical condition was carried out since decades yet remain obscure. this study aimed to analyze different clinical presentations, diagnostic modalities, treatment approaches and outcomes, as well as to emphasize the importance of long term follow up. methods: thirty-five superior mesenteric artery syndrome cases were collected retrospectively from a facebook group called 'superior mesenteric artery syndrome awareness & support'. a questionnaire was designed using google form to obtain the demographics, presenting symptoms, risk factors and co-morbidities, investigations, means of treatment and the outcomes. data was entered into microsoft office excel for statistical analysis. results: the median age at diagnosis was years. the median body mass index was . kg/ m ;. the median time interval from symptom onset to initial diagnosis was months. the major presenting symptoms were abdominal pain ( . %), nausea ( . %), and vomiting ( . %). abdominal computed tomography scan with contrast ( . %) was commonly used for confirmation of diagnosis. thirteen cases ( . %) were congenital. thirty patients ( . %) had received treatment. the overall management success was only . %. surgical management ( . %) was the most used regimen. conclusion: diagnosis of superior mesenteric artery syndrome is established after a thorough assessment of the clinical presentations and confirmation with suitable imaging modalities. the choice of treatment should be dependent on the causes and severity as different patients respond differently to therapy. recurrence is possible in all patients thus a long-term follow up is required. aims: in the last hundred years much has been written on peptic ulcer disease and the treatment options for one of its most common complications: perforation. laparoscopic repair of perforated peptic ulcer has been gaining popularity in recent years. treatment for perforated ulcer can be performed laparoscopically in % of cases, making it possible to avoid a median laparotomy which can lead to wound infection and late eventration. methods: a -year-old male presented to emergency room with a three-hour history of progressively worsening epigastric pain and nausea. physical examination revealed rebound tenderness compatible with an acute abdomen. a ct scan showed: important pneumoperitoneum unable to define the drilling point; distended stomach with plenty of fluid inside and dense content fundus / body suggestive of active arterial bleeding . results: the patient was emergently taken to the operating room for diagnostic laparoscopy . perforation shown in greater gastric curvature associated blood remnants. gastrotomy for clot removal is done without observing active bleeding. the gastrotomy was repaired using standard stitches. all exudate was aspirated and the peritoneal cavity was irrigated with warm saline solution the patient had an uncomplicated post-operative course. jp drain was removed and he was discharged one week after surgery. conclusion: the role of laparoscopic surgery in emergencies is well documented. laparoscopic approach is indicated in any case of suspected gastroduodenal perforation and seems to offer the same advantages as for the vast majority of laparoscopic procedures. laparoscopic surgery may therefore have a real place in the treatment of perforated peptic ulcer. the aim: of our study was to evaluate of effectiveness of local injection of platelet-rich plasma for treatment of peptic ulcer bleeding with hemorrhagic shock in experiment. methods: the study was performed on wistar rats according to local and international rules for working with experimental animals. the average weight of animals was ± grams. in all animals our modification of type acetic acid ulcer (susumu okabe, ) was modeled. we randomly divide all animals in groups. rats with only modeled ulcer were included in group . rats with modeled ulcer and hemorrhagic shock after - . ml blood sampling were included in group . in group we included rats with modeled ulcer and hemorrhagic shock and performed local injection of platelet-rich plasma (local periulcelar injection of . ml of autologous platelet-rich plasma). on st, th and th day measurement of the ulcers square and morphological study were performed. results: the data we have received demonstrate a tendency of decrease of ulcers' square in all groups with time flow. we also compared sizes of ulcerative defects in all groups at every point of the study. on the st day of investigation there were no differences (p [ . ) between ulcers' square in all groups. on the th day we found out more rapid decrease of size in group (p [ . ). however, this tendency had no statistical significance. on the th day difference was larger and it was statistically significant this time (p \ . ). also the better ability to stimulate the activity of fibroblasts and revascularization in the young connective tissue with improving oxygenation in the ulcers and enhancing of cell proliferation, differentiation and accelerating of maturation of connective tissue and healing of ulcers was demonstrated in group . conclusion: platelet rich plasma reduces inflammatory response and stimulates proliferation of gastric epithelial cells on th day with the restoration of secretory activity and epithelialization of ulcers in . % of experimental animals on th day, the activation of the fibroblastic reaction during the all experiment and decreasing of ulcers' square. h. fujii, depat. of surgery, japanese red cross fukui hospital, fukui, japan introduction: in conjunction with charmant, a local eyeglass frame manufacturer, we developed novel devices called the fj (free jaw) clip to grasp organs in the abdominal cavity and the f (free) loop plus to pull thread extracorporeally from within the abdominal cavity. product summary: the fj clip is used to grasp organs in the abdominal cavity, a stainless steel, removable forceps for use in laparoscopic surgery. it provides a strong grip but rarely crushes organ tissue. the clip comes in two sizes, one for use in a -mm port and the other for use in a -mm port, and in two lengths, . mm and . mm, respectively. to pull out thread tied to the fj clip, we developed the f loop plus, which is a g by -mm-long special stainless needle with f . -mm niti alloy thread which is used pull suture threads from inside the abdominal cavity to outside the body. case: we performed cases of reduced port laparoscopic and endoscopic cooperative surgery (lecs). we performed reduced port surgery (rps) by making a . -cm incision at the umbilicus, inserting trocars ( mm and mm), and inserting another trocar ( mm) at the left side of the abdomen. we expanded the left hepatic lobe with a -mm fj clip for penrose drain placement, grasped the front wall of the gastric body with a -mm fj clip, applying traction toward the legs to pull up the tissues around the tumor, and resected all layers of the tumor via oral endoscopic submucosal dissection technique. the resected area was closed with a suturing device or interrupted sutures in the abdominal cavity. a year-old female was admitted to the emergency department with complaints of abdominal cramping pain, back pain and diarrhea for one day. she also had fever, ever up to °. in these two weeks, she felt occasionally epigastric pain. her past medical history included hypertension. on physical examination, she was conscious and alert. abdominal examination revealed diffuse tenderness and knocking pain over right flank. laboratory tests indicated an degraded white cell count of /cumm with % band forms, c-reactive protein of mg/dl and abdominal liver function tests (alanine aminotransferase: u/l, alkaline phosphatase: u/l, gammaglutamyl transferase: u/l) without hyperbilirubinemia. abdominal x-ray showed paralytic ileus. our presumptive diagnosis was acute peritonitis, based on the patient's symptoms. empirical antibiotics were administered immediately, and a computed tomography (ct) imaging study was performed. the ct scan showed a stick like foreign body noted between ventral side of pylorus and smv lumen, about . cm in length and associated with perifocal infiltration and segmental smv thrombus formation. (fig. ) however, there is no obvious pneumoperitoneum and no evident ascites is associated. an emergency exploratory laparotomy was performed, revealing stomach perforation at posterior wall with a cm fish bone thourgh pancreas into smv. localized inflammation and fibrosis were identified without obvious fluid accumulation( fig. - ) . removal of fish bone and simple closure of stomach perforation were performed. blood cultures revealed bacteroides thetaiotaomicron. three weeks later, she received a follow-up ct scan which showed smv obliteration with chronic pylephlebitis. aim: here we present a case report about the endoscopic treatment for iatrogenic gastric perforation secondary to a chest tube insertion. methods: a case report of a -year-old male with history of a road traffic accident. described injuries were severe brain injury with gcs \ at pre-hospital care arrival, thoracic injury with several rib fractures on the left hemithorax and hypoventilation on the left side. prior to hospital transfer a chest drain was inserted on the left side, and the patient was intubated. results: at hospital admission, the patient was hemodynamically stable and connected to a mechanical ventilator. thoracic exam showed persistent hypoventilation on the left chest. no other abdominal or pelvic injuries were found in the physical exam. a frontal chest x-ray revealed pneumothorax and the chest tube was not viewable. a further ct scan showed the chest drain placed in the abdominal cavity, into the stomach, besides a subdural hematoma, comminuted pelvic fracture of the pubic rami and a left sacroiliac fracture. during the first h in the icu, neurological worsening was observed, and a new cranial ct revealed enlargement of the subdural hematoma, for what the patient underwent decompressive craniectomy, with improvement thereafter. following a five-day period of stabilization after surgery, the patient was evolving satisfactorily, and the removal of the intragastric chest drain was considered. endoscopy was performed to confirm the placement of the drain, and it was removed under direct vision. approximately twenty five centimeters of the catheter were visualized in the gastric lumen, and then successfully removed. the patient recovered well and was discharged from icu to medical hospital ward after fourteen days, and a week later he was discharged home. conclusion: endoscopic management for gastric perforation after a chest drain insertion may result effective and can prevent open surgery morbidity. aims: intestinal infusion treatment with levodopa/carbidopa (duodopa) is a therapeutic option concerning the advanced parkinson disease cases with no response to the conventional treatment. the drug requires carrying out a gastrostomy either by percutaneous endoscopy way, or by laparoscopy -if the first one is not possible-. later, a duodenum-yeyunum tube is placed in order to infuse the duodopa gel continuously by a portable bomb. in this report, we explain the laparoscopic gastrostomy technique. method: sin this report, we include two patients with advanced parkinson disease: the first one is a year-old female patient suffering from an important gait disorder; and the second one is a year-old male patient with uncontrolled motor fluctuations. in both cases, a percutaneous endoscopic gastrostomy was proposed, but neither was feasible because of the non-traslumination between the gastric and the abdominal wall. under general anesthesia, neumoperitoneum by veress needle was performed. three main trocars and one accessory were placed. at the level of the gastric antrum, a cm incision was conducted to insert a gastrostomy tube, to be the guide for the drug infusion catheter. next, the gastrostomy is fixed to the abdominal wall by the stamm technique, externalizing the catheter through the accessory trocar in the medial line. results: on the first post-operative day, a duodenum-yeyunum tube is placed by endoscopic control through the gastric device. both patients got well satisfactorily, and no complications were described; and they develop a total normal life within the limitations of their underlying disease. conclusions: the duodopa intestinal infusion shows a significative improvement for the advanced parkinson disease symptoms, compared with oral medication; appreciating positive results referring to life quality. when the catheter placement by endoscopy way does not seem posible, gastrostomy by laparoscopy constitutes a valuable surgical option for the treatment of this kind of patients. peptic perforated ulcus (ppu) is a common surgical emergency and laparoscopic repair has been introduced as an alternative to open repair. it has shown good results and allows closure and peritoneal lavage, just like the open repair does but with the advantages of a minimally invasive surgery. the objective is to report the outcome of laparoscopic ppu in our hospital. methods: from january to october , patients with a clinical diagnosis of ppu were assigned to undergo laparoscopic repair. this retrospective study included all husm patients who underwent laparoscopic ppu repair by emergency surgeons. minimum follow-up of months is carried out. results: of the patients in this series, % were men and % were women, between and years of age at the time of surgery, average of years. the time between the manifestation of symptoms and surgery was [ to h in % of patients. in patients there was a history of previous ulcer or non-steroidal anti-inflammatories intake and up to % were smokers. a ct scan was performed in all cases to reach the diagnosis primary closure with simple suture plus omental patch was the elected technic ( %). the approach was performed with trocars in %, trocars in % and in case. cases ( %) were gastric ulcer, duodenal cases ( %) and in one case no perforation was found. the conversion rate was %, in two cases due to technical difficulty and in the other case because the level of the perforation was not found. the median postoperative stay was days although there were cases with intrabdominal complications. there was an exitus due to a metastasic pulmonary neoplasia diagnosed in the immediate postoperative period. there were no cases of recurrence in the follow-up time. conclusion: in most centers, including ours, the rate of laparoscopic management has gradually increased along with the improvement of technical skills. improvements in the outcome of laparoscopic ppu repair are to be expected with more experience surgeon and a good selection of the cases. general surgery, jzu hospital ,,sveti vracevi,, bijeljina, bosnia-herzegovina introduction: diverticulum is an outpouching of a hollow organ. gastric diverticulum is rare form od this disease. incidence of detection varies depending on investigation method. it has been reported in . % cases of autopsies, . % cases of gastroduodenal roentgenographies with contrast, and . - . % cases of upper endoscopies.small diverticula are usually asimptomatic, but bigger diverticula can cause variable symptoms such as abdominal pain, feeling of epigastric fullness right after meal, feeling of discomfort in upper parts of abdomen, and severe 'foetor ex ore' .diagnosis is usually established in procedures such as gastroduodenal roentgenographies with contrast, upper endoscopies and abdominal ct scan. case report: a -year-old woman came to our hospital because of feeling of discomfort and mild pain in upper abdomen that lasted for last year. diagnosis is established after ct scan of abdomen and upper endoscopy procedure. initially she has been prescribed conservative therapy (proton pump inhibitors). since the symptoms persisted, laparoscopic resection of the gastric divertuculum was performed using endogia stapler. considering the feeling of discomfort and abdominal pain dissapeared, the patient was discharged from hospital on the fourth postoperative day. conclusion: asymptomatic gastric diverticula doesn't require treatment. since gastric diverticulum can have complications such as bleeding, perforation and neoplasia, patient without symptoms should be monitored. initial therapy for symptomatic diverticula is conservative therapy (proton pump inhibitors). if conserative therapy doesn't procude expected results, laparoscopic resection of the diverticulum should be considered. introduction: the acute perforation of a gastric ulcer is a serious entity that requires urgent surgical treatment in most of the occasions, it is increasingly accepted that the approach of choice is laparoscopic, depending, above all, on the time of evolution of the process. objectives: to demonstrate the safety and efficacy of the laparoscopic approach in the perforation of a pyloric peptic ulcer, even in cases of severe peritonitis, by means of a standardized procedure, insisting on the sequential thorough washing of the cavity.material and methods: we present a video of the surgical intervention of a patient with acute abdomen, with a history of nsaid ingestion, exploration and ct-analysis compatible with perforation of hollow viscus, probably of gastric origin. results: intervention: complete laparoscopic approach, trocars. severe biliopurunitic peritonitis, by pyloric perforation 'acute', liquid culture, suture of the perforation, epipoplasty, sequential thorough washing of the cavity with physiological saline and placement of drainages.correct postoperative period, discharge from the hospital on the th day after completing antibiotic treatment. endoscopy and helycobacter test are performed on an outpatient basis with normal results. conclusion: the laparoscopic approach is safe and effective in acute and complicated gastric ulcer disease, even in cases of severe peritonitis. surgical procedure: the clean-net procedure involves the selective dissection of both the serosa and muscle layer using a laparoscopic monopolar endoscopic scissor. the preserved mucosal layer provides a mechanical barrier between the gastric lumen and peritoneal cavity that aids in the prevention of peritoneal cavity contamination with gastric contents. tumors are observed with an upper gastrointestinal endoscope with the injection of indocyanine green (icg) into peri-tumoral submucosal layers at points. selective seromuscular dissection is performed using a laparoscopic electrocautery monopolar scissor. the mucosa surrounding the gist is then resected using a endoscopic mechanical stapler to prevent exposure of the gastric lumen to the peritoneal cavity and peritoneal tumor cell seeding. results: there were males and female, and the average age was years. the operation time was min, the average bleeding volume was . ml, the postoperative hospital stay was . days. the mean tumor diameter was . mm, the final histopathological diagnosis was gist, schwannoma. there were no postoperative complications of clavien-dindo classification or more. conclusion: clean-net was found to be safe and useful for the treatment of gastric smt with ulceration. year outcomes: laparoscopic heller myotomy stands the test of time aims: laparoscopic cardiomyotomy leads to excellent relief of dysphagia in % of patients and avoids thoracotomy or laparotomy. methods: we present a video illustration of the procedure that was modified at the american university of beirut medical center. so far, patients underwent laparoscopic cardiomyotomy, age range of to years, with males and females. most of them have had previous balloon dilatation. results: all cases were successfully completed laparoscopically without complications. followup of months to years revealed excellent results with complete resolution of symptoms and no need for further medications. this will result in minimal post-operative pain and very short recovery period and is associated with low complication rate. conclusion: cardiomyotomy for achalasia is ideal for laparoscopic approach. magnification allows for precise division of muscle fibers. the new technique of hydro dissection and enseal for division of esophageal muscle allows for completion of the procedure without injury of the mucosa. therefore, adequate release of the obstructing segment followed by anti reflux procedure toupet will lead to excellent results with minimal morbidity and no mortality. aims: laparoscopic repair of huge hiatus hernia methods: twenty two cases of huge hiatus hernia presented to the american university of beirut medical center. patients underwent through trocars in the upper abdomen reduction of the hernial sac from the chest. special care was taken in the dissection of the mediastinum to keep the thoracic fascia and pleura intact. the defect was sutured primarily by -ethibond sutures reinforced by onlay prolene mesh u-shaped was fixed at the rt. and lt. crus and a floppy nissen fundoplication performed . results: the video presentation includes the technical aspects and the method of reducing and repair of huge hiatus hernia.aim: nowadays, there is little experience in the world of applying robotic surgical system (rss) in treatment of patients with hiatal hernia (hh) and reflux-esophagitis (re). the aim of study was to determine the possibility and feasibility of using rss in treatment of patients with hh. materials and methods: a total of patients underwent robot-assisted hh repair without mesh, followed by fundoplication with our original method ( °full symmetric wrap). the clinical and technical analysis did not reveal any advantages over similar laparoscopic procedures, so we abandoned the use of rss for hh type i, and these patients were excluded. there were ( %) patients with hh type iii and ( %) type iv. the surgeries were performed by experienced robotic upper gastrointestinal surgeon and conducted with the davinci si surgical system (intuitive surgical, sunnyvale, ca). results: average operation time was ± ( - ) min. the respondents' mean age was . ± . years (range - ) and bmi was . ± . (range . - . ) cm/kg . average blood loss was ± ( - ) ml. average hospital stay was ± . ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) days. the average follow-up time was ± . ( - ) months. postoperative x-ray imaging and upper gi endoscopy was conducted in all ( %) patients. there was no hh recurrence diagnosed. we did not observe a relapse of hh or clinical manifestations of re in the early (less than days) and long-term (more than months) postoperative periods. conclusion: we can conclude that robot-assisted surgery is safe, appropriate and justified in patients with hh type iii and iv. all procedures performed to the patients with giant hh revealed clear technical advantages of rss over similar laparoscopic operations: an enlarged d hd image, bendable instruments with endowrist technology allowed for precise dissection of tissues (hernial sac, cicatricial adhesions) in a narrow anatomical space-posterior mediastinum without damage to pleura, pericardium and vagus nerves. we believe that use of rss in treatment of patients with reflux esophagitis and/or hh type i is unjustified, due to the lack of proven advantages over laparoscopy. introduction: the presence of major anatomical obstacles -such as massive caudate lobe-in the confined operative field of laparoscopic hiatal hernia repair (lhhr) poses significant challenge to the foregut surgeon. aim: to provide a safe alternative for lhhr using a laparoendoscopic approach. method: this patient is a year old female, with bmi of . . her past medical history includes diabetes, hypertension and hyperlipidemia. she had gerd for years. her egd showed x cm hiatal hernia and class b esophagitis. manometry showed ineffective esophageal motility. we used the classic five ports approach for lhhr. we found a massive caudate lobe which was comparable to the size of an already enlarged left lobe of the liver. the operative strategies: terminating the procedure proceeding with the standard approach and taking the risk of bleeding from the caudate lobe itself or the inferior vena cava (ivc) with possible catastrophic outcome. using the laparoendoscopic approach. the following three steps facilitated the performance of safe and effective surgery. additional liver retractor this improved exposure and minimized manipulation of the caudate lobe. extracorporeal sliding arthroscopic knots (esak) esak are similar to the knots used in endoloop. they are tied extracorporeally and require a single insertion of the knot pusher as they do not unravel. transoral incisionless fundoplication (tif) we performed tif to avoid a limited operative field and to prevent excessive tissue manipulations associated with laparoscopic fundoplication. tif also preserves the angle of his and produces partial fundoplication which has less side effects of dysphagia and gas bloat syndrome. results: the operative time was min (lhhr min and tif min). there were no complications. patient discontinued omeprazole which she used daily for years. at months follow up, her gerd related quality of life (hrql) and gerd symptom (gerss) scores were ( vs ) and ( vs ). conclusion: the laparoendoscopic repair of hiatal hernia in the presence of anatomical obstacles is safe and effective. longer follow up is needed to assess the durability of this repair. gastroesophageal reflux disease (gerd) is a condition that reduces the quality of life and can causedisorders associated with acid reflux, such as bronchial asthma, barrett's esophagus and esophagealadenocarcinoma. gerd is often caused by existing of hiatal hernia. nowadays, some surgeons haddifficulties with the laparoscopic approach to treatment of recurrent hiatal hernias.patient was a -year-old man. he requested medical assistance with dysphagia, nausea after eatingand heartburn getting worse in a horizontal position. conservative treatment was not effective.transthoracic nissen fundoplication was performed in . the main complaints of the patientpersisted during the postoperative period. the upper half of stomach and s-like curved esophagus werelocated in the mediastinum according to multislice computed tomography of the thorax in august.in our clinical center was performed laparoscopic cruroraphy, cardiomyotomy and nissen fundoplicationin november. during the surgery the normal anatomical position of stomach has been restored, s-like curve of esophagus has been removed; a gastric cuff (collis-nissen) has been created and anteriorand posterior cruroraphy has been performed. the patient was in intensive care during h. anasogastric tube feeding was continued during the first h. passage of the contrast through theesophagogastric junction was free within h after surgery. patients had been discharged within days after surgery.this case report shows that at the current stage of surgery laparoscopic approach can be useful not onlyfor treatment of primary hiatal hernias-but also for treatment of recurrent ones. aims: laparoscopic heller myotomy procedure, completed with an anti-reflux procedure is technically demanding. we report a case of laparoscopic heller myotomy followed by a dor anterior fundoplication. methods: this is the case of a -year-old caucasian woman with gradual dysphagia for solids and liquids, accompanied by severe regurgitation and chest pain. an initial diagnosis of achalasia was made in , with the use of manometry and barium swallow. endoscopic dilatations were attempted pre-operatively with no clinical improvement. decision was made to perform a laparoscopic heller myotomy, combined with a standard dor anterior fundoplication. a -ports operation took place (one intra-umbilical mm trocar-single incision laparoscopic surgery (sils) technique, two -mm subcostal trocars, and one another mm subcostal trocar for the use of liver retractor). the operation lasted h and min. results: no post-operative complications were noted. the post-operative swallow test showed improvement of the esophageal patency. the patient started a liquid diet three days later and was discharged six days post-operatively. two months later the patient presented no complications. conclusions: heller's myotomy has demonstrated good long-term results in the treatment of esophageal achalasia and the laparoscopic approach has been well established in the last two decades. it is a very demanding operation to perform and the disease is relatively rare, making the learning curve difficult to achieve. aims: achalasia is a type of motor disorder of the esophagus due to degeneration of ganglion cells in the myenteric plexus, leading to failure of relaxation of the lower esophageal sphincter, accompanied by a loss of peristalsis in the distal esophagus. the association of a long-term achalasia and a large size hiatus hernia is an infrequent entity. among the therapeutic options is medical treatment, endoscopic treatment and surgical treatment associated with an antireflux procedure. the laparoscopic approach being the more indicated due to its better results in terms of morbidity, mortality and recurrences. the aim of the video is to show the effectiveness and safety of the laparoscopic approach in this infrequent pathology, pointing out the importance of performing a standardized procedure. methods: -year-old male patient, with personal history of chronic ischemic heart disease and obesity, diagnosed with long-term achalasia with moderate dilatation of the esophagus associated with giant hiatus hernia. the complementary explorations and iconography of interest are exposed. results: intervention: complete endoscopic approach, trocars. reduction of hernial content into the abdominal cavity, dissection of the hernial sac and esophageal lipoma. extended mediastinal esophageal dissection. complete resection of both the sac and lipoma, respecting the posterior vagus. heller's myotomy of cm, including cm distal to the ueg, perforation of mm of the mucosa at the ueg level, suture and blue methylene verification of the sealing. hiatorraphy and dor-type anterior fundoplication as antireflux technique. correct postoperative, with egd control on the rd po day and discharge on the th. asymptomatic at months after surgery. conclusion(s): for achalasia laparoscopic heller myotomy with a partial fundoplication should be the treatment of choice in patients who are at low surgical risk. the length of the myotomy, especially distal to ueg is one of the most important aspects of the surgery, to achieve an effective disruption of the les. the presence of a giant hiatus hernia makes the procedure difficult, increasing the risk of complications, such as perforation. standardization is essential to increase safety and efficacy in these complex cases. purpose: there is evidence that the application of mesh-reinforced hiatal repair has resulted in a significant reduction in recurrence rates in comparison with primary suture repair, at least in short-term follow-up. however, and instead of this, the standard of care for repairing large paraesophageal hiatal hernias (lphh) remains controversial because no clear guidelines are given regarding indications, mesh type, shape and position. the aim of this study is to evaluate our short-term outcomes in management of lphh with a biosynthetic monofilament polypropylene mesh surrounded by a high-purity and adherent titanium dioxide surface coating to enhance the biocompatibility (tio mesh tm ). methods: a retrospective study was conducted on our institution between december and october . data were collected on patients with lphh greater than cm in which a laparoscopic repair was carried on by primary suture and additional reinforcement with a tio mesh tm . clinical and radiological recurrences, dysphagia and mesh-related complications were investigated. results: there were females and males with a mean age of years (range, - years). all operations were completed laparoscopically. median postoperative stay was days. after a mean follow-up of months, patients developed clinical recurrence of reflux symptoms ( . %) and radiological recurrences ( . %). there were no mesh-related complications. conclusions: the use of tio mesh tm for laparoscopic repair of lphh is suited and with a reasonably low recurrence rate in this short-term study. additional long-term studies with enormous numbers carried out for years will be necessary to affirm whether this mesh is convenient in the prevention of recurrences and mesh related complications. background: surgery for refractory gastroesophageal reflux disease (gerd) has a satisfactory outcome, however sometimes fundoplication fails and redo surgery is required. several publications have investigated the feasibility of performing reoperative fundoplications using laparoscopic techniques. the aim of this study was to describe our experience in laparoscopic redo fundoplications in the last years. material and methods: we retrospectively reviewed consecutive patients who required laparoscopic redo fundoplication from january to august .the indications were recurrent symptoms of gastroesophageal reflux disease (gerd) ( . %), recurrent symptomatic paraesophageal hernia ( . %), dysphagia ( . %) and acute volvulus ( . %). results: all redo fundoplications (basically toupet . % and nissen . %) were completed laparoscopically. the mean operative time was min (range, - . min). a mesh was placed in % of cases. intraoperative and postoperative complication rates were . % and . % respectively. the mean hospital stay was days (range, - days). one patient ( . %) from the laparoscopic group required a third operation-one for acute recurrent paraesophageal herniation of the redo wrap one month after surgery, which was repair laparoscopically again. symptomatic outcome was successful in . % without any kind of proton bomb inhibitors therapy. conclusion: laparoscopic redo fundoplication is technically feasible and clinically effective with a reasonable low rate of postoperative complications p -upper gi-reflux-achalasia objectives: in recent years, balloon dilatation (bd) for diseases requiring correction of the impaired patency of the sphincter zones of the esophagogastroduodenal region has become widespread. purpose: to assess the effectiveness of the use of the balloon dilatation in patients with impaired sphincter zones of the esophagogastroduodenal region. materials and methods: in the institute department of surgery for the period from to , bd was performed in patients. of them diagnosed with achalasia of cardia (ac): - stage, - stage, - stage, - stage. patients diagnosed with pylorospasm, patients had compensated stenosis and patients had subcompensated ulcerative pyloroduodenal stenosis. there were males, females, average age ( . ± . ). bd was performed under endoscopic and / or x-ray control by 'boston scientific' balloons with a diameter of - mm, mm and mm, a course of - sessions with an interval of - days and a cylinder exposure of - min. evaluation of bd was performed using esophagogastroscopy, balloon manometry and x-ray passage of barium. results: in the course of the study, the existing indications were refined and new indications were developed for performing an endoscopic bd in pyloroduodenal stenosis and in ac. in patients with stage - ac, a positive result was noted in . % of cases already after the first session of bd. recurrences of ac after bd for up to years were established in ( . %) patients: at stage -in . %, at stage -in . %, at stage -in . % and at stage -in . %. repeated bd courses in case of ac recurrence in ( . %) cases turned out to be ineffective. recurrence of pyloroduodenal subcompensated stenosis was diagnosed in . % of cases in the period of months after performing bd. conclusions: bd is an effective method for correcting the permeability of the sphincter zones caused by the pathology of the esophagogastroduodenal region. keywords: balloon dilatation, achalasia of cardia, pylorospasm, ulcerative pyloroduodenal stenosis, recurrences. introduction: the reoperation in antireflux surgery significantly increases morbidity and mortality up to - %, reaching rates of % in patients undergoing or more surgeries. the advantages of laparoscopic surgery used in this surgical technique have amplified its acceptance and use, resembling its results in terms of feasibility, safety and efficacy of laparoscopic surgery to open surgery.objective: :evaluate the currently literature about antireflux surgery reintervention, focusing on the main indications of re-intervention, type of approach and morbidity and mortality of laparoscopic antireflux surgery. material and methods: a literature search was conducted in two electronic databases, med-line and embase. the search was limited to the period to . terms were used in relation to the procedure or intervention and the underlying disease. we chose observational studies (cohort, cases and controls and series of cases), where the main indication for antireflux surgery would have been gastroesophageal reflux disease. results: a total of studies were selected, most of them were case series ( . %), cohort studies ( %) and case-control studies ( . %). a total of patients. the main indications were anatomical faults, of these failures, recurrent hiatus hernia and sliding occupy the highest percentage, while physiological failures, failure in esophageal and gastric motility occur more frequently. the main type of approach was laparoscopic in %, the conversion rate was . % and the open approach was reserved for complex cases with more than one re-intervention . %, for abdomen . % and chest . %, this last for cases with high esophageal lesions that can not be repaired via trans-abdominal.the main complications were injuries to hollow viscera, such as: esophagus and stomach among others. these complications are related to the complexity of the procedure. mortality has remained low up to . %, however, the cause of death was due to medical complications and not related to the procedure. conclusions: this systematic review on reoperation in reflux surgery has confirmed that morbidity after reoperation surgery is higher than after primary surgery and reoperation indications increase with the use of new technologies (manometry) and the laparoscopic approach continues on the rise, with great adaptation to its use and improvement in results. aims: eras protocol is not commonly used in acute emergency procedures. elective lc is commonly performed as one day surgery, while in an emergency setting of acute cholecystitis, the in hospital stay averages , days. the aim of this trial is the application of eras protocol in patients with acute cholecystitis, undergoing laparoscopic cholecystectomy. methods: a randomized prospective trial was conducted in first surgical department of sismanogleion g.h.a. the study included patients, who were admitted with acute cholecystitis and underwent lc into h from their admission. preoperatively, they all received crystalloid isotonic solutions and antibiotics. . % were submitted to ercp, preoperatively, due to choledocholithiasis. the postoperative care included early mobilization into h after surgery, early fluid intake (into h) and early liquid food intake (into h). they all received systematically antibiotics, analgesics and antiemetic on demand. asa score was not an exclusion criterion. results: conversion to open procedure was necessary in . % of patients, whom were excluded from the study. all the rest were discharged into h from the surgery with the guidance to receive oral antibiotics for more days. readmission was necessary for patients, one week after the operation. the first one presented with bile leak and submitted to ercp with stent placement and percutaneous drainage of the intrabdominal collection. the second one presented with choledocholithiasis and underwent ercp with balloon catheterization. conclusion: it is commonly accepted that eras protocol in elective procedure enhances the postoperative recovery while reduces the in hospital stay and cost. in emergency condition eras cannot be applicated preoperatively. however, a modified post surgery application seems to have advantages equal to those observed in elective procedures. aim: laparoscopic cholecystectomy is the gold standard for the treatment of symptomatic cholelithiasis. administration of one single dose of chemoprophylaxis before an elective laparoscopic cholecystectomy is a broadly accepted practice. however, its value is currently questioned, especially in low risk patients. method: this study was conducted in a high volume surgical department. one hundred and twelve patients submitted to elective laparoscopic cholecystectomy were included in this research. a written consent was acquired after thorough patient briefing. half the patients that underwent surgical operation received one dose of antibiotics min prior to the incision and the other half did not receive any chemoprophylaxis. results: the age ranges from to years old. commonest concomitant diseases were arterial hypertension, type ll diabetes, hypothyroidism and respiratory deficiency. approximately % of patients were smokers and % were obese (bmi [ ). the duration of the operations was between and min. intra-operative gallbladder rupture was observed in patients (rate %). all the patients were discharged the first post-operative day and their monitoring continued for more days. in the chemoprophylaxis group, no surgical site infection or other major complication was observed. from the group that did not receive any antibiotics, one patient developed surgical site infection and specifically infection of the surgical port in the epigastrium, which was treated with drainage of the abscess and oral antibiotics administration. no other complications were recorded. conclusion: our study concluded no statistically significant difference between the two patient groups, which depicts that chemoprophylaxis may not be necessary in elective cholecystectomy operations. on the contrary, antibiotics increase the cost of hospital stay and are often accompanied by multiple mild or severe side effects. publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. key: cord- -ubazgvov authors: cafiero, concetta; re, agnese; micera, alessandra; palmirotta, raffaele; monaco, delio; romano, francesca; fabrizio, claudia; di francia, raffaele; cacciamani, andrea; surico, pier luigi; d’amato, gerardo; pisconti, salvatore title: pharmacogenomics and pharmacogenetics: in silico prediction of drug effects in treatments for novel coronavirus sars-cov disease date: - - journal: pharmgenomics pers med doi: . /pgpm.s sha: doc_id: cord_uid: ubazgvov the latest developments in precision medicine allow the modulation of therapeutic approaches in different pathologies on the basis of the specific molecular characterization of the patient. this review of the literature coupled with in silico analysis was to provide a selected screening of interactions between single-nucleotide polymorphisms (snps) and drugs (repurposed, investigational, and biological agents) showing efficacy and toxicityin counteracting covid- infection. in silico analysis of genetic variants related to each drug was performed on such databases as pharmgkb, ensembl genome browser, www.drugs.com, and snpedia, with an extensive literature review of papers (to may , ) on covid- treatments using medline, embase, international pharmaceutical abstracts, pharmgkb, and google scholar. the clinical relevance of snps, known as both drug targets and markers, considering genetic variations with known drug responses, and the therapeutic consequences are discussed. in the context of clinical treatment of covid- , including infection prevention, control measures, and supportive care, this review highlights the importance of a personalized approach in the final selection of therapy, which is probably essential in the management of the covid- pandemic. covid- , an emergency all over the world, is caused by severe acute respiratory syndrome coronavirus (sars-cov ), a positive-sense rna virus with higher mutation rates than dna viruses. , laboratory tests on respiratory tract specimens (swab/saliva/tears pcr and serological tests) and computed tomography (ct; for chest or other tissue) should stage as soon as possible the presence of disease and its evolution/progression. , sars-cov binds principally to the cell-membrane ace receptor through the viral structural spike (s) protein, although other "virus doors" have been suggested (integrins and toll-like receptors) (figure ) . at the intracellular level, the virus activates cellular processes to produce viral proteins that replicate the virus's genetic material, providing potential targets for drug therapy. , , covid- features, diagnostic route, and early, mild, and severe covid- symptoms are summarized in figure . virus entry and multiple signaling pathways (ca + release, csrc, fak, mapk, and pi k) occur upon spike -rgd-integrin interaction. a "cytokine storm" is locally released (il β, il , il , tnfα, mip α, and vegf), as first observed in patients showing fatal complications. this specific panel was used to screen patients requiring prompt intervention to avoid acute respiratory distress syndrome (ards). in a recent study, candidate drug targets for nonstructural proteins ( -chymotrypsin-like protease, papain-like protease, rnadependent rna polymerase), viral access, and related immuno regulatory pathways have been prospected for evaluation. , , a wide range of pulmonary manifestations can be observed, varying from mild respiratory symptoms (cough or sore throat) to severe pneumonia, up to a sudden development of respiratory failure. silent hypoxemia is a peculiar aspect frequent in frail and elderly patients that usually precedes the onset of an overt acute and severe respiratory syndrome. , chest ct imaging is strongly recommended for an early diagnosis of novel coronavirus pneumonia. , ct findings, including patterns associated with less frequent signs, eg, lobular, bronchial, pleural, and subpleural involvement, as well as pleural lymphadenopathy and pericardial effusion, have been described. sars-cov initially causes airspace exudates, interstitial edema, hyaline membranes, and inflammatory infiltrates in the alveoli. other than the deleterious lung effects, systemic sars-cov has a significant impact on the hematopoietic system and tissue homeostasis. initially, lymphopenia showed interesting prognostic value, for both neutrophil:lymphocyte and platelet:lymphocyte ratios in severe sars-cov cases. lymphocyte parameters (count dynamics), some inflammatory indices (ldh, crp, and il ), and some recent circulating biomarkers (high serum procalcitonin and ferritin) have been suggested for identifying cases with poor prognosis (prompt intervention and improved outcomes). as observed, blood hypercoagulability, high d-dimer levels (particularly associated with disease worsening), protraction of both prothrombin (pt) time, activated partial thromboplastin time (aptt), and disseminated intravascular coagulation overview of covid- infection: sars-cov -host interaction and tissue manifestation. schematic representation of sars-cov virus interacting with mucosa epithelia (framed) and gradual sprouting to gut, kidney, brain, and lung tissue. "virus doors" reportedwere ace , integrin, tlr , or tmprss . overall symptoms are listed. briefly, most common covid- symptoms occur at the upper respiratory tract, together with asthenia and general malaise. early, less common clinical features include gastrointestinal symptoms (nausea, anorexia, diarrhea), anosmia and dysgeusia. severe cases encompass pneumonia or bronchopneumonia, severe acute respiratory syndrome, renal failure, up to death. the lower respiratory tract participation and complications are more frequent in people aged over with pre-existing chronic diseases of cardiovascular and/or respiratory system, as well as some autoimmune diseases (diabetes). cardiac involvement represents another potentially life-threatening complication, caused by direct viral damage, hypoxic injury, microvascular dysfunction and disclosing with diverse clinical pictures (arrhythmias, myocarditis, and heart failure). finally, virus can reach central nervous system causing central (acute cerebrovascular diseases, impairment of consciousness) and peripheral complications. the evolution of infection from early detection severe complications and death (shaded arrow). as reported, molecular and serological, as well as imaging tests, are useful depending on disease evolution: real-time pcr applied to nasopharyngeal swabs, venous blood as well as conjunctival swabs can track disease ongoing, while early-released igm and late-released igg might assess for immune response, in line with cytokine storm panel (il , tnfα, ifnγ, and il ) typifying tissue/organ complications. require constant surveillance to allow prompt intervention. in addition to upper-airway contact, conjunctivitis may be an ocular manifestation of sars-cov infection, if quickly detected. in december , a chinese ophthalmologist reported an unusual viral conjunctivitis. to date, several internet articles and scientific reports have documented the potential use of eye swabs as a tool to screen virus infection, although contrasting data are available, most probably related to progression of infection and virus detection. in january , a worldwide expert in infectious diseases referred to conjunctivitis during an inspection of wuhan and tested positive for sars-cov , but quickly recovered from infection. this led to the idea of "eye infection" as a possible alternative route of sars-cov transmission, alternative to the respiratory one. ocular secretion might represent a reservoir of virus at the early stages of contagious. when pinkeye occurs as a sign of conjunctivitis, a differential diagnosis can be of great utility to screen symptomatic and even presymptomatic individuals. recently, pharmacogenomics (the effects of a single genetic marker) and pharmacogenetics (the collective influence of variability across the genome to modulate an individual's drug response) have received great attention for their abilities to provide a new way to select drugs for personalized therapy (optimal dosing for maximizing drug efficacy or minimizing the risk of toxicity). , through drug therapy, pharmacogenetics might influence both pharmacokinetics and pharmacodynamics with respect to dosing, formulation sensitivity, and adverse drug reactions (adrs), as well as drug-hypersensitivity reactions (allergic, pseudoallergic, and exaggerated pharmacological reactions to medications), determining an enhanced immunologic reaction or inflammatory response (side effects). genetic assessment can predict the occurrence of drug-related toxic effects. single-nucleotide polymorphisms (snps) are the most common type of polymorphism found in the human genome, and represent the main reason for % of all types of genetic variations among individuals. an example of an adr is the hypersensitivity reaction occurring in snp carriers of the hla-b* allele who receive the antiviral abacavir for treatment of hiv. , covid- therapy is wide-ranging and multiple, and risk factors for adrs can occur. therefore, optimal doses, duration of treatment, side effects. and long-term outcomes are critical aspects of covid- therapy. cov-mediated inflammation may be counteracted by anti-inflammatory cytokines, including il family members, il , and tnfα. since no specific drug/therapy for covid- treatment has been us food and drug administration (fda)-approved, an array of drugs approved for other diseases and under investigation (including off-label and biological drugs) have been included in clinical trials. , as observed, the metabolic pathways of these drugs included various polymorphic cytochrome p enzymes, strongly suggesting genotyping for the cyp d * , cyp d * , cyp d * , and cyp d * alleles. , as an example, no predictability in the metabolic function of the cyp a * allele can result in alternative mrna splicing with a trunked protein, due to the formation of an untimely stop codon. moreover, haplotype cyp a * has been related to a reduced clearance of both ritonavir and lopinavir (substrates) ( table ) . of interest is the association between polymorphisms inabcc and therapy efficacy, as the drug transporters are one of the primary mechanisms related to subtherapeutic antiretroviral-drug concentrations. prominent research has highlighted the relationship between the abcb polymorphism ( c>t) and hepatotoxicity risk after antiviral treatments, and few additional studies were found regarding other nucleoside analogues. more recently, the presence of grade - hyperbilirubinemia is directly proportional to the homozygosity, heterozygosity, and wild-type genotyping for the ugt a * allele in patients who receive ritonavir and lopinavir. therefore, the attempt of this literature review coupled with in silico analysis was to provide a selected screening of drugs showing efficacy and toxicity effects useful for counteracting covid- infection. an extensive literature review of papers published until may , was performed based on a standard procedure (medline, embase, international pharmaceutical abstracts, pharmgkb. and google scholar). search terms were "covid- ", "novel coronavirus", "sars-cov ", "pharmacogenetics", "treatment/s", "adverse side effects", "therapy", "lung", "ocular", "pulmonary infection", "drugs", "drug response", "virus", "candidate drugs", "potential inhibitors", "protease inhibitors", "personalized medicine", "individual therapy", "pneumonia", "ace", "heparin", "vasculitis", "conjunctivitis", "rhinitis", "hematological complication" and "main metabolic routes", either alone or in combination. from this manually performed analysis, drugs reported in at least two studies or in a clinical trial were included. ongoing clinical trials and the index of studies of covid- were identified using the search term "coronavirus infection" on clinicaltrials.gov and the chinese clinical trial registry (http://www/chictr.org/enindex.aspx). in silico analysis of genetic variants related to each drug was performed on dedicated databases, such as pharmgkb (table ) , ensembl genome browser, www.drugs.com, and snpedia. the allelic frequency of each variant average in all populations was based on data from the genomes project phase . we considered snps related to both efficacy and toxicity response with allele frequencies ≥ %, as already described in previous studies. , the quality of each study was assured, and resulting information included study design, baseline characteristics of disease, treatment regimens, and allelic frequencies of the genetic variant. drugs in use as routine therapy or in clinical trials for covid- include steroids and antiviral and biological humanized neutralizing antibodies against some proinflammatory cytokines, such as il , il , ifn, and tnfα, in addition to supportive measures and symptomatic treatment, according to the severity of the disease. data analysis on registered clinical trials of covid- in the table overview of pharmgkb • pharmgkb is one of the foremost worldwide resources for pgx knowledge, and the organization has been adapting and refocusing its mission along with the current revolution in genomic medicine. annotates drug labels containing pharmacogenetic information approved by the us food and drug administration, european medicines agency swiss agency for therapeutic products, pharmaceuticals and medical devices agency (japan) and health canada. attempts to interpret the level of action implied in each label with the "pgx level". • pharmgkb website provides a diverse array of pgx information, from annotations of the primary literature to guidelines for adjusting drug treatment based on genetic information. • pharmgkb online pharmacogenomics knowledge resource maintains a list of very important pharmacogene summaries (www. pharmgkb.org/view/vips.jsp), which (until march ) describes , allelic variant annotation in which allelic variation has been shown to significantly influence drug metabolism, drug transport, drug-target response, expression of genes encoding drug-metabolizing enzymes, or risk of adverse drug reactions. us is available at https://clinicaltrials.gov. nowadays, a great number of agents have been evaluated for potential use in covid- management, and only a fewhave been included within international and/or local protocols. according to the us national institutes of health, no pharmacological agent has earned approval for safe and effective use yet, mainly because of the lack of evidence in favor or against these agents (https://covid treatmentgui delines.nih.gov). one important aspect of a therapeutic approach consists in the choice of the right drugs throughout the natural history of disease. indeed, a three-phase pathogenetic model has been proposed, with different clinical and laboratory features, each requiring a specific treatment based on the changing role over time,of direct viral damage and host inflammatory response in the disease course. this model describes an early stage (stage i), coinciding with incubation and/or mild flulike symptoms, during which antiviral drugs might reach high effectiveness, a moderate stage (stage ii) characterized by pulmonary involvement without iia or with iib hypoxia, which may benefit from the use of antivirals and anti-inflammatory therapy (including steroids), and lastly a severe stage (stage iii), in which a dysregulated, systemic hyperinflammatory response takes place, thus requiring the administration of immunomodulating agents, several of which are currently under investigation, and in some cases already in use within management protocols. gene variants associated with pharmacological responses to drugs are reported in a dedicated database -pharmgkb (https://www.pharmgkb.org) -allowing the identification of relationships between genetic variations (eg, snps, indels, repeats, haplotypes) and individual drug responsiveness. , herein, in silico pharmacogenetic analysis shows the potential clinical efficacy and/or toxicity of the major drugs selected for covid- treatment. the main drugs proposed for covid- treatments and reference sequence (rs) related to adrs and efficacy are shown in table . genes and related snps (rs) associated with drug effects and their study annotation are summarized in table . major clinical information regarding "variant drug" responsiveness (clinical annotations) is highlighted. bloodstream fluidity requires a tidy balance among factors favoring flow of blood and thrombosis. any modification in this physiological balance triggers pathological conditions: deficit of coagulation factors favor bleeding, while genetic mutations of coagulation factors can determine a thrombotic risk framework characterized by differences in genetic variants of coagulation (table ). all drugs used as therapeutic options and their study annotation based on pharmacogenetic data are discussed. chloroquine (cq) and hydroxychloroquine (hcq) cq is used for chemoprophylaxis of malaria and amebiasis, while hcq is used to treat autoimmune disease. the mechanism of action includes the blocking of viral entry through the inhibition of glycosylation of host receptors, proteolytic processing, and endosomal acidification. effects of immunomodulation on cytokine production and inhibition of autophagy/lysosomal activity have been also reported. [ ] [ ] [ ] several randomized controlled trials (rcts) are currently investigating cq and hcq in covid- treatment (https:// clinicaltrials.gov). based on current data, both drugs are recommended for treatment of unhospitalized covid- patients, and the effects of cardiotoxicity in immunosuppressed subjects or patients with kidney or liver problems are known. recommendations for oral administration in covid- treatment are mg twice a day and mg twice a day, followed by mg twice a day for cq and hcq, respectively. blood monitoring is required, as hemolytic anemia might occur, particularly when the drug is delivered in association with other drugs that cause hemolysis. it should not to be underestimated the extent to which both drugs may cause hemolysis in glucose- phosphate dehydrogenase (g pd)-deficient individuals. of note, about % of covid- patients suffering from lupus have failed to respond or were even intolerant to hcq. moreover, long-term cq-hcq treatment induces retinal toxicity, and particularly when hcq-related retinopathy is diagnosed, the retinal damage endures, even after cessation of therapy. high doses or prolonged administration of hcq, even at recommended doses, may increase the risk of ocular toxicity (paracentral scotomas, color-vision changes, corneal/ciliary body/conjunctival as well as retinal abnormalities), and visual disturbances (retinal and macular toxicity). this would imply that accurate eye screening for confirming sars-cov presence in early conjunctivitis or monitoring ocular structure during covid- therapy is recommended to counteract early or even prevent eventual signs of ocular drug toxicity, including the retinopathy. the oral combination of these two agents (fda-approved and currently authorised as anti-hiv medicine) demonstrate activity against other novel coronaviruses. , several rcts examining lopinavir/ritonavir in covid- are in progress. recommendations for administration in covid- treatment is mg/ mg twice daily for up to days. adverse effects of lopinavir/ritonavir include several gastrointestinal complains, such as nausea, vomiting, and diarrhea, and hepatotoxicity, pancreatitis, and cardiac conduction abnormalities. these adverse effects are increased in %- % of covid- patients with elevated transaminases. previous studies have shown that these adrs with lopinavir-ritonavir combination are related to several polymorphisms present in the genes ugt a , ugt a , apoe, and apoc (table ) . this antiviral drug (guanine analogue) inhibits viral rnadependent rna polymerase. ribavirin activity against covid- disease is limited and requires high doses or combination therapy to be effective in humans. no evidence exists for inhaled ribavirin for covid- treatment -no benefit over enteral or intravenous administration though several studies have demonstrated possible harm due to adverse effects (hematologic and liver toxicity). ribavirin causes severe dose-dependent hematologic toxicity. the inconclusive efficacy and toxicity results suggest that ribavirin has limited value in treatment of covid- . case-control pharmacogenetic association studies indicate different polymorphisms in the itpa, vdr, and slc a genes that are related to toxicity and adverse effects, while an increased pharmacological response is associated when some variants of the vdr, slc a , ifnl , and micb-oasl genes are present. it must be noted that numerous studies have undertaken pharmacogenetic evaluations on populations undergoing ribavirin therapy combined with peg-ifnα. this is an antiviral agent that exerts a mechanism of action targeting the s protein-ace interaction, inhibiting membrane fusion of the viral envelope. the recommendation for umifenovir oral dose ( mg every hours, - days) for influenza treatment was studied for covid- therapy (nct ). in covid- patients treated with umifenovir, adverse effects include allergic-reaction gastrointestinal upset and elevated transaminases, although there are no studies that describe an association of these episodes with genetic variants. , miscellaneous agents ifnα and -β have been studied for novel covs. several studies reported clinical outcomes in combination with ribavirin and/or lopinavir/ritonavir. adverse effects have been described in almost every organ, clearly dosedependent. , several toxic mechanisms for ifnα/β have each variant report show the reference snp (refsnp) cluster id numbers (rs#), a code by which each snp can be queried from the dbsnp website (https://www.ncbi.nlm.nih.gov/ snp) and through which further information is available (such as functional analysis, population-specific allele frequencies, validation information, or clinical significance). furthermore, for each variant, a summary of pharmgkb clinical annotations with respective identification codes (phenotype for any given genotype) is reported. using the access codes for dbsnp and pharmgkb, it is thus possible to find more information for the sequence variants and the respective variant-drug responsiveness associations. finally, the last columnshows the most significant bibliographic reference concerning the association between the genetic variant reported and individual drug responsiveness. pharmacogenomics and personalized medicine : submit your manuscript | www.dovepress.com dovepress been investigated in recent years. much remains still to be elucidated, although most side effects disappear on dose reduction or interruption of treatment. previous genomewide association studies on the response to ifnβ in neurological degenerative diseases suggest an increase in therapeutic response with the presence of several snps in the genes cd , znf , and fhit. in parallel, adrs have been observed with the presence of variants of the gapvd and irf genes. as of now, the use of interferons to treat covid- disease is controversial. although an antihelminthic agent, nitazoxanide has shown antiviral activity with a favorable safety profile. , camostat mesylate prevents novel cov-cell entry through inhibition of the host surface transmembrane protease/serine (tmprss ), as observed by in vitro studies. neither drug has pharmacogenetic studies regarding efficacy or toxicity effects associated with genetic variants. this macrolide antibiotic is used extensively in patients with viral infections to prevent severe respiratory tract infections. azithromycin-hcq combination shows a synergistic effect on covid- disease in vitro at concentrations comparable with that observed in human lung, and has been found useful in combination with remdesivir, lopinavir/ritonavir and ifnβ. to date, the interaction between this macrolide and genetic factors is unknown. however, due to the potential risk of prolonged qt interval, remarkably increased by the mutual interaction between these two agents, their concomitant use is not recommended by several guidelines, unless within the setting of controlled trials (https://covid treatmentguidelines.nih.gov). this anticoagulant is used to reduce thromboembolic events in patients with covid- infection. as known, the sars-cov pandemic is characterized by the development of ards that results from acute inflammation within the alveolar space and prevention of normal gas exchange. indeed, huge deposits of fibrin in the lung parenchyma and air spaces have been reported. the raising of proinflammatory cytokines within the lung leads to recruitment of leukocytes, increasing the local inflammatory response, and since the coagulation route contributes to reducing pathogen invasion by improving compartmentalization, this anticoagulant treatment has potential risk in those covid- patients with no significant coagulopathy. the drug enoxaparin can be started as soon as the day of covid- diagnosis and continued over days, after baseline assessment and monitoring of pt, aptt, complete blood-cell count, and creatinine levels. clinical aggravation causing worsening and death in covid- inpatients appears to be thrombotic. therefore, special attention should be devoted to both risks and benefits of using heparin in covid- patients. prescreening is essential to highlight genetic predisposition related to thrombophilia, as these subjects with thrombophilic mutations (based on the degree found) are at greater risk of thrombotic complications. remdesivir this is an rna-polymerase inhibitor (gs- ), a retroviral drug belonging to the class of nucleotide analogues, and a monophosphate prodrug that was discovered during a screening study of antimicrobials with antiviral activity, showing promise against the ebola virus. , recently approved by the fda for the treatment of patients with covid- , remdesivir is recommended as a single mg dose, followed by mg daily infusion. besides the drug's clinical use in the treatment of ebola, several clinical trials are ongoing to evaluate the antiviral activity of remdesivir in patients with covid- (nct , nct , nct , nct , and nct ). no pharmacogenetic indications are present, allowing modulation of dosage for therapy. due to its toxicity, remdesivir is not currently fda-approved, and must be obtained via compassionate use, expanded access, or enrollment in a clinical trial. favipiravir ribofuranosyl- ′-triphosphate is a retroviral drug acting as an inhibitor of viral replication (rna-polymerase inhibitor t ). this agent demonstrates broad activity against ebola infection and other rna viruses. favipiravir is recommended at a dose of , - , mg every hours (two doses) followed by maintenance doses of , - , mg every hours. favipiravir is overall well tolerated, although a mild adverse-event profile for higher-dose regimens has been observed. [ ] [ ] [ ] the high doses used result in hyperuricemia, diarrhea, elevated transaminases, and reduction in neutrophil count, but nothing is known about any pharmacogenetic correlations. favipiravir presents efficacy in the treatment of covid- disease, but to date limited clinical experience has reported support for its use. no pharmacogenetic indications are present, allowing modulation of dosage for therapy using this drug. these drugs are well-known protease inhibitors used for the treatment of aids, with good efficacy and safety profiles. while atazanavir is combined with other antiretrovirals, darunavir is used in a fixed-dose combination with cobicistat, a new pharmacokinetic enhancer. with respect to the other protease inhibitors, atazanavir is less likely to cause lipodystrophy and is preferentially used in combination with other antiviral agents (ritonavir), providing antiviral potency equivalent to lopinavir, although concomitant use of ritonavir decreases the efficacy of atazanavir. valid pharmacogenetic correlations of the efficacy of these antivirals can be deduced from studies carried out on hiv patients in which the efficacy of polymorphisms in the ugt a , cyp a , cyp a , and slco a genes has been demonstrated. in contrast, cases of toxicity and adrs are related to sequence variants in the ugt a , ugt a , ugt a , apoe, and apoc genes. [ ] [ ] [ ] [ ] [ ] , , , in some settings, darunavir-cobicistat may be used in the presence of tolerability or availability of the lopinavir-ritonavir combination (https://covid treatmentguidelines.nih.gov). concerning the metabolism of azatavir, the variants cyp a * , cyp a * , cyp a * , cyp a * in cyp a (rs ) have been reported. briefly, individuals carrying one or two copies of the * allele may metabolize atazanavir more rapidly than individuals with one or more copies of the * , * , or * alleles. anticytokine or immunomodulatory agents (tocilizumab, sarilumab, and bevacizumab) monoclonal antibodies directed against key inflammatory cytokines represent another potential class of adjunctive anti-covid- therapies. , il is a key driver of this dysregulated inflammation. the use of monoclonal antibodies against il shows a dampening of this process and improves clinical outcomes. tocilizumab, a monoclonal antibody il -receptor antagonist, is used in severe covid- cases with success. adult doses are mg or corticosteroids are used to reduce lung inflammatory responses that in many cases evolve into acute lung injury and ards. at present, the effects of corticosteroids in patients affected by covid- have been poorly described, so our considerations are based on observations in other viral pneumonia types, such as sars and mers. these previous studies do not indicate any association between corticosteroid use and increased survival, but slower viral clearance in the respiratory and blood tracts, hyperglycemia (high blood sugar), vascular necrosis, and psychotic episodes. as stated, sars-cov has the ability to introduce and infect the host cell using the ace receptor. this has alarmed several researchers, who hypothesized how ace inhibitors and angiotensin-receptor blockers could interfere negatively or positively with the viral infection process. , since ace inhibitors upregulate ace receptors, possible worsening of disease under ace inhibitor therapy has been hypothesized. by contrary, angiotensin-receptor blockers could theoretically prevent the entry of the virus at the cellular level. some rcts specific for captopril used alone or in combination in patients with covid- with severe pneumonia are currently under investigation in order to understand ards (nct , https://clinicaltrials.gov). since ace inhibitors are among the most frequently used drugs in medical practice, consequent knowledge on related pharmacogenetic aspects is now widely known. the polymorphisms that modulate the activity of these drugs in ace, ace , and agtr genes have been widely studied and described in several recent studies. the covid- pandemic is due to the novel pathogenic coronavirus sars-cov , which emerged in china and spread quickly worldwide. , therapeutic options for covid- are wide-ranging, and some drugs have gained emergency-use authorization from the fda and/or european medicines agency. at present, patients are treated with symptomatic therapy and vital support in severe cases. several international efforts are aimed at the investigation and development of antiviral agents, other immunotherapies, and vaccine strategies. pharmacogenomics might be a promising tool in the development of more appropriate therapies (including drug management) and the prevention of fatal-complication onset due to adrs. pharmacogenomics can predict from the beginning the effect of a specific drug formulation in terms of efficacy/ toxicity with respect to individual genetic background and minimize exposure to drugs potentially less/ineffective other than toxic (precision medicine). , as known, drug formulations can elicit different cell/tissue responses depending on individual genetic background. this is possible because each subject can have variations in nucleotide sequences belonging to genes encoding for enzymes involved in the activity of the drug that has been considered for therapy. [ ] [ ] [ ] this aspect appears of great importance in patients having several comorbidities or simply "fragile" old patients. as there is no specific cure for covid- , we reviewed all the therapies (drugs) actually in use to counteract sars-cov effects and the related adverse effects to certain drugs (antiviral, antimalarial, and several biological humanized agents able to reduce the levels of some cytokines belonging to the cytokine storm), as reported by rcts. [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] response to these drugs was extremely complex, and numerous cases of toxicities and antiretroviral drug resistance (viral mutations) have been reported. a possible explanation of this variability might be the presence of factors that modify pharmacokinetics/pharmacodynamics and the activity of the virus itself (viral pharmacodynamics). in addition, viral pharmacodynamics and mutagenesis are still unclear with regard to covid- drug resistance. genetic factors might account at least in part for the unpredictability of therapy among covid- patients. merely, a significant number of snps in genes encoding proteins implicated in the transport and metabolization of drugs may be responsible for the wide variability in drug pharmacokinetics and toxicity. consistently, this review, coupled with a wide in silico analysis on the relevance of identification of snps involved in drug metabolism, provides a list of specific drug-associated snps associated with efficacy (green) or toxicity (red), useful in predicting individual response to therapy in covid- patients. this would imply the possibility of checking variants in biological samples collected and evaluated before the beginning of therapy with the aim of predicting the outcome of a single or combined covid- therapy. to our knowledge, although a considerable number of adr episodes in covid- patients have to date been described in the literature, there has been no pharmacogenetic study attempting to correlate the clinical outcomes of drug treatment with gene variants. the identification of gene variants is only the first step in a complex process prior to applicability into clinical practice. in fact, the clinical application of pharmacogenetic analysis requires previous studies confirming its validity and usefulness. to support this, essential measures applied to genetic tests are required: analytical and clinical validity and clinical utility. while analytical validity defines test accuracy, sensitivity, and specificity, guaranteeing that a "positive" or "negative" result corresponds with the real presence or absence of the sequence variant investigated, clinical validity represents the ability to identify the clinical phenotype of interest, evaluating clinical sensitivity and specificity, and positive or negative predictive values, or in other cases, the association measured as a risk or odds ratio. , of note, clinical utility is related to the evidence that genetic testing can provide useful information for the diagnostic process, better measures for clinical outcomes, and odds ratios for patient-management decision-making (precision medicine). , as such, a pharmacogenetic testpotentially useful for patient treatment -must improve clinical outcomes. evidence on the clinical utility of a pharmacogenetic assay is obtained by experimental studies, preferably rcts. a valid method to evaluate clinical utility is the use of prospective trials on randomized subjects undergoing genetic testing or not to compare the same treatment between the two groups. similarly, prospective trials on genetically stratified groups are also mandatory to comparing treatment outcomes between different groups. , in other cases, clinical utility is determined by a "chain of indirect evidence" linking the results of a genetic test to intermediate data that are associated with improved clinical outcomes. , however, pharmacogenetic research remains an expanding field, and to date there is no unanimous consensus on the best appropriate study designs to uniquely evaluate drug-response variability related to genetic variations. finally, several national drug agencies are carefully evaluating risk:benefit ratios in individual cases, carefully considering the concomitant pathologies (long qt syndrome, major arrhythmias, liver or kidney failure, electrolyte disorders), pharmacological associations (in particular for drugs that increase the qt), and above all the clinical anamnesis and identification with genetic diagnosis of favism (g pd deficiency). in our opinion, this is the first study to suggest the application of personalized medicine tools during the treatment of sars-cov infection. all identified snps, including allelic efficacy/toxicity, selected from an accurate in silico analysis have been identified for the most promising and repurposed drugs, and the investigational and adjunctive experimental drugs have been reported in both tables and figures. particularly, in figure we graphically represent the frequency of snp alleles related to an efficacy response (green bars) or toxicity (red bars), useful in predicting individual response to therapy with the main therapies used for covid- patients. in this study, tocilizumab showed varying efficacy, while inside the antiviral group a divergent response was observed. therefore, to understand from the beginning specific susceptibility (efficacy/toxicity) to a drug, as displayed by the presence of specific functional clusters in the genetic background of the patient under treatment, might assist the specialist toward a more "specific" selection of therapeutic agent. this would result in a more appropriate therapeutic response, with fewer adrs. as reported in other therapies, this individualized approach dovepress appears of great utility, and particularly for the covid- pandemic could improve the choice of more efficient therapy. the screening is less invasive for the patient, as it is possible by venous blood or buccal-cell swab using realtime pcr analysis. any attempt to find more suitable tests, identify asymptomatic/presymptomatic and/or confirm symptomatic subjects, and therapeutic agents/strategies to sustain therapeutic decisions in covid- -affected patients appears mandatory. herein, we performed a wide in silico study of genetic variants associated with the main drugs in use for covid- therapy, providing a list of genetic variants of efficacy/toxicity. this study highlights the clinical utility of a pharmacogenetic tool in planning personalized treatments that are likely to become essential in the pharmacological management of covid- patients. journal to which the article has been submitted, and agree to be accountable for all aspects of the work. the authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest and report no conflicts of interest for this work. pharmacogenomics and personalized medicine is an international, peer-reviewed, open access journal characterizing the influence of genotype on pharmacology leading to the development of personalized treatment programs and individualized drug selection for improved safety, efficacy and sustainability. this journal is indexed on the american chemical society's chemical abstracts service (cas). the manuscript management system is completely online and includes a very quick and fair 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pharmacogenetic inference clinical utility of genetic and genomic services: context matters am and ac thank the italian ministry of health and fondazione roma (italy). cc, ar, am, rp, and sp conceived the study and participated in its design and coordination. cc, ar, am, and rp contributed to data collection and analysis. all authors made a significant contribution to the work reported, whether in its conception, study design, execution, acquisition of data, analysis and interpretation, or all these areas, took part in drafting, revising, or critically reviewing the article, gave final approval to the version to be published, have agreed on the key: cord- - ffnejwj authors: kwon, seungwon; lee, wonhaeng; jin, chul; jang, insoo; jung, woo-sang; moon, sang-kwan; cho, ki-ho title: could herbal medicine (soshihotang) be a new treatment option for covid- ?: a narrative review date: - - journal: integr med res doi: . /j.imr. . sha: doc_id: cord_uid: ffnejwj background: while the world struggles under the coronavirus disease (covid- ) pandemic, a variety of antiviral agents and symptomatic treatments are being administered to patients and urgent clinical trials are underway. under these circumstances, it is important to explore various possibilities for the treatment of covid- including herbal medicines. among various herbal medicines, soshihotang (ssht,xiao chai hu tang in chinese) has been prescribed to treat various viral diseases and is used in combination with other herbal medicines depending on the patient’s symptoms. methods: for conducting the present review, we searched electronic databases focusing on the antiviral effect of ssht in experimental and clinical study until april . the search keywords included ssht, constituents of ssht, and antiviral effect. we also searched for materials related to topic directly from websites and published books. based on these search results, we summarized the results of the included materials in the form of a narrative review. results: in a number of recent clinical studies, treatment with ssht improved the infection status of the respiratory and hepatobiliary systems, and experimental studies demonstrated the antiviral effect of ssht and its components. furthermore, ssht are being used in china—where covid- outbreak first took place—and offer a new option to treat covid- . conclusion: based on the present evidences, it is believed that ssht is likely to be a new therapeutic option for covid- . conducting further studies might provide improved understanding regarding the use of ssht in treating covid- . on march , , the world health organization declared that the outbreak of coronavirus disease (covid- ) is a global pandemic. the decision came as a result of , covid- infections and , deaths worldwide. currently, there are no established treatments other than supportive therapies that treat the symptoms of covid- . however, as covid- is a viral infectious disease caused by sars-cov- , some antiviral agents have been used for treatment. antiviral agents such as lopinavir-ritonavir, chloroquine (including hydroxychloroquine), remdesivir, umifenovir, and ribavirin are being used, and clinical trials are ongoing. however, clinical trials of lopinavir-ritonavir (a combination of the hiv protease inhibitors) in patients admitted with severe covid- did not show a significant effect. in addition, ribavirin is known to have specific adverse effects such as psychiatric problems, making it unsuitable as a first-choice medication. clinical trials involving remdesivir and chloroquine are still in progress. in addition to treatment with antiviral agents, interferons, steroids, intravenous immunoglobulin, antibiotics, and convalescent blood plasma are used depending on the patient's condition. there is no conclusive evidence that these antiviral agents and other treatments are effective against covid- . consequently, there is a need to search for candidate drugs other than conventional therapies. in this situation, china, the first country to experience covid- , has used traditional chinese herbal medicine (tchm) for the prevention and treatment of covid- based on the experience of using tchms during the past epidemic of severe acute respiratory syndrome (sars). , in the chinese guidelines for the prevention, diagnosis, and treatment of novel coronavirus-induced pneumonia ( th edition), qingfei paidu tang (qpt) has been suggested as a herbal medicine that can be used regardless of the stage of the disease, along with prescriptions for herbal medicines that are stage-specific. based on this guideline, herbal medicine treatment has been used in more than % of confirmed patients with covid- in j o u r n a l p r e -p r o o f a region. in a recent study aimed at evaluation of the combined effect of herbal medicine and conventional treatments, the rate of symptom loss at discharge, the rate of chest computed tomography (ct) image improvement, and the rate of clinical cure were significantly improved and the rate of disease exacerbation was significantly decreased compared with those after conventional treatments only. in addition, clinical trials of various oral medications and injections based on herbal medicine are underway in china. in this short narrative review, we will discuss the current clinical use and antiviral effects of soshihotang (ssht, xiao chai hu tang in chinese, shosaikoto in japanese), which has been used in the past mainly for infectious diseases with chronic progression. in addition, we suggest the possibility of utilizing ssht as a new therapeutic option for covid- . for conducting the present review, we searched electronic databases (pubmed, scopus, recens, zizyphi fructus, glycyrrhizae radix et rhizoma, and antiviral effect. there was no language restriction in the searching process. in addition to searching for electronic databases, we also searched for materials related to topic directly from websites and published books. based on the search results, we summarized the following items in the form of a narrative review; i) indications of ssht in classical medicine and in symptoms of covid- , ii) utilization status and clinical evidence of ssht in infectious diseases, especially viral diseases, iii) antiviral effect of ssht in experimental studies, iv) potential role of ssht in repurposing j o u r n a l p r e -p r o o f the treatment of covid- , v) ssht variants that can be used according to various clinical symptoms, and vi) cautions when using ssht. through the electronic databases search, we found articles evaluating the clinical usefulness of ssht for infectious diseases, especially viral diseases (n= ), [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] and experimental studies (n= ) for antiviral effects of ssht and its constituents. in addition to these, we wrote this review using articles found through direct searches on websites and published books. ssht is a traditional herbal medicine prescription that consists of a total of seven herbs (bupleuri radix, scutellariae radix, pinelliae tuber, ginseng radix, zingiberis rhizoma recens, zizyphi fructus, and glycyrrhizae radix et rhizoma) ( table ). ssht appeared first in shanghan zabing lun, a classic of traditional east asian medicine that is thought to have been published before ad . one part of shanghan zabing lun is shanghan lun, translated as "treatise on cold-induced diseases"-a medical classic that contains traditional medical treatments for infectious diseases with fever. in shanghan lun infectious diseases are categorized as "greater yang," "lesser yang," "yang brightness," "greater yin," "lesser yin," or "reverting yin" according to the stage of disease progression, and the text describes the indications and the prescriptions that could be used at each stage. ssht has been classified as a representative prescription of "lesser yang," but it is suggested as a prescription that can be used at almost any stage of the disease. ssht appears in several verses of shanghan lun, and the representative indications are as follows: -after suffering from zhong feng syndrome with cold damage for five or six days, there is alternating chills and fever, discomfort and fullness in the chest and hypochondriac region, taciturnity with no desire to eat, a sick and discomforting feeling in the stomach and easily vomiting with any of the following possible symptoms and signs; vexation in the chest and absence of vomiting, thirst, abdominal pain, fullness and hardening below the hypochondriac region, palpitation in the epigastrium and abnormal urination, absence of thirst and slight fever on the body or cough. ssht should be prescribed. -in yang brightness disease, when there is tidal fever, loose stool, normal urination, and fullness in the chest and costal/hypochondriac region that has not abated, ssht might be prescribed. -in zhong feng syndrome of yang brightness disease, there are wiry, floating and big pulses, shortness of breath, fullness in the abdomen, pain in the epigastric region and costal/hypochondriac region, a sense of qi blockage under prolonged pressure, a dry nose, the absence of sweating somnolence, yellow coloration all over the body and the eyes, difficult urination, tidal fever, hiccup at times, and swelling in front of and behind the ears. the condition is slightly better after needling, but the exterior syndrome remains unchanged. if the disease has lasted for more than ten days and the pulse is still floating, ssht might be prescribed. considering the indications above, ssht should be prescribed when there are symptoms in fever and chest discomfort along with the symptoms of digestive tract (loss of appetite, nausea, vomiting, diarrhea, or constipation, etc.) after initial onset or within days of the occurrence of infectious diseases. based on the indications and recommendations in the shanghan lun, ssht has been used for various infectious diseases, especially respiratory, gastrointestinal, and liver diseases with or without fever. the typical clinical symptoms of covid- are lower respiratory symptoms (including dry cough), high fever, and difficulty breathing. in a chinese study of , diagnosed covid- cases, approximately % revealed severe dyspnea (oxygen saturation of % or less, lung infiltration %), and % showed fatal symptoms such as respiratory failure, organ j o u r n a l p r e -p r o o f failure, dysfunction, and septic shock. there have also been reports of accompanying gastrointestinal symptoms such as nausea, vomiting, and abdominal discomfort (although the frequency is low) after the initial respiratory symptoms. in another investigation in wuhan, hubei, the most commonly reported clinical manifestations were fever ( . %), cough ( . %), fatigue ( . %), and gastrointestinal symptoms ( . %). in addition, there have been some cases that have shown only gastrointestinal symptoms from the onset. the first covid- case in the united states is the representative example. this patient was hospitalized with nausea and vomiting on the second day of onset and was confirmed as a covid- case after the symptom of loose stool was observed on the second day of hospitalization. the clinical appearance of covid- , which is accompanied by fever, respiratory and gastrointestinal symptoms at a relatively early stage, is similar to the indications of ssht described in the medical classic, shanghan lun. ssht has been used to treat infectious diseases caused by various bacteria and, particularly, viruses. with respiratory system infections, in particular, there have been reports of ssht used to treat viral infections such as influenza or the common cold. in a study comparing the effects of oseltamivir in patients with influenza a, ssht treatment had an antipyretic effect equivalent to that of oseltamivir. the time required for the antipyretic effect was evaluated according to the treatment: oseltamivir (n = participants), mahwangtang (mht, ma huang tang in chinese, maoto in japanese; n = ), or ssht (n = ). the oseltamivir group required . ± . days for antipyretic effect, and both the mht and ssht groups showed antipyretic effect after . ± . days, with no significant difference between the two groups. ssht has j o u r n a l p r e -p r o o f also been reported to be a treatment for the common cold with more than five days progress. ssht (n = ) or placebo (n = ) was administered to patients ( to years old) with colds more than days after the onset of illness, accompanied by oral discomfort, anorexia, and tiredness. within one week ( days) after treatment, ssht group showed better results than placebo in the overall improvement (total effective rate: . % vs . %, ssht vs placebo). the ssht group showed significant improvement in the symptoms of sore throat and tiredness in to days compared with the placebo group. after the final ssht administration, appetite, arthralgia, and muscle pain were significantly improved compared with placebo administration. this result suggests that ssht might be an effective treatment of the common cold with delayed progress. in a report of a non-viral infection, pulmonary tuberculosis, ssht has also been used in the treatment of idiopathic interstitial pneumonia. tanaka et al. divided idiopathic interstitial pneumonia patients into a control group (n = ) without additional medication administration and a treatment group (n = ) administered ssht and compared the treatment results after more than months. improvement was shown in . % ( / ) of the patients in the treatment group and slight improvement ( . %, of patients) was shown in the n treatment group. j o u r n a l p r e -p r o o f ssht has attracted much more attention for its antiviral effect in chronic hepatitis b and c. although the shanghan lun did not intend for ssht to be used in liver disease, ssht has been used for this purpose based on indicative phrases in the text such as "yellow coloration all over the body and the eyes" and "discomfort and fullness in the chest and hypochondriac region". in cases of hepatitis c, it was confirmed that fever, alopecia, and leukocyte levels were significantly improved following the combination therapy of ssht and interferon compared with those following interferon monotherapy. improvements in the levels of aspartate transaminase (ast), alanine transferase (alt), and knodell's histology activity index, in % ( / patients) were evident when patients were administered ssht for months. in another study, ssht was administered for three years, and fibrosis markers were regularly followed (n = ). as a result, alt levels were reduced in both chronic active hepatitis and chronic persistent hepatitis (cph) patients. in addition, in cph, procollagen iii peptide (piiip) was normalized in % of cases and s collagen in % of cases, which suggests a liver fibrosis suppressive effect of ssht in chronic hepatitis c. there are an increasing number of reports of the use of ssht in the treatment of chronic hepatitis b. in most of these studies, patients are given combination therapy of ssht with interferon-based chemotherapy. although there was a slight difference in the results of each study, the adjunctive or single administration treatment using ssht showed a tendency to improve liver function, partial hbeag negative, and reduced viral load in patients with hepatitis b compared with chemotherapy alone or placebo. [ ] [ ] [ ] [ ] these results suggest that ssht has an antiviral effect against the chronic hepatitis virus. j o u r n a l p r e -p r o o f as described above, ssht has been applied to the treatment of viral diseases of the respiratory system and hepatobiliary system. the clinical results of ssht treatment can be explained by the antiviral effects of ssht itself and the effects of each constituent herb. ssht has been shown to inhibit coxsackievirus b infection by inducing the expression of type i interferons , and has been reported to inhibit antigen production through chemical promoters against epstein-barr virus. it has also been reported that ssht could prevent hepatitis c virus (hcv) disease progression by promoting interleukin- and - production. experimental research has shown that each constituent herb in ssht has antiviral effects. in particular, saikosaponin, a major component of bupleuri radix, has been reported to have antiviral activity against hcov- e , a coronavirus similar to covid- . in addition, saikosaponin a inhibits influenza a replication. it has been found that ginsenoside rb , a major component of ginseng, can remove cytoprotective macrophages found in human immunodeficiency virus type (hiv- ) infection by inhibiting the akt pathway. the most extensively studied antiviral herb is scutellariae radix. the major component of scutellariae radix, baicalin, is known to have antiviral activity against influenza a, , hiv- , , respiratory syncytial virus (rsv), dengue, chikungunya, duck hepatitis virus (dhv), , enterovirus, and hbv. another component of scutellariae radix, wogonin, also has an antiviral effect against the influenza virus and hbv. lastly, glycyrrhizae radix et rhizoma and its components have been reported to have antiviral activity against hcv, coxsackievirus b , dhv, influenza, rotavirus, rsv, and herpes simplex virus , (table in china, which saw the first manifestation of covid- and experienced local epidemics, treatment for the disease included tchms in combination with conventional therapies. , in the chinese guidelines for the prevention, diagnosis, and treatment of novel coronavirus-induced pneumonia ( th edition), qpt has been suggested as a general treatment regimen for the results of a network pharmacology analysis of the effect of ssht on covid- also suggested that ssht may be effective for early covid- prevention and treatment. the authors investigated components of ssht that show anti-sars-cov- activity (baicalein, beta-carotene, coptisine, formononetin, glycyrrhizic acid, kaempferol, moupinamide, quercetin, saikosaponin a, saikosaponin b , saikosaponin d, and -methoxy- -methyl isoflavone) could be effective for pneumonia treatment and immunoregulation by acting on a total of key targets (il- , nos , esr , etc.). based on these results, it was assumed that ssht could have effects such as inhibition of sars-cov activity, blocking of sars-cov invasion pathway, and suppression of cytokine storm expression. this phenomenon demonstrates multi-target and multi-directional activity, which is an advantage of herbal medicine composed of various herbs (table ) . furthermore, it is necessary to pay special attention to the immunomodulatory effect of ssht. in an experimental study using a cyclophosphamide-induced immunosuppression animal model, ssht was shown to exert an immunomodulatory effect that increases lymphocytes only in the immunosuppressive model (and is invalid in the normal animal model). in an observational study of patients with covid- , early lymphocyte degradation was observed to be a characteristic observation in the patients, suggesting that early lymphocyte degradation would have diagnostic value. considering these serologic abnormalities associated with early covid- and the immunomodulatory effect of ssht, it is possible that the use of ssht in the early to mid-term stages of the disease could be helpful (table ) . most minor liver injuries will recover without special treatment, but severe liver injuries will result in significant disease burden. as mentioned earlier, ssht has been utilized in patients with hbv or hcv infection and has shown significant antiviral and hepato-protective effects. [ ] [ ] [ ] [ ] [ ] [ ] [ ] these clinical and pharmacological evidences of ssht will be expected to play a role in the management of liver injury in patients with covid- (table ) . traditionally, ssht has been used in combination with various prescriptions depending on the symptoms accompanying various infectious diseases. an example is given in table . as we discussed earlier, ssht (as part of qpt) has been utilized in the covid- epidemic as a basic prescription that can be used at various stages. , this history of ssht use suggests that each prescription for each patient can be modified according to symptoms and that the antiviral action of ssht can also form the basis of prescription. ssht should be used with caution. the korean ministry of food and drug safety permits the use of ssht, except in the following contraindications (table ) : patients receiving interferon; patients with liver cirrhosis and liver cancer (use of ssht can lead to interstitial pneumonia, which can further cause serious consequences such as death); patients with platelet counts of less than , /mm owing to liver dysfunction. it is known that administering ssht in the above situations may cause interstitial pneumonia; therefore, use of ssht in these situations should be avoided. in particular, because of the risk of interstitial pneumonia, using ssht requires caution with combination with interferon. according to the covid- treatment guideline of korean association of internal medicine, use of type i interferon as monotherapy is not recommended, but use of combined therapy is recommended. therefore, when considering the use of ssht in clinical practice, it is necessary to confirm whether interferon is used or not. moreover, there have also been case reports of pulmonary edema occurring after ssht was used for liver dysfunction of unknown etiology. , therefore, it is necessary to pay attention to the use of ssht when there is a liver dysfunction of unknown cause. ssht has been used for infectious diseases for perhaps the last , years, and its efficacy in infectious diseases has been scientifically established. [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] in particular, ssht has been used in various viral diseases based on its antiviral effect and-if contraindications are dully considered-it can be regarded as a relatively safe medication given its long history of use. in addition, considering the indications of ssht, and the scope of its previous usage, we think that ssht could be prescribed for covid- patients with persistent fever, respiratory symptoms such as cough or sputum, and liver injury caused by conventional therapies. based on the evidence so far, it is believed that ssht is likely to be a repurposing medication for covid- . conducting further studies might provide improved understanding regarding the use of ssht in treating covid- . the authors declare that there is no conflict of interest regarding the publication of this paper. not applicable. data will be made available upon request. all data used for this study are from previous studies which are included in references. the authors declare that no funding was received in relation to this study. ) patients with liver cirrhosis and liver cancer (interstitial pneumonia can occur, which can lead to serious consequences such as death) ) patients with platelet counts less than , /mm because of liver dysfunction j o u r n a l p r e -p r o o f table . antiviral effect of soshihotang as observed in experimental studies tonsillitis and peritonsillitis. these conditions accompanied by sore throat: ssht; soshihotang * the indications are based on drug approvals from korea and japan. sars-cov- and covid- : the most important research questions discovering drugs to treat coronavirus disease (covid- ) a trial of lopinavir-ritonavir in adults hospitalized with severe covid- managing psychiatric side effects of antiviral therapy in chronic hepatitis c can chinese medicine be used for prevention of corona virus disease (covid- )? a review of historical classics, research evidence and current prevention programs covid- : an 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pneumonia: comparison with the control group combination therapy of interferon and sho-saiko-to in chronic hepatitis c. abstracts of the a single arm phase ii study of a far-eastern traditional herbal formulation (sho-sai-ko-to or xiao-chai-hu-tang) in chronic hepatitis c patients examination of various fibrosis markers during long-term administration of sho-saiko-to in chronic hepatitis c effect of sho-saiko-to(xiao-chai-hu-tang) on hbeag clearance in children with chronic hepatitis b virus infection and with sustained liver disease clinical effects of sho-saiko-to on chronic hepatitis b study on the efficacy of sho-saikoto for chronic hepatitis b in hbeag positive children therapeutic effect of ifn-β (feron) and shosaikoto combination therapy on chronic active hepatitis b antiviral natural products and herbal medicines xiao chai hu tang inhibits cvb virus infection of ccfs- cells through the induction of type i interferon expression inhibitory effects of kampo medicine on epstein-barr virus antigen induction by tumor promoter effects of the japanese herbal medicine "sho-saiko-to" (tj- ) on interleukin- production in patients with hcv-positive liver cirrhosis saikosaponin a inhibits influenza a virus replication and lung immunopathology ginsenoside rb eliminates hiv- (d )-transduced cytoprotective human macrophages by inhibiting the akt pathway in vivo effect of quantified flavonoids-enriched extract of scutellaria baicalensis root on acute lung injury induced by influenza a virus the inhibitory effect of sodium baicalin on oseltamivir-resistant influenza a virus via reduction of neuraminidase activity flavonoid baicalin inhibits hiv- infection at the level of viral entry baicalin, an inhibitor of hiv- production in vitro baicalin from scutellaria baicalensis blocks respiratory syncytial virus (rsv) infection and reduces inflammatory cell infiltration and lung injury in mice. sci rep baicalin, a metabolite of baicalein with antiviral activity against dengue virus. sci rep deciphering the potential of baicalin as an antiviral agent for chikungunya virus infection assessment of the effect of baicalin on duck virus hepatitis inhibition mechanisms of baicalin and its phospholipid complex against dhav- replication the antiviral effect of baicalin on enterovirus in vitro baicalin benefits the anti-hbv therapy via inhibiting hbv viral rnas wogonin, a flavonoid isolated from scutellaria baicalensis, has anti-viral activities against influenza infection via modulation of ampk pathways anti-hepatitis b virus activity of wogonin in vitro and in vivo anti-hepatitis c virus compounds obtained from glycyrrhiza uralensis and other glycyrrhiza species the antiviral and antimicrobial activities of licorice, a widelyused chinese herb integrated drug information system treatise on cold-induced and miscellaneous diseases). beijing digital museum of tcm a study on the transmutation among six-channels in shanghanlun a study on the complex efficacy of soshihotang characteristics of and important lessons from the coronavirus disease (covid- ) outbreak in china: summary of a report of cases from the chinese center for disease control and prevention clinical characteristics of hospitalized patients with novel coronavirus-infected pneumonia in wuhan clinical characteristics of patients infected with sars-cov- in wuhan first case of novel coronavirus in the united states expression of animal virus genomes clinical observation of qingfeipaidu decoction in the treatment of novel coronavirus pneumonia. pharmacology and clinics of chinese materia medica mechanism by which ma-xing-shi-gan-tang inhibits the entry of influenza virus study on the effect of kampo treatment for infectious diarrhea. recent progress of kampo medicine in traditional chinese medicine master professor zhou zhongying's interpretation for "traditional chinese medicine differentiation and treatment of new coronavirus pneumonia tcm differentiation and treatment of new coronavirus pneumonia in jiangsu province network pharmacological analysis and mechanism prediction of xiaochaihu decoction in treatment of covid- with syndrome of pathogenic heat lingering in lung and obstructive cardinalate immunoregulatory activity of bupleuri decoction on the expression of costimulatory molecules on the lymphocytes in immunosuppressed mice expression of lymphocyte subsets in peripheral blood of patients with novel coronavirus pneumonia and its clinical significance liver injury in covid- : management and challenges covid- treatment guideline of korean association of internal medicine a non-cardiogenic type of pulmonary edema after administration of chinese herbal medicine (shosaikoto)--a case report pulmonary edema associated with the chinese medicine shosaikoto group v: influenza group of virus are determined based on baltimore classification group i: viruses possessing double-stranded dna group ii: viruses possessing single-stranded dna group iii: viruses possessing double-stranded rna genomes group iv: viruses possessing positive-sense single-stranded rna genomes group v: viruses possessing negative-sense single-stranded rna genomes group vi: single-stranded rna viruses that replicate through a dna intermediate group vii: viruses possessing double-stranded dna genomes and replicating using reverse transcriptase key: cord- - yoilsho authors: nan title: abstracts of the (nd) annual meeting of the german society for experimental and clinical pharmacology and toxicology (dgpt) and the (th) annual meeting of the network clinical pharmacology germany (vklipha) in cooperation with the arbeitsgemeinschaft für angewandte humanpharmakologie e.v. (agah) date: - - journal: naunyn schmiedebergs arch pharmacol doi: . /s - - -y sha: doc_id: cord_uid: yoilsho nan in vitro systems and mechanistic investigations i the demand of alternative test systems which closely mirror the in vivo situation is one of the main challenges in modern toxicity testing. the major goal is the development of in vitro systems that partly display the complexity of an organism and thus may mimick in vivo conditions. despite great efforts in the past no adequate in vitro systems are available yet. on the other hand, cell cultures from almost every organ are easily accessible and therefore may help to roughly assess the toxic potential of substances at target structures. nonetheless, the complex interactions which take place in vivo cannot be addressed in single cell cultures. in the liver, hepatocytes comprise % of the total liver volume while non-parenchymal cells -endothelial cells, stellate cells and kupffer cells (that is, liver resident macrophages) -contribute only . % of the volume, but % of the total cell number (kmiec ) . it has been increasingly recognized that in the liver neighboring non-parenchymal cells release molecules which contribute to the inflammatory damage and even aggravate it (adams et al. ) . in our project a human in vitro co-culture system was established by combining a hepatic and a monocytic cell line, the latter of which can be differentiated to a macrophage-like phenotype. in this system the hepatotoxicty of substances has been analyzed, and the results were compared to single cultures and to published data from in vivo studies. using ketoconazole, an antifungal, as a known hepatotoxic substance, inflammatory markers were studied and proved to be significantly upregulated only in coculture. conversely, cultures of hepatic cells only did not display this increase in inflammatory markers. at the same time, a negative substance, caffeine, failed to show any hepatotoxic potential in the co-culture system. our results demonstrate that this novel in vitro co-culture model represents a promising tool to evaluate the hepatotoxic potential of substances. in drug research, it might help to reduce animal testing as drugs with a high dili potential can be dropped early in the development phase. question: raman spectroscopy (rs) is a highly sensitive analytical method for markerfree and non-invasive identification and characterization of cells. here, we present rs as a novel tool for gentle yet precise cell analysis in three independent experiments, focusing on monitoring cellular reactions upon treatment. we could provide evidence that rs is a suitable tool to monitor cell differentiation, analyze cell modification and study cell apoptosis after drug application. methods: in a first experiment, mesenchymal stem cells (mscs) were treated with erythropoetin (epo) for certain time points and subsequently fixed with paraformaldehyde (pfa) for raman analysis. in addition, skbr breast cancer cells were exposed to the anti-cancer drug herceptin ( μg/ml). cells were then fixed in pfa for rs. in a last experiment, molm- cells were separately cultivated in microwells and treated with thymidine for different time points prior to raman analysis. results: raman spectroscopy was able to monitor differentiation of epo treated mscs and found that around % of treated cells showed fibroblast like raman profiles. in case of herceptin treated skbr cells, rs found internal changes of the cell´s metabolism as reaction on drug application. analyzing the most prominent differences in raman spectra revealed discrimination of cells to be mainly due to changes in amid i, lipid and protein content. in the last experiment, rs was able to follow apoptosis of molm- cells after thymidine application and discriminate early from late apoptotic states. discussion: rs is a photonic marker for gentle yet highly specific cell analysis, which allows monitoring of single cell reaction after drug treatment. thereby, rs provides information about changes within the entire metabolome on a single cell level. raman spectra are as characteristic as a "fingerprint". rs works label-free and non-invasive and thus does not impare cell viability. this allows to gain new insights in pharmacological development and toxicological survey. acknowledgement: this project received funding from the eu th health program grant agreement no . deutsches zentrum für herzinsuffizienz, würzburg, germany extracellular signal-regulated kinases and (erk / ) are essential for the regulation of cell growth and cell survival and their kinase activity is up-regulated for example in different types of cancers and pathological cardiac hypertrophy. while inhibition of erk / activity by kinase inhibitors prevents tumor growth, it can also lead to exacerbated cardiomyocyte death and impaired heart function. interestingly, we have previously identified an erk autophosphorylation at threonine as a prerequisite for nuclear erk / signaling and erk-mediated cardiac hypertrophy. here, we investigated an alternative strategy to interfere with erk / signaling: since activation of erk / triggers erk dimerization, a prerequisite for erk t autophosphorylation, we chose the erk dimer interface as a possible target to selectively interfere with erk t -phosphorylation. first, we investigated the impact of monomeric erk on cardiac function. to address this issue, we generated mice with cardiac overexpression of monomeric erk ∆ - and performed transverse aortic constriction (tac) to induce cardiac hypertrophy. compared to wild-type mice, erk ∆ - overexpression attenuated tac-induced cardiac hypertrophy, interstitial fibrosis and mrna expression levels of collagen and brain natriuretic peptide (bnp), while cardiomyocyte survival and cardiac function were largely preserved. because of the positive effects of monomeric erk ∆ - in the heart, we designed a peptide to interfere with endogenous erk dimerization. cross-linking and coimmunoprecipitation experiments showed that the peptide binds to erk and prevents its dimerization. moreover, the peptide effectively inhibited erk t -phosphorylation and nuclear translocation of yfp-tagged wild-type erk after phenylephrine stimulation. further, adenoviral or adeno-associated virus serotype (aav )-induced overexpression of the peptide in neonatal rat cardiomyocytes (nrcm) or mouse hearts resulted in a significantly reduced hypertrophic response to phenylephrine or tac, background: g i -proteins have been proposed to be cardioprotective. it's matter of debate whether this depends on the particular g i isoform and/or on the particular conditions (e.g. cardiac "stress") only. in our study we investigated effects of a gα i knockout on cardiac function and survival in a murine heart-failure model of cardiac β adrenoceptor overexpression. methods and results: β -adrenoceptor overexpressing mice lacking gα i (β -tg/gα i -/-) were compared to wild-type (c bl/ ) mice and littermates either overexpressing cardiac β -adrenoceptors (β -tg) or lacking gα i (gα i -/-). at days of age mortality of mice only lacking gα i was higher compared to wild-type or β -tg, but similar to β tg/gα i -/mice. beyond days mortality of β -tg/gα i -/mice was enhanced compared to all other genotypes (mean survival time: ± days). echocardiography revealed similar cardiac function of wild-type, β -tg and gα i -/mice, but significant impairment for β -tg/gα i -/mice (e.g. ejection fraction ± % versus ± % in wild-type mice). significantly increased ventricle-to body-weight ratio ( . ± . % versus . ± . % in wild types), left-ventricular size (length . ± . cm versus . ± . cm in wild types) and anp and bnp expression (mrna: % and % of wild type, respectively) clearly indicated hypertrophy. gα i was significantly upregulated in gα i -knockouts (protein compared to wild-type mice: ± % in gα i -/and ± % in β -tg/gα i -/-, respectively). radioligand binding experiments confirmed cardiac overexpression of β adrenoceptors in β -tg mice. of note, overexpression levels differed depending on the particular wild-type background. on an fvb/n background we found the overexpression level to be more than -fold higher (b max : ± fmol/mg) than on the otherwise used c bl/ background. accordingly, fvb/n-based β -tg mice showed a significantly impaired cardiac function at an age of d while c bl/ -based β -tg mice did not. conclusions: gα i -deficiency combined with cardiac β -adrenoceptor overexpression strongly impaired survival and cardiac function. on a c bl/ background β adrenoceptor overexpression alone had not induced cardiac hypertrophy or dysfunction at day while there was overt cardiomyopathy in mice additionally lacking gα i . we propose an enhanced effect of increased β -adrenergic drive by lack of protection via gα i . the observed gα i upregulation was not sufficient to compensate for gα i deficiency suggesting an isoform-specific and/or a concentration-dependent mechanism. the role of gα i is currently addressed in a subsequent study using β -tg and gα i deficient mice. heart failure is accompanied by morphological and functional alterations (e.g. hypertrophy, decreased contractility) which are summarized by the term "cardiac remodeling". while the β-adrenergic signaling pathway is essential for short-term modulation of cardiac performance, its chronic stimulation by elevated plasma catecholamines and the subsequent activation of camp-dependent signal transduction pathways is regarded as a fundamental factor in the pathogenesis of cardiac remodeling. however, the mechanisms mediating the transition of physiological conditions of short-term to detrimental remodeling under long-term β-adrenergic stimulation are not understood in detail so far. in this context, icer, an isoform of the camp dependent transcription factor crem (camp responsive element modulator), acts as an early response gene strongly induced by beta-adrenergic stimulation via camp responsive elements (cre) in its promoter. contrary to its cre-mediated induction, icer is a strong inhibitor of cre-mediated transcription by itself. here we study the role of icer induction in the catecholamine-induced cardiac remodeling in a time dependent manner by the use of icer deficient mice (iko) and wild type (wt) controls, which were treated with isoproterenol (iso; mg/kg per d) for and hours and days. overall days of iso stimulation resulted in an elevation of cardiomyocyte length in iko (in µm; d iso ± ) vs. wt cardiomyocytes ( d iso ± ). at this time point a % decrease of cardiac output and a % decrease of the maximal rate of rise of left ventricular pressure (dp/dt max ) in iko vs. wt animals was detectable. the maximum increase of icer mrna in wt cardiomyocytes already occurred after h ( -fold), and declined after h ( -fold) to . fold increase after days, while icer mrna was not detectable in iko mice. this raised the hypothesis, that the early induction of icer modulates transcriptional processes after beta-adrenergicstimulation, involved in cardiac remodeling of the heart. profiling of mrna expression levels between iko vs. wt cardiomyocytes at the different time points revealed: regulated genes (up-regulated: %) in untreated; altered genes (up %) after h; changed genes (up %) after h and altered genes (up %) after days of iso treatment. in summary, the absence of icer induction in myocytes resulted in an increase of cardiomyocytes length and a decrease of heart performance after days of betaadrenergic stimulation. this is preceded by upregulated mrna levels of several hundred genes at h, which is going along with the induction of transcriptional inhibitor icer after a few hours of beta-adrenergic stimulation. this suggested a protective role of icer by inhibiting the progression of cardiac remodeling after betaadrenergic stimulation in an early responsive manner. (supported by the dfg) the performance of the adult heart is tightly regulated by g protein-coupled receptors. adrenergic and angiotensin receptors efficiently control heart rate and contractility. muscarinic receptors, on the other hand serve as master regulators of the conduction system, which is often lost upon myocardial infarction. this function of muscarinic receptors has been well described in the adult or late embryonic heart. here we provide evidence that muscarinic receptors are crucial to constrain pacemaker cell identity. we applied subtype-specific inhibitors of muscarinic receptors to zebrafish embryos of different stages. we observed that both, early cardiac function as well as specification are specifically regulated by muscarinic m receptors, while m receptors appear to exert a heart-specific function only at later stages. continuous m blockage renders zebrafish with greatly altered cardiac morphology, particularly of the conduction system. furthermore, embryos with m inhibition display impaired ventricular function most likely due to an av-block and substantial arrhythmia in the atrium. importantly, to observe these phenotypes it was sufficient to block m receptors during stages of cardiac differentiation, which is long before a heart tube has formed. we corroborated our findings regarding these morphological changes using marker gene analysis. furthermore, we obtained evidence for m receptors preventing a transcriptional program towards the induction of pacemaker cells at the expense of av canal cells. importantly, this is not only true during heart development. a pacemaker program is also induced in adult hearts upon m inhibition. taken together, we postulate that muscarinic m receptors confine a pacemaker lineage during early steps of heart development as well as in the adult heart. our data suggests m receptors as potential new therapeutic targets for the regeneration of hearts with an injured sinoatrial node. systemic inhibition of mir- has proved effective against fibrosis of the myocardium and in other organs. mir- has been reported to exert detrimental effects in cardiac fibroblasts and protective roles in cardiac myocytes and other myocardial cell types. a better definition of the cell types that contribute to the beneficial effects of inhibiting mir- in vivo may aid the development of strategies with enhanced therapeutic efficacy. thus far, no approach to selectively manipulate micrornas in the non-myocyte population of cardiac cells in vivo has been available. in this study, we developed an icre-encoding mml virus for application in mir- fl/fl mice. delivery of this vector to neonates achieved targeted genetic ablation of mir- in non-myocyte cardiac cells. immunohistochemistry and flow cytometry confirmed that mmlv was highly selective and effective for cardiac fibroblasts and endothelial cells. in parallel, an aav -icre vector allowed for specific and almost complete deletion of mir- in cardiac myocytes. when tested in a model for chronic left ventricular pressure overload, mmlv-icremediated deletion of mir- in cardiac fibroblasts and endothelial cells significantly reduced cardiac fibrosis and hypertrophy and improved cardiac function. the benefit of this cell-type-specific inhibition exceeded that observed upon global genetic deletion of the mir- gene in mice. aav -mediated deletion of mir- , albeit lowering cardiac hypertrophy, had no effect on fibrosis or cardiac function. taken together, neonatal delivery of engineered icre-encoding viruses enabled for the first time a differential gene targeting in non-myocyte and myocyte cells in myocardium. non-myocyte deletion of mir- demonstrated that mir- exerts its cardiac profibrotic activity directly in cardiac fibroblasts and in endothelial cells. this novel finding should encourage tailoring of antimir- therapy towards cellular tropism. chronic inflammatory diseases, such as psoriasis or rheumatoid arthritis, are characterized by constant leukocyte infiltration and ongoing angiogenesis in the inflamed tissue. as current anti-inflammatory pharmacotherapy is not always satisfying, there is a great demand for the discovery of new drug leads as well as novel drug targets. the synthetic carbazole alkaloid derivative c acts as a multikinase inhibitor. results of a thermal shift assay revealed that c shows by far the highest binding affinity to the bmp- -inducible kinase (bmp k/bike). bmp k represents an as yet largely uncharacterized protein, which is not regulated by bmp- in endothelial cells. therefore, we aimed to analyze (i) the pharmacological potential of c and (ii) the role of bmp k in angiogenic and inflammatory processes in the vascular endothelium. initial experiments show that only high concentrations of c affected the viability of human umbilical vein endothelial cells (huvecs). both c and the knock-down of bm k (rnai) reduced the migratory capacity of a human microvascular endothelial cell line (hmec- ). also the proliferation of hmec- was reduced by c treatment (ic : µm). a tube formation assay on matrigel demonstrated that c significantly impaired the formation of capillary-like structures in a dose-dependent manner. interestingly, the analysis (western blot) of signaling molecules in huvecs that play a crucial role in cell proliferation (e.g. erk, akt) revealed that these pathways are not influenced, neither by c treatment nor by bmp k gene silencing. in regard to inflammatory processes, c treatment or bmp k silencing of huvecs decreased the adhesion of thp- cells, a monocytic cell line, onto the activated endothelial cells. as the interaction of leukocytes is mainly mediated by cell adhesion molecules (cams), the effect of c or bmp k silencing on their expression was analyzed (flow cytometry, qpcr). while the expression of cams was strongly decreased after c treatment, the knock-down of bmp k did not markedly affect their expression. furthermore, both approaches did not lead to the reduction of tnf-induced iκbα degradation (western blot) or p translocation into the nucleus (microscopy). our study provides first insights into the anti-inflammatory and anti-angiogenic potential of the carbazole alkaloid derivative c in vitro. the precise role of bmp k in angiogenic and inflammatory endothelial processes as well as the involved pathways during bmp k silencing and c treatment will be further elucidated. moreover, since the inhibition of bmp k seems not to be responsible for all actions of c , we will investigate the role of other kinases affected by the compound in these processes. the chemokine receptor cxcr is a multifunctional receptor which is activated by its natural ligand c-x-c motif chemokine (cxcl ). cxcr seems to be part of the lipopolysaccharide sensing complex, suggesting that an intervention with cxcr agonists or antagonists could result in reduced tlr signaling. however, the role of cxcr and the influence of different cxcr ligands in acute as well as chronic inflammatory diseases are still contradictious. therefore, we aimed to characterize the systemic effects of cxcr activation in severe systemic inflammation and to evaluate its impact on endotoxin induced organ damages by applying a sublethal lps dose ( mg/body weight) in mice. the plasma stable cxcl analog ctce- d was synthesized and administered subcutaneously shortly before lps treatment to ensure a delayed release and thereby a prolonged effect of the drug. hours following lps administration, mice were sacrificed and blood was obtained for tnf alpha, ifn gamma and blood glucose evaluation. additionally, histopathological changes and oxidative stress in the liver and spleen were assessed and liver biotransformation capacity was determined. finally, cxcr , cxcl and tlr expression patterns in liver, spleen and thymus tissue as well as the presence of different markers for oxidative stress and apoptosis were evaluated by means of immunohistochemistry. ctce- d improved the health status and distinctly reduced the lps mediated effects on tnf alpha, ifn gamma and blood glucose levels by approximately %, % or %, respectively. it attenuated oxidative stress in the liver and spleen tissue and enhanced liver biotransformation capacity unambiguously. ctce- d diminished the lps induced expression of cxcr , cxcl , tlr , nf-κb, cleaved caspase- and gp phox, whereas heme oxygenase expression and activity were induced above average. furthermore, tunel staining revealed anti-apoptotic effects of ctce- d in all organs. the cxcr is undoubtedly involved in inflammation. its activation was accompanied by anti-inflammatory, anti-oxidative and cytoprotective effects as ctce- d attenuated tlr signaling, induced heme oxygenase activity and mitigated apoptosis. thus, the administration of cxcl analogs seems to be a promising treatment option to control acute systemic inflammation, especially when accompanied by a hepatic dysfunction and an excessive production of free radicals. the neurodegenerative disease friedreich ataxia (frda) is caused by a gaa triplet repeat expansion in the first intron of the frataxin gene, which results in a reduction of the corresponding mitochondrial protein. despite several cellular and animal models the exact function of frataxin is still a matter of debate, but the role of frataxin in iron sulfur cluster biosynthesis is generally accepted. however, we still don't know which primary metabolic events are caused by a frataxin deficit and until now, there is no therapeutic option available. we developed a new cellular model for frda by using the cre/loxp recombination system in mouse embryonic fibroblasts (mef). c bl/ j mouse strains with a loxp flanked exon of the frataxin gene and an tamoxifen-inducible cre-recombinase (creer t ) were crossed and several mef cell lines isolated. after selection by genotype and growth manner the fx-mef - (fxn -/-) and fx-mef - (fxn +/-) cell lines were finally choosed. the generation of the homozygous or heterozygous frataxin knockout was successfully tested on rna and protein level. long maintenance of the frataxin depleted fibroblasts revealed a strong growth inhibition consistent to earlier observations in other cell systems. therefore, we established a pattern of treatment over days, with medium and substance changes at day and , which allows us to get a fully functional knockout and overcome the growth inhibition problem. endpoint measurements of known metabolic phenomena from mammalian and non-mammalian models were studied at day of our novel cell system. the induced total disruption of frataxin leads to a clearly reduced aconitase activity, cell division and oxygen consumption as well as an increase in ros production. in the heterozygous knockout with residual frataxin activity no such changes were observed. in addition, our pattern of treatment enables us to monitor the full and partial frataxin knockout in the course of time, to detect early and late metabolic events after frataxin disruption. therefore we analysed the mentioned parameters (with additional atp and iron content) in parallel at day , , and and could identify an initial event followed by secondary consequences and parameters, which seem to play only a minor role in the frda pathogenesis. on the contrary, a partial deficit of frataxin didn't result in any differences over time and suggests that there are only cellular alterations below a critical threshold. in conclusion, our new established mammalian cellular frda model mimics typical metabolic consequences of the human disease and seems to be qualified for frda research. the model shows for the first time six different metabolic events in the course of time in parallel and reveals insights into primary and secondary events of frda pathogenesis. these observations can be used to better understand the function of frataxin and can help to develop new therapeutic strategies to address the consequences of frataxin deficiency. moreover, the transfer of this cell model into well plates offers the possibility for a high-throughput screening of potential therapeutic substances. the disease diphtheria is caused by the diphtheria toxin (dt) which belongs to the group of single-chain ab-type bacterial protein toxins. receptor-binding of the b-domain on the target cell surface is followed by receptor-mediated endocytosis and internalization into early endosomal vesicles. endosomal acidification triggers membrane insertion and pore formation of the transmembrane (t) domain together with translocation of the (partially) unfolded catalytic (c) domain into the cytosol. herein, dta catalyzes adp-ribosylation of elongation factor which leads to disruption of protein synthesis and finally causes cell death [ ] . in hela cells, these events are related to cell-rounding functioning as a specific endpoint to monitor the uptake of dta into the cytosol of the host cell. as for other adp-ribosylating toxins such as c. botulinum c toxin, c. perfringens iota toxin and c. difficile cdt, also in case of native dt we demonstrated the involvement of several host cell factors during the translocation step of the catalytic domain across the endosomal membrane [ , ] . in detail, we confirmed the involvement of the host cell chaperone hsp and the thioredoxin reductase (trxr), the latter presumably responsible for the reduction of the interchain disulfide bond between the dta and dtb moieties [ , , ] . furthermore, we identified another group of protein folding helpers, the family of peptidyl-prolyl cis/trans isomerases (ppiases) including cyclophilin a (cypa), cyp and fk -binding protein (fkbp) as required cytosolic factors for dta translocation. to characterize the role of the protein folding helpers in more detail, we investigated their interaction with purified dta in vitro by performing dot blot analysis with immobilized recombinant host cell factors, co-precipitation of cellular factors with dta from hela lysate and isothermal titration calorimetry with purified proteins therewith determining the thermodynamic parameters of the individual binding events. thereby, we detected binding of dta to hsp , cypa, cyp , fkbp and fkbp . the data increase the knowledge of the molecular mechanisms underlying dt uptake and especially dta translocation which can be medically used to develop novel therapeutic strategies against the disease diphtheria. [ ] murphy ( ) toxins , - . [ ] barth ( ) naunyn-schmied arch pharmacol , - . [ ] kaiser et al. ( ) cell. microbiol. , - . [ ] dmochewitz et al. ( ) cell. microbiol. , - . [ ] ratts et al. ( ) j. cell biol. , - . [ ] schnell et al. ( ) novel afflictions as for example clostridium (c.) difficile associated diseases (cdad) caused by clostridium difficile are on the increase and challenging to treat. cdad most frequent occur in hospitalized patients after prolonged treatment with antibiotics. cdad includes among others diarrhea and the severe form of pseudomembranous colitis. not only the treatment of the infection, but also the treatment of the toxins has a high clinical significance. c. difficile secretes the exotoxins a (tcda) and b (tcdb), which glycosylate and thereby inactivate rho-gtpases in mammalian cells. tcda and tcdb are considered as the causative agents of cdad. in the last few years, more and more hypervirulent strains of c. difficile were described. in these hypervirulent strains, the adp-ribosyltransferase cdt was found as a third toxin in addition to tcda and tcdb. given the lack of agents effective against antibiotic-resistant bacterial strains and bacterial exotoxins, the development of novel pharmacological strategies is needed. the antimicrobial activity of naturally occurring substances is already known for a long time. one important mechanism of the innate immune system is the production of natural peptides showing antibiotic features. in recent years, it was shown that human antimicrobial peptides as important part of the native innate immune system plays a crucial role not only in inactivation of bacteria but also in inhibition of bacterial toxins ( ). prompted by these result, we found that only human α-defensin- (hnp- ) but not human β-defensin- (hbd- ), both important effectors of the innate immune system, protected cultured epithelial cells from intoxication with tcda and cdt when applied prior to the toxins to the cells. moreover, α-defensin- prevented also the cytotoxic effects of all three c. difficile toxins tcda, tcdb and cdt combined in the medium. the combined investigation of all three toxins might be even more suitable to mimic the situation after an infection with hypervirulent c. difficile. the inhibition of the toxins was monitored by cell rounding caused by each of the toxins. currently, the molecular mechanisms underlying the inhibitory effects are still unknown and will be investigated in different cell lines. in conclusion, our results demonstrate that hnp- causes a loss of cytotoxicity of the c. difficile toxins and may act as novel drugs to cure c. difficile infections that contribute to cdad. neurodegenerative diseases like parkinson´s disease (pd) are accompanied by altered gene expression levels in the brain. recent studies support a role of regulatory noncoding rnas, such as micrornas (mirnas), which silence a specific set of mrnas at the post-transcriptional level. upon their aberrant expression, they are likely involved in the pathophysiology of specific neuronal loss. manipulation of neuronal gene expression is pivotal for understanding the function of proteins and the development of new therapeutic strategies. rna interference (rnai) strategies can be employed through the administration of small interfering rnas (sirna), which mediate the specific knockdown of a selected target gene. however, the main challenge is the delivery of these rnas into the neurons of interest. in this pilot study, we present a method for delivering sirnas in polymeric nanoparticles based on low molecular weight polyethylenimines (peis). their intracerebroventricular (icv) injection leads to in vivo silencing of neuronal gene expression in the brain of mice overexpressing α-synuclein (thy -asyn mice). in a first step, pei-complexed sirna tagged with afluorescencedye were injected to track the localization and distribution after icv administration. five days later, fluorescent cells were visible throughout the brain, with the highest fluorescence intensity around the ventricles. fluorescence was also observed in large cells of the lumbar spinal cord. moreover, preliminaryresultsdemonstrate a . % knockdown (p< . student's t-test, n= ) of human α-synuclein (snca) in thetargetstructurestriatum upon a single icv injection of pei-complexed specific sirna compared to the control injection group (n= ). hence, our first results support the usability and efficacy of pei nanoparticle-mediated delivery of short rnas, namely sirnas, for rapidly and efficiently reducing the expression of a neuronal target gene of interest in the brain in vivo. this may allow the development of gene therapy strategies for the treatment of neurodegenerative diseases. is a propenylic alkenylbenzene found in several plants, e.g. acorus calamus. bacontaining plant materials are used to flavor foods, and are active ingredients in traditional plant medicines. thus, human exposure results primarily from the intake of bitters and teas, as well as from calamus-containing medicines and plant food supplements. although many (positive) pharmacological properties/effects of asarone isomers are described in the literature, ba was found to be carcinogenic in rodents (liver, duodenum) when given daily or in a single dosage. early experiments indicated that ba is not activated via hydroxylation and sulfonation as it is the case for known hepatocarcinogenic allylic alkenylbenzenes such as estragole or methyleugenol. because the mechanism of metabolic activation of ba in not known, we investigated the metabolism of ba in liver microsomes and human cytochrome p (cyp) enzymes, the mutagenicity of ba and its metabolites in the ames fluctuation assay and the dna adduct formation in primary rat hepatocytes. we found that side-chain epoxidation (leading to diols and a ketone) was by far the most dominating metabolic route of ba in liver microsomes and human cyp enzymes. ba was mutagenic in the ames test (+s mix), as was the synthesized ba-epoxide (-s mix). furthermore, we were able to synthesize and characterize a ba epoxide-derived dna adduct with deoxyguanosine. this dna adduct was formed in a concentration-dependent manner in rat hepatocytes incubated with ba. our results strongly indicate that ba is genotoxic with the side-chain epoxide being its ultimate carcinogen. morbid obesity is an independent risk factor for cardiovascular disease, type diabetes mellitus and certain types of cancer. bariatric surgery -with the roux-en-y gastric bypass (rygb) being the gold standard -has become the therapeutic option of choice as a sustained weight loss and improvement of associated morbidity is achieved in the majority of patients. there is, however, a lack of evidence focusing on bariatric surgery induced sustained weight loss and its possible impact on cancer risk. we investigated the association between obesity, oxidative stress and genomic damage after roux-en-y gastric bypass surgery (rygb) or caloric restriction induced weight loss in the obese zucker rat. obese male zucker fa/fa rats were divided into three groups: sham surgery (sham), rygb and caloric restriction (cr) and were compared with lean controls (lean; zucker fa/+ rats). shams showed impaired glucose tolerance and elevated plasma insulin levels, which were less severe in rygb and cr. oxidative stress was elevated in kidney, liver and colon tissue of sham and reduced again after weight loss induced by either rygb or bwm. urine-derived oxidization products of lipids, dna and rna increased in shams and decreased after weight loss (rygb and cr). dna double strand breaks were more frequent in shams than in the weight loss groups or lean. dna damage in zucker fa/fa rats correlated with their basal plasma insulin values. obese rats showed elevated oxidative stress and genomic damage in comparison to lean rats. after body weight loss, achieved by either rygb or caloric restriction alone, oxidative stress level and genomic damage were decreased. this may indicate a reduction of the elevated cancer risk in obesity. ) mice were treated with the nocrelated compound azoxymethane (aom) followed by the administration of dextran sodium sulfate to trigger crc. tumors were quantified by non-invasive mini-endoscopy, which revealed a non-linear increase in crc formation in wt and aag -/mice. in contrast, a linear dose-dependent increase in tumor frequency was observed in mgmt -/and mgmt -/-/aag -/mice. the data was corroborated by hockey stick modeling, which yielded similar carcinogenic threshold doses for wt and aag -/mice. o -meg levels and depletion of mgmt activity correlated well with the observed dose-response in crc formation. aom dose-dependently induced double strand breaks (dsbs) in colon crypts including in lgr -positive colon stem cells, which coincided with atr-chk -p signaling. intriguingly, mgmt-deficient mice displayed significantly enhanced levels of γ-h ax, suggesting the usefulness of γ-h ax as an early genotoxicity marker in the colorectum. this study demonstrates for the first time a non-linear dose-response for alkylation-induced carcinogenesis and reveals dna repair by mgmt, but not aag, as a key node in determining a carcinogenic threshold at low alkylation dose levels [ ] . obesity is characterized as a status where the excessive accumulation of fat in adipocytes leads to local inflammation and hypoxia; both contributing to severe obesity associated co-morbidities such as cardiovascular disease and type diabetes mellitus. local inflammation is mediated by macrophages, stromal vascular cells, preadipocytes, and adipocytes as well as by a number of proinflammatory cytokines and chemokines ( ). in particular, the chemokines monocyte chemoattractant protein (mcp- , ccl ), interleukin- (il- /cxcl ) and stromal cell-derived factor (sdf- a/cxcl ) secreted by stromal vascular cells, preadipocytes, and adipocytes exert paracrine effects by recruiting neutrophils, monocytes/macrophages, and t-and b-cells. interestingly, deficiency in cxcl was shown to attenuate obesity in mice ( ) . the cc chemokine ccl is known to stimulate ccr receptors, and the cxc chemokines cxcl and cxcl to activate cxcr and cxcr or cxcr and cxcr , respectively. the receptor(s) activated by cxcl is currently unknown. a role of cxcl in modulating cxcr signaling has been proposed. we initiated our studies to determine the presence and functional significance of chemotaxin receptors in human adipocytes and their precursor cells. to this end, the mrna expression pattern of cc chemokine receptors, cxc chemokine receptors formylated peptide receptor fpr and the related receptor fprl , and cc and cxc chemokines was analyzed during in vitro adipose differentiation of human simpson-golabi-behmel-syndrome (sgbs) preadipocytes, and under conditions mimicking an inflammatory response. in particular, we focused on the expression pattern of human ccr receptors, since previous reports indicated a role in adipogenic differentiation. however, our comprehensive analysis using different sources of adipocytes and their precursors indicated that ccr receptors were absent ( ) . yet, the analysis revealed appreciable levels of mrna encoding ccl , cxcl , and cxcl , and ccr , cxcr , cxcr , fpr , and fprl , and cxcr . of interest, cxcr -and cxcr -mrna were found to be up-regulated under the proinflammatory conditions. to analyze the responses of adipocytes and their precursors to chemokine receptor agonists, we used chemokine-mcherry fusion proteins purified from baculovirus-infected insect cells, e.g ccl , cxcl , cxcl . while sgbspreadipocytes and adipocytes did not accumulate ccl -mcherry upon stimulation, they showed a small accumulation of cxcl -mcherry, and a strong accumulation of cxcl -mcherry in the endosomal compartment. similar results were obtained in murine t l- preadipocytes. using mass spectrometry analysis, we set out to identify the cxcl -binding putative receptor protein(s) in murine t l- preadipocytes. ( ) makki, k. et al., ( ) in personalized medicine tumors are screened for several mutations in oncogenes or tumor suppressors. however, the cellular protein content not exclusively depends on the dna. we identified new rac variants generated on the mrna level in androgenindependent prostate cancer cells. all variants represent active forms of the gtpase. they are capable to suppress rhoa-induced apoptosis and additionally, mediate the synthesis of genes which are under the control of the androgen receptor. importantly, expression of the rac variants is sufficient to support tumor growth in mice. we prove the existence of the variants and verify their clinical appearance and relevance in tissue samples of a prostate cancer patient. dna analysis, however, revealed the wildtype sequence of rac. therefore, routine analysis of patient tumor tissue would miss the detection of active rac which precludes the success of therapy. the existence of active rac variants in prostate cancer tissue that promote resistance towards androgen deprivation suggest rac inhibition as an effective add on therapeutic strategy against prostate cancer. the bacterial effector protein exotoxin y (exoy) of pseudomonas aeruginosa is delivered into host cells via the bacterial type iii secretion system. once arrived in the host cell nucleotidyl cyclase activity of exoy is activated by a yet unknown cofactor and thus has a profound effect on concentrations of cyclic nucleotides: in addition to production of cyclic amp (camp) and cyclic gmp (cgmp) there is a massive synthesis of cyclic ', and to some extent of the corresponding cytidylyl analogue ccmp , . currently, the role of cump and ccmp during the pathogenesis of p. aeruginosa infection remains unknown . one of our hypotheses is that these cyclic nucleotides fulfil a role as first messengers, e.g. in the communication between individual bacteria or bacterial populations during establishment of acute or chronic infections. to test this hypothesis, the intra-and extrabacterial concentrations of cyclic nucleotides were measured via hplc-ms/ms at different time-points in liquid cultures of p. aeruginosa, either in a complete (lb medium) or a starving medium (vogel-bonner medium). additionally, we tested if supplementation of the media with extrinsic cump or ccmp had an effect on these measured concentrations. the influence of extrabacterial cyclic nucleotides on the bacterial metabolism and homeostasis was evaluated with a microarray of bacterial total cdna extracted at different time points of p. aeruginosa liquid culture with or without extrinsic cump/ ccmp. furthermore we investigated a potential function of the cyclic nucleotides in biofilm formation. cyclic ump and cyclic cmp have differential roles in bacterial metabolism and communication. for example, whereas ccmp is synthesized by p. aeruginosa when the bacteria are in a nutrient-rich environment, we could not detect bacterial cump under any tested circumstance. in our biofilm formation assays, only ccmp had a biofilmpromoting effect, but only in very high concentrations. the currently ongoing analysis of gene expression data in the presence or absence of cump may reveal a role of this cyclic nucleotide as first messenger, too. in further studies we will elucidate the signal transduction processes underlying the observed cump / ccmp effects, for example by identifying cump and ccmp binding proteins and their coupling mechanisms to intracellular signalling cascades. synapses are complex computational platforms that transmit information encoded in action potentials but also transform their functionality through synaptic plasticity. g protein-coupled receptors (gpcrs) play a major role in modulating the strength of the synapses via the second messenger camp . however the spatio-temporal dynamics of the mode of action of camp underlying synaptic plasticity are still controversial. the role of this study was to investigate the dynamics of camp signaling at the drosophila neuromuscular junction, where octopamine binding to its receptors has been shown to cause camp-dependent synaptic plasticity . for this purpose, we generated a transgenic drosophila expressing the camp sensor epac -camps in motor neuron. this allowed us to directly follow the octopamine-induced camp signals in real time by fluorescence resonance energy transfer (fret) in different compartments of the motor neuron (i.e. cell body, axon, boutons). we found that octopamine induces a steep camp gradient from the synaptic bouton (high camp) to the cell body (low camp), which was due by higher pde activity in the cell body. high octopamine concentrations evoked a response also in the soma. notably, these signals were independent and isolated form each other. moreover, application of octopamine by iontophoresis to single synaptic boutons induced bouton-confined camp signals. these data reveal that a motor neuron can posses multiple and largely independent camp signaling compartments, and provide new basis to explain how camp could control neurotransmission at a level of a single synapse. kandel, e.r., dudai, y. & mayford, m.r. the molecular and systems biology of memory. cell , - ( ) . koon, a.c., et al., autoregulatory and paracrine control of synaptic and behavioral plasticity by octopaminergic signaling. nat neurosci. ( ): p. - ( ) . nikolaev vo, bünemann m, hein l, hannawacker a, lohse mj novel single chain camp sensors for receptor-induced signal propagation. j. biol. chem. , - ( ) cardiovascular pharmacology hyaluronic acid deposition determines engineered heart muscle characteristics and can be pharmacologically targeted to enhance function s. schlick background: engineered human myocardium (ehm) can be generated from psc derived cardiomyocytes (cms) and primary fibroblasts suspended in a collagen i hydrogel ( %: %: . mg/ml). ehm development encompasses an early consolidation phase followed by functional maturation. the presence of fibroblasts is essential for consolidation into a force-generating ehm. here we assessed the hypothesis that fibroblasts of different origin support ehm formation differentially as a function of hyaluronic acid deposition. methods and results: oscillatory rheology ( % strain, hz) on cell-free and cell containing collagen i hydrogels directly after casting revealed enhanced consolidation in the presence of human foreskin fibroblasts (ffbs) compared to primary adult cardiac fibroblasts (cfbs) -change in storage modulus over time (pa/min): collagen . ; collagen + cms . ; collagen + cms + cfbs . , collagen + cms + ffbs . . we next generated ehm with cms and ffbs or cfbs. after weeks of culture under serum-free conditions, we assessed ehm function by contraction measurements. ffb-ehms developed a significantly (p< . ) higher force of contraction (foc) per cross sectional area (csa) than cfb-ehms (maximal foc/ csa are in mn/mm : . ± . , n= vs. . ± . , n= ). cross sectional area (csa) of tissues was greatly increased (p< . ) in cfb-ehms (csa in mm : . ± . , n= vs. . ± . , n= ) and nonmyocyte content was higher in cfb-ehms ( . ± . , n= vs. . ± . , n= ; x cells/ml). histological analysis revealed that cardiomyocytes were only poorly matured in cfb-ehms compared to ffb-ehms. extending ehm functional data, principal component analysis of rnaseq data revealed distinct expression patterns for ffbs and cfbs, in which hyaluronic acid synthase (has ) enzyme was significantly (p< . ) upregulated. based on these findings, we pharmacologically intervened with has mediated hyaluronic acid (ha) deposition by treating cfb-ehms with hyaluronidase during all weeks of culture. interestingly, ecm manipulation with low concentrations of enzyme significantly (p< . ) reduced csa (csa in mm : control . ± . , n= ; hyaluronidase of concentrations from . u to u . ± . , n= ) with a concurrent, statistically significant (p< . ), increase in contractile function and improved cardiomyocyte morphology on a histological level (maximal foc/csa in mn/mm : control . ± . , n= ; hyaluronidase of concentrations from . u to u . ± . , n= ). summary and conclusions: our data suggest that ehm consolidation is influenced differentially by fibroblasts of different tissue origin with hff-ehm being functionally superior to cfb-ehm. cfb-ehm could be rescued by hyaluronidase leading to reduced ha deposition. the latter demonstrates that extracellular matrix composition is centrally involved in ehm development. angiogenesis is the process of formation of new blood vessels from the pre-existing ones. vascular endothelial growth factor (vegf) is the most studied regulator of this process. by binding to its type receptor (vegfr ), it has been shown to activate a variety of different signaling-pathways leading to enhanced angiogenesis. camp, on the other hand, is a versatile second messenger which regulates various endothelial functions including barrier function. it directly activates protein kinase a (pka) or the exchange protein directly activated by camp (epac) which is a guanine exchange factor (gef) for the small monomeric gtpase rap. as human umbilical vein endothelial cells (huvec) express both camp effectors (epac and pka), we investigated the role of camp-signaling using a spheroid based sprouting assay as an in vitro model for angiogenesis. interestingly, the activation of β-adrenergic receptors with µm of isoproterenol significantly increased the cumulative sprout length. similarly, the selective activation of epac with µm of the camp analog -pcpt- '-o-camp ( ) significantly increased the basal and the vegf-induced cumulative sprout length. in accordance, sirna-mediated depletion of epac in huvec decreased the basal and vegf-induced sprouting. surprisingly, µm of forskolin increased basal and vegf-induced cumulative sprout length stronger than , indicating an additional role of pka. in accordance, µm of myristoylated pki, a membrane-permeable specific pka inhibitor, significantly attenuated the forskolin-induced increase in sprouting. in all conditions tested, ng/ml of vegf always showed an additive effect to the same extent on cumulative sprout length. therefore, our data indicate that the vegf-pathway is acting independently of the camp-pathway in the regulation of the sprouting angiogenesis. the β-adrenergic receptor-mediated activation of camp signaling in huvec induces angiogenic sprouting by activation of epac and pka. introduction: hypertension is one major risk factor for the development of chronic heart and kidney disease. mineralocorticoid receptor (mr) antagonists are a cornerstone in the therapy of heart failure and there is first evidence for a beneficial effect on the kidney as well. inflammation plays an important role in hypertensive organ injury. thus, this study was designed to evaluate and directly compare the effect of mr deletion in endothelial cells on blood pressure and cardiac vs. renal injury in a mouse model of deoxycorticosterone acetate-induced hypertension. methods and results: mice lacking the mineralocorticoid receptor in endothelial cells (mr cdh cre ) were created using the cre/loxp system. mr cdh cre and cre-negative littermates (mr wildtype ) underwent unilateral nephrectomy and received % nacl with drinking water for weeks. the mineralocorticoid deoxycorticosterone acetate (doca, . mg/d) was delivered by subcutaneous pellets. untreated mice served as controls (ctrl). ambulatory blood pressure was determined by implantable telemetry in awake mice. doca/salt treatment increased mean blood pressure in mr wildtype ( . ± . vs. ctrl . ± . mmhg, p< . ) and mr cdh cre ( . ± . vs. ctrl . ± . mmhg, p< . ) without differences between genotypes. cardiac hypertrophy after doca/salt treatment was ameliorated in mr cdh cre mice (ventricle weight . ± . mg vs. mr wildtype . ± . mg, p< . ). doca/salt significantly increased cardiac fibrosis and the expression of fibrotic marker genes in mr wildtype but not in mr cdh cre mice. this was accompanied by an increased expression of the vascular cellular adhesion molecule (vcam ) in mr wildtype cardiac endothelial cells. renal function was not altered by mr deletion in endothelial cells at baseline. doca/salt treatment lead to marked interstitial fibrosis in the kidneys of mr wildtype (sirius red fibrosis score: . ± . vs. ctrl . ± . , p< . ) and mr cdh cre ( . ± . vs. ctrl . ± . , p< . ) mice. mrna expression of the fibrosis marker gene col a (mr wildtype . ± . -fold; mr cdh cre . ± . -fold vs. ctrl) was similarly increased. periodic acid-schiff staining revealed glomerular injury in both genotypes. this was associated with a marked rise in urinary albumin / creatinine ratio (mr wildtype . ± . fold; mr cdh cre . ± . -fold vs. ctrl). in the kidney vcam mrna expression and the number of macrophages was increased by doca/salt treatment independently from endothelial mr deletion. conclusion: in conclusion, mr deletion from endothelial cells ameliorated doca/saltinduced cardiac but not renal inflammation and remodeling independently from blood pressure. these findings suggest different mechanisms for the beneficial effect of mr antagonists in hypertensive heart vs. kidney disease. platelets are relevant cells implicated in morbidity and mortality provoked by cardiovascular thrombosis. even with the actual antiplatelet therapy there is still a substantial incidence of arterial thrombosis. therefore, a better understanding of the mechanisms involved in platelet activation and aggregation is required to develop improved antiplatelet therapies. the increase in the intracellular ca + concentration due to ca + entry from the extracellular space is critical for platelet activation and aggregation. ca + entry follows activation of plasma membrane receptors including gqcoupled receptors for adp, thromboxane a (txa ) or thrombin, as well as the collagen receptor glycoprotein vi (gpvi). the cellular signalling pathways downstream these receptors involve activation of phospholipase c and second messengers that are known to mediate activation of trpc channels. trpc proteins form receptor-operated cation channels, but their regulation and permeability differ depending on the cell type. it has been proposed that trpc proteins might contribute to platelet function as constituents of agonist-activated ca + entry channels; however, the experimental approaches used so far and the lack of specific agonists or antagonists have not allowed to determine the individual contribution of trpc proteins for agonist-induced ca + entry in platelets, aggregation and thrombosis formation. we detected the expression of trpc and trpc in human and mouse platelets. we identified that those proteins together are essential components of a system of coincidence detection in cellular ca + signalling. this coincidence detection triggered by simultaneous stimulation of both thrombin and collagen receptors is required for the phosphatidylserine exposure in human and murine platelets, indicating the role of trpc /c proteins for procoagulant activity. in addition, we detected the expression of s trpc transcripts in mouse platelets. therefore, we tested trpc /c /c -deficient mice in an in vivo model of arterial thrombosis where they showed reduced thrombus formation. regardless of the protective effect of trpc /c /c inactivation observed in the thrombosis model, no differences were detected in tail bleeding. to evaluate the relevance of these trpc proteins in platelet aggregation we measured in vitro platelet aggregation in platelets from trpc /c /c -deficient mice and we observed that the aggregation was reduced after adp ( µm) or txa -analogue ( µm) stimulation, but not after collagen stimulation ( µg/ml). we are currently analyzing the in vitro aggregation and the agonist-evoked ca + response in platelets from different trpc-compound and single deficient mouse lines to understand the mechanisms behind this phenotype with regard to its complementarity to actual antiplatelet therapy. background: thrombin signaling initiates inflammatory events directly and through activation of platelets. endogenous and pharmacologic inhibitors of thrombin are therefore of relevance during atheroprogression and for therapeutic intervention. the small leucine-rich proteoglycan biglycan (bgn) is such an endogenous thrombin inhibitor that acts through activation of heparin cofactor ii (hcii). here, the effect of genetic deletion of bgn on thrombin activity, inflammation and atherosclerosis was addressed. methods and results: bgn concentrations were elevated in the plasma of patients with acute coronary syndrome. in apoe -/mice, bgn was detected in the plasma as well as in the glykokalyx of capillaries. additionally, bgn expression occurred in the subendothelial matrix of arterioles as well as in atherosclerotic plaques. in line with a role of bgn in balancing thrombin activity, apoe -/-/bgn -/ mice exhibited higher activity of circulating thrombin and increased numbers of activated platelets than did apoe -/mice. furthermore, higher concentrations of circulating cytokines in apoe -/-/bgn -/ mice suggested a pro-inflammatory phenotype. likewise, immunohistochemistry and facs analysis of the aorta demonstrated increased macrophage content in atherosclerotic lesions of these mice. in addition, apoe -/-/bgn -/ mice exhibited higher aortic plaque burden and larger atherosclerotic lesions at the aortic root. of note, apoe -/-/bgn -/ mice showed progressive dilatation of the aortic arch corresponding to a decrease in collagen fibril density suggestive of an outward remodelling in the absence of bgn. no differences were evident with respect to lipid content of the aortic root plaques or circulating plasma lipids. treatment with the thrombin inhibitor argatroban reversed platelet activation and aortic macrophage accumulation in apoe -/-/bgn -/ mice. conclusions: the present results strongly suggest a protective role of bgn during the progression of atherosclerosis by inhibiting thrombin activity and platelet activation, and ultimately macrophage-mediated plaque inflammation. the exposure to environmental or human-made xenobiotics including drugs induces the hepato-intestinal transcription of metabolizing enzymes and transporters. the time-span of induction is thought not to exceed xenobiotic exposure, in order to minimize disturbances of endobiotic metabolism. in contrast, we find cross-generational transmission of the induction of the phase i enzyme cyp b ( -fold in females, -fold in males) in -day old offspring of adult female mice exposed one week prior mating to tcpobop ( mg/kg i.p.) , the model ligand of the xenosensing nuclear receptor car. such cross-generational effects of xenobiotics are of great clinical interest as they could have profound consequences on the health status of the offspring, including interferences with drug therapies. the multigenerational transmission of tcpobop-driven induction could be mediated by pre-uterine/pre-conceptional epigenetic changes of oocytes. alternatively, they could be brought about by direct intrauterine/post-conceptional contact with tcpobop released from long-term depots. to discriminate between these mechanisms we conducted embryo transfer experiments. both donor mothers and foster mothers were injected with tcpobop ( mg/kg) prior to mating. the analysis of hepatic cyp b expression in -day-old offspring is clearly consistent with a post-conceptional onset of tcpobop effects. thus, offspring of solvent-injected donor mothers transferred to tcpobopexposed foster mothers display a -fold induction while offspring from the reciprocal experiment show no changes. cesarean sections on day e . followed by crossfostering proved transmission to be mediated predominantly via lactation (f hepatic cyp b induction -fold) and only to a minor part via intra-uterine exposure ( fold). this mechanism is consistent with the absence of induction transmission via the male germline. to analyze if tcpobop leads to functional consequences in drug metabolism of f and f generation, we conducted in vivo zoxazolamine paralysis assays taken as a functional test for cyp b catalytic activity. in both tcpobop-pretreated f and in their f descendants, the induction reduced the duration of paralysis evoked by zoxazolamine by > %. the characterization of cross-generational tcpobop-mediated effects on other processes controlled by car such as energy and bone metabolism is in progress. first tests indicate a transmission of anabolic effects on bone, as evidenced by the induction of serum osteocalcin expression by % in -weeks-old offspring. in summary, the car-mediated cyp b induction by tcpobop is transmitted to the offspring mainly via lactation, resulting in lasting phenotypic consequences in drug and bone metabolism. the effects of similarly lipophilic drugs and anthropogenic environmental pollutants are currently being investigated. such compounds could affect offspring despite discontinuation of intake or exposure well ahead of pregnancy. age-related cognitive decline can eventually lead to dementia, the most common mental illness in elderly people and an immense challenge for patients, their families and caregivers. cholinesterase inhibitors constitute the most commonly used antidementia prescription medication. the standardized ginkgo biloba leaf extract egb ® is approved for treating age-associated cognitive impairment and has been shown to improve the quality of life in patients suffering from mild dementia. a clinical trial with alzheimer´s disease patients indicated that the combined treatment with donepezil and egb ® had less side effects than donepezil alone (yancheva et al., ) . in an animal model of cognitive aging, we compared the effect of combined treatment with egb ® or donepezil monotherapy and vehicle. we compared the effect of chronic treatment ( days of pretreatment) with donepezil ( , mg/kg p. o.), egb ® ( mg/kg p. o.), or the combination of the two drugs, or vehicle in - month old male ofa rats. learning and memory performance were assessed by morris water maze testing, motor behavior in an open field paradigm. in addition to chronic treatment, the substances were administered orally minutes before testing. compared to the first day and to the control group, only the combination group showed a significant reduction in latency to reach the hidden platform on the second day of testing. moreover, from the second day of testing onwards, the donepezil, the egb ® and the combination group required less time to reach the hidden platform compared to the first day. the control group did not reach the same latency reduction until day three. there were no effects on motor behavior. these results suggest a superiority of the combined treatment of donepezil with egb ® compared to monotherapy. literature: yancheva, s., ihl, r., nikolova, g., panayotov, p., schlaefke, s., & hoerr, r. ( ) . ginkgo biloba extract egb (r), donepezil or both combined in the treatment of alzheimer's disease with neuropsychiatric features: a randomised, double-blind, exploratory trial. aging ment health, ( ) , [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] institut für vegetative physiologie und pathophysiologie, göttingen, germany values are well below the plasma concentrations ( - µm; just et al. expert opin emerging drugs : - , ) observed in patients treated with dantrolene. although not yet proven directly, oat may be involved in renal secretion of dantrolene and -oh dantrolene by mediating the first step, i.e. the uptake across the basolateral membrane of proximal tubule cells. the second step, the release of these compounds into the urine across the luminal membrane, is possibly mediated by mrp . since oat was also detected in the cytoplasmic membrane of skeletal muscle cells (takeda et al. europ. j. pharmacol. : - , ) , dantrolene may reach its target, the intracellular ryanodine receptor, ryr , by influx through oat , where it inhibits calcium efflux by ryr thereby preventing severe muscle contraction and malignant hyperthermia. this assumption, however, awaits a direct demonstration of dantrolene transport by oat . in addition, we identified, besides dantrolene and -oh dantrolene, several further fdaapproved drugs such as tyrphostin ag , ceefourin , glafenine, nalidixic acid, and prazosine, as inhibitors of es uptake by oat . controls with other defects and controls with genetic disorders. all drugs used in the first trimester were identified from the database, and were cross-referenced against previously compiled lists of drugs with reactive intermediates and drugs with faa. drugs with reactive intermediates, with systemic absorption and with a daily dose ≥ mg were considered os-inducing drugs. when there was an association between os-inducing drugs and a group of birth defects, we further investigated two different faa exposure categories: concurrent exposure to both os-inducing drugs and faa drugs (os+/faa+) and exposure to os-inducing drugs only (os+/faa-). when the number of subjects allowed (at least five cases/controls were exposed), we examined the role of folic. odds ratios (ors) with % confidence intervals were adjusted for maternal smoking and alcohol use in the first trimester in controls and additionally adjusted for maternal age in controls . results: a total of nine groups of birth defects were investigated. only nervous system defects were associated with os-inducing drugs. exposure rates were / ( . %) for cases, / ( . %) for controls and / ( . %) for controls and adjusted ors ( %cis) were . ( . - . ) and . ( . - . ), respectively. this association was unchanged when we examined os+/faa+ and os+/faa-separately. the os+/faa+ category, however, had slightly higher or values than the os+/faa-( . vs. . for controls , and . vs. . for controls ). because of the low number of exposed subjects, we could only examine folic in relation to os+/faa-. using os-/faa-/folic+ as reference, we found the highest risk with os+/faa-/folicand a lesser magnitude with os+/faa-/folic+ (ors being and . times respectively for both controls). conclusion: our study suggests an increased risk of having a child with nervous system defects in mothers who were exposed to os-inducing drugs during pregnancy, and a potential risk reduction with folic. background: inhibition of rho-gtpases with statins as well as specific inhibition of the small gtpase rac protects non-transformed cells from topoisomerase ii-(top )-poisoninduced cleavable complex formation and thereof derived dna double-strand breaks. this effect rests at least partially on rac -mediated regulation of topoisomerase ii activity. however, the link between rac and top -poisoning is only poorly understood. furthermore, it is unclear whether mitochondrial or nuclear type ii topoisomerases are the most relevant target for top -poison-induced cytotoxicity. here, we investigated the relevance of rac -regulated actin cytoskeleton integrity as well as mitochondrial integrity in top -poison-induced dna damage responses as well as cytotoxicity under situation of rac inhibition. methods: since endothelial cells are the first barrier for any kind of systemically administered chemicals and cardiomyocytes are particular sensitive to anthracyclines, endothelial cells (h v) as well as cardiomyocytes (h c ) were chosen as in vitro model systems for top -poisoning. the cells were pre-treated with rac inhibitors, statins or actin cytoskeleton disruptors and were subsequently treated with the topoisomerase ii poisons doxorubicin or etoposide. to compare the levels of induced dna damage, γh ax foci quantifications as well as the comet assay were employed. actin disruption was visualized by phalloidin-fitc staining. to be able to detect relevant changes in mitochondrial mass or integrity, high doses of top -poisons had to be used in both cell lines. changes in mitochondrial homeostasis as well as integrity were detected by the jc -assay, mitotracker assay as well as atp-assay. additionally, pcr-and gelelectrophoresis-based methods were used for detecting mitochondrial dna damages. selected components of the dna damage response machinery as well as factors of mitochondrial homeostasis were detected by western blot. results: disruption of the integrity of the actin cytoskeleton attenuated the dna damage response to a similar extent as seen by rac inhibition, pointing to a role of actin filaments in the dna damage response after genotoxic insults. the actin cytoskeleton seems to participate in genotoxin-induced dna damage, -repair or in the dna damage response as reflected by reduced numbers of nuclear h ax-foci as well as the comet assay after treatment with doxorubicin. this was not related to nuclear import or export of doxorubicin. disturbance of mitochondrial homeostasis or integrity was only detectable at high doses of topoisomerase ii poisons. this was largely unaffected by pre-treatment with statins or rac -inhibitor. top -poison-induced raise in mitochondrial mass was slightly enhanced by the rac -inhibitor and statins. interestingly, inhibition of rac counteracted doxorubicin-induced phosphorylation of the amp-kinase in endothelial cells but not in cardiomyocytes. conclusion: mitochondrial toxicity seems to play only a minor role in top -poisoninduced cytotoxicity in h c and h v cells. the data point to a role of rac -regulated filamentous (nuclear?) actin in the dna repair and/or dna damage response after treatment with top -poisons. poly(adp-ribose) polymerase (parp ) and the recq helicase werner syndrome protein (wrn) are important caretakers of the genome. they physically interact with each other and are both localized in the nucleus and in particular in the nucleoli. both participate in various overlapping mechanisms of dna metabolism, in particular genotoxic stress response and dna repair [ ] . previously, we and others have shown in biochemical studies that enzymatic functions of wrn are regulated by parp as well as by non-covalent poly(adp-ribose)-wrn interaction [ ] [ ] [ ] . furthermore, pharmacological parp inhibition as well as a genetic parp ablation in hela cells alters the recruitment kinetics of wrn to sites of laser-induced dna damage [ ] . here we report a novel role for parp and poly(adp-ribosyl)ation in the regulation of wrn's subnuclear spatial distribution upon induction of oxidative stress. we could verify previous reports that wrn is transiently released from nucleoli upon induction of oxidative stress, camptothecin (cpt) treatment, and laser-induced dna damage in a time-dependent manner. while, cpt-induced translocation appears to be a parpindependent process, our results reveal that upon h o -induced oxidative stress, parp is essential for the translocation of wrn from the nucleoli to the nucleoplasm. parp activity only partially contributes to wrn release from nucleoli, underlining the importance of a direct wrn-parp interaction for subnuclear wrn redistribution. furthermore, we identified a novel par-binding motif within the wrn sequence that is located in its rqc domain, which also harbors the binding site for parp and is necessary for wrn's nucleolar localization under non-stress conditions. currently, we are testing corresponding wrn mutants to analyze if this region is responsible for the parp -dependent release of wrn from nucleoli to sites of dna damage. in conclusion, we provide novel insight into the role of parp in wrn's spatio-temporal regulation in the nucleus during the oxidative stress response. host-cell reactivation (hcr) is an assay used to determine dna repair capacity of cells. in its canonical layout, the test utilised a virus or a plasmid with a marker gene, inactivated by uv-damage [ , ] . among the infected or transfected host cells types, only those with functional dna repair pathway would re-activate the damaged dna, thus providing a rationale for identification of dna repair genes in the mutant screens. an obvious advantage of hcr is that repair can be measured in cells that have not been exposed to a damaging agent. however, because of multiple variables of the damage generation, transfection and interpretation of results, the assay has been hard to harmonise and develop into a widely accepted quantitative dna repair assay. over the last years, my team has developed and validated several major improvements of the mammalian hcr assay. exploiting sequence-specific nicking endonucleases and customised design of the reporter vectors, we proposed an innovative and very efficient technique for incorporation of synthetic oligonucleotides, containing single structurally defined dna base and backbone modifications, into desired gene elements [ ] . this ad hoc approach allows examination of the repair in a stand-specific manner and at single nucleotide resolution. we efficiently applied hcr in its new layout for measurement of the nucleotide excision repair of various dna adducts. moreover, we demonstrated that the enhanced hcr assay can differentiate between the transcription-coupled (tc-ner) and global genome (gg-ner) subpathways of ner [ ] . we further obtained new significant insights into the lesion-specific mechanisms of base excision repair of several endogenously occurring aberrant dna bases [ - ] and plan to adapt the assay to the detection of mismatch repair and translesion dna synthesis. in addition to the applications in the dna repair field, the enhanced hcr assay provides a tool for investigation of the dynamics and transcriptional impact of the regulatory dna bases methylcytosine and -hydroxymethylcytosine as well as their derivatives ( formylcytosine and -carboxycytosine a coordinated and faithful dna damage response is of central importance for maintaining genomic integrity and cell survival. transcriptional activation of dna repair genes is an important regulatory mechanism contributing to the adaptation of cells to genotoxic stress and protection against genotoxin-mediated cell death. here we show that exposure to a low dose of benzo(a)pyrene , , the active metabolite of benzo(a)pyrene (b[a]p), which represents the most important carcinogen formed by incomplete combustion during food preparation and smoking, causes upregulation of several dna repair genes. combined induction of the nucleotide excision repair (ner) genes ddb , xpc, xpf and xpg enhanced repair activity and protected cells against a subsequent bpde exposure. furthermore induction of the translesion polymerase polh was also involved in protection against bpde-induced apoptosis, however led to an enhanced mutation frequency in the surviving cells. activation of these dna repair pathways was also observed upon exposure to b[a]p and in vivo in buccal cells of male individuals upon smoking, indicating that this mechanism may be involved in the formation of smoking-related cancers. altogether, we could show that low-dose bpde exposure activates a complex network of transcriptional alterations, leading to protection against cell death, at the cost of increased mutation frequency, highlighting the danger of occasional smoking. poly(adp-ribosyl)ation (parylation) is an essential posttranslational modification with the biopolymer poly(adp-ribose) (par). the reaction is catalyzed by poly(adp-ribose) polymerases (parps) and plays key roles in cellular physiology and stress response by regulating physico-chemical properties of target proteins. of the members of the human parp gene family, at least four have been shown to exhibit par-forming capacity. upon dna damage parp is catalytically activated and is thought to contribute to the bulk of the cellular par formation. parp inhibitors are currently being tested in clinical cancer treatment, in combination therapy, or as monotherapeutic agents by inducing synthetic lethality (mangerich and bürkle , mangerich and bürkle ) . here we generated a genetic knock out of parp in one of the most widely used human cell systems, i.e. hela parp ko cells, via talen-mediated gene targeting and characterized these cells with regards to parylation metabolism and genotoxic stress response. furthermore, by reconstituting hela parp ko cells with a series of artificial and natural parp variants, we analyzed structure-function relationships of parp in a cellular environment without interfering with endogenously expressed wt-parp . we confirmed that the parp e k mutant exhibits mono-adp-ribosylation activity and extended previous reports by demonstrating that the parp l f mutant is constitutively active in a cellular environment, leading to high cellular par levels even in unchallenged cells. additionally, both mutants exhibited significantly altered recruitment and dissociation kinetics at sites of laser-induced dna-damage, which can partially be attributed to non-covalent parp -par interaction via at least one specific par binding motif located in zinc finger of parp . expression of both artificial mutants led to distinct cellular consequences, caused by the altered cellular biochemistry. while the expression of parp l f itself triggered apoptosis, parp e k expression led to a strong g -arrest during cell cycle and sensitized cells to camptothecin treatment. interestingly, pharmacological parp inhibition with abt mitigated effects of the e k mutant, suggesting distinct functions of mono-adp-ribosylation. finally, by reconstituting parp ko cells with a natural cancer-associated parp snp variant (v a), as well as a newly identified parp mutant present in a patient of pediatric colorectal carcinoma (f l-v a), we demonstrate, that these variants exhibit altered biochemical and cellular properties, potentially supporting carcinogenesis. together, this study establishes a novel model to study parp -dependent parylation during genotoxic stress response and reveals new insight into the structure-function relationships of artificial as well as natural parp variants in a cellular environment, with implications for parp research in general. mangerich, a. and a. bürkle ( ) . "how to kill tumor cells with inhibitors of poly(adpribosyl)ation." int j cancer ( ): - . mangerich, a. and a. bürkle ( ) . multitasking roles for poly (adp-ribosyl) ation in aging and longevity. parp inhibitors for cancer therapy, springer: - . leukemic cells frequently overexpress the transcription factor wilms tumor (wt ) and the persistence of wt expression after chemotherapy indicates remaining leukemic stem cells. hydroxyurea induces replicative stress by its ability to inhibit ribonucleotide reductase, an enzyme that catalyzes the synthesis of dntps from ntps. we demonstrate that the expression levels of wt determines the extent of dna damage and apoptosis in a panel of leukemic cells treated with hydroxyurea. accordingly, inhibiting apoptosis through chemical inhibition of caspases or by overexpression of mitochondrial anti-apoptotic bcl proteins prevents the hydroxyurea-induced depletion of wt and cell death. in addition, we show that an rna interference-mediated elimination of wt sensitizes leukemic cells to the pro-apoptotic and dna damaging effects of hydroxyurea. furthermore, such a loss of wt suppresses hydroxyurea-induced erythroid differentiation. pharmacological approaches that diminish wt also sensitize cells to hydroxyurea. these include the tyrosine kinase inhibitor (tki) imatinib or epigenetic modifiers belonging to the histone deacetylase inhibitor (hdaci) group. thus, an inhibition of wt is therapeutically exploitable for a targeting approach against leukemic cells undergoing replicative stress. our novel findings reveal that wt is a novel biological target of hydroxyurea and they suggest that wt has a previously unrecognized ability to prevent dna damage when replication forks halt and eventually collapse. fret (fluorescence resonance energy transfer)-based cell assays were developed to directly monitor receptor activation and receptor-stimulated camp response. mutant ß ar were generated by insertion of cyan and yellow fluorescent proteins (cfp and yfp) into the third intracellular loop and the c-terminus, respectively (bornholz et al., cardiovasc res : , ) and stably transfected to hek cells (hekß -fret). to monitor the camp response the epac -based fret sensor of camp, was stably transfected alone (hekwt-e ) and together with a moderate level of native ß ar to hek cells (hekß -e ; nikolaev et al. jacc : , ) . fret-activity was measured with recently developed fluorescence detectors ( channels) equipped with fast semiconductor technology, avoiding any movable optical and mechanical parts, using nm for excitation and / nm for the emmission ratio. cells were cultivated in -format -well strips, incubated in physiological hepes-buffered salt solution and treated with ßar agonists of different selectivity and affinity to determine their ßar-subtype preference. catecholamines tested in hekß -fret cells exhibited ec -values (-log, m) which matched k d -values (-log, m) known from native heart receptor membranes (isoprenaline, iso: . ± . , adrenaline . ± . , noradrenaline . ± . ). ßar-expression levels were controlled by radioligand binding with [ h]-(-)-cgp , resulting in different densities of ~ x and ~ . x receptors/cell in hekß -fret and hekß -e , respectively, whereas in hekwt-e cells only ~ ß ar were found. surprisingly, the low level of ßar in hekwt-e cells allowed the measurement of the action of ß -sympathomimetics (ß sym), e.g. fenoterol, thereby amplifying receptor binding (pk d~ . ) to an effective regulation of fret activity in the presence of . mm ibmx (pec ~ . ± . ), nearly matching the ~ -fold amplification of iso (pk d~ . ; pec ~ . ). in order to determine ß ar-mediated side effects of ß sym, hekß -e cells characterized by a -fold higher level of ß ar over ß ar were assayed for fret activity. fenoterol maximally inhibited fret activity with a pec ~ . whereas the high affinity ß sym salmeterol acted a partial agonist (~ % of iso maximum, pec ~ . ), both compounds being rather insensitive against the highly effective ß ar-blockade with µm cgp , a. for that reason hekß -fret cells were used characterizing fenoterol as partial agonist (~ %) whereas salmeterol activated less than % of maximum receptor activation by iso. thus, it has to be concluded that the low level of effectively coupled wt-ß ar present in hekß -e cells precludes the exact determination of ß ar-mediated side effects of ß sym, and that cfp/yfp labelled receptors have to be used for the determination of the subtype specific intrinsic activity of an agonist. they account for about one third of all drug targets. their regulation from desensitization to internalization and alternative signal transduction is largely dependent on phosphorylation of intracellular serine and threonine residues of the activated receptor. even though the β -adrenoceptor is of tremendous importance in a number of diseases its phosphorylation remains poorly understood. we addressed this question in a qualitative and quantitative way. by using radioactive phosphorylation assays and mass spectrometry, we were able to elucidate the phosphorylation pattern of the human β -adrenoceptor in vitro. we identified ten previously unknown phosphorylation sites in the third intracellular loop and the receptor's c-terminus. labeling hek cells with stable heavy isotopes (silac) lead to the discovery of a stimulation-dependent regulation of several of these phosphorylation sites. furthermore, mutagenesis studies in stably transfected hek cells revealed the impact of phosphorylation for arrestin binding and internalization of the receptor. fluorescence resonance energy transfer experiments with β -adrenoceptor variants carrying point mutations of putative phosphorylation sites identified two c-terminal phosphosites that determine arrestin recruitment. our current goal is to further investigate the functional implications of these newly identified phosphorylation sites on downstream signal transduction, with an emphasis on the map kinase pathway. a moderate increase in arrestin affinity to the β -adrenergic receptor is sufficient to induce arrestin internalization. the homologous desensitization of g-protein-coupled receptors is a two-step process. initially, g-protein-coupled receptor kinases phosphorylate agonist-occupied receptors which are subsequently bound by arrestins. in many cases, the resulting receptorarrestin complex is then internalized via clathrin-coated pits. dependent on the identity of the receptor and the ligand, the complex between receptor and arrestin may exist only in the proximity of the plasma membrane or internalize into the cell interior. we constructed mutants of the β -adrenergic receptor carrying three additional serine residues in various positions at the c-terminal tail. one of these mutants which carried the serine residues in close proximity to the endogenous grk phosphorylation sites (β ar-sss) showed increased isoprenaline-stimulated phosphorylation and differences in arrestin- affinity and trafficking. the affinity of arrestin- to the receptor was measured by fluorescence resonance energy transfer (fret) between the receptor and arrestin- and by two-color fluorescence recovery after photobleaching (frap). in the fret assay, arrestin- dissociation from the β ar-sss receptor upon agonist washout was prolonged approximately two-fold compared to the wild-type receptor. frap was performed with an n-terminally tagged receptor immobilized with an antibody against the n-terminal tag either in solution or on a micropatterned surface. in these assays, the recovery of arrestin- into the bleached region was prolonged between two-and fourfold for the β ar-sss receptor compared to the wild-type. even though this two-to fourfold increase in affinity seemed rather modest, it resulted in the trafficking of receptorarrestin complexes to the early endosome whereas the wild-type receptor interacted only transiently with arrestin at the plasma membrane. furthermore, the increased affinity of arrestin led to more efficient internalization of the β ar-sss compared to the wild-type receptor. however, recycling to the plasma membrane after agonist washout was very similar for both receptors. we conclude that even a modest change in affinity between a g-protein-coupled receptor and arrestin can lead to substantial alterations in arrestin trafficking which in turn may have effects on cellular signaling. despite recent structural research allow for better understanding of gpcr structure, the crucial aspects of the selectivity mechanism of receptor -g protein subtype coupling remain unresolved. based on the hypothesis that the affinity of the ternary complex (agonist/gpcr/g-protein) in the nucleotide-free state determines the selectivity of gpcr-g protein coupling, we set out to measure gpcr-g protein interaction in membranes of single cells. in order to quantify the affinity of gα-subunit towards gpcrs in single cell, we determined the lifetime of the receptor-g protein complex in living cells upon agonist withdrawal under conditions of gtp-depletion. therefore, we utilized förster resonance energy transfer (fret) based assays to study interactions between fluorescent muscarinic receptors and heterotrimeric g proteins in single permeabilized hek t cells transfected with the appropriate cdnas. here we focused on muscarinic m -, m -, and m -receptors and characterized the kinetics of agonist-induced binding of go/i -and gq/ -proteins to muscarinic receptors and their subsequent dissociation in the absence of nucleotides. as a measure of affinity we calculated the rate constant of g protein dissociation from the receptor after agonist withdrawal. the dissociation kinetics of go protein from m -and m -achrs was found to be -fold faster in comparison to gq. similarly, we observed a -fold right shift of the concentration-response curves of go proteins binding to m -achr in comparison to gq. in order to ensure, that the affinity of the ternary complex correlates with the efficiency of g protein activation, we performed experiments on the g protein activity in intact cells expressing non-fluorescent m -achr by using a fret-based assay. our results showed that gq activation required -fold lower agonist concentration compared to go activation, suggesting that indeed the stability of the ternary complex in the absence of nucleotides determines the selectivity of gpcr-g protein coupling. we further explored the subtype selectivity of m -achr for gi family members by comparison of dissociation kinetics of gi -, gi , gi -, and go-proteins from m -achr under nucleotide depleted conditions. k off of gi and gi were found to be two-fold higher in comparison to gi and go proteins, indicating the higher affinity of the latter ones to m -achr. our fret-based assay to study receptor-g-protein interactions in membranes of single cells has been proven to be a fast and reliable method to quantify the affinity of the ternary complex. the g protein subtype dependent differences in the affinity towards activated receptors correlate with the g protein coupling efficiency of this receptor. despite their tremendous pharmacological relevance and potential for the development of new drugs, our understanding of g protein-coupled receptor (gpcr) architecture and signaling mechanisms are still limited. major reasons for this are the low abundance and poor biophysical properties of gpcrs, which makes them one of the most challenging class of proteins for structural and biophysical studies. among the superfamily of gpcrs, the class b receptors comprising receptors are structurally least understood because to date it has not been possible to obtain a crystal structure of this receptor class. to overcome these limitations, we have developed a method for improving functional expression and simultaneous thermo-stabilization of gpcrs by directed evolution which is based on expression of receptors in saccharomyces cerevisiae and subsequent selection of highly expressing variants by flow cytometry with fluorescent ligands. by this strategy, key residues within a receptor sequence can be rapidly identified that are responsible for improved biophysical properties without greatly affecting the pharmacological features of the receptor. we have now applied this method to the human parathyroid hormone receptor, a member of the class b of gpcrs which is a major regulator of calcium homeostasis in the body and a key target for the treatment of osteoporosis. from two rounds of directed evolution in yeast we obtained several mutants of parathyroid hormone receptor that exhibit strongly improved expression levels and that remain stable after solubilization in detergents. these receptor variants are ideal candidates for subsequent structural and biophysical analysis. opioid drugs exert nearly all of their clinically relevant actions through stimulation of mors (μ-opioid receptors). the molecular biology of endogenous opioid peptides and their cognate receptors has been studied extensively in vitro. for mor, signaling efficiency is tightly regulated and ultimately limited by the coordinated phosphorylation of intracellular serine and threonine residues. morphine induces a selective phosphorylation of serine that is predominantly catalyzed by g protein-coupled receptor kinase . as a consequence, the selective morphine-induced s phosphorylation does not lead to a robust beta-arrestin mobilization and receptor internalization. by contrast, high-efficacy opioid agonists such as fentanyl or etonitazene not only induce phosphorylation of s but also drive higher order phosphorylation on the flanking residues threonine , threonine , and threonine in a hierarchical phosphorylation cascade that specifically requires grk and grk isoforms. as a consequence, multisite phosphorylation induced by potent agonist promotes both betaarrestin mobilization and a robust receptor internalization. however, little is known about agonist-selective phosphorylation patterns in vivo after acute and chronic drug administration. to learn more about mor regulation in vivo we have generated a new μopioid receptor knock in mouse with an n-terminal ha-tag. using these mice, we were able to study in vivo phosphorylation of an endogenous g protein-coupled receptor using both mass spectrometry and phosphosite-specific antibodies. we were also able to address the question which of the many putative mor splice variants detected on the mrna level are indeed expressed as functional receptors in mouse brain. ion channels hcn in thalamic relay neurons is necessary for oscillatory activity in the thalamocortical system institut für physiologie i, westfälische wilhelms-universität, münster, germany hcn channels underlie the i h current and are involved, among other functions, in the genesis of epilepsy. the significance of hcn and hcn isoforms for brain function and epilepsy has been demonstrated, however the role of hcn , the third major neuronal hcn subunit, is not known. here we show an unexpected role of hcn in controlling oscillations in the thalamocortical network. hcn is predominantly expressed in several thalamic relay nuclei, but not in the thalamic reticular nucleus and the cerebral cortex. hcn -deficient thalamocortical relay neurons showed a massive reduction of i h and strongly reduced intrinsic burst firing. evoked thalamic oscillations in a slice preparation were completely abolished. in vivo, brain-specific hcn null mutants were protected against induced spike-and-wave discharges (swd), the hallmark of absence seizures. our findings indicate that hcn is necessary for rhythmic intrathalamic oscillations and that the channels constitutes an important component of swd generation. ludwig-maximilians-universität, walther-straub-institut für pharmakologie und toxikologie, münchen, germany trpc and channels are members of the classical transient receptor potential (trpc) family whose activation mechanism downstream of phospholipase c (plc) largely remained elusive until now. while trpc / / channels are directly activated by diacylglycerol (dag), trpc and channels are commonly regarded as daginsensitive. in contrast to trpc / / channels, they contain a c-terminal pdz-binding motif allowing for binding of na + /h + exchanger regulatory factor (nherf) and . interestingly, performing electrophysiological measurements, co-immunoprecipitations and intermolecular dynamic fret experiments, we found that dissociation of nherf proteins from the c-terminus of trpc confers dag-sensitivity on trpc channels. trpc channels were dag-sensitive under the following experimental conditions: inhibition of protein kinase c, amino acid exchange in the c-terminal pdz-binding motif, pip depletion with and without involvement of plc, over-expression of g-protein coupled receptors, down-regulation of endogenous nherf and proteins and overexpression of a nherf mutant incapable of trpc binding. these findings strongly argue for nherf proteins as molecular determinants for channel activation. interestingly, pip depletion itself caused slight trpc current increases while during pip depletion, the membrane permeable dag analogue oag evoked even higher trpc currents suggesting that pip depletion induces an active and dag-sensitive channel conformation. receptor mediated pip depletion also resulted in dissociation of nherf and from the c-terminus of trpc thereby eliciting a dag-sensitive trpc channel conformation. thus, our findings suggest that dag-sensitivity of trpc is the result of an activation cascade starting with pip depletion and subsequent dynamic dissociation of nherf and from the c-terminus of trpc . altogether, dagsensitivity is a unifying functional hallmark of all trpc channels. the melastatin-related transient receptor potential channel trpm is a heat-activated nonselective cation channel expressed in sensory neurons of dorsal root ganglia. since trpm -deficient mice show impaired inflammatory thermal hyperalgesia, the pharmacological inhibition of trpm may exert antinociceptive properties. fluorometric ca + assays and a compound library containing approved drugs were used to identify trpm inhibitors and to characterize their potency and selectivity. biophysical properties of the block were assessed using electrophysiological patch-clamp methods. microfluorometry in fura- -loaded single cells was applied to monitor [ca + ] i signals in isolated dorsal root ganglion (drg) neurons. analgesic effects were assessed applying pregnenolone sulfate (pregs)-induced chemical pain and heat stimuli at mice. in the screening approach using stably transfected hek trpm cells we identified the nonsteroidal anti-inflammatory drug (nsaid) diclofenac, the tetracyclic antidepressant maprotiline and the anticonvulsant primidone as highly efficient trpm inhibitors. the compounds exhibited half-maximal inhibitory concentrations of . - µm. the selectivity profiles of maprotiline and primidone for trpm were promising with no inhibitory effects on trpm , trpm , trpa , trpv , trpc , trpc and p x receptor channels. primidone inhibited pregs-induced [ca + ] i signals in rat drg neurones, indicating a block of native trpm channels. consistently, primidone attenuated nocifensive responses of mice to paw-injected pregs. furthermore, intraplantar primidone reduced nociception in healthy and hyperalgesic cfa-inflamed paws in the hot plate test. the finding that an approved drug can inhibit trpm at concentrations that may be therapeutically relevant and thereby can act as an analgesic, provides a method to study trpm -related effects by acutely challenging the channel´s function. pharmacological interference with trpm applying an approved drug or optimised successor compounds may pave the way to better understanding of physiological functions of trpm in humans and may represent a novel concept for analgesic treatment. excitotoxicity, calcium deregulation, mitochondrial dysfunction and neuroinflammation contribute to progressive cell death in many neurodegenerative diseases. therefore, proteins that prevent deregulation of these pathways are considered as drug targets. potential therapeutic approaches may benefit from modulation of small-conductance calcium-activated potassium (sk) channels, since recent data supports the hypothesis that sk channel activity promotes neuronal survival against cellular stress via a dual mechanism of action: i) by controlling neuronal excitability and ii) by preventing mitochondrial dysfunction and inflammation. our previous studies showed that activation of sk channels in neurons exerted protective effects through inhibition of nmdarmediated excitotoxicity. further, we revealed recently that in a model of glutamate oxytosis, activation of sk channels attenuated mitochondrial fission, prevented the release of pro-apoptotic mitochondrial proteins, and reduced cell death. however, little is known about the function of sk channels in cell metabolism and neuroinflammatory processes in non-neuronal cells, such as microglial cells. in this study, we addressed the question whether sk channel activation affected primary mouse microglia activation upon lps and α-synuclein challenge. we found that activation of sk channels significantly reduced activation of microglia in a concentration-dependent manner, as detected by real-time xcelligence cell impedance measurements. further data on cytokine (tnf-alpha and il- ) analysis revealed that activation of sk channels attenuated α-synuclein-induced cytokine release. inhibition of glycolysis prevented microglial activation and cytokine release. although sk channel activation slightly reduced atp levels, it attenuated α-synuclein-induced no release. furthermore, glycolytic products and ampk signaling were evaluated. overall, our findings show that activation of sk channels attenuates microglial cell activation. thus, sk channels are promising therapeutic targets for neurodegenerative disorders, where neuroinflammation and cell metabolic deregulation are associated with progression of the disease. mutant of the residue pair e /k can be crosslinked efficiently in both states, the closed-and open state of the p x r. interestingly, oxidative crosslinking of cysteine substitution mutants of each individual residue pair significantly reduced the atpinduced current amplitudes. charge reversal or swapping mutagenesis and cysteine modification by charged mts-reagents indicated the electrostatic nature of the pairwise interactions in these four residue pairs. furthermore, preliminary data from triple, tetra and penta mutant cycle analysis indicated energetic coupling between the residue pairs e /r , e /k , e /r and e /k and thus indicates the cooperative interaction in a larger salt bridge network. together with the markedly reduced current amplitudes following disulfide crosslinking, our data suggest that the salt bridge network serves to stabilize the closed-state conformation of the p x r. the comparison of the closed-state and open-state model of the rat p x r showed that atp promotes a marked rearrangement of the side chains of the residues r and k to enable the strong ionic coordination of the γ-phosphate oxygen of atp. in summary, our data are in line with the concept that the electrostatic interaction of r and k with atp competitively releases e , e and e from their strong electrostatic coupling and thus initiates a destabilization of the closed-state, which favors channel opening. fig. in a similarity search using sequence motifs conserved amongst various members of the trp protein family we identified three non-annotated putative membrane proteins that we initially termed tmem , tmem and tmem . expression analysis using the nanostring ncounter system, northern blotting and rt-pcr showed that murine tmem is expressed in various tissues including heart, brain, lung, endothelium, colon, cardiac myocytes, cardiac fibroblasts, embryonic fibroblasts, mast cells and pancreatic acinar cells. hydropathy analysis predicts that tmem proteins exhibit to plasma-membrane spanning domains, but fluorescently labeled tmem fusion constructs expressed in mouse embryonic fibroblasts revealed a vesicular subcellular localization pattern. in contrast to the prediction by the psort ii algorithm, tmem -eyfp could not be identified in the plasma membrane of fibroblasts, cardiac myocytes, mast cells or pancreatic acinar cells but showed a significant colocalization with markers and fusion constructs specific for acidic compartments including lysosomes. in tmem -/mice, a marked elevation of amylase and lipase plasma levels was observed. we found that constitutive but not stimulated amylase secretion from tmem -deficient acinar cells is elevated indicating a cell autonomous defect. calcium (ca ++ ) is an important signaling molecule regulating stimulated as well as constitutive secretion from pancreatic acinar cells. microfluorimetric measurements using fura- or indo- indicate higher resting ca ++ concentrations in tmem -/-pancreatic acinar cells correlating with elevated basal enzyme secretion. in tmem -yfp-knock-add-on mice we identified tmem in organelles of the apical acinar cell pole and a partial colocalisation with lamp proteins. furthermore, largely increased elevations in cytoplasmic ca ++ concentration were observed upon osmotic lysis of lysosomes triggered by gly-phe β-naphthylamide (gpn) or by nh cl application. the role of tmem for ca ++ release was evaluated by stimulation with low concentration of cholecystokinin pm) in the absence of extracellular ca ++ using both microfluorimetric recording of cytosolic ca ++ transients as well as electrophysiological recordings of ca ++ -activated chloride currents. these measurements revealed a higher frequency of intracellular ca ++ oscillations and a larger area under the curve of ca ++ activated chloride currents upon cck- stimulation indicating that tmem inactivation leads to an enhancement of the globalization of cck- evoked ca + release from intracellular organelles. taken together, our study identifies tmem as a novel regulator of ca ++ release from intracellular organelles including endo-lysosomes and as a critical determinant of constitutive protein secretion in pancreatic acinar cells. while generally highlighting toxicology as a translational science that requires academic anchoring, gundert-remy and co-workers [ ] have called for efforts to improve the relevance of in vitro methodologies in predicting in vivo effects. against this background, the german society of toxicology working group on alternative approaches to animal testing proposes specific quality criteria (qc) for in vitro methods and for research work using in vitro methods. these qc may serve to evaluate in vitro methods that are developed or applied in-house or that are described in work plans, peer reviewed articles, etc. for the time being, the qc focus on in vitro cell or tissue culture methods that address human health endpoints in the context of substance-related regulatory toxicity testing. nevertheless, these qc are also generally applicable to in vitro research conducted for other toxicological purposes. relevant work from, e.g., the organisation for the economic co-operation and development has been taken into account in specifying the qc that cover the following aspects:  the rs impact of an in vitro method in replacing, reducing (and refining) a specific animal test for a specific toxicological endpoint. this aspect also includes scientific hurdles that, in the past, had impeded the successful development of in vitro methods for the given toxicological endpoint.  scientific relevance and reliability, i.e. which fundamental requirements should an in vitro method meet to ensure that its results are relevant and reliable.  practicability and applicability, i.e. what is the expected expenditure for the in vitro method, and have relevant authorities and industrial sectors been involved in the development of the in vitro method. qc related to the scientific relevance of research work using a specific in vitro method provide a tool to justify, e.g., the suitability of the selected test system and in vitro endpoint(s) for the given purpose; the selection of test substances, positive and negative controls; the setting and control of test concentrations; and the definition of acceptance criteria to determine the relevance of test results. the proposed qc may serve as a framework to assess the relevance of in vitro methods and in vitro research work. thereby, they aim at improving in vitro predictivity of in vivo toxicological effects, which in return contributes to reducing and replacing the need for animal testing. [ ] gundert-remy, u. et al. ( ) . toxicology: a discipline in need of academic anchoring -the point of view of the german society of toxicology. arch toxicol : - . during the past decades, considerable progress has been made in implementing r approaches in routine safety assessment. in spite of these achievements, animal tests still need to be conducted if legal requirements prescribe in vivo tests or if no reliable, accepted alternative method exists. efforts to foster r approaches and make them 'ready for use' focus on three levels: development and validation of scientific methods/strategies, regulatory acceptance of acknowledged approaches and global harmonization of standards. strong cooperation between toxicological experts from scientific bodies, national and international authorities and industry is needed to advance on all three levels for the benefit of animal welfare. r approaches that have already been implemented in routine safety assessment of consumer goods do not focus solely on replacement of animal testing by use of accepted alternative methods. in cases where reliable alternative approaches are not yet available, reduction in animal numbers and refinement of testing procedures can be achieved on a case-by-case basis. a tailor-made, tiered testing strategy is usually pursued that involves knowledge on specific characteristics of the test item and makes use of all available data, including details on exposure and results obtained with structural homologues. hurdles to apply alternative approaches can even occur for established methods. as legislations give different priority to alternative approaches, it remains challenging to fulfil conflicting legal requirements in different regions of the world, or even to address horizontal legislations of the same region. furthermore, successfully validated and legally implemented alternative approaches might not always provide the safety assessor with meaningful test results. with gaining experience, limitations of test systems can become evident that affect for example the applicability domain of the method, as has been the case both for some in vitro and in vivo methods. in these cases, the new information needs to be shared not only among safety assessors, but also with method developers and regulators to facilitate refinement of scientific approaches and/or amendments of regulations. leibniz-institut für arbeitsforschung (ifado), vistox, dortmund, germany two-photon microscopy facilitates imaging of biological processes in vivo. establishing this recent technique in mouse liver allowed us to record in a real-time the sequence of events during acetaminophen (apap) induced-liver damage. although apap is intensively studied and described in vivo imaging revealed so far unknown scenarios of cell death. the hepatocytes close to the central vein of a liver lobule went within hours into cell death as commonly described due to the toxic metabolite napqi. surprisingly, we observed a distinct way of cell killing at the outer border of the dead cell area which is accompanied by bile acid decompartmentalization. there, within an hour after apap administration dilatation of bile canaliculi was observed. subsequently, bile acids containing invaginations arouse from the apical side of a hepatocyte into the cytosol. these invaginations ballooned until the bile leaked into the hepatocyte volume and subsequently the plasma membrane of the affected hepatocytes lost its integrity leading to cell death. this mechanism emerged in an environment for hepatocytes where moderate napqi levels meet intracellular high bile salt concentrations of the midzonal region. in conclusion, establishing in vivo imaging in mouse liver enabled us to identify new cellular mechanisms which cannot be discovered by conventional methods. universitätsklinikum düsseldorf, institut für toxikologie, düsseldorf, germany introduction: lung inflammation and fibrosis are considered as major toxicities after thoracic cancer radiotherapy. up to now effective pharmacological interventions for normal tissue protection are largely missing. hmg-coa reductase inhibitors (statins), which are used in the clinic for lipid-lowering purpose, are reported to have multiple inhibitory effects on genotoxic stress responses. for this reason we aim to investigate the usefulness of statins to protect normal lung cells in vitro and lung tissue in vivo from damage provoked by ionizing radiation (ir). methods: according to clinically relevant anticancer radiation regimens, we used fractionated irradiation schemes ( x gy) for both in vitro as well as in vivo experiments. we analyzed the effect of lovastatin on ir-induced dna damage formation and repair, dna damage response (ddr) and cell death in non-proliferating human lung fibroblasts, epithelial as well as endothelial cells. furthermore, we established an irradiation device that is useful to selectively irradiate the right lung of mice and investigated the influence of lovastatin on lung damage following fractionated and selective irradiation of the lung in vivo (balb/c mice). results: compared to lung fibroblasts and epithelial cells, endothelial cells exhibited the highest radiosensitivity and underwent ir-induced apoptosis which was partly prevented by lovastatin. by contrast fibroblasts and epithelial cells did not undergo apoptosis upon irradiation. lovastatin did not affect initial dna damage formation in any of these cells. in all three lung cell types lovastatin enhanced the repair of dna double-strand breaks as analyzed h after the last irradiation by γh ax nuclear foci formation. depending on the cell type lovastatin affected various components of the ddr machinery in vitro. in vivo, lovastatin prevented ir-mediated increase in breathing frequency as determined two and four weeks after fractionated irradiation. moreover, statin treatment attenuated the level of residual dna damage and ir-induced apoptosis as analyzed four weeks after irradiation. these results were mimicked when eht , a small molecule inhibitor of the small rho-gtpase rac , was applied in vivo, pointing to an involvement of rac in statin-mediated radioprotective effects. conclusion: bearing in mind that statins are well tolerated in humans, we suggest the application of statins as a promising pharmacological strategy for the prevention of irradiation-induced damage of the lung. targeted genome engineering by crispr/cas is an evolving tool for generating specific knockout cell lines. co-expression of crispr/cas allows for efficient dna cleavage and introduction of so called indel mutations (insertion/deletion point mutations) that lead to either misfolded non-functional proteins or complete knockout. we exploited this tool to generate a bid (bh -interacting domain death agonist) knockout cell line in neuronal ht- cells. bid has been shown to be involved in regulated cell death pathways like oxytosis where its activation mediates mitochondrial demise, subsequent release of apoptosis inducing factor (aif) and cell death. in the cell death model of oxytosis the cystine/glutamate antiporter (x c -) is inhibited by high extracellular glutamate concentrations. following events such as increasing lipid peroxidation and ros production resemble major characteristics of another emerging cell death pathway, called ferroptosis. in this study we generated a bid crispr/cas -knockout cell line to elucidate the role of bid as a potential link of oxytosis and ferroptosis in the ht- cell line. in order to investigate the potential mechanistic overlap at the level of mitochondrial death pathways, we induced oxytosis with glutamate or ferroptosis with erastin in wild-type cells and analyzed the respective effects of the well-established inhibitors ferrostatin- and the bid inhibitor bi- c on cell death and mitochondrial paradigms. these results were then compared to the effects of glutamate or erastin in crispr/cas -bid-knockout cells. bi- c inhibited glutamate-induced morphological changes of ht- cells and also prevented cell death as assessed using the mtt assay and annexin v/pi staining. similar results were observed with ferrostatin- in the model of erastin-induced ferroptosis. subsequent facs analysis of lipid peroxidation by bodipy staining demonstrated that bi- c abolishes lipid peroxide formation in the erastin model and ferrostatin- in the model of oxytosis. facs analysis was further employed for the detection of mitochondrial ros formation. mitosox staining revealed a significantly decreased production of mitochondrial ros by bi- c and ferrostatin- in the respective model systems. investigating the crispr/cas -bid-knockout ht- cell line revealed that bid knockout prevented cell death, lipid peroxidation and mitochondrial toxicity in both model systems of cell death, oxytosis and ferroptosis. in conclusion, the present study exposes bid as a pivotal molecular link between the previously separated cell death pathways oxytosis and ferroptosis at the level of mitochondria. parkinson's disease is a common neurodegenerative movement disorder characterized by midbrain dopaminergic neuronal loss in the substantia nigra that has been linked to alpha-synuclein toxicity. however, the molecular mechanisms underlying alphasynuclein-mediated toxicity in human dopaminergic neuronal loss are not well defined. the goal of this study was to investigate the deleterious effects of alpha synuclein in particular mitochondrial toxicity in human dopaminergic cells. therefore, we have generated neuron specific, adeno associated virus type (aav ) expressing cytosolic as well as mitochondrial targeted alpha synuclein and egfp expressing viruses used as respective controls. overexpression of both, the cytosolic and the mitochondrial variants of alpha synuclein severely disrupted the dendritic network, induced loss of cellular atp, enhanced mitochondrial ros production, and was associated with activation of caspases and dopaminergic cell death in a time-dependent manner. in addition, real-time analysis of mitochondrial bioenergetics using the seahorse bioscience system following aav infection elicited a complete damage to mitochondrial respiration capacity in the dopaminergic neurons. our results suggested that mitochondrial targeted expression of alpha synuclein appeared to be more toxic than the cytosolic form of alpha synuclein. in addition, ultrastructural mitochondrial morphological analysis by transmission electron microscopy illustrated a number of deformed cristae in cells expressing the cytosolic alpha synuclein and a complete loss of cristae structure and massively swollen mitochondria following the expression of mitochondrial targeted alpha synuclein in the human dopaminergic neurons. in addition, we found that inhibition of caspases by the broad spectrum caspase inhibitor qvd significantly ameliorated alpha synuclein-induced dopaminergic neuronal death. interestingly, inhibition of caspases preserved neuronal network integrity, atp levels and mitochondrial respiration capacity in both paradigms of cytosolic and mitochondrial alpha synuclein overexpression. overall, our findings show that cytosolic as well as mitochondrial targeted expression of alpha synuclein is detrimental to human dopaminergic neurons, while inhibition of caspases amend alpha synuclein toxicity at the level of mitochondria. thus, caspase inhibitors provide promising therapeutic potential to prevent dopaminergic neuronal death in parkinson's syndromes that are associated with alpha synuclein toxicity. degradation of and adverse effects caused by tattoo and permanent make-up pigments upon sunlight exposure and laser removal have been occasionally reported in the last decades. until now, only the ban of certain azo-pigments has been addressed in the national legislation. the regulation was based on a number of studies showing the cleavage of azo-bonds by ultra violet light and laser-irradiation leading to the formation of carcinogenic aromatic amines. as a result, especially german tattoo ink manufactures switched to the use of more light-fast polycyclic pigments assuming these would be safer for this kind of application when compared to azo-pigments. to assess the potential risks of polycyclic pigments in terms of decomposition in the skin, we compared the photochemical cleavage of the widely used azo-pigment orange and the polycyclic pigment copper phthalocyanine blue. main decomposition products are qualitatively and quantitatively analyzed after q-switched laser irradiation of mg/ml aqueous suspensions and tattooed pig skin. irradiated specimen were extracted with ethyl acetate and analyzed with gas chromatography coupled to mass spectrometric detection (gc/ms) using liquid injection and head-space sampling techniques. we were able to confirm the cleavage of pigment orange at the azo-and other weak bonds in our experimental set-up (fig. a) . amongst other substances, the carcinogens aniline (max. conc. . ± . µg/ml) and , -dichlorobenzidine (max. conc. . ± . µg/ml) are formed. despite the lack of such weak bonds, the highly stable porphyrin-like structure of copper phthalocyanine blue is as well decomposed upon laser-irradiation (fig. b) . here, , -benzenedicarbonitrile (max. conc. . ± . µg/ml) were found as the main decomposition product in all experimental setups. concentrations of cleavage products were generally higher in aqueous suspensions compared to pig skin extracts with both pigments. additionally, the highly toxic gas hydrogen cyanide (max. conc. . ± . µg/ml) and the human carcinogen benzene (max. conc. . ± . µg/ml) were formed from both pigments, dependent on the laser wavelengths used. cyanide levels of ≥ µg/ml evolving upon ruby laser irradiation of > . mg/ml aqueous suspensions of phthalocyanine blue were proven to significantly reduce cell viability in human skin cells in vitro. reference schreiver, i., hutzler, c., laux, p., berlien, h. p. & luch, a. formation of highly toxic hydrogen cyanide upon ruby laser irradiation of the tattoo pigment phthalocyanine blue. sci rep , ( ) . understanding the interactions between nanoscaled objects and living cells is of great importance for risk assessment, due to rising application of nanomaterials in foodrelated products. several studies show that silver nanoparticles can reach the intestinal epithelia in nanoform in a human in vitro digestion model. nevertheless, only sparse data concerning the direct quantification of cellular uptake of silver nanoparticles are available. therefore, this study was focused on a systematical quantitative comparison of the cellular uptake of differently coated silver nanoparticles of comparable size. intracellular uptake was determined quantitatively via a transwell tm -system with subsequent elemental analysis (aas) and ion beam microscopy (ibm). silver nanoparticles were coated with poly (acrylic acid) and polyvinylpyrrolidone and characterized extensively by tem, dls, saxs, zetasizer and nanosight. agpure tm as a widely used reference nanoparticle coated with tween and tagat to v was also used for comparison. different intestinal cell models were applied to get closer to the complex in vivo situation: beside the widely used caco- model we also investigated particle uptake in a model which considered the enterocyte-covering mucus layer, as well as in a model specialized on particle uptake, the so-called m-cell model. our findings suggest that silver uptake is clearly a particle-and not an ion-related effect. the internalization of silver nanoparticles was enhanced in uptake-specialized m-cells, although no enhanced transport through the cells was observable. furthermore, the mucus did not providing a substantial additional barrier for nanoparticle internalization. rutherford backscattering spectrometry (rbs) via ibm allowed distinguishing between adsorbed an internalized material and the results were in accordance with the transwell tm -data. additionally, ibm investigations via particle-induced x-ray emission (pixe) showed intracellular association of silver with sulfur. the quantification of silver nanoparticle internalization revealed a clear particle-specific and a coating-related uptake. furthermore, a high amount of silver nanoparticles is taken up in cell models of higher complexity. thus, an underestimation of particle effects in vitro might be prevented by considering cell models with greater proximity to the in vivo situation. analyzing iron oxide nanoparticles for drug delivery -innovative investigation tools for nanotoxicology nanoparticles offer promising new possibilities for medical applications including therapy and diagnosis of various diseases. especially nanoparticle systems with magnetic cores provide a broad application spectrum as contrast agents, magnetic transporters, or heat carriers in hyperthermia treatment. for bench to bedside translation of superparamagnetic iron oxide nanoparticles (spions) for medical applications, safety issues have to be clarified. for that, reliable standards must be established on the basis of comprehensively validated physicochemical and biological characterization methods. spions consisting of maghemite and magnetite are usually of brown or black color. due to these special properties, spions and other metal oxide nanoparticles are prone to interfere with classical toxicological assays relying on optical detection of colorimetric, fluorescence or luminescence signals. particularly, nanoparticle concentration and cellular uptake are further influencing factors. consequently, for reliable analysis of nanoparticle mediated effects, alternative robust and interference-free readouts have to be established. based on long lasting experience working with spions, we suggest a combination of complementary methods to analyse nanoparticle-mediated effects: multiparameter analyses in flow cytometry deliver statistically relevant data and link uptake of nanoparticles (side scatter increase) with cellular effects in a high-content style. combination of noninvasive, label-free impedance measurements (xcelligence system) with real-time (fluorescence) microscopy enables us to monitor cellular proliferation and morphology over several days without interference by nanoparticles. additional experiments in multicellular tumor spheroids provide information about tissue infiltration and thus, more closely resemble the in vivo situation. using those complementary methods, several drug-loaded spion systems dedicated for medical applications have been successfully characterized previously. in sum, nanotoxicology is a complex and interdisciplinary challenge, where physicochemical parameters, as well as in vitro and in vivo behavior of nanoparticles have to be considered. to address these basic requirements, we are working on a stringent standardized road of characterization for iron oxide nanoparticles synthesized for medical applications. reference: lyer s, tietze r, unterweger h, zaloga j, singh r, matuszak j, poettler m, friedrich rp, duerr s, cicha i, janko c, alexiou c. nanomedical innovation: the seon concept for an improved cancer therapy with magnetic nanoparticles. nanomedicine (lond). ; ( ) acrylamide (aa) is an α,β-unsaturated compound, which is categorized as probably carcinogenic to humans [ , ] . aa is known to arise in foods by heat treatment in the course of the maillard reaction between reducing sugars and amino acids at processing temperatures > °c [ ] . dietary aa exposure has mainly been estimated on the basis of dietary recall, assessing consumption of foods with known aa contents. the use of human biomarkers of aa exposure, primarily haemoglobin adducts of aa and its genotoxic metabolite, glycidamide ( ga) in red blood cells, as well as mercapturic acids excreted in the urine, is a promising alternative. such biomarkers are to be validated by exact measurement of aa uptake in duplicates of food as consumed (duplicate diet studies) [ ] . we here present results of a nine-day human intervention study with healthy male volunteers. aa contents were determined in duplicates of servings as consumed and kinetics of aa-associated mercapturic acids (aama and gama) monitored in total urine [ ] . the study design included washout periods with an aa-minimized diet ( - ng /kg bw), a low aa intake day ( . - . µg /kg bw) as well as a high aa intake day ( . - . µg /kg bw). after a three-day washout period an aama baseline level of ± nmol/d was determined. low aa intake led to an aama excretion within h of ± nmol/d, high intake to ± nmol/d corresponding to an aama excretion rate of about % of the ingested aa dose within h, whereas aama output within h corresponded to % of the respective aa intake, the aama baseline after days washout corresponds to a net exposure level of . - . μg aa/kg bw/d. whether this represents a true baseline level is to be clarified in a follow-up study. in summary, this study provides important quantitative information on kinetics of urinary short-term exposure biomarkers validated by analytically verified dietary aa intake at present day food contamination levels. [ ] deutsche forschungsgemeinschaft (dfg), mak-und bat-werte-liste , doi: . iarc, iarc monographs on the evaluations of carcinogenic risks to humans , . [ ] tareke et al., j. agric. food chem. , , - . [ ] efsa panel on contaminants in the food chain (contam), efsa journal ; ( ): [ pp.] . [ ] ruenz et al., arch. toxicol. doi: . /s - - heinrich-heine-universität, institut für toxikologie, düsseldorf, germany objective: flavonoids are known to modulate distinct signaling pathways thereby causing different physiological effects. effects of the flavonoids baicalein and myricetin as well as several methylated derivatives were analyzed in the nematode caenorhabditis elegans and in in hct colon carcinoma cells and to get insights in molecular mechanisms modulated by these compounds. methods: radical-scavenging activity (teac, dcf), stress resistance (sytox, sodium arsenite), modulation of signaling pathways (nrf /skn- , daf ), life span. results: baicalein enhances the resistance of c. elegans against lethal thermal and sodium arsenite stress and dose-dependently prolongs the life span of the nematode (median life span: + %). using rna interference we were able to show that the induction of longevity and the enhanced stress-resistance were dependent on skn- (homolog to mammalian nrf ), but not daf- (homolog to mammalian foxo), another pivotal transcription factor. negletein was the only methylated derivative which was able to enhance the life span of the nematode. in hct cells, baicalein activates nrf ; the methylated derivatives oroxylin a and negletein showed a comparable redox-active potential in these cells, but only negletein was able to activate nrf . the dietary flavonoid myricetin as well as the methylated derivatives laricitrin, syringetin and myricetintrimethylether strongly enhance life span of c. elegans, decreased oxidative stress (dcf) and accumulation of lipofuscin. in contrast to myricetin, the methylated compounds strongly enhanced the resistance against thermal stress. furthermore, treatment with the derivatives induced a much stronger nuclear localization of the daf- transcription factor. conclusion: baicalein increases stress-resistance and life span in c. elegans via skn- but not daf- . experiments with methylated baicalein derivatives suggest that the redox-active potential has a minor impact on the nrf /skn- activation since only distinct derivates activate this pathway. in case of myricetin, the methylation increases the stress resistance of the flavonoid. methylation seems to enhance the biofunctionality of the flavonoids. our results may be useful to understand molecular mechanisms of flavonoids and methylated derivatives used as food supplements or pharmacological extracts. the loss of progesterone during menopause is linked to common sleep complaints of the affected women. consequently, a previous study of our laboratory demonstrated sleep promoting effects of oral progesterone replacement in postmenopausal women [ ] . the oral administration of progesterone, however, is compromised by individual differences in bioavailability and metabolism of the steroid. we therefore investigated the sleep-eeg effects after intranasal application of progesterone in healthy postmenopausal women ( - yrs).in a randomized doubleblind protocol each subject received four treatments, doses of intranasal progesterone ( . mg mpp ; . mg mpp ), mg of zolpidem and placebo. the conditions consisted of experimental nights (adaptation + examination) separated by at least one week. during each examination sleep eeg was recorded from : to : . simultaneously blood was collected every min between : and : by long catheter for later analysis of the hormones growth hormone (gh), cortisol, melatonin and progesterone. conventional sleep-eeg was statistically evaluated by multivariate analyses of variances (manovas) with repeated measures designs after removal of two outliers, which showed a low sleep efficiency index (sei) after . and . mg mpp . univariate f-tests in the manovas pointed to the following results (significant p-values at α= . ). sei was higher after zolpidem than after the other three treatments. after . mg mpp sei was elevated significantly in comparison to placebo. subjects spent more time in nonrem sleep and less time in intermittent wakefulness after . mg mpp and after zolpidem than after placebo. total sleep time was elevated and wake after sleep onset (waso) was reduced after . mg mpp and after zolpidem. after all active treatments with mpp and zolpidem the time spent in sleep stage was higher than after placebo. the amount of slow-wave sleep was higher after zolpidem than after placebo. in addition, the higher dose of mpp resulted in an increase of spindle and β frequencies combined with a decrease of δ oscillations during nonrem sleep. in comparison, administration of zolpidem resulted in strong increase of δ, spindle and high β frequencies as well as strong decrease in θ and α frequencies. nocturnal progesterone levels increased after . mg mpp . no other changes of hormone secretion were found. our study show sleep promoting effects of . mg mpp. as expected the sleep promoting effect of zolpidem was confirmed. the spectral signature of intranasal progesterone partly resembled the well-known sleep-eeg alterations induced by gaba active compounds. progestereone levels were elevated after . mg mpp . no other endocrine effects were observed. introduction: anticholinergic drugs or drugs with anticholinergic side effects are commonly used for the treatment of various diseases in the elderly population. elderly patients are particularly vulnerable to anticholinergic-related cognitive effects. moreover, there is a relationship between anticholinergic exposure and cognitive impairment. however, there is currently a lack of data on the anticholinergic burden in geriatric patients in germany. it was therefore the aim of this study to evaluate the anticholinergic burden in a large representative cohort of geriatric patients. materials and methods: in this retrospective cohort study, (co)-prescriptions of anticholinergic drugs as well as anti-dementia drugs were evaluated using the discharge medication of geriatric patients between january and june from the geriatrics in bavaria-database (gib-dat). anticholinergic drugs were classified according to the anticholinergic cognitive burden (acb) scale in three groups (definite anticholinergics with a score of or and possible anticholinergics with a score of ). the acb scale was modified by omitting trospium and by adding the three drugs biperiden, metixen and maprotilin, which are used in germany, with a score of . a patient's individual score of or higher is considered to be clinically relevant. in total, , geriatric patients (median age years, . % female, median no. of drugs ) were evaluated. of these, , ( . %) patients took at least one drug with anticholinergic properties. two or more anticholinergic drugs were coprescribed in , ( . % of the patients taking anticholinergic drugs) patients. , ( . % of the patients taking anticholinergic drugs) patients had a score of or higher. the most common anticholinergic drug combinations involving two definite anticholinergic drugs were amantadine/quetiapine ( ), amitriptyline/quetiapine ( ) and amitriptyline/carbamazepine ( ). , ( . %) patients received anticholinergic drugs in combination with anti-dementia drugs. conclusions: one third of patients in a large geriatric population were prescribed at least one anticholinergic drug. one quarter received a co-prescription of anticholinergic drugs. caution is advised prescribing anticholinergic drugs to elderly patients especially with dementia. the antiglaucoma agents brimonidine and timolol are novel substrates of the organic cation transporters oct and mate expressed in human eye c. neul purpose: glaucoma is a leading cause of visual loss in the world population. lowering intraocular pressure by topical administration of antiglaucoma agents is still the mainstay for glaucoma treatment. , although many effective drugs exist, the major challenge is their efficient intraocular delivery, which is estimated to amount to the involvement of membrane drug transporters in the intraocular delivery of the widely prescribed antiglaucoma prostanoid latanoprost has been described. however, it is currently unknown whether the cationic drugs brimonidine and timolol, which are also commonly used antiglaucoma agents, are similarly transported by drug transporters and whether these transporters are expressed in human eye. brimonidine is an α -adrenergic agonist, which inhibits the activity of the adenylate cyclase subsequently leading to a reduced production of aqueous humor. timolol is a β-adrenergic receptor antagonist, which blocks β-receptors on the ciliary epithelium also resulting in a reduced aqueous humor production. the aim of the present study was to determine whether brimonidine and timolol are substrates of the organic cation drug transporters oct (encoded by slc a ), oct (slc a ), oct (slc a ) and mate (slc a ). a further aim was to investigate whether these transporters are localized in different human eye substructures. experimental design: transport of brimonidine and timolol was studied using the mammalian cell line hek stably expressing the organic cation transporters oct , oct , oct or mate . intracellular accumulation of brimonidine and timolol was analyzed by mass spectrometry. immunohistochemistry and immunofluorescence experiments were performed to study the localization of these transporters in different substructures from glaucomatous and non-glaucomatous human eyes. results: uptake experiments revealed that brimonidine is transported by oct and mate in a time-and concentration-dependent manner, but not by oct or oct . timolol is only transported by mate , but not by the octs. as shown by immunolocalization studies, the oct and mate transporter proteins were expressed in all anterior eye substructures of non-glaucomatous and glaucomatous eyes, i.e. the cornea, the conjunctiva and the ciliary body. conclusion: our data demonstrate that oct and mate may play a role in the ocular disposition of the antiglaucoma drugs brimonidine and timolol and may contribute to interindividual variability of drug concentrations and effects. references: . zhang et al., nat rev drug discov. jun ; ( ) : - . . lavik et al., eye (lond). may; ( ): - . . gaudana et al., pharm res. may; ( ): - . . kraft et al., invest ophthalmol vis sci. ( ): - . . nies et al., plos one. ( ) :e . supported by the robert bosch foundation, stuttgart, germany. immature platelet count or immature platelet fraction as optimal predictor of antiplatelet response to thienopyridine therapy c. stratz , t. nuehrenberg background: previous data suggest that reticulated platelets impact significantly on antiplatelet response to thienopyridines. it is unknown which of the parameters describing reticulated platelets is the optimal predictor of antiplatelet response to thienopyridine therapy. methods: this study is a prespecified subanalysis of the excelsiorload trial that randomized elective patients undergoing coronary stenting to loading with clopidogrel mg, prasugrel mg or prasugrel mg (n= ). adp-induced platelet reactivity was assessed by impedance aggregometry before loading (=intrinsic platelet reactivity) and on day after loading. multiple parameters of reticulated platelets were assessed by an automated whole blood flow cytometer: immature platelet fraction (ipf, proportion of reticulated platelet of the whole platelet pool), highly immature platelet fraction (hipf), absolute immature platelet count (ipc). results: each parameter of reticulated platelets correlated significantly with adpinduced platelet reactivity: ipf (r s = . ; p= . ), hipf (r s = . ; p= . ), ipc r s = . ; p< . ). in a multivariable model including all three parameters, only ipc remained as significant predictor of platelet reactivity (p< . ). after adjustment to known predictors of on-clopidogrel platelet reactivity including cytochrome p c polymorphisms (* and * ), age, body mass index, diabetes, smoking and intrinsic platelet reactivity, ipc s was the strongest predictor of on-treatment platelet reactivity (partial η = . ; p< . ) followed by intrinsic platelet reactivity (partial η = . ; p < . ). these findings prevailed when analyzing subgroups of patients on clopidogrel or on prasugrel. conclusion: immature platelet count is the strongest platelet count derived predictor of antiplatelet response to thienopyridine treatment. given its easy availability together with its even stronger association with on-treatment platelet reactivity when compared to known predictors including the cyp c * polymorphism, immature platelet count might become the preferable predictor of antiplatelet response to thienopyridine treatment. cutaneous squamous cell carcinoma (cscc) is the second most common human cancer with continuously rising incidences worldwide. primarily caused by cumulative uvb exposure, cscc accounts for considerable costs for health care systems and poses a deadly risk especially to organ transplant recipients [ ] . current chemotherapy needs to be improved, because even the topical treatment for cscc's carcinoma in situ bears limited efficacy and painful adverse effects [ ] . however, animal-based approaches in preclinical development contribute to the frequent failure of investigational new drugs in clinical trials [ ] . herein, we characterized a human cell-based cscc model, normal reconstructed human skin (rhs) served as control. whereas rhs exhibited low proliferation, the co-culture with cscc increased ki- index -fold in the cscc model (p£ . ). while the presence of claudin- and occludin were distinctly reduced, zonula occludens protein- was more wide-spread, and claudin- was heterogeneously distributed within the cscc model compared with rhs. this is in accordance to the in vivo situation [ ] and likely contributes to the impaired barrier function of the cscc model, as demonstrated for . -fold increased caffeine permeation. finally, the ingenol mebutate effects in the cscc model and rhs closely mimic the anti-tumor effect and the adverse reactions in patients [ ] , both linked to the drug's inherent cytotoxicity. in conclusion, the thoroughly characterization of disease models fosters both advanced preclinical drug development and improved cscc treatment. funded by the german government, the berlin-brandenburg research platform bb r with integrated graduate education was launched in . the aim of this research platform, along with the associated graduate school, is to close substantial knowledge gaps in the fields of the rs and to find alternatives to animal experimentation within the next years. a panel of r experts has been set up to provide advice and assistance and to raise awareness in society for r-related issues. research in bb r investigates physiological functions on different levels to establish alternative methods for preclinical drug development and basic research. the principal investigators aim at facilitating research collaborations and sustainable research activities in the region berlin-brandenburg and abroad. an integrated bb r graduate program has been developed to offer structured training to graduate students in a specific, mandatory course program on r including modules on ethics and legislation. currently, phd students are qualified for management positions in professional areas related to the rs, and three junior research groups are now ready to expand their regional research activities nationwide. furthermore, the concept of a novel lecture series for master students and undergraduates has been designed and awarded the animal welfare research award for berlin-brandenburg in teaching and education. the state government of berlin supports the research platform bb r and will be funding an additional professorship at the fu berlin to further promote research on alternative testing. finally, co-operations with national and international partners are being built to facilitate the project-based exchange of scientists and joint research. currently, the identification and evaluation of skin sensitizers is mainly restricted to animal testing using the guinea pig maximization test, buehler test or the murine local lymph node assay. recently, an adverse outcome pathway of skin sensitization has been released by the oecd, identifying the key events leading to allergic contact dermatitis. in vitro tests address these key events and two assays are now regulatory adopted (oecd c and d). the use of the current in chemico and in vitro models is, however, limited since they do not reflect dermal penetration, complete biotransformation and cell cross-talk in an organotypic environment. in this study, we aimed to overcome these limitations by establishing reconstructed skin tissues containing langerhans cells (lcs). in vitro generated immature monocyte-derived (molcs) or mutz- -derived cells (mutz-lcs) cultivated with keratinocytes on a dermal compartment with fibroblasts form a stratified epidermis after days as indicated by the expression of epidermal differentiation markers. molcs or mutz-lcs were mainly localized in suprabasal layers of the epidermis and distributed homogeneously in accordance with native human skin. topical application of the extreme contact sensitizer , -dinitrochlorobenzene (dncb) induced il- and il- secretion in skin models with lc-like cells, whereas no change was observed in control rhs lacking immune cells. increased gene expression of cd and pd-l in the dermal compartment indicated lc maturation. we confirmed the enhanced mobility from epidermal to dermal compartments for mutz-lcs and molcs in the presence of dncb. in summary, we successfully integrated immature and functional lc-like cells into reconstructed human skin. this fosters the development of animal-free test systems for advanced and potentially individualized hazard assessment of skin sensitization. computational methods for prediction of in vitro activity of new chemical structures. background: with a constant increase in the number of new chemicals synthesized every year, it becomes highly important to employ the most reliable and fast in silico screening methods to predict their safety and activity profiles. in recent years, in silico prediction methods received great attention as alternatives to animal experiments for evaluation of various toxicological endpoints, complementing the theme of replace, reduce and refine ( rs). various computational approaches have been proposed for prediction of toxicity of chemicals ranging from quantitative structure activity relationship modeling to molecular similarity based methods and machine-learning methods. within the "toxicology in the st century" screening initiative, a crowdsourced platform was established for development and validation of computational models to predict the interference of chemical compounds in nuclear and stress receptor pathways based on a training set containing more than , compounds tested in high-throughput screening assays. methods: here we present the results of various molecular similarity-based and machine-learning-based methods over an independent evaluation set containing compounds. further, we compare the performance of these methods when applied individually and together. in retrospect we also discuss the reasons behind the superior performance of an ensemble approach, that combines a molecular similarity approach and a naïve bayes machine learning algorithm in achieving best prediction rates in comparison with other individual methods, explaining their intrinsic limitations. results and conclusions: our results suggest that, although prediction methods were optimized individually for each modeled target, an ensemble of similarity and machinelearning approaches provides promising performance indicating its broad applicability in toxicity prediction. charité -universitätsmedizin berlin, structural bioinformatics group, berlin, germany a multitude of drug candidates (approx. %) fail in the late drug development due to toxicity and adverse effects [ ] . immunotoxicity can be divided into four types of immune-mediated adverse effects: immunosuppression, immunostimulation, hypersensitivity and autoimmunity. current safety evaluations of drug candidates with respect to immunotoxicity are comprised of in vivo and in vitro assays. here, we present an in silico approach for predicting immunotoxic substances based on immune suppressive and not toxic compounds using the laplacian-modified naϊve baysian model as a supervised machine learning method. therefore, we examined the relations between about , compounds and cancer cell lines from the national cancer institute's (nci) nci- growth inhibition data [ ] with focus on five immune cell lines (rpmi- , ccrf-cem, . different fingerprints encoding the chemical structures have been evaluated for their predictive power (e. g. extended-connectivity fingerprints, substructure fingerprints) and showed good prediction rates in a retrospective analysis. acting in phase ii metabolism, sulfotransferases (sult) transform endo-and exogenous molecules such as drugs into more hydrophilic entities that are easily excreted from the human body [ ] . although serving detoxification, sult-mediated transformation of molecules has also been associated with the formation of chemically reactive metabolites that could promote adverse reactions [ ] . the development of a computerbased model that allows prediction of molecules susceptible to metabolism would improve drug development and drug safety [ ] , and encourage the reduction of in vivo testing according to the principles of the rs (replacement, reduction and refinement). in our study, we developed an in silico model to predict human sult subtype e activity acting in phase ii metabolism. structure-based molecular modelling of sult activity is challenging due to the broad and overlapping substrate spectrum of sult subtypes. this low substrate specificity can be attributed to the high degree of conformational flexibility of the enzyme, particularly in the active site. therefore, molecular dynamics simulations were performed to address enzyme flexibility and the broad substrate spectrum of sult ( figure ). based on a collection of selected enzyme conformations from molecular dynamics simulations and a dataset of active sult e ligands, ensemble docking was utilized to generate ligand-protein complexes that served as a basis for d pharmacophore development. eight specific d pharmacophores were created that allow identification of sult e substrates and inhibitors. for further refinement of the computer-based prediction, machine learning models and post-filtering steps were generated that allow classification of predicted hits. the final prediction model was used to screen the drugbank (a database comprising over , experimental and approved drugs). a major part of the predicted hits could be confirmed from literature. from the remaining hits, a representative selection of molecules was experimentally tested for sult e inhibition or biotransformation. experimental results were in agreement with our computer-based models and revealed previously-unknown biotransformation by or inhibition of sult e for compounds listed in the drugbank. introduction: vascularization of the dermal equivalent of full-thickness skin constructs by endothelial cells is highly desirable, because such constructs closely mimic the architecture of real skin. unfortunately, the realization of a capillary network in skin constructs is still difficult. in our study of full-thickness skin constructs, following the methodologies of küchler et al. ( ) , there were alterations in the epidermal differentiation after endothelialization of the dermal equivalent. the aim of this study was to characterize these changes on a morphological level. material and methods: non-endothelialized constructs (keratinocytes, fibroblasts) were prepared according to küchler et al. ( ) . to obtain endothelialized constructs, the dermal equivalent of the non-endothelialized constructs was enriched with endothelial cells. after two weeks of in vitro culture, the skin constructs were processed for quantitative as well as qualitative assessment by light and electron microscopy. results: both types of skin construct developed all strata, i.e., stratum basale, spinosum, granulosum, corneum of a stratified soft-cornified epidermis, although the two constructs displayed differences in every stratum: significantly more mitoses occurred in the epithelial germ layers of the endothelialized constructs (p= . ). in addition, significantly more keratohyalin granules were counted within their stratum granulosum (p= . ). % of the shapes of the spinous and the granulosum cells were irregular and these cells were separated by wide intercellular spaces. the typical epidermal lamellar bodies appeared in the endothelialized constructs more often than in the nonendothelialized ones. at the stratum granulosum -stratum corneum interface, no cohesion between the strata was present. background and novelty: during the last decade organ-on-a-chip technologies received increasing attention in the scientific community. the idea of combining different tissue types on a physiological-like system creates completely new options on how substances can be characterized without the use of animal experiments. animal models were used for the investigation of skin sensitization as a standard method until animal testing for cosmetic substances was banned in the e.u. in . by combining skin models with an immunological counterpart, new data will be presented to see if the multi-organ-chip add value to the current need of alternative methods regarding skin sensitization and immunotoxicity testing. experimental approach: the multi-organ-chip platform is designed to combine different human cell and tissue types like d-spheroids, barrier models or biopsies in one microfluidic system. a peristaltic on-chip micropump enables circulation of medium, allowing for a constant perfusion between the compartments. first experiments were performed using a dendritic-cell-only approach in the -organ-chip. in subsequent cocultivation experiments ex vivo human epidermis and dendritic cells were cultivated each in one culture compartment connected by the microfluidic channels. for analysis we measured the typical activation marker cd and the vitality of the dendritic cells by flow cytometry. functionally different sensitizers were selected to investigate their effects in our model. finally a more complex d matrices including different immunological cell types to emulate in vivo-like reactions like in the human lymph node were cultivated in the -organ-chip. results and discussion: our data show a strong influence of pump pressure and pumping frequency on the activation of dendritic cells. hence, we established an adequate set up by cultivating the dendritic cells in cell culture inserts, preventing cell activation due to shear stress. compared to existing sensitization assays, the main advantage of the perfused -organ-chip sensitization assay is the presence of an epidermis equivalent, partially integrating important parameters such as metabolism and skin barrier function. we compared our data with reference cd -values from the pbmdc (peripheral blood monocyte derived dendritic cells) skin sensitization assay. for identical substances, we observed differences in dendritic cell activation between the pbmdc assay and the -organ-chip perfused assay. here we present the first-time cultivation of primary derived immune cells cultivated on our microfluidic system which is a promising enhancement to integrate immunological reactions on further multi-organ combinations. due to growing social and political pressure, the interest in alternatives to animal testing has constantly increased during the past years stimulating the development and validation of new in vitro test systems including reconstructed skin models. additional to toxicological studies and permeability assays, skin models are of high interest for fundamental research to elucidate basic physiological and pathophysiological processes in human skin [ , ] . as for today, most of the in vitro skin models are grown from primary keratinocytes and fibroblasts that were either isolated from excised human skin or from juvenile foreskin following circumcision. in this project, we aimed for the generation of in vitro skin models using hair folliclederived cells. therefore, different methods to optimize cell isolation and expansion of outer root sheath (ors) cells from human hair follicles were systematically investigated. the best procedure for isolation of ors cells was the direct cell outgrowth on a cell culture insert which was co-cultured with a feeder layer of postmitotic human dermal fibroblasts. following outgrowth, the cells were either further cultivated with feeder cells in specific serum-enriched cell culture medium to obtain hair follicle-derived keratinocytes or using the same culture medium without feeder cells to obtain fibroblasts. afterwards, the generation of hair follicle-derived fibroblasts and keratinocytes was verified via the fibroblast-specific markers vimentin and desmin and the keratinocyte marker cytokeratin (ck) clearly showing that vimentin and desmin are expressed in hair follicle-derived fibroblasts and in dermal fibroblasts. as expected, these cells were negative for ck , which was abundantly expressed in hair folliclederived keratinocytes. moreover, the expression of collagen type i, iv, tgf-beta, alpha sma and il- alpha in hair follicle-derived fibroblasts and dermal fibroblasts showed no significant differences. ultimately, hair follicle-derived keratinocytes and fibroblasts were used to grow full-thickness skin models which were subsequently characterized with regard to epidermal differentiation, skin permeability and skin surface ph. again, no significant differences compared with skin models grown from skin-derived cells were detected showing the potential of using hair follicle-derived cells for generating in vitro skin models. [ ] vávrová, k., henkes, d., strüver, k., sochorová, m., Školová, b. et al. filaggrin deficiency leads to impaired lipid profile and altered acidification pathways in a d skin construct. the journal of investigative dermatology. , - ( bundesinstitut für risikobewertung, experimentelle toxikologie und zebet, berlin, germany background: the eu directive / has been drawn up with the aim of ultimately replacing animal testing. wherever animal experimentation is necessary, the -rprinciple of russel and burch (replace, reduce, refine) has to be observed. the primary goal of the -r-principle is to replace animal testing with alternative methods. if no alternative method can be applied, the total number of animals is supposed be reduced. consequently, some animals are used multiple times in the course of an experiment. for example, in imaging studies, rodents are exposed to anesthesia several times in order to control the progress of a disease. however, the directive claims that "the benefit of reusing animals should be balanced against any adverse effects on their welfare, taking into account the lifetime experience of the individual animal". objective: we are looking into whether multiple exposures to anesthesia cause more stress than a single exposure. methods: the most common mouse strain c /bl j and anesthetics isoflurane and the combination of ketamine/xylazine are used. with regard to recent studies, the animals are anesthetized six times for minutes over a period of three weeks. all parameters observed are compared between controls, animals with a single and repeated anesthesia. the interval between the administration of the anesthesias is three to four days. when the animals are under anesthesia, their vital parameters are continuously monitored and afterwards their general condition is examined. the grimace scale is scored and minutes after anesthesia. besides pain, the grimace scale can also assess anxiety, stress and malaise. the display of so-called luxury behaviors like nest building and burrowing behavior serves as an indicator of wellbeing. furthermore, activity, food and water intake are monitored for hours. a behavioral test battery including the free exploratory paradigm, open field, balance beam and rota rod test is performed one, seven and ten days after the last anesthesia. motor coordination and balance are assessed by the balance beam and rota rod. the open field is a test to investigate anxiety-related and exploratory behavior, the free exploratory paradigm estimates trait anxiety. moreover, corticosterone metabolites are measured in feces and fur in order to prove evidence of cumulative stress. results: the first results of our study will be presented at the nd meeting of dgpt. conclusion: we are confident that the results of our study will contribute to the assessment of the severity level caused by multiple exposures to anesthesia and in this way be a benefit for the welfare of laboratory rodents. bb r is funded by bmbf. in the r-principle was defined by the british scientists william russel and rex burch in their book 'the principles of human experimental techniques'. the r refer to replace, reduce, and refine. they set the goals to use alternative non-animal methods (replace), to reduce the number of laboratory animals (reduce) and to minimize the distress of laboratory animals and to refine their welfare (refine). the implementation of the r-concept is the overall goal of scientific animal welfare. article of the 'directive / /eu on the protection of animals used for scientific purposes' state that the research on refinement is as important as on replacement and reduction [ ] . according to the current statistics on laboratory animals, the mouse is the most commonly used animal in experiments with approximately % [ ] [ ] . effective pain treatment is crucial not only for ethical and legal considerations but also to achieve highquality results [ ] . pain in mice is only obvious if it is severe or acute pain. however, it is difficult to identify slight or moderate pain. the determination of pain levels and effective dosages of analgesics is therefore challenging. the most commonly used analgesics for postsurgical pain treatment in mice are opioids. however, the recommendations for their use show vast dosage ranges. for example, the recommended dose of buprenorphine ranges from . to . mg/kg per bodyweight [ ] [ ] [ ] depending on the pain model used. additionally, putative pharmacogenetic strain differences have to be considered. for example, the analgesic treatment with morphine shows mouse strain specific differences in pain sensitivity [ ] . the goal of the project is the refinement of the recommendations for effective dosage of opioid analgesics in laboratory animals for mouse inbred strains by incorporating strain specific differences. regarding the phenotype, we want to identify a putative inbred strain dependent pain threshold and measure the drug level in plasma and brain. additionally the metabolic capacity and mrna expression level will be investigated. genotype identification is based on a data bank analysis used for correlation with phenotypical parameters. [ ] rl / /eu. [ ] bmel ( ) . anzahl der für versuche und andere wissenschaftliche zwecke verwendeten wirbeltiere. [ ] eu commission ( ) . seventh report on the statistics on the number of animals used for experimental and other scientific purposes in the member states of the european union. [ ] carbone l ( ) pain in laboratory animals: the ethical and regulatory imperatives. plos one , e . [ ] gv-solas, a.f. a.d. ( ) . empfehlung zur schmerztherapie bei versuchstieren. [ ] carpenter, j.w., t.y. mashima, and d.j. rupiper ( ) . exotic animal formulary, nd edition, w.b. saunders co., phila. [ ] flecknell, p. ( ) . laboratory animal anaesthesia, nd edition, academic press, san diego, ca. introduction: göttingen minipigs™ are frequently used large animal models for orofacial research, for example dental implant surgery. requests from experimental surgeons for detailed anatomical information can not be answered because there is no existing data, especially not age-related. because of unavailable data and the false choice of animal age, surgical interventions fail or lead to enormous post-operative suffering. therefore the aim of this study is the acquisition of detailed anatomical data of the mandibula and other organs and structures without sacrificing pigs for this reason. animals, materials and methods: ct scans of a -slice scanner were collected from female minipigs, consisting of animals aged months (group , n= ) and animals (group ; n= ) examined at the age of and months. these minipigs were involved in experiments, approved by the regional office for health and social affairs, berlin. image analysis was performed using vitrea advanced® (vital images). more than parameters concerning teeth, the mandibular body, frame and canal, coronoid process and mandibular condyle were defined and measured. for now, we focused on the development of the mandibular canal and the distance between the dorsal borders of the mandibular canal to the alveolar ridge at the most posterior mental foramen, parameters immensely important for planning interventions when testing new dental implants. results: the measurements by computed tomography showed variations of several parameters between left and right ramus mandibulae and within the different age groups. the volume of the canalis mandibulae increases in time. animals of the same age show significant differences in volume, with a range of up to % where the largest volume was , ml and the lowest , ml. the distance between the dorsal borders of the mandibular canal to the alveolar ridge decreases between and months of age. comparing and months old minipigs, no significant difference in distance could be observed. from the age of months the position of the mandibular canal in relation to the alveolar ridge remains constant. conclusion: the decrease of the distance between the mandibular canal and the alveolar ridge between and months of age indicates ongoing anatomical changes of this parameter until the age of months. therefore animals should be older than months if included in long-term studies after orofacial experiments, like implant surgery of the mandibula. because of the described individual differences, the authors strongly suggest to support the planning of orofacial interventions by ct imaging or other radiographic techniques. background: laboratory housing conditions are standardized to a high level. under these conditions, the occurrence of stereotypic behaviour (sb) can be observed. stereotypies are commonly known as deviations from normal behaviour that are repetitive, invariant and without any obvious function or aim for the animal [ ]. worldwide it is estimated that over million animals perform sb, with the highest prevalence in laboratory animals and the agricultural sector. fvb/n is a typical inbred mouse-strain that shows different types of stereotyped movements. it is known that environmental enrichment decreases the incidence of sb, yet they still occur [ ] . since animal's behaviour highly influences its metabolism and immune system, differences in handling, caring and keeping can lead to varying results, even with an identical experimental setup [ ] . aim: of the study aim of the study is to observe different life stages of fvb/n-mice and immediately detect the development of sb. observations are linked to various behavioural tests and the characterisation of the metabolic and immunological phenotype. the results will lead to a better understanding of the mechanisms driving the development of sb and clarify its implication to animal welfare or to what extent the performance of stereotypies even reflect emotional suffering. the strain-related behaviour and sb are recorded with computer-assisted programmes. observational periods already begin with the parental generation. as possible indicators for later developing sb, data on reproductive success and maternal care are collected, such as different behavioural tests. the animals are characterized by a specific protocol for detecting the metabolic and immunological phenotype. finally, histological and molecular biological analyses follow. outlook: it is of paramount importance to take good care for the welfare of laboratory animals ( r-refinement). though, the knowledge about the ethological particularities of animals and the motivational base of animals performing sb are not enough to generally avoid stereotypies. therefore the meaning according to the character of sb has to be analysed more intensively to understand the needs of laboratory animals and evolve recommendations for optimizing the breeding and keeping such as for the assessment of possible distress in animals performing sb. objective: thermoregulation is a vital function in both humans and animals with the serotonin ( -ht) system, in particular the -ht a receptor, playing a major role. activating -ht a receptors by the -ht a receptor agonist -hydroxy- -(dipropylamino)tetralin ( -oh-dpat) leads to reduced body temperature. while there is consensus that hypothermia is induced by the stimulation of postsynaptic -ht a receptors in rats and humans, the regulatory mechanisms in mice are less clear. in our group, within phenotyping a transgenic mouse line permanently overexpressing the -ht a receptor in serotonergic projection areas, bert et al. ( , pmid: ) revealed exaggerated -oh-dpat-provoked hypothermic response. thus, the objective of the present study was to substantiate the contribution of postsynaptic -ht a receptors to thermoregulation, more precisely to the hypothermic effect of -oh-dpat, in mice. methods: we used radio telemetry technique to monitor the basal body temperature and the hypothermic effect of different doses of -oh-dpat ( . mg/kg - mg/kg i. p.) in male transgenic mice in comparison to nmri wild-type males. additionally, we investigated whether reduction of serotonergic activity by pretreatment with the -ht synthesis inhibitor parachlorophenylalanine (pcpa; mg/kg, i. p. on four consecutive days) would alter the effects of -oh-dpat on body temperature in transgenic mice postsynaptically overexpressing the -ht a receptor. results: -ht a overexpressing mice revealed lower levels of basal body temperature than wild types (transgenic mice: . °c; nmri wild-type mice: . °c). in both genotypes, systemic administration of -oh-dpat dose-dependently decreased body temperature, being significantly more pronounced in mutant mice (- . °c compared to - . °c in nmri wild types). dose response curves of -oh-dpat revealed an ed = . mg/kg in transgenic and an ed = . mg/kg in nmri wild-type mice. pcpa pretreatment did not alter the hypothermic response to -oh-dpat in mice. the dose-response curves indicate a higher potency of -oh-dpat in transgenic mice. the exaggerated hypothermic response to -oh-dpat in mutant mice implies that postsynaptic -ht a receptors could be involved in thermoregulatory function in mice. this assumption is further confirmed by the fact that -oh-dpatevoked thermal responses were not influenced by pretreatment with pcpa, most notably in transgenic mice overexpressing -ht a receptors postsynaptically. genetic variation within g protein-coupled receptors compromises the therapeutic application of drugs targeting these receptors. one of the most intensely studied variation is p.arg gly in the human beta -adrenoceptor (adrb ). the adrb carrying arginine at position in helix in the proximal carboxy terminus is more frequent among caucasians and is hyperfunctional. yet, the molecular basis for the differences between the beta -adrenoceptor variants arg -adrb and gly -adrb is poorly understood. despite its hyperfunctionality, we found the arg -variant of the adrb to be hyperphosphorylated upon continuous stimulation with norepinephrine when compared to the gly -variant. using adrb sensors to monitor activation kinetics by fluorescence resonance energy transfer (fret), the arg -adrb exerted faster activation speed and arrestin recruitment than the gly -variant. both depended on phosphorylation of the receptor as shown by knockdown of g protein-coupled receptor kinases and by fret experiments using phosphorylation-deficient adrb mutants. point mutation of single serines and threonines in the carboxy terminus of the adrb finally revealed a variant-specific phosphorylation pattern that determines arrestin recruitment. taken together, these findings suggest that differences in receptor phosphorylation determine the differences in activation speed, efficacy and arrestin recruitment of adrb variants. opioid drugs are the most potent analgesics, which are used in the clinic; however, by activating the μ-opioid receptor (mor) they also produce several adverse side effects including constipation, antinociceptive tolerance, and physical dependence. there is substantial evidence suggesting that g protein-coupled receptor kinases (grks) and βarrestins play key roles in regulating mor signaling and responsiveness. following phosphorylation by grks, β-arrestins bind to phosphorylated mors, which prevents further interactions between the receptor and g proteins even in the continued presence of agonist resulting in diminished g protein-mediated signaling. we have previously shown that agonist-induced phosphorylation of mor occurs at a conserved -residue sequence, trehpstant , in the carboxyl-terminal cytoplasmic tail. morphine induces a selective phosphorylation of serine (s ) in the middle of this sequence that is predominantly catalyzed by g protein-coupled receptor kinase (grk ). by contrast, high-efficacy opioids not only induce phosphorylation of s but also drive higher-order phosphorylation on the flanking residues threonine (t ), threonine (t ), and threonine (t ) in a hierarchical phosphorylation cascade that specifically requires grk / isoforms. to investigate this mechanism further, we have developed novel β-galactosidase complementation assays to monitor agonist-dependent recruitment of grk and grk to activated mors. using this assay, we were able to show that activation of mor by high-efficacy agonists such as damgo results in a robust translocation of grk / . in contrast, activation by low-efficacy agonists such as morphine results in a much less pronounced recruitment of grk / isoforms. interestingly, damgo-induced β-arrestin recruitment was strongly inhibited by sirna knock down of grk or grk . conversely, the morphine-induced β-arrestin recruitment was strongly enhanced by overexpression of grk or grk . mutation of s to alanine strongly inhibited both grk and β-arrestin recruitment. however, mutation of all carboxyl-terminal serine and threonine residues of mor was required to completely abolish its interaction with arrestins and grks resulting in a complete loss of mor internalization and desensitization. heterotrimeric g proteins are located at the inner leaflet of plasma membranes and are a major primary transducer of cell signaling initiated by g protein-coupled receptors (gpcrs). based on sequence similarity, heterotrimeric g proteins can be subdivided into four main classes, i.e. gi/o, gs, gq/ , and g / , which interact with distinct cellular effectors to shape the final cellular response . identification of new selective and cell-permeable g protein inhibitors is of great interest as these may be beneficial in complex pathologies that involve signaling of multiple gpcrs . mechanistically, small molecule g protein inhibitors may, for instance, block nucleotide exchange by inhibiting gdp release (i.e. guanyl nucleotide dissociation inhibitors, gdis) or allow gdp release but block gtp entry by stabilizing the g protein in an empty pocket conformation . here, we set out a new approach to classify g protein inhibitors regarding their mechanism of action in radioligand binding experiments. in particular, we investigated the influence of the specific gα q/ / inhibitor fr on agonist-radioantagonist binding experiments performed with membranes of cho cells stably expressing the muscarinic m acetylcholine receptor (cho-m ). agonistradioantagonist competition under these conditions is biphasic because agonists bind with higher affinity in the ternary complex consisting of agonist, receptor and nucleotidefree g protein compared with a g protein-free receptor , . we show that fr can be classified as a gdi as it significantly reduced high affinity binding of carbachol in cho-m membranes. in contrast to this, bim- , a pan g protein inhibitor with a cell-type-dependent preference for gq, did not influence high affinity agonist binding and thus stabilized gq in an empty pocket conformation . interestingly, inhibition of high affinity agonist binding by fr was incomplete in agonist-radioantagonist displacement studies and also when a radioagonist was applied. to fully prevent high affinity agonist binding by fr , combined uncoupling of both gi and gs proteins from m was required by pre-treatment with pertussis toxin and cholera toxin, respectively. these data demonstrate that not only gq, but also gi, and gs, contribute to the high affinity fraction of m receptors. taken together, our findings show that radioligand binding experiments are an attractive approach to classify new g protein inhibitors according to their mechanism of action. universität, würzburg, germany g protein-coupled receptors (gpcrs) are cell surface receptors which, upon a conformational change in the receptor protein induced by an extracellular stimulus, can transduce the signal onto intracellular adaptor proteins such as heterotrimeric g proteins [ ] . gpcr-induced cell signaling can be rather complex as several gpcrs may activate multiple different adaptor proteins and can additionally be activated via distinct binding sites, i.e. the orthosteric transmitter binding site and other "allosteric" binding sites [ ] . in the present work, we wanted to investigate the influence of an allosteric binding site on receptor activation of muscarinic acetylcholine receptors (machrs). to this end, we employed the orthosteric full agonists acetylcholine and iperoxo as well as several dualsteric compounds consisting of iperoxo linked to an allosteric phthalimide (phth) or naphthalimide (naph) moiety through alkyl chains of different length or through a diamide linker (fri). binding of the allosteric part to the receptor protein may restrict the conformational flexibility of the receptor protein and thus interfere with receptor activation [ ] . therefore, application of different linker length may control the signaling outcome. here, we applied the human m machr which preferentially activates g proteins of the g q/ type but can also promiscuously stimulate g s proteins. g q/ -and g sdependent signaling pathways were analyzed by application of cho cells stably transfected with the human m machr in ip and camp accumulation assays, respectively. in comparison to the orthosteric building block iperoxo, all dualsteric compounds under investigation showed a decrease in potency for both g q -mediated and g s -mediated signaling. our findings show that the bulkier allosteric naph residue impaired both signaling pathways to a greater extent than the smaller substituent phth. particularly, the compound iper- -naph completely lost intrinsic activity for both g q/ and g s activation at the m machr. moreover, g s -mediated pathway activation is more sensitive to spatial restriction in the allosteric vestibule than g q -signaling. interestingly, longer linker length led to improved signaling for both pathways (g q and g s ) in both hybrid series. iper- -phth seems to be an exception as it had a higher intrinsic efficacy for g s -dependent signaling than the other phth hybrids with longer linker chains. strikingly, only iper-fri-phth, which corresponds to iper- -phth in linker length, but is able to engage increased hydrogen bonding with the receptor protein, acted as a full agonist on m machr for both signaling pathways under investigation. taken together, these data strongly suggest that, in comparison to g q/ -mediated signaling, activation of the g s protein in m machr is more sensitive to spatial restriction in the allosteric vestibule. thus, it appears to be possible to control signaling of the m machr by allosteric constraint of the receptor's conformational flexibility. for more than three decades -( h-imidazol- -yl)propylguanidine (sk&f- , ( ) [ ] ) is known as the prototypic pharmacophore of highly potent histamine h -receptor (h r) agonists of the guanidine class of compounds including, e.g., impromidine and arpromidine. [ ] in order to get more insight into the structure-activity relationships of alkylated analogues of sk&f- , , we characterized newly synthesized derivatives including several bivalent compounds (e.g., ) by using different pharmacological in-vitro methods. [ ] the potential h r agonists were subjected to a broad screening procedure utilizing radioligand binding assays with membranes of sf cells [ ] (hh , , , r). compounds were also functionally characterized in the [ s]gtpgs assay (hh r, sf cell membranes). [ ] selectivity vs. hh , , r was determined for selected derivatives also using this technique. organ bath studies (gph r (ileum), gph r (right atrium)) yielded functional data in a more physiological environment. the major part of the new sk&f- , analogues displayed partial or full agonism via hh r and gph r, respectively. the most potent analogue, bivalent thiazole-type bisguanidine , was a partial agonist (e max = %) and -times as potent as histamine vis-à-vis the gph r. attempts to antagonize the positive chronotropic effect of (partial) agonists by preincubation with cimetidine, or by adding a cimetidine bolus at the end of the concentration-response curve, respectively, were successful and furnished pa values for the antagonist ( . - . ) which are in accordance with literature data. however, in the functional in-vitro assay on gph r, the positive chronotropic response evoked by sk&f- , was surprisingly resistant to antagonism by cimetidine and other typical h r antagonists (ranitidine, famotidine), although the compound so far has been unanimously classified by others as a weak partial h r agonist. this behaviour is unique within the large series of sk&f- , analogues studied so far under similar conditions. probably the positive chronotropic effect of the lead compound is -at least in part -the result of a second molecular interaction which has been overlooked so far. [ ] parsons, m.e. et al.; agents actions , , . [ ] buschauer, a.; j. med. chem. , , - [ ] pockes, s.; dissertation, univ. regensburg . [ ] seifert, r. ; j. pharmacol. exp. ther. , ( ) , - . the nociceptin/orphanin fq (n/ofq) peptide (nop) receptor is the fourth most recently discovered and least characterized member of the opioid receptor family (mor, kor and dor). nop receptor is widely distributed and modulates several physiological processes by its endogenous ligand nociceptin. the nop receptor is a potential target for the development of ligands with therapeutic use in several pathophysiological states such as chronic and neuropathic pain. consequently, there is increasing interest in understanding the molecular regulation of nop receptor. recently, we generated two phosphosite-specific antibodies directed against the carboxyl-terminal residues serine (s ) and threonine /serine (t /s ), which enabled us to selectively detect either the s -or the t /s -phosphorylated forms of the receptor. our results show that nociceptin, mcoppb, sch and ro - induce a stably phosphorylation at s and t /s followed by a profound internalization of the receptor. the nociceptin-induced s and t /s phosphorylation can be blocked by selective nop receptor antagonists such as j or sb , . nnc - , buprenorphine and norbuprenophine failed to induce a phosphorylation at these sites. in the presence of nociceptin, s phosphorylation occurred at a faster rate than phosphorylation at t /s indicating that s is the primary site of agonistdependent phosphorylation. activation of pkc by phorbol -myristate -acetate facilitated receptor phosphorylation only at s but not at t /s , indicating that s can also undergo heterologous phosphorylation. using nop-gfp knock in mice, we detected nop receptors in brain, spinal cord and dorsal root ganglia (drg). we were also able to demonstrate a dose-dependent nop receptor phosphorylation at t /s in mouse brain in vivo using western blot and mass spectrometry. in contrast, mcoppb and sch failed to induce phosphorylation in vivo. together, these data provide new insights into the molecular regulation of the nop receptor in vitro and in vivo. several findings indicate that inflammatory diseases are initiated or maintained by an imbalance of receptor baised signaling; the latter referring to the ability of distinct ligands to endue individual receptors with qualitatively different g-protein-and/or b-arrestindependent signaling ( ). chemokines and their receptors regulate a wide array of leukocyte functions, including chemotaxis, adhesion, and transendothelial migration, and thus play important roles in regulating inflammation ( ) . in man, two cc chemokine receptors ccr a and ccr b are present that only differ in their carboxyl terminal portions; the latter known to interact with multi-protein complexes made up of heterotrimeric g proteins (pertussis toxin sensitive and -insensitive) and non-g-protein components, including b-arrestin ( ) . interested in differential signaling of ccr a and ccr b we comparatively analyzed ligand-induced g-protein-regulated signaling pathways (e.g. activation of phospholipase c isoenzymes and rhogtpase-induced serum response factor [srf] activity) and b-arrestin-regulated pathways (e.g. internalization of receptors and phosphorylation of erk / ) in the presence of ccl , ccl , ccl , and ccl . all these chemokines have been shown to interact with human ccr receptors. in addition, the structural requirements of the carboxyl terminal portions involved in determining specificity in g-protein-dependent signaling was addressed by using ccr receptor mutants. the comparative analysis revealed that differences in ligand-induced activation of g-protein-dependent (pertussis-toxin-sensitive versus pertussis-toxin-insensitive) and/or b-arrestin-dependent signaling exist. for example, activation of ccr b receptors by ccl induced both rho-dependent srf activation and receptor internalization, while ccl -stimulation resulted in srf but little if any receptor internalization. in contrast, ccr a-expressing cells showed ccl dependent srf-activation but any receptor/ligand internalization. analysis of the structural requirements of ccr receptors for coupling to g proteins revealed that arginine within the putative 'eighth helix' of the carboxyl-terminal portions of ccr a and ccr b is not involved in ga i -mediated induction of erk / and plays a minor role in ccr b receptor internalization, but is specifically required for the ccr a/ and ccr b/ga q -mediated activation of srf. serotonin -ht c receptors ( -ht c r) are functional engaged with gq proteins and expressed in the central nervous system (cns). -ht c r significantly regulate emotion, feeding, reward or cognition and thus might serve as promising targets for drugs against psychiatric disorders or obesity. due to the technical difficulties in isolating cells from the cns and the hitherto lack of suitable cell lines that would endogenously express -ht c r, our knowledge about this receptor subtype is rather limited. recently established hypothalamic mhypoa - cells show some characteristics of appetite-regulating hypothalamic neurons of the paraventricular nucleus, where -ht c r in vivo expression has been detected. thus, we tested mhypoa - cells for putative -ht c r expression by performing single cell calcium imaging. we observed that serotonin and the specific -ht c r agonist, way , induced robust calcium transients, which were strongly inhibited by two unrelated -ht c r-selective antagonist (sb , , rs , ). serotonin and way , also activated a camp response element-dependent reporter gene construct and induced significant phosphorylation of extracellularregulated kinases- / in a sb , and rs , sensitive manner, providing further evidence for functional -ht c r expression in mhypoa- / cells. intrinsic activity of way , ranged between . and . compared to serotonin in all assays, defining way , as a partial -ht c r agonist. in conclusion, we provide convincing data that hypothalamic mhypoa- / cells endogenously express -ht c r and thus represent the first cell line to analyse -ht c r pharmacology, signaling and regulation in its natural environment. optical and electrophysiological methods allow detection and characterization of g i/o -protein coupled receptors j. straub walther-straub-institut für pharmakologie und toxikologie, münchen, germany g-protein mediated signaling pathways are essential components of basic cellular functions. of note, g-protein coupled receptors (gpcrs) constitute one of the major drug targets in modern medicine. however, despite their clinical importance, fundamental properties of these receptors remain unknown. in particular, regulation of the major second messenger camp by g s -and g i/o -protein coupled receptors is of special interest. the classical biochemical method to detect receptor-mediated camp level changes uses pre-labeling with h-adenine and calculation of the conversion rate to h-camp. although, this multi-cellular method is highly sensitive and reproducible, it lacks time resolved and spacial assessment of camp formation in single living cells. to measure g s -protein induced increases of intracellular camp levels in single living cells in a time resolved manner, the fret-based camp-sensor epac is commonly used. however, it was unknown whether this sensor might be suitable to detect g i/o -protein mediated decreases of intracellular camp levels as well. in this study, we show that fret-based camp sensors can be deployed to reliably monitor g i/o -protein mediated camp level decreases. fret experiments with adrenergic α a or µ opioid receptors in combination with different fret-based camp sensors showed a notable reduction of intracellular camp levels upon receptor activation which could be significantly reduced by selective receptor antagonists. of note, hek cells had to be pre-incubated with forskolin in submaximal concentration to increase basal camp levels. our findings suggest that fret based epac sensors are suitable to detect g i/o -protein activation similar to electrophysiological whole-cell measurements with g i/o -protein coupled receptors and trpc or heteromeric kir . /kir . or kir . /kir . channels coexpressing cells. hereby, agonist stimulations caused current increases with characteristic current-voltage relationships. altogether, our findings indicate that both optical and electrophysiological approaches allow time resolved detection and characterization of g i/o -protein coupled receptor activation in single living cells. histamine can exert positive inotropic and chronotropic effects in humans via histamine h -receptors. we have generated and partially characterized transgenic mice (tg) which overexpress the human histamine h -receptor specifically in cardiomyocytes via the α-myosin heavy chain promoter. in these mice, but not in wild type mice (wt), histamine increased heart rate and ejection fraction (ef) measured in vivo by echocardiography under isoflurane anesthesia. to investigate some aspects of the signaling pathway in these mice, we crossed the tg mice with pp a mice leading to double transgenic mice (h xpp a = dt). pp a mice (j biol chem ; : ) overexpress the catalytic subunit of protein phosphatase a (pp a) in cardiac myocytes and develop a cardiac hypertrophy. at an age of about days we noted reduced ef in pp a ( . ± . %, n= ) compared to wt ( . ± . %, n= ) and tg ( . ± . %, n= ). interestingly, in dt the ef ( . ± . %, n= ) was higher than in pp a at similar heart rates. e´/a´ was elevated in dt compared to wt. relative heart weights were unchanged between these groups. in summary, we demonstrated that pp a is involved in h -receptor signaling and we tentatively conclude that the h -receptor is able to ameliorate systolic but not diastolic cardiac function of pp a mice. serotonin ( -ht) can exert positive inotropic and chronotropic effects in humans via -ht -receptors. we have generated transgenic mice (tg) which overexpress the human -ht -receptor selectively in cardiomyocytes via the α-myosin heavy chain promoter. in these mice, but not in wild type mice (wt), serotonin induced increases in heart rate and ejection fraction. we treated the mice with µg lps (lipopolysaccharide, i.p.; a standard model of sepsis) per g body weight or isotonic sodium chloride solution (as solvent control). echocardiography with isoflurane anesthesia was performed before and , and hours after lps treatment. lps led to a time-dependent deterioration of cardiac function in both tg and wt. the deterioration included systolic function (left ventricular ejection fraction=ef) as well as diastolic function (height of a and e waves through the mitral valve: e/a). for instance, ef amounted to . ± . % seven hours after lps in wt and to . [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] p< . vs pre-lps value). however, hours after lps, diastolic function, measured as e/a, amounted to . ± . in p< . tg vs. wt). moreover, after hours a less pronounced decline in body temperature (probably due to superficial abdominal hyperemia) occurred in tg versus wt. in contrast, while all flow parameters declined after and hours of lps, they were not different between wt and tg. for instance, maximum flow (in mm/s) through the ascending aorta declined from . ± . to . ± . in wt and from . ± . to . ± . in tg (tg vs. wt, p> . , n= - ; after hours). we tentatively conclude: -ht -receptors overexpression protects the heart against sepsis, putatively by interference with the intracellular biochemical pathway of lps in cardiomyocytes. histamine can exert positive inotropic and chronotropic effects in humans via histamine h -receptors. we have generated transgenic mice (tg) which overexpress the human h -receptor specifically in cardiomyocytes via the α-myosin heavy chain promoter. in tg, but not in wild type mice (wt), histamine (ec = nm) or amthamine (ec = nm), a more selective and potent h -receptor agonist, induced positive inotropic effects (pie) and positive chronotropic effects (pce) in isolated left and right atrial preparations, respectively. in order to investigate the signal transduction for the pie in atrium, contractile studies using partially depolarized preparations were performed. therefore, left atrial preparations were equilibrated in the organ bath to mm potassium chloride. thereafter, histamine ( µm) induced a pie ( . ± . % of control, n= ) in tg but not in wt preparations whereas isoprenaline ( µm) increased force in both wt and tg. the pie of histamine in potassium treated tg atrium could be blocked by cimetidine. compound / , a releasing agent of endogenous histamine, increased force of contraction in tg left atria to a higher extent than in wt. furthermore, we tested whether analgetics known to release histamine were inotropically active in tg. however, morphine ( µm) was unable to affect contractility in wt or tg, whereas ketamine and fentanyl increased left atrial contractility in both tg and wt. in summary, we demonstrated an involvement of the l-type calcium channel current in the h -receptor mediated pie in tg atria. we failed to release inotropically active histamine using classical analgetics, arguing that a direct effect also in the human heart is unlikely to occur. the initial step in the homologous desensitization of g-protein-coupled receptors is their phosphorylation by one of the g-protein-coupled receptor kinases (grks). we demonstrate here measurement of the interaction of grk , a ubiquitously expressed grk, with the μ-opioid receptor (µor) by fret and its dependence on agonist efficacy. hek t cells transfected with yfp-tagged µor and mturquoise-tagged grk as well as non-fluorescent gα i , gβ and gγ subunits showed a robust increase in fret upon superfusion with µm [d-ala , n-mephe , gly-ol]-enkephalin (damgo) which was reversible upon agonist washout. the partial agonist morphine ( µm) also caused a fret increase but the amplitude of the fret signal was reduced to approximately - % of that of the corresponding damgo signal. grk binds g-protein βγ (gβγ) subunits, and therefore we aimed to find out how cotransfection of grk affected the interaction of gβγ with the µor. however, we could not measure any damgo-induced fret changes between yfp-tagged µor and mturquoise-tagged gβ in the presence of non-fluorescent gα i and gγ. this was unexpected because we had previously successfully determined interactions between gβγ and the α a -adrenergic receptor or the m muscarinic acetylcholine receptor. this lack of fret was not due to an inability of the tagged gβ to interact with the µor as we could measure damgo-induced fret changes between yfp-tagged gα i and gβγ (gβ tagged with mturquoise) in the presence of non-fluorescent µor. moreover, when we attempted to establish an effect of grk on the interaction between the µor and gβγ, we could pick up fret between the µor and gβγ. comparison of the on-and off-kinetics of the µor-grk interaction with that of the µor-gβγ interaction in the presence of grk revealed similar time constants both for the on-and off-kinetics (grk : k on . s ). this suggests that, in the absence of grk , the orientation of the two fluorophores on the µor and gβγ may be unfavorable or the interaction may be too short-lived to produce an appreciable fret signal. in the presence of grk , however, gβγ changes its position relative to the µor in a way that allows the interaction of the grk -gβγ complex with the µor to be detected by fret. similarly, we measured fret between gβγ and the α a -adrenergic receptor or the m muscarinic acetylcholine receptor in the absence and presence of grk and compared the kinetics with the kinetics of grk binding and unbinding to these receptors. in both cases, we found that grk and gβγ in the presence of grk associate and dissociate from these receptors with comparable kinetics. our results suggest that ligand efficacy for µors is already apparent on the level of receptor-grk interaction. institute of pharmacology, university medical center göttingen, ag lutz, göttingen, germany introduction: the monomeric gtpase rhoa is dysregulated in heart disease and in vivo models provide evidence of rhoa signaling being involved in the progression of cardiac fibrosis and hypertrophy. how rhoa is regulated within this context on a cellular level is not defined. objective: the goal of this study was to analyze rhoa activation in adult cardiomyocytes (amcm) from normal and diseased mouse hearts in response to g protein-coupled receptor activation. this project also aimed at providing new insight into the dependence of rhoa localization and activation on the signaling organizing caveolae in neonatal as well as adult cardiomyocytes and engineered heart muscles. methods: cardiomyocytes from sham-operated c bl/ mice, from mice subjected to transverse aortic constriction (tac) or from neonatal rats were either directly fixed after isolation or cultured in the presence or absence of methyl-b-cyclodextrin (mβcd). for analyses of rhoa activation cells were treated with endothelin- (et- ) for sec. cells were prepared for immunofluorescence analysis or lyzed for immunoblotting. imaging was performed using confocal microscopy. effects of mβcd were further studied in d engineered heart muscles (ehm) made from total neonatal rat cardiac cells. the contractile function of ehm was assessed in the organ bath and cells were studied in sections by immunofluorescence analysis. results: in amcm from sham mice active rhoa mainly localizes at the sarcolemma and is augmented in response to et- treatment. in tac-amcm the basal level of active rhoa is increased and surprisingly et- had no further effect. immunoblot analysis demonstrated that in tac-amcm rhoa expression was per se higher and the major caveolae protein caveolin- was reduced. to test the influence of caveolae on rhoa activation and expression, we treated nrcm with mβcd and found the expression of rhoa as well as of rhoa target genes ccn and ccn to be moderately up-regulated after h. in addition, an intensified longitudinal alignment of sarcomeric actin fibers was detectable, which could also be seen in mβcd-treated ehm. however, mβcd had no effect on ehm twitch tension but increased the resting tension compared to control. we further treated amcm with mβcd and found rhoa expression to be increased and its activity less sensitive to et- treatment. finally, we could show that the perinuclear localization of cav and rhoa was strongly reduced after mβcd treatment. whereas g-protein coupled receptors (gpcrs) have been long believed to signal through cyclic amp only at cell surface, our group has previously shown that gpcrs not only signal at the cell surface but can also continue doing so once internalized together with their ligands, leading to persistent camp production ( ). this phenomenon, which we originally described for the thyroid stimulating hormone receptor (tshr) in thyroid cells, has been observed also for other gpcrs ( ) ( ) ( ) . however, the intracellular compartment responsible for such persistent signaling was insufficiently characterized. the aim of this study was to follow by live-cell imaging the internalization and trafficking of tshr, tsh and effector proteins in thyroid cells. mouse primary thyroid cells were transfected with fluorescent-protein tagged tshr, g-proteins, nanobody specific for active g-proteins and/or subcellular markers by electroporation, stimulated with fluorescently labeled tsh and visualized using highly inclined thin illumination (hilo) microscopy. our results suggest that tsh is internalized in complex with its receptor and they traffic retrogradely via the trans golgi network (tgn). while we could not find any evidence of internalized tsh/tshr complexes activating g-proteins in early endosomes, we show that tsh/tshr complexes meet the intracellular pool of gαs in the tgn and activate it, as visualized in real-time by a nanobody specific for active gαs. upon acute brefeldin a-induced golgi collapse, the retrograde trafficking of tsh/tshr via tgn is hindered. bulk tsh stimulations in primary mouse thyroid cells isolated from transgenic mice expressing the camp sensor, epac -camps, also show a significantly reduced camp production in the presence of brefeldin-a. these data provide evidence that internalized tsh/tshr complexes meet and activate g-proteins at the tgn, which might serve as the main platform of persistent camp signaling after receptor internalization. objective: sphingosine -phosphate (s p) is generated by sphingosine kinase (sk)- and - and acts mainly as an extracellular ligand at five specific g protein-coupled receptors, denoted s p - . after activation, s p receptors regulate important processes in the progression of renal diseases, such as mesangial cell migration methods and results: here we demonstrate that dexamethasone treatment lowered s p mrna and protein expression levels in rat mesangial cells measured by taqman® and western blot analyses. this effect was abolished in the presence of the glucocorticoid receptor antagonist ru- . in addition, in vivo studies showed that dexamethasone downregulated s p expression in glomeruli isolated from c bl/ mice treated with dexamethasone ( mg/kg body weight). functionally, we identified s p as a key player mediating s p-induced mesangial cell migration. using boyden chamber assays, we could show that dexamethasone treatment significantly lowered s p-induced migration of mesangial cells. this effect was again reversed in the presence of ru- . conclusion: we suggest that dexamethasone inhibits s p-induced mesangial cell migration via downregulation of s p . overall, these results demonstrate that dexamethasone has functional important effects on sphingolipid metabolism and action in renal mesangial cells (koch et al., biol. chem. ; : - ) . the g protein-coupled receptor mrgd is a receptor for angiotensin-( - ) involving g alphas , camp, and phosphokinase a rationale: angiotensin (ang)-( - ) has cardiovascular protective effects and is the opponent of the often detrimental ang ii within the renin-angiotensin system. although it is well-accepted that the g-protein coupled receptor mas is a receptor for the heptapeptide, the lack in knowing initial signalling molecules stimulated by ang-( - ) prevented final verification of ligand/receptor interaction as well as the identification of further hypothesized receptors for the heptapeptide. objective: the study aimed to identify a second messenger stimulated by ang-( - ) allowing confirmation as well as discovery of the heptapeptide's receptors. we identified camp as the second messenger for ang-( - ). the heptapeptide elevates camp concentration in primary cells such as endothelial or mesangial cells. using camp as readout in receptor-transfected hek cells, we provided final pharmacological proof for mas to be a receptor for ang-( - ). more important, we identified the g-protein coupled receptor mrgd as a second receptor for ang-( - ). consequently, the heptapeptide failed to increase camp concentration in primary mesangial cells with genetic deficiency in both mas and mrgd. furthermore, we excluded the ang ii type receptor at as a receptor for the heptapeptide, but discovered that the at blocker pd can also block the mas and mrgd receptors. conclusions: our results lead to an expansion and partial revision of the reninangiotensin system, by identifying a second receptor for the protective ang-( - ) but excluding the at receptor, and by enforcing the revisit of such publications which concluded at function by using pd as a specific at blocker. members of the g protein-coupled receptor (gpcr) superfamily are integral membrane proteins that are activated by extracellular ligands and induce cell signaling via g proteins and other adaptor proteins. rhodopsin, the prototypical gpcr that mediates vision, is activated by photons that isomerize its covalent ligand. spectroscopic analyses of the cognate agonist retinal allow a detailed description of rhodopsin dynamics at submillisecond resolution. using rhodopsin as a model, it has been demonstrated that receptor activation, i.e. a switch from the fully inactive to the fully active state, occurs within ms . activation kinetics of other receptors have been studied mainly using fluorescence resonance energy transfer (fret) which allows kinetic studies with high resolution in living cells . in contrast to rhodopsin, activation constants of several gpcrs using agonist superfusion have been determined to range between - ms . however, it is unknown if all gpcrs with diffusible ligands are really activated on a longer timescale or if ligand diffusion to the binding site is rate limiting. in this study, we intend to overcome ligand diffusion by using photodestruction of caged ligands. we monitor activation-related conformational changes of homodimeric metabotropic glutamate receptor (mglur ) sensors by fret after uncaging of an inert glutamate derivative. -methoxy- -nitroindolinyl-l-glutamate (mni-glutamate) is a caged derivative of glutamate that does not activate mglur s. upon pre-incubation of hek-tsa cells expressing both cfp-and yfp-tagged mglur protomers with mniglutamate, a short uv laser pulse releases active l-glutamate close to the receptor binding site. we demonstrate very rapid mglur activation kinetics and this allows us to study the process of signal transduction of this homodimeric gpcrs opioids are still the mainstay of modern pain treatment. most of the clinically established substances primarily exert their effects via the µ-opioid receptor (mor). however, many side effects such as tolerance, constipation and respiratory depression limit their therapeutic use. the efficacy of mor agonists in the treatment of chronic pain is unsatisfactory. in general analgesic effects can be mediated by all four members of the opioid receptor family. the nociception receptor (nop) is the latest member of the opioid receptor family. there is a rapidly growing interest for the development of novel nop and combined mor/nop agonists. the aim of this developement is novel therapeutic agents with improved analgesic characteristics and less classical mor-mediated side effects. here we used buprenorphine as a clinically established opioid which exerts its effect on multiple opioid receptor subtypes. recently, nalfurafine, a potent kappa-opioid receptor (kor) agonist was granted by japanese authorities for the treatment of uremic pruritus. even though kor agonists are known to mediate dysphoria and hallucinations this has not been reported for nalfurafine. rudolf-virchow-zentrum für experimentelle biomedizin, würzburg, germany g protein-coupled receptors (gpcrs) belong to a superfamily of cell surface signaling proteins that mediate many physiological responses to hormones and neurotransmitters. they represent the prime targets for therapeutic drugs in healthcare. however, due to the limited knowledge about the pharmacology of the majority of gpcrs, only few of them are employed as therapeutic target. in our lab, the activation kinetics of the α aadrenergic receptor, among others receptors, has been extensively studied in single cell assays ( ) ( ) . the activation kinetics of the labeled α a -adrenergic were monitored by förster resonance energy transfer (fret). the goal of our study is to design a sensor to monitor receptor activation kinetics in high throughput screening assays. for the proof of concept, we used the α a -adrenergic receptor as a prototype. to optimize the fret efficiency we exchanged the previous acceptor (yfp) with the halotag technology ( ) . additionally, we used halotag in combination with the nanoluc ( ) to explore the possibility of using bret as a high-throughput approach to monitor receptor activation kinetics. the fret-based sensor α a -halo/cfp showed an increase in fret upon application of the full endogenous agonist norepinephrine with an ec value in accordance with the previously published data. this suggests the functionality of the fret-based α a -halo/cfp sensor. similar results were obtained with the α a -adrenergic receptor bret-based sensor. in contrast to the full agonist norepinephrine, the inverse agonist, yohimbine, decreased the ratio in both, fret as well as bret-based α aadrenergic receptor sensors. this suggests the sensitivity of the methods to discriminate among agonist (increased ratio) and antagonist (decreased ratio) induced receptor kinetics. our results show the feasibility of using halotag to monitor receptor activation via fret in a single cells format and halotag, in combination with nanoluc, can be used to monitor receptor activation in high-throughput format. , c. hoffmann the homologous visual arrestins) that has recently been solved by x-ray crystallography. here we investigated both the interaction with gpcrs and β-arrestin conformational changes in real time and in living cells with a series of fret-based β-arrestin biosensors. upon stimulation, β -adrenergic receptors bound β-arrestin with a time constant τ = . ± . s, indicating that β-arrestin binding rapidly terminates their gprotein signaling. we observed a subsequent receptor-mediated conformational change in β-arrestin with a τ = . ± . s. stimulation of β -adrenergic vs. m muscarinic or ffa receptors resulted in different patterns of conformational changes in the various β-arrestin sensors and also in downstream kinase signaling, revealing receptor-specificity in β-arrestin activation. upon agonist removal, first the interaction (delay = . ± . s) and only then the active state of β-arrestin (delay = . ± . s) were reversed. accordingly, β-arrestin localization at the cell membrane lasted much longer than the direct interaction with β -adrenergic receptors. our data indicate a rapid, receptorspecific, two step binding and activation process between gpcrs and β-arrestins; they further suggest that β-arrestins remain active following dissociation from receptors, allowing them to remain at the cell surface and presumably signal independently. thus, gpcrs trigger a rapid, receptor-specific activation/deactivation cycle of β-arrestins, which permits their active signaling. patghogenic clostridium difficile produce two large glucosyltransferases, tcda and tcdb, which are the main pathogenicity factors. the cytotoxin tcdb is about , fold more potent than tcda. tcda and tcdb are a/b structure toxins exhibiting an enzymatically active (a) domain and a binding/translocation domain (b) to deliver the active glucosyltransferase domain into the cytosol of host cells. beside its glucosyltransferase activity by which the substrate proteins mainly of the family of rho gtpases are inhibited, tcdb has additional cytotoxic effects that are independent of rho glucosylation. to investigate the mechanism by which tcdb induces early cell death, we applied chimeras of tcdb from different toxinotypes where different glucosyltransferase domains were combined with different translocation domains. to this end we cloned tcdb from strain vpi (historical strain), strain (serotype f, variant tcdbf), strain r (hypervirulent strain, ribotype o ), and strain r (hypervirulent strain with tcdbf characteristics). we were able to investigate the impact of the glucosyltransferase domains with different substrate specificity when translocated into the host cell by identical translocation domains. furthermore, we tested different translocation domains to deliver the same glucosyltransferase domain into host cells. we found that the glucosyltransferase domain of tcdbf (strain ) is less cytotoxic with respect to early cell death mediated by reactive oxygen species than that from reference strain vpi . in addition, the translocation domain also showed significant impact on cytotoxicity, probably by faster intracellular delivery of the gtd. by using glucosyltransferase deficient mutants where the highly conserved dxd-motif was changed to nxn, we were able to show that glucosylation of rho gtpases counteracts the cytotoxic effect, since the mutants were more cytotoxic than wildtype toxins. in conclusion, the cytotoxicity of tcdb mainly depends on the translocation efficiency into the host cell and on the kinetic of glucosylation of their substrate gtpases. thus, sensitivity of target cells towards cytotoxic effect also depends on receptor abundancy and intracellular status of rho gtpases, whereas the cytopathic effect, i.e. cell rounding, is predominatly determined by the substrate specificity. introduction: p rhogef activates the g protein-coupled receptor (gpcr)-mediated induction of rhoa in different cells. however, its role in cardiac fibroblasts (cf) is not defined yet. thus we studied its localization and function in cf in d and d culture experiments. methods: neonatal rat cardiac fibroblasts (nrcf) and adult ventricular fibroblasts (amcf) from wild type mice and p rhogef-knockout mice were adenovirally transduced for to h with recombinant adenoviruses or directly used. for d studies the cells were treated with angiotensin ii (ang ii). the location of the involved signaling components, rhoa activation and down-stream effects were studied by confocal microscopy and biochemical analyses. in addition, cf were used to prepare cf-containing engineered connective (ect) or muscle (ehm) tissues. results: we could show that p rhogef locates at the plasma membrane, adjacent to the golgi apparatus and at the base of primary cilia. in accordance, p rhogef regulates in response to ang ii the expression and secretion of the connective tissue growth factor (ctgf) in nrcf involving the serum response factor. in ect, p rhogef increases the stiffness of these tissues and in ehm containing cf expressing gain-and-loss-of-function p rhogef variants it influences the contractility. interestingly, the increase in ect stiffness was independent of p rhogef's regulatory function of ctgf, as overexpression of ctgf in cf had no impact on ect properties arguing for a more general role of p rhogef in auto-and paracrine signaling. moreover, our data on amcf with a genetic deletion of p rhogef implies that p rhogef is not only a transducer of gpcr-dependent rhoa activation as its loss led to an increase in rhoa expression accompanied by an increase in rhoa-dependent gene expression suggesting a role of p rhogef in the feedback regulation of this signaling cascade. conclusion: in summary, our data show that p rhogef regulates auto-and paracrine signaling in cardiac fibroblasts. the atrophic rhinitis is characterized by a drastic destruction of nasal turbinate bones in different animals. it leads to shortening and twisting of the snout and a growth retardation of young pigs. this bone degradation is induced by pasteuralla multocida toxin (pmt), a toxin produced by p. multocida serogroups a and d. this destructive effect indicates an interaction of pmt with bone cells like osteoclasts and osteoblasts. we demonstrated that pmt stimulates the differentiation of osteoclasts and inhibits the differentiation of osteoblasts in a gq-dependent mechanism. the underlying molecular mechanism of the toxin is the deamidation of an essential glutamine residue in the αsubunits of heterotrimeric g proteins, which results in the constitutive activation of the g protein. until now only the function and the pmt-dependent effects on osteoblasts and osteoclasts were studied in detail, but there is also a third important cell type in bone, the osteocytes. osteocytes are discussed as the regulator of the bone turn-over by interacting with osteoclasts and osteoblasts e.g. via secretion of several osteoclastogenic and osteoblastogenic cytokines. therefore, we studied the effects of pmt on the function of osteocytes in more detail. we utilized an osteocyte like cell line and primary osteocytes isolated from tibiae and femurs from mice. the susceptibility of primary osteocytes and the osteocyte like cell line towards pmt was demonstrated by detection of toxin-induced deamidation of g proteins. we also observed a pmt-induced secretion of different cytokines, like rankl, il- and tnf-α, which are known to induce osteoclastogenesis or inhibit osteoblastogenesis. furthermore, we studied the underlying signal transduction pathways and other pmtinduced effects on osteocytes, like morphological changes. in summary, we show that pmt acts on osteocytes by stimulating heterotrimeric g proteins. this might have impact on overall bone metabolism due to modulation of osteoblast and osteoclast activity. pasteurella multocida is an opportunistic pathogen often residing in the nasal pharyngeal space of animals. one virulence factor of p. multocida serogroups a and d is the protein toxin pmt (p. multocida toxin), which is the causative agent of atrophic rhinitis characterized by degradation of nasal turbinate bones in pigs and other animals. on the molecular level, pmt activates distinct members (g q/ , g / and g i ,) of heterotrimeric g proteins leading to a modulation of bone metabolism: the toxin stimulates osteoclastogenesis but blocks osteoblastogenesis which results in bone loss. this mechanism of action of pmt might be exploited to counteract the human disease fibrodysplasia ossificans progressiva (fop), a rare and highly disabling disorder of extensive heterotopic bone growth. the underlying cause of fop is a point mutation in the activation domain of acvr (r h), a bmp (bone morphogenic protein) type receptor. this mutation leads to an inflated bmp-signaling and heterotopic osteoblastogenesis. here, we report that c c cells, a mouse myoblast cell line often used as a fop model, are susceptible to pmt intoxication. pmt induces deamidation of g proteins in these cells. furthermore, pmt very efficiently inhibits bmp -induced osteoblast differentiation in c c cells. this has been shown by measuring alkaline phosphatase expression which is an early marker of osteoblast differentiation. additionally, the impact of pmt on acvr r h induced osteoblastogenesis will be investigated and the involved cellular signaling pathways will be characterized in detail. the data indicate that activation of heterotrimeric g-proteins might be a rationale for pharmacological therapy of fop. p rhogef is an activator of the monomeric gtpase rhoa and was shown to be expressed in the heart. in cardiac fibroblasts and smooth muscle cells, p rhogef regulates rhoa in response to angiotensin ii and controls the actin cytoskeleton as well as protein expression and secretion. its role in cardiomyocytes, however, has not been elucidated so far. cardiomyocytes were isolated from neonatal rat hearts (nrcm), wild type mouse hearts (wt-amcm) and homozygous (ko-amcm) p rhogef knockout mouse hearts. the cells were either directly fixed or adenovirally transduced for h in culture. for activation of the g q/ -signaling the cells were treated with endothelin- (et- ), angiotensin ii (ang ii) or phenylephrine (pe) for s. rhoa activation was assessed by affinity binding or with a specific active-rhoa antibody. other proteins were detected by immunoblot or immunofluorescence analysis with subsequent confocal imaging. in nrcm p rhogef is involved in the regulation of the et- -induced rhoa activity and thus increases the expression and secretion of the rhoa target gene ctgf. in accordance, p rhogef was found to be localized at the sarcolemma as well as in intracellular membrane compartments. the strongest co-localization was detected with the kdel-receptor (kdelr ) which resides in the endoplasmatic reticulum membrane. next, we analyzed rhoa activation in wt and ko-amcm and could show that a loss of p rhogef led to an increase in basal rhoa activity and an uncoupling from the gpcrs. interestingly, in the ko-amcm caveolin- the major component of caveolae, in which several gpcrs are clustered, was reduced in its expression and a shift in localization from transverse to longitudinal membrane tubules was found, arguing for a role of p rhogef in intracellular protein transport. in accordance, golgi apparatus particles, which were demonstrated to play role in caveolae formation, were reduced in size in ko-amcm. to further address the role of p rhogef in the transport of membrane proteins, we overexpressed p rhogef in wt-amcm and could show that this led to an increase in the expression of the kdelr and its co-localization with p rhogef in the perinuclear region and at the sarcolemma. no sarcolemmal localization of kdelr was found in control-transduced cells. further, p rhogef was localized adjacent to golgi apparatus particles which were similar reduced in size as detected in the ko-amcm. finally, we expressed the dominant negative construct p dn and detected similar changes with respect to kdelr localization and golgi structure suggesting that this regulatory function of p rhogef is not dependent on its activity. conclusion: p rhogef mediates the activation of rhoa from gpcrs coupled to g q/ proteins. moreover, it has a function in intracellular transport and distribution of membrane proteins independent of its activity. universität bonn, pharmacology and toxicology section, bonn, germany g protein signaling is a means allowing cells to quickly respond and adapt to environmental changes. four major g protein classes (gs, gi/o, gq/ , g / ) exist in mammals and these must suffice to convey signals from about g protein-coupled receptors to the cell interior. as such, g proteins receive, interpret, and finally route the gpcr signals to diverse sets of downstream target proteins and thereby permit cells to respond to their ever changing environment. understanding contribution of individual g protein classes or even isoforms to complex signaling networks in living cells requires capacity to activate or inactivate proteins with great precision and selectivity. one approach towards inactivation of g protein function is via chemical inhibition. however, "true specificity" of chemical inhibitors for their associated targets may often be debated. in this study we posit that fr , a cyclic depsipeptide isolated from the leaves of ardisia crenata, may clearly be designated as "truly specific" for inhibition of gq signaling. using a broad set of complementary methods based on label-free holistic cell sensing, classical endpoint assays, and bioluminescence resonance energy transferbased g protein biosensors we assign exceptional selectivity to fr for inhibition of gq/ / over all other mammalian isoforms ("on-target effects"). in holistic label-free recordings using hek cells that lack functional gq/ alleles by crispr-cas genome editing, bona-fide gq stimuli were undetectable. however, reintroduction of gq into the knockout background was required and sufficient to fully restore both, agonist responses and their inhibition by fr. moreover, fr was completely ineffective in cells lacking gq/ using phenotypic assays that examine basic cellular functions such as cell growth, viability, morphology and expression of housekeeping genes ("off-target effects") . from these results we conclude that fr is of outstanding value as molecular probe to unravel contribution of gq signaling in complex biological processes in vitro, ex vivo and in vivo. just as pertussis toxin, applied world-wide by numerous laboratories to diagnose signaling of gi/o proteins, we anticipate fr to stand out at least equally for investigations into the biological relevance of gq. binary actin adp-ribosylating toxins like c. perfringens iota toxin and c. difficile transferase cdt cause depolymerisation of the cortical actin cytoskeleton, induce the formation of microtubule-based cell membrane protrusions and redirect rab-dependent intracellular traffic (schwan et al. ). here, we employed the model of toxin-induced protrusions to study the formation of cilia. we found that toxin-induced microtubule-based protrusion formation at the cell membrane depends on recruitment of septins, which are highly conserved, small gtpbinding proteins. similar to toxin-caused protrusions, septins are also recruited to the site of ciliogenesis. inhibition of septins by shrna-based knockdown inhibits ciliogenesis as well toxin-induced protrusion formation. septins are suggested to be involved in exocytotic processes, which are important for ciliogenesis and also for toxin-induced protrusion formation. accordingly, translocation of septins is accompanied by a recruitment of rab proteins and proteins of the exocytotic machinery. the data indicate that septins function as a scaffold at the base of cellular processes like cilia and toxin-induced protrusions, organizing the cross-talk between the actin cytoskeleton and microtubules to regulate the vesicle traffic-and exocytotic machinery. hypervirulent clostridium difficile strains are associated with increased morbidity and mortality. these strains produce the actin-adp-ribosylating clostridium difficile toxin cdt. cdt depolymerizes the actin cytoskeleton, causes formation of microtubule-based protrusions and increases pathogen adherence. septins are essential for cdt-induced protrusion formation. sept , , and accumulate at predetermined protrusion sites and form collar-like structures at the base of protrusions. the septins are a prerequisite for protrusion formation. the inhibitor forchlorfenuron or knock-down of septins inhibit protrusion formation. septins colocalize with active cdc and its effector borg which act as up-stream regulators of septin polymerization. microtubules interact with septin structures. precipitation and surface plasmon resonance studies revealed high-affinity binding of septins to microtubule plus end tracking protein eb thereby guiding incoming microtubules. the data indicate that cdt hijacks conserved regulatory principles involved in microtubule-membrane interaction, depending on septins, cdc , borgs and restructuring of the actin cytoskeleton. the zebrafish danio rerio has become an important vertebrate model organism for a wide range of scientific questions [ ] . current studies are mainly focused on development, genetics and disease for which the zebrafish is particularly well suited due to its small size, rapid development, short generation time, optical transparency of embryos and larvae as well as conservation in functional domains [ ] . hitherto, nothing is known about the composition and endogenous level of different cnmps in various developmental stages and organs of danio rerio. therefore, we used the zebrafish in our study as a vertebrate model to characterize systematically the temporal-and organspecific occurrence(s) of all cnmps including cump in vivo. cyclic nucleotides were quantified by high performance liquid chromatography quadrupole tandem mass spectrometry. we observed specific cnmp patterns in developmental stages and different organs from adult zebrafish, which is in support of the hypothesis of a distinct cnmp signaling code [ ] . camp, cgmp and cump were present in tissue samples of both developmental stages (embryos at hours post fertilization, larvae at days post fertilization) and within all harvested organs. remarkably, these three cnmps were the only ones detected in the brain. camp concentration of entrails as well as camp and cgmp concentrations in the brain were similar to those previously described in mouse tissues [ ] . ccmp was detected throughout development and was present in all organs except the brain. the identity of ccmp and cump in the zebrafish was confirmed by high performance liquid chromatography quadrupole time-of-flight mass spectrometry (hplc-ms/tof). thus, we unequivocally show for the first time that cump occurs in vertebrates. furthermore, we detected cimp in several developmental stages of the zebrafish, and observed the highest concentrations in testes and heart, but we were unable to unequivocally identify cimp via hplc-ms/tof. in the zebrafish, sac is evolutionarily not conserved and absent, since a search in the ncbi gene data base revealed no entry for sac (also referred to as ac ). therefore, sac can be excluded as cump-and ccmp generator in this system and sgc remains as the only bona fide cump-and ccmp generator in the zebrafish. to test this hypothesis, the effects of no donors, sgc stimulators and sgc activators on cump levels in zebrafish should be examined in future studies. recently, induction of apoptosis in mouse lymphoma cells by ccmp-am has been described [ ] . thus, it would be interesting to examine the effect of ccmp-am on zebrafish embryos in future studies as well. [ ] seifert, r.: ccmp and cump: emerging second messengers, trends in biochemical sciences , - ( ) . ccmp, ', '-cump and ', '-cimp were ineffective. to further characterize the action of ', '-cgmp on hut- cells, we determined apoptosis (propidium iodide/annexin v staining) and proliferation (carboxyfluorescein succinimidylester staining). ', '-cgmp significantly increased apoptosis (ec = µm) and inhibited proliferation (ec = µm) of okt -activated hut- cells. interestingly, also ', '-cgmp exhibited comparable effects on apoptosis and proliferation with ec values of µm and µm, respectively, while ', '-camp, ', '-ccmp and ', '-cump were ineffective. this indicates that the pro-apoptotic and antiproliferative action of cgmp does not depend on the position of the phosphodiester bond. we also tested ', '-cgmp degradation products under the same experimental conditions and found that both '-gmp and guanosine increased apoptosis and inhibited proliferation with ec -values between and µm. by contrast, adenosine did not influence cell growth and viability, suggesting that adenosine receptors are not involved in the observed effects. our results suggest that the guanosine moiety is responsible for the pro-apoptotic and antiproliferative effects of ', '-cgmp, ', '-cgmp, '-gmp. it has been reported earlier that guanosine is toxic to jurkat cells, another t cell lymphoma cell line [ ]. ', '-cgmp may be hydrolyzed by an ekto-phosphodiesterase on the cell surface of hut- cells (e.g. enpp ), yielding '-gmp, which could be further degraded to guanosine by the '-ekto-nukleotidase cd . a similar pathway may lead from ', '-cgmp to guanosine. a previous analysis of phosphodiesterases (pdes) revealed that the dual-specific pde isoforms a and b as well as the cgmp-selective pde a also degrade the emerging second messenger cump [ , ] . we analyzed the enzyme kinetics of pde b-mediated cump-hydrolysis using recombinant gst-tagged pde b and a highly sensitive and specific hplc-ms/ms method. our data show that pde b is a low-affinity enzyme for cump with a cump k m -value of > µm. the pde -selective competitive inhibitor milrinone inhibited pde b-mediated cump degradation, suggesting that cump binds to the catalytic center. pde b is highly expressed in adipose tissue [ , ] . thus, we differentiated murine t -l -mbx-fibroblasts into adipocytes and analyzed differentiation-dependent alterations of pde b expression and basal cnmp-concentrations. in both differentiated and undifferentiated t -l cells cump and ccmp were detected in addition to the established second messengers camp and cgmp. differentiation to adipocytes reduced camp and cgmp by % and %, respectively, while ccmp was reduced by % and cump even by %. these findings suggest that cump plays a distinct role in adipocyte differentiation. the cump-hydrolyzing pde b was upregulated ~ -fold on mrna level after adipocyte differentiation, which may contribute to the observed reduction of basal cump concentrations. we currently investigate the potential biological role of cump in differentiation and lipolysis experiments, analyzing the effects of the membrane-permeant cumpacetoxymethyl ester cump-am. in future experiments, we will also analyze the enzyme kinetics of pde a-mediated cump hydrolysis. pde a is the first example of a cgmp-"specific" cump-hydrolyzing pde. background: cgmp and camp are cyclic nucleotide messengers relevant to many physiological and pathophysiological conditions. live-cell imaging with fret-based biosensors is a powerful method to study the spatiotemporal dynamics of cgmp and camp under close-to-native conditions. however, with the existing biosensors it is difficult to resolve potential membrane-associated cgmp microdomains and to monitor cgmp and camp signals in parallel in the same cell. we have generated novel versions of the "green" cfp/yfp-based cytosolic cgmp biosensor, cgi . they comprise a "green" membrane-targeted version (mcgi ) and a "red" variant (red cgi ) that contains the fluorophores tsapphire and dimer . methods: the sensors were expressed and characterised in primary vascular smooth muscle cells (vsmcs). intracellular cgmp was elevated in intact vsmcs by application of a nitric oxide donor or natriuretic peptides, and the sensor's sensitivity to each stimulation and its signal-to-noise ratio were determined. to test each sensor's sensitivity and specificity for cgmp versus camp, sensor-expressing cells were permeabilised with β-escin and exposed to defined concentrations of cyclic nucleotides. results: the original cgi sensor showed a good signal-to-noise ratio, an ec value of ≈ . µm for cgmp, and a high selectivity for cgmp over camp (> -fold). flincg , a non-fret-based cgmp sensor, showed similar properties as cgi . the new membrane-targeted mcgi and the new red cgi displayed ec values of ≈ . µm cgmp and a high selectivity for cgmp over camp (> -fold). in vsmcs, the red cgi showed a better signal-to-noise ratio than the previously described "red" cgmp sensor, red cges-de . the "green" fret-based camp sensor, epac -camps, showed a signal-to-noise ratio comparable to that of cgi , an ec value of ≈ µm for camp and a selectivity for camp over cgmp of ≈ -fold. finally, imaging of cells expressing both the epac -camps and the red cgi demonstrated the feasibility of combined visualisation of camp and cgmp signals in the same cell. the new cgmp biosensors should be useful for a broad spectrum of applications requiring real-time monitoring of cgmp signals. for example, mcgi would be useful to investigate membrane-associated cgmp compartments and red cgi to study the crosstalk between cgmp and camp signalling in living cells and tissues. the cgmp-system is a major regulator of blood pressure. cgmp-dependent protein kinases (cgks), located in the smooth muscle layer of vessels, enable cells to dilate and therefore cause a decrease in blood pressure (bp). to the contrary, the reninangiotensin-aldosteron-system (raas) acts as opponent and causes an increase in bp; furthermore, it influences fluid-electrolyte balance. renin, which is secreted from reninproducing cells located in the juxtaglomerular apparatus (jga), is the key regulator enzyme in this system. pharmacological inhibition of the raas, e.g. via ace-inhibitors or at -receptor-antagonists, is a powerful tool to treat hypertension, but chronically challenges this endocrine system, resulting in an enhancement of renin expression. this is caused by an increased number of renin-expressing cells (the so-called reninrecruitment), which derive from a reversible metaplastic retransformation of extraglomerular and smooth muscle cells of afferent arterioles. next to regulation of renin-function via camp/pka, it has been shown that enos-derived no supports this recruitment via activation of sgc and subsequent generation of cgmp [ ] . whether this causes an activation of cgks is not known. these enzymes exist in different isoforms, cgkiα, cgkiβ und cgkii. in contrast to the β-isoform, cgkiα (as well as cgkii) is highly expressed in the jga [ ] , [ ] . therefore, we analyzed, whether cgkiα also plays a role regarding renin synthesis, secretion or recruitment. to characterize the function of cgkiα in jga-cells, we generated renin-cell specific cgkiα-knockout mice (ren cre-cgki fl/fl) and stimulated renin recruitment via administration of a low salt diet ( . % na + ) and enalapril ( mg/kg/d) for weeks. we analyzed blood pressure, mrna and renal protein content of renin and cgkiα, plasma renin activity and renin recruitment. furthermore, we activated the cgmp-system in these mice using bay - , a sgcstimulator, and re-analyzed the above-mentioned parameters. our results indicate that cgkiα could be an additional system supporting renin recruitment but is not a crucial pre-requisite. in contrast, the basal renin concentration and activity appears to be downregulated in ren cre-cgki fl/fl-mice, thus, cgki could be an important regulator of renin synthesis. universität regensburg, pharmakologie und toxikologie, regensburg, germany jaw /lrmp (lymphoid-restricted membrane protein) is a type membrane protein, localised to the cytoplasmic face of the endoplasmic reticulum. it encodes a amino acid protein with a highly conserved coiled-coil domain in the middle third of the protein and a cooh-terminal transmembrane domain [ ] , [ ] . jaw and irag have a limited homology throughout the length of the protein. the coiled-coil domain and the putative transmembrane anchor at the c-terminus of jaw and irag share the highest homology [ ] , [ ] . the coiled coil domains of irag and jaw are important for the interaction with ip rs. as already known, irag forms a trimeric complex with cgkiβ and ip r and gets phosphorylated by cgkiβ [ ] . hence we examined if jaw is a new target protein of cgkiβ. the recognition site, where a substrate can be phosphorylated by cgki, is composed of the following amino acids: (k/r)(k/r)x(s/t). in the amino acid sequence of jaw possible phosphorylation sites can be found. our in vitro studies with jaw and cgki showed that jaw gets phosphorylated in a cgmp-dependent manner by cgkiβ. in contrast, jaw was not phosphorylated by cgkiα. furthermore, no stable interaction between jaw and cgkiβ was detected. to examine the importance of jaw in vivo, we generated a conditional knockout mouse. mating with a cmv cre mouse, resulted in an ubiquitous deletion of jaw . mrna analysis and western blot analysis approved the deletion. the expression pattern revealed high expression in the thymus and weaker expression in the lung, spleen, colon, pancreas and the tongue. as already published by shindo et al., jaw was found in sweet, bitter, and umami taste receptor-expressing cells of mouse circumvallate, foliate, and fungiform papillae. we confirmed these results by x-gal staining and mrna analysis. therefore, we decided to analyse if jaw influences taste perception. two bottle preference tests did not result in significant differences between wildtype and knockout mice, indicating that taste perception is not altered by jaw . hence, the function of jaw in taste receptor expressing cells has to be further examined in future studies. the cyclic purine nucleotides adenosine ', '-cyclic monophosphate (camp) and guanosine ', ' cyclic monophosphate (cgmp) are well-characterized second messengers. both are generated by nucleotidyl cyclases and degraded by phosphodiesterases. several binding partners of camp and cgmp were already identified and functionally analyzed, e.g. camp-dependent protein kinase (pka) and cgmp-dependent protein kinase (pkg) as well as exchange protein activated by camp and , hyperpolarization-activated cyclic nucleotide gated channels and phosphodiesterases. recent data indicate that the cyclic pyrimidine nucleotides cytosine ', '-cyclic monophosphate (ccmp) and uridine ', '-cyclic monophosphate (cump) also fulfill the criteria of second messengers [ , ] . the interaction of ccmp with the regulatory subunits of pka (pkariα and pkariiα) has already been shown by using ccmpagarose [ ] . additional ccmp-and cump-binding proteins such as calnexin (chaperone), myomegalin (phosphodiesterase-interacting protein) and akap (a-kinase anchoring protein) were identified by mass spectrometry analysis. to verify the interaction of ccmp and cump with these potential target proteins, ccmp and cump linked to biotin were used as another approach. the biotin-constructs exhibit lower steric interference than the ccmp-and cump-agarose matrices, which were previously used to confirm the binding of pkariα to ccmp and cump [ ] . flag-tagged calnexin, flag-tagged myomegalin and myc-tagged yotiao (smallest splice-variant of akap ) were examined as potential ccmp and cump target proteins. hek cells were transiently transfected with the cdna of the respective proteins. the lysates of the protein-overexpressing cells were then incubated with ccmp-and cumpbiotin matrices and bound proteins were purified using strep-tactin® beads (iba). afterwards, the interaction of ccmp and cump with the potential binding partners was analyzed by western-blotting. a pkariα antibody was used as a positive control. analogous experiments were also performed using ccmp-and cump-agaroses. once the interaction between the cyclic pyrimidine nucleotides and the potential binding partners has been confirmed, deletion mutants will be cloned to localize the ccmp-and cump-binding area of the target proteins in further studies. axonal branching is essential for the correct formation of neuronal circuits and enables the simultaneous transmission of information throughout the body. in mice, the bifurcation of axons of sensory neurons at the dorsal root entry zone of the developing spinal cord depends on a cgmp signaling cascade that includes c-type natriuretic peptide (cnp), natriuretic peptide receptor (npr , also termed gc-b), and cgmpdependent protein kinase iα. in this study it was investigated, if a disturbance of cgmp signaling induced by manipulation of cgmp breakdown or cnp scavenging affects axon bifurcation of murine embryonic dorsal root ganglion (drg) neurons. rt-pcr screens, in situ hybridization, and fret-based cgmp imaging in living neurons revealed phosphodiesterase a (pde a) as the major enzyme for degradation of cnp-induced cgmp in embryonic drg neurons. interestingly, cgmp measurements and dii labeling of pde a knockout embryos indicated that a strongly elevated concentration of cgmp does not impair sensory axon bifurcation of drg neurons in vivo. the natriuretic peptide receptor (npr ) was found to be expressed in the roof and floor plate of the spinal cord as well as in the dorsal roots of e . embryos. because npr binds natriuretic peptides, but does not generate cgmp, it is thought to act as a natriuretic peptide clearance receptor. by scavenging cnp, npr could lower the activity of the cnp-npr -cgmp signaling cascade in drg neurons. in the absence of npr , the majority of sensory axons showed normal bifurcation, but » % of the axons turned only in rostral or caudal direction. this study shows ( ) that pde a is important for the degradation of cgmp in embryonic drg neurons, ( ) that the bifurcation of sensory axons in the spinal cord can tolerate high levels of intracellular cgmp in the absence of pde a, and ( ) in the central nervous system, no-dependent cgmp signalling is associated with many different developmental processes and brain functions, and plays an important role in memory consolidation and cognition. to analyse cgmp signals in primary cells, a knock-in mouse was generated which stably and ubiquitously expresses a fret-based cgmp indicator (cgi ). cultured cortical and hippocampal neurons were found to respond to exogenously applied no (gsno). in these cell types, endogenous no is mainly generated by the neuronal no synthase (nnos) isoform which requires a rise in intracellular calcium for activation of the no/cgmp-signalling cascade. here, we show that ampa-type ionotropic glutamate receptors were capable to induce cgmp response in cultured cortical and hippocampal neurons. surprisingly, amparinduced cgmp signals were independent of nmdar activation, as inhibition of nmdars with the nmdar antagonist d-apv (d- -amino- -phosphonopentanoic acid) did not block ampar-induced cgmp response. however, cgmp accumulation depends on no synthase activation as the nos inhibitor l-nna (ng-nitro-l-arginine) completely abolished cgmp accumulation. whether ampar-induced nos activation depends on calcium influx via calcium permeable ampars, vgccs (voltage gated calcium channels) or calcium release from intracellular stores will further be investigated in detail. cyclic adenosine monophosphate (camp) is an important and ubiquitous cellular second messenger. a dogma in signaling is that camp is distributed homogenously in the cell and that its concentration changes equally upon stimulation. in contrast, a large body of evidence suggests the existence of concentration gradients (so-called microdomains) of camp. in this regard, phosphodiesterases (pdes), the only enzymes which can degrade camp, have been suspected to be responsible for maintaining those gradients. however, how pdes establish camp gradients is entirely unknown. here, we measure local camp levels in hek cells and cytosolic fractions thereof using the camp fretsensor epac -camps fused to a phosphodiesterase (pde a ). we demonstrate the existence of low camp concentrations in close proximity to pdes and show that this gradient is maintained by pde hydrolytic activity. further we establish that camp gradients cannot be maintained solely on the basis of pde activity as the camp turnover is very slow. we provide evidence that pdes are structurally organized in yet unspecified 'microstructures' in which camp diffusion must be considerably slowed down. taken together, we suggest that camp gradients are established by pde hydrolytic activity in cellular regions with slow diffusion of camp. our study sheds light on the organization and maintenance of signaling compartments in cells. the influence of pde hydrolytic activity on camp gradients universität würzburg, pharmakologie und toxikologie, würzburg, germany phosphodiesterases (pdes) are a family of enzymes that degrade cyclic amp (camp) and cyclic gmp (cgmp) to their respective monophosphates. although several pdes have been shown to play an important role in a wide variety of physiological and pathological processes, their complexity and function in cell signalling is only beginning to be understood. it is especially astonishing that eukaryotes express more than different pde isoforms while their single function is to degrade camp, cgmp or both. in recent years, a large body of evidence has suggested that pdes (especially isoforms of the pde families , and ) are key players in establishing signalling compartments. these so-called microdomains are yet unspecified regions in cells where the concentrations of camp and cgmp are higher or lower than in the bulk cytosol. in a companion abstract (bock & lohse) we provide evidence that camp nanodomains, i.e. regions of low camp concentrations, exist in cells in the direct vicinity of pde . however, the mechanisms by which pdes establish and maintain camp gradients are largely unknown. here we study if establishing camp gradients is a general role of pdes and, moreover, if the size of camp nanodomains mainly depends on pde hydrolytic activity. by fusing an ultra-fast pde a (v max = µmol/min/mg) to a camp fret sensor (epac -camps) we monitor camp concentrations in direct vicinity of pde a . in comparison to pde , we show that pde a , albeit displaying a high camp turnover, only establishes a small camp gradient in both cytosol preparations of transfected hek cells and in living cells. interestingly, this gradient can be increased by deleting the nterminal regulatory domains while maintaining fast camp turnover. biochemical mapping of the camp gradient gives an estimate of the size of nanodomains. taken together, our data suggest that establishing camp gradients does not exclusively depend on pde hydrolytic activity. arglabin is a plant-derived sesquiterpene lactone used for cancer therapy in kazakhstan and russia. signaling pathways targeted by arglabin are poorly understood. we have isolated arglabin by using high performance liquid chromatography from a methanolic extract of artemisia glabella, a plant endemic in kazakhstan. mass spectrometric analyses confirmed the chemical structure and the purity of the isolated arglabin. in j macrophages, arglabin strongly induced accumulation of lc type ii protein in the absence of inflammasome activators, and also in cells activated with lps and cholesterol crystals. in addition, arglabin induced clustering of lc -ii at autophagosomal membranes, as evidenced from its punctuated pattern in confocal microscopic images of arglabin-treated macrophages, which is a characteristic sign for autophagy. since autophagy activation leads to increased degradation of nlrp and pro-interleukin (il)- β, we further analyzed whether arglabin inhibits the nlrp inflammasome. arglabin reduced expression of nlrp and pro-il- β, inhibited activation of caspase- , and release of mature il- β by lps-and cholesterol-crystal-stimulated macrophages consistent with inhibition of the nlrp inflammasome. intraperitoneal injection of arglabin into female apoe .ki mice fed a high fat diet resulted in significantly decreased plasma levels of proinflammatory il- β. moreover, arglabin markedly reduced mean lesion areas in the sinus and whole aorta in mice. thus, arglabin may represent a new promising drug to treat diseases associated with inflammasome activation, e.g. atherosclerosis. this work was supported in part by a grant from the nouvelle société francophone d'athérosclérose (nsfa). recently, we found that activation of the proteinase-activated receptor (par) stimulates renin release in the isolated perfused kidney model. therefore, we determined in the current experiments the response of plasma renin concentration (prc) to acute intraperitoneal administration of the par activating peptide sligrl ( µg/kg), hydralazine ( mg/kg), isoproterenol ( mg/kg), losartan ( mg/kg) and furosemide ( mg/kg) in conscious wild-type (wt) and par -deficient mice. prc was measured in plasma obtained by tail vein puncture. renal renin expression was determined by quantitative rt-pcr. renal protein expression was measured by immunohistochemistry. on a control diet ( . % nacl), plasma renin concentration (in ng angiotensin i per ml per hour) was significantly lower in par -deficient mice than in wild-type mice ( ± versus ± ). renin mrna expression was ± % of wt. renin-expressing cells were located at the juxtaglomerular position and renal renin protein expression was lower in par -deficient mice. as measured by tail-cuff method, systolic blood pressure was not different between par (-/-) and wt mice. administration of sligrl increased renin secretion about -fold (p< . ). acute stimulation of renin release by furosemide, isoproterenol, losartan and hydralazine caused significant increases of plasma renin concentration in both par (-/-) and wt mice. the absolute changes (delta prc) were similar ( ± , ± , ± , ± in wt, and ± , ± , ± , ± in par (-/-)). in conclusion, chronic absence of par reduces basal renin expression and renin release. however, par -deficiency does not alter renin release in response to typical stimuli for renin secretion. therefore, par does not appear to be a mandatory and specific requirement for acute regulatory responsiveness. increased myofilament ca + sensitivity could be the underlying cause of diastolic dysfunction. we evaluated acute effects of epigallocatechin- -gallate (egcg), which has been shown to decrease myofilament ca + sensitivity, on cardiac myocyte contractility and force-ca + relationship of skinned cardiac muscle strips in an hcm mouse model with left ventricular hypertrophy and both systolic and diastolic dysfunction. methods: the hcm mouse model used in this study carries a point mutation in the cardiac myosin-binding protein c gene at the homozygous state (mybpc -targeted knock-in; ki). we isolated ventricular myocytes from adult ki and wt mice and analyzed sarcomere shortening and ca + transients at °c under hz pacing using the ionoptix system in the absence or presence of egcg ( . µm). furthermore, force-ca + relationships of skinned cardiac muscle strips of ki and wt mice were obtained ±egcg ( µm). results: in baseline settings and absence of fura- , ki cardiomyocytes displayed higher sarcomere shortening ( type- serine/threonine protein phosphatase (pp ) comprises a family of enzymes that dephosphorylate cardiac regulatory proteins, thereby modulating ca + handling and contractility. all pp heterodimers possess a catalytic subunit, which is selectively inhibited by inhibitor (i- ). it has been shown by our group that the heart-directed overexpression of a truncated, constitutively active form of i- resulted in an improved basal ca + handling and contractility. in contrast, chronic pressure overload by transverse aortic constriction exacerbated the progression of cardiac remodeling and heart failure in transgenic mice. in the present study, we tested whether the overexpression of a full-length form of i- , regulated by gsk -dependent phosphorylation at thr , resulted in comparable functional alterations using a model of induced heart failure. for this purpose transgenic (tg) and wild-type (wt) mice were subjected to chronic application of isoprenaline (iso, mg/kg/d) via osmotic minipumps. iso-stimulated mice were compared to mice treated with . % nacl (n= ). after one week of iso administration, cardiac hypertrophy was comparable in tg and wt. ca + transients were measured in isolated, indo- -loaded myocytes. the peak amplitude of [ca] i was reduced by % in tg nacl compared to wt nacl (p< . ), whereas chronic iso application was associated with comparable effects in tg and wt. [ca] i decay kinetics were comparable in nacl-treated groups but hastened by % in tg iso compared to wt iso (p< . ). consistently, sr ca + load was diminished by % in tg nacl compared to wt nacl (p< . ). chronic iso stimulation led to an unchanged sr ca + content in tg and wt myocytes. biochemical analyses revealed that chronic βadrenergic stimulation was accompanied by a more than -fold higher phospholamban phosphorylation at ser in tg (p< . ). thus, these findings suggest that overexpression of i- is able to reduce the progression of heart failure by an improvement of myocyte ca + handling. the ligand-activated farnesoid x receptor (fxr) is a nuclear receptor highly expressed in gastrointestinal and metabolic tissues, such as the duodenum, jejunum, ileum, colon and the liver, but also in lower amounts for instance in macrophages. the endogenous agonists for this receptor are bile acids with the primary bile acid chenodeoxycholic acid as the most active one. activation of fxr regulates the transcription of target genes relevant in bile acid homeostasis, glucose and lipid metabolism, liver protection, inflammation, and cancerogenesis. agonists for fxr have been discussed as possible therapeutic options for the treatment of obesity and the metabolic syndrome. atherosclerosis is the main pathology underlying cardiovasular diseases and often occurs side-by-side with the metabolic syndrome. cholesterol deposition and the formation of cholesterol-loaded foam cells from macrophages lead to the formation of atherosclerotic plaques. this can be prevented by stimulation of cholesterol efflux from macrophages. based on leoligin, a lignan-type secondary plant metabolite, naturally occuring in leontopodium alpinum cass., derivatives were synthesized and subjected to a fxr pharmacophore-based in silico screening. testing of virtual hits in a luciferase-based fxr transactivation assay yielded one compound with promising activity on fxr. moreover, the heterodimer partner of fxr, rxrα, was not activated by this leoligin derivative in a luciferase-based rxrα assay. in addition, this compound was able to increase cholesterol efflux in thp- macrophages without affecting cell viability. western blot experiments revealed an increase in atp-binding cassette transporter a (abca ) expression in human thp- macrophages by this leoligin derivative. the transporters abcg and scavenger receptor class b (sr-bi), which also play a key role in macrophage cholesterol efflux, will be investigated. moreover, the effect of the leoligin derivative on liver x receptor activation, the nuclear receptor responsible for upregulation of these transporters, has to be studied. based on this data, further characterization of the molecular mechanism underlying the described effects will provide valuable insights in a possible crosstalk between macrophage cholesterol efflux and fxr activation. background: rho-associated kinases rock and rock are serine/threonine kinases that are downstream targets of the small gtpases rhoa, rhob, and rhoc. rock and rock are known to play a pivotal role in the pathogenesis of myocardial fibrosis. however, their specific function in cardiac fibroblasts (cf) remains unclear. remodelling of the diseased heart results in the transition of fibroblasts to a myofibroblast phenotype exemplified by an increased proliferation, migration rate and synthesis of extracellular matrix (ecm) proteins. therefore, we sought to investigate whether rock protein signalling intermediates have an impact on cellular characteristics, intracellular protein expression and mechanical properties in cf and engineered tissues. methods: neonatal cardiac fibroblasts were isolated from wild type rats and downregulation of rock and rock by % was achieved by lentiviral transduction or transfection. wild type fibroblasts were treated with μm fasudil or µm h p for general rock inhibition and µm slx- for inhibition of rock . protein expression and modification was determined by immunoblot analysis, gene expression by qpcr analysis, cf morphology and the localisation of cytoskeletal proteins by immunofluorescence analysis, cell proliferation by automated nuclei counting, cell migration on a planar surface by life cell imaging, and rigidity of engineered tissues by rheological measurement. results: our results show that both rock and rock influence cf morphology, gene expression, proliferation and migration. the knockdown and inhibition of rocks was associated with changes in cf morphology accompanied by a disorganization of higher-order actin structures including stress fibers and geodesic domes. moreover, the knockdown of rock and rock in cf increased adhesion velocity, whereas proliferation was attenuated. interestingly, downregulation of rock , but not of rock led to a significantly decreased migration velocity and distance suggesting an isolated principle role for rock in cardiac fibroblast migratory behavior. analysis of a three dimensional engineered tissue model composed of cardiac fibroblasts (engineered connective tissue, ect) suggested that rocks are involved in the regulation and turnover of the extracellular matrix (ecm) and thus influence viscoelastic properties of engineered tissues. destructive tensile strength measurement in ect treated with rock inhibitors showed that rigidity was significantly reduced when compared to control tissues. rna sequencing of ect treated with the rock inhibitor h p and qpcr analysis of cf with a downregulation of rock and rock showed that both rocks are involved in the regulation of ecm proteins, such as collagens a , a, and a , biglycan, decorin, elastin and its respective degrading enzyme mmp . conclusion: this study demonstrates that rock signalling controls myofibroblast characteristics of cf via remodelling of the cytoskeleton and the ecm. background: regulation and fine-tuning of gene transcription in cardiomyocytes (cms) is a centerpiece of cardiac development, function, and disease. in order to obtain authentic data, cell type-specific analyses are indispensable. recently, high-purity isolation protocols for cm nuclei were established [bergmann, exp cell res, ] and employed for detailed genetic and epigenetic studies on cardiac gene transcription [gilsbach, nat commun, ] . however, corresponding protein analyses, which bridge from transcriptional control to cm function are still lacking. therefore, we aimed to map the landscape of nuclear protein expression in newborn and adult mice in order to complement and extend our epigenetic studies. methods and results: cardiac nuclei were isolated from homogenized adult and p mouse frozen hearts by sucrose gradient centrifugation. magnetic-assisted cell sorting (macs) with pcm- as a nucleus-specific marker was used to enrich cm nuclei to > %. proteins were extracted from nuclear lysate with % sds. quantitative protein data were obtained from silac-based liquid chromatographytandem mass spectrometry (lc-ms/ms) experiments with an ltq orbitrap xl mass spectrometer after in-gel digestion with trypsin. nuclear protein extracts from murine cell lines served as silac (lys /arg )-labeled internal standard. finally, protein data are correlated with corresponding mrna data obtained by rna-sequencing. we identified proteins, of which are annotated to the nucleus. %/ % (adult / p ) of nuclear proteins are annotated as dna-binding. . %/ . % belong to transcription factor complexes; . %/ . % are able to bind transcription factors. . %/ . % have chromatin modification functions; . %/ . % modify histones. nuclearenriched go terms include mrna processing and transport, transcription, nucleosome assembly and protein degradation. % of proteins are shared between p and adult nuclei. proteins are exclusive to p , are only found in adult. proteins are enriched ( . -fold increase in abundance) in p hearts, proteins in adult proteins related to heart development, gene silencing, and dna replication are more prominent in or exclusive to newborn mice. adult nuclei strongly express proteins related to regulation of actin fibers and cm function, proteins involved in protein degradation, and chaperones. although high mrna expression increases the chance of protein identification, a significant correlation between mrna and protein level could not be observed on a genome-wide scale. conclusions: we present a comprehensive and specific protein landscape of newborn and adult cm nuclei. young cm nuclei appear as a developing tissue, show the ability for proliferation, and indicate ongoing alterations in gene expression. adult cm nuclei prominently display a focus on regulation of contractile fibers and cm function, as well as chaperones and proteasomal proteins indicative of its arduous function. background: fibrosis is a hallmark of many myocardial pathologies and contributes to distorted organ architecture and function. recent studies have identified premature senescence as regulatory mechanism of tissue fibrosis. however, its relevance in the heart remains to be established. objective: to investigate the role of premature senescence in myocardial fibrosis. methods: murine models of cardiac disease and human heart biopsies were analyzed for characteristics of premature senescence and fibrosis. results: senescence markers p cip /waf , senescence-associated ß-galactosidase (sa-ß-gal) and p ink a were increased -, -and -fold (n= - ; p < . ), respectively, in perivascular fibrotic areas after transverse aortic constriction (tac) when compared to sham-treated controls. similar results were observed with cardiomyocytespecific β -adrenoceptor transgenic mice and human heart biopsies. senescent cells were positive for vimentin ( ± . %), platelet derived growth factor receptor α ( ± . %) and α-smooth muscle actin ( ± . %), specifying myofibroblasts as the predominant cell population undergoing premature senescence in the heart. conclusion: our data provide first evidence for an essential role of premature senescence of myofibroblasts in myocardial fibrosis. it is tempting to speculate that pharmacologic modulation of premature senescence might provide a novel therapeutic target for anti-fibrotic therapies in the heart. introduction: the endocannabinoid system is increasingly studied in cardiac research due to its role in fibrosis, inflammation and cell fate modulation. the deregulation of this system has been implicated in myocardial infarction (mi) and consequent heart failure development. a recent study suggests cannabinoid receptor (cb ) inhibition to improve cardiac function and to reduce adverse remodeling after cardiac stress, but the exact underlying molecular mechanisms of these beneficial effects are still unknown. micrornas (mirnas, mirs) provide a complex layer of post-transcriptional regulation modulating key biological processes such as tissue remodelling in heart failure. the aim of the present study was to explore microrna pathways in the chronic effect of cb receptor inhibition after angiotensin-fibrosis induction and left ventricular remodeling. methods and results: adverse cardiac remodelling was induced in mice by chronic administration of angiotensin ii (angii, , mg/kg/day) with osmotic minipumps for days. treatment with cb antagonist, or vehicle was performed every second day during the angii administration period. hemodynamic parameters were measured by echocardiography and cardiac pressure volume catheter and tissue samples were taken for molecular and histological analysis. after two weeks of angii infusion, left ventricular dysfunction was prevented by cb antagonist treatment. this was shown by significantly improvements of the myocardial performance index and end-diastolic pressure values. at the tissue level, anti-fibrotic effects of cb antagonist treatment was confirmed histologically and by expression analysis of pro-fibrotic genes. these beneficial effects were also observed in cb ko mice and in an aging mice model. the particular role of tissue fibroblast in aii-induced cardiac fibrosis was further explored. primary cardiac fibroblasts (cf) from each experimental group were isolated and analysed by next generation deep rna sequencing to identify differentially regulated micrornas. microrna- a/b family was downregulated by in vivo angii delivery and vice versa upregulated after cb antagonist treatment and foxb (a direct target of mir- a family) was differentially regulated, suggesting a possible mechanism of action for the benefits of cb receptor inhibition. conclusion: we found that in angii-induced cardiac remodelling, lv function is preserved by chronic cb antagonist treatment and that cardiac fibrosis is reduced with concomitant downregulation of fibrogenic genes. also, cf-enriched mir- a/b family seems to be sensitive to cb antagonist treatment, thereby affecting cardiac fibrosis. the current study employs a novel concept regarding chronic cb inhibitor treatment and may provide important details and novel targets for anti-fibrotic approaches in heart failure. background: low homoarginine (harg) was recently identified as an emerging biomarker for stroke, myocardial infarction, and heart failure in clinical and epidemiological studies. harg competes with arginine as a substrate for nitric oxide (no) synthase and weakly inhibits arginase. both mechanisms might lead to increased no formation in vivo. the aim of this study was to investigate whether harg effects the development of atherosclerosis as a potential underlying mechanism of cardiovascular diseases. methods: harg-deficient agat-knockout (agat -/-) and wildtype (wt) mice were crossed with apolipoprotein e (apoe) deficient mice and fed with high fat diet (hfd) for three months to induce atherosclerosis. harg plasma concentrations were determined using mass spectrometry. en face preparation of aortae followed by red oil staining of atherosclerotic plaques and quantitative evaluation of plaque areas was performed for female mice. endothelial function of male mice was tested with acetylcholine (ach) and nitroglycerin (ntg) after contraction with prostaglandin f α. background: the direct oral thrombin inhibitor dabigatran etexilate (dabigatran) is used for the prevention and treatment of venous thromboembolism. obese patients as well as patients with type diabetes mellitus (t dm) have an increased risk for thrombotic disease and show enhanced thrombin generation. besides its role in blood coagulation, thrombin is known to be involved in many pro-inflammatory processes. in obesity, adipose tissue (at) inflammation plays a crucial role in the development of insulin resistance and t dm and contributes to atherosclerosis development. the aim of the present study was to analyse the effects of dabigatran on at inflammation in a mouse model of diet-induced obesity in the context of accelerated atherosclerosis. methods: -week-old female low-density lipoprotein receptor-deficient (lldr -/-) mice were fed a high-fat diet containing mg/g dabigatran or respective placebo for weeks. results: analysis of visceral at revealed a significant increase in adipocyte size in dabigatran-treated mice, although body weight, fat mass, glucose tolerance, and insulin resistance were unchanged between groups. this effects seemed to be directly mediated by thrombin, as treatment with another thrombin inhibitor (argatroban) also resulted in the development of adipocyte hypertrophy. accordingly, in vitro studies in t -l cells revealed an inhibitory effect of thrombin on lipid accumulation in adipocytes. the amount of pro-inflammatory cd c-positive macrophages (atms) in visceral adipose tissue was significantly reduced, and the secretion of pro-inflammatory il- from visceral at was significantly lower in dabigatran-treated animals. in vitro studies using t l cells and primary bone marrow-derived macrophages revealed that the changes in macrophage polarization were not directly mediated by thrombin, but indirectly by a change in the secretion profile of adipocytes. a similar reduction in proinflammatory macrophages as detected in at could also be observed in the aortic wall of dabigatran-treated mice. conclusions: the direct thrombin inhibitor dabigatran inhibits at inflammation and the accumulation of pro-inflammatory macrophages in vat but also the aortic wall of ldlr -/mice. these anti-inflammatory effects of dabigatran might contribute to the known atheroprotective effects of dabigatran. background: sarco/endoplasmic reticulum ca + -atpase (serca a) and its inhibitor phospholamban (pln) are critical determinants of cardiomyocyte calcium cycling and hence, cardiac contractility. pln exists in an equilibrium between mono-and pentamers. while monomeric pln has been implicated in direct serca a inhibition, a functional role for the pentamers remains ambiguous. recently it has been shown that pln pentamers modulate pka-dependent phosphorylation of pln monomers in vitro. using transgenic mouse models we now investigated the effects of pln pentamers on pln phosphorylation, myocyte ca + cycling and contractility in cardiac myocytes. methods: phosphorylation patterns of pln were analyzed by western blot using phospho-specific antibodies as well as phosphate affinity sds-page. to assess the phosphorylation at baseline, pln knockout (pln-ko) mice expressing either wild type pln (tgpln) or the solely monomeric pln afa mutant (tgafa) transgene were deeply anesthetized, whereas pln phosphorylation by pka was induced using the betaadrenergic agonist isoproterenol. the consequences on myocyte ca + kinetics were measured in isolated, fura -loaded and electrically paced ( . hz) cardiomyocytes as the time to % decay of the ca + signal (t % ). the time to % baseline of sarcomere length (t % baseline) characterized the speed of myocyte relaxation. results: under basal conditions, we found stronger phosphorylation of pln pentamers than monomers, pointing at pentamers as the preferred pka target. pln afa monomers showed . -fold stronger phosphorylation signals if pentamers were absent (p< . ). consistent with a higher basal phosphorylation of pln afa monomers, measurements of calcium kinetics revealed a faster decay of calcium signals in tgafa compared with tgpln cardiomyocytes (t % [ms]: ± and ± , respectively, p< . ). notably, t % of pln-ko myocytes was ± ms (p= not significant versus tgafa), indicating that the strong basal phosphorylation of monomers leads to near complete inactivation of pln in tgafa. upon stimulation of pka, pln monomer phosphorylation and calcium kinetics of tgpln and tgafa mouse myocytes were indistinguishable, because monomer phosphorylation and the speed of cytosolic ca + clearance strongly increased only in tgpln. acceleration of sarcomere relaxation upon pka stimulation was also more pronounced in tgpln than in tgafa and pln-ko myocytes (increase of t % baseline [ms]: ± in tgpln versus ± in tgafa-pln and ± in pln-ko, p< . ). even high-dose isoproterenol induced phosphorylation of only about half of all protomers of pln pentamers suggesting a high capacity of pentamers to attenuate monomer phosphorylation by acting as a phosphate scavenger. conclusions: our data demonstrate that pln pentamers reduce basal phosphorylation of pln monomers in myocytes. nevertheless, pentamers allow strong phosphorylation of monomers during beta-adrenergic stimulation, thereby extending the range within which pln can modify diastolic ca + kinetics and myocyte relaxation. therapeutic inhibition of micrornas is a promising field in cardiovascular research. vector-based overexpression of an inhibitor construct (e.g. microrna sponge) is one approach to achieve sustained inhibition with potential applicability in humans. yet the strength of expression achieved by the currently available gene therapy vectors (e.g. aavs) in humans remains a limiting factor, therefore inhibitory constructs with increased potency would provide an improvement of this approach and bring it closer to therapeutic application. micrornas are believed to discriminate between potential binding sites, based on additional factors provided by the endogenous untranslated regions at the ' end of mrnas ( ' utrs) and the proteins that are bound to them. aim of this project was to investigate whether selected endogenous ' utrs can likewise increase the potency of microrna inhibitory constructs. to this end several known targets for a cardiac microrna were selected and their relative potencies of microrna inhibition was compared. to accurately assess changes in the activity of the respective micrornas we constructed dual-fluorescent reporter plasmids and established an automated fluorescent microscopy acquisition and analysis pipeline. among several tested utr constructs we found one which strongly increased the inhibitory potency of the microrna binding site in primary rat cardiac myocytes (nrcms). furthermore a similar effect was obtained when the binding site was exchanged for that of a different microrna and analyzed in the nih- t fibroblast cell line. we therefore conclude that endogenous utr contexts can indeed be successfully applied to increase the potency of vector-based microrna inhibitors. the g-protein-coupled protease-activated receptor- (par ) regulates inflammatory responses including monocyte migration and cytokine release. par is activated by the coagulation factor-xa or by the tissue-factor (tf)/factor viia complex. the immunomodulatory lipid sphingosine- -phosphate (s p) is released from activated platelets and interlinks blood coagulation and inflammation. this study investigates the impact of s p on the expression of par , tf and of the anticoagulant protein thrombomodulin (tm) in human monocytes and after pma-induced differentiation into macrophage-like cells. monocytic thp and u cell lines were used as human monocyte models. primary monocytes were isolated from healthy volunteers using a magnetic bead-based monocyte isolation kit. expression of par , tf and tm was measured by quantitative real-time pcr and western blotting. differentiation of monocytes into macrophage-like cells was induced by incubation with ng/ml pma (phorbol -myristate -acetate) over h. calibrated automated thrombin (cat) generation was determined in plateletrich plasma from healthy volunteers. in thp and u cells s p induced a time-( to h) and concentration-dependent ( . to µm) significant upregulation of par mrna and total protein expression. par total protein was upregulated maximally (about . -fold, n= ) with µm s p after h incubation. comparable effects were seen in human primary monocytes. in comparison, tf mrna and protein were only marginally elevated in non-differentiated thp monocytes and tm was not regulated by s p. after differentiation of cultured monocytic cells with pma into adhesive macrophage-like cells, incubation with s p resulted in a time-( to h) and concentration-dependent ( . to µm) significant upregulation of tf expression within to h of incubation. conversely, par total protein expression was reduced by about % after h s p incubation. the expression of tm was again not affected. the generation of thrombin in platelet-rich plasma was determined using pma-differentiated thp cells as tf source. timedependent incubation with s p ( µm) in differentiated monocytes shortened the time to the onset (lag time) of thrombin generation in plasma from . ± . to . ± . min and elevated total the thrombin generation capacity from ± to ± nm. peak thrombin formation was elevated from ± to ± nm/min (control versus s p for h, mean±sd, n= , respectively). these data suggest that s p induces an enhanced expression of par in undifferentiated human monocytes while tf and tm are not regulated. in differentiated monocytes/macrophages, s p does upregulate tf expression but attenuates par levels. since par is involved in regulation cell migration, s p may stimulate a phenotypic switching from a migratory to a procoagulant phenotype during differentiation of monocytes into macrophages. the pro-inflammatory cytokine interleukin- (il- ) plays an important role in vascular inflammation. coagulation factors such as the activated factor-x (fxa) may regulate local inflammatory responses of the vessel wall. in this study we investigated whether fxa regulates il- expression and secretion in human vascular smooth muscle cells (smc) as well as in failed thrombosed vein grafts. also, we analysed its possible prothrombotic impact on monocytes. il- mrna expression was determined in primary human saphenous vein smc by taqman® real-time pcr. secretion to the cell culture media was measured by elisa. tissue factor (tf) expression in monocytic thp- cells was determined by western blot. immunostainings for il- and the smc marker smoothelin were performed on paraffin embedded tissue sections from failed thrombosed vein grafts and control veins. incubation of cultured human venous smc with fxa ( nm) induced a time-dependent ( - h) increase in il- mrna expression. maximum expression was observed within h to a . ± . fold increase (mean±sd, n= , p< . ). incubation with an inhibitor of p map kinase (sb , µm) or pi k (ly , µm) significantly attenuated fxa-induced il- mrna expression (n= ). inhibition of p / mapk, rho kinase or nf-kb had no significant effect. stimulation with fxa for h resulted in a markedly increased il- secretion into the smc culture media from . ± . to . ± . ng/ml (p< . , n= ). stimulation of thp- cells with il- ( ng/ml) induced a time dependent ( - h) increase of up to . ± . fold (p< . , n= ) in tf protein expression. immunostainings of tissue sample of failed vein grafts revealed enhanced il- expression in smc-rich regions in vessel walls compared to non-thrombosed control veins suggesting an elevated il- regulation in thrombosed vein grafts in vivo. in conclusion, fxa induced il- expression and secretion in venous smc which may be regulated via p and pi k signaling. il- enhanced tf expression in thp- monocytes and was found in smc-rich regions in failed thrombosed vein grafts. fxa-stimulated il- release may be involved in regulating local pro-thrombotic processes during vascular inflammation and possibly vein graft failure. rationale: the transcription factors camp-response element binding protein (creb) and camp-responsive element modulator (crem) bind to camp response elements (cres) and mediate a camp dependent gene regulation. suppression of cre mediated transcription is linked to atrial remodeling in genetic mouse models. inhibition of creb target genes is associated with atrial fibrillation (af) susceptibility in patients. creb and crem affect histone acetylation recruiting the creb-binding protein (cbp/p ). the histone acetyltransferase (hat) activity of cbp facilitates gene transcription by loosening chromatin structure. histone deacetylases (hdacs) catalyze the inverse reaction: histone deacetylation with consecutive gene silencing. mice with heart directed expression of the human cardiac isoform crem-ib∆c-x (tg) show atrial dilatation, morphological and physiological alterations in atria preceding spontaneous-onset af. the hdac inhibitor (hdac i ) valproic acid (vpa) reduced atrial weight and af incidence in tg mice. here we tested the hypothesis, that vpa attenuates the structural remodeling in tg atria by reversing changes in atrial gene regulation due to the transgene. methods and results: tg and wt mice were treated from week - with vpa ( . % in drinking water, ad libitum) or vehicle (veh). atrial ultrastructure was studied by electron microscopy (em) (week and ). veh-treated tg atria showed a progressive dysorganisation of sarcomeres (sm) with less mitochondria and more collagen fibers between cardiomyocytes as compared to veh-treated wt atria. the fraction of sm structure in veh-treated tg atria was significantly reduced as compared to veh-treated wt atria (week : tg veh : ± %, wt veh : ± %; week : tg veh : ± %, wt veh : ± %, p< . ). vpa led to a more organized ultrastructure and restored, at least partially, the degradation of the sm in the tg atria (tg vpa at week : ± %, tg vpa at week : ± %, p< . vs. tg veh ). the structure of wt atria was not affected by vpa. we further analyzed the protein abundance profiles in the groups of all animals (wt veh , wt vpa, tg veh , tg vpa) by using lc-ms/ms. between veh-treated genotypes (tg veh vs. wt veh , p< . ) proteins were significantly changed while proteins were differentially abundant between vpa-treated groups (tg vpa vs. wt vpa, p< . ). proteins were regulated by vpa in wt atria (wt vpa vs. wt veh , p< . ), whereas vpa affected proteins in tg atria (tg vpa vs. tg veh , p< . ), out of which proteins were common. prominent changed proteins between veh-treated tg and wt atria were significantly regulated by vpa in tg atria in the opposite direction. a functional pathway analysis showed that pathways activated in tg atria such as cardiac fibrosis, mitochondrial dysfunction were inhibited by vpa treatment. conclusion: similar to human af, crem-tg mice present atrial dilatation, ultrastructural changes and impaired conduction and spontaneous af. while vpa had little to no effect in wt mice, valproate improved the tg phenotype by interfering with pathways involved in structural remodeling. this supports the idea that hdac inhibition by vpa antagonizes effects of crem expression in atria. in isolated mouse cardiac preparations, histamine is ineffective regarding inotropic or chronotropic effects, presumably because of lack of receptor protein expression. on the other hand, histamine can exert positive inotropic and chronotropic effects in humans via cardiac histamine h -receptors. hence, we have generated transgenic mice (tg) which overexpress the human h -receptor specifically in cardiomyocytes. in isolated left and right atrial preparations of these mice, we investigated the histamine metabolism on a functional level. preparations of wild type mice (wt) served as control. histamine induced positive inotropic effects (pie) and positive chronotropic effects (pce) in left and right atria of tg mice, respectively, but not in wt. interestingly, the inhibitor of histamine oxidation, aminoguanidine ( mm), shifted the concentration response curves for the pie of histamine from ec = nm to nm (p< . ). furthermore, the unspecific inhibitor of mono amine oxidase, tranylcypromine ( µm), shifted the pie of histamine from ec = nm to nm and increased the efficacy of histamine for the pie (p< . ). these data indicate that exogenously applied histamine is subject to degradation in the mouse heart by two different pathways namely via diaminoxidase and mono amine oxidase. drugs that inhibit theses enzymes could conceivably alter cardiac function also in the human heart. protein phosphorylation by kinases and dephosphorylation by protein phosphatases has a crucial function in cell signal cascades. it has been shown that cardiomyocyte specific overexpression of serine /threonine protein phosphatases pp , pp a, pp b (calcineurin) and pp in mice leads to cardiac hypertrophy and alters cardiac function. to examine the function of another important protein phosphatase in the heart we established a mouse model overexpressing protein phosphatase cβ (pp cβ) under control of the α-myosin heavy chain promoter. cardiac overexpression was demonstrated by western blotting. like other serine/threonine phosphatases, pp cβ can lead to cardiac hypertrophy. in transgenic mice (tg), relative ventricular weight was increased ( . ± . mg/g) compared to wild type (wt) littermates ( . ± . mg/g; p< . ) whereas weights of right and left atria were unchanged. therefore, relative heart weight was increased in tg ( . ± . mg/g) vs. wt ( . ± . mg/g; n= - ; - months of age; p< . ). left ventricular function, measured in vivo by echocardiography under isoflurane anesthesia was diminished in tg compared to wt (ejection fraction: . ± . % (tg) versus . ± . % (wt); n= - ; - months; p< . and fractional shortening: . ± . % (tg) versus . ± . % (wt); n= - ; - months; p< . ). the left ventricle was dilated (systolic diameter: . ± . mm (tg) versus . ± . mm (wt); n= - ; - months; p< . ; diastolic diameter: . ± . mm (tg) versus . ± . mm (wt); n= - ; - months; p< . ). in contrast, atrial function measured as response to β-adrenergic stimulation in isolated left and right atrial preparations was unchanged in tg vs. wt. in summary, our results indicate that pp cβ overexpression can lead to ventricular dysfunction and hypertrophy. the underlying signal transduction pathways need to be elucidated. the insulin-like growth factor binding protein (igfbp ) -a potential developmental gene is regulated upon cardiac stress m. wölfer background: cardiac remodeling is a complex biological adaptation process of the failing heart accompanied by a re-activation of embryonic gene expression, which so far has unclear pathophysiological relevance. we and others showed that insulin-like growth factor binding protein (igfbp ) is expressed in the early pre-cardiac region in mouse embryos and its up-regulation impairs cardiac progenitor differentiation. igfbp functions as an extracellular growth factor binding protein for igf and also has igfindependent activities. the role of this factor in the context of cardiac remodeling is still unknown. the aim of this study was to investigate the relevance of igfbp in cardiogenesis and cardiac remodeling and its role as a potential target for ameliorating stress-induced cardiac remodeling methods and results: we investigated the expression of igfbp in murine cardiac tissue at different developmental stages by qpcr normalized to tpt (tumor protein, translationally-controlled ). this analysis showed temporal changes of cardiac igfbp expression from developing to postnatal hearts, where a high expression was detected in early heart stages, which decreased during cardiac development and became low in the postnatal heart. the analysis of igfbp expression in different heart cells showed a very low igfbp in adult cardiomyocytes in contrast to a high expression in undifferentiated sca- positive cells. in a mouse model with cardiac specific wnt/βcatenin activation, which led to cardiac dysfunction, igfbp was found up-regulated (p< . ). further we found an increased igfbp expression after pressure induced cardiac hypertrophy using mice with transverse aortic constriction (tac) (p< . ). in line with this data, an in vitro model of human heart muscle hypertrophy using engineered cardiac heart muscle (ehm) showed an up-regulation of igfbp upon adrenergic activation via norepinephrine stimulation accompanied by a functional deterioration in comparison to untreated controls (p< . ). all these findings were further supported by rna-sequencing analysis from human aortic stenosis patient samples, where igfbp expression was found increased in patients with compensatory hypertrophy and in a higher extent in patients with heart failure in comparison to non-failing heart samples. interestingly, the expression of igfbp in angiotensin or norepinephrine stimulated neonatal murine cardiomyocytes, as well as in hearts of mice treated with angiotensin , showed the opposite results, namely a reduction in its expression (p< . ; p< . , respectively). summary and conclusion: our results show active igfbp transcription in the early developing heart but a low expression in the postnatal heart. a re-activation of expression was found in the process of pathological heart remodeling in mouse and human, in vivo as well as in vitro, indicate the participation of igfbp in a conserved manner. we hypothesize that igfbp may participate in the developmental gene program becoming activated in the diseased adult heart again. the functional role and regulation of igfbp is under investigation. we have recently shown that perivascular adipose tissue (pvat) plays a crucial role in obesity-induced vascular dysfunction. in pvat-free aortas isolated from male c bl/ j mice fed a high-fat diet (hfd) for weeks, the endothelium-dependent nitric oxide (no)-mediated vasodilator response to acetylcholine remained normal. in contrast, a clear reduction in the vasodilator response to acetylcholine was observed in aortas from obese mice when pvat was left in place. these results suggest that the reason for vascular dysfunction in diet-induced obese mice is a pvat dysfunction rather than an endothelial dysfunction. treatment of hfd mice during the last weeks with crataegus extract ws® ( mg/kg/day) completely normalized vascular function in pvatcontaining aorta. the expression of endothelial no synthase (enos) was not changed by ws® , neither in pvat nor in aorta. phosphorylation at serine is the most important positive modulation of enos activity. hfd-induced obesity was associated with a reduction in enos phosphorylation at serine in pvat, but not in aorta. ws® treatment significantly improved enos serine phosphorylation selectively in pvat but had no effect in aorta. a major upstream kinase for enos serine phosphorylation is akt. the activity of this kinase is inhibited in the pvat of hfd mice, which was largely reversed by ws® treatment. in addition, ws® treatment enhanced the mrna expression of the nad-dependent deacetylase sirtuin- (sirt ), known also as a longevity gene. the activity of sirt depends, among others, on the intracellular content of its cofactor nad. ws® treatment led to an upregulation of nicotinamide phosphoribosyltransferase (nampt), a rate-limiting enzyme in the salvage pathway of nad biosynthesis. one of the non-histone substrates of sirt is enos. deacetylation of enos at lysine residues and by sirt enhances the activity of the enos enzyme. currently, we are studying the effect of ws® on nad synthesis, sirt activity, and enos (de)acetylation. in conclusion, crataegus extract ws® reverses obesity-induced vascular dysfunction by improving pvat function. the molecular mechanisms may involve enos phosphorylation at serine and upregulation of sirt . the raf kinase inhibitor protein (rkip) inhibits g-protein-coupled receptor kinase (grk ) and the raf-erk / pathway. these two functions of rkip could counteract each other. while grk inhibition is cardio-protective, inhibition of the pro-survival erk / axis promotes signs of heart failure in patients and experimental models. in view of this ambivalent nature, the function of rkip in vivo is not clear. furthermore, rkip could have a pathophysiological role because heart specimens from patients with heart failure showed rkip up-regulation (ref. ). to investigate the impact of cardiac rkip upregulation in vivo, we generated transgenic mice with myocardium-specific expression of the human rkip gene (pebp ) under control of the alpha-mhc promoter. two different rkip-transgenic lines with . -fold and . -fold increased cardiac rkip protein level were generated (ref. , and jax id number ). we investigated the cardiac phenotype and found that tg-rkip mice developed cardiac hypertrophy with a significantly increased heart weight to body weight ratio and a decreased left ventricular ejection fraction relative to non-transgenic fvb controls, as early as weeks of age. histology analysis revealed progressive atrial and ventricular enlargement of tg-rkip hearts. ecg abnormalities, a lower maximum rate of left ventricular pressure rise, and a strongly decreased left ventricular ejection fraction of . ± . % (n= ; ±s.d.) were documented at an age of months. down-regulation of the transgenic rkip by lentiviral transduction of an rkip-targeting mirna retarded the cardiac phenotype of tg-rkip mice. thus, dual-specific inhibition of the grk and raf-erk / axis by the human rkip gene (pebp ) triggers signs of heart failure in vivo, and the documented upregulation of the cardiac rkip in heart failure patients could aggravate disease pathogenesis. these findings are in contrast to rodent rkip (pebp ), which does not seem to inhibit the raf-erk / axis in vivo but instead confers grk inhibition- heterodimerization between the at receptor (at r) for the vasopressor peptide, angiotensin ii, and the b receptor (b r) for the vasodepressor peptide, bradykinin, enhances angiotensin ii-stimulated signalling in cells. in addition, at r--b r heterodimerization has a major pathophysiological role and contributes to the angiotensin ii hypersensitivity in women with preeclampsia hypertension. to analyse the vascular function of the at r--b r heterodimer in vivo, we generated a transgenic model of at r--b r heterodimerization (tg-b r+) by transgenic expression of the b r gene (bdkrb ) in the b r-deficient tg-b r-/-strain. fluorescence resonance energy transfer (fret) imaging was applied to analyse the interaction between different gprotein-coupled receptors in the aorta of transgenic mice. we report here that fret imaging detected the close interaction between the aortic at r and b r at a distance of less than nm in tg-b r+ mice whereas the at r--b r heterodimer was absent in tg-b r-/-mice. in contrast, fret was not detectable between the endothelin eta receptor (etar) and the b r in the aorta of tg-b r+ mice, although immunofluorescence and immunohistology confirmed the aortic (co-)-localization of both, etar and b r. the efficient at r--b r heterodimerization in tg-b r+ mice was accompanied by an enhanced angiotensin ii at r-stimulated vasopressor response relative to that of tg-b -/-mice, which lack the at r--b r heterodimer. as a control, the endothelin- -stimulated vasopressor response mediated by the etar, which did not dimerize with b r, was not significantly different between tg-b r+ and tg-b r-/-mice. together these findings provide strong evidence that at r--b r heterodimerization occurs in vivo and enhances the angiotensin ii at r-stimulated vasopressor response. dysfunction of the cardiac energy substrate metabolism is a characteristic feature of late-stage heart failure. the dysfunctional cardiac substrate metabolism contributes to insufficient energy generation and has limited treatment options. in search for a treatment approach, we investigated whether inhibition of g-protein-coupled receptor kinase (grk ) could confer cardioprotection by targeting the dysfunctional cardiac substrate use. the impaired substrate metabolism of late-stage heart failure was reproduced in a transgenic model with myocardium-specific expression of fatty acid synthase (fasn), which is the major palmitate-synthesizing enzyme. experiments with a seahorse xf extracellular flux analyzer revealed that in an adult-like lipogenic milieu, fasn-transgenic cardiomyocytes reproduced the overall depressed substrate use of late-stage heart failure with a switch from fatty acid to predominant glucose utilization. the impaired substrate use was largely retarded by co-expression of a small peptide inhibitor of grk , grkinh. the grkinh-mediated protection against cardiometabolic remodelling required an intact raf-erk / axis and involved the erk / -dependent inactivation of the heart failure-promoting peroxisome proliferatoractivated receptor gamma (pparg) by phosphorylation of serine- . as a consequence of erk-dependent phosphorylation of pparg on serine- , the expression of heart failure-related pparg targets such as fatty acid synthase, resistin and adiponectin was decreased. the importance of pparg serine- phosphorylation was further shown in transgenic mice with myocardium-specific expression of the phosphorylation-deficient pparg serine- a mutant, which was resistant to the cardioprotective activity of grkinh. taken together our experiments show that grk inhibition could target cardiometabolic remodelling by inhibition of the heart failure-promoting transcription factor pparg. the effect of sodium valproate on the action potential of atrial myocytes of crem ib∆c-x transgenic mice introduction: in mouse, cardiomyocyte directed over-expression of transcription factor crem (camp response element modulator) causes an atrial phenotype characterized by hypertrophy, reduced contractility and increased duration of the monophasic action potential (map). moreover, this animal model (crem ib∆c-x) showed spontaneous atrial fibrillation (af) episodes as early as weeks of age in homozygous mice and - weeks of age in heterozygous mice (phenotype delayed towards adult stage). previous studies in heterozygous mice targeted hdac inhibition by sodium valproate (vpa, an anticonvulsant drug, acting also as inhibitor of hdac class i>ii). vpa treatment delayed significantly the development of atrial hypertrophy and the incidence of af episodes, without affecting cellular hypertrophy. our aim was to investigate the effect of chronic vpa treatment on the electrical activity of atrial myocytes isolated from crem ib∆c-x and wild type (wt) littermate mice. methods and results: atrial myocytes were isolated from weeks old wild type mice (wt) and heterozygous crem ib∆c-x transgenic mice with enlarged atria (tg), treated for weeks with vpa ( . mm in the drinking water) vs. water (vehicle control). action potentials (ap) were measured at room temperature using the patch-clamp technique. atrial myocytes of water treated tg mice had the ap amplitude significantly reduced by mv compared to water treated wt, and, in line with previous results for the map, the tg cells depolarized with a slower slope of . ± v/s (tg: n= cells) vs. . ± . v/s (wt: n= , p= . ). moreover, ap of atrial myocytes isolated from water treated tg mice had longer duration (apd) at % (tg: . ± . ms, n= vs. wt: . ± . ms, n= , p< . ), at % (in ms: . ± . vs. . ± , p< . ) and at % (in ms: . ± . vs. ± . , p< . ) repolarization. vpa treatment reduced ap amplitude in wt mice by mv (n= , p< . ) vs. water treated wt, without altering the slope of depolarization or the apd. in vpa treated tg mice the apd was reduced ( %: . ± . ms, %: . ± . ms, %: . ± . ms, n= , p< . vs. untreated tg), the amplitude was increased by mv (n.s.) and the slope of depolarization was increased by % (p= . , n.s.). membrane capacitance evaluation, as an estimation of atrial myocyte size, showed that in untreated tg mice the cells were larger than in wt (tg: ± . pf, n= vs. wt: ± . pf, n= , p< . ), in line with the occurrence of cellular hypertrophy in tg atria. chronic vpa treatment did not change the cell size in either genotype (wt-vpa: . ± pf, n= n.s. vs. wt; tg-vpa: ± pf, n= , p< . vs. wt-vpa; p< . vs. wt; n.s. vs. tg). conclusions: in hypertrophied atrial myocytes of crem-ib∆c-x, ap were characterized by smaller amplitude, slower onset of depolarization and increased duration compared to wt cells. despite having no effect on atrial myocytes size, vpa treatment reduced the duration and showed a tendency to increase the amplitude and the slope of depolarization of the action potential in tg mice to values similar to wt. these data suggest that chronic treatment with vpa restored partially the electrical activity of atrial myocytes and may reverse the electrical remodeling via hdac inhibition. (supported by the dfg) of the transcription factor crem (camp response modulator) icer, smicer and crem-ib∆c-x are inducible by β-adrenergic stimulation and code for similar or even identical proteins. thus, these isoforms are able to repress expression of respective target genes in response to camp and might play a role in an arrhythmogenic remodeling during the development of chronic heart diseases. here we test this hypothesis in a mouse model with transgenic expression of crem-ib∆c-x (tg). these mice develop not only spontaneous onset atrial fibrillation but likewise arrhythmogenic alterations in the ventricle. patch clamp experiments revealed an increased na + -ca + exchanger current (i ncx ) and decreased transient outward current (i to ) in tg ventricular cardiomyocytes (vcms) vs. wild-type controls (ctl). these alterations were associated with an increased arrhythmogenicity in tg vcms. action potentials were prolonged in tg vcms vs. ctls leading to an increased proportion of vcms displaying early afterdepolarizations. ca + imaging revealed that the transduction rate of spontaneous sub-threshold ca + -waves into supra-threshold transient-like ca + -events which is mediated by the ncx was increased in tg vcms. at the same time the serca mediated ca + transport rate (r serca ) was enhanced in tg vcms potentially limiting ca + extrusion by the ncx. underlining the in-vivo relevance of our findings ventricular extrasystoles (ves) were augmented in ecgs of tg mice (ves/mouse during - m isoproterenol challenge, tg: . *, ctl: . ; n= /condition). the increase in i ncx and r serca and the decrease in i to went along with an increase of ncx , serca a and decrease of kchip protein levels. however, the respective mrna levels (slc a , atp a and kcnip ) were unaltered between groups pointing to a post-transcriptional regulation of these genes. in a mrnasequencing approach we identified the downregulation of precursor mirnas inter alia for mir- (fold change in tg: . *) and mir- (fold change in tg: . *) (n= /condition). atp a is a predicted target of mir- and mir- has recently been shown to regulate ncx and i to related potassium channel subunits. (*p< . vs. ctl) our results demonstrate that transgenic expression of crem-ib∆c-x in mouse vcms leads to distinct arrhythmogenic alterations. they further indicate that the repression of micro rnas by short crem repressor isoforms may lead to the upregulation of genes in the context of an arrhythmogenic remodeling. since crem-repressors are inducible by chronic β-adrenergic stimulation our results suggest that the inhibition of credependent transcription contributes to the formation of an arrhythmogenic substrate in chronic heart disease. ( chronic overstimulation of cardiac β-adrenergic receptors (β-ar) is a major trigger for the development and maintenance of cardiac hypertrophy and heart failure. although the camp activated proteinkinase a (pka) is known as a prominent downstream effector of β-ar signaling, its functional contribution to pathological cardiac remodeling is neither well understood nor directly studied so far. to address this issue we used mice carrying a point mutation in the regulatory pka subunit riα (pkariαb), which prevents binding of camp and consequently diminished kinase activity. this dominant negative mutation was controlled by a tamoxifen (tam) inducible αmhc promotor driven cre transgene which allows a selective expression in the ventricular myocardium. the inducible and tissue specific gene expression was analyzed and confirmed by pcr, rt-pcr and immunohistochemistry. furthermore diminished phosphorylation of several pka targets verifies impaired pka activity in tam treated double transgenic animals. hypertrophic response in ventricular pka mutants was studied in genetic, pharmacological and surgical mouse models of heart disease as well. genetically induced heart failure was observed following tam treatment in mice expressing an inducible myocardial-specific cre transgene. this deleterious cardiac phenotype develops independently of the presence of the floxed transgene. days after tam treatment, controls displayed elevated heart weight to bodyweight ratio (hbr) and heart weight to tibia length (htr). hbr shifted from . (mg/g) in untreated control animals to . (mg/g) in tam injected mice. in contrast pka inhibited mutants displayed a minor increased hbr of . (mg/g). for the pharmacological induction of cardiac hypertrophy we implanted osmotic mini pumps, delivering a combination of isoproterenol and phenylephrine. control animals showed a significantly increased hbr ( . mg/g) compared to saline treated animals ( . mg/g) and pka mutants ( . mg/g). paradoxically, all pka inhibited animals displayed a consistent elevation in important hypertrophic markers like anp. surgical constriction of the aortic arch (transverse aortic constriction tac) led to a pressure induced hypertrophic response (hbr: . vs . mg/g) followed by a pronounced elevation in several hypertrophic factors such as anp, myh / ratio and myocytes size. in contrast pka mutants displayed an irregular progression of cardiac hypertrophy presented by two groups with either an unchanged ( . mg/g) or a strongly elevated hbr ( . mg/g). however, additional hypertrophic factors including anp, myh / ratio and myocyte size were significantly increased in both groups. to our knowledge this is the first report, which directly studies the role of ventricular pka activity in cardiac hypertrophy in a genetically altered mouse model. our results suggest that in an early stage of cardiac remodeling pka inhibition alleviates cardiac weight gain but provokes a detrimental shift during further progression, which implicates a protective role of ventricular pka activity in cardiac disease. acetyl-coa carboxylase catalyzes the first step in the biosynthesis of fatty acids in bacterial and eukaryotic cells, i.e. the conversion (carboxylation) of acetyl-coa into malonyl-coa. acc-generated malonyl-coa functions as a substrate for de novo lipogenesis and acts as an inhibitor of mitochondrial β-oxidation of fatty acids. because of its role in lipid metabolism this enzyme has become an interesting target in drug discovery in the field of metabolic diseases and cancer. despite this interest in acc, no attention has as yet been given to the role of acc in endothelial cells. we aimed to investigate the role of acc in two functional key aspects of angiogenesis: endothelial cell proliferation and migration. we used the acc inhibitor soraphen a, a polyketidic natural compound isolated from the myxobacterium sorangium cellulosum, as well as an rnai-based approach to inhibit the function of acc. primary human umbilical vein endothelial cells (huvecs) were used as in vitro model. first, we analyzed the action of soraphen a on cell viability. the compound did neither lower the metabolic activity of huvecs up to a concentration of µm after and h (ctb assay) nor increase in the apoptosis rate after , , or h up to µm. measuring adenosine triphosphate (atp) levels revealed that µm soraphen a does not alter the atp levels in huvecs after h treatment. in contrast, a h treatment significantly lowered the atp levels by %. also gene silencing of acc in huvecs attenuated the atp levels by %. mitochondrial membrane potential (mmp) assays showed decreased mmp levels ( %) in soraphen a-treated cells after h. interestingly, the compound inhibited the proliferation of endothelial cells with an ic value of µm. cell cycle analysis showed that soraphen a decreases the amount of cells in the g /g phase by % and increases the number of cells in the g /m phase by %. the compound also inhibited the activation of akt (western blot analysis). in a wound healing/scratch assay, µm soraphen a lowered the migration of endothelial cells by %. gene silencing of acc in huvecs strongly decreased endothelial migration, whereas a knockdown of acc had no influence. furthermore, boyden chamber assays revealed that soraphen a can also lower chemotactic migration by %. since actin rearrangement is necessary for migratory processes, we analyzed the factin cytoskeleton (microscopy) and found that soraphen a decreases the number of filopodia by % but did not influence stress fiber formation. surprisingly, soraphen atreated cells did not exhibit significant alterations in their capacity to form tube-like structures on matrigel. in summary, we could gather first hints that inhibiting acc has an immense impact on the proliferation and migration of primary endothelial cells. the mechanistic basis of this phenomenon will be investigated in future studies by analyzing the lipid profile and the transcriptome of endothelial cells. acknowledgement: this work was supported by the german research foundation (dfg, for , fu / - ) . introduction: statins are among the best examined drugs with excellent efficacy and safety profiles. lowered low-density lipoprotein (ldl) cholesterol goals, new indications for treatment and new knowledge about their pleiotropic effect have promoted a considerable increase in statin use. but as statin use becomes more widespread, awareness of their adverse effects as well as the recognition of statin intolerance problems increase. statin intolerance is a significant problem in the treatment of dyslipidemia, understood as the inability to tolerate a dose of statin required to reduce individual cardiovascular risk sufficiently and could result from different statin-related side effects. muscle-related adverse events, elevation of liver enzymes, cognitive problems and new onset diabetes mellitus have all been described, especially at higher doses. although muscle symptoms are the common side effects observed, excluding other adverse events might underestimate the number of patients with true statin intolerance. these patients represent a target population for the newest lipid lowering drug category i.e. the proprotein convertase subtilisin/kexin type (pcsk ) inhibitors. this work aimed to give an overview of published definitions derived from clinical studies, associations as well as major drug regulatory agencies. we discussed overlaps, differences and limitations in the current definitions. methods: literature based search included pubmed and uptodate publications in english and german language until october . we performed hand searches of the references retrieved and performed an overview. results: a definition of statin intolerance of the european medicines agency (ema) or the us food and drug administration (fda) is not available. in clinical studies, different definitions are chosen and the results are not comparable. also different associations, such as the american heart association (aha), the european atherosclerosis society (eas), the canadian working group or the national lipid association (nla) are not able to agree on one common definition. statin intolerance definitions included different types of muscle symptoms, integration of ck levels and minimal requirements of statin doses. there are currently no validated questionnaires or specific laboratory parameters available. in addition, the term 'myopathy' is often considered as a synonym to statin intolerance. overall, only a few major studies have been conducted with statin intolerant patients so far using inconsistent definitions. discussion and conclusion: there is an unmet need to find a robust and clear definition of statin intolerance as overemphasizing it might hinder appropriate clinical use of this important drug class. thus, further work is required to develop a consensus definition on statin intolerance or a more focused definition regarding statin-associated muscle symptoms only. subsequently, these definitions could be implemented in patient care and their relevance being analyzed and tested in future studies. background: development of cardiac hypertrophy is characterized by reactivation of genes involved in cardiac development. wnt/β-catenin signaling is essential for embryonic cardiac development and is known to be dysregulated in pathological heart remodeling. our previous work suggested a cardiac specific protein complex regulating wnt/b-catenin/tcf transcription in the adult heart. we aim to identify and to characterize this complex in order to find potentially interesting targets for pharmacological therapy preventing maladaptive cardiac remodeling and the onset of heart failure. results: we previously demonstrated that the krüppel-like-factor (klf ) is a βcatenin interaction partner and a cardiac specific nuclear inhibitor of the wnt/β-catenindependent transcription. because klf and β-catenin are ubiquitously expressed, we suggest the existence of cardiac specific co-factors responsible for cardiac specificity in this complex. we identified the basic leucine zipper and w domain containing protein (bzw ), a phylogenetically conserved protein, as a β-catenin and klf interaction partner using yeast-two-hybrid screen. in vitro overexpression experiments and coimmunoprecipitation validated these interactions, which were also confirmed by mass spectrometry. in the developing mouse embryo bzw mrna expression is detectable in the heart, neuronal tissue, somites, limbs and branchial arches as shown by whole mount in situ hybridization. in the adulthood expression of bzw is confined to the heart, predominantly in cardiomyocytes and in cardiac progenitor cells compared to cardiac fibroblasts (*p< . , cm n= , cfb n= , cpc n= ), and skeletal muscle. bzw was localized in both the cytosol and in the nucleus. mutation analysis showed the importance of the n-terminus of bzw , containing a putative bzip dna interaction domain, for the nuclear placement of the protein. bzw protein expression was significantly increased under cardiac wnt/β-catenin signaling activation in vivo in two mouse models (klf knockout (ko) mice **p< . n= , and in a cardiac specific β-catenin stabilized mouse model, **p< . n= ). a mouse model with constitutively bzw loss of function (bzw ko) showed cardiac specific upregulation of β-catenin on rna level (***p< . , p< . , ctrl n= , bzw ko n= ) and on protein level (**p< . , ctrl n= , bzw ko n= ). echocardiography analysis in eight-weeks-old bzw ko mice showed increased left ventricle wall thickness indicating a hypertrophic phenotype at baseline. we also observed increased levels of bzw expression in angiotensin ii treated mice as a model for cardiac hypertrophy (*p< . ctrl n= , angii n= ) as well as in human samples derived from patients with dilated cardiomyopathy and ischemic cardiomyopathy (*p< . ctrl n= , dcm n= , icm n= ). conclusion: these data demonstrated that bzw is associated with components of the canonical wnt cascade and suggest its relevance in the constitutive regulation of the wnt/β-catenin components specific in the heart. this study further contribute to the elucidation of the tuning of the wnt-off/-on states aiming to establish a proof-of-concept model for wnt-modulation as a therapeutic strategy in hypertrophic-induced heart failure. objective: sphingosine- -phosphate (s p) is involved in the regulation of cell growth, survival, migration and adhesion. it is formed by sphingosine kinases and degraded by phosphatases and s p lyase [ ] . mice that lack s p lyase are characterized by the accumulation of s p and sphingosine in their cells and tissues, and by lymphopenia, generalized inflammation, multiple organ damage, and a strongly reduced life span [ ] [ ] [ ] . on the other hand, embryonic fibroblasts from s p lyase-deficient mice (sgpl -/--mefs) are resistant to chemotherapy-induced apoptosis [ ] , in part due to an upregulation of multidrug transporters of the atp-binding cassette (abc) transporter family [ ] . interestingly, s p lyase-deficient mice have elevated plasma levels of cholesterol and triglycerides, while suffering from strongly reduced body fat [ ] . the aim of the present study was to analyze the link between s p lyase deficiency and altered cholesterol homeostasis using sgpl background: cardiac gene expression changes during cardiac development and under pathophysiological conditions. these alterations in gene expression are regulated by several processes and the exact regulation of gene expression is essential for the proper development and function of the heart. crucial steps in transcription regulation are rna polymerase ii (pol ii) recruitment and changes in pol ii activity. pol ii activity is tightly linked with phosphorylation at serine- (p-ser ) of the carboxyterminal domain of pol ii. thus, the aim of the present study was to identify cardiomyocyte-specific genomewide pol ii and p-ser -pol ii enrichments to get insight into pol ii activity and recruitment in development and disease. methods and results: to get insight into rna polymerase ii dynamics, genome-wide maps of rna polymerase ii occupancy were generated by chromatinimmunoprecipitation in cardiomyocyte nuclei purified from normal neonatal and adult mouse hearts. in addition, cardiomyocyte nuclei were obtained from adult hearts after weeks of pressure overload induced by transverse aortic constriction (tac). cardiomyocyte nuclei were isolated by magnetic beads with an anti-pcm antibody. nuclei were used for pol ii chromatin-immunoprecipitation followed by deep sequencing (chip-seq). to test if pol ii marks correlate with nuclear mrna expression in cardiomyocyte nuclei all coding genes were ranked according to their expression level. genes expressed in cardiomyocyte nuclei (> . fpkm, gene expression rank < , ) showed high pol ii enrichment at promoters as well as in genomic regions. many of the gene promoters showed high levels of pol ii accumulation at the transcription start site, as compared to genic regions, which have been associated with pol ii pausing. in contrast, p-ser -pol ii showed enrichment downstream of the transcription start site. the genomic region of troponin i type (tnni ) which is expressed in cardiac muscle only during development but not in adult cardiomyocytes, was enriched for pol ii in neonatal cardiomyocytes. at the tnni gene, pol ii was absent in adult or pressure-overloaded cardiomyocytes. in contrast, pol ii enrichment at the alpha actin (acta ) locus was only present in pressure-overloaded cardiomyocytes. these data are consistent with cellular rna-seq data showing an induction of acta after tac. furthermore no pol ii enrichment could be detected in the genomic region of biglycan (bgn), a matrix proteoglycan that is not expressed in cardiomyocytes. this confirms a high purity of cardiomyocyte chromatin. conclusions: this study provides, for the first time, cardiomyocyte-specific landscapes of rna polymerase ii occupancy in heart development and disease. cardiac myocyte maintenance dna methyltransferase is essential for embryonic heart development but is dispensable for cardiac function and remodeling postnatally t. nührenberg background: recent studies have identified dynamic changes in dna methylation in cardiac myocytes during development, postnatal maturation and in disease. however, the enzymes involved in shaping the cardiac myocyte dna methylome are only partially known. here, we explored the role of maintenance dna methyltransferase dnmt in cardiac development and in remodeling after chronic left ventricular pressure overload. methods: in mice, deletion of the dnmt gene was accomplished by use of two different cre recombinases. crosses of homozygous dnmt fl/fl mice with heterozygous dnmt fl/+ mice expressing a cre recombinase under control of the atrial myosin light chain gene promoter (myl -cre) resulted in embryonic deletion of dnmt (ko). embryos without myl -cre served as controls (ctl). embryos were dissected and genotyped at e . , e . , e . and e . . rna-seq and pyrosequencing of genomic dna was performed on e . hearts, histology on e . hearts and electron microscopic imaging on e . hearts. for deletion of dnmt in adult mice, homozygous dnmt fl/fl mice expressing an inducible cre recombinase (myh -mcm) were given tamoxifen i.p. over days. homozygous dnmt fl/fl mice not carrying myh -mcm as well as myh -mcm carrying mice without dnmt fl alleles were also injected with tamoxifen and served as controls. cardiac phenotyping including histology, echocardiography and qpcr was carried out without (sham) or with left ventricular pressure overload induced by transverse aortic constriction (tac). results: myl -cre mediated loss of dnmt resulted in progressive embryonic lethality with absence of living ko embryos after e . . ko embryos displayed loss of cardiomyocyte gene expression patterns, decreased promotor cpg methylation of aberrantly expressed genes and ultrastructural features of wide-spread cardiac myocyte cell death. in contrast, tamoxifen-induced ablation of dnmt in adult mice did not affect survival of ko mice. cardiac phenotyping of adult mice revealed no significant differences between ko and ctl mice under sham and tac conditions. conclusion: dna methyltransferase dnmt in embryonic cardiac myocytes is essential for proper heart development. in adult cardiomyocytes, dnmt is dispensable for normal cardiac function and for adaptation to chronic cardiac pressure overload. background: recent studies showed that mice with general deletion of the oxidoreductase tet involved in dna demethylation are embryonic lethal, the underlying cause remaining unknown. this prompted us to investigate wether embryonic lethality is caused by cardiomyocyte-specific loss of tet . methods: female mice homozygous for tet flox and male mice heterozygous for tet flox and heterozygous for myl -cre were mated and offspring were genotyped after weaning. mice homozygous for tet flox and heterozygous for myl -cre (ko) or homozygous for tet flox without myl -cre (controls) were sacrificed at weeks of age and ventricles were harvested. mrna of the ventricles was isolated and expression of cardiomyocyte-specific genes was evaluated by quantitative real-time pcr. cardiomyocyte-specific genomic dna from ko and control mice was obtained from facs-sorted cardiomyocyte nuclei and bisulfite-converted for analysis of dna methylation by pyrosequencing. results: ko mice showed embryonic lethality of nearly %. born ko mice developed without phenotypic abnormalities (normal heart weight/tibia length ratio) and displayed compensatory upregulation of tet and tet . cardiomyocyte genomic dna of ko mice showed significantly higher methylation levels in the body of the atp a gene and at the binding site of the transcription factor gata but not near the promotor and the binding site of the transcription factor tbx . higher methylation levels were not accompanied by changes in atp a expression. however, both myh and nppb were upregulated in ko mice compared to control mice. conclusions: our findings suggest that tet is involved in dna demethylation in cardiomyocytes. loss of tet expression resulted in embryonic lethality. compensatory upregulation of tet and tet isoenzymes may contribute to the incomplete penetrance of this phenotype. further studies are ongoing to investigate the functional relevance of tet in cardiomyocytes. to identify novel proteins secreted by the myocardium, we have previously conducted a genetic screen, which led to the identification of protease inhibitor (pi ). a recent gwas analysis showed an association of a genetic variant in the pi genomic locus (rs ) with chemerin plasma levels. here we tested the hypothesis that pi determines chemerin plasma levels through regulation of chemerin processing. we generated mice deficient for pi , which did not display an overt phenotype under basal conditions. plasma levels of chemerin were found significantly lower in pi -deficient animals compared to littermate controls. to investigate whether pi and chemerin interact, we performed co-immunoprecipitation experiments. indeed, we found pi to co-precipitate with chemerin from both murine plasma and cell culture supernatants. as chemerin is proteolytically processed and activated, we next asked whether the presence of pi would affect the processing of pro-chemerin to its processed forms in native tissue. western blot analysis on cardiac and adipose tissue lysates that detected both the unprocessed precursor and the processed forms of chemerin showed a significant shift towards the processed forms upon genetic deletion of pi . when we assayed for the activity of the chemerincleaving protease cathepsin k, we found recombinant pi to potently inhibit cathepsin k activity. taken together, we propose pi to act as a regulator of chemerin processing. the transient receptor potential canonical (trpc ) is a second messenger-gated cation channel, which mediates depolarization and ca + entry. it is known to be activated by diacylglycerol derivatives (dag, -oleoyl- -acetyl-sn-glycerol oag) [ ] in a pkc-independent manner and plays important roles in lung and kidney physiology. gain-of-function mutations in the trpc gene can cause focal segmental glomerulosclerosis (fsgs), a kidney dysfunction leading to end stage renal disease. [ ] thus, the discovery of potent inhibitors of trpc may help to develop new therapeutic strategies. urban et al. discovered that larixol, a natural product with a labdane skeleton found in the oleoresin of the european larch (larix decidua), blocks the oag-dependent activation of trpc . [ ] larixyl acetate, another component of the resin showed an even higher potency in trpc inhibition (ic = . µm) and a -fold selectivity compared to trpc . these findings led to the idea that further modifications of the larixol lead structure may reveal even more potent inhibitors. furthermore, changes in selectivity and efficacy of such compounds may also provide a deeper insight about relevant structural elements for channel binding. as larixyl carbamate was assumed to exhibit a higher metabolic stability as larixyl acetate, this compound was already investigated in previous studies. it showed a potent and subtype-selective inhibition of trpc . hence, the development of further carbamates was a priority objective. as an alternative to the use of different isocyanates for the introduction of a carbamate function at the c position of the molecule we found an elegant way via formation of an active ester with carbonyldiimidazole. this precursor allowed the design of several isosteric compounds like larixyl methylcarbamate, larixyl hydrazide and larixyl methylcarbonate, which were all able to block trpc with similarly low ic values. the introduction of more bulky side chains appeared to diminish the bioactivity of the compounds, the stereochemistry at the c position, however, seems to play no important role for the inhibition of trpc currents. larixyl methylcarbamate lead to trpc inhibition with an ic value of . ± . µm. compared to larixyl carbamate and larixyl methylcarbonate, which are also very potent blockers of trpc , this compound bears the benefit of high subtype selectivity towards trpc . even with concentrations up to µm of larixyl methylcarbamate, no complete inhibition of the ca + influx via trpc channels could be achieved. this fact distinguishes this larixol derivative as a very promising compound for further studies of trpc in health and disease. poisoning by organophosphorus compounds (opc) including pesticides and highly toxic nerve agents is based on irreversible inhibition of acetylcholinesterase (ache) resulting in an excess of acetylcholine causing accumulation. the subsequent overstimulation at nicotinic and muscarinic receptors finally leads to respiratory arrest due to paralysis of the respiratory muscles. therapy focuses on competitive antagonism at muscarinic acetylcholine receptors and reactivation of inhibited ache by bisquarternary pyridinium oximes. thereby, nicotinic malfunction is not directly approached. for that reason, an alternative strategy appears rational using nicotinic acetylcholine receptor (nachr) active substances to counteract the effects of accumulated acetylcholine and thus to restore the loss of function of nachrs. different bispyridinium-non-oxime-compounds (bps) have been demonstrated to be able to serve as target structures for the identification of new positive allosteric modulators of nicotinic receptors. unlike nicotinic agonists, positive allosteric modulators can reinforce the endogenous cholinergic neurotransmission despite of acetylcholine accumulation in the synaptic cleft. to this end, the following electrophysiological in vitro study investigated the effect of twelve diversely substituted bps on human α nachr using whole-cell patch clamping under voltage-clamping conditions (- mv) performed with planar electrodes in an automatic system (nanion technologies gmbh, munich). cholinergic currents of hα nachr that have been expressed in stably transfected cho cells were activated by the agonist nicotine. measurements of the effect of various bps concentrations in the presence of nicotine were performed to establish concentration-response relations. cholinergic inward currents were generated by human α nachrs in response to low nicotine concentrations. at high concentrations of the drug the currents were decayed reflecting both, desensitization of the receptors and presumably block of the open channel by high agonist concentrations. four out of twelve bps co-applicated with nicotine showed a concentration-dependent enhancement of peak agonist-evoked currents and, most pronounced, -tert-butyl-substitued-bp, also demonstrated a marked elongation of the evoked response. this suggests a positive allosteric effect of these compounds on the nicotinic receptor. however, at high bp concentrations in the presence of agonist, responses were decayed significantly, presumably resulting from an open channel block induced by bps. hence, further compounds have to be synthesized to identify promising candidate compounds for improvement of effective therapy against nerve agent poisoning. the transient receptor potential channels (trp) are a family of tetrameric nonselective cation channels, which are involved in a variety of physiological and pathological processes ( ). among the mammalian trp channels, the canonical channel (trpc ) is a ca + -permeable ion channel, which is predominantly expressed in the brain ( ) . many aspects of trpc function are still elusive although behavioral experiments with trpc -knock-out mice suggest a role in innate fear-response ( ) and some studies indicate a trpc -mediated down regulation of neurite outgrowth in nerve cells ( , ) . to elucidate trpc function on a cellular level, selective and potent compounds are required to acutely control channel activity. despite extensive research, trpc modulators often lack selectivity or exhibit toxicity, limiting their applicability in vivo ( , ) . thus, there is still a need for identifying novel and efficient trpc modulators. we therefore screened a compound library (chembionet) and identified a benzothiadiazine derivative (btd) as a novel, potent, and selective trpc activator. hek cells heterologously expressing trpc upon tetracycline induction (hek trpc ) show a btd-induced concentration-dependent activation in both ca + assays (ec = . µm) and in electrophysiological whole cell patch clamp recordings (ec = . µm). btd elicits currents with an n-shaped i/v curve, typical for trpc . the resulting activation is long lasting, reversible and sensitive to clemizole, a recently established trpc inhibitor ( ) . mtt assays revealed that incubating hek trpc cells for h with btd concentrations above µm results in a concentration-dependent decrease in viability and cell proliferation, indicating a ca + -mediated cytotoxic effect in consequence of sustained channel activity. non-induced control cells remain unaffected by btd at concentrations up to µm. ca + assays showed no influence of btd on closely related trpc channels, as well as trpc / / at concentrations up to µm. the same applied to more distantly related trpv and trpm channels. besides a homotetrameric organization, trpc subunits can also assemble to heteromeric channel complexes with their closest relatives trpc and trpc ( ) . trpc / and trpc / heteromers can also be activated by btd as evident from their typical i/v curves in patch clamp experiments, suggesting a high selectivity of btd for channel complexes bearing at least one trpc subunit. transient receptor potential canonical channels / and are controlled by membrane lipids and highly expressed in neuronal and cardiac tissues. the involvement of these channels in development and (patho)physiology of these tissues is well documented, while our understanding of structure-function relations, specifically in terms of the lipid sensing machinery, in these channel proteins is still incomplete. using a homology model of trpc , based on the recently available structural information on trpv , we performed structure-guided mutagenesis and identified a single residue in transmembrane domain (g ), which is conserved within the canonical family of trp channels. single point mutations at position in trpc largely eliminated lipid sensitivity. trpc g a expressed in hek cells was found resistant not only to activation via the phospholipase c pathway but also to direct administration of diacylglycerols. on the contrary, a synthetic agonist of trpc / / channels (gsk a) activated wild-type trpc and trpc channels as well as the respective lipid insensitive mutants (trpc g a, trpc g a ). interestingly, the synthetic activator was found to generate substantially enhanced trpc conductances in cells expressing the lipid-insensitive mutants as compared to wild-type proteins. closer inspection of sensitivity of the wt and mutant proteins to various gsk derivatives argue against a contribution of g to gsk recognition by trpc . our results demonstrate the existence of two different mechanisms of trpc / activation supposedly involving distinct gating movements in the channel complex. we suggest that lipid gating of trpc / involves a hinge-point and/or requires a certain level of flexibility within transmembrane segment s provided by g . lipids and synthetic activators of trpc / may be capable of initiating markedly different structural rearrangement in these channels. objective: organophosphorus compounds (opcs), i.e. nerve agents or pesticides, are highly toxic due to their strong inhibition potency against acetylcholinesterase (ache). inhibited ache results in accumulation of acetylcholine in the synaptic cleft and thus the desensitisation of the nicotinic acetylcholine receptor (nachr) in the postsynaptic membrane is provoked. as the therapeutic efficacy of oximes is limited, e.g. poisoning by soman or tabun, the direct targeting of nachr may be an alternative therapeutic approach. studies with the non-oxime bispyridinium compound (bp) mb ( , '-(propane- , -diyl) bis ( -tert-butylpyridinium) di(iodide)) demonstrated a therapeutic effect against soman in vitro and in vivo. consequently, studying the affinity of bps at muscle-type nachrs and functional effects are topics of interest. to identify potential candidates, homologous series of substituted and non-substituted analogues (linker c -c ) of mb were investigated by using binding and functional assays. experimental procedures: crude membranes from frozen electric organ of torpedo californica were purified by sucrose-gradient density centrifugation and used in both affinity and functional assays. in competition radio-ligand binding assays, the influence on [³h]epibatidine binding sites of torpedo muscle-type nachr was determined. functional assessments were carried out with a bilayer method to investigate the effect on the cholinergic signal induced by µm carbamoylcholine. results: bispyridinium compounds bearing unsubstituted pyridinium rings and long alkyl linkers (> c ) inhibited the binding of [³h]epibatidine and decreased the cholinergic signal of µm carbamoylcholine in the functional assay. mb and several bispyridinium structure analogues (mainly c -c linker) exhibited no regular displacement curves at [ h]epibatidine binding sites and enhanced the carbamoylcholine-induced signal. the results demonstrate that the described affinity and functional screening methods detected some structure-activity-relationships (sar). depending on linker length and substitution pattern, the investigated bispyridinium compounds seemed to interact as positive allosteric modulators. further research is necessary to verify this hypothesis. non oxime bispyridinium compounds with an effect on soman-blocked respiratory muscle function have no effect on normal muscle function the life threatening toxicity of organophosphorus compounds (op), like nerve agents or pesticides, lies in the inhibition of acetylcholinesterase (ache) which causes cholinergic crisis. the accumulated acetylcholine in neuromuscular synapses results in the desensitization of nicotinic acetylcholine receptors (nachr) and paralysis of respiratoric muscles. the -tert-butyl-substituted bispyridinium compound mb showed therapeutic efficacy in soman and tabun poisoned guinea pigs in vivo. partial restauration of neuromuscular transmission by bispyridinium compounds (bp), e.g. mb or mb , could also observed in soman paralysed respiratory muscles in vitro and was partly attributed to an interaction of bp with nachrs. however, it is unknown, whether these bp might affect normal respiratory muscle function in the absence of cholinergic crisis. therefore this study investigated the effect of bp on physiological rat diaphragm muscle function. force generation of rat diaphragm hemispheres was determined after incubation with increasing bp concentrations ( - µm) and compare to sham treatment. the diaphragm hemispheres were stimulated every ten minutes by an indirect electrical field ( , , hz). muscle force was analyzed as time-force integral and is expressed as percentage of the individual control values, measured at the outset of the experiment. the muscle force dropped during the experiment. the application of the bispyridinium compounds mb ( , ′-(propan- , -diyl) bis ( -tertbutylpyridinium) di(iodide)) and mb ( , ′-(propan- , -diyl) bis ( -ethylpyridinium) di(iodide)) in the tested concentration range ( - µm) did not change muscle force production compared to the sham treated muscle. this was equally true for low ( hz) and high ( and hz) stimulation frequencies. this study showed that bispyridinium compounds which can partially reverse somaninduced neuromuscular block in rat diaphragms show no effect on respiratory muscle function in absence of the op-induced neuromuscular block. these results suggest that the bp tested in this study interacted with desensitised nachrs only, but do not affect physiological neuromuscular transmission. this effect needs to be investigated with further, promising bp compounds. interaction of recombinant pain-relevant atp-and proton-gated ion channels in an expression system; potentiation of the p x receptor-induced current by the opening of asic channels g. stephan , p. illes universität leipzig, rudolf-boehm-institut für pharmakologie und toxikologie, leipzig, germany the p x receptor (r) is a ligand-gated cationic channel, which is activated by extracellular atp. the acid sensing ion channel (asic ) belongs to the enac/degenerin family and is gated by extracellular protons. despite their different amino acid sequences both ion channels share the same structure and pore architecture, by i.e. consisting of three identical subunits. besides, they are both located at partially overlapping subpopulations of dorsal root ganglia neurons and are implicated in acidic pain signaling. consequently, their physical interaction in the cell membrane or even the formation of heteromeric receptor channels from p x and asic subunits has to be taken into consideration. we transfected rat (r)p x r and rasic constructs individually or together in a ratio of : into cho cells. we further used the whole cell patch clamp technique to analyze the current responses either elicited by the application of α,β-methylene-atp (α,β-meatp) or by a decrease in the extracellular ph value. the functionality of the individually transfected p x r-and asic -constructs was verified by recording concentration-response curves for the agonists α,β-meatp and protons, respectively. after co-transfection of both ion channels, a ph-shift from . to . caused a rapidly desensitizing current response and a subsequent strong potentiation of the α,β-meatp-induced current. an even larger potentiation was achieved after a decrease of the ph value to . . the opening of asic channels failed to facilitate the p x r current when -guanidine- -methylquinazoline was used to stimulate a non-proton ligand-sensor of asic . then, we substituted ca + in the extracellular medium by ba + or decreased the intrapipette concentration of egta, to modify the free intracellular ca + concentration. in cells individually transfected with the receptor-channels, external ba + increased the effect of α,β-meatp but decreased the effect of protons. the lowering of intrapipette egta modified p x r-and asic -specific currents in a similar manner as external ba + . in cells co-transfected with p x r/asic , the ionic manipulations mentioned above abolished the potentiation of the α,β-meatp currents by asic activation. taken together, our results suggest that p x r and asic interact with each other, since the activation of asic had a marked impact on the p x r specific current response. further experiments are required to clarify the mechanism of this interaction, although it has been shown that extra-and intracellular ca + and the proton sensor of asic appear to critically participate in this process. university of duisburg-essen, institute for anatomy, essen, germany background: the sperm acrosome reaction is an all-or-none secretion process, mainly following the conserved principles of calcium-regulated exocytosis in neurons and neurosecretory cells. however, the relationship between the formation of hundreds of fusion pores and the required mobilization of calcium from the lysosome-related acrosomal vesicle has only been partially defined. hence, the second messenger, nicotinic acid adenine dinucleotide phosphate (naadp), known to promote efflux of calcium from lysosome-like acidic compartments, was analyzed for its ability to trigger acrosome reaction in mouse sperm. in addition, the expression of two-pore channel (tpc) proteins, which are primarily localized in lysosome-related acidic organelles and which present potential molecular targets of naadp were examined in mammalian spermatozoa. methodology/ principal findings: our results show that treatment of spermatozoa with naadp resulted in a loss of the acrosomal vesicle, which shows typical properties, described for tpcs: (i) registered responses were not detectable for its chemical analogue nadp, and (ii) where blocked by the naadp antagonist trans-ned- . in addition, (iii) two narrow bell-shaped dose-response-curves were found, with maxima either in the nanomolar or low micromolar naadp concentration range. performing immungold-electron microscopy with a tpc specific antibody, a co-localization with naadp-binding at the acrosomal region was detectable. moreover, quantifying loss of the acrosomal vesicle in tpc null sperm upon application of different naadp concentrations, responsiveness to low micromolar naadp concentrations was completely abolished. conclusions/significance: our finding that two convergent naadp-dependent pathways are operative in driving acrosomal exocytosis and that zona pellucida induced acrosomal exocytosis is prevented by trans-ned- support the concept that both naadp-gated cascades match local naadp concentrations with the efflux of acrosomal calcium, thereby ensuring reliable and complete fusion of the large acrosomal vesicle. since the acrosome reaction shares the same basic sequence of events typical for the conserved process of calcium regulated exocytosis, such as tethering, docking, priming and final vesicle fusion, the sperm model system may also be useful to comparatively examine whether the same convergence of naadp-dependent pathways is also operative in cellular systems with many secretory vesicles. walther-straub-institut, münchen, germany trpv channels are members of the vanilloid family of trp proteins. the channel is nearly ubiquitously expressed and can be found in brain, kidney, skin, heart, blood vessels as well as in the lung. pulmonary expression of trpv has been identified in endothelial cells ( ), epithelial cells ( ) and arterial smooth muscle cells ( ) . most interestingly, the channel is known to be involved in the development of several lung diseases such as cough, asthma and pulmonary edema formation, due to its activation by heat, changes in osmolarity and shear stress (reviewed in ). it is a matter of debate however if trpv activation in pulmonary endothelial as well as epithelial cells induces disruption of the barrier and an increased fluid leak into the alveolus as described for trpc ( ) which is also expressed in both cell types. to analyze the potential role of trpv on ischemia-reperfusion-injury(iri)-induced pulmonary edema formation we utilized the isolated perfused mouse lung model. much to our surprise, we detected a significantly enlarged edema formation after minutes of ischemia in trpv -deficient mice in comparison to wild-type (wt) mice. this effect was observed by constant weight measurements as well as wet-to-dry ratio gain and was not dependent on the initial perfusion rate. most interestingly, edema formation of trpv /trpc double deficient lungs was indistinguishable from wt lungs, indicating antagonizing effects of both channels, because trpc deficiency protected lungs from iri-induced edema ( ) . moreover, we identified reduced expression levels of aquaporin in trpv -deficient lung lysates compared to wt lungs. these findings raise the intriguing possibility that trpv might be involved in the regulation of aquaporin expression in lung endothelial cells. endosomes and lysosomes are cell organelles involved in transport, breakdown and secretion of proteins, lipids, and other macromolecules. endolysosomal dysfunction can cause storage disorders such as mucolipidoses, sphingolipidoses, or neuronal ceroid lipofuscinoses, but is also implicated in the development of metabolic and neurodegenerative diseases, retinal and pigmentation disorders, trace metal dishomeostasis, infectious diseases, and cancer. endolysosomal ion channels and transporters are highly critical for the tight regulation of the multiple endolysosomal fusion and fission processes including endo-and exocytotic events as well as the regulation of proton and other ionic concentrations in the lumen of endolysosomal vesicles. methods to patch-clamp endolysosomal organelles are continuously improving. yet until now it has not been possible to selectively enlarge endosomal or lysosomal organelles with pharmacological tools for patch-clamp experimentation. we show here by using a combination of two small molecules that we can selectively enlarge early endosomes to a degree sufficient for patch-clamp experimentation. the ability to more selectively patch-clamp intracellular organelles will substantially improve the functional investigation of endolysosomal ion channels under physiological and pathophysiological conditions. the transient receptor potential (trp) channels are a superfamily of non-selective ion channels involved in a variety of physiological processes and in the pathgenesis of many disorders. in the kidney, trp channels have been implicated to be involved in diabetic nephropathy, focal, segmental glomerulosclerosis, polycystic kidney disease, hypomagnesemia with secondary hypercalcemia and idiopathic hypercalcuria. the melastatin-like trp channel subfamily (trpm ) has been shown to be expressed in human kidney , . using newly developed anti-trpm antibodies, we are able to visualize trpm protein in epithelial cells of proximal tubule as well as collecting ducts in the mouse kidneys. therefore, we compared renal function of male, five month old mice lacking trpm (trpm the atp-gated p x receptor (p x r) is a non-selective cation channel widely expressed in epithelia, endothelia, and cells of hematopoietic origin. it plays a central role in cytokine release and studies in p x -/animals indicate its involvement in inflammatory and neurodegenerative diseases. in addition, accumulating data suggests a functional role in neurons and its involvement in neurotransmitter release in the brain. however, despite its importance as a drug target, its precise localization and its molecular and physiological functions remain poorly understood. in particular, the location and function of p x r in neurons remain a matter of ongoing debate. to clarify the cellular and subcellular distribution of the p x r and to investigate its physiological and pathophysiological role in the brain we generated bac transgenic mouse models in which murine polymorphic variants of egfp-tagged p x r are overexpressed under the control of the endogenous p x promoter. the egfp-tagged p x rs are efficiently overexpressed in the plasma membrane and can be directly visualized by green fluorescence or indirectly by anti-egfp antibodies. the obtained mouse lines show different expression levels but identical expression patterns with predominant expression in the cerebellum, hippocampus, and thalamus. using cell type-specific markers, p x -egfp was identified in almost all microglia and subpopulations of oligodendrocytes and astrocytes in the brain. in the spinal cord, numerous astrocytes in the white matter showed egfp immunoreactivity. so far, no egfp immunostaining was found on map -and neun-positive cells indicating that under non-pathological conditions, the p x receptor is not expressed in neurons of the cns. interestingly, a higher expression level of cd protein was observed in the p x r-overexpressing mice. these results suggests that overexpression of p x rs alone is sufficient to induce microglia activation, even under non-pathological conditions. since cd primarily localizes to lysosomes and endosomes, this further supports a role of the p x r in the regulation of phagocytosis. to validate these data, conditional knockout mice are generated. the current status of the project will be presented. the two-pore channels (tpcs) -tpc and tpc -are located in membranes of intracellular organelles of the endo-lysosomal system. the tpc-protein-monomer contains two homologous domains with six transmembrane α-helices each. a functional tpc probably consists of a dimer of two tpc-proteins resembling an ion channel architecture with the typical four domain organization like voltage gated na + or ca + channels or such as trp channels. due to their biophysical properties, tpc and tpc are assumed to be involved in the efflux of ca + from intracellular organelles and thereby contribute to fusion/fission processes of endosomes and lysosomes. thus, tpcs are supposed to be important regulators for vesicle trafficking, sorting and degradation/recycling processes. recently, it was shown that virus entry and replication of certain strains of filoviridae -such as ebola -depends on functional tpcs and that either block or genetic inactivation of tpcs reduces virus infectivity. a large family of bacterial protein toxins elicit their effects by modification of intracellular target proteins of host cells. these toxins are taken up by receptor mediated endocytosis and follow different endosomal routes to reach their final cytosolic destination. these toxins principally use two different intracellular routes: the first group uses an entry route via early or late endosomes (short-trip toxins), the second group takes a retrograde route via endosomes, golgi network and the endoplasmic reticulum (long-trip toxins) to get access to the cytosol. translocation of short-trip toxins -such as diphtheria toxin (dt), pasteurella multocida toxin (pmt) and bacillus anthracis lethal factor (pa/lf) -from early and late endosomes into the cytosol is driven by ongoing acidification. long-trip toxins -including cholera toxin (ct) -are retrogradely transported after endocytosis via the golgi apparatus to the endoplasmic reticulum (er). within the er a specific peptide-motif allows the translocation into the cytosol. due to the role of tpc for vesicle fusion & fission processes we investigated a potential impact of tpc on the uptake of bacterial toxins. first we determined the precise localization of tpc in intracellular compartments. to deduce its role for trafficking processes we performed co-localization and correlation studies with a whole set of established markers such as rab-gtpases and pips. second we intoxicated wild-type and tpc deficient cell lines with different bacterial protein toxins such as cholera (ct), diphtheria (dt) or pasteurella multocida (pmt) toxin. using cell viability and other intoxication assays we investigated the consequences of tpc -deletion on bacterial toxin uptake, translocation and cytotoxicity. universität des saarlandes, institut für experimentelle und klinische pharmakologie und toxikologie, homburg/saar, germany trpm ion channels are considered to be involved in hormone release from pancreatic islets and the pituitary gland , . the trpm gene encodes a number of different splice variants that differ in their permeation properties and their activity in response to agonists , . variations include the presence or absence of five stretches of to amino acid residues within the aminoterminus, long or short pore loops and long or truncated carboxytermini . furthermore, three different aminotermini of human and mouse proteins have been described , but presumably these differences are caused by the activity of different promoters. screening of a mouse pituitary gland cdna library identified variants that differ in exons , , , and . however, only variants bearing the short, ca + permeable pore loop were detected. ´ rapid amplification of cdna ends ( ´race) revealed that trpm proteins of the pituitary gland carry truncated c-termini exclusively. ´race identified five independent regions of transcription initiation within the trpm gene implying the presence of five independent promotors. the different transcripts encode four trpm amino termini α, β, γ and δ of - amino acid residues including those described in humans (β,γ). however, the activity of these variants after stimulation with pregnenolone sulfate varied largely just as their frequency in the pituitary with shortened γ-variants being most abundant (~ %). two-pore channels (tpcs) are a small family of ion-channels found throughout the endolysosomal system of eukaryotic cells. phylogenetically tpcs belong to the voltagegated ion channel superfamily sharing common traits with ca v / na v and trp channels. tpcs show a duplicated architecture with two homologous trans-membrane domains. each domain is build up by six membrane spanning alpha helices linked by short loops. it is very likely that tpcs form dimers maintaining the four-fold symmetry found in other members of the voltage-gated ion channel superfamily. due to their localization in the endolysosomal system tpcs are not accessible to conventional patch clamping. to investigate tpcs electrophysiological properties we use black lipid bilayer measurements. purified channels are integrated into an artificial phospholipid bilayer that separates two chambers enabling us to apply different buffers. upon activation by naadp ions flow through the channel and can thereby pass the diffusion barrier. the movement of charged molecules through tpcs results in currents which can be amplified and recorded. the controlled environment of the lipid bilayer setup allows testing of different ions as well as putative activating and inhibitory substances. one of the major drawbacks of conventional lipid bilayer setups are long preparation times between each measurement. stability of the phospholipid bilayer can pose another issue. often several membranes have to be established before a measurement can be performed making it very time consuming to achieve adequate experiment numbers. new multichannel systems resolve this issue supporting fast formation of bilayers while allowing measurement of up to different bilayers at a time. here we utilize the "orbit" multichannel system with a meca chip by ionera to measure tpc channel activity. we will present data generated by the "orbit" system and a conventional bilayer setup using different channel constructs and charge carriers. cardiac action potentials are generated and propagated through the coordinated activity of multiple ion channels, including voltage-gated sodium channels (nav ) and potassium channels (like kv , kv ). the voltage-gated na + channel nav . initiates the cardiac action potential (ap), is essential for rapid depolarization, and is also known to control the ap duration in cardiomyocytes. the voltage-gated k + channel kv . is responsible for the early repolarization of action potentials in human heart. similar to many membrane proteins, nav . and kv . have been found to be regulated by several interacting proteins. the transmembrane β subunit dipeptidyl aminopepidase-like protein (dpp) is known to interact with the kv . channel complex, modulating kinetics and voltage dependence. the overexpression of dpp in ventricular cardiomyocytes of rats revealed strong reduction of ap amplitude and significant slowing of ap upstroke velocity and ap duration, which could not be explained by the effects on cardiac kv channels. to study the potential influence of dpp on nav . channels, we performed whole-cell patch-clamp analysis of transiently transfected cho-k cells, expressing scn a alone or with dpp . surprisingly, we observed significant effects of dpp on nav . channel voltage dependence and kinetics. thus, the co-expression of dpp significantly shifted the half-maximal voltage of steady-state activation and steady-stateinactivation to more positive potentials compared to nav . channels alone. in addition we analysed the effects of dpp on the kinetics nav . currents. while time to current peak was not affected in cells co-expressing nav . and dpp compared to nav . alone, dpp slightly accelerated the inactivation. in addition, the time course of recovery from inactivation was clearly accelerated in cells expressing both nav . and dpp compared to nav . alone. in summary, we provide first evidence that dpp not only interacts with kv channels, but also influences nav . channels modulating the depolarization as well as the early repolarization phase of the cardiac ap. therefore, it becomes likely that these ion channels are part of large, multi-protein complexes, and that the pore-forming subunits kv . and nav . behave very differently depending on the expression of its associated proteins like dpp . cardiac fibroblasts (cf) comprise the most abundant cell type of the mammalian heart and it is known that they contribute to maladaptive cardiac remodeling processes. in response to pressure or volume overload, ischemia-reperfusion injury or myocardial infarction, cardiac fibroblasts proliferate and transdifferentiate into myofibroblasts which produce collagen and pro-hypertrophic cytokines influencing cardiomyocyte function and size. it was shown that β-adrenergic stimulation of cfs with isoproterenol leads to angiotensin ii (at-ii) production and autocrine stimulation of these cells (jaffre et al, ). activation of phoypholipase c triggered by at-ii leads to formation of inositol trisphosphate (ip ) and subsequent release of calcium from intracellular stores as well as calcium entry across the cell membrane. the focus of our research is the identification of the plasmalemmal channel proteins such as trpc channels mediating this calcium entry, and whether these calcium entry pathways in cfs contribute to pathological remodeling. to date the precise role of calcium entry for these pathological processes is largely unknown. trpc channels are candidates for the analysis of calcium homeostasis in cf. recently, we showed that trpc /c -deficient mice are protected from maladaptive cardiac remodeling after neurohumoral stimulation or pressure overload, respectively, which can be explained by a significant reduction of a background ca + -entry (bcge) pathway in cardiomyocytes; this bgce is enhanced by stimulation with agonists such as isoproterenol or angiotensin ii and it critically depends on trpc and trpc (camacho londoño et al., ) . nevertheless, the role of trpc /c for calcium homeostasis in cfs has not been analyzed so far. we established an in vitro model that allows the analysis of calcium release and entry triggered by several (patho)physiological agonists in cultured primary adult cfs from mice. cfs were isolated using langendorff-perfusion and were cultured for maximal days. our results show that there is no difference in nm at-ii induced ca + -release or ca + -entry in trpc /c -deficient cf compared to wt. to evaluate whether the lack of trpc /c can be compensated by other trpc channels we currently analyze cfs from trpc hepta ko mice lacking all seven trpc channel proteins concerning at-ii induced ca + -release and ca + -entry and we will also analyze the influence of other agonists on cfs which are known to evoke a longer lasting rise in the [ca + ] i like isoproterenol, -ht, thrombin and endothelin- . cardiovascular and metabolic diseases are currently the primary cause of morbidity and mortality in the western world and are spreading to the rest of the world following globalization. adipose tissue, in particular perivascular adipose tissue (pvat) is recognized as an important player in the development of these diseases. the release of relaxing factor(s) from the pvat has been a matter of interesting and highly spirited debates about its nature, the channels that govern its activities and its role in vascular dysfunction. data from our laboratory indicate that adipose-derived relaxing factor (adrf) is an important player, however the potential channels necessary for its downstream activities are still under study. our recent research primarily focuses on kv . channels, which are known to be expressed in vascular smooth muscle cells. k v . voltage-gated potassium channels are expressed in vascular smooth muscle cells (vsmc) of diverse arteries, including mesenteric arteries. based on pharmacological evidence using r-l (k v . opener), hmr , chromanol- b (k v . inhibitors), these channels have been suggested to be involved in the regulation of vascular tone. however, the specificity of these drugs in vivo is uncertain. we used kcnq -/-mice to determine whether k v . plays a role in the regulation of arterial tone. we found that r-l produces similar concentration-dependent relaxations (ec ~ , µm) of wild-type (kcnq +/+) and kcnq -/-arteries pre-contracted with either phenylephrine or mm kcl. this relaxation was not affected by µm chromanol- b, µm hmr or µm xe (pan-k v blocker). the anti-contractile effects of pvat were normal in kcnq -/-arteries. chromanol- b and hmr did not affect the anti-contractile effects of perivascular adipose tissue (pvat). isolated vsmcs from kcnq -/-mice exhibited normal peak k v currents. the k v . - opener retigabine caused similar relaxations in kcnq -/-and wild-type vessels. we conclude that k v . channels are apparently not involved in the control of arterial tone by alpha adrenergic vasoconstrictors and pvat. in addition, r-l is an inappropriate pharmacological tool for studying the function of native vascular k v . channels in mice. introduction: according to international guidelines [ ] [ ] [ ] [ ] [ ] [ ] [ ] , both human and animal skin in vitro models have been used and validated to predict percutaneous penetration in humans. excellent correlations have been found for domestic pig as surrogate for human skin [ ] [ ] . material and methods: tissue the skin samples are descended from female pigs of german landrace ( kg weight, approx. month). process approved under german welfare law. after narcotization and euthanization the animals were shaved with an electric shaver, washed and dried. microbiological investigation swabs from different skin area (fig. ) were taken before next preparation step. skin areas were cut, stretched and subcutaneous fatty tissue was carefully removed. the skin was harvested at thickness of . µm by dermatome. after dermatomization, samples were taken for histological examination. skin disks of mm were punched out from the frozen skin stripes and stored at - °c. hplc and skin absorption waters corporation hplc containing sample manager, binary gradient pump, pda detector (optional: electron spray mass spectrometer); column: nucleodur® - c ec mm x . mm id. hanson microette™ vision® diffusion test system (hanson vision® autoplus™ autosampler/autofill™ collector, -cell drive system with vertical diffusion cell "standard". the permeation experiment was performed over a period of h at °c. the dosage compartments of each cell were filled with approximately µl of the caffeine solution ( mg/ml). samples of ml are taken after , , , and hours from receptor medium of each cell. aliquots from each vdc are analyzed by hplc in duplicate. microbiology staphylococcus spp. were found explicitly on pig skin surface. bacteria are facultative anaerobe, gram-positive bacteria that are physiologically colonizing the skin, oropharynx and the gastrointestinal tract. histology and skin thickness he staining and mechanical skin thickness determinations confirmed intact dermatomizing process of skin (fig. ) . thickness was in the order of magnitude between to . µm and intra variations were less than %. caffeine skin absorption permeability coefficients and lag-phases recorded are in the same order of magnitude of previous work [ ], demonstrating intact barrier properties of the membranes after month storage process. until today, intra-assay variations are superior or equal to interregional and inter-animal variations. discussion: well characterized dps provides ready to use research tool for locally and systemic skin investigations. ongoing experiments will cover skin structure analysis by raman spectroscopy, biophotonics and storage impact on skin barrier function. respirable biopersistent granular dusts (gbs) should fulfill the criteria of i.) a negligible solubility in physiological lung fluid that ii.) do not exhibit a specific surface chemistryrelated toxicity at volumetric non-overload conditions in lungs. in , the mak commission derived a new threshold value of . mg/m for gbs with a density of , recognizing that at this concentration a chronic inflammation and increase of the lung cancer risk will not occur. -the objectives of the project were i.) to determine an experimental dissolution value for 'low soluble' gbs using six candidate dusts; ii.) in addition, to measure the inflammatory response in lung lavage fluid and to decide on the criterion 'inert dust'; iii.) to investigate whether nanoscaled dusts could possibly fulfill the criteria to be included in the gbs class. -six micro-and nanoscaled dusts (one of them a well-characterised inert tio dust (microscaled; rutile modification) were compared analysing the solubility in the lung fluid (day , and ) and the lung toxicity after intratracheal instillation in rats (day and ): tio (rutile, micro), tio (anatase, nano), eu o (micro-nano mixed), baso (micro), zro (micro) and amorphous sio (nano). two doses of . and . µl per rat were administered to wistar rats; these volume doses resulted in a non-overload and moderate overload of lungs, respectively. -the differential cell count showed only slight inflammatory cell levels after treatment with tio (rutile) and baso (pmn < % after days in the low dose group; < % in the high dose group; full recovery after days). in contrast, the tio (anatase) showed a stronger response (pmn > % after and days). the rare earth eu o (micro-nano) dust showed the strongest effect (approx. % pmn after and days) including a red-coloured lung lavage fluid. µ-zro and amorphous sio showed a strong acute response after days, however, mostly complete recovery after days. the low solubility criterion was met by the following dusts: tio (both) and zro . -similar volumetric lung burdens were deposited in a parallel validation experiment ( -day subacute inhalations). overall the physiological inhalation route confirmed the results obtained in the instillation study, thus suggesting the applicability of the latter as a tool for identification for gbs dusts. however, for nanoscaled dusts an individual toxicological characterization seems to be adequate. polycyclic aromatic hydrocarbons (pah) represent a complex mixture of compounds and occur in considerable amounts as contaminants in the environment and food. some pah have been demonstrated to be carcinogenic and mutagenic. benzo[a]pyrene (bp), the most known and studied member of the potent carcinogenic pah, is classified by iarc as group carcinogen and is present in a wide variety of food items. however, other non-carcinogenic pah such as pyrene (pyr) and fluoranthene (fa) are also found in substantial amounts in the diet and are strongly suspicious to cause interactive effects. reporter gene assays were used for analyzing interactive effects of a ternary mixture including bp, pyr and fa in relative proportions occurring in food on the nuclear receptors aryl hydrocarbon receptor (ahr) and constitutive androstane receptor (car). the observed activations were verified at the gene expression level in the human hepatoma cell line heparg. beside the well characterized ligand bp, µm of pyr and µm fa also activated the ahr, even though to a much lesser extent. no significant higher activation over the level of bp alone was reached when testing different pah mixtures. however, in heparg cells the analysis of cyp a gene expression as a model target gene of ahr showed synergistic effects after pah co-exposure. in addition, the activation of human car was analyzed. pyr and fa are each strong agonists, whereas bp was less potent. for the ternary pah mixture with bp a strong decrease of the induction was observed. this inhibiting effect was verified at the mrna level using the model car target gene cyp b in heparg cells. in conclusion, really occurring mixtures with non-carcinogenic pah can modulate the effects of carcinogenic pah. such effects warrant to be investigated in more detail to enhance our knowledge of interaction of pah mixtures at the molecular level. cytochrome p enzymes and transporters are important for the turnover of pharmaceutical compounds. their expression levels and activity influence bioavailability and convey drug-drug interactions. moreover, transporters mediate barrier maintenance of several organs such as blood-brain-barrier and placenta-barrier. overexpression of export transporters in tumors can lead to multiple drug resistance. however, membrane associated proteins are difficult to quantify by conventional bioanalytical methods such as sandwich immunoassays because of their hydrophobicity. antibody -based analysis of cytochrome p enzymes and transporters is challenging due to their sequence homology. therefore, we developed a test system for protein quantification which combines the sensitivity of immunoprecipitation and the specificity of mass spectrometry: this method is especially convenient for hydrophobic proteins because denatured samples are analyzed on peptide level. one peptide from each protein, which can be assigned unambiguously, is identified via tandem ms and quantified by means of an isotope labeled reference. prior to ms-read-out, the peptides are enriched by antibodies which recognize a very short c-terminal epitope. these epitopes are selected in such way that they are common in peptides derived from target proteins and therefore allow the analysis of protein groups with few antibodies. the major advantage of this method is that whole cell or tissue lysates -without preparation of microsomal fractions -can be used for quantification by lc-ms. also, samples from different model organisms can be analyzed with the same assay which enhances the comparability of experiments. physiologically based toxicokinetic modeling (pbtk) is an in silico tool to predict compound kinetics based on test substance related properties and physiological parameters of the organism. pbtk is a key element for inverse dosimetry to relate effect concentrations in vitro to external, e.g. oral doses. in our investigations, we use compartment models for the rat including adrenals and testes or ovaries. test substance specific properties taken for pbtk modeling are molecular weight and logp o/w as well as ivis based tissue specific partition coefficients, hepatic clearance, intestinal permeability and plasma protein binding. berkeley madonna software was applied to solve consequent differential equations. here we present the above described model for the test substances bisphenol a (bpa), fenarimol (fen) and ketoconazole (keto). using the lowest effect concentrations (loecs) of bpa, fen and keto from ) an in vitro yeast based assays with human estrogen and androgen receptor combined with a reporter gene and ) the interaction of steroidogenesis model calculations were made to relate in vitro concentrations to oral doses in the rat. model calculations, based on in vitro loecs of µm (bpa), µm (fen) and . µm (keto), for concentrations in target organs resulted in estimated oral loels of , and . mg/kg. when calculations were made for plasma levels oral loels were estimated to be , and mg/kg for bpa, fen and keto, respectively when compared to existing in vivo data with endocrine related loels of mg/kg bw day for bpa ( ), mg/kg day for fen ( ) and mg/kg day for keto ( ) , it can be concluded that for the exemplary test substances addressed, ivis related risk assessment approaches based on target tissues seems overpredictive, whereas plasma related loels were closer to the in vivo situation, to study the activation of the nuclear receptor pxr a gal /uas-based pxr transactivation assay was used. the pxr-mediated induction of cyp a promotor activity was investigated using a pxr-dependent cyp a reporter gene assay. cyp a induction was analyzed at the mrna and protein levels in hepg cells using qpcr and western blot. to cover the most frequently occurring pa structures (retronecine, heliotridine and otonecine type as well as monoester, open-chain diester and cyclic diester) the four pa senecionine, heliotrine, echimidine and senkirkine were selected as representative pa for initial analyses. out of the four investigated pa only echimidine activated pxr. accordingly, pxrmediated induction of cyp a promotor activity could only be detected for echimidine. cyp a induction by echimidine was verified at the mrna and protein level in hepg wildtype and hepg pxr-overexpressing cells. taking heinrich-heine universität düsseldorf, institut für toxikologie, düsseldorf, germany introduction: in higher concentrations, the blood pressure regulating hormone angiotensin ii (ang ii), leads to vasoconstriction, hypertension and oxidative stress by activation of the renin angiotensin system (ras). here we investigate if nadphoxidases are responsible for ras-mediated oxidative stress in kidney and heart. nadph-oxidases ( isoforms are known, nox - , duox & ) are membrane-bound enzymes that produce reactive oxygen species (ros) for example during the immune response and cell signaling. material and methods: to clarify the role of nadph-oxidases, wildtype mice and nox -, nox -and nox -deficient mice were equipped with osmotic minipumps, delivering ang ii in a concentration of ng/kg during days to stimulate high blood pressure. kidney and heart were investigated for steady-state ros levels and dna damage (dna single and double strand breaks). results: in wildtype mice, ang ii leads to hypertension, a declined renal function, formation of ros in kidney and heart and to dna single and double strand breaks in the kidney. all nox-knockout mice exhibited ang ii-mediated hypertension and albuminuria. the lack of nox and nox could neither protect from the formation of oxidative stress in the kindey nor from dna double strand breaks in the kidney. initial findings from the nox -knockout mouse do not show an increase in dna double strand breaks in the kidney. discussion: contrary to published results of nox -knockout mice, we observed a constant rise in blood pressure over the treatment period compared to the control. this can possibly be due to different ang ii doses. in nox -knockout mice we observed increased oxidative stress and increased renal dna damage already in untreated control animals, which is in line with reports suggesting a protective effect of nox . conclusion: separate eliminations of nadph-isoforms did not allow the identification of the enzyme which is responsible for ang ii-induced oxidative stress. a possible explanation is that oxidative stress is caused by more than one nox-isoform or other enzymes like xanthine oxidase or nitrogen synthase take major part in the formation of ros. of mice (rats, cats, dogs, monkey) and men -how to measure kidney biomarkers across species introduction and objectives: there is a need for reliable biomarker assays to detect organ toxicity induced by drug candidates. in the last years about drugs were withdrawn from the market due to liver and/or kidney damage. for the detection of druginduced organ injury, safety-tox studies in rodents, dogs, non-human primates and humans are mandatory in the drug development process. currently, several protein biomarkers for kidney, liver and cardiovascular organ toxicitity are being clinically validated by international consortia like the safer and faster evidence-based translation (safe-t) or the predictive safety consortium (pstc). we are developing mass-spectrometry-based immuoassays suitable for the detection of these markers in animal models to support these efforts method: urinary proteins are proteolytically digested to peptides using trypsin. subsequently synthetic isotope-labelled peptide standards are spiked in at known concentrations. we employ multi-specific antibodies (txp-antibodies) targeting cterminal amino acid motifs for the enrichment of peptides derived from the protein biomarkers. finally, the protein biomarkers are quantified using nanolc-parallel reaction monitoring-ms. the use of our group-specific txp-antibodies allows protein analysis of samples from different species using the same antibody. results and discussion: we established an ms-based immunoassay platform for the analysis of kidney (diki) injury protein biomarkers in urine across species; human, cynomolgus, mouse, rat and dog. we analyzed the potential diki biomarkers aquaporin , podocin, synaptopodin, retinol-binding protein , clusterin and osteopontin in urine samples from toxicity studies in cynomolgus monkeys, rodents and humans. conclusion: the application of group-specific txp-antibodies and mass spectrometry allows the quantification of biomarkers in urine of all relevant model organisms. the results strongly support the validation of translational drug-induced organ injury protein biomarkers. although effective anticancer-therapeutic regimen are available, they are accompanied by severe adverse effects on normal tissue, for instance chemotherapy induced peripheral neuropathy (cipn) caused by platinum compounds. the pathophysiology of this clinically highly relevant side-effect is still unknown and neither prophylaxis nor specific treatment is available. therefore, further research elucidating the underlying molecular mechanisms of platinating anti-tumor drugs leading to cipn is required as basis for future development of preventive or therapeutic strategies. in general, platinum compounds lead to cell death mainly via dna damage induction (mostly intrastrandcrosslinks) and through interference with the redox homeostasis of cells. here, we introduce and suggest the well-known nematode model organism c. elegans to elucidate mechanisms of neurotoxicity triggered by platinating agents. so far, we determined doses for cis-and oxaliplatin, which have only moderate effects on development, reproduction and body movement (muscular read-out). however, these doses are sufficient to trigger apoptosis in c. elegans and to induce a considerable amount of , -intrastrand crosslinks in dna (measured by south-western blotting). even more important they lead to strong neurotoxicity in a functional read-out (pharyngeal pumping). with regard to redox homeostasis, we determined the oxidative stress resistance showing that e.g. cisplatin sensitizes c. elegans to reactive oxygen species (ros), which could be prevented if worms were co-or pretreated with n-acetylcysteine. furthermore we determined the level of ros in living c. elegans after treatment with platinating agents and also in combination with protective compounds. using the advantages of c. elegans as a genetic model system, we will further clarify the relevance of different defense mechanisms, including dna repair (nucleotide excision repair, base excision repair), detoxification systems (antioxidative stress factors, metallothioneins) as well as drug transporters and signaling proteins. this will be achieved by using rna interference approaches that allow targeting either the whole animal or specific tissues (i.e. neurons) only. first results of this approach will be presented. finally we aim to use this setup to identify neuroprotective compounds that prevent chemotherapy induced peripheral neuropathy induced by platinating anti-tumor drugs. clostridium botulinum c exoenyzme (c ) exclusively adp-ribosylates rhoa, b and c leading to reorganization of the actin cytoskeleton and morphological changes. in addition to the enzyme-based inhibition of rho-gtpases, c promotes in an enzymeindependent manner axonal and dendritic growth in neurons. as c lacks the canonical binding and translocation domains of bacterial protein toxins, cell entry is currently not well understood. based on overlay assays and mass spec analyses the intermediate filament vimentin was identified as the putative membrane receptor for c . knock down of vimentin by sirna and application of the selective vimentin disruptor acrylamide led to a significantly delayed uptake of c . moreover, addition of extracellular vimentin to cells induced an enhanced uptake of c . proof of principle experiments in astrocytes and neurons from vimentin knock out mice showed c -induced morphological changes (astrocyte stellation and axon growth) to a reduced extent and a significantly delayed uptake of c compared to wild type cells. as vimentin knock out did not completely inhibit c uptake into cells, an additional uptake mechanism or additional receptor for c is likely. nevertheless, our data reveals that c employs a specific endocytosis mechanism with involvement of the intermediate filament vimentin to gain access to host cells. the primary target organ of organic hg species-mediated toxicity is the central nervous system (cns). humans are exposed to organic hg mainly in the form of methylmercury (mehg) via the consumption of contaminated fish and other seafood products. in terrestrial food sources hg is mostly found as inorganic hg. thiomersal is a further organic hg compound which is used as a preservative in medical preparations. exposure to organic hg promotes primarily neurological effects. the understanding of transfer mechanisms regarding the cns is an important precondition for an evaluation of hg species-induced neurotoxicity. thus, primary porcine in vitro models of the bloodbrain barrier and the blood-cerebrospinal fluid (csf) barrier were used to investigate effects of mehgcl, thiomersal and hgcl on the barriers as well as transfer properties into and out of the cns in vitro. the results show significant transfer differences of the various incubated species as well as in the different barrier systems. whereas the bloodbrain barrier seems to account for the transfer of organic hg species from the blood side to the brain side, these species are transferred in the contrary direction by the blood-csf barrier. inorganic hgcl was not transferred across both brain barriers towards the brain side but was able to leave the brain side across the blood-brain barrier. additionally, cytotoxic effects of the hg species by themselves as well as the combination of organic and inorganic hg species have been investigated in human astrocytes and human differentiated neurons. differentiated neurons were much more sensitive towards all hg species. organic species exerted stronger cytotoxic effects in both cell types as compared to hgcl . interestingly, a coincubation of organic and inorganic hg species led to an increased cytotoxicity in the astrocytes. this cocytotoxic effect is currently investigated in differentiated neurons. the species-specific differences with respect to both, effects on and transfer across the blood-brain and the blood-csf barrier in vitro as well as toxic effects in brain target cells, clearly emphasizes the necessity for comparative analyses. introduction: the neural crest is a multipotent stem cell population that arises at the neural plate border during early fetal development. neural crest cells (nccs) migrate to target sites in the periphery, where they differentiate into multiple cell types, including melanocytes, cranial bones and peripheral neurons. failure of ncc migration can lead to severe disorders, such as hirschsprung's disease. aim: to test whether toxicants interfere with human ncc migration, a high-throughput migration assay was established. this test system was used to screen an compound library of potential developmental toxicants. methods: nccs were derived from human embryonic stem cells. the cells were allowed to migrate for h before toxicants were added to the cells. migration and viability of the cells were then measured after another h by high-content image analysis and a custom-developed software package. results: the screening library was assembled by the us national toxicology program (ntp) and consisted of different substance classes, e.g. organophosphates, organochlorines, drug-like compounds, pesticides and polycyclic aromatic hydrocarbons (pahs). out of the tested potential developmental toxicants, compounds reduced ncc migration at non-cytotoxic concentrations. hit-confirmation testing confirmed of the compounds as concentration-dependent inhibitors of ncc migration. among the potential developmental toxicants identified here, there were several organophosphates (e.g. chlorpyriphos) and drug-like compounds as well as polybrominated diphenyl ethers (pbdes) and organochlorine pesticides (e.g. ddt and dieldrin), while none of the tested pahs inhibited ncc migration. the negative controls in the screening library, like acetylsalicylic acid, acetaminophen and saccharin, proved to be non-toxic. conclusion/outlook: the newly established test system allows screening of potential developmental toxicants in a high throughput manner for interference with human ncc migration. confirmation in other types of migration assays is ongoing, and selected compounds from amongst the screen hits are undergoing mechanistic evaluation. oxidative stress is regarded as a major trigger for neuronal dysfunction and death in the ageing brain and in multiple neurodegenerative disorders. how oxidative stress mediates neuronal death and whether the associated mechanisms are accessible for therapeutic intervention strategies is not clarified. increasing evidence suggests, however, that oxidative stress triggers molecular mechanisms of regulated necrosis that involve the activation of receptor interacting protein (rip ) independently of death receptor activation. here, we show that erastin-induced ferroptosis which involves inhibition of the glutamate-cystein transporter (xc -), glutathione depletion and lethal formation of reactive oxygen species (ros) , triggers mechanisms of regulated necrosis independent of tnfα-signaling. in hippocampal ht- cells erastin promotes activation of rip and subsequent rip -rip necrosome formation which has been investigated as a hallmark of regulated necrosis . in fact, silencing of rip by sirna or by the rip inhibitor necrostatin- prevents ferroptosis-induced cell death whereas the ferroptosis inhibitor ferrostatin- fails to protect cells against tnfα-induced classical necroptosis, a form of programmed cell death that is mediated by receptor interacting protein- (rip ) and rip kinases downstream of death receptor activation (e.g. tumor necrosis factor receptor tnfr) , . recently, a genome-wide sirna screen linked cylindromatosis (cyld) to rip /rip -dependent necroptosis and also in the present paradigm of ferroptosis, cyld depletion promotes neuronal survival and decreases rip -rip complex formation, suggesting a role of cyld in intrinsic pathways of regulated necrosis triggered by oxidative stress. the ns a inhibitor daclatasvir is used in combination with other antivirals such as the polymerase inhibitor sofosbuvir for treatment of chronic infection with the hepatitis c virus. daclatasvir is embryotoxic and teratogenic in rats and rabbits at exposures at or above the clinical exposure. in contrast, no teratogenic effects were observed in rat and rabbit developmental toxicity studies with ledipasvir, another ns a inhibitor. we studied these compounds in the embryonic stem cell test (est) alone and in combination with sofosbuvir. the ns a inhibitors were obtained from selleckchem, the main metabolite of sofosbuvir, psi- , was from medchem express. murine embryonic stem cells (es-d ) were obtained from atcc. they were kept in iscove's modified dulbecco's medium (imdm). substances were dissolved in dmso at a final dmso-concentration of . % in the culture medium. a cytotoxicity assay as well as a differentiation assay were performed. after days in culture the cells were evaluated. cytotoxicity was measured by an mtt test. differentiation into contracting myocardial cells was determined using direct phase contrast microscopy. the substances were tested at concentrations between . and mg/l, which is a broad coverage of the therapeutically relevant concentrations reached in patients. at a concentration of mg daclatasvir / l medium and higher the substance inhibited differentiation of cells. we observed contracting myocytes in , and wells out of wells in total at concentrations of , and mg/l. at mg/l no differentiation was observed. effects on cell viability were observed at mg/l. unexpectedly, we found a higher potency with ledipasvir. at the low, therapeutically relevant concentration of mg/l this nsa -inibitor showed a clear impact on differentiation with out of wells affected and no differentiation at higher concentrations. addition of sofosbuvir or its main metabolite psi- at concentrations up to mg/l had no influence on the concentration effect curves established for daclatasvir or ledipasvir. this is the first indication of an embryotoxic potential of ledipasvir. the difference to the results from the routinely performed animal experiments is unknown. possibly, metabolic activity in the maternal organism is responsible for this discrepancy. dimoxystrobin is a european-registered pesticidal active ingredient. biologically it is acting as an inhibitor of the fungal respiratory chain. for the purpose of european registration a full set of toxicological studies has been conducted with dimoxystrobin, including reproduction toxicity studies (according to the most recent oecd tg ) and developmental toxicity studies (oecd tg ) in rats and rabbits. dimoxystrobin interferes with the iron transport in rats and mice. this leads to lower serum iron levels and anemia in rats after repeated exposure. this holds true for treated dams and offspring in reproduction toxicity studies. furthermore, offspring effects seen at the high dose of the -generation toxicity study were a hypochromic microcytic anemia, impaired body weight development, which only developed postnatally, and reversible cardiomegalies in some -days old pups. for all effects clear noaels were determined. in the -generation toxicity study no dose adjustment during pregnancy and lactation was performed, which resulted in considerably higher food and compound intakes in dams and offspring during these lifestages. as a result, it seemed, that pups were more severely affected by body weight effects compared to the parental generation. by performing a life-stage specific comparison of body weight and substance intakes, as well as benchmark dose calculations (bmd) for these parameters, it could be demonstrated that the point of departures (pods) and the loaels for direct dimoxystrobin-related effects were comparable for offspring and parents. the heart effects (cardiomegaly), which were reversible, occurred only after direct dimoxystrobinexposure and are considered to be secondary to the detected offspring anemia. both effects (lower body weights and offspring cardiomegalies) only occur postnatally and are not the consequence of in-utero exposure, as no respective effects at higher doses in rat prenatal toxicity studies were seen. two new mechanistic studies ( -generation toxicity study and a -week study in young and adult rats, additionally investigating serum iron levels and anemia) confirmed, that pups and young rats were not more sensitive than adult animals to develop anemia or decreased serum iron levels. in , dimoxystrobin was classified with r (possible risk of harm to the unborn child) by the ecb, which was the european authority responsible for classification and labeling, before echa in helsinki was formed. the r (which has been translated into the ghs classification repr. , h d) was based on offspring body weight and heart effects seen in the -generation toxicity study. based on a comprehensive re-evaluation of existing and on new data of dimoxystrobin, the conclusion can be drawn, that a classification for reproduction toxicity is scientifically not justified and should be reconsidered. perfluorooctanesulfonic acid (pfos) and perfluorooctanoic acid (pfoa) are perfluorinated substances (pfas) which are used for the fabrication of surfaces with water-and dirt-repellent properties. due to their reprotoxic properties and their persistence in the environment, the use of pfos was restricted in and a restriction program for pfoa was initiated in . therefore, industry switches to pfoa and pfos substitutes, which are predominantly pfas with a shorter carbon chain length, or structure-related compounds. in contrast to pfoa and pfos only few toxicological data are available for their substitutes. aim of this study was to examine endocrine effects of the substitutes perfluorohexanesulfonic acid (pfhxs), perfluorobutanesulfonic acid (pfbs), perfluorohexanoic acid (pfhxa), perfluorobutanoic acid (pfba) and , , , -tetrafluoro- -(heptafluoropropoxy)propionic acid (genx) in comparison to pfoa and pfos. a hek- t cell-based dual-luciferase reporter gene assay was used to investigate the potential of these compounds to affect the activity of the human estrogen receptors herα and herβ. the reporter gene assay revealed no activation of herα or herβ by the pfas tested in this study. to investigate the potential inhibition of herα and herβ by pfas, a coincubation with the estrogen receptor agonist β-estradiol was performed. none of the tested pfas inhibited herα or herβ activity. however, in the case of herβ an enhancement of β-estradiol-stimulated activity was observed. thus, pfas do not directly activate or inhibit the human estrogen receptors but have an impact on herβ activity as they amplify the activation mediated by β-estradiol. further studies will be conducted to examine this synergistic effect in more detail. the xeer-reporter cell line: a novel dual-color luciferase reporter assay for simultaneous detection of estrogen and arylhydrocarbon receptor activation p. tarnow consumers are exposed to a multitude of anthropogenic and natural substances capable of activating or inhibiting ligand activated transcription factors, respectively. this in turn can lead to adverse health effects, particularly for substances acting on signalling pathways that are subject to regulatory crosstalk such as xenoestrogens and polycyclic aromatic hydrocarbons (pahs). xenoestrogens are known to activate human estrogen receptors (ers), whereas pahs or dioxins act on the arylhydrocarbon receptor (ahr). importantly, both receptor signalling pathways are interconnected by a complex crosstalk on multiple levels. this ranges from direct protein-protein interactions to competition for common co-factors. however, although this cross-talk has been long known we still lack a deeper understanding of its molecular mechanisms and physiological implications. one reason for this is a lack of tools to visualise and investigate receptor interaction in vivo. based on the breast cancer cell line t d we thus developed a dualcolour reporter assay which allows time-resolved simultaneous monitoring of the activation of er and ahr in living cells. the assay uses two beetle luciferases emitting luminescence in the red (slr) and the green (eluc) spectrum, respectively. while eluc is expressed under the control of a -fold repeated xenobiotic response element (xre) slr is subject to transcription regulation by a -fold repeated estrogen response element (ere). both constructs were stably transfected into t d human breast cancer cells, which endogenously express erα and ahr and are thus ideally suited for monitoring interactions with both receptors. the respective "xeer"-cell line has been successfully subjected to proof of principle studies, using prototypical er-and ahrligands as well as various phytochemicals and xenobiotics. besides e and tcdd ligands included various pahs, polychlorinated biphenyls, alpha-and betanaphthoflavone, cosmetic ingredients (butylparaben, benzophenone- and -mbc), bisphenol a, genistein, resveratrol, diindoylmethane as well as pharmacological antagonists of both receptors. asian women consuming soy rich food throughout life possess lower levels of betaestradiol (e ) in plasma (pl) than western women, whose diet is characterized by less soy consumption during early life and possible intake of soy based dietary supplements during adulthood. however, the impact of these soy exposure scenarios on estrogen (biotrans)formation and the consequence thereof in female mammary glands (mg) has not been investigated yet. thus, female august copenhagen irish rats were fed either isoflavone (if) depleted diet (idd, western exposure scenario without if supplement) or if rich diet (ird, asian exposure scenario) until the end of the study at postnatal day (pnd) . furthermore, rats fed idd until pnd were fed ird for days (idd+ird, western dietary exposure scenario with if supplement). estrous was determined histologically. levels of transcripts were determined by qpcr and e and estrone (e ) in pl and mg were quantified by gc-ms/ms. statistical analyses of estrogens were performed by kruskal wallis and unpaired wilcoxon tests and of transcript levels by linear regression models considering the explanatory variables tissue levels of e and diet (idd vs ird and idd vs idd+ird). e levels in pl and mg did not coincide with those predicted by estrous. furthermore, median levels of e and ratios e /e in mg and ratio of e levels in pl/mg were not affected by diet. in contrast, diet tended to affect e concentrations in pl (p= . ) due to an increase in the ird group (p= . ) whereas e levels in the idd+ird group only tended to be elevated (p= . ). in mg, ird and idd+ird increased e levels only weakly (p= . each). likewise, besides significant changes in transcript levels of cyp a and a , putatively decreasing oxidation of e to catechols, in the idd+ird group and (not significantly) also in the ird group, no changes in transcript levels putatively affecting e levels were observed. moreover, no decrease in levels of transcripts indicative for cellular (oxidative) stress (gclc, tp , mt a) was observed in the idd+ird group. e mg levels were significantly associated with an increase in transcript levels of areg and pgr, indicating activation of estrogen receptor (er). in contrast, ird was associated with a significant and idd+ird with a not significant decrease in pgr transcript levels. e levels but not diet were significantly associated with gata transcript levels, indicating tissue differentiation. furthermore, levels of transcripts involved in intercellular communication (egfr, wnt ) were significantly decreased by idd+ird and not significantly by ird and differed from that affected by e (increase in gdf , hgf, igf r, wnt a). bmf, a marker transcript for apoptosis was increased by ird, but not affected by e and even decreased not significantly by idd+ird. taken together, despite an increase in e levels in pl, less er activation was observed after dietary exposure to if. whereas e and transcript levels of enzymes involved in e (biotrans)formation as well as er activation and cellular communication were affected similarly but to a different extend in both asian and western if exposure scenarios, differences in apoptosis were observed between ird and idd+ird groups. supported by dfg le / - . august copenhagen irish (aci) rats with β-estradiol (e )-releasing implants are an accepted model to study the etiology of breast cancer, but neither e (biotrans)formation in mammary gland tissues (mg) during tumorigenesis, nor the impact of isoflavones (if) shown to affect tumorigenesis in aci rats, has been investigated, yet. therefore at postnatal day (pnd) and , placebo (-e ) or silastic implants containing mg e were implanted in female aci rats exposed to either if depleted diet (idd) or if rich diet (ird) since conception until the end of the study at pnd . palpable mg tumors (pt) and - mg per animal without pt were characterized histologically and categorized into normal (-e group, n= ), hyperplasia and non-pt and pt with and without solid tumors (+e group, n= ). e , estrone (e ), their hydroxylation products and methylation (meo-) products thereof, as well as conjugates of e and e in plasmas and mg were analyzed by gc-and uhplc-ms/ms, respectively. levels of transcripts involved in (biotrans)formation of e and estrogen receptor (er) activation were determined by taqman®-pcr. without exogenous e , plasma e as well as e and (borderline) e levels in mg were higher in ird. plasma e as well as e and e levels in mg were lower in the -e group than that in the +e group. e levels as well as e /e and e mg/plasma ratios were elevated in pt, accompanied by a significant increase in transcript levels indicative for estrogen receptor activation (areg, pgr) and proliferation (mki ). ird increased e /e ratio in pt and, although ird did not affect er activation (areg, pgr), ird increased differentiation (gata ) in normal and hyperplastic tissues and tended to decrease proliferation in hyperplastic (ccnd ) tissues. levels of e and -meo-e were highest in hyperplastic tissues, accompanied by an increase in transcript levels of hsd b (conversion e to e ) and cyp a . transcript levels of gstm and gstm were decreased in the whole +e group and of gstt and gstt in hyperplastic tissues, possibly decreasing inactivation of electrophilic metabolites. accordingly, maximum transcript levels of tp and mt a indicating cellular (oxidative) stress were observed in hyperplastic tissues. ird did neither affect levels of -meo-e nor cellular stress (gclc, mt a, tp ). of note, neither -meo-e , nor e catechols, nor e catechols nor methylation products of the latter were observed in any sample. furthermore, no conjugates of e or e were detected in plasmas and mammary gland tissues. thus, changes in transcript levels of conjugating enzymes induced by tumorigenesis and by ird were not related with detectable conjugate levels of e or e . taken together, whereas hyperplastic tissues were characterized by maximum oxidative metabolism of e and cellular (oxidative) stress, pt exhibited highest e levels and er activation. ird increased differentiation and decreased proliferation in normal and hyperplastic tissues but increased e /e ratio in pt. supported by dfg le- / - . level of beta-estradiol (e ) in human breast tissue is considered to affect breast cancer initiation, promotion and progression. although putatively beneficial and adverse effects of soy isoflavones (if) on the human mammary gland, in particular in western women, have been discussed extensively, the influence of if levels on estrogen formation in human mammary gland tissue has not been investigated yet. thus, glandular tissues were dissected from mammoplasty specimen obtained from women (age - years old) not taking estrogen active drugs. of these women had been exposed to if by their usual diet or by intake of a soy-based dietary supplement for days prior to mammoplasty. information on soy consumption and lifestyle were collected by questionnaire and tissues were characterized histologically. genistein, daidzein their conjugates (n= ) and bacterial metabolites (n= ) as well as the estrogens estrone (e )-sulfate, e , e and -methoxy-e were determined by uhplcand gc-ms/ms, respectively and transcript levels of enzymes involved in e (biotrans)formation were quantified by taqman®-pcr in glandular tissues. isoflavonoids were categorized into the if parameters aglycones (agl) and conjugates (con) of either genistein, daidzein or sum of both and were further statistically analyzed by spearman`s rank correlation analysis. a positive correlation of e /e ratio with agl(+con) was observed in glandular tissues (r= . , p= . ), accompanied by a significant negative correlation of e levels with agl (r=- . /p= . ), possibly due to reduction of beta-hydroxysteroid dehydrogenase (conversion of e to e ) expression as indicated by a weak negative correlation of transcript levels of beta-hydroxysteroid dehydrogenase with agl+con (r=- . , p= . ). further statistical analysis taking into account multiple variables using linear regression models will provide more insights into variables affecting e /e ratio. taken together, estrogen profile in human glandular breast tissue seems to be affected by if levels. supported by dfg le- / - . allergic contact dermatitis (acd) is a widespread disease often caused by substances in consumables. the eu prohibits the testing of cosmetic ingredients in vivo. this urges the development of reliable in vitro testing strategies. activation of dendritic cells (dcs) represents a key step during sensitization as they are essential for selection and priming of allergen specific effector t cells. in an integrated omics approach we aimed to further elucidate the molecular mechanisms of dc activation using quantitative metabolomics and proteomics. monocytic thp- cells were used as a model system and treated with the sensitizer , dinitrochlorobenzene (dncb; , and µm) and the irritant sodium dodecyl sulfate (sds; µm). samples were taken after , and hours. thp- activation was analyzed by measuring the established activation markers cd and cd after hours. a targeted lc-ms/ms approach was used to analyze metabolites including amino acids and lipids. protein levels were quantified by nano-lc-maldi-ms/ms after stable isotope labeling by amino acids in cell culture (silac). data sets were examined by multivariate analyses for identification of biomarker candidates. regulated metabolites and proteins were subjected to pathway analysis. the data presented might contribute to the further development of suitable in vitro testing methods for chemical-mediated sensitization. drug induced liver injury (dili) is one of the most frequent causes of acute liver injury and a main cause for drug withdrawals. currently there are no reliable models to test the dili potential of new compounds available. kupffer cells (kc) play an important role in hepatic cell stress mediated through chemokines and release of endogenous proteins. kc activation by damaged or stressed hepatocytes can lead to activation of the nf-κb signaling pathway transmitted by reactive oxygen intermediates (roi). we have recently established a liver model composed of primary human hepatocytes (phh) and kc which enables investigation of immune reactions after induction of hepatocyte stress (kegel et al., ) . aim of the present study was the kinetic investigation of hepatic cell stress induction and macrophage activation after treatment with subtoxic concentrations of hepatotoxic drugs. primary human hepatocytes (phh) and kc were isolated from human liver resectates using a two-step collagenase perfusion technique. initial kc activation was characterized by the dcf assay and immunofluorescence staining. phh were incubated with different concentrations of acetaminophen (apap) and diclofenac (dic) for different time intervals. cell stress was evaluated by measurement of oxidative stress (dcfassay) and viability (xtt-assay). in order to simulate macrophage activation following hepatocyte damage, kc and macrophages derived from the monocytic cell line thp- were incubated with supernatants of phh treated with hepatotoxic compounds. kc and thp- -macrophage activation were investigated by measuring intracellular formation of roi using the dcf-assay and cell activity using the xtt-assay. the characterization of kc activation revealed a donor and disease dependent kc activation resulting in kc differentiation to pro-and anti-inflammatory macrophages. therefore, kc were substituted by macrophages derived from thp- cells. evaluation of hepatic cell stress showed the strongest effect on thp- -macrophages when phh were incubated with apap or dic for h.treatment of kc and thp- -macrophages with supernatants of phh challenged for h with hepatotoxic compounds indicates that thp- -derived macrophages react similar to kc when treated with phh supernatants in terms of cell activity and roi-production. in conclusion, thp- derived macrophages might be a suitable alternative to kc concerning macrophage activation. the evaluated kinetic window of h covering hepatic stress induction and immune reaction allows to perform these measurements in a since the use of cerium dioxide nanoparticles is known to be beneficial e.g. in terms of reducing fuel consumption when added to diesel fuel it has become a frequently used nanomaterial. to compensate the concurrent lack of information on its toxicology a day nose-only inhalation study was initiated. by comparing the results to a combined chronic inhalation toxicity and carcinogenicity study using the same test items and experimental conditions (basf, ludwigshafen, germany) early indicators for genotoxic and carcinogenic effects should be determined. rats were exposed to , . , . , and mg/cm³ ceo as well as mg/m³ baso nanoparticles ( h/day, days/week, weeks). animal dissections were conducted at five time points (exposure day and ; recovery day , and ) aiming for endpoints mandatory according to oecd guideline . additionally, gene expression analyses in isolated pneumocytes type ii were performed using pathway arrays for inflammation, oxidative stress, genotoxicity, apoptosis and lung cancer. the given results intend the identification of marker genes displaying modulated expression in response to nanoparticle exposure. investigations on ceo and baso retention in the lung are also included in this project. in bronchoalveolar lavage fluid (balf) a time and dose-dependent increase of inflammatory cells has been detected up to the end of exposure. the amount of inflammatory cells decreased during post-exposure; however, in the high dose group a persistent inflammation up to days was detected by balf and histopathology examination. based on our current results effects of ceo nanoparticles on the respiratory system are suggested. its relevance in the context of long term effects such as tumor development needs to be estimated considering all investigations included in this study. the inhalt- project is funded by the german federal ministry of education and research (bmbf) - x a. core or coating material? what dictates the uptake and translocation of nanoparticles in vitro? nanoparticles are becoming increasingly important role in consumer-related products. understanding the interactions between nanoscaled objects and living cells is therefore of great importance for risk assessment. in this context, it is generally accepted that nanoparticle size and shape are crucial parameters regarding the potential of nanoparticles to penetrate cell membranes and epithelial barriers. current research in this field additionally focuses on the particle coating material. in order to distinguish between core-and coating-related effects in nanoparticle uptake and translocation behavior, this study investigated two nanoparticles equal in size, coating and charge but different in core material. silver and iron oxide were chosen as core materials to ensure similar nanoparticles characteristics after particle synthesis. nanoparticles were coated with poly (acrylic acid) (pas) and extensively characterized by tem (transmission electron microscopy), saxs (small-angle x-ray scattering), zetasizer tm and nanosight tm . for uptake and transport studies the widely used human intestinal caco- model in a transwell tm -system with subsequent elemental analysis (aas) was used. for evaluation and particle visualization transmission electron microscopy (tem) and ion beam microscopy (ibm) were conducted. although similar in size, charge and coating material, the behavior of particles in caco- cells was quite different. the internalized amount was comparable, but pas-coated iron oxide nanoparticles were additionally transported through the cells. by contrast, pascoated silver nanoparticles remained in the cells. our findings suggest that the coating material influenced only the uptake of the nanoparticles whereas the translocation was determined by the core material. in summary, a core-dependent effect on nanoparticle translocation was revealed. both the uptake and transport of nanoparticles in and through cells should be considered when discussing nanoparticle fate and safety. nanotechnology is having a great impact not only on basic research but also on many sectors of industry opening the market for numerous new applications ranging from electronics to the health care system. besides their great innovative potential, the large variety of existing synthetic nanomaterials used in the last decade represents a major challenge for scientists and regulators in terms of measuring and assessing the potential hazard caused by the materials or the products themselves. equally, consumers often miss reliable and easy-to-understand information on nanomaterials and nanotechnology and do not know where to get such information. therefore, the international dana . expert team brings together its expertise and knowledge from different research areas dealing with all aspects of nanosafety research in order to create and provide easy-to-understand, up-to-date and quality-approved nanomaterials' knowledge base on www.nanopartikel.info. this information platform covers the market-relevant nanomaterials focusing on their effects on the safety of humans and the environment.in order to manage and asses the rapidly increasing number of publications related to nanosafety issues, the dana . project developed a customised methodology «literature criteria checklist», which includes mandatory and desirable assessment criteria covering physico-chemical characterisation, sample preparation and (biological) testing parameters. this checklist facilitates the discrimination between high-and low quality publications and all positively evaluated literature is then fed into the dana knowledge base. accounting for the need to harmonise experimental practices, the dana team also developed a template for standard operation procedures (sop) to support careful scientific practice. validated protocols generated within the german bmbf-funded nanosafety research projects are presented together with results from the swiss ccmx project v.i.g.o. and available for download. another unique feature of the dana knowledge base is the integrated application-based database that provides a unique link between nanomaterials in real applications (e.g. environmental remediation or medical products) and their potential impacts/ toxicological effect(s) that can be easily accessed by the interested visitor. additionally, dana . provides a list of faqs, a link platform with contact data to other information portals and the opportunity to directly pose questions to our experts via e-mail. dana . is also present on twitter, follow us @nano_info. background: particulate matter of combustion processes enhances cardio-vascular diseases and increases associated mortality rates. around % of total pm emissions are emitted by wood burners (uba ) . how wood combustion aerosols (particles and gasses) can affect human lung cells and how such cellular responses depend on the usage of different wood types and burners is widely unknown. methods: in an exposure chamber imitating the human respiratory tract human alveolar cells (a ) were exposed at an air-liquid-interface (ali) to gasses and particles of wood combustion aerosols. log wood of beech, birch and spruce was burnt in a conventional oven and compared to the combustion of wood pellets in a modern pellet burner. the combustion aerosols were diluted : and directly delivered to the exposure chamber. after h exposure the lung cells were lysed and rna was isolated. in an array based transcription analysis of the whole genome the effects of the aerosol exposures on lung cells was assessed. in parallel, physical and chemical parameters of the combustion aerosols were analyzed. results: the combustion aerosol of wood pellets contained less organic substances than the log wood aerosols, but was higher in its zinc content. genome-wide we found a higher number of regulated genes with combustion of pellets compared to combustion of log wood. the gas phase alone (filtered aerosol) showed comparable gene regulatory activity as the particle-containing total aerosol. aerosol from log wood burning induced mainly genes of the xenobiotic metabolism and cellular signaling. pellet aerosols additionally regulated apoptosis and dna repair processes. conclusions: modern pellet burners reach better combustion efficiencies than conventional log wood ovens, but their emissions seem to stress human lung cells stronger. one reason might be the higher zinc content of wood pellet aerosols. multiwalled carbon nanotubes (mwcnts) may pose as a risk similar to asbestos in causing cancer, notably mesothelioma, which is a malignant tumor originating from mesothelial cells. to identify molecular cues leading to mesothelioma development, we performed genome-wide transcriptome analysis using microarrays in primary human peritoneal mesothelial lp cells treated with two different tumor-inducing tailor-made mwcnts (rat model; rittinghausen et al. part fibre toxicol : ), or amosite asbestos at µg/cm for h. specifically, we determined how the transcriptomic changes of the highly tumorigenic mwcnt a would differ from another tumor-inducing mwcnt with albeit lesser potency (mwcnt d), long amosite asbestos as positive control, and milled mwcnt a as material control. initial analysis using bioinformatic tools, revealed significantly differentially regulated genes for mwcnt a, for mwcnt d, for amosite, and for milled mwcnt. further analyses with ingenuity pathway analysis comparing the two different mwcnt types and amosite, found common as well as exclusive biomarkers. interestingly, we identified many differentially regulated genes implicated in cellular senescence, a growth arrest in response to different stressors including dna damage, disrupted chromatin, and strong mitogenic signals. paradoxically, cellular senescence can represent both tumor suppression and tumor promotion mechanisms. more important, we found differential expression of genes associated with senescence-associated secretory phenotype (sasp) such as inflammatory cytokines, chemokines, proteases, and growth factors, which were manyfolds up-and down-regulated in mwcnt a, compared to mwcnt d and amosite. the mechanisms leading to mesothelioma induction by mwcnts are from far clear, but the key information emerging from the present transcriptomic data, together with our previously identified senescence markers, indicate that cellular senescence has a likely role. nanotechnology offers great advantages for the food industry despite its partly unknown risks, whose enlightenment is the main target of nanotoxicology. due to variability in terms of size, material, shape, surface texture and several endogenous influences, the toxicity of most frequently used and ingested nanomaterials is difficult to estimate. therefore, the aim of this study was the in vitro investigation of toxicological endpoints such as cell viability, dna integrity and the induction of apoptotic processes in human colon carcinoma cells (ht ). for this purpose ht cells were exposed for hours with metal nanoparticles (gold, silver) and metal oxide nanoparticles (copper oxide, titanium dioxide, zinc oxide) in concentrations of - µg/ml. at first the cellular uptake of the nanoparticles by means of an icpms was determined. the influence of cell viability was demonstrated by the trypan blue staining and the mtt assay. the alkaline comet assay gave information about possible dna damages and the use of the repair enzyme formamidopyrimidine dna glycosylase (fpg) additionally allowed the detection of oxidized bases. the induction of programmed cell death was examined using by annexin v fitc assay. the icp-ms data showed a maximum particle content of . pg per cell for the used concentration range. the metal oxide nanoparticles resulted in a significant reduction of cell viability with a decrease up to % after copper oxide and zinc oxide treatment. for metal particles, only for silver a reduced cell metabolism of about % was detectable by the mtt assay. low genotoxic effects could be determined for silver nanoparticles (tail intensity about %; control about %), while for titanium dioxide the amount of oxidized bases was additionally increased (tail intensity about %; control about %) for concentrations above µg/ml. induction of apoptosis was determined for silver particles (up to % early apoptotic and % late apoptotic cells) as well as for titanium dioxide and zinc oxide ( % each early apoptotic cells), whereby the most significant increase in late apoptotic cells was detected for zinc oxide (up to %). the results obtained in our studies indicate a clear particle-dependent influence on cell viability and apoptosis-triggering processes, depending on the used material or the concentration deployed, while only minor changes of dna integrity were detected. the evolution in the field of nanotechnology led to a variety of novel materials at the nanoscale. among them are different carbon materials like buckyballs, graphene nanoplates and carbon nanotubes (cnts). cnts are hollow carbon fibres with either one (sw) or multiple sidewalls (mw). mwcnts usually show a diameter of up to nm and can be several micrometres long. because of their nanoscale diameter cnt-uptake can take place directly through the plasma membrane of cells by the so called nanoneedle effect [ ] . additionally cnts, like most nanomaterials, show a high surface to volume ratio and, because of their micro scale length, a potentially high loading capacity. these properties make cnts interesting for the potential use as drug delivery carriers (ddcs). mwcnts, produced via chemical vapour deposition with a diameter of nm and µm length, were used in three different forms, unmodified, acid oxidized (ox_cnt) and ground. cytotoxicity testing was performed in human umbilical vein endothelial cells (huvec). the cells were seeded in -well plates and exposed to doses of , , and µg/cm² growth area of the respective cnt type for h. the wst- assay was applied for testing cell viability and the ldh cytotoxicity assay to identify potential damage to the plasma membrane and to calculate overall cytotoxicity. the results show that an increased oxidation time for the ox_cnts, in a h so /hno mixture, leads to decreased cytotoxicity in huvec, compared to unmodified mwcnts. during the oxidation reactive oxygen groups are formed on the cnt surface [ ] . these groups lead to a reduced hydrophobicity of the cnt surface which could be responsible for the decline in cytotoxicity. future investigations will include the toxicological analysis of mwcnts functionalized with polyethylene glycol (cnt-peg). the hydrophilic polymer peg will be covalently bound to the cnt surface and is expected to further reduce the cytotoxic effect. for these investigations different analytical methods will be used. among others, cell cycle analysis, the brdu assay, pathway arrays and qrt-pcr for the investigation of gene expression and cytokines will be measured. these methods will involve a co-culture model of huvec and human umbilical vein smooth muscle cells (huvsmcs) for a better approximation to the cellular in vivo situation. additionally the peg modified mwcnts will be tested for their loading capacity and efficacy with the anticancer drug doxorubicin for a potential use as an intravenous drug delivery carrier in vivo. although aluminium is one of the most common elements in the biosphere, up to now little is known about its impact on human health. aluminium and its chemical derivatives are highly abundant in food, food contact materials and consumer products what leads to an exposition via the gastrointestinal tract (gi tract), the lung and via skin contact. recently, aluminium is hypothized to cohere with cancer and neurodegenerative disorders. lately, due to an increasing attentiveness on this topic, limiting values for food additives have been tightened by the eu commission. however, cellular effects of aluminium and especially aluminium-containing nanomaterials, are in the focus of our research activities, for example in the international solnanotox project. we established an in vitro simulation system of the gi tract, where nanomaterials undergo the different physiological, chemical and proteinbiochemical conditions of saliva, gastric juice and the intestine. the artificially digested nanomaterials, as well as soluble aluminiumchloride as ionic control substance, were subjected to several analytical and biochemical methods to characterize their change of appearance and their cytotoxic effects on intestinal cellular models. we observed the fate of the nanomaterials during typical ph-values of saliva, gastric and intestinal juice with dynamic light scattering measurements and icp-ms in the single particle mode. after observable disappearance at ph the particles recovered in the simulated intestinal fluid. the simulation of the gi tract, mainly the change of ph settings, may lead to a certain chemical activation of aluminium that can increase bioavailability in the intestine after oral uptake of aluminium-containing food products. in vitro assays like ctb, mtt and cellular impedance measurements showed that there were no acute cytotoxic effects measurable after a period up to h after incubation, comparable to undigested particles. in contrast, high amounts of aluminium ions showed additional effects on cell viability compared to non-digested aluminium ions. although toxicological potential of al ions to healthy tissue appears to be low, increased hazardous potential cannot be ruled out to pre-damaged tissue and can have a relevance for special consumer groups with for example chronical intestinal inflammation or dietary eating behavior combined with high exposure to al-containing food products. in the eu, there is a strong need for solutions to substitute halogenated flame retardant (hfr) additives, employed in the fabrication of fr thermoplastic and thermoset materials. these materials are used in diverse commercial products, applications and markets, such as electrical/electronic devices, low-voltage wires or household appliances. the phoenix project, funded by the european union th framework program (grant agreement no. ), therefore investigates e.g. several tailor-made, nano-layered hybrid particles as alternatives to hfr additives. considering "safer-bydesign" strategies, potential fr nanomaterials (nm) were physico-chemically characterized (e.g. particle size distribution, zeta potential) and screened early in development for their (geno)toxic and pro-inflammatory potential to timely reject nm with high health hazard. as inhalation is the most important exposure route for nm, lungrelevant cells were used as in vitro screening models. to better enable detection and differentiation of the biologic effects of the most promising nm, screening was started with primary rat lung alveolar macrophages (am; cells of first contact for inhaled nm), at a high concentration of µg/cm ( h of incubation), using membrane damage (lactate dehydrogenase release assay), direct dna-damage (alkaline comet assay), and il- liberation (elisa) as primary endpoints, and quartz dq and al o as particulate positive and negative controls, respectively. in this screening system, biologically inert nm could be differentiated from more active ones. thereby, mg(oh) nanoplatelets (mg ; mean lateral size: , - µm; mean thickness: - nm) represented the least, and pristine few layers graphene nanoplatelets (gr ; mean lateral size: µm; mean thickness: nm; graphene layers: ± . ) the most biologically active nm. clear concentration dependencies were detected for gr in follow-up experiments. mg and gr were further tested in other lung-relevant cell types, i.e. mrc- primary human lung fibroblasts and a lung adenocarcinoma epithelial cells. interestingly, mrc- cells were less sensitive towards biological effects of gr , compared to am, whereas a cells showed nearly no effect, keeping in mind that lung epithelial cells are the target cells of lung tumor development. to test the hypothesis that the observed cellspecific differences in sensitivity might in part be based on cellular uptake, cells were exposed for h to . or µg/cm of gr on chamber slides. slides were finally stained with dapi and analyzed by dark field microscopy. cells indeed demonstrated differences in uptake capacity and also showed unique pattern of cellular localization of gr , i.e. with tight perinuclear agglomeration in am, a more scattered cytoplasmic distribution in mrc- cells and limited uptake in a cells. additionally, biological activity of the diverse nm seemed also to correlate with cellular uptake, as determined by light and dark field microscopy in am and mrc- cells. in conclusion, an am-based screening system was able to differentiate biological activity of diverse nm, with morphology, physico-chemical characteristics, and related cellular uptake most likely to be key for nm-and cell type-specific hazard. lung carcinogenicity and putative systemic effects of low-dose life-time inhalation exposure to biopersistent nanoparticles were examined in a chronic inhalation study performed according to oecd test guideline no. with several protocol extensions. female rats ( /group) were exposed to cerium dioxide (nm- , . ; . ; ; mg/m³) for two years; a control group was exposed to clean air. after one year exposure, µg/lung was found in animals exposed to . mg/m³ and . mg/lung in animals exposed to mg/m³. histological examination of lungs revealed several adverse and non-adverse effects in the lung. the non-adverse effects comprised accumulation of particle-laden macrophages in alveolar/interstitial areas and in the balt, particle-laden syncytial giant cells in the balt and bronchiolo-alveolar hyperplasia (alveolar bronchiolization). the adverse effects included (mixed) alveolar/interstitial inflammatory cell infiltration, alveolar/interstitial granulomatous inflammation, interstitial fibrosis and alveolar lipoproteinosis. the incidence and severity of the effects were concentration-related. alveolar lipoproteinosis was not observed at low concentrations of . and . mg/m³ ceo . neither pre-neoplastic nor neoplastic changes were observed after -months exposure. a no observed adverse effect concentration could not be established in this study. the comprehensive histopathological examinations of lungs and other tissues will be finalized in . this project is part of the eu project nanoreg. moreover, german federal ministry for the environment, nature conservation, building and nuclear safety, german federal institute for occupational safety and health, german federal environment agency funded this project. lung carcinogenicity and putative systemic effects of low-dose life-time inhalation exposure to biopersistent nanoparticles were examined in a chronic inhalation study performed according to oecd test guideline no. with several protocol extensions. female rats ( /group) were exposed to cerium dioxide (nm- , . ; . ; ; mg/m³) and barium sulfate (nm- ; mg/m³) for two years; a control group was exposed to clean air. lung burdens and burdens in extrahepatic tissues were measured at various time-point. the two year exposure period was successfully terminated and animals per dose group were examined for organ burden and histopathology. the remaining animals currently are kept exposure-free for maximally additional months. up to two years exposure to both nanoparticles did not lead to body weight reduction compared to control animals. the mortality rates were in an acceptable range. macroscopically evident tumors were not detected after two years. the ceo lung burdens were maximally . mg/g lung tissue at the highest exposure concentration of mg/m³. in comparison, highest ceo burdens in organs remote to exposure were liver and spleen with maximally roughly x - g/g tissue. in brain, maximum ceo levels were x - mg/g lung tissue. baso lung burdens were comparatively low ( mg/g) within the first weeks of exposure and steeply increased to mg/g lung tissue after one year. the comprehensive histopathological examinations of lungs and other tissues will be finalized in . the european centre for ecotoxicology and toxicology of chemicals (ecetoc) 'nano task force' proposes decision-making framework for the grouping and testing of nanomaterials (df nano) that consists of tiers to assign nanomaterials to main groups, to perform sub-grouping within the main groups and to determine and refine specific information needs. the df nanogrouping covers all relevant aspects of a nanomaterial's life cycle and biological pathways, i.e. intrinsic material and systemdependent properties, biopersistence, uptake and biodistribution, cellular and apical toxic effects. use (including manufacture), release and route of exposure are applied as 'qualifiers' within the df nano to determine if, e.g. nanomaterials cannot be released from a product matrix, which may justify the waiving of testing. the four main groups encompass ( ) soluble nanomaterials, ( ) biopersistent high aspect ratio nanomaterials, ( ) passive nanomaterials, and ( ) active nanomaterials. the df nano aims to group nanomaterials by their specific mode-of-action that results in an apical toxic effect. this is eventually directed by a nanomaterial's intrinsic properties. however, since the exact correlation of intrinsic material properties and apical toxic effect is not yet established, the df nano uses the 'functionality' of nanomaterials for grouping rather than relying on intrinsic material properties alone. such functionalities include system-dependent material properties (such as dissolution rate in biologically relevant media), bio-physical interactions, in vitro effects and release and exposure. the df nano is a hazard and risk assessment tool that applies modern toxicology and contributes to the sustainable development of nano-technological products. it ensures that no studies are performed that do not provide crucial data and therefore saves animals and resources. the the grouping decisions of df nano for nanomaterials were validated against grouping by results of existing in vivo data and demonstrated concordant grouping decisions. serum concentrations in cell culture medium influence the effect of cerium oxide nanoparticles on human lung a cells: cytotoxicity, proinflammation, cellular uptake, and particle properties k. burchardt the wide use of cerium oxide (ceo ) nanoparticles (np), e.g. as fuel additive and for industrial and biomedical applications, evoked intense studies to understand the effects those particles might have on living organisms. contradictory results of ceo nanoparticle toxicity have been published as they depend on many variables like shape, size, diluent and others. in our work we used an in vitro model of ceo nanoparticles and lung carcinoma cells to investigate the role of serum content in the cell culture medium on cellular toxicity, particle uptake, proinflammation and particle characteristics. proinflammatory ceo np with an average diameter of - nm and different concentrations were diluted in cell culture medium with different fetal calf serum (fcs) concentrations ( . , . , and %) and were used to expose human lung adenocarcinoma cells (a ) for up to hours. at µg/ml ceo np showed little to no toxic effecton growth arrested a cells at fcs concentrations of % or below, but cell viability was decreased to about % in proliferating cells in cultures with % fcs. the proinflammatory effect of ceo np was investigated through measurement of il- mrna expression after hours and cellular il- secretion after hours. the qrt-pcr showed that the expression of il- mrna in cells treated with µg/ml ceo np in % fcs medium was three times higher than in cells treated with lower fcs concentrations. this finding correlated with the cellular il- secretion, which showed a stronger increase by cells treated at % fcs. differences in cellular uptake of ceo np was determined by fluorescence-activated cell sorting (facs) after and hours of exposition. after hours, the cells treated with ceo np in % fcs medium showed a lower mean granularity (∆gmean) as measure for cellular particle uptake than those with less fcs in medium. after hours all probes showed about the same granularity. to examine the effect the fcs concentrations on ceo np characteristics in cell cultures we used dynamic light scattering (dls) and phase contrast microscopy (pcm). dls measurements revealed an increasing hydrodynamic diameter of the particles with decreasing fcs concentrations (about nm ( % fcs) to nm ( . % fcs)), which was correlated by an increasing particle agglomeration shown by pcm. our results show that the fcs concentration in cell culture medium has a direct or indirect impact on the cytotoxicity, the proinflammatory effect, the facs parameter for cellular particle uptake as well as on particle properties, which should be taken into account when designing, performing and interpreting in vitro experiments to investigate the toxicity of nanoparticles. toxic and inflammatory effects of shape-engineered titanium dioxide nanoparticles in nr rat alveolar macrophages. knowledge about the contrasting toxicity of nanoparticles (np) of different chemical composition has steadily increased over the past decade. however, available literature often reveals considerable differences in effects within a specific type of nanomaterial. these contrasts have been contributed to different handling and testing protocols as well as to sample-specific differences in physico-chemical properties of np that could affect their mode of interaction with cells. within the nanometrology project setnanometro, the highly controlled generation and characterisation of a large set of shape-engineered tio np allows us to investigate the potential role of subtle shape-and surface structure changes on np toxicity. as inhalation represents the most relevant uptake route of np, the nr rat alveolar macrophage cell line was selected for in vitro toxicological testing. since oxidative stress and inflammation are considered as key biological pathways in nanotoxicity, we evaluated the expression of the oxidative stress marker genes heme oxygenase- (ho- ) and g-glutamylcysteine synthetase (g-gcs) as well as the pro-inflammatory genes interleukin (il)- β, il- , il- and inducible nitric oxide synthase (inos) by qrt-pcr. protein levels of il- β and tumour necrosis factor-α (tnf-α) were measured by elisa. cytotoxicity testing of the tio np by wst- assay overall revealed only minimal toxicity in comparison to sio np which were used as reference material. ho- and g-gcs mrna analyses indicated that specific tio np triggered a moderate induction of oxidative stress. il- was only induced after sio treatment, whereas il- was not affected by any of the tested np. in contrast, various tio np caused a significant induction of il- β mrna expression. however, no significant induction of il- β and tnf-α protein secretion was observed for any of the tio np. the results obtained from these and ongoing investigations will be linked to the physico-chemical database as being developed for all tio np within the setnanometro project, with the overall aim to build and model nano-structure activity relationships (nsar) for this widely applied type of nanomaterial. acknowledgements: the setnanometro project is supported by the eu-fp programme. specific types of tio particles were obtained by solaronix (switzerland), evonik and cristal. potential of silver and silver nanoparticles to reduce n-acetyltransferase (nat ) activity j. lichter , b. blömeke trier university, department of environmental toxicology, trier, germany humans are exposed to various kinds of engineered nanoparticles including silver, which is frequently used in consumer and biomedical product due to its bactericide properties. despite their widespread usage, knowledge about influences on cellular functions is still incomplete. n-acetyltransferase (nat ), an enzyme which is ubiquitously expressed in human tissues, catalyzes the transfer of an acetyl group to its substrates and although its endogenous function is not clear yet, it is well known to be involved in the n-acetylation of arylamines. in addition nat enzyme activity is known to modulated by non-substrates including metals and certain nanoparticles, however, the influence of silver on nat has not been analyzed yet. to address whether human nat is a target of silver nanoparticles and released irons on protein, purified nat was exposed to silver ions (agno ) and silver nanoparticles (ag -cooh, average size nm, carboxyl functionalized), and nat enzyme activity was analyzing the n-acetylation of the nat substrate para-aminobenzoic acid (paba). therefore, purified nat ( ng/µl) was co-exposed for min to paba ( mm) and agno or ag -cooh ( . , . , , and µg/ml each), resulting in a nat :silver relation of : . - (w/w). both, agno and ag -cooh inhibited the n-acetylation of paba in a concentration dependent manner. using equal amounts of silver and nat (w/w, µg/ml) enzyme activity was reduced about ± . % (agno ) and ± . % (ag -cooh). the lowest concentration analyzed ( . µg/ml) reduced nat activity about ± % (agno ) and ± % (ag -cooh). fifty percent activity reduction was caused by . ± . µg/ml of agno and . ± . µg/ml of ag -cooh, which is -fold lower compared to the published ic values for other metal oxide nanoparticles ( - µg/ml). these data indicate that both chemical silver species are able to modulate paba acetylation. further studies will be performed to clarify whether silver ions and/or silver nanoparticles could affect the specific n-acetylation of arylamines in human cells. colloidal silver has been used in medicine for centuries and nanosilver is present in many consumer-related products. however, despite of intense research in the past few years, the potential of nanosilver to induce effects different from ionic silver in vivo and in vitro, is still under debate. in this study, we compared proteomic effects of nanosilver (agpure™) and ionic silver (silver acetate) in the kidney of male rats after repeated oral delivery in a rat -days toxicity study. in order to avoid overt signs of toxicity, silver was dosed moderately in amounts of and mg/kg body weight for nanosilver and corresponding amounts of silver acetate ( . and . mg/kg). accordingly, no pathologic effects, including results from clinical chemistry and hematology, were reported. kidney tissue protein crude extract was separated by -d gel electrophoresis and differentially expressed spots were identified by maldi-ms. unique proteins, showing a log ratio of ≤ - . for downregulation and ≥ . for upregulation were identified in all treatment groups. protein lists were analyzed with ingenuity pathway analysis (ipa). when comparing effects of particulate and ionic treatments, similar alterations were indicated for canonical pathways associated with glycolysis, gluconeogenesis and tricarboxylic acid cycle. regarding inflammatory responses, stronger effects were derived for ionic treatments. for both types of silver exposures, changes of protein expressions were linked to changes of fatty acid metabolism and nrf -mediated stress. mitochondrial dysfunction was highlighted for both nanosilver treatments only, as well as activation of the insulin receptor. in the top-scored network of the higher dose nanosilver treatment, upregulated - - protein zeta (ywhaz) displays a central position. ywhaz, an important regulator of cell cycle and apoptosis, interacts with the insulin receptor and is well known to be envolved in many types of cancer. overall, both forms of silver treatment revealed similar patterns of affected cellular and molecular functions in rat kidney, supporting common and overlapping mechanisms of particulate compared to ionic silver. because of the widespread application of nanomaterials and the fact that for some nanomaterials effects on different organisms where shown, nanomaterials are still in focus of interest. moreover the fate of nps is only partiallyassessed over the lifecycle of products containing nanomaterials. while general toxicological properties of nps are well described in diverse in-vitro and in-vivo experiments, the distribution of these particles during the whole and complex process of waste incineration shows big knowledge gaps. in the "nanoemission"-project the entire route from the residual material via incineration, filtering of the exhaust gas up to a possible release into the environment are considered together with the toxicological evaluation of effects on humans and the environment. in these experiments the influence of thermal waste treatment on the toxicological profile of nanoparticles, contained in the waste, will be described. after a complete characterization of the two types of baso -nps from two different manufacturers by scanning electron microscopy/ energy dispersive x-ray analysis (sem/edx), measurement of the specific surface area (bet) and dynamic light scattering (dls) we investigated the impact of the pure baso -nps on primary cells (normal human bronchial epithelial cells (nhbec) and peripherial lung cells (plc)). both materials show statistically significant cytotoxic effects in the resazurin-assay (decreased viability below % for mg/ml after h). in general the effects of both nps were almost similar. additionally the effects of the baso -nps were compared more in detail. uptake of the baso was quantified by icp-ms after h and h as well as the release of ba-ions into the cell culture medium after centrifugal separation. the incubation with baso of plc and nhbec to . mg/ml over h and h leads to ~ µg baso / mio cells. the uptake is dose dependent but not time dependent. the impact on the secretion of inflammatory cytokines was determined by bead-based multiplex-elisa flow cytometry. tnf-α, il- and il- could be detected in nhbec and plc after np incubation. the possible induction of apoptosis was measured by flow cytometry as well. first investigations showed no induction of apoptosis for both materials. the impact of both nps on the intracellular glutathione level was measured by hplc and showed a decrease of gsh after h. summing up baso -nps showed toxic effects in primary human lung cell cultures after h for concentrations under mg/ml. c exoenzyme from c. botulinum is an adp-ribosyltransferase that inactivates selectively rhoa, b and c by coupling an adp-ribose moiety. rho-gtpases represent a molecular switch integrating different receptor signalling to downstream transcriptional cascades that regulate various cellular processes, such as regulation of actin cytoskeleton, cell proliferation and apoptosis. previous studies with the murine hippocampal cell line ht revealed a c -mediated inhibition of cell proliferation and a prevention of serum-starved cells from apoptosis (rohrbeck et al., ) . former results of studies on map kinase signalling indicated c -induced modulations of downstream signalling modules. therefore, ht cells treated with nm c for h were applied for screening of the activity of various transcription factors followed by luciferase reporter assays. five transcription factors namely sp , atf , e f- , cbf, stat were identified as significantly regulated in their activity. for validation of identified transcription factors, studies on the protein level of certain target genes were performed. western blot analyses exhibited an enhanced abundance of sp target genes p and cox- as well as a raise in phosphorylation of c-jun. in contrast, the level of apoptosisinducing gadd , a target gene of atf , was decreased. our results suggest that c is able to modulate the activity of transcription factors whose target genes are involved in the regulation of cell proliferation and apoptosis. via covalent binding of chemical compounds to dna, adducts can be formed. as a consequence, mutations may occur, which represent stages of chemical mutagenesis and carcinogenesis. the isolation of leucocytes represents an essential field of work within dna-adductomics of blood cells, in which adducts serve as markers of exposure for biological monitoring. peripheral mononuclear blood cells (pbmc) comprising monocytes and lymphocytes can be separated from other blood cells like granulocytes, erythrocytes (and dead cells) by isopycnic density gradient centrifugation of buffy coats (bc´s). bc´s are blood concentrates rich in leucocytes and thrombocytes, prepared from whole blood samples thorough removal of plasma and erythrocytes. for the experiments only bc´s from healthy donors were used. while erythrocytes contain no dna, lymphocytes, which constitute a subcategory of leucocytes, carry genetic information. a variety of commercially available fluids with a density of . g/cm , based on different polymers, exists. these materials form the gradient required for the centrifugation. furthermore, there are several methods available, which differ in the ratio blood vs. fluid, duration of the different work up steps, centrifugation parameters and others. the aim of this work was to compare the effectivity of the different fluids and optimize the workflow. for isolation of pbmc the fluid was put in a tube and then covered by a thin layer of blood. after centrifugation, five layers were obtained (figure ). the interphase was removed carefully, washed and the cells were counted. the yield is expressed as percentage of isolated vs. total leucocytes in the bc, which was based on the leucocyte count of the whole blood sample. as separation fluids, ficoll® paque plus (ge healthcare), histopaque® (sigma aldrich) and lsm® (ge healthcare) were tested. no significant differences between the different fluids were observed. although dilution is often recommended in literature, it was found that dilution had no effect on the yield. similarly, using different fluids (rpmi or pbs) for the washing steps did not reveal any differences. increasing centrifugation speed from to xg resulted in higher yields. in general, large variations in yield ( . % ± . %) among the various bc´s arose. this result is due to the different parameters such as age, storage, leucocyte and erythrocyte counts of the different bc´s used. therefore, the test conditions were optimized using the same batch of bc. the results show that the low priced separation fluids are comparable in performance tothe more expensive ones. by the direct lamination with bc (without dilution) the wastage could be minimized, the yield increased and thus the isolation made more efficient. the franz cell is a well-established model in lots of skin research fields. we adapted the diffusion cell system to additives and contaminants of consumer products which are designated for skin contacts. we were aimed to simulate real exposure as realistic as possible. to meet requirements like longevity, haptic properties and factory costs, different polymers are used as the raw material of choice and modified by a variable number of additives in the majority of commodities. besides additives with a defined function such as plasticizers, stabilizers, colorants and vulcanization accelerators, contaminants as well as decomposition products or so-called non-intentionally added substances (nias) can be part of the material, among them potentially harmful substances. in a first step, polymers of consumer products like flashlights or tools have been characterized concerning additive composition. possible breakdown products were identified by means of gc-ms/ms or pyrolysis-gc-ms. we focused on analytes of toxicological relevance including antioxidants such as n-phenyl- -naphthylamine (neozon d), which is suspected of causing cancer, and on degradation products like cresol and its derivatives (e.g., mesitol or -tert-butyl- -methylphenol). subsequently, analytes of interest were brought into direct skin contact using porcine, human and artificial skin models in the franz cell chamber assay. the analytes were either followed up layer by layer using tape stripping or examined utilizing cryo sections. for visualization purposes, analytical evaluation has been completed by use of imaging techniques like he staining or atr-ftir (attenuated total reflectance fourier transform infrared) microscopy. the latter was used with intrinsic markers for tissue specific distribution. our project provides evidence for the potential of polymer components to overcome the natural epidermal barrier and, in part, to enter the viable layers of the epidermis. during skin contact with consumer products several substances migrate out of the matrix and penetrate the skin, among them substances which are hazardous to health such as neozon d. depending on its dose, the blister agent sulfur mustard (sm) may lead to painful erythema, blistering with complicated wound healing, pulmonary edema, pulmonary bleeding and temporary blindness. sm is listed as a schedule chemical in the chemical weapons convention and thus its production, stockpiling and use is prohibited. sm still represents a serious threat for civilians and military forces, especially in asymmetric, terroristic and accidental scenarios. after exposure, the highly reactive molecule alkylates nucleophilic sites in endogenous biomacromolecules forming the characteristic and stable hydroxyethylthioehtyl (hete) residue. hence, bioanalytical methods targeting theses adducts in forensic post-exposure verification analysis are of high interest. herein, we present an optimized, accurate and comparably simple method to detect adducts of sm and human serum albumin (hsa) alkylated at its cysteine -residue. since albumin extraction from human plasma is a time-consuming and expensive step of an established procedure, an alternative method for direct proteolysis of human plasma was developed. plasma samples were cleaved directly with pronase resulting in the alkylated dipeptide hete-cysteine-proline (hete-cp) which is detected by micro-liquid chromatography-electrospray ionization high-resolution tandem-mass spectrometry (µlc-esi hr ms/ms). in order to optimize reproducibility and yield of proteolysis, kinetics were investigated for different kinds of plasma (edta-, citrate-and heparin-) as well as serum. two different mass spectrometers, a triple quadrupole system ( qtrap) and a hybrid quadrupole time-of-flight instrument (tt + ), were compared. the latter one proved to be the more selective and sensitive system. the method was successfully applied to in vitro and in vivo samples of real cases of sm poisoning. organophosphorus compounds (op), which were originally intended to be used as pesticides to increase agricultural yields at the onset of the th century, still represent a considerable threat to human health. by irreversible inhibition of acetylcholinesterase op lead to cholinergic crisis due to uncontrolled increase of acetylcholine in the synaptic cleft. finally, sudden death by respiratory failure may result if medical countermeasures are lacking. therefore exceptionally toxic compounds were designed und synthesized as chemical warfare agents (cwa), among which v-type nerve agents, i.e. vx, chinese vx and russian vx, belong to the most toxic artificial substances. recent events like the first gulf war, terrorist attacks in tokyo and the conflict in syria underline the need for ongoing and strict surveillance of cwa prohibition by the chemical weapons convention. unambiguous evidence of such substances (verification analysis) plays an important role with great political and legal impact. a variety of such bioanalytical methods have been established at the bundeswehr institute of pharmacology and toxicology in munich, which is accounted for medical chemical defence in germany. exhibiting quite short half-lives in vivo nerve agents can hardly be detected days or even weeks after exposure. accordingly, there is a great need for additional long-term biomarkers like specific protein adducts. consequently, the current work focuses on examination of adducts between nerve agents and human serum albumin (hsa) as its high abundance and stability in vivo provide relative ease of sampling. after incubation of hsa with v-type nerve agents in vitro the protein was subjected to proteolysis. subsequently resulting peptides were separated using microbore high-performance liquid chromatography (µlc) and detected on-line by modern high-resolution tandemmass spectrometry (hr ms/ms). this allowed unambiguous identification of already known phosphylated tyrosines as well as novel adducts between cysteine-proline dipeptides and the thiol-containing leaving group of v-type nerve agents. simultaneous detection of both biomarkers was realized by a new method, which was applicable even at the very low toxicologically relevant concentrations of v-type agents. therefore, this method represents a valuable and novel supplement of existing methods for verification. fatty acid esters of glycidol (glycidyl esters) are processing contaminants formed as byproducts of industrial deodorizing of plant fats or during other heating processes. following oral intake, glycidyl esters are mainly cleaved to release the reactive glycidol in the gastrointestinal tract. according to the national toxicology program (ntp), glycidol is carcinogenic, genotoxic and teratogenic in rodents. it is classified as probably carcinogenic to humans (iarc group a). the exposure assessment of the oral intake of glycidyl esters in humans is difficult, because the current data set for glycidyl ester contents in food is incomplete. we developed a method for the determination of the internal exposure to glycidol by mass spectrometric quantification of a hemoglobin adduct reflecting the total glycidol burden over approximately three months. a modified edman degradation was adapted for the cleavage of the valine residues from the n-termini of hemoglobin by fluoresceinisothiocyanat (fitc) (von stedingk et al. ( ) chem res toxicol , resulting in the formation of dihydroxypropyl-valine-fluorescein thiohydantoin (dhp-val-fth). the target analyte is purified with mixed-mode anion-exchange solid-phase extraction and analyzed by lc-ms/ms. a major advantage of the technique is the application to whole blood samples, which renders the time-consuming isolation of erythrocytes unnecessary. we synthesized dhp-d -val-fth as an internal standard for the quantification of the glycidol adduct by lc-ms/ms multiple reaction monitoring. a limit of detection of fmol per injection ( pmol adduct/g hemoglobin) was achieved. the application of this method will possibly allow future monitoring of the internal exposure of glycidol in human studies. glycidol and -monochloropropane- , -diol ( -mcpd) are carcinogenic food contaminants, which are present in heat-processed oils and fats mainly in form of fatty acid esters. the risk assessment concerning human consumption of these substances is complicated by various reasons. for example, the data on the occurrence in food stuffs is incomplete. also, the amounts of the proximate carcinogens released from ester hydrolysis in the gastrointestinal tract in humans are not known. monitoring of the internal exposure would be an alternative strategy to support the assessment of possible health risks related to the intake of glycidol and -mcpd and their fatty acid esters. for short-term monitoring of the internal exposure, urinary metabolites are suitable biomarkers. we study the potential use of two different substances as descriptors of the oral intake of glycidol and -mcpd. the metabolite , -dihydroxy mercapturic acid (dhpma) is generated following glutathione conjugation of both compounds. the second target analyte is -mcpd itself, which may also be formed from glycidol in the reaction with hydrochloric acid in the stomach. a method for the quantification of urinary -mcpd by gc-ms is currently developed. an lc-ms/ms multiple reaction monitoring technique was devised for the quantification of dhpma in urine samples with the isotope-labeled reference compound c -dhpma. the limit of quantification is µg dhpma/l. related to creatinine, the analyte was detected to be in a relatively small concentration range in urine samples from humans. the average concentration in urine samples (n = ) of one male volunteer collected over ten days was ± µg dhpma/g creatinine. a meal of a highly contaminated, commercially available frying fat (containing . mg of glycidol equivalents) did not lead to a visible increase of the urinary concentrations. the considerable background levels of dhpma in urine of humans and also in urine samples of other mammals support the hypothesis that dhpma may be also be formed from an endogenous c -metabolite, as already reported by eckert et al. furfuryl alcohol is a common food contaminant formed by acid-and heat-induced dehydration from pentoses. it induced renal tubule neoplasms in male b c f mice and nasal neoplasms in male f /n rats in a study of the national toxicology program (ntp). the neoplastic effects may originate from sulfotransferase (sult)-catalyzed conversion of furfuryl alcohol into the dna reactive and mutagenic -sulfoxymethylfuran. the incomplete data set of furfuryl alcohol contents in food does not allow estimating the human exposure. thus, we sought a method for the determination of the internal exposure. recently, the dna adduct of furfuryl alcohol n -[(furan- -yl)methyl]- ′deoxyguanosine was detected in specimen of human lung tissue. however, human biomonitoring of dna adducts has various disadvantages. for example, dna adducts are removed by various repair systems and human dna samples are usually not accessible in sufficient quantities. we decided to develop a biomarker for the internal exposure to furfuryl alcohol using blood proteins as dosimetric targets. bladder cancer (bc) is a smoking and occupation related disease showing a substantial genetic component. though the prognosis is generally good, a major problem is the frequent relapses affecting about half of the patients. n-acetyltransferase (nat ) is well-known to modulate bc risk in persons heavily exposed to carcinogenic aromatic amines. we aim to investigate the impact of nat genotypes, in particular, the ultraslow genotype, on relapse-free time after first diagnosis in bladder cancer cases. we used follow-ups of three case-control studies from lutherstadt wittenberg (n= ), dortmund (n= ) and neuss (n= ). nat was genotyped using seven characteristic polymorphisms (rs , rs , rs , rs , rs , rs , rs ). haplotypes were reconstructed using phase v. . . . we compared slow to rapid acetylators. additionally, we differentiated between the most frequent slow nat * b/* b and * b/other slow haplotypes as well as between the ultra-slow * a/* a and * a/other slow haplotypes compared to rapid acetylators. chi-square tests used to check the frequency of relapses in ultra-slow, slow and rapid acetylators. genotype differences in relapse-free time up to yr after first diagnosis of bc were analysed using cox proportional hazards models adjusted for age, gender, smoking habits, invasiveness and study group. a total of ( %) patients showed a relapse within the first yr after bc diagnosis. slow acetylators show a higher frequency of relapses than rapid acetylators ( % vs. %, p= . ). this frequency is even higher in ultra-slow acetylators ( %, or= . , p= . ) but not in slow * b/* b genotypes ( %, p= . ). ultra-slow acetylators had a significantly shorter relapse free time within yr after bc diagnosis than rapid acetylators (median . vs. . yr, hr= . , p= . ). this trend was not that pronounced in all slow acetylators combined ( . yr, hr= . , p= . ) nor in the subgroup of nat * b/* b genotypes ( . yr, hr= . , p= . ). the effect of ultraslow nat is even more pronounced in smokers (hr= . , p= . ) but absent nonsmokers (hr= . , p= . ). ultra-slow nat seems to be associated with a higher recurrence risk and a shorter relapse-free time, especially in smokers. slow nat in general seems to have less impact on recurrence. aalborg university, department of biotechnology, chemistry and environmental engineering, aalborg, denmark xenoestrogens with the potential for endocrine disruption like bisphenol a (bpa) may bind to the estrogen receptors (ers) and modulate expression of er target genes mimicking the natural ligand β-estradiol (e ). the potential for endocrine adversity is still predominantly assessed in vivo as existing in vitro tests have only limited value for an exposure-based risk assessment. thus, the development of reliable bioassays for the detection of endocrine disruptors is one of the paramount challenges faced by modern toxicology. a targeted metabolomics approach in mcf- cells treated with e or bpa revealed potential biomarkers for the estrogenic potency of the studied compounds. among them were several phosphatidylcholines and amino acids. we further addressed proline levels that were found to be strongly increased. investigations of proline levels over time showed a clear proliferation correlated concentration dependency after both e and bpa stimulation. furthermore, sirna knockdown experiments suggested an influence of the oncogenic transcription factor myc and the dependency of erα activation on the estrogen-mediated proline increase. our study demonstrates metabolomics as a powerful tool for biomarker identification and hypothesis generation. the results could be used further to develop bioassays for the detection of endocrine disruptive chemicals. children are considered to be more sensitive to most chemicals than the general population due to a variety of factors, including dynamic growth and developmental processes as well as physiological, metabolic and behavioral differences [ ]. however, only a few data are available on the magnitude of preschool children's exposure to most chemicals present in many consumer products. several of these chemicals are linked to endocrine disrupting effects in animal studies and are suspected to have also adverse effects e.g. on development and function of the reproductive organs as well as on neurological and behavioral development in humans. among of the chemicals that have been a major focus of discussion in the last years are phthalates, dinch, parabens, bisphenol a, and triclosan due to their suspected health effects. therefore we aimed to investigate exposure levels to metabolites of different phthalates and parabens as well as to bisphenol a and triclosan in urine samples collected from preschool children in german day-care centers from north rhine-westphalia (lupe iii; / ). urine specimens from children aged from to months from different day-care centers were analyzed. in total, preschool children were recruited with mean age of months. our study results show that nearly all children (> %) of the study population had urine concentrations equal to or above the limit of quantification for five most common phthalates metabolites (mnbp, mibp, oh-mehp, oxo-mehp, oxo-minp), for bisphenol a and methylparaben. triclosan was detected in % of the study population. in general, the median urinary concentrations of the above mentioned phthalate metabolites were about - µg/l in spot urine samples. the highest amount among the phthalate metabolites was observed for mibp with maximal values of about µg/l. median urinary concentration for methylparaben and bisphenol a were about µg/l and µg/l respectively. the maximum methylparaben, bisphenol a and triclosan level found were µg/l, . µg/l and , µg/l respectively. in conclusion, our study shows a widespread exposure of young children to various phthalates, parabens and bisphenol a in north rhine-westphalia, germany. a follow-up human biomonitoring study ( / ) has finished recruitment and is in the process of analyzing data. polycyclic aromatic hydrocarbons (pahs) represent a large group of organic compounds that are common environmental contaminants. they are formed by incomplete combustion of organic matter such as coal or crude oil and are often known to be carcinogenic, mutagenic and teratogenic. the acute toxicity of pahs is rather low, but because of their stability and lipophilic character those compounds can accumulate in the human body and cause severe chronic effects. additionally pahs may enter the food chain when preserving meat or fish by exposure to smoke. in the european union maximum levels of µg/kg benzo[a]pyrene and µg/kg as the sum of benzo[a]pyrene, benz[a]anthracene, benzo[b]fluoranthene and chrysene in the meat of smoked fish and smoked fishery products are set, respectively. smoked fish is often handmade in small fishery stores in schleswig-holstein, where self caught fish is prepared in smoke houses. this technique implies the danger of pahs to accumulate in smoked fishery products above allowed maximum levels. here, we report our findings of pahs in smoked fishery products bought in local convenience and fishery stores in schleswig-holstein and give a brief overview about actual contaminant levels. hplc with fluorescence detection was used to determine the quality and quantity of several toxic pahs in smoked fishery products made locally. pahs may constitute risks for human health when exposed to hazardous levels and therefore it is important to have knowledge about given contaminant levels. colorectal cancer (crc) is one of the most frequent cancers worldwide and is tightly linked to dietary habits. epidemiological studies provided evidence that the intake of red meat is associated with an increased risk to develop crc [ ]. red meat contains high amounts of heme iron, which is thought to play a causal role in tumor formation. the underlying molecular mechanism, however, remains elusive and may involve increased cell proliferation and dna damage induction by heme-iron. in this study, we set out to analyze the genotoxic and cytotoxic effects of heme-iron in human colonic epithelial cell lines. we used hemin (fe iii ) as commercially available heme source, which was compared to inorganic iron chloride (fecl ). first, the time-dependent internalization of hemin and fecl into hct cells was determined using icp-ms/ms analysis. treatment of cells with inorganic iron resulted in a maximum of intracellular iron content after h at all doses tested, while hemin particularly at high doses caused an iron accumulation up to h. hemin catalyzed the formation of reactive oxygen species (ros) in a dose-dependent manner in caco- and hct -cells as shown by flow cytometry. consistent with this finding, hemin dose-dependently induced the oxidative dna lesion -oxoguanine ( -oxog) as revealed by slot blot analysis and fpg-modified alkaline comet assay. using a pharmacological inhibitor of mutt homologue (mth ), which protects the nucleotide pool by hydrolysis of -oxogtp, -oxog dna adduct levels in hemin-treated cells were further enhanced. in contrast, inorganic iron hardly affected the cellular ros level and only slightly increased oxidative dna damage. subsequently, a time-and dose-dependent activation of the dna damage response (ddr) by hemin was shown in hct and caco- cells using western blot analysis, which was followed by a reduction in cell viability at high doses after h. finally, the cytotoxic effects of hemin and inorganic iron were tested using an ex vivo model of intestinal crypt organoids. preliminary results indicate that hemin is highly cytotoxic in organoids, whereas inorganic iron does not impair their viability. taken together, this study demonstrated that hemin induces oxidative stress and dna damage, resulting in the activation of the ddr and subsequent cytotoxicity. in contrast, inorganic iron displayed only modest effects. further in vivo studies using dna-repair deficient and proficient animals will shed light on the contribution of specific dna lesions to hemeassociated colorectal carcinogenesis. red and processed meat consumption is known to be a crucial risk factor in the development of colon cancer, which is one of the most common cancers worldwide. a diet rich in red and processed meat increases n-nitrosation within the colon leading to an increase in endogenously formed nitroso compounds. these compounds are able to alkylate dna of gastrointestinal tract cells, resulting in the formation of dna adducts such as -meg is repaired by mgmt, the potential of this enzyme to repair o -cmg in cells is not well characterized. additionally, adenomas containing a k-ras gc-at transition mutation have lower mgmt levels than adenomas without this mutation. therefore, the aim of this study is to determine the role of mgmt in protecting colorectal cells from genotoxicity by repairing o -cmg adducts. for this purpose, an mgmt-deficient non-transformed human colon epithelial cell line was established by stable transfection via rna interference to inhibit the expression and therefore the activity of mgmt. the transfected cell line was analyzed for complete mgmt gene silencing by activity and expression analyses and cell characterization. results confirmed that there was neither expression nor activity for mgmt in the transfected cells, and the cell characterization data showed that mgmt deficiency did not lead to differences in growth behavior or cell morphology or malignant cell transformation. cytotoxicity experiments performed in the transfected and nontransfected cell lines by treatment with dna alkylating agents suggest that the mgmtdeficient cell line is more sensitive to dna alkylating agents than the non-transfected cell line. these results were also supported by dna damage analysis via comet assay. asarones are secondary plant constituents mainly occurring in acorus calamus l. and guatteria gaumeri. the essential oil of the rhizome of acorus calamus l. is used for flavoring of food and alcoholic beverages. the concentration of β-asarone (ba) in these oils varies between . % and %. the bark of guatteria gaumeri, which is rich in αasarone (aa), is used as cholesterol-lowering drug and to treat gallstones in traditional mexican medicine. both, aa and ba are carcinogenic in rodents and mutagenic in the ames test after metabolic activation and thus classified as genotoxic carcinogens. [ , ] previously, the major metabolites in microsomal incubations with aa and ba were identified and synthesized in our laboratory. side-chain epoxides, the corresponding diols, side-chain alcohols and aldehydes were identified as the major metabolites of aa and ba. [ ] the investigation of the mutagenic potency in the ames fluctuation test showed positive results in the salmonella strain ta for aa and ba with metabolic activation and for aa-and ba-epoxide without metabolic activation. while it is known that epoxides are reactive against nucleophiles we set up the hypothesis of dna-adduct formation by epoxides to explain the mutagenic effect. this adducts are currently isolated, characterized by nmr-spectroscopy and used to quantify adducts in cells. at the same time primary rat hepatocytes were incubated with non-cytotoxic concentrations of aa and ba for h. after harvest and lysis of the cells, the dna was isolated by chloroform/phenol extraction and enzymatically hydrolyzed. [ ] the residual hydrolysates will be used to identify the dna-adducts formed in cells and to determine the adduct formation rate. preliminary experiments indicate that both, aa and ba also form dna-adducts in intact cells in a concentration-dependent manner. [ ] göggmann, schimmer ( ) . mutagenicity testing of α-asarone and commercial calamus drugs with salmonella typhimurium. mutation research. , [ ] [ ] [ ] [ ] wiseman et al. fatty acid esters of -chloro- , and of -chloro- , are food process contaminants that are formed, e.g., during refinement of vegetable oils. after ingestion, the esters are hydrolyzed in the gut, thereby releasing free -mcpd and -mcpd. -mcpd has been identified by the international agency for research on cancer (iarc) to be possibly carcinogenic to humans (class b) and is therefore in the focus of food safety authorities. to elucidate the toxicological properties of these compounds at the molecular level (mode of action) a proteomic study was conducted in which mg/kg b.w./day of either -mcpd or -mcpd were orally administered to rats over a period of days. total protein was extracted from different tissues of the animals and separated via twodimensional gel electrophoresis ( de). among others, the redox sensor protein dj- was identified to be deregulated in liver, kidney, testis, and heart of rats treated either with -mcpd or -mcpd. up to six different isoforms of dj- were identified by de-western blot analysis, all of them having the same molecular weight but different pi values, indicating protein modifications of low molecular weight but with a strong impact on the protein charge. treatment of the animals with either -mcpd or -mcpd predominantly led to a shift of the abundance between two dj- isoforms in the rat tissues. this effect was more pronounced with -mcpd compared to -mcpd. mass spectrometric analysis of these two isoforms identified an oxidation of a conserved cysteine residue (cys ) of dj- to a cysteine sulfonic acid to be the protein modification induced by treatment of the rats with either -mcpd or -mcpd. dj- is discussed to participate in a number of biological processes such as proteolysis, protein folding, or redox regulation. oxidation of cys was shown to be crucial for the activity of dj- , and the irreversible oxidation of cys to a cysteine sulfonic acid as observed in the present study was shown to result in a loss of protein function and was correlated with diseases related to oxidative stress such as parkinson's disease. thus, the potential impact of -mcpd and -mcpd on cellular oxidative stress and on associated neurodegenerative diseases has to be considered in the ongoing risk assessment of these food contaminants. pyrrolizidine alkaloids (pa) are secondary plant compounds and widely spread in plant kingdom. humans can therefore be regularly exposed via direct or indirect contamination of food, like herbal teas, honey, wheat or salad. , -unsaturated pa are known for their potentially harmful effects. an acute intoxication may cause venoocclusive disease leading to hepatomegaly, ascites as well as liver hardening resulting in high mortality. on the other hand, chronic pa intoxications due to regular consumption of small amounts of pa are characterized by hepatic necrosis, fibrosis and cirrhosis. an initial whole genome transcriptome study in hepatocytes revealed that molecular pathways related to cancer development, cell cycle regulation and cell death are regulated by the four structurally different pa echimidine, heliotrine, senecionine and senkirkine in short-term exposure ( h). additionally, lipid and bile acid metabolism was affected. however, the uptake of pa by food is more likely to be continuous than singular. therefore, the aim of this study was to investigate molecular effects of longterm exposure ( d) comparatively to short-term exposure ( h) in the hepatoma cell line heparg with the four structurally different pa. in this context we analyzed selected cellular parameters like cytotoxicity and morphology. in contrast to short-term exposure, structure-and concentration-dependent cytotoxicity was found for the long-term exposure (sn>he>em/ski). furthermore, obvious morphological changes such as destructuration and perforation of the heparg cell monolayer were seen after d of incubation. based on these findings, a possible induction of apoptosis or necrosis by pa was examined. effects of long-term exposure to pa on gene expression were investigated for a set of genes found to be regulated in the short-term whole genome transcriptome study. the identified regulation of gene expression was confirmed for both terms, with the strongest regulation for cyp a (down-regulation), a gene involved in cholesterol metabolism. therefore, the effects of pa on various parameters related to cholesterol metabolism were analyzed, showing pa effects on cholesterol levels and bile acid secretion. short-term exposure to pa did not affect cell viability. however, repeated doses of pa resulted in severe effects on hepatic cells, concerning viability and morphology. at the mrna level, short-and long-term incubation with pa seem to affect a wide range of signaling pathways. in conclusion, we show for the first time that heparg cells can serve as an in vitro model for hepatotoxicity following chronic intake of pa. shiga toxin-producing e. coli (stec) strains cause a diversity of enteric symptoms in humans, ranging from mild diarrhea to severe diseases such as the hemolytic uremic syndrome (hus). hus is a life threatening disease with microvascular endothelial damage in the gastrointestinal tract and the kidneys, which often leads to haemolytic anemia, thrombocytopenia and acute renal failure. shiga toxin plays a major role for the pathogenesis of hus but the subtilase cytotoxin, which was identified during an hus outbreak in in stec strains, might contribute as an additional potent enterotoxin. like shiga toxin, subab is an ab protein toxin. the pentameric binding/transport subunit (subb) delivers the enzymatic active subunit (suba), a protease, into the endoplasmic reticulum (er) of human target cells. in the er, suba cleaves the chaperone bip/grp , which results in cell stress and caspase / dependent cell death. recently, we discovered that higher concentrations of suba ( mg/ml) causes cytotoxic effects in human epithelial cells (hela, in the absence of subb. the cytotoxic effects were investigated in hela cells in more detail. here, suba binds in a concentration dependent manner to the cell surface and induces dramatic morphological changes as well as caspase-dependent cell death [ ] . in contrast to hela and caco- cells, cho fibroblasts did not respond to suba. currently, further cell types including macrophages are tested for suba effects and the molecular mechanisms underlying the cytotoxic effects caused by suba and the cell type selectivity are investigated. although there are strong cytotoxic effects caused by suba on some human epithelial cells in vitro, the situation in vivo and the pathogenic relevance of the newly observed suba effect are not known. thermal treatment of fat-containing foodstuff in the presence of salt leads to formation of -mcpd and its esters. high amounts of -mcpd esters detected in food raised toxicological concern. recent studies revealed that food may also contain significant amounts of structurally related -mcpd and its fatty acid esters. toxicological studies indicate genotoxicity in vitro and a carcinogenic potential of -mcpd, pointing to kidney and testes as main target organs. -mcpd esters were shown to cause similar, but milder effects. few unpublished data exist for -mcpd, showing similar organ toxicity compared to -mcpd and identifying heart as additional target organ. no such data exist for -mcpd diesters. in consequence, further toxicological data were required in order to complete risk assessment for -mcpd, -mcpd and their esters. hence, an oral -days study was performed in male rats in order to fill data gaps and provide essential information for risk assessment. a proteomic analysis was included in order to compare molecular effects induced by -mcpd and -mcpd and its dipalmitic ester in rat liver, kidney, testes and heart. in order to avoid overt toxicity, moderate doses of -mcpd + -mcpd ( mg/kg body weight), and -mcpd-dipalmitate ( + . mg/kg body weight) were applied. accordingly, no pathologic effects were reported. here, we present proteomic results obtained after analysis of heart tissue. after separation of heart tissue protein crude extract by -d gel electrophoresis , differentially expressed spots were identified by maldi-ms. a total of unique proteins deregulated at a log ratio of ≤ - . for downregulation and ≥ . for upregulation at p ≤ . were identified. comparing deregulated spots induced by different treatments revealed that a higher number of spots was deregulated by -mcpd versus -mcpd. dipalmitate treatment even caused more deregulation than -mcpd. upregulated cytochrome b-c complex subunit rieske (ucri) and downregulated acetyl-coa acetyltransferase (thil) were among the top deregulated proteins after -mcpd and -mcpd dipalmitate treatment. pronounced upregulation of respiratory chain protein ucri, not deregulated after -mcpd treatment, indicates an effect on energy metabolism. downregulation of thil, involved in ketone body metabolism, was only weakly affected after -mcpd treatment. protein dj- (park ), a multifunctional redoxsensitive chaperone and protease protecting the cell against oxidative stress, was significantly downregulated after treatment with -mcpd and the higher dose of the -mcpd diester. tropomyosin beta chain (tpm ) was commonly upregulated after -mcpd and -mcpd treatments, possibly indicating a tgf-beta induction of actin stress fibers. for rat heart, data show that similarities but also some significant differences of -mcpd-and -mcpd dipalmitate-induced proteomic changes exist compared to -mcpd, indicating different mechanisms of toxicity for this structural analogues. oxidation products (oxy) of cholesterol (chol) such as α-hydroxy-chol ( α-ho-chol), β-hydroxy-chol ( β-ho-chol), -keto-chol ( -o-chol), , α-epoxy-chol (α-epoxy-chol) and , β-epoxy-chol (β-epoxy-chol) are formed by autoxidation of chol and are discussed as biomarkers for inflammation and oxidative stress in human tissues to be used in the identification of risk factors for disease. however, oxy-chols are also present in processed foodstuff where β-ho-chol (milk) and -o-chol (fish, meat, and egg) tend to represent the main oxychols, whereas epoxy-chols, are generally minor constituents. thus, levels of oxychols in tissues may result from both endogenous formation as well as dietary exposure. since quantitative profiles of oxy-chols have not been determined in human adipose tissues yet, levels of oxychols and chol were quantified using gc-ms/ms (internal standards: deuterated oxychols) and gc-fid (internal standard: α-cholestan- β-ol), respectively in breast adipose tissues of healthy women undergoing mammoplasty. furthermore, tissue levels of fatty acids in adipose tissues were determined by gc-fid (internal standard: undecanoic acid) to assess relative levels of pentadecanoic acid, docosahexaenoic acid and elaidic acid, indicative for consumption of dairy products, fish, and processed fats, respectively. all oxychols were detected in all breast adipose tissues. the most abundant oxychol was β-epoxy-chol (median: . nmol/g tissue, range: . - . nmol/g), followed by α-epoxy-chol > -o-chol > α-ho-chol> β-ho-chol ( . nmol/g, range: . - . nmol/g). tissue levels of chol ( . micro mol/g, range: . - . micro mol/g) did not correlate (spearman's rank analysis) with that of epoxy-chols and correlated even negatively with that of α-ho-, β-ho-, and -o-chol (r = - . , p= . - . ) median oxychol/chol ratios ranged from . ( , to . ( β-ho-chol). -o-chol and -ho-chols correlated strongly with each other (r= . - . , p oxy-chol levels did not correlate with relative amounts of pentadecanoic acid and docosahexaenoic acid, whereas total oxychol, β-ho-chol, and β-epoxy-chol levels correlated with relative amounts of elaidic acid (r= . , . , and . , respectively, p= . , . , . , respectively) . no correlations of oxychol levels, individual or total oxychol/chol ratios with age or bmi were observed. taken together, oxychol profiles in breast adipose tissues were different from that usually present in food but could be affected by dietary habits. classification and labelling of hazardous substances and hazardous consumer products ( ) has proven to be a very efficient tool for risk communication. consumer products, such as glue, varnish, or washing and cleansing products need to be classified and labelled if they contain dangerous ingredients that render the mixture hazardous. personal care products, however, need not be classified and labelled if they contain dangerous substances above the thresholds for classification. they are excluded in the clp regulation. what would happen without this exception? when i applied the criteria for classification and labelling to a selection of cosmetic product formulas in a conservative approach, most products would have to be labelled and classified, mainly due to hazardous effects to the eye and to the skin ( ) . benefits of personal care products can go along with unwanted properties such as the hazards for the human health, and consumers should be informed about them ( ) . risk communication for every day products like personal care products should be clear, easily and quickly understandable. according to the cosmetic regulation ( ) the ingredients must be listed on the containers. it must be questioned whether the listing of the ingredients without hazard pictograms on the products could be considered as a clear, easily and quickly understandable risk communication instrument ( ). the results show that it is urgent to inform consumers better about the potential dangers of personal care products, because cosmetics need to be applied even with more care than any other consumer product. it is strongly recommended to delete the exception provision in the clp regulation for personal care products. the infochemical effect describes that anthropogenic substances can interfere with the chemical communication and influence organisms so that they perceive their chemical environments differently ( , ). infochemicals play a role in life history, habitat search, food related aspects and survival which shows that disturbed communication (infodisruption) could affect population vulnerability at various decisive points ( ). the classical ecotoxicological standard tests do not allow to observe the infochemical effect. systematic analyses are needed to find out more about the relevance of this new chapter in ecotoxicology for natural ecosystems. the first crucial step is to select suitable test substances. repellents (substances used to keep away target organisms, e.g. invertebrates such as midges or fleas via olfaction) enter surface waters mainly indirectly via wastewater discharges from sewage treatment plants or directly by being washed off from the skin and clothes of bathers. there are various indications that repellents which are not toxic for aquatic animals could induce effects like organismic downstream drift of non-target species (downstream dislocation of e.g. crustacean and insect larvae in streams). in a literature study, three repellents were identified to be suitable test compounds for proof of concept of the infochemical effect. deet (cas - - ), icaridine (cas - - ) and ebaap (cas - - ) ( ). these substances are investigated in new test designs in a subsequent experimental part of the project which are designed to detect and quantify the infochemical effect. persistent, bioaccumulative and toxic (pbt) substances or very persistent and very bioaccumulative (vpvb) substances are compounds with hazardous properties. the non-biodegradability (persistence) and high accumulation in organisms (bioaccumulation) may elicit long-term adverse effects in the environment. persistent and bioaccumulative substances concentrate in the environmental compartments (water, sediment, soil, air) and can be distributed in the food chains. ecotoxicological effects are strengthened by bioaccumulation and appear often in remote areas like marine and polar regions. in the framework of pbt assessment, contrary to the risk assessment, the substances are evaluated regardless of the emission into the environment. an evaluation of medicinal active ingredients under assessment in the german federal environment agency (uba) identified less than % as potential pbt candidates. due to data lacks in many cases a definite pbt classification is not possible. the poster presents results of an extensive literature research on the global occurrence of pharmaceuticals in the environment. data on measured environmental occurrences from more than , international publications have been transferred to a database, with more than , entries. according to the database, pharmaceuticals have been found in the environment of countries worldwide in all five un regions. most published data are for the compartments surface water and sewage effluent; less information is available for groundwater, manure, soil, and other environmental matrices. more than active pharmaceutical substances (or their metabolites and transformation products) have been detected in the environment. most findings have been published for industrialized countries. monitoring campaigns are increasingly being conducted in developing and emerging countries. these have revealed the global scale of the occurrence of pharmaceuticals in the environment. for example, diclofenac, a non-steroidal inflammatory drug, has been detected in the aquatic environment in countries worldwide. a number of globally marketed pharmaceuticals have been found in both developing and industrialized countries. the available ecotoxicological information indicates that certain pharmaceuticals pose a risk to the environment at measured concentrations. options for cooperative action to address the risk of are also presented. the aim of the research presented was to support the discussion of the proposed emerging policy issue pharmaceuticals in the environment under the strategic approach to international chemicals management (saicm), which is a global initiative of united nation environment programme (unep). the european chemicals' legislation reach aims to protect man and the environment from substances of very high concern (svhc). chemicals with (very) persistent, (very) bioaccumulative and toxic properties (pbt and vpvb compounds), substances that are carcinogenic, mutagenic and toxic to reproduction (cmr compounds), as well as chemicals of comparable concern like endocrine disruptors (eds) may be subject to authorization. the identification of eds is limited as yet, because specific experimental assessments are not required under reach. evidence is currently based on a combination of few experiments, expert judgement and structural analogy with known eds. structural alerts for the identification of potential eds: predictions of properties and effects from chemical structures are based on similarities with either active or inactive substances. structural alerts for the identification of potential estrogen/androgen-ed activities are relevant parts of the structures of compounds that are known to interact with estrogen and androgen receptors as either agonists or antagonists. in addition to the backbones of the chemical structures (pharmacophore) for steric fit to the receptors, modulating factors may be small substructures for local interactions with receptor binding sites and physicochemical properties related to the strength of binding to the receptor. comparison of evidence from in silico, in vitro and in vivo assays for potential eds: identification of potential eds based on findings from mammalian long-term reproduction studies, fish life-cycle tests, receptor assays, and chemical alerts were compared and differences analysed. agreement is limited because in vivo, in vitro and in silico methods address different aspects of potential effects on endocrine systems regarding toxicological targets, modes of action and functional similarity of chemical structures. a combination of toxicological and chemical assays can provide comprehensive and complementary information to support evidence-based identification of potential eds among the chemicals released into the environment. application of structural alerts for the identification of potential eds to the einecs inventory: more than discrete organic einecs compounds are within the applicability domain of the structural alerts for potential estrogen/androgen-ed activities. among them, chemicals (ca. %) are indicated as potential candidates for endocrine effects based on structural alerts. due to the possibility that these chemicals may interact with estrogen/androgen receptors they should be subject to further investigations regarding their potential for endocrine effects, eventually leading to regulatory actions. within the imi (innovative medicine initiative) project "intelligence-led assessment of pharmaceuticals of the environment " (ipie;http://i-pie.org/), a more intelligent environmental testing and tools for prioritisation of legacy compounds shall be developed. regarding the evaluation of fish toxicity, screening approaches in fish embryos are pursued. while the standard fish embryo toxicity (fet) test is restricted to lethal parameters more relevant as substitutes for acute effects, additional sublethal endpoints may provide expanded applicability of the fet assay for chronic effect assessment in fish. in this respect, the analysis of the metabolome could provide additional insights into biochemical processes elicited by pharmaceutical compounds and could potentially support the extrapolation from fish embryo to chronic fish toxicity as displayed in the standard early life stage (els) test. in the context of ipie a pilot study was performed with the aim to quantify and comparatively assess changes in the metabolic signatures of fish and fish embryos induced by the reference compound amikacin, an aminoglycoside antibiotic, in order to identify metabolic patterns applicable as biomarker profiles that can be linked to apical endpoints in terms of an integrated approach. therefore, toxic effects in fathead minnow embryos and els fish were investigated following a and days exposure, examining conventional endpoints and additionally using a combined direct injection and lc-ms/ms assay for metabolite identification and quantification. metabolic endpoints were found to be at least as sensitive as standard apical endpoints such as growth and mortality as detected in the longer-term fish study. furthermore, multivariate data analysis (pca-x, opls-da) revealed substance induced metabolic perturbations specific for fish and fish embryos, respectively. beyond that, the statistical approach of shared and unique structure (sus) identified some metabolites from the classes of amino acids, biogenic amines and lipids to be similarly changed in both developmental stages related to amikacin treatment, representing shared biomarker candidates. in this first pilot study, the integrated metabolomics approach yielded insights into the molecular consequences of amikacin exposure and provided indications for biomarkers for common effects in fish embryos and fish. due to the different exposure levels in the fet ( - mg/l) and els study ( . - . mg/l), more definitive conclusions regarding the predictivity of metabolic responses in fish embryos for apical endpoints in chronic fish tests are yet not possible. further studies are ongoing with a range of pharmaceutical compounds of different chemical classes which will reveal more substantial information on the applicability of this technology in the prediction of longterm effects in fish. the human cationic amino acid transporter hcat- (slc a ) represents the major uptake route for arginine and other cationic amino acids (such as the essential amino acid lysine) in most mammalian cells. it thus provides these amino acids for protein synthesis as well as for essential metabolic pathways. in endothelial cells, special attention has been given to the role of hcat- for supplying arginine to nitric oxide synthase. in spite of its wide distribution, hcat- expression is highly regulated both, on the transcriptional and post-transcriptional level. however, the genetic elements involved in transcriptional regulation a largely unknown. here we studied the expressional regulation of hcat- in human ea.hy endothelial cells. starvation of these cells from cationic amino acids led to a pronounced induction of both, hcat- mrna and protein. the mrna induction was almost completely abolished by the transcription elongation inhibitor drb ( , -dichloro- -β-dribofuranosylbenzimidazole), suggesting the involvement of transcriptional regulation. we thus aimed at identifying the promoter elements in the hcat- gene responsible for this regulation. to our surprise and in contrast to data published by others the chromosomal region up to kb upstream of the first hcat- exon exhibited no promoter activity in either endothelial or dld- colon carcinoma cells that exhibit a very strong endogenous hcat- expression. we could however identify a promoter element within the first intron of the hcat- gene. transcriptional activity of this element increased upon amino acid starvation in a similar way as endogenous hcat- expression. our results indicate starvation-induced transcriptional regulation of hcat- through newly identified promoter regions distinct from those published previously. the transport of a multitude of drug molecules into the cell is mediated by multispecific organic cation transporters (octs), belonging to the solute carrier group (slc). one of these families within this group of membrane transport proteins is the slc -family consisting of the two multidrug and toxin extrusion transporters mate- (slc a ) and mate -k (slc a ). while mate- is highly expressed in several different tissues like kidney, liver, skeletal muscle, adrenal glands, testes and heart, mate -k exclusively occurs in the apical membrane of proximal tubular epithelial cells within the kidney. both transport proteins translocate organic cations in exchange of protons into as well as out of the cell. to define the affinity of both transporters for the anti-diabetic drug metformin and to investigate their interactions with different anti-neoplastic agents comparative transport experiments with the model substrate -methyl- -phenylpyridinium (mpp) have been carried out. therefore stably transfected hek -cells expressing mate- or mate -k transport proteins generated by portacelltec biosciences gmbh and vector transfected hek -cells were used. the interaction analyses were carried out by determining the uptake of [ c]-metformin and the inhibition of [ university of basel, basel, switzerland drug transporters play a pivotal role in pharmacokinetics by modulating the cellular entry or efflux of compounds. one transporter facilitating the transport of bile acids, steroid hormones, and statins is the organic anion transporting polypeptide (oatp) b that is highly expressed in placenta, liver, and small intestine. especially its activity in small intestine and liver is assumed to be basis for specific drug-drug interactions. understanding mechanisms involved in pharmacokinetics is a prerequisite in drug development. to test whether there are species differences in transport activity we compared the expression and function of the human and rat orthologue. first, we determined the transport activity of the known oatp b substrate estrone sulfate (e s), and observed a significantly lower k m for mdck-hoatp b compared to . ± . µm, *p< . student´s t-test) whereas there was no difference in v max (mdck-hoatp b . ± . fmol/min/µg protein; mdck-roatp b . ± . fmol/min/µg protein). the human oatp b exhibits multiple binding sites for its substrates that may explain specific drug-drug interactions [ ] . to identify whether rat oatp b owns the same characteristics, the cellular accumulation of µm e s (low affinity site) or . µm e s (high affinity site) was determined in presence of specific inhibitors/substrates of oatp b . as observed for atorvastatin, a known inhibitor of both affinity sites, the rat transporter failed to exhibit the low affinity site. in detail, while atorvastatin reduced the accumulation of e s in mdck-hoatp b cells ( . ± . fmol/min/µg protein vs. . ± . fmol/min/µg protein, *p< . student´s t-test), there was no inhibition of e s accumulation in mdck-roatp b cells ( . ± . fmol/min/µg protein vs. . ± . fmol/min/µg protein). additionally, we observed a different membrane localization of both transporters as assessed by immunofluorescent staining showing an apical localization for rat oatp b while human oatp b is localized at the basolateral pole of the cellular model. absolute quantification of mrna (copy number per ng of total rna) in different tissues of rat revealed a high expression of oatp b in liver ( . ± . ), a moderate expression in small intestine ( . ± . ) and colon ( . ± . ), and a low expression level in kidney ( . ± . ) . the latter is in accordance with previous findings showing that oatp b is abundant in rat kidney as quantified by absolute proteomics technics [ ] . our data demonstrated species differences in localization and activity of the drug transporter. further studies are warranted to proof whether this knowledge will help in future drug development and which molecular cause is responsible for the observed data. background: intestinal drug absorption depends on various factors including aqueous volume, site-specific ph and intestinal motility. moreover, the expression of efflux-and uptake-transporters vary in dependence of the anatomical localization making the gut a complex barrier for drug transfer into the body. in a recent study, site-specific protein and mrna expression levels of drug transporters were determined along the entire length of the human gut. interestingly, discrepancies between mrna expression and protein levels were observed. moreover, there were quantitative differences between small intestine and colon. as a consequence the question arose if this observation could be explained by small non-coding rnas acting as highly tissue-specific posttranscriptional regulators of gene expression. hence, in our current study, we aimed to investigate the impact of mirnas on site-specific transporter expression along the human intestine. methods: total rna was isolated from biopsies obtained from six disease-free organ donors. tissue samples were acquired from the duodenum, the upper and lower jejunum, the upper and lower ileum, and the transversal or descending colon. the expression of mirnas was measured using rt-pcr based low density arrays. expression of all detected mirnas was correlated with transporter protein data recently determined by lc-ms/ms-based targeted proteomics. mirnas and transporter genes showing an inverse pearson's correlation between mirna and protein expression underwent an in-silico search (microcosm targets v. , targetscan . ) for putative mirna/mrna interaction. to investigate those interactions in more detail, reporter gene assays and site directed mutagenesis were conducted. results: out of mirnas, were detected in all tissue types. out of ten transporters five showed significant inverse correlations with putatively targeting mirnas (e.g. pept and hsa-mir- a, r= - . , p= . ). reporter gene assays indicated interactions of mir- a/b with pept '-utr (p = . and p = . ) as well as of mir- a with abcb '-utr (p = . ). the site-specific abundance of intestinal drug transporters is significantly affected by microrna-mediated post-transcriptional regulation under physiological conditions as exemplified for pept and abcb . background: the human uptake transporter nact [gene symbol slc a ; also known as mindy, the human orthologue of the drosophila indy (i´m not dead yet) transporter] is expressed in liver and brain. nact is important for energy metabolism and brain development and mediates the uptake of tricarboxylic acid (tca) intermediate such as citrate and succinate. reduced expression of this transporter, as studied in knock-out mice, mimics aspects of dietary restriction, promotes longevity and protects against insulin resistance and adiposity. furthermore, mutations in the human slc a gene are associated with epileptic encephalopathy with seizure onset in the first days of life, possibly due to the reduced uptake of tca intermediates into neurons. to gain more insights into the role of nact in drug transport and into structure-function relationships, we studied the inhibition of nact-mediated citrate transport by various drugs and analyzed the effect of known mutations in the slc a gene on nact-mediated transport. methods: drug inhibition studies were performed using hek cells stably expressing human nact with citrate as prototypic substrate. twenty-four drugs were used as potential inhibitors of nact-mediated uptake. the effects of eight mutations, three of them (nactp.g r, -p.t m and -p.l p) associated with epileptic encephalopathy, were analyzed using a transient transfection approach. furthermore, the first computational-based structural model of the nact transporter was established and the impact of all mutations on substrate transport was modeled. results: inhibitions studies demonstrated that only a few drugs (three out of tested) inhibited nact-mediated citrate transport at the tested drug concentration of µm. from these, benzbromarone shows the strongest inhibition with an ic value of . µm. furthermore, citrate transport was also slightly inhibited by pioglitazone and rosiglitazone. citrate transport of the mutated proteins nactp.g r, -p.g e,p.t m, -p.l p and -p.l p was totally abolished and the effect of these mutations could be explained on the basis of the structural model. conclusion: inhibition studies demonstrated that simultaneously administered drugs can inhibit nact-mediated uptake of the prototypic substrate citrate. nact-mediated uptake is abolished by mutations in the slc a gene associated with epileptic encephalopathy. the effect of these mutations can be explained on the basis of the first structural model of this uptake transporter. the atp-binding cassette subfamily b member (abcb ) is a drug efflux pump responsible for the classic multi-drug resistance phenotype in cancer cells. increased activity of abcb in cancer cells contributes to protection against a wide range of chemotherapeutic agents. this dramatically decreases therapeutic options and the chance of patient survival. knowledge of the underlying mechanisms for abcb deregulation is a critical step for the reversal of this unfavorable condition. of note, phosphatidylinositol- , -bisphosphate (pip ) is a known regulator of abcb . the protein "myristoylated alanine-rich c-kinase substrate" (marcks) is known for its ability to bind and sequester the phospholipid pip . in various forms of colorectal cancer the deregulation of marcks protein goes hand in hand with an increase in malignancy and therapeutic resistance. in this study, we characterized the enigmatic marcks as a modulator of abcb activity. we focused on a subgroup of colon cancers, where marcks resides in a hyperphosphorylated state for which the established cell line ht- served as a model. we employed various in-vitro methods for the measurement of abcb activity, in combination with imaging experiments, assays for cellular viability and classical methods of molecular biology. we combined these approaches with pharmacological inhibition of marcks phosphorylation state or rnai-mediated depletion of marcks. with these interventions we could modulate endogenous abcb activity and re-sensitize our cell model against chemotherapeutic agents like -fluorouracil which are known to be substrates of abcb . taken together, our findings suggest a new way how a cancer cell can gain a state of therapeutic resistance. the exploitation of marcks as modulator of abcb might be a new approach to target resistant tumors without interfering with the natural function of abcb in non-malignant tissue. background: in several large clinical studies low blood concentrations of homoarginine were identified as independent risk marker for stroke, cardiovascular events and mortality. experimental data suggest an active role of homoarginine deficiency in disease development. interference with l-arginine-dependent pathways and signaling has been implicated as a possible mechanism. it was the aim of the present study to identify transport mechanisms involved in the cellular uptake and tissue distribution of homoarginine, which is poorly understood, so far. the experiments focused on cationic amino acid transporters (cats) and possible interactions with known cat substrates. methods: uptake assays were performed using [ h]-labeled homoarginine as substrate and human embryonic kidney (hek ) cells stably overexpressing human cat [gene: slc a (solute carrier family )], cat a (slc a a) or cat b (slc a b). cells transfected with an empty vector were used as control. unlabeled known catsubstrates l-arginine and asymmetric dimethylarginine (adma) were investigated as inhibitors. results: compared to the uptake into control cells, uptake of homoarginine was significantly higher in hek cells overexpressing cat ( -fold), cat a ( . -fold) or cat b ( . -fold) after . min using µm substrate (each p< . ). apparent k m values for cellular net uptake of homoarginine were . µm for cat , µm for cat a and . µm for cat b. homoarginine uptake by the three cats could be inhibited by addition of l-arginine and adma. conclusion: the protective biomarker homoarginine is a substrate of the human cationic amino acid transporters cat , cat a and cat b. compared to other cat substrates, the cat -and cat b-mediated homoarginine transport is characterized by relatively high affinity. the uptake of homoarginine by all three cats can be inhibited by l-arginine and adma. taken together these findings make cat-mediated transport of homoarginine a possible target for interactions and pharmacological interventions aimed at homoarginine homeostasis. this project is supported by the doktor robert pfleger-stiftung. background and aim: organic cation transporter (oct , alternative name slcc a ) is a polyspecific membrane transporter, which has been suggested to play a role in absorption, distribution and elimination of drugs and toxins. besides endogenous compounds like thiamine (vitamin b ), known oct substrates are toxins like mpp + as well as drugs like metformin, o-desmethyltramadol, ranitidine, and sumatriptan. tissue distribution of oct has been shown to have strong inter-species differences. in rodents oct is strongly expressed in both the sinusoidal membrane of hepatocytes and the basolateral membrane of kidney epithelial cells. human oct is strongly expressed on the sinusoidal membrane of hepatocytes, but not in the kidney. furthermore, substrate specific differences have been observed between the human and rodent oct orthologs. the aim of this study is to characterize the mechanisms causing substrate specificity between rodent and human oct orthologs. methods: overexpression of oct orthologs in mouse, rat and human cells was performed by targeted chromosomal integration of t-rex™ . the cells were characterized in detail for their ability to transport the model substrates tea + , mpp + , and asp + , the drugs ranitidine, sumatriptan and fenoterol. results: mouse and rat oct orthologs showed similar transport activity for all the model substrates and drugs tested. however, significant differences were observed when rodent orthologs were compared to the human oct . human oct showed a fold higher v max for the uptake of asp + and -fold increase of v max for sumatriptan in comparison to the rodent oct orthologs. conversely, human oct showed a -fold lower v max for the uptake of fenoterol compared to rodent oct s. there was no difference between rodent and human oct in the uptake of ranitidine. these differences were further characterized in detail using chimeric mouse-human oct constructs and by comparing the effects of key point mutations in mouse and human oct orthologs. conclusions: these data demonstrate strong differences in the substrate specificity between rodent and human oct orthologs. therefore oct pharmacokinetic data obtained in mouse or rat models could not be directly extrapolated for use in human. furthermore, comparative functional analyses of orthologs may help reveal the mechanisms underlying polyspecificity of oct . ranitidine is a histamine h -receptor antagonist which is commonly used without prescription for the treatment of pyrosis and gastric ulcers. approximately % of the systemic clearance of ranitidine is via hepatic metabolism. ranitidine is known to be a substrate of the hepatic organic cation transporter oct [ ]. oct is expressed on the sinusoidal membrane of human hepatocytes and is highly genetically variable. sixteen major oct alleles are known [ ] . thereof alleles confer partial or complete loss of oct activity. the observed loss of activity was highly substrate specific and should be analyzed substrate by substrate. in this study we analyzed the effects of genetic polymorphisms in oct on the uptake of ranitidine. we used hek cells stably transfected to overexpress wild type or variant oct isoforms. the variant oct alleles oct * a (met val), oct * c (phe leu), oct * d (pro leu/met val), oct * (met del), oct * (arg cys), oct * (gly ser), oct * (gly arg/met del), oct * (cys arg/met del), oct * (ser phe), oct * (arg met), oct * (pro leu), oct * (ser leu), oct * (ile thr), oct * (ser leu) and oct * (thr met) were analyzed. we characterized in ranitidine uptake determined k m and v max for the different polymorphic oct isoforms. wild type oct showed a time and concentration dependent uptake of ranitidine with a k m of . ± . µm and a v max of . ± . pmol/min/mg protein. variants oct * , oct * , oct * and oct * completely lacked ranitidine transport activity. variants oct * , oct * , oct * and oct * showed v max values decreased by , , and %, respectively. oct * variant showed an increase of v max by %. there was no significant changes in ranitidine uptake by variants oct * a, oct * c, oct * d, oct * , oct * and oct * compared to the wild type. there were no significant differences in the k m values between the wild-type and variants. in conclusion, we confirmed ranitidine as an oct substrate and demonstrated that genetic polymorphisms in oct can strongly affect ranitidine uptake. the effects of oct polymorphisms on ranitidine pharmacokinetics in humans remain to be analyzed. otto-von-guericke university, institute for pharmacology and toxicology, magdeburg, germany serotonergic hallucinogens ( s hgs), such as lysergic acid diethylamide (lsd), induce profound alterations of human consciousness, which are thought to be mediated by activation of -ht a receptors. with repeated application, the mind-altering effects of most s hgs rapidly are undermined by tolerance. the only exception seems to be dimethyltryptamine (dmt), whose mind-altering effects for reasons unknown even with repeated application do not decrease. assuming that dmt differs from other s hgs in its capacity to regulate -ht a receptors, we here compare lsd and dmt with regard to processes of -ht a downregulation. in heat-exposed rats, lsd and dmt induce a marked increase in body core temperature (hyperthermia) accompanied by "defensive hypersalivation". both effects are mimicked by the -ht selective agonist dimethoxybromoamphetamine (dob) and can be blocked by the selective -ht a antagonists ketanserin and mdl . after repeated application, the temperatureregulatory effects of lsd are subject to tolerance, whereas the ones of dmt are not. tolerance to lsd (as measured by dob induced [ s]gtpуs binding) is paralleled by a desensitisation of frontocortical -ht receptors; for dmt, there is no such decrease. applying techniques of immunocytochemistry, transphosphatidylation, and quantitative real-time pcr to (ha- -ht a transfected) hek and (endogenously -ht a expressing) c glioma cells, respectively, we furthermore demonstrate that dmt in contrast to lsd fails to internalise -ht a receptors, fails to activate the phospholipase d (which is needed for -ht a internalisation), and fails to inhibit the synthesis of -ht a receptors. given that dmt unlike lsd turns out to be inactive as to all processes of -ht a downregulation investigated, our data suggest that the differential tolerance development noted for dmt and lsd indeed might be accounted for by differential regulation of -ht a receptors. lsd and dmt both have recently regained scientific attention as potential therapeutics in the treatment of depression and/or anxiety disorders. providing mechanistic insights into their action, thus, is of timely clinical relevance. increased gaba release in human neocortex at high intracellular sodium and low extracellular calcium -an anti-seizure mechanism? ] e , this reduction might induce an anti-seizure mechanism by augmenting gat-mediated gaba release, a mechanism absent in rats. aging is complex on the systems as well as on the molecular level. the process of aging is characterized by a progressive loss of physiological functions and accumulation of cellular damage. one hallmark of aging is an impaired protein homeostasis. the imbalance of the quality control of both de novo protein synthesis and protein degradation, therefore, is likely to contribute to the phenotype of aging. we investigated protein turnover rates with the state-of-the art techniques funcat (dieterich et al., ) and sunset (schmidt et al., ) in aging neuronal cell cultures . using these techniques we show a prominent decrease in protein synthesis and degradation that progressed gradually in aging neuronal cells cultured up to div . in order to rejuvenate the protein turnover in aged neuronal cells we applied the selective eukaryotic elongation factor- kinase inhibitor a and the polyamine spermidine and observed protein translation utilizing funcat and sunset. whereas both a and spermidine had no effect on de novo protein synthesis in juvenile neurons (div ) , both substances increased the de novo protein synthesis to a juvenile level in aged neuronal cultures (div ). this effect is seen in neuronal somata and dendritic spines. the molecular function of spermidine as an "anti-aging agent" is not defined yet. thus, additional pharmacological interventions are used for further examination of specific molecular spermidine targets. in conclusion, the described experimental setup is used to investigate impaired protein homeostasis as one hallmark of aging. agents with a presumed "anti-aging" effect can be tested for a potential rejuvenating effect on the level of protein homeostasis. a screening approach to test tolerability of multitargeted drug combinations for antiepileptogenesis in mice a large variety of brain insults can induce the development of symptomatic epilepsies, particularly temporal lobe epilepsy. in the latent period after the initial insult multiple molecular, structural, and functional changes proceed in the brain and finally lead to spontaneous recurrent seizures. prevention of these developments, called antiepileptogenesis, in patients at risk is a major unmet clinical need. several drugs underwent clinical trials for epilepsy prevention, but none of the drugs tested was effective. similarly, most previous preclinical attempts to develop antiepileptogenic strategies failed. in the majority of studies, drugs were given as monotherapy. however, epilepsy is a complex network phenomenon, so that it is unlikely that a single drug can halt epileptogenesis. recently, multitargeted approaches were proposed ("network pharmacology") to interfere with epileptogenesis. developing novel combinations of clinically used drugs with diverse mechanisms that are potentially relevant for antiepileptogenesis is a strategy, which would allow a relatively rapid translation into the clinic. we developed an algorithm for testing such drug combinations in a screening approach, modelled after the drug development phases in humans. tolerability of four repeatedly administered drug combinations was evaluated by a behavioral test battery: a, levetiracetam and phenobarbital; b, valproate, losartan, and memantine; c, levetiracetam and topiramate; and d, levetiracetam, parecoxib, and anakinra. as in clinical trials, tolerability was separately evaluated before starting efficacy experiments to identify any adverse effects of the combinations that may critically limit the successful use in preclinical studies on antiepileptogenesis and translation of these preclinical findings to the clinic. based on previous studies, we expected that tolerability would be lower in epileptic mice than in nonepileptic mice. therefore nonepileptic mice were used as a first step, followed by epileptic mice and mice during the latent period shortly after status epilepticus. except combination b, all drug cocktails were relatively well tolerated. in contrast to our expectations, except combination c, no significant differences were determined between nonepileptic and post-status epilepticus animals. as a next step, the rationally chosen drug combinations will be evaluated for antiepileptogenic activity in mouse and rat models of symptomatic epilepsy. major depression is one of the most common mental disorders worldwide, with serious social and economic consequences. there are many different hypotheses concerning the pathophysiology of this disease. the complex brain serotonin system and particularly the serotonin a receptors ( -ht a r) apparently play a pivotal role in the development of depression. the involvement of an altered, -ht a r-mediated signalling in adult neurogenesis is also discussed. however, in this context the effects of pre-and postsynaptically located -ht a rs have not been clarified yet. mice with a permanent overexpression of postsynaptic -ht a rs (oe mice) represent a unique tool to elucidate the effects of postsynaptic -ht a rs in adult neurogenesis and depressive-like behaviour. previous studies demonstrated an increased proliferation and survival of newborn cells in the adult dentate gyrus of female oe mice in comparison to controls. in the present study, we investigate the proliferation and survival of adult born cells after chronic treatment ( days) with the selective -ht a r agonist -oh-dpat ( , mg/kg/day) in young adult oe and wt mice. on the last three days of treatment, newly generated cells of oe and wt mice are labelled by injections with bromodeoxyuridine (brdu; mg/kg/day). mice are sacrificed either one day (proliferation) or days (survival) after the last injection. we hypothesise that the data we will present will confirm our previous results, with possibly more pronounced proneurogenic effects and differences in male mice. further immunohistochemical studies post-exercise and behavioural analyses are in progress to identify the relation between chronic postsynaptic -ht a r stimulation, depressive-like behaviour and hippocampusdependent learning. dystonia is a common movement disorder characterized by intermittent and prolonged muscle contractions resulting in involuntary movements and/or abnormal postures. the lack of knowledge of the pathophysiology of dystonia hampers the development of effective therapeutics. although benzodiazepines can improve dystonic symptoms, tolerance and side effects limit their use. there is evidence for striatal dysfunctions in human dystonia. gabaergic striatal interneurons (in) are important for the regulation of striatal signaling. in the dt sz mutant hamster, a model of paroxysmal dystonia, immunoreactive in were reduced at the age of maximum severity of dystonia ( days), but not after spontaneous remission (age days). as indicated by unaltered homeoboxprotein nkx . (cell density, mrna), the age-dependent deficit seems not to be related to a disturbed migration, but to a retarded maturation of in in mutant hamsters. here we further determined the maturation of striatal gabaergic neurons in the dt sz hamster compared to healthy controls. kcc and cavii mrna, used as markers for the gaba-switch, were unchanged in and day old mutant hamsters, indicating that there is no general delay in gabaergic maturation. as a retarded maturation seems to be specific for in, we used another marker for gabaergic maturation: the expression of specific gaba a receptor (gaba a r) subunits (mature striatal in express the alpha subunit). by stereological determination, we found a % decrease in alpha subunit expressing neurons. a lower immunoreactive intensity was restricted to the somata of dorsomedial striatal in ( %) of dt sz hamsters, indicating both a reduced density as well as a delayed maturation. these findings prompted us to examine the effects of the αlpha gaba a r preferring compound zolpidem in comparison with the benzodiazepine clonazepam. zolpidem ( . and . mg/kg i.p.) only exerted moderate antidystonic effects compared to the benzodiazepine clonazepam ( . and . mg/kg i.p.) in the dt sz hamster. examinations of αlpha gaba a r preferring compounds are ongoing. in summary our studies indicate that there is no general defect in striatal gabaergic maturation in the dt sz mutant but a specific alteration of striatal gabaergic interneurons which express αlpha gaba a r subunits. changes in αlpha gaba a r subunit expression and differences in the antidystonic efficacy of zolpidem and clonazepam indicate that further investigations on the role of gaba a r subunits could lead to new therapeutic approaches for the treatment of dystonia. ) . therefore, the hypothesis of the present study was that pregnenolone attenuates the inhibition of synaptic transmission elicited by cannabinoids. methods: µm-thick slices containing the cerebellum and the nucleus accumbens were prepared from the brains of mice and rats. spontaneous and electrically evoked gabaergic inhibitory postsynaptic currents (sipscs and eipscs) and evoked glutamatergic excitatory postsynaptic currents (eepscs) were analyzed in superfused brain slices with patch-clamp electrophysiological techniques. results: a) the synthetic cannabinoids jwh- ( x - m) and jwh- ( x - m) inhibited the spontaneous gabaergic synaptic input (sipscs) to purkinje cells in mouse cerebellar slices. the inhibition by jwh- was not affected by pregnenolone ( - m), the inhibition by jwh- was only marginally attenuated. b) the depolarization of the purkinje cells induced suppression of the gabaergic input to purkinje cells (dsi); pregnenolone ( - m) did not affect this endocannabinoid-mediated form of synaptic suppression. c) in rat nucleus accumbens slices, gabaergic and glutamatergic synaptic input to medium spiny neurons was activated by electrical stimulation of axons. ∆ -tetrahydrocannabinol ( x - m) suppressed the gabaergic and glutamatergic synaptic transmission in the nucleus accumbens. these suppressive effects of ∆ tetrahydrocannabinol were not changed by pregnenolone ( - m). d) finally, we tested whether we can observe neurosteroid-mediated effects in our brain slice preparations. tetrahydro-deoxycorticosterone (thdoc, - m) markedly prolonged the decay time constant (τ) of spontaneous gabaergic postsynaptic currents (sipscs), similarly as in previous experiments (ej cooper et al., j physiol : - , ) . the results show that inhibition of gabaergic and glutamatergic synaptic transmission by synthetic-, endogenous,-and phyto-cannabinoids is not changed by pregnenolone. therefore, it is unlikely that interference with cannabinoid-induced inhibition of synaptic transmission is the mechanism by which pregnenolone attenuates behavioural and somatic effects of ∆ -tetrahydrocannabinol in vivo. the hypothalamus is one of the key players in the regulation of the energy homeostasis. cold stress leads to an activation of neurons in the paraventricular hypothalamic nucleus (pvn) and increases thermogenesis. the thyrotropin-releasing-hormone (trh) neurons have an important function in this effect. however it is hardly understood which role the trh neurons exactly play and how they are connected to other regions of the brain. we have transduced neurons in the pvn of mice with a recombinant adeno associated virus which contains an activating "designer receptors exclusively activated by designer drugs" (dreadd) system under the control of a shortened trh promotor. two weeks after transduction the animals were injected with clozapine-n-oxide (cno). to analyse the physiological function of this neurons we performed indirect calorimetry, measured rectal temperature and thermogenesis in the brown adipose tissue (bat), analysed drinking feeding behaviour and the home cage activity. after stimulation we measured the expression of genes in bat as well plasma hormone levels of pituitary hormones. propranolol and the specific β -antagonist sr a were used to analyse the relevance of the sympathetic system. to further characterise the transduced neurons and their projections we used immunohistochemistry methods. after stimulation with cno the energy expenditure and body temperature were increased. these effects were mostly driven through an activation of the brown adipose tissue (bat). in dreadd transduced trh-receptor (trh-r ) knockout mice this effects were abolished. in parallel the plasma levels of tsh, the ucp mrna level in the bat, the home cage activity as well the food and water intake were increased. after the treatment with propranolol and sr a the effects on the thermogenesis were reduced, but the home cage activity was not affected. sr a treatment normalised the food intake and increased in parallel the plasma leptin concentrations after cno stimulation. transduced neurons project into the raphe nucleus, the medial part of the thalamus and the spinal cord. with our experiments we could provide strong evidence for a sympathetic connection of the transduced neurons in the pvn to the bat and for the involvement of thr neurons in these effects. therefore, this system is a suitable tool to investigate the metabolic relevance of trh neurons in detail. background & objective: during obesity development, tissue factor signalling contributes coagulation-independently to inflammatory and metabolic dysfunction of adipose tissue. adipogenesis involves proliferation and differentiation of preadipocytes, apoptosis and hypertrophic growth of differentiated adipocytes, angiogenesis and extracellular matrix reorganisation. the coagulant protease thrombin promotes similar processes in various cell types, through activation of protease-activated receptors par- , par- and par- . in human adipose tissue, par- is found in vascular stromal cells and par- in preadipocytes and differentiated adipocytes. thrombin stimulates mitogenic kinase signalling and induces inflammatory cytokine and angiogenic growth factor secretion in adipocytes. we have examined the contribution of thrombin receptor activation to adipogenesis processes in t l cells. results: differentiation of t l preadipocytes with insulin, dexamethasone and isobutylmethylxanthine increases leptin and pparg gene expression and accumulation of triglycerides and oil red o-stained lipids. par- is time-dependently upregulated in maturing cells while par- expression is detectable but not altered. in preadipocytes, thrombin ( u/ml) activates the mitogenic kinase erk / , promotes cell proliferation and induces gene expression of the maturation markers leptin and pparg and the inflammatory marker tumor necrosis factor alpha (tnfa). repeated stimulation of differentiating adipocytes with thrombin suppresses induction of leptin and pparg and attenuates lipid accumulation, while expression levels of the proliferation marker ki and the inflammatory cytokine interleukin (il)- are increased compared to differentiated control cells. similar proliferative and anti-adipogenic effects are seen with the selective par -activating peptide (gypgkf, µm) and cathepsin g, a proteolytic par- activator released from neutrophils and mast cells. repeated exposure of maturing t l cells to conditioned medium from degranulating mouse peritoneal mast cells (mccm) augments lipid accumulation and il- expression. pretreatment of mccm with a par- inhibitor further drives lipid accumulation, the induction of il- by contrast is suppressed. conclusion: par- activation by thrombin or inflammatory cell-derived cathepsin g appears to suppress adipogenesis, possibly by maintaining proliferative capacity and preventing the growth arrest essential for initiating matuation. increased par- expression in maturing adipocytes may instead support inflammatory changes, thereby promoting the onset of insulin resistance. the chemokine receptor cxcr antagonist amd exerts deleterious effects in endotoxemia in vivo s. seemann , a. lupp the chemokine receptor cxcr is a multifunctional receptor which is activated by its natural ligand c-x-c motif chemokine (cxcl ). although a blockade of the cxcr /cxcl axis revealed beneficial outcomes in chronic inflammatory diseases, its importance in acute inflammatory diseases remains contradictious and not well characterized. as cxcr seems to be part of the lipopolysaccharide sensing complex, cxcr agonists or antagonists may have a positive impact on tlr signaling. additionally, cxcr is involved in the production of pro-inflammatory cytokines, suggesting the receptor to be a promising target in terms of mitigating the cytokine storm. therefore, we aimed to investigate the impact of a cxcr blockade on endotoxemia by applying a sublethal lps dose ( mg/body weight) in mice. the selective cxcr inhibitor amd was administered intraperitoneally shortly after lps treatment to ensure an immediate effect after endotoxemia onset. hours after lps administration, the clinical severity score, the body temperature and the body weight of the animals were determined. afterwards, the mice were sacrificed and serum tnf alpha as well as ifn gamma levels were measured. furthermore, the oxidative stress in the brain, liver, lung and kidney tissue was assessed. in addition, the biotransformation capacity of the liver was evaluated and finally, the expression of gp phox as well as of heme oxygenase in the spleen and liver were determined by means of immunohistochemistry. the mice of the amd plus lps treatment group displayed a significantly impaired general condition, a reduced body temperature and a decreased body weight in comparison to the control and to the lps treated animals, respectively. tnf alpha levels were significantly increased by more than % or % when compared to the control or to the lps group, respectively, whereas ifn gamma levels were elevated by about % in comparison to mice which had received lps only. in all investigated organs, but especially in the liver and in the kidney, co-administration of amd and lps caused massive oxidative stress. furthermore, the protein contents and the activities of several cyp enzymes in the liver were significantly reduced. immunohistochemistry revealed gp phox to occur above average, whereas heme oxygenase expression was distinctly decreased. our results indicate that a blockade of the cxcr in endotoxemia is disadvantageous and even worsens the disease. co-administration of amd and lps impaired the health status of the animals, caused massive oxidative stress and diminished the biotransformation capacity. thus, handling acute systemic inflammation with a cxcr antagonist cannot be recommended, hence indicating the activation of cxcr to be an attractive treatment option. toll-like receptors (tlrs)recognizemicrobial pathogens and trigger inflammatory immune responses to control infections. in acne vulgaris, activation of tlr by propionibacterium acnes contributes to inflammation. although glucocorticoids have immunosuppressive and anti-inflammatory effects, acne can be provoked by systemic or topical treatment. enhanced tlr expression by glucocorticoids has been reported in undifferentiated keratinocytes, however, human skin cells of different epidermal and dermal layers have not been investigated. in this study, the modulation of tlr expression by dexamethasone was assessed in monolayer cultures of primary human keratinocytes and dermal fibroblasts, as well as the immortalized keratinocyte cell line hacat. constitutive tlr , tlr and tlr mrna and protein expression was confirmed in basal keratinocytes, calcium-induced differentiated keratinocytes, hacat cells and fibroblasts by qpcr and western blotting. dexamethasone induced tlr expression in a time-dependent and concentration-dependent manner and reduced tlr / expression in keratinocytes but not in hacat cells or fibroblasts. stimulation with dexamethasone in the presence of the pro-inflammatory cytokines tnfα or il- β further increased tlr mrna levels. gene expression of mapk phosphatase- (mkp- ) was also upregulated by dexamethasone. glucocorticoid-induced tlr expression was negatively regulated by p mapk signalling under inflammatory conditions through mkp- induction which functions to deactivate mapks. as expected, dexamethasone inhibited the immune responses linked to tlr signalling as demonstrated by reduced il- , il- β, mmp- and mcp- levels. however, the expression of traf , a critical cytosolic regulator of tlr-and tnf family-mediated signalling, was further upregulated by the tlr agonist hklm (heat-killed lysteria monocytogenes) in dexamethasonepretreated basal keratinocytes.conclusively, our results provide novel insights intothe molecular mechanismsof glucocorticoid-mediatedtlr expressionand function in human skin cells. psoriasis is a cutaneous chronic inflammatory disease characterized by increased amounts of il- cytokines and t helper (th ) related cytokines in lesional psoriatic skin. treatment with beta-adrenoceptor antagonists is associated with induction or aggravation of psoriasis, however, the underlying mechanism is poorly understood. previously, we could demonstrate a pivotal role for langerhans cells and dermal dendritic cells in antimalarial-provoked psoriasis by maintaining a potent th activity. in the present study, we investigated the effect of propranolol on human monocyte-derived langerhans-like cells (molc) and dendritic cells (modc) under inflammatory conditions. in the presence of il- β, propranolol induced the th priming cytokines il- and il- in a concentration-dependent manner. the increased cytokine release was not mediated by camp suggesting gpcr-independent pathways. in contrast, il- γ and lps failed to increase il- release in molc and modc in the presence of propranolol but further induced secretion of il- β. autophagy has been linked with the secretion of il- family cytokines that are upregulated in chronic inflammatory disorders such as psoriasis. propranolol upregulated the expression levels of the autophagy marker p and lc -i to lc -ii conversion, induced accumulation of lc positive vesicles, as well as expression of il- signalling downstream adapter molecule traf , indicating a late-stage block in autophagy. in summary, our results suggest a prominent role of cutaneous dendritic cell subtypes in psoriasis-like skin inflammation mediated by propranolol and possibly other beta blockers. langerhans cells (lcs) represent a highly specialized subset of epidermal dendritic cells (dcs), yet not fully understood in their function of balancing skin immunity. in the present study, we investigated in vitro generated langerhans-like cells obtained from the human acute myeloid leukaemia cell line mutz- (mutz-lcs) to study tlr-and cytokine-dependent activation of epidermal dcs. mutz-lcs revealed high tlr expression and responded robustly to tlr engagement, confirmed by increased cd and cd expression, upregulated il- , il- p and il- p mrna levels and il- release. tlr activation reduced ccr and elevated ccr mrna expression and induced migration of mutz-lcs towards ccl . similar results were obtained by stimulation with pro-inflammatory cytokines tnf-α and il β whereas ligands of tlr and tlr failed to induce a fully mature phenotype. despite limited cytokine gene expression and production for tlr -activated mutz-lcs, co culture with naive cd + t cells led to significantly increased ifn-γ and il- levels indicating th differentiation independent of il- . tlr -mediated effects were blocked by the putative tlr / antagonist cu-cpt , however, no selectivity for either tlr / or tlr / was observed. computer-aided docking studies confirmed non-selective binding of the tlr antagonist. taken together, our results indicate a critical role for tlr signalling in mutz-lcs considering the leukemic origin of the generated langerhans-like cells. the stagnation in the development of new antibiotics during the last decades and the concomitant high increase of resistant bacteria emphasize the urgent need for new therapeutic options. antimicrobial peptides are promising agents for the treatment of bacterial infections and recent studies indicate that pep - . , a synthetic antimicrobial and lps-neutralizing peptide (salp), efficiently neutralizes pathogenicity factors of gram-negative and gram-positive bacteria and protects against sepsis. in the present study, we investigated the potential of pep - . and the structurally related compound pep - lf for their therapeutic application in bacterial skin infections. primary human keratinocytes responded to tlr (fsl- ) but not tlr (lps) activation by increased il- production, as determined by elisa. western blot analysis showed that both salps inhibited fsl- -induced phosphorylation of nf-κb p and p mapk. furthermore, the peptides significantly reduced il- release and gene expression of il- β, ccl (mcp- ) and hbd- as assessed by qpcr. no cytotoxicity (mtt test) was observed at salp concentrations below µg/ml. in lps-stimulated monocyte-derived dendritic cells, the peptides blocked il- secretion, downregulated expression of the maturation markers cd and cd , as analysed by flow cytometry, and inhibited ccr -dependent migration capacity. similarly, monocyte-derived langerhans-like cells activated with lps and pro-inflammatory cytokines showed reduced il- levels and cd /cd expression in the presence of salps. in addition to acute inflammation, bacterial infections often result in impaired wound healing. since re-epithelialization is a critical step in wound repair, we tested whether pep - . affects keratinocyte migration using the scratch wound assay. the peptide markedly promoted cell migration and accelerated artificial wound closure at concentrations as low as ng/ml and was equipotent to tgf-β. conclusively, our data suggest a novel therapeutic target for the treatment of patients with acute and chronic skin infections. recently, we and others have shown that the transcription factor nuclear factor erythroid -related factor (nrf ), a major regulator of the cellular antioxidant defence system, is activated by mechanical ventilation. during ventilator-induced lung injury, nrf exerts a protective role by interaction with the stretch-induced growth factor amphiregulin. in the current study, we aimed to investigate the role of nrf in acid-induced lung injury, a model for aspiration-induced ards. methods: nrf -deficient (nrf -/-) mice and wild type (wt) littermates were tracheotomised and ventilated for min (v t = ml/kg, f= min - , peep= cmh o, fio = . ), before µl hydrochloric acid (hcl) with ph= . or ph= . were instilled intratracheally, controls received nacl. mice were then ventilated for further h under monitoring of lung mechanics and vital parameters. blood gases as well as proinflammatory mediators, neutrophil recruitment and microvascular permeability were examined to assess lung injury. results: instillation of hcl ph= . induced mild lung injury, indicated by hypoxemia (po /fio ~ mmhg) and continuously increasing lung tissue elastance (stiffness), from which nrf -/mice were protected. pulmonary inflammation, characterized by liberation of cytokines, chemokines and oedema formation, was attenuated in nrf -/mice. in contrast, hcl ph= . caused more severe lung injury (po /fio ~ mmhg) with a steeper incline in elastance and more severe inflammation in both wt and nrf -/mice. conclusion: we conclude that the presence of nrf augments mild acid-induced lung injury, but plays no role in more severe injury. these discrepant results will be elucidated in future investigations. uniklinik rwth aachen, institut für pharmakologie und toxikologie, aachen, germany fakultät für maschinenwesen der rwth aachen, werkzeugmaschinenlabor, aachen, germany rationale: reproducibility is key to science. in recent times, the reproducibility of biomedical research has been questioned increasingly. this reproducibility crisis also affects complex animal experiments, which -if not reproducible -might also be regarded as unethical and lose public acceptance. part of the problem is frequently that the provided documentation is not sufficient for reproduction. therefore, in this study we analyzed the potential of conventional quality management tools -used as standard in machine production -as an approach to improve the documentation and ascertain the quality of complex animal experiments. methods: quality management tools were transferred to an experimental animal set up -the mouse intensive care unit (micu) -which we use for lung injury studies. the tools included visualization of the experimental set-up, transfer of the experimental procedures to an event-driven process chain (epc) and statistical process control (spc) of all crucial pulmonary and cardiovascular parameters. data from ventilator-and acidinduced lung injury studies acquired in the micu were analyzed retrospectively. results: schematic visualization of the micu resulted in a chart comprising medical components, hardware, software and generated data types. the customized epc included all important activities and the resulting events for preparation of the mouse and the workplace, the actual animal ventilation experiment and sample-taking. in addition, checklists were provided for these activities and events, to ensure standardization of every work step. lung impedance and cardiac functions from ventilator-and acid-induced lung injury models were analyzed by spc and correlated with events in the epc. the spc proved to be suitable to identify outliers, predict processes and thereby validate the lung injury models. conclusions: conventional quality management tools were successfully adapted to analyze the quality of lung injury experiments in the micu. we suggest that this new approach is suitable to standardize animal testing procedures and increase the reproducibility of animal studies. background: a dysfunctional endothelial l-arginine-nitric oxide (no) pathway is a key pathomechanism of idiopathic pulmonary arterial hypertension (ipah) that can be provoked by hypoxia in cell culture models [ ] [ ] [ ] [ ] . the small peptide apelin is involved in the maintenance of pulmonary vascular homeostasis and angiogenesis although its precise mechanism of action is still unclear [ ] . asymmetric dimethylarginine (adma) is known to be an endogenous inhibitor of endothelial no synthase and is associated with several cardiovascular diseases [ ] . adma is degraded by dimethylarginine dimethylaminohydrolase and (ddah) enzymes [ ] . objective: to determine the effect of apelin on the l-arginine/no pathway in human pulmonary microvascular endothelial cells (hpmecs). methods: hpmecs were cultured under normoxic and ph-related hypoxic conditions and treated with apelin. the expression of regulators of the l-arginine/no pathway were analysed using real-time pcr. the effect of apelin on the phosphoinositide- kinase (pi k)/akt signalling pathway was determined using immunoassays and specific inhibitors[lh ] . apelin and adma concentrations were measured in cell culture supernatants using an enzyme-linked immunosorbent assay and a liquid chromatography-tandem mass spectrometry assay. results: treatment with apelin resulted in a reduced expression of the apelin receptor (aplnr) on hpmecs suggesting a negative feedback mechanism. apelin directly influenced the l-arginine/no pathway by increasing the expression of ddah and ddah enzymes. thus, the concentration of adma was decreased in hpmecs supernatant following treatment with apelin. the effect of apelin could be abrogated by modulation of the pi k/akt pathway. conclusion: apelin modulates the l-arginine/no pathway and mediates enhanced degradation of adma via an upregulated expression of ddah and enzymes. the pi k/akt pathway might play a decisive role in regulation of the effect of aplein. an apelin receptor agonist could be a novel and promising therapeutic option for ipah treatment. background and purpose: there is presently no proven pharmacological therapy for the acute respiratory distress syndrome (ards). recently, we and others discovered that the heptapeptide angiotensin (ang)-( - ) shows significant beneficial effects in preclinical models of acute lung injury (ali). here, we aimed to identify the best time window for ang-( - ) administration to protect rats from oleic acid (oa) induced ali. experimental approach: the effects of intravenously infused ang-( - ) were examined over four different time windows before or after induction of ali in male sprague-dawley rats. hemodynamic effects were continuously monitored, and loss of barrier function, inflammation, and lung peptidase activities were measured as experimental endpoints. key results: ang-( - ) infusion provided best protection from experimental ali when administered by continuous infusion starting min after oa infusion till the end of the experiment ( - min). both pretreatment (- - min before oa) and short-term therapy ( - min after oa) also had beneficial effects although less pronounced than the effects achieved with the optimal therapy window. starting infusion of ang-( - ) min after oa (late-term infusion) achieved no protective effects on barrier function or hemodynamic alterations, but still reduced myeloperoxidase and angiotensin converting enzyme activity, respectively. conclusions and implications. our findings indicate that early initiation of therapy after ali and continuous drug delivery are most beneficial for optimal therapeutic efficiency of ang-( - ) treatment in experimental ali, and presumably accordingly, in clinical ards. airway epithelium functions as a physicochemical barrier against dust, air pollutants and other pathogens and plays a critical role in physiological and pathological processes including modulation of the inflammatory response, innate immunity and airway remodeling such as in human asthma, copd and equine recurrent airway obstruction (rao). models of the airway epithelia are, indeed, missing for the horse; thus, we established long-term equine bronchial epithelial cell cultures using the rock inhibitor y- and cell growth and differentiation was characterized. bronchial epithelial cells (ebec) from adult horses were cultured in the presence and absence of µm y- under conventional and air-liquid-interface (ali) culture conditions. cell proliferation and differentiation were analyzed. formation of a functional epithelial barrier was investigated by transepithelial electric resistance (teer) measurement and immunocytochemical staining of the tight-junction-protein zonula occludens- (zo- ). under conventional culture, y- induced higher growth rate of primary ebec and increased the passage number up to passages with retained epithelial cell behavior. in the presence of y- , ebecs under ali showed higher teer values. expression of zo- correlated with the increase in teer, but in y- -treated ebec tight-junctionformation was more rapid, indicating accelerated differentiation, as well h/e-staining and scanning electron microscopic imaging showed a higher amount of cilia and microvilli and pas-positive cells. in conclusion, the data suggest that the rock inhibitor y- facilitates long-term culture of equine bronchial epithelial cells which can be used to study airway disease mechanisms and to identify pharmacological targets. leishmaniasis is a neglected disease of tropical and subtropical regions with millions of people at risk of infection with severe consequences including death. current antileishmanial drugs exhibit serious side effects and also development of resistances is rising. this disease is caused by protozoal organisms from the genus leishmania. in their insect vector they exist in the promastigote form, while in the mammalian host they survive as amastigotes inside the phagolysosomes of macrophages. this makes a specific pharmacotherapy complicated. due to the success of artemisinin in malaria therapy, it was of interest whether endoperoxides are also useful to treat leishmaniasis. in a previous study we demonstrated that ascaridole, an endoperoxide from chenopodium ambrosioides, can cure cutaneous leishmaniasis in a mouse model and exhibited ic values for the viability in the low micromolar range [ ] . even though in chemical model systems some basic ideas about the mechanism of activation of these endoperoxides exist, in biological systems including leishmania parasites this activation step has never been demonstrated. therefore, we set up experiments to identify primary drug intermediates formed from ascaridole by activation in leishmania tarentolae promastigotes using electron spin resonance spectroscopy in combination with spin trapping methods. ascaridole was activated in a cell-free system by fe + . the radicals were trapped by -methyl- -nitrosopropane (mnp). the resulting esr spectra consisted of the triplet of duplets. spectral simulations revealed coupling parameters of a n = . g, and a h = . g. these coupling constants are compatible with iso-propyl radicals as primary intermediates. in the cellular system, consisting of leishmania tarentolae promastigotes, instead of mnp the less cytotoxic , -dimethyl- pyrroline-n-oxide (dmpo) was used for spin trapping. without addition of fe + a six line esr signal was observed. spectral simulations of the dmpo spin adduct revealed coupling constants of a n = . and a h = . g. according to previously published data [ ] from other spin trapping experiments, this corresponds to the formation of carboncentered radicals from ascaridole by leishmania parasites. additional experiments using iron chelators and antioxidants as well as a comparison with the endoperoxide artemisinin were performed. in summary, this study for the first time demonstrated the activation of the endoperoxide ascaridole by a protozoal organism to its active intermediate as a prerequisite to understand its mechanism of action. [ ] l. monzote, j. pastor, r. scull, and l. gille. antileishmanial activity of essential oil from chenopodium ambrosioides and its main components against experimental cutaneous leishmaniasis in balb/c mice. phytomedicine : - , . nitric oxide (no), produced by the inducible nitric oxide synthase (inos) has many functions in physiological and pathophysiological pathways. after induction of inos expression by cytokines and other agents the enzyme produces high amounts of no in a ca + -independent way. this high no production can have beneficial microbicidal, antiparasital, antiviral and antitumoral effects. in contrast, aberrant inos induction may have detrimental consequences and seems to be part of many diseases such asasthma, arthritis, multiple sclerosis, colitis, psoriasis, neurodegenerative diseases, tumor development, transplant rejection or septic shock. analysis of the human inos-mrna structure revealed the existence of an upstream open reading frame (µorf) and a putative internal ribosome entry site (ires) in the ' untranslated region ( 'utr) in front of the start codon of the inos coding sequence (cds). to analyze the function of the µorf and the putative ires we cloned different egfp and luciferase reporter constructs and transfected them into the human colon carcinoma cell line dld . using a plasmid construct with the µorf fused with the egfp cds, we could show that the µorf can be translated. however, compared to the positive control plasmid less egfp was produced, which can be explained by a weak kozak sequence of the µorf. blocking the mrna cap-dependent translation by cloning a stem loop structure in front of the inos 'utr within a luciferase reporter plasmid led to a remarkable loss of luciferase production. thus, the expression of inos seems to be cap-dependent. furthermore, transfection experiments with dld cells using constructs coding for a bicistronic renilla-firefly luciferase mrna showed that there is no ires in front of the inos cds. taken together, the inos expression seems to be cap-dependent and without influence of an ires, while the µorf is translatable. therefore we speculate that inos expression is only possible due to a leaky scanning mechanism depending on the weak kozak sequence of the µorf. objectives: vascular oxidative stress is considered a pathophysiologic factor promoting cardiovascular diseases such as coronary artery disease, heart failure, diabetes and hypertension. there are several sources of superoxide in vascular smooth muscle and endothelial cells but whether an impairment of the catalytic function of enos and thus generation of oxidative stress is involved in blood pressure (bp) regulation and/or the development of hypertensive disease states is unknown. methods: we generated a mutant enos in which one of the two essential cysteines required for the coordination with the central zn-ion, correct dimer formation and normal activity is replaced by alanine (c a-enos). normal enos (enos-tg) or a novel dimer-destabilized c a-enos described previously (antioxid redox signal. sep ; ( ) : - ) were introduced in c bl/ in an endothelial-specific manner. mice were monitored for enos expression and localization, aortic relaxation, systolic blood pressure, levels of superoxide and several post-translational modifications indicating activity and/or increased vascular oxidative stress. some groups of mice underwent voluntary exercise training for weeks or treatment with sod mimetic tempol. results: c a-enos-tg showed significantly increased superoxide generation, protein-and enos-tyrosine-nitration, enos-s-glutathionylation, enos / phosphorylation and amp kinase (ampkα) phosphorylation at thr in aorta, skeletal muscle, left ventricular myocardium and lung as compared to enos-tg and wild type (wt) controls. the localization of enos-c a-tg was restricted to endothelium as evidenced by immunohistochemically staining for enos and an endothelial-specific marker cd . exercise training increased phosphorylation of enos at ser / and of ampkα at thr in wt but not in c a-enos-tg. aortic endothelium-dependent and endothelium-independent relaxations were similar in all strains. in striking contrast, c a-enos-tg displayed normal blood pressure despite higher levels of enos, while enos-tg showed significant hypotension. tempol completely reversed the occurring protein modifications and significantly reduced bp in c a-enos-tg but not in wt controls. conclusions: by means of a novel transgenic mouse model we demonstrated that vascular oxidative stress generated by endothelial-specific expression of a dimerdestabilized variant of enos selectively prevents bp reducing activity of vascular enos, while having no effect on aortic endothelial-dependent relaxation. these data suggest that oxidative stress in microvascular endothelium may play a role in the development of essential hypertension. the herbal medicinal product myrrhinil-intest ® consists of myrrh, chamomile flower dry extract and coffee charcoal. clinical data prove the effectiveness of this herbal preparation for inflammatory intestinal disorders. to further investigate the anti-inflammatory potential of the single components as part of a multi-target principle, an ethanolic (my) and aqueous (mya) myrrh extract, ethanolic chamomile flower extract (ka) and aqueous coffee charcoal extract (cc), were examined in an in vitro tnbs inflammation model using rat small intestinal preparations. the effect of the plant extracts on tnbs induced inflammatory damage was characterised based on tnfα-gene expression analysis, isometric contraction measurement and histological analysis. furthermore, tnfα-release from lpsstimulated thp- cells was determined. budesonide was used as positive control. additionally, microarray gene expression analysis was performed in lps/ifnγ stimulated native human macrophages to determine potential underlying mechanisms. the tnbs-induced overexpression of tnfα-mrna was reduced after ka ( . mg/ml) and mya ( mg/ml) treatment down to % and % resp.; tnbs-induced loss of contractility and reduction of mucosal layer thickness was inhibited after ka ( mg/ml) treatment by % and % resp.; after mya ( . - mg/ml) treatment by % and % resp. lps-induced tnfα release from thp- cells was inhibited concentrationdependently by my (ic = . μg/ml; % inhibition), ka (ic = μg/ml; % inhibition) and cc (ic = μg/ml; % inhibition). furthermore, ka ( µg/ml) and cc ( µg/ml) inhibited the lps/ifnγ-induced expression of genes associated with chemokine signalling up to -fold (for cxcl ). the presented study demonstrates further evidence for anti-inflammatory properties of the herbal components which contribute to the reported clinical effectiveness. introduction: the purine nucleoside adenosine, which is involved in a variety of physiological functions, regulates immune and inflammatory responses and acts as a modulator of gut functions. although it is present at low concentrations in the extracellular space, stressful conditions, such as inflammation, can markedly increase its extracellular level up to micromolar range. by activation of different receptor subtypes adenosine is able to induce anti-inflammatory or pro-inflammatory impacts. aim: the current study examined the impact of adenosine a a receptors (a ar) and adenosine a b receptors (a br) to regulate contractility in untreated and inflamed rat colon preparations using a specific a ar agonist (cgs ) and an a br antagonist (psb- ) on acute inflammation in rat colon preparations. further it focused on interactions of the multi-herbal drug stw with a ar as a possible mechanism of the protective effect of stw in gastrointestinal disorders. methods: inflammation was induced by intraluminal instillation of , , -trinitrobenzene sulfonic acid (tnbs). contractions were measured isometrically in an organ bath set up. gene expression was determined using rt-pcr. radio ligand binding assays (competition experiments) were carried out with rat brain homogenates. morphological changes were estimated after van gieson staining. results: all four adenosine receptor subtypes were expressed in untreated colon preparations. activation of a , a b, and a receptor with specific agonists reduced the acetylcholine (ach, µm)-induced contractions, while activation of a br enhanced it. after incubation with tnbs morphological damages in colonic mucosa and muscle walls were detectable followed by reduced ach-contractions. the tnbs-mediated decrease of ach-contractions as well as the morphological damages were partially normalized by co-incubation of tnbs with cgs ( µm) or with psb ( µm). the same effects with smaller intensity were found for stw ( µg/ml) in female but not in male colon preparations. these results are in accordance with ligand binding studies indicating that stw interact with the a ar. conclusion: anti-inflammatory mechanisms and cell protective actions of stw are partly due to the interaction with adenosine receptors. the results give a clear-cut correlation with symptom improvements in clinical trials and thereby highlight the relevance of stw as a therapeutic approach in ibs. (allescher ) . therefore, a multi-target approach is a promising therapeutic strategy, as is exemplified by stw (ottillinger et al. ) . stw (iberogast®) is a fixed combination of nine plant extracts with iberis amara (stw ) as one of its components. it is successfully used for treatment of functional dyspepsia and irritable bowel syndrome (ibs). to allow an overview of targets addressed by stw and the role of its components in relation to the different forms and causes of functional gi diseases, an evaluation of the data, which have been gained from more than pharmacological tests, is needed. all data from studies including stw alone, or stw and its components, were retrieved and sorted according to types of study models (human and animal systems, animal disease models, gi-preparations, cell cultures, in vitro-systems) and respective etiologic mechanisms related to fgds and then visualized in the form of d histograms (lorkowski et al. ) . results: more than pharmacological tests indicated anti-oxidative activity, electrophysiological effects, ulcer protection, anti-inflammatory actions, pro-kinetic and spasmolytic effects as well as reflux and acid reduction. moreover, the analysis indicated that the components of stw contribute differently to the overall effect of stw . altogether, the evaluation of the data shows that stw is active in response to multiple etiologic factors involved in fgds, especially functional dyspepsia and irritable bowel syndrome, and to which extent the herbal extract components of the combination are relevant for the different mechanisms of action and their translation to clinical efficacy. conclusion: multi step clustering allows the transformation of complex data sets. it makes the allocation of specific actions to the different components of stw manageable, so also giving support to its clinical use in patients with different symptoms. introduction: stw ii has been recently developed in an effort to reduce the number of active extracts in the mother multi-component herbal preparation, stw (iberogast ® , steigerwald arzneimittelwerk gmbh, darmstadt, germany) without affecting the overall therapeutic efficiency. stw consists of a mixture of standardized extracts: bitter candytuft (iberis amara), lemon balm (melissa officinalis), chamomile (matricaria recutita), caraway fruit (carum carvi), peppermint leaf (mentha piperita), liquorice root (glycyrrhiza glabra), angelica root (angelica archangelica), milk thistle (silybum marianum) and celandine herb (chelidonium majus), whereas stw ii lacks the last components. stw was shown to be effective clinically to treat functional dyspepsia ( ) and irritable bowel syndrome ( ) and was shown experimentally to be effective to guard against the development of radiation induced intestinal mucositis ( ) and in the management of ulcerative colitis ( ) . the present study was initiated to show whether stw ii with the reduced component extracts would also be as effective in the latter condition. this was induced in wistar rats by feeding them with % dextran sodium sulfate in drinking water for week when lesions were observed in the colon evidenced by histological examination as well as colon shortening and reduction of colon mass index. this was associated with a rise in myeloperoxidase and a fall in reduced glutathione, glutathione peroxidase, and superoxide dismutase in colon homogenates as well as a rise in tnfα in serum. oral administration of stw in doses of and ml/kg or stw ii in a dose of ml/kg for week before and continued during dss feeding tended to normalize all the changes in a fashion comparable to sulfasalazine, used as a reference drug in a dose of mg/kg. conclusions: the modified preparation, stw ii thus proved to be as effective as stw , thereby reflecting its potential usefulness in ulcerative colitis possibly by virtue of its anti-inflammatory and anti-oxidant properties. ( ) schmulson mj ( ) the emetic pathways include the action of neurotransmitters dopamine, serotonin and substance p in the emetic centers localized in the brainstem, area postrema and vagal nerve afferents. previous in vivo studies in beagle dogs revealed that the plant alkaloid lycorine potentially induce nausea and emesis. though antagonists of the tachykinin receptor (maropitant) and serotonin receptor (ondansetron) prevented lycorinemediated emesis, the molecular mechanism of nausea and vomiting remain still unknown. to study the mechanism of action of the emetic agents, we analyzed the effect of lycorine (direct activation of nk ) and channel opening (activation of ht ) on the intracellular calcium homeostasis (using fluorometric ca + analysis) and cell proliferation rates in endogenously nk and ht receptor expressing cell lines as well as in cho and hek cells stably expressing the receptors. neither endogenously receptor expressing nk or ht cells nor receptor overexpressing cells showed calciumflux or calcium mobilization after stimulation with lycorine. furthermore, we are measuring the receptor number and subtypes using radioligand binding studies. it is planned, moreover, to obtain fluorescent labeled constructs of the nk receptor to gain insights into the involvement of receptor internalization which might mediate emesis. by characterizing these molecular principles of the nk and ht receptors, we are attempting to obtain more information in predicting drug-induced side effects such as nausea and emesis. the intestinal epithelium is completely renewed every - days. this process is driven by stem cells, which reside within specialized niches in the intestinal crypts and give rise to several differentiated cell types, including enterocytes, paneth, enteroendocrine, goblet and tuft cells. however, the molecular mechanisms that establish and maintain differentiated cell numbers and proportions remain largely unknown. here, we systematically analyzed the intestinal expression of semaphorins and plexins, which constitute a ligand-receptor system that plays central roles in cell-cell communication in various biological contexts. we identified plexin-b and its semaphorin ligands to be highly expressed in intestinal epithelial cells. genetic inactivation of plexin-b in intestinal organoids strongly reduced the number of enteroendocrine cells. our data suggest that semaphorin-plexin-b signaling promotes differentiation of intestinal epithelial cells towards the enteroendocrine lineage. the gastric epithelium contains several types of differentiated cells, including foveolar cells that produce mucus, parietal cells that secrete gastric acid and intrinsic factor, chief cells that synthesize pepsinogen and gastric lipase, and enteroendocrine cells that release different hormones. these differentiated cell types all originate from multipotent stem cells, yet little is known about how this differentiation process is regulated on a molecular level. the gap protein rasal controls the activity of small gtpases of the ras family, and its expression levels have been shown to inversely correlate with progression of stomach cancers. however, functional studies on the physiological role of rasal in the gastric epithelium are lacking. here, we established and characterized a mouse line with inactivation of the rasal gene. we observed that these mice showed increased numbers of enteroendocrine cells in the gastric mucosa. conditional inactivation of rasal in enteroendocrine cells, using a mouse line in which cre expression is driven by the atoh promoter, further corroborated that rasal expression in enteroendocrine cells determines enteroendocrine cell numbers. these findings identify rasal as a regulator of gastric epithelial cell differentiation. ). the present study investigates the impact of two faah inhibitors (arachidonoyl serotonin [aa- ht], urb ) on a lung cancer cell metastasis and invasion. lc-ms analyses revealed increased levels of faah substrates (aea, -ag, oea, pea) in cells incubated with either faah inhibitor. in athymic nude mice faah inhibitors were shown to elicit a dosedependent antimetastatic action. in vitro, a concentration-dependent anti-invasive action of either faah inhibitor was demonstrated, accompanied with upregulation of tissue inhibitor of matrix metalloproteinases- (timp- ). using sirna approaches, a causal link between the timp- -upregulating and anti-invasive action of faah inhibitors was confirmed. moreover, knockdown of faah by sirna was shown to confer decreased cancer cell invasiveness and increased timp- expression. inhibitor experiments point toward a decisive role of cb and transient receptor potential vanilloid in conferring the anti-invasive effects of faah inhibitors and faah sirna. finally, antimetastatic and anti-invasive effects were confirmed for all faah substrates. collectively, the present study provides first-time proof for a pronounced antimetastatic action of the faah inhibitors aa- ht and urb . as underlying mechanism of its anti-invasive properties an upregulation of timp- was identified. regenerative activity in tissues of mesenchymal origin depends on the migratory potential of mesenchymal stem cells (mscs). the present study focused on inhibitors of the enzyme fatty acid amide hydrolase (faah), which catalyzes the degradation of endocannabinoids (anandamide, -arachidonoylglycerol) and endocannabinoid-like substances (n-oleoylethanolamine, n-palmitoylethanolamine). in boyden chamber assays, the faah inhibitors, urb and arachidonoyl serotonin (aa- ht), were found to increase the migration of human adipose-derived mscs. lc-ms analyses revealed increased levels of all four aforementioned faah substrates in mscs incubated with either faah inhibitor. following addition to mscs, all faah substrates mimicked the promigratory action of faah inhibitors. promigratory effects of faah inhibitors and substrates were causally linked to activation of p / mitogen-activated protein kinase (mapk), as well as to cytosol-to-nucleus translocation of the transcription factor, peroxisome proliferator-activated receptor α (pparα). whereas pparα activation by faah inhibitors and substrates became reversed upon inhibition of p / mapk activation, a blockade of pparα left p / mapk phosphorylation unaltered. collectively, these data demonstrate faah inhibitors and substrates to cause p / mapk phosphorylation, which subsequently activates pparα to confer increased migration of mscs. this novel pathway may be involved in regenerative effects of endocannabinoids whose degradation could be a target of pharmacological intervention by faah inhibitors. background: the hematopoietic disorder chronic myeloid leukemia (cml) is one of the most extensively studied neoplasms. it is caused by translocation between chromosomes and leading to the formation of the philadelphia chromosome and the bcr-abl fusiongene. first-line targeted therapy is still the tyrosine-kinase inhibitor imatinib (im), which led to tremendous success in treatment. however, the amount of therapeutic resistances is increasing, caused either by bcr-abl-dependent mechanisms (e.g. bcr-abl amplification/overexpression, point mutations) or bcr-ablindependent mechanisms. these might be linked to alterations in drug transporter expression or particularly, microrna-expression levels. in our previous study, we analyzed the changes of microrna expression profiles during the development of imresistances in the leukemic cell line k . an inverse correlation of mir- expression and protein levels of the efflux transporter atp-binding cassette transporter g (abcg ) was observed in cells resistant to different im-concentrations, pointing to a relation of mir- to im-resistance. hence, we investigate in current studies, how the influence of mir- on im-sensitivity could be explained. methods: we transfected k cells, sensitive treatment-naïve cells and cells resistant to various im-concentrations, either with mir-mimic pre-mir- or inhibitory anti-mir- , challenged them with im and analyzed effects on cell viability, activation of apoptosis and cell death using wst- -, caspase glo -assay and cell counting. in addition, we analyzed changes in abcg expression using flow cytometry and qrt-pcr and investigated alterations in im-efflux using hplc and hoechst efflux assay. results: under im-treatment, sensitive k showed an effect of mir- -inhibition using anti-mir- . this led to a significant promotion of cell survival apparent on the level of respiratory chain function (p< . ) and cell membrane integrity and reduced capase- activity (p< . ). furthermore, these mirna-effects are dose-dependent as confirmed in concentration row-experiments. regarding transport and abcg expression, we found that µm im-resistant k do not express higher amounts of abcg , but showed higher transport rates of im or the abcg -substrate hoechst . conclusions: overall, these experiments indicate that mir- does not only affect abcg -expression, but also influences cell sensitivity to im in a more direct manner. further analysis will now be performed to reveal the underlying mechanism, how cell sensitivity to im is altered and if these effects occur due to a direct regulation of abcg . in summary, these findings could be relevant in cml-therapy, overcoming imresistances with a better understanding of mirna-and drug transporter alteration in cml. acknowledgments: we would like to thank all the authors for their contribution to this project. this work was funded by the university hospital schleswig-holstein. oxidized silicon nanoparticles and iron oxide nanoparticles for radiation therapy s. klein radiation therapy often combined with surgery and/or chemotherapy is applied to more than % of patients at some point of their treatment. the cytotoxic effects of ionizing radiation occur from their ability to produce dna double-strand breaks through the formation of free radicals within cells. however, the curative potential of radiotherapy is often limited by intrinsic radio resistance of cancer cells and normal tissue toxicity. to overcome this resistance and enhance the effectiveness of ionizing radiation, radio sensitizers are used in combination with radiotherapy. in our studies we used amino functionalized, oxidized silicon nanoparticles (sinp), superparamagnetic iron oxide nanoparticles (spion) and iron doped silicon nanoparticles (fe( %)-sinp) to increase the formation of reactive oxygen species (ros) in cells. cancer and tissue cells loaded with the various nanoparticles were irradiated with a single dose of - gy using a kv x-ray tube. after irradiation, the formation of the different ros species including superoxide, hydroxyl radicals and singlet oxygen was investigated. sinps with sizes around nm can easily cross the cell and nuclear membrane. the positively charged amino functionalized sinps stick in all membranes as well in those of the mitochondria. irradiation of the mitochondria may cause the depolarization of the mitochondrial membrane, which enables the release of cytochrome c and simultaneously, an inhibition of the respiratory chain, which leads to an increased generation of superoxide. amino functionalized sinps, as being embedded in the outer mitochondrial membrane, evidently enhance the depolarizing effect of the x-ray radiation on the mitochondria and therefore increase the concentration of superoxide. [ ] oxidized sinps with larger sizes accumulate in the cytoplasm and generate mainly singlet oxygen after irradiation. spions enter the cells via endocytosis, whereas the uncoated spions remain in the vesicles and the citrate coated spions accumulate in the cytoplasm. cells loaded with citrate coated spions show no higher ros concentration than in media-cultured cells. but after irradiation, the ros formation increased drastically. this enhancing effect is explained with the impact of x-rays onto the surface of spions which is due to the destruction of surface structures. the freed spion surface contains easier accessible iron ions. this ions can participate in the fenton and haber-weiss chemistry and thus, catalyze the hydroxyl radical formation. [ ] to % iron doped sinp increase the formation of hydroxyl radicals as well as the generation of singlet oxygen after irradiation. chronic pain in response to tissue damage (inflammatory pain) or nerve injury (neuropathic pain) is a major clinical health problem, affecting up to % of adults worldwide. currently available treatments are only partially susceptible and are accompanied with therapy limiting side effects. thus it is important to elucidate molecular mechanisms of pain signaling in detail to obtain new insights in potential future therapies. recent data indicate that hydrogen sulfide (h s) contributes to the processing of chronic pain, however pro-as well as antinociceptive effects have been described so far. moreover the sources of h s production in the nociceptive system are only poorly understood. here we investigated the expression of the h s releasing enzyme cystathionine g-lyase (cse) in the nociceptive system and characterized its role in chronic pain signaling using cse deficient mice. paw inflammation and peripheral nerve injury led to upregulation of cse expression in dorsal root ganglia. however, conditional knockout mice lacking cse in sensory neurons as well as global cse knockout mice demonstrated normal pain behaviors in inflammatory and neuropathic pain models as compared to wt littermates. thus, our results suggest that cse is not critically involved in chronic pain signaling in mice and that sources different from cse mediate the pain relevant effects of h s. this work was supported by the deutsche forschungsgemeinschaft (sfb -a ) and in part by loewe-schwerpunkt "anwendungsorientierte arzneimittelforschung". heinrich-heine-universität, institut für toxikologie, düsseldorf, germany heinrich-heine-universität, urologie, düsseldorf, germany background: cisplatin (cispt) is frequently used in the therapy of advanced stage urothelial cell carcinoma (ucc). yet, inherent and acquired drug resistance limits the clinical use of cispt. here, we comparatively investigated the response of epithelial-like (rt- ) and mesenchymal-like (j- ) uc cells following cispt treatment. methods: upon selection with equitoxic doses of cispt for months, we obtained cispt resistant variants (rt- r , j- r ). cell viability was measured using the alamar blue assay. cell cycle distribution was analysed by flow cytometry. immunocytochemistry was used to quantify the number of nuclear γh ax and bp foci representing dna double strand breaks (dsbs), while western blot was used to unravel the role of dna damage response (ddr) to acquired cispt resistance. qrt-pcr was performed to analyse the mrna expression of genes associated with cispt resistance. j- and j- r cells were treated with different concentrations of lovastatin and selected ddr inhibitors to elucidate their influence on cell viability. results: untreated rt- cells showed an about - -fold higher resistance to cispt than j- cells. both cell lines differed in the expression pattern of genes that are associated with cispt resistance. rt- r and j- r revealed a - -fold increased cispt resistance as compared to the parental cells. during the selection procedure, we observed that acquired cispt resistance goes along with morphological alterations that resemble epithelial mesenchymal transition (emt). cell cycle analysis of rt- r cells disclosed a reduced apoptosis and enhanced g /m arrest following cispt exposure as compared to rt- wild-type cells. by contrast, induction of cell death was similar in j- and j- r cells. notably, j- r cells showed a reduced formation of cispt-induced dsbs. correspondingly, the related ddr was diminished in j- r as compared to their parental cells. this was not found when ddr was comparatively analysed between rt- r and rt- cells. data obtained from qrt-pcr analysis indicate that different mechanisms contribute to acquired drug resistance of j- r and rt- r . unexpectedly, j- r and rt- r shared the upregulation of xaf- . treatment of j- r cells with statins and protein kinase inhibitors revealed an enhanced sensitivity to pharmacological inhibition of chk- and, moreover, re-sensitization to cispt by chk- inhibitor. based on the data we suggest that mechanisms of acquired cispt resistance of epithelial and mesenchymal uc cell lines are different with apoptosisrelated mechanisms appear to be more relevant for epithelial-like rt- cells and ddr-related mechanisms dominating cispt susceptibility in mesenchymal-like j- cells. furthermore, our findings indicate that chk- might be an appropriate target to deal with acquired cispt resistance in ucc. in many patients, gastric cancer treatment with conventional cytostatic agents shows only limited clinical response. novel therapeutics, which inhibit rtk signaling by targeting c-met or her family receptors, have demonstrated some efficacy; however, primary resistance of gastric cancer cells against these inhibitors is still a major problem. in the present study we investigated the mechanism of heregulin (hrg)-promoted survival of gastric cancer cells after treatment with c-met inhbitors or sirna-mediated downregulation of c-met. we found that hrg treatment of gastric cancer cells with a c-met amplification partially rescued the cells from the antiproliferative effects of pharmacological c-met inhibition or sirna-mediated downregulation of c-met. moreover, c-met inhibition or downregulation led to an induction of her expression on mrna and protein level, whereas other her family receptors were unaffected. downregulation of her impaired the hrg-mediated rescue of cell survival upon c-met inhibition. in other tumor entities the chromatin organizer special at-rich sequence-binding protein (satb ) has been described as a regulator of her family receptor expression involved in adaptive responses of tumor cells. thus, we investigated the contribution of satb in the upregulation of her after c-met inhibition. of note, c-met inhibitors as well as c-met-specific sirnas markedly induced satb expression in gastric cancer cells, and the downregulation of satb by sirnas completely prevented the induction of her upon c-met inhibition. in contrast, her or her expression levels were not affected by satb -specific sirnas. the function of satb as transcriptional regulator is controlled by its phosphorylation status, which in turn is modulated by pkc activity. thus, we also tested the effect of pkc inhibitors on her expression after c-met inhibition. interestingly, the upregulation of her in gastric cancer cells was significantly reduced by pkc inhibitors. to summarize, satb and pkc are critically involved in the regulation of her expression in gastric cancer cells after treatment with c-met inhibitors and the oncogene her plays a crucial role for tumor cell survival in this context. thus, inhibition of pkc or satb may help to overcome resistance against c-met inhibition in this tumor entitiy. in the rising field of nanomedicine, development of new approaches in diagnosis and treatment of cancer is a challenging task. typically, a nanocarrier is synthesized and linked to functional compounds displaying either diagnostic or therapeutic effects in cancer models. recently, nanomaterials combining both diagnostic and therapeutic properties, so-called 'theranostics', became of primary interest. here we used a human albumin-polyethylene glycol (peg) copolymer (hsa) as a theranostic platform for molecular integration of the chemotherapeutic drug doxorubicin (dox) and the magnet resonance imaging (mri) contrast agent gadolinium (gd) yielding gd-hsa-dox nanoparticles. besides in vitro testing, which demonstrated cytotoxic efficacy of gd-hsa-dox, we used the chorioallantoic membrane (cam) of fertilized chick eggs as a preclinical xenotransplantation model. the cam assay, which in legal terms does not represent an animal experiment, allows testing of compounds in an in vivo setting. this model is particularly helpful to narrow the gap between in vitro and in vivo applications in rodents, because it can help to reduce number of elaborate experiments with typically nude mice, and it reduces or even avoids exposure of those animals to adverse effects and distress. treatment-resistant mda-mb- breast cancer cells stably transfected with luciferase were xenotransplanted onto the chorioallantoic membrane. after formation of solid breast cancer xenografts, gd-hsa-dox was injected intravenously and its antiproliferative effect was evaluated by ivis imaging of luciferase activity and by immunohistochemical analysis of the tumor xenografts for the ki- proliferation antigen. in comparison to conventional dox, gd-hsa-dox showed increased antiproliferative efficacy and reduced general toxicity in the cam assay. on the basis of these findings, a rodent model was established, where the mda-mb- breast cancer cells were orthotopically xenotransplanted into the mammary fat pads of female nmri nu/nu mice. in this model, we further investigated biocompatibility, as well as diagnostic and therapeutic properties of the engineered nanomaterial. after repeated administration of gd-hsa-dox into the tail vein of the animals, biocompatibility of gd-hsa-dox was confirmed by uncompromised liver, kidney and hematopoietic parameters. to warrant diagnostic properties, accumulation of the nanomaterial in tumor tissue is indispensable. by small animal mri of gd, kinetics of intravenously applied gd-hsa-dox in tumor tissue was monitored. an enhancement of the engineered nanomaterial in tumor tissue was detected for up to h after injection indicating successful enrichment of gd-hsa-dox within the tumor tissue, which can be ascribed to the enhanced permeability and retention (epr) effect observed in the microenvironment of many solid tumor tissues. we are currently investigating the antitumor efficacy of gd-has-dox in this mouse model and preliminary data seem to indicate a dose-dependent anticancer effect. supported by the volkswagenstiftung. tubulin-binding agents are the most important anti-tumoral drugs. due to the side effects and the development of resistances, the discovery of new agents is still of importance. recently, pretubulysin (pt), a naturally occurring precursor of the myxobacterial compound tubulysin, was identified as a novel tubulin-binding compound. in the dfg research group for , pt was characterized as anti-tumoral, antiangiogenic and vascular-disrupting compound. moreover, pt was also found to inhibit the formation of metastases in vivo. aim of the present study was to gain first insights into the mechanisms underlying this anti-metastatic effect by investigating the influence of pt on the interaction of endothelial and tumor cells in vitro. pt treatment of primary human endothelial cells (huvecs) strongly increased the adhesion of breast cancer cells (mda-mb- ) on huvecs, but limited their transmigration through the endothelium (transwell assay). based on this data, the gene expression of presumably involved adhesion molecules was determined by qrt-pcr: icam- , vcam- , e-selectin, n-cadherin, and galectin- . moreover, the chemokine system cxcl /cxcr was analyzed. it could be demonstrated that the mrna level of endothelial n-cadherin is upregulated by pt. while total protein expression of ncadherin was enhanced in pt treated huvec, its surface expression was not largely influenced by pt (western blot, flow cytometry). in line with this, blocking endothelial ncadherin by a neutralizing antibody revealed that this protein is not involved in ptevoked tumor cell adhesion. interestingly, pt strongly augmented the mrna and protein expression of cxcl in huvecs (qrt-pcr, western blot), whereas its endothelial secretion was not affected by pt (elisa). an autocrine action of cxcl could be excluded, since blocking the cxcl receptor cxcr on endothelial cells with plerixafor did not influence cancer cell adhesion. by microscopic analyses, we observed that pt treatment causes transient gaps in the huvec monolayer, where tumor cells prefer to adhere. since β -integrins on the tumor cells could mediate interactions between cancer cells and extracellular matrix proteins in the gaps (e.g. collagen), their influence in cell adhesion and transmigration assays was examined. both the pt-evoked increase in cell adhesion and decrease in transmigration was completely abolished when β -integrins were blocked on mdas by a neutralizing antibody. these results indicate that the anti-metastatic action of pretubulysin might be based on the trapping of tumor cells on the endothelium. whether this effect is also relevant in vivo, will be analyzed in future studies using intravital microscopy. this work was supported by the german research foundation (dfg, for , fu / - ). introduction: tyrosine kinase inhibitors (tkis) for the treatment of non-small cell lung cancer (nsclc) patients harboring activating mutations in the epidermal growth factor receptor have shown prominent success. nevertheless, patients treated with tkis eventually acquire resistance and relapse ( ). based on an evolutionary cancer model ( ) , weekly high dose-pulsed tki regimens were proposed to delay resistance. using data from nsclc bearing mice treated with erlotinib at different dosing regimens, we developed a semi-mechanistic pharmacokinetic/pharmacodynamic model for erlotinib effects on tumor killing and resistance development. methods: data was available from experiments in xenograft mice bearing nsclc tumors (pc and hcc cell lines; both erlotinib sensitive) ( ). plasma concentrations from two single-dose groups, mg/kg and mg/kg, were used for pharmacokinetic modeling. relative tumor volume changes in mice randomized to five dosing regimens ( mg/kg daily, mg/kg daily, mg/kg every days, mg/kg every days, or vehicle) was the pharmacodynamic endpoint. a tumor growth inhibition model was developed by testing linear, exponential and logistic models to account for the tumor growth kinetics, as well as fitting an emax model to explain the effect of exposure on killing the sensitive tumor cells, and resistance development. analysis was performed using nonmem . . results: absorption was dose dependent, and a precipitate compartment accounted for dissolution limited absorption for the mg/kg dose. a -compartment model with first order elimination kinetics described distribution and elimination. to describe tumor volume changes, a tumor was assumed to be a mixture of sensitive and resistant cells (represented by distinct compartments and ordinary differential equations). exponential kinetics best described natural growth (doubling times: and days, for sensitive and fully resistant cells, respectively). a tumor was found to transit through a less sensitive phase before acquiring full resistance. an e max model (less than linear) best described effect on the sensitive cells (ec = . μm for both cell lines), and on the partially sensitive transit phase (ec = . μm and . μm, for hcc and pc cell lines, respectively), urging to provide adequate trough erlotinib concentrations for optimal effects. conclusions & future perspectives: an exposure-driven tumor growth inhibition model accounting for the kinetics of resistance development was developed. the model emphasizes the need for establishing an adequate trough erlotinib concentrations to delay disease progression. extracts of the stem bark of ficus platyphylla (fp) have been used in traditional nigerian medicine to treat psychoses, depression, epilepsy, pain and inflammation. previous studies have revealed the analgesic and anti-inflammatory effects of fp in different assays including acetic acid-induced writhing, formalin-induced nociception, and albumin-induced oedema. in this study, we assessed the effects of the standardised extract of fp on hot plate nociceptive threshold and vocalisation threshold in response to electrical stimulation of the tail root in order to confirm its acclaimed analgesic properties. we also investigated the molecular mechanisms underlying these effects, with the focus on opiate receptor binding and the key enzymes of eicosanoid biosynthesis, namely cyclooxygenase (cox) and -lipoxygenase ( -lo). fp (i) increased the hot plate nociceptive threshold and vocalisation threshold. the increase in hot plate nociceptive threshold was detectable over a period of min whereas the increase in vocalisation threshold persisted over a period of min. (ii) fp showed an affinity for µ opiate receptors but not for δ or κ opiate receptors, and (iii) fp inhibited the activities of cox- and -lo but not of cox- . we provided evidence supporting the use of fp in nigerian folk medicine for the treatment of different types of pain, and identified opioid and non-opioid targets. it is interesting to note that the dual inhibition of cox- and -lo appears favourable in terms of both efficacy and side effect profile. despite the fact, that the enormous economic burden and individual suffering caused by gastrointestinal infections permanently persists in developing and newly industrialized countries, healthcare systems in first world countries underestimated its significance for a long time. the alarming prevalence of multidrug-resistant gram-negative bacteria, combined with a high epidemic potential of gastrointestinal pathogens, however, demonstrates the urgent need for new antibiotics and antiinfectives worldwide. , million deaths per year were actually caused by acute diarrheal infections. the most common causative agents of acute diarrheal infections, amongst others, are yersinia enterocolitica, campylobacter jejuni, salmonella spp., shigella spp., escherichia coli, vibrio cholerae, and clostridium difficile. the established treatment based on antibiotics is mostly ineffective or may even have adverse side effects and result in prolonged shedding. in either way, antibiotic treatment also eradicates at least parts of the intestinal microbiome, and thereby disrupts colonization resistance, fosters overgrowth of pathogens and prolongs shedding times. therefore, the development of future drugs should be focused on highly specific antiinfectives, which enable a direct pathogenspecific treatment. one very promising strategy is the inhibition of the biogenesis of outer membrane virulence factors. due to the fact that many decisive virulenceassociated outer membrane proteins (omps) of gram-negative enteropathogens are substrates of the periplasmic chaperone sura exclusively, we developed a new assay format to determine sura in vitro chaperone activity. previous publications by behrens et al., and buchner et al., documented an assay to determine sura in vitro chaperone activity with extremely limited sensitivity and minimal detectable concentration, which was not suitable for high throughput screening (hts). we now developed a luciferase-based screening assay. this highly sensitive and robust test system has been validated extensively and now gives reliable output with an appreciable z-factor of > , . in cooperation with the hzi braunschweig (germany) and the hzi saarbrücken (germany), we were able to screen over purified compounds and over extracts of myxobacteria. during the ongoing screening period, the assay generated four validated primary actives, which corresponds to a positive hit rate of , %. additionally, we developed an elaborate follow-up strategy to validate positive hits, which includes a well-established mouse infection model. we are looking forward to escalate our screening efforts and would like to use this abstract to invite all scientist who are interested in testing compound/natural extract libraries for an activity against the target structure sura. the potential atypical antipsychotic and dopamine d receptor partial agonist bromoterguride antagonizes phencyclidine-and apomorphine-induced prepulse inhibition and novel object recognition deficits in rats e. tarland objectives: schizophrenia is a disabling mental disorder affecting more than million people worldwide. available medical therapies are effective in the treatment of psychosis and other positive symptoms, however come with considerable side effects and often fail to ameliorate cognitive deficits and negative symptoms of the disorder. the dopamine d receptor partial agonist -bromoterguride ( -bt) has recently been shown to exhibit antipsychotic effects in rats without causing adverse side effects common to antipsychotic drugs [ ]. to determine its atypical character in vivo, the ability of -bt to antagonize the disruptive effects of phencyclidine (pcp) and apomorphine on sensory motor gating was determined in the prepulse inhibition paradigm. the effect of -bt on cognitive deficits was assessed in the novel object recognition (nor) test after object recognition memory deficits were induced by pcp treatment. method: week old male sprague-dawley rats were injected with -bt ( . or . mg/kg; i.p.) followed by pcp ( . mg/kg; s.c.) or apomorphine ( . mg/kg; s.c.). prepulse inhibition was measured in two sound-proof startle chambers. the attenuating effect of -bt ( . or . mg/kg; i.p.) on visual learning and memory deficits following subchronic administration of pcp ( . mg/kg; i.p. twice daily for days) was assessed in the nor task consisting of a min acquisition trial and a min retention trial separated by a h inter-trial interval. clozapine ( . mg/kg; i.p) or haloperidol ( . mg/kg; i.p) were used as positive controls. results: the dopamine d receptor partial agonist -bt ( . mg/kg) and the typical antipsychotic haloperidol successfully antagonized apomorphine-induced ppi-deficits. interestingly -bt also ameliorated the pcp-induced ppi-deficits to the same extent as the atypical antipsychotic clozapine. preliminary data from the nor test indicate that -btreduces subchronic pcp-induced cognitive deficits in novel object recognition analogous to clozapine. the disrupting effects of pcp on ppi are mediated by non-competitive antagonism at nmda sites indirectly influencing a series of neurotransmitter systems. our results indicate that -bt mediates actions at multiple neurotransmitter receptors as it successfully ameliorated both the pcp-and apomorphine-induced ppi disruptions in rats, showing an atypical antipsychotic character. furthermore, our preliminary results support the potential atypical antipsychotic effect of -bt as it restored performance in the nor test, a test with good predictive validity. due to the previously shown properties and antipsychotic-like effects of -bromoterguride [ ], this substance may be a promising candidate for treatment of schizophrenic patients. ongoing experiments investigate the potency of -bt to improve social deficits following a sub-chronic pcp regime in rats. background and objectives: cannabinoid- receptor signaling increases the rewarding effects of food intake and promotes the growth of adipocytes, whereas cb possibly opposes these pro-obesity effects by silencing the activated immune cells that are key drivers of the metabolic syndrome. pro-and anti-orexigenic cannabimimetic signaling may become unbalanced with age because of alterations of the immune and endocannabinoid system. methods: to specifically address the role of cb for age-associated obesity we analyzed metabolic, cardiovascular, immune and neuronal functions in . - . year old cb -/and control mice, fed with a standard diet and assessed effects of the cb agonist, hu during high fat diet in - week old mice. results: the cb -/mice were obese with hypertrophy of visceral fat, immune cell polarization towards pro-inflammatory sub-populations in fat and liver and hypertension, as well as increased mortality despite normal blood glucose. they also developed stronger paw inflammation and a premature loss of transient receptor potential responsiveness in primary sensory neurons, a phenomenon typical for small fiber disease. the cb agonist hu prevented hfd-evoked hypertension, reduced hfdevoked polarization of adipose tissue macrophages towards the m -like proinflammatory type and reduced hfd-evoked nociceptive hypersensitivity but had no effect on weight gain. conclusion: cb agonists may fortify cb -mediated anti-obesity signaling without the risk of anti-cb mediated depression that caused the failure of rimonabant. leishmaniasis is a neglected tropical disease caused by leishmania, eukaryotic protozoal organisms, which infect humans and other mammals. this disease is transmitted by sandflies of the genus phlebotomus. due to global warming the endemic region of these vectors expands further to northwards and threatens south european countries as well. the treatment of leishmaniasis is difficult due to toxicity and resistance development for current drugs. the so far unexplored inhibition of mitochondrial functions in leishmania by natural products or even food ingredients seems to be an interesting alternative. two food ingredients, resveratrol (res) and xanthohumol (xan), were widely studied in mammalian cells but little is known about their actions on protozoal parasites. therefore, we compared the influence of res and xan on the function of leishmanial and mammalian mitochondria. anti-leishmanial activities of xenobiotics were assessed in cell culture of leishmania tarentolae promastigotes (ltp), leishmania amazonensis amastigotes (laa) and compared to peritoneal macrophages from mouse (pmm) using viability assays. furthermore, mechanistic studies regarding mitochondrial functions were conducted in ltp, mitochondrial fractions isolated from ltp and bovine heart submitochondrial particles using oxygen consumption measurements, assays of individual mitochondrial complex activities, membrane potential and superoxide radical formation by photometry, fluorimetry and electron spin resonance spectroscopy. in ltp, xan inhibited the viability more effective than res (ic : xan µm, res µm). likewise, xan and res demonstrated anti-leishmanial activity in laa (ic : xan µm, res µm) while had less influence on the viability of pmm (ic : xan µm, res > µm). in contrast to res, xan strongly inhibited oxygen consumption in leishmania. further studies demonstrated that this is based on the inhibition of the mitochondrial electron transfer complex ii/iii by xan which was less pronounced with res. however, xan also demonstrated inhibitory activity on mammalian mitochondrial complex iii. in addition, xan caused no decrease of the membrane potential in leishmanial mitochondria, while res resulted in mitochondrial uncoupling. neither xan nor res increased mitochondrial superoxide release in ltp. these data show that res, a major polyphenol from red wine, and xan, an ingredient of hop-containing beer, may have selective anti-leishmanial activity. tryptophan hydroxylase (tph) is the rate-limiting enzyme in serotonin ( -ht) biosynthesis. its two existing isoforms are exclusively expressed in the periphery (tph ), or the raphe nuclei of the brainstem (tph ) and the respective -ht populations are distinctly separated by the blood-brain barrier, offering the possibility to pharmacologically modulate central and peripheral functions in an independent manner. peripheral -ht is mainly produced by tph -expressing enterochromaffin cells of the gut and taken up into platelets and transported in the blood stream. upon platelet activation, -ht is rapidly released and locally induces multiple effects, such as vasoconstriction, cell proliferation or fibrosis and is furthermore involved in the regulation of e.g. vascular tone, gut motility, primary hemostasis, insulin secretion and t-cell-mediated immune response. following the classical early drug development pathway, we developed a fluorescencebased tph activity assay and performed a high-throughput screening of about small chemical compounds. we discovered a novel class of tph inhibitors, which was thoroughly validated in a variety of in vitro assay setups. combining medicinal chemistry and x-ray crystallography, we further aimed to develop these inhibitors into preclinical drug candidates. to date we were able to generate and patent a series of novel tph inhibitors with optimized affinity and an in vitro ic in the low nanomolar range. this novel class of tph inhibitors could potentially be used to treat a variety of disorders with aberrant peripheral -ht signaling, such as gastrointestinal disorders (e.g. irritable bowel syndrome, crohn's disease, various forms of diarrhea), cardiac valve diseases, pulmonary hypertension, chronic respiratory diseases and some neuroendocrine (carcinoid) tumors. primary hepatocellular carcinoma (hcc) is the most frequent type of liver cancer. therapeutic options are rare. beside sorafenib, a tyrosinkinase inhibitor, which is only used in end stage liver cancer, the surgical intervention is the only successful clinical treatment option. hence there is an urgent need to develop new therapeutic strategies and to identify new drugs for therapy of hcc. hcc often arises in fibrotic or cirrhotic liver, which is accompanied by a change of the extracellular matrix (ecm) composition. in addition it was shown that hepatoma cells express different integrins, which interact with ecm and intracellular cell signaling, compared to hepatocytes. snake venoms have gained increased attention, as it was shown that some of their enzymes and peptides directly act on tumor cells and their multicellular arrangement or indirectly by influencing the stroma environment of the tumor. aim of the present study was to investigate the effect of snake venoms on liver cancer related cell lines as well as their specific action on the ecm-integrin axis. the effects of the snake venoms vipera palestinae (vp), calloselasma rhodostoma (cr) and echis sochureki (es) on a cellular level (mtt, ldh release), on cell-cellconnections (caco permeability assay) and on cell-matrix-interactions (adherence test) were investigated. cell-matrix interactions were tested with an adhesion assay using collagen i (c-i), collagen iv (c-iv), fibronectin (fn) and laminin (lm) as ecm compounds. in our in vitro models we used hepg as a hcc tumor cell line and the fibroblast cell line fi as stroma simulation. additionally caco cells were used, a colon carcinoma cell line representing colorectal liver metastasis. the toxicity of snake venom on liver cancer related cell lines was determined in the range of . - µg/ml and plotted into dose response curves. the noaels were calculated from these dose response curves: vp: . µg/ml -cr: µg/ml -es: µg/ml. performance of the caco -transwell permeability assay revealed no influence of the tested venom concentrations on the integrity of the cellular arrangement. investigations for integrin inhibition revealed that the venom from vp reduced adherence on lm coated plates and the venom of ec reduced adherence on lm and fn coated plates compared to untreated cells. there was no effect on the adherence on any matrix from the venom of cr observable. co-incubation of the snake venoms of vp and es (below or near noael concentrations) with -fluorouracil ( fu), which is used as a chemotherapeutic agent, caused a reduction of its ic values. the results indicate that components of vp and ec inhibit the formation of cell-matrixinteractions possibly acting as disintegrins. the co-incubation experiments demonstrated a synergistic effect of fu and snake venoms. further experiments should enable the isolation of therapeutic active venom compounds, identification of disintegrins and their role in synergistic mechanisms in liver cancer therapy. modulation of the blood-brain barrier with peptidomimetics to improve drug delivery s. dithmer after decades of research, the blood-brain barrier (bbb) still remains a major problem for successful delivery to the brain for the vast majority of drugs. the main component forming the bbb is the brain microvascular endothelium. the paracellular permeation is limited by tight junctions (tjs), a multiprotein complex composed of the members of the claudin family claudin- , - , - , - . claudin- is known to be the key tj protein tightening the bbb. therefore, claudin- has been selected as target to modulate the bbb. for this reason, drug enhancer peptides (peptidomimetics) were designed to modulate transiently claudin- and, thereby, permeabilize the bbb. by combining biochemical protein/peptide interaction and tissue culture methods, we identified, validated and optimized peptide sequences modulating claudin- containing barriers. the claudin- targeting peptides decreased the transcellular electrical resistance and increased the permeability through mdck-ii cell monolayers stably expressing yfpclaudin- and immortalized brain endothelial cells (bend. ). the peptides decreased the amount of claudin- and zo- at cell-cell contacts and changed the cell morphology from spindle-shaped to more round-shaped. all tested peptides showed no signs of toxicity on cell cultures and in vivo (intravenous injection). permeability measurements in mice proved enhanced permeation of na-fluorescein ( da) through the bbb, which was confirmed by magnet resonance imaging of contrast agents (gd-dtpa, da). in summary, we identified new peptides with the potential to enhance cerebral delivery of small molecules through the bbb. treatment of cerebral diseases is limited by the capability of pharmacologically active agents to penetrate the blood-brain barrier (bbb). this paracellularly tight diffusion barrier is formed by brain capillary endothelial cells. the paraendothelial cleft is sealed by tight junctions (tjs), a multiprotein complex. cerebral tjs predominantly consist of claudin- (cldn ) which tightens the bbb for molecules < da. consequently, cldn is a potential target for transient and size-specific modulation of the bbb to improve cns penetration for pharmaceutically active agents. in high throughput screening using a cldn assay, the barrier opener (bo ) was identified as a cldn modulator. initially, a significant removal of cldn from the plasma membrane was shown by confocal microscopy using epithelial and endothelial cell lines. measurement of transcellular electrical resistance and of paracellular permeability using lucifer yellow (mw da) demonstrated the effect of bo . concentration dependent treatment ( - µm) of cell monolayers with bo reduced tightness of the tjs between some hours and h. applying -hydroxypropyl-ß-cyclodextrin as a solubilizer, opening activityof bo became detectable in mice. due to short stability (< h) of bo in the bloodplasma repeated administration ( . mg/kg i.v.) was required to induce significantly increased permeability of the bbb for na-fluorescein(mw da). the small molecule bo is a promising new approach for transient opening of the bbb in vivo. further modification of the stability and solubility of bo is necessary to optimize its applicability. the complex of tight junction (tj) proteins is located between opposing epithelial or endothelial cells. tjs restrict the paracellular permeation of ions and other solutes. tricellulin (tric) tightens tricellular tjs (ttjs) and regulates bicellular tj (btj) proteins like claudins and occludin (occl). current data suggest an important role of ttjs at the blood-brain barrier (bbb). a main pharmacological problem is modulation of the bbb to improve drug delivery to the cns. therefore, tricsi has been developed as a peptide taken from tric to open tissue barriers specifically and transiently.initially, a recombinant protein was generated based on a sequence of an extracellular loop of tric, tagged with maltose binding protein. the fusion protein caused down-regulation of tric, internalization of both tric and occl (confocal laser scanning microscopy), and a significant decrease in transcellular electrical resistance (ter) of a human epithelial colorectal adenocarcinoma cell line. then, studies with the synthetic peptide tricsi indicated its capacity of cell barrier openingafter about h of incubation with concentrations varying from to µmaffecting the membrane localization of tricand occl. barrier opening was proven by decreasing ter, increasing permeability coefficient of lucifer yellow ( da) and fitc-dextran ( kda); the localization of tric elongated from ttjs towards btjs and cldn was weakened at btjs.physiochemical properties of tricsiexamined by circular dichroism spectroscopy suggested ß-strand structure and no helical propensity. taken together, a tric-derived peptide has been identified increasing the paracellular permeability of tissue barriers and redistributing the cellular localization of tj proteins. tricsi is a novel, promising tool to overcome cerebral barriers with the potential to improve drug delivery to the cns. further experiments are needed to better understand the role of tric in tissue barriers as well as to clarify the mode of action of tricsi. introduction: lung transplantation has become an established treatment option for a variety of end-stage lung diseases, but the long-term survival is often disappointing. the leading cause of death is generally chronic rejection which is characterized by inflammation and fibrous obliteration of the small airways, progressively leading to a reduction of the airflow. the mouse heterotopic tracheal transplantation model is widely used as an experimental model to study the development of obliterative airway disease. despite its widespread application, the heterotopic transplantation model does have a number of limitations, as for example the lack of airflow. the present study provides a description of the orthotopic tracheal transplantation mouse model, which shares more similarities with transplant situation in humans, and provides the analysis of airway obliteration via micro ct and histological evaluation. methods: a seven-ring donor trachea from balb/c mice was implanted into the recipient c bl/ mice. c bl/ mice without transplantation were used as normal controls. donor c bl/ mice to recipient c bl/ mice were served as the isograft group. days after transplantation, mice were scanned using an in vivo small animal µct (skyscan ). tracheal tissue was harvested and fixed in formalin, embedded in paraffin, cut and stained with hematoxylin and eosin (h&e) as well as sirius-red/fast-green. results and conclusions: histologic evaluation showed luminal narrowing with subepithelial inflammatory cell infiltrates and fibrosis, as well as partially damaged and flattened epithelium. the aerated volume of the allogeneic grafts, analyzed by micro ct was significantly reduced compared to the isogenic control grafts and normal controls. non-invasive imaging via micro ct may offer an option for longitudinal monitoring of the progression of obliterative airway disease as well as response to treatment. c. elegans is a well-established model organism to study the aging process as well as effects of various substances in vivo. its lifespan is regulated by multiple signaling pathways (e.g. insulin or mtor signaling), which are well conserved up to humans. the insulin/igf- pathway was the first pathway shown to effect ageing in animals. mutations that decrease the activity of daf- (igf r) lead to a significant increase of lifespan accompanied by a decrease of age pigment accumulation in c. elegans. the relevant effector of the insulin/igf- pathway is the transcription factor daf- (hfoxo a). inhibition of hmg-coa reductase (enzyme of mevalonate pathway) by statins, which are frequently used as cholesterol-lowering agents in the clinic, has been shown to attenuate protein prenylation and glycosylation. notably, prenylated-, membrane-bound small gtp-binding proteins are important for the regulation of the afore mentioned age-related signaling pathways like the insulin/igf- pathway. recently, a cohort study showed that a decreased mortality rate in humans between age - correlates with statin treatment, but is independent of total cholesterol levels. as c. elegans harbors the mevalonate pathway, but the branch leading to cholesterol synthesis is missing, it is a well-suited model to study cholesterol -independent effects of statins on aging-associated phenotypes and the underlying molecular mechanisms. here, we show that exposure of c. elegans to statins substantially decelerated the accumulation of age pigments. while the level of age pigments roughly doubled in control animals, there was only a slight increase in the lovastatin group. the use of atorvastatin gave comparable results indicating a more general effect of the inhibition of the hmg-coa reductase. the retarded accumulation of age pigments could be partly phenocopied using an inhibitor of the small gtpase rac or using rnai against the hmg-coa reductase. a reduced level of age pigments is prognostic for an elevated mean lifespan (about %) in c. elegans. a post reproductive treatment with lovastatin, mimicking the use of statins in patients of advanced age increased the mean lifespan in c. elegans even further. in addition, we could show a mild reduction of fertility and a developmental delay as well as a marked increase in acute thermal stress resistance mediated by lovastatin. besides the reduced accumulation of age pigments and the increased lifespan these are phenotypes which are usually observed under accumulation of daf- overactivity. consequently we found an increased nuclear localization of daf- in the presence of lovastatin and lovastatin completely failed to reduce age pigments in a daf- -ko mutant background. rt-qpcr brought jnk- , a known activator of daf- , into play as a possible effector induced by statins. this is currently under investigation. in summary, statin exposure induces a longevity phenotype in c. elegans, which might be daf- dependent. this findings indicates that a product of the mevalonate pathway might influence the insulin/igf- pathway and particularly the transcription factor daf- . the high-fat diet (hfd)-fed, streptozotocin (stz)-treated rat model is one of the experimentally-induced animal models of diabetes. this model is often used to evaluate the antidiabetic activity of several agents. according to srinivasan et al. ( ) , prolonged exposure of high-fat diet leads to insulin resistance, and the development of diabetes occurs only in insulin-resistant hfd-fed rats following low dose stz, because the hfd-fed rats are already mildly hyperglycemic due to insulin resistance ( ). in hfd/stz model, the rats are fed with high-fat diet for - weeks or for a relatively long time (≥ months) in order to simulate the insulin resistance and/or glucose intolerance. after induction of diabetes with multiple or single low-dose of stz ( - mg/kg), some of the diabetic rats receive treatment ( ) . in this way, the impact of treatment can be determined by comparing the differences between groups. despite the lack of methodological information concerning the feeding time in some studies, all rats should be allowed to continue to feed on their respective diets until the end of the study. but what would happen if the hfd was switched to normal pellet diet in these diabetic rats? in our experience, the feeding of npd for weeks significantly decreased fbg in diabetic rats compared to hfd-fed diabetic rats ( . ± . mg/dl vs. . ± . mg/dl, p < . ). although diet regulation could not restore normal blood glucose, such a decrease was unexpected. in addition, the body weights of the npd-fed diabetic rats were significantly lower than the body weights of the hfd-fed diabetic rats ( ± . gvs. . ± . g, p < . ). there was no significant difference in body weight between nondiabetic control rats and diabetic rats fed npd for weeks. further details can be found in table . diet regulation and weight loss may prevent, control and reverse diabetes. however, at later stages of the disease, it is difficult to improve blood glucose control without medication, because the disease progresses from insulin resistance to insulin deficiency ( ) . according to some diabetes researchers, the amount of residual functional betacells mass is an important issue, and another important question is whether hfd/stz rat mimics an early or late stage of type diabetes ( ). these preliminary findings suggest the possibility that hfd/stz rat model may simulate the characteristics of early stage more than the final stage of type diabetes, and hyperglicemia in the experimental model can partially reverse with diet regulation. references: . srinivasan, k., viswanad, b., asrat, l., kaul, c. l., ramarao, p. ( ) . combination of high-fat diet-fed and low-dose streptozotocin-treated rat: a model for type diabetes and pharmacological screening. pharmacol res ( ): - . . oztürk z, gurpinar t, vural k, boyacıoglu s, korkmaz m, var a. ( ) . effects of selenium on endothelial dysfunction and metabolic profile in low dose streptozotocin induced diabetic rats fed a high fat diet. biotech histochem ( ): - . . franz, m. j. ( ) . the dilemma of weight loss in diabetes. diabetes spectr ( ) animal models are pivotal for studies of pathogenesis and treatment of movement disorders. dystonia, characterized by sustained or intermittent muscle contractions causing twisting movements/postures, is regarded as a basal ganglia disorder. the pathophysiology is however poorly understood. in mouse models of dyt dystonia, which is caused by a gag deletion in tor a that encodes for the protein torsin a, ex vivo electrophysiological studies have shown an abnormal d receptor mediated release of acetylcholine from striatal interneurons. in these models, which do not exhibit a dystonic phenotype, the functional relevance of the increased d receptor mediated acetylcholine release has not been examined yet. the aim of present study was to ( ) generate more powerful tests to detect behavioural alterations in the dyt knock-in mouse and to ( ) examine the behavioral effects of the d receptor agonist quinpirole. for this purpose, a sequence of cognitive, motoric and sensorimotor tests were performed in this mouse model. only the adhesive removal test that explores sensorimotor connectivity revealed significant impairments in the dyt knock-in mice compared to controls. to induce a more characteristic and stronger phenotype, the "rotating beam test" was developed. this motoric test measures motor coordination and balance. interestingly, dyt knock-in mice showed significant motor deficits in the rotating beam test. based on these results, the acute effects of quinpirole ( . - mg/kg i.p.) were tested in dyt knock-in and wildtype mice. subsequent to the injections, mice were tested in the open field, the rotating beam test and the adhesive removal test, respectively. in the open field test, dyt knock-in mice showed increased thigmotaxis at a dose of . mg/kg quinpirole. in the rotating beam test, both groups showed a dose-dependently reduced performance. in the adhesive removal test, quinpirole improved the reaction time in dyt mice independently of dosage, while no effects were observed in the wildtype littermates. however, in vehicle follow-up (post-drug control), this effect remained consistent in the dyt model, suggesting a habituation effect. in conclusion, we generated a new test, i.e., the rotating beam test which improves the detection of mild motor impairments in dyt knock-in mice. furthermore, the adhesive removal test revealed sensorimotor dysfunctions in this animal model. these results represent an important step for our ongoing optogenetic examinations on the role of abnormal neuronal plasticity in dyt dystonia and for pharmacological studies. the first data on the effects of quinpirole do not indicate a critical role of d dysregulated acetylcholine release, but this has to be clarified by ongoing local striatal injections of quinpirole and by pharmacological manipulations of the cholinergic system. renal fibrosis is characterized by decreased nitric oxide (no) bioavailability and pronounced transforming growth factor β (tgfβ) signalling subsequently excessive extracellular matrix (ecm) deposition. here, the effects of the soluble guanylate cyclase (sgc) stimulator bay - after unilateral ureter obstruction (uuo) have been studied. kidney fibrosis was induced by unilateral ureter obstruction (uuo) in wild type (wt) and cgki knock-out (cgki ko) mice. starting one day after uuo, the sgc stimulator bay - was ( mg/kg/daily) i. p. injected for seven days. biomarkers indicating remodelling processes in the kidney were analysed via mrna expression and protein expression. bay - administration influenced the activity of the ecm degrading matrix metalloproteases (mmp and mmp ) and their inhibitor timp- , the expression pattern of extracellular matrix proteins (e.g. collagen and fibronectin) of profibrotic mediators (e.g. connective tissue growth factors (ctgf) and plasminogen-activator inhibitor- (pai- )) and the secretion of cytokines, e.g. il- . thereby, bay - increments the cgmp pool among others via modulation of endothelial no synthase (enos) expression. agents, which enhance no and cyclic guanosine monophosphate (cgmp) ameliorate the progression of fibrotic tissue. however, the molecular mechanism by which cgmp via cgki affects the development of kidney fibrosis has not fully been elucidated. accordingly, the present study investigates the functional role of sgc stimulation in regulating the fibrotic process, the signalling pathway and the underlying mechanisms involved. we hypothesize that the antifibrotic potential of bay - might be related to the increased cgmp pool and the inhibition of the mapk and smad signalling pathway. the elucidation of the signalling allows the development of new therapeutic options. infection of mice with listeria monocytogenes (lm) results in a strong t-cell response that is critical for an efficient defense. here, we demonstrate that the adapter protein sly (sh -domain protein expressed inlymphocytes ) is essential for the generation of a fully functional t-cell response. the lack of sly leads to reduced survival rates of infected mice. the increased susceptibility of sly ko mice was caused by reduced proliferation of differentiated t cells. ex vivo analyses of isolated sly ko t cells displayed a dysregulation of forkhead box protein o (foxo ) shuttling after tcr signaling, which resulted in an increased expression of cell cycle inhibiting genes, and therefore, reduced expansion of the t-cell population. foxo shuttles to the cytoplasm after phosphorylation in a protein complex including - - proteins. interestingly, we observed a similar regulation for the adapter protein sly , where tcr stimulation results in sly phosphorylation and sly export to the cytoplasm. moreover, immunoprecipitation analyses revealed a binding of sly to - - proteins. altogether, this study describes sly as an immunoregulatory protein, which is involved in the generation of adaptive immune responses during lm infection, and provides a model of how sly regulates t-cell proliferation (schäll et al., eur j immunol. ) . the catalytical isoforms p γ and p δ of phosphatidylinositol- , -bisphosphate kinase γ (pi kγ) and pi kδ play an important role in the pathogenesis of asthma. two key elements in allergic asthma are increased eosinophil and ige levels. whereas dual pharmacological inhibition of the catalytical subunits p γ and p δ reduces asthmaassociated eosinophilic lung infiltration and ameliorates disease symptoms, it has been shown that dual genetic deficiency in pi kγ and pi kδ in p γ ko δ d a mice increases serum ige and basal eosinophil counts in mucosal tissues and blood. this suggests that long-term inhibition of p γ and p δ might exacerbate asthma. here we analysed p γ/δ -/mice and determined ige and eosinophil counts in a basal state and the immune response to ovalbumin (ova)-induced allergic asthma. we found that serum concentrations of ige, il- and eosinophil numbers in blood, spleen and bone marrow were significantly increased in p γ/δ -/mice in comparison to single knock-out (ko) and wildtype (wt) mice. nevertheless, p γ/δ -/mice were protected against ovainduced infiltration of eosinophils, neutrophils, b cells and t cells into the lung tissue and the bronchoalveolar space. moreover, p γ/δ -/mice, but not single ko mice, showed a reduced bronchial hyperresponsiveness as measured with the isolated and perfused lung. we conclude that although the dual deficiency of p γ and p δ causes eosinophilia and ige hyperproduction, p γ/δ -/mice are not prone to develop ovainduced allergic asthma. an increase of plasma extravasation induced by activation of constitutively expressed endothelial bradykinin type receptors (b ) has been shown to contribute to the development of angioedema occurring as a sometimes life-threatening side effect of angiotensin-converting enzyme inhibitors such as enalapril (new engl j med : ; - ) . these drugs inhibit the degradation of bradykinin and increase its vascular steady-state concentration. hence, it is reasonable to assume that bradykinin may destabilise the endothelial barrier, i.e. may increase physiologic extravasation. while the commonly used miles assay provides a useful and relatively easy tool to study the effect of permeabilizing mediators in-vivo, it does not distinguish between intravascular and interstitial evan's blue dye. likewise, extravasation can only be quantified at one particular time point per animal, usually - min. furthermore, evaluation of physiologic extravasation is not possible. in contrast, non-invasive twophoton laser microscopy may allow separating the intravascular from the interstitial compartment and thereby investigations of changes of the physiologic endothelial barrier induced by drugs or transgenes. therefore, we have evaluated this methodology for its suitability to study endothelial permeability in mice in vivo. to establish this, we used two different fluorescent dyes of different molecular weight. a , kda dextran equipped with a green fluorescent chromophore which cannot leave vascular lumen was injected intravenously to visualize small dermal blood vessels of the mouse ear located approximately µm below the surface. after stabilization of the green fluorescent signal, a , kda dextran equipped with a red fluorescent chromophore which easily traverses the endothelial barrier was applied by intravenous injection. the red fluorescence permeates into the interstitium during physiologic extravasation and accumulates in the interstitial space. this process can be followed by measuring the decrease of intravascular red fluorescence over various time periods. using this methodology we have studied whether endothelial-specific overexpression of b changes physiologic endothelial permeability. this newly developed transgenic mouse line (b tg ) was established using a plasmid consisting of pbluescript ii sk+ -vector, the tie- -promotor, the human b cdna, the sv poly-a-signal and a tie- intron fragment. we observed that b tg showed a significantly stronger extravasation than their transgene negative littermates as evidenced by the more rapid extravasation of the , kda dextran at each time point (fig. ) .we conclude that two-photon laser microscopy is suitable to study endothelial permeability non-invasively in-vivo and that this methodology allows to study the effects of drugs and transgenes on the endothelial barrier under non-inflammatory conditions. furthermore, our results suggest that endothelial-specific overexpression of b increases physiologic extravasation. non-allergic angioedema such as angioedema induced by angiotensin converting enzyme inhibitors (acei) develops as a consequence of increased activation of bradykinin receptor type (b ). using a plasmid consisting of pbluescript ii sk+ -vector, the tie- -promotor, the human b cdna, the sv poly-a-signal and a tie- intron fragment a transgenic mouse line harbouring an endothelial-specific overexpression of b was generated and backcrossed to c bl/ for more than times (b tg ). lung mrna using primers specific for the human or the mouse b cdna revealed a . -fold stronger expression of human b in b tg (n= ), while the expression of murine b mrna was unchanged and similar to transgene negative littermates (b n ). we have evaluated the specificity of several antibodies directed against b and found that a rabbit monoclonal anti b antibody appears to be reliable, i.e. there was just a faint staining in lung tissue of b -/mice. however, this antibody primarily stains rodent b and has only little cross-reactivity to human b . hence, we were not able to detect a significant increase of b protein in tissues of b tg . previous experiments have shown that bradykinin induced concentration-dependent constrictions of aortic rings with a maximal effect at µm of bradykinin. the contraction due to bradykinin was completely inhibited by icatibant or diclofenac indicating that it is mediated by endothelial b activation and dependent on cyclooxygenase activity. in striking contrast to their transgene negative littermates b n , we found a significant icatibant sensitive aortic dilation in b tg following preincubation with diclofenac which indicates functional overexpression of b in conductance vessels of b tg . to evaluate whether this applies to dermal micro vessels we used the miles assay to quantify dermal extravasation of the albumin-bound dye evans blue following intradermal injection of µl of either vehicle, bradykinin, labradimil and histamine (control). increasing concentrations of bradykinin caused a significant increase of extravasation reaching . ± . fold at . nmol bradykinin in c bl/ (n= each, p< . vs. vehicle). a similar increase was found in b n ( . ± . fold, n= , p< . vs. vehicle), while there was a stronger response in b tg ( . ± . fold, n= , p< . vs. vehicle) which was significantly different to b n (p< . ) and c bl/ (p< . ). in another set of experiments the specific and ace-resistant b agonist labradimil ( . nmol) was used instead of bradykinin. labradimil increased extravasation by . ± . fold in c bl/ (n= each, p< . vs. vehicle), by . ± . fold in br n (n= each, p< . vs. vehicle) and . ± , fold in b tg (n= , p< . vs. vehicle) which was significantly different to c bl/ (p< . ) but not to b n (p> . ). the effects of bradykinin and labradimil were largely blocked by nmol icatibant (i.v.) in c bl/ , b n and b tg mice (p< . ) and hence mediated by activation of b . these data suggest that overexpression of b in b tg is functionally active in endothelial cells of large conductance and small dermal vessels. therefore, b tg represents a new animal model suitable for cardiovascular and non-allergic angioedema research. pharmacokinetic pharmacodynamic modeling of irreversible effects: the rituximab example f. keller universitätsklinikum, innere , nephrologie, ulm, germany background: for pharmacokinetic-pharmacodynamic modeling usually the sigmoid emax model is used as described by the hill equation. however, treatment regimens exist where the effect is only exerted as long as the drug concentration increases whereas decreasing concentrations produce no longer an effect. examples are the pulse anti-cancer therapy such as originally proposed by the devita protocols. methods: here, the new model for irreversible drug action is derived from the time dependent change of the concentration that must be larger than the time-dependent growth of the number of target cells (tumor or bacteria). the irreversible effect can be assumed if the is no further growth of the target cells occurs. de/dt = + dc/dt -dn/dt dn/dt = a solution for the above differential equation can be obtained by use of the integral exponential function iec based on the euler-mascheroni constant (gamma = . …). this model of an irreversible effect was applied.to the example of rituximab where the initial effect on cd + and cd + b-cells completely persists for month. to obtain a numerical solution, the following parameters are needed to be determined: the target concentration ctarget = mcg/ml and the infusion time t = hours. results: it can be shown that a plausible result for rituximab can be estimated only under the condition that a short distribution half-life is assumed of t / = hours (not shorter than the time t of infusion). with the terminal half-life of hours no plausible solution is obtained. under these conditions two observations are made: there is a negative effect both, initially for low concentrations and after cessation of the infusion when concentrations decrease (in reality this means no effect in both cases). the irreversible effect is proportional to the target concentration. the shorter the half-life comes out relative to the infusion time (t / < t) the stronger is the effect (figure) . occasionally there are specific questions occurring on the ruminant xenobiotic metabolism: ) are the observed metabolites ruminant specific and formed directly in the rumen? ) are ruminants able to cleave plant specific metabolites like glycosides to the respective aglycon? in the past new additional in vivo goat metabolism studies with at least one animal were performed. the aim of the project was to elucidate an alternative in-vitro method to replace the existing in vivo method in order to address robustly specific questions on xenobiotic metabolism in ruminants for registration of ppp. fresh sheep rumen fluid was incubated in-vitro > days by using rumen simulation technology (rusitec). the conservation of the physiological conditions were proven by measurement of ph (~ph . ) and redox potential (~- mv). the microflora composition and their viability (bacteria, protozoa and fungi) of the rumen were monitored by microscopy, incubation on agar plates and performing several viability tests (e.g. glycosidase-test, nh and short fatty acids). all the tests showed that the rusitec is a successful tool to maintain sheep rumen fluid for at least days in -vitro. the metabolic behavior and performance of the rumen fluid was tested by e.g. incubating c-triazol derivative metabolites (tdm) like triazol-alanin (ta); triazol-acetic-acid (taa) and triazol-lactic-acid (tla), which are usually formed in plants after application of triazol-containing fungicides. it was shown that ta was cleaved within h to . . .-triazol, while taa and tla were stable under these conditions. these data are in a good accordance with available in vivo data in cows. moreover glycosides ( c-polydatin, octyl- c-β-d-glucopyranosid) were cleaved within hour completely. all these data show, that the rumen fluid maintained its metabolic performance by using rusitec. basf identified the rusitec method, which is usually used in different areas (e.g. investigation of methane production in-vitro) as suitable and adapted this method for the purpose of investigation of ruminant xenobiotic metabolism. it was shown that rusitec is a robust method to analyze rumen xenobiotic metabolism and therefore can clearly substitute in vivo animal studies on ruminant metabolism studies beyond oecd and contribute significantly to animal welfare ( r: replacement). results: by using the training set, physicochemical (e.g. lipophilicity) and pharmacokinetic characteristics of mtx (e.g. v max for active tubular secretion) were slightly adjusted. using the gfr formula of morris et al. ( ) and including an empiric correction factor, mrd for the training set was . whereas bias was . µmol/l. by applying the developed pbpk model to the test set the respective values were mrd= . and bias= . µmol/l. for the covariates "at least one potentially interacting co-medication" and "trimethoprime/sulfamethoxazole" a significant impact on the prediction quality was found. conclusions: using the developed pbpk-model, a good prediction of the pharmacokinetics of hd mtx in severely ill children was found. by including additional factors influencing the prediction of mtx characteristics (e.g. co-medications) an improved prediction of mtx-sl might be reached. in prospective clinical trials, those more complex models should be evaluated and might be helpful to predict hd mtx pharmacokinetics and reduce unwanted side effects. hypericin is a natural polycyclic quinone found in hypericum perforatum. although hypericin reportedly has numerous pharmacological activities, only a limited number of studies have been performed on the absorption and transport characteristics of this compound, presumably, because hypericin is a highly lipophilic compound which is poorly soluble in physiological medium. recently we have shown that quercitrin and isoquercitrin, but not hyerosid, quercetin or rutin increased the uptake of hypericin in caco- cells. the major aim of this study was to get a detailed understanding of the exposure and fate of hypericin in the caco- cell system under different experimental conditions. the permeation characteristics of hypericin ( µm) in absence or presence of hypericum extract , . µg/ml) were studied in the absorptive direction. following application of hypericin to the apical side of the monolayer only negligible amounts of the compound were found in the basolateral compartment. the amount of hypericin in the basolateral compartment increased concentration-dependently in the presence of the extract (from to . %). the majority of hypericin was found after cell extraction ( % in absence and % in presence of the extract). the recovery was in the range of %, and significant amounts of hypericin found after cell extraction. fluorescence microscopy and imaging analysis revealed that hypericin is mainly accumulated in the cell membrane. the precise mechanism through which hypericin might overcome the hydrophobic barrier of cell membranes remains to be elucidated. however, our experiments demonstrated that the permeation characteristics of hypericin significantly improved in presence of the extract. background: the combination of gamithromycin (gam), a novel drug with the big advantage of a once weekly administration, and rifampicin (rif) is used in the treatment of lower airway disease in foals. both are effective in the therapy of infections with rhodococcus equi, a gram-positive coccobacillus bacterium, which is known to survive and reproduce within alveolar macrophages. macrolides are combined with rif to prevent resistance developing with single agent therapy. both drug classes reach high concentrations in the lung, penetrate into phagocytes and kill intracellular pathogens. methods: a controlled, single-and multiple dose study with four-periods was conducted in healthy foals ( ♂ and ♀, age: - days, body weight: - kg) which were treated once with rif alone ( mg/kg s.i.d., p.o., a) followed by the administration of gam ( mg/kg once weekly, i.v., b) for weeks. study period ("rif-gam acute", c) includes the administration of gam and rif for days with an administration interruption after the first rif dose for blood sampling. for the last study period ("rif-gam chronic", d) both gam and rif were coadministered for weeks. all periods were completed with blood sampling for pharmacokinetic analysis for ( . rif is also accumulated in the lung, but to a much lower degree than gam (elf/c h : . ± . ; balc/c h : . ± . ). conclusion: pharmacokinetic data of the present study provides surprising results. in previous studies coadministration of clarithromycin and rif show a dramatic decreased plasma exposure of the macrolide, whereas the balc/c h -ratio was unaffected (peters et al. ) . in contrast, systemic exposure of gam increase significantly in case of the combined therapy and the balc/c h -ratio was nearly halved. both macrolides have in common, that they are intensively accumulated in the lung (elf << balc). at the moment there is further research required (e.g. in vitro studies) for a better understanding of the very interesting in vivo data. institut für klinische pharmakologie, göttingen, germany background and aim: desvenlafaxine is a selective serotonin and norepinephrin reuptake inhibitor, which is approved in the usa (but not in europe) for treatment of major depressive disorder. desvenlafaxine is the major active metabolite of the antidepressant venlafaxine. desvenlafaxin is produced by o-desmethylation via cyp d . direct administration of desvenlafaxine should bypass the variability in venlafaxine pharmacokinetics caused by the highly polymorphic cyp d . however, desvenlafaxine is less lipophilic than venlafaxine and may require carrier-mediated transport to penetrate cell membranes. based on our in vitro data, desvenlafaxine is a substrate of the hepatic organic cation transporter oct and common genetic polymorphisms abolished desvenlafaxine cellular uptake. about % of caucasians are compound heterozygous carriers of loss-of-function oct polymorphisms. therefore, oct polymorphisms may cause substantial inter-individual variability in the hepatic uptake and plasma concentrations of desvenlafaxine. in this study we evaluated the influence of genetically-determined loss of oct function on the pharmacokinetics and pharmacodynamics of desvenlafaxine. primary aim was dependence of desvenlafaxine plasma concentrations (represented by auc as primary endpoint) on the number of active oct alleles. methods: mg desvenlafaxine (pristiq®) was orally administered to healthy subjects preselected according to their oct genotypes. oct * allele was regarded full active, oct * to * alleles were regarded loss of function. plasma concentrations of desvenlafaxine and its main metabolite didesmethylvenlafaxine were quantified in plasma sampled up to hours after administration using lc-ms/ms. pupillographic measurements were performed as possible surrogate markers for desvenlafaxine pharmacodynamics. results out of the subjects carried two active, one active, and zero active oct alleles. age, height and weight were . ± . years (mean ± standard deviation), . ± . m and . ± . kg with no significant differences among the oct genotypes. there were strong variations in the pharmacokinetics of desvenlafaxine and its metabolite didesmethylvenlafaxine. the auc -infinity of desvenlafaxine varied between . and . min*mg/l and auc -infinity of didesmethylvenlafaxine between . and . mg*min/l. however, neither desvenlafaxine nor didesmethylvenlafaxine pharmacokinetics significantly differed among the three oct genotypes. concerning pharmacodynamics of desvenlafaxine, pupil diameters at maximal constriction after a standardized light exposure were on average % greater around the time of t max than before administration. in line with the pharmacokinetic results there were no significant differences in maximal constriction or other pupillographic parameters among the oct genotype groups. conclusions: our results suggest that oct genotype does not affect the pharmacokinetics of desvenlafaxine and therefore no dose adjustment in respect to oct genotype should be considered. other factors like renal transporters or polymorphic glucuronidation may explain the great variability in desvenlafaxine pharmacokinetics. background: cardiovascular disorders and medication are highly prevalent in elderly ( ). due to age related changes in the body, the elderly are particularly vulnerable to side effects and adverse drug reactions. some psychotropic drugs are linked with reports of cardiac side effects. additionally, some cardiac drugs may also cause psychiatric symptoms. of these, angiotensin converting enzyme inhibitors, beta blockers, methyldopa and calcium channel antagonists can induce or exacerbate symptoms of depression ( ) . the aim of this study was to provide information on the concomitant use of cardiovascular drugs among elderly patients who took psychotropic medication. methods: we conducted a single-center, retrospective study between september and december using the medical records of elderly patients (≥ years of age) admitted to basin sitesi polyclinic, izmir ataturk research hospital, turkey. demographic characteristics of patients, diagnoses, prescription drugs were evaluated, and spss . statistical software was used for data analysis. number, percent, mean and standard deviation were used as descriptive statistics. results: a total of elderly patients with psychiatric disorders were identified. one in four patients receiving psychotropic medication took at least one cardiovascular agent concomitantly (n= ). median age was (min: , max: ), patients were female ( . %). according to medical records of patients, the most commonly used drugs were escitalopram, sertraline, mirtazapine, quetiapine, mianserin and risperidone. the proportion of the concomitantly use of cardiovascular drugs was higher among the patients who took more than one psychotropic drug ( . % vs. % . ) compared to patients taking psychotropic monotherapy. a higher percentage of women used diuretics ( . % vs. . %) and angiotensin receptor blockers ( . % vs. . %) concomitantly with psychotropic drugs when compared to men. the proportion of men using angiotensin-converting enzyme inhibitors and lipid-modifying agents was higher than women ( . % vs. %, . % vs. . %, respectively). conclusions: the world's population is ageing rapidly. according to world health organization, over % of elderly suffer from a psychiatric or neurological disorder. our data showed that use of cardiovascular drugs among elderly patients with psychiatric disorders was extensive. the effects and interactions of these drugs should be discussed and carefully evaluated before starting treatment in the elderly. further studies focusing on drug use in elderly will increase the success in geriatric pharmacotherapy. since the adoption of the ich e guideline [ ], the thorough qt (tqt) study has become a standard element of clinical drug development. however, with the iq/csrc study [ ] the ability to detect qtc-prolongations of about ms in a phase i setting has been demonstrated. as a consequence, regulatory agencies have begun to grant waivers for a tqt study based on negative qt findings obtained from first-in-man studies. a concentration-response model is the key tool that gives sufficient power to an analysis based on data from single or multiple ascending dose studies. this power has been investigated in subsampling studies that simulate situations comparable to those encountered in first-in-man studies [ , ] . other topics to be addressed are the assurance of sufficient quality of the ecgs obtained, in particular in doses that cause adverse reactions, and a replacement for the active control that is part of a tqt study. if a model based statistical analysis is used for confirmatory inference, it must be specified in advance. this pre-specification includes tests to ascertain that the model assumptions are met and alternative methods to be used in case they are violated. in particular linearity and the absence of a hysteresis, i.e. a delay between the drug concentration and the observed qt effect need to be tested. this is an area of active research. in this contribution, i will share current experience from a statistical perspective, both based on real data and on simulated studies. i will also discuss critical points in the design of first-in-man studies that are intended to be used to obtain a waiver for a tqt study. human platelets express the g-protein-coupled angiotensin receptor-like- (apj) receptor. apj is activated by apelin, which is produced as pre-apelin and cleaved into several bioactive peptides such as apelin- , - and - . apelin and apj are expressed in a variety of tissues such as the heart, the vessel wall, several tumor types, and in platelets. to date, there is no description or a suggested function of the apelin/apj system in platelets to date. here, we investigate apj expression and function in human platelets. apelin and apj expression were determined in platelet-rich plasma from healthy donors by immunofluorescence, western blotting and flow cytometry. in a pilot study apelin and platelet apj expression were analyzed in patients with nstemi, stemi patients and controls. here, platelet aggregation was analyzed by light transmission aggregometry (lta); platelet cd and apj expression by flow cytometry and circulating plasma apelin by elisa. in resting human platelets, apj receptor expression was observed predominantly in the outer cell membrane, as determined by immunofluorescence staining and flow cytometry. activation with a selective thrombin receptor-activating peptide (ap ) resulted in decreased apj protein levels determined by western blotting in platelet lysates compared to untreated controls. preincubation of platelets with different apelin isoforms for sec to min reduced platelet aggregation in lta studies by up to % for apelin- . this effect was inhibited by preincubation of the platelets with the enos inhibitor l-name ( µm), suggesting the involvement of a no-dependent mechanism. in patients with myocardial infarction the expression of platelet apj was significantly reduced compared to the control group ( , % ± , % in mi versus % ± , %in controls; p = . ). this reduction in apj expression on platelets was accompanied by decreased plasma levels of apelin- in patients with mi ( . ± . pg/ml versus . ± . pg/ml; p = . ). interestingly, the decreased apj expression on platelets in mi patients significantly correlated inversely with the troponin t plasma levels (r = - . ; p = . ). this may suggest an association of apj expression with lower plasma levels of troponin t and possibly tissue damage. in conclusion, our study shows for the first time the expression of apj and a possible function in human platelets. apj may act as an endogenous inhibitor of platelet aggregation in response to certain apelin isoforms, predominantly apelin- . upon platelet activation, apj is internalized and surface expression is reduced by about %. in mi patients, plasma levels of apelin- and platelet apj expression were reduced. this correlated inversely with troponin t levels. reduced circulating apelin- levels and platelet apj expression may be associated or partly account for platelet hyperactivity in mi patients. anticholinergic drug use, m receptor affinity and dementia risk-a pharmacoepidemiological analysis using claims data f. thome background: dementia is characterized by cumulative cognitive decline and progressive inability for independent living. the lack of suitable therapies for terminating the progression of this disease underlines the importance of the detection of risk factors. anticholinergic drugs have been shown to enhance cognitive decline in the elderly. the classification of anticholinergic drugs according to their anticholinergic burden, however, is inconsistent. since cholinergic transmission is mainly mediated by the m muscarinic acetylcholine receptor in the brain, we classified anticholinergic drugs from anticholinergic risk lists according to their affinity for the m receptor subtype and calculated the risk for the onset of incident dementia. methods: our analyses are based on claims data of the public health insurance fund aok. data include information of inpatient and outpatient diagnoses and treatment from to . inclusion criteria comprised the initial absence of dementia and age of years or older in . anticholinergic drugs were taken from three anticholinergic risk lists. the pdsp-database and literature search were used to define k i -values for the substances. hazard ratios were calculated using time-dependent cox regression including covariates like age, gender, and several comorbidities. results and conclusion: anticholinergic drug exposure increases the risk for dementia. we found that anticholinergics with small k i -values are at a higher risk than those with greater k i -values. furthermore, conventional risk factors for dementia (e.g. age, depression, stroke) could be confirmed. in conclusion, the intake of anticholinergic drugs increases the risk for incident dementia in the elderly. taking into account the m receptor affinity may be a contribution in determining the anticholinergic load in view of the risk for incident dementia. safety signal detection in a large german statutory health insurance databasefirst results of a feasibility assessment f. andersohn , , s. schmiedl , , k. janhsen , , p. thuermann , , j. walker background: during the last years, approaches to routinely screen health care databases based on electronic medical records or claims to identify drug safety signals were proposed. to evaluate the performance of such methods, reference sets of index drugs have been compiled consisting of ( ) drugs with a known association to a certain adverse event (=positive controls) and ( ) drugs without any evidence to cause this adverse event (=negative controls). the best possible signal detection method would identify a safety signal for % of the positive control drugs, and for none of the negative controls. ryan et al. developed drug reference sets for four adverse events of interest (acute myocardial infarction=ami, acute kidney injury =aki, acute liver injury=ali, and upper gastrointestinal bleeding=ugib) and have shown feasibility of using these reference sets in us health care databases. if the use of these us specific drug lists for evaluation of signal detection methods is also feasible within german health care databases, is unknown. aims: to evaluate if the drug reference sets developed by ryan et al. (drug saf. ; suppl :s - ) could be used for testing signal detection methods in a large german statutory health insurance database. methods: data source was the health risk institute (hri) database, an anonymized healthcare database with longitudinal health insurance data from approximately six million germans. new users (initiators) of index drugs in to were identified and followed-up for one year from their first prescription. exposed person-time to the respective index drug was assessed to estimate for which of these drugs an increase in risk of % (relative risk . ) compared to the background incidence of the respective adverse event (ami, aki, ali or ugib) could be identified with % statistical power. results: from a total of index drugs in the reference sets of ryan et al., ( . %) were also available on the german drug market and were used by at least one insurant in the hri database during the study period. a total of , , index drug initiators were included in the analysis. for a total of index drugs, a relative risk of . could be detected with % power. the numbers of index drugs for each of the outcomes of interest were: ami ( positive controls; negative controls); aki ( positive controls; negative control); ugib ( positive controls; negative control). as the background incidence of ali was low, no positive or negative control with sufficient power was identified for this outcome. conclusions: using the set of reference drugs proposed by ryan et al., the number of drug-event pairs with % power to detect a relative risk of . was low, despite the magnitude of the database used. this may be attributable to differences of drug exposure in germany and the us. hence, an adaptation of the drug list to the german drug market and consumption data might be relevant for future evaluations of signal detection methods using german databases. correlation of sativex™ doses to steady state concentrations of -nor- -carboxy- administration of the oromucosal spray sativex™ represents a therapy option for treatment of spasticity in patients with multiple sclerosis. sativex™ is an extract containing equal amounts of the cannabis-derived cannabinoids ∆ tetrahydrocannabinol (thc) and cannabidiol (cbd). in cases of cannabis abuse a long elimination half life of some thc metabolites is known. therefore, in patients receiving sativex™, the long elimination half life of these metabolites should allow a drug monitoring under conditions of steady state. due to the fact that immunologically based methods for thc determination are very common in medical chemistry, a monitoring might be simply performed even in patients under sativex™ therapy. in a preliminary observational study -nor- -carboxy-∆ -thc (thc-cooh) concentrations were measured with a commercial immunoassay in urine samples of patients with multiple sclerosis obtaining sativex™. in addition, thc-cooh, thc, cbd as well as the hydroxy metabolites of thc and cbd were measured by gc/ms in urine and blood samples. using this analytical technique, only an excessive dosing (as compared to the declaration by the patient) can be detected. as a result of this approach, thc-cooh concentrations determined by the immunoassay were found not to correlate to the daily applicated amount of sativex™ as indicated by the patients (spearman rang order test: p > . ). two patients mentioned not to have taken sativex™ on the day the samples had been taken, and one patient predicated an additional cannabis abuse. in three patients the immunological thc-cooh determination was negative or nearly negative. interpretation of the data is hampered by the fact that an incorrect declaration of sativex™ applications by the patients cannot be excluded. introduction: learning analytics seeks to enhance the learning process through systematic measurement and analysis of learning related data to provide informative feedback for students and lecturers. however, which parameters have the best predictive power for academic performance remains to be elucidated. objective: to analyze the potential of different learning analytics parameters to predict exam performance in undergraduate medical education of pharmacology. methods and results: hypertext preprocessor (php) as server-side scripting language was used to develop a learning analytics platform linked to a my structured query language (mysql) database for storage and analysis of data (www.tumanalytics.de). the database consisted of lecturer-authored multiple choice questions that were made available to a cohort of undergraduate medical students enrolled in a pharmacology course (winter term / ) at technische universität münchen (tum). the course consisted of a -day teaching period, followed by a -day self-study period and a final written exam. students' assessment data of tumanalytics was collected during the self-study period and correlated to the individual exam results in a pseudonymized manner. a total of out of ( %) students participated in the study. the coefficient of multiple correlation (r) was calculated for different parameters in relation to exam results as a measure of predictive power. of different parameters investigated, the total score and the score of the first attempt in tumanalytics had the highest positive correlation with exam performance (abb. ). no sex-specific differences were observed. summary and conclusion: in this study we systematically investigated the potential of different learning analytics parameters to predict learning outcome and exam performance. total score and score of the first attempt were identified as parameters with the highest predictive power. in conclusion, our study underscores the potential of learning analytics as valuable feedback source in undergraduate medical education of pharmacology. in educational settings, tests (e.g., written or oral exams) are usually considered devices of assessment. however, a recent and intriguing line of evidence from basic cognitive psychological research suggests that tests may not only help to assess what students know, but may also help to improve the learning and long-term retention of information. the goal of the present study was to apply such test-enhanced learning to pharmacological teaching. after the last lecture of a pharmacology class (n= rd -year medical students, n= th -year medical students: basic or clinical pharmacology, respectively), one week prior to the final exam, students were given the opportunity to voluntarily participate in online exam. because pilot work from previous semesters had revealed relatively low levels of participation in such formative exams, students were offered bonus points for (successful) participation as an incentive. the online exam consisted of items (i.e., selected pieces of information from the lectures and seminars) and was provided on the e-learning platform ilias. twenty of the items were presented as statements for restudy, items were tested using single-choice questions, and items were tested using short-answer questions. randomly a third of the students were assigned to different sets of questions. the summative final written exam for each group consisted of single-choice questions, questions of which had not been used before (as a standard of comparison). the remaining questions of the final exam were taken from the previous online exam, but were slightly reworded to avoid ceiling effects. each of of these reworded questions from the final exam corresponded to restudy items, single-choice items, and short-answer items from the online exam, respectively. the main points of interest were (i) whether the re-processing (rewording and asking for transfer of knowledge) of information in the online exam affected participants' performance on the final exam, and (ii) whether any effect depended on the specific type of re-processing (restudy vs. single-choice test vs. shortanswer test). if previous findings from basic cognitive psychological research on testenhanced learning can be generalized to more applied settings and educationally more relevant materials such as pharmacological information, students' performance in the final exam should be better for questions corresponding to previously tested items than for questions corresponding to previously restudied items. moreover, if more difficult tests lead to more test-enhanced learning than less difficult tests, as is suggested by recent findings from cognitive psychological research, performance for questions corresponding to (supposedly more difficult) short-answer items should even exceed that for questions corresponding to (supposedly less difficult) single-choice items. the present findings bear direct implications for educational practice. safe and rational prescribing is one of future physicians' key skills [ ] . in order to address the persisting prescribing deficiencies [ ] , we set out to develop a learning tool for pharmacotherapies of the most important diseases worldwide. the format, scope, information architecture, and functionalities of the app were identified through assessment of existing apps, literature analysis, app simulation-based student surveys, and expert advice. a fully functional offline app format for smartphones was selected based on the trends in using digital technologies for educational purposes [ ] and on the unreliable internet and power availability in many learning settings. a relational database based on semantic relationships was chosen to minimize information redundancy and to enable the retrieval of drug-related information in the context of mechanisms, contra-and indications, adverse drug reactions, interactions, and common prescribing situations. the usability was optimized using a simulation of the app evaluated by medical students from germany and tanzania, and by experts. a list of indications was assembled beginning with disease burden data for the seven who world bank regions. each disease accounts for at least . % of life years lost due to premature death or lived with ill-health or disability (daly) in at least one region. the list was further complemented according to expert recommendations. therapeutic recommendations are based on current guidelines, considering cheaper treatment alternatives provided in the who list of essential medicines. a novel dual-scale classification system lists drug mechanisms according to the affected physiological process and to the resulting therapeutic effect [ ] . contraindications, adverse drug reactions, and interactions were compiled using drug monographs of the european medical agency, the us food and drug administration, and health canada. unexpectedly, we found significant differences among these sources in respect of adverse drug reactions. this necessitated the ongoing verification through surveying general practitioners and specialists in internal medicine. during the dgpt meeting we will present the results of testing of the cardiovascular section comprising indications, drugs representing mechanisms, and up to adverse drug reactions. the european certified pharmacologists (eucp) programme was lauched in july by the federation of european pharmacological societies with the intention to identify experts in the field of pharmacology whose competency profile, in addition to their personal specialised scientific expertise, covers expert knowledge in all major fields of the discipline. seventeen ephar member societies have declared their active participation in the eucp programme so far (austria, croatia, czech republic, finland, france, germany, greece, hungary, italy, the netherlands, norway, poland, portugal, serbia, slovenia, spain, turkey) . eacpt, the european association of clinical pharmacology and therapeutics, has also recently decided to participate in the eucp programme. national programmes must meet all requirements of the eucp guidelines including a clear catalogue of criteria with respect to knowledge, practical awareness and skills, as well as general rules including rules for final assessment of candidates. such programmes may be based on existing diplomas or training schemes or may consist of a set of rules how applicants may submit credentials for their expertise with respect to the eucp criteria. so far, three ephar member societies have submitted a national eucp program: austria, italy and the netherlands. the programmes differ in structure and reflect the flexibility of the eucp programme with respect to the respective national conditions. while the italian programme is based on a catalogue of criteria where applicants have to certify and document their expertise on the basis of this catalogue and the dutch program is based on a structured phd training course, the eucp scheme submitted by the austrian pharmacological society aphar is based on the legally regulated diploma medical specialist (facharzt) in pharmacology and toxicology (aphar also plans to submit separate regulations for specialists in clinical pharmacology and for nonmedically qualified pharmacologists). the aphar eucp scheme has been approved by the eucp committee in november and its regulations are available on the eucp website (www.eucp-certification.org). the differently structured programs of the italian and dutch pharmacological societies will also be available at this website, once approved by the eucp committee and may thus serve as 'case studies' for other ephar and eacpt member societies wishing to take part in the eucp programme. introduction: the outstanding importance of pharmacovigilance (pv) for the safe use of medicines has increasingly been recognised during recent years. the multidisciplinary character of pv requires know-how in topics as different as pharmacology, clinical medicine, pharmacoepidemiology, information technology, pharmaceutical manufacturing, legal aspects, public health policies, and medical traditions in different regions of the world. in this complex situation there is a growing need for pv capacity building, in particular by professional training through high quality pv courses with different focuses and different levels of detailing. against this background, the world health organization (who) and the international society of pharmacovigilance (isop) have co-operated to create a curriculum for teaching pv which can be used for a wide range of audiences and in very different settings and situations. the purpose was to provide an inventory and systematically structured overview of pv including recent developments of topics like pharmacogenomics, consumer reporting of adrs, risk management and who-led international projects, and to propose a range of tasks for practical training. we made use of several relevant already existing packages of pv topics and concepts of pv teaching from national and international institutions. we also drew from extensive printed material as well as comprehensive reviews, textbooks and guidelines developed by international organisations which are often available online. results: the curriculum includes a main component consisting of a major part for theoretical lecture-based training and a minor component with suggestions for hands-on exercises. the theoretical part has a three-level hierarchical and modular structure with evenly divided tiers. there are chapters. each of them is divided into four sections and each section into four to six sub-sections. the practical part consists of twelve times three or four proposals for practical tasks which are related to the theoretical lectures. since its launch in it has successfully been used in several international courses. currently a pilot project is under way to explore its use for 'crowd sourcing': it is placed on the isop homepage with a programme allowing for institutions or persons experienced in pv teaching to upload any relevant presentations they may have with a link to related chapters, sections or subsections. these presentations will be offered for downloading by interested users. the curriculum provides a comprehensive coverage of almost all areas of pv. the structure and content allows almost every kind of focusing on specific issues and going into depth, while maintaining the overall context. it offers opportunities of tailoring courses specifically to the needs of different audiences and can be applied to various forms of training, such as broad, comprehensive and intensive courses, short overviews or focuses on specific narrow topics in perspective. according to the reach regulation (ec) no. / chemicals produced, marketed or used within the european union have to undergo a registration process, wherein the registrants have to provide information on hazard and potential risks presented by the substances. however, the standard information requirements defined in annexes vii to x of the regulation might be waived or adapted by the registrants if adequate documentation and justification according to criteria specified in annexes vii to xi are provided. to evaluate the data availability in registration dossiers of high tonnage substances (above tpa) and their compliance with the reach regulation, the federal institute for risk assessment (bfr) in cooperation with the federal environment agency (uba) developed a systematic web-based scheme. in total, dossiers were checked for selected human health and environmental endpoints such as repeated dose toxicity, genetic toxicity and ecotoxicity. a remarkable high rate, % to % depending on the endpoint, of the evaluated dossiers included waiving or adaptations from the standard information requirements. therefore, those dossiers were not concluded, but categorised as 'complex' (springer et al., ) . the use of waiving and adaptations in 'complex' endpoints were part of a follow-up project. herein, it was evaluated whether the given justifications were in accordance with the criteria set out in the respective reach annexes. the results will show the frequency and pattern of waiving/adaptation approaches for the human health as well as the environmental endpoints. besides this general overview, specific problems regarding the application of the reach regulation were identified and their significance with regard to remaining data gaps will be discussed. the german commission for the investigation of health hazards of chemical compounds in the work area has re-evaluated dimethylformamide, and classified it in the carcinogen category . this category is for chemicals with carcinogenic potential for which a non-genotoxic mode of action is of prime importance and genotoxic effects play no or at most a minor part provided the mak and bat values are observed. under these conditions no contribution to human cancer risk is expected. dmf was identified as a substance of very high concern by european commission. the amount of dmf manufactured and/or imported into the eu is, in the range of - t/y. n,n-dimethylformamide is a hepatotoxin in humans and rats. the carcinogenicity studies in both mouse and rat were conducted with test material of an acceptable purity and physical form. the critical study involved administration of dmf via inhalation, which is relevant to human exposure. there is conclusive evidence that dmf induces significant increases of hepatocellular carcinomas in rats after exposure to ml/m³ and in mice in response to ml/m³ and higher. several in vitro and in vivo studies have indicated that dmf is not genotoxic. the results of the long-term studies reveal that the tumors develop in the liver only after chronic toxic inflammatory and degenerative changes have developed in this organ. the commission concluded that the tumors are a result of chronic liver damage, occurring at high exposure concentrations. the available evidence therefore suggests that there is a threshold dose for the carcinogenic effects of dmf. accordingly, dmf was classified in carcinogen category with a mak-value of ml/m³, an exposure concentration which does not induces liver toxicity and as a consequence is not associated with an increased cancer risk. today, a large majority of people is constantly exposed to electromagnetic radiation. many studies have been performed to investigate whether this type of radiation has a potential to affect biological systems at low intensity levels. even though no complete consensus has been reached so far in this issue, most of the investigations do not indicate a harmful potential of this radiation. two questions remain open until today, i. e. long-term effects and specific effects on children. it has been demonstrated that in comparison to adults, children absorb far higher doses of mobile phone radiation in the skull, particularly in the bone marrow, where hematopoiesis takes place. these absorptions occasionally exceed the recommended safety limits. the aim of this study was to elucidate, whether cells of the hematopoietic system can be affected by different forms of mobile phone radiation. as biological systems, two cell types were investigated, hl- cells as an established cell line, and human hematopoietic stem cells. the radiation was modulated according to the two major technologies, gsm ( mhz) and umts ( mhz). additionally, lte ( . mhz) modulation was applied because this technology is used worldwide already but has not been studied sufficiently. cells were exposed for a short and a long period and with different intensities ranging from to w/kg. studied endpoints included oxidative stress, differentiation, dna repair, cell cycle, dna damage, histone acetylation, and apoptosis. appropriate negative and positive controls were included and three independent replicate experiments were performed. exposure to radiofrequency radiation did not induce any alterations of cell functions, measured as oxidative stress and cell cycle. cell death in the form of apoptosis was not observed. primary dna damage was not induced and dna repair capacity for nucleotide excision repair was not changed. epigenetic effects (measured as histone acetylation) were not observed. finally, differentiation was not affected. the effect of treatment with various chemicals as positive controls was different in the two cell types. all in all, mobile phone radiation did not induce effects on human hematopoietic cells. in who published guidance on evaluating and expressing uncertainties in human health hazard characterisation (hc). in this approach, the outcome of hc is expressed as an interval or distribution rather than a "traditional" deterministic point estimate, such as a reference dose (rfd), thereby communicating potential uncertainties more clearly. risk management protection goals, such as the acceptable magnitude of effect (m) and incidence (i) in the population, are made explicit quantitatively along with the confidence with which they are achieved, e.g. by an rfd. specifically, the goal of this approach to hc is to estimate the "hd m i" , i.e. the "true" human dose associated with m and i (e.g. body weight decreased by ≥ % (m) in % (i) of the population). if uncertainties are expressed by providing estimates of the hd m i as confidence intervals or uncertainty distributions, both the "degree of uncertainty" (ratio of upper and lower limit of the interval/relevant distribution segment) and the "coverage" (statistical confidence) associated with a given rfd value can be characterised. alternatively, one may start from a chosen coverage and calculate the associated "probabilistic rfd". uncertainty in each hc aspect, e.g. inter-/intraspecies or time extrapolation, can be characterised by a "generic default uncertainty distribution" which has been derived from historical data, but may be replaced by a substance-or effect-specific distribution (analogous to a chemical-specific adjustment factor in the "traditional" deterministic approach), where available. the uncertainty distributions for the individual hc aspects can then be combined into an overall uncertainty interval/distribution in ( ) a simple non-probabilistic way, ( ) a more refined "approximate probabilistic analysis" (aproba, a free spreadsheet tool for easy implementation also by non-statisticians is available from the who website), or ( ) a fully probabilistic monte carlo analysis. the hc aspects contributing most to overall uncertainty are also identified and may be prioritised for refinement in a next assessment tier. the who approach uses a tiered strategy which may start with evaluating the uncertainties in the outcome of a "traditional" deterministic hc. in this way it represents a unified framework integrating deterministic and probabilistic hc methodologies. moreover, the concept can be easily combined with exposure uncertainty assessment. risk managers may use the additional information in better weighing potential health effects against other interests. when they consider the overall uncertainty larger than desirable in view of the problem formulation, they may decide to ask for a more refined (higher tier) assessment. if all possibilities for refinement are exhausted, the new approach can also aid in the selection of new data which might need to be generated. due to a constant improvement in analytical methods an increasing number of substances are found in drinking water. the joint project toxbox aimed for the development of a reliable test battery, allowing for a rapid evaluation of single substances in water. eleven partners either from the research (nine) or the business sector ( ) formed the project. the attention was focused on genotoxic, neurotoxic and endocrine effects, which are considered to be of most concern to the consumer. by the end of the project a set of guidelines is published that describes the analytical methods in detail. the project was based on a theoretical concept, called "health-related indicator value" (hriv), which was developed by the german federal environment agency (uba) for the assessment of substances with incomplete toxicological data. depending on the type of effect a hriv between . and . µg/laws derived for the substance which had to be evaluated. during the years an increasing amount of substances as well as an increase in finds was observed in drinking water. this called for the creation of an evaluation scheme that offers rapid and at the same time reliable evaluations of chemicals for which there are no data available. the concept is in accordance with tox , which envisages the trustworthy evaluation of relevant endpoints by two or three in vitro assays. in the context of toxbox this was provided for the endpoints genotoxicity, neurotoxicity and endocrine effects. in all cases a hierarchic strategy is applied that enables a first assessment via relatively simple test assays and only when these test give a hint towards an effective more elaborate techniques are applied for a final assessment. the ames test and micronucleus assay in combination with the umu test will form the panel for genotoxicity testing. neurotoxicity will be assessed by comparing necrotic and apoptotic effects as well as the development of reactive oxygen species in human nervous cell with human liver cells. additionally neuron specific assay like the neurite outgrowth test are performed. this is complemented by measuring the activity of acetyl choline esterase activity and the development of the side line organ in zebra fish (danio rerio). the test battery for endocrine effects consists of hormone specific reporter gene s assays in addition to the h r assay. when necessary a reproduction assay in the mud snail potamopyrgus antipodarum is carried out. during the project some substances were evaluated. this allowed for the development of a reliable test strategy. currently the guidelines for performing the required tests are in the making. metabolomics has gained increasing interest over the last years with numerous possible applications ranging from strain optimization for industrial production over drug discovery to improved toxicity testing. however, regulatory acceptance of this promising approach is still not reached, mostly because standardization and evaluation of reproducibility are still mostly lacking. the metamap®tox database has been developed by basf over the last ten years containing toxicity and metabolome profiles of more than different compounds. to ensure maximum reliability, data was gained from plasma samples of highly standardized week rat studies. animal maintenance and treatment, sampling and work-up of plasma, measurement of the metabolome as well as data interpretation and storage were standardized including thorough documentation, the compliance with sops and safe data storage. data from more than control groups with each males and females were analyzed to assess variability. an in depth analysis of this showed a high stability and robustness of the metabolome over a period of ten years. after artificially splitting the groups of control groups into groups of five animals and comparing the number of statistically significantly regulated (false positive) metabolites, the peak of the distribution curve was located to the left of the exact (gaussian) center, but tailed off to the right more than expected under the normal distribution. from this analysis we were able to calculate density distributions (relative ratio and standard deviation) for the control values of each metabolite, which can serve as a historical control displaying the range of changes which can be expected as normal. during the course of our project we have used more than ten exact repeats to show reproducibility and reliability of the metabolome analysis (kamp et al., ) . comparing these exact repeats at different levels of statistical significance, we noted that at a level of statistical significance of approximately p = . , the best balance between matches (metabolites regulated in the same direction) and mismatches (metabolites regulated in opposite directions) was obtained. the high quality standards applied as well as the examination of control data increase the robustness of this approach, going also hand in hand with improved data quality. this significantly facilitates decision making based on the gained data. due to these improvements a new level of transparency is reached, which might allow inclusion of metabolome data in a regulatory environment. hydroxycitric acid (hca) is a fruit acid naturally occurring in fruits of the tropical plant garcinia cambogia. a number of dietary supplements intended for weight loss contain hca, which is added in form of g. cambogia extracts. the composition of these extracts is often not clearly specified. health concerns about safety of the hca-containing supplements have been raised, based on results from animal studies, which observed toxic effects on the testis and on spermatogenesis after administration of preparations containing high hca doses. in the current risk assessment, the possible health risks associated with consumption of hca-containing dietary supplements (hca doses of approximately to mg per day) were evaluated based on relevant animal and human studies with the focus on testicular toxicity as a critical endpoint. in several published animal studies, repeated (short-term or subchronic) ingestion of certain hca-preparations (g. cambogia-extract or ca + -hca salt) induced testicular atrophy (i. e. atrophy of seminiferous tubules, degenerative changes of sertoli cells at histological examination) and impaired spermatogenesis (i. e. decreased sperm counts) in male rats at high doses (noael and loael of and mg hca/kg body weight & day, respectively). animal studies with other hca-preparations (ca +/ k + -hca salt) found no such effects at the highest hca-doses tested (noael: , mg hca/kg bwt & day). human intervention studies which addressed the safety of hca in healthy test persons reported no substancespecific adverse effects after ingestion of hca doses up to mg per day over the period of up to weeks. however, the question of possible adverse effects of hca on the human testes was not adequately addressed in studies with human volunteers. in a single clinical study with male test subjects, no significant changes in endocrinologically relevant parameters such as serum inhibin b or fsh were observed after consumption of mg of hca for weeks. however, no investigations of direct parameters that might inform on potential effects on spermatogenesis, such as sperm quality and sperm count, were conducted in this study. considering the serious adverse effects on the testes observed in several animal studies as well as in view of lack of the adequate human data on the safety of the long-term use of hca-preparations, it is concluded that knowledge gaps and substantial uncertainties exist regarding the safety with respect to human health of high amounts of hca found in commercially available food supplements, particularly with regard to the human male reproductive system. a critical look on the passing-bablok-regression b. mayer universität ulm, institut für epidemiologie und medizinische biometrie, ulm, germany background: the passing-bablok (pb)-regression is a commonly used approach to prove the equality of different analytical methods when studying quantitative laboratory data. it is based on the assumption that the measurements of two methods are linearly related. if then one method is regressed onto the other and the respective confidence intervals of the intercept and the slope include and , respectively, it is assumed to have a proof of methods equality. however, this conclusion is problematic in respect of an essential principle of statistical hypothesis testing. methods: in this talk the general idea behind the pb-regression is discussed critically. although the method makes use of confidence intervals a decision is made, which is why it is important to discuss how the results of a statistical hypothesis test have to be interpreted. moreover, alternative statistical approaches to investigate agreement in biometrical practice are pointed out by means of a practical example and their advantages and limitations are addressed. results: all approaches applied to a sample data set led to the same conclusions. demonstrating methods equality though necessitates an a-priori definition of an appropriate equivalence margin. conclusion: the pb-regression may give useful advice when comparing two measurement methods towards equality. however, its results are statistically inconclusive, since the pb-method does not follow the principle of equivalence testing. alternative measures of agreement should be applied instead to ensure results which are not attackable and serve as a statistical proof. insulin is an important parameter both in toxicology (toxicity to the endocrine pancreas) and pharmacology (models of diabetes and metabolic syndrome). currently available elisa and ria methodologies for insulin often require up to µl plasma or serum for a single measurement. in order to meet the general trend to include more relevant parameters in animal studies and restrictions through animal welfare requirements to limit the volume of interim blood draws we explored the rat/mouse insulin singleplex assay of meso scale discovery (msd) as an alternate assay consuming only µl serum or plasma or less for a single measurement. the assay is a sandwich immunoassay, whereby insulin in the sample binds to the capture antibody immobilized on the working electrode surface at the bottom of each well and recruitment of the labeled detection antibody (anti-insulin labeled with electrochemiluminescent compound, msd sulfo-tag™ label) by bound analyte completes the sandwich. voltage applied to the plate electrodes then causes the label bound to the electrode surface to emit light the intensity of which is a quantitative measure of insulin. the msd insulin assay was characterized by a robust calibration and only small variations within repeated measurements. the assay presented a broad dynamic range and differences in insulin levels of normal and rats suffering from metabolic syndrome could readily be demonstrated. furthermore, the high sensitivity may even allow the use of smaller sample volumes. these features render this assay an attractive alternative for the measurement of insulin. the lack of corresponding quality control samples for internal quality control may be considered as a relative drawback. however, the cross reactivity of the assay with human insulin provides the opportunity to use qcs designed for human assays and to possibly participate in ring trials for human insulin for external quality control if needed. surfactants are main constituents of different consumer products, e.g. detergents or cosmetic cleansing products. since surfactants show an intrinsic skin irritation potential, dilutions are used in the final products to avoid adverse effects like irritant contact dermatitis from product use. in addition, mixtures of different surfactants are typically formulated, as it is a long-standing experience that those mixtures exhibit much lower acute irritation potential than expected from the mere summation of their individual irritation potential, an effect coined surfactant antagonism. only few studies were performed to gain a more fundamental understanding of the effect, and it's mechanistic basis remains unclear. however, a thorough understanding of the surfactant antagonism is not only of value for the formulation of products that are considered 'mild to the skin'. it is also important for the classification of products according to the clp regulation in cases when data of the mixtures is missing, because summation of the ingredients' irritating effects usually results in over-classification as skin irritant. due to the progress in the development of alternatives to animal testing, different in vitro methods have become available to determine skin irritating properties of substances. methods like the oecd tg and especially aim at deriving a classification for skin irritation/corrosion effects according to the clp regulation. however, even though these methods became the preferred test methods for skin irritation testing, to our knowledge hitherto isolated investigations on the surfactant antagonism were only performed either by human patch test studies or by non-standard in vitro assays. in this study, the irritation potential of binary mixtures of sodium dodecylsulfate (sds), linear alkylbezene sulfate (las), cocamidopropyl betaine (cabp) and alkylpolyglucosid (apg) compared to the single compounds was investigated using open source reconstructed epidermis (os-rep) models. combinations of sds or las with cabp and apg, respectively, resulted in a clear decrease of the irritation potential compared to the irritation exerted by the single surfactants, even though the total surfactant concentration was higher in the mixtures. in addition, the effect of surfactant antagonism was also observed in a mixture of cabp and apg. the reduced irritation potential of mixed surfactants came along with both reduced skin penetration of fluorescein and reduced release of ldh. since no surfactant antagonism is observed in monolayer cultures of keratinocytes that were exposed to mixtures of surfactants, it is assumed that keratinocytes in the viable parts of the reconstructed epidermis are promptly damaged by the surfactants once the model's barrier is destroyed. hence, surfactant antagonism appears to be primarily driven by the mixture's lower ability to damage the skin model's barrier. the micronucleus (mn) test is a reliable method for the detection of cytogenetic damage in proliferating cells. in recent years, substantial progress has been made on automated, thus faster and more objective scoring of mn test samples, i.e., methods based on flow cytometry. the aim of the present study was to use the adherently growing human bladder cancer cell line rt to carry out a comparison between traditional (fluorescence microscopy) and automated (flow cytometry) mn scoring. for this purpose, different substances which are known to be positive controls were used. rt cells were either continuously incubated for h (approximately . cell cycles duration) with methyl methanesulfonate (mms; - µm), benzo[a]pyrene (b[a]p; . - µm), vincristine ( - nm) , and colcemid ( - nm) or cells were irradiated with xrays ( . - sv) and then cultured for h. for standard mn scoring, cells were harvested, subjected to hypotonic treatment, fixed with methanol/acetic acid, placed on glass slides, stained with acridine orange and observed by fluorescence microscopy. for the flow cytometric method, harvested cells were stained in two sequential steps. intact cells were subjected to ethidium monazide bromide followed by photoactivation ( w, min) to label dead or dying cells. then, cells were lysed and stained with sytox green for a pan-dna labelling and analyzed on a flow cytometer. both, chemically-and radiation-induced treatment led to a dose-dependent induction of mn when evaluated by fluorescence microscopy. when the flow cytometry-based method was applied, clearly positive results including a dose-dependent induction of mn, however, were obtained only for out of the treatments (vincristine, colcemid and x-rays); whereas, treatment with mms and b[a]p led to only minor increases in relative mn frequencies (≤ -fold), even at the maximum concentrations. in summary, flow cytometry-based mn scoring has been successfully applied in rt cells. however, our initial results suggest that flow cytometry-based mn scoring is less sensitive than microscopic scoring when rt cells are used. so far, only few adherently growing cell lines have been applied to flow cytometry-based mn scoring. further substances (positive and negative controls) and possibly other adherent cell lines need to be tested to expand our knowledge on the effectiveness of automated mn scoring in vitro and compared to traditional approaches. background: the platinating agent cisplatin is commonly used in the therapy of various types of solid tumors, especially urogenital cancers. its anticancer efficacy largely depends on the formation of bivalent dna intrastrand crosslinks, which impair dna replication and transcription. these crosslinks stimulate mechanisms of the dna damage response (ddr), thereby triggering checkpoint activation, gene expression and cell death. the clinically most relevant adverse effect associated with cisplatin treatment is nephrotoxicity, which mainly results from damaged tubular cells. here, we analyzed the influence of the hmg-coa-reductase inhibitor lovastatin on the cisplatin-induced geno-and cytotoxicity in the rat renal proximal tubular epithelial cell line nrk- e. methods: cell viability was determined by using the alamar blue assay, as well as by electrical impedance measurements via the icelligence system. alterations in cell cycle progression were assayed by flow cytometric analysis. the formation of pt-(gpg) intrastrand crosslinks was determined via southwestern blot. the amount of dna double-strand breaks (dsbs) was quantified by measuring the level of s phosphorylated h ax (γh ax) via immunocytochemistry as well as by western blot. additionally, neutral and alkaline comet assays were performed to determine the amount of dna single-and dna double-strand breaks. mechanisms of the ddr were analyzed by western blot as well as by quantitative real-time pcr. results: the data show that pretreatment of nrk- e cells with a subtoxic dose of lovastatin reduced the cytotoxicity evoked by high doses of cisplatin by protection from cisplatin-stimulated apoptotic cell death. moreover, lovastatin had extensive inhibitory effects on cisplatin-induced ddr, as reflected on the level of p-atm, p-p , p-chk , p-chk and p-kap . furthermore, activation of mitogen-activated kinases (mapks) was also reduced. the lovastatin-mediated mitigation of cisplatin-induced ddr was independent of the initial formation of dsbs as well as of pt-(gpg) intrastrand crosslinks. lovastatin protects nrk- e cells from cisplatin-induced cytotoxicity by interfering with proapoptotic mechanisms of the ddr independently from initial dna damage formation. with respect to the clinic, the data indicate that lovastatin might be useful to mitigate cisplatin-induced nephrotoxicity. the influence of oxidant tert-butylhydrochinone (tbhq) on endothelial cell migration in wrn-deficient cells k. laarmann , g. fritz institut für toxikologie, düsseldorf, germany introduction: wrn is a dna helicase and possesses a ´- ´exonuclease and atpase activity as well as a single strand annealing activity. it is involved in dna repair, by interacting with proteins of base excision repair (ber) and nucleotide excision repair (ner). defects of wrn are marked by genome instability which, in turn, is caused by defects in dna damage repair. patients with a mutation in the wrn gene show premature aging and early mortality. the latter is mainly caused by arteriosclerosis. furthermore, wrn participates in the regulation of genotoxic stress responses stimulated by reactive oxygen species (ros) and alkylating agents. the aim of this study was (i) to investigate whether endothelial cell migration and adhesion were effected by sub-toxic (ic ) and moderate toxic (ic ) concentrations of the oxidant tertbutylhydrochinone (tbhq) and (ii) whether wrn influences migration and adhesion in the presence or absence of tbhq. methods: endothelial-like ea.hy cells were treated with different concentrations of the redox cycling and thus ros producing oxidant tbhq. viability was measured by the alamar blue assay. ic and ic were determined after h permanent treatment. to investigate the influence of wrn on endothelial cell migration and adhesion, a wrn knock-down was performed in ea.hy cells using rna interference. to measure migration, a confluent cell monolayer was scratched using a pipet tip, h after permanent tbhq treatment. pictures were taken at the time points h, h and h after performing the scratch. the non-closed area was measured. in a second part, adhesion of the calcein-labeled colon adenocarcinoma ht- cell line on the ea.hy monolayer was investigated. wrn-deficient or non-deficient cells were treated with µm and µm tbhq or with tnfα. results: for ea.hy cells, µm and µm tbhq were determined as ic and ic , respectively. performing the migration assay, ea.hy cells showed % gap closure, whereas wrn-deficient cells showed a closure of only % after h. the gap was closed of % and % after µm and µm tbhq treatment. in wrndeficient cells no remarkable effect on migration was observed after µm tbhq treatment, whereas the treatment with µm tbhq showed a slight decrease in migration of about % compared to wrn-deficient cells. no effect on adhesion was observed after tnfα treatment. after µm tbhq treatment a slight increase of adhesion was detected in ea.hy cells. the influence of moderate tbhq concentration on adhesion was reduced in the absence of wrn. conclusion: wrn influences endothelial cell migration. in contrast to wild-type ea.hy cells, no significant effect of tbhq was observed on migration of wrndeficient cells. furthermore, the moderate toxic concentration of tbhq showed slightly increased ht- adhesion to ea.hy , which was not found in wrn-deficient cells. outlook: in forthcoming studies we analyse the effect of alkylating agents on migration and adhesion. data will be presented and discussed. the aim of the present work was to compare the sensitivity of leukemia cell lines (hl , jurkat and tk ) and hematopoietic stem cells with regard to the response to genotoxic agents. chromosomal damage was analyzed by evaluation of the micronucleus frequency. furthermore, changes in the proliferation index and the frequencies of apoptotic and mitotic cells were assessed. several cytostatic drugs with different mechanisms of action were used as genotoxic agents. doxorubicin was used as an intercalator, radical producer and topoisomerase ii inhibitor. also, the effects of vinblastine, a mitosis-inhibiting drug and of methyl methanesulfonate, which forms dna-adducts and stalls replication forks, were analyzed. in general, a difference in sensitivity between the different substances was observed. with regard to the formation of micronuclei after treatment with doxorubicin, jurkat and tk cells showed similar increasing trends, whereas hl cells showed a much higher increase in micronucleus frequency. a clear decrease in proliferation and the frequency of mitotic cells was observed at the highest concentration ( nm doxorubicin) investigated, and only a slight increase in the number of apoptotic cells could be shown. the biggest differences in formation of micronuclei could be detected after treatment with vinblastine. hl cells showed only a slight increase of micronuclei, but the effect on jurkat cells was stronger. the highest micronucleus frequency after vinblastine treatment was detectable for the tk cells. the results for the highest investigated concentrations ( . nm and nm vinblastine) showed a significant reduction of the proliferation index. this effect is reflected by the increasing numbers of apoptotic cells in all cell lines. the results for methyl methanesulfonate demonstrated only a small increase in micronucleus formation for the jurkat cells, but higher values for the tk cells. in contrast the hl cells did not lead to a concentration-dependent effect with methyl methanesulfonate. these results are complemented by preliminary findings in hematopoietic stem cells at selected compound concentrations. the different results between the leukemia cell lines and the stem cells might possibly originate from the different p status of hl (null), jurkat (multiple mutations), tk (wild type) and hematopoietic stem cells (wild type). this difference might also cause differences in cell cycle control or repair mechanisms, and needs further investigations. hyperinsulinemia is thought to enhance cancer risk. a possible mechanism is induction of oxidative stress and dna damage by insulin, here, the effect of a combination of metformin with insulin was investigated in vitro and in vivo. the rational for this were reported antioxidative properties of metformin and the aim to gain further insights into mechanisms responsible for protecting the genome from insulin mediated oxidative stress and damage. comet assay, micronucleus frequency test and a mammalian gene mutation assay were used to evaluate the dna damage produced by insulin alone or in combination with metformin. for analysis of antioxidant activity, oxidative stress and mitochondrial disturbances, the cell-free frap assay, the superoxide-sensitive dye dihydroethidium and the mitochondrial membrane potential-sensitive dye jc- were applied. accumulation of p and pakt were analysed. as an in vivo model, hyperinsulinemic zucker diabetic fatty rats, additionally exposed to insulin during a hyperinsulinemic euglycemic clamp, were treated with metformin. in the rat kidney samples, dhe staining, p and pakt analysis, and quantification of the oxidized dna base -oxodg was performed. metformin did not show intrinsic antioxidant activity in the cell free assay, but protected cultured cells from insulin mediated oxidative stress, dna damage and mutation. treatment of the rats with metformin protected their kidneys from oxidative stress and genomic damage induced by hyperinsulinemia. metformin may protect patients from genomic damage induced by elevated insulin levels. this may support efforts to reduce the elevated cancer risk that is associated with hyperinsulinemia. the human skin is the primary barrier against environmental and chemical impacts. as such it shields us against a plethora of xenobiotics such as potentially carcinogenic polycyclic aromatic hydrocarbons (pahs). at the same time it is the second most densely populated organ, harbouring more than bacterial species and population densities of up to cfu per cm . yet little is known about this microbiome's potential to metabolise and toxify pahs such as benzo[a]pyrene (b[a]p). previous work at the bfr showed that degradation of b[a]p and other pahs is a universal feature of the skin's microbiome (sowada et al., ) . the corresponding metabolites only partly overlap with those known from eukaryotic metabolism and possess cytotoxic as well as genotoxic properties. excretion of these metabolites will lead to exposure times of - hours or longer for full and partial metabolisers, respectively. while in vitro studies show the corresponding substances to exert their effects synergistically, an assessment of their potential impact on human carcinogenesis is pending. one obvious mode of action would be direct genotoxicity. however, another option is interference with uv-damage repair. ultraviolet radiation (uvr) from sunlight is regarded the main causative factor for the induction of skin cancer. it induces two of the most abundant mutagenic and cytotoxic dna lesions, that is cyclobutane-pyrimidine dimers (cpds) and - photoproducts ( - pps). these lesions are repaired primarily by nucleotide excision repair (ner), a system that is also responsible for the removal of pah-derived dna adducts. we therefore wanted to know whether and to what extent bacterial b[a]p metabolites have the capacity to interfere with ner, potentially contributing to uv-induced dna-damage. to investigate this selected genotoxic metabolites were examined for their potential to affect the dna repair capacity of skin cells (hacat). following treatment with uva/b and bacterial b[a]p-metabolites the skin's repair capacity was assessed using a modified comet-assay. ionizing radiation (ir) is a well-established model to induce dna double-strand breaks (dna-dsbs), but it also generates a broad range of other dna lesions including dna single-strand breaks as well as oxidative dna base modifications. furthermore, ir is able to modify membrane components and triggers the activation of epidermal growth factor receptor. a more specific dsb-inducer is cytolethal distending toxin (cdt), which is produced by a variety of gram-negative bacteria and harbours an intrinsic dnase-like endonuclease activity [ ] . dsbs are potent cytotoxic lesions and promote genomic instability, e.g. by formation of chromosomal aberrations. a cellular mechanism to prevent genomic instability and maintain cell homeostasis could be autophagy. this process is highly regulated involving the lysosomal degradation of damaged organelles and proteins. here, we study autophagy induction following dsb generation in human colorectal cancer cells as well as in primary human colonic epithelial cells (hcec) and analyzed regulatory mechanisms. first, the autophagy-specific marker lc b was shown to increase in a dose-and time-dependent manner after treatment with both cdt and ir as assessed by confocal immunofluorescence microscopy and western blot analysis in hct . similar results were obtained in sw and hcec cells via western blot. these findings are in agreement with the enhanced formation of autophagosomes and the dose-dependent decrease of the autophagy substrate p as observed by flow cytometry and western blot analysis in hct , sw and hcec. cdt-and irinduced autophagy rates in hct increased over time correlating well with the dsb induction. importantly, a dnasei-defective mutant of cdt did neither cause dsbs nor induce autophagy. additionally, the time-dependent accumulation of the lysosomal associated membrane protein (lamp- ) was observed by confocal immunofluorescence microscopy. dsb-induced autophagy was blocked by chemical inhibitors. next, we showed that both ir and, to a lesser degree, cdt induce the phosphorylation of akt at ser . pharmacological inhibition of akt in hct cells enhanced the cdt-and ir-induced autophagy shown by accumulation of lc b and lamp after h and increased autophagosome formation. upregulation of dsbinduced autophagy by akt inhibition resulted in a decreased cytotoxicity after h and significantly lower apoptosis/necrosis rates after h, which were determined by mts cell viability assay and annexin-v/pi staining. ongoing studies will evaluate the impact of other dna damage response pathways and the potential protective role of autophagy against genomic instability. mustard agents are potent dna alkylating agents. among them, the bi-functional agent sulfur mustard (sm) was used as a chemical warfare agent due to its vesicant properties. although the use of sm in warfare has been banned in most countries of the world, its use in terroristic attacks or asymmetrical conflicts, such as the syrian civil war, still represents a realistic and significant threat. on the other hand, especially nitrogen mustards, such as cyclophosphamide or melphalan, have been used as chemotherapeutic agents due to their cytostatic properties. thus, mustard-induced dna damage, in particular dna crosslinks, can trigger complex pathological states, as it is observed in sulfur mustard exposed victims, but on the other hand also lead to the chemotherapeutic effects of clinically-used nitrogen mustards. mass spectrometric monitoring and quantitation of mustard-induced dna adducts can help to unambiguously identify and verify sm-exposed victims and to monitor the efficiency, as well as potential side-effects of mustard-based chemotherapy. up to now, the verification of mustard-induced nucleic acid damage is mainly based on immunohistochemical methods, which have several drawbacks such as limited specificity, sensitivity, and low dynamic range of quantitation. with this project, we aim to develop a (hplc/uplc)-ms/ms-based platform for the quantitation of the most common mustard-induced dna adducts including bis(n -guanine-ethyl) sulfide dna crosslinks. up to date, we established methods for the quantitation of the several common dna adducts induced by the mono-functional sulfur-mustard derivative chloroethyl ethyl sulfide ("half mustard", cees). for that reason purification protocols, chromatographic conditions and mass spectrometric settings were developed to detect n -ethylthioethyl- ´desoxyguanosine (n -ete-dg) and n -ethylthioethyl- ´desoxyadenosine (n -ete-da) and their thermal hydrolysis products n ethylthioethyl-guanine (n -ete-gua) and n -ethylthioethyl-adenine (n -ete-ade), respectively, and the sensitivity was compared to immunohistochemical methods. additional non-radioactive isotope-labelled standards are being synthesized, which will be spiked into samples to account for technical variability during sample work-up and to improve ms-based quantitation. this procedure requires minimal cellular material and therefore should be transferred to quantitation of dna adducts in human blood samples. this will allow to monitor dna adducts as biomarkers of exposure in potential smexposed victims as well as in mustard-based chemotherapy. this method also sets a basis to investigate specific mustard-induced dna repair mechanisms and their cellular consequences. the γh ax assay vs. comet assay for genotoxicity testing universitätsmedizin mainz, institut für toxikologie, mainz, germany dna damage leads to activation of the cellular dna damage response (ddr). this signalling network results in activation of various dna repair proteins and chromatin structure modulators. a frequent manifestation of ddr is the phosphorylation of histone ax (gh ax), which can be visualised as gh ax foci by immunocytochemistry. in the present study, we tried to assess if gh ax is a reliable biomarker for detecting the cellular response to dna damage. we selected well-characterised genotoxic compounds and compared them with non-genotoxic chemicals in the wellcharacterised cho cell system. we measured quantitatively γh ax by manual and automatic scoring of γh ax foci, and by flow cytometry counting of γh ax positive cells. the cytotoxicity dose-response was determined by the mtt cell proliferation/viability assay. we show that a) all genotoxic agents were able to induce dose-dependently γh ax in the cytotoxic range whereas no induction was observed after treatment with non-genotoxicants; b) manual scoring of γh ax foci and automated scoring gave similar results, with the automated scoring being faster and more reproducible; c) data obtained by foci counting and facs analysis of γh ax positive cells showed a significant correlation. further we compared dna damage induced by selected genotoxins at the time-points using the alkaline and neutral comet assay. significant correlation with the alkaline and neutral comet assay was observed for some but not all genotoxins and, predominantly, at earlier time points. we suggest that comet assays detect mainly primary dna damage, whereas γh ax assay detects a specific response to dna damage which can persist longer. the γh ax foci and flow-cytometry assays allow for a rapid and reliable determination of genetic damage in mammalian cells and can be used as additional genotoxicity assays. available in vitro methods to investigate the genotoxic potential of drugs fall short of throughput, specificity and mode of action information. a set of mechanistic biomarkers for clastogenic, aneugenic or apoptotic effects may help to overcome these limitations. thus, a staining assay amenable to flow cytometric analysis is being developed by litron laboratories, rochester, ny, supported by international collaborators. the experimental design of this assay consists of stages. the objective of this work is the evaluation of this assay in the laboratories of bayer pharma ag. the biomarkers covered by the assay are associated with dna damage response pathways that have potential for class discrimination (clastogen/aneugen/cytotoxicant) of in vitro genotoxicants: dna double strand breaks (γh ax), nuclear division (phospho-h , dna content), apoptosis (cleaved parp). based on the pilot work at litron laboratories, tk cells were introduced to the genetic toxicology of bayer pharma ag. cells were exposed for and hrs in triplicates on a microwell plate to one reference clastogen (etoposide, eto), aneugen (vinblastine, vb) and cytotoxicant (carbonyl cyanide -chlorophenylhydrazone, cccp). after staining, the samples were analyzed with the flow cytometer bd accuri c (bd biosciences, heidelberg, germany). the reference substances yielded the responses expected from the pilot study at litron laboratories: vb showed distinct increases of phospho-h events at and hrs and polyploidy at hrs time point. eto induced a clear increase of yh ax with a simultaneous reduction of phospho-h at and hrs. finally, cccp caused a reduction of phospho-h events, increased cleaved parp events and did not influence γh ax. moreover, benchmarking experiments under pilot work conditions were performed with high content imaging analysis. we compared yh ax and phsopho-h pilot study results as well as cleaved parp with caspase / . in addition, the tunel assay (click-it ® tunel alexa fluor, thermofisher) was executed to benchmark cleaved parp. the benchmarking results support the selected biomarkers of the multiplexed assay. in stage , additional reference compounds (three aneugens/clastogens/cytotoxicants) were investigated. so far, the chosen biomarkers of dna damage response appear useful for class discrimination and provide additional information to existing genotoxicity tests. cell-cell contacts are involved in keeping a physiological balance between proliferation, differentiation and apoptosis. far less is known about the role of cell-cell-contacts in regulating necrosis, for instance in response to oxidative stress. previous findings of our group demonstrated that, in contrast to semi-confluent proliferating cultures, confluent murine fibroblasts (nih t , mef) and human keratinocytes (hacat) are protected against necrosis induced by tert-butyl hydroperoxide (t-booh). comparison of confluent cells (g /g = ~ %) and semi-confluent cultures, similarly arrested in the g /g phase by serum-starvation or the mek inhibitor u , ascertained that the resistance against t-booh is mediated by cell-cell contacts and not by cell cycle arrest. we further revealed that confluent cultures are protected against t-booh-induced dna double strand breaks as assessed by the neutral comet assay and against mitochondrial damage detected by flow cytometric analysis of dioc staining. to better understand the protective role of cell-cell-contacts in ros-mediated necrosis, we started characterizing the signaling cascade induced by t-booh in semi-confluent proliferating cultures. in accordance with the observed formation of dna double strand breaks in response to t-booh, we detected phosphorylation of the checkpoint kinase chk . however, inhibition of atm, the kinase responsible for chk activation, did not influence t-booh-induced cell death. interestingly, first experiments gave a hint for the participation of rip , since the chemical rip kinase inhibitor necrostatin- (nec- ) blocked cell death up to averagely %, what is described as a specific marker for regulated necrosis. in line with this observation, t-booh-induced cell death could not be blocked by the pan-caspase inhibitor z-vad-fmk strongly indicating that caspase activity is not required. moreover, parp- and p are probably not involved. deeper analyses could give evidence that nec- did not block formation of dna double strand breaks nor mitochondrial damage indicating that the kinase blocked by nec- , possibly rip , acts downstream of dna double strand breaks and / or mitochondrial damage. in the end, we could identify a crucial role of ca + signaling for t-booh-mediated toxicity. as the calcium chelator bapta-am was able to completely block not only cell death, but also mitochondrial damage and dna double-strand break formation, there is a strong need for further investigations of the possible interplay between regulated necrosis and calcium, regulated by cell-cell contacts among oxidative stress. the work was supported by the hoffmann-klose-stiftung, the promotionsförderung rheinland-pfalz, the johannes gutenberg-university and the university medical center of the johannes gutenberg-university. the mammalian target of rapamycin (mtor) forms two multiprotein complexes (mtorc and mtorc ) and influences cell growth, proliferation, survival and metabolism. constitutively activated mtor was found to be deregulated in several cancer types, which makes it an interesting target for therapeutic cancer strategies. rapamycin is able to inhibit mtor and its downstream targets and is currently studied for its anticancer properties in clinical trials. despite previous evidence, there are studies that show an adverse effect in cancer treatment causing tumour growth, evolving the question of the effectiveness of the drug in cancer treatment. therefore, we examined the transformational potential of rapamycin in a balb/c cell transformation assay (cta) as well as markers of proliferation and protein synthesis. the balb/c t cell transformation assay mimics different stages of in vivo carcinogenicity (initiation, promotion, post-promotion phase) and is a promising alternative to rodent bioassays. balb/c fibroblasts are treated for days with the tumour initiator mca ( -methylcholanthrene) followed by days with the promotor tpa ( -o-tetradecanoylphorbol- -acetate). upon treatment with these chemicals cells are transformed into morphologically aberrant foci and can be visualized after six weeks by giemsa staining. it is possible to apply additional substances during the whole assay or in several phases of transformation and evaluate the colony formation. furthermore, our improved protocol allows additional westernblot or immunofluorescence analysis. the influence on cell proliferation of different concentrations of rapamycin was investigated by cell counting (living and dead) to choose a suitable concentration for the cta. performances of balb/c ctas with nm rapamycin showed, contrary to expectations, an increase in cell transformation. by administration of rapamycin only in the promotion phase we could detect an increase in colony formation, whereas a treatment with rapamycin in the post-promotion phase with already established foci, seemed to reveal its therapeutic properties. to better understand the role of mtor in our cell transformation system we used another mtor inhibitor called osi- . surprisingly, an incubation with µm osi- led to a decrease in colony formation. we are now able to investigate the underlying mechanism with westernblot and immunofluorescence analysis and can compare regulations of downstream targets like the marker of protein synthesis p-s . our investigations revealed different cell transformation outcomes by comparing the two known mtor inhibitors rapamycin and osi- , which need to be further evaluated. in the ongoing project we want to detect differences between rapamycin and osi- by protein analysis and identify key proteins, which are involved in this opposed colony formation of the balb/c cells. these results can be helpful to better understand mtor inhibition in matters of tumour therapy. introduction: over the past years, the biguanide compound metformin has been widely prescribed as an insulin sensitizer in type diabetes mellitus. interestingly, recent meta-analyses of epidemiological studies have shown that metformin might be involved in risk reduction of carcinogenesis. in vitro studies have described amp-activated protein kinase (ampk)-dependent, by inhibition of the respiratory chain complex i, as well as ampk-independent actions of metformin. however, the detailed molecular mechanisms by which metformin affects cell proliferation and carcinogenesis have not been well identified up until now. method: to evaluate the protective potential of metformin, balb/c t cell transformation assays were performed. this valid toxicological method is an alternative to in vivo carcinogenic testing and mimics the different stages of cell transformation during carcinogenesis. in detail, mouse fibroblasts are treated with metformin and/or the tumour initiator -methylcholanthrene (mca) and the tumour promotor -otetradecanoylphorbol- -acetate (tpa). in the first experiment several metformin concentrations ( . - mm metformin) were applied answering the question of an effective metformin concentration. next, metformin treatment during the different phases of carcinogenesis (initiation, promotion, post-promotion phase) was done determining the most effective phase for an intervention, i.e. chemopreventive or chemotherapeutical properties of metformin. additionally, the effect of metformin on the energy metabolism of the cells was analysed using various methods like immunoblot and oxygen measurement by clark electrode. results/discussion: analysis of different metformin concentrations revealed a concentration-dependent effect of metformin. in detail, decreased colony forming potential of balb/c cells was most prominent using mm metformin. this effect was not caused by growth inhibition of metformin itself since mm metformin showed no growth inhibitory properties in a cellular growth pretrial. interestingly, the phase cell transformation assay showed that the metformin effect is more pronounce in the postpromotion phase than in the initiation and promotion phase pointing to a chemotherapeutical potential. investigating several energy metabolism parameters, the results indicate that metformin may affect cell respiration as well as energy-dependent mechanistic markers like ampk. the presented results support rather the idea of the chemotherapeutic potential of metformin than a chemopreventive, using mm metformin. the initial analysis of energy metabolism markers discovered interesting starting points for further investigations. johannes gutenberg university, institute of toxicology, mainz, germany nvp, widely used e. g. as a monomer for polyvinylpyrrolidones (pvp) with applications in food technology or cosmetics is a known hepatocarcinogen in rats after inhalative exposure to , , and ppm for years. nvp is tested in a battery of genotoxicity assays (e.g. ames, hprt, mouse lymphoma, uds, chromosome aberration, cell transformation, micronucleus test (mnt) in mice bone marrow) [ ]) that all yielded negative results. however, nvp induces cell proliferation in liver (loaec: . ppm) after whole body exposure to vapor [ ] . to confirm the absence of genotoxicity in the context of a potentially non-genotoxic mode of action, a five day whole body inhalation study to nvp vapor with concentrations of , , , ppm was conducted in wistar rats (six animals per gender and group, ethyl methanesulfonate mg/kg bw p.o. as positive control). genotoxicity was investigated by the mnt in bone marrow and the comet assay (± fpg) in liver and lung. further investigated endpoints related to possible non-hepatogenotoxic moa were: enzyme induction (erod, prod, brod), oxidative stress (gsh-, gssg-, non-protein sulfhydryl group level), and peroxisome proliferation (cyp a, cyanide-insensitive palmitoyl-coa-oxidase). at carcinogenic inhalative doses, the results of this study proved the absence of genotoxicity in lung, liver and bone marrow as neither the tail intensity in the comet assay nor the number of micronuclei in the mnt was increased compared to the controls. however, also the non-genotoxic parameters (cyp-enzyme activity, glutathione levels, cyanide-insensitive-palmitoyl-coa-oxidase) were not affected by nvp-treatment. as potential metabolic activation cannot be excluded and may essentially contribute to the understanding of the carcinogenic mechanism, in vitro investigations in rat liver systems (subcellular fractions, hepatocytes, precision cut liver slices (pcls)) were performed additionally. up to now, -pyrrolidone is the only identified in vitro metabolite. as these results cannot mimic the in vivo situation of two described, ring-and vinylmajority containing unidentified metabolites [ ] detailed investigations on metabolism may be a future perspective to approach the overall understanding of the carcinogenic mechanism of nvp. introduction: in ischemic conditions such as wound healing and myocardial infarction, new vessels are generated by vasculogenesis and angiogenesis. these processes are stimulated by the signalling peptide vascular endothelial growth factor which therefore has been proposed as a promising compound for the treatment of ischemic conditions. however, results of respective clinical studies have not been fully convincing yet. here, we investigated principles underlying the selforganization of newly formed vessels to functionally adequate microvascular networks indispensable for proper tissue substrate supply. intravital microscopy of the chick chorioallantoic membrane (cam), a non animal model as defined by the american national institutes of health's office for protection from research risks, was used to study peripheral expansion of existing arteriolar and venular trees by recruiting segments of the dense polygonal capillary mesh. this process we call "emerging angiogenesis". methods: white leghorn chicken eggs were put into incubators on embryonic day (e ) at . °c and % humidity. on e , the eggs were cracked open and transferred into petri dishes. on e , cam microcirculation was recorded using time-lapse intravital videomicroscopy at discrete time points for up to hours. to improve the visibility of the capillary mesh, videorecordings were processed offline by generating coefficient of variation images of pixel grey values over time. changes of network topology during the observation time were investigated. results: in the cam, a sequence of specific events leading to extension of existing vessel trees was observed: in a capillary mesh region near terminal branches of existing vessel trees, homogeneous flow distribution is transferred to inhomogeneous flow distribution: preferred flow pathways through the mesh evolve carrying most of the blood. over time, these flow pathways exhibit diameter increase, straighten and connect the mesh to arteriolar and venular trees. in contrast, less perfused parallel mesh flow pathways and transversal mesh segments exhibit progressive decrease of flow and diameter resulting in vessel regression. as a result, hierarchical vessel tree structures are extended into the mesh region. while newly generated tree extensions are located above the mesh at the beginning, they sink to a lower level at later stages until they are finally covered by a reconstituted mesh network. the cam ex ovo model is well suited for studying emerging angiogenesis. vessel tree extension occurs via parallel processes of vessel maturation and capillary mesh segment regression. at later stages, newly formed vessel tree branches sink and the capillary mesh is reconstituted above. in the next step of our project, we will implement these phenomena in a computer simulation and use theoretical modeling to further investigate and better understand principles underlying microvascular network maturation. this will allow us to derive effective therapeutic strategies which could be tested in the cam model. chemicals are able to induce cancer in a wide range of organs. therefore, it is very important to investigate the toxic properties of chemical substances, especially their carcinogenic potential. in this context the number of animal experiments will drastically increase in the future. in order to avoid the use of expensive and time consuming animal experiments for long-term carcinogenic studies, the development of an in vitro system to test the carcinogenic potential of a high number of chemicals in a highly reproducible manner within a short period of time is imperative. by combination of the well-established balb/c cell transformation method with the soft agar colony formation assay, we developed a high-throughput in vitro system to identify effects of chemicals on cell transformation for the first time. balb/c mouse fibroblasts are treated with -methylcholanthrene as a tumour initiator and -o-tetradecanoylphorbol- -acetate as promotor for several days, whereby foci of transformed cells are developed. after the promotion phase of the common balb/c cell transformation assay, cells are transferred into soft agar to further monitor the anchorage independent growth of transformed cells only. the established soft agar transformation assay reproduces the foci growth of previous experiments and is performed in -well plate format. hence, we can analyse the carcinogenic potential of several chemical substances in parallel and are also searching for alternative endpoint analysis, e.g. the usage of fluorescing cells stably expressing irfp, instead of the former time-consuming microscopic assessment. the here presented new technique is a high-throughput and low priced alternative for the evaluation of the carcinogenic potential of chemical substances in a short period of time without animal testing. the effort to develop new or refine established in vitro test systems rises due to animal welfare, scientific and/or regulatory reasons (e.g. the animal testing ban concerning the risk assessment of cosmetic product ingredients in march ). this progress, among others, leads to an increased performance of cell-based assays. the majority of model cell lines are routinely cultured using medium supplemented with fetal bovine serum (fbs) in amounts between - %. the application of serum-substitutes will provide a reduction of the animal number needed, which corresponds to the guiding principles of the three r's ( r), described by russel and burch in . in addition, chemically defined serum-substitutes have the potential to reduce the inter-experimental variability of test conditions caused by the inherent differences in chemical composition across fbs batches , resulting in a refinement of in vitro testing. in this study, human tk cells were gradually adapted to serum-free conditions, where they show comparable growth gradients at the exponential phase. for cells under serum-free conditions a mean doubling time of . (± . ) h was observed while fbs supplemented cells showed a doubling time of . (± . ) several non-animal test methods addressing key events in the sensitization process have passed formal validation and oecd (draft) test guidelines are available. one of these methods is the direct peptide reactivity assay (dpra) assessing the ability of a chemical to bind to proteins to form a complete antigen (oecd tg c). the test is used to obtain a yes/no answer on whether the substance has a protein-binding potential. for a complete risk assessment, however, an estimation of a chemical's potency is also needed. in this study we examined if an assessment of potency could be achieved by ) determining reactivity class cut offs based on published data on substances for the dpra performed according to oecd c to predict un ghs sensitizer classes, ) a variant of the dpra assessing reaction kinetics (time and concentration) for substances or ) an extended protocol testing several test substance concentrations for reference substances and estimating the concentration of a test substance that is needed to cause a peptide depletion of . % (ec . %). results of the first approach indicated that cut offs to differentiate the un ghs sensitizer classes a and b could indeed be defined. secondly, evaluating the reaction time based assay in which several time points between min and hours were assessed, it was found that not all reactions followed ideal kinetics. hence further investigations are needed to eventually derive a reaction time based prediction model. the results of the rd approach (the standard protocol of the dpra was amended by testing three concentrations i.e. , , and mm) indicated that potency classes could be assigned using the ec . % value to assess potency. in summary, using quantitative information derived from the dpra in particular using ec . % value may support the assessment of the skin sensitizing potency. identification of pre-and pro-haptens with non-animal test methods for skin sensitization since pro-haptens may be metabolically activated in the skin, information on xenobiotic metabolizing enzyme (xme) activities in cell lines used for testing of sensitization in vitro is of special interest. metabolic activity of e.g. n-acetyltransferase (nat ) and esterase in the keratinocyte (keratinosens tm and lusens) and dendritic cell-like cells (u and thp- ) was previously demonstrated. aldehyde dehydrogenase (aldh) activities were found in keratinosens tm and lusens cells. activities of the investigated cytochrome p -dependent alkylresorufin o-dealkylases, flavin-containing monooxygenase, alcohol dehydrogenase as well as udp glucuronosyl transferase activities were below detection in all investigated cell lines. a set of putative pre-and pro-haptens (no obvious structural alert for peptide reactivity but positive in vivo) was routinely tested using the above mentioned cell lines as well as in the direct peptide reactivity assay (dpra). of the compounds were unexpectedly positive in the dpra und further analyzed by lc/ms techniques to clarify the reaction mechanism leading to true positive results in this assay. oxidation products like dipeptide formations or the oxidation of the peptide-based sulfhydryl group led to positive results for benzo[a]pyren or -amino- -methylphenol, respectively. in contrast, covalent peptide adducts were identified for putative pre-haptens, indicating the dpra to be suitable for compounds requiring abiotic oxidation to get activated. for some dpra negatives, the keratinocyte and dendritic cell based assays provided true positive results. a combination of dpra, keratinosens tm and h-clat within a ' out of ' prediction model provided a high sensitivity of % for the set of the pre-/pro-haptens. the sensitivity of this combination of non-animal test methods in the ' out of ' prediction model in a set of direct haptens was comparable (sensitivity = % when compared to llna skin sensitization testing is mandatory for all substances produced or marketed in volumes larger than tonne per year under the european reach legislation. with reach supporting in vivo testing only "as a last resort" and the marketing ban for finished cosmetic products with ingredients tested in animals, attention has been given to developing integrated testing strategies combining in vitro, in silico and in chemico methods. key challenges are which tests to select and how to combine non-animal methods into testing strategies. this study suggests a bayesian value of information (voi) approach for developing non-animal testing strategies, which consider information gains from testing, but also expected payoffs from adopting regulatory decisions on the use of a substance, and testing costs. the 'value' of testing is defined as the expected social net benefit from decision-making on the use of chemicals with additional, but uncertain information from testing. the voi is calculated for a set of individual nonanimal methods including dpra, oecd qsar toolbox, are-nrf luciferase method covered by keratinosens and lusens, and hclat, seven battery combinations of these methods, and two-test and three-tests sequential strategies consisting of nonanimal methods. their voi is compared to the voi of the local lymph node assay (llna) as the animal test. we find that battery and sequential combinations of nonanimal methods reveal a higher voi than the llna. in particular, for small prior beliefs (i.e. a chemicals is, prior to testing, assumed to be a non-sensitiser), a battery of dpra + lusens reveals the highest voi. if there are strong beliefs that a chemical is a sensitizer, a sequential combination of the battery dpra + lusens, followed by keratinosens + hclat at the second stage and by the oecd qsar toolbox at the third stage performs best. for given specifications of expected payoffs the voi of the nonanimal strategy significantly outperformed the voi of the llna, for the entire range of prior beliefs. this underlines strong economic potential of non-animal methods for skin sensitization assessment. a chemical series to predict the proarrhythmic potential of drugs with low solubility for which no reliable purkinje fiber results could be obtained. these validation results showed that this cardiosafety in silico model can successfully be applied in r&d to predict the proarrhythmic potential of drug candidates within the model ad. introduction: the use of p-phenylenediamine (ppd) and derivatives (tab. ) in oxidative consumer hair dye products is considered as key in hair dye allergic contact dermatitis [ ] [ ] [ ] [ ] . in recent supplement, -methoxymethyl-ppd (me+) shows significantly reduced sensitizing properties [ , ] . since overcoming the skin barrier is a prerequisite for sensitization, numerous in vitro an in vivo studies on skin penetration of ppd and derivatives have been performed. the aim of the present study is the in silico prediction of the penetration of ppds, because such computations may help in understanding the processes involved in sensitization. for the first time, software dskin [ ] is challenged to simulate this class of compounds. in silico results are retrospectively compared to previously published experimental data and may assist in future tailoring of in vitro experiments. material and methods: the permeabilities, lag-times and the time-dependent accumulated amounts of ppds were computed using dskin. input parameters for the latter were a concentration of mg/ml ( %), finite dosing and min in use incubation periods. molecular structures were optimized ab initio and the condensed fukui functions (ff) were estimated from mulliken population analyses [ ] and electrostatic potentials using gamess [ ] . results: initial results agree with experimental results using ppd in white petrolatum, demonstrating the applicability of dskin to ppds. the four ppds exhibit only small differences in permeabilities in silico (tab. ). toluene- , -diamine shows a higher accumulated mass due to increased lipophilicity (fig. ) . in general, the ff were very similar for all ppds and indicated that the n atoms would be the preferred targets for radical and electrophilic attack. discussion and outlook: in silico methods may be used to model the permeation of ppds despite their low molecular weight and low lipophilicity. the low amounts of ppds under in use conditions result from oxidative conditions. computed me+ permeation was not different to other ppds, therefore other properties account for the reduced sensitization potential. the very similar ff values hint at similar reaction pathways. furthermore, ppd and its derivatives are prone to n-acetylation in living skin resulting in metabolites exhibiting higher molecular weight and greater lipophilicity than the parent compounds. the effects of n-acetylation and reactions of ppd and its derivatives with histidine and cysteine residues are subject of upcoming computations. dermal absorption is an important factor in regulatory science regarding the registration of chemicals, agrochemicals and cosmetics. the issue has gained importance since it has been realized that the skin is not completely impenetrable for chemical substances. [ ] the different ways to assess dermal absorption range from qsar models to complex in vivo studies including a complete toxicokinetic examination. the choice of method depends on the question that has to be answered as different systems give different results: absorption as % of applied dose in in vivo studies or permeability coefficient and lag time in infinite dose in vitro studies [ ] . ideally both data would be available. since the oecd has adopted a guideline for assessing dermal penetration in vitro in the number of in vitro studies is rising continuously. depending on the chosen method results may vary in reliability and in acceptance by regulatory authorities. the skinab database [ba ] contains data for about substances on dermal absorption which has been found through the echemportal [ ] and extended with data from the edetox database. for selected substances with a broad spectrum of data available further analysis has now been started. chemicals have been investigated in a comparable test system; from these were shown to have a low dermal absorption of less than % and compounds showed a high absorption rate of more than %. for the assessment of dermal exposure either the absorbed dose in percent or the flux can be measured. data analysis showed that only for substances both is available: flux data from in vitro studies and absorption data from in vivo studies. this data could be used to clarify which parameter would be most useful for exposure assessment regarding dermal exposure. seven substances in the dataset were conspicuous for their range of absorption rates in different studies: less than % to more than %. an in depth analysis revealed the complex influence that different exposure parameters have on the results of dermal absorption studies. for some chemicals the influence of exposure time on increasing absorption values could be clearly demonstrated. beside other factors such as the chosen vehicle, and the (non-)occlusion of the site of exposure especially the choice species introduced a high variability; this holds even for the most common laboratory animals t. a review published by jung in [ ] which comes to the conclusion that i.e. hairless species are usually not a good model to predict dermal absorption in humans. [ ]who ( ) ehc dermal absorption [ ] scholz et al ( ) naunyn-schmiedeberg´s arch pharmacol (suppl ):s [ ] www.echemportal.org [ ] http://edetox.ncl.ac.uk [ ] jung et al ( ) in-silico methods have evolved to indispensable tools in various areas of life sciences. several stages in drug development including hit identification and lead optimization, for instance, highly benefit from an accurate estimation of binding free energies associated with biological host-guest systems. as a consequence, the need for laboratory experiments including in-vivo experiments and animal testing is considerably reduced. another field profiting from free energy calculations is human as well as ecotoxicology. upon the development and risk assessment of new chemicals, transformation products arising from biotic or abiotic degradation of the parent substance have usually been neglected. however, since few years, the risk assessment of new chemicals often includes transformation products probably causing more harm than the parent substance itself. such studies as well are mostly carried out on the basis of in-vitro and in-vivo tests. moreover, many metabolites can be detected but neither enriched nor synthesized in amount sufficient for toxicological evaluations. at this stage, computational methods come into play. using classical molecular dynamics simulations in combination with an empirical linear prediction model, we have investigated several metabolites of the drugs sulfamethoxazole and carbamazepine and prioritized them according to their estimated binding affinities to potential biological target proteins. consequently, a couple of metabolites were identified that bind to one or more human cytochrome p variants and the bacterial enzyme dihydropteroate synthase, respectively, which are known to be sensitive to the two drugs. the investigations were carried out in the framework of the bb r poject funded by the german government through bmbf. instituto superiore di sanità, environment and primary prevention dept., rome, italien introduction: in vitro methods have been increasingly used to characterize pharmacological and toxicological properties of substances. to address the problem of nominal versus actual concentrations, in vitro biokinetic studies were recently undertaken (truisi et al., toxicol lett : - , ) . we use those data as input into a physiologically based human kinetic model (pbhkm) to model the in vivo doses leading to the in vitro measured concentrations. methods: a pbhkm was used to simulate the concentration time profile of ibuprofen in the hepatic vein after oral administration. the details of the model and the physiological parameters used have been described elsewhere (abraham et al., arch. toxicology : - , ) . we modelled the concentration time profile exploring the dose which would lead to a concentration at hour and at hour as similar as possible to the concentration measured in the supernatant of human freshly prepared cell cultures after dosing the culture with ibuprofen. we parametrized the pbhkm with the parameters which have been estimated from the in vitro kinetic studies (clearance between and µm /sec (truisi et al., ) and an absorption of % and an absorption rate of /h (cristofoletti and dressman, j pharm sci : - , ). results: the data of the in vitro study with µm ibuprofen could well be modelled. when assuming a clearance of µm /sec the dose of mg resulted in an hour concentration of . µm in the hepatic vein of pbhkm equal to . nmol/well (volume of the well = ml) in the in vitro study in which the measured concentration was . nmol/well. the concentration at hours of . µm (equal to . nmol/well) corresponded with the in vitro concentration ( . nmol/well). the modelling approach was less successful with in vitro dosing of µm. the fold higher dose of mg lead to nearly double the concentration at hour than measured in vitro. with a dose of mg/kg an approximation was feasible resulting in . µm in the hepatic vein at hour which is equal to . nmol/well whereas the measured concentration in vitro was . nmol/well. even with a clearance value as low as the . percentile ( µm /sec), the concentration at hours was modelled to be lower than the in vitro measured value (in vivo model: . µm which corresponds to . nmol/well; measured in vitro concentration: . nmol/well). discussion: this is the first attempt to use kinetic data obtained in vitro to feed in in a pbhkm for reverse dosimetry finding the dose which corresponds in vivo to the in vitro situation. in the case presented here, the in vitro dose assumed to be low in vitro ( µm) corresponds to a dose of mg (note: the highest approved daily dose is , mg). for the high in vitro dose modelling was successful only for the concentration hour after dosing and a dose of , mg. conclusions: in vitro kinetic parameters, such as clearance, can successfully be used for parametrizing a pbhkm. it is of utmost importance for the relevance of in vitro finding to assure that the concentrations used in vitro can be obtained with relevant in vivo doses. in this case, the in vitro concentrations were within (low dose) and . fold above (high dose) the in vivo relevant therapeutic concentration range. introduction: a variety of drug residues have been detected in sewage plant run-offs, rivers and lakes, but also in groundwater and tap water samples. studies have yet to identify a risk for human health from these contaminants, but adverse health effects have been reported for various species, including fish and birds. it has recently been suggested that for a comprehensive risk assessment toxicologists should also consider transformation products (tps) of such water contaminants that may arise from abiotic and biotic (metabolic) reactions. with aciclovir (acv), a well-known antiviral drug, as the parent drug we tried an in-silico approach to identify tps that might be of interest due to some mutagenic or carcinogenic toxicophores. methods: from a literature and database search we picked up acv-tps. predicted acute toxicities and mutagenic / carcinogenic properties for these tps were derived from an expert system analysis using the lazar portal (http://lazar.in-silico.ch/) as front end. results: two of the identified acv-tps could not be handled by lazar because of insufficient training data in one out of eight queried categories. the highest score ( positive out of possible genotoxicity categories) was assigned to of the tps, including acv itself. this is a rather low score when compared to other water-borne drug residues, e.g. carbamazepine. cofa, an imidazole derivative of acv seen in advanced oxidation processes, had shown antiproliferative effects in several ecotoxicologic screening assays, e.g. [ ], but was unremarkable in our tests. additionally, a computer-based simulation of the respective tps interacting with human cyp isozymes did not support concerns that these tps may pose a risk for human health. conclusions: our in-silico analyses of acv-tps did not provide evidence for any adverse health effects in the micromolar concentration range. further studies are needed to clarify if the biological activity of some acv-tps in ecotoxicological assays may eventually affect yet unidentified biological targets in the human body. sulfur mustard (sm) is a chemical warfare agent which was first used in world war i, but has found use in several conflicts afterwards. although sm is prohibited by geneva protocol, terroristic attacks cannot be ruled out. latest news give rise to concern that is may be in the possession of sm and is willing to deploy it. even years after the initial synthesis of sm its mode of action is not fully unraveled. thus, no antidote does exist. however, chemosensing ion channels have been shown to be activated by highly toxic chemicals and might represent a specific therapeutic target. previous studies have shown that the sm-surrogate cees (mono-functional alkylating agent) is able to activate transient receptor potential ankyrin (trpa ) channels that are known to affect mapk cell signaling. mapk-pathways, especially perk / , are known to increase protein biosynthesis through activation of transcription factors binding to the serum response element (sre). it is unknown whether alkylating agents have also impact on mapk signaling mediated through trpa activation. our results demonstrate that aitc resulted in phosphorylation of the mapk perk / and increased protein biosynthesis of sre-regulated genes in hek cells overexpressing htrpa . cees increased perk / levels already after . min which could be prevented by the trpa blocker ap . activation of target genes through perk / signaling was also evident, but less pronounced compared to aitc. our results demonstrate that alkylating agents have impact on cell signaling through trpa channel activation. thus, trpa might represent a promising target for counteracting sm toxicity. sulfur mustard (sm) is a chemical warfare agent that provokes severe inflammation and blistering upon exposure to the skin accompanied by disturbed wound healing. the potential use of sm in terroristic assaults amplified the interest in understanding the underlying cellular and molecular pathomechanisms in order to improve therapeutical intervention. autophagy is a highly conserved catabolic pathway in eukaryotes that ensures the degradation and recycling of cellular components through the lysosomal machinery. autophagy is important for cell survival in physiological and pathological stress situations. emerging knowledge indicates that imbalanced regulation of autophagy disturbs basal cell functions including proliferation, differentiation and migration, thus contributing to the pathophysiology of various diseases. after penetration into skin cells, sm alkylates and thereby modifies nucleic acids and proteins thus forming aggregates of dysfunctional proteins destined for autophagic disposal. in our studies, we analyzed the influence of sm on protein expression (western blotting) of autophagy-related (atg) genes as well as proliferation (wst- ) of primary normal human keratinocytes (nhek) and primary normal human dermal fibroblasts (nhdf). preliminary results demonstrate that sm strongly dysregulates the biosynthesis of atg proteins that may contribute to the diminished cell migration and proliferation under these conditions. our findings suggest that sm affects autophagy in correlation with an impairment of physiological functions in keratinocytes and fibroblasts that are essentially required for normal tissue regeneration. thus, application of pharmacological modulators of autophagy might be useful in the treatment of the delayed wound healing in skin upon exposure to sm. exposure of the respiratory tract to airborne particles is a major risk to human health. due to the ubiquitous application of these particles in the field of pharmacy, industry and in daily life, there is a strong necessity to investigate the toxic properties and the underlying pathomechanisms of these inhalable substances. in addition, the eu chemicals regulation requires not only that all substances placed on the market have to undergo a toxicological characterization, including the identification of potential toxic inhalation hazards (reach), but also that animal testing shall be undertaken only as a last resort (" rs" principle) and the promotion of the development of alternative methods. thus, the development, establishment and validation of alternative in vitrobased test systems for the assessment of pulmonary toxicity are in the focus of current research. until now, most of the available in vitro cell culture models are limited to some extent as in those studies the exposure is either done under submerged conditions, not resembling the exposure conditions in vivo, or a homogeneous particle distribution is not guaranteed. the cultex ® radial flow system (rfs) is a specially designed in vitro modular exposure system that overcomes these limitations. it enables the homogenous exposure of human lung epithelial cells at the air-liquid interface (ali), thereby mimicking the physiological conditions of the alveolae. however, further optimizations are needed for the enhancement of the cultex® methodology. aim of this study was first the optimization of the test methodology in general (i.e. focus on clean air controls of the human lung epithelial cell line a ), and second the improvement of cultivation conditions. parameters such as handling of the cultex® device (proper closing and opening operation of the cultex® rfs module; improved washing conditions and media supply), treatment of the incubator controls, adjustment of clean air pressure and flow rates, and integration of two additional filters were sequentially adjusted in order to enhance the methodical setup. our results show that the test parameters for clean air exposure of the a cells were successfully optimized resulting in more accurate and robust data. cultivation conditions were improved by changing from closed-wall cell culture inserts to open-wall cell culture inserts. the openwall inserts turned out to be more suitable for exposure experiments as they provided a better medium supply and preserved humidity. deductive, the change of the cell culture inserts was identified as the deciding factor for the improvement of cell morphology. hence, we have successfully optimized the cultex ® rfs methodology for clean air exposure of a cells. human primary hepatocytes represent the gold standard in in vitro liver research. due to their low availability and high costs, alternative liver cell models with comparable morphological and biochemical characteristics have come into focus. the human hepatocarcinoma cell line hepg is often used as a model for liver toxicity studies. however, under two-dimensional ( d) cultivation conditions the expression of xenobiotic-metabolizing enzymes and typical liver markers is very low. cultivation for days in a three-dimensional ( d) matrigel culture system has been reported to strongly increase the metabolic competency of hepg cells. in our present study we extended previous studies and compared hepg cell cultivation in three different d culture systems: collagen, matrigel and alvetex culture system. cell morphology, albumin secretion, cytochrome p monooxygenase (cyp) enzyme activities, as well as expression of xenobiotic-metabolizing and liver-specific enzymes were analyzed after , , , and days of cultivation. our results show that the previously reported increase of metabolic competency of hepg cells is not primarily the result of d culture but a consequence of the duration of cultivation. hepg cells grown for days in d monolayer exhibit comparable biochemical characteristics, cyp activities and gene expression patterns as all d culture systems used in our study. however, cyp activities did not reach the level of heparg cells. in conclusion, the increase of metabolic competence of the hepatocarcinoma cell line hepg is not due to d cultivation but rather a result of prolonged cultivation time. in vitro assessment of the neurotoxic potential of arsenolipids arsenolipids are organic, lipid-soluble arsenic compounds, which occur mainly in marine organisms. major human exposure routes are fatty fish including herring or fish oil-based food supplements. about different arsenolipids have been identified so far. thereby, arsenic-containing hydrocarbons (ashc) and arsenic-containing fatty acids (asfa) represent two subgroups of the arsenolipids [ ]. our in vitro studies have demonstrated high cellular bioavailability and a high cytotoxic potential of ashcs in human liver and bladder cells [ ] , whereas asfas were less toxic [ ] . a substantial transfer across an intestinal barrier model (caco- ) indicated that ashcs are highly intestinal available. in comparison, asfas showed lower intestinal bioavailability and underwent a presystemic metabolism [ ] . moreover, in drosophila melanogaster ashcs exerted late developmental toxicity and accumulated in the fruit fly's brain. these results suggest that ashcs might pass the blood-brain-barrier due to their amphiphilic structure [ ] . in order to assess the neurotoxic potential we currently investigate the toxicity of several arsenolipids in differentiated, human neurons (luhmes). after h incubation with ashcs or asfas, cell number (hoechst) as well as cellular dehydrogenase activity (resazurin) were measured, with the latter endpoint turning out to be more sensitive. ashcs showed substantial cytotoxic effects (ic ~ - . µm) in a concentration range comparable to that of arsenite (ic ~ . µm), whereas asfas were less cytotoxic (ic > µm). after incubation with ashcs the cellular arsenic concentrations increased - fold as compared to incubation with arsenite. further studies indicated that one possible toxic mode of action of arsenolipids could be a disruption of the cellular energy level. therefore, the mitochondrial membrane potential was investigated after incubation with the arsenic compounds in differentiated neurons. whereas arsenite did not exert an impact, ashcs reduced the mitochondrial membrane potential significantly. this might be due to interactions of the amphiphilic ashcs with mitochondrial membranes. currently we investigate the impact of the arsenolipids on neurite outgrowth as a developmental toxicity endpoint. standard treatment of poisoning by organophosphorus compounds (op; e.g. nerve agents and pesticides) consists of co-administration of atropine and an oxime-based reactivator of inhibited cholinesterases. due to lack of efficacy of clinically used oximes against various op-inhibited human acetylcholinesterase (ache) (e.g. soman) research started focusing on new therapeutic approaches. several research groups conducted in silico screenings [ , ] in order to identify new non-oxime reactivators, presenting amodiaquine as a promising candidate for paraoxon-inhibited hache. for decades, antimalarial drugs like amodiaquine and chloroquine have been closely investigated regarding their side effects, thereby discovering interaction with cholinesterases, which could pose a new potential therapeutic benefit for inhibited cholinesterases. therefore, in this study interactions between antimalarial agents in presence or absence of ops were examined spectrophotometrically by a modified ellman assay. reversible inhibition of cholinesterases was observed with both antimalarial agents. amodiaquine had higher inhibitory potency for hache than human butyrylcholinesterase (bche), being confirmed by ic values of . ± . µm for hache and . ± . µm for hbche. ic values with chloroquine were . ± . µm for hache and . ± . µm for hbche, thus representing a weaker inhibition of hache than amodiaquine. furthermore, reactivation of paraoxon-(pxe), sarin-(gb), cyclosarin-(gf), and vxinhibited hache and hbche by amodiaquine and chloroquine was determined. after minutes, only paraoxon-inhibited hache ( %) and cyclosarin-inhibited hbche ( %) were reactivated by µm chloroquine. on the contrary, µm amodiaquine reactivated all tested ops after minutes in the following order: pxe > vx > gf > gb. in contrast, with hbche the highest reactivation was generated with µm amodiaquine in the following order: vx > gb > gf > pxe. due to the high reversible inhibitory potency of amodiaquine, an increased concentration does not result in a higher reactivation of op-inhibited hache. in summary, our results show that amodiaquine is a reactivator of op-inhibited cholinesterases. in the future, non-oxime reactivators that are structurally-related to amodiaquine should be further investigated. [ ] bhattacharjee, a.k., marek, e., le, h.t., gordon, r.k., eur. j. med. chem., , , - . [ ] katz, f.s., pecic, s., tran, t.h., trakht, i., schneider, l., zhu, z., ton-that, l., luzac, m., zlatanic, v., damera, s., macdonald, j., landry, d.w., tong, l., stojanovic, m.n., chembiochem., , , - bundesinstitut für risikobewertung, lebensmittelsicherheit, berlin, germany development of mammary gland tumors is connected to a deregulation of breast epithelial cell differentiation, a complex process which cannot be reproduced in vitro under standard cell culture conditions. however, cultivation of cells in a tissue-like environment in an in vitro three dimensional ( d) model can mimic general architecture, function and differentiation of mammary bulks. in this project, a d model was used consisting of the permanent breast epithelial cell lines mcf a (er -, estrogen receptor negative) and mcf a (er + , estrogen receptor negative) grown in matrigel tm , which mimics the complex extracellular matrix in vivo. the d culture of mcf a and mcf a cells in matrigel tm results in the formation of growth-arrested, polarized spheroids with a lumen (acini-like organoids). in order to perform a semi-quantitative estimation on the influence of substances on the differentiation of the breast cells for the identification of non-genotoxic carcinogens a scoring method was developed. this scoring method provides information about substance-induced morphological changes of the spheroids during differentiation based on the following parameters: size of the spheroids, the formation of the lumen, and the degree of polarization. furthermore, the model allows distinguishing between erdependent (mcf a) and er-independent (mcf a and mcf a) effects. the d in vitro model is a useful tool for toxicologists to study substance effects on differentiation processes. the system will be used to examine the potential of e.g. food contaminants such as phthalates or perfluorinated substances (pfas) to disrupt the differentiation process of breast epithelial cells and will therefore serve as a valuable in vitro tool to assess their carcinogenic potential. inflammatory episodes occur erratically throughout life and are likely to play a critical role in the alteration of the individual susceptibility of a person to idiosyncratic druginduced liver injury (idili), a particular severe form of drug-induced liver injury (dili). in concordance with the inflammatory stress hypothesis, modest inflammatory stress can lower the threshold for hepatotoxicity and make an individual susceptible to develop liver injury during exposure to therapeutic doses of a drug. in order to evaluate the role of immune cells and its secreted factors during drug therapy, we established an in vitro test battery consisting of two cell culture systems in presence or absence of proinflammatory factors (lps, tnfα): (a) the monoculture of human hepatoma (hepg ) cells and (b) co-culture systems of human monocytic or macrophage-like (thp- ) and hepg cells. with these different test settings we aimed to identify whether the introduction of inflammatory immune cells and/or pro-inflammatory factors could increase the sensitivity of liver cells towards idili compounds. three reference substance pairs were tested, namely troglitazone -rosiglitazone, trovafloxacin -levofloxacin, and diclofenac -acetylsalicylic acid, each of them being composed of a compound that is known to induce idili and a partner compound of the same substance class that does not induce idili. first, all compounds were tested for cytotoxicity towards the single cell systems using the wst-assay. co-culture experiments with hepg and thp- monocytes or macrophages as well as co-exposure experiments with lps or tnfα were then done at about % cytotoxicity of the respective substance in the most sensitive cell type. subsequently the results were compared to the experiments in the monoculture of hepg . we observed that every idili compound showed a significant increase in cytotoxicity in a minimum of one exposure combination while this effect was not observed with the corresponding non-dili partner compound. in conclusion, a combination of different culture systems and co-exposures with proinflammatory factors is needed for a valid differentiation between non-dili and idili compounds. this test battery could provide a useful tool for the prediction of inflammation-associated idiosyncratic drug-induced hepatotoxicity. furthermore, our results support the inflammatory stress hypothesis and points to an involvement of proinflammatory factors in the development of idili. extensive animal models of carcinogenicity ensure a safe usage of chemicals. to elucidate fundamental molecular mechanisms of carcinogenicity these methods are expensive, time consuming and above all too complex. in contrast, most in vitro methods are rather simple and detect only selected endpoints, like dna damage, mutations or changes in proliferation. the balb/c cell transformation assay is a validated toxicological method to identify potential tumour initiators and promotors. first, balb/c mouse fibroblasts form a monolayer culture and get contact-inhibited after reaching confluence. upon treatment with a tumour initiator ( -methylcholanthrene) and promotor ( -o-tetradecanoylphorbol- -acetate) transformed cells do not stop proliferation and grow as morphologically aberrant foci over the monolayer of normal cells. after fixation with methanol at day , morphological aberrant foci can be visualized with giemsa staining. because the balb/c assay mimics different stages of the malignant cell transformation process (initiation, promotion and post-promotion phase) and detects with the colony formation a late endpoint of carcinogenicity we improved this method for mechanistic cancer research. using the example of insulin-signalling pathway we can show that ( ) several substances have a different impact on the transformation process, ( ) it is possible to identify for each substance the phase with the greatest effectiveness and ( ) we can detect additional endpoints to elucidate the mechanistic mode of action. therefore we used several compounds (linsitinib, metformin, rapamycin, …) to manipulate the insulin-signalling pathway on different levels (insr, ampk, mtor, …) and analysed a number of characteristic endpoints of carcinogenesis. changes on protein level and signalling (westernblot, immunofluorescence, flow cytometry) or parameters of energy metabolism (oxygen consumption, glucose or atp measurement) are measurable and enable new insights into the process of cancer origin. summing up, the balb/c t assay proves to be a cheap and short-time alternative to rodent bioassays. although this method does not mimic the whole in vivo neoplastic process, it can be used to provide essential information regarding key proteins and their signalling, during the different stages of transformation. is there hope to correctly classify severe ocular irritant agrochemical formulations using in vitro methods: a proof of concept using the isolated chicken eye test, two modified bcop protocols and an epiocular™ et protocol while some in vitro methods addressing ocular irritancy have gained regulatory acceptance, to date the draize rabbit eye test (oecd tg ) is the only world-wide regulatory accepted test for the determination of the full range of eye irritation potential. further although several in vitro methods for the severe eye irritation have gained regulatory acceptance, agrochemical formulations are nor explicitly included nor excluded from the applicability domain to predict severe ocular irritant formulations. systematic analyses are only available for e.g. the hen's egg test-chorioallantoic membrane (het-cam), and bovine corneal opacity and permeability (bcop, oecd tg ) assays both showing that the used protocols do not provide sufficient sensitivity to reliably predict severe ocular irritating formulations. the purpose of this study was to evaluate whether the regulatory accepted isolated chicken eye (ice, oecd tg ) test including corneal histopathology (as suggested for evaluation of the depth of injury), as well two modified protocols of the bcop and/or an et (exposure time reducing viability of treated tissue to %) protocol using the reconstructed cornea model epiocular™ are useful to predict severe ocular irritant agrochemical formulations. a proof of concept comprising the testing of ten to twelve agrochemical formulations with available in vivo data in each assay was conducted. in summary, based on the ice evaluation described in oecd tg , one of the five severe ocular irritant formulations (un ghs cat ) was predicted correctly. using both modified protocol versions of the bcop the result for one of the four tested un ghs cat formulations was just above the un ghs cat classification border for using one of the modified protocols. lastly and most promising, the epiocular™ et predicted four of five tested un ghs formulations correctly with the fifths being close to the classification border. additional agrochemical formulations will be tested to further evaluated the epiocular™ et protocol to identify severe ocular irritant agrochemical formulations. drug-induced pancreatic toxicity comprises effects on the exocrine and/or the endocrine pancreas, which both can have serious clinical implications, e.g. acute pancreatitis or diabetes mellitus. adverse effects on the pancreas are occasionally observed during drug discovery and development and often prohibit further development. hence, there is a need for reliable in vitro models to early on identify the pancreas-toxic potential of drug candidates. permanent cell lines and primary cells have many shortcomings, e.g. loss of cell-to-cell and cell-to-matrix relationships or changes in cell physiology due to the isolation procedure. pancreas tissue slices are a potential alternative, circumventing most of these limitations. their preparation is rather elaborate which may explain its rare use. so far, pancreas tissue slices have predominantly been used to address physiological or pharmacological questions, although they might also serve as valuable in vitro model for toxicological applications. therefore, this work aimed to establish and characterize rat pancreas tissue slices as in vitro model for studying drug-induced pancreatic toxicity. results will be compared to the responses of the permanent endocrine (ins- e) and exocrine (ar j) pancreatic cell lines to evaluate a potential added value. rat pancreas tissue slices were prepared by a protocol adapted from marciniak et al. (nat protoc, . ( ): p. . briefly, pancreas was infused and embedded with agarose. tissue sections of app. µm were prepared using a vibratome and maintained in cell culture medium for up to days. cell viability was determined by daily measurement of lactate dehydrogenase (ldh) in medium supernatants and by microscopic evaluation following fixation in % formalin and h&e staining. functional integrity of acinar and beta cells were assessed by cell-type specific secretory responses (i.e. insulin, amylase, lipase) to physiological stimuli. moreover, the effects of the pancreas toxins streptozotocin (stz), alloxan (all), and the cholecystokinin (cck) analogue cerulein on the viability and functional integrity of tissue slices were compared to the respective responses of the cell lines. we were able to establish an optimized isolation and cultivation procedure for rat pancreas tissue slices applying minor modifications to the original protocol. cell viability declined over the cultivation period. stimulation of the cell lines with glucose or cerulein increased secretion of insulin (ins- e cells) or amylase/lipase (ar j cells), respectively. the pancreas slices responded to both stimuli, demonstrating functional integrity of endocrine and exocrine cells. treatment of ins- e islet cells with the betacell toxicants all or stz only slightly affected islet cell viability, whereas treatment of ar j acinar cells with cerulein at supraphysiological concentrations had no effect. this set of experiments is currently completed by investigating the effects of all, stz and cerulein on the viability of acinar and islet cells in pancreas slices. our preliminary data demonstrate feasibility to prepare and cultivate rat pancreas tissue slices over a period of days thereby maintaining functional integrity to some extent. coculture of human monocytes with the keratinocyte cell line hacat in serumcontaining medium leads to higher sensitivity to weak contact allergens: an improvement for the loose-fit coculture-based sensitization assay (lcsa) a. sonnenburg , j. the loose-fit coculture-based sensitization assay (lcsa) has proved reliable for the in vitro detection of contact sensitizers in the past. however, the use of primary human keratinocytes has some disadvantages. to facilitate high throughput screening of chemicals, we replaced primary keratinocytes from the original assay setup (setup a) by the human keratinocyte cell line hacat. these cells were cocultured with monocytederived dendritic cells in serum-free medium (setup b) or fetal calf serum (fcs)containing medium (setup c). upregulation of the dendritic cell maturation marker cd assessed by flow cytometry served as endpoint. we have tested four substances known as sensitizers and four non-sensitizers in both new setups as well as in the original setup with primary cells. three out of four sensitizers ( , -dinitrochlorobenzene, -mercaptobenzothiazole, and coumarin) , and three out of four non-sensitizers (glycerol, monochlorobenzene, and salicylic acid) were correctly assessed under all culture conditions. the weak sensitizing potency of resorcinol was only detected by setup b with fcs supplemented medium. a false positive reaction to caprylic (octanoic) acid in all three setups confirms earlier results from our laboratory that some fatty acids are able to induce cd on dendritic cells in vitro. culture in fcs supplemented medium led to generation of dendritic cells showing a more pronounced upregulation of cd after application of substances with rather high sensitization potency compared to dendritic cells which are formed under serum-free conditions. therefore, we characterized dendritic cells from setups b and c by flow cytometric measurement of additional dendritic cell surface markers. dendritic cells from the original setup a had been characterized extensively before (schreiner et al., toxicology ; : - ) . dendritic cells generated in fcs supplemented medium were cd a+/cd c+, whereas dendritic cells from serum free culture conditions were cd a−/cd c− regardless whether cocultured with primary human keratinocytes or hacat. populations with cd a+/cd c+ dendritic cells in coculture seem to show a higher sensitivity to weak sensitizers, which proved beneficial for the identification of resorcinol. in conclusion, modification of the lcsa protocol led to an increased sensitivity of the assay. due to ethical and social reasons, in vitro assays are being developed to replace animal tests for addressing e.g. toxicological questions. for the induction of skin sensitization by chemicals, resulting in tolerance or allergic contact dermatitis after repeated exposure, prerequisites are the induction of inflammatory responses in keratinocytes supporting maturation of dendritic cells (dc), which is needed for the t cell response. although related in vitro assays consisting of one single cell type have good hazard prediction capacities, they have limitations in predicting sensitization potency. one drawback could be the lack of communication between keratinocytes and dc. with respect to the activation of keratinocytes and maturation of dc, intercellular communication between these two cells may include the release of danger molecules such as cytokines, damage-associated molecules such as atp, and metabolized chemicals. beside this, microrna (mirna), among them those that can regulate dc activation or maturation, can be differentially expressed upon stimulation but can also be transferred between cells. for skin sensitizers, we reported already that cross talk between hacat keratinocytes and thp- cells, as model for dc, enhanced cyp enzyme activity in hacat cells exposed to benzo[a]pyrene (b[a]p) and eugenol, belonging to a subgroup of chemicals (prohaptens) whose sensitizing potential depend on prior metabolic activation e.g. via cytochrome p (cyp) enzymes. furthermore, coculture clearly increased the upregulation of the cell surface molecule cd on thp- cells after incubation with these prohaptens and also several other skin sensitizers. in this study we further elucidate the cross talk between thp- cells and hacat cells by analyzing the impact of hacat cells on the expression of mirnas in thp- cells by microarray technology. we identified differentially expressed mirnas in cocultured thp- cells compared to monocultured thp- cells irrespective of the treatment (medium, . % dmso as solvent control, b[a]p). in the presence of dmso and b[a]p (after h) additional mirnas are differentially expressed. up to now it is not clear whether the cross talk between hacat and thp- cells comprises the exchange of mirna between the cocultured cells or whether it influences the expression of these mirna in thp- cells, or both. given that one mirna has several gene targets these results illustrate that the cross talk between thp- and hacat cells also impacts on the mirnome. walther-straub-institut der lmu-münchen, münchen, germany transient receptor potential (trp) proteins represent a large superfamily of nonselective cation channels sensing toxic stimuli in the human body. trpa expresses a high number of aminoterminal ankyrin repeats and is the only member of the trpa family. channel monomers form homotetramers in the plasma membrane with six transmembrane segments (tm) and a pore forming loop between tm and . trpa has been extensively described in sensory nerve endings as an important cellular detector for toxic stimuli and as an oxygen sensor (reviewed in ). although recently two reports identified trpa in pulmonary epithelial and endothelial cells ( , ) , its expression in non-neuronal tissues is still a matter of debate. after isolation and identification of different murine lung cells we were able to identify murine trpa protein in primary endothelial cells, pneumocytes type ii (atii) and fibroblasts by using specific antibodies in a western blot analysis, but not in cells from trpa -deficient mice. atii cells were identified by specific cell markers such as surfactant protein c and were further differentiated to ati cells characterized by their specific expression of podoplanin. quantitative trp expression patterns will now be evaluated by quantitative reverse transcription (rt)-pcr as well as utilizing nanostring ® technology in different lung cells. to characterize trpa on a cellular level we cultured a hek cell line stably expressing trpa ( ) . allylisothiocyanate (aitc) a specific activator as well as hypoxia and hyperoxia was able to induce ca + -influx in this cell line, which was blocked by the specific inhibitor a . in the future, we will utilize the isolated perfused lung model ( ) to quantify toxin-induced edema formation in ex vivo lungs from wt and trpa -deficient mice after exposure to potential toxic inhalation hazards (tih see ) to challenge the hypothesis of trpa as an important toxin sensor in the lung. by this strategy we hope to understand trpa function in lung cells and to evaluate trpa proteins as potential pharmacological targets for a specific therapeutic intervention during toxin-induced edema formation. metabolism by the intestinal microbiota is likely to contribute essentially to the plasma metabolite profile of the mammalian host organism and it requires adequate identification of effects of the microbiome on the endogenous plasma metabolite patterns. the current investigations present insights in the mammalian-microbiome cometabolism of endogenous metabolites. antibiotics have a profound effect on the micro-organism composition of the microbiome and hence on the mammalian-microbiome co-metabolism. the consequences, however, on the functionality of the microbiome (defined as the production of metabolites absorbed by the host) and which of these changes are related to the microbiome are not well understood. to identify plasma metabolites related to microbiome changes due to antibiotic treatment, we have employed a metabolomics approach. to this purpose broadspectrum antibiotics belonging to the class of aminoglycosides (streptomycin, neomycin, gentamicin), fluoroquinolones (moxifloxacin, levofloxacin) and tetracyclines (doxycycline, tetracycline) were administered orally for days to male rats including blood sampling for metabolic profiling after , and days. fluoroquinolones and tetracyclines can be absorbed from the gut whereas aminoglycosides cannot. to distinguish between metabolite changes caused by systemic toxicity of the antibiotics and microbiome related changes, the metabolites identified in the metabolome pattern were compared to a list of metabolites known to be produced by the gastro-intestinal micro-organisms. beside changes mainly concerning amino acids and carbohydrates, hippuric acid and indole- -acetic acid were identified as key metabolites being affected by antibiotic treatment. for each class the following gut metabolites were found to be unique: indole- -propionic acid for aminoglycosides, taurine for fluoroquinolones, indoxylsulfate, uracil and allantoin for tetracyclines. for each class of antibiotics specific and selective metabolome patterns could be established. the results suggest that plasma based metabolic profiling (metabolomics) could be a suitable tool to investigate the effect of antibiotics on the functionality of the microbiome and to obtain insight in the mammalian-microbiome co-metabolism of endogenous metabolites. drug-induced liver injury (dili) is still a major reason for termination of clinical trials and thus is an important concern in drug development. identification and prediction of dili in the clinic and in preclinical safety testing still relies on the classical clinical chemistry panel and histopathology with known limitations in sensitivity and specificity. in the last years bile acids (bas) have been studied as potential biomarkers to better characterize drug-induced liver injury with promising results (ellinger-ziegelbauer et al., ; luo, schomaker, houle, aubrecht, & colangelo, ; yamazaki et al., ) . to evaluate whether a targeted bile acid profiling via lc-ms/ms in plasma and liver tissue can improve assessment of liver injury, methapyrilene (mpy) a known hepatotoxin, or corresponding vehicle, was administered daily to male wistar rats at a low ( mg/kg) and a high ( mg/kg) dose. rats were sacrificed following , , or consecutive daily doses, or after recovery days following consecutive administrations of mpy or vehicle. in addition to bile acids which were determined both in plasma and tissue, conventional preclinical safety endpoints (histopathology and clinical chemistry) assessment and gene expression profiling was performed in liver to obtain mechanistic information about potential changes in regulation of bile acid levels. conventional findings included periportal necrosis, inflammation and biliary hyperplasia, and increased liver enzyme activity and bilirubin levels during the treatment phase. the bile acid pattern showed increased levels of conjugated and unconjugated bile acids in low dose and high dose groups compared to the controls after administration of methapyrilene. furthermore, although liver enzyme activity and bilirubin levels in serum were decreased again in the recovery groups, suggesting recovering liver injury, bile acid concentrations remained elevated with no signs of recovery. analysis of transcriptomics data revealed decreased levels of mrna encoding α-methylacyl-coa racemase (amacr) and days after dosing, a gene responsible for bile acid synthesis. membrane transport systems for bile acids like sodium/taurocholate co-transporting polypeptide (ntcp) and organic anion transporting polypeptide (oatp ) expression were down regulated as well, indicating that the increased bile acid concentrations in plasma and tissue could be attributable to reduced uptake by the hepatocyte. in summary the data suggest that targeted bile acid profiling could be used as potential biomarkers to enhance assessment of drug-induced liver injury. photorhabdus asymbiotica is an entomopathogen and emerging human pathogen causing soft tissue infections in humans. photorhabdus asymbiotica produces the bacterial protein toxin patox, which is cytotoxic for various cell lines and kills insect larvae. previous studies have established that patox harbors two enzymatic active domains, a glycosyltransferase and a deamidase domain. the glycosyltransferase domain inactivates host gtpases of the rho family by glcnacylation of a tyrosine residue in the effector binding loop, which results in the disassembly of the actin cytoskeleton. the deamidase domain deamidates a crucial glutamine residue in heterotrimeric gα i and gα q/ proteins, which renders the g proteins constitutive active. sequence and structural homology analyses of patox revealed a third domain (patox p ) resembling peptidases of the c protease family. patox p contains the conserved catalytic triade (c/h/d) of papain-like cysteine proteases and shares sequence similarity with effectors from yersinia pestis (yersinia outer protein yopt) and pseudomonas syringae (avirulence protein avrpphb). transient expression of patox p in hela cells induces cell rounding and indicates a cytotoxic potential of patox p . incubation of patox p with linearized bovine serum albumin (bsa) results in cleavage products of bsa assuming proteolytic activity of patox p . mutation of the catalytic cysteine in patox p prevents cleavage of bsa and blocks cytotoxicity. we were not able to observe autocatalytic cleavage of patox constructs under various conditions. the intracellular activity of the protease domain is most likely involved in the pathogenicity of patox. vitamin d metabolism -involved in triazole fungicide toxicity? a. lehmann background: in a -day rat feeding study with the azole fungicides cyproconazole (c), epoxiconazole (e), propiconazole (p), tebuconazole (t), prochloraz (pz) as well as combinations c+e and c+e+pz, a reduction of vitamin d (vitd) receptor mrna levels was reproducibly observed in adrenals for c, e and p. transcription of various enzymes related to vitd homeostasis (including cyp r , gc, cyp a, ugt a) in liver was also affected, while initial indications for modulation of renal cyp a and renal and hepatic cyp b could not be confirmed. a possible induction of parathormone (pth) was noted for the high dose of c, but statistical significance could not be shown. we have now performed supporting analyses for serum vitd levels, measured additional transcript levels and will provide a framework for the interpretation of the findings. methods: male wistar rats (n= for single substances, n= for combinations) were treated for days at dose levels tested based on noaels from -day subchronic feeding studies and ranged from noael/ to noaelx . quantitative rt-pcr analyses were performed on organ samples obtained at sacrifice. serum vitd levels were determined using the total ( -oh) vitamin d elisa (drg instruments gmbh, marburg, germany). results: the elisa established for diagnostic analysis of human serum and plasma samples could be applied to rat serum. vitd levels in control animals (n= ) were . ± . ng/ml (min/max: / ng/ml), i.e. in the range of values reported previously for rats. for the high dose of c ( ppm in food, n= ), there was a statistically nonsignificant reduction of vitd levels to . ± . % of the concurrent control (n= ). however, for of animals of this group, measured vitd level were below the range observed in pooled controls (n= ). an according follow-up is ongoing. qrt-pcr analysis of adrenal tissue showed deregulation of apoptosis related genes (p for c, e and pz; cdk and gadd a for e; cdkn c for c), which is in agreement with an involvement of vitd in the autocrine/paracrine regulation of cell proliferation. conclusion: reduction of circulating vitd levels would be plausible as a result of induction of hepatic cyp a / and ugt a. however, this could not be confirmed by elisa as a general mechanism for all azole fungicides under investigation. only for rats fed with ppm cyproconazole, there were indications for a moderate reduction of -oh vitamin d, which would correlate with the previously reported moderate increase in serum pth for this group. hansen's disease during pregnancy and lactation: two babies born to a mother using antileprosy drugs z. ozturk hansen's disease, also known as leprosy, during pregnancy has been rarely reported in europe and united states. early diagnosis is important, and medication can decrease the risk of those living with leprosy patients from acquiring the disease. this report presents a case of multidrug antileprosy therapy during pregnancy and lactation. a -year-old multiparous woman with a known case of multibacillary leprosy presented with unplanned pregnancy. her pregnancy was discovered in the th week, and she has been taking a multidrug therapy (dapsone mg/day, rifampicin mg/month, clofazimine mg /day and clofazimine mg/month) for the past months. diagnosis of leprosy was established in her previous pregnancy. the patient was informed about the risks of drugs used in pregnancy. the treatment was continued unchanged during pregnancy. a detailed fetal ultrasonography was offered to scan the development of the fetus at about weeks. in the th, nd, th weeks of pregnancy, prenatal sonographic examinations revealed normal fetal growth and amniotic fluid volume. at weeks pregnant, she was diagnosed with gestational diabetes. diabetes did not cause any symptoms during pregnancy, and it was controlled with a reduced-calorie diet in a week. the patient delivered a healthy baby girl by vaginal birth in the th week of gestation without perinatal complications. the baby was also healthy (apgar - , g, cm), and its growth and development were normal during a -month follow-up period. the patient decided to breastfeed while taking medication. she had a previous experience with use of anti-leprosy drugs while breastfeeding, her other child was months old and healthy. as well as in the first child, skin discoloration was observed in newborn due to clofazimine during lactation. after months, she stopped breastfeeding, and the infant's skin changes were reversed. for pregnant women and practitioners, treatment of leprosy in pregnancy can be complicated. physical and neurological damage may be irreversible even if cured. multidrug therapy consisting dapsone, rifampicin and clofazimine is highly effective for people with leprosy and considered safe, both for the mother and the child. antileprosy drugs are excreted into human milk but there is no report of adverse effects except for skin discolouration of the infant due to clofazimine. therefore, multidrug therapy for leprosy patients should be continued unchanged during pregnancy and lactation. methods: individuals included in the analysis were participants of the berlin initiative study (bis). bis is a population-based prospective cohort study initiated in in berlin, germany, to evaluate kidney function in people ≥ years. medication was assessed through personal interviews and coded using the anatomical therapeutic chemical classification system. for estimation of glomerular filtration rate (egfr) we used the ckd-epicr equation. predictor analysis was conducted via logistic regression. results: figure illustrates the percentage of drug use for the three noacs and phenprocoumon, the most common vitamin k antagonist in germany, over the course of four years. table shows the characteristics of patients for each oral anticoagulant group during the four-year follow-up visit (from january until april ). the probability of dabigatran use rose with increasing age (+ %), and the probability of phenprocoumon use rose in case of egfr < ml/min/ . m (+ %) or male sex (+ %). discussion: our data show that also in the elderly noac use increased over the past years. characteristics such as age, sex or kidney function had an impact on the choice of oral anticoagulation. objective: orthostatic hypotension (oh) is an important factor in determining cardiovascular mortality especially in older age. different factors were discussed to influence oh. arterial stiffness, medication and frailty were demonstrated as modifying factors of oh. the aim of this study was to assess prevalence of and influencing factors on oh in nursing home residents (nhr) in germany. methods: systolic (sbp) and diastolic (dbp) blood pressure as well as pulse pressure (pp) and pulse wave velocity (pwv) as markers of arterial stiffness were measured in nhr aged ≥ years in nursing homes in berlin, germany. measurements were first performed in the sitting position and then repeated after standing up. oh was defined as a sbp decrease of > mmhg and/or dbp decrease of > mmhg within min after standing up. hypertension was defined as the presence of diagnosis arterial hypertension, the prescription of at least one antihypertensive drug, or mean sbp values > mmhg and/or mean dbp > mmhg. information about antihypertensive medication was received from interviews and medical records. frailty was determined by geriatric assessments, e.g. "timed up and go test" (tug) or barthel scale. results: oh testing could be performed with nhr (mean age = . ± . years). in total, subjects ( . %) had oh. the mean change in sbp from sitting to standing was . ± mmhg (range + . to - . mmhg) in patients with oh and . ± . mmhg (range + . to - mmhg) in patients without oh. mean sbp was significantly higher ( . ± . mmhg) in people with oh than in those without ( . ± . mmhg). all of the nhr with oh were hypertensive compared to % of the nhr without oh. sex, mean age, pwv and pp was not significantly different between individuals with or without oh (p> . ). medication data was available for patients. all individuals with oh and nhr without oh ( %) had antihypertensive medication. more than different antihypertensive drugs were present in patients with oh ( . %) and in patients without oh ( . %). the intake of beta-blockers had no impact on oh development. geriatric assessments did not differ significantly between the oh group and the non-oh group. more than % of patients in both groups reached points as maximum in barthel scale defining a need for assistance and tug analyses demonstrated that around % of patients with oh as well as patients without oh needed more than sec showing a motor slowing. conclusion: we found a relatively low prevalence of oh in our very old patient cohort and the overall bp control was good. similar to earlier publications mean sbp was significantly higher in nhr with oh. all of the other investigated factors were not associated with the occurrence of oh. the small cohort size might have limited the detection of cardiovascular, epidemiological or geriatric associations. in addition, important confounding factors such as the inability to stand of some nhr and the lack of standardized fraility assessments must be addressed. impact of reticulated platelets on the initial antiplatelet response to thienopyridine loading in patients undergoing elective coronary intervention c. stratz , t. nuehrenberg are known to be involved in cell metabolism pathways and therefore ccrcc is supposed to be a metabolic disease. in order to facilitate a better understanding of cancer metabolism and to support tumor classification on the metabolite level we have developed a novel analytical approach for comprehensive metabolomic profiling of small molecules and lipids in kidney tissue. the method was established and validated based on porcine tissue and, as proof of concept, applied to a small cohort of human normal and ccrcc tissue samples for molecular tissue differentiation. methods: five fresh frozen ccrcc samples and corresponding normal tissue were used for cancer-specific metabolomic profiling and were derived from patients who underwent partial or radical nephrectomy. metabolites and lipids were recovered from tissue samples by a two-step extraction protocol. tissue homogenization and extraction of polar metabolites was performed in methanol/water (aqueous extract) by a beadbeating approach. lipids were recovered by consecutive extraction of the pellet with methanol/methyl tert-butyl ether (organic extract). metabolites in aqueous extracts were separated by hydrophilic liquid interaction chromatography whereas compounds in organic extracts were separated by reversed phase chromatography prior high resolution mass spectrometry. results: reproducibility of tissue extraction and metabolite analysis was assessed by the analysis of multiple individually prepared porcine kidney samples. more than metabolic features including amino acids, nucleotides, small organic acids, phospholipids, sphingolipids, glycerolipids and fatty acids could be reproducible (cv ≤ %) analyzed with the novel non-targeted metabolomics approach. the validated protocol was applied for metabolomic profiling of kidney tissue derived from ccrcc patients. based on unsupervised multivariate statistics, a clear differentiation between cancerous and normal tissue for the small metabolites profile as well as for the lipid profile could be observed. a first subset of differentially regulated metabolites responsible for tissue differentiation could be tentatively identified. conclusion: metabolomic profiling of kidney tissue extracts enables differentiation between ccrcc and normal kidney tissue samples based on the lipid and small molecule metabolomic profiles. further studies on larger and independent sample groups are necessary to confirm and validate our preliminary findings. in summary, the presented approach provides a first basis for comprehensive metabolomics studies in human kidney tissue and thus offers great potential for the metabolic characterization of ccrcc with important prognostic and therapeutic implications in the future. introduction: clomiphene (clom) citrate as mixture of trans-and cis-isomer ( : ) is the first line therapy for the treatment of infertility caused by the polycystic ovary syndrome. treatment schedule includes dose escalation from mg/d clom citrate to up to mg/d in case of non-ovulation. however, therapy outcome is variable and approximately - % of patients do not benefit from clom treatment. the pro-drug clom is bioactivated via -hydroxylation of trans-clom by the highly polymorphic cytochrome p (cyp) d leading to the major active metabolite trans- hydroxyclomiphene (trans- -oh-clom) [ ] . recently, we identified a less active trans- -oh-clom which is also formed by cyp d . besides the formation of the active metabolites, their plasma concentrations are influenced by their clearance e.g. via glucuronidation and sulfation. here we investigated the glucuronidation and sulfation of both hydroxyl-metabolites. methods: isoforms of udp-glucuronosyl-transferase (ugt) and sulfotransferase (sult) responsible for conjugation of oh-clom were identified using commercially available supersomes. glucuronidation and sulfation kinetics were determined in pooled human liver microsomes. conjugated clom metabolites were quantified in plasma and urine samples obtained from healthy female volunteers who received a single dose of mg clom citrate. results: incubations with human liver microsomes revealed an almost -fold higher glucuronidation rate for trans- -oh-clom, which is exclusively catalyzed by ugt b , compared to the more potent trans- -oh-clom. for the latter a pattern of multiple ugts was identified. in contrast, the intrinsic clearance of trans- -oh-clom to its sulfate is -fold higher compared to -oh-clom. for both metabolites a participation of sult a and sult e was identified. these results were in line with previous studies, which identified the same sults [ ] and ugts [ ] responsible for the conjugation of the structurally related trans- -hydroxytamoxifen. in addition, in vivo data from plasma and urine samples confirmed the reverse regioselective glucuronidation and sulfation of trans- -oh-clom and trans- -oh-clom. overall, concentrations of clomglucuronides were significantly higher than those of sulfates. highest concentrations in plasma and urine samples were measured for trans-clom- -o-glucuronide. conclusion: our results suggest a new metabolic route via trans- -oh-clom which appears to be a potential inactivation pathway of clom. institut für pharmakologie und toxikologie der bundeswehr, münchen, germany for decades the biological effect of sm has been investigated. it is well known how sm interacts and destroys cells. unfortunately, it is still unknown if and how a cell can become resistant against sm. within the here described experiments we investigated a new approach adapting cells to the presence of sm. over a time period of nearly three years the cells were cultivated in presence of sm with increasing concentrations. before starting the initial sm sensitivity was investigated. at the beginning cells were cultivated with a concentration of . µm sm (ic ). today the cells are able to tolerate a concentration of . µm sm (ic ), which reflects to a concentration of which % of the original cells would have died. to determine cellular characteristics, the resistant cells were compared with wildtype cells. the following cell characteristics were investigated: proliferation, apoptosis, clonogenicity, size of nuclei and cytoplasm, cell-cell contacts, dna adducts formation, secretome, screening of mirna expression, next generation sequencing, vital observation and scratch assay, nad(p) + /nad(p)h, h o , glutathione, ca + -influx, mdrchannels, resistance to other alkylating agents and the reversibility of the resistance. the resistant cells demonstrate smaller nuclei and cytoplasm, less dna adducts, a higher clonogenicity as well as proliferation and less apoptosis. the secretome analysis showed an up-regulation of anti-apoptotic acting cytokines timp and ang and the proproliferative acting cytokines timp and pdgf-aa. in contrast, immunologically active cytokines were down-regulated. concerning cell-cell contacts no differences were seen. in the mirna screening significant up-regulated and significant down-regulated mirnas have been observed. noteworthy was the regulation of various members of different families. during vital observation and in a scratch-assay the resistant cells were show to have disadvantages. the observed resistance was not unique for sm but also towards other alkylating agents and cytostatic drugs. by analyzing the reversibility cells stayed resistant over more than weeks. in conclusion, many aspects investigated in this study have an influence on the sm resistance, pointing out that it is a combination of various effects that are involved to switch on resistance. more likely, there are many aspects working together. the present results are an important step in the characterization of the sm-resistant cell line and further studies may be able to directly use these as a start for target identification in antidote or prophylactic agent discovery. the arylhydrocarbon receptor (ahr) is localized in a cytosolic complex that contains several co-chaperones and associated factors. the protein is shifted into the nucleus in response to endogenous and xenobiotic ligands. however, a transient nuclear transport does also occur in the absence of any ligands, while the predominant cytoplasmic compartmentalization is maintained by parallel export. we have analyzed the interplay between this basal nucleo-cytoplasmic shuttling and ligand induced transport in hepg cells, using a yfp-tagged fusion protein that is capable to respond to ligands and to trigger the induction of cyp a expression. basal import was assessed in cells that had been treated with leptomycin b (lmb), an inhibitor of crm -mediated nuclear export. interestingly, the apparent ahr import rate in lmb-treated cells was comparable with nuclear import as trigged by xenobiotic (b-naphthoflavone) or endogenous (kynurenine) ligands. this observation was confirmed for endogenous ahr in hepg cells, since both ligands and lmb showed comparable effects on nuclear compartmentalization. however, the basal nuclear import rate in lmb-treated cells was strongly increased by ahr ligands. ligand-induced nuclear transport was therefore confirmed as an import step in receptor activation. interestingly, lmb did also accelerate nuclear import of ahr after pretreatment of cells with ahr ligands. these data suggest that nuclear export of the ahr is maintained in the presence of ligands. receptor activation might therefore comprise several rounds of shuttling, thereby involving both accelerated import and continued export of the ahr protein fraction that has not already undergone interactions with arnt or dna. we suggest that nuclear export provides an additional kinetic control of ahr activation and function. mitochondrial toxicology: rescuing mitochondria in wilson disease avoids acute liver failure h. zischka institut für molekulare toxikologie und pharmakologie, ag zischka, neuherberg, germany in wilson disease (wd) functional loss mutations in the hepatocyte atp b gene cause dramatic copper overload leading to acute liver failure, posing an unmet therapeutic issue. we find that the pathology of severe wd cases is mirrored in lpp (-/-) rats carrying a functional loss atp b mutation. this is especially apparent in the hepatocyte mitochondrial compartment. a progressive copper deposition increasingly harms the lifesustaining mitochondrial membrane integrity. thus, depleting this devastating mitochondrial copper burden is a core requirement for a treatment strategy against acute liver failure in this wd animal model. preparation for the master degree program in toxicology started in as a cooperation of charité universitätsmedizin berlin with the university of potsdam and other institutions of the region. first enrollment of students was done in . the program was accredited in by the central evaluation and accreditation agency. it offers a modern curriculum encompassing a wide variety of scientific aspects with an interdisciplinary character. this training program in toxicology is organized in modules and ends with the degree "master of science" (m.sc.). the goal of this program in toxicology is to teach the basis of the interactions between substances at toxic concentrations and living organisms, as well as the molecular mechanism of the adverse effects of chemicals. the understanding of the mechanism of a toxic action is an important prerequisite for the scientifically based evaluation of a hazard associated with a substance. furthermore, only with the knowledge of the mechanism of action and a deduction of structure activity relationships it is possible to predict toxic effects of new substances. this knowledge should enable students to perform a risk evaluation of chemicals or to predict the adverse effects of chemicals with the aim that human beings and the environment can be protected from harmful consequences of chemical exposure. the program allocates places per year to an average of applicants. most applicants have a basic training in the fields biology, chemistry, pharmacy, veterinary medicine and nutritional sciences. about % of the students are female. the majority of them have a bachelor's degree before starting the master program, other degrees are diploma and state examination as pharmacists or physicians. ninety percent of the students pass the final examination consisting of the master's thesis and disputation at the end of the four semesters. afterwards, most of the graduates aim to obtain a phd degree. the program is well established in the education of toxicologists in germany. respiratory injury due to chlorine developed from consumer products. still an issue in germany u. stedtler , m. hermanns-clausen uniklinikum freiburg, vergiftungs-informations-zentrale, freiburg, germany objective: in the last decades strong effords have been took to improve product safety, especially in products intended for domestic use. hypochlorite-containing cleaners may develop chlorine gas when acidified e.g. by adding an acid sanitary cleaner. usually these cleaners contain sodium hydroxide or other strong alkalines to avoid this reaction. we analysed reports to our poisons center concerning inhalation exposure to chlorine developed from hypochlorite-containing mixtures. method: retrospective search in the case database of the poisons center. human inhalative exposures to chlorine released from mixing hypochlorite as well as human inhalative hypochlorite exposure alone were analysed. frequency and symptoms were compared. results: from to in total cases of human exposures to chlorine developed from mixtures of hypochlorite and acids ( . of cases) were registered. in cases the exposure was due to mixtures of products intended for domestic use. % of the exposed patients reported symptoms. only in two cases the symptoms were not considered to be caused by the inhalation accident. most frequent symptoms reported were (percent of symptomatic patients): cough ( %), dyspnea ( %), irritated upper airway ( %), abdominal discomfort (pain, nausea, vomiting) ( %), thoracic pain ( %), irritated eyes ( %), dizziness ( %), and bronchospasm ( %). further symptoms were malaise, headache, irritated nose, sweating, muscle pain, and others. in patients ( %) the symptoms were graded as moderate severe. main symptoms in this group were dyspnoea ( % ), cough, and irritated airway. one third of the patients experienced bronchial obstruction. all symptomatic patients developed symptoms while exposed or shortly after exposure. there were no severe or fatal cases (especially no lung edema) and all symptoms were expected to resolve completely. because hypochlorite containing procucts sontanously release "chlorine-like" smelling gases, we additionally analysed inhalation exposures to hypochlorite solutions alone in the same period. there were patients in the same period exposed to hypochlorite evaporation alone. of them ( %) had symptoms of which in cases these were considered to be caused or possibly be caused by the hypochlorite. most frequent symptoms were irritated upper airway ( %), nausea or vomiting ( %), cough ( %), irritated eyes ( %). dyspneoa was less fequent than in the mixture group ( %). all symptoms were considered mild. there was no bronchospasm or thoracic discomfort. conclusion: respiratory injuries by chlorine from hypochlorite-containing solutions still occur despite clear warning on the label. the majority of cases was due to products for domestic use. symptoms develop shortly after exposure. the γh ax assay for genotoxic and nongenotoxic agents: comparison of h ax phosphorylation with cell death response perturbation of mitosis through inhibition of histone acetyltransferases: the key to ochratoxin a toxicity and carcinogenicity? regulation of chromatin by histone modifications transcriptomic alterations induced by ochratoxin a in rat and human renal proximal tubular in vitro models and comparison to a rat in vivo model in vitro gene expression data supporting a dna non-reactive genotoxic mechanism for ochratoxin a fragment ion patchwork quantification for measuring site-specific acetylation degrees combinatorial patterns of histone acetylations and methylations in the human genome inroads to predict in vivo toxicology -an introduction to the etox project value of shared preclinical safety studies -the etox database acknowledgements: support of the bfr through grant - is gratefully acknowledged. acknowledgement: supported by the robert bosch foundation, stuttgart, germany. [ ] mürdter t, et al. hum mol genet, , : - [ ] nishiyama t. et al., biochemical pharmacology, , : - [ ] sun d. et al., drug metabolism and disposition, , : background: infections are a major problem in patients with burn diseases (bd). due to severe injuries of their total body surface area (tbsa), burn patients have altered pharmacokinetic characteristics. therefore, insufficient plasma concentrations may be achieved, when standard dosing schedules are applied for antibiotics such as piperacillin. for time-dependent antibiotics, the duration how long drug concentration exceeds the minimal inhibition concentration (mic) is crucial for their antibacterial effects. since pseudomonas spp. is the main problematic pathophysiological bacterium for bd patients. the aim of the present study was to monitor the plasma concentrations of piperacillin during piperacillin/tazobactam treatment in bd patients. patients from intensive care units (icu) served as controls. methods: bd patients ( / m/f, . ± . y, tbsa . ± . %) and patients ( . ± . y) from the icu were included in this observational study. blood samples were taken within the rd interval of the h-lasting dosing period of piperacillin/tazobactam ( / . g within . h) at , and . h after the end of infusion. total and free piperacillin concentrations were determined in plasma using hplc-uv after deproteinisation with acetonitrile and by ultrafiltration, respectively. pharmacokinetic parameters and dosing simulations were calculated by tdmx (www.tdmx.eu). free plasma concentrations of piperacillin exceeding at least xmic but preferably xmic over the whole dosing interval were considered to be sufficient for antibiotic efficacy (mic mg/l for pseudomonas spp.,www.eucast.org). results: the pharmacokinetic parameters of total piperacillin, calculated for each bd or icu patient using the concentrations at , , and . h, were as follows: c max . ± . vs. . ± . mg/l, p< . , half-life . ± . vs. . ± . h, p> . , clearance . ± . vs. . ± . l/h, p< . , volume of distribution . ± . vs. . ± . l, p< . . free concentrations (which were included in tdmx calculations) were ± vs. ± % (p< . ) of total concentrations. duration per day while concentrations exceeded xmic ( . ± . vs. . ± . h, p< . ) or xmic ( . ± . vs. . ± . h, p< . ) were lower in bd than in icu patients. moreover, tdmx simulations predicted that the duration per day for xmic could be enhanced to . ± . h if the piperacillin amount will be increased to x g/d and the infusion duration to h. pharmacokinetic parameters have, however, to be determined in a pilot study with bd patients to ensure predicted values. conclusions: standard dosage regimens for piperacillin/tazobactam could result in suboptimal plasma concentrations of piperacillin in bd patients as well as in icu patients. drug monitoring and tdmx simulation of kinetic parameters may easily help to improve piperacillin treatment in bd patients. background: high dose methotrexate (hd mtx), defined as > mg mtx/m bodysurface-area (bsa) is used in children to treat a variety of malignant diseases since the s. clinicians observe relevant rates of severe unwanted side effects. identifying patients having an increased risk for toxicity due to altered mtx pharmacokinetics is urgently needed. we aim to develop and evaluate a physiology-based pharmacokinetic (pbpk) model for hd mtx in children using pk-sim® (bayer technology services gmbh, leverkusen, germany) with a special emphasize on relevant covariates. methods: in this non-interventional observational study, children receiving hd mtx intravenously at two major german pediatric oncology departments during the years - were included if at least one mtx serum level (mtx-sl) was determined during clinical routine. patients aged - years (male = , female = ) with following diagnoses were included: acute lymphoblastic leukemia, non-hodgkin lymphoma, burkitt lymphoma, brain stem glioma and glioblastoma multiforme. in total, mtx treatment cycles corresponding to mtx-sl were used in this study. patients were randomized into two patient sets (training set and test set). based on literature data, mtx pbpk-models were developed and slightly adapted taking into account mean relative deviation (mrd) and bias of predicted versus observed mtx-sl of the training set. the pbpk model with the lowest mrd and bias was chosen and finally evaluated using the test set. the impact of the covariates urine ph < . , trimethoprime/sulfamethoxazole, proton-pump-inhibitors, non-steroidal anti-inflammatory drugs and ß-lactam antibiotics on the prediction quality was assessed using the mann-whitney u test. ochratoxin a (ota) is a wide-spread food contaminant and one of the most potent renal carcinogens [ ] . recent data by our group demonstrate that ota inhibits histone acetyltransferases (hats), thereby causing a global reduction of lysine acetylation of histones and non-histone proteins [ ] . based on these findings and the importance of specific histone acetylation marks in regulating gene transcription [ ] , we speculated that repression of gene expression as the predominant transcriptional response to ota [ , ] may be linked to loss of histone acetylation. in this study we therefore used a novel mass spectrometry approach, which is based on chemical acetylation of unmodified lysine residues of histones using c-labeled acetic anhydride and subsequent calculation of the degree of acetylation based on the measured intensities of heavy and light acetylated isotopologues [ ] , to identify and quantify site-specific alterations in histone acetylation in human kidney epithelial (hk- ) cells treated with ota. our results demonstrate ota-mediated loss of acetylation at almost all important lysine residues at histones h a, h b, h and h . we further selected acetylation at histone h lysine (h k ), a well-known euchromatic hallmark that is elevated at promoter regions of transcriptionally active genes [ ] and which was reduced from ~ % in controls to < . % in response to ota, to establish a link between loss of h k acetylation and expression of genes consistently shown to be down-regulated in response to ota [ , ] . using chromatin immunoprecipitation followed by quantitative real-time pcr (chip-qpcr), we observed ota-mediated loss of h k acetylation at promoter regions of the selected genes (% of controls: amigo : %, clasp : %, ctnnd : %). overall, these data provide first evidence for a mechanistic link between h k hypoacetylation as a consequence of ota-mediated inhibition of hats and repression of gene expression by ota. a new paradigm to assess the proarrhythmic potential of drugs is proposed by the cipa (comprehensive in vitro pro-arrhythmia assay) initiative combining a suite of a priori in vitro assays ( most important ion channels for cardiac activity) coupled to in silico reconstructions of cellular cardiac action potential (ap). the etox consortium has developed a multiscale simulation in silico model based on o'hara/rudy incorporating the principles of this new paradigm. the core model simulates the effects of drugs on a virtual cardiac tissue composed by different types of cardiomyocytes. the input of this model, the blockade of a set of ion channels (ikr/herg, iks, ical), can be obtained experimentally or predicted using advanced d-qsar models. the system predicts the % change of the qt interval at different drug concentrations in order to facilitate risk assessment. this in silico model was validated using purkinje fiber assay results (input: ap prolongation and arrhythmogenic risk assessed by early after-depolarisation occurrence) from in-house drug candidates. the validation showed that predictivity is highly dependent on the model's applicability domain (ad): for some chemical series the proarrhythmic potential could not be identified, for others, however, most of the positive drugs were correctly predicted with sensitivities up to - % (average prediction accuracy was %). retraining of this model with additional internal data should help to improve the model ad and predictivity. it is important to note that ap prolongation was correctly predicted for many proarrhythmic drugs with only low (> µm) in vitro herg inhibition. furthermore, the model showed high additional benefit for read-across within bayer pharma ag, investigational toxicology, berlin, germany etox [ ] [ ] started in and is a public-private partnership project within the european innovative medicines initiative (imi) [ ] . the etox project is building a toxicology database relevant to pharmaceutical development and to elaborate innovative strategies and software tools. the overall goal is to better predict the toxicological profiles of new chemical entities in early stages of the drug development pipeline based on existing in vivo study results contributed by the participating efpia * companies in the consortium. the etox database is a relational database with a specifically designed schema to store complex and comprehensive preclinical safety data like the study design, toxicokinetics, adme data, clinical chemistry, hematology, gross necropsy, histopathological findings and general toxic effects. in addition relevant data from public sources has been included into the database. the primary focus for data collection are systemic toxicity (up to week) repeated dose studies, mostly in rodent. overall more than study reports for approximately investigated compounds. in order to optimize the usage and mapping of data from different sources the development of common ontologies was a key task within the project. this timeconsuming step was necessary to make a high quality read-across analysis possible and valuable. therefore the ontobrowser [ ] tool was developed to curate and harmonize the verbatim terms to standardize terms which are used within the etox database. until now more than million verbatim terms were curated. additionally to the toxicology database, a web-based user interface called etoxsys was developed to allow the retrieving of toxicity information, as well as the prediction of toxic endpoints for chemical compounds. due to the complex search capabilities, the database can be queried for structural similarity, similar target classes and specific toxicological endpoints. approximately prediction models based on public data are available and first models based on in vivo data are in development. the etox database therefore represents a valuable tool for early animal-free assessment of drug candidates [ ] . * european federation of pharmaceutical industries and associations cell lines background: consumers are constantly exposed to chemical mixtures e. g. to multiple residues of different pesticides via the diet. this raises questions concerning potential cumulative effects, especially for substances causing toxicity by a common mode of action. since substances are tested for regulatory purposes on an individual basis at generally high dose levels, there is only limited data available on potential mixture effects especially in the low dose range. with more than active substances approved for being used in pesticides and over chemicals registered under reach there are more possible combinations than one could test with classical animal experiments. the development of in vitro tools for assessment of mixture effects consequently is of tremendous importance. methods: as a first step in the development of such in vitro tools we used a group of fungicides, (tri-)azoles, as model substances in a set of different cell lines from known target tissues, basically liver (human: hepg , heparg, rat: h iie) and adrenal gland (human: h r). concentrations were taken from measured tissue concentrations in vivo to ensure that used concentrations of the (tri-) azoles reflect realistic effect levels. the cell lines were exposed with the triazoles cyproconazole and epoxiconazole as well as with the azole prochloraz as individual substances and in binary or ternary combinations of these substances at three dose levels and three different time periods. the effects of the substances were subsequently analysed by transcriptomics and metabolomics. a support vector machine will be utilized to integrate the data from the different sources to gain a complete picture of affected adverse outcome pathways and mechanistic information about the applied fungicides. first results indicate combination effects of the substances also at the omics level depending on the specific endpoint and the concentration used. some of these are comparable to effects found with similar methods in a standard toxicity test, a -day feeding study in the rat, thus raising hope for the development of in vitro methods suitable to detect combination effects. background: plant protection and biocide products are chemical mixtures, which contain one or more active substances as well as several co-formulants (e.g. solvents, wetting agents, thickener or preservatives). nevertheless, to this day extensive toxicological testing is performed only with the individual active substances, while the plant protection products are only evaluated for acute toxicity, ie, a single dose group experiment with rats is performed as well as testing for skin-and eye-irritation. current pesticides regulation foresees testing of potential harmful mixture effects but only when adequate methods are available making the development of such methods a high priority. several published studies both in vitro and in vivo have shown fortified toxic effects of plant protection products compared to individual active substances. methods: here we present effects of plant protection products as a whole as compared to the individual active substances or co-formulants in a set of human cell lines of hepatic and renal origin (hepg , heparg, hek ). cytoxicity has been analysed by wst- and nru assay as well as gene expression of several marker genes involved in xenobiotic metabolism. additionally reporter gene assays have been conducted for nuclear receptors such as ahr and car. results: while some active substances showed lower toxicity as compared to the respective products, this cannot be confirmed as a general rule for all endpoints for all of the analysed fungicides or herbicides containing active substances such as epoxiconazole, cyproconazole, azoxystrobin or glyphosate. chemical compounds may induce skin sensitization in humans, resulting in tolerance or allergic contact dermatitis after repeated exposure. mechanistically, the activation of dendritic cells is one of the prerequisites for the induction of skin sensitization. a subgroup of sensitizing chemicals, prohaptens, need metabolic activation, e.g. via cytochrome p (cyp) enzymes. thus, xenobiotic metabolism may crucially impact on a chemical's potential for the induction of skin sensitization by activation, but also deactivation of reactive molecules via conjugation, which determines the concentration and the chemical species available for protein haptenation and cell activation. we established a coculture model consisting of hacat keratinocytes and thp- as surrogate dendritic cells for the detection of sensitizing chemicals and found enhanced cyp enzyme activity in hacat cells exposed to benzo[a]pyrene (b[a]p) and eugenol as well as clearly increased expression of cell surface molecule cd on thp- cells after incubation with these prohaptens (hennen et al., ) . here, we studied the impact of intercellular cross talk on activation and conjugation capacities in more detail. treatment of thp- with b[a]p and eugenol in coculture with hacat cells augmented cyp a and/or cyp b mrna levels, while this was not found for thp- monoculture. augmentation of cyp a mrna needed continuous presence of hacat cells. in coculture, levels of -oh-b[a]p as exemplary cyp-dependent metabolite were increased compared to single cultures. in contrast to this, total glutathione contents as well as n-acetyltransferase enzyme activities in both cell types were not modulated in coculture, furthermore the capacity for sulfation/glucuronidation of -oh-b[a]p was maintained in coculture. additionally, the decrease of the total glutathione content in thp- cells by , -dinitrochlorobenzene (dncb) was much less pronounced when exposed in coculture with hacat cells, showing that hacat cells provide additional targets for cysteine-reactive chemicals such as dncb, diminishing the total amount of chemicals available for thp- cells.overall, results indicate that the cross talk between keratinocytes and antigenpresenting cells enhances their capacities for metabolic activation of chemicals, while hacat cells also provide supplementary capacities for phase ii reactions. references: hennen j et al. cross talk between keratinocytes and dendritic cells: impact on the prediction of sen-sitization. toxicol sci : - .toxicology -toxic pathway analysis/aop background: reticulated platelets are associated with impaired antiplatelet response to thienopyridine treatment. this interaction might be caused by intrinsic properties of reticulated platelets or a decreased drug exposure due to high platelet turnover reflected by reticulated platelets as surrogate. we investigated the impact of reticulated platelets on antiplatelet response to thienopyridines and if this effect is linked to platelet turnover. methods: this study randomized elective patients to loading with clopidogrel mg or prasugrel mg (n= ). adp-induced platelet reactivity was assessed by impedance aggregometry to minutes and day after loading but before intake of the next dose of thienopyridines. immature platelet count (ipc) was assessed as marker of reticulated platelets by whole blood flow cytometry. results: platelet reactivity increased with rising tertiles of ipc (figure) . this effect was more pronounced in patients on clopidogrel as compared to patients on prasugrel. overall, ipc correlated well with on-treatment platelet reactivity at min (r= . ; p< . ). this correlation did not change over time indicating an effect independent of platelet turnover (comparison of correlations min/day : p= . for clopidogrel, p= . for prasugrel). conclusion: a high immature platelet count is associated with impaired response to thienopyridine loading. this effect is independent of platelet turnover indicating a relation to intrinsic properties of reticulated platelets. introduction: one of the biggest drawbacks of protein-based therapeutics with intracellular targets is their inability to enter the cytosol. targeted toxins are known to be used in drug delivery. aim of the study was to target epidermal growth factor (egf) receptor overexpressed on pancreatic carcinoma using a novel well-defined targeted toxin consisting of egf fused to the toxic plant ribosome-inactivating protein dianthin and a glycosidic triterpenoid (so ) as efficacy enhancer. methods: the enzymatic activity of dianthin-egf was verified by an adenine release assay. the kinetics of cytotoxicity were evaluated in pancreatic adenocarcinoma bxpc- and miapaca- cells in comparison to the non-target cell line nih t with an impedance-based real time cell analyzer (xcelligence) and final cytotoxicity analyses with conventional end-point mtt assays. acute toxic of dianthin-egf was studied in male balb/c mice. a xenograft solid tumor model was developed in male nude mice by injecting bxpc- cells into the dorsal part subcutaneously. dianthin-egf was administered at the vicinity of the tumor and so by subcutaneous injection at the neck. after the tumor reached a diameter of to mm in size treatments were given in total. tumor volumes and body weight shifts were observed twice weekly to determine the potency of dianthin-egf when given alone and in combination with so in comparison to placebo. immunohistochemical detection of egf receptor was performed according to the manufacturers's advice (dako, glostrup, denmark, k ). complete blood count analysis was done by labor gmbh, berlin. results: the adenine release mediated by dianthin-egf was . pmol adenine/pmol toxin/h. the in vitro efficacy of the targeted toxin was proven by an ic value of approximately nm for egf receptor expressing miapaca- and bxpc- cells as compared to nm for non-target nih t cells. real time measurement of the cytotoxicity showed a dose-dependent decrease in cell viability from pm to µm. toxicity studies in balb/c mice revealed . µg/mouse to be non-toxic and maximum tolerated dose (mtd) whereas µg caused moribundity accompanied with white ocular discharge. efficacy studies were performed for a period of days. the combination therapy showed that the average tumor volume measured by a digital vernier caliper was found to be % less than for placebo whereas single therapy using dianthin-egf alone caused a further increase in tumor volume which was although yet % less when compared to placebo. immunohistochemistry slides showed egf receptor expression in each of all untreated xenograft tumors, which further confirms the presence of egf receptor overexpression in the target bxpc- cell line. enlarged spleen was only observed in untreated xenografts. no significant change in various blood parameters (rbc counts, wbc counts, hgb, hct, mcv, mch and mchc) were observed on hematological analysis except for the platelet (plt) counts in comparison to healthy male nude mice. conclusion: combination therapy with so proves to be a promising approach for the targeted delivery of toxins instead of single therapy administering targeted toxin alone. the strategy is specific for egf receptor overexpressing tumors such as pancreatic cancer. introduction: moringa oleifera (mo) is a popular herbal supplement used for treatment and management of diverse diseases in sub-saharan africa. its intake among individuals infected with hiv/aids has increased recently due to the purported immune boosting property. limited information, however, is available regarding its potential to cause interactions with commonly prescribed medications that are substrates of cyp a and p-glycoprotein. methods: the methanol extract and four fractions of mo were tested on recombinant cyp a at different concentrations with and without nadph to determine the ic shift reduction. the crude methanol extract of mo was incubated with testosterone (tst) and cryopreserved hepatocytes to evaluate its influence on clearance of tst. effect of mo on the efflux transporter, p-glycoprotein was investigated by incubating the methanol extract with mdr -mdckii cells. virtual screening was conducted to predict physicochemical properties, bioavailability and interaction potential of phytochemical compounds unique to mo using combination of molinspiration version . and admetsar. results: fractions (f -f ) indicated ic shift reduction ≥ post-incubation with and without nadph. mo showed moderate interaction (auc i /auc = . ) with tst in cryopreserved hepatocytes. also, mo mildly inhibited the transport of digoxin (ic = . µg/ml) across mdr -mdckii cells. niaziminin indicated . % bioavailablity via the human intestinal membrane with % chance of inhibiting cyp a . βsitostenone showed strong p-gp inhibition ( . %) with % absorption via the intestine. conclusions: mo has the potential to inhibit the metabolism or excretion of other medications that are eliminated by cyp a or p-glycoprotein, respectively, if adequate amounts of the active constituents such as niaziminin and β-sitostenone enter the circulation. background: herb-induced liver injury (hili) has attracted attention in the past years due to an increasing number of publications reporting cases of hepatotoxicity associated with use of phytotherapeutics. here, we present data on hili from the berlin case-control surveillance study fakos. methods: fakos was initiated in to study serious toxicity of drugs including hepatotoxicity. potential cases of liver injury were ascertained in more than departments of all berlin hospitals from october until december . through a standardised face-to-face interview and review of medical charts information on all previous intakes of drugs or herbals, on co-morbidities, and demographic data was ascertained. inclusion criteria were an elevation of alanine aminotransferase or aspartate aminotransferase threefold above the upper limit of normal or an elevation of total bilirubin higher than mg/dl. excluded were patients with underlying liver disease (e.g., alcoholic fatty liver disease). drug or herbal aetiology was assessed based on the updated council for international organizations of medical sciences (cioms) scale. results: of all cases of hepatotoxicity included into the fakos study, herbs were involved in ten cases ( . %). demographic, clinical, and laboratory characteristics of these ten cases are illustrated in table . among the six patients with available liver biopsy results, five patients showed signs of necrosis, either disseminated or predominantly near the central vein. portal inflammation was more common than lobular inflammation, and the infiltrates contained mostly lymphocytes, neutrophil or eosinophil granulocytes. herbal aetiology was judged two times as probable (ayurvedic herb in patient , pelargonium sidoides in patient ), and eight times as possible (valeriana in patients , , , , , mentha piperita in patient , hypericum perforatum in patient , eucalyptus globulus in patient ). in nine cases other non-herbal drugs were also suspected as potentially hepatotoxic (exception: patient ). seven cases occurred in the ambulatory setting requiring hospitalisation, three cases occurred during hospital stay. discussion: this case series provides further information on laboratory and clinical aspects of hili. it corroborates known risks for valeriana and ayurveda treatment, and suggests that further herbals rarely or never associated with liver injury before such as pelargonium sidoides, hypericum perforatum or mentha piperita could also exhibit a hepatotoxic potential. clinical routine often requires to evaluate the cause of a newly occurring adverse event. if this event is regarded to be iatrogen, further information of the association between the drugs in the current medication list and the adverse event is needed. this information should ideally reflect the true risk and allow ranking of the drugs according to this risk to identify which drug to discontinue first. we discuss the summary of product characteristics (spc), the sider side effect resource and openvigil as possible sources of information. spcs are becoming more and more a vindicative charter for pharmaceutical companies that contain misleading information which is not based on evidence (ref. ). since it relies on the spcs, sider inherits these shortcomings and flags warnings that result from confounding factors (ref. , fig. ). furthermore, if any rates are given, they are not easily comparable since they stem from different studies. pharmacovigilance data are biased by the very nature of the data and the collection method. however, once confounders are eliminated, pharmacovigilance offers better information om how to rank the drugs than spcs/sider. we present decision-guiding information obtained by sider and by openvigil for one of our patients ( fig. & ) and discuss how this information was used to modify the therapy. institut für naturheilkunde und klinische pharmakologie, universität ulm, ulm, germany background: differences (polymorphisms) in target genes or genes encoding drug transport proteins or drug metabolizing enzymes may be responsible, among other factors, for observed variation in patients' response to medications. pharmacogenetics aims at identification of patients at higher, genetically determined, risk of adverse drug effects or ineffective medication, to modify dosage or switch to alternative therapy. there is, however, a lack of awareness of pharmacogenetic-based clinical practise guidelines. methods: a systematic literature review was conducted which focused on published guidelines on genotype-based (germ-line genetic variants) dosage modification or selection of drugs. we serched the medline and the pharmacogenomics knowledgebase (pharmgkb) databases. prescribing information was also screened for pharmacogenetic guidance. results: the systematic review revealed recommendations for drugs (table) that enable the translation of genetic test results into actionable prescribing decisions. for % of these drugs the respective german drug labels recommend or even require pharmacogenetic testing (table, rd column). although pharmacogenetic testing is recommended, the prescribing information not always provides guidance on how to adjust the drug dosage based on the pharmacogenetic test result. compared with the german or european drug labels, the fda drug labels povide more detailed information on pharmacogenetic dose modifications. conclusions: academic working groups have a front-runner role in the development of prescribing recommendations based on genetic markers. to date, drug labels rarely contain detailed guidelines how available genetic test results should be used to adjust drug dosage. because pharmacogenetics has a growing role during drug development and pre-prescription genotyping will become more widespread, it is expected that specific pharmacogenetic guidance for the treating physicians will become increasingly important. bisphenol a (bpa) is a high production volume compound mainly used as a monomer to make polymers for various applications, including food-contact applications. people are exposed to low levels of bpa because very small amounts of bpa may migrate from the food packaging into foods or beverages. however, other potential sources of exposure, such as dermal contact have also been identified (efsa, ) . a substance evaluation process (corap) was initiated for bpa by the european chemicals agency (echa). as part of the safety evaluation of bpa, a study was required by echa to assess absorption and metabolism of bpa following dermal exposure to human skin. an in vitro study with human skin was requested according to oecd tg under consideration of the scientific committee on consumer safety (sccs) criteria for the in vitro assessment of dermal absorption. to investigate potential dermal bpa metabolism fresh human skin was used. abdominal skin was obtained fresh from surgery from different donors. split-thickness human skin membranes were mounted into flow-through diffusion cells (n= per dose and donor) and the receptor fluid was pumped underneath the skin at a constant flow rate. the skin surface temperature was maintained at °c throughout the experiment and electrical resistance barrier integrity testing was performed at the start ( h) and end of the experiment ( h). four test preparations at final bpa concentrations of . , , , and mg/l were investigated. the highest concentration was chosen based on the maximum solubility of bpa in water and the lowest concenration was chosen based upon the specific activity of the radiolabelled [ c]-bpa that could be used for mass balance. percutaneous absorption was assessed by collecting receptor fluid (tissue culture medium (dmem), containing ethanol (ca %, v/v), uridine '-diphosphoglucuronic acid (udpga, mm) and '-phosphoadenosine- '-phosphosulfate (paps, µm)), at multiple time points througout the experiment. at termination the skin was removed from the cells and the stratum corneum was removed with successive tape strips. the exposed epidermis was separated from the dermis using a scalpel. metabolism was investigated for the highest concentration ( mg bpa/l) only, using a hplc with in-line radiodetection and confirmed bpa-glucuronide (bpa-g) and bpa-sulfate (bpa-s) standards for comparison. no metabolism was observed in any of the epidermis samples, however some metabolism is observed in dermis and receptor fluid samples. metabolites were identified with retention consistent with bpa-g and bpa-s, and also some more polar components. the mean total absorbed dose (receptor fluid + receptor chamber wash + receptor rinse) was between . and . % of the applied dose and the mean dermal delivery (epidermis + dermis + total absorbed dose) was between and % of the applied dose, with the majority of the radioactivity associated with epidermis samples compared to dermis and receptor fluid samples. a linear dose-response relationship is observed over the whole concentration range. anastrozole is a well-known non-steroidal aromatase-inhibiting drug approved for the second-line treatment of breast cancer after surgery and for treating postmenopausal women. treatment with the only available dosage form, anastrozole film-coated tablets for oral administration, is frequently associated with concentration-dependent unwanted side effects like hot flashes, fatigue, joint pain, joint stiffness, vaginal dryness, hair loss, skin rash, nausea, diarrhea and headache. in order to minimize the local gastrointestinal as well as systemic side effects, a system for transdermal anastrozole delivery has recently been developed. in this study, we describe the first experimental in vivo application of a transdermal therapeutic system (tts) to beagle dogs and, as a necessary prerequisite for the analysis of the time course of anastrozole release and uptake, a simple, sensitive and accurate lc-ms method for quantifying anastrozole in plasma. the detection of fragment ions at m/z and instead of the molecule ions (m/z and ) generated from the elevated collision energy, and the use of a deuterated internal standard resulted in increased relative abundances and improved signal-to-noise ratios.the lower limit of quantification and the limit of detection were . ng/ml and . ng/ml, respectively. the developed method was successfully applied in a pharmacokinetic study of anastrozole plasma levels in beagle dogs, measuring percutaneous drug absorption from an experimental, newly designed glycerol-based patch / tts. a distinct time course was observed, with an initial linear increase over hours and a plateau thereafter. this offers promising strategies for the transdermal application of anastrozole with improved pharmacokinetics. background: the monocarboxylate transporter (mct ), encoded by the slc a gene, mediates h + -coupled transport of lactate across the plasma membrane. for cells with high glycolytic activity lactate export is of major importance for the maintenance of the glycolytic metabolism and for the prevention of intracellular acidification. in glycolytic tumor cells, the acidic extracellular environment resulting from export of lactate and h + , furthermore promotes anti-apoptotic effects and metastasis. clear cell renal cell carcinoma (ccrcc) is the most common subtype of renal cell carcinoma (rcc) and is characterized by a metabolic shift towards enhanced aerobic glycolysis and hence, increased lactate production. mct and its epigenetic regulation by slc a promoter methylation has previously been identified as prognostic marker for ccrcc outcome and as target for ccrcc treatment. since metastatic ccrcc is associated with poor overall survival and represents a major challenge for treatment, mct /slc a might represent a promising prognostic marker and a target for therapeutic intervention also for metastatic disease. methods: mct protein expression was analysed in paraffin embedded tissue samples of distant metastases derived from different organs by immunohistochemical staining of tissue microarrays. protein expression was evaluated semi-quantitatively using tissue studio v. . (definiens ag). dna methylation in the slc a promoter, specifically at the previously identified cpg site with prognostic potential in primary ccrcc, was analysed in paraffin embedded metastasis samples by maldi tof-ms. mct protein expression data and dna methylation at the specific cpg site in the slc a promoter were correlated with clinicopathological parameters and outcome data. results: distant metastases of primary ccrcc showed high mct protein expression irrespective of the affected organ. the most frequently affected organs like lung or bone, with approximately % and % in our cohort respectively, showed similar expression levels as less frequent metastatic sites such as thyroid gland or spleen. accordingly, dna methylation at the identified cpg site in the slc a promoter was low in metastatic tissue in all investigated organ sites. an association of low promoter dna methylation level at the previously identified prognostic cpg site in metastases with poor tumor-specific survival of the patients was observed. conclusion: from these results we hypothesize that dna methylation at specific cpg sites in the '-regulatory region of mct may not only serve as a predictor for patient outcome and as potential novel target for therapeutic intervention in primary, but also for metastatic disease. tamoxifen is used to treat pre-and postmenopausal women with estrogen-receptor (er) positive breast cancer. as a prodrug, tamoxifen undergoes extensive hepatic metabolism resulting in a complex mixture of metabolites with estrogenic and antiestrogenic effects. while endoxifen and (z) -hydroxytamoxifen are the most potent antiestrogenic metabolites, bisphenol and both isomers (e) and (z) of metabolite e are the most potent compounds with estrogenic properties at the er. the mixed antagonist/agonist pharmacodynamic effects of the selective estrogen receptor modulator tamoxifen at the er have been mainly attributed to tissue specific action of er coregulators, yet little is known about agonistic metabolites contributing to its estrogenic actions. the aim of the present study was to clarify whether there is a genetic component for interindividual differences in the formation and clinical effect of agonistic tamoxifen metabolites. a genome-wide association study (gwas) was conducted on steady-state agonist plasma levels in postmenopausal breast cancer patients of european origin who were treated with mg/day of tamoxifen for at least months. plasma concentrations of estrogenic metabolites bisphenol, (e), and (z) metabolite e were quantified using a recently established lc-ms/ms method . promising snps for an association between genotype and either plasma metabolite concentration or clinical outcome were confirmed for their relevance in an independent patient cohort of premenopausal breast cancer patients mainly of european descent , . twelve snps close to or above genome-wide significance (p < e- ) were found to be associated with allele-dependent variable (e) or (z) metabolite e plasma levels, while no genomic hit was found for the tamoxifen metabolite bisphenol. here, positive intergenic or genic regions mapped to chromosomes , and for (e) metabolite e and to chromosomes and for (z) metabolite e. upon genotyping of the validation cohort, two genetic loci with minor allele frequencies < % were confirmed as putative candidates: rs was associated with a - % variant allele-dependent increase of (e) and (z) metabolite e isomers (p< . ), and rs , mapping to a gene encoding zinc finger protein znf , was associated with increased risk of reccurrence or death (hr carriers . , % ci: . - . ; p < . ). these findings suggest the existence of genetic loci that may contribute to the formation and clinical effect of estrogenic tamoxifen metabolites and therefore could explain therapeutic failure of tamoxifen and/or the occurrence of adverse events during treatment. introduction: metabolomic monitoring of endogenous biomarkers is of increasing importance for the assessment of drug safety and efficacy during clinical drug development. myrcludex b, a novel lipopetide-based entry inhibitor for the therapy of hepatitis b and d, exerts its function through inhibition of the hepatic bile acid transporter na + -taurocholate cotransporting polypeptide (ntcp). in order to assess a myrcludex binduced metabolomic response in humans, lc/ms-based monitoring of endogenous metabolites was performed in blood and urine samples from healthy individuals before and during treatment with myrcludex b. methods: plasma and urine samples were collected from healthy volunteers participating in clinical phase i trials to evaluate safety, tolerability, and pharmacokinetics of single doses of the ntcp inhibitor myrcludex b. using quadrupole time-of-flight mass spectrometry coupled to reversed-phase chromatography (lc-qtof-ms) a set of known ntcp substrates (bile acids) was quantified by targeted metabolomics. protein precipitation was performed in the presence of deuterium-labeled internal standards (istds) which allowed absolute bile acid (ba) quantification in low amounts of plasma. ba profiling in urine was performed after dilution with methanol/water ( : ) in the presence of istds. both methods were validated according to fda guidance and applied to monitor the effect of myrcludex b treatment on human bile acid homeostasis. results: dynamic quantification in plasma and urine was achieved in the range from . nm to nm depending on the ba species analyzed. intraday-and interday accuracy and precision were in the % tolerance range for all analytes in all matrices. matrix effects were between - % (plasma) and - % (urine), apparent recoveries in plasma were above %. basal plasma ba level (mean ± sd) in fasting healthy subjects were ± nm (unconjugated bas), ± nm (glycine-conjugated bas) and ± nm (taurine-conjugated bas). urinary ba level (nmol/g creatinine) were ± nm (unconjugated bas), ± nm (glycine-conjugated bas) and ± nm (taurine-conjugated bas). myrcludex-induced ntcp inhibition resulted in significantly elevated amounts of conjugated ba species demonstrating a spillover of ntcp substrates into the systemic circulation. furthermore, higher urinary ba level were observed during treatment indicating accelerated elimination of excessive bas from the body. conclusion: lc/ms-based monitoring of endogenous biomarkers has been successfully established and applied to study the effect of myrcludex b treatment on human ba metabolism. the results obtained by our assay demonstrate that a myrcludex-induced ntcp inhibition drastically affects human ba homeostasis. this observation provides valuable insights into the drug´s mode of action and will be indispensable for the assessment of side effects and dose-finding processes during future clinical trials. further studies are required to assess a possible role of ba modification (e.g. sulfation) in the process of ba detoxification during myrcludex treatment. key: cord- -i amqpmt authors: krawczyk, noa; fingerhood, michael i.; agus, deborah title: lessons from covid : are we finally ready to make opioid treatment accessible? date: - - journal: j subst abuse treat doi: . /j.jsat. . sha: doc_id: cord_uid: i amqpmt nan j o u r n a l p r e -p r o o f covid- has devastated americans across many communities, bringing unprecedented challenges to our economy, our healthcare system, and our way of life as we knew it. like many historical moments and life-changing events, the covid- pandemic has forced us to look inward and reflect deeply on our existing systems, shining a painful light on profound inequities and shortcomings of our healthcare and social support structures. the addiction treatment system is no exception. while there is growing recognition among experts that opioid use as a leading public health problem, addiction treatment programs remain siloed from the healthcare system and burdened with protocols based on punitive ideologies rather than evidence-based practices. despite overwhelming evidence for methadone and buprenorphine, two opioid agonists that substantially reduce overdose risk (sordo, barrio, and bravo, et al, ) , these medications remain highly controlled and inaccessible to most individuals in need of treatment for opioid use disorder. strict regulations on the provision of such medications, often upheld as necessary to promote safety and avoid illicit diversion, are deeply embedded in a culture of stigma and criminalization that instead limit their use (doernberg, krawczyk, agus, and fingerhood, ) . this approach has generated treatment programs that prioritize adherence to rules, whether or not they are rational and effective, rather than promoting inclusion and retention. like most patients failed by our current health system, those who suffer the most are the same vulnerable groups that will likely be hardest hit by covid- : those who are victims of poverty, trauma, and discrimination and who frequently suffer from co-occurring conditions, such as depression, heart disease, hiv, and other illnesses. yet this restrictive approach has dramatically changed overnight, not because the paradigm has suddenly changed, but because the covid- health crisis emerged. in just a matter of weeks, swift modifications in our opioid treatment regulations that the substance abuse and mental health administration announced in march have revealed an alternative reality by which patients with opioid use disorder in the u.s. can now access treatment. longer take-homes for methadone-which previously were only allowed after a patient completed years of daily visits to clinics-are now considered standard. buprenorphine treatment initiationpreviously requiring a lengthy evaluation process by a waivered physician followed by frequent monitoring-can now be done over a simple phone call. mandates for supervised urine drug screens and in-person behavioral counseling sessions have been largely relinquished or adapted to be remote. at the same time, the drive to prevent the spread of covid- in detention centers j o u r n a l p r e -p r o o f has led to the unprecedented dismissal of thousands of low-level drug charges, which would have otherwise led to the incarceration of many drug users with minimal or no access to effective treatment. these changes are a reaction borne out of necessity to prevent a disastrous surge of covid- cases and a simultaneous surge in relapse and overdose deaths (becker and fiellin, ) . social distancing policies and quarantine orders made requirements for numerous inperson visits and high vigilance of patients unrealistic and unsustainable. the truth, however, is that these requirements were never realistic or sustainable. years of research have shown that requiring frequent visits, heavy monitoring, and mandatory participation in adjunct services to be eligible for life-saving medications created unnecessary barriers to accessing care (krawczyk, buresh, gordon, blue, et al, ) . obstacles, such as long transportation times, difficulty managing appointments around work and childcare responsibilities, and the stigma associated with waiting in long lines to access treatment or provide urine drug tests under supervision, impede initiation and retention in treatment (reisinger, schwartz, mitchell, et al, ). these barriers have not only resulted in limited utilization of available treatment programs but have likely helped to sustain an illicit market of buprenorphine that allows opioid users to access treatment and reduce overdose risk more easily than enrolling in a formal treatment program (carlson, daniulaityte, silverstein, nahhas, ) . similarly, the health risks associated with crowded jails and cycling in and out of the criminal justice system did not begin with covid- : for decades, incarceration has created devastating outcomes for public health (wildeman and wang, ) , increasing risk for overdose, trauma, homelessness, and reduced access to healthcare. the current morass and devastation of covid- , therefore, offers an opportunity to adopt a much-needed revision to the status-quo and create a more sustainable, equitable, and harm reduction-oriented system. existing models for services both in the u.s. and other countries exemplify the potential for offering opioid treatment through more accessible mechanisms (krawczyk, buresh, gordon, blue, et al, ; calcaterra, bach, chadi, et al, ) , when epidemics collide: coronavirus disease (covid- ) and the opioid crisis methadone matters: what the united states can learn from the global effort to treat opioid addiction unintentional drug overdose: is more frequent use of non-prescribed buprenorphine associated with lower risk of overdose? demystifying buprenorphine misuse: has fear of diversion gotten in the way of addressing the opioid crisis? expanding lowthreshold buprenorphine to justice-involved individuals through mobile treatment: addressing a critical care gap decriminalization: different models in portugal and spain. in: dual markets: comparative approaches to regulation premature discharge from methadone treatment: patient perspectives mortality risk during and after opioid substitution treatment: systematic review and meta-analysis of cohort studies mass incarceration, public health, and widening inequality in the usa key: cord- -cxz hf q authors: matarazzo, laura; casilag, fiordiligie; porte, rémi; wallet, frederic; cayet, delphine; faveeuw, christelle; carnoy, christophe; sirard, jean-claude title: therapeutic synergy between antibiotics and pulmonary toll-like receptor stimulation in antibiotic-sensitive or -resistant pneumonia date: - - journal: front immunol doi: . /fimmu. . sha: doc_id: cord_uid: cxz hf q bacterial infections of the respiratory tract constitute a major cause of death worldwide. given the constant rise in bacterial resistance to antibiotics, treatment failure is increasingly frequent. in this context, innovative therapeutic strategies are urgently needed. stimulation of innate immune cells in the respiratory tract [via activation of toll-like receptors (tlrs)] is an attractive approach for rapidly activating the body's immune defenses against a broad spectrum of microorganisms. previous studies of the tlr agonist flagellin in animal models showed that standalone tlr stimulation does not result in the effective treatment of pneumococcal respiratory infection but does significantly improve the therapeutic outcome of concomitant antibiotic treatment. here, we investigated the antibacterial interaction between antibiotic and intranasal flagellin in a mouse model of pneumococcal respiratory infection. using various doses of orally administered amoxicillin or systemically administered cotrimoxazole, we found that the intranasal instillation of flagellin (a dose that promotes maximal lung pro-inflammatory responses) induces synergistic rather than additive antibacterial effects against antibiotic–susceptible pneumococcus. we next set up a model of infection with pneumococcus that is resistant to multiple antibiotics in the context of influenza superinfection. remarkably, the combination of amoxicillin and flagellin effectively treated superinfection with the amoxicillin-resistant pneumococcus since the bacterial clearance was increased by more than -fold compared to standalone treatments. our results also showed that, in response to flagellin, the lung tissue generated an innate immune response even though it had been damaged by the influenza virus and pneumococcal infections. in conclusion, we demonstrated that the selective boosting of lung innate immunity is a conceptually advantageous approach for improving the effectiveness of antibiotic treatment and fighting antibiotic-resistant bacteria. bacterial infections of the respiratory tract constitute a major cause of death worldwide. given the constant rise in bacterial resistance to antibiotics, treatment failure is increasingly frequent. in this context, innovative therapeutic strategies are urgently needed. stimulation of innate immune cells in the respiratory tract [via activation of toll-like receptors (tlrs)] is an attractive approach for rapidly activating the body's immune defenses against a broad spectrum of microorganisms. previous studies of the tlr agonist flagellin in animal models showed that standalone tlr stimulation does not result in the effective treatment of pneumococcal respiratory infection but does significantly improve the therapeutic outcome of concomitant antibiotic treatment. here, we investigated the antibacterial interaction between antibiotic and intranasal flagellin in a mouse model of pneumococcal respiratory infection. using various doses of orally administered amoxicillin or systemically administered cotrimoxazole, we found that the intranasal instillation of flagellin (a dose that promotes maximal lung pro-inflammatory responses) induces synergistic rather than additive antibacterial effects against antibiotic-susceptible pneumococcus. we next set up a model of infection with pneumococcus that is resistant to multiple antibiotics in the context of influenza superinfection. remarkably, the combination of amoxicillin and flagellin effectively treated superinfection with the amoxicillin-resistant pneumococcus since the bacterial clearance was increased by more than -fold compared to standalone treatments. our results also showed that, in response to flagellin, the lung tissue generated an innate immune response even though it had been damaged by the influenza virus and pneumococcal infections. in conclusion, we demonstrated that the selective boosting of lung innate immunity is a conceptually advantageous approach for improving the effectiveness of antibiotic treatment and fighting antibiotic-resistant bacteria. keywords: flagellin, toll-like receptor , antibiotic, resistance, streptococcus pneumoniae, pneumonia, superinfection introduction pneumonia constitutes a major cause of death, morbidity and health resource use worldwide. the main causative agents identified in adult patients hospitalized for community-acquired pneumonia (cap) are viruses (in - % of cases, the most common being rhinovirus, influenza and coronavirus) and bacteria ( - % of cases, with a marked predominance of streptococcus pneumoniae infections) ( ) ( ) ( ) . when faced with overt clinical signs of bacterial pneumonia, the standard of care is antibiotic treatment. the combination of a constant rise in antibiotic resistance in recent decades with a decline in the discovery of new drugs has led to an increase in treatment failure and mortality ( ) . in , the world health organization's global action plan highlighted the urgent need to control the emergence of antibiotic resistance ( ) . given this context, a number of new anti-infectious treatment strategies are being developed. the modulation of innate immunity [by targeting immune receptors, such as toll-like receptors (tlrs)] is a promising approach ( , ) . indeed, innate immunity is highly conserved in evolution, and this system constitutes the first line of defense against invading pathogens. moreover, innate immunity triggers a broad range of antimicrobial defense mechanisms and immune cells-thereby greatly reducing the risk of resistance in the pathogens. moreover, activation of tlr signaling has been associated with a favorable outcome in infections with antibiotic-resistant bacteria or colonization resistance by such pathogens ( ) ( ) ( ) . these observations support that stimulation and effector activities of innate immunity are not influenced by the antibiotic resistance mechanisms carried by bacteria. flagellin is the main protein component of the bacterial flagellum and is a natural agonist of tlr ; the latter is expressed at the surface of a many different cell types, including mucosal epithelial cells and immune cells such as dendritic cells, macrophages, and lymphocytes ( ) . various studies in animal models have highlighted the antimicrobial potency of flagellin against a wide variety of bacterial infections [such as intestinal infections caused by salmonella enterica, enterococcus faecium, clostridium difficile, and escherichia coli ( , ( ) ( ) ( ) , respiratory infections caused by pseudomonas aeruginosa and s. pneumoniae ( , ) ], and viral and fungal infections ( ) ( ) ( ) . although most studies have demonstrated the protective effect of flagellin administered before or during exposure to a microbial pathogen, the protein's immunostimulatory efficacy in therapeutic context has not been extensively characterized. using a mouse model of s. pneumoniae lung infection, we recently demonstrated that combination treatment with mucosally administered flagellin and an orally or intraperitoneally administered low-dose (i.e., subtherapeutic) antibiotic is more effective than the antibiotic alone (i.e., with a lower bacterial load in the lung, and a lower mortality rate). furthermore, the combination treatment was also effective in a model of post-flu pneumococcal superinfection ( ) . the effectiveness of these combination therapies depends on tlr signaling as demonstrated using tlr -deficient animals and tlr -mutated recombinant flagellin ( ) . our studies highlighted that the airway epithelium is the main tlr -specific signaling compartment ( ) ( ) ( ) . taken as a whole, these observations are the first to highlight the added value of respiratory delivery of flagellin as an immunomodulatory biologic for the adjunct treatment of bacterial pneumonia (i.e., in addition to the standard of care). our working hypothesis was that simultaneous treatment with an antibiotic and intranasal, i.e., respiratory flagellin constitutes a "double hit" against the pathogen. a combination of two drugs may result in independent actions or specific (i.e., additive, synergistic, or antagonistic) effects that define the biological outcome ( ) ( ) ( ) . an interaction between two drugs is considered to be synergistic when the measured effect of the combination treatment exceeds the predicted cumulative value of the two components given separately. synergy increases treatment efficacy, and is expected to limit the emergence of drug resistance. furthermore, synergy allows the physician to decrease the dose level or the frequency of dosing, which thereby dampens adverse drug reactions and may even enable the rehabilitation of neglected drugs. conversely, an antagonistic combination treatment has a smaller effect than the predicted cumulative value of the two components given separately. most studies of potentially synergistic antimicrobial agents are performed in in vitro systems such as bacterial cultures, using checkerboard assays and increasing doses of each drug ( , ) . unlike antibiotics that directly affect the bacteria, immunomodulatory biologic activity requires sentinel cells for detection, downstream signaling and thus the production of antimicrobial effectors and the recruitment and/or activation of innate immune cells. at present, there are no comprehensive in vitro models of this complicated physiological system. in the present study, we quantified the nature and magnitude of the interactions between antibiotics and intranasal instillation of flagellin with regard to antibacterial effectiveness in a murine model of s. pneumoniae respiratory infections. furthermore, we wanted to assess the efficacy of this novel therapeutic strategy against infection with antibiotic-resistant bacteria, which represents major public health issues today. to this aim, we investigated the combination's effect on antibiotic-resistant s. pneumoniae in a relevant model of post-flu pneumococcal pneumonia, and characterized the immune response induced by the flagellin-mediated protection. serotype s. pneumoniae (sp ; clinical isolate e ) was obtained from the national reference laboratory-ministry of health, uruguay ( ) . serotype s. pneumoniae (sp ; strain ) was provided by the institut pasteur (paris, france); it is a multidrug-resistant clinical isolate from a human bronchial secretion, and is resistant to amoxicillin (amx), cefotaxime, doxycycline, erythromycin, chloramphenicol, streptomycin, and cotrimoxazole (sxt). working stocks were prepared as described previously ( , ) . briefly, fresh colonies grown on bloodagar plates were incubated in todd hewitt yeast broth (thyb) (sigma-aldrich, saint-louis, mo) at • c until the od nm reached . - . units. cultures were stored at − • c in thyb + glycerol % (vol./vol.) for up to months. for infection, working stocks were thawed and washed with sterile dulbecco's phosphate-buffered saline (pbs, gibco, grand island, ny) and diluted to the appropriate concentration. the number of bacteria (as colony forming units [cfus] ) was confirmed by plating serial dilutions onto % sheep blood agar plates. female balb/cj mice, female swiss mice, and male c bl/ j mice ( - weeks old) (janvier laboratories, saint berthevin, france, or envigo, huntingdon, uk) were maintained in individually ventilated cages and handled in a vertical laminar flow cabinet (class ii a , esco, hatboro, pa). all experiments complied with institutional regulations and ethical guidelines (c - , institut pasteur de lille; protocol ). prior to intranasal infection, the mice were anesthetized via the intraperitoneal injection of . mg ( mg/kg) ketamine plus . mg ( mg/kg) xylazine in µl of pbs. for primary infections with sp , - × cfu were inoculated intranasally in µl pbs, as described previously ( ) . the influenza infection model was developed in our laboratory on the c bl/ j mice ( , ) . the sp pneumococcal superinfection model was therefore performed in these animals. briefly, mice were first infected intranasally with µl pbs containing plaque-forming units (pfus) of the pathogenic, murine-adapted h n influenza a virus strain scotland/ / , as described previously ( , ) . seven days later, animals were infected intranasally with cfu of sp in µl pbs. for the determination of bacterial counts in lung and spleen, mice were sacrificed at selected times via the intraperitoneal injection of . mg of sodium pentobarbital in µl pbs. tissues were collected and homogenized with an ultraturrax homogenizer (ika-werke, staufen, germany), and viable counts were determined by plating serial dilutions onto blood agar plates and incubating them at • c for - h. the recombinant flagellin flic − came from s. enterica serovar typhimurium flic and was produced with an histidine tag, as described previously ( , ) . the protein flic − was certified to be immunologically active in reporter cells and in mouse assays, and the residual lipopolysaccharide concentration was determined to be < pg per µg of flagellin ( ) . the treatments' effects on s. pneumoniae lung infection were quantified as the percentage bacterial growth (% growth ), corresponding to the ratio of the mean bacterial load in the lungs of infected, treated mice to the load in infected, nontreated (control) mice. for example, the effect of treatment a was calculated as follows: % growth[a] = (mean cfu [a] /mean cfu [control] ) × . the predicted additive effect (or predicted % growth ) of a combination treatment was calculated as described previously ( ) . briefly, the predicted % growth of a treatment combining compounds a and b is the product of the experimentally defined % growth values for each standalone treatment (predicted% growth[a+b] = % growth[a] × % growth [b] ). if the experimental % growth for the combination treatment is lower or higher than the predicted % growth , then the two drugs are synergistic or antagonistic, respectively. when the experimental and predicted % growth values are identical, the two drugs' effects are additive. total lung rna was extracted with the nucleospin rna plus kit (macherey-nagel, duren, germany) and reverse-transcribed with the high-capacity cdna archive kit (applied biosystems, foster city, ca). the cdna was amplified using sybr greenbased real-time pcr on a quantstudio k pcr system (applied biosystems). relative mrna levels ( − ct ) were determined by comparing first the pcr cycle thresholds (c q ) for the gene of interest and the reference genes actb and b m ( c q ), and then the c q values for infected mice treated with the amx+flagellin combination treatment and with amx alone (control group) ( cq). all the primers used in the study (listed in table ) were validated for efficacy. bronchoalveolar lavage (bal) fluid samples were obtained after intratracheal injection of × ml of pbs supplemented with % fetal calf serum (fcs). lungs were perfused with pbs, excised and finely minced then digested in a solution of rpmi medium (gibco) containing mg/ml collagenase viii (sigma-aldrich) and µg/ml dnase i (sigma-aldrich) for min at • c. after washes, red blood cells were removed using a lysis solution (pharmlyse, bd bioscience). lung cell homogenates were then suspended in a % percoll gradient and centrifuged at , rpm without brake at room temperature for min. the cell pellets were washed with pbs supplemented with % fcs and cells were filtrated before antibody labeling. bal and lung cells were stained with anti-cd -allophycocyanin-cyanine (clone f ), anti-cd b-brilliant violet (clone m . ), anti-siglecf-alexafluor (clone e - ), anti-ly c-peridinin chlorophyll protein-cyanine . (clone hk . ), anti-ly gphycoerythrin (clone a ), anti-cd c-phycoerythrin-cyanine (clone hl ), and ccr -brillant violet (clone sa g ) antibodies. dead cells were excluded from the analysis using propidium iodide. the antibodies were purchased from bd biosciences (san jose, ca) or biolegend (san diego, ca). data were collected on a bd lsr fortessa and analyzed with the bd facsdiva software. concentration of ccl , cxcl , cxcl , il- , il- β, and tnf was determined in bal fluids and lung homogenates by enzymelinked immunosorbent assay (elisa kit from ebioscience, r&d systems or becton dickinson). bal fluids were obtained by intratracheal injection of × ml pbs supplemented with protease inhibitors (roche). lungs were perfused with pbs and collected in t-per reagent (pierce) supplemented with protease inhibitors and debris were eliminated by centrifugation. all samples were stored at − • c. the results were described as the mean ± standard error of the mean (sem) or the median (range), as indicated. intergroup differences were analyzed using the mann-whitney test and the log rank test. all analyses were performed with prism software (version . , graphpad software, la jolla, ca). the threshold for statistical significance was set to p < . . in earlier research, we had shown that the intranasal administration of a combination of flagellin flic − and low-dose antibiotics improved the therapeutic outcome of lung infection with the antibiotic-susceptible sp [minimum inhibitory concentration (mic) amx = . µg/ml] ( ) . given the difficulty of performing in vitro checkerboard assays with immunomodulators, we therefore sought to evaluate the nature of antibiotic-flagellin interactions in vivo. we first defined the dose of flagellin that promoted saturating immune responses in sp -infected mice (figure ) . intranasally administered flagellin was associated with the production of various innate immunity-related components, including chemokines (cxcl , cxcl , and ccl ), inflammatory cytokines (il- β and il- ), and antimicrobial peptides (s a ), along with the recruitment of neutrophils to the airways ( , , , , , ) . mice were treated simultaneously with oral amx ( . mg/kg) and intranasal flagellin flic − (at doses of . µg to mg/kg, i.e., ng to µg per animal). immune responses were analyzed by monitoring the lung transcription of inflammatory genes associated with tlr signaling and by comparing mrna levels to animals that received amx alone. the results showed that doses from to µg per animal saturated the upregulation of transcriptional response for cxcl , cxcl , ccl , il b, and il genes. ultimately, the dose of . µg of flic − was selected as a saturating immunostimulatory dose in the context of pneumococcal infection and lung inflammation. the next set of experiments was designed to characterize the therapeutic interaction between intranasal flagellin flic − and oral amx. mice were infected with sp and treated h later with either a single intranasal instillation of flagellin ( . µg), a single intragastric administration of suboptimal amx doses of µg ( . mg/kg) or µg ( . mg/kg) or the combination treatment. to define the treatments' efficacy, lung bacterial counts were measured at h post-treatment. the results showed that flagellin alone had mostly no antibacterial effect, whereas and µg doses of amx alone were, respectively, associated with -and -fold smaller bacterial loads, relative to untreated mice (figure a) . the combination treatment (amx + flic − ) induced a -fold relative decrease in bacterial counts for µg of amx and a -fold relative decrease for µg of amx-showing that amx-flagellin combination treatment is more effective than the corresponding dose of amx or flagellin as monotherapy (figure a) . the nature of the interactions between flagellin and antibiotics was further analyzed by comparing the bacterial growth upon treatment. the % growth values for the combination treatment ( . % for flagellin + amx µg and . % for flagellin + amx µg) were much lower than the corresponding predicted % growth values for additive effects, calculated as % growth[amx] × % growth[flagellin] ( . % for flagellin + amx µg and . % for flagellin + amx µg) (figure b) . this experiment indicated strong synergy between the two compounds. similar experiments were carried out with the combination of the antibiotic sxt and flagellin (figures c,d) . the antibiotic sxt was administered intraperitoneally at doses of and mg ( and mg/kg, respectively). flagellin ( . µg) significantly improved the therapeutic outcome of sxt treatment, as evidenced by cfu counts in the mice's lungs h after administration of the treatments ( figure c) . the experimental % growth values for the combination treatment were lower than the corresponding predicted % growth values ( vs. . % for sxt mg, and . vs. . % for sxt mg)-reflecting a synergy between flagellin and sxt ( figure d ). taken as a whole, these results show that antibiotics + flagellin had a strong synergistic effect on pneumococcal lung infection in mice. furthermore, the synergy seems to be independent of the type of antibiotic, since it was observed with a compound that inhibits bacterial cell wall (amx) and a pair of compounds that inhibits folic acid synthesis (sxt). next, we looked at whether the combination treatment's effect on an antibiotic-sensitive s. pneumoniae strain was also exerted on antibiotic-resistant bacteria. to this end, a mouse model of infection with a sp strain that is resistant to a wide range of antibiotics including amx (mic amx = µg/ml, i.e., -fold higher than for sp ) was developed. we found that the sp strain failed to induce a lethal infection and other signs of disease (weight loss) in naïve mice-even at high doses of challenge ( or bacteria per animal) (figures a,b) . given that the influenza virus infection increases susceptibility to bacterial infections even after it has been eliminated ( - ), sp infection was assessed in mice that had already been exposed to the virus. briefly, mice were infected first with an intranasal, sublethal dose of h n virus ( pfu) and then infected days later with cfu of sp . this bacterial superinfection induced significant weight loss and was % lethal (figures a,b) . the bacterial counts increased gradually over time, and reached cfu per lung h post-infection ( figure c) . sp was also detected in the spleen-indicating a translocation and systemic dissemination of the bacteria-from h post-infection onwards (figure c ). in conclusion, the antibiotic-resistant sp strain induced effective pneumonia when animals had been previously exposed to experimental flu. in order to test the efficacy of an antibiotic+flagellin combination treatment in the post-influenza sp superinfection model, mice were treated with amx alone, flagellin flic − alone, or a combination of both compounds h after the bacterial infection ( figure a ). due to the high level of amx resistance, the doses of antibiotic used were µg ( mg/kg) and µg ( mg/kg). using this regimen, the serum concentration levels of amx in naïve animals were expected to be close to × mic and × mic, respectively (professor charlotte kloft, personal communication). flagellin treatment alone decreased bacterial counts in the lungs by . -fold, whereas amx treatments decreased bacterial counts by . -fold (for a dose of µg) and . -fold (for a dose of µg). when amx was combined with flagellin, bacterial counts were of , -and , -fold lower for the and µg doses of antibiotic, respectively. these results show a significant therapeutic advantage for the combination treatment, relative to standalone amx or flagellin treatments ( figure b) . we also determined cfu counts in the spleen; both amx and amx + flagellin treatments (either with or µg of the antibiotic) were able to prevent systemic dissemination of the infection (data not shown). comparison of % growth for the observed effect of the combination treatment vs. predicted additive effect ( . vs. . % for amx µg, and . vs. . % for amx µg) demonstrated the synergy of the combination in the context of superinfection and antibiotic resistance ( figure c) . after two administrations of treatments and h after sp superinfection, the flagellin + amx combination was found to significantly improve the survival of mice, relative to standalone treatments ( figure d) . these data strongly suggest that flagellin + amx have synergistic therapeutic effects to control the antibiotic-resistant pneumococcal infections in relevant pathophysiological contexts. since infection by influenza virus induces major changes in lung integrity and immune cell populations, we investigated the immunomodulatory impact of flagellin on post-flu respiratory infections by the antibiotic-resistant sp strain. to this end, c bl/ mice were infected with influenza a virus at day and then challenged with antibiotic-resistant sp at day . treatments with oral amx ( µg) combined or not with intranasal flagellin ( . µg) were administered h after sp infection. lungs were collected h post-treatment for transcriptional analysis using rt-qpcr assays, as described in figure . we observed that despite the superinfection, flagellin still enhanced the transcription of cxcl , cxcl , ccl , il b, il , and s a genes, i.e., surrogate markers of tlr mediated lung stimulation ( figure a) . we next quantified the cytokine/chemokine production after h of treatment both in the bal fluids and lung protein extracts. delivery of flagellin in the lung of amx-treated pneumococcal superinfection significantly increased levels of ccl , cxcl , cxcl , and tumor-necrosis factor (tnf) both in the lungs ( figure b ) and in the bal fluids ( figure c ) in amx+flagellin-treated mice compared with amx+pbs-treated mice. we also observed increased il- production in both compartments although it was not statistically significant. production of il- β (or pro-il- β) was detected only in the lung tissue and was increased in flagellin-treated mice. finally, we used flow cytometry to evaluate immune cell populations in bal fluids and lung tissue collected h posttreatment. the analysis showed that the neutrophil counts were higher in mice having receiving the combination treatment (i.e., tlr stimulation and amx) than in mice having receiving amx alone both in the lung tissues ( figure d ) and the bal fluids ( figure e) . interestingly, the innate response to combination treatment was also detectable in blood since the production of the inflammatory mediators were significantly augmented at h (for il- , ccl , cxcl , and cxcl ) and h (ccl and cxcl ) compared to amx alone treatment (supplementary figure ) . the blood cytokine production then diminished to an undetectable or very low level at h. thus, these observations showed that the mucosal delivery of flagellin does not induce sustained systemic inflammation. overall, the innate immune response to flagellin was effectively stimulated in the context of the influenza immunological imprinting, the superinfection challenge, and the antibiotic treatment. our present results demonstrated the synergistic efficacy of a combination of an antibiotic (amx or sxt) and the local administration of the immunomodulatory biologic flagellin against respiratory infections caused by s. pneumoniae. of note, the efficacy of combined antibiotic + flagellin treatment, previously demonstrated in inbred balb/c and c bl/ mice by porte et al. ( ) , was here extended to outbred swiss mice, showing genetic background independence of the protection. remarkably, flagellin was able to trigger lung innate immune responses in the context of inflammation (i.e., airways damaged by bacterial pneumonia and flu). immunostimulation in the lung was a dose-dependent process that was saturating by microgram-per-animal levels of flagellin. the synergy appeared to be independent of the antibiotic dose level and the antibiotic's target, since amx acts on the bacterial cell wall and sxt inhibits dna synthesis. the present study is also the first to have demonstrated that stimulating innate immunity can treat severe pneumonia induced by antibiotic-resistant pathogenic bacteria; this may open up new avenues for the treatment of pneumonia in the context of growing antimicrobial resistance. it has been demonstrated that intranasal administration of flagellin activates tlr -dependent local innate responses with broad-spectrum antibacterial activity ( , , , , , ) . the pulmonary response includes the production of various antimicrobial peptides (i.e., cathelicidin antimicrobial peptide and the β-defensins), cytokines (tnf, il- β, and il- ), and chemokines (i.e., ccl , cxcl , cxcl , cxcl , and cxcl ). this cytokine and chemokine production is in line with the observed recruitment of phagocytes (and especially neutrophils) in the lung following the intranasal administration of flagellin to naïve mice ( , , ) . flagellin intranasal administration specifically triggers tlr -mediated transcription in the lungs from to h after a pneumococcus infection or from to days after an influenza infection ( ) . here, we demonstrated that the lung innate immune signature induced by intranasal instillation of flagellin is still effective in a highly inflammatory context with associated lung damage (pneumococcal postinfluenza superinfection), and is not influenced by antibiotic treatment (figure ) . interestingly, earlier reports indicated that influenza infections promote the partial but sustained desensitization of tlr-mediated lung innate responses and a reduction in tlr expression ( ) . our observations demonstrate that, in the physiopathological context of superinfection, flagellin is still able to trigger sufficient levels of innate defense and exert synergy with antibiotics (figure ) . airway epithelial cells have been identified as an important component for detection of flagellin and tlr signaling at homeostasis ( , ) . these sentinel cells not only sense danger signals introduced in the conducting airways but also produce factors to directly impair the colonization and growth of pathogens or indirectly mobilize phagocytic and immune cells to clear infection. more generally, airway epithelium tlr signaling represent a key driving force in antibacterial defense ( ). recently, anas et al. demonstrated an essential contribution of epithelial signaling in the respiratory tract in response to flagellin in the context of infection with pseudomonas aeruginosa ( ) . our data showed that several antimicrobial peptides (s a ), cytokines (il- β and tnf), and chemokines (ccl , cxcl , and cxcl ) that were associated to epithelial responses are also upregulated after the administration of the combination treatment in the post-flu superinfection model, suggesting that the epithelium is also an important flagellin-specific driving force in the lung damaged by viral and bacterial infections. targeting epithelium is a serious benefit for immunostimulation since it allows reducing the dose and bypassing systemic adverse effects. our data contribute to highlight the therapeutic potential of the association of two drugs with distinct modes of action: an antibiotic with a direct effect on bacteria, and a tlr specific stimulator of innate immunity with indirect antibacterial activity mobilizing both multiple phagocytic host cells and various antimicrobial factors such as antibacterial peptides, and chemokines and cytokines that mobilize and activate immune cells. besides pathogen killing, the multitargeting of innate immunity by flagellin could impact on bacterial fitness and thereby increase susceptibility to the antibiotic. the innate immune response induced by tlr signaling may also modify the distribution of antibiotic in lung tissues while the antibiotic, by damaging the pathogen, could also enhance the immune signaling. in addition, the pharmacokinetics of the antibiotic and the immunostimulator, i.e., a short-term dose-dependent effect for the antibiotic, and an immediate and long-lasting impact of the immunostimulator due to cell mobilization, are likely complementary. finally, flagellin, by modulating innate immunity in the respiratory tract, has been shown to enhance the mucosal and systemic adaptive immunity ( , ) . such property may be of interest to elicit anti-pathogen immune memory and prevent recurrent/relapse infections. as an opportunistic bacterium, s. pneumoniae frequently colonizes the upper respiratory tract and thus represents lungs were collected h after treatment, and homogenized. after rna extraction, expression levels of selected genes were then analyzed using rt-qpcr assays. the relative expression level for each gene is expressed against that of the reference genes actb and b m and the reference condition amx+pbs (arbitrarily set to a value of ). the data represent the mean ± sem. lungs (b) and bal fluids (c) were collected h after treatment and cytokine (continued) figure | and chemokine levels were measured by elisa. data from amx+flagellin-treated and amx+pbs-treated mice were compared in a mann-whitney test and are represented as individual values and mean. lungs (d) and bals (e) were collected h after treatment. lungs and bal cell suspensions were stained using a mixture of antibodies specific for surface markers before flow cytometry analysis. neutrophils were defined as cd + cd b + ly g + cells after exclusion of dead cells and alveolar macrophages (cd + siglecf + cd c + cells) from the analysis. numbers of neutrophils in the lung parenchyma (d) and bal fluids (e) are shown for individual animal and the line represents the mean. data from amx+flagellin group were compared to those of amx+pbs group in a mann-whitney test. statistical significance is indicated as follows: *p < . , and **p < . . the prime cause of bacterial-associated cap ( ) . however, other microorganisms can cause cap and healthcare-associated pneumonia; they include gram-positive bacteria such as staphylococcus aureus, gram-negative bacteria like p. aeruginosa, klebsiella pneumoniae, haemophilus influenzae, mycoplasma (m. pneumoniae) and intracellular bacteria (legionella pneumophila) ( ). the diagnosis and treatment of cap is complicated by the broad variety of causative agents, and the progression of antibacterial resistance. in this context, immunomodulators such as flagellin are of great interest because they activate a large number of antimicrobial immune mechanisms. indeed, flagellin has already demonstrated its ability to protect against various pathogens including gram-negative and gram-positive bacteria ( , ( ) ( ) ( ) ( ) ( ) ) . furthermore, our present results showed that the therapeutic synergy between antibiotic and intranasal flagellin is independent of the antibiotic's mechanism of actionsuggesting that flagellin can potentially be combined with various antibiotics for a wide range of clinical situations. the synergistic effects of the combined therapy have been determined to be independent of capsule antigenicity (serotype or ) of pneumococcus, suggesting that the general innate immune protecting mechanisms triggered by flagellin could potentially be effective against a large variety of serotypes. given the progression of antibiotic resistance, a model of infection by antibiotic-resistant bacteria would constitute an important tool for developing alternative anti-infectious approaches. we first attempted to develop such a model in immunocompetent animals. the multidrug-resistant clinical isolate of pneumococcus sp was unable to induce a lethal infection, even at high doses. acquisition of antibiotic resistance is often associated with a loss of bacterial fitness ( ) , which might explain the sp 's very low virulence in naïve mice. it is now becoming clear that many cases of bacterial pneumonia result from co-infections or consecutive infections (especially influenza virus infections) ( ) . as shown by figures d,e, , influenza virus infection creates a favorable environment for colonization and invasion by the low-virulence antibioticresistant pneumococcus sp strain. our data demonstrated that the flagellin+amx combination treatment effectively reduces the bacterial burden caused by the sp strain in the lung, and improves the survival rate among treated mice. our proof-of-concept findings may be transposable to the clinic for patients with co-infections and superinfections, which are relevant physiopathological causes of hospitalization and complicated pneumonia. antibiotics constitute the current standard of care for bacterial pneumonia, and the growing threat of antibiotic resistance is a major public health concern. when defining the dosing regiments of antibiotics used to treat a patient, the physician must take account of the antibiotic' pharmacokinetic and pharmacodynamic characteristics. the relationship between in vivo exposure to the drug and in vitro susceptibility of the bacteria conditions not only the treatment's clinical outcome (i.e., clearance of the infection) but also adverse effects or drug toxicity ( ) . thus, the maximum dose of antibiotic that can be administered to a patient may not be enough to totally clear highly resistant bacteria. our data suggest that the antibacterial efficacy of these antibiotic dose levels can be synergistically enhanced by the effect of flagellin on lung innate immunity. taken as a whole, the present results suggest that the selective boosting of innate lung immunity by flagellin improves the therapeutic outcome of antibiotic treatment. in humans, this approach might be a useful generic alternative to the treatment of bacterial pneumonia, thereby reducing the antibiotic dose and regimen as well as the emergence of antibiotic resistance. moreover, such strategy promotes multitarget inhibition through multiple innate immune effectors that should be more resistant to the development of resistance and may restore some antibacterial activity to antibiotic in the context of antibiotic resistance. characterization of flagellin's contribution to the lung antibacterial defenses at the molecular and cellular level and the protein's synergy with antibiotics is likely to open up new avenues for the immunotherapy of respiratory tract infections. all experiments complied with institutional regulations and ethical guidelines (c - , institut pasteur de lille; protocol apafis # - ). the protocols were validated by the ethical committee for animal experiments (comitéd'éthique en expérimentation animale-nord-pas-de-calais ceea ). lm performed all animal, rt-qpcr, and flow cytometry experiments. fc, rp, dc, and cf provided lm with technical assistance. fw analyzed the bacterial species and antibiotic resistance. lm, cc, and j-cs designed experiments and wrote the manuscript. j-cs and cc supervised the experimental work as a whole. the study was funded by inserm, institut pasteur de lille, université de lille, inserm-transfert (grant: copoc innatebiotic r es), and the era-net joint programming initiative on antimicrobial resistance and the agence nationale de la recherche (grant anr- -jamr- - ). lm is a fellow of the innovation pharmaceutique et recherche program. aetiology of lower respiratory tract infection in adults in primary care: a prospective study in european countries community-acquired pneumonia requiring hospitalization among u.s. adults dynamics of lung defense in pneumonia: resistance, resilience, and remodeling overcoming the current deadlock in antibiotic research global action plan on antimicrobial resistance targeting toll-like receptors: promising therapeutic strategies for the management of sepsis-associated pathology and infectious diseases modulating immunity as a therapy for bacterial infections bacterial flagellin stimulates toll-like receptor -dependent defense against vancomycin-resistant enterococcus infection vancomycinresistant enterococci exploit antibiotic-induced innate immune deficits tlr- activation enhances il- -mediated colonization resistance against vancomycin-resistant enterococcus compartmentalized antimicrobial defenses in response to flagellin flagellin treatment protects against chemicals, bacteria, viruses, and radiation toll-like receptor stimulation protects mice from acute clostridium difficile colitis cutting edge: tlr -/-mice are more susceptible to escherichia coli urinary tract infection mucosal administration of flagellin protects mice from streptococcus pneumoniae lung infection flagellin stimulates protective lung mucosal immunity: role of cathelicidin-related antimicrobial peptide viral infection. prevention and cure of rotavirus infection via tlr /nlrc -mediated production of il- and il- recombinant tlr agonist cblb promotes nk cell-mediated anti-cmv immunity in mice flagellin-induced expression of cxcl mediates direct fungal killing and recruitment of nk cells to the cornea in response to candida albicans infection a toll-like receptor agonist improves the efficacy of antibiotics in treatment of primary and influenza virus-associated pneumococcal mouse infections radioresistant cells expressing tlr control the respiratory epithelium's innate immune responses to flagellin airway structural cells regulate tlr -mediated mucosal adjuvant activity indirect toll-like receptor -mediated activation of conventional dendritic cells promotes the mucosal adjuvant activity of flagellin in the respiratory tract analysis of drug combinations: current methodological landscape assessment and modelling of antibacterial combination regimens when does plus equal ? a review of antimicrobial synergy testing comparison of techniques for measurement of in vitro antibiotic synergism activation of type innate lymphoid cells and interleukin secretion in the lungs during streptococcus pneumoniae infection interleukin- is produced by invariant natural killer t lymphocytes during influenza a virus infection: potential role in protection against lung epithelial damages potential role of invariant nkt cells in the control of pulmonary inflammation and cd + t cell response during acute influenza a virus h n pneumonia invariant nkt cells modulate the suppressive activity of il- -secreting neutrophils differentiated with serum amyloid a deletion of flagellin's hypervariable region abrogates antibody-mediated neutralization and systemic activation of tlr -dependent immunity synergy testing of fda-approved drugs identifies potent drug combinations against trypanosoma cruzi both influenza-induced neutrophil dysfunction and neutrophil-independent mechanisms contribute to increased susceptibility to a secondary streptococcus pneumoniae infection influenza a inhibits th -mediated host defense against bacterial pneumonia in mice influenza and bacterial superinfection: illuminating the immunologic mechanisms of disease the co-pathogenesis of influenza viruses with bacteria in the lung mucosal administration of flagellin induces innate immunity in the mouse lung flagellin promotes myeloid differentiation factor -dependent development of th -type response lung epithelial cells: therapeutically inducible effectors of antimicrobial defense lung epithelial myd drives early pulmonary clearance of pseudomonas aeruginosa by a flagellin dependent mechanism understanding the pneumococcus: transmission and evolution antibiotic resistance and its cost: is it possible to reverse resistance? clinical applications of population pharmacokinetic models of antibiotics: challenges and perspectives we thank dr. aneesh vijayan for technical assistance in the production and quality control of recombinant proteins. we also thank the bicel flow cytometry core facility and the animal facility at the institut pasteur de lille for technical assistance. the supplementary material for this article can be found online at: https://www.frontiersin.org/articles/ . /fimmu. . /full#supplementary-material key: cord- -etb d y authors: shin, hyoung-shik title: empirical treatment and prevention of covid- date: - - journal: infect chemother doi: . /ic. . . . sha: doc_id: cord_uid: etb d y the rapid spread of severe acute respiratory coronavirus syndrome (sars-cov- ) in the population and throughout the cells within our body has been developing. another major cycle of coronavirus disease (covid- ), which is expected in the coming fall, could be even more severe than the current one. therefore, effective countermeasures should be developed based on the already obtained clinical and research information about sars-cov- . the aim of this review was to summarize the data on the empirical treatment of covid- acquired during this sars-cov- infection cycle; this would aid the establishment of an appropriate healthcare policy to meet the challenges in the future. the infectious disease caused by sars-cov- is characterized by common cold along with hypersensitivity reaction. thus, in addition to treating common cold, it is essential to minimize the exposure of cells to the virus and to mitigate the uncontrolled immune response. a proper combination of antiviral agents, immune modulators such as prednisolone, and anticoagulants such as heparin and anti-c a antagonists could be employed to minimize lung damage and prevent systemic involvements. finally, strategies to achieve population immunity against sars-cov- should be developed through understanding of the interaction between the immune system and the virus. novel coronavirus (severe acute respiratory coronavirus syndrome , sars-cov- ) has been rapidly spreading in the population [ ] as well as throughout the cells within their bodies [ , ] . to date, it has been around months that the whole world suffered from it. another major cycle of the infection is expected in the coming fall from the northern hemisphere which would be even more severe than the first one [ ] . therefore, it is important to develop more effective countermeasures based on the scientific data obtained during the first round of coronavirus disease . our previous article defined the nature of the infectious diseases as the hypersensitivity reaction by the virus and presented the basic treatments based on the hypersensitivity pneumonitis (hp) [ , ] . the diagnosis of covid- can be empirically achieved by one or though the covid- showed pandemic spread and unexpected clinical manifestations characterized by various symptoms throughout the whole body, sars-cov- seems to be less virulent especially in children and adolescents, in whom the disease mimics common cold caused by seasonal coronaviruses [ ] . therefore, basic therapeutic approaches used for common cold would be effective in case of mild symptoms and further treatment is not required in the absence of any other clinical manifestations [ ] . table summarizes the treatments used for common cold including that caused by coronaviruses. non-steroidal anti-inflammatory drugs (nsaids) can be safely used for - days without affecting the pentose phosphate pathway. in contrast, acetaminophen can increase reactive oxygen species in the cell and induce cell death [ , ]. however, use of nsaids can result in hypersensitivity [ ] and acute thromboembolic events [ ] . there were a few reports regarding concerns that nsaids can weaken the immune system if applied a week or longer [ , ] . prednisolone is safer and more efficacious, considering that it can overcome the overall inflammatory process in a cell by suppressing the diverse kind of cytokines including interleukins and tumor necrosis factor-α [ ] . hydrocortisone is considered the best medicine with fewer side effects. pseudoephedrine at dose of - mg is effective for the protection of epithelial cells by raising the intracellular cyclic guanosine monophosphate [ ] . antihistamine can help lessen the vascular permeability by blocking the platelet activating factor [ ] and alleviate allergic symptoms [ ] . cimetidine can improve the heartburn symptom and elevate the immune functions [ ] . theophylline at low doses ( - mg twice daily), the medicine applied to the treatment of asthma for a long time, can be administered safely. it can protect alveolar epithelium with the suppression of cytokine-inducible nitric oxide synthase (nos) and raising intracellular cyclic adenosine monophosphate [ ] . macrolide antibiotics including azithromycin cause few side effects and their early application can support epithelial cells for some time [ ] . macrolides transform gut microbiome so that they protect against the respiratory virus and strengthen endothelial nos pathway [ ] [ ] [ ] . human immunodeficiency virus (hiv) non-nucleoside reverse transcriptase inhibitors (nnrtis) such as rilpivirine described below can be used for the patients with common cold symptoms preemptively, instead of all medications mentioned above. that is what we experienced the effect of oseltamivir in the influenza (h n ) pandemic. at the early stage of the epidemic, it had been recommended to apply the treatment regimen of middle east respiratory syndrome coronavirus (mers-cov) in the case of the patients with severe symptoms [ ] . an interim guideline was suggested by the members of korean society of infectious diseases (ksid) in april, [ ] . this treatment strategy is further proposed with taking into consideration of the ksid guideline. pneumonia features observed in covid- are similar to that of hp. therefore, it is needed to follow the application of basic treatment strategy for hp [ ] , which is to prevent cell exposure to the virus and to abate the excessive immune reactions. in addition to this treatment strategy, it is needed to apply anticoagulants [ , ] . it is required not to interrupt the initiation of adaptive immunity as augmenting the innate immune system. another purpose of the treatment regimen in this review is to sustain lifeforce without the application of the mechanical ventilator and extracorporeal membrane oxygenation and thereby to result in the blockade of breakdown of healthcare system ( table ). the aim of the administration of antiviral agents is to lessen the exposure to antigen (virus). ribonucleic acid (rna) dependent rna polymerization is considered as a crucial step in the rna virus because sars-cov- is positive sense single-stranded (ss)rna virus. unfortunately, it appeared to be controversial to apply remdesivir that was developed for the negative sense ssrna virus such as ebola virus [ , ] . also, side effects of remdesivir were not well known, and its intravenous administration can cause another burden to the healthcare system. safer medicine is the best for patients as an empirical regimen. treatment with most nucleotide/ nucleoside inhibitors is theoretically applicable [ , ] . tenofovir disoproxil fumarate/ emtricitabine (tdf/ftc), which has been prescribed for hiv-infected or hepatitis b virusinfected patients for a long time can be used safely as a short-term medicine for covid- patients. despite the unfavorable result in a small case series study [ ] , tdf/ftc would serve a good candidate because of its high concentration in the epithelium and safety profile. an in vivo study showed that an hiv nnrti rilpivirine was very effective against positive sense ssrna zika virus [ ] . there was a report on hiv nnrtis to be effective with the molecular docking by computational simulation [ ] . furthermore, it was reported that rilpivirine had comparable efficacy to remdesivir in vitro [ ] . antiviral therapy has the best effect when administered for a minimum of days and a maximum of days to avoid unexpected side effects; earlier discontinuation should be considered if clinical progress is evident, including clearance of symptoms, improved immune response, resolution of pneumonia as revealed by chest radiography. however, patients aged years and older [ ] or those with the impaired immune status due to diabetes mellitus, hypertension, and other conditions could receive the drugs beforehand and for a longer time. lopinavir/ritonavir does not appear to be a promising treatment for covid- [ ] , although it was reported to have good efficacy for the treatment of sars [ ] . it may be effective to apply the kind of antimalarial drugs such as chloroquine, hydroxychloroquine, and po; preemptive and prophylactic use is considered for high-risk patients. drug interactions are common. interferon: ) interferon-β b, mainly by inhalation. consider the combination of sq + inhalation. ) patients of the age ≥ years are indicated. consider the administration of interferon for the high-risk patients of ≥ years. the maximum effect of interferon will be achieved within days of the onset of covid- . ) duration: days for patients of ≥ years, days for the patients of ≥ years and high-risk patients antipyretics: hydrocortisone - mg po/iv, or prednisolone mg po phosphodiesterase type- inhibitors (sildenafil): rescue therapy ( mg po every h) for patients with impending respiratory failure epinephrine: nebulization/endotracheal/iv; emergency use for patients showing acute hypersensitivity reactions with shock hiv, human immunodeficiency virus; nnrti, non-nucleoside reverse transcriptase inhibitor; po, per os; iv, intravenously; crrt, continuous renal replacement therapy; ecmo, extracorporeal membrane oxygenation; sq, subcutaneously; aptt, activated partial thromboplastin time. all medications should be administered with caution as they might cause unexpected hypersensitivity reactions and serious side effects. older medications are desirable but may have minor side effects that are easy to control. all medications can be used preemptively for patients with symptoms of pneumonia or systemic involvement and can be adjusted based on the ideal body weight, but should be prescribed for children at recommended doses. mefloquine [ , , ] , however, side effects are concerned due to higher doses than those generally used for the treatment of malaria. it may be better not to exceed the treatment doses and period for malaria. the mechanism of azithromycin seems to be efficacious by strengthening the innate immunity [ ] rather than antiviral efficacy against sars-cov- [ ] . serine protease inhibitors [ ] such as camostat mesylate/nafamostat mesylate are limited options as they suppress the facilitation of c b and c b [ ] . antiviral agents should be prescribed at the earlier stage of pneumonia to stop the progression to acute respiratory distress syndrome. if the supply of medicine is not enough, it can also be started around - days after the infection. even so, antiviral treatment should be given to the patients with older age or risk factors such as diabetes mellitus, hypertension, or immunosuppressive disorders immediately. as for the covid- , the application of steroids can be the basis for the treatment since the main symptom might be developed due to hypersensitivity reaction [ ] . although the various steroid inhaler could be effective, oral administration of prednisolone up to . mg/kg per day can treat a moderate degree of pneumonia. the nebulization with hydrocortisone would be safer among steroid inhalers. prednisolone mg per hours po is recommended to the patients with severe pneumonia [ ] . in the case of patients requiring intensive care, the equivalent dose of methylprednisolone/hydrocortisone can be administered intravenously [ ] . the short term treatment for - days for moderate pneumonia may be preferable [ ] . the duration of administration for the severe cases can be extended to - days after the onset of infection until the immune function is optimal. if the clinical improvement of covid- becomes obvious, rapid tapering is needed for optimal immune function. although hyperinflammation by elevated cytokines such as il- , il- , or tnf-α can contribute to the lung damage, certain anti-cytokine strategy would be not good enough to suppress the whole inflammatory process [ ] . in the case of severe/critical pneumonia, anticoagulants have to be applied as a basic treatment regimen [ ] to help avoiding the use of mechanical ventilation or extracorporeal membrane oxygenation. it is required to make an adequate choice according to the symptom of the patients among warfarin, heparin [ ] , or camostat mesylate/nafamostat mesylate. warfarin can be administered to high-risk groups from the beginning of infection as an oral medication. because anti-c a antagonist is not easily accessible and very expensive, inhalation of heparin [ ] is more suitable in the case of lung involvement. furthermore, injection of heparin is required for thrombin lysis if a patient shows symptoms of thromboembolism. rapid alleviation of symptoms can be expected with intravenous administration of heparin and an anti-c a antagonist in combination, especially in cases when the virus invades the central nervous system; therefore, camostat mesylate/nafamostat mesylate are not recommended as they suppress the formation of c b and c b [ ] . interferon (inf)β- b is the most effective among various infs [ ] and is recommended in combination with other antiviral agents. inf treatment should initiate within three days of infection [ ] and the duration of the treatment should depend on the age and immune status. a one-and two-week treatment regimen is recommended for people in their s and s, respectively, and longer treatment is recommended for those with weakened innate immunity [ ] . antibiotics can be used empirically for the treatment of superimposed/combined bacterial pneumonia. vancomycin [ ] , teicoplanin [ , ] , and azithromycin [ , ] , which are expected to show efficacy against sars-cov- , can be administered. if secondary infections emerge in intensive care units, the epidemiology profile of multidrug-resistant bacteria at the hospital should be taken into account, and an empirical combination of vancomycin/ teicoplanin, meropenem, and macrolides can be used. country-specific influenza trends should also be considered, and if a rapid diagnostic test is positive, oseltamivir is the treatment of choice; it should also be employed if false negative results are obtained for patients with typical flu symptoms, patients who are elderly ( years and older), or those on immunosuppressants. phosphodiesterase type- inhibitors may relieve acute exudative damage in the lungs via the downregulation of proinflammatory and profibrotic cytokines induced in response to reactive oxygen species, thereby representing a rescue therapeutic modality [ ] . epinephrine should be also used in patients with acute hypersensitivity reactions with shock. it should be always kept in mind that overtreatment may trigger and/or worsen efferocytosis or cause side effects; therefore, the clinical status of the patients should be closely monitored and even small changes should be considered for treatment adjustments. at present, it is not likely that effective strategies to block the spread of sars-cov- have already been developed in the present crisis and we can expect nothing more than the initiation of appropriate immune responses to lower the exposure to the virus. changes in virus characteristics during the hiv epidemic provide a glimpse of how sars-cov- could evolve depending on the immune response. we can assume that the faster transmissibility (and/or higher pathogenicity) appears as the virus circulates in the elderly who have weaker innate immunity, while the slower transmissibility (and/or lower pathogenicity) appears in the younger people who have higher innate immunity. it can also be expected that individuals with allergic disorders may show a different clinical course and/or more severe symptoms than the general population. to prevent infection and initiate appropriate immunity to the virus, a sufficient level of air circulation indoors, cough etiquette and maintenance of hand hygiene are required. furthermore, social and physical distancing among people should help prevent the breakdown of the medical system. it also seems reasonable to allow a temporary increase in patient numbers to the level which can be managed by the current medical system. these strategies also include appropriate healthcare policies, for example acquisition of herd immunity, which has been adopted in sweden [ ] . with proper measures, it is quite possible that we should be able to overcome the expected second wave predicted in the northern hemisphere in the coming late fall and winter [ ] . it is quite unlikely that adaptive immunity would be activated with a vaccine that induces igg via antibody-dependent immune enhancement, similar to the one observed in case of infection with the dengue virus [ ] . it should also be noted that convalescent serum therapy may be harmful. therefore, increasing of nonspecific innate immunity is needed surely for the elderly and the people with defective innate immunity. increasing innate immunity in the epithelium as the first line defense is as follows. moderate mountain hiking can lead to the increase of muscle tissue and strengthen the lung capacity [ ] . being exposed to nature will lead to an increase of innate immunity by the sound microbiome [ ] . in addition, spending time on the beach such as, playing, reading, or swimming would be effective in reducing the viral load infected to upper respiratory tracts [ ] . it is well known that probiotics such as lactobacillus spp. can enhance immunity. vitamin d supplements also reinforce the resilience against the virus as it enhances immunity [ ] . antibiotics of macrolides kinds, metronidazole, trimethoprim/sulfamethoxazole, dapsone may help increase the immunity as well [ ] . rosiglitazone and pioglitazone can promote innate immunity as a ppar-γ agonist [ ] . cimetidine which is helpful in the case of heartburn will enhance immunity [ ] . bcg vaccine can stimulate the immune system [ ] . also, the innate immunity of t lymphocyte can be elevated by the application of rna delivery into cells [ ] . the precise therapeutic mechanisms of the medications recommended in this review should be clarified in future studies, and the efficacy of antiviral agents and anticoagulants needs to be confirmed in randomized controlled trials. a bulk of clinical and research data cannot be interpreted at present. considering that the infection can be asymptomatic and as it can rapidly spread across national borders, studies-to elucidate the life cycle of sars-cov- , innate and adaptive immune responses to the virus, and side effects of medicationsshould be conducted on a global scale; this would help in developing appropriate treatment strategies. studies pertaining to the lifestyle, including diet, living conditions, and working environment, and hospital policies are also necessary. considering the high intracellular concentration of tdf/ftc in the epithelium, short-term preexposure and postexposure prophylaxis with tdf/ftc or rilpivirine for healthcare workers and high-risk groups could be useful [ , ] and its effectiveness should be evaluated. in addition, the short course of tdf/ ftc can contribute to decrease viral shedding in stool. vaccine development is urgent. as it is challenging to produce a proper vaccine that takes into consideration the interaction between the immune system and coronaviruses such as sars-cov- , comprehensive studies should be attempted using several viral strains and up-to-date techniques as well as conventional approaches, including inactivated whole virus. furthermore, the efficacy of different inoculation methods should be compared. there are several reports on the status of sars-cov and mers-cov survivors, including their low lung capacity and cognitive problems [ ] [ ] [ ] . systematic studies are required to address these complications. isolation restricts motor activity, which would add considerable physical and mental problems for patients with deteriorated lung function, especially those in intensive care units. if possible, various rehabilitation activities are recommended at the beginning of the isolation rather than after recovery. considering that sars-cov- is less virulent in the younger population, employment of young healthcare workers should contribute to prevention of secondary infections and accelerate patient recovery. sars-cov- is a virus that causes common cold and various hypersensitivity reactions. the lack of immunity against sars-cov- results in the worldwide spread of covid- , a novel disease with diverse clinical manifestations and pathophysiological mechanisms. after the initial confusion among the scientific community and healthcare professionals, extensive basic and clinical research has been conducted to understand the course of covid- and reactions triggered by sars-cov- in the host. these findings could contribute to our understanding of the pathophysiology not only of covid- but also of other infectious diseases. we need to analyze the data obtained through evaluation of covid- survivors as well as covid- -related deaths, so that the losses associated with the pandemic can be minimized. it is also necessary to evaluate our natural environments and review the extensive scientific data obtained in the past, so that better solutions for combating the next wave could be identified. strategies developed through analysis of the current pandemic should prepare us for future crises caused by pathogens more lethal than sars-cov- . 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syndrome i am grateful to dr. dong-gyun lim (immunologist at national medical center, seoul, korea), dr. yoon-keun kim (allergist, immunologist, and ceo at md healthcare, seoul, korea), and dr. sang il kim (president, committee of emerging infectious diseases of korean society of infectious diseases) for sharing their inspiring ideas. i also would like to thank jeewon lee for the translating the present manuscript. key: cord- - hkogdh authors: samaddar, arghadip; grover, malika; nag, vijaya lakshmi title: pathophysiology and potential therapeutic candidates for covid- : a poorly understood arena date: - - journal: front pharmacol doi: . /fphar. . sha: doc_id: cord_uid: hkogdh coronavirus disease (covid- ), an acute onset pneumonia caused by a novel betacoronavirus, severe acute respiratory syndrome coronavirus (sars-cov- ), emerged in the wuhan city of china in december and evolved into a global pandemic. to date, there are no proven drugs or vaccines against this virus. hence, the situation demands an urgent need to explore all potential therapeutic strategies that can be made available to prevent the disease progression and improve patient outcomes. in absence of clinically proven treatment guidelines, several repurposed drugs and investigational agents are currently being evaluated in clinical trials for their probable benefits in the treatment of covid- . these include antivirals (remdesivir, lopinavir/ritonavir, umifenovir, and favipiravir), interferon, antimalarials (chloroquine/hydroxychloroquine), antiparasitic drugs (ivermectin and nitazoxanide), biologics (monoclonal antibodies and interleukin receptor antagonist), cellular therapies (mesenchymal stem cells and natural killer cells), convalescent plasma, and cytokine adsorber. though several observational studies have claimed many of these agents to be effective based on their in vitro activities and extrapolated evidence from sars and middle east respiratory syndrome (mers) epidemics, the currently available data remains inconclusive because of ill-defined patient selection criteria, small sample size, lack of concurrent controls, and use of intermediary outcomes instead of patient-relevant outcomes. moreover, there is a need to clearly define the patient populations who warrant therapy and also the timing of initiation of treatment. understanding the disease pathology responsible for the clinical manifestations of covid- is imperative to identify the potential targets for drug development. this review explains the pathophysiology of covid- and summarizes the potential treatment candidates, which can provide guidance in developing effective therapeutic strategies. in december , a cluster of cases of unexplained acute pneumonia was reported from the wuhan city of china's hubei province. as the causative agent could not be identified, these initial cases were classified as "pneumonia of unknown etiology." later on, the cause of this illness was attributed to a novel betacoronavirus, which was designated as -novel coronavirus ( -ncov) by the world health organization (who) (cascella et al., ) . on january , , as per the international health regulations (ihr, ) , the outbreak was declared a public health emergency of international concern (pheic) by the who. on february , , the disease was renamed as coronavirus disease , and on the same day, the coronavirus study group (csg) of the international committee on taxonomy of viruses designated -ncov as severe acute respiratory syndrome coronavirus (sars-cov- ) due to its phylogenetic similarity with severe acute respiratory syndrome coronavirus (sars-cov) (cascella et al., ) . considering its potential to evolve into a pandemic, the who raised the threat to the epidemic to the "very high" level on february , . with the alarming increase in the number of covid- cases outside china, affecting thousands of people across several countries, the who declared covid- a pandemic on march , . as of august , , covid- has affected more than million people across countries and territories, with , deaths. usa accounts for the maximum number of cases, followed by brazil, india, and russia. coronaviruses (covs) are a group of enveloped viruses with positive sense single-stranded rna genome and having a crownlike appearance under an electron microscope. they belong to the order nidovirales, family coronaviridae, and subfamily orthocoronavirinae. based on genetic and antigenic criteria, covs are classified into four genera: alphacoronavirus (a-cov), betacoronavirus (b-cov), deltacoronavirus (d-cov), and gammacoronavirus (g-cov). to date, seven covs capable of infecting humans (hcovs) have been identified (cascella et al., ) . according to an estimate, % of the population are healthy carriers of covs and they account for to % of acute respiratory infections . the common hcovs, hcov-oc and hcov-hku (b-covs) and hcov- e and hcov-nl (a-covs), cause mild self-limiting respiratory tract infections. other human covs, sars-cov, sars-cov- , and middle east respiratory syndrome coronavirus (mers-cov) (b-covs), cause epidemics with variable clinical severity featuring respiratory and extrarespiratory manifestations. sars-cov and mers-cov infections possess pandemic potential and can cause life-threatening disease with mortality rates up to % and %, respectively (cascella et al., ) . the g-covs infect avian species, while d-covs tend to infect both mammals and birds (zumla et al., ; de wilde et al., ) . phylogenetic analysis has placed sars-cov- under the subgenus sarbecovirus of the genus betacoronavirus. next generation sequencing data has revealed that the genome of sars-cov- bears . % sequence homology with a bat coronavirus ratg and shares . % identity with sars-cov (zheng, ) . based on phylogenetic and evolutionary analyses, it has been proposed that both bat-cov ratg and sars-cov- might have evolved from a common ancestor, and sars-cov- might have jumped from bats to humans via some unknown intermediate hosts (perrotta et al., ) . covid- is an acute respiratory disease with a clinical spectrum ranging from mild and moderate disease ( %) to severe ( %) and critical illness ( %), with an overall case fatality rate (cfr) of . - . %. the severe and critical illness categories (nearly % of all infections) are of special concern in elderly population and those with underlying comorbidities, as the severity and cfr are particularly high in these groups (perrotta et al., ) . several risk factors related to disease severity have been outlined by the united states centers for disease control and prevention (cdc). advanced age, male sex, and smoking have been reported as independent risk factors for disease progression, severity, and mortality. it was observed that % of the patients in italy over years of age succumbed to the disease (livingston and bucher, ) , and as per cdc reports, - % of the patients above the age of in the united states required hospitalization (vishnevetsky and levy, ) . a weekly surveillance report by the who regional office for europe reported that over % of all deaths due to covid- were people aged years or above, and more than % were people aged years or older. it has been hypothesized that there occurs an age-related decline in the clearance of inhaled particles in small airways, possibly due to decrease in the number of cilia and ciliated epithelial cells in the airways (svartengren et al., ) . an age-dependent increase in nasal-cavity volume coupled with decreased nasal resistance and upper airway size are other contributory factors (levitzky, ) . as age advances, there occurs a disruption of the innate and adaptive arms of the immune system with an impairment of both effector memory t cell and competent b cell functions, along with continuous production of inflammatory mediators and cytokines (inflammaging) (aw et al., ) . in healthy state, angiotensin converting enzyme (ace ) catalyzes the conversion of angiotensin to angiotensin − and thus, maintains a homeostasis between inflammatory and anti-inflammatory pathways. ace levels have been found to decrease in old age causing elevated angiotensin- , which increases pulmonary vascular permeability and inflammation, thereby worsening lung injury due to covid- in such patients (dhochak et al., ) . moreover, in the elderly, there occurs an age-related decrease in the vital capacity of lungs and perfusion of vital organs, such as, heart, lungs, and kidneys. sars-cov- causes a much more severe pneumonia in the aged than younger individuals. it has been observed that the incidence of acute respiratory distress syndrome (ards) is higher in the elderly and those with heart, liver and kidney ailments (perrotta et al., ; wang l. et al., ) . also, older age is a surrogate for comorbid illnesses, such as, respiratory and cardiovascular disorders, morbid obesity (i.e., body mass index of ≥ ), hypertension, diabetes mellitus, and significant renal and hepatic impairment (preskorn, ) . all these risk factors have been linked to higher rates of intensive care unit (icu) admission, greater disease severity, and poor prognosis. it has been observed that % of the patients who require hospitalization, icu admission, or succumb to the disease have one or more comorbid conditions, irrespective of age (garg et al., ) . therefore, in the elderly, immunosenescence and underlying comorbidities are likely to be the major contributory factors for life-threatening respiratory failure and multisystemic involvement associated with covid- . on the contrary, children develop milder symptoms, rarely require hospitalization, and have an overall better prognosis when compared to adults (ludvigsson, ) . a systematic review and meta-analysis including children with covid- from countries reported milder self-limiting symptoms in majority of the cases, with . % being critical and seven deaths. unlike adults, children rarely progressed to severe disease requiring icu admission (hoang et al., ) . this can be attributed to the immature immune system in pediatric population, cross-protection from related coronaviruses and other rna viruses to which they get exposed early in life, competitive inhibition of sars-cov- by other respiratory viruses simultaneously invading the airways and the lungs, trained non-specific immunity due to childhood immunization (e.g., bacillus calmette-guerin vaccine and mumps measles rubella vaccine), good regenerative capacity of lungs in children, absence of immunosenescence and age-related comorbidities, and high ace expression causing increased metabolism of angiotensin (dhochak et al., ) . despite overwhelming global efforts, covid- remains a poorly understood disease with limited success in the field of drug development. understanding the disease pathogenesis is crucial for choosing effective drug targets. this review explains the pathophysiology of covid- and summarizes the potential treatment candidates, which can provide guidance in developing efficient therapeutic strategies. sars-cov- is a positive sense, single-stranded rna virus belonging to the genus betacoronavirus (subgenus sarbecovirus, subfamily orthocoronavirinae). the genomic mrna has a ´-cap and a ´-poly (a) tail and can act as an mrna for translation of the viral polyproteins. in addition, both ´and ´ends of the genomic rna contain a highly structured untranslated region (utr) that plays an important role in the regulation of rna replication and transcription. the sars-cov- genome contains open reading frames (orfs), preceded by transcriptional regulatory sequences (trss). the two main transcriptional units, orf a and orf ab, comprise two-thirds of the viral genome and encode two major polyproteins: pp a (~ kda) and pp ab (~ kda), respectively. the synthesis of pp ab involves programmed ribosomal frame shifting during translation of orf a. these polypeptides are cleaved by virally encoded chymotrypsin-like protease ( clpro), main protease (mpro), and papain-like protease (plpro) into non-structural proteins (nsp -nsp ), which assemble to form the replicationtranscription complex (rtc) involved in genome transcription and replication (naqvi et al., ; romano et al., ) . pp a is cleaved into non-structural proteins (nsp -nsp ) and pp ab into five (nsp -nsp ). the non-structural proteins play an important role in the pathogenesis of covid- . nsp and nsp encode plpro and clpro, respectively, which help in peptide cleaving and host innate immune antagonism. nsp and nsp encode rna-dependent rna polymerase (rdrp) and rna helicase, respectively. other orfs at the ´end of the viral genome encode four structural proteins: the spike surface glycoprotein (s), membrane (m), envelope (e), and the nucleocapsid (n) proteins, which are the major components of the virus playing a crucial role in structural integrity and pathogenesis (romano et al., ; . the s protein is a homotrimeric transmembrane glycoprotein that determines diversity to coronaviruses and host tropism. it has two functional subunits: s , responsible for binding to the host ace receptors and s , for the fusion of the virion and cellular membranes. the m protein helps in transport of nutrients across the cell membrane, bud release, and the formation of viral envelope. the e protein plays a significant role in viral morphogenesis and assembly. the n protein plays an important role in packaging of viral rna into ribonucleocapsid and also helps in immune evasion by attenuating host immune responses (astuti, ; naqvi et al., ) . besides these structural proteins, the ´end also contains eight putative orfs for accessory proteins: a, b, p , a, b, b, b, and orf . the structural and accessory proteins are translated from a set of nested sub-genomic rnas (sgrnas) . the life cycle of sars-cov- consists of five steps: attachment, penetration, biosynthesis, maturation, and release. entry of the virus into the host cells is facilitated by interactions between the s protein and its receptors, ace , which are found in various organs such as heart, lungs, kidneys, and gastrointestinal tract. the s protein binds to ace through the receptor binding domain (rbd) region of the s subunit, which consists of a core and a receptor binding motif (rbm). rbm specifically recognises human ace as its receptor (yuki et al., ) . the s protein/ace interaction (attachment) is the primary determinant to infect a host species and also controls tissue tropism. ace mediates human-to-human transmission, and also acts as a receptor for sars-cov and respiratory coronavirus nl (astuti, ) . following binding of the virus to the host ace receptors, the s protein undergoes a two-step sequential proteolytic cleavage, one at s /s cleavage site for priming and another at s ˊsite for activation. the latter acts as a viral fusion peptide that inserts into the membrane, followed by the joining of two heptad repeats in s forming a six-helix bundle. the formation of this bundle results in fusion and entry of virus into the host cell (penetration) (tang et al., ) . another receptor, which has found to be of importance in viral invasion, is cluster of differentiation (cd ), also known as extracellular matrix metalloproteinase inducer (emmprin) or basigin . a characteristic unique to sars-cov- is the existence of a novel furin cleavage site (prrars) at s / s , which confers the ability to infect organs and tissues where furin is ubiquitously expressed such as the brain, lung, liver, gastrointestinal tract, and pancreas . other proteases that may play a role in virus entry are transmembrane protease serine (tmprss ) and cathepsin l. following internalization, there is uncoating and release of viral ssrna in the host cell cytoplasm, which then gets attached to the ribosomes and is translated into two large polyproteins, pp a and pp ab. these polyproteins are cleaved by virus-encoded proteinases into nsps. many of these non-structural proteins congregate to form the rtc in double-membrane vesicles (dmvs), which are mainly an assembly of rdrp-and helicase-containing subunits (astuti, ; . synthesis of genomic rna follows the translation and assembly of viral replicase complexes. rtc is responsible for rna replication and transcription of the sgrnas. the latter serve as mrnas for the translation of structural and accessory proteins (biosynthesis). following translation, the s, e, and m proteins are transported to the endoplasmic reticulum where they move along the secretory pathway into the endoplasmic reticulum-golgi intermediate compartment (ergic). in the compartment, the viral genomes are encapsidated by the n protein, which then bud into the membrane resulting in formation of the mature virus (maturation) (fehr and perlman, ) . the m protein regulates most of the protein-protein interactions required for virus assembly. however, virus-like particles (vlps) can only be formed when m protein is co-expressed with e protein, suggesting the role of these two proteins for production of viral envelope. following assembly, the virions are transported to the cell surface in vesicles and released by exocytosis (release) (fehr and perlman, ; astuti, ) . host immune response to sars-cov- the entry of virus into the host cells triggers stimulation of innate immune response via antigen presenting cells (apcs) like dendritic cells and macrophages, which represent the first line of defence against viruses. apcs have pattern recognition receptors (prrs), such as, toll-like receptors (tlrs), nod-like receptors (nlrs), rig-i-like receptors (rlrs), and melanoma differentiationassociated protein (mda ) present at various locations like plasma membrane, endosomal membrane, lysosomes, and cytosol . they recognize various structural components of the virus, such as, nucleic acids, carbohydrate moieties, glycoproteins, lipoproteins, and dsrna and induce a signaling cascade to produce the immune system effectors. the apcs present the viral antigenic peptides to the cd + t cells in association with major histocompatibility complex (mhc) class i. the cd + t cells get activated, undergo clonal expansion and develop into virus-specific effector and memory t cells. with their perforin and granzymes, cd + t cells lyse the virusinfected cells and induce apoptosis. in addition, there occurs an upregulation of natural killer (nk) cell activation and production of pro-inflammatory cytokines via the nuclear factor kappa b (nf-kb) and interferon regulatory factor (irf ) signaling pathways. this leads to further recruitment of neutrophils and monocytes to the site of infection and activation of several other pro-inflammatory cytokines (astuti, ; li et al., ) . during an infection, activation and priming of innate and adaptive immune responses result in pathogen clearance and recovery. however, sars-cov- causes suppression of host's innate immune response by inhibiting certain signaling pathways and thus, evades detection by the immune system, leading to a more severe disease and fatal outcomes (felsenstein et al., ) . it has been postulated that sars-cov- , like sars-cov, alters the ubiquitination and degradation of rna sensors (rig-i and mda ) and inhibits the activation of mitochondrial antiviral-signaling protein (mavs), thereby preventing the activation and nuclear translocation of irf in response to activated rna sensors. moreover, sars-cov inhibits tumor necrosis factor (tnf) receptor-associated factors (traf) and , which are crucial for the induction of irf- / in response to tlr / and nfkb signaling pathways. it also inhibits the phosphorylation of janus kinase/signal transducers and activators of transcription (jak/stat) transcription factor and blocks type i/iii interferon (ifn) signaling pathways (kindler et al., ) . these mechanisms allow the virus to replicate evading the innate antiviral responses and induce the production of cytokines required for recruitment of adaptive immune cells. the transition between innate and adaptive immune responses is critical for the clinical course of covid- . this phase determines whether the immune regulatory events will culminate in protective immunity or an exacerbated immune response. the protective immunity is t cell mediated, with cd + t cells eliminating the virus-infected cells and cd + t cells helping the b cells to produce neutralizing antibodies and orchestrating the response of other immune cells. the t cells account for % of the infiltrating cells in sars-cov- infection. however, a dysregulated t cell response can result in immunopathology leading to exaggerated cytokine release and a cytokine storm (cao, ; tay et al., ) . this condition is characterized by increased secretion of pro-inflammatory cytokines, such as interleukin (il)- b, il- , il- , il- , il- , il- , il- , and il- ; granulocyte-macrophage colony stimulating factor (gm-csf); tnf-a, ifn-g and ifn-g inducible protein (ip ); monocyte chemoattractant protein (mcp- ); macrophage inflammatory protein- alpha and - beta (mip- a and - b); chemokines like cc chemokine ligand (ccl ), ccl , and ccl ; and c-x-c motif chemokine ligand (cxcl ), cxcl , and cxcl . the cytokine storm induces a hyperinflammatory state causing acute lung injury and various complications like ards, respiratory failure, shock, disseminated intravascular coagulation, multiorgan failure and death (qin et al., ; xu z. et al., ) . this complex cascade of inflammatory response triggers platelet activation, endothelial dysfunction, and vascular stasis. recent studies suggest that covid- induces a hypercoagulable state that may predispose to venous and arterial thromboembolic events and worsened outcomes (abou-ismail et al., ) . the humoral immune response is critical for virus clearance and preventing reinfection. sars-cov- elicits a robust b cell response, as evidenced by detection of virus-specific neutralizing antibodies in most cases following infection. seroconversion occurs between and days after symptomonset, and antibody titers persist in the weeks following virus clearance (vabret et al., ) . the rbd of s protein is highly immunogenic, and antibodies against this domain can block virus interaction with the host ace receptors and thus, prevent virus entry (ju et al., ) . the subepithelial dendritic cells and macrophages recognize the viral proteins and present them to cd + t cells in association with mhc class ii, which induces differentiation of these t cells into th , th , and memory t follicular helper (t fh ) subsets. the t fh cells induce the conversion of b cells to plasma cells and promote the production of virus-specific igm, iga, and igg antibodies (cao, ) . like other viral infections, the initial antibody response in covid- is predominantly igm, which is transient and shortlived and soon gets replaced by igg antibodies. the latter has a longer half-life and lower molecular weight, which enable it to confer long-term protection and effective tissue penetration. however, different patterns of igm and igg seroconversion have been observed, such as synchronous seroconversion, igm seroconversion preceding that of igg, and igm seroconversion later than that of igg. secretory iga plays a crucial role in mucosal immunity by neutralizing the virus and preventing its attachment to the mucosal epithelium (long et al., ) . the proposed host immune response to sars-cov- has been shown in figure . currently, there are no clinically proven antiviral drugs or biologics for the treatment of covid- patients. a protocol issued by national health commission of the people's republic of china states that optimized symptomatic management, together with respiratory support should be the mainstay of treatment . most existing data on antiviral therapy for covid- are derived from related coronaviruses, such as, sars-cov ( ) , and mers-cov ( ) and noncoronaviruses such as ebola virus. how well these data can be extrapolated to sars-cov- remains unclear. moreover, a lack of pharmacokinetic/pharmacodynamic or clinical data comparing achievable exposures with treatment outcomes further questions the clinical relevance of in vitro activity of antiviral drugs, which may vary widely and therefore, should be compared cautiously. since the onset of this pandemic, several studies emphasizing the therapeutic benefits of a wide range of antiviral drugs and biologics have been published in medical literature. however, a thorough analysis of these drugs is warranted to ascertain whether the existing evidence supports the currently proposed management strategies. an overview of various repurposed and investigational drugs undergoing clinical trials against covid- has been depicted in figure (tu et al., ) . there are more than ongoing clinical trials evaluating the safety and efficacy of these drugs. the major proposed therapeutic candidates that seem promising for the treatment of covid- are summarized in table . remdesivir (veklury; gilead sciences, inc.) is an analog of adenosine triphosphate, which incorporates into the nascent viral rna chains and results in delayed chain termination during replication of viral rna. it has broad-spectrum antiviral activity against several rna viruses including ebola, marburg, mers-cov, sars-cov, respiratory syncytial virus (rsv), nipah virus, and hendra virus and has demonstrated prophylactic and therapeutic efficacy against coronaviruses (gordon et al., ) . use of remdesivir in sars-covinfected mice resulted in reduced viral loads and improved disease outcomes. recently, the drug has been shown to possess in vitro activity against sars-cov- . remdesivir seems to possess a favorable safety profile, as evidenced in participants, including healthy volunteers and patients who received remdesivir for ebola virus disease (mulangu et al., ) . its prophylactic and therapeutic efficacy was demonstrated in a rhesus macaque model of mers-cov infection, in which prophylactic administration of remdesivir hours prior to mers-cov inoculation completely prevented clinical disease, inhibited viral replication, and prevented the development of pulmonary lesions. therapeutic administration of the drug hours post-inoculation reduced the severity of clinical symptoms, attenuated viral replication, and decreased the pulmonary lesions (de wit et al., ) . gilead sciences, in a recent case series, considered compassionate-use of remdesivir in covid- patients with severe disease and reported that % of the cases showed clinical improvement after a median followup of days, with mortality of % and a favorable safety profile (grein et al., ) . the findings were, however, not compared with a control group that received only standard care. at present, there are six ongoing clinical trials evaluating the safety and efficacy of remdesivir in adult patients diagnosed with covid- (moderate/severe disease): two initiated by gilead sciences, one by national institute of allergy and infectious diseases (niaid), one by inserm (france), and two by china-japan friendship hospital. all these clinical trials are currently in phase iii. formal recommendations regarding the use of remdesivir can be made once these trials come up with some conclusive evidence. lopinavir/ritonavir (lpv/r; kaletra) is a combination of protease inhibitors used for the treatment of hiv infection. ritonavir is also a potent inhibitor of cytochrome p , a class of enzymes responsible for metabolism of lopinavir, and the co-administration augments the plasma levels of lopinavir, improving its antiviral activity (molla et al., ) . lpv/r has demonstrated in-vitro antiviral activity against sars-cov and mers-cov. since this combination was not specifically formulated for treatment of coronavirus infections, this alone may not demonstrate a significant advantage over placebo in reducing viral load (yao et al., ) . a clinical trial involving patients with laboratory-confirmed sars-cov- infection reported that lpv/r combination did not offer any clinical benefit over the standard management . there are several ongoing clinical trials comparing the efficacy of lpv/r alone and in combination with other drugs like umifenovir, carrimycin, danoprevir/ritonavir, interferon, xiyanping, and traditional chinese medicines. lpv/r in combination with ifn-b b reduced mers-cov viral load and improved lung pathology in a marmoset model (yao et al., ) . however, sheahan et al. ( ) reported that combining lpv/r with ifn-b did not significantly augment the antiviral activity of the latter against mers-cov. in an open label clinical trial involving hospitalized sars patients, lpv/r in combination with ribavirin was found to decrease the mortality rate and requirement of ventilator support compared to the control group (median, days versus days; % ci, − - ) . thus, considering the therapeutic benefits in the treatment of sars and mers, the safety and efficacy of lpv/r based combination regimen in the treatment of covid- needs to be evaluated. figure | host response to sars-cov- . the virus attaches to ace receptors and enters the target cell by membrane fusion. upon entry, the virus is recognized by innate immune receptors tlr / , cytosolic rna sensors rig-i/mda- , and the inflammasome sensor nlr family pyrin domain-containing- (nlrp ). this leads to the activation of nf-кb and irf / and the subsequent production of pro-inflammatory cytokines (e.g., il- b, il- , and tnf-a) and type i ifns, respectively. cytokines released by infected cells modulate the adaptive immune response by causing recruitment and activation of macrophages, b cells, and t cells which facilitate elimination of the virus. however, an unbalanced immune response can cause massive release of pro-inflammatory cytokines, leading to a cytokine storm which is responsible for the severe clinical manifestations of covid- . umifenovir (arbidol, pharmstandard ltd.) is a fusion inhibitor that interacts with viral hemagglutinin and prevents the fusion of viral envelope with host cell membrane. the drug is currently licensed for use only in russia and china for the treatment and prophylaxis of influenza and other respiratory viral infections. umifenovir has a broad-spectrum antiviral activity due to its dual action as direct-acting antiviral and host-targeting agent. it has been found to be active against several enveloped and nonenveloped rna and dna viruses, including chikungunya virus, zika virus, foot-and-mouth disease virus, lassa virus, ebola virus, hsv, hbv, hcv, chikungunya virus, reovirus, hantaan virus, and coxsackie virus b (blaising et al., ; kadam and wilson, ) . it also inhibits clathrin-mediated exocytosis and intracellular trafficking by interacting with the cell membrane (blaising et al., ) . considering its unique mechanism of action, umifenovir alone and in combination with antiretroviral drugs is currently being investigated for treatment and prophylaxis of covid- . however, a retrospective study by lian et al., patients showed that umifenovir did not shorten the sars-cov- negativity time or improve the prognosis in non-icu patients compared to the supportive treatment . there are currently four ongoing clinical trials of umifenovir for covid- treatment: one in comparison with the basic treatment , and the other three comparing the effects in combination with oseltamivir , lopinavir/ ritonavir , and carrimycin. , ) . besides influenza a and b, it has been found to be effective against avian influenza. it has also been investigated for the treatment of infections caused by ebola virus, lassa virus, and now, sars-cov- . favipiravir is a prodrug that gets metabolized to an active form favipiravirribofuranosyl- ′-triphosphate (favipiravir-rtp), which selectively binds to rdrp and inhibits viral replication. in contrast to the existing antivirals against influenza that primarily block the entry and exit of the virus from cells, favipiravir's novel mechanism of action allows its active form to get incorporated into the nascent rna strand, thus preventing strand elongation and viral proliferation. the drug has an oral bioavailability of . and is % plasma protein-bound with an elimination half-life of - hours . the rdrp gene of sars-cov- is structurally similar to that of sars-cov and mers-cov, as revealed by genome sequencing (cascella et al., ) . a clinical trial (chictr ) conducted in shenzhen, china reported that covid- patients who received favipiravir demonstrated significantly shorter viral clearance time and higher improvement in chest imaging, compared to the control group ( days, . % versus days, %) (cai et al., ) . in another multi-centre randomized trial (chictr ), treatment with favipiravir was found to be beneficial for covid- patients with diabetes and/or hypertension as evidenced by decreased time-to-relief for fever and cough. also, seven days clinical recovery rate increased from . to . % . these studies indicate that favipiravir can be a safe and effective treatment option for covid- . the drug is currently undergoing phase iii clinical trial, which is expected to be completed by july . ifns are a family of inducible cytokines produced by various cell types in response to viral infections. ifns exert their actions through pattern recognition receptors (prrs), which are largely species specific. of particular interest are the type ifns (viral ifns), which are secreted by the plasmacytoid dendritic cells and are among the first cytokines produced during a viral infection. ifn-i comprises of several subtypes (a, b, ϵ, w, and k) (samuel, ) , which exert their actions after binding with interferon-a/b receptor (ifnar). ligand binding induces phosphorylation of the receptor and activation of signal transducers and several transcriptional factors such as stat and stat . these form complexes that are translocated to the nucleus, where they activate interferon-stimulated genes (isg). isgs include prrs, irfs, and members of the jak-stat signaling pathway, which sensitize the cell to pathogens, and play a prominent role in inflammation, antiviral innate signaling, immunomodulation, and interfere with several steps of viral replication (schneider et al., ) . thus, ifn-i plays a vital role in antiviral immunity. because of their immunomodulatory and antiviral properties, they are often evaluated for the treatment of several emerging viral infections. sars-cov- bears a close resemblance with other members of the coronaviridae family such as mers-cov and sars-cov and exhibits similar properties, despite differences in their epidemiology, pathology, and several of their structural proteins. numerous in vivo and in vitro studies have evaluated the role of ifn-i in the treatment of mers-cov and sars-cov, either alone or in combination with lopinavir/ritonavir (chan et al., ) , ribavirin (omrani et al., ) , remdesivir, corticosteroids, and ifn-g (sainz et al., ) . though both ifn-a and-b have demonstrated efficacy in vitro and succeeded in certain animal models, they failed to improve the disease in humans. such difference in therapeutic responses could be attributed to ifn signaling pathway used by the viruses, limited number of study subjects, varied experimental settings or clinical conditions, and ifn-subtype diversity. studies have shown that ifnb, particularly the b subtype (ifnb b or ifnb a), is a more potent inhibitor of coronaviruses than ifna and thus appears to be more relevant in the treatment coronavirus infections (stockman et al., ) . in the lungs, ifnb stimulates the secretion of anti-inflammatory adenosine and promotes maintenance of endothelial barrier function by up-regulating cd in pulmonary endothelial cells. this can be a possible explanation to the reduction of vascular leakage in ards with ifnb a treatment (bellingan et al., ) . the timing of ifn-i administration plays a critical role, with positive effects being observed early in the course of infection while delayed administration failed to inhibit viral replication (channappanavar et al., ) . based on previous knowledge, it has been hypothesized that sars-cov and mers-cov are able to disrupt the interferon signaling pathway probably through involvement of orf and orf b (kopecky-bromberg et al., ) . however, due to the truncated nature of orf and orf b proteins in sars-cov- , they may have lost their antiinterferon activities. this could be a possible explanation for sars-cov- displaying substantial in vitro sensitivity to ifn-i. thus, ifn-i is expected to be more promising for the treatment of covid- than for sars (lokugamage et al., ) . the assumption is further supported by the fact that ifna b sprays minimise the infection rate of sars-cov- and can be used prophylactically against the virus administration of million units of ifna by vapor inhalation twice a day, in combination with ribavirin (dong et al., ) . vapor inhalation offers the advantage of specifically targeting the respiratory tract. the efficacy of ifn-i can be further improved if given in combination with lopinavir/ritonavir, ribavirin, or remdesivir because of the efficacy of such combinations observed in vitro against other coronaviruses (sheahan et al., ) . further research on ifn-based treatment is expected in near future, which should give more accurate information on the efficacy of this therapy and possible outcomes. ivermectin (stromectol; merck & co., inc.) is a broad spectrum anthelmintic agent belonging to class of avermectins and is derived from the soil bacterium streptomyces avermitilis. it's selective and high affinity binding with glutamate-gated chloride channels in nerve and muscle cells of nematode, increases the permeability of the cell membrane to chloride ions, resulting in hyperpolarization of cells and paralysis and death of the parasite. it is . % plasma protein-bound and has a half-life of hours following oral administration. the drug was originally launched by merck laboratories in for use against onchocerciasis (river blindness) as a part of the onchocerciasis control programme in west africa. subsequently, the drug was approved for the treatment of a number of human parasitic infections including strongyloidiasis, ascariasis, trichuriasis, enterobiasis, lymphatic filariasis, and scabies in several countries (australia, france, japan, the netherlands, usa, etc) (ikeda, ) . besides its anti-parasitic action, several studies have demonstrated the potent antiviral activity of ivermectin against a broad range of viruses in vitro (caly et al., ) . it has been shown to inhibit the interaction between the hiv- integrase protein (in) and the importin (imp) a/b heterodimer, causing inhibition of hiv- replication (wagstaff, ) . ivermectin has also been reported to limit infections caused by several rna viruses (dengue viruses - , west nile virus, venezuelan equine encephalitis virus, and influenza virus) and dna virus (pseudorabies virus) (wagstaff, ; caly et al., ) . studies have found that host cell division might be affected during sars-cov infection, due to a signal-dependent nucleocytoplasmic shutting of the viral nucleocapsid protein involving impa/b (timani, ; wulan, ) . the antiviral activity of the stat transcription factor is blocked by sars-cov accessory protein orf , which causes sequestration of impa/b on the rough endoplasmic reticulum/golgi membrane (frieman, ) . considering ivermectin's inhibitory action on impa/b -mediated nuclear import, it is presumed to be effective against sars-cov- . caly et al. ( ) studied the antiviral activity of ivermectin against sars-cov- and observed that a single treatment with ivermectin was able to cause ∼ -fold reduction of virus titre at h in vero/hslam cell culture. ivermectin has a favorable safety profile in humans with high dose therapy considered as safe as the standard low-dose regimen. however, the therapeutic benefits from multiple drug dosing need to be evaluated in covid- patients. an effective antiviral drug given early in the course of infection can help reduce the viral load and prevent disease progression while limiting person-person transmission. ivermectin's unique antiviral action combined with a favorable safety profile allows it for further consideration as a possible treatment option in covid- . hydroxychloroquine (hcq) (plaquenil; sanofi-synthelabo inc.) is an aminoquinoline like chloroquine and is indicated for the treatment of uncomplicated malaria, prophylaxis of malaria in places without chloroquine resistance, chronic discoid lupus erythematosus, systemic lupus erythematosus, and rheumatoid arthritis. in addition, hcq has been found to be effective against intracellular bacteria such as coxiella burnetii (raoult et al., ) and tropheryma whipplei (boulos et al., ) . hcq has also been shown to possess antiviral properties and is already being used in clinical trials for the treatment of hiv infection. it increases endosomal ph which prevents viral fusion and entry into the host cells, inhibits antigen processing and presentation, blocks dimerization of major histocompatibility complex (mhc) class ii, and reduces host inflammatory response by decreasing the release of cytokines like il- and tnf-a. hcq inhibits terminal glycosylation of ace receptor, the main portal of entry for sars-cov and sars-cov- . non-glycosylated ace interacts less efficiently with the viral spike protein, thus preventing viral entry (colson et al., ) . several studies have proposed that repurposing of approved drugs such as chloroquine, hcq, azithromycin, metformin, losartan, and simvastatin could be useful in the treatment of covid- . clinical trials from china have shown the efficacy of chloroquine in the treatment of covid- patients, as evidenced by subsidence of fever, improvement of radiological findings, and delay in disease progression. azithromycin (az) is a macrolide antibiotic that has demonstrated in vitro activity against zika and ebola viruses (bosseboeuf et al., ) . several authors have mentioned a synergistic effect of hcq/az combination in the treatment of covid- . an open label non-randomized clinical trial from france showed that covid- patients treated with mg of hcq daily had a significant reduction in viral carriage at day post-inclusion, with % of the patients having a negative pcr test result compared to only . % in the untreated control group. moreover, patients who were treated with a combination of hcq and az ( mg on day , followed by mg daily for the next four days) showed complete virological cure at day postinclusion compared to . % in the group that received hcq alone (gautret et al., a) . another study from france claimed that patients who received a combination of hcq and az had a significant clinical improvement as evidenced by a rapid fall in viral load, with % tested negative by quantitative pcr on day and % on day . virus cultures of respiratory samples were negative in . % patients on day (gautret et al., b) . however, the apparent beneficial effects of hcq in the treatment of covid- have been completely negated by a pilot study from china, where no significant differences in outcomes were observed between hcq-treated group and the control group . a large observational study in hospitalized covid- patients in the us also showed that treatment with hcq was not associated with significant clinical benefits and has no influence on intubation or death (geleris et al., ) . furthermore, the use of hcq alone or in combination with az is not free from hazards. both these drugs are associated with an increased risk of qt c prolongation, torsades de pointes, ventricular tachycardias, and gastrointestinal side effects. it has been observed that patients receiving a five-day course of az had an increased risk of sudden cardiac death with a hazard ratio of . (ray et al., ) . considering the cumulative adverse effects of hcq and az on cardiac conduction, it is advised to have baseline and follow-up ecg monitoring, along with careful consideration for other concomitant medications known to prolong the qt c interval, if this combination has to be used. guidelines published by the infectious disease society of america mentioned that despite a higher proportion of clinical improvement in the hcq group, the beneficial effect of hcq on viral clearance or disease progression cannot be judged by the currently available evidence due to certain drawbacks such as small sample sizes, ill-defined patient selection criteria, cointerventions, and methodological limitations (bhimraj et al., ) . moreover, none of the studies have addressed patientrelevant outcomes like mortality, rate of disease progression to ards, and need for mechanical ventilation. also, the mortality rate among patients receiving hcq/az combination was not compared with an untreated cohort. though studies have claimed that patients receiving hcq and az experienced less virologic failure ( % pooled virologic failure) as compared to historical controls ( % virologic failure) (gautret et al., b; molina et al., ) , such comparison lacks certainty because of unmeasured confounding and selection bias. furthermore, these studies have relied mainly on intermediary outcomes such as reduction in development of pneumonia, and less hospital or icu admission to ascertain therapeutic benefits, which raise question on their precision and feasibility. therefore, a rct should be the ideal approach for determining the therapeutic effects of hcq in covid- patients. the leading cause of mortality in covid- is respiratory failure from ards. a cytokine profile resembling secondary hemophagocytic lymphohistiocytosis (hlh), characterized by a fulminant and fatal hypercytokinemia with multiorgan failure is associated with covid- . there is a massive and uncontrolled release of pro-inflammatory cytokines like il- , il- , g-csf, ip , mcp- , mip- -a and tnf-a (mehta et al., ; xu z. et al., ) . a recent retrospective study involving confirmed covid- cases from wuhan, china, revealed that elevated levels of serum ferritin and il- were independent predictors of fatality, probably due to virally driven hyperinflammation (ruan et al., ) . tocilizumab (actemra, roche) is a humanized monoclonal antibody against the interleukin- receptor (il- r) approved for the treatment of seriously ill covid- patients with elevated il- by the national health commission of china. xu x. l. et al. ( ) observed the effects of tocilizumab in covid- patients with severe disease, in addition to routine therapy, and reported significant therapeutic benefits as evidenced by subsidence of fever and other symptoms within a few days and improvement of oxygen saturation in % of patients. there were no obvious treatment-related adverse reactions. in another report from china, a case of covid- with pre-existing multiple myeloma was successfully treated with tocilizumab, highlighting its potential therapeutic benefits in the treatment of covid- patients . on march , , the drug entered phase iii clinical trial for the treatment of covid- pneumonia. the main contributory factors for increased mortality in covid- patients are acute lung injury (ali) and ards, brought about by a cytokine-mediated hyperinflammatory response. pulmonary edema is the key detrimental feature of ali/ards. covid- is associated with more exaggerated pulmonary mucus exudation than sars as revealed by autopsy . pulmonary imaging and histopathological examination also support similar findings. however, specific pharmacotherapy to combat this pathology is lacking. vascular endothelial growth factor (vegf) is one of the most potent inducers of increased vascular permeability in covid- affected lungs, causing fluid extravasation and pulmonary edema. expression of vegf is induced by hypoxia through activation of prolyl hydrolases (phd)-hypoxia inducible factor (hif)- pathway, which upregulates transcription of vegf. therefore, blockade of vegf signaling pathway might help in reducing inflammation and improving tissue perfusion in patients with severe covid- . bevacizumab (avastin; genentech ltd.) is a recombinant humanized monoclonal antibody targeted against vegf and is currently recommended for the treatment of malignancies (colorectal, lung, breast, renal, brain, and ovarian), age-related macular degeneration, and diabetic retinopathy. it acts by reducing the elevated vegf levels secondary to hypoxia and severe inflammation, thereby improving tissue perfusion. (wang et al., ) . this might help in subsidence of pulmonary edema in covid- patients. qilu hospital of shandong university, china is conducting two clinical trials of bevacizumab, both of which are expected to be over by may . thus, bevacizumab holds promise as a potential therapeutic option in the treatment of severe covid- patients. studies till date recognize angiotensin converting enzyme (ace ) as the major entry portal for sars-cov- . however, a novel route of viral invasion through direct interaction between the sars-cov- spike protein and cd , also known as emmprin, expressed on epithelial cells has been recently described by wang k. et al. ( ) meplazumab (ketantin, jiangsu pacific meinuoke biopharmaceutical co. ltd.) is a humanized igg monoclonal antibody against cd that has demonstrated dose-dependent inhibitory action on sars-cov- replication and virus-induced cytopathic effect in vitro (bian et al., ) . cd binds to cyclophilin a (cypa), a proinflammatory cytokine up-regulated in viral infection, and regulates cytokine secretion and leukocyte chemotaxis. meplazumab is a monoclonal anti-cd antibody that inhibits cypa-induced t cell chemotaxis and thus reduces local inflammation. bian et al. ( ) studied the effects of meplazumab in hospitalized patients with covid- at tangdu hospital, china, and reported that meplazumab treatment significantly improved the clinical outcomes in severely ill patients. also, the time to virus negativity in the meplazumab group was shortened compared to the control group. these evidences suggest that meplazumab therapy improves the recovery of patients with sars-cov- pneumonia and has a favorable safety profile. the drug is currently in phase ii clinical trial, which is expected to be completed by december . itolizumab (alzumab, biocon ltd.) is a humanized anti-cd igg monoclonal antibody that was introduced in india in for the treatment of chronic plaque psoriasis. it binds specifically to domain of cd and modulates the activation and proliferation of t cells by cd co-stimulation, without interfering with the interaction between cd and activated leukocyte-cell adhesion molecule. it inhibits intracellular phosphoproteins like mitogen-activated protein kinase (mapk) and stat and interferes with cd mediated intracellular signaling pathways and th development. itolizumab downregulates the transcription of pro-inflammatory cytokine genes and thus leads to decreased levels of ifn-g, il- , and tnf-a, causing attenuation of cytokine storm and t cell infiltration (menon and david, ) . considering its unique mechanism of action, the drug has been repurposed for the treatment of crs, which is the leading cause of death in covid- . a prospective, multi-centric, randomized phase ii study conducted on severely ill covid- patients ( cases and controls) in india showed significant improvement in blood oxygen levels with reduced levels of proinflammatory cytokines and reduced mortality rate in patients who received itolizumab. a similar trial conducted in cuba also indicated positive results with . % of the patients discharged from icu after weeks of treatment. itolizumab has been approved by drugs controller general of india for the treatment of crs in moderate to severe ards patients with covid- . anakinra (kineret; amgen inc.) is a recombinant human il- receptor antagonist that competitively inhibits the binding of il- a and il- b to the high-affinity il- receptor. it is the first biological agent approved for the treatment of rheumatoid arthritis. it is administered through subcutaneous route and has an absolute bioavailability of % (cvetkovic and keating, ) . in covid- patients, halting the disease progression from manageable hypoxia to frank respiratory failure and ards can have a significant impact on patient management and outcomes. therefore, a therapy directed at intercepting the cytokine storm may be beneficial in this regard. there is an ongoing prospective, randomized, interventional trial comparing the therapeutic effects of individual and simultaneous blockade of il- and il- versus standard care in covid- patients. the trial will include participants whose clinical status after days of treatment will be assessed to measure the effectiveness of anakinra alone and in combination with tocilizumab and siltuximab in restoring lung homeostasis. the study is estimated to be completed in december . considering the role of il- in the pathogenesis of acute lung injury in covid- , anakinra seems to be a promising therapeutic option in the management of such patients. several studies have recognized the potential benefits of cellbased therapies in a number of disease processes including pulmonary, cardiovascular, hepatic, renal, metabolic, and mulculoskeletal disorders. a guideline published by the italian college of anesthesia, analgesia, resuscitation and intensive care has mentioned that stem cells have the potential to decrease icu admission and curtail the number of icu days in covid- (vergano et al., ) . currently, usfda recommends autologous bone marrow stem cells as the only candidate for stem cell therapy. mesenchymal stem cells (mscs) have shown benefit in the treatment of musculoskeletal disorders such as lowback pain and spinal injuries. the other stem cells that can be considered for clinical use include adipose, amniotic, and umbilical cord stem cells. among these, umbilical cord stem cells seem to be the more attractive as unlike bone marrow, umbilical cord (wharton jelly) has a high concentration of mscs that can be extracted noninvasively (arutyunyan et al., ) . moreover, they have fast doubling times, more plasticity, greater potency, and can be efficiently be expanded in the laboratory to cater the large number of expected coronavirus patients (nagamura-inoue and he, ). despite being allogenic, mscs can evade the host immune system as they express low levels of mhc i, mhc ii, and t cell co-stimulatory molecules, cd and cd , on their surface. at a cellular level, mscs demonstrate powerful immunomodulatory activity through secretion of anti-inflammatory molecules by paracrine effect and direct interaction with t and b lymphocytes, dendritic cells, macrophages, and nk cells. all these may help in attenuating the cytokine storm (tipnis et al., ) . they suppress the hyperactive immune system and promote endogenous repair by improving the cellular microenvironment. multiple studies have demonstrated the beneficial effects of mscs in the settings of ali and ards. when given intravenously, mscs accumulate in the lungs and improve lung function by decreasing inflammation, reducing pulmonary endothelial permeability, facilitating alveolar fluid transport, preventing pulmonary fibrosis, and promoting tissue repair. several clinical trials have documented the safety and efficacy of mscs in immune-mediated inflammatory diseases, such as graft versushost disease (gvhd) and autoimmune disorders (li et al., ; atluri et al., ; behnke et al., ) . mscs secrete antimicrobial peptides and proteins (amps) such as cathelicidin ll- , human beta-defensin- (hbd- ), hepcidin, and lipocalin- (lcn ) and anti-inflammatory molecules such as indoleamine , dioxygenase (ido) and interleukin (il)- . amps cause disruption of membrane integrity, inhibition of protein and nucleic acid synthesis, and blockade of interaction with intracellular targets (alcayaga-miranda et al., ) . mscs regulate the host immune response by maintaining a dynamic equilibrium between pro-and anti-inflammatory cytokines. there was a concern that sars-cov- can infect the stem cells and render them ineffective. however, a study of seven covid- patients (one critically ill, four serious and two mild) in beijing revealed that sars-cov- was not able to infect the injected umbilical cord mscs. all patients who received single dose of stem cell therapy recovered during the days follow-up period, while two out of three patients (with serious disease) who did not receive stem cell therapy (control group) had unfavorable outcomes (one died and one developed ards). there was gradual normalization of oxygen saturation and levels of inflammatory biomarkers like crp, aspartic aminotransferase, creatine kinase, and myoglobin in the treated group with no treatment-related adverse events. follow-up ct scan of lungs showed significant radiological improvement (leng et al., ) . thus, mscs can be a safe and effective treatment option for patients with covid- pneumonia. natural killer (nk) cells (large granular lymphocytes) are innate lymphocyte subsets that constitute the frontline defence system against virus infected and tumor cells. they originate in the bone marrow and represent up to % of peripheral blood mononuclear cells. nk cells are phenotypically defined by expression of cd and absence of cd and do not require prior stimulation to perform their effector functions. nk cells display a diverse range of biological activities that are controlled by several inhibitory and activating receptors. the inhibitory receptors recognize self-mhc class i and prevent nk cell activation. in viral infections, there is upregulation of activating receptors and downregulation of mhc class i expression, which causes activation of nk cells. the major activating receptors include cytotoxicity receptors (nkp and nkp ), c-type lectin receptors, and immunoglobulinlike receptors. among the inhibitory receptors, the killer immunoglobulin-like receptors and leukocyte inhibitory receptors have prominent role in defence against viral infections. nk cells lack antigen-specific receptors and kill virus-infected cells through the production of cytokines (tnf-a, gm-csf, ccl /rantes, and ifn-g), perforin-granzyme-mediated cellular destruction, and death receptor-mediated cytolysis (cooper et al., ) . perforin, a pore forming protein, increases the cell permeability, which allows granzymes, a family of serine proteases, to enter into the cell and disrupt cell cycle progression, inflict dna damage, and promote karyolysis (vivier et al., ) . they also cause recruitment and activation of other effector cells, including cd + t cells and cd + th cells. patients with deficient nk cell response are predisposed to recurrent viral infections (jost and altfeld, ) . currently, the role of nk cells for immunotherapy in infectious diseases is being explored and results seem to be promising. as hunt for new therapeutic options in the treatment of covid- continue to expand, focus has been on the potential benefits of nk cell-based therapy. on april , , usfda approved the use of cynk- , the only cryo-preserved allogeneic nk cell therapy, derived from placental hematopoietic stem cells, in adults with covid- . the agent's manufacturer celularity, a new jersey-based therapeutic company, in collaboration with sorrento therapeutics is about to launch a phase i/ii clinical trial on cynk- , involving covid- patients. the therapy is already being tested in patients with acute myeloid leukemia, multiple myeloma, and various solid tumors. in january , celularity's cynk- was approved by usfda for treatment of glioblastoma multiforme. thus, considering the potent antiviral and immunomodulatory properties of nk cells, their efficacy in the treatment of covid- seems promising and needs to be evaluated in clinical trials. convalescent plasma therapy (cpt) is a passive immunization strategy that has been used for the prevention and treatment of several infectious diseases for more than a century. cpt has been successfully used in the treatment of sars (cheng et al., ) , mers (ko et al., ) , and influenza a h n (hung et al., ) , with satisfactory efficacy and safety profile. a protocol for the use of convalescent plasma (cp) in the treatment of mers was established in . cpt is associated with a significant reduction in viral load and pooled mortality as revealed in a large meta-analysis on sars and severe influenza (mair-jenkins et al., ) . patients with a high titer of nab, after having recovered from covid- may be a valuable donor for cp. it has been observed that the nabs titers in covid- patients remain low for the first days following disease-onset and tends to increase thereafter, reaching a peak in to days after the onset . usfda has laid down eligibility criteria for covid- cp donors which include: i) evidence of confirmed covid- documented by a positive nasopharyngeal pcr at the time of illness or a positive sars-cov- antibody test after recovery, ii) complete resolution of symptoms at least days prior to donation or at least days prior to donation and negative results for covid- , either from a nasopharyngeal swab specimen or by a molecular diagnostic test from blood, iii) male/female donors tested negative for hla antibodies, and iv) sars-cov- neutralizing antibody titers of ≥ : . in a study from china, cpt supplemented with supportive care and antiviral agents was associated with significant clinical and radiological improvement with a rise in neutralizing antibody titers and a fall in c-reactive protein levels within days of initiation of treatment. no treatment-related adverse effects were observed (duan et al., ) . similar findings were reported by . a systematic review on cpt for the treatment of covid- revealed that cpt is safe, effective, and reduces mortality in critically ill patients (rajendran et al., ) . a clinical trial evaluating the benefits of cp in the treatment of covid- is being conducted by universidad del rosario, colombia (nct ), the results of which are expected to be declared by december . cytosorb (cytosorbents corp.) is an extracorporeal cytokine adsorber that acts by removing the circulating cytokines and redirecting the activated neutrophils to the site of infection. this may help in ameliorating cytokine storm that can otherwise trigger uncontrolled systemic inflammatory response, organ failure, and death. cytosorb offers significant survival benefits in septic shock as observed in several studies. it has been safely used in over , cases worldwide, primarily in the treatment of several immune-mediated life-threatening conditions such as septic shock, influenza, ards, secondary hlh, liver failure, and pancreatitis. cytosorb helps in protecting endothelial tight junctions, thus reducing capillary leak syndrome. it also modulates pulmonary metabolism, edema formation, and cellmediated infiltration and injury to the lungs. on april , , the usfda approved emergency use of cytosorb for the treatment of adult covid- patients admitted to icu with features of respiratory failure. sars-cov- can induce a sepsis-like syndrome, and in such cases, since pharmacological approaches fail to give promising results, removal of proinflammatory cytokines by hemoadsorption through cytosorb should be considered. to date, more than critically ill patients with covid- infection have been treated with cytosorb across various centers in italy, china, and germany. based on positive results in italy, the brescia renal covid task force has formally recommended the use of cytosorb in severe covid- patients with stage acute kidney injury, receiving continuous renal replacement therapy (crrt). cytosorb therapy has also been recommended by the national guidelines for the care of adult patients covid- , panama. in addition, the handbook of covid- prevention and treatment, issued by zhejiang university school of medicine, china is also recommending cytosorb therapy for the management of cytokine storm in critically ill covid- patients. currently, an ongoing clinical trial (nct ) is investigating the efficacy of cytosorb in the treatment of patients with severe covid- disease. it is expected to be completed by november . formulating appropriate treatment strategies for covid- poses a considerable challenge. during pandemics, in absence of clinically proven treatment guidelines, the tendency is to repurpose drugs based on their antiviral and immunomodulatory activities, as evidenced through observational studies. however, such studies have certain drawbacks like lack of concurrent controls, ill-defined patient selection criteria, small sample size without randomization, and use of intermediary outcomes like viral clearance rather than patient-relevant outcomes. though several repurposed drugs have shown promising results, and their potential clinical benefits appear to outweigh the relatively minor risk of adverse events, conclusive evidence is lacking. there is a need to clearly define the patient populations who warrant therapy and the timing of initiation of treatment. since viral loads are highest early in the course of infection and the disease progression can occur rapidly in stable patients, it is rational to consider rapid initiation of therapy in highrisk populations (old age, hospitalized patients, those with underlying diseases and comorbidities), ideally in the context of a well-controlled, randomized clinical trial. moreover, the demand for unproven therapies can cause shortages of medications that are otherwise indicated for more prevalent diseases like hiv, malaria, hypertension, and diabetes mellitus. the idsa guidelines for treatment of patients with covid- raise concern upon these aspects. in an attempt to generate and disseminate clinical data on an urgent basis, a phenomenal increase in fast-track publications related to covid- has been observed. however, caution should be exercised because the bulk of the available clinical data are often uncontrolled, not peer reviewed, and subject to publication bias (with an intention to publish outstanding results, there may be a tendency to publish positive outcomes and disregard the negative findings). there are several ongoing clinical trials, some with versatile designs that can reasonably explain the therapeutic benefits offered by these drugs in the management of covid- . given the plethora of uncertainties concerning the reliability of existing data and the safety and efficacy of the proposed treatments, it would be wise to wait for the results of clinical trials than to adopt clinically unproven therapies. this article has been released as a 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findings of covid- associated with acute respiratory distress syndrome effective treatment of severe covid- patients with tocilizumab a systematic review of lopinavir therapy for sars coronavirus and mers coronavirus-a possible reference for coronavirus disease- treatment option covid- pathophysiology: a review first case of covid- in a patient with multiple myeloma successfully treated with tocilizumab sars-cov- : an emerging coronavirus that causes a global threat coronaviruses-drug discovery and therapeutic options the authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.copyright © samaddar, grover and nag. this is an open-access article distributed under the terms of the creative commons attribution license (cc by). the use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. no use, distribution or reproduction is permitted which does not comply with these terms. key: cord- -sqrbj r authors: vanden eynde, jean jacques title: covid- : an update about the discovery clinical trial date: - - journal: pharmaceuticals (basel) doi: . /ph sha: doc_id: cord_uid: sqrbj r finding efficacious and safe treatments for covid- emerges as a crucial need in order to control the spread of the pandemic. whereas plasma therapy attracts much interest, the european project discovery focuses on the potentialities of small molecules like remdesivir, the combination of lopinavir/ritonavir, hydroxychloroquine, and chloroquine. results recently published on the clinical evaluation of those drugs are compiled in this brief report, although complete data are still impatiently awaited. deconfinement linked to covid- is becoming a huge cause of concern for inhabitants of many countries and their political leaders. in the meantime, researchers from diverse scientific fields are gathering their efforts in order to combat sars-cov- . targeting the virus itself, testing infected people, offering treatments, seeking immunized patients, and developing vaccines are among the numerous avenues actually considered. on march , the world health organization (who), in collaboration with several partners, created the solidarity response fund to support studies on covid- [ ] . in the wake, the french institut national de la santé et de la recherche médicale (inserm) launched a european initiative in the form of a clinical trial named discovery. a couple of weeks ago, we briefly reviewed the first potential treatments under study in those projects [ ] . we now wish to provide an updated situation. as of may , the search term "covid- " in the database of the u.s. national library of medicine of the national institutes of health (bethesda, md, usa) [ ] gave answers. less than weeks before (march ), the same query had resulted in titles (table ) . that incredible increase clearly reflects the worldwide concern created by the disease. considering the most cited options, as of march [ ] , for a potential treatment, we analyzed the evolution of the number of clinical trials on april , april , and may . as indicated in table , actually, researches on the efficacy of hydroxychloroquine ( , figure ) and plasma therapy constitute, by far, the most explored fields. they are followed by studies involving chloroquine ( ) and the combination lopinavir ( )/ritonavir ( ). to date, tocilizumab emerges as a lead in the category of monoclonal antibodies and cell therapy is focused on the potentialities of mesenchymal stem cells. many other small molecules (essentially antiviral agents) and proteins remain attractive subjects of trials, but to a lesser extent. comparison with clinical trials reported in the chinese clinical trial registry [ ] deserves some attention. in that registry, the vast majority of trials concern traditional chinese medicine (plant extracts). on march , the inserm announced the start of a european adaptive clinical trial entitled "trial of treatments for covid- in hospitalized adults (discovery)" (nct ). [ ] the trial is supposed to enroll , patients in seven countries, namely france, spain, the united kingdom, germany, luxemburg, the netherlands, and belgium. [ ] it started in three french hospitals: centre hospitalier régional universitaire de lille (lille, france), centre hospitalier universitaire de nantes (nantes, france), and assistance publique hôpitaux de paris-bichat claude bernard (paris, france). to date, there are study hospitals, in france and in luxembourg. the five other countries are not yet represented [ ] . initially, the drugs to be evaluated in the discovery project are • remdesivir ( ); • the combination lopinavir ( )/ritonavir ( ), eventually with the addition of interferon β- a; • hydroxychloroquine ( ) or chloroquine ( ), eventually associated with an antibiotic (azithromycin or other). as indicated in the protocol, exclusion criteria comprise, among others, • patients with liver damage as indicated by alanine/aspartate aminotransferases levels, in blood, more than times the upper limit of normal; • patients suffering of severe chronic kidney disease; • patients using medications that are contraindicated with lopinavir/ritonavir (e.g., amiodarone, colchicine, simvastatine) or hydroxychloroquine (e.g., citalopram, escitalopram, hydroxyzine, domperidone, piperaquine). it is noteworthy that suffering of cardiac problems was not a criterion of exclusion from the study. the estimated study completion date has been fixed on march , years after the starting date. meanwhile, some partial reports on the efficacy of those molecules in the treatment of covid- have been made public. their conclusions are often contradictory as reported hereafter. pharmaceuticals , , x for peer review of  patients with liver damage as indicated by alanine/aspartate aminotransferases levels, in blood, more than times the upper limit of normal;  patients suffering of severe chronic kidney disease;  patients using medications that are contraindicated with lopinavir/ritonavir (e.g., amiodarone, colchicine, simvastatine) or hydroxychloroquine (e.g., citalopram, escitalopram, hydroxyzine, domperidone, piperaquine). it is noteworthy that suffering of cardiac problems was not a criterion of exclusion from the study. the estimated study completion date has been fixed on march , years after the starting date. meanwhile, some partial reports on the efficacy of those molecules in the treatment of covid- have been made public. their conclusions are often contradictory as reported hereafter. remdesivir (gs- ™) is an antiviral agent developed by gilead sciences in the frame of the ebola virus outbreak. it was considered in one clinical trial only on the subject: "investigational therapeutics for the treatment of people with ebola virus disease" (nct ). [ ] the study was interrupted because the number of deaths in the group receiving remdesivir was higher than in the control group [ ] . the molecule was designated as an orphan drug for treatment of ebola disease on september , [ ] . gilead was also granted the orphan drug designation for treatment of covid- in march , . [ ] however, days later, under an explosion of criticisms, the remdesivir (gs- ™) is an antiviral agent developed by gilead sciences in the frame of the ebola virus outbreak. it was considered in one clinical trial only on the subject: "investigational therapeutics for the treatment of people with ebola virus disease" (nct ). [ ] the study was interrupted because the number of deaths in the group receiving remdesivir was higher than in the control group [ ] . the molecule was designated as an orphan drug for treatment of ebola disease on september , [ ] . gilead was also granted the orphan drug designation for treatment of covid- in march , . [ ] however, days later, under an explosion of criticisms, the company asked for a cancellation of its designation [ ] . access to the drug has also been expanded, exceptionally, to the us army [ ] . the first patient infected by sars-cov- in the united states was hospitalized on january and treated with compassionate-use remdesivir. [ ] the authors concluded: " . . . as of january , , the patient remains hospitalized. he is afebrile, and all symptoms have resolved with the exception of his cough, which is decreasing in severity. . . . although a decision to administer remdesivir for compassionate use was based on the case patient's worsening clinical status, randomized controlled trials are needed to determine the safety and efficacy of remdesivir and any other investigational agents for treatment of patients with -ncov infection." at the end of january, gilead accepted to provide remdesivir for compassionate-use to a series of clinicians in austria, canada, france, germany, italy, japan, the netherlands, spain, and the united states. the authors of the study concluded that "in this cohort of ( ) patients hospitalized for severe covid- , clinical improvement was observed in of patients ( %). measurement of efficacy will require ongoing randomized, placebo-controlled trials of remdesivir therapy." [ ] gilead has extended the research (nct [ ] ) by providing intravenous infusions of remdesivir to hospitals in countries: belgium ( hospitals), canada ( ), france ( ), germany ( ), israel ( ),italy ( ), netherlands ( ), romania ( ), spain ( ), switzerland ( ), the united kingdom ( ), and the united states ( ). in a press release, on april , k. mullane, from the university of chicago announced that patients, mostly with severe covid- , had entered into the phase trial and she concluded that "the best news is that most of our patients have already been discharged, which is great. we've only had two patients perish." however, no placebo group was included in the trial. [ ] on april , gilead disclosed another partial result concerning the efficacy of -day and -day treatments among patients distributed in a : ratio ( : ). results indicated that "the study demonstrated that patients receiving a -day treatment course of remdesivir achieved similar improvement in clinical status compared with those taking a -day treatment course." a. subramanian, a lead investigator for the stanford university school of medicine, added: "while additional data are still needed, these results help to bring a clearer understanding of how treatment with remdesivir may be optimized, if proven safe and effective." [ ] in an independent study, wang et al. examined patients over hospitals in the province of hubei, china. in this randomized, double-blind, placebo-controlled trial, people were administered remdesivir and received a placebo. the authors interpreted their results in the following terms: "in this study of adult patients admitted to hospital for severe covid- , remdesivir was not associated with statistically significant clinical benefits. however, the numerical reduction in time to clinical improvement in those treated earlier requires confirmation in larger studies." [ ] . from a chemical point of view, it must be underlined that remdesivir has six chiral centers and is manufactured as a single stereoisomer under aseptic conditions. globally, its synthesis requires several key intermediates (a-f) represented in figure [ ] . therefore, production relies on different suppliers whose capacities must be expanded in order to satisfy the eventual high demand of doses, as underlined by gilead [ , ] . ( ). yields were not mentioned in [ ] . commercially available under the brand name keletra ® , the combination is manufactured by abbvie in several countries of the world, sometimes in a generic version. availability is not a concern. the combination has been the subject of more than registered clinical trials [ ] and it is prescribed for treatment of hiv infection. in the case of covid- , the combination lopinavir/ritonavir is evaluated in clinical trials. there are several anecdotal reports indicating that japanese, chinese, and taiwanese patients treated with lopinavir/ritonavir survived the disease, but nothing indicated the benefit of the use of those antiviral agents. addition of umifenovir (arbidol ® ) to the combination did not show any improvement in the treatment [ ] [ ] [ ] [ ] [ ] . a randomized, controlled, open-label trial conducted in wuhan (china) concerned two groups of and patients, respectively. the first group was assigned the combination of antiviral drugs whereas the second group received standard care. the authors [ ] concluded: "we found that lopinavir-ritonavir treatment did not significantly accelerate clinical improvement, reduce mortality, or diminish throat viral rna detectability in patients with serious covid- .". both molecules are frequently prescribed for the treatment of malaria since decades and have been largely studied. their side-effects are widely known as well as all their pharmacological properties. both hydroxychloroquine (plaquenil ® ) and chloroquine (aralen ® ) have been clinically tested for their anti-hiv activity [ , ] . hydroxychloroquine is also recommended to treat lupus erythematosus and rheumatoid arthritis [ ] . hydroxychloroquine and chloroquine, eventually associated with an antibiotic, are the subjects of many contradictory reports about their usefulness in the treatment of covid- . positive effects with viral clearance have been observed whereas other groups concluded at the absence of efficacy or at cardiotoxicity when compared with standard care. discussions are articulated among four main aspects that should be taken in account: (i) stage of the disease; (ii) presence/absence of a control group; (iii) efficacy; (iv) safety. as earlier mentioned, controversial results have been published on the efficacy of treatments associating hydroxychloroquine and azithromycin for french patients hospitalized for moderate [ ] commercially available under the brand name keletra ® , the combination is manufactured by abbvie in several countries of the world, sometimes in a generic version. availability is not a concern. the combination has been the subject of more than registered clinical trials [ ] and it is prescribed for treatment of hiv infection. in the case of covid- , the combination lopinavir/ritonavir is evaluated in clinical trials. there are several anecdotal reports indicating that japanese, chinese, and taiwanese patients treated with lopinavir/ritonavir survived the disease, but nothing indicated the benefit of the use of those antiviral agents. addition of umifenovir (arbidol ® ) to the combination did not show any improvement in the treatment [ ] [ ] [ ] [ ] [ ] . a randomized, controlled, open-label trial conducted in wuhan (china) concerned two groups of and patients, respectively. the first group was assigned the combination of antiviral drugs whereas the second group received standard care. the authors [ ] concluded: "we found that lopinavir-ritonavir treatment did not significantly accelerate clinical improvement, reduce mortality, or diminish throat viral rna detectability in patients with serious covid- .". both molecules are frequently prescribed for the treatment of malaria since decades and have been largely studied. their side-effects are widely known as well as all their pharmacological properties. both hydroxychloroquine (plaquenil ® ) and chloroquine (aralen ® ) have been clinically tested for their anti-hiv activity [ , ] . hydroxychloroquine is also recommended to treat lupus erythematosus and rheumatoid arthritis [ ] . hydroxychloroquine and chloroquine, eventually associated with an antibiotic, are the subjects of many contradictory reports about their usefulness in the treatment of covid- . positive effects with viral clearance have been observed whereas other groups concluded at the absence of efficacy or at cardiotoxicity when compared with standard care. discussions are articulated among four main aspects that should be taken in account: (i) stage of the disease; (ii) presence/absence of a control group; (iii) efficacy; (iv) safety. as earlier mentioned, controversial results have been published on the efficacy of treatments associating hydroxychloroquine and azithromycin for french patients hospitalized for moderate [ ] or severe [ , ] covid- infection. another trial [ ] , involving male patients only at us veterans health administration medical centers, suggested caution in using hydroxychloroquine, particularly when not combined with azithromycin. regarding cardiotoxicity, it was attributed either to the combination of hydroxychloroquine and azithromycin or to each of those two drugs independently. thus, a study [ ] indicated that, for patients treated with the combination, critical corrected qt interval prolongations were higher than for patients treated with the antibiotic alone. this contrasts with the conclusion of j.c.e. lane et al. [ ] who reported that "short-term hydroxychloroquine treatment is safe, but addition of azithromycin may induce heart failure and cardiovascular mortality, potentially due to synergistic effects on qt length." on the other hand, data [ ] collected from four french hospitals revealed that patients receiving hydroxychloroquine experienced electrocardiogram modifications requiring discontinuation of the treatment with that molecule. in the case of chloroquine, studies on dose-dependence safety can be found. a brazilian trial [ ] revealed that treatment had to be interrupted for a cohort of patients allocated to receive a total dose of chloroquine of g, -fold the dosage recommended in the discovery project. the results were confirmed in a french study [ ] that concluded that "high-dose chloroquine treatment regimens which result in whole blood chloroquine concentrations below µmol/l for the majority of patients should not result in life-threatening cardiovascular toxicity." all those observations confirm a recent theoretical model that attracted attention to the fact that both hydroxychloroquine and chloroquine were characterized by narrow therapeutic windows overlapping with the highest tolerated doses [ ] . the problem could be overcome by using the medications as an aerosol as suggested by klimke et al. [ ] . as of may , there are clinical trials on covid- that are referenced in the u.s. national library of medicine of the national institutes of health [ ]. the most considered potential treatments are centered on plasma therapy and evaluation of the potentialities of hydroxychloroquine, chloroquine, and the combination lopinavir/ritonavir. protein and cell therapies attract less interest, despite their high promises in other diseases. the antiviral agent remdesivir exerts a moderate focus in the medical community, despite a large mediatic audience. great hope had been put in the european trial discovery. it must be admitted, however, that the actual situation is rather disappointing since many countries are not yet enrolled and consequently not recruiting. results on the efficacy of remdesivir are fragmentary and disclosed by the manufacturer. the combination lopinavir/ritonavir does not provide promising curative effects. in-depth studies are still awaited in order to clarify contradictory data on the usefulness of hydroxychloroquine and chloroquine. in conclusion, to date no treatment can be proposed despite the urgency of the situation. foundation and partners launch first-of-its-kind covid- solidarity response fund covid- : a brief overview of the discovery clinical trial chinese clinical trial registry trial of treatments for covid- in hospitalized adults les essais cliniques pour un traitement du covid- n'ont toujours pas débuté en belgique investigational therapeutics for the treatment of people with ebola virus disease a randomized, controlled trial of ebola virus disease therapeutics search orphan drug designations and approvals. available online search orphan drug designations and approvals. available online gilead sciences statement on request to rescind remdesivir orphan drug designation expanded access remdesivir (rdv; gs- ™) first case of novel coronavirus in the united states compassionate use of remdesivir for patients with severe covid- 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arbidol in the treatment of hospitalized patients with covid- : a pilot retrospective study a trial of lopinavir-ritonavir in adults hospitalized with severe covid- chloroquine and beyond: exploring anti-rheumatic drugs to reduce immune hyperactivation in hiv/aids clinical and microbiological effect of a combination of hydroxychloroquine and azithromycin in covid- patients with at least a six-day follow up: a pilot observational study hydroxychloroquine and azithromycin as a treatment of covid- : results of an open-label non-randomized clinical trial no evidence of rapid antiviral clearance or clinical benefit with the combination of hydroxychloroquine and azithromycin in patients with severe covid- infection outcomes of hydroxychloroquine usage in united states veterans hospitalized with covid- experience with hydroxychloroquine and azithromycin in the covid- pandemic: implications for qt interval monitoring safety of hydroxychloroquine, alone and in combination with azithromycin, in light of rapid widespread use for covid- : a multinational, network cohort and self-controlled case series study no evidence of clinical efficacy of hydroxychloroquine in patients hospitalised for covid- infection and requiring oxygen: results of a study using routinely collected data to emulate a target trial chloroquine diphosphate in two different dosages as adjunctive therapy of hospitalized patients with severe respiratory syndrome in the context of coronavirus (sars-cov- ) infection: preliminary safety results of a randomized, double-blinded concentration-dependent mortality of chloroquine in overdose pharmacokinetic bases of the hydroxychloroquine response in covid- : implications for therapy and prevention hydroxychloroquine as an aerosol might markedly reduce and even prevent severe clinical symptoms after sars-cov- infection this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license funding: this research received no external funding. any bibliographic omission must not be linked to a conflict of interest but simply reflects a gap when searching the oversized sources of information on the subject. key: cord- -a ft wdy authors: custovic, a.; johnston, s. l.; pavord, i.; gaga, m.; fabbri, l.; bel, e. h.; le souëf, p.; lötvall, j.; demoly, p.; akdis, c. a.; ryan, d.; mäkelä, m. j.; martinez, f.; holloway, j. w.; saglani, s.; o'byrne, p.; papi, a.; sergejeva, s.; magnan, a.; del giacco, s.; kalayci, o.; hamelmann, e.; papadopoulos, n. g. title: eaaci position statement on asthma exacerbations and severe asthma date: - - journal: allergy doi: . /all. sha: doc_id: cord_uid: a ft wdy asthma exacerbations and severe asthma are linked with high morbidity, significant mortality and high treatment costs. recurrent asthma exacerbations cause a decline in lung function and, in childhood, are linked to development of persistent asthma. this position paper, from the european academy of allergy and clinical immunology, highlights the shortcomings of current treatment guidelines for patients suffering from frequent asthma exacerbations and those with difficult‐to‐treat asthma and severe treatment‐resistant asthma. it reviews current evidence that supports a call for increased awareness of (i) the seriousness of asthma exacerbations and (ii) the need for novel treatment strategies in specific forms of severe treatment‐resistant asthma. there is strong evidence linking asthma exacerbations with viral airway infection and underlying deficiencies in innate immunity and evidence of a synergism between viral infection and allergic mechanisms in increasing risk of exacerbations. nonadherence to prescribed medication has been identified as a common clinical problem amongst adults and children with difficult‐to‐control asthma. appropriate diagnosis, assessment of adherence and other potentially modifiable factors (such as passive or active smoking, ongoing allergen exposure, psychosocial factors) have to be a priority in clinical assessment of all patients with difficult‐to‐control asthma. further studies with improved designs and new diagnostic tools are needed to properly characterize (i) the pathophysiology and risk of asthma exacerbations, and (ii) the clinical and pathophysiological heterogeneity of severe asthma. and risk of asthma exacerbations, and (ii) the clinical and pathophysiological heterogeneity of severe asthma. at a recent summit organized by the european academy of allergy and clinical immunology (eaaci), a group of experts discussed current issues of concern and unmet needs in regard to the treatment of asthma. most attendees presented evidence that the current guideline-driven treatment strategies fail in two vital aspects of asthma. there was a general consensus that the needs of patients with severe asthma or frequent asthma exacerbations are not being adequately covered by the current treatment guidelines and are of major health and socio-economic concern. such patients suffer from significantly reduced quality of life and incur disproportionately higher costs on health service resources. this report summarizes the current data that indicate the need for a more rational approach to the treatment of asthma and one that takes into account the emerging evidence for pathophysiological heterogeneity of the disease, including its more severe forms. a significant outstanding problem in the clinical management of asthma is the failure to prevent and/or efficiently treat asthma exacerbations, which are associated with significant morbidity, risk of death and high treatment cost ( ) ( ) ( ) . generally, an asthma exacerbation is considered to be an increase in a patient's asthma symptoms with increasingly impaired lung function that require increased medication, an unscheduled visit to a physician or hospitalization. a single asthma exacerbation requiring extra medication and possibly emergency treatment and hospitalization can increase the annual treatment costs by more than threefold ( ) . recurrent asthma exacerbations lead to a progressive decline in lung function ( ) , and the risk of an exacerbation doubles in children who have had one or more in the previous year ( ) . a rare but distinct phenotype of asthma exacerbation is characterized by the development of sudden severe asthma symptoms in an otherwise mild or asymptomatic asthmatic subject, which may be triggered by an allergen, drug (e.g. aspirin), food, air pollutant, occupational agent, virus infection or, in many cases, an unknown (or unidentified) trigger ( ) . it has been proposed that within the group of patients with recurrent exacerbations, detailed phenotyping in terms of clinical symptoms, lung function, inflammatory and other biomarkers is warranted ( , ) . there is a significant unmet need for identifying and characterizing the factors that increase the risk of asthma exacerbations and the therapeutic and preventive options that reduce these risks. patients with severe asthma have high morbidity and mortality, often require hospitalization and are expensive to treat. they have diverse clinical profiles, which probably reflect diverse disease mechanisms, and, for many of them, standard treatment is not sufficiently effective ( ) ( ) ( ) . severe asthma comprises a highly heterogeneous group of patients, which is defined in various ways in the published literature and in the national and international guidelines. a consensus is emerging that patients should be considered to have a 'difficultto-control asthma' if they have persistent symptoms and recurrent exacerbations despite being prescribed therapy at the highest steps of the guidelines' pharmacological management ( ) . however, it is worth emphasizing that the guidelines also make clear that 'difficult-to-control asthma' is multifactorial, and issues such as incorrect diagnosis, comorbid conditions, nonadherence to prescribed medication, psychosocial morbidity and a number of other factors discussed later in this manuscript are major causes of 'difficult' asthma ( ) . patients should be considered to have severe asthma that is resistant to currently available therapies only following a detailed analysis and appropriate management of all these background problems that are amenable to intervention. a recently published consensus statement on severe asthma broadened the concept of 'difficult asthma' to reflect the situation in less developed countries, where access to medications and appropriate care is a major issue, by defining three different patient groups including un(der)treated symptomatic patients, patients with low treatment adherence or unconventional therapies, and those remaining symptomatic despite high doses of anti-asthmatic therapies ( , ) . nonadherence to prescribed medication has been identified in a number of studies in the developed countries as the most common clinical problem amongst adults ( ) and children ( ) with asthma, including those with difficult-to-control asthma ( , ) . appropriate assessment of adherence ( ) and other potentially modifiable factors (such as passive or active smoking, ongoing allergen exposure, psychosocial factors, etc.) ( ) has to be a priority in clinical assessment of all patients with difficult-to-control asthma, before any decision about increasing the treatment is made (including possible prescription of an expensive biological therapy) ( ) . the clinical diversity and the underlying pathophysiology of severe treatment-resistant asthma need to be characterized, so that rational therapeutic targets can be identified and relevant biomarkers validated ( ) . in addition, there is a need for controller as well as noninterventional studies in this patient population. although inhaled corticosteroids may protect against asthma exacerbations due to allergen exposure, they are reported to be relatively ineffective in children with virus infectioninduced wheezing ( ) . this suggests the existence of different types of childhood asthma with different underlying pathophysiologies ( , ) . recent joint modelling of longitudinal observations on wheezing from parental reports and medical records identified a novel phenotype of persistent troublesome wheeze with high rates of severe asthma exacerbations and healthcare utilization ( ) . despite having phenotypic markers commonly considered to be indicators of good therapeutic response (atopy and eczema), these children had relatively poor response to currently available antiinflammatory treatments ( ) . an atopy-related phenotype of children with high risk of asthma exacerbations has recently been identified by bayesian inference in two birth cohort studies in which multiple skin and ige tests were collected throughout childhood ( , ) . the analysis revealed several different atopic vulnerabilities, only one of which had a much higher risk of asthma exacerbations ( , ) . however, this group of children with a significant risk of asthma exacerbations was identified only using longitudinal data, and cross-sectional biomarkers allowing their identification in clinical practice are still lacking. several attempts have been made to identify predictors of asthma exacerbations. several comorbidities associated with recurrent asthma exacerbations have been identified in adult patients ( ) , including severe nasal sinus disease, gastrooesophageal reflux disease, recurrent respiratory infections, psychological dysfunction and obstructive sleep apnoea. psychological dysfunction ( ) and treatment nonadherence are separate psychosocial factors that may significantly contribute to the risk of asthma exacerbations. a significant number of patients with high rates of asthma exacerbations, and increased airway eosinophilia, were found to have a low perception of their lung dysfunction ( ) . asthma exacerbations are frequent in asthma patients with poor treatment adherence, and poor adherence remains one of the major challenges in the treatment of severe asthma ( , ) . the basis of asthma treatment guidelines is the use of clinical symptoms or impaired lung function to guide treatment of airway inflammation. however, there is a strong rationale for using direct measurement of airway inflammation as an additional means to guide treatment in severe asthma. green et al. ( ) reported that titrating treatment to sputum eosinophil counts was more successful in reducing asthma exacerbations than treatment in accordance with guidelines. this was confirmed in a larger, multicentre study ( ) , which also reported that the frequency and severity of eosinophilic exacerbations were reduced without increasing the dose of inhaled corticosteroids (ics) (the severity but not the frequency of noneosinophilic exacerbations was also reduced). the treatment strategy of these authors was to (i) treat patients with sputum eosinophil counts of > % with the minimal ics dose required to reduce sputum eosinophil counts to normal and (ii) consider other treatment options in patients with normal sputum eosinophil counts, such as treatment of airway obstruction with long-acting beta-agonists (labas) or a leukotriene receptor antagonist, or treatment of neutrophilic inflammation with antibiotics. of interest, a treatment approach aimed at specifically reducing airway eosinophils using a monoclonal antibody directed against interleukin (il)- reduced the risk of asthma exacerbations in patients with severe asthma and persisting airway eosinophilia ( , ) . however, it is of note that even after using this targeted approach, approximately % of severe exacerbations remained unaffected by the treatment. attempts to identify clinical biomarkers for predicting the risk of asthma exacerbation have so far failed. however, some small studies have identified possible candidate biomarkers. for example, gelb et al. ( ) evaluated the use of spirometry and exhaled nitric oxide (f e no) in predicting the risk of asthma exacerbations in stable, mild-to-severe patients with asthma over months. those patients with a baseline fev < % of predicted plus an f e no > ppb had a probability of an asthma exacerbation in months of %, while those with fev > % of predicted plus a f e no < ppb had zero probability of an asthma exacerbation in the same period. the f e no parameter may be a robust measure of the degree of eosinophil airway inflammation ( , ) . numerous epidemiological studies indicate that asthma exacerbations are associated with upper respiratory viral infections, mostly with rhinoviruses, and to a lesser degree with respiratory syncytial virus or coronavirus, with frequency estimates of % and % for childhood and adult asthma, respectively ( , ) . this was confirmed by the ga len-dare systematic review ( ) that reviewed data from published epidemiological studies. the data for childhood asthma are more extensive than that for adult asthma and reveal the absence of geographical influence. the same review indicated that high rates of respiratory bacterial infections are also associated with asthma exacerbations, but the data are inconsistent. however, bisgaard et al. ( ) provided evidence that bacterial infection and viral infection were independently associated with wheezing episodes in infants (< years old), with odds ratios of . and . , respectively. although confirmatory studies need to be performed, current data strongly suggest that respiratory infections are the major cause of asthma exacerbations. case-control studies have revealed a synergism between viral infection and allergen exposure in increasing the risk of asthma exacerbation requiring hospitalization in children ( ) and in adults ( ) . atopic asthmatic patients have more severe and prolonged lower respiratory tract symptoms during rhinovirus infections than nonatopic healthy controls ( ) . this may be explained by impaired innate and acquired immunity of the airways in asthma, as indicated from the studies of experimental and clinical viral infection ( , ) . such impairments in airway immunity correlate with the in vivo severity of the infections and with the viral load ( , ) . consequently, specific and nonspecific antiviral strategies may have great potential as therapeutic and preventative strategies for asthma exacerbations, a hypothesis that is supported by preliminary clinical studies ( ) . patients with asthma also have deficient interleu-kin- and type iii interferon responses to bacterial stimuli, suggesting that inadequate host defence mechanisms and mechanisms specific to the infectious agents are the underlying factors for increased susceptibility ( , ) . rhinovirus and enterovirus infections are more likely to cause an asthma exacerbation than most other viruses in patients of any age, with the exception of rsv in infants ( ) , while virus load and virus co-infection rates correlate with symptom severity ( ) . case-control studies indicate that asthma subjects are at greater risk of invasive pneumococcal infections than patients without asthma, with reported ors ranging from . to . ( - ). for example, the population-based case-control study by klemets and colleagues ( ) assessed the risk of invasive pneumococcal (streptococcus pneumoniae) infection (ipi) amongst adult patients with asthma. using a national population-based laboratory surveillance, , cases of ipi were selected in patients aged - years (thus largely excluding copd patients) along with noninfected controls per ipi case, matched for age, sex and health district. asthma cases were categorized as high (≥ hospitalization within the previous months) and low risk (with prescription drug entitlement and no hospitalization within the previous months). overall, . % of cases had asthma ( . and . % with high-and low-risk asthma, respectively) vs . % of controls ( . and . % with high-and low-risk asthma, respectively), indicating that adults of working age with asthma are at substantially increased risk of ipi. impaired immune responses may be associated with exacerbations in asthmatic children with reduced lung function, but not in those with normal lung function ( ) . specifically, at the time of an asthma exacerbation, a lower expression of th response genes was observed in children with reduced lung function than in children with normal lung function. other studies have shown that genetic factors such as vitamin d ( ) or particulate matter (pm ) ( ) can modify the effect of environmental exposure on exacerbation frequency. the advent of genomewide association studies in populations with severe asthma ( ) and asthma exacerbations ( ) may aid in better prediction of exacerbation phenotypes and the subclassification of patients into subphenotypes that may reflect the differing aetiopathogenesis and response to treatment and so allowing better targeting of treatment. attempts to characterize severe asthma in childhood in childhood asthma, guidelines that outline stepwise treatment escalation with increased disease severity or impaired symptom control fail to adequately deal with nonresponders ( ) ( ) ( ) . in particular, the stepwise treatment appears not always to be appropriate for children younger than years, particularly those with mainly virus-driven asthma, who often do not respond to inhaled corticosteroids ( ) . severe asthma in children is complex, with the asthma phenotype changing during development and requiring continual reassessment ( , , ) . this makes cross-sectional analyses of childhood asthma less useful, as any apparent phenotypic stability within a population will obscure the significant individual instability of disease expression. one of the characteristics of severe treatment-resistant asthma in childhood is the large size of skin test wheal to inhalant and food allergens ( ) . furthermore, in this patient group, the results of skin tests and ige measurements for individual allergens are not always concordant; as a consequence, both tests should be carried out and quantified ( ) . similar quantitative relationship between skin tests (and sige levels) has also been reported in relation to severity of airway hyper-reactivity in adults ( ) . rhinovirus infection in infants induces wheeze and, in a longitudinal study, was shown to be significantly associated with the development of childhood asthma ( ) . in another -year prospective study, teenage asthma was strongly associated with infant wheezing requiring hospitalization ( ) . this study identified eczema and allergen-specific ige as early asthma-predictive factors and the risk of developing teenage asthma to be increased fivefold after respiratory syncytial virus-induced wheezing in infants and > -fold after rhinovirusinduced wheezing. rhinoviruses are frequently found in the lower airways in infants with recurrent respiratory symptoms, with the majority of these rhinovirus-infected infants exhibiting increased airway resistance ( ) . in infants with wheezing requiring hospitalization, sole rhinovirus infection, but not sole infection with any other common airway viruses, was associated with atopy ( ) . a recent study has demonstrated that a cardinal feature of bronchial epithelial cells from children with severe treatment-resistant asthma is impaired interferon-b and ifn-k induction by rhinovirus ( ) . although this patient group was highly atopic, no relationship was observed between atopy, allergy or th -mediated inflammation with impaired interferon ( ) . a longitudinal study of an unselected birth cohort, which monitored lung function from the age of - years ( ), reported that persistent wheezing, starting early in life, was associated with a decline in lung function in adult life and increased risk of exacerbations. a decline in lung function has also been associated with severe asthma exacerbations in adult asthma ( ) . a german birth cohort of more than children showed that the risk of development of persistent asthma at age years was significantly increased by early allergen sensitization in combination with exposure to high levels of perennial allergens early in life ( ) . in a recent study, predictors of subsequent troublesome symptoms amongst -year-old children with wheezing were large skin test responses to allergens and history of previous exacerbations and eczema ( ) . attempts to identify phenotypes of adult asthma include the use of unsupervised cluster analyses ( , ) aiming to group patients who share key features of asthma and airway inflammatory disease. haldar and colleagues ( ) grouped patients according to clinical symptoms and evidence of airway inflammation (based on sputum eosinophil count) and found that symptom-led treatment of airway inflammation was appropriate in patients with mild and moderate asthma, but failed in more severe forms. they identified two discordant groups of patients who were refractory to standard treatment approaches and represented about % of all patients. one discordant group of patients were characterized as an obese, symptom-predominant, noneosinophilic phenotype, while the other group had few asthma symptoms, but a high degree of airway inflammation. using symptom-driven asthma treatment in these two discordant groups would lead to overtreatment of the former and undertreatment of the latter group. one difficulty with attempts to use clustering techniques to define disease mechanisms is defining cause and effect. in other words, 'are the pathophysiological features a consequence or an underlying cause of the disease?' a further confounding factor is the influence of treatment or lack of it (nonadherence). defining groups of patients with chronic diseases according to different personality traits ( ) has identified personality traits that govern treatment adherence. there was a significant overlap between the phenotypes identified by haldar et al. ( ) and those identified by moore et al. ( ) . other similar initiatives included the eu-sponsored unbiased biomarkers for the prediction of respiratory disease outcomes (u-biopred) consortium that has published a consensus-based systematic algorithm approach to differentiate between 'problematic', 'difficult' and 'severe refractory' asthma in the evaluation of patients with chronic severe asthma symptoms for use in clinical research and specialized care ( ) . the published practal consensus report on 'endotypes' ( ) attempts to assign patients with asthma to groups sharing specific pathophysiological features, with the aim of identifying a basis for rational treatment of heterogeneous groups. patients with severe asthma are found in each of these groups. three recognizable clinical phenotypes of severe asthma emerge from these various analytical studies (see table ): (i) a severe atopic form, (ii) severe 'intrinsic' asthma (the most malignant severe asthma phenotype ( )) and (iii) severe asthma with obesity. however, it has to be emphasized that distinct pathophysiological mechanisms underpinning these different clinical phenotypes of severe asthma have not as yet been identified. one potential problem of the cross-sectional approach to unbiased clustering is that the analysis does not include the important dimension of time, which may be essential to take into account potentially crucial longitudinal changes. furthermore, while unsupervised learning may be a useful tool to generate new hypotheses, using these techniques to find an association with predefined outcomes such as severe asthma can be misleading if asthma severity is derived using the same variables that are used for clustering. there is mounting evidence to demonstrate a close association between sensitisation to fungi and asthma severity ( ) , and the term 'severe asthma with fungal sensitization' (safs) has been proposed for patients with persistent severe asthma and fungal sensitization ( ) . proof-of-concept pilot studies have suggested an improvement in asthma after antifungal treatment in this patient group ( ) . several studies have shown that the standard guideline treatment of persistent asthma with ics provides a variable response, with - % of asthmatic subjects showing little improvement in fev and/or bronchial hyper-responsiveness ( ) ( ) ( ) . in the gaining optimal asthma control ('goal') study ( ) , bateman and colleagues used year of increasing doses of combined ics and laba treatment in patients with persistent asthma and reported that about % of patients, with varying degrees of disease severity, did not achieve 'well-controlled asthma'. asthma exacerbation risk may be further reduced using the same medication (i.e. an inhaled combination of a rapid-acting beta- agonist and corticosteroid ( )) as a controller and as a reliever of the disease. the price trial ( ) aimed to identify predictors of short-term ( weeks) response to ics. although several baseline biomarkers and asthma symptoms correlated with short-term improvements, only greater bronchodilator (short-acting b agonist) reversibility showed a strong (p < . ) correlation. differentiating between responders (> % fev improvement) and nonresponders (< % fev improvement) revealed that asthma control in responders was maintained only with continued ics, while, in nonresponders, no improvement was observed with or without ics. interestingly, tiotropium, a long-acting antimuscarinic agent, still approved only for copd, has been recently shown to further improve lung function in patients with severe uncontrolled asthma ( ) . of the four clinical phenotypes of severe asthma described in table , the severe atopic form partially responds to standard treatment. table indicates possible treatment approaches in the two groups of patients with severe asthma, which were described by haldar et al. ( ) , that are less responsive to standard treatment. these treatment options for patients with severe asthma who remain symptomatic despite adhering to standard medical care include novel anti-inflammatory drugs that have been shown in preliminary studies to be effective in treating airway inflammation in asthma and so warrant further investigation ( , ( ) ( ) ( ) ( ) , and other novel approaches such as bronchial thermoplasty ( ) . it is important to note that, for a more effective use of these novel treatment options, a better understanding of the pathophysiology and of the inflammatory mechanisms of the severe asthma subtypes are required in order that studies can delineate specific response patterns. as previously noted, antifungal treatments may be of benefit in patients with severe asthma with fungal sensitization ( , ) , but large studies are needed to support these initial findings. current treatment of asthma exacerbations is inadequate, and new approaches to treatment are needed. these may include interferon-based treatments, treatments that aim to boost deficient antiviral immune responses and/or specific antiviral treatments. there may be patients with severe asthma who could benefit from treatments that target neutrophilic inflammation without further suppressing anti-infective immunity. another question that needs to be addressed is the possible benefit in asthma exacerbations of antibacterial treatments that are widely used ( ), despite not being recommended in guidelines. the advances in molecular biology and immunology are being used to develop novel biological drugs for asthma treatment. these include therapeutic antibodies, soluble receptors, cytokines, small molecules and combinations thereof that target different effector molecules that influence the underlying immune and inflammatory processes. some biological drugs are currently in clinical trials in asthma ( ) . however, there are major difficulties in developing novel drugs to treat asthma. these include (i) the complexity of the disease (in terms of the different disease phenotypes and the underlying molecular mechanisms), (ii) the limited number of biomarkers that have been identified for disease classification, (iii) the effectiveness of the current standard treatment approaches (combined inhaled steroid and beta-adrenergic agonist is not only effective but cheap) makes any comparative improvement difficult to identify in multicentre clinical trials, (iv) low patient adherence, which is characteristic of treatments of chronic disease, and (v) preclinical animal models may be poorly predictive of clinical efficacy ( ) . importantly, future clinical trials will need to identify the patient groups that respond to novel treatment to provide evidence for the stratified, personalized approach to asthma management. in primary care, recognition of the clinical heterogeneity of asthma and the existence of different forms of severe asthma is obscured by a number of general deficiencies, including limited available time and clinical resources and lack of capacity and clinical capability. nonguideline treatment of asthma is high, and provision of treatment to patients with asthma varies greatly, for example, in the use of ics across european countries ( ) . the influence of comorbidities and of asthma exacerbations on asthma symptoms, in both children and adults, are not sufficiently recognized ( , ) . most patients with asthma in primary care have been found to have uncontrolled disease ( ) . furthermore, it is becoming increasingly clear that many patients diagnosed as asthmatic, even after full evaluation at tertiary centres, do not have asthma, but various other diagnoses ( , ) , which indicate a fundamental need to establish improved diagnosis as a basis of appropriate management ( ) . the resources needed to review patients frequently until disease control is achieved vary between healthcare systems. the finnish national asthma programme ( ) , predicated on a systematic approach to disease management and underpinned by educational and skills training in primary care, demonstrates that investment in the structure of the health system that delivers asthma care reduces morbidity significantly and at a lower overall cost. the above discussion aims to highlight the prominent issues and the attempts to acquire a better understanding of asthma exacerbations and severe asthma. however, there are several additional clinical and pathophysiological issues of importance for improving our understanding of asthma as a complex disease. these have not been highlighted here partly because there is no scientific consensus of their exact relevance. however, two examples are briefly reviewed here. airway remodelling is associated with poor clinical outcomes amongst asthmatic patients, but the pathophysiological relevance of, and the effect of treatment on, airway remodelling is unclear ( ) . airway remodelling is a feature of adult asthma and is found to a similar extent, and quite early, in children with difficult-to-treat asthma ( ). using epithelial reticular basement membrane thickening as a marker for airway remodelling, no association between airway remodelling and age, symptom duration, lung function and concurrent eosinophilic airway inflammation was found ( ) , albeit in a small number of patients. inflammatory and structural changes typical of asthma, such as airway eosinophilia and angiogenesis, have been observed not only in children with asthma but also in atopic children without asthma, raising the possibility that some of these pathological lesions may be associated with atopy even in the absence of asthmatic symptoms. reticular membrane thickening and the eosinophilic inflammation characteristic of asthma in older children and adults are not present in the wheezing infants with reversible airflow obstruction, even in the presence of atopy ( , ) . it was proposed that this lack of rbm thickening in wheezy infants was due to the apparent paucity of eosinophilic inflammation ( ) , which may have a role in driving allergic airway remodelling ( ) . based on the data from many population studies, it is generally considered that the environment has an important influence on the development of asthma and other allergic diseases. however, the proposed mechanisms, particularly the role of atopy, that underlie the effects of environment on asthma aetiology need to be revised in the light of recent findings ( ) , such as the evident increase in prevalence of severe asthma in developing countries and its parallel decline in several developed countries ( ) . the interaction of environment and asthma disease mechanisms is complex, and genetic variants that are protective in one environment may be associated with increased risk in another environment ( ) . • although clinical guidelines improve patient treatment by bringing treatments to groups of patients who best benefit from them, they fail many patients who fall outside of the 'mean' clinical characteristics on which clinical guidelines are based. labas is insufficiently effective in many patients with severe asthma. • young children, particularly those with virus-driven asthma, are often poorly managed with currently available medications. • in asthma, there is a need to focus more on the individual patient, particularly those with severe asthma. • there is a need to recognize asthma as a heterogeneous disease and to properly identify the different disease mechanisms involved in patients with severe asthma. only in this way, we will begin to understand what is 'driving' severe asthma and identify novel therapeutic targets. • in childhood asthma, expression of atopy varies over time and in different characteristic ways that suggest differences in underlying pathophysiological mechanisms in relation to exacerbation-prone asthma phenotype. • in adult asthma, several forms of severe asthma have become recognized, and different treatment approaches to these forms of severe asthma are proposed. • there is a need for a consensus definition of asthma exacerbation that could usefully guide treatment. we need to better understand the mechanisms of asthma exacerbation, develop novel treatments for exacerbations and carry out studies of existing and new treatments to better guide their use. • as in copd, asthma diagnosis and treatment decisions should include consideration of future risk of exacerbations. • current data strongly link impaired innate immune responses and consequent increased risk of infection with increased risk of asthma exacerbations. this provides a sound basis for the development of novel treatments. • there is general concern that patients with asthma are not being sufficiently alerted to the risk of asthma exacerbations and that another term be considered other than 'asthma exacerbation' when describing these events to patients (such as 'lung attack' or 'asthma attack' to equate the seriousness of such an event with a heart attack). • development of diagnostic procedures accessible within primary care to ensure correct diagnosis. • an acceptance of the need for iterative review to gain control of the disease; patients, in whom asthma fails to become controlled, need further evaluation to confirm that asthma is the correct diagnosis and what further evaluations are required. • improved tools for 'scoring' the asthma patient in terms of disease severity, and future risk needs to be developed for use in primary care ( , ) . • future studies should aim to establish whether serum ige, f e no and induced sputum eosinophil counts are valuable biomarkers of the severity of asthmatic airway inflammation. • new biomarkers are needed to predict the severity of asthma, the risk of exacerbation and the response to treatments. • there is a need for a more objective definition of childhood asthma, with broader use of lung function tests, especially in preschoolers, and so obtain more uniform criteria for diagnosis before initiating treatment to control the disease. • in both childhood and adult asthma, expression of atopy varies over time and in different characteristic ways that reveal differences in underlying pathophysiological mechanisms, including a severe asthma-prone phenotype. • observational longitudinal studies should be performed in a standardized way with patient and biological data sampling (using an asthma register) to allow a better characterization of the epidemiology, current healthcare utilization, risk factors (including genetic susceptibility) and comorbidities that are linked to exacerbations and severity. • the future task is to devise studies that differentiate between patient phenotypes, use robust clinically relevant biomarkers, include longitudinal outcomes (such as time to exacerbation and increase in airway remodelling) and identify relevant environmental factors, including the influence of current and prior medication. to facilitate the identification of new asthma endotypes, such studies should contribute to a repository (or biobank) of biological samples from the asthma population. • for characterization of the heterogeneity of severe asthma, more and improved clinical studies are needed to improve the evidence base. • randomized, controlled trials in asthma include highly selected patients, who are, almost exclusively, 'healthy asthmatics' with ß -agonist reversibility. • cohort studies may complement clinical trials. • there are still insufficient longitudinal data in adult asthma, and cohort studies in this age group need to be established. • improving primary care of the asthmatic patient is in need of urgent attention and requires radical changes. • the ideal approach to dealing with the asthmatic patient in primary care is to (i) characterize the patient, (ii) confirm diagnosis, (iii) confirm whether a new or existing patient gains control by the iterative application of a structured review ( ) and consider reducing treatment when control is achieved, while undertaking appropriate monitoring, (iv) maintain control by teaching the patient about asthma and developing the patient's self-management skills ( ) according to the model developed by glasziou ( ) , (v) attempt to understand the patient's perspective; this may be the key to improving patient compliance ( ) , (vi) consider the risk of exacerbations (which is separate from controlling everyday symptoms) and factors that may increase the risk of exacerbations ( ) and (vii) realize that nonsymptomatic patients are also at risk of exacerbations. • the complexity of the multifactorial nature of asthma and the resource limitations in primary care needs to be better characterized in order to address the wide variability of care delivered in this environment ( ) . • support mechanisms that enable readily accessible means for patient self-management and self-education, having already met with varying degrees of success ( ) ( ) ( ) ( ) , need to be further developed. • primary clinicians have themselves recognized the research agenda that is needed to direct improvement in asthma care ( ). • whether seen in primary care or secondary care, patients with uncontrolled asthma either (i) have treatment-resistant disease, (ii) are not fully compliant with treatment, (iii) are unable to appreciate deterioration in their disease, (iv) have a physician who is underestimating the degree of disease control, is undertreating or not recognizing the effect of comorbidities, or (v) do not have asthma. l. m. fabbri has received consultancy fees from: boehringer ingelheim, chiesi, glaxosmithkline, msd, nycomed, pearl therapeutics, sterna, peer voice europe, om pharma sa, kyorin pharmaceutical, boston scientific and bayer. readings, advisory board or reimbursement of expenses: astrazeneca, novartis, sigma-tau, roche, deutsches zentrum f€ ur luft und raumfahrt, german aerospace center, mundipharma int., genetech inc., elevation pharmaceutical, ferrer group, nycomed, dynamicon and laboratori guidotti. e. bel has received consultancy fees from novartis, gsk and sanofi-regeneron, and fees for speaking from gsk. p. le sou€ ef has received speaker fees from glaxo smith kline and astrazeneca and has received research funding from astrazeneca and pharmanet ag. he has received research grants from the national health and medical research council of australia and the australian research council. j. l€ otvall has over the last five years been a consultant and/or given lectures for gsk, astrazeneca, aerovant, novartis, ucb, oriel and merck, for which he has received honoraria. he has also received research grants and participated in clinical trials for novartis, gsk, astrazeneca and actelion under the full organization of the university of gothenburg. p. demoly is a consultant and a speaker for stallergenes, alk, circassia and chiesi and is a speaker for merck, astrazeneca, menarini and glaxosmithkline. c. akdis serves 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monitoring of asthma: multicentre randomised controlled trial slj is funded by the asthma uk clinical professorship (ch sj). we acknowledge the editorial support of gerard p mcgregor, of omniscience sa, who was financed by a grant from the eaaci. the authors wish to thank professor christian virchow, universit€ at rostock medizinische fakult€ at, klinik & poliklinik f€ ur innere medizin, abteilung pneumologie, ernst-heydemann-str. , rostock, germany, for reviewing the manuscript and extremely useful comments. a. custovic serves as a consultant for circassia. he received speaker fees from glaxo smith kline, thermo fisher scientific, airsonet, novartis, msd and alk. he received research grants from the uk medical research council, moulton charitable foundation national institute of health research.in the past five years s. l. johnston has had research grants from astra zeneca, centocor, glaxosmithkline, med-immune, sanofi-pasteur and synairgen. s. l. johnston holds share options in synairgen. s. l. johnston does some consultancy work for astrazeneca, centocor, glaxosmithkline, medimmune, sanofi-pasteur and synairgen.in the last five years, i. d. pavord has received speaker's honoraria for speaking at sponsored meetings from astra zeneca, boehringer inglehiem, aerocrine and gsk. he has received honoraria for attending advisory panels with almirall, astra zeneca, boehringer ingelheim, gsk, msd, schering-plough, novartis, dey and napp. he has received sponsorship to attend international scientific meetings from boehringer ingelheim, gsk, astra zeneca and napp.m. gaga received research grants from novartis, bi, cephalon, teva and gsk. the other authors of the paper declare no conflicts of interest. key: cord- -ohw chbg authors: ma, hui; zhu, jiangong; liu, jianfei; zhang, xin; liu, yunxi; song, hongbin title: hospital biosecurity capacitation: analysis and recommendations from the prevention and control of covid- date: - - journal: j biosaf biosecur doi: . /j.jobb. . . sha: doc_id: cord_uid: ohw chbg the outbreak of covid- epidemic in december has highlighted issues with hospital biosafety capacitation in the people’s republic of china, although the epidemic has been controlled now. this study examined the primary issues, including an absence of hospital emergency system, inadequate management and control of nosocomial infection, limited hospital laboratory capacity, and poor hospital admission capacity. accordingly, the study put forward the following countermeasures and suggestions for hospitals to deal with future biosecurity events, such as a major epidemic: first, there is a need to build biosecurity management systems and emergency response mechanisms in hospitals; second, the investment and guarantee mechanisms for hospital biosecurity construction should be improved; third, the capacity building of biosecurity incident treatment needs attention in general hospitals; and fourth, comprehensive plans need to be developed for the integrated construction of medical treatment and prevention facilities through disease-control systems. in december , the coronavirus disease was detected in wuhan city, hubei province, people's republic of china, and rapidly spread to many provinces and cities across the country. at : on april , , the national health commission reported a total of cumulative , confirmed cases of covid- , including , deaths, and , cured cases, from provinces (autonomous regions and municipalities); in the hubei province, there were , confirmed cases, , deaths, and , cured cases [ ] . in contrast to the severe acute respiratory syndrome (sars) and influenza a virus, subtype h n (h n ), infections that respectively occurred in and in the people's republic of china, the severe acute respiratory syndrome coronavirus (sars-cov- ) that causes covid- is a new pathogen characterized by the following features: unknown animal origin, strong transmissibility, high susceptibility of the general population, and uncertain mortality rates in high-risk populations. the lack of an effective treatment for severe covid- has contributed to the considerable destructive power of the disease with regard to its effects on the society and economy [ , , ] . moreover, the epidemic has exposed inadequacies of biosecurity governance. a greater concern is that the slow early warning of the epidemic has seriously undermined the effectiveness of prevention and control measures as well as treatment in the later stages of the infection. thus, from the perspectives of ensuring the people's health, safeguarding national security, and maintaining the long-term national stability, it is essential to incorporate biosecurity into the national security system, systematically plan the construction of a national biosecurity risk-control and governance system, and comprehensively improve the national biosecurity governance capacity [ ] . after the outbreak of the covid- epidemic, the people's republic of china set up a leading group for a timely response to the epidemic. the state, the army, and local governments at all levels responded forcefully, and the military-civilian joint prevention and control mechanism was rapidly established to undertake decisive measures to prevent the import, spread, and transmission of the epidemic and thus block the nationwide transmission of the sars-cov- [ ] [ ] [ ] . the majority of military and civilian medical workers have fought hard at the frontline to reach the phased goals of "double increases" (increased treatment rate and cure rate) and "double decreases" (decreased infection rate and mortality rate), to achieve remarkable results in epidemic prevention and control [ ] . however, in the fight against the covid- epidemic, we found many issues that emerged in local hospitals in the response to a major epidemic. these issues indirectly reflected that hospitals have many shortcomings and weaknesses in the prevention and treatment of infectious diseases as well as with regard to hospital biosecurity construction [ ] . therefore, we aimed to evaluate those issues and develop suitable countermeasures. after the outbreak of the covid- epidemic, all provinces (autonomous regions and municipalities) across the country initiated first-level responses to public health emergencies to ensure the momentum of the epidemic was effectively contained. nevertheless, medical institutions at all levels, especially hospitals, demonstrated a weak response to the epidemic in the early stages, which was attributable to the following four reasons. first, the emergency response force for biosecurity was insufficient. although hospitals set up infection control or disease prevention department, due to the shortage of personnel skilled in biosecurity and lack of professional knowledge and skills, such as surveillance and early warning, sample collection, disinfection and quarantine, and protection training, the clinicians who had a poor understanding of the disease implemented inappropriate measures in the early stage, and thereby missed the best timepoint for disease control [ ] . second, the interactive emergency response mechanism did not function smoothly. with the large number of patients visiting hospitals, the poor information exchange among medical institutions, disease control institutions, and scientific research institutions caused doctors to have scant knowledge of the epidemiological characteristics, transmission patterns, and human-to-human transmission of sars-cov- infection, with the consequence of disappointing treatment results [ ] . third, the emergency reserves were inadequate. owing to the defective emergency reserve system and the large number of people quarantined for prevention and protection purposes, there was a nationwide shortage of masks, goggles, protective clothing, and quarantine clothing in hospitals [ ] . fourth, the hospital infectious disease monitoring network system does not play an early warning role in the early stage. since , the people's republic of china has successively established direct epidemic reporting system, pathogen surveillance system, unknown pneumonia case surveillance system, and symptom surveillance system, in order to facilitate early detection of new emerging infectious diseases. however, judging from the response to the epidemic, many of these systems did not play an adequate role in early warning [ ] . covid- is transmitted from the carrier to the infected mainly through droplets and close unprotected contact, and there is a possibility of airborne transmission due to aerosols produced during medical procedures [ ] . thus, covid- can be detected in ambient air of medical institutions [ ] , which everyone is generally susceptible to [ ] . it has been confirmed that there is human-to-human transmission and medical staff infection [ , , , ] . by february , , a total of , medical staff in hospitals were reported to have contracted the sars-cov- infection [ ] , and most ( %) were from the hubei province and diagnosed in the early stage of the outbreak in wuhan. therefore, the biosecurity protection of medical staff is of particular significance. because patients in the incubation period could not be detected in time at the outset of the epidemic, the medical staff failed to implement graded protection and standard prevention protocols [ ] , which resulted in nosocomial infections. after identifying the confirmed cases, the shortage of protective materials or gear and the lax implementation of hospital rules and regulations on nosocomial infections further exposed medical staff to the risk of nosocomial infection. in addition, nosocomial cross-infection among ordinary patients was not given due importance. cross-infection among patients or between doctors and patients is caused by poor conditions at the fever clinic or inadequate management of nosocomial infection. in particular, in the treatment of covid- , the vast majority of non-infectious and respiratory professionals had limited knowledge of the disease and its prevention and control, which contributed to the growth of the nosocomial infection rate, accounting for a large proportion of covid- cases. one example of this is the earliest nosocomial event at the department of neurology in wuhan union hospital [ ] . one of the gold standards for confirming the diagnosis of patients with sars-cov- infection is the etiological evidence, namely nucleic acid testing through real-time fluorescent polymerase chain reaction [ ] . however, the covid- epidemic has exposed several problems with regard to laboratory conditions and capabilities. first, there is a lack of bio-secure laboratories in hospitals. the covid- test needs to be carried out in secondary biosecurity laboratories [ , , ] , which are unavailable at many hospitals; moreover, hospitals that have these laboratories may be unable to obtain the testing qualification from relevant state departments in time, with a resultant failure to in timely detection and delay in the diagnosis and treatment of the disease. second, there is a lack of hospital testing materials. due to improper sampling, non-standard protocols, and issues with the stability and reliability of many hastily developed new kit products at some hospitals, the rate of positive detection was low. in addition, some patients had residual viral loads detected in stool samples after discharge from the hospital, which resulted in "re-positivity" [ ] and a risk of infection re-spread. during the epidemic, several hospitals faced difficulties with expanding capacities for quarantine and admission purposes in a short period. as of february , , patients received treatment across the country, and hospitals strived to expand hospital bed capacity [ ] . the first difficulty was the limited capacity for housing patients with infectious diseases. for instance, weeks after the outbreak, although there were designated hospitals in wuhan, a large number of patients were waiting for beds. two hospitals were temporarily built, and square cabin hospitals were quickly set up; therefore, the bed capacity increased sharply, which greatly relieved the pressure with regard to hospitalization of patients. the second challenge was the limited emergency treatment capacity. during the epidemic, many general hospitals undertook the tasks of emergency admission and treatment of patients with covid- and quarantine of suspected patients. however, most hospitals were apparently inexperienced at reforming medical institutions for segregated diagnosis and treatment, complete quarantine of confirmed and suspected cases, effective interruption of the route of transmission, and diagnosis and treatment of the disease [ , ] . moreover, the lack of treatment capacity delayed the treatment of other patients with tumors or traumatic infection. the third challenge was poor conditions at fever clinics. during the sars outbreak of , many hospitals set up fever clinics,, but some were put on hold for a long time, and their infrastructure could not fulfil the biosecurity requirements for sars-cov- . the covid- epidemic necessitated resumption or construction of temporary fever clinics and improvement of the facilities and conditions. moreover, these fever clinics strictly followed the observation and diagnostic protocols during quarantine, which subsequently increased the time to detection and hospitalization admission, thereby contributing to long wait times. at the core of the national medical treatment system, hospitals play a major role in biosecurity defense. in recent years, hospitals have gained remarkable achievements in responding to new outbreaks of infectious diseases such as sars, h n , ebola, and covid- [ , ] . therefore, it is of immense importance to clarify the status and role of hospitals in the national biosecurity system. first, it is recommended that future biosecurity laws or implementation regulations should clearly define the functions and roles of hospitals at all levels, from the national level onward, to legally define and safeguard the responsibilities of hospitals. second, it is necessary to call on hospitals at all levels to establish leading groups for biosecurity management and define their responsibilities and tasksnamely, undertaking emergency response to biosecurity emergencies in wartime and enhancing leadership and supervision over biosecurity work in hospitals in peacetime. third, it is essential to refine and improve emergency plans for different types of biosecurity emergencies [ ] . special attention should be paid to the following aspects: the establishment of a regional joint prevention and management mechanism; the overall planning of biothreat assessment, surveillance and early warning, emergency treatment, and disease treatment; the whole-chain link and process of restoration and reconstruction; and the coordination of the organization and command; talent; disease treatment; information platform; and material and equipment systems [ , ] . particularly, it is imperative to strengthen the setting up of symptom surveillance sentinel points, such as fever clinic and intestinal clinic, in hospitals; integrate the symptom surveillance and pathogen surveillance systems; enhance the ability to identify unknown pathogens; and improve the early identification and early warning capabilities of biothreat hospital outposts [ ] . as the epidemic swept through the country, all levels and types of hospitals across the country participated in covid- treatment, and nosocomial infections occurred in some hospitals for non-communicable diseases in wuhan and beijing. this suggests that general hospitals for non-communicable diseases can encounter biosecurity incidents and face serious risks similarly as hospitals for infectious diseases. therefore, it is suggested that, under the unified planning and guidance of the competent authorities, a biothreat treatment system should be developed at the national level, and funding support and specialist training should be reinforced. first, it is essential to increase investment in specialized hospitals such as those for infectious diseases. according to the proportion of the resident urban population, it is necessary to increase the number of hospitals that specialize in infectious diseases and set up biosecurity laboratories to meet the need for medium-scale treatment of infectious diseases. second, it is important to increase investment in public health and epidemic prevention in general hospitals. sufficient number of infectious diseases specialty and standardized fever clinics should be established in accordance with the construction requirements. the negative pressure isolation wards should be increased or modified to fulfil the requirements for accepting and treating patients with respiratory infectious diseases, which are normally used for the general hospitalization of patients in "peacetime" and for quarantine and emergency treatment in "wartime" [ , ] . drawing on effective practices in the united states, bio-control training and treatment wards should be set up in hospitals for ready-to-use purposes. third, it is necessary to improve the guarantee mechanism for emergency materials. it includes improving the national emergency materials reserve system, optimizing the production capacity guarantee and regional layout of important emergency materials, and unblocking the emergency procurement and supply channels [ , ] , in order to ensure the supply of emergency materials and outfit, such as medicines, vaccines, antibodies, masks, protective clothing, disinfectants, and goggles, for ready-to-use availability in critical conditions. the emergency treatment capacity of biosecurity incidents is related to the effectiveness of the treatment of biosecurity incidents, the health of the people, and national security and stability. first, it is necessary to establish and improve the biosecurity incident treatment system. relying on the medical treatment alliance and graded diagnosis and treatment, we should establish and improve the classification, stratification, and diversion of biosecurity incident treatment mechanism, unblock the conversion mechanism in peacetime and wartime, and urgently authorize non-public medical institutions and laboratories to rapidly expand their detection and treatment capabilities in "wartime." the application of g and artificial intelligence image-assisted technologies can help to carry out remote consultation on major infectious diseases and other biological events. it is vital to better the construction of medical personnel, encourage all medical staff to acquire the knowledge and basic skills of infectious diseases and biosecurity protection, and lay stress on the training on protection knowledge and skills of infectious diseases and biosecurity among non-infectious medical staff and grass-roots medical staff with low seniority and professional titles [ , ] . second, the technical standards and quality management standards of diagnosis and treatment need to be improved [ ] . the intervention measures for the prevention and control of infectious diseases should be strictly implemented, and the strategic pass should be moved up to achieve the "four early" (early detection, early reporting, early quarantine, and early treatment). in particular, priorities should be given to the medical treatment of mild patients to reduce the transition from mild cases to severe ones, as well as to the treatment of severe cases to reduce the mortality rate. third, scientific and technological researches, such as developing robot delivery systems and uav sterilization devices, upgrading medical emergency vehicles, negative-pressure quarantine stretchers, and negative-pressure first aid devices, and accelerating the research and application of novel technologies and treatments, including convalescent plasma treatment and blood purification treatment need to be carried out. it is vital to advance laboratory detection and diagnosis and establish on-site rapid detection technologies such as isothermal amplification, mass spectrometry, to improve the ability of rapid detection of pathogens [ ] . disease-control systems and medical institutions are crucial components of national biosecurity construction. through a dynamic integration of and cooperation between these two components, it is possible to ensure population health and construct better biosecurity systems. however, the problems of "attaching importance to treatment but neglecting prevention" and "separating treatment from prevention" are ubiquitous in the country. the lessons learned from the epidemic are extremely profound. therefore, greater effort should be invested to integrate medical and preventive forces and form a pattern of integrated construction of treatment and prevention facilities. first, it is necessary to further promote reforms of the disease-control system [ ] . the tripartite forces of disease-control institutions; general and specialized hospitals; and grassroots medical and health units should be coordinated to establish an interdependent "trinity" of disease-control systems characterized by division of labor, cooperation, and interdependence on each other's strengths [ ] . this would further intensify the role and function of hospital disease-control departments. in key and sensitive departments such as the emergency department, disease-control experts should be assigned and conferred adequate governance authority in terms of rights and responsibilities to enhance the ability of hospitals to deal with biosecurity incidents represented by public health emergencies. second, it is vital to improve the emergency response mechanism for integrated treatment and prevention. we recommend improvement of the effective interaction of mechanisms for scientific research, disease control, and clinical treatment, as well as coordination of research, 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(rcce) readiness and response to the covid- ( -ncov) interim guidance v regional joint prevention and control of major diseases not applicable data sharing not applicable to this article as no datasets were generated or analyzed during the current study. the authors have no competing interests to declare. this article is distributed under the terms of the creative commons attribution . international license (http://creativecommons.org/licenses/by/ . /), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (http://creativecommons.org/publicdomain/zero/ . /) applies to the data made available in this article, unless otherwise stated. data sharing not applicable to this article as no datasets were generated or analyzed during the current study. this work was supported by medical innovation project ( cxz ), logistics scientific research project (alb j ) and national social science foundation ( gj - ). none. mh and shb conceived and wrote the manuscript.zjg, ljf,zx and lyx critically reviewed and revised the manuscript. all authors have read and approved the final manuscript. key: cord- - c d ynz authors: cagetti, maria grazia; angelino, eleonora title: could sars‐cov‐ burst the use of non‐invasive and minimally invasive treatments in paediatric dentistry? date: - - journal: int j paediatr dent doi: . /ipd. sha: doc_id: cord_uid: c d ynz nan a new virus called severe acute respiratory syndrome coronavirus- (sars-cov- ) was identified as the aetiological agent of a disease outbreak that began in china in , denominated coronavirus disease . the who emergency committee declared a global health emergency on january and in march classified covid- as a pandemic, with the consequence of generating a worldwide lockdown, drastically limiting the access to dental care to emergencies only. the virus spreads by respiratory droplets emitted by infected subjects when coughing, sneezing, or talking. clinical manifestations usually start after less than a week: fever, cough, nasal congestion, fatigue, and shortness of breath. asymptomatic infections, especially among young children, are described. however, reported case fatality rates vary from % to more than % mainly due to bilateral pneumonia. children infected with sars-cov- do not commonly experience severe symptoms, even though younger children might. in addition, affected children might be potential carriers of the infection. dentistry is one of the professions the most exposed to high risks of cross-infection ; the use of dental handpieces creates splatters and aerosols which can act as bacteria, fungi, and virus spreaders. the stability of sars-cov- in aerosols and on various surfaces was investigated in experimental conditions, showing that the airborne transmission of sars-cov- is plausible, since the virus can remain viable and infectious up to hours in aerosols and up to hours on surfaces. these data suggest that the dental environment is favourable for the transmission of this viral infection. this situation calls for dental care protocols in order to reduce the risk of infection. dentistry is rapidly evolving, and technological innovations become part of the daily routine of dental professionals. contrastingly, the recent increase of caries prevalence in younger children worldwide demonstrates the need for simple but effective care protocols. different caries treatments that do not include the use of handpieces are available: the so-called non-invasive treatment, mostly carried out on initial lesions, and the minimally invasive treatment, on more severe caries lesions. both treatments are particularly suitable for children ( table ) . the non-invasive treatment includes the non-restorative cavity control that manages non-cavitated and cavitated active caries lesions making them cleanable and promoting their arrest through the use fluoride vehicles only. the success of this non-operative treatment is strongly related to the possibility of changing the child's and the parents' oral health behaviours. the scientific evidence of fluoridated toothpastes, gels, rinses, and varnishes in caries preventive effect and control is high both in quality and in quantity for both primary and permanent dentitions. non-operative caries treatment is mostly recommended for decayed primary teeth, but may represent a suitable alternative also for permanent teeth of children with dental anxiety or disabilities, who offer insufficient collaboration for the traditional restorative treatment. professionally applied fluorides, as % sodium fluoride and silver diamine fluoride, quarterly or semi-annually applied, combined to tailored recall appointments to assess oral hygiene adherence, have shown to obtain comparable results to those obtained using conventional restorations in primary molars with cavitated lesions. the non-invasive treatment also includes initial caries lesions management using therapeutic sealants and resin infiltration on approximal surfaces. the use of sealants in order to treat active non-cavitated lesions is supported by strong evidence. moderate evidence shows that resin infiltration represents an effective treatment for arresting non-cavitated enamel and dentine lesions. in addition to caries control, non-invasive treatments such as remineralization and sealants use can reduce hypersensitivity, caries risk, and post-eruptive breakdown in permanent teeth affected by a mild form of molar incisor hypomineralization (mih) and in hypomineralized second primary molars (hspm). all these strategies appear to be strongly ethical since, in case of failure, the minimally invasive treatment can always be carried out. in addition, they do not require the use of handpieces and they are carried out relatively quickly, requiring patients to stay on the dental chair only a short period of time. the non-invasive treatment can therefore be considered as no sars-cov- friendly. the minimally invasive treatment is an approach to caries treatment that aims to preserve as much tooth structure as possible. this approach includes the atraumatic restorative treatment (art). as the non-invasive treatment, the minimally invasive treatment is a personalized treatment based on the control of individual caries risk. art, first proposed to treat caries in children living in under-served areas of the world, is a minimally invasive approach to treat caries lesions. infected hard tissue is removed using hand instruments without the administration of local anaesthesia. the cavity's restoration is provided simultaneously with the sealing of caries-prone pits and fissures with a high-viscosity glass ionomer cement (gic). even though a cochrane review concluded that scientific evidence on the effects of art is scarce, other systematic reviews disagreed. [ ] [ ] [ ] restorations' survival rates after more than years in primary teeth is reported to be . % (± . ) for restorations at one surface and . % (± . ) for those at multiple surfaces. art was recently assessed as an effective treatment for special needs patients, contributing in the reduction of t a b l e clinical indications, treatments options, advantages, and disadvantages of non-invasive and minimally invasive treatments inequalities in access to oral care. in addition to caries treatment, the minimally invasive treatment especially art technique has proven to be an effective approach to preserving first permanent molars affected by severe form of mih. halfway through the minimally invasive and the non-invasive treatment, the hall technique (ht) is a mixed caries treatment modality: a caries removal approach consisting in the cementation of a stainless-steel crown with gic on primary molars with severe caries lesions. ht has shown after . years from application a very high success rate ( %) in young children at high caries risk. the reported strategies do not involve the use of handpieces, reduce aerosol production and therefore can be considered no sars-cov- friendly treatments as well. compared with more invasive procedures, ht and the non-operative treatment were preferred by both children and parents. paediatric dentists have the challenging task of treating young children, sometimes also affected by disabilities, when minimizing the risk of infections. for this reason, the simpler the treatments are and the shorter time they require the child to stay at the dental chair, the greater is the probability of the treatment being successful and the lower is the risk of infection. although the bacterial and fungal presence derived from water, human skin, and oral cavity was repeatedly investigated in the dental setting, viruses' presence has never been studied. this shortcoming, together with the unique infectivity of sars-cov- , make the indications for the restart of the dental activities provided by eminent dental associations not ad hoc for controlling this viral transmission. the centers for disease control and prevention (cdc) has suggested dental-specific recommendations to prevent the diffusion of sars-cov- in the dental setting. these recommendations underline that in the absence of airborne precautions, the risk of sars-cov- transmission during aerosol generating dental procedures cannot be eliminated. therefore, a reduction of treatments that can produce droplets or aerosols is recommended. the cdc and the american dental association in recommended to avoid aerosol-producing procedures in patients with active sars. however, the majority of the dental treatments as oral hygiene procedures, restorative, prosthetic, and surgical treatments are usually carried out with the use of handpieces under water spray, with an increased risk of cross-infections. pre-operative antimicrobial mouth-rinse is recommended to reduce the number of oral microorganisms. since chlorhexidine appears not to be efficient against sars-cov- , new active compounds need to be tested against this virus. the use of a mouth-rinse in children, especially if young, might be contraindicated, since an unevaluable portion of the product could be swallowed. for this reason, the use of gauze impregnated with mouth-rinse, which has shown to significantly reduce the plaque index, could be an effective solution. the non-invasive treatment and the minimally invasive treatment are often recommended in controlling and treating dental caries in children; however, even though dentists seem to know the advantages of these strategies, the traditional caries removal and restoration therapy are still preferred. in addition to their documented efficacy, the non-invasive treatment and the minimally invasive treatment have the advantage of producing very small amounts of aerosol, since handpieces are not required. conversely, a weak point related to their use during this epidemic is that rubber dam usage is not generally included in these procedures. although the rubber dam seems to result in significantly higher aerosol levels, it acts as a barrier by limiting that the microbial content of the oral cavity is spread during the operating procedures. in conclusion, caries treatment using the non-invasive or the minimally invasive treatments is desirable, especially since the transmission risk of sars-cov- is potentially higher in the dental environment. in , nigel pitts wondered: 'are we ready to move from operative to non-operative/preventive treatment of dental caries in clinical practice?'. sixteen years later, this 'treatment philosophy' is still struggling to take off; given today's unique circumstances, we cannot help wondering: 'will sars-cov- be able to change the way of thinking and acting in paediatric dentistry?'. we want to thank roberta saverio for editing the paper. no funding was received regarding the present paper. the rest of the authors declare no conflict of interests. mgc conceived the ideas and let the writing; ea searched and collected the references and contributed to the writing. https://orcid. org/ - - - case-fatality rate and characteristics of patients dying in relation to covid- in italy coronavirus disease (covid- ): characteristics in children and considerations for dentists providing their care cross-transmission in the dental office: does this make you ill? curr oral health rep a scoping review on bio-aerosols in healthcare and the dental environment aerosol and surface stability of sars-cov- as compared with sars-cov- early childhood caries epidemiology, aetiology, risk assessment, societal burden, management, education, and policy: global perspective non-restorative cavity treatment: should this be the treatment of choice? reflections of a teacher in paediatric dentistry guidelines on the use of fluoride for caries prevention in children: an updated eapd policy document alternative 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treatment an option for restoring occlusoproximal caries lesions in primary teeth? a systematic review and meta-analysis survival percentages of atraumatic restorative treatment (art) restorations and sealants in posterior teeth: an updated systematic review and meta-analysis high-viscosity glass-ionomer vs. composite resin restorations in persons with disability: five-year follow-up of clinical trial leal sc glass hybrid restorations as an alternative for restoring hypomineralized molars in the art model when to intervene in the caries process? an expert delphi consensus statement parental perceptions and acceptance of silver diamine fluoride staining covid- ). dental settings aerosols and splatter in dentistry: a brief review of the literature and infection control implications covid- : a recommendation to examine the effect of mouthrinses with β-cyclodextrin combined with citrox in preventing infection and progression effect on plaque control in children patients with down syndrome using digital brush with or without chlorhexidine: a randomized clinical trial knowledge and attitude among general dental practitioners towards minimally invasive dentistry in riyadh and alkharj the effect of rubber dam on atmospheric bacterial aerosols during restorative dentistry are we ready to move from operative to non-operative/ preventive treatment of dental caries in clinical practice? key: cord- -ivtunxrd authors: yerramilli, divya; xu, amy j.; gillespie, erin f.; shepherd, annemarie f.; beal, kathryn; gomez, daniel; yamada, josh; tsai, c. jillian; yang, t. jonathan title: palliative radiotherapy for oncologic emergencies in the setting of covid- : approaches to balancing risks and benefits date: - - journal: adv radiat oncol doi: . /j.adro. . . sha: doc_id: cord_uid: ivtunxrd nan radiotherapy (rt) is critical for the treatment of oncologic emergencies, including neurologic injury from cord compression or brain metastases, airway compromise and bleeding ( ) ( ) ( ) ( ) . palliative rt for patients with limited functional status is crucial for providing effective care and limiting morbidity from disease progression. the current covid- pandemic has heightened our awareness of resource constraints, prompting institutions to create guidelines to delay treatments whenever possible and prioritize cases that are clinically urgent ( ) ( ) ( ) ( ) . recent data from china and italy have demonstrated that cancer patients have a higher risk of contracting the virus, as well as a higher case-fatality rate ( ) ( ) ( ) ( ) . it is therefore imperative to be judicious in the use of rt and to consider shorter courses of palliative rt for oncologic emergencies. existing recommendations, such as those from the choosing wisely campaign, support the use of short-course rt as a component of value-based care ( ) . however, utilization in the united states has been limited, and therefore less equipped to optimally manage patients considered for palliative radiation ( , , ) . here, we aim to provide a more detailed departmental approach to triaging and shortening radiation therapy for oncologic emergencies at a major comprehensive cancer center in new york city, an epicenter of covid- in the united states. radiation oncologists with expertise in the management of metastatic disease and inpatient oncologic emergencies at a high-volume comprehensive cancer center in the initial epicenter of the current covid- outbreak emergently convened to discuss best practices at this time. we reviewed high-impact evidence, prior systematic reviews, and national guidelines to compile recommended practices for the treatment of common oncologic emergencies. while this was not a comprehensive systematic review of the literature, we discussed our individual institutional best practices in the unique circumstances of this global pandemic. specific attention was given to balancing the risk of infection with sars-cov- and the potential morbidity of delaying treatment. in response to departmental guidance to limit clinical exposure and maximize single-use personal protective equipment, the majority of patient assessments, including history of present illness, performance status, current symptoms and imaging are evaluated virtually via telemedicine. prior studies have shown the feasibility and efficacy of assessing symptoms and performance status through electronic and telemedicine platforms ( ) ( ) ( ) . when in-person physical examination is crucial to treatment decision-making, including neurologic evaluation and pain assessments, patient encounters are limited to a single radiation oncologist or an advanced practice provider. we recommend discussion of the patient's overall prognosis and goals of care with the patient, the primary medical oncologist, and supportive care specialists prior to determining a radiation plan, with validated prognostic models at provider preference ( ) ( ) ( ) . for patients with an estimated life expectancy of days to weeks, best supportive care with medical therapies alone is encouraged. for subsequent on-treatment visits and follow-ups, our institution has implemented telemedicine visits as default to reduce the risk of exposure. for patients needing urgent supportive care while receiving rt, a nursing visit and/or physician visit can be arranged with the designated rotating radiation oncology healthcare providers of the day. when face-to-face evaluation is clinically indicated, we recommend that all patients, caregivers and providers adhere to institutional policies and cdc recommendations on social-distancing, handwashing, assessment of personal risk factors and using appropriate personal protective equipment (ppe) to mitigate risk of exposure of patients and staff ( ) . in the setting of the covid- pandemic, our department developed and implemented a three-tiered system to identify clinically urgent cases, in which delaying treatment would result in compromised outcomes or serious morbidity. for patients with metastatic cancer requiring palliative rt, patients with oncologic emergencies are assigned with the tier designation (table ) . this includes patients with cord compression, symptomatic brain metastases requiring whole brain radiotherapy, life-threatening tumor bleeding and malignant airway obstruction (table ) . tier includes patients with symptomatic disease exclusionary of oncologic emergencies which rt is the standard of care, and patients with asymptomatic disease which rt is recommended to prevent imminent functional deficits. tier includes patients with symptomatic or asymptomatic disease which rt is one of the effective treatment options. need for urgent rt is guided by a simple triage flowsheet which includes active symptoms that can be addressed with rt, prognosis, goals of care, and tier designation (fig ) . the following management recommendations below pertain to patients with oncologic emergencies, which are departmentally categorized with tier designation. the management of brain metastases has been an evolving clinical paradigm for which patient prognosis, histology, age, competing risks and neurologic symptoms must be considered. patients with favorable prognosis and appropriate for stereotactic radiosurgery (srs), we continue to provide srs for patients an treat all or the dominant lesion(s) that is most likely to cause morbidity, in order to delay or potentially avoid whole brain radiation. however, for patients with urgent indications, such as progressive neurologic symptom from multiple brain metastases or leptomeningeal disease, whole brain radiation is often indicated. for these patients, particularly those who are hospitalized, ten-fraction treatment increases the risks for patients and staff exposure to sars-cov- . thus, while several dose options are available, though we favor gy in fractions, which has been safely used in multiple studies ( , ) . standard fractionation ( gy in fractions) with memantine could be considered for patients in whom longer term survival is expected, in order limit neurocognitive complications ( ) . in patients with limited prognosis, the quartz study demonstrated similar rates of overall survival and quality of life with steroids and best supportive care alone as compared to whole brain radiation therapy ( ) , and therefore observation is likely preferred to limit unnecessary exposure to sars-cov- . the management of patients with spinal cord compression requires multidisciplinary discussion especially with neurosurgery, and evaluation of several factors including degree of spinal cord compression and presence or absence of spinal instability. we utilized the noms paradigm to facilitate selection of optimal treatment ( ) . if radiation is indicated, over studies have shown equivalent functional outcomes of single-fraction radiation treatment instead of multifraction radiation treatment ( , ) , with recent meta-analysis of three randomized clinical trials demonstrating preserved motor response with no clinical difference between single-fraction radiation treatment ( gy x fraction) and multifraction treatment at a two month timepoint ( ) ( ) ( ) ( ) ( ) . while there is conflicting evidence regarding the role of single-fraction radiotherapy for spinal cord compression, particularly given that the scorad iii study did not meet its prespecified non-inferiority endpoints even though the absolute difference of ambulatory status at weeks was small ( . % in the single-fraction group vs. . % in the multifraction group). however, gy x provides acceptable rates of palliation and allows for safe retreatment with either conventionally fractionated or sbrt approaches if warranted. in the setting of covid- pandemic, the risk for nosocomial infection from patient daily exposure and prolonged hospitalizations, and the potential exposure to staff and other patients must be balanced against the potential benefit of multifractionated treatment. uncontrolled tumor bleeding is a life-threatening condition that can be effectively relieved with palliative radiation. rtog used gy x to palliate advanced pelvic malignancies, but due to frequent late gastrointestinal toxicities (grade - late toxicities in % of patients), it was closed prematurely and replaced with . gy x fractions twice daily, repeated at three week intervals for a total of courses ( ). this "quad shot" regimen has also been effective in head and neck malignancies ( ) . due to potential increased risk of nosocomial sars-cov exposure, our center has recommended limiting treatment of covid-confirmed or suspicious cases to a single treatment machine at the end of the day to facilitate disinfection and risk reduction procedures. as such, it may be logistically preferable to avoid twice-daily treatments and instead, favor gy x as an alternative. week apart may offer logistical advantages, particularly for inpatients who may be discharged after the first fraction, we felt that this must be balanced with concerns for spinal cord toxicity, especially in patients with prior radiation treatments and those who may need future treatments. for patients with airway obstruction from a lung or mediastinal tumor, there is no data at this time on the effect of rt exposure to lung in patients with sars-cov- infection. given the danger of acute respiratory distress syndrome, the possible need for mechanical ventilation and the potential of structural and obstructive lung disease, a multidisciplinary discussion is recommended for patients requiring rt palliation for malignant airway obstruction. while not an oncologic emergency, patients with painful bone metastases frequently required radiation oncology consultation for symptom management. per nccn guidelines for supportive care, many medical strategies can also be considered for the management of bone metastases ( ) . if patients have an impending fracture, we recommend a multidisciplinary discussion with orthopedic surgery and/or interventional radiology to decide on mechanical stabilization and potential role for radiation therapy. the risk of prolonged hospitalization from pathologic fracture may expose the patient to potential hospital acquired infections including sars-cov- , and thus planned surgical intervention should be considered for patients with impending fracture. otherwise, radiation should be considered if it is anticipated that localized pain from a metastasis would result in potential admission for pain crisis. if radiation is indicated, several studies and the choosing wisely campaign support gy x fraction treatment for uncomplicated bone metastases ( , , ) . additionally, for patients with less urgent symptoms who are able to wait for complex treatment planning, single-fraction stereotactic body radiotherapy (sbrt) may also be an appropriate way to provide faster and more durable palliation still in a single treatment session, based on randomized evidence ( ) . palliative radiation therapy plays a critical role in the prevention of serious morbidity for patients with metastatic cancer in the setting of oncologic emergencies, even in the midst of the current covid- pandemic. for patients with metastatic cancer, prognosis must first be clearly estimated and communicated with the patient, followed by a goals of care conversation. data from china suggests that % of patients with active cancer diagnoses required either intubation or died, although the authors report that they are only presenting a small sample size, and acknowledge the presence of other comorbidities such as age, and smoking history ( ) . patients who have prognostic awareness are less likely to choose and therefore receive aggressive oncologic treatments in the last month of life ( ) . as such, these patients may opt for medical supportive care. for patients suitable and requiring palliative rt, abbreviated courses of treatment is of particular importance to reduce the risk of viral exposure to all patients and staff, without compromising functional outcomes. furthermore, as staffing and clinical treatment capacity remains at risk for fluctuation, abbreviated rt courses better allow for treatment completion without delay. fortunately, there is high-level evidence supporting these courses for oncologic emergencies to maximize patient benefit and resource allocation. as such, hypofractionated regimens for palliative radiation are preferred to reduce risk and maximize benefit for both individuals and the population during the covid- pandemic. patients with oncologic emergencies (neurologic symptoms, tumor bleeding, airway compromise, etc.) requiring palliative rt. patients with symptomatic disease exclusionary of oncologic emergencies which rt is the standard of care. patients with asymptomatic disease which rt is recommended to prevent imminent functional deficit. patients with symptomatic or asymptomatic disease which rt is one of the effective treatment options. evaluation of five radiation schedules and prognostic factors for metastatic spinal cord compression dose escalation of radiotherapy for metastatic spinal cord compression (mscc) in patients with relatively favorable survival prognosis radiotherapy with gy× versus gy× for metastatic epidural spinal cord compression: final results of the score- trial (aro / ) radiation oncology in palliative cancer care covid yale radiation oncology flowchart -version prostate cancer radiotherapy recommendations in response to covid- breast radiotherapy under covid- pandemic resource constraints --approaches to defer or shorten treatment from a comprehensive cancer center in the united states radiotherapy in the time of the coronavirus pandemic: when less is better cancer patients in sars-cov- infection: a nationwide analysis in china risk of covid- for patients with cancer case-fatality rate and characteristics of patients dying in relation to covid- in italy covid- and italy: what next? the lancet choosing wisely: the american society for radiation oncology's top list contemporary statewide practice pattern assessment of the palliative treatment of bone metastasis survey on use of palliative radiotherapy in hospice care study protocol: optimization of complex palliative care at home via telemedicine. a cluster randomized controlled trial telemedicine: the future of outpatient therapy? symptom monitoring with patient-reported outcomes during routine cancer treatment: a randomized controlled trial a predictive model for survival in metastatic cancer patients attending an outpatient palliative radiotherapy clinic predicting life expectancy in patients with metastatic cancer receiving palliative radiotherapy: the teachh model refining the teachh model: towards improved clinical utility in the modern era how to protect yourself covid- ) ultra-rapid high dose irradiation schedules for the palliation of brain metastases: final results of the first two studies by the radiation therapy oncology group a new scoring system to predicting the survival of patients treated with whole-brain radiotherapy for brain metastases memantine for the prevention of cognitive dysfunction in patients receiving whole-brain radiotherapy: a randomized, double-blind, placebo-controlled trial dexamethasone and supportive care with or without whole brain radiotherapy in treating patients with non-small cell lung cancer with brain metastases unsuitable for resection or stereotactic radiotherapy (quartz): results from a phase , non-inferiority, randomised trial. the lancet the noms framework: approach to the treatment of spinal metastatic tumors handbook of palliative radiation therapy one & done: treating cord compression with single-fraction radiation therapy single versus multifraction radiotherapy for spinal cord compression: a systematic review and metaanalysis gy singledose radiotherapy is effective in metastatic spinal cord compression: results of a phase iii randomized multicentre italian trial icorg - : prospective randomized non-inferiority phase trial comparing two radiation schedules in malignant spinal cord compression not proceeding with surgical decompression effect of single-fraction vs multifraction radiotherapy on ambulatory status among patients with spinal canal compression from metastatic cancer: the scorad randomized clinical trial effect of rest interval on tumor and normal tissue response-a report of phase iii study of accelerated split course palliative radiation for advanced pelvic malignancies (rtog- ) palliative head and neck radiotherapy with the rtog regimen for incurable primary or metastatic cancers hypofractionated palliative radiotherapy ( gy per two fractions) in advanced non-smallcell lung carcinoma is comparable to standard fractionation for symptom control and survival: a national phase iii trial a prospective, randomised study to compare two palliative radiotherapy schedules for non-small-cell lung cancer (nsclc) adult cancer pain, version . , nccn clinical practice guidelines in oncology randomized trial of short-versus long-course radiotherapy for palliation of painful bone metastases rtog phase / study of image guided stereotactic radiosurgery for localized ( - ) spine metastases: phase results single-fraction stereotactic vs conventional multifraction radiotherapy for pain relief in patients with predominantly nonspine bone metastases: a randomized phase trial palliative radiation before hospice: the long and the short of it longitudinal perceptions of prognosis and goals of therapy in patients with metastatic non-small-cell lung cancer: results of a randomized study of early palliative care randomized noninferiority phase iii trial of single-dose radiotherapy (rt) compared to multifraction rt in patients (pts) with metastatic spinal canal compression (scc palliation of advanced pelvic malignant disease with large fraction pelvic radiation and misonidazole: final report of rtog phase i/ii study acknowledgements: we thank our departmental leadership especially dr. simon powell, dr.oren cahlon and dr. sean mcbride in their guidance and design of the department-wide tier system for patient triage. key: cord- -c z ys q authors: xu, yushuang; xiong, lina; li, yanan; jiang, xin; xiong, zhifan title: diagnostic methods and drug therapies in patients with ischemic colitis date: - - journal: int j colorectal dis doi: . /s - - -z sha: doc_id: cord_uid: c z ys q purpose: ischemic colitis (ic) is the most prevalent ischemic injury of thegastrointestinal tract. clinical features of ic such as acute abdominal pain, hematochezia,and diarrhea are similar to those of acute mesenteric ischemia, inflammatorybowel disease, or infectious bowel disease, and their relative ambiguity candelay diagnosis and treatment. to comprehensively detail the current state ofdiagnostic methods and available drug therapies for detecting and treating ic,this review aims to provide a concise and practical summary of thecorresponding literature. methods: pubmed and cochrane library were searched toretrieve all published studies reporting the diagnostic methods and drugtherapies in patients with ischemic colitis. the search strategy of drugtherapy includes human and animal data. results: colonoscopy combined with histopathologicalbiopsy is the standard of diagnosis for the ic. most patients respond well tothe conservative treatment, and surgical consultation is needed when conservativetreatment is ineffective. studies of potential drug therapy have beendeveloped, including phosphodiesterase type inhibitors, pentoxifylline,rebamipide, prostaglandin e , and polydeoxyribonucleotide. conclusion: accurate diagnoses and effective treatmentshave helped reduce the mortality rate and improve prognoses for patientsafflicted with ic, and corresponding drug therapies have been constantlyupdated as new research has emerged. ischemic colitis (ic) includes a group of clinical syndromes with existence of vascular occlusive or nonocclusive diseases, and is characterized by colonic blood supply deficiencies [ , ] . the overall aged-adjusted and sex-adjusted incidence rates of ic in the general population were . cases per , individuals. ic is more common among individuals older than years and increases in prevalence with age [ ] , and the incidence of colon ischemia in females is higher than in males [ ] . the incidence of ic has increased nearly fourfold within years, especially in relatively older patients with multiple comorbidities [ ] . with the greater awareness of the impacts of ic, a rapidly aging population, and the rising incidence of blood vessel diseases, it is estimated that the prevalence of ic will continue to increase, especially over the next few or several years. on the basis of clinical and experimental work in the laboratory, marston et al. firstly proposed in that ic can be divided into gangrenous, stricturing, and transient forms [ ] . brandt and boley later classified intestinal ischemia into types according to the degree of the histopathological damage in the colonic tissue which included reversible colopathy, transient colitis, chronic colitis, stricture, fulminant universal colitis, and gangrene [ ] . however, ic has emerged as the most common type of intestinal ischemia. thus, the goals of this narrative-based review mainly concentrate upon three aspects. firstly, we sought to examine the hypothesis that it is necessary to timely identify the people with an increased risk of ic. secondly, based upon examinations of the latest reference materials, we sought to provide relevant and current information regarding diagnostic methods for ic. finally, we summarize the current states and efficacies of drug therapies for ic and focus on emerging drugs. two independent authors (ysx, lnx) searched pubmed and the cochrane library to identify studies regarding the diagnostic methods and drug-based treatments for ic. the search terms used were "ischemic colitis" (mesh terms) or "ischemic colitis" (title/abstract) or "intestinal ischemia" (title/abstract) and "diagnosis" (mesh terms) or "diagnosis" (title/abstract) or "diagnoses" (title/abstract) or "treatment" (mesh terms) or "treatment" (title/abstract) or "therapeutic" (title/abstract) or "therapies" (title/abstract) or "therapy" (title/abstract) or "treatments" (title/abstract). author ysx screened titles and abstracts of all initially selected potentially relevant publications, and selected the relevant abstracts. the second author (lnx) revisited the selected abstract. any divergence between the first and second authors was resolved through discussion with a third author (ynl). language restrictions were applied to include only english. articles published within the last years were considered as part of the prioritized list. if studies were based upon a series, or were duplicated, only the most complete and recent reports or outcomes were included. systematic-based searches produced records after elimination of duplicates from the two databases. after initial screening and review of titles and abstracts, full-text articles were included as potentially relevant for subsequent assessments. age is one of the important risk factors for ic. according to statistics, the annual incidence rate of ic ranged from as low as . per , among people under years of age to as high as per , for people exceeding . years old [ ] . additionally, ic is most prominent among elderly females [ ] . a retrospective study from south korea found that % of patients with acute nonocclusive ischemic colitis also had a variety of diseases including cancer, hypertension, coronary artery disease, diabetes, kidney disease, respiratory disease, and cirrhosis. hypertension was the most common cooccurring diseases ( %), followed by diabetes, kidney disease, and coronary artery disease [ ] . approximately % of patients with segmental and non-gangrenous ischemic colitis also had a "proven" potential source of cardiac embolism (mainly persistent or paroxysmal atrial fibrillation) [ ] . patients with acute myocardial infarction complicated with cardiogenic shock also can develop ic, and the application of vasoconstrictor in cardiopulmonary resuscitation may contribute to this process [ ] . phlebosclerotic colitis is a rare but increasingly recognized cause of ic related to venous obstruction [ ] . systemic lupus erythematosus can also be complicated by ic [ ] . thus, ic is both prevalent, and complicated by other also relatively common afflictions and diseases, which complicates its management. the factors related to ic, such as including some drugs, pathogenic microorganisms, hereditary coagulative disorders, strenuous physical activity, abdominal fat accumulation, and smoking also can affect the occurrence of ic [ ] [ ] [ ] . drugs related to ic are known to include diuretics, antibiotics, antihypertensive drugs, digoxin, nonsteroidal anti-inflammatory drugs, oral contraceptives, pseudoephedrine, cocaine abuse, and interferon [ , , ] . a recent application-based study from fda's adverse event reporting system (faers) revealed that chemotherapeutic drugs, immunosuppressive agents, sex hormones, and anticoagulants may promote the occurrence and development of ic [ ] . likewise, influenza-fighting oseltamivir could increase the risk of ic. patients taking baloxavirmarboxil, a novel oral antiinfluenza medication, may also be at risk of developing ic with hematochezia [ ] . other possible correlated drug factors reported in recent years include rizatriptan, a cure for migraines; nintedanib, a protein kinase inhibitor; and intravitreal injections of antivascular endothelial growth factor agents; however, relative measures of their relevance require further study [ ] [ ] [ ] . for pathogenic microorganisms, many recent clinical case reports have indicated that covid- patients had small-bowel ischemia and a hypercoagulable state [ , ] . ic is also an iatrogenic complication that can arise following surgical repairs of abdominal aortic aneurysms and after cardiovascular surgery [ ] . gangrenous ic following lung wedge resection has also been reported [ ] . even rarer have been reports of ic following colonoscopy and colonic ischemia after vaginal delivery [ , ] . in addition, relatively young aged persons who habitually smoke are more likely to develop ic [ ] . constipation is also considered to be a risk factor for the development of ic and may be related to the decrease of blood flow caused by compression of the blood vessels as due to increased intraluminal pressures [ ] . frequent use of laxatives also may aggravate the ic and even cause associated perforations [ ] . stercoral colitis is a rare yet serious inflammatory process secondary to fecal impaction and, in rare cases, may be complicated by ic. stercoral colitis complicated with ic can further lead to focal ulceration, perforation, peritonitis, septic shock, or even death if there is a lack of prompt diagnosis and treatment [ ] . the clinical manifestations of ic largely depend upon the degree of ischemia and the site of involvement [ ] . abdominal pain, hematochezia, and diarrhea are the most common presenting symptoms. abdominal pain is usually described as an "acutely emerged, cramping pain," often accompanied by the urge to defecate [ ] . eating can aggravate the symptoms of abdominal pain; thus, the loss of appetite and refusal of food are common in ic-afflicted patients. usually, bloody stools may occur within h, but bleeding tends not to be severe. for patients with ischemia isolated to the right side of the colon (irci), abdominal pain is usually severe, accompanied by rectal bleeding, and prognoses are poor. it is noteworthy that these patients may not bleed at all [ ] . in addition, the effusion of intestinal liquid, intestinal mucosal injury, and necrosis can also cause diarrhea. other common symptoms include abdominal distention, nausea, and vomiting [ ] . symptoms in severe cases may appear as systemic inflammatory response (sirs) including sepsis, tachypnea, and tachycardia [ ] . the left side of the colon is the most frequently involved portion, followed by the distal colon, right colon, transverse colon, and pan colon [ ] . patients often have acute abdominal pain and lower gastrointestinal bleeding when the left colon is involved, and the prognosis is relatively good. when the right colon is involved, patients mostly present with acute severe abdominal pain, hematochezia, and/or diarrhea. this is mostly related to the stenosis or occlusions of the superior mesenteric artery, and most commonly seen in patients with sepsis, hypotension, shock, or chronic renal failure requiring hemodialysis. patients with irci usually have worse prognoses and require a greater degree of attention to avoid delays in diagnoses and treatments [ , ] . upon physical examination, the majority of patients have mild-to-severe abdominal tenderness in the corresponding site of the colon ischemia [ , ] . the most common clinical signs of gangrenous colitis include severe abdominal tenderness, rebound pain, fever, the weakening or disappearance of abdominal rumbling sounds, or even shock. in the intensive care unit, many symptoms such as abdominal pain are not obvious in patients undergoing intubation and sedation; therefore, such symptoms are easily neglected [ ] . routine laboratory tests are of some value in assessing the degree of ic, but are limited with respect to early diagnosis. relevant laboratory tests include complete blood count, comprehensive metabolic panel (cmp), serum lactic acid, lactate dehydrogenase (ldh), d-dimer, creatine kinase (ck), amylase, fecal culture, fecal examination, and determination of clostridium difficile toxin [ , ] . however, these parameters lack sensitivity and specificity. d-lactate (d-lac), a stereoisomer of l(+)-lactic acid in serum, may be a potential biomarker for the early diagnosis of acute mesenteric ischemia (ami) [ ] . for example, the pooled sensitivity and specificity for d-lactate were . % and . %, respectively [ ] . plasma dlactate levels are also considered to be a useful marker for early diagnosis of ic secondary to aortic surgery [ ] . the intestinal fatty acid-binding protein (i-fabp) has value for diagnosing intestinal mucosal damage and has been widely studied as a plasma-based marker. i-fabp may be a useful diagnostic marker to identify acute intestinal ischemia in for acutely affected abdomens [ , ] . about % of icafflicted patients also have one or more concomitant prothrombin abnormalities [ ] , and the risk for thrombosis should be evaluated in young and recurrent patients [ ] . single factor analysis completed by miguel et al. suggested that the following test results are indicative risk factors for an unfavorable outcome: leukocyte > × /l, hemoglobin < g/dl, albumin < . g/l, and additional metabolic acidosis and liver biochemical tests showing abnormal results [ ] . in addition, serum procalcitonin (pct) was found to have been correlated with the colonoscopybased assessment of the severity of post-operative ischemic colitis (poic) and can guide therapeutic decisions [ ] . abdominal plain film has no obvious advantages in the diagnosis of ic, but it can be used to rule out other emergencies such as organ perforations or intestinal obstructions [ ] . barium enema examinations have almost entirely been replaced by ct imaging or colonoscopy because of its low sensitivity. barium enema examinations also can aggravate intestinal ischemia injury or even cause perforation, and contrast agent residues may influence the follow-up ct imaging or endoscopic examination [ , ] . ultrasound is a noninvasive imaging-based examination and is sensitive to the early structural changes in colonic walls caused by ischemia. lopez et al. [ ] found that the positive predictive value (ppv) of abdominal ultrasound in detection of ic was . %. a retrospective study reported that the predictive model consisting of sonographic features and clinical findings could accurately predict the outcomes of ic affliction and distinguish properly between patients with mild and severe cases of ic [ ] . for high-risk cases or patients with contraindications, ultrasound can be regarded as an alternative diagnostic technique for colonoscopy. however, findings from ultrasounds for colonic wall thickening are nonspecific and should be differentiated from other causes. a prospective study proposed that magnetic resonance imaging (mri) can be used as an alternative to invasive examinations for the diagnosis of and follow-up examinations of patients afflicted with acute ic [ ] . mesenteric angiography examinations have proven to hold no great importance for the diagnosis of non-vascular occlusive ischemic damage, but they have obvious advantages in the detection of mesenteric vascular atherosclerosis and thromboembolism. for patients with suspected acute mesenteric ischemia or isolated rightsided ischemia disease, multiphasic ct angiography (cta) is recommended [ , ] . the common computed tomography (ct) manifestations of ic include colonic wall thickening, edema, thumbprinting, bowel dilatation, and effusion of intestinal circumference, sometimes with "double halo" or "target" signs [ , , ] . pneumatosis and portal venous gas are also possible manifestations, and these findings may be the results of transmural ischemia and subsequent bacterial translocation [ , ] . the haustra of the large intestine becomes thicker and projects into the intestine at regular intervals, leading to the appearance of thumbprinting. this radiographic-based signature can also be seen in the exacerbations of inflammatory bowel disease (ibs) and infectious colitis like pseudomembranous colitis [ ] . iacobellis et al. [ ] retrospectively analyzed the ct-based manifestations of patients with confirmed ic afflictions at different phases (i.e., acute, subacute, and chronic). their findings suggested that ct-based methods were able to distinguish between occlusive and nonocclusive ischemic damage by evaluating the morphofunctional alterations associated with ic, and that such methods can also be used for assessing the timing of ischemic damage. colonoscopy, which can help make a definite diagnosis by directly observing the colonic mucosa and obtaining biopsy specimens, has been regarded as the gold standard method for the diagnosis of ic in recent years [ , ] . under the condition of hemodynamic stability and without contraindications like acute peritonitis or evidence of irreversible ischemic damage, early colonoscopies should be performed for patients with suspected ic within the first - postonset of symptoms [ , ] . the most frequent observations in patients with the early onset of ic are edematous, and fragile mucosa, segmental erythema, petechial hemorrhages, longitudinal ulcer, and lesions are always segmented and patchily distributed [ , ] . "single stripe" refers to a single line of erythema with inflammatory erosion or ulceration along the longitudinal axis of the colon, and is highly specific [ , ] . in a few rare cases, ic lesions can form tumor-like lesions that are similar to malignant tumors [ , ] . intestinal mucosal biopsy-based examinations are recommended for patients with ic (except gangrenous ic). the common pathologic features of ic include mucosal and submucosal hemorrhage and edema, erosion, granulation tissue hyperplasia, gland atrophy, macrophage cells containing hemosiderin, and inflammatory infiltration of lamina propria [ , , , ] . infarction and "ghost cells" are the most specific pathological manifestations, but are relatively rare [ ] . moreover, it is worth mentioning that confocal laser endomicroscopy (cle) was able to, in real time, display the cellular and subcellular details correlating with histopathology in vivo, and was used to identify "ghost glands" [ ] . the american college of gastroenterology (acg) clinical guidelines suggest the redefinition of the severity of colon ischemia such as to better guide treatments [ ] , and corresponding diagnostic methods and severity classifications of ic are shown in fig. . patients with mild diseases such as transient ischemic colitis do not usually require special treatment, and their prognoses are good. hospitalization is recommended in cases with more significant symptoms or signs. the major therapy measures presently employed mainly include bowel rest, intravenous fluids, correction of underlying conditions, and antibiotic therapies. for the patients with colon ischemia complicated with hypotension, tachycardia, abdominal pain without rectal bleeding, afflicted by gangrene, and or that have lesions isolated to the right side of the colon and pan colon, surgical consultation should be considered [ ] . positive surgical treatments in patients with multiple organ failure and findings of severe forms of ischemia at endoscopy are recommended [ ] . in the prior decade, drugs used to treat ic have proven to be controversial; however, some new targets for medical therapy have been identified and hold promise. some relevant insights into drug therapy and their results are presented in fig. . conservative measures including fasting and bowel rest can reduce oxygen demand in the colon and help to prevent icrelated symptoms. meanwhile, intravenous fluids, optimizing cardiac status, and supplemental oxygen are also recommended to enhance the perfusion of the large bowel [ , , ] . if a protracted course of treatment is expected, administration of total parenteral nutrition may be required. nasogastric intubation treatments should be used if patients show signs of intestinal obstruction [ ] . in addition, discontinuation of ic-related drugs such as constipation-inducing medications, immunomodulators, and vasoconstrictor should be undertaken [ ] . although only based upon relatively very low levels of evidence, antimicrobial therapies have been recommended for patients with moderate or severe colon ischemia. one such acg-recommended antimicrobial regimen is an antianaerobic antibiotic combined with agents against gramnegative bacteria like fluoroquinolone or aminoglycoside, or, alternatively, cephalosporin of the third generation [ , ] . using antibiotics was found to have effectively reduced pathogenic bacteria and bacterial translocation, and reduced overall inflammatory responses to ischemic injury [ , ] . acg guidelines proposed that antibiotics should be used for at least h, and proposed that a -day course of treatment should be considered if the clinical symptoms have improved fig. the diagnosis methods and severity classification of ischemic colitis after h. if patients have no obvious clinical effects, it is suggested to redefine the antibacterial program. but, as recommendations for antimicrobial treatment are mostly based upon animal studies and because there is a lack of basic or prospective random clinical contrast studies, the clinical value of antimicrobial treatments for ic remains to be further explored. one consideration is that increased antibiotic use could promote inflammation through the translocation of native commensal colonic microflora [ ] . therefore, further work to define the most appropriate and safe doses, frequencies, durations, and types of antibiotics used is necessary. tsimperidis et al. evaluated a variety of thrombotic factors including protein c (pc), protein s, antithrombin (at), and resistance to activated protein c (apcr) in ic-afflicted patients. their study proposed that the role of hypercoagulability through hereditary or as otherwise acquired was essential for the mechanisms underlying ic [ ] . acute superior mesenteric venous thrombosis (smvt) is a cause of mesenteric ischemia disease. some researchers have proposed that heparin prophylaxis could have a preventive effect in patients with acute smvt [ ] . huguier et al. suggested that ic-afflicted patients with cardiovascular disease should be treated with prophylactic anticoagulation or antiarrhythmia to decrease the risk of death from a vascular disease post-discharge [ ] . patients with segmental, non-gangrenous ic are more likely to have potential cardiac sources of embolism compared with control patients, and anticoagulant therapies are recommended for these patients [ ] . iloprost is an effective antiplatelet agent and has a protective effect in the early stage of intestinal ischemia in rats. the underlying mechanism may have been related to inhibited leukocyte infiltration, reduced proinflammatory cytokines, promoted angiogenesis, or reduced oxidative stress and inflammatory response, which ultimately resulted in decreased tissue damage [ ] . however, the current roles of anticoagulant or antiplatelet therapies in the acute presentations of ic, or for the prevention of recurrence still need to be confirmed, such as through prospective clinical studies. glucocorticoids are not recommended for the treatment of or prevention of ic, and several studies have reported steroidrelated ic or ischemic pancolitis [ , ] . systemic use of glucocorticoids may also exacerbate ischemic damage and cause perforation of the colon. however, wolfgang kruis et al. recently suggested a potential protective effect of the combination of intravenous antibiotics and intravenous prednisolone for cases of severe ic. this preliminary study may offer a new pathway for the field of study of conservative management of severe ic [ ] ; however, this result still needs further exploration. vardenafil and pentoxifylline exert positive effects upon the hemodynamics associated with vascular smooth muscle, and have proven useful as therapeutic options for rat-based models of ic [ ] . in a case report, prostaglandin e also increased blood flow to the colon and might be a potential approach for treating ic cases complicated by stricture formations [ ] . polydeoxyribonucleotide (pdrn) is a mixture of nucleotides and is mainly found in the human placenta or such as in salmon sperm. it was reported that pdrn potently has a therapeutic action upon ic by way of increasing the expression of vegf and inhibiting inflammatory cytokines and cox- through enhancing the expression of a ar [ ] . rebamipide, an antiulcer drug, has been reported to have ulcer-healing and anti-inflammatory effects [ ] . in a rebamipide enema-treated group, left-sided ic-afflicted patients with ulcerative lesions had a shorter fasting period and reduced durations of hospitalization compared with the control group. however, there lacks sufficient evidence to fully support the potentially positive effects of sulfonapyridine, amino salicylic acid, or fatty acid enemas for the treatment of ic [ ] . sun d et al. retrospectively analyzed studies including ic-afflicted patients and showed that the total rate of adverse reactions was . % [ ] . male gender, tachycardia, a lack of rectal bleeding, peritonitis, arterial hypotension (< mmhg), and right colon involvement are considered risk factors related to a poor prognosis for ic-afflicted patients. a novel prognostic scoring model provided a useful method for assessing the prognosis of patients, whereby the presence of tachycardia (≥ beats/min), shock within h after admission, and endoscopic evidence of ulceration were the key predictive factors [ ] . one group of researchers found that acute physiology and chronic health evaluation ii (apache ii) scores were more suitable for predicting gangrenous ischemic changes and mortality in patients with gangrenous ic. the absence of hematochezia, abdominal tenderness, absence of diarrhea, and albumin levels were found to have been significant predictors of ic [ ] . ange et al. prospectively analyzed patients who met the criteria for definitive or probable ic according to brandt criteria, and found that the recurrence rates were . %, . %, . %, and . % at years , , , and , respectively [ ] . this paper reviewed the diagnostic methods for ic and added new content. it is the first to summarize new progress on the currently available drug-based treatments, including for some drugs derived based upon animal experimentation. our review also has several limitations: firstly, we searched only two databases, albeit they are widely used, and no studies were added through other manual searches. thus, we might have missed some relevant publications. secondly, we focused upon the diagnostic methods and drug therapies for ic, and introduced briefly the surgical indicators. we did not discuss surgical methods for treatment and the clinical effects. thirdly, the treatment of ic could be heterogeneous with respect to their uses across diverse subsets of different populations, and patients treated with individual regimes could improve the desired curative effects. lastly, some low quality and moderate levels of evidence were applied and consulted. nonetheless, further studies based upon more high-quality, large-sample randomized controlled trials will ensue, and as they do, the information can be assessed in the context of this review. clinicians usually have a low level of awareness and vigilance to the ic afflictions because of the ambiguity of symptoms and complications forming often other associated diseases. this may lead to misdiagnoses. for patients with typical clinical characteristics complicated with some underlying diseases such as hypertension and diabetes, or whom have a special history of drug use and abdominal surgery, the possibility of ic should be considered. colonoscopy combined with histopathological biopsy is the gold standard for ic disease diagnosis. treatment involves conservative treatment and surgical therapy. conservative treatments mainly include bowel rest, intravenous fluids, correction of underlying conditions, and some necessary anti-infection therapies. most patients have positive responses. other drugs presently under evaluation include phosphodiesterase type inhibitors, pentoxifylline, rebamipide, prostaglandin e , and polydeoxyribonucleotide. although researchers have done many useful exploration studies with respect to the development of a new therapeutic drug target, there is still a lack of evidence-based data on the appropriate drug therapy of colon ischemia. author contributions liyanan and xin jiang contributed significantly to the analysis and manuscript preparation; yushuang xu and lina xiong wrote the manuscript; zhifan xiong helped perform the analysis with constructive discussions. all authors have made substantive contributions to the manuscript. conflict of interest the authors declare that they have no conflicts of interest. ethics approval this article does not contain any studies with human participants or animals performed by any of the authors. acg clinical guideline: epidemiology, risk factors, patterns of presentation, diagnosis, and management of colon ischemia 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volunteers and intestinal ischemia role of acquired and hereditary thrombotic risk factors in colon ischemia of ambulatory patients serum procalcitonin correlates with colonoscopy findings and can guide therapeutic decisions in postoperative ischemic colitis positive predictive value of abdominal sonography in the diagnosis of ischemic colitis predictors of severity in ischemic colitis: usefulness of early ultrasonography magnetic resonance imaging: is there a role in clinical management for acute ischemic colitis? diagnostic accuracy of multidetector ct in acute mesenteric ischemia: systematic review and meta-analysis ischemic colitis: clinical practice in diagnosis and treatment ischemic colitis and portal venous gas bowel ischemia and portal venous gas: what to do? thumbprinting in ischemic colitis ct findings in acute, subacute, and chronic ischemic colitis: suggestions for diagnosis imaging of ischemic colitis mass-forming ischemic colitis: a potential mimicker of malignancy massforming" variant of ischemic colitis is a distinct entity with predilection for the proximal colon real-world multicentre experience of the pathological features of colonic ischaemia and their relationship to symptom duration, disease distribution and clinical outcome endoscopic findings and clinicopathologic characteristics of ischemic colitis: a report of cases gastrointestinal: "ghost gland" in probe-based confocal laser endomicroscopy for diagnosing ischemic colitis: a novel approach ischaemic colitis: indications, extent, and results of standardized emergency surgery advents in the diagnosis and management of ischemic colitis translocation of coagulase-negative bacterial staphylococci in rats following intestinal ischemia-reperfusion injury organ distribution of radiolabeled enteric escherichia coli during and after hemorrhagic shock antibiotics promote inflammation through the translocation of native commensal colonic bacteria acute ischaemic colitis: outcome in elderly patients iloprost reduces colonic injury in ischemic colitis in rats steroid-induced ischemic pancolitis cholesterol emboli-induced ischemic colitis combination treatment with antibiotics and glucocorticosteroids for severe ischemic colitis successful treatment with prostaglandin e of ischemic colitis complicated by colonic stricture polydeoxyribonucleotide exerts therapeutic effect by increasing vegf and inhibiting inflammatory cytokines in ischemic colitis rats rebamipide enema therapy for left-sided ischemic colitis patients accompanied by ulcers: open label study the predictors of the severity of ischaemic colitis: a systematic review of patients from studies development and validation of a novel prognostic scoring model for ischemic colitis fulminant gangrenous ischemic colitis: is it the solely severe type of ischemic colitis? prognosis and follow-up of patients with ischemic colitis over a five-year period publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations key: cord- -xxov x authors: cisneros, b.j. title: safe sanitation in low economic development areas date: - - journal: treatise on water science doi: . /b - - - - . - sha: doc_id: cord_uid: xxov x this chapter presents the advances in sanitation for developing countries as well as the needs in terms of goals, standards, technology, and policy. to understand why a special chapter for low-income areas is needed, it describes the main types of pollutants, their origins, and treatment options. as part of the text and to face the requirements for poor rural and urban areas and water-scarce regions, basic sanitation, wastewater treatment, and water reuse alternatives are described with emphasis on their constraints and limitations for developing countries. some aspects concerning the development of policies, costs, and funding to fulfill the millennium development goals are also included. the importance of developing innovative solutions that can be sustainable, affordable, and progressively implemented is discussed. emerging chemical pollutants . . . . slow filtration . . . . waste stabilization ponds . . . . wetlands . . . . land treatment . . . . reservoirs and water storage tanks . . . . upflow anaerobic sludge blanket before reading this chapter, it should be considered whether it is justifiable to have a specific section dealing with sanitation for low economic development areas (developing countries). evidently, the editors of this book think so. the reasons include • an increasing evidence that wastewater quality in high and low economic areas is different regarding some parameters that determine treatment options and • differences in economic conditions necessitate alternative solutions not only at the technical level but also in terms of the ways to implement them. to protect health, raise the quality of life, and increase the economic level, a good sanitation service is required in developing countries. while in developed countries, sanitation coverage is almost % as a result of a clear commitment of governments to provide it as part of the public services, in developing ones it is only around % (who-unicef, ). in addition, in the developed countries, the term sanitation applies not only to the installation of sewers but also to the full implementation of systems for the safe disposal and reuse of treated wastewater, sludge, and septage. in contrast, in developing countries, the term sanitation mostly applies to the use of sewers not always ending in treatment plants. in fact, reported sanitation figures frequently do not reveal the disposal of wastewater or excreta uncontrolled into the environment, the existence of malfunctioning wastewater treatment plants, or the use of rudimentary and inefficient basic sanitation facilities sometimes contributing to increased environmental pollution rather than to control it. as a result, waterborne diseases affect millions of people in the developing world, and the water quality of surface and groundwater bodies is increasingly deteriorating. the aim of this chapter is to assist the process of increasing sanitation in low-income regions by contrasting the differences in needs and solutions' options with high-income regions. most technical publications have traditionally grouped developing countries together as low-income societies without considering that in them there are high-and low-income areas and that among the latter ones there are several factors that create differences that need to be taken into consideration to provide suitable solutions, that rarely fall under the logic used in developed countries to provide sanitation. most people lacking sanitation include the millions of poor people ( figure ) living under precarious institutional conditions and under an economical and social situation that avoids the use of conventional solutions. this renders the provision of sanitation in low-income areas a major challenge. the history of sanitation is mainly about three aspects: toilets, sewers, and final disposal. as sanitation is a broken subject in developing countries, the story of these three is also the same. when mankind was nomadic and lived in very small communities, sanitation was not an issue. nature could absorb human wastes. later, when villages grew, there was the need to set up special practices and facilities. in ancient egypt (b bc), each household had the responsibility to dispose of their garbage and excreta at the communal dump, in irrigation canals, or in open fields. irrigation canals were the first drainage and waste disposal systems. at that time, toilets were a luxury that only the wealthier people could afford in cities. toilets were carved of limestone, and the used water was disposed of into pits in the streets (msu, ) . flushing toilets -some of them communal -existed in india since the twenty-sixth century bc. reports on the use of toilets and other safe sanitation practices in ancient civilizations from asia, latin america, and africa were common in places where nowadays lack of sanitation is a problem. the earliest covered sewers reported are from the indus civilization ( ( - where pakistan is located today. cities used sewers to control inundations caused by pluvial water. the cloaca maxima or roman sewer dates from around bc. initially, it was an open drain that was covered and left below the urban level, as the city building space became costly (wikipedia, ) . later, when water began to be supplied in large quantities to households, getting rid of the used water became a problem and water was considered as a waste. it was then when sewers were found to be a useful infrastructure to convey wastewater out of the city in addition to stormwater. concerning disposal, land application of wastewater and excreta has a long tradition in many countries. for centuries, farmers in china used human and animal excreta as fertilizers. the oldest references to the use of excreta in aquaculture come from some asian countries, where it was employed to increase fish production (who, ) . further, even now in china, mexico, peru, egypt, lebanon, morocco, india, and vietnam wastewater is used as a source of crop nutrients (jiménez and asano, ) . according to rusong ( ) , in contrast to the 'mechanical' ideas predominant in industrial societies, human ecological thoughts in ancient china emphasized the use of systems advocating 'man and nature as one' . this principle is considered as equivalent to the sustainability principle and is based on terms describing concepts that are dissociated in modern civilizations, such as • tian -heaven or nature; • di -earth or resources; • ren -people or society; • wuxing -the five fundamental elements and movements within any ecosystem, that need to be in equilibrium by promoting and restraining each other; and • zhong yong -describing that things should never go to their extremes but should be kept at equilibrium. for several centuries, based on these ecological principles, china has developed and supported % of the world's population with only % of the world's arable land and less than % of the world freshwater resources (rusong, ) . once again, similar conceptions can be found in ancient civilizations from asia, africa, and latin america, in the same places where there are environmental crises now. the urban water cycle is a relatively new concept used to analyze water quality problems in cities (jiménez, b) , which is depicted in figure . it is useful in identifying conventional and nonconventional sources of pollution, in particular those that are specific to developing countries. it is important to understand the difference in order to be able to apply proper solutions to sanitation that go beyond the simplistic approach of merely installing wastewater treatment plants. a similar analysis could be made for rural areas. the urban water cycle is important because of the large increase in urban population that is being experienced worldwide. by , the urban proportion of the global population is expected to be around %. over the next years, in developing countries, most of the population growth will occur in urban and periurban areas. furthermore, most of the cities with the most rapid growth are located in chronically water-short regions in the developing world (un-habitat, ) . providing water sources to urban areas from the developing world is a challenge because nearly one-third of the population ( . % compared to a % in developed countries in ) are poor people living in slum areas. the slum growth rate is of . %, a value significantly higher than the average world urban growth rate of . %. traditionally, pollution sources are classified as point and nonpoint sources. municipal and industrial wastewater discharges are considered to be point sources, while agriculture (considered as the surface return flow from irrigation), storm runoff, and a wide variety of others are considered as nonpoint sources (jiménez, a) . municipal discharges are those produced by cities and small towns. they are considered to be point sources of pollution where they are produced and collected in sewers and thus disposed of as a well-identified source. when not treated, the main environmental concerns relate to conventional pollutants, such as biological, biodegradable, and nonbiodegradable organic matter, and heavy metals, in that order of importance. the content of almost all these of pollutants is similar around the world, tending to be more concentrated in arid and semiarid areas because of lack of water. in some cases, higher concentrations of pollutants result from increased industrialization of cities. unfortunately, even when treated, municipal discharges introduce used water containing used compounds, some of which are pollutants, to water bodies. municipal wastewater is never treated to recover its original quality (the one it had at the water source) as the selfcleansing and dilution capability of nature is used to complete the task. this is confirmed by the increasing amount of trace pollutants, such as endocrine disrupters, found in water sources. the presence of these compounds might be considered as an indicator that we have surpassed the natural depollution capability of the environment. despite this, the idea of using water bodies or soil to depollute wastewater is still very common, and it could be reduced in water bodies as the depollution capability is lost as result of the water temperature increase due to climate change. in developing countries, the environment is frequently used to depollute wastewater, included when not treated at all, explaining the low quality of water bodies and the widespread presence of diarrheic diseases. industrial wastewater has very variable quality and volume depending on the type of industry producing it. it may be highly biodegradable or not at all, and may or may not contain compounds recalcitrant to treatment. these include organic synthetic substances or heavy metals whose content in developing countries' wastewater may be considerably different (in quantity and quality) from that of developed ones. the main concern with industrial wastewater is the increasing amount (in quantity and variety) of synthetic compounds contained in and discharged to the environment. a list of the most common pollutants in industrial discharges can be found in jiménez ( a) . due to the difficultly in tracking toxic compounds and their fate, combined with the need to use complex and costly treatment methods to remove them from wastewater, it is advisable and cost effective to consider the implementation of cleaner production methods in industries (such as the replacement of toxic recalcitrant compounds with others that are less harmful or not harmful at all) and, also to raise awareness of society to reduce the use of such types of compounds (jiménez, b) . water pollutants come not only from urban and municipal wastewater discharges, but also from nonpoint sources, some of which are not perceived as such. most of the nonpoint sources have been initially recognized as such by groundwater experts (foster et al., ) who realized that soil (urban or rural) was an important means of transporting pollution to ground and surface water through complex interactions. a list of such pollutants is presented in table and a detailed description of some of the pollution sources can be found in jiménez ( a) . in this section, the types of different pollutants are reviewed, emphasizing those of special interest in developing countries. biological pollutants are the major threat to low-income countries as diseases caused by them are rapidly manifested and have important effects on children and the elderly, sometimes even resulting in fatalities. according to who ( ) , diarrheal diseases accounts for an estimated . % of the total daily global disease burden and is responsible for . million deaths every year. it is estimated that % of that burden is attributable to unsafe water supply, sanitation, and hygiene. biological pollutants cause hydraulic diseases that are frequently divided into three categories: . waterborne diseases that are caused by pathogenic organisms ingested when consuming water polluted with fecal contamination or food irrigated with polluted water. examples of these types of diseases are giardiasis and amebiasis. . water-washed diseases that are caused by the lack of safe water or simply any water for hygiene purposes. disease transmission is linked to skin or eye contact. an example is trachoma, a disease that causes blindness. some million people have been blinded by trachoma. another million need treatment, and an estimated million are at risk. the disease is endemic in countries, with only china and india accounting for million cases. productivity losses caused by trachoma are estimated to be us$ . billion (who, ) . . water-based diseases that are caused when water accumulates and stagnates, promoting the breeding of vectors such as mosquitoes that cause dengue or malaria. there are four groups of organisms that can be found in waste and polluted water: viruses, bacteria, protozoa, and helminths (in the form of eggs, jiménez ( ) ). the general characteristics of these organisms can be found in specialized literature. in the following sections, properties relevant to developing countries will be highlighted for each type of group. a list of pathogens that have been detected in wastewater is presented in annex . the main aspect to highlight is the notable difference in the quantity and variety of pathogens found in wastewater between developed and developing countries ( table ) . viruses are the smallest ( . - . mm) infectious agents. there are more than types of enteric viruses capable of producing infections or illnesses that multiply in the intestine and are expelled in feces. unlike bacteria, pathogenic viruses are found in wastewater and feces when people are infected, independently of whether they display symptoms. in regions where viral diseases are endemic, they are constantly isolated from wastewater. the presence of viruses and their concentration in wastewater is linked to the season of the year and the age distribution of the population. concentrations are usually higher during summer and lower in the autumn months. the composition, type, and especially the content of viruses contained in wastewater are poorly known, particularly in developing countries, as a result of the complex and costly analytical techniques required to identify them (jiménez, ) . the enteric viruses most relevant to man are enteroviruses (polio, echo, and coxsackie viruses), norwalk, rotaviruses, reoviruses, caliciviruses, adenoviruses, and hepatitis a viruses. rotaviruses are responsible for between . and billion cases of diarrhea per year in children under years of age in africa, asia, and latin america and up to . million deaths. usually, between % and % of the cases of children with gastroenteritis that are hospitalized are caused by rotaviruses. reoviruses and adenoviruses are the main causes of respiratory illness, gastroenteritis, and eye infections and have been isolated from wastewater. to date, there is no evidence that the human immunodeficiency virus (hiv) causing the acquired immunodeficiency syndrome (aids) can be transmitted via a waterborne route. it is recognized that low virus levels may cause infection or illness; wastewater contains thousands of them, some of which are much more resistant to chlorine disinfection than bacteria (jiménez, ) . viruses discharged in polluted water can migrate long distances in soil and groundwater. the reported horizontal migration varies between and m, while vertical migration ranges from . to m depending on soil conditions. industrial sources industries located in urban or rural areas, in general variable, mostly synthetic compounds bacteria are single-celled microorganisms ranging from . to m in size with different shapes. they reproduce and grow in an appropriate environment at defined ranges of temperature, salinity, ph, etc. they may or may not be encapsulated. the environmental distribution of bacteria is ubiquitous and has different nutritional requirements. many species of bacteria are not harmful to man. in fact, some even live inside humans forming intestinal colonies. bacteria are expelled in feces at high concentrations (jiménez, ) . table shows some characteristics of pathogenic bacteria that can be found in the feces of infected people. in wastewater, pathogenic bacteria are always present but at a variable concentration, depending on the local health conditions. as shown in table , due to the high rate of diseases caused in developing countries, salmonella, shigella, and helicobacter pylori are bacteria of importance as agents causing endemic diseases. in contrast, vibrio cholerae is present only when an epidemic exists. protozoa are the group of parasites most closely associated with diarrheas. they are single-celled organisms ( - mm in size) that develop in two ways: as trophozoites and as cysts. infections are produced when mature cysts are consumed. cysts are resistant to gastric juices and transform themselves into trophozoites in the small intestine, lodging in the wall where they feed on bacteria and dead cells. in time, table characteristics of some bacteria frequently found in wastewater (with information from jiménez ( ) and lenghton et al. ( ) ) escherichia coli is commonly found in wastewater at high concentrations. different e. coli strains can cause gastroenteritis in both animals and humans and pose a high risk to newborns and children under years of age. e. coli strains implicated with human diseases are: ( ) enteropathogenic e. coli ; ( ) e. coli that is the common cause of traveler's diarrhea, which provokes a liquid and profuse diarrhea with some mucosity, nausea, and dehydration; ( ) enteroinvasive e. coli that invades the intestinal mucus lining like shigella spp., and ( ) e. coli (ehec) that produces a similar toxin to shigella causing hemorrhagic colitis. infective doses are relatively low ( organisms). salmonella spp. is frequently present in wastewater at content always lower than that of fecal coliforms by - log. there is a wide variety of strains capable of infecting humans and animals. the incidence in humans is lower than in animals and has a seasonal variation. the most severe form of salmonellosis is typhoid fever caused by salmonella typhi. typical symptoms are chronic gastroenteritis with diarrhea, stomach cramps, fever, nausea, vomiting, and headache. in severe cases, collapse and death might occur. transmission is through ingestion of polluted water or food, and is very common in developing countries. infective dose is of the order - microorganisms, but for salmonella typhi doses as low as - have been reported. shigella is similar to salmonella spp. but less frequent in wastewater. there are more than strains, but s. sonnei and s. flexeneri represent almost % of total wastewater isolations. it rarely infects animals and lives for a shorter period in the environment. one route of transmission is through swimming in polluted water. shigella spp. produces bacillary dysentery or shigellosis. this is light watery diarrhea that can develop into full-blown dysentery. the symptoms are fever, nausea, vomiting, abdominal pain, migraine, and myalgia. the classic form of dysentery is characterized by the expulsion of feces containing blood with or without mucus. the infective dose is less than microorganisms. helicobacter pylori is found in wastewater. its major habitat is the human gastric mucosa. three species are human pathogens: h. pylori, h. fennelliae, and h. cinaedi. the pathway of transmission is not entirely clear but water could be involved. in developing countries, h. pylori is acquired early in childhood, and up to % of children are infected by the age of . this contrasts with the low infection rate during childhood observed in developed countries ( . - %). campylobacter jejuni usually is a pathogen to animals but it can cause severe gastroenteritis in humans. the main source of infection is nonchlorinated water supplies. mycobacterium tuberculosis along with m. balnei (marinum) and m. boris causes pulmonary diseases and tuberculosis. for m. tuberculosis, contaminated water is the main source of infection. vibrio cholerae is the cause not only of epidemic but also eight pandemics, the last one between and . cholera epidemics are caused by v. cholerae group o and some non-o . symptoms are abundant liquid diarrhea with significant loss of hydro-electrolytes and severe dehydration associated with vomiting. v. cholerae is rare in developed countries but frequent in poor ones. humans are the only known hosts. the most frequent pathway of transmission is water, either through direct consumption or when used to irrigate produce that is consumed uncooked. fish grown in polluted water are another source of transmission. since , there have been outbreaks of cholera in india, iraq, congo, vietnam, and zimbabwe. in , west africa suffered more than cases of cholera, leading to deaths. - - fecal streptococci, no. ml À (u, b, k) - - protozoan cysts, organisms l À (u, m) giardia lamblia, cysts l À (u, e, k) - - cryptosporidium parvum, oocysts l À (u, e) - nd helminth ova, egg l À - - trophozoites become once again cysts that are expelled in feces. infected persons may or not display symptoms. protozoa do not reproduce in the environment, only in their host. however, they are able to survive in the environment and remain active for periods ranging from some months to up to several years, depending on the environmental conditions. most intestinal protozoa are transmitted through polluted water and food contaminated with polluted water or unsanitary handled (jiménez, ) . table shows the characteristics of some protozoa. in the developing world, the more relevant protozoa because of their effects on humans are giardia and amoeba. cryptosporidium is a threat to developed countries, as was unfortunately demonstrated in milwaukee, us, when people became ill and more than died after an infection was transmitted through the drinking water supply (hrudey and hrudey, ). helminths are worms some of which are parasites in humans. where helminths are the origin of waterborne diseases, they are mainly transmitted through the consumption of contaminated food (crops, meat, or fish). helminths can also be transmitted through the oral-fecal route and, therefore, hygiene is important as a factor in their control. as helminths are associated with turbid water, they normally are not a concern in drinking water. helminths are pluri-cellular worms and because of this they are poorly addressed in environmental microbiology books. the eggs -their infective form -are microscopic and travel along with wastewater. helminths occur in different types and sizes (from mm to several m in length), and have diverse and complex life cycles compared to most of the microorganisms known in the sanitary field (jiménez, a) . before infecting humans, in some cases, they may have an intermediary host as is the case for schistosoma spp. that temporarily lives in snails. there are three different types of helminths: ( ) plathelminths or flat worms, ( ) nemathelminths, nematodes or round worms, and ( ) annelids. if plathelminths have their body formed by segments, they are called cestodes; if not, they are then called trematodes. only the first two types are of sanitary importance. although common in sanitary engineering literature, it is improper to use the terms nematodes, ascaris, and helminths as synonyms. this misunderstanding comes from the fact that ascaris (a nematode) is the most common helminth egg in wastewater and sludge. a list of helminth eggs found in wastewater and sludge and its classification can be found in jiménez ( a) . helminthiases are diseases of high incidence in developing countries compared with developed ones. globally, there are around - thousand million people suffering of helminthiases but most of them are from developing countries where it affects up to % of the population. the incidence rate may reach % in regions where poverty and poor sanitary conditions prevail. in contrast, in developed countries, helminthiases' incidence is at the most . % and affects mainly poor immigrants (jiménez, a) . helminthiases have different manifestations but, in general, they cause intestinal wall damage, hemorrhages, deficient blood coagulation, and undernourishment. they can degenerate into cancer tumors. helminthiases affect mainly children, the elderly, and poor people . around % of the more than billion cases of diarrhea in the world are caused by helminths (murray and ló pez, ) . there are several kinds of helminths with different local names (annex ). this along with the fact that it is hard to properly identify them clinically unless a costly laboratory analysis is performed, makes it difficult to track the actual incidence of all the table protozoa related to sanitation problems and that are of interest for developing countries (with information from jiménez ( )) entamoeba histolytica is one of the most important parasites detected in municipal wastewater and is commonly known as amoeba. trophozoites measure - mm and t cysts - mm. amoebae usually lodge in the large intestine; occasionally they penetrate the intestinal wall, traveling and lodging in other organs. they are the cause of amoebic and hepatic dysentery. entamoeba histolytica infects % of the world's population -mostly in the developing world -resulting in approximately million infected persons; there are between and million cases of invasive amebiasis per year resulting in up to annual deaths (placing it second after malaria in mortality caused by protozoan parasites). ninety-six percent of these cases occur in poor countries, especially on the indian subcontinent, west africa, the far east, and central america. giardia spp. are common in wastewater as it frequently causes endemic diseases. it especially affects children under suffering from malnutrition. the total number of sick people is of the order . billion, % of whom live in poor countries. giardia spp. is the most common parasite of humans but water is not necessarily the main pathway of transmission. cysts (that are - mm long and - mm wide) can survive in water bodies for long periods, especially in winter. giardia lives in the intestines of a large number of animals as trophozoites. the disease is characterized by very liquid and smelly explosive diarrhea, stomach and intestinal gases, nausea, and loss of appetite. cryptosporidium spp. is a parasite widespread in nature. oocysts are resistant to chlorine and due to their small size ( - mm) are difficult to remove from water, as many other protozoan. cryptosporidium spp. infects a large spectrum of farm animals and pets and was recently recognized as a human pathogen that is why it is considered as an emerging pathogen. cryptosporidium spp. is capable of completing a life cycle within the same host and causing reinfection. once an individual has been infected, the person carries the parasite for life and can be reinfected. the disease rate in developing countries has been poorly studied, in particular due to the higher occurrence of other types of diseases. cryptosporidiasis in developing countries has shown a greater incidence among immune depressed people and in rural areas (snelling et al., ) . the main symptoms of cryptosporidiasis are stomach cramps, nausea, dehydration, and headaches. although it is known that the infectious dose varies between and , outbreaks have always been associated with large concentrations in water. helminthiases. that is why frequently figures are underestimated. technically, helminthiases take their name from their causative agent. for instance, trichuriasis is named after thrichuris. ascariasis, affecting nearly million people, is the most common of the helminthiases and is endemic in africa, latin america, and the far east. even though the mortality rate is low, most of the people infected are children under years of age with problems of faltering growth and/ or decreased physical fitness. around . million of these children will probably never bridge the growth deficit, even if treated (silva et al., ; jiménez, a) . the helminthiases' infective agents are the eggs, not the worms. actually, worms cannot live either in wastewater or in sludge because they need a host. helminth eggs are transmitted through ( ) the ingestion of crops polluted with wastewater or sludge, ( ) direct contact with polluted sludge or fecal material, and ( ) the ingestion of polluted meat or fish (jiménez, a) . each type of helminth has its own pathways of infection. eggs of different helminths generally occur in different shapes, sizes, and resistances ( figure ) . as a result of the higher incidence of ascariasis, in wastewater and sludge, these examples of local names given to helminth and helminthiases diseases are the eggs found in the highest concentrations ( figure ) . the percentage of types of helminths might vary from one region to another following the disease's pattern. due to differences in health conditions in developed and developing countries, their helminth eggs content is very different in wastewater and sludge ( table ) . eggs contained in sludge are not always viable and infectious. to be infectious, the larvae need to develop, and, for that, a certain temperature and moisture are needed. the necessary conditions are frequently met in soil or crops, where eggs are deposited when polluted wastewater, sludge, or excreta is used as fertilizer. under such conditions, the larvae develop in days. according to previous information (that has not been updated using better analytical techniques), ascaris eggs remain viable - months in crops and many months in soil, freshwater, sewage, feces, night soil, and sludge -periods which are much longer than those for microorganisms (jiménez, a, figure ). this high resistance is due to a cover composed of - layers that gives mechanical resistance to eggs and protects them from desiccation, strong acids and bases, oxidants, reducing agents, detergents, and proteolytic compounds (jiménez, a) . the resistance of different helminth eggs genera under environmental conditions has not been reported in literature. to inactivate helminth eggs, it is recommended to raise the temperature above c for - days for ascaris or to reduce moisture levels below %. these conditions are not ease of use during wastewater treatment; thus, helminths are usually removed from wastewater to be subsequently inactivated in sludge. helminth ova of interest in the sanitary field figure continued. measure - mm, have a specific density of . - . , and are very sticky. these properties are used to remove eggs from wastewater (jiménez, a) . helminth ova criteria. as shown in table , not all wastewater and sludge contain significant amounts of helminth ova. for this reason, they are not included in all countries' wastewater, sludge, or fecal sludge norms, as is the case with biochemical oxygen demand (bod) or fecal coliforms, which are universal parameters used to design wastewater treatment (jiménez, a) . based on toxicological and epidemiological studies, the world health organization who ( ) suggested a value of r egg l À in wastewater intended for the irrigation of crops that are eaten uncooked. wastewater used for the culture of fish should contain egg l À , since trematode eggs (schistosoma spp., basically) may multiply in an intermediary host (a snail) before infecting fish and humans. for excreta, the recommended criterion is of egg g À total solids (ts). thermotolerant coliform bacteria (commonly referred as fecal coliforms) are the group most frequently used as indicators of fecal pollution because they behave in a similar way to most pathogenic bacteria in the environment, and, during treatment, they are abundant and easy to determine. hy me no lep is sp p. to xo ca ra sp p. tri ch os om oid es sp p. en ter ob ius sp p. ta en ia sp p. un cin ari a thermotolerant coliforms are less specific indicators of fecal contamination than escherichia coli, since they may sometimes arise from nonfecal sources, especially in tropical climates (who, ) . however, it is becoming increasingly evident that they are not useful to simulate the behavior of all enteric viruses, protozoa -in particular with regard to giardia and amoeba -and helminth eggs that are of concern in low-income regions. despite this, it is frequently, but wrongly, assumed that fecal coliforms are indicators of all kinds of biological pollution. even though they can be useful indicators of fecal pollution in developed countries' drinking water, this is not always the case for water and wastewater from developing ones, owing to the presence of a wider variety and larger quantities of microorganisms (jiménez, ). this does not mean that fecal coliforms are not useful for developing countries; it simply means that care must be taken to select additional indicators for specific purposes, such as for wastewater and sludge reuse in agriculture and aquaculture. in these cases, the helminth egg content (who, ) needs also to be specified. it is worth mentioning that the treatment procedures to inactivate helminth eggs are frequently developed using ascaris eggs as models as they have been informally considered as indicators for all helminth eggs, although this has not been fully proven experimentally. in other cases, taenia saginata or ascaris galli, types of eggs that are rarely present in wastewater, are used to test treatment procedures. some pathogens that are not usually followed during conventional monitoring have been linked to outbreaks in developed countries. these pathogens have been called 'emerging' pathogens. they have led to new regulations as well as to improvements in water and wastewater treatment procedures. some of the microorganisms considered as emerging pathogens are giardia lamblia, cryptosporidium parvum, cyclospora cayetanensis, blastocystis hominis, legionella pnuemophila, e. coli h , campylobacter, mycobacterium, and norovirus (jiménez, b) . in developing countries, some of these pathogens are endemic, while others have either not been studied or not reported as disease-causing agents. assessing the biological quality of water is always a challenge due to the diversity of organisms and the need for different and proper methods to identify and enumerate them, some of which are complex, time consuming, and costly. in the following sections, a short description on the techniques used for different type of organisms is described. viruses. identification and quantification of viruses in wastewater, sludge, or excreta is complicated due to the low level of recovery from wastewater and the need to use complex and costly techniques to analyze them. a laboratory requires days, on average, to determine the presence or absence of a virus in water and another days to identify them, using conventional procedures. polymerase chain reaction (pcr) techniques have considerably speeded up the process, as they can be used to determine viruses online. these techniques are based on the amplification of a single or few copies of a piece of dna allowing the identification of different types of viruses. however, quantification with the precision required in the sanitary field remains a challenge. in addition, the method is sophisticated, and requires highly specialized equipment and highly trained personnel. due to these difficulties, it is sometimes preferred to detect bacteriophages, that is, bacteria infected by viruses. bacteriophages are used as informal indicators of viruses and not been linked to human diseases; therefore, their presence has no health significance (jiménez, ) . bacteria. as mentioned previously, thermotolerant bacteria are the common accepted indicator of bacterial fecal pollution. they are detected by using a selective medium and incubating it after inoculation at or . c and/or or . . c, depending on the medium used. the materials and equipment used for this analysis are very common in most wastewater laboratories. pcr techniques to detect e. coli are useful as well. protozoa. there are enough accessible techniques to determine the presence of the main protozoan pathogens in wastewater and sludge; however, fewer techniques are available to quantify them with the required precision for the sanitation field. the presence of protozoa on samples does not necessarily always imply a risk, since this requires them to be also viable. to determine the viability, several days are required. pcr techniques for protozoa are not as well developed as they are for bacteria and viruses. helminth eggs. helminths eggs require laborious techniques to detect them and even more so to enumerate them. fortunately, the technique is readily available and does not use complex equipment, although it does require well-trained laboratory personnel. currently, there is no standardized method and most of the few laboratories trained to detect them are using either different analytical procedures or similar ones with modifications. moreover, most of the laboratories, instead of reporting the total content of helminth eggs, only report the ascaris content, as is done in developed countries where it is frequently the single type of helminth eggs present (jiménez, a) . analytical techniques for quantifying helminth eggs can be divided into two: direct and indirect techniques (jiménez, a) . the first consists of separating helminth ova from the other particles contained in wastewater or sludge (where there are many) and then identifying and counting different genera using a microscope. some examples of these techniques used the us-epa (united states-environment protection agency), the membrane filter, the leeds i and leeds ii, and the faust techniques. the most widely used technique seems to be the us-epa ( ) . a comparison of the performances of the above-mentioned methods has been made by maya et al. ( ) . the recovery rate among them varies from % to %. sensitivity for each notably varies as well and not all are capable of measuring the criteria values set by who ( ) of egg l À for wastewater and egg g À ts for sludge. the second types of techniques are indirect ones, and these have been applied only for wastewater. they are based on measuring either the total suspended solids (tss) content or the particle size distribution (psd), and then correlating the concentration to the helminth egg content. calibration curves need to be established for each type of wastewater and treatment process. nevertheless, it is a worthwhile method because the helminth egg determination costs us$ - if tss are used, and us$ with the psd, instead of us$ , which is the cost of direct methods. it is important to distinguish between fertile viable and nonfertile eggs as only the viable eggs are infectious. this can be done visually using stains or by incubation at c for - weeks (jiménez, a) . conventional parameters as understood in this text are those commonly used to design or select wastewater and sludge treatment processes worldwide, and they refer mainly to the organic matter content (measured as bod or codbiological or chemical oxygen demand), or suspended solids. in general, they are similar worldwide except for the heavy metals content that in general -and especially for sludge -is notably lower in developing countries than in developed ones (leblanc et al., ) as result of the difference at the industrialization level. however, at a local level, metal content in some industrialized areas of developing countries, notably where metal or tanning industries are placed, may be high. a detailed description of conventional parameters and their significance can be found in jiménez ( a) . the term (chemical) 'emerging pollutant' is used to describe a wide variety of complex organic chemical compounds that are candidates for future regulation and that have not usually been monitored. to detect them, complex and costly analytical equipment is needed, such as gc-ms or gc-ms-ms (gas chromatography coupled with one or two mass spectrometers) as these are the only ones capable to measure the very low concentrations at which the pollutants are present (in the order of micro-or ng l À ) and to identify them. emerging pollutants have been detected in untreated wastewater, treated wastewater, surface water, groundwater, and even in drinking water of both developed and developing countries (some). among the countries that have measured and detect emerging pollutants, the following can be cited: austria, brazil, canada, finland, germany, italy, japan, mexico, the netherlands, spain, switzerland, uk, and usa (jiménez, b) . the sources of emerging pollutants are diverse. they come from nonpoint sources, municipal wastewater (treated or nontreated), and industrial discharges. they are also the result of the improper disposal of solid wastes. two groups of compounds that are considered as emerging pollutants are: endocrine disrupter compounds (box ) and personal care and pharmaceutical products (pcpps). wastewater treatment processes have not been designed to remove them; thus, they are randomly removed during conventional treatment. from the limited literature currently available, emerging pollutants -as other organic compoundsare concentrated in sludge during wastewater treatment. initial risk studies suggest minimal ecological and health effects through biosolids recycling to soils (leblanc et al., ) . as most of these pollutants have only been recently studied, the knowledge of their fate, transport, behavior during treatment, and risks is still poor in the sanitary engineering field. chemical emerging pollutants, in general, are not considered at the moment as a priority for the developing world as there are more pressing health and environmental pollutants of concern. it is important to bear in mind that the simple presence of a pathogen or a toxic chemical in wastewater, sludge, or excreta does not necessarily mean that a negative effect will occur. for that, several other things need to happen. these include ( ) the need for a compound/pathogen to reach a certain concentration; ( ) the existence of a pathway for transmission to human or the environment; ( ) the ingestion or presence of a certain dose to cause long-or short-term effects; ( ) sufficient exposure times to the pollutant; and ( ) sufficient sensitivity of a person or of the environment to pollutants. in addition, it should be remembered that, for humans, water is not the only source of risk, as food and air are also sources of pollutant ingestion and, in some cases, they may be the main ones. in terms of the differences of biological risks to humans in developing and developed countries, there are additional aspects to consider as humans develop immunity to pathogens depending on the type of environment they are exposed to, and thus infectious doses may be higher. genetic history, nutrition, and the combination of social patterns also intervene. for these reasons, data developed for developed countries are not always applicable to developing ones to perform risk analysis. in order to quantitatively assess risks, it is necessary ( ) to establish the type and quantity of given microorganisms in a region, ( ) to know the actual infectious dose, and ( ) to define and evaluate the possible infection route. to box endocrine compounds. from jiménez b ( b) wastewater risks in the urban water cycle. in: jiménez b and rose j (eds.) urban water security: managing risks, p. . paris: unesco leiden: taylor and francis group. endocrine disruptors are chemicals that mimic hormones or have antihormone activity interfering with the functioning of endocrine systems in various living species. they derive from many sources including pesticides, persistent organic pollutants, nonionic detergents, and human pharmaceutical residues. some of them have been identified in municipal wastewater and many of them may persist in the environment for some time. endocrine disruptors have been also found in drinking water. their presence in recycled waters also raises broader questions about the risks and benefits of water recycling and our approaches to anticipating the emergence of new contaminants. human health effects potentially linked to exposure to these chemicals include breast, prostate, and testicular cancer; diminished semen quantity and quality, and impaired behavioral, immune or thyroid functions in children. although direct evidence of adverse health effects in humans is lacking, reproductive abnormalities, altered immune function, and population disruption potentially linked to exposure to these substances has been observed in amphibians, birds, fish, invertebrates, mammals, and reptiles. notably, feminization or masculinization on male or female animals, respectively, has been reported. quantitatively evaluate the risk from a chemical or microbial pollutant, several methodologies are available in literature, but the data needed to apply them may be lacking for special cases in developing countries. sanitation is a term that has a clear meaning in the developed world. however, for the developing one, there is need to have a better definition. traditionally, sanitation has been reported as the percentage of the population having access to the service. in practice, this service in low-income regions ranges from simple access to sewers that are discharging the wastewater just behind households or into the streets to sewers connected to sophisticated wastewater treatment plants coupled with water reuse projects and comprising safe sludge management practices. for basic sanitation -sanitation provided in rural or poor periurban areas, the term sanitation includes a wide variety of on-site sanitation options going from simple pit to highly comfortable package treatment plants, which may or may not be functioning. to overcome this, the joint monitoring programme (jmp) from who-unicef proposed in to introduce the term 'improved sanitation' . improved sanitation is a system in which excreta are disposed of in such a way that the risk of fecal-oral transmission to users and to the environment is reduced (who-unicef, ). table shows which options qualify as improved sanitation and which do not. in , the world summit on sustainable development (wssd) provided a definition for basic sanitation that, besides considering the service itself, considered its impact on human health. this definition comprises the following: • the development and implementation of efficient household sanitation systems; • the improvement of sanitation in public institutions, especially in schools; • the promotion of safe hygiene practices; • the promotion of education and outreach focusing on children, as agents of behavioral change; • the promotion of affordable and socially and culturally acceptable technologies and practices; • the development of innovative financing and partnership mechanisms; and • the integration of sanitation into water resources management strategies in a manner that does not negatively affect the environment (it includes protection of water resources from biological or fecal contamination). as a result, the wssd's focus is not only on the construction of a particular number of toilets but also on the effective improvement of health and hygiene through basic sanitation. however, still new elements are needed to be added as problems caused by lack of sanitation are combined with those arising from the lack of economic resources and frequently also with lack of water in societies lacking even from social, economical, and political rights (box ). the millennium development goals (mdgs) are drawn from the actions and targets contained in the millennium declaration that was adopted by nations and signed by heads of state and governments during the un millennium summit held in new york city on september (who-unicef, ). they comprise eight goals and quantifiable targets. water is part of the th goal under target c: ''reduce by half the proportion of people without sustainable access to safe drinking water and basic sanitation.'' fulfilling this target represents the challenge of providing safe water supply to . million people and safe sanitation to . million people within years. table improved and unimproved sanitation facilities according to who-unicef ( ) connection to public service or bucket latrine sewer or septic tank traditional latrine pour-flush latrine public latrine or shared toilet pit latrine with slab open pit or pit latrine without a slab vip latrine open defecation in bush or field ecological sanitation box what sanitation should include, with some information from lenghton l, wright a, and davis k (eds.) ( ) health, dignity and development: what will it take? millennium development goals. london: earthscan. reporting figures concerning the state of sanitation in the developing world is a difficult task. first, there is a lack of information; second, the information available is generally presented in a heterogenic way; and third, different sources tend to contradict each other despite national and international efforts to produce consensus. the worsening situation with regard to sanitation in developing countries can be described using different indicators (box ). contaminated water and poor sanitation account for the vast majority of the . million child deaths each year from diarrhea -almost every day -making it the second largest cause of child mortality (undp, ) . the expansion of water services is essential to reduce the burden of waterrelated diseases and to improve the well-being of a large part of the world's population. it is also vital for economic development and poverty alleviation (who, ) . according to the figures presented by who-unicef ( ) , despite the efforts made and due to population growth, between and , the population with access to sanitation services has increased from million to million ( %), while the net number of people without improved sanitation decreased by only million. the difference between the level of sanitation in developed and developing countries is high: % versus % (table ) . however, between and , the percentage of people with access to improved sanitation increased from % to % with countries' variations ranging from % to % (who-unicef, ) . the difference observed between rich and poor countries is also observed between urban ( %) and rural ( %) areas from developing countries and as well between rich and poor people living there following the inequities of wealthy distribution. the sanitation coverage as percent of the population with service per country is presented in the map of figure for the year . annex contains a table with countries with less of % of the total, urban, or rural population. sanitation in developing countries is quite a complex issue, because the lack of it is combined with other several problems, some of which are geographically described on the maps - from annex . by analyzing these maps, the following conclusions may be drawn: . several low-income countries are located in arid or semiarid regions; thus, besides sanitation problems, they face the problem of water scarcity. . many of the areas under greatest stress (where people are already overexploiting rivers by tapping water that should be reserved for environmental flows) coincide with areas that are heavily developed for irrigation to provide water for food, that is, mostly in developing countries. . water withdrawal for agriculture is mainly performed in developing countries as a result of low water availability and the high dependence of agriculture. . areas where poverty and hunger are prevalent coincide with areas lacking sanitation. . in the future, it seems that the situation may worsen as water availability will decrease in the countries already experiencing water-related problems, including lack of sanitation. as result of the past and present situations, sanitation has different aspects on developing countries that cannot be described simply using the percent of population-covered index. in the following, some of these aspects will be described. basic sanitation versus sanitation. providing services for excreta management in poor rural or urban areas is frequently known as basic sanitation. thus, it has to do with excreta management rather than with sewerage and wastewater treatment plants (box and figure ). the quality of the service is frequently associated with peoples' economic level, and thus, is box some figures for global sanitation * for each four persons that do not have access even to a simple pit latrine, six have it. * for each one person that does not have access to sanitation, another one has it. * in rural areas, for each two persons, only one person has access to a sanitation service. * for each l of wastewater that is nontreated, l is treated. also a sign of status. another aspect to consider is that the lack of basic sanitation frequently is associated with lack of water. leblanc et al. ( ) highlights that research and experience suggest the following hierarchy of risk to human health: ''living in a dense community without basic sanitation (is more risky thany) irrigation of crops with untreated, pathogencontaminated wastewater use of untreated, pathogen-contaminated excreta or wastewater sludge on soils use of untreated, pathogencontaminated animal manures on soils use of treated manures, wastewater, or biosolids on crops use of these treated materials in accordance with strict modern regulations that address heavy metal and chemical contaminants.'' differences on sanitation services. possibly, one of the aspects that contributes the most to render sanitation in developing countries a challenge is the variety of needs and circumstances arising from social differences. as shown in figure , for instance, poor people not only are less served but also the quality of the services is lower. one of the deepest disparities is between urban and rural areas as for the former the coverage is twice as much than for the latter in developing countries. traceable differences in sanitation services have been reported as well among indigenous and nonindigenous people and minorities such as castes and women (box ). among these differences, the following common challenges can be identified: • the need to provide the service in poor areas with large population increases. • for urban areas, a very fast service demand growth in slums that are spread out in cities, have high population density, and there is no land to place the infrastructure. • for rural areas, the need to assist a population frequently dispersed and hence at higher cost. • the need to fund projects combining liquid and solid waste collection and treatment infrastructure. • the need to develop new or different management structures to provide services in social and political complex areas. • the need to include health education and awareness programs on sanitation projects. • the need to use public funding to provide services that are to be subsided. • the existence of regions having high income where services can be provided in a similar way to developed countries. sanitation versus wastewater treatment. as described previously, sanitation coverage does not necessarily result in wastewater being treated or safely disposed of. to illustrate this, figures for the situation in some developing countries are provided. two comments on this figure are that ( ) it is really difficult to find data on wastewater treatment, notably for the asian and african regions and ( ) although there should not be a full correspondence between the sanitation coverage and the wastewater treatment -as some people are served using basic sanitation facilities -the figures should not be as different as they are for some countries. in latin-america, for instance, although the sanitation coverage was % in , only % figure ). according to lenghton et al. ( ) , the amount of money needed to fulfill the sanitation mdgs ranges from us$ billion to us$ billion representing, in mean conditions, an annual average investment of us$ . billion. to put these figures in perspective, the above-mentioned authors mention that each year europe and the united states spend us$ billion on pet food and europe spends us$ billion on ice cream. the overall cost estimation of the current water and sanitation deficit is of the order of us$ billion, equivalent to . % of developing countries' gross domestic product (gdp). for each us$ invested for sanitation, the economic even if sanitation represents an economic benefit, its cost is still important to societies in which this is not the only requirement. therefore, it is useful to combine options that involve building infrastructure with others that do not (such as washing or cooking produce that has been irrigated with polluted water) in order to improve health conditions while the sanitation services can be gradually provided. such an approach is described in who ( ) . in the next sections, options to build up wastewater management systems are reviewed. a wastewater management system (wwms) is understood in this chapter as the combination of one or several of the following components: ( ) basic sanitation facilities or toilets; ( ) wastewater collection systems (sewers) or box some challenges to provide basic sanitation in low-income countries * open defecation is practiced by % of the population in southern asia and % in sub-saharan africa. * in ouagadougou, the capital of burkina faso, the access to sanitation facilities is % while the figure for the country is . %, a figure that reduces to only % for rural areas (paskalev, ) . * in yaoundé, cameroon's capital with inhabitants, the available facilities for most people ( %) are external and in shared proprieties (figure ). * basic sanitation and sanitation figures reported are not the same. for instance, for cote d'ivoire, a coverage of % is reported for rural areas, but, in fact, % refers to basic facilities and only % to adequate systems (angoua, ) . ( ) wastewater disposal or reuse facilities. before presenting these components in detail, the two options in which they can be managed (centralized or decentralized) are discussed. conventionally, to handle wastewater, sewers connected to wastewater treatment plants have been used. this is known as a centralized system and is a well-mastered and well-managed technology approach applicable to cities, provided funds for its construction and operation are available. in terms of operation, centralized systems are often cheaper and easier to handle than decentralized ones. for isolated slums and dispersed rural areas and even for cities where new sewerage systems is too costly, it is advisable to use decentralized wastewater management systems. in these, sewers of reduced size result in a lower capital cost (around %) due to the smaller diameter and length of the used pipelines. in addition, they offer the following benefits (lenghton et al., ; correlje and schuetze, ) : ( ) they allow investments to be made stepwise, in line with available funds, local development, and population growth; ( ) they are used in smaller areas of service that are easier to manage; ( ) they allow the use of different technologies to provide services to different socioeconomic groups; and ( ) they facilitate the reuse of water on-site. nevertheless, all these advantages need to be assessed in practice, as they cannot be taken for granted universally. as for many water utilities, decentralized systems represent a higher number of systems to manage, which is difficult and complex; to overcome this limitation, centralized management of decentralized systems is recommended. this way it is possible to ensure high performance and reliable operation, reduce costs, and also ensure the need for specialized operators (hughes et al., ) . from a technical point of view, there are four important components to consider when providing a basic sanitation service: ( ) the type of toilet, ( ) the storage facility for feces which frequently are associated to the toilet, ( ) the way in which feces are extracted from the pit, and ( ) their further management. this section deals with the first two components. their main characteristics are discussed here; for design, it is recommended to consult specialized books. a good option to begin with is the united nations environment programme (unep) website (see section titled 'relevant websites'). latrines are the most widespread type of on-site sanitation facility. they are used in rural settings and deprived areas in cities. they consist of a makeshift pit dug in the ground and box women and sanitation (with information from lenghton l, wright a, and davis k (eds.) ( ) health, dignity and development: what will it take? millennium development goals. london: earthscan.) one explanation for the low effective demand for sanitation is gender inequality. women tend to place a higher value on household toilets than do men for a number of reasons, among them privacy, cultural norms, care-giving responsibilities, and the risk of sexual harassment and assault. in addition, the unique sanitation needs of women and girls (e.g., during menstruation and during and after pregnancy) receive little recognition when discussions about sanitation and hygiene occur. yet, the limited political and personal power of women in many developing countries means that some of sanitation's strongest advocates are virtually absent from decision making and priority-setting processes. generally covered with any material (a wooden, plant, or metallic cover, whichever is available). when latrines are full they can be emptied (this is unpleasant and has an associated cost) or closed to build another one (this requires the availability of land). these latrines, instead of having a single vault, are made up of a shallow pit divided into two - m vaults. their major advantage is that they are a permanent facility due to the alternate use of each pit. the name comes from the inclusion of a properly designed pipe allowing ventilation, which also requires a screen to avoid the accumulation of flies. the pit cover is made of precast concrete, wood, palm leaves, or metallic material, and is removable. emptying is performed manually in low-income areas, but can be done mechanically every - years. the ventilated improved pit (vip) latrine with multiple pits can be built for collective use, such as in schools, markets, fueling stations, and administrative buildings (mamadou, ) . the septic tank is commonly used as primary treatment in rural areas, low-income urban settings, isolated households, or on sites where soil is not suitable for the installation of sewers (jiménez and wang, ) . they are built where a constant water supply is available and are used to partially treat domestic wastewater and to digest the settled sludge. they remove around % of the organic matter and suspended solid content in - days. for sludge digestion, . - year is required; during this time, sludge is mineralized and its volume is reduced. septic tanks are made up of a series of communicating chambers. they must be water sealed to avoid underground infiltration and are built using bricks, mortar, or concrete. a variation of the septic tank is the imhoff tank, having the advantage of a shape that allows the removal of suspended solids and the control of foul odors in a better manner. septic tanks need to be periodically cleaned ( - times per year, leaving % of the mature sludge as inoculum for digestion). this represents an additional cost that cannot always be afforded by poor people. septage (the slurry taken out of septic tanks) is sent to wastewater treatment plants or treated separately. to treat septage, lime is frequently added until a ph of is reached, over a period of min (jiménez and wang, ) . effluents from septic tanks are discharged into trenches for subsoil infiltration or diverted to the sewerage system (when available). septic tanks are widespread sanitation systems but are often responsible for environmental pollution due to poor purification effects and leakages notably affecting groundwater. composting toilets are characterized by the separation of urine and feces. for this reason, they are also referred to as urine diversion (ud) toilets. they are constructed with two vaults or chambers. when the first vault is full, the pedestal is moved over to the second vault, and the first hole is closed. when the second vault is full, the first vault is emptied and so on. the urine is diverted to a soakaway. in comparison to vip latrines, they have a lower cost associated with emptying the pits (snyman, ) . urine is collected in small cans ( - l) and can be used to enrich the soil after a stabilization period of days. feces are treated using an aerobic composting process. to control odors and to assist in the mineralization of feces, materials, such as ashes or pieces of wood, are used daily to raise the ph. the pathogens in fecal matter are inactivated over time through the drying process so they can be safely removed by the owner at no cost to the municipality. once the sludge is digested, disinfected, and removed, it is used as fertilizer. ud toilets are seen as a viable option for rural applications. the main reasons are that they are cost-effective and, since the rural community is accustomed to the use of manure, the ud toilet is socially acceptable. however, its use in periurban areas is more problematic. the emptying of the vaults requires large-scale programs for which small businesses can contribute to the emptying of tanks (from ud or vips) either manually, using appropriate safety equipment, or by the use of a tanker. the disposal of the fecal matter in periurban areas is challenging due to the lack of land. if space allows, fecal sludge is buried on-site. where this is not feasible, the sludge is blended into the waterborne system. this frequently leads to the complete overloading of the wastewater treatment plant (snyman, ) . there are several options of composting toilets (see section titled 'relevant websites'). pour-flush toilets have been developed based on traditional flush toilets, which rely upon a water seal to perform cleansing and to control odors and insect infestations. the system works via a manual flush, where - l of water are poured into the toilet. the water, urine, and excreta are collected in an anaerobic chamber, which works similarly to a septic tank. the chamber needs to be periodically emptied and the partially treated wastewater needs to be disposed of, normally to land (hughes et al., ) . in the context of water-scarce areas, a very interesting option is combining graywater reuse with basic sanitation using pour-flush toilets. this concept was developed by united nations international children's emergency fund (unicef) on a system called the wise water management scheme (godfrey et al., ) . this system was conceived to provide both water supply and sanitation services for water-scarce areas and can be used for both rural and lowincome urban areas. it was conceived in madhya pradesh, india, a densely populated and poor area. the wwms uses groundwater as the primary source of water and also includes rainwater harvesting, used to dilute groundwater when polluted with fluoride to reduce its content for human consumption ( figure ) . first-use water is employed for cooking, handwashing, and bathing. water from these two activities is recovered and properly treated in a sand filter to be used for toilet flushing and kitchen garden irrigation. the graywater reuse system can be installed independently of the rainwater harvesting system. by matching water demands, in quantity and quality, to different conventional and nonconventional water sources, the wwms increases water availability by nearly %. sanitation using low-consumption reused water flush toilets has proven sustainable under the prevailing local conditions and has eradicated open defecation. . . . . additional recommendations to set up basic sanitation facilities one important aspect to keep in mind when selecting the technology is that facilities need to be operational and, to achieve this, there is a need to sustain them under operation from the economical, technical, and cultural perspectives. investment costs are linked to the type of sanitation system selected, the construction materials, and labor. frequently, to reduce costs, cheap materials and the users are employed to build the facilities. however, this may result in failures, as cheap material frequently means low quality and the users are not people experienced enough, even if trained. it is thus preferable to invest in good and durable material and to use experienced workers. in india, for instance, sanitation programs using professional well-trained masons are being implemented in which the same masons for whom sanitation is a source of income become at the same time sanitation promoters. norms and institutional capacity to provide basic sanitation constitute another weak link in the complex chain needed to implement and provide services. how to build institutions, policies, and human resources to provide successful sanitation services is better known in high-income countries than in developing ones. each country/region needs to look for the proper way to solve their problems. finally, concerning basic sanitation, it needs to be considered that in several places, providing basic sanitation means to change open defecation habits and to handle domestic solid wastes (box ). it means as well to properly dispose of the toilet paper. under this section, only the toilets using less water or none at all are described as compared to the others (pour flushing toilets using l of water is a well-known technology widely spread commercially). concerning these toilets, one aspect to highlight is that even if convenient from the point of view of the used water, care must be taken when designing treatment plants as wastewater will be not only lower in volume but also highly concentrated, notably in terms of its organic matter content. these toilets are based on the same working principles as common flush toilets but they are specially designed to fully operate with less water ( - l). in such toilets, it is possible to select either a full flush (with , , or l depending on the model) for solids or a half flush ( - . l) for liquids. box poor people have a globalized attitude towards excreta management as described for senegal by ba ( ) , in most poor areas of the developing world, water from baths and in some cases from showers are routed to septic tanks from which the effluent is sent to infiltration wells or trenches. kitchen and laundry water is generally poured directly into the street, discharge areas in the wild, a well, a nearby river, or riverbed. wastewater and noncollected solids are also frequently mixed creating breeding sites, odor problems, and development of flies. these toilets are also available with separate drainage for urine to reduce the impact of nutrients and pharmaceuticals on the sewage and to facilitate the reuse of urine as a fertilizer. however, most water-saving toilets available on the market are designed to be connected to typical drainage systems. there are several technological options on the market, some of which use a vacuum to transport feces at a much higher cost. the investment cost for low-volume toilets is comparable to high-volume toilets. however, dual flush toilets may cost more than common ones (nearly double). the installation of water-saving toilets must be stimulated by education (e.g., in the form of campaigns to raise awareness concerning watersaving issues), water metering, and pricing. water-saving urinals, using - l, are also available (correlje and schuetze, ) . the idea of dry toilets is not new. they have been used for thousands of years in east asia (china, japan, and korea). dry toilets are available as industrial prefabricated products and can also be constructed in local workshops; however, knowhow for its good operation and to avoid foul odors is required. investment, construction, or installation costs vary significantly and depend on the specific system and design. the cost ranges from low investment for simple dry toilets to comparatively high cost for industrialized composting toilets. due to the large size of the storage and composting chambers, these toilets require a large space underneath; if this is not possible, then they need to be regularly emptied and feces need to be transported to treatment facilities. user acceptance depends on cultural background and awareness. generally, people who are already using flush toilets do not readily switch to dry toilets because the image of dry toilets is less attractive than that of flush toilets. equally important as the type of on-site sanitation system selected is the provision of all the services associated. past experiences (water decade, - ) have shown that massive sanitation infrastructure provision without a proper planning of the whole scheme can be a complete failure (koné, ) . besides the technical aspects that are discussed later, the most worrying aspect is the lack of financial, institutional, and regulatory framework in most of the developing countries to establish the network required. management of on-site sanitation infrastructure comprises on-site sanitation systems emptying, fecal sludge haulage, treatment, and safe reuse or disposal (koné, ) . fecal sludges refer to sludge collected from on-site sanitation systems such as latrines, nonsewered public toilets, or septic tanks. the criteria to select an extraction method -a task that is never pleasant -depend on ( ) the ts content and ( ) the funds available. sludges with less than b % ts, such as those produced in septic tanks, can be pumped; but, for the rest of facilities producing all sludge with % ts, pits need to be emptied using cesspit trucks or manually by laborers (koné, ) . even though when mechanically emptied and water is used for toilet cleansing, - % of the contents in the lower pit part need to be manually emptied to extract the thicker sludge. the use of mechanical equipment allows carrying away the sludge several kilometers for disposal on controlled sites or on treatment facilities, but this is often expensive and needs proper equipment and skilled laborers. in contrast, when sludge is manually emptied, this is deposited in nearby lanes or on open spaces representing a source of risk. according to koné ( ) - % of the on-site sanitation facilities from west african countries are emptied manually. in addition, in almost every developing country, fecal sludge collection and haulage are conducted by private entrepreneurs. however, their important role and responsibilities as key stakeholders are not yet fully recognized and legalized (koné, in many low-income areas, the sanitation problem begins with the lack of sewerage. one option is to build sewers of small extent coupled with on-site sanitation systems. sewers carry the treated effluent to disposal (usually to soil for infiltration, to irrigation canals, or into water receptors), to wastewater treatment plants, and/or to reuse sites located within a short distance. as these sewers frequently convey partially treated wastewater (such as septic tank effluents), they are designed for self-cleaning using a high wastewater velocity and/or a steep slope. this option is applicable for rural areas or urban ones where adequate land is available. another option is to use simplified sewers. these are recommended where an uncertain population increase is occurring, as normally happens in periurban areas or slums. small sewers are built to reduce the infrastructure and maintenance costs, as well to allow high operational flexibility. inspection chambers such as manholes are replaced by inspection cleanout. the life expectancy of such sewers is in the order of years rather than the years quoted for conventional sewers. such sewers are short and shallow (hughes et al., ) . one example of simplified sewers are condominial ones in which pipelines are laid through housing lots instead of on the side street, in a way that allows isolated and stepwise construction (unep, ) . condominial sewers were developed in the s in brazil with the aim of extending sanitation services to low-income communities. this technology has now become a standard sanitation solution for some urban areas in brazil, irrespective of income levels. condominial sewers reduce the per capita costs of service by replacing the traditional model of individual household connections to a public sewer with a model in which household waste is discharged into branch sewers, and eventually into a public sewer through a group (or block) connection (watson, cited in lenghton et al., . these are structures that are bigger and deeper than those previously discussed. details for design can be found in conventional literature on sewers. many developing countries are located within regions subject to tropical storms, or in areas where there are only two seasons per year: wet and dry. therefore, urban hydraulic infrastructure needs to be designed accordingly to have sewers that can handle large peaks of stormwater and the normal wastewater flows (wastewater treatment plants should also be capable of dealing with the varying wastewater characteristics in quantity and quality, at least in large cities). sewers in tropical areas produce a high amount of sediments to be disposed off, which turns out to be a peculiar and difficult-to-solve problem not frequently commented upon in specialized literature but that needs proper methods to extract sludge and handle it. in addition, when conveyed in sewerage systems, stormwater must be treated in treatment plants at the same time as wastewater; but, if transported separately, it can be discharged to surface water or into wells for groundwater infiltration receiving treatment in soil. in this case, it must be kept in mind that stormwater quantity and quality are determined by rainfall, catchment processes, and human activities, which cause its flow and composition to vary in space and time. normally, for the first rains of the year, stormwater has higher suspended solids, heavy metal content, and bacterial numbers than nontreated wastewater, and lower dissolved solids, nutrients, and oxygen demand than secondary-treated sewage effluent. wastewater treatment is the typical method applied for sanitation, and is the predominant option used in developed countries for that purpose. although it cannot be considered a caveat for all the negative impacts produced by wastewater, it is still a very important option, and, in many cases, the only one. there are several steps to treat wastewater. the primary step basically serves to remove easily decantable and floating solids. the secondary one, generally a biological process, is used to remove biodegradable (mostly) dissolved suspended material. the tertiary step is used to refine the quality of the effluent produced by a secondary treatment. it may have different purposes, most commonly being the removal of nutrients (n and p). as the treatment steps were conceived following treatment needs, in practice, they are usually implemented in separate tanks or in well-defined sections of wastewater treatment facilities; however, it is possible to use compact processes eliminating physical separation among steps and thus reducing costs (jiménez, ) . wastewater treatment plants are not common facilities in low-income countries. in contrast to developed countries, in developing ones, the sanitation figure ( % according to who-unicef ( ) ) does not include the treatment of wastewater, which barely reaches % (us-epa, ). moreover, when available, the treatment merely consists of a primary step or including eventually a secondary step that is not always properly functioning. in many developing countries, the main issue concerning treatment is still the proper disposal of feces, particularly in low-income urban or rural areas. this, combined with a high content of pathogens in wastewater, sludge, or fecal sludge, implies the need to properly select the treatment process in order to effectively control disease dissemination. in general, coupling any kind of secondary wastewater treatment process (biological or physico-chemical) with a filtration step before disinfection will considerably reduce the pathogen content. however, this is rarely feasible for economic reasons and therefore it is sensible to consider the use of other technologies alone or combined with other type of intervention methods to build up a multiple barrier system to control wastewater risks (jiménez, b) . in the following sections, guidance will be provided to support the selection for treatment options, based on the type of pollutants. to address problems caused by suspended solids, organic matter, nutrients, and fecal coliforms, there is a wide variety of available technologies supported by literature and practical results. their affordability in economic terms and the suitability of the processes for local conditions are among the important aspects to consider for developing countries. it is beyond the scope of this chapter to provide a full description of treatment technologies for conventional pollutants, which can be found elsewhere in the literature. table shows the removal of pollutants by different processes so that it is possible to identify those acting upon the same type of pollutants. . . . . pathogens treatment table presents organisms' removal or inactivation achieved by different wastewater treatment processes. this table is a guide for selecting a process. however, to design complete treatment schemes, the operating conditions need to be properly selected as well as the pre-and post-treatment. table differs from the one presented by who ( ) in showing the removal efficiency data for helminth eggs in terms of a percentage instead of log removal. this is because helminths eggs' content is by far much lower and log units are meaningless. for developing countries, the removal of protozoa and helminths eggs is the main concern, considering their content and the occurrence of diseases caused by these types of agents. to remove protozoa, filtration is a good treatment option. conditions used to remove cryptosporidium oocyststhe targeted protozoan for developed countries -can be used as well to remove protozoa relevant to developing countries. helminth eggs are not affected by conventional disinfection methods (chlorination, ultraviolet (uv) light, or ozonation); thus, they are first removed from wastewater using sedimentation, coagulation-flocculation, or filtration processes to be subsequently inactivated in sludge (jiménez, a) . removal occurs because eggs are particles - mm in size. it is estimated that for contents of - mg l À of tss in treated wastewater, the concentration of eggs is around - eggs l À , while for values below mg l À it is around egg l À or less (jiménez, a) . however, for a process to be reliable, besides the removal efficiency attained, it is important for it to produce an effluent with constant concentration. the removal efficiency of emerging chemical compounds during conventional treatment can be found in jiménez ( b) . it is recommended that experimental tests be performed under laboratory conditions, prior to treatment selection. in the following, a description of main wastewater treatment processes is made, highlighting aspects that are relevant to developing countries, notably concerning their efficacy to control pathogens. table removal of pollutants by different wastewater treatment process that can be used to buildup a multiple barriers treatment scheme (with information from jiménez ( ) noxious by-products can be formed. if there is no competition with organic matter (bod or cod). doses are several orders of magnitude higher than those used for disinfection. if granular carbon is used. high for nonpolar organic compounds with log k ow > and when there is no competition with organic matter. medium to high depending on the presence of cations and organic matter. high but not for low molecular weight uncharged compounds. effective for several ec but not for carbamazepine, primidone, and iodinated x-ray contrast media. high for some ec, as it depends on the strength of solar irradiation removal will be different for different latitudes, or conditions. can be enhanced with photosensitizers. ? unknown or insufficient information * , can be removed or inactivated. no, not applicable for the pollutant. , . . . . slow filtration slow filtration is recognized in water potabilization as an efficient method to control microbial pollution in rural and low-income communities. the few studies carried out on slow filtration of wastewater have demonstrated a removal range of - % of suspended solids and - e. coli log, with coarse sand (jiménez, ) . in rural areas, it may be coupled with absorption wells, irrigation reuse, or a soil aquifer treatment (sat) system. waste stabilization ponds (wsps) are shallow basins that use natural factors such as biodegradation, sunlight, temperature, sedimentation, predation, and adsorption to treat wastewater (mara, ) . wsps are capable of removing organic matter with efficiencies similar to the activated sludge process and all kind of pathogens. they are easy to design and operate but require long retention times (several weeks). wsp systems comprised several ponds connected in series. lagoons are made through the shallow excavation of around - m, and they are frequently unlined to reduce investment costs. after a period of time, soil percolation and sedimentation form an impermeable barrier. if the water table is very high at the site, ponds need to be impermeable from the beginning. wsps remove up to bacteria log, up to viruses log, and almost all the protozoa and helminth ova. to control cryptosporidium spp., almost days' retention time is needed . in developing countries with wet warm climates, the use of stabilization ponds is recommended if land is available at a reasonable price. for arid and semiarid regions, high evaporation rates limit their application as there is a net loss of water of - % due to evaporation. this, in addition, increases the salinity of the effluent limiting its use for agricultural irrigation . sludge production in ponds is low but if extracted it needs disinfection as helminth ova remain viable in ponds for more than years (nelson et al., ) . wsps can be coupled with aquaculture systems that are shallow ponds or wetlands where fish, duckweed, or aquatic vegetables are produced as is frequently done in indonesia, china, and thailand. ponds can be used to produce only one crop such as duckweed that is used as food for the next pond where grass carp are grown. different species can also be cultured in the same pond, as happens in nature. to operate the system, wastewater is applied to ponds at the required rate (estimated in terms of the organic load applied per hectare of ponds per unit time), and the organic matter and the nutrients contained serve as food for plant and animal production (hughes et al., ) . in order to avoid health problems, wastewater needs to be previously disinfected according to who guidelines ( ) . constructed wetlands are used to naturally remove organic matter, pathogens, and nutrients from wastewater through biodegradation, adsorption, or filtration in a similar way to wsps. nutrients are also removed by plant uptake and pathogens by competition and sun uv-light inactivation (jiménez, ) . wetlands are shallow ponds where aquatic macrophytes are planted in soil, sand, or gravel. there are three main types: surface-flow, horizontal-flow subsurface, and vertical-flow systems. juncus spp. or phragmites are commonly used plants but any local plant can be employed. construction requires expertise and skilled labor. once installed, operation is relatively easy. wetlands remove nitrogen, phosphorus, and heavy metals. up to - % of thermo-tolerant coliforms, - % of ms coliphages, and - % of protozoa are inactivated or removed using hydraulic retention times of - days. in practice, pathogen removal is highly variable and depends on climate, type of wetland, and the kind of plant used. to completely remove helminth ova, it is necessary to couple wetlands with filtration, otherwise effluent with variable content may be produced. breeding of mosquitoes and unpleasant odors can be a problem if wetlands are not operated correctly. subsurface wetlands are used to avoid mosquito breeding (correlje and schuetze, ) . wetlands are a good solution for wastewater treatment in urban or rural areas where space is available; as a rule of thumb, . - . m per person is required for the treatment of graywater and - m per person for domestic wastewater. they are considered environmentally sound technology by unep for the treatment of graywater and stormwater urban runoff. they are used as secondary or tertiary treatment units, in which case, they treat effluents from septic tanks, anaerobic ponds, upflow anaerobic sludge blanket (uasb) reactors, or conventional wastewater treatment plants. treated wastewater can be reused for agricultural irrigation, although its nutrient content is low. wetlands have been used in bangladesh and china to treat wastewater and to cultivate fish and ducks. in addition, they have the advantage of producing a low quantity of sludge. soil can be used to treat wastewater by infiltration. it has a greater depollution capacity than water receptors, as there is no limit for the oxygen transfer needed for biodegradation. land-based treatment is recognized as an environmentally sound technology by unep ( ) that has a low cost when used for primary effluents. among its disadvantages is the high demand for land (jiménez, ) . in the case of land treatment, depollution takes place in the unsaturated zone through biodegradation, adsorption, ion-exchange filtration, and precipitation. for the removal of organisms, in addition to predation and humidity, the temperature also plays a role. heavy metals and trace organic compounds (such as emerging pollutants) are removed mainly by adsorption. to operate, wastewater is to be applied at specific rates; if pretreatment is needed primary sedimentation or sand filtration might be used (brissaud and salgot, ; jiménez, ; bouwer, ) . in developed countries, pre-treatment usually consists of a secondary treatment. wastewater application occurs in cycles at a rate that depends on the soil infiltration characteristics. in a typical situation, the cycle involves week of wastewater flooding where infiltration is reduced by organic buildup, and week of drying where bacteria consume the organic matter and soil drying takes place. there are several types of land treatment options in specialized literature that can be consulted. for efficient functioning, hydraulic loads ( - m m À yr À ) and mass loads should be limited. to avoid aquifer pollution, application of wastewater (preferably partially treated) is restricted to sites where groundwater is a minimum of m in depth. applied as primary or secondary treatment, land treatment produces a consistently high-quality effluent (tss o mg l À , organic carbon mg l À , and total nitrogen mg l À , with a phosphorus removal of almost % with minimal pre-treatment). as tertiary treatment, it removes % of bod, % of cod, % of ts, % of detergents, % of ammoniacal nitrogen, % of total nitrogen, and % of phosphorus. land treatment is effective for the removal and/or inactivation of helminth eggs, protozoa, bacteria, and even viruses (jiménez, ) .treated wastewater can be used for irrigation or any other use and can be collected on the surface or underground. reservoirs or wastewater storage tanks can be used as well to treat wastewater. while wastewater is stored during the wet season to provide water for irrigation during the dry season, pathogens are removed or inactivated via sedimentation, uvsunlight inactivation, predation, and other similar processes, which also occur in wsps. nevertheless, the efficiency is lower. procedures for designing wastewater storage and treatment reservoirs are detailed in juanicó and milstein ( ) and mara ( ) . reservoirs and storage tanks are easy to operate and maintain, and if considered as part of the irrigation system, they result in a low investment cost. however, they facilitate vector breeding if they are not well maintained and operated, and algal development in effluents may interfere with irrigation applications. effluent storage reservoirs remove À -log of viruses, À -log of bacterial pathogens, and À -log units of protozoan (oo)cysts. if treatment reservoirs are operated as batch systems with retention times over days, the complete removal of helminth eggs can be achieved (juanicó and milstein, ) . in addition to large storage reservoirs, small storage ponds can be utilized for pathogen removal when used for urban agriculture irrigation as intermediate water storage reservoirs. such reservoirs reduce the helminth ova content by around % (keraita et al., ) . the uasb is used to remove organic biodegradable matter. a uasb is a kind of attached system where microorganisms adhere to themselves, forming flocs. uasbs are considered as the most successful anaerobic process applied to treat wastewater due to low hydraulic retention time compared to other anaerobic processes thanks to the high density of biomass attained in the blanket (campos, ) . the reactor is designed to not only produce the biological reaction but also to sediment and filter suspended solids from wastewater. in addition, sludge retained in the bottom part of the reactor is anaerobically digested (campos, ) . the uasb produces better results when the wastewater has a high organic matter content. as by-products, it produces methane and partially treated sludge. the gas can be used as a source of energy, while the sludge remaining, after proper treatment to control the pathogen content, can be used to fertilize soil. uasbs remove - % of bod and cod and helminth eggs through filtration in the sludge blanket and through sedimentation. however, their efficiency with regard to the removal of helminth eggs is very variable. from wastewater containing - eggs l À , they produce effluents with - eggs l À ( - % removal). therefore, uasbs are frequently coupled with other treatment process such as stabilization ponds or filtration to completely and reliable remove helminth ova and to inactivate other pathogens. several stand-alone uasb plants or those coupled with wsp are currently under operation in curitiba, brazil. uasb reactors require careful design and operation to avoid bypasses (campos, ). the construction, operation, and maintenance of improved anaerobic technology such as biogas installations require considerable expertise and skilled labor as well as space (correlje and schuetze, ) . uasb reactors have a low capacity for tolerating toxic loads, need several weeks to start up the process, and require a post-treatment step. it is the most common way to treat wastewater in developed countries. compared to other secondary biological processes, activated sludge is effective for pathogen control as it removes % more than trickling filters. both sedimentation and aeration play an important role in this. sedimentation eliminates heavy and large pathogens, while aeration promotes antagonistic reactions between different microorganisms, causing their elimination. as a result of becoming entrapped within the flocs (which are subsequently sedimented), there is fairly good removal of small nonsedimentable microorganisms, such as giardia spp. and cryptosporidium spp., which remain concentrated within the sludge (jiménez, ) . helminths eggs are also removed, but due to continuous difficulties in achieving efficient and reliable sedimentation of suspended solids in secondary decanters, protozoan and helminths eggs may be found in effluents along with flocs. for an initial helminths egg content of - eggs l À , effluents with - eggs l À are produced . other biological secondary treatment options include aerated ponds, oxidation ditches, and trickling filters. much specialized literature exists describing the processes that are used to treat effluents before discharge into water bodies. this is a process that was almost abandoned for the treatment of municipal wastewater in the - s due to the high sludge production, which considerably increased the overall wastewater treatment cost. the introduction of new chemical products, in particular flocculants, combined with the possible reuse of treated effluent for agricultural irrigation and ocean disposal, has been instrumental in its reintroduction. coagulation-flocculation removes helminths eggs while preserving nutrients and organic matter in contents suitable to grow plants. when this process is applied using low coagulant doses combined with a high molecular weight and high charge density flocculants, it is called chemical enhanced primary treatment (cept). if, a high-rate settler is used instead of a conventional settler, it is referred to as advanced primary treatment (apt). as a result, cept has a total hydraulic retention time of - h while, for apt, this is only . - h. among the coagulants that have been used, iron and alum compounds are the most common. apt removes - % of protozoan cysts (giardia, entamoeba coli, and e. histolytica) and - % of helminths eggs. from a content of up to eggs l À , an apt can consistently produce an effluent containing . - eggs l À . this process produces an effluent with a low content of suspended solids or turbidity, which leads to greater disinfection efficiency, either with chlorine or with uv light. likewise, the process allows the use of sprinkler irrigation in high-tech countries or countries where water is scarce. the effluent quality is improved by the soil effect, and aquifers can be used as water supply storage (jiménez, . apt and cept are useful in middle-and high-low-income countries on large urban areas as an economical alternative to an activated sludge process as the treatment cost for apt is one-third of this process when considering sludge treatment and disposal within km. coagulation-flocculation can also be applied as a tertiary treatment after a biological process. this is a very good method to remove enteric viruses (jiménez, ) . rapid filtration (at rates over m m À h À ) is very efficient in removing protozoa and helminth eggs from wastewater, primary effluents, and biological or physicochemical effluents. it removes % of fecal coliforms, salmonella, pseudomonas aeruginosa and enteroviruses, - % of protozoan cysts (giardia, entamoeba coli, and e. histolytica), and - % of helminths eggs. efficiency can be increased to easily reach % if coagulants are added . for helminth ova removal, rapid filtration is performed in silica sand filters with . - . mm media size, a bed depth of at least m and filtration rates of - m m À h À . the helminth ova content in the effluent is constantlyo . ho l À in filtration cycles of - h for primary effluent (jiménez, . the challenge for any disinfection method is that microorganisms respond differently. efficiency depends on the disinfecting agent, the type and content of microorganism, the dosage, and the exposure time. the water matrix has as well a relevant influence, which becomes more important as its concentration and complexity increase. the most common disinfection processes for wastewater are chlorination, ozonation, and uv-light disinfection. . chlorination. it is the most widely used process to control microorganisms. it is effective for the inactivation of bacteria, less so for viruses and protozoa, and not at all for helminth eggs. with regard to virus and bacteria, chlorine has inactivation efficiencies of up to - log. however, chlorine is a very reactive agent and, therefore, before attacking microorganisms, it reacts with many substances contained in wastewater, in particular with organic matter, hydrogen sulfide, manganese, iron, nitrites, and ammonia. as a result, chlorination is a process that, in order to be efficient, needs to be applied at the end of treatment schemes to avoid interferences. if, in treated wastewater, ammoniacal nitrogen and organic matter are still presented, chloramines and organo-chlorinated compounds are formed. these are compounds that increase cancer risks. notwithstanding such risks, it is always preferable to chlorinate wastewater as microbial diseases have faster and often more dramatic health effects (jiménez, ) . . ozonation. ozone is very effective at inactivating viruses and bacteria. it inactivates - log concentration units in a very short time, provided there is a low demand for oxidizing agents by wastewater. there is abundant information in the literature concerning the design and operation of the processes. required ozone doses for several microorganisms are also available in the literature but, frequently, they are not affordable. as happens with chlorine, by-products generated during ozonation are a source of concern as many of them have been reported in the literature as toxic (jiménez, ) . . uv light. nowadays, uv-light disinfection closely competes with chlorination because it does not generate by-products that are too costly to remove from wastewater. besides, compared to chlorination, uv light does not need storage facilities, does not imply the handling of hazardous chemicals, and uses very small-size treatment tanks as disinfection contact times are very small (in the range of seconds or minutes). furthermore, due its simplicity of operation and high adaptive potential, it is suitable for rural and isolated communities. . . . sanitation and wastewater treatment costs figure presents estimated cost for different sanitation options, including from basic sanitation system to wastewater treatment plants. simple services certainly are much cheaper to provide, but they do not necessarily represent what the society wishes to have due to the comfort level. as cost is an important barrier to spread sanitation services, one would expect that these data is a well-known parameter. despite this, in many developing countries there are no reference costs, as exist in developed ones. as result of this situation, in many bids, costs are established using international data that do not necessarily reflect the local conditions (table ) . differences are due not only to build the sanitation facilities but also for the use of fuel and electricity, two important inputs to operate wastewater treatment plants. sludge management and disposal ( figure ) is another source of different affecting costs ( figure ). table also shows that the cost of emptying onsite sanitation systems is not negligible. the selection criteria for wastewater treatment processes are presented in table , emphasizing the needs of developing countries. after treating wastewater, the next step is its disposal. recently, some researchers have suggested (asano, ) to use the term 'dispersion' instead of 'disposal' in order to change the perception of getting rid of used water, but this term has to an extent the connotation of wanting to dilute a problem. in this chapter, the term 'reintegration' is introduced in order to emphasize that water needs to be returned to the environment or used once again (reuse). by reintegrating the water to the environment, the responsibility of using it and then restoring it back to the environment in a proper way may be realized. as, well water can be reintegrated into the hydraulic cycles in which is been used by the society, thus reducing the negative impact of extracting water from the environment beyond the amount needed for ecological use (environmental flow). water can be reintegrated to the environment by discharging it to the soil or into water bodies. in the following, different ways to reintegrate used water are discussed. this is followed by discussing the reintegration of water through reuse. soil reintegration (disposal) consists of discharging treated or nontreated water into land. as discussed in the section . . . the soil may act as a treatment step if a proper management is provided. the options to reintegrate treated wastewater into the environment are presented below. after discharging used water to soil, it will be evaporated, infiltrated, or will percolate to reach surface or groundwater bodies. the extent of each of these will depend on the soil and local conditions. they are used mostly for on-site sanitation effluents. they consist of a trench in which partially treated wastewater is discharged to allow its infiltration to the subsoil. the seepage in the trench allows uniform disposal of the wastewater over a given area. the leach drain is often filled with gravel or highly permeable material and a perforated pipe -from which used water is distributed -is placed in the centre at about . m beneath the soil surface. the perforated pipe is typically around . m in diameter (hughes et al., ) . the size of the trench depends on the wastewater load and the soil type, groundwater depth, and precipitation. leach drains are not recommended disposal options if the groundwater table is close to the surface (e.g.,o . m depth) or the soil has low permeability (e.g.,o mm d À ). they are convenient where soil is highly impermeable (e.g., clay) but can also be used in permeable soil from where water is both evaporated and infiltrated. in each case, plants are positioned to increase evapotranspiration and to remove nutrients from wastewater. if a limited area is available, evapotranspiration beds can be used in conjunction with a seepage trench. to increase dispersal of the wastewater throughout the whole bed, perforated pipes surrounded by gravel are used. the design of the bed should ensure it is large enough to hold wastewater loading and pluvial precipitation while, at the same time, providing sufficient water and nutrients to plants (hughes et al., ) . soil disposal can be coupled with soil treatment in the soil aquifer treatment-aquifer storage recovery system (sat-asr). an aquifer storage recovery system (asr) consists of holding water in an appropriate underground formation, where it remains available in such a way that it can be recycled by extraction when needed. an asr can have several objectives, some of which are (dillon and jiménez, ; jiménez, ) temporary or long-term storage; decrease of disinfection by-products; reestablishment of underground water levels; maintenance or improvement of underground water quality; prevention of saline intrusion; deferment of expansion of water supply systems; aggressive water stabilization; hydraulic control of contaminant plumes; and compensation of soil salinity lixiviation. the major advantages of underground storage is that evaporation losses are considerably lower than dams (b %) and do not have the eco-environmental problems associated with them (dillon and jiménez, ) . aquifers can be an economical option to reintegrate water to the environment in arid and semi-arid countries where it remains available for future use. they are also convenient in densely populated urban areas where, besides storing treated water, aquifiers can store stormwater runoff. effluents from treatment plants can be used for the augmentation of surface water bodies, in which the effluent is diluted with freshwater and reused as a source for water. the water quality of receiving water should be preserved to facilitate a safe water supply. for this, it is important to control pollutant content in the effluent, notably pathogens, organic matter, and nutrients (especially for surface water bodies with slow flow). two aspects need to be monitored: oxygen depletion in rivers and eutrophication in dams and lakes. to avoid oxygen depletion, biodegradable organic matter needs to be removed before introducing the wastewater. there is considerable literature available concerning this aspect as it has been the main target for most wastewater treatment processes. control of eutrophication is achieved by removing n and/or p from effluents; this is an operation costly to perform in wastewater treatment plants for most developing countries. as an alternative, land treatment can be used or treated wastewater used first for agricultural irrigation recovering it from the agricultural drainage before sending it to on lakes. eutrophication of dams and lakes is a frequent problem in developing countries; alternatives for its control are discussed in box . reuse is another option to reintegrate water to the environment but through its use. due to the increase in the human population and the increased use of water for almost all human activities, water is becoming scarce and new tools are needed to use it better. such tools are ( ) the efficient use of water (using less water for the same activity -this is beyond the scope of this chapter) and ( ) water reuse. water reuse is a key component to alleviate the mismatch between water supply and water demand. at the global level, water availability is of around m inhab À yr À but with important variations at a regional, national, and local level. for instance, it is estimated that around million people ( % of the total population) in countries live in areas with less than m inhab À yr À . by the year , % of the total world population will live under such water stress, increasing to % (in countries) by the year (undp, ) . as shown in maps , , and (annex ), most of the affected people live in developing countries. for these countries, three aspects can be highlighted concerning water stress and water demand. first, water is needed for economic development and a better quality of life (even if industrialized countries are not completely making an efficient use of water; they use - times more water than developing ones (un/wwap, ) ). second, agriculture is the dominant user of water worldwide, but, in addition, for developing countries, agriculture is usually the criteria for selecting wastewater treatment operation and processes must be evaluated based on past experience, data from full-scale plants, published data, and from pilot and full-scale plant studies. if few data or unusual conditions are encountered (atypical wastewater characteristics) pilot plant studies are essential. for developing countries: -since much less experience is available, a good wastewater characterization is needed as well as a request during bids that the applicability of the processes should be demonstrated before construction. -bids should encourage operating at lower costs at the same pace the process is optimized. -technology complexity need to be in agreement with the type of community being served: rural areas, rural isolated areas, small urban towns, large towns, and megacities (low-, middle-, and high-income urban and periurban areas densely or dispersed populated). -possibility to combine treatment technologies with soft intervention methods (management). performance needs to be expressed not only in terms of the effluent quality but also on its allowed variability, and both must be consistent with the effluent discharge requirements and the possible use of treated wastewater. performance needs also to be considered in terms of its reliability, as it may vary according to the process type. reliability is very important when the effluent is to be reused or treated water is to be discharged into sensitive aquatic environments. performance should be verified in terms of the disinfection needs locally required. consider wastewater characteristic variations in probabilistic terms. consider wastewater variability in terms of climate change impacts and climate variability. for developing countries: -it is important to have a statistically representative wastewater characterization considering parameters not only defined in norms but also those that might interfere with the treatment processes or the future use of treated water. -design data should not be based on bibliography data, especially that coming from other countries. -since segregation and pretreatment of industrial discharge is not common, there are high chances that the wastewater to be treated will contain inhibiting constituents. an evaluation of these is important but not as intensive as the one required for the characterization of the targeted treatment parameters. -consider wastewater quantity and quality possible variation if programmes to reduce water consumption (such as the use of water less toilets) are to be implemented. achievable performance needs to be expressed in statistical terms and in short and long terms, taking into account water flow and wastewater quality variations. for developing countries: -unusual situations and emergencies are common. selecting robust albeit more expensive processes might be cheaper long term, both economically as well as in terms of the negative effects that malfunctioning can produce. reactor sizing is based on the governing reaction and kinetic coefficients. if kinetic data are not available, process loading criteria are used, but not always with good results, even in developed countries. -most of the available information used in the design of biological process comes from the developed world, where wastewater and climatic conditions, among others, are different, and so bibliographic kinetic data and load criteria use should be avoided as much as possible. -for coagulation-flocculation process doses and mixing conditions determine at laboratory conditions are essential to minimize cost and sludge production. -for disinfection processes conditions need to be determined or checked up using laboratory data -if experimental data are not available, the adjustment of published data to local conditions, such as pressure and temperature, should always be checked in bids. the process should be matched to the expected ranges of flow rates. moreover, whenever possible, considering the presence of stormwater, notably considering impacts of climate change. for developing countries: -for those located in regions with high pluvial precipitation concentrated in short periods of time, treatment processes must be able to deal with flow and major variations in quality. -alternatively, the use of flow equalization tanks and their cost should be considered. -processes that can be operated as modules than can be easy to start should be preferred to match variable influents in terms of quantity and quality. the types and amounts of solid, liquid, and gaseous residuals produced must be estimated. use pilot plant studies to identify and quantify residuals. continued for developing countries: -by-products and wastewater treatment residues are often disregarded in proposals in order to offer a lower operating cost. to avoid this, it is important to clearly state in bids that any residues must be quantified and the management options considered within costs. design, operation, and maintenance must have the same degree of investment and complexity of its management as that of the wastewater treatment. for developing countries: revalorization of sludge as biosolids (treated sludge) for soil fertilization, erosion control, or land remediation are to be considered as a priority. for urban areas, use of biosolids to cover landfill cells can be an interesting disposal option. temperature affects the reaction rate of most chemicals and biological processes; therefore, local water temperature should be taken into account when selecting a processes. for developing countries: -in most developing countries temperature is relatively high, so problems arise due to high temperatures not low ones. high temperature may accelerate odor generation and also limit solubilization of gases such as oxygen. in densely populated urban areas, temperatures may rise even more than expected due to the 'heat islands' phenomena. environmental factors, such as prevailing winds, may restrict or affect the use of certain processes, especially where odors are produced near residential areas. a wastewater treatment plant may have negative impact on the environment if not properly designed. the disposal site restrictions of the treated wastewater need to be considered regardless of the norms to be met. water reuse can be a way of making wastewater treatment more attractive in economic terms. for countries located in water-stressed areas, besides being ecologically sound to reintegrate water to the environment as disposal option, reuse serves to alleviate water scarcity. for developing countries -land degradation is costing - % of their agricultural production (young, ) and fertilizers have often a prohibitive cost for farmers; in both cases, biosolids can be used to remedy these problems. wastewater treatment plants are often accompanied by ancillary (complementary) processes that do not necessarily directly relate to the wastewater treatment process, such as power plants, special storing facilities for reagents, etc. it is important therefore to know, before selecting a process, what are those needs, their cost and viability to obtain them from the local market. the type and amount of chemicals to be used need to be considered as well as their cost and market availability, both now and in the future. if chemicals are added during the treatment of wastewater or sludge and these are to be reused, their selection needs to be compatible. for developing countries: -although the use of chemicals is often prohibited, an economic comparison is worth making, especially if chemicals are locally available. the present and future cost of the energy used is something to consider. in selecting and designing wastewater treatment plants, the location, efficient use of energy, and the possibility of recovering/producing energy for in-plant use must form part of the selection criteria that in the long term will contribute to properly closing the urban water cycle. the energy foot print of the wastewater and sludge treatment plant should be minimized to contribute to the reduction of ghg (greenhouse gases). the amount of people as well as their skill levels need to be well defined. for developing countries -the most common situation is a high availability of low-skilled personnel working for low salaries. thus, selected processes may have a high labor demand but cannot be very sophisticated. alternatively, intense training programs should be considered; nevertheless, high indexes of personal rotation are frequently experienced in developing countries when personnel are trained. define operational needs under routine and emergency conditions. define the type and need for repairs. it is important that the items selected be compatible for efficient operation. for developing countries: -it should be considered that cheap or obsolete equipment may become costly if frequent repair is needed. -equipment and spare parts must be available within an appropriate period of time. obsolete equipment is very difficult to repair. main source of income and the main mean to feed a growing population. third, the increasing demand for water by municipalities and industries is increasing the competition for its use with farmers. it is estimated that, in developing countries, water withdrawals will increase more ( %) than in developed ones (undp, ) . among the uses demanding water, sanitation needs to be considered and, in that respect, water reuse may be a component in some areas to promote it through the alleviation of water demand, saving water for sanitation facilities or through coupling projects to treat wastewater with reclamation ones. two types of water reuse can be distinguished: nonintentional and intentional or planned. as, in several developing countries, lack of sanitation is generating nonintentional reuse, national policy will need to encourage controlled options -normally, few items are produced or available locally, therefore overall equipment selection needs to consider compatibility between different equipment traders. many treatment plants will need to adapt to future conditions and not all systems have the same capability to be adapted. cost evaluation must consider initial capital cost and long-term operating and maintenance costs. the plant with lowest initial capital investment may not be the most effective with respect to operating and maintenance costs. the nature of the available funding will affect the choice of the process. it is important to consider the size of the selected treatment process with respect to available land, including buffering zones for future expansions. for developing countries: -there is not always land or cheap land available, as frequently believed. -considering the fast growth of cities in the developing world and the possibility of building plants in modules, it is very useful to consider buffering zones to increase treatment capacity, complete the treatment process or even to avoid building human settlements near to the facilities. communities reject systems producing foul odors or vector breeding. communities also tend to more readily accept natural process that are integrated with the landscape. low-income communities accept better technologies that are a source of jobs for local people than rich ones. eutrophication is a process in which plants (such as water lilies or hyacinths (eichornia crassipes), hydrilla (hydrilla verticillata), cattail -(thypa sp.), and duckweed (lemna sp.)) proliferate in surface water bodies due to the presence of high concentrations of phosphorus and/or nitrogen that may come from wastewater, treated effluents, or agricultural runoff. it is commonly observed in polluted lakes or dams, but problems in low flow rivers and agricultural canals have also been observed. aquatic plants cover the water surface preventing sunlight and oxygen from entering the water. other negative effects that are provoked are ( ) oxygen depletion in the hypolimnion; ( ) release of fe, mn, nh , and heavy metals from the sediments; ( ) vector breeding, such as schistosomas and mosquitoes; ( ) loss of biodiversity, especially in higher trophic levels; ( ) displacement of native species, ( ) obstruction of hydroelectric plants and irrigation canals and drains; and ( ) restrictions on tourist, recreational, and fishing activities. to reduce aquatic weed density (plants m À ), five methods are available: * biological control. it consists of using living organisms to control weeds. in theory, it is a cheap option as no equipment or chemicals are required but it has an associated labor cost in order to perform maintenance. to be completely effective, the rate of grazing needs to be higher than the plant growth rate, which is very difficult to match in practice. a wide variety of fish, arthropod, fungi, and bacteria have been used for this purpose. * mechanical control. these methods remove or cut weeds into pieces using mechanically or manually operated equipment. it is an expensive option that can play a role in quickly reducing the extent of infested areas prior to the application of another control method. * chemical control. pesticides are also used to control weeds. some substances that have been used are terbutryn, diquat, , -d, glyphosphate, paraquat, and simazine. however, due to their toxicity, they can only be applied under controlled conditions and for a limited period of time. * water level control. in this method, the water level is decreased so the weeds located close to the edges of the water body dry out. the applicability of this method is limited to dams where water levels can be controlled, and to the dry season in which rain would not convey plants once again to the water. * nutrient control. weed growth is caused by high n or p content in water, and so, lowering their concentration through wastewater treatment is another alternative. unfortunately, the cost remains high. due to their low efficiency or cost implications, in practice, two or more methods are often used to control weeds. instead of promoting practices to start up water reuse. this is the biggest difference with developed countries, where reuse is being promoted once wastewater is treated. in literature, water reuse is considered merely as an activity where wastewater is intentionally treated to be used once again. therefore, water reuse is understood as an artificial man-made practice. however, unintentional reuse also exists as part of the natural hydrological cycle, but this is frequently not acknowledged. (jiménez, a) . 'nonintentional', 'nonplanned' or 'incidental' water reuse describe situations where used water is mixed with (or becomes part of) the water supply. in most cases, this unplanned reuse is difficult to identify, although it would be important to acknowledge it in order to properly control it. the nonplanned use of water is at the origin of the presence of emerging chemical pollutants in water sources and the reason why drinking water standards are becoming increasingly comprehensive and stringent and more sophisticated technologies to treat water are needed (jiménez, b) . nonplanned reuse of wastewater is happening for agricultural irrigation, aquifer recharge, and human consumption. . nonplanned reuse for agriculture. three-quarters of the total irrigated area worldwide is located in developing countries, and, as a consequence, there is a high dependence on water for food production. frequently, due to lack of sanitation in these countries, wastewater is used to irrigate land. this is a practice that happens almost naturally because of the combination of the high demand for water for irrigation ( % of total use compared to only % in developed countries, figure ), the availability of wastewater, the productivity boost that the added nutrients and organic matter provide, and the possibility to sow crops all year round (jiménez, ) . it is estimated that at least million hectares in countries (around % of irrigated land) are irrigated with raw or partially treated wastewater (who, ) . approximately one-tenth of the world's population consumes crops irrigated with wastewater, diluted or not. as an example, in hanoi, vietnam, wastewater is used in the production of % of the vegetables consumed locally (ensink et al., ) . the use of nontreated wastewater is also common for urban agriculture, which is practiced in urban and periurban areas of arid or wet countries where there is local demand for fresh food products, and people live on the verge of poverty with no job opportunities (jiménez, b) . for urban agriculture, wastewater flowing in open channels is used to irrigate very small urban plots of land where trees, fodder, or any other product that can be introduced to the market in small quantities (flowers and vegetables) or be used as part of the family diet are grown (ensink et al., ) . in terms of volume, reuse of nontreated wastewater is at least times higher than of treated wastewater (jiménez, ; jiménez and asano, ) . as a consequence, any sanitation project in localities using wastewater should consider its actual use. . unintentional reuse for water recharge. since groundwater is not water that can be observed as in lakes or dams, very often its pollution and nonintentional recharge is not perceived. infiltration may result from agricultural irrigation, leakages from wastewater and water urban networks, unlined dams, tanks or reservoirs, and on-site sanitation systems. little information on the extent of this problem is reported in literature, but some cases (a summary is presented in table ) have been described highlighting the importance of this phenomenon as a source of water supply. for the one referring to the tula valley, it has been the best documented (jiménez, b ) that recharge with wastewater amounts to at least m s À , and the aquifer is used to supply people. infiltration and pollution of groundwater supplies varies from negligible to severe, and the recognition of unplanned reuse is needed in order to advance understanding of how to manage the risks. this may involve continuing groundwater recharge with water of improved quality and/or separating the recharge areas further from points of water abstraction. appropriate monitoring information will allow the most cost-effective investments to be identified (dillon and jiménez, ) . . nonintentional reuse for human consumption. nonintentional reuse for human consumption occurs as described previously, not only through aquifer recharge but also through surface water sources when effluents, treated or nontreated, are discharged into them. this has been documented in developed countries. for instance, in the river thames in england, during dry periods, % of the water used as supply downstream comes from treated effluent. in california's santa ana river, a large part of the supply consists of treated wastewater (gray and sedlak, ) and in berlin, - % of the city's water supply comes from an advanced treated effluent that is discharged to a nearby water supply (jekel and gruenheid, ) . the increasing evidence of the presence of emerging contaminants in water sources is an indication of the nonintentional reuse of water. information on this subject for developing countries is very poor, and possibly only reported as pollution cases. recognizing the nonintentional reuse of water for human consumption will help society to acknowledge that water reuse is unavoidable in the future and also to understand that, to properly reintegrate used water to the environment is needed. for this, tools other than wastewater treatment plants will be needed. according to asano ( ) , wastewater reclamation involves the treatment or processing of wastewater to make it reusable; and wastewater reuse or water reuse is the beneficial use of treated water. planned reuse may be performed for agricultural irrigation, industrial purposes, environment restoration, and municipal uses. . reintegrating water for irrigation. most of the world's poorest people, million to billion rural people, live in arid areas and depend directly on natural resources, including water, for their livelihoods (dobie, ) . in such a context, safe wastewater reuse can be a sanitation option that could also be coupled with food security and economic development goals. under prevailing land and water management practices, a balanced diet represents a depleting water use of m inhab À yr À , which is times more than the l inhab À d À required for basic household water needs (siwi-imwi, ) . for several middle-and low-income countries, agriculture is currently, and will continue to be, a key sector representing % of export earnings. limited and unreliable access to water is a determining factor in agricultural productivity in many regions, a problem rooted in rainfall variability that is likely to increase with climate change (lenghton et al., ) . to feed this sector, water reuse can be one option. planned reuse of water for agricultural irrigation in developing countries is a convenient strategy for many reasons (jiménez and garduñ o, ; jiménez, jiménez, , a who, ; keraita et al., ) , such as • it is an easy option to increase controlled reuse when nontreated wastewater is already in use as it allows more profitable and safe products. • it can be a low-cost option to manage wastewater and to reintegrate water into the environment. • it allows the reclamation of nutrients (n and p, to increase soil fertility) and organic matter (to improve soil characteristics) at no cost. • particularly in (but not limited to) arid and semi-arid areas, it permits higher crop yields, as it allows crops to be sown year-round due to higher water availability. • due to the availability and reliability of water, crops with better profitability can be selected. • it avoids discharging pollutants to surface water bodies (which have a considerably lower treatment capability than soils). • it is possible to recharge certain type of aquifers through infiltration. • it can be part of a strategy to secure food and increase poor people's income in water-scarce areas. to obtain all the advantages from reusing wastewater for agriculture in planned projects, it is important ( ) to control possible negative effects (jiménez, ; who, ) such as those related to health; ( ) to keep in mind that in many cases nontreated wastewater is being reused at low or even no cost by poor farmers and, hence, they will be unable to afford reuse costs; and ( ) from the legal aspect, the historical use of nontreated wastewater by farmers confers riparian rights. . reintegrating water for industrial reuse. industrial reuse (reclamation of wastewater from a different use, i.e., reuse of a municipal effluent for industrial cooling) differs from municipal and agriculture reuse as it involves the private sector that has its own rules and well-defined needs driven by economic factors (jiménez and asano, ) . before reusing water, industries always prefer to implement watersaving projects as these immediately reflect on their budgets; for reusing water, investments to provide proper treatment and monitoring programs are needed. to promote industrial reuse, the best government strategy is to provide incentives rather than setting compulsory regulations (jiménez and asano, ) . among the different industrial reuse options, cooling is the most popular due to its high water demand, and the possibility of using secondary-treated municipal effluents, sometimes coupled with filtration or softening processes. as a consequence, power plants located near urban areas are potential sites of industrial water reuse. . reintegrating water to the environment. more than . billion people live in river basins where the intense use of water threatens freshwater ecosystems (smakhtin et al., ) . reintegrating water to the environment is a practice that is gaining momentum, as it is being recognized that ( ) the environment needs water and ( ) the environment has the same entitlement to water as other uses. unfortunately, these two aspects are better recognized by developed countries than developing ones. overuse of water tends to occur in regions heavily dependent on irrigated agriculture or where there is rapid growth of densely populated areas (undp, ) , two characteristics common in developing countries. among the more prominent examples (undp, ) of water overuse, the exploitation of the yellow river basin, in northern china, can be cited: human withdrawal currently leaves less than % of the flow remaining in the river. the river ran dry km inland for a record days in . the drying up of the river caused a drop in agricultural production averaging . - . million tons a year, with losses estimated at us$ . billion for . the purified effluent from sewage treatment plants can be used for the augmentation of river flows, to raise the level of wetlands or lakes, to recover dried lakes, or even to create new lakes or wetlands. in doing so, biodiversity may recover. care must be taken when restoring water into water bodies to preserve or improve the actual quality of water. used water reclamation can be combined with rainwater reclamation. water reuse with environmental restoration can be coupled with projects of urban image improvement or programs to provide better facilities at recreational areas. . restoring water to aquifers. aquifer recharge is not, itself, a use of reclaimed water but is often part of the pathway to reuse. it is a convenient way to reintegrate water into the environment but can be used only under certain circumstances related, in particular, to the type of soil and groundwater. aquifer recharge can be performed to recover groundwater levels, to control saline intrusion, to augment drinking water sources, to protect and, in some cases, to improve underground water quality, to protect surface water bodies from contamination by effluents, to increase water availability for any use, and simply to store water for the future (dillon and jiménez, ; corrleje et al., ) . intentional recharge with reclaimed water can play a role in providing balanced storage and supplemental treatment for water (bouwer, ; dillon and toze, ) . it also provides low-cost storage that occupies a minimum of valuable urban land, while stored water is protected from pollution and evaporation. there are two methods to recharge aquifers. the first is known as land-spread infiltration where treated wastewater infiltrates through soil by gravity. this option has relatively low operating and maintenance costs. the second method for recharge is direct well injection. in this option, wells are used to convey a highly treated effluent directly to aquifers. regulation to recharge aquifers are very different from one country to another; some are set at a national level while others are defined using a case-by-case approach (jiménez, ) . most of the projects to recharge aquifers are found in developed countries. in developing ones, some examples are found in atlantis, south africa (for drinking and agricultural purposes, using pond infiltration), in windhoek, namibia (for drinking purposes and using injection wells), in new delhi, india (for irrigation using infiltration ponds for treated urban wastewater and stormwater), in beijing, china (for drinking purposes using wells and recharge basins), and in mexico city, mexico (for drinking purposes on a limited scale and using infiltration ponds; dillon and jiménez, ) . in all these cases, wastewater is treated to at least at a secondary level (see section titled 'relevant websites'). . reintegrating water for municipal use. in years, % of the world's population will be living in cities (un, ) . this being the case, more water will be needed for municipal use and, at the same time, more municipal wastewater will be produced. this situation, therefore, represents an opportunity to increase municipal wastewater reuse. water reuse in cities represents an opportunity to conveniently treat wastewater, with environmental and even economic advantages. opportunities to reuse wastewater in cities are classified into two groups: ( ) those demanding relatively low-quality water and involving low health risks, and ( ) those demanding high-quality water where health risks are high. in the first group, there are several types of uses, such as: (a) the filling of recreational lakes or the operation of fountains; (b) car, truck, or street washing; and (c) green area irrigation. options demanding high water quality include reuse for drinking supply. around the world, there are successful examples of both types of reuse, low risk options being the most common. water reuse for human consumption, although less common, is no less important. moreover, the only two examples of the reuse of water for human consumption in the world are notably from two countries from the developing world: namibia and singapore (box ). graywater (i.e., domestic wastewater not containing toilet wastewater) is more accessible for reuse as it is less contaminated than wastewater, notably in terms of (but not limited to) pathogens. typical sources of graywater are bathing, laundry, dishwashing, and food preparation. due to its comparably low and easily degradable contamination, it can be relatively easily treated for reuse. graywater reclamation entails the production of less wastewater to be treated in centralized plants. graywater reuse is performed at the same facilities where it is produced and, as a result, a short storage time is needed ( day retention time). graywater reuse can be performed individually (for a single home) or collectively (several groups of houses or larger buildings). treated graywater may be used for watering plants, kitchen gardens, and for the safe augmentation of ground-or surface water. treatment can be very simple or highly sophisticated, ranging from simple manually operated sand filters to biomembrane reactors, hence, covering the needs for rural areas or buildings located in upmarket areas in megacities. further details on design and operation can be found in correlje and schuetze ( ) . graywater reuse can be as well an important component for basic sanitation, as described in section . . . . as the quantum of wastewater treatment is still low in developing countries, little information is available concerning the actual situation. leblanc et al. ( ) performed a survey in some countries showing that the tendencies are the following: . for middle-income countries. from information coming from middle-income countries, including africa (namibia and south africa), the middle east (iran, jordan and turkey), asia (china and russian federation), and latin america (brazil, colombia and mexico), it is shown that wastewater treatment facilities serve mostly urban areas using preliminary, primary, and, in some cases, secondary processes. for rural or poor periurban areas, basic sanitation facilities are provided. although sludge is produced in these facilities, this is not always managed as part of the sanitation service. the disposal options for the sludge from wastewater treatment plants produced are landfill dumping, dumping into sewers, storage at wastewater treatment plants, land application, and agricultural reclamation. land application and agricultural reclamation are options limited by space problems, while the use of landfills is restricted in densely populated urban areas, where solid wastes compete for space with sludge. as sludge production is still low in the few wastewater treatment plants available, sludge management policies are novel, and are still in a maturation phase. some of these policies offer new approaches different to those used in developed countries (leblanc et al., ) . with regard to fecal sludge, the main constraint for their management is the cost to empty on-site sanitation systems as these are often located in inaccessible areas, are large in number, and are frequently highly dispersed. it is noted that the high cost of latrine emptying is not sustainable, even for large municipalities. extracted fecal sludge is often buried on-site, dumped into landfills or sewers or sent to uncontrolled discharge sites. discharge of sludge and fecal sludge in sewers often lead to surpass the wastewater treatment plants' capacity when available. . for low-income countries. data from different african countries (burkina faso, cameroon, cô te d'ivoire, ethiopia, mali, mozambique, namibia, nigeria, senegal, and south africa) demonstrated a similar situation focused on the need to provide basic sanitation services either in rural or urban areas. few cities have complete sewerage systems and, when available, sewers frequently feed into partially functioning wastewater treatment plants. in these countries, the use of on-site sanitation systems, such as septic tanks, bucket latrines, pit latrines, and dry latrines, produces fecal sludge, which is often 'contaminated' with domestic waste. in dense informal settlements, the challenges to properly handle fecal sludge are significant as besides the technical constraints other factors related to the social, political, and cultural aspects come into play. fecal sludge handling includes the need to provide reliable and low-cost options to emptying the facilities, to provide proper and affordable treatment and transportation, and to have suitable sites for safe disposal. literature exists concerning the alleviation of sludge and fecal sludge disposal and revalorization problems, not all of which is relevant for developing countries. common issues in box reuse of wastewater for human consumption in namibia and singapore windhoek, namibia, has been reusing wastewater for human consumption for more than years (van der merwe et al., ) as result of an original idea in . since its operation, no measurable health risk has been observed and neither have people drinking reused water displayed associated health problems. the reclamation plant has undergone several modifications to improve the technology used. the quality of the water supplied can be consulted every day in the local newspaper. the amount of water reused is around ls À , which is distributed after dilution by a factor of - with first-use water. the monitoring program for the facility represents % of the operating costs, and is performed by the wastewater treatment plant and also by three independent laboratories. the system is operated using a multiple barrier concept that goes beyond the wastewater treatment plant. the astute words ''water should be judged by its quality; not its history'' are attributed to dr. lucas van vuuren (van der merwe et al., ) , one of the pioneers of the windhoek reclamation system. this refers to the fact that fear of reused water should be based on rational aspects. the other example of direct reuse of wastewater for human consumption comes from singapore (funamizu et al., ) and is known as the newater project. it started in and uses a secondary effluent that is further treated with a membrane system (microfiltration (mf) and reverse osmosis (ro)) and uv-light disinfection. the water produced is cleaner than tap water as it fulfills all the requirements set by us-epa and who for drinking purposes. treated water is channeled to a reservoir, from which it is taken as supply after dilution with first-use water. water is distributed through the network for use for domestic and industrial purposes. when the newater project was launched, it operated at a rate of l s À . this will be progressively increased to reach l s À by (b . % and . % of total water consumption, respectively). in both cases, namibia and singapore, before the implementation of the reuse programs, stringent industrial pre-treatment programs and segregation of industrial effluent from the sewer were put in place. properly managing sludge and excreta in developing countries are as follows (leblanc et al., ; jiménez, • conventional sludge and excreta treatment options used in industrialized countries do not necessarily achieve the levels of pathogen inactivation required for its safe reuse. • nutrients, organic matter, and energy are resources available in fecal and wastewater sludge that should be utilized as best as possible. there are examples around the world showing the feasibility and convenience of reclaiming them. • applying properly treated excreta and biosolids to soils in a safe way can contribute to soil fertility and with it to food security; it can also raise income for poor farmers. • proper management of excreta and wastewater sludge can significantly reduce releases to the atmosphere of potent greenhouse gases such as methane and contribute to carbon sequestration in soils. the mdg target stating ''reduce by half the proportion of people without sustainable access to safe drinking water and basic sanitation is considered under goal : ensuring environmental sustainability'' (box ). therefore, sanitation is to be provided in a sustainable framework which, in practice, means to provide a service comprising much more than was expected in the past. to implement it, a proper policy is needed. in order to consistently provide sustainable water services, it is recommended that an integrated water resources management (iwrm) approach is used. this approach is useful to analyze situations such as when • multiple barrier system comprising solutions that go beyond the construction of wastewater treatment plants need to be implemented to protect health and the environment; • sanitation needs to be provided as a tool (sometimes indispensable) to have clean water supplies and to provide a safe water supply (box ); • sanitation is coupled with projects contributing to food security, job opportunities, increases in exportation, soil erosion control, efficient use of water, etc.; • sanitation needs to be provided over a wide area rather than to a single section of it to effectively control negative environmental impacts; • sanitation needs to be part of a three r concept system (reduce, reuse, and recycle); • sanitation is considered as part of a cycle in which wastewater is properly reintegrated to the environment; • sanitation needs to consider the impacts caused by climate change; • projects need to be designed, operated, and/or managed by different institutions, sectors, basin agencies, or even countries; box what does sustainability mean? ''a process that promotes the coordinated development and management of water, land and related resources, in order to maximize the resultant economic and social welfare in an equitable manner without compromising the sustainability of vital ecosystems'', un-water, according to leblanc et al., , elements defining sustainability are * dealing transparently and systemically with risk, uncertainty, and irreversibility; * ensuring appropriate valuation, appreciation, and restoration of nature; * integrating environmental, social, human, and economic goals in policies and activities; * providing equal opportunities and community participation; * conservation of biodiversity and ecological integrity; * ensuring inter-generational equity; * recognizing the global integration of localities; * a commitment to best practice; * avoiding net losses of human or natural capital; * implementing principles for continuous improvement; and * providing good governance. bissau, guinea, in west africa is a city attracting huge numbers of people from the surrounding countryside. most of them have settled in squatter new areas around the old colonial center. during a study performed in the s, it was found that the newly piped water taps ran dry several times per day. as a result, many people returned to the old wells. these were often more contaminated than before because the new pit latrines installed close to the wells polluted the groundwater. groundwater quality was also impacted by solid waste thrown into the pits dug for the production of adobe blocks to build new houses. moreover, the new network of gutters was now efficiently removing most of the clean rainwater that used to recharge the groundwater. the gutters caused an extra problem. on the edge of the settlements, where the gutters ended, storm water peaks caused serious soil erosion. this created problems for a newly developed scheme of vegetable gardens on the urban fringe, and even threatened houses.the original problem -the lack of water in piped water taps -was related to electrical power failures causing water pumps to stop. similar situations can be encountered in many developing countries and they cannot be easily solved as long as their roots are not properly and integrally tackled. • good technical solutions needing proper social, economic, and political policies are to be put in place; and • wastewater, treated or not, is being nonintentionally reused. developed countries, through experience, research, and technological innovations have progressively improved their sanitation services and have developed systems that are what they need. however, as described in this chapter, the problems they have faced and the problems they are now facing, although similar, are not the same as those confronted by developing countries. thus, there is a need for low-income nations to develop their own processes using part of the developed countries' experience. to contribute to this process, a definition of the issues to address and the challenges to face is provided in the following. the issues that need to be addressed are as follows: • low sanitation coverage lagging behind population growth, needing an intense effort in order to be tackled. • need/importance to couple sanitation programs with others addressing problems such as food security, low income, and soil erosion control. in practice, this requires increased efforts of coordination. • lack of sanitation as a component of poverty, and therefore, as a problem that cannot be completely solved if its roots are not properly addressed (box ). • lack of sanitation, particularly in vulnerable groups that, due to their own characteristics, are often more difficult to provide services for. • a growing population, notably in urban areas and, within them, in slums. • higher vulnerability to the negative impacts of economic and climatic change on sanitation needs. • for low-income countries, lack of economic capacity to deal with the cost of covering the sanitation mdg targets and, for middle-income countries, the need to mobilize funding required to put sanitation above other needs. • the proper management of sludge and excreta, two byproducts often not considered as part of sanitation targets of funding programs. the challenges to be encountered are listed below: . the lack of political will and commitment at the highest level (who/unicef, ) is a barrier that is greater than, for instance, the lack of economic resources, the capacity for building, or the acquisition of appropriate technology, since all these may be overcome by a strong political support. in order to develop political will, politicians and society need to appreciate the value of sanitation. an understanding that it is through the provision of water supply and sanitation that industrialized countries build up strong societies with good health and good economic conditions is needed (box ). . the second challenge is to put in place accountability mechanisms to ensure that resources provided to fulfill in cameroon, some houses are equipped with a m-deep hole for a latrine, surrounded by pieces of timber. when the hole is full, it is covered with earth and medicinal or aromatic plants, and another facility is built. if the family has no land to dig another hole (as frequently happens), they call the tanker to empty it at a cost of us$ . sometimes, while the family saves up the money, excreta overflows and pollutes the nearby area where wells and boreholes are located, threatening drinking water quality. when feces are removed by tanker trucks, they are often dumped into rivers or the forest, because there are no treatment facilities. houses in modern residential areas have septic tanks, and their effluents are directed into wells for filtration. often, this does not happen in the correct way because builders have not mastered the technology. some collective residential areas, universities, and hospitals are connected to sewers that convey wastewater to a treatment plant, from where treated water is directed to a river. but still, there are people without access to any of the facilities described above who go into the bush to relieve themselves on the spot. villagers continue to use this practice because they have no choice. box clean meansy yy y healthy? mexico city produces % of mexico's gross domestic product (gpd) (us$ per capita). after the swine flu (h n flu) outbreak in may , a loss of us$ million was experienced solely due to the shutting down of restaurants, and us$ . million were lost due to the closure of public transport for just days. to allow the city to return to normal conditions, health experts advised constant handwashing and the disinfection of school toilets. at this point, politicians realized that public schools had no water at all, had malfunctioning toilets and more had no facilities at all. before the swine flu epidemic, politicians had not understood the link between water, sanitation, and health and had not addressed this problem, although on many occasions parents' associations had requested the services. the president of one parents' association commented on the news that, in contrast to most mexicans, he believed that the swine flu had been a blessing as it was the only way to ensure proper sanitation facilities at schools. the mexico city government invested us$ million on the school program 'clean means healthy'. the mdgs (public and private from donors) will be used wisely and for what they were originally intended for. . the third challenge involves a broader aspect. even if sanitation programs are put in place, if poverty is not properly addressed, most of the solutions provided will be unsustainable. this will possibly lead in the future to adding addressing poverty to the already lengthy list of reasons why sanitation has failed in developing countries (this list already comprises financing, institutions, education, the need for decentralization, and the need for private participation). although there is no recipe for success, strategies that can be considered when developing plans for sanitation include the following (jiménez and garduñ o, ; jiménez, jiménez, , lenghton et al., ; undp, ; who, ; leblanc et al., ; correlje and schuetze, ) : to develop policies: • take time to perform proper planning in order to identify the resources (human and economic) needed to design, build, operate, and maintain facilities, and to develop policies and institutions. do not initiate projects for which this has not been previously defined, otherwise there is a risk of losing any investments made (a case in point is the existence of many facilities installed around the world, which have been subsequently abandoned). • take time to define how much money is needed, supported by experts with no commercial interest, specifically not those from companies that are potential participants in bids. • define needs and priorities using the best available information even if it does not come from the water sector. priorities can be set by using the methodology proposed by lenghton et al. ( ) , which considers actual water service coverage, and mortality due to gastrointestinal diseases and density of settlements, considering urban and rural areas. evaluate risks using quantitative methodologies to properly identify and prioritize problems, and select solutions accordingly (in terms of size, and economic and human resource investments). • as much as possible during the planning stage, involve sectors related to the solutions other than the water sector (e.g., the federal, regional, and local governments, ministers of the environment, urbanism, agriculture, land use, transport, economic development, social development, finance, etc.). • couple sanitation programs with programs related to food security, soil remediation, and economic development. • produce efficient, affordable, and enforceable norms and set goals for them that are easy to understand. • promote innovation at all levels (institutional -box -, financial, regulatory, and technological). • combine different intervention methods to control problems; consider not only of sewers, latrines, and wastewater treatment plants. • consider water reuse and the safe reintegration of sludge and fecal excreta as an important part of the overall sanitation program. • promote the management of the environment in an integrated way, even considering climate change effects. • design monitoring programs that wisely use resources by including information that will be used. use the new information obtained to evaluate and improve the program. • review the program to ensure it covers the specific targeted population sectors (women, the poor, rural areas, etc.) and meet the defined goals. for funding: • be creative in finding solutions to funding needs; • extend financial support to the poorest households to ensure that sanitation is an affordable option; • discern whether there is an absolute lack of resources for expanding water supply and sanitation coverage, or if there is a need to redistribute potentially sufficient existing resources; and • develop and put into practice transparent mechanisms to easily and rapidly transfer monetary resources from central to local institutions. for institutional design: • develop national and local political institutions that reflect the importance of sanitation in terms of social and economic progress. • promote institutions throughout government that use or at least understand concepts of integrated management, not only for water. • develop institutions where innovation and solidarity are considered as a virtue. water and sanitation service agencies are typically modeled after utilities in industrial countries, and as such are organized around the goals of maximizing operational efficiency for public sanitation components (trunk sewers and treatment plants) rather than providing services to poor people, slums, disadvantaged groups, etc. as result, in, in developing countries, experience and institutional structures to provide the type of services needed is deficient. as a result, services are being provided by other means. data from india indicate that as much as % of rural households across the country invest their own money and use small private providers to construct latrines. self-provision accounts for about million privately installed septic tanks in manila and in jakarta. research in africa confirms that the role of the small-scale private sector in sanitation provision is significant. these findings are further supported by data from the jmp (who-unicef joint monitoring programme): between and , the increase in the number of people served by sanitation reported by the jmp was much larger than the expected impacts of the public investment that occurred during this period. the reorientation of public programs to either modify their structures or to promote and assist the provision of sanitation services by small private and even familiar companies is needed. this does not currently occur in developed countries. • consider the need to have as part of the institutions welltrained and highly professional personnel. • identify which problems should be addressed by using norms (compulsory), criteria (recommendations), or other type of tools (such as incentives and education). • set appropriate and affordable sanitation risk-based standards, designed to contribute to solving local problems that can be reviewed over time to integrate experience. these should be able to be adapted to new and better conditions in order to move progressively to an ideal situation. • allow the development of norms that are adapted to local needs and capabilities (table ) . sanitation systems are often adopted from other developed countries without sufficient adaptation and users tend to put in place an idealized solution in which a uniformly high level of service is provided and the technology to be used is already set. • set up regulations that combine different intervention methods to control risks that are not based only on wastewater treatment plants. • keep in mind that parameters selected are to be enforced and they will demand economic and human resources for. • review the whole legal framework related to the standard so they can fit in and be implementable. • set up standards using a participatory approach, which includes stakeholders and expert participation, notably coming from local universities. • where noncontrolled reuse is already in place, regulations need to maintain the benefits already obtained while progressively controlling drawbacks; this can be done by promoting controlled reuse rather than adopting vanishing current practices. • incorporate reuse as part of the sanitation standards. to set up programs: • perform a national inventory of the actual needs and solutions to be implemented to manage wastewater, excreta, and sludge, include a survey on water reuse possibilities to couple them with sanitation solutions when feasible. • implement policies by promoting incentives rather than imposing rules and fines; but when rules are to be observed, be firm on decisions, and inform society in order for it to be perceived that jeopardizing the health of others is important. • as there is no universal solution, support a wide range of sanitation technologies and service levels that are technically, socially, environmentally, and financially appropriate. • promote innovation to have both technically and economically feasible technologies to deal with local pollutants, notably for the high and varied pathogen content. • implement pilot plant programs to test policies and use the information obtained to retrofit your program before scaling it up (box ; spaliviero and carimo, ). • empower local authorities and communities with the authority, resources, and professional capacity required. • in order to fund the maintenance and expansion of services, local governments and utilities should ensure that users who can pay, do so. • carry out training programs addressing all stakeholders needs, from plumbers to politicians. some aspects to consider when setting regulations definition of fixed treatment option(s) to use and inclusion of predefined treatment design and operating criteria. -reduces the need for monitoring and surveillance. -limits innovation -renders project implementation easier. -encourages bias in regulators who will be responsible for both selecting the method of control and meeting objectives. -may lead to nonviable schemes from an economic point of view. selection and use of the best indicators as parameters. reduces monitoring and surveillance cost. -introduces the idea that indicators are the best and ideal parameters to define pollution. -most of the current best indicators have been proven effective for developed countries but have not been tested for all conditions in developing countries. -may give a false impression of safety. selection of normal monitoring parameters and establishment of limits for each one. -facilitates surveillance. -cannot be universal or static over time. -increases supervision costs. use of epidemiological local data. -introduce protection for local problems. -information not always available for all of the diseases currently present. use of toxicological tests. -data available internationally. -often render norms too stringent. -helps to establish cause-effect relationship. -for diseases originating from microbial pollution do not correspond to local conditions when diseases are endemic. use of risk evaluation models. -help governments to make rational decisions. -difficult to explain their meaning to the population. • implement programs to segregate and/or pre-treat industrial discharges to sewers to render municipal wastewater treatment more affordable and to avoid the presence of noxious compounds in treated wastewater and sludge that will limit their revalorization options. • as wastewater, sludge, and excreta management regulation compliance often depend on the work of different ministries, coordinate the work of such institutions taking care that the objectives of each are compatible. • develop public indicators to follow up progress globally and also consider the implementation of indicators to follow specific targets such as wastewater treatment coverage, safe reintegration of treated water to the environment, and sludge and fecal excreta management. attention should also be provided to deprived sectors (women, poor people, slums, dispersed rural areas, etc.) • seek to validate your indicators by a third independent party such as a university or a non-governmental organization (ngo). • verify that the same information is provided international, nationally, and locally. to raise support for the program: • make it understandable to all that lack of sanitation means a barrier for economic development is an unsustainable way to manage the environment, is at the origin of local pollution problems, contributes to water scarcity as it reduces water availability, and increases vulnerability and reduces the capacity to adapt to climate change. all of these issues have broad support among society and different groups, not all of which are concerned by sanitation for the poor. • build community-level initiatives through government interventions aimed at scaling up best practice. • create awareness of the nonplanned reuse of wastewater and the importance of investing in it as an option to make clean water accessible for any use. figure shows the investments made for water supply and sanitation from to ; it can be observed that, in the past, most efforts were orientated to water supply and cities, leaving sanitation (only about one-fourth of investments made for water supply) and rural areas far behind. figure shows the origin of investments. in the case of asia and latin-america, almost all the finances have come from governments, while, for africa, it represented nearly a half. from the previous analysis, it is evident that there is need to invest money to catch up with the level of services needed. before calling for funding, it is convenient to analyze (preferably only within each country, without the input of donors or enterprises) what the money should be used for. to sustainably increase sanitation coverage, economic resources are needed not only to build sanitation infrastructure, but also for planning according to local needs and possibilities, developing research and technology, and developing institutional capacity in a local context. unfortunately, most of the time, funding is provided only for some of these activities (mostly for infrastructure); one major reason being that, often, this is the only type of funding that is sought. there are two funding options: public or private, each of which has different modalities. for public funding, the money comes from federal or local governments either directly from tax revenues or user charges, or, indirectly through crosssubsidies from users who can afford to pay, private-sector investment, or international and national loans. private sector box development of a stepwise program in mozambique (with information from spaliviero m and carimo d ( ) mozambique. in: leblanc rj, matthews p, and richard rp (eds.) global atlas of excreta, wastewater sludge, and biosolids management: moving forward the sustainable and welcome uses of a global resource: unhsp, pp. - . vienna: un.) following mozambique' s independence in , the government identified sanitation as one of the key components to improve health conditions. as such, in , the ministry of health launched an intensive national campaign for the self-help construction of latrines. many thousands of latrines were constructed during a relatively short period. however, there were numerous problems, including insufficient awareness about environmental conditions, a lack of technical guidance in latrine design and construction, and shortages of critical building materials. consequently, many of the latrines became structurally unsafe and unusable. in response, a research project was initiated in to ''identify and develop a suitable technology and method for large-scale implementation of improved sanitation in periurban areas.'' the result was the development and successful pilot testing of an appropriate and cost-effective technology. from to , around improved latrines were produced. in addition, an awareness campaign was carried out on the use of the latrine, hygiene promotion, and capacity building. in , the program was extended to the rural areas. prior to , more than latrines were constructed and installed. in december , the program was formally transferred to the national directorate of water affairs. overall, it has been a long and steady scaling-up process over more than years that ended by ensuring a progressive withdrawal of the government from latrine production. the emphasis now is given to decentralization and privatization for the services, although the responsibility for the program remains with the government. from this experience, some lessons learned, are * although technology must be simple, it is important for massive use to ensure its local production and commercialization. there must be several types of sanitation facilities with different prices in order to commercialize. * a good network needs to be established between users (periurban communities, the government, nongovernmental organizations (ngos), small private companies, and donors) to ensure that the program progressively developed its own dynamism. * latrines need to be emptied and the service needs to be provided. investments and national and international loans are to be paid from taxes, the difference is only that payments differ in time and are used simply because it is very difficult to finance sanitation projects directly from users. as a result, people who pay for the services are not always the same who will be using them. private aid is made available by private enterprises or ngos. private funding is used simply because developing countries have greater needs than economic resources. the participation of private enterprise cannot be taken for granted as there are several factors that actually inhibit their participation. these include low accessibility to loans from towns and municipalities, the need to organize projects that have payback periods of years, and the need to recover costs through water tariffs (lenghton et al., ) . private funding includes not only international or national firms, but also self-provision schemes provided by nonconventional private enterprise. these nonconventional private enterprises have been called by some 'informal' although for several developing countries, they have in many cases proven to be more formal, useful, and to provide more reliable services than formal ones. for example, in india, an ngo named sulabh has installed pour-flush toilets that are operated on a fee-paying basis and are maintained by attendants who live at the facilities. through providing good reliable service, sulabh's facilities have become a model for sustainable public sanitation services. this shows that there is growing knowledge and capacity provided by small and even family-run companies that are capable of producing significant and innovative improvements in access to sanitation. financing strategies are specific for each country and situation and depend on the political will, the compatibility with existing institutional arrangements, the degree of community involvement in decision making, the available economic and financial resources, and the prevailing social and cultural preferences, among other aspects. when either private or public funding is used, some key elements to make a good use of it according to lenghton et al. ( ) are • maximum scalability. the selected financing strategy needs to be one that can be scaled up quickly and in a straightforward manner to allow for rapid increases in the population served. • minimal transaction costs. • full financial accountability. • closed revenue cycle, that is, financially viable in the sense that all capital and operating costs are fully covered -either through user fees, government subsidies, or external finance. sanitation is of public interest (box ) and hence is a public process. in order to implement what needs to be provided is, for the governments, to identify the main requirements, the areas of responsibility, the risks associated, who is responsible for what, the different options to address needs, and the associated costs. once this is performed, it is required to review, set up or adapt the legal and institutional framework, and to educate all the persons involved (from society to politicians, experts, regulators, private companies and functionaries, besides children and women). sanitation management (basic sanitation facilities management, wastewater collection, treatment and reintegration, by-product management, and risk control) requires the coordination of different public institutions, society, academia, private enterprises, and in some cases, even different countries. therefore, the government is needed to set up the programs. today, around the world, it is still mostly government agencies that construct and operate wastewater collection and treatment systems. however, private companies are contracted to conduct operations in many places, and all countries have significant commercial enterprises built around collecting excreta and septage and managing wastewater sludge and biosolids, mostly in cities. theoretically, private companies, if well used by the government, could be useful to increase sanitation coverage if the level of society is raised and private companies are not used to increase the already-considerable differences existing between economic social classes. nevertheless, private participation is not increasing in sanitation. after steadily increasing at a global level between and , it began to decrease (lenghton et al., ) . there are many reasons for this, one of which is that it is not easy to build up successful schemes combining private and public interests. box how industrialized governments approached funding for sanitation (with information from lenghton l, wright a, and davis k (eds.) ( ) health, dignity and development: what will it take? millennium development goals. london: earthscan.) in general, in developed countries, public water infrastructure components have been highly subsidized by governments, reflecting an understanding that the public health benefits of sanitation generate substantial positive external gains that merit public investment. in britain, for example, urban authorities borrowed more than d . million for sewerage work during the period - . eventually, the public provision of sanitation became an uncontroversial and indeed, an expected part of life. similarly, for many municipalities in the united states, public financing of sanitation infrastructure was seen as the only option for ensuring investment adequate to protect public health. in the nineteenth century, boston, for example, had lower-than-expected connection rates among households to the city's new water and sewer network; this prompted the city to cover the cost of service pipes for all unconnected households. in , an influential state sanitary survey concluded that governments must accept responsibility for financing public sanitation infrastructure because, left to their own devices, a large proportion of massachusetts residents would be unable or unwilling to take on personal responsibility to conduct their lives in accord with recommended sanitary principles. until recently, grants of up to % or more were provided for innovative sanitation technologies in the united states. one aspect to keep in mind concerning public and private participation is that for the sanitation field, these funding options combine better with certain type of sanitation systems, characterized in terms of their size and used technology (table ) . low-income countries need to invest - % of their gdp to fulfill their mdgs (lenghton et al., ) . for some, these are figures difficult to reach even if the use of loans is considered. for them, external donors can play an important role. middleincome countries have fewer needs and more economical capacity to meet their mdgs. for some, it is estimated that they could use up to % of their gdp, and hence it is considered that no external finance is needed (lenghton et al., ) . moreover, this situation, from the point of view of some authors, offers to inform the private sector of great opportunities to conduct a business and, as a result, in several middle-income countries private funding is being promoted. one possible risk, which needs to be considered by local government and known by society in general, is that through private participation and international loans, technology and sanitation schemes from other countries are promoted, which do not always effectively solve local problems in the cheapest and most efficient way. another risk is the use of the money for additional purposes. to deal with this, it is important, on the one hand, for the government to be accountable and, on the other hand, for society to demand transparency. in any case, it is certain that developing countries need to be creative to raise funds for sanitation. one option is to raise them as part of other projects in which sanitation can be a component; these include those considering goals for food security, health, land remediation, environmental problems control, and adaptation to climate change, for which several donors may be available. as an example, carbon credits could be used to fund projects to manage sludge and fecal sludge. in developed countries, a complex and complete system of public agencies, private companies, equipment vendors, consultants, scientists, engineers, operators, and supporting professional and educational organizations makes sanitation possible. promoting this organizational and human capacity in developing countries is one of the challenges on the path to increasing adequate sanitation, wastewater reuse, and proper fecal sludge and wastewater sludge management. science and innovation are needed in developing countries to reduce their intense dependence on developed countries. unfortunately, in many situations, technology originating in high-income countries is still preferred and implemented. however, this may not match the actual needs or promote local the brazilian sanitation research programme (prosab) is a public program that has received financial support for different projects since . its goal is to develop and optimize existing technologies for water supply, wastewater treatment, and solid residues management. for that, its objectives are * to establish the state of the art of technology; * to adapt or develop technology to provide sanitation services in local and regional conditions, and to meet the different needs of all population sectors, preserving and restoring the environment; * to make technology and knowledge part of the public domain; and * to support participatory processes, creating cooperative research networks to discuss subjects. the total investment for the three phases listed is around us$ million distributed as shown in table , in which investments made for salaries and scholarships are not considered. both, research papers and technological innovation, were produced from this program. economic development. in some other cases, developing countries are even used as laboratory testing grounds for new magic solutions. in low-and middle-income countries, examples can be found where a significant part of the investment made for wastewater treatment plants is used to pay for the intellectual property rights of the processes, as happens with many other activities. in figure , it is shown that royalties received because of patents in developing countries are nonexistent or low while those for developed countries are high; sanitation could be in the future another source of this dependency and inequity. on the top of this, some of these processes do not solve actual problems and, as a result, around the world, several places can be found where new solutions for providing sanitation to poor people have been installed in series unsuccessfully. this situation has two negative effects: first, it discourages donors from making further investments and, second, it makes local people wary of possible solutions. the only way to prudently overcome this is to promote the development of technology by people immersed in local problems. for this purpose, investment in education and local research is important (box and table ). as presented here, the solution to sanitation problems can be combined with the solutions to other problems. the possibility therefore exists to develop new and individual technologies, to adapt the existing ones, and even to rediscover ancient local solutions. in parallel, the same can be done with policies to manage water. at an international level, there is current mobilization to support and improve sanitation conditions in developing countries. this mobilization is being expressed in terms of donors, private participation, and international aid agencies support. from this chapter, it is concluded that there are many reasons explaining why providing sanitation in developing countries is different to the solutions implemented in developed ones; therefore, care must be taken to not to use the aid to implement projects, which may prove not successful. for this reason, it is important to promote that each country defines first its needs and works defining programs. as the challenges to provide sanitation are many and very complex (policy definition, technologies to be used, education and awareness programs implementation, development of adequate institutional capacity, finding new financing options, etc.) it is important for developing countries to share among them their knowledge and experiences in the framework of the so-called south-south cooperation. sanitation is an important pillar to develop wealthy societies (in terms of health and economic capacity) and, for this reason, governments should promote investments in this field that are to be properly and responsible managed. the only way to assure this is to promote, allow, or to demand a participatory approach. finally, the water situation in developing countries has some bright sides. the first consists in the fact that the wide divisions observed in developed countries within the water sector (water supply and wastewater experts) does not exist or is not so pronounced. this allows easier understanding and promotes the integrated management of the problem. the second has to do with the high degree of solidarity existing among the population, which may play an important role in speeding up a sanitation program proven successful and contributing to raising the quality of life. global atlas of excreta, wastewater sludge, and biosolids management: moving forward the sustainable and welcome uses of a global resource: unhsp global atlas of excreta, wastewater sludge, and biosolids management: moving forward the sustainable and welcome uses of a global resource: unhsp wastewater reclamation and reuse the role of wastewater reuse in water resources management senegal water reuse: an international survey of current practice, issues and needs artificial recharge of groundwater: hydrogeology and engineering infiltration percolation as a tertiary treatment tratamento de esgostos sanitarios por processo anaeróbio e disposicao controlad no solo, st edn regional document for the americas prepared for the th world water forum every drop counts: environmentally sound technologies for urban and domestic water use efficiency. division of technology, industry and economics water reuse via aquifer recharge: intentional and unintentional practices water quality improvements during aquifer storage and recovery poverty and the drylands. nairobi: united nations development programme a nationwide assessment of wastewater use in pakistan: an obscure activity or a vitally important one? sanitation and disease: health urban wastewater as groundwater recharge evaluating and managing the risks and benefits water reuse: an international survey of current practice, issues, and needs water safety plans for grey water in tribal schools removal of -b-estradiol and -a-ethinyl estradiol in engineered treatment wetlands safe drinking water: lessons from recent outbreaks in affluent nations conventional small and decentralized wastewater systems in developing countries indirect water reuse for human consumption in germany -the case of berlin state of the art report health risk in aquifer recharge using reclaimed water irrigation in developing countries using wastewater water reuse new paradigm towards integrated water resources management unplanned reuse of wastewater for human consumption: the tula valley coming to terms with nature: water reuse new paradigm towards integrated water resources management encyclopedia of biological, physiological and health sciences wastewater risks in the urban water cycle water reclamation and reuse around the world. in: water reuse: an international survey of current practice using ecosan sludge for crop production navigating rough waters: ethical issues in the water industry. american water works association jiménez b and wang l ( ) sludge treatment and management semi-intensive treatment plants for wastewater reuse in irrigation extent and implications of agricultural reuse of untreated, partly treated and diluted wastewater in developing countries. cab reviews: perspectives in agriculture, veterinary science making urban excreta and wastewater management contribute to cities' economic development: a paradigm shift water policy global atlas of excreta, wastewater sludge, and biosolids management: moving forward the sustainable and welcome uses of a global resource un-habitat dignity and development: what will it take? millennium development goals global atlas of excreta, wastewater sludge, and biosolids management: moving forward the sustainable and welcome uses of a global resource: unhsp domestic wastewater treatment in developing countries comparison of techniques for the detection of helminth ova in drinking water and wastewater global atlas of excreta, wastewater sludge, and biosolids management: moving forward the sustainable and welcome uses of a global resource: unhsp sludge accumulation, characteristics, and pathogen inactivation in four primary waste stabilization ponds in central mexico global atlas of excreta, wastewater sludge, and biosolids management: moving forward the sustainable and welcome uses of a global resource: unhsp system consideration of eco-sanitation wastewater irrigation in developing countries: health effects and technical solutions morbidity and mortality due to ascariasis: reestimation and sensitivity analysis of global numbers at risk water -more nutrition per drop. towards sustainable food production and consumption patterns in a rapidly changing taking into account environmental water requirements in global-scale water resources assessments. comprehensive assessment of water management in agriculture cryptosporidiosis in developing countries south africa. faecal sludge management global atlas of excreta, wastewater sludge, and biosolids management: moving forward the sustainable and welcome uses of a global resource: unhsp water for people, water for life. the united nations world water development report united nations development programme human development report beyond scarcity: power, poverty and the global water crisis international source book on environmental sound technologies for wastewater and stormwater management the state of the world's cities report / ; the millennium development goals and urban sustainability: years of shaping the habitat agenda united nations/world water assessment programme guidelines for water reuse targeting sanitation water reuse in windhoek, namibia: years and still the only case of direct water reuse for human consumption guidelines of the safe use of wastewater and excreta in agriculture and aquaculture guidelines for drinking-water quality: recommendations guidelines for the safe use of wastewater global water supply and sanitation assessment report, joint monitoring programme for water supply and sanitation meeting the mdg drinking water and sanitation target: a mid-term assessment of progress meeting the mdg drinking water and sanitation target: the urban and rural challenge of the decade progress on drinking water and sanitation: special focus on sanitation. geneva: who and unicef earth trends: environmental information key: cord- - s p authors: dover, jeffrey s.; moran, mary lynn; figueroa, jose f.; furnas, heather; vyas, jatin m.; wiviott, lory d.; karchmer, adolf w. title: a path to resume aesthetic care: executive summary of project aescert guidance supplement—practical considerations for aesthetic medicine professionals supporting clinic preparedness in response to the sars-cov- outbreak date: - - journal: facial plast surg aesthet med doi: . /fpsam. . sha: doc_id: cord_uid: s p nan extremis with severe respiratory and renal failure, stroke, pericarditis, neurologic deficits, and other suddenly lifethreatening complications, in addition to its pernicious effects on those with pre-existing morbidities and advanced age. accordingly, the guidance supplement seeks to establish an elevated safety profile for providing patient care while reducing, to the greatest extent reasonably possible, the risk of infectious processes to both patients and providers. while the guidance supplement cannot foreclose the risk of infection or serve to establish or modify any standards of care, it does offer actionable risk-mitigation considerations for general office comportment and for certain nonsurgical procedures typically performed in aesthetic medical settings. it is axiomatic that all such considerations are necessarily subject to the ultimate judgment of each individual health-care professional based on patient situation, procedure details, office environment, staffing constraints, equipment and testing availability, and local legal status and public-health conditions. federal, state, and local government legal pronouncements and public-health conditions will inform the gating decisions of when permissible and prudent to reopen practices and re-engage with patients, and whether to limit certain procedures that may present greater contagion risk. while such gating decisions are not the focus of this guidance supplement, it is advisable that practices should consider, at a minimum, whether in their local communities: ( ) new covid- cases are declining sequentially to eliminate or at least substantially control community spread; ( ) testing is available at a meaningful scale to validate perceived prevalence reductions; and ( ) adequate protocols and resources are in place in conjunction with local health departments to conduct effective contact tracing where necessary in response to covid- incidents. without robust testing, the ability to identify individuals with covid- , do appropriate contact tracing, and isolate and treat the infected is substantially reduced. therefore, in the absence of these enumerated local conditions, practices must factor cautiously the attendant increased risk of transmission into their reopening calculus. significantly, the principal variables within the control of the practicing aesthetic medicine physician are office and staff preparation, and communication and transparency with patients. the guidance supplement is focused heavily on these subjects, offering consensus guidance from authors representing relevant scientific and clinical disciplines. the project aescert guidance supplement provides specific recommendations and considerations for preparing to reopen a medical aesthetic office and begin to deliver aesthetic patient care in a covid- environment, including: patient communication-establishing appropriate expectations for office visits and attendant risks; clinic schedule management-considerations for schedule modification to convert non-treatment interactions to telehealth consultations, separate patients from one another in the office and avoid unnecessary staff contact; facility management-physical modification of office common areas and treatment rooms, as well as check-in and check-out procedures, to promote safe practices and physical distancing; cleaning procedures-discussion of disinfection methods and practices in each office area, ranging from medical instruments and treatment rooms to administrative items and reception areas; personal protective equipment (ppe) for providers, staff and patients-recommendations for ppe types and use depending upon procedure-based risk assessment, and recognizing current global equipment shortages; employee health screening and training-procedures and methods for identifying staff members who may be unwell before, during, and after work, and training of staff to identify potential covid- presentation in coworkers, patients, and other office visitors; risks associated with exposure to known or suspected covid- -positive individuals are also discussed; patient health and screening-procedures and methods for symptom recognition in patients before, during, and after office visits, with follow-up monitoring where appropriate; remedial measures following onsite symptom presentation-a framework for addressing isolation of symptomatic individuals, office containment and disinfection, and contact tracing; treatment room setup-preparing and securing treatment rooms for patient entry to contain office contamination and reduce overall potential covid- exposure; and aesthetic treatment considerations-pretreatment preparation and precautions, and other suggestions for minimizing risk of transmission in performing the most common types of office-based aesthetic procedures, such as neurotoxin and dermal filler injections, noninvasive body contouring, lasers and other similar energy-emitting devices, and a range of medical skin care treatments. the project aescert guidance supplement also contains summary charts and checklists designed in collaboration by both infectious disease and aesthetic experts, which can be utilized immediately to assist office staff in understanding and modeling sound safety practices. aesthetic medicine practices must navigate a daunting series of medical and business challenges occasioned by the covid- pandemic. most offices have been closed by operation of both common sense and legal requirement, as the public health community labors to comprehend both the magnitude and complexity of severe acute respiratory syndrome coronavirus (sars-cov- ) and its sequelae. this crisis has created significant safety concerns and occasioned severe financial hardship for aesthetic physicians, staff, and patients alike. however, the authors posit that application of sound safety measures identified and considered in the guidance supplement will serve to assist aesthetic medicine specialties in returning to the delivery of patient care with reasonable risk-minimization strategies. it is critical that all disciplines of medicine, aesthetic and otherwise, share available information and work together to evolve effective approaches to practicing in a dramatically changed environment. this project aescert guidance manuscript (''guidance'') was developed in partnership with a multidisciplinary panel of board-certified physician and doctoral experts in the fields of infectious disease, immunology, public health policy, dermatology, plastic surgery and facial plastic surgery. this guidance is intended to provide aesthetic medicine physicians and their staffs with a practical guide to safety considerations to support clinic preparedness for patients seeking non-surgical aesthetic treatments and procedures following the return-towork phase of the covid- pandemic arising out of the novel coronavirus sars-cov- , once such activity is permitted by applicable law. many federal, state and local governmental authorities, public health agencies and professional medical societies have promulgated covid- orders and advisories applicable to health care practitioners, largely focused on the threshold determination of whether and when to reopen for business. these standards should be seriously considered, and where required by law or otherwise applicable or prudent, followed thoughtfully. this guidance is not intended to contravene any such other mandates, which supersede this guidance in the event of any conflict, but rather, to provide aesthetic physicians and their staffs with an additional set of practical considerations for delivering aesthetics care safely and generally conducting business responsibly in the new world of covid- . aesthetic physicians and their staff will face new and unique challenges as government stay-at-home orders and related commercial limitations are eased, and the u.s. economy reopens and healthcare systems transition from providing only urgent and other essential care to resuming routine care, elective procedures and services. debate will continue about the wisdom, pace and scope of such reopening, but in the meantime patient demand for aesthetic treatments will return. the medical aesthetics specialties will therefore wish to resume practice in order to ensure high quality, expert care is available, and importantly to help promote patients' positive selfimage and sense of well-being following a lengthy and stressful period of quarantine. in reopening aesthetic practices during the ongoing pendency of the covid- outbreak, delivery of care must be accompanied by necessary precautions to safeguard the health and welfare of not only the patients and providers within the context of the office environment, but also the community at large with whom they interact immediately beyond the office walls. there is widespread perception that, while aesthetic procedures are self-esteem and self-image enhancing, they are generally considered elective, with notable exceptions that may be deemed medically necessary (e.g., cases of congenital anomaly or traumatic injury). because of their elective nature, extraordinary care must be taken to protect patients and healthcare professionals from covid- . while physician practice guidance is available from many sources, the aescert guidance has been developed specifically for aesthetic medicine settings. in a number of areas, this guidance exceeds traditional aesthetic office safety precautions, recognizing reduced tolerance in an elective treatment environment for any risk associated with covid- 's highly variable presentation and unpredictable course. the disease has placed a disturbing number of young, otherwise healthy patients in extremis with severe respiratory and renal failure, stroke, pericarditis, neurologic deficits and other suddenly life-threatening complications, in addition to its pernicious effects on those with pre-existing morbidities and advanced age. accordingly, the guidance seeks to establish an elevated safety profile for providing patient care while reducing, to the greatest extent reasonably possible, the risk of infectious processes to both patients and providers. while the guidance categorically cannot foreclose the risk of infection, nor serve to establish or modify any standards of care, it does offer actionable risk-mitigation considerations for general office comportment and for certain non-surgical procedures typically performed in aesthetic medical settings. this guidance is purely advisory in nature and should be regarded as a set of baseline precautions that should be considered; however, it is not an exhaustive list of everything required to operate safely. it is axiomatic that all such considerations are necessarily subject to the ultimate judgment of each individual healthcare professional based on patient situation, procedure details, office environment, staffing constraints, equipment and testing availability, and local legal status and public health conditions. importantly, this guidance is also subject to present limitations on medical and scientific understanding of covid- , and any future changes in such understanding will need to be evaluated by providers in determining its continuing utility. additionally, this guidance has been prepared in a nationwide environment marked by limited diagnostic resources for both active disease and possible immune response, and an absence of validated pharmaceutical treatments or vaccines. as point of care testing becomes more widely available, affordable and reliable, and once therapeutic or preventive protocols are in place, such developments may permit certain modulation of the guidance. in the interim, federal, state and local government legal pronouncements and public health conditions will inform the gating decisions of when it is permissible and prudent to reopen practices and re-engage with patients, and whether to limit certain procedures which may present greater contagion risk. given the multiplicity of such circumstances across the country, these are necessarily highly localized and indeed individualized assessments. while such gating decisions are not the focus of this guidance, it seems clear that practices should consider, at a minimum, whether in their local communities: ( ) new covid- cases are declining sequentially to eliminate or at least substantially control community spread, ( ) testing is available at meaningful scale to validate perceived prevalence reductions, and ( ) adequate protocols and resources are in place in conjunction with local health departments to conduct effective contact tracing where necessary in response to covid- incidents. without robust testing, the ability to effectively identify individuals with covid- , do appropriate tracing, and isolate and treat the infected is substantially reduced. therefore, in the absence of these enumerated local conditions, practices must cautiously factor the attendant increased risk of transmission into their reopening calculus. further, subsequent to the threshold decision to reopen, it is possible that future covid- prevalence in a particular community, along with limits on testing and treatment availability, could periodically require limitations in scope of practice or even temporary office closure to reduce risk of harm. again, this guidance takes no position on these contingencies, and seeks only to provide information and best practices for operational implementation where it is otherwise legally permissible and medically responsible to interact with patients in the office setting for delivery of medical aesthetics care. more broadly, in this highly dynamic pandemic environment, this guidance is necessarily based on, and its applicability confined to, the public health environment and related government pronouncements in effect as of the date of publication. subsequent evolution in transmission prevalence, testing and tracing capacity, and treatment as well as vaccine availability could warrant either further restriction or expansion of aesthetic practice from this guidance, depending on the direction of such evolution. in the meantime, based on the current public health landscape and the medical and scientific information now available, the guidance next proceeds to outline a series of practical considerations associated with practice reopening, ranging from preparing the medical office environment, staff training, and patient and staff health screening, to treatment room set-up, selection of personal protective equipment (ppe), and precautions for common office aesthetic procedures, such as neurotoxin and dermal filler injections, energy-emitting devices, body contouring and medical skin care treatments. while effective patient communication and transparency are always a hallmark of any well-functioning medical practice, they are particularly critical during the returnto-work phase of this covid- outbreak. accordingly, it is important for practices not only to implement and follow high safety standards as a substantive matter of public health, but also to clearly convey these steps to their patients to foster a sense of awareness and confidence. therefore, as an overarching theme to this entire guidance, measures and changes undertaken by practice in response to the covid- outbreak should be proactively signaled to patients to heighten confidence. utilizing established means to communicate to patients, such as the practice's website and notifying patients via digital and direct personal communication, is an important first step in conveying the practice's commitment to the health and safety of patients and the public, while maintaining high-quality patient care. communicating new policies and protocols throughout the clinic with visible reminders such as display posters and other signage will assist staff in remaining vigilant, in addition to conveying a practice's emphasis on safety for patients and others. it is advisable to display such materials throughout the clinic, including common areas, reception areas, waiting room, treatment rooms and bathrooms, reminding patients and staff of symptoms related to covid- , healthy hygiene and prevention etiquette. examples of display posters are provided in the following links, although it should be noted with respect to the symptoms poster that this is not an exhaustive list, and additional symptoms are increasingly recognized, such as severe fatigue, nausea and diarrhea, chills, repeated shaking with chills, myalgia, headache, sore throat, new loss of taste or smell, and unexplained anorexia: symptoms of covid- -sample poster/flyer, preventing the spread of covid- -sample poster/flyer, and handwashing and respiratory hygiene -sample poster/flyer. additionally, in the same spirit of patient transparency and disclosure, given that there remains inherent, ineliminable risk of an infectious process or other complication arising from any sort of medical procedure during an ongoing global pandemic, even after respecting the considerations set forth in this guidance and elsewhere, practices may wish to append a covid- disclosure to their standard patient consent form. an example consent form developed by the american society of plastic surgeons (asps) may be found using the provided link. further, in the case of patients at higher risk of covid- complications, such as those who are of advanced age, immunocompromised, or otherwise afflicted with cardiac or respiratory conditions or other comorbidities such as diabetes, hypertension or obesity, consideration should be given to possibly delaying aesthetics intervention, if patient risk factors are deemed too high. managing the office environmentgeneral guidance it is clear that during this pandemic, social distancing (hereinafter referred to as ''physical distancing'' in order to emphasize the intended minimum physical separation of six-feet between individuals, and limits on congregating in large groups) is as important to the safe operation of a medical aesthetics practice as to any other business, household or community. and it will remain so for the foreseeable future. accordingly, as a second overarching theme running through this guidance, physical distancing principles should be incorporated throughout the practice, from the moment of initial patient scheduling through post-procedure check-out, and all office workflows from staff's arrival in the morning until the doors are locked at night. put simply, limiting the number of individuals in a particular setting and space at a given time is fundamental to minimizing transmission. utilizing telemedicine and leveraging remote videoconferencing technology for patient consultations and non-procedure visits will aid in minimizing office traffic while allowing for the development of a treatment plan (both short-and long-term), building rapport with patients and reducing in-office contact time. , , , the efficiency and value of this approach can be enhanced by sending patients a pre-consultation form in advance of a scheduled telehealth interaction to learn more about patient's primary concerns and the type of information or treatment they are seeking. capturing this information in a more formal manner will help facilitate and guide discussion between the patient and clinician in a manner that timely surfaces various opportunities to divert in-person visits to safer, more efficient interactions. various enabling developments have occurred in this regard, ranging from the proliferation of telehealth and other video technology platforms, to certain applicable standards surrounding the privacy and reimbursement of distance versus in-person provider interactions (n.b. -legal requirements vary by jurisdiction). with respect to treatment-related visits or other necessary in-person office visits, consider spacing or staggering appointments to reduce the number of patients in the office at one time and to allow for proper disinfection between patients. mindful of office size and staffing constraints, consider limiting overall patient volume per day, or extending office hours to spread patients out over a longer time horizon throughout the day. remind patients of the need to arrive to their appointment promptly and alone, and that individuals accompanying patients will be required to wait in their vehicle or outside of the office for the duration of the appointment. , special arrangements may be made in advance for minors, elderly patients or persons with disabilities. visitors spending any time in the office should be screened in the same manner as patients. and remember for any staff, patients or other visitors in the office, it is important to observe and model safe physical distancing by limiting greetings to a smile, wave and other noncontact gestures. for treatment interactions, endeavor to limit the number of staff members in the treatment room during procedures. for example, where possible, consider whether a sole provider is able to appropriately perform a particular procedure without the need for other staff in the treatment room. if not, consider allowing the provider to be accompanied in the treatment room by no more than one medical assistant, with such staff person observing safe physical distancing across the room as circumstances permit. develop and adopt policies regarding fellows, residents, medical students, and visitors to reduce to an absolute minimum the number of individuals in any given treatment room and the office as a whole. training opportunities for staff and residents should be subordinated to the requirements of physical distancing, and this safety measure may be worth expressly messaging to patients, who may appreciate understanding that the practice has taken measures to prioritize their health. keep treatment room doors closed and utilize place card signage on treatment room beds or chairs to inform patients that rooms, beds, chairs, surfaces and instruments have been disinfected. remove unnecessary blankets, pillows, robes or headbands from treatment rooms, and limit items on countertops. reorganize waiting rooms by either removing chairs and spacing the remaining chairs at least six feet apart, or by designating certain chairs to be used and others not to be occupied. consider limiting the size of the waiting room or common areas to create ''natural'' barriers (e.g. potted plants, tables) to prevent individuals from congregating in one area. remove magazines, promotional or other collateral reading materials from the waiting room, treatment room and reception areas. patient reception coffee, beverage and snack bar service should be discontinued. for the occasional patient who might require food or drink for a medical condition, such as a diabetic who develops hypoglycemia, especially when instructed to be npo pre-procedure, items can be provided as needed from storage. and importantly, place alcohol-based hand sanitizer, hand wipes and tissues, with no-touch trash cans, liberally throughout the clinic, accessible to both patients and staff. , in managing the movement of patients and others through the office, consider limiting points of entry and exit, strive for one-way traffic in hallways where possible, and try to designate separate areas for patient screening and check-in, as well as check-out. care should be taken to ensure any such special ingress/egress restrictions do not violate applicable building codes and can be overridden to permit safe evacuation in case of emergency. if possible, take patients upon arrival directly to treatment rooms for screening and check-in, in order to limit or entirely eliminate people congregating in the waiting room. ideally, check-out could be handled the same way, and for all patient administrative paperwork at check-in and check-out, clean and disinfect clipboards between each use, and consider providing single-use disposable pens to avoid multiple individuals handling the same writing instrument. for the same reason, if possible, encourage the use of remote payment systems instead of credit cards and cash, in order to minimize touching of credit card machines and office tablets. staff seating and work-stations should be reconfigured to respect physical distancing. for internal collaboration, staff should employ one-on-one or small meetings (depending on space availability) to allow for appropriate safe interpersonal distancing or arrange for virtual meetings. alert all vendors and contractors regarding new office policies limiting the number of visitors to those that are integral to either clinical practice or the business functions of the office. additionally, insist that vendors and contractors be aware of and follow the clinic's ''stay home if sick'' policy. direct all delivery personnel to a designated area for drop-off of packages and proper package disinfecting. in additional to proper physical distancing, the cleaning and disinfecting practices that are part of any medical aesthetics practice in ordinary times should be elevated and sustained during this period. first, prior to reopening a practice to patients, a qualified professional cleaning service should conduct an initial, comprehensive deep cleaning and disinfecting of the entire facility. a professional service should similarly perform a thorough cleaning and disinfecting process following the close of business each workday. on a regular basis throughout each workday, the entire staff should be trained on and committed to ongoing cleaning and disinfecting roles. based on the transferrable nature of covid- , enhanced frequency of disinfecting surfaces throughout the day and between patients is critical in protecting the health of patients and staff members. developing a protocol and crosstraining individuals responsible for managing and monitoring cleaning may be helpful in the adoption and consistent execution of these new processes. creating a checklist and schedule and displaying it on treatment room doors can serve as a reminder for staff and demonstrates to patients that treatment rooms are being consistently supervised and disinfected before their particular treatment (appendix figures a and a ) . with the aforementioned frequency, cleaning should also include disinfecting all common, high-touch areas such as the waiting room, reception areas, check-in and check-out areas, kitchen and break rooms, labs, offices and workstations, computer keyboards, tablets, credit card machines, pens and bathrooms (table ) . and again, at the end of each workday, a thorough, supervised professional cleaning service is an essential daily practice. when disinfecting surfaces, staff should wear disposable gloves and any additional protection based on the cleaning products being used and the potential risk of exposure. use of % ethyl alcohol is recommended in disinfecting small areas, or discrete items between repeated use such as reusable dedicated equipment (e.g. thermometers). environmental protection agency (epa) registered disinfectants include the use of sodium hypochlorite at . % (equivalent to ppm) for disinfecting surfaces, as well as a range of other common cleaners such as clorox disinfectants containing either sodium hypochlorite or quaternary ammonium; lysol products containing sodium hypochlorite, quaternary ammonium, hydrochloric acid, or citric acid; and purell ethanol-based products. , , , the list of disinfectants that meet epa criteria for use against sars-cov- may be found in the link provided here. steps to properly disinfect surfaces include first cleaning an area or item with soap and water or another detergent prior to using a proper disinfectant. in addition to recommended use of epa-registered disinfectants, make sure rooms are adequately ventilated and follow label instructions, as some products recommend keeping surfaces and items wet for a period of time to enhance antimicrobial activity. it is recommended before donning and immediately after doffing gloves to wash hands thoroughly or use an alcohol degerming solution (hand hygiene solution). cdc steps for cleaning and disinfection may be found here. personal protective equipment and medical supplies adequate ppe (principally, face masks, gloves, gowns, and goggles, shields or other eye protection) are necessary to protect providers and serve to protect patients alike, and therefore should be viewed as indispensable for reopening, and continuing to operate, any medical aesthetic office. this guidance recognizes the lamentable reality that severe ppe shortages on a global scale continue to pose significant challenges to the entire u.s. healthcare system at the time of guidance publication, and in some cases the impact of this shortage on particular practices has been exacerbated by those practices' decisions during the last several months to contribute ppe inventory to hospitals, emergency rooms and first responders in their respective communities. notwithstanding such supply chain challenges, however, adequate access to and deployment of ppe within a practice, both initially and on an ongoing basis, should be viewed as a precondition to medical office and patient care activity. it is imperative that practices proactively develop a plan to optimize their supply of ppe, both for current needs and in the event of future shortages, and to identify mechanisms to procure additional supplies when needed. continually assessing quantities and replenishing supplies throughout the day, as well as monitoring public health agency recommendations regarding the use of ppe for healthcare professionals, are critical as the covid- outbreak evolves and public health guidance shifts. the type of face mask and other ppe recommended for use by healthcare professionals is based upon anticipated risk of exposure to covid- while performing specific procedures. more broadly, occupational safety and health administration (osha) recommendations regarding the type of ppe used by a healthcare professional or individuals working in a healthcare setting are based upon anticipated risk of exposure while performing specific tasks or procedures (table ). , , starting from this framework and given the current state of the covid- crisis, this guidance recommends that practices should consider a strategy of having every employee in the office, irrespective of function, wear a three-ply surgical mask. given existing supply chain limitations, if it is impossible to source such three-ply surgical masks for an office's clerical or administrative employees who have no or minimal patient interaction, a professionally-manufactured cloth mask with full mouth and nose coverage is preferable to no protection; however, this guidance deems a three-ply surgical mask to be the recommended practice for all staff in the current environment. for reasons of both substantive protection and patient confidence, handkerchiefs, scarves and other homemade masks should not be utilized by any staff, and if inventory constraints require that these are the only option, practices should seriously consider the wisdom of having such employees on-site at all. it is recommended that surgical masks used by clerical or administrative staff be discarded and replaced on at least a daily basis. to the extent such employees are permitted by an office to utilize cloth masks, they should generally be deployed for no longer than one day without being professionally laundered prior to next use. providers or staff who are involved in administering treatment or are otherwise in the treatment room for any patient assessment or general treatment or care should wear, at a minimum, a three-ply surgical mask, eye protection in the minimum form of safety glasses, and gloves. inventory permitting, use of a gown is also recommended for all such individuals associated with the treatment room. masks, gloves and gowns involved in treatment should generally be considered single-use and safely disposed after each patient procedure, and eye protection should be cleaned and disinfected with the same regularity. for those providers or staff performing, assisting with, or otherwise in the treatment room for any aerosol-generating procedures (agps) as described more fully later in the clinical and non-surgical treatment section of this guidance, the use of an n filtering face piece respirator (n mask), or its equivalent, is the minimum nose and mouth protection required, providing respiratory protection and protection from blood and body fluids. for such agps, in the absence of n availability, osha indicates other types of acceptable respirators with similar or greater protection may be used, such as r/p , kn , n/r/p , and n/r/p . these respirators are often more comfortable for the wearer when fitted with a valve exhalation feature, but this feature has the effect of elevating wearer safety over that of patients and others in the vicinity, and therefore is generally discouraged. single-use gloves and gowns should also be used for all providers and staff in the treatment room for agps, and providers administering treatment should consider use of a single-use surgeon's cap. further, providers administering agps should consider using heightened eye protection beyond standard safety glasses, such as full goggles or face shields, which should be thoroughly cleaned and disinfected after each use. notwithstanding any inventory challenges, n masks used in agps should generally be considered single-use only, unless used in conjunction with a face shield and proper disinfection procedures are utilized ( table ). the cdc generally recommends use of a cleanable face shield over an n when feasible. non-agp procedures performed above the clavicle generally pose greater risk than lower body procedures, and therefore practices should consider whether higher level ppe items should be utilized. for non-agp procedures involving the head and neck region, particularly where detailed work requires the provider to remain in close face-to-face proximity with a patient's airways, use of an n mask and more substantial eye protection is preferable. irrespective of job function or procedure type, ppe training should be provided to all providers and staff throughout the office and across job function, including proper hand hygiene practices, correct fit, donning and doffing to avoid cross-contamination, and considerations for contemplated extended use or reuse of ppe. , in particular, users of n s or other respirators should be fittested prior to first use, thereafter on an annual basis, or more frequently in the event of significant weight loss or change in facial hair. the cdc fact sheet on use of ppe and proper donning and doffing may be found here. due to ppe shortages, certain medical societies and other public health authorities have advised that healthcare professionals who typically wear a mask for procedures may consider wearing the same mask throughout the day in an effort to conserve ppe. for example, the cdc has provided guidance on practices allowing the extended use and limited reuse of n masks when supplies are depleted. extended use (leaving the mask on for multiple patient encounters, without removal) is generally favored over reuse (using the same mask for multiple encounters and removing it between encounters), as there is less risk of repeat handling-related contact transmission. in addition to strict adherence to proper hand hygiene practices before and after touching or adjusting the mask, proper fit and function are paramount to safe extended use or reuse. manufacturers may have specific guidance regarding reuse. however, variables such as contamination over time make it difficult determine the maximum number of reuses. ultimately, single use of a mask is lower risk than extended use or reuse, and therefore reflects the general consensus of this guidance, particularly for agps, unless, as stated above, a mask is used underneath a face shield and proper disinfection of the face shield occurs after each procedure. the other variable here involves the highly dynamic state of ppe decontamination technology. for example, certain hospitals have been developing vaporized hydrogen peroxide systems for decontaminating n masks, and studies are beginning to validate various other modalities and protocols as well. accordingly, it is impossible for the guidance to anticipate and adjudicate every permutation of ppe deployment duration and decontamination, for example, the possible single use of a surgical mask over an extended use n for a non-agp procedure. such decisions are necessarily subject to the best professional judgment of the provider on a case-by-case basis, based on the specific combination of patient and procedure risk factors and the overall ppe availability and decontamination landscape. if extended use or reuse of face protection is necessary, take care to avoid touching the mask or respirator itself, touching only the fasteners when donning and doffing. if reuse across multiple days is unavoidable, it is incumbent upon providers to ensure thorough decontamination and safe storage. such contingencies are beyond the scope of the position taken by this guidance, but it is observed that thoughtful procedures have been articulated elsewhere, ranging from a study on a proposed n decontamination protocol, to a proposal for cycling five masks over a five-day period, using one mask per day and then storing each individually until the same day the following week to allow for a seven-day period of non-use of each mask. if attempted, any such storage should be in a sealed, breathable container between uses to reduce damage, labeled to identify user, date and duration of prior use, and with thorough disinfecting or disposal of containers on a regular basis. beyond mouth and nose protection, wearing protective eyewear in conjunction with a mask when treating patients reduces exposure and inadvertent touching of facial mucous membranes. with respect to eye protection, prescription eyeglasses do not afford adequate protection in the covid- treatment environment, without wearing a wraparound style of secondary eyewear. for agps in particular, full wraparound goggles are recommended, again with a face shield advisable as well. special attention should be paid throughout the office, and not just the treatment room, to those wearing prescription eyeglasses or non-prescription readers, as plastic or metal surfaces have the potential to become a fomite for covid- given the propensity of frequent touching of one's eyeglasses throughout the day. as with staff cell phones, eyeglasses should be cleaned and disinfected throughout the day, and staff should avoid touching or handling such objects between hand washings. as a corollary to the need for consistent use of ppe, there are emerging reports of skin complications resulting from repeated ppe exposure and excessive hand hygiene, especially among healthcare workers. these complications variously include skin breakdown, erythema, papules, scaling, burning, itching and stinging. providers may wish to consider proactive and therapeutic use of emollients, barrier repair creams and other skin calming and hydration preparations to mitigate such conditions. in addition to ppe, other medical supplies of particular import to managing the covid- environment include alcohol-based hand sanitizer and hand wipes, which should be placed at entry and exit points and throughout the office including in the waiting area, reception area(s), treatment rooms, and bathrooms. ensure the availability of liquid soap at sink areas, and facial tissues and notouch wastebaskets with disposable liners and lids throughout the office. non-contact thermometers (infrared or thermal scanner models) are recommended in lieu of forehead, oral or tympanic (auditory canal) thermometers. , iv. employee and patient health employee health and training in order to offer safe care in a safe environment to their patients, practices must first ensure that providers and staff are healthy and do not constitute a transmission vector. this starts with clearly and proactively communicating to all employees the clear mandate to stay home if sick or experiencing any early suggestion of symptoms, and reviewing applicable benefits and provisions related to sick leave, caring for sick family members and children, and flexible scheduling. questions and concerns regarding employee health, safety, compensation and benefits may arise, and are heightened during these uncertain times. information should be provided about available employee assistance services and steps employees can take to protect themselves at home. with respect to covid- in particular, practices should develop an infectious disease preparedness plan that addresses the level of risk associated with various jobs and tasks to help guide actions and reduce the risk of employee exposure to covid- . assessments should be undertaken of potential sources of employee exposure to covid- , including coworkers, patients, the general public, individuals that are symptomatic or who have recently been symptomatic for covid- or a febrile respiratory tract infection, and those at high risk (e.g., other healthcare workers, travelers who have visited locations with widespread covid- transmission, including domestic locations with significant community spread, etc.). attention should be given to nonoccupational risk factors at home, including family and immediate or close contacts, and community settings (e.g., attendance at recent large gatherings or events) and individual risk factors (e.g., immunocompromised status and various chronic conditions). as part of this larger process, an employee health screening should be completed every day before staff enters the office or beyond a designated assessment area. models vary, but at a minimum this could be accomplished with a short form, or even an email to a designated responsible person in the office, constituting a quick self-attestation that an employee is asymptomatic and otherwise unaware of any exposure to a confirmed or suspected covid- -positive individual, with such records being maintained by the practice in either paper or preferably digital form. even better, if feasible, a daily employee wellness check should be performed in addition to the symptoms self-report, comprised of a temperature check using a non-contact thermometer, and any necessary follow-up. any employee who reports feeling sick, senses any early hint of symptoms, or exhibits elevated temperature or other symptoms is required to refrain from entering, or immediately leave the office and follow up with their primary care physician or other appropriate offsite care facility for evaluation and, as indicated, viral testing. depending on the nature and extent of any positive findings and follow-up testing, office policy should dictate a protocol for minimum time off work and appropriate timing of return based on symptom progression, cessation, and all test results. it is advisable to select one or two individuals (''workplace coordinators'') in the practice to serve as point persons in this regard, and more generally for all covid- -related issues in the practice, including oversight of clinic infection prevention measures. establish this communication plan early, clearly communicate and share it with all employees. beyond this initial screening and preparedness plan, as a general matter, all employees should model physical distancing and good hygiene practices in all office activities, whether related to patient interactions or otherwise. this includes minimizing use of shared workspaces, office supplies and medical instruments, such as sharing other employees' phones, desks, offices, computers and other equipment. staff should minimize handling of personal cell phones throughout the workday, and refrain from any cell phone handling between their last hand washing and any patient contact. lunch rooms and staff lounges should be closed or restricted to limited size and spaced groups and alternating schedules. with respect to hygiene, all employees should engage in frequent, thorough handwashing (for at least seconds) and cough and sneeze etiquette. the world health organization (who) counsels healthcare professionals to follow ''my five moments for hand washing,'' using alcohol-based hand sanitizer or soap and water: ( ) before touching a patient, ( ) before engaging in clean or aseptic procedures, ( ) after potential exposure to body fluids, ( ) after touching a patient, and ( ) after touching patient surroundings. to keep employees safe, as previously discussed, it is advisable to consider use of surgical masks by all staff regardless of job function; a minimum of surgical masks, protective eyewear, gowns and gloves for all staff involved in any procedures; and the addition of n or equivalent masks, more fulsome eye protection and/or a face shield, and possibly a surgical cap for all staff involved in agps. again, effectiveness of ppe is highly dependent on proper handling, fit, and correct and consistent use; therefore, employee training on these topics is critical. and in addition to the aforementioned who handwashing moments, handwashing is also required before putting on, after taking off, and whenever touching or adjusting ppe, always careful to handle face protection only by the fasteners without touching the mask itself. more generally, employees should avoid touching their eyes, nose or mouth with gloves or bare hands, both in connection with ppe use and otherwise around the office and throughout the workday. in addition to ppe, staff clothing decisions bear on office safety and patient confidence. to avoid the risk of clothing as a transmission vector into or out of the office, it is recommended that surgical scrubs or other dedicated office uniforms be worn by all providers and staff, even those who are not in immediate proximity to patients. when practicable, these should be worn only in the office, not commuting to and from work, changed daily, and thoroughly laundered by a professional service that collects soiled garments from the office to avoid employees bringing dirty laundry home and risking crosscontamination. it is vital that all providers and staff, including those who serve in non-clinical patient contact roles such as receptionists and other administrative personnel involved in patient scheduling, check-in or check-out procedures, be able to identify and report the symptoms associated with covid- . symptoms may range from mild to severe and appear anywhere from approximately - days following exposure. symptoms of covid- to be on alert for include flu-like symptoms, fever ( ‡ . °f or °c), cough or shortness of breath, new nasal congestion or runny nose, loss of taste or smell, as well as non-specific symptoms such as sore throat, myalgia, fatigue, nausea and diarrhea. additional symptoms reported include chills, repeated shaking with chills, muscle pain, and headache. all employees should also be trained to identify emergency warning signs that require immediate medical attention, such as trouble breathing, persistent pain or pressure in the chest, new confusion, inability to arouse a patient, and bluish lips or face. employees should be vigilant for all these symptoms, not only in themselves and coworkers in the office, but also patients, vendors, contractors and other visitors to the office. at any sign or suspicion of covid- symptoms, the affected individual should be required to refrain from entering, or immediately leave, the office, and a workplace coordinator should be promptly notified, in a hipaa-compliant manner in the case of patients. with respect to prospective patient visits, appointment scheduling processes should be modified to include prescreening patients before their office visit in conjunction with appointment reminder calls to help identify potential infection and recent risk of exposure. a phone screening tool may be developed for use as a wellness checklist in this regard to aid in surfacing any areas of concern (appendix figure a ). if through such telephonic pre-screening efforts patients report symptoms potentially associated with covid- or have indicated potential sources of exposure by other means based on recent contacts or travel, explain to patients that out of an abundance of caution, they will need to reschedule their appointment for a later time. in the event of symptoms, also recommend they promptly follow up with their primary care physician or other appropriate offsite care facility for evaluation and, as indicated, viral testing. the minimum timeframe for rescheduling any such patients is a riskbased assessment depending on symptom presentation and testing results and should be governed by applicable cdc guidelines. in addition to patient pre-screening, offices must implement a protocol for health screening patients immediately upon arrival on the date of appointment, ideally in a contained area designated for this purpose to minimize other interactions prior to clearance (appendix figure a ). as with employee health screening, this process should include both a form of questionnaire for eliciting disclosure of symptoms or other exposures, and a staffadministered temperature check using a no-touch thermometer. if on the appointment date a patient presents and reports symptoms or exposure to known or suspected covid- -positive individuals, or if temperature check or other assessment by staff reveals that a patient is symptomatic or at high risk upon arrival, immediately isolate the patient in an unoccupied room, provide a surgical mask for the patient to apply, irrespective of whether the patient arrived uncovered or over whatever mask with which the patient arrived, minimize contact with others in the clinic, and quickly and discretely remove the patient from the office. if the patient is well enough to drive home, send the patient home immediately. recommend that patients isolate themselves at home, practice careful infection prevention measures, and follow up immediately upon returning home with their primary care physician or other appropriate offsite care facility for evaluation and, as indicated, viral testing. patients may be alarmed and anxious to discover that they may have symptoms or are otherwise at risk of prior exposure related to covid- . remain calm and supportive of the patient and continue to adhere to predefined infection prevention protocols. depending on the nature and extent of the patient's positive follow-up findings and testing, office policy should dictate a protocol for minimum time away from the office before a rescheduled office visit may be permissible, based upon the patient's symptom progression, cessation, and all test results. this same isolation-and-exit protocol applies equally to employees, who despite having presumably observed the practice's stay-home-if-sick policy, may first become symptomatic at work, or otherwise stimulate a positive finding during the previously described employee arrival screening process. the procedure would similarly apply to any vendors, contractors or other visitors to the office, all of whom should be notified to stay away if sick or at risk, and then subjected to a similar screen-on-arrival protocol. in the event of a positive visitor screen, the same isolation-and-exit protocol obtains. following execution of the isolation-and-exit protocol, in the event of any on-site presence, however brief, by any patient, employee, vendor, contractor or other visitor who is either suspected or confirmed to have covid- , it is imperative to immediately switch focus to minimizing risk to the office premises. in this regard, care should be taken to follow applicable infection control guidelines, and thoroughly clean and disinfect all area(s) the individual had accessed or moved through. the cdc recommends closing off all areas accessed by that individual to reduce intra-office contamination, opening external doors and windows to that contained area to increase air circulation from the outside, and (if feasible) waiting hours before cleaning and disinfecting to minimize potential exposure of others to respiratory droplets. , ideally a professional service should be utilized for this reactive cleaning, and any staff involvement should require use of adequate ppe. depending on the nature, duration and overall extent of the individual's activity in the office, including interactions with other patients, employees and others, the practice may need to consider further prophylactic measures up to and including temporary office closure, in order to minimize further exposure, ensure adequate site remediation, and assess the risk of further transmission. finally, it is advisable to notify all patients, employees and others who may have been exposed to any such known or suspected covid- -positive individual in the office. state and local laws and public health regulations, as well as other canons of professional responsibility, are likely to govern or otherwise inform these disclosure obligations, and accordingly such contact tracing ought to be undertaken in coordination with local health departments and other authorities. pre-screening patients much of the physical distancing-related protections that a medical aesthetics practice can leverage to enhance covid- safety are a function of decisions made before a patient ever arrives at the office. thoughtful prescreening procedures and advance communications serve to limit the need for office visits and minimize the duration of and unnecessary contacts during those that do occur. patients should be educated on how these new measures have been implemented to enhance their safety, and what they should expect when they arrive. as discussed previously, consultations and other nontreatment appointments may be arranged through patient portals, telemedicine or other technology-enabled communications. , billing and other administrative matters, treatment plans and other preparatory items can be addressed over the phone or by video-conference, thereby shortening office stays. office arrival, check-in and check-out patients should be encouraged to arrive to their appointments alone, and notified that individuals accompanying them will be required to wait in their vehicle or outside the office for the duration of the appointment. , special arrangements can be made for the elderly, minors and persons with disabilities. from their vehicle, an arriving patient may call or text the contact number for a designated hippa-trained staff member and wait until the staff member indicates the patient may enter the office. staff should greet each patient at the entrance to guide them through the intake process and to an appropriate location. a patient screening flow chart may assist staff in mapping this and subsequent steps in a patient arrival process designed to combine heightened safety protocols with efficient and responsive customer service (appendix figure a ). patients should be advised to bring a face mask or similar covering with them to their appointment, and informed that they will be required to wear it for the duration of their appointment, to be removed only if and to the extent they are undergoing facial procedures. in the event patients forget or are unable to bring a face mask, they should be provided one for use throughout their appointment. while a three-ply surgical mask is ideal and will inspire elevated patient confidence, limitations on ppe availability would alternatively justify providing another form of commercially-manufactured cloth mask instead. staff should remind patients not to adjust their face mask or touch their eyes, nose or mouth, and that if they must do so they will need to wash or sanitize their hands before and after such contact. similarly, patients should be counseled to minimize handling their cell phones during the appointment, and to rewash or re-sanitize their hands following any such use. for those practices located in multi-story buildings serviced by elevator access, patients should be counseled on best practices for elevator use in this environment, beginning with the need to arrive early to allow extra time to wait for a less crowded elevator that permits physical distancing. once inside, maximum spacing from other riders should be sought, facing forward, and ideally as close to the front of the elevator, and hence the doors, as possible for access to outside air during any intervening stops. patients should wear their mask at all times, and avoid touching elevator buttons with bare hands, instead using a clean tissue, elbow or other similar approach. alternatively, if elevator circumstances appear to defy safe usage and stairs are a viable option given the office's floor location and the patient's physical capacity, it may be useful to provide the location of applicable stairwells. upon arrival in the office suite, consider having designated staff take the patient directly to an exam room for check-in, in order to avoid congregating in the waiting room or the common area around the reception desk. confirm the patient has already donned a mask, request the patient wash or sanitize their hands, and then proceed to conduct a wellness assessment to confirm the absence of a fever, other covid- symptoms or related highrisk exposures. a similar form of the wellness screening checklist used at the prior time of telephonic appointment confirmation may be repurposed at the time of office arrival (appendix figure a ) . following the wellness screening, it is advisable to endeavor to complete the patient's ensuing aesthetic services with minimal relocation throughout the office, preferably in the same treatment room in which checkin occurred if possible, or alternatively in such other manner as reduces the patient's geographic footprint and multiplicity of interactions within the office. further, it is recommended that, if possible, patient check-outs be conducted within the treatment room, or an otherwise designated, separate check-out area to avoid re-exposure to reception or other common areas. finally, the office should conduct a post-visit followup video-conference or telephone call to the patient several days after the appointment, both to monitor progress post-procedure and also to ascertain whether any covid- symptoms have recently developed despite the patient having been asymptomatic at the time of the appointment. here again, a wellness screening checklist may be a useful tool for staff (appendix figure a ). any positive report during this follow-up may trigger contact tracing considerations and other remedial measures by the practice. further, even if patients report being asymptomatic at this follow-up, they should be asked to notify the office in the event they subsequently develop any covid- symptoms within the balance of the remaining -day period of their recent appointment, again in order to permit appropriate contact tracing. treatment room set-up due to the duration and proximity of patient and other interpersonal contact, as well as the possibility for various procedure-specific activities to elevate the risk of viral shedding, the treatment room requires particularized attention to safety concerns and practices. for containment purposes, doors to treatment rooms should remain closed during and in-between use. office-wide air handling systems should be evaluated to understand the path and extent of circulation of air from the treatment room vents into other rooms and common areas throughout the office, and where possible, to minimize such flow. where available, external windows may be opened during inter-procedure treatment room cleaning to provide maximum ventilation. thorough cleaning and disinfecting of treatment rooms and all exposed surfaces and equipment, whether or not utilized in the prior procedure, must be performed after each patient. patient visits often involve more than one type of procedure during a scheduled appointment (e.g., neuromodulator injections and dermal fillers). where possible in view of device and other equipment (including digital photography or camera systems) deployment throughout the office, consider consolidating multiple patient treatments into a single treatment room to minimize multiple points of exposure. further, it may be advisable to consider limiting the number of procedures or grouping the type of procedures per patient visit in order to reduce multiple patient exposures, contact time and overall appointment duration. in advance of a patient procedure, it is advisable to take all steps necessary to prepare equipment, supplies and other positioning of assets prior to bringing the patient into the treatment room, in order to minimize exposure time between the staff and patient. examples of advance planning in this regard includes preparing all trays, instruments, supplies, drugs, and injectables. in the case of energy-based devices, this might include turning the equipment on and pre-performing setup tasks, including calibration to the treatment parameters if known for the specific upcoming case. sterile items should be left in packaging to be opened in the patient's presence, both for safety reasons and to instill patient confidence. it is important to train staff on, consistently follow, and consider visibly displaying confirmation of, a treatment room cleaning and disinfecting protocol and schedule in each room, again both to ensure substantive office compliance and to promote patient confidence (appendix figure a ) . additionally, as previously reported elsewhere in sections iii and iv of this guidance, it bears reemphasis that ppe is of particularly critical import within the treatment room during this time, for reasons of safety, patient perception and the overall risk minimization required to justify elective aesthetic procedures during the current phase of the covid- outbreak. accordingly, this will result in recommended use of masks, gowns and protective eyewear in certain procedures where many healthcare professionals previously may have justifiably used none, and heightened ppe protocols across a number of other procedures beyond what was previously the norm. when topical anesthetic agents are used for office-based aesthetic procedures, it is common for application time to range from approximately - minutes. for reasons identified above, ideally such application would occur within the same room as the ensuing treatment to minimize movement; however, if office capacity precludes that option, an alternative is to use another dedicated room for this purpose, during which a thorough cleaning and disinfecting process can be completed of the treatment room between each patient. following application, patients should be encouraged to continue wearing their masks for the duration of the waiting time until they are ready for the actual procedure. other pain management options include topically applied cooling gel or ice packs, which typically have a plastic cover that can serve to retain the virus or other contaminants. wherever possible, consider disposing of these items entirely after each use. if not, care should be taken when reusing these packs to thoroughly cleanse and disinfect before returning to a common freezer unit, perhaps after being placed within a new, single use plastic bag to be used for storage only. also, be aware patients may lay these items down during treatment and check-out, which also creates a potential risk for reuse. if disposing of otherwise reusable cold packs is impractical within a particular office, an effective alternative could simply be the single use of double-bagged ice, which in many cases is colder and longer lasting. nitrous oxide inhalational analgesia is occasionally used in aesthetic practices and creates an exhaled gas that is directional in nature. for the reasons set forth below, the use of this pain management modality should be reduced to a minimum given the current covid- environment. patients receiving this analgesic treatment may inhale on a regular basis throughout the procedure. while some clinics deliver this gas mixture using a traditional facial mask (similar to mask oxygen delivery in hospital settings), the most common method of delivery is a disposable plastic mouthpiece. these mouthpieces will become contaminated with the patient's saliva after the first use, and the mouthpiece is then stored with the device, and this process occurs repeatedly during the course of the treatment, after which the entire breathing mouthpiece and hoses are disposed of. review of existing procedures and protocols for protection from saliva on the mouthpiece should be performed and adapted as needed for covid- risks. additionally, the patient is typically encouraged to inhale (and thus exhale) deeply for several times at each use of this gas. this policy should be cautiously reviewed in light of covid- risk data on aerosolized droplets resulting from deep breathing, and any necessary use of this pain management modality should be construed as an agp and subject to the corresponding highest levels of ppe requirements for agps recommended throughout this guidance, including use of an n mask and a face shield. dermal fillers, botulinum toxins, and other similar minimally-invasive facial injectables and other injectable procedures are among the most common treatments performed in many aesthetic offices and are likely to be in great demand by patients who have had their regular treatment cycles interrupted by covid- stay-athome orders. these procedures usually take only several minutes of actual injection time but may take longer depending on the type of treatment being performed and the number of treatment areas being injected. despite the short duration of treatment, anatomic location of injections, largely in the face and neck area, combined with the extremely close proximity to the patient's airways necessary for the high-detail work, create exposure risk. irrespective of prior practice, post-covid- it is important to deploy adequate ppe for these procedures, at a minimum including the use of a three-ply surgical mask, wraparound safety glasses, gown and gloves for the provider administering the injections, as well as all staff in the treatment room. wherever possible, it is advisable to consider elevating the ppe set-up for these procedures to include the use of an n mask and full goggles and face shields. in all cases, intra-procedure discussion by both provider and patient should be kept to an absolute minimum to reduce the risk of airborne transmission through speaking. as a general practice, vials and syringes should be laid out and prepared prior to patient entrance into the treatment room to minimize exposure time. proper hand washing and infection control procedures should also be followed when handling vials and syringes, and when applying ice and topical anesthetic agents. patients should reapply their masks post-procedure. injectable procedures below the clavicle, for example such as sclerotherapy and fda-pending treatments for cellulite reduction, allow some additional distance from the patient's respiratory pathways; however, they still require close physical contact and risk of disease transmission through airborne droplets in shared airspace due to normal breathing and talking, and further exposure may occur through sneezing and coughing. therefore, this guidance recommends the same minimum baseline ppe protocol for all injectable procedures irrespective of anatomical region. non-invasive body contouring because they are largely focused on anatomical regions other than the face, the category of cryolipolysis, radiofrequency, electromagnetic and other similar body contouring and body sculpting procedures often do not involve the same face-to-face proximity between provider and patient during treatment. this is also true because certain body contouring procedures require limited in-room contact with the patient once the device has been applied and the procedure has commenced. that said, all such procedures nonetheless require a provider or staff to interact closely with the patient during set-up and application of the device to the selected treatment areas, and during that time the risk of transmission through breathing, talking, coughing and sneezing is omnipresent. further, some of these body contouring procedures do involve treatment in the neck area to address submental fat. accordingly, for all body contouring procedures, this guidance recommends the same minimum ppe level required as a baseline for any form of office treatment, namely a three-ply surgical mask, wraparound eye protection, gown and gloves for all providers and staff in the treatment room. this consistent approach to ppe prioritizes patient and employee safety, minimizes the risk of errors by attempting to parse ppe levels too finely, and fosters maximum patient confidence in the practice. when contouring procedures are performed above the clavicle, consider heightened ppe including an n mask, goggles, and possibly a face shield. for body contouring procedures below the clavicle, it is advisable for patients to remain masked throughout the treatment, and particularly when a provider or staff is in the treatment room. as mentioned above, following commencement of certain of these procedures, the patient is often in a separate room from the provider while the treatment takes place, which may take to minutes depending on the device and the treatment area. in such scenarios, ppe may be removed upon exiting the treatment room and reapplied on reentry; however, in so doing, it is critical to scrupulously observe proper donning and doffing protocols and associated handwashing requirements, in order to avoid cross-contamination. with some body contouring devices, it is possible to position a disposable pad between the treatment area and device, a practice that should be followed wherever possible. often a measuring tape is used in conjunction with these procedures for initial patient assessment, and if so, it is advisable to utilize a single-use measuring tape in this regard, when measurement is needed. to the extent support pillows are used during the procedure, consider using disposable pillows or pillows that have a waterproof, plastic or vinyl covering capable of being thoroughly disinfected. following each procedure, the entire body contouring device, not simply the contact points, should be comprehensively cleaned and disinfected, using approved disinfecting agents, and in conformance with any manufacturer instructions. energy-based procedures of the face and neck depending on the type of device used, setting and depth of treatment, the various laser, light, heat and other similar energy-based procedures of the face and neck performed in a medical aesthetic office are often mechanically disruptive and thus need to be deployed with a high degree of safety protocols. in addition to the inherent risks associated with the fact that they involve extended contact time at close proximity with patient airways, a number of these treatments may be categorized as non-respiratory agps based upon emission of airborne debris particles or other contaminants. for example, certain laser and other energy-emitting device procedures may produce a plume of vaporized and ejected tissue that, even when evacuated by suction, has the potential to exit into the treatment room. evacuator suction systems should have adequate and regularly monitored twostage filtration type, and require frequent inspection and replacement of the filters. further, it is common for cooling positive air pressure to be used for pain management during a number of laser and other energy-emitting device procedures, often engineered into the operation of the devices themselves. these devices typically have a control for air speed/velocity. such positive air pressure increases the risk of transmission; therefore, for those procedures where use of cooling air is a function of patient comfort and not required device safety, consider substituting other forms of pain management where possible to achieve adequate pain control with other modalities. where such pain control is not possible, and/or if cooling air is required for device safety, consider modulating air speed, duration of use, and vector of flow to reduce usage to a minimum level required for safety and/or comfort. for all these reasons, consider limiting all such agps to one or more designated treatment rooms with appropriate air handling, containment and evacuation systems, in order to avoid exposing other treatment rooms or office areas. review air filter replacement policies and consider accelerated replacement schedules in consultation with device manufacturers. in the event an office has any treatment rooms equipped with negative air pressure capacity, agps should be concentrated in these facilities to the maximum extent possible. similarly, the maximum available level of ppe should be deployed for all these energy-based procedures of the face. minimum required ppe for providers and staff either administering, or otherwise in the treatment room for, these agps should include an n or equivalent mask, wraparound safety glasses or full goggles, gloves and a gown, and if available a surgical cap. use of a face shield is also strongly advised. gloves, gowns and caps used in agps should be considered single use only, and eye protection should be thoroughly cleaned and disinfected with an approved disinfectant after each use. it is strongly advised that masks should similarly be disposed after each procedure, unless used under a face shield in conjunction with thorough disinfecting protocols. in all cases, despite ppe utilization, intraprocedure discussion by both provider and patient should be kept to an absolute minimum to reduce risk of airborne transmission through speaking. and other than the provider administering the procedure and the patient, nobody else should be in the treatment room, unless a staff member is required to be present, and then only with full ppe consistent with the provider's set-up. special consideration should be given to integrating various ppe elements for safe use in practice during performance of these agps. while it is true that all procedures involving use of a mask in combination with protective eyewear carry the risk of a gap or slip midprocedure that creates an exposure to contaminants, such risk is amplified with these agps given the possible presence of plumes and positive air pressure, as well as the contingency of laser energy being misdirected and impairing a provider's vision. it is important that employees are not just educated on proper use of ppe, but also practice integrating kits to ensure comfort, fit, coverage, stability and visibility. across all energy-based procedures, comprehensive cleaning and disinfection should occur after each treatment, using approved disinfecting agents and pursuant to manufacturer instructions. this should include both the tip of the handpiece and other patient and operator contact points, as well as the entirety of the device and all surfaces in the treatment room that may have been subject to plume or other positive air pressure displacement effect. it is also critical to establish a protocol for appropriate frequency of sterilization procedures for, and inspection and replacement of, all device filters and cartridges. as an additional final step, disinfect the tip of the handpiece again in front of the next patient prior to the next procedure. as a result of disruption to the skin barrier following all these treatments, skin may be more susceptible to infection. it is advisable to provide patients with a new, clean face mask following all such procedures. patients should not reuse the mask they wore into the office, if at all possible. with respect to patient masks, it also bears noting that, to the extent certain laser, light and other similar energybased procedures are sometimes performed below the clavicle, patients should wear a mask for the entirety of such procedures. irrespective of the anatomical area of treatment, however, providers and staff should remain at the highest level of ppe protection described above, as these particular procedures remain properly regarded as agps, even when focused on the body. skin care treatments encompass a wide range of procedures from those that are non-invasive (e.g., medical facials, water-based facials, chemical peels, and nonablative fractional resurfacing), to those that are moderately invasive (e.g., microneedling) and may result in a nominal amount of localized (pinpoint) bleeding. given the positioning of such treatments within a busy aesthetics practice and the designation of staff often responsible for administering them, there may be some tendency to default to a lower level of safety vigilance for such procedures; however, any such impulse should be categorically resisted. these treatments are labor-and timeintensive and may require anywhere from - minutes of time spent in close proximity to the patient, often with staff hands directly in contact with a patient's face. accordingly, in addition to consistent use of proper baseline ppe as with any office aesthetic treatment discussed in this guidance, it is advisable to limit the number and duration of treatments provided per patient visit, provide pain management through modalities other than cooling fans or handheld cooling devices wherever possible, and minimize intra-procedure discussion by both staff and patient. additionally, preference should be given to utilizing devices with disposable tips, cartridges, blades, and applicators and mixing bowls. within the broader category of skin care treatments, some procedures require additional consideration in the current covid- climate. for example, deeper microneedling may produce bloodborne pathogen risk, and certain micro-and hydra-dermabrasion procedures may actually be properly regarded as non-respiratory agps due to risk of emission of airborne particles or contaminants as a result of device features such as positive pressure water jets, closed loop vacuum or other vortex type treatments. in such cases, it is advisable to approach this subset of skin care treatments with the same heightened safety protocols as other energy-based procedures of the face, as outlined above. thus, in addition to complying with device-specific and room-wide infection control and cleaning protocols, consider limiting use of these procedures to a specific treatment room with appropriate air evacuation systems, and enhancing the type of ppe for all staff in the room (e.g., single-use n or equivalent mask, single-use gown, gloves and wraparound glasses or goggles, possibly even in conjunction with a face shield). also, it is prudent to provide patients with a new, clean disposable face mask following all these procedures. in sum, across the various categories of common office aesthetic procedures discussed throughout this guidance, the key considerations for enhanced covid- vigilance through ppe selection and disinfection protocols are summarized below (table ) . this aescert guidance is intended to supplement other advice offered by professional societies and governmental agencies. it has been deliberated and prepared on a multi-disciplinary basis so as to consider many relevant factors involved in operating an aesthetic practice in a covid- environment, as we today understand the virus and its contagious properties. progress will be made in the months ahead in testing capability, both for active disease and antibody production. similarly, progress is likely in clinical evaluation of drug therapies and, ultimately, development of a vaccine. it is incumbent upon every practitioner to stay abreast of these developments as they will affect the practice of aesthetic medicine and patient care and safety in important ways. outpatient and ambulatory care settings: responding to community transmission of covid- in the united states everyday health and preparedness steps in clinic get your clinic ready for coronavirus disease (covid- ) guidance on preparing workplaces for covid- . occupational safety and health administration website getting your workplace ready for covid- . world health organization the covid- risk communication package for healthcare facilities. world health organization interim infection prevention and control recommendations for patients with suspected or confirmed coronavirus disease healthcare infection prevention and control faqs for covid- thermometer for detecting fever: a review of clinical effectiveness. ottawa (on): canadian agency for drugs and technologies in health website comparison of non-contact infrared skin thermometers prepare your small business and employees for the effects of covid- disinfecting your facility html#suspected-or-confirmed-cases-of-covid- -in-the-workplace recommended guidance for extended use and limited reuse of n filtering facepiece respirators in healthcare settings covid- resources for plastic surgeons and their practices. american society of plastic surgeons website opening up america again. centers for medicare & medicaid services (cms) recommendations. re-opening facilities to provide nonemergent non-covid- healthcare: phase i cms website skin experts covid- groups at higher risk for severe illness dermatologists can use telemedicine during covid- outbreak. american academy of dermatology association website list n: disinfectants for use against sars-cov- . united states environmental protection agency website using personal protective equipment (ppe) assessment of n respirator decontamination and resue for sars-cov- . medrxiv preprint covid- pandemic and the skin -what should dermatologists know? published online ahead of print american society for laser medicine and surgery (aslms) laser and energy device plume position statement visualizing speech-generated oral fluid droplets with laser light scattering the authors wish to acknowledge the scientific and clinical staff of the skinbetter science instituteÔ for its key: cord- -x nxxled authors: di lorenzo, giuseppe; di trolio, rossella; kozlakidis, zisis; busto, giuseppina; ingenito, concetta; buonerba, luciana; ferrara, claudia; libroia, annamaria; ragone, gianluca; ioio, concetta dello; savastano, beatrice; polverino, mario; de falco, ferdinando; iaccarino, simona; leo, emilio title: covid therapies and anti-cancer drugs: a systematic review of recent literature date: - - journal: crit rev oncol hematol doi: . /j.critrevonc. . sha: doc_id: cord_uid: x nxxled background: it is reasonable to think that cancer patients undergoing chemotherapy, targeted therapy or immunotherapy could have a more aggressive course if positive for coronavirus disease cov- (covid- ). methods: we conducted a literature review on https://www.ncbi.nlm.nih.gov/pubmed/, https://scholar.google.com, www.arxiv.org, www.biorxiv.org, of all articles published using the keywords covid- therapy or treatment and cancer until may , . a total of articles were identified and were included in this review. results: we describe the ongoing covid- therapies that should be known by oncologists and highlight the potential interactions with antineoplastic drugs, commonly used in clinical practice. the main drug interactions were found with tocilizumab, ruxolitinib and colchicine. conclusions. the literature provides an inconclusive picture on potential preferred treatments for covid- and their interactions with antineoplastic agents. future clinical trials are needed to better understand the interactions between different drugs in the context of covid- pandemic. in our recent history there have been three epidemics related to coronavirus infections: the sars-cov (severe acute respiratory syndrome), - ; the mers-cov (middle-east-respiratory-syndrome), ; and currently the sars-cov- , ( - ) ( ) . until may , , there were approximately confirmed cases, with deaths due to coronavirus disease cov- (covid- ) in italy, according to the italian civil protection bulletin ( ). according to the world health organization (who) as of may due to covid- , in spain there were confirmed cases and deaths; in the united states, milion confirmed cases and deaths; france has confirmed cases with deaths while united kingdom has cases and deaths ( ). from the available scientific literature it is evident that about . % of the deaths with the coranavirus had an oncological pathology as comorbidity ( , ) . thus, during this covid- crisis, cancer patients are regarded as a highly vulnerable group. it was found that within days, anti-cancer treatments were significantly associated with occurrence of severe clinical events in j o u r n a l p r e -p r o o f covid- infection ( ) . the cancer population subjected to chemotherapy and/or radiotherapy is more exposed to infections in general and, therefore, also to that from coronavirus primarily due to the effect of the cytotoxic action on the hematopoietic and immune systems with a reduction in the number of neutrophils, the first bulwark of infections, and decreased immune capacity ( ) . although there is no data yet on the risks of contracting coronavirus infection or on the clinical course of the infection during immunotherapy and/or immunosuppressive treatment with chemotherapy. it is reasonable to think, by analogy of what happens in the case of seasonal flu, due to the presence of immunosuppression, that in treated cancer patients, there may be a greater number of complications and the clinical course to be more serious ( ) . therefore there remains an urgent need to answer whether covid- -positive cancer patients will have worse outcomes, such as death, from the coronavirus-induced pneumonia for example, and whether cancer patients should receive anti-cancer treatments. additionally, oncologists are required to know the toxic effects of the drugs used in the experimental therapy of covid- and the possible interactions of these drugs with the commonly used antineoplastic drugs. the systematic review followed the prisma guidelines (figure ) ( ) . two investigators (el and rdt) independently conducted literature search using as combined keywords covid- therapy or treatment and cancer on https://www.ncbi.nlm.nih.gov/pubmed/, www.arxiv.org ( ), www.biorxiv.org ( ) and https://scholar.google.com ( ) . the database search was run of all the published articles from database inception until may , . in pubmed the following strategy was used: (covid- or novel coronavirus-infected pneumonia or novel coronavirus or -ncov or sars-cov- therapy or treatment) and cancer. the strategy was then adapted for the other databases, including website of italian medicines agency (aifa) for ongoing trials ( https://www.aifa.gov.it/emergenza-covid- ) ( ). all studies reporting information on both covid- therapy/treatment and cancer were included. articles were identified and reviewed independently by two authors (el and rdt) and articles were considered relevant to the scope of the current review, as described in figure ( , . any inconsistencies were resolved by consensus with a third author (gdl). all health outcomes were included, due to the anticipated scarcity of data. the lists of the drugs being tested and their side-effects are listed in table . they are presented below in more detail. considering the etiological therapy of sars-cov- , antiviral agents, already on the market and in use for other viral pathologies, in monotherapy or in combination are currently being tested. it has a mechanism of action related to the selective inhibition of the viral polymerase-rnadependent rna and is used as a backup drug when other therapies do not work ( ) . commonly used for the treatment of hepatitis c and for inflammatory lung diseases, such as bronchiolitis, this antiviral drug is always used in combination with other medicines, such as interferon alfa and peginterferon alfa and can be used both in the treatment of adult patients and in the treatment of pediatric patients ( ). it is an antiviral drug in the class of nucleotide analogues. it was developed as a treatment for ebola virus disease and marburg virus infections. it has also been shown to have antiviral activity against rna viruses such as human respiratory syncytial virus and coronaviruses, including viruses that cause the mers and sars ( ) . on april, the director of the us national institute of allergy and infectious diseases (niaid), announced the results of a study in which patients taking remdesivir recovered in days compared with days for those on a placebo. the shortened recovery time was so significant that investigators decided to stop the trial ( ). this news contradicts previous mixed results on the drug. gilead sciences announced that in a non-randomized trial, more than half of participants with severe covid- had recovered from their disease within two weeks of receiving treatment. another smaller trial in china announced that it had found no benefits from remdesivir when compared with a placebo. the niaid did not release informations on safety data ( ). lopinavir and ritonavir is indicated, in combination with other antiretroviral medicines, for the treatment of adults, and children over the age of years with human immunodeficiency virus (hiv- ) infection ( ) . lopinavir-ritonavir in association with ribavirin is being evaluated. it is a drug that counteracts the over-reaction of the immune system, at the origin of some of the most serious complications of covid- and which in these days seems to offer hope to patients with coronavirus-induced pneumonia. in addition to rheumatoid arthritis therapy, the medicine is also used to treat cytokine release syndrome, a side effect of car-t anticancer therapy which consists of a massive release of inflammatory molecules in response to the immune cells used in the treatment ( ). it is an anti-interferon gamma. this drug keeps children with hemophagocytic lymphohistiocytosis (hlh) alive, awaiting transplantation. the administration of emapalumab is able to "turn off" the abnormal and excessive inflammatory response in patients with hlh, neutralizing the effects deriving from the excessive production of interferon-gamma ( ). sarilumab is an interleukin- (il- ) receptor antagonist indicated for the treatment of adult patients with moderately to severely active rheumatoid arthritis who have had an inadequate response or intolerance to one or more disease-modifying antirheumatic drugs (dmards) ( ). it is a member of the drug class selective immunosuppressants and is used to treat hemolytic uremic syndrome, myasthenia gravis, neuromyelitis optica and paroxysmal nocturnal hemoglobinuria ( ). it inhibits the activity of interleukin- (il- ), and has already been approved for the treatment of siltuximab like tocilizumab, binds to interleukin- and is indicated for the treatment of adult patients with castleman disease ( ) . the sisco study (siltuximab in serious covid- ) is configured as an observational study conducted both on hospitalized patients and those already in intensive care ( ). table shows italian medicines agency (aifa) approved experimental studies in covid- therapy ( - ). the main currently ongoing studies are: ) tocivid- , multicenter study on the efficacy and tolerability of tocilizumab in the treatment of patients with covid- pneumonia; ) sobi study, immuno- , a randomized, open, parallel, multicenter, phase / groups, that evaluates the efficacy and safety of intravenous doses of emapalumab, antiinterferon gamma monoclonal antibody (anti-ifnγ), and anakinra, interleukin receptor antagonist- (il- ), compared to standard therapy; ) sarilumab covid- study: a randomized, double-blind, placebo-controlled phase / study evaluating the efficacy and safety of intravenous administration of sarilumab, an interleukin receptor antagonist- (il- ). other potential therapeutic agents. the required urgency for the identification of potential treatments has necessitated the further investigation of a wide-range of potential therapeutic agents. the ones identified in this review are listed below in some detail. ruxolitinib is an inhibitor of the signal transmission pathway mediated by janus kinase (jak), with anti-inflammatory effects related to the inhibition of the release of cytokines. normally ruxolitinib is used in the hematology field and is indicated for the treatment of splenomegaly or disease-related symptoms in adult patients with primary myelofibrosis. it is also approved for the treatment of adult patients with polycythemia vera who are resistant or intolerant to hydroxyurea ( ) . a compassionate use of ruxolitinib has also been approved by aifa in covid- patients with respiratory failure who do not require invasive assisted ventilation. baricitinib is another jak inhibitor indicated for the treatment of active rheumatoid arthritis ( ) . aifa has licensed a randomized phase trial to evaluate the efficacy, safety and tolerability of j o u r n a l p r e -p r o o f baricitinib in addition to the usual treatment in patients with pneumonia in covid- (barcivid study) ( ). a new line of research comes from diabetologists. according to a study, in addition to the main entrance door of virus, the angiotensin-converting enzyme (ace ) receptor, the dpp receptor must be evaluated. the dipeptidyl peptidase (dpp ) receptor is present on all human cell types (bronchi and hearth) and is the same on which many medicines for diabetes work ( ) . colchicine is a molecule, capable of interfering with the inflammatory immune response observed in subjects with covid- . colchicine is a drug that has been used for a long time and is effective for the treatment of acute attack of gouty arthritis. specifically, it manages to reduce the release of cytokines, molecules that, like il- , are responsible for the inflammatory ( , ). a study has recently started in italy ( ). a reduction of up to % in mortality among covid- patients with a marked increase in an indicator of the presence of blood clots, was achieve due to the use of an old drug, heparin ( ). this was reported by a study according to which the use of heparin in covid- patients could have anticoagulant effects, as well as anti-inflammatory and potentially even antiviral ones. it has been shown that new coronavirus infections are associated with a high mortality in the presence of high value of d-dimer, a particularly important marker for coagulopathy ( ) . however, it will be necessary to study in depth at what dosage the drug could have such potential antiviral properties. a recent study has been approved by aifa with enoxeparin (inhixacovid) ( ). table table shows interferences with tocilizumab, ruxolitinib and colchicine. tocilizumab increases immunosuppressive action and inhibits fluouracil-resistance ( ) ; it interferes with pharmacodynamic activity and the therapeutic efficacy of durvalumab, nivolumab, atezolizumab ( , , ) . moreover it is important to emphasize that tocilizumab decreases the concentration of several medications as a cytochrome p (cyp), isoenzyme cyp a inducer ( ) ( ) ( ) ( ) ( ) ( ) ( ) ) . therefore if drugs in lung cancer are used, such as ceritinib, crizotinib, brigatinib, gefitinib, docetaxel, a reduction in the anticancer drug may become noticeable, as well as paying attention in the case of concomitant use of tyrosine kinase inhibitors. anakinra and ruxolitinib could interfere with checkpoint inhibitors (cpi) in terms of antagonisms or synergy but this is not yet entirely clear ( , , ) . several drugs, such as cyp a inhibitors, increase concentration of colchicine and attention should be paid when the latter is used with cisplatin or vinca alkaloids ( ). furthermore, one should not forget a concomitant use of antidiabetic drugs with antineoplastics that require cortisone ( ) or cytostatic drugs that reduce the value of platelets with the concomitant use of heparin ( ) . based on the increased risk of disease aggression of covid- in patients with cancer it is important to describe which anti covid- drugs could be administered and which not in cancer patients. the current review attempts to provide a first systematic glance at this issue. there are certain emergent points of attention that have already been described. specifically, particular attention to the potential cardiotoxicity of chloroquine with anthracyclines is necessary. hydroxychloroquine is an antimalarial that has become a mainstay in the management of systemic lupus erythematosus and rheumatoid arthritis. similar to chloroquine in structure, hydroxychloroquine is used more frequently because it confers lower toxicity. cardiotoxicity manifests as restrictive or dilated cardiomyopathy or with conduction system abnormalities such as atrioventricular and bundle-branch block ( ) . recently, some doubts it is important also to note that some chemotherapeutic agents or hormonal therapies such as abiraterone require concomitant steroids that are immunosuppressive agents and could weaken anticitokines drugs such as tocilizumab ( ) . however in some cases, the use of steroids could be reduced without interfering with the efficacy and toxicity profile. tocilizumab decreases concentrations of many anticancer drugs due to interference with cyp ( ). deserving to underline that today many patients carry out cpi, currently used in daily practice for the treatment of solid tumors. cpi, activating t-lymphocytes, increase the risk of autoimmune disease such as pneumoniae ( ). few case-reports have described significant reduction in il- and cpi immunorelated toxicity after tocilizumab administration ( ). to date the interaction between cpi and anti covid- agents is not well-described. consideration could be given to either extending the timing of the doses or delaying pretreated patients. thirdly the data are based on retrospective findings, while the results of prospective cohorts are being awaited and expected to shed more light. moreover considering the rapid evolution of information related to the pandemic we conducted a search on arxiv and biorxiv databases indentifying articles of interest; these are preliminary reports that have not been peer-reviewed. among the articles only were considered as relevant ( , ) and subsequently has been published in peer-reviewed journal ( ) , testifying to the current urgent need of relevant, well-designed studies. the literature so far available provides an inconclusive picture on potential preferred treatments for covid- and their interactions with antineoplastic agents. in order to continue treating cancer patients likely to be infected with covid- , we believe that it is appropriate to modify available therapeutic choices and arrive at a new therapeutic protocol that provides: ) where there are no interactions to continue or delay antineoplastic therapy by - weeks; ) where there are interactions and the patient has already done many cycles to stop the administration of the anticancer drug; ) for newly diagnosed cancer patients to prefer antineoplastic drugs without interactions; ) where further attention is given to cpi, the choice of which may vary from case to case. 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and randomized clinical trials during pandemics novel coronavirus (covid- ) based on current evidence covi d : combining antiviral and anti inflammatory disease challenges and countermeasures of integrative cancer therapy in the epidemic of covid- . integr cancer ther sars-cov- transmission in cancer patients of a tertiary hospital in wuhan pakdzad-shahabi l. estimating the risks from covid- infection in adult chemotherapy patients. medrxiv, -medrxiv comparative therapeutic efficacy of remdesivir and combination lopinavir, ritonavir, and interferon beta against mers-cov hydroxychloroquine and azithromycin as a treatment of covid- : results of an open-label non-randomized clinical trial fda approval: siltuximab for the treatment of patients with multicentric castleman disease prospects in connective tissue diseases covid- and diabetes: can dpp inhibition play a role? the versatile heparin in covid- abiraterone and increased survival in metastatic prostate cancer zip a phase / , randomized, openlabel, parallel, -arm, multicenter study investigating the efficacy and safety of intravenous doses of emapalumab, a monoclonal antiinterferon gamma (anti-ifnγ) and anakinra antibody all authors declare no conflict of interest a randomized phase study to evaluate the safety and antiviral activity of remdesivir key: cord- - h mld x authors: butler, m. title: virus removal by disinfection of effluents date: - - journal: viruses and wastewater treatment doi: . /b - - - - . - sha: doc_id: cord_uid: h mld x the safe disposal of effluents can present a major problem to large urban communities because of their inevitable content of potentially pathogenic enteric viruses. at least one hundred types of virus may be present although many of these are difficult or even impossible to characterise under these conditions. wastewater treatment does not greatly effect the survival of many enteric viruses and some survive well even after effluent disposal. the use of disinfectants for the inactivation of virus in effluent is practicable but requires careful manipulation in order to avoid the disemination of byproducts toxic to man or capable of interferring with the ecology of the receiving waters or soils. no one system is likely to be either universally acceptable because of the variable quality of effluents and much research remains to be done before guidelines can be recommended or established. is disinfection of effluents necessary? seven years ago berg ( ) made the point that although it was not easy to remove all viruses from sewage, the technology to do so existed and we should be prepared to pay the cost. it is the object of this brief review to re-examine the practicability of achieving virus-free effluents, a subject recently reviewed by several others in particular, grabow ( ) , white ( ) and bitton ( ) . the safe disposal of effluents and the associated sludges can present a major problem to urban communities where the volumes involved may exceed millions of litres each day. although these products of wastewater treatment are potentially valuable for irrigation and fertilisation of land, they are usually discarded because it is simpler and cheaper . sludges are frequently dumped in the sea, but may be spread on land where the treatment works are too far from the coast for transportation to be economical. effluents typically pour into rivers, estuaries or the sea depending on the location of the treatment works, but, where water is scarce,they may be used as an irrigant or even recycled for Μ. butler potable supply (grabow, ) . however, apart from the technical and engineering problems involved in such productive distribution of effluent, serious consequences may result from their use because of their load of chemical contamination and the presence of pathogenic microorganisms including viruses. the degree of chemical and biological contamination reflects on the origin of the wastewater which may range from purely domestic sewage to principally industrial effluents. furthermore, the quality of products of wastewater treatment depends on the type of process used which range very widely indeed. the final processing or finishing of effluents and sludges is necessarily different because of their different constitution and this is particularly obvious so far as the removal of viruses is concerned. the removal of viruses from sludges has only relatively recently attracted serious attention (cliver, ; berg, ; osborn and hattingh, ) but for effluents, various procedures have been adopted for some time, particularly disinfection with chlorine, a treatment now under critical review. the problems associated with the removal of viruses from effluents are complex and it is essential to pay close attention to the following interdependent questions if a proper evaluation of suitable methods of treatment is to be reached: . how many types of viruses are present in effluent, how numerous are they and what is their pathogenic potential? . how reproducible and sensitive are the methods for the isolation and characterisation of viruses in effluent and is there a representative virus. how does wastewater treatment affect the distribution and fate of viruses and how well do viruses survive after the disposal of untreated effulent? what methods are available and practicable for the removal of viruses from effluents, how do these work and is there a recommended procedure? . viruses get into wastewater with the faecal solids within which they may be present at levels of up to '^/g as judged by electron microscopy (flewett, ) . however, levels of infectious virus in faeces may be much lower (madely, ) and since faecal solids represent only a minute fraction of wastewater, the predicted input of infectious virus may be no more than vlitre (melnick, gerba and wallis, ) . it is well known that at least a hundred different types of enteric viruses (table ) may be found in human faeces (melnick, gerba and wallis, ) , of which at least some could be expected to be in final effluents. it'is also possible that certain viruses excreted with the urine could also be present (utz, ) but in general, it is likely that the frequency and pathogenic potential of enteric viruses will be influenced by geographic, seasonal,as well as socioeconomic factors. most enteric virus infections in developed countries are sporadic and episodic but in developing regions they may well be seriously epidemic. the range of symptoms they may cause include not only gastroenteritis but such divergent clinical features as meningitis, exanthema and even respiratory symptoms (andrews, perlera and wildy, ) . some enteric viruses, for instance poliovirus vaccine strains, may for obvious reasons be regularly isolated from effluent or contaminated waters although apparently not necessarily so even during a vaccination campaign (katzenelson & kedmi, ) . of the other common enteric viruses, the echoviruses, the coxsackieviruses, the reoviruses and the adenoviruses many may be isolated throughout the year, but the serotypes may vary from year to year and valuable corroborative data for this has been provided in the u.k., by the public health authority through its weekly and quarterly reports (cdsc, i o). unfortunately, several important enteric viruses such as hepatitis a, the rotaviruses and several so-called 'small round viruses' cannot be readily cultivated in the laboratory (table ) and evidence for them depends wholly on clinical or immunological data, or on their visualisation in the electron microscope. although many different enteric viruses are likely to be present in wastewater, the risks of transmission of infection via contaminated water in developed countries by various routes (fig. ) is thought to be slight although probably increasing, but elsewhere the risks may be very great indeed (who, ) . undoubtedly, outbreaks of gastroenteritis have been associated with effluentpolluted lake water (cdc, ; denis et al., ) and bathing beaches (cabelli et al., ) and many cases of hepatitis a as well as other enteric virus infections have resulted from the consumption of shell fish harvested from contaminated waters . in general, where epidemiological evidence for gastroenteritis and diarrhoeal diseases has been assembled, it accounts for about half the recorded outbreaks of waterborne diseases (craun, mccabe and hughes, ) , although in relatively few cases is the aetiological agent identified either by isolation or by serological means. it is however believed that a substantial proportion of these infections could be of viral origin because of the development of symptoms between one and two days after infection and the recovery of the subject within two to three days without significant sequelae. although clinically characteristic infections such as hepatitis a may well occur, it must be borne in mind that only a small proportion of infected subjects, especially children, develop symptoms (evans, ) and this is also true of virtually all enteric virus infections even those which may be very serious, such as poliomyelitis. the significance of this observation is that infected symptomless individuals may well represent foci for further infection in the community, and should this happen, then disease of epidemic proportion could subsequently develop. of course, in these circumstances, it would be very difficult to relate such an epidemic to an original waterborne infection. incidentally, it is suggested by some that low levels of infection through the water route may be advantageous to a community by providing it with a relatively harmless mechanism for the circulation of viruses which could otherwise become dangerously epidemic in a largely susceptible population (mosley, ) . it has also been argued (gamble, ) that even if the elimination of such low-level transmission of viruses were possible it would be unlikely to have much effect on endemic infection which is commonly by the direct person to person method. neverhteless, it is thought that viruses in water represent an underestimated problem (mahdy, ) . . an assessment of the extent of the hazards of viral contamination of effluents and the effectiveness of any treatment for its removal depends critically on the sensitivity and reliability of the procedures for the recovery and characterisation of the viruses. successful characterisation of viruses depends essentially on the infectivity test because not only is this the paramount property under scrutiny but the levels likely to be present are very small indeed. certainly they would not be sufficient, without impractical levels of concentration, for detection by electron microscopy or serological techniques, both of which require at least ^ particles/ml. although infectivity assays may be quite sensitive, it must be borne in mind it is possible that only one infectious particle is sufficient to infect a .pa susceptible subject and in this regard, it is important to note the difficulty which exists in defining an infectious particle (floyd and sharp, ) which may be an aggregate of particles, or even particles embedded in organic floe. another impoortant limitation on the interpretation of infectivity assays relates to the sensitivity of the selected cell culture. the choice of this is often dictated by such pragmatic considerations as cost and practicability, for instance, it is claimed that one of the most sensitive cell systems for a wide range of enteric viruses is the primary rhesus kidney cell culture but this is now virtually unobtainable and one or more monkey kidney cell lines like vero and bgm have become popular alternatives . none of these cell cultures is equally sensitive to all the enteric viruses, furthermore, some viruses replicate in them much more slowly than others so that overgrowth of the culture by one virus may occur, a not unlikely event, from an effluent sample which could well be expected to be contaminated with several different viruses. this problem would be less troublesome where the assay for infectivity was the plaque test, but it would be intractable where a quantal assay was employed based on degeneration of the whole culture. even greater problems occur when the virus is noncytopathogenic, and this could be compounded if such a virus interfered with the growth of a cytopathogenic virus. another limitation which must be applied to the interpretation of infectivity assays is that cell sensitivity to laboratoryadapted virus and to fresh viral isolates is known to differ, especially to isolates from faecal samples (madeley, ) with which virus in effluents are comparable. these various points highlight the difficulties in developing viral standards for effluent quality where the assay of infectivity is only effective for some, uncertain for others and totally unavailable for those in which we are particularly interested another constraint on the sensitivity of the infectivity assay relates to the small number of infectious particles which may be present, such that concentration of the sample before isolation may well be essential. many methods for concentration of viruses from water have been recommended, such as filtration, flocculation or two phase liquid separation, but their value for effluent treatment will be greatly influenced by the effluent quality especially its content of suspended solids. (seeley and primrose, ) . one particular problem is the concentration of cytotoxic substances which may be difficult to characterise and remove (glass, sluis and yanko, ; schmidt et al., ) . having isolated and cultured a virus from effluent, there remains its characterisation and identificationwhich is a major task. this, to a large extent, depends on the development of a characteristic cytopathology and the application of serological tests, particularly the neutralisation test. other serological tests like immunoflourescence for non-cytopathogenic viruses may have to be used and characterisation by electron microscopy may also be necessary. clearly, the complexity of this situation makes the testing for the presence of all possible enteric virus out of the question, yet it is equally true that the monitoring for the effectiveness of effluent treatment is essential, so the selection of an indicator virus would be useful. for bacteria it is generally agreed that certain coliform bacteria may be regarded as representative, but with viruses it is not at all obvious which, if any one type, could be selected. the idea that enteric bacteria could be used as models for enteric viral contamination has been rejected, not only because there is little correlation between the levels found of the two groups, but because many viruses are more resistant to disinfection, which is the usual object of the study (berg, et al., ) . furthermore, the range of types of enteric viruses which may be present vary widely because, unlike many enteric bacteria, they do not appear to form part of the natural gut flora but occur sporadically. however, it has been frequently suggested that a coliphage,which would be expected to be part of the natural flora, would be suitable indicator of enteric virus pollution (scarpino, ; kott et al ) . the coliphages certainly fulfil a number of recommended prerequisites (haas, ) that they are present whenever their pathogenic hosts are present, they are incapable of regrowth in the effluent, but are at least equally resistant to environmental stress, including disinfection. furthermore, they are present in large numbers and are readily enumerated. however the selection of a particular coliphage poses a problem, for instance, an obvious contender like the f coliphage recommended by shah and mccabe ( ) is not the only phage to replicate in its specific host escherichia coli (k-, hfr). the use of the less selective £^ coli Β strain would isolate even more types of coliphages (kott, et al., ) . the deliberate introduction of a phage type unlikely to occur naturally, for example, a phage of serratia m^rc^seng (castens and coetzee, ) would be impractical for routine monitoring of effluent treatment, even supposing it had the right properties, like high resistance to disinfectant. to take a phage dependent on a host thought to be commonly present in wastewater treatment like a cyanophage (smedberg and cannon, ) would only be useful if it occurred reliably and was also very resistant to effluent treatment. nearly all these studies, as well as those in which a model enterovirus was propsed, suffer from the disadvantages peculiar to such laboratory studies, in that it is not certain how far results can be extrapolated to field conditions. so how worried need we be about viruses in effluent? the answer depends essentially on the nature of the wastewater treatment providing the effluent and, of course, on the fate of the effluent and the survival of the viruses in the receiving waters or soil. the nature of the wastewater treatment will inevitably influence the behaviour and fate of viruses, for instance, it is well known that much more virus is found in effluents after percolating filtration than those from the activated sludge treatment (berg, ) . the degritting and settling procedures carried out during the early stages of sewage treatment lead to an unpredictable dispersion of the virus originally present in the faecal solids. for instance, although a substantial proportion of the solids settle out into the primary sludges there is little apparent loss of infectivity in the settled sewage effluent (kollins, ) presumably due to a break up of vvviral aggregates and floes to release individual infectious virions and the fact that viruses have a strong predeliction to adsorp to solids (bitton, ) accounts for their effective removal during the activated sludge aeration. indeed, good quality effluents from such treatment should have a very low suspended solids content and a good correlation between low solids content and low viral infectivity of effluents has been observed (balluz and butler, ) . the absence of solids from effluent is also important because they provide a mechanism for the protection of adsorbed virus against disinfection (boardman and sproul, ; hajkal, et al, ) virus in untreated final effluents is ultimately subject to various forms of environmental stress in the receiving waters or soil (bitton, ) , but the fact that virus is readily isolated from effluent polluted river water obviously implies reasonable survival and experimental studies in different types of water provide additional evidence of good survival (gerba, wallis and melnick, ) especially in clean (mehnel et al., ) or heavily polluted waters but surprisingly and inexplicably, less so in moderately dirty water (clarke, et al ) . virus apparently survives less well in sea water (gerba and schaiberger, b) indeed there is some evidence that it is specifically inactivated (fujioka, loh and lau, ) . disposal of effluent to land may result in percolation of virus through the soil to contaminate ground water supplies (schaub and sorber, ) but normally viruses eventually disappear, due to adsorption and ultimately inactivation. .pa the distribution of viruses in soil is known to be strongly influenced by the degree of hydration, the ph, the ionic strength and the organic content of the medium (akin et al., ) . it is clear from all this that the ecology of viruses during wastewater treatment and after the disposal of the products is evidently very complex. furthermore, it is also worth noting that virions enter the sewage plant discontinuously and in various states of aggregation so that no one sample at any one stage in the process can be taken as representative of anything other than what is present at that time in that sample. . the methods available for the inactivation of viruses in effluent differ little in principle from those applied to potable water, but are distinct from the disinfection of viruses contaminating, laboratory or medical equipment, where highly toxic chemicals like detergents, phenols, formaldehyde or permanganate may be used (spalding et al ) . for effluents, the choice of treatment is limited by the requirement for a high quality final effluent free from harmful by-products. the treatment must be cheap, easy to produce. the disinfection methods available range from the purely physical (table ) , to purely chemical (table ) like the application of the halogen disinfectants. in addition, there is the more complex and interesting application of a combination of one or more of these basic methods. indeed, the distinction between the categories is by no means clear cut, especially in effluents where, because of the impurities, a number of mechanisms may operate antagonistically or synergistically. for example, ionising irradiation although able to act directly on the virus, may also function chemically in so far as it may induce the production of toxic free radicals. in contrast, a chemical disinfectant like chlorine, may react preferentially with organic and inorganic contaminants so that its full potential is lost. thus, the effectiveness of any one of these treatment systems may be much influenced by the presence of chemical and physical impurities and the pretreatment of effluents to remove these may be essential for the effective, economic and safe disinfection of viruses (guy and mclver, ) . culp ( ) questioned the need for disinfection after effective per treatment but this very much depends on the fate of the effluent and a number of procedures have been adopted for the improvement of effluent quality before disinfection. of the most commonly applied methods, flocculation with a variety of salts or synthetic polyelectrolytes is probably the most useful, but not all viruses behave in the same way, for instance rotavirus is less efficiently adsorbed to aluminium hydroxide than poliovirus, (farah et al., ) , but in practice such differences might not be important. filtration of effluents by slow sand fliberation (poynter and slade, ) results in the removal of virus by adsorbtion to the complex microbial population which grows in the upper layers,but rapid sand filtration although removing solids from effluent and therefore effecting some useful clarification does not remove suspended virus well (guy and mclver ) furthermore its function in this regard is greatly influenced by ph, ionic concentration and organic contamination. adsorption of virus to such substances as activated charcoal is efficient from clean water (oza and chang, ) but such substances are rapidly blocked by organic matter (sproul, ) . incidently all these transport and store. it must be potent at low dosage and readily decompose, either spontaneously or by the application of a neutralising agent, into harmless by-products. furthermore, it must be simply and reliably assayed and unreactive with other chemical or physical constituents of the effluent. in this regard, the characterisation of effluent is an important consideration because wide variations in physical and chemical quality are known to occur and are likely to influence the effectiveness of disinfection (tonelli, ) . treatments which result in the removal of virus merely defer the problem of its inactivation, to the treatment of the resultant sludge. excess lime treatment has the greatest promise for the treatment of effluent with resultant inactivation of virus (grabow, middendorf and basson, ) it is thought that the single-stranded rna viruses are particularily susceptible to the high ph values obtained with the genome as the prime target although sproul ( ) thought that inactivation was the result of denaturation of the capsid. in general, enteric viruses have a wide ph tolerance which is, presumably, a reflection on their natural history as gut parasites transmitted by the faecal oral route and, therefore, exposed to the acidity of the stomach and compensating alkaline secretions of the small intestine. inactivation of virus present in good quality effluents by physical of physicochemical methods has attracted increasing attention because disinfection by chlorine has come increasingly under attack. the most promising developments use ionising (sinsky, ) and non-ionising irradiation (vajdic, ) not only alone but in conjunction with chemical methods. the main disadvantages in these methods is that ionising irradiation by gamma rays or high energy electrons, like that with ultraviolet, has poor penetrating power and its effect is greatly diminished by turbidity. however, although expensive in comparison to the application of conventional disinfectants they may, as a result of improved, technology become competitive and acceptable (singer and nash , ) heat also would work well but remains impractical for effluents, although applicable to sludges (ward and ashley, ) where anaerobic digestion results in the development of elevated temperature. however, studies of heat inactivation of viruses in water have, incidently, provided a useful basis for understanding viral inactivation in general. in particular, of the characteristic biphasic inactivation where after treatment there remains a residual of apparently unaffected virus. the influence of ph, divalent cations and redox potential on heat inactivation may also provide some insight into the influence of these factors on chemical disinfection, indeed the action of ph, cations or redox potential alone on viruses should not be ignored (poynter, slade & jones ) because both redox potential and ph are both believed to act on viral capsid proteins (mandel, ) which may either alter their sensitivity to disinfectants or their ability to adsorb to sensitive cells. the most practical and successful disinfectants of wastewater effluents are the oxidising agents like the halogens, ozone and peroxides, although it is likely that the action of these chemicals is not exclusively through oxidation. the general principles of disinfection were established by chick (i o ) who formulated a law which stated that the ratio of a given population decreased exponentially with time, that is that the reaction obeyed 'first order* kinetics. however this only applies if the disinfectant is in excess (hiatt, ) , if the system is homogeneous and if the interaction between virus and the disinfectant is direct. such conditions do not, of course, apply in sewage effluent which has a complex and variable constitution. deviations from first order reactions have been commonly observed and they mainly fall into two categories, those which show an initial lag before maximum or optimum rates of inactivation develop and those where, after an initial period of rapid inactivation, a plateau develops representing a persistant infectious fraction. sometimes both features are observed in the same system (fujoka and ackerman, ) . various explanations have been sought for these phenomena. for instance, an initial shoulder would appear when the multihit response occurred as would be expected with most suspensions of infectious virions which, of course, include viral aggregates of various size (floyd & sharp ) . there would be, in such examples, a delay in the measured loss even though much virus was actually inactivated. aggregation could equally explain residual infectivity where infectious particals remained inaccessible to the disinfectant (broardman and sproul, ) it is also possible that viral populations are genetically heterogenous with respect to sensitivity to disinfection, indeed some studies have resulted in the selection of population with increased resistance (bates, shaffer and sutherland, ) but it is also possible that some residual infectivity is the result of multiplicity reactivation (young and sharp, ) that is the restoration of the complete replication mechanism due to the multiple infection of a cell with virions with differntly but only slightly damaged genomes. such doubts re-emphasise the neeed for reliable and reproducable infectivity assays and in such situations each virus particle must be assumed to be infectious and its infectivity determinable. there are infact few examples where the total number of virions present corresponds to the number of infectious units and usually there is a considerable difference. this also emphasises that a disinfection activity may have to be determined empirically for each virus in question if precise data is required (hajenion and butler, ) . certainly, assay of its efficacy depends not only on effective assay of infectivity but also on that of the disinfectant. the mechanism by which the oxidative disinfectants work is probably complex and a basic understanding is required. so far as the halogens are concerned they are known to react with viral proteins and nucleic acids ( ivieri et al., ; »brien and newan, ) and in this debate it is worth noting the essential structural features of the enteric viruses which have a proteinaceous capsid enclosing the single or double stranded nucleic acid genome. the capsid proteins may be organised as specific receptors, the integrity of which is vital to the infectious process but damage to the receptors may not result in de naturation of the genome which, of course, leaves the possibility that viral replication could ultimately occur. furthermore, as noted above, partial denaturation of the genome may not inevitably result in failure to replicate. a disinfectant may dissociate or denature viral proteins or react with the genome or both and one which reacts specifically with the genome must be able to penetrate the capsid. of the halogen disinfectants, chlorine has a long history as a successful disinfectant (white, ) . it is most commonly used for finished potable waters and swimming pools but is widely used for treatment of effluents, particularly storm waters and even for oxidation ponds (kott, ) . its chemial properties have been exhaustively examined and described. basically, when a halogen is dissolved in water it hydrolizes to form the hypohalous acid. x + h o >-hox + x" + h+ and the acid ionises to the hypohalite ion. ox" + Η·*-hydrolysis and ionisation are ph, temperature and concentration dependant and the three halogens chlorine, bromine and iodine behave differently. it is important to know this because it is the hypohalous acid which is the most active molecule. for instance at low ph the chlorine molecule is predominant whereas above ph the hypochlorite ion is present. chlorine functions best against viruses at about ph when optimum levels of the acid are formed (kott, nupen and ross, ) and it is worth noting, here, that the ph of many effluents is about ph . halogens react with other nitrogenous matter to form similar derivatives but the chemistry of such compounds is complex. halogens also react with inorganic matter to produce stable but non-disinfecting compounds and the loss of halogen this way is referred to as the halogen demand of the system, which is usually high in effluents. in the case of chlorine it is clear that it has some remarkably useful characteristics especially in water with slight nitrogenous contamination when it forms stable, persistent and disinfecting chloramines. these are, however, less active against viruses than against bacteria (shah and mccamish ; hart, ) . in heavily polluted effluents the loss of chlorine, its conversion into chloramines and many even less acceptable byproducts may be so great as to render its highly unsuitable (ward and degraeve, ; smith, mccall and chen, ) mainly because of their toxicity to the natural flora and fauna of the receiving waters and their carcinogenic potential. furthermore, it may be necessary to acidify effluent to obtain optimum conditions for chlorine disinfection (mills, ) . the disinfection potential of chlorine against viruses has been demonstrated by many people with experimental model systems as well as in the field situation. it is important to note that viruses range in their sensitivity (lund ) for instance a laboratory strain of coxsackievirus was the most resistant enterovirus tested and some other enteritis viruses like reovirus and adenovirus were more sensitive than than any of the tested enteroviruses. more interesting is the observation that fresh isolates of enterovirus appeared to be more resistant than laboratory adapted strains (kelly and sanderson, , lui et al ) . furthermore, certain viruses may have resistance selectively induced by cultivation in the presence of chlorine (bates, shaffer and sutherland, ) . this observation raised objections to inadequate chlorination (nupen and morgan, ) because of the possibility that such resistant viruses may, when released in effluent, ultimately replicate in susceptible people. the need for thorough mixing of disinfectant to ensure optimal activity is stressed (longley, ) and this is especially important where virus is another interesting and important phenomenon is that hypohalous acids react with ammonia to form mono, di and tri halomines: hox + nh nh x + h o. hox + nh nhx + hox + nhx >-nx + h o these reactions are concentration dependant such that, for instance, when the ratio of chlorine to ammonia is greater than : , free chlorine is again available for hydrolysis, a phenomenon well known as break-point chlorination (palin, ) . the reaction is also ph dependant with the highly substituted derivatives being found in acid conditions. the mono and dihalomines decompose to release nitrogen and those formed with chlorine are the most stable: nh x + hox >-n + hx + h o nhx n + hx + x adsorbed to particulate matter by which it is protected (boardman and sproul, ; hijkal et al, ) so the design of efficient chlorinating systems is .pa important (tickhe, ) . furthermore, its meaningful assay in effluent has been closely questioned (morrow and martin, ) . of these methods chemical assay, especially by the dpd method (palin, ) , is the most accurate and reproducible but for automatic monitoring the known relationship between redox potential and disinfection potential (victorian, hellstrom and rylander, ) has led to the development of assay based on the electrical charge however, the value of this has been questioned (rosenblalt, ) especially its application to water heavily contaminated with nitrogenous compounds (johnson, edwards and keeslan, ) when an electrode responding directly to hypochlorous acid was used. no one method is wholly satisfactory because the chemical property of a disinfectant may not correspond with its disinfecting potential. the problems resulting from the excessive use of chlorine for effluent disinfection (comp. general, ) has led to quite extensive searches for alternative. furthermore, the disontinuance of the production and distribution of liquid chlorine, which some critise (humphrey, ) ,has precitated even more active interest in alternative disinfectants. of the other halogens the one least likely to be useful alone is iodine. it is both poorly soluble in aqueous solution and not very reactive. however, it is easily stored and transported and is therefore useful for emergency sterilisation of water. in aqueous solution it forms hypoiodous acid and hydrogen iodide, the acid being the most active molecule: hoi + hi it experiences considerable demand but it persists for longer in effluent than chlorine (cramer et al., ) and is a more effective virucide than chlorine both at neutral ph and, especially, at higher ph values. bromine, although known to be a powerful virocide (taylor and johnson, , floyd, johnson and sharp, ; hajenian and butler, i o) is poorly soluable in water and is a highly corrosive liquid. although, as such, it is not suitable for effluent treatment its chlorine derivative, bromine chloride has great promise. indeed this has been found to be more effective against viruses than chlorine on a weight for weight basis (keswick et al., ; kawata et al., ) and experienced less interference from added ammonia or glycine in sewage effluent. however,.its potential against a wide spectrum of enteric viruses has yet to be evaluated as has the effect of its residual on the ecology of the receiving waters (mills, ) . it is readily soluable in water and in a aqueous solution hypobromous acid is formed which is readily ionised: brcl + h o hobr + hcl if some hypochlorous acid is also formed it is unstable in the presence of the bromide ion forming further hypobromous acid, the most active molecule hocl + br >-hobr + cl" these reactions are ph dependant and the greatest disinfecting potential is between ph and which would mean that for use in effluent no acidification would be required. the disinfectant reacts, of course, with nitrogenous compounds to form bromamines which are claimed to be highly virucidal (mills, ) . however, they are short lived which although a disadvantage for clean water treatment would therefore be a valuable property for effluents treatment. the excellent potential for disinfection possessed by chlorine dioxide was recognised over thirty years ago (ridenour and ingols, ) and it has been .pa shown to be very useful against viruses (dowling, ; kawata et al., ) .in aqueous solution it produces chlorous and chloric acids the normal method of production of chlorine dioxide which is from chlorine and sodium chlorite means that a residual of chlorine remains which in the form of hypochlorous acid reacts with chlorine dioxide to produce the highly reactive chloride ion (tifft et al., ) : some of the early reports on the disinfecting activity of chlorine dioxide failed to take into account that chlorine was present but in more recent studies, especially where the disinfectant is made by heating potassiun chlorate with oxalic acid (palin, ) its activity is better understood. fortuitously, chlorine dioxide does not readily react with nitrogenous compounds although it does experience a demand from phenolic chemicals. it is this property, resulting in the elimination of colour, taste and odour which has attracted much attention (ingols, ) . its assay in the presence of chlorine is complex but recently a specific spectrophotometric assay has been reported (knechtel, janzen and davis, ) which is useful. from the earliest times ozone has attracted a lot of attention as a water disinfectant. like chlorine dioxide, it has to be produced in situ but the equipment is simple depending on the convertion of oxygen in an electric arc. however, for accurate and reliable delivery considerable care has to be exercised, and its assay is frought with difficulty because its chemistry in aqueous solution is complex (peleg, ) . its disinfectant activity probably resides in the hydroxy and oxide radicals (hoigne and baden, ; kim, gentile and sproul, o) but its value also lies in its capacity to react with many organic carbon compounds incidently resulting in the removal of colour, odour and taste, a subject which has been critically reviewed (kinman, ) . it has been shown to be active against a range of viruses (evison, ) and its potential is greatly enhanced by good mixing particularly the application of ultrasound (dahi, , burleson, murray and pollard, ) which probably affects not only the bubble size (farouq, chian and engelbrecht, ) but may be useful in the break-up of viral aggregates and the release of virus from floe. its effectiveness has been compared to that of chlorine (bollyky and siegel, ; wyatt and wilson, ) , but its main disadvantage for effluent is the great demand which has to be met before the formation of the active residual, however there is a complete absence of harmful biproducts. there remains a small miscellany of chemicals which are known to have a disinfecting potential but which have not been adequately tested. prime amongst these is peracetic acid. its virucidal activity was first reported by klein and hull ( ) and later by sprossig and mucke ( ) and there is a recent laboratory study on viruses in effluent (hajenian and butler, i o) . this is complemented by a similar, although more extensive study of its bacteriocidal aativity in effluent (poffe et al., ) in aqueous solution nascent oxygen is produced which presumably imparts the disinfecting property:- the byproduct, acetic acid, is unlikely to be toxic although it is undoubtedly a microbial metabilite. it appears to suffer negligable demand in effluent since its activity is fully retained against added virus up to thirty minutes after its original application (hajenian and butler, i o) . another common peroxide,the peroxide of hydrogen is a very weak disinfectant (bayliss and waites, ) and is unlikely to be useful for wastewater treatment except for the control of hydrogen sulphide and bulking. one of the most interesting developments in the disinfection of effluents could be the application of two or more treatments sequentially or simultaneously to achieve a real or apparent synergistic effect. apparent synergism would occur, of course, when the action of one treamtent simply removed a substance capable of blocking or inactivating the other reactant. examples of this have already been noted, for instance the pretreatment of effluent to make it more suitable for chemical disinfection or the more special case of the value of ultra sound during ozonisation (dahi, ) .a good example of real synergism is demonstrated by the sequential addition of chlorine and chlorine dioxide where the nett disinfection is improved (tifft et al., ) . usually the advantages of such treatment or equivalent procedures with chlorine and ozone (ross, van leeuven and grabow, ; wyatt and wilson, ) is mainly in the production of a better quality water free from irritating or toxic residuals. true synergism has also been thought to be the result of the combination of monochl or amine and iodine (kerman and layton, ) and iodine with ozone (buddie, ) . a number of other combinations of disinfectants could be usefully explored, for instance chlorine with peracetic acid where the application of the latter causes a fall in ph to acid values (hajenian and butler, b) at which chlorine is at its greatest efficiency. a particular problem with such studies especially where the chemicals are applied simultaneously could be in the determination of specific disinfectant residual. in conclusion it should be stressed that few of the viruses present in effluent can be properly characterised. furthermore, the health hazard that any potentially pathogenic enteric virus represents in effluent can only be guessed at. however, although the disinfection of effluents, will improve the situation the variable quality of effluents will make it difficult to standardise any procedure. it should also be stressed that overdosing with disinfectant, especially chlorine, should be discouraged and critical studies of alternatives continued, especially, perhaps the development of the combination of disinfectants. proc. th water quality conf. univ. illinois, snoeyink introduction to ewnvironmental virology am. water wks. m water sew water sew. wks. ih i o) in: disinfection -water and waste water div, water air waste chem, pacs ϋ transmission of viruses byy the water route waste water eng inrdisinfection-water and wastewater in:discharge of sewage from sea outfalls water pollut. cont. fed. highlights (deeds & data) proc. biochem. j¿ chemistrv of water suddiv treatment and distribution water pollut viruses in water surveillance of drinking-water quality who monograph series no key: cord- -hnf vayd authors: ford, richard b.; mazzaferro, elisa m. title: emergency care date: - - journal: kirk and bistner's handbook of veterinary procedures and emergency treatment doi: . /b - - - / - sha: doc_id: cord_uid: hnf vayd nan in the event that you suspect peritonitis and have a negative tap with abdominal paracentesis, a diagnostic peritoneal lavage can be performed. to perform abdominal paracentesis, follow this procedure: . place the patient in left lateral recumbency and clip a -to -inch square with the umbilicus in the center. . aseptically scrub the clipped area with antimicrobial scrub solution. . wearing gloves, insert a -or -gauge needle or over-the-needle catheter in four quadrants: cranial and to the right, cranial and to the left, caudal and to the right, and caudal and to the left of the umbilicus. as you insert the needle or catheter, gently twist the needle to push any abdominal organs away from the tip of the needle. local anesthesia typically is not required for this procedure, although a light sedative or analgesic may be necessary if severe abdominal pain is present. in some cases, fluid will flow freely from one or more of the needles. if not, gently aspirate with a -to -ml syringe or aspirate with the patient in a standing position. avoid changing positions with needles in place because iatrogenic puncture of intraabdominal organs may occur. . save any fluid collected in sterile red-and lavender-topped tubes for cytologic and biochemical analyses and bacterial culture. monitor hemorrhagic fluid carefully for the presence of clots. normally, hemorrhagic effusions rapidly become defibrinated and do not clot. clot formation can occur in the presence of ongoing active hemorrhage or may be due to the iatrogenic puncture of organs such as the spleen or liver. if abdominal paracentesis is negative, a diagnostic peritoneal lavage can be performed. peritoneal dialysis kits are commercially available but are fairly expensive and often impractical. to perform a diagnostic peritoneal lavage, follow this procedure: . clip and aseptically scrub the ventral abdomen as described previously. . wearing sterile gloves, cut multiple side ports in a -or -gauge over-the needle catheter. use care to not cut more than % of the circumference of the catheter, or else the catheter will become weakened and potentially can break off in the patient's abdomen. . insert the catheter into the peritoneal cavity caudal and to the right of the umbilicus, directing the catheter dorsally and caudally. . infuse to ml of sterile lactated ringer's solution or . % saline solution that has been warmed to the patient's body temperature. during the instillation of fluid into the peritoneal cavity, watch closely for signs of respiratory distress because an increase in intraabdominal pressure can impair diaphragmatic excursions and respiratory function. . remove the catheter. . in ambulatory patients, walk the patient around while massaging the abdomen to distribute the fluid throughout the abdominal cavity. in nonambulatory patients, gently roll the patient from side to side. . next, aseptically scrub the patient's ventral abdomen again, and perform an abdominal paracentesis as described previously. save collected fluid for culture and cytologic analyses; however, biochemical analyses may be artifactually decreased because of dilution. remember that you likely will retrieve only a small portion of the fluid that you instilled. during the early stage of repair, granulation tissue, some exudate, and minor epithelialization is observed. place a nonadherent bandage with some antibacterial properties (petroleum or nitrofurazone-impregnated gauze) or absorbent material (foam sponge, hydrogel, or hydrocolloid dressing) in direct contact with the wound to minimize disruption of the granulation tissue bed. next, place an absorbent intermediate layer, followed by a porous outer layer, as previously described. granulation tissue can grow through gauze mesh or adhere to foam sponges and can be ripped away at the time of bandage removal. hemorrhage and disruption of the granulation tissue bed can occur. later in the repair process, granulation tissue can exude sanguineous drainage and have some epithelialization. a late nonadherent bandage is required. the contact layer should be some form of nonadherent dressing, foam sponge, hydrogel, or hydrocolloid substance. the intermediate layer and outer layers should be absorbent material and porous tape, respectively. with nonadherent dressings, wounds with viscous exudates may not be absorbed well. this may be advantageous and enhance epithelialization, provided that complications do not occur. infection, exuberant granulation tissue, or adherence of absorbent materials to the wound may occur and delay the healing process. moist healing is a newer concept of wound management in which wound exudates are allowed to stay in contact with the wound. in the absence of infection a moist wound heals faster and has enzymatic activity as a result of macrophage and polymorphonuclear cell breakdown. enzymatic degradation or "autolytic debridement" of the wound occurs. moist wounds tend to promote neutrophil and macrophage chemotaxis and bacterial phagocytosis better than use of wet-to-dry bandages. a potential complication and disadvantage of moist healing, however, is the development of bacterial colonization, folliculitis, and trauma to wound edges that can occur because of the continuously moist environment. use surfactant-type solutions (constant clens; kendall, mansfield, massachusetts) for initial wound cleansing and debridement. use occlusive dressings for rapid enzymatic debridement with bactericidal properties to aid in wound healing. bandage wet necrotic wounds with a dressing premoistened with hypertonic saline (curasalt [kendall] , % saline) to clean and debride the wounds. hypertonic saline functions to desiccate necrotic tissue and bacteria to debride the infected wound. remove and replace the hypertonic saline bandage every to hours. next, place gauze impregnated with antibacterial agents (kerlix amd [kendall] ) over the wound in the bandage layer to act as a barrier to bacterial colonization. if the wound is initially dry or has minimal exudate and is not obviously contaminated or infected, place amorphous gels of water, glycerin, and a polymer (curafil [kendall] ) over the wound to promote moisture and proteolytic healing. discontinue moisture gels such as curafil once the dry wound has become moist. finally, the final stage of moist healing helps to promote the development of a healthy granulation tissue bed. use calcium alginate dressings (curasorb or curasorb zn with zinc [kendall] ) in noninfected wounds with a moderate amount of drainage. alginate gels promote rapid development of a granulation tissue bed and epithelialization. foam dressings also can be applied to exudative wounds after a healthy granulation bed has formed. change foam dressings at least once every to days. for closed wounds without any drainage, such as a laceration that has been repaired surgically, a simple bandage with a nonadherent contact layer (telfa pad [kendall] , for example), intermediate layer of absorbent material, and an outer porous layer (elastikon, vetrap) can be placed to prevent wound contamination during healing. the nonadherent pad will not stick to the wound and cause patient discomfort. because there usually is minimal drainage from the wound, the function of the intermediate layer is more protective than absorptive. any small amount will be absorbed into the intermediate layer of the bandage. it is important in any bandage to place the tape strips or "stirrups" on the patient's limb and then overlap in the bandage, to prevent the bandage from slipping. place the intermediate and tertiary layers loosely around the limb, starting distally and working proximally, with some overlap with each consecutive layer. this method prevents excessive pressure and potential to impair venous drainage. leave the toenails of the third and fourth digits exposed, whenever possible, to allow daily examination of the bandage to determine whether the bandage is impairing venous drainage. if the bandage is too tight and constricting or impeding vascular flow, the toes will become swollen and spread apart. when placed and maintained properly (e.g., the bandage does not get wet), there usually are relatively few complications observed with this type of bandage. in some cases, it is necessary to cover a wound in which a penrose drain has been placed to allow drainage. in many cases, there is a considerable amount of drainage from the drain and underlying soft tissues. the function of the bandage is to help obliterate dead space created by the wound itself, absorb the fluid that drains from the wound and that will contaminate the environment, and prevent external wicking of material from the external environment into the wound. when the bandage is removed, the clinician can examine the amount and type of material that has drained from the wound in order to determine when the drain should be removed. when placing a bandage over a draining wound, the contact layer should be a commercially available nonadherent dressing and several layers of absorbent wide-mesh gauze placed directly over the drain at the distal end of the incision. overlay the layers of gauze with a thick layer of absorbent intermediate dressing to absorb fluid that drains from the wound. if the gauze and intermediate layers are not thick or absorbent enough, there is a potential for the drainage fluid to reach the outer layer of the bandage and provide a source of wicking of bacteria from the external environment into the wound, leading to infection. some wounds such as lacerations have minor bleeding or hemorrhage that require an immediate bandage until definitive care can be provided. to create a pressure bandage, place a nonadherent dressing immediately in contact with the wound, followed by a thick layer of absorbent material, topped by a layer of elastic bandage material such as elastikon or vetrap. unlike the bandage for a closed wound, the top tertiary outer layer should be wrapped with some tension and even pressure around the limb, starting from the distal extremity (toes) and working proximally. the pressure bandage serves to control hemorrhage but should not be left on for long periods. pressure bandages that have been left on for too long can impair nerve function and lead to tissue necrosis and slough. therefore, pressure bandages should be used in the hospital only, so that the patient can be observed closely. if hemorrhage through the bandage occurs, place another bandage over the first until the wound can be repaired definitively. removal of the first bandage will only disrupt any clot that has formed and cause additional hemorrhage to occur. fractures require immediate immobilization to prevent additional patient discomfort and further trauma to the soft tissues of the affected limb. as with all bandages, a contact layer, intermediate layer, and outer layer should be used. place the contact layer in accordance with any type of wound present. the intermediate layer should be thick absorbent material, followed by a top layer of elastic bandage material. an example is to place a telfa pad over a wound in an open distal radius-ulna fracture, followed by a thick layer of cotton gauze cast padding, followed by an elastic layer of kling (johnson & johnson medical, arlington, texas) , pulling each layer tightly over the previous layer with some overlap until the resultant bandage can be "thumped" with the clinician's thumb and forefinger and sound like a ripe watermelon. the bandage should be smooth with consecutive layers of even pressure on the limb, starting distally and working proximally. leave the toenails of the third and fourth digits exposed to monitor for impaired venous drainage that would suggest that the bandage is too tight and needs to be replaced. finally, place a top layer of vetrap or elastikon over the intermediary layer to protect it from becoming contaminated. if the bandage is used with a compound or open fracture, drainage may be impaired and actually lead to enhanced risk of wound infection. bandages placed for initial fracture immobilization are temporary until definitive fracture repair can be performed once the patient's cardiovascular and respiratory status are stable. wounds with exuberant granulation tissue must be handled carefully so as to not disrupt the healing process but to keep an overabundance of tissue from forming that will impair epithelialization. to bandage a wound with exuberant granulation tissue, place a corticosteroid-containing ointment on the wound, followed by a nonadherent contact layer. the corticosteroid will help control the exuberant growth of granulation tissue. next, carefully wrap an absorbent material over the contact layer, followed by careful placement of and overlay of elastic bandage material to place some pressure on the wound. leave the toenails of the third and fourth digits exposed so that circulation can be monitored several times daily. bandages that are too tight must be removed immediately to prevent damage to neuronal tissue and impaired vascularization, tissue necrosis, and slough. because wound drainage may be impaired, there is a risk of infection. gaping wounds or those that have undermined in between layers of subcutaneous tissue and fascia should be bandaged with a pressure bandage to help obliterate dead space and prevent seroma formation. an example of a wound that may require this type of bandage is removal of an infiltrative lipoma on the lateral or ventral thorax. use caution when placing pressure bandages around the thorax or cervical region because bandages placed too tightly may impair adequate ventilation. to place a pressure bandage and obliterate dead space, place a nonadherent contact layer over the wound. usually, a drain is placed in the wound, so place a large amount of wide-mesh gauze at the distal end of the drain to absorb any wound exudate or drainage. place several layers of absorbent material over the site to further absorb any drainage. place a layer of elastic cotton such as kling carefully but firmly over the dead space to cause enough pressure to control drainage. place at least two fingers in between the animal's thorax and the bandage to ensure that the bandage is not too tight. in many cases, the bandage should be placed once the animal has recovered from surgery and is able to stand. if the bandage is placed while the animal is still anesthetized and recumbent, there is a tendency for the bandage to be too tight. finally, the tertiary layer should be an elastic material such as elastikon or vetrap. many wounds require a pressure relief bandage to prevent contact with the external environment. wounds that may require pressure relief for healing include decubitus ulcers, pressure bandage or cast ulcers, impending ulcer areas (such as the ileum or ischium of recumbent or cachexic patients), and surgical repair sites of ulcerated areas. pressure relief bandages can be of two basic varieties: modified doughnut bandage and doughnut-shaped bandage. to create a cup or clamshell splint, follow this procedure (figures - to - ): . place a nonadherent contact layer directly over the wound. . place stirrups of tape in contact with the skin of the dog, to be placed over the intermediate layer and prevent the bandage from slipping. . place a fairly thick layer of absorbent intermediate bandage material over the contact layer such that the bandage is well-padded. pull the tape stirrups and secure them to the intermediate layer. . place a length of cast material that has been rolled to the appropriate length, such that the cast material is cupped around the patient's paw, and lies adjacent to the caudal aspect of the limb to the level of the carpus or tarsus. in the case of a clamshell splint, place a layer of cast material on the cranial and caudal aspect of the paw and conform it in place. . take the length of cast padding and soak it in warm water after it has been rolled to the appropriate length. wring out the pad, and secure/conform it to the caudal (or cranial and caudal, in the case of a clamshell splint) aspect of the distal limb and paw. . secure the cast material in place with a layer of elastic cotton gauze (kling). . secure the bandage in place with a snug layer of elastikon or vetrap. short or long splints made of cast material can be incorporated into a soft padded bandage to provide extra support of a limb above and below a fracture site. for a caudal or lateral splint to be effective, it must be incorporated for at least one joint above any fracture site to prevent a fulcrum effect and further disruption or damage to underlying soft tissue structures. a short lateral or caudal splint is used for fractures and luxations of the distal metacarpus, metatarsus, carpus, and tarsus. to place a short lateral or caudal splint, follow this procedure: . secure a contact layer as determined by the presence or absence of any wound in the area. . place tape stirrups on the distal extremity to be secured later to the intermediate bandage layer and to prevent slipping of the bandage distally. . place layers of roll cotton from the toes to the level of the mid tibia/fibula or mid radius/ulna. place the layers with even tension, with some overlap of each consecutive layer, moving distally to proximally on the limb. . secure the short caudal or lateral splint and conform it to the distal extremity to the level of the toes and proximally to the level of the mid tibia/fibula or mid radius/ulna. . secure the lateral or caudal splint to the limb with another outer layer of elastic cotton (kling). . cover the entire bandage and splint with an outer tertiary layer of vetrap or elastikon. make sure that the toenails of the third and fourth digits remain visible to allow daily evaluation of circulation. long lateral or caudal splints are used to immobilize fractures of the tibia/fibula and radius/ulna. the splints are fashioned as directed for short splints but extend proximally to the level of the axilla and inguinal regions to immobilize above the fracture site. • packed cell volume drops rapidly to less than % in the dog and less than % to % in the cat • acute loss of more than % of blood volume ( ml/kg in dog, ml/kg in cat) • clinical signs of lethargy, collapse, hypotension, tachycardia, tachypnea (acute or chronic blood loss) • ongoing hemorrhage is present • poor response to crystalloid and colloid infusion • life-threatening hemorrhage caused by thrombocytopenia or thrombocytopathia • surgical intervention is necessary in a patient with severe thrombocytopenia or thrombocytopathia plasma support • life-threatening hemorrhage with decreased coagulation factor activity • severe inflammation (pancreatitis, systemic inflammatory response syndrome) • replenish antithrombin (disseminated intravascular coagulation, protein-losing enteropathy or nephropathy) • surgery is necessary in a patient with decreased coagulation factor activity • severe hypoproteinemia is present; to partially replenish albumin, globulin, and clotting factors type a cats typically possess weak anti-b antibodies of igg and igm subtypes. transfusion of type b blood into a type a cat will result in milder clinical signs of reaction and a markedly decreased survival half-life of the infused rbcs to just days. because type ab cats possess both moieties on their cell surface, they lack naturally occurring alloantibodies; transfusion of type a blood into a type ab cat can be performed safely if a type ab donor is not available. the life span of an rbc from a type-specific transfusion into a cat is approximately days. . indications for fresh whole blood transfusion include disorders of hemostasis and coagulopathies including disseminated intravascular coagulation, von willebrand's disease, and hemophilia. fresh whole blood and platelet-rich plasma also can be administered in cases of severe thrombocytopenia and thrombocytopathia. stored whole blood and packed rbcs can be administered in patients with anemia. if pcv drops to below % or if rapid hemorrhage causes the pcv to drop below % in the dog or less than % to *indicates that this must be done for each donor being tested. minor crossmatch* . obtain a crossmatch segment from blood bank refrigerator for each donor to be crossmatched, or use an edta tube of donor's blood. make sure tubes are labeled prop-erly. . collect ml of blood from recipient and place in an edta tube. centrifuge blood for minutes. . extract blood from donor tubing. centrifuge blood for minutes. use a separate pipette for each transfer because cross-contamination can occur. . pipette plasma off of donor and recipient cells and place in tubes labeled dp and rp, respectively. . place µl of donor and recipient cells in tubes labeled dr and rr, respectively. . add . ml . % sodium chloride solution from wash bottle to each red blood cell (rbc) tube, using some force to cause cells to mix. . centrifuge rbc suspension for minutes. . discard supernatant and resuspend rbcs with . % sodium chloride from wash bottle. . repeat steps and for a total of three washes. . place drops of donor rbc suspension and drops of recipient plasma in tube labeled ma (this is the major crossmatch). . place drops of donor plasma and drops recipient rbc suspension in tube labeled mi (this is the minor crossmatch). . prepare control tubes by placing drops donor plasma with drops donor rbc suspension (this is the donor control); and place drops recipient plasma with drops recipient rbc suspension (this is the recipient control). . incubate major and minor crossmatches and control tubes at room temperature for minutes. . centrifuge all tubes for minute. . read tubes using an agglutination viewer. . check for agglutination and/or hemolysis. . score agglutination with the following scoring scale: + one solid clump of cells + several large clumps of cells + medium-sized clumps of cells with a clear background + hemolysis, no clumping of cells neg = negative for hemolysis; negative for clumping of red blood cells fresh whole blood coagulopathy with active hemorrhage (disseminated intravascular coagulation, thrombocytopenia; massive acute hemorrhage; no stored blood available) stored whole blood massive acute or ongoing hemorrhage; hypovolemic shock caused by hemorrhage that is unresponsive to conventional crystalloid and colloid fluid therapy; unavailability of equipment required to prepare blood components packed red blood cells nonregenerative anemia, immune-mediated hemolytic anemia, correction of anemia before surgery, acute or chronic blood loss fresh frozen plasma factor depletion associated with active hemorrhage (congenital: von willebrand's factor, hemophilia a, hemophilia b; acquired: vitamin k antagonist, rodenticide intoxication, dic); acute or chronic hypoproteinemia (burns, wound exudates, body cavity effusion; hepatic, renal, or gastrointestinal loss); colostrum replacement in neonates frozen plasma acute plasma or protein loss; chronic hypoproteinemia; (contains stable colostrum replacement in neonates; hemophilia b and clotting factors) selected clotting factor deficiencies platelet-rich plasma* thrombocytopenia with active hemorrhage (immune-mediated thrombocytopenia, dic); platelet function abnormality (congenital: thrombasthenia in bassett hounds; acquired: nsaids, other drugs) cryoprecipitate congenital factor deficiencies (routine or before surgery): (concentration of factor hemophilia a, hemophilia b, von willebrand's disease, viii, von willebrand's hypofibrinogenemia; acquired factor deficiencies factor, and fibrinogen) *must be purchased because logistically one cannot obtain enough blood simultaneously to provide a significant amount of platelets; platelets infused have a very short (< hours) half-life. dic, disseminated intravascular coagulation; nsaids, nonsteroidal antiinflammatory drugs. universal donor (e.g., should be administered whenever possible. because there is no universal donor in the cat and because cats possess naturally occurring alloantibodies, all cat blood should be typed and crossmatched before any transfusion. if fresh whole blood is not available, a hemoglobin-based oxygen carrier (oxyglobin, to ml/kg iv) can be administered until blood products become available. table - indicates blood component dose and administration rates. blood products should be warmed slowly to °c before administering them to the patient. blood warmer units are available for use in veterinary medicine to facilitate rapid transfusion without decreasing patient body temperature (thermal angel; enstill medical technologies, inc., dallas, texas). red blood cell and plasma products should be administered in a blood administration set containing a -µm in-line filter. smaller in-line filters ( µm) also can be used in cases in which extremely small volumes are to be administered. blood products should be administered over a period of hours, whenever possible, according to guidelines set by the american association of blood banks. the volume of blood components required to achieve a specific increment in the patient's pcv depends largely on whether whole blood or packed rbcs are transfused and whole blood ml/kg will increase max rate: ml/kg/ max: ml/kg/ volume by % hours hour packed red ml/kg will increase critically ill blood cells volume by % patients (e.g., cardiac failure or renal failure): - ml/kg/hour fresh frozen ml/kg body mass (repeat - ml/minute or use rates as for plasma in - days or in - days whole blood (infuse within - hours) or until bleeding stops); monitor act, aptt, and pt before and hour after transfusion cryoprecipitate general: unit/ kg/ hours - ml/minute or use rates as for whole or until bleeding stops blood (infuse within - hours) hemophilia a: - units factor viii/kg; unit of cryoprecipitate contains approximately units of factor viii platelet-rich unit/ kg ( unit of ml/minute plasma platelet-rich plasma will check platelet count before and hour increase platelet count after transfusion hour after transfusion by , /µl) whether there is ongoing hemorrhage or rbc destruction. because the pcv of packed rbcs is unusually high ( % for greyhound blood), a smaller total volume is required than whole blood to achieve a comparable increase in the patient's pcv. in general, ml/kg of packed rbcs or ml/kg whole blood will raise the recipient's pcv by %. the "rule of ones" states that ml per lb of whole blood will raise the pcv by %. if the patient's pcv does not raise by the amount anticipated by the foregoing calculation(s), causes of ongoing hemorrhage or destruction should be considered. the goal of red blood component therapy is to raise the pcv to % to % in dogs and % to % in cats. if an animal is hypovolemic and whole blood is administered, the fluid is redistributed into the extravascular compartment within hours of transfusion. this will result in a secondary rise in the pcv hours after the transfusion in addition to the initial rise to hours after the rbc transfusion is complete. the volume of plasma transfused depends largely on the patient's need. in general, plasma transfusion should not exceed more than ml/kg during a -hour period for normovolemic animals. thaw plasma at room temperature, or place it in a ziplock freezer bag and run under cool (not warm) water until thawed. then administer the plasma through a blood administration set that contains an in-line blood filter or through a standard driptype administration set with a detachable in-line blood administration filter. the average rate of plasma infusion in a normovolemic patient should not exceed ml/kg/hour. in acute need situations, plasma can be delivered at rates up to to ml/kg/minute. for patients with cardiac insufficiency or other circulatory problems, plasma infusion rates should not exceed ml/kg/hour. plasma or other blood products should not be mixed with or used in the same infusion line as calcium-containing fluids, including lactated ringer's solution, calcium chloride, or calcium gluconate. the safest fluid to mix with any blood product is . % sodium chloride. administer fresh frozen plasma, frozen plasma, and cryoprecipitate at a volume of ml/kg until bleeding is controlled or source of ongoing albumin loss ceases. the goal of plasma transfusion therapy is to raise the albumin to a minimum of . g/dl or until bleeding stops as in the case of coagulopathies. monitor the patient to ensure that bleeding has stopped, coagulation profiles (act, aptt, and pt) have normalized, hypovolemia has stabilized, and/or total protein is normalizing, which are indications for discontinuing ongoing transfusion therapy. plasma cryoprecipitate can be purchased or manufactured through the partial thawing and then centrifugation of fresh frozen plasma. cryoprecipitate contains concentrated quantities of vwf, factor viii, and fibrinogen and is indicated in severe forms of von willebrand's disease and hemophilia a (factor viii deficiency). platelet-rich plasma must be purchased from a commercial source. one unit of fresh whole blood contains to platelets. the viability of the platelets contained in the fresh whole blood is short-lived, just to hours after transfusion into the recipient. because platelet-rich plasma is difficult to obtain, animals with severe thrombocytopenia or thrombocytopathia should be treated with immunomodulating therapies and the administration of fresh frozen plasma. in dogs, blood and plasma transfusions can be administered intravenously or intraosseously. the cephalic, lateral saphenous, medial saphenous, and jugular veins are used most commonly. fill the recipient set so that the blood in the drip chamber covers the filter (normal -µm filter). with small amounts of blood ( ml) or critically ill patients, use a -µm filter. avoid latex filters for plasma and cryoprecipitate administration. blood can emergency care be administered at variable rates, but the routine figure of to ml/minute often is used. normovolemic animals can receive blood at ml/kg/day. dogs in heart failure should receive infusions at no more than ml/kg/hour. volume is given as needed. to calculate the approximate volume of blood needed to raise hematocrit levels, use the following formula for the dog: anticoagulated blood volume (ml) = body mass (kg) × × pcv desired − pcv of recipient pcv of donor in anticoagulant an alternative formula is the following: . × recipient body mass (kg) × (dog) × pcv desired − pcv of recipient pcv of donor in anticoagulant surgical emergencies and shock may require several times this volume within a short period. if greater than % of the patient's blood volume is lost, supplementation with colloids, crystalloids, and blood products is indicated for fluid replacement. one volume of whole blood achieves the same increase in plasma as two to three volumes of plasma. if the patient's blood type is unknown and type a-negative whole blood is not available, any dog blood can be administered to a dog in acute need if the dog has never had a transfusion before. if mismatched blood is given, the patient will become sensitized, and after days, destruction of the donor rbcs will begin. in addition, any subsequent mismatched transfusions may cause an immediate reaction (usually mild) and rapid destruction of the transfused rbcs. the clinical signs of a transfusion reaction typically only are seen when type a blood is administered to a type a-negative recipient that has been sensitized previously. incompatible blood transfusions to breeding females can result in isoimmunization and in hemolytic disease in the puppies. the a-negative bitch that receives a transfusion with a-positive and that produces a litter from an a-positive stud can have puppies with neonatal isoerythrolysis. cats with severe anemia in need of a blood transfusion are typically extremely depressed, lethargic, and anorexic. the stress of restraint and handling can push these critically ill patients over the edge and cause them to die. extreme gentleness and care are mandatory in restraint and handling. the critically ill cat should be cradled in a towel or blanket. supplemental flow-by or mask oxygen should be administered, whenever possible, although it may not be clinically helpful until oxygen-carrying capacity is replenished with infusion of rbcs or hemoglobin. blood can be administered by way of cephalic, medial saphenous, or the jugular vein. intramedullary infusion is also possible, if vascular access cannot be accomplished. the average -to -kg cat can accept to ml of whole blood injected intravenously over a period of to minutes. administer filtered blood at a rate of to ml/kg/hour. the following formula can be used to estimate the volume of blood required for transfusion in a cat: anticoagulated blood volume (ml) = body mass (kg) × × pcv desired − pcv of recipient pcv of donor in anticoagulant the exact overall incidence and clinical significance of transfusion reactions in veterinary medicine are unknown. several studies have been performed that document the incidence of transfusion reactions in dogs and cats. overall, the incidence of transfusion reactions in dogs and cats is . % and %, respectively. transfusion reactions can be immune-mediated and non-immune-mediated and can happen immediately or can be delayed until after a transfusion. acute reactions usually occur within minutes to hours of the onset of transfusion but may occur up to hours after the transfusion has been stopped. acute immunologic reactions include hemolysis and acute hypersensitivity including rbcs, platelets, and leukocytes. signs of a delayed immunologic reaction include hemolysis, purpura, immunosuppression, and neonatal isoerythrolysis. acute nonimmunologic reactions include donor cell hemolysis before onset of transfusion, circulatory volume overload, bacterial contamination, citrate toxicity with clinical signs of hypocalcemia, coagulopathies, hyperammonemia, hypothermia, air embolism, acidosis, and pulmonary microembolism. delayed nonimmunologic reactions include the transmission and development of infectious diseases and hemosiderosis. clinical signs of a transfusion reaction typically depend on the amount of blood transfused, the type and amount of antibody involved in the reaction, and whether the recipient has had previous sensitization. monitoring the patient carefully during the transfusion period is essential in recognizing early signs of a transfusion reaction, including those that may become life threatening. a general guideline for patient monitoring is first to start the transfusion slowly during the first minutes. monitor temperature, pulse, and respiration every minutes for the first hour, hour after the end of the transfusion, and every hours minimally thereafter. also obtain a pcv immediately before the transfusion, hour after the transfusion has been stopped, and every hours thereafter. monitor coagulation parameters such as an act and platelet count at least daily in patients requiring transfusion therapy. the most common documented clinical signs of a transfusion reaction include pyrexia, urticaria, salivation/ptyalism, nausea, chills, and vomiting. other clinical signs of a transfusion reaction may include tachycardia, tremors, collapse, dyspnea, weakness, hypotension, collapse, and seizures. severe intravascular hemolytic reactions may occur within minutes of the start of the transfusion, causing hemoglobinemia, hemoglobinuria, disseminated intravascular coagulation, and clinical signs of shock. extravascular hemolytic reactions typically occur later and will result in hyperbilirubinemia and bilirubinuria. pretreatment of patients to help decrease the risk of a transfusion reaction remains controversial, and in most cases, pretreatment with glucocorticoids and antihistamines is ineffective at preventing intravascular hemolysis and other reactions should they occur. the most important component of preventing a transfusion reaction is to screen each recipient carefully and process the donor component therapy carefully before the administration of any blood products. treatment of a transfusion reaction depends on its severity. in all cases, stop the transfusion immediately when clinical signs of a reaction occur. in most cases, discontinuation of the transfusion and administration of drugs to stop the hypersensitivity reaction will be sufficient. once the medications have taken effect, restart the transfusion slowly and monitor the patient carefully for further signs of reaction. in more severe cases in which a patient's cardiovascular or respiratory system become compromised and hypotension, tachycardia, or tachypnea occurs, immediately discontinue the transfusion and administer diphenhydramine ( mg/kg im), dexamethasone-sodium phosphate ( . to . mg/kg iv), and epinephrine to the patient. the patient should have a urinary catheter and central venous catheter placed for measurement of urine output and central venous pressures. aggressive fluid therapy may be necessary to avoid renal insufficiency or renal damage associated with severe intravascular hemolysis. overhydration with subsequent pulmonary edema generally can be managed with supplemental oxygen administration and intravenous or intramuscular administration of furosemide ( to mg/kg). plasma products with or without heparin can be administered for disseminated intravascular coagulation. the hbocs can be stored at room temperature and have a relatively long shelf life compared with red blood component products. the hbocs function to carry oxygen through the blood and can diffuse oxygen past areas of poor tissue perfusion. an additional characteristic of hbocs is as a potent colloid, serving to maintain fluid within the vascular space. for this reason, hbocs must be used with caution in euvolemic patients and patients with cardiovascular insufficiency. central venous pressure (cvp) measures the hydrostatic pressure in the anterior vena cava and is influenced by vascular fluid volume, vascular tone, function of the right side of the heart, and changes in intrathoracic pressure during the respiratory cycle. the cvp is not a true measure of blood volume but is used to gauge fluid therapy as a method of determining how effectively the heart can pump the fluid that is being delivered to it. thus the cvp reflects the interaction of the vascular fluid volume, vascular tone, and cardiac function. measure cvp in any patient with acute circulatory failure, large volume fluid diuresis (i.e., toxin or oliguric or anuric renal failure), fluid in-and-out monitoring, and cardiac dysfunction. the placement of central venous catheters and thus cvp measurements is contraindicated in patients with known coagulopathies including hypercoagulable states. to perform cvp monitoring, place a central venous catheter in the right or left jugular vein. in cats and small dogs, however, a long catheter placed in the lateral or medial saphenous vein can be used for trends in cvp monitoring. first, assemble the equipment necessary for jugular catheter (see vascular access techniques for how to place a jugular or saphenous long catheter) and cvp monitoring (box - ). after placing the jugular catheter, take a lateral thoracic radiograph to ensure that the tip of the catheter sits just outside of the right atrium for proper cvp measurements (see to establish an intravenous catheter for cvp, follow this procedure: . assemble the cvp setup such that the male end of a length of sterile intravenous catheter extension tubing is inserted into the t port of the jugular or medial/lateral saphenous catheter. make sure to flush the length of tubing with sterile saline before connecting it to the patient to avoid iatrogenic air embolism. . next, insert the male end of a three-way stopcock into the female end of the extension tubing. . attach a -ml syringe filled with heparinized sterile . % saline to one of the female ports of the three-way stopcock and either a manometer or a second length of intravenous extension tubing attached to a metric ruler. . lay the patient in lateral or sternal recumbancy. . turn the stopcock off to the manometer/ruler and on to the patient. infuse a small amount of heparinized saline through the catheter to flush the catheter. . next, turn the stopcock off to the patient and on to the manometer. gently flush the manometer or length of extension tubing with heparinized saline from the syringe. use care not to agitate the fluid and create air bubbles within the line or manometer that will artifactually change the cvp measured. . next, lower the cm point on the manometer or ruler to the level of the patient's manubrium (if the patient is in lateral recumbancy) or the point of the elbow (if the patient is in sternal recumbancy). . turn the stopcock off to the syringe, and allow the fluid column to equilibrate with the patient's intravascular volume. once the fluid column stops falling and the level rises and falls with the patient's heartbeat, measure the number adjacent to the bottom of the meniscus of the fluid column. this is the cvp in centimeters of water (see figure - ). . repeat the measurement several times with the patient in the same position to make sure that none of the values has been increased or decreased artifactually in error. alternately, attach the central catheter to a pressure transducer and perform electronic monitoring of cvp. there is no absolute value for normal cvp. the normal cvp for small animal patients is to cm h o. values less than zero are associated with absolute or relative hypovolemia. values of to cm h o are borderline hypervolemia, and values greater than cm h o suggest intravascular volume overload. values greater than cm h o may be correlated with congestive heart failure and the development of pulmonary edema. in individual patients, the trend in change in cvp is more important than absolute values. as a rule of thumb, when using cvp measurements to gauge fluid therapy and avoid vascular and pulmonary overload, the cvp should not increase by more than cm h o in any -hour period. if an abrupt increase in cvp is found, repeat the measurement to make sure that the elevated value was not obtained in error. if the value truly has increased dramatically, temporarily discontinue fluid therapy and consider administration of a diuretic. delaforcade am, rozanski ea: central venous pressure and arterial blood pressure measurements, vet clin north am small anim pract ( ) the diagnosis of intracellular fluid deficit is difficult and is based more on the presence of hypernatremia or hyperosmolality than on clinical signs. an intracellular fluid deficit is expected when free water loss by insensible losses and vomiting, diarrhea, or urine is not matched by free water intake. consideration of the location of the patient's fluid deficit, history of vomiting and diarrhea, no visible clinical signs of deficit % dry mucous membranes, mild skin tenting % increased skin tenting, dry mucous membranes, mild tachycardia, normal pulse* % increased skin tenting, dry mucous membranes, tachycardia, weak pulse pressure % increased skin tenting, dry corneas, dry mucous membranes, % elevated or decreased heart rate, poor pulse quality, altered level of consciousness* the respiratory system further contributes to acid-base status by changes in the elimination of carbon dioxide. hyperventilation decreases the blood pco and causes a respiratory alkalosis. hypoventilation increases the blood pco and causes a respiratory acidosis. depending on the altitude, the pco in dogs can range from to mm hg. in cats, normal is to mm hg. venous pco values are to mm hg in dogs and to mm hg in cats. use a systematic approach whenever attempting to interpret a patient's acid-base status. ideally, obtain an arterial blood sample so that you can monitor the patient's oxygenation and ventilation. once an arterial blood sample has been obtained, follow these steps: . determine whether the blood sample is arterial or venous by looking at the oxygen saturation (sao ). the sao should be greater than % if the sample is truly arterial, although it can be as low as % if a patient has severe hypoxemia. . consider the patient's ph. if the ph is outside of the normal range, an acid-base disturbance is present. if the ph is within the normal range, an acid-base disturbance may or may not be present. if the ph is low, the patient is acidotic. if the ph is high, the patient is alkalotic. . next, look at the base excess or deficit. if the base excess is increased, the patient has higher than normal bicarbonate. if there is a base deficit, the patient may have a low bicarbonate or increase in unmeasured anions (e.g., lactic acid or ketoacids). . next, look at the bicarbonate. if the ph is low and the bicarbonate is low, the patient has a metabolic acidosis. if the ph is high and the bicarbonate is elevated, the patient has a metabolic alkalosis. . next, look at the paco . if the patient's ph is low and the paco is elevated, the patient has a respiratory acidosis. if the patient's ph is high and the paco is low, the patient has a respiratory alkalosis. . finally, if you are interested in the patient's oxygenation, look at the pao . normal pao is greater than mm hg. the metabolic acidosis early in renal failure may be hyperchloremic and later may convert to typical increased anion gap acidosis. . next, you must determine whether the disorders present are primary disorders or an expected compensation for disorders in the opposing system. for example, is the patient retaining bicarbonate (metabolic alkalosis) because of carbon dioxide retention (respiratory acidosis)? use the chart in table - to evaluate whether the appropriate degree of compensation is occurring. if the adaptive response falls within the expected range, a simple acid-base disorder is present. if the response falls outside of the expected range, a mixed acid-base disorder is likely present. . finally, you must determine whether the patient's acid-base disturbance is compatible with the history and physical examination findings. if the acid-base disturbance does not fit with the patient's history and physical examination abnormalities, question the results of the blood gas analyses and possibly repeat them. the most desirable method of assessing the acid-base status of an animal is with a blood gas analyzer. arterial samples are preferred over venous samples, with heparin used as an anticoagulant (table - ) . potassium primarily is located in the intracellular fluid compartment. serum potassium is regulated by the actions of the sodium-potassium-adenosinetriphosphatase pump on cellular membranes, including those of the renal tubular epithelium. inorganic metabolic acidosis artifactually can raise serum potassium levels because of redistribution of extracellular potassium in exchange for intracellular hydrogen ion movement in an attempt to correct serum ph. metabolic acidosis potassium is one of the major players in the maintenance of resting membrane potentials of excitable tissue, including neurons and cardiac myocytes. changes in serum potassium can affect cardiac conduction adversely. hyperkalemia lowers the resting membrane potential and makes cardiac cells, particularly those of the atria, more susceptible to depolarization. characteristic signs of severe hyperkalemia that can be observed on an ecg rhythm strip include an absence of p waves, widened qrs complexes, and tall tented or spiked t waves. further increases in serum potassium can be associated with bradycardia, ventricular fibrillation, and cardiac asystole (death). treatment of hyperkalemia consists of administration of insulin ( . to . units/kg, iv regular insulin) and dextrose ( g dextrose per unit of insulin administered, followed by . % dextrose iv cri to prevent hypoglycemia), calcium ( to ml of % calcium gluconate administered iv slowly to effect), or sodium bicarbonate ( meq/kg, iv slowly). insulin plus dextrose and bicarbonate therapy help drive the potassium intracellularly, whereas calcium antagonizes the effect of hyperkalemia on the myocardial cells. all of the treatments work within minutes, although the effects are relatively short-lived ( minutes to hour) unless the cause of the hyperkalemia is identified and treated appropriately (box - ). dilution of serum potassium also results from restoring intravascular fluid volume and correcting metabolic acidosis, in most cases. treatment with a fluid that does not contain potassium (preferably . % sodium chloride) is recommended. hypokalemia elevates the resting membrane potential and results in cellular hyperpolarization. hypokalemia may be associated with ventricular dysrhythmias, but the ecg changes are not as characteristic as those observed with hyperkalemia. causes of hypokalemia include renal losses, anorexia, gastrointestinal loss (vomiting, diarrhea), intravenous fluid diuresis, loop diuretics, and postobstructive diuresis (box - ). if the serum potassium concentration is known, potassium supplementation in the form of potassium chloride or potassium phosphate can be added to the patient's intravenous fluids. correct serum potassium levels less than . meq/l or greater than . meq/l. potassium rates should not exceed . meq/kg/hour (table - ) . metabolic acidosis from bicarbonate depletion often corrects itself with volume restoration in most small animal patients. patients with moderate to severe metabolic acidosis may benefit from bicarbonate supplementation therapy. the metabolic contribution to acid-base balance is identified by measuring the total carbon dioxide concentration or calculating the bicarbonate concentration. if these measurements are not available, the degree of expected metabolic acidosis can be estimated subjectively by the severity of underlying disease that often contributes to metabolic acidosis: hypovolemic or traumatic shock, septic shock, diabetic ketoacidosis, or oliguric/anuric renal failure. if the metabolic acidosis is estimated to be mild, moderate, or severe, add sodium bicarbonate at , , and meq/kg body mass, respectively. patients with diabetic ketoacidosis may not require bicarbonate administration once volume replacement and perfusion is restored, and the ketoacids are metabolized to bicarbonate. if the bicarbonate measurement of base deficit is known, the following formula can be used as a gauge for bicarbonate supplementation: base deficit × . = body mass (kg) = meq bicarbonate to administer osmolality osmolality is measured by freezing point depression or a vapor pressure osmometer, or it may be calculated by the following formula: mosm/kg = [(na + ) + (k + )] + bun/ . + glucose/ where sodium and potassium are measured in milliequivalents, and bun and glucose are measured in milligrams per deciliter. osmolalities less than mosm/kg or greater emergency care than mosm/kg are serious enough to warrant therapy. the difference between the measured osmolality and the calculated osmolality (the osmolal gap) should be less than mosm/kg. if the osmolal gap is greater than mosm/kg, consider the presence of unmeasured anions such as ethylene glycol metabolites. the volume of extracellular fluid is determined by the total body sodium content, whereas the osmolality and sodium concentration are determined by water balance. serum sodium concentration is an indication of the amount of sodium relative to water in the extracellular fluid and provides no direct information about the total body sodium content. unlikely to cause hyperkalemia in presence of normal renal function unless iatrogenic (e.g., continuous infusion of potassium-containing fluids at an excessively rapid rate) acute mineral acidosis (e.g., hydrochloric acid or ammonium chloride) insulin deficiency (e.g., diabetic ketoacidosis) acute tumor lysis syndrome reperfusion of extremities after aortic thromboembolism in cats with cardiomyopathy hyperkalemic periodic paralysis (one case report in a pit bull) mild hyperkalemia after exercise in dogs with induced hypothyroidism infusion of lysine or arginine in total parenteral nutrition solutions nonspecific β-blockers (e.g., propranolol)* cardiac glycosides (e.g., digoxin)* urethral obstruction ruptured bladder anuric or oliguric renal failure hypoadrenocorticism selected gastrointestinal disease (e.g., trichuriasis, salmonellosis, or perforated duodenal ulcer) late pregnancy in greyhound dogs (mechanism unknown but affected dogs had gastrointestinal fluid loss) chylothorax with repeated pleural fluid drainage hyporeninemic hypoaldosteronism † angiotensin-converting enzyme inhibitors (e.g., enalapril)* angiotensin receptor blockers (e.g., losartan)* cyclosporine and tacrolimus* potassium-sparing diuretics (e.g., spironolactone, amiloride, and triamterene)* nonsteroidal antiinflammatory drugs* heparin* trimethoprim* from dibartola sp: fluid, electrolyte and acid-base disorders in small animal practice, st louis, , saunders. *likely to cause hyperkalemia only in conjunction with other contributing factors (e.g., other drugs, decreased renal function, or concurrent administration of potassium supplements). † not well documented in veterinary medicine. if refractory hypokalemia is present, supplement magnesium at . meq/kg/day for hours. alone unlikely to cause hypokalemia unless diet is aberrant administration of potassium-free (e.g., . % sodium chloride or % dextrose in water) or potassium-deficient fluids (e.g., lactated ringer's solution over several days) bentonite clay ingestion (e.g., cat litter) alkalemia insulin/glucose-containing fluids catecholamines hypothermia hypokalemic periodic paralysis (burmese cats) albuterol overdosage patients with hyponatremia or hypernatremia may have decreased, normal, or increased total body sodium content (boxes - and [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] ). an increased serum sodium concentration implies hyperosmolality, whereas a decrease in serum sodium concentration usually, but not always, implies hypoosmolality. the severity of clinical signs of hypernatremia and hyponatremia is related primarily to the rapidity of the onset of the change rather than to the magnitude of the associated plasma hyperosmolality or hypoosmolality. clinical signs of neurologic disturbances include disorientation, ataxia, and seizures, and coma may occur at serum sodium concentrations less than meq/l or greater than meq/l in dogs. therapy of hypernatremia or hyponatremia with fluid containing low or higher concentrations of sodium should proceed with caution, for rapid changes (decreases or increases) of serum sodium and osmolality can cause rapid changes in the intracellular and extracellular fluid flux, leading to intracellular dehydration or edema, even though the serum sodium has not been returned to normal. a rule of thumb is to not raise or lower the serum sodium by more than meq/l during any one -hour period. restoration of the serum sodium concentration over a period of to hours is better. in almost all circumstances, an animal will correct its sodium balance with simple fluid restoration. if severe hypernatremia exists that suggests a free water deficit, however, the free water deficit should be calculated from the following formula: hypernatremia can be corrected slowly with . % sodium chloride plus . % dextrose, % dextrose in water, or lactated ringer's solution (sodium content: meq/l). correct hyponatremia initially with . % sodium chloride. sodium is balanced predominantly by chloride and bicarbonate. the difference between these concentrations, (na , has been called the anion gap. the normal anion gap is between and meq/l. when the anion gap exceeds , consider the possibility of an accumulation of unmeasured anions (e.g., lactate, ketoacids, phosphate, sulfate, ethylene glycol metabolites, and salicylate). abnormalities in the anion gap may be helpful in determining the cause of metabolic acidosis (boxes - and - ). the colloid oncotic pressure of blood is associated primarily with large-molecular-weight colloidal substances in circulation. the major player in maintaining intravascular and interstitial oncotic pressure, the water-retaining property of each fluid compartment, is albumin. albumin contributes roughly % to the colloidal oncotic pressure of blood. the majority of albumin is located within the interstitial space. hypoalbuminemia can result from increased loss in the form of protein-losing enteropathy or nephropathy and wound exudates, or it may be due to lack of hepatic albumin synthesis. serum albumin pools are in a constant flux with interstitial albumin. once interstitial albumin pools become depleted from replenishing serum albumin, serum albumin levels can continue to decrease, which can lead to a decrease in colloidal oncotic pressure. serum albumin less than . g/dl has been associated with inadequate intravascular fluid retention and the development of peripheral edema and third spacing of fluid. oncotic pressure can be restored with the use of artificial or synthetic colloids or natural colloids (see colloids). maintenance fluid requirements have been extrapolated from the formulas used to calculate a patient's daily metabolic energy requirements because it takes ml of water to metabolize kcal of energy (table - ) . the patient's daily metabolic water (fluid) requirements can be calculated by the following formula: administration of an isotonic crystalloid fluid for maintenance requirements often can produce iatrogenic hypokalemia. in most cases, supplemental potassium must be added to prevent hypokalemia resulting from inappetance, kalliuresis, and supplementation with isotonic crystalloid fluids. the most reliable method of determining the degree of fluid deficit is by weighing the animal and calculating acute weight loss. acute weight loss in a patient with volume loss in the form of vomiting, feces, wound exudates, and urine is due to fluid loss and not loss of muscle or fat. lean body mass normally is not gained or lost rapidly enough to cause major changes in body weight. one milliliter of water weighs approximately g. this fact allows calculation of the patient's fluid deficit, if ongoing losses can be measured. when a patient first presents, however, the body weight before a fluid deficit has occurred rarely is known. instead, one must rely on subjective measures of dehydration to estimate the patient's percent dehydration and to calculate the volume of fluid required to rehydrate the patient over the next hours. to calculate the volume deficit, use the following formula: body mass (kg) × (% dehydration) × = fluid deficit (ml) the patient's fluid deficit must be added to the daily maintenance fluid requirements and administered over a -hour period. ongoing losses can be determined by measuring urine output, weighing the patient at least to times a day, and measuring the volume or weight of vomitus or diarrhea. a crystalloid fluid contains crystals of salts with a composition similar to that of the extracellular fluid space and can be used to maintain daily fluid requirements and replace fluid deficits or ongoing fluid losses (table - ) . metabolic, acid-base, and electrolyte imbalances also can be treated with isotonic fluids with or without supplemental electrolytes and buffers. depending on the patient's clinical condition, choose the specific isotonic crystalloid fluid to replace and maintain the patient's acid-base and electrolyte status ( table - ) . crystalloid fluids are readily available, are relatively inexpensive, and can be administered safely in large volumes to patients with no preexisting cardiac or renal disease or cerebral edema. following infusion, approximately % of the volume of a crystalloid fluid infused will redistribute to the interstitial fluid compartment. as such, crystalloid fluids alone are ineffective for ongoing intravascular volume depletion when given as a bolus. the crystalloid fluid bolus must be followed by a constant rate infusion, taking into consideration the patient's daily maintenance fluid requirements and ongoing fluid losses. administration of a large volume of crystalloid fluids can cause dilutional anemia and coagulopathies. * × bw kg + = kcal/day = ml/day. note: this formula will slightly underestimate the requirements for patients that are less than kg and will slightly overestimate the requirements for patients greater than kg. retain fluid in the vascular space, the volume of crystalloid fluid infused (maintenance + deficit + ongoing losses) should be decreased by % to % to avoid vascular volume overload. two major classes of colloids exist: natural and synthetic. natural colloids (whole blood, packed rbcs, plasma) are discussed elsewhere in this text. concentrated human albumin is a natural purified colloid that recently has become more popular in the treatment of advanced hypoalbuminemia and hypoproteinemia and will be discussed here. synthetic colloids are starch polymers and include dextrans and hetastarch. concentrated human albumin is available as a % or % solution. the % solution has an osmolality similar to that of serum ( mosm/l), whereas the % solution is hyperoncotic ( mosm/l). a % albumin solution draws fluid from the interstitial space into the intravascular space. concentrated albumin solutions often are used to restore circulating volume when synthetic colloids are not available. albumin not only is important at maintaining the colloidal oncotic pressure of blood but also serves as a valuable free-radical scavenger and carrier of drugs and hormones necessary for normal tissue function and healing. albumin levels less than . g/dl have been associated with increased morbidity and mortality. concentrated human albumin solutions can be administered as an effective method of restoring interstitial and serum albumin concentrations in situations of acute and chronic hypoalbuminemia. albumin ( %) is available in -and -ml vials and is more cost-efficient as an albumin replacement than procurement and administration of fresh frozen plasma. recommended albumin infusion rates are to ml/kg over hours, after pretreatment with diphenhydramine. although concentrated human albumin is structurally similar to canine albumin, closely monitor the patient for signs of allergic reaction during and after the infusion. dextran- is a synthetic high-molecular-weight polysaccharide (sucrose polymer) with a molecular weight of , d. particles less than , d, are cleared rapidly by the kidneys, whereas larger particles are cleared more slowly by the hepatic reticuloendothelial system. dextran- can coat platelets and inhibit platelet function and so must be used with caution in patients with known coagulopathies. the total daily dosage should not exceed ml/kg/day. hetastarch (hydroxyethyl starch) is a large-molecular-weight amylopectin polymer, has molecules with a molecular weight that exceeds , d, and has an average half-life of to hours in circulation. hetastarch can bind with vwf and cause prolongation of the act and aptt; however, it does not cause a coagulopathy. recommended rates of hetastarch infusion are -to -ml incremental boluses for the treatment of hypotension and to ml/kg/day as a constant rate infusion for maintenance of colloidal oncotic pressure. many are the acceptable ways to administer the fluids prescribed for each patient based on the degree of dehydration, estimation of ongoing losses, ability to tolerate oral fluid, and metabolic, acid-base, and electrolyte derangements. administer the fluids in a manner that is best for the patient and most appropriate for the practice. to determine the rate of intravenous fluid infusion, take the total volume of fluids that have been prescribed and divide the total volume by the total number of hours in a day that intravenous fluids can be delivered safely and monitored. the safest and most accurate way to deliver intravenous fluids, particularly in extremely small animals or those with congestive heart failure, is through an intravenous fluid pump. fluid should not be administered intravenously if the patient cannot be monitored to make sure that the fluids are being delivered at a safe rate and that the fluid line has not become disconnected. supplement fluids over as many hours as possible to allow the patient as much time as possible to redistribute and fully utilize the fluids administered. fluids administered too quickly can cause a diuresis to occur, such that the majority of the fluids administered will be excreted in the urine. if time is limited or if extra time is needed for safe administration of fluids, consider using a combination of intravenously and subcutaneously emergency care administered fluids. intravenous is the preferred route of administration of fluids in any patient with dehydration and hypovolemia. as intravascular volume depletion occurs, reflex peripheral vasoconstriction occurs to restore core perfusion. the subcutaneous tissue are not perfused well and therefore fluids administered subcutaneously will not be absorbed well into the interstitial and intravascular spaces. subcutaneously administered fluids can be absorbed slowly and delivered effectively in the management of mild interstitial dehydration and in the treatment of renal insufficiency. subcutaneously administered fluids should never take the place of intravenously administered fluids in a hypovolemic patient or one with severe interstitial dehydration. intramedullary (intraosseous) infusion works well in small patients in which vascular access cannot be established. shock doses of fluids and other substances, including blood products, can be administered under pressure through an intraosseous cannula. because of the inherent discomfort and risk of osteomyelitis with intraosseous infusion, establish vascular access as soon as possible. the safest and most efficient method of intravenous fluid infusion is through a fluid pump. in cases in which a fluid pump is unavailable, infusion by gravity feed is the next option. infusion sets from various manufacturers have calibrated drip chambers such that a specific number of drops will equal ml of fluid. fluid rates can be calculated based on the number of drops that fall into the drip chamber per minute: fluid volume to be infused (ml) = ml/hour number of hours available many pediatric drip sets deliver drops/ml, such that milliliters/hour equals drops/ minute. carefully record fluid orders so that the volume to be administered is recorded as milliliters/hour, milliliters/day, and drops/minute. this will allow personnel to detect major discrepancies and calculation errors more readily. the volume actually delivered should be recorded in the record by nursing personnel. all additives should be listed clearly on the bottle on a piece of adhesive tape or a special label manufactured for this purpose. a strip of adhesive tape also can be attached to the bottle and marked appropriately to provide a quick visualization of the estimate of volume delivered. includes a large-bore flexible orogastric lavage tube, permanent marker or white tape, lubricating jelly, warm water, two large buckets, a roll of -inch white tape, and a manual lavage pump. to perform the orogastric lavage, follow this procedure: . place all animals under general anesthesia with a cuffed endotracheal tube in place to protect the airway and prevent aspiration of gastric contents into the lungs. . place a roll of -inch white tape into the animal's mouth, and secure the tape around the muzzle. you will insert the tube through the hole in the center of the roll of tape. . next, place the distal end of the tube at the level of the last rib, directly adjacent to the animal's thorax and abdomen. measure the length of the tube from the most distal end to the point where it comes out of the mouth, and label this location on the tube with a permanent marker or piece of white tape. . lubricate the distal portion of the tube, and gently insert it through the roll of tape in the animal's mouth. . gently push the tube down the esophagus. palpate the tube within the esophagus. two tubes should be palpable, the orogastric tube, and the patient's trachea. push the tube down into the stomach. you can verify location by blowing into the proximal end of the tube and simultaneously auscultating the stomach for borborygmi. . insert the manual pump to the proximal end of the tube, and instill the warm water. alternate instilling water with removal of fluid and gastric debris by gravity. repeat the process until the efflux fluid is clear of any debris. . save fluid from the gastric efflux fluid for toxicologic analyses. hackett tb: emergency approach to intoxications, clin tech small anim pract ( ): - , . hypoxia, or inadequate tissue oxygenation, is the primary reason for supplemental oxygen therapy. major causes of hypoxia include hypoventilation, ventilation-perfusion mismatch, physiologic or right-to-left cardiac shunt, diffusion impairment, and decreased fraction of inspired oxygen (table - ) . inadequate tissue perfusion caused by low cardiac output or vascular obstruction also can result in circulatory hypoxia. finally, histiocytic hypoxia results from inability of cells to use oxygen that is delivered to them. this form of hypoxia can be observed with various toxin ingestions (bromethalin, cyanide) and in septic shock. a patient's oxygenation status can be monitored invasively by drawing of arterial blood gas samples or noninvasively through pulse oximetry, in most cases (see acid-base physiology and pulse oximetry). inspired air at sea level has a po of mm hg. as the air travels through the upper respiratory system to the level of the alveolus, the po drops to mm hg. tissue oxygen saturation in a normal healthy animal is mm hg. after oxygen has been delivered to the tissues, the oxygen left in the venous system (pvo ) is approximately mm hg. normally, oxygen diffuses across the alveolar capillary membrane and binds reversibly with hemoglobin in rbcs. a small amount of oxygen is carried in an unbound diffusible form in the plasma. when an animal has an adequate amount of hemoglobin and hemoglobin becomes fully saturated while breathing room air, supplemental oxygen administration will only increase the sao a small amount. the unbound form of oxygen dissolved in plasma will increase. if, however, inadequate hemoglobin saturation is obtained by breathing room air, as in a case of pneumonia or pulmonary edema, for example, breathing a higher fraction of inspired oxygen (fio ) will improve bound and unbound hemoglobin levels. the formula for calculating oxygen content of arterial blood is as follows: where cao is the arterial oxygen content, . is the amount of oxygen that can be carried by hemoglobin (hb), sao is the hemoglobin saturation, and . × pao is the amount of oxygen dissolved (unbound) in plasma. dissolved oxygen actually contributes little to the total amount of oxygen carried in the arterial blood, and the majority depends on the amount or availability of hemoglobin and the ability of the body (ph and respiratory status) to saturate the hemoglobin at the level of the alveoli. oxygen therapy is indicated whenever hypoxia is present. the underlying cause of the hypoxia also must be identified and treated, for chronic, lifelong oxygen therapy is rarely feasible in veterinary patients. if hemoglobin levels are low due to anemia, oxygen supplementation must occur along with rbc transfusions to increase hemoglobin mass. whenever possible, use arterial blood gas analyses or pulse oximetry to gauge a patient's response to oxygen therapy and to determine when an animal can be weaned from supplemental oxygen. the goal of oxygen therapy is to increase the amount of oxygen bound to hemoglobin in arterial blood. oxygen supplementation can be by hood, oxygen cage or tent, nasal or nasopharyngeal catheter, or tracheal tube. in rare cases, administration of oxygen with mechanical ventilation may be indicated. administration of supplemental oxygen to patients with chronic hypoxia is sometimes necessary but also dangerous. with chronic hypoxia the patient develops a chronic respiratory acidosis (elevated paco ) and depends almost entirely on the hypoxic ventilatory drive to breathe. administration of supplemental oxygen increases pao and may inhibit the central respiratory drive, leading to hypoventilation and possibly respiratory arrest. therefore, closely monitor animals with chronic hypoxia that are treated with supplemental oxygen. oxygen hoods can be purchased from commercial sources or can be manufactured in the hospital using a rigid elizabethan collar, tape, and plastic wrap. to make an oxygen hood, place several lengths of plastic wrap over the front of the elizabethan collar and tape them in place. leave the ventral third of the collar open to allow moisture and heat to dissipate and carbon dioxide to be eliminated. place a length of flexible oxygen tubing under the patient's collar into the front of the hood, and run humidified oxygen at a rate of to ml/kg/minute. animals may become overheated with an oxygen hood in place. carefully monitor the patient's temperature so that iatrogenic hyperthermia does not occur. commercially available plexiglass oxygen cages can be purchased from a variety of manufacturers. the best units include a mechanical thermostatically controlled compressor cooling unit, a circulatory fan, nebulizers or humidifiers to moisten the air, and a carbon dioxide absorber. alternately, a pediatric (infant) incubator can be purchased from hospital supply sources, and humidified oxygen can be run into the cage at to l/minute (depending on the size of the cage). high flow rates may be required to eliminate nitrogen and carbon dioxide from the cage. in most cases, the fio inside the cage reaches % to % using this technique. disadvantages of using an oxygen cage are high consumption/ use of oxygen, rapid decrease in the fio within the cage whenever the cage must be opened for patient treatments, lack of immediate access to the patient, and potential for iatrogenic hyperthermia. one of the most common methods for oxygen supplementation in dogs is nasal or nasopharyngeal oxygen catheters: . to place a nasal or nasopharyngeal catheter, obtain a red rubber catheter ( f to f, depending on the size of the patient). a. for nasal oxygen supplementation, measure the distal tip of the catheter from the medial canthus of the eye to the tip of the nose. b. for nasopharyngeal oxygen supplementation, measure the catheter from the ramus of the mandible to the tip of the nose. . mark the tube length at the tip of the nose with a permanent marker. . instill topical anesthetic such as proparacaine ( . %) or lidocaine ( %) into the nostril before placement. . place a stay suture adjacent to (lateral aspect) the nostril while the topical anesthetic is taking effect. . lubricate the tip of the tube with sterile lubricant. . gently insert the tube into the ventral medial aspect of the nostril to the level made with the permanent marker. if you are inserting the tube into the nasopharynx, push the nasal meatus dorsally while simultaneously pushing the lateral aspect of the nostril medially to direct the tube into the ventral nasal meatus and avoid the cribriform plate. . once the tube has been inserted to the appropriate length, hold the tube in place with your fingers adjacent to the nostril, and suture the tube to the stay suture. if the tube is removed, you can cut the suture around the tube and leave the stay suture in place for later use, if necessary. . suture or staple the rest of the tube dorsally over the nose and in between the eyes to the top of the head, or laterally along the zygomatic arch. . attach the tube to a length of flexible oxygen tubing, and provide humidified oxygen at to ml/kg/minute. . secure an elizabethan collar around the patient's head to prevent the patient from scratching at the tube and removing it. the rule of s states that if a patient's pao is less than mm hg, or if the paco is mm hg, mechanical ventilation should be considered. for mechanical ventilation, anesthetize the patient and intubate the patient with an endotracheal tube. alternately, a temporary tracheostomy can be performed and the patient can be maintained on a plane of light to heavy sedation and ventilated through the tracheostomy site. this method, a noninvasive means of determining oxygenation is through the use of pulse oximetry. a pulse oximeter uses different wavelengths of light to distinguish characteristic differences in the properties of the different molecules in a fluid or gas mixture, in this case, oxygenated (oxyhemoglobin) and deoxygenated hemoglobin (deoxyhemoglobin) in pulsatile blood. the process is termed pulse oximetry. oxyhemoglobin and deoxyhemoglobin are different molecules that absorb and reflect different wavelengths of light. oxyhemoglobin absorbs light in the infrared spectrum, allowing wavelengths of light in the red spectrum to transmit through it. conversely, deoxyhemoglobin absorbs wavelengths of the red spectrum and allows wavelengths in the infrared spectrum to transmit through the molecule. the spectrophotometer in the pulse oximeter transmits light in the red ( nanometers) and infrared ( nanometers) spectra. the different wavelengths of light are transmitted across a pulsatile vascular bed and are detected by a photodetector on the other side. the photodetector processes the amount of light of varying wavelengths that reaches it, then transmits an electrical current to a processor that calculates the difference in the amount of light originally transmitted and the amount of light of similar wavelength that actually reaches the photodetector. the difference in each reflects the amount of light absorbed in the pulsatile blood and can be used to calculate the amount or ratio of oxyhemoglobin to deoxyhemoglobin in circulation, or the functional hemoglobin saturation by the formula: where hbo is oxygenated hemoglobin, and hb is deoxygenated hemoglobin. four molecules of oxygen reversibly bind to hemoglobin for transport to the tissues. carbon monoxide similarly binds to hemoglobin and forms carboxyhemoglobin, a molecule that is detected similarly as oxygenated hemoglobin. thus sao as detected by a pulse oximeter is not reliable if carboxyhemoglobin is present. in most cases, pulse oximetry or sao corresponds reliably to the oxyhemoglobin dissociation curve. oxygen saturation greater than % corresponds to a pao greater than mm hg. above this value, large changes in pao are reflected in relatively small changes in sao , making pulse oximetry a relatively insensitive method of determining oxygenation status when pao is normal. because pulse oximetry measures oxygenated versus nonoxygenated hemoglobin in pulsatile blood flow, it is fairly unreliable when severe vasoconstriction, hypothermia, shivering or trembling, or excessive patient movement are present. additionally, increased ambient lighting and the presence of methemoglobin or carboxyhemoglobin also can cause artifactual changes in the sao , and thus the measurement is not reliable or accurate. most pulse oximeters also display a waveform and the patient's heart rate. if the photodetector does not detect a good quality signal, the waveform will not be normal, and the heart rate displayed on the monitor will not correlate with the patient's actual heart rate. the efficiency of ventilation is evaluated using the paco value on an arterial blood gas sample. alternatively, a noninvasive method to determine end-tidal carbon dioxide is through use of a capnograph. the science of capnometry uses a spectrophotometer to measure carbon dioxide levels in exhaled gas. the capnometer is placed in the expiratory limb of an anesthetic circuit. a sample of exhaled gas is aliquoted from the breath, and an infrared light source is passed across the sample. a photodetector on the other side of the sample flow measures the amount or concentration of carbon dioxide in the sample of expired gas. the calculated value is displayed as end-tidal carbon dioxide. this value also can be displayed as a waveform. when placed in graphic form, a waveform known as a capnograph is displayed throughout the ventilatory cycle. normally, at the onset of exhalation, the gas exhaled into the expiratory limb of the tubing comes from the upper airway or physiologic dead space and contains relatively little carbon dioxide. as exhalation continues, a steep uphill slope occurs as more carbon dioxide is exhaled from the bronchial tree. near the end of exhalation, the capnogram reaches a plateau, which most accurately reflects the carbon dioxide level at the level of the alveolus. because carbon dioxide diffuses across the alveolar basement membrane so rapidly, this reflects arterial carbon dioxide levels. if a plateau is not reached and notching of the waveform occurs, check the system for leaks. if the baseline waveform does not reach zero, the patient may be rebreathing carbon dioxide or may be tachypneic, causing physiologic positive end-expiratory pressure. the soda-sorb in the system should be replaced if it has expired. conversely, low end-tidal carbon dioxide may be associated with a decrease in perfusion or blood flow. decreased perfusion can be associated with low end-tidal carbon dioxide values, particularly during cardiopulmonary cerebral resuscitation. end-tidal carbon dioxide levels are one of the most accurate predictors of the efficacy of cardiopulmonary cerebral resuscitation and patient outcome. additionally, the difference between arterial carbon dioxide levels (paco ) and end-tidal carbon dioxide can be used to calculate dead-space ventilation. increases in the difference also occur with poor lung perfusion and pulmonary diffusion impairment. thoracocentesis refers to the aspiration of fluid or air from within the pleural space. thoracocentesis may be diagnostic to determine whether air or fluid is present and to characterize the nature of the fluid obtained. thoracocentesis also can be therapeutic when removing large volumes of air or fluid to allow pulmonary reexpansion and correction of hypoxemia and orthopnea. to perform thoracocentesis, follow this procedure: . first, assemble the equipment necessary (box - ). . next, clip a -cm square in the center of the patient's thorax on both sides. . aseptically scrub the clipped area. . ideally, thoracocentesis should be performed within the seventh to ninth intercostal space. rather than count rib spaces in an emergent situation, visualize the thoracic cage as a box, and the clipped area as a box within the box. you will insert your needle or catheter in the center of the box and then direct the bevel of the needle dorsally or ventrally to penetrate pockets of fluid or air present. . attach the needle or catheter hub to the length of intravenous extension tubing. attach the female port of the intravenous extension tubing to the male port of the three-way stopcock. attach the male port of the -ml syringe to one of the female ports of the three-way stopcock. the apparatus is now assembled for use. . insert the needle through the intercostal space such that the bevel of the needle initially is directed downward. . next, push down on the hub of the needle such that the needle becomes parallel with the thoracic wall. by moving the hub of the needle in a clockwise or counterclockwise manner, the bevel of the needle will move within the thoracic cavity to penetrate pockets of air or fluid. in general, air is located dorsally and fluid is located more ventrally, although this does not always occur. . aspirate air or fluid. save any fluid obtained for cytologic and biochemical analyses and bacterial culture and susceptibility testing. in cases of pneumothorax, if the thoracocentesis needs to be repeated more than times, consider using a thoracostomy tube. place a thoracostomy tube in cases of pneumothorax whenever negative suction cannot be obtained or repeated accumulation of air requires multiple thoracocentesis procedures. thoracostomy tubes also can be placed to drain rapidly accumulating pleural effusion and for the medical management of pyothorax. before attempting thoracostomy tube placement, make sure that all necessary supplies are assembled (box - ; table - ) . to place a thoracostomy tube, follow this procedure: . lay the patient in lateral recumbency. . clip the patient's entire lateral thorax. . aseptically scrub the lateral thorax. . palpate the tenth intercostal space. . have an assistant pull the patient's skin cranially and ventrally toward the point of the elbow. this will facilitate creating a subcutaneous tunnel around the thoracostomy tube. . draw up mg/kg % lidocaine ( mg/kg for cats) along with a small amount of sodium bicarbonate to take away some of the sting. . insert the needle at the dorsal aspect of the tenth intercostal space and to the seventh intercostal space. inject the lidocaine into the seventh intercostal space at the point where the trocarized thoracic drainage catheter will penetrate into the thoracic cavity. slowly infuse the lidocaine as you withdraw the needle to create an anesthetized tunnel through which to insert the catheter. . while the local anesthetic is taking effect, remove the trocar from the catheter and cut the proximal end of the catheter with a mayo scissors to facilitate adaptation with the christmas tree adapter. . attach the christmas tree adapter to the three-way stopcock and the three-way stopcock to a length of intravenous extension tubing and the -ml syringe so that the apparatus can be attached immediately to the thoracostomy tube after placement. . aseptically scrub the lateral thorax a second time and then drape it with sterile huck towels secured with towel clamps. . wearing sterile gloves, make a small stab incision at the dorsal aspect of the tenth intercostal space. . insert the trocar back into the thoracostomy drainage tube. insert the trocar and tube into the incision. tunnel the tube cranially for approximately intercostal spaces while an assistant simultaneously pulls the skin cranially and ventrally toward the point of the elbow. . at the seventh intercostal space, direct the trocar and catheter perpendicular to the thorax. grasp the catheter apparatus at the base adjacent to the thorax to prevent the trocar from going too far into the thorax. . place the palm of your dominant hand over the end of the trocar, and push the trocar and catheter into the thoracic cavity, throwing your weight into the placement in a swift motion, not by banging the butt of your hand on the end of the stylette. for small individuals, standing on a stool, or kneeling over the patient on the triage table can create leverage and make this process easier. the tube will enter the thorax with a pop. . gently push the catheter off of the stylette, and remove the stylette. . immediately attach the christmas tree adapter and have an assistant start to withdraw air or fluid while you secure the tube in place. . first, place a horizontal mattress suture around the tube to cinch the skin securely to the tube. use care to not penetrate the tube with your needle and suture. . next, place a purse-string suture around the tube at the tube entrance site. leave the ends of the suture long, so that you can create a finger-trap suture to the tube, holding the tube in place. . place a large square of antimicrobial-impregnated adhesive tape over the tube for further security and sterility. . if antimicrobial adhesive is not available, place a gauze pad × inches square over the tube, and then wrap the tube to the thorax with cotton roll gauze and elastikon adhesive tape. . draw the location of the tube on the bandage to prevent cutting it with subsequent bandage changes. an alternate technique to use if a trocar thoracic drainage catheter is not available is the following: . prepare the lateral thorax and infuse local lidocaine anesthetic as listed before. . make a small stab incision with a no. scalpel blade, as listed before. . obtain the appropriately sized red rubber catheter and cut multiple side ports in the distal end of the catheter, taking care to not cut more than % of the circumference of the diameter of the tube. . insert a rigid, long urinary catheter into the red rubber catheter to make the catheter more rigid during insertion into the pleural space. . grasp the distal end of the catheter(s) in the teeth of a large carmalt. tunnel a metzenbaum scissors under the skin to the seventh intercostal space and make a puncture through the intercostal space. . remove the metzenbaum scissors, and then tunnel the carmalt and red rubber tube under the skin to the hole created in the seventh intercostal space with the metzenbaum scissors. . insert the tips of the carmalt and the red rubber catheter through the hole, and then open the teeth of the carmalt. . push the red rubber catheter cranially into the pleural cavity. . remove the carmalt and the rigid urinary catheter, and immediately attach the suction apparatus. secure the red rubber catheter in place as listed before. placement of a temporary tracheostomy can be lifesaving to relieve upper respiratory tract obstruction, to facilitate removal of airway secretions, to decrease dead space ventilation, to provide a route of inhalant anesthesia during maxillofacial surgery, and to facilitate mechanical ventilation. in an emergent situation in which asphyxiation is imminent and endotracheal intubation is not possible, any cutting instrument placed into the trachea distal to the point of obstruction can be used. to perform a slash tracheostomy, quickly clip the fur and scrub the skin over the third tracheal ring. make a small cut in the trachea with a no. scalpel blade, and insert a firm tube, such as a syringe casing. alternately, insertion of a -gauge needle attached to intravenous extension tubing and adapted with a -ml syringe case to attach to a humidified oxygen source also temporarily can relieve obstruction until a temporary tracheostomy can be performed. in less emergent situations, place the patient under general anesthesia and intubate the patient. assemble all the equipment necessary before starting the temporary tracheostomy procedure (box - ). to perform a tracheostomy, follow this procedure: . place the patient in dorsal recumbency. . clip the ventral cervical region from the level of the ramus of the mandible caudally to the thoracic inlet and dorsally to midline. . aseptically scrub the clipped area, and then drape with sterile huck towels secured with towel clamps. . make a -cm ventral midline skin incision over the third to sixth tracheal rings, perpendicular to the trachea. . bluntly dissect through the sternohyoid muscles to the level of the trachea. . carefully pick up the fascia overlying the trachea and cut it away with a metzenbaum scissors. . place two stay sutures through/around adjacent tracheal rings. . incise in between trachea rings with a no. scalpel blade. take care to not cut more than % of the circumference of the trachea. . using the stay sutures, pull the edges of the tracheal incision apart, and insert the tracheostomy tube. the shiley tube contains an internal obturator to facilitate placement into the tracheal lumen. remove the obturator, and then insert the inner cannula, which can be removed for cleaning as needed. . once the tube is in place, secure the tube around the neck with a length of sterile umbilical tape. postoperative care of the tracheostomy tube is as important as the procedure itself. because the tracheostomy tube essentially bypasses the protective effects of the upper respiratory system, one of the most important aspects of tracheostomy tube care and maintenance is to maintain sterility at all times. any oxygen source should be humidified with sterile water or saline to prevent drying of the respiratory mucosa. if supplemental oxygen is not required, instill to ml of sterile saline every to hours to moisten the mucosa. wearing sterile gloves, remove the internal tube and place it in a sterile bowl filled with sterile hydrogen peroxide and to be cleaned every hours (or more frequently as necessary). if a shiley tube is not available, apply suction to the internal lumen of the tracheostomy tube every to hours (or more frequently as needed) with a sterile f red rubber catheter attached to a vacuum pump to remove any mucus or other debris that potentially could plug the tube. unless the patient demonstrates clinical signs of fever or infection, the prophylactic use of antibiotics is discouraged because of the risk of causing a resistant infection. after the temporary tracheostomy is no longer necessary, remove the tube and sutures, and leave the wound to heal by second intention. primary closure of the wounds could predispose the patient to subcutaneous emphysema and infection. baker gd: trans-tracheal oxygen therapy in dogs with severe respiratory compromise due to tick (i. holocyclus) toxicity, aust vet pract ( ) urohydropulsion is a therapeutic procedure for removal of uroliths from the urethra of the male dog. the technique works best if the animal is heavily sedated or is placed under general anesthesia (figure - ) . to perform urohydropulsion, follow this procedure: . place the animal in lateral recumbency. . clip the fur from the distal portion of the prepuce. . aseptically scrub the prepuce and flush the prepuce with to ml of antimicrobial flush solution. . have an assistant who is wearing gloves retract the penis from the prepuce. . while wearing sterile gloves, lubricate the tip of a rigid urinary catheter as for urethral catheterization. . gently insert the tip of the catheter into the urethra until you meet the resistance of the obstruction. . pinch the tip of the penis around the catheter. . have an assistant insert a gloved lubricated finger into the patient's rectum and press ventrally on the floor of the rectum to obstruct the pelvic urethra. . attach a -ml syringe filled with sterile saline into proximal tip of the catheter. . quickly inject fluid into the catheter and alternate compression and relaxation on the pelvic urethra such that the urethra dilates and suddenly releases the pressure, causing dislodgement of the stone. small stones may be ejected from the tip of the urethra, whereas larger stones may be retropulsed back into the urinary bladder to be removed surgically at a later time. the type of catheter that you choose for vascular access depends largely on the size and species of the patient, the fragility of the vessels to be catheterized, the proposed length of time that the catheter will be in place, the type and viscosity of the fluid or drug to be administered, the rate of fluid flow desired, and whether multiple repeated blood samples will be required (table - ) . a variety of over-the-needle, through-the-needle, and over-the-wire catheters are available for placement in a variety of vessels, including the jugular, cephalic, accessory cephalic, medial saphenous, lateral saphenous, dorsal pedal artery, and femoral artery. one of the most important aspects of proper catheter placement and maintenance is to maintain cleanliness at all times. the patient's urine, feces, saliva, and vomit are common sources of contamination of the catheter site. before placing a peripheral or central catheter in any patient, consider the patient's physical status including whether vomiting, diarrhea, excessive urination, or seizures. in a patient with an oral mass that is drooling excessively or a patient that is vomiting, peripheral cephalic catheterization may not be the most appropriate, to prevent contamination. conversely, in a patient with excessive urination or diarrhea, a lateral or medial saphenous catheter is likely to become contaminated quickly. whenever one places or handles a catheter or intravenous infusion line, the person should wash the hands carefully and wear gloves to prevent contamination of the intravenous catheter and fluid lines. one of the most common sources of catheter contamination in veterinary hospitals is through caretakers' hands. in emergent situations, placement of a catheter may be necessary under less than ideal circumstances. remove those catheters as soon as the patient is more stable, and place a second catheter using aseptic techniques. in general, once the location of the catheter has been decided, set up all equipment necessary for catheter placement before starting to handle and restrain the patient. lists the equipment needed for most types of catheter placement. after setting up all of the supplies needed, clip the fur over the site of catheter placement. make sure to clip all excess fur and long feathers away from the catheter site, to prevent contamination. for catheter placement in limbs, clip the fur circumferentially around the site of catheter placement to facilitate adherence of the tape to the limb and to facilitate catheter removal with minimal discomfort at a later date. next, aseptically scrub the catheter site with an antimicrobial scrub solution such as hibiclens. the site is now ready for catheter insertion. consider using a central venous catheter whenever multiple repeated blood samples will need to be collected from a patient during the hospital stay. central venous catheters also can be used for cvp measurement, administration of hyperoncotic solutions such as parenteral nutrition, and administration of crystalloid and colloid fluids, anesthesia, and other injectable drugs (figures - and - ) . to place a jugular central venous catheter, place the patient in lateral recumbancy and extend the head and neck such that the jugular furrow is straight. clip the fur from the ramus of the mandible caudally to the thoracic inlet and dorsally and ventrally to midline. wipe the clipped area with gauze × -inch squares to remove any loose fur and other debris. aseptically scrub the clipped area with an antimicrobial cleanser. venocaths (abbott laboratories) are a through-the-needle catheter that is contained within a sterile sleeve for placement. alternately, other over-the-wire central venous catheters can be placed by the seldinger technique. sterility must be maintained at all times, regardless of the type of catheter placed. wearing sterile gloves, drape the site of catheter placement with sterile drapes, and occlude the jugular vein at the level of the thoracic inlet. pull the clear ring and wings of emergency diagnostic and therapeutic procedures figure - : lateral thoracic radiograph of a central venous catheter. note that the tip of the catheter is inserted in its proper location, just outside of the right atrium. the catheter cover down toward the catheter itself to expose the needle. remove the guard off of the needle. lift the skin over the proposed site of catheter insertion and insert the needle under the skin, with the bevel of the needle facing up. next, reocclude the vessel and pull the skin tight over the vessel to prevent movement of the vessel as you attempt to insert the needle. in some cases, it may be difficult actually to see the vessel in obese patients. if you cannot visualize or palpate the needle, gently bounce the needle over the vessel with the bevel up. the vessel will bounce in place slightly, allowing a brief moment of visualization to facilitate catheter placement. once the vessel has been isolated and visualized, insert the needle into the vessel at a -to -degree angle. watch closely for a flash of blood in the catheter. when blood is observed, insert the needle a small distance farther, and then push the catheter and stylette into the vessel for the entire length, until the catheter and stylette can be secured in the catheter hub. if the catheter cannot be inserted fully into the vessel for its entire length, the tip of the needle may not be within the entire lumen, the catheter may be directed perivascularly, and the catheter may be caught at the thoracic flexure and may be moving into one of the tributaries that feeds the forelimb. extend the patient's head and neck, and lift the forelimb up to help facilitate placement. do not force the catheter in because the catheter potentially can form a knot and will need to be removed surgically. remove the needle from the vessel, and have an assistant place several × -inch gauze squares over the site of catheter placement with some pressure to control hemorrhage. secure the catheter hub into the needle guard, and remove the stylette from the catheter. immediately insert a -to -ml syringe of heparinized saline and flush the catheter and draw back. if you are in the correct place, you will be able to draw blood from the catheter. to secure the catheter in place, tear a length of -inch white tape that will wrap around the patient's neck. pull a small length of the catheter out of the jugular vein to make a semicircle. the semicircle should be approximately / inch in diameter. let the length of catheter lie on the skin, and then place × -inch gauze squares impregnated with antimicrobial ointment over the site of catheter insertion. secure the proximal end of white tape around the white and blue pieces of the catheter, and wrap the tape around the patient's neck so that the tape adheres to the skin and fur. repeat the process by securing the gauze to the skin with two additional lengths of white tape, starting to secure the gauze in place by first wrapping the tape dorsally over the patient's neck, rather than under the patient's neck. in between each piece of tape and bandage layer, make sure that the catheter flushes and draws back freely, or else occlusion can occur. gently wrap layers of cotton roll gauze, kling, and elastikon or vetrap over the catheter. secure a male adapter or t port that has been flushed with heparinized saline, and then label the catheter with the size and length of catheter, date of catheter placement, and initials of the person who placed the catheter. the catheter is ready for use. monitor the catheter site daily for erythema, drainage, vessel thickening, or pain upon infusion. if any of these signs occur, or if the patient develops a fever of unknown origin, remove the catheter, culture the catheter tip aseptically, and replace the catheter in a different location. as long as the catheter is functional without complications, the catheter can remain in place. central catheters also can be placed via the seldinger or over-the-wire technique. a number of companies manufacture kits that contain the supplies necessary for over-the-wire catheter placement. each kit minimally should contain an over-the-needle catheter to place into the vessel, a long wire to insert through the original catheter placed, a vascular dilator to dilate the hole in the vessel created by the first catheter, and a long catheter to place into the vessel over the wire. additional accessories can include a paper drape, sterile gauze, a scalpel blade, local anesthetic, -gauge needles, and -or -ml syringes. restrain the patient and prepare the jugular furrow aseptically as for the percutaneous through-the-needle catheter placement. the person placing the catheter should wear sterile gloves throughout the process to maintain sterility. pick up the skin over the site of catheter placement, and insert a small bleb of local anesthetic through the skin. the local anesthetic should not be injected into the underlying vessel (figure - ) . make a small nick into the skin through the local anesthetic with a no. or no. scalpel blade. use care to avoid lacerating the underlying vessel. next, occlude the jugular vein as previously described, and insert the over-the-needle catheter into the vessel. watch for a flash of blood in the catheter hub. remove the stylette from the catheter. next, insert the long wire into the catheter and into the vessel (figures - and - ) . never let go of the wire. remove the catheter, and place the vascular dilator over the wire and into the vessel (figure - ) . gently twist to place the dilator into the vessel a short distance, creating a larger hole in the vessel. the vessel will bleed more after creating a larger hole. remove the vascular dilator, and leave the wire in place within the vessel. insert the long catheter over the wire into the vessel (figure - ) . push the catheter into the vessel to the catheter hub (figure - ) . slowly thread the wire through a proximal port in the catheter. once the catheter is in place, remove the wire, and suture the catheter in place to the skin with nonabsorbable suture. cover the catheter site with sterile gauze and antimicrobial ointment, cotton roll bandaging material, gauze, and kling or vetrap. flush the catheter with heparinized saline solution, and then use the catheter for infusion of parenteral nutrition, blood products, crystalloid and colloid fluids, medications, and frequent blood sample collection. examine the catheter site daily for evidence of infection or thrombophlebitis. the catheter can remain in place as long as it functions and no complications occur. place the patient in sternal recumbency as for cephalic venipuncture. clip the antebrachium circumferentially, and wipe the area clean of any loose fur and debris (figure - ) . aseptically scrub the clipped area, and have an assistant occlude the cephalic vein at the crook of the elbow. the person placing the catheter should grasp the distal carpus with the nondominant hand and insert the over-the-needle catheter into the vessel at a -to -degree angle ( figure - ) . watch for a flash of blood in the catheter hub, and then gently push the catheter off of the stylette (figure - ) . have the assistant occlude the vessel over the catheter to prevent backflow. flush the catheter with heparinized saline solution. make sure that the skin and catheter hub are clean and dry to ensure that the tape adheres to the catheter hub and skin. secure a length of / -inch white tape tightly around the catheter and then around the limb. make sure that the catheter hub does not "spin" in the tape, or else the catheter will fall out. next, secure a second length of -inch adhesive tape under the catheter and around the limb and catheter hub (figure - ). this piece of tape helps to stabilize the catheter in place. finally, place a flushed t port or male adapter in the catheter hub and secure to the limb with white tape. make sure that the tape is adhered to the skin securely, but not so tightly as to impede venous outflow (figure - ) . the catheter site can be covered with a cotton ball impregnated with antimicrobial ointment and layers of bandage material. label all catheters with the date of placement, the type and gauge of catheter inserted, and the initials of the person who placed the catheter. the femoral artery can be catheterized for placement of an indwelling arterial catheter. indwelling arterial catheters can be used for continuous invasive arterial blood pressure monitoring and for procurement of arterial blood samples. place the patient in lateral recumbancy, and tape the down leg in an extended position. clip the fur over the femoral artery and aseptically scrub the clipped area. palpate the femoral artery as it courses distally on the medial surface of the femur and anterior to the pectineus muscle. make a small nick incision over the proposed site of catheter placement using the bevel of an -gauge needle. place a long over-the-needle catheter through the nick in the skin and direct it toward the palpable pulse. place the tip of the catheter so that the needle tip rests in the subcutaneous tissue between the artery and the palpating index finger. advance the needle steeply at a -degree angle to secure the superficial wall of the vessel and then the deep wall of the vessel. the spontaneous flow of blood in the catheter hub ensures that the catheter is figure - : catheter is taped in place with a t-port. situated in the lumen of the artery. feed the catheter off of the stylette, and cover the hub with a catheter cap. flush the catheter with sterile heparinized saline solution, and then secure it in place. some persons simply tape the catheter in place with pieces of / -and -inch adhesive tape. others use a "butterfly" piece of tape around the catheter hub and suture or glue the tape to the adjacent skin for added security. the dorsal pedal artery commonly is used for catheter placement. to place a dorsal pedal arterial catheter, place the patient in lateral recumbency. clip the fur over the dorsal pedal artery, and then aseptically scrub the clipped area. tape the distal limb so that the leg is twisted slightly medially for better exposure of the vessel, or the person placing the arterial catheter can manipulate the limb into the appropriate position. palpate the dorsal pedal pulse as it courses dorsally over the tarsus. place an over-the-needle catheter percutaneously at a -to -degree angle, threading the tip of the needle carefully toward the pulse. advance the needle in short, blunt movements, and watch the catheter hub closely for a flash of pulsating blood that signifies penetration into the lumen of the artery. then thread the catheter off of the stylette, and cover the catheter hub with a catheter cap. secure the catheter in place with lengths of / -and -inch adhesive tape as with any other intravenous catheter, and then flush it with heparinized saline solution every to hours. any vessel that can be catheterized percutaneously also can be catheterized with surgical cutdown. restrain the patient and clip and aseptically scrub the limb or jugular vein as for a percutaneous catheterization procedure. block the area for catheter placement with a local anesthetic before cutting the skin over the vessel with a no. scalpel blade. while wearing sterile gloves, pick up the skin and incise the skin over the vessel. direct the sharp edge of the blade upward to avoid lacerating the underlying vessel. using blunt dissection, push the underlying subcutaneous fat and perivascular fascia away from the vessel with a mosquito hemostat. make sure that all tissue is removed from the vessel. using the mosquito hemostat, place two stay sutures of absorbable suture under the vessel. elevate the vessel until it is parallel with the incision, and gently insert the catheter and stylette into the vessel. secure the stay sutures loosely around the catheter. suture the skin over the catheter site with nonabsorbable suture, and then tape and bandage the catheter in place as for percutaneous placement. remove catheters placed surgically as soon as possible and exchange them for a percutaneously placed catheter to avoid infection and thrombophlebitis. the most important aspect of catheter maintenance is to maintain cleanliness and sterility at all times. an indwelling catheter can remain in place for as long as it is functional and no complications occur. change the bandage whenever it becomes wet or soiled to prevent wicking of bacteria and debris from the environment into the vessel. check the bandages and catheter sites at least once a day for signs of thrombophlebitis: erythema, vessel hardening or ropiness, pain upon injection or infusion, and discharge. also closely examine the tissue around and proximal and distal to the catheter. swelling of the paw can signify that the catheter tape and bandage are too tight and are occluding venous outflow. swelling above the catheter site is characteristic of perivascular leakage of fluid and may signify that the catheter is no longer within the lumen of the vessel. remove the catheter if it is no longer functional, if there is pain or resistance upon infusion, if there is unexplained fever or leukocytosis, or if there is evidence of cellulitis, thrombophlebitis, or catheter-related bacteremia or septicemia. aseptically culture the tip of the indwelling catheter for bacteria. animals should wear elizabethan collars or other forms of restraint if they lick or chew at the catheter or bandage. catheter patency may be maintained with constant fluid infusion or by intermittent flushing with heparinized saline ( units of unfractionated heparin per to ml of saline) every hours. flush arterial catheters more frequently (every hours). disconnect intravenous connections only when absolutely necessary. wear gloves whenever handling the catheter or connections. label all fluid lines and elevate them off of the floor to prevent contamination. date each fluid line and replace it once every to hours. if an intravenous catheter cannot be placed because of small patient size, hypovolemia, hypothermia, or severe hypotension, needles can be placed into the marrow cavity of the femur, humerus, and tibia for intraosseous infusion of fluids, drugs, and blood products. this technique is particularly useful in small kittens and puppies and in exotic species. contraindications to intraosseous infusion is in avian species (which have air in their bones), fractures, and sepsis, because osteomyelitis can develop. an intraosseous catheter is relatively easy to place and maintain but can cause patient discomfort and so should be changed to an intravenous catheter as soon as vascular access becomes possible. to place an intraosseous catheter, clip and aseptically scrub the fur over the proposed site of catheter placement. the easiest place for intraosseous placement is in the intertrochanteric fossa of the femur. inject a small amount of a local anesthetic through the skin and into the periosteum where the trocar or needle will be inserted. place the patient in lateral recumbency, and grasp the leg in between your fingers, with the stifle braced against the palm of your hand. push the stifle toward the abdomen (medially) to abduct the proximal femur away from the body. this will shift the sciatic nerve out of the way of catheter placement. insert the tip of the needle through the skin and into the intertrochanteric fossa. gently push with a simultaneous twisting motion, pushing the needle parallel with the shaft of the femur, toward your palm. you may feel a pop or decreased resistance as the needle enters the marrow cavity. gently flush the needle with heparinized saline. if the needle is plugged with bone debris, remove the needle and replace it with a fresh needle of the same type and size in the hole that you have created. a spinal needle with an internal stylette also can be placed. the stylette will prevent the needle from becoming clogged with bone debris during insertion. secure the hub of the needle with a butterfly length of white adhesive tape and then suture it to the skin to keep the catheter in place. the catheter is now ready for use. the patient should wear an elizabethan collar to prevent disruption or removal of the catheter. the intraosseous catheter can be maintained as any peripheral catheter, with frequent flushing and daily evaluation of the catheter site. the definition of pain has been debated philosophically over the ages and has changed as knowledge has increased. pain is defined as an unpleasant sensory or emotional experience associated with actual or perceived tissue damage. until recognition of a noxious stimulus occurs in the cerebral cortex, no response or adaptation results. rational management of pain requires an understanding of the underlying mechanisms involved in pain and an appreciation of how analgesic agents interact to disrupt pain mechanisms. multiple factors and causes produce pain in human beings and domestic animal species. the causes of pain, psychological and physical, may derive from many different mechanisms within emergency medicine, among them trauma, infectious disease, neglect, environmental stress, surgery, and acute decompensation of chronic medical conditions. the two major classes of pain are acute and chronic pain. box - gives specific categories and causes of pain. the pain sensing and response system can be divided into the following categories: nociceptors, which detect and filter the intensity of the noxious stimuli; primary afferent nerves, which transmit impulses to the central nervous system (cns); ascending tracts, which are part of the dorsal horn and the spinal cord that conveys stimuli to higher centers in the brain; higher centers, which are involved in pain discrimination, some memory, and motor control; and modulating or descending systems, which are a means of processing, memorizing, and modifying incoming impulses. current analgesic therapies may inhibit afferent nociceptive transmission within the brain and spinal cord; directly interrupt neural impulse conduction through the dorsal horn, primary afferent nerves, or dorsal root ganglion; or prevent the nociceptor sensitization that accompanies initial pain and inflammation. the physiologic aspects of pain are believed to be produced by the transmission, transduction, and integration of initial nerve endings, peripheral neuronal input, and ascending afferent nerves via the thalamus to the cerebral cortex. ascending afferent nerves to the limbic system are believed to be responsible for the emotional aspects of pain. there are several classification schemes for different types of pain. acute pain, such as that which results from trauma, surgery, or infectious agents, is abrupt in onset, relatively short in duration, and may be alleviated easily by analgesics. in contrast, chronic pain is a long-standing physical disorder or emotional distress that is slow in onset and difficult to treat. both types of pain can be classified further based on site of origin. somatic pain arises from superficial skin, subcutaneous tissue, body wall, or appendages. visceral pain arises from abdominal or thoracic viscera and primarily is associated with serosal irritation. analgesia, then, is the loss of pain without the loss of consciousness. this is in contrast to anesthesia, which is the loss of sensation in the whole body or a part of the body with the loss of consciousness or at least depression of the cns. untreated pain causes immediate changes in the neurohormonal axis, which in turn causes restlessness, agitation, increased heart and respiratory rates, fever, and blood pressure fluctuations, all of which are detrimental to the healing of the animal. a catabolic state is created as a result of increased secretion of catabolic hormones and decreased secretion of anabolic hormones. the net effect the majority of neurohormonal changes produce is an increase in the secretion of catabolic hormones. hyperglycemia is produced and may persist because of production of glucagon and relative lack of insulin. lipolytic activity is stimulated by cortisol, catecholamines, and growth hormone. cardiorespiratory effects of pain include increased cardiac output, vasoconstriction, hypoxemia, and hyperventilation. protein catabolism is a common occurrence and major concern regarding healing. pain associated with inflammation causes increase in tissue and blood levels of prostaglandins and cytokines, both of which promote protein catabolism indirectly by increasing the energy expenditure of the body. powerful evidence indicates that local anesthetic, sympathetic agonist, and opioid neural blockade may produce a modification of the responses to these physiologic changes. variable reduction in plasma cortisol, growth hormone, antidiuretic hormone, β-endorphin, aldosterone, epinephrine, norepinephrine, and renin is based on the anesthetic technique and the drugs selected. prophylactic administration of analgesics blunts the response before it occurs; analgesics administered following perception or pain are not as effective, and higher doses are generally necessary to achieve an equivalent level of analgesia. effective pain control can be achieved only when the signs of pain can be assessed effectively, reliably, and regularly. the experience of pain is unique to each individual, which makes pain assessment difficult, especially in traumatized and critical patients. most attempts to assess clinical pain use behavioral observations and interactive variables in addition to assessment of physiologic responses such as heart rate and respiratory rate, blood pressure, and temperature. but many factors can influence the processing and outward projection of pain, including altered environments, species differences, withinspecies variations (age, breed, sex), and the type, severity, and chronicity of pain. within-species differences (age, breed, and sex) further complicate the pain assessment. most notable is that different breeds of dogs act differently when confronted with pain or fear. labrador retrievers tend to be stoic, whereas greyhounds and teacup breeds tend to react with a heightened state of arousal around even the simplest of procedures (e.g., subcutaneous injections and nail trims). the individual character and temperament of the animal further influences its response. pediatric and neonatal animals seem to have a lower threshold for pain and anxiety than older animals. in any species, the duration and type of pain make it more (acute) or less (chronic) likely to be expressed or exhibited outwardly. unfamiliarity with normal behaviors typical of a particular species or breed makes recognition of their painful behaviors and responses impossible. the definition and recognition of pain in an individual animal is challenging. because of all the differences discussed, there is no straight line from insult, albeit actual or perceived, to degree of pain experienced. nor is there a formula for treating "x" type of pain with "y" type of analgesic. a goal of analgesia is to treat all animals with analgesic drugs and modalities as preemptively as possible and using a multimodal approach. use analgesic treatment as a tool for diagnosis of pain in the event that recognition of these phenomena is difficult for the patient. in other words, with countless drugs and treatment modalities available, analgesic administration should never be withheld in an animal, even if pain is questionable. it is important to remember that no behavior or physiologic variable in and of itself is pathognomonic for pain. interactive and unprovoked (noninteractive) behavior assessments and trending of physiologic data are useful to determine the pain in an individual animal. this is known as pain scoring. baseline observations, especially those observations from someone who has known the animal well, can be helpful to serial behavior and pain assessments. pain scoring systems have been developed and are reviewed elsewhere; the purposes of these systems are to evaluate and to help guide diagnostic and analgesic treatments (table - ) . regardless of the scale or method used to assess pain, the caregiver must recognize the limitations of the scale. if in doubt of whether pain is present or not, analgesic therapy should be used as a diagnostic tool. classic behaviors associated with pain in dogs and cats include abnormal postures, gaits, movements, and behaviors (boxes - and . stoicism is the apparent apathy and pain: assessment, prevention, and management indifference in the presence of pain and is perhaps the no. sign of ineffective pain relief or persistent pain in many animals, because so many display apathy and classically normal physiologic parameters even in the face of severe distress, overt suffering, or blatant trauma and illness. the absence of normal behaviors is also a clinical sign of pain, even when abnormal behaviors are not observed. acute pain results in many of the aforementioned behavioral and physiologic signs, but chronic pain in small animals is an entirely different and distinct entity. chronic pain is often present in the absence of obvious tissue pathology and changes in physical demeanor. again, the severity of the pain may not correlate with the severity of any pathologic condition that may or may not be present. chronic pain, especially if insidious in onset (cancer, dental, or degenerative pain), may well go unnoticed in dogs and cats, even by family members or intermittent caregivers. inappetance, lack of activity, panting in a species classically designed to be nose breathers, decreased interest in surroundings, different activity patterns, and abnormal postures are just a few signs of chronic pain in cats and dogs. cats are a species that in particular are exemplary in their abilities to hide chronic pain. they will exhibit marked familial withdrawal, finding secluded areas where they may remain for days to weeks when they experience acute and chronic pain. when deciding on a pain management protocol for a patient, always perform a thorough physical examination and include a pain score assessment before injury and pain has occurred, whenever possible. form a problem list to guide your choice of anesthesia and analgesia. for example, using a nonsteroidal antiinflammatory drug (nsaid) in an animal with renal failure would not be wise. remember to account for current medications that the patient may be taking that may augment or interfere with the analgesic or anesthetic drugs. use multimodal techniques and regional therapy and drugs to target pain at different sites before it occurs. once a strategy is decided upon, frequently reassess the patient and tailor the protocol to meet each patient's response and needs. drug therapy (in particular, opioids with or without α -agonists) is a cornerstone for acute pain treatment and surgical preemptive pain prevention. however, local anesthetics delivered epidurally, via perineural or plexus injection, intraarticular or trigger point injection, are also effective analgesics for acute and chronic forms of pain and inflammation. the nsaids that classically have been reserved for treatment of more chronic or persistent pain states now are being used regularly for treatment of acute and perioperative pain once blood pressure, coagulation, and gastrointestinal parameters have been normalized. an opioid is any natural or synthetic drug that is derived from the poppy, which interacts with opiate receptors identified on cell membranes. the drugs from this class constitute the most effective means of controlling acute, perioperative, and chronic pain in human and veterinary medicine (table - ) . their physiologic effects result from the interaction with one or more of at least five endogenous opioid receptors (µ, σ, δ, ε, and κ). µ-receptor agonists are noted for their ability to produce profound analgesia with mild sedation. these drugs diminish "wind-up," the hyperexcitable state resulting from an afferent volley of nociceptive impulses. they elevate the pain threshold and are used preemptively to prevent acute pain. as a class, opioids cause cns depression with their intense analgesia. dose-related respiratory depression reflects diminished response to carbon dioxide levels. cardiac depression is secondary only to bradycardia and is more likely with certain opioids such as morphine and oxymorphone. narcotics produce few if any clinically significant cardiovascular effects in dogs and cats; they are considered cardiac soothing or sparing. because opioids increase intracranial and intraocular pressure, use them more cautiously in patients with severe cranial trauma and or ocular lesions. opioids directly stimulate the chemoreceptor trigger zone and may cause nausea and vomiting. most opioids depress the cough reflex via a central mechanism; this may be helpful in patients recovering from endotracheal intubation irritation. a key characteristic of opioids that makes them desirable for use in emergency and critical care situations is their reversibility. antagonists block or reverse the effect of agonists by combining with receptors and producing minimal or no effects. administer all reversal agents, such as naloxone and naltrexone, slowly if given intravenously and to effect. α α -agonists as a class of drugs, α -agonists warrant special attention because most members of the group possess potent analgesic power at doses that are capable of causing sedation, cns depression, cardiovascular depression, and even general anesthetic states. originally developed for antihypertensive use, α -agonists quickly have attained sedative analgesic status in veterinary medicine (table - ) . like the opioids, α -agonists produce their effects by aggravating α-adrenergic receptors in the cns and periphery. emergency care among them cyclooxygenase- (cox- ), the major constitutive enzyme primarily involved in normal physiologic functions, and cox- , the enzyme responsible for most of the hyperalgesia and pain responses experienced after tissue injury or trauma. some nsaids inhibit cyclooxygenase and lipoxygenase activity. most of the currently available oral and parenteral nsaids for small animal medicine and surgery target the cyclooxygenase pathways predominantly, although one (tepoxalin) is thought to inhibit both pathways. inhibition of cox- and cox- can inhibit the protective effects and impair platelet aggregation and lead to gastrointestinal ulceration. there are definite contraindications and relative contraindications for the use of nsaids. nonsteroidal antiinflammatory drugs should not be administered to patients with renal or hepatic insufficiency, dehydration, hypotension or conditions that are associated with low circulating volume (congestive heart failure, unregulated anesthesia, shock), or evidence of ulcerative gastrointestinal disease. trauma patients should be stabilized completely regarding vascular volume, tone, and pressure before the use of nsaids. patients receiving concurrent administration of other nsaids or corticosteroids, or those considered to be cushingoid, should be evaluated carefully for an adequate "washout" period (time of clearance of drug from the system) before use of an nsaid or before switching nsaids. patients with coagulopathies, particularly those that are caused by platelet number or function defects or those caused by factor deficiencies, and patients with severe, uncontrolled asthma or other bronchial disease are probably not the patients in which to use nsaids. other advice is that nsaids not be administered to pregnant patients or to females attempting to become pregnant because cox- induction is necessary for ovulation and subsequent implantation of the embryo. the administration of nsaids should be considered only in the well-hydrated, normotensive dog or cat with normal renal or hepatic function, with no hemostatic abnormalities, and no concurrent steroid administration. nonsteroidal antiinflammatory drugs can be used in many settings of acute and chronic pain and inflammation. among these are the use in well-stabilized musculoskeletal trauma and surgical pain, osteoarthritis management, meningitis, mastitis, animal bite and other wound healing, mammary or transitional cell carcinoma, epithelial (dental, oral, urethral) inflammation, ophthalmologic procedures, and dermatologic or otic disease. whereas opioids seem to have an immediate analgesic effect when administered, most nsaids will take up to minutes for their effect to be recognized. as such, most perioperative or acute nsaids use is part of a balanced pain management scheme, one that uses narcotics and local anesthetic techniques. nonsteroidal antiinflammatory drugs are devoid of many of the side effects of narcotic administration; namely, decreased gastrointestinal motility, altered sensorium, nausea/vomition, and sedation. nonsteroidal antiinflammatory drugs are also devoid of many of the side effects of steroid administration; namely, suppression of the pituitary adrenal axis. the toxic effects of salicylates in cats are well documented. cats are susceptible because of slow clearance and dose-dependent elimination because of deficient glucuronidation in this species. because of this, the dose and the dosing interval of most commonly used nsaids need to be altered in order for these drugs to be used. cats that have been given canine doses of nsaids (twice daily or even once daily repetitively) may show hyperthermia, hemorrhagic or ulcerative gastritis, kidney and liver injury, hyperthermia, respiratory alkalosis, and metabolic acidosis. acute and chronic toxicities of nsaids have been reported in cats, especially after repeat once daily dosing. ketoprofen, flunixin, aspirin, carprofen, and meloxicam have been administered safely to cats, although like most antibiotics and other medications, they are not approved and licensed for use in cats. an important note, though, is that dosing intervals ranging from to hours have been used, and antithrombotic effects often can be achieved at much lower doses than those required to treat fevers and inflammation. i recommend the use of no loading doses, minimum -hour dosing intervals, and assurance of adequate circulating blood volume, blood pressure, and renal function. because many of the nsaids are used off-label in cats, it is imperative that the clinician carefully calculate the dose, modify the dosing interval, and communicate this information to the client before dispensing the drug. even drugs that come in liquid form (meloxicam), if administered to cats via box-labeled directions used for dogs, will be given in near toxic doses. to worsen the misunderstanding about dosages for cats, drops from manufacturer's bottles often are calibrated drops; when these same liquids are transferred into pharmacy syringes for drop administration, the calibration of course is lost, and the animal potentially is overdosed. a more accurate method of dispensing and administering oral nsaids in cats is to calculate the dose in milligrams and determine the exact number of milliliters to administer, rather than use the drop method. ketamine classically was considered a dissociative anesthetic, but it also has potent activity as an n-methyl-d-aspartate (nmda) receptor antagonist. this receptor located in the cns mediates windup and central sensitization (a pathway from acute to chronic pain). blockade of this receptor with microdoses of ketamine results in the ability to provide body surface, somatic, and skin analgesia with potentially lower doses of opioids and α-agonists. loading doses of . to mg/kg are used intravenously with continuous rate infusions of to µg/kg/minute. in and of itself, this drug possesses little to no analgesic ability and indeed in high doses alone often can aggravate, sensitize, or excite the animal in subacute or acute pain. amantadine is another nmda blocker that has been used for its antiviral and parkinson's stabilizing effects. amantadine has been used for neuropathic pain in human beings but is only available in an oral form. suggested starting doses for cats and dogs range from to mg/kg po daily. when the drug is given orally and intravenously, patients are unlikely to develop behavioral or cardiorespiratory effects with ketamine or amantadine. tramadol is an analgesic that possesses weak opioid µ-agonist activity and norepinephrine and serotonin reuptake inhibition. tramadol is useful for mild to moderate pain in small animals. although the parent compound has very weak opioid activity, the metabolites have excellent binding affinity for the µ-receptor. tramadol has been used for perisurgical pain control when given orally in cats and dogs at a dose of to mg/kg po sid to bid. cats appear to require only once daily dosing. regardless of its affinity for the opioid receptors, the true mechanism of action of tramadol in companion animals remains largely unknown. gabapentin is a synthetic analog of γ-aminobutyric acid (gaba). originally introduced as an antiepileptic drug, the mechanism of action of gabapentin remains somewhat unclear in veterinary medicine. the drug is among a number of commonly used antiepileptic medications used to treat central pain in human beings. the rationale for use is the ability of the drugs to suppress discharge in pathologically altered neurons. gabapentin does this through calcium channel modulation without binding to glutamate receptors. chronic, burning, neuropathic, and lancinating pain in small animals responds well to to mg/kg po daily. local anesthetic agents are the major class used as a peripheral-acting analgesic ( table - ) . local anesthetics block the transmission of pain impulses at the peripheral nerve nociceptor regions. local anesthetics may be used to block peripheral nerves or inhibit nerve "zones" using regional techniques. although all local anesthetics are capable of providing pain relief, agents with a longer duration of action are preferred for pain management purposes. bupivacaine is an example of a long-acting local anesthetic drug that is used along with lidocaine for long-acting pain relief. a single dose of bupivacaine injected at a local site will provide local anesthesia and analgesia for to hours. when lidocaine is administered as an intravenous constant rate infusion ( to µg/kg/minute in dogs, to µg/kg/minute in cats) is effective in the treatment of chronic neuropathic pain and periosteal and peritoneal pain (e.g., pancreatitis). mexiletine, an oral sodium channel blocker, can be used as an alternative to injectable lidocaine for provision of background analgesia. many drugs (table - ) are used in combination with opioids, α -agonists, and ketamine to provide anxiolysis and sedation. injection of local anesthetic solution into the connective tissue surrounding a particular nerve produces loss of sensation (sensory blockade) and/or paralysis (motor nerve blockade) in the region supplied by the nerve. local anesthetics also may be administered epidurally, intrathoracically, intraperitoneally, and intraarticularly. lidocaine and bupivacaine are the most commonly administered local anesthetics. lidocaine provides for quick, short-acting sensory and motor impairment. bupivacaine provides for later-onset, longerlasting desensitization without motor impairment. combinations of the two agents diluted with saline are used frequently to provide for quick-onset analgesia that lasts between and hours in most patients. adding narcotic and/or α agent often maximizes the analgesia and increases the pain-free interval to to hours. epinephrine and preservative-free solutions are recommended. precision placement of anesthetic close to nerves, roots, or plexuses is improved with the use of a stimulating nerve locator. cats seem to be more sensitive to the effects of local anesthetics; as such the lower ends of most dosing ranges are used for blockades in this species. unlike most instances of general anesthesia, during which the animal is rendered unconscious and nerve transmission is decreased by virtue of cns depression, local and regional techniques block the initiation of noxious signals, thereby effectively preventing pain from entering the cns. this is an effective means of not only preventing initial pain but also reducing the changes that take place in the dorsal horn of the spinal cord, spinothalamic tracts, limbic and reticular activating centers, and cortex. frequently, the neurohormonal response that is stimulated in pain and stress is blunted as well. overall, the patient has fewer local and systemic adverse effects of pain, disease processes are minimized, chronic pain states are unlikely, and outcome is improved. regional techniques are best used as part of an analgesic regimen that consists of their continuous administration, narcotics, α-agonists, anxiolytics, and good nursing. lidocaine can be added to sterile lubricant in a one-to-one concentration to provide decreased sensation for urinary catheterization, nasal catheter insertion, minor road burn analgesia, and pyotraumatic dermatitis analgesia. proparacaine is a topical anesthetic useful for corneal or scleral injuries. local anesthetics can be used to infiltrate areas of damage or surgery by using long-term continuous drainage catheters and small, portable infusion pumps. this is an effective means of providing days of analgesia for massive surgical or traumatic soft tissue injury. even without the catheter, incisional or regional soft tissue blocking using a combination of to mg/kg lidocaine and . to mg/kg bupivacaine diluted with equal volume of saline and : with sodium bicarbonate is effective for infiltrating large areas of injury. administration of local anesthetic drugs around the infraorbital, maxillary, ophthalmic mental, and alveolar nerves can provide excellent analgesia for dental, orofacial, and ophthalmic trauma and surgical procedures. each nerve may be desensitized by injecting . to . ml of a % lidocaine hydrochloride solution and . to . ml of . % bupivacaine solution using a . -to . -cm, -to -gauge needle. precise placement perineurally versus intraneurally (neuroma formation common) is enhanced by using catheters in the foramen versus needle administration. always perform aspiration before administration to rule out intravascular injection of agents. this block is used to provide analgesia for thoracic, lower cervical, cranial abdominal, and diaphragmatic pain. following aseptic preparation, place a small through-the-needle ( -to -gauge) catheter in the thoracic cavity between the seventh and ninth intercostal space on the midlateral aspect of the thorax. aseptically mix a . to mg/kg lidocaine and a . to . mg/kg bupivacaine dose with volume of saline equal to the volume of bupivacaine, and slowly inject it over a period of to minutes following aspiration to ensure that no intravascular injection occurs. depending on where the lesion is, position the patient to allow the intrapleural infusion to "coat" the area. most effective is positioning the patient in dorsal recumbency for several minutes following the block to make sure local anesthetic occupies the paravertebral gutters and hence the spinal nerve roots. the block should be repeated every hours in dogs and every to hours in cats. secure the catheter to the skin surface for repetitive administration. administration of local anesthetic around the brachial plexus provides excellent analgesia for forelimb surgery, particularly that distal to the shoulder, and amputations. nerve locator-guided techniques are much more accurate and successful than blind placement of local anesthetic; however, even the latter is useful. to administer a brachial plexus blockade, follow this procedure: . aseptically prepare a small area of skin over the point of the shoulder. . insert a -gauge, / -to -inch spinal needle medial to the shoulder joint, axial to the lesser tubercle, and advance it caudally, medial to the body of the scapula, and toward the costochondral junction of the first rib. aspirate first before injection to make sure that intravenous injection does not occur. . inject one third of the volume of local anesthetic mix, and then slowly withdraw the needle and fan dorsally and ventrally while infusing the remaining fluid. . local anesthetic doses are similar to those for intrapleural blockade. epidural analgesia refers to the injection of an opioid, a phencyclidine, an α-agonist, or an nsaid into the epidural space. epidural anesthesia refers to the injection of a local anesthetic. in most patients a combination of the two is used. epidural analgesia and anesthesia are used for a variety of acute and chronic surgical pain or traumatically induced pain in the pelvis, tail, perineum, hind limbs, abdomen, and thorax (table - ) . procedures in which epidural analgesia and anesthesia are useful include forelimb and hind limb amputation, tail or perineal procedures, cesarean sections, diaphragmatic hernia repair, pancreatitis, peritonitis, and intervertebral disk disease. epidural blocks performed using opioids or bupivacaine will not result in hind limb paresis or decreased urinary or anal tone (incontinence), unlike lidocaine or mepivicaine epidural blocks. morphine is one of the most useful opioids for administration in the epidural space because of its slow systemic absorption. epidural catheters used for the instillation of drugs through constant rate infusion or intermittent injection can be placed in dogs and cats. routinely placed at the lumbosacral junction, these catheters are used with cocktails including preservative-free morphine, bupivacaine, medetomidine, and ketamine. extremely effective for preventing windup pain in the peritoneal cavity or caudal half of the body, the catheters may be maintained if placed aseptically for to days. to provide epidural analgesia or anesthesia, follow this procedure: . position the animal in lateral or sternal recumbency. . clip and aseptically scrub over the lumbosacral site. . palpate the craniodorsal-most extent of the wings of the ileum bilaterally and draw an imaginary line through them to envision the spine of l located immediately behind the imaginary line. . advance a -to -gauge, / -to -inch spinal or epidural needle through the skin just caudal to the spine of l . . the needle will lose resistance as it is introduced into the epidural space. drop saline into the hub of the needle, and the saline will be pulled into the epidural space as the needle enters. discrete intercostal nerve blocks can provide effective analgesia for traumatic or postsurgical pain. identify the area of the injury, and infiltrate three segments on either side of the injury with analgesic. to perform an intercostal nerve block, follow this procedure: . clip and aseptically scrub the dorsal and ventral third of the chest wall. . palpate the intercostal space as far dorsally as possible. . use a -gauge, . -inch needle at the caudolateral aspect of the affected rib segments and those cranial and caudal. . direct the tip of the needle caudally such that the tip of the needle "drops" off of the caudal rib. (this places the needle tip in proximity to the neuromuscular bundle that contains the intercostal nerve that runs in a groove on the caudomedial surface of the rib.) . aspirate to confirm that the drug will not go intravenously. . inject while slowly withdrawing the needle. inject . to . ml at each site, depending on the size of the animal. gaynor js, an acute condition in the abdomen is defined as the sudden onset of abdominal discomfort or pain caused by a variety of conditions involving intraabdominal organs. many animals have the primary complaint of lethargy, anorexia, ptyalism, vomiting, retching, diarrhea, hematochezia, crying out, moaning, or abnormal postures. abnormal postures can include generalized rigidity, walking tenderly or as if "on eggshells," or a prayer position in which the front limbs are lowered to the ground while the hind end remains standing. in some cases, it may be difficult initially to distinguish between true abdominal pain or referred pain from intervertebral disk disease. rapid progression and decompensation of the patient's cardiovascular status can lead to stupor, coma, and death in the most extreme cases, making rapid assessment, treatment, and definitive care extremely challenging. often the patient's signalment and history can increase the index of suspicion for a particular disease process. a thorough history often is overlooked or postponed in the initial stages of resuscitation of the patient with acute abdominal pain. often, asking the same question in a variety of methods can elicit an answer from the client that may lead to the source of the problem and the reason for acute abdominal pain. important questions to ask the client include the following: • what is your chief complaint or reason that you brought your animal in on emergency? • when did the signs first start, or when was your animal last normal? • do you think that the signs have been the same, better, or getting worse? • does your animal have any ongoing or past medical problems? • have similar signs occurred in the past? • does your animal have access to any known toxins, or does he or she run loose unattended? as with any other emergency, the clinician must follow the abcs of therapy, treating the most life-threatening problems first. first, perform a perfunctory physical examination. examination of the abdomen ideally should be performed last, in case inciting a painful stimulus precludes you from evaluating other organ systems more thoroughly. briefly observe the patient from a distance. are there any abnormal postures? is there respiratory distress? is the animal ambulatory, and if so, do you observe any gait abnormalities? do you observe any ptyalism or attempts to vomit? auscultate the patient's thorax for crackles that may signify aspiration pneumonia resulting from vomiting. examine the patient's mucous membrane color and capillary refill time, heart rate, heart rhythm, and pulse quality. many patients in pain have tachycardia that may or may not be accompanied by dysrhythmias. if a patient's heart rate is inappropriately bradycardic, consider hypoadrenocorticism, whipworm infestation, or urinary obstruction or trauma as a cause of hyperkalemia. assess the patient's hydration status by evaluating skin turgor, mucous membrane dryness, and whether the eyes appear sunken in their orbits. a brief neurologic examination should consist of whether the patient is actively having a seizure, or whether mental dullness, stupor, coma, or nystagmus are present. posture and spinal reflexes can assist in making a diagnosis of intervertebral disk disease versus abdominal pain. perform a rectal examination to evaluate for the presence of hematochezia or melena. finally, examination of the abdomen should proceed first with superficial and then deeper palpation. visually inspect the abdomen for the presence of external masses, bruising, or penetrating injuries. reddish discoloration of the periumbilical area often is associated with the presence of intraabdominal hemorrhage. it may be necessary to shave the fur to inspect the skin and underlying structures visually for bruising and ecchymoses. auscultate the abdomen for the presence or absence of borborygmi to characterize gut sounds. next, perform percussion and ballottement to evaluate for the presence of a gas-distended viscus or peritoneal effusion. finally, perform first superficial and then deep palpation of all quadrants of the abdomen, noting abnormal enlargement, masses, or whether focal pain is elicited in any one area. once the physical examination has been performed, implement initial therapy in the form of analgesia, fluid resuscitation, and antibiotics. treatment for any patient with an acute condition in the abdomen and shock is to treat the underlying cause, maintain tissue oxygen delivery, and prevent end-organ damage and failure. a more complete description of shock and oxygen delivery is given in the section on shock. emergency care the administration of analgesic agents to any patient with acute abdominal pain is one of the most important therapies in the initial stages of case management. many patients with acute abdominal pain are clinically dehydrated or are in hypovolemic shock because of hemorrhage. careful titration of intravenous crystalloid and colloid fluids including blood products is necessary based on the patient's perfusion parameters including heart rate, capillary refill time, blood pressure, urine output, and pcv. fluid therapy also should be based on the most likely differential diagnoses, with specific fluid types administered according to the primary disease process. in dogs, a shock volume of fluids is calculated based on the total blood volume of ml/kg/hour. in cats, shock fluid rate is based on plasma volume of ml/kg/hour. in most cases, any crystalloid fluid can be administered at an initial volume of one fourth of a calculated shock dose and then titrated according to whether the patient's cardiovascular status responds favorably or not. in cases of an acute condition in the abdomen from known or suspected hypoadrenocorticism, severe whipworm infestation, or urinary tract obstruction or rupture, . % sodium chloride fluid without added potassium is the fluid of choice. when hemorrhage is present, the administration of whole blood or packed rbcs may be indicated if the patient has clinical signs of anemia and shows clinical signs of lethargy, tachypnea, and weakness. fresh frozen plasma is indicated in cases of hemorrhage resulting from vitamin k antagonist rodenticide intoxication or hepatic failure or in cases of suspected disseminated intravascular coagulation (dic). a more thorough description of fluid therapy is given under the sections on shock and fluid therapy. the empiric use of broad-spectrum antibiotics is warranted in cases of suspected sepsis or peritonitis as a cause of acute abdominal pain. ampicillin sulbactam ( mg/kg iv q - h) and enrofloxacin ( mg/kg once daily) are the combination treatment of choice to cover gram-negative, gram-positive, aerobic, and anaerobic infections. alternative therapies include a second-generation cephalosporin such as cefotetan ( mg/kg iv tid) or cefoxitin ( mg/kg iv tid) or added anaerobic coverage with metronidazole ( to mg/kg iv tid). tissue oxygen delivery depends on a number of factors, including arterial oxygen content and cardiac output. if an animal has had vomiting and subsequent aspiration pneumonitis, treatment of hypoxemia with supplemental oxygen in the form of nasal, nasopharyngeal, hood, or transtracheal oxygen administration is important (see oxygen supplementation under emergency diagnostic and therapeutic procedures). perform a complete blood count in all cases of acute abdominal pain to determine if lifethreatening infection or coagulopathy including dic is present. in cases of sepsis, infection, or severe nonseptic inflammation, the white blood cell count may be normal, elevated, or low. examine a peripheral blood smear for the presence of toxic neutrophils, eosinophils, atypical lymphocytes, nucleated rbcs, platelet estimate, anisocytosis, and blood parasites. a falling pcv in the face of rbc transfusion suggests ongoing hemorrhage. perform a biochemistry panel to evaluate organ system function. azotemia with elevated bun and creatinine may be associated with prerenal dehydration, impaired renal function, or postrenal obstruction or leakage. the bun also can be elevated when gastrointestinal hemorrhage is present. serum amylase may be elevated with decreased renal function or in cases of pancreatitis. a normal serum amylase, however, does not rule out pancreatitis as a source of abdominal pain. serum lipase may be elevated with gastrointestinal inflammation or pancreatitis. like amylase, a normal serum lipase does not rule out pancreatitis. total bilirubin, alkaline phosphatase, and alanine transaminase may be elevated with primary cholestatic or hepatocellular diseases or may be due to extrahepatic causes including sepsis. obtain a urinalysis via cystocentesis whenever possible, except in cases of suspected pyometra or transitional cell carcinoma. azotemia in the presence of a nonconcentrated (isosthenuric or hyposthenuric) urine suggests primary renal disease. secondary causes of apparent renal azotemia and lack of concentrating ability also occur in cases of hypoadrenocorticism and gram-negative sepsis. renal tubular casts may be present in cases of acute renal ischemia or toxic insult to the kidneys. bacteriuria and pyuria may be present with infection and inflammation. when a urinalysis is obtained via free catch or urethral catheterization, the presence of bacteriuria or pyuria also may be associated with pyometra, vaginitis, or prostatitis/prostatic abscess. serum lactate is a biochemical indicator of decreased organ perfusion, decreased oxygen delivery or extraction, and end-organ anaerobic glycolysis. elevated serum lactate greater than mmol/l has been associated with increased morbidity and need for gastric resection in cases of gdv and increased patient morbidity and mortality in other disease processes. rising serum lactate in the face of adequate fluid resuscitation is a negative prognostic sign. obtain abdominal radiographs as one of the first diagnostic tests when deciding whether to pursue medical or surgical management. the presence of gdv, linear foreign body, pneumoperitoneum, pyometra, or splenic torsion warrants immediate surgical intervention. if a loss of abdominal detail occurs because of peritoneal effusion, perform additional diagnostic tests including abdominal paracentesis (abdominocentesis) and abdominal ultrasound to determine the cause of the peritoneal effusion. abdominal ultrasonography is often useful in place of or in addition to abdominal radiographs. the sensitivity of abdominal ultrasonography is largely operator dependent. indications for immediate surgical intervention include loss of blood flow to an organ, linear bunching or placation of the intestinal tract, intussusception, pancreatic phlegmon or abscess, a fluid-filled uterus suggestive of pyometra, gastrointestinal obstruction, intraluminal gastrointestinal foreign body, dilated bile duct, or gallbladder mucocele, or gas within the wall of the stomach or gallbladder (emphysematous cholecystitis). the presence of peritoneal fluid alone does not warrant immediate surgical intervention without cytologic and biochemical evaluation of the fluid present. see also abdominal paracentesis and diagnostic peritoneal lavage. abdominal paracentesis (abdominocentesis) often is the deciding factor in whether to perform immediate surgery. abdominocentesis is a sensitive technique for detecting peritoneal effusion when more than ml/kg of fluid is present within the abdominal cavity. abdominal effusion collected should be saved for bacterial culture and evaluated biochemically and cytologically based on your index of suspicion of the primary disease process. if creatinine, urea nitrogen (bun) or potassium is elevated compared with that of serum, uroabdomen is present. elevated abdominal fluid lipase or amylase compared with serum supports a diagnosis of pancreatitis. elevated lactate compared with serum lactate or an abdominal fluid glucose less than mg/dl is highly sensitive and specific for bacterial/ septic peritonitis. the presence of bile pigment or bacteria is supportive of bile and septic peritonitis, respectively. free fibers in abdominal fluid along with clinical signs of abdominal pain strongly support gastrointestinal perforation, and immediate surgical exploration is required. text continued on p. the following are clinical conditions, patient signalment, common history, physical examination, and characteristic findings of various diagnostic tests. a blank column next to a condition indicates no specific signalment, history, physical examination, or diagnostic test characteristic for a particular disease process. lack of contiguity of body wall surgical ( medical unless perforation present present c-shaped abnormal gas pattern with plication on radiographs surgical (immediate) dilation of bowel cranial to foreign object, radiopaque object in surgical (immediate) stomach or intestines, hypochloremic metabolic acidosis on bloodwork if pyloric outflow obstruction is present elevated or decreased wbc; foreign material, wbcs and medical unless perforation bacteria on abdominal fluid, elevated lactate and decreased present glucose on abdominal fluid target shaped soft tissue density on abdominal u/s, soft tissue surgical (immediate): density with gas dilation cranially on abdominal radiographs medical management of primary cause colonic distension with hard feces on radiographs medical increased or decreased wbc, septic abdominal effusion surgical (immediate) elevated t bili, alt, alk phos, and wbc hypoechoic hepatic medical after biopsy parenchyma on ultasound hepatomegaly elevated t bili, alt, alk phos, and wbc hyperechoic foci in surgical (immediate) gallbladder or sludge on u/s, free gas in wall of gall bladder abdominal effusion, bile pigment in effusion surgical (immediate) elevated t bili, alk phos, alt surgical (immediate) elevated or decreased wbc, elevated t bili, alk phos and surgical (immediate) alt, free gas in hepatic parenchyma on rads, hypoechoic mass with hyperechoic material in hepatic parenchyma on u/s heteroechoic liver with hyperechoic center on ultrasound surgical (immediate) mixed echogenic mass on ultrasound, soft tissue mass surgical (immediate or density on radiographs, elevated alk phos, alt, delayed) t bili, hypoglycemia pain-cont'd elevated t bili, alk phos, alt, amylase and/or lipase, elevated medical in most cases or decreased wbc, hypocalcemia, focal loss of detail in right unless abscess or cranial quadrant on radiographs hypo-to hyperechoic phlegmon is present pancreas with hyperechoic peri-pancreatic fat on ultrasound, abdominal and/or pleural effusion on radiographs and ultrasound pancreatic soft tissue mass effect on radiographs and surgical if mass identified, ultrasound, elevated amylase and lipase, hypoglycemia, otherwise medical elevated serum insulin management of hypoglycemia splenomegaly on radiographs, hyperechoic spleen with no surgical (immediate) blood flow on ultrasound soft tissue mass effect and loss of abdominal detail on surgical (immediate) radiographs, cavitated mass with abdominal effusion on u/s hyperechoic spleen with no blood flow on abdominal u/s, surgical (immediate) abdominal effusion, thrombocytopenia loss of abdominal detail on radiographs, peritoneal effusion medical unless refractory on u/s, hemoabdomen on abdominocentesis hypotension diagnosis based primarily on clinical signs medical fracture of the os penis on radiographs largely medical unless urethral tear diagnosis based primarily on clinical signs medical, although prepuce may need to be incised to allow replacement of penis into sheath prostatomegaly on radiographs and ultrasound hypoechoic medical prostate on u/s, pyuria and bacteriuria and u/a prostatomegaly on radiographs and ultrasound hypo-to surgical (delayed) hyperechoic prostate on u/s, bacteriuria and pyuria on u/a prostatomegaly on radiographs and ultrasound, prostatic medical/surgical mineralization on radiographs and ultrasound hypoechoic kidneys on u/s, pyuria on u/a, elevated wbc, medical azotemia pyuria, bacteriuria on u/a medical pyelectasia in abdominal u/s, azotemia surgical (immediate) renomegaly on radiographs, azotemia renal mass on u/s, renomegaly on radiographs surgical (immediate) renal mass on u/s, azotemia, lack of renal blood flow surgical (delayed) on u/s calculi in renal pelvis on radiographs and ultrasound, azotemia medical unless both kidneys affected ureteral calculi on radiographs and ultrasound, hydronephrosis, medical unless both azotemia kidneys affected ureteral calculi on radiographs and ultrasound, hydronephrosis, surgical (delayed until fluid or soft tissue density on u/s, azotemia electrolyte stabilization) diagnosis largely based on physical examination medical unless cannot pass findings urethral catheter azotemia, no peritoneal effusion, lack of urine output or surgical (delayed until outflow with ureteral catheterization, double contrast electrolyte stabilization) cystourethrogram indicated transitional cellular casts on u/a, hematuria, mass effect or surgical and medical thickened irregular urethra on ultrasound or management cystourethrogram hypoechoic swollen testicle on testicular ultrasound surgical (immediate) fluid or gas-filled tubular structure on abdominal ultrasound or surgical (immediate) abdominal radiographs soft tissue tubular structure on radiographs, fluid-filled uterus surgical ( in the event of a negative abdominocentesis, but peritoneal effusion or bile or gastrointestinal perforation are suspected, perform a diagnostic peritoneal lavage. peritoneal dialysis kits are commercially available but are often expensive and impractical (see p. ). animals that have acute abdominal pain can be divided into three broad categories, depending on the primary cause of pain and the initial definitive treatment (table - ) . some diseases warrant a nonsurgical, medical approach to case management. other conditions require immediate surgery following rapid stabilization. other conditions initially can be managed medically until the patient is hemodynamically more stable and then may or may not require surgical intervention at a later time. specific management of each disease entity is listed under its own subheading. box - lists specific indications for exploratory laparotomy. the best means to explore the abdominal cavity accurately and thoroughly is to open the abdomen on midline from the level of the xyphoid process caudally to the pubis for full exposure and then to evaluate all organs in every quadrant in a systematic manner. address specific problems such as gastric or splenic torsion, enteroplication, and foreign body removal, and then copiously lavage the abdomen with warmed sterile saline solution. suction the saline solution thoroughly from the peritoneal cavity so as to not impair macrophage function. in cases of septic peritonitis, the abdomen may be left open, or a drain may be placed for further suction and lavage. the routine use of antibiotics in irrigation solutions is contraindicated because the antibiotics can irritate the peritoneum and delay healing. when the abdominal cavity is left open, secure sterile laparotomy towels and water-impermeable dressings over the abdominal wound with umbilical tape, and then change these daily or as strike-through occurs. open abdomen cases are often effusive and require meticulous evaluation and management of electrolyte imbalances and hypoalbuminemia. the abdomen can be closed and/or the abdominal drain removed when the volume of the effusion decreases, when bacteria are no longer present, and when the neutrophils become more healthy in appearance. bischoff mg: radiographic techniques and interpretation of the acute abdomen, clin tech small anim pract ( ) anaphylactic shock occurs as an immediate hypersensitivity reaction to a variety of inciting stimuli (box - ). in animals, the most naturally occurring anaphylactic reaction results from wasp or bee stings. most other reactions occur as a result of an abnormal sensitivity to items used in making medical diagnoses or treatment. during an anaphylactic reaction, activation of c a and the complement system results in vascular smooth muscle dilation and the release of a cascade of inflammatory mediators, including histamine, slow-reacting substance of anaphylaxis, serotonin, heparin, acetylcholine, and bradykinin. clinical signs associated with anaphylaxis differ between dogs and cats. in dogs, clinical signs may include restlessness, vomiting, diarrhea, hematochezia, circulatory collapse, coma, and death. in cats, clinical signs often are associated with respiratory system abnormalities. clinical signs may include ptyalism, pruritus, vomiting, incoordination, bronchoconstriction, pulmonary edema and hemorrhage, laryngeal edema, collapse, and death. the most important steps to remember in any emergency is to follow the abcs of airway, breathing, and circulation. first, establish an airway through endotracheal intubation or emergency tracheostomy, if necessary. concurrently, an assistant should establish vascular or intraosseous access to administer drugs and fluids (box - ). the patient should be hospitalized until complete resolution of clinical signs. after initial stabilization and treatment, it is important to maintain vascular access and continue intravenous fluid therapy until the patient is no longer hypotensive, and vomiting and diarrhea have resolved. in cases of fulminant pulmonary hemorrhage and edema, administer supplemental oxygen until the patient is no longer hypoxemic or orthopneic on room air. normalize and maintain blood pressure using positive inotropes (dobutamine, - µg/kg/ minute cri) or pressors (dopamine, to µg/kg/minute iv cri; see shock). if bloodtinged vomitus or diarrhea has been observed, administer antibiotics to decrease the risk of bacterial translocation and sepsis (cefoxitin, mg/kg iv tid; metronidazole, mg/kg iv tid). also consider using gastroprotectant drugs (famotidine, . to . mg/kg iv; ranitidine, . to . mg/kg po, iv, im bid; sucralfate, . to . g po tid; omeprazole, . to . mg/kg po sid). a second and less serious form of allergic reaction is manifested as angioneurotic edema and urticaria. in most cases, clinical signs develop within minutes of an inciting allergen. although this type of reaction causes patient discomfort, it rarely poses a life-threatening problem. most animals have mild to severe swelling of the maxilla and periorbital regions. the facial edema also may be accompanied by mild to severe generalized urticaria. some animals may paw at their face, rub at their eyes, or have vomiting or diarrhea. the treatment for angioneurotic edema involves suppressing the immune response by administration of short-acting glucocorticoid drugs and blocking the actions of histamine by the synergistic use of histamine and histamine receptor blockers (box - ). in some cases, the inciting cause is a known recent vaccination or insect sting. many times, however, the inciting cause is not known and is likely an exposure to a stinging insect or arachnid. differential diagnoses for acute facial swelling and/or urticaria include acetaminophen toxicity (cats), anterior caval syndrome, lymphadenitis, vasculitis, hypoalbuminemia, and contact dermatitis. observe animals that have presented for angioneurotic edema for a minimum of to minutes after injection of the short-acting glucocorticoids and antihistamines. monitor blood pressure to make sure that the patient does not have concurrent anaphylaxis and hypotension. after partial or complete resolution of clinical signs, the animal can be discharged to its owner for observation. in dogs, mild vomiting or diarrhea may occur within to days after this type of reaction. wherever possible, exposure to the inciting allergen should be avoided. • administer short-acting glucocorticoid: complications observed while a patient is under anesthesia can be divided into two broad categories: ( ) those related to equipment malfunction or human error and ( ) the patient's physiologic response to the cardiorespiratory effects of the anesthetic drugs. careful observation of the patient and familiarity with anesthetic equipment, drug protocols, and monitoring equipment is necessary for the safest anesthesia to occur. despite this, however, anesthetic-related complications are frequent and need to be recognized and treated appropriately. many anesthetic drugs have a dose-dependent depressive effect on the respiratory system and cause a decrease in respiratory rate and tidal volume, leading to hypoventilation. respiratory rate alone is not a reliable indicator of the patient's oxygenation and ventilatory status. the respiratory tidal volume can be measured with a wright's respirometer. perform pulse oximetry and capnography as noninvasive measures of the patient's oxygenation and ventilation. ventilation can be impaired as a result of anesthetic drugs, patient position, pneumothorax, pleural effusion (chylothorax, hemothorax, pyothorax), equipment malfunction, rebreathing of carbon dioxide, thoracic wall injury, or alveolar fluid (pulmonary edema, hemorrhage, or pneumonia). problems such as a diaphragmatic hernia, gdv, or gravid uterus can impede diaphragmatic excursions once the patient is placed on its back and can lead to impaired ventilation. the work of breathing also may be increased because of increased resistance of the anesthesia circuit and increased dead space ventilation. this is particularly important in small toy breeds. clinical signs of inadequate ventilation and respiratory complications include abnormal respiratory pattern, sudden changes in heart rate, cardiac dysrhythmias, cyanosis, and cardiopulmonary arrest. end-tidal carbon dioxide, or capnography, gives a graphic display of adequacy of ventilation. rapid decreases in end-tidal carbon dioxide can be caused by disconnection or obstruction of the patient's endotracheal tube or poor perfusion, namely, cardiopulmonary arrest (see capnometry [end-tidal carbon dioxide monitoring]). postoperatively, hypoventilation can occur because of the residual effects of the anesthetic drugs, hypothermia, overventilation during intraoperative support, surgical techniques that compromise ventilation (thoracotomy, cervical disk surgery, atlantooccipital stabilization), postoperative bandaging of the abdomen or thorax, ventilatory muscle fatigue, or injury to the cns. cardiac output is a function of heart rate and stroke volume. factors that influence stroke volume include vascular and cardiac preload, cardiac afterload, and cardiac contractility. the patient's cardiac output can be affected adversely by the negative inotropic and chronotropic and vasodilatory effects of anesthetic drugs, all leading to hypotension. emergency care bradycardia, tachycardia, cardiac dysrhythmias, and vascular dilation can lead to hypotension and inadequate organ perfusion. table - lists the normal heart rate and blood pressure in dogs and cats. bradycardia is defined as a heart rate below normal values. many anesthetic drugs can cause bradycardia. causes of bradycardia include the use of narcotics or α -agonist drugs, deep plane of anesthesia, increased vagal tone, hypothermia, and hypoxia. table - lists the causes of bradycardia and the necessary immediate action or treatment. tachycardia is defined as a heart rate above normal values. common causes of tachycardia include vasodilation, drugs, inadequate anesthetic depth and perceived pain, hypercapnia, hypoxemia, hypotension, shock, or hyperthermia. table - lists the causes and immediate action or treatment for tachycardia. hypotension is defined as physiologically low blood pressure (mean arterial pressure less than mm hg). a mean arterial blood pressure less than mm hg can result in inadequate tissue perfusion and oxygen delivery. the coronary arteries are perfused during diastole. inadequate diastolic blood pressure, less than mm hg, can cause decreased coronary artery perfusion and myocardial hypoxemia that can predispose the heart to dysrhythmias. causes of perianesthetic hypotension include peripheral vasodilation by anesthetic drugs, bradycardia or tachyarrhythmias, hypothermia, inadequate cardiac preload from vasodilation or hemorrhage, decreased venous return from patient position or surgical manipulation of viscera, and decreased cardiac contractility. electrocardiogram monitoring is useful for the early detection of cardiac dysrhythmias during the perianesthetic period. clinical signs of cardiac dysrhythmias include irregular pulse rate or pressure, abnormal or irregular heart sounds, pallor, cyanosis, hypotension, and an abnormal ecg tracing. remember that the single best method of detecting cardiac emergency care vagolytic drugs atropine allow time for the drug to wear off. glycopyrrolate allow time for the drug to wear off. sympathomimetic drugs epinephrine allow time for the drug to wear off; administer a β-blocker; turn off infusion. isoproterenol administer a β-blocker. turn off infusion; administer a β-blocker. allow time for drug to wear off. inadequate anesthetic depth increase anesthetic depth. hypercapnia increase ventilation (assisted ventilation). hypoxemia increase gas flow and oxygenation. hypotension decrease anesthetic depth; administer an intravenous crystalloid or colloid bolus, positive inotrope drug, positive chronotrope drug, or pressor. hyperthermia apply ambient or active cooling measures; administer dantrolene sodium if malignant hyperthermia is suspected. hypothermia provide ambient rewarming. hypocalcemia * administer calcium chloride ( mg/kg iv) or calcium gluconate ( mg/kg). decrease vaporizer setting/anesthetic depth. reverse with opioids or a -agonists. vasodilation administer an intravenous crystalloid bolus ( ml/kg). administer an intravenous colloid bolus ( ml/kg). administer a pressor (epinephrine, phenylephrine dysrhythmias is with your fingertips (palpate a pulse or apex heartbeat) and ears (auscultate the heart). confirm the dysrhythmia by auscultating the heart rate and rhythm, identify the p waves and the qrs complexes, and evaluate the relationship between the p waves and qrs complexes. is there a p wave for every qrs, and a qrs for every p wave? during anesthesia, fluid, acid-base, and electrolyte imbalances can predispose the patient to dysrhythmias. sympathetic and parasympathetic stimulation, including the time of intubation, can predispose the patient to dysrhythmias. if the patient's plane of anesthesia is too light, perception of pain can cause catecholamine release, sensitizing the myocardium to ectopic beats. atrioventricular blockade can be induced with the administration of α -agonist medications, including xylazine and medetomidine. thiobarbiturates (thiopental) can induce ventricular ectopy and bigeminy. although these dysrhythmias may not be harmful in the awake patient, anesthetized patients are at a particular risk of dysrhythmia-induced hypotension. carefully monitor and treat all dysrhythmias (see cardiac dysrhythmias). box - lists steps to take to prevent perianesthetic dysrhythmias. awakening during anesthesia can occur and can be caused by equipment failure and simply, although no one likes to admit it, human error. table - lists causes of arousal during anesthesia and appropriate immediate actions. awaken patient, and administer dantrolene arousal (e.g., malignant hyperthermia) sodium. • stabilize acid-base and electrolyte balance before anesthetic induction, whenever possible. • rehydrate patient before anesthetic induction. • select anesthetic agents appropriate for the particular patient. • be aware of the effects of the drugs on the myocardium. • ensure adequate anesthetic depth and oxygenation before anesthetic induction. • ensure ventilatory support during anesthesia. • monitor heart rate, rhythm, blood pressure, pulse oximetry, and capnometry during anesthesia. • ensure adequate anesthetic depth before surgical stimulation. • avoid surgical manipulation to the heart or great vessels, whenever possible. • avoid changes in perianesthetic depth. • avoid hypothermia. delayed recovery can be caused by a number of factors, including excessive anesthetic depth, hypothermia, residual action of narcotics or tranquilizers, delayed metabolism of anesthetic drugs, hypoglycemia, hypocalcemia, hemorrhage, and breed or animal predisposition. careful monitoring of the patient's blood pressure, acid-base and electrolyte status, anesthetic depth, pcv, and vascular volume intraoperatively and taking care with supportive measures to prevent abnormalities can hasten anesthetic recovery and avoid postoperative complications. gaynor the presentation of a patient with a bleeding disorder often is a diagnostic challenge for the veterinary practitioner (boxes - and - ). in general, abnormal bleeding can be caused by five major categories: ( ) vascular trauma, ( ) circulating inhibitors of coagulation heparin fibrin degradation products development of spontaneous deep hematomas, unusually prolonged bleeding after traumatic injury, bleeding at multiple sites throughout the body involving multiple organ systems, delayed onset of severe hemorrhage after bleeding, and an inability on the practitioner's part to find an organic cause of bleeding. the signalment, history, clinical signs, and results of coagulation often can aid in making a rapid diagnosis of the primary cause of the disorder and in the selection of appropriate case management. when taking a history, ask the following important questions: • what is the nature of the bleeding? • what sites are affected? • how long has the bleeding been going on? • has your animal had any previous or similar episodes? • is there any possibility of any toxin exposure? • if so, when and how much did your animal consume? • is there any possibility of trauma? • does your animal run loose outdoors unattended? • have you ever traveled, and if so, where? • has your animal been on any medications recently or currently? • has your animal been vaccinated recently? • have any known relatives of your animal had any bleeding disorders? • are there any other abnormal signs that you have seen? abnormalities found on physical examination may aid in determining whether the hemorrhage is localized or generalized (i.e., bleeding from a venipuncture site versus bleeding diathesis). note whether the clinical signs are associated with a platelet problem and superficial hemorrhage or whether deep bleeding can be associated with abnormalities of the coagulation cascade. also, make an attempt to identify any concurrent illness that can predispose the patient to a bleeding disorder (i.e., pancreatitis, snakebite, sepsis, immunemediated hemolytic anemia, or severe trauma and crush or burn injury). abnormalities associated with coagulopathies include petechiae and ecchymoses, epistaxis, gingival bleeding, hematuria, hemarthrosis, melena, and hemorrhagic cavity (pleural and peritoneal or retroperitoneal) effusions. disseminated intravascular coagulation is a complex syndrome that results from the inappropriate activation of the clotting cascade, leading to disruption of the normal balance between thrombosis and fibrinolysis. the formation of diffuse microthrombi with concurrent consumption of platelets and activated clotting factors leads to end-organ thrombosis with various degrees of clinical hemorrhage. in animals, dic always results from some other pathologic process, including various forms of neoplasia, crush and heat-induced injury, sepsis, inflammation, and immune-mediated disorders (box - ). the pathophysiologic mechanisms involved in dic include vascular endothelial damage, activation and consumption of platelets, release of tissue procoagulants, and consumption of endogenous anticoagulants. because dic always results from some other disease process, diagnosis of dic is based on a number of criteria when evaluating various coagulation tests, peripheral blood smears, platelet count, and end products of thrombosis and fibrinolysis. there is no one definitive criterion for the diagnosis of dic (box - ). thrombocytopenia occurs as platelets are consumed during thrombosis. it is important to remember that trends in decline in platelet numbers are just as important as thrombocytopenia when making the diagnosis. in some cases the platelet count still may be within the normal reference range but has significantly decreased in the last hours. early in dic the procoagulant cascade dominates, with hypercoagulability. activated clotting time, aptt, and pt may be rapid and shorter than normal. in most cases, we do not recognize the hypercoagulable state in our critically ill patients. later in dic, as platelets and activated clotting factors become consumed, the act, aptt, and pt become prolonged. antithrombin, a natural anticoagulant, also becomes consumed, and antithrombin levels decline. antithrombin levels can be measured at commercial laboratories and in some large veterinary institutions. the end products of thrombosis and subsequent fibrinolysis also can be measured. fibrinogen levels may decline, although this test is not sensitive or specific for dic. fibrin degradation (split) products also become elevated. fibrin degradation products are normally cleared by the liver, and these also become elevated in cases of hepatic failure because of lack of clearance. more recently, cageside d-dimer tests have become available to measure the breakdown product of cross-linked fibrin as a more sensitive and specific monitor of dic. management of dic first involves treating the primary underlying cause. by the time dic becomes evident, rapid and aggressive treatment is necessary. if you are suspicious of dic in any patient with a disease known to incite dic, then ideally, you should begin treatment before the hemostatic abnormalities start to occur for the best possible prognosis. treatment involves replacement of clotting factors and antithrombin and prevention of further clot formation. to replenish clotting factors and antithrombin, administer fresh whole blood or fresh frozen plasma. heparin requires antithrombin as a cofactor to inactivate thrombin and other activated coagulation factors. administer heparin ( to units/kg sq q - h of unfractionated heparin; or fractionated enoxaparin [lovenox], mg/kg sq bid). aspirin ( mg/kg po bid in dogs; every third day in cats) also can be administered to prevent platelet adhesion. management of dic also involves the rule of twenty monitoring and case management to maintain end-organ perfusion and oxygen delivery (see the rule of ). hemophilia a is a sex-liked recessive trait that is carried by females and manifested in males. female hemophiliacs can occur when a hemophiliac male is bred with a carrier female. hemophilia a has been reported in cats and a number of dog breeds, including miniature schnauzer, saint bernard, miniature poodle, shetland sheepdog, english and irish setters, labrador retriever, german shepherd, collie, weimaraner, greyhound, chihuahua, english bulldog, samoyed, and vizsla. mild to moderate internal or external bleeding can occur. clinical signs of umbilical cord bleeding can become apparent in some animals shortly after weaning. gingival hemorrhage, hemarthrosis, gastrointestinal hemorrhage, and hematomas may occur. clotting profiles in animals with factor viii deficiency include prolonged aptt and act. the pt and buccal mucosa bleeding time are normal. affected animals have low factor viii activity but normal to high levels of factor viii-related antigen. carrier females can be detected by low ( % to % of normal) factor viii activity and normal to elevated levels of factor vii-related antigen. von willebrand's disease is a deficiency or defect in von willebrand's protein. a number of variants of the disease have been described: von willebrand's disease type i is associated with a defect in factor viir/protein concentration, and von willebrand's disease type ii is associated with a defect in viiir:vwf. type i von willebrand's disease is most common in veterinary medicine. von willebrand's disease has been identified in more than breeds of dogs, with an incidence that varies from % to % depending on the breed of origin. affected breeds include doberman pinchers, german shepherd dogs, scottish terriers and standard manchester terriers, golden retrievers, chesapeake bay retrievers, miniature schnauzers, and pembroke welsh corgis. two forms of genetic expression occur: ( ) autosomal recessive disease in which homozygous von willebrand's disease individuals have a bleeding disorder, whereas heterozygous individuals carry the trait but are clinically normal. the second variant of genetic expression involves an autosomal dominant disease with incomplete expression such that heterozygous individuals are affected carriers and homozygous individuals are severely affected. von willebrand's disease has high morbidity, but fortunately a low mortality. dogs with % or less than normal vwf tend to hemorrhage. platelet counts are normal, but bleeding times can be prolonged. the aptt can be slightly prolonged when factor viii is less than % of normal. routine screening tests are nondiagnostic for this disease, although in a predisposed breed with a normal platelet count, a prolonged buccal mucosa bleeding time strongly supports a diagnosis of von willebrand's disease. documentation of clinical bleeding with low or undetectable levels of factor viii antigen or platelet-related activities of vwf support a diagnosis of von willebrand's disease. recessive animals have zero vwf:antigen (a subunit of factor iii); heterozygotes have % to % of normal. in the incompletely dominant form, levels of vwf antigen are reduced (less than % to %). clinical signs in affected animals include epistaxis, hematuria, diarrhea with melena, penile bleeding, lameness, hemarthrosis, hematoma formation, and excessive bleeding with routine procedures such as nail trimming, ear cropping, tail docking, surgical procedures (spay, neuter), and lacerations. estrous and postpartum bleeding may be prolonged. a dna test to detect carriers of the vwf gene is available through vetgen (ann arbor, michigan) and michigan state university. patients with von willebrand's disease should avoid drugs known to affect platelet function adversely (sulfonamide, ampicillin, chloramphenicol, antihistamines, theophylline, phenothiazine tranquilizers, heparin, and estrogen). hemophilia b is an x-linked recessive trait that occurs with less frequency that hemophilia a. the disease has been reported in scottish terriers, shetland and old english sheepdogs, saint bernards, cocker spaniels, alaskan malamutes, labrador retrievers, bichon frises, airdale terriers, and british shorthair cats. carrier females have low ( % to % of normal) factor ix activity. clinical signs are more severe than for hemophilia a. congenital deficiencies of factor vii have been reported as an autosomal, incompletely dominant characteristic in beagles. heterozygotes have % factor vii deficiency. bleeding tends to be mild. the pt is prolonged in affected individuals. factor x deficiency has been documented in cocker spaniels and resembles fading-puppy syndrome in newborn dogs. internal or umbilical bleeding can occur, and affected dogs typically die. bleeding may be mild in adult dogs. in severe cases, factor x levels are reduced to % of normal; in mild cases, factor x levels are % to % of normal. factor xii deficiency has been documented as an inherited autosomal recessive trait in domestic cats. heterozygotes can be detected because they have a partial deficiency ( % of normal) of factor xii. homozygote cats have less than % factor xii activity. deficiency of hageman factor usually does not result in bleeding or other disorders. factor xi deficiency is an autosomal disease that has been documented in kerry blue terriers, great pyrenees, and english springer spaniels. in affected individuals, protracted bleeding may be observed. homozygotes have low factor xi activity (< % of normal), and heterozygotes have % to % of normal. the management of congenital defects of hemostasis typically involves replenishing the clotting factor that is present. usually, this can be accomplished in the form of fresh frozen plasma transfusion ( ml/kg). if anemia is present because of severe hemorrhage, fresh whole blood or packed rbcs also can be administered. recent research has investigated the use of recombinant gene therapy in the treatment of specific factor deficiencies in dogs; however, the therapy is not yet available for use in clinical practice. in cases of von willebrand's disease, administration of fresh frozen plasma ( to ml/kg) or cryoprecipitate ( unit/ kg body mass) provides vwf, factor viii, and fibrinogen. doses can be repeated until hemorrhage ceases. -desamino- -d-arginine vasopressin (ddavp) also can be administered ( µg/kg sc or iv diluted in . % saline given over to minutes) to the donor and patient to increase the release of stored vwf from endothelial cells. a fresh whole blood transfusion can be obtained from the donor and immediately administered to the patient, or spun down and the fresh plasma administered if rbcs are not needed. administer a dose of ddavp to any affected dog before initiating any elective surgical procedures. a supply of fresh frozen plasma and rbcs should be on hand, should uncontrolled hemorrhage occur. platelets are essential to normal blood coagulation. after a vessel is damaged, release of vasoactive amines causes vasoconstriction and sluggish flow of blood in an attempt to squelch hemorrhage. platelets become activated by platelet activating factor, and attach to the damaged vascular endothelium. normal platelet adhesion depends on mediators such as calcium, fibrinogen, vwf:antigen, and a portion of factor viii. after adhesion, the platelets undergo primary aggregation and release a variety of chemical mediators including adenosine diphosphate, prostaglandins, serotonin, epinephrine, thromboplastin, and thromboxane a that promote secondary aggregation and contraction. platelet abnormalities can include decreased platelet production (thrombocytopenia), decreased platelet function (thrombocytopathia), increased platelet destruction, increased platelet consumption, and platelet sequestration. thrombocytopathia refers to platelet function abnormalities. alterations in platelet function can affect platelet adhesion, aggregation, or release of vasoactive substances that help form a stable clot (box - ). in von willebrand's disease there is a deficiency in vwf:antigen that results in altered platelet adhesion. vascular purpuras are reported and have been seen in collagen abnormalities such as ehlers-danlos syndrome, which can be inherited as an autosomal dominant trait with complete penetrance and has been recognized in german shepherd dogs, dachshunds, saint bernards, and labrador retrievers. thrombasthenic thrombopathia is a hereditary autosomal dominant abnormality that has been described in otterhounds, foxhounds and scottish terriers. in this condition, platelets do not aggregate normally in response to adenosine diphosphate and thrombin stimulation. evaluation of platelet function is based on a total platelet count, buccal mucosa bleeding time, and thromboelastography. platelet function defects (thrombocytopenia and thrombocytopathia) can affect both sexes. clinical signs can resemble von willebrand's disease. in most cases, buccal mucosa bleeding time will be prolonged, but platelet count and clotting tests will be normal. platelet count can be decreased because of problems with production, increased consumption, sequestration, or destruction. causes of accelerated platelet destruction are typically immune-mediated autoantibodies, drug antibodies, infection, and isoimmune destruction. consumption and sequestration usually are caused by dic, vasculitis, microangiopathic hemolytic anemia, severe vascular injury, hemolytic uremic syndrome, and gram-negative septicemia. primary thrombocytopenia with no known cause has been called idiopathic thrombocytic purpura. in approximately % of the cases, thrombocytopenia is associated with immune-mediated destruction caused by immune-mediated hemolytic anemia, systemic lupus erythematosus, rheumatoid arthritis, dic, and diseases that affect the bone marrow. in systemic lupus erythematosus, % to % of the affected dogs have concurrent idiopathic thrombocytic purpura. when immune-mediated hemolytic anemia and idiopathic thrombocytic purpura are present in the same patient, the disease is called evans syndrome. pf- is a non-complement-fixing antibody that is produced in the spleen and affects peripheral and bone marrow platelets and megakaryocytes. antibodies directed against platelets are usually of the igg subtype in animals. antiplatelet antibodies can be measured by a pf- release test. platelet counts with immune-mediated destruction typically are less than , platelets/µl. infectious causes of thrombocytopenia include ehrlichia canis, anaplasma phagocytophilum (formerly, ehrlichia equi), and rickettsia rickettsii (rocky mountain spotted fever). primary immune-mediated thrombocytopenia has an unknown cause and most frequently is seen in middle-to older-aged female dogs. breed predispositions include cocker spaniels, german shepherd dogs, poodles (toy, miniature, standard), and old english sheepdogs. thrombocytopenia usually is manifested as petechiae, ecchymoses of skin and mucous membranes, hyphema, gingival and conjunctival bleeding, hematuria, melena, and epistaxis. to make a diagnosis of idiopathic thrombocytic purpura, measure the severity of thrombocytopenia (< , platelets/µl), analyze the peripheral blood smear for evidence of platelet fragmentation or microthrombocytosis, normal to increased numbers of megakaryocytes in the bone marrow, detection of antiplatelet antibody, increased platelet counts after starting glucocorticoid therapy, and elimination of other causes of thrombocytopenia. if tick-borne illnesses are suspected, antibody titers for e. canis, a. phagocytophilum (formerly e. equi), and r. rickettsii should be performed. treatment of immune-mediated thrombocytopenia involves suppression of the immune system to stop the immune-mediated destruction and to stimulate platelet release from the bone marrow. traditionally, the gold standard to suppress the immune system is to use glucocorticoids (prednisone or prednisolone, to mg/kg po bid divided, or dexamethasone, . to . mg/kg iv or po q h). more recently human serum immunoglobulin (igg) also has been used ( . to . g/kg iv in saline over hours; pretreat with mg/kg diphenhydramine minutes before starting infusion). vincristine ( . mg/m iv once) can stimulate the release of platelets from the bone marrow if megakaryocytic precursors are present; however, the platelets released may be immature and potentially nonfunctional. treatment with fresh whole blood or packed rbcs is appropriate if anemia is present; however, unless specific platelet-rich plasma has been purchased from a blood bank, fresh whole blood contains relatively few platelets, which are shortlived ( hours) and will not effectively raise the platelet count at all. finally, long-term therapy is usually in the form of azathioprine ( mg/kg po once daily, tapered to mg/kg daily to every other day after week) and cyclosporine ( to mg/kg po divided). if a tickborne illness is suspected, administer doxycycline ( to mg/kg po bid) for weeks or if titers come back negative. thrombocytopenia also can occur in the cat. causes for thrombocytopenia in cats include infections ( %), neoplasia ( %), cardiac disease ( %), primary immune-mediated disease ( %), and unknown causes ( %). in one study of cats with feline leukemia and myeloproliferative disease, % of cases had thrombocytopenia. warfarin and coumarin derivatives are the major class of rodenticides used in the united states. vitamin k antagonist rodenticides inhibit the epoxidase reaction and deplete active vitamin k, causing a depletion of vitamin k-dependent coagulation factors (ii, vii, ix, x) within hours to week of ingestion, depending on the ingested dose. affected animals can spontaneously hemorrhage anywhere in the body. clinical signs can include hemoptysis, respiratory difficulty, cough, gingival bleeding, epistaxis, hematuria, hyphema, conjunctival bleeding, petechiae and ecchymoses, cavity hemorrhage (pleural, peritoneal, retroperitoneal) with acute weakness, lethargy or collapse, hemarthrosis with lameness, deep muscle bleeds, and intracranial or spinal cord hemorrhage. diagnosis of vitamin k antagonism includes prolonged pt. a pivka (protein induced by vitamin k absence or antagonism) test also can be performed, if possible. treatment of vitamin k antagonist rodenticide intoxication and other causes of vitamin k deficiency involves supplementation with vitamin k (phytonadione, mg/kg sq once with -gauge needle in multiple sites, and then . mg/kg po bid to tid for days). never administer injections of vitamin k intramuscularly, because of the risk of causing deep muscle hematomas, or intravenously, because of the risk of anaphylaxis. the pt should be rechecked days after the last vitamin k capsule is administered, for some of the secondgeneration warfarin derivates are fat-soluble, and treatment may be required for an additional weeks. act, activated clotting time; aptt, activated partial thromboplastin time; bmbt, buccal mucosa bleeding time; fdp, fibrin degradation products; n, normal; pt, prothrombin time. thermal burns are fortunately a relatively infrequent occurrence in veterinary patients. box - lists various causes of malicious and accidental burns. the location of the burn is also important in assessing its severity and potential to lose function. burns on the perineum, feet, face, and ears are considered to be the most severe because of loss of function and severe pain. often the severity of thermal injury is difficult to assess in animals because hair coat potentially can mask clinical signs and because the thermal injury can continue after the animal has been removed from the heat source. the skin cools slowly and warms slowly, considerations that become important when initiating therapy for burns. the severity of thermal injury is associated with the temperature to which the animal is exposed, the duration of contact, and the ability of the tissue to dissipate heat. the tissue closest to the heat source undergoes necrosis and has decreased blood flow. the severity of thermal burn injury is associated directly with the temperature to which the animal is exposed, the percentage of total body surface area affected, the thickness of injured tissue, and whether underlying complications with other body systems occur. prognosis largely depends on the total body surface area affected (table - ) . superficial partial thickness, or first-degree, burns offer the most favorable prognosis. the affected epidermis initially appears erythematous and then quickly desquamates within to days. in most cases, fur grows back without leaving a scar. deep partial thickness, or second-degree, burns involve the epidermis and dermis and are associated with subcutaneous edema, inflammation, and pain. deep partial thickness burns heal from deeper adnexal tissues and from the wound edges and are associated with an increased chance of scarring and depigmentation. the most severe type is known as full thickness, or third-degree, burns, in which thermal injury destroys the entire thickness of the skin and forms an eschar. thrombosis of superficial and deeper skin vasculature and gangrene occurs. treatment involves sequential wound debridement. healing occurs by second intention and reepithelialization or by wound reconstruction. in most cases, scarring is extensive in affected areas. burns greater than % of total body surface area will have systemic effects, including impaired cardiovascular function, pulmonary dysfunction, and impaired immune function. burned tissue, with capillary damage, has increased permeability. the release of inflammatory cytokines, oxygen-derived free radical species, prostaglandins, leukotrienes, emergency care histamine, serotonin, and kinins results in increased vascular permeability and leakage of plasma proteins into the interstitium and extravascular space. at the time of presentation, first examine the patient and ascertain whether airway obstruction, impaired ventilatory function, circulatory shock, or pain are present. if necessary, establish an airway with endotracheal intubation or emergency tracheostomy. next, cool the burned area(s) with topical cool water. use care to avoid overcooling and iatrogenic hypothermia. the best approach is to cool only one portion of the patient's body at a time, then dry, and repeat the process for all affected areas to avoid overcooling and iatrogenic hypothermia. establish vascular access and administer appropriate and judicious analgesic drugs and intravenous fluid therapy. whenever possible, avoid placing a catheter through an area of burned or damaged skin. in the early stages of burn injury, shock doses of intravenous crystalloid fluids usually are not required. later, however, as severe tissue exudation occurs, protein and fluid losses can become extensive, requiring aggressive crystalloid and colloid support to treat hypovolemia and hypoproteinemia. flush the eyes with sterile saline and examine behind the third eyelids for any particulate matter. stain the corneas to make sure that superficial corneal burns are not present. treat superficial corneal burns with triple antibiotic ophthalmic ointment. next, assess the total body surface area affected, as this will gauge prognosis. depending on the extent of the damage, decide whether the burn is superficial and local therapy is indicated or whether more severe injuries exist that may involve systemic therapy or possibly euthanasia. in most cases the diagnoses of thermal burns are based on a clinical history of being in a house fire, clothes dryer, or under a heating lamp. too frequently, however, thermal burns become apparent days after an elective surgical procedure in which the patient was placed on a faulty heating pad rather than a circulating warm water or warm air blanket. superficial burns appear as singed fur with desquamating, easily epilated hair. this condition also can resemble a superficial or deeper dermatophytosis if history is unknown. other differential diagnoses include immune-mediated vasculitis or erythema multiforme. unless the superficial dermis is blistered, it may be difficult to distinguish between a thermal burn, chemical burn, or electrical burn if the trauma went unnoticed. management of burn injury largely depends on the depth of injury and the total body surface area affected. partial thickness burns and those affecting less than % of the total body surface area will require support in the form of antibiotic ointment and systemic analgesic drugs. burns affecting greater than % of total body surface area or deep thickness burns require more aggressive therapy. central venous catheters can be placed to administer crystalloid and colloid fluids, parenteral nutrition if necessary, antibiotics, and analgesic drugs. monitor perfusion parameters closely, including heart rate, blood pressure, capillary refill time, and urine output. respiratory function can be impaired because of concurrent smoke inhalation, thermal damage to the upper airways and alveoli, and carboxyhemoglobin or methemoglobin intoxication. respiratory function also can be impaired because of burn injury to the skin around the thoracic cage. thoracic radiographs may reveal patchy interstitial to alveolar infiltrates associated with pulmonary edema, pneumonia, and atelectasis. bronchoscopy often reveals edema, inflammation, particulate matter, and ulceration of the tracheobronchial tree. in some cases, upper airway inflammation is so severe that an emergency tracheostomy must be performed to treat airway obstruction. administer supplemental humidified oxygen at to ml/kg/minute via endotracheal tube, tracheostomy, nasal or intratracheal tube, or hood oxygen if respiratory function and hypoxemia are present. perform blood work including a hematocrit, albumin, bun, creatinine, and glucose at the time of presentation. monitor serum electrolytes, albumin, and colloid oncotic pressure closely because derangements can be severe as burns become exudative. the goal of fluid therapy in the burn patient is to establish and maintain intravascular and interstitial fluid volume, normalize electrolyte and acid-base status, and maintain serum albumin and oncotic pressure. in the first hours following burn injury, direct fluid therapy to maintaining the patient's metabolic fluid requirements. crystalloid fluids in the form of normosol-r, plasmalyte-m, or lactated ringer's solution can be administered according to the patient's electrolyte and acid-base status (see fluid therapy). monitor urine output, and keep it at to ml/kg/hour. avoid overhydration in the early stages of burn injury. in affected burn patients, calculate the amount of fluid that should be administered over a -hour period from the formula − ml/kg × percent total body surface area. administer half of this calculated dose over the first hours and then the remaining half over the next hours. in cats, administer only % to % of this calculated volume. to administer this volume and also avoid fluid overload is often difficult in critically ill patients with pulmonary involvement associated with smoke inhalation injury. avoid colloids in the first hours after burn injury. monitor the patient closely for serous nasal discharge, chemosis, and rales that may signify pulmonary edema. as burns become exudative, weigh the patient at least twice daily. infused fluid should equal fluid output in the form of urine and wound exudates. acute weight loss signifies acute fluid loss and that crystalloid fluid infusion should be more aggressive. ideally, keep the patient's serum albumin equal to or greater than . g/dl and total protein between . and . g/dl using a combination of fresh frozen plasma or concentrated human albumin. adjunct colloidal support can be provided with synthetic colloids including hetastarch or hbocs. keep serum potassium within . to . meq/l using potassium chloride or potassium phosphate supplementation. if potassium supplementation exceeds to meq/l and the patient continues to have severe refractory hypokalemia, administer magnesium chloride ( . meq/kg/day) to enhance potassium retention. if anemia occurs, administer packed rbcs or whole blood (see blood component therapy). lavage wounds daily with lactated ringer's solution or . % sodium chloride solution. place wet-to-dry bandages or bandages soaked in silver sulfadiazine or nitrofurazone ointment over the wounds. depending on the thickness of the burn, epilation and eschar formation and separation may take to days. at each bandage change, debride devitalized tissue to normal tissue. perform staged partial or total escharectomy, and leave the wound to heal by second intention or by reconstruction using skin advancement flaps or grafts. maintain meticulous sterility at all times, given that burn patients are at high risk for infection. administer broad-spectrum antibiotics including cefazolin and enrofloxacin. perform wound culture if a resistant bacterial infection is suspected. the most common cause of electrical injury is associated with an animal chewing on low-voltage alternating current electrical cords in the household. damage is caused by the current flowing through the path of least resistance, causing heat and thrombosis of vessels and neurons. in some cases, the owner witnesses the event. in other cases, the owner presents the patient because of vague nonspecific signs, and characteristic abnormalities on physical examination support a diagnosis of electrocution. burns on the face, paws, commissures of the mouth, tongue, and soft palate may be present. electrocution causes a massive release of catecholamines and can predispose the patient to noncardiogenic pulmonary edema within hours of the incident. clinical signs may be isolated to the pulmonary system, including orthopnea, pulmonary crackles, and cyanosis. assess the patient's lips, tongue, soft palate, gingivae, and commissures of the mouth. early after electrocution, the wound may appear small and white, black, or yellow. later, the wound may become larger as tissue sloughs because of damaged vascular supply. assess the patient's respiratory status. auscultate the lungs to determine whether pulmonary crackles emergency care are present. if the patient is stable, thoracic radiographs may demonstrate an interstitial to alveolar lung pattern in the dorsocaudal lung fields. measure the patient's heart rate, blood pressure, oxygenation as determined by pulse oximetry or arterial blood gas and urine output. immediate treatment consists of judicious use of analgesics for the burn injury, antibiotics (cefazolin, mg/kg q h; cephalexin, mg/kg q h), and humidified supplemental oxygen ( to ml/kg/minute). direct fluid therapy at providing the patient's metabolic fluid requirements. because of the risk of development of noncardiogenic pulmonary edema, avoid overzealous administration of crystalloid fluids. differential diagnoses for the patient with electrical burn injury and electrocution include chemical or thermal burn, immune-mediated glossitis, cardiogenic pulmonary edema, and pneumonia. management of the patient with electrical burn injury and electrocution primarily involves the administration of analgesic agents, supplemental humidified oxygen, and topical treatment of electrical burns. the noncardiogenic pulmonary edema is typically unresponsive to diuretics (i.e., furosemide), bronchodilators (i.e., aminophylline), and splanchnic vascular dilators (i.e., low-dose morphine). the use of glucocorticoids has no proven benefit and may impair respiratory immune function and is therefore contraindicated. oral burns may require debridement and advancement flaps if large defects or oronasal fistulas develop. if oral injury is severe, place an esophagostomy or percutaneous gastrostomy tube to ensure adequate nutrition during the healing process. if an animal survives the initial electrocution, prognosis is generally favorable with aggressive supportive care. chemical burns are associated with a number of inciting causes, including oxidizing agents, reducing agents, corrosive chemicals, protoplasmic poisons, desiccants, and vesicants. the treatment for chemical burns differs slightly from that for thermal burns, so it remains important to investigate the cause of the burn when providing initial treatment, whenever possible. at the scene, advise the owner to wrap the patient in a clean towel for transport. chilling can be avoided by then wrapping the patient in a second or third blanket. placement of ointments by well-doers should be avoided. encourage immediate transport to the nearest triage facility. the first and foremost consideration when treating a patient with chemical burn is to remove the animal from the inciting cause or offending agent. make no attempt to neutralize alkaline or acid substances because the procedure potentially could cause an exothermic reaction, leading to thermal injury in addition to the chemical injury. remove collars or leashes that may act as tourniquets or constricting devices. flush affected areas with copious amounts of cool water for several minutes, not cooling more than % to % of the body at any one time to prevent iatrogenic hypothermia. support breathing by extending the patient's head and neck. carefully clip the fur over affected areas for further evaluation of the extent of the injury. lavage exposed eyes with sterile saline, and stain the cornea to evaluate for any corneal burns. debride any wounds carefully, knowing that the full extent of the wound may not manifest itself for several days. then cover the wounds with antibiotic burn ointment such as silver sulfadiazine and an occlusive dressing. without a history of exposure, the differential diagnosis for any chemical burn includes thermal burn, necrotizing vasculitis, erythema multiforme, or superficial or deep pyoderma. contact local or national animal poison control regarding whether to attempt neutralization. perform daily bandage changes with staged debridement as the full extent of the wound manifests itself. place antimicrobial ointment and silver sulfadiazine ointment over the wound to prevent infection. the routine use of antibiotics may promote the development of a resistant bacterial infection. first-generation cephalosporin can be administered. if a more serious infection develops, perform culture and susceptibility testing to direct appropriate antibiotic therapy. the wound can heal by second intention or may require reconstructive repair for definitive closure. the primary cause of radiation injury in small animal patients is radiation therapy for neoplastic conditions. the goal of radiation therapy is to kill neoplastic cells. an unfortunate side effect is damage to adjacent normal tissue that results in necrosis, fibrosis, and impaired circulation to the affected area. radiation burns result in dermatitis, mucositis, impaired surgical wound healing, and chronic nonhealing wounds. in many cases, the degree of secondary radiation injury to normal tissue can be prevented or decreased with careful radiation planning and mapping of the radiation field, such that radiation exposure to normal tissue is limited to the smallest extent possible. with the advent of three-dimensional imaging modalities such as computed tomography (ct) and magnetic resonance imaging (mri), this has become more routine in veterinary oncology to date. radiation injury can be early and appear at the later stage of the course of radiation therapy. late effects can be delayed and occur months to years after treatment. the degree of radiation injury is categorized based on the depth of tissue affected. first-degree changes cause cutaneous erythema. second-degree changes cause superficial desquamation. thirddegree changes cause deeper moist desquamation, and fourth-degree changes are associated with complete dermal destruction and ulceration. during the early stages of radiation injury, affected tissues may appear erythematous and edematous. wound exudates may be moist, or the skin may appear dry and scaly with desquamation or ulceration. later, the area may scar and depigment or may have induration, atrophy, telangiectasia, keratosis, and decreased adnexal structures. treatment for radiation dermatitis is to irrigate the area with warmed saline and to protect the area from self-mutilation. no-bite, or elizabethan, collars or loose clothing can be used to protect the area for patient-induced injury. mucositis can be treated with topical green tea baths and the administration of an oral solution of l-glutamine powder ( g/m ). local irrigation of xylocaine or lidocaine viscous jelly can be used in dogs but should be avoided in cats because of the risk of inducing hemolytic anemia and neurotoxicity. topical and systemic antibiotics (cephalexin, mg/kg po tid) also can be administered. avoid antibiotics that can be sensitized by radiation (i.e., metronidazole). because most radiation burns are associated with a known exposure to radiation therapy, the cause of the patient's injury usually is known. if an animal presents to you with a scar, however, differential diagnoses may include nasal planum solar dermatitis, pemphigus foliaceus, discoid lupus, superficial necrolytic dermatitis, superficial or deep pyoderma, chemical burn, or thermal burn. treatment of radiation injury involves making the patient as comfortable as possible with analgesic drugs, prevention of self-mutilation, and staged debridement techniques. wounds can heal by second intention or may require reconstructive surgery. distress syndrome (ards), and anesthetic agents. the acute onset of bradycardia, change in mucous membrane color and capillary refill time, change in respiratory pattern, and change in mentation are signs of possible deterioration and impending cardiopulmonary arrest. the diagnosis of cardiopulmonary arrest is based on the absence of effective ventilation, severe cyanosis, absence of a palpable pulse or apex heartbeat, absence of heart sounds, and ecg evidence of asystole or other nonperfusing rhythm such as electricalmechanical dissociation (aka pulseless electrical activity) or ventricular fibrillation. the goals of cpcr are to obtain airway access, provide artificial ventilation and supplemental oxygen, implement cardiac compressions and cardiovascular support, recognize and treat dysrhythmias and arrhythmias, and provide stabilization and treatment for cardiovascular, pulmonary, and cerebral function in the event of a successful resuscitation. even with aggressive treatment and management, the overall success of cpcr is less than % in critically ill or traumatized patients and % to % in anesthetized patients. basic life support involves rapid intubation to gain airway access, artificial ventilation, and cardiac compressions to promote blood flow and delivery of oxygen to the brain and other important tissues (figure - ). perform the abcs or cabs of cpcr, where a is airway, b is breathing, and c is compression and circulation. recently, the paradigm has shifted to cabs. while a team member is grabbing an endotracheal tube, clearing the airway of foreign debris, and establishing airway access through endotracheal intubation, a second person starts external cardiac compressions to deliver oxygen that is in the bloodstream to the vital organs. the patient should be positioned in dorsal (> kg) or lateral (< kg) recumbency for external cardiac compressions. approximately to external compressions should be performed over the patient's sternum. a team member should palpate for a peripheral pulse to determine whether cardiac compressions are actually effective. if a peripheral pulse cannot be palpated for every chest compression, change the patient's position and have a larger individual perform compressions, or initiate open-chest cardiac resuscitation. once the patient is intubated, tie in the endotracheal tube and attach it to an oxygen source (anesthetic machine or mechanical ventilator or ambu bag) for artificial ventilation. the oxygen flow rate should be ml/kg/minute. give two long breaths, and then to breaths per minute. simultaneous ventilation with thoracic compression increases the pressure difference in the thorax and allows more forward flow of oxygenated blood through the great vessels into the periphery. if possible, a third team member can initiate interposed abdominal compressions, compressing the abdomen when the thoracic cage is relaxed, to improve forward flow. if only one person is available to perform the thoracic compressions and ventilation, give two breaths for every compressions (i.e., thoracic compressions followed by two long breaths, and then start thoracic compressions again). the jen chung maneuver can be performed by placing a -to -gauge hypodermic needle through the skin of the nasal philtrum and twisting the needle into the periosteum to stimulate respirations. this maneuver appears to work better in cats than dogs at return to spontaneous respiration. advanced life support during cpcr involves ecg, pulse oximetry and capnometry monitoring, administration of drugs, and the administration of intravenous fluids (in select cases). most of the drugs used during cpcr can be administered directly into the lungs from the endotracheal tube (intratracheal tube). therefore, only in select instances is it necessary to establish vascular or intraosseous access during cpcr (figure - ) . if an animal experiences cardiopulmonary arrest because of extreme hemorrhage or hypovolemia, inappropriate vasodilation caused by sepsis or systemic inflammation, or vasodilation resulting from anesthesia, the administration of shock volumes ( ml/kg/hour in dogs and ml/kg/hour in cats) is appropriate. if a patient is euvolemic and experiences cardiopulmonary arrest, however, an increase in circulating fluid volume actually can impair coronary artery perfusion by increasing diastolic arterial blood pressure and is asystole is one of the most common rhythm disturbances that causes cardiac arrest in small animal patients. one of the most important things to do when the ecg looks like asystole is to make sure that the ecg monitor is working properly and that all ecg leads are attached properly to the patient. if asystole is truly present, reverse any opiate, α -agonist, or benzodiazepine drugs with their appropriate reversal agents. lowdose epinephrine ( . to . mg/kg diluted with ml sterile saline) can be administered directly into the endotracheal tube via a rigid or red rubber catheter. if vascular access is available, epinephrine ( . to . mg/kg) can be administered intravenously. no drug should ever be administered directly into the heart by intracardiac injection. unless the heart is in the veterinarian's hand during open-chest cpcr, intracardiac injection is risky and potentially could lacerate a coronary artery or cause the myocardium to become more irritable and refractory to other therapies, if a drug is delivered into the myocardium and not into the ventricle. for these reasons, intracardiac injections are contraindicated. administer atropine ( . mg/kg iv, io, or . mg/kg it) immediately after the epinephrine. atropine, a vagolytic drug, serves to decrease tonic vagal inhibition of the sinoatrial and atrioventricular node and increase heart rate. administer atropine and epinephrine every to minutes during asystole while cardiac compressions, interposed abdominal compressions, and artificial ventilation are continued. although discontinuation of thoracic compressions can decrease the chance of success during cpcr, you must intermittently evaluate the ecg monitor for any rhythm change that may require different drug therapies. if the cardiac arrest was not witnessed or more than to minutes have passed without successful return to a perfusing rhythm, perform open-chest cpcr, if the client wishes. administer sodium bicarbonate ( to meq/kg iv) every to minutes during cpcr. sodium bicarbonate is the only drug used in cpcr that should not be administered intratracheally because of inactivation of pulmonary surfactant. electrical-mechanical dissociation also is known as pulseless electrical activity and is an electrical rhythm that may look wide and bizarre and irregular with no associated mechanical contraction of the ventricles. the rhythm can appear different from patient to patient. electrical-mechanical dissociation is one of the more common nonperfusing rhythms observed during cardiopulmonary arrest in small animal patients (figure - ) . when electrical-mechanical dissociation is identified, first confirm the rhythm and proceed with cpcr as previously described. electrical-mechanical dissociation is thought to be associated with high doses of endogenous endorphins and high vagal tone. the treatment of choice for electrical-mechanical dissociation is high-dose atropine ( mg/kg iv, it [ times the normal dose]) and naloxone hydrochloride ( . mg/kg iv, io, it). administer epinephrine ( . to . mg/kg diluted in ml sterile . % saline it). if the rhythm does not change within minutes, consider open-chest cardiac massage. ventricular fibrillation can be coarse (figure - ) . patients with coarse ventricular fibrillation are easier to defibrillate than those with fine defibrillation. if ventricular fibrillation is identified, initiate cpcr as described previously (figure - ) . if an electrical defibrillator is available, administer j/kg of direct current externally. when a patient in cardiopulmonary arrest is attached to ecg leads, it is important to use contact electrode paste, water-soluble gel such as ky jelly, or water, rather than any form of alcohol. electrical defibrillation of a patient who has alcohol on the ecg leads can lead to fire and thermal burns. reverse any opioid, α -agonist, and phenothiazine drugs that have been administered to the patient. if fine ventricular fibrillation is identified, administer epinephrine figure - : electrical-mechanical dissociation (emd), also known as pulseless electrical activity (pea). the complexes often appear wide and bizarre without a palpable apex beat or functional contraction of the heart. this is just one example of emd, as many shapes and complexes may be observed. organized according to whether an electrical defibrillator is available. after each intervention step, the ecg should be reevaluated and the next step initiated if v-fib is still seen. if a new arrhythmia develops, the appropriate therapy for that rhythm should be inititated. if a sinus rhythm is seen with a palpable apex beat, postresuscitation measures should be implemented. perform open-chest cpcr immediately if a pathologic condition exists that prevents enough of a change in intrathoracic pressure that closed-chest cpcr will not be effective in promoting forward blood flow (box . to perform open-chest cpcr, place the patient in right lateral recumbency. clip a wide strip of fur over the left fifth to seventh intercostal space and quickly aseptically scrub over the clipped area. using a no. scalpel blade, incise over the fifth intercostal space through the skin and subcutaneous tissue to the level of the intercostal muscles. with a mayo scissors, make a blunt stab incision through the intercostal muscles in the left sixth intercostal space. make sure that the person who is breathing for the patient deflates the lungs as you make the stab incision to avoid iatrogenic lung puncture. after the stab incision, open the tips of the mayo scissors and quickly open the muscle dorsally and ventrally to the sternum with a sliding motion. avoid the internal thoracic artery at the sternum and the intercostal arteries at the caudal aspect of each rib. cut the rib adjacent to the sternum and push it behind the rib in front of and at the caudal aspect of the incision to allow more room and better visualization if a rib spreading retractor is not available. visualize the heart in the pericardial sac. visualize the phrenic nerve, and incise the pericardium just ventral to the phrenic nerve. make sure to not cut the phrenic nerve. grasp the heart in your hand(s) and gently squeeze it from apex to base, allowing time for the ventricle to fill before the next "contraction." if the heart does not seem to be filling, administer fluids intravenously or directly into the right atrium. the descending aorta can be cross-clamped with a rummel tourniquet or red rubber catheter to improve perfusion to the brain and heart. postresuscitation care and monitoring (prolonged life support) postresuscitation care involves careful monitoring and management of the adverse effects of hypoxia and reperfusion injury on the brain and other vital organs. the first hours after an arrest are most critical, because this is the time period in which an animal is most likely to rearrest unless the underlying cause of the initial arrest has been determine and treated (table - ) . until an animal is adequately ventilating on its own, artificial ventilation by manual bagging or attaching the patient to a mechanical ventilator with supplemental oxygen must continue. the efficacy of oxygenation and ventilation can be monitored using a wright's respirometer, pulse oximetry, capnometry, and arterial blood . once an animal is extubated, administer supplemental oxygen ( to ml/ kg/minute) (see oxygen supplementation). the brain is sensitive to ischemia and reperfusion injury. the effects of cellular hypoxia and reperfusion include the development of oxygen-derived free radical species that contribute to cerebral edema. administer mannitol ( . to g/kg iv over to minutes), followed by furosemide ( mg/kg iv) minutes later, to all patients that have experienced cardiopulmonary arrest and have had successful resuscitation. mannitol and furosemide work synergistically to decrease cerebral edema formation and scavenge oxygen-derived free radical species. the combination of cardiac arrest, myocardial ischemia and acidosis, and external or internal cardiac compressions often make the myocardium irritable and predisposed to dysrhythmias following successful cpcr. start lidocaine ( to mg/kg iv, followed by to µg/kg/minute iv cri) in all patients following successful resuscitative efforts. monitor the ecg continuously for the presence of cardiac dysrhythmias and recurrence of nonperfusing rhythms. perform direct or indirect blood pressure monitoring. if a patient's systolic blood pressure is less than mm hg, diastolic pressure is less than mm hg, or mean arterial blood pressure is less than mm hg, administer positive inotropic drugs (dobutamine, to µg/kg/minute) and pressor agents (epinephrine, . to . mg/kg iv, io, it) to improve cardiac contractility, cardiac output, and core organ perfusion. the kidneys are sensitive to decreased perfusion and cellular hypoxia. place a urinary catheter and monitor urine output. in a euvolemic patient, normal urine output should be no less than to ml/kg/hour. if urine output is low, administer low-dose dopamine ( to µg/kg/minute iv cri) in an attempt to dilate afferent renal vessels and improve renal perfusion. maintain acid-base and electrolyte status within normal reference ranges. monitor serum lactate as a rough indicator of organ perfusion and cellular oxygen extraction. the presence of elevated or rising serum lactate in the face of aggressive cardiorespiratory and cerebral support makes prognosis less favorable. cole sg, otto cm, hughes d: cardiopulmonary cerebral resuscitation: a clinical practice review part i, j vet emerg crit care ( ) immediate action depends largely on recognition of the primary or secondary cause of the dysrhythmia and treating the dysrhythmia and underlying cause. diagnosis of cardiac dysrhythmias is based on physical examination findings of abnormal thoracic/cardiac auscultation, the presence of abnormal pulse rhythm and quality, and recognition of ecg abnormalities. the ecg is critical to the accurate diagnosis of dysrhythmias. ventricular dysrhythmias arise from ectopic foci in the ventricles that cause the wave of depolarization to spread from cell to cell rather than spread through fast-conducting tissue. this causes the qrs complex to appear wide and bizarre, unless the ectopic focus originates close to the atrioventricular node high in the ventricle. other ecg features of ventricular dysrhythmias include a t wave polarity that is opposite to the qrs complex and nonrelated p waves. ventricular dysrhythmias may manifest as isolated ventricular premature complexes, couplets, or triplets; bigeminy; or ventricular tachycardia. relatively slow ventricular tachycardia is known as an idioventricular rhythm and is not as hemodynamically significant as faster ventricular tachycardia. idioventricular rhythm usually is less than beats per minute and may alternate spontaneously with sinus arrhythmias (figures - to . supraventricular dysrhythmias arise from ectopic foci in the atria and are commonly associated with atrial dilatation and structural heart disease such as advanced acquired or congenital heart disease, cardiomyopathies, cardiac neoplasia, or advanced heartworm disease. occasionally, supraventricular dysrhythmias may be associated with respiratory or other systemic illness. sustained supraventricular tachycardia in the absence of underlying structural heart or systemic disease is disturbing and should alert the clinician that an accessory pathway conduction disturbance may be present, particularly in labrador retrievers. supraventricular dysrhythmias can manifest as isolated premature complexes (atrial premature complexes or contractions), sustained or paroxysmal supraventricular tachycardia (atrial tachycardia), or atrial fibrillation or flutter. in the dog, atrial fibrillation most commonly is associated with dilative cardiomyopathy. rarely and primarily in giant breed dogs, lone atrial fibrillation can occur with no underlying heart disease. atrial fibrillation and the resultant sustained elevation in ventricular rate are presumed to progress to dilative cardiomyopathy in such breeds. by comparison, atrial fibrillation is relatively uncommon in cats because of the small size of their atria but is associated most commonly with hypertrophic and restrictive cardiomyopathy. the ecg is critical to the diagnosis of a supraventricular dysrhythmia. the ecg usually demonstrates a normal appearance to the qrs complex unless aberrant conduction occurs in the ventricles, in which case the qrs can be wide but still originate from above the atrioventricular node. in most cases of a supraventricular dysrhythmia, some evidence of atrial activity including p waves, atrial flutter, or atrial fibrillation is apparent. in some cases, it may be difficult to diagnose the exact rhythm without slowing the rate down mechanically or through pharmacologic intervention. once a rhythm diagnosis is made, appropriate treatment strategies can be implemented (figures - and - ). treatment of ventricular dysrhythmias largely depends on the number of ectopic foci discharging, the rate and character of the dysrhythmia, and whether the presence of the abnormal beats is of adverse hemodynamic consequence, including risk of sudden death. many ventricular dysrhythmias, including slow idioventricular rhythms, ventricular bigeminy, or intermittent ventricular premature complexes, do not warrant antiarrhythmic therapy unless the patient is hypotensive and the dysrhythmia is thought to be contributing to the hypotension. in such cases, correction of the underlying disease process including hypoxia, pain, or anxiety often alleviates or decreases the incidence of the dysrhythmia. more serious ventricular dysrhythmias that warrant antiarrhythmic therapy (table - ) include sustained ventricular tachycardia (> beats/minute in dogs; > beats/minute in cats), multifocal ventricular premature complexes originating from more than one place in the ventricles, and the presence of r-on-t phenomena where the t wave of the preceding complex is superimposed on the qrs of the next complex with no return to isoelectric shelf in between complexes. treat these ventricular dysrhythmias immediately and aggressively. in dogs, the mainstay of emergency treatment for ventricular dysrhythmias is lidocaine therapy. administer lidocaine ( to mg/kg iv bolus) over a period of minutes to prevent the adverse side effects of seizures or vomiting. the bolus can be repeated an additional times (total dose mg/kg) over minutes, or the patient can be placed on a constant rate infusion ( to µg/kg/minute) if control of ventricular tachycardia is accomplished. also correct the patient's magnesium and potassium deficiencies to maximize the success of lidocaine therapy in the treatment of ventricular tachycardia. procainamide ( mg/kg iv slowly over to minutes) also can be used to control ventricular tachycardia. if procainamide is successful at controlling ventricular tachycardia, administer it as a constant rate infusion ( to µg/kg/minute). side effects of procainamide include vomiting, diarrhea, and hypotension. chronic oral therapy may or may not be necessary in the treatment of acute ventricular tachycardia. the decision to continue antiarrhythmic therapy depends on the underlying disease process and the expectation of persistent arrhythmogenesis of the underlying disease process. oral antiarrhythmic therapy is warranted in cases in which a serious ventricular dysrhythmia is recognized but the animal does not require hospitalization, such as the syncopal boxer with intermittent ventricular dysrhythmias and no evidence of structural heart disease. it deserves emphasis that asymptomatic, low-grade ventricular dysrhythmias probably do not require treatment. if maintenance therapy for ventricular dysrhythmias is needed, use an oral drug based on the underlying disease process, clinical familiarity, class of drug, dosing frequency, owner compliance, concurrent medications, cost, and potential adverse side effects. in the cat the mainstay of antiarrhythmic therapy is the use of a β-adrenergic antagonist. in the acute management of ventricular dysrhythmias in cases of hypertrophic, restrictive, or unclassified cardiomyopathies, consider using injectable esmolol ( . to . mg/kg iv slowly to effect) or propranolol ( . to . mg/kg iv slowly to effect), particularly if the dysrhythmia results from hyperthyroidism. for chronic oral ventricular antiarrhythmic therapy in cats, propranolol ( . to . mg po per cat q h) or atenolol ( . to . mg po per cat q - h) can be used. the decision to treat supraventricular dysrhythmias depends on the ventricular rate and the hemodynamic consequences of the dysrhythmia. for intermittent isolated atrial emergency care procainamide - mg/kg po q - h tocainide* - mg/kg po q h sotalol - mg per dog q h (start low, then titrate up to effect) mexiletine - mg/kg po q h atenolol . - . mg/kg po q - h (start low, titrate upward to effect) *do not use for longer than weeks because of idiosyncratic blindness. premature contractions, couplets, and triplets, usually no treatment is required. when the ventricular rate exceeds beats/minute, diastolic filling time is shortened, causing the heart to not fill adequately. the consequence is decreased cardiac output and decreased coronary artery perfusion. the goal of therapy is rhythm control or, in most cases, rate control. in cases of atrial fibrillation and congestive heart failure, conversion to a normal sinus rhythm rarely can be achieved, although electrocardioversion or pharmacoconversion can be attempted. in the dog a vagal maneuver can be attempted by pressing on the eyeballs or massaging the carotid body. for sustained supraventricular tachycardia, diltiazem ( . mg/kg iv), esmolol ( . to . , titrated upward to a cumulative dose of . mg/kg iv), or propranolol ( . to . mg/kg iv slowly to effect) can be administered in an attempt to slow the ventricular rate in emergent situations. administer oral diltiazem ( . mg/kg po q h), diltiazem (dilacor-xr) ( . to mg/kg po q - h), propranolol ( . to . mg/kg tid, titrated up to a maximum of . mg/kg po q h), atenolol ( . to mg/kg q - h), or digoxin ( . to . mg/kg bid or . mg/m for dogs greater than kg). in the cat a vagal maneuver can be attempted by ocular or carotid massage. (diltiazem [dilacor] to po q - h), propranolol ( . to mg/kg q - h), or atenolol ( . mg q - h) also can be administered. if structural heart disease is present, treat pulmonary edema and start angiotensin-converting enzyme inhibitor therapy. table - summarizes the drugs used in the management of supraventricular dysrhythmias. severe bradycardia often results from systemic disease, drug therapy, anesthetic agents, or hypothermia and thus rarely requires specific therapy except to treat or reverse the underlying mechanisms promoting bradycardia. hemodynamically significant bradyarrhythmias that must be treated include atrial standstill, atrioventricular block, and sick sinus syndrome. atrial standstill most commonly is associated with hyperkalemia and is seen most often in urinary obstruction, renal failure, urinary trauma with uroabdomen, and hypoadrenocorticism. characteristic ecg abnormalities observed in atrial standstill are an absence of p waves, widened qrs complexes, and tall spiked t waves (figure - ). the treatment for hyperkalemia-induced atrial standstill is to correct the underlying cause and to drive potassium intracellularly and protect the myocardium from the adverse effects of hyperkalemia. regular insulin ( . to . units/kg iv) followed by dextrose ( g/unit insulin iv, followed by . % dextrose cri to prevent hypoglycemia) or sodium bicarbonate ( meq/kg iv) can be administered to drive potassium intracellularly. calcium gluconate ( . ml/kg of % solution iv over minutes) also can be administered as a cardioprotective drug until the cause of hyperkalemia has been identified and resolved. also administer sodium chloride fluids ( . % sodium chloride iv) to promote kaliuresis. less commonly, atrial standstill is associated with atrial cardiomyopathy or silent atrium syndrome. persistent atrial standstill has been recognized without electrolyte abnormalities in the english springer spaniel and the siamese cat. short-term therapy for persistent atrial standstill includes atropine ( . mg/kg sq) until definitive treatment by implantation of a cardiac pacemaker can be performed. complete or third-degree atrioventricular block or high-grade symptomatic seconddegree atrioventricular block can be hemodynamically significant when ventricular rates are less than beats/minute in the dog. classic clinical signs include weakness, exercise intolerance, lethargy, anorexia, syncope, and occasionally seizures. advanced atrioventricular block usually is caused by advanced idiopathic degeneration of the atrioventricular node. less commonly, atrioventricular block has been associated with digoxin toxicity, magnesium oversupplementation, cardiomyopathy, endocarditis, or infectious myocarditis (lyme disease). an accurate diagnosis is made based on the ecg findings of nonconducted p waves with ventricular escape beats. first-and second-degree atrioventricular block may not be hemodynamically significant and therefore may not require therapy. initially treat third-degree (complete) or symptomatic high-grade second-degree atrioventricular block (< beats/minute) with atropine ( . mg/kg sq or im). perform a follow-up ecg in to minutes. atropine is rarely successful in treating complete atrioventricular block. also attempt treatment with isoproterenol ( . to . µg/kg/minute iv cri or . mg in ml % dextrose in water iv slowly), a pure β-agonist. definitive treatment requires permanent pacemaker implantation. consultation with a veterinary cardiologist who implants pacemakers is suggested. never attempt to convert or treat the observed ventricular escape beats with lidocaine ( figure - ) . sick sinus syndrome most commonly is recognized in the miniature schnauzer, although any dog can be affected. sick sinus syndrome usually results from idiopathic degeneration of the sinus node in the dog. in the cat, sinus node degeneration usually is associated with cardiomyopathy. dysfunction of the sinus node may manifest as marked bradycardia with periods of sinus arrest followed by junctional or ventricular escape complexes. a variant of sick sinus syndrome is the presence of severe bradycardia followed by periods of supraventricular tachycardia, often termed bradycardia-tachycardia syndrome. the most common clinical signs are syncope, exercise intolerance, and lethargy. in cats, hypertrophic cardiomyopathy is the most common form of acquired cardiac disease observed. congestive heart failure resulting from hypertrophic cardiomyopathy can occur in animals as young as to months of age. hypertrophic cardiomyopathy is characterized by stiff, noncompliant ventricles that do not relax during diastole, causing an increase in left atrial pressures and left atrial enlargement. other cardiomyopathies, including unclassified, restrictive, and dilated, are less common but also can occur in the cat. cats often develop acute exacerbation of clinical signs because of stress or arterial embolization. the rapid diagnosis of chf often is made on owner history, signalment, and physical examination findings (box - ). typical physical examination findings include a cardiac murmur or gallop dysrhythmia, abnormal breath sounds, respiratory difficulty and orthopnea, tachycardia, weak pulse quality, cool peripheral extremities, and pale or cyanotic mucous membrane. initiate immediate treatment based on physical examination findings and index of suspicion. in some cases, it is difficult to distinguish between chf and feline lower airway disease (asthma) without performing thoracic radiographs. let the animal rest and become stabilized before attempting any stressful procedures, including thoracic radiographs. immediate treatment consists of administering supplemental oxygen, decreasing circulating fluid volume with furosemide, dilating pulmonary and splanchnic capacitance vessels with topical nitroglycerine and morphine, and alleviating patient anxiety and stress (box - ). primary differential diagnoses are made based primarily on the patient's breed, age, clinical signs, history, and physical examination abnormalities. the most common differential diagnoses in a patient with chf are cardiac abnormalities and respiratory disease (chronic bronchitis [asthma], pulmonary hypertension, cor pulmonale, neoplasia). postpone diagnostic tests in any patient with suspected chf until the immediate treatments have taken effect and the patient is cardiovascularly more stable. in most cases, lateral and dorsoventral thoracic radiographs are one of the most important diagnostic tools in helping make a diagnosis of chf. increased perihilar interstitial to alveolar infiltrates are characteristic of pulmonary edema. left atrial enlargement may be observed as a "backpack" sign at the caudal cardiac waist. cardiomegaly of the right or left side also may be present in cases of valvular insufficiency. in cats, increased sternal contact and a classic valentine-shaped heart may be observed in cases of hypertrophic cardiomyopathy. perform a vertebral heart score (sum) to measure cardiac size and determine whether cardiomegaly is present (box - ). also obtain arterial blood pressure and ecg readings to determine whether hypotension and dysrhythmias are present. atrial fibrillation, ventricular premature contractions, and supraventricular tachycardia are common rhythm disturbances that can affect cardiac output adversely and influence treatment choices. the echocardiogram is a useful noninvasive and nonstressful method to determine the degree of cardiac disease present. the echocardiogram is largely user-dependent. the quality of the study is based on the experience of the operator and the quality of the ultrasound machine. echocardiography can be a useful tool in making a diagnosis of pericardial effusion, dilated or hypertrophic cardiomyopathy, cardiac neoplasia, and endocarditis. the medical management of chf is designed to improve cardiac output and relieve clinical signs. the immediate goal of therapy is to reduce abnormal fluid accumulation and provide adequate cardiac output by increasing contractility, decreasing preload and ventricular afterload, and/or normalizing cardiac dysrhythmias. strict cage rest is of utmost importance when managing a patient with chf. after initial administration of furosemide, morphine, oxygen, and nitroglycerine paste, clinical signs of respiratory distress should show improvement within minutes. if no improvement is observed, administer repeated doses of furosemide. reevaluate severe cases that are refractory to this standard treatment protocol. vasodilation should be the next step in the management of refractory cases, provided that a normal blood pressure is present. sodium nitroprusside is a potent balanced vasodilator that should be administered ( to µg/kg/minute iv cri), taking care to monitor blood pressure continuously because severe vasodilation and hypotension can occur. the goal of nitroprusside therapy is to maintain a mean arterial blood pressure of mm hg. sodium nitroprusside should not be considered in cases of refractory chf with severe hypotension. for more long-term management of chf, the use of angiotensin-converting enzyme (ace) inhibitors including enalapril ( . mg/kg po q - h), benazepril ( . mg/kg po q h), and lisinopril ( . mg/kg po q h) have become the mainstay of therapy to reduce sodium and fluid retention and decrease afterload. start angiotensin-converting enzyme inhibition as soon as a patient is able to tolerate oral medications. dobutamine ( . to µg/kg/minute cri diluted in % dextrose in water) can be administered to improve cardiac contractility, particularly in cases of dilated cardiomyopathy. at low doses, dobutamine, primarily a β-adrenergic agonist, will improve cardiac output with minimal effects on heart rate. dobutamine must be given as a constant rate infusion with careful, continuous ecg monitoring. despite minimal effects on heart rate, emergency management of specific conditions the vertebral heart sum can be calculated by performing the following steps: . measure the long axis of the heart from the apex to the carina on the lateral view and mark the distance on a sheet of paper. . measure the length of the long axis of the heart in terms of vertebral bodies, starting by counting caudally from the fourth thoracic vertebra; count the number of vertebrae that are covered by the length of the long axis of the heart. . measure the short axis of the heart at the caudal vena cava, perpendicular to the long axis of the heart. . count the number of thoracic vertebrae covered by the short axis of the heart, starting at t . . add the two numbers together to yield the vertebral heart sum; a vertebral heart sum greater than . is consistent with cardiomegaly. sinus tachycardia or ventricular dysrhythmias may develop during infusion. cats are more sensitive to the effects of dobutamine than dogs. monitor carefully for seizures and facial twitching. digoxin is a cardiac glycoside that acts as a positive inotrope and negative chronotrope in the long-term management of chf. digoxin has a long ( hours in dogs, and hours in cats) half-life and so has minimal use in the emergency management of chf. in chronic management of chf resulting from dilated cardiomyopathy or advanced mitral disease, however, digoxin is extremely useful. oral digitalization protocols have been developed but are risky in that dysrhythmias and severe gastrointestinal side effects can occur. cats with chf often have fulminant pulmonary edema, pleural effusion, arterial thromboembolism, or some combination of all three. if the pleural effusion is significant, perform therapeutic thoracocentesis to relieve pulmonary atelectasis and improve oxygenation. once the diagnosis and initial management of chf has been made, formulate a plan for continued management and monitoring. tailor the therapeutic plan to the patient based on the cause of the chf, the presence of concurrent diseases, and response to therapy. an important and often overlooked part of the successful emergency management of chf is the open communication with the owner regarding the owner's emotional and financial commitment for immediate and long-term management to ensure appropriate quality of life for each patient. pathophysiology and treatment, vet j ( ) caval syndrome resulting from severe heartworm disease is caused by the rapid maturation of a large quantity of adult worms in the right atrium and cranial and caudal venae cavae. most cases of caval syndrome occur in regions of the world where heartworm disease is highly endemic and dogs spend a large portion of time living outdoors. caval syndrome is recognized by the following clinical signs and results of biochemical analyses: acute renal and hepatic failure, enlarged right atrium and posterior vena cava, ascites, hemoglobinuria, anemia, acute collapse, respiratory distress, dic, jugular pulses, circulating microfilariae, and sometimes tricuspid insufficiency. immediate action in cases of caval syndrome in dogs involves immediate stabilization of the cardiovascular and respiratory systems with supplemental oxygen, furosemide ( mg/kg iv), and careful crystalloid fluid infusion. diagnosis of caval syndrome is based on clinical signs of cardiogenic shock with right ventricular heart failure, intravascular hemolysis, and renal and hepatic failure. thoracic radiographs reveal cardiomegaly of the right side and enlarged tortuous pulmonary arteries. a right axis deviation may be seen on ecg tracings. clinicopathologic changes observed include azotemia, inflammatory leukogram, regenerative anemia, eosinophilia, elevated hepatocellular enzyme activities, hemoglobinuria, and proteinuria. circulating microfilariae may be observed on peripheral blood smears or in the buffy coat of microhematocrit tubes. heart worm antigen tests will be strongly positive. echocardiographic changes include visualization of a large number of heartworms in the right atrium, pulmonary arteries, and vena cava, tricuspid insufficiency, and right atrial and ventricular enlargement. treatment involves surgical removal of as many of the adult heartworms as possible from the right jugular vein and right atrium. glucocorticosteroids are recommended to decrease inflammation and microangiopathic disease associated with heartworm infection. for more long-term management, administer adulticide therapy several weeks following surgery, followed by routine microfilaricide therapy and then prophylaxis. calvert pericardial effusion often develops as a consequence of neoplasia in the older dog and cat. the most common types of neoplasia that affect the heart and pericardium include hemangiosarcoma, chemodectoma, mesothelioma, and metastatic neoplasia. more rarely, other causes of pericardial effusion include benign idiopathic pericardial effusion, coagulopathy, left atrial rupture in dogs with chronic mitral valvular insufficiency, infection, or pericardial cysts. regardless of the cause of the effusion, the development of pericardial tamponade adversely affects cardiac output. cardiac output is a function of heart rate and stroke volume. stroke volume depends on cardiac preload. the presence of pericardial effusion can impede venous return to the heart and thus adversely affect preload. in addition, as preload decreases, heart rate reflexively increases in an attempt to maintain normal cardiac output. as heart rate increases more than beats/minute, diastolic filling is impaired further, and cardiac output further declines. animals with pericardial effusion often demonstrate the classic signs of hypovolemic or cardiogenic shock: anorexia, weakness, lethargy, cyanosis, cool peripheral extremities, tachycardia, weak thready pulses, hypotension, and collapse. physical examination abnormalities may include muffled heart sounds, thready femoral pulses, pulsus paradoxus, jugular venous distention, weakness, tachycardia, cyanosis, and tachypnea. electrocardiogram findings may include low amplitude qrs complexes (< . mv), sinus tachycardia, ventricular dysrhythmias, or electrical alternans (figure - ) . thoracic radiographs often demonstrate a globoid cardiac silhouette, although the cardiac silhouette rarely may appear normal with concurrent clinical signs of cardiogenic shock in cases of acute hemorrhage. in such cases the removal of even small amounts of pericardial effusion by pericardiocentesis can increase cardiac output exponentially and alleviate clinical signs (table - ) . unless an animal is dying before your eyes, ideally perform an echocardiogram to attempt to determine whether a right atrial, right auricular, or heart base mass is present before pericardiocentesis. before attempting pericardiocentesis, assemble all of the required supplies (box - ) . to perform pericardiocentesis, follow this procedure: . place the patient in sternal or lateral recumbency. . attach ecg leads to monitor the patient for dysrhythmias during the procedure. . clip a -cm square caudal to the right elbow over the fifth to seventh intercostal space. . aseptically scrub the clipped area, and infuse to mg/kg of % lidocaine mixed with a small amount of sodium bicarbonate just dorsal to the sternum at the sixth intercostal space. bury the needle to the hub, and inject the lidocaine as you withdraw the needle. . while the local anesthetic is taking effect, assemble the intravenous extension tubing, three-way stopcock, and -ml syringe. . wearing sterile gloves, make a small nick incision in the skin to decrease drag on the needle and catheter during insertion. . slowly insert the needle and catheter, watching for a flash of blood in the hub of the needle, and simultaneously watching for cardiac dysrhythmias on the ecg monitor. . once a flash of blood is observed in the hub of the needle, advance the catheter off of the stylette further into the pericardial sac, and remove the stylette. . attach the length of intravenous extension tubing to the catheter, and have an assistant withdraw the fluid slowly. . place a small amount of fluid in a red-topped tube, and watch for clots. clot formation could signify that you have penetrated the right ventricle inadvertently or that active hemorrhage is occurring. withdraw as much of the fluid as possible, and then remove the catheter. monitor the patient closely for fluid reaccumulation and recurrence of clinical signs of cardiogenic shock. less rd, bright jm, orton ec: intrapericardial cyst causing cardiac tamponade in a cat, j am anim hosp assoc ( ) foreign bodies within the ear canal (e.g., foxtails) can present as emergencies because of acute inflammation and pressure necrosis of the tissue of the external auditory meatus causing pain and discomfort. clinical signs may be limited to incessant head shaking or scratching of the ear canal. complete examination of the ear canal and removal of any foreign body often requires administration of a short-acting anesthetic agent. once the animal has been restrained sufficiently and placed under anesthesia, carefully examine the ear canal and remove any foreign material with an alligator forceps. stimulation of the ear canal can cause awakening after removal of all debris and detritus, gently wipe the internal and external ear canal with a sterile gauze. place a topical antimicrobial-antifungal-steroid ointment such as otomax in the ear every to hours. if pain and discomfort is severe, systemically effective opioids or nsaids may be required. otitis externa is a common emergency that causes excessive head shaking, scratching, and purulent malodorous aural discharge. clean the ear canal with an irrigating solution such as epiotic and wipe it clean of debris. perform a complete aural examination to determine whether a foreign body or tumor is present and whether the tympanic membrane is intact. heat-fix any discharge and examine it cytologically for bacteria and fungal organisms. following careful cleansing, instill a topical antibiotic-antifungal-steroid ointment. in severe cases in which the ear canal has scarred and closed down with chronicity, consider administering systemically effective antibiotics (cephalexin, mg/kg po tid) and antifungal agents (ketoconazole, mg/kg po q h) instead of topical therapy. systemically effective steroids (prednisone or prednisolone, . mg/kg po q h) may be indicated in cases of severe inflammation to decrease pruritus and patient discomfort. presentation of a patient with otitis interna often is characterized by torticollis, head tilt, nystagmus, circling to the affected side, or rolling. fever, pain, vomiting, and severe depression may accompany clinical signs. most cases of severe otitis interna are accompanied by severe otitis media. both conditions must be treated simultaneously. the most common causes of otitis interna are staphylococcus aureus, pseudomonas, escherichia coli, or proteus spp. otitis interna can develop by infection spreading across the tympanic membrane, through the eustachian tubes, or by hematogenous spread from the blood supply to the middle ear. in most cases of otitis media, the tympanic membrane is ruptured. perform a culture and susceptibility test of the debris behind the tympanic membrane and within the aural canal. carefully clean the external ear canal. medicate with a topical combination antibiotic, antifungal, and antibiotic ointment. administer high-dose antibiotics (cephalexin, mg/kg po q h, or enrofloxacin, to mg/kg po q h). if the tympanic membrane is not ruptured but appears swollen and erythematous, a myringotomy may need to be performed. if clinical signs of otitis media persist despite topical and systemic therapy, radiographic or ct/mri examination of the tympanic bullae may be required. chronic shaking of the head and ears or aural trauma (bite wounds) causes disruption of the blood vessels and leads to the development of unilateral or bilateral aural hematomas. aural hematomas are clinically significant because they cause patient discomfort and are often due to the presence of some other underlying problem such as otitis externa, atopy, or aural foreign bodies. acute swelling of the external ear pinna with fluid is characteristic of an aural hematoma. in some cases, swelling can be so severe that the hematoma breaks open, bathing the patient and external living environment in blood. when a patient has an aural hematoma, investigate the underlying cause. perform a complete aural examination to determine whether an aural foreign body, otitis externa, or atopy are present. carefully examine and gently clean the inner ear canal. treat underlying causes. management of an aural hematoma involves draining the hemorrhagic fluid from the aural tissue and tacking the skin down in multiple places to prevent reaccumulation of fluid until the secondary cause is resolved. many techniques have been described to surgically tack down the skin overlying the hematoma. after the animal has been placed under general anesthesia, lance the hematoma down the middle with a scalpel blade and remove the fluid and blood clot. tack down the skin with multiple through-and-through interrupted or mattress sutures through the ear. some clinicians prefer to suture through and attach a sponge or length of x-ray film to the front and back of the ear for stabilization and support. more recently, a laser can be used to drill holes in the hematoma and tack the skin down in multiple areas. compress the ear against the head with a compression bandage, whenever possible, for to days after the initial surgery, and then recheck the ear. the patient must wear an elizabethan collar until the surgical wound and hematoma heal to prevent selfmutilation. also systemically treat underlying causative factors such as otitis externa with antibiotics, antifungals, and steroids as indicated. investigate and treat other underlying causes such as hypothyroidism or allergies. bass electrocution usually is observed in young animals after they have chewed on an electric cord. other causes of electrocution include use of defective electrical equipment or being struck by lightning. electric current passing through the body can produce severe dysrhythmias, including supraventricular or ventricular tachycardia and first-and thirddegree atrioventricular block. the electric current also can produce tissue destruction from heat and electrothermal burns. electrocution also commonly results in noncardiogenic pulmonary edema caused by massive catecholamine release and increase in pulmonary vascular pressures during the event. ventricular fibrillation can occur, although that depends on the intensity and path of the electrical current and duration of contact. clinical signs of electrocution include acute onset of respiratory distress with moist rales, and localized necrosis or thermal burns of the lips and tongue. often the skin at the commissures of the mouth appears white or yellow and firm to the touch. muscle fasciculations, loss of consciousness, and ventricular fibrillation may occur. thoracic radiographs often reveal an increased interstitial to alveolar lung pattern in the dorsocaudal lung fields. noncardiogenic pulmonary edema can develop up to to hours after the initial incident. the first hours are most critical for the patient, and then prognosis improves. the most important aspect in the treatment of the patient with noncardiogenic pulmonary edema is to minimize stress and to provide supplemental oxygen, with positive pressure ventilation, when necessary. although treatment with vasodilators (low-dose morphine) and diuretics (furosemide) can be attempted, noncardiogenic pulmonary edema is typically resistant to vasodilator and diuretic therapy. positive inotropes and pressor drugs may be necessary to treat shock and hypotension. opioid drugs (morphine, hydromorphone, oxymorphone) may be useful in controlling anxiety until the pulmonary edema resolves. administer broad-spectrum antibiotics (cefazolin; amoxicillin and clavulanic acid [clavamox]) to treat thermal burns. use analgesic drugs to control patient discomfort. if thermal burns are extensive and prohibit adequate food intake, place a feeding tube as soon as the patient's cardiovascular and respiratory function are stable and the patient can tolerate anesthesia. prolapse of the uterus occurs in the immediate postparturient period in the bitch and queen. excessive straining during or after parturition causes the uterus to prolapse caudally through the vagina and vulva. immediate intervention is necessary. examine the bitch or queen for a retained fetus. treatment consists of general anesthesia to replace the prolapsed tissue. if the uterus is edematous, physical replacement may be difficult or impossible. application of a hypertonic solution such as hypertonic ( %) saline or dextrose ( %) to the exposed endometrium can help shrink the tissue. that, combined with gentle massage to stimulate uterine contraction and involution and lubrication with sterile lubricating jelly, can aid in replacement of the organ into its proper place. to ensure proper placement in the abdominal cavity and to prevent recurrence, perform an exploratory laparotomy and hysteropexy. postoperatively, administer oxytocin ( to units im) to cause uterine contraction. if the uterus contracts, it is usually not necessary to suture the vulva. administer antibiotics postoperatively. recurrence is uncommon, even with subsequent pregnancies. if the tissue is damaged or too edematous to replace or if the tissue is devitalized, traumatized or necrotic, perform an ovariohysterectomy. in some instances, replacement of the damaged tissue is not necessary before removal. pyometra occurs in dogs and cats. the disease process occurs as a result of infection overlying cystic endometrial hyperplasia under the constant influence of progesterone. during the -month luteal phase after estrus or following copulation, artificial insemination, or administration of hormones (particularly estradiol or progesterone), the myometrium becomes relaxed and favors a quiescent environment for bacterial proliferation. clinical signs of pyometra are associated with the presence of bacterial endotoxin and sepsis. early, affected animals become lethargic and anorectic. polyuria with secondary polydipsia is often present because of the influence of bacterial endotoxin on renal tubular concentration. if the cervix is open, purulent or mucoid vaginal discharge may be observed. later in the course of pyometra, vomiting, diarrhea, and progressive debilitation resulting from sepsis occur. diagnosis is based on clinical signs in an intact queen or bitch and radiographic or ultrasonographic evidence of a fluid-filled tubular density in the ventrocaudal abdomen, adjacent to the urinary bladder (figures - and - ) . treatment of open and closed pyometra is correction of fluid and electrolyte abnormalities, administration of broad-spectrum antibiotics, and ovariohysterectomy. close pyometra is a life-threatening septic condition. open pyometra also can become life-threatening and so should be treated aggressively. in closed pyometra, conservative medical therapy is not advised. administration of prostaglandins and oxytocin do not reliably cause the cervix to open and can result in ascending infection from the uterus into the abdomen or uterine rupture, both of which can result in severe peritonitis. for animals with an open pyometra, ovariohysterectomy is the most reliable treatment for chronic cystic endometrial hyperplasia. although less successful than ovariohysterectomy, medical therapy may be attempted in breeding bitches as an alternative to surgery. the most widely used medical therapy in the breeding queen and bitch is administration of prostaglandin f α . this drug has not been approved for use in the queen or bitch in the united states. to proceed with medical management of pyometra, first determine the size of the uterus. start the patient on antibiotic therapy (ampicillin, mg/kg iv q h, or enrofloxacin, mg/kg po q h). administer the prostaglandin f α ( µg/kg sq q h) for to days until the size of the uterus approaches normal. measure serum progesterone concentrations if the bitch is in diestrus. as the corpus luteum degrades under the influence of prostaglandin f α , serum progesterone levels will decline. prostaglandin f α is an abortifacient and thus should not be administered to the pregnant bitch or queen. clinical signs of a reaction to prostaglandin f α can occur within to minutes in the bitch and can last for as long as minutes. clinical signs of a reaction include restlessness, hypersalivation, panting, vomiting, defecation, abdominal pain, fever, and vocalization. in a very ill animal, death can occur. the efficacy of prostaglandin f α is limited and may require more than one treatment. the bitch should be bred on the next heat cycle and then spayed because progressive cystic endometrial hyperplasia will continue to occur. acute metritis is an acute bacterial infection of the uterus that typically occurs within to weeks after parturition. the most common organism observed in metritis is e. coli ascending from the vulva and vaginal vault. sepsis can progress rapidly. clinical signs of acute metritis include inability to nurse puppies, anorexia, lethargy, foul-smelling purulentsanguineous vaginal discharge, vomiting, or acute collapse. physical examination may reveal fever, dehydration, and a turgid distended uterus. septic inflammation will be observed on vaginal cytologic examination. an enlarged uterus can be observed with abdominal radiographs and ultrasonography. treatment of acute metritis is directed at restoring hydration status with intravenous fluids and treating the infection with antibiotics. because the primary cause of metritis is e. coli infection, start enrofloxacin ( mg/kg iv or po once daily) therapy. as soon as the patient's cardiovascular status is stable enough for anesthesia, perform an ovariohysterectomy. if the patient is not critical and is a valuable breeding bitch, medical therapy can be attempted. medical management of acute bacterial metritis includes administration of oxytocin ( to units q h for three treatments) or administration of prostaglandin f α ( µg/kg/day for to days) to evacuate the uterine exudate and increase uterine blood flow. either drug should be used concurrently with antibiotics. rupture of the gravid uterus is rare in cats and dogs but has been reported. uterine rupture may occur as a consequence of parturition or result from blunt abdominal trauma. feti expelled into the abdominal cavity may be resorbed but more commonly cause the development of peritonitis. if fetal circulation is not disrupted, the fetus actually may live to term. uterine rupture is an acute surgical emergency. an ovariohysterectomy with removal of the extrauterine puppies and membranes is recommended. if only one horn of the uterus is affected, a unilateral ovariohysterectomy can be performed to salvage the remaining unaffected puppies and preserve the breeding potential for the valuable bitch. if uterine rupture occurs because of pyometra, peritonitis is likely, and copious peritoneal lavage should be performed at the time of surgery. the patient should be placed on to days of antibiotic therapy (amoxicillin or amoxicillin and clavulanic acid [clavamox] with enrofloxacin). vaginal prolapse occurs from excessive proliferation and hyperplasia of vaginal tissue while under the influence of estrogen during proestrus (figure - ) . the hyperplastic tissue usually recedes during diestrus but reappears with subsequent heat cycles. vaginal prolapse can be confused with vaginal neoplasia. the former condition occurs primarily in younger animals, whereas the latter condition occurs primarily in older animals. treatment for vaginal hyperplasia or prolapse generally is not required if the tissue remains within the vagina. the proliferation can lead to dysuria or anuria, however. in some cases, the tissue becomes emergency care dried out and devitalized or becomes traumatized by the animal. such extreme cases warrant immediate surgical intervention. the treatment for vaginal prolapse consists of ovariohysterectomy to remove the influence of estrogen, placement of an indwelling urinary catheter if the patient is dysuric, and protection of the hyperplastic tissue until it recedes on its own. although surgical resection of the hyperplastic tissue has been recommended, excessive hemorrhage after removal can occur, and so the procedure should not be attempted. the patient should wear an elizabethan collar at all times to prevent selfmutilation. administer broad-spectrum antibiotics for a minimum of to days or until the hyperplastic tissue recedes. keep the tissue clean with saline solution. dystocia, or difficult birth, can occur in the dog and cat but is more common in the dog. a diagnosis of dystocia is made based on the time of onset of visible labor and the time in which the last puppy or no puppy has been born, the intensity and timing of contractions, the timing of when the amniotic membranes first appear, the condition of the bitch, and the timing of gestation. causes of dystocia can be maternal or fetal and include primary or secondary uterine inertia, narrowing of the pelvic canal, hypocalcemia, psychological disturbances, or uterine torsion. maternal-fetal disproportion, or large fetus size in relation to the bitch or queen, also can result in dystocia (box - ). obtain an abdominal radiograph for all cases of suspected dystocia at the time of presentation to determine the size of the fetus, presentation of the fetus (both anterior or posterior presentation can be normal in the bitch or queen, but fetal malpositioning can cause dystocia), and whether there is radiographic evidence of a uterine rupture or torsion. if maternal-fetal disproportion, uterine torsion, or uterine rupture is observed, take the patient immediately to surgery. if the puppies or kittens are in a normal position for birth, medical management can be attempted. clip the perineum and aseptically scrub it. wearing sterile gloves, insert a lubricated finger into the vagina and palpate the cervix. massage (or "feather") the dorsal wall of the vagina to stimulate contractions. place an intravenous catheter, and administer oxytocin ( to units im), repeating up to times at -minute intervals. in some cases, hypoglycemia or hypocalcemia can contribute to uterine inertia. administration of a calciumcontaining solution (lactated ringer's solution) with . % dextrose is advised. alternately, administer % calcium gluconate ( mg/ kg iv slowly). if labor has not progressed after hour, immediately perform a cesarean section. uterine torsion is an uncommon emergency seen in the gravid and nongravid uterus and has been reported in dogs and cats. the onset of clinical signs of abdominal pain and straining as if to whelp/queen or defecate is usually acute and constitutes a surgical emergency. in some cases, there may have been a history of delivery of a live or dead fetus. vaginal discharge may or may not be present. radiographs or ultrasound examination reveal a fluid-filled or air-filled tubular density in the ventral abdomen. treatment consists of placing an intravenous catheter, stabilizing the patient's cardiovascular status with intravenous fluids and sometimes blood products, and performing an immediate ovariohysterectomy. if there are viable feti, the uterus should be delivered en mass and the puppies or kittens delivered. the expulsion of one or more fetus before term is known as spontaneous abortion. in dogs and cats, it is possible to expel or abort one or more fetuses and still carry viable fetuses to term and deliver normally. clinical signs of spontaneous abortion include vaginal discharge and abdominal contractions. in some cases, the fetus is found, or there may be evidence of fetal membranes or remnants. causes of spontaneous abortion in dogs include brucella canis, herpesvirus, coronavirus, and toxoplasmosis. in cats, herpesvirus, coronavirus, and feline leukemia virus can cause spontaneous abortion. in both species, trauma, hormonal factors, environmental pathogens, drugs, and fetal factors also can result in spontaneous abortion. the safest method of pregnancy termination in the bitch or queen is by performing an ovariohysterectomy. oral diethylstilbesterol is not an effective mechanism of pregnancy termination in the bitch. a so-called mismating shot, an injection of estradiol cypionate ( . mg/lb im) is effective at causing termination of an early pregnancy but can be associated with severe side effects, including bone marrow suppression and pyometra. estradiol cypionate is not approved for use in the bitch or queen and is not recommended. prostaglandin f α is a natural abortifacient in the bitch if treatment is started within days of cytologic evidence of diestrus (noncornified epithelium on a vaginal smear). the prostaglandin f α causes lysis of the corpora lutea and a rapid decline in progesterone concentration. the prostaglandin f α is administered for a total of eight injections ( µg/kg q h for days), along with atropine ( to µg/kg sq). side effects can occur within to minutes of injection and include restlessness, panting, salivation, abdominal pain, urination, vomiting, and diarrhea. walking the patient for to minutes after each treatment sometimes decreases the intensity of the reactions. bitches in the first half of the pregnancy often resorb the embryos. if prostaglandin f α is administered in the second half of the pregnancy, the fetuses are aborted within to days of treatment. measure serum progesterone concentrations at the end of treatment to ensure complete lysis of the corpus luteum. prostaglandin f α is not approved for pregnancy termination in the bitch. in cats, prostaglandin f α can terminate pregnancy after day of gestation. prostaglandin f α should be used only in healthy queens ( to µg/kg sq q h for days). side effects in the queen are similar to those observed in the bitch but typically have a shorter duration ( to minutes). prostaglandin f α is not approved for use in cats in the united states. the use of prostaglandin f α does not preclude breeding and pregnancy at a later date. biddle d, macintire dk: obstetrical emergencies, clin tech small anim pract ( ) in the dog and cat the majority of injuries to the scrotum are associated with animal fights or shearing and abrasive injuries sustained in accidents involving automobiles. scrotal injuries should be categorized as superficial or penetrating. treatment of superficial injuries to the scrotum includes cleaning the wound with dilute antimicrobial cleanser and drying it. administer antiinflammatory doses of steroids (prednisolone, . to . mg/kg po q - h) or nsaids (carprofen, . mg/kg po q h in dogs) for the first several days after scrotal injury to prevent or treat edema. administer topical antibiotic ointment until the wound heals. in most cases, place an elizabethan collar to prevent self-mutilation. prognosis is generally favorable; however, semen quality may be affected for months after injury because of scrotal swelling and increased scrotal temperature. penetrating injuries to the scrotum are more serious and are associated with severe swelling and infection. surgically explore and debride penetrating scrotal wounds. administer systemically effective antibiotics and analgesics. in extreme cases, particularly those that involve the testicle, consider castration and scrotal ablation. scrotal dermatitis is common in intact male dogs and can be associated with direct physical injury, self-infliction from licking, chemical irritation, burns, or contact dermatitis. in affected animals, the scrotum can become extremely inflamed, swollen, and painful. if left untreated, pyogranulomatous dermatitis can develop. make an attempt to determine whether an underlying systemic illness is present that could predispose the animal to scrotal dermatitis. widespread vasculitis with scrotal edema, pain, fever, and dermatitis has been associated with rickettsia rickettsii (rocky mountain spotted fever) infection. brucella canis also has been associated with scrotal irritation and dermatitis. if scrotal dermatitis follows from an infectious cause, empiric use of glucocorticosteroids potentially can make the condition worse by suppressing immune function. empiric treatment with antibiotics also potentially can confound making an accurate diagnosis. treatment of scrotal dermatitis is to eliminate predisposing causes, if possible. place an elizabethan collar at all times to prevent self-mutilation. bathe the scrotum with a mild antimicrobial soap and dry it to remove any offending chemical irritants. topical medications including tar shampoo, tetracaine, neomycin, and petroleum can cause further irritation and are contraindicated. use oral or parenteral administration of glucocorticosteroids or nsaids to control discomfort and inflammation. scrotal hernias occur when the contents of the abdomen (intestines, fat, mesentery, omentum) protrude through the inguinal ring into the scrotal sac. like inguinal hernias, scrotal definitive therapy for a scrotal hernia involves exploratory laparotomy and surgical reduction of the contents of the hernia, surgical correction of the rent in the inguinal ring, and castration. trauma to the epididymis or testicle can cause testicular pain and swelling of one or both testes. treat penetrating trauma to the testicle by castration to prevent infection and selfmutilation. administer oral antibiotics (amoxicillin or amoxicillin-clavulanate) for to days after the injury. nonpenetrating injuries to the scrotum and testicle rarely may cause acute testicular hemorrhage or hydrocele formation. palpation of the affected area often reveals a peritesticular, soft, compliant area. treatment consists of cool compresses on the scrotum and testicle and administration of antiinflammatory doses of glucocorticosteroids or nsaids. if the swelling does not resolve spontaneously in to days, consider surgical exploration and drainage. increased scrotal temperature and testicular inflammation can affect semen quality for months after the initial incident. testicular torsion, or torsion of the spermatic cord, causes rotation of the testicle, ultimately causing obstruction to venous drainage. testicular torsion often is associated with a neoplastic mass of a retained testicle within the abdomen but also can be observed with nonneoplastic testes located within the scrotum. the predominant clinical signs are pain, stiff stilted gait, and the presence of an abnormally swollen testicle (if located within the scrotum). if an intraabdominal testicular torsion is present, pain, lethargy, anorexia, and vomiting can occur (see acute condition in the abdomen). an intraabdominal mass may be palpable. perform an abdominal or testicular ultrasound, preferably with color flow doppler to evaluate perfusion to the testicle. treatment involves surgical removal of the involved testes. bacterial infections of the testicle or epididymis most commonly are caused by ascending infections of the normal bacterial flora of the prepuce or urethra. common inhabitants include escherichia coli, staphylococcus aureus, streptococcus spp., and mycobacterium canis. brucella canis and r. rickettsii are also capable of causing orchitis and epididymitis in the dog. clinical signs of orchitis or epididymitis include testicular enlargement, stiff stilted gait, and reluctance to walk. physical examination often reveals a fever and self-induced trauma to the scrotum from licking or chewing at the inflamed area. collect a semen sample by ejaculation, and culture it to identify the causative organism. alternately, collect samples by needle aspiration of the affected organ(s) and test serologically for b. canis. treatment of infectious orchitis involves a minimum of to weeks of specific antimicrobial therapy, based on culture and susceptibility testing, whenever possible. if a bacterial culture cannot be obtained, initiate fluoroquinolone therapy (enrofloxacin, mg/kg po q h). doxycycline ( mg/kg po bid for days) has been shown to suppress but not eradicate b. canis infection. testicular inflammation and increased temperature can affect sperm quality for months after infection. the most common causes of acute prostatitis are associated with acute bacterial infection (e. coli, proteus spp., pseudomonas spp., and mycoplasma spp.). less common causes include fungal infection (blastomyces dermatitidis) or anaerobic bacterial infection. acute prostatitis is characterized by fever, caudal abdominal pain, lethargy, anorexia, blood in the ejaculate, hematuria, dyschezia, and occasionally stranguria or dysuria. the patient often appears painful and depressed and may be dehydrated on physical examination. symmetric or asymmetric prostatomegaly and prostate pain may be evident on rectal palpation. in severely affected dogs, clinical signs of tachycardia, hyperemic or injected mucous membranes, bounding pulses, lethargy, dehydration, and fever may be present because of sepsis. death can occur within days if a prostatic abscess ruptures. diagnosis of acute prostatitis is confirmed based on the presenting clinical signs, neutrophilic leukocytosis (with or without a left shift), and positive urine culture results. prostatic samples may be obtained from the prostatic portion of the ejaculate, prostatic massage, urethral discharge, urine, or (less commonly) prostatic aspirate. although semen samples can yield positive bacterial cultures, dogs with acute prostatitis are often unwilling to ejaculate. radiography may reveal an enlarged prostate, but this alone does not confirm the diagnosis of prostatitis. an abdominal ultrasound often reveals prostatic abscessation and allows for the collection of samples from the affected area(s) via prostatic aspirate. aspiration of the affected tissue potentially can wick infection into periprostatic tracks. cytologic examination of the patient's ejaculate or prostatic wash from a dog with acute prostatitis reveals numerous inflammatory cells and may contain bacterial organisms. the treatment of a patient with acute prostatitis is directed at correcting dysuria and constipation associated with prostatic enlargement. enrofloxaxin ( mg/kg po sid) can penetrate the inflamed prostatic tissue and is effective in treating gram-negative and mycoplasma spp. infections. ciprofloxacin does not appear to penetrate prostatic tissue as readily. alternatives to enrofloxacin therapy are trimethoprim-sulfamethoxazole ( mg/kg po q h) or chloramphenicol ( - mg/kg po q h) for a minimum of to weeks. castration is recommended because benign prostatic hyperplasia may be a predisposing factor in the development of acute prostatitis. do not perform castration until the patient has been on antibiotic therapy for a minimum of days, to prevent the surgical complication of schirrous cords. finasteride (proscar, mg/kg po q h), an antiandrogen α-reductase inhibitor, may help reduce the size of prostatic tissue until the effects of castration are observed. if a prostatic abscess is present, perform marsupialization, surgical drainage, or ultrasonographic drainage. surgical therapy is associated with a large incidence of complications, including incontinence, chronic drainage from fistulas and stomas, septic shock, and death. fracture of the os penis is an uncommon condition encountered in male dogs. os penis fractures can occur with minimal soft tissue damage but cause hematuria and dysuria. on physical examination, urethral obstruction and crepitus in the penis are found. a lateral abdominal radiograph is usually sufficient to document the fracture. treatment consists of conservative therapy, in most cases, and consists primarily of analgesia administration. if the urethra also is damaged, place a urethral catheter for to days to allow the urethral mucosa to heal. fractures of the os penis that are comminuted or severe enough to cause urethral obstruction require open reduction and fixation, partial penile amputation, or antescrotal (prescrotal) urethrostomy. lacerations of the penis cause significant bleeding because of the extensive vascular supply to the penis. dogs and cats tend to lick penile lacerations and prevent adequate clot formation. sedation or general anesthesia often is required to evaluate and treat the laceration. after sedation or general anesthesia, place a urinary catheter and examine the penis under a stream of cold water. small lacerations can be managed with cold compresses and one to several absorbable sutures. extensive suturing usually is not required. prevent erection by isolating the patient from females in estrus or allowing excitement or excessive activity. place an elizabethan collar to prevent self-mutilation. initiate systemic antibiotic therapy to prevent infection. the inability to withdraw the penis into the prepuce in male dogs or cats is known as paraphimosis. paraphimosis usually develops following an erection in young male dogs and in emergency care older dogs after coitus. mucosal edema, hemorrhage, self-mutilation, and necrosis requiring penile amputation can occur if left untreated. treatment consists of applying cold water to the penis and reducing edema with application of an osmotic substance such as sugar. examine the base of the penis for hair rings that can prevent retraction of the penis into the prepuce. rinse the penis carefully with cold water and lubricate it with sterile lubricant and replace it into the prepuce. if the penis cannot be reduced easily into the prepuce, anesthetize the patient and make a small incision at the lateral aspect of the preputial opening. replace the penis and close the incision with absorbable suture. place a purse-string suture and leave it in place for several days to prevent recurrence. instill topical antimicrobial ointment with steroids into the prepuce several times a day. in severe cases, a urinary catheter may need to be placed to prevent urethral obstruction, until penile swelling and edema resolve. place an elizabethan collar to prevent excessive licking during the healing process. prolapse of the distal urethra is a condition usually confined to intact male english bulldogs, although isolated incidences also have been reported in yorkshire and boston terriers. the exact cause of this condition is unknown but usually is associated with a condition that causes increased intraabdominal pressure or urethral straining, including sexual excitement, coughing, vomiting, obstructed airway or brachycephalic airway syndrome, urethral calculi, genitourinary tract infection, and masturbation. the urethral prolapse usually appears as a mushroom-tip congested, irritated mass at the end of the penis that may or may not bleed (figure - ) . in some cases, bleeding occurs or worsens with sexual excitement. clinical signs associated with the prolapsed urethra include excessive licking of the prepuce, stranguria, and preputial bleeding. once the mass is observed, other differential diagnoses include transmissible venereal tumor, urethral polyp, trauma, urethritis, and neoplasia. in most cases, however, the prolapse occurs in intact young dogs, making neoplastic conditions less likely. treatment for urethral prolapse should occur at the time of diagnosis to prevent selfinduced trauma and infection. immediate therapy includes manual reduction of the prolapsed tissue and placement of a purse-string suture around an indwelling urinary catheter. the purse-string suture can remain in place for up to days until definitive repair. until the time of surgery, place an elizabethan collar on the patient to prevent self-mutilation. several forms of surgical correction have been described. in some cases, surgical resection of the prolapsed tissue with apposition of the urethral and penile mucosa can be attempted. more recently, a technique involving placement of several mattress sutures to reduce and secure the prolapsed tissue has been described. recurrence of prolapse can occur with either technique, particularly if the inciting event recurs. because there may be a genetic predisposition in this breed and because the prolapse can recur with sexual excitement, neutering should strongly be recommended. local freezing or frostbite most commonly affects the peripheral tissues of the ears, tail, paws, and genitalia that are sparsely covered with fur, are poorly vascularized, and may have been traumatized previously by cold. clinical signs of frostbite are paleness and appearance of a blanched pink to white discoloration to the skin. the skin also may appear black and necrotic. immediate treatment consists of slowly rewarming the affected area with moist heat at . ° c ( °f) or by immersion in warm water baths. analgesics may be required to alleviate patient discomfort. carefully dry the injured areas and protect them from further trauma. the use of prophylactic antibiotics is controversial because it can promote resistant bacterial infection. use of antibiotics should be based on the presence of infection. treatments that are ineffective and may be harmful include rubbing the affected areas, pressure bandages, and ointments. corticosteroids can decrease cellular immunity and promote infection and are therefore contraindicated. many frostbitten areas that appear nonviable can regain function gradually. use care when removing areas of necrotic tissue. affected areas may take several days to a week before fully manifesting areas of demarcation between healthy viable and necrotic nonviable tissue. chilling of the entire body from exposure or immersion in extremely cold water results in a decrease in core body temperature and physiologic processes that become irreversible when the body temperature falls below °c ( °f). mild hypothermia can be °to °c, moderate hypothermia from °to °c, and severe hypothermia below °c. the duration of exposure and the general condition of the animal influences its ability to survive. clinical signs and consequences associated with hypothermia include shivering, vasoconstriction, mental depression, hypotension, sinus bradycardia, hypoventilation with decreased respiratory rate, increased blood viscosity, muscle stiffness, atrial and ventricular irritability, decreased level of consciousness, decreased oxygen consumption, metabolic (lactic) acidosis, respiratory acidosis, and coagulopathies including dic. if the animal is breathing, administer warm, humidified oxygen at to breaths per minute. if the animal is not breathing or is severely hypoventilating, endotracheal intubation with mechanical ventilation may be necessary. place an intravenous catheter and infuse warmed crystalloid fluids. if the blood glucose is less than mg/dl, add supplemental dextrose ( . %) to the crystalloid fluids. monitor the core body temperature and ecg closely. rewarming should occur in the form of external circulating warm water blankets, radiant heat, and circulating warm air blankets (bair hugger). never use a heating pad, to avoid iatrogenic thermal burn injury. severe hypothermia may require core rewarming in the form of intraperitoneal fluids ( to ml/kg of lactated ringer's solution warmed to . °c [ °f]). place a temporary peritoneal dialysis catheter, and repeat the dialysis every minutes until the patient's body temperature reaches . °to . °c ( °to °f). the body temperature should rise slowly, ideally no more than °f per hour. because the response of the body to drugs is unpredictable, avoid administering drugs whenever possible, until the body temperature returns to normal. complications observed during rewarming include dic, cardiac dysrhythmias including cardiac arrest, pneumonia, pulmonary edema, cns edema, ards, and renal failure. heat stroke and heat-induced illness in dogs can be associated with excessive exertion, exposure to high environmental temperatures, stress, and other factors that cause an inability to dissipate heat. brachycephalic breeds, obesity, laryngeal paralysis, and older animals with cardiovascular disease can be particularly affected. hyperthermia is defined as a rectal temperature of °to °c ( °to °f). clinical signs of hyperthermia include congested hyperemic mucous membranes, tachycardia, and panting. more severe clinical signs include collapse (heat prostration), ataxia, vomiting, diarrhea, hypersalivation, muscle tremors, loss of consciousness, and seizures. heat-induced illness can affect all major organ systems in the body because of denaturation of cellular proteins and enzyme activities, inappropriate shunting of blood, hypotension, decreased oxygen delivery, and lactic acidosis. cardiac dysrhythmias, interstitial and intracellular dehydration, intravascular hypovolemia, central nervous dysfunction, slough of gastrointestinal mucosa, oliguria, and coagulopathies can be seen as organ function declines. excessive panting can result in respiratory alkalosis. poor tissue perfusion results in a metabolic acidosis. loss of water in excess of solutes such as sodium and chloride can lead to a free water deficit and severe hypernatremia. a marked increase in pcv occurs because of the free water loss. severe abnormalities in electrolytes and ph can lead to cerebral edema and death. treatment goals for the patient with heat-induced illness are to lower the core body temperature and support cardiovascular, respiratory, renal, gastrointestinal, neurologic, and hepatic functions. at the scene the veterinarian or caretaker can spray the animal with tepid (not cold) water. immersion in cold water or ice baths is absolutely contraindicated. cold water and ice will cause extreme peripheral vasoconstriction, inhibiting the patient's ability to dissipate heat through conductive and convective cooling mechanisms. as a result, core body temperature will continue to rise despite the good intentions of well-doers at the scene. animals that present to the veterinarian that have been cooled to the point of hypothermia have a worse prognosis. once the animal has presented to the veterinarian, the goal is to cool the animal's body temperature with towels soaked in tepid water, cool intravenous fluids, and fans until the temperature has decreased to °f. organ system monitoring and support is based on the severity and duration of the heat stroke and the ability of the body to compensate and respond to treatment. management of the patient with heat-induced illness involves prompt aggressive cooling without being overzealous and creating iatrogenic hypothermia. administer cool intravenous crystalloid fluids to replenish volume and interstitial hydration and correct the patient's acid-base and electrolyte abnormalities. management consists of rule of twenty monitoring (see rule of ), taking care to evaluate, restore, and maintain a normal cardiac rhythm, blood pressure, urine output, and mentation. administer antibiotics if there are any signs of gastrointestinal bleeding that will predispose the patient to bacterial translocation. monitor baseline chemistry tests including a complete blood count, biochemical panel, platelet count, coagulation tests, and urinalysis. treat coagulopathies including dic aggressively and promptly (see also disseminated intravascular coagulation). severe changes in mentation including stupor or coma worsen a patient's prognosis. following initial therapy, monitor the patient for a minimum of to hours for secondary organ damage, including renal failure, myoglobinuria, cerebral edema, and dic. dogs that are going to die of heat-induced illness usually die within the first hours. animals that survive longer than hours have a more favorable prognosis. immediate treatment consists of cooling the patient with cooling measures as for hyperthermia and heat-induced illness (see the previous discussion), and eliminating the cause (i.e., exertion, anesthesia, or neuromuscular blockers such as succinylcholine). if the patient is under general anesthesia, hyperventilate the patient to help eliminate carbon dioxide and respiratory acidosis. administer dantrolene sodium ( to mg/kg iv) to stabilize the sarcoplasmic reticulum and decrease its permeability to calcium. animals with malignant hyperthermia should avoid any predisposing factors, including exertion, hyperthermia, and anesthesia. after an episode of malignant hyperthermia, administer crystalloid fluids intravenously to aid in the elimination of myoglobin. monitor renal function closely for myoglobinuria and pigment damage to the renal tubular epithelium. monitor and correct acid-base and electrolyte changes. walters jm: hyperthermia. in wingfield we, editor: the veterinary icu book, jackson, wyo, , teton newmedia. sometimes it is difficult to assess whether an animal has been bitten by a poisonous or nonpoisonous snake. in colorado, the bull snake closely resembles the prairie rattlesnake. both snakes make similar noise and can be alarming if noticed on a hike or in the backyard. whenever possible, identify the offending reptile but never risk being bitten. know what types of venomous creatures are in the geographic area of the practice. if an animal has been bitten by a nonpoisonous snake, usually the bite marks are small with multiple small tooth punctures, and the bite is relatively nonpainful. usually local reaction is negligible. however, large boas or pythons also can inflict large crushing injuries that can cause severe trauma, including bony fractures. treatment for a nonpoisonous snakebite involves clipping the bite wound and carefully cleaning the area with antimicrobial scrub solution. broad-spectrum antibiotics (e.g., amoxicillin-clavulanate, . mg/kg po q h) are indicated because of the extensive bacterial flora in the mouths of snakes. monitor all snakebite victims for a minimum of hours after the incident, particularly when the species of the offending reptile is in question. if clinical signs of envenomation occur, modify the patient's treatment appropriately and aggressively. the two major groups of venomous snakes in north america are the pit viper and the coral snake. all venomous snakes are dangerous. the severity of any given bite depends on the toxicity of the venom, the amount of venom injected, the site of envenomation, the size of the animal bitten, and the time from bite/envenomation to seeking appropriate medical intervention. the majority of reptile envenomations in the united states are inflicted by pit vipers, including the water moccasin (cottonmouth), copperhead, and numerous species of rattlesnakes. pit vipers are characterized by a deep pit located between the eye and nostril, elliptic pupils, and retractable front fangs (figure - ) . localized clinical signs of pit viper envenomation may include the presence of bleeding puncture wounds, local edema close to puncture wounds, immediate severe pain or collapse, edema, petechiae, and ecchymosis with subsequent tissue necrosis. systemic signs of pit viper envenomation may include hypotension, shock, coagulopathies, lethargy, weakness, muscle fasciculations, lymphangitis, rhabdomyolysis, and neurologic signs including respiratory depression and seizures. neurologic signs largely are associated with envenomation emergency management of specific conditions by the mojave and canebrake rattlesnakes, although a potent neurotoxin, mojave toxin a, also has been identified in other subspecies of rattlesnake. clinical signs of envenomation may take several hours to appear. hospitalize all suspected victims and monitor them for a minimum of hours. the severity of envenomation cannot be judged solely on the basis of local tissue reaction. first aid measures by animal caretakers do little to prevent further envenomation. the most important aspect of initiating therapy is to transport the animal to the nearest veterinary emergency facility. to determine whether an animal has been envenomated by a pit viper, examine a peripheral blood smear for the presence of echinocytes. echinocytes will appear within minutes of envenomation and may disappear within hours. other treatment should be initiated as rapidly and aggressively as possible, although controversy exists whether some therapies are warranted. the mainstay of therapy is to improve tissue perfusion with intravenous crystalloid fluids, prevent pain with judicious use of analgesic drugs, and when necessary, reverse or negate the effects of the venom with antivenin. because pit viper venom consists of multiple fractions, treat each envenomation as a complex poisoning. obtain vascular access and administer intravenous crystalloid fluids (one fourth of a calculated shock dose) according to the patient's perfusion parameters of heart rate, blood pressure, and capillary refill time (see also shock and fluid therapy). opioid analgesics are potent and should be administered at the time of presentation. (see also pharmacologic means to analgesia: major analgesics). diphenhydramine ( . to mg/kg im or iv) also can be administered to decrease the effects of histamine. famotidine, a histamine receptor antagonist, also can be administered ( . to mg/kg iv) to work synergistically with diphenhydramine. although antihistamines have no effect on the venom per se, they may have an effect on the tissue reaction to the venom and may prevent an adverse reaction to antivenin. the use of glucocorticosteroids is controversial. glucocorticosteroids (dexamethasone sodium phosphate [dex-sp], . to . mg/kg iv) may stabilize cellular membranes and inhibit phospholipase, an active component of some pit viper toxins. polyvalent antivenin is necessary in many cases of pit viper envenomation, except in most cases of prairie rattlesnake (crotalus viridis viridis) envenomation in colorado. a recent study demonstrated no difference in outcome with or without the use of antivenin in cases of prairie rattlesnake envenomation. clinically, however, patients that receive antivenin are more comfortable and leave the hospital sooner than those that do not receive antivenin. the exact dose of antivenin is unknown in small animal patients. administer a dose of at least vial of antivenin to neutralize circulating venom. mix antivenin with a swirling, rather than a shaking motion, to prevent foaming. mix the antivenin with a -ml bag of . % saline, and then administer it slowly over a period of hours. pretreat animals with diphenhydramine ( . to mg/kg im) before the administration of antivenin, and then monitor the animal closely for clinical signs of angioneurotic edema, urticaria, tachyarrhythmias, vomiting, diarrhea, and weakness during the infusion. administration of antivenin into the bite site is relatively contraindicated and ineffective because uptake is delayed, and systemic effects are the more life-threatening. management of pit viper envenomation largely involves maintenance of normal tissue perfusion with intravenous fluids, decreasing patient discomfort with analgesia, and negating circulating venom with antivenin. hydrotherapy to the affected bite site with tepid water is often soothing to the patient. the empiric use of antibiotics is controversial but is recommended because of the favorable environment created by a snakebite (i.e., impregnation of superficial gram-positive bacteria and gram-negative bacteria from the mouth of the snake into a site of edematous necrotic tissue). administer amoxicillin-clavulanate ( . mg/kg po q h, or cephalexin, mg/kg po q h). also consider administration of nsaids (carprofen, . mg/kg po q h). monitor the patient closely for signs of local tissue necrosis and the development of thrombocytopenia and coagulopathies including dic (see management of disseminated intravascular coagulation). treat coagulopathies aggressively to prevent end-organ damage. coral snakes are characterized by brightly colored bands encircling the body, with red and black separated by yellow. "red on black, friend of jack; red on yellow, kill a fellow." types of coral snakes include the eastern coral, texas coral, and sonoran coral snakes. clinical signs of coral snake envenomation may include small puncture wounds, transient initial pain, muscle fasciculations, weakness, difficulty swallowing/dysphagia, ascending lower motor neuron paralysis, miotic pinpoint pupils, bulbar paralysis, respiratory collapse, and severe hemolysis. clinical signs may be delayed for as long as hours after the initial bite. immediate treatment with antivenin is necessary in cases of coral snake envenomation before the clinical signs become apparent, whenever possible. support respiration during paralysis with mechanical ventilation. secure the patient's airway with a cuffed endotracheal tube to prevent aspiration pneumonia. clinical signs will progress rapidly once they develop. rapid administration with antivenin is the mainstay of therapy in suspected coral snake envenomation. respiratory and cardiovascular support should occur with mechanical ventilation and intravenous crystalloid fluids. keep the patient warm and dry in a quiet place. turn the patient every to hours to prevent atelectasis and decubitus ulcer formation. maintain cleanliness using a urinary catheter and closed urinary collection system. perform passive range of motion and deep muscle massage to prevent disuse atrophy of limb muscles and function. treat aspiration pneumonia aggressively with broad-spectrum antibiotics (ampicillin, mg/kg iv q h, with enrofloxacin, mg/kg iv q h, and then change to oral once tolerated and the patient is able to swallow) for weeks past the resolution of radiographic signs of pneumonia, intravenous fluids, and nebulization with sterile saline and coupage chest physiotherapy. several weeks may elapse before a complete recovery. the adult black widow spider (latrodectus spp.) can be recognized by a red to orange hourglass-shaped marking on the underside of a globous, shiny, black abdomen. the immature female can be recognized by a colorful pattern of red, brown, and beige on the dorsal surface of the abdomen. adult and immature females are equally capable of envenomation. the male is unable to penetrate the skin because of its small size. black widow spiders are found throughout the united states and canada. black widow spider venom is neurotoxic and acts presynaptically, releasing large amounts of acetylcholine and norepinephrine. there appears to be a seasonal variation in the potency of the venom, lowest in the spring and highest in the fall. in dogs, envenomation results in hyperesthesia, muscle fasciculations, and hypertension. muscle rigidity without tenderness is characteristic. affected animals may demonstrate clinical signs of acute abdominal pain. tonic-clonic convulsions may occur but are rare. in cats, paralytic signs predominate and appear early as a ascending lower motor neuron paralysis. increased salivation, vomiting, and diarrhea may occur. serum biochemistry profiles often reveal significant elevations in creatine kinase and hypocalcemia. myoglobinemia and myoglobinuria can occur because of extreme muscle damage. management of black widow spider envenomation should be aggressive in the cat and dog, particularly when the exposure is known. in many cases, however, the diagnosis is made based on clinical signs, biochemical abnormalities, and lack of other apparent cause. antivenin (one vial) is available and should be administered after pretreatment with diphenhydramine. if antivenin is unavailable, administer a slow infusion of calcium-containing fluid such as lactated ringer's solution with calcium gluconate while carefully monitoring the patient's ecg. the small brown nonaggressive spider is characterized by a violin-shaped marking on the cephalothorax. the neck of the violin points toward the abdomen. brown spiders are found primarily in the southern half of the united states but have been documented as far north as michigan. the venom of the brown spider has a potent dermatonecrolytic effect and starts with a classic bull's-eye lesion. the lesion then develops into an indolent ulcer into dependent tissues promoted by complement fixation and influx of neutrophils into the affected area. the ulcer can take months to heal and often leaves a disfiguring scar. systemic reactions are rare but can include hemolysis, fever, thrombocytopenia, weakness, and joint pain. fatalities are possible. immediate management of an animal with brown spider envenomation is difficult because there is no specific antidote and because clinical signs may be delayed until necrosis of the skin and underlying tissues becomes apparent through the patient's fur to days after the initial bite. dapsone has been recommended at a dose of mg/kg for days. surgical excision of the ulcer may be helpful if performed in the early stages of wound appearance. glucocorticosteroids may be of some benefit if used within hours of the bite. the ulcer should be left to heal by second intention. deep ulcers should be treated with antibiotics. bufo toad species (b. marinus, aka cane toad, marine toad, giant toad; and the colorado river toad or sonoran desert toad b. alvarius) can be associated with severe cardiac and neurotoxicity if an animal licks its skin. the severity of toxicity depends largely on the size of the dog. toxins in the cane toad, b. marinus, include catecholamines and vasoactive substances (epinephrine, norepinephrine, serotonin, dopamine) and bufo toxins (bufagins, bufotoxin, and bufotenine), the mechanism of which is similar to cardiac glycosides. clinical signs can range from ptyalism, weakness, ataxia, extensor rigidity, opisthotonus, and collapse to seizures. clinical signs associated with b. alvarius toxicity are limited largely to cardiac dysrhythmias, ataxia, and salivation. the animal should have its mouth rinsed out thoroughly with tap water even before presentation to the veterinarian. if the animal is unconscious or actively seizing and cannot protect its airway, flushing the mouth is contraindicated. once an animal presents to the veterinarian, the veterinarian should place an intravenous catheter and monitor the patient's ecg and blood pressure. attempt seizure control with diazepam ( . mg/kg iv) or pentobarbital ( to mg/kg iv to effect). ventricular dysrhythmias can be controlled first with esmolol ( . mg/kg). if esmolol is ineffective, administer a longer-acting parenteral β-antagonist such as propranolol ( . mg/kg iv). ventricular tachycardia also can be treated with lidocaine ( to mg/kg iv, followed by to µg/kg/minute iv cri). case management largely depends on supportive care and treating clinical signs as they occur. monitor baseline acid-base and electrolyte balance because severe metabolic acidosis may occur that should be treated with intravenous fluids and sodium bicarbonate ( . to meq/kg iv). monitor ecg, blood pressure, and mentation changes closely. control seizures and cardiac dysrhythmias. eubig pa: bufo species intoxication: big toad, big problem, vet med ( ) lizards of the family hemodermatidae are the only two poisonous lizards in the world. they are found in the southwestern united states and mexico. the venom glands are located on either side of the lower jaw. because these lizards are typically lethargic and nonaggressive, bite wounds are rare. the lizards have grooved teeth that introduce the venom with a chewing motion as the lizard holds tenaciously to the victim. the majority of affected dogs are bitten on the upper lip, which is very painful. there are no proven first aid measures for bites from gila monsters or mexican bearded lizards. the lizard can be disengaged by inserting a prying instrument in between the jaws and pushing at the back of the mouth. the teeth of the lizard are brittle and break off in the wound. topical irrigation with lidocaine and probing with a needle will aid in finding and removing the teeth from the victim. bite wounds will bleed excessively. irrigate wounds with sterile saline or lactated ringer's solution, and place compression on the affected area until bleeding ceases. monitor the patient for hypotension. establish intravenous access, and administer intravenous fluids according to the patient's perfusion parameters. antibiotic therapy is indicated because of the bacteria in the lizard's mouth. because no antidote is available, treatment is supportive according to patient signs. the majority of musculoskeletal emergencies are the result of external trauma, most commonly from motor vehicle accidents. blunt trauma invokes injury to multiple organ systems as a rule, rather than an exception. because of this, massive musculoskeletal injuries are assigned a relatively low priority during the initial triage and treatment of a traumatized animal. perform a rapid primary survey and institute any lifesaving emergency therapies. adhere to a crash plan or the abcs of resuscitation (see initial emergency examination, management, and triage). although musculoskeletal injuries are assigned a relatively lower priority, the degree of recovery from these injuries and financial obligation for fracture repair sometimes becomes a critical factor in a client's decision whether to pursue further therapy. one of the most important deciding factors is the long-term prognosis for the patient to have a good quality of life following fracture repair. the initial management of musculoskeletal injuries is important in ensuring the best chance for maximal recovery with minimal complications after definitive surgical fracture repair. this is particularly important for open fractures, spinal cord compromise, multiple fractures, open joints, articular fractures, physeal fractures, and concomitant ligamentous or neurologic compromise (box - ). immediately after the initial primary survey of a patient, perform a more thorough examination, including an orthopedic examination. multiple injuries often are observed in the patient that falls from height (e.g., "high-rise syndrome"), motor vehicle accidents, gunshot wounds, and encounters with other animals (e.g., "big-dog-little-dog"). address the most life threatening injuries, and palliate musculoskeletal injuries until more definitive repair can be attempted when the patient is more stable. in animals with the history of potential for multiple injuries, search thoroughly and meticulously for areas of injury to the spinal column, extremities, and for small puncture wounds. helpful signs that can provide a clue as to an underlying injury include swelling, bruising, abnormal motion, and crepitus (caused by subcutaneous emphysema or bony fracture). if the patient is alert, look for areas of tenderness or pain. in unconscious or depressed patients, reexamine the patient after the patient becomes more mentally alert. injuries often are missed during the initial examination in obtunded patients because of the early response and attenuation of pain. unconscious or immobile patients must have radiographic examination of the spinal column following stabilization and support. palpate the skull carefully for obvious depressions or crepitus that may be associated with a skull fracture. localization of the injury can be determined by motion in abnormal locations, swelling caused by hemorrhage or edema, pain during gentle movement or palpation, deformity, angular change, or a significant increase or decrease in normal range of motion of bones and joints. perform a rectal examination in all cases to palpate for pelvic fractures and displacement. once the diagnosis of a fracture or luxation has been confirmed, look for any evidence of skin lacerations or punctures near the fracture site. in long-haired breeds, clipping the fur near the fracture site often is necessary to perform a thorough examination of the area. if any wounds are found, the fracture is classified as an open fracture until proven otherwise. in some cases, the open fracture is obvious, with a large section of bone fragment protruding through the skin. in other cases, the puncture wound may be subtle, with only a small amount of blood or pinpoint hole in the skin surface. characteristics observed with open fractures include bone penetration, fat droplets or marrow elements in blood coming from the wound, subcutaneous emphysema on radiographs, and lacerations in the area of a fracture. protect the patient from further injury or contamination of wounds. excessive palpation to intentionally produce crepitus is inappropriate because it causes severe patient discomfort and has the potential to cause severe soft tissue and neurologic injury at the fracture site. sedation and analgesia aids in making the examination more comfortable for the patient and allows localization of the injury and comparison with the opposite extremity. higher-quality radiographs can be performed to determine the extent of the injury when the animal is sedated adequately and pain is controlled. sedate the patient judiciously with analgesic drugs. opioid drugs work well for orthopedic pain, produce minimal cardiorespiratory depression, and can be reversed with naloxone if necessary. handle the fracture site gently to avoid causing further pain and soft tissue injury at the fracture site. rough or careless handling of a fracture site can cause a closed fracture to penetrate through the skin and become an open fracture. cover open fractures immediately to prevent contamination of the fracture with nosocomial infection from the hospital. administer a first-generation cephalosporin (cephalexin, mg/kg po q h, or cefazolin, mg/kg iv q h). the bandage also serves to control hemorrhage and prevent desiccation of the bones and surrounding soft tissue structures. leave the initial bandages in place until the patient's cardiorespiratory status has been determined to be stable and more definitive wound management can occur in a clean, preferably sterile location. examine the neurologic status and cardiovascular status of the limb before and after treatment. determine the vascular status of the limb by checking the color and temperature of the limb, the state of distal pulses, and the degree of bleeding from a cut nail bed. in patients with severe cardiovascular compromise and hypotension caused by hemorrhagic shock, the viability of the limb may be in question until the cardiovascular status and blood pressure are normalized. reduction of the fracture or straightening of gross deformities may return normal vascularity to the limb. when checking neurologic status, examine for motor and sensory function to the limb. swelling may increase pressure on the nerves as they run through osteofascial compartments, resulting in decreased sensory or motor function, or neurapraxia. diminished function often returns to normal once the swelling subsides. serial physical examinations in the patient and response to initial stabilization therapy can lead to a higher index of suspicion that more occult injuries are present, such as a diaphragmatic hernia, perforated bowel, lacerated liver or spleen, or uroabdomen. to prevent ongoing trauma, reduce any fracture and then stabilize the site above and below the fracture. a modified robert jones splint or bandage often works well for fractures emergency management of specific conditions involving the distal extremities. fractures of the humerus or femur are difficult to immobilize without the use of spica or over-the-hip coaptation splints to prevent mobility. inappropriate bandaging of humerus or femur fractures can result in a fulcrum effect and worsen the soft tissue and neurologic injuries. further displacement of vertebral bodies or luxations can cause cord compression or laceration such that return to function becomes impossible. immediately place any patient with a suspected spinal injury on a flat surface, and tape down the animal to prevent further movement until the spine has been cleared by a minimum or two orthogonal radiographic views (lateral and ventrodorsal views performed as a cross-table x-ray technique). wounds associated with musculoskeletal trauma are common and include injury to the bones, joints, tendons, and surrounding musculature (box - ). major problems associated with these cases are the presence of soft tissue trauma that makes wound closure hazardous or impossible, because of the risk of infection. chronic deep infection of traumatized wounds can cause delayed healing and sequestrum to develop, particularly if there is avascular bone or cartilage within the wound. in the early management of an open fracture, the areas should be splinted without pulling any exposed bone back into the soft tissue. the wound should not be probed or soaked, as nosocomial bacteria and other external contaminants can be introduced into the wound, leading to severe infection. because of the risk of actually causing infection, probing, flushing, or replacing tissues back into the wound should be performed at the time of formal debridement when the patient is physiologically stable. immediate bactericidal antibiotic therapy with a first-generation cephalosporin should be started immediately to obtain adequate concentrations of antibiotics at the fracture site. the duration of antibiotic therapy should ideally be limited to - days to prevent the risk of superinfection. treatment of open musculoskeletal injury involves three considerations: initial inspection and wound debridement, stabilization and repair, and wound bandaging. emergency care when associated with a fracture, wound is created from the inside out by penetration of bone fragments through the skin or from a low-energy gunshot. simple or comminuted fracture pattern good stability of the two main bone segments treatment and prognosis are good and similar to those of a closed injury if wound is debrided and stabilized within to hours. when associated with a fracture, wound is created from the outside in. major deep injury with considerable soft tissue stripping from bone and muscle damage simple or comminuted fracture pattern prognosis is good if wound is debrided within hours of injury and provided rigid stabilization with a bone plate or external fixator. results from major external force severe damage and necrosis of skin, subcutaneous tissue, muscle, nerve, bone, tendon, and arteries soft tissue damage may vary from crush injury to shearing injury associated with bite wounds or low-speed automobile accidents. requires immediate and delayed sequential debridement and rigid external fixation can require prolonged healing times guarded prognosis initial inspection and wound debridement include the following steps: . after the patient's cardiovascular status has been stabilized and it has been determined that it can withstand anesthesia, place the animal under general anesthesia and remove the temporary splint. . keeping the wound covered, shave the surrounding fur. . remove the covering and then place sterile lubricant jelly over the wound. shave the fur to the edges of the wound margin. . wash away any entrapped fur and the lubricant jelly. . complete an antiseptic scrub of the surrounding skin. . if the wound is a small puncture (e.g., gunshot pellets or bites), probe the wound with a sterile hemostat. do a thorough debridement if tissues deep to the hole are cavitated. if not deep, create a hole for drainage. . flush the wound with a physiologic solution (lactated ringer's solution is preferred). . debride the wound from outward to inward. cut away damaged areas of skin and deeper tissues to open up underlying cavitations and tissue injury. . continuously irrigate with warm physiologic solution (lactated ringer's solution is preferred). the stream must be strong enough to flush debris out of the bottom of the wound. to accomplish this, attach a -gauge needle to a -ml syringe (will deliver psi). excise any obviously devitalized tissue. . do not remove any bone fragments that are firmly attached to soft tissue. do not cut into healthy soft tissue to find bullet or bone fragments, unless the bullet can cause injury to joints or nerve tissue. . do a primary repair of tendons and nerves if the wound is type i and recent (within hours of the initial injury). if the wound is too severe or if there is obvious infection, tag the ends of the tendons and nerves for later repair. it is best to stabilize and repair open fractures as soon as the patient's cardiovascular and respiratory status can tolerate general anesthesia, provided that adequate stabilization is possible. if this is not possible because of the level of experience of the surgeon or the lack of necessary equipment, it is best to perform wound management and place a temporary splint until definitive repair can be performed. wound bandaging is discussed in the section on bandaging techniques. structural injuries to the joints are common and can involve both ligaments and articular cartilage injuries. cartilage does not heal well; therefore, injuries involving articular cartilage can lead to a significant loss of function and degenerative joint disease (osteoarthritis). cartilage injuries that are superficial evoke a short-lived enzymatic and metabolic response that does not stimulate enough cellular growth to repair the defect. superficial lesions remain as defects but do not progress to chondromalacia or osteoarthritis. deep cartilage lacerations that extend to subchondral bone produce an exuberant healing response from the cells of the underlying cartilage. in many cases, this material undergoes degeneration and leads to osteoarthritis. impact injuries to surface cartilage can cause chondrocyte and underlying bone injury. these lesions rapidly progress to osteoarthritis; however, they may be totally or partially reversible. treatment of grade i injuries requires short-term coaptation splints and has a good prognosis. grade ii injuries require surgical treatment with a suture stent and consistent postoperative coaptation splints to heal and maintain good function. healing of grade iii injuries often is a problem, and suture stents or surgical reapproximation may be indicated. failure to immobilize joints that are frequently flexed (elbow and stifle) can result in late complications of ligament repair. ligamentous injuries of joints, particularly the collateral ligaments of the stifle, elbow, and hock, and carpal hyperextension injuries are commonly missed and may require surgical fixation, including arthrodesis (box - ). fractures in immature animals differ from those in adults in that young puppies and kittens have a great ability to remodel bone. remodeling is dependent on the age of the patient and the location of the fracture. the younger the puppy or kitten and the closer the fracture to the epiphysis or growth plate, the greater the potential for remodeling and the development of angular limb deformities. remodeling occurs more effectively in longlimbed breeds of dogs than in short-limbed breeds. fractures through the growth plate of immature animals may potentially cause angular limb deformities, joint dislocations or incongruity, and osteoarthritis. this form of injury is commonly observed in the distal ulnar growth plate and the proximal and distal radial growth plates. high-rise syndrome in cats is seen in cats that fall from a height usually greater than feet. it occurs most frequently in high-rise buildings in urban areas where cats lie on window ledges and suddenly fall out the window. the most common lesions observed in cats that fall from heights are thoracic injuries (rib and sternal fractures, pneumothorax, and pulmonary contusions) and facial and oral trauma (lip avulsions, mandibular symphyseal fractures, fractures of the hard palate, and maxillary fractures). limb and spinal cord fractures and luxations, radius and ulna fractures, abdominal trauma, urinary tract trauma, and diaphragmatic hernias are also common. the injuries sustained are often found in combination, rather than as an isolated injury of one area of the body. follow the mnemonic a crash plan when managing a cat suffering from high-rise syndrome, treating the animal immediately for shock. following cardiovascular and respiratory stabilization, evaluate thoracic and abdominal radiographs, including those of the spine. evaluate the bladder closely, making sure that the cat is able to urinate effectively. examine the hard palate, maxilla, and mandibular symphysis for fractures. palpate the pelvis and carefully manipulate all limbs to examine for fractures or ligamentous injuries. finally, perform a complete neurologic examination. patients that fall less than five stories often have a more guarded prognosis than patients that fall from higher levels. sometimes the owner witnesses the ingestion of a foreign body during play, such as throwing a stick or fetching a ball. cats tend to play with string or thread that becomes caught around the base of the tongue. in many cases, however, ingestion of the foreign object is not witnessed, and diagnosis is made based on clinical signs and physical examination. foreign bodies lodged in the oral cavity often cause irritation and discomfort, including difficulty breathing and difficulty swallowing. often, an animal paws at its mouth in an attempt to dislodge a stick or bones wedged across the roof of the mouth. irritation, inability to close the mouth, and blockage of the orpharynx can result in excessive drooling. the saliva may appear blood-tinged due to concurrent soft tissue trauma (figs - and - ) . obstruction of the glottis by a foreign body (e.g., tennis ball or toy) can result in cyanosis secondary to an obstructed airway and hypoxemia. in many cases, the object is small enough to enter the larynx but too large to be expelled. if a foreign object is lodged in the mouth for more than several days, halitosis and purulent discharge may be present. many animals are anxious at the time of presentation and may require sedation or a light plane of anesthesia to remove the foreign object. the animal may bite personnel and may have bitten the owner during his or her attempt to remove the object from the mouth en route to the hospital. propofol ( mg/kg iv) or a combination of propofol with diazepam ( . - mg/kg iv) is an excellent combination for a light plane of anesthesia. exercise caution when anesthetizing a patient with a ball lodged in the airway, as further compromise of respiratory function may occur and cause worsening of the hypoxemia. before inducing anesthesia, assemble all supplies necessary to remove the object. make sure that rigid towel clamps, sponge forceps, and bone forceps are on hand, because the foreign object is often very slippery with saliva. hemostats and carmalts may slip and not be useful in the removal of the foreign object. place a peripheral intravenous catheter to secure vascular access prior to anesthetic induction. have available the supplies necessary for an emergency tracheostomy, if the foreign object cannot be removed by usual methods. induce a light plane of anesthesia and then grasp the object with the sponge forceps or towel clamps, and extract. monitor the cardiorespiratory status of the animal at all times during the extraction process. if you are unable to remove the object, and if severe respiratory distress, including cyanosis, bradycardia, or ventricular dysrhythmias, develop, perform a tracheostomy distal to the site of obstruction. once the foreign body has been removed, administer supplemental flow-by oxygen until the animal awakens. if laryngeal edema or stridor on inspiration is present, administer a dose of dexamethasone sodium phosphate ( . mg/kg iv, im, sq) to decrease inflammation. the patient should be carefully monitored for hours, because noncardiogenic pulmonary edema can develop secondary to airway obstruction. esophageal foreign bodies pose a serious medical emergency. it is helpful if the owner witnessed ingestion of the object and noted rapid onset of clinical signs. in many cases, however, ingestion is not witnessed, and the diagnosis must be made based on clinical signs, thoracic radiographs, and results of a barium swallow. the most common clinical signs are excessive salivation with drooling, gulping, and regurgitation after eating. many animals will make repeated swallowing motions. some animals exhibit a rigid "sawhorse" stance, with reluctance to move immediately after foreign body ingestion and esophageal entrapment. after completing a physical examination, evaluate cervical and thoracic radiographs to determine the location of the esophageal obstruction. esophageal foreign objects are lodged most commonly at the base of the heart, the carina, or just orad to the lower esophageal sphincter. if the object has been lodged for several days, pleural effusion and pneumomediastinum may be present secondary to esophageal perforation. endoscopy is useful for both diagnosis and removal of the foreign object; however, it is invasive and requires general anesthesia ( fig. - ) . remove foreign objects lodged in the esophagus with a rigid or flexible endoscope after the patient has been placed under general anesthesia. evaluate the integrity of the esophagus both before and after removal of the material because focal perforation or pressure necrosis can be present. necrosis of the mucosa and submucosa of the esophagus often leads to stricture formation or perforation. attempt to retrieve the object with a flexible fiberoptic endoscope if available. rigid tube endoscopy can also be performed. in many cases, smooth objects that cannot be easily grasped can be pushed into the stomach and allowed to dissolve or may be removed by gastrotomy. if the foreign body is firmly lodged in the esophagus and cannot be pulled or pushed into the stomach, or if perforation has already occurred, the prognosis for return to function without strictures is not favorable. in such cases, referral to a surgical specialist is recommended for esophagostomy or esophageal resection. after removal of the object, carefully examine the esophagus and then administer gastroprotectant agents (famotidine, . mg/kg po bid; sucralfate slurry, . - . g/dog) for a minimum of to days. to rest the esophagus, the patient should receive nothing per os (npo) for to hours. if esophageal irritation or erosion is moderate to severe, a percutaneous gastrotomy tube should be placed for feeding until the esophagus heals. perform repeat endoscopy every days to evaluate the healing process and to determine whether stricture formation is occurring. persistent vomiting immediately or soon after eating is often associated with a gastric foreign body. in some cases, the owner knows that the patient has ingested a foreign body of some kind. in other cases, continued vomiting despite lack of response to conservative treatment (npo, antiemetics, gastroprotectant drugs) prompts further diagnostic procedures, including abdominal radiographs and bloodwork. obstruction to gastric outflow and vomiting of hydrochloric acid often cause a hypochloremic metabolic acidosis. radiopaque gastric foreign bodies may be observed on plain films. radiolucent cloth material may require a barium series to delineate the shape and location of the foreign body ( fig. - ) . treatment consists of removal with flexible endoscopy or a simple gastrotomy. most animals with uncomplicated gastric foreign bodies are relatively healthy, but any metabolic and electrolyte abnormalities should be corrected prior to anesthesia and surgery. small intestinal obstruction can be caused by foreign bodies, tumors, intussusception, volvulus, or strangulation within hernias. regardless of the cause, clinical signs of small intestinal obstruction depend on the location and degree of obstruction, and whether the bowel has perforated. clinical signs associated with a high small intestinal obstruction are usually more severe and more rapid in onset compared with partial or complete obstruction of the jejunum or ileum. complete obstructions that allow no fluid or chyme to pass are worse than partial obstructions, which can cause intermittent clinical signs interspersed with periods of normality (table - ). the most common clinical signs associated with a complete small intestinal obstruction are anorexia, vomiting, lethargy, depression, dehydration, and sometimes abdominal pain. early clinical signs may be limited to anorexia and depression, making a diagnosis challenging unless the owner has a suspicion that the animal ingested some kind of foreign object. obstructions cranial to the common bile duct and pancreatic papillae lead to vomiting of gastric contents, namely hydrochloric acid, and a hypochloremic metabolic alkalosis. obstructions caudal to the common bile duct and pancreatic papillae result in loss of other electrolytes and sometimes mixed acid-base disorders. eventually, all animals with small intestinal obstruction vomit and have fluid loss into dilated segments of bowel, leading to dehydration and electrolyte abnormalities. increased luminal pressure causes decreased lymphatic drainage and bowel edema. the bowel wall eventually becomes ischemic and may rupture. linear foreign bodies should be suspected in any vomiting patient, particularly cats. string or thread often is looped around the base of the tongue and can be visualized in many cases by a thorough oral examination. to look properly under the tongue, grasp the top of the animal's head with one hand, and pull the lower jaw open with the index finger of the opposite hand while pushing up the thumb simultaneously on the tongue in between the intermandibular space. thread and string can be observed lying along the ventral aspect of the tongue. in some cases, if a linear foreign body is lodged very caudally, it cannot be visualized without heavy sedation or anesthesia. linear foreign bodies eventually cause bowel obstruction and perforation of the intestines along the mesenteric border. the foreign material (e.g., string, thread, cloth, pantyhose) becomes lodged proximally, and the intestines become plicated as the body attempts to push the material caudally through the intestines ( fig. - ) . continued peristalsis eventually causes a sawing motion of the material and perforation of the mesenteric border of the intestines. once peritonitis occurs, the prognosis is less favorable unless prompt and aggressive treatment is initiated. reevaluate any patient that does not respond to conservative symptomatic therapy, performing a complete blood count, serum biochemical panel (including electrolytes), and abdominal radiographs. intestinal masses may be palpable on physical examination and are often associated with signs of discomfort or pain when palpating over the mass. radiography and abdominal ultrasound are the most useful diagnostic aids. plain radiographs may be diagnostic when the foreign object is radiodense or there is characteristic dilation or plication of bowel loops. as a rule of thumb, the width of a loop of small bowel should be no larger than twice the width of a rib. diagnosis of small intestinal obstruction or ileus can be based on the appearance of stacking loops of dilated bowel. comparison of the width of the bowel with the width of a rib is often performed. with mild dilation, the bowel width is three to four times the rib width; with extensive dilation, five to six times the rib width ( fig. - ) . in cases of linear foreign bodies, c-areas (comma-shaped areas) of gas trapped in the plicated bowel will appear stacked on one another. blunt, wedge-shaped areas of gas or square linear areas of gas adjacent to a distended bowel loop are characteristic of a foreign body lodged in the intestine. contrast radiography is indicated when confirmation of the suspected diagnosis is necessary and ultrasonography is not available. contrast material may outline the object or abruptly stop orad to the obstruction. the definitive treatment of any type of small intestinal foreign body is surgical removal. linear foreign bodies sometimes pass, but they should never be left untreated in a patient that is demonstrating clinical signs of inappetence, vomiting, lethargy, and dehydration. the timing of surgery is critical because the risk of intestinal perforation increases with time. prior to surgery, correct any acid-base and electrolyte abnormalities with intravenous fluid therapy. administer broad-spectrum antibiotics. perform an enterotomy or intestinal resection and anastomosis as soon as possible once the patient's acid-base and electrolyte status have been corrected. clinical signs of a foreign body in the large bowel are usually nonexistent. in most cases, if a foreign object has passed successfully through the small bowel, it will pass through the large bowel without incident unless bowel perforation and peritonitis occur. penetrating foreign bodies such as needles often cause localized or generalized peritonitis, abdominal pain, and fever. hematochezia may be present if the foreign object causes abrasion of the rectal mucosa. symptomatic patients should have abdominal radiographs performed. colonoscopy or exploratory laparotomy should be performed if survey radiographs are suggestive of a large intestinal obstruction or perforation. in most cases, large intestinal foreign bodies will pass without incident. surgery is required to treat perforations, peritonitis, or abscesses. emergency care figure - : after minutes, the barium has stopped moving and has reached a blunt, intraluminal intestinal foreign body. note that barium appears wedge-shaped or square at the site of the foreign body. foreign bodies in the rectum and anus often are the result of ingestion of bones, wood material, needles, and thread, or malicious external insertion. often the material can pass through the entire gastrointestinal tract and then get stuck in the anal ring. clinical signs include hematochezia and dyschezia with straining to defecate. diagnosis is made by visual examination of the item in the anus, or by careful digital palpation after heavy sedation or short-acting general anesthesia. radiography is helpful in locating needles that have penetrated the rectum and lodged in the perirectal or perinatal tissues. treatment consists of careful removal of the needle digitally or surgically. intussusception is the acute invagination of one segment of bowel (the intussusceptum) into another (the intussuscipiens). the proximal segment always invaginates into the distal segment of bowel. intussusception most commonly occurs in puppies and kittens less than year of age but can occur in an animal of any age with hypermotility of the small bowel, gastrointestinal parasites, and severe viral or bacterial enteritis. intussusception occurs primarily in the small bowel in the jejunum, ileum, and ileocolic junction. clinical signs include vomiting, abdominal discomfort, and hemorrhagic diarrhea. usually, hemorrhagic diarrhea is the first noticeable sign, and in puppies, may be due to parvoviral enteritis, with secondary intussusception. usually, the obstruction is partial with mild clinical signs. more serious clinical signs develop as the obstruction becomes more complete. differential diagnoses include hemorrhagic gastroenteritis, parvoviral enteritis, gastrointestinal parasites, intestinal foreign body, bacterial enteritis, and other causes of vomiting and diarrhea. the diagnosis of intussusception is often made based on palpation of a sausage-shaped firm, tubular structure in the abdomen accompanied by clinical signs and abdominal pain. plain radiographs may demonstrate segmental or generalized dilated segments of bowel, depending on the duration of the problem. ultrasonographs of the palpable mass resemble the layers of an onion, with hyperechoic intestinal walls separated by less echogenic edema. treatment consists of correction of the patient's acid-base and electrolyte abnormalities with intravenous fluids and surgical reduction or removal of the intussusception with resection and anastomosis. although enteroplication has been suggested, the technique has fallen out of favor because of the increased risk of later obstruction. the primary cause of intestinal inflammation and hypermotility must be identified and corrected. gastric dilatation can occur with or without volvulus in the dog. gastric dilatationvolvulus (gdv) occurs primarily in large-and giant-breed dogs with deep chests, such as the great dane, labrador retriever, saint bernard, german shepherd dog, gordon and irish setters, standard poodle, bernese mountain dog, and bassett hound. the risk of gdv increases with age; however, it can be seen in dogs as young as months. deep, narrow-chested breeds are more likely to develop gdv than dogs with broader chests. the overall mortality for surgically treated gastric dilatation-volvulus ranges from % to %, with most deaths occurring in patients that required splenectomy and partial gastrectomy. clinical signs of gdv include abdominal distention, unproductive vomiting or retching, lethargy, weakness, sometimes straining to defecate, and collapse. the owner may think that the animal is vomiting productively because of the white foamy froth (saliva) that is not able to pass into the twisted stomach. in some cases, there is a history of the dog's being fed a large meal or consuming a large quantity of water prior to the onset of clinical signs. instruct the owner of any patient with a predisposition for and clinical signs of gdv to transport the animal to the nearest veterinary facility immediately. physical examination often reveals a distended abdomen with a tympanic area on auscultation. in dogs with very deep chests, it may be difficult to appreciate abdominal distention if the stomach is tucked up under the rib cage. depending on the stage of shock, the patient may have sinus tachycardia with bounding pulses, cardiac dysrhythmias with pulse deficits, or bradycardia. the mucous membranes may appear red and injected or pale with a prolonged capillary refill time. the patient may appear anxious and attempt to retch unproductively. if the patient is nonambulatory at the time of presentation, the prognosis is more guarded. the definitive diagnosis of gdv is based on clinical signs, physical examination findings, and radiographic appearance of gas distention of the gastric fundus with dorsocranial displacement of the pylorus and duodenum (the so-called "double-bubble" or "popeye arm" sign) ( fig. - ) . in simple gastric dilatation without volvulus, there is gas distention of the stomach with anatomy appearing normal on radiography. with "food bloat," or gastric distention from overconsumption of food, ingesta is visible in the distended stomach ( fig. - ) . as soon as a patient presents with a possible gdv, place a large-bore intravenous catheter in the cephalic vein(s) and assess the patient's ecg, blood pressure, heart rate, capillary refill time, and respiratory function. obtain blood samples for a complete blood count, serum biochemistry profile, immediate lactate measurement, and coagulation tests before taking any radiographs. rapidly infuse a colloid (hetastarch or oxyglobin, ml/kg iv bolus) along with shock volumes of a crystalloid fluid (up to ml/kg/hour) (see section on shock). monitor perfusion parameters (heart rate, blood pressure, capillary refill time, and ecg) and titrate fluid therapy according to the patient's response. the use of short-acting glucocorticosteroids is controversial. glucocorticosteroids may help stabilize cellular membranes and decrease the mechanisms of ischemia-reperfusion injury, but no detailed studies have proved them to be beneficial versus not using glucocorticosteroids in the patient with gdv. attempt gastric decompression, either with placement of an orogastric tube or by trocharization. to place an orogastric tube, position the distal end of the tube at the level of the patient's last rib ( fig. - ) and place it adjacent to the animal's thorax; then put a piece of tape around the tube where it comes out of the mouth, once it is in place. put a roll of -inch tape in the patient's mouth behind the canine teeth and then secure the roll in place by taping the mouth closed around the roll of tape. lubricate the tube with lubricating jelly and slowly insert the tube through the center of the roll of tape into the stomach. the passing of the tube does not rule out volvulus. in some cases, the front legs of the patient need to be elevated, and the caudal aspect of the patient lowered (front legs standing on a table with back legs on the ground) to allow gravity to pull the stomach down to allow the tube to pass. once the tube has been passed, air within the stomach is relieved, and the stomach can be lavaged. the presence of gastric mucosa or blood in the efflux from the tube makes the prognosis more guarded. if an orogastric tube cannot be passed, clip and aseptically scrub the patient's lateral abdomen and then insert -gauge over-the-needle catheter. "pinging" the animal's side with simultaneous auscultation allows determination of the location that is most tympanic-that is, the proper location for catheter insertion. once intravenous fluids have been started in the animal, take a right lateral abdominal radiograph to document gdv. if no volvulus is present, the owner may elect for more conservative care, and the animal should be monitored in the hospital for a minimum of hours. because some cases of gdv intermittently twist and untwist, the owner should be cautioned that although the stomach is not twisted at that moment, a volvulus can occur at any time. if radiographs demonstrate food bloat, induce emesis (apomorphine, . mg/kg iv) or perform orogastric lavage under general anesthesia. documentation of gastric dilatation-volvulus constitutes a surgical emergency. figure - : example of "food bloat" with severe gastric distention caused by overconsump-following diagnosis of gdv, continue administration of intravenous fluids. serum lactate measurements greater than . mmol/l are associated with an increased risk of gastric necrosis, requirement for partial gastrectomy, and increased mortality. administer fresh frozen plasma ( ml/kg) to patients with thrombocytopenia or prolonged pt, activated partial thromboplastin time (aptt), or activated clotting time (act). cardiac dysrhythmias, particularly ventricular dysrhythmias, are common in cases of gdv and are thought to occur secondary to ischemia and proinflammatory cytokines released during volvulus and reperfusion. lidocaine ( - mg/kg followed by mcg/kg/minute iv cri) can be used to treat cardiac dysrhythmias preemptively that are associated with ischemia-reperfusion injury, or administration can be started when ventricular dysrhythmias are present. correct any electrolyte abnormalities, including hypokalemia and hypomagnesemia. the use of nonsteroidal antiinflammatory drugs (flunixin meglumine, carprofen, ketoprofen) that can potentially decrease renal perfusion and predispose to gastric ulcers is absolutely contraindicated. administer analgesic drugs (fentanyl, µ/kg iv bolus, followed by - µ/kg/hour iv cri; or hydromorphone, . mg/kg iv) before anesthetic induction. after carrying out a balanced anesthesia protocol, the patient should be taken immediately to surgery for gastric derotation and gastropexy. postoperatively, assess the patient's ecg, blood pressure, platelet count, coagulation parameters, and gastric function (see section on rule of twenty). if no resection is required, the animal can be given small amounts of water beginning hours after surgery. depending on the severity of the patient's condition, small amounts of a bland diet can be offered to hours postoperatively. continute supportive care with analgesia and crystalloid fluids until the patient is able to tolerate oral analgesic drugs (tramadol, - mg/kg po q - h). once the patient is ambulatory and able to eat and drink on its own, it can be released from the hospital; instruct the owner to feed the animal multiple small meals throughout the day for the first week. when the intestines twist around the root of the mesentery, a small intestinal or mesenteric volvulus occurs. the problem is most common in the young german shepherd dog, although it has been observed in other large and giant breeds. predisposing factors include pancreatic atrophy, gastrointestinal disease, trauma, and splenectomy. clinical signs of mesenteric volvulus include vomiting, hemorrhagic diarrhea, bowel distention, acute onset of clinical signs of shock, abdominal pain, brick-red mucous membranes (septicemia), and sudden death. diagnosis is based on an index of suspicion and the presence of clinical signs in a predisposed breed. plain radiographs often reveal grossly distended loops of bowel in a palisade gas pattern. in some dogs, multiple, tear-drop-shaped, gas-filled loops appear to rise from a focal point in the abdomen. usually, massive distention of the entire small bowel is observed ( fig. - ) . the presence of pneumoperitoneum or lack of abdominal detail secondary to the presence of abdominal fluid is characteristic of bowel perforation and peritonitis. in a patient with mesenteric volvulus, immediate aggressive action is necessary for the animal to have any chance of survival. treatment consists of massive volumes of iv crystalloid and colloid fluids (see section on iv therapy), broad-spectrum antibiotics (ampicillin, mg/kg iv qid, with enrofloxacin, mg/kg iv once daily), and surgical correction of the bowel. because of the massive release of proinflammatory cytokines, bacterial translocation, and ischemia, treatment for shock is of paramount importance (see sections on rule of twenty and shock). prognosis for any patient with mesenteric volvulus is poor. obstipation (obstructive constipation) is most common in the older cat. in cases of simple constipation, rehydrating the animal with intravenous fluids and stool softeners is often volvulus. this consistutes an immediate surgical emergency, and the prognosis is often poor. this condition is most common in young german shepherd dogs, but can be observed in any breed. sufficient for it to regain the ability to have a bowel movement. obstipation, however, is caused by adynamic ileus of the large bowel that eventually leads to megacolon. affected cats usually are anorectic, lethargic, and extremely dehydrated. treatment consists of rehydration with intravenous crystalloid fluids, correction of electrolyte abnormalities, enemas, and promotility agents such as cisapride ( . mg/kg po q - h). the use of phosphate enemas in cats is absolutely contraindicated because of the risk of causing acute, fatal hyperphosphatemia. in many cases, the patient should be placed under general anesthesia and manual deobstipation is performed with warm water soapy enemas and a gloved finger to relieve and disimpact the rectum. stool softeners such as lactulose and docusate stool sofener (dss) may also be used. predisposing causes of obstipation such as narrowing of the pelvic canal, perineal hernia, and tumors should be ruled out. adenocarcinoma is the most common neoplasm of the gastrointestinal tract that causes partial to complete obstruction. adenocarcinomas tend to be annular and constricting, and they may cause progressive obstruction of the lumen of the small or large bowel. siamese cats tend to have adenocarcinomas in the small intestine, whereas in dogs, the tumor tends to occur in the large intestine. clinical signs of adenocarcinoma are both acute and chronic and consist of anorexia, weight loss, and progressive vomiting that occur over weeks to months. effusion may be present if metastasis to peritoneal surfaces has occurred. diagnosis is based on clinical signs and physical examination findings of a palpable abdominal mass, radiographic evidence of an abdominal mass and small or large intestinal obstruction, or ultrasonographic evidence of an intestinal mass. treatment consists of surgical resection of the affected bowel segment. the prognosis for long-term survival ( - months) is good if the mass is completely resected and if other clinical signs of cachexia or metastasis are observed at the time of diagnosis. median survival is to weeks if metastasis to lymph nodes, liver, or the peritoneum are absent at the time of diagnosis. in dogs, the prognosis is more guarded. leiomyoma and leiomyosarcoma are tumors that can cause partial or complete obstruction of the bowel. clinical signs are often referred to progressive anemia, including weakness, lethargy, inappetence, and melena. hypoglycemia can be observed as a paraneoplastic syndrome, or due to sepsis and peritonitis secondary to bowel perforation. leiomyomas are most commonly observed at the ceco-colic junction or in the cecum. surgical resection and anastomosis is usually curative, and has a favorable prognosis. incarceration of a loop of bowel into congenital or acquired defects in the body wall can cause small bowel obstruction. pregnant females and young animals with congenital hernias are most at risk. rarely, older animals with perineal hernias and animals of any age with traumatic hernias can be affected. clinical signs are consistent with a small intestinal obstruction: anorexia, vomiting, lethargy, abdominal pain, and weakness. diagnosis is often made based on physical examination of a reducible or nonreducible mass in the body wall. hernias whose contents are reducible are usually asymptomatic. treatment consists of supportive care and rehydration, administration of broad-spectrum antibiotics, and surgical correction of the body wall hernia. in some cases, intestinal resection and anastomosis of the affected area is necessary when bowel ischemia occurs. the potential for bowel perforation should be suspected whenever there is any penetrating injury (knife, gunshot wound, bite wound, stick impalement) of the abdomen. injuries that result in bowel ischemia and rupture can also occur secondary to nonpenetrating blunt emergency care trauma or shear forces (e.g., big dog-little dog/cat). perforation of the stomach and small and large intestines can occur with use of nonsteroidal antiinflammatory drugs. diagnosis of bowel perforation first depends on the alertness to the possibility that the bowel may have been perforated or penetrated. as a general rule, all penetrating injuries of the abdomen should be investigated by exploratory laparotomy. diagnostic peritoneal lavage (dpl) can be performed; however, early after penetrating injury of the bowel, dpl may be negative or nondiagnostic until peritonitis develops. whenever any patient with blunt or penetrating abdominal trauma does not respond to initial fluid therapy, or responds and then deteriorates, the index of suspicion for bowel injury should be raised. the findings of pneumoperitoneum on abdominal radiographs or of intracellular bacteria, extracellular bacteria, bile pigment, bowel contents, and cloudy appearance of fluid obtained by abdominocentesis or diagnostic peritoneal lavage fluid (see sections on abdominocentesis and diagnostic peritoneal lavage) warrant immediate surgical exploration. treatment largely consists of stabilizing the patient's cardiovascular and electrolyte status with intravenous fluids, administration of broad-spectrum antibiotics, and definitive surgical exploration and repair of injured structures. prolapse of the rectum is observed most frequently secondary to parasitism and gastrointestinal viral infections in young puppies and kittens with chronic diarrhea. older animals with rectal prolapse often have an underlying problem such as a tumor or mucosal lesion that causes straining and dyschezia. the diagnosis of a rectal prolapse is made based on physical examination findings. the diagnosis of rectal prolapse is sometimes difficult to distinguish from small intestinal intussusception. in rare cases, the intussusception can invaginate through the large bowel, rectum, and anus. the two entities are distinguished from one another by inserting a lubricated thermometer or blunt probe into the cul-de-sac formed by the junction of the prolapsed mucosa and mucocutaneous junction at the anal ring. inability to insert the probe or thermometer indicates that the rectal mucosa is prolapsed. passage of the probe signifies that the prolapsed segment is actually the intussusceptum. treatment can be performed easily if the prolapse is acute and the rectal mucosa is not too irritated or edematous. the presence of severely necrotic tissue warrants surgical intervention. to reduce an acute rectal prolapse, after placing the patient under general anesthesia, lubricate the prolapsed tissue and gently push it back into the rectum, using a lubricated syringe or syringe casing. apply a loose purse-string suture, leaving it in place for a minimum of hours. de-worm the patient and administer stool softeners. if a rectal prolapse cannot be reduced, or if the tissue is nonviable, surgical intervention is warranted. in patients in which viable tissue does not stay reduced with a purse-string suture, a colopexy can be performed during a laparotomy. first, place tension on the colon to reduce the prolapse, and then suture the colon to the peritoneum of the lateral abdominal wall with two to three rows of - or - monofilament suture material. if the prolapsed tissue is nonviable, it must be amputated. place four stay sutures at -degree intervals through the wall of the prolapse at the mucocutaneous junction. resect the prolapse distal to the stay sutures and then reestablish the rectal continuity by suturing the seromuscular layers together in one circumferential line and the mucosal layers together in the other. replace the suture incision into the anal canal. following surgery, de-worm the patient and administer a stool softener and analgesic drugs. avoid using thermometers or other probes in the immediate postoperative period because they may disrupt suture lines. acute gastritis may be associated with a variety of clinical conditions, including oral hemorrhage, ingestion of highly fermentable nondigestable foods or garbage, toxins, foreign bodies, renal or hepatic failure, inflammatory bowel disease, and bacterial and viral infections. diarrhea often accompanies or follows acute gastritis. hemorrhagic gastroenteritis often occurs as a shock-like syndrome with a rapidly rising hematocrit level. clinical signs of gastritis include depression, lethargy, anterior abdominal pain, excessive water consumption, vomiting, and dehydration. differential diagnosis of acute gastritis includes pancreatitis, hepatic or renal failure, gastrointestinal obstruction, and toxicities (box - ). the diagnosis is often a diagnosis of exclusion of other causes (see preceding text). a careful and thorough examination of the vomitus may be helpful in arriving at a diagnosis. a complete blood count, serum biochemistry profile including amylase and lipase, parvovirus test (in young puppies), fecal flotation and cytology, abdominal radiographs (plain and/or contrast studies), and abdominal ultrasound may be warranted to rule out other causes of acute vomiting. while diagnostic tests are being performed, treatment consists of withholding all food and water for a minimum of hours. after calculating the patient's degree of dehydration, administer a balanced crystalloid fluid to normalize acid-base and electrolyte status. control vomiting with antiemetics such as metoclopramide, prochlorperazine, chlorpromazine, dolasetron, and ondansetron (table - ). if vomiting is accompanied by diarrhea, administer broad-spectrum antibiotics (cefazolin, mg/kg iv q h, with metronidazole, mg/kg iv q h; or ampicillin, mg/kg iv q h, with enrofloxacin, mg/kg iv q h) to decrease the risk of bacterial translocation and bacteremia/septicemia. although antacids (famotidine, ranitidine, cimetidine) do not have a direct antiemetic effect, their use can decrease gastric acidity and esophageal irritation during vomiting. if gastritis is secondary to uremia or nonsteroidal antiinflammatory drug use, administer gastroprotectant and antiemetic drugs (ranitidine, mg/kg po q h; sucralfate, . - g/dog po q h; or omeprazole ( . - mg/kg po q h) to decrease acid secretion and coat areas of gastric ulceration (table - ) . once food and water can be tolerated, the patient can be placed on an oral diet and medications, and intravenous fluids can be discontinued. do not use until a gastrointestinal obstruction has been ruled out. hemorrhagic gastroenteritis (hge) is an acute onset of severe hemorrhagic vomiting and diarrhea most commonly observed in young small-breed dogs (e.g., poodles, miniature dachshunds, miniature schnauzers) to years of age. clinical signs develop rapidly and include vomiting and fetid diarrhea with hemorrhage, often strawberry jam-like in appearance. the hematocrit can rise from % to %. often, the animal is extremely hypovolemic but has no apparent signs of abdominal pain. there is no known cause of hge, although clostridium perfringens, escherichia coli, campylobacter, and viral infections have been suggested but not consistently confirmed. other differential diagnoses of of hematemesis and hemorrhagic diarrhea include coronavirus, parvovirus, vascular stasis, sepsis, hepatic cirrhosis with portal hypertension, and other causes of severe shock. immediate treatment consists of placement of a large-bore intravenous catheter and replenishment of intravascular fluid volume with crystalloid fluids (up to ml/kg/hour), while carefully monitoring the patient's hematocrit and total protein. administer broad-spectrum antibiotics (ampicillin, mg/kg iv q h, and enrofloxacin mg/kg iv q h) because of the high risk of bacterial translocation and sepsis. control vomiting with antiemetic drugs. monitor the patient's platelet count and coagulation tests for impending disseminated intravascular coagulation (dic), and administer fresh frozen plasma and heparin, as needed (see section on disseminated intravascular coagulation). when vomiting has ceased for hours, offer the animal small amounts of water, and then a bland diet (e.g., boiled chicken and rice or boiled ground beef and rice mixed with low-fat cottage cheese). pancreatitis occurs most frequently in dogs but can occur in cats as well. in dogs, the onset of pancreatitis is sometimes preceded by ingestion of a fatty meal or the administration of drugs (e.g., potassium bromide or glucocorticoids). glucocorticoids can increase the viscosity of pancreatic secretions and induce ductal proliferation, resulting in narrowing and obstruction of the lumen of the pancreatic duct. pancreatitis can also occur following blunt or penetrating abdominal trauma, high duodenal obstruction causing outflow obstruction of the pancreatic papilla, pancreatic ischemia, duodenal reflux, biliary disease, and hyperadrenocorticism. in cats, acute necrotizing pancreatitis is associated with anorexia, lethargy, hyperglycemia, icterus, and sometimes acute death. chronic pancreatitis is more common in cats and results in intermittent vomiting, anorexia, weight loss, and lethargy. predisposing causes of chronic pancreatitis in cats include pancreatic flukes, viral infection, hepatic lipidosis, drugs, organophosphate toxicity, and toxoplasmosis. clinical signs of acute pancreatitis include sudden severe vomiting, abdominal pain, and lethargy. depending on the severity of pancreatic inflammation, depression, hypotension, and systemic inflammatory response syndrome (sirs) may be present. subacute cases may have minimal clinical signs. severe pancreatic edema can result in vascular changes and ischemia that perpetuates severe inflammation. hypovolemic shock and dic can also decrease pancreatic perfusion. severe pancreatic edema, autolysis, and ischemia lead to pancreatic necrosis. duodenal irritation is manifested as both vomiting and diarrhea. pain may be localized to the right upper abdominal quadrant or may be generalized if peripancreatic saponification occurs. differential diagnosis of pancreatitis is the same as for any other cause of vomiting. complications that occur in patients with severe pancreatitis include dehydration, acidbase and electrolyte abnormalities, hyperlipemia, hypotension, and localized peritonitis. hepatic necrosis, lipidosis, congestion, and abnormal architecture can develop. inflammatory mediators (bradykinin, phospholipase a, elastase, myocardial depressant factor, and bacterial endotoxins) stimulate the inflammatory cascade and can lead to sirs, with severe hypotension, clotting system activation, and dic. electrolyte imbalances and hypovolemia secondary to vomiting all can lead to multiple organ dysfunction syndrome (mods), and ultimately, death. if a patient survives an episode of acute pancreatitis, long-term sequelae can include diabetes mellitus. monitor patients with recurrent pancreatitis for clinical signs of polyuria, polydipsia, polyphagia, hyperglycemia, and glucosuria. the diagnosis of pancreatitis is based on the presence of clinical signs (which may be absent in cats), laboratory findings, and ultrasonographic evidence of pancreatic edema and increased peripancreatic echogenicity. serum biochemistry analyses can sometimes support a diagnosis of pancreatitis; however, serum amylase and lipase are often unreliable indicators of pancreatitis, depending on the chronicity of the process in the individual patient. both serum amylase and lipase are excreted in the urine. impaired renal clearance/ function can cause artifactual elevations of serum amylase and lipase in the absence of pancreatic inflammation. furthermore, serum lipase levels can be elevated as a result of gastrointestinal obstruction (e.g., foreign body). early in the course of the disease, levels can be two to six times normal, but they may decrease to within normal ranges at the time of presentation to the veterinarian. the transient nature of amylase elevation makes this test difficult to interpret, and it is not highly sensitive if a normal value is found. lipase levels also increase later in the course of the disease. amylase and lipase should be tested concurrently with the rest of the biochemistry profile. other changes often observed are elevations in bun and creatinine levels secondary to dehydration and prerenal azotemia, hyperglycemia, and hyperlipemia. hypocalcemia can occur secondary to peripancreatic fat saponification, and its presence warrants a more negative prognosis. a more specific measure is pancreatic lipase immunoreactivity, which becomes elevated in dogs and cats with pancreatitis. this test, combined with ultrasonographic or computed tomography evidence of pancreatitis, is the most sensitive and specific test available for making an accurate diagnosis. however, because the results of this test take time to obtain, animals must be treated in the meantime. abdominal effusion or fluid from diagnostic peritoneal lavage can be compared with serum amylase and lipase activity. abdominal lipase and amylase concentrations in the fluid greater than that in the peripheral blood are characteristic of chemical peritonitis associated with pancreatitis. wbc counts greater than cells/mm , the presence of bacteria, toxic neutrophils, glucose levels less than mg/dl, or lactate levels greater than that of serum are characteristic of septic peritonitis, and immediate exploratory laparotomy is warranted. if a biopsy sample obtained during laparotomy does not demonstrate inflammation, but this does not rule out pancreatitis, because disease can be focal in nature and yet cause severe clinical signs. abdominal radiographs may sometimes reveal a loss of abdominal detail or a ground glass appearance in the right upper quadrant. pancreatic edema and duodenal irritation can displace the gastric axis toward the left, toward the left with dorsomedial displacement of the proximal duodenum (the so-called "backwards " or "shepherd's crook" sign). ultrasonography and ct are more sensitive in making a diagnosis of pancreatitis. treatment of pancreatitis is largely supportive in nature and is designed to correct hypovolemia and electrolyte imbalances, prevent or reverse shock, maintain vital organ perfusion, alleviate discomfort and pain, and prevent vomiting (see section on rule of twenty). when treating pancreatitis in dogs, all food and water should be restricted. however, food should not be withheld from cats with chronic pancreatitis. give fresh frozen plasma to replenish alpha- -macroglobulins. administer antiemetics such as chlorpromazine (use with caution in a hypovolemic or hypotensive patient), dolasetron, ondansetron, or metoclopramide to prevent or control vomiting. analgesic drugs can be provided in the form of constant rate infusion (fentanyl, - µ/kg/hour iv cri, and lidocaine, - µ/kg/minute iv cri), intrapleural injection (lidocaine, - mg/kg q h), or intermittent parenteral injections (morphine, . - mg/kg sq, im; hydromorphone, . mg/kg im or sq). because the pancreas must be rested, consider using parenteral nutrition. acute hepatic failure may be associated with toxins, adverse reaction to prescription medication, and bacterial or viral infections. the most frequent clinical signs observed in a patient with acute hepatic failure are anorexia, lethargy, vomiting, icterus, bleeding, and cns depression or seizures (associated with hepatic encephalopathy). differential diagnosis and causes of acute hepatic failure are listed in box - . diagnosis of acute hepatic failure is based on clinical signs and biochemical evidence of hepatocellular (ast, alt) and cholestatic (alk phos, t bili, ggt) enzyme elevations. ultrasonography may be helpful in distinguishing the architecture of the liver, but unless a mass or abscess is present, cannot provide a specific diagnosis of the cause of the hepatic damage. management of the patient with acute hepatic failure includes correction of dehydration and acid-base and electrolyte abnormalities, as shown in the following list: • hypoalbuminemia: plasma or concentrated albumin. plasma also is an excellent source of clotting factors that can become depleted. • clotting abnormalities: vitamin k ( . mg/kg sq or po q - h) to • severe anemia: fresh or stored blood • gastric hemorrhage: gastroprotectant drugs (omeprazole, ranitidine, famotidine, cimetidine, sucralfate) • hypoglycemia: dextrose supplementation ( . %- %) • hepatic failure, particularly when hypoglycemia is present: broad-spectrum antibiotics (ampicillin mg/kg iv q h; with enrofloxacin, mg/kg iv q h) • hepatic encephalopathy: lactulose or betadine enemas • cerebral edema: mannitol ( . - . g/kg iv over to minutes) followed by furosemide ( mg/kg iv minutes later). deterioration of clinical signs may signify the development of cerebral edema. applewhite aa, cornell kk, selcer ba: diagnosis and treatment of intussusception in dogs. comp cont educ pract vet ( ) often, systemic hypertension is diagnosed when the animal is seen by the veterinarian because of some other clinical sign, such as acute blindness, retinal detachment, hyphema, epistaxis, and cns signs following intracranial hemorrhage. diagnosis of systemic hypertension is often difficult in the absence of clinical signs and without performing invasive or noninvasive blood pressure monitoring. normal blood pressure (bp) measurements in dogs and cats are listed in table - . hypertension is defined as a consistent elevation in systolic bp > mm hg, consistent diastolic bp > mm hg, and consistent mean arterial blood pressure > mm hg. the effects of systemic hypertension include left ventricular hypertrophy, cerebrovascular accident, renal vascular injury, optic nerve edema, hyphema, retinal vascular tortuosity, retinal hemorrhage, retinal detachment, vomiting, neurologic defects, coma, and excessive bleeding from cut surfaces. emergency care dog - - - cat - - - patients with systemic hypertension should have a thorough diagnostic work-up to determine the underlying cause. although uncommon, hypertensive emergencies can occur with pheochromocytoma, acute renal failure, and acute glomerulonephritis. sodium nitroprusside ( - µ/kg/minute iv cri) or diltiazem ( . - . mg/kg iv given slowly over minutes, followed by µ/kg/minute) can be used to treat systemic hypertension. with the use of sodium nitroprusside or diltiazem, monitor carefully for hypotension. diagnosis is based on consistent elevations in systolic, diastolic, and/or mean arterial bp. because many of the clinical signs associated with systemic hypertension involve hemorrhage into some closed cavity, other causes of hemorrhage, such as vasculitis, thrombocytopenia, thrombocytopathia, and hepatic or renal failure, should be investigated (see section on coagulation disorders). diagnostic testing is based on clinical signs and index of suspicion for an underlying disease and may include a complete blood count; urinalysis; urine protein:creatinine ratio; acth stimulation test; thoracic and abdominal radiographs; thoracic and abdominal ultrasound; tick serology; brain ct or mri; and assays of serum electrolytes, aldosterone concentration, t , endogenous tsh, plasma catecholamine, and growth hormone. management of systemic hypertension involves treatment of the primary underlying disorder, whenever possible. long-term adjunctive management includes sodium restriction in the form of cooked or prescription diets to decrease fluid retention. obese animals should be placed on dietary restrictions and undergo a weight reduction program. thiazide and loop diuretics may be used to decrease sodium retention and circulating blood volume. alpha-and beta-adrenergic blockers may be used, but they are largely ineffective as monotherapeutic agents for treating hypertension. calcium channel blockers and angiotensin-converting enzyme (ace) inhibitors are the mainstay of therapy in the treatment of hypertension in dogs and cats ( diabetic ketoacidosis (dka) is a potentially fatal and terminal consequence of unregulated insulin deficiency and possible glucagon excess. in the absence of insulin, unregulated lipolysis results in the beta-hydroxylation of fatty acids by abnormal hepatic metabolism. as a result, ketoacids-namely, acetoacetic acid, beta-hydroxybutyric acid, and acetoneare produced. early in the course of the disease, patients exhibit clinical signs associated with diabetes mellitus: weight loss, polyuria, polyphagia, and polydipsia. later, as ketoacids stimulate the chemoreceptor trigger zone, vomiting and dehydration occur, with resulting hypovolemia, hypotension, severe depression, abdominal pain, oliguria, and coma. at the time of presentation, often a strong odor of ketones (acetone) is present on the patient's breath. physical examination often reveals dehydration, severe depression or coma, and hypovolemic shock. in extreme cases, the patient exhibits a slow, deep kussmaul respiratory pattern in an attempt to blow off excess co to compensate for the metabolic acidosis. a serum biochemistry profile and complete blood count often reveal prerenal azotemia, severe hyperglycemia (blood glucose > mg/dl), hyperosmolarity (> mosm/kg), lipemia, hypernatremia (sodium > meq/l), elevated hepatocellular and cholestatic enzyme activities, high anion gap, and metabolic acidosis. although a whole body potassium deficit is usually present, the serum potassium may appear artifactually elevated in response to metabolic acidosis. with severe metabolic acidosis, potassium moves extracellularly in exchange for a hydrogen ion. phosphorus too moves intracellularly in response to acidosis, and serum phosphorus is usually decreased. hypophosphatemia > mg/dl can result in intravascular hemolysis. urinalysis often reveals + glucosuria, ketonuria, and a specific gravity of . or greater. the urine of all diabetic animals should be cultured to rule out a urinary tract infection or pyelonephritis. treatment of a patient with dka presents a therapeutic challenge. treatment is aimed at providing adequate insulin to normalize cellular glucose metabolism, correcting acidbase and electrolyte imbalances, rehydration and restoration of perfusion, correcting acidosis, providing carbohydrate sources for utilization during insulin administration, and identifying any precipitating cause of the dka. obtain blood samples for a complete blood count, and serum biochemistry electrolyte profiles. whenever possible, insert a central venous catheter for fluid infusion and procurement of repeat blood samples. calculate the patient's dehydration deficit and maintenance fluid requirements and give appropriate fluid and electrolytes over a period of hours. it is advisable to rehydrate patients with severe hyperosmolarity for a minimum of hours before starting insulin administration. use a balanced electrolyte solution (e.g., plasmalyte-m, normosol-r, lactated ringer's solution) or . % saline solution for maintenance and rehydration. balanced electrolyte solutions contain small amounts of potassium and bicarbonate precursors that aid in the treatment of metabolic acidosis. treat animals with severe metabolic acidosis with an hco − > meq/l or a ph < . with supplemental bicarbonate ( . - . meq/kg). add supplemental dextrose to the patient's fluids as a carbohydrate source during insulin infusion. both insulin and carbohydrates are necessary for the proper metabolism of ketone bodies in patients with dka. the rate and type of fluid and amount of dextrose supplementation will change according to the patient's blood glucose concentration. serum potassium will drop rapidly as the metabolic acidosis is corrected with fluid and insulin administration. measure serum potassium every hours, if possible, and supplement accordingly (see section on fluid therapy for chart of potassium supplementation). if the patient's potassium requirement exceeds meq/l, or if the rate of potassium infusion approaches . meq/ kg/hour in the face of continued hypokalemia, magnesium should be supplemented. magnesium is required as a cofactor for many enzymatic processes and for normal function of the na,k-atpase pump. hypomagnesemia is a common electrolyte disturbance in many forms of critical illness. replenishing magnesium (mgcl , . meq/kg/day iv cri) often helps to correct the refractory hypokalemia observed in patients with dka. patients with hypophosphatemia that approaches . mmol/l should receive potassium phosphate ( . - . mmol/kg/hour iv cri). when providing potassium phosphate supplementation, be aware of the additional potassium added to the patient's fluids, so as to not exceed recommended rates of potassium infusion. to determine the amount of potassium chloride (kcl) to add along with potassium phosphate (kpo ), use the following formula: meq k + derived from kcl = total meq of k + to be administered over hours − meq in which k + is derived from kpo clinical signs of severe hypophosphatemia include muscle weakness, rhabdomyolysis, intravascular hemolysis, and decreased cerebral function that can lead to depression, stupor, seizures, or coma. regular insulin can be administered either im or as a constant rate infusion in the treatment of patients with dka. subcutaneous insulin should not be administered. because of the severe dehydration present in most patients with dka, subcutaneous insulin is poorly absorbed and is not effective until hydration has been restored. in the low-dose intravenous method, place regular insulin ( . units/kg for a cat, and . units/kg for a dog) in ml of . % saline solution. run ml of this mixture through the intravenous line to allow the insulin to adsorb to the plastic tubing. administer the patient's insulin fluid rate according to blood glucose levels ( table - ) . adjust the patient's total fluid volume according to changes in the insulin fluid rate as necessary. in many cases, multiple bags of fluids are necessary because they must be changed when fluctuations in blood glucose concentrations occur in response to therapy. infusion of the insulin mixture should be in a separate intravenous catheter. to replenish hydration, use a second intravenous line for the more rapid infusion of non-insulin-containing fluids. to administer the regular insulin im, first give . unit/kg im and then re-check the patient's blood glucose every hour. additional injections of regular insulin ( . unit/kg other fluid type (ml/hour) > . % nacl - . % nacl + . % dextrose - . % nacl + . % dextrose - . % nacl + . % dextrose < . % nacl + % dextrose im) should be administered based on the patient's response to subsequent injections. once the patient's blood glucose falls to to mg/dl, add . % to % dextrose to the fluids to maintain the blood glucose concentration at to mg/dl. continue intramuscular injection of regular insulin ( . - . unit/kg q - h) until the patient is rehydrated, no longer vomiting, and able to tolerate oral fluids and food without vomiting. even in patients with intramuscular regular insulin therapy, a central venous catheter should be placed for frequent blood sample collection. as the patient begins to respond to therapy, monitor electrolytes, glucose, and acid-base status carefully. hypokalemia, hypophosphatemia, and hypomagnesemia can occur. when the patient's hydration and acid-base status has normalized and the patient is able to tolerate oral food and water, a longer-acting insulin can be administered as for treatment of a patient with uncomplicated diabetes. extreme hyperosmolarity can result in a coma, if uncorrected. in patients with diabetes mellitus, hyperglycemia and hypernatremia secondary to osmotic diuresis and free water loss can lead to severe hyperosmolarity. in dogs, normal serum osmolality is < mosm/l of serum. hyperosmolarity is expected when serum osmolality is > mosm/l. if equipment for determining serum osmolarity is not available, osmolarity can be calculated by the following formula: osm/l = (na + k) + (glucose/ ) + (bun/ . ) patients with severe dehydration, hyperglycemia, hypernatremia, and azotemia may experience cerebral edema without ketonemia. treatment is directed solely at rehydrating the patient and slowly reducing blood glucose levels using a hypotonic solution such as . % nacl + . % dextrose or % dextrose in water (d w). after the initial rehydration period, administer potassium supplementation conservatively. red blood cells and the brain absolutely depend on the oxidation of glucose for energy. hypoglycemia can be caused by various systemic abnormalities that can be related to intestinal malabsorption of nutrients, impaired hepatic glycogenolysis or gluconeogenesis, and inadequate peripheral utilization of glucose. clinical signs of hypoglycemia are extremely variable and can include weakness, tremors, nervousness, polyphagia, ataxia, tachycardia, muscle twitching, incoordination, visual disturbances, and generalized seizures. clinical signs typically occur when serum glucose levels are < mg/dl. the combination of the clinical signs listed previously, documentation of low serum glucose, and alleviation of clinical signs upon glucose administration is known as whipple's triad. whenever a patient presents with hypoglycemia, consider the following important factors: the age of onset, the nature of the hypoglycemic episode (transient, persisent, or recurrent) , and the pattern based on the patient's history . treatment of hypoglycemia is directed at providing glucose supplementation and determining any underlying cause. administer supplemental dextrose ( %- % dextrose, - ml/kg iv; or % dextrose, ml/kg po) as quickly as possible. do not attempt oral glucose supplementation in any patient having a seizure or if the airway cannot be protected. administer intravenous fluids (e.g., normosol-r, lactated ringer's solution, . % saline solution) with . %- % supplemental dextrose until the patient is eating and able to maintain euglycemia without supplementation. in some cases (e.g., insulinoma), eating or administration of supplemental dextrose can promote insulin secretion and exacerbate clinical signs and hypoglycemia. in cases of refractory hypoglycemia secondary to iatrogenic insulin overdose, glucagon ( mg/kg iv bolus, then - ng/kg/minute iv cri) can also be administered along with supplemental dextrose. to make a glucagon infusion of ng/ml, reconstitute ml ( mg/ml) of glucagon according to the manufacturer's instructions and add this amount to ml of . % saline solution. emergency care the diagnosis of eclampsia (puerperal tetany) is often made on the basis of history and clinical signs. clinical signs can become evident when total calcium decreases to < . mg/dl in dogs and < . mg/dl in cats. the disease is often observed in small, excitable dogs, and stress may play a complicating role in the etiology. in most bitches, the disease manifests itself to weeks after parturition. in some cases, however, clinical signs can develop before parturition occurs. hypophosphatemia may accompany hypocalcemia. clinical signs of hypocalcemia include muscle tremors or fasciculations, panting, restlessness, aggression, hypersensitivity, disorientation, muscle cramping, hyperthermia, stiff gait, seizures, tachycardia, a prolonged qt interval on ecg, polydipsia, polyuria, and respiratory arrest. treatment of eclampsia consists of slow, cautious calcium supplementation ( % calcium gluconate, . mg/kg iv over minutes). severe refractory tetanus can be controlled with intravenous diazepam. supportive care includes intravenous fluid administration and cooling (see section on hyperthermia and heat-induced illness). instruct the owner to give the patient oral calcium supplements (e.g., to tablets of tums bid-tid) after discharge from the hospital. also instruct the owner about how to wean the puppies, allowing the bitch to dry up, in order to prevent recurrence. recurrence with subsequent pregnancies is common, particularly in patients that receive calcium supplementation during gestation (table - ) . hypercalcemia can occur from a variety of causes. the gosh darn it mnemonic can be used to remember the various causes of hypercalcemia in small animal patients (box - ) . the gastrointestinal, renal, and nervous systems are most commonly affected, particularly when serum total calcium rises above . mg/dl. clinical signs of severe hypercalcemia include muscle weakness, vomiting, seizures, and coma. ecg abnormalities include prolonged pr interval, rapid qt interval, and ventricular fibrillation. the most serious clinical signs are often seen when hypercalcemia is observed in combination with hyperphosphatemia or hypokalemia. pay special attention to the "calcium × phosphorus product." if this product exceeds , dystrophic calcification can occur, leading to renal failure. renal complications include polyuria, polydipsia, dehydration, and loss of renal tubular concentrating ability. renal blood flow and the glomerular filtration rate (gfr) are impaired when serum total calcium exceeds mg/dl. the extent, location, and number of renal tubular injuries are the main factors in determining whether renal damage secondary to hypercalcemia is reversible or irreversible. emergency therapy of hypercalcemia is warranted when severe renal compromise, cardiac dysfunction, or neurologic abnormalities are present, or if no clinical signs occur but the calcium × phosphorus product exceeds . the treatment of choice is correction of the underlying cause of hypercalcemia, whenever possible. in some cases, the results of diagnostic tests take time, and emergency therapy should be initiated immediately, before a definitive cause of the hypercalcemia is found. emergency management of hypercalcemia consists of reduction of serum calcium levels. administer intravenous fluids ( . % saline solution) to expand extracellular fluid volume and promote calciuresis. to promote diuresis, initial intravenous fluid rates should approach two to three times maintenance levels ( - ml/kg/day). potassium supplementation may be required to prevent iatrogenic hypokalemia. administration of a loop diuretic such as furosemide ( - mg/kg iv) will promote calcium excretion. calcitonin ( iu/kg im q h for cats and iu/kg im q h for dogs) can be administered to decrease serum calcium levels. in severe refractory hypercalcemia secondary to cholecalciferol toxicity, more aggressive calcitonin therapy ( - iu/kg sq q - h) can be attempted. side effects of calcitonin treatment include vomiting and diarrhea. alternatively, bisphosphonates (pamidronate, . - . mg/kg iv) are useful in rapidly reducing serum calcium concentrations. glucocorticosteroids reduce calcium release from the bone, decrease intestinal absorption of calcium, and promote renal calcium excretion. administer glucocorticosteroids only after the underlying cause of hypercalcemia has been determined and appropriate therapy started. because many forms of neoplasia can result in hypercalcemia as a paraneoplastic syndrome, empiric use of glucocorticosteroids can induce multiple drug resistance, making the tumor refractory to the effects of chemotherapeutic agents. hypoadrenocorticism is most commonly observed in young to middle-aged female dogs, but it can occur in animals of any age, gender, and breed. clinical signs, which are referable to deficiency in glucocorticoid (cortisol) and mineralocorticoid (aldosterone) hormones, may develop slowly over time, leading to a waxing and waning course; acute clinical signs occur when > % of the adrenal functional reserve has been destroyed. in such cases, complete adrenocortical collapse can result in an addisonian crisis. lack of aldosterone causes a lack of renal sodium and water retention, and impaired potassium excretion. the most significant clinical signs associated with hypoadrenocorticism are depression, lethargy, weakness, anorexia, shaking, shivering, vomiting, diarrhea, weight loss, abdominal pain, weakness, hypotension, dehydration, and inappropriate bradycardia (box - ) . the diagnosis of hypoadrenocorticism is made based on the patient's clinical signs in combination with electrolyte abnormalities that include hyperkalemia, hyponatremia, and hypochloremia. serum sodium concentration ( - meq/l) is often greatly reduced, and serum potassium is elevated (> . meq/l). a sodium:potassium ratio of < is characteristic of hypoadrenocorticism, although not exactly pathognomonic. electrocardiographic changes associated with hyperkalemia include inappropriate bradycardia, absence of p waves, elevated spiked t waves, and widened qrs complexes. other more variable bloodwork abnormalities include a lack of a stress leukogram, eosinophilia, hypoglycemia, hyperphosphatemia, hypercalcemia, azotemia, and hypocholesterolemia. a definitive diagnosis of hypoadrenocorticism is based on an adrenocorticotropic hormone (acth) stimulation test. in patients with hypoadrenocorticism, baseline cortisol levels are usually low, with a lack of appropriate cortisol release after administration of acth analogue. rarely, animals with "atypical" hypoadrenocorticism lose glucocorticoid secreting ability from the zona fasciculata, but retain mineralocorticoid secretory ability from the zona glomerulosa. atypical addisonian patients have normal serum electrolytes but still have clinical signs of vomiting, diarrhea, weakness, lethargy, inappetence, muscle wasting, and weight loss. the diagnosis is more difficult in such cases because of the presence of normal electrolytes. an acth stimulation test should be considered, particularly in predisposed breeds. treatment of hypoadrenocorticism includes placement of a large-bore intravenous catheter, infusion of intravenous crystalloid fluids ( . % saline solution), and replenishment of glucocorticoid and mineralocorticoid hormones. administer dexamethasone or dexamethasone-sodium phosphate ( . - . mg/kg iv). dexamethasone will not interfere with the acth stimulation test, unlike other longer-acting steroids (e.g., prednisolone, methylprednisolone sodium succinate, triamcinolone). depending on the severity of the patient's condition, consider monitoring using the rule of twenty. administer antiemetics and gastroprotectant drugs to treat nausea, vomiting, and hematemesis. give the patient broad-spectrum antibiotics (ampicillin, mg/kg iv q h) if hematochezia or hemorrhagic diarrhea is present. if severe gastrointestinal blood loss occurs, whole blood, packed red blood cells, or fresh frozen plasma may be required. control hypoglycemia with . %- . % dextrose. use sodium bicarbonate, regular insulin with dextrose, or calcium gluconate to correct severe hyperkalemia with atrial standstill (see section on atrial standstill). chronic therapy for hypoadrenocorticism consists of mineralocorticoid and glucocorticosteroids supplementation for the rest of the animal's life. mineralocorticoid supplementation can be in the form of desoxycorticosterone pivalate (docp) ( . mg/kg im) or fludrocortisone acetate ( . mg/ . - kg body weight daily). fludrocortisone acetate possesses both mineralocorticoid and glucocorticoid activities and can be used as the sole daily treatment of hypoadrenocorticism. (because fludrocortisone is poorly absorbed in some dogs, it may not completely normalize electrolyte abnormalities in these animals.) docp is primarily a mineralocorticoid. give supplemental glucocorticosteroids in the form of prednis(ol)one ( - . mg/kg/day). in dogs, iatrogenic hypoadrenocorticism can be caused by abrupt discontinuation of glucocorticosteroid treatment. long-term glucocorticosteroid supplementation can downregulate the pituitary gland's excretion of endogenous acth and the zona fasciculata's ability to excrete cortisol. however, the zona glomerulosa's ability to secrete aldosterone does not appear to be affected. clinical signs of iatrogenic hypoadrenocorticism include inability to compensate for stress, weakness, lethargy, vomiting, diarrhea, and collapse. treatment of iatrogenic hypoadrenocorticism is the same as for naturally occurring disease. following immediate emergency treatment, the patient should be weaned slowly from exogenous glucocorticosteroid supplementation. severe hyperthyroidism can manifest as a medical emergency as a result of hypermetabolism. clinical signs in affected cats with severe thyrotoxicosis include fever, severe tachycardia (heart rate > bpm), vomiting, hypertension, congestive heart failure with pulmonary edema, and fulminant collapse. clinical signs typically are manifested as an end-stage of chronic debilitation associated with hyperthyroidism and are often preceded by polyphagia, weight loss, cardiac murmur, polyuria/polydipsia (pu/pd), vomiting, and diarrhea. treatment of thyrotoxicosis includes antagonizing the adrenergic activity by administration of a beta-adrenergic blocker (esmolol, ( - µ/kg/minute, or propranolol, . mg/ kg/hour). administration of glucocorticosteroids (dexamethasone, mg/kg) may inhibit the conversion of thyroxine (t ) to the active form triiodothyronine (t ) and decrease peripheral tissue responsiveness to t , effectively blocking its effects. correct hypoglycemia with supplemental dextrose ( . %). use care to avoid overhydration in a patient with cardiac failure or insufficiency. start the patient on methimazole as quickly as possible and consider the use of radioactive iodine therapy. to maintain cerebral perfusion pressure, blood pressure must be normalized. if other concurrent injuries are suspected (e.g., pulmonary contusions), administer synthetic colloid fluids (dextran- , - ml/kg iv, or hetastarch, - ml/kg iv) to normalize blood pressure. although the use of colloids is controversial because of their potential to leak into the calvarium, the benefits of reestablishing cerebral perfusion far outweigh the risks of their use. hypertonic saline ( . % nacl, - ml/kg iv) can also be administered over to minutes to expand intravascular volume. maintain blood glucose within normal reference ranges whenever possible, because hyperglycemia is a negative prognostic indicator in cases of head trauma. if tremors or seizures cause hyperthermia or increased metabolism, active cooling of the patient is warranted (see sections on hyperthermia and heat-induced injury). all patients with head trauma should receive care and monitoring based on the rule of twenty (see section on rule of twenty). examine the patient's level of consciousness, response to various stimuli, pupil size and reactivity to light, physiologic nystagmus, and cranial nerve deficits. in dogs, damage to the midbrain often produces coma and decerebrate rigidity. initial consciousness followed by a unconsciousness or stupor usually involves an injury to the brainstem. brainstem lesions can be caused by compressive skull fractures, extradural or subdural hematomas, or herniation through the foramen magnum from cerebral edema (box - ) . the patient's pupil size and response to light can be used to localize a diagnosis and give a rough prognosis for severity of disease and possibility for return to function. pupils can be normal in size, mydriatic, or miotic. whenever a pupil appears miotic, direct ocular emergency care unconscious with no response to noxious stimuli injury with uveitis or secondary miosis due to brachial plexus injury should be ruled out. the eyes should always be examined to rule out ocular trauma. in a patient with head trauma, a change from dilated to constricted to normal pupil size is suggestive of improvement in clinical function. bilateral mydriatic pupils that are unresponsive to light in an unconscious animal are a grave prognostic sign and usually indicate an irreversible severe midbrain contusion. bilateral miotic pupils with normal nystagmus and ocular movements are associated with diffuse cerebral or diencephalic lesions. miotic pupils that become mydriatic indicate a progressive midbrain lesion with a poor prognosis. unilateral, slowly progressive pupillary abnormalities in the absence of direct ocular injury are characteristic of brainstem compression or herniation caused by progressive brain swelling. asymmetric pupils are seen in patients with rostral brainstem lesions and can change rapidly. unresponsive pupils that are seen in the midposition occur with brainstem lesions that extend into the medulla and are a grave sign. visual deficits are common with intracranial injury. lesions that are less severe and limited to the cerebrum produce contralateral menace deficits with normal pupillary light response. bilateral cerebral edema can cause blindness with a normal response to light if the midbrain is not disturbed. a patient that is severely depressed and recumbent may not respond to menacing gestures, even when visual pathways are intact. ocular, optic tract, optic nerve, or optic chiasm lesions can interfere with vision and the pupillary light response. brainstem contusion and cerebral edema may produce blindness and dilated unresponsive pupils due to disturbance of the oculomotor area. examine all cranial nerves carefully. cranial nerve abnormalities can indicate direct contusion or laceration of the neurons in the brainstem or where they exit the skull. cranial nerves that are initially normal then later lose function indicate a progressively expanding lesion. when specific cranial nerve deficits are present, the prognosis is considered guarded. clinical signs such as rolling to one side, torticollis, head tilt, and abnormal nystagmus are usually associated with petrosal bone or cerebellomedullary lesions that produce vestibular neuron dysfunction. fractures of the petrosal temporal bone often cause hemorrhage and cerebrospinal fluid (csf) leak from the external ear canal. if the lesion is limited to the membranous labyrinth, the loss of balance will be toward the injured side and the quick phase of the nystagmus will be toward the injured side. normal physiologic nystagmus requires that the pathway is between the peripheral vestibular neurons and the pontomedullary vestibular nuclei to the nuclei of the cranial nerves that innervate the extraocular muscles (iii, iv, vi). severe brainstem lesions disrupt this pathway. disruption of the pathway is manifested as an inability to produce normal physiologic nystagmus by moving the patient's head from side to side. in patients with severe central nervous system depression, this reflex may not be observed. next, assess postural changes and motor function abilities. a loss of the normal oculocephalic ("dolls-eye") reflex is an early sign of brainstem hemorrhage and a late sign of brainstem compression and herniation. any intracranial injury may be accompanied by a concurrent cervical spinal cord injury. handle animals with such injuries with extreme care to avoid causing further damage. whenever there is uncertainty whether a spinal cord lesion exists, strap the patient down to a flat surface and obtain radiographs of the spine. at least two orthogonal views may be required to see fractures; however, do not manipulate the patient until radiography has been completed. crosstable views, in which the bucky is turned perpendicular to the patient's spine, with a radiograph plate secured behind the patient, may be required to minimize patient motion. in patients with cerebral lesions, hemiparesis usually resolves within to days. evaluation of cranial nerve function at frequent intervals may reveal an initial injury or a progressively expanding lesion in the brain. signs of vestibular disorientation, marked head tilt, and abnormal nystagmus occur with contusions of the membranous labyrinth and fracture of the petrous temporal bone. hemorrhage and cerebrospinal fluid otorrhea may be visible from the external ear canal. rolling movements indicate an injury to the cerebellar-medullary vestibular system. respiratory dysfunction and abnormal respiratory patterns are sometimes observed with severe head injury. lesions of the diencephalon produce cheyne-stokes respirations, in which the patient takes progressively larger and larger breaths, pauses, then takes progressively smaller and smaller breaths. mesencephalic lesions cause hyperventilation and can result in respiratory alkalosis. medullary lesions result in a choppy, irregular respiratory pattern. clinical signs of respiratory dysfunction in the absence of primary respiratory damage indicate a guarded prognosis. after injury, seizures may be associated with intracranial hemorrhage, trauma, or an expanding intracranial mass lesion. immediately begin medical therapy to control the seizure. administer diazepam ( . mg/kg iv or . - . mg/kg/hour iv cri) to treat seizures. if diazepam is not effective in combination with other treatments to control intracranial edema, consider giving pentobarbital . loading doses of phenobarbital ( - mg/kg iv divided into or doses, given every to minutes) may be beneficial in preventing further seizures. severe refractory seizures or decreased mentation may be associated with cerebral edema and increased intracranial pressure. mannitol, an osmotic diuretic, is effective at reducing cerebral edema ( . - . g/kg iv over to minutes). mannitol also acts as a free radical scavenger that can inhibit the effects of cerebral ischemia-reperfusion injury. mannitol works synergistically with furosemide ( mg/kg iv given minutes after the mannitol infusion). corticosteroids have not been demonstrated to be beneficial in the treatment of head trauma and may induce hyperglycemia. hyperglycemia has been shown to be a negative prognostic indicator in cases of head trauma. also, glucocorticoids can suppress immune system function and impair wound healing. because of the known risks and lack of known benefits of glucocorticosteroids, their use in treatment of head trauma is contraindicated. the prognosis for any patient with severe head trauma is guarded. management of head trauma patients may include intense nursing care for a period of weeks to months, depending on the presence and extent of concurrent injuries. if progressive loss of consciousness occurs, surgery for decompression of compressive skull injuries should be considered. the most common injury associated with head trauma in small animals is a contusion with hemorrhage in the midbrain and pons. subdural or extradural hemorrhage with space-occupying blood clots is uncommon. diagnostic tests of head trauma may include skull radiographs, ct, and mri of the brain. special studies can help detect edema and hemorrhage in the brain and brainstem, and aid in making an accurate diagnosis and prognosis. a cerebrospinal fluid tap is contraindicated in patients with head trauma because of the risk of causing a rapid decrease in intracranial pressure and brainstem herniation. if a compressive skull fracture is present, the patient should be stabilized for surgery to remove the compression. surgery to alleviate increased intracranial pressure is rarely performed in veterinary medicine because of the poor prognosis and results. in some cases, when a lesion can be localized to one area, -to -cm burr holes can be placed through the skull over the affected area of the cerebrum, exposing the underlying brain tissue. blood clots can be removed through the holes. the bone flap may or may not be replaced, depending on the surgeon's preference and the degree of brain swelling. spinal cord injuries may be associated with trauma, disk rupture, fractures, and dislocation of the spinal column. proceed with caution when moving a patient with suspected spinal cord injury. avoid flexion, extension, and torsion of the vertebral column. all animals that are unconscious following a traumatic event should be considered to have cervical or thoracolumbar spinal injury until proved otherwise by radiography, ct, or mri. the animal should be moved onto a flat surface (e.g., board, door, window, picture frame) and taped down to prevent motion and further displacement of vertebrae. sedation with analgesics or tranquilizers may be necessary to keep the animal immobile and to minimize patient motion. whenever possible, avoid the use of narcotics in patients with head trauma because of the risk of increasing intracranial pressure. as in other emergencies, the abcs emergency care should be evaluated, and the patient treated for shock, hemorrhage, and respiratory compromise. once the cardiovascular and respiratory systems have been evaluated and stabilized, a more thorough neurologic examination can be performed. protrusion of an intervertebral disk indicates that the disk is bulging into the vertebral canal as a result of dorsal shifting of the nuclear pulposus disk material. disk extrusion refers to the rupture of the outer disk membrane and extrusion of the nuclear material into the vertebral column. in dogs and cats, there are intervertebral disks that potentially can cause a problem. chondrodystrophic breeds of dogs are predisposed to endochondral ossification and include the dachshund, shih tzu, french bulldog, bassett hound, welsh corgis, american spaniel, beagle, lhasa apso, and pekingese. initial examination of the patient with suspected intervertebral disk disease includes identifying the neuroanatomic location of the lesion based on clinical signs and neurologic deficits and then establishing a prognosis. the neurologic examination should be carried out without excessive manipulation of the animal. the presence of pain, edema, hemorrhage, or a visible deformity may localize an area of vertebral injury. once an area of suspected lesion is localized based on physical examination findings, take radiographs to establish a diagnosis and to institute therapy. in most cases, the animal must receive a short-acting anesthestic for proper radiographic technique and to prevent further injury. lateral and crosstable ventrodorsal (vd) or dorsoventral (dv) radiographs require less manipulation of the animal compared with traditional vd and dv projections. myelography is often required to delineate the location of the herniated disk material. prognosis in spinal cord injury depends on the extent of the injury and the reversibility of the damage. perception of noxious stimuli, or the presence of "deep pain," by the animal when the stimulus is applied caudal to the level of the lesion is a good sign. to apply a noxious stimulus, apply firm pressure to a toe on one of the rear limbs using a thick hemostat or a pair of pliers. flexion or withdrawl of the limb is simply a local spinal reflex, and should not be perceived as a positive response to or patient perception of the noxious stimulus. turning of the head, vocalization, dilation of the pupils, change in respiratory rate or character, or attempts to bite are behaviors that are more consistent with perception of the noxious stimulus. absence of perception of the noxious stimulus ("loss of deep pain") is a very poor prognosis for return to function. focal lesions are usually associated with vertebral fractures and displacement of the vertebral canal. focal lesions in one or more of the spinal cord segments from t to t can cause complete dysfunction of the injured tissue as a result of concussion, contusion, or laceration. the degree of structural damage cannot be determined from the neurologic signs alone. transverse focal lesions result in paraplegia, with intact pelvic limb spinal reflexes and analgesia of the limbs and body caudal to the lesion. clinical signs in patients with spinal injury are summarized in table - . carefully evaluate the cardiovascular and respiratory status of patients with spinal injuries. immediately address specific injuries such as pneumothorax, pulmonary contusions, hypovolemic shock, and open wounds. if there is palpable or radiographic evidence of a vertebral lesion causing compressive injury, surgery is the treatment of choice unless the displacement has compromised most or all of the vertebral canal. displacements through % to % of the vertebral canal are associated with a poor prognosis, particularly if deep pain is absent caudal to the lesion. in the absence of a radiographic lesion and in the presence of continued neurologic deficits, an mri or ct scan or myelography is warranted to localize a potentially correctable lesion. surgical exploration can be considered: with the objectives of providing spinal cord decompression by hemilaminectomy or laminectomy with removal of disk material or blood clots, realign and stabilize the vertebral column, and perform a meningotomy, if necessary. place the patient on a backboard or other rigid surface, taped down for transport and sedated, to be transported to a surgical specialist. the presence of worsening or ascending clinical signs may signify ascending-descending myelomalacia and is characteristic of a very poor prognosis.in acute spinal trauma, the use of glucocorticoids has been the mainstay of therapy; however, controversy exists about whether they actually offer any benefit. traditional glucocorticosteroid therapy is listed in box - . more recently, the use of propylene glycol has proved to be beneficial in the treatment of acute traumatic herniated disk. high-dose glucocorticoids should only be used for the first hours after initial injury. side effects of glucocorticosteroid therapy include gastric and intestinal ulceration. the prophylactic use of gastroprotectant drugs will not prevent gastrointestinal ulcer formation; however, if signs of gastrointestinal ulcer are present, institute gastroprotectant therapy. management of the patient with spinal cord injury includes aggressive nursing care and physical therapy. many patients with spinal cord injury have little to no control over bladder function, which results in chronic dribbling or retention of urine and overdistention of the urinary bladder with overflow incontinence. urinary bladder retention can lead to urinary tract infection, bladder atony, and overflow incontinence. manual expression of the bladder several times a day may be enough to keep the bladder empty. alternatively, place a urinary catheter to maintain patient cleanliness and to keep the bladder decompressed. (see section on urinary catheterization). paralytic ileus and fecal retention are frequent complications of spinal cord injury. to help prevent constipation, provide highly digestable foods and maintain the patient's hydration with oral and intravenous fluids. mild enemas or stool softeners can also be used to treat fecal retention. to prevent decubital ulcer formation, turn the patient every to hours, and use clean, dry, soft padded bedding. apply deep muscle massage and passive range of motion exercises to prevent disuse atrophy of the muscles and dependent edema. the radial nerve innervates the extensor muscles of the elbow, carpus, and digits. the radial nerve also supplies sensory innervation to the distal craniolateral surface of the forearm and the dorsal surface of the forepaw. injuries to the radial nerve at the level of the elbow emergency care cranial to c spastic tetraplegia or tetraparesis hyperreflexive all four limbs severe injury can result in death from respiratory failure. c -t tetraparesis or tetraplegia depressed thoracic limb spinal reflexes (lower motor neuron) hyperreflexive pelvic limbs (upper motor neuron) t -t horner' syndrome (prolapsed nictitans, enophthalmos, and miosis) t -l schiff-sherrington syndrome (extensor rigidity of thoracic limbs, flaccid paralysis with atonia, areflexia, and analgesia of pelvic limbs) result in an inability to extend the carpus and digits. as a result, the animal walks and bears weight on the dorsal surface of the paw. there is also loss of cutaneous sensation, which leads to paw injury. injuries to the radial nerve above the elbow (in the shoulder area) results in an inability to extend the elbow and bear weight on the affected limb. it can take weeks before the full extent of the injury and any return to function are manifested. the animal may need to be placed in a carpal flexion sling or have eventual amputation if distal limb injury or self-mutilation occurs. the sciatic nerve primarily innervates the caudal thigh muscles that flex the stifle and extend the hip. the tibial branch of the sciatic nerve innervates the caudal leg muscles that extend the tarsus and flex the digits. the tibial nerve provides the sole cutaneous sensory innervation to the plantar aspect of the paw and digits. the peroneal branch of the sciatic nerve provides the sole sensory cutaneous innervation to the dorsal surface of the paw ( table - ) . sciatic nerve injury may occur with pelvic fractures, particularly those that involve the body of the ileum at the greater ischiatic notch, or with sacroiliac luxations that contuse the l and l spinal nerves that pass ventral to the sacrum to contribute to the sciatic nerve. with sciatic nerve injury, there is decreased stifle flexion and overflexion of the hock (tibial nerve), and the animal walks on the dorsal surface of the paw (peroneal nerve). clinical signs of tibial or peroneal damage are seen with femur fractures or with inadvertent injection of drugs into the caudal thigh muscles. the femoral nerve innervates the extensor muscles of the stifle. the saphenous branch of the femoral nerve provides the sole cutaneous innervation to an area on the medial distal thigh, the leg, and the paw. the femoral nerve is protected by muscles and is rarely injured in pelvic fractures. clinical signs of femoral nerve injury are inability to support weight on the pelvic limb, absence of a patellar reflex, and analgesia in the area of cutaneous innervation. coma is complete loss of consciousness, with no response to noxious stimuli. in some animals that present in a coma or stuporous state, the immediate cause will be apparent. in other cases, however, a careful and thorough diagnostic work-up must be performed. a coma scale devised to assist in the clinical evaluation of the comatose patient is shown in table - . whenever an animal presents in a comatose state, immediately secure the emergency management of specific conditions c -t nerve roots radial nerve paralysis musculocutaneous nerve inability to flex the elbow axillary or thoracodorsal dropped elbow nerve median and ulnar nerves loss of cutaneous sensation on the caudal surface of the forearm and palmar and lateral surfaces of the paw; inability to flex the carpus and digits c -t nerve roots radial, median, or ulnar nerve injury c -c nerve roots musculocutaneous, suprascapular, and axillary injury c -t horner's syndrome (miosis, enophthalmos, and prolapsed nictitans) airway by placing an endotracheal tube (see section on endotracheal intubation). if necessary, provide respiratory assistance, or at a minimum, supplemental oxygen. control existing hemorrhage and treat shock, if present. take a careful and thorough history from the owner. make careful note of any seizure, trauma, or toxin exposure, and whether prior episodes of coma have ever occurred. perform a careful physical examination, taking note of the patient's temperature, pulse, and respiration. an elevated temperature may suggest the presence of systemic infection, such as pneumonia or hepatitis, or a brain lesion with loss of hypothalamic thermoregulatory control. very high temperatures associated with shock and coma are often observed in animals with heat stroke (see section on heat stroke and heat-induced illness). circulatory collapse or barbiturate overdose can produce coma and hypothermia. abnormal respiratory patterns also may be observed in a comatose patient. hypoventilation may occur with elevated intracranial pressure or barbiturate overdose. rapid respiratory rate may be associated with pneumonia, metabolic acidosis (dka, uremia), or brainstem injury. examine the skin for any bruises or external trauma. examine the mucous membranes and make note of color and capillary refill time. icterus with petechiae or ecchymotic hemorrhage in a comatose patient may be associated with end-stage hepatic failure and hepatic encephalopathy. smell the patient's breath for the odor of ketones that may signify dka or end-stage hepatic failure. motor activity normal gait, normal spinal reflexes hemiparesis, tetraparesis, or decerebrate activity recumbent, intermittent extensor rigidity recumbent, constant extensor rigidity recumbent, constant extensor rigidity with opisthotonus recumbent, hypotonia of muscles, depressed or absent spinal reflexes normal papillary reflexes and oculocephalic reflexes slow pupillary light reflexes and normal to reduced oculocephalic reflexes bilateral unresponsive miosis with normal to reduced oculocephalic reflexes pinpoint pupils with reduced to absent oculocephalic reflexes unilateral, unresponsive mydriasis with reduced to absent oculocephalic reflexes bilateral, unresponsive mydriasis with reduced to absent oculocephalic reflexes occasional periods of alertness and responsive to environment depression of delirium, capable of responding to environment but response may be inappropriate semicomatose, responsive to visual stimuli semicomatose, responsive to auditory stimuli semicomatose, responsive only to repeated noxious stimuli comatose, unresponsive to repeated noxious stimuli *neurologic function is assessed for each of the three categories and a grade of to is assigned according to the descriptions for each grade. the total score is the sum of the three category scores. this scale is designed to assist the clinician in evaluating the neurologic status of the craniocerebral trauma patient. as a guideline and according to clinical impressions, a consistent total score of to represents a grave prognosis, to a poor to guarded prognosis, and to a good prognosis. (modified from the glasgow coma scale used in humans.) from shores a: craniocerebral trauma. in kirk rw, ed: current veterinary therapy x. small animal practice. philadelphia, wb saunders, , p . finally, conduct a complete neurologic evaluation. the presence of asymmetric neurologic signs may suggest an intracranial mass lesion (e.g., hemorrhage, neoplasia, injury). usually, toxicities or metabolic disturbances (e.g., dka, hepatic encephalopathy) cause symmetric clinical signs of neurologic dysfunction, with cerebral signs predominating. in hepatic encephalopathy, pupils are usually normal in size and responsive to light. in toxicities, the pupils are abnormal in size and may be unresponsive to light. obtain a complete blood count, serum biochemistry profile, urinalysis, and specific tests for glucosuria and ketonuria. findings of a drastically elevated blood glucose with glucosuria, ketonuria, and high specific gravity are characteristic of dka. fever and uremic encephalopathy are characterized by severe azotemia with a low urine specific gravity. if barbiturate intoxication is suspected, save urine for later toxin analysis. evaluate urine sediment for calcium oxalate crystalluria that may indicate ethylene glycol toxicity. calculate plasma osmolality (see following section) to check for nonketotic hyperosmolar diabetes mellitus. elevated blood ammonia levels may be associated with hepatic encephalopathy. in uncontrolled diabetes mellitus, hyperosmolarity can result in clinical signs of disorientation, prostration, and coma. plasma osmolarity can be calculated from the formula: mosm/l = (na + k) + (glucose/ ) + (bun/ . ) clinical signs of hyperosmolarity can occur when the plasma osmolarity exceeds mosm/l. treatment of dka or nonketotic hyperosmolar syndrome is aimed at reducing ketoacid production, stimulating carbohydrate utilization, and impeding peripheral release of fatty acids. the treatment of choice is rehydration and provision of supplemental regular insulin and a carbohydrate source (see section on diabetic ketoacidosis). during ketosis, insulin resistance may be present. slow rehydration with . % saline solution or other balanced crystalloid fluids (e.g., normosol-r, plasmalyte-m, lactated ringer's solution), should occur, with the goal of rehydration over to hours. too rapid rehydration can result in cerebral edema and exacerbation of clinical signs. hepatic encephalopathy (he) is characterized by an abnormal mental state associated with severe hepatic insufficiency. the most common cause of he is congenital or acquired c o m a portosystemic shunts. acute hepatic destruction can also be caused by toxins, drugs, or infectious causes. the treatment of he is considered a medical emergency (table - ) . absorption of ammonia and other nitrogenous substances from the gastrointestinal tract is thought to be one of the complicating factors in he. prevent absorption of ammonia and other nitrogenous substances from the gastrointestinal tract by restricting dietary protein to % to % for dogs, and to % to % (on a dry matter basis) for cats. dietary protein should be from a nonanimal plant source (e.g., soybean) whenever possible. caloric requirements are met with lipids and carbohydrates. also prescribe cleansing enemas to rid the colon of residual material, and antibiotic therapy to reduce gastrointestinal tract bacteria. neomycin ( mg/kg q h) can be administered as a retention enema. metronidazole ( . mg/kg po, q - h) or amoxicillin-clavulanate ( . mg po q h) can also be administered. administer lactulose ( . - . ml q h for cats; . - ml q h for dogs) to trap ammonia in the colon to prevent absorption (table - ) . administer lactulose orally to an alert animal, or as a retention enema to a comatose animal. if lactulose is not available, betadine retention enemas will change colonic ph and prevent ammonia absorption. a side effect of lactulose administration (po) is soft to diarrheic stool. a seizure is a transient disturbance of brain function that is sudden in onset, ceases spontaneously, and has a tendency to recur, depending on the cause. most seizures are generalized and result in a loss of consciousness and severe involuntary contraction of the skeletal muscles, resulting in tonic-clonic limb activity and opisthotonus. mastication, salivation, urination, and defecation are common. partial (petit mal) seizures range from limited limb activity, facial muscle twitching, and episodic behavioral abnormalities to brief loss of consciousness. similar clinical signs also can occur with syncopal episodes. conduct a careful cardiac examination in any patient with a history of petit mal seizures. seizures of any form constitute a medical emergency, particularly when they occur in clusters, or as status epilepticus. most seizures are of short duration and may have subsided by the time the animal is presented for treatment. whenever a seizure occurs, however, it is important that the animal does not inadvertently injure itself or a bystander. it is important to evaluate whether the patient has a coexisting disease that can predispose it to seizures, such as hepatic failure, uremia, diabetes mellitus, hypoglycemia, toxin exposure, insulin-secreting tumors, and thiamine deficiency. many toxins are responsible for clinical signs of tremors or seizures (see section on poisons and toxins). treatment of a primary disease entity can help control seizures, in some cases, provided that the underlying cause is investigated and treated. status epilepticus, a state of continuous uncontrolled seizure activity, is a medical emergency. when an animal is in a state of status epilepticus, immediately place a lateral or medial saphenous intravenous catheter and administer diazepam ( . mg/kg iv) to help control the seizure. in most cases, the seizure must be controlled before a diagnostic workup is attempted. whenever possible, however, blood samples should be collected before administration of any anticonvulsant agent because of the risk of incorrect test results. for example, the propylene glycol carrier in diazepam can cause a false-positive ethylene glycol test using an in-house testing kit. whenever possible, check blood glucose levels, particularly in young puppies or kittens, to evaluate and treat hypoglycemia as a cause of seizures. if hypoglycemia exists, administer % dextrose ( g/kg iv). if diazepam partially controls the status epilepticus, administer a constant rate infusion ( . mg/kg/hour in % dextrose in water). diazepam is sensitive to light, and the bag and infusion line must be covered to prevent degradation of the drug. if diazepam fails to control status epilepticus, give pentobarbital ( - mg/kg iv to effect). the animal's airway should be intubated and protected while the patient is kept in the drug-induced coma. protracted cases of seizures may require mannitol and furosemide therapy to treat cerebral edema. administer intravenous fluids (balanced crystalloid at maintenance doses [see section on intravenous fluid therapy]). the patient should be turned every to hours to emergency care prevent atelectasis. insert a urinary catheter for cleanliness, and place the animal on soft dry padded bedding to prevent decubital ulcer formation. depending on the length of time that the patient is rendered unconscious, apply passive range of motion exercises and deep muscle massage to prevent disuse atrophy of the muscles and dependent or disuse edema. monitor the patient's oxygenation and ventilation status by arterial blood gas measurement or pulse oximetry and capnometry (see section on blood gas, pulse oximetry, and capnometry). administer supplemental oxygen to any patient that is hypoxemic secondary to hypoventilation or other causes. severe refractory seizures can result in the development of neurogenic pulmonary edema. lubricate the animal's eyes every hours to prevent drying out and corneal abrasions. depending on the cause of the seizure, administer phenobarbital at a loading dose of to mg/kg iv given in four to five injections, every to minutes; make sure that the patient is rousable in between injections). seizures in cats often are associated with structural brain disease. the occurrence of partial focal seizures is unequivocally associated with a focal cerebral lesion and acquired structural brain disease. an initial high frequency of seizures is also a strong indication that structural brain disease is present. seizure activity in cats may occur as mild generalized seizures or complex partial seizures and may be associated with systemic disorders such as feline infectious peritonitis virus, toxoplasmosis, cryptococcus infection, lymphosarcoma, meningiomas, ischemic encephalopathy, and thiamine deficiency. thiamine deficiency in the cat can be a medical emergency characterized by dilated pupils, ataxic gait, cerebellar tremor, abnormal oculocephalic reflex, and seizures. treatment consists of administration of thiamine ( mg/day) for three days. steffen f, grasmueck s: propofol for treatment of refractory seizures in dogs and a cat with intracranial disorders. j small anim pract ( ) ( ) ( ) ( ) . j am vet med assoc ( ): [ ] [ ] [ ] [ ] [ ] [ ] . an ocular emergency is any serious condition that causes or threatens to cause severe pain, deformity, or loss of vision. treat ocular emergencies immediately, within to several hours after the emergency, whenever possible (box - , - ). to assess the location and degree of ocular injury, perform a complete ocular examination. in some cases, short-acting sedation or general anesthesia in conjunction with topical local anesthetic may be necessary to perform the examination, because of patient discomfort and blepharospasm. the equipment listed in box - may be necessary and may be invaluable in making an accurate diagnosis. to perform a systematic and thorough ocular examination, first obtain a history from the owner. has there been any prior incident of ocular disease? is there any history of trauma or known chemical irritant or exposure? did the owner attempt any irrigation or medical techniques prior to presentation? when was the problem first noticed? has it changed at all since the owner noticed the problem? after a history has been obtained, examine the patient's eyes for discharge, blepharospasm, or photophobia. if any discharge is present, note its color and consistency. do not attempt to force the eyelids open if the patient is in extreme discomfort. administer a short-acting sedative and topical local anesthetic such as . % proparacaine. note the position of the globe within its orbit. if the eye is exophthalmic, strabismus and protrusion of the third eyelid are often visible. exposure keratitis may be present. in cases of retrobulbar or zygomatic salivary gland inflammation, the patient will resist opening the mouth and exhibit signs of discomfort or pain. note any swelling, contusions, abrasions, or lacerations of the eyelids. note whether the lids are able to close completely and cover the cornea. if a laceration of the lid is present, determine the depth of the laceration. palpate the orbit for fractures, swelling, pain, crepitus, and cellulitis. examine the cornea and sclera for penetrating injury or foreign material. the use of lid retractors or small forceps can be very helpful in these cases. if a wound appears to penetrate completely into the globe, look for loss of uveal tissue, lens, or vitreous. do not put any pressure on the globe, because intraocular herniation may result. examine the conjunctiva for hemorrhage, chemosis, lacerations, and foreign bodies. examine the superior and inferior conjunctival cul-de-sacs for foreign material. in such cases, placement of a topical anesthetic and use of a moistened cotton swab is invaluable to sweep the conjunctival fornix to pick up foreign bodies. use a small, fine-tipped forceps to retract the third eyelid away from the globe and examine behind the third eyelid for foreign bodies. next, examine the cornea for opacities, ulcers, foreign bodies, abrasions, or lacerations. place a small amount of fluroescein stain mixed with sterile water or saline on the dorsal sclera. close the eye to disperse the stain over the surface of the cornea, then flush gently with sterile saline irrigation. examine the cornea again for any defects. a linear defect perpendicular to the long axis of the eye should alert the clinician to investigate the conjunctiva for dystechia. record the pupil size, shape, and response to light (both direct and consensual). examine the anterior chamber and note its depth and whether hyphema or aqueous flare are present. is the lens clear and is it in the normal position? lens luxation can cause the lens tissue to touch the cornea and cause acute corneal edema. measure intraocular pressure with a schiotz tonometer or tonopen. finally, dilate the pupil and examine the posterior chamber using a direct or indirect ophthalmoscope to look for intraocular hemorrhage, retinal hemorrhage, retinal detachment, tortuous retinal vessels, optic neuritis, and inflammation. the basic surgical instruments listed in box - may be useful in the treatment of ocular lacerations and other ophthalmic injuries: bite wounds and automobile trauma commonly cause lacerations and abrasions of the lid margins. the lids can be considered to be two-layer structures, with the anterior composed of the skin and orbicularis muscle and the posterior layer composed of the tarsus and conjunctiva. the openings of the meibomian glands in the lid margin form the approximate line separating the lids into anterior and posterior segments. splitting the lid into these two segments facilitates the use of sliding skin flaps to close wound defects, if necessary. clean and thoroughly but gently irrigate the wound with sterile saline solution before attempting any lid laceration repair. use sterile saline solution to irrigate the wound and conjunctiva. a % povidone-iodine scrub can be used on the skin, taking care to avoid getting any scrub material in the soft tissues of the eye. drape the eye with an adhesive ocular drape, if possible, to prevent further wound contamination. trim the ragged wound edges, but be very conservative with tissue debridement. leave as much tissue as possible to insure proper wound contracture with minimal lid deformity. close a small lid wound with a figure-of-eight or two-layered simple interrupted suture of absorbable suture material or nylon in the skin. the lid margins must be absolutely apposed to prevent postoperative lid notching. direct blunt trauma to the eye can cause severe ecchymosis because of the excellent vascular supply of the eyelids. other associated ocular injuries such as orbital hemorrhage, proptosis, and corneal laceration may also occur. trauma, allergic reactions, inflammation of the sebaceous glands (hordeolum), thrombocytopenia, and vitamin k antagonist rodenticide intoxication can all cause ecchymoses of the lids. treat eyelid ecchymoses initially with cool compresses, followed by warm compresses. resorption of blood can occur from to days after the initial insult. ocular allergies respond well to topical application (dexamethasone ophthalmic ointment q - h) and systemic administration of glucocorticosteroids, along with cool compresses. in order to fully assess the conjunctiva for abnormalities, it may be necessary to carefully dissect it away from the underlying sclera. when performing this dissection, do not place undue pressure on the globe because of the risk of herniation of the intraocular contents through a scleral wound. repair large conjunctival lacerations with - absorbable sutures, using an interrupted or continuous pattern. carefully approximate the margins of the conjunctiva to prevent formation of inclusion cysts. when large areas of the conjunctiva have been damaged, advancement flaps may be required to close the defect. subconjunctival hemorrhage is a common sequela of head trauma, and it may also be observed in various coagulopathies. by itself, it is not a serious problem but may signify severe underlying intraocular damage. a complete ocular examination is indicated. other causes of subconjunctival hemorrhage include thrombocytopenia, autoimmune hemolytic anemia, hemophilia, leptospirosis, vitamin k antagonist rodenticide intoxication, severe systemic infection or inflammation, and prolonged labor (dystocia). uncomplicated subconjunctival hemorrhage usually clears on its own within days. if the conjunctiva is exposed because of swelling and hemorrhage, administer a topical protective triple antibiotic ophthalmic ointment every to hours until the conjunctival hemorrhage resolves. toxic, acid, and alkaline chemical injuries to the eye can sometimes occur. the severity of the injury caused by ocular burns depends on the concentration, type, and ph of the chemical and on the duration of exposure. weak acids do not penetrate biologic tissue very well. the hydrogen ion precipitates the protein upon contact and therefore provides some protection to the corneal stroma and intraocular contents. precipitation of corneal proteins produces a ground-glass appearance in the cornea. alkaline solutions and very strong acids penetrate tissues rapidly, causing saponification of the plasma membrane, denaturation of collagen, and vascular thrombosis within the conjunctiva, episclera, and anterior uvea. severe pain, blepharospasm, and photophobia are produced by exposure of free nerve endings in the corneal epithelium and conjunctiva. severe alkaline burns cause an increase in intraocular pressure. intraocular prostaglandins are released, and the intraocular aqueous ph increases, producing changes in the blood-aqueous barrier and secondary uveitis. uveitis with anterior synechia formation, eventual chronic glaucoma, phthisis, secondary cataract, and corneal perforation can occur. healing of the corneal epithelium is usually accomplished by neovascularization and sliding and increased mitosis of the corneal epithelium. severe stromal burns within the cornea heal by degradation and removal of necrotic debris, followed by replacement of the collagen matrix and corneal epithelial cells. the release of collagenase, endopeptidase, and cathepsins from polymorphonuclear cells serves to cause further corneal breakdown. in severe cases, only pmns may be present, and fibroblasts may never invade the corneal stroma. all chemical burns should be washed copiously with any clean aqueous solution available. if any sticky paste or powder is adherent to the conjunctival sac, remove it with moist cotton swabs and irrigation. begin mydriasis and cycloplegia by topical application of % atropine ophthalmic drops or ointment. start antibiotic therapy with triple antibiotic ophthalmic ointment or gentocin ointment every to hours. treat secondary glaucomas with topical carbonic anhydrase inhibitors. to avoid fibrinous adhesions and symblepharon formation, keep the conjunctival cul-de-sacs free of proteinaceous exudate that can form adhesions. analgesics are required for pain. oral nonsteroidal antiinflammatory agents such as carprofen, ketoprofen, meloxicam, or aspirin are recommended. persistent epithelial erosions may require a conjunctival flap left in place for to weeks or placement of a topical collagen shield (contact lens). topical antibiotics, mydriatics, and lubricants (lacrilube or puralube ointment) should also be used. strong acid or alkali burns can result in severe corneal stromal loss. in the past, topical n-acetylcysteine ( % mucomyst) has been recommended. this treatment is very painful. other treatments are also available, such as ethylenediaminetetraacetic acid (edta) ( . m solution) and patient serum to inhibit mammalian collagenase activity. to prepare patient serum, obtain to ml of whole blood from the patient. spin it down in a serum separator tube after a clot forms and then place the serum in a red-topped tube on the patient's cage. (the contents of the tube are viable for days without refrigeration.) apply the serum topically to the affected eye every to hours. avoid using topical steroids because they inhibit fibroblast formation and corneal healing. in severe cases, if conjunctival swelling and chemosis also are present, antiinflammatory doses of oral steroids can be administered short-term. oral steroids and nonsteroidal antiinflammatory drugs should never be administered to the patient concurrently, because of the risk of gastrointestinal ulcer and perforation. corneal abrasions are associated with severe pain, blepharospasm, lacrimation, and photophobia. animals with such intense pain are often difficult to examine until analgesia has been administered. topical use of proparacaine ( . % proparacaine hydrochloride) is usually sufficient to permit relaxation of the eyelids so that the eye can be examined. using a focal source of illumination and an eye loupe, examine the cornea, inferior and superior conjunctival fornixes, and medial aspect of the nictitans for foreign bodies. place a sterile drop of saline on a fluorescein-impregnated strip and touch the superior conjunctiva once to allow the stain to spread onto the surface of the eye. irrigate the eye to remove excess stain and then examine the corneal surface for any areas of stain uptake. if an area of the cornea persistently remains green, there is damage to the corneal epithelium in that area. initial treatment consists of application of a topical mydriatic ( drop of % atropine in affected eye q h) to prevent anterior synechiae and improve cycloplegia. triple antibiotic ointment is the treatment of choice (a / -inch strip in the affected eye q h) until the ulcer heals. in some cases, nonhealing ulcers (e.g., boxer ulcer, indolent ulcer) form in which the epithelial growth does not adhere to the underlying cornea. gently debride the loose edges of the ulcer/erosion with a cotton swab and topical anesthesia. more severe cases in which only minimal healing has occurred after days of treatment require grid keratectomy, in which a -gauge needle is used to gently scratch the surface of the abrasion or ulcer in the form of a grid to promote neovascularization. apply a topical anesthetic before performing the procedure. a collagen contact lens also may be required to promote wound healing. all corneal abrasions should be reevaluated in hours, and then every to days thereafter until they have healed. acute infectious keratitis secondary to bacterial infection is characterized by mucopurulent ocular discharge, rapidly progressing epithelial and corneal stromal loss, inflammatory cellular infiltrates into the corneal stroma, and secondary uveitis, often with hypopyon formation. confirmation of infectious keratitis is based on corneal scrapings and a positive gram stain. initial treatment for bacterial keratitis consists of systemic antibiotics and topical ciprofloxacin ( . % eyedrops or ointment). penetrating injuries through the cornea may result in prolapse of intraocular contents. frequently, pieces of uveal tissue or fibrin effectively but temporarily seal the defect and permit the anterior chamber to re-form. avoid manipulation of these wounds until the animal has been anesthetized, as struggling or excitement can promote loss or dislodgement of the temporary seal and cause the intraocular contents to be extruded. superficial corneal lacerations need not be sutured and can be treated the same as a superficial corneal ulcer or abrasion. if the laceration penetrates more than % the thickness of the cornea, or extends more than to mm, it should be sutured. when placing sutures in the cornea, it is helpful to use magnification. referral to a veterinary ophthalmologist is advised. if a veterinary ophthalmologist is not available, use - or - silk, collagen, or nylon sutures on a micropoint spatula-type needle. use a simple interrupted suture pattern and leave the sutures in place for a minimum of weeks. because many corneal lacerations are jagged and corneal edema forms, most of the wound edges cannot be tightly juxtaposed. in such cases, pull a conjunctival flap across the wound to prevent leakage of aqueous fluid. never suture through the full thickness of the cornea; rather, the suture should pass through the mid-third of the cornea. following closure of the corneal wound, the anterior chamber must be re-formed to prevent anterior synechia formation with secondary glaucoma. taking care to avoid iris injury, use a -or -gauge needle to insert sterile saline at the limbus. any defect in the suture line will be apparent because of leakage of the fluid from the site and should be repaired. incarceration of uveal tissue in corneal wounds is a difficult surgical problem. persistent incarceration of uveal tissue can result in development of a chronic wick in the cornea, a shallow anterior chamber, chronic irritation, edema, vascularization of the cornea, and intraocular infection that can lead to panophthalmitis. referral to a veterinary ophthalmologist is strongly recommended. the most common foreign bodies associated with ocular injuries in small animals are birdshot, bb pellets, and glass. the site of intraocular penetration of the foreign bodies may be obscured by the eyelids. a foreign body entering the eye may penetrate the cornea and fall into the anterior chamber or become lodged in the iris. foreign bodies may occasionally penetrate the lens capsule, producing cataracts. some metallic high-speed foreign bodies may penetrate the cornea, iris, and lens to lodge in the posterior wall of the eye or vitreous chamber. direct visualization of a foreign body is the best means of localization. examination of the eye with an indirect ophthalmoscope or biomicroscope (if available) is invaluable for locating foreign bodies. indirect visualization of the ocular foreign body can also be achieved through radiographic techniques. three separate views should be obtained to determine the plane of location of the foreign object. ct or mri may prove useful, although scatter from the foreign body may make it difficult to directly visualize with these techniques. ocular ultrasound is perhaps the most useful and refined radiographic technique for locating intraocular foreign bodies. before removing any foreign body from the eye, the risk and surgical danger of removing it must be weighed against the risks of leaving it in place. metallic foreign bodies in the anterior chamber are much easier to remove than nonmagnetic ones. attempted removal of foreign objects from the vitreous chamber of the eye has consistently produced poor results. for the best chance of recovery, ocular foreign bodies should be removed by a veterinary ophthalmologist whenever possible. blunt trauma to the globe can result in luxation or subluxation of the lens. the subluxated lens may move anteriorly and make the anterior chamber more shallow. trembling of the iris (iridodonesis) may be noticed when the lens is subluxated. in complete luxation, the lens may fall totally into the anterior chamber and obstruct aqueous outflow, causing secondary glaucoma. alternatively, the lens may be lost into the vitreous cavity. luxation of the lens is almost always associated with rupture of the hyaloid membrane and herniation of the vitreous through the pupillary space. emergency surgery for lens luxation is required if the lens is entirely within the anterior chamber or incarcerated within the pupil, causing a secondary pupillary block glaucoma. acute elevation in intraocular pressure can cause vision loss within hours; thus, lens removal should be accomplished as quickly as possible. referral to a veterinary ophthalmologist is recommended. severe trauma to the globe or a direct blow to the head can result in retinal or vitreous hemorrhage. there may be large areas of subretinal or intraretinal hemorrhage. subretinal hemorrhage assumes a discrete globular form, and the blood appears reddish-blue in color. the retina is detached at the site of hemorrhage. superficial retinal hemorrhage may assume a flame-shaped appearance, and preretinal or vitreous hemorrhage assumes a bright-red amorphous appearance, obliterating the underlying retinal architecture. retinal and vitreous hemorrhage secondary to trauma usually resorbs spontaneously over a -to -week period. unfortunately, vitreous hemorrhage, as it organizes, can produce vitreous traction bands that eventually produce retinal detachment. expulsive choroid hemorrhage can occur at the time of injury and usually leads to retinal detachment, severe visual impairment, and total loss of vision. treatment of vitreal and retinal hemorrhage includes rest and correction of factors that may predispose to intraocular hemorrhage. more complicated cases may require vitrectomy performed by a veterinary ophthalmologist. hyphema refers to blood in the anterior chamber of the eye. the most common traumatic cause of hyphema is an automobile accident. hyphema may also present because of penetrating ocular wounds and coagulopathies. blood within the eye may come from the anterior or posterior uveal tract. trauma to the eye may result in iridodialysis or a tearing of the iris at its root, permitting excessive bleeding from the iris and ciliary body. usually, simple hyphema resolves spontaneously in to days and does not cause vision loss. loss of vision following bleeding into the anterior chamber is associated with secondary ocular injuries such as glaucoma, traumatic iritis, cataract, retinal detachment, endophthalmitis, and corneal scarring. treatment of hyphema must be individualized, but there are severe general principles of treatment. first, stop ongoing hemorrhage and prevent further bleeding whenever possible. this may involve correction of the underlying cause, if a coagulopathy is present. next, aid in the elimination of blood from the anterior chamber, control secondary glaucoma, and treat associated injuries, including traumatic iritis. finally, detect and treat any late complications of glaucoma. in most cases of traumatic hyphema, little can be done to arrest or prevent ongoing hemorrhage. it is best to restrict the animal's activity and prohibit exertion. rebleeding can occur within days, and intraocular pressure must be monitored closely. after to days, the blood in the anterior chamber will change color from a bright red to bluish-black ("eight-ball hemorrhage"). if total hyphema persists and intraocular pressure rises despite therapy, surgical intervention by a veterinary ophthalmologist may be necessary. the primary route of escape of rbcs from the anterior chamber is via the anterior drainage angle. iris absorption and phagocytosis play a minor role in the removal of blood from the anterior chamber. because of the associated traumatic iritis in hyphema, topical administration of a glucocorticoid ( % dexamethasone drops or % prednisolone drops) is advised to control anterior chamber inflammation. a cycloplegic agent ( % atropine) should also be used. the formation of fibrin in the anterior chamber of the eye secondary to hemorrhage can produce adhesions of the iris and secondary glaucoma (see section on glaucoma secondary to hyphema) by blocking the trabecular network. hyphema secondary to retinal detachment (collie ectasia syndrome) and end-stage glaucoma are extremely difficult to treat medically and have a poor prognosis. proptosis of the globe is common secondary to trauma, particularly in brachycephalic breeds. proptosis of the globe in dolichocephalic breeds requires a greater degree of initiating contusion than the brachycephalic breeds because the orbits are so much deeper. therefore, secondary damage to the eye and cns associated with proptosis of the globe may be greater in the collie or greyhound than in the pug. when proptosis occurs, carefully evaluate the cardiovascular system for evidence of hypovolemic or hemorrhagic shock. examine the respiratory and neurologic systems. be sure to establish an airway and treat shock, if present. control hemorrhage and stabilize the cardiovascular system before attempting to replace the globe within its orbit or perform enucleation. during the initial management of the cardiovascular and respiratory systems, the eye should be covered with an ophthalmic grade ointment or sponges soaked in sterile saline to prevent the globe from drying out. proptosis of the globe can be associated with serious intraocular problems including iritis, chorioretinitis, retinal detachment, lens luxation, and avulsion of the optic nerve. stain the surface of the eye with fluorescein to look for topical abrasions or ulcers. carefully examine the sclera, cornea, and conjunctiva for penetrating injuries that may allow aqueous leakage. evaluate the size, location, and response to light of the pupil. a reactive pupil is better than a mydriatic fixed pupil. topical administration of a mydriatic (atropine %) to prevent persistent miosis and synechia formation is indicated, along with topical and oral antibiotics and oral analgesic therapy. reposition the proptosed globe with the patient under general anesthesia. make a lateral canthotomy incision to widen the palpebral fissure. lavage the globe with sterile saline irrigation to remove any external debris. place a copious amount of triple antibiotic ophthalmic ointment on the surface of the eye and then gently press the globe into the orbit using the flat side of a scalpel handle or a moistened sterile surgical sponge. do not probe the retro-orbital space with a needle or attempt to reduce intraocular pressure by paracentesis. when the globe is replaced in the orbit, close the lateral canthotomy incision with simple interrupted sutures. place three non-penetrating mattress sutures in the lid margins but do not draw them together. tighten the lid sutures through small pieces of a red rubber catheter or length of intravenous extension tubing to prevent the sutures from causing lid necrosis. leave the medial canthus of the eye open in order to allow topical treatment. postoperative treatment is directed at preventing further iritis and preventing infection. administer systemic broad-spectrum antibiotics (clavamox, . mg/kg po bid) and analgesic drugs. apply topical triple antibiotic ophthalmic ointment ( / inch in affected eye q - h) and atropine ( % in affected eye q h) to prevent infection, cycloplegia, and anterior synechiae. antiinflammatory doses of systemic steroids can also be added to the treatment if severe periorbital inflammation is present. systemic steroids should never be used in conjunction with nonsteroidal antiinflammatory drugs, because of the risk of gastrointestinal ulceration and perforation. the sutures should remain in place for a minimum of weeks. after this time, remove the sutures and inspect the globe. if proptosis recurs, repeat the treatment. following proptosis, strabismus is common secondary to periorbital muscle injury. even after extensive treatment, vision in the eye may still be lost. nonvisual eyes can remain in place, but phthisis may develop. carbonic anhydrase inhibitors such as acetazolamide and dichlorphenamide decrease aqueous secretion and may effectively reduce intraocular pressure if the trabecular outflow is still functioning at % of its capacity. an eye with a poorly functional trabecular outflow system will respond poorly to therapy with carbonic anhydrase inhibitors. osmotic agents such as mannitol or glycerol may be helpful in controlling glaucoma secondary to hyphema. reduction in vitreous chamber size can make the anterior chamber deeper and may allow increased aqueous outflow. evacuation of blood or blood clots from the anterior chamber is not advisable unless the glaucoma cannot be controlled medically or there is no indication after a prolonged period of time that blood is being resorbed. tissue plasminogen activator (t-pa) has proved to be useful in may be helpful in lysing blood clots and preventing excessive fibrin formation. the t-pa is reconstituted to make a solution of µ/ml, which is then frozen at − °c in . -ml aliquots. the thawed, warmed reconstituted t-pa is injected into the anterior chamber. blind probing of the anterior chamber of the eye and surgical intervention in an attempt to remove blood clots can cause serious complications such as rebleeding, lens luxation, iris damage, and damage to the corneal epithelium, and therefore is not advised. acute glaucoma is a rise in intraocular pressure that is not compatible with normal vision. glaucoma may present as early acute congestive or noncongestive glaucoma, or as end-stage disease. cardinal signs of glaucoma are a sudden onset of pain, photophobia, lacrimation, deep episcleral vascular engorgement, edematous insensitive cornea, shallow anterior chamber depth, dilated unresponsive pupil, loss of visual acuity, and buphthalmia. intraocular pressure usually exceeds mm hg but may be normal or only slightly increased if glaucoma is secondary to anterior uveitis. most forms of clinical glaucoma in dogs are secondary to some other intraocular problem. primary glaucoma is recognized in some breeds, including the bassett hound, cocker spaniel, samoyed, bouvier des flandres, and some terrier breeds either from goniodysgenesis or a predisposition to lens luxation. other common causes of acute glaucoma are anterior uveitis and intumescent lens secondary to rapid cataract development, particularly in dogs with diabetes mellitus. treatment involves investigation of the underlying cause of the sudden rise in intraocular pressure and rapid reduction in intraocular pressure. permanent visual impairment is often associated with chronically buphthalmic globes or the presence of rippling or striae formation on the cornea. referral to a veterinary ophthalmologist is recommended. if the eye is still visual and not buphthalmic, the prognosis is favorable, depending on the cause of the acute glaucoma. treatment to reduce intraocular pressure consists of improving aqueous outflow, reducing intraocular volume with osmotic agents, and reducing aqueous formation (table - ). the use of topical mydriatic agents in acute glaucoma is contraindicated because of the risk of making lens luxation or anterior uveitis worse. referral to a veterinary ophthalmologist for emergency surgery is indicated in cases of iris bombe, intumescent lens, or lens subluxation. administer osmotic agents to reduce the size of the vitreous body and the amount of aqueous. osmotic agents create an osmotic gradient between the intraocular fluids and the emergency management of specific conditions vascular bed, thus allowing osmotic removal of fluid independent of the aqueous inflow and outflow systems. if no other treatments are available, oral glycerol ( %, . ml/kg or . g/kg) can be used to effectively reduce intraocular pressure. an adverse side effect of oral glycerol treatment is protracted vomiting. do not use glycerol in a diabetic patient. mannitol ( - g/kg iv over hour) also effectively reduces intraocular pressure but does not cause vomiting. carbonic anhydrase inhibitors can be used to reduce intraocular volume by reducing aqueous production. oral administration of dichlorphenamide, methazolamide, and acetazolamide ( - mg/kg) is usually not very effective alone in reducing aqueous volume and intraocular pressure and also can cause metabolic acidosis. topical carbonic anhydrase inhibitors appear to be more effective (dorzolamide, trusopt) when used in conjunction with topical beta-blockers (timolol, . % or . % solution q h). the most effective treatment for acute pressure reduction is use of a topical prostaglandin inhibitor (latanaprost). usually just one or two drops effectively reduces intraocular pressure in the emergency stages, until the patient can be referred to a veterinary ophthalmologist the following day. many clinical conditions that are presented as emergencies may be due in part or wholly to the presence of a neoplasm. paraneoplastic signs are summarized in table - . prompt identification of the neoplasia combined with knowledge of treatment, expected response to therapy, and long-term prognosis can aid owners and practitioners in making appropriate treatment decisions. hemorrhage or effusion can occur in any body cavity as a result of the presence of benign or malignant tumors. tumors secrete anticoagulants to allow angiogenesis to grow unchecked. hemorrhage often occurs as a result of rupture of a neoplasm or invasion of a neoplasm into a major vascular structure. effusion may be the result of direct fluid production by the mass or may be due to obstruction of lymphatic or venous flow. hemorrhagic effusions in the abdominal cavity occur most commonly with neoplastic masses of the spleen or liver. the most common causes are hemangiosarcoma and hepatocellular carcinoma. clinical signs associated with acute abdominal hemorrhage, regardless of the cause, are related to hypovolemic shock and decreased perfusion and include pale mucous membranes, tachycardia, anemia, lethargy, and acute collapse. treatment for abdominal hemorrhage includes placement of a large-bore peripheral cephalic catheter and starting one fourth of a shock dose ( ml/kg/hour for dogs, and ml/kg/hour for cats) of intravenous crystalloid fluids, taking care to carefully monitor perfusion parameters of heart rate, capillary refill time, mucous membrane color, and blood pressure. administer intravenous colloids such as dextran- , hetastarch, and oxyglobin ( - ml/kg iv bolus) to restore intravascular volume and normotension. treat severe anemia with whole blood or packed rbcs to improve oxygen-carrying capacity and oxygen delivery (see sections on transfusion medicine and treatment of shock). confirm the presence of hemoabdomen abdominocentesis (see section on abdominocentesis). the presence of nonclotting hemorrhagic effusion is consistent with free blood. packed cell volume of the fluid is usually the same or higher than that of the peripheral blood. an abdominal compression bandage can be placed while further diagnostics are being performed. in cases of acute hemoabdomen, obtain right lateral, left lateral, and ventrodorsal or dorsoventral thoracic radiographs to help rule out obvious metastasis. monitor the patient's ecg and correct dysrhythmias as necessary (see section on cardiac dysrhythmias). surgery is indicated once the patient is stabilized. in some cases, hemorrhage is so severe that the patient should be taken immediately to surgery. when recommending surgery for a hemorrhaging intraabdominal mass, it is important to discuss likely diagnoses and long-term prognosis with the owner. hemangiosarcoma usually involves the spleen or liver or both. the presence of free abdominal hemorrhage is associated with a malignant tumor in % of cases. even when free abdominal hemorrhage is not present, the tumor is malignant in % of cases. approximately % (two thirds) of masses in the spleen are malignant (hemangiosarcoma, lymphoma, mast cell tumor, malignant fibrous histiocytoma, leiomyosarcoma, fibrosarcoma), and approximately one third are benign (hematoma, hemangioma). hepatocellular carcinoma usually affects one liver lobe (usually the left), and surgery is the treatment of choice. with complete surgical excision, median survival in dogs is longer than days. if diffuse disease is observed at the time of surgery, the prognosis is poor. nonhemorrhagic effusions are associated with mesothelioma, lymphoma, carcinomatosis, or any mass that causes vascular or lymphatic obstruction. clinical signs of respiratory distress and abdominal distention with nonhemorrhagic effusions are usually slowly progressive in onset and not as severe as those observed with hemorrhage. treatment is usually aimed at identification of the underlying cause. obtain a fluid sample via thoracocentesis or abdominocentesis. to obtain further cells for cytologic evaluation, aspirate fluid from the thoracic or abdominal mass with ultrasound guidance. cytologic evaluation of the fluid will often elucidate the causative tumor type. an abdominal ultrasound can determine the degree of metastasis. perform therapeutic abdominocentesis or thoracocentesis if the effusion is causing respiratory difficulty. rapid re-accumulation of the fluid potentially can cause hypoproteinemia and hypovolemic shock. mesothelioma is a rare tumor most commonly observed in urban environments. in humans, mesothelioma has been associated with exposure to asbestos. it is sometimes difficult to differentiate between reactive mesothelial cells and malignant mesothelial cells. treatment is aimed at controlling the neoplastic effusion. intracavitary cisplatin has been demonstrated to slow rates of fluid re-accumulation, but is largely a palliative therapy. lymphoma is another tumor type that can cause thoracic or abdominal effusion. cytologic evaluation of the fluid usually reveals abundant lymphoblasts. treatment with multiagent chemotherapy protocols, with or without adjunctive radiation therapy, can prevent tumor remission and stop fluid accumulation. carcinomatosis occurs as a result of diffuse seeding of the abdominal cavity with malignant carcinomas and has a poor prognosis. carcinomatosis may occur de novo or from metastasis of a primary tumor. treatment consists of fluid removal when respiratory difficulty occurs, with or without intracavitary cisplatin as a palliative measure. cisplatin should never be used in cats due to fatal acute pulmonary edema. clinical signs of hemorrhagic thoracic effusion include acute respiratory distress, anemia, hypovolemic or cardiogenic shock, and collapse. hemorrhagic thoracic effusions are rare in association with neoplastic effusions. a notable exception is intrathoracic hemorrhage in young dogs with osteosarcoma of the rib. hemorrhage can result when a primary lung tumor erodes through a vessel. hemangiosarcoma of the lungs or right auricular area can also result in hemorrhagic thoracic effusion. in many cases, hemorrhage may be confined to the pericardial sac with a right auricular mass, causing a globoid cardiac silhouette on thoracic radiographs. treatment consists of pericardiocentesis (see section on pericardial effusion and pericardiocentesis) and placement of a pericardial window, or the mass may be removed if it is in the right auricular appendage and resectable. although surgery can resolve clinical signs of right-sided heart failure, metastatic disease often develops soon afterward. nonhemorrhagic thoracic effusion is more common than hemorrhagic thoracic effusion, and is caused most commonly by mesothelioma, lymphoma, carcinomatosis, and thymoma. clinical signs develop gradually and include respiratory difficulty, cyanosis, and cough. supplemental oxygen should be administered. in many cases, thoracocentesis can be therapeutic and diagnostic. obtain thoracic radiographs both before and after thoracocentesis to determine whether a mass effect is present. following identification of a cause, definitive therapy can be instituted. mesotheliomas are rare and are associated with diffuse serosal disease. they are more common in dogs than in cats. effusions caused by mesotheliomas can affect the pleural or pericardial cavities. treatment is directed at removing effusion fluid and controlling reaccumulation with use of intracavitary platinum compounds, carboplatin, and cisplatin can be used in dogs. (cisplatin and carboplatin should never be used in cats.) chemical or physical pleurodesis may be helpful in controlling reaccumulation of fluid, but it is very painful in small animal patients. thoracic effusion secondary to lymphoma often is associated with an anterior mediastinal mass. t-cell lymphoma is the most common type of mediastinal mass observed in dogs. b-cell lymphoma is associated with a decreased response to chemotherapy and shorter survival times. treatment consists of combination chemotherapy with or without radiation therapy to decrease mass size. carcinomatosis is a diffuse disease of the pleural cavity that often is a result of metastasis from a primary pulmonary carcinoma or mammary adenocarcinoma. treatment is similar to that for mesothelioma and is aimed at controlling the effusion and delaying its recurrence. thymomas have been documented in both dogs and cats. dogs most commonly present with a cough, while cats present with clinical signs of respiratory distress and a restrictive respiratory pattern associated with the presence of pleural effusion. an anterior mediastinal mass is often observed on thoracic radiographs. in some cases, the pleural effusion must be drained via thoracocentesis before a mass is visible. ultrasound-guided aspiration and cytologic evaluation of the mass reveal a malignant epithelial tumor with small lymphocytes and mast cells. prognosis is good if the tumor can be completely excised. treatment consists of surgical removal with or without presurgical radiation therapy to shrink the mass. paraneoplastic syndromes of myasthenia gravis have been documented in dogs with thymomas. if megaesophagus or aspiration pneumonia is present, the prognosis is more guarded because of the high rate of complications. obstructive lesions affecting the urinary tract can be extramural (intra-abdominal, pelvic, or retroperitoneal) or intramural (urethral, bladder, or urethral wall) . transitional cell carcinoma is the most common type of bladder tumor observed in dogs. prostatic adenocarcinoma, or neoplasia of the sublumbar lymph nodes (lymphoma, adenocarcinoma from apocrine gland adenocarcinoma), also can cause urethral obstruction. treatment is aimed at relieving the obstruction and then attempting to identify the cause of the disease. to alleviate the obstruction, pass a urinary catheter whenever possible. perform cystocentesis only as a last resort because of the risk of seeding the peritoneal cavity with tumor cells if transitional cell carcinoma is the cause of the obstruction. institute supportive therapy including intravenous fluids and correction of electrolyte abnormalities. plain radiographs may reveal a mass lesion or may not be helpful without double contrast cystography. abdominal ultrasound is more sensitive in identifying a mass lesion in the urinary bladder. masses in the pelvic urethra are difficult to visualize with ultrasonography. double contrast cystourethrography is preferred. once the patient is stabilized, biopsy or surgery is indicated to identify the cause of the mass and attempt resection. urine tests for transitional cell carcinoma are available for identification of transitional cell carcinoma in the dog. complete surgical excision of transitional cell carcinoma or removal of benign tumors of the urinary bladder yields a favorable prognosis. poorer prognosis is seen with incomplete excision. many transitional cell carcinomas are located in the trigone region of the bladder and cannot be completely excised. the nonsteroidal antiinflammatory drug piroxicam is helpful in alleviating clinical signs for a reported -month median survival. in some dogs, cisplatin and carboplatin may delay recurrence of transitional cell carcinoma. tumors of the prostate gland are always malignant and occur with equal frequency in castrated and uncastrated male dogs. diagnosis of prostatic tumors is based on ultrasonographic evidence of a mass effect or prostatomegaly and on transrectal or transabdominal aspiration or biopsy. surgery, chemotherapy, and radiation therapy generally are unrewarding over the long term, although palliative radiation therapy may relieve clinical signs for to months. luminal tumors of the gastrointestinal tract typically cause obstruction, with slowly progressive clinical signs including vomiting, inappetence, and weight loss, or with acute severe protracted vomiting. extraluminal obstructive lesions usually arise from adhesions, or strangulation may occur, resulting in obstruction. perforation of the mass through the gastric or intestinal wall can cause peritonitis. treatment consists of initial stabilization and rehydration, evaluation for evidence of metastasis, and surgical resection of the affected area in cases of adenocarcinoma, leiomyoma, leiomyosarcoma, and obstructive or perforated lymphoma. gastric and intestinal adenocarcinoma are the most common gastrointestinal tumors observed in dogs. affected animals typically have a history of anorexia, weight loss, and vomiting. obtain an abdominal ultrasound before performing any surgery. fine needle aspirates of the mass and adjacent lymph nodes are usually diagnostic and can determine whether there is local metastasis. many tumors are not resectable, and metastasis occurs in approximately % of cases. dogs with smaller tumors that can be resected typically have longer survival times. leiomyosarcomas occur in the intestines of dogs, and carry a more favorable prognosis than adenocarcinoma if the mass can be completely resected. with complete resection, the average survival time is longer than year. the paraneoplastic syndrome of hypoglycemia has been observed with this tumor type. gastrointestinal lymphoma is the most common tumor of the gastrointestinal tract observed in cats. in comparison, it is relatively rare in dogs. unless there is complete obstruction or perforation of the gastrointestinal tract, surgical treatment for gastrointestinal lymphoma is not indicated. rather, multiple chemotherapy drugs are used in combination to achieve remission and resolution of the clinical signs of anorexia, weight loss, and vomiting. treatment responses unfortunately are poor. mast cell tumors of the gastrointestinal tract typically are manifested as gastrointestinal ulceration and hemorrhage in up to % of patients. the gastrointestinal hemorrhage that occurs with mast cell tumors results from increased acid secretion as a result of histamine receptor stimulation. treatment consists of histamine or proton pump inhibition (ranitidine, famotidine, cimetidine, or omeprazole). bowel perforation is a rare complication. many chemotherapy agents exert their effects on rapidly dividing normal and neoplastic cells. normal tissues that are commonly affected include the bone marrow, gastrointestinal tract, skin and hair follicles, and reproductive organs. some drugs have unique organspecific toxicities that must be monitored. knowledge and recognition of the expected type and onset of complications can alleviate their severity by rapid treatment, when complications occur (see table - ) . neutropenia is the most common bone marrow toxicity observed secondary to chemotherapy in small animal patients (table - ) . in most cases, the neutropenia is dose-dependent. the nadir, or lowest neutrophil count, is typically observed to days after chemotherapy treatment. once the nadir occurs, bone marrow recovery is observed, with an increase in circulating neutrophils within to hours (table - ) . treatment of myelosuppression is largely supportive to treat or prevent sepsis. prophylactic antibiotics are recommended in the afebrile patient with a neutrophil count < /µl. acceptable antibiotics include trimethoprim-sulfa and amoxicillin-clavulanate. granulocyte-colony stimulating factor (g-csf) (e.g., neupogen) is a recombinant human product that stimulates the release of neutrophils from the bone marrow, and its use shortens the recovery time following myelosuppressive drug therapy. disadvantages of g-csf include antibody production in response to the drug within weeks of use and its high cost. to prevent ongoing neutropenia, subsequent chemotherapy dosages should be decreased by %, and the interval in between treatments increased. whenever possible, overlap of myelosuppressive drugs should be avoided. acute gastrointestinal toxicity can occur within to hours after administration of cisplatin and actinomycin d. in many cases, pretreatment with the antiemetics metoclopramide, butorphanol, chlorpromazine, dolasetron or ondansetron can prevent chemotherapyinduced nausea and vomiting. vomiting can also occur as a delayed side effect to days after treatment with doxorubicin (adriamycin), actinomycin d, methotrexate, and cytoxan. in delayed reactions, vomiting and diarrhea are caused by damage to intestinal crypt cells. treatment consists of administration of antiemetics, intravenous fluids, and a bland highly digestible diet. doxorubicin also can cause hemorrhagic colitis within to days of administration. treatment includes a bland diet, metronidazole, and tylosin tartrate (tylan powder). emergency care mild to none not observed vincristine (low-dose), l-asparaginase, glucocorticosteroids moderate - days melphalan, cisplatin, mitoxantrone, actinomycin d severe - days doxorubicin, cyclophosphamide, vinblastine paralytic ileus can be observed to days after administration of vincristine. this side effect is more common in humans than animals and can be treated with metoclopramide once a gastrointestinal obstruction has been ruled out. cardiotoxicity doxorubicin (adriamycin) causes a dose-dependent dilative cardiomyopathy when the cumulative dose reaches to mg/m . in many cases, however, clinical signs do not occur until the cumulative dose is mg/m . the myocardial lesions are irreversible. treatment of cardiac dysrhythmias is dependent on the type of dysrhythmia (see section on treatment of dysrhythmias). discontinue doxorubicin and administer diuretics and positive inotropic therapy for dilative cardiomyopathy in order to delay the progression of congestive heart failure (see sections on treatment of congestive heart failure). if abnormalities are shown on electrocardiography performed before beginning therapy, substitute liposome-encapsulated doxorubicin or mitoxantrone substituted in the chemotherapy protocol. cardioprotectant drugs such as vitamin e, selenium, and n-acetyl cysteine have shown some promise in the prevention of doxorubicin-induced cardiotoxicity. cyclophosphamide can cause a sterile hemorrhagic cystitis. damage to the urinary bladder mucosa and vessels is caused by the toxic metabolite acrolein. clinical signs of sterile hemorrhagic cystitis include a history of cyclophosphamide administration, stranguria, hematuria, and pollakiuria. treatment for sterile hemorrhagic cystitis is discontinuation of the drug, treatment of any underlying urinary tract infection with antibiotic therapy based on susceptibility testing, and intravesicle drug administration. in extremely refractory cases, surgical debridement and cauterization of the bladder mucosa may be necessary. prevention of sterile hemorrhagic cystitis includes emptying the bladder frequently and administering the drug in the morning. concurrent administration of prednisone can induce polyuria and polydipsia. if sterile hemorrhagic cystitis occurs, chlorambucil can be substituted as a chemotherapeutic agent. anaphylactic reactions have been observed with the administration of l-asparaginase, adriamycin, etoposide, and paclitaxel. the risk of anaphylaxis increases with repeated administration, although in some animals anaphylaxis will occur on the first exposure to the drug. treatment consists of administration of epinephrine, diphenhydramine, famotidine, and glucocorticosteroids, as with any other life-threatening allergic reaction (see section on treatment of allergic reactions). to decrease the risk of an adverse reaction, give diphenhydramine ( . mg/kg im) to minutes before drug administration. slowing the rate of intravenous infusion also can decrease the chance of an anaphylactic reaction. cisplatin can cause a fatal irreversible pulmonary edema in cats, even at low dosages. -fluorouracil ( -fu) can cause a severe neurotoxicity in cats that results in ataxia and seizures. never use cisplatin or -fu in cats. poisoning cases benefit from a rapid, organized approach. key points in this approach are giving appropriate advice over the telephone, being able to access information sources, and providing appropriate treatment. there are only a few classes of poisons that account for the majority of toxicities reported in dogs and cats. every veterinarian should develop a familiarity with the clinical management of rodenticide and insecticide toxicity and be prepared with antidotes on hand. beyond the most common toxins, the spectrum of possibilities is endless, and the veterinarian must rely on appropriate information resources. it is important to have available a comprehensive source of pharmaceutical and plant identification resources. remarkably, considering the myriad of potentially toxic substances to which an animal can be exposed, relatively few specific antidotes are commonly used in veterinary medicine. because of the lack of specific antidotes, the veterinarian must treat each toxicity with general methods of poison management, applying basic critical care in the treatment of specific clinical signs associated with the poison exposure or toxicity. the adage "treat the patient, not the poison" often comes into play when the exact toxic substance is unknown, or has no specific antidote. before an animal arrives, the staff should be prepared to ask specific questions over the phone, and provide initial advice for clients, particularly if the animal lives some distance from the hospital (box - .) it is important to have access to a database of information on toxic substances. thousands of potentially toxic substances are available on the market today. the american society for the prevention of cruelty to animals (aspca) animal poison control center provides direct access to veterinary toxicologists hours a day, days a year. for additional information, call the nearest veterinary school or emergency center (box - ). also, see section for a table of emergency hotlines. check your local telephone book for a poison control center listing under emergency numbers, usually found on the front cover. although these numbers are for human poisonings, they have access to extensive poison and toxin databases and can potentially provide useful information for veterinarians, particularly regarding antidotal substances suitable for out of the ordinary toxins and human medications. information on the toxic ingredients in thousands of medications, insecticides, pesticides, and other registered commercial products has been confidentially placed by the government in these poison control centers. as new products are marketed, information regarding toxin ingredients is forwarded to the centers. various e-mail discussion lists can serve as an informative resource for practitioners, but access generally requires an initial subscription and may have the disadvantage of delayed *do not keep the client on the telephone for too long. lengthy histories can be performed once the animal is at your hospital and you have started to initiate treatment. † hair dressing products sometimes have hydrogen peroxide as a % w/v; this concentration is not suitable for induction of emesis. is your animal breathing or does it have respiratory difficulty? what is the color of the gums or tongue? is your animal able to walk? is there any vomiting, diarrhea, trembling, or seizures? does it appear lethargic or hyperactive? what is the substance that your animal ingested (was exposed to)? did you witness the ingestion or exposure? how much did the animal consume? how long ago was the exposure? was the substance swallowed, or is it on the animal's skin or eyes? how is the patient acting? how long has the animal been acting that way? or when was the last time you saw your animal act normally? . first aid instructions for the client: induce vomiting at home and save the vomitus. never induce vomiting if the patient is depressed, appears comatose, or is actively seizing. if the animal has ingested a caustic substance (strong alkali or acids) or a petroleum-based product (kerosene or turpentine), never recommend induction of emesis. hydrogen peroxide ( % w/v † ) ml = tsp/ lb of body weight can repeat once if no vomiting occurs after minutes . remind the owner to bring a sample of the toxin and the vomitus in with the patient. . advise the owner to transport the patient as rapidly as possible to the nearest veterinary hospital. response times. they are useful for ideas on standard and long-term therapy, but not emergency stabilization. an exception to this is the veterinary interactive network (vin), which posts message board communications. previous communications from veterinarians who treated a case with the same poison/toxin can be accessed with a subscription. many manufacturers operate an information service about their products. if the product label or name is available, check for a telephone number that may route you to a specialist. there are six essential steps in treating toxicities: . performing a physical examination . stabilizing the patient's vital signs . taking a thorough history . preventing continued absorption of the toxin . administering specific antidotes when available . facilitating clearance or metabolism of the absorbed toxin it is most important to provide symptomatic and supportive care both during and following emergency treatment. immediately on presentation, perform a brief but thorough physical examination. obtain a minimum database as well as serum, urine, or orogastric lavage samples for later toxicologic analyses. it is important at this time to systematically evaluate the patient's physical status, focusing particularly on the toxins most common to a particular geographic location and the organ systems most commonly affected by toxins in veterinary medicinenamely, the neurologic and gastrointestinal tracts. a checklist is useful when performing a complete physical examination (box - ). the minimium database includes a urine sample, packed cell volume, total protein, serum urea, and serum glucose. the information obtained from these simple cage-side tests is useful for determining dehydration, hemoconcentration, azotemia (renal or prerenal), and hypo-or hyperglycemia. when appropriate, obtain samples for serum biochemistry profiles, serum electrolytes, blood gases, serum osmolality, a complete hemogram, and coagulation profiles. samples of serum, urine, and any vomitus or orogastric lavage contents should be collected and saved for later toxicologic analyses as required later. stabilization of vital signs includes four major goals of treatment: maintain respiration, maintain cardiovascular function, control cns excitation, and control body temperature. in any patient with clinical signs of respiratory distress or respiratory dysfunction, supplemental oxygen should be administered via flow-by, oxygen hood, oxygen cage, nasal, nasopharyngeal, or transtracheal oxygen sources. ventilatory assistance may be necessary. irritant or corrosive substances can cause damage to the oropharyngeal mucosa to such an extent that airway obstruction occurs. when necessary, a temporary tracheostomy should be performed. arterial blood gases, pulse oximetry, and capnometry may be required to monitor oxygenation and ventilation. at the time of presentation, immediately place an intravenous catheter for administration of intravenous fluids, inotropes, antiarrhythmics, and antidotes, if necessary. the initial fluid of choice is a balanced crystalloid solution such as normosol-r, plasmalyte-m, or lactated ringer's solution. fluid therapy can later be changed based on the patient's acidbase and electrolyte status. some toxins can cause severe dysrhythmias and hyper-or hypotension. monitor blood pressure and perform ecg and correct any abnormalities according to standard therapy (see sections on hypotension and cardiac dysrhythmias). what is the pupil size? what is the pupil reactivity to light? is the ocular examination normal? what is the sensitivity to light or sound? nose: is it moist, dry, bubbling, or frothy, or caked with dirt? throat: are there any characteristic odors on the breath? are there any traces of foreign material on the tongue or in the crevices of the teeth or gums? are there petechiae or ecchymosis on the gums or bleeding from the gumline? what is the mucous membrane color? is it normal and pink, or dark red (injected), pale, or icteric? what is the capillary refill time? is it fast, normal, or slow? what is the patient's heart rate? are there any pulse deficits or dysrhythmias auscultated? what is the patient's blood pressure? what is the quality of the femoral pulse? is it synchronous with the heart rate, or are there dropped pulses? is the pulse bounding, normal, thready, or not palpable? what is the patient's electrocardiogram? what is the patient's respiratory rate? what is the patient's respiratory character? is it normal, fast, shallow, or labored? what do you hear on thoracic auscultation? do you hear harsh airway sounds or pulmonary crackles? what is the patient's rectal temperature? is there excessive salivation? is there evidence of vomiting or diarrhea? is abdominal palpation painful? do the intestinal loops feel normal, or are they fluid-filled or gas-filled? what is the color and consistency of the feces? is there a palpable urinary bladder? is there urine production? what is the color of the urine? peripheral lymph nodes should be normal in poisonings. some toxins cause hemolysis, methemoglobinemia, heinz body anemia, and coagulopathies. whole blood, fresh frozen plasma, packed rbcs, or hemoglobin-based oxygen carriers should be available and used if necessary. treat methemoglobinemia with a combination of ascorbic acid and n-acetylcysteine. many toxins affect the cns, producing clinical signs of excitation and/or seizures. diazepam is the drug of choice for most but not all seizures and tremors. if an animal has cns excitation secondary to the ingestion of selective norepinephrine reuptake inhibitors, avoid using diazepam, as it can potentially exacerbate clinical signs. muscle relaxants such as guaifenesin or methocarbamol may be required to control muscle spasm and tremors associated with some toxicities. consider animals that are in status epilepticus because of toxin exposure at high risk. such patients may not require the full dose of anesthetics or sedatives for seizure control. give phenobarbital ( - mg/kg iv) or pentobarbital ( - mg/kg iv to effect) for longer-term management of seizures. core body temperature can easily increase or decrease secondary to increased muscle activity or coma. animals may present as hypo-or hyperthermic, depending on the toxin ingested and the stage of toxicity. manage hypothermia with circulating hot water or hot air blankets, or place bubble wrap or saran wrap around the animal's peripheral extremities. manage hyperthermia by placing lukewarm wet towels on the patient until the rectal temperature has decreased to . °c ( °f). (see section on of hyperthermia and heat-induced illness). if sedatives or anesthetics have been used, initial hyperthermia may initially resolve due to hypothalamic loss of thermoregulatory control, cool water bathing should not be performed. when the patient is first presented to the veterinarian, have the owner complete a toxicologic history form (figure - ) while the animal is being initially assessed and vital signs are being stabilized. when initial stabilization of vital signs has been accomplished, the veterinarian can discuss the patient's history with the owner. in urgent situations, the veterinarian should obtain a brief history as an initial procedure (box - ). knowing when the animal was last seen as normal provides a time frame in which the toxic substance was most likely accessed, allowing differential diagnoses to be ranked in some order of probability by rate of onset. in eliciting a history from the owner about the animal's access to poisons, it is important not to take anything for granted. many owners do not realize how poisonous some substances can be, such as insecticide products, garbage, cleaning chemicals, and over-the-counter drugs commonly used by humans. many owners will deny that an animal could have ingested anything that might be toxic, not wanting to believe that the source of the toxin is within their household or property, particularly if recreational drug exposure is suspected. it is useful to phrase questions in a neutral fashion-for example, "is such-and-such present on the premises?" rather than "could the dog have eaten such-and-such?" if recreational drug exposure is suspected, another way to question the owners is to ask whether they have had any guests in their house recently that may have had such-and-such (e.g., marijuana, cocaine, methamphetamine). this approach serves to minimize the suggestion of any bias or preconceptions. when questioning an owner about recent events, it is useful to realize and acknowledge that disruption in the household routine is a distinct factor in the occurrence accidents, including poisonings. examples of such disruptive events include moving from the house, family member is ill or in the hospital, and renovations or recent construction. while these events are occurring, the safeguards followed by a normally careful owner may be disrupted. often, doors or gates may be left open, animals may be outside instead of inside (or vice versa), and inexperienced people may be pet-sitters. once owners are made aware of the importance of assessing such risks, they are often able to provide insight into otherwise baffling circumstances. various methods can be used to remove toxins from the gastrointestinal tract, including emesis, orogastric lavage, cathartics, and enemas. adsorbents, ion exchange resins, or precipitating or chelating agents may be used. removal of a toxic substance from the body surface may be necessary, depending on the toxin.the use of both emesis and orogastric lavage is less and less frequent in human medicine because of the risk of aspiration pneumonia and doubts about their efficacy. currently, management of poisonings in human medicine relies heavily on the use of activated charcoal combined with sorbitol as a cathartic, when appropriate, and supportive critical care. it should be emphasized, however, that the majority of poisonings in humans are due to drug overdoses (illicit or otherwise) (which have a relatively small volume and rapid absorption), for which this treatment is appropriate. furthermore, adoption of the approach rests on the availability of a hospital intensive care infrastructure, which is not always available in veterinary practice. induce emesis if the animal's physiology and neurologic status are stable (i.e., does not have respiratory depression or is not actively seizing, obtunded, unable to swallow or protect its airway). do not administer the same emetic more than twice. if the emetic doesn't work after two doses, give a different emetic or perform orogastric lavage under general anesthesia. emetics are strictly contraindicated for toxicity from petroleum-based products and corrosives because of the risk of aspiration pneumonia and further esophageal damage. emetics may also be of little value if poisons with antiemetic properties have been ingested, such as benzodiazepines, tricyclic antidepressants, and marijuana (table - ) . various emetics traditionally have been recommended for use in veterinary medicine. many have fallen out of favor because of the risk of causing adverse consequences and side effects. apomorphine ( . mg/kg iv or in the conjunctival sac) remains the standard but is less useful in certain situations in which the poison causes cns excitation or stimulation. it is ineffective in cats. other emetics include xylazine and hydrogen peroxide. do not use table salt because of the risk of severe oropharyngeal irritation and hypernatremia. do not use mustard powder or dishwashing liquid detergent because of the risk of severe oropharyngeal, esophageal, and gastric irritation. orogastric lavage is described in detail in the section on emergency procedures gastric lavage is contraindicated in treatment of toxicity from petroleum-based compounds and acid/alkali ingestion. the procedure can be messy but is very effective if performed within to hours of ingestion of the poison. to prevent aspiration, the patient should be placed under general anesthesia. keep the animal's head lowered during the procedure to prevent aspiration of stomach contents into the trachea. it is sometimes helpful to put the animal in both right and left lateral recumbency to allow complete emptying of gastric contents. repeat the procedure until the fluid runs clear from the stomach. in some cases in which solid material has been ingested, this process can take a long time, so be prepared with a large volume of warm water. following successful evacuation and lavage, administer a slurry of activated charcoal through the orogastric tube before removing it. keep the endotracheal tube cuffed and in place until the animal is semi-conscious, is starting the fight the tube, and is visibly able to swallow and protect its airway. • when was the animal last seen as normal? • what clinical signs developed? • how fast did the clinical signs develop? • when was the onset of clinical signs? • what is the animal's activity level? • does the animal have access to any poisonous substances? • this includes known toxins or chemicals, over-the-counter or prescription medications (including the owner's), and recreational drugs. enemas are useful to facilitate the action of cathartics and in cases in which the poison is a solid material (e.g., compost, snail bait, garbage) (box - ). it is best to use just lukewarm water. commercially available phosphate enema solutions can cause severe electrolyte disturbances (hyperphosphatemia, hyponatremia, hypocalcemia, and hypomagnesemia) and acid-base abnormalities (metabolic acidosis); therefore, they are absolutely contraindicated in small animal patients. use nonsterile nonspermicidal water-soluble lubricants (k-y jelly) old intravenous fluid bag enema bag -to -ml syringe fluid warm water, with or without hand or liquid dish soap the fluid volume required depends on the size of the animal and the state of its lower gastrointestinal tract. as with orogastric lavage, continue the procedure until the water runs clear. if difficulty is encountered emptying the lower gastrointestinal tract, repeat the enema in or hours, rather than be overzealous on the first attempt. cathartics are useful for hastening gastrointestinal elimination of toxins, and they are particularly useful for elimination of most solid toxicants (e.g., compost, garbage, snail baits). cathartics can be used in conjunction with activated charcoal. do not use magnesium-based cathartics in patients with cns depression, because hypermagnesemia can worsen this disorder and also cause cardiac rhythm disturbances (table - ) . activated charcoal ( - ml/kg) is the safest and to date the most effective adsorbent for the treatment of ingested toxins. activated charcoal can be administered after emesis or orogastric lavage or can be administered as the sole treatment. various preparations are available on the market, including dry powder, compressed tablets, granules, liquid suspensions, and concentrated paste preparations. commercially available products are relatively inexpensive and should be used whenever possible for ease of administration. vegetableorigin activated charcoal is the most efficient adsorbent and binds compounds with weak, nonionic bonds. some preparations are combined with sorbitol to provide simultaneous administration of an adsorbent and a cathartic; this combination has been shown to be most efficacious. repeated administration of activated charcoal every to hours has been shown to be beneficial in the management of a toxin that undergoes enterohepatic recirculation. administration of an oily cathartic or mixing the activated charcoal with food only serves to reduce the absorptive surface of the activated charcoal and therefore is not recommended. in general, substances that are very soluble and are rapidly absorbed are not well adsorbed by activated charcoal, including alkalis, nitrates, mineral acids, ethanol, methanol, ferrous sulfate, ammonia, and cyanide. kaolin and bentonite are clays that have been used as adsorbents. both are usually less effective than activated charcoal. however, they are reported to be better adsorbents than activated charcoal for the herbicide paraquat. ion exchange resins can ionically bind certain drugs or toxins. cholestyramine is one such resin, commonly used in human medicine to bind intestinal bile acids and thereby decrease cholesterol absorption. its application in toxicology extends to the absorption of fat-soluble toxins such as organochlorine and certain acidic compounds such as digitalis. ion exchange resins also have been used to delay or reduce the absorption of phenylbutazone, warfarin, chlorothiazide, tetracycline, phenobarbital, and thyroid preparations. precipitating, chelating, and diluting agents precipitating, chelating, and diluting agents are used primarily in the management of heavy metal intoxications, such as alkaloids or oxalates. they work by binding preferentially to the metal ion and creating a more soluble complex that is amenable to renal excretion. those chelating agents in common usage are calcium edta, deferoxamine, and d-penicillamine. calcium edta and deferoxamine should both be on hand in the veterinary hospital because they are necessary to treat zinc and iron toxicity, respectively, both of which have a short window of opportunity for therapeutic intervention. d-penicillamine has a wide application for a number of metal toxicities but tends to be used for long-term chronic therapy because it can be administered orally. various agents used for nonspecific dilution of toxins, including milk of magnesia and egg whites, although old-fashioned, still have wide application in many cases in which low-grade irritants have been ingested. bathing the animal is an important aspect of treatment for topical exposures to toxins such as insecticidal products, petroleum-based products, and aromatic oils. bathing an animal is not an innocuous procedure. to avoid hypothermia and shock, use warm water at all times. actively dry the animal to further minimize the risk of hypothermia. when bathing the animal, use rubber gloves and a plastic apron to avoid exposure to noxious agents. in most cases, a mild dishwashing soap is appropriate. medicated or antibacterial shampoos are less appropriate in this situation. for petroleum-based products in particular, dawn dishwashing liquid that "cuts the grease" works well to remove the oils. if dawn is not available, mechanics' hand cleaners or coconut oil-based soaps can be used instead. as a general principle, best results are obtained by barely wetting the patient's fur until the detergent is worked well into the fur, keeping the amount of water to a minimum until ready for the rinse. oil-based paint is best removed by clipping rather than by attempting removal with solvents, because solvents are also toxic. to remove powder products, brush and vacuum the animal before bathing it to eliminate further toxic exposure. with caustic alkaline or acidic products, the primary treatment is to dilute and flush the skin with warm water; do not attempt neutralization. neutralization can cause an exothermic reaction that causes further damage to the underlying tissues. eliminating poison from the eyes for ocular exposures, irrigate the eyes for a minimum of to minutes with warm (body temperature) tap water or warmed . % sterile saline solution. the use of neutralizing substances is not recommended because of the risk of causing further ocular damage. following adequate irrigation, treat chemical burns of the eyes with lubricating ointments and possibly a temporary tarsorrhaphy. atropine may be indicated as a cycloplegic agent. systemic nonsteroidal antiinflammatory drugs can be used to control patient discomfort. daily follow-up examinations are required because epithelial damage may be delayed, especially with alkali burns, and it is difficult to predict the final extent of ocular damage. topical glucocorticosteroids are contraindicated if the corneal epithelium is not intact. if severe conjunctival swelling is present with a corneal ulcer, parenteral glucocorticosteroids can be administered to help alleviate inflammation, but nonsteroidal antiinflammatory drugs should not be used simultaneously due to the risk of gastrointestinal ulceration or perforation. whenever possible, administer specific antidotes to negate the effects of the toxin and prevent conversion of the substance to the toxic metabolite. three categories of agents are used in the management of poisonings. the first category is specific antidotes. unfortunately, few specific antidotes are available for use in veterinary medicine. some "classic" toxins and antidotes are now considered to be rare, such as curare and physostigmine, thallium and prussian blue, and fluoride and calcium borogluconate. these and a few others have been omitted from the table. the second, broader category of antidotes includes those drugs used in the symptomatic management of clinical signs, which are part of our routine veterinary stock. drugs such as atropine, sedatives, steroids, antiarrhythmics, and beta-blockers fall into this category. the third category comprises nonspecific decontaminants such as activated charcoal, cathartics, and emetics. these were discussed previously. many patients benefit from efforts to enhance clearance or metabolism of the absorbed toxins. some specific therapies have been developed for this purpose, including -methylpyrazole for ethylene glycol toxicity and specific antibodies such as digibind (digoxin immune fab [ovine]) for digitalis toxicity. other strategies are aimed at promoting renal excretion. renal excretion strategies include diuresis, ion trapping, and peritoneal dialysis or hemodialysis (see section on peritoneal dialysis). diuresis and ion trapping are applicable to a large number of toxins and are discussed here in more detail. other toxins respond to urine acidification and urine alkalinization. enhancing renal excretion of substances is most useful for those organic substances that are present in significant concentrations in the plasma. substances that are non-ionic and lipid-soluble, such as certain herbicides, are likely to be less affected by attempts to promote rapid renal elimination. before starting diuresis or ion trapping, intravenous fluid therapy should be adequate as determined by normal central venous pressure, urine output, and mean arterial blood pressure. if any of these values are less than normal, use other measures to ensure adequate renal perfusion, including but not limited to a constant rate infusion of dopamine. simple fluid diuresis can influence the excretion of certain substances. the use of mannitol as an osmotic diuretic may reduce the passive reabsorption of some toxic substances in the proximal renal convoluted tubule by reducing water reabsorption. dextrose ( %) can be used as an osmotic diuretic. furosemide can be used to promote diuresis, but again, there is no substitute for intravenous fluid therapy. the use of mannitol, dextrose, and furosemide is contraindicated in hypotensive or hypovolemic patients. take care to avoid causing dehydration with any diuretic; central venous pressure monitoring is strongly recommended. ion trapping is based on the principle that ionized substances do not cross renal tubular membranes easily, and are not well reabsorbed. if the urinary ph can be changed so that the toxin's chemical equilibrium shifts to its ionized form, then that toxin can be "trapped" in the urine and excreted. alkaline urine favors the ionization of acidic compounds, and acidic urine favors the ionization of alkaline compounds. those toxins that are amenable to ion trapping are mostly weak acids and weak bases. ammonium chloride can be used to promote urinary acidification. contraindications to the use of ammonium chloride include a preexisting metabolic acidosis, hepatic or renal insufficiency, and hemolysis or rhabdomyolysis leading to hemoglobinuria or myoglobinuria. signs of ammonia intoxication include cns depression and coma. when performing urine acidification, frequently check the serum potassium concentration and urine ph. urine alkalinization can be performed with use of sodium bicarbonate. contraindications to the use of sodium bicarbonate include metabolic alkalosis (particularly with concurrent use of furosemide), hypocalcemia, and hypokalemia. as with urine acidification, monitor the serum potassium concentration and urine ph frequently. the major steps in management of poisonings discussed here must be accompanied by application of the fundamentals of critical care. respiratory and cardiovascular support have been discussed previously. renal and gastrointestinal function and analgesia are particularly important in the management of the poisoning patient. maintenance of renal perfusion is a priority in the poisoning patient. fluid, electrolyte, and acid-base balance must be controlled and be accurate. poisoning patients are at particularly high risk for renal damage and acute renal failure, whether by primary toxic insult to the renal parenchyma or by acute or prolonged renal hypoperfusion. for this reason, a protocol that aims at preventing oliguria and ensuing renal failure is one of the therapeutic strategies that should be routinely employed. this protocol is described in box - . gastrointestinal protectant drugs may be indicated for the management of those poisons that are gastrointestinal irritants or ulcerogenic. commonly used gastroprotectant drugs include cimetidine, ranitidine, famotidine, omeprazole, sucralfate, and misoprostol. antiemetics may be used to suppress intractable vomiting. metoclopramide is commonly used, and it is the drug of choice for centrally mediated nausea. antiemetics that work by different mechanisms can be used in combination as necessary. examples are dopamine -receptor antagonists such as prochlorperazine, -hydroxytryptamine antagonists such as ondansetron and dolasetron, and h- receptor antagonists such as diphenhydramine and meclizine. analgesics are more appropriate to treat poisonings than once thought. common effects of poisons including severe gastroenteritis and topical burns or ulcerations may warrant the use of analgesics. longer-acting analgesics such as morphine, hydromorphone, and buprenorphine are particularly useful. nutritional support may be necessary in the form of enteral or parenteral feeding in patients that have esophageal or gastric damage or that need to be sedated for long periods of time. endoscopy may be useful in assessing the degree of esophageal and gastric damage, particularly after ingestion of caustic substances. introduction: acetaminophen (paracetamol) is the active ingredient in tylenol and many over-thecounter cold products. acetaminophen is converted to n-acetyl-p-benzoquinonimine in the liver, a toxic substance that can cause oxidative injury of red blood cells and hepatocytes. clinical signs of acetaminophen toxicity include respiratory distress from lack of oxygen-carrying capacity, cyanosis, methemoglobinemia (chocolate-brown appearance of the blood and mucous membranes), lethargy, vomiting, and facial and paw swelling (cats). the toxic dose of acetaminophen is > mg/kg for dogs, and mg/kg for cats. treatment of acetaminophen toxicity includes induction of emesis or orogastric lavage if the substance has been ingested within minutes. activated charcoal should also be administered. in cases of severe anemia, give supplemental oxygen along with a packed rbc transfusion. administer intravenous fluids to maintain renal and hepatic perfusion. n-acetylcysteine, vitamin c, and cimetidine are the treatments of choice for methemoglobinemia in patients with acetaminophen toxicity. introduction: hydrochloric, nitric, and phosphoric acids cause chemical burns through contact with the skin and/or eyes. localized superficial coagulative necrosis occurs upon contact. usually, the patient's skin is painful to the touch or the animal may lick or chew at an irritated area that is not visible under the haircoat. if the chemical is swallowed, do not induce emesis or perform orogastric lavage, because of the risk of worsening esophageal irritation. rinse the patient's skin and eyes with warm water or warm saline for a minimum of / hour. use analgesics and treat corneal ulcers (see section on corneal ulcers) as required. do not attempt chemical neutralization, because of the risk of causing an exothermic reaction and worsening tissue injury. aflatoxin (aspergillus flavus) is found in moldy feed grains. clinical signs of toxicity occur after ingestion and include vomiting, diarrhea, and acute hepatitis; abortion may occur in pregnant bitches. treatment of suspected aflatoxin ingestion consists of gastric decontamination, administration of activated charcoal, intravenous fluids, and hepatic supportive care (s-adenosyl methionine [same], milk thistle). drinking (ethanol), rubbing (isopropyl), and methyl (methanol) alcohols can be harmful if ingested ( . to . g/kg po). all cause disruption of neuronal membrane structure, impaired motor coordination, cns excitation followed by depression, and stupor that can lead to cardiac and respiratory arrest, depending on the amount ingested. affected animals may appear excited and then ataxic and lethargic. contact or inhalant injury can occur, causing dermal irritation and cutaneous hyperemia. methanol also can cause hepatotoxicity. and diarrhea result from muscarinic overload. nicotinic overload produces muscle tremors. toxicity can result in seizures, coma, and death. and cause severe irritation and corrosion of the mucous membranes and skin. some compounds also can cause clinical signs similar to those observed with anticholinesterase compounds, including muscle tremors, seizures, paralysis, and coma. methemoglobinemia can occur. signs of ethylene glycol intoxication and renal impairment or failure, a negative test for the presence of calcium oxalate crystalluria means that there is no more ethylene glycol in the patient's serum because it has all been metabolized. cats are very sensitive to the toxic effects of ethylene glycol. in many cases, cat may have ingested a toxic dose, but because the sensitivity of the assay is low, test results will be negative. lack of treatment can result in death. there are three phases of ethylene glycol intoxication. in the first to hours after ingestion (stage i), the patient may appear lethargic, disoriented, and ataxic. in stage ii ( to hours following ingestion), the patient improves and appears clinically normal. in stage iii ( to hours following ingestion), the patient demonstrates clinical signs of renal failure (polyuria and polydipsia) that progress to uremic renal failure (vomiting, lethargy, oral ulceration). finally, seizures, coma, and death occur. crosses, old english sheepdogs, and some terriers. clinical signs of ivermectin toxicity include vomiting, ataxia, hypersalivation, agitation, tremors, hyperactivity, hyperthermia, hypoventilation, coma, seizures, signs of circulatory shock, bradycardia, and death. clinical signs often occur within to hours after ingestion or iatrogenic overdose. blood ivermectin levels can be measured, but diagnosis is often made based on clinical signs and knowledge of exposure in predisposed breeds. there is no known antidote. the clinical course can be prolonged for weeks to months before recovery occurs. to treat known exposure, induce emesis or perform orogastric lavage if the substance was ingested was within hour of presentation and the patient is not symptomatic. administer activated charcoal. control seizures with phenobarbital, pentobarbital, or propofol administered as intermittent boluses or as a constant rate infusion. diazepam, which potentially can worsen central nervous stimulation, is contraindicated. administer intravenous fluids to maintain perfusion and hydration, and treat hyperthermia. supportive care may be necessary, including supplemental oxygen (or mechanical ventilation, if necessary), frequent turning of the patient and passive range-of-motion exercises, placement of a urinary catheter to maintain patient cleanliness and monitor urine output, lubrication of the eyes, and parenteral nutrition (see section on rule of twenty). specific antidotes used to treat ivermectin toxicity include physostigmine and picrotoxin. physostigmine therapy was beneficial in some patients for a short period; picrotoxin caused severe violent seizures and therefore should be avoided. introduction d-limonene and linalool are components of citrus oil extracts used in some flea control products. the toxic dose is unknown, but cats appear to be very sensitive to exposure. clinical signs of toxicity include hypersalivation, muscle tremors, ataxia, and hypothermia. treatment of d-limonene and linalool exposure includes treatment of hypothermia, administration of activated charcoal to prevent further absorption, and careful, thorough bathing to prevent further dermal exposure. lead is ubiquitous, and is found in some paints, car batteries, fishing equipment/ sinkers, and plumbing materials. lead can be toxic at doses of mg/kg. if more than than - mg/kg of lead is ingested, death can occur. lead causes toxicity by inhibiting sulfur-containing enzymes, leading to increased rbc fragility, and cns damage. clinical signs of hyperexcitability, dementia, vocalization, seizures, and lower motor neuron polyneuropathy can occur. affected animals may appear blind, or vomiting, anorexia, and constipation or diarrhea may occur. if lead toxicity is suspected, blood and urine lead levels can be measured. treatment of lead toxicity is supportive and is directed at treatment of clinical signs. control seizures with diazepam or phenobarbital. if cerebral edema is present, administer mannitol ( . - . g/kg iv), followed by furosemide ( mg/kg iv minutes after mannitol). sodium or magnesium sulfate should be administered as a cathartic. initiate chelation therapy with dimercaprol, penicillamine, or calcium edta. if a lead object is identified in the gastrointestinal tract on radiographs, remove the object using endoscopy or exploratory laparotomy. hyperthermia, that occurs within - minutes of ingestion. diarrhea and convulsions can develop. if hyperthermia is severe, renal failure secondary to myoglobinuria and disseminated intravascular coagulation can result. delayed hepatic failure has been described days after initial recovery. if metaldehyde toxicosis is suspected, analysis of urine, serum, and stomach contents is warranted. to treat metaldehyde toxicity, procure and maintain a patent airway and control cns excitation and muscle tremors. if an animal has just ingested the metaldehyde and is not symptomatic, induce emesis. if clinical signs are present, perform orogastric lavage. both emesis and orogastric lavage should be followed by administration of one dose of activated charcoal. administer intravenous fluids to control hyperthermia, prevent dehydration, and correct acid-base and electrolyte abnormalities. methocarbamol is the treatment of choice to control muscle tremors. diazepam can be used to control seizures if they occur. introduction mushroom ingestion most commonly causes activation of the autonomic nervous system, resulting in tremors, agitation, restlessness, hyperexcitability, and seizures. in some cases slud (salivation, lacrimation, urination, and defecation) is seen. some mushrooms (amanita spp.) also can cause hepatocellular toxicity. clinical signs include vomiting, anorexia, lethargy, and progressive icterus. hemoglobinuria and pigment damage of the renal tubular epithelium. heinz bodies may be observed on cytologic evaluation of the peripheral blood smear. paint in a sorbitol or glycerol carrier. when large quantities of these osmotically active sugars are ingested, osmotic shifts of fluid cause a sudden onset of neurologic or gastrointestinal signs, including ataxia, seizures, and osmotic diarrhea caused by massive fluid shifts into the gastrointestinal tract. the loss of water in excess of solute can result in hypernatremia, a free water deficit, and increased serum osmolality. following orogastric lavage, treatment of ingestion includes administering warm water enemas to help speed the movement of the paintballs through the gastrointestinal tract. do not administer activated charcoal (usually in a propylene glycol carrier), because the compound's cathartic action will pull more fluid into the gastrointestinal tract. baseline electrolytes should be obtained and then carefully monitored. if severe hypernatremia develops, administer hypotonic solutions such as . % nacl + . % dextrose or % dextrose in water after calculating the patient's free water deficit. because of the large volume of fluid loss, intravenous fluid rates may seem excessive but are necessary to normalize acid-base, electrolyte, and hydration status. in most cases, these patients can survive if the problem is recognized promptly and corrected with careful electrolyte monitoring, aggressive decontamination strategies, and intravenous fluid support. introduction paraquat, a dipyridyl compound, is the active ingredient in some herbicides. the ld of paraquat is - mg/kg. paraquat initially causes cns excitation. it also causes production of oxygen-derived free radical species in the lungs, that can lead to the development of acute respiratory distress syndrome. initial clinical signs include vomiting, diarrhea, and seizures. within to days, clinical signs associated with severe respiratory distress and acute respiratory distress syndrome (ards) can develop, leading to death. chronic effects include pulmonary fibrosis, if the patient survives the initial toxicity period. the prognosis for paraquat toxicity is generally unfavorable. to treat paraquat ingestion, remove the toxin from the gastrointestinal tract as rapidly as possible after ingestion. there are no known antidotes. if the compound was ingested within the past hour and the animal is able to protect its airway, induce emesis. otherwise, perform orogastric lavage. activated charcoal is not as effective as clay or bentonite adsorbents for removing this particular toxin. early in the course of paraquat toxicity, oxygen therapy is contraindicated because of the risk of producing oxygen-derived free radical species. later, oxygen therapy, including mechanical ventilation, is necessary if ards develops. experimentally, free radical scavengers (n-acetyl cysteine, vitamin c, vitamin e, same) have been shown to be useful in preventing damage caused by oxygen-derived free radical species. hemoperfusion may be useful in eliminating the toxin, if it is performed early in the course of toxicity. pennyroyal oil is an herbal flea control compound that contains menthofuran as its toxic compound. menthofuran is hepatotoxic and may cause gastrointestinal hemorrhage and coagulopathies. to treat toxicity, administer a cathartic and activated charcoal and antiemetic and gastroprotectant drugs, and thoroughly bathe the animal to prevent further dermal exposure. petroleum distillates: see fuels phenobarbital: see barbiturates phenylcyclidine (angel dust) introduction phenylcyclidine (angel dust) is an illicit recreational drug that causes both cns depression and excitation, decreased cardiac output, and hypotension. to treat phenylcyclidine toxicity, place an intravenous catheter, and administer intravenous fluids and antiarrhythmic drugs to maintain organ perfusion. administer supplemental oxygen, and administer diazepam to control seizures. urine alkalinization can help eliminate the compound. phenylephrine is an α-adrenergic agonist in many over-the-counter decongestant preparations. clinical signs of intoxication include mydriasis, tachypnea, agitation, hyperactivity, and abnormal flybiting and staring behavior. tachycardia, bradycardia, hypertension, hyperthermia, and seizures can occur. to treat phenylephrine toxicity, place an intravenous catheter and give intravenous fluids to maintain hydration, promote diuresis, and treat hyperthermia. administer prazosin or sodium nitroprusside to treat hypertension, antiarrhythmic drugs as necessary, and diazepam to control seizures. phenylpropanolamine has both αand β-adrenergic agonist effects, and is used primarily in the treatment of urinary incontinence in dogs. the drug was taken off of the market for use in humans because of the risk of stroke. clinical signs of phenylpropanolamine intoxication include hyperactivity, hyperthermia, mydriasis, tachyarrhythmias or bradycardia, hypertension, agitation, and seizures. to treat toxicity, administer prazosin or nitroprusside to control hypertension, a betablocker (esmolol, propranolol, atenolol) to control tachyarrhythmias, diazepam to control seizures, and intravenous fluids to maintain hydration and promote diuresis. urine acidification may aid in facilitating excretion. if bradycardia occurs, do not use atropine. pseudoephedrine is an αand β-adrenergic agonist that is a component of many over-thecounter decongestants and is used in the manufacture of crystal methamphetamine. clinical signs of toxicity include severe restlessness, tremors, mydriasis, agitation, hyperthermia, tachyarrhythmias or bradycardia, hypertension, and seizures. to treat toxicity, administer activated charcoal, intravenous fluids to promote diuresis and treat hyperthermia, chlorpromazine to combat α-adrenergic effects, a beta-blocker (propranolol, esmolol, atenolol) to treat β-adrenergic effects, and cyproheptadine (per rectum) to combat serotoninergic effects. piperazine is a gaba agonist, and causes cervical and truncal ataxia, tremors, seizures, coma, and death. salt used for thawing ice commonly contains calcium chloride, a compound that has a moderate toxic potential. calcium chloride produces strong local irritation and can cause gastroenteritis and gastrointestinal ulcers if ingested. respiratory emergencies consist of any problem that impairs delivery of oxygen to the level of the alveoli or diffusion of oxygen across the alveolar capillary membrane into the pulmonary capillary network. decreased respiratory rate or tidal volume can result in hypoxia and buildup of carbon dioxide, or hypercarbia, leading to respiratory acidosis. conditions most frequently encountered result in airflow obstruction, prevention of normal lung expansion, interference with pulmonary gas exchange (ventilation-perfusion mismatch), and alterations of pulmonary circulation. evaluation of the patient with respiratory distress is often challenging, because the most minimal stress can cause rapid deterioration, or even death in critical cases. careful observation of the patient from a distance often allows the clinician to determine the severity of respiratory distress and localize the lesion based on the patient's respiratory pattern and effort. animals in respiratory distress often have a rapid respiratory rate (> breaths per minute). as respiratory distress progresses, the patient may appear anxious and start openmouth breathing. the animal often develops an orthopneic posture, characterized by neck extension, open-mouthed breathing, and elbows abducted or pulled away from the body. cyanosis of the mucous membranes often indicates extreme decompensation. clinical signs of respiratory distress can develop acutely, or from decompensation of a more chronic problem that was preceded by a cough, noisy respirations, or exercise intolerance. localization of the cause of respiratory distress is essential to successful case management. in any patient with clinical signs of respiratory distress, the differential diagnosis should include primary pulmonary parenchymal disease, airway disease, thoracic cage disorders, congestive heart failure, dyshemoglobinemias (carbon monoxide, methemoglobin), and anemia. careful observation of the patient's respiratory pattern can aid in making a diagnosis of upper airway disease/obstruction, primary pulmonary parenchymal disease, pleural space disease, and abnormalities of the thoracic cage. it is often helpful to rest a hand on the patient and breathe along with the patient's effort, to confirm the periods of inhalation and exhalation. the pharynx, larynx, and extrathoracic trachea comprise the upper airway. obstructive lesions are associated with a marked inspiratory wheeze or stridor and slow deep inspiratory effort. auscultation of the larynx and trachea may reveal more subtle obstructions of normal air flow. stridor can usually be auscultated without the use of a stethoscope. lung sounds are usually normal. the neck should be carefully palpated for a mass lesion, tracheal collapse, and subcutaneous emphysema. subcutaneous emphysema suggests tracheal damage or collapse secondary to severe trauma. in some cases, there is a history of voice, or bark, change secondary to laryngeal dysfunction. differential diagnosis is usually based on the patient's signalment, history, and index of suspicion of a particular disease process. differential diagnoses of upper airway obstruction are listed in box - . diseases of the pleural space often are associated with a restrictive respiratory pattern. inspiratory efforts are short, rapid, and shallow, and there is often a marked abdominal push. the pattern has been referred to as a choppy "dysynchronous" respiratory pattern. depending on the disease present, lung sounds may be muffled ventrally and enhanced dorsally. percussion of the thorax reveals decreased resonance if fluid is present. increased resonance is present with pneumothorax. decreased compressibility of the anterior thorax may be present with an anterior mediastinal mass lesion, particularly in cats and ferrets. a pneumothorax or diaphragmatic hernia is commonly associated with evidence of trauma, with or without rib fractures. respiratory distress due to hemothorax may be exacerbated by anemia. differential diagnoses for patients with evidence of pleural cavity disease include pneumothorax, diaphragmatic hernia, neoplasia, and various types of pleural effusion. primary pulmonary parenchymal disease can involve the intrathoracic airways, alveoli, interstitial space, and pulmonary vasculature. a rapid, shallow, restrictive respiratory pattern may be observed with a marked push on exhalation, particularly with obstructive airway disease such as chronic bronchitis (asthma) in cats. crackles or wheezes are heard on thoracic auscultation. differential diagnoses for pulmonary parenchymal disease include cardiogenic and noncardiogenic pulmonary edema, pneumonia, feline bronchitis (asthma), pulmonary contusion, aspiration pneumonitis, pulmonary thromboembolism, neoplasia, infection (bacterial, fungal, protozoal, viral) , and/or chronic bronchitis. other abnormal respiratory patterns may be evident, and warrant further consideration. tachypnea present in the absence of other signs of respiratory distress can be a normal response to nonrespiratory problems, including pain, hyperthermia, and stress. a restrictive respiratory pattern with minimal thoracic excursions can be associated with diseases of neuromuscular function, including ascending polyradiculoneuritis, botulism, and tick paralysis. if adequate ventilation cannot be maintained by the patient, mechanical ventilation may be indicated. kussmaul respiration manifests as very slow, very deep respirations when a metabolic acidosis is present. this type of respiratory pattern typically is observed in patients with severe diabetic ketoacidosis and renal failure in a compensatory attempt to blow off carbon dioxide. cheyne-stokes respiration is usually observed with a defect in the central respiratory control center. the classic pattern of cheyne-stokes respiration is normal or hyperventilation followed by a period of apnea or hypoventilation. in cases of lower cervical cord damage or damage to the central respiratory control center in the cns, the diaphragm alone may assume most of the ventilatory movement. with diaphragmatic fatigue, severe hypoventilation and resultant hypoxemia may require mechanical ventilation. immediate management of any patient in respiratory distress is to minimize stress at all costs. relatively benign procedures such as radiography or intravenous catheter placement can be fatal in patients with severe respiratory compromise. stabilization should always precede further diagnostic evaluation. in some cases, sedation may be required before performing any diagnostics, to prevent further stress. all patients should receive some form of supplemental oxygen, either by mask, cage, or flow-by techniques. in cases in which a severe pneumothorax or pleural effusion is suspected, perform therapeutic and diagnostic thoracocentesis bilaterally to allow lung re-expansion and alleviate respiratory distress, whenever possible. if thoracocentesis alone is not effective at maintaining lung re-expansion, place a thoracostomy tube (particularly in cases of tension pneumothorax). if hypovolemic/ hemorrhagic shock is present, initiate treatment while stabilizing the respiratory system (see section on shock). if an animal is suspected of having an upper airway obstruction, reestablish airflow. in cases of laryngeal paralysis, tracheal collapse, and brachycephalic airway syndrome, sedation is often very useful in alleviating the distress of airway obstruction. in cases of laryngeal collapse, however, sedation may make the condition worse. if laryngeal edema is severe, administer a dose of short-acting glucocorticosteroids (dexamethasone sodium phosphate) to decrease laryngeal inflammation and edema. if a foreign body is lodged in the pharynx, perform the heimlich maneuver by thrusting bluntly several times on the patient's sternum. objects such as balls or bones may be small enough to enter the larynx but too large to be expelled, and will require rapid-acting general anesthesia to facilitate dislodgement and removal. if the obstruction cannot be removed, bypassing the obstruction with an endotracheal tube or temporary tracheostomy should be considered. in an emergency, a temporary transtracheal oxygen catheter can quickly be placed in the following manner. connect a -or -gauge needle to a length of intravenous extension tubing and a -ml syringe. place the male connector of the syringe into the female portion of the extension tubing. cut off the syringe plunger and connect the resulting blunt end to a length of flexible tubing attached to a humidified oxygen source. run the oxygen at l/minute to provide adequate oxygenation until a tracheostomy can be performed. (see sections on oxygen supplementation and tracheostomy). once the animal's condition has been stabilized, specific diagnostic tests, including arterial blood gas analyses, thoracic radiographs, and/or transtracheal wash, can be performed, depending on the patient's condition and needs. specific therapies for management of upper airway obstruction, pleural space disease, and pulmonary disease are discussed next. upper airway obstruction can occur as a result of intraluminal or extraluminal mass lesions or foreign bodies in the oropharynx (abscess, neoplasia), laryngeal paralysis, trauma, and anatomic abnormalities. clinical signs of an upper airway obstruction are associated with an animal's extreme efforts to inhale air past the obstruction. marked negative pressure occurs in the extrathoracic airways and can cause worsening of clinical signs. mucosal edema and inflammation further worsen the obstruction. therapy for upper airway obstruction is aimed at breaking the cycle of anxiety and respiratory distress. administer the anxiolytic tranquilizer acepromazine ( . - . mg/kg iv, im, sq) to decrease patient anxiety. many animals develop hyperthermia from increased respiratory effort and extreme anxiety. implement cooling measures in the form of cool intravenous fluids and wet towels soaked in tepid water placed over the animal (see section on hyperthermia). administer supplemental oxygen in a manner that is least stressful for the animal. short-acting glucocorticosteroids can also be administered (dexamethasone sodium phosphate, . mg/kg iv, sq, im) to decrease edema and inflammation. if the airway obstruction is severe and there is no response to initial measures to alleviate anxiety and decrease inflammation, establish control of ventilation by placement of an endotracheal tube (see section on endotracheal intubation), tracheal oxygen catheter, or temporary tracheostomy. to obtain airway control, administer a rapid-acting anesthetic (propofol, - mg/kg iv to effect), and intubate with a temporary tracheostomy. an intratracheal oxygen catheter can be placed with sedation and/or a local anesthetic (see technique for transtracheal wash). laryngeal paralysis is a congenital or acquired condition that occurs primarily in largebreed dogs secondary to denervation of the arytenoid cartilages by the recurrent laryngeal nerve. congenital laryngeal paralysis occurs in the bouvier des flandres, siberian husky, and bull terrier. acquired laryngeal paralysis occurs in labrador retrievers, saint bernards, and irish setters. acquired laryngeal paralysis can be idiopathic, acquired secondary to trauma to the recurrent laryngeal nerve, or can be a component of systemic neuromuscular disease. although rare, this condition also occurs in cats. with dysfunction of the recurrent laryngeal nerve, the intrinsic laryngeal muscles atrophy and degenerate. as a result, the vocal folds and arytenoid cartilage move in a paramedian position within the airway and fail to abduct during inhalation, causing airway obstruction. laryngeal paralysis can be partial or complete, unilateral or bilateral. in many cases, a change in bark is noted prior to the development of clinical signs of respiratory distress or exercise intolerance. when a patient presents with severe inspiratory stridor (with or without hyperthermia) initiate stabilization with anxiolytic tranquilizers, supplemental oxygen, and cooling measures. once the patient's condition has been stabilized, definitive measures to accurately document and assess the patient's airway should be considered. place the patient under very heavy sedation with short-acting barbiturates or propofol ( - mg/kg iv) and observe the arytenoid cartilages closely in all phases of respiration. administer just enough drug to allow careful examination without getting bitten. if the arytenoid cartilages do not abduct during inhalation, administer dopram (doxapram hydrochloride, - mg/kg iv) to stimulate respiration. absent or paradoxical laryngeal motion (closed during inspiration and open during exhalation) is characteristic of laryngeal paralysis. correction of the defect involves documentation and treatment of any underlying disorder and surgical repair of the area to open the airway. partial laryngectomy, arytenoid lateralization ("tie-back" surgery), or removal of the vocal folds has been used with some success. aspiration pneumonitis is common following these procedures. brachycephalic airway syndrome is associated with a series of anatomic abnormalities that collectively increase resistance to airflow. affected animals typically have stenotic nares, an elongated soft palate, and a hypoplastic trachea. components of the syndrome can occur alone or in combination. in severe cases, laryngeal saccular edema and eversion, and eventual pharyngeal collapse, can occur secondary to the severe increase in intrathoracic airway pressure required to overcome the resistance of the upper airways. specific airway anomalies can be identified with general anesthesia and laryngoscopy. severe respiratory distress should be treated as discussed previously. treatment requires surgical correction of the anatomic abnormalities. in animals with laryngeal collapse, surgical correction may not be possible, and a permanent tracheostomy may be required. because an elongated soft palate and stenotic nares can be identified before the onset of clinical signs, surgical correction to improve airflow when the animal is young may decrease the negative intra-thoracic pressure necessary to move air past these obstructions. the chronic consequences of everted laryngeal saccules and laryngeal collapse potentially can be prevented. tracheal collapse is common in middle-aged and older toy and small-breed dogs. the owner typically reports a chronic cough that is readily induced by excitement or palpation of the trachea. the cough often sounds like a "goose honk." diagnostic confirmation is obtained by lateral radiography or fluoroscopy of the cervical and thoracic trachea during all phases of respiration. acute decompensation is uncommon but does occur, particularly with excitement, exercise, and increased environmental temperatures or ambient humidity. therapy of the patient with acute respiratory distress secondary to tracheal collapse includes sedation, administration of supplemental oxygen, and provision of cooling measures to treat hyperthermia. cough suppressants (hydrocodone bitartrate-homatropine methylbromide, . mg/kg po q - h, or butorphanol, . mg/kg po q - h) are useful. tracheal collapse is a dynamic process that usually involves both the upper and lower airways. because of this, bypassing the obstruction is often difficult. tracheal stents have been emergency care used with limited success in combination with treatment of chronic lower airway disease. crush or bite injuries to the neck can result in fractures or avulsion of the laryngeal or tracheal cartilages. bypassing the obstructed area may be necessary until the patient is stable and can undergo surgical correction of the injury. if there is avulsion of the cranial trachea, it may be difficult to intubate the patient. a long, rigid urinary catheter can be inserted past the area of avulsion into the distal segment, and an endotracheal tube passed over the rigid catheter, to establish a secure airway. neck injury can also result in damage to the recurrent laryngeal nerve and laryngeal paralysis. foreign bodies can lodge in the nasal cavity, pharynx, larynx, and distal trachea. signs of foreign bodies in the nares include acute sneezing and pawing at or rubbing the muzzle on the ground. if the object is not removed, sneezing continues and a chronic nasal discharge develops. respiratory distress is uncommon, but the foreign body is severely irritating. pharyngeal and tracheal foreign bodies can cause severe obstruction to airflow and respiratory distress. diagnosis of a foreign body is based on the patient history, physical examination findings, and thoracic or cervical radiographs. smaller foreign bodies lodged in the distal airways may not be apparent radiographically but can cause pulmonary atelectasis. foreign bodies of the nose or pharynx can often be removed with an alligator forceps with the patient under anesthesia. if removal is not possible with a forceps, flushing the nasal cavity from cranial to caudal (pack the back of the mouth with gauze to prevent aspiration) can sometimes dislodge the foreign material into the gauze packing. rhinoscopy may be necessary. if an endoscope is not available, an otoscope can be used. foreign objects lodged in the trachea can be small and function like a ball valve during inhalation and exhalation, causing episodic hypoxia and collapse. when attempting to remove these objects, suspend the patient with its head down. remove the object with an alligator forceps, using a laryngoscope to aid in visualization. foreign bodies lodged in the trachea or bronchi require removal with endoscopic assistance. nasopharyngeal polyps (in cats, tumors, obstructive laryngitis, granulomas, abscesses, and cysts) can cause upper airway obstruction. clinical signs are usually gradual in onset. the lesions can be identified through careful laryngoscopic examination performed with the patient under general anesthesia. the nasopharynx above the soft palpate should always be included in the examination. pedunculated masses and cysts are excised at the time of evaluation. biopsy of diffusely infiltrative masses is indicated for histologic examination and prognosis. it is impossible to distinguish obstructive laryngitis from neoplasia based on gross appearance alone. whenever possible, material should be collected from abscesses and granulomas for cytologic evaluation and bacterial culture. extraluminal masses impinge on and slowly compress the upper airways, resulting in slow progression of clinical signs. masses are usually identified by palpation of the neck. enlarged mandibular lymph nodes, thyroid tumors, and other neoplasms may be present. diagnosis is usually based on a combination of radiography and ultrasonography. ct and/or mri are helpful in identifying the full extent and invasiveness of the lesion. definitive diagnosis is made with a fine-needle aspirate or biopsy. many thyroid tumors bleed excessively. the inside of each side of the hemithorax is covered in parietal pleura. the lung lobes are covered in visceral pleura. the two surfaces are in close contact with each other, and are contiguous at the hilum under normal circumstances. pneumothorax refers to free air within the pleural space, accumulating in between the parietal and visceral pleura. the term pleural effusion refers to fluid accumulation in that area but does not reflect the amount or type of fluid present. the mediastinal reflections of the pleura typically are thin in dogs and cats, and usually, but not always, connect. bilateral involvement of pneumothorax or pleural effusion is common. both pneumothorax and pleural effusion compromise the lungs' ability to expand and result in hypoxia and respiratory distress. pneumothorax can be classified as open versus closed, simple versus complicated, and tension. an open pneumothorax communicates with the external environment through a rent in the thoracic wall. a closed pneumothorax results from tears in the visceral pleura but does not communicate with the outside. a tension pneumothorax occurs as a result of a tear in the lung or chest wall that creates a flap valve, such that air is allowed to leave the lung and accumulate in the pleural space during inhalation, and closes to seal off exit of air from the pleural space during exhalation. tension pneumothorax can cause rapid decline in cardiopulmonary status and death if not recognized and treated immediately. a simple pneumothorax is one that can be controlled with a simple thoracocentesis. complicated pneumothorax involves repeated accumulation of air, requiring placement of a thoracic drainage catheter. in many cases, pneumothorax develops as a result of trauma. spontaneous pneumothorax occurs with rupture of cavitary lesions of the lung that may be congenital or acquired as a result of prior trauma, heartworm disease, airway disease (emphysema), paragonimiasis, neoplasia, or lung abscess. pneumothorax also rarely occurs as a result of esophageal tears or esophageal foreign bodies. rapid circulatory and respiratory compromise following traumatic pneumothorax can develop as a result of open or tension pneumothorax, rib fractures, airway obstruction, pulmonary contusions, hemothorax, cardiac dysrhythmias, cardiac tamponade, and hypovolemic shock. any patient that is rapidly decompensating after a traumatic episode must be quickly assessed, and emergency therapy initiated (see section on immediate management of trauma, a crash plan). diagnosis of pneumothorax is usually made based on a history of trauma, a rapid, shallow, restrictive respiratory pattern, and muffled heart and lung sounds on thoracic auscultation. the clinical signs and history alone should prompt the clinician to perform a bilateral diagnostic and therapeutic thoracocentesis before taking thoracic radiographs (see section on thoracocentesis). the stress of handling the patient for radiography can be deadly in severe cases of pneumothorax. although the mediastinum on both sides of the thorax connects, it is necessary to perform thoracocentesis on both sides to ensure maximal removal of free air in the pleural space and allow maximal lung expansion. if negative pressure cannot be obtained, or if the patient rapidly reaccumulates air, place a thoracostomy tube connected to continuous suction. (see section on thoracostomy tube placement). treat all penetrating wounds to the thorax as open sucking chest wounds unless proved otherwise. to "close" an open sucking chest wound, clip the fur around the wound as quickly as possible, and place sterile lubricant jelly or antimicrobial ointment circumferentially around the wound. cut a sterile glove to provide a covering. place the covering over the wound, making sure to cover all of the sterile lubricant, thus creating a seal to close the wound temporarily from the external environment. evaluate the patient's thorax via thoracocentesis while placing a thoracostomy tube. once the patient is stable, the open chest wound can be surgically explored, lavaged, and definitively corrected. all animals with open chest wounds should receive antibiotics (first-generation cephalosporin) to prevent infection. following stabilization, radiographs can be taken and evaluated. pneumothorax is confirmed by evidence of elevation of the cardiac silhouette above the sternum, increased density of the pulmonary parenchymal tissue, free air in between the parietal and visceral pleura (making the outline of the lungs visible), and absence of pulmonary vascular structures in the periphery. parenchymal lesions within the lungs are best identified after as much air as possible has been removed from the thorax. obtain left and right lateral and ventrodorsal or dorsoventral views. a standing lateral view may reveal air-or fluid-filled cavitary masses. if underlying pulmonary disease is suspected as a cause of spontaneous pneumothorax, a transtracheal wash, fecal flotation, and heartworm test may be indicated. treatment of pneumothorax includes immediate bilateral thoracocentesis, covering of any open chest wounds, administration of supplemental oxygen, and placement of a thoracostomy tube if negative pressure cannot be obtained or if air rapidly reaccumulates. serial radiography, ct, or mri should be performed in dogs with spontaneous pneumothorax, because the condition can be associated with generalized pulmonary parenchymal disease. strict cage rest is required until air stops accumulating and the thoracostomy tube can be removed. the patient's chest tube should be aspirated every hours after discontinuing continuous suction. if no air reaccumulates after hours, the chest tube can be removed. exercise restriction is indicated for a minimum of week. if bullae or mass lesions are present, exploratory thoracotomy should be considered as a diagnostic and potentially therapeutic option for long-term management in prevention of recurrence. pleural fluid cytologic analysis is indicated for all patients with pleural effusion before administration of antibiotics. the general term pleural effusion means a collection of fluid in the space between the parietal and visceral pleura but does not indicate what kind or how much fluid is present. clinical signs associated with pleural effusion depend on how much fluid is present, and how rapidly the fluid has accumulated. clinical signs associated with pleural effusion include respiratory distress, reluctance to lie down, labored breathing with an abdominal component on exhalation, cough, and lethargy. auscultation of the thorax may reveal muffled heart and lung sounds ventrally and increased lung sounds dorsally, although pockets of fluid may be present, depending on the chronicity of the effusion. percussion of the thorax may reveal decreased resonance. in stable patients, the presence of pleural effusion can be confirmed radiographically. radiographic confirmation of the pleural effusion should include right and left lateral and dorsoventral or ventrodorsal views. a handling or standing lateral view should be obtained if an anterior mediastinal mass is suspected. the standing lateral view will allow the fluid to collect in the costophrenic recess. in patients with respiratory distress, muffled heart and lung sounds, and suspicion of pleural effusion, thoracocentesis should be performed immediately. thoracocentesis can be both therapeutic and diagnostic. radiography is contraindicated because the procedure can cause undue stress and exacerbation of clinical signs in an unstable patient. pleural effusion can cause severe respiratory distress, and can be the result of a number of factors that must be considered when implementing an appropriate treatment plan. pathology of the pleura is almost always a secondary process except for primary bacterial pleuritis and pleural mesotheliomas. causes of pleural effusion in the cat and dog include pyothorax, feline infectious peritonitis, congestive heart failure, chylothorax, heartworm disease, hemothorax, hypoalbuminemia, lung lobe torsions, neoplasia, diaphragmatic hernia, and pancreatitis (box - ). in stable animals, diagnosis of pleural effusion can be made based • imbalance of transpleural or hydrostatic or protein osmotic forces • change in membrane permeability • decrease in rate of fluid reabsorption • combination of foregoing mechanisms on thoracic radiography or ultrasound. thoracic radiographs can show whether the pleural effusion is unilateral or bilateral. effusions in dogs and cats are usually bilateral. the lung parenchyma and the cardiac silhouette cannot be fully evaluated until most of the fluid has been evacuated from the pleural cavity. following thoracocentesis, radiography should be performed with left and right lateral and ventrodorsal or dorsoventral views. in cases of suspected heart failure, echocardiography also is necessary. pleural fluid cytologic analysis is indicated for all patients with pleural effusion. collect specimens before administering antibiotics, whenever possible, because treatment with antibiotics can make a septic condition (pyothorax) appear nonseptic. the remainder of the diagnostic workup and treatment is based on the type of fluid present (table - ). the fluid may be a transudate, nonseptic exudate, septic exudate, chylous, hemorrhagic, or neoplastic. ultrasonographic evaluation of the thorax can be helpful in identifying intrathoracic masses, diaphragmatic hernias, lung lobe torsions, and cardiac abnormalities. unlike radiography, ultrasonography is facilitated by the presence of fluid in the pleural space. pyothorax refers to a septic effusion of the pleural cavity. the infection is generally the result of a combination of aerobic and anaerobic bacteria. rarely, fungal organisms are present. the source of the underlying organisms is rarely identified, particularly in cats, but can be caused by penetrating wounds through the chest wall, esophagus, migrating foreign bodies (especially grass awns), or primary lung infections. the most common organisms associated with pyothorax in the cat are pasteurella, bacteroides, and fusobacterium. fever is often present in addition to clinical signs of pleural effusion. septic shock is ununcommon. diagnosis of pyothorax is made based on cytologic analysis and the demonstration of intracellular and extracellular bacteria, toxin neutrophils and macrophages, and sometimes the presence of sulfur granules. gram stains of the fluid can assist in the initial identification of some organisms. bacterial cultures are indicated for bacteria identification and antibiotic susceptibility testing. administration of antibiotics before cytologic evaluation can cause a septic effusion to appear nonseptic. emergency treatment for pyothorax involves placement of an intravenous catheter, intravenous fluids to treat hypovolemic shock, and broad-spectrum antibiotics (ampicillin, mg/kg iv q h, and enrofloxacin, mg/kg iv q h). chloramphenicol also is an appropriate antibiotic to use for penetration into pockets of fluid. administration of a beta-lactam antibiotic (ampicillin or amoxicillin) with a beta-lactamase inhibitor (amoxicillin clavulanate or ampicillin sulbactam) is helpful in achieving better coverage of bacteroides spp. treatment of pyothorax differs in the cat and dog. in the cat, placement of one or two thoracic drainage catheters is recommended to allow continuous drainage of the intrathoracic abscess. inadequate drainage can result in treatment failure. fluid should be evaluated and the pleural cavity lavaged with ml/kg of warmed . % saline or lactated ringer's solution every hours. approximately % of the infused volume should be recovered after each lavage. in dogs, or in cats with refractory pyothorax, perform an exploratory thoracotomy to remove any nidus of infection. rarely a foreign body is visible that can be removed at the time of surgery, but this finding is rare. antibiotics are indicated for a minimum of to weeks after removal of the thoracostomy tube. early diagnosis and aggressive treatment result in a good prognosis in the majority of patients with pyothorax. in cats, clinical signs of ptyalism and hypothermia at the time of presentation worsen the prognosis. chylothorax refers to the abnormal accumulation of chyle (lymphatic fluid) in the pleural cavity. the cisterna chili is the dilated collection pool of lymphatic ducts in the abdomen that accumulate chyle prior to entry into the thoracic duct located within the thoracic cavity. the thoracic duct enters the thorax at the aortic hiatus. numerous tributaries or collateral ducts exist. the functions of the lymphatic vessels collectively serve to deliver triglycerides and fat-soluble vitamins into the peripheral vascular circulation. damage of the thoracic duct or lymphatic system or obstruction to lymphatic flow can result in the development of chylous effusion in the pleural or peritoneal space. it is difficult to identify chylous effusions based on their milky appearance alone. to identify a chylous effusion versus a pseudochylous effusion, the triglyceride and cholesterol levels of the fluid must be compared with those of peripheral blood. chylous effusions have a higher triglyceride and lower cholesterol levels than peripheral blood. pseudochylous effusions have a higher cholesterol and lower triglyceride levels than peripheral blood. disease processes that can result in chylous effusions are listed in the box - . clinical signs associated with chylous effusion are typical of any pleural effusion and of the disease process that caused the effusion. weight loss may be evident, depending on the chronicity of the process. the diagnosis is made based on thoracocentesis, cytology, and biochemical evaluation of the fluid (i.e., triglyceride and cholesterol levels). the fluid often appears milky or bloodtinged but can be clear if the patient has significant anorexia. typical cytologic characteristics are listed in table - . lymphangiography can be used to confirm trauma to the thoracic duct, but this is usually not necessary unless surgical ligation is going to be attempted. the diagnostic evaluation must also attempt to identify an underlying cause. therapy for chylothorax is difficult and primarily involves documentation and treatment of the underlying cause. if an underlying cause is not found, treatment is largely supportive and consists of intermittent thoracocentesis to drain the fluid as it accumulates and causes respiratory dysfunction, nutritional support, and maintenance of fluid balance. a variety of surgical techniques, including ligation of the thoracic duct, pleural-peritoneal shunts, and pleurodesis, have been attempted but have had limited success. most recently, the combination of thoracic duct ligation with subtotal pericardectomy has been shown to improve surgical success rates in the treatment of chylothorax. rutin, a bioflavinoid, has been used with limited success in the treatment of idiopathic chylothorax in cats. prognosis in many cases of chylothorax is guarded. extensive hemorrhage into the pleural cavity can cause fulminant respiratory distress due to sudden hypovolemia and anemia and interference with lung expansion. hemothorax typically is associated with trauma, systemic coagulopathy, lung lobe torsions, and erosive lesions within the thorax (usually neoplasia). diagnosis of hemothorax involves obtaining a fluid sample via thoracocentesis. hemorrhagic effusion must be differentiated from systemic blood inadvertently collected during the thoracocentesis procedure. unless the hemorrhage is peracute, fluid in cases of hemothorax is rapidly defibrinated and will not clot, has a packed cell volume less than that of venous blood, contains rbcs and macrophages. hemorrhagic effusions also usually contain a disproportionately higher number of white blood cells compared with peripheral blood. hemothorax commonly is the sole clinical sign observed in animals with vitamin k antagonist rodenticide intoxication and systemic coagulopathy. whenever an animal presents with signs of a hemorrhagic pleural effusion, perform coagulation testing immediately to determine whether a coagulopathy exists. the prothrombin time test is fast and can be performed as a cage-side test (see section on coagulopathy). therapy for hemorrhagic pleural effusions should address the blood and fluid loss. administer intravenous crystalloid fluids and rbc products (see section on transfusion therapy). when necessary, administer coagulation factors in the form of fresh whole blood or fresh frozen plasma, along with vitamin k ( mg/kg sq in multiple sites with a -gauge needle). if severe respiratory distress is present, evacuate the blood within the pleural space via thoracocentesis until clinical signs of respiratory distress resolve. fluid that remains aids in the recovery of the patient, because rbcs and proteins eventually will be reabsorbed. autotransfusion can be performed to salvage blood and reinfuse it into the anemic patient. in cases of neoplastic or traumatic uncontrollable hemorrhagic effusions, surgical exploration of the thorax is warranted. diaphragmatic hernia, or a rent in the diaphragm, can result in the protrusion of abdominal organs into the thoracic cavity and impair pulmonary expansion. organs that are commonly herniated into the thorax include the liver, stomach, and small intestines. diaphragmatic hernia usually is secondary to trauma but can occur as a congenital anomaly. in cases of trauma, rib fractures, pulmonary contusions, traumatic myocarditis, hemothorax, and shock are also often present concurrently with diaphragmatic hernia. respiratory distress can be caused by any one or a combination of the above lesions. animals with prior or chronic diaphragmatic hernias may have minimal clinical signs despite the presence of abdominal organs within the thorax. clinical signs of acute or severe diaphragmatic hernia include respiratory distress, cyanosis, and shock. a diagnosis of diaphragmatic hernia is made based on the patient's history (traumatic event), clinical signs, and radiographs. in some cases, ultrasonography or contrast peritoneography is necessary to confirm the diagnosis. contrast radiographs may show the presence of the stomach or intestines within the thorax following oral administration of barium. never administer barium directly into the peritoneal cavity or in cases of suspected gastrointestinal rupture. treatment of a patient with a diaphragmatic hernia includes cardiovascular and respiratory system stabilization before attempting surgical repair of the diaphragm. if the stomach is within the thorax, or if the patient's respiratory distress cannot be alleviated with medical management alone, immediate surgery is necessary. if the respiratory distress is minimal and the stomach is not located within the thorax, surgery can be postponed until the patient is a more stable anesthetic candidate. at the time of surgery, the abdominal organs are replaced into the abdominal cavity, and the rent in the diaphragm is closed. air must be evacuated from the thorax following closure of the diaphragm. if chronic diaphragmatic hernia is repaired, the complication of reexpansion pulmonary edema can occur. cardiac injury is a common complication secondary to blunt thoracic trauma. in most cases, cardiac injury is manifested as arrhythmias, including multiple premature ventricular contractions, ventricular tachycardia, st segment depression or elevation secondary to myocardial hypoxemia, and atrial fibrillation (see section on cardiac emergencies). myocardial infarction and cardiac failure can occur. careful and repeated assessments of the patient's blood pressure and ecg tracing should be a part of any diagnostic work-up for a patient that has sustained blunt thoracic trauma. rib fractures are associated with localized pain and painful respiratory movements. radiographs are helpful to confirm the diagnosis. careful palpation may reveal crepitus and instability of the fractured ribs. common problems associated with rib fractures emergency care include pulmonary contusions, pericardial laceration, traumatic myocarditis, diaphragmatic hernia, and splenic laceration or rupture. a flail segment results from rib fractures of more than three adjacent ribs that produce a "floating segment" of the chest wall. the flail segment moves paradoxically with respiration-that is, it moves inward during inhalation and outward during exhalation. respiratory distress is associated with the pain caused by the fractures and the presence of traumatic underlying pulmonary pathology. therapy for rib fractures and flail chest includes administration of supplemental oxygen, treatment of pneumothorax or diaphragmatic hernia, and administration of systemic and local anesthesia to alleviate the discomfort associated with the fractures. although controversial, positioning the patient with the flail segment up may reduce pain and improve ventilation. avoid the use of chest wraps, which do nothing to stabilize the flail segment and can further impair respiratory excursions. following administration of a systemic analgesic, administer a local anesthetic at the dorsocaudal and ventrocaudal segment of each fractured rib, and in one rib in front of and behind the flail segment. often, pulmonary function will improve once the pain associated with rib fractures has been adequately treated. in rare cases in which the flail segment involves five or more ribs, surgical stabilization may be necessary. single rib fractures or smaller flail segments are allowed to heal on their own. feline bronchitis has a variety of names (bronchial asthma, asthma, acute bronchitis, allergic bronchitis, chronic asthmatic bronchitis, feline lower airway disease) and refers to the acute onset of respiratory distress secondary to narrowing of the bronchi. cats may present with an acute onset of severe restrictive respiratory pattern associated with lower airway obstruction. acute bronchitis in cats typically has an inflammatory component in the lower airways, resulting in acute bronchoconstriction, excessive mucus production, and inflammatory exudates. in cats with chronic bronchitis, there may be damage of the bronchial epithelium and fibrosis of the airways. these patients often have a history if intermittent exacerbation of clinical signs, intermittent cough, and periods of normality throughout the year. because there appears to be an allergic or inflammatory component in feline bronchitis, clinical signs can be acutely exacerbated by stress and the presence of aerosolized particles such as perfume, smoke, and carpet powders. causes of feline bronchitis include heartworm disease, parasitic infestation (lungworms), and (rarely) bacterial infection. on presentation, the patient should be placed in an oxygen cage and allowed to rest while being observed from a distance. postpone performing stressful diagnostic procedures until the patient's respiratory status has been stabilized. after careful thoracic auscultation, administer a short-acting bronchodilator (terbutaline, . mg/kg sq or im) along with a glucocorticosteroid (dexamethasone sodium phosphate mg/kg im, sq, iv) to alleviate immediate bronchospasm and airway inflammation. clinical signs of feline bronchitis are characterized by a short, rapid respiratory pattern with prolonged expiration with an abdominal push. wheezes may be heard on thoracic auscultation. in some cases, no abnormalities are found on auscultation, but become acutely worse when the patient is stimulated to cough by tracheal palpation. radiographs may reveal a hyperinflated lung field with bronchial markings and caudal displacement of the diaphragm. in some cases, consolidation of the right middle lung lobe is present. a complete blood count and serum biochemistry profile can be performed, but results usually are unrewarding. in endemic areas, a heartworm test is warranted. fecal examination by flotation and the baermann technique is helpful in ruling out lungworms and other parasites. bronchoalveolar lavage or transtracheal wash is useful for cytologic and bacterial examination. long-term management of feline bronchitis includes isolation from environmental exposure to potential allergens (litter dust, perfumes, smoke, incense, carpet powders) and treatment of bronchoconstriction and inflammation with a combination of oral and inhaled glucocorticosteroids and bronchodilators (table - ). antibiotic therapy is contraindicated unless a pure culture of a pathogen is documented. oral therapy with steroids and bronchodilators should be used for a minimum of weeks after an acute exacerbation and then gradually decreased to the lowest dose possible to alleviate clinical signs. metered dose inhalers are now available (aerokat.com) for administration of inhaled bronchodilators and steroids. fluticasone (flovent, mcg/puff ) can be administered initially every hours for week and then decreased to once daily, in most cases. inhaled glucocorticosteroids are not absorbed systemically, and therefore patients do not develop the adverse side effects sometimes documented with oral glucocorticosteroid administration. because it takes time for glucocorticosteroids to reach peak effects in the lungs, administration of inhaled glucocorticosteroids should overlap with oral prednisolone administration for to days. treatment of pulmonary contusions is supportive. administer supplemental oxygen in a manner that is least stressful for the animal. arterial blood gas analysis or pulse oximetry can determine the degree of hypoxemia and monitor the response to therapy. intravenous fluids should be administered with caution to avoid exacerbating pulmonary hemorrhage or fluid accumulation in the alveoli. treat other conditions associated with the traumatic event. possible complications of pulmonary contusions are rare but include bacterial infection, abscessation, lung lobe consolidation, and the development of cavitary lesions. the routine use of antibiotics or steroids in cases of pulmonary contusions is contraindicated unless external wounds are present. empiric antibiotic use without evidence of external injury or known infection can potentially increase the risk of a resistant bacterial infection. steroids have been shown to decrease pulmonary alveolar macrophage function and impair wound healing and are contraindicated. aspiration pneumonia can occur in animals as a result of abnormal laryngeal or pharyngeal protective mechanisms or can be secondary to vomiting during states of altered mentation, including anesthesia, recovery from anesthesia, and sleep. megaesophagus, systemic polyneuropathy, myasthenia gravis, and localized oropharyngeal defects such as cleft palate can increase the risk of developing aspiration pneumonitis. iatrogenic causes of aspiration pneumonia include improper placement of nasogastric feeding tubes, overly aggressive force-feeding, and oral administration of drugs. aspiration of contents into the airways can cause mechanical airway obstruction, bronchoconstriction, chemical damage to the alveoli, and infection. severe inflammation and airway edema are common. pulmonary hemorrhage and necrosis can occur. diagnosis of aspiration pneumonia is based on clinical signs of pulmonary parenchymal disease, a history consistent with vomiting or other predisposing causes, and thoracic radiographs demonstrating a bronchointerstitial to alveolar pulmonary infiltrate. the most common site is the right middle lung lobe, although the pneumonia can occur anywhere, depending on the position of the patient at the time of aspiration. a transtracheal wash or bronchoalveolar lavage is useful for bacterial culture and susceptibility testing. treatment of aspiration pneumonia includes antibiotic therapy for the infection, administration of supplemental oxygen, and loosening the debris in the airways. administer intravenous fluids to maintain hydration. nebulization with sterile saline and chest physiotherapy (coupage) should be performed at least every hours. antibiotics to consider in the treatment of aspiration pneumonia include ampicillin/enrofloxacin, amoxicillinclavulanate, ampicillin-sulbactam, trimethoprim sulfa, and chloramphenicol. the use of glucocorticosteroids is absolutely contraindicated. continue antibiotic therapy for a minimum of weeks after the resolution of radiographic signs of pneumonia. pulmonary edema arises from the accumulation of fluid in the pulmonary interstitial alveolar spaces, and airways. ventilation-perfusion abnormalities result in hypoxia. pulmonary edema can be caused by increased pulmonary vasculature hydrostatic pressure, decreased pulmonary oncotic pressure, obstruction of lymphatic drainage, or increased capillary permeability. multiple factors can occur simultaneously. the most common cause of edema is increased pulmonary hydrostatic pressure resulting from left-sided congestive heart failure. decreased plasma oncotic pressure with albumin < . g/dl can also result in accumulation of fluid in the pulmonary parenchyma. overzealous intravenous crystalloid fluid administration can result in dilution of serum oncotic pressure and vascular overload. obstruction of lymphatic drainage is usually caused by neoplasia. other causes of pulmonary edema include pulmonary thromboembolic disease, severe upper airway obstruction (noncardiogenic pulmonary edema), seizures, and head trauma. increased capillary permeability is associated with a variety of diseases that cause severe inflammation (systemic inflammatory response syndrome). the resultant pulmonary edema contains a high amount of protein and is known as acute respiratory distress syndrome (ards). ards can be associated with pulmonary or extrapulmonary causes, including direct lung injury from trauma, aspiration pneumonia, sepsis, pancreatitis, smoke inhalation, oxygen toxicity, electrocution, and immune-mediated hemolytic anemia with disseminated intravascular coagulation. diagnosis of pulmonary edema is made based on clinical signs of respiratory distress and the presence of crackles on thoracic auscultation. in severe cases, cyanosis and fulminant blood-tinged frothy edema fluid may be present in the mouth and nostrils. immediate management includes administration of furosemide ( - mg/kg iv, im) and supplemental oxygen. sedation with low-dose morphine sulfate ( . - . mg/kg iv) is helpful in dilating the splanchnic capacitance vasculature and relieving anxiety for the patient. if fluid overload is suspected secondary to intravenous fluid administration, fluids should be discontinued. severely hypoalbuminemic patients should receive concentrated human albumin ( ml/kg of a % solution) or fresh frozen plasma. furosemide as a constant rate infusion ( . - . mg/kg/hour) also can dilate the pulmonary vasculature and decrease fluid accumulation in cases of ards. following initial stabilization of the patient, thoracic radiographs and an echocardiogram should be assessed to determine cardiac side, pulmonary vascular size, and cardiac contractility. further diagnostic testing may be required to determine other underlying causes of pulmonary edema. heart failure is managed with vasodilators, diuretics, oxygen, and sometimes positive inotropes. treatment ultimately consists of administration of supplemental oxygen, minimal stress and patient handling, and judicious use of diuretics. in cases of cardiogenic pulmonary edema, administer furosemide ( - mg/kg iv, im) every to minutes until the patient loses % of its body weight. positive inotropic and antiarrhythmic therapy may be necessary to improve cardiac contractility and control dysrhythmias. the clinician should determine whether the cause of the pulmonary edema is secondary to congestive heart failure with pulmonary vascular overload, volume overload, hypoalbuminemia, or increased permeability (ards). pulmonary edema secondary to ards typically is refractory to supplemental oxygen and diuretic therapy. in many cases, mechanical ventilation should be considered. a diagnosis of pulmonary thromboembolism (pte) is difficult to make and is based on clinical signs of respiratory distress consistent with pte, lack of other causes of hypoxemia, a high index of suspicion in susceptible animals, the presence of a condition associated with pte, and radiographic findings. virchow's triad consists of vascular endothelial injury, sluggish blood flow with increased vascular stasis, and a hypercoagulable state as predisposing factors for thromboembolic disease. clinical conditions that predispose an animal to pte include hyperadrenocorticism, disseminated intravascular coagulation (dic), catheterization of blood vessels, bacterial endocarditis, protein-losing nephropathy or enteropathy, hyperviscosity syndromes, heat-induced illness, pancreatitis, diabetes mellitus, inflammatory bowel disease, and immune-mediated hemolytic anemia. definitive diagnosis requires angiography or a lung perfusion scan. clinical signs associated with pte include an acute onset of tachypnea, tachycardia, orthopnea, and cyanosis. if the embolism is large, the patient may respond poorly to supplemental oxygen administration. pulmonary hypertension can cause a split second heart sound on cardiac auscultation. in some cases, a normal thoracic radiograph is present in the face of severe respiratory distress. this is a classic finding in cases of pte. potential radiographic abnormalities include dilated, tortuous, or blunted pulmonary arteries; wedge-shaped opacities in the lungs distal to an obstructed artery; and interstitial to alveolar infiltrates. the right heart may be enlarged. echocardiography can show right heart enlargement, tricuspid regurgitation, pulmonary hypertension, and evidence of underlying cardiac disease, possibly with clots in the atria. measurement of antithrombin (at) and d-dimer levels can be useful in the identification of hypercoagulable states, including dic. treatment of any patient with at deficiency or dic includes replenishment of at and clotting factors in the form of fresh frozen plasma. treatment of pte includes therapy for cardiovascular shock, oxygen supplementation, and thrombolytic therapy (see section on thromboembolic therapy). for short-term treatment, administer heparin (heparin sodium, - units/kg sq once, followed by units/kg q h of unfractionated heparin; or fractionated heparin). thrombolytic therapy may include tissue plasminogen activator, streptokinase, or urokinase. long-term therapy with low molecular weight heparin or warfarin may be required to prevent further thromboembolic events. ideally, management should include treatment and elimination of the underlying disease. smoke inhalation commonly occurs when an animal is trapped in a burning building. the most severe respiratory complications of smoke inhalation are seen in animals that are close enough to the flames to also sustain burn injuries (see section on burn injury). at the scene, many animals are unconscious from the effects of hypoxia, hypercapnia, carbon monoxide intoxication, and hydrogen cyanide gases that accumulate in a fire. carbon monoxide produces hypoxia by avidly binding to and displacing oxygen binding to hemoglobin, resulting in severe impairment of oxygen-carrying capacity. the percentage of carboxyhemoglobin in peripheral blood depends on the amount or carbon monoxide in inhaled gases and the length of time of exposure. clinical signs of carbon monoxide intoxication include cyanosis, nausea, vomiting, collapse, respiratory failure, loss of consciousness, and death. smoke inhalation of superheated particles also causes damage to the upper airways and respiratory tree. the larynx can become severely edematous and obstruct inspiration. emergency endotracheal intubation, tracheal oxygen, or tracheostomy tube may be required in the initial resuscitation of the patient, depending on the extent of airway edema. inhalation of noxious gases and particles can cause damage to the terminal respiratory bronchioles. specific noxious gases that can cause alveolar damage include combustible particles from plastic, rubber, and other synthetic products. pulmonary edema, bacterial infection, and ards can result. in any case of smoke inhalation, the first and foremost treatment is to get the animal away from the source of the flames and smoke and administer supplemental oxygen at the scene. at the time of presentation, carefully examine the animal's eyes, mouth, and oropharynx suction soot and debris from the mouth and upper airways. evaluate the patient's respiratory rate, rhythm, and pulmonary sounds. arterial blood gases should be analyzed with co-oximetry to evaluate the pao and carboxyhemoglobin concentrations. evaluation of sao by pulse oximetry is not accurate in cases of smoke inhalation, as the pao may appear normal, even when large quantities of carboxyhemoglobin are present. radiographs are helpful in determining the extent of pulmonary involvement, although radiographic signs may lag behind the appearance of clinical respiratory abnormalities by to hours. bronchoscopy and bronchoalveolar lavage provide a more thorough and accurate evaluation of the respiratory tree; however, these procedures should be performed only in patients whose cardiovascular and respiratory status is stable. management of the patient with smoke inhalation includes maintaining a patent airway, administration of supplemental oxygen, correction of hypoxemia and acid-base abnormalities, preventing infection, and treating thermal burns (see section on burn injury). if severe laryngeal edema is present, a temporary tracheostomy may be necessary to allow adequate oxygenation and ventilation. glucocorticosteroids should not be empirically used in the treatment of smoke inhalation, because of the risk of decreasing pulmonary alveolar macrophage function and increasing the potential for infection. in cases of severe laryngeal edema, however, glucocorticosteroids may be necessary to decrease edema and inflammation. the use of empiric antibiotics is contraindicated unless clinical signs of deterioration and bacterial pneumonia develop. epistaxis can be caused by facial trauma, a foreign body, bacterial or fungal rhinitis, neoplasia, coagulopathies, and systemic hypertension. acute, severe bilateral hemorrhage without wounds have been classified in several ways according their degree of tissue integrity, etiologic force, degree of contamination and duration, and degree of contamination and infection (table - ) . there are also unique causes of wounds such as burns, psychogenic dermatoses, frostbite, decubital ulcers, and snake bite. the animal should be transported to the nearest veterinary facility for definitive care. the wound should be covered or packed with dry gauze or clean linen to protect the wound, and to prevent further hemorrhage and contamination. if an open fracture is present, the limb should be splinted without placing the exposed bone back into the wound. replacing the exposed bone fragment back through the skin wound can cause further damage to underlying soft tissue structures and increase the degree of contamination of deeper tissues. if a spinal fracture is suspected, the patient should be transported on a stable flat surface to prevent further spinal mobilization and neurologic injury. at the time of presentation, first refer to the abcs of trauma, taking care to evaluate and stabilize the patient's cardiovascular and respiratory status. after a complete physical examination and history, ancillary diagnostic techniques can be performed if the patient is hemodynamically stable (see section on triage, assessment, and treatment of emergencies). initially, every patient with superficial wound should receive some degree of analgesia and an injection of a first-generation cephalosporin, preferably within hours of the injury. evaluate the wound after the patient's cardiovascular and respiratory status have been stabilized. always cover an open wound before taking an animal to the hospital to prevent a nosocomial infection. evaluate limb wounds for neural, vascular, and orthopedic abnormalities. carefully examine the structures deep to the superficial wounds. when there has been a delay in assessment of the wound, obtain samples for culture and antimicrobial susceptibility testing. if the wound is older and obviously infected, a gram stain can help guide appropriate antimicrobial therapy pending results of culture and susceptibility testing. place a support bandage saturated with a water-soluble antibiotic ointment or nonirritating antimicrobial solution (e.g., . % chlorhexidine, if bone or joint tissue is not exposed) around the wound. in addition to a first-generation cephalosporin, other appropriate antibiotic choices include amoxicillin-clavulanate, trimethoprim-sulfadiazine, amoxicillin, and ampicillin. if gram-negative flora are present, administer enrofloxacin. administer the antibiotics of choice for a minimum of days unless a change of antibiotic therapy is indicated. at the time of wound cleansing or definitive wound repair, the patient should be placed under general anesthesia with endotracheal intubation, unless the procedure will be brief (i.e., less than minutes). in such cases, a short-acting anesthetic combination open lacerations or skin loss closed crushing injuries and contusions etiologic force abrasion loss of epidermis and portions of dermis, usually caused by shearing between two compressive surfaces avulsion tearing of tissue from its attachment because of forces similar to those causing abrasion but of a greater magnitude incision wound created by a sharp object; wound edges are smooth and there is minimal trauma in the surrounding tissues laceration irregular wound caused by tearing of tissue with variable damage to the superficial and underlying tissue puncture penetrating wound caused by a missile or sharp object; superficial damage may be minimal; damage to deeper structures may be considerable; contamination by fur and bacteria with subsequent infection is common class i - hours with minimal contamination class ii - hours with significant contamination class iii > hours with gross contamination (analgesia + propofol, analgesia + ketamine/diazepam) can be administered to effect. heavy sedation with infiltration of a local anesthetic may also be appropriate for very small wounds, depending on the location of the wound and temperament of the patient. protect the wound by packing it with sterile gauze sponges soaked in sterile saline, or with watersoluble lubricating gel such as k-y jelly. clip the fur surrounding the wound, moving from the inner edge of the wound outward, to help prevent wound contamination with fur or other debris. scrub the wound and surrounding skin with an antimicrobial soap and solution such as dilute chlorhexidine until the area is free of all gross debris. gross debris within the wound itself can be flushed using a -ml syringe filled with sterile saline or lactated ringer's solution and an -gauge needle. pressure-lavage systems are also available for use, if desired. grossly contaminated wounds can be rinsed first with warm tap water to eliminate gross contamination, and then prepared as just described. debride the wound, removing skin and other soft tissue that is not obviously viable. obviously viable and questionable tissue should remain, and the wound left open for frequent reassessment on a daily basis. remove any dark or white segments of skin. questionable skin edges may or not regain viability and should be left in place for hours, so the wound can fully reveal itself. excise grossly contaminated areas of fat and underlying fascia. blood vessels that are actively bleeding should be ligated to control hemorrhage, if collateral circulation is present. if nerve bundles are ligated cleanly in a clean wound, the nerve edges should be reapposed and anastomosed. if gross contamination is present, however, definitive neurologic repair should be delayed until healthy tissue is present. excise contaminated muscle until healthy bleeding tissue is present. anastamoe tendon lacerations if the wound is clean and not grossly contaminated. if gross contamination is present, the tendon can be temporarily anastomosed and a splint placed on the limb until definitive repair of healthy tissue is possible. thoroughly lavage open wounds to a joint with sterile saline or lactated ringer's solution. infusion of chlorhexidine or povidone-iodine solution into the joint can cause a decrease in cartilage repair and is contraindicated. smooth sharp edges and remove any obvious fragments. whenever possible, the joint capsule and ligaments should be partially or completely closed. after removing bullets and metal fragments, the subcutaneous tissue and skin should be left open to heal by second intention, or should be partially closed with a drain. the joint should then be immobilized. injuries and exposed bone should be carefully lavaged, taking care to remove any gross debris without pushing the debris further into the bone and wound. the bone should be covered with a moist dressing and stabilized until definitive fracture repair can be made. this type of injury typically is seen with shearing injuries of the distal extremities caused by interaction with slow-moving vehicles. perform wet-to-dry or enzymatic debridement until a healthy granulation bed is present. if large areas of contamination are present (e.g., necrotizing fasciitis), en bloc debridement may be necessary. en bloc debridement consists of complete excision of badly infected wounds without entering the wound cavity, to prevent systemic infection. this technique should be used only if there is sufficient skin and soft tissue to allow later closure and it can be performed without damaging any major nerves, tendons, or blood vessels. open wounds often are managed by second intention healing, delayed primary closure, or secondary closure. see section on wound management and bandaging for a more complete discussion on the use of various bandaging materials in the treatment of open wounds. if an animal is presented very shortly after a wound has occurred and there is minimal contamination and trauma, the wound can be closed after induction of anesthesia and careful preparation of the wound and surrounding tissues. close any dead space under the skin with absorbable suture material in an interrupted suture pattern. avoid incising major blood vessels or nerves. close the subcutaneous tissues with absorbable suture material in an interrupted or continuous suture pattern. take care that there is not too much tension on the wound, or else surgical dehiscence will occur with patient movement. close the skin with nonabsorbable suture or surgical staples ( - to - ) . if there is any doubt at the time of repair about tissue status or inability to close all dead space, place a passive drain (penrose drain) so that the proximal end of the drain is anchored in the proximal aspect of the wound with a suture(s). leave the ends long so that the suture can be accurately identified at the time of drain removal. pass the suture through the skin, through the drain, and out the other side of the skin. place the rest of the drain into the wound and then secure it at the most ventral portion of the wound or exit hole in the most dependent area of the body, to allow drainage and prevent seroma formation. close the subcutaneous tissue over the drain before skin closure. during wound closure, be sure to not incorporate the subcutaneous or skin sutures into the drain, or it will not be possible to remove the drain without reopening the wound. bandage the area to prevent contamination. the drain can be removed once drainage is minimal (usually to days). active drains can be constructed or purchased; their use is indicated in wounds that are free of material that can plug the drain. to construct a small suction drain, remove the female portion or catheter hub at the end of a butterfly catheter. fenestrate the tubing so that there are multiple side holes, taking care to avoid making the holes larger than % of the circumference of the tubing. place the tubing into the wound via a small stab incision distal to the wound. use a purse-string suture around the tubing to facilitate a tight seal and prevent the tubing from exiting the wound. following wound closure, insert the butterfly needle into a -to -ml evacuated blood collection tube to allow fluid to drain into the tube. incorporate the tube into the bandage, and replace it when it becomes full. alternatively, the butterfly portion of the system can be removed and the tube fenestrated as described previously. place the tube into the wound and suture it in place to create a tight seal. secure the catheter hub to a syringe in which the plunger has been drawn back slightly to create suction. insert a metal pin or -to -gauge needle through the plunger at the top of the barrel to hold it at the desired level. incorporate the suction apparatus into the bandage and replace it when it becomes full. delayed primary closure should be considered when there is heavy contamination, purulent exudate, residual necrotic debris, skin tension, edema and erythema, and lymphangitis. delayed primary closure usually is made to days after the initial wound infliction and open wound management has been performed. once healthy tissue is observed, the skin edges should be debrided and the wound closed as with primary closure. secondary wound closure should be considered when infection and tissue trauma necessitate open wound management for more than days. secondary wound closure is performed after the development of a healthy granulation bed. this technique also is useful when a wound has dehisced and has formed granulation tissue. if the wound edges can be manipulated into apposition and if epithelialization has not begun, the wound can be cleansed and the wound edges apposed and sutured. this is known as early secondary closure. late secondary closure should be performed whenever there is a considerable amount of granulation tissue, the edges of the wound cannot be manipulated into position, and epithelialization has already started. in such cases, the wound should be cleaned, and the skin edges debrided to remove the epithelium. the remaining wound edges are then sutured over the granulation tissue ( shock is defined as a state of inadequate circulating volume and inability to meet cellular oxygen demands. there are three types of shock: hypovolemic, cardiogenic, and septic. early recognition of the type of shock present is crucial in the successful clinical management of shock syndrome. tissue oxygen delivery is based on cardiac output and arterial oxygen concentration. knowledge of the components of normal oxygen delivery is essential to the treatment of shock in the critical patient. improper handling of animal during further tissue and neurologic damage may occur transport (e.g., improper limb or spine immobilization). inadequate assessment of animal's animal's condition may worsen or animal may general condition or wounded tissues succumb; tissue injuries may be overlooked. inadequate wound protection during further wound contamination may occur at assessment, resuscitation, or veterinary facility. stabilization procedures inadequate wound protection while further wound contamination with fur and preparing the surrounding area debris may occur. insufficient wound lavage wound infection may occur. hydrogen peroxide wound lavage lavage offers little bactericidal activity and contributes to irritation of tissues and delayed healing. lavage has short residual activity and absorption with large wound. overly aggressive initial layered debridement may result in the removal of viable debridement tissue. en bloc debridement debridement results in removal of large amounts of tissue and a large defect for closure. use of drains potential exists for bacteria to ascend along the drain, for drain removal by the animal or breakage of the drain, and for possible tissue emphysema with air being sucked under the skin with patient movement. tube-type drains drains may cause postoperative discomfort; fenestrations may become occluded to stop intraluminal drainage. deeply placed sutures in the presence drain may be incorporated into the repair and of a drain prevent drain removal. active drains high negative pressure may cause tissue injury; highly productive wounds may necessitate changing the evacuated blood tubes several times a day with constructed drains. oxygen delivery (do ) = cardiac output (q) × arterial oxygen content (cao ) where q = heart rate × stroke volume. stroke volume is affected by preload, afterload, and cardiac contractility. where hb = hemoglobin concentration, sao = oxygen saturation, and pao = arterial partial pressure of oxygen in mm hg. thus, factors that can adversely affect oxygen delivery include inadequate preload or loss of circulating volume, severe peripheral vasoconstriction and increased afterload, depressed cardiac contractility, tachycardia and decreased diastolic filling, cardiac dysrhythmias, inadequate circulating hemoglobin, and inadequate oxygen saturation of hemoglobin. during septic shock, enzymatic dysfunction and decreased cellular uptake and utilization of oxygen also contribute to anaerobic glycolysis. an inadequate circulating volume may develop secondary to maldistribution of available blood volume (traumatic, septic, and cardiogenic origin) or as a result of absolute hypovolemia (whole blood or loss of extracellular fluid). normally, the animal compensates by ( ) splenic and vascular constriction to translocated blood from venous capacitance vessels to central arterial circulation, ( ) arteriolar constriction to help maintain diastolic blood pressure and tissue perfusion, and ( ) an increase in heart rate to help maintain cardiac output. arteriolar vasoconstrictions support perfusion to the brain and heart at the expense of other visceral organs. if vasoconstriction is severe enough to interfere with delivery of adequate tissue oxygen for a sufficient period of time, the animal may die. hypovolemic shock can result from acute hemorrhage or from severe fluid loss from vomiting, diarrhea, or third spacing of fluids. early in shock, baroreceptors in the carotid body and aortic arch sense a decrease in wall stretch from a decrease in circulating fluid volume. tonic inhibition of sympathetic tone via vagal stimulation is diminished, and heart rate and contractility increase and peripheral vessels constrict to compensate for the decrease in cardiac output. the compensatory mechanisms protect and support blood supply to the brain and heart at the expense of peripheral organ perfusion. this is called early compensatory shock. early compensatory shock is characterized by tachycardia, normal to fast capillary refill time, tachypnea, and normothermia. as shock progresses, the body loses its ability to compensate for ongoing fluid losses. early decompensatory shock is characterized by tachycardia, tachypnea, delayed capillary refill time, normotension to hypotension, and a fall in body temperature. end-stage decompensatory shock is characterized by bradycardia, markedly prolonged capillary refill time, hypothermia, and hypotension. aggressive treatment is necessary for any hope of a favorable outcome. septic shock should be considered in any patient with a known infection, recent instrumentation that could potentially introduce infection (indwelling intravenous or urinary catheter, surgery or penetrating injury), disorders or medical therapy that can compromise immune function (diabetes mellitus, immunodeficiency virus, parvovirus or feline panleukopenia virus infection, stress, malnutrition, glucocorticoids, chemotherapy). the presence of bacteria, viruses or rickettsiae, protozoa, or fungal organisms in the blood constitutes septicemia. septic shock is characterized by the presence of sepsis and refractory hypotension that is unresponsive to standard aggressive fluid therapy and inotropic or pressor support. septic shock and other causes of inflammation can lead to systemic inflammatory response syndrome (sirs). in animals, the presence of two or more of the criteria in table - in the presence of suspected inflammation or sepsis constitutes sirs (table - ). clinical signs associated with sepsis may be vague and nonspecific, including weakness, lethargy, vomiting, and diarrhea. cough and pulmonary crackles may be associated with pneumonia. decreased lung sounds may be associated with pyothorax. abdominal pain and fluid may be associated with septic peritonitis. vaginal discharge may or may not be present in patients with pyometra. diagnostic tests should include a white blood cell count, serum biochemical profile, coagulation tests, thoracic and abdominal radiographs, and urinalysis. the white blood cell count in a septic patient that is appropriately responding to the infection will be elevated with a left-shifted neutrophilia and leukocytosis. a degenerative left shift, in which leukopenia with elevated band neutrophils suggests an overwhelming infection. biochemical analyses may demonstrate hypoglycemia and nonspecific hepatocellular and cholestatic enzyme elevations. in the most severe cases, metabolic (lactic) acidosis, coagulopathies, and end-organ failure, including anuria and ards, may be present. cardiogenic shock occurs as a result of cardiac output inadequate to meet cellular oxygen demands. cardiogenic shock is associated with primary cardiomyopathies, cardiac dysrhythmias, pericardial fluid, and pericardial fibrosis. abnormalities seen on physical examination often are similar to those seen in other categories of shock, but they can also include cardiac murmurs, dysrhythmias, pulmonary rales, bloody frothy pulmonary edema fluid from the nares or mouth, orthopnea, and cyanosis. it is important to distinguish the primary cause of shock before implementing treatment (table - ) , whenever possible, because treatment for a suspected ruptured hemangiosarcoma differs markedly from the treatment for end-stage dilatative cardiomyopathy. the patient's clinical signs may be similar and include a peritoneal fluid wave, but the treatment for hypovolemia can dramatically worsen the congestive heart failure secondary to dilatative cardiomyopathy. when a patient presents with some form of shock, immediate vascular access is of paramount importance. place a large-bore peripheral or central venous catheter for the infusion of crystalloid or colloid fluids, blood component therapy, and drugs. monitor the patient's cardiopulmonary status (by ecg), blood pressure, oxygen saturation (as determined by pulse oximetry or arterial blood gas analyses), hematocrit, bun, and glucose. ancillary diagnostics, including thoracic and abdominal radiography, urinalysis, serum biochemistry profile, coagulation tests, complete blood count, abdominal ultrasound, and echocardiography, should be performed as determined by the individual patient's needs and the type of shock. the following list, called the "rule of twenty," is a guideline for case management of the shock patient. consideration of each aspect of the rule of twenty on a daily basis ensures temperature < °f or > . °f < °f or > . °f heart rate > beats/minute in dogs < or > beats/minute in cats respiratory rate > breaths/minute or paco > breaths/minute or paco < mm hg < mm hg white blood cell > , cells/µl , cells/µl count or < cells/µl o r < cells/ml or > % bands or > % bands that major organ systems are not overlooked. the list also provides a means to integrate and relate changes in different organ systems functions with one another.* the treatment of hypovolemic and septic shock requires the placement of large-bore intravenous catheters in peripheral and central veins. if vascular access cannot be obtained percutaneously or by cutdown methods, intraosseous catheterization should be considered. once vascular access is achieved, rapidly administer large volumes of crystalloid or colloid fluids. as a rule of thumb, administer / of a calculated shock dose of fluids-that is, / × ( ml/kg/hour) in dogs and / × ( ml/kg/hour) in cats) of a balanced crystalloid fluid ( normosol-r, plasmalyte-m, lactated ringer's solution, or . % sterile saline). reassess the patient's perfusion parameters (heart rate, capillary refill time, blood pressure, urine output) on a continual basis to direct further fluid therapy. synthetic colloid fluids (hetastarch, dextran , or oxyglobin) can also be administered in the initial resuscitation from shock. a guideline is to administer to ml/kg of hetastarch or dextran as a bolus over to minutes and then reassess perfusion parameters. hypertonic saline ( . % nacl, ml/kg) can be used in cases of hemorrhagic shock to temporarily restore intravascular fluid volume by drawing fluid from the interstitial space. because this type of fluid resuscitation is short-lived, hypertonic saline should always be used with another crystalloid or colloid fluid, and it should not be used in patients with interstitial dehydration. if hemorrhagic shock is present, the goal should be to return a patient's blood pressure to normal (not supraphysiologic) levels (i.e., systolic pressure - mm hg, diastolic pressure > mm hg, and mean arterial pressure ≥ mm hg) to avoid iatrogenically causing clots to fall off and hemorrhage to re-start. in critically ill patients, fluid loss can be measured in the form of urine, vomit, diarrhea, body cavity effusions, and wound exudates. additionally, insensible losses (those that cannot be readily measured from sweat, panting, and cellular metabolism) constitute ml/kg/ day. measurement of fluid "ins and outs" in conjunction with the patient's central venous pressure, hematocrit, albumin, and colloid oncotic pressure can help guide fluid therapy (see also section on fluid therapy). maintenance of normotension is necessary for adequate oxygen delivery to meet cellular energy demands. blood pressure can be measured using direct arterial catheterization, or through indirect means such as doppler plesthymography or oscillometric methods. the systolic pressure should remain at or greater than - mm hg at all times. the diastolic pressure is very important, too, as it constitutes two thirds of the mean arterial pressure; it must be greater than mm hg for coronary artery perfusion. the mean arterial pressure should be greater than mm hg for adequate tissue perfusion. if fluid resuscitation and pain management are not adequate in restoring blood pressure to normal, vasoactive drugs including positive inotropes and pressors should be considered (table - ). in cases of cardiogenic shock, vasodilator drugs (table - ) can be used to decrease vascular resistance and afterload. low-dose morphine ( . mg/kg, iv, im) dilates splanchnic vessels and helps reduce pulmonary edema. furosemide ( mg/kg/hour) also can dilate pulmonary vasculature and potentially reduce edema fluid formation in cases of ards. cardiac output is a function of both heart rate and stroke volume. stroke volume or (the amount of blood that the ventricle pumps in minute) is affected by preload, afterload, and contractility. during hypovolemic shock, there is a fall in cardiac preload due to a decrease in circulating blood volume. during septic and cardiogenic shock, there is a decrease in contractility secondary to inherent defects of the myocardium or due to the negative inotropic effects of inflammatory cytokines such as tnf-alpha, myocardial depressant factor, il- , and il- released during sepsis and systemic inflammation. afterload also may be increased because of the compensatory mechanisms and neurohumoral activation of the renin-angiotensin-aldosterone axis in hypovolemic or cardiogenic shock. as heart rate increases to compensate for a decline in cardiac output, myocardial oxygen demand increases and diastolic filling time becomes shorter. because the coronary arteries are perfused during diastole, coronary perfusion can be impaired, and myocardial lactic acidosis can develop, causing a further decline in contractility. in addition to lactic acidosis, acid-base and electrolyte abnormalities, inflammatory cytokines, direct bruising of the myocardium from trauma, and areas of ischemia can further predispose the patient to ventricular or atrial dysrhythmias. cardiac dysrhythmias should be controlled whenever possible. treatment of bradycardia should be directed at treating the underlying cause. administer anticholinergic drugs such as atropine ( . mg/kg im) or glycopyrrolate ( . mg/kg im) as necessary. in cases of third-degree or complete atrioventricular (av) block, administer a pure betaagonist such as isoproterenol ( . - . µg/kg/minute iv cri, or . mg in ml of % dextrose in water iv slowly). perform passive rewarming if the patient is hypothermic. receptor activity dosage (iv) dopamine da , da , α +++ , - µg/kg/minute (blood pressure support)* β +++ - µg/kg/minute (renal afferent diuresis) dobutamine α + , β +++ - µg/kg/minute* (blood pressure support, positive inotrope) norepinephrine α +++ , β + . - . mg/kg/minute; . - . mg/kg phenylephrine α +++ , β . - . mg/kg epinephrine α +++ , β +++ . - . mg/kg, . - . mg/kg/minute +++, strong receptor activity; , no receptor activity; +, weak receptor activity. *monitor for tachyarrhythmias at higher doses. correct any underlying electrolyte abnormalities such as hyperkalemia and hypo-and hypermagnesemia. treat ventricular dysrhythmias such as multifocal premature ventricular contractions (pvcs), sustained ventricular tachycardia > beats per minute, and r on t phenomenon (the t wave of the preceding beat occurs superimposed on the qrs complex of the next beat, and there is no return to isoelectric shelf), or if runs of ventricular tachycardia cause a drop in blood pressure. intravenous lidocaine and procainamide are the first drugs of choice for ventricular dysrhythmias. supraventricular tachycardia can impair cardiac output by impairing diastolic filling time. control supraventricular dysrhythmias with calcium channel blockers, beta-adrenergic blockers, or quinidine (table - ) . (disorientation); is minute; minutes) light sensitive and must be covered in foil and not kept for longer than hours albumin can decrease as a result of loss from the gastrointestinal tract, urinary system, and wound exudates, or into body cavity effusions. albumin synthesis can decrease during various forms of shock due to a preferential increase in hepatic acute phase protein synthesis. serum albumin contributes % of the colloid oncotic pressure of blood, in addition to its important roles as a free radical scavenger at sites of inflammation and as a drug and hormone carrier. albumin levels < . g/dl have been associated with an increase in morbidity and mortality in human and veterinary patients. administer fresh frozen plasma ( ml/kg) or concentrated human albumin ( ml/kg of % solution) to maintain serum albumin ≥ . g/dl. additional oncotic support can be in the form of synthetic colloids, as indicated. colloid oncotic pressure within the intravascular and interstitial spaces contributes to fluid flux. oncotic pressure can be measured with a colloid osmometer. normal oncotic pressure is mm hg. in cases of sepsis and sirs, increased vascular permeability increases the tendency for leakage of fluids into the interstitial spaces. colloids that can be administered until the source of albumin loss resolves include the synthetic colloids hetastarch and dextran ( - ml/kg/day), synthetic hemoglobin-based oxygen carriers (oxyglobin, - ml/kg/day), concentrated human albumin ( % albumin, ml/kg), and plasma ( ml/kg). oxygenation and ventilation can be evaluated by arterial blood gas analysis or by the noninvasive means of pulse oximetry and capnometry (see sections on pulse oximetry and capnometry). oxygen delivery can be impaired in cases of hypovolemic shock because of hemorrhage and anemia, and thus a decrease in functional capacity to carry oxygen, and is not to be used for more than weeks due to idiosyncratic blindness. in cases of cardiogenic shock as a result of impaired ability to saturate hemoglobin due to pulmonary edema in the lungs, or decrease in cardiac output. in septic shock, decreases in cardiac output due to inflammatory cytokines and a decrease in cellular oxygen extraction can lead to lactic acidosis. increased cellular metabolism and decreases in respiratory function can lead to respiratory acidosis as co increases. administer supplemental oxygen as flow-by, nasal or nasopharyngeal catheter, oxygen hood, or oxygen cage. supplemental oxygen should be humidified, and delivered at - ml/kg/minute. if oxygenation and ventilation are so impaired that the pao remains < mm hg with the patient on supplemental oxygen, a paco > mm hg, or severe respiratory fatigue, develops, and mechanical ventilation should be considered. glucose is a necessary fuel source for red blood cells and neuronal tissues, and serum glucose should be maintained within normal reference ranges. glucose supplementation can be administered as . - % solutions in crystalloid fluids, or in parenteral and enteral nutrition products. arterial and venous ph can be measured by performing blood gas analyses. decrease in tissue perfusion, impaired oxygen delivery, and decreased oxygen extraction in the various forms of shock can lead to anaerobic metabolism and metabolic acidosis. in most cases, improving tissue perfusion and oxygen delivery with crystalloid and colloid fluids, supplemental oxygen, and inotropic drugs will help normalize metabolic acidosis. serial measurements of serum lactate (normal, < . mmol/l) can be used as a guide to evaluate the tissue response to fluid resuscitative efforts. serum electrolytes often become severely deranged in shock states. serum potassium, magnesium, sodium, chloride, and total and ionized calcium should be maintained within normal reference ranges. if metabolic acidosis is severe, sodium bicarbonate can be administered by calculating the formula base deficit × . × body weight in kg = meq bicarbonate to administer because iatrogenic metabolic alkalosis can occur, a conservative approach is to administer / of the calculated dose and then recheck the patient's ph and bicarbonate levels. if the base excess is unknown, sodium bicarbonate can be administered in incremental doses of meq/kg until the ph is above . . complications associated with bicarbonate therapy include iatrogenic hypocalcemia, metabolic alkalosis, paradoxical cerebrospinal fluid acidosis, hypotension, restlessness, and death. massive trauma, neoplasia, sepsis, and systemic inflammation can all lead to coagulation abnormalities, including disseminated intravascular coagulation (dic). cage-side coagulation monitors are available for daily measurement of prothrombin time (pt), activated partial thromboplastin time (aptt), and platelet counts. fibrin degradation products (fibrin split products) become elevated in dic, trauma, hepatic disease, and surgery. coagulation proteins (clotting factors) and antithrombin often are lost with other proteins in hypoproteinemia or are consumed when microclots are formed and then dissolved. antithrombin levels can be measured by commercial laboratories. antithrombin and clotting factors can be replenished in the form of fresh frozen plasma transfusions. a more sensitive and specific test for dic is the detection of d-dimers, which can be measured by commercial laboratories. treatment for dic involves treatment and resolution of the underlying disease and administration of antithrombin and clotting factors in the form of fresh frozen plasma ( ml/kg) and heparin (unfractionated, - units/kg sq tid; fractionated [lovenox], mg/kg sq bid). monitor the patient for changes in mental status, including stupor, coma, decreased ability to swallow and protect the airway, and seizures. elevation of the patient's head can help to protect the airway and decrease the risk of increased intracranial pressure. serum glucose should be maintained within normal levels to prevent hypoglycemia-induced seizures. one of the major components of oxygen delivery is the binding to hemoglobin. packed cell volume must be kept above - % for adequate cellular oxygen delivery. acid-base status can adversely affect oxygen offloading at the tissue level if metabolic or respiratory alkalosis is present. oxygen-carrying capacity and hemoglobin levels can be increased with administration of rbc component therapy or with hemoglobin-based oxygen carriers. monitoring of renal function includes daily measurement of bun, creatinine, and urine output. normal urine output in a hydrated euvolemic patient is - ml/kg/hour. fluid ins and outs should be measured in cases of suspected oliguria or anuria. in patients with oliguria or anuria, furosemide can be administered as a bolus ( - mg/kg) or by constant rate infusion (cri)( . - mg/kg/hour). mannitol should also be administered ( . - g/kg over to minutes). dopamine ( - µg/kg/minute cri) can be administered to dilate renal afferent vessels and improve urine output. the patient's white blood cell count may be elevated, normal, or decreased, depending on the type of shock. the decision to administer antibiotics should be made on a daily basis. superficial or deep staphylococcus or streptococcus infection usually can be treated with a first-generation cephalosporin (cefazolin, mg/kg iv tid). if a known source of infection is present, administer a broad-spectrum antibiotic (cefoxitin, mg/kg iv tid; ampicillin, mg/kg qid, or enrofloxacin, - mg/kg once daily) pending results of culture and susceptibility testing. if broader anaerobic coverage is required, metronidazole ( mg/kg iv tid) should be considered. gentamicin ( - mg/kg iv once daily) is a good choice for gram-negative sepsis, provided that the patient is well hydrated and has normal renal function. ideally, patients receiving any aminoglycoside antibiotic should have a daily urinalysis to check for renal tubular casts that signify renal damage. in dogs, the gut is the shock organ. impaired gastrointestinal motility and vomiting should aggressively be treated with antiemetics and promotility drugs (dolasetron, . mg/kg iv once daily, and metoclopramide, - mg/kg/day iv cri). metoclopramide is contraindicated in cases of suspected gastrointestinal obstruction. histamine-receptor blockers such as famotidine ( . mg/kg bid iv) and ranitidine ( . to mg/kg iv bid, tid) or proton-pump inhibitors (omeprazole, . - mg/kg po once daily) can be administered for esophagitis. administer sucralfate ( . - g po tid) to treat gastric ulceration. if the gastrointestinal barrier function is diminished due to poor perfusion, infection, or inflammation, administer broad-spectrum antibiotics such as ampicillin ( mg/kg iv qid) to prevent gastrointestinal bacterial translocation. the course of drug therapy should be reviewd daily and the patient should be monitored for potential drug interactions. for example, metoclopramide and dopamine, working at the same receptor, can effectively negate the effects of each other. cimetidine, a cytochrome p enzyme inhibitor, can decrease the metabolism of some drugs. drugs that are avidly protein-bound may have an increase in unbound fraction with concurrent hypoalbuminemia or when hypoalbuminemia is present. decreased renal function may impair the renal clearance of some drugs, requiring increased dosing interval or decreased dose. nutrition is of utmost importance in any critically ill patient. patients with septic shock may become hypermetabolic and require supraphysiologic nutrient caloric requirements, while others may actually become hypometabolic. enteral nutrition is preferred, whenever possible, because enterocytes undergo atrophy without luminal nutrient stimulation. a variety of enteral feeding tubes can be placed, depending on what portion of the gut is functional, to provide enteral nutrition in an inappetent patient. loss of gastrointestinal mucosal barrier function may predispose the patients to the development of bacterial translocation and may contribute to sepsis. if enteral nutrition is impossible because of protracted vomiting or gastrointestinal resection, glucose, lipid, and amino acid products are available that can be administered parenterally to meet nutrient needs until the gastrointestinal tract is functioning and the patient can be transitioned to enteral nutrition. assessment of pain in animals in shock can be challenging. pain can result in the release of catecholamines and glucocounterregulatory hormones that can impair nutrient assimilation and lead to negative nitrogen balance, impaired wound healing, and immunocompromise. in any animal determined to be in pain, analgesic drugs should be administered to control pain and discomfort at all times. opioids are cardiovascularly friendly, and their effects can easily be reversed with naloxone if adverse effects such as hypotension and hypoventilation occur. if the patient is nonambulatory, rotate the animal from side to side every to hours to prevent lung atelectasis. passive range-of-motion exercises and deep muscle massage should be performed to increase tissue perfusion, decrease dependent edema, and prevent disuse atrophy. animals should be kept completely dry on soft, padded bedding to prevent the development of decubital ulcers. all bandages, wound sites, and catheter sites should be checked daily for the presence of swelling, erythema, and pain. soiled bandages should be changed to prevent strike-through and contamination of the underlying catheter or wound. hospitalization can be a stressful experience for patient and client alike. allowing brief visits and walks outside in the fresh air can improve a patient's temperament and decrease stress. the preemptive use of analgesic drugs on a regular schedule (not prn) should be used to prevent pain before it occurs. pain decreases the patient's ability to sleep. lack of sleep can promote further stress and impaired wound healing. the use of glucocorticosteroids and antiprostaglandins in shock therapy remains a topic of wide controversy. although the use of these agents potentially may stabilize membranes, decrease the absorption of endotoxin, and decrease prostaglandin release, the routine use of glucocorticosteroids and antiprostaglandins can decrease renal perfusion and gastrointestinal blood flow, promoting gastrointestinal ulceration and impaired renal function. the administration of supraphysiologic levels of glucocorticosteroids in patients in any type of shock can increase sodium and water retention, depress cellular immune function, and impair wound healing. in clinical studies of small animal patients, the routine use of glucocorticosteroids and antiprostaglandins has not demonstrated definite improved survival. the risks of therapy do outweigh the anecdotal reported benefits, and therefore the empiric use of glucocorticosteroids and antiprostaglandins in any shock patient is urinary tract emergencies azotemia azotemia occurs when % or more of the nephrons are nonfunctional. the magnitude of the azotemia alone cannot be used to determine whether the azotemia is prerenal, renal, or postrenal in origin, or whether the disease process is acute or chronic, reversible or irreversible, progressive or nonprogressive. before beginning treatment for azotemia, the location or cause of the azotemia must be identified. take a thorough history and then perform a physical examination. obtain blood and urine samples before initiating fluid therapy, for accurate assessment of the location of the azotemia. for example, an azotemic animal with a history of vomiting and diarrhea that appears clinically dehydrated on physical examination, normally should have a concentrated urine specific gravity (> . ) reflecting the attempt to conserve fluid. if this level is found, the azotemia is much less likely to be renal in origin, and the azotemia will likely resolve after rehydration. if, however, the urine specific gravity is isosthenuric or hyposthenuric ( . - . ) in the presence of azotemia and dehydration, primary intrinsic renal insufficiency is likely present. if the azotemia resolves with fluid therapy, the patient has prerenal and primary renal disease. if the azotemia does not resolve after rehydration, the patient has prerenal and primary renal failure. dogs with hypoadrenocorticism can have both prerenal and primary renal disease secondary to the lack of mineralocorticoid (aldosterone) influence on the renal collecting duct and renal interstitial medullary gradient. medullary washout can occur, causing isosthenuric urine in the presence of dehydration from vomiting and diarrhea. the patient often has azotemia due to fluid loss (dehydration and urinary loss) and gastric or intestinal hemorrhage (elevated bun). the prerenal component will resolve with treatment with glucocorticoids and crystalloid fluids, but the renal component may take several weeks to resolve, until the medullary concentration gradient is reestablished with the treatment and influence of mineralocorticoids. drugs such as corticosteroids and diuretics can influence renal tubular uptake and excretion of fluid, and cause a prerenal azotemia and isosthenuric urine in the absence of primary renal disease. treatment of azotemia includes calculation of the patient's dehydration estimate and maintenance fluid volumes, and administering that volume over the course of hours. identify and treat underlying causes of prerenal azotemia (shock, vomiting, diarrhea). monitor urine output closely. once a patient is euvolemic, oliguria is defined as urine output < - ml/kg/hour. urine output should return to normal in patients with prerenal azotemia as rehydration occurs. if a patient remains oliguric after rehydration, consider the possibility of oliguric acute intrinsic renal failure, and administer additional fluid therapy based on the patient's urine output, body weight, central venous pressure, and response to other medical therapies. prerenal azotemia is caused by conditions that decrease renal perfusion, including hypovolemic shock, severe dehydration, hypoadrenocorticism, congestive heart failure, cardiac tamponade, cardiac dysrhythmias, and hypotension. once renal perfusion is restored, the kidneys can resume normal function. glomerular filtration rate decreases when the mean arterial blood pressure falls to less than mm hg in a patient with normal renal autoregulation. renal autoregulation can be impaired in some diseases. passive reabsorption of urea from the renal tubules can occur during states of low tubular flow (dehydration, hypotension) even if glomerular filtration is not decreased. if renal hypoperfusion is not quickly restored, the condition can progress from prerenal disease to acute intrinsic renal failure. prerenal and renal azotemia can coexist in animals with primary renal disease, as a result of vomiting and ongoing polyuria in the absence of any oral fluid intake. the treatment of prerenal azotemia consists of rehydration, antiemetic therapy, and treatment of the underlying cause of vomiting, diarrhea, or third spacing of fluids. acute intrinsic renal failure is characterized by an abrupt decline in renal function to the extent that azotemia and an inability to regulate solute and fluid balance. patients with acute intrinsic renal failure may be oliguric or polyuric, depending on the cause and state of renal failure. in small animals, the most common causes of acute intrinsic renal failure are renal ischemia and toxins. there are three phases of acute intrinsic renal failure: induction, maintenance, and recovery. during the induction phase, some insult (ischemia or toxin) to the kidneys occurs, leading to a defective concentrating mechanism, decreased renal clearance of nitrogenous waste (azotemia), and polyuria or oliguria. if treatment is initiated during the induction phase, progression to the maintenance phase potentially can be stopped. as the induction phase progresses, there is worsening of the urine-concentrating ability and azotemia. renal tubular epithelial cells and renal tubular casts can be seen on examination of the urine sediment. glucosuria may be present. the maintenance phase of acute intrinsic renal failure occurs after a critical amount of irreversible nephron injury. correction of the azotemia and removal of the cause of the problem do not result in return to normal function. in patients with oliguria, the extent of nephron damage is greater than that observed in patients with polyuria. the maintenance phase may last for several weeks to months. recovery of renal function may or may not occur, depending on the extent of injury. the most serious complications (overhydration and hyperkalemia) are observed in patients with oliguria. the recovery phase occurs with sufficient healing of damaged nephrons. azotemia may resolve, but concentrating defects may remain. if the patient was oliguric in the maintenance phase, a marked diuresis develops during the recovery phase that may be accompanied by fluid and electrolyte losses. this phase may last for weeks to months. treatment of acute intrinsic renal failure consists of determining the cause and ruling out obstruction or uroabdomen whenever possible. a careful history can sometimes determine whether there has been exposure to nephrotoxic drugs, chemicals, or food items. if ingestion or exposure to a toxic drug, chemical, or food occurred recently (within to hours), induce emesis with apomorphine ( . mg/kg iv). next, administer activated charcoal either orally or via stomach tube, to prevent further absorption of the toxin. obtain blood and urine samples for toxicologic analysis (e.g., ethylene glycol) and to determine whether azotemia or abnormalities in the urine sediment exist. (see section on ethylene glycol, grapes and raisins, and nonsteroidal antiinflammatory drugs). obtain a complete blood count, biochemical profile, and urinalysis to determine the presence of signs of chronic renal failure, including polyuria, polydipsia, and nonregenerative anemia. radiographs and abdominal ultrasound can help in determining the chronicity of renal failure. normal renal size is . - . times the length of l in dogs and . - . times the length of l in cats. monitor the patient's body weight at least twice a day to avoid overhydration. also monitor urine output; normal output is - ml/kg/hour. in cases of polyuric renal failure, massive fluid and electrolyte losses can occur. place a urinary catheter for patient cleanliness and to facilitate urine quantitation. measure fluid ins and outs (see section on fluid therapy). after the patient has been rehydrated, the amount of fluids administered should equal maintenance and insensible needs plus the volume of urine produced each day. if a urinary catheter cannot be placed or maintained, serial body weight measurements and central venous pressure should be used to monitor the patient's fluid balance and prevent overhydration. if the patient is oliguric (urine output < - ml/kg/hour), pharmacologic intervention is necessary to increase urine output. first, administer furosemide ( - mg/kg or . mg/kg/hour iv cri). repeat bolus doses of furosemide if there is no response to initial treatment. if necessary, administer low-dose dopamine ( - µg/kg/minute iv cri) to increase renal afferent dilatation and renal perfusion. dopamine and furosemide may be synergistic if administered together. if dopamine and furosemide therapy is ineffective, administer mannitol ( . - . g/kg iv) once only. if polyuria is present, management is simplified because of the decreased risk of overhydration. if oliguria cannot be reversed, monitor the central venous pessure, body weight, and respiratory rate and effort, auscultate for crackles, and examine the patient carefully for signs of chemosis and the presence of serous nasal discharge. correct hyperkalemia with sodium bicarbonate ( . - . meq/kg iv) or with insulin ( . units/kg) plus dextrose ( g/unit of insulin iv, followed by . % dextrose iv cri). treat severe metabolic acidosis (ph < . or hco − < meq/l) with sodium bicarbonate. if anuria develops or oliguria is irreversible despite this therapy, begin peritoneal dialysis. obtain a renal biopsy to establish a diagnosis and prognosis (see section on renal biopsy). administer gastroprotectant drugs and antiemetics to control nausea and vomiting. if possible, avoid the use of nephrotoxic drugs and general anesthesia. initiate nutritional support in the form of an enteral feeding tube or parenteral nutrition as early as possible. once the patient enters the recovery phase, diuresis may occur that can lead to dehydration and electrolyte imbalances (hyponatremia, hypokalemia). dehydration and electrolyte imbalances can be treated with parenteral fluid and electrolyte supplementation. postrenal azotemia is primarily caused by urethral obstruction or leakage from the urinary tract into the abdomen (uroabdomen). complete urinary tract obstruction and uroabdomen are both ultimately fatal within to days if left untreated. in dogs, the most common causes of urethral obstruction are urinary (urethral) calculi or tumors of the urinary bladder or urethra. in male cats, feline urologic syndrome (fus) is the most common cause of urethral obstruction, although there has been an increased incidence of urethral calculi observed in recent years. a ruptured urinary bladder is the most common cause of uroabdomen and is usually secondary to blunt trauma. clinical signs of urinary tract obstruction include dysuria, hematuria, inability to urinate or initiate an adequate stream of urine, and a distended painful urinary bladder. late in the course of obstructive disease, clinical signs referable to uremia and azotemia (vomiting, oral ulcers, hematemesis, dehydration, lethargy, and anorexia) occur. the initial goal of treatment of urinary tract obstruction is to relieve the obstruction. in male dogs, a lubricated catheter can be inserted past the area of obstruction with the animal under heavy sedation or general anesthesia (see section on urohydropulsion). depending on the chronicity of the obstruction, serum electrolytes should be measured;an ecg should be obtained before administering any anesthetic drugs, because of the cardiotoxic effects of hyperkalemia (see section on atrial standstill). correct fluid, electrolyte, and acid-base abnormalities. if a urinary catheter cannot be placed, perform cystocentesis only as a last resort, because of the risk of urinary bladder rupture. definitive treatment includes identification and treatment of the underlying cause (tumor versus urinary calculi). in most cases, surgical intervention is necessary. if an unresectable tumor is present, a low-profile permanent cystostomy tube can be placed, if the owner desires. administration of piroxicam (feldene, . mg/kg po q - h) with or without chemotherapy may shrink the tumor mass and delay the progression of clinical signs. a complete discussion of this disorder is beyond the scope of this text (see additional reading for other sources of information). feline lower urinary tract disease can cause urethral obstruction, particularly in male cats. clinical signs include stranguria, dribbling of small amounts of urine, lethargy, inappetence, and vomiting. often, owners call with the primary complaint of constipation, because the cat is making frequent trips to the litterbox and straining. cases with a duration of obstruction < hours are considered uncomplicated; those with a duration > hours are complicated. treatment of urethral obstruction includes stabilizing and normalizing the patient's electrolyte status, induction of sedation or general anesthesia, and relieving the obstruction. obtain blood samples for analysis of electrolyte abnormalities. treat hyperkalemia (k + > . meq/l) with sodium bicarbonate ( . - . meq/kg iv), regular insulin ( . unit/ kg iv) plus dextrose ( g//unit of insulin iv), followed by . % dextrose iv cri to prevent hypoglycemia; or calcium gluconate ( . ml/kg % iv slowly). administer non-potassiumcontaining intravenous fluids in . % saline solution. obtain an ecg to detect atrial standstill (see section on atrial standstill). in some cases, a urethral plug is visible at the tip of the penis. the urethral plug can sometimes be manually extracted or massaged from the penis, and the obstruction temporarily relieved. in such cases, it is still necessary to pass a urethral catheter to flush sediment from the urethra and urinary bladder. unless a patient is obtunded, administer an anesthetic such as ketamine, atropine, or propofol ( - mg/kg iv) with diazepam iv for patient comfort and muscle relaxation. once the patient is under anesthesia or heavily sedated, urinary catheterization should be performed. in some cases, it will be difficult to advance the catheter. lubricate a closedended tomcat catheter and pass the tip into the distal urethra. fill a -ml syringe with sterile saline and sterile lubricant and connect the syringe to the hub of the catheter. pulse the fluid into the catheter as you gently move the catheter tip back and forth against the urethral obstruction. when the catheter has been passed into the urinary bladder, obtain a urine sample for urinalysis. drain the bladder and flush with sterile saline solution until the urine efflux appears clear. remove the tomcat catheter and insert a - fr red rubber tube or argyle infant feeding catheter into the urethra for urine collection and quantitation. secure the urinary catheter to prepuce with a butterfly strip of -inch adhesive tape secured around the catheter and then sutured to either side of the prepuce. the catheter should be connected to a closed urinary collection system for cleanliness and to reduce the risk of ascending bacterial infection. an elizabethan collar should be placed at all times to prevent the patient from damaging or removing the catheter. when the urethral obstruction has been relieved and the catheter placed, continue intravenous fluid diuresis to alleviate postrenal azotemia. monitor the urine for bacteria and other sediment. in some cases, postobstructive diuresis can be severe. carefully monitor fluid ins and outs, along with body weight, to maintain adequate hydration and perfusion. remove the urinary catheter can be removed after to hours. palpate the bladder frequently to make sure that the patient is voiding normally and to detect the recurrence of obstruction. in patients with severe penile or urethral trauma or edema, administer a short-acting steroid (dexamethasone sodium phosphate, . mg/kg iv, im, sq). at the time of initial diagnosis and again at the time of discharge, the clients need to be instructed about the long-term management of feline lower urinary tract disease at home, and informed of the risks and consequences of recurrence. uroabdomen can occur from trauma or leakage from the kidneys, ureter, or urinary bladder. clinical signs of uroabdomen (azotemia, uremia, hyperkalemia) can also occur secondary to third spacing of urine and leakage into muscular tissue from a ruptured urethra. in most cases, urinary bladder trauma and rupture are secondary to blunt trauma. abdominocentesis should be performed in any animal with suspected blunt abdominal trauma, and any fluid obtained should be analyzed for creatinine or potassium and compared with the patient's serum levels. an abdominal effusion that has a low packed cell volume and a potassium or creatinine level greater than that of the patient's serum is consistent with the diagnosis of uroabdomen. uroabdomen is not a surgical emergency. however, medical management consists of placement of a temporary abdominal drainage catheter into the abdomen, to facilitate removal of urine from the peritoneal cavity. to place the catheter, position the patient in dorsal or lateral recumbency, shave the ventral abdomen, as for any exploratory laparotomy. aseptically scrub the clipped area, and instill a local anesthestic (lidocaine, - mg/kg) caudal and to the right of the umbilicus, through the skin, subcutaneous tissues, and rectus emergency care clinical differentiation of acute necrotizing from chronic nonsuppurative pancreatitis in cats: cases acute pancreatitis in dogs mesenteric volvulus in the dog: a retrospective study of cases incidence and prognostic value of low plasma ionized calcium concentration in cats with pancreatitis: cases ( - ) review of feline pancreatitis. part : clinical signs, diagnosis and treatment gastric dilatation-volvulus syndrome in dogs diagnostic approach to acute pancreatitis pathophysiology of organ failure in severe acute pancreatitis in dogs washabau rj: gastrointestinal motility disorders and gastrointestinal prokinetic therapy watson pt: exocrine pancreatic insufficiency as an end-stage of pancreatitis in dogs clinical signs, underlying cause, and outcome in cats with seizures: cases fibrocartilaginous embolism in dogs: clinical findings and factors influencing the recovery rate kirk's current veterinary therapy xiii intervertebral disc extrusion in six cats medical management of acute spinal cord disease risk factors for recurrence of clinical signs associated with thoracolumbar intervertebral disk herniation in dogs: cases intervertebral disk disease in cats long-term functional outcome of dogs with severe injuries of the thoracolumbar spinal cord: cases canine status epilepticus: a retrospective study of cases risk factors for development of status epilepticus in dogs with idiopathic epilepsy and effects of status epilepticus on outcome and survival time: cases ( - ) skills laboratory part i: performing a neurologic examination skills laboratory part ii: interpreting the results of the neurologic examination accuracy of localization of cervical intervertebral disk extrusion or protrusion using survey radiography in dogs medical and surgical management of the glaucoma patient the feline glaucomas: cases ( - ) the canine glaucomas traumatic ocular protrusion in dogs and cats: cases traumatic glaucoma in a dog ocular and orbital porcupine quills in the dog: a review and case series hyphema: pathophysiologic considerations. comp cont educ pract vet van der woerdt a: the treatment of acute glaucoma in dogs and cats administer crystalloid intravenous fluids at maintenance rates using a balanced electrolyte solution perform urinary catheterization and collection to monitor urine output monitor serum urea nitrogen and creatinine every hours treat oliguria, defined as a drop in urine output to less than ml/kg/hour ml/kg) bolus start dopamine at to µg/kg/minute if no response to crystalloid/colloid bolus occurs within minutes consider mannitol ( . to g/kg iv) administration if no response to dopamine occurs within minutes consider furosemide ( to mg/kg iv, or . to mg/kg/hour iv cri) if no response to dopamine or mannitol occurs in to minutes if no response to furosemide, peritoneal dialysis or hemodialysis is indicated immediately, particularly if anuria is present administered with caution, because of the risk of exacerbating increased capillary permeability and causing pulmonary edema. animal patients. chlorphenoxy derivatives exert their toxic effects by an unknown mechanism, and cause clinical signs of gastroenteritis and muscle rigidity severe anemia should be treated with packed rbcs or hemoglobin-based oxygen carriers handbook of small animal toxicology and poisonings macadamia nut toxicosis in dogs the recognition and treatment of the intermediate syndrome of organophosphate poisoning in a dog acute renal failure in four dogs after raisin or grape ingestion pleural effusion in cats pulmonary function, ventilator management, and outcome of dogs with thoracic trauma and pulmonary contusions: cases ( - ) acute lung injury and acute respiratory distress syndrome smoke exposure in cats: cases ( - ) smoke exposure in dogs: cases ( - ) thoracic duct ligation and pericardectomy for treatment of idiopathic chylothorax use of intraluminal nitinol stents in the treatment of tracheal collapse in a dog clinical approach to epistaxis the veterinary icu book. teton newmedia radiographic diagnosis of diaphragmatic hernia: review of cases in dogs and cats tracheal collapse: diagnosis and medical and surgical management acute respiratory distress syndrome brachycephalic syndrome in dogs outcome and postoperative complications in dogs undergoing surgical treatment of laryngeal paralysis: cases ( - ) full recovery following delayed neurologic signs after smoke inhalation in a dog aspiration pneumonitis the veterinary icu book. teton newmedia allergic airway disease canine pleural and mediastinal effusion, a retrospective study of cases suggested strategies for ventilatory management in veterinary patients with acute respiratory distress syndrome laryngeal and tracheal disorders the veterinary icu book. teton newmedia medical and surgical treatment of pyothorax in dogs: cases traumatic diaphragmatic hernia in cats: cases canine pyothorax: clinical presentation, diagnosis, and treatment canine pyothorax: pleural anatomy and pathophysiology treatment of chronic pleural effusion with pleuroperitoneal shunt in dogs: cases ( - ) effects of doxapram hydrochloride on laryngeal function of normal dogs and dogs with naturally occurring laryngeal paralysis an overview of positive pressure ventilation risk factors, prognostic indicators, and outcome of pyothorax in cats: cases ( - ) use of percutaneous arterial embolization for the treatment of intractable epistaxis in dogs systemic inflammatory response syndrome, sepsis, and multiple organ dysfunction cardiogenic shock and cardiac arrest hemostatic changes in dogs with naturally occurring sepsis multiple organ dysfunction syndrome in humans and dogs increased lactate concentrations in ill and injured dogs the role of albumin in health and disease pathophysiologic characteristics of hypovolemic shock usefulness of systemic inflammatory response syndrome criteria as an index for prognosis judgement current principles and application of d-dimer analysis in small animal practice choosing fluids in traumatic hypovolemic shock: the role of crystalloids, colloids and hypertonic saline colloid and crystalloid resuscitation thromboembolic disease: predispositions and management marks sl: systemic arterial thromboembolism retrospective study of streptokinase administration in cats with arterial thromboembolism feline arterial thromboembolism: an update arterial thromboembolism in cats: acute crises in cases ( - ) and long-term management with low-dose aspirin in cases cut multiple holes in the side of a - fr red rubber tube or thoracic drainage catheter, using care not to make the cut wider than % of the circumference of the tube. insert the catheter into the abdominal cavity in a dorsal caudal direction. make sure that all incisions within the abdomen. secure the tube by placing a pursestring suture around the tube entrance site in the abdominal musculature with absorbable suture material. close the dead space in the subcutaneous tissues with absorbable suture. close the skin around the tube with another purse-string suture secured using a finger-trap technique. connect the tube to a closed urinary collection system and bandage the catheter to the abdomen. the tube can remain in place until the patient retrospective evaluation of acute renal failure in dogs uroabdomen in dogs and cats drug-induced nephrotoxicity: recognition and prevention peritoneal dialysis in emergency and critical care acute renal failure caused by lily ingestion in six cats early diagnosis of renal disease and renal failure acute renal failure in four dogs after raisin or grape ingestion disorders of the feline lower urinary tract the use of a low-profile cystostomy tube to relieve urethral obstruction in a dog renal biopsy: methods and interpretation feline idiopathic cystitis: current understanding of pathophysiology and management today's problem when did you first notice that something was wrong with your pet? when was the last time you noticed your pet act normally? what was the first abnormal sign noticed? what other conditions have developed and what are they? how soon did other signs develop? have the signs become better or worse since you first saw them? what is the name of the product? do you have the container with you today? is it a liquid concentrate, dilute spray, or solid? how long ago do you think that your pet was exposed to the poison? where do you think it happened? do you have any over-the-counter or prescription medications that your animal may have had access to? did you give any medications to your animal? is there any possibility of recreational drug exposure?your pet's recent activity did your pet eat this morning or last night? what is he/she normally fed? is there a chance that your pet may have gotten into the garbage? have you fed table scraps or anything new recently? if so, what? has your pet been off your property in the last - hours? does your pet run loose unattended? has your pet had any antiflea/tick medication within the last week?your pet's environment is your animal kept inside or outside of the house? is your pet kept in a fenced-in yard or allowed to run loose unattended? does your pet have access to neighboring properties (even for a short time)? where has your pet been in the last hours? has your pet traveled outside of your immediate geographic location? if so, when? has your pet been to rural areas in the last week? has there been any gardening work recently? does your pet have access to a compost pile? any fertilizers or weed killer used in the last week? any construction work or renovation recently? any mouse or rat poison in your house, yard, or garage? any cleaning products used inside or outside the house within the last hours? if so, which? have you changed your radiator fluid or does a car leak antifreeze? induce and maintain a patent airway and stabilize the patient's cardiovascular and respiratory status. control cns excitation with diazepam, if necessary, and control the patient's body temperature (both hypo-and hyperthermia) . induce vomiting if the patient is alert and can protect its airway; otherwise, perform orogastric lavage with the patient under general anesthesia with a cuffed endotracheal tube in place. alcohols do not bind well with activated charcoal. treat dermal exposure by bathing the area with warm water. introduction: if ingested, sodium or potassium hydroxide can cause severe contact dermatitis or irritation of the gastrointestinal tract. esophageal burns and full-thickness coagulative necrosis can occur. if an animal ingests a caustic alkali substance, feed the animal four egg whites mixed with quart of warmed water. perform endoscopy within hours to evaluate the extent of injury and to place a feeding tube, in severe cases. do not induce emesis , and do not perform orogastric lavage, because of the risk of worsening esophageal irritation. in cases of contact exposure to the skin or eyes, rinse the exposed area with warm water baths for at least minutes. administer gastroprotectant, antiemetic, and analgesic drugs as necessary. avoid neutralization, which can cause a hyperthermic reaction and worsen injury to the skin and gastrointestinal tract. amitraz is the active ingredient in ascaricides and anti-tick and anti-mite products such as mitaban and taktic. the toxic dose is to mg/kg. amitraz exerts its toxic effects by causing α-adrenergic stimulation, and causes clinical signs similar to those observed with administration of xylazine: bradycardia, cns depression, ataxia, hypotension, hyperglycemia, hypothermia, cyanotic mucous membranes, polyuria, mydriasis, and emesis. a coma can develop. treatment of amitraz intoxication includes cardiovascular support with intravenous crystalloid fluids and induction of emesis in asymptomatic animals. if clinical signs are present, orogastric lavage may be required. many toxic compounds are impregnated in a collar form. if the patient has ingested a collar and does not vomit it, it should be removed using endoscopy or gastrotomy. administer activated charcoal to prevent or delay absorption of the toxic compound. yohimbine or atepamizole, both α-adrenergic antagonists, are the treatment(s) of choice to reverse the clinical signs of toxicity. avoid the use of atropine, because it can potentially increase the viscosity of respiratory secretions and cause gastrointestinal ileus, thus promoting increased absorption of the toxic compound. ammonium hydroxide, or cleaning ammonia, can be caustic at high concentrations (see alkalis/caustics) and cause severe injury to the respiratory system if inhaled. pulmonary edema or pneumonia can occur, resulting in respiratory distress. ingestion of ammonia can cause severe irritation to the gastrointestinal tract and cause vomiting and esophageal injury. if ammonia is ingested, administer a dilute solution of egg white.administer gastroprotectant, antiemetic, and analgesic drugs as necessary. if pneumonia or pulmonary edema occurs secondary to aspiration of ammonia into the airways and alveolar spaces, treatment is largely supportive with supplemental oxygen administration, antibiotics, fluid therapy, and mechanical ventilation as necessary. diuretics may or may not be useful in the treatment of pulmonary edema secondary to ammonia inhalation. amphetamines cause cns excitation due to neurosynaptic stimulation, resulting in hypersensitivity to noise and motion, agitation, tremors, vomiting, diarrhea, and seizures. clinical signs of amphetamine toxicity include muscle tremors, tachyarrhythmias, mydriasis, ptyalism, and hyperthermia. amphetamines are rapidly absorbed from the gastrointestinal tract. treatment includes administration of intravenous fluids to maintain hydration and renal perfusion and correction of hyperthermia. administer sedative drugs such as chlorpromazine to control agitation and tremors, and diazepam to control seizures. urinary acidification can promote excretion and prevent reabsorption from the urinary bladder. in severe cases, treat cerebral edema with a combination of mannitol followed by furosemide to control increased intracranial pressure.antifreeze: see ethylene glycol antihistamines introduction antihistamines (loratadine, diphenhydramine, doxylamine, clemastine, meclizine, dimenhydrinate, chlorpheniramine, cyclizine, terfenadine, hydroxyzine) are available as over-thecounter and prescription allergy and anti-motion sickness products. clinical signs of antihistamine toxicity include restlessness, nausea, vomiting, agitation, seizures, hyperthermia, and tachyarrhythmias. treatment of antihistamine intoxication is largely symptomatic and supportive, as there is no known antidote. if ingestion is recent (within to hours) and the patient is not actively seizing and can protect its airway, induce emesis or perform orogastric lavage, followed by administration of activated charcoal and a cathartic. monitor the patient's heart rate, rhythm, and blood pressure. treat cardiac arrhythmias, if present, with appropriate therapies (see section on cardiac dysrhythmias). administer cooling measures and intravenous fluids to treat hyperthermia. a constant rate infusion of guaifenasin can be used to control muscle tremors. introduction α-naphthylthiourea (antu) is manufactured as a white or blue-gray powder. the toxic dose in dogs is - mg/kg, and in cats is - mg/kg. younger dogs appear to be more resistant to its toxic effects. antu usually causes profound emesis and increased capillary permeability that eventually leads to pulmonary edema. treatment of antu toxicity includes respiratory support. mechanical ventilation may be required in severe cases of pulmonary edema. if an animal does not vomit, orogastric lavage should be performed. administer gastrointestinal protectant, antiemetic, and analgesic drugs. cardiovascular support in the form of intravenous crystalloids should be arsenic introduction inorganic arsenic (arsenic trioxide, sodium arsenite, sodium arsenate) is the active ingredient in many herbicides, defoliants, and insecticides, including ant killers. the toxic dose of sodium arsenate is - mg/kg; that of sodium arsenite is - mg/kg. sodium arsenite is less toxic, although cats are very susceptible. arsenic compounds interfere with cellular respiration by combining with sulfhydryl enzymes. clinical signs of toxicity include severe gastroenteritis, muscle weakness, capillary damage, hypotension, renal failure, seizures, and death. in many cases, clinical signs are acute in onset. treatment of arsenic toxicity involves procuring and maintaining a patent airway. administer intravenous crystalloid fluids to correct hypotension and hypovolemia, and normalize acidbase and electrolyte balance. if no clinical signs are present and if the compound was ingested within hours, induce emesis. if clinical signs are present, perform orogastric lavage followed by administration of activated charcoal. if dermal exposure has occurred, throughly bathe the animal to prevent further absorption. dimercaprol (bal, - mg/kg im q h) can be administered as a chelating agent. n-acetylcysteine (mucomyst) (for cats, - mg/kg po iv, then mg/kg po iv q h for days; for dogs, mg/kg po or iv, then mg/kg po iv q h for days) has been shown to decrease arsenic toxicity in rats. aspirin causes inhibition of the production of prostaglandins, a high anion gap metabolic acidosis, gastrointestinal ulceration, hypophosphatemia, and decreased platelet aggregation when ingested in high quantities (> mg/kg/ hours in dogs; > mg/kg/ hours in cats). clinical signs of aspirin toxicity include tachypnea, vomiting, anorexia, lethargy, hematemesis, and melena. treatment of aspirin toxicity is largely supportive. if the ingestion was recent (within the last hour), induce emesis or perform orogastric lavage followed by administration of activated charcoal. administer intravenous crystalloid fluids to maintain hydration and correct acid-base abnormalities. administer synthetic prostaglandin analogues (misoprostol), gastroprotectant drugs, and antiemetics. alkalinization of the urine can enhance excretion. introduction baclofen is a gaba agonist centrally acting muscle relaxant. clinical signs of toxicity include vomiting, ataxia, vocalization, disorientation, seizures, hypoventilation, coma, and apnea. clinical signs can occur at doses as low as . mg/kg. treatment of baclofen ingestion includes induction of emesis if the animal is asymptomatic. otherwise, perform orogastric lavage. emesis or orogastric lavage should be followed by administration of activated charcoal. perform intravenous crystalloid fluid diuresis to promote elimination of the toxin, maintain renal perfusion, and normalize body temperature. supplemental oxygen or mechanical ventilation may be required for hypoventilation or apnea. if seizures occur, avoid the use of diazepam, which is a gaba agonist and can potentially worsen clinical signs. control seizures with intravenous introduction β-adrenergic agonists, including terbutaline, albuterol (salbutamol), and metaproterenol, are commonly used in inhaled form for the treatment of asthma. animals commonly are exposed to the compounds after chewing on their owners' inhalers. clinical signs of β-adrenergic stimulation include tachycardia, muscle tremors, and agitation. severe hypokalemia can occur. treatment of β-adrenergic agonist intoxication includes treatment with beta-blockers (propranolol, esmolol, atenolol), intravenous fluids, and intravenous potassium supplementation. diazepam or acepromazine may be administered for sedation and muscle relaxation. introduction barbiturates such as phenobarbital are gaba agonists and induce cns depression. clinical signs of barbiturate overdose or toxicity include weakness, lethargy, hypotension, hypoventilation, stupor, coma, and death. treatment of barbiturate toxicity includes maintenance and support of the cardiovascular and respiratory systems. if clinical signs are absent and the patient can protect its airway, induce emesis followed by repeated doses of activated charcoal. perform orogastric lavage if emesis is contraindicated. administer supplemental oxygen if hypoventilation occurs. some animals may require mechanical ventilation. administer intravenous fluids to control perfusion and blood pressure. positive inotropic drugs may be required if dosedependent decrease in cardiac output and blood pressure occurs. alkalinization of the urine and peritoneal dialysis can be performed to enhance excretion and elimination. hemodialysis should be considered in severe cases, if available. automotive and dry cell batteries contain sulfuric acid that can be irritating on contact with the eyes, skin, and gastrointestinal tract. button batteries, which contain sodium or potassium hydroxide, cause contact irritation if chewed. to treat exposure, rinse the eyes and skin with copious amounts of warm tap water or sterile saline solution for a minimum of minutes. if ingestion occurred, administer gastroprotectant and antiemetic drugs. induction of emesis and orogastric lavage is absolutely contraindicated because of the risk of aspiration pneumonia and worsening esophageal irritation. no attempt should be made at performing neutralization because of the risk of causing an exothermic reaction and worsening tissue damage. administer analgesics to control discomfort. benzoyl peroxide is the active ingredient in many over-the-counter acne preparations. ingestion can result in production of hydrogen peroxide, gastroenteritis, and gastric dilatation. topical exposure can cause dermal irritation and blistering. if an animal has ingested benzoyl peroxide, do not induce emesis, because of the risk of worsening esophageal irritation. instead, perform orogastric lavage. administer gastroprotectant and antiemetic medications and closely observe the patient observed for signs of gastric dilatation.bismuth subsalicylate (pepto-bismol): see aspirin bleach, chlorine (sodium hypochlorite) introduction sodium hypochlorite is available in dilute ( %- %) or concentrated ( % industrial strength or swimming pool) solutions for a variety of purposes. sodium hypochlorite can cause severe contact irritation and tissue destruction, depending on the concentration. affected animals may have a bleached haircoat. treatment of exposure includes dilution with copious amounts of warm water or saline baths and ocular lavage. induction of emesis and orogastric lavage is absolutely contraindicated because of the risk of causing further esophageal irritation. to treat ingestion, give the animal milk or large amounts of water, in combination with gastroprotectant and antiemetic drugs, to dilute the contents in the stomach. administration of sodium bicarbonate or milk of magnesia is no longer recommended. nonchlorine bleaches (sodium peroxide or sodium perborate) have a moderate toxic potential if ingested. sodium peroxide can cause gastric distention. sodium perborate can cause severe gastric irritation, with vomiting and diarrhea; renal damage and cns excitation followed by depression can occur, depending on the amount ingested. to treat dermal or ocular exposure, rinse the skin or eyes with copious amounts of warm tap water or sterile saline for a minimum of minutes; treat ocular injuries as necessary, if corneal burns have occurred. if the bleach has been ingested, do induce emesis and perform orogastric lavage. administer milk of magnesia ( - ml/kg). boric acid is the active ingredient in many ant and roach killers. the toxic ingredient (in amounts of - g/kg) can cause clinical signs in dogs by an unknown mechanism. clinical signs include vomiting (blue-green vomitus), blue-green stools, renal damage, and cns excitation and depression. treatment of boric acid or borate ingestion includes gastric decontamination with induction of emesis or orogastric lavage, followed by administration of a cathartic to hasten elimination. activated charcoal is not useful to treat ingestion of this toxin. administer intravenous fluid therapy to maintain renal perfusion. administer gastroprotectant and antiemetic drugs, as necessary. clostridium botulinum endospores can be found in carrion, food, garbage, and the environment. ingestion of endospores and c. botulinum endotoxin rarely can cause generalized neuromuscular blockade of spinal and cranial nerves, resulting in miosis, anisocoria, lower motor neuron weakness, and paralysis. respiratory paralysis, megaesophagus, and aspiration pneumonia can occur. clinical signs usually develop within days of ingestion. differential diagnosis includes acute polyradiculoneuritis (coonhound paralysis), bromethalin intoxication, and tick paralysis. treatment of botulism is largely supportive; although an antitoxin exists, it often is of no benefit. treatment may include administration of intravenous fluids, frequent turning of the patient and passive range-of-motion exercises to prevent disuse muscle atrophy, and supplemental oxygen administration or mechanical ventilation. administer amoxicillin, ampicillin, or metronidazole. recovery may be prolonged, up to to weeks in some cases. bromethalin is the active ingredient in some brands of mouse and rat poisons. it usually is packaged as . % bromethalin in green or tan pellets, and packaged in - . g place packs. the toxic dose for dogs is . g/kg, and for cats g/kg. bromethalin causes toxicity by uncoupling of oxidative phosphorylation. an acute syndrome of vomiting, tremors, extensor rigidity, and seizures occurs within hours of ingestion of high doses. delayed clinical signs occur within to days of ingestion of a lower dose and include posterior paresis progressing to ascending paralysis, cns depression, and coma. treatment of known bromethalin ingestion includes induction of emesis or orogastric lavage, and repeated doses of activated charcoal every to hours for days, because bromethalin undergoes enterohepatic recirculation. supportive care includes intravenous fluids, anticonvulsants, muscle relaxants (methocarbamol up to mg/kg/day iv to effect), frequent turning of the patient, and passive range-of-motion exercises. supplemental oxygen and /or mechanical ventilation may be required in patients with coma and severe hypoventilation. administer mannitol ( . - g/kg) in conjunction with furosemide ( mg/kg iv) if cerebral edema is suspected. the majority of caffeine toxicities occur in dogs that ingest coffee beans. caffeine causes phosphodiesterase inhibition, and can cause cardiac tachyarrhythmias, cns stimulation (hyperexcitability and seizures), diuresis, gastric ulcers, vomiting, and diarrhea. muscle tremors and seizures can occur, resulting in severe hyperthermia. treatment of caffeine toxicity is largely symptomatic and supportive, as there is no known antidote. if clinical signs are not apparent and the patient is able to protect its airway, induce emesis. alternatively, orogastric lavage can be performed, followed by administration of activated charcoal. administer diazepam to control seizures. administer betaadrenergic blockers (e.g., esmolol, propranolol, atenolol) to control tachyarrhythmias. give intravenous fluids to maintain hydration and correct hyperthermia. the patient should be walked frequently or have a urinary catheter placed to prevent reabsorption of the toxin from the urinary bladder. carbamate compounds are found in agricultural and home insecticide products. examples of carbamates include carbofuran, aldicarb, propoxur, carbaryl, and methiocarb. the toxic dose of each compound varies. carbamate compounds function by causing acetylcholinesterase inhibition. toxic amounts cause cns excitation, muscarinic acetylcholine overload, and slud (salivation, lacrimation, urination, and defecation). miosis, vomiting, treatment of carbamate intoxication includes maintaining an airway and, if necessary, artificial ventilation. administer intravenous crystalloid fluids to control the patient's hydration, blood pressure, and temperature. cooling measures may be warranted. induce emesis if the substance was ingested within minutes and the animal is asymptomatic. give repeated doses of activated charcoal if the animal can swallow and protect its airway. control seizures with diazepam ( . mg/kg iv). bathe the patient thoroughly. atropine ( . mg/kg iv) is useful in controlling some of the muscarinic signs associated with the toxicity. pralidoxime hydrochloride ( -pam) is not useful in cases of carbamate intoxication. control muscle tremors with methocarbamol (up to mg/kg iv) or guaifenesin. in humans, ingestion or inhalation of - ml of carbon tetrachloride can be fatal. clinical signs of carbon tetrachloride toxicity include vomiting and diarrhea, then progressive respiratory and central nervous system depression. ventricular dysrhythmias and hepatorenal damage ensue. the prognosis is grave. treatment of carbon tetrachloride inhalation includes procurement and maintenance of a patent airway with supplemental oxygen, and cardiovascular support. to treat ingestion, administer activated charcoal, and give intravenous fluids to maintain hydration and support renal function. chlorinated hydrocarbons include ddt, methoxychlor, lindane, dieldrin, aldrin, chlordane, chlordecone, perthane, toxaphene, heptachlor, mirex, and endosulfan. the toxic dose of each compound varies. chlorinated hydrocarbons exert their toxic effects by an unknown mechanism, and can be absorbed through the skin and the gastrointestinal tract. clinical signs are similar to those observed in organophosphate toxicity: cns excitation, seizures, slud, (salivation, lacrimation, urination, defecation), excessive bronchial secretions, vomiting, diarrhea, muscle tremors, and respiratory paralysis. secondary toxicity from toxic metabolites can cause renal and hepatic failure. chronic exposure may cause anorexia, vomiting, weight loss, tremors, seizures, and hepatic failure. the clinical course can be prolonged in small animal patients. treatment of chlorinated hydrocarbon toxicity is largely supportive in nature, as there is no known antidote. procure and maintain the patient's airway. normalize the body temperature to prevent hyperthermia. if the substance was just ingested and the patient is not demonstrating any clinical signs, induce emesis. if the patient is symptomatic, perform orogastric lavage followed by activated charcoal administration. bathe the patient thoroughly in cases of topical exposure. administer intravenous crystalloid fluids to maintain hydration. these compounds do not appear to be amenable to fluid diuresis. introduction: chlorphenoxy derivatives are found in , -d, , , -t, mcpa, mcpp, and silvex. the ld of , -d is mg/kg; however, the toxic dose appears to be much lower in small treatment treatment of chlorphenoxy derivative toxicity is largely supportive in nature, as there is no known antidote. secure the patient's airway and administer supplemental oxygen, as necessary. control cns excitation with diazepam ( . mg/kg iv). intravenous crystalloid fluid diuresis and urinary alkalinization can promote elimination. administer gastroprotectant and antiemetic drugs, as needed. the toxic effects of chocolate are related to theobromine. various types of chocolate have different concentrations of theobromine and thus can cause clinical signs of toxicity with ingestion of varying amounts of chocolate, depending on the type. the toxic dose of theobromine is - mg/kg in dogs. milk chocolate contains mg/oz ( mg/ g) of chocolate, and has a low toxic potential. semisweet chocolate contains mg/oz ( mg/ g), and baking chocolate contains mg/oz ( mg/ g). semisweet and baking chocolate, being the most concentrated, have a moderate to severe toxic potential, even in large dogs.clinical signs of theobromine intoxication are associated with phosphodiesterase inhibition and include cns stimulation (tremors, anxiety, seizures), myocardial stimulation (tachycardia and tachyarrhythmias), diuresis, and (at very high doses) gastrointestinal ulceration. with treatment, the condition of most dogs returns to normal within to hours (t / = . hours in dogs). potential side effects include gastroenteritis and pancreatitis due to the fat content of the chocolate. treatment of chocolate toxicity includes obtaining and maintaining a protected airway (if necessary), intravenous fluid diuresis, induction of emesis or orogastric lavage followed by administration of repeated doses of activated charcoal, and placement of a urinary catheter to prevent reabsorption of the toxin from the urinary bladder. cholecalciferol rodenticide ingestion can lead to increased intestinal and renal reabsorption of calcium, causing an increase in serum calcium and dystrophic mineralization of the kidneys and liver at - mg/kg. clinical signs include lethargy, anorexia, vomiting, constipation, and renal pain within to days of ingestion. seizures, muscle twitching, and central nervous system depression may be observed at very high doses. as renal failure progresses, polyuria, polydipsia, vomiting/hematemesis, uremic oral ulcers, and melena may be observed. if the compound was ingested recently (within to hours) induce emesis or perform orogastric lavage, followed by administration of activated charcoal. check the patient's serum calcium once daily for three days following ingestion. if clinical signs of toxicity or hypercalcemia are present, decrease serum calcium with loop diuretics (furosemide, - mg/kg po or iv q h) and glucocorticosteroids (prednisone or prednisolone, - mg/kg po bid) to promote renal calcium excretion. in severe cases, salmon calcitonin ( - iu/kg sc q - h in dogs) or bisphosphonate compounds may be required. correct acid-base abnormalities with intravenous crystalloid fluid diuresis and sodium bicarbonate, if necessary. (see section on hypercalcemia.) denture cleaners contain sodium perborate as the active compound. sodium perborate can cause severe direct irritation of the mucous membranes and may also act as a cns depressant. clinical signs are similar to those seen if bleach or boric acid compound is ingested, namely vomiting, diarrhea, cns excitation then depression, and renal failure. treatment for ingestion of denture cleaner includes gastric decontamination along with induction of emesis or orogastric lavage and administration of a cathartic to hasten elimination. activated charcoal is not useful for treatment of ingestion of this toxin. administer intravenous fluid therapy to maintain renal perfusion. administer gastroprotectant and antiemetic drugs, as necessary. deodorants are usually composed of aluminum chloride and aluminum chlorohydrate. both have a moderate potential for toxicity. ingestion of deodorant compounds can cause oral irritation or necrosis, gastroenteritis, and nephrosis. treatment of deodorant ingestion includes orogastric lavage, and administration of antiemetic and gastroprotectant drugs. introduction anionic detergents include sulfonated or phosphorylated forms of benzene. dishwashing liquid is an example of an anionic detergent that can be toxic at doses of - g/kg. anionic detergents cause significant mucosal damage and edema, gastrointestinal irritation, cns depression, seizures, and possible hemolysis. ocular exposure can cause corneal ulcers and edema. treatment of anionic detergent exposure is largely symptomatic, as there is no known antidote. to treat topical toxicity, flush the patient's eyes and skin with warmed tap water or . % saline solution for a minimum of minutes, taking care to avoid hypothermia. to treat ingestion, feed the patient milk and large amounts of water to dilute the toxin. do not induce emesis, because of the risk of worsening esophageal irritation. to dilute the toxin, perform orogastric lavage, followed by administration of activated charcoal. closely monitor the patient's respiratory status, because oropharyngeal edema can be severe. if necessary, perform endotracheal intubation in cases of airway obstruction. monitor the patient for signs of intravascular hemolysis. administer intravenous crystalloid fluids to maintain hydration until the patient is able to tolerate oral fluids. cationic detergents and disinfectants include quaternary ammonia compounds, isopropyl alcohol, and isopropanol. quaternary ammonia compounds have a serious toxic potential treatment treatment of cationic detergent exposure includes careful bathing and ocular rinsing of the patient for a minimum of minutes, taking care to avoid hypotension. secure the patient's airway and monitor the patient's respiratory status. administer supplemental oxygen, if necessary. place an intravenous catheter and administer intravenous crystalloid fluids to maintain hydration. do not induce emesis, because of the risk of causing further esophageal irritation. give milk or large amounts of water orally, as tolerated by the patient, to dilute the toxin. nonionic detergents include alkyl and aryl polyether sulfates, alcohols, and sulfonates; alkyl phenol; polyethylene glycol; and phenol compounds. phenols are particularly toxic in cats and puppies. clinical signs of exposure include severe gastroenteritis and topical irritation. some compounds can be metabolized to glycolic and oxalic acid, causing renal damage similar to that observed with ethylene glycol toxicity. topical and ocular exposure should be treated with careful bathing or ocular irrigation for at least minutes. administer activated charcoal to prevent absorption of the compound. as tolerated, give dilute milk or straight tap water orally to dilute the compound. administer antiemetic and gastroprotectant drugs to control vomiting and decrease gastrointestinal irritation. administer intravenous crystalloid fluids to maintain hydration and decrease the potential for renal tubular damage. monitor the patient's acid-base and electrolyte status and correct any abnormalities with appropriate intravenous fluid therapy. introduction diclone (phigone) is a dipyridyl compound that is a cns depressant. the ld in rats is - mg/kg. dichlone reacts with thiol enzymes to cause methemoglobinemia and hepatorenal damage. to treat dichlone ingestion, induce emesis or perform orogastric lavage, followed by administration of activated charcoal and a cathartic. procure and maintain a patent airway. perform intravenous fluid diuresis to maintain renal perfusion. n-acetylcysteine may be useful in the treatment of methemoglobinemia. diethyltoluamide (deet) is the active ingredient in many insect repellants (e.g., off, cutters, hartz blockade). the mechanism of action of deet is not fully understood, but it acts as a lipophilic neurotoxin within to minutes of exposure. cats appear to be particularly sensitive to deet. a lethal dermal dose is . g/kg; if ingested, the lethal dose is much less. the toxic dose of dermal exposure in dogs is g/kg. clinical signs of toxicity include aimless gazing, hypersalivation, chewing motions, and muscle tremors that progress to seizures. recumbency and death can occur within minutes of exposure at high doses. treatment of deet toxicity is largely supportive, as there are no known antidotes. procure and maintain a patent airway and perform mechanical ventilation, if necessary. place an intravenous catheter and administer intravenous crystalloid fluids to control hydration and treat hypotension, as necessary. treat seizures with diazepam ( . mg/kg iv) or phenobarbital. because of the rapid onset of clinical signs, induction of emesis is contraindicated. perform orogastric lavage if the compound was ingested within the last hours. administer multiple repeated doses of activated charcoal. cooling measures should be implemented to control hyperthermia. if dermal exposure has occurred, bathe the patient thoroughly to avoid further exposure and absorption. diquat is a dipyridyl compound that is the active ingredient in some herbicide compounds. the ld of diquat is - mg/kg. like paraquat, diquat induces its toxic effects by causing the production of oxygen-derived free radical species. clinical signs of diquat intoxication include anorexia, vomiting, diarrhea, and acute renal failure. massive dehydration and electrolyte imbalances can occur as a result of fluid loss into the gastrointestinal tract. treatment of diquat intoxication is similar to that for paraquat ingestion. if the animal had ingested diquat within hour of presentation, induce emesis. in clinical cases, orogastric lavage may be required. both emesis and orogastric lavage should be followed by administration of kaolin or bentonite as an adsorbent, rather than activated charcoal. place an intravenous catheter and administer crystalloid fluids to restore volume status and maintain renal perfusion. monitor urine output. if oliguria or anuria occurs, treatment with mannitol, furosemide, and dopamine may be considered. ecstasy ( , -methylenedioxymethylamphetamine; mdma) is a recreational drug used by humans. ecstasy causes release of serotonin. clinical signs of intoxication are related to the serotonin syndrome (excitation, hyperthermia, tremors, and hypertension), and seizures may be observed. a urine drug screening test can be used to detect the presence of mdma. treatment of ecstasy intoxication is largely supportive, as there is no known antidote. administer intravenous fluids to maintain hydration, correct acid-base status, and treat hyperthermia. serotonin antagonist drugs (cyproheptadine) can be dissolved and administered per rectum to alleviate clinical signs. intravenous propranolol has additional antiserotonin effects. administer diazepam ( . - mg/kg iv) to control seizures. if cerebral edema is suspected, administer mannitol, followed by furosemide. ethylene glycol is most commonly found in antifreeze solutions but is also in some paints, photography developer solutions, and windshield wiper fluid. ethylene glycol in itself is only minimally toxic. however, when it is metabolized to glycolate, glyoxal, glyoxylate, and oxalate, the metabolites cause an increased anion gap metabolic acidosis and precipitation of calcium oxalate crystals in the renal tubules, renal failure, and (ultimately) death.the toxic dose in dogs is . ml/kg, and in cats is . ml/kg. the toxin is absorbed quite readily from the gastrointestinal tract and can be detected in the patient's serum within an hour of ingestion. colorimetric tests that can be performed in most veterinary hospitals can detect larger quantities of ethylene glycol in the patient's serum. in a dog with clinical treatment begin treatment of known ethylene glycol ingestion immediately. induce emesis or perform orogastric lavage and adminiser repeated doses of activated charcoal. place an intravenous catheter and perform crystalloid fluid diuresis with a known antidote. the treatment of choice for dogs is administration of -methylpyrrazole ( -mp), which directly inhibits alcohol dehydrogenase, thus preventing the conversion of ethylene glycol to its toxic metabolites. the dose for dogs is mg/kg initially, followed by mg/kg at and hours and mg/kg at hours. -mp has been used experimentally at . times the recommended dose for dogs. in cats, treatment with -mp is effective if it is administered within the first hours of ingestion.cats will demonstrate signs of sedation and hypothermia with this treatment. if -mp is not available, administer ethanol ( mg/kg iv loading dose, followed by mg/ kg/hour), or as a % solution (for dogs, . ml/kg iv q h for five treatments, then q h for five more treatments; for cats, ml/kg q h for four treatments). grain alcohol ( proof) contains approximately mg/ml of ethanol. antiemetics and gastroprotective agents should be considered. urinary alkalinization and peritoneal dialysis may enhance the elimination of ethylene glycol and its metabolites. many fertilizers are on the market, and may be composed of urea or ammonium salts, phosphates, nitrates, potash, and metal salts. fertilizers have a moderate toxic potential, depending on the type and amount ingested. clinical signs of fertilizer ingestion include vomiting, diarrhea, metabolic acidosis, and diuresis. nitrates or nitrites can cause formation of methemoglobin and chocolate-brown blood. electrolyte disturbances include hyperkalemia, hyperphosphatemia, hyperammonemia, and hyperosmolality. treatment of fertilizer ingestion includes cardiovascular support, and administration of milk or a mixture of egg whites and water, followed by induction of emesis or orogastric lavage. correct electrolyte abnormalities as they occur (see section on hyperkalemia). administer antiemetic and gastroprotectant drugs, as necessary. administer intravenous fluids to control hydration and maintain blood pressure. n-acetylcysteine may be useful if methemoglobinemia is present. fipronil is the active ingredient in frontline, a flea control product. fipronil exerts its effects by gaba antagonism and can cause cns excitation. treatment of fiprinol toxicity includes treatment of cns excitation, treatment of hyperthermia by cooling measures, and administration of activated charcoal. fire extinguisher fluid contains chlorobromomethane or methyl bromide, both of which have a serious toxic potential. dermal or ocular irritation can occur. if ingested, the compounds can be converted to methanol, and cause high anion gap metabolic acidosis, cns excitation and depression, aspiration pneumonitis, and hepatorenal damage. to treat ocular or dermal exposure to fire extinguisher fluids, flush the eyes or skin with warmed tap water or . % saline solution for a minimum of minutes. do not induce emesis or perform orogastric lavage to treat ingestion, because of the risk of causing severe aspiration pneumonitis. gastroprotectant and antiemetic drugs may be used, if indicated. administer intravenous fluids to maintain hydration and renal perfusion. supplemental oxygen or mechanical ventilation may be required in severe cases of aspiration pneumonitis. fireplace colors contain salts of heavy metals-namely, copper rubidium, cesium, lead, arsenic, antimony, barium, selenium, and zinc, all of which have moderate toxic potential, depending on the amount ingested and the size of the patient. clinical signs are largely associated with gastrointestinal irritation (vomiting, diarrhea, anorexia). zinc toxicity can cause intravascular hemolysis and hepatorenal damage. to treat ingestion of fireplace colors, administer cathartics and activated charcoal and gastroprotectant and antiemetic drugs. place an intravenous catheter for intravenous crystalloid fluid administration to maintain hydration and renal perfusion. specific chelating agents may be useful in hastening elimination of the heavy metals. fireworks contain oxidizing agents (nitrates and chlorates) and metals (mercury, copper, strontium, barium, and phosphorus). ingestion of fireworks can cause hemorrhagic gastroenteritis and methemoglobinemia. to treat firework ingestion, induce emesis or perform orogastric lavage and administer activated charcoal. administer specific chelating drugs if the amount and type of metal are known, and administer gastroprotectant and antiemetic drugs. if methemoglobinemia occurs, administer n-acetylcysteine; a blood transfusion may be necessary. introduction fuels such as barbecue lighter fluid, gasoline, kerosene, and oils (mineral, fuel, lubricating) are petroleum distillate products that have a low toxic potential if ingested but can cause severe aspiration pneumonitis if as little as ml is inhaled into the tracheobronchial tree. cns depression, mucosal damage, hepatorenal insufficiency, seizures, and corneal irritation can occur. if fuels are ingested, administer gastroprotectant and antiemetics drugs. do not induce emesis or perform orogastric lavage, because of the risk of aspiration pneumonia. to treat topical exposure, rinse the skin and eyes copiously with warm tap water or . % saline solution. administer antiemetic and gastroprotectant drugs, as necessary. administer intravenous fluids to maintain hydration and treat acid-base and electrolyte abnormalities. children's glue contains polyvinyl acetate, which has a very low toxic potential. if inhaled, the compound can cause pneumonitis. treatment of polyvinyl acetate should be performed as clinical signs of pneumonitis (increased respiratory effort, cough, lethargy, respiratory distress) occur. introduction superglue contains methyl- -cyanoacrylate, a compound that can cause severe dermal irritation on contact. do not induce emesis. do not bathe the animal, and do not apply other compounds (acetone, turpentine) in an attempt to remove the glue from the skin. the fur can be shaved, using care to avoid damaging the underlying skin. the affected area should be allowed to exfoliate naturally. glyophosate is a herbicide found in roundup and kleenup. if applied properly, the product has a very low toxic potential. clinical signs of toxicity include dermal and gastric irritation, including dermal erythema, anorexia, and vomiting. cns depression can occur. treatment includes thorough bathing in cases of dermal exposure, and induction of emesis or orogastric lavage followed by administration of activated charcoal. administer antiemetic and gastroprotectant drugs as necessary. administer intravenous crystalloid fluids to prevent dehydration secondary to vomiting. even small amounts of grapes and raisins can be toxic to dogs. the mechanism of toxicity remains unknown. clinical signs occur within hours of ingestion of raisins or grapes, and include vomiting, anorexia, lethargy, and diarrhea (often with visible raisins or grapes in the fecal matter). within hours, dogs demonstrate signs of acute renal failure (polyuria, polydipsia, vomiting) that can progress to anuria. to treat known ingestion of raisins or grapes, induce emesis or perform orogastric lavage, followed by repeated doses of activated charcoal. if clinical signs of vomiting and diarrhea are present, administer intravenous fluids and monitor urine output. aggressive intravenous fluid therapy, in conjunction with maintenance of renal perfusion, is necessary. in cases of anuric renal failure, dopamine, furosemide, and mannitol can be useful in increasing urine output. peritoneal or hemodialysis may be necessary in cases of severe oliguric or anuric renal failure. calcium channel blockers such as amlodipine and diltiazem can be used to treat systemic hypertension. supportive care includes treatment of hyperkalemia, and administration of gastroprotectant and antiemetic drugs and (if the animal is eating) phosphate binders. aromatic hydrocarbons include phenols, cresols, toluene, and naphthalene. all have a moderate toxic potential if ingested. toxicities associated with ingestion of aromatic hydrocarbons include cns depression, hepatorenal damage, muscle tremors, pneumonia, methemoglobinemia, and intravascular hemolysis. if an aromatic hydrocarbon is ingested, do not induce emesis, because of the risk of aspiration pneumonia. a dilute milk solution or water can be administered to dilute the compound. perform orogastric lavage. carefully monitor the patient's respiratory and cardiovascular status. administer supplemental oxygen if aspiration pneumonia is present. to treat topical exposure, thoroughly rinse the eyes and skin with copious amounts of warm tap water or . % saline solution. imidacloprid is the compound used in the flea product advantage. clinical signs of toxicity are related to nicotinic cholinergic stimulation, causing neuromuscular excitation followed by collapse. the compound may induce respiratory paralysis. to treat imidacloprid toxicity, procure and maintain a patent airway with supplemental oxygen administration. control cns excitation with diazepam, phenobarbital, or propofol. administer enemas to hasten gastrointestinal elimination, and administer activated charcoal. bathe the animal thoroughly to prevent further dermal absorption. closely monitor the patient's oxygenation and ventilation status. if severe hypoventilation or respiratory paralysis occurs, initiate mechanical ventilation. iron and iron salts can cause severe gastroenteritis, myocardial toxicity, and hepatic damage if high enough doses are ingested. lawn fertilizers are a common source of iron salts. treatment of ingestion of iron and iron salts includes cardiovascular support in the form of intravenous fluids and antiarrhythmic drugs, as needed. induce emesis or perform orogastric lavage for gastric decontamination. a cathartic can be administered to promote elimination from the gastrointestinal tract. antiemetic and gastroprotectant drugs should be administered to prevent nausea and vomiting. in some cases, radiographs can aid in making a diagnosis of whether the compound was actually ingested. iron toxicity can be treated with the chelating agent deferoxamine. ivermectin is a gaba agonist that is used in commercial heartworm prevention and antihelminthic compounds and can be toxic in predisposed breeds, including collies, collie loperamide is an opioid derivative that is used to treat diarrhea. clinical signs of loperamide intoxication include constipation, ataxia, nausea, and sedation. induce emesis or perform orogastric lavage, followed by administration of activated charcoal and a cathartic. naloxone may be beneficial in the temporary reversal of ataxia and sedation. ingestion of macadamia nuts can cause clinical signs of vomiting, ataxia, and ascending paralysis in dogs. the toxic principle in macadamia nuts is unknown. there is no known antidote. treatment consists of supportive care, including administration of intravenous fluids and antiemetics and placement of a urinary catheter for patient cleanliness. clinical signs resolve in most cases within hours. marijuana is a hallucinogen that can cause cns depression, ataxia, mydriasis, increased sensitivity to motion or sound, salivation, and tremors. along with these findings, a classic clinical sign is the sudden onset of dribbling urine. urine can be tested with drug test kits for tetrahydrocannabinoid (thc), the toxic compound in marijuana. there is no known antidote for marijuana toxicity; therefore, treatment is largely symptomatic. place an intravenous catheter and administer intravenous fluids to support hydration. administer atropine if severe bradycardia exists. induction of emesis can be attempted but because of the antiemetic effects of thc, is usually unsuccessful. orogastric lavage can be performed, followed by repeated doses of activated charcoal. clinical signs usually resolve within to hours. introduction "strike anywhere" matches, safety matches, and the striking surface of matchbook covers contain iron phosphorus or potassium chlorate. both compounds have a low toxic potential but can cause clinical signs of gastroenteritis and methemoglobinemia if large quantities are ingested. treatment of match and matchbook ingestion includes gastric decontamination with induction of emesis or orogastric lavage and administration of activated charcoal and a cathartic. if methemoglobinemia occurs, administer n-acetylcysteine, intravenous fluids, and supplemental oxygen. metaldehyde is the active ingredient in most brands of snail bait. the exact mechanism of toxicity is unknown but may involve inhibition of gaba channels. clinical signs associated with metaldehyde toxicity include severe muscle tremors, cns excitation, and treatment treatment of mushroom toxicity is largely supportive. if the mushroom was ingested within the last hours, induce emesis or perform orogastric lavage and then administer activated charcoal. symptomatic treatment includes intravenous fluids to promote diuresis and treat hyperthermia and skeletal muscle relaxants to control tremors and seizures (methocarbamol, diazepam). if amanita ingestion is suspected, administer hepatoprotectant agents including milk thistle. mycotoxins from penicillium spp. are found in moldy foods, cream cheese, and nuts. clinical signs of intoxication include tremors, agitation, hyperesthesia, and seizures. if tremorigenic mycotoxin toxicity is suspected, a sample of the patient's serum and gastric contents or vomitus can be submitted to the michigan state university veterinary toxicology laboratory for tremorigen assay. there is no known antidote. perform orogastric lavage, followed by administration of activated charcoal. control tremors and seizures with methocarbamol, diazepam, phenobarbital, or pentobarbital. administer intravenous fluids to control hyperthermia and maintain hydration. in cases in which cerebral edema is suspected secondary to severe refractory seizures, administer intravenous mannitol and furosemide. naphthalene is the active ingredient in mothballs and has a high toxic potential. clinical signs associated with naphthalene toxicity include vomiting, methemoglobinemia, cns stimulation, seizures, and hepatic toxicity. a complete blood count often reveals heinz bodies and anemia. do not induce emesis if naphthalene ingestion is suspected. if the ingestion was within hour of presentation, perform orogastric lavage. control seizures with diazepam or phenobarbital. administer intravenous fluids to control hyperthermia and maintain hydration. n-acetylcysteine can play a role in the treatment of methemoglobinemia. a packed rbc transfusion may be necessary if anemia is severe. observe the patient for clinical signs associated with hepatitis. nicotine toxicity occurs in animals as the result of ingestion of cigarettes, nicotine-containing gum, and some insecticides. nicotine stimulates autonomic ganglia at low doses, and blocks autonomic ganglia and the neuromuscular junction at high doses. absorption after ingestion is rapid. clinical signs include hyperexcitability and slud (salivation, lacrimation, urination, and defecation). muscle tremors, respiratory muscle fatigue or hypoventilation, tachyarrhythmias, seizures, coma, and death can occur. if the patient presents within hour of ingestion and has no clinical signs, induce emesis, followed by administration of repeated doses of activated charcoal. in patients with clinical signs of toxicity, perform orogastric lavage. administer intravenous fluids to maintain hydration and promote diuresis, and treat hyperthermia. administer atropine to treat cholinergic symptoms. urinary acidification can promote nicotine excretion. nonsteroidal antiinflammatory drugs (nsaids) include ibuprofen, ketoprofen, carprofen, diclofenac, naproxen, celecoxib, valdecoxib, rofecoxib, and deracoxib. nsaids cause inhibition of prostaglandin synthesis, leading to gastrointestinal ulceration, renal failure and hepatotoxicity. ibuprofen toxicity has been associated with seizures in dogs, cats, and ferrets. the toxic dose varies with the specific compound ingested. to treat nsaid toxicity, induce emesis or perform orogastric lavage, followed by administration of multiple repeated doses of activated charcoal. place an intravenous catheter for crystalloid fluid diuresis to maintain renal perfusion. administer the synthetic prostaglandin analogue misoprostol to help maintain gastric and renal perfusion. control seizures, if present, with intravenous diazepam. administer gastroprotectant and antiemetic drugs to control vomiting and gastrointestinal hemorrhage. continue intravenous fluid diuresis for a minimum of hours, with frequent monitoring of the patient's bun and creatinine. when the bun and creatinine levels are normal or have plateaued for hours, slowly decrease fluid diuresis % per day until maintenance levels are restored. onions, garlic, and chives contain sulfoxide compounds that can cause oxidative damage of rbcs, leading to heinz body anemia, methemoglobinemia, and intravascular hemolysis. clinical signs of toxicity include weakness, lethargy, tachypnea, tachycardia, and pale mucous membranes. vomiting and diarrhea can occur. intravascular hemolysis can cause treatment treatment of onion, chive, and garlic toxicity includes administration of intravenous fluid diuresis, and induction of emesis or orogastric lavage, followed by administration of activated charcoal and a cathartic. in cases of severe anemia, packed rbc transfusion or administration of a hemoglobin-based oxygen carrier should be considered. opiate drugs include heroin, morphine, oxymorphone, fentanyl, meperidine, and codeine. opiate compounds bind to specific opioid receptors throughout the body and produce clinical signs of miosis or mydriasis (cats), and cns excitation, followed by ataxia and cns depression, leading to stupor and coma. hypoventilation, bradycardia, hypoxia, and cyanosis can occur. to treat known overdose or ingestion of an opiate compound, induce emesis (in asymptomatic animals) or perform orogastric lavage, followed by administration of activated charcoal. administer intravenous fluids and supplemental oxygen to support the cardiovascular and respiratory systems. mechanical ventilation may be necessary until hypoventilation resolves. administer repeated doses of naloxone as a specific antidote to reverse clinical signs of narcosis and hypoventilation. if seizures are present (meperidine toxicity), administer diazepam. organophosphate compounds traditionally are used in flea control products and insecticides. common examples of organophosphates include chlorpyrifos, coumaphos, diazinon, dichlorvos, and malathion. the toxic dose varies, depending on the particular compound and individual animal sensitivity. organophosphate toxicity causes acetylcholinesterase inhibition, resulting in clinical signs of cns stimulation, including tremors and seizures. muscarinic acetylcholine overload causes the classic slud signs of salivation, lacrimation, urination, and defecation. miosis, excessive bronchial secretions, muscle tremors, and respiratory paralysis can occur. an intermediate syndrome of generalized weakness, hypoventilation, and eventual paralysis with ventral cervical ventroflexion that may require mechanical ventilation has been described. if organophosphate toxicity is suspected, whole-blood acetylcholinesterase activity can be measured and will be low. treatment of toxicity includes careful and thorough bathing in cases of dermal exposure and, if the substance was ingested, gastric decontamination with induction of emesis or orogastric lavage, followed by administration of activated charcoal, and administration of the antidote pralidoxime hydrochloride . atropine can help control the muscarinic clinical signs. supportive care in the form of cooling measures, intravenous crystalloid fluids, and supplemental oxygen or mechanical ventilation may be required, depending on the severity of clinical signs. introduction ingestion of large amounts of paintballs can cause neurologic signs, electrolyte abnormalities, and occasionally death. paintballs are gelatin capsules that contain multiple colors of if ingestion was recent and if no clinical signs of toxicity are present, induce emesis or perform orogastric lavage, followed by administration of a cathartic and activated charcoal. there is no known antidote. treatment includes supportive care in the form of intravenous fluids and administration of phenobarbital or methocarbamol to control seizures and tremors. diazepam, a gaba agonist, is contraindicated, because it can potentially worsen clinical signs. urine acidification may hasten elimination. clinical signs can last from to days. pyrethrin and pyrethroid compounds are extracted from chrysanthemums, and include allethrin, decamethrin, tralomethrin, fenpropanthrin, pallethrin, sumethrin, permethrin, tetramethrin, cyfluthrin, and resemethrin. the oral toxicity is fairly low; however, the compounds can be significantly harmful if inhaled or applied to the skin. pyrethrin and pyrethroid compounds cause depolarization and blockade of nerve membrane potentials, causing clinical signs of tremors, seizures, respiratory distress, and paralysis. contact dermatitis can occur. to distinguish between pyrethrin/pyrethroid toxicity and organophosphate toxicity, acetylcholinesterase levels should be obtained; they will be normal if pyrethrins are the cause of the animal's clinical signs. treatment of toxicity is supportive, as there is no known antidote. carefully bathe the animal in lukewarm water to prevent further oral and dermal exposure. both hyperthermia and hypothermia can worsen clinical signs. administer activated charcoal to decrease enterohepatic recirculation. atropine may control clinical signs of excessive salivation. to control muscle tremors, administer methocarbamol to effect. administer diazepam or phenobarbital to control seizures, as necessary. rotenone is used as a common garden and delousing insecticide. fish and birds are very susceptible to rotenone toxicity. rotenone inhibits mitochondrial electron transport. clinical signs of tissue irritation and hypoglycemia can occur after topical or oral exposure. if the compound is inhaled, cns depression and seizures can occur. to treat toxicity, perform orogastric lavage, followed by administration of a cathartic and activated charcoal. bathe the animal carefully to prevent further dermal exposure and further ingestion. administer diazepam or phenobarbital to control seizures. the prognosis generally is guarded. treatment of ingestion includes dilution with milk, water, or egg whites. perform orogastric lavage, followed by administration of activated charcoal. administer intravenous crystalloid fluids to maintain hydration. administer antiemetic and gastroprotectant drugs to treat gastroenteritis and vomiting.shampoos, nonmedicated: see detergents, nonionic shampoos, selenium sulfide introduction selenium sulfide shampoos (e.g., selsun blue) have a low toxic potential, and primarily cause gastroenteritis. treatment of ingestion includes dilution with water, milk, or egg whites and administration of activated charcoal. carefully and thoroughly rinse the skin and eyes to prevent further exposure. administer antiemetic and gastroprotectant drugs in cases of severe gastroenteritis. zinc-based (zinc pyridinethione) anti-dandruff shampoos have a serious toxic potential if ingested or if ocular exposure occurs. gastrointestinal irritation, retinal detachment, progressive blindness, and exudative chorioretinitis can occur. treatment of ingestion includes gastric decontamination. induce emesis or perform orogastric lavage, followed by administration of a cathartic and activated charcoal.to treat ocular exposure, thoroughly rinse the patient's eyes for a minimum of minutes. carefully monitor the animal for clinical signs of blindness. implement intravenous fluid to maintain hydration and renal perfusion in cases of severe gastroenteritis. silver polish contains the alkali substance sodium carbonate and cyanide salts, and has a serious toxic potential. ingestion results in rapid onset of vomiting and possibly cyanide toxicity. to treat ingestion, monitor and maintain the patient's respiration and cardiovascular status and administer intravenous crystalloid fluids. induce emesis, followed by administration of activated charcoal. administer sodium nitrite or sodium thiosulfate iv for cyanide toxicity. bath soap (bar soap) usually has low toxic potential and causes mild gastroenteritis with vomiting if ingested. to treat ingestion, include dilution with water, administration of intravenous fluids to maintain hydration, and administration of antiemetic and gastroprotectant drugs to treat gastroenteritis. sodium fluoroacetate is a colorless, odorless, tasteless compound that causes uncoupling of oxidative phosphorylation. the toxic dose in dogs and cats is . - . mg/kg. clinical signs of toxicity include cns excitation, seizures, and coma secondary to cerebral edema. the prognosis is guarded. to treat toxicity, procure and maintain a patent airway, monitor and stabilize the cardiovascular status, and control hyperthermia. perform orogastric lavage, followed by administration of activated charcoal. if clinical signs are not present at the time of presentation, induce emesis. administer intravenous fluids and supplemental oxygen, as necessary. strattera (atomoxetine hydrochloride) is a selective norepinephrine reuptake inhibitor used in the treatment of attention deficit hyperactivity disorder (adhd) in humans. peak serum concentrations occur in dogs within to hours of ingestion, with a peak half-life at to hours following ingestion. clinical signs of toxicity include cardiac tachyarrhythmias, hypertension, disorientation, agitation, trembling, tremors, and hyperthermia. treatment of intoxication is largely symptomatic and supportive in nature. first, induce emesis if the patient is conscious and has an intact gag reflex. orogastric lavage can also be performed. administer one dose of activated charcoal to prevent further absorption of the compound from the gastrointestinal tract. identify cardiac dysrhythmias and treat accordingly. control hypertension with sodium nitroprusside or diltiazem as a constant rate infusion. administer acepromazine or chlorpromazine to control agitation. do not use diazepam, because it can potentially worsen clinical signs. administer intravenous fluids to maintain hydration and promote diuresis. strychnine is the active ingredient in pesticides used to control rodents and other vermin. the toxic dose in dogs is . mg/kg, and in cats is mg/kg. strychnine antagonizes spinal inhibitory neurotransmitters and causes severe muscle tremors, muscle rigidity, and seizures. clinical signs are stimulated or exacerbated by noise, touch, light, and sound. mydriasis, hyperthermia, and respiratory paralysis can occur. if strychnine toxicity is suspected, gastric contents should be collected and saved for analysis. if the animal is asymptomatic at the time of presentation, induce emesis. if clinical signs are present, perform orogastric lavage. both emesis and orogastric lavage should be followed by the administration of activated charcoal. administer intravenous crystalloid fluids to support the cardiovascular system, aid in cooling measures, and improve renal diuresis. treat cns stimulation with methocarbamol, diazepam, or phenobarbital. the animal should have cotton packed in its ears to prevent noise stimulation, and should be placed in a quiet, dark room. treatment of ingestion includes dilution with milk of magnesia or water, administration of antiemetic and gastroprotectant drugs, and administration of intravenous crystalloid fluids to maintain hydration. do not induce emesis, because of the risk of causing further esophageal irritation.sunscreen: see zinc and zinc oxide suntan lotion: see shampoos, zinc-based, and alcohols tar: see fuels tea tree oil (melaleuca oil) introduction tea tree (melaleuca) oil is an herbal-origin flea-control product. the toxic principles in tea tree oil are monoterpenes, which produce clinical signs of neuromuscular weakness, and ataxia. treatment of tea tree oil toxicity includes administration of cathartics and activated charcoal to prevent further absorption. carefully bathe the animal to prevent further dermal exposure. tetanus spores from clostridium tetani organisms are ubiquitous in the soil and feces, particularly in barnyards. cases have been reported in dogs after tooth eruption and after abdominal surgeries performed with cold sterilization packs. anaerobic wound infections can contain tetanus spores. the neurotoxin from c. tetani inhibits spinal inhibitory neurons, causing motor neuron excitation. extensor muscle rigidity ("sawhorse stance"), erect ears, and risus sardonicus (a sardonic grin) are characteristic features of tetanus. administer tetanus antitoxin if toxin has not already been bound in the cns. to eliminate the source of the toxin (e.g., abscess), open and debride all wounds. intravenous administration of ampicillin or penicillin g is the treatment of choice for tetanus. supportive care in the form of skeletal muscle relaxants, intravenous fluids and parenteral nutrition, and nursing care to prevent decubitus ulcer formation is required. in extreme cases, mechanical ventilation may be necessary. triazene compounds include atrazine, prometone, and monuron (telvar). the toxic mechanism of triazene compounds is unknown. clinical signs of toxicity include salivation, ataxia, hyporeflexia, contact dermatitis, hepatorenal damage, muscle spasms, respiratory difficulty, and death. treatment of triazene exposure includes cardiovascular and renal support in the form of intravenous crystalloid fluids, inotropic drugs, and antiarrhythmic agents, as necessary. if the exposure is recent, induce emesis. perform orogastric lavage in animals that cannot protect the airway. emesis and orogastric lavage should be followed by the administration of activated charcoal and a cathartic. carefully bathe the patient to prevent further dermal absorption. a variety of tricyclic antidepressants are available for use in both humans and animals, including amitriptyline, amoxapine, desipramine, doxepine, fluoxetine (prozac), fluvoxamine (luvox), imipramine, nortriptyline, paroxetine (paxil), protriptyline, sertraline (zoloft), and trimipramine. selective serotonin reuptake inhibitors (ssris) are rapidly absorbed from the digestive tract, with peak serum concentrations occurring to hours after ingestion. the elimination half-life for each drug differs in dogs, but typically last to hours. ssris inhibit the reuptake of serotonin, causing serotonin to accumulate in the brain. this can cause "serotonin syndrome," characterized by trembling, seizures, hyperthermia, ptyalism or hypersalivation, cramping or abdominal pain, vomiting, and diarrhea. other clinical signs of ssri intoxication include depression, tremors, bradycardia, tachyarrhythmias, and anorexia. any animal that has ingested an ssri should be promptly treated and carefully observed for at least hours for side effects. the treatment of suspected ssri intoxication involves gastric decontamination if the patient is not depressed and has an intact gag reflex. perform orogastric lavage and administer activated charcoal to prevent further toxin absorption and hasten elimination from the gastrointestinal tract. treat other clinical signs symptomatically. administer intravenous diazepam to control seizures. treat tachyarrhythmias according to type. administer methocarbamol to control muscle tremors. cyproheptadine ( mg/kg), a serotonin antagonist, can be dissolved in water and administered per rectum. vitamin k antagonist rodenticides, which are commonly found in pelleted or block form, inhibit the activation of the vitamin k-dependent coagulation factors ii, vii, ix, and x. clinical signs of hemorrhage occur within to days of exposure. hemorrhage can occur anywhere in the body, and can be manifested as petechiation of the skin or mucous membranes, hemorrhagic sclera, epistaxis, pulmonary parenchymal or pleural hemorrhage, gastrointestinal hemorrhage, pericardial hemorrhage, hematuria, retroperitoneal hemorrhage, hemarthrosis, and central nervous system hemorrhage. clinical signs include respiratory distress, cough, bleeding from the gums or into the eyes, ataxia, paresis, paralysis, seizures, hematuria, joint swelling, lameness, lethargy, weakness, inappetence, and collapse.diagnosis is made based on clinical signs and a prolonged activated clotting time, or prothrombin time. the pivka (proteins induced by vitamin k antagonism) test may be helpful but usually cannot be performed in-house. slight thrombocytopenia may be present secondary to hemorrhage; however, blood levels usually do not reach the critical level of < , platelets/µl to cause clinical signs of hemorrhage. in some cases, severe stressinduced hyperglycemia and glucosuria may be present but resolves within hours. if the rodenticide was ingested within the last hours, induce emesis. alternatively, orogastric lavage can be performed in an uncooperative patient. both emesis and orogastric lavage should be followed by administration of activated charcoal. the stomach contents can be submitted for analysis. following successful treatment, administer oral vitamin k for days after the exposure; or a check prothrombin time days after gastric decontamination. if the prothrombin time is prolonged, administer fresh frozen plasma and vitamin k.if the prothrombin time is normal, gastric decontamination was successful, and no further treatment is necessary.if an animal presents with clinical signs of intoxication, administer activated clotting factors in the form of fresh frozen plasma ( ml/kg), and vitamin k ( mg/kg sq in multiple sites with a -gauge needle). packed rbcs or fresh whole blood may be required if the patient is also anemic. supportive care in the form of supplemental oxygen may be necessary in cases of pulmonary or pleural hemorrhage. following initial therapy and discharge, the patient should receive vitamin k ( . mg/kg po q - h for days), and prothrombin time should be checked days after the last vitamin k capsule is administered. in some cases, depending on the type of anticoagulant ingested, an additional weeks of vitamin k therapy may be required. xylitol is a sugar alcohol that, when ingested by humans, does not cause a significant increase in blood glucose, and therefore does not stimulate insulin release from the human pancreas. in dogs, however, xylitol causes a massive rapid and dose-dependent release of insulin from pancreatic beta-cells. following insulin release, clinically significant hypoglycemia can develop, followed by signs of vomiting, weakness, ataxia, mental depression, hypokalemia, hypoglycemic seizures, and coma. clinical signs associated with xylitol ingestion can be seen within minutes of ingestion and can last for more than hours, even with aggressive treatment. known xylitol ingestion should be treated as for other toxin ingestion. if no neurologic abnormalities exist at the time the patient is seen, induce emesis, followed by administration of activated charcoal. it remains unknown at this time whether activated charcoal actually delays or prevents the absorption of xylitol from the canine gastrointestinal tract. if clinical signs have already developed, perform orogastric lavage and gastric decontamination. blood glucose concentrations should be analyzed and maintained with supplemental dextrose as a constant rate infusion ( . %- %) until normoglycemia can be maintained with multiple frequent small meals. hypokalemia may develop because it is driven intracellularly by the actions of insulin. treat hypokalemia with supplemental potassium chloride by infusion, not to exceed . meq/kg/hour. pennies minted in the u.s. after contain large amounts of zinc rather than copper. other sources of zinc include zinc oxide ointment and hardware such as that found in metal bird cages. zinc toxicity causes intravascular hemolysis, anemia, gastroenteritis, and renal failure. if zinc toxicity is suspected, take an abdominal radiograph to document the presence of the metal in the stomach or intestines. (if zinc-containing ointment was ingested, this will not be visible on radiographs.) induce emesis or perform orogastric lavage, depending on the size of the object ingested. often, small objects such as pennies can be retrieved using endoscopy or surgical gastrotomy/enterotomy. always take an additional radiograph after the removal procedure to ensure that all objects have been successfully removed. administer intravenous fluids to maintain renal perfusion and promote fluid diuresis. administer gastroprotectant and antiemetic drugs. chelation therapy with succimer, calcium edta, dimercaprol, or penicillamine may be necessary. do not administer pulmonary contusions are a common sequela of blunt traumatic injury. a contusion basically is a bruise characterized by edema, hemorrhage, and vascular injury. contusions may be present at the time of presentation or can develop over the first hours after injury. a diagnosis of pulmonary contusion can be made based on auscultation of pulmonary crackles, presence of respiratory distress, and the presence of patchy interstitial to alveolar infiltrates on thoracic radiographs. radiographic signs can lag behind the development of clinical signs of respiratory distress and hypoxemia by hours. in most cases, cage rest is sufficient to temporarily diminish blood loss. sedation (acepromazine, . - . mg/kg iv, im, sq) may be helpful in alleviating anxiety and decreasing blood pressure. the hypotensive effects of acepromazine are potentially harmful if severe blood loss has occurred. if evidence of hypovolemia is present (see section on hypovolemic shock), intravenous fluid resuscitation should be administered. rapid assessment of clotting ability, with a platelet count estimate and clotting profile (act or aptt and pt), should be performed. if epistaxis secondary to vitamin k antagonist rodenticide intoxication is suspected, administer vitamin k and fresh frozen plasma or fresh whole blood.persistent hemorrhage from a nasal disorder can be treated with dilute epinephrine ( : , ) into the nasal cavity with the nose pointed toward the ceiling to promote vasoconstriction. if this fails, the animal can be anesthetized, and the nasal cavity packed with gauze, and the caudal oropharynx and external nares covered with umbilical tape to control hemorrhage. a rhinoscopy should be performed to determine the cause of ongoing hemorrhage. continued excessive hemorrhage can be controlled with ligation of the carotid artery on the side of the hemorrhage, or with percutaneous arterial embolization. systemic thromboembolism is most commonly recognized in cats with cardiomyopathies (hypertrophic, restrictive, unclassified, and dilatative) but can also occur in dogs with hyperadrenocorticism, disseminated intravascular coagulation (dic), systemic inflammatory response syndrome (sirs), protein-losing enteropathy and nephropathy, and tumors affecting the aorta and vena cava. thrombosis occurs through a complex series of mechanisms when the components of virchow's triad (hypercoaguable state, sluggish blood flow, and vascular endothelial injury or damage) are present. in cats, blood flow through a severely stretched left atrium is a predisposing factor to the development of clots and thromboembolism.the most common site of embolism is the aortic bifurcation, or "saddle thrombus." other, less common locations of thromboembolism include the forelimbs, kidneys, gastrointestinal tract, and cerebrum. diagnosis usually is made based on clinical signs of cool extremities, the presence of a cardiac murmur or gallop rhythm, auscultation of pulmonary crackles resulting from pulmonary edema, acute pain or paralysis of one or more peripheral extremities, respiratory distress, and pain and lack of a palpable pulse in affected limbs. the affected nailbeds and paw pads are cyanotic, and nails do not bleed when cut with a nail clipper.client education is one of the most important aspects of emergency management of the patient with thromboembolic disease. concurrent congestive heart failure (chf) occurs in % to % of cats with arterial thromboembolism. more than % of cats are euthanized during the initial thromboembolic event because of the poor long-term prognosis and the high risk of recurrence within days to months after the initial event, even with aggressive therapy. although the long-term prognosis varies from months to years after initial diagnosis and treatment, in the majority of cats thromboembolic disease recurs within months. rectal temperature hypothermia and bradycardia on presentation are negative prognostic indicators.immediate treatment of a patient with chf and thromboembolic disease involves management of the chf with furosemide, oxygen, and vasodilators (nitroglycerine paste, morphine, nitroprusside). additional management includes analgesia (butorphanol, . - . mg/kg iv, im) and prevention of further clot formation. aspirin ( mg/kg po q h) is beneficial bcause of its antiplatelet effects. heparin works in conjunction with antithrombin to prevent further clot formation ( - units/kg iv, followed by - units/kg sq q h in cats, and - units/kg sq q h in dogs). acepromazine can cause peripheral vasodilation and decreased afterload but also can promote hypotension in a patient with concurrent chf. acepromazine ( . - . mg/kg sq) should be used with extreme caution, if at all.thrombolytic therapy can also be attempted, but in most cases is not without risk, and may be cost-prohibitive for many clients. streptokinase ( , units iv over minutes and then , units/hour iv cri for hours) was administered with some success in cats; however, many died of hyperkalemia or other complications during the infusion. tissue plasminogen activator ( . - mg /kg/hour iv cri, up to mg/kg total dose, to effect) has been used with some success but is cost-prohibitive for most clients. side effects of thrombolytic therapy include hyperkalemia with reperfusion and hemorrhage.in cats, the primary cause of arterial thromboembolism is cardiomyopathy. once an animal is determined to be stable enough for diagnostic procedures, lateral and dv thoracic radiographs and an echocardiogram should be performed. ultrasound of the distal aorta and renal arteries should also be performed to determine the location of the clot and help establish the prognosis.other diagnostic procedures to evaluate the presence and cause of thromboembolism include a complete blood count, serum biochemistry profile, urinalysis (to rule out proteinlosing nephropathy), urine protein:creatinine ratio, antithrombin levels, acth stimulation test (to rule out hyperadrenocorticism), heartworm antigen test (in dogs), thyroid profile (to rule out hyperthyroidism in cats, and hypothyroidism in dogs), thoracic radiographs, arterial blood gas analyses, coagulation tests, and coombs' test. selective and nonselective angiography can also be performed to determine the exact location of the thrombus.long-term management of thromboembolism involves management of the underlying disease process and preventing further clot formation. begin therapy with heparin until the aptt becomes prolonged . times; then administer warfarin ( . - . mg/kg/day). monitoring therapy based on prothrombin time and the international normalized ratio (inr, . - . ) is recommended. low-dose aspirin ( - mg/kg q h) also has been recommended. physical therapy with warm water bathing, deep muscle massage, and passive range-of-motion exercises should be performed until the patient regains motor function. future therapy may involve the use of platelet receptor antagonists to prevent platelet activation and adhesion. key: cord- -o cz authors: menzella, francesco; biava, mirella; barbieri, chiara; livrieri, francesco; facciolongo, nicola title: pharmacologicaltreatment of covid- : lights and shadows date: - - journal: drugs context doi: . /dic. - - sha: doc_id: cord_uid: o cz at the end of december , a novel coronavirus, the severe acute respiratory syndrome coronavirus , caused an outbreak of pneumonia spreading from wuhan, hubei province, to the whole country of china and then the entire world, forcing the world health organization to make the assessment that the coronavirus disease (covid- ) can be characterized as a pandemic, the first ever caused by a coronavirus. to date, clinical evidence and guidelines based on reliable data and randomized clinical trials for the treatment of covid- are lacking. in the absence of definitive management protocols, many treatments for covid- are currently being evaluated and tested worldwide. some of these options were soon abandoned due to ineffectiveness, while others showed promising results. the basic treatments are mainly represented by antiviral drugs, even if the evidence is not satisfactory. among the antivirals, the most promising appears to be remdesivir. corticosteroids and tocilizumab seem to guarantee positive results in selected patients so far, although the timing of starting therapy and the most appropriate therapeutic schemes remain to be clarified. efficacy of the other drugs is still uncertain, and they are currently used as a cocktail of treatments in the absence of definitive guidelines. what will represent the real solution to the enormous problem taking place worldwide is the identification of a safe and effective vaccine, for which enormous efforts and investments are underway. at the end of december , a novel coronavirus, the severe acute respiratory syndrome coronavirus (sars-cov- ), caused an outbreak of pneumonia spreading from wuhan, hubei province, to the whole country of china and then the entire world, forcing the world health organization (who) to make the assessment that the coronavirus disease (covid- ) can be characterized as a pandemic, the first ever caused by a coronavirus. the coronaviridae family comprises pathogens that primarily target the human respiratory system. of the other six coronaviruses known to infect humans, two, previously characterized as agents that are a great public health threat, present with major symptoms (severe acute respiratory syndrome [sars]-cov and the middle east respiratory syndrome [mers]-cov), and four present with mild symptoms (hku , nl , oc , and e). coronaviruses (covs) (order nidovirales, family coronaviridae, subfamily coronavirinae) are enveloped viruses with a positive sense, single-stranded ribonucleic acid (rna) genome. based on genetic and antigenic criteria, covs have been organized into three groups: α-covs, β-covs, and γ-covs. genome sequencing analysis attributed sars-cov- to the genus betacoronavirus, within a subgenus (sarbecovirus) that includes sars-cov (whereas mers-cov falls in a separate subgenus, merbecovirus). the origin of sars-cov- was explained with two possible scenarios: natural selection in an animal host before zoonotic transfer and natural selection in humans following zoonotic transfer. sars-cov- possesses the typical coronavirus structure with spike protein and other polyproteins, nucleoproteins, and membrane proteins, such as rna polymerase, -chymotrypsinlike protease, papain-like protease, helicase, glycoprotein, and accessory proteins. the spike protein of sars-cov- contains the glutamine residue in the receptor-binding domain region of sars-cov- , which is recognized by the critical lysine residue on the human angiotensin converting enzyme (ace ) receptor. thus, sars-cov- uses the same ace cell receptor and mechanism for entry into the host cell as sars-cov, , with a single n t mutation in sars-cov- 's spike issn: - review -pharmacological treatment of covid- drugsincontext.com protein that may have significantly enhanced its binding affinity for ace . infection with sars-cov- results in mild and nonspecific symptoms, such as fever and cough (common symptoms), and nasal congestion, fatigue, loss of appetite and smell, body ache, and diarrhea (noted in a small number of patients). on the contrary, severe cases might rapidly progress to acute respiratory distress syndrome (ards), septic shock, and difficult-to-tackle metabolic acidosis and bleeding and coagulation dysfunction. suspicions have risen regarding the possibility that an excessive immune response -the socalled cytokine storm -associated with macrophage activated syndrome (mas) may be driving covid- -related ards. specifically, a cytokine profile resembling mas has been noted in covid- patients, with increased interleukin (il)- β, il- , il- , il- , il- , tumor necrosis factor, and c-c motif chemokine ligand . current recommendations for the treatment of covid- severe cases consist of using existing, approved therapies with proven safety profiles to address the immediate need to reduce the rising mortality. the aim of this review is to explore covid- treatment options and describe the potential benefits or disadvantages of their use in severe cases. a search strategy based on validated keywords filters was devised to select articles regarding sars-cov- and related treatments. in detail, a selective search on pubmed was carried out up to april , and research papers, international guidelines, case reports, and meta-analyses have been considered. the search strategy was based on the following keywords: coronavirus, sars-cov- pneumonia, covid- , severe acute respiratory syndrome, antivirals, corticosteroids, biologics, and anticoagulants. a total of potential papers were identified in the first search through pubmed, and of these were considered eligible for inclusion in this review by the authors. because of the rapid developments in this area, we have also added and cited any newsworthy reports, as appropriate. to date, clinical evidence and guidelines based on reliable data and randomized clinical trials (rcts) for the treatment of covid- are lacking. in the absence of definitive management protocols, many treatments for covid- are currently being evaluated and tested worldwide ( table ) . some of these options were soon abandoned due to ineffectiveness, while others have shown promising results, , although it is still too early to have conclusive results, especially from rigorous rcts. the use of many drug classes is producing numerous data, which are often contradictory. it is extremely difficult to evaluate the results of clinical studies during a pandemic. so far, no therapy has been proven to be effective for treating the severe evolution of sars-cov- virus infection. current antiviral treatments are mainly based on previous experiences (favipiravir) or on experimental drugs (remdesivir) used for the treatment of viral infections due to different viruses, such as influenza virus (infv), ebolavirus (ebov), human immunodeficiency virus (hiv), mers, and sars. these molecules act as nucleoside analogues, either in the form of adenine or guanosine, and target the rna-dependent rna polymerase (rdrp), causing the block of viral rna synthesis. favipiravir favipiravir, a guanine analogue, was able to block the rdrp of sars-cov and mers in vitro. due to the high similarity of sars-cov- genome with sars-cov, this treatment is considered a potential candidate for covid- , even if in vitro efficacy on sars-cov- has not been tested yet. favipiravir is now being assessed in rcts recruiting patients with covid- , to evaluate its efficacy when combined with interferon-α or baloxavir marboxil (approved infv inhibitor) (chictr ). remdesivir, a nucleotide analogue inhibitor of rdrp, is considered one of the most promising antivirals for the treatment of covid- . this drug has a broad antiviral spectrum against hepatitis b virus and hiv and mers-cov and sars-cov, both in vivo and in vitro. , the safety profile also appears reassuring. two trials on the efficacy of remdesivir on mild-tomoderate (nct ) and severe (nct ) covid- patients are currently ongoing in china; these studies may provide very important data on the efficacy of remdesivir. a recent work has shown that the antiviral activity of remdesivir begins immediately after the virus enters vero e cells, carrying out its antiviral mechanism as a nucleotide analogue. this drugs acts as a competitor by incorporation with adenosine triphosphate to confuse viral rdrp, evading proofreading from viral exoribonuclease and causing a decrease in viral rna production. a trial on remdesivir was conducted by the us national institute of allergy and infectious diseases on a cohort of patients. preliminary data showed a positive effect in diminishing the time to recovery and reducing mortality rate. however, the latter result was not statistically significant. in a very recent randomized, double-blind, rct, patients with covid- pneumonia and acute respiratory failure were randomly assigned in a : ratio to intravenous remdesivir or placebo infusions for days. unfortunately, also in this case, remdesivir was not associated with statistically significant clinical improvements. neuraminidase inhibitors, such as oral oseltamivir and intravenous peramivir, have demonstrated significant clinical improvement in the treatment of patients with influenza in the past. oseltamivir has recently been used for sars-cov- suspected and confirmed patients in china. unfortunately, to date, no other data are available on their efficacy in covid- . chloroquine sulfate and phosphate salts were both marketed as antimalarial drugs. hydroxychloroquine has been widely used as an antimalarial and in autoimmune diseases, such as lupus and rheumatoid arthritis (ra). these are drugs with a good safety profile with mild and transient side effects, if correctly dosed. in case of overdose or prolonged treatments, they can cause cardiomyopathies and qt prolongation. chloroquine has also been used in various chronic viral diseases. in hiv infection, no positive results emerged, so the drug was not included in the recommended panel for the treatment of hiv. the only viral infection in which hydroxychloroquine showed any efficacy was found in chronic hepatitis c, especially if associated with interferon pegylated plus ribavirin. interestingly, wang and colleagues evaluated various antivirals and chloroquine in vitro, concluding that this is highly effective in controlling sars-cov- replication. some data indicate that chloroquine interferes with the ability of sars-cov- to acidify lysosomes; moreover, it inhibits cathepsins, allowing the cleavage of the spike protein of sars-cov- . in a recent study, chloroquine phosphate was found to be superior to control in the treatment of covid- pneumonia, improving clinical and imaging aspects and shortening the course of the disease. in a nonrandomized clinical trial on a small group of patients, a significant improvement in viral clearance was demonstrated. furthermore, the combination with azithromycin was significantly more effective for the reduction or disappearance of the viral load compared with hydroxychloroquine monotherapy. on the contrary, in a study with a small cohort of patients hospitalized for severe sars-cov- infection, no strong antiviral activity or clinical efficacy of the combination of hydroxychloroquine and azithromycin was found. the strong discrepancy of what emerged from the results of these studies highlights the fundamental need of rcts to assess the efficacy of these drugs in the treatment of covid- . conclusions from the published data are that there is currently no evidence of the efficacy of chloroquine for the treatment of covid- . the use should be limited to clinical studies to further clarify its role in the management of covid- . the evidence on the efficacy of corticosteroids is conflicting, and the setting of application of these drugs needs further clarification. in the absence of reliable data, the who interim guidance on covid- management does not recommend their routine use. furthermore, according to version of the national health commission of china guidelines, corticosteroids should be used carefully in the case of sars-cov- infection. in a recent study in patients with ards due to covid- , a significant increase in survival was found in those who received methylprednisolone treatment (p= . ). in a retrospective study on a cohort of critically ill patients with sars-cov- , appropriate use of corticosteroids was found to significantly reduce hospitalization mortality and duration. all this without increasing superinfections and other important complications. another study in intensive care unit patients treated with corticosteroids had no conclusions due to the small sample size. corticosteroids associated with invasive and noninvasive mechanical ventilation should be considered to prevent progression to ards, especially in severe patients. the chinese thoracic society has defined an expert consensus statement on the use of corticosteroids for the treatment of covid- pneumonia. according to this document, corticosteroids should be used with caution in critically ill patients, and the dosage should be low to moderate (≤ . - mg/kg per day of methylprednisolone or equivalent) with a short course (≤ days). other authors argue that rcts are needed to obtain more precise indications on the correct use of these important drugs. tocilizumab tocilizumab (atlizumab) is a humanized igg k monoclonal antibody that targets the soluble or membrane il- receptors (sil- r and mil- r). this drug has so far been used in the treatment of autoimmune diseases such as ra or large vessels vasculitis. as for sars-cov- infection, it is now known that the serum levels of inflammatory mediators are proportional to the severity of the clinical picture. in these patients, exaggerated immunological responses can trigger cytokine storms and cause damage to multiple organs. the increase in il- levels can also be a sensitive biomarker of clinical worsening and serious organ damage. tocilizumab can block two fundamental inflammatory factors, il- and granulocyte-macrophage colony-stimulating factor , thereby reducing the level of inflammation. a multicenter rct to evaluate the efficacy and safety of tocilizumab in the treatment of moderate patients at high risk of evolution toward serious and critical illness (registration number: chictr ) was recently concluded. results of this trial are not yet available; however, they are assumed to be positive in patients with elevated il- levels. sarilumab is a fully human monoclonal igg antibody targeting soluble and membrane il- receptors, inhibiting il- -mediated signal transduction mediated by these receptors. this biologic is approved as subcutaneous treatment in patients over years of age with moderate-to-severe active ra refractory or intolerant to one or more disease-modifying antirheumatic drugs. based on the experience of tocilizumab, sarilumab is recently being used in the treatment of patients with severe forms of covid- . five rcts are ongoing (clinicaltrials.gov identifier: nct , nct , nct , nct , and nct ), the results of which will be of great value. the latest version of the guidelines issued by the chinese national health commission for the diagnosis and treatment of covid- infection and the who interim guidelines advise against the unnecessary use of antibiotics, even on a broad spectrum. these should be used in the event of an increase in procalcitonin (pct), in the case of hospital-acquired pneumonia or ventilator-associated pneumonia, in case of microbiological tests indicative of bacterial superinfection. if fungal infection is suspected, voriconazole is indicated for aspergillus infections, while fluconazole is indicated for candida spp. infections. for pneumocystis pneumonia in immunosuppressed patients, the drugs to be considered are sulfamethoxazole and caspofungin. teicoplanin teicoplanin is a first-generation glycopeptide with antimicrobial activity against aerobic and anaerobic grampositive bacteria including multi-resistant staphylococci. this antibiotic has shown efficacy in the past against numerous viruses, such as ebov, infv, flavivirus, hepatitis c, hiv, mers-cov, and sars-cov. , the antiviral activity has recently been confirmed against sars-cov- . it will be necessary to confirm these results and the possible use of teicoplanin in covid- through rcts. it is now known that about % of patients with covid- have clotting alterations; thrombosis of lungs, liver, and other organs; and marked increase in d-dimer. , anticoagulant therapy should be administered carefully in clinical practice or in case of surgery. in these cases, platelet transfusion, administration of fresh frozen plasma, or more commonly low molecular weight heparin (lmwh) is recommended. in critically ill patients, anticoagulant therapy is recommended if no contraindications are present. recently, new evidence has appeared on coagulopathies and the appearance of antiphospholipid antibodies with consequent multiple heart attacks in patients with sars-cov- infections. large cohorts of severe covid- patients showed a high risk of disseminated intravascular coagulation and venous thromboembolism. low molecular weight heparin therapy is related to a higher survival rate in patients with severe covid- . in light of these data, it is even more important to reiterate the importance of anticoagulant therapy in severe covid- patients. the concern about the possibility that drugs blocking the renin-angiotensin system (ras) might increase the risk of developing a life-threatening sars-cov- infection could be due to the fact that the ace receptor allows the entry of coronavirus into cells. however, there are no data to support the possibility that ace inhibitors or angiotensin ii receptor blockers (arbs) favor the entry of coronaviruses by increasing the expression of ace in humans. ras dysfunction is present in patients with covid- , but clinical outcomes of ras inhibitor therapy, for example, with angiotensin converting enzyme inhibitors (ace inhibitors) or arbs are currently unknown, and there is no evidence for their suspension. in a retrospective study of patients with covid- , patients treated with an acei or arb had a better prognosis and lower levels of il- in peripheral blood. in addition, therapy with these drugs had increased cd and cd t-cell counts in peripheral blood and reduced viral load. these data could indicate that the treatment with an acei or arb issn: - review -pharmacological treatment of covid- drugsincontext.com may have positive effects on a more favorable evolution of the covid- infection. to assess more clearly the potential benefits of arbs, such as valsartan or losartan, on the evolution of covid- , rcts are ongoing (nct , nct , and nct ). only when the data of these studies are published, it will be possible to define the potential benefits or the risks related to these treatments. exploring and understanding the immunogenicity of covid- are essential for developing the most effective vaccine. however, evidence on the immunogenicity of sars-cov- is limited. the genome of the sars-cov- is over % identical to the sars-like bat cov, and studies on b-cells and t-cells epitopes have revealed high homology between sars-cov and sars-cov- proteins. previously, studies on sars-cov- vaccines revealed that the s protein on the surface of the virus is an ideal target for a vaccine, as antibody responses directed against it showed promising results in protecting from infection in mouse models. , moreover, while b-cell response toward sars-cov gave limited protection over time, t-cell response provided long-term protection, even up to years post-infection, and are thus considered as a potential target for vaccines against coronaviruses. research efforts are aimed at identifying the ideal sars-cov- epitopes, against which directing vaccines is increasing. many vaccines are currently under development (table ) , following different strategies. , whole virus vaccines are currently being investigated by companies such as johnson & johnson. they have the advantage of eliciting a strong immune response, through the stimulation of toll-like receptors; however, they require longer testing to guarantee safety. furthermore, subunit vaccines, which rely on stimulating an immune response against the viral s-protein preventing its binding with the cell-receptor, are already under investigation by companies such as novavax, clover biopharmaceuticals, and different consortia in the usa and australia. [ ] [ ] [ ] finally, nucleic acids vaccines, both based on deoxyribonucleic acid and rna platforms, are being considered by biotech companies, such as inovio pharmaceuticals and moderna therapeutics, both at phase i stage (nct and nct ). these latter formulations have not been successful in eliciting protective immunity in humans so far; however, expectations are high that this approach might eventually be successful. targeted therapies. corticosteroids and tocilizumab seem to guarantee positive results in selected patients so far, although the timing of starting therapy and the most appropriate therapeutic schemes remain to be clarified. efficacy of the other drugs is still uncertain, and they are currently used in combination and in variable ways in the absence of definitive guidelines. what will represent the real solution to the enormous problem taking place worldwide is the identification of a safe and effective vaccine, for which enormous efforts and investments are underway. at the moment, treatment of covid- unfortunately has more shadows than lights. the basic treatments are mainly represented by antiviral drugs such as remdesivir, chloroquine, or lopinavir/ritonavir, even if the evidence for their use is not satisfactory. among the antiviral agents, the most promising appears to be remdesivir, though this needs to be confirmed by ongoing rcts. however, many questions remain open about pathogenesis, the molecular mechanism of input, viral replication, and immunological pathways, in order to identify contributions: fm and mb conceived the manuscript outline, contributed to all the sections, and revised the whole manuscript. cb and fl drafted the paragraphs concerning antibiotics and anticoagulants. nf reviewed and approved the manuscript. all the authors read and approved the final version. all named authors meet the international committee of medical journal editors (icmje) criteria for authorship for this article, take responsibility for the integrity of the work as a whole, and have given their approval for this version to be published. who. rolling updates on coronavirus. disease (covid- hosts and sources of endemic human coronaviruses coronavirus envelope protein: current knowledge a genomic perspective on the origin and emergence of sars-cov- the proximal origin of sars-cov- covid- infection: origin, transmission, and characteristics of human coronaviruses receptor recognition by the novel coronavirus from wuhan: an analysis based on decade-long structural studies of sars coronavirus return of the coronavirus: -ncov evolution of the novel coronavirus from the ongoing wuhan outbreak and modeling of its spike protein for risk of human transmission clinical features of patients infected with novel coronavirus in wuhan the role of cytokines including interleukin- in covid- induced pneumonia and macrophage activation syndrome-like disease characteristics of lymphocyte subsets and cytokines in peripheral blood of hospitalized patients 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yr n authors: nan title: poster exhibition date: - - journal: hepatol int doi: . /s - - - sha: doc_id: cord_uid: p yr n nan background: biliary atresia (ba) is one of the most common causes of neonatal cholestasis and the most frequent hepatic cause of death in early childhood. the incidence rate of ba is higher in asian countries, occurring in approximately of , (asian countries ) to of , (european countries) live births. early identification and prompt intervention is very important. to im prove the early diagnosis, we used proteomic technology to screen serum biomarker for ba. methods: two-dimensional electrophoresis ( -de) and matrix-assisted laser desorption /ionization time-of-flight mass spectrometry (maldi-tof-ms) were employed to screen serum biomarkers specific to ba sera from idiopathic neonatal hepatitis. after pretreatment including albumin and immunoglobulin (igg ) depletion, sera were subjected to -de and there after image analysis. the differentially expressed protein spots were identified by maldi-tof-ms. result: from optimized -de gel images, thirty-four spots were differentially expressed and identified by maldi-tof-ms to be eight proteins. overall, kininogen variant was under expressed and alpha- -b-glycoprotein, leucine-rich alpha- -glycoprotein , 'sp , ', a bg protein, vitamin d-binding protein/group specific component , apolipoproteina-, aqgv were over expressed in ba group com pared to idiopathic neonatal hepatitis. conclusion: -de based serum proteome analysis can be useful in detecting protein expression alteration and new discovered biomarkers might be an aid in the diagnosis of ba, though further validation is needed. s. somani , a. somani , a. jain , v. dixit suvidha, navjeevan hospital, ims, bhu, varanasi, india background: a variety of autoreactive antibodies are detected in patients with chronic liver disease. this prospective, nonrandomized study was undertaken to evaluate the nature & prevalence of various autoantibodies in patients with chronic liver disease of diverse etiologies. methods: study population included patients ( % males), who met defined criteria for chronic liver disease. detailed clinical, laboratory and sonographic evaluation was done. sera were tested for asma, anti-lkm type , ama, apa, ana, by standard methods. p< . was considered significant. results: among various etiologies for chronic liver disease, hepatitis b was most common ( %), followed by alcohol ( %), autoimmune hepatitis in %, hepatitis c ( %) and miscellaneous ( %). % of patients were labeled as cryptogenic after detailed investigations. ana (> / ) was positive in % of definite aih, % of hcv related cld but at titer of > / , . % of hcv related cld & % of probable aih were found positive. asma (> / ) was positive in % of hbv related cld, % of alcohol related cld, % of definite aih, % of probable aih, % of hcv related cld but asma in titer of > / was positive only in % oh definite aih. apa was detected in . % of cryptogenic cld, . % of hbv related cld & % of alcohol & probable aih related cld each. ama was detected in % of cryptogenic, hbv, aih (definite) & hcv related cld each, and % of alcohol related cld & % of pbc. conclusions: apart from aih there is high prevalence of ana & sma in hcv related cld while other antibodies has low prevalence in non-aih related clds. this study also suggests that prevalence of various autoantibodies should be borne in mind while considering the diagnosis of cld especially of mixed etiology. conclusions: oa infusion did not lower ammonia levels or improve survival. results: the mortality ( . %) of patients in lamivudine group with meld score from to was lower than that ( . %) of control group ( = . , p= . ). univariate analysis showed that mortality was significantly related to age (p= . ), meld score (p= . ), treatment method (p= . ), pretreatment hbv dna load (p= . ), the decline of hbv dna load during therapy (p= . ) and encephalopathy (p= . ). in multivariate analysis, in patients with meld scores - , treatment method (p= . ), pretreatment hbv dna load (p= . ), decline of hbv dna load during therapy (p= . ) and encephalopathy (p= . ) were independent predictors of mortality; for meld scores above , only meld score (p= . ) was independent predictive. conclusions: lamivudine treatment significantly decreases the month's mortality of patients with meld score - , and a low viral load pre-treatment and quick decline of hbv dna load are good predictors for the survival of lamivudine treatment. background/aims: early identification of patients with fulminant hepatic failure (fhf) who need a liver transplantation is very important. to construct a prediction model for early diagnosis and prognosis of fhf, we studied dynamics of metabolic profiles using a d-galactosamine/lipopolysaccharide (galn/lps)-treated mouse model. methods: balb/c mice were used to construct fhf model and sacrificed for blood collection at , , and hour after treatment, respectively. levels of plasma metabolites were quantified using gas chromatography/time-of-flight mass spectrometry and data were processed using partial least squares discriminant analysis (pls-da). results: distinct clustering differences were observed and h after treatment between survival and dead groups. at h, plasma levels of some metabolites differed significantly between survival, dead and control groups. ketogenesis and the tca cycle were inhibited in both survival and dead groups, but in dead group, the urea cycle was also inhibited and glycolysis was elevated. pls-da indicated that principal component weighting was greatest for plasma levels of phosphate, -hydroxybutyrate, urea, glucose and lactate. the y-predicted scatter plot in pls model assigned samples to survival or dead groups using an apriori cutoff of . with % sensitivity and specificity. similar results were observed in fhf patients with different outcomes. pe association between polymorphisms in the interleukin- gene promoter and hepatitis b-related acute liver failure conclusions: the pls model based on metabonomics analysis can be used to predict outcomes well, and plasma levels of phosphate, -hydroxybutyrate, urea, glucose and lactate may constitute a set of markers for early diagnosis and prognosis of fhf. il- promoter are associated with the susceptibility to hepatitis b-related alf in the chinese population. il- a- c may be a regulatory polymorphism that affects gene regulation. hepatocyte cell death in aclf: mechanism and significance -an immunohistochemical study. p. sakhuja , a. rastogi , s. s hissar , a. singh , a. kumar , r. gondal , s.k. sarin gb pant hospital, institute of liver and biliary sciences, new delhi, india background: acute on chronic liver failure (aclf) is defined as acute hepatic insult complicated within weeks by ascites and/or encephalopathy in a patient with previously diagnosed or undiagnosed chronic liver disease. caspases play an essential role in apoptosis. cox- is an inducible immediate early gene responsible for the release of prostaglandins during inflammatory response. we studied the immunohistochemical expression of cox- and caspase- in liver tissue to assess their role in pathophysiology and in predicting outcome of aclf. method: a retrospective analysis of liver biopsies with clinical diagnosis of aclf was undertaken. patients were divided into two groups a and d based on clinical outcome (alive/died respectively). immunohistochemical analysis for cox- and caspase was performed on and cases respectively and scored from - as per intensity and distribution. score - indicated high intensity with focal to diffuse distribution, and was considered significant. results: etiology of acute liver failure was viral or alcoholic. increased expression of caspase was observed in / cases in group d and none of the cases in group a(n= ) (p= . ). increased expression of cox- was observed in / cases in group d and none of the cases in group a (n= ) (p= . ). conclusion: increased immunoreactivity of caspase in liver biopsies of patients of aclf may indicate worse prognosis and its important role in the pathophysiology of aclf. immunostaining for caspase is useful for assessment of prognosis and possibility of anti-apoptotic and anti-fibrotic therapies in future. conclusion: hhgf expression vector (pcmv-hhgf) has been successfully constructed and repeated hydrodynamic injections can promote sustained and high expression of hhgf in vivo. j.h. kim , k.w. kim asan medical center, seoul, korea background: splenic artery embolization (sae) is performed to increase hepatic arterial flow or to decrease portal venous flow in recipients of liver transplantation (lt). thus, the purpose of this study was to estimate sae effect on the basis of changes in caliber of related vessels and splenic volume on pre-sae and serial post-sae ct scans in lt recipients. methods: between and , among lt recipients who underwent sae and serial follow-up ct, with no compounding factor that may obscure sae effect were included in this study. they underwent ct before and after ( week, month, and year) sae. a radiologist retrospectively measured diameters of ca, cha, sa, sv and splenic volume on serial ct scans. their diameters and splenic volume on each ct were compared with those on the prior and pre-sae ct. the difference was compared using repeated-measures anova tests. results: cas decreased between week and month after sae (p<. ), but were stable before week and after month. chas increased within week (p<. ) but decreased between week and month (p<. ) and remained stable after month. compared with pre-sae ct, chas were larger for month after sae. sas continuously decreased for year (p<. ). svs decreased for month (p<. ) and remained stable after month. compared with pre-sae ct, sas and svs were smaller from week after sae and on. splenic volume continuously decreased for year except a period between week and month. conclusion: the increase of hepatic arterial flow persists for month after sae, but returns to baseline thereafter. the decrease of portal flow may lasts for at least year after sae. poster exhibition -cholangioca and other liver neoplasm poster session, hall b background: now, rfa has becoming an important practice of hcc therapy. in this study, we evaluated whether rfa therapy for metastatic liver tumor has a beneficial effect on patients' survival. methods: forty six patients were treated by rfa for metastatic liver tumor from july through february in our hospital, of the , patients were metastasis either form colon or stomach cancer. these patients were analyzed in this investigation. cumulative survival rate from initial rfa therapy was calculated by kaplan-meier method. predictive factors for survival were identified using cox proportional hazard regression model. results: the mean age of the patients were . (range, - ) . the mean size of the tumor is mm (range, - mm) and the numbers of tumor foci are . nodules range, . the survival rates of patients treated by rfa were . % at years and . % at years in colon cancer, . % at years and . % at years in gastric cancer. in this series of patients, primary cancer: colon (p= . odds ratio . %ci . - . ), younger patients ( ) (p= . odds ratio . %ci . - . ) and multiagent chemotherapy (p= . odds ratio . % ci . - . ) were significantly correlated with better survival. conclusion: the survival of patients treated by rfa for metastatic colon cancers had better survival than those of gastric cancers. in addition, good indication of rfa is for metastatic colon cancers, younger patients and has to be treated by multiagent chemotherapies. utility of contrast enhanced ultrasonography with sonazoid in radiofrequency ablation (rfa) for liver metastasis e. goto , s. shiina , r. tateishi , r. masuzaki , k. enooku , t. sato , j. imamura , t. goto , y. sugioka , h. ikeda , , h. yoshida , m. omata department of gastroenterology, university of tokyo, department of clinical laboratory, tokyo, japan background & aims: contrast enhanced ultrasonography (ceus) with sonazoid is effective for liver metastasis because enhance defect in kupffer imaging is well delineated. the aim of this study is to investigate the detection ability of ceus and the utility of sonazoid in rfa for metastasis liver tumors. material & methods: from january to december , a total of liver metastatic nodules in patients ( colon cancer, breast cancer, gastric cancer, islet cell tumor, and others) admitted to receive rfa were studied. the detection ability of liver metastasis was compared between ceus and conventional us using enhanced ct as reference standard. the mean numbers of treatment session of rfa were compared between patient treated with ceus assistance and historical controls matched for size and number of tumors. results: the detection rate was . % with conventional us and . % with ceus (p= . ). nodules in patients were not detected by conventional us and detected after injection of sonazoid. in addition, nodules in patients were detected not by ct but only by ceus. the mean number of session was . ± . as compared to . ± . in the historical controls (p< . ). conclusions: ceus with sonazoid is useful for detection of liver metastasis. sonazoid is an excellent supportive agent in rfa of liver metastasis. background/aims: carcinogenesis of intrahepatic cholangiocarcinoma (icc)-associated liver fluke infection accumulated genetic and epigenetic alterations. cholangiocarcinoma cell line (kku-m ) is adenosquamous carcinoma which rare variants and not commonly found in icc. however, interactions of liver fluke-associated icc proceed to genetic alterations in adenosquamous carcinoma that have been not elucidated. objectives: to analyze the whole genome-wide genetic alterations in kku-m using microarray comparative genomic hybridization. methods: dna of kku-m and matched-sex reference were differentially labeled with fluorescence dries (cy and cy ) and mixed together with cot- dna. the mixture was hybridized on array with spotting , human bacterial artificial chromosomal (bac) clones in triplicate and mapped these directly onto human genome sequence. the genetic alterations were classified the dna copy-number variations according to the intensities of log ratio (cy /cy ) as dna copy-number loss/gain and deletion/amplification. results: the whole genomic alterations in kku-m , which revealed a variety of chromosomal aberrations with a part and/or entire chromosomal gain and loss. chromosomal amplifications were detected on q . , q . , q . , p tel, and p . , whereas homozygous deletions were detected on q , q , q , q - , q . , q , q , q - q , p - p , p , q . , q . - q . , q . , q . and q . . conclusions: the whole genome-wide genetic alterations were characterized which previously not defined in adenosquamous carcinoma. this recent advance tool is usefulness for discovering novel cancer-related gene (oncogene/tumor suppressor gene) and substitutes in in vivo experiment for functional testing of candidate gene involving liver fluke-associated icc carcinogenesis. artificial chromosomal (bac) clones in triplicate and mapped these directly onto human genome sequence. the genetic alterations were classified the dna copy-number variations according to the intensities of log ratio (cy /cy ) as dna copy-number loss/gain and deletion/amplification. results: the whole genomic alterations in kku-m , which revealed a variety of chromosomal aberrations with a part and/or entire chromosomal gain and loss. chromosomal amplifications were detected on q . , q . , q . , p tel, and p . , whereas homozygous deletions were detected on q , q , q , q - , q . , q , q , q - q , p - p , p , q . , q . - q . , q . , q . and q . . conclusions: the whole genome-wide genetic alterations were characterized which previously not defined in adenosquamous carcinoma. this recent advance tool is usefulness for discovering novel cancer-related gene (oncogene/tumor suppressor gene) and substitutes in in vivo experiment for functional testing of candidate gene involving liver fluke-associated icc carcinogenesis. acknowledgements: this work was supported by faculty of medicine, kku, thailand (grant no. i background/aims: we studied the clinical efficacy of arterial chemoinfusion therapy through an implanted port system for patients with intrahepatic cholangiocarcinoma (icc). thirty patients with unresectable icc or intrahepatic recurrence of icc after surgery were studied. comparison was made between patients who received arterial chemoinfusion therapy through an implanted port system with adriacin and lecithin-added lipiodol emulsion in patients and -fluorouracil ( -fu) in patients. eighteen patients were treated without port system. results: disease was stable in patients with adriacin and lecithin-added lipiodol emulsion and in patients with -fu. disease was progressed in patients with -fu. the mean survival period was . months in patients with adriacin and lecithin-added lipiodol emulsion, . months in patients with -fu, and . months in patients without port system (p= . , p= . ). conclusion: arterial chemoinfusion therapy through an implanted port system is useful for patients with intrahepatic recurrence of icc after surgery. pe s. kaur , t. kaur department of biophysics, panjab university, chandigarh. india background: a number of dietary factors have been involved in the pathogenesis of cholelithiasis. cholesterol overfeeding is the primary means of inducing supersaturated bile and cholesterol gallstones in animal models.aim of the study was to investigate the rate of epithelial cell death and proliferation in gallbladder during gallstones formation. methods: balb/c mice was divided into two groups control in this group animals were fed normal chow diet, high fat diet group in this group ( % cholesterol, . % sodium cholate, % butter fat and % coconut oil) mixed with chow diet was fed to the mice for weeks. cell apoptosis and proliferation was assayed in gallbladder epithelial cells. histological analysis of gallbladder sections were done with hematoxylin and eosin staning. results: mice fed high fat diet had apoptotic as well as necrotic epithelial cells. rate of proliferation was enhanced after and hrs in mice fed high fat diet group as compared to the control group. the histopathological section of control gallbladder has normal morphology whereas gallbladder wall thickness was markedly increased; epithelial cells appeared more elongated in mice fed high fat diet. conclusion: results obtain show that high fat diet markedly induced biliary epithelial cell proliferation and biliary epithelial cell apoptosis. it has been determined that when there is an injurious stimulus that leads to apoptosis, it is later followed by reparative proliferation and when there is no injurious stimulus, apoptosis occurs late in the course as part of remodeling. background: obstructive jaundice can be caused by malignancy. the treatment can be drainage by biliary stenting. in advanced malignant jaundice, the stent placement is often difficult. objective: to evaluate the success rate of malignant obstructive jaundice evaluation of ercp and success rate of stent placement. methods: retrospective study based on data of ercp from october until july . results: we evaluated patients who has done ercp examination, ( , %) patients have clinical diagnosis of obstructive jaundice. there were ( , %) male and ( , %) female, age range - (median age was ). there were no malignancy in ( , %) patients; malignancy in ( , %) patients and ( %) patients need further evaluation.. from patients, ( %) patients attempted to have stent placement, ( , %) patients do not and ( , %) patients have no data. we done descriptive study on patients attempted to have stent placement, ( , %) patients succeed in stent placement whereas ( , %) failed. malignancy was showed to be a factor of stent failure (malignancy: fail and success ( , %) vs non malignancy: fail and success ( , %)). conclusion: ercp can identify the cause of obstructive jaundice in % patients. the success rate of stent placement was , %. the success rate of biliary stenting in malignant obstructive jaundice was , % whereas in non-malignant cases was , %. papillary carcinoma was the most frequent cause of malignant obstructive jaundice. background: in hydatid disease of the liver cystobiliary fisula (cbf) constitutes an entity characterized by the occurrence of a life-threatening cholangitis with increased morbidity. aim: to study the different diagnostic and therapeutic aspects of cystobiliary fistula in hydatid disease of the liver. patients and methods: fourteen patients with complicated cysts were divided into groups; group a: nine patients presented with cholangitis, and group b: five patients had history of jaundice. in all patients, the diagnosis of cbf was confirmed by erc (endoscopic retrograde cholangiography). preoperative endoscopic sphincterotomy (es) was done in group a with retrieval of hydatid daughter cysts. seven patients (subgroup a ) were subsequently submitted to surgery entailing endocystectomy in and hepatic resection in two. the remaining patients in group a (subgroup a ), were managed by endoscopic therapy only. patients of group b (n= ), were not submitted to preoperative es and were subsequently managed by hepatic resection in one patient and endocystectomy in four. results: there was no mortality in the studied group. postoperative bile leak occurred in four cases in group b. in contrast, none of the patients who were submitted to preoperative es (subgroup a ) had bile leak. all patients received albendazole treatment. conclusion: erc is important in confirming the diagnosis of cbf. also, therapeutic erc has a place in the treatment algorithm of cbf as it was found to be a safe and a reliable therapeutic alternative especially in high risk patients for surgery. v. singh , g. singh , g.r. verma , v. gupta , s. ghosh , r. gupta , r. kapoor , n. sharma , a. bhalla , s.k. mahi background: endoscopic palliation in malignant hilar biliary obstruction requires ercp. however, contrast injection leads to cholangitis. recently, contrast-free metal stenting with or without mrcp has shown encouraging results. however, mrcp and metal stents are costly. there have been no reports on the use of air cholangiography in these patients. methods: we prospectively studied the role of air cholangiogaphy assisted unilateral plastic stenting in these patients. results: ten patients with unresectable malignant hilar biliary obstruction were studied. air cholangiography detected type ii obstruction in and type i in patients which is similar to mrcp. all patients underwent unilateral plastic stenting. a successful endoscopic drainange was achieved in % patients. cholanngitis occurred in none and there was no -day mortality. no major complications were observed. conclusion: air cohlangiography assisted plastic stenting in these patients is a safe and effective method of palliation. however, it requires a larger study. introduction: a description of igg -related sclerosing cholangitis (igg -sc) without pancreatic lesion has recently been reported. in addition to imaging, diagnosis relies on findings of elevated serum igg and immunodetection of invading igg -positive cells. here we report a case of igg -sc with only slight common bile duct abnormalities and normal pancreatic findings. case study: a -year-old man suffering from cephalalgia, general malaise and muscle ache was admitted to our hospital. his blood examinations on admission revealed eosinophilia, mild anemia, liver dysfunction and an igg level of mg/dl (igg mg/dl). although ercp did not reveal typical stenosis or irregularities of the bile duct wall, visualization of peripheral bile ducts was slightly impaired. echography revealed thickening of the intrahepatic bile duct and gallbladder walls as well as adenopathy. due to a gradual increase in pleural effusion and a progression of anemia, oxygenation was begun on the seventh day of illness. based on the combination of eosinophilia, elevated serum igg levels, image findings and a negative result for helminth, igg -sc was suspected. liver biopsy was performed on the ninth day of illness and steroid therapy was initiated, after which symptoms and laboratory findings improved. the igg -positive plasmocytic infiltrate present around the portal region at the time of biopsy disappeared within eight months of treatment. summary: this case displayed two unusual features that are not generally observed with igg -sc: complications due to hemolytic anemia, and destruction of the peripheral bile duct with little damage to the common bile duct. introduction: various systemic diseases have been reported to be associated with igg . although steroids are effective in the treatment of igg -related diseases, there are some reports on relapses with their treatment, and cases are often difficult to differentiate from malignant diseases. we encountered a case of autoimmune pancreatitis with sclerosing cholangitis (aip-sc), in whom ca - was elevated with episodes of exacerbation and an elevated serum igg concentration. igg staining was also useful for the diagnosis. case study: an -year-old woman noticed tumors beneath the bilateral jaw and was found to have an elevated level of ca - ( ) seven years previously. her left submandibular gland was removed and diagnosed as sclerosing sialadenitis. four years previously, she was diagnosed as having diabetes mellitus complicated by a recurrence of ca - ( ) elevation and liver dysfunction. cholangiocarcinoma was suspected based on ercp, but was not confirmed by histologic findings of bile duct biopsy. elevated igg and other test results established the diagnosis of aip-sc, so steroid therapy was initiated, after which symptoms and laboratory findings improved. this recurrence of ca - elevation ( ) was diagnosed as a relapse of aip-sc based on an increased igg level and histologic findings. summary: some papers have reported that igg -positive cells are found in liver tissue in this disease, but such cells were not detected in the liver specimens in our case. this might be because intra-liver sites may have differed in the degree of morbidity, and long-term steroid therapy might have suppressed inflammation in the liver tissue. s. kaur , t. kaur department of biophysics, panjab university, chandigarh, india background: cholelithiasis, a gallstone disease is major cause of morbidity affecting millions of people throughout the world. aim of the present study was to investigate the predisposing factors that lead to the formation of gallstones. methods: the study was carried out on gallstones, bile and serum of patients. gallstones and bile were divided into three groups' cholesterol, pigmented and mixed gallstones. blood of the patients was divided into two groups with gallstones and without gallstones patients. trace elements and various biochemical estimations were carried out. clinical history of the gallstones patients was recorded from the hospital records. results: trace elements analysis in bile and gallstones showed that calcium is the main element in all the three types of stones. iron was the main element in mixed gallstones. in pigmented gallstones magnesium and zinc were the major trace elements. liver function tests and lipid peroxidation levels in sera were significantly increase whereas, antioxidant enzymes concentrations in sera were significantly decreased in patients with gallstones. clinical history of the gallstones revealed the cases had jaundice, diabetes mellitus and estrogen replacement therapy respectively. conclusion: results suggest that trace elements in gallstones and bile as well as clinical history of patients with chronic cholelithiasis could be the underlying factor in the pathogenesis of gallstones. the concentration of products derived from the free radicals reactions increases with degree of inflammation. such a condition increases risk of bile saturation which would further contribute to the progress of gallstones formation. background and aims: diseases of the biliary tree and gallbladder are being described with increasing frequency among patients with the acquired immunodeficiency syndrome (aids).therefore there is a need to do a research about the risk factors of gallbladder diseases in hiv/aids patients. so it can be useful to clinicians to predict the possibility of a patient having gallbladder disease and consider the options of further plans. the aim of this study was to find the prevalence and varieties of gallbladder diseases in hiv/aids patients. methods: a cross sectional study was performed in patients with hiv/aids who visited ciptomangunkusumo hospital, jakarta. the risk factors (route of transmision,cd ,arv,hepatitis) and clinical presentations were studied.ultrasonography examinations were performed to detect gallbladder annormalities. results: patients with hiv/aids match the study criteria. there were gallbladder abnormalities in ( . %) subjects, which ( . %) had acalculous cholecystitis and ( . %) had cholecystitis with cholelithiasis. on bivariate analysis, there was a significant association between abdominal pain, jaundice and the use of arv to gallbladder abnormalities (p = . ; . ; . ; . ). however, there was no association between age, sex, transmision route of hiv, hepatitis and cd to gallbladder abnormalities. conclusion: hiv/aids patients are susceptible to opportunistic gallbladder infection. acalculous cholecystitis is the most frequently encountered gallbladder abnormalities of hiv/aids patients in this study. poster exhibition -hbv poster session, hall b long-term stopping therapy t.b. trung , p.h. phiet university medical center, hochiminh city, vietnam background: among the approved nucleos(t)ide analogues therapies for chronic hepatitis b, lamivudine was used widely, sometime inappropriate in practice due to high safe and low price but lamivudine is associated with the highest rate of drug resistance. objectives: the aim of the study was to determine the ymdd variants after long-term stopping treatment in lamivudine-resistant patients using more sensitive technique. methods: blood samples from lamivudine resistant patients were collected after long-term stopping therapy. the ymdd variants are detected using technique pcr restriction fragment length polymorphism (pcr-rflp) at hcmc university medical center results: after stopping lamivudine treatment months ( - months) ymdd mutants were detected in ( , %) of patients. among them ( . %) had the most important m v/i mutant, ( %) had accompanying l m mutant. it means that once drug resistant mutants have been selected, they are archived for the long time even if treatment is stopped. many of patients have the features characterized for the patients in immune tolerance phase (young age, hbeag positive, normal alt). the treatment of this group is not strongly recommended due to low efficacy and high risk of drug resistance. conclusion: the most important m v/i mutant was still detected with significant portion of the virus population after long-term stopping therapy in lamivudine resistant patients. the options of retreatment for this patients when necessary are limited due to cross-resistance. the management of chronic hepatitis b should be followed strickly the recommendations of specialized association to avoid this problem. background/aim: whether liver stiffness measurement (lsm) using transient elastography is reliable to assess liver fibrosis in the settings of severe acute exacerbation of chronic hepatitis b (chb) is uncertain. methods: we prospectively recruited consecutive patients with severe acute exacerbation of chb (alanine aminotransferase or alt > x upper limit of normal). the relationship of alt levels and lsm were serially assessed and liver biopsy was performed after alt normalization. results: eleven patients ( male, median age years) were followed up for weeks; patients received anti-viral therapy. overall, lsm was positively correlated with alt levels (r= . , p< . ). at initial presentation, the median serum alt and lsm was ( - ) iu/l and . ( . - . ) kpa. a progressive reduction in lsm was observed during subsequent visits in parallel with the reduction of alt levels. even after the normalization of alt at week , lsm of patients continued to drop at week . at the last visit, the median alt was ( - ) iu/l and lsm was . ( . - . ) kpa. among the patients who had liver biopsy performed at week , patients had f fibrosis (lsm . - . kpa) and patient had f fibrosis (lsm . kpa). conclusions: lsm using transient elastography may misdiagnose liver cirrhosis in patients suffering from severe acute exacerbation of chronic hepatitis b. lsm should be assessed after normalization of alt levels in order to accurately assess the degree of fibrosis. h.c. lai , s.w. lai , k.f. liao , c.s. liu , t. lin , c.c. lin china medical university hospital, taichung, taiwan background: in , chronic liver disease was the seventh leading cause of death in taiwan. hepatitis b and hepatitis c are two major causes of chronic liver disease in taiwan. the purpose was to investigate the seroepidemiology of hepatitis b surface antigen (hbsag) and hepatitis c virus (hcv) antibody in taiwan. method: this was a hospital-based cross-sectional study. we analyzed viral hepatitis data from subjects who received health checkups at one medical center in taichung from to . all subjects were divided into three age groups, including - , - and . this study emphasized the prevalence of hbsag and hcv antibody by gender and age. the statistical analysis was performed by t test and . result: there were men ( . %) and women ( . %). the mean age was . (standard deviation . , range - ). the overall prevalence of hbsag was . %, with statistically significant difference(ssd) between gender ( . % for men vs . % for women, p < . ). the prevalence of hbsag was decreased with age in men, with ssd (p < . ), and also decreased in women, without ssd (p = . ). the overall prevalence of hcv antibody was . %, without ssd between gender ( . % for men vs . % for women, p = . ). the prevalence of hcv antibody was increased with age both in men and in women, with ssd (p < . ). conclusion: we hope this study can provide the epidemiological data for further studies of hepatitis b and hepatitis c virus infection in taiwan. s.m. wu , x. zhou wuhan medical treatment center, center for gene diagnosis, zhongnan hospital, wuhan university, china e-selectin is revealed to facilitate leukocyte adhension to the endothelium and migration into inflamed tissue in inflammatory diseases. chronic hepatitis b virus infection is regarded as a chronic inflammatory process. to examine the possible involvement of e-selectin in the etiology of chronic hbv infection, we analyzed two polymorphisms of e-selectin and determined the plasma souble e-selectin levels in patients with chronic hbv infection and controls. the frequency of c allele of the a c polymorphism was significantly increased in patients with lc campared with controls. no significant positive association was observed between the g t polymorphism and chronic hbv infection. but in patients with lc, divided according to the child-pugh classification, the frequency of t allele was of significant difference between child'class a and class b plus c. plasma levels of soluble e-selectin were significantly increased in patients with chronic hepatitis and liver cirrhosiscompared with controls. in the liver cirrhosis group, levels of se-selectin were significantly decreased from child' class a to class c. in each group, patients with c allele of the a c polymorphism showed higher soluble e-selectin levels than those with a allele. this is the first report describing the association between e-selectin polymorphisms and hbv-related hepatic fibrosis. our data showed the a c polymorphism of e-selectin gene is associated with disease progression in patients with hbv infection and controls the expression of plasma soluble levels, the g t polymorphism may be related to fibrotic severity in patients with liver cirhosis. background: chronic hepatitis b (chb) patients with high serum hbv-dna and normal serum alanine aminotransferase (alt) levels might be considered for treatment if histopathological findings show fibrosis stage or more. however, to our knowledge there is no recommendation with regard to the therapeutic agents for this group of patients. objective: this study was aimed to evaluate the efficacy of nucleoside analogues (entecavir or telbivudine) in treating chronic hepatitis b patients with high serum hbv-dna and normal serum alt levels. patients and method: this was an open-label study in chb patients with high level serum hbv-dna levels between january and october . patients were included if they showed normal serum alanine aminotransferase (alt) level at two measurements within a -month interval and had fibrosis stage > on liver biopsy specimens. patients were treated with entecavir . mg/day or telbivudine mg/day. the primary endpoint was the reduction or undetectable of serum hbv-dna at week and week of treatment, while the secondary endpoint was hepatitis b e antigen (hbeag) seroconversion. results: during a -year period, chb patients with high level serum hbv-dna with normal alt two times with months interval underwent a liver biopsy. twenty-eight ( . %) of pts showed fibrosis stage on histological findings (metavir score). twelve of these patients received nucleoside analogues, ( . %) of them were men. patients' median age was (range: - ) years. there were patients with stage- , patients with stage- and patient with stage- fibrosis. eleven ( . %) patients had genotype b virus. at baseline, the mean serum alt level was + . u/l and mean hbv-dna level was . x iu/ml, ranging from . x to . x iu/ml. six patients received entecavir and the other six received telbivudine therapy. undetectable hbv-dna was achieved by ( . %) patients at week- and ( . %) patients at week- of treatment. one patient who had the highest hbv-dna level had viral load reduction to . x iu/ml at week- of treatment. two out of patients with positive hbeag achieved hbeag seroconversion at week- of treatment. conclusion: this preliminary study has shown that nucleoside analogues might be considered in the treatment for chronic hepatitis b patients with high serum hbv-dna and normal serum aminotransferases levels. j. chen , x.j.. wu , y. wang , g.q. wang department of infectious diseases, peking university first hospital, beijing, china background: the dysfunction of t cells may represent a mechanism of hepatitis b virus (hbv) persistence. programmed death- (pd- ) and its ligands, pd-l /pd-l , are new members of cd /b family, as co-stimulatory molecules expressing on t cells and antigen present cells (apcs). their engaging can downregulate the t cells function, including proliferation, cytokines secretion and cytotoxicity. in periphery blood, pd- was upreguated on virus specific-t cells, leading to the impairment of t cells. blocking the pd- /pd-l can improve the function of t cells. methods and patients: patients with chronic hepatitis b (chb) were treated by pegylated ifn - b (pegintron from schering-plough, once a week, . or g/kg/weight). the periphery blood were taken at weeks, weeks, weeks, and weeks. periphery blood mononuclear cells (pbmc) were isolated from fresh heparinized blood by ficoll-hypaque (density: . g/l) density gradient centrifugation. then the cells were incubated with apc-conjugated anti-pd- antibodies. the pd- expression on lymphocytes was detected by flow cytometry (fcm). results: the pd- expression on lymphocytes at weeks was . ± . %, at weeks was . ± . %, at weeks was . ± . %, at weeks was . ± . % (p< . ). conclusion: treatment with ifn - b can downregulate the pd- expression on lymphocytes and may partially restore the function of t cells. to investigate the effects of nucleoside analogs therapy in hepatitis b related acute-on-chronic liver failure, we treated hbv related acute-on-chronic liver failure patients with entecavir. as control, the remaining were not treated with nucleoside analogues. results show the survival rate of entecavir therapy group has no significantly difference with none-treated group (p> . ). although entecavir greatly reduced hbv replication during different therapy times (p< . ), the meld score and liver function (alt, albumin, bilirubin, prothrombin time) had no significant changes (p> . ). further more, we analyzed the meld score and liver function in different hbv-dna level patients .no significantly difference was observed (p> . ). there is no significant correlation between hbv-dna level and meld score in different therapy times (p> . ).the hbv-dna level between patients with over months and less than months survival patients showed no significant difference either (p> . ). however, meld score and some parameters of liver function (albumin, bilirubin, prothrombin time) showed significant difference (p< . ). these results suggest hbv-dna loading may not be a direct factor to increased liver injury and suppression of hbv replication may not reduce the severity of liver failure in hbv related acute-on-chronic hepatitis. s. firdoos , u. adeeb , a. mehmood , m. gill islamabad specialists clinic, islamabd, pakistan background: before the availability of etv, it was common to use adv for treatment of chronic hepatitis b patients. primary nonresponse and suboptimal response is a common problem with adv treatment. methods: we wanted to study the outcomes of entacavir therapy in this subset of patients. study was conducted between april to april . we enrolled chb patients who had non response to - weeks of mg adv therapy. non response and suboptimal response was defined as non dimunition of at least one log of hbvdna from baseline after weeks of therapy and persistence of log after weeks of therapy respectively.they were switched to mg entacavir before breakfast daily for at least months.they had serial alt cbc and hbvdna measured every weeks. results: out of patients male and were female. only patients were hbeag(+).mean hbvdna level prior to adv exposure was . log copies/ml.mean duration of exposure to adv was weeks. patients lost to f/u.we did intention to treat analysis. out ( %) patient has, undetectable level of hbvdna after weeks of therapy labelled as group . out of ( %) had hbvdna level reduced by a mean of log copies/ml labelled as group .on week treatment analysis all patients from group was hbvdna undetectable, additional patients from group had undetectable hbvdna. conclusion: entacavir therapy results in rapid suppression of hbvdna levels in majority of patients with primary nonresponse or partial non response to adv therapy. background: except for serum alt level, baseline factors predictive of therapeutic response to lamivudine in patients with hbeag-positive chronic hepatitis b remain largely unknown. we thus studied the influence of pre-therapy viral factors on end-of-treatment responses to lamivudine therapy. methods: a total of treatment-naïve hbeag carriers who had pre-therapy serum alt level> xuln and received lamivudine for months reimbursed by the national health insurance were prospectively enrolled. hbeag seroclearance and combined hbeag seroclearance, alt normalization as well as undetectable hbv dna at the end of therapy were defined as primary and secondary endpoint, respectively. the pre-therapy viral factors including viral load, genotype, precore stop codon (pc)/ basal core promoter (bcp) status, and pre-s deletion were determined to correlate with therapeutic endpoints. results: the frequency of patients with detectable pc mutation (g a), bcp mutation (a t/g a), and pre-s deletion at baseline was . %, . %, and . %, respectively. after completing -month lamivudine therapy, overall hbeag seroclearance rate was . %. patients with hbeag seroclearance had a higher prevalence of baseline pc mutation than those without ( . % vs, . %, p= . ). by multivariate analysis, the odds ratio of patients with pc mutation to develop hbeag seroclearance was . (p= . ). in addition, the presence of pc mutation also correlated with the combined response. conclusions: for hbeag-positive chronic hepatitis b patients with serum alt> xuln, pc mutation could predict a higher hbeag seroclearance rate at the end of -month lamivudine therapy. the efficacy of adefovir dipivoxil against all patterns of lamivudine resistant hepatitis b d.j. kim , y.d. park , y.g. kwon , h.g seo daegu fatima hospital, kunngpook national university hospital, daegu, korea background: our aim was to evaluate the efficacy of adefovir dipivoxil (adv) and determine patient-dependent or laboratoroy variables that are predictive of hbeag loss and ivr for hepatitis b patients resistant to lamiduvine. also we evaluated the activity of adv against all patterns of lamivudine-resistant hbv. method: hbv-infected patients with lamivudine resitance received adv for months. quantitative hbv dna, hbeag/anti hbeag, alt was checked every - months. the hbv polymerase of patients were sequenced for baseline samples to determine the presence of lamivudine resistance mutations. result: there is no significant difference in all patterens of hbv mutation about hbv dna reduction at w, w, w. there is no significant difference in all patterens of hbv mutation about alt normalization at w, w, w. conclusion: adefovir dipivoxil demonstrated similar potent anti-hbv efficacy regardless of the different patterns of lamivudine-resistant hbv mutations. g. novelli , m. rossi , v. morabito , f. pugliese , p. berloco la sapienza university, rome, italy background: hepatitis b (hbv)-related end-stage liver disease is one of the most common indication for liver transplantation (lt). a number of patients dying while on the waiting list or removed because of being too ill is progressively increasing. we valued the possibility to improve the model end-stage liver disease (meld) of patients awaiting liver transplantation using a albumin dialysis: molecular adsorbent recirculating system (mars). methods: we treated patients ( male and female) with a mean age . . inclusion criteria: serum bilirubine > mg/dl, meld , inr > . , encephalopathy grade ii. all patients were treated with mars mean ± . hr cycles and mean treatments (range - ). all patients received standard medical treatment in addition to mars dialysis. the patient survival was valued at six months. results: we obtained a significant change of cytokines levels as interlukine (p< . ) and tumor necrosis factor alfa (p< . ) in association with an improvement of kidney, hepatic and hemodynamic parameters. at the end of mars treatments we observed a significant reduction of meld score (p< . ). the results of meld show a rebound effect between the end of treatment and the follow up at six months without returning at starting values (p< . ). twenty patients lived and dead for clinical complications. conclusion: the improved meld score with mars gave patients on lt waiting list more time of survival, thus allowing them more opportunity for liver transplantation. entecavir for treatment of lamivudine-refractory patients chronic hepatitis b h.t. dat , p.t.t. thuy medic medical centre, ho chi minh, vietnam lamivudine treatment is associated with frequent development of resistant hepatitis b virus. this incidence especially is higher in longer time of treatment and loss of treatment benefit. entercavir is a new antiviral agent shown its high efficacy even in cases of mutations with lamivudine resistance. in this study, we evaluate the efficacy, the safety of entercavir in treatment of lamivudine-refractory patients chronic hepatitis b. sixty chronic hepatitis b patients with evidence of lamivudine resistance were randomly divided into two groups in proportion of : . group i (n= ) used entecavir mg/day, group ii (n= ) used lamivudine mg/day. treatment time was weeks. histology, alt, hbvdna were evaluated in the end of the treatment. age, sex, alt, hbvdna, genotype, hbeag were analyzed to evaluate their influences to the treatment. the results have showed hbvdna< copies/ml in entecavir group . % vs. % lamivudine group (p< . ). hbvdna negative in entecavir group was . % and incidence of seroconversion of hbeag was . %. alt was normal in entecavir group . % vs. . % in lamivudine group (p< . ).histologic improvement in entecavir group was . % vs. . % in lamivudine group (p< . ). patients with hbeag negative, genotype b, low viral load were shown better results. entecavir was shown to be efficacious in treatment for chronic hepatitis b patients experienced with lamivudine resistance. entercavir is safe, with almost no side effects. factors such as hbeag negative, genotype b, low viral load seems to be better in response to treatment. recurrence or mutation of entecavir resistance should be studied further in future. j.m. kim , s.k. hwang , b.h. choe department of pediatrics, kyungpook national university hospital, daegu, korea backgrounds: by analyzing the characteristics of children with chronic hepatitis b who have lost hbsag by long-term lamivudine treatment, the selection of target patients could be relevantly predictable in the treatment of chronic hepatitis b in children. methods: a total of hbeag positive children (< y-o) were recruited who have visited kyungpook national university hospital from mar. , to may , . they were treated with lamivudine for at least months. hbeag seroconversion occurred during lamivudine treatment in out of children. they were divided into hbsag clearance and non-clearance group. parameters influencing treatment results were analyzed according to hbsag loss. result: thirteen out of the ( . %) patients with hbeag seroconversion were classified as hbsag clearance group, while ( . %) as non-clearance group after lamivudine treatment. twenty five of patients with hbeag seroconversion were under years old, in ( / , %) of whom hbsag loss occurred as well. twenty four of patients were over years old, in ( / , . %) hbsag loss occurred, that showed significantly difference (p-value= . , or: . , ci: . - . ) compared to younger group. age was significantly lower in hbsag clearance group ( . ± . years) than non-clearance group ( . ± . years) (p= . ), but no difference was observed in other parameters. anti-hbs appeared in patients. conclusion: in the treatment of hbeag positive chronic hepatitis b with lamivudine, age was significantly lower in hbsag clearance group than non-clearance group. background: dysfunction of t cells may represent a mechanism of hepatitis b virus (hbv) persistence. programmed death- (pd- ) and its ligands, pd-l /pd-l , are members of cd /b family, was reported to transfer inhibitory signal, leading to the dysfunction of t cell. background: hepatitis b viral mutants can emerge in patients as a result of selection pressure from either immune response or treatment options. mutations of hbsag allow mutant virus to propagate in the presence of a neutralizing immune response, while wild-type virus in reduced to undetectable levels. methods: immunohistochemical analysis of tissue samples from patients with chronic hepatitis b (chb), acute hepatitis b (ahb) patients and health controls was performed. results: pd- was positively expressed on lymphocytes infiltrating the portal area.pd-l expression was the same as pd- ,also expressed in interlobular.pd-l expressed on kupffer cells and dendritic cells.pd- -,pd-l -,and pd-l -positive cells express index of chb patients were much more than that of health controls and ahb patients(p . ).between groups in chb,the expression rate increase with the disease progression (p . ). methods: chronic hepatitis b patients with both positive for hbsag and hbsab were studied.serological markers of hbv were detected by elisa and microparticle enzyme immunoassay. hbv dna levels were determined by fluorescent quantitative pcr, s gene fragments were directly sequenced, liver function was analyzed by automatic biochemistry analyzer au . correlation test was conducted to evaluate their dependablity. conclusion: overexpression of pd- and pd-l within liver might be involved in inhibiting the immune response and be a mechanism of chronicity in hbv infection. results: the level of hbsag and hbsab was . ± . s/n and . ± . miu, respectively. hbv dna was detectable in patients. fifty-one mutations of s gene were detected in patients, and the relating amino acid substitution was at the sites of , , , , , , , , , , and . eight ( . %) out of mutations were located at the "a" determinant region in patients, while no mutation was found at the sites of , and . however, the mutation did not affect hbv replication. hbv dna was positive correlated with hbeag. conclusions: change in hbsag antigenicity due to s gene resulted in concurrent hbsag and hbsab. the existence of hbsab did not affect hbv replication. the damage of liver failure in those patients was slight. background: hbv infection is common in bangladesh. we often encounter young patients incidentally detected with hbeag negative chronic hepatitis b (chb) in our clinical practice. however the characteristics of these patients is yet to be studied in this country. the aim of this study was to study the characteristics of young bangladeshis incidentally detected with hbeag negative chb. methods: we did percutaneous liver biopsies of chb patients aged between to years. they were all hbeag negative with persistently normal or raised serum alt values. we did pre-core mutation (pcm) study in patients who were randomly selected. results: % patients had significant necro-inflammation (hai-ni > ), while significant fibrosis (hai-f > ) was seen in . %. serum alt (cut off u/l) was raised in . %, while high hbv dna load (> copies/ml) was observed only in . %. pcm was negative in all . conclusion: although chb patients between - years of age are supposed to be in immune clearance phase, which is characterized by low hbv dna and hbeag positivity, the study shows that hbeag negative chb is an entity that can also be seen in this age group and a significant percentage of such patients may have considerable hepatic involvement. this challenges our current concept about immune clearance state of hbv infection, although much larger study is needed to draw any specific conclusion. background: hbv infection is common in bangladesh, but characteristics of young patients incidentally detected with chronic hepatitis b is yet to be studied in this country. methods: we did percutaneous liver biopsies of chb patients aged between to years. results: significant necro-inflammation (hai-ni > ) was seen in . % patients with hbeag positive and % patients with hbeag negative chb, while significant fibrosis (hai-f > ) was seen in . % and . % patients in these two groups respectively. serum alt (cut off u/l) was raised in % hbeag positive and . % hbeag negative patients, while in these two groups % and . % patients respectively had high hbv dna load (> copies/ml). conclusion: hbeag negative chb is an entity that can also be seen in young population. a significant percentage of both hbeag positive and negative patients may have considerable hepatic involvement. profile of hbeag +ve chronic hbv infection in bangladesh m. mahtab , s. rahman , f. akbar , f. karim , a. shrestha , m. khan , m. kamal bangabandhu sheikh mujib medical university, toshiba general hospital, dhaka, bangladesh background: inactive hbv carriers constitute the major reservoir of hbv. present management guidelines provide inadequate treatment modalities. they are recommended for regular check-up; treatment is only recommended when patients exhibit evidence of liver damage. this is due to lack of information about their extent of liver damage. aim of this study was to assess extent of liver damage in hbeag +ve patients, unaware of their infection. methods: in this retrospective study, records of hbeag +ve chb patients from our pool of chb patients were reviewed. they were tested for hbsag, hbeag, hbv dna, anti-hcv and serum alt. all underwent per-cutaneous liver biopsy. results: . % ( / ) patients were males and . % ( / ) females. they were between - years of age. alt was raised > times unl in % ( / ). . % ( / ) patients had high hbv dna (> copies/ml), while low hbv dna (< copies/ml) was seen in . % ( / ) . in high hbv dna group, significant necro-inflemmation (hai-ni > ) was seen in . % ( / ) and significant fibrosis (hai-ni > ) in . % ( / ) . figures were . % ( / ) and . % ( / ) respectively in low viral load group. none tested positive for hcv infection. conclusion: study indicates that machinery should be developed to characterize undetected hbv carriers in developing countries by conducting multi-center clinical studies. we have shown that considerable number of patients, unaware of their hbv infection, suffer from progressive liver damage. the overall strategy of management of chronic hbv infection should also be revisited. high viral load does not necessarily represent significant liver damage in patients with chronic hbv infection in bangladesh m. mahtab , s. rahman , f. akbar , f. karim , a. shrestha , m. khan , m. kamal bangabandhu sheikh mujib medical university, toshiba general hospital, dhaka, bangladesh background: in general, it is assumed that patients with chronic hepatitis b virus (hbv) infection with high viral load exhibit increased liver damages. treatment guidelines also emphasize on reducing viral load. these observations were mainly accumulated from developed countries. > % chronic hbv carriers live in the developing nations, but little is known about relationship between hbv viral load and extent of liver damage in these countries. in this study, we addressed this issue. methods: in this retrospective study we reviewed records of chb patients from our pool of patients. all had high hbv dna (> copies/ml). . % ( / ) were hbeag +ve and . % ( / ) hbeag -ve. they were alsotested for anti-hcv and serum alt. all underwent per-cutaneous liver biopsy. results: . % ( / ) hbeag +ve patients with high hbv dna had non-significant hepatic necro-inflammation (hai-ni < ); this figure was . % ( / ) in hbeag -ve patients. non-significant hepatic fibrosis (hai-f < ) was observed in . % ( / ) and . % ( / ) in hbeag +ve and -ve patients respectively. none tested positive for hcv. conclusion: correlation doew not exist between viral load and liver damage in chb in bangladesh. many with both hbeag +ve and -ve chb with high hbv dna do not have significant hepatic necro-inflammation and fibrosis. further study may be needed to find out influence of other factors on liver damages in chb in bangladesh. most of these patients have not been characterized and treatment modalities have not been defined for them. background/aims: expression of intrahepatic hepatitis b core antigen (hbcag) is related to the immunopathogenesis of hepatitis b virus (hbv) infection. the role of hbv genotype and basal core promoter (bcp) mutation in expression of hbcag was investigated. methods: seventy hbeag-positive chronic hepatitis patients (genotype b in and c in ; bcp t /a mutation in ) were enrolled. clinical, virologic and histologic features were compared with regard to localization and expression of intrahepatic hbcag. the effects of hbv genotype and bcp t /a mutation on the expression of hbcag were further evaluated by in vitro assays. results: cytoplasmic, mixed cytoplasmic/nuclear, and nuclear localization of intrahepatic hbcag were found in ( . %), ( . %) and ( . %), respectively. fifty-eight ( . %) of these patients expressed a high level of hbcag. in multivariate analysis, cytoplasmic localization of hbcag correlated only with low serum viral load (p= . ) and bcp mutation (p= . ). high expression level of hbcag also correlated with high serum viral load (p= . ) and bcp wild-type sequence (p= . ). in vitro assays supported that hbv bcp mutant had lower subcellular expression of hbcag compared with bcp wild-type strain. conclusions: hbv bcp mutation and viral load but not genotype contributes to the expression of intrahepatic hbcag. hepatitis b virus (hbv) genotypes show distinct geographical distributions and virological and clinical differences. in some of genotypes, specific substitutions and mutations have been described in association with hepatitis b e (hbe) protein expression and viral replication. in this study, genetic characteristics of hbv genotype e (hbv/e) were investigated using clinical samples obtained from hepatitis b e antigen (hbeag)-positive, and anti-hbe-positive asymptomatic carriers (ascs) in west-africa. full-genome analysis of isolated hbv strains revealed strong association between precore (pc) mutation and hbeag to anti-hbe seroconversion. furthermore, using partial genome sequences, correlation among hbeag/anti-hbe status, viral load and key mutations were analyzed. the data showed that pc mutation is associated with hbeag seroconversion and enhanced viral replication efficiency. comparison between hbv/e and hbv/d strains reveals these two genotypes to have an identical sequence in their core-promoter-upstream and basic core promoter (curs/bcp) regions. it has been known from the previous phylogenetic studies, that hbv/d and hbv/e cluster together in trees reconstructed on x and precore/core orfs. in addition, this study, demonstrates that in spite of the high sequence similarity of curs/bcp region, the seroconversion-related mutation patterns are different between hbv/e and hbv/d in asc. further studies are needed to clarify the clinical significance of the regulatory sequence similarity between hbv/e and hbv/d. necro-inflammation and fibrosis p. siddappa , p. kar , b. das , r. gondal , m. asim maulana azad medical college, icpo, new delhi, india background: chronic hepatitis b(chb) is an important cause of morbidity and mortality. methods: pilot study involving patients of chb, were equally randomized to receive either adefovir or lamivudine for months. quantification of serum and hepatic hbv dna levels by real time pcr and liver biopsy done at start and end of months. results: after months there was significant and comparable reduction in serum and hepatic hbv dna viral load and liver biopsy showed significant reductions in hai scores in both the groups. serum alt which was elevated to or more times normalized in both the groups. in the adefovir group patients became hbeag negative and patients who were hbeag negative at the start of therapy remained so. in the lamivudine group one patient became hbeac negative and patients who were negative at the start of therapy remained so. in the adefovir group patients became hbv dna (qualitative test) and in the lamivudine group patients became hbv dna negative. there was strong correlation between serum and hepatic hbv dna levels both before and after the completion of therapy. conclusion: both the drugs bring about biochemical, histological and serological improvement with significant reduction in viral load in serum liver after months without complete clearance of virus. there was not enough evidence to show therapeutic advantage of one drug over the other. the serum and hepatic hbv dna levels correlate well with eachother before and after treatment. aim: assessing efficacy and safety of treatment of chronic hepatitis b in children with pegylated ifn. materials and methods: children ( boys and girls) aged - years with chb treated with peg-ifn alfa- a, g/m /week during weeks, hbeag-positive and hbeag-negative children, previously treated with recombinant interferon. no child had liver disease greater than grade , stage . serum hbv dna was quantified at baseline, tw , ("rvr") tw , tw (etr) and w (svr) with rt pcr method (roche taqman). alt activity, haematology and adverse events were monitored. results: after weeks treatment median hbv dna level decreased from . x iu/ml at baseline to . x iu/ml (p< . ). "rvr" -undetectable hbv dna at tw was observed in / children and associated with lower pretreatment alt levels < iu and pretreatment viral load < iu/ml. all children with "rvr" were hbeag-negative pretreatment. at tw and tw seven children including all with "rvr" had undetectable hbv dna. children achieved svr (undetectable serum hbv dna in w ), among them with "rvr". in / children with "rvr" hbsag disappearance was observed since tw . leukopenia was reported in children, thrombocytopenia in . no adverse events were observed following dose modifications. conclusions: . peg-ifnalfa- a is a good therapeutic option for children with chb, in particular with hbeag-negative chb . low pretreatment viral load and "rvr" seem to be predictive factors of efficient therapy. control by investigating the sanitizing modes among appliances used in the public service places (psp) and hbsag among appliances and practitioners worked in those places. methods: beauty parlors, barber shops and bathing centers selected by stratified randomization sampling, workers were investigated in questionnaire. the hbsag in appliances of psp and employee was detected by ria. results: the rate of hbsag among appliances of psp was . %. the rate of hbsag in large-, medium-and small-sized appliances was . %, . % and . %. the rate of hbsag has different( = . p . ). the rate of hbsag among appliances of beauty parlors, barbering shops and footbath inns was . %, . % and . %. different appliances had different rate of hbsag, such as the rate of acne needle and the forceps was . % and . %. the positive of hbsag amongworkers in psp was . %. the rate of hbsag among workers in large-, medium-and small-sized psp was . %, . % and . %. the rate of hbsag among workers in beauty parlors, barbering shops, footbath inns and bathing centers was . %, . %, . % and . %. the hbsag rate among workers was different in different works, the rate was higher in tattoo workers ( . %), pedicures workers ( . %), massagists ( . %). conclusions: it is important to enhance the sanitizing management in psp and improve workers kap) of hepb. and we should promote health education to enhance the knowledge of hepatitis b control and build up supervision consciousness. background: integration of hepatitis b virus (hbv) dna into host chromosomes is often found in chronic liver disease and hepatocellular carcinoma, which is likely an early event of hbv-related carcinogenesis. however, the molecular mechanism of integration remains unclear. here we describe a potential mechanism of hbv integration and identify that ku and ku , the gatekeepers of non-homologous end-joining (nhej) repair pathway, can serve as targets for anti-hepatitis virus integration. methods: using i-sce endonuclease-based system, we induced a dna double-strand break (dsb) in human hepatoma cell line huh- . the cells were then incubated with serum from patients with chronic hbv infection. pcr amplification and direct sequencing were used to detect the inserted sequence in the site of dsb. finally, we employed taqman-based real-time pcr assay to quantify the integrated hbv dna and evaluate the effects of shrna on hbv integration. result: when huh- were exposed to viral serum and incubated for several days, hbv dna was detected in integrated form at the exact site of dna damage. furthermore, small interference rna (sirna) targeted against gatekeeper genes for nhej can down-regulate nhej repair and even the frequency of hbv integration. conclusion: thus, this project provided us with the first direct evidence that dna double-strand breaks are potential targets for hbv integration. the study has also shown that shrnas targeted against gatekeeper genes for nhej can regulate the frequency of hbv integration. objective: to screen proteins of human pancreas cdna library interacting with hbsag protein. methods: the library was amplifed, purified and evaluated, and then the puried library plasmids were transformed into yeast strain y . the reconstructed plasmid pgbkt -hbsag was transformed into yeast strain ah and screened on the nutrient deficiency medium sd/-trp. the transformed ah mated with y containing the library plasmid. the diploid yeast cells were plated on nutrient deficiency medium sd/-trp/-leu/-his/-ade and sd/-trp/-leu/-his/-ade containing x--gal for selecting. the plasmids in diploid yeast cells were extracted and electrotransformed into e.coli dh . the plasmids in dh were extracted, sequenced and analyzed by bioinformatic methods. results: sixteen proteins interacting with hbsag were founded. conclusions: these results show that hbsag protein may be related with metabolism of glucose and lipid. comparison of the sensitivity and specificity of the elecsys ® hbsag ii assay with other available assays in china for detection of hbsag j.d. jia , l. wei , x.x. zhang , y.l. mao , l.l. wang , z.l. gao , j.l. hou , j. zhang , w. melchior , w. van der helm , beijing friendship hospital, beijing, china, beijing people hospital, beijing, china, ruijin hospital, shanghai, china, beijing hospital, beijing, china, west china hospital, chengdu, china, guangzhou, china, guangzhou nanfang hospital, guangzhou, china, shanghai public health clinical centre, china, roche diagnostics ltd, rotkreuz, switzerland, conclusions: in this patient population the prevalence of hbsag positive and anti-hcv were much higher than reported in community studies. genotypes and accounted for most of hcv. these very high rates of viral hepatitis in a hospital setting challenge to healthcare providers in terms of patient management as well as caregiver's prevention. hepatitis b is one of the major diseases of mankind that kills about one million persons each year in the world. accoring to primary study about % of iranian population is chronic hbv carriers. among iranian cirrhotics, - % has evidence of exposure to hbv and - % is carriers. because increase demand of blood transfusion, high blood dependent patients and long term window period of hbv infection, any controlling hbv infection program in blood donors can enhance the blood safety and public health. pe in this descriptive study included all the blood donors that referred to dezful blood transfusion center during - . all the blood donors screened for hbs ag by using enzyme immuno assay and repeatedly reactive (r.r) samples confirmed by hbc-ab or confirmatory (neutralization) tests. the data analyzed by using spss . . we found that in the first year . % were repeatedly reactive and . % confirmed. the results for other years as the followed: . %(r.r) and . % confirmed and in the last . % (r.r) and . % confirmed. the repeated blood donors increase in this period ( . %, . % and . % respectively). aim: we aimed to evaluate the cost-effectiveness of telbivudine versus entecavir with reference to lamivudine by roadmap model. methods: decision analysis model was used to study the incremental cost-effectiveness ratios (icer), i.e. the additional cost (in usd) required to achieve undetectable hbv dna or hbeag seroconversion for a patient at years in america and hong kong. entecavir was used as a continuous monotherapy. lamivudine and telbivudine would be shifted to entecavir if hbv dna was detectable at month and continued otherwise with drug resistance treated by add-on adefovir. weighted event rates based on previous reports were estimated for analysis. according our study, although the prevalence was higher than other region in our province, the hbv prevalence showed good decrease after stablishment strategies such as of repeated blood donor recruitment , improvement the donor selection and other educational programs . good following up those strategies to enhance the blood safety recommended. results: telbivudine was generally cheaper than entecavir to achieve an incremental case of undetectable hbv dna from lamivudine at years. entecavir was least effective and most costly for hbeag seroconversion. conclusions: telbivudine is a cost-effective alternative to entecavir particularly when its cost is low in hong kong. h. tang , g.l. zhang , y.x. li , r.q. tian , m. liu , x. li tianjin life science research center, tianjin medical university, tianjin , china micrornas (mirnas) are single-stranded noncoding rnas of to nucleotides that play critical roles in a wide spectrum of biological processes. we investigated whether the mirnas-silencing machinery influences hbv replication or antigen expression. on the basis of elisa and mtt, the effect of mirnas on the hbsag expression and cell proliferation was examined. three micrornas efficiently inhibited hbsag expression without significant effect on the proliferation of hepg . . cells compared to lacz control. subsequently, bioinformatics analysis were used to predict targets for the three mirnas, and the prediction results were conformed by cdna microarray analysis. the target region in hbv genome and the 'utr region of one cellular gene were identified by fluorescent reporter assay, semi-quantitative rt-pcr and western blot. the results demontrated that mirna may play an important role in replication and gene expression of hbv. hepatitis b virus (hbv) infection is a global public health problem, which plays a crucial role in the pathogenesis of chronic hepatitis, cirrhosis and hepatocellular carcinoma. although considerable progress has been made, the pathogenesis of hbv infection is still elusive. there's an urgent need to elucidate the mechanisms of hbv-host interactions, to discover novel biomarkers for diagnosis and prognosis and to develop therapeutic targets for anti-hbv treatment. herein, we applied a two-dimensional gel electrophoresis and maldi-tof/ms based comparative proteomics approach to globally analyze the host response to hbv by using an inducible hbv-producing cell line hepad . of the differentially expressed proteins identified, glucose regulated protein (grp ) was one of the most striking proteins elevated by hbv replication, which was confirmed by real-time pcr and western blotting. knockdown of grp expression by rna interference resulted in a significant increase of both intracellular and extracellular hbv virions in hbv-transfected hepg cells. reversely, grp overexpression led to hbv suppression. the expression levels of hepatitis b surface antigen (hbsag) and hepatitis b e antigen (hbeag) were determined by enzyme linked immunosorbent assay (elisa). immunofluoresce further revealed a positive correlation between the expression levels of grp and hbsag in both hbv-transfected hepg cells and hbv-infected human liver tissues. altogether, these data demonstrate for the first time that grp is an endogenous anti-viral factor in hbv-transfected hepg cells and may serve as a potential prognostic indicator of viral status in anti-hbv therapies. background/aims: to evaluate the predictors of response to long-term treatment of adefovir dipivoxil (adv) in patients with emerging lamivudine (lam)-resistant hepatitis b e antigen (hbeag)-positive chronic hepatitis b (chb) patients. methods: one-hundred-thirty-four lam-resistant hbeag-positive chb patients were treated with adv for a median of . months (range, - months), following lam therapy for a median of . months (range, - months). patients ( . %) were switched from lam to adv monotherapy, ( . %) were switched to adv with month of lam overlap therapy, and ( . %) were switched to adv with months of lam overlap therapy. the influence of baseline parameters on treatment response to adv in patients with lam-resistant hbeag positive chb was analyzed. result: during the follow-up period, ( . %) of patients achieved complete response, defined as normalization of alt level, negative hbv dna by a digene hybrid capture assay and achievement of hbeag loss. sixteen ( . %) patients achieved hbeag seroconversion. twenty-eight ( . %) patients developed adv-related mutations during adv treatment. in multivariate analysis, virological response at months (or= . , % ci: . - . , p= . ), defined as serum hbv dna levels less than log copies/ml or a reduction in serum hbv dna levels greater than log copies/ml after months of adv therapy, independently predicted complete response. conclusions: virological response at months was the strongest predictor of adv response in lam-resistant hbeag-positive chb patients. background/aims: to explore the effects of hbv dna level hbv genotype/subgenotype on the pathogenesis of severe liver diseases in chongqing. methods hbv dna level was analyzed in patients with severe liver diseases in retrospect,and hbv genotype/subgenotype hbv dna level and hbeag were determined in patients with hepatocellular carcinoma (hcc,n= ), liver cirrhosis(lc, n= ),chronic hepatitis b(chb, n= ) and acute on chronic liver failure(aclf, n= ). results hbv level from high to low with chb were lc, aclf and hcc in turn(p . ). hbv genotype was mainly genotype b.the rate of genotype b and c were . % and . respectively in hcc patients, . % and . in lc patients, % and in chb patients, % and in aclf patients. the percentage of genotype b/c in aclf patients was higher in compared with other groups. but the distribution of hbv genotype among groups was not statistically different(p . ).subgenotypes of genotype b were almost ba but one. subgenotypes of genotype c were mainly ce in chongqing area, and there was no statistical difference among the groups (p . ). conclusion: hbv dna level seems not to be a determining factor at end point of severe liver disease. both genotype b and c of hbv can lead to severe liver diseases, and there are more mixed infections by different genotypes in aclf. the efficacy of switching to entecavir (etv) monotherapy in japanese lamivudine (lvd)-experienced patients. background: this study aims to determine the efficacy of switching to . mg etv daily in chronic hepatitis b (chb) patients previously treated with lvd. method: retrospective analysis of chb patients (n= ) previously on mg lvd daily and switched to . mg etv daily. results: lvd-experienced patients were divided into three groups based on hbv viral load at time of switching to etv (< . log copies/ml; . - . log copies/ml and > . log copies/ml). detection of lvd-resistant virus at the time of switching was higher in the group with hbv dna . log copies/ml ( % in both . - . and > . log copies/ml groups versus % in < . log copies/ml group) and was higher in patients treated with lvd for years ( % versus % for patients on < year of lvd). a year after switching to . mg etv daily, hbv dna undetectable rates were % ( / ), % ( / ) and % ( / ) for < . , . - . and > . log copies/ml groups, respectively. alt normalization occurred in more than % patients at the end of the first year of switching to etv for all three patient groups. only one patient in the . - . log copies/ml group, who had lvd-resistant mutants at the time of switching, developed etv resistance during follow-up. conclusion: switching from lvd to etv maintains or improves viral suppression and alt normalization, especially in patients with viral load < . log copies/ml. background/aims: we investigated the association between on-treatment hbsag decline and sustained response in patients treated with pegasys±lamivudine. methods: hbsag levels were measured retrospectively pre-treatment and at weeks , , and using the abbott architect hbsag assay in sera from patients ( % asian) treated with pegasys alone ( g qw; n= ) or combined with lamivudine ( mg qd; n= ) alone for weeks as part of a large multinational trial. response was measured months post treatment. results: more patients treated with combination therapy had > log decline in hbsag from baseline to week ( figure) . hbsag level < iu/ml at week was associated with higher rates of response to pegasys±lamivudine months post treatment ( figure) . data comparing hbsag and hbv dna as on-treatment predictors of response will be presented. conclusion: on-treatment hbsag monitoring may be useful for predicting response in patients treated with pegasys. y. wakui , j. inoue , y. ueno , t. shimosegawa division of gastroenterology, tohoku university graduate school of medicine, sendai, japan background/aim: chronic hepatitis b patients are clinically treated with nucleot(s)ide analogues and ifn-. nucleot(s)ide analogues have problems including drug resistance in continuous treatment, and ifn-has disadvantages of limited effectiveness and side effects. therefore, novel antiviral drugs are still needed. in this study, the suppressive effect to the replication of hbv was examined in vitro by using bezafibrate and rosiglitazone, which are ligands of peroxisome proliferator activated receptor (ppar) and , respectively. methods: the cytotoxicity of bezafibrate and rosiglitazone to hepg cells was examined with mts assay, and the concentration of % cytotoxicity (cc ) was calculated. hepg cells were transiently transfected with the plasmid containing . -fold hbv genome of a genotype b strain. after hours of transfection, rosiglitazone and bezafibrate was added to the cells. using the medium at day after the addition of drugs, hbv dna was quantified with real-time pcr. results: the cc of bezafibrate and rosiglitazone in hepg cells were m and m, respectively. the amount of hbv-dna in the medium was decreased when the density of bezafibrate was over m, but the density demonstrated considerable cytotoxicity. in contrast, rosiglitazone of m, which showed no cytotoxicit, decreased the amount of hbv dna. the % effective concentration (ec ) was calculated to be . m. conclusions: in this study, it was suggested that the replication of hbv was inhibited by rosiglitazone of the density without cytotoxicity. the mechanism is uncertain and being investigated now. q. zheng center for liver diseases, the first affiliated hospital, fujian medical university, fuzhou, p. r. china background: the objective of this study was to evaluate the early virologic response for prediction of achievement of hbeag seroconversion and hepatitis b virus (hbv) dna negativity after two years of lamivudine treatment in chronic hepatitis b (chb) patients. methods: in this retrospective study, adult patients with chronic hepatitis b ( hbeag-positive and hbeag-negative) were treated with lamivudine ( mg/day), and followed-up up to months. response and resistance to the treatment were assessed during the treatments with lamivudine. results: it was found that gender, age, baseline levels of alt and hbv dna, serum hbv dna at week (p = . , or = . ) were closely related to the achievement of hbeag seroconversion, undetectable hbv dna level and emergence of drug resistance after years of lamivudine treatment. hbeag positive patients with baseline serum hbv dna in - copies/ml and serum hbv dna copies/ml at week showed high response rate of alt normalization rate ( . %), undetectable hbv dna rate ( . %), hbeag seroconversion rate ( . %), as well as low drug resistance rate ( . %) after years of treatment. similarly, hbeag negative patients with serum hbv dna copies/ml at week could achieve high -year response rate of alt normalization rate ( . %), undetectable hbv dna rate ( . %), and low drug resistance rate ( . %). conclusion: serum hbv dna copies/ml at -week provide the best prediction of -year lamivudine treatment response. background/aims: unlike oral antivirals, a finite course of (peg)interferon can induce sustained post-treatment response in patients with chronic hepatitis b (chb), with increasing rates of hbsag clearance observed in patients who respond during post-treatment follow-up. hbsag clearance is considered to be the closest outcome to a cure, being associated with improved histological outcome, reduced incidence of hcc and increased survival. methods: in a randomised multinational study, patients (hbeag-negative) received µg pegasys+placebo (n= ); µg pegasys+ mg lamivudine (n= ); or mg lamivudine (n= ) for weeks, and were assessed months post-treatment. from this initial study, of those who had received pegasys±lamivudine and patients who had received lamivudine monotherapy participated in a long-term observational study to investigate post-treatment response. hbsag clearance at yearly post-treatment follow-up visits up to years post-treatment was analysed. results: hbsag clearance in patients treated with pegasys±lamivudine increased post-treatment ( % at year to %, %, % and . % at years , , and ). at year , pegasys-treated patients ( . %) had cleared hbsag compared with ( . %) of lamivudine-treated patients (p= . ). / pegasys-treated patients had anti-hbsag (hbsag seroconversion). detailed analysis of the -year follow-up data will be presented. conclusion: the ability of a finite course of pegasys to induce sustained response with increasing hbsag clearance rates in responders during post-treatment follow-up supports its use as first-line therapy in hbeag-negative patients with chb. background/aims: recent studies suggest that quantification of hbsag levels early during treatment can be used to predict post-treatment response to pegasys. elecsys ® hbsag ii (roche) is a sensitive assay for the detection of hbsag. this assay can be used for the quantification of hbsag levels using a simple dilution algorithm. we compared results obtained using the elecsys ® hbsag ii method with those of a commonly used quantification assay. methods: hbsag levels obtained using the elecsys ® hbsag ii assay were compared with those obtained using the abbott architect ® hbsag assay for a total of samples from patients infected with hbv genotypes a (n= ), c (n= ), d (n= ) and f (n= ). samples were diluted : in diluent provided by the manufacturer. samples with hbsag levels > iu/ml were retested at a final dilution of : . samples with hbsag levels < . iu/ml were retested undiluted. results: overall, hbsag levels measured with the two assays correlated well (r = . ) over a wide range ( - x iu/ml). discrepancies in hbsag levels >± % were reported for a minority of the samples (n= ), mainly distributed evenly above and below the ideal line (n= ). in the four low titre (range - x iu/ml) samples with greatest discrepancy elecsys ® underestimated values (in two cases by > %). conclusion: the elecsys ® hbsag ii assay provides a simple and reliable means for determining hbsag levels. this simple assay format could be used to provide useful information during on-treatment monitoring of hbsag levels in patients with chronic hepatitis b undergoing therapy. conclusions: hbv/a has been increasing in chb patients in japan as the consequence of ahb, spreading in the younger generation through promiscuous sexual contacts, thrust by an inclination of hbv/a to induce chronic hepatitis. the spread of hbv/a infection in japan should be prevented by universal vaccination programs. introduction: chronic viral hepatitis is common in end-stage renal disease (esrd), from endemic hepatitis b (chb) and nosocomial hepatitis c (chc). reduced outcomes post-renal transplant were reported thus chb and chc cirrhosis became contraindications to listing. however, these predated effective anti-viral therapies. we reviewed outcomes of patients with chronic viral hepatitis following assessment for renal transplantation. methods: prospective database of esrd patients with viral hepatitis referred for renal transplantation was reviewed. results: patients were assessed. patients underwent kidney transplantation. two were cirrhotic and had liver/kidney transplantation; both died within months. were non-cirrhotics, of whom are alive. / have functioning allografts; predictors were normal alt and low viral load. of the non-transplanted, had cirrhosis; / received anti-virals. mortality was % - liver-related ( hepatoma, bacterial peritonitis, sepsis - inactive cirrhosis); non-liver related ( cerebral, haemorrhage, renal - inactive cirrhosis). / surviving cirrhotics received anti-virals. in non-transplanted non-cirrhotics, mortality was %; % of survivors had inactive disease. chb patients received lamivudine; adefovir (lamivudine resistance). chc patients received ifn-based therapy. conclusion: excellent outcomes are achieved in esrd patients with chb/chc post-renal transplant, in absence of cirrhosis. normal alt/non-detectable viral load can predict graft function. however, cirrhosis is associated with high mortality on dialysis whereas non-cirrhotics with inactive disease do well. the role of kidney transplantation in cirrhotics with suppressed viral replication needs to be reassessed. the truncated hbc interferes with replication of hepatitis b virus j.c. han , , x.b. pan , , l. wei , , k. deng , institute of hepatology, peking university people's hospital, china hepatitis b virus (hbv) capsids play an important role in production of progeny virus and other elements of the virus life cycle. misdirection of capsid assembly and formation of aberrant particles may be an effective approach to interfere with virus replication. hbv capsids can be assembled in vivo and vitro from the dimeric hbv core protein (hbcag). the interaction of single and dimeric hbcag with some truncated hbcag is verified in vitro. the truncated hbcag consists of the first amino acids and lacks the c-terminal, -residue rna-binding domain. method: we transiently transfected hepg . . with pcdna . hbc by fugene .after and h, hbvdna, hbeag and hbsag in culture supernatant were detected and cell subjected to southern blot and immunofluorescence analysis. result: the level of hbsag and hbeag had gentle change, we found that hbvdna decreased at h after transfection( copies/ml p< . ) ,but replication intermediates obviously decreased from h. some positive signal of hbcag located around the nuclear and conglomerated in cytoplasm compared to the control. conclusion: the truncated hbc can inhibit replication of hepatitis b virus. misdirection of capsid assembly and formation of aberrant particles could be an important cause. y.p. li , r.c. li objective: to assess the long-term efficacy of recombinant yeast derived hepatitis b vaccine in infant s born to hbsag and hbeag carrier mother. methods: a total of neonates born to hbsag, hbeag both positive mothers were vaccinated with , , g doses of recombinant yeast derived hepatitis b vaccine by , , and months schedule. they were all followed for years after the primary vaccination. results: twelve infant s ( . %) become hbsag positively conversed in year after primary vaccination ,and the positive rate of hbsag in - year was . %- . % , . % of child in no/ lowly respond become hbsag positively. at the ninth year, the positive rates of anti-hbs were % above. anti-hbs positive rates and immunity level were higher at - year old by repetition immunity than others. conclusion: the recombinant yeast derived hepatitis b vaccine have good immunogenecity and long-term protective efficacy to hbv interruption of perinatal transmission , a booster dose seems necessary in aged - years to the mother with hbsag and hbeag.it is high risk tobecome hbsag positively in the baby of norespones to hepatitis b vaccine. chb patient group-initiated programme to improve awareness, adherence and treatment outcomes in asia pacific n. leung founding chairperson of asiahep background: worldwide, over million people live with chronic hepatitis b (chb); million in asia pacific. regional survey data from , patients in countries showed a lack of knowledge and understanding of chb, its severity and impact on quality of life. this initiative aims to coordinate patient groups in the region and devise programmes to improve knowledge and healthcare outcomes. methods: the patient groups met in hong kong in may and identified common needs to: ( ) improve educational resources; ( ) raise awareness; ( ) increase diagnostic yield; and ( ) enhance treatment compliance through education about the need for sustained viral suppression to reduce long-term complications. results: a patient engagement programme was developed for people with newly diagnosed or known chb. the programme comprises: -detailed information about chb -a health-tracking tool for self-monitoring of blood tests and treatment progress -detailed information for carers/family -a patient-physician communications video (including role-play) -mobile phone text messages providing advice and compliance/appointment reminders conclusion: this programme was developed to address the needs of patients and clinicians. improved knowledge and long-term support, particularly for patients on antiviral medication, is expected to improve quality of life. the programme encourages clinicians and patients to develop enduring therapeutic partnerships to promote optimal outcomes. acknowledgement: the chb patient group meetings and the patient engagement programme are supported by an unrestricted educational grant from glaxosmithkline. serum hbv rna level reflects the potency of nucleos(t)ide analogue y.w. huang , , k. chayama , , m. tsuge , , s. takahashi , , t. hatakeyama , , m.y. lai , , h.l. you , j.t. hu , c.j. liu , , p.j. chen , , d.s. chen , , s.s. yang , j.h. kao , liver unit, cathay general hospital medical center, background and aims: serum hbv rna is detectable in patients treated with lamivudine (lmv) or entecavir (etv) (hatakeyama, and huang, ) . the aim of this study was to determine the clinical significance of serum hbv rna levels in patients treated with nucleos(t)ide analogues of different potency. methods: serum hbv rna was serially determined in patients treated with nucleos(t)ide analogues for to weeks ( with adefovir (adv), with lmv, and with etv). serum hbv rna was quantified by reverse transcription of hbv nucleic acid extract with subsequent real-time pcr. results: hbv rna was detectable in patients as follows: of in adv ( %), of in lmv ( %), and of in etv ( %) (p = . ). mean log serum hbvdna levels at baseline were . ± . for adv, . ± . for lmv, and . ± . for etv, which were comparable between less potent adv and most potent etv (p = . ). during antiviral therapy, peak log hbv rna level of patients with etv was significantly higher than that of those with adv or lmv ( . ± . vs. background: in the phase iii clinical trials, clevudine mg for months showed potent antiviral activity along with a marked post-treatment antiviral effect. the objective of this study is to compare the anti-hbv activity of combination of clevudine and vaccine over clevudine alone in chronic hepatitis b (chb) patients in a randomised way. methods: the patients are received clevudine for weeks and then combination of clevudine and vaccine for another weeks or clevudine alone for weeks. eligible patients were treatment-naïve hbeag(+) chb patients with hbv dna levels , copies/ml. the primary endpoint is the proportion of patients with hbeag loss. preliminary results are presented here. results: thirty-one patients have completed week visits and from them, patients ( in clevudine alone and in combination group) have completed week visits. at week , % of patients had hbeag loss. at week , % in clevudine alone and % in combination group ( months on combination after clevudine monotherapy) had hbeag loss. at week , % of patients had negative hbv dna by amplicor pcr (< copies/ml). at week , all of patients in both groups had negative hbv dna by pcr and % in clevudine alone and % in combination group had normal alt. conclusion: clevudine demonstrated good serologic response as well as significant viral suppression and alt normalization. with this data, we conclude that combination therapy of clevudine and vaccine for short period does not show the superiority over clevudine alone. background/aims: to determine the reasonable number of clones for hbv quasispecies analysis. methods: chronic hepatitis b patients were enrolled with hbvdna levels range from ~ log copies/ml. hbvdna was extracted. hbv reverse transcriptase (rt) gene encompassing the overlapping surface s gene was amplified by polymerase chain reaction, then cloned and sequenced. ten positive clones for each sample were sequenced in the first group, and then additional ten positive clones were sequenced in other groups until up to thirty clones. the characteristics of hbv quasispecies including shannon entropy and genetic distance were calculated. results: the shannon entropy and genetic distance of clones group was higher than those of and clones group, either in rt gene or in s gene (p< . ). while the shannon entropy and genetic distance of clones group showed on difference with those of clones group, neither in rt gene nor in s gene (p> . ). the number of different quasispecies detected in clones group was higher than that of and clones group (p< . ). the shannon entropy and genetic distance in three different clones group had no correlation with hbv dna levels (p> . ). conclusion: although the number of different quasispecies detected was increased with the augmentation of clone number, the quasispecies characteristic didn't changed significantly when the clone number more than . the information contained in clones per sample could well represent the quasispecies characteristics. the clone number was not necessary modulated according to different hbv dna levels. background: recent studies reported that basal core promoter mutation (a t and g a) was associated with more aggressive progression of liver disease from inactive carrier to active hepatitis, and eventually to liver cirrhosis and hcc. but the effect of the double mutations on the activity of enhancer ii/basal core promoter is still uncertain. objectives: to evaluate the influence of nt a/t and nt g/a mutations on hbv enhancer ii/basal core promoter activity. methods: the pcr fragments of hbv enhancer ii/basal core promoter (nt to nt ) from the serum-derived genotype b hbv dnas of one hbv carrier aged and one hbv related hepatocellular carcinoma patient aged were introduced into the pgl -basic-vector from promega via restriction sites of xho i and hind iii. the nt a to t and t to a, the nt g to a and a to g mutations were carried out by genetailor site-directed mutagenesis system from invitrogen. the promoter activity was evaluated by comparing firefly luciferase measurement with renilla luciferase as the internal control using the dual-luciferase reporter assay system from promega. results: the luciferase reporter assay results indicated that the t to a combined with a to g mutations increase (p< . ) while the a to t combined with g to a mutations decrease (p< . ) the hbv enhancer ii/basal core promoter activity significantly. conclusions: associated with increased risk of hepatocellular carcinoma, a t and g a double mutations of hepatitis b virus reduce the enhancer ii/basal core promoter activity. background/aims: a substantial proportion of chronic hepatitis b (chb) patients with mildly elevated alanine aminotransferase (alt) have significant fibrosis. we evaluated the factors associated with significant fibrosis and clinical outcomes in these patients. methods: one hundred five chb patients with alt less than two times the upper limit of normal underwent liver biopsy. multiple clinical, biochemical and virologic variables were evaluated to determine the predictors of significant fibrosis and progressive liver disease. results: there were patients in the low normal alt group, in the high normal alt group, in the low elevated alt group, and in the high elevated alt group. fifty eight patients ( . %) had significant fibrosis ( stage ) and ( . %) had significant inflammation ( grade ). the age, platelet count and grade of inflammation were factors associated with significant fibrosis. progressive liver disease was observed in ( . %) of the followed-up patients. the stage of fibrosis, alt group and antiviral therapy were significant predictive factors for progressive liver disease. conclusion: liver biopsies should be recommended in patients over years with mildly elevated alt levels, and antiviral therapy should be considered in patients with significant fibrosis to prevent progressive liver disease. background: four nucleos(t)ide analogues (nas) are currently approved for the treatment of hbv infection in china. however, long-term benefits are limited by the emergence of drug-resistant viruses. methods: patients accepted the examination based on physician's instruction. hbv reverse transcriptase gene was amplified from serum via nested pcr and sequenced directly. results: well-recognized drug-resistant mutations were detected in of , patients. in patients receiving na monotherapy, corresponding drug-resistant mutations were detected in / for lamivudine (lam), / receiving adefovir (adv), / for entecavir (etv), and / for telbivudine (l-dt). the mutations were detected in / patients receiving kinds of sequential/combined usages of the nas. m i ( %), m v+l m v l ( %), and m i+l m ( %) were identified as major mutant patterns of lam monotherapy. n t a substitution was the dominant adv-resistant mutation. t substitution was the dominant etv-resistant mutation always accompanied with lam-resistant mutation. l-dt-resistant mutation was m i l m exclusively. adv-resistant mutation was frequently seen in lam-resistant patients receiving adv sequential therapy rather than those receiving adv add-on therapy. controversial lam/adv-resistant mutations including a t, v a, q s and i v were detected in some patients singly or with the well-recognized drug-resistant mutations. interestingly, the drug-resistant mutations were also observed in a few of patients naïve to nas. conclusions: the exploration of hbv drug-resistant mutation profile in large clinical samples furthers our understanding of hbv drug-resistant status in china with implications for administrating anti-hbv therapy more reasonably. toll-like receptor (tlr) , tlr and cd +cd +cd low/-regulatory t cells correlate with hepatitis b virus infection y. zhang , j.q. lian , c.x. huang , x. wei , j.p. wang , p.z. wang , x.f. bai center of infectious diseases, tangdu hospital, the th military medical university, xi'an, china background: tlrs play a crucial role in sensing and initiating innate antiviral response and tregs actively suppress immune response, contributing to viral persistence and chronic tissue damage. in this study, we determined tlr and expression and treg frequency, as well as their function in the effect of hbv infection. methods: tlr and tlr expression on monocytes and circulating cd + cd + cd low/-tregs were determined by flow cytometry in ahb, chb, asc and nc. spearman correlation was performed to investigate associated variables on treg or tlrs. pbmcs were stimulated with hbeag or hbcag and the tlrs profile was examined. result: tlr expressions were up-regulated in chb and asc, while tlr were increasingly expressed in ahb and asc. treg frequency in chb was significantly higher than that in nc. in chb, the increased tlr negatively correlated with hbv dna loads and treg frequency negatively correlated with tlr expressions. tlr was up-regulated after hbeag stimulation in both nc and chb. conclusion: increased tregs may be associated with chb and there might be possible interactions between hbeag, tlr signaling and the innate immune response, which may partially explain the mechanism of hbv infection induced immuno-tolerance. ( . ± . ) . hbv-dna was quantitatively determined by polymerase chain reaction (pcr) technique, and hbv genotype was determined by pcr microwave gene chip technique. antiviral efficacy was assessed using measuring the following scales: the alt normalization rate, hbv-dna negative conversion rate and the hbeag/anti-hbe seroconversion rate. results: among serum specimen, hbv genotype distribution was genotype c, genotype b, and genotype non-b or c respectively. in genotype b, alt normalization rate was . %( cases), hbv-dna negative conversion rate was . %( cases) and the hbeag/anti-hbe seroconversion rate was . %( cases). in genotype c, alt normalization rate was . % ( cases), hbv-dna negative conversion rate was . %( cases) and the hbeag/anti-hbe seroconversion rate was . %( cases). the efficacy of adefovir dipiroxil showed no significant differences between genotype b and c in the treatment of chronic hepatitis b p> . . conclusion: adefovir dipiroxil is an effective antiviral drug. hbv genotype is irrelevant to the antiviral efficacy of adefovir dipiroxil in treatment of patients with chronic hepatitis b. the effect of anti-hbv drugs on albumin and bilirubin levels, and platelet count h. yoshida , h. taniguchi , r. nagano , k. sakitani , e. seki , t. serizawa , y. ito , h. mizuno , y. mitsuno , r. nakata , m. omata japanese red cross medical center, university of tokyo, japan background/aim: we assessed the efficacy of anti-hbv drugs on the liver function. methods: patients with hbv-related disease followed at our center between and were enrolled. lamivudine ( mg), lamivudine ( mg) +adefovir ( mg), or entecavir ( . mg) was administered to the patients with detectable hbv dna and elevated alt. liver function (alt, alb, and t.bil) and platelet count were observed. alt, alb, t.bil, and platelet count of treated group at pretreatment, year , and year were compared with untreated group. results: eighty six patients with positive hbsag were enrolled between jan and dec . seven patients ( acute infection, overlap infection with hcv, lost of follow up) were excluded. in total patients were followed up for a median follow up of (range - ) months. of patients, received anti-viral treatment. twenty one patients were treated with lamivudine, with lamivudine+adefovir, and with entecavir. the mean of levels of pre-treatment-year -year were alt: - - (u/l), alb: . - . - . (g/dl), t.bil: . - . - . (mg/dl), and plt: . - . - . (x mcl) respectively. markers of untreated group (n= ) (at baseline-year -year ) were alt: - - (u/l), , t. bil: . - . - . (mg/dl), and plt: . - . - . (x mcl) respectively. although all of four markers in treated group were significantly worse than untreated group at baseline, all of four markers did not showed significant difference from untreated group at year . conclusion: treatment with anti-hbv drugs showed the efficacy not only transaminase levels, but also on albumin, bilirubin, and platelet count improvement-improvement of "hepatic reserve" which is valuable for prevention of cirrhosis. background: currently, hbeag-negative chronic hepatitis b(chb) is increasing. but there are still controversial on the treatment of hbeag-negative chb with alt ×uln. we have investigated the clinical efficacy of nucleotide analogues(nas) in the treatment of hbeag-negative chb with alt ×uln. methods: the data of patients who were treated by nas for more than years and with alt ×uln (n= ) , alt ×uln(n= ) and alt ×uln(n= ) were collected, and w and w virologic response, w and w complete response, virologic breakthrough and clinical resistance were analyzed. results: compared with the base line, hbv dna level in all three groups were significantly decreased (p . ), and there was no significant difference between alt ×uln group and alt ×uln group. the viral load was significant decreased in alt ×uln group at w, w and w (p< . ). virologic response at w and w complete response at w and w was . %, . % , . % and . % respectively in alt ×uln group and was . %, . %, . % and . % respectively in alt ×uln group. there was no significant difference between alt ×uln group and alt ×uln group. virologic response at w and w and complete response at w were significant decreased (p< . ) in alt ×uln group. there was no significant difference among the three groups in virologic breakthrough and clinical resistance. conclusion: hbv replication can be satisfactory inhibited by nas in hbeag-negative chb patients with alt ×uln, which suggests that in these patients the indication of alt is different from hbeag-positive patients. quantitative hbeag assay as a predictive factor of hbeag seroconversion induced by peg-ifn - a therapy to hbeag-positive chronic hepatitis b y.y. zhu , j. dong , y.t. chen , j. chen , j.j. jiang liver diseases research center, the first affiliated hospital of fujian medical university, fuzhou, fujian, china rp, background: to find predictive factor for hbeag seroconversion in the treatment of hbeag-positive chronic hepatitis b (chb) by peg-ifn - a. methods: hbeag-positive chb patients were given peg-ifn - a treatment for weeks. clinical data were collected every months. receiver operator characteristic (roc) curve was employed to calculate positive predictive value (ppv), negative predictive value (npv), sensitivity and specificity. results: sixty-five patients completed peg-ifn - a therapy. among them, ( . %) were found hbeag seroconversion and ( . %) were found hbeag loss at cessation of therapy. none of age, gender, alt level and hbv dna load at baseline had relationship with hbeag seroconversion. hbeag level of baseline was correlated to hbeag seroconversion, with p value as . (table ) . according to roc curve, supposed auc as . and p value as . , the ppv, npv, sensitivity and specificity of hbeag level as at week were . , . , . and . , respectively. supposed auc as . and p value as . , the ppv, npv, sensitivity and specificity of hbeag level as at week were . , . , . and . , respectively. the hbeag level (s/co) and decreased degree (percentage) at week and week were significant related to hbeag seroconversion (table ) . conclusion hbeag level at baseline and at th and th week and its decreased degree (percentage) during the treatment course could be used as predictive factor for hbeag seroconversion. background: it is well documented that perinatal transmission is the major cause of chronic hbv infection in china. the aim of this study was to evaluate the efficacy of interruption of hbv intrauterine infection with hepatitis b immunoglobulin (hbig) in pregnant women with hbeag positive. methods:: a prospective randomized controlled trial was adopted. each subject in the trial group ( cases) was given iu hbig intramuscularly every weeks from -week of gestation, while each subject in the control group ( cases) received placebo in the same way. the cord blood of newborns were collected for detecting hbsag, hbeag and hbv-dna. results: for newborns, hbeag positive rate in trial group was . %( / ).hbeag positive rate in control group was . %( / ). there was significant difference in hbeag positive rate of newborns between the two groups( p < . , rr = . ). hbv-dna positive rate in trial group was %( / ). hbv-dna positive rate in control group was . %( / ). there was significant difference in hbv-dna positive rate of newborns between the two groups( p < . , rr = . ). hbv-dna load of cases of newborns in trial group was lower than that of their mothers(t = ,p = . ). there was no significant difference in hbv-dna load between women and their newborns after delivery in control group (t = . ,p > . ). conclusion: it is effective and safe to prevent hbv intrauterine infection with hbig from the (th) wk in pregnant women with hbeag positive. ), especially, the cirrhosis and hcc cases obviously more in both hbeag and anti-hbe patients are negative than hbeag-negative but anti-hbe positive patients (. . % vs . %; . %vs . %, p ) .the prevale nce of pre-core g a mutate have no significant difference regardless of hbv serum marker status or the state of illness. conclusion: recent years the hbeag-nagative chronic hepatitis b patients are gradually increasing in yunnan province. while the hbeag disappear but no anti-hbe serum transfer, and the virus still active replication -it may be a crucial phase determined the diseases outcome, which should be pay more attention by physicians. the clinical significant of pre-core g a mutate remain unknow. efficacy of interferon for chronic hepatitis b patients with normal or paranormal alt z. liu , j.z. guo , y.j. lin , y.j. zhang , z.w. lang beijing ditan hospital, beijing, china background: we reported interferon treatment for cases with normal or paranormal alt but in which liver histologic exam showed g - and/or s - . methods: patients were male with an average age of years.mean alt was . iu/l and hbv dna level was ~ log copies/ml. two patients were hbeag positive; one patient was both negative for hbeag and anti-hbe and one patient was anti-hbe positive. liver biopsy showed g ~g and s ~s respectively. patients were treated with ifn-alpha, liver biopsy was repeated after year.only one patient had received combination therapy with ifn and adefovir after months treated ifn monotherapy and liver biopsy was taken after . years. results: all patients got normal alt after year treatment. hbv dna was undetectable in patients. patients with initial positive hbeag cleared. but patients still were anti-hbeag negative.liver biopsy showed change fromg s - to g s - in patient; fromg s to g s in patient and no change in the other patients. conclusions: though alt and hbv dna improved after year treatment, histological improvement is not satisfying. patient's improvement in liver histology may be due to seroconversion before treatment and adding adefovir after months of interferon therapy. after months of combination therapy we did liver biopsy again. the other patients were hbeag negative, but hbeab were also negative, liver biopsy was taken year later without combination of nucleoside analogs. evaluation of long term efficacy of hepatitis b vaccination r.c. li , j. gong , j.y. yang objective: to evaluate the long term effectiveness of preventive hbv infection and to monitor the incidence of hepatitis b in children to see possible impact on the program of long an that was launched in . methods: ( ) set up a surveillance systemof hepatitis ,to evaluate the possible impact on incidence of hepatitis b. ( ) to serologically evaluate the effect of the program, a stratified random sampling of subjects in birth cohorts was recruited for long term follow up at the age - years. ( ) cross-sectional seroepidemiolgical survey was carried out in the county in before the program and years later. hbsag , anti-hbs and anti-hbc were tested by ria. results: the average coverage of hepatitis b vaccine was . %. at years after vaccination, the seropositivity for hbsag in population of - years has decreased from . % to . %, the annual effectiveness was . %. hbv accumulated infection rate was . %, protective rate was . %. the incidence of acute hepatitis b was . per , in population aged - years , it decreased by . % as compared with the incidence of . per , in same age group in - . conclusion: mass hepatitis b vaccination program in long an county has proved to be effective in control of hbv chronic infection and incidence of acute hepatitis b. background and aims: although the evolution of viral quasispecies may be related to the pathological condition of disease, little is known about this in hepatitis b virus (hbv), especially during hbeag seroconversion. methods: nucleotide sequences of hbv precore/core genes from time points were analyzed in four cohorts of chronic hepatitis b, interferon-induced seroconverters (is, n= ), interferon non-responders (in, n= ), spontaneous seroconverters (ss, n= ) and non-seroconverters (sn, n= ), followed during months on average. only patients with genotype c were used. viral diversity was then estimated after nucleotide genetic distance was assessed and phylogenetic trees were constructed. results: analysis of nucleotide sequences showed that the nucleotide genetic distance of seroconverters (is and ss; x - substitutions/site and . x - subsititutions/site, respectively) was similar to that of non-seroconverters (in and sn; both x - substitutions/site) before seroconversion. compared to that of nonseroconverters (in and sn; substitutions/site and . x - substitutions/site, respectively) the viral diversity of seroconverters (is and ss; x - substitutions/site and x - substitutions/site, respectively) was significantly higher after seroconversion (p< . ) and it was higher after seroconversion in seroconverters compared with that berore seroconversion (p< . ) while it almost didn't change in non-seroconverters irrespective seroconversion. phylogenetic trees also showed that complex trees appeared in secoconverters and relatively simple in nonseroconverters. conclusions: the distinctly higher viral diversity after seroconversion in hbeag seroconverters could be related to increased hbv-specific t-cell responses and escape mutant which arise from stronger selective pressure caused by host immune activity. adefovir dipivoxil mg (adv) resistance at yrs in chinese hbeag+ve chronic hepatitis b (chb) j.l. hou , y.z. wang , x.q. zhou , j.q. niu , y.m. wang , h. wang , y.m. mao , k.f. barker nanfang hospital, guangzhou, prc, jinan infectious disease hospital, jinan, prc, ruijin hospital, shanghai, prc, st hospital of jilin university, changchun, prc, xinan hospital, chongqing, prc, people's hospital, beijing, prc, renji hospital, shanghai, prc, glaxosmithkine r&d, london, uk background: long term adv provides clinical and histological improvement in chb, but may lead to emergence of treatment associated resistant mutations. we report on adv resistance data from chinese hbeag positive subjects treated for years. methods: hbeag positive chb subjects were randomized in an initial weeks controlled adv study (with a weeks placebo period in half of patients) and then offered open label adv treatment for a further weeks. a total of , , , and subjects completed the st , nd , rd , th and th yr, respectively. at the end of each year samples were analysed from those subjects with protocol-defined hbv dna breakthrough for the rtn t or rta v adv mutations associated with resistance. sera from subjects with breakthrough were analysed at all subsequent yearly timepoints whenever possible. results: at the end of the st yr, none of the subjects with hbv dna breakthrough had either mutation. sera were available for analysis from , , and subjects with viral breakthrough at the end of the nd , rd , th and th yr, respectively, with new mutations identified in , , and subjects at the same timepoints. of the cumulative subjects at the th yr analysis had rtn t, had rta v, and had both mutations. conclusion: treatment with adv in chinese hbeag positive chb subjects for up to yrs resulted in a cumulative rate of . % ( / ) adv resistance-associated mutations with hbv dna breakthrough. background and aims: to evaluate the predictive significance of rapid virologic response (rvr) for achieving an end-of-treatment virologic response (er) or hbeag seroconvertion and the predicting indicator of nonresponse (nr). methods: patients with chronic hepatitis b were treated with adv and prospectively observed to weeks. we assessed the values of virus load reduction at weeks , , and weeks to predict the er and hbeag seroconversion. the association between less reduction of viral load at and weeks and nonresponse was also analyzed. results: of etv-treated patients enrolled in etv- , met criteria for inclusion into year etv treatment analyses. the proportion of patients achieving efficacy endpoints through years of etv therapy is presented the table. results: after weeks of therapy, serum hbv dna levels decreased with a median . ± . log copies/ml. twenty-three( . %) of patients had er. twenty-six ( . %) patients achieved hbeag seroconversion. hbv dna < log copies/ml at week predict both er and hbeag seroconversion. hbv dna> log copies/ml at weeks but decline to < log copies/ml at weeks or weeks both can predict er and hbeag seroconversion. less than log hbv dna reductions at weeks might predict nr. conclusions: the majority of patients experienced durable serum hbv dna suppression ( %) and alt normalization ( %) after years etv therapy. conclusions: the virologic response within weeks could be useful for prediction of er and hbeag seroconversion of adefovir therapy. failing to evr might not predict nr. objectives: to determine the accuracy of hbcigm in diagnosing ahb and the correlation between hbcigm and liver inflammation (alt), bilirubin & biosynthetic functions (albumin,pt). result: a total of patients were included: in patients, adv was added on lam (add-on therapy), and in patients, lam was switched to adv (switch therapy). during . months of follow-up, patients developed adv resistance (rta v and/or rtn t) and all had undergone switch therapy. the cumulative probability of adv resistance at the th month was . %. although add-on therapy induced no adv resistance, it failed to show significant superiority over switch therapy (p= . ). in multivariable analysis, female (odds ratio [or], . ; % confidence interval [ci], . - . ; p= . ), liver cirrhosis (or, . ; % ci, . - . ; p= . ), and age > yr (or, . ; % ci, . - . ; p= . ) were independent risk factors of adv resistance. methods: a retrospective cross-sectional study involving patients with hbcigm positivity between june -december , satisfying the definition for ahb and chbf,and fulfilling the exclusion criteria was performed. hbcigm test were done by using microparticle enzyme immunoassay (meia) and results were expressed as an index value.hbcigm positivity was defined as index value of > . results: patients were positive for hbcigm and fulfilled the criteria( ahb, chbf).hbcigm was significantly higher in ahb compared with chbf(median . vs . ;p < . ).the hbcigm arbitary index value of . was highly sensitive( %) and specific( %) in diagnosing ahb with high accuracy(auroc . ; % ci: . - . ;p< . ).among patients in both groups, there was a weak, but significant negative correlation between hbcigm and pt above control(r = - . ,p = . ).however, among patients with chbf,the negative correlation between hbcigm and pt above control was moderately strong(r = - . ,p = . ).there was also a weak, but significant positive correlation between hbcigm and albumin in with chbf(r = + . ,p = . ). conclusion: adv add-on therapy developed no adv resistance during the observation period. therefore, add-on therapy is recommended to lam-resistant chb patients with genotype c who have any risk factors for development of adv resistance: female, liver cirrhosis, and age > yr. hbcigm-hepatitis b core igm antibody ahb-acute hepatitis b,chbf-chronic hepatitis b flare alt-alanine transaminase,pt-prothrombin time pe detection of emerging drug resistance mutations associated with major approved hbv antivirals using a novel line probe assay (lipa). j. doutreloigne , f. shapiro , r. maertens , e. van assche , e. sablon hepatitis diagnostics unit, innogenetics nv, belgium background: in study etv- , etv demonstrated superior virologic, histologic and biochemical benefit compared to lamivudine (lvd). this study (etv- /- ) presents efficacy and safety results for patients who received years continuous etv treatment. background/aims: an increasing number of antiviral drugs are being used to treat chronic hepatitis b virus (hbv)-infected patients. however, induced viral escape mutants -some potentially cross-resistant -lead to viral non-responsiveness and treatment failure. effective treatment strategies must therefore take possible drug resistance (dr) into account with respect to monitoring and selection of alternative drugs. we evaluated the use of an updated inno-lipa hbv dr v +v reverse hybridization assay versus sequence analysis to detect resistance mutations. methods: the study evaluates etv-treated nucleoside-naïve hbeag (+) patients who completed etv- and enrolled into etv- with a treatment gap days. the proportion of patients with hbv dna < copies/ml, alt normalization, hbeag loss or hbeag seroconversion was evaluated at week . background: etv resulted in improved liver histology compared to lvd at year. histologic data for patients on etv for a median of years is evaluated. methods: clinical samples (from untreated hbv patients or treated with different antivirals; hbv genotypes a-h) were tested for mutations with the lipa assay and sequencing. for lipa, samples were extracted with the qiaamp® dna blood mini kit (qiagen), and then tested on the lipa strips. sequencing-derived reference data were subjected to phylogenetic analysis (kodon version . applied maths, neighbour joining, with kimura- parameter). sequential samples from patients were evaluated as well. methods: etv-treated patients completing etv- or etv- received etv ( . mg daily) in etv- . primary endpoints included -point decrease in knodell necroinflammatory score, no worsening of knodell fibrosis score and improvement in ishak fibrosis score (ifs) ( -point decrease) vs. baseline. secondary endpoints included proportions with hbv dna< copies/ml, alt normalization, and ifs normalization in patients with advanced fibrosis/cirrhosis. results: quasi-perfect concordance (> . %) was obtained between the two assays for the samples tested. no indeterminate results were observed. for one sample, lipa provided additional information (wild-type/mutant mix), whereas sequencing showed only wild type. for sequential samples, lipa was clearly able to detect emerging treatment-resistance mutations associated with viral breakthrough. results: etv treatment led to significant histological improvements and improved ifs in % ( / ) and % ( / ) of patients respectively. of patients with baseline fibrosis/cirrhosis (ifs ), all demonstrated -point improvement in ifs (median change of - ). conclusions: lipa accurately detects the complex quasispecies nature of hbv and can help unravel the dynamics of emerging hbv resistance during treatment with different antiviral drugs. like its predecessor, it is useful for the monitoring and early detection of drug resistance. conclusions: long-term etv therapy in nucleoside-naïve chb patients results in durable virologic suppression, continued histologic improvement and regression of fibrosis/cirrhosis. precore (pc, g a) and basal core promoter (bcp, a t and g a) mutations of hbv are important for predicting the risk of hepatocellular carcinoma (hcc). we developed a new mass spectrometry-based assay using restriction fragment mass polymorphism (rfmp) to detect a and t /a mutations, and applied it to analyze their clinical significance in type b liver diseases (n= ), including hccs, liver cirrhosis (lc), chronic hepatitis b (chb), and hbsag-positive with low level viremia (inactive hbsag carrer, ihc). we devided patients into major groups according to the presence of wild (w) or mutant (m) genes in bcp/pc regions; w/w, w/m, m/w and m/m gene types. each proportion was . %, . %, . % and . %, respectively. mixed infection (x) was also found as minority; w/x, m/x, x/w, x/m and x/x. disease distributions (hcc, lc, chb and ihc) in each group were as follows; [w/w (n= )] . %- . %- . %- ; [w/m (n= )] - . %- . %- %; [m/w (n= )] . %- . %- %- . %; [m/m (n= )] . %- . %- . %- . %. these results suggest that, in korea where only genotype c has been identified, bcp dual mutation is predominant (> . %), while bcp wild alone is only . %. especially, a mutation alone without bcp mutation (w/m type) is uncommon, while bcp mutation alone without a mutation (m/w type) is most common. it might be suggested that prognosis of wild type in bcp and pc region (w/w type) is much better than that of m/w or m/m types. background/aims: entecavir is a potent inhibitor of hbv dna polymerase, which has been shown to be safe and effective for the treatment of chronic hepatitis b (chb) patients. the aim of this study was to evaluate the virologic, biochemical, and serologic responses of entecavir through year in chb patients. methods: from may to october, we reviewed patients (mean age ± years, male:female= : ) who were diagnosed as chb patients (hbeag (+) ). forty-seven patients ( . %) had been treated with . mg of entecavir and ( . %) with mg of entecavir, respectively. mean follow-up period was ± weeks. hbv dna was quantified by bdna assay with a lower limit of detection of , copies/ml. results: median hbv dna levels before therapy was . log copies/ml and the median decreases from baseline in hbv dna were - . , - . , - . , - . , and - . log copies/ml at (n= , p< . ), (n= , p< . ), (n= , p< . ), (n= , p< . ), and (n= , p = . ) weeks of follow-up, respectively. at baseline, overall median alt was iu/l and the proportions of patients with normal alt were %, %, %, %, %, and % at baseline (n= ), (n= ), (n= ), (n= ), (n= ), and weeks (n= ) after entecavir therapy, respectively. thirteen cases ( . %) of hbeag seroconversion were noted. background: hepatitis b virus (hbv) infection is a major risk factor for the progression of liver diseases. because its clinical course varies, it is difficult to detect the predictive factor for the prognosis of patients with hbv infection. the aim of the present study was to determine the risk factors for the occurrence of hcc. methods: a total of patients who tested positive for hepatitis b surface antigen and were referred to chiba university hospital between february and march were included in the study, and their following characteristics were analyzed: age, gender, the status of hbeag, alt, hbv-dna level, and plt. result: hcc was detected in cases during the follow-up period ( . ± . years). multivariate analysis revealed that age [compared with young patients: odds ratio (or) = . , % confidence interval (ci) = . - . ] and plt level (compared with patients with low plt level: or = . , % ci = . - . ) were the predictive factors for hcc occurrence. in patients with age more than years, the hbv-dna level (compared with < . log copies/ml: or = . , % ci = . - . ) and plt level (or = . , % ci = . - . ) were the predictive factors for hcc occurrence. conclusion: advanced age and low plt level were the risk factors for hcc occurrence in patients with hbv infection irrespective of the plt level at baseline. in patients with age more than years, viral load was also a risk factor for hcc. results: before treated by lps, the total mapk p level of pbmcs have no significant difference among the healthy control group, different stage groups with hbv infection, however, after treated with lps, the phosphorylated mapk p (ptpy / ) in healthy control group are significant elevate than hbv infected groups( . ± vs . ± . , p< . ). in the two groups which hbsag, hbv dna are positive, alanine aminotransferase elevate than normal and hbsag positive, but hbv dna lower under the detect limited level, after treated by lps the ptpy / although lower than healthy control yet, but significant elevated than themselves before treated by lps( . ± . vs . ± . , . ± . vs . ± . ; p< . ).otherwise, in the group of both hbsag and hbv dna are positive, but alt is normal, before and after treated by lps, the level of ptpy / have no significant difference. conclusion: mapk p is a important signal transduction pathway which involving in inflammation and immune response, especially, mapk p activated up-regulate the ifn-gamma mrna. according to the result shown, we propose a hypothesis, hbv infection and virus active replication inhibit the mapk p activated, consequent on host immunotolerance and hbv persistence, thus, mapk p may be as a potential therapeutic target to break immnotolerance and establish host anti-viral states. van der helm siriraj hospital, bangkok, thailand, ramathibodi hospital, bangkok, thailand, phyathai hospital, bangkok, thailand, singapore general hospital, singapore, national university hospital, singapore, changi general hospital, singapore, cheil general hospital, korea, hwasun jeonnam university hospital, korea, st mary hospital, korea, roche diagnostics ltd, rotkreuz, switzerland background/aims: hepatitis b virus (hbv) surface antigen (hbsag) is one of the most important markers for diagnosis of acute and hbv infection. high sensitivity of hbsag assays can reduce the diagnostic window during course of disease. in addition, the presence of hbv mutants may be affected by the performance of the hbsag kit. therefore, the technical performance of the elecsys ® hbsag ii assay was explored, using samples (including recombinant mutants), at multiple sites in three countries. methods: nine hbsag screening centers in thailand, korea and singapore compared the sensitivity of elecsys ® hbsag ii assay with that of their routine testing procedure -abbott architect ® ( centers), abbott axsym ® ( center) and bayer advia ® centaur hbsag assays ( center) using preselected seroconversion panels (n= ), recombinant hbv mutant panels (n= ) and routine clinical practice samples (n= , ). results: the sensitivity of elecsys ® in seroconversion samples was equivalent to the architect ® assay, but more sensitive than the axsym ® and advia ® centaur assays ( vs and vs positive bleeds, respectively). there was concordance between the elecsys ® and architect assay results with respect to potentially cross-reactive samples ( . %). the elecsys ® and architect ® assays detected all recombinant mutant samples, whilst axsym ® and advia ® centaur failed to detect three and nine samples, respectively. conclusion: elecsys ® hbsag ii assay was not only highly sensitive and specific when compared with established hbsag screening assays, but also reliably detected hbsag mutants. therefore, this attractive assay is suitable for hbv diagnosis and assessing safety of blood products. background: recent studies have shown a higher rate of adefovir-resistant mutation in lamivudine-resistant chronic hepatitis b (chb) patients treated with switch-to therapy than those treated with add-on therapy. we compared the clinical efficacy of adefovir monothrapy and lamivudine-adefovir combination therapy in lamivudine-resistant chb. methods: a prospective cohort study was performed in patients with lamivudine-adefovir combination therapy and patients with adefovir monotherapy for lamivudine-resistant chb over months. result: biochemical response was achieved in patients ( . %) treated with combination therapy and in patients ( . %) treated with monotherapy (p= . ). virologic response was observed in patients ( . %) in combination therapy and in patients ( . %) in monotherapy (p= . ) and treatment periods for virologic response was significantly shorter in patients with combination therapy than in monotherapy ( . ± . months vs. . ± . month, p= . ). cumulative rate of virologic response was significant higher in patients with combination therapy than monotherapy (p= . ). hbeag loss was found in patients ( . %) in combination therapy and patients ( . %) in monotherapy (p= . ). biochemical breakthrough was found in patients ( . %) with monotherapy significantly more frequent than patients ( . %) with combination therapy (p= . ). genotypic resistance to adefovir was developed in patient ( . %) in combination therapy and patients ( . %) in monotherapy conclusion: to achieve a complete virological response and reduce the risk of adefovir-resistant mutants in lamivudine-resistant chb patients, adefovir in combination with lamivudine is preferable. background/aims: adefovir dipivoxil (adv) effectively inhibits both wild-type and lamivudine (lam)-resistat chonic hepatitis b virus (chb) replication. the aims of this study were to determine the factorts associated with antiviral effect of adv in lam-resistant chb. methods: one hundred-eighteen lam-resistant chb patient ( . % hbeag-positive) were treated with adv plus lam (n= ) or adv monotherapy (n= ) for a mean of . months. restriction-fragment mass polymorphism analysis was used for detection ymdd and adv mutants. results: fifty-eight patients ( . %) achieved complete response(cr) defined as hbv-dna levels < copies/ml and alt normalization. twenty-eight patients ( . %) achieved initial vilologic response(ivr) defined as hbv-dna levels < copies/ml within the first month of treatment. ( . %) of hbeag-positive patients exhibited hbeag loss and % seroconverted to anti-hbe ab. five ( . %) patients developed adv-related mutations. factors associated with ivr were pretreatment level of alt (p= . ), ast (p= . ), pretreatment hbv dna level (p= . ), hbeag negativity (p= . ) and hbeab positivity (p= . ). factors associated with cr were ivr (p= . ), hbeab positivity (p= . ), pretreatment level of alt (p= . ), ast (p= . ) and y-glutamyl transferase (p= . ). age, sex, presence of liver cirrhosis, pretreatment hbv dna level and the type of ymdd mutants were not related to an cr during adv treatment. conclusions: adv therapy achieved cr in more than % of lam-resistant chb. factors associated with cr were ivr, hbeab positive status, high base line alt, ast, ggt levels. q.j. sheng , y. ding , x.g. dou department of infectious disease, shengjing hospital affiliated to china medical university, shenyang, , china objectives: to study a kinetics of hepatitis b virus during -week and -week of treatment with enticavir (ent); to compare the detecting results of hbvdna levels from different detection reagents. methods: thirty-seven cases of chronic hbv infections were selected randomly, treated with daily dose of ent . - . mg ( . mg for nucleoside-naïve patients, . mg for lamivuding-refractory patients). evaluation indexes: serum hbvdna, hbv serological markers, and liver function tests. hbvdna levels were measured by pcr assay, using both domestic reagents and roche cobas amplicor,. the lower limits of measure level of hbvdna were copies/ml and copies/ml, respectively. results: mean baseline of hbvdna was . log copies/ml for detection using domestic reagents and . log copies/ml for that using roche cobas amplicor, (p> . ). the ratios of cases with undetectable (< copies/ml) hbvdna at week- and week- were . % and . %, respectively. the ratios of cases with undetectable (< copies/ml) hbvdna at week- were . %. among the cases whose hbvdna were lower than copies/ml(using domestic reagents), the ratio of hbvdna lower than copies/ml(using roche cobas amplicor) was . %. conclusions: ent can suppress hbv dna rapidly no matter the patients with alt elevation or not. there is a concordance on hbvdna levels detection between domestic reagents and roche cobas amplicor. background the study on the effect of nucleoside analogue therapy on the quantity of hepatocellular cccdna and tdna and sera hbv dna, hbsag to probe reliable marks for evaluation of therapy endpoint. methods the quantity of hepatocellular cccdna and tdna and sera hbvdna were assayed by fq-pcr, and sera hbsag by elisa in chb patients over years nucleoside analogue therapy satisfied the china criteria of therapy endpoint (therapy group)and chb patients without antiviral therapy and sera hbvdna< copies/ml(control group). results: the quantity of hepatocellular cccdna, tdna and sera hbvdna, hbsag in therapy group were lower than that of control group,but low level hepatocellular cccdna in therapy group could be detected. conclusion: long term nucleoside analogue therapy may consume hepatocellular cccdna with decreasing of hepatocellular tdna and sera hbvdna, hbsag; although the patients have satisfied the china criteria of therapy endpoint, low level of hepatocellular hbvcccdna were detected, cessation of therapy may cause relapse. peptides that lead nuclear entry of nucleocapsid of hepatitis b virus in hepg . . cells x.b. pan , , l. wei , , j.c. han , , k. deng , peking university hepatology institute, peking university people's hospital background: the nuclear entry of nucleocapsid is a key step for the hbv life cycle and the formation of covalently closed circled dna (cccdna). it has been supposed that the carboxyl-terminal arginine-rich domain of the core protein contains a signal for nuclear localization (nls). whereas hbcag was primarily distributed in cytoplasm and no marked cccdna was detected in hepg . . cells. methods: we designed peptides containing a cell-penetrating sequence (rrrrrrr) and a nucleocapsid binding sequence (gsllgrmkga) with/without a classic nuclear localization sequence (pkkkrkv) and these sequences were linked by a soft linker acp. hepg . . cells were treated with the peptides at levels of m, m and m for days. results: compared with that of control cells, the results showed hbv dna levels in culture medium decreased at least log both in m of peptide rrrrrrracpgsllgrmkga treatment group and rrrrrrracpgsllgrmkgaacppkkkrkv treatment group; whereas hbsag and hbeag increased at . + . folds and . + . folds respectively. the signal strength of cytoplasmic hbcag increased at about . -fold in both groups. in rrrrrrracpgsllgrmkgaacppkkkrkv treatment group, nuclear hbcag increased about . -fold and obvious cccdna signal was detected by southern blot. conclusion: our results implied that the nls of core protein likely does not expose to surface of nucleocapsid in hepg . . cells, the artificial peptide containning nls binds to the nucleocapsid and leads nuclear entry of nucleocapsids and then facilitates the formation of cccdna. our study presents a tool for study on cccdna formation and nuclear entry of nucleocapsid. b. tang , j. xia , y.m. wang , h.f. wang liver failure treatment and research center, rd military hospital, the dept. aims: to establish a reliable real-time fluorescence quantitative (rfq) pcr method to quantify hbv cccdna, basing on lightcycler system and taqman probe. methods: hbv genotypes a-g were aligned to obtain a conserved sequence, crossing rcdna gap, which was used to design cccdna primers and taqman-mgb probe. also another pair of primers for quantify hbv total dna (tdna) was designed, utilizing the same probe. to increasing specificity, we added plasmid-safe atp-dependent dnase (psad) digestion step just before cccdna pcr amplification. a standard curve from standard plasmid samples, from . × to . × copies, was created to examine our system. hbv cccdna samples with known-amount were quantified by creating standard curve from standard samples. results: the standard curve had clear log-phase and excellent parallelism, which means nice and equal amplification efficiency in all reaction capillarys. the slope (regression coefficient) of standard curve was - . , mean square error was . and regression coefficient was - . . all of these key indexes measured up. in tests, we got right results if the starting templates of cccdna copies were between ~ copies. the range was superior to commercial hbv kits. by quantifying samples containing different amounts of cccdna and rcdna, digested or undigested, psad digestion would eliminate rcdna molecules, leaving cccdna molecules untouched. the test specificity was maintained up to : , ratio of cccdna:rcdna. conclusions: the rfq-pcr based on lightcycler system for hbv cccdna quantification is reliable, sensitive, with high specificity and low cost. background: to study the changes of toll-like receptor (tlr) on dendritic cells derived from peripheral blood mononuclear cells(modc) and its role in the pathogenesis of chronic hepatitis b(chb) and chronic severe hepatitis b(cshb). methods: the expressions of tlr on modc were stimulated by poly i:c, and then were determined by flow cytometry in healthy controls, patients with chb and patients with cshb.the level of interferon ifn-was determined by elisa. the differences of expression of tlr on modc and serum ifn-among the three groups of study subjects were determined by student-t test.the correlation between tlr and ifn-were determined by linear correalation test. results: the values of mean fluorescence intensity(mfi) of tlr on modc of the healthy controls, patients with chb and cshb were . ± . , . ± . ,and . ± . .the serum ifn-(pg/l) of respective groups was . ± . , . ± . and . ± . . there was a gradual decrease of these values from the group of healthy controls to the group of patients with chb and cshb .significant positive correlations between tlr and serum ifn-were found. conclusion: tlr may have a role in the pathogenesis of chb and cshb. background/aim: to evaluate the efficacy and safety of entecavir treatment in patients with hbeag-positive chronic hepatitis b who had not previously received a nucleoside analogue. methods: fifty-five patients received -week entecavir . mg/d therapy. serum hbv dna load was measured with quantitative real-time-pcr. alanine aminotransferase (alt) activity, hbeag, anti-hbe-antibodies, hbv dna level in serum were evaluated at baseline, week , , and during therapy. evaluation of safety and tolerance was based on clinical adverse events and laboratory analyses. results: hbv dna levels declined sharply by around log copies/ml during the first two weeks, with a highly significant reduction (p< . ) at week and thereafter, as compared to those at baseline; %, % and % of the patients had undetectable serum hbv dna levels at week , and respectively. highly significantly decreasing serum alt (p< . ) occurred during the first weeks of the study. at week , alt levels were normalized in % of the patients. hbeag seroconversion (hbeag negative, hbeab positive) was achieved in . % and . % of patients by and week. at the end of th and th weeks, complete response (alt normalization and hbv dna and hbeag loss) was observed in % and %, respectively. there was no evidence of drug resistance or adverse effect in chb patients treated for up to weeks. conclusion: entecavir treatment through weeks was well tolerated and resulted in continued benefit for patients with hbeag-positive chronic hepatitis b. aim: to assess the associations of single nucleotide polymorphisms of the mxa gene promoter and sustained treatment response of chronic hepatitis b or c patients with interferon treatment by meta-analysis of individual dataset from all studies published till date. methods: to clarify the impact of mxa gene promoter polymorphisms on sustained treatment response of chronic hepatitis b or c patients with interferon treatment, we performed a meta-analysis of the published data from eight studies comparing the frequencies of mxa gene promoter polymorphisms at nt - g/g, - g/t, - t/t and nt - c/c, - c/a , - a/a alleles in individuals with interferon treatment. as we identified the heterogeneity between studies, summary statistical data were calculated based on a random-effect model. results: the sustained treatment response rate was higher in patients with the nt - g/t and nt - c/aalleles in the mxa promoter snp . the meta-analyses yielded summary estimatesodds ratio (or) were . [ %ci ( . , . ), p < . ] and . [ %ci ( . , . ), p = . ] of the nt - g/t and nt - c/a alleles, respectively. conclusion: mxa gene promoter polymorphisms at nt - g/t and nt - c/a may be useful as a marker to predict the sustained treatment response of chronic hepatitis b or c patients with interferon treatment, and further investigation regarding their real significance is warranted in a large series of patients. background: to determine whether hbv with the same characteristics causes dissimilar mutations in different hosts. methods: full-length hbv genome was amplified and linked with pmd t vector. positive clones were selected by double-restriction endonuclease digestion (ecori and hindiii) and pcr. twenty seven clones were randomly selected from an asymptomatic mother [at two time points: ( d) and ( mo)] and her son [ (s)]. bioeditor, clustal x and mega software were used to perform phylogenetic and mutational analysis. potential immune epitopes were determined by the stabilized matrix method (smm), smm-align method and emini surface accessibility prediction. result: all of the sequences were genotype c, the inner-divergence for the mother and son was %- . %. specific nucleotides differed from the other pubished genotype c isolates were co-exist in the mother and her son. aa - deletion in pres was the dominant mutation in the mother ( / ). the t/ a double mutation existed in all clones of the mother, of them were also coupled with g a mutation, but none were found in the son. bp deletion starting at nucleotide was the major mutation ( / ) in the son, which caused seven potential hla class i epitopes and one b cell epitope deletion, and produced a presumptive new start codon, downstream from the original one of the p gene. conclusion: the son was infected hbv from his mother, and discrepant mutation occurred in the mother and her son during infection. background/aims: nucleos(t)ide analogues have been recognized as an effective treatment for chronic hepatitis b. this randomized, double-blind trial compared the efficacy and safety of telbivudine and lamivudine after -week therapy in patients with compensated chronic hepatitis b in taiwan. methods: we analyzed taiwanese patients from globe trial receiving telbivudine mg (n= ) or lamivudine mg (n= ) once daily for weeks. the primary efficacy endpoint was therapeutic response with serum hbv dna < log copies/ml and either hepatitis b e antigen (hbeag) loss or alanine aminotransferase (alt) normalization. results: the therapeutic response at week was . % in telbivudine group versus % in lamivudine group (p= . ). more patients with telbivudine achieved nondetectable serum hbv dna (< copies/ml) (p= . ) and alt normalization (p= . ) at the end of treatment. the cumulative resistant rate was significantly lower in those with telbivudine treatment (p= . ). the rate of hbeag seroconversion was comparable in both groups (p= . ). although a lower percentage of patients in lamivudine group ( . %) reported adverse events than those in telbivudine group ( . %), the difference was not significant. conclusions: telbivudine demonstrates a significantly greater efficacy and a lower resistant rate than lamivudine in treatment of chronic hepatitis b in taiwan. background: tumor necrosis factor-(tnf-) plays a pivotal role in the viral clearance and host immune response to hbv, and the capacity for tnf-production in individuals is influenced by a major genetic component. the studies of tnf-- gene promoter polymorphism in chronic hbv infection have reported apparently conflicting results. objective: to derive a more precise estimation of the relationship between the polymorphism of tnf-- gene promoter and chronic hbv infection. method: meta-analysis was done of case-control studies in relation to tnf-- gene promoter, involving a total of chronic hbv infection cases and controls. the pooled odds ratios (ors) for the risk associated with the genotypes of ga, aa, and ga+aa (a-allele carriers) compared with the gg genotype were calculated. results: overall meta-analysis indicated that - a heterozygotes (ga) had % decreased risk of developing chb with a borderline significance (or = . ; % ci: . - . ; p = . ). for the - a allele homozygotes (aa) and carriers (ga+aa), the pooled ors both indicated a significantly decreased risk of chb (or = . ; % ci: . - . ; p = . ; and or = . ; % ci: . - . ; p = . , respectively) ( table ). in the subgroup analyses by ethnicity, significantly decreased risks were associated with - variant genotypes (ga and aa) in mongoloid populations in all genetic models. however, no significant associations were found in caucasoid. conclusion: the meta-analysis suggests that the tnf-- a allele is a low-penetrant protective factor for chronic hbv infection, especially in mongoloid. aim: to define the potential role of pd- /pd-lpathway in different hbv infection status; we examined the expression of pd- on cd + t cells in pbmc of patients with chb and aehb infection. methods: the pd- level on cd + t lymphocytes and the number of hbv specific cd + t lymphocytes in patients and healthy controls were analyzed by flow cytometry. pcr was used to measure the serum hbvdna levels. results: the level of pd- expression on cd + t cells in chb patients was higher than that in aehb patients and healthy individuals. compared to aehb patients, lower frequency of hbv-specific cd + t cells was detected in chb patients. there was an inverse correlation between the strength of hbv-specific cd + t-cell response and the level of pd- expression. besides, there was a significant positive correlation between hbv viral load and the percentage of pd- expression on cd + t cells in chb and aehb subjects. however, pd- expression was not associated with alt levels. conclusion: our results confirm previous reports that hbv specific cd + t-cell response in the peripheral blood is more intense in patients with aehb than in chb with persistent viral infection. moreover, there is a negative correlation between the level of pd- and the intensity of virus specific cd + t cell response. observed in . % of patients with a mean age of . ± . . the ethnic composition was . % chinese; . % malay; % indigenous sabahans; . % indigenous sarawakians; . % indians and . % others. chinese patients were on average, older (mean . ± . years), indians patients had higher mean alanine transaminase and indigenous sarawakian patients had the highest rate of cirrhosis (p< . ). during the study period, . % of patients were on treatment and they were significantly older than those who were not on treatment (mean age . ± . vs . ± . ). lamivudine was the first agent used in . % of cases. conclusions: in malaysia, chb remains a public health issue and significantly afflicts males in the productive age groups and of chinese ethnicity. the observed differences among ethnic groups could point to different disease severity which needs to be addressed in the local treatment guideline and policy. background/aims: liver stiffness measurement (lsm) has been validated for predicting fibrosis stage in patients with chronic hepatitis c. however, studies on lsm for chronic hepatitis b (chb) are few, and the relationship between histologic findings and liver stiffness needs to be further elucidated. this study was conducted to assess the association of histologic activity on liver stiffness in addition to fibrosis in patients with chb methods: thirty three patients who had taken liver biopsy and lsm at korea university ansan hospital between march and october were enrolled. necroinflammatory activity and fibrosis stage were assessed by metavir system. activity, fibrosis, and the sum of both score were included for the correlation analysis with lsm results: among patients, ( . %) were male, and median values were as follows: age, ( ~ ); ast, iu/l ( ~ ); alt, iu/l ( ~ ); total bilirubin, . mg/dl ( . ~ . ); lsm, . kpa ( . ~ . ). fibrosis stages were f in ( . %), f in ( . %), f in ( . %), and f in ( . %) patients. spearman correlation coefficient with lsm were . (p= . ) for activity, . (p< . ) for fibrosis stage, and . (p< . ) for the sum of activity and fibrosis. in linear regression analysis, only the sum of activity and fibrosis remained to be significant. conclusions: not only fibrosis but also activity was an important factor for determining lsm for chb. it would be more appropriate to consider both activity and fibrosis for interpretation of lsm in patients with chb background: hbeag seroconversion is a key goal of chb therapy. hbeag kinetics may predict hbeag seroconversion during treatment. we aim to develop a robust hbeag quantitative method as the value of hbeag quantitation is undefined and data is limited. methods: we evaluated two commercially available qualitative hbeag assays (abbott architect, siemens centaur) for their linear range and validated them against paul-ehrlich institute (pei) standards. hbeag levels were determined from samples of untreated and telbivudine-treated chb patients. results: as a pre-requisite for quantitative use, the linear range for the architect ( . - peiu/ml) and centaur ( . > peiu/ml) assays were defined. architect was selected for further investigation. hbeag levels of untreated patients (mean hbv-dna . log copies/ml, mean alt . iu/ml) varied from . to . peiu/ml (median . peiu/ml). in patients (mean hbv-dna . log copies/ml, alt iu/ml) treated with telbivudine for weeks, baseline hbeag levels varied from . to peiu/ml (median . peiu/ml). after weeks of telbivudine treatment, median hbeag level was . peiu/ml, with % decline from baseline (median decline . peiu/ml, range . - . peiu/ml). individual hbeag decline from baseline varied but occurred in all patients and was not correlated to baseline or decline from baseline hbvdna. conclusion: hbeag quantitation is feasible and robust with architect hbeag assay. hbeag decline occurred in all telbivudine-treated patients, and was not correlated to hbvdna. whether the magnitude of hbeag decline is predictive of future hbeag seroconversion merits further investigation. experience from the combined globe (nv- b- /cldt a ) and (nv- b- ) study clinical safety database. c. avila , r. laeufle , w.b. bao novartis pharma ag, fabrikstrasse , basel, switzerland, novartis pharma ag, basel, switzerland, novartis pharma, east hanover, us background: creatine phosphokinase (ck) is a commonly used marker of muscle damage and is elevated by many factors (e.g. exercise, injury, drugs). normal ck levels are affected by muscle mass and elevated levels are described during the natural course of chb. % of patients in the globe study had pretreatment grade - ck elevations. methods: we reviewed data from this combined study clinical safety database, and describe the experience of ck elevation and its relationship to adverse event reports of muscle related symptoms. results: the frequency of new onset of grade - ck elevations in telbivudine-treated patients (combined database itt population) was . % ( / ), . % ( / ), . % ( / ) and . % ( / ) from weeks - , - , - and - respectively. the frequency of grade - ck elevations for all patients from week - was . % ( / ). the majority of grade - ck elevations were asymptomatic, rarely resulted in discontinuation or interruption, spontaneously declined within or visits and were not associated with more frequent muscle-related adverse events. cumulative data from this combined database showed no relationship of the degree of increased ck to acute or persistent muscle disease. conclusion: ck elevations are associated with hbv disease and were also common during the globe and trials and were not predictive of the development of muscle related symptoms. onset of muscle-related symptoms should prompt clinical and treatment review, including concomitant medications. backgrounds: leptin plays a crucial role in the regulation of energy balance and body weight control by activating the long form of the leptin receptor (ob-rl). epidemiologic studies showed that obesity is one of the factors associated with hbv related hepatocellular carcinoma. methods: huh cells were transiently transfected with . copies of hbv-replicon plasmid. after h, cells were harvested and total rna of the cells were extracted and reverse-transcribed into cdna. long form and short form leptin receptor (ob-rl, ob-rs) mrna transcription levels were assayed by real-time pcr respectively. and mrna transcription levels and protein expression of ob-rl and ob-rs in hepg . . cells were also detected. results: after transfected by . copies hbv-replicon plasmid, the mrna transcription level of ob-rl was inhibited significantly (**p< . ), but the mrna transcription level of ob-rs did not change, and the ob-rl protein expression was reduced. in hepg . . cells, the mrna transcription level of ob-rl was also significantly lower than the mrna transcription level of ob-rl in hepg cells, while the mrna transcription of ob-rs in hepg . . and hepg cells didn't show significant difference. besides, the protein expression level of ob-rl in hepg . . was also lower than it in hepg cells. conclusion: hbv replication down-regulated the expression of long form leptin receptor in cell cultures, which could in part explain the clinical observation of obesity in association with development of serious sequelae in hbv infections. the results of entevavir treatment in patients with chronic hepatitis b s. kose , g. akkoclu , m. turkeri , a. gozaydin the ministery of health tepecik training and research hospital, izmir purpose: we evaluated the short and long term effectiveness of entecavir. patients and methods: those patients had received diagnosis of chronic hepatitis b. their pretreatment transaminases, hbsag, anti-hbs, hbeag, anti-hbe, hbv-dna were checked and a liver biopsy and a resistance test for lamivudine (lam) and adefovir (adv) were performed. a total of patients who were taking entecavir for at least weeks were included in the study. findings: the biochemical and virologic response were observed in . % at and months and in % at months. in hbeag positive patients who had received therapy previously, the biochemical response was observed in . % at and months and in % at months. the virologic response in . % at , in . % at , and % at months. posttreatment hbeag seroconversion did not develop. in hbeag negative patients the biochemical and the virologic responses were observed in . % at months and % and months, respectively. in hbeag negative patients had received therapy previously, the biochemical response was observed in . % at , in % at and months. the virologic response in . % at , in % at and at months. conclusion: in our study, a higher therapy-response rate was achieved, especially in hbeag negative patients. in hbeag positive patients biochemical and virologic response rates were high. background/summary: patients with liver disease are known to have a higher prevalence of glucose intolerance. preliminary studies suggest that viruses can be an additional risk factor for the development of diabetes mellitus. individuals with type ii diabetes have an increased prevalence of cirrhosis, and a proportion of patients with acute and chronic liver disease develop diabetes mellitus. there is now emerging epidemiological data to suggest that hepatitis c virus (hcv) infection may also contribute to the development of diabetes reported to be higher than expected compared with the general population. while these investigations suggest an epidemiological association between hcv infection and diabetes, large controlled studies are required to observe association between hbv infection and diabetes. the present study was designed to study the relative proportion of diabetes mellitus in patients suffering from hepatitis b virus (hbv) infection. background: in easl , we reported significant liver disease among hbeag negative patients with serum hbv-dna level < log copies/ml (i.e. . x log iu/ml) and alanine aminotransferase (alt) < iu/l. this reflects fluctuating nature of these levels. the aim of this retrospective study is to demonstrate the frequency of fluctuation among this group of chb patients. methods: clinical records of hbeag negative treatment naïve chb patients with at least one serum hbv-dna < log copies/ml were reviewed. results: there were ( . % male, median age . years) chb patients with negative hbeag and hbv-dna < log copies/ml (roche cobas amplicor pcr assay, lod< copies/ml). had serial hbv-dna measurements within years; of them ( . %) had increase serum hbv-dna level by > log copies/ml; patients had associated serum alt elevation from normal (normal range < iu/l), had persistent normal alt, and one had persistently raised alt. ( . %) had serum hbv-dna level decrease by > log copies/ml. another patients had hbv-dna levels fluctuating within log copies/ml. hbeag negative patients with single hbv-dna measurement showing < log copies/ml had serial serum alt measurements within years. ( . %) patients had intermittent / persistently raised alt; while ( . %) patients had persistently normal alt. conclusions: hbeag negative chb is common among chinese. serial serum hbv-dna and alt measurements are necessary to detect fluctuating levels and progressive liver disease that may require antiviral therapy. background: to determine the best vaccination strategy, a model that reflects the country-specific infection profile is needed. methods: a model was built in order to obtain the age-specific infection frequency q(t) for neonates(n), infants(i), children(c), and adults(a). the infected group can either become hbsag(+) or anti-hbs(+)* based on f(t). q(t) can be found from p(t) = [q(t) x ( -f(t)) x crs + q(t) x f(t) x ( -cras)], where p(t) represents the proportion of the late anti-hbs(+)** group and crs/cras denote natural conversion of hbsag/anti-hbs. to test the model, cross-sectional serologic marker data in korea were used. because f(t), crs, and cras were known(f(n)= . , f(i)= . , f(c)= . , f(a)= . , crs= . , cras= . ), in order to determine q(t), only p(t) values were needed, which were evaluated from logistic modeling using the glm() function of s-plus. results: the infection frequencies during neonate, infant, children, and adult periods in non-vaccinees were . %, . %, . %, and . %, respectively. each group's likelihood of infection compared to adults was then: neonates . times more likely, infants . times, and children . times, making a strong case for neonatal and infantile vaccination for the studied region. conclusions: the hbv infection model can be used for determining the most cost-effective strategy for hb vaccination in nations where longitudinal data are not available. and where longitudinal data are available, it can be used to determine the appropriate time of transition of vaccination strategy to maintain cost-effectiveness. the effect of telbivudine on peripheral blood regulatory t cells and its significance in patients with chronic hepatitis b x.c. pan , f. yang , m. chen objective: to investigate the effect of telbivudine on peripheral blood regulatory t cells and its significance in patients with chronic hepatitis b. methods: patients with hbeag positive chronic hepatitis b were recruited and receiving telbivudine treatment for months. before and during months of treatment , flow cytometry was used to detect the proportion of peripheral blood tregs; real-time pcr was used to detect the levels of hbv dna in surum, markers of hepatitis b virus infection were detected by elisa assay and levels of alanine aminotransferase in serum were measured. results: the proportion of peripheral blood tregs in patients with chb was significantly higher than that in healthy controls and decreased over or months of treatment to a level comparable to that of healthy controls. after months of treatment, the rate of alt normalization in patients which the proportion of peripheral blood tregs was unreduced was significantly lower than that in patients which the proportion of peripheral blood tregs was reduced (p< . ). , or months of telbivudine treatment resulted in negative hbeag in ( %) patients, ( %) patients or ( %) patients respectively. within months of treatment, ( %) patients seroconverted from hbeag to anti-hbe , in which the proportion of peripheral blood tregs had decreased to a level comparable to that of healthy controls over or months of treatment. conclusion: during antiviral treatment with subsequent reduction of the viral load or alt levels, the proportion of tregs decreased to a level similar to that of normal healthy controls. in addition, seroconversion from hbeag to anti-hbe was prone to be established in patients which the proportion of tregs decreased quickly at the early phase of antiviral treatment with telbivudine. background: in china a part of patients with alt < . ×uln and hbv dna > copies/ml will advance into hepatic cirrhosis even hepatoma. so these patients should not only be monitored but also be treated. this study was made to determine the safety and efficacy of combining therapy of pegylated interferon alpha a (peg-ifn - a) and entecavir in treating naive patients with alt < . ×uln and hbv dna> copies/ml. methods: nine patients with hbsag positive over months and alt< . ×uln hbv dna > copies/ml were taken as research subjects. before treatment,liver biopsy was used to assess histological damage. patients were treated with peg-ifn - a g /week for weeks, and in the first weeks entecavir . mg/day was applied, then it was stopped. results: liver biopsy showed that patients had mild inflammation. after weeks' treatment , hbv dna level in all patients decreased to less than copies/ml, and after weeks' treatment( weeks after entecavir was stopped)hbv dna in all patients was less than copies/ml. normal alt was seen in all patients after weeks' treatment and weeks' treatment. none of the patients had peripheral neuropathy with combining treatment. conclusions: . bulk of patients with alt < . ×uln and hbv dna> copies/ml had mild inflammation and need treatment. combing treatment of peg-ifn and entecavir was safe and effective to this group. it proved that it was safe for patients to stop treatment with entecavir after short time use. background & aims: quantification of serum hbv dna levels is important to monitor viral replication in chronic hepatitis b (chb) patients. both abbott realtime hbv and roche cobas amplicor hbv monitor are updated fully automatic commercial assays for hbv dna quantification. the aim of this study is to compare the performance of these two assays on the hbv dna quantification in chb patients. methods: serial serum samples from chb patients were collected at the baseline and at days , , and and weeks , , and after the commencement of therapy. genotype was determined by sequence alignment. abbott and roche assays were employed for hbv dna extraction and quantification according to the instructions of manufactories. results: hbv dna quantification results of abbott assay was significantly correlated with those of roche assay (r= . , p< . ). for genotype c, the difference in hbv dna levels [median (range): . (- . - . ) log units] measured by these two assays was significantly higher than that for genotype b [ . (- . - . ) log units, p< . ]. moreover, the difference in serum hbv dna levels after weeks antiviral treatment [ . (- . - . ) log units] measured by these two assays was significantly higher than that in baseline serum hbv dna levels [ . (- . - . ) log units, p< . ]. conclusion: the quantification results of abbott realtime hbv showed a good correlation with those of roche cobas amplicor hbv. but the performances of these two assays have significant difference in the quantifications of serum hbv dna levels in genotype c patients and in patients after weeks antiviral therapy. background: guidelines suggest hepatitis b virus (hbv) vaccination to all hepatitis c virus (hcv) infected patients and healthcare workers. we attempted to find out hbv vaccination status in our hcv infected population, and healthcare workers. methods: prospective survey of consecutive hcv infected patients and also doctors and paramedical staff in our hospital. results: major sources of viral infection in study patients ( males; average age years -range to yrs) were reused syringes ( pts). twenty had a household member infected with hcv. twenty were co-infected with hbv. eighty five of hcv infected patients were not vaccinated.against hbv. twenty five of them ( %) had financial reasons and patietns ( %) had lack of awareness. out of doctors, and did not know about their hbv and hcv status respectively, but none was known to have either of these infections. four ( %) were not vaccinated against hbv. out of paramedical staff, was hcv positive, each were unaware of their hbv and hcv status, and remaining were negative for these markers. thirteen of them ( %) were not vaccinated against hbv. conclusion: thirty eight percent hcv infected patients were infected by reuse of syringes. eighty five percent were not vaccinated against hbv, out of which % had no awareness about it, whereas % could not financially afford it. a significant number of paramedical staff and some doctors were also not vaccinated background: early prediction of efficacy could decrease unnecessary interferon exposure of patients with chronic hepatitis b. methods: a multi-center clinical study. patients were injected interferon alpha b million iu subcutaneously every other day for weeks and -week follow-up was followed. results: patients ( male) were enrolled, . ± . years old. hours after administration, hepatitis b virus (hbv) load decreased significantly ( . ± . log copies/ml, p< . ) from baseline ( . ± . log copies/ml). hbv load was . ± . and . ± . log copies/ml at week and , respectively. at the two points upwards, complete response rate was . %( / ) and . %( / ), partial response rate was . %( / ) and . %( / ), respectively. at week and , hbv dna levels of complete responder and partial responder were lower than those of non-responder (p< . ) at week . at baseline, on hour , day , , week , and , hbv dna levels of complete responder were lower than those of non-responder at week (p< . ). multiple linear regression showed that baseline hbv dna was the independent variables to predict the response at week and . conclusions: interferon alpha b was effective in treating patients with hbeag positive chronic hepatitis b. it could decrease the hbv dna level rapidly. early hbv dna levels were predictive to response at the end of treatment and follow-up. baseline hbv dna level was the independent predictor of the response at the end of treatment and follow-up. aim: to investigate features of pd- expression on peripheral tcells and pd-l expression in liver in chronic hepatitis b (chb) patients in immune clearance phase. methods: pd- expression on total peripheral t cells were evaluated by using flow cytometry. immunostaining was performed according to the envision chemmate methods. the degree of pd-l expression was scored and assessed according to the percentage and staining intensity of positive cells. results: compared to health control, the percentage of total peripheral t cells expressed pd- was elevated in chb with repeatedly increasing alt level. no specific association between the percentage of pd- positive and the mean fluorescence intensity mfi of pd- expression on total t cells with serum viral load were found. but alt level was correlated with the mfi of pd- expression on total cd +t cells significantly. pd-l is up-regulated on hepatocytes by viral infection, and high expressed in fibrosis section. conclusion: the mfi of pd- on cd +t cells plays important role in regulating the immune-host interaction in chb in immune clearance phase. and pd- expression on t cells is correlated with high immune inflammatory refection. aim: to study the quantity, characteristic of hbv-specific t-cell and the extent of liver damage in chronic hepatitis b (chb) patients with different hbeag status. methods: chb patients were enrolled and divided into two groups according to the hbeag status, and the liver damage index were analyzed. the frequency and foxp expression of cd + cd + regulatory t cells (treg) were measured, as well as the frequency and phenotypic molecules expression of hbv-pentamer+ t-cell. hbv specific t-cell responses including cellular proliferation and ifn-production, with or without anti-pd-l and/or anti-ctla- blocking, were also observed. results: the demographic characters, serum alt, ast levels, the frequency and foxp expression of cd + cd + treg were similar, while the serum hbv dna levels were higher in hbeag+ patients (p < . ). the liver necroinflammation was comparatively more severe in hbeag-patients (p = . ), but the median percentage of liver cirrhosis was much higher in hbeag+ patients (p < . ). the difference of hbv-specific t-cell frequency was not significant between two groups, while the expression levels of pd- and ctla- on hbv-specific cd t cells were significantly higher in hbeag+ patients (p both < . ). combined using of anti-pd-l and anti-ctla- mab significantly increased the cellular proliferation in either hbeag+ or hbeag-patients, but only markedly enhanced the ifnproduction in hbeag+ patients. conclusion: hbeag persistency could probably induce higher expression of pd- and ctla- on the hbv-specific t cells and result in t-cell impairment, high hbv dna load and high percentage of liver cirrhosis in hbeag+ chb patients. hepatocyte apoptosis in patients with chronic hepatitis b y. liu , k. wang background: to investigate the relationship between hepatocyte apoptosis and the level of inducible nitric oxide synthase (inos) in hepatic tissue in the patients with chronic hepatitis b chb . methods: we observed cases with chb and normal controls. transferase-mediated-utp-biotin nick-end labling ( tunel) technique was used to detect apoptosis cells and immunohistochemical staining were also performed to investigate the expression of inducible nitric oxide synthase (inos) in biopsy samples .the serum level of alt hbv-dna grading of necroinflammatory activity and staging of fibrosis were also assessed. results: hepatocytes in all chb liver tissues were positively stained by tunel in various degree. in contrast, control tissues did not show dna fragmentation. a significant correlation was seen between apoptosis index (ai) and necroinflammatory grading ((r= . , p= . ) and serum inos level r= . , p= . . it did not correlate with fibrosis stage and serum alanine aminotransferase level. conclusion: the oxidative stress.in patients with chb may reflected the apoptosis of hepatocyte. apoptosis involves in liver injury of chb,but with no significant correlation to serum level of alt. objectives: to investigate the genotype-dependent development of lamivudine resistance in hepatitis b virus (hbv). methods: patients with chronic hepatitis b who had been treated with lamviudine for more than year, and become lamviudine resistance were analysed for the hbv genotypes and cumulative rate of rt region mutant with standard dna sequencing technology. results: among the patients, patients were infected with hbv genotype b (hbv/b)( . %), and with genotype c (hbv/c)( . %). in the hbv/b patients, / ( . %) were of subtype ba, and / ( . %) were of of subtype bj. the cumulative type and ymdd mutation rates in patients with genotype c were showed as l m+m v ( / , . %) > l m+m i ( / , . %) > m i ( / , . %), while in patients with genotype b as l m+m v / ( . %) > m i( / , . %), none of l m+m i. conclusions: our results indicated that in patients with lamivudine resistance, hbv genotype c (hbv/c) were higher than genotype b (hbv/b). in both genotypes the combined mutations ( + sites) were found more than the single site, showed some significance for monitoring lamivudine resistance. background & aims: il- , a novel identified inhibitory cytokine specifically produced by regulatory t cells (tregs), is an ebi -il- heterodimer encoded by epstein-barr-virus-induced gene (ebi ) and interleukin- alpha (il ). the aim of the study is to determine the expression levels of il- in peripheral blood mononuclear cells (pbmcs) of chronic hepatitis b (chb) patients in different phases. methods: a total of treatment naïve chb patients, including in immune-tolerant phase [group , alt: ( - ) u/l, serum hbv dna: . x ( . x - . x ) copies/ml] and in immune-clearance phase [group , alt: ( - ) u/l, serum hbv dna: . x ( . x - . x ) copies/ml] were enrolled in the study. the relative mrna expression levels of ebi , il and foxp were determined by semi-quantitative pcr. results: the significant correlations were observed between the expression of ebi and il (r= . , p< . ), ebi and foxp (r= . , p< . ), il and foxp (r= . , p< . ). the relative expression levels of ebi and il in pbmcs were significantly higher in group when compared with those in group ( . ± . vs . ± . and . ± . vs . ± . , p< . , respectively). furthermore, the relative expression levels of ebi and il in group were significantly correlated with alt levels (r= . , r= . , p< . , respectively), but not with serum hbv dna levels. conclusions: the expression levels of il- in pbmcs were significantly higher in chb patients in immune-clearance phase than that in immune-tolerant phase. increased il- expression levels were associated with liver injury. background: there are a number of oral antivirals approved for chronic hepatitis b. lamivudine, the first oral nucleoside analog, is associated with increased rates of drug resistance with prolonged use--from % at one year to % at three years. therefore, an alternative or add-on treatment is necessary. adefovir, an oral nucleotide analog, is used either in combination with lamuvudine or as monotherapy in lamivudine-resistant chronic hepatitis b. we did a meta-analysis to compare the efficacy of adefovir in combination with lamivudine versus adefovir alone in the treatment of lamivudine-resistant chronic hepatitis b infection. methods: a comprehensive literature search was performed using the following databases: medline, cochrane, and embase. a total of randomized controlled trials were retrieved and analyzed. outcomes measured were virologic response, biochemical response and resistance rates. results: meta-analysis on virologic response showed that combination treatment with adefovir and lamivudine is as effective as adefovir monotherapy (or . , % ci . - . , p= . ). likewise, in terms of biochemical response, both regimens were equally effective (or . , % ci . - . , p= . ). one study showed statistically significant increase in adefovir resistance rate in the monotherapy arm compared to combination arm (p= . ) after the first year of therapy. conclusion: in patients with lamivudine-resistant chronic hepatitis b infection and compensated liver disease, adding adefovir to lamivudine is as effective as switching to adefovir alone in terms of virologic and biochemical response. r. safadi , q. xie , y.g. chen , y.k. yin , l. wei , s.g. hwang south korea, bnai zion medical center, haifa, israel, beijing friendship hospital, beijing, china, novartis pharma ag, basel , switzerland background: ldt produces greater viral suppression than lam. we investigated whether patients receiving lam can benefit from switching to ldt. methods: hbeag positive and negative persistently viraemic patients (median hbv dna . (ldt), . (lam) log copies/ml) and lam treated for - months, were randomized to either switch to ldt or continue lam. we report the benefit of ldt switch assessed by primary treatment failure (tf, < log hbv dna decline) and viral breakthrough (vb, > log above nadir). results: % ( / ) of the ldt switch and % ( / ) continuing lam patients had pre-existing m mutations at screening. tf was % (ldt) versus % (lam, p< . ). in patients with > weeks prior lam treatment, tf was % (ldt) versus % (lam). % ldt tf ( / ) was associated with resistance at screening versus % lam tf. in ldt switch with < weeks prior lam, no ldt tf occurred versus % lam. in hbeag positive, tf occurred in % (ldt) versus % (lam). among hbeag positive with > weeks prior lam treatemtn, vb was % (ldt) versus % (lam, p< . ). differences were not significant for hbeag positive with > weeks lam or for hbeag negative regardless of duration of prior lam treatment. conclusions: early switch to ldt is associated with better virological outcomes in these patients. persistent viraemia for > months on lam treatment is associated with a high risk of tf and vb. for these patients, genotypic analysis is recommended prior to screening. objective: the aim of this study is to evaluate the proper endpoint in the treatment of chronic hepatitis b with antivirals by investigating the viral rebound ratio after one year's nucleosides or (three months) sustained treatment with lamivudine, adefovir, entecavir, or interferon when viral response and seroconversion response have been finished . methods: eag positive chronic hepatitis b naïve patients with alanine aminotransferase (alt) more than uln were assigned to receive mg of lamivudine, mg of adeforvir, or . mg of entecavir once daily, respectively. patients in the interferon group were administrated with , , iu of a interferon on every other day, and the therapeutic duration lasted for another three months after eag-ab seroconversion appeared. hbv dna and eag-ab in the serum were tested during the off-treatment period of months. results: thirty four patients in lamivudine group of cases got eag-ab seroconversion after treatment with ± months of average duration, and the viral rebound ratios in the off -treatment an months follow up period were . / and . / , respectively. in adeforvir group were / and . / . in enticavir group were / and . / . in interferon group was . / in the off-treatment months follow up period. conclusions: we conclude that eag-ab seroconversion in the treatment of eag positive chronic hepatitis b patients is the goal but not an endpoint of therapy physicians should aim at. to gain everlasting effect, longer duration of treatment may be needed. background: universal hepatitis b(hb) vaccination of hbsag negative people (especially infants) is widely recommended and practised. objective: to assess whether there is robust evidence of protective efficacy to back such practice. methods: this cochrane review included randomised trials identified from six databases through detailed electronic searches. trials comparing hb vaccine versus placebo/another vaccine, in hbsag negative persons were included without any restrictions. the primary outcome was hb infection (developing hbsag or anti-hbc). robustness of evidence was assessed through comparison of available-case analysis versus intention-to-treat(itt) analysis using four different models: (i)assuming unfavourable event for all missing data, (ii)assuming favourable outcome for all missing data, (iii)best-case-scenario and (iv)worst-case-scenario results: twelve trials were eligible among citations; all were methodologically poor (high risk of bias). data from four trials could be included in meta-analysis. efficacy of vaccination varied with the type of data analysis. available-case analysis suggested efficacy in reducing risk of developing hbsag (rr= . ; %ci= . - . ;n= ) and anti-hbc (rr= . ; %ci= . - . ;n= ). itt analysis results varied depending on the model chosen (table) , but liberal approaches suggested high efficacy, whereas conservative approaches did not. the available evidence on efficacy of hb vaccination in hbsag negative people is not robust; there are serious limitations in quality and quantity. background: open-label rollover study (etv- ) assessed histologic improvement in chb patients on at least years etv therapy. methods: % nucleoside-naïve patients and % lamivudine (lvd)-refractory patients from etv- and etv- studies, respectively, entered etv- study and received etv at . / mg for greater than weeks. improvement in knodell necroinflammatory (ni) score and knodell fibrosis score at weeks and were studied. results: at week , % of nucleoside-na ve patients and % of lvd-refractory patients achieved hbv dna < copies/ml. furthermore, % of nucleoside-na ve patients and % of lvd-refractory patients had normalized alt levels. mean platelet counts in both naïve and lvd-refractory patients were improved at weeks and compared with baseline. conclusions: naïve and lvd-refractory chb patients showed significant improvement in liver histology after year etv therapy, and improved dna and serum alt levels. results: . percent of patients were younger than years old, . percent were older than in this study. . % patients' mothers were hbsag positive. high levels of serum hbv dna were founded in all patients, > copies/ml were . %. only cases ( . %) whose liver inflammation grade were g , the rest patients were mild inflammation, in which g were cases ( . %), g were ( . %); there were patients ( . %) had no signifecant liver fibrosis, the rest cases ( . %) had different fibrosis, among those s were cases ( . % , s were . % , s were . % , none of patients had cirrhosis. the fibrosis stages of higher alt level were markedly severer than lower alt in patients with normal alt p < . . conclusions: most of patients with chronic hepatitis b virus in immune tolerant phase present mild inflammation in liver, part of them have already appeared fibrosis, so some patients determinated by clinics are actually not in immune tolerant phase. although alt testing are in the normal range, but the possibility of liver fibrosis is increased in patients with relative higher alt level, so liver pathology should be recommended to judge illness correctly. background/aims: hepatitis b virus infection (hbv) is a global health problem. in bangladesh, - % of people are hbsag positive. this study was carried out to evaluate the efficacy and safety of peginterferon alfa- a in chronic hepatitis b patients. methods: a total of patients with chronic hepatitis b, ( . %) were hbeag positive (group a) while ( . %) were hbeag negative (group b) were included in this study after meeting the following criteria: age to years, hbsag positive for more than months, serum hbv-dna was > log( ) copies/ml and alt more than two times the upper normal limit. they were given peginterferon alfa- a ( microgram once weekly) for weeks and followed for an additional weeks. results: after weeks of follow-up, the percentage of patients with normalization of alanine aminotransferase levels or hbvdna levels below , copies per milliliter was significantly higher in hbeag positive patients ( percent and percent, respectively) than among hbeag negative patients ( percent and percent). loss of hepatitis b surface antigen occurred in patients in group a, as compared with patients in the group b (p< . ). adverse events including pyrexia, fatigue, myalgia, headache and haematologic abnormalities were similar in both groups. conclusions: patients with hbeag positive chronic hepatitis b had significantly higher rates of response, sustained for weeks after the cessation of therapy, with peginterferon alfa- a. background: the effect of hepatitis b vaccination on individuals with isolated anti-hbc in endemic areas is not clear. we investigated the prevalence of individuals positive for anti-hbc only and their antibody response after hepatitis b vaccination in a single healthcare center. methods: the study included , healthcare workers. after screening for hbsag and anti-hbs, the individuals negative for both hbsag and anti-hbs were examined for anti-hbc and were vaccinated with a recombinant hepatitis b vaccine at , , and months. the serum anti-hbs level was measured after the vaccination. results: of the subjects, ( females) were negative for both hbsag and anti-hbs. forty ( . %) subjects had isolated anti-hbc, including more males ( . % vs. . %) and older people ( . ± . vs. . ± . years), compared with individuals negative for all of the viral markers. the anti-hbs seroconversion rate and anamnestic response in the individuals with isolated anti-hbc after the first vaccine injection were % and . %, respectively. in the persons who were negative for all hepatitis b viral markers, the seroconversion rate after the first vaccination was . %. the anti-hbs seroconversion rate did not differ between the isolated anti-hbc positive individuals and those negative for all hepatitis b markers ( . % vs. . %) after the full course of vaccination. conclusions: serum hbsag and anti-hbs tests are sufficient for screening before hepatitis b vaccination, especially in healthcare workers. objective: to understand the quantity and distribution of cd + mature dendritic cells in patients with hepatitis b virus in immune tolerant phase. methods: there were immune tolerant phase patients with hepatitis b virus infection (fibrosis stages were s ), immune clerance phase patients, non-active status patients and healthy controls involved in our research. the quantity and distribution of cd + mature dendritic cells in liver were determined by immunohistochemical staining. result: the liver inflammation grades were between g -g in patients who in inmmune tolerant phase and non-active status, moreover, patients in immune clerance phase were between g -g . there were a small amount of cd + dendritic cells in healthy liver tissue, scattered in portal areas and hepatic lobules. the quantity and distribution of cd + dendritic cells in patients who in inmmune tolerant phase and non-active status were similar to the healthy, and the quantity were no difference among them p . .the number of cd + cells in patients of immune clerance phase was significant increased compared with other groups, there were differences among them p . , the cd + cells mainly distributed in portal areas infiltrated with inflammatory cells and hepatic lobules with inflammatory necrosis. conclusion: cd + mature dendritic cells are involved in liver immune response in patients of inmmune clerance phase, is likely to related to hepatitis b virus clearance. lack sufficient mature dendritic cells may be one of the mechanisms of immune tolerance. background: local hospitals provide obstetric services including antenatal care to women normally living in the mainland china, whose prevalence of hepatitis b carrier is unknown. objectives: compare prevalence of hbv carrier of pregnant women from the mainland china with local counterparts and discuss the implications of results. materials and methods: antenatal serological results were retrieved from corporate laboratory information system databases. pregnant women from the mainland china were identified by a specific set of temporary-allocated identity number during january -october . results: pregnant local residents and pregnant women from the mainland china underwent antenatal serological tests for hepatitis b surface antigen. positive hepatitis b surface antigen results were more frequent in pregnant women from the mainland china ( . %) than in local pregnant women ( . %) (p< . ). discussion: because infected pregnant women can transmit the hepatitis b virus to the infant at delivery, specific management could entail maternal medication, injection of hepatitis b immune globulin to the infant at birth and immunization later on. however, early repatriation to the mainland china, which is common, will make completion of immunization program difficult. these babies will be at a higher risk to be infected by hbv, particularly when breast-fed by hbv carriers. their return to hong kong later will dilute the effects of local immunization program. the volume of work derived from the provision of obstetric services to women from the mainland chinese is larger with regard to medication, counseling and immunization for babies born to hbv carriers. immunosuppressive or anticancer therapy k. hirano , t. kodani , s. sato , y. narita , t. kikuchi , t. genda , k. iijima , k. ogawa , t. ichida background/aim: we compared the prevention of hbv reactivation in (hbsag)-positive patients with hbsag-negative patients who were positive for antibody to (anti-hbc) and/or (anti-hbs) undergoing immunosuppressive, anticancer or molecular target therapy. methods: from sep to nov hbsag-positive patients and anti-hbc and/or anti-hbs-positive patients were enrolled in this study. we compared with groups about background disease, age, blood examination, and nucleoside analogues. results: in hbsag-positive patients mean age were . ± . years old, median ast levels were ( - ) iu/l, and median alt levels were ( - ) iu/l for ( %) haematological disease and ( %) collagenosis disease. in anti-hbc and/or anti-hbs-positive patients mean age were . ± . years old, median ast levels were ( - ) iu/l, median alt levels were . ( - ) iu/l for ( %) haematological disease and ( %) collagenosis disease. serum hbv-dna levels > . log copies/ml were ( %), . ~ . were ( %), < . were ( %) in hbsag-positive patients, and serum hbv-dna levels < . were all cases in anti-hbc and/or anti-hbs-positive patients. ( %) of hbsag-positive patints received nucleoside analogues ( lam and etv), and ( %) of anti-hbc and/or anti-hbs-positive patients received nucleoside analogues ( lam and etv). mean duration of treatment for . months in hbsag-positive patients, and for . months in anti-hbc and/or anti-hbs-positive patients, the resistance virus occurred to ( %) of hbsag-positive patients treated with lam for collagenosis disease more than two years. conclusion: when hb carriers of collagenaous disease undergoing immunosuppressive therapy required the nucleoside analogues more than two years, we recommended treatment to prevent hbv reactivation with etv. background: adefovir dipivoxil is used for the initial treatment of chronic hepatitis b or rescue treatment of lamivudine-resistant chronic hepatitis b, and exhibits excellent antiviral activity. however, the presence of resistance to adefovir dipivoxil was more frequently in lamivudine-resistant chronic hepatitis b patients than in lamivudine-naïve patients during adefovir dipivoxil monotherapy. but the rate of adefovir resistance related mutations is little known in lamivudine-resistant patients before adefovir dipivoxil treatment. the aim of this study was to investigate the rate of adefovir resistance-related mutations in polymerase gene of hepatitis b virus in lamivudine-resistant patients not treated with adefovir dipivoxil. methods: the existence of adefovir resistance-related mutations was examined in lamivudine-resistant chronic hepatitis b patients with breakthrough hepatitis and antiviral-naïve chronic hepatitis b patients. both polymerase chain reaction restriction fragment length polymorphism (pcr-rflp) and directly sequencing of pcr product were used to detect resistant viruses. results: rta t mutants were detected in only two sera of lamivudine-resistant patients, while none in the antiviral-naïve chronic hepatitis b patients. there was no rtn t detected in the two groups. conclusion: our results suggest that the rta mutant virus were present in a few lamivudine-resistant chronic hepatitis b patients before they have been treated with adefovir dipivoxil, but the rtn t mutant was not detected in any of the two groups. the rate of adefovir resistance-related mutations in polymerase gene of hepatitis b virus was low in such lamivudine-resistant patients before adefovir dipivoxil treatment. objective: in this study, we tried to detect and identify the special protein of hbv related chronic hepatitis, liver cirrhosis and hepatocellular carcinoma. to find new opinion on the developing of chronic liver disease. methods: the sera of health adult, hbv related chronic hepatitis, liver cirrhosis and hepatocellular carcinoma were respectively detected by surface enhanced laser desorption/ionization time-of-flight mass spectrometry (seldi-tof-ms). the arrays of every group were analysised by clustering analysis and to establish disease predictive model. then the sample was eluted with different ph tris, trypsinization on-chip, mass determination and peptide database comparison. results: according cm chip we find protein with obviously deviation (p< . ) among hbv related chronic hepatitis, liver cirrhosis and hepatocellular carcinoma. clustering analysis for the data from seldi-tof-ms confirmed differentially expressed proteins. then we developed disease predictive mathematic models ( decision tree model, dt model ) with average validity up to . . the da protein peak was identified to be chondroitin sulfate synthase (chss ), which is a potential molecule involved in the pathologic process and a potential serum marker for the hbv related hepatic diseases as well. conclusions: our results suggest that seldi-tof-ms is a usefull technique for differential expressed proteins screening and analysis in hbv related chronic liver disease. chss may be useful during the developing of hbv related chronic liver disease. backgound: clevudine is a new nucleoside analogue with potent antiviral activity in chronic hepatitis b patients. however, the efficacy and safety of clevudine in cirrhotic patients are not well recognized. this study was conducted to evaluate the early virologic and biochemical response rate as well as safety of clevudine in cirrhotic patients with chronic hbv infection. methods: patients with chronic hbv infection who visited korea university ansan hospital and guro hospital between may and may were included. patients had chronic hepatitis b (group a) and had liver cirrhosis (group b). early virologic response was defined as hbv dna less than iu/ml at week . early biochemical response was defined to be normalization of alt (< iu/l) at week . result: pretreatment hbv dna levels were higher in group a compared with group b ( . log iu/ml vs . log iu/ml, p= . ). pretreatment alt levels were not significantly different between the two groups ( iu/l vs iu/l, p= . ). the rate of early virologic response was significantly higher in group b compared with groups a ( . % vs %, p= . ). the rate of early biochemical response were not significantly different in both groups ( % vs . %, p= . ). conclusion: clevudine is considered to be safe and effective in cirrhotic patients with chronic hbv infection as well as chronic hepatitis b patients. long term safety and efficacy need to be evaluated in the future. objective: the aim of this study was to evaluate the role of nucleos(t)ide analogues against hbv reactivation in immunosuppression. methods: non-active hbsag carriers suffering from cancer, autoimmune diseases and needing the treatment of immunosuppressants or cytotoxic chemotherapy were enrolled in the study. the outpatients or in-patients from april to july were enrolled. the nucleos(t)ide analogues were used in cancer patients - weeks before chemotherapy, and the duration lasted - months according to patients' compliance after completion of chemotherapy. patients with other diseases used nucleos(t)ide analogues in - months before using glucocorticoids or other immunosuppressive agents, and continued to use for - months after accomplishing the course of immunosuppressant treatment. the characheristics and clinical manifestations about hbv reactivation were investigated. results: of the thirty two patients in prospective group, twenty two patients suffered from cancer, eight patients suffered from idiopathic thrombocytopenic purpura, two patients suffered from chronic nephritis. the amount of hbv dna was detected in the first, third, sixth and th month after the use of nucleos(t)ide analogues. after chemotherapy or immunosuppressant treatment, only . % ( / ) of them suffered from hbv reactivation, which presented with hbv dna positive and abnormal liver function. conclusion: non-active hbsag carriers would appear potential incidence of hbv reactivation during use of chemotherapy or immunosuppressant. nucleos(t)ide analogues could be used in early phase as prophylaxis for reactivation of hepatitis b in immunosuppression and to improve clinical prognosis. background: hbv therapies are evolving toward combination antivirals. this study evaluated the combination of clevudine (clv), a potent nucleoside analog, with tenofovir dipivoxil (tdf). methods: a phase i, single-arm, multi-dose study in healthy adult volunteers to evaluate pharmacokinetic and safety interactions between clv and tdf. subjects received days of clv mg followed by days of clv mg +tdf mg. pk profiles were obtained on days , and . clv auc and cmax were compared on days and . day tenofovir pk was compared to historical data. safety assessments were conducted throughout. results: subjects were enrolled ( m/ f); completed the study. the mean (range) age was y ( - ) and body mass index (kg/m ) was . ( . - . ). aes were reported by subjects, with aes reported during clv-only dosing and aes reported during clv+tdf dosing. aes included nausea ( ) and pharyngolaryngeal pain ( ). the majority of the aes were mild. there were no clinically significant changes in ecgs or laboratory parameters. comparisons of clv auc and cmax on day and revealed no significant impact of tdf upon the plasma clv exposure (d /d auc ratio= . , d /d cmax ratio= . ). there is no significant effect of clv on tenofovir when comparing auc and cmax of tdf to historical values. conclusion: safety and pharmacokinetic results demonstrate that clv and tdf may be safely co-administered, supporting the further study of this drug combination for the treatment of chronic hbv infection. s. kuznecovs , , i. kuznecovs , k. jegina , g. kuznecova background: dolichyl (dol), the main lipid intermediator of dolichyl phosphate cycle (dpc) has been reported to be elevated in urine of patients with multidrug resistance in cancer. drug resistance poses a major threat to nucleoside analogue-based therapies for chronic hbv infection. methods: with focus on a risk predictor for susceptibility to the development of hbv drug resistance the present study was carried out to estimate urinary levels of dol in chronic hbv infection. the samples obtained every week before and during the course of treatment from patients with hbv. the occurrence of exacerbations of chronic hbv were registered for years. dol in urine was assayed by hplc method. results: the normal amounts of dol in healthy persons urine (n= ) are , + , mkg/mmol creatine. during the period of observation ( %) of patients treated with nucleoside analogue-based therapies were diagnosed with exacerbations due to resistance of hepatitis b virus to antiviral drugs. from this group of hbv patients ( %) have had elevated urinal dol excreation ( , ± , g/ml vs . , ± , g/ml, p< . ) in more than months of observation. conclusion: there is a reason to suggest that elevated urinal dol detected in patients with exacerbations during hbv treatment may evidence of possible defect of host mechanism of drug resistance development to nucleoside analogue-based therapies. the interest drawn to the employment of dol as a predictor for exacerbation of chronic hbv is explained by the role of dpc in p-glycoprotein regulation in human hepatocytes. background: a significant proportion chb patients treated with adv have a suboptimal response, increasing the risk of disease progression and development of resistance. we report clinical results from patients who either failed or relapsed following adv therapy and were subsequently switched to etv. methods: study etv- was a randomized, open-label study comparing antiviral efficacy of etv ( . mg/day) vs adv ( mg/day) in nucleoside-naïve hbeag-positive patients. after up to weeks of treatment in etv- , patients treated with adv ( suboptimal responders) rolled over into study etv- ( . mg/day). hbv dna viral suppression and safety was evaluated during weeks of etv treatment. results: at entry to etv- , the median hbv dna was . log copies/ml. median exposure to etv ( . mg) in etv- was weeks and patients currently remain on study therapy. at week , the mean reduction in hbv dna was . log copies/ml and / ( %) reached hbv dna levels < copies/ml. nine patients have achieved week and all have achieved hbv dna < copies/ml and / ( %) had hbv dna levels < copies/ml. no patients experienced virologic breakthrough on etv. the safety profile of etv in adv-treated patients remained consistent with the previously reported experience. conclusions: the majority of patients who were suboptimal responders or virologic rebounders following adv treatment in study etv- , experienced rapid reductions in hbv dna levels when switched to etv. hbv dna levels continued to decline to undetectable levels with weeks of etv treatment. y. li , , t. han tianjin third central hospital, aim:to quantify hepatitis b virus (hbv) total dna and covalently closed circular dna (cccdna) in liver biopsies and sera which from chronic hepatitis b(chb) liver cirrhosis of hepatitis b(lc) and hepatitis b relevance hepatocellular carcinoma(hcc) patients, and analysis hbv replication under the circumstances of different diseases. methods:total hbv dna and cccdna in serum and liver biopsy samples were measured in chb lc and hcc patients by the real-time pcr assay. results: the levels of total hbv dna in serum,intrahepatic total hbv dna, intrahepatic cccdna, as well as the proportion of intrahepatic cccdna in total hbv dna decreased progressively in chb,lc and hcc ,moreover chb had significantly higher levels of total hbv dna in serum and liver biopsy samples than lc (log [total serum hbv dna] p = . ;log [total intrahepatic hbv dna] p = . ); chb and lc had significantly higher levels of intrahepatic cccdna and the proportion of intrahepatic cccdna in total hbv dna than hcc(p < . ); cccdna couldn't be detect in all patients'serum. in chb ,the levels of serum's total hbv dna,intrahepatic total hbv dna and cccdna in hbeag-positive group had significantly higher than the hbeag-negative group(p < . ) ,but in lc only intrahepatic total hbv dna had statistical difference between hbeag-positive and negative group (p= . ) , no statistical difference between hbeag-positive and negative group in hcc. conclusions: the replication activity of hepatitis b virus in chb,lc were higher than hcc, hbv reproduction reduced significantly in hcc. duplication of hbv in lc was lower than chb but had no statistical difference. the levels of hbv reproduce in hbeag-positive group was higher than hbeag-negative group of all three desease. background: clevudine is a pyrimidine analogue with potent and sustained antiviral activity against hbv in the week therapy. the present study assessed the efficacy and viral resistance of week clevudine therapy in patients with chronic hepatitis b. method: a total of patients ( hbeag positive and hbeag negative) who were received clevudine mg once daily for weeks were included in this analysis. serum hbv dna was quantified by real time pcr assay. result: at week , median reductions of serum hbv dna from baseline were . log iu/ml ( . log iu/ml for hbeag positive and . log iu/ml for hbeag negative) and . % of patients showed undetectable serum hbv dna (< iu/ml) ( . % for hbeag positive and . % for hbeag negative). the normalization of alt levels (< iu/l) was achieved in . % ( . % for hbeag positive and . % for hbeag negative). . % of hbeag positive patients showed hbeag loss or seroconversion. hbv dna negativity at week was associated with hbeag negativity (p = . ), hbv dna < , iu/ml at weeks and (p = . and . , respectively). two hbeag positive patients showed viral breakthrough with m i mutation during week. conclusion: clevudine therapy in patients with chronic hepatitis b showed potent virologic responses at week , especially in those with hbeag negativity and complete early virologic response (hbv dna < , iu/ml at weeks and ). but clevudine resistance can occur in hbeag positive patients. background: serum alanine aminotransferase (alt) activity, the variable most commonly measured to assess hepatic disease, fails to identify many patients with hepatic injury. current standards for "normal" alt level were defined by using populations that included persons with subclinical liver disease. there is no study regarding normal level of alt and its modulating factors in healthy thai people. objective: to definitions of normal ranges for serum alt level in thai people. design: prospective observational study setting: phramongkutklao hospital and army institute of pathology pramongkutklao medical center(a.i.p.), bangkok, thailand participants: persons who were first-time blood donors from august through december were negative for anti-hepatitis c virus(hcv), negative hbsag(hbv), and had no contraindications to donation. measurements: univariate and multivariate analyses examined associations between clinical and laboratory factors and alt levels. normal ranges for alt were computed from the population at lowest risk for liver disease. results: serum alt activity was independently related to body mass index, age, alcoholic consumption and to laboratory indicators of abnormal lipid or carbohydrate metabolism. normal ranges for serum alt level in thai people upper limits for men u/l and for women . u/l. conclusion: in men serum alt is strongly associated with body mass index, age, alcoholic consumption and to laboratory indicators of abnormal lipid or carbohydrate metabolism. the normal range of alt should be defined for male and female separately. background: the open-label rollover study etv- was conducted after etv phase ii clinical study etv- for nucleoside-na ve adult chb patients in japan. in this analysis, we report etv long-term efficacy and safety in patients who were switched from -week lvd treatment to etv therapy. methods: ninety-seven percent ( / ) of lvd-treated patients from etv- were rolled over into etv- treated with . mg of etv. thirty patients completed weeks of etv therapy and were evaluated for hbv dna level, alt normalization, hbeag seroconversion, resistance and safety. results: comparing to baseline before switching to etv, after week of etv treatment, the proportion of patients achieving undetectable hbv dna (< copies/ml) increased from % to %. increases were also observed for alt normalization ( % to %) and hbeag seroconversion ( % to %). three patients had detectable hbv dna at week after etv treatment and samples from two were tested for resistance. neither demonstrated substitutions associated with etv or lvd resistance. five patients had grade - laboratory abnormalities, including increased ast/alt and increased lipase levels. conclusions: switching patients from lvd therapy to etv resulted in increased proportions of patients achieving hbv dna suppression, alt normalization and hbeag seroconversion, with no evidence of etv resistance. etv was well tolerated during treatment. backgrounds/aims: hepatitis b virus (hbv) reactivation in patients undergoing chemotherapy hampers an adequate administration of cytotoxic agents and even causes an treatment failure. prophylaxis failure occasionally results from viral breakthrough or withdrawal flare. the aims of this study were to identify predictors of anti-viral prophylaxis failure and to determine the optimal strategy for anti-viral prophylaxis. methods: cancer patients with positive hbsag who underwent cytotoxic chemotherapy in a tertiary medical center from january to june were included. prophylactic lamivudine was started with initiation of chemotherapy, continued during the chemotherapy, and discontinued within months after the completion of chemotherapy. all patients were followed up even after withdrawal of lamivudine. results: patients were enrolled. twenty-nine patients ( . %) had hematologic malignancies and eighty-six ( . %) had solid tumors. median follow-up duration was . months and twenty-six patients ( . %) experienced the prophylaxis failure: viral breakthrough ( patients, . %), withdrawal flare ( patients, . %). ymdd mutation developed in four patients. withdrawal flare occurred at a median . months after discontinuation of lamivudine. using log-rank test and cox multi-variate analysis, our results showed that the type of underlying malignancies (hr . , % ci, . - . ; p= . ) and baseline hbv dna titer (hr . , % ci, . - . ; p= . ) were significant independent risk factors for antiviral prophylaxis failure. conclusion: cancer patients with high viral load of hbv and hematologic malignancies may need more prolonged and potent anti-viral prophylaxis to avoid interruption or delay of chemotherapy. back ground: the usefulness of hepatitis b virus (hbv) dna and hbv core-related antigen (hbcrag) was evaluated for timing hepatitis flare after viral breakthrough or withdrawal of antiviral treatment in chronic hepatitis b. method: a total of events of hbv reactivation due to withdrawal of lamivudine (lam) or emergence of mutants resistant to lam or adefovir dipivoxil (adv) virus were analyzed in patients with chronic hepatitis b ( men, median age years [range: - ]). they were followed monthly for serum alt, hbv dna and hbcrag before, during and after the treatment. result: high alt flare (alt > iu/ml) after viral breakthrough or withdrawal was related with baseline hbeag positivity (p= . ), hbcrag level at hbv dna elevation (p= . ) and duration from hbcrag elevation to salvage therapy (p= . ). in multivariate analysis, hbcrag > . log u/ml (or . , %c.i. . - . , p= . ) and salvage therapy after weeks from hbcrag elevation (or . , %c.i. . - . , p= . ) were selected as related factor with high alt flare. after appearance of resistant-virus or withdrawal of lam or adv therapy, hbv dna re-elevated without increase of hbcrag, then hbcrag elevated with hbv dna. re-elevations of alt occurred in of the ( %) events. in of the ( %) events, alt re-elevated within weeks from the start of hbcrag increase. conclusion: hbcrag was useful for timing the re-elevation of alt after hbv dna re-elevation induced by drug-resistant virus or withdrawal of lam or adv therapy. background and objectives: the aim of the study was to observe the efficacy of a patient's therapy for switching lamivudine + placebo to adefovir dipivoxil (adv), and modeling the viral dynamics. methods: the studied object was a chinese chb patient with lamivudine mutation. used the lvd + placebo for weeks' therapy. then switched adv for another weeks. after that stopping the treatment and following up for weeks. based on our modified basic virus infection model, we introduce a personalized model consisting of four variables: x, y, v, e , representing uninfected cells, infected cells, free virus, and ctl cells, respectively. results: selected the model parameters, the simulation data of hbv dnas of our model are good in agreement with the clinical ones. observe that after weeks' treatment cessation, the benefit (hbv dna < copies/ml) for suppressing hbv replication can still be kept. numerical simulation show that if the patient's immune functions can be kept after therapy stops, it needs years to replace all infected cells by normal ones. conclusion: for lvd mutation patients, lvd+ placebo to avd therapy scheme may help patients to suppressing hbv replication. further researches are promising. acknowledgments: this work is jointly supported by the nnsf of china background: g-a- pre-core mutants (p-c-mt) cause hbeag-negative chronic hepatitis (chb) in genotype d infected mediterranean adults. we studied their emergence during chronic hbv infection in children. methods: eighty consecutive hbsag carriers ( / males/females, age y, range . - y) with vertical ( %) or intra-familial ( %) transmissions were followed-up for . y (range - y). hbv genotype and hbeag status were determined at the admission, hbeag/anti-hbe every years thereafter. during the follow-up, hbv-dna was measured in sera ( - sera/patient) (cobas-amplicor, roche); p-c populations were characterized by direct sequencing (ds), by oligo-hybridization (oha) and allele-specific-pcr (as-pcr) with %, % and . % sensitivities, respectively. results: seven children were genotype a and d; ( . %) were hbeag-positive. fifty-five ( . %) underwent hbeag/anti-hbe seroconversion (median age y, range . - y). baseline hbv-dna (cp/ml) was lower in seroconverters ( . + . vs , + , , anova p= . ). ds/oha p-c-mt were . % at the admission and . % after follow-up; as-pcr p-c-mt . % and % respectively. after seroconversion ( . %) became inactive carriers, ( . %) lost hbsag ( genotype d/p-c-wt); p-c-mt had chb. hbv-dna (cp/ml) was lower in p-c-wt than in p-c-mt inactive carriers ( . + . vs . + . ; anova p= . ). conclusions: in genotype-d infected children p-c-mt is selected progressively after hbeag/anti-hbe seroconversion to become predominant in hbeag-negative chb. early and efficacious immune control of hbv replication avoids p-c-mt selection and leads to hbsag loss. , a, , d, k, u, m, n , k ,k and k . here k , k , and k are the rate of ctl production and dead, killing virus, respectively. results: the patients with hbv dna levels less than copies/ml were reported in . % ( / ). a patient whose hbv dna levels were higher than copies/ml can keep treatment benefits even stopping the therapy for over ten weeks. the simulation data of our model are in agreement with the patient's hbv dna data. our simulation also shows that it needs to spend about years for clearing all infected cells. conclusion: the simulation result implies that some chinese patients may need long term's therapy to clear all infected cells. patients' ctls assays are needed to confirm the effectiveness of the personalized modeling, and help doctors to decide whether stop the drug treatment even patients' hbv dnas are higher than undetectable levels. background/aim: recent reports have shown that programmed death (pd- ) expression is associated with t cell exhaustion and persistent viral infection. we studied longitudinally chronic hepatitis b(chb) patients undergoing treatment with nucleos(t)ide analogues or pegylated interferon-(peg-ifn-) in - weeks to determine the relationship between pd- expression levels on t cells and early reduction of viral load induced by treatment. methods: our investigations were focused on three points: baseline (time point , t ), treatment weeks - (time point , t ) and treatment weeks - (time point , t ). pd- expression on total cd and cd t cells in chb patients during antiviral therapy was detected by flow cytometry. serum hepatitis b virus (hbv)-dna load was measured by real time polymerase chain reaction. results: between t and t , pd- expression on total cd (p< . ) and cd t cells (p< . ) dropped concurrently with treatment-induced hbv-dna decline(p< . ). between t and t , however, only the hbv-dna levels reduced significantly (p< . ). conclusion: early suppression of hbv replication induced by antiviral treatment results in a significant decrease in pd- expression on total cd and cd t cells in chb patients. c. zhao , , w. zhang , , x.c. tian , c.y. fang , , h.j. lu , , p.y. yang , , y.m. wen , background/aims: hepatitis b virus (hbv) is still regarded as one of the major causes of chronic hepatitis, cirrhosis and hepatocellular carcinoma worldwide. the interactions between hepatitis b surface antigen (hbsag) and host cells still remain largely unknown and need to be explored in detail. methods: differential protein expression profiles of hepg -s-g ( stably expressing hbsag cell line) and hepg -neo-f ( control cell line) were compared using two dimensional gel based differential proteomic approach. cell proliferation assay and survival assay were used for further studies on the candidate protein. results: compared with the control down regulation of proteins and up regulation of proteins were found in hepg -s-g cell. all these regulated proteins were identified by ms/ms and could be fell into several categories including metabolism-associated, immune-response-related, protein modification, signal transduction and others. among them, a group of proteins in putative pathways associated with apoptosis were found out and discussed, including glucose-regulated protein kd (grp /bip), heterogeneous nuclear ribonucleoprotein (hnrnp), far upstream element-binding protein (fusebp), rho gdp dissociation inhibitor (gdi), cystatin b and some scaffold proteins. grp , an important chaperone protein involved in multiple functions in host cells, was consistently decreased in hepg -s-g and in huh cell transiently transfected with hbsag expression plasmid. decreased crp inducing by hbsag or blockage of rnai consistently led to the less resistance to staurosporine-induced cell death. conclusions: these results revealed a possible pathogenesis induced by hbsag via grp . background/aim: to evaluate the efficacy of adefovir dipivoxil alone and in combination with lamivudine in treating patients with lamivudine-refractory hbeag-positive chronic hepatitis b. methods: eighty-five hbeag-positive patients who had received lamivudine treatment for various periods and had a lamivudine-resistant liver function abnormality, documented ymdd mutations and persistent viremia were randomized to adefovir dipivoxil mg, lamivudine mg, or addition of adefovir dipivoxil to ongoing lamivudine daily. the primary efficacy measure was virological response. the secondary efficacy measure was serological response (hbeag loss rate and hbeag seroconversion rate) and alt normalization rate. results: after weeks of therapy, mean reduction of hbv-dna level, the percentage of patients with hbv-dna lower than log copies/ml and the percentage of patients with hbv-dna level decrease of more than log copies/ml in patients of adefovir dipivoxil/lamivudine and adefovir dipivoxil monotherapy groups were significantly higher than those in patients of lamivudine group ( . , . log copies/ml vs. . log copies/ml, . %, . % vs. . %, . %, . % vs. . %; p < . , respectively). at the end of weeks, mean reduction from baseline in serum hbv-dna level at was . , . , and . log copies/ml in the lamivudine, adefovir dipivoxil/lamivudine, and adefovir dipivoxil groups, respectively. alt normalization rates were significant hihger in adefovir dipivoxil/lamivudine and adefovir dipivoxil recipients than those in lamivudine recipients ( %, % vs. %, p < . , respectively). a similar pattern was observed in hbeag loss among three groups. conclusions: adefovir dipivoxil is an effective treatment option for patients with lamivudine-refractory hbeag-positive chronic hepatitis b. aim: to find the prevalence of hbv virologic flare as defined by hbv dna viral load of > , iu/ml in inactive chronic hepatitis b (hbv dna less than , iu/ml), hbeag-negative patients who have not received any treatment and to identify if there are any predictors that can predict virologic flare. methods: we retrospectively analyzed medical records of the patients who have attended hepatitis clinic, siriraj hospital from january , to february , . the patients were eligible if they were naïve to any treatment and hbv dna less than iu/ml at entry. co-infection with hiv and/or hepatitis c virus were excluded. hbv dna measurement determine by roche amplicor ® (detection limit of iu/ml). hbv virologic flare was defined as hbv dna more than iu/ml during follow up period. result: there were patients with mean follow up time was days with annual prevalence of hbv virologic flare of . , . , and . % for the first, second and third year of follow up, respectively. initial hbv dna level was the only predictor that can predict reactivation. no patients with hbv dna at entry below detection limit developed flare and the patients with hbv dna above iu/ml had times higher chance to develop flare during follow up. conclusion: hbv dna flare is not uncommon in inactive chronic hepatitis b patients. most of the virologic flares occur in the first year. the most important predictor or virologic flare is higher hbv dna at beginning. background: multi-drug resistant hbv developed with multiple antiviral agents. there existed difficulty in dealing with multi-drug resistant hbv. methods: retrospective analysis of consecutive patients who exhibited chronic hepatitis b associated with multiple drug-resistant mutations to lamivudine and adefovir during antiviral treatment. multiple drug-resistant mutations were detected in those patients by dna direct sequencing. result: before multiple drug-resistant hbv emerged, patients accept sequential antiviral therapy, patients accept na monotherapies. there were cases of rta t/v rtm v/i mutation, cases of m v/i +n t mutation, cases of a t/v+m v/i +n t mutation, case of l m+a t/v mutation. cases received rescue therapy of interfronand hbv dna level of cases decreased; other cases received combination treatment and hbv dna level of cases decreased. conclusion: the main reason of multiple drug-resistant mutations was sequential antiviral therapy. another reason may be pre-exist drug-resistant mutation before nucleoside or nucleotide analogue treatment. de novo combination of antiviral agents should be recommended. combination therapy directed against mutants resistant to each treatment may not be adequate in suppressing multi-drug resistant hbv. interfron may be one choice for hbv of multiple drug-resistant mutations. background: to furnish basis for an accurate evaluation of hbeag negative chronic hepatitis b (e chb), the present study studies the clinical features and hepatic pathology, and analyzes the relation between the data and the grade and stage of hepatic pathology in e chb. methods: a study is performed in chinese e chb patients ( men and women; mean age sd, . . years). the relationship between the clinical features and the grade and stage of hepatic pathology was analyzed by spearman's rank correlation test or kruskal-wallis test by applying stata . software. result: negative correlation is shown between the grade and leucocyte count methods: patients with hbeag-positive compensated chb with hbv dna > log copies/ml, serum alt x uln were divided two groups:one treated with telbivudine and the other treated with entecavir. results: baseline characteristics were well balanced between treatment groups. at wk of the treatment the hbv dna undetectable rates of hbeag-poitive patients in the telbivudine group and the entecavir were respectively . (p . ), the rates of hbeag negative were respectively, the rates of hbeag seroconversion were respectively; at wk of the treatment the hbv dna undetectable rates of hbeag-poitive patients in the telbivudine group and the entecavir were respectively (p . ), the total rates of hbeag negative were respectively, the total rates of hbeag seroconversion were . . respectively(p . ).no adverse reactions were found in both groups conclusion: there was no significant difference in hbv dna undetectable rates between two nucleotide analogs in short-term ( weeks).the telbivudine group has better effect in hbeag seroconversion rate than the entecavir group in early stage,but no statistical significance. j.w. song , , z. xin , j.x. tang , l. yao , b. wu sun yat-sen university, zhuhai sinochips biosci. co.,ltd., china background: to develop a equipment free, and can be widely used in clinical practice biosensor-based microarray for hepatitis b virus pre-c/bcp mutation assay. methods: a thin film optical biosensor were applied for amplification the microarray signal in situ. and hbv sites , , , and were selected as the targets and the microarray were be fabricated. the mutated plasmids contained , , , and sites and hbv sera were be tested in our study and all the plasmids and sera pcr products were be assayed by really time pcr and sequencing. results: the biosensor based microarray signal can be easily record by digital camera or even by the naked eyes and the detection signal for positive discriminated from negative were sharply contrasted as whole yes or no and it looks be significantly superior to classical microarray technique; . the sensitivity of the detection limitation of sera hbv load is x e copies/ml with % reproducibility. the concordance index of times negative and mutated plasmids were %(kappa= . ). . sera samples of hbv> e load and sera of hbv negative tested by pcr fragment sequencing were showing very good agreement between sequencing with our biosensor based microarray and the concordance index kappa was . . conclusion: our biosensor-based microarray for pre-c/bcp mutation assay were a both sensitive and accurate method. and its advantages of equipment free, sharply contracted signal of positive vs negative and easily be perform in testing were make it be a promised assay for clinical application. objective: to investigate the frequencies of cd + cd + regulatory t cells in the cord blood of fetuses whose mothers are patients with chronic hepatitis b, we assayed the differences among hbsag-positive and healthy subjects by flow cytometry. the results might offer some experimental evidence to explain the high rates of hbv persistent infection in vertical transmission of hbv from hbv-infected mothers. methods: newborns born from hbsag positive mothers were recruited , healthy subjects being used as a control group. the cord blood and peripheral blood of mothers were collected respectively .frequencies of cd + cd + regulatory t cells in the cord blood of fetuses whose mothers are patients with chronic hepatitis b were analyzed by flow cytometric analysis. result: the number of cd + cd + regulatory t cells/pbmcs in the cord blood of newborns born from hbsag positive mothers . ± . significantly exceeded that in normal controls . ± . ,p . ;and newborns born from hbsag positive mothers presented a much higher fraction of cord blood cd + cd + /cd + . ± . than those in normal controls . ± . ,p p= . p . . conclusions: the results indicate that the proportion of cd + cd + regulatory t cells in hbsag positive mother cord blood was higher than those of healthy cord blood. objective: to study the clinical features of chronic severe hepatitis b with negative hepatitis b e-antigen (hbeag) and positive hepatitis b e-antigen (hbeag) methods: a total of in-patients with chronic severe hepatitis b were recruited into the study and divided into two groups according to the hbeag status. the serological chemistry data, hepatitis b virus (hbv) dna quantification data were detected, and morbility of cirrhosis, its complications and prognosis were also studied. results: of the in-patients, ( . %) patients were hbeag-negative. ( . %) patients were hbeag-positive. the ratio of hbeag-positive patients was significantly higher than that of hbeag-positive patients (p< . ).the average age of hbeag-negative patients was older than that of hbeag-positive patients (p= . ). the serum hbv dna level of hbeag-negative patients was significantly lower than that of hbeag-positive patients ( . ± . ) vs( . ± . ) log copies/ml (p< . ).the ratio of patients who had a serum hbv dna level less than log copies/ml in hbeag-negative patients was significantly higher than that in hbeag-positive patients ( . % vs . % ,p= . ). there was no significant difference in serological chemistry data, morbility of cirrhosis and its complications on infections, ascites, hepatoencephalopathy, gastrointestinal hemorrhage, as well as prognosis of the patients between those two groups. conclusions: the study suggested that serological chemistry data, morbility of complications and prognosis of the disease of hbeag-negative patients mimics that of hbeag-positive patients. the hbeag-negative patients had a higher level of age, while a lower level of serum hbv dna. to reduce the incidence of liver failure, more frequent monitoring and earlier antiviral therapy prone to be reasonable for chronic hepatitis b patients with negative hepatitis b e-antigen. background: the emergence of lam-resistant virus greatly limits the efficacy of therapy and induces the liver injury. the aims of this study were to assess the related factors of lam-resistant mutation in hbeag positive chb patients. methods: thirty-five patients carrying lam-resistant with hbeag positive were enrolled in this study. all of them underwent percutaneous liver biopsy, histological findings and had detectable viral load. age, viral load, levels of alt, types of mutation and hbv genotype was monitored. result: the median year of mutation found was months. . % were genotype c and . % were genotype b. the mutation of l i, l v, g l, l m, m v and m i were detected. the emergence rates were . %( / ), . %( / ), . %( / ), %( / ), . %( / ), . %( / ) respectively. the rate of patients with two or three mutation were much more than one or four mutation. . % patients were found to have significant histological findings, even had established cirrhosis. two had no histological finding. one had rtl i and rtm i. the other had rtl v, rtl m and rtm v. the number of resistant mutation has no significant finding with histological finding, basic alt level and basic viral load. conclusions: the emergence rate of l m, m v and m i were higher than that of l i, l v, g l in hbeag positive chb patients with lam-resistance. most of them have two or three lam-resistant mutation regardless of histological finding severity, level of basic alt and viral load. we must select the efficacious method to treat the patients with lam-resistant. objective: to investigate the therapeutic efficacy of foscarnet sodium in the treatment of patients with severe chronic hepatitis b. methods: forty four patients were randomly divided into foscarnet sodium treatment and placebo groups.each group consisted of patients, patients in foscarnet sodium group were treated with foscarnet sodium twice daily . g given by intravenous infusions ,in addition to general therapy for days.the other cases were treated without any form of antiviral therapy as control.all patients were followed up for months.the hbv markers, quantification of hbv-dna, serological chemistry data were measured at baseline , during therapy period and the end of follow-up period . results: clinical symptoms were improved in two groups patients, meanwhile alanine aminotransferase (alt) and total serum bilirubin (tbil) decreased. compare alt and tbil at the end of trentment, there were no significant differences between the two groups (p> . ). in foscarnet sodium treatment group, the level of serum hbv-dna descreased from ( . ± . ) log copies/ml to( . ± . ) log copies/ml (p< . ), the rate of hbv-dna descrease of more than two log was . % / . in the control group, the level of serum hbv-dna descreased from( . ± . ) log copies/ml to ( . ± . )log copies/ml, the rate of hbv-dna descrease of more than two log was . % / .a comparison of serum hbv-dna showed significant differences between the two groups(p< . ) conclusion: foscarnet sodium administered can inhibit hbv replication in treating severe chronic hepatitis b.it can rapid lower the level of serum hbv-dna obviously.but the relapse rate was . % in foscarnet sodium treated at the end of follow up period objective: evaluation of efficacy and safety of five years trail of entecavir for chronic hepatitis bpatients failed with lamivudine therapy in the chongqing area. methods: thirty-two eligible patients were enrolled who had documented lvd failure.in the double-blind phase,patients were randomized( : )to etv . mg/d (n= )and placebo (n= ) for weeks.in the open-lable phase ,patients received etv . mg/d for weeks.hbv-dna level,liver function tests,hbv serology and safety assessments were conducted. results: the mean reduction in hbv dna levels at week was logl copies ml in etv group compared to . logl copies ml in placebo group(p< ). the mean of hbv dna levels after weeks of etv treatment decreased to . logl copies m the proportion of hbv dna< log copy/ml raised from at baseline to . % at week ,to . % at week ,to % at week ,and raised to . % at week .there were two patients with hbsag seroconversion and four patients with hbeag seroconversion at the end of study. the mean of alt became normal at week and remained normal throughout week .there was one patient who had a severe adverse event during the trail. conclusion: the findings from this study demonstrated the antiviral activity and safety of etv in adults with chb who have failed lvd pe showing delayed response on t cells as increased on day .the mrna expression of il- and il- showed no response to hbv vaccine but highly regulated in tt after day (p= . , . ).myd andtraf (p= . )upregulated in hbv vaccine group followed by of ifn-( . )no change of ifn found in tt conclusions: i) hbv vaccine stimulates innate response by day which potentiates further cascade,peripheral dendritic cells plays significant role in generating immune flare follows myd pathway and releases ifn-.ii) whereas t cells marjory involved in tt showed delayed immune response.iii) identification of key factors at different time points may prove to be a novel model to study the initial events after vaccination. objective: to compare th /th cytokines' dynamic change and its clinical significance in hepatitis b e antigen-positive patients treated with telbivudine. methods: twelve hepatitis b e antigen-positive patients treated with telbivudine.the blood sample was collected at baseline, week , week , week , week and week and stored at - c; serum il- , il- , il- , il- , tnf-and ifn-were tested at each time point by cytometric bead array (cba), compare th /th cytokines' dynamic change at different time point in each group and compare th /th cytokines' dynamic change cross four different groups: complete response, partial response, non-response and break through . results:the level of th type cytokines in complete response group are obviously higher than the group of partial response non-response and breakthrough,but the level of th type cytokines are lower than the group of partial response, non-response and breakthrough. conclusions: th /th cytokines is essential for the regulation of the immune function of the body. after treated with telbivudine, the level of th -type cytokines in the complete response group increased significantly, while the level of th cytokines declined trend. a. soamni , s. somani , a. jain , v. dixit navjeevan hospital, suvidha, background: chronic infection with hepatitis b virus causes spectrum of manifestations ranging from asymptomatic carrier state (often inactive with low replication) to the development of cirrhosis-related complications.the characterization of asymptomatic state has not been done in this part of the country, which forms important objective of present study. methods: incidentally detected asymptomatic hepatitis b surface antigen positive (idahs) subjects having hbsag positivity for > month presenting to our liver clinic were enrolled after appropriate consent. detailed clinical, laboratory and sonographic evaluation was done. they were divided into two groups according to presence or absence of e antigen. group a -hbeag + (n= ) group b -hbeag -(n= ) results: most of our patients ( %) were young adults ( - years) with male to female ratio of . : . approximately half of our patients were detected during routine medical checkup, followed by family screening of contacts. most of our patients were asymptomatic, and fatigue was most common symptom found in %. all demographic and biochemical parameters other than ast & alt were comparable in both groups. among hbeag negative ( %) subjects, hbv dna level > copies/ml was found in %. subjects with positive hbeag as compared to non-replicative infection (antihbe positive and hbv dna negative) had more frequent elevation of transaminase levels ( % versus %, p< . ). antihbe antibody was positive in all hbeag negative subjects. mean age of seroconverted (antihbe positive) individuals was a decade older than hbeag positive. conclusion: from our study we can suggest that ongoing liver disease is present in approximately one-thirds of incidentally detected asymptomatic hepatitis surface antigen positive subjects previously referred to as carrier state. hbsag testing should be mandatory in all routine medical checkup and family and sexual contacts of index case should be screened. background and objectives: this research was carried out to determine the prevalence of hbcab among the hbsag negative first-time blood donors who had referred to khorramabad and borujerd centers for blood donation. materials and methods: this study was established on a descriptive cross-sectional basis in which hbsag test (elisa) was primarily performed on all of the donors having referred to khorramabad and borujerd blood centers; then, out of all those referred subjects, who were first-time and hbsag negative, were selected for furthur investigation. the information concerning age, gender, job, blood transfusion, and hbv vaccine injection was included in the questionnaire of the study. hbcab (total & igm) and hbsab tests were performed on the selected donors. data were collected and finally the prevalence rate of hbcab was determined. results: the results of the study showed that out of hbsag-negative first-time blood donors, only were hbcab+, from which were hbcab (total)+, and were hbcab (igm)+. were both hbsab+ and hbcab+, and were seropositive only for hbsab. conclusions: it was demonstrated that the first-time blood donors who are seronegative for hbsag marker will be easily identified through hbcab test if they are in the so-called core window period of the virus. meanwhile, this group of donors have been implicated as high-risk for transfusiontransmitted hbv infection. so, detecting this marker will remarkably reduce the chance of latent cases of hbv infection and help promote blood safety. background: tumor necrosis factor-(tnf-) plays a pivotal role in the viral clearance and host immune response to hbv, and the capacity for tnf-production in individuals is influenced by a major genetic component. the studies of tnf-- gene promoter polymorphism in chronic hbv infection have reported apparently conflicting results. objective: to derive a more precise estimation of the relationship between the polymorphism of tnf-- gene promoter and chronic hbv infection. method: meta-analysis was done of case-control studies in relation to tnf-- gene promoter, involving a total of chronic hbv infection cases and controls. the pooled odds ratios (ors) for the risk associated with the genotypes of ga, aa, and ga+aa (a-allele carriers) compared with the gg genotype were calculated. results: overall meta-analysis indicated that - a heterozygotes (ga) had % decreased risk of developing chb with a borderline significance (or = . ; % ci: . - . ; p = . ). for the - a allele homozygotes (aa) and carriers (ga+aa), the pooled ors both indicated a significantly decreased risk of chb (or = . ; % ci: . - . ; p = . ; and or = . ; % ci: . - . ; p = . , respectively) ( table ). in the subgroup analyses by ethnicity, significantly decreased risks were associated with - variant genotypes (ga and aa) in mongoloid populations in all genetic models. however, no significant associations were found in caucasoid. conclusion: the meta-analysis suggests that the tnf-- a allele is a low-penetrant protective factor for chronic hbv infection, especially in mongoloid. method: hbv transgenic mice were randomly divided into physiologic saline group and matrine injection group. another normal mice at the same species and age with hbv transgenic mice were regarded as the normal group. the mice in matrine injection group were administrated at dosage of . mgkg - d - by intraperitoneal for days. the mice in physiologic saline control group and normal group were administrated normal saline with the same volume at same time. the contents of hbv dna in serum and liver were quantitated by pcr. and the spleens were separated for cultivating dendritic cells. the surface molecules of dendritic cells were tested by flow cytometry. ifn-mrna and tnf-mrna in liver were tested by rt-pcr. result: there was no significant difference of the serum hbv-dna level between physiologic saline and matrine injection groups. the content of serum hbv-dna after treatment showed a significant decrease in two groups. the content of serum hbv-dna in matrine injection dropped significantly as compared with that in the physiologic saline group. but there was no significant difference in the content of hbv-dna in liver between physiologic saline and matrine injection groups. the expression level of mhc-ii on dendritic and hepatic ifn-r mrna and tnf-a mrna showed a significant decrease in hbv transgenic mice than normal mice. in comparison with physiologic saline group the expression level of them in matrine injection group showed a significant increase. conclusion: matrine injection was effective on depressing hbv-dna in hbv transgenic mice. its antiviral action may be achieved through regulating mhc-ii on dcs surface and promoting the production of antiviral factor such as ifn-and tnf-. purpose: to stimulate non-specific immune response capacity as the main content of the study to explore the hbv-dna and non-specific immune responses in the relationship between the low response capability, methods: cases of asymptomatic carriers, double-blind, randomized into mycobacterium fu , lamivudine and traditional chinese medicine for the treatment group, mycobacterium fu with traditional chinese and lamivudine with traditional chinese medicine were in the control group, a total of weeks of treatment, follow-up six months after the termination of treatment. results: different treatment of hbv -dna effect of the existence of significant differences; p> . , the performance of different types of asymptomatic carriers negative rate of hbv-dna there is a significant difference; p> . , as well as the performance of the different types of asymptomatic carriers continued application a treatment plan presented hbv-dna rebound rate there is a significant difference; p> . , conclusion: hbv-dna and non-specific immune responses in response to the lower capacity, anti-hbv therapy is not associated with non-specific immune response capacity or improve is the anti-hbv drugs alone can not solve the asymptomatic carriers in anti-hbv therapy where the cause of the problem, solve the asymptomatic carriers in the anti-hbv treatment although the need for anti-hbv drugs with non-specific immune activation synchronous drugs on the basis of the joint application , but the simultaneous combination of two drugs rather than as a result of hbeag and hbv-dna can hbeag-positive asymptomatic carriers receive hbv-dna negative effect of the results. background: adefovir dipivoxil (adefovir) effectively inhibits both wild-type and lamivudine (lam)-resistant hepatitis b virus (hbv) replication and resistance to this drug is infrequent compared with lam. in this study, we tried to identify factors affecting the emergence of resistant mutants after adefovir monotherapy in lam-resistant chronic hepatitis b (chb) patients. methods: the subjects were chb patients with lam-resistance who had received adefovir for more than months (range - months). the initial viral response (ivr) was defined as hbv dna < . log copies/ml. the adefovir resistant mutant was assayed at baseline and every months during adefovir administration. results: ivr was observed in % of patients. the cumulative emergence rates of adefovir resistance were . % at months, . % at year, . % at years and % at years. in univariate analysis, factors contributing to the emergence of adefovir resistant virus were baseline hbv dna > log copies/ml (p= . ) and ivr (p< . ). the presence of precore mutation and type of ymdd mutants were not related. in multivariate analysis, only ivr was an independent factors affecting the emergence of adefovir resistant virus (p< . ). conclusion: ivr is a useful predictor for emergence of adefovir resistant mutants after adefovir monotherapy in lam-resistant chb patients. for ivr-negative patients, the change of therapeutic options such as add-on lam or switch to other drugs should be considered because of the high incidence of the emergence of adefovir resistant mutants. background: elevated hbv dna is strongly associated with the risk of disease progression. this study investigated the early viral suppression effects of etv and lvd in nucleoside-naïve chinese patients with active hbeag (+) chb. methods: this open-label study was conducted in major hospitals in china. at study entry all patients had hbv dna levels copies/ml, elevated alt ( . - xuln) and compensated liver function. patients received either . mg etv or mg lvd daily. hbv dna measurements were taken at baseline and at weeks , , and during treatment, using roche cobas amplicor assay (llod copies/ml). results: a total of patients were enrolled; / etv patients and / lvd patients completed weeks of treatment. at baseline, mean hbv dna levels were . . in etv group and . . log copies/ml in lvd group (p< . ). the mean change in hbv dna from baseline (log copies/ml) was - . ± ngo's/funding-agencies representative at apasl -conference need to address-this-issue. we ngo-representatives from developing-nations need exposure to research treatments used by european/american experts. do we all failed in addressing socio-economic issues of cancer-sufferers? we need to address these socio-economic issues of affected population in resource-poor-nations. background: a garlic derivative s-allylcysteine (sac) has anti-cancer effect in human prostate and colon cancers. we aimed to investigate the effect of sac and combination of chemo-drug on tumorigenesis and metastasis of liver cancer. methods: the orthotopic liver tumor model using a metastatic liver cancer cell line mhcc l labeled with luciferase gene was applied. sac was given at day after tumor implantation at mg/g/day, or mg/g/day combined with low dose cisplatin for weeks. tumor growth and metastasis were monitored by xenogen in vivo imaging system. hepatic stellate cell (hsc) activation and tumor-associated macrophage (tam) in the tumor tissue were detected by -sma and ed /ed staining. tumor micro-vessel density (mvd) and apoptosis were also analyzed. in vitro functional tests including proliferation assay, cell cycle analysis and apoptosis analysis were performed. results: tumor growth was inhibited by sac combined with cisplatin treatment at different time points accompanied by lower incidence of lung metastasis compared with other groups. the observation of xenogen ivis was confirmed by histopathological examination. the hsc activation by -sma staining in the liver tumors was suppressed by sac and cisplatin treatment accompanied with less tam infiltration. consistent with in vivo study, in vitro functional study also demonstrated that sac not only induced cell cycle arrest, apoptosis, and inhibited tumor cell proliferation, but also sensitized the anti-cancer effect of cisplatin. conclusion: sac treatment inhibited liver tumor growth and metastasis by inhibiting tumor cell proliferation, inducing apoptosis and sensitization of chemotherapy. background: anti-angiogenic therapy would be a promising approach against hepatocellular carcinoma (hcc). although a sorafenib has survival benefits in patients at advances stages of hcc, there seem to be several serious concerns to employ this agent for chemoprevention against hcc. branched-chain amino acid (bcaa) reportedly inhibits the incidence of hcc in patients with insulin resistance (ir). however, the possible mechanism is still obscure. the aim of the current study was to examine the effect of bcaa on hepatocarcinogenesis under the condition of ir, especially in conjunction with angiogenesis. methods: the effect of bcaa on the development of liver enzyme-altered pre-neoplastic lesions and angiogenesis in the obese diabetic otsuka long-evans tokushima fatty rats was examined. we also performed an in-vitro study to elucidate the possible mechanisms involved. result: treatment with bcaa markedly inhibited the glutathione-s-transferase placental form (gst-p)-positive pre-neoplastic lesions along with suppression of neovascularization in the liver. the hepatic expression of the vascular endothelial growth factor (vegf), a potent angiogenic factor, was also attenuated. bcaa treatment significantly suppressed the glucose-and insulin-induced in-vitro angiogenesis in the presence of vegf. these results indicate that bcaa exerted a chemopreventive effect under the condition of ir via suppression of vegf-mediated angiogenesis. conclusion: since bcaa is widely used in the clinical practice for patients with chronic liver diseases, this agent may represent a new strategy for chemoprevention against ir-based hcc in the future. background: krüppel-like factor (klf ) is a member of transcription factors. whether and how klf signaling pathways contribute to hepatocellular carcinoma (hcc) development and progression is unknown. this study investigated role of klf in hepatocellular carcinoma cell line hcclm proliferation, invasiveness and epithelial to mesenchymal transition (emt). methods: the expression of klf in different liver cell lines was detected by quantitative real-time pcr and immunocytochemistry. we used small interfering rna (sirna) to down-regulate klf expression in hcclm . the change of proliferation and invasive ability of klf down-regulated hcclm was investigated by mtt reduction assay and trans-well invasive assay respectively. the change of proliferation, invasiveness and emt related gene in klf down-regulated hcclm was evaluated by quantitative real-time pcr. result: klf protein expressed predominantly in the nuclei of cancer cells and its expression is positively correlated with metastatic potential of these cell lines. hcclm has the highest klf level. decreased klf expression can notably inhibit the proliferation (p< . , n= ), mobility and invasiveness of hcclm (p< . , n= ). we found that the mrna level of n-cadherin, fibronectin and vimentin is much higher than that of e-cadherin in hcclm . the expression of cyclin d , focal adhesion kinase (fak) and fibroblast markers including n-cadherin and fibronectin was obviously suppressed in klf down-regulated hcclm . conclusion: klf plays an important role in the process of hcclm proliferation, invasiveness and emt. background: insulin resistance (ir) has shown to play an important role in the progression of chronic liver diseases, including liver fibrosis development and hepatocellular carcinoma. the aim of this study was to elucidate the possible mechanisms of ir on the liver fibrosis development and hepatocarcinogenesis using obese diabetic otsuka long-evans tokushima fatty (oletf) rats. methods: to induce liver fibrosis, . ml/kg of pig serum was injected twice a week for weeks in the oletf and leto rats. in the hepatocarcinogenesis model, glutathione-s-transferase placental form (gst-p)-positive pre-neoplastic lesions were induced by a single injection of mg/kg of diethyl nitrosamine (den). we also performed in-vitro studies to examine the mechanistic insights. results: the liver fibrosis development and gst-p-positive pre-neoplastic lesions were both markedly accelerated in oletf. in the fibrosis experiment, -smooth muscle actin-positive activated hepatic stellate cells (hsc) also increased in oletf along with augmentation of the hepatic collagen content and transforming growth factor-b . in the den model, the neovascularization was up-regulated in oletf almost in parallel with the pre-neoplastic lesions development and a potent angiogenic factor, the vascular endothelial growth factor. our in-vitro study showed that both glucose and insulin stimulated the proliferation of the activated hsc and augmented the neovascularization. conclusion: these results indicated that the ir status directly accelerated the liver fibrosis development and hepatocarcinogenesis at least partly through the stimulation of activated hsc proliferation and hepatic neovascularization, respectively, in the rat. n. wakui , t. ikehara , r. takayama , m. takahashi , k. shiozawa , h. nagai , m. watanabe , k. ishii , k. iida , y. igarashi , y. sumino case: a years old man diagnosed with chronic hepatitis c regularly visited our hospital. in april of , ultrasonography revealed a tumor mm in diameter in s of the liver and another tumor mm in diameter in s / of the liver. the patient was hospitalized for further examination. computer tomography (ct) revealed that the tumor localized in s / presented a pattern of hypervascular hepatocellular carcinoma (hcc). for the tumor localized in s , the following were revealed. ) contrast-enhanced ultrasound findings: a tumor vessel passed from outside the tumor to the center of the tumor in the early vascular phase, then radiated in a wheel-like shape at the center of the tumor; parenchymal phase perfused imaging in the area produced a similar imaging obtained from the area surrounding the liver. ) ct: no tumor was detected. ) spio-mri (t weighted imaging): iso-low intensity images were obtained. although these imaging findings indicated fnh, the patient was hcv positive. in order to disprove the possibility of hcc, a biopsy was performed on the tumor at s in the liver. the resulting diagnosis was well-differentiated hcc. discussion: until now, a characteristic finding of fnh has been spoke-like vasculariation, which is considered diagnostically quite important. however, some recent cases of hcc have been reported to present fnh-like vascularization. from now on, when evaluating a tumor that presents spoke-like vascularization underlining chronic hepatitis, the possibility of hcc should be considered and a close examination may be needed. chronic infection with hcv is problem .clinical management of chronic hcv depend on extent liver fibrosis .liver biopsy gold stander an invasive procedure responsible for severe complications and sample variability interpretation. serum biomarkers for inflammation/fibrosis investigated to wave liver biopsy. diagnostic accuracy panel of non-invasive serum biomarkers for hepatic fibrosis (fibrosure , apri score, forn's score) versus liver biopsy. hcv patients subjected for: apri, forn's , fibrosure scores pcr quantitative hcv-rnaliver functions .lipid profile cbc . ultrasound guided liver biopsy. forns score; auroc ( . ) with % ci( . - . ) for(fof ) vs. (f f f ) while( . )with % ci( . - . )for(fof f ) vs.(f f ). cutoff(> . )sensitivity for significant fibrosis(f f f )and extensive fibrosis (f f )were ( %) and with low specificity ,with accuracy( %) and ( %)respectively.-apri score; auroc( . )with % ci( . - . )comparing(f f ) vs.(f f f )while was( . )with % ci( . - . )for( f f f )vs.(f f ).cutoff(< . ) had low sensitivity and specificity( %)with accuracy( %)for significant fibrosis and( %)for extensive fibrosis.-fibrosure(fibro-acti test); showed best auroc( . )in different fibrotic stages with % ci ( . - . ).cutoff(> . ) sensitivity( %)for significant fibrosis and( %)for extensive fibrosis while specificity( %)in all fibrotic stages. the ppv ( %)for significant and extensive fibrosis .npv and accuracy( %, %)respectively for significant fibroses,while it was ( %) for extensive fibrosis respectively.significant correlation between liver biopsy and fibro-test(p . )and acti-test(p . ).significant correlation between liver biopsy hepatitis activity score and apri (p . )and forns score (p . ). conclusion: forns score wasn't considered since does not discriminate between significant and extensive fibrosis. low sensitivity of apri prohibtes detection of minmal fibrosis and allow undetermined results. fibrosure classified all cases of chronic hcv sufficient to wave liver biopsy pe introduction: hcc is the th common cancer. global increase of hepatitis b and c infection, the incidence of hcc steadily increasing. egypt seroprevalence of hcv in nile delta - %. afp had limited sensitivity % and specificity % for small hcc. gpc- oncofetal protein over expressed in hcc. evaluating validity of glypican- as early detector of hcc.: healthy controls and hcv positive patients: patients chronic hepatitis c virus infection. patients compensated cirrhosis [child-pugh class a and b]. patients decompensated cirrhosis [child-pugh class c]. patients hcc. liver functions: alt, ast, bilirubin(t), albumin, gt.tumor markers: afp and gpc- .viral markers: hcv antibodies, hbs ag and hbc ab. the median value of gpc- in hcc, dc, cc significantly higher than chronic hepatitis and control groups. no significant correlation between afp and gpc- . auroc of afp . & auroc of gpc- . . the diagnostic sensitivity of afp ( ng/ml) % with ppv . %. the specificity % with npv . %. while the diagnostic sensitivity of gpc- ( ng/ml) % with ppv %. the specificity . % with npv %. combined serial approach of afp and gpc- improved specificity to . %. conclusion:gpc- although a serological test for early detection of hcc, showed limited specificity, where detected in different stages of chronic liver disease,it is oncofetal protein produced by regenerating liver cells. the diagnostic signature approach for simultaneous determination of afp and gpc- improve prediction accuracy of hcc patients in those showing seronegativity to afp. results: patients with hcv infection (n= ) were significantly older (mean age, years) than patients with dual virus (n= , years) and hbv infection (n= ; years) (p< . ). the male-to-female ratio for hbv, dual virus and hcv group was . , . and . , respectively (p< . ). patients in the hbv group more often had higher total tumor volume (mean, cm ) than the dual virus group ( cm ) and hcv ( cm ) group (p< . ). no significant differences of the severity of liver cirrhosis, performance status, cancer staging and tumor cell differentiation were noted among the three groups. patients in the hcv group had a significantly poor survival in comparison to the hbv group only in the subset of patients with small tumor volume (< cm ) in the cox proportional hazards model (relative risk: . , p= . ). conclusions: dual hbv and hcv virus infection does not accelerate the speed of hcc formation in patients with chronic hepatitis b, and appears to have a modified course of carcinogenesis pathway diverted away from the biological behavior of hbv and hcv infection. background: patients presenting with hcc is not infrequent in our clinical practice. the aetiology vary ranging from hbv, hcv, nash and alcohol. the aim of this study was to see the aetiology of hcc in bangladeshi patients. methods: in this retrospective study, records of patients who attended our opd between july to august were reviewed. patients having hepatic sol and/or heterogeneous echotexture of liver on usg and/or ct scan were included. diagnosis of hcc was confirmed at usg guided fine needle aspiration cytology with or without elevated serum afp (> ng/ml). results: of the patients, % ( / ) had hbv infection. hcv infection was diagnosed in % ( / ). nash was responsible for % ( / ) cases, alcohol in % ( / ), while in the rest % ( / ) cases no specific aetiology could be established. conclusion: the study shows that hbv is the commonest cause for hcc in bangladesh followed by hcv. background: the aim of this study was to determine whether the hepatitis b virus (hbv) dna viral load and antiviral therapy is associated with hepatocellular carcinoma (hcc) recurrence. methods: this retrospective study involved patients who underwent hepatic resection or radiofrequency ablation for initial hcc curative treatment. the patients were divided into four groups. fifteen patients with low serum hbv dna levels ( log copies/ml) at the time of initial hcc treatment received antiviral therapy (lamivudine, adefovir, dipivoxil, entecavir) before hcc appeared (pre antiviral therapy group; pre-tg). thirty-four had low serum hbv dna levels without antiviral therapy (low virus group; lvg). fourteen had high serum hbv dna levels and received antiviral therapy after hcc appeared (post antiviral therapy group; post-tg). thirty patients had high serum hbv dna levels without antiviral therapy (high virus group; hvg). results: the cumulative hcc recurrence rates at years in the hvg, lvg, pre-tg, and post-tg groups were . %, . %, . %, and . %, respectively. there were significant differences in the hcc recurrence rates between the hvg and lvg groups (p = . ), and between the hvg and pre-tg groups (p = . ). the recurrence rate was lower, though not significantly, in the post-tg group than in the hvg group (p = . ). conclusions: not only hbv dna viral load but also antiviral therapy is associated with hcc recurrence. antiviral therapy before hcc appears is important for patients with high serum hbv dna levels to prevent hcc recurrence. background/aims: few reports have described methods for predicting prognosis in unresectable hepatocellular carcinoma (hcc) patients, especially those treated by repeated transcatheter arterial chemoembolization (tae). to determine risk factors for death and determine prognosis in patients treated with repeated-tae, we evaluated clinical data. methodology: we retrospectively analyzed clinical parameters of unresectable hcc patients treated with repeated-tae from january to december . tae was repeated when recurrence was diagnosed by tumor marker elevation and/or dynamic computed tomography findings. factors affecting survival were evaluated using multivariate analysis after univariate analysis. next, we combined the score for each significant factor into a single prognostic score, after which the results were compared with jis and clip score methods. results: multivariate analysis revealed that bilobular hcc, alpha-fetoprotein ( ng/ml), tumor invasion of the portal vein, tumor size ( cm), and albumin (< . g/dl) were related to poor prognosis, using those factors, we developed a new prognostic scoring system. the % survival period was . months for all subjects, while it was . , . , . , . , and . months for those with scores of , , , , and or over, respectively (p< . ), using our new system. clip score was not useful to predict prognosis, while jis score was better. however, subjects with jis scores of and were difficult to differentiate. conclusion: our scoring system was easy to perform and the results showed that repeated-tae was effective for unresectable hcc with a score of or less. local ablative therapies and intrahepatic pressure c. kawamoto , a. yamauchi , k. kaneko , n. miyagi , k. kani , t. aoyama , k. yakabi saitama medical center, saitama medical university, japan background: some of the unexpected recurrence observed after radiofrequency ablation (rfa) might be caused by increased intratumoral pressure. the present study examined the relationship between local ablative therapies and intrahepatic pressure. methods: a. basic study: under general anesthesia, laparotomy was performed on pigs. a leveen needle and a percutaneous ethanol injection (pei) needle were inserted into the liver and intrahepatic pressure was monitored using an invasive blood pressure monitor. ablation was performed as follows: . rfa. ) single-step method: after fully deploying the electrode, the power was initially applied at w, then increased in increments of w/min until power roll-off. ) multi-step method: the array was deployed in steps. at each step, the power was fixed at w until power roll-off. . pei. injection of ethanol ( ml). b. clinical study: we examined the multi-step rfa and pei for hcc. under local anesthesia, intratumoral pressure was monitored. . rfa. patients with a mean tumor size of . ± . mm were studied. . pei. in patients with a mean tumor size of . ± . mm, to ml of ethanol was injected per session. results : a. basic study: the intrahepatic pressures were: single-step method, . ± . mmhg; multi-step method, . ± . mmhg; and pei, . ± . mmhg. b. clinical study: intratumoral pressure was . ± . mmhg for rfa and . ± . mmhg for pei. conclusion: these results suggest that consideration of intrahepatic pressure is crucial in local ablative therapies. background: a late evening snack (les) is recommended for liver cirrhosis. however, no clinical study has evaluated the nutrition status and the effect of les in cirrhotic patients with hepatocellular carcinoma (hcc). we investigated the effect of les undergoing hepatic arterial infusion chemotherapy (haic) in patients with hcc. method: nineteen patients with hcc were enrolled. ten patients were les group, and nine were control group. in the les group, the patients received les supplementation with a branched-chain amino acid (bcaa)-enriched nutrient mixture. in the control group, the patients received ordinary food. there were no significant differences in relation to age, gender, etiology, child-pugh scores, tumor stage, clinical responses to haic between two groups. blood biochemical data, nutrition status using an indirect calorimeter were evaluated at before and at the end of chemotherapy. results: the non-protein respiratory quotient (nprq) and molar ratio of branched-chain amino acid to tyrosine (btr) were significantly improved in the les group but not in the control group. there were no significant differences in the area under the concentration curve for glucose between before and the end of chemotherapy in two groups. background & aims: hepatocellular carcinomas (hccs) often show hypoor mixed vascularity, and the prognosis of these relatively hypovascular hccs is not fully elucidated. cytokeratin (ck) expression profiles may also be useful prognostic indicators, and specifically ck may reflect metastastic potency in hccs. this study was to assess the prognostic implication of tumor vascularity and its relation to ck expression in hcc patients. methods: a total of patients who underwent surgical resection for hcc were enrolled. tumor vascularity was evaluated according to arterial enhancement pattern on ct scans and ck expression was evaluated using tissue microarray methods. clinicopathologic data were analyzed using kaplan-meier and cox proportional hazard model. results: during follow-up period, ( . %) patients experienced tumor recurrence. forty-five patients ( %) had hypovascluar tumor at the time of diagnosis, and they showed significantly higher positivity for ck expression (p= . ) and shorter disease-free survival (p= . ) than patients with hypervascular hccs. in addition, recurred tumors in these patients showed more frequently hypovascular pattern than in patients with hypervascular hccs (p= . ). hypovascularity at initial diagnosis and microvascualr invasion were independent poor prognostic factors predicting survival. following treatment of recurred hccs, hypovascular tumors showed poor response to transarterial chemoembolization (tace), which resulted in shorter overall survival than hypervascular tumors (p= . ). conclusions: these results demonstrate that tumor hypovascularity in hccs is associated with positive ck expression, early tumor recurrence, poor tace response and poor survival. therefore, tumor vascularity may also be a prognostic indicator in hcc patients. background: hepatic stellate cells (hscs) transdifferentiate to become extracellular matrix-producing myofibroblasts during liver injury. myofibroblasts can also promote invasion and metastasis of hepatocellular carcinoma(hcc). in this study, we determine gene expression changes in two different models of hscs activation and investigate whether induction-activated hscs(ihscs) gene expression changes are different from culture-activated hscs(ahscs). methods: hscs were isolated by density centrifugation and exposed to conditioned medium from rat hcc cell lines c f. twenty-seven thousands and one hundred gene expression between quiescent hscs(qhscs), ahscs and ihscs was analyzed by microarray and confirmed by real-time rt-pcr and western blot. results: sixteen hundreds and seventy-one probe sets were differentially expressed in ahscs, including genes that encode proinflammatory factors, adhesion molecules, cell surface receptors, signaling transduction and immune factors. seven hundreds and eleven probe sets were differentially expressed in ihscs. induction-activated hscs showed specific gene expression patterns including raf , rac , adam , wnt , mmp- and tnf, suggesting that hcc cells can specifically induce hscs activation. induction-activated hscs might play a important role in invasion and metastasis of hcc. conclusions: induction-activated hscs gene expression patterns are different from ahscs. culture-activated hscs does not properly regulate gene expression in hscs, suggesting that ihscs may be considered the model for the study of hscs biology in hcc. background: hepatocellular carcinoma (hcc) is a hypervascular tumor, and angiogenesis is important for tumor growth. ephrin receptors are related with vascular system development and the polymorphism of ephb in the carcinogenesis of digestive tract has been reported. our aim was to examine the polymorphsims of ephb with the occurrence of hepatocelluar carcinoma in korean population. methods: genomic dna was extracted from patients with hepatocellular carcinoma (hcc), healthy subjects. ephb polymorphism was determined by polymerase-chain reaction-based assays, and the association with hcc was investigated. results: with regard to ephb polymorphism, a/a genotype at rs , t/t genotype at rs , a/a genotype at rs , t/t genotype at rs and g/g genotype at rs were significantly associated with hcc but these were not associated with clinical characteristics of hcc. conclusions: five out of seven polymorphisms on ephb gene were statistically associated with hcc, in the korean population. therefore, more studies of ephb gene polymorphisms including various risk factors should be performed to use as genetic markers of hcc occurrence. background: we aimed to compare the results of hepatectomy for hcc in patients older than years old with those for younger patients. methods: clinicopathological data and outcomes for elderly patients and younger patients with hcc who underwent hepatectomy between and were retrospectively compared. results: although postoperative delirium was more common in the elderly group, there were no significant differences between the groups with regard to operative morbidity, hospital death, disease-free survival, and overall survival. the overall recurrence rate was significantly higher in the elderly patients with alcohol abuse than in younger patients with alcohol abuse. multivariate analysis revealed that preoperative alcohol abuse was a prognostic factor for elderly patients. conclusions: elderly patients with preoperative alcohol abuse should be followed closely, even after r surgery, because alcohol abuse is strongly correlated with postoperative recurrence and worse survival. background: little is known about the effect of transfusing fresh frozen plasma on the outcome after hepatectomy for hepatocellular carcinoma. methods: among patients who underwent curative resection between and , patients had perioperative transfusion with whole blood or packed red blood cells and fresh frozen plasma (group a), while patients were only transfused with packed red cells (group b), patients were only transfused with fresh frozen plasma (group c), and patients had no transfusion (group d). results: group c had significantly fewer postoperative complications and a shorter hospital stay than group a. preoperative coagulation was significantly worse in group c. survival was significantly better in groups c and d than in group a. conclusions: perioperative transfusion of fresh frozen plasma improves clotting factors without an adverse influence on the survival of patients with liver dysfunction undergoing resection of hepatocellular carcinoma. background: this study investigated risk factors for postoperative liver failure after resection of hepatocellular carcinoma to detect markers that could identify candidates for hepatectomy. methods: perioperative risk factors for liver failure after hepatectomy were analyzed in patients with hepatocellular carcinoma. results: liver failure occurred postoperatively in patients, of whom died. the hyaluronate/gsa-rmax ratio was a risk factor for postoperative liver failure by univariate analysis and was the only risk factor according to multivariate analysis. all patients who died had a hyaluronic acid/gsa-rmax ratio mg min/dl. conclusions: to reduce postoperative liver failure, preoperative planning should employ various measures of the hepatic functional reserve, including tests of both parenchymal and nonparenchymal liver function. the hyaluronate/gsa-rmax ratio can predict liver failure after hepatectomy, and a ratio greater than mg min/dl is a relative contraindication to liver resection. the patient was a -year old japanese man with chronic hepatitis c(ch-c) who achieved a sustained virological response(svr) to interferon(ifn) therapy. as a result the liver functions were normalized and the histological findings of the liver also improved. however, years after svr, mild liver dysfunction was noticed along with a marked increase of tumor markers. several modalities revealed huge liver tumors about cm in greatest diameter in the left lobe invading the bile ducts and another tumor about cm diameter in segment v. we performed liver biopsy and confirmed that this tumor was well-differentiated hepatocellular carcinoma (hcc). only mild fibrosis development could be observed in the adjacent non-cancerous lesions. we successfully treated these tumors with transcatheter arterial chemoembolization and stereotactic radiosurgery. recent studies revealed that the risk of developing hcc still exists even after svr. since most of hcc that develop in patients with svr are usually detected within years, several investigators speculate that hcc is already present but too small to be detected at the time of completion of ifn therapy. this speculation is not the case in our patient, since svr was achieved years ago and no hcv-rna could be detected when hcc appeared. therefore, another possible mechanism should be considered. an annual follow-up with strict surveillance program for hcc should be performed for more than years after the completion of ifn therapy. background/aims: in order to investigate the role and importance of oxidative stress as to carcinogenecity of hepatocellular carcinoma (hcc) we analyze the expression of -hydroxydeoxyguanosine ( -ohdg) in the liver tissue of the hcc patients with and without hepatitis viral marker. methods: patients undergoing hepatic resection for the first hcc from to were enrolled into the study. only the cases that took no alcohol or small amount of alcohol were enrolled. cases were negative for hepatitis b surface antigen (hbsag) and antibody to hepatitis c virus (hcvab) (nbnc group). were positive for hbsag and negative for hcvab (b group). were positive for hcvab and negative for hbsag and antibody to hepatitis b core antigen (c group). staining with hematoxylin and eosin (h&e) and berlin-blue, and immunohistochemical staining for -ohdg were performed using the non cancerous liver regions. the degree of -ohdg immunostaining was expressed as the labeling index, which means the percentage of positive hepatocytes per hepatocytes. results: the labeling index of -ohdg for nbnc group is . (± . ), significantly lower (p= . ) than that for b group . (± . ), and also lower (p= . ) than that for viral group (b group and c group)( . ± . ). the labeling index of -ohdg had no correlation with grading, staging, fatty and iron deposit among all cases. conclusions: there is possibility that oxidative stress might not associate with the carcinogenesis of hcc in some cases without hepatitis viral infection. background: no effective chemopreventive agent has been approved against hepatocellular carcinoma (hcc) yet. since neovascularization plays a pivotal role in hcc, an angiostatic agent is considered as one of the promising approaches. recently, it has reported that vitamin k (vk) and angiotensin-converting enzyme inhibitor (ace-i) exert anti-angiogenic activity. the aim of the current study was to elucidate the combination effect of the clinically used vk and ace-i on cumulative recurrence after curative treatment, especially in consideration of neovascularization. methods: vk (menatetrenone; mg/day) and/or ace-i (perindopril; mg/day) were administered for to months after the curative therapy for hcc. the cumulative recurrence and several indices were analyzed. results: a -month follow-up revealed that the combination treatment with vk and ace-i markedly inhibited the cumulative recurrence of hcc in association with suppression of the serum level of vascular endothelial growth factor (vegf); a central angiogenic factor. the serum level of lectin-reactive a-fetoprotein was also suppressed almost in parallel with vegf. these beneficial effects were not observed with single treatment of vk or ace-i for months. conclusions: the combination treatment of vk and ace-i may suppress the cumulative recurrence of hcc after the curative therapy, at least partly through suppression of the vegf-mediated neovascularization. aim: the aim of this study was to clarify the cilnicopathologic features and management of hepatocellular carcinoma (hcc) patients surviving more than years after hepatectomy. materials & methods: retrospective study was carried out on hcc patients who underwent curative hepatectomy between and . clinicopathologic factors in -year survivors and patients who died within years were compared. the prognostic factors affecting survival were examined among the -year survivors. results: there were patients who survived for more than years after initial hepatectomy, and of those patients survived for more than years after hcc recurrence. the overall -, -, -and -year survival rates were . %, . %, . %, and . % respectively. in multivariate analysis, absence of underlying cirrhosis, solitary tumor, alfa-fetoprotein less than ng/ml, and absence of microscopic vascular invasion were favorable independent factors associated with -year survival. negative hepatitis c virus antibody status was favorable independent factor associated with longer disease-free interval and survival after tumor recurrence. multimodal treatments such as repeat hepatectomy or percutaneous ablation led to improved survival after recurrence, compared with the survival after transarterial chemoembolization (p<. ). conclusions: the results suggest that patients without underlying cirrhosis who have a solitary hcc that does not demonstrate vascular invasion or high afp levels might survive for longer than years after the initial hepatectomy. close follow-up and multimodal treatment could contribute to prolongation of survival in such patients, even if cancer recurrence occurs. the history of the use of carbon ion radiotherapy (cirt) for treating hepatocellular carcinoma (hcc) goes back to , when clinical trials were initiated at the national institute of radiological sciences. we have already reported that cirt used for the treatment of hcc is safe and effective, and that it causes only minor liver damage. in a phase ii clinical trial, the local control and cumulative overall survival rates were % and % at years, respectively. however, the patients with tumor adjacent to the gastrointestinal tract are thought to be ineligible for cirt because of the high risk of radiation injury of the digestive organs. in order to extend the indication of cirt, we have challenged the cirt for such patients under the use of spacers. a case was a -year-old female with cm tumor in segment . in radiological findings, the tumor revealed typical enhancement pattern for hcc, and was near the ec junction. she had been judged ineligible for hepatectomy because of the high retention rate of indocyanine green. she could undergo the . gye/ -fraction cirt after the placement of gore-tex soft tissue patch under the laparoscopic procedure. up to the present date, no adverse effect due to the spacer has been occurred, and an apparent anti-tumor effect has been observed. this method seems to have a promising efficacy for extension of the indication of cirt to the patients with tumors adjacent to the gastrointestinal tract. background: previously we reported that high ubiquitination was marker of human hepatocellular carcinoma. on the basis of these finding, we firstly analyzed the effect of bortezomib(proteasome inhibitor) on human hcc cell line. we also reported that hhm/dip /gcip was early marker for human hepatocarcinogenesis. hhm was suggested to be a new tumor suppression gene, but the mechanism was not well confirmed. we analyzed change of hhm signal by bortemib. method and result: we used hcc cell line (huh , hlf, hepg ) . the inhibitory effect of bortezomib was evaluated using mtt assay. nm bortezomib significantly inhibited proliferation of hcc cell line. the inhibitory effect by nm bortezomib was similar with m cisplatin. on the other hand, bortezomib has no inhibit effect in isolated hepatocyte from rat. in this condition, we analyzed the expression of cyclin d , phospho-rb and hhm in hcc cell line by western blot analysis. expression of cyclin d , phospho-rb decreased, but hhm was increased with time. next we analyzed cell cycle by facs. bortezomib induced hcc cell line into cell cycle arrest in g /m. the transcriptional activity of hhm was also activated by bortezomib administration using ptimer-promoter-hhm plasmid. conclusion: bortezomib has specific anti-proliferative effect on hepatocellular carcinoma. the induction of hhm by bortezomib might be related with cell cycle arrest. bortezomib will be a useful drug for hcc. neovascularization is required for carcinogenesis of non-alcoholic steatohepatitis: experimental and clinical study m. kitade , h. yoshiji , r. noguchi , k. kaji , t. namisaki , y. aihara , h. background/aim: non-alcoholic steatohepatitis (nash) may progress to liver cirrhosis, and finally hepatocellular carcinoma. recent study suggested that development of hepatic angiogenesis correlates the risk for hepatocarcinogenesis in liver cirrhosis patient. we therefore examined the role of angiogenesis in the hepatocarcinogenesis of nash in both experimental and human study. methods: as an experimental nash model, zucker (z) rats, which naturally develop leptin receptor mutations, and their lean littermate (l) rats were fed a choline-deficient, amino acid-defined (cdaa) diet. in human study, patients with nash-related cirrhosis or pre-cirrhosis, regarded as high risk group of hepatocarcinogenesis, and with simple fatty liver (fl) were enrolled and underwent clinico-pathological examinations. immunohistochemical analysis of -hydroxy- -noneal ( -hne) and cd were employed for detection of reacrive oxidative stress (ros) and angiogenesis in the liver tissues, respectively. results: in experimental nash model, both groups showed marked steatohepatitis by feeding cdaa diet. in sharp contrast, the development of glutathione-s-transferase placental form (gst-p)-positive pre-neoplastic lesions and hcc could be observed only in the l-rats. the hepatic neovascularization was also significantly increased only in the l-rats. in human study, both nash and fl exerted a marked elevation of ros. in sharp contrast, significant development of hepatic neovascularization was observed only in nash, whereas almost no neovascularization could be observed in fl. conclusion: in conclusion, these results suggested that neovascularization might play a important role in hepatocarcinogenesis in nash. background: paternally expressed gene (peg ), which was an imprinted gene with an active paternal allele but silent maternal allele, was highly expressed in a great majority of hepatocellular carcinoma(hcc). the aim of this study was to generate transgene mice expressing peg in the liver under the control of mouse albumin (alb) promoter and study the integration, transcription, expression of peg gene in the transgenic mice methods: the linearized bp transgene fragments, which contained alb promoter and structural gene of peg , were microinjected into fertilized eggs of mice. then manipulated embryos were transferred into the oviducts of pseudo-pregnant female mice. all the newborn mice were screened and identified by pcr detecting genomic dna in tail tissue. as the transgene was driven by the alb promoter, we examined its expression in the liver of transgenic mice by rt-pcr and western blotting. results: the transgene fragment was microinjected into the male pronucleus of fertilized oocytes. the injected eggs were implanted into oviducts of pseudo-pregnant foster mothers, of which mice became pregnant and give birth to offspring. of them died from unknown reason. among the offspring, were identified to carry peg cdna as demonstrated by pcr, and peg transgene could be expressed successfully in the liver of the established transgenic mice. the ratio of transgene integration were . % ( / ) by pcr. conclusions: the peg transgenic mouse model should be valuable for studying the in viro function of this imprinted gene in hcc. background/aims: brivanib alaninate is the l-alanine ester prodrug of bms- , an oral selective dual inhibitor of vascular endothelial growth and fibroblast growth pathway receptors. it is being developed in treating hepatocellular carcinoma (hcc), a disease highly prevalent in asia-pacific region. this analysis investigated whether bms- exposure was different between asian and non-asian subjects. methods: a population pharmacokinetic (ppk) model was developed with data collected in subjects ( non-asian, asian) with advanced and metastatic solid tumors (including hcc) from clinical studies. potential effects of the following covariates on model parameters were examined: age, gender, race, and baseline body weight. model-based simulation was performed to examine bms- exposure in asian and non-asian patients following brivanib doses of mg qd (phase iii dose). results: the ppk of bms- was characterized by a -compartment model with first-order absorption and elimination. clearance was found to slightly increase with body weight (p< . ). however, effects of age, gender and race on clearance were not statistically significant. the median of apparent clearance in asian was . % lower than that of non-asians, which was adequately explained by % lower body weight in asians. there was substantial overlap in steady-state bms- auc of asian and non-asian patients, simulated based on their observed body weight distributions in these patient groups. conclusions: bms- pk can be adequately described by a linear -compartment model; exposures in asian and non-asian subjects are similar following brivanib doses of mg qd. background/aims: hepatic resection is the standard treatment for hepatocellular carcinoma. in some patients with multiple hcc, one-block resection can not be feasible due to either the tumor location or the reserved liver function. in this study, we attempted to analyze the outcome of multiple-site resection or combined resection and rfa in patients with multiple hcc. the prognostic factors for postoperative survival were also investigated. methods: among patients who received resection from january to august , patients had a radiologically detected multiple hcc. patients with multiple hcc were divided into: group a, patients treated with one-block resection (n= ) and group b, patients with multiple-site resection or combined resection and rfa (n= ). results: in group b, received multiple-site resection and underwent combined resection and rfa. the clinicopathological variables and postoperative complication rate were not significantly different between the two groups. the -year disease-free survival rates for group a and b were . % and . %, respectively (p= . ). the overall survival rates were also not significantly different ( . % vs. . %, p= . ). the multivariate analysis revealed that radiological tumor number , edmondsons-steiner grade (iii-iv) and indocyanine green retention rate at minutes> % were adverse prognostic factors for overall survival. conclusions: active treatments including multiple-site resection and combined resection and rfa showed similar treatment outcomes compared with one-block resection in patients with multiple hcc. the prognosis after treatment was associated with tumor number, tumor grade and icg r . background: nasopharyngeal carcinoma (npc) is endemic to southern china. mortalities are mostly associated with secondary metastases. novel treatments for npc metastases are thus urgently needed. we aim to test the efficacy of a physiologically stable gold compound, gold (iii) meso-tetraarylporphyrin a (gold- a), in treating intrahepatic npc metastasis in athymic mice. methods: twenty million of c - human npc cells were injected into the livers of athymic mice to induce primary tumors. gold- a was administrated by intraperitoneal injection. survival times, tumor volumes and degrees of metastasis of the animals were evaluated. intratumoral microvessel density was determined by immunohistochemical staining for cd . tube formation by ms mouse endothelial cells were conducted with an in vitro angiogenesis assay kit. gene expression level was determined by semi-quantitative reverse transcription-polymerase chain reaction. cell proliferation was performed by methylthiazolyldiphenyl-tetrazolium bromide assay. result: gold- a prolonged the survival and inhibited intrahepatic and lung metastasis of the tumor-bearing animals. the compound induced tumor tissue necrosis and reduced tumor microvessel formation. in in vitro studies, gold- a inhibited tube formation and proliferation of ms cells, and downregulated the expression of stanniocalcin (stc ), which plays roles in angiogenesis. furthermore, our preliminary data showed that overexpression of stc in ms cells rescued cells from gold- a-induced death. conclusion: gold- a is a novel anticancer agent that prolongs survival of the npc metastases-bearing mice. it inhibits intrahepatic and lung metastasis in vivo and inhibits angiogenesis in vitro, in part via downregulation of stc . tbx is a transcriptional repressor that is important for embryonic development. overexpression of tbx was found in a large variety of cancers, including breast cancer, ovary cancer, cervical cancer, lung cancer, bladder cancer and liver cancer. tbx promote carcinogenesis by bypass cellular senescence via suppression of p arf . our resent studies revealed that two key motifs composed of + residues are essential for its transcriptional repression. based on this finding, we designed a set of peptides to block its transcriptional repression activity and tested their antiviral effects. we found that tat-tagged peptides (taps) effectively transduced hepatoma hepg and bel cells at almost % efficiency and inhibited cell growth in a dose dependent manner. further studies revealed that the tap treated cells underwent up-regulate apoptosis via suppression of p arf both at mrna and protein levels, demonstrating the potential of novel taps for anti-hcc treatment in the future. safety and long-term outcomes of radiofrequency ablation therapy in elderly and cirrhotic patients with hepatocellular carcinoma k. kakisaka , h. kuroda , k. kasai , y. takikawa , k. suzuki iwate medical university background and purpose: a tendency of the aging in patients with hepatocellular carcinoma (hcc) is predominantly seen in japan. in fact, the mean age of patients with hcc in our institute in was . years old, while that in was . years old. it is not still remained whether the percutaneous radiofrequency ablation (rfa) therapy in elder patients with hcc is safety and equal in therapeutic usefulness compared to the non-elder patients with hcc. subjects and methods: two hundred six cirrhotic patients with hcc ( tumor nodules) received rfa therapy curative intent since august, were enrolled. we divided all patients into two groups: over years (elder group: n= ) and under years (non-elder group: n= ), and compared the patient's characteristics, tumor factors and survival rate and causes of death in two groups. results: the characteristics of patients, tumor factors, cumulative survival rate and recurrence rate were not revealed in two groups. although in elder group two patients complicated aspiration pneumonia and respiratory depression due to sedation under rfa respectively, total occurrence rate of complications did not differ between two groups. conclusion: rfa therapy is safety and effective even in elder patients with hcc, although their care is necessary to prevent any complications which are often occurred during the rfa therapy. background and purpose: the aim of this study is to evaluate whether administration of the branched-chain amino acid (bcaa) enriched nutrient (namely, aminoleban en, ostuka pharmaceutical company, japan) might improve protein-energy malnutrition (pem) status and quality of life (qol) in cirrhotic patients with hcc receiving rfa therapy. subjects and methods: thirty-five cirrhotic patients with hcc who had received rfa therapy from october to october in our institute were randomized into two groups: diet with supplementation of aminoleban en (en group: patients, kcal/day) and diet only (control group; patients). the total intakes of calories ( - kcal/kg) and protein ( . - . g/kg) were equal between tow groups. the primary end point was event-free survival rate (development of liver cancer, rupture of esophageal varices, or progression of hepatic failure) and second end points were serum albumin levels and the health-related qol by shortform- questionnaire (sf- ). results: total intakes of calories and protein were similar during the one year after rfa. no significant differences in event-free survival rate were seen between two groups. however, decreased serum albumin levels and one (general health perception) of domains in sf- were significantly improved in en group compared to the control group. conclusion: supplementation of bcaa-enriched nutrient may improve the impaired liver function and qol after rfa therapy. large scale prospective study should conduct to confirm these results near the future. backgrounds and aims to investigate the effects of selective cox- and cox- inhibitor on proliferation and apoptosis of hcc cell. methods hep b and snu cells were treated with ns- and sc- . mtt assay, caspase / activity assay and tunel assay were performed. cox protein and mrna expression were measured by western blot and real time rt-pcr. results in hep b cell line, cox- , cox- ( , , um) and combination ( + , + , + um) treatment after hr showed a significant dose dependent inhibitory effect on cell growth (p< . ). cox- , cox- ( um) and combination ( + , + um) treatment after hr significantly increased caspase / activity (p< . ) and induced apoptosis (p < . ). however, the combination treatment could not showed a additive effect to cox- or cox- inhibitor (p> . ). in snu cell line, cox- inhibitor and combination treatment showed a inhibitory effect on cell growth (p < . ) similar to hep b cell line but any of treatment could not induce apoptosis significantly (p > . ). in cox protein and mrna expression, snu cell line showed significant cox- predominency (p= . ) but hep b cell line showed cox- predominency (p= . ). conclusions in hcc cells, no additive effect of the combination treatment of cox- and cox- inhibitors could be anticipated. the apoptosis inducing effect of cox inhibitor could be different between hcc cell lines. more studies for the mechanism of different response to cox inhibitor between cell lines is needed. background: the aim of this study was to determine the maximum tolerated dose and recommended dose of combination chemotherapy with mitoxantrone and uracil/tegafur (uft) (phase i part), and to clarify its efficacy (tumor response, overall survival, and progression free survival) and safety in patients with advanced hepatocellular carcinoma (hcc) at the recommended dose (phase ii part). methods: patients eligible for study had histologically confirmed, chemo-naïve advanced hcc, who were unsuitable for resection, local ablation therapy or transcatheter arterial chemoembolization. the therapy consisted of mitoxantrone dosages ( , and mg/m /day) intravenously on day and oral administration of uft mg/m on day through day . the treatment was repeated every four weeks if there was no evidence of tumor progression or unacceptable toxicity. results: a total of patients were entered into the study. all had a good ecog performance status score of - . in phase i part, dose limiting toxicities occurred in all three patients (two patients: grade neutropenia, one patient: grade creatinine elevation) given mitoxantrone at dosage of mg/m /day, and the recommended mitoxantrone dosage was mg/m /day. among patients administered at the recommended dosage, one patient ( . %) achieved a partial response, patients ( . %) had stable disease and patients ( . %) had progressive disease. one-year survival proportion, median survival and median progression free survival were . %, . months and . months, respectively. the most common toxicities were grade - leucopenia ( . %) and neutropenia( . %). conclusion: mitoxantrone mg/m with uft mg/m /day is recommended dose. this regimen is generally well tolerated, but appears to have little activity for advanced hcc. these findings do not support its use in practice, and further trials with this regimen in patients with advanced hcc are not recommended. the study assessed the benefits of -d reconstruction of spiral ct scans for the diagnosis of and surgical guidance to large liver tumors or tumors at the hepatic hilum. we retrospectively analyzed cases of children with such tumors treated in past years.the patients were examined by -d reconstruction using slice spiral ct. in cases, the volume of tissue removed exceeded / the entire volume of the liver. in cases, the excised tissue represented less than / of the total liver volume, but the location of the tumor was adjacent to major hepatic vessels. pathological diagnoses included hepatoblastoma (n = ), hepatocellular carcinoma (n = ), mesenchymal hamartoma (n = ), teratoma (n = ) and adenoma (n = ). all children had curative resections with tumor-free microscopic margins. -d ct imaging can provide high quality images and accurate location of the tumors. it could help the surgeon identify the tumor borders accurately and devise a safe surgical strategy. with its help the surgeon could identify vital hepatic blood vessels before operation, and can avoid massive hemorrhaging during operation. background: to investigate the association between c- t polymorphism of transforming growth factor (tgf)- gene and hbv-related hepatocellular carcinoma (hcc). methods: patients with hbv infection ( cases were hbv carriers, cases were hcc) and healthy volunteers were enrolled. the polymorphism of tgf- gene c- t was identified by polymerase chain reaction-restriction fragment length polymorphism method. the concentrations of plasma tgf- were measured by enzyme linked immunosorbent assay (elisa). tgf- mrna expression was quantified by real-time pcr. a recombinant construct containing - c>t variant as promoter and cat as reported gene was transfected into hepg cells. the reporter gene cat was detected with elisa. results: the ct genotype at position - of tgf- gene prevailed in all three groups, the frequency of genotype cc and allele c at - in hcc were significantly higher than those of the hbv carriers and controls. the plasma tgf- concentration among the three genotypes did not show any significant difference in three groups. however, both the tgf- concentration and liver mrna levels were statistically higher in patients with cc genotype than in those with tt genotype in the hcc group. reporter gene cat was elevated when hepg were transfected with - c-cat recombinant construct compared to that with - t-cat one (p< . ) conclusion: the presence of c allele at position - may play an important role in the development of hbv-related hcc through influencing tgf- expression both at mrna level and protein level. background: to assess diagnostic value of n-glycan markers in identifying hepatocelluar carcinoma (hcc) from liver fibrosis after hbv infection. methods: a total of cases of hbv related liver fibrosis (n= ) and hcc (n= ) patients as well as matched healthy controls (n= ) were recruited. routine liver function and tumor markers were detected by automatic biochemistry or immunological analyzer. n-glycome of serum protein was profiled by dna sequencer-assisted fluorophore-assisted carbohydrate electrophoresis with a capillary electrophoresis-based abi sequencer. results: the abuncance of a single agalacto biantennary glycan (ng a f, peak ) was increased in liver fibrosis and decreased in hcc, while that of a branching triantennary glycan (na fb, peak ) was decreased in fibrosis and increased in hcc. the efficacy of the log ratio of above two n-glycan abundance [log (p / )] was similar to afp in differentiation hcc from fibrotic patients. with logistic regression analysis, the accuracy and sensitivity of the diagnostic model combining afp with n-glycan analysis(cscore b) were increased - % compared to afp. log(p / ) was even more powerful in monitoring the progresison of hcc with the specificity improved % and accuracy improved % compared to that of afp. besides, log(peak / ) was correlated well with other tumor markers and tnm stages. conclusions: the log ration of the abundance of a branching triantennary glycan (na fb, peak ) to a single agalacto biantennary glycan (ng a f, peak ) and the model combining afp with n-glycome markers are promising in hcc diagnosis and progression monitoring. the low incidence of tumor seeding and post-procedure bleeding after radiofrequency ablation (rfa) of hepatic tumors has been attributed to the use of thermocoagulation of the tract, which results in necrosis, upon electrode withdrawal. however, different investigators use different techniques with no experimental evidence of the effectiveness of a particular technique. objective: we aimed to compare the necrotic zone produced using different electrode withdrawal techniques. methods: eighteen tract ablation zones were created in ex vivo porcine livers by withdrawing an internally-cooled rfa electrode (cool-tip radiofrequency system, valleylab) - mm/second using energy-dependent ( vs. vs. vs. watts) and temperature-dependent ( vs. c) techniques. horizontal mathematical modeling suggests an impractical number of radiofrequency ablation (rfa) zones needed in order to ablate a medium-large hepatic tumor. however, overlapping rfa zones may increase the necrotic diameter disproportionately to that deduced from single ablation alone. objectives: to compare the necrotic diameter in single (group ), dual overlapping (group ) and dual non-overlapping (group ) ablation. methods: single (n= ) and dual (overlapping n= ; non-overlapping n= ) ablation zones were created in ex vivo porcine livers using cool-tip rfa electrodes. necrotic diameter was measured at the midpoint (maxd) of the single and the two distinct rfa zones of the dual ablation groups and compared with the necrotic diameter at the tip of the second ablation (maxd-o), corresponding to the point of overlap in group . the rfa electrode was withdrawn . and . cm before re-ablating for group and group , respectively. results: despite no difference in end-rfa temperature between groups (group = . + . cvs.group = . + . cvs.group = . + . c; p= . ), maxd was significantly greater (p= . ) in group ( . + . cm) as compared to group ( . + . cm) and group ( . + . cm), with no difference between group and group (p= . ). further proof of synergism between two overlapping ablations is that the maxd-o in group ( . + . cm) was larger than maxd of group (p= . ) and group (p= . ), and was similar to maxd of group (p= . ). conclusions: overlapping two rfa zones results in incremental increase in necrotic diameter compared to single and dual non-overlapping ablation. this may explain the discrepancy in the number of ablation zones needed between clinical and mathematical modeling studies. background: hepatocellular carcinoma (hcc) is the fourth most common cancer worldwide, main etiological factors being chronic infections with hepatitis b and c viruses. the present study was undertaken to evaluate the association of glutathione-s-transferase (gst) t and m null genotypes and microsomal epoxide hydrolas e(mephx) polymorphisms with hepatitis virus related hcc risk in indian population. subjects and methods: three groups of subjects were considered viz. control (n= ), chronic viral hepatitis (n= ) and hcc (n= ). pcr-rflp was used for this polymorphic study. genotype distributions between categories were compared using the test; odds ratios (ors) and % ci were calculated to express the relative risk. results: presence of gstm null genotype significantly (p< . ) decreased the risk for hcc development among chronic viral hepatitis subjects. however, gstt null genotype was associated with an increased risk for hcc by . and . times among control and hepatitis subjects respectively. in case of mephx, tyr his and his his genotypes significantly (p< . ) reduced the risk of hcc development in both viral hepatitis and control subjects. in case of mephx exon genotypes, arg arg imposed an approximate fold risk for hcc development in the two groups. combination of heterozygous mutant genotypes at mephx exons & also imposed around fold risk (non-significant) for hcc. conclusions: polymorphic forms of gst and mephx share an association with viral related hcc risk in indian population and should be further evaluated as the candidate genes to determine individual susceptibility for viral related hcc. background : the association between type diabetes mellitus (dm ) and hepatocarcinoma (hcc) has been identified in the last ten years. methods: to clarify the temporal relationship between dm and hcc and the possible effects of antidiabetic therapy on hcc risk, we recruited patients with hcc compared with control subjects without liver diseases and cirrhotic patients. results: prevalence of dm was . % in hcc, . % in cirrhotic and . % in control group. in univariate and multivariate analysis, the odds ratio (or) for hcc in diabetic patients were respectively . (ci . - . ; p < . ) and . (ci . - . ; p= . ). or in univariate analysis were higher in male than in female patients. in . % of the patients dm pre-exists the diagnosis of hcc from a mean time of . months. moreover, the insulin treatment was more frequent in diabetic hcc patients than controls and we report an or for hcc of . (ci . - . ; p= . ) in patients treated with insulin or sulfonylureas, and an or of . (ci . - . ; p= . ) in patients treated with metformin. conclusion: our study confirms that male patients with type diabetes mellitus have a significantly increased risk of hcc independently of other cofactor such as hbv, hcv and alcoholic abuse. dm is a pre-existing disease in most hcc patients and suggests that insulin and sulphonylurea treatments in dm are associated with an increased risk of hcc development, while metformin may have a protective effect. background & aims: over the last few years, techniques that allow systematic analysis of chromosome aberrations at a genome-wide level were applied to hcc. the purpose of this study is to apply gene loss expression profiling in the attempt to discover new related genomic regions not revealed by loh or cgh, and search the new tumor suppression genes for hcc. methods: primary hcc and corresponding non-tumor liver tissues were obtained from surgery. serologically, cases were with hepatitis b virus infection and cases were with hepatitis c virus infection. four non-viral infected tissues from four patients receiving surgical resection for hepatic adenoma or focal nodular hyperplasia.affymetrix genechip, u a, was used to compare the loss and gained gene expression in liver needle biopsy samples (n= ). results: after adjusting by chromosome arm length, p, p, p, q and q showed higher gene loss-expression ratio (>= loss / cm) in the comparison between normal samples and tumor samples; q, p and q showed higher gene loss-expression ratio in the comparison between tumor and non-tumor tissues. more than genes showed different loss expression level in this study. for example, cd was loss expression in all non-tumor samples comparing to four normal samples. ficolin and ficolin were loss expression in hcc samples with hbv infection and with hcv infection, respectively. conclusion: our results revealed the potential tumor suppression genes and the genomic region they harbored. further study is needed to validate the observation. background/aims: hepatocellular carcinoma is common malignancy in human, accounting for million deaths in the world annually. caspase , as an initiator caspase, is involved in the induction of apoptosis. survivin, a novel inhibitor of apoptosis is related to the ability to inhibit caspases and involved in critical steps of onset and progression of hcc with unfavorable prognosis. methods: to explore the possibility that the epigenetic alteration of caspase and survivin genes is implicated in the development and progression of hcc, promoter methylation of two genes was analyzed in cases of primary hcc by methylation specific pcr. the relationship between immunohistochemical expression of gene products and proliferative/apoptotic indices, and clinicopathologic parameters was also investigated. results: the methylation of caspase ( . %, / ) and survivin ( . %, / ) demonstrated a negative correlation with immunohistochemical expression of capsase ( . %, / ) and survivin ( . %, / ) (p= . and p= . respectively). methylation of caspase and immunohistochemical expression of its gene product was significantly correlated with apoptosis (p= . and p= . ). survivin nuclear immunoreativity revealed significantly correlated with proliferative activity of tumor cells (p= . ). by survivial analysis, the negative caspase expression and positive survivin expression showed worse prognosis in hcc, that was statistically insignificant (p> . ). conclusion: in conclusion, caspase and survivin may contribute an important regulatory mechanism for tumor cell proliferation and apoptosis, and may be prognostic predictors in hcc. injection was recently reported to be effective against hcc with pvi, though the therapy is not always applicable for the patients with arterial abnormality. therefore we tried combination therapy of transcatheter arterial cisplatin embolization and radiation, and will report the effectiveness and toxicity of the therapy. methods: the combined therapy was conducted in hcc patients with pvi. transcatheter arterial embolization with mg/kg cisplatin powder (ia call) was performed against intralobar lesions, followed by external radiation targeted for pvi ( gy in gy fractions). the following variables were evaluated with the survival rate: gender, age, viral etiology, child's class, performance status, and location of pvi. results: one ( %) patient showed complete response and another two ( %) partial response. two ( %) showed no change, and one ( %) showed progress of disease. the survival rates at six months among overall patients were . %. adverse events were limited to nausea and appetite loss. one of the patients with partial response underwent curative resection, and is still alive without any recurrence for days. conclusions: the combination therapy of cisplatin embolization and radiation is safe, effective and also feasible to the patients with arterial abnormality. this therapy is suggested to be a useful alternative therapy for the patients with extensive pvi. recently, the injection port has been used for hepatic arterial infusion chemotherapy (hai) in japan. hai is usually used for the treatment of multifocal bilobar tumors of the liver or hccs combined with portal vein tumor thrombosis (pvtt), not amenable to tace. this study examined the efficacy and toxicity of repeated hepatic hai using lipiodol suspension mixed with cisplatin powder. methods: from april to september , patients with inoperable advanced hcc were enrolled in this study. all received cisplatin powder ( mg) and lipiodol ( ml) suspension, with an intervening weeks interval. the drugs were delivered from an injection port. patients had hcc with pvtt, and had hcc without pvtt. patients with liver function of child grade a, of grade b, and of grade c were enrolled. result: the mean number of hai given during the follow-up period was . times. we found complete response in case, partial responses in , no change in , and progressive disease in . the overall response rate was . %. the -year survival rate was . % and the -year survival rate was . %. although patients had cisplatin-induced anaphylaxis, no severe adverse events (hepatic failure and renal failure) were observed. conclusion: chemo-lipiodolization using cisplatin powder delivered via an injection port provides some clinical benefits without severe adverse events in patients with far advanced hcc. background: recently, the antitumor efficacy of angiogenesis inhibitors is expected in the treatment to hepatocellular carcinoma. the gene expression relevant to the vascularization, which is a target of these inhibitors, has a difference according to each case and it is thought that it influences the therapeutic effect of them. however, there are still few reports of mrna expression of vascular endothelial growth factor (vegf) receptors in hcc. methods: the relative mrna level of vegf and its receptors (kdr and flt- ) was analyzed using quantitative rt-pcr in patients with hcc. matched samples of hcc (t) and non-tumor liver tissue (nt) were obtained by fine needle ( gauge) biopsy. results: gene expression level of vegf and flt- was significantly higher in hcc than nt (vegf; p< . , flt- ; p< . ). according to the clinicopathological findings, gene expression level of vegf and kdr in hcc was significantly high in hypervascular hcc compared to hypovascular hcc (vegf; p= . , kdr; p= . ). additionally, flt- tended to be expressed higher in hypervascular hcc than hypovascular hcc (p= . ). moreover, gene expression level of vegf, kdr and flt- tended to be higher in advanced-stage hcc than early-stage hcc. conclusion: not only vegf but kdr and flt- were highly expressed in hypervascular and advanced hcc. aims: fibrinogen-like protein /fibroleukin (fgl ) has been reported to play a vital role in the pathogenesis in mhv- (mouse hepatitis virus) induced fulminant and severe hepatitis, spontaneous abortion, allo-and xeno-graft rejection by mediating "immune coagulation". fgl functions as an immune coagulant with the ability to cleave prothrombin to thrombin directly. therefore, this study was designed to examine the role of fgl in tumor development. methods: tumor tissues from patients with six types of distinct cancers and the animal tumor tissues from human hepatocellular carcinoma (hcc) model on nude mice (established from high metastasis hcc cell line mhcc lm ) were obtained. results: hfgl was detected in tumor tissues from out of patients as well as tumor tissues collected from human hcc nude mice. hfgl was highly expressed both in cancer cells and interstitial inflammatory cells including macrophages, nk cells, and cd + t lymphocytes and vascular endothelial cells. hfgl mrna was localized in cells that expressed hfgl protein. fibrin (nogen) co-localization with hfgl expression was determined by dual immunohistochemical staining. in vitro, il- and ifn-increased hfgl mrna by - folds and protein expression in both thp- and huvec cell lines. one-stage clotting assays demonstrated thp- and huvec cells expressing hfgl had increased procoagulant activity following cytokines stimulation. conclusion: the hfg contributes to the hypercoagulability in cancer and may induce tumor angiogenesis and metastasis via cytokine induction. . the therapy was either terminated at the end of the first cycle in cases with progressive disease, or continued for at least cycles, when responses to treatment were evaluated by eastern cooperative oncology group criteria. results: of patients treated (male, %; median age, years), % had child-pugh a, and % had b. % had either metastasis or vascular invasion. % had metastasis and % had vascular invasion. on the basis of independent assessment, three ( . %) patients achieved a complete response, thirteen ( . %) had a partial response, and ( . %) had stable disease. there was no grade / drug related toxicities. median overall survival was . months. conclusion: combination therapy of ifn + -fu has modest efficacy in hcc. background: amt is a mixture of approved pharmaceuticals in low therapeutic doses (human insulin and chlorpheniramine) and herbal components (aqueous camomile extract). preclinical and phase i data in healthy volunteers showed a favourable safety profile for amt. this pilot study should examine efficacy and safety of amt in the patients with advanced hepatocellular carcinoma (hcc). methods: thirteen patients with advanced hcc (tnm stage iii-iv), who did not respond to existing therapy, were treated with i.m. amt at . ml/kg up to a maximum volume of ml twice daily for - months. primary study objectives: clinical benefit response (cbr). secondary objectives: safety of amt, tumor response according to who-recist criteria, quality of life (qol) and iimmunomodulatory effects. the effects were evaluated by cytokine production of pbmcs before and after the treatment. results: there were no significant safety issues. four and patients showed positive and stable responses for cbr, respectively. tumor response was pr, sd and pd. even in the patients with pd, and patients showed positive and stable responses for cbr. qol data showed clear improvement. immune monitoring demonstrated effects of amt on the functional immune parameters in about half of patients. in the patients with pr, histological examination showed tumor necrosis and many lymphocytes including plasmacytes infiltrating in the tumor. conclusion: these results suggest that a promising rate of patients with advanced hcc respond clinically to the amt treatment without significant safety issue and amt has some immuno modulatory capacities. background/aims: dysplastic nodules are important due to premalignant potential. the aim of this study was to evaluate the electron microscopic findings of liver dysplastic nodule in patients with liver cirrhosis. methods: a total of patients (mean age: ± years old, male ) with dysplastic nodules which suspected as malignant nodule (mean size . ± . cm) was enrolled from cases of liver cirrhosis undergone ultrasonography-guided biopsy from december to january . the etiologies of liver cirrhosis were as follows; alcohol ( patient), hepatitis b virus ( ), and hepatitis c virus ( ). results: hepatocytes showed rosette formation of regenerative hepatocyte or degeneration. the nucleus was round or oval shaped and the nucleus membrane was irregular. the nucleolus was prominent and clear, the mitochondria were crowded to one side in the cytoplasm with megamitochondria. glycogen granules and lipofuscin pigments were abundant. sinusoid formation was poorly developed and collagen fiber bundles were increased. the hepatocytes of rosette formation and bile ductules cell made of canal of hering, which was dilated and microvilli was decreased. the number of canal of hering was , which was composed of . ± . with hepatocyte and . ± . with bile ductule cell, respectively. there was no oval cell in the canal of hering, which was relatively well developed. schwann cells were clustered together in nerve plexus. therefore, these electron microscopic findings showed that dysplastic nodule was similar to early hepatocellular carcinoma. conclusions: this study showed that dysplastic nodule in liver cirrhosis is nearly identified to early hepatocellular carcinoma. dcp is an important risk factor for recurrence after radiofrequency ablation of single hepatocellular carcinoma -< cm in diameter r. kuromatsu , a. takata , n. fukushima , s. sumie , m. nakano division of gastroenterology, department of medicine, kurume university school of medicine background and aims: the aim is to analyze the risk factors for local recurrence + intrahepatic metastasis after radiofrequency ablation (rfa) and hepatic resection (hr) for single hepatocellular carcinoma (hcc) < cm in diameter. methods: between and , patients with single nodule < cm in diameter and child-pugh grade a were treated by hr and rfa, and recurrence rate and survival rate using kaplan-meier method, and important risk factors for recurrence using cox's proportional-hazards regression model were analyzed. factors used for multivariate analyses were age, gender, viral marker, tumor diameter, afp, afp-l , dcp, and platelet count. results: mean age was years old, m/f ratio was / , hr/rfa was / , and mean observation period was days. five-year survival rates, and -year local recurrence-free + intrahepatic metastasis-free rates were not significant between hr group and rfa group ( / %, / %). in rfa group, the only independent risk factor for local recurrence-free + intrahepatic metastasis-free survival was dcp (p= . ). tumor diameter was not significant for recurrence. in hr group, there was no risk factor for recurrence. in pathological analyses of hr group, dcp had a tendency to associate with microvascular invasion (p= . ). conclusions: rfa was effective for hcc < cm in diameter and dcp < mau/ml. hepatic resection should be selected for single hcc with dcp > mau/ml even though hcc < cm in diameter. background: radiofrequency ablation (rfa) is now a common treatment for small hepatocellular carcinoma (hcc). however, critical complications after rfa such as rapid intrahepatic dissemination have been reported. in this study, we investigated the method how to estimate the malignant potential of small hcc by dynamic ct before rfa. methods and results: firstly, hccs less than cm in diameter were analyzed. those tissues were classified into groups as followed, small nodular type with indistinct margin (type e), simple nodular type (type ), simple nodular type with extranodular growth (type ), confluent multinodular type (type ). in the type and groups, portal invasion over vp were observed more frequently than those in the type and e groups. at the next step, these hccs were classified into above-mentioned types by two radiologists according to the shape of early stain or defect of delay phase of dynamic ct before operation. the accorded rate was % between those classifications. next, patients, which had solitary hcc less than cm in diameter and treated with rfa, were classified into those types by dynamic ct before rfa. the recurrence rate and prognosis of those patients were examined. in the type and groups, the recurrence rate was higher and significant worse prognosis was showed than those in type and e group . conclusion: it was suggested that hcc with type and might process higher malignant potential and rfa should be carefully performed on those types of hcc. background/aims: hypoxia-inducible factor- (hif- ) is the central transcriptional factor in the cellular response related to various aspects of cancer biology, including proliferation, survival, angiogenesis, and extracellular matrix metabolism to hypoxia. il- became known to replace hif- functions in the other cancer cell lines. the aim of this study was to evaluate whether il- may induce angiogenic factors without hif- by inflammation signal of hypoxic condition. methods: hif- knockdown cell lines of hcc (huh and hepg ) were constructed by rna interference tools, and cultured under normoxia ( %o , hours) and hypoxia ( %o , hours) conditions. following transfection, the amounts of hif- , il- , angiogenic factors and matrix metalloproteinase (mmp) were examined using rt-pcr and western blotting, respectively. results: the expression of hif- , angiogenic factors, mmp, il- was markedly enhanced in wild types that were cultured under hypoxia, and the hypoxic induction of angiogenic factors and mmp was partially blocked in hif- knockdown hcc cell lines. nf-b inhibitor suppressed angiogenic effects by blocking il- activity. conclusion: these data suggest that il- induced tumor angiogenic factors in hif- knockdown hcc cell lines. background there were some reports that liver caner related to the levele of sera hbvdna our research focused on the relationship between the quantity of hepatocellular hbv cccdna , tdna and liver cancer. methods the samples included the liver tissue of chb patients (chb group) and the para-liver cancer tissue of primary liver cancer patients (phc group) the quantity of hepatocellular hbvcccdna, tdna were assayed by fq-pcr in both groups. result: the quantity of hepatocellular hbv cccdna in chb group was . ± . copys/cell higher than phc group( . ± . copys/cell), p= . ; the quantity of hepatocellular hbv tdna in chb group was . ± . copys/cell higher than that of phc group( . ± . copys/cell),p= . .; conclusion: the quantity of hepatocellular hbvcccdna, tdna can not be used as predictors of liver cancer for hepatitis b patients. hepatic cancer predominantly occurs in males. this is almost a commonsense to most of us. but the detailed mechanisms underlying such phenomenon are still not well-known. the average age of liver cancer patients are about - years old. so most female patients have udergone pregnancy at least one time. pregnancy is a very important event before or during the development of liver cancer in females. in this special period, not only sex hormones secrete in a strange manner, but also immune system functions in a special module which is very different from normal. so it is urgent to investigate the impact of process of pregancy on the development of hepatic cancer. in this study, female sd rats are randomly divided into two groups: pregance group and controll group. rats in both groups are injected iv diethylnitrosomine(a chemical carcinogen). in pregnance group, rats are raised together with male rats in : ratio( female, male) to make every rats undergo pregnancy. while in controll group, rats are coupled with spermaduct-ligated male rats. the size and amount of hepatic cancers in pregancy group are smaller and less than those in controll group. the survial rate is also significantly higer than that in controll group. we conclude that the process of pregnancy exerts an inhibitory role in the development of chemical induced hepatic cancer in rats. acknowledgement: this project was sponsed by the national natural science foundation of china. the number of the grant is : the use of alpha-fetoprotein measurement in detection of recurrent hepatocellular carcinoma after living donor liver transplantation n. yamashiki , , y. sugawara , , s. tamura , r. tateishi , h. yoshida , j. kaneko , y. matsui , n. kokudo , , m. omata organ transplantation service, department of gastroenterology, university of tokyo, department of surgery, university of tokyo background: the recurrent hepatocellular carcinoma (rhcc) after liver transplantation (lt) can occur in to % of transplant recipients despite with a careful patient selection. for the surveillance of rhcc, frequent measurement of alpha-fetoprotein (afp) and annual ct scan is commonly used. however, the usefulness of afp is not clear. we report the update of our experience using our surveillance protocol. methods: between and march , adult living donor lt were performed at the university of tokyo. among them, recipients with hcc in their explanted liver were subjected to analysis. we used monthly measurement of afp and des-gamma carboxy prothrombin (dcp) with annual dynamic ct scan. results: met milan criteria pre-operatively and did not. were incidental hcc. rhcc was experienced in patients at ( - ) months after lt. recurrence sites were graft ( ), lung ( ), bone ( ), and multiple organs ( ). rhcc was first suspected from elevation of tumor markers in ; afp in , dcp in , and both afp and dcp in . rhcc was confirmed with ct scan ( ) or mri ( ) in ( - ) months after the first sign of rhcc. when the cutoff level of afp> ng/ml was used, the sensitivity and specificity for rhcc were % and %. six cases were treated surgically of which two achieving prolonged survival. conclusions: although the confirmation of the rhcc sites required multiple imaging studies, afp measurement was useful as for the first sign of rhcc. purpose: to evaluate the therapeutic effect of heated ( c) lipiodol via hepatic artery administration in vx rabbit liver cancer model. materials and methods: thirty male new zealand white rabbits were randomly divided into groups with rabbits for each group. vx carcinoma cells were surgically implanted into the left liver lobe. the tumors were allowed to grow for weeks, and studies were performed until the diameter of tumors detected by ultrasonograph reaching to cm. under the anaesthesia, transcatheter hepatic arterial embolization was performed and doxorubicin-lipiodol ( ºc) ( ml), lipiodol ( ºc) ( ml) and control (physiological saline ( ºc) ( ml)) were injected into hepatic artery of the different groups. one week later, the volume of tumor was measured by ultrasonograph again. the serum of all rabbits was collected before injection and at and days after injection and the level of aspartate aminotransferase (ast) was checked. the survival period of groups of rabbits after treatment was also recorded. during the last course of their disease, the rabbits were given some analgetics to relieve suffering. results: the tumors' growth rate in lipiodol ( ºc) background/aims: hepatocellular carcinoma (hcc) is one of the male-dominant cancers, and hepatitis c virus (hcv) is one of the causes of hcc. it was reported that androgen receptor (ar) is expressed in hcc and its surrounding tissues. androgen signaling and ar may be involved in hepatocarcinogenesis. in this study, we investigated whether hcv interacts with androgen signaling in human hepatocytes. methods: hcv protein expression vectors were co-transfected with ar-expression vectors and ar-responsive element-driven reporter vector into immortalized human hepatocytes (ihhs) and human hepatoma cell lines. kinase inhibitors were used to examine the activation of the akt, mapk, and jak/stat pathways. real-time pcr and western blotting were performed. cell culture grown hcv (hcvcc) were also used, and angiogenesis was evaluated by tubule formation assays in human coronary microvascular endothelial cells in the presence of -androgen- -ol- -one. results: hcv enhances ar-responsive gene expression in the presence of androgen. hcv core protein has the strongest effects and induced ar activation associated with jak/stat signaling. hcvcc enhances vegf mrna expression and angiogenesis. conclusions: hcv core protein is an enhancer in androgen signaling and can be expected to play an important role in hcv-related hepatocarcinogenesis. background: to evaluate the therapeutic outcomes and the toxicity of the combination of arsenic trioxide and the chinese traditional jianpiliqi (jplq) formula in the treatment of advanced hepatocellular carcinoma (hcc). methods: patients with advanced hcc, not suitable for resection but with normal major organ functions, were enrolled to receive a therapeutic regimen consisting of intravenous arsenic trioxide ( mg / m ) administration from days - , and an oral administration of jplq formula twice daily from days - . each cycle was composed of days and treatment could expand up to cycles before evidences of intolerable toxicity or disease progression. result: one patient had partial response, one had minor response, showed stable disease and ( . %) had disease progression. total disease control rate was . %, median survival time was . months ( - . ms), and time to progression was . months ( - . months). the incidences of grade - abdominal distention and nausea/vomiting were . % and . %, respectively. increases in ggt occurred in patients ( grade , grade , and grade ) and increases in serum creatinine in patients ( grade and grade ), respectively. conclusion: compared with the single arsenic trioxide treatment reported in past literature, treatment by arsenic trioxide combined with jplq showed modestly higher anti-tumor activity and tolerable toxicity in patients with advanced hcc; its manageable toxicity and increased tumor response rate may offer a better treatment regimen, and deserve further investigation. aim: to investigate the effect of osteopontin (opn) expressions down-regulated by rna interference (rnai) on the invasion and metastasis of human hepatocelluar carcinoma (hcc). methods: hcc cell line (hcc-lm ) was transfected with the chemically synthesized small interfering rna (sirna) in study arm and with non-specific sirna in control arm. real-time pcr and western blotting were used to quantify the mrna and opn protein levels. the malignant phenotypes including cellular growth rates, colony formation and matrigel invasion activities of the hcc cell line were analyzed. results: in study arm opn mrna expressions decreased % and opn protein decreased % compared to those of blank arm. the number of formed colonies and migrating numbers of the cells in vitro decreased significantly ( . % and . % respectively) in study arm compared to these of blank controls (p< . ). the parameters in the control arm did not differ from those of the blank arm (p> . ). conclusion: the specific sirna was able to reduce opn expressions at both the mrna and protein levels and significantly diminished the invasiveness of hcc cells. methods: the expressions of mif and vegf in hcc and adjacent tissues were detected from patients. specific sirna targeting mif gene was synthesized, and transfected into the hcc cell lines (plc and hepg ) in study group and non-specific sirna was used in controls. the mrna and protein expressions of mif and vegf were examined by pcr and western blot. results: mif and vegf mrnas were overexpressed in the hcc tissues compared with adjacent tissues (rq= . ± . and . ± . , p . ). the mrna and protein expressions of mif and vegf of hcc cell lines significantly decreased in study group compared with controls (p . ). vegf mrna levels decreased . %± . %; . %± . % in plc, and . %± . %; . %± . % in hepg cells when disposed with sirna nm and nm. vegf protein levels also significantly reduced in study group p . . conclusions mif and vegf mrnas were overexpressed in the hcc tissues in vivo, and mif sirna was able to knock down the expressions of mif and vegf in hcc cell lines in vitro. y.y. li, y.c. zhang, y.j. zhou, y.m. wei aim: to identify tumor-associated genes by constructing transcription profiles of pure hepatocellular carcinoma (hcc) tissues and normal liver tissues with the combination of laser capture microdissection and microarray. methods: hcc cells and normal liver cells from resection samples of patients were laser capture microdissected. micro-rna was isolated from them for linear amplification then crna was tested with whole genome microarray. differentially expressed genes were screened. results: the quality control of this technique was satisfactory with rna integrity number> , a /a ratio for crna measurement= . ~ . and good pictures for microarray. compared with normal liver tissues, hcc had differentially expressed genes, with being up-regulated and being down-regulated genes respectively. among the top ten ranked up-and down-regulated genes (total ), genes were known as hcc differentially expressed genes, , known as other tumors expressed genes previously. four unknown tumor related genes (depdc b, aspm, fcn and bbox ) were detected in this study. conclusion: the combination with laser capture microdissection and microarray was effective in screening the differentially expressed genes of hcc. background/objective: young patients present with large hcc on initial presentation are not uncommon. our aim is to study the computed tomography(ct) imaging of hcc and the clinical features of this special group of patients. methods: hcc patients had ct imaging of liver peformed in a three year period, patients had ct imaging peformed at the time of initial hcc diagnosis in our centre and were selected. they were divided into three age groups: young patients with age </= year-old(group ), age to (group ), age > (group ) to study imaging and clinical factors. univariate and multivariate analysis by cox regression model done to look for prognostic predictive factors. results: infiltrative tumour in ct scans, symptomatic presentation, child's and tm staging are prognostic factors in hcc. conclusion: young hcc patients have larger infiltrative tumour in initial ct scans and more being symptomatic. age is not an independent prognostic factor. aim: to investigate the expression change of nk cells receptor nkg d from human peripheral blood in patients with primary carcinoma of liver and study the relationship between nkg d expression and cytotoxicity of nk cells. background/aims: lens culinaris agglutinin-reactive alpha-fetoprotein (afp-l ) is a specific protein produced by hepatocellular carcinoma(hcc), which is more valuable than afp in the diagnosis of hcc. aptamers are oligonucleotide ligands binding to target molecules sensitively and specifically, which are screened from a great capacity of synthetically oligonucleotide library by systematic evolution of ligands by exponential enrichment (selex). our aims were to select the aptamers against afp-l from a self-designed ssdna library for potential application in diagnosis of hcc. methods: a random ssdna library and its corresponding primers were designed and synthesized. aptamers against afp-l were selected by selex. individual aptamers were separated by polymerase chain reaction-single strand conformation polymorphism (pcr-sscp) analysis and characterized. results: a ssdna library of nucleotides with random nucleotides in middle were designed and used for the selection. the binding rate of library against afp-l was increased from . % to . % after round selection. seven aptamers (s to s ) were isolated, and their sequences in random region and secondary structures were different from each other. all aptamers could bind afp-l in a different extent, and the dissociation constants of s and s are nmol/l and nmol/l. conclusions: aptamers for afp-l are successfully screened out and could bind afp-l specifically. methods: flow cytometry was used to determine the number of nk cells and the expression of nk cells receptor nkg d from human peripheral blood in patients with case primary carcinoma of liver case hepatitis b cirrhosis case hepatitis b and healthy cases and enzyme mark instrument was used to detect cytotoxicity of nk cells in all cases. results: killing rate of nk cell for k cell,nkg d expression level of nk cells, and the number of nk cells in the patients with primary carcinoma of liver decreased significantly p< . compared with those in the healthy subjects and hepatitis b group ,and decreased a little compared with those in the hepatitis b cirrhosis (p> . ).the activity of nk cells showed a obvious positive-correlation with the number of nk cell and expression level of nk cell receptor nkg d. conclusion: the cytotoxicity of nk and the nkg d expression of nk cells decreased significantly from human peripheral blood in patients with primary carcinoma of liver .the activity of nk cells is closely related to the nkg d expression level of nk cells. enhancing the nkg d expression level of nk cell may provide a new idea for adoptive immunotherapy of primary carcinoma of liver. and alpha-fetoprotein afp in serum and tissues for primary hepatic cancer(phc). methods: sixty-six phc and cirrhotic patients were enrolled. in phc patients,male /female was : , age was . ± . .of them, patients were defined as stage a-a. in cirrhotic patients, male /female was : , age was . ± . . serumgpc was detected using elisa. serum afp was detected using electrochemiluminescence. the hepatic expressions of gpc and afp were measured using immunohistochemistry in phc and cirrhotic patients. results: the cutoff value of afp diagnosis for phc was g / l or more, afp positive in phc patients was . % ( / ); the cutoff value of gpc diagnosis for phc was ng / l or more, gpc positive was in . % ( / ), p = . . in a-a stage phc patients,the positive of gpc and afp was . % ( / ), ( / ), respectively,p = . . in serum afp negative or positive patients, the positive of gpc was . % ( / ) , . % ( / ), respectively,p = . . the relationship between gpc with age, sex, child-pugh grade, hbv infection, tumor size and metastasis were not observed.the positive expression of gpc and afp in hepatocellular carcinoma tissue was . % ( / ), . % ( / ), respectively, p = . . neither gpc ,nor afp in the paracarcinomatous and cirrhotic tissue, was expressed. conclusions: diagnosis of glypican- protein for primary hepatic cancer is superior to afp.gpc can be regared as a early marker to diagnosis phc. objective: to investigate the effects and the possible mechanism of curcumin on the proliferation and the invasion of human hepatocellular carcinoma in vitro and in vivo. methods: hcclm -rfp cell lines were maintained in dmem medium supplemented with % fetal bovine serum. the fluorescent areas of hcclm -rfp were photographed daily and repeated in consecutive days after curcumin treatment for obtaining cell growth curves. the cell morphologic changes were also observed. cell invasion experiment was performed with boyden chamber array. the rfp-expressing human hcc xenograft model in nude mice was established to study the anti-tumor effects of curcumin. the ctc was detected by facs. the expression of cyclind and mmp- was detected by sybr green real-time pcr. results: after incubation with m, m and m curcumin respectively for , and hours, the growth of hcclm -rfp was significantly inhibited and some morphologic changes were observed. the mean tumor size in nude mice treated with curcumin since day were significantly less than those of the control group(p . ). the mean metastasis area of lung and the number of ctc in curcumin group on day were remarkably less than in the control group(p . ). the mrna levels of cyclin d p . and mmp- p . in curcumin group on day were significantly lower than in the control group. conclusion: curcumin can inhibit the proliferation and invasion of hcclm cell line not only in vitro but also in vivo mainly by down-regulating the expression of cyclin d and mmp- in mrna levels. phosphorylated erk is a potential predictor of sensitivity to therapy with sorafenib in hepatocellular carcinoma -evidence from in vitro study z. zhang , y.h. wang background: sorafenib is the first agent that has demonstrated an improved overall survival benefit in advanced hepatocellular carcinoma (hcc) and thus sets the new standard for the first-line treatment of advanced hcc. however, it remains unresolved to predict the drug sensitivity in treating hcc with sorafenib. pretreatment perk level has been shown to be associated with favorable response to such therapy in a phase preclinical study, indicating that perk may be a potential biomarker for treatment of hcc with sorafenib. methods: the effects of sorafenib and -fluorouracil on cell proliferation were evaluated by cell viability assay in four types of hcc cell line (smmc- , mhcc -l, mhcc -h and hcclm ), with different metastatic potential and basal perk expression. levels of perk expression were determined by immunocytochemical analysis and quantification, along with western blot analysis. correlation analysis was carried out between the ic values of drugs and mean optical density values of perk. results: the basal perk levels increased stepwise in cell lines in accordance with their metastatic potential. sorafenib inhibited erk phosphorylation at a concentration between and m dose-dependently, while no changes were observed after -fu treatment. correlation analysis between the ic values and mod values of perk revealed that the effects of sorafenib were significantly correlated with basal perk levels (spearman r=- . , p= . ). on the other hand, the resistance to -fu were significantly associated with basal perk expression in these hcc cell lines (spearman r= . , p= . ). conclusions: in this vitro study, perk was confirmed to be a useful biomarker predictive of sensitivity in treating hcc with sorafenib. the raf/mek/erk pathway may be involved in invasion, metastasis and drug resistance to traditional chemotherapy in hcc. background: to investigate the dynamic expression of igf-ii and igfbp- and its alteration of bcl- in hcc. methods: hcc models were induced with -faa on male sd rats. morphological changes of livers were observed and the dynamic changes of liver or serum igf-ii, igfbp- , and bcl- were quantitatively analyzed by elisa. the expression and distribution of liver igf-ii were observed by immunohistochemistry. result: hepatocytes from granule-like degeneration to a typical hyperplasia to hcc and the progressing increasing of the levels of hepatic igf-ii after rats induced by -faa. the levels of igf-ii in hepatoma and sera were significantly higher than any of other groups. the positive relationship of igf-ii was found between liver and sera (p< . ). the igfbp- levels in hepatoma were significantly lower than that in other groups (p< . ) and the progressing increasing of the levels of hepatic bcl- expression during the course. the levels of bcl- in hepatoma tissues were significantly higher than those in normal and degeneration ones. the immunohistochemistry evidences indicated the positive expression and hepatocyte distribution of bcl- in rat hepatoma. conclusion: hepatic igf-ii, igfbp- and bcl- may participate in hepatocyte canceration and accelerate the occurrence and development of hcc. the expression of igf-ii and igfbp- could be useful molecular markers for early diagnosis and prognosis of hcc. background: this study was done to assess the etiological role of hepatitis b virus (hbv), hepatitis c virus (hcv) and aflatoxin b (afb ) in development of hepatocellular carcinoma (hcc) in bangladesh. it was also investigated whether alpha-feto protein (afp) and protein induced by vitamin k absence or antagonist ii (pivka-ii) has any diagnostic advantage over each other methods: fifty five histologically proven hcc patients were tested for serological markers of hepatitis b and hepatitis c, and afb -dna adduct. during the diagnosis, they were also investigated for liver function tests, afp pivka-ii. results: out of fifty five hcc patients, ( . %) were found positive for serological markers of hbv, ( %) for hcv and ( %) for both. eight cases ( . %) were negative for the markers of hbv and hcv. however, none had afb -dna adduct above normal range. both pivka-ii and afp is strong marker for hcc with satisfactory level of sensitivity and specificity; but pivka-ii is more sensitive ( . %) and afp is more specific ( %). conclusions: hbv and hcv is the major etiological agent responsible for the development of hcc in bangladesh. background: to investigate the influences on the malignant transformation of hepatocytes through the intervention of nf-b activation pathway. method: hcc models were induced with -faa on sd rats, thalidomide was administered intragastrically and rats were sacrificed fortnightly interval to the twelfth week. morphological changes were observed by he staining. nf-b expressions were detected by ihc. the relationship between nf-b expression and pathological characteristics in hcc and non-hcc were analyzed. results: rat hepatocytes showed vacuole-like denaturations at the early stages, then dysplastic nodules appeared at middle stage, and finally progressed to tubercles of cancerous nest, all of which were highly differentiated hcc. thalidomine can repress the morphologic change of liver cells. there were only punctiform denaturations at the early and middle stage; nodosity hyperplasy and minority atypical hyperplasia were found at the finally stage. the ihc results demonstrated that nf-b level was significantly higher than those in normal ones, and the nf-b level of livers in hcc was higher than those in thalidomide group. an increasing tendency of nf-b was found from normal to hcc. nf-b in hcc were significantly higher than those in nc. the nf-b levels with thalidomide intervence raised first and decreased later. nf-b expressions in hcc were higher than that in their non-cancerous tissues. no positive relationship presented between nf-b expression and histological differentiation grade or the number of tumor, and size of tumor. conclusion: decrease nf-b expression can inhibit hcc development and nf-b is expected to be a new molecular target of hcc therapy. method: the cellular distributions of vegf expression in hcc tissues were investigated by immunohistochemistry. the levels of total rna and vegf were quantitatively detected in hcc, their paracancerous, and distal cancerous tissues, respectively. simultaneitily, serum vegf were analyzed in patients with chronic liver diseases for clinical values. results: the positive expression showed palm-yellow or palm-brown granules and distributed in hepatocyte plasma of hccs. the incidence of vegf was . % in hcc tissues, . % in non-encapsulated hccs, and . % in hccs with extrahepatic metastasis, respectively. no significant difference was found between hepatic vegf and hcc diameter or differentiation degree. the specific concentration (pg/mg liver) of vegf expression was significantly higher (p< . ) in hcc than their paracancerous or distal cancerous tissues, respectively. the circulating vegf was abnormally elevated in hcc. if the cut off values was more than pg/ml, the incidence of serum vegf was . % in hcc, . % in chronic hepatitis, and % in liver cirrhosis, respectively. the combined vegf and afp can increase positive rate up to . % for hcc. conclusion: the vegf overexpression is a useful marker for vascular invasion and metastasis of liver tumors. background: hepatocellular carcinoma (hcc) represents a major health problem world wide. it accounts for % of all primary liver cancers and is the fifth most common malignancy ( ). objectives: evaluation of radiofrequency thermal ablation versus transarterial hepatic chemoembolization with the effect of viscum (fraxini ) on tumour recurrence. methods: patients with hcc were enrolled in the study. group include patients and were treated with radiofrequency thermal ablation ( patients of them received viscum by subcutaneous route for years). group included patients with hcc and were treated by tace ( patients of them received viscum subcutaneously for years). results: group patients showed total ablation in % with persistant inactivity during years follow up. group did not show significant difference from group as regards relapse rate nor the performance status. complications as nausea, vomiting, fever, jaundice, and elevation of transaminases were significantly more encountered with tace. viscum did not significantly arrest tumour recurrence. conclusion: non surgical patients with hcc can achieve curative treatment with radiofrequency with minmal side effects. tace is a palliative treatment option for large hcc. a new technique had been attempted to increase the field of radiofrequency ablation of expandable electrode needles in the treatment of hepatic neoplasms much larger than the routinely covered size of - cm according to the needle size overcoming the technical difficulties usually met with in the overlapping balls technique due to the hyperechoic focus that develops at the needle tip making reinsertion difficult and inaccurate. in this technique, two or three needles were inserted from the start into the mass with accurate estimation of the exact field of ablation of each needle trying to cover the whole extent of the mass before application of radiofrequency waves. patients were included in the study, all presented with hepatic neoplastic mass lesion that range in size between and cm in its maximum diameter. all had a pretreatment helical (triphasic) ct study for accurate delineation of the whole extent and vascularity of the mass. two needles were sufficient to cover the whole extent of the mass in patients ( %) while in the remaining patients ( %) three needles were necessary. the procedure was done under general anathesia and ultra sound guidance, patients tolerated procedure well with smooth recovery. no major complications. follow up spiral (triphasic) ct was done weeks after ablation revealed percentage of tumour necrosis of % or more in patients ( %), - % in patients ( %) while in the remaining four patients ( %) the percentage was - % necrosis. in conclusion this technique should be considered in the treatment of hepatic masses larger than the usual field of the needle. results: the median value of gpc- in hcc, dc, cc was significantly higher than chronic hepatitis and control groups. no significant correlation found between afp and gpc- . auroc of afp was . & auroc of gpc- was . . the diagnostic sensitivity of afp ( ng/ml) was % with ppv . %. the specificity was % with npv . %. while the diagnostic sensitivity of gpc- ( ng/ml) was % with ppv %. the specificity was . % with npv %. combined serial approach of afp and gpc- improved the specificity to . %. conclusion:gpc- although it is a serological test for early detection of hcc, it showed limited specificity, where it is detected in different stages of chronic liver disease, as it is an oncofetal protein produced by regenerating liver cells. the diagnostic signature approach for simultaneous determination of afp and gpc- may improve the prediction accuracy of hcc patients in those showing seronegativity to afp. outcome of inoperable hepatocellular carcinoma patients receiving transarterial chemoembolization: retrospective analysis in an asian regional hospital w.m. yip , k.f. li , k.k. li , m.l. szeto background: hepatocellular carcinoma (hcc) is a common cancer worldwide causing substantial mortality. although surgical resection is a form of curative treatment in hcc, only a minority of patients is suitable for this treatment and the postoperative recurrence remains high. transarterial chemoembolization (tace) is a treatment option for inoperable hcc and it was proven by randomized control trials that tace can prolong survival in selected patients. the aim of this study is to evaluate the survival and the prognostic factors in patients with advanced hcc treated by tace. methods: seventy four patients with inoperable hcc diagnosed from january to december were analyzed retrospectively in this study. only patients with unresectable hcc or who refused operation were included. patients with advanced cirrhosis, extrahepatic metastasis or previously treated hcc were excluded. multiple host, tumor and treatment variables were analyzed in order to evaluate the predictive factors of favorable response to treatment and better survival. results: the median survival of the study patients was . days. the cumulative survival rates at year, year and year were . %, . % and . % respectively. by multivariate analysis, superselective cannulation performed in tace (hazard ratio: . , % ci: . - . , p= . ), embolization with gelfoam (hazard ratio: . , % ci: . - . , p= . ), treatment interval more than days (hazard ratio: . , % ci: . - . , p= . ), child-pugh grade b (hazard ratio: . , % ci: . - . , p= . ), and pre-treatment serum fp level (hazard ratio: . , % ci: . - . , p= . ) were independent predictors of survival. conclusions: survival of patients with inoperable hcc is still grave despite treatment. this study provided information in predicting the survival of patients with inoperable hepatocellular carcinoma treated by transarterial chemoembolization. result: age < , total bilirubin (tb) < . mg/dl, albumin (alb) . g/dl, prothrombin time (pt) %, platelet counts (plt) . /mm , single nodule, and type of treatment (surgery or local ablation therapy) were linked to increased survival at univariate analysis of clip - hcc patients. of clip - hcc patients, tb < . mg/dl, alb . g/dl, des-gamma-carboxy prothrombin (dcp) < mau/ml, absence of vascular invasion, and type of treatment were correlated with survival. the following factors were related to survival by multivariate analysis: clip - hcc patients; age, alb, single nodule, and absence of vascular invasion, clip - hcc patients; age, tb, alb, alpha-fetoprotein (afp) < ng/ml, dcp, absence of vascular invasion, and type of treatment. conclusion: age, albumin, vascular invasion were significant predictors of survival both clip - and clip - hcc patients. clip - hcc patients: single nodule; clip - hcc patients: lower levels of tumor markers and patients receiving promising treatment had a better chance of prolonged survival. the role of gross classification as the predictor of microvascular invasion in hepatocellular carcinoma. s. sumie , r. kuromatsu , k. okuda , e. ando , a. takata , n. fukushima , m. sata background; the presence of microvascular invasion (mvi) as the risk factor in hepatocellular carcinoma (hcc) is controversial. the aim of this study was to determine the outcomes and predictive factors after hepatic resection for hcc with mvi. methods; one hundred and ten patients who underwent curative resection for hcc were included in this retrospective study. the risk factors of these patients for recurrence-free and disease-specific survival were investigated, and the clinicopathological factors predicting the presence of mvi were also evaluated. result; multivariate analysis showed that cirrhosis and mvi were identified as independent risk factors for recurrence-free survival. the -year recurrence-free survival rates for patients with and without mvi were . % and . %, respectively. multivariate analysis showed that the number of tumors, presence of mvi, and im were identified as independent predictors of disease-specific survival. the -year disease-specific survival rates for patients with and without mvi were . % and . %, respectively. by univariate analysis, mvi was significantly associated with greater tumor size, gross classification, histological grade, and intrahepatic micrometastasis (im). gross classification proved to be the only independent predictive factor for mvi by multiple logistic regression analysis. the gross classification could be evaluated by preoperative imaging diagnosis. conclusion; mvi is strongly associated with recurrence and survival in hcc patients after curative resection. furthermore, gross classification of hcc can be helpful in predicting the presence of mvi. background: hcc is a common cause of cancer morbidity and mortality. pxd is a novel, low molecular weight, histone deacetylase inhibitor. this phase i study aims to determine dose limiting toxicity (dlt) and maximum tolerated dose (mtd). methods: patient eligibilities include unresectable disease, ecog , adequate organ functions. pxd was given intravenously on day - every weeks; dose levels were: (level ), (level ), (level ) and mg/m /day (level ). dlts are defined as grade hematological toxicity or grade / non-haematological toxicity during cycle (according to nci ctc v ), or treatment delay > weeks. the mtd is defined as the dose below which > of or > of patients experiencing dlt. results: patients were entered; level ( ), level ( ), level ( ) and level ( ). grade / / toxicities in cycle included: raised alt / / , diarrhea / / , abdominal distension / / , anaemia / / . a total of cycles were administered; overall grade / / toxicities: raised alt / / , bilirubinaemia / / ; cardiac ischaemia / / ; diarrhoea / / , abdominal distension / / , anaemia / / ; variceal haemorrhage / / ; hypercalcaemia / / ; hyperkalaemia / / ; hyponatraemia / / ; infection / / ; liver dysfunction / / ; muscle weakness / / ; abdominal pain / / ; prolonged qtc / / ; syncope / / ; seizure / / . there were sd and pd. conclusion: at the maximum dose of mg/m /day, mtd has not been reached. pxd is very well tolerated. sponsor: the division of cancer treatment and diagnosis, national cancer institute, usa. tumor thrombus (pvtt) is prone to be produced in the portal vein near the main tumor nodule for hepatocellular carcinoma (hcc) patients and its molecular mechanism is still unclear. in this study, we first established a hcc cell line named csqt- from resected tumor thrombus in portal vein in a patient with histopathologically proved to be a moderately differentiated hepatocellular carcinoma . this cell line was composed of polygonal shaped cells and its peaks of the chromosome number was and . study on stem cell biology in this cell line suggests that cd cells represent about one fourth of the tumor cell population and cd (+) cells possess a greater colony-forming efficiency, higher proliferative output, and greater ability to form tumor in vivo. with this cell line model and resected tumor thrombi specimen, we also studied the different expression of proteins in primary tumor and tumor thrombus and found proteins expressed differentially between primary tumor and the pvtt. from these proteins, annexinv, prx , cycb were selected for further analysis to find potential biomarkers of pvtt in hepatocarcinogenesis. for clinical study, we recommended a new tumor thrombus type system ( type i iv) according to anatomic features of portal vein and tumor thrombus of hcc developing modes, then evaluate this type system to predict prognosis of hcc patients. the retrospective data of hcc patients with pvtt underwent resection shows that the y, y, y overall survival rates were . , . and . for type i, . , . and . for type ii, . , . and . for type iii, . , and for type iv, respectively, suggests tumor thrombus type system may be helpful to determine treatments and prognosis of hcc patients with pvtt. polyprenol could decrease the risk of hepatocarcinogenesis in hbv g. kuznecova , , s. kuznecovs , , i. kuznecovs , background: over-expression of p-glycoprotein (pgp) is associated with liver cancer development from hbv . glycoprotein synthesis in malignant tissues is limited by dolichyl phosphate (dolp). the aim of the present study was to investigate the effect of polyprenol (pp) which provides a dolp substitute in regulation of n-glycosylation on pgp over-expression in the development of liver cancer in hbv infection. methods human hepatocytes, infected with hbv and human hepatocarcinoma hep b cell line were used. pgp was assessed by an immunohistochemical technique. dolp fractions were analysed by hplc methods. results it is confirmed that plasmatic membrans of hepatocytes cells contain , - , % of pgp (the total protein amount) as a resistance marker. hbv infected cells differ from normal hepatocytes in pgp content by - times and hep b cells differ by - times the study showed -fold dolp decrease in hbv infected cells and -fold dolp decrease in hep b cells. the investigations demonstrate that the situation can be changed by treatment with dolp and pp. the dolp concentration in hbv infected hepatocytes was returned to the normal level. it is established that dolp in the concentration - m aid - -fold reducing pgp in membranes of hbv infected cells. background: metastasis is one of the most complicated and major pathological processes responsible for poor prognosis of hepatocellular carcinoma. snail was recently highlighted as a critical transcriptional factor for tumor metastasis. method & result: real time rt/pcr and western blot analysis demonstrated that snail mrna and protein, respectively, were induced by -otetradecanoylphorbol- -acetate (tpa) in hepatoma cell hepg . blockade of gene expression of snail by antisense oligodeoxynucleotide and/or sirna technique can prevent not only the tpa-triggered emt/cell migration and growth inhibition of hepg but also tpa-induced down-regulation of e-cadherin and up-regulation of p ink b. moreover, the tpa-triggered promoter activation of p ink b was also prevented. on the other hand, two of the hepg clone overexpressing snail, namely s and s , had a scattered fibroblastic morphology and acquired higher motility than parental hepg . also, the proportion of g /g phase of s and s was higher than that of parental hepg , consistent with the longer doubling time of both cells. semiquantitative rt/pcr analysis demonstrated a greatly elevated gene expression of snail accompanied with decreased e-cadherin and increased p ink b in both snail-overexpressing cells. on the transcriptional level, p ink b promoter activity was . -fold higher in s as compared with parental hepg . furthermore, electrophoretic mobility of dna fragments encompassing proximal p ink b promoter can be retarded by incubation of nuclear extract of s . conclusion: our results demonstrated that snail play diverse trans-regulatory roles in hepg . notably, we suggested that snail may upregulate p ink b gene expression by directly activating its promoter. a. schmitt-graeff , r. fischer , m. grosse-perdekamp , o. skalli universityhospital freiburg , louisiana state university health sciences center, shreveport background/aims: synemin is an intermediate filaments (if) protein which affects the motility of several cell types by modulating the dynamic properties of alpha-actinin and f-actin. we have previously shown that synemin is expressed in resident hepatic stellate cells (hsc) and myofibroblasts (mf) in hepatic inflammation and fibrosis. in the present study we evaluated systematically the expression of synemin in a large cohort of western european hepatocellular carcinoma (hcc). methods: single and double immunolabelin for alpha-smooth muscle actin (sma), vimentin, cd , cd , cd , cea, cd , cellular retinol-binding protein (crbp- ) and synemin were performed on paraffin-embedded hccs and controls. results: synemin-positive hscs/ mfs were a hallmark of non-neoplastic fibrotic liver tissue at the border to the neoplastic lesion but were absent from normal controls. tumour cell plates of the trabecular and pseudoglandular types of hcc were covered by scattered synemin-positive cells outlining sinusoidal structures. a subpopulation of these cells showed features of pericytes while others resembled endothelium. this pattern correlated with the degree of differentiation and was not observed in poorly differentiated hccs which generally contained rare intratumoral mfs. conclusion: the presence of synemin-positive hscs/mfs in the vicinity of hccs suggests a possible contribution of mesenchymal cells to the promotion of liver carcinogenesis. since synemin expression is linked to motility, a migration of this cell type into the tumour and a differentiation in vascular mural cells may be implicated in sinusoidal remodeling and the expansion of the neoplastic population. a.s. butt , a. ahmed , s. hamid , w. jafri , h. ali shah aim: to estimate the prevalence of viral marker negative hcc and to compare the clinical, biochemical, histological, radiological characteristics and initial treatment response among patients with viral marker negative and viral marker positive hcc. methods: medical records of patients diagnosed to have hcc visiting aga khan university hospital, karachi during january to december were reviewed. patients were divided in to nbnc-hcc(those who have negative hbsag and anti-hcv antibody)and viral hcc(those who have positive hbsag and anti-hcv antibody)group. results: out of patients ( . %) had nbnc-hcc. over all mean age was . ± . years and . % were males. the proportion of hcc detected under surveillance was significantly smaller in nbnc-hcc group(p . ). there was no difference in distribution of age, gender, bmi, child score, bilirubin, serum albumin, prothrombin time and alfa feto protein in both groups. however, patients with viral-hcc were found to be more thrombocytopenic( . ± . vs. . ± . ,p< . ) and had hepatopulmonary syndrome. on liver biopsy greater proportion of moderate to poorly differentiated hcc was observed in nbnc group( . %vs. . %,p< . ). hcc measuring cm in diameter( . %vs. . %, p . ), non -solitary hcc(p . ) and portal thromboses(p . ) were strongly demonstrated in nbnc-hcc group. involvement of right hepatic lobe and extra hepatic tumor spread was greater in nbnc-hcc group but that difference was not statistically significant. out of patients who underwent for liver transplantation( . %),tace( . %),resection( %),ethanol ablation( %) and chemotherapy( %), poorer responses were observed in nbnc-hcc group (p . ). conclusion: hcc secondary to nbnc-cirrhosis is not uncommon. patients with nbnc-hcc tended not to be under surveillance that leads to diagnoses at more advanced stage and poor prognosis. background: hepatocellular carcinoma is a common malignancy in asia and is related to the high prevalence of chronic viral hepatitis. we examined the clinical features, treatments and survival rates in asian americans with hcc. methods: retrospective cohort study of hcc patients who presented to the ucla liver cancer center in los angeles, california, usa from september to december . results: two hundred and seventeen of ( %) hcc patients were male, % and % had hbv and hcv infection respectively, and % had cirrhosis. hcc patients detected by surveillance had smaller tumor sizes, more within the milan and ucsf criteria, lower hcc tokyo system scores and had improved , , year overall patient and disease free survival rates compared to hcc patients who presented with symptoms (p< . to p< . ). by multivariate analysis, independent predictors of patient survival were tumor volumes greater than cm (hr . , p= . ), afp per unit log increase (hr . , p= . ), hcc tokyo score per unit increase (hr . , p< . ), liver transplantation (hr . , p< . ), hepatic resection (hr . , p< . ), rfa (hr . , p< . ), tace (hr . , p= . ), and hepatitis b infection (hr . , p= . ). factors associated with disease free survival were age per year increase (hr . , p= . ), meld per unit increase (hr . , p= . ), liver transplantation (hr . , p< . ), and hepatic resection (hr . , p< . ). conclusion: hbv and hcv infection accounts for the majority of hcc in asian americans. hcc detected by surveillance resulted in treatments which improved overall patient and disease free survival. treatment of small ( cm) hcc tumours can be achieved by surgical resection and complete eradication always correlates with good patient's outcome, with low local recurrence and high survival rates. indeed, surveillance program for the early detection of small hcc tumour is imperative to facilitate curative treatment, and hence better survival. discovery of new blood-based biomarkers is obligatory and vimentin is a distinct novel small hcc tumour marker herein identified using proteomics. experimental design: a total of liver tissues were evaluated by -de analysis. differentially expressed proteins were unequivocally identified by maldi-tof/tof and validation of the best candidate from protein to gene levels. indirect elisa assay was developed to detect soluble vimentin from serum samples. results: vimentin was significantly over-expressed in small hcc tumours compared to non-malignant controls and maintained expression in > cm tumours using -de analysis. blind verification displayed over-expression of vimentin in both transcripts and proteins levels. soluble vimentin was significantly detected at high level in small hcc as well as in overt hcc tumours. receiver operating characteristic analysis showed vimentin exhibited . % sensitivity and . % specificity in detecting small hcc at a cutoff of ng/ml. combined diagnostic performance of soluble vimentin and serum afp increases the detection sensitivity and specificity to . % and . %, respectively. conclusion: in this context, over-expression of vimentin is associated with the favourable cm sub-class of hcc thus may potentially be used as an effective serum-based diagnostic marker for cancer surveillance in high-risk cirrhotic patients. purpose: our recent comparative oncogenomic analysis in mouse model has identified yap (yes associated protein) as a novel oncogene in hcc. however, its clinical significance is unknown. in this study, we aimed to investigate the clinical values of yap as an independent prognostic marker in hcc. experimental design: a total of hcc cases with retrospective clinicopathologic and follow-up data were recruited in this study. both tumor and adjacent non-tumor tissues were examined for immunoreactivity of yap expression by immunohistochemistry. clinicopathologic features and yap expression were investigated with pearson test. hcc-specific disease free survival and overall survival with yap expression were analyzed by kaplan-meier curves and log-rank test. cox regression was used to test the independence and magnitude of the effects. results: yap was found over-expressed in hcc ( . %) with nuclear expression pattern. positive yap immunoreactivity was significantly correlated with worse tumor differentiation grade (p= . ) and high serum alpha-fetoprotein (afp) level > ng/ml (p< . ). kaplan-meier plot and cox regression showed that yap was an independent predictor for hcc-specific disease free survival (hazard ratio, . ; % ci, . - . ; p= . ) and overall survival (hazard ratio, . ; % ci, . - . ; p= . ). conclusions: yap expression in hcc is correlated with tumor differentiation and serum afp level. it served as an independent prognostic marker for hcc. background: integrative analysis of global protein and mrna expression patterns could help researchers to understand cancer cell physiology without the need of any prior hypothesis. methods: we used a d-page approach to profile and compared the global protein expression profiles of hepatitis b virus-related hcc tissues, adjacent non-tumor liver tissues, normal liver tissues and hcc cell lines. subsequently, we established the bioinformatic tools for integrative analysis of gene expression and protein expression data. we compared the dysregulated protein list and the dysregulated gene lists obtained by meta-analysis of microarray gene expression data from research centers in different countries. results: we identified proteins dysregulated in hcc. hierarchical clustering analysis revealed that there was a progressive change of protein expression patterns from normal liver, adjacent non-tumor liver tissues, hcc tissue, then to hcc cell lines. according to the biological functions, the differential proteins could be classified into various groups, including heat shock protein, chaperone, kinase substrate, cell signaling, apoptosis regulation, transcription regulation, free-radical scavenger and metabolic enzyme. ontology analysis of the genes with consistent dysregulations at both mrna and protein levels identified specific pathways down-regulated during the progression of hcc. the inhibition of those pathways provides new insights in the hepatcarcinogensis and treatment strategies. results: in pre-s/surface regions, hcc patients had higher frequencies of pre-s deletions, amino acid substitutions at codon , , and in pre-s genes, at the start codon in pre-s genes, and at codon in surface genes. but they had a lower frequency of amino acid substitution at codon in pre-s genes than those without hcc. in bcp/precore regions, hcc patients had higher frequencies of c or g , a /t , t , and a than those without hcc. multivariate analysis showed that pre-s deletions, i t in surface gene, t /a , and a were independent factors for hcc. the hbv with a complex mutation pattern (pre-s deletion, t /a , and a ) rather than a single mutation was associated with hcc. patients with combined mutations of t /a and pre-s deletion, t /a and a , pre-s deletions and a , and t /a , pre-s deletions and a had a . , . , . , and . fold increased risk of hcc, respectively, compared to patients with wild-type at both or three genomic regions. conclusions: pre-s deletions, i t in surface gene, t /a , and a were independent factors for hcc. combination of these viral mutations appeared increasing hcc risks. high peritumoral expression of placental growth factor in hepatocellular carcinoma is a poor factor for survival after curative resection h.x. xu , x.d. zhu , p.y. zhuang , w.zhang , h.chuan sun background/aims: angiogenesis plays a significant role in the metastasis and recurrence of hepatocellular carcinoma (hcc). placental growth factor (plgf), which is one member of the vascular endothelial growth factor family, may have prognostic values in patients after curative resection of hcc. methods: expression of plgf was assessed by immunohistochemistry in tissue microarray containing paired peritumoral liver tissue and tumor from patients underwent hepatectomy for histologically proved hcc. prognostic values of plgf and clinicopathological factors were evaluated. result: plgf staining was mainly on the cytoplasm of tumor cells or hepatocytes. the mean integrated optical densities of peritumoral and intratumoral density of plgf were . ± . and . ± . respectively. peritumoral plgf density was significantly higher than that in tumor (p< . ), and this result was also validated in another cohort of patients by quantitative real-time reverse transcription-pcr (p= . ). intratumoral density of plgf was not correlated with common clinicopathological factors (eg, tnm stage, tumor size, microvascular invasion, intra-hepatic metastasis) or overall survival (os) (p= . ) and time to recurrence (ttr) (p= . ). however, peritumoral density of plgf, which was correlated with tumor size (p= . ) and intrahepatic metastasis (p= . ), was a prognostic factor for both os (p= . ) and ttr (p= . ). in multivariate analysis, peritumoral expression of plgf was also an independent prognostic factor for os (p= . , rr: . % ci: . - . ) and ttr (p= . , rr: . % ci: . - . ). conclusion: peritumoral expression of plgf in hcc patients is an independent risk factor for survival and recurrence, and may be a target of anti-angiogenic therapy in preventing post-operative recurrence. purpose: to further research rfa in combination with hepatic artery-portal vein chemotherapy and ethanol injection for treatment of advanced hepatocelluar carcinoma (hcc). methods: cases were treated with transhepatic artery chemoembolization (tace) + radiofrequency ablation (rfa) + introportal vein chemotherapy (pvc) + percutaneous ethanol injection (pei) (four combined group) and this method was compared with cases that were performed tace + pei (two combined group) . the serum level of afp was measured respectively after and months, ct scan and color doppler ultrasound were measured after treatment for six months. results: the serum level of afp declined in two groups after months. for treatment after six months, afp in four combined groups was rose lower than two combined group (x = . , p< . ). ct and doppler ultrasound examination, four combined groups was superior than two combined groups to the control in tumor shrinkage (x = . , p< . ) and blood supply x = . , p< . ), relapse and mortality are also less. conclusions: rfa in combination with hepatic artery-portal vein chemotherapy and ethanol injection is a safe, effective combined method and has less complication in treatment of advanced hcc. poster exhibition -hcv poster session, hall b on the average, hepatitis c virus infects . % of the population worldwide. in egypt, the prevalence rates reach % in some areas. ability of the virus to persist in about - % of infected individuals is related to the virus higher mutation rate. six major hcv genotypes have been identified. genotype seems to be confined to the middle east and central africa. extra hepatic syndromes have been reported in up to / of hcv patients. we aim in this study to determine the relationship between viral genotypes and specific extra hepatic haematological disease in patients with chronic hepatitis c. the study group included selected patients with chronic hepatitis c having various haematological problems. we studied hepatitis c virus genotypes using rt-pcr. we found among patients , genotype ( %) and patients genotype a ( %). patients ( . %) were diagnosed as chronic hepatitis c with associated thrombocytopenia, patients ( . %) were diagnosed mixed essential cryoglobulinemia(mec), patients ( . %) were diagnosed non-hodgkin's lymphoma, and patients ( %) were aplastic anemia. positive serum cryoglobulins level was found in patients ( . %).no significant correlation was found between the level of viraemia and specific haematologic disease, biochemical liver markers or liver enzymes (p> . ). we did not find correlation between hcv genotype and specific extrahepatic haemological disorder in hcv infected patients. several environmental, genetic and immunological factors may contribute in disease progression. results: in the targeted area shops of barbers were successfully interviewed and total questionnaires were filled by both groups. the mean age were found in both groups of barbers (n= ) and clients (n= ), . years. the both groups showed that there are no any drugs which can protect us from diseases. both of the groups were not vaccinated for hepatitis b diseases. regarding the care providers the barbers replied that they prefer registered medical practitioners and the clients generally prefer the hakeems. those who knew hepatitis as liver disease, were ( . %), out of barbers only ( . %) were knowing about hepatitis-b&c, when we enquired about routes of hbv& hcv transmission only ( %) replied correct routes of transmission in both groups. about hbv vaccination ( . %) were aware, only ( . %) were vaccinated against hbv. % barbers claimed for disinfection of instruments before shaving ( . %) claimed for use of new blades. in the sero-surveillance the hbv found was very low and hcv became epidemic ( . % - . %) respectively. conclusion: the both groups need awareness for transmission. the use of new blade for the clients reduces the burden of hbv and hcv. the study highlights the roles of male sex, older age, and genotype b in the progression from chc infection to hcc. patients with higher hcv viral load potentially tend to develop hcc; however, hcc occurrence could be prevented using antiviral treatment. these two points need to be clarified further by a larger study population with longer follow-up period. an approach have recently been described that retroviral vectors encoding t cell receptor (tcr) genes are used to redirect the specificity of normal peripheral blood lymphocyte (pbl)-derived t cells to recognize the tumor antigens. the therapy in which t cells have been genetically modified with tcr genes to recognize hcv would represent a novel approach for the treatment of hcv infections and hcv-related malignancies. we have previously shown that hcv+ liver transplant patients that have received hla disparate liver allografts have hcv reactive t cells of host origin in their peripheral blood that are restricted by the donor hla molecules. initial studies indicate that the tcrs expressed by hcv reactive t cell clones from these patients have relatively high affinity for their ligands. we have cloned and expressed two tcrs which mediate recognition of the - and - epitopes from the hcv ns protein. the results indicate that these tcr transduced t cells can recognize the wild type epitopes, as well naturally occurring mutant variants of these epitopes. most importantly, the tcr transduced t cells could also recognize hcv+ hepatocellular carcinoma cells. these data suggest this high affinity hcv-specific tcr might have potential new immunotherapeutic implications. background: factors associated with svr in patients without an rvr remains unclear. methods: hcv- ( for and weeks, separately) and hcv- ( for weeks, for weeks) patients were randomized to peginterferon-alpha- a and ribavirin for analysis. results: multivariate analysis showed that treatment duration and a complete evr were the strongest independent factors associated with an svr. a higher svr rate and a lower relapse rate were observed in the standard regimen group than in the abbreviated group in patients who had a cevr (table ). the best levels of viral loads in predicting cevr at week were < iu/ml (table ) . conclusion: it was crucial to achieve a cevr with adequate treatment duration in patients who failed to achieve an rvr. our aim was to evaluate the impact of some biochemical, histological and viral factors on both evr and svr in patients with genotype chronic hepatitis c (chc) treated with peginterferon plus ribavirin. patients and methods: we evaluated retrospectively naïve patients with chc treated with peginterferon plus ribavirin at standard weight-based doses for weeks. biopsies were assessed for inflammatory activity and fibrosis. steatosis was categorized by the proportion of hepatocytes per low-power field with fatty changes: > %, > - %, - %, > %. biopsies were also assessed for stainable iron using the brissot scoring system. all patients were evaluated for metabolic syndrome (ms) using the ncep-atp iii criteria. results: evr was achieved in / pts ( . %) while svr occurred in / ( . %). after adjusting for sex and age, independent factors that negatively interfered with both evr and svr were: fibrosis score, steatosis, iron score, homa-ir index and viral load. after excluding the patients with ms criteria (n= ), evr was observed in / ( . %) and svr in / ( . %). factors that independently influenced both evr and svr were: fibrosis score, steatosis, iron score and viral load. conclusion: fibrosis, steatosis and iron scores, as well as viral load are independent parameters that can affect both evr and svr in genotype chc patients, regardless the presence of ms. if ms is present, high homa-ir index can also additionally impair viral response. issue/argument: asia has rising cases of hepatitisb/c. alcohol/food-habits cause high prevalence in rural/tribal areas. lack of monitoring/follow-up complicates management. vaccines emerge as hope. clinical-trials of vaccines debated-issue. design of hepatitis-vaccine-trials in developing-countries complex ethical-issue. we focus on controversies identified in international/regional/local cme/pharma programs as vulnerability of volunteers to exploitation by foreign/local research-groups/funding-agencies. critical task is protect interests of vaccine-subjects in face of substantial-risks. determine if hepatitis-vaccine-volunteers will have access to treatment during trial. access to vaccine-trial-outcome. interaction with seniors th apasl-congress from developed-countries will give voice to such burning-issues. methodology: researchers/pharmaceuticals/govt-policy planners need to develop forum to solve these problems. ngo's can play pivotal role. obligation on part of researchers to create mechanisms to offset anticipated risks of participation in controversial, risky vaccine-development. conclusion: counselling/right to withdraw from trial be made basic guideline. apart from monetary aspects unsuspected adverse reactions/deaths be properly evaluated/monitored. researchers need to evolve policy-guidelines to overcome barriers as variation in interpretation of essential ethical ideas, legal-system-differences, educational/economic-status. need to develop common consensus between research-community/pharma sector to reduce suffering of hepatitis-affected patients community. recommendations: researchers/ngos should come together at th apasl-congress platform to form workgroup to settle these issues. we shall raise our this burning issue & present hepatitis-prevention-advocacy plan of our ngo graphically to apasl- participants. results: % patients expressed that alternative-medicines-rx most important factor to cope with hepatitis. higher scores of qol (anova p < . ) correlated with alternative-medicines-rx. our ngo-initiative suggests that over % patients will need well trained specialist for home-based-care unit. conclusions: life-span/qol of hepatitis-sufferers depends on appropriate-palliative-care. ngo-personals should be trained in palliative-care-services. our data is being used for palliative care advocacy. field of spiritual/psycho-social/community support is fertile ground for further investigations. such use of complimentary indian medicinal plant extracts needs further evaluation in a large group in multicentre trial. treatment with adacolumn in patients with hepatitis c related who have undergone kidney transplantation: preliminary study g. novelli la sapienza university introduction: patients who have undergone kidney transplant and suffer from hepatic c related (hcv) cannot be treated with standard therapy (peg-ifn combined with ribavirine) due to acute rejection risk. furthermore, immuno-suppressive therapy facilitates progression and infection and chronic hepatopathesis. monocytes and macrophages are known to produce extra-hepatic breeding sites and spread disease. our aim was to lower macrophages, granulocytes,monocytes, pro-inflammatory cells and viremia levels using an extra-corporeal device:adacolumn®(otzuka). methods: the adalcolumn filter is filled with mm. cellulose acetate beads immersed in sterile saline solution. these carriers absorb granulocytes and monocytes/macrophanges through fcr receptors. six patients were treated in our department. all patients were affected by virale genotype b. patients underwent five hour treatments for five consecutive days according to protocol. results: during treatment cycles and successive follow ups we observed a stabilization of kidney parameters and a non significant decrease in transaminase levels. at rd month follow up we observed a significant decrease in plasma hcv-rna in patients (p< . ) associated with attenuation of inflammatory phase (p< . ) and variations in immunomodulation. only one patient presented altered cd + and cd + where positive was observed at rd month. in another patient, even though immunomodulation improved, there was no reduction in viremia. conclusions: considering the results this method should be used on a greater number of patients evaluating successive treatment times in case of viremia increase. background: patients who have undergone kidney transplant and suffer from hepatic c related (hcv) cannot be treated with standard therapy (peg-ifn combined with ribavirine) due to acute rejection risk. furthermore, immuno-suppressive therapy facilitates progression and infection and chronic hepatopathesis. monocytes and macrophages are known to produce extra-hepatic breeding sites and spread disease. our aim was to lower macrophages, granulocytes,monocytes, pro-inflammatory cells and viremia levels using an extra-corporeal device:adacolumn®(otzuka). methods: the adalcolumn filter is filled with mm. cellulose acetate beads immersed in sterile saline solution. these carriers absorb granulocytes and monocytes/macrophanges through fcr receptors. six patients were treated in our department. all patients were affected by virale genotype b. patients underwent five hour treatments for five consecutive days according to protocol. results: during treatment cycles and successive follow ups we observed a stabilization of kidney parameters and a non significant decrease in transaminase levels. at rd month follow up we observed a significant decrease in plasma hcv-rna in patients (p< . ) associated with attenuation of inflammatory phase (p< . ) and variations in immunomodulation. only one patient presented altered cd + and cd + where positive was observed at rd month. in another patient, even though immunomodulation improved, there was no reduction in viremia. conclusions: the treatment was found to be safe without hemodynamic or infective complications. considering the results this method should be used on a greater number of patients evaluating successive treatment times in case of viremia increase. m. sharaf-eldin , h. el batae , n. abd el-ghaffar , w. rasheed tanta faculty of medicine , egypt., national research centre, cairo, egypt aim: we aimed to characterize serum cytokine levels of interleukin- beta (il- ) and interleukin - (il- ) in hcv infected patients & in patients with hepatocellular carcinoma (hcc) in comparison to control group and their possible use as markers of disease progression. patients and methods: sixty patients were divided into three groups: group i: twenty hcv infected patients without cirrhotic changes. group ii: twenty hcv infected patients with liver cirrhosis (lc). group iii: twenty hcv infected patients with hcc and healthy subjects as control group. all patients and control group were subjected to biochemical and serological tests, anti hcv, hcv (rt-pcr) and cytokines measurements of serum il- & serum il- levels. results: showed a high statistically significant elevated serum il- and il- levels in patients with chronic hcv infection in comparison to control group. highly statistically elevated levels of il- and il- in liver cirrhosis and higher levels were found in hcc group in comparison to control group. the levels of il- and il- increased significantly in hcv infected patients as the disease progress. conclusion: serum il- , and il- levels are elevated in patients with hepatitis c-related liver diseases, especially in lc and hcc patients. their levels reflect hepatic dysfunction better than liver inflammation parameters; accordingly, we may use serum il- and il- as markers for liver disease progression in hcv-infected patients instead of invasive techniques. atsushi tanaka , naoko hanawa , mitsuhiko aiso , yoriyuki takamori , hajime takikawa teikyo university school of medicine background and aim: pegylated interferon (peg-ifn) therapy is not indicated for many cases with hcv-related cirrhosis due to various adverse effects. however, patients with hcv cirrhosis are at high risk for development of hepatocellular carcinoma (hcc). thus we have introduced low-dose peg-ifn treatment for patients for compensated hcv cirrhosis. patients and methods: selection criteria for low dose peg-ifn is ) compensated hcv-related cirrhosis, and ) either the elderly (> ) or presence of thrombocytopenia (< . x / l). we have treated patients who met these criteria with low-dose peg-ifn, consisting of either peg- a g/ - w or peg- b . g/kg/w+ribavirin mg/d. [results] twenty patients with compensated hcv cirrhosis (all patients genotype b) have been treated with low-dose peg-ifn (peg- a: , peg - b+rib: . the age, platelet counts (x / l), and alt (iu/l) of patients at baseline were . ± . , . ± . , and . ± . respectively. all patients were well tolerated. low-dose peg-ifn has been continued . ± . weeks on average. although viral response was not detected, biological response (br), defined as maintenance of alt within normal range, was obtained in patients ( / = %). of note, neither development of hcc nor decompensated cirrhosis was observed in these br cases. by contrast, hcc and decompensation developed in and patients respectively among patients who failed to achieve br. conclusion: low-dose peg-ifn treatment was safe and well tolerable, and could potentially prevent hcc or decompensation in patients with liver cirrhosis when br was obtained. aims: to study the efficacy of peginterferon and ribavirin in treating chronic hepatitis c (chc) with genotype a in hong kong chinese. methods: to assess sustained virological response (svr) (serum hcvrna< iu/ml) at -months follow-up. results: nine patients with genotype a chc (included from jan to dec ) received peginterferon and ribavirin. mean age: (range - ). mean alt before treatment: iu/l (range - iu/l). seven patients had liver biopsy performed, only one showed stage - fibrosis and others showed active hepatitis without advanced fibrosis. mean serum hcv-rna: . x iu/ml(range . x - . x iu/ml). six patients had received peginterferon alfa- b ( . mcg/kg/week), other received peginterferon alfa- a ( mcg/week). ribavirin dosage ranged from mg- mg/day depending on body weight and baseline haemoglobin. treatment durations were - weeks in patients, - weeks in patients as one showed rapid virologic response at week and the other was intolerant to side effect of peginterferon. eight patients had early virologic response at week and one had > log drop of hcvrna. eight patients had end-of-treatment response. eight patients ( . %) achieved svr at end of follow-up. two patients who received only - weeks of combination therapy also achieved svr. the one who failed to achieve svr was at older age of and had advanced fibrosis. conclusions: the efficacy of pegylated interferon and ribavirin in treating chinese patients with chronic hepatitis c genotype a can achieve high sustained virologic response rate of . %. t. bharati , , p. kar , a. mohammad , k. mariappan , j. annamalai , r. introduction: hcv is a recognized cause of hcc. information on hcv genotypes in hcc are scanty in india. methods: a total of hcc cases from delhi, hcc cases from madurai and cases of chronic hepatitis without hcc were controls in the study. rt-pcr for hcv rna and genotyping were carried out in all the cases results: in group-i, hcv rna was positive in . % hcc cases in which genotype was found in . % genotype was observed in . % hcc cases. whereas . % cases remained nontypable. in group-ii, hcv rna was positive in . % hcc cases, with genotype in . % cases, genotype in . % cases and genotype in . % cases. however, . % cases remained nontypable. out of the control cases, were ch and were cirrhosis. in ch group, hcv rna was positive in . % cases in which, genotype was detected in . % cases whereas genotype was observed in . % cases . however . % cases remained nontypable. in cirrhosis group, hcv rna was positive in . %cases. genotype was found in . % cases. while genotype was present in . % cases and . % cases remained nontypable. conclusion: genotype in delhi and genotype in madurai were predominant. in hcc cases. our study demonstrates that no particular hcv genotypes were associated with hcc and genotype did not appear to influence the development of hcv-associated hcc. background/aims: the standard treatment for chronic hepatitis c infected with hcv genotype- is a combination of pegylated interferon alfa and ribavirin for a weeks. it is unclear if weeks treatment is possible for patients showing a rapid virologic response (rvr) without compromising the sustained virologic response (svr) in korea. method: between june and july , among patients chronically infected with the hcv genotype- (hcv- ) who were treated with pegylated interferon alfa subcutaneously once weekly plus ribavirin (weight-based), consecutive paients who had low pretreatment viral load ( . x copies/ml) and rvr were treated for weeks and then followed up for weeks. the hcv rna was quantitatively assessed pretreatment, at weeks of treatment and was qualitatively assessed at weeks of treatment, the end of treatment ( weeks), weeks after end of treatment. rvr was defined as undetectable hcv rna at the weeks. results: baseline characteristics of patients was as followed; age ( - years:mean years), bmi ( - kg/m²:mean . kg/m²), hcv rna titer ( . - . × copies/ml:mean . × copies/ml), alt ( - iu/l:median iu/l). among the patients, all patients ( %) had sustained virologic response (svr). conclusions: hcv- infected patients with a low baseline hcv rna concentration ( . × copies/ml) who had hcv rna negative at week of treatment may be treatment for weeks without compromising sustained virlolgic response. however, an additional trial will be needed to optimize the treatment duration. background/aims: acute hepatitis c (ahc) has a high chronicity rate of up to ~ % if it is not treated. although the good treatment response to pegylated interferon (peg-interferon) therapy has reported, there is not definite guideline to treat of ahc in korea yet. the aim of our study was to investigate the clinical course and treatment outcome of ahc in single center of korea. methods: we performed a retrospective analysis of patients who were diagnosed with ahc during the period from may to december . the diagnosis of ahc was based on seroconversion to anti-hcv antibody or the clinical and biochemical diagnostic criteria satisfactory to ahc and on the presence of hcv rna in first serum sample. the spontaneous resolution was defined as loss of hcv rna in serum for -month in untreated group, and in treatment group, the sustained virological response (svr) was defined as a index of treatment success. results : thirteen of thirty-five patients were treated, six of thirty-five were untreated and observed clinical course, and sixteen patients were not followed up after diagnosis. in treatment group, nine of thirteen ( %) acquired svr, and two of six ( %) showed spontaneous resolution in untreated group. ten of thirteen treatment patients used conventional interferon, and another three patients used peg-interferon. conclusion : compared with untreated group, there was higher svr rate in treatment group ( % vs. %). so early interferon treatment in acute hepatitis c should be considered. background: this study was conducted to identify predictors of thyroid dysfunction and to determine whether virologic factors or treatment response affect thyroid dysfunction development during peginterferon (pegifn) therapy in chronic hepatitis c patients. methods: sixty chronic hepatitis c patients treated with pegifn - a or - b in combination with ribavirin from st july to th july were included in this study. treatment responses were evaluated and thyroid functions were assessed every weeks. results: seventeen patients ( . %) experienced thyroid dysfunction during treatment, and that occurred more frequently in women and in patients with a lower body mass index (bmi). the proportion of patients with a high viral load (a serum hcv rna titer > , iu/ml) was significantly higher in the thyroid dysfunction group rather than in the euthyroid group( . % vs. . %, p= . ). among patients with hcv genotype , the rate of sustained virologic response was lower, and relapse occurred more frequently in the thyroid dysfunction group than in the euthyroid function group during pegifn-based therapy(svr, p= . ; relapse, p= . ). the female gender and the high viral load were independent predictors of thyroid dysfunction in multivariable analyses (female, or . , p= . ; high hcv rna titer, or . , p= . ) . conclusion: the risk of thyroid dysfunction during pegifn therapy for chronic hepatitis c was found to be higher for women and for those with a low bmi and a high viral load. background: in peginterferon alpha b (peg-ifn b) and ribavirin (rbv) combination therapy for weeks for patients with chronic hepatitis c, it is still difficult to predict which patients will achieve sustained viral response (svr) at the completion of this therapy. aim: to predict svr and non-svr (relapse) at the end of this combination therapy by determining changes of serum hyaluronic acid (ha) levels. methods: eighteen patients were enrolled and their serum ha levels were measured before therapy, and after the st, nd, rd, and last trimesters during therapy. results: eleven patients achieved svr and became relapsers. all patients showed higher ha levels in the st trimester than the pretreatment levels. in the svr group, of ( . %) patients in the nd, of ( . %) in the rd, and of ( . %) in the last trimester showed lower ha levels than the pretreatment levels. by contrast, in the relapser group, none in the nd, of ( . %) in the rd, and of ( . %) (p< . ) in the last trimester showed lower ha levels than the pretreatment levels. this study revealed that as the -week therapy went on, ha levels were more likely to fall below the pretreatment levels by the last trimester in patients achieving svr. however, ha levels of relapsers tended to continuously be above the pretreatment levels. conclusion: determination of changes of serum ha levels during peg-ifn b and rbv therapy predicts svr and non-svr at the completion of this therapy. results: the most frequent lymphomas were with high malignancy ( %), intermediate ( . %) and low degree ( . %). cryopathy was negative ( . %). the presence of viral markers was performed soon as possible after the nhl diagnosis, at the same time ( . %) or during the first year of evolution ( . %). the prevalence of the hcv infection was %, comparable to the one in the control patients group ( . %), admitted in a gastroenterological clinic. on the other hand, this prevalence is significantly increased compared to the one in the general romanian population ( . %). the patients with nhl and hcv infection belonged especially to the low and intermediate malignancy degrees; the survival was influenced by the malignancy degree and not by the presence of hcv infection. the prevalence of hbv infection in the tested patients was . %, being lower than that of hcv infection ( . % vs. %, p = . ) but comparable to the one in the general population ( . % vs. . %, p = . ). conclusions: the prevalence of hcv infection in the patients having nhl was %, comparable to the one in the control group, but significantly increased compared to the one in the general population, leaving open the issue of a causal relationship between hcv infection and nhl. iron hepatic overload and hepatitis c d. damian , m. grigorescu , m.d. grigorescu , t. zaharie third medical clinic, cluj napoca, romania aim: evaluation of the prevalence and the degree of iron loading and the relationships with the clinical, biological and morphological changes. method: patients with chronic hepatitis c were included, to whom we tested the blood iron level. in order to evaluate the hepatic iron accumulation we performed the perls staining, using a qualitative analysis and a semiquantitative scoring system (deugnier). results: from a total of patients, . % presented increased blood iron level (p = . ). the evaluation of the liver iron loading was performed in patients, some having normal blood iron level (n = ) and others (n= ) increased (p = . ). the stainable iron was observed in patients. the iron loading was usually low, the deposits were observed mostly at the sinusoid cells and the hepatocyte and less in the portal spaces, usually as a pale staining or of small, nonmerging granules. the total iron score deugnier was low. the increased blood iron correlated with the alt and ggt levels, the necroinflamatory activity and fibrosis. no correlationships between stainable iron and increased blood iron. the presence of liver iron accumulation only correlated with the fibrosis degree. conclusions: of the patients to whom we tested the blood iron, . % had increased levels. the perls staining was positive in % of the patients. the iron loading was mainly low, with a more frequent distribution in the sinusoid cells and in the hepatocytes and correlated only with the stage of fibrosis. response patients whose hcv rna became negative at - weeks t. ide , t. arinaga , k. ogata , i. miyajima , k. kuhara , r. kuwahara , m. background/aim: chronic hepatitis patients whose hcv rna became negative at weeks of peg-interferon/ribavirin treatment achieved excellent svr(sustained viral response) rate of almost %. however, in patients whose rna became negative after weeks, the svr rate is very low. since many patients became rna negative at - weeks, it is important to clarify the characteristics of the patients. material and method: among patients, became rna negative at - weeks and the therapy completed (total - weeks). the characteristics were analyzed by using sex, age, weight, bmi, alt, gtp, hemoglobin, platelet counts, ccr, hyaluronic acid, the mutation of hcv core region (aa , ) and interferon sensitivity determining region, adiponectine, home-ir, rna dynamics, dose and the treatment period. result: the svr rate was . %( / ). because all patients of non svr were female, we compared these patients and female svr. the platelets counts were low in non svr (non svr . ± . (x /mm ) vs svr . ± . (p< . )). the mean dose of ribavirin was lower ( ± mg/day) in non svr (p< . ) than in svr ( ± ). conclusion: as for the characteristics of the patients whose hcv rna became negative at - weeks but became non svr, female, low platelet count and low dose of ribavirin were important factors. in the patients who received reduced ribavirin doses, the idea to increase the ribavirin dose and to maintain it are necessary. (ex, use mg and mg alternately) pe background: chronic hepatitis c virus (hcv) infection poses a challenge for a growing number of infected patients who exhibit disease complications, including cirrhosis, hepatocellular carcinoma, and liver failure in china. the combination treatment of peginterferon alpha (peg-ifn alpha) plus ribavirin (rbv) is recommended as a standard care for hcv infections, which can improves hepatic markers and eradicates the virus in about % of patients. however, a significant number of patients do not respond to therapy or relapse following treatment discontinuation. several viral, hepatic, and patient-related factors influence response to therapy. methods: in our clinical practice, a total of interferon-naïve patients ( % male; median age years) with chronic hepatitis c include cirrhotic patients (no genotyping) received peg-ifn alpha- a mcg/week plus rbv - mg/day for weeks and follow up weeks. results: show that the patients have more rvr and evr rate ( % and . % respectively). while the svr (undetectable hcv-rna weeks after treatment completion) rate is only . % in conclusion: comparing with the data of clinical trail, the rvr, evr and eotr were higher, while svr was the same in chinese patient with chronic hepatitis c patients received the combination therapy of peg-ifn plus rbv. the reason of high relapse was still unknow. although optimal duration of retreatment and benefits and safety of maintenance therapy have not been determined, an extended duration is likely needed, even for the patients who achieved evr. s. nakamoto , f. imazeki , k. background/aims: recently amino acid (aa) substitutions in hepatitis c virus (hcv) core region (double wild (dw); arginine at aa , leucine at aa ) were reported to be associated with sustained virological response (svr) in a combination therapy of peginterferon and ribavirin. we evaluated the viral factors influencing treatment response. methods: nucleotide sequences of core region were determined directly in patients with genotype and high viral load ( kiu/ml) treated with peginterferon-alpha b and ribavirin for weeks. rapid virologcal response (rvr) was defined as more than log decrease of hcv-rna during the first four weeks of therapy and early virological response (evr) as that during the first weeks. svr was defined as negative hcv-rna months after the end of treatment and non-virological response (nvr) as less than log decrease of hcv-rna during the treatment. results: dw at aa and was shown in / ( %) patients with rvr and in / ( %) with non-rvr (p= . ), in / ( %) with evr and in / ( . %) with non-evr (p= . ), in / ( %) with svr and in / ( %) with non-svr (p= . ), and in / ( %) with nvr and in / ( %) with non-nvr (p= . ). in multiple logistic regression analysis, dw was significantly associated with rvr, evr, svr and nvr. conclusions: dw at aa and in hcv core region was closely associated with virological response in a combination therapy of peginterferon and ribavirin. medicine and hepatology, henry dunant hospital, athens, greece, biometrics, ist gmbh, mannheim, germany, background: among patients with chronic hcv treated with pegylated interferon and ribavirin, the highest sustained virologic response (svr) rates are achieved in patients with a rapid virological response (rvr). here we investigate how the time taken to become hcv rna undetectable influences the probability of relapse during untreated follow-up. methods: data from patients treated for weeks with peginterferon alfa- a ( kd) µg/week plus ribavirin / mg/day were included in the intent-to-treat analysis. response was classified as rvr, complete early virological response (cevr) slow responder and non-evr. results: there was a correlation between the time required to become hcv rna undetectable and the relapse rate after stopping treatment. patients with an rvr had the lowest relapse rate ( %); this increased among patients with slower responses. conclusion: there was an inverse correlation between the time taken to achieve a virologic response and the probability of relapse. background: rapid virologic response (rvr; hcv rna < iu/ml) at week of treatment with pegylated interferon plus ribavirin can be used to predict the probability of achieving an svr. patients with detectable hcv rna at week have a lower probability of achieving an svr than those with an rvr; further subdivision of these patients may be useful in predicting outcomes. methods: we conducted a retrospective analysis including genotype patients treated for weeks with peginterferon alfa- a ( kd) g/week and ribavirin / mg/day. patients were categorized as rvr and non-rvr. those without an rvr were further subdivided into detectable but unquantifiable, , , or < log drop in hcv rna. the proportion of patients with undetectable hcv-rna at week and achieving an svr was calculated within each category. results: rvr and non-rvr patients had an % and % rate of svr respectively. among non-rvr patients, rates of svr depended on the categorical response at week : detectable but unquantifiable hcv rna, %; log drop in hcv rna, %; log drop, %; log drop, %; and < log drop, %. independent of week response, undetectable hcv rna at week was also highly predictive of svr. conclusions: patients achieving an rvr have high rates of svr. among patients who do not achieve an rvr a more precise prediction of svr can be achieved by considering the extent of viral load reduction at week and week . retrospective japanese validation study of fibrotest and actitest in patients with chronic hepatitis c. n. nagata , t. mine background: fibrotest (ft) and actitest (at) are biochemical markers of fibrosis and activity for use as a non-invasive alternative to liver biopsy in patients with chronic hepatitis c virus. the aim of this study was to perform a validation study the discordances between ft and at(ft/at) and liver biopsy in patients with chronic hepatitis c in japan. methods: serum samples of chronic hepatitis c patients sended at - °c at the biochemistry department of pitié salpetrière hospital were analysed between july and august . ft/at components were assessed on thawed sera for patients. from patients had liver biopsy at the moment of serum analysis. liver biopsy fibrosis and activity scores were assessed by a pathologist in japan according to metavir scoring system. for each individual test-ft/at the following statistical analysis were performed result: ft observed auroc for the diagnosis of advanced fibrosis was . and after adjustment according to the prevalence of different stages of fibrosis the auroc was . . this difference could be explained by the non-homogenous distribution of different stages of fibrosis (low prevalence of extremes stages of fibrosis -f and f -and high prevalence of adjacent intermediate stages -f and f ). the observed auroc of ft for the diagnosis of precirrhosis and cirrhosis was . and the observed auroc of at for the diagnosis of moderate to severe activity was . . conclusion: these results are similar to those observed in all independent validations worldwide. background: accurate monitoring of hcv-rna level throughout anti-hcv therapy is key factor for predicting sustained virological response (svr). real-time detection polymerase chain reaction (rtd-pcr) based methods are sensitive, have wide dynamic range of quantification and carryover contamination caused by classical pcr. aim: to compare rtd-pcr based assays; cobas ampliprep/cobas taqman (cap/ctm) and recently developed abbott realtime hcv for hcv rna quantification and measurements differences by assays in different genotypes. methods: in total, serum samples were used including, , , , , and with genotypes b, a, b, a and respectively were tested quantatively for hcv-rna by cap/ctm and abott realtime. results: good correlation between two assays as overall (r= . ) with correlation coefficient (r) in genotypes b, a, b, a ranged between . to . and least in genotype (r= . ). mean differences between cap/ctm and abott realtime was significnat in genotypes b and . significantly hcv-rna genotype underestimation by cap/ctm ( . + . log iu/ml) than abbott realtime ( . + . log iu/ml; p= . ). in genotype b, significantly higher hcv-rna measurement by cap/ctm ( . + . log iu/ml) than abbott realtime ( . + . log iu/ml, p= . ). two hcv genotype samples showed measurement differences (cap/ctm minus abbott realtime) of - . and - . log iu/ml. studying genotype sequences within utr , target for cap/ctm rt-pcr amplification, revealed nucleotide polymorphisms at positions a , a , t , a , and a . conclusion: different measurement efficiency by commonly used cap/ctm in different genotypes compared to abbott realtime. new york, new york, usa, vertex pharmaceuticals, cambridge, ma, usa, duke clinical research institute , duke university, durham, nc, usa background: prove is a placebo-controlled study of subjects with genotype chronic hepatitis c randomized to weeks of peginterferon-alfa- a ug/week (p) plus ribavirin - mg/d (r) (pr , n= ), or regimens of mg q h telaprevir (tvr) with pr: tvr/pr for wks followed by pr for wks (t /pr , n= ), wks (t /pr , n= ) or wks (t /pr , n= ). the impact of african american race (aa) and bridging fibrosis on sustained virologic response (svr) was examined. methods: subjects with cirrhosis were excluded from study. fibrosis was categorized as mild/minimal, portal, or bridging from biopsy within years. itt analysis was performed. results: overall, svr was achieved by % of subjects in the pr group, % in t /pr group, % in t /pr group, and % in t /pr group. subgroup analyses indicated svr was improved with tvr/pr (tvr/pr arms pooled) vs pr alone in aa subjects ( % ( / ) vs % ( / )), and in subjects with bridging fibrosis ( % ( / ) vs. % ( / )). adverse events leading to discontinuations were more frequent in the tvr/pr groups ( % vs. %). rashes, gastrointestinal events and anemia were more common in the t/pr arms, and rashes were more frequently severe ( % vs %). conclusions: tvr-based treatment for or weeks was associated with an increase in svr rates compared to pr . subgroups with impaired response to standard peg-ifn/rbv therapy appeared to benefit from the addition of telaprevir. adverse events leading to discontinuation were more frequent in tvr-based regimens. background and aims: induction of type i ifns is a core issue in antiviral responses and must be tightly controlled. the protein kinase tbk is critically involved in virus-triggered type i ifn signaling. in previous studies, an alternatively spliced isoform of tbk , termed tbk s, was identified to be induced in both human and mouse cells. bound to rig- , it is able to disrupt the interaction between rig-i and visa. this study was designed to observe the expression of tbk s in hcv-infected patients. methods: total rna was extracted from samples of peripheral blood mononuclear cells obtained from hcv patients, hcv patients treated with ifn-/ribavirin and healthy controls, and subjected to real -time pcr using the primer-probe sets for human tbk s, tbk and ifn-genes. results: the tbk s expression was significantly elevated in hcv-infected patients, while treatment of hcv-infected patients with ifn-/ribavirin resulted in down-regulation of tbk s to the normal level. conclusions: the study strongly supports the idea that expression of tbk s is correlated with hcv infection, and indicates that tbk s may play an important role in the regulation of hcv infection.this work was supported by nsfc( , , background: infringement of iron metabolism is one of fibrosis progressing factors during diffuse liver diseases. the interrelation between the syndrome of iron overload (sio) and svr achievement is studied during chronic hcv infection treatment. methods: patients with chronic hcv infection (genotyping: - ; + - ; - ; - ; - ) are investigated. sio criteria: iron increase-more than mkmol/l, ferritin -more than mkmol/l, percent of transferriny saturation with iron (%tf) -more than %. results: sio revealed in patients ( . %): patients - genotype ( assotiative with a diabetes) and patients-genotype ( -in combination with liver steatosis and obesity). venipuncture series were done up to getting ferritin referential parameter values before therapy beginning. rvr: sio - patients, normal metabolism - ; evr: and , svr: and relatively. nonresponding patients (sio) had steatosis and diabetes, hereditary hemochromatosis (c y/h d) is verified in case. increase of ferritini values and %tf during therapy and positive hla-a and hla-b is registered in nonresponding patients. conclusions: sio in hla-a , hla-b and c y/h d positive patients is independent predictor of nonresponse during peginterferon alpha- a ( kd)" ribavirin treatment. a.p. srivastava , g. dogra , s. sachdeva , n. nigam , a. chakravarty dr. rml hospital, new delhi (india)- , maulana azad medical college & associated hospitals, new delhi, india background: hepatitis c virus (hcv) has emerged as a leading cause of chronic hepatitis, liver cirrhosis and hepatocellular carcinoma worldwide. genotyping and assessment of viral load in hcv patients are vital for designing therapeutic strategies. we aimed to determine the pattern of hcv genotypes and its association with viral load and biochemical profile. methods: hcv rna positive patients were included in the present study attending the medical-opd and wards of dr rml hospital, a tertiary care hospital in new delhi during - . hcv genotyping was carried out by restriction fragment length polymorphism (buoro et al ) followed by the type specific primers from the core region (ohno et al ) . viral load estimation was carried out by taqman real time pcr system using previously described method (martell et al ) . result: . % of cases were having genotype ( a, b, f & i) followed by genotyping ( a & b) in . % and genotype in . %. there was no statistical significant difference seen in the biochemical profile between the three groups of genotypes. genotype one was associated with a significantly higher viral load as compared to the genotypes three and two. parentral mode of transmission was accounted for the % of all the infected cases. conclusion: hcv genotypes and accounted for % of our cases. the genotype is associated with higher degree of disease severity as assessed by viral load. also two unusual subtypes i and f were identified from this geographical region. a.p. srivastava , g. dogra , s sachdeva , n. nigam background: the development and resolution of an inflammatory process is regulated by a complex interplay among cytokines that have pro and anti-inflammatory effects. regulatory mechanisms that control the production of cytokines include genetic polymorphism in particular promoter/leader region. polymorphisms may directly or indirectly affect the binding of transcriptional factors, consequently increasing or decreasing the production of mrna, thus regulating cytokine production. we aimed to determine the polymorphism of tumor necrosis factor-alpha (tnf-alpha) and interleukin- (il- ) genes in chronic hepatitis c patients. methods: hcv rna positive patients were included in the present study conducted during - . healthy controls were also included. genomic dna was extracted by using q a amp dna blood kit protocol according to manufacture's instruction and desired fragment was amplified by using the primer's of vidigal et al . result: genotyping of - -promoter variant of tnf-alpha was performed by pcr. polymorphism in the tnf-alpha (g/g, g/a and a/a allele) was different between hcv patients and healthy controls. il- variants (c/t, c/c) were more frequent among hcv patients as compared to healthy controls. conclusion: genetic polymorphism analysis on il- promoter have indicated that distribution pattern of il- polymorphism was significantly different between controls and hcv patients. furthermore, polymorphism in promoter region of tnf-alpha (- ) was found, though the difference was not significant. since this is a preliminary study, we believe that our findings may stimulate further research on larger number of patients. introduction: the assessment of liver fibrosis provides useful information not only for diagnosis but also for therapeutic decision. although liver biopsy is the gold standard for fibrosis assessment, it is invasive and may have some risks, this has led to the development of non-invasive biochemical markers of liver fibrosis. fibro-test which have five parameters used for the quantitative assessment of liver fibrosis. our aim is to validate the performance of fibro-test in an independent cohort of patients with chronic hepatitis c genotype . methods: subjects were patients with chronic hepatitis c genotype . all biopsies were scored using metavir system by two independent pathologists. fibro-test was done with (biopredictive, houilles, france) for the assessment of liver fibrosis. sensitivity, specificity, ppv and npv were measured for distinguishing between different degrees of severity of fibrosis. results: patients ( male and female) age ranged - years, liver biopsy showed % (f ), % (f ), % (f ), % (f ), % (f ). the efficacy of fibrotest is . %, sensitivity . %, specificity %, positive predictive value % and negative predictive value %. conclusion: fibrofast has a low performance in assessment in fibrosis in chronic hepatitis c genotype . introduction: liver biopsy is the reference method for assessing liver fibrosis. however, it is invasive, costly and has some limitations. european liver fibrosis (elf) markers have shown to be accurate in assessing liver fibrosis in a range of chronic liver disorders. our aim is to test the performance of elf markers in an independent cohort of patients with chronic hepatitis c genotype . methods: subjects were patients with chronic hepatitis c genotype . all biopsies were staged for fibrosis using metavir system by two independent pathologist. elf markers were done by (diagnostic & operations, england) and fibrosis scores were derived using the published elf algorithm. the area under the curve (auc) for receiver operator characteristic curves was measured along with sensitivity and specificity, positive (ppv) and negative (npv) predictive values for distinguishing between different stages. results: patients ( male and female), age was ranged - years, liver biopsy showed % (f ), % (f ), % (f ), % (f ) and % (f ). elf markers had no correlation with fibrosis score where r = - . , p = . , aucs: . , specificity . %, sensitivity only . %, ppv: only . %, npv: . % and efficacy . %. conclusion: the performance of elf marker is low and can not be used for assessment of fibrosis in chronic hepatitis c genotype . background: the prove trial is a randomized, placebo-controlled study that assessed the safety and efficacy of mg q h telaprevir (tvr) combined with g/week peg -ifn alfa- a (p) ± - mg/day ribavirin (r) in chronic hcv genotype -infected treatment-naïve patients without cirrhosis. methods: overall, patients received tvr + pr for weeks (t /pr ; n= ), tvr + pr for weeks then pr for weeks (t /pr ; n= ), tvr + p for weeks (t /p ; n= ), or to pr for weeks (pr ; n= ). primary endpoint: sustained virologic response (svr, undetectable hcv-rna weeks post-treatment). results: baseline characteristics were well balanced across groups. numerically higher svr rates were observed in patients receiving t /pr ( %; p= . for difference vs. pr ) than t /pr ( %), t /p ( %) or pr ( %). relapse rates were lower in the t /pr group ( %) than the t /pr ( %), t /p ( %) and pr ( %) groups. the relapse rate in patients receiving t /pr with -week and -week undetectable hcv-rna was % ( / ). the aes occurring more frequently with the t/pr regimen were pruritus, rash, asthenia, nausea and anemia. in the t/pr arms, patients discontinued due to rash, discontinued due to pruritus, and patients due to anemia. conclusion: these results showed that a telaprevir-based regimen led to significantly higher svr rates than pr, and indicate that this regimen could shorten the overall treatment duration from weeks to weeks for most patients infected with hcv genotype . a.c. cardoso , c. stern , r. moucari , n. giuily , p. bedossa , p. marcellin hopital beaujon background/aim: this study evaluated the effect of the response (svr) to therapy on fibrosis stage, as assessed by ls, in patients with advanced fibrosis (f ) or cirrhosis (f ). methods: hcv patients with f or f who received interferon-based treatment were studded. ls was assessed after treatment (median delay of months, - ) in patients with or without svr. correlations between ls and clinical and treatment characteristics were analyzed. results: patients were included: male gender ( %), mean age ( ± years), diabetes ( %), mean bmi ( ± kg/m ), genotype ( %). % had svr. ls was performed - , - , > years following treatment. by linear regression, the median of the ls was independently associated with svr (p= . ) and diabetes (p= . ). svr patients had lower ls ( . kpa; range . - ) than non svr patients ( . kpa; range . - ) (p< . ). among the svr patients the median ls was lower when the delay between ls and the end of treatment was longer ( . , . , . ) (p= . ). on the opposite, among the non-svr patients the median ls was not significantly different (p= . ). the median of liver stiffness was higher in patients with diabetes (p= . ). bmi and dyslipidemia did not influence the median of the ls. conclusion: in patients with advanced fibrosis or cirrhosis, ls was lower in patients with svr and decreased with time while it was higher and did not decrease in non-svr patients. ls could be important for assessment of fibrosis stage during the post-treatment follow-up. to study peripheral blood and intrahepatic natural killer (nk) cells in patients with chronic hepatitis c in relation to disease activity and severity of hepatic fibrosis. patients & methods: fifteen untreated patients with histologically-proven chronic hepatitis c, and matched healthy subjects. the nk cells and natural killer t (nkt) cells were identified in fresh whole blood samples using two-color flow cytometric assay as cd -cd + and cd + cd + positive cells. immunohistochemical staining of liver biopsies taken from all patients was done using monoclonal antibody against cd for detection of nk cells and rabbit polyclonal antibody against smooth muscle actin (sma) for identification of activated hepatic stellate cells (hscs). results: patients with chronic hepatitis c showed significant decreases in the percentages of nk cells and nkt cells in peripheral blood. a negative correlation was found between serum hcv rna levels and the percentages of peripheral blood nk cells and the intensity of intrahepatic nk cells. the percentages of circulating nk cells and nkt cells and the intensity of intrahepatic nk cells were inversely correlated with the metavir fibrosis stage and the steatosis grade, and also with the intensity of intrahepatic activated hscs. conclusion: patients with chronic hepatitis c had significant deficiency in circulating nk and nkt cells as well as in intrahepatic nk cells. this may provide a possible mechanism for the suppression of innate immunity against hcv. background: hcv infection is the major cause of chronic hepatitis, cirrhosis and hepatocellular carcinoma. the virus is classified in six genotypes and more subtypes, which are related distinct with antiviral therapies reply. in brazilian amazon, epidemiologist's studies in blood donors had pointed high frequency of genotype ( %) followed by genotypes ( %) and ( %). however, epidemiological research in populations of risk to the infection still is scarce. aim: to determine hcv genotypic frequency in blood donors, patients with blood transfusions multiples, patients in hemodialysis and drugs users in the state of pará, brazilian amazon. methods: using real time pcr and nucleotide sequencing followed phylogenetic analysis had been gotten viral diagnosis and genotyping. results: in blood donors, hcv distribution was constituted by genotypes ( . %) and ( . %). in multitransfunded patients occurs maximum prevalence of genotype ( %), probably reflect of genotype specific transmission of blood donors population. on the other hand, in hemodialysis patients had been detected genotypes ( . %), ( . %) and ( . %), result of a bigger diversity of transmission routes (transfusional, interfamilial, nosocomial, etc) . in drug users occurs the biggest frequency of genotype ( . %) with prevalence of genotype ( . %), suggesting that the sharing of abuse machinery is allowing strains diffusion of genotype . conclusions: the genotype possesses the biggest frequency in different population. moreover, through hcv genotypic frequency if it detached the contribution of transmission distinct routes indicated by previous epidemiologists researches. virol. ). we established real-time polymerase chain reaction (pcr) assays for the easy detection of these hcv mutations. methods: plasmids p-core-w, including wild type hcv core coding region ( r and l), and p-core-m, including mutant type hcv core ( q/h and m), were constructed by cloning and pcr-based mutagenesis for control vector of wild type core and that of mutant core, respectively. using serially diluted forms of these vectors, sybr green-based real-time pcr detections with mutation-specific primers were performed. results: analysis of known scalar concentrations of references indicated that the detection limits of these methods were at least copies, copies, copies, and copies of -wild, -mutant, -wild, and -mutant, respectively. each primer could clearly distinguish the difference between p-core-w and p-core-m at the same copy numbers. concerning substitution , the ratios : , : , : , : , and : of p-core-w versus p-core-m could be distinguished. on the other hand, for substitution , the ratios : , : , : , : , : , and : could be distinguished, confirming the sensitivity and specificity of the assay. conclusions: this method could represent a useful alternative for the detection of genotype b hcv core amino acid substitutions and and be reliably applied for rapid screening. efficacy and tolerability of hcv treatment in asian patients according to age and genotype at a tertiary centre in western australia n. saroj , n. kontorinis , t. lorenzo , m. marion , s.l. chen , w. cheng , royal perth hospital, centre for international health, curtin introduction: race and ethnicity can influence efficacy and tolerability to treatment in hcv. the higher response rate in asians is thought to be associated with better adherence and tolerability. objectives: ( ) to evaluate the adherence according to age and genotype ( ) to assess the effect of age on treatment efficacy ( ) background: hepatitis c virus (hcv) infection is a major health problem. there is huge regional variation in its prevalence and genotypic distribution. voluntary blood donors are thought to have somewhat lesser prevalence than the rest of the community. reliable statistics are not available for the entire country, particularly for the rural areas. it is important to know local situation and rationalize use of limited resources. methods: retrospective study of the records of patients attending the free liver clinic (flc) of our hospital located in a rural area of pakistan, and those screened for hcv infection prior to voluntary blood donation. results: patients at flc ( out of [ %; males %] were found to have higher chances of being reactive for hcv antibodies as compared to voluntary blood donors ( / [ %]; p = . ; or . - % ci = . - . ). out of a total of hcv reactive patients, ( %) were found to be positive on hcv rna testing. out of a total of typeable genotypes, ( %; % ci = . - . , estimated odds = . ) were infected with a single genotype, and only patients ( %) were infected with genotype , either alone (n= ) or in combination with a. conclusions: one out of every people tested in our flc is seropositive for hcv, and % of "healthy" voluntary blood donors have the same results. genotype is very rare in our region. s.a. batool , s.z. abbas department of gastroenterology, muhammad hospital, mirpurkhas, pakistan background: hepatitis c viraus (hcv) infection is common in our region. data is not available on success rates of conventional interferon (inf) based products here. we attempted to find out the dominant genotype, and to determine the success rate of conventional inf-based treatment in eradicating hcv. methods: retrospective case series study of hcv infected patients' records treated with different brands of inf. results: / ( %) of all patients tested were positive for hcv antibodies. hcv-rna was tested by pcr for patients, of which ( %) turned out to be positive. genotype type was the dominant genotype -found in / ( %) patients. men and women were treated with various brands of inf with the same manufacturer's brand of ribavirin. the overall etr achieved was / ( %) - / ( %) men and / ( %) women. / ( %) of genotype achieved etr. there was no significant difference in average ages for those who achieved good etr and those who did not ( years each). the etr achieved by different brands ranged from % to %. svr was achieved by / patients. conclusions: % of all people tested positive for hcv antibodies, of which about % had evidence of active hcv infection. etr achieved by different brands averaged %. this was % in female sex, although age did not appear to be a factor in determining a favourable etr. patients & methods: a total of consecutive diabetic patients of either sex were evaluated for hcv and hbv infection by using enzyme linked immunosorbant assay (eliza- ) along with serum alt levels. on the basis of this test, the patients were divided into two groups, sero +ve and sero -ve. different variables were: age, sex, bmi, area of residence (rural or urban), type and duration of dm, smoking, literacy and alt. results: males . % and females . %. age ranged from to . majority were married ( . %), from rural area ( . %), had type- dm ( . %), normal weight ( . %), normal alt( . %) and non-smokers ( . %). seroprevalence for hcv, hbv and both were . %, . % and . %. two groups were made, sero +ve and sero -ve. raised alt ( . %) was significant (p< . ) factor while all others variables were insignificant (p> . ). conclusion: hbv and hcv infections are more prevalent in dm with increased alt levels. while hcv infection is more common than hbv in patients with dm. hepatitis c virus (hcv) envelope proteins (e and e ) mediate the entry of virus into host cells by binding to its cellular receptors and resulting in the fusion of the viral membrane with host cell membrane. the expression and secretion of biologically active envelope proteins in vitro have proven to be a difficult task due to the high degree of glycosylation and the existence of hydrophobic domains within these sequences. in order to obtain glycosylated, correctly-folded hcv envelop proteins in large quantities, we optimized the dna sequences of hcv envelop proteins by substituting the encoded sequence with human preferable codons and expressed them in human embryonic kidney (hek) cells. both proteins were detected intracellularly, with a small portion secreted into supernatant. in order to enhance secretion, truncated forms of envelop proteins including e tm, e - , e - were also expressed. both full-length and truncated forms of envelop proteins were glycosylated and expressed at high level. in addition, we also expressed the codon-optimized hcv receptors cd and claudin- in cells. by comparing the expression level of codon-optimized sequences and the sequences that were obtained from cdna library by pcr, we found that codon-optimization enhance protein expression significantly in cells. these results not only lay solid foundation for further research concerning the mechanism of hcv entry, including the optimal ph and right protein conformation for fusion, cell types that permit viral entry; but also potentiate a useful cell model for testing antiviral agents. background: prolactin (prl) is an immunoregulatory hormone secreted from lymphocytes, however, prl induction in relation to hepatitis c virus (hcv) infection has not been elucidated. methods: serum prl levels were measured in both subjects of our hcv cohort study and male patients of the hospital, who were chronically infected with hcv. furthermore, serum prl levels were compared in male patients before and after interferon therapy. we measured expression of prl mrna level in pbmcs in male patients, and also investigated prl mrna of pbmcs collected from healthy men that stimulated by hcv produced by huh . cells in vitro. result: serum prl levels were significantly higher in the hcv-infected subjects than in the controls (p< . ). they were significantly higher in hcv-infected male subjects than in the controls (p< . ). serum prl levels were significantly higher in male patients than in the controls (p< . ). serum prl levels decreased significantly after interferon therapy in patients with sustained virological response to therapy (p< . ). the levels of prl mrna in pbmcs derived from hcv-infected patients were significantly higher in male patients than in the controls (p< . ). conclusion: the high levels of prl expression are associated with hcv infection in carriers. background and objectives: hepatitis c virus (hcv) is a major cause of chronic liver hepatitis, cirrhosis, and hepatocellular carcinoma.current clinic standard therapy is interferon alpha (ifn-) combination with ribavirin, but this treatment is associated with adverse effects and often fails to induce a sustained response. until recently, development of a hcv cell culture system (hcvcc) provides a suitable tissue culture system to study the complete hcv life cycle. in this study, we tested the effect of ifn omega (ifn-)-a member of type interferon on hcv compared with ifnbased on hcv b replicon and hcvcc. methods: we compared ifn-and ifn- a effects on hcv rna replication and protein expression, as measured by ribozyme protection assay and western blot. we also compared the intracellular protein level of phosphorylated signal transducer and activator of transcription (p-stat ) treated with different interferon type and concentration with western blot analysis. results: hcv rna and protein level were inversely related with ifnconcentration and compared with ifn- a, at the same concentration, the hcv rna and protein levels treated with ifn-were lower than that treated with ifn- a p . .also based on the hcv rna analysis, ec of ifn-was folds lower than ifn- a. ifns increased intracellular p-stat level at a dose dependent manner and compared the same concentration of ifn-and ifn- a, p-stat protein level was higher in ifn-treated group p . . conclusions: these results demonstrate distinct antiviral effect of ifncompared with ifn- a and this difference maybe partly caused by the stronger stimulation of ifn receptor . outstanding antiviral activity of ifnmay be useful for developing new hcv treatment strategies. background & aim: hepatitis b virus (hbv) infection with undetectable levels of hepatitis b surface antigen (hbsag) is called an occult infection, which although has been described among subjects with chronic hepatitis c liver disease in the western world, it's prevalence and clinical significance are still ambiguous in the indian subcontinent. materials and methods: we investigated hbv-dna pcr in serum samples of hbsag negative subjects with chronic hcv-related liver disease, and apparently healthy volunteers negative for hbsag and anti-hcv as control. results: serum samples found positive by at least two independent pcr assays were considered hbv dna positive. hbv-dna was detected among hcv-related chronic liver disease (cld) patients ( . %), which was higher (p = . ) as compared with the control volunteers ( . %). it was more frequent ( . %) in anti-hbs negative/anti-hbc positive patients than in anti-hbs/anti-hbc positive ( %, p < . ). hcv rna by qualitative pcr was significantly (p < . ) higher in occult hbv compare to non-occult. hcv genotype b was predominantly associated with occult hbv ( %), especially among subjects with hepatocellular carcinoma (hcc) (p< . ) as compared to non-occult hbv cases. though not significant, frequency of occult hbv infection was higher than healthy controls and hcv b genotype was significantly associated in patients with hcc. conclusion: this study suggests that in all hbv-endemic areas, the possibility of occult hbv in patients with hcv should be considered and hbv-dna should be performed. j. zhao , , w.d. cai , l. chen , y.x. gan , m.l. he , x.r. wang background: besides hiv and syphilis, hepatitis c virus (hcv) is also rapidly spread among men who have sex with men (msm). this study was designed to identify the prevalence of these sexual transmitted diseases in msms in shenzhen, china. methods: a cross sectional study was conducted by using time location sampling method from april to july, . msm participants (including male sex workers) were recruited and finished guided self-administered questionnaires (or interviews if they have difficulty in reading or understanding) in venue-date-time randomly selected from active venues. results: results were analyzed using spss. blood samples were collected for hiv, syphilis and hcv test. participated msms were between the age of to years ( . ± . ) with a majority of - years ( . %). most of them finished junior high school education ( . %). . % had high level of knowledge on modes of transmission and prevention. likewise, . % msms have ever sold sex to men, . % of them were self identified as gay, . % as bisexual. . % msms had multiple male sexual partners and . % msms always used condom. . % of them had sex with women in the past month, and the condom use rate decline to . % during both male and female sex. hiv positive rate is of . % and syphilis for . %, hcv is only found in cases ( . %). conclusions: a greater number of the participants have both male and female sex partners. this survey shows that hcv infection rate is still low among msms in shenzhen, although the hiv and syphilis rate is high and continuing increased in the past few years. the change of insulin sensitivity in hepatitis c patients with normal insulin sensitivity s.g. park , y.k. cho , j.w. lee , j.w. yun , h.j. kim , w.k. jeon , b.i. background: hepatitis c virus (hcv) infection is associated with a high prevalence of diabetes mellitus (dm). insulin resistance (ir) is known to play a crucial role in the development of dm in chronic hepatitis c (chc) patients. we prospectively investigated the change of insulin sensitivity in chc patients during -year period, and analyzed factors significantly associated with ir. methods: subjects consisted of non-cirrhotic chc patients with normal alanine aminotransferase (alt) and normal insulin sensitivity (chc group), and healthy control group of subjects matched by age, sex, body mass index and life styles. we compared initial baseline insulin sensitivity, metabolic parameters and incidence rate of ir at the end of follow up period in both groups. the change of insulin sensitivity and metabolic parameters and development of ir was analyzed, and factors associated with development of ir were evaluated. results: ir developed in . % of chc patients and . % of normal individuals (p< . ). hcv infection per se and genotype were independent risk factors of ir. initial fasting glucose - mg/dl, fasting insulin uiu/ml, homa-ir . - . were significantly associated with development of ir in chc group. conclusions: hcv infection is independent risk factor of ir. even if chc patients with normal insulin sensitivity, careful monitoring for ir is necessary. prevalence of viral hepatitis c in latvia i. tolmane , , b. rozentale , , j. keiss , f. arsa sa infectology center of latvia, riga stradin's university background and aim: viral hepatitis c (vhc) because of its prevalence and clinical course has become one of the most actual infectious diseases in the world. to date chronic hepatitis c affects over million individuals worldwide. chronic vhc is a leading cause of cirrhosis and hepatocellular carcinoma. the aim of this study was to investigate how many residents of latvia, that are over years of age have been exposed to vhc (anti-hcv prevalence) and how many are infected at the moment (hcv-rna prevalence). until now such research has not been performed in latvia. methods: from the register of general practitioners there were randomly selected gp's from different regions of latvia, persons over years of age were selected out of each gp register and tested for anti-hcv with screening test (elisa). in case of positive result antibodies were confirmed with western-blot reaction and person was tested for hcv-rna (pcr). results: in total person was invited by general practitioners for the test and persons responded (response rate . %). confirming test (western-blot) was positive in participants and out of which hcv rna test was positive in patients. conclusions: there are . % of people exposed to hepatitis c virus in latvia and . % are infected with hepatitis c virus, respectively, infected persons per thousand individuals. genetic variation in the ikk/nf-b pathway and the live fibrosis progression in chronic hepatitis c r. sho , k. ishii , r. ishii , h. watanabe , k. sugahara , y. nishise , k. okumoto , t. saito , s. kawata , a. fukao department of public health, department of gastroenterology, yamagata university faculty of medicine background/aims: i b kinase/nf-b (ikk/nf-b) signaling pathway is thought to play critical roles in liver inflammation and fibrogenesis. we carried out a haplotype-based association study to examine the contribution of common genetic variations in the genes encoding nf b inhibitor kinase alpha and beta (ikbka and ikbkb; the major components of ikk/nf-b pathway) to the progression of live fibrosis in chronic hepatitis c. methods: based upon the common single nucleotide polymorphisms (snps; minor allele frequency(maf) . ) and linkage disequilibrium (ld) information derived from the hapmap, we selected and tag snps from ikbka, and ikbkb, respectively, for genotyping. by using melting curve analysis, snps were genotyped in chronic hepatitis c patients, including patients with hepatocellular carcinoma. association between common genetic variations in ikbka/ikbka and platelet count (plt) was tested by both genotype-and haplotype-based approaches. results: we succeeded in genotyping a total of tag snps that efficiently capture common variation across the kb-block of ikbka and the kb-block of ikbkb. for each of genes tested, haplotypes were found in population studied. all snps were in hardy-weinberg equilibrium, but no significant association was observed between any single tag snp or haplotype and decreased plt in patients analyzed. conclusions: our data suggest that it is unlikely that polymorphisms within the ikbka and ikbkb genes are involved in the progression of live fibrosis in chronic hepatitis c. further studies on genetic variations in other nf-b-related genes in chronic hepatitis c are needed. background: hepatitis c virus infection is a major burden after liver transplantation. the effective treatment for patients who underwent liver transplantation has not been well established. management of these patients is the most challenging task. cyclophilins are essential host factors for hcv replication. we report here the efficacy of divided administration of ifn plus cyclosporine a in the treatment of chronic hepatitis c patients who failed peg-ifn or ifn combined ribavirin. patients and method: we prospectively included patients (median age, ) with genotype b and, failures to combination ifn plus ribavirin or combination pegylated ifn plus ribavirin. the present treatments consisted of an induction therapy, an intensified therapy and a maintenance therapy. the induction therapy comprised intravenous mu ifn every hours for the first days, . mu ifn every hours for the next days and mu ifn every hours for the following weeks, totaling mu of ifn . the intensified therapy was induction therapy shortened to weeks. the maintenance therapy comprised of pegylated ifn b and ribavirin. csa was given times daily during the induction and the intensified therapies. ribavirin was given twice daily during the maintenance therapy. results: the end treatment response and sustained virological response rate of the present study were % ( / ) and % ( / ), respectively. the relapse rate was %( / ). non-responders was % ( / ). all adverse effects were completely reversible. the treatment protocol was well tolerable. conclusion: we concluded that our protocol should be effective in failures to the previous combination therapies. host factor targeting treatment will become a promising treatment option. cyclophilin targeting treatment is a promising new anti-hcv treatment k. inoue , t. watanabe , s. yoshiba background: hepatitis c virus (hcv) is the most common cause of chronic liver disease. however, the efficacy of currently available treatments is limited. we recently reported the effects of combined interferon-/cyclosporin a treatment. cyclophilins are associated with hcv replication and bind cyclosporin a. which cyclophilins are closely associated with hcv replication remains controversial. in this study, several cyclophilins were found to be essential host factors for hcv replication and hcv replication was rescued by overexpression of cyclophilin a in the presence of cyclosporin a. methods: we evaluated the effect of cyclosporin a and its analogues on the replication of hcv in vitro using several types of hcv replicon. the gene expression of representative cyclophilins and pin- was knocked down using small interfering rna (sirna) to identify cyclophilins associated with hcv replication. the specificity of the effect of sirna was confirmed by western blot analysis. the effect of overexpression of cyclophilins on hcv replication in the presence of cycloporin a was also studied. results: cyclosporin a and its analogues suppressed hcv replication in a dose dependent manner. cyclophilin f, cyclophilin lc and cyclophilin lc as host factors which are closely associated with hcv replication, in addition to the previously reported cyclophilin a. knockdown of chclophilin b showed little effect on hcv rna replication. cyclophiln-dependent hcv replication varied among the three hcv replicon cell-lines used. overexpression of cyclophilin a rescued hcv replication in the presence of cyclosporin a. conclusions: these findings suggest several cyclophilins are essential host factors for hcv rna replication. thus potent cyclophilin inhibitors have the potential to be anti-hcv drugs. background/aims: hepatitis c virus (hcv) genotypes - have a worldwide distribution. types a and b are predominant in northern europe and north america, and in southern and eastern europe and japan, respectively. type is endemic in south asia and is variably distributed in different countries. genotype in egypt, genotype in central and south america and genotype is common in china, japan and south east asia. in pakistan a is the commonest genotype, which is associated with the most favorable outcome regarding end treatment response and sustained virological response after weeks of therapy. the aim of this study is to find out hcv genotypes in newly diagnosed chronic hepatitis c patients. methods: this observational study was conducted in chronic hepatitis c patients. all patients had raised alt levels for last months, had positive polymerase chain reaction (pcr) for hcv rna by real time method and liver biopsy was done in all patients under national program for prevention and control of hepatitis during year - . genotyping was done on roche genotyping kit. data was analyzed by spss . results: out of patients, . % (n= ) were genotype a. . % (n= ) were genotype b. . % (n= ) were genotype a. n= had genotype b. . % (n= ) had mixed genotype ( a, b/ a, b, a, b). conclusion: majority ( . %) of chronic hepatitis c patients were genotype a which is associated with favorable outcome after weeks of interferon and ribavirin therapy and only . % had genotype a in this cohort. s.t. zhou , y. zhao , f.j. zhang background/aims: as human immunodeficiency virus (hiv) infected children who are receiving antiretroviral therapy (art) are living longer in china, comorbidities of hepatitis b virus (hbv) and hepatitis c virus (hcv) coinfection should be carefully considered when making management decisions. however, the coinfection rate of either hbv or hcv is unknown in hiv-infected children in china. we evaluated the seroprevalence of hbv and hcv in the china national pediatric art cohort of hiv-infected patients. methods: patients were selected from hiv infected children medically eligible for art who were enrolled into the china national pediatric art cohort since . interviews, medical assessment, serology for hbsag, anti-hcv antibody, transaminase levels, and hiv serostatus and cd counts at baseline of patients were obtained. results: of hiv-infected children were hbsag seropositive ( . %; %ci: . %- . %), and of children were anti-hcv antibody seropositive ( . %; %ci: . %- . %). only age was associated with hbv coinfection. multivariate analysis revealed that children infected with hiv through contaminated blood or transfusion of blood products were . times more likely to be anti-hcv antibody positive than those infected with hiv through other routes. and children from central china provinces, henan, anhui, shanxi, and hubei were . times more likely to be hcv seropositive. conclusion: the high seroprevalence of hbv and hcv coinfection in hiv-infected children attending china national pediatric art cohort calls for routine screening for hepatitis viral coinfection and modification of the management of hiv-infected children in china. background: bms- is a first-in class and highly selective hepatitis c virus (hcv) ns a inhibitor with picomolar in vitro potency against genotypes a and b. in a sad study with healthy subjects, bms- was safe, well-tolerated, and had a pharmacokinetic profile suggestive of once-daily dosing. methods: the objectives of this randomized, double blind, placebo-controlled, sad study were to evaluate the safety, tolerability, antiviral effect and pharmacokinetics of bms- in patients with genotype chronic hepatitis c (chc). treatment naïve or experienced patients were randomized to receive , , or mg of bms- or placebo. results: all bms- single doses were well tolerated and had a safety profile similar to that of placebo. following oral administration, bms- was readily absorbed with dose proportional exposures over the studied dose range. the mean terminal half-life of bms- was approximately hours. mean decline in hcv rna hours after a single , and mg dose of bms- was . log (range . to . log ), . log (range . to . log ) and . log (range . to . log ), respectively. the mg dose resulted in a mean decline of . log (range . to . log ) hours after dosing, which was maintained at hours. conclusions: single doses of up to mg of bms- were safe and well tolerated in patients chronically infected with hcv genotype . bms- produced a robust decline in hcv rna and has a pharmacokinetic profile that potentially supports once-daily dosing. background: the global infection rate of hcv is approximately %, and nearly . % in china. only %- % of patients with genotype b can achieve sustained virological response (svr) after antivirus therapy, nearly half of them experienced treatment failure. the study aimed to determine hcv- b sequence evolution in patients experienced treatment failure during and after therapy, and further analyze relations between the mutations and treatment outcome. methods: patients with genotype b accepted antiviral treatment of ifn plus ribavirin for weeks, and long-term follow-up after therapy. patients experienced treatment failure were further analyzed (one for relapser, another for nonresponder). sera were reserved at baseline, w, w and -year after therapy. hcv-rna was extracted. hcv full-length orf was amplified by rt-nested-pcr and sequencing. result: of the patients achieved svr ( . %). from sequence alignments of relapser at baseline and w, we find that p , ns a and ns a have higher mutation rate both in nucleotide and amino acid level ( . % and . %, . % and . %, . % and . %, respectively). but there is no significant difference in the alignments of w and -year after therapy, the mutation rate is lower. mutation rates of the non-responder among baseline, w, w and -year after therapy are very low. conclusion: antivirus effect is correlated with specific hcv sequences in chronic hepatitis c, mutations in hcv non-structure protein p , ns a and ns a have important impacts on treatment outcome in ifn-based therapy. background: the results of antiviral therapy for hepatitis c (hcv) have improved recently with the use of peg-interferon (peg-ifn)/ribavirin therapy. however, age of patients are concerned because of side effects and safety. as we known, a few studies have targeted therapy in elder with chronic hcv. aim: we reviewed the results of interferon based antiviral therapy in the elderly with chronic hcv at our institution. methods: patients were defined as elderly if they were years and elder who received therapy for hcv. the prescribed treatment duration, end of treatment response were mention. the data recorded included laboratory tests, adverse events (ae), dose modification, and withdrawal rate of therapy. results: of chronic hcv patients treated with peg-ifn/ribavirin between nov and feb . patients were older than years old. the mean age of the elder patients was . ± . years old. were male and were female. histological studies showed with cirrhosis. almost all patients had experienced ae/side effects. the most common abnormalities were anemia and neutropenia. therapy was discontinued in % ( / ). the rate of dose modification was % ( / ) patients who received weeks therapy. transaminases were normalized in % ( / ) after weeks treatment and sustained in % ( / ) one year later. conclusion: the elder patients are more at risk of developing ae while on treatment. most patients should be discontinued or decreased dosage of medication. however, the elder patients with chronic hcv can be treated successfully. background: in the general population the incidence of interstitial lung disease is estimated to be . % and has also been reported with the use of interferons. the higher reporting rate of ip in japan has created interest and warrants further investigation. methods: using both data from randomized clinical trials (ex-japan) and the roche world-wide safety database (advent), the frequency of ip was estimated in patients treated with peginterferon alfa- a ± ribavirin. ip was defined as: interstitial lung disease, alveolitis, pulmonary fibrosis, pneumonitis and pulmonary toxicity. results: one case of ip was reported among the patients included in the clinical trials ( . %). in the advent database considering the estimated , patients with cumulative exposure to peginterferon alfa- a ( , in japan and , us/row) the reported cases of ip represent a rate of . % with a proportional reporting ratio (prr) of . (p< . ). of these cases, were reported in japan (prr . ; p< . ), in the usa (prr . ; p= . ) and row (prr . ; p= . ) representing reporting rates of . % in japan and . % in the usa and row. japanese patients with reported ip were older ( versus - years) and were more likely to have been treated with peginterferon alfa- a monotherapy ( % versus - %). furthermore, the yearly incidence rate has remained unchanged. conclusions: the apparently higher rate of ip reported in japan may result from differences in patient demography, diagnostic criteria and treatment patterns. the overall incidence of ip remains low. background: hepatitis c virus (hcv) infection carries a significant risk for development of insulin resistance (ir) and/or diabetes (dm). recently, retinol-binding protein (rbp ) has been reported as a protein contributing to ir. this study aimed to assess the different expression of serum rbp between chronic hcv infection (chc) patients and non-chc controls. methods: serum rbp was measured in treatment-naïve chc patients and its correlation with the homeostasis model assessment of insulin resistance index (homa-ir), liver histology, virology and metabolic factors was investigated. patients were stratified into different stages of glucose tolerance by oral glucose tolerance test. another sex-and age-matched non-chc adults served as the controls. results: the mean rbp level of controls tended to be higher than that of chc patients ( . ± . vs . ± . g/ml, p= . ). the mean rbp level of igt control-group subjects was . ± . g/ml, which was significantly higher than that of ngt ( . ± . g/ml, p< . ) and dm controls ( . ± . g/ml, p< . ). in contrast, the mean rbp level ( . ± . g/ml) of dm/chc patients was not significantly different from that of ngt/chc ( . ± . g/ml, n= ) and igt /chc ( . ± . g/ml, n= ) patients. amongst chc patients, there was a significant decreasing linear trend of rbp dependent of both histological grading and staging progression, whilst a significant increment of homa-ir was found. conclusion: serum rbp is dysregulated in chc patients. introduction: sustained viral response (svr) in hepatitis c treatment with interferon alfa and ribavirin is affected by adherence and compliance due to severe myalgia, fatigue-anxiety and disturbed sleep. pregabalin, an orally effective gabasergic drug is not metabolized via cytochrome p and is used in fibromyalgia and fatigue-anxiety syndromes without hepatic toxicity.this study evaluates the addition of pregablin to standard agents in achieving svr by reducing side events. methods: thirty patients with chronic hepatitis c {mean age - years, male: female - : ,genotype(g) (n= ), g (n= ), fibrotic score f - (n= ) and f (n= ), mean bmi > kg/m , initial viral load > , iu/ml} were randomized to pregablin mg (n= ) or duloxetine mg (n= ) both orally daily with interferon alfa a mcg sq once a week and ribavirin mg daily for weeks. myalgia anxiety scale, modified quality of life score -evaluated at entry and tri-monthly. all were tested for rapid viral response, early viral response and end treatment viral response and svr. results: at the end of weeks, in the pregablin arm, ( . %) completed the therapy without interruption, one stopped due to excessive somnolence. duloxetine arm - ( . %) completed with interruptions, ( . %) withdrew from the trial due to side events, one left the country. ( . %) achieved svr in pregablin arm and ( . %) with duloxetine. conclusions: pregablin may be considered with ifn and rbv for better adherence and compliance in achieving svr in treatment of chronic hepatitis c. larger randomized studies are needed to confirm the findings. in this study we extended this treatment approach to on treatment nonresponders (defined as having detectable hcv-rna after at least weeks of soc). methods: so far, pts. hcv-rna pos. after weeks of soc ( male, female, genotype : ; genotype a: , with cirrhosis) participated in this protocol; were treatment naïve pts, relapser to two previous therapies ( and weeks). mg/kg/d sil was given for days, soc was continued. hcv-rna was quantified by taqman (roche diagnostics, usa) at monthly intervals on standard treatment and weekly after starting sil. results: all patients received at least weeks of soc, at week had a log drop < , two patients had detectable but unquantifiable hcv-rna (< iu/ml). after days of sil all had undetectable hcv-rna, in one hcv-rna increased to iu/ml and recived after a second course of sil. .all patients are still on soc and are hcv-rna negative. conclusion: sil iv. is an effective "rescue treatment" for on treatment nonresponders to full dose of peginterferon/ribavirin combination therapy. poster exhibition -imaging modalities poster session, hall b background: levovist-enhanced ultrasonography using subtractions makes it possible to depict the perfusion of hyperechogenic nodules. our institution performs sonazoid-enhanced ultrasonography using a toshiba aplio that is set to a ps low images, as generally recommended. the resulting images, however, are difficult to evaluate the kind of staining image that is obtained from a hyperechogenic nodule. these staining images were then compared to advanced dynamic flow (adf) images of a hyperechogenic nodule recorded using levovist-enhanced ultrasonography. methods: the subjects were five nodules who had undergone sonazoid-enhanced ultrasonography. two patients had experienced a recurrence of hcc after tace, while three patients had a hyperechogenic nodule of hcc that had never been treated. one patient with hcc after tace was imaged at a ps low. the second patient with hcc after tace and the three patients with hcc showing a high echoic nodule, were imaged using adf. results: in the patients with hcc after tace, the remaining tumor was difficult to observe in both the vascular phase and the kupffer phase taken at a ps low. in the other patients, however, images taken using adf clearly showed the residual tumor. also, with regard to the findings from the perfused images obtained from the three patients with hyperechogenic nodules of hcc, the hcc was more easily detectable in the adf images than in those taken at a ps low. conclusion: hyperechogenic perfused nodules are easier to identify in images taken using adf than in images taken using ps low. y. komorizono , t. shibatou , k. sako nanpuh hospital background: this study aimed to evaluate the usefulness of sonazoid enhanced radiofrequency ablation under real-time virtual sonography (rvs) guidance in a series of patients with hepatocellular carcinoma (hcc). method: twenty-five patients with a solitary hcc tumor measuring < = . cm in greatest dimension were enrolled in this study. eight patients received an initial treatment, seven also received an additional treatment for local recurrent tumors, and the remaining ten had distant recurrent tumors. all patients were easy to scan by multiple detector ct (mdct), but not by conventional ultrasound ( conclusions: the combination of the rvs system with sonazoid-enhanced us appears to have a high potential for use on patients that are difficult-to-scan by us examinations for percutaneous radiofrequency ablation. background & aims: contrast enhanced ultrasonography (ceus) with sonazoid can be expected to be useful not only for detection of tumor but also for us guided ablation therapy because kupffer imaging lasts for long time. the aim of this study is to investigate the usefulness of sonazoid in rfa for hcc. material & methods: a total of hcc nodules in patients admitted to receive rfa were studied. the detection ability of hcc was compared between ceus and conventional us using dynamic ct as reference standard. the effectiveness in the treatment was assessed by comparing the mean numbers of treatment session of rfa in patient treated with ceus assistance and that in historical controls matched for tumor and background conditions. results: the detection rate was . % in conventional us and . % in ceus (p= . ). sixty-nine nodules in patients were not detected by conventional us and detected after injection of sonazoid. the mean increase in detected tumor number with contrast enhanced us were well correlated with serum albumin level (p= . ). ceus was not superior to conventional us in patients with low albumin level. the mean number of session was . ± . as compared to . ± . in the historical controls (p= . ). conclusions: ceus with sonazoid is useful for detection of tumor in patients with well-conserved hepatic reservoir. the decrease in the mean number of sessions compared to historical controls suggested that sonazoid is an excellent supportive agent in rfa treatment of hcc. direct measurement of peri-operative change in portal blood flow and pressure is difficult in human. in the present study, computational simulation of pre-and post-operative portal blood flow and pressure was performed using computational flow dynamic (cfd) software in patients with primary liver cancers. methods: patients with fibrotic or non-fibrotic livers were analyzed. according to preoperative md-ct, mesh models of portal branches were constructed. cfd software (fluent . , fluent inc.) was employed for flow simulation. on the fluent . , changes in flow dynamics in the remnant portal branches were simulated by virtual cutting of an interested portal branch. the simulation was also performed days after the operation using dicom data obtained at that time. results: relative increase in blood flow in each remnant portal branch was not uniform throughout the liver in each patient. the sudden increase in portal pressure just after the virtual cutting of interested portal branch was almost normalized by day in non-fibrotic liver according to the flow simulation, while the increase in fibrotic liver did not return to the pre-operative values by day . these results suggest that responsive dilatation of remnant portal branches and subsequent regional regeneration could normalize the sudden increase in portal pressure after surgery in non-fibrotic livers, while the mechanism is impaired in fibrotic livers. discussion: computational flow dynamic simulation is useful to analyze the differences in the peri-operative portal flow dynamics and liver regeneration between non-fibrotic and fibrotic livers. aim: to determine if roi analysis can characterize washout in hepatocellular carcinoma (hcc) better than visual analysis. methods: surgically proven hccs from a single institution were studied. the patients' gender, age, date of scan, date of surgery were recorded. patients with pre-operative triphasic (n= ) and quadriphasic ct scans (n= ) were included. a representative section containing the lesion was selected for each case. the hu change between the precontrast and arterial (huabsolute hypervascularity) and the hu change between the peak attenuation and late portovenous phases (huabsolute washout) were recorded. cases were deemed positive if the hu change was more than the standard deviation ( hu). this was compared against visual analysis to determine if our method would increase sensitivity of ct for hcc. results: the mean patient age was . years (range to years); there were males and females. the mean duration between surgery and the scan was . days (range to days). peak enhancement was seen in the early portal venous phase in . % cases. the mean huabsolute washout was . hu (range - - ). roi analysis detected / cases ( . %). this was . % more than visual assessment, which detected / cases. this was statistically significant (p= . ). conclusion: visual assessment of lesion density is subjective. quantitative measurement of lesion attenuation changes between scan phases is a simple and objective method that is more sensitive than visual assessment in determining lesion washout. background: abdominal ultrasonogram(usg) is a common available diagnostic tool to screen and follow up for hepatocellular carcinoma(hcc). but it has been reported that the specificity of ultrasonogram is high but the sensitivity of it is insufficient. we investigated the characteristics of hccs that was missed in the usg but was detected in the ct. methods: total patients who were diagnosed with hcc between december, and february, , were enrolled and analysed retrospectively. all patients were performed with a usg prior to a spiral ct. the period between usg and spiral ct was limited within month. we investigated age, gender, cause(hbv, hcv, alcohol), the size of hcc(the length of long diameter), stage(modified uicc), child-pugh grade, cirrhosis, tumor number, portal vein thrombosis, diffuse type of hcc, regenerative nodules(rns), and the tumor location at segement as the possible related factors. results: the mean period between usg and spiral ct was . ± . days. the diagnostic accuracy rate to hcc was . %( / ). there was no interobserver variation. in analysis of associated factors, there was no statistical significance in age, gender, cause(hbv, hcv, alcohol), stage(modified uicc), child-pugh grade, cirrhosis, portal vein thrombosis, diffuse type of hcc, regenerative nodules(rns) (p > . ). there was statistical correlation in the tumor size less than cm, the solitary tumor and location at segement . (p > . ). conclusion: tumor size less than cm, solitary lesion and location at segment are significant factors to miss hccs in usg diagnosis. s. somani , a. somani , a. jain , v. dixit suvidha, navjeevan hospital, background: histopathological examination is required in the evaluation of various liver diseases for both diagnosis and prognosis. earlier blinded percutaneous liver biopsy was done commonly but now there are various studies suggesting that sonographic guided percutaneous liver biopsy could be more precise and safer. our aim was to compare the safety and diagnostic utility of sonographic guided versus blind percutaneous liver biopsy. methods: it was a retrospective single center study done between june and may . trucut liver biopsy needle was used in all patients. demographic, clinical and histological characteristics between the two groups were evaluated. insufficient biopsy was defined as a sample with less than portal spaces. we reviewed the type of complications and if hospitalization was required, or any mortality related to the procedure. results: out of liver biopsies done in this period after excluding patients we included patients, in group a( %, blind approach) and in group b ( %, sonographic guided approach). mean age was ± . years and male: female ratio was . : . biopsy was sufficient in % in group a and % in group b (p < . ). minor complications occurred in % in group a and % in group b which was not significant. major complications occurred in . % in group a and . % in group b which was statistically significant. mortality was . % in group a and . % in group b which was statistically significant. conclusion: our study suggest that sonographic guided percutaneous liver biopsy is superior in the diagnosis of liver diseases in all aspects when compared to blind approach as it is more safe, has more diagnostic utility with significantly less complications and mortality. poster exhibition -liver fibrosis poster session, hall b background/aims: hmg-coa reductase inhibitors have been shown to reduce hepatic stellate cell proliferation and collagen production and decrease oxidative stress and hepatic vascular tone in cirrhotic patients. therfore, the aim of the present study was to examine whether the lipid lowering agents atorvastatin (ato) or rosuvastatin (ros) would prevent experimentally-induced acute or chronic hepatic damage in rats. methods: liver cirrhosis was induced by thioacetamide (taa, mg/kg, i.p.) twice a week, for weeks. acute damage was induced by two consecutive taa injections ( mg/kg in a h interval). rats were treated concurrently with taa only or taa and either ato or ros daily by nasogastric gavage. another group was treated with taa+pentoxifyline (ptx), an agent with known antifibrotic effect through a different mechanism and served as positive control. results: presented in the conclusions: the lipid lowering agents used in our study had no effect on the development of acute or chronic hepatic damage in rats or on oxidative stress induced by taa. purpose: the development of hepatic fibrosis in patients with chronic liver disease increases the risk of liver cancer. the present study was conducted to determine whether an easily performed myocardial examination technique can be applied to the assessment of hepatic fibrosis. strain rate imaging is a new method based on tissue doppler imaging (tdi). the usefulness of strain rate imaging in assessing the degree of hepatic fibrosis was evaluated. this time, it mede comparative study with fibroscan in cases. methods: strain rate imaging was performed using a diagnostic ultrasound system (aplio tm , toshiba medical systems corporation, tochigi, japan) in a total of subjects: in the chronic hepatitis group, in the cirrhosis group, and in the normal control group. tdi-q, the tissue doppler analysis software installed in the aplio system, was used for analysis. measurement was performed five times from the epigastrium, with the roi size set to mm and the derivative pitch to mm. results: (i): both scores were largely reproducible among the different laboratories. however, compared to the histological findings, the error ratio was % for all results calculated by fibrotest and actitest. (ii): calculated scores varied among f ( %), f ( %), f -f ( %), and f ( %) (fibrotest), as well as a /a ( %), a ( %), a -a ( %), and a ( %) (actitest). results: the mean strain value was . in the chronic hepatitis group, . in the cirrhosis group, and . in the normal control group.the correlation was not thought to be fibroscan. conclusion: the results of the present study suggest that this noninvasive method permits quantitative assessment of the degree of hepatic fibrosis to be performed easily and in a short time. it is expected that the accuracy of the strain rate imaging method in determining the degree of hepatic fibrosis will be improved when it is used in combination with histological examination. conclusion: despite reproducibility of fibro-and actitest results among the six laboratories, large scale investigation (n= ) displayed increasing variability of the results depending on interlaboratory differences that were still in a quality controlled, analytically acceptable range. furthermore, calculated scores coincided with histological findings only in less than % of all cases. thus, the diagnostic accuracy of these tests seems low, if histology is accepted as gold standard. background: current knowledge attributes connective tissue growth factor (ctgf/ccn ) a crucial role in enhancing tgf-actions during hepatic fibrogenesis. recently, we demonstrated that caffeine leads to an upregulation of ppar in hepatocytes, thus sensitizing these cells to the well known inhibitory effect of -deoxy- , -prostaglandin j ( -d-pgj ) on ctgf expression. however, upregulation of the receptor alone is not sufficient per se, its physiological ligand -d-pgj is required for exerting its inhibitory effect on ctgf synthesis. aim and methods: this study compares serum concentrations of -d-pgj in caucasian patients with fibrotic liver diseases (n= ), caucasian controls (n= ) and caucasian non-liver disease sick (n= ), as well as of chinese patients with hepatocellular carcinoma (n= ) and chinese healthy controls (n= ) in order to characterize their suitability for therapeutic approaches with ppar inducing (i.e. ctgf inhibitory) drugs such as caffeine. results: presented data show that caucasian patients with ongoing hepatic fibrogenesis (mean . ± . µg/l) display impressingly higher serum concentrations of -d-pgj than healthy probands (mean . ± . ) and caucasian patients with non-liver disease (mean . ± . µg/l). similar results are found in chinese patients with fully developed hcc (mean . ± . µg/l) compared to chinese healthy controls (mean . ± . µg/l). we identified the predictors of tumor recurrence using cox-regression model. introduction: non-invasive, i.e. serum-based multiparametric panels of biomarkers have been proposed for the diagnostic assessment of liver fibrosis. aims/methods: (i) haptoglobin, alt, ggt, alpha -macroglobulin, apolipoprotein a and bilirubin in sera of patients with histological proven fibrosis (f -f , a -a ) were determined in different quality-controlled laboratories. interlaboratory variations of the calculated fibrotest score for staging and actitest score for grading (both biopredictive tm ), and their error ratios compared to biopsy results were calculated. (ii) the variability of obtained fibrotest/actitest scores depending on differential combinations of the allowed analyt-specific maximum/minimum permissible values as determined by the external quality control of the german association of laboratory medicine was determined and the frequency distribution of the results calculated. results: a total of patients (mean age, . ± . years; male, . %) were included. median follow-up duration was . months (range, . - . ) and patients ( . %) experienced local tumor recurrence during the observational period. multivariable analyses showed that low p /ms level (relative risk, . ; % confidence interval [ci], . - . ; p= . ) and serum alpha-fetoprotein level > ng/ml (relative risk, . ; % ci, . - . ; p= . ) were independent risk factors for tumor recurrence. patients with p /ms level < . revealed . -fold ( % ci, . - . ; p= . ) increase in the risk of recurrence after adjustment for serum alpha-fetoprotein level, as compared to those with p /ms level > . . however, tumor size, child-pugh score, and hepatitis b virus dna level failed to significantly affect the time-to-recurrence. conclusion: our study suggests that lower p /ms value, which means more severe liver fibrosis, is an independent predictor for hcc recurrence after rfa. background/aims: despite of its high prevalence, osteoporosis is an underestimated complication of liver cirrhosis. the aims of this study is to prove the prevalence of osteoporosis and osteopenia in patients with liver cirrhosis and to identify the principal risk factors associated. methods: the prevalence of osteoporosis and osteopenia was studied in patients with alcoholic or viral liver cirrhosis who were admitted to the institute of gastroenterology and hepatology, cnuh between march and september . osteoporosis and osteopenia was evaluated by measuring their bone density using dual energy x-ray absorptiometry (dexa) at lumbar spine and femoral head. the variables taken into consideration were: sex, body mass index (bmi), presence of cholestasis, severity and duration of liver disease. results: total patients (male and female , respectively) were estimated for association of liver disease and osteoporosis. of these, patients were estimated for bone density of lumbar spine and neck of femur by dual x-ray absorptiometry (dexa). morning blood samples were taken for hormonal and biochemical analysis from all patients. among patients, patients ( %) were found to have osteopenia or osteoporosis. there was no statistically significant correlation between age, bmi, severity and duration of liver disease, pth, vitamin d, alp and igf- . conclusion: there is high prevalence rate of osteopenia or osteoporosis in liver cirrhosis. although the causes of osteopathy are heterogeneous, the early diagnosis and treatment of osteopathy in patients with liver cirrhosis is important. background: to build and to evaluate mathematical models for predicting liver fibrosis progression by using conventional laboratory indicators in chronic hepatitis b. methods: liver biopsy and routine laboratory tests were performed in patients with chronic hepatitis b. using multiple logistic regression to analyze evidently relevant indicators, then the predicting models were built and analyzed by roc curve. results: after spearman analysis, factors such as age, platelet count(plt), international rate(inr), total bilirubin(tbil), albumin(alb), aspartate aminotransferase (ast), gamma glutamyltranspeptidase (ggt), total bile acid(tba) and cholinesterase(che) were found to be correlated with liver fibrosis p . . three models (s , s , s= , respectively) were built by plt, inr, alb, ggt and che, which were independent predictors after multiple logistic regression analysis.finally, fibrosis score (fs) was calculated to predict different liver fibrosis stages. roc curve analysis revealed that the auc of fs was . in model (s ), . in model (s ) and . in model (s= ) fig .the cut-off fs in model was at . with . % sensitive, . % specificity and the accuracy was . %. the cut-off fs in model was at . with . % sensitive, . % specificity and the accuracy was . %. the cut-off fs in model was at . with . % sensitive, . % specificity and the accuracy was . %. conclusions: the predicting models, built by using conventional laboratory indicators, have fairly well value for diagnosing hepatic fibrosis or hepatocirrhosis in chronic hepatitis b. background: to investigate the effect of liver cirrhosis on the development of atherosclerosis in the rabbits chronically fed with high fat diet. methods: normal male new zealand white rabbits were randomly divided into four groups: a control group, a high fat diet group, a carbon tetrachloride (ccl ) group and a complex group. pathologic changes in ascending aortas and livers were observed. the levels of serum alanine aminotransferase alt , lipid, c-reactive protein (crp) were also determined. results: significant hepatic steatosis, inflammation and fibrosis could be observed in the three treatment groups; while atherosclerosis and typical arteriosclerotic plaques in ascending aortas could only be observed in the two high fat diet groups. compared with the control group, serum alt and lipid levels in ccl group were increased significantly (p< . ), but no difference of arterial intima-media thickness (imt) and i/m ratio between these two groups. the levels of serum alt, lipid, crp and imt in two high fat diet groups were significantly increased compared with the control group (p< . ). the level of serum alt in the complex group was significant higer than that in the high fat diet group, but the i/m ratio was just opposite (all p< . ), and there was no difference of imt between the two groups. conclusions rabbits treated with ccl can elevate serum lipid levels, but can not induce atherosclerosis. though the activity of liver inflammation was aggravated in the complex model group, it has no effect on atherosclerosis possibly partly because of malnutrition. higher values of liver stiffness in males with mild chronic hepatitis c c. stern , a.c. cardoso , r. moucari , a.d. pumpo , n. giuily , p. bedossa , p. marcellin hopital beaujon background/aim: liver stiffness (ls) measured by fibroscan (echosens) is a noninvasive method to assess liver fibrosis in patients with chronic liver diseases. we evaluated the impact of factors on ls results in mild chronic hepatitis c (chc). methods: chc patients with metavir fibrosis stage at liver biopsy and a reliable ls exam were eligible. all patients had no prior antiviral treatment. the ls values were compared to clinical and biochemical data. results: patients were included with the following characteristics: mean age , male gender ( %), mean bmi . , median ls . kpa ( . - . ), diabetes ( %), genotype ( %), metavir activity a ( %), a ( %), steatosis at biopsy % ( %), mean glucose . , abnormal alt ( %), abnormal ggt ( %), homa ( . ). the ls values were associated wtih male gender (median . in males vs . in females) (p= . ), bmi (p= . ), alt (p= . ), ggt (p= . ) and glucose levels (p= . ). no association was found between ls and activity stage (p= . ) or steatosis (p= . ). in the linear regression, the only factor independently associated with higher ls was gender (p= . ). in men, higher ls was related to levels of alt (p= . ), but not to necro-inflammation grade (p= . ). in women, ls was not associated with alt levels, but with bmi (p= . ) and ggt levels (p= . ). conclusion: in patients with mild chc, liver stiffness values are higher in males. these results suggest that different cut-off for fibrosis stage should be proposed according to gender. aims: to investigate the effects of shuanghu qinggan granule(sqg) on prevention and treatment of hepatic fibrosis induced by carbon tetrachloride in rats. methods: sd rats were divided into groups, normal control groupamodel groupb, sqg largec , middlec small dose groupsc and silymarin positive contrast groupd. the rats of bc c c d were injected with carbon tetrachloride for weeks. the rats of c c c were then administered with sqg for weeks. the rats of d were then administered with silymarin for weeks. results the liver structure of rats of b was severely damagedlarge amount of liver cells became obviously degeneratedand hepatic veins were clearly congested. the hepatic cells fatty degeneration and infiltration of inflammatory cells in rats of c c c d reduced significantly. there was no fiber hyperplasia in liver tissues of rats of c c c d. blood serum ha cp p levels in rats of b were significantly higher than those in ac c c d. conclusion: sqg has remarkable therapeutic effects on rats with hepatic fibrosis induced by carbon tetrachloride, the higher the dosage of sqg was, the more effective the results would be. conclusions: none of sophisticated biomarkers had value in addition to readily available laboratory data for the prediction of significant fibrosis in hbeag positive patients. two markers out of sophisticated biomarkers provide additional diagnostic information in hbeag negative patients. before new biomarkers are accepted, their superiority to routine laboratory data should be meticulously appraised. objective: to evaluate the efficiency and safety of "tinmax" hb- herbal compound (cpd) in treatment of hepatofibrosis and cirrhosis post chronic hepatitis b. methods: a double-blind randomized method was employed. patients of hepatofibrosis or cirrhosis post hepatitis b were separated into study group ("tinmax" hb- group) and control group (natural vitamin group) by randomized method. the course was weeks. patients visited once every weeks and the last visit at weeks after the cessation of treatment. part of patients had liver biopsy before and after treatment. before, during the course and at the end of therapy, clinical symptoms and physical signs were evaluated, hepatic function, and serum markers of hepatofibrosis (such as hyaluronate acid, laminin, serum type iii procollagen and collagen iv) were tested, and ultrasound evaluation was performed. results: patients enrolled in the evaluation. patients completed the evaluation according to the protocol. patients had liver biopsy twice, from the study group and from the other one. at the end of therapy, the total effective rate of hepatofibrosis in histopathology is . % in the study group, much higher than that of . % in the control group (p< . ). the total effective rate of serum markers of hepatofibrosis at the end of therapy in the study group was . %, much higher than that of . % in the control group (p< . ). the total effective rate of non-invasion markers of hepatofibrosis at the end of therapy in the study group was . %, much higher than that of . % in the control group (p< . ). the drugs of adverse event had not happened in both groups. conclusion: "tinmax" hb- herbal compound (cpd) is effective and safe in treatment of hepatofibrosis and cirrhosis post chronic hepatitis b. w.h. sha , xiaohui zeng , yuyuan li gi department, first municipal hospital of guangzhou, guangzhou aim: to investigate the clinical value of serum indices for hepatic fibrosis in chronic liver diseases. methods: competitive radioimmunoassay was used to determine the serum level of collagen type ( c), laminin (ln) and hyaluronic acid(ha) in patients with different severity degree of chronic liver diseases, and in healthy subjects. results: the serum levels of c, ln, and ha in the patients with liver diseases increased to different extent, compared with those in the healthy subjects. of which the highest of c, ln, and ha were found in the patients with primary carcinoma of liver or hepatocirrhosis and the serum level of ha is highlight. the combination detection of serum c, ln, and ha is more valuable than single index. conclusion: joint detection of serum c , ln, and ha is of higher significance in clinical diagnosis and prognosis of hepatocirrhosis, and is also available for successive observation on the development of liver diseases. aims: to investigate the mechanism of fuzheng huayu decoction (fzhy) on hepatic stellate cells (hscs) activation relating to tgf- signal transduction pathway. methods: hscs were isolated from normal rats by in situ pronase/collagenase perfusion followed by density gradient centrifugation. at day after isolation, cells were stimulated with pm tgf- for h, then incubated with % fzhy pharmacological serum or m t r -i inhibitor (sb- ) for h. protein expression of -sma, smad was assayed by immunofluorescent stain; total protein expression of -sma, t r -i, smad / and nuclear expression of smad was analyzed by western blotting. results: fzhy pharmacological serum significantly decreased expression of -sma, t r -i, and inhibited smad nuclear expression and translocation in tgf- stimulated hscs. conclusions: fuzheng huayu decoction can prevent hscs activation through tgf- signaling transduction pathway in hscs, which may be the important molecular pharmacological mechanism of fuzheng huayu decoction action against liver fibrosis. background: fatty liver disease has become a health problem related to metabolic syndrome worldwide although its molecular pathogenesis has remained further studied and it is unclear whether advanced fibrosis induced by steatohepatitis will regress when diet is controlled. aim of this study is ) to study the involvement of endoplasmic reticulum stress (er stress) in the occurrence of seatohepatitis and ) to obtain the evidence of resolution of fibrosis by changing the diet. methods: non-alcoholic steatohepatitis with advanced fibrosis was produced in rats by giving methionine-choline-deficient diet (mcdd) for weeks. methionine-choline-control diet (mccd) instead of mcdd was given for the last weeks in an experimental group. fibrosis and inflammation was determined by several tissue stainings. gene expression related to fibrosis and inflammation was determined by immunoblotting and real-time pcr. expression of caspase- , caspase- , and glucose-regulated protein was evaluated to clarify the presence of er stress aim against liver fibrosis relating to hypoxia and angiogenesis regulation. methods: the rats were divided into normal, model, sa-b and perin control group. rats in sa-b and perindopril group were administrated with sa-b and perindopril respectively. liver fibrosis was induced by ip dimethylnitrosamine (dmn) for w. fibrosis degree was observed by sirius red staining. col-i protein expression was analyzed by western blot; col-i , vcam- , icam- , hif- and vwf expression in liver tissue was checked by immunohistochemistry; gelatinase activities in liver tissue were detected by gelatin zymography and in situ flourescent zymography. result: compared to normal group, col-i, hif- , icam- , results: ) changing the diet from mcdd to mccd triggered the reduction in fat in hepatocytes, the decrease of inflammatory gene expression and oxidative stress, and the regression of fibrosis accompanied by the disappearance of activated stellate cells and macrophages. ) immunohistochemistry, immunoblotting, and rt-pcr analysis all indicated the occurrence of er stress in steatohepatitis while it recovered immediately after changing the diet from mccd to mcdd. vwf protein expression and gelatinase activity in liver tissue were increased obviously in model group, while sa-b and perindopril treatment significantly decreased these protein expressions and gelatinase activity. conclusions: this simple experiment clearly shows that the changing diet from steatohepatitis-causing mcdd to mccd triggers the resolution of inflammatory and fibrotic reaction in the liver, suggesting that food intake is a very important factor for controlling the state of fat and pathology of the liver. er stress is involved in the process. background: liver fibrosis results from chronic damage to the liver in conjunction with the accumulation of extracellular matrix proteins, which is a characteristic of most types of chronic liver disease. under injury conditions, hepatic stellate cells (hscs) are activated to transdifferentiate into myofibroblasts, which are capable of secretion of many connective tissue elements, especially collagens i, iii, and iv. gynostemma pentaphyllum is a popular folk medicine that has been used for treatment of hepatitis in asia. gypenosides are the major saponins derived from g. pentaphyllum. in previous study, gypenosides have hepatoprotective and anti-fibrotic activities in rat chronic liver injury induced by ccl , and anti-proliferative effect in rat isolated hscs. methods: in cultured hscs model, we detected type procollagen protein and mrna by western blot and rt-pcr. result: we found that g. pentaphyllum inhibited type procollagen protein expression in % at hours. furthermore, g. pentaphyllum also inhibited type procollagen and mrna expression in % and % respectively. in addition to transcriptional inhibition, we found that g. pentaphyllum also enhanced the degradation rate of type procollagen protein. base on the effect of enhancing protein degradation, we used some protease inhibitors like ca- me, z-fa-fmk, aebsf, tpck and tlck to identify the potential target of g. pentaphyllum. on the other hand, in the ubiquitin-proteasome system analysis, we quantified the change of some target proteins of proteasome in the presence or absence of g. pentaphyllum. conclusion: g. pentaphyllum reduced type procollagen protein by inhibiting transcription and enhancing protein degradation. aim: excessive oxidative stress in diabetic patients has been implicated in the pathology and complication of liver. the present study was designed to examine whether ginger has a direct hepatoprotective effect in diabetic cases. methods: wistar strain albino rats were selected for this study. the rats were divided into groups: (i) control, (ii) ginger treated ( mg/kg b.w. orally, days) (iii) diabetic ( mg/kg b.w., i.p.) and (iv) diabetic + ginger treatment. the lipid metabolic profiles such as total cholesterol, triglycerides, phospholipids and lipid peroxidation as stress markers and histopathological studies were carried out to assess the damage in hepatic tissue. results: ginger treated diabetic rats demonstrated significant reduction in glucose levels as compared to the nontreated diabetic animals. diabetic rats have shown increased total cholesterol, triglycerides, phospholipids and lipid peroxidation content in hepatic tissue compared to control, indicate prevailing of oxidative stress and alterations in fatty acid metabolism in these rats. further, degenerative changes of hepatic cells in diabetic group are minimized to nearness in structure by administration of ginger as evinced by histopathological examination. conclusion: we summarize that the hypolipidemic and antioxidant compounds present in ginger may be useful in delaying the complicated effects of diabetes. this results also reveal that ginger possess hepatoprotective properties in diabetic cases. anti-fibrotic action m. naime , s. ali hamdard university rhizomes of valeriana jatamansi (family, valerianaceae) have long been used in indian subcontinent by the traditional healers for the treatment of various diseases. this study provides experimental evidence suggesting the therapeutic effect of the crude extract of rhizomes on rat liver fibrosis, and demonstrates its antiproliferative role. crude extract ( % ethanolic) at a dose level of mg/kg body weight was administered to rats to study the effect on biochemical and other markers of liver fibrosis. administration of the extract for weeks could bring down elevated the levels of biochemical markers of liver injury, and modulate several other biochemical responses. morphology and hisopathological examination cooroborated with the biochemical changes, and indicated partial reversal of fibrosis. dpph assay confirmed the antioxidant property of the extract, which is suggested to be due to -ionone, -sitosterol and other chemical constituents. further, treatment could restore depleted glutathione level, inhibit lipid peroxidation, and inhibited elevated xanthine oxidase activity in fibrosis. the study also reports anti-tumour promotion activity of the extract as evident by a significant decrease in [ h]-thymidine incorporation by hepatic dna in extract treated rats. results suggest that v. jatamansi extract has curative effect and can partially reverse biochemical and histological changes associated with liver fibrosis. with chronic hepatitis c c. wongjitrat , s. chainuvati , a. manuyakorn , s. aroonparkmongkol , t. tanwandee mahidol university, background: leptin is a peptide hormone that mainly regulates food intake, energy expenditure and reproductive function. leptin also releases from activated hepatic stellate cells and may have a role in regulation of fibrogenesis and inflammation. in human chronically infected by hcv, the role of leptin-associated fibrosis of the liver is still unclear. there is no data in thai patients chronically infected by hcv regarding leptin level and its correlation with hepatic histology and fibrosis.the purpose of this study was to evaluate the relationship between leptin level and severity of liver fibrosis in thai patients chronically infected by hcv. methods: sixty-six patients ( men, women) with chronic hcv infection and liver biopsy was done within months were enrolled. fasting blood samples were obtained and serum leptin levels were measured by elisa. bmi, blood sugar, liver function test, lipid profile, hcv rna viral load and hcv genotype were also measured and related to histological findings. results: mean serum leptin levels were significantly higher in women than in male. there was a significantly correlation between serum leptin and bmi (r = . , p < . ). leptin levels were not associated with hepatic fibrosis (r = . , p = . ) and necroinflammation (r = . , p = . ). steatosis was significantly associated with severe necroinflammation (r = . , p = . ), but not fibrosis (r = . , p = . ). conclusions: these findings failed to demonstrate correlation of serum leptin and hepatic fibrosis in thai patients chronically infected with hcv. background and aim: liver cirrhosis is one of the leading causes of mortality in our country as well as in our region. even though deterioration of glucose metabolism and existence of insulin resistance in liver cirrhhosis has been well documented in many studies, it is still unclear how insulin resistance mechanism develops. the aim of the present study is to assess insulin resistance, cytokines and crp levels in patients with liver cirrhosis and control subjects. in additon, we aimed to investigate the relation of insulin resistance in liver cirrhosis with such parameters as age, sex, etiology, child-pugh classification, spleen size, tnf-?, il- ?, il- res, il- , il- , il- , crp and hs-crp. material and method: a total of patients with cirrhosis of different etilogy ( male, female) were included into the study. as controls, ( male and female) subjects were taken. the two groups were compared with each other in terms of glucose, insulin, c-peptid, homa-ir, tnf-?, il- ?, il- res, il- , il- , il- , crp and hs-crp levels. in the second part of our study, the liver cirrhosis group was divided into two subgroups: patients with homa-ir value > . as insulin resistance positive, and those with homa-ir value > . as insulin resistance negative. these two groups, i.e. , homa-ir positive and homa-ir negative, were compared in terms of age, sex, etiology, child-pugh classification, spleen size, tnf-?, il- ?, il- res, il- , il- , il- , crp and hs-crp levels. results: in liver cirrhosis group, glucose, insulin, c-peptid, homa-ir, tnf-?, il- res, il- , crp and hs-crp levels were determined to be significantly higher than controls. between patients with homa-ir positive and negative, however, statistically no significant difference was found in terms of age, sex, etiology, child-pugh classification, spleen size, tnf-?, il- ?, il- res, il- , il- , crp and hs-crp levels, but il- level was seen to be significantly low in patient homa-ir positive. conclusion: in patients with liver cirrhosis, the levels of glucose, insulin, c-peptid, homa-ir, tnf-?, il- res, il- , crp and hs-crp increase with respect to normal population. determination of increased homa-ir level in liver cirrhosis supports the view that insulin resistance develops in liver cirrhosis as reported in related studies. in the study, it was also determined that the mechanism of insulin resistance development occurs independent of age, sex, etiology, child-pugh classification, spleen size, tnf-?, il- ?, il- res, il- , il- , crp and hs-crp levels. the determination of statistically lower level of il- in patients with homa-ir positive with respect to those with homa-ir negative does not indicate similarity with the studies carried out earlier. ) in patients ( . %) than in controls( %)in group i hla-b significantly increased in patients ( %)as compared to controls ( %) . in group ii hla -b significantly higher in patients ( . %)than controls ( %) also hla-aw significantly higher ( . %) in patients than controls ( . %).in group iii hla-aw significantly increased in patients ( . %) compared to controls.no significant association between hla antigens and cases with hbv or hcv infection. conclusion: the significantly high association of hla-aw and hla-b in patients with hepatic schistosomiasis as compared to normal controlstogether with the lack of any association with active intestinal schisto . antigens predispose to liver affection.individuals possessing hla-aw appear to be more prone to severeform of liver disease background: atp b mutation is one of the factors that result in cholestasis and progress to chronic liver disease, but has never been reported in the mainland china before. the aim of this study was to elucidate the role of atp b mutation in mainland chinese patients with progressive intrahepatic cholostasis and low ggt. methods: children who presented with progressive intrahepatic cholostasis and low ggt were admitted in a tertiary pediatric hospital in eastern china. abcb gene was analyzed firstly to exclude bsep deficiency. afterwards, all the encoding exons and their flanking areas of atp b gene were sequenced in the remaining patients in whom only one or no mutations of abcb were found. results: mutations of atp b gene were found in patients. i n had been reported in taiwanese patients with pfic , and the others were novel. p t and ivs + t g were linkage and found in of patients, including homozygote and heterozygote. liver biopsy had been performed in patients with atp b mutations and with abcb pe mutations. variety portal fibrosis was showed in patients with atp b mutations and patients with abcb mutations. giant cell transformation was detected in one patient with atp b mutations and patients with abcb mutations. laboratory of exercise biochemistry, taipei physical education college, jhongcheng rd., no. , sec. , taipei city- , taiwan, roc background/aim: generation of reactive oxygen metabolites are depends on the consumption of oxygen and their cumulative effects may be different from lean to obese population. this study was designed to investigate the deleterious effects of oxidants on hepatic antioxidant defence system in lean and obese rats under hypoxic condition. methods: zucker rats lean ( ± gms) and obese ( ± gms) were divided into control and acute hypoxia groups. the acute hypoxia treatment was performed in a hypoxic chamber at % oxygen consumption. objectives: to compare the diagnostic value of morning urine copper to zinc (copper/zinc) ratio and hour urinary copper excretion in wilson's disease (wd) children. results: in the results, acute hypoxia caused a significant (p< . ) decrease in major antioxidant enzymes including superoxide dismutase (sod), catalase (cat), glutathione peroxidase (gsh-px), glutathione reductase (gr) and glutathione (gsh) content in lean groups when compare to their controls. the decrease in the activities of all antioxidant enzymes was also noticed in obese group with hypoxia treatment. however, this decrease was not significant in case of cat, gsh-px activities and gsh content. the mda levels (lipid peroxidation marker) were higher in obese rats compare to lean rats. methods: morning urine and hour urine were collected from patients over three years age who were hospitalized in a tertiary pediatric liver service. each patient was re-evaluated according to wd scoring system, and was assigned to one of the three groups: wd, suspecting wd, and non-wd. , , and cases were assigned to wd, suspecting wd, and non-wd respectively. urine copper and zinc concentration was determined simultaneously by using inductively coupled plasma mass spectrometry. conclusions: the higher hepatic mda values observed in obese rats indicate that accumulation of free radicals may be more in obese rats thus leads to promote the lipids oxidation. from this study it is concluded that decrease of antioxidant enzymes (except gr) with acute hypoxia treatment were more in lean group compared to with that of obese group. results: the morning urine copper/zinc ratio and hr urinary copper excretion correlated well (r= . , p < . ). the median of morning urine copper/zinc ratio, hr urine copper/zinc ratio, h copper excretion, and h zinc urinary excretion were . , . , . and . in wd group, and . , . , . and . in the non-wd group respectively. the differences of morning urine copper/zinc ratio, hr urine copper/zinc ratio, and h copper excretion were significant (z-value - . , - . and - . respectively, all p values < . chd l is a recently discovered oncogene localized at q , one of the most frequently amplified chromosomal regions in hcc. herein, by yeast-two hybrid assay, we demonstrate that the anti-apoptotic ability of chd l is associated with its interaction with nur , a critical member of a p -independent apoptotic pathway. as the first cellular protein identified to bind nur , chd l inhibits the nucleus-to-mitochondria translocation of nur , and subsequently hinders the release of cytochrome c and the initiation of apoptosis ( figure ). further study found that c-terminal macro domain of chd l is responsible for the interaction with nur , and a chd l mutant lacking residues - failed to interact with nur and prevent nur -mediated apoptosis. we also find that chd l confers cellular chemoresistance to drugs that induce apoptosis via the nur -mediated pathway, which may lead to the identification of new therapeutic targets for hcc treatment. background/aim: accumulation of oxidative damage to proteins, lipids and mitochondria could increase with advancing of age. the current study was aimed to test the hypothesis that swimming exercise training could revert the age dependent oxidative damages in liver. methods: sprague-dawley rats of young ( months) and old ( months) were divided into four groups; young control (n= ), young exercise (n= ), old control (n= ) and old exercise (n= ). minutes of swimming exercise was given to the exercise group for a period of two weeks. results: the estimated antioxidant enzyme activities including, superoxide dismutase (sod), catalase (cat), glutathione peroxidase (gsh-px) and glutathione reductase (gr) were decreased with age and significantly (p< . ) increased with exercise training. however, elevated protein carbonyls and mda levels were noticed in old animals, which indicate that old liver had greater accumulated oxidative damages. the significant drop in protein carbonyl content and increase in mitochondrial succinate dehydrogenase (sdh) activity was observed with response to swim training in old rats. conclusions: this data implied that swim exercise training could revert the oxidative damages in liver. this was also proven by enhanced antioxidant enzyme status with response to exercise training in old rats. to sum-up these results it is cleared that age induced detrimental effects to the liver might be reversed by regular swimming exercise training in old rats. results: peg was expressed in l /peg (fig. ) . peg accelerated the growth of l . after treatment with mm h o for h, the inhibitory rate of l /peg cells was . %; the chromosomal condensation and ladder-like dna fragmentation were not observed (fig. ) . methods: hepg or hepg . . were co-cultured with jurkat cells, with blocking test by adding anti-pd- antibody. the pd- expression was detected by flow cytometry (fcm); cytokines in culture supernatant in blocking groups and controls were measured by enzyme-labeled immunosorbent assay (elisa); cytotoxic test of t cells were measured by methyl thiazolyl tetrazolium (mtt). conclusions: over-expression of peg can significantly promot l proliferation and ameliorate apoptosis-inducing effects of h o on l . results: the pd- expression on jurkat cells was induced by hepatoma cells, the expression rate were . ± . % (by hepg ) and . ± . % (by hepg . . ), respectively. the cytokines il- level ( . ± . pg/ml), inf-level ( . ± . pg/ml) and il- level ( . ± . pg/ml) in culture supernatant of blocking groups were significant higher than that of controls (il- , . ± pg/ml, inf-, . ± . pg/ml and il- , . ± . pg/ml, respectively. p < . ). the cytotoxic test (od value) was markedly higher in blocking group ( . ± . ) than that of control group ( ± . p< . ) . conclusion: the pd- expression on lymphocytes can be induced by hepatoma cells, and cytokines expression and cytotoxic test were recovered by blocking pd- /pd-l interaction. background: hedgehog (hh) pathway is well known as a positive regulator for tissue construction( during development) and reconstruction (in adults). our aim to observe the expression change of hh pathway on rat hepatic regeneration . materials and methods: adult male sprague-dawley rats underwent approximately % partial hepatectomy (ph) or sham operation (so). liver specimens were collected at , , , , , , , and h after ph or so. hedgehog expression was determined in mrna level by rt-qpcr as well as in protein levels via immunohistochemical staining and western-blotting. results: so treatment did not induce remarkable changes in hedgehog expression; however, the level of transcript for hedgehog was significantly upregulated after ph. we found sonic hedgehog(shh )and glioblastoma (gli - ) mrna expression in the regenerating liver arrive at its peak at as early as h and returned to its physiologyical level h later. it is similar to the change of proteins (shh and gli ) .as seen from immunohistochemistry experiments; shh protein was expressed uniquely in regenerating hepatocytes. similarly, ph induced over expression for shh protein occurred from h with a peak level at h after surgery. but gli protein mainly located in nucleus and no significantly changes in the phrase of liver regeneration. conclusion: hedgehog pathway may play a role in the activation of hepatic proliferation during liver regeneration induced by physiological stress or pathological states, such as ph. background: to investigate whether peg , an imprinted gene with an active paternal but silent maternal allele, was involved in hydrogen peroxide (h o ) induced cellular apoptosis. methods: peg gene was stable transfected into l . cellular gene expression was determined by rt-pcr, western blot and immunocytochemistry. cell proliferation was analyzed by mtt. after treatment with different concentrations ( - mm) of h o , cell proliferation inhibition rate was measured by mtt. morphological changes of apoptotic cells were determined by hoechst staining, dna fragmentation was observed by agarose gel electrophoresis. hua tang , xiao-yan tang , min liu , xin li tianjin life science research center, tianjin medical university, tianjin , china we determined how afp modulates the proliferation of hepatoma cells. a recombinant adenovirus expressing sirna against afp (adv-afpsirna) was created and found that it reduced expression of afp specifically in hepatoma cells, and markedly inhibited the proliferation of hepatoma cells in vitro. local treatment using adv-afpsirna caused significant repression of the growth of hepatoma derived hepg cells in xenograft in nude mice. knockdown of afp resulted in an obvious delay in the g /s transition of cell cycle, but did not affect apoptosis in hepg cells, as analyzed by flow cytometry and tunel assay. also, differential expressions of some genes related to the cell cycle, including skp , cyclin d , csk and ebag were identified by microarray and rt-pcr in hepg cells and hepg cells with knocked down afp. these results suggest that endogenous afp is a critical determinant of the growth of hepatoma cells. hematopoietic stem cell (cd +) therapy can improve liver function in patients with cirrhosis. these cells can be mobilized into peripheral blood using granulocyte colony stimulating factor (gcsf). this study was undertaken to assess feasibility and safety and of gcsf induced cd + cell mobilization and its impact on liver function in patients with cirrhosis. patients with liver cirrhosis (cryptogenic or alcoholic with m abstinence) with cpt > and < , and splenic diameter < cm were included. gcsf injection was given for days ( mcg/kg/dose). baseline & day- cd + counts in peripheral blood were done by flow cytometry. follow up was weekly for weeks and then monthly. cpt was compared at baseline and months. patients (median age y, range - y, males; etiology: alcohol, cryptogenic; median cpt , range - ) were included. cd + cell counts at baseline and day were ( - ) and ( - ) respectively (median, range). side effects were fever in , allergic reaction in and increase in splenic size in (excluded). in follow up, patients died ( , & m after therapy, after olt), lost to follow-up. patients showed improvement in - ) at -month follow-up. gcsf treatment is safe and yields adequate cd + cells in peripheral blood. in short term it results in improvement in liver function in patients with cirrhosis pe molecular cloning and transcriptional analysis of kctd gene promoter b. pi , j.s. wang , m.f. han , y.y. zhou , x.j. liu , x.p. luo , q. ning department of infectious disease, tongji hospital, tongji medical college, huazhong university of science and technology, department of pediatrics, tongji hospital, tongji medical college, huazhong university of science and technology aim: our previous work has shown that high expression of kctd , a potassium channel associated gene, correlated with the disease severity of patients with severe chronic hepatitis b(schb). to further understand the gene transcription and regulation, kctd promoter was cloned and gene transcription was studied. methods: a full length of isolated promoter and series of ' truncated promoter of kctd gene was subcloned into the luciferase report vector pgl -basic to form the promoter-report constructs. the kctd promoter-report construct upstream of the luciferase report gene was cotransfected with constructs expressing hbv x,c and s protein respectively or stimulated with cytokines (il- , ifn and tnf ) in t cells to investigate kctd gene regulation upon both viral factors and host cytokines. result: a bp kctd segment upstream of atg translation start site was evidenced to contain potential regulative domains. an important regulation site located between - bp and - bp upstream of atg translation start site. based upon the luciferase activity assay, il- was able to upregulate the transcription of kctd whereas there was no effect from neither hbv viral proteins nor ifn and tnf . conclusion: here we first successfully cloned the full length promoter of kctd . il- significantly enhanced the transcription of kctd , a gene which has been shown to be involved in t cell activation and disease severity of schb from our group. this work was supported by nsfc( , , ) istanbul university, cerrahpasa medical school, marmara university, okmeydani teaching hospital, background: the treatment in chronic hepatitis c virus (hcv) is not highly effective, and cost, duration, and side effects are challenging. predicting favorable factors of response to treatment would make it possible to give it only responsive patients. recent studies report more conclusive results about the role of apoptosis in inflammation and fibrosis seen in chronic viral hepatitis. hepatocyte damage in hcv is mediated by cytotoxic t-cells. apoptosis primarily developed by the interaction between fas antigen on hepatocyte and fas ligand on t-cell corresponds to a main mechanism for hepatocyte damage. methods: in this study, we aimed to detect any relationship between apoptotic markers (fas, fas ligand, fas-associated death domain, caspases , , and , insitu apoptosis) in liver biopsy taken before the treatment and response to the treatment of interferon+ribavirin. additionally, any relationship between these parameters and the other ones predicting the response to therapy including alt level, viral load, genotype, and gender were studied. results: the study includes the patients in centers managing chronic hcv infection. all parameters were studied in patients. study results revealed that histological activity index is correlated with cd staining density, caspase intensiveness, and portal and parenchymal fas ligand scores. fibrosis is also seen to be correlated with the same parameters. apoptotic parameters of the responsive cases were not significantly different from unresponsive ones. conclusion: apoptotic parameters studied in the liver tissue is associated with inflammation and fibrosis, however these parameters may not predict the response to the treatment. s. gao , d. xi , j.w. guo , c.l. zhu , x.p. luo , q. ning department of infectious disease, tongji hospital, tongji medical college, huazhong university of science and technology, department of pediatrics, tongji hospital, tongji medical college, huazhong university of science objective: this study was designed to explore the opportunity of microrna interference technique in the inhibitory application of human fgl , human fas and tnfr expression. methods: the eukaryotic expression plasmids of human fgl , fas and tnfri genes were constructed and have successfully expressed hfgl , hfas and htnfri protein. mirna expression plasmids of hfgl , hfas and htnfri complimentary to the sequence responsible for hfgl , hfas and htnfri respectively were also constructed, meanwhile an irrelevant mirna plasmid was used as control. by respective cotransfection of p-hfgl mirna and pcdna . -hfgl , p-hfasmirna and pcdna . -hfas, p-htnfri mirna and pcdna . -htnfri expression construct into t cells, the inhibition of hfgl , hfas and htnfri expression were analyzed by quatitative real time pcr and western blot. results: the experiments showed the significantly inhibitory effect of p-hfgl mirna on hfgl , p-hfasmirna on hfas and p-htnfri mirna on htnfri expression at h post-transfection both at rna level and at protein level, as well in t cell lines the inhibitory efficiency reached as high as . % for hfgl , . % for hfas and % for htnfri, respectively. conclusions: the study demonstrated the constructs of p-hfgl mirna, p-hfasmirna and p-htnfri mirna successfully interfered their target genes expression in vitro, which provides the foundation for further investigation of these constructs' application in vivo and further more as a therapeutic strategy for a targeting intervention in the diseases which the gene fgl , fas and tnfri contribute to. this work was supported by nsfc , , ; cb , cb pe influence of the id on the anti-tumor activity of histone deacetylase inhibitor in hepatocellular carcinoma cells r. tsunedomi , , s. harada , n. iizuka , m. oka dept. of digestive surgery and surgical oncol., yamaguchi univ. , research fellow of the japan society for the promotion of science for young scientists background: our recent study revealed that levels of the inhibitor of dna binding/differentiation (id ) were associated with the progression of hcv-related hepatocellular carcinoma (hcc) and can affect susceptibility of hcc cells to histone deacetylase (hdac) inhibitors. we here aimed to investigate how and whether id expression affected on the anti-tumor activity of sodium butyrate (nab), one of hdac inhibitors. methods: two hcc cell lines, hle and huh- , were used for gene targeting experiments. the id over-expressing and knockdown cells were subjected to mts assay to evaluate the susceptibility to nab. time-course of the expressional change of bcl- and bcl-xl genes after nab administration was measured by real-time rt-pcr. result: upregulation and downregulation of id levels in hcc cells resulted in decreased and increased susceptibility to nab, respectively. we observed that after nab administration, the id expression was induced gently, the bcl- expression was greatly increased immediately, and the bcl-xl expression was decreased to less than half once and then recovered. these increase and recovery of the expression of anti-apoptotic genes were inhibited in the id knockdown cells. in the id overexpressing cells, the bcl- expression was more upregulated than mock-transfected cells. conclusion: in hcc cells, id influences the susceptibility to the hdac inhibitor by regulating the expression of anti-apoptotic genes caused by the hdac inhibitor stimulus. we suggest that id could serve as a fascinating marker predictive of response to hdac inhibitors. the role of zinc finger protein in liver cancer m.m.y. waye , , t.l. yeung , , j.l. zhu , the chinese university of hong kong, croucher laboratory for human genomics background/aims: the aim of this research project is the characterization of a krüppel zinc finger protein, zinc finger protein (znf ) using hepatocellular carcinoma as a disease model. zinc finger protein (znf ), also named as only zinc fingers protein (ozf), is a kda nuclear zinc finger protein consisting solely of ten c h zinc finger motifs of the krüppel type. like most of krüppel proteins, it is assumed to be the transcription factor and involved in the regulation of gene expression. the znf gene is amplified in - % of pancreatic carcinomas and overexpressed in more than half of the tumors including liver cancer. it is thus proposed that overexpression of the znf may contribute to the development or progression of hepatocellular carcinoma. methods: we used flow cytometry, microarray, green fluorescent recombinant protein, rt-pcr site-directed mutagenesis, and transfection to study the effect of expression of znf . results: our results shown that znf was over-expressed in two human hcc cell lines hepg and hep b. expression profiles of znf over-expressing shown that genes related to the p tumor suppressor activity or dna damage, repair response and control were deregulated upon overexpression of znf . conclusions: znf is possibly involved in liver carcinogenesis by affecting dna repair and cell cycle control upon induced dna damage. background: in the present study, we reported the establishment of a real-time monitor system for directly observing the catalytic, kinetic characteristics of dnazyme - in vitro cleavage on the target rna molecules as well as for rapid, accurate, high-throughout evaluation of varied dnazymes on their counterpart rna molecules. methods: dnazyme named dz-hcv- specific to hepatitis c virus (hcv) orf aug were designed and synthesized. dz-hcv-mis- with mismatched substrate-recognition domains, dz-hcv-mut- with mutant catalytic domains, antisense oligonucleotide ason and nonsense oligonucleotide nson were synthesized respectively as controls. a chimeric oligonucleotide of nt containing both rna and dna bases was designed and synthesized as the substrate: ' fam-gt agaccgugcaccaugagcacgaaucct-bhq ', corresponding to the - nt (underline) of hcv genome(gi: ) the reporter fam/bhq was incorporated at the ' and ' end, respectively. under simulated physiological conditions ( ), kinetic characterization of rna-cleaving dnazyme was analyzed in a real-time way. factors that influencing dnazyme cleavage were analyzed. results: dz-hcv- specific to hcv orf aug could cleave target rna at a•u site, a continuous change of fluorescence intensity was monitored. while the control oligonucleotides couldn't cleave rna, there were no change of fluorescence intensity. factors that influencing dnazyme cleavage concluded different substrate-recognition domain, mg + concentration and ph. conclusion: a real-time monitoring system for kinetic characterization of rna-cleaving dnazyme was successfully established in the first time. the study on the apoptosis of hepatoma cells synergeticly induced by plasmid-mediated anti-angiogenesis and immunopotentiation therapy p.y. li , q. zhang , y. chang , j.s. lin , d.a. tian background: angiogenesis is improtant to hepatoma and decreasing of host immunity promotes the development of tumor. we want to study the effect and mechanism of apoptosis of mice implanted hepatoma cells induced by eukaryotic plasmid-mediated anti-angiogenesis and immmunopotentiation therapy. methods: mouse endostatin eukaryotic plasmid (pseces) and mouse il- (interleukin ) eukaryotic plasmid (pmil- ) were extracted and purified from e. coli. h hepatoma cells were inoculated into the leg muscle of mice, which was divided into four groups and injected with pseces, pmil- , pseces+pmil- or pcdna . naked plasmid dna respectively into implantation sites repeatedly. tumor formation and its weight was evaluated. tumor microvessel density, tumor infiltrating lymphocytes and apoptosis of tumor cells were assayed by cd staining, he staining and tunel assay respectively. results: inoculated mice received pseces, pmil- injection formed tumor slowly with less microvessel density, more tumor infiltrating lymphocytes in the latter and more tumor apoptosis cells in both groups compared with pcdna . injection. there were much more tumor apoptosis cells in pseces+pmil- group ( . ± . per × microscope field p< . ) than any other single plasmid injection group ( × microscope field: pseces . ± . , pmil- . ± . , pcdna . . ± . ). conclusion: tumor cells of implanted hepatoma in mice could be synergeticly induced to apoptosis by eukaryotic plasmid-mediated anti-angiogenesis and immunotherapy through inhibiting tumor angiogenesis and promoting tumor lymphocytes to infiltrate, by which mice implanted hepatoma was inhibited. ( , , , , ng/ml) in a serum-free medium for h. cell proliferation was measured by brdu incorporation analysis, untreated wb-f cells were taken as controls. after treatment with wnt a ( ng/ml) for h, subcellular localization and protein expression of -catenin in wb-f cells treated and untreated with wnt a were examined by immunofluorescence staining and western-blot analysis. cyclind mrna expression was determined by semi-quantitative reverse-transcript polymerase chain reaction (rt-pcr). mrna levels of some phenotypic markers (afp, ck- , alb) and two hepatic nuclear factors were measured by rt-pcr. expressions of ck- and afp protein were detected by western-blot analysis. results: wnt a promoted proliferation of wb-f cells. stimulation of wb-f cells with recombinant wnt a resulted in accumulation of the transcriptional activator -catenin, together with its translocation into the nuclei, and up-regulated typical wnt target gene cyclind . after d of wnt a treatment in the absence of serum, wb-f cells retained their bipotential to express several specific phenotypic markers of hepatocytes and cholangiocytes, such as afp, ck- following activation of the canonical wnt signaling pathway. conclusion: the canonical wnt signaling pathway promotes proliferation and self-renewal of rat hepatic oval cells. the expression level of bid and other pro-and anti-apoptotic proteins were detected by immunoblotting. results: hbx/ showed the most sensitive towards dox treatment, and truncated bid (tbid) was also only detected in this cell line. the level of bax was also increased in hbx/ cells. conclusions: the carboxy-terminal of hbx may enhance the processing of bid into tbid, which may contribute to increased sensitivity of the cell towards the dox treatment. cell homeostasis were performed with concentrations of oxysterol ( x - - - m) faraway from the physiological and/or pathological one ( . and x - m). in our study, we asked the effects of oxysterols ( k and ' s) on hepatoma cell lines homeostasis. to this purpose we used concentrations similar to those described in physiological or pathological conditions. sub-physiological ( - m) to pathological ( - m) oxysterol ( k and ' s) concentrations were used to stimulate hepg cells. a surprising pro-proliferative effect of ' s at sub-physiological ( - m) concentration was observed. this behaviour was confirmed by the synergic increase of erk / levels. facs analysis revealed an early progression of cells in s phase at the lowest concentration of ' s, while all the remaining concentrations of the two studied oxysterols induced a weakly accumulation of cells in g /m phase. apoptosis was absent at all concentration used, except for the highest one ( - m). at this point we asked if cells didn't undergo apoptosis but acquired a senescent profile. effectively, both k and ' s, at all concentration used (except for - m), induced cell senescence (revealed by sa-ß-gal staining and sirt and p over-expression). in conclusion the two oxysterols analyzed have different and in same case opposite effects on hepatocellular line. the main effect is surely the senescence induction, but it is important to highlight the proproliferative effects of ' secosterol at low concentration. mortalin, a member of hsp family protein, has been shown to play an important role in hepatocellular carcinoma (hcc). it has been reported that mortalin is binding to the c-terminal of p , which acts as a safety guard and is a commonly mutated gene in hcc. in this study mortalin was silenced by specific shrna in plc/prf/ , a hcc cell line constitutively expressing p ser , and normal liver cells miha, and we found that suppression of mortalin can selectively trigger the mitochondria mediated apoptosis pathway by p dependent way in plc cells. tunel staining positive cells were only found in the plc cells mortalin knockdown group, and apoptosis associated protein, such as p , bax, bcl-xl, cleaved-caspase , have been screened by western blot after transfection. quantitative-pcr data also showed that p mrna level are upregulated about folds in mortalin knockdown group compared with the control groups in liver tumor cells. two p inhibitors, pft-and pft-, which can reverse this apoptosis was applied to demonstrate p dependent way. in summary, knockdown mortalin can selectively kill liver cancer cells through reactive apoptosis by sensitizing mutant p in plc cells, but had no effect on normal cells. the clinical application of this study suggested that motalin specific shrna might be a potential anti-cancer drug for hcc. background: nafld can proceed to nash and are at risk of cirrhosis and hcc. aim was to study profile of bangladeshi nafld patients. methods: patients with nafld were included. of them . % were males and . % females. patients were between - years of age. they presented with dull right upper abdominal ache and/or incidental detection of raised alt/ast and/or fatty liver on ultrasonography. all tested negative for hepatitis b and c. none had history of alcohol. all underwent per-cutaneous liver biopsy for histopathology. they were also tested for dm, dyslipidaemia, insulin resistance, hypothyroidism and hepatitis c. their bmi and bp were recorded. results: . % had nash. . % of them were males and rest . % females. . % had nafl. of them % each were males and females. majority had nash. . % were obese and . % had dyslipidaemia. . % had hypertension, . % insulin resistance and % were diabetics. . % had hypothyroidism. none had hepatitis c. alt was raised in % and ast in %. although all patients with nash did not have elevated alt, it was raised in majority, contrary to ast, which was normal in most. conclusion: majority nash patients in bangladesh are obese. other leading causes of nash include dyslipidaemia, hypertension and insulin resistance. some nash also had diabetes and hypothyroidism. this study also reveals that elevated alt in patients with nafld is suggestive of fibrosis, although normal serum alt does not exclude nash. the study further suggests that alt is superior to ast in predicting nash. background: non-alcoholic fatty liver disease is prevalent in obese patients. liver biopsy remains the best diagnostic tool for confirmation. we tried to find out the correlations of laparoscopic parameters with histology and laboratory data. besides, we also evaluated the effectiveness of laparoscopy in liver disease diagnosis. methods: in the period of one year and five months, morbidly obese patients submitted to laparoscopic bariatric surgeries at our institutions were prospectively studied. results: laparoscopic parameters of significant correlations with histologic steatosis, inflammation and fibrosis were summarized in table . besides, important parameters with relationships to laboratory data were summarized in table department of internal medicine, seoul national university hospital gangnam healthcare center, seoul, south korea, department of internal medicine and liver research institute, seoul national university college of medicine, seoul, south korea background/aims: hepatic fibrosis is associated with poor prognosis in non-alcoholic fatty liver disease (nafld). recently, many non-invasive fibrosis markers have been studied to overcome the limitations of liver biopsy. among them, bard score and guha's simple panel are easy to use in clinical practice. in this study, we evaluated the efficacy of bard score and guha's simple panel as a noninvasive fibrosis marker in korean nafld patients. methods: data from patients with biopsy-proven nafld in seoul national university hospital from to were used. bard score and guha's simple panel were calculated by using clinical and biochemical data and were compared with the histological fibrosis stages. results: stage fibrosis were found in patients, stage in , stage in , stage in and stage in . the relationship between fibrosis stage and bard score ( = . , p < . ) was statistically significant. all patients with advanced fibrosis (stage - ) had bard score greater than . mean values from original guha's simple panel for no fibrosis were not different between the patients with and without fibrosis. however, after adjusting coefficients by logistic regression analysis, the differences in mean values became statistical significant (p < . ). conclusions: our data suggest that bard score may be effective for detecting high risk patients for advanced fibrosis, and modification of coefficients within the guha's simple panel may be needed to use as a fibrosis marker in asian nafld patients. s.k. mohan , s. subramaniam , s. subramaniam assistant professor, department of biochemistry, saveetha medical college & hospital, saveetha university, t.n, india., consultant, department of biochemistry, apollo hospitals, chennai, t.n, india. , department of biochemistry, apollo first med hospitals, chennai, t.n, india. background: non-alcoholic fatty liver disease (nafld) covers a spectrum of liver diseases from simple fatty infiltration to progressive fibrosis. non-alcoholic steato hepatitis (nash) is a severe form of nafld and progresses to the end stage of liver disease. it is becoming the leading cause for referral to liver clinics in most areas. the prevalence of nafld in indian population is estimated around - %. the nafld has the potential to progress to hepatocellular carcinoma or liver failure, both events that ultimately lead to early death. aim: to evaluate the combination of inter cellular adhesion molecule - (icam - ), adiponectin and type-iv collagen, a new biomarker profile for nash in patients with nafld. methods: patients with nafld and age & sex matched normal healthy individuals as controls were selected for this study. levels of serum icam - , adiponectin, type-iv collagen, lipid profile and liver function test parameters were estimated in patients and compared with controls. results: serum icam - & type -iv collagen levels were significantly increased in patients with nash among the nafld patients compared to controls. the serum adiponectin levels were significantly reduced in patients with nash among the nafld patients compared to controls. compared to liver function test parameters and lipid profile levels, nash profile has got positive negative predictive value among the nafld patients. conclusion: in patients with nafld, nash profile test -a simple, noninvasive and reliable to predict the presence or absence of nash. background/aim: oxidative stress and cytokines plays an important role in the pathogenesis of nonalcoholic fatty liver disease (nafld). aim of study was to assess lipid peroxidation, serum levels of transforming growth factor-( tgf-) and tumor necrosis factor-( tnf-) in patients with nafld and compare it with patients of chronic viral hepatitis (cvh) and healthy controls (hc). methods: lipid peroxidation was studied by estimating plasma malondialdehyde (mda) levels as per the methodology described by buege and aust and tgf-& tnf-levels were measured by elisa kits (ray biotech, usa, & diaclone, uk) in the stored sera in biopsy proven patients with nafld (m: , f: , mean age: . ± . yrs), patients with cvh ( m: , f: , mean age: . ± . yrs) and hc (m: , mean age: . ± . yrs). results: there was no difference in mean plasma mda levels amongst patients with nafld ( . ± . mol/l), cvh ( . ± . mol/l) and hc ( . ± . mol/l). serum tgf-levels between nafld ( . ± . ng/ml) and cvh ( . ± . ng/ml) patients and hc ( . ± . ng/ml) were also comparable. though patients with cvh ( . ± . pg/ml) and nafld ( . ± . pg/ml) had higher levels of tnf-than hc ( . ± . pg/ml), the difference was not significant statistically. conclusion: lipid peroxidation, tgf-and tnf-need to be studied in a larger number of patients with nafld. background/aim: burnt out nonalcoholic fatty liver disease (nafld) may be responsible for cirrhosis and hepatocellular carcinoma (hcc) in the absence of other causes. aim of this study was to evaluate the surrogate markers of nafld in patients with cryptogenic cirrhosis (cc) and cryptogenic hcc (chcc). methods: sixty five patients with cc and patients with chcc were analyzed for the presence of abnormal body mass index (bmi) and type diabetes mellitus (dm aim: to investigate the relation of phosphatidylethanolamine n-methyltransferase pemt gene g a single nucleotide polymorphism (snp) with the susceptibility to nonalcoholic fatty liver disease nafld . methods the genotypes and allele frequencies of pemt exon snp g a were analyzed by using pcr-rflp in nafld patients and controls. results: the g to a variation of the pemt gene g a snp was significantly higher in nafld group compared with controls. the frequencies of gg ga and aa genotypes were . . and . in nafld and . . and . % in controls (p= . . the a allele of the pemt gene was significantly more frequent in nafld group ( . %) than that ( . %) in controls p= . .there were significant differences in serum levels of cholesterol, triglyceride, hdl-c and ldl-c between gg and ga/aa genotypes p < . . n. assy , , g. lipez , s. korem , m. grozovski sieff hospital, safed, israel, technion institute, faculty of medicine, haifa, israel, ort braude college, karmiel, israel background: previous studies reported increase in serum protein c and decrease in serum paraoxonase levels in patients with non alcoholic fatty liver diseases (nafld). conclusion people with pemt gene g a snp were more susceptible to develop nafld aim: ) determine whether there is a relationship between nafld, protein c and paraoxonase levels in quiescent and in regenerating rats fatty liver ) determine the effect of isa on hepatic "protein c" and paraoxonase mrna. pe methods: forty-eight sd rats were treated with fructose enriched diet (fed), or fed with metformin ( mg/kg/d), fed with rosiglitazone ( mg/kg/d), or the combination of both drugs for wks. % phx was performed at wk . protein c, paraoxonase mrna expressions, lipids, mda were measured before and hours after phx. results: hepatic "protein c" mrna was higher in rats with fatty liver than control rats (+ %, p< . ) whereas hepatic paraoxonase mrna was lower in rats with fatty liver than control rats (- %, p< . ). hepatic protein c and paraoxonase mrna increased in rats with fatty liver in regeneration (+ %, p< . , and + %, p< . respectively). the combination of metformin and rosiglitazone decreased hepatic protein c expression at hours after phx by - % (p< . ) and increase paraoxonase mrna by + % (p< . ). serum paraoxonase correlates with serum protein c (r=- . ), mda (r= . ), background: non-alcoholic steatohepatitis (nash) is a type of non-alcoholic fatty liver disease (nafld), and may progress to hepatic fibrosis and cirrhosis. the pathogenesis of nash remains unclear. the aim of this study was to explore the arginase change in the progress of steatohepatitis in rats. methods: male sd rats weighing - g were obtained. twenty animals were randomly divided into two groups. in the model group, five animals were fed with high lipid forage that includes % cholesterol and % lard for weeks, five were fed for weeks, while the control group ate normal foods. the animals were sacrificed after weeks. the animals were sacrificed after weeks and weeks. liver and blood serum were collected while the serum levels of alt, ast, tg and tc were measured. the pathology of liver was observed by he staining. western blot was used to investigate the expression of arginase in control and model group. tg (r=- . ). conclusion: hepatic "protein c" mrna levels are high at baseline, up regulated during liver regeneration and decrease after treatment with (isa) whereas hepatic paraoxonase mrna levels are low at baseline, up regulated during liver regeneration and increase after treatment with isa. results: vacuolization were observed extensively in hepatic cells in the model group after weeks and weeks of high-fat diet. it is demonstrated that rats fed with high-cholesterol food are indeed fatty liver models. western blot showed that the level of arginase ii increase in the liver of model group rats as compared to the control group. furthermore, the level of arginase was higher in liver samples obtained from model rats that were weeks on a fat diet as compared to rats that were only weeks on the same diets. conclusion: the level of arginase ii was altered in the progress of non-alcoholic steatohepatitis in rats suggesting that arginase ii is putative biomarkers and may represent new targets in the development of therapeutic strategies against fatty liver disease hepatic fibrosis and cirrhosis. methods: c bl /j mice were fed with mcd diet to induce hepatic fibrosis and rosiglitazone was given in treated group. effect of rosiglitazone was assessed by comparison of the severity of hepatic fibrosis in liver sections, expression of mmp- / , timp- / mrna and protein detected by rt-pcr and western blot respectively. the ethanolic extract of fructus schisandrae chinensis decreased hepatic triglyceride level in mice fed with a high fat/cholesterol diet results at week , fibrosing nash models showed severe hepatic steatosis, infiltration of inflammation and fibrosis, which is associated with down-regulated mmp- / mrna and protein, up-regulated timp- / mrna and protein. rosiglitazone significantly reduced mcd-induced fibrosis by induced mmp- / expression and reduced timp- / expression by activating ppar . s.y. pan , z.l. yu beijing university of chinese medicine, hong kong baptist university effects of the ethanolic extract of fructus schisandrae chinensis (etfsc) on serum and liver lipid contents were investigated in mice fed with normal diet or high fat/cholesterol diet for or days. single dose of etfsc ( or g/kg/day, i.g.) increased the serum triglyceride (tg) level ( and %, respectively), but decreased hepatic total cholesterol (tc) level ( and %, respectively) in normal mice. the hypertriglyceridemia produced by etfsc was suppressed by the co-administration of fenofibrate. the induction of hypercholesterolemia by high fat/cholesterol diet caused significant increases in serum and hepatic tc levels (up to %) and hepatic tg levels (up to %) in mice. etfsc treatment ( or g/kg/day for days, i.g.) significantly decreased the mouse hepatic tg level (by %) and slightly increased the hepatic index (by %). whereas fenofibrate treatment ( . g/kg/day for days, i.g.) significantly lowered the hepatic tg level (by %), it significantly elevated the hepatic index (by %) in hypercholesterolemic mice. the results indicate that etfsc treatment can invariably decrease hepatic tg in hypercholesterolemic mice, suggesting its potential use for fatty liver treatment. aim: to investigate the influence of multiple gene polymorphisms in the susceptibility of nafld. methods: the data of single nucleotide polymorphisms (snps) in nafld patients who had at least one of the genetic variations at the sites of tnf-- , adiponectin - and leptin- were analyzed. the genotypes were determined by using pcr-rflp. our previous studies showed that the variations of these sites increased the susceptibility of nafld. results: the prevalence of nafld in adiponectin variation alone group (n= ) was . %; in tnf-alone group (n= ) . %; in leptin alone group (n= ) . % (p> . ). in comparison with the above groups with single snp, the prevalence of the groups with two gene variations of tnf-plus adiponectin ( . %, n= ) increased significantly (p< . ). however the prevalence of other two groups i.e. adiponectin plus leptin ( . %, n= ) and tnf-plus leptin ( . %, n= ) did not differed significantly from those of groups with single snp (p> . ). the prevalence in the group with three gene variations ( . %) differed significantly from all (p< . ) except that of tnf-plus adiponectin group (p> . ). the metabolic features of the nafld patients in the groups mentioned above were not different significantly (p> . ). conclusion: nafld is a polygenic disease. multiple gene polymorphisms may, but not always, increase the susceptibility of nafld. chronic hepatitis b patients with nonalcoholic fatty liver disease r.d. zheng , c.r. xu , j. chen , b.f. chen southeast hospital background: to investigate clinical pathological characteristic in hbeag negative chronic hepatitis b (chb) patients with nonalcoholic fatty liver disease (nafld). methods: we measured fasting blood glucose, insulin, triglyceride, cholesterol, alanine aminotransferase (alt), aspartate aminotransferase (ast) in hbeag negative chronic hepatitis b (chb) patients with nonalcoholic fatty liver disease (nafld). and we detected hepatitis b virus marker, hbv-dna, counted body mass index, insulin resistance index and observed pathological characteristic. all these patients with diagnosis were confirmed by clinical and pathological evidence. result : the body mass index, homeostatic model assessment (homa) of insulin resistance, fasting blood glucose, insulin, triglycerides, cholesterol, were significantly higher in hbeag negative chronic hepatitis b (chb) patients with nonalcoholic fatty liver disease (nafld) than hbeag negative chronic hepatitis b patients. but the alanine aminotransferase (alt), aspartate aminotransferase (ast), hbv dna levels were significantly lower in hbeag negative chb patients with nafld than in hbeag negative chronic hepatitis b patients. histologic features in hbeag negative chronic hepatitis b(chb) patients with nonalcoholic fatty liver disease (nafld) are in zone predominate macrovesicular steatosis and mild inflammatory infiltrate in portal region. conclusion: the hbeag negative chronic hepatitis b (chb) patients with nonalcoholic fatty liver disease, whose hepatic steatosis changes are mainly caused by the metabolic factors. to carry out liver biopsy selectively for the patients with hbeag negative chronic hepatitis b having metabolic factors, which is helpful for early diagnosis in hbeag negative chronic hepatitis b (chb) patients with nonalcoholic fatty liver disease (nafld). aims: to investigate the preventive effect of cordyceps sinensis and its possible mechanism on apoptosis of nafld. methods: rats were randomly divided into basic diet group (b group), pathologic group (nash group) and cordyceps sinensis group(cs group).the latter two groups were administered with high-fat diet to establish nafld animal models. cs group were treated with cs at the th week after high fat diet. rats were sacrificed at the end of the th week. biochemical examination were used to detect superoxide dismutase (sod) of liver tissue. hepatocyte apoptosis was assessed in each group using the tunel assay and immunohistochemistry for activated bax bcl- caspase- and nf-kb p . results: ( ) compated with the b group, severe hepatosteatosis, inflammative necrosis and local fibrigenisis were showed in liver of nfsh group. sod lever was significantly decreased (p< . ) and tunel-positive cells were significantly increased (p< . ). immuunohistochemistry test demonstrated active bax caspase- was increased (p< . ) while no apparent change was observed in bcl- . ( ) in cs group, only diffusive steatosis but not inflammation or fibrosis was found. sod lever was increased than that of nash group (p< . ). tunel-positive cells and active bax caspase- were significantly decreased (p< . p< . ) that those of nash group. bcl- and nf-kb p were increased (p< . ) than those of nash group. conclusions: hepatocyte apoptosis is a prominent feature of nafld. cordyceps sinensis may be useful as an antiapoptosis theraphy in this syndrome through increasing activity of sod, decreasing express of bax and increasing express of bcl- and nf-kb p . background: non-alcoholic steatohepatitis (nash) is a leading cause of chronic liver disease. insulin-sensitizing , anti-inflammatory and anti-fibrotic effect of thiazolidinediones support their use in the treatment of nash. we aimed to evaluate the efficacy of thiazolidinediones in the treatment of nash. methods: we have identified randomised clinical trials, evaluating the efficacy of thiazolidinediones versus placebo in nash, through medline, embase, ami, cochrane central register of controlled trials. data were abstracted from each study and disagreements were resolved by consensus. dichotomous outcomes were reported as relative risk with % confidence interval based on fixed-effects model. results: we included three trials, two evaluating pioglitazone and another rosiglitazone. a total of patients were involved in the analysis. thiazolidinediones was noted to improve liver function tests. it was effective in the reduction of steatosis among patients with nash (rr . , % ci . - . ). it was found to be beneficial in improving ballooning necrosis (rr . , % ci . - . ). it was also found to improve lobular inflammation (rr . , background: it is well known that the weight reduction is effective for alt normalization in patients with non-alcoholic fatty liver disease (nafld). the necessary condition for alt normalization is still unclear. to clarify the necessary and sufficient condition for alt normalization, we investigated the effects of body fat decrease in nafld patients by body composition analyzer. methods: forty-six nafld patients ( male, female, mean age . ± . years old) with abnormal alt levels were evaluated. the volume of skeletal muscle, body fat and bmr were examined by using the body composition analyzer (in body ; biospace co. ltd., tokyo japan). all patients were received an individualized diet consultation by dietician every weeks for months. daily energy was bmr (basal metabolic rate) x . kcal and protein was . - . g per ideal body weight. result: twenty-eight of patients ( . %) were achieved normal alt level. in alt normalized group, the body weight and fat loss were . ± . kg, . ± . kg ( . ± . %body fat) respectively. on the other hand, in cases with alt remained abnormal level, the body weight and fat loss were . ± . kg, . ± . kg ( . ± . %body fat). conclusion: our results demonstrate that the fat loss of kilograms or more was necessary to normalize alt level in nafld patients. a. somani , s. somani , a. jain , v. dixit navjeevan hospital, suvidha, background : nafld is often clustered within families and the causes include both genetic and environmental factors. family studies done thus far have been limited by small sample size. to examine the familial patterns , we performed a prospective study to see (a) whether nafld is more common in first degree relatives (b) genetically determined risk factors associated for clustering. methods: first degree relatives of histologically confirmed nafld patients and spouses (controls) were included after excluding other causes of fatty liver. those having raised transaminases > months or sonographic examination consistent with fatty liver, had undergone liver biopsy for histological confirmation. they were divided into three groups. group i patients group ii first degree relatives group iii spouses results: nafld was more prevalent among first degree relatives then spouses ( % and %, p< . ). anthropometric measurements, systolic and diastolic blood pressure, lipid profile and liver function tests were comparable in three groups. homa-r was similar in group i and ii (p= . ), but was significantly different in group i and iii (p= . ) and group ii and iii (p= . ) respectively. metabolic syndrome was present in > % of patients and were comparable in three groups except for fasting glucose > , which was present in %, % and % of patients in group i, ii and iii respectively. majority (> %) of our patients among groups i, ii and iii were having only steatosis while nash was present in %, % and % of patients. a. somani , v. dixit , a. jain , s. somani navjeevan hospital, ims, bhu, varanasi, suvidha background: normal levels of alanine aminotransaminase (alt) have been demonstrated in nafld patients. alt levels are also modulated by age, gender, bmi, fasting glucose, and serum triglyceride levels. we performed a prospective study of patients with histologically confirmed nafld and having alt < . times and compared them with those having raised alt to determine (a) clinico-pathologic features of nafld patients with normal alt (b) to observe any differences between them. methods: patients with fatty liver on sonography had under gone biopsy for histological confirmation after excluding other causes of fatty liver. participants were divided into two groups (a) those having alt > . times normal (n= ) (b) those having normal alt (n= ) results: mean age was comparable with slight male predominance. there were significant differences in anthropometric measurements like bmi (p= . ) and whr ( . ± . and . ± . , p= . ). mean bp, lipid profile, fasting glucose, insulin, and homa r were comparable. there were significant differences in both mean ast ( . ± and . ± . , p= . ) and alt ( ± . and . ± . , p= . ) levels. metabolic syndrome was present in > % of patients and individual components were comparable except for increased waist circumference which was significantly more in those with raised alt ( . % and . %, p< . ). majority of our patients were having only steatosis, while nash was present in ( . % and . %, p< . ) of patients. conclusion: nafld can exist in patients with normal alt values. although more work is needed to determine who should be screened for nafld and how such individuals should be evaluated, this study is a step toward the identification and characterization of nafld patients with normal alt. we can suggest that patients having metabolic syndrome or insulin resistance, despite having normal alt, should be screened for nafld. also alt values should be adjusted for variables like bmi to appropriately screen nafld patients. background: scientific evidence has demonstrated that traditional chinese medical (tcm) approaches and products can be beneficial for managing non-alcoholic fatty disease (nafld), but few rigorous criteria of patterns of tcm therapy are available to guide practitioners in deciding the cam interventions. objectives: to evaluate criteria of patterns of tcm therapy for the management of nafld identified by biomedicine. methods: literature research, clinical epidemiological investigation and mathematical statistics were employed to make information collecting tables and to establish database. descriptive analysis, factor analysis, and cluster analysis were involved. results: ( ) background/aim: serum uric acid level has been suggested to be associated with factors that contribute to the metabolic syndrome. the aim of this study was to investigate the association of serum uric acid level with nonalcoholic fatty liver disease (nafld). methods: a cross-sectional study was performed among the employees of zhenhai refining & chemical company ltd., ningbo, china. results: the study included subjects ( men) with a mean age of years. the prevalence rate of nafld and hyperuricemia was . % and . %, respectively. nafld patients had significantly higher level of serum uric acid than controls ( . ± . vs. . ± . mol/l; p < . ). the prevalence rate of nafld was significantly higher in the subjects with hyperuricemia than those without hyperuricemia ( . % vs. . %; p < . ), and the prevalence rate increased along with serum uric acid levels (p value for trend < . ). multiple regression analysis showed that hyperuricemia was associated with increased risk for nafld (odds ratio [or]: . , % confidence interval [ci]: . - . ; p < . ). conclusion: serum uric acid level is significantly associated with nafld, and increased serum uric acid level is an independent risk factor for nafld. background: development of fatty liver is believed to be an early and reversible consequence of excessive alcohol consumption. however, the cellular and molecular events in the early development of alcoholic liver diseases (ald) and the contributory effects of a high fat diet are not fully understood. methods: this study was designed to quantify specific enzymatic and cytokinetic activity as well as the development of hepatic steatosis in a rat model of alchohol-induced liver injury without high fat diet. results: ethanol-fed rats exhibited high blood ethanol levels ( . + . %) and significant increases in serum alt ( . + . unit/l), ast ( . + . unit/l), and alp ( + . unit/l) when compared with control rats (p< . , respectively). histopathological examination found unevenly raised knodell scores ( . + . in the ethanol-fed livers vs. . + . in control), which were characterized by scattered hepatocyte ballooning, portal inflammation and collagen fiber deposition. however, typical steatosis lesions were absent. qpcr demonstrated up-regulation of genes in the ethanol-fed livers, including hepatocyte metabolism enzymes/receptor (adh , p< . ; cytochrome p e , cyp e , p< . ; gsta , p< . ; ppar , p< . ), and genes coding for pro-inflammatory cytokines (il- , p< . vs. control livers; tnf-p< . ; tgf -, p< . ; rantes p< . ), ecm components and proteinases (collagen- , p< . ; sma, p< . ; mmp - , p< . and timp- , p< . ). conclusion: chronic administration of ethanol to rats without high fat diet productively induces alcohol hepatitis in the absence of fatty liver, suggesting that alcohol hepatitis may precede steatosis in the development of ald. the aim of the present study was to evaluate the changes of several cytokines associated with inflammatory liver disease and liver regeneration by molecular adsorbent recirculating system (mars) in aclf patients versus patients treated with medical standard therapy (smt) that presented alcoholic liver disease etiology and similar model end-stage liver disease (meld). methods: mars group: fifteen ( male and female) patients were treated with mars® (gambro). five patients were excluded by study.the number of mars applications was about , the length of applications was about h. smt group: fifteen patients ( male and female) were treated medical standard therapy such as prophylaxis against bacterial infections, albumin and fresh plamsa and judicious use of diuretics. three patients were excluded by the study. the patients were valued during days from inclusion with a survival follow up a three months. results: mars group: we observed a significant changes in levels of il- (p< . ), il- (p< . ), il- (p< . ) and tnf-alfa (p< . ) in association with improvement of hepatic growth factor (p< . ). the patient's survival at three months was %. smt group: we observed only a significant changes in il- (p< . ) and tnf-alfa (p< . ). the patient's survival at three months was %. conclusion: the mars liver support device has corrective effects on disturbed pathophysiology of aclf and may be used to enhance spontaneous recovery or as bridge to transplant. a study of protective effect of centella asiatica in -methyl- phenyl- , , , -tetrahydropyridine (mptp)-induced liver injury n. haleagrahara , s. chakravarthi , p. kumar international medical university, malaysia background: centella asiatica has been used for centuries as a medicinal herb for wound healing, memory enhancement, cancer, vitality, respiratory ailments, psoriasis and eczema, revitalizing connective tissue, burn and scar treatment, skin infections, arthritis, rheumatism, periodontal disease, varicose veins, hypertension, sedative, anti-stress, anti-anxiety, aphrodisiac, and as immune booster. results: ppc significantly reduced hepatocyte damage, hepatitis, and hepatic fibrosis, but did not affect steatosis. phosphorylation of apoptosis signal-regulating kinase , p mitogen-activated protein kinase, and protein kinase c, as well as activation of nuclear factor-kappa b, were markedly suppressed by ppc. these effects were likely a consequence of decreased oxidative stress through down-regulation of reactive oxygen species (ros)-generating enzymes, including cytochrome p e , acyl-coa oxidase, and nadph oxidases, in addition to restoration of ethanol-induced increases in toll-like receptor and cd . ppc also decreased the pro-apoptotic proteins bax and truncated bid, thus inactivating mitochondrial permeability transition. furthermore, ppc suppressed overexpression of transforming growth factor- and hepatic stellate cell activation, which retarded hepatic fibrogenesis. conclusion: ppc exhibited anti-inflammatory, anti-apoptotic, and anti-fibrotic effects on ald as a result of inhibition of alcohol-induced ros production. background: dysctamnus dasycarpus has used for the promotion of health in south korea. but, there were rare a report concerning the hepatotoxicity. we report cilinical features of liver injury by dysctamnus dasycarpus. method: eighteen patients diagnosed as acute toxic hepatitis by dysctamnus dasycarpus in chungnam national university hospital between january and arpil was enrolled. toxic hepatitis was diagnosed by rucam score ( ). the medical records were reviewed, retrospectively. result: eleven patients ( %) were female and the mean age was . . most common symptom was jaundice. initial laboratory findings were as follows(mean value): wbc /ul, hemoglobin . g/dl, platelet × /l,alt iu/l, total bilirubin . mg/dl, alkaline phosphatase u/l, ggt u/l, prothrombin time(inr) . . the mean hospitalization was . days. peak laboratory findings were as follows: alt iu/l, total bilirubin mg/dl. recovery time of each biochemical finding was as follows: alt days, total bilirubin . days. recovery rates of alt and total bilirubin were . % and . %, . % and . % at weeks, weeks, respectively. the main biochemical pattern of hepatotoxicity was hepatocellar ( . %) type. prednisolone was prescribed in six patients. progressive anemia and thrombocytopenia were detected in one patient diagnosed as pure red cell aplasia. other one patient had prolonged jaundice ( days). but, all patients had recovered without sequelae. conclusion: in south korea, liver injury by dysctamnus dasycarpus was more frequent in women. the main pattern of hepatotoxicity was hepatocelluar type. most patients had prolonged icteric phase and hospitalization. patients were recovered by supportive management after drug cessation or prednisolone therapy. in korea, traditional medicine that is based on the use of herbal medicine developed from a long time ago. however, clinical study of the herbal medicine is not conducted in a structured manner. we report three cases of toxic hepatitis caused by the intake of dictamnus albus. the first patient, a year old woman was admitted due to nausea after ingestion of liquor containing dictamnus albus for months. total bilirubin was . mg/dl ast/alt / , iu/l on admission. liver biopsy observed hepatocyte necrosis and cholestasis. the elevated bilirubin and transaminase returned to normal weeks later after cessation of dictamnus albus. the second patient, a year old man was admitted due to jaundice after ingestion of boiling dictamnus albus for months. total bilirubin was . mg/dl ast/alt , / , iu/l on admission. liver biopsy observed pericellular fibrosis and necrosis. the bilirubin decreased slowly compared to the transaminase and normalized months later after cessation of dictamnus albus. the third patient, a year old man was admitted due to jaundice after ingestion of liquor containing dictamnus ablus for month. total bilirubin was . mg/dl ast/alt , / , iu/l the hepatocyte necrosis was observed by liver biopsy. the elevated bilirubin and transaminase levels normalized month later after cessation of dictamnus albus. all patients had negative viral markers and non-specific ultrasonographic findings. the above mentioned three cases demonstrate that liver may have been damaged by dictamnus albus, which indicated clinical characteristics. background/aims: cmili poses a diagnostic challenge as no tests are available to confirm the causality. the aims of this study were ) to evaluate clinical features and patterns of cmili and ) to assess the likelihood of causality among patients with liver impairment and exposure to chinese medicine (cm) by a multidisciplinary approach. method: between / and / , patients who had liver derangement and cm or proprietary cm exposure within six months managed in the united christian hospital were studied. clinical features and the cm were reviewed by a multidisciplinary team involving a hepatologist, a toxicologist and cm experts. literature search of relevant herbs in chinese and western journals were performed. cm samples or residue were sent to toxicology laboratory for analysis to look for any toxic constituents, adulterant or contaminant. the likelihood of causality was ranked by various experts independently and disagreements were settled by a consensus meeting. results: there were forty-six cases of suspected cmili, nineteen cases with alternative causes of liver diseases were excluded. twenty-seven cases of cmili proceeded to detailed analysis. median age of patients was ( - ) with female predominance. the median duration of cm exposure to presentation was ( - ) days. majority of them ( %) had hepatocellular liver injury pattern. one case of adulteration with nsaid and erroneous substitution of herb was identified respectively causality were classified as unlikely, possible, probable and highly probable in , , and patients respectively. conclusion: a multidisciplinary approach allows systemic evaluation of suspected cmili. mouse model i. nassar , t. pasupati , i. segarra , j.p. judson international medical university, kuala lumpur, malaysia background: imatinib, a selective tyrosine kinase inhibitor, exhibits drug interactions with other drugs that are metabolised via the cytochrome p pathway. acetaminophen, a widely used analgesic and anti-pyretic drug is also metabolised via p pathway. this study aimed to evaluate the nature of hepatotoxicity after co-administration of imatinib and acetaminophen in a preclinical mouse model. methods: four groups of male icr mice ( - g) were used. the mice were administered either saline solution orally, imatinib mg/kg orally (control), acetaminophen mg/kg intraperitoneally (positive control) or co-administered imatinib mg/kg and ip acetaminophen mg/kg (study group). the mice (n= per group) were fasted overnight, dosed respectively and sacrificed at pre-determined time intervals of , minutes, , , , and hours and liver samples obtained by dissection. h&e stained liver sections ( µm thick) were histopathologically analysed. results: the liver samples showed reversible cell damage like feathery degeneration, microvesicular fatty change, sinusoidal congestion and pyknosis, with both imatinib and acetaminophen, administered separately. the damage increased gradually with time, peaked at hours and then resolved completely by hours. liver samples showed irreversible damage (cytolysis, karyolysis and karyorrhexis) when both drugs were administered concurrently, the damage increased with time and had not resolved after hours duration. conclusion: co-administration of acetaminophen and imatinib increased the hepatoxicity caused by acetaminophen and imatinib to become irreversible. this may be due to the fact that both drugs are metabolised by the cytochrome p pathway in the liver. background: a higher risk of antituberculosis drug (att) induced hepatotoxicity has been reported in indian subcontinent compared to the western counterparts. slow acetylator genotype of n-acetyltransferase (nat ) and ci genotype of cytochrome p e (cyp e ) gene are two known risk factors associated with this disease. cyp e gene encodes a rifampicin inducible enzyme which increases hepatotoxicity. therefore slow acetylation of isoniazid and simultaneous use of rifampicin may augment the toxicity of isoniazid. objectives: to analyze the allelic distribution of nat and cyp e gene in patients of pulmonary tuberculosis who developed att induced hepatitis materials and methods: the study included cases of pulmonary tuberculosis ( ) and att induced hepatitis ( ). polymorphism of nat and cyp e gene was studied by pcr-rflp method in both these groups. results: occurrence of att hepatotoxicity was . %. there was a higher prevalence of slow acetylator genotype particularly nat * /* and nat * /* in patients with hepatotoxicity compared to patients without hepatotoxicity ( . % vs . %, p value < . ). no association of cyp e rsai polymorphism could be considered with att hepatotoxicity. however, drai c/d genotype of cyp e appears as a risk factor for predicting the occurrence of antituberculosis drug induced hepatitis (or . , p value < . ). conclusion: the study demonstrates that patients with slow acetylator genotype particularly nat * /* and nat * /* and heterozygous mutant c/d genotype of cyp e gene are predisposed to develop antituberculosis drug induced hepatotoxicity. regular monitoring of clinical and biochemical profile may be considered in these patients when they receive antituberculosis treatment. background: drug-induced liver injury is the most common adverse drug reaction. we often use two kinds of diagnostic scales to evaluate suspected patients. however, we still can't diagnose accurately without the direct drugs history and the pathological evidence. methods: twenty-seven drug-induced liver injury cases with liver biopsies from to were reviewed retrospectively by maria and japanese scale. result: there were . % of cases with increasing eosinophils. herbs ( . %) were the most common suspected drug and unknown drugs intake history ( . %) were described in these cases. the high possibility and possibility were . %, . % by maria scale and . %, . % by japanese scale, respectively (p= . ). conclusions: japanese scale seems more sensitive than maria scale in these cases. however, there are still some definite cases ignored as low possibility due to absence of obvious drug using history. early treatment and suspected drugs prohibition interferes the outcomes of the two diagnosis systems and lead to a false result. it is still a clinical challenge without strong drug using history or pathological evidence of liver biopsies to diagnose the drug-induced liver injury quickly and accurately. background: previous study suggested that oxidative stress may be an important mediator of methamphetamine-mediated tissue injury. the study was to examine the mechanism of antioxidant activity and methamphetamine-mediated liver injury. materials and methods: the days old male sprague-dawley rats were subcutaneous injected daily with methamphetamine ( mg/kg body weight) for , , and days. control group received equal volumes of vehicle. the liver tissues were extracted to measure the activities of sod, catalase, glutathion reductase (gr), and glutathione peroxidase (gpx), and the level of glutathione. western blot were used to measure the expression of rho and phosphor-ezrin-radixin-moesin (p-erm). results: compared with vehicle group, treated with methamphetamine for and days, the activities of liver sod, gpx, and catalase were significantly decreased. in and days group, the activities of antioxidant enzymes of methamphetamine-treated liver was not different from that of vehicle group. the levels of glutathione production also had the same trend. the activities of gpx and catalase on vehicle group gradually reduced following the days of treatment. however, administration of methamphetamine resulted to a lower activity of catalase through the treated days. there was no difference on the activity of gr between vehicle and methamphetamine group. the expression of rho and p-erm were also increased by methamphetamine treated for days. conclusion: these results suggested the methamphetamine lead to liver remodeling via decreased antioxidant activity. finally, the situation of mechanism needs taking in advantage discussion. background: to observe intervening effects of preventive and theraptical treatment of radix sophorae tonkinensis's polysaccharides(rstp) on alpha-naphthylisotheganate(anit)-induced cholestasis in mice. methods: kunming mice intoxicated with anit mg/kg orally and treated with rstp mg/kg for days before anit exposure and for days after anit exposure respectively, the general condition,mortality rate and serum alt activity are obeverated. result: it was found that by preventive treatment the general condition and mortality rate were improved, serum alt activity reduced.by therapeutic treatment,the general condition deteriorated,mortality rate and serum alt activity increased. conclusion: the preventive treatment of rstp reduce the liver damage due to increasing the anti-stress ability such as the antioxidant capacity,its therapeutic treatment increase the injuried liver damage due to increasing the non-specific immune response and aggregating the preexisting liver inflammation. background: the product's instruction pointed out that in some patients polyphenolic acids' salt from salvia miltiorrhiza(ppas-sm) may lead to a temporary increase in serum alt activity.so we observe effects of ppas-sm on alpha-naphthylisotheganate(anit)-induced cholestasis in mice. methods: hours after intoxicated with anit mg/kg orally, kunming mice were treated with ppas-sm , , mg/kg/days for days orally, then serum alt activity was measured. result: all doses of ppas-sm led to rise of serum alt activity in mice, most obvious in group of high dose.but the general situation and mortality rate did not increase significantly. conclusion: ppas-sm lead to rise of serum alt activity in mice with damaged liver.the auther suggests as a double-edged sword,the antioxidant ppas-sm may have a prooxidative effect in some condition too. *this project was supported by grants from shanghai municipal education commission under high school high-tech characteristic development programme (no smec finance ( ) ) pe a. somani , a. jain , v. dixit , s. somani navjeevan hospital, ims, bhu, varanasi, suvidha introduction: hepatic encephalopathy, a complex neuropsychiatric syndrome secondary to acute liver failure, chronic parenchymal liver disease or portal-systemic shunting, may possibly develop through mediators of endotoxin and tumor necrosis factor-alpha (tnf-). several studies have shown that serum levels of (tnf-) are significantly elevated in patients with acute and chronic liver diseases, where these elevations are independent of the etiology of the underlying disease. it has been shown that plasma levels of tnf-correlate with the severity of hepatic encephalopathy (he) in fulminant hepatic failure. however, still there is very few published data regarding the relationship between serum levels of tnf-and the presence or severity of he in patients with chronic liver failure. methods: the aim of this study is to determine the relationship between serum levels of tnf-and clinical grades of he in patients with chronic liver failure. this prospective study included consecutive male patients with alcoholic cirrhosis in various clinical grades of he (according to west haven criterion). detailed clinical, biochemical and sonographic examination was done in all patients. circulating levels of tnf-was measured using solid-phase elisa. results: the mean±sem values of serum tnf-at presentation in patients with mhe (n= ), grade (n= ), grade (n= ), grade (n= ), and grade (n= ) were . ± . , . ± . , ± . , . ± . , and ± . pg/ml, respectively. significant positive correlation was found between serum levels of tnf-and severity of he (correlation coefficient = . ). conclusion: from the present study we can suggest that there is significant relationship between tnf-and he in patients with alcoholic cirrhosis and it could be involved in its pathogenesis. background: acute hepatitis a (aha) is one of the most common infectious diseases and usually a self-limiting disease. although extrahepatic manifestations are not common, a few cases associated with acute renal failure (arf) have been reported. methods: we reviewed clinical features of aha patients complicated with arf (group a) and compared with non-complicated aha patients (group b). medical records of patients with aha were reviewed between january and december . we experienced patients ( . %) with arf associated aha. result: there were no differences between group a and group b in sex ratio and age. the peak value of alt (median: iu/l vs iu/l, p< . ), alkaline phosphatase (median: iu/l vs iu/l, p= . ), prothrombin time (inr, median . vs . , p< . ) was significantly higher in group a than b. nine patients ( . %) recovered completely with hemodialysis ( patients, . %) and only conservative management ( patients, . %), while patient underwent liver transplantation and patient died due to fulminant hepatic failure. there were patients who underwent kidney biopsy. two patients were diagnosed as acute tubular necrosis and patient as acute interstitial nephritis and iga nephropathy. conclusion: aha patients with arf had higher alt and more prolonged prothrombin time. the prognoses were poorer than those without arf. however, arf patients with nonfulminant aha had a good prognosis with a proper treatment and should not be confused with hepatorenal syndrome. background/aims: to investigate the hev infection among different animals and people with special profession, and to analyse the genotype of hev isolated in this study. methods: serum and fecal samples were collected from various animals and people with special profession in the south suburbs of beijing. hev antigen and anti-hev antibody were detected by das-elisa. hev rna was extracted from fecal samples and amplified by rt-npcr. the nucleotide sequence homology and phylogenetics of hev strains isolated from swine were analysed. results: the anti-hev antibody positive rate of adult swine, cow, sheep and younger swine were . % ( / ), . % ( / ), . % ( / ) and . % ( / ), respectively. the hev antigen positive rates of adult swine, cow, sheep and younger swine were . % ( / ), . % ( / ), . % ( / ) and . % ( / ), respectively. the hev antigen and anti-hev antibody positive rate of professional group was . % ( / ) and . % ( / ) respectively. the hev rna positive rate of fecal samples from younger swine was . %( / ). of samples were hev rna positive by pcr with primers of hev orf and orf . the sequence analysis of the samples showed that there were groups designated as bj- ( / ) and bj- ( / ). the nucleotide homology of bj- and bj- was %. phylogenetic analysis of hev orf indicated that both of them belonged to genotype d. conclusion: phylogenetic analysis of hev orf indicated that hev isolated in the south suburbs of beijing belonged to genotype d. bracops hospital brussels , st. jan hospital, bruges , chu brugmann, chu sart tilman, liège , gent university hospital , zna middelheim, antwerp hepatitis delta virus is a subviral satellite requiring hepatitis b virus to propagate, usually leading to severe, chronic liver disease. as data on epidemiology and management practice of hdv infection in belgium are lacking, a retrospective and prospective, multi-centric questionnaire-based registry is performed in . results of patients are reported. background/ aims: hepatitis a is an acute infectious disease that is transmitted by fecal-oral root. because the incidence of hepatitis a has been increased in gwangju and chonnam province of korea recently, hepatitis a patients in chonnam national university hospital employees had been increased. so we investigated the seroprevalence of igg anti-hav in hospital empolyees less than years old. methods: we analysed seroprevalence of anti-hav igg from , hospital employees (men: , women: ) . serum alt and bilirubin at admission were , , iu/l and . . mg/dl, respectively. these levels were elevated up to , , iu/l and . . mg/dl, respectively. ana was positive in patients ( . %). age, duration from peak-alt day, duration from peak-bilirubin day, alt level, and peak-bilirubin level were not different between ana(-) patients and ana(+) patients. in the while, sex, duration from symptom-onset day, and bilirubin level, and peak-alt level were significantly different. in ( %) of patients with positive ana, ana was followed after month and ana became negative in patients ( . %). among patients with positive ana after month, titer decreased from the baseline in patients, showed no interval change in , and increased in . conclusions: positive ana result is not rare in patients with acute hepatitis a. it is considered that ana transiently appear during the course of acute hepatitis a and then, disappear with the improvement of acute hepatitis. ( ), ( ). the clinical data such as sex, admission period, ast, alt, total bilirubin, prothrombin time, crp, alt normalization time did not show difference. just wbc and gtp were higher on group. the older age patients were more on group. the patients admitted mainly on april, may, june, july ( %) on while admitted even on past years. conclusion: acute hepatitis a ptients is increasing. it is occurring in older age people and mainly on specific period. the more concern to prevention should be needed. background: we analyzed the ' non-translated region ( 'ntr), non-structural proteins b and c of hepatitis a virus (hav) genome, whose mutations have previously been shown to be important for enhanced replication in cell culture systems, in order to align all of our data and examine whether genomic differences in hav are responsible for the range of clinical severities. methods: our accumulated hav strains of 'ntr (nt and ), entire b and c from japanese patients with sporadic hepatitis a, consisting of patients with fulminant hepatitis (fh), with severe acute hepatitis (ahs), and with self-limited acute hepatitis (ah), in whom the sequences of all regions were available, were subjected to phylogenetic analysis. results: fh patients had fewer nucleotide substitutions in 'ntr, had a tendency to have more amino acid (aa) substitutions in b, and had fewer aa substitutions in c, than ah patients. four fh and ahs with higher viral replication were located in the near parts of the phylogenetic trees, indicating the association between the severity of hepatitis a and genomic variations in 'ntr, b and c of hav. conclusions: our study suggests that genetic variations in some parts of hav might cooperatively influence replication of the virus, and thereby affect virulence. viral factors should be considered and examined when discussing the mechanisms responsible for the severity of hepatitis a. aims: the incidence of acute viral hepatitis a in adults is increasing very much in south korea, . the aim of this study was to the clinical features and course in daejoen and its surrounding area. methods: forty seven patients admitted as acute viral hepatitis a in chungnam national university hospital between january and june were enrolled. the medical records were reviewed, retrospectively. results: the mean age was . . common occupations were company employee and studuents. most common symptom was jaundice. presumptive infection sources were raw fish or shellfish and raw meat. initial laboratory findings were as follows(mean value): wbc /ul, hemoglobin . g/dl, platelet × /l, ast iu/l, alt iu/l, total bilirubin . mg/dl, alkaline phosphatase u/l, ggt u/l, prothrombin time(inr) . . hospitalization was . days. peak laboratory findings were as follows: alt iu/l, total bilirubin . mg/dl. leukopenia (< /ul) and thrombocjtopenia (< × /l) were ocurred in sixteen and six patients, respectively. recovery time of each biochemical finding was as follows: alt . days, total bilirubin days. recovery rates of altand total bilirubin were . % and %, . % and % at weeks, weeks after diagnosis, respectively. prolonged jaundice ( days) was detected in one patient. all patients were recovered by supportive management. conclusions: in south korea, acute viral hepatitis a was more prevalent in young adults, recenlty. presumptive infectious sources were raw fish or guangxi center for disease prevention and control shellfsh and raw meat. if it can not change the food style that many korean enjoy raw seafood, vaccination for adults must be considered to prevent it. objective: to assess the safety and immunogenicity of a new inactivated hepatitis a vaccine (vero cell). pe methods: subjects were selected in gongcheng city of guangxi zhuang autonomous region, and the clinical trail was carried out according to the random, double-blind and parallel principle from january to august, . after vaccination by , schedule, adverse events of the subjects were observed, the seroeonversion rate and geometric mean titer (gmt) were tested by the competitive inhibition elisa. results: after immunization, the systemic and local reaction rates of adults were . % and . %, which was no significantly statistical difference compared with control group, . %and . %; while the rates of children were . and . %%, and no significant statistical difference compared with control group, . %and . %. one month after first dose of vaccination, the seroconversion rates of children and adults were . % and . %, and one month after second dose of vaccination, the rates were all %, the gmts of children and adults were miu/m and miu/ml, which was significant statistical difference in children compared with control group, miu/ml and miu/ml, respectively. methods: igg anti-hav was measured in a total of subjects under the age of , who visited hanyang university seoul and guri hospitals between january and may . results: fig. shows the relatively low positive rates of the antibody in ages of to and the lowest rates of . % and . % in the age group of to , following the ages of to with rates of background: some viruses encode proteins that affect their cap-independent internal ribosomal entry site (ires)-mediated translation and their replication. it was recently reported that hepatitis a virus (hav) proteases interact with intracellular dsrna-induced retinoic acid-inducible gene (rig-i)-mediated signaling, but it remained unknown whether hav proteins have any effects on hav ires-independent translation. in this study, we investigated the effects of hav non-structural proteins on their ires-mediated translation using a reporter assay. pe methods: the bicistronic reporter constructs, termed psv -hm -ires, psv -a -ires, psv -a -ires, psv -f -ires, and psv -f -ires, contain the sv promoter that controls the expression of a bicistronic message coding for renilla and firefly luciferases separated by hav ires, and are derived from strain hm , acute convalescent hepatitis clones a , a , fulminant hepatitis clones f , f , respectively. human hepatoma cell lines were co-transfected with psv -hav-ires and each hav protein-expression vector. luciferase activity was determined h after transfection. were from other countries within asia, africa, middle east, and eastern europe. patients of a wide age range were affected by hepatitis delta (mean age . , median . , range - ). ( %) of were co-infected with hcv. hepatitis b virus (hbv) dna was detectable in ( %) patients and negative in ( %) patients. all hepatitis delta patients were extracted from a prior study conducted by this collaboration. there were , chronic hbv carriers. ( . %) were hbv/ hcv/hdv infected. ( %) of patients carried a diagnosis of cirrhosis compared to ( %) of chronic hbv patients. ( %) hcv co-infected patients had evidence of cirrhosis while ( %) patients did not. conclusion: individuals with hbv/hdv co-infection have higher rates of cirrhosis. individuals with hbv/hcv/hdv infection have rates of cirrhosis significantly higher than individuals with either chronic hbv infection or hbv/hdv co-infection. testing for hdv should be performed in all patients, especially those with advanced liver disease or high risk behavior. clinical characteristics were compared between the patients with significant endoscopic findings (group a) and without such findings (group b). peak ast and alt level were higher in group a (p< . ). there were no statistical differences in age, gender, comorbidity, and etiology of acute hepatitis between group a and group b conclusion: significant endoscopic findings were found in considerable proportion of patients with acute hepatitis. severity of acute liver injury was associated with significant upper gastrointestinal endoscopic findings. in patients with severe acute hepatitis who complain of upper gastrointestinal symptom, esophago-gastro-duoenoscopy should be performed. background: in japan, hepatitis e virus (hev) testing is not allowed as routine one. to study the role of hev testing, we checked sera of the patients diagnosed as etiology-obscure acute liver injury. methods: we have seen cases of acute liver injury from january through december in our hospital and cases of them were etiology-obscure. in cases, were retrospectively tested for hev-igm, hev-iga and hev-rna (rt-pcr) by direct sequence method on stored sera taken at the time of presentation. result: two of cases ( . ) were positive for both hev-igm and hev-iga and one case was positive for hev-rna. in cases of acute liver injury, the cause of virus was cases ( . %) and unknown was cases ( . %). hev was occupied in . % in all cases and . % in the cases caused by virus. one of the two cases had been misdiagnosed as "drug induced hepatitis". hev of genotype was detected in one case and its nucleotide sequences of hev showed quite a high degree of similarity to the reported one at closed city in the same year. conclusion: hev is not rare in japan and the hev testing can reverse the diagnosis of acute liver injury. hev testing sould be used as routine one for acute liver injury. association of progesterone receptor gene with hepatitis e disease severity in pregnancy p.d. bose , b. das , a. kumar , p. kar maulana azad medical college, background/aims: incidence of fulminant hepatic failure (fhf) in hepatitis e is high in pregnancy particularly during rd trimester when there is an altered status of hormone and immunity. progesterone receptor (pr) up regulation provides fetal protection via immunosuppression but lower immune status in pregnancy may add to the disease severity. till now, no data is available whether pr can play any role in hepatitis e disease severity during pregnancy. progins, a haplotype of pr consisting of -bp insertion in intron g together with point mutations in exons and is associated with increased stability and higher transcriptional activity. the aim of the study is to analyze pr mutation (progins) and m rna expression in hepatitis e virus infected pregnant women with avh and fhf. methods: a total of avh and fhf cases were studied. blood and placental tissue were collected from the medicine and gynecology wards of lnjp hospital, new delhi. cases were screened for acute viral markers by commercially available elisa kit. extraction of dna from blood and rna from placental tissue was done by qiagen kit. mutation in pr was detected by pcr-rflp. semiquantitative rt-pcr for pr expression was performed in placental tissue using beta-actin as internal control. results: pr mutation (progins) was significantly more in fhf compared to avh ( . % vs . %, p value< . ). protein expression was found higher in progins carriers. conclusion: progesterone receptor mutation (progins) may have a role in the hepatitis e disease severity in pregnant women. results: the hepatitis e was predominantly sporadic, some patients superinfected with other viral hepatitis, especially hepatitis b. in the old patients, jaundice lasted longer and the length of stay was longer, the incidence of complication was higher than the young men. the incidence of complication in the superinfected group was higher than the simple infection. the transaminase in the simple infection group was obviously raise than superinfected with liver cirrohsis. methods: liver sample were paraform-glutaral fixed, paraffin-embedded, sectioned and immunohistochemical stained, and positive samples were selected for histological analysis and rt-pcr detection. result: positive rate of hev immunohistochemistry ranged from % to % (fig. ) . hepatocyte degeneration, scattered singled karyopyknosis, lymphocytic infiltrate, hyperplasia of bile canaliculus at the portal area and fibrous connective tissue hyperplasia been observed during histological analysis (fig. ) , and two genotype hev which closely related to many strain isolated from patients with sporadic acute hepatitis been detected. conclusion: the patients infected with hepatitis e of young men were frequently. jaundice lasted long in the old patients, the incidence of complication was higher in the superinfected men and the old men. conclusion: additional public-health concerns might be placed on pork safety and the risk of hev infection via the consumption of undercooked pork products. poster session, hall b aim: esophageal varices (ev) recurs frequently after endoscopic variceal ligation (evl) or endoscopic injection sclerotherapy (eis). we retrospectively investigated risk factors for early recurrence of ev after endoscopic treatment. methods: we treated patients with ev, who had no past history of ev, at ehime prefectural central hospital from october to june . of those, ( %) were observed for at least months after treatment and enrolled. we divided them into rupture cases at initial endoscopic treatment [(bleeding group; n= ( %)], and cases with preventive evl or eis performed [preventive group; n= ( %)]. all received periodic upper endoscopy examinations to confirm recurrence or no recurrence of ev. results: recurrence of ev occurred in of all subjects and the average period after treatment was . ± . months. the recurrence rate was significantly higher in the bleeding group ( / ) as compared to the preventive group ( / ) (p= . ). there was a significant relationship between recurrence of ev and hepatic reserve function (child-pugh a+b, c; / , / respectively; p= . ). in logistic multi-variant analysis, ev rupture at initial treatment and child-pugh c were risk factors for recurrence. in contrast, age, sex, hepatocellular carcinoma, portal tumor thrombosis, continuous alcohol consumption, therapeutic modality (evl or eis), number of treatment sessions, and operator experience did not have a significant relationship with recurrence. conclusion: in cases with ev rupture at initial treatment or child-pugh c, the risk for early recurrence must be considered and patients carefully observed in follow-up examinations. endoscopic cyanoacrylate injection: less oil for less ectopic embolism c.z. li , l.f. cheng , z.q. wang , f.c. cai , q.y. huang , e.q. linghu general hospital of chinese pla background and aim: endoscopic injection sclerotherapy with n-butyl- cyanoacrylate (nbca, histoacryl) has been reported to be effective for hemostasis of bleeding gastric varices, but occasionally the gel flows to other organs and causes ectopic embolism. the present study aimed to determine whether less amount of iodized oil preload in nbca injection helps in decreasing ectopic embolism. methods: from january to april , different methods of endoscopic nbca injection, "sandwich method" and "modified sandwich method" (in which iodized oil preload was minimized), were applied on gv cases, to evaluate if decrease of iodized oil preload resulted in less ectopic embolism. results: altogether cases of ectopic embolism occurred in the whole group ( . %), including cases of splenic infarction, case of transient paralysis and case of minor infarction of the lung. the modified sandwich method showed some superiority over original method in decreasing ectopic embolism ( / vs. / , p= . ). less cough during procedure was also found with the modified method ( / vs. / , p= . ). conclusions: less amount of iodized oil preload in endoscopic nbca injection is beneficial to decrease ectopic embolism. background: portal hypertension is closely associated with serious complications of liver cirrhosis which contribute to bad prognosis. hepatocellular carcinoma (hcc) and low serum sodium (sna) are manifestations of end-stage liver disease (esld) and are associated with poor survival in decompensated cirrhosis patients. therefore, we aimed to determine the relationship between hepatic venous pressure gradient (hvpg) and the development of hcc or low sna in decompensated alcoholic cirrhosis patients. methods: child-pugh scores, meld scores, and hvpg at baseline, and the development of low sna (sna < meq/l) or hcc during follow-up were analyzed prospectively in patients with decompensated alcoholic liver cirrhosis. the predictive values of different risk factors for the progression to the esld were investigated by multivariate analysis and the kaplan-meier method results: twenty-four patients developed hcc during the follow-up period. in the multivariate analysis, only baseline hvpg> mmhg was an independent predictive factor for the development of hcc (relative risk (rr)= . , p< . ). those with hvpg > mmhg showed a significantly shorter time for the development of hcc on kaplan-meier analysis. twenty patients developed low sna during follow-up. initial hvpg was also an independent predictive value for the development of low sna in the multivariate analysis (rr= . , p< . ). those with hvpg> mmhg also showed significantly shorter times for the development of low sna on kaplan-meier analysis. conclusions: in decompensated alcoholic cirrhosis, hvpg may be a useful predictive factor for the development of hcc and low sna, both of which are characteristic of esld and poor prognosis. the effectiveness of the treatment of octreotide on chylous ascites after liver cirrhosis d.x. zhou , , h.p. hu , background: octreotide is a crucial drug used for treating patients with chylous ascites; however, there have been few reports related to octreotide that are being used in cirrhotic patients. thus, this thesis is designed to determine the effects of octreotide on patients with chylous ascites after liver cirrhosis. methods: eight patients were diagnosed with chylous ascites, on the basis of laboratory findings on ascites samples, between january and may . octreotide was given to the six patients, while the remaining two were treated as a control. all patients had persistent peritonea drainage with the quantity and quality of the drainage fluid observed once every other day. all the necessary care was individually given to the patients during the therapy results: all patients properly received combined therapy including low fat and sodium diet, and diuretic and peritoneal drainage. the volume of the peritoneal drainage was reduced to zero in one of the six patients who received octreotide therapy, while the other five had the drainage volumes decreased from ml to ml with a clear appearance and negative qualitative analysis of chyle for those two patients who did not receive octreotide therapy, the conditions of peritoneal drainage seldom changed both from the qualitative and quantitative aspects. conclusion: octreotide, along with combined therapy, can rapidly relieve portal hypertension and reduce fat absorption from intestinal mucosa. it appears to be an effective therapy available for the treatment of chylous ascites caused by liver cirrhosis. albumin < g/l were the best predictors of large varices. a model using these predictors in a validation cohort study is planned. background-aim: cirrhosis is associated with raised acute phase proteins (app), irrespective of infection. it is, however, unclear whether their values differ significantly or whether a particular app might be more indicative of infection, and these questions were addressed in our study. methods: we measured serum crp, fibrinogen, ferritin, haptoglobin, -microglobulin, c , c , and c inhibitor in consecutive, cirrhotic patients, on admission. all patients were investigated according to a standard protocol for infection. child-pugh scores (cps) were calculated. results of app were expressed as means sem and compared with the mann-whitney test. results: ( , %) patients, median age years, (cps: a= ; b= ; c= ), were diagnosed with infection (spontaneous bacterial peritonitis= ; pneumonia= ; septic shock= ; extensive cellulitis= ; listeria monocytogenes meningitis= ; viral infection= ), while ( %) patients, median age years, (cps: a= ; b= ; c= ), showed no infection. although most app values were raised, there was no statistically significant difference between patients with or without infection, or among different cps groups, except for crp, which was significantly more raised in patients with infection (p< . ). this difference remained even after cps a cases in the non-infection group were excluded from analysis. interpretation: a significantly raised crp in cirrhosis would seem to be independent of cps staging and should prompt a thorough work up to exclude infection. by contrast, the discriminating power of all other app in the face of possible infection is negligible. the predictive value of crp towards infection is under investigation prospectively. although bleeding from ectopic varices such as duodenal, jejunal, ileal, colonic, and rectal varices is less common, it can also cause life-threatening problem, which is often difficult to diagnose and treat successfully. here we present a novel endoscopic approach for hemorrhagic rectal varices using endoscopic injection sclerotherapy with ligation (eisl). patients and methods: in - , we performed endoscopic treatment in patients with portal hypertensive varices. among those, four cases of hemorrhagic rectal varices were treated with the combined evl and sclerosing technique. the etiology of portal hypertension included oen idiopathic portal hypertension and three hcv cirrhosis. all patients had a history of prior abdominal surgery or endoscopic treatment for gastro-esophageal varices. results: hemostasis was obtained easily by the evl initially. furthermore, to avoid recurrent bleeding, the patients underwent endoscopic varicerography injection sclerotherapy (evis) using % ethanolamine oleate with iopamidol and the feeding vein was sclerosed successfully with no major complication occurred during the entire course of the treatment. conclusions: it is important to recognize the possibility of ectopic varices as a cause of gastro-intestinal haemorrhage especially in patients with a history of variceal therapy or abdominal surgery. the eisl technique is useful to control the initial and recurrent bleeding from rectal varices. t. hirano , t. okada , j. yamanaka , y. iimuro , n. kuroda , k. oh , y. yoshida , j. fujimoto aim: interferon (ifn) therapy is a powerful treatment for hcv-related hepatitis and is known to decrease the incidence of progression of hepatocellular carcinoma (hcc). however, thrombocytopenia is a common side effect of ifn treatment, often leads to discontinuance without insufficient therapeutic effect. in this study, we investigated the efficacy and safety of laparoscopic splenectomy ( ) in reversing thrombocytopenia in patients with hepatitis c cirrhosis and portal hypertension. patients and methods: out of patients who underwent ls in our department during aug and december , patients associated with portal hypertension. among these patients, three patients had hcc, and they were simultaneously underwent partial hepatectomy after splenectomy. platelet count, operative time, blood loss, complications and length of stay were calculated. results: thirteen patients underwent laparoscopic splenectomy; their mean age was years (range to years). six patients were child's class a and seven patients were class b. mean operative time was minutes (range to minutes). blood loss was little, and none required transfusion with packed red cells. a hand-assisted laparoscopic technique was used in four cases ( . %). average length of stay was . days. there have been no major complications during follow-up. platelet counts improved from a preoperative mean of /ul ( to ) to /ul ( to ) postoperatively. six patients are ongoing ifn treatment without remarkable thrombocytopenia. conclusion: laparoscopic splenectomy is safe and in patients with portal hypertension and thrombocytopenia. it may allows these patients by reversing thrombocytopenia. background: hepatic encephalopathy (he) is a significant cause of mortality in advanced cirrhosis patients. l-acyl-carnitine has been suggested as an alternative treatment for patients with he patients. to assess the clinical efficacy of acetyl-l-carnitine in the treatment of hepatic encephalopathy in cirrhotic patient, especially in diminishing the recurrence and reduction serum ammonia level. methods: we performed a randomized placebo-controlled, cross-over study. we administered acetyl-l-carnitine to group during months first then placebo during later months, and administering acetyl-l-carnitine to group alternatively. results: between january and february , thirty two selected cirrhotic patients were enrolled in this study. following randomization, the patients were divided into two groups (group = , group = ). during administering acetyl-l-carnitine period, serum ammonia level was decreased significantly in both groups significantly (p= . , vs. p= . respectively). however, during administering placebo period, serum ammonia level changes were not significant. in group , the first recurrence cases of hepatic encephalopathy were more than group (group = , group = ), and the first recurrences were occurred during first months in all groups. conclusion: our study demonstrates that acetyl-l-carnitine administration reduced serum ammonia level, but not definitely diminishing the recurrence of hepatic encephalopathy. sodium (na + ) and water retention are the most common abnormalities in cirrhotic patients and the magnitude varies from patients to patients. aim: to assess the relationship between the meld score and urinary excretion of na+ in non-azotemic cirrhotic patients. methods: fifty four cirrhotic patients with ascites and normal serum creatinine (< . mg/ml) were admitted and placed on a low sodium diet ( g/day), while all diuretics were withdrawn for days. the electrolytes (na + , k + , na + / k + ) were measured in a random urine and both the volume and na + concentration of urine collected for h after administration of furosemide mg i.v. were determined. results: table. conclusions: the meld score was significantly correlated with the degree of impairment of urinary na+ excretion. the ratio of na + /k + in a random urine specimen and furosemide-induced na+ excretion reflect the degree of impaired natriuresis in non-azotemic cirrhotic patients with ascites. background: portal hypertensive gastropathy (phg) is common finding in patients with liver cirrhosis and portal hypertension. despite portal hypertension remains the crucial trigger for the development of phg, the relationship between portal hypertension and phg has not been widely investigated. methods: fifty-three cirrhotic patients ( males, mean age years) who were performed hepatic vein catheterization between november and august were prospectively included in this study. the degree of phg was assessed according to the third baveno international consensus workshop, and classified three degrees as no, mild and severe. the hepatic venous pressure gradient (hvpg=whvp-fhvp) measurements were performed by triplicate in each case, and results were given as arithmetic means of the three determinations. result: hvpg values did not differ between the patients without phg ( . ± . mmhg) and those with phg ( . ± . , p= . ), nor between those with mild ( . ± . mmhg) or severe phg ( . ± . mmhg, p= . ). the degree of phg and hvpg did not differ regarding the etiology of the cirrhosis(p= . , p= . ) nor regarding the child pugh classification(p= . , p= . ). no correlations were found between the degree of phg and child pugh score, age, with or without ascites, albumin, bilirubin, creatinine, meld score and the degree of gastroesophageal varices. conclusions: our data show that the presence and the severity of phg does not correlate with the degree of hvpg, and that correlate with esophageal varices in patients with liver cirrhosis. introduction: phlebosclerotic colitis is a rare form of ischemic colitis characterized by the thickening of the colonic wall due to fibrous degeneration of the submucosal layer and fibrotic sclerosis of the venous wall. there are a few reports those this entity might be related to portal hypertension with disturbed venous return from the colon and mesentery. case description: a -year old man with alcoholic liver cirrhosis presented with right lower abdominal pain/tenderness and bloody diarrhea. a colonoscopy revealed multiple circumferential ulcerations in the transverse colon and the scope could not get through the ascending colon due to luminal stenosis, showing histologic finding of ulcerative inflammation with inflammed granulation tissue. abdominal computed tomography demonstrated liver cirrhosis with splenomegaly, multiple portosystemic venous collaterals, diffuse vascular engorgement and the wall thickening of right proximal to mid ascending colon with increased density in the surrounding fatty tissue. a follow-up colonoscopy performed one month later showed still remained multiple ulcerations in the transverse colon and could not further advance to ascending colon. superior mesenteric angiography revealed no main branch occlusion but pooling at the venous phase on ascending colon. a right hemicolectomy was performed because of the colonic obstruction. gross findings on operation showed thickening of the cecum and ascending colon. microscopic examination showed fibrous thickening in the submucosa, abundant neurovascular bundles in the mesentery and several intravascular hyaline thrombi of the mesenteric vessels. here we report the first case of early stage of phlebosclerotic colitis in a cirrhotic patient in korea. spontaneous bacterial peritonitis (sbp) is one of the severe complications in advanced cirrhotic patients with a high mortality rate. although a more rapid diagnosis should lead to the better survival, it takes several days to detect the causal bacteria from ascitic fluid cultures. furthermore, despite the use of sensitive methods, ascitic fluid cultures were negative in more than % of patients with suggestive clinical manifestations of sbp. therefore, diagnosis of sbp is based on the polymorphonuclear leucocytes (pmn) cell count in the ascitic fluid. the hybrizep kit (fuso pharmaceutical industries, osaka, japan) detects the dna of bacteria that have been phagocytized in neutrophils and macrophages, using in-situ hybridization method within one day. here we present a case of the patient for whom the hybrizep kit was used to detect the causal pathogen of sbp. a -year-old man had been admitted for the treatment of ascites and esophageal varices. one week after the admission, he complained abdominal pain and fever. because the pmn cell count in ascites fulfilled the criteria of sbp ( /mm ), we started an empirical antibiotic therapy without waiting for a result of the culture, and his symptoms improved within a few days. on the following day of the onset, in situ hybridization showed the positive signals by the ek probe, which detected the genomeic dna of e.coli species. however, the ascitic fluid culture was negative. this case suggested that the hybrizep kit was useful for the rapid diagnosis of sbp with high sensitivity. background: it has not been known that the hemodynamic effect of a portal hypertension for splenomegaly or esophageal and gastric variceal formation. this study was performed to access the parameters of doppler ultrasonography associated with splenomegaly or varices in patients with cirrhosis. patients and methods: from may to may , cirrhotic patients were performed the doppler ultrasonography. of these patients were accessed the severity of varices endoscopically. the three dimensional volume of spleen was measured from a length, width and thickness on sonography. results: the splenic volume ( . ml vs . ml, p= . ) and blood flow of main portal vein ( . cm/s vs . cm/s, p= . ) were statistically significant different in alcoholic ( / ) and non-alcoholic ( / ) cirrhosis groups. the splenic volume ( . ml vs . ml, p= . ), damping index ( . vs . , p= . ), and blood flow of main portal vein( . cm/s vs . cm/s, p= . ) were statistically significant different in esophageal variceal groups ( / ) and non-esophageal variceal groups( / ). the only splenic volume ( . ml vs . ml, p= . ) were statistically significant different in gastric variceal groups ( / ) and non-gastric variceal groups ( / ). the hemodynamic parameters venous ammonia and cff at baseline and after one month of treatment with lactulose. mhe diagnosed by abnormal psychometry and/or p erp.response defined by normalization of abnormal test parameters. results: mhe diagnosed in ( %) patients. of patients ( %) had both abnormal psychometry and p erp whereas ( %) alone had abnormal psychometry, ( %) had abnormal p erp.cff was < hz in ( %) patients. mhe recovered in % with treatment and cff > hz was seen in ( %) of patients. cff sensitivity, specificity, positive predictive value (ppv), negative predictive value (npv) and diagnostic accuracy before and after treatment is shown in table. conclusions: critical flicker frequency is a simple and accurate test without any age or literacy dependence for the diagnosis and recovery of patients with mhe. background/aims: endoscopic injection of n-butyl- -cyanoacrylate (histoacryl) is an effective treatment of varix bleeding. but nontarget embolizations and septicemia are unwanted complications. we evaluate the risk factors for complications. methods: thirty-three patients with esophageal or gastric varix bleeding received endoscopic histoacryl therapies ( procedures). baseline varix size, ctp score were checked. serum leukocyte, blood culture and body temperatures were repeated checked within one week after procedure. average volume of histoacryl per each session was . ml, and dilution volume ratio of histoacryl/lipiodol was / or / . results: average of ctp score was . ± . . three cases of septicemia were correlated with ctp score rather than session frequency or injection volume. two cases of systemic embolizations (pulmonary and splenic arterial embolism) were correlated with high lipiodol dilution ratio ( / ) and lipiodol volume rather than histoacryl volume or ctp score. conclusion: ctp score, lipiodol volume and dilution ratio of histoacryl/lipiodol were significant risk factors for complications. detection of circulating toll-like receptor and and cd +cd + regulatory t cells in patients with hbv-related liver cirrhosis x.q. wang , y. zhang , x.f. bai , j.q. lian background : to detect circulating cd + cd + regulatory t cells and toll-like receptor(tlr) and tlr expression on the peripheral blood mononuclear cells (pbmcs) of patients with hbv-related liver cirrhosis (lc), and to explore the correlation between them. methods: pbmcs isolated from lc patients , chronic hepatitis b (chb) patients and normal controls(nc) were stained with fluorescent labeling anti-tlr -pe, anti--tlr -apc, anti--cd -fitc monoclonal antibodies and anti-cd -percp anti-cd -fitc anti-cd -pe. samples were collected and detected of three-color immunofluo rescence by flow cytometry. results: the expression of tlr and tlr were significantly up-regulated in patients with lc than those in the controls.the expression of tlr was significantly increased in patients with lc than those in patients with chb, but there were no differences of tlr expression between lc and chb.treg/cd + t cells were significantly increased in patients with chb than those in patients with nc and lc, but there were no differences between lc and nc. there were no correlation between the expression of tlr ,tlr and treg in patients with lc . the expression of tlr and tlr on pbmcs in patients with lc were positive correlation.the expression tlr and hbv dna level were negative correlation in patients with lc. conclusion: the expression of tlr and tlr were up-regulated on pbmcs in patients with lc. it seems to be expression of tlr and tlr invovlved in the pathogenesis of lc. evaluation of c-phenylalanine breath test for the measurement of hepatocyte function in patients with chronic liver disease z.j. bao , d.k. qiu , , x. ma , , g.s. zhang , y.q. huang , z.p. fan , , s.m. yin huadong hospital, fudan university, renji hospital, shanghai jiao tong university school of medicine, background: the objective is to investigate whether the c-phenylalanine breath test(pbt) would be useful for the evaluation of hepatic function in patients with chronic hepatitis b, liver cirrhosis and minimal hepatic encephalopathy (mhe). methods: l- [ - c] phenylalanine was administered orally in a dose of mg to patients with liver cirrhosis, with chronic hepatitis b and healthy subjects. the pbt was measured at different time points ( , , , , , , , min) to obtain the values of delta over baseline, percentage co exhalation rate and cumulative excretion (cum). the relationships of the cumulative excretion with the c-%dose/h and blood biochemical parameters were investigated. results: the c dose h - at and min combined with the cumulative excretion at and min showed correlations with the chronic liver diseases, especially child-pugh score and mhe or not. and the data showed correlations with serum albumin hemoglobin platelet and child-pugh score. prothrombin time, total and direct bilirubin were significantly increased, while serum albumin, hemoglobin and platelet, the cumulative excretion at and min values decreased by degrees in healthy controls, child-pugh a, b, and c patients (p< . ). similar results of pbt were in the patients with and without mhe, while only prothrombin time prolonged and total bilirubin increased (p< . ). conclusions: the pbt can be used as a non-invasive assay to evaluate hepatic function in patients with liver cirrhosis and mhe. the % c dose h- at min, % c dose h- at min and cumulative excretion at min may be the key value for determination at a single time-point. branched chain amino acids in improving survival and decreasing risk of liver failure among cirrhotic patients: a meta-analysis h. flores , e.l. ang , n. iv estanislao philippine general hospital background: the state of a patient's nutritional status greatly affects disease outcome. among cirrhotic patients, approximately - % are in a state of protein-energy malnutrition. hence, adequate nutritional support is essential to improve their general medical condition and long term prognosis. several studies have shown than branched chain amino acids (bcaa) may be of benefit for this purpose. it is the aim of this study to evaluate the effectiveness of diet plus bcaa compared to diet alone in improving survival and in decreasing liver failure among cirrhotic patients. methods: pubmed, cochrane, and embase search was done for articles which compared the clinical effects of bcaa supplementation versus diet alone among patients with liver cirrhosis. the following free-text terms and mesh words were used -"branched chain amino acids", "amino acids, branched chain", "bcaa", "liver cirrhosis", "cirrhosis", "randomized controlled trials'" and "meta-analysis". after critical appraisal of the included studies, a random effects model using odds ratio was used to synthesize the results (revman . ). results: rcts were included for analysis with a total study population of . combination of the studies showed a significant decrease in the risk of liver failure (or . , % ci . - . , p= . ) and a trend towards benefit in improving survival (or . , % ci . - . , p= . ). conclusions: the overall trend appears to show benefit in the use of branched chain amino acids for patients with cirrhosis with respect to liver failure and survival. background: the proxisome prolifrator-activated receptor gamma (ppar ) is a member of the nuclear hormone receptor superfamily that is involved in the control of inflammation, carcinogenesis and gastric ulcer. on the other hand, the frequency of gastrointestinal ulceration is higher in cirrhotic patients compared with the normal population. the present study was designed to investigate the effect of specific ppar ligand, pioglitazone, on the mucosal lesions induced by ethanol in cirrhotic rats and the possible involvement of nitric oxide in the pioglitazone effect. methods: cirrhosis was induced by surgical ligation of bile duct and sham-operated rats served as controls. both cirrhotic and sham rats were kept for days after the operation. different groups of sham and cirrhotic animals received saline, or , or mg/kg pioglitazone, daily during last days of the fourth week after the surgery. another groups of bdl or groups of sham rats received l-name, a non selective inhibitor of nitric oxide synthase, alone or along with mg/kg pioglitazone for days. on day , rats were killed hour after ethanol administration and the area of gastric lesions was measured. results: the ethanol-induced gastric mucosal damage was significantly more sever in cirrhotic rats than sham-operated ones (p < . ). pretreatment with pioglitazone dose dependently attenuated gastric lesions induced by ethanol in both sham and cirrhotic rats, but this effect was more significant in cirrhotic ones. concurrent treatment of l-name and pioglitazone decreased the ulcer index in bdl rats more than the groups that received l-name or pioglitazone alone. conclusion: we conclude that chronic treatment with pioglitazone exerts a potent gastroprotective effect on the stomach ulcers of cirrhotic rats probably due to inhibition of nitric oxide synthase. inhibition of phosphodiesterase -a novel therapeutic strategy for portal hypertension l. halverscheid , p. deibert , b. pannen , r. schmidt , m. roessle , w. kreisel university hospital duesseldorf, germany, university hospital freiburg, germany introduction: the no-cyclic gmp system is a key factor in the regulation of splanchnic and hepatic blood flow and may be a target for medical treatment of portal hypertension. clinical data have shown that inhibitors of phosphodiesterase (pde ) lower portal pressure in cirrhotics. methods: we monitored in rats the effects of the pde inhibitors vardenafil and sildenafil on systemic and hepatic hemodynamic parameters up to minutes after the drug. the drugs were administered intravenously into the tail vein at (group a), (group b), and g/kg body weight (group c). . % nacl was the control. n = for each group. results: the most prominent changes were observed in the vardenafil b group: mean arterial and portal venous pressure decreased (- %, - %), as well as portal venous, hepatic arterial, and systemic vascular resistance (- %, - %, - %). portal venous and sinusoidal flow increased (+ %, + %). in the vardenafil c and sildenafil b and c groups there was an increase of portal venous flow by - %, an increase of sinusoidal flow by - %, and a decrease of portal venous resistance by about %. there was a trend for reduction of portal venous pressure. conclusions: vardenafil and sildenafil influence portal hemodynamics in the rat. portal venous flow increases by - %, portal venous resistance decreases by > %. dependent on the dose, portal venous pressure decreases significantly. these data yield further evidence that pde inhibitors may be a novel therapeutic option for portal hypertension. groups of liver cirrhosis e. havrilyuk lviv national medical university introduction: rupture of esophageal varicose resulting in posthemorrhagic anemia is a common life-threatening complication of liver cirrhosis. but it is not clear, why the other patients, having the same degree of sclerosis and histologic activity index, die from hepatocellular failure or other reasons. aims & methods: autopsy cases performed in lviv regional hospital in - were analyzed. screening of slides with liver tissue allow to select cases ( , %) with cirrhosis (complete and incomplete), which are examined in order to evaluate the frequency of lethal portal hypertension complications in the different etiologic groups of liver cirrhosis. results: according to the etiologic factor the following groups of liver cirrhosis were examined: alcoholic disease ( , %), viral hepatitis ( , %), nonalcoholic steatohepatitis ( , %), secondary biliary cirrhosis ( , %), cardiac sclerosis ( , %), combined lesions ( , %) and cryptogenic cirrhosis ( , %). analysis shows that in cases ( , %) patients die from cirrhotic complications (hepatocellular failure, jaundice, portal hypertension) and only in cases ( , %) -from posthemorrhagic anemia caused by rupture of esophageal varicose. in the latter cases correlation between the etiologic types of cirrhosis is almost the same, as in the main group and only alcoholic lesions ( %) and biliary cirrhosis ( , %) are more frequent. conclusion: analysis shows that development of lethal complications of portal hypertension can not be explained only by etiologic factor. probably additional stimuli are more important for morphogenetical variants of cirrhotic transformation. patients with viral cirrhosis k. mumtaz , s. ahmed , h. ali shah , s. hamid , w. jafri background and aims: increased nitric oxide (no) production is incriminated in the pathogenesis of arterial vasodilation and hyperdynamic circulatory state in non cirrhotic models of portal hypertension (pht). we investigated the relative roles of constitutive nos (enos) and inducible nos (inos) isoforms in the development of rabbit models of endotoxemia induced portal hypertension (eipht) methods: eipht was induced by chronic injection of lipopolysaccharide via an indwelling cannula placed in the gastrosplenic vein of rabbit and maintained for months. the concentration of no, expression of nos (enos and inos) mrna and protein was measured in eipht and sham operated control animals. results: rabbits with eipht compared with controls had raised portal pressure (in mmhg- . ± . vs . ± . ;p< . ; mo; . ± . vs . ± . ; p< . , mo; . ± . , vs . ± . ;p< . ), arterial hypotension (in mmhg- . ± . vs . ± . , p< . , mo; . ± . vs . ± . ,p< . , mo; . ± . vs . ± . , p< . , mo), splenomegaly (in g- . ± . vs . ± . , mo; . ± . vs . ± . , mo; . ± . vs . ± . , mo), normal liver functions and preserved hepatic architecture at , and mo. serum levels of no as well as the no were significantly elevated in eipht rabbits as compared to the controls. the expression of enos, at the level of mrna, was significantly increased in eipht rabbits consistent with increased levels of expression of inos as compared to the controls. the enos but not inos protein expression was elevated in eipht than control rabbits. conclusion: vascular dysfunction in the splanchnic circulation during the development of endotoxemia induced portal hypertension is predominantly characterized by enos and partly by inos gene up-regulation. liver cirrhosis contributed to the immunocompromised status by shedding the membranous tnfrii t.n. lin , c.h. chao , i.s. sheen , y.p. ho , w.t. chen , c.j. lin , c.t. yeh , c.y. lin liver research unit, linkou medical center, chang gung memorial hospital, chang gung university, taoyuan, taiwan background & aim: patients with decompensated liver cirrhosis (dlc) were regarded as immunocompromised, reflected by high incidence of bacterial infection. paradoxically, the proinflammatory cytokine like tnfincreased significantly in patients with dlc even in the face of this immunocompromised status. on the other hand, regulatory t cell (treg cell) is believed to play an important role in inhibiting immune responses, including innate immune responses like blockade of tnf-effect through soluble tnfrii. here, we studied the role of treg cells and tnfrii in patients with decompensated liver cirrhosis. patients and methods: healthy volunteers and cirrhotic patients were enrolled. the percentage of treg cells were enumerated by flow and serum levels of il- , tgf-and tnf-by elisa. results: the percentage of treg cells increased significantly in patients with dlc associated with increased serum levels of il- and tgf-. in addition, these treg cells were mainly memory type reflected as high cd ro. furthermore, the tnfrii expression increased significantly on these treg cells of dlc. interestingly, these membranous tnfrii on treg cells could be shed-off. lastly, we found the serum soluble tnfrii concentration increased significantly in patients with dlc when compared with normal volunteers. conclusion: our results demonstrated memory treg cells with high tnfrii expression increased significantly in patients with decompensated liver cirrhosis that could possibly blocked the biological effect of tnf-by shedding membranous tnfrii and contributed to the immunocompromized status of dlc. background: portal pressure measured as hepatic venous pressure gradient (hvpg) correlates with severity of portal hypertension and the development of complications. hvpg measurement is invasive. recently, liver stiffness measurement has been shown to correlate with liver biopsy and helps predict outcome in chronic liver disease patients. this study was conducted with the aim to study the correlation between portal pressure as measured by hvpg and liver stiffness as measured by fibroscan among patients with portal hypertension due to various causes. methods: between august and september , consecutive patients with portal hypertension were included and were subjected to hvpg measurement and fibroscan (echosens, france). results: of the patients with portal hypertension, both hvpg and liver stiffness were measurable in [ ( %) males; mean age . ( . ) years]. the etiological distribution was hbv related cirrhosis in patients, hcv cirrhosis in , cryptogenic cirrhosis in , alcoholic cirrhosis in , hbv and alcoholic cirrhosis in and primary extra-hepatic portal vein obstruction in . the mean hvpg and liver stiffness of this group were . ( . ) mm hg and . ( . ) kpa respectively. there was a strong positive correlation between hvpg and liver stiffness [r = . ; p = . ]. conclusions: non-invasive measurement of liver stiffness correlates well with invasive measurement of portal pressure. liver stiffness measurement could be used as a prognostic indicator to predict the severity of portal hypertension. endpoints were rate of rebleeding and mortality till day after inclusion and to see for any adverse events. results: the bleeding was stopped in all patients ( %). rebleeding till day was observed in ( %) patients ( each in group a and b). total patients ( %) died ( each in both groups) due to rebleeding. transfusion needs were higher in group a ( . ± . versus . ± . , p<. ). serious adverse effects leading to treatment discontinuation were not seen in any patients in both groups. conclusion: prolonging terlipressin treatment did not confer any significant decrease of mortality or bleeding recurrence. however transfusion requirements were significantly decreased in patients receiving prolonged treatment. serious adverse effects leading to treatment discontinuation are rare. poster exhibition -miscellaneous poster session, hall b background: it is important to know the prevalence of atp b gene mutations of different geographical areas to justify the local screening strategies for wilson disease (wd). materials: eleven unrelated lithuanian families, including wd patients were tested. genomic dna was extracted from whole venous blood using a salt precipitation method. firstly, semi-nested pcr technique was used to detect the c. c>a (p.h q) mutation. patients not homozygous for c. c>a (p.h q) mutation were further analyzed. the exons of the wd gene were amplified in a thermal cycler. direct sequencing of the amplified pcr products was performed by cycle sequencing using fluorescent dye terminators in an automatic sequencer. results: total of wd patients (mean age . years; range - ; male/female, / ) presented with hepatic disorders and their first degree relatives were studied. some of wd patients in addition to hepatic symptoms have had extrahepatic disorders (haemolytic anaemia ; fanconi syndrome ; neurophsychiatric and behavioural disorder ). twelve of ( . %) wd patients have had c. c>a (p.h q) mutation, of them in both chromosomes, were presented as compound heterozygotes with additional c. - delggtttaaccat, c. delc or c. g>a (p.r q) mutation. for one patient with liver cirrhosis and psychiatric disorder no mutations were found. out of first degree wd relatives ( . %) were heterozygous for c. c>a (p.h q) mutation. conclusion: c. c>a (p.h q) missense mutation is characteristic for lithuanian wd patients. even . % of wd patients with hepatic presentation of the disease are homozygous or compound heterozygote for this mutation. background: diabetic dyslipidemia is a crucial problem of diabetic patients with inadequate control. we investigated the relationship between glutamic-pyruvic transaminase (gpt) and high-density lipoprotein cholesterol (hdl-c) in diabetic patients. methods: with informed consents, we recruited outpatients with diabetes at a hospital in rural area in taiwan in [ ] [ ] [ ] [ ] . anthropometric measures, blood tests and urine screening were examined in diabetic patients. results: overall, there were diabetic patients aged - years enrolled in this study and ( . %) of them had low hdl-c. diabetic patients with the highest quintile of gpt had higher average of body mass index (p< . ), diastolic blood pressure (p = . ), but lower average of hdl-c (p< . ) compared with diabetic patients with the lowest quintile of gpt. the prevalence of obesity ( . % vs. . %, p< . ) and low hdl-c ( . % vs. . %, p< . ) were higher in diabetic patients with highest quintile of gpt than in diabetic patients with lowest quintile of gpt. in the multivariate logistic regression, diabetic patients with highest quintile of gpt had higher odds ratio (or) of low hdl-c compared with diabetic patients with lowest quintile of gpt (or = . , % confidence interval [ci] = . - . ). the corresponding or of low hdl-c in patients aged years and older was . ( % ci = . - . ). conclusion: high gpt is one of factors associated with low hdl-c in diabetic patients. the effect of desferrioxamine as supplement to cefotaxime in the treatment of spontaneous bacterial peritonitis na. seda , m. el-hamamsy , r. el-wakil , m. al azizi ain shams specialized hospital, faculty of pharmacy,ain shams university, faculty of medicine,ain shams university, faculty of pharmacy ,ain shams university background: oxidative damage lead to cell damage, organ dysfunction and death in sepsis. desferrioxamine (dfx), an antioxidant iron chelators. the aim was to assess the efficacy of desferrioxamine supplemented to cefotaxime in the treatment of spontaneous bacterial peritonitis (sbp) in cirrhotic patients. methods: thirty patients divided into two groups: group i (n= ) with sbp and receiving cefotaxime ( g iv every hours) alone and group ii (n= ) with sbp receiving cefotaxime ( g iv every hours) with desferrioxamine ( mg im twice daily).all patient were monitored for seven days, their vital organs were screened and their ascitic fluid was assessed completely including microbiological investigations. results: the concomitant administration of desferrioxamine with cefotaxime significantly at (p< . )and(p< . ) improved the therapeutic outcome and the cure rate after days of treatment as compared to patients using cefotaxime only. conclusions: desferrioxamine can improve the therapeutic outcome by preventing iron-induced organ damage and inhibiting bacterial growth. oligella ureolytica is a gram-negative, nonfermenting rod that is infrequently recovered from clinical specimens and is most commonly isolated from the urine of patients with chronic indwelling urinary catheters or other urinary drainage systems. bacteremia due to this organism is an extraordinary finding. we describe here a case of oligella ureolytica being detected in the blood of a patient with decompensated cirrhosis. a -year-old male man was admitted to hospital with -month duration of debility, poor appetite and abdominal distension. decompensated cirrhosis was diagnosed based on clinical findings such as hepatic face, ascites, edema of lower limbs and icteric sclera. laboratory results showed positive serum anti-hcv and high serum hcv rna level. the patient received a therapeutic regimen of pegylated interferon alpha a plus ribavirin after being admitted to hospital. during hospital stay, a fever of -day duration with shivering occurred to the patient. three blood cultures were drawn, which all grew oligella ureolytica in pure culture. the organism was identified by the viteck compact (biomerieux, france). additional tests for identification resulted positive for nitrate reduction and urea hydrolysis, strongly positive for phenylalaninedeaminase activity and showed no growth at . c. tests for nitrite reduction and motility resulted negative. the organism was resistant to amikacin, cefoperazone, levofloxacin, piperacillin/tazobactam, trimethoprimsulfamethoxazole, aztreonam, cefotaxime, piperacillin and was susceptible to gentamicin, imipenem, meropenem, and netilmicin. a -day of combined therapeutic regimen with cefminox and isepamicin was administered to the patient. within days, the patient became afebrile. background: endoscopic ultrasound (eus) is often performed in patients with unexplained liver tests to assess the gallbladder, bile ducts and pancreas. an unremarkable eus exam and negative hepatology workup often leads to a liver biopsy. eus may provide histopathologic evaluation of the liver in these cases under direct, real-time visualization. aim: to assess the feasibility and efficacy of eus guided core biopsy of the liver in a porcine model. methods: female pigs were used and live procedures were performed under general anesthesia. a linear echoendoscope was used and the liver identified endosonographically. transgastric core biopsies of the liver were obtained with a gauge quick-core ultrasound biopsy needle (wilson-cook) and sent for histopathologic evaluation. live animals were euthanized at the end of the procedure and necropsy performed. results: core biopsies of the liver biopsy were obtained in animals ( cadaver and live anesthetized). a total of thirteen needle passes were made (mean . ; range - needle passes per animal) and a visible core of tissue obtained. the maximum length of liver tissue obtained was mm and considered adequate for assessment as more than one such specimen could be obtained. microscopic evaluation confirmed liver tissue. no complications were noted. necropsy did not show any evidence of bleeding, perforation or damage to surrounding structures. conclusion: eus-guided liver biopsy is feasible and can be performed at the time of routine echoendoscopic exam in select patients undergoing eus examination for abnormal liver tests. background: as the common indexes, alt, ast and plt play an important role in disease diagnosis, treatment and prognosis. many researchers suggested that there was inflammatory changes and fibrosis in chronic hepatitis b and c patients whose alt level was persistently normal. a large sample investigation showed that the serum level of alt in healthy persons is lower than the normal reference value. this study re-evaluated the normal serum level of alt, ast and plt. methods: people were enrolled in the study between sep. and oct. . the platelet count and serum alt and ast levels were measured. frequencies, one-sample kolmogorov-smirnov test and nonparametric tests were used to analyze the difference between age groups, male and female, glucose groups, cholesterol groups and triglyceride groups. result: in the five groups, there is significant difference in alt and ast levels between male and female. in group , the alt and ast levels showed a significant difference between different age groups, between different glucose groups and triglycide groups. in the three groups the plt level is significantly different between male and female, and the serum level in male is higher than female. there is significant difference between different age groups conclusion: the serum levels of alt, ast and plt are all significantly different between male and femal. there is significant difference between different genders and age groups for plt. the serum level of plt is higher than the reference value. background/aims: myeloproliferative disorders (mpd) (like polycythemia vera, essential thrombocythemia and primary myelofibrosis) are responsible for % cases of hepatic venous thrombosis (hvt) and % of portal venous thrombosis (pvt) in western series. latent form of mpd lacks the characteristic blood picture and may be classified as idiopathic thrombotic disorder. a point mutation at val phe of janus kinase tyrosine kinase gene (jak v f mutation) occurs in high proportion of the patients with mpd. this non-invasive test with high positive predictive value is now considered to be essential for diagnosis of various mpd. this test may be useful in diagnosing latent form of mpd in splanchnic venous thrombosis methods: patients with confirmed pyogenic liver abscesses admitted from to in our institution were included. there were men and women ranging in age from to years. the medical records were reviewed for clinical, laboratory and radiographic characteristics. results: among patients, ( . %) experienced at least one complication. there were pulmonary (pleural effusion, pneumonia, empyema) complications, septic shock, acute renal failure, abscess rupture, pseudomembranous colitis, and pericardial effusion. the predictive factors for its complications were: systemic inflammatory response syndrome (sirs, factors), thrombocytopenia ( , /ml), hypoalbuminemia ( . g/dl), elevated ast or alt (> iu/l), hyperbilirubinemia ( > . mg/dl), k. pneumonia, air within abscess cavity (p< . ). conclusions: the incidence of complications in the pyogenic liver abscess was . %. the various predictive factors of complication should be monitored carefully. further large scaled study should be warranted. background/aims: hepatic iron deposition is a common feature in chronic hepatitis c (ch-c), however, whether it could enhance the progression of fibrosis or not is controversial. the aim of this study was to evaluate the status and significance of hepatic iron deposition in the korean patients with chronic hepatitis c. methods: untreated, ch-c patients who underwent liver biopsy were included. the hepatic iron was assessed by scheuer's scoring system, and activity, fibrosis, and steatosis were scored by a pathologist in a blind manner to the clinical features. clinical and laboratory data including serum iron indices, virological, biochemical results were analyzed to search for significant factors associated with hepatic iron deposition. results: hepatic iron staining was positive in ( %). among patients with hepatic iron deposition, serum levels of ferritin (p= . ) and -fetoprotein (p= . ), and body mass index(bmi) (p= . ) were significantly elevated. there was no significant association between the degree of hepatic iron deposition and fibrosis stage (p= . ), although elevated levels of serum hyaluronic acid (p= . ), -glutamyl transpeptidase (p= . ), and prothrombin time (p= . ) were associated with advanced fibrosis. conclusions: hepatic iron deposition in asian-pacific ch-c patients seemed to be neither frequent nor related to hepatic fibrosis, but related to obesity. therefore, phlebotomy might not commonly applicable to this area. further studies on the pathogenic role of iron in ch-c in asian-pacific countries are warranted. a late stage of progressive hepatic fibrosis characterized by distortion of the hepatic architecture, necrosis of hepatocytes and the formation of regenerative nodules contributes to cirrhosis. limitations like organ donors shortage, high cost, absence of proliferation in cultured hepatocytes, inherent risks of infection, rejection in xenogenic cells and other socio-economical complications emerges advanced regenerative human hepatic stem cells(hhpscs) transplantation. hhpscs are located in the ductal plates in fetal and canals of hering in adult livers [schmelzer et al.( ) ]. hepatoblasts, in turn, give rise to the hepatocytic and biliary lineages, the hepatocytes and cholangiocytes [schmelzere etal( ) ].hhpscs express cd (epcam)marker. scjelzer etal demonstrated that during embryogenesis % of the epcam positive cells had hepatoblast phenotype. in animal study, on transplantation of freshly isolated hhpscs in scid mice results in mature liver tissue expressing human-specific proteins. recently, we(aleem etal )have shown clinical improvement in study in patients with crigler-najjar syndrome, biliary atresia using hhpscs infusion. in the present study we transplanted hepatic progenitors to five subjects of end stage liver cirrhosis with meld score > . hhpscs were sorted using macs with cd antibody microbeads and infused through hepatic artery via femoral artery catheterization, a safe procedure provided portal pressure to monitor cell infusion route in order to prevent vascular thrombosis. all the patients showed improvement clinical and functional biochemical parameters after first month of cell infusion. ascites was decreased and changed encephalopathy grade into normal level was observed. meld score system falling to normal level from > to < after infusion. the aga khan university patients. the apri of . in combination with a cut-off ha of ng/ml can best detect patients with moderate to severe fibrosis (stages - ). it has a ppv of . %. also, for patients without moderate to severe fibrosis, the test is hardly ever positive (specificity of . %). but the apri of . in combination with different ha as cut-off points is not possible to detect patients with no or mild fibrosis. objectives: terlipressin is used in esophageal variceal bleed (evb) along with endoscopic band ligation (ebl) for days (uc). due to its high cost, it was stopped < days (sc) who could not afford & were stable after achieving hemostasis with ebl. we retrospectively assessed the efficacy of sc vs uc of terlipressin for control of evb and length of stay. conclusion: the apri of . in combination with ha ng/ml as cut-off points to predict patients with moderate to severe fibrosis (stages - ) is an easy and accurate method. methods: patients with evb who had achieved hemostatsis with ebl from jan -dec were included. all were managed on standard protocol on hospital variceal bleeding pathway. the course of terlipressin as sc or uc was based on patient's inability to afford the cost of hospitalization and terlipressin. the efficacy of terlipressin in the control of evb was defined based on baveno iii criteria. results: total of patients were admitted during the study period. out of them, received uc & sc of terlipressin. the base line characteristics were comparable except younger age in sc. there were re-bleed ( %) in uc and ( %) in sc terlipressin group. the length of stay was shorter in sc group. ( . ± . vs . ± . days). conclusions: sc seems as effective as uc terlipressin in the control of evb after initial control of hemostatsis with ebl and may reduces the length of hospital stay. rcts are needed to assess this as all stable patients may not need to continue terlipressin for hours. background/aims: to analyze the relationship between conventional laboratory results and death risk in patients with esophageal varices bleeding due to cirrhosis (cevb), and establish a simple model for timely predicting death rsik of the patients. outcome of patients with gastro-oesophageal bleeding in a tertiary center j. wat, w.h. li, m.t. cheung methods: the medical documents of cevb patients were reviewed retrospectively and the data were collected. univariate and multivariate logistic regressions were performed, in which the discharged results (survival or death) as dependent variable and the results of liver function, kidney function, serum electrolytes and blood cell analysis as independent variables. the multivariate regression equation was as the model for the prediction of patient outcome and its predictive performance was evaluated. objectives: to determine the rebleeding rate, mortality and long term survival in cirrhotic patients presented with acute gastro-oesophageal variceal bleeding. method: this is a retrospective review of adult patients who were admitted to our hospital with the diagnosis of acute gastro-oesophageal variceal bleeding for the first time regardless of their underlying causes for cirrhosis. the study period was from january -october . data were collected from our hospital computer system and records. results: in univariate regression, the significant positive variables for death outcome were dbil, akp, k, wbc and plt, and the significant negative variables were tp, ap, a/g, na, cland ca + . the variables entered the multivariate regression are alt, tbil, dbil, gp, a/g, cr, na + , cl -, ca + , wbc, hb, plt. the sensitivity, specificity and accuracy of the regression model for predicting death of cevb patients were . %, . % and . %. results: a total of patients were included in this study, with male and female. their mean age was . . the initial failure rate in endoscopic haemostasis was . %. the -day and -week mortality rates were . % and . %, respectively. poor child's grading, multiple columns of oesophageal varices, high grade of varices, failed initial endoscopic haemostasis, presence of inoperable hcc, low platelet count on admission, and short duration from index bleed to rebleed were factors associating with increased risk of -week mortality (p < . ). mean duration from index bleed to first rebleed was . months. poor child's grading and presence of inoperable hcc were associated with both early or multiple rebleed (p < . ). overall, . % of our patients developed rebleed before their variceal eradication. -year survival in patients with child's a, b and c were %, %, and %, respectively (log rank test p . ). conclusions: the liver function, kidney function, serum electrolytes and blood cell analysis are generally independent factors for cevb patient death risk, especially dbil, a/g and ca + . the established model shows a excellent predictive performance. an imbalance in plasma amino acids of advaced cirrhotic patients impairs the maturation of dendritic cells via mtor/s k signaling pathway e. kakazu , y. ueno , y. kondo , k. fukushima , m. shina , j. inoue , k. tamai , m. ninomiya , t. shimosegawa division of gastroenterology, tohoku university hospital conclusion: although endoscopic haemostasis is an effective treatment modality; rebleeding is still commonly seen among patients with poor child's grading and inoperable hcc. this will result in significant bleeding-related death and poor overall survival. further advancement in treatment strategies for this group of patients are required to improve their outcome and prognosis. background: we have demonstrated that extracellular branched-chain amino acids (bcaas), especially valine, regulate the maturation and function of monocyte-derived dendritic cells (j immunol. : ) . however, it is not clear whether an imbalance in plasma amino acids of advaced cirrhotic patients influence the function of dendritic cells (dcs). methods: we used human pbmcs and cd c+dcs in this study. we made two mediums: a serum free culture medium consistent with the average concentration of the plasma amino acids from a healthy volunteer (n= ) was defined as the healthy control medium (hcm); whereas that from advanced cirrhotic patients (n= ) was defined as the advanced cirrhotic active hepatitis b replication is defined as hbeag + or hbv dna > fibrosis was scored according to the metavir system. alt levels were characterized as being normal, < x normal, and > x normal. conclusions: pe frequency of portal hypertensive gastropathy and its non-invasive predictors in patients with viral methods: medical record of all patients with cirrhosis due to hepatitis b and c who underwent for screening egd for varices in last years was reviewed. phg was defined endoscopically by using mccormack classification. noninvasive markers such as spleen/platelets ratio, meld score and child score of all the patients who underwent for egd were recorded. results: out of patients ( . %) were males. out of ( . %) patients who had phg, ( . %), ( %) and ( . %) had mild, intermediate and severe phg respectively. higher proportion of esophageal varices ( . %) was present among those who have phg (p< . ). ( . %) with phg has child score of . meld score > and were seen in . % and . % of patients with phg, respectively. platelet/spleen ratio was . ± in patients with phg as compared to methods: retrospective analysis of cirrhotics undergoing surveillance endoscopy was undertaken assessing for oesophageal varices. clinical, biochemical and radiological indices were analysed. results: cirrhotics underwent surveillance endoscopy during the study. childs pugh scoring (cps) to assess prognosis of liver disease showed cps a( %), cps b( %) and cps c( %). % were male albumin ( g/l vs g/l significant factors on multivariate analysis were albumin (p= . ) and platelet count (p= . ) conclusion: in our cohort there were significant biechemical and radiological differences in differentiating patients with large varices (grade - ) on surveillance endoscopy aims and objectives: to study the frequency of ev in patients with cirrhosis due to viral etiology and its correlation with different non-invasive markers. methods: medical record of all patients with cirrhosis due to hepatitis b and c who underwent screening egd for varices in last years was reviewed. ev were divided in two grades (small and large) as proposed in consensus development workshop. noninvasive markers such as spleen/platelets ratio, meld and child turcotte pugh (ctp) scores of all patients were recorded. results: out of patients, ( . %) were males on multivariate analysis ctp score of (or . , p< . ), meld score > (or . , p< . ) and platelet/spleen ratio (or . , p= . ) were found as significant predictors of large ev. conclusion: the frequency of ev is high in viral cirrhosis patients on screening egd. meld score> , ctp score and spleen/platelets ratio can be used as non-invasive predictors of large ev. pe treatment outcome and prognostic factors of spontaneous bacterial peritonitis and culture negative neutrocytic ascites in patients with hepatitis b virus-related thirty-seven ( . %) patients had sbp while ( . %) had cnna. except the higher proportion of renal failure at admission in patients with sbp than cnna ( . % vs. . %, p= . ), no significant difference in the clinical and laboratory data related to liver and renal function was observed. overall mortality during hospitalization was higher in patient with sbp than that of cnna evl was repeated every -weeks till varicial eradication.bb dose was titrated to achieve a resting heart-rate of bpm or a maximum dose mg/d or when side-effects began to appear.primary end-points were rebleed and death.secondary end-points were complications as a result of evlor beta-blocker,variceal recurrence afterevl,and decrease in variceal grade inbb limb. results: patients (median age [range - ] yrs, males %) were included (evl arm[n= ]and bb arm[n= ]. median grade of varices was iii(range ii to iv) nitric oxide synthase isoforms play distinct roles in the evolution of hyperdynamic state in endotoxemia induced portal hypertension m.r. rizvi , m. shahid institute of genomics and integrative biology, mall road, delhi , department of physiology a seconderc was performed after two or more years to assess the progression of the disease. results: ehpvo patients(median age [range - ]yr, males %) were studied.history of present or previous jaundice was present in %,ascites % and pain %. on erc, % had portal biliopathy.the type of bile duct involvement was categorized as: type b( %) and type ( %).the pattern of involvement included indentations( %) and dilatation and strictures( %). %of the patients had bile duct stone and % had history of cholangitis.the mdian bilirubin was . (range . - . ) mg/dl and median serum alkaline phosphatase (range - ) iu/l.all patients were treated endoscopically by endoscopic stone extraction, dilations with/without stenting. ( %) patients underwent second erc after a median interval of (range - )months.the type of involvement progressed, % patients developed type- involvement compared to % at the baseline (p=ns).indentations progressed to develop strictures, from % to %.the frequency of new bile duct stones per year was %(p= ns). conclusions: portal biliopathy is very common in ehpvo, often remaining asymptomatic.however,it is slowly progressive leading to development of biliary strictures objective: to investigate the mechanisms of angiotonin ii (angii)-induced ca ( +)-independent pathways mediated by rho kinase in hepatic stellate cells (hscs) various vasoactive drugs that reduce portal pressure are used in treatment of esophageal variceal bleeding alongwith endoscopic treatment. terlipressin use decreases both, recurrent bleeding and mortality. it is given usually for - days, nevertheless there is very little data comparing different time periods. our aim was to compare the efficacy and safety of -days versus days of terlipressin treatment in bleeding esophageal varices. methods: out of patients who presented with variceal bleeding, were randomized to receive terlipressin mg hrly, i.v. daily for first days and placebo for next days (group a) and to receive terlipressin mg hrly, i.v. daily for days (group b). both groups were both age and sex matched. (svt) {consisting of hvt and pvt}. there is no such data from india a comparative study of male vs background: mucosal lesions are frequently observed.gender differences are expected due to food habits, nature of job, mobility related to work, consumption of alcohol, tobacco etc. material and methods: procedure done in m & ( . %) f& duo ( . %) m & %)f.varices ( ) eso varices ( . %) m & ( . %) f & gastric varices (. %) m & (. %) f .growth ( )eso growth (. %) m & (. %) f & stomach growth ( . %)m & (. %) f & laryngeal (. %)m. eso monoliasis ( ) (. %) m & (. %) f.polyp ( ) eso polyp (. %) m & (. %) f & gastric polyp (. %)m & (. %) f & moniliasis and ulcers are more common in female lee department of internal medicine, gyeongsang national university school of medicine background/aims: although the pyogenic liver abscess is a common intraabdominal inflammatory disease, this complications are not rare. however, reports dealing with this complications are not good enough and results are often variable. the aim of this study was to identify the predictive factors of complication in the pyogenic liver abscess. pe effects of saikosaponinsd (ssd) on expression of c-myc and pcna in experimental hepatocarcinoma of all rats were killed in the th week, then general conditions of rats were recorded, the serum alt akp ggt afu was detected and pathological examination was made. the expression of pcna and c-myc were tested by immunohistochemistry. results: he staining showed that rats were induced to hepatocellular carcinoma,the results of liver function in the th week displayed that alt akp ggt and afu of all groups were increased than that of normal control group conclusion: ssd can inhibit development of hepatoma induced by den, possibly by down-regulating the expression of pcna and c-myc protein lethal endotoxic shock was induced by single endotoxin (e.coli) mg/kg injection into abdominal cavity. ppc in % gs was given via tail vein at ml/ g ( . mg/kg) h and h before endotoxin. rats' behavior and h survival were recorded, venous blood taken for ast and alt, liver preserved for he staining and liver/body weight ratio l/b and liver wet/dry weight ratio (w/d) calculated. intercellular adhesion molecule- (icam- ) expression in liver tissue was observed with -step immunohistochemistry assay. results: rats of ns and ppc group demonstrated similar normal activity, histology and other characters (p> . ), while lps group showed sag and less water-intak and severe inflammation in liver including inflammatory cell accumulation, parenchymal cells edema and tissue exudation. p+l group turned tired but could drink water the role of insulin resistance, adipokine and cytokine pro-inflammatory in non-alcoholic fatty liver disease n. ratnasari , , s. anam , p. bayupurnama , , s. maduseno , , s. nurdjanah , dr sardjito general hospital yogyakarta indonesia, background: non-alcoholic fatty liver disease (nafld) is a benign disease during - years period, with %- % survival. nafld can progress to fibrosis, cirrhotic and cancer of the liver. the etiopathogenesis of nafld is still unknown, however genetic and environment factors are predicted. objective: to know the role of insulin resistance, adipokine and cytokine pro-inflammatory on nafld. methods: the cross sectional study was performed on general check-up population at dr. sardjito general hospital yogyakarta, indonesia. the study was begun from january until november at internal medicine outpatient department. inclusion criteria: adult, alcohol consumtion g/day, metabolic syndrome patients, and healthy subjects. exclusion criteria: the diseases with increasing liver enzymes (hbv, hcv, ischemic hepatitis, congestive liver), a "bright liver" on ultrasound examination (malnutrition, rapid weight decreased, post gut surgery on obesity patients, and drug induced). based on liver ultrasound subjects were devided into steatosis group and non-steatosis group. data were analyzed by t-test and non-parametrical test. results: subjects that were enrolled the study steatosis ( . %) and non-steatosis ( . %) and the subjects who completed cytokine and adipokine examination were steatosis and non-steatosis. there were significantly different on homa -ir and adiponectin level in steatosis group (homa-ir . ± . vs. . ± . , p= . ; adiponectin . ± . vs. . ± . , p= . ). there were not significantly different on tnf-, il- , leptin and visfatin level (p> . ). conlusions: there were significantly different on homa-ir and adiponectin level in nafld patients compared non-nafld patients. background: to optimize management of nonalcoholic fatty liver disease (nafld), a simple screening tool is necessary. in this study, we aimed to devise a simple index that reflects the presence of nafld in the korean population. methods: a cross-sectional study was conducted on , health check-up subjects at a healthcare center ( , cases with nafld versus age-and sex-matched controls). study subjects were randomly assigned to a derivation cohort or a validation cohort. an index reflecting the presence of nafld was derived in the derivation cohort and validated in the validation cohort. results: multivariable analysis indicated that body-mass index (bmi), serum alanine aminotransferase (alt) to serum aspartate aminotransferase (ast) ratio, sex, and the presence of diabetes mellitus were independent predictors of nafld. using these variables, a formula was derived using a linear regression model: nafld index (nafldi) = ×alt/ast ratio +bmi (+ , if female; + , if diabetes mellitus).nafldi had an area under receiver-operating curve of . ( % confidence interval, . - . ). at a value < . , nafldi ruled out nafld with a sensitivity of . % and a negative likelihood ratio of . , and at a value > . , nafldi detected nafld with a specificity of . % and a positive likelihood ratio of . . in the validation cohort, the predictive power of nafldi was maintained at similar levels.aim: since nash could progress to liver cirrhosis and hepatocellular carcinoma, it is important to correctly diagnose between nash and simple steatosis (ss). the aim of this study was to determine the prevalence of nash among nafld patients and to clarify differences in clinical features between nash and ss. subjects and methods: thirty-one patients with nafld showing abnormalities in serum transaminase (ast and /or alt > iu/l) were enrolled (sex: male , female ; mean age: . yrs, mean body mass index: . ), after obtaining informed consent. differential diagnosis between nash and ss was performed histologically according to the matteoni classification and clinical features were compared. results: among the patients with nafld, % and % were diagnosed with ss and nash, respectively. no significant differences in the sex, mean age and bmi were seen between nash and ss groups. the levels of ast, alt, homeostasis model assessment-insulin resistance (homa-ir) and hyaluronic acid were significantly elevated in nash patients compared to ss patients. no significant differences in serum levels of adiponectin, as well as the rates of occurrence of diabetes, hypertension and hyperlipidemia were observed between the two groups. conclusion: the prevalence of nash in nafld patients was about %. nash patients showed higher levels of serum transaminase, homa-ir and hyaluronic acid, compared to ss patients. a large-scale biochemical study is required to accurately diagnose nash patients and confirm these results. conclusion: nafldi was a simple, efficient screening tool for nafld that could be utilized for selecting individuals for liver ultrasonography and for determining the need for lifestyle modifications.pe aim: this study was conducted to evaluate the hepatoprotective effects of the centella asiatica extract in -methyl- phenyl- , , , -tetrahydropyridine (mptp)-induced liver injury in rats. methods: sprague dawley rats were treated with alcohol extract of centella asiatica orally in two doses ( and mg/kg/day) for months along with intraperitoneal injection of mptp ( ml/kg). biochemical parameters such as serum total protein, albumin and marker enzymes were estimated. histopathological studies of liver were also carried out to confirm the biochemical changes.results & discussion: mptp -induced hepatotoxic effects were evident by a significant (p < . ) increase in the serum marker enzymes and a decrease in the total serum protein and albumin. administration of extract of centella asiatica effectively inhibited these changes in a dose-dependent manner; maximum effect was with mg/kg. histopathological examination of liver tissue corroborated well with the biochemical changes. hepatic steatosis, hydropic degeneration and necrosis were observed in mptp-treated group, while there was a significant reduction in these changes in the treatment group. conclusion: centella asiatica extract exhibited hepatoprotective action against mptp induced liver injury. further optimization of tuberculosis chemotherapy requires a comprehensive evaluation of the effects of antitubercular drugs on metabolic processes in organism.wistar albino male rats, body weight (b.w.) of - g, were divided into three groups: group i received pyrazinamide per os at a dose of mg/kg b.w./day, whereas group ii received a dose of mg/kg b.w./day, in both groups it was given for days; the control group was composed of intact animals. the contents of free amino acids were determined using an amino acid analyzer - (czech republic). the study of the effects of pyrazinamide administered in different doses on the liver contents of free amino acids showed the largest number of changes at a dose of mg/kg b.w./day. the content of free amino acids at the level of amino acids and total sum of amino acids significantly differed from controls. part of these changes could be regarded as compensatory answer of organism to this drug action. further pyrazinamide dose increasing caused exhaustion of liver adaptive possibilities. the study of the influence of pyrazinamide on liver contents of free amino acids allows to fully estimate the effects of this substance on metabolic processes in this organ. moreover, the effect of pyrazinamide on the majority of free amino acids in the liver is dose-dependent. background: taiwan is an endemic area of hbv and hcv infection, chemotherapy for lymphoma patients who has been hbv infection, may induce serious clinical sequela due to reactivation of hbv. this study want to clarify the difference of the chemotherapy induced hepatitis between hbv and hcv carrier in lymphoma patients. methods: from july, to july , non-hepatocellular carcinoma patients were enrolled, ( . %) cases were lymphoma, in these lymphoma patients, ( . %) cases have been hbv infected, and ( . %) cases have no hbv or hcv infected. ( . %) cases have been infected with hcv. all patients received chemotherapy with the regimen of chop or r-chop. liver function , viral markers, hbv dna, hcv rna were checked before and after chemotherapy. results: hepatitis happened in ( . %) lymphoma patients, ( . %) cases were in hbv infected patients, ( %) cases were in non-hbv infected patients, cases of hcv infected patients suffered from hepatitis. hbv infected hepatitis patients hbv dna elevated more than log as before chemotherapy. non of the hcv infected patient has elevated of hcv rna after chemotherapy. the mortality rate in hbv infected patient is %. no mortality in hcv infected patients after chemotherapy. conclusions: .high rate of hbv reactivation and mortality in chemotherapeutic lymphoma patients who has been hbv infected. screening of hbv viral markers among candidates for cancer chemotherapy is mandatory, especially in lymphoma patients. large number and prospect study for chemotherapy induced hepatitis in hcv carrier are needed. background: excessive drinking leads to social, psychological, physical and other problems. this study investigated the epidemiology of ald and analyses the associated risk factors. methods: from , residents , blood samples were collected. alcohol consumption and the impact of alcohol on liver function, blood lipids, blood pressure and bmi and mcv have been evaluated. results: the drinking rate and average daily alcohol intake was . % and . ± . g respectively. the total alcohol intake was . ± . kg and the average drinking age was . ± . years. the average -gt, ast, alt, mcv, chol, tg, ldl-c, hdl-c and bp increased gradually with increase in alcohol intake. the population ald prevalence was . %. the prevalence of ald among the drinking population and the alcoholic population was . % and . % respectively. conclusion: chol, -gt, ast, alt, and mcv were highly correlated with daily alcohol intake which closely related to the occurrence of ald. n. tanaka , w. okiyama , t. aoyama background: alcoholic liver disease (ald) is one of the leading causes of cirrhosis and yet efficient therapeutic strategies are lacking. polyenephosphatidylcholine (ppc), a major component of essential phospholipids, prevented alcoholic liver fibrosis in baboons. however, its precise mechanism remains uncertain. we examined the effects of ppc on ald using peroxisome proliferator-activated receptor (ppara)-null mice treated with an ethanol-containing diet, which showed pathological features similar to human ald. methods: male ppara-null mice were pair-fed a lieber-decarli control or % ethanol-containing diet with or without ppc at a clinically comparable dose ( mg/kg/day) for months. o. parkash , a. almas , s.h. ali shah , w. jafri , s. hamid , j. akhtar aga khan university hospital karachi .hdv-hbv co-infection presents mostly as moderate to advanced liver disease. background: liver injury due to dengue infection is not uncommon. acute liver injury is a severe complicating factor in dengue, predisposing to life-threatening hemorrhage, dic and encephalopathy. results: there were no significant differences of demographic features and laboratory parameters such as peak serum alt, total bilirubin and creatinine between groups. however, peak ast was higher in superinfected group than control group (median: , iu/l vs iu/l, p= . ,). additionally, the peak serum albumin levels, prothrombin time and platelet counts were lower in superinfected group than control group (median: . mg/dl vs . mg/dl, p= . , . % vs . %, p= . and x /mm vs x /mm , p< . , respectively). of superinfected group, patients were followed over months after resolution of aha. interestingly, serum hbv-dna levels decreased significantly over months following resolution of aha, then rebounded subsequently (median: - . , - . , - . , . and . log copies/ml at , , , and months, respectively).methods: the overlapping fragments of hev isolate swgx were amplified with reverse-transcription nested polymerase chain reaction (rt-npcr) and the ' and ' ends of viral genome were amplified with rapid amplification of cdna ends (race). the pcr products were cloned and sequenced. the phylogenetic analysis of swgx was performed.result: the genome of swgx consisted of , nucleotides, excluding the poly (a) tail of residues. the genome contained three open-reading frames (orfs), orf- encoding amino acids, orf- encoding amino acids and orf- encoding amino acids. the full-length genomic sequencing showed that swgx strain shared similarity with all known hev genotype , and isolates by . % to . %, and with an identity of . % to . % among genotype hev isolates, and a high nucleotide identity as % with chinese guangxi human strain lz- .conclusions: acute hav super-infection may suppress hbv-dna replication in chronic hbv carriers and chronic hepatitis b, although the suppressive effect did not seem to sustain longer than months. conclusion: the swine hev strain swgx was phylogenetically close to the human hev strain lz- , both from the same region in south china. therefore it was concluded that hev sub-genotype b might have existed in south china at least for years and now it was prevalent both in local human and swine, which also strongly supported the zoonosis hypothesis of hepatitis e. associated with splenic volume were damping index (r= . , p= . ) and blood flow of portal vein (r=- . , p= . ). conclusions: the splenomegaly in portal hypertension was more frequent in non-alcoholic groups, and associated with a damping index and a blood flow of portal vein. the measurement of blood flow of portal vein, damping index, and splenic volume by a doppler sonography can be helpful to predict the varices.z.q. zhang , j. cao , w. lu , l.g. shi objective: to appraise the clinical efficacy of simple non-invasive models of ast-to-alt ratio (aar), ast-to-platelet ratio index (apri), spleen-to-platelet ratio index (spri), age-platelet index (api), age-spleen-to-platelet ratio index (aspri) for predicting hepatitis b associated cirrhosis. methods: patients and patients were diagnosed pathologically as non-cirrhosis and cirrhosis, respectively. the simple non-invasive models were calculated as described originally. spss . was used for statistical analyses.background: to reveal the microrna (mirna) expression profile of the hepatic fibrosis inducing cells, rat hepatic stellate cells (hscs), during in vitro activation. results: the areas under roc curve of aar, apri, spri, api, aspri for predicting the cirrhosis were . , . , . , . , . , respectively which were larger than those under the diagnosis reference line (p . , . , . , . , . , respectively).methods: the hscs were isolated from male sd rats by in situ perfusion and density-gradient centrifugation. the quiescent and activated hscs, which were harvested at day and , respectively, were then subjected to immunocytochemical staining (desmin and -sma), oil red o staining and quantitative rt-pcr (desmin, -sma, albumin, cd , cd and cytokeratin- ). after extraction and labeling, the hy -labeled cellular rna samples and hy -labeled reference pool rna samples were mixed pair-wise and hybridized to the lna mercury microarray. differentially expressed mirnas were filtered and randomly verified by stem-loop rt followed by quantitative pcr.conclusion: all of the simple non-invasive models of aar, apri, spri, api, aspri can be used for predicting hepatitis b associated cirrhosis; and aar has the most practical efficacy for predicting hepatitis b associated cirrhosis. results: both the purity and the total activation of hscs were validated. global analysis of the mirna expression profile based on quiescent and activated hscs demonstrated differentially expressed mirnas. among these, mirnas were up-regulated more than -fold in activated hscs as compared to that in quiescent hscs, while mirnas were less than the threshold level ( . -fold) during the hsc activation. furthermore, the expression of mir- , b, , , and had been proved. background/aims: only limited patients with chronic hepatitis b virus (hbv) infection will develop liver cirrhosis, and no effective methods to precisely predict ones who will develop cirrhosis. we try to establish a model to predict the patients with the risk of cirrhosis development basing on a clinical epidemiological factor survey. z.q. zhang , w.y. bao , w. lu , l.g. shi methods: cirrhosis patients with hbv markers (case group) and asymptomatic hbsag carriers (control group) were recruited and inquired by researchers with a specific designed questionnaire including items. a multivariate logistic regression analysis were conducted to establish a predictive model, in which two third patients selected randomly as model sample and another / patients as validating sample, key factors screened out as variables. the predictive performance of the model was evaluated. objective: to explore the practical significance of the peripheral blood corpuscle counts for prediction of hepatitis b associated cirrhosis. methods: and male patients with chronic hepatitis b were pathologically diagnosed as non-cirrhosis and cirrhosis. peripheral blood corpuscle counts were measured by coulter ac•t diff hematology analyzer. results: red blood cell (rbc), platelet (plt), neutrophil (n) counts in cirrhosis were significantly lower than those in non-cirrhosis; and lymphocyte, mid-cell counts were similar to those in non-cirrhosis. the areas under the roc curves of rbc, plt, n counts for prediction of cirrhosis were . , . , . respectively; according the optimal cut-off determined by the roc curves, the sensitivity, specificity, positive predictive value, negative predictive value, accuracy of rbc, plt, n counts for prediction of cirrhosis were . - . method: pbmcs of active chb patients under pyg-interferon treatment were analyzed for their th , treg and pdc by flow cytometry. they were determined by cd /il- for th- , cd /cd /foxp for treg and cd /cd /cd -for pdc. pbmc were collected every weekly during the treatment until end of therapy (week ) and every weekly until the end of follow-up (week ). alt was quantified at every time of the pbmc collection. ifn-gamma release cells were analyzed by elispot to hbv-core and s ag.background: alpha fetoprotein (afp) is a well-recognized tumor marker for hcc; elevated level of afp is found in at least % of hcc. other liver diseases such as cirrhosis and chronic hepatitis are also related with an elevated level of afp. the regulation of afp gene expression has been relatively less studied although the gene has been suggested to play a role in hcc development. in this study, we tried to identify genetic variations in afp gene and analyze its effect on serum afp level and possible hcc progression.results: in parallel with decline in alt for the first weeks, we found decline in both pdc (r= . , p= . ) and elispot (r= . , p= . for hbv-core ag; r= . , p= . for hbv-s ag). although there is trend that th- decline with treg decline, but they are not statistically significant differences in the same period. there is no significant difference between the svp and non-svp patients.methods: direct dna sequencing was carried out to sequence afp promoter and bp upstream and downstream of afp coding regions in dna samples isolated from hcc subjects and controls respectively. for each samples serum afp levels were determined using commercially available elisa kits. conclusions: under pegyintron treatment, pdc, ifn-gamma change in the same trend of alt during weeks of treatment. it implied that pdc take regulatory effects on ifn-gamma releasing cells and be very tightly related to alt. there wasn't a significant difference in both treg and th- , which implies that treg and th might be of important cells in keeping the stability of the immune system.results: a total of snps were detected in the afp genomic region analyzed, including known snps and one novel snp. among the identified snps, the c>g nucleotide change in the position - bp upstream of afp transcriptional start site showed a significant association with hcc (p < . ) and a decrease in afp gene expression level. conclusion: our preliminary results indicated a possible association between serum afp expression and - g allele. the identified snp is located in afp promoter region with possible binding sites for known transcription factors, such as tfiid, coup, apf and nfiii. - °tail-suspension (ts) rats were used as the model to simulate the physiological effects of weightlessness. thirty-two wistar male rats were randomly divided into groups: control for d ( d con), d con, ts for d (ts d) and ts d. histopathological changes of testicle of the rat were observed by he stain. localization and expression of ar and hsp in testicle of rat were observed comparatively by means of immunohistochemistry, and the density of ar and hsp immunoreactivety in four groups were compared. results: signal molecules mrna level are shown in the table (** p< . , * p< . ). tnfa, il , il and il were higher in group , and than those in group . ifna was higher in group than that in other groups. there are no significant difference in infc, il , and il . there was a positive correlation between tnf and myd in group , tnf and nfkb in group and . results: obvious pathological lesions presented in testicle of ts d and ts d rat. germinal epithelium irregularity and malformed spermatozoa were found in seminiferous tubules. degeneration and necrosis of germinal epithelium appeared in testicle of ts d and ts d rat. ar immunoreactive cell density in the ts d and ts d groups were significantly decreased compared with the in-phase normal control groups ( p < . ). while hsp immunoreactive cell density in the ts d and ts d rats were significantly increased than those of control rats( p < . ), and in testicular interstice or extracellular there were very strong ehsp immunoreactive positive staining signals. the results indicate that ground simulated weightlessness induced by d- d tail-suspension in rats can lead to the serious injury , depressed expression of ar and enhanced expression of hsp in testicle. despite the absence of any serologic marker of hbv recurrence, however, it remains unknown whether there is occult reinfection in the liver graft. we aimed to detect and quantify the presence of intrahepatic hbv dna in the liver grafts of patients who remain seronegative for hbsag for more than year after liver transplantation. materials and methods: liver biopsy and blood samples were obtained from patients who had been receiving nucleoside analogue prophylaxis alone and remained persistently seronegative for hbsag for at least year (median . months, range . to . months) after liver transplantation for chronic hepatitis b. quantitative polymerase chain reaction was performed to detect and quantify total and covalently-closed circular (ccc) hbv dna in the liver (lowest detection limit, copies/ml), serum and pbmc. direct sequencing was used for hbv quasispecies screening. results: liver biopsy was performed and intrahepatic hbv dna as measured by quantitative real-time pcr was detectable in of recipients. donors anti-hbc status before liver transplant was significantly related to the presence of intrahepatic hbv dna in the recipient's study biopsy (p= . ). donor intrahepatic hbv cccdna levels correlated with recipient post-liver transplant intrahepatic hbv cccdna levels (p= . ). hepatitis b virus sequencing results and phylogenetic analysis revealed that hbv reinfection in two recipients were of donor origin, four recipients were of recipient origin and four recipients were of both donor and recipient origins. conclusions: our findings demonstrate the presence of occult hbv reinfection with persistence of hbv dna in liver allografts despite long term nucleoside analogue prophylaxis after liver transplantation, suggesting the need to continue indefinite antiviral therapy. the use of liver grafts from anti-hbc-positive donors might increase the risk of occult hbv reinfection. both donor and recipient hbv dna could contribute to occult hbv reinfection in liver transplant recipients. aim: to construct one noninvasive assessment model consisting of routine laboratory data to predict both significant fibrosis and cirrhosis among patients with chronic hepatitis b(chb). methods: we have retrospective analyzed consecutive patients with chronic hepatitis b who underwent percutaneous liver biopsy. we calculated sensitivity, specificity, positive predictive value(ppv), and negative predictive value(npv) of an apri . in combination with different hyaluronic acid(ha) cut-off points medium (acm). we stimulated pbmcs or dcs under hcm and acm, and evaluated the function. results: after adding the stimulants under hcm, the cd and cd expression of dcs from cirrhotic patients (lc) were lower than those from healthy contorols (hc). in both hc and lc, the cd and cd expression of dcs stimulated under acm was lower than that under hcm. the il- production in acm was lower than that in hcm. the expression of cd , which is related to amino acid transport, was not different between hcm and acm. however, dcs cultured in acm expressed lower levels of phospho-p s k than those cultured in hcm. finally, we ascertained that the ifn gamma production by pbmcs was significantly decreased under acm.conclusions: an imbalance in plasma amino acids of advanced cirrhotic patients suppresses the maturation of dcs via mtor/s k signaling pathway. key: cord- -edf xjwr authors: yan, junqiang; liu, anran; huang, jiarui; wu, jiannan; fan, hua title: research progress of drug treatment in novel coronavirus pneumonia date: - - journal: aaps pharmscitech doi: . /s - - -z sha: doc_id: cord_uid: edf xjwr as of march , , more than , novel coronavirus pneumonia cases have been confirmed globally. with the continuous spread of the new coronavirus pneumonia epidemic in even the world, prevention and treatment of the disease have become urgent tasks. the drugs currently being developed are not adequate to deal with this critical situation. in addition to being controlled through effective isolation, we need a rapid response from the healthcare and biotechnology industries to accelerate drug treatment research. by reviewing the currently available literature published at home and abroad, we summarize the current research progress of drug treatment during the epidemic period. at present, the drugs that can be used for treatment mainly include antiviral drugs, antimalarials, glucocorticoids, plasma therapy, biological agents, and traditional chinese medicine. the effectiveness and safety of drug therapy need to be confirmed by more clinical studies. on december , , an unknown outbreak spread from wuhan city, hubei province, china, and spread rapidly worldwide ( ) . the main clinical symptoms of this unexplained pneumonia are similar to severe acute respiratory syndrome (sars) and middle east respiratory syndrome (mers), which can quickly develop from mild fever, fatigue, and dyspnea to severe pneumonia. starting from the management experience of the sars epidemic, china has rapidly carried out comprehensive prevention and control. on january , , china officials officially announced that it would temporarily name the unexplained pathogen in wuhan as -novel coronavirus (ncov) ( , ) . the confirmed cases reported from outside china support human-to-human transmission ( , ) , which indicates that the outbreak is difficult to control ( , ) . after two meetings on january , (january and january , respectively), the world health organization regarded the outbreak of the -ncov as a public health emergency ( , ) . although the development of vaccines has long-term prevention and control effects, rapid identification of drug treatment during the epidemic is the key to responding to the outbreak ( ), and there is no clear treatment method at present ( ) . studies have found that -ncov is a single-stranded rna beta coronavirus similar to sars and mers ( ) , so current treatment is mainly based on the treatment experience of these two diseases ( ) and further development of new targeted drugs. currently, the drugs studied for the treatment of -ncov mainly include antivirals, antimalarials, glucocorticoids, plasma therapy, biological agents, and traditional chinese medicine, among which lopinavir/ritonavir, ribavirin, remdesivir, chloroquine phosphate, and interferon are the main drugs. here, we systematically review the current research that can be used in the treatment of -ncov, providing a theoretical basis for the next step of treatment and prevention. disulfiram, as a protease inhibitor, is mainly represented by lopinavir and ritonavir, which have been proved to have inhibitory effects on sars and mers ( ) . chinese studies have found that the combined use of lopinavir and ritonavir has a more obvious inhibitory effect on coronavirus during sars ( ) . it is considered that the half-life of lopinavir can be increased by inhibiting cytochrome p , thereby enhancing the antiviral effect. lopinavir/ritonavir is a known antiretroviral drug targeting the human immunodeficiency virus (hiv), which is being evaluated for anti- -ncov treatment ( ) . a randomized controlled clinical study of the effect of -ncov cases (chictr ) is also underway ( , ) . at present, the national health council has recommended the use of lopinavir and ritonavir as antivirus regimens for -ncov-related pneumonia. the latest recommended dose is listed in our table ( ) . favipiravir and ribavirin are representatives of nucleoside analogues and have broad-spectrum antiviral effects. theoretically, favipiravir and ribavirin have certain antivirus effects, while in vitro experiments have proved that ribavirin has little antivirus effects ( ) . however, their combined effect cannot be ignored. for example, favipiravir combined with oseltamivir is better than application of oseltamivir in severe influenza ( ) . ribavirin combined with lopinavir/ ritonavir seems to improve the clinical efficacy of sars ( ) . it has been used for experimental treatment of -ncov. remdesivir (gs- ), a new nucleoside analogue, has been shown to be a potential broad-spectrum anticoronavirus drug ( , ) . however, unlike the approved nucleotide analogues, experimental results confirmed that they had a stronger effect on both human infection coronavirus and various bat-derived coronavirus, significantly inhibiting virus replication in human primary cell culture ( ) . a recent cell experimental study indicated that remdesivir could inhibit -ncov in vitro infections ( ) . it is considered that remdesivir can effectively inhibit respiratory virus replication and improve virus-infected lung tissues ( ) . here is a report on the cure of an american patient infected with -ncov after remdesivir ( ) . theoretically, remdesivir is currently the most promising drug for the treatment of -ncov and has relatively complete data on human pharmacokinetics and safety ( ) . more relevant clinical randomized controlled studies have been registered (mild-to-moderate -ncov: nct ; severe -ncov: nct ) and are expected to be completed within the next months. neuraminidase inhibitors (nai), such as oral oseltamivir, inhaled zanamivir, and intravenous peramivir, are recommended as antiviral therapy for influenza ( ) . studies have shown that neuraminidase inhibitors have been used to control mers-cov infection ( ) . according to empirical treatment, clinical used oseltamivir is widely to treat confirmed or suspected cases of -ncov in hospitals in china. and the research mentioned above shows that oseltamivir combined with fapilavir is more effective in treating severe influenza ( ) . abidol, as a non-nucleoside drug, is a membrane fusion inhibitor with the activity of broad-spectrum antiviral drugs ( ) . it is more commonly called arbidol, as a membrane inhibitor, that blocks viral replication by inhibiting the fusion of influenza virus lipid membranes with host cells ( ) . research considerations are mainly to prevent hemagglutinin (ha), a protein on the surface of influenza virus, which mediates membrane fusion, thereby inhibiting virus attachment to host cells ( , ) . recent studies have shown that abidol can be used for the treatment of -ncov ( ) . currently, a randomized multicenter controlled clinical study of abidol for -ncov (chictr ) has been initiated in china. a multicenter clinical trial of chloroquine phosphate for treating the -ncov-associated pneumonia is underway in china, according to a press conference held by the state council of china on february , . soon, chloroquine or hydroxychloroquine was tested in hospitals of beijing, shanghai, wuhan, and other places for the treatment of -ncov-associated pneumonia ( ) . chloroquine, as a known antimalarial drug, can inhibit the production and release of inflammatory factors in viral diseases and has antiviral effects on many diseases including hiv- , hepatitis b, and hcov- e ( ) . recent studies have shown that chloroquine can inhibit -ncov by increasing the endosome ph required for viral cell fusion ( ) , and its antiviral and antiinflammatory activity considerations are also involved ( ) . a related open trial (chictr ) is ongoing. a recent article published did not recommend glucocorticoids for -ncov patients ( ) . and study also opposes the widespread use of corticosteroids according to the latest expert consensus ( ) . however, there is also research evidence that low-dose corticosteroids can be used appropriately in subgroups such as severe patients to improve the survival advantage of patients ( , ) . study suggested that low-to-moderate short-term corticosteroids can be used in severe patients with -ncov ( ) . therefore, the current glucocorticoid treatment of -ncov-related pneumonia is still controversial. at present, it is only recommended to try intravenous methylprednisolone for - days, and it is not suitable for long-term use ( , ) . previous research has shown that convalescent plasma can produce polyclonal antibodies to neutralize the virus ( ) , which can reduce the mortality of patients with viral infection ( ) . therefore, cured patients can donate plasma for treatment ( ) and research ( ) . and the chinese academy of sciences research found that the -ncov virus isolated from the bronchoalveolar lavage fluid of severe patients could be neutralized by the serum of several patients. however, due to the timing of the recovery period, plasma may have lower antibody titers ( ) and even other disease infections may occur. therefore, the collection of plasma is very important; it needs to be at the right time and to ensure its safety. due to the rapid outbreak and virus variability, plasma treatment has become relatively unsatisfactory ( ) . regarding monoclonal antibodies, some studies have suggested that monoclonal antibody cr for sars treatment may be used to treat -ncov ( ) . monoclonal antibodies based on passive immunotherapy overcome many shortcomings of serum and intravenous immunoglobulin preparations and have been the focus of antiviral therapy. previous studies have shown that monoclonal antibodies can remarkably improve the mers-cov infection ( ) . research by mark et al. shows that monoclonal antibodies regn-eb and mab can significantly reduce the mortality of patients with ebola ( ) . reviewing the recently research progress, it is suggested that monoclonal antibodies can be used for the treatment of -ncov ( ) . however, no relevant monoclonal antibodies have been successfully marketed yet ( ) . it is mainly based on the latest experiments that the cr can effectively bind to the -ncov receptor-binding domain ( ) that mainly targets the spike protein and inhibits the virus from attaching to the host cell, thereby preventing the virus from invading. through this passive immunotherapy, it makes the treatment more targeted, and it is conducive to the development of vaccines ( ) . studies have shown that the treatment of -ncov infection can improve survival by interferon ( ). interferon and ribavirin, these two antiviral drugs, are always used in combination for hepatitis c treatment. studies show that ribavirin can enhance the antiviral effect of interferon through the mtor ( ) and ekr / pathways ( ). and trials involving it, such as the approved interferon plus ribavirin trial (chictr ), have begun. using marmoset animal models, chinese scholars found that interferon-β combined with lopinavir/ritonavir had better efficacy to treat the mers-cov ( ) . new research shows that interferon-α nebulization, injection of interferon-α b ( ) , and α-interferon combined with lopinavir/ritonavir drugs ( ) may be applicable to the current treatment of -ncov infection. studies have shown that the entry receptor for -ncov-infected lung cells may be angiotensin-converting enzyme ii (ace ) ( ), so cells expressing ace can serve as target cells ( ) . moreover, studies have shown that the receptor mechanism about -ncov is mainly based on the coronavirus spike (s) glycoprotein ( , ) . current treatments can fuse the ace into the immunoglobulin fc domain to block virus entry and establish lasting immunity ( ) . this provides a new direction for the treatment of the -ncov. relevant research has used computer and biological processing to extract natural compounds with antiviral effect that have been verified by pubmed. these compounds were searched in the unique research database, found out compounds, and identified more than kinds of herbs. at last, kinds of herbal plants, such as bupleurum, coptischinensis, forsythia, and glycyrrhizae, were selected out, which are highly likely to directly inhibit the -ncov ( ) . this method of promoting drug research through science and technology promotes the choice of clinical treatment. an example of combining traditional chinese and western medicine shows that sfjdc can be used for the treatment of new coronary pneumonia ( ) . this drug is also recommended in the treatment on the disease ( th edition). of course, the treatment principle is constantly being updated. current studies have shown that the drug treatment of -ncov-related pneumonia mainly includes antivirals, antimalarials, and interferon. the main representative drugs are lopinavir/ritonavir, ribavirin, remdesivir, interferon, and so on (table i) . more choices are being put into the research process, such as barretinib ( ), imatinib ( ) , sunitinib, erlotinib ( ) , nitazoxanide ( ) , and other potential drugs, as well as fusion peptide (ek ) ( ), hr p ( ) , and other new peptides. and the development of vaccines is also a longterm goal. we need more clinical practice to test out more old drugs that can be used for treatment and, at the same time, search for new drugs with targeted and effective results. this work was supported by the natural science foundation of henan 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gómez-huelgas, ricardo title: differences between clinical protocols for the treatment of coronavirus disease (covid- ) in andalusia, spain date: - - journal: int j environ res public health doi: . /ijerph sha: doc_id: cord_uid: u alc rs our objective was to compare clinical protocols for the treatment of the novel coronavirus disease (covid- ) among different hospitals in andalusia, spain. we reviewed the current covid- protocols of the largest hospitals in andalusia. antiviral treatment, empirical antibacterial agents, adjunctive therapies, anticoagulant treatment, supportive care, hospital organization, and discharge recommendations were analyzed. all protocols included were the latest updates as of july . hydroxychloroquine in monotherapy was the most frequent antiviral drug recommended for mild respiratory illness with clinical risk factors ( . %). combined hydroxychloroquine with azithromycin or lopinavir/ritonavir was found in % of protocols. the recommended treatment for patients with mild and moderate pneumonias was different antiviral combinations including hydroxychloroquine plus azithromycin ( . %) or hydroxychloroquine plus lopinavir/ritonavir ( . %). different combinations of hydroxychloroquine and lopinavir/ritonavir ( . %) and triple therapy with hydroxychloroquine, azithromycin, and lopinavir/ritonavir ( %) were the most recommended treatments for patients with severe pneumonia. there were five corticosteroid regimens, which used dexamethasone, methylprednisolone, or prednisone, with different doses and treatment durations. anakinra was included in seven protocols with six different regimens. all protocols included prophylactic heparin and therapeutic doses for thromboembolism. higher prophylactic doses of heparin for high-risk patients and therapeutic doses for patients in critical condition were included in . % and . % of protocols, respectively. this study showed that covid- protocols varied widely in several aspects (antiviral treatment, corticosteroids, anakinra, and anticoagulation for high risk of thrombosis or critical situation). rigorous randomized clinical trials on the proposed treatments are needed to provide consistent evidence. the global pandemic of the novel coronavirus disease (covid- ) caused by a newly emergent severe acute respiratory syndrome coronavirus (sars-cov- ) was firstly recognized in wuhan (china) in december . it quickly became a global pandemic, spreading worldwide [ ] . spain is one of the most affected countries, with more than , confirmed cases and more than , deaths. andalusia-one of the autonomous communities of spain and the most populous of them, with a total population of over eight million-has officially registered around , cases ( . % of total confirmed cases nationwide) and deaths ( . % of total deaths nationwide) [ ] . currently, efficacy has not been fully established for any drug therapy for sars-cov- . several agents are being used in clinical trials and compassionate-use protocols based on in vitro activity against sars-cov- or related viruses, and on limited clinical experience [ ] . early detection and optimized supportive care to relieve symptoms and support organ function in more severe presentations are the mainstay of management. where possible, moderate to severely ill patients should be managed in a hospital setting [ ] . there are hundreds of clinical protocols around the world adapted locally to patient characteristics, prevention measures, diagnostic tests, availability of potential therapy options, and possibility of follow-up. the use of clinical protocols in health care aims to provide practitioners with locally agreed information about what is currently the recommended approach for a specific practice. such protocols should be systematically developed and based on an evaluation of the current best evidence. thus, they also have the potential advantage of reducing unnecessary variations in care and contributing to evidence-based health care [ ] . based on this premise, we conducted this study, whose main objective was to compare updated clinical protocols for treatment of covid- among the largest university hospitals in andalusia, spain. we hypothesized that clinical protocols could vary in several aspects among andalusian hospitals, regardless of whether they belong to the same local health system administration and have similar resources. in this study, we used the clinical information provided in the covid- protocols of the largest university hospitals in andalusia. in andalusia, hospitals are stratified into categories according to service area and number of medical and surgical specialties [ ] : ( ) regional university hospitals (referral hospital in the whole autonomous community with all specialties available); ( ) specialized university hospitals (referral hospital in a province and with wide number of specialties available); ( ) basic general hospitals (referral hospital in a region and with all basic specialties available); ( ) highly-specialized hospitals (referral hospital in a local area and with all basic specialties available). we included regional university hospitals and specialized university hospitals: hospital universitario reina sofía (córdoba), hospital universitario juan ramón jiménez (huelva), hospital universitario virgen del rocío (sevilla), hospital universitario virgen macarena (sevilla), hospital virgen de valme (sevilla), complejo hospitalario torrecárdenas (almería), hospital universitario de jerez de la frontera (jerez de la frontera), hospital universitario puerta del mar (cádiz), hospital de puerto real (puerto real), hospital universitario virgen de las nieves (granada), hospital universitario san cecilio (granada), complejo hospitalario de jaén (jaén), hospital universitario virgen de la victoria (málaga), hospital costa del sol (marbella), and hospital regional universitario de málaga (málaga). this study was approved by the institutional research ethics committee of málaga on may (ethical code: pi-prot- ) we excluded basic general hospitals and highly-specialized hospitals. normally, the treatment recommendations adopted in the reference hospital indicate how their area of influence proceeds. antiviral treatment, empirical antibacterial agents, adjunctive therapies, anticoagulant treatment, supportive care (oxygen, intravenous fluids, monitoring, high-flow nasal oxygen/noninvasive ventilation, and mechanical ventilation, among others), dosage, method of administration and duration of treatment, drug side effects and interactions, nonrecommended treatment or recommendation for other drugs, hospital circuits, ward organization and care planning, and discharge recommendations were collected from all clinical protocols for covid- . covid- protocols contained patient groups according to the patient's clinical condition: mild upper respiratory illness with and without clinical risk factors (aged ≥ years old and comorbidities), mild pneumonia (defined as curb- severity score [ ] ≤ or pneumonia severity index [ ] i or ii, basal oxygen saturation > %, respiration rate at rest < , unilateral opacity, d-dimer < ng/ml (normal range: - ng/ml), ferritin < mcg/l (normal range: - mcg/l), interleukin- < pg/ml (normal range: < . pg/ml)), moderate pneumonia (defined as curb- severity score ≥ or pneumonia severity index ≥iii, basal oxygen saturation > - %, respiration rate at rest - , bilateral opacities, d-dimer > ng/ml, ferritin > mcg/l, interleukin- < pg/ml), and severe pneumonia (defined as sepsis or shock with acute respiratory distress syndrome (ards), basal oxygen saturation < %, respiration rate at rest > , bilateral opacities, d-dimer > ng/ml, ferritin > mcg/l, interleukin- > pg/ml, elevated troponin i). prophylaxis in suspected cases was not taken into consideration. all protocols included were obtained from covid- teams of each hospital and were the latest updates as of july . protocols are only available for healthcare providers on previous request to covid- teams of each hospital. the update of protocols was routinely made by covid- teams when they considered necessary. all variables analyzed were categorical and are shown as the absolute value and percentage, respectively. statistical analyses were performed using spss statistics for windows, version . (ibm, armonk, ny, usa). symptomatic treatment, recommendations for infection prevention and control, and recommendations for early identification of covid- alarm symptoms were adopted for patients with mild upper respiratory illness without clinical risk factors and confirmed cases without symptoms. antiviral treatment was recommended for patients with mild upper respiratory illness with clinical risk factors and patients with mild, moderate, and severe pneumonia. patients could be treated with monotherapy using hydroxychloroquine or lopinavir/ritonavir; dual therapy with hydroxychloroquine plus azithromycin or lopinavir/ritonavir; or triple therapy with hydroxychloroquine, azithromycin, and lopinavir/ritonavir. hydroxychloroquine could be used in four different regimens, and lopinavir/ritonavir could be used in two different regimens, with varied dosages and duration of treatment-either a short ( -day) regimen or long ( -day) regimen. azithromycin was recommended at the same dosage and duration of treatment. protocols included the combination of all four hydroxychloroquine regimens with azithromycin. regimens and of hydroxychloroquine were combined in dual therapy with the two regimens of lopinavir/ritonavir, which in turn were combined with azithromycin in triple therapy. chloroquine mg twice per day was recommended as an alternative when hydroxychloroquine was not available. in patients with three antiviral agents, lopinavir/ritonavir could be replaced with once-daily remdesivir if the patient was enrolled in a clinical trial. the dosage and durations of antiviral treatments are shown in table . for treating mild respiratory illness in patients with clinical risk factors, up to six antiviral options were found. monotherapy with regimen of hydroxychloroquine was the most frequent antiviral treatment recommended ( / protocols, . %), followed by hydroxychloroquine regimen plus azithromycin ( / , %). dual antiviral treatment using hydroxychloroquine with azithromycin or lopinavir/ritonavir in combination was found in % of protocols. no treatment was recommended in two protocols. in regard to mild pneumonia, protocols recommended dual therapy: seven recommended hydroxychloroquine plus azithromycin, and seven recommended hydroxychloroquine plus lopinavir/ritonavir. only one protocol did not recommend any antiviral treatment. for moderate pneumonia, hydroxychloroquine regimen in combination with lopinavir/ritonavir regimen was the most recommended treatment ( / , . %). different combinations of hydroxychloroquine and lopinavir/ritonavir ( / , . %) and triple therapy with hydroxychloroquine regimen , and azithromycin and lopinavir/ritonavir regimen ( / , %) were the most recommended treatments for patients with severe pneumonia. most protocols showed a preference for dual or triple antiviral therapy for patients with pneumonia. further details about recommended antiviral treatment of covid- are summarized in table . all protocols recommended initiating empirical antibacterial treatment when secondary bacterial infection was suspected, according to local antibacterial therapy guidelines. empirical antibiotics were also indicated when pneumonia was diagnosed in seven protocols regardless of suspected bacterial infection. amoxicillin plus clavulanic acid or ceftriaxone were the main antibiotics recommended for use. all protocol considered the management of ards with signs of cytokine release syndrome, which included elevation of interleukin- , fibrinogen, d-dimer, and c-reactive protein levels [ ] . the therapies (corticosteroids, anticytokine or immunomodulatory agents, and immunoglobulin therapy) were recommended once these syndromes were observed. the choice of which therapy to use was made by physicians according to their own clinical judgment. corticosteroids were widely included in all protocols; indeed, only out of hospitals did not include any corticosteroid regimen. there was a total of five corticosteroid regimens, which used dexamethasone, methylprednisolone, or prednisone. dexamethasone was recommended in eight protocols with two different regimens: mg ( / , . %) or mg ( / , . %) daily. methylprednisolone was included in protocols with different regimens: - mg ( / , . %) or mg/kg ( / , . %) daily. only one protocol included prednisone with a single regimen of mg daily. the duration of treatment varied from to days, depending on the patient's clinical condition. tocilizumab was recommended in all protocols with the same dosage ( or mg) according to body weight. anakinra was included in seven protocols with six different regimens. immunoglobulins were included as possible therapy in three protocols. in six protocols, other optional therapies were included, such as sarilumab, baricitinib, colchicine, ciclosporin a, sirolimus, tacrolimus, and vitamin d, according to clinical trials. dosage and durations of corticosteroids, anticytokine or immunomodulatory agents, and immunoglobulin therapy are shown in table . all protocols included anticoagulant treatment (low-molecular-weight heparin as the first option and unfractionated heparin as an alternative) and recommended prophylactic heparin during hospitalization. in of the covid- protocols ( . %), the dose of prophylactic low-molecular-weight heparin was increased if there was a high risk of thrombosis (severe covid- with evidence of cytokine release syndrome, previous venous thromboembolism or acute ischemic artery disease, or d-dimer > ng/ml). in five protocols ( . %), heparin was increased to therapeutic doses if the condition was critical or if there was a progressive increase in d-dimer levels. all protocols included therapeutic heparin if there was evidence of venous thromboembolism. at discharge, prophylactic heparin was recommended if d-dimer > - ng/dl for days or during the time of the expected severe immobilization in seven protocols ( . %). adjustments of heparin doses were indicated in the respective protocols. supportive care, hospital circuits, ward organization, and care planning were included in all protocols. drug side effects (including follow-up electrocardiogram for qt prolongation), interactions, nonrecommended treatment, or recommendation for other drugs were included in protocols ( , %), and discharge recommendations in ( %). this study showed that the covid- protocols of the largest hospitals in andalusia (spain) varied widely in several aspects, including antiviral treatment: they used different dosages, durations, and combinations of treatment for the same clinical condition. corticosteroid and anakinra regimens varied among hospitals, whereas tocilizumab was uniform across all protocols. although anticoagulant treatment was recommended in all protocols, including prophylactic heparin during hospitalization for all patients and therapeutic heparin for patients with evidence of venous thromboembolism, only a few protocols included higher prophylactic doses for patients at high risk of thrombosis and therapeutic doses for patients in critical condition or who experience a progressive increase in d-dimer levels. on the other hand, all treatment protocols included the same patient groups, defined according to the clinical situation, symptomatic treatment and recommendations for infection prevention and control, supportive care and hospital organization, equivalent empirical antibacterial agents, drug warnings and interactions, and discharge recommendations. the clinical presentation of the novel covid- may vary from mild cases with fever, fatigue, and cough to moderate-severe cases involving pneumonia and multiorgan failure [ ] , and several factors may predispose covid- patients to adverse outcomes. the older age, critical disease, and high levels of inflammatory markers have been associated with increased risk of death [ ] . patients with moderate to severe forms of covid- normally require hospitalizations and pharmacological treatments. however, currently, there is no solid evidence that any potential drug improves outcomes in patients with suspected or confirmed covid- [ , ] . only clinical experience and treatment guidance based on repurposed and experimental treatments are available. several antiviral agents have been proposed for use in combatting covid- based on apparent in vitro activity [ ] . one of the most widely used agents has been hydroxychloroquine and chloroquine. although studies from china [ ] and france [ ] have reported improved radiologic findings, improved viral clearance, and reduced disease progression with the use of chloroquine and hydroxychloroquine compared to standard supportive care, their efficacy remains inconclusive, and further studies are warranted. in addition, it seems that hydroxychloroquine may act synergistically in combination with azithromycin [ , ] . recently, in a large observational study from italy, hydroxychloroquine was associated with a % lower risk of death in covid- hospitalized patients [ ] . despite these results, these studies had severe methodological limitations, such as lack of randomization, lack of covariate-adjusted analysis, and potential selection bias. recovery trial-the largest randomized controlled study on hydroxychloroquine-has suggested that hydroxychloroquine might not reduce deaths and might increase length of hospital stay [ ] . chloroquine dosage has been mg orally once or twice daily. however, hydroxychloroquine dosage recommendations have varied from a total daily dose of mg (with a loading dose of mg twice daily for day) to mg orally, based on safety and clinical experience for other diseases [ ] . with this limited evidence, international guidelines with consensus statements on the treatment of covid- have not included any recommendation about using hydroxychloroquine/chloroquine as a potential treatment [ , [ ] [ ] [ ] , but rather have only suggested its use in the context of a clinical trial [ , ] . in our study, monotherapy with mg hydroxychloroquine twice daily the first day followed by mg twice daily from day to day , alone and in combination with azithromycin, were the preferred recommended regimens among protocols in andalusia for treating mild respiratory illness with clinical risk factors. for mild pneumonia, dual therapies consisting of hydroxychloroquine-azithromycin or hydroxychloroquine-lopinavir/ritonavir were the most frequent treatments recommended, with regimens that included different dosages and durations of treatment. for moderate pneumonia, a shorter regimen of hydroxychloroquine in combination with a longer regimen of lopinavir/ritonavir was the most recommended treatment among all protocols. for the most severe form of pneumonia, the triple therapy with a longer regimen of hydroxychloroquine and lopinavir/ritonavir in combination with azithromycin was the most commonly indicated treatment. thus, more complex and longer antiviral therapies were recommended according to the severity of covid- in our protocols. lopinavir/ritonavir has had the same limitations of use as hydroxychloroquine/chloroquine, with no clear benefits beyond standard care [ , ] . considering the uncertainty and the likely increase in gastrointestinal side effects, principal guidelines around the world have not contemplated its use in patients with covid- [ , [ ] [ ] [ ] or have only considered it in the context of a clinical trial [ , ] . remdesivir was only considered when patients were enrolled in a clinical trial. randomized controlled trials have reported that remdesivir reduces the duration of mechanical ventilation and time to symptom resolution, but its effect on mortality and other adverse outcomes remains uncertain [ ] . other antivirals were not routinely included in our protocols. antiviral agents such as oseltamivir, umifenovir, favipiravir, or ribavirin as well as miscellaneous agents such as interferon-α or interferon-β are being studied for use as possible treatments for covid- [ ] . currently, principal guidelines have either not reported any recommendation for their use [ , [ ] [ ] [ ] [ ] or have suggested not using them in patients with covid- [ ] . in regard to management of ards with evidence of cytokine release syndrome, several adjunctive therapies have been proposed. the rationale for the use of corticosteroids is to reduce host inflammatory responses in the lungs. the potential harm, such as delayed viral clearance, increased risk of secondary infection, and hyperglycemia episodes, have led to caution in their routine use in covid- patients unless the patient had other conditions for which these are indicated [ , , [ ] [ ] [ ] [ ] . however, in observational and randomized studies focused on hospitalized patients with covid- pneumonia, the administration of corticosteroids reduced the risk of mortality [ ] [ ] [ ] . based on this fact, a recently published guideline suggested using mg methylprednisolone intravenously for days in patients with severe covid- and ards [ ] . in our study, corticosteroids were included in . % of the protocols. methylprednisolone was the most frequently included corticosteroid in the protocols ( / protocols) with high-dose regimens (≥ mg/kg/day) and a variable duration of treatment (between and days). high-dose dexamethasone ( or mg) was included in . % of the protocols and prednisone in just one protocol ( mg per day for days). monoclonal antibodies targeting key inflammatory citokines or other aspects of the innate immune response are another potential treatment for covid- [ ] . tocilizumab, an anti-interleukin receptor antibody, has been used in small studies with early reports of success. a dose of mg was associated with clinical improvements and successful discharge, with most patients only receiving a single dose [ , ] . several randomized clinical trials on tocilizumab, either alone or in combination, in patients with covid- with severe pneumonia are underway, and its use was included in the chinese national treatment guidelines [ , ] . likewise, tocilizumab was recommended in all protocols in andalusian hospitals; the protocols indicate a single dose of mg or mg, according to body weight, and a second dose - h later, if required. although tocilizumab is a promising therapy, the data currently available are still too limited to draw any conclusion about its viability. anakinra, an interleukin receptor antagonist, has also been proposed in order to reduce hyperinflammation and respiratory distress in patients with sars-cov- infection, but here, too, limited evidence has been published [ ] . in this study, less than half of the protocols included anakinra in their recommendations, and six different regimens were described with significant differences in dosage (ranging from to mg per day) and duration of treatment (between and days). other monoclonal antibodies, immunomodulatory agents, and immunoglobulin therapy are in clinical trials for the treatment of covid- -associated cytokine release syndrome [ ] . as recent studies have found, severe covid- is commonly complicated with coagulopathy, including disseminated intravascular coagulation and venous thromboembolism [ , ] . for this reason, the administration of heparin has been recommended for covid- patients according to expert consensus [ , ] , although its efficacy remains to be validated. in a study of patients with severe covid- and sepsis-induced coagulopathy criteria or with markedly elevated d-dimer levels (higher than sixfold of upper limit of normal), anticoagulant therapy, mainly with low-molecular-weight heparin, was associated with better prognosis [ ] . beyond severe coagulopathy, special attention to venous thromboembolism prophylaxis is necessary in the management of covid- [ ] . low-molecular-weight heparin is preferred over unfractionated heparin in order to reduce patient contact (depending on the patient's bleeding risk and creatinine clearance) [ ] . we found that all protocols analyzed included anticoagulant treatment, with low-molecular-weight heparin as the first option. it was recommended that all hospitalized covid- patients receive prophylactic heparin. this recommendation was extended to after discharge if necessitated by the patient's clinical condition in . % of protocols. an increase in prophylactic heparin doses was recommended in . % of the protocols for patients at high risk of thrombosis. in five protocols ( . %), heparin was increased to therapeutic doses if the condition was critical or if there was a progressive increase in d-dimer levels. all protocol included therapeutic heparin if there was evidence of venous thromboembolism. our findings show significant differences among local protocols throughout andalusia (spain) regarding the management of covid- patients. there are some possible explanations for these disparities, including a lack of strong evidence about medical therapies that have been definitively reported to be effective at this time, the local availability of therapies, and administrative decisions about organization and care planning. although consensus statements in some international guidelines recommend against routine use of most antiviral agents, the eagerness to help our patients leads healthcare providers to explore different therapeutic strategies, balancing benefits and detriments. the same issue occurs with adjunctive therapies that are only suggested for treating ards with evidence of cytokine release syndrome as well as with anticoagulation in patients at high risk of thrombosis. there is greater consensus on the routine use of thromboembolism prophylaxis or anticoagulation for established venous thromboembolism. all protocols analyzed, in accordance with other guidelines, emphasize the prompt implementation of recommended infection prevention and supportive care for complications. these results are important because they show significant differences among the recommended treatments for covid- , according to the treatment protocols of large university hospitals in a region of spain. they reveal a need for specifically designed randomized clinical trials to determine the most appropriate evidence-based treatment regimen. covid- is having a strong impact in several countries, including spain, in several aspects, especially health, economic, and social. there is a quickly growing body of evidence on this topic trying to find the best practice for the treatment of symptomatic patients with covid- [ ] . this study has several limitations. first, we only analyzed the data provided in the hospitals' treatment protocols, and no information on treated actually provided to patients was obtained. furthermore, we did not know the degree of protocol implementation in the hospital or its coverage area. second, only the protocols of the largest hospitals of andalusia were analyzed in this study, even though there are many smaller hospitals and healthcare centers. normally, the treatment recommendations adopted in reference hospitals indicate how their area of influence proceeds, but this cannot be definitively assured. third, our study focused only on adult patients, and the recommendations were not applicable to pediatric populations. finally, the recommendations provided in the protocols are based on local expert opinions, clinical experience in managing covid- patients, and current international evidence regarding major proposed treatments, whether repurposed or experimental, for covid- . therefore, no strong therapeutic recommendations could be drawn from the protocols analyzed in this study. in conclusion, this study showed that the covid- protocols of the largest hospitals in andalusia, spain, varied widely in several aspects, including antiviral treatment; corticosteroids; anakinra; prophylactic heparin for patients at high risk of thrombosis; therapeutic doses of heparin for patients in critical condition or with a progressive increase in d-dimer levels; and different dosage, duration, and combinations of treatment for patients in the same clinical condition. the use of tocilizumab for selected patients, prophylactic heparin for all patients, therapeutic heparin for evidence of venous thromboembolism, general symptomatic and supportive care, and hospital organization were recommended in all protocols. rigorous randomized clinical trials on the proposed interventions are needed in order to provide solid evidence. funding: this work did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. china novel coronavirus investigating and research team. a novel coronavirus from patients with pneumonia in china pharmacologic treatments for coronavirus disease (covid- ): a review clinical management of severe acute respiratory infection when novel coronavirus (ncov) infection is suspected: interim guidance clinical guidelines and care protocols consejería de salud y familias 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hospitalized non-critically ill patients with sars-cov- infection remdesivir in adults with severe covid- : a randomised, double-blind, placebo-controlled, multicentre trial risk factors associated with acute respiratory distress syndrome and death in patients with coronavirus disease dexamethasone in hospitalized patients with covid- : preliminary report glucocovid: a controlled trial of methylprednisolone in adults hospitalized with covid- pneumonia hlh across speciality collaboration, uk. covid- : consider cytokine storm syndromes and immunosuppression effective treatment of severe covid- patients with tocilizumab current pharmacological treatments for covid- : what's next? national health commission and state administration of traditional chinese medicine. diagnosis and treatment protocol for novel coronavirus pneumonia continuous intravenous anakinra infusion to calm the cytokine storm in macrophage activation syndrome abnormal coagulation parameters are associated with poor prognosis in patients with novel coronavirus pneumonia anticoagulant treatment is associated with decreased mortality in severe coronavirus disease patients with coagulopathy attention should be paid to venous thromboembolism prophylaxis in the management of covid- covid- and vte/anticoagulation: frequently asked questions coronavirus diseases (covid- ) current status and future perspectives: a narrative review we thank all hospital covid- teams for the protocol developments and updates, sociedad andaluza de medicina interna for the coordination, and claire conrad for her help with the final english-language version. the authors declare no conflict of interest. key: cord- -t kjpk authors: szperka, christina l.; ailani, jessica; barmherzig, rebecca; klein, brad c.; minen, mia t.; halker singh, rashmi b.; shapiro, robert e. title: migraine care in the era of covid‐ : clinical pearls and plea to insurers date: - - journal: headache doi: . /head. sha: doc_id: cord_uid: t kjpk objective: to outline strategies for the treatment of migraine which do not require in‐person visits to clinic or the emergency department, and to describe ways that health insurance companies can remove barriers to quality care for migraine. background: covid‐ is a global pandemic causing widespread infections and death. to control the spread of infection we are called to observe “social distancing” and we have been asked to postpone any procedures which are not essential. since procedural therapies are a mainstay of headache care, the inability to do procedures could negatively affect our patients with migraine. in this manuscript we review alternative therapies, with particular attention to those which may be contra‐indicated in the setting of covid‐ infection. design/results: the manuscript reviews the use of telemedicine visits and acute, bridge, and preventive therapies for migraine. we focus on evidence‐based treatment where possible, but also describe “real world” strategies which may be tried. in each section we call out areas where changes to rules from commercial health insurance companies would facilitate better migraine care. conclusions: our common goal as health care providers is to maximize the health and safety of our patients. successful management of migraine with avoidance of in‐person clinic and emergency department visits further benefits the current urgent societal goal of maintaining social distance to contain the covid‐ pandemic. covid- was declared a global pandemic on march , by the world health organization. at the time we write this, there have been more than , confirmed cases and more than , deaths, with both of those figures predicted to increase exponentially in the coming weeks. in these unprecedented and uncertain times, headache medicine clinicians are working to keep individuals with migraine out of the emergency department (ed) and hospital, while also foregoing or at least minimizing face-to-face visits and procedural treatments. this is of critical importance not only in protecting the safety of our patients and limiting their exposure to covid- , but also as part of the greater efforts to avoid infection of healthcare workers, and to minimize additional demands on an already oversaturated hospital infrastructure. this manuscript is focused on audiences. first, we seek to outline strategies which may be helpful to primary care clinicians, neurologists, and headache specialists who are trying to provide the best possible care for patients with migraine despite overwhelming constraints. we will review the use of telehealth for patient communication, and review acute and preventive treatment strategies, with attention to concerns specific to covid- . second, we call upon health insurance providers, both government-funded and commercial, to remove barriers to quality migraine care. migraine is highly prevalent, and is the second leading cause of years lost to disability worldwide. in the united states chronic migraine disproportionately affects those of low socioeconomic status, who are also bearing the financial brunt of the covid-related economic crisis. with this in mind, we applaud the efforts of the federal and state governments and many commercial insurance providers who have quickly altered rules and regulations to facilitate the use of telehealth. in addition, we call upon insurance providers to eliminate prior authorization and step therapy requirements for migraine therapies, so that patients may have access to appropriate treatments in a time-sensitive manner and without undue administrative encumbrances. further, given that nearly / of households in the united states reported a layoff or reduction in work hours related to coronavirus by march , , it is imperative that insurance providers minimize or eliminate copays for migraine medications. while it may seem unthinkable to ask insurers to pay additional money for these therapies as other health care costs increase, multiple pharmacoeconomic studies have demonstrated that coverage of expensive migraine medications is actually cost-saving, as it decreases disability and reliance on hospital care. [ ] [ ] [ ] telehealth becomes mainstream.-telemedicine, which is real time interactive audio and video remote communication between a patient and a provider, has been practiced for over a decade in the united states. single clinic studies of telemedicine visits for headache care have demonstrated that patients perceive telemedicine as cost-effective and convenient. compared to traditional in-person headache visits, telemedicine achieves similar satisfaction rates and outcomes, and recent investigations demonstrated non-inferiority in multiple neurological diseases. however, many factors have precluded its widespread use, including large scale verification of clinical efficacy and safety in comparison to live visits, technological capabilities, patient confidentiality/privacy, licensing restrictions and malpractice, reimbursement, and frank inertia. federal and state governments have not championed this modality, despite ongoing need to care for patients otherwise unable to reach providers' offices. in the era of covid- , telehealth has become an essential modality for most headache specialists, given the need for providers to take significant precautions for both their patients and themselves, limiting touch or close contact. clinicians have had to rapidly learn local and federal laws, regulations, coding, and reimbursement options that may also change by the day. qualified providers may now bill fee for service medicare patients using traditional evaluation and management codes for telemedicine visits, regardless if they are in a health professional shortage area. however, medicaid and medicare advantage patients are excluded from recent emergency declarations. parity laws also vary per state, which impacts commercial insurance reimbursements. furthermore, while federal restraints have been waived to allow qualified providers to practice in any state, state laws may nonetheless continue to prohibit aspects of interstate practice, such as restrictions on new patient consultations or prescribing controlled substances. in some circumstances when telemedicine visits are not permitted or feasible, telephone visits can be performed and billed. as these rules are changing rapidly, the american academy of neurology has launched a website which assists with practical details for conducting telehealth visits, coding, and state-by-state coverage (https://www.aan.com/teleh ealth). despite the challenges, telemedicine is long overdue as an effective means to help patients receive care. patients who live remotely, perhaps hundreds of miles from the nearest headache specialist can now have a clinical encounter via a smart phone. patients no longer have to miss work, drive long distances, spend money on gas, tolls, and parking lots, and wait prolonged periods in a doctor's office to be seen, where they might also be exposed to communicable diseases. we hope that the widespread use of telehealth will be supported even after the covid- pandemic has resolved. acute therapies.-this is a particularly vulnerable time for individuals with migraine and other disabling headache disorders, with many physical and mental stressors, increased anxiety, and changes in daily routine which may serve as triggering factors for worsening headache. as headache has been reported as an early symptom of covid- , patients with worsening or new onset severe headache should be reviewed for exposure risk and any other symptoms which may be consistent with covid- infection. we note that non-steroidal anti-inflammatory drugs (nsaids), triptans, and neuroleptics may be used in combination therapy when needed. medications within the same drug category should not be combined. triptans, dihydroergotamine (dhe) and lasmiditan should not be co-administered within hours. headache society guideline for acute treatment in described strong evidence of benefit for several nsaids, triptans, and anti-emetics in the acute treatment of migraine headaches. lasmiditan has high affinity and selectivity for -ht f receptors and lacks the vasoconstrictor activity inherent with triptans, thereby making lasmiditan a different class of treatment, designated as a "ditan." , lasmitidan can cause significant sedation and dizziness, so patients must wait at least hours between dosing and driving. in addition, lasmitidan should be used with caution in patients who have a history of drug abuse, as there is concern that it may have the potential to be abused. • neuromodulation devices have been studied as safe and well-tolerated strategies for the acute treatment of migraine. these devices provide electrical stimulation to extracranial sensory afferent fibers above their depolarization thresholds but below the perceived pain threshold, which activates the central descending inhibitory pathways to inhibit pain. these devices typically require patient payment and need to be obtained from the manufacturer directly. • remote electrical neuromodulation (ren) device. • external trigeminal neurostimulation (etns) device. • single-pulse transcranial magnetic stimulation (stms) device. • external vagal nerve stimulation (vns) device. . "bridge" strategies to help break a severe or continuous pain cycle: in contrast to the relative depth and breadth of evidence for first line acute migraine treatment, very few therapies have been studied as "bridge" strategies for severe headaches that are unusually prolonged. however, in practice it is common for headache clinicians to recommend strategies for patients to treat refractory symptoms before seeking care in the ed or infusion center. because there is such a paucity of evidence these strategies are rarely described in the literature. however, given the immediate need to support social distancing and keep patients out of the hospital, we feel there is benefit in trying these agents if deemed clinically appropriate, even if the evidence is not fully established. non-steroidal anti-inflammatory drugs (nsaids) are frequently used as "bridge" strategies by headache providers. nsaids inhibit the neuroinflammatory cascade and prostaglandin synthesis, which are implicated in the pathogenesis of a migraine attack. cox /cox inhibition may also inhibit prostaglandin release in nociceptive neurons in the trigeminal nucleus caudalis (tnc) which is involved in central sensitization in migraine. contraindications to nsaid use include a history of gi bleeding, other bleeding risks, and renal impairment. in addition, diclofenac should be avoided in patients with heart failure or previous myocardial infarction. the world health organization initially expressed that nsaids may exacerbate covid- symptoms, but then retracted their recommendation to avoid nsaids due to lack of evidence for this claim. the fda issued an advisory on march , , that it "is not aware of scientific evidence connecting the use of nsaids, like ibuprofen, with worsening covid- symptoms. the agency is investigating this issue further …." recommendations may change further as our understanding of covid- evolves. clinicians should consider these differing viewpoints, the most current guidelines and recommendations, and the needs of their individual patient when deciding to use nsaids. neuroleptics.-dopamine and serotonin ( -ht ) are thought to be implicated in the pathogenesis of migraine. neuroleptics act as dopamine antagonists and also have substantial anti-cholinergic, anti-serotonergic, anti-histaminergic, and anti-adrenergic effects. , some neuroleptics also have a role as anti-emetics. side effects may include dizziness, somnolence (especially if taken during daytime, so avoid driving after use), and extra-pyramidal symptoms (especially with prolonged and frequent use). some of these can prolong the qt interval on ekg, so use caution if the patient has known prolonged qt syndrome or if the patient is taking multiple qt prolonging medications. options include: • prochlorperazine - mg po tid or qhs × days. • also available as mg rectal suppository. • promethazine . - mg po tid or qhs × days. • also available as a mg rectal suppository. • metoclopramide - mg po tid or qhs × days. • chlorpromazine mg po tid or qhs × days. • olanzapine mg po qhs or bid × - days. • quetiapine - mg qhs × days. triptans.-long-acting triptan medications can be used as bridge therapies, as is often done in the treatment of menstrually related migraine or in the treatment of medication overuse headache. [ ] [ ] [ ] we propose a similar strategy can be trialed as a therapeutic option for refractory or persistent migraine. options include: • frovatriptan . mg po bid × days. • naratriptan mg or . mg po, bid × days. anti-epileptics.-the action of anti-epileptic drugs in migraine likely involves several proposed mechanisms including sodium channel blockade and enhancement of gaba activity in the brain, from increased gaba synthesis and decreased gaba degradation. options include: • valproic acid - mg po qhs × days or mg po tid × - days. however, given known teratogenicity, valproic acid should not be used in women of childbearing age. corticosteroids.-although recommendations may evolve as more data become available, currently the centers for disease control (cdc) states in the treatment of covid- "corticosteroids should be avoided, because of the potential for prolonging viral replication as observed in mers-cov patients, unless indicated for other reasons." as above, for otherwise healthy, immunocompetent individuals without any infectious symptoms or fever and who are not self-monitoring due to possible covid- exposure, a steroid taper may be considered at the clinician's discretion, weighing potential benefits, and risks. steroids should be taken in the morning and with food to avoid gastrointestinal upset. options include: • methylprednisolone (medrol dose pack), with a taper over days. • dexamethasone mg × days, with an option to extend as a taper if not sufficient ( mg × days, then mg × days. • prednisone mg × days, mg × days, mg × days. • these medications typically require prior authorization and/or may need to be obtained from a special pharmacy. • intranasal lidocaine ( % lidocaine oral solution with nasal atomizer) one spray in each nostril every hours as needed. , • intranasal dihydroergotamine (dhe) one spray ( . mg) in each nostril, repeat in minutes ( mg); can also be used bid × days as "bridge" strategy. , • intranasal ketorolac one spray ( . mg) in each nostril (total dose: . mg). we encourage providers to avoid the use of opioids and butalbital. headaches treated with opioids have a high recurrence rate after the initial analgesic effect, and opioids may exert a pro-nociceptive state that may prevent the reversal of central sensitization following a migraine attack. additionally, both of these classes of medication carry a high risk of habituation and dependency, and over time may contribute to medication overuse headache. preventive therapies.-while the injection of on-abotulinumtoxina is an effective treatment for chronic migraine, the procedure can put the patient and the provider at higher risk of covid- given the close contact encounter. we believe that other migraine preventive treatments should be utilized first when possible. some patients on onabotulinumtoxina may have been started on it and stable before newer preventive medication results have been published/approved. thus, we urge providers to first consult the american academy of neurology/american headache society guidelines (last published in ; new ones are currently being produced) and to re-evaluate patients' responses to the medications listed in those guidelines. in addition, therapies which have been demonstrated to be beneficial since the development of that guideline include: • cgrp and cgrp receptor antagonist monoclonal antibodies (mabs): in the past years, mabs against cgrp or the cgrp receptor have been fda approved for preventive treatment of both episodic and chronic migraine -erenumab-aooe, [ ] [ ] [ ] galcanezumab-gnlm, - fremanezumab-vfrm, , and eptinezumab-jjmr. first and foremost, migraine preventive prior authorization restrictions need to be lifted for evidence-based, fda-approved therapies; patients need to be able to access these medications quickly and easily. patients should not be required to fail older medications (which often have higher rates of side effects and lower evidence for benefit, or even have evidence of ineffectiveness for benefit for chronic migraine ) or onabotulinumtoxina injections (which are not feasible right now) in order to qualify for the anti-cgrp/cgrp receptor mabs. similarly, in order to permit the transition of patients from onabotulinumtoxina to anti-cgrp mabs, insurers should remove the prohibition against simultaneous coverage of these drug classes. in addition, insurers should loosen restrictions on the use of acute and preventive medication for adolescents (add reference to pmid: ). the biology of migraine is very similar in adolescents and adults, so we anticipate that the trials of novel therapies will likely have similarly positive results in adolescents. however, ongoing trials of new migraine therapies have been paused in order to prevent spread of covid- . during this time when we can not enroll patients into trials, it would be better to use these medications off label to prevent ed visits and hospitalizations. medical office staff have an increasing number of responsibilities during the pandemic and many need to be repurposed to other duties. many are also unable to work due to sickness, childcare issues, etc thus, we call on the insurance companies to lift restrictions on accessing migraine medications. the covid- pandemic highlights significant weaknesses in our health care system and has left clinicians and patients scrambling to find solutions to maintain health that for many may have taken years to achieve. migraine can worsen during times of stress, so having available options that bypass insurance hurdles and can be administered at home without patient training is imperative. telehealth provides an important opportunity to continue to care for our vulnerable population and help avoid emergency room and urgent care visits that put patients at risk and burden the overwhelmed healthcare system. the largest at-risk group of established migraine patients are those that depend on procedures to allow them to remain functional and out of the emergency room. the shortage of personal protective equipment has caused an unfortunate break in care for many of these patients. during the current pandemic we, headache specialists, make a plea to insurers to lift cumbersome restrictions to allow patients greater availability of evidence-based treatment options to reduce the burden of their disease. one example would be to allow patients who were being treated with onabotulinumtoxina to bridge with an anti-cgrp/ cgrp-receptor mab while their procedures may be postponed. our common goal as health care providers is to maintain the health of our patients while continuing to keep ourselves, our staff, and our families safe. successful management of migraine with avoidance of in-person patient clinic visits further benefits the current urgent overall societal goal of maintaining social distance to contain the pandemic. given that the practice of medicine is changing rapidly during this pandemic, these recommendations may evolve over 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antagonists in covid- randomised clinical trial comparing melatonin mg, amitriptyline mg and placebo for migraine prevention use of melatonin versus valproic acid in prophylaxis of migraine patients: a double-blind randomized clinical trial. restorative neurology and neuroscience efficacy of zonisamide in migraineurs with nonresponse to topiramate zonisamide versus topiramate in migraine prophylaxis: a double-blind randomized clinical trial zonisamide for migraine prophylaxis in patients refractory to topiramate a comparative effectiveness meta-analysis of drugs for the prophylaxis of migraine headache acknowledgments: the idea for this editorial grew out of conversations during a meeting of the american headache society (ahs) practice management committee, though this editorial is not an official opinion of the ahs. the acute and preventive treatment regimens are derived from the personal experience of the authors and their local colleagues, supplemented by discussion from the migraine mavens group, an online network of women headache specialists from across the united states and canada. key: cord- -x z nvt authors: ben-arye, eran; gressel, orit; samuels, noah title: feasibility of an online integrative oncology treatment program during covid- date: - - journal: j pain symptom manage doi: . /j.jpainsymman. . . sha: doc_id: cord_uid: x z nvt nan to the editor, the present covid- pandemic has led to significant restrictions on access to supportive and palliative cancer care. in order to ensure continuity of care, many oncology healthcare practitioners are turning to the use of "telemedicine", which allows them to conduct medical consultations, assessment and communication with their patients , , . in the integrative oncology (io) setting, online practitioner-patient interactions entail a broader context of communication, in which a therapeutic process takes place under the instruction and guidance of the io practitioner. the present study examined the feasibility of an online treatment program developed by an integrative oncology (io) service in northern israel during the covid- lockdown, with the goal of providing continuous weekly care during and after the pandemic. this was a prospective, controlled and non-randomized study, which took place from march to may at the lin and zebulon medical centers of the haifa and western galilee district, clalit healthcare services, israel . in our practice, eligible patients age ≥ years old undergoing adjuvant, neoadjuvant, or palliative chemotherapy for solid tumors were referred by their oncologist, nurse oncologist, or psycho-oncologist to a consultation with an integrative physician (ip), trained in io and supportive cancer care. the ip consultation begins with an assessment of quality of life-related concerns, and concludes with the ip and patient co-designing an integrative treatment program of ≥ weekly sessions, with the goal of alleviating chemotherapy-induced toxicities and resolving the patients' concerns (e.g., worries about daily functioning, psycho-social concerns, fear of disease progression or recurrence). during the first round of covid- restrictions, the integrative oncology program initiated an online program for patients who were unable to continue treatment at the centers, with io practitioners providing -minute weekly sessions using available online video applications. the intervention entailed practitioner-guided self-treatment by patients with manual/touch, acupuncture, movement, and/or mind-body modalities. during the study period, patients continuing oncology treatment at the study centers were encouraged to participate in online treatments, as either an alternative or an 'add-on' to their current io regimen. an io practitioner was assigned as an integrative case manager for each patient to facilitate continuity of care, through either providing treatments or coordinating sessions between other io practitioners. data extracted from electronic medical records included patient demographics; cancer diagnosis and treatment; and data on the io interventions employed. data were entered into an spss software program (version ; spss inc., chicago, il), with t-tests identifying differences in continuous variables when normality was assumed; and mann-whitney u tests for non-normal distribution. for all findings, a p< . was considered statistically significant. fisher exact testing examined differences in prevalence of categorical variables. following univariate analysis, a multivariate logistic regression model examined the following variables: gender, tumor site, cancer treatment setting and presence of metastatic disease. the study protocol was approved by the ethics review board at the carmel medical center in haifa, israel, and registered at clinicaltrials.gov (nct ). of the patients seen by the study ip, were designated as the "online" group after undergoing ≥ online treatments during the -week study period. an additional patients received only one online treatment, and were therefore not included in this group. the remaining patients ( . %) continued treatments when possible at the oncology center ("non-online" group). the demographic, cancer and oncology treatment-related characteristics of the two groups are presented in table . the patients in the online treatment group underwent a total of online j o u r n a l p r e -p r o o f interventions during the -month study period, which were comprised of treatments by io-trained practitioners. io practitioner-guided self-administered treatments included manual-touch therapies, practitioner-guided self-acupuncture, movement therapies, mind-body-spiritual approaches, and herbal medicine consultation. demographic parameters (age, gender, language, country of birth, distance of residence from oncology centers) were similar in both study groups, as were rates of cancer-and non-cancer related use of complementary medicine. patients in the online group had higher rates of breast cancer (p= . ) and lower rates of metastatic disease (p= . ), with cancer recurrence rates similar in both groups. patients who were more likely to adhere to the integrative treatments as planned (attending ≥ sessions in the -week period following the ip consultation) were found to be more likely to choose the online treatment route than those who were non-adherent ( % vs. %, p= . ). a two-step logistic multivariate regression model confirmed the finding that patients with metastatic disease were less likely to choose the online treatment option [odds ratio= . , %ci= . - . , p= . ]. despite the small size of the study sample, the findings presented indicate that oncology patients are likely to adhere to an online io treatment regimen. the online approach may be applicable not only during the current pandemic but also for the post-covid- era, especially for patients with difficulties in accessing io care. most io programs take place in large oncology treatment centers, which may be far from peripheral communities where high-level care is less available, if provided at all. the study's limitations include its small sample size, as well as the potential for a selection bias, in which patients who may have been seen to be more interested in and able to participate in the online program were preferentially chosen. further research is needed in order to better understand the reproducibility of the study's findings, as well as its potential as an option for patients who may find it difficult to participate in an online io treatment format. factors limiting the ability of patients to participate in online j o u r n a l p r e -p r o o f treatments may include geography (i.e., patient lives in the periphery, far from the medical center); advanced age or culture (e.g., elderly patients who are more likely to be unfamiliar with online technologies); socio-economic status (i.e., technologies not available or accessible); lack of knowledge or awareness of available technologies; an informal caregiver who is not supportive of the io treatment program and whose help is needed in the performance of self-treatments, providing emotional support, etc.; and severity of the patients' illness, as demonstrated in the finding of lower rates of participation among patients with metastatic disease. these factors need to be addressed in order to provide equal access to care for all patients. other challenges which need to be explored include ensuring confidentiality of the io treatment with the use of non-secured popular online software; difficulties in maintaining a high level of treatment when performed by untrained patients and their caregivers; and the possibility that patients will continue to self-treat without the guidance or supervision of a trained io practitioner. nevertheless, the findings of the present study are encouraging, and suggest that online io treatments are feasible and can be provided to patients, once challenges facing the ability to provide equitable and effective access to care are met. the relevance of this project may continue long after the current covid- pandemic has been resolved, though it is serving as an impetus for this process. at the same time, there is a need to create practice guidelines with specific recommendations on how to perform effective and safe online io consultations and treatments. all authors have completed the unified competing interest form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare that they have received no support from any organization for the submitted work; have no financial relationships with any organizations that might have an interest in the submitted work in the previous years; and no other relationships or activities that could appear to have influenced the submitted work. j o u r n a l p r e -p r o o f adapting care for older cancer patients during the covid- pandemic: recommendations from the international society of geriatric oncology (siog) covid- working group telemedicine for outpatient neurosurgical oncology care: lessons learned for the future during the covid- pandemic we would like to thank ms. ronit leiba for her assistance in statistical analysis. ethics: participation in this study was voluntary and verified by participants' consent. key: cord- -rtzf dvp authors: kirkby, charles; mackenzie, marc title: response to: low dose radiation therapy for covid- pneumonia a double-edged sword date: - - journal: radiother oncol doi: . /j.radonc. . . sha: doc_id: cord_uid: rtzf dvp nan we thank the authors for their response and welcome critical discussion on the potential of ldrt as a treatment for covid- pneumonia. kefayat and ghahremani raise several valid points in their letter. certainly further study on the matter is warranted. based on historical evidence in the literature and the current pandemic status, the radiation therapy community would be justified in designing both pre-clinical and clinical trials to modern standards to investigate the effectiveness of ldrt against covid- pneumonia using end points such as progression to the need for ventilator support, duration of hospitalisation, length of intensive care, and overall mortality rates. we agree that the timing of the irradiation in relation to disease progression is likely to influence treatment outcomes. as such the treatment should be designed to emulate fast-track, palliative treatments with minimal planning and complexity in order to easily adapt to treating large numbers of patients in rapid response to a localized outbreak (e.g. parallel opposed pair chest treatments with standard linear accelerators). this constraint may challenge the authors' proposition of tbi-type treatment which often requires specialized facilities and increases the plan complexity, although whole lung fields would still irradiate large volumes in order to encompass both lungs simultaneously. we believe the risks to patients from such studies would be very low. rates of radiationinduced pneumonitis after whole-lung irradiation for diffuse lung or bone metastasis or prophylactic treatments fall to negligible levels for single fractions of < cgy.( ) and while the interplay between radiation dose and viral activity is certainly complex, at the < cgy doses proposed, it is unlikely that radiation-induced immunosuppression will have a significant impact on overall disease progression. to date there are no indications that multiple imaging doses exacerbate covid- symptoms. even in the case of much higher palliative rt doses, consensus statements in the community suggest such treatments may proceed; concerns about population mixing and equipment sterilization notwithstanding. ( ) radiation dose-volume effects in the lung adapting palliative radiation therapy for bone metastases during the covid- pandemic: gemo position paper key: cord- -fzgxuak authors: penman, sophie l.; kiy, robyn t.; jensen, rebecca l.; beoku‐betts, christopher; alfirevic, ana; back, david; khoo, saye h.; owen, andrew; pirmohamed, munir; park, b. kevin; meng, xiaoli; goldring, christopher e.; chadwick, amy e. title: safety perspectives on presently considered drugs for the treatment of covid‐ date: - - journal: br j pharmacol doi: . /bph. sha: doc_id: cord_uid: fzgxuak intense effort is underway to evaluate potential therapeutic agents for the treatment of covid‐ . in order to respond quickly to the crisis, the repurposing of existing drugs is the primary pharmacological strategy. despite the urgent clinical need for these therapies, it is imperative to consider potential safety issues. this is important due to the harm‐benefit ratios that may be encountered when treating covid‐ , which can depend on the stage of the disease, when therapy is administered and underlying clinical factors in individual patients. treatments are currently being trialled for a range of scenarios from prophylaxis (where benefit must greatly exceed risk) to severe life‐threatening disease (where a degree of potential risk may be tolerated if it is exceeded by the potential benefit). in this perspective, we have reviewed some of the most widely‐researched repurposed agents in order to identify potential safety considerations using existing information in the context of covid‐ . taleb-gassabi, & dayer, ) . a standard dose of lopinavir-ritonavir is mg/ mg twice a day for hiv- treatment, and this has also been used for sars-cov- treatment . the most frequent reported aes for lopinavir-ritonavir treatment are gastrointestinal disturbances including diarrhoea, nausea and vomiting (chandwani & shuter, ) . dose-related diarrhoea have been reported in up to % of patients and are thought to occur through a number of mechanisms including decreased proliferation of intestinal epithelial cells, disruption of intestinal barrier function, inducing endoplasmic reticulum stress and activating the unfolded protein response (x. wu, li, peng, & zhou, ) . diarrhoea is also a symptom in some covid- patients and so lopinavir-ritonavir has the potential to exacerbate this. pancreatitis has been reported in a small number of patients following lopinavir-ritonavir treatment although this was more frequent in those with a pre-existing history of pancreatitis (chandwani & shuter, ; oldfield & plosker, ) . additionally, patients with underlying liver diseases should have regular monitoring of hepatic function (palacios et al., ) . caution should be exerted for those patients taking concomitant medication as lopinavir-ritonavir inhibits p-glycoprotein (p-gp) and cytochrome p (cyp) - a , which therefore may alter the pk of other compounds (l. zhang, zhang, & huang, ) . a covid- drug interaction website has been developed by the liverpool drug interaction group which details ddis with lopinavir-ritonavir and a number of drugs, which in some cases can lead to potentially serious and/or life-threatening reactions (group, ; abbvie inc., ) . since the sars-cov- outbreak, clinical trials have been registered (up to th july ) to test lopinavir-ritonavir as a potential treatment for sars-cov- with variable outcomes in terms of efficacy. in one trial of patients with confirmed sars-cov- , patients on the lopinavir-ritonavir arm were withdrawn due to aes . in a different trial, patients who were administered lopinavir-ritonavir ( mg/ mg) also experienced gastrointestinal aes (y. li et al., ) . chloroquine and its derivative, hydroxychloroquine, are widely used as inexpensive and safe antimalarial drugs. in particular, the established good tolerability of chloroquine/hydroxychloroquine has made them safe to use even in pregnancy (villegas et al., ) . in addition to anti-malarial activity, both drugs have immunomodulating effects and are used for the treatment of autoimmune diseases including systemic and discoid lupus erythematosus, psoriatic arthritis, and rheumatoid arthritis. chloroquine/hydroxychloroquine concentrate extensively in acidic vesicles including the endosomes, golgi vesicles, and the lysosomes (ohkuma & poole, ) . this leads to lysosomal membrane permeabilisation or dysfunction of several enzymes including acid hydrolases and palmitoyl-protein thioesterase (rebecca et al., ; savarino, boelaert, cassone, majori, & cauda, ; schrezenmeier & dorner, ) . although the precise mechanisms of the anti-viral effects are not fully understood, it has been proposed that chloroquine/hydroxychloroquine can prevent virus infection (pre-infection) by interfering with the glycosylation of cellular receptors and impair viral replication by increasing endosomal ph (post-infection) (savarino et al., ; savarino et al., ; vincent et al., ) . owing to their efficacy against viruses (mostly demonstrated in vitro) including influenza, hiv, coronavirus oc , and sars-cov, a large number of clinical trials (> ) have been registered worldwide using chloroquine/hydroxychloroquine alone, or in combination with other drugs (e.g. azithromycin) for the treatment of covid- . despite promising in vitro antiviral results for hydroxychloroquine/chloroquine, there is no convincing evidence of efficacy at present (gao, tian, & yang, ; gautret, lagier, parola, hoang, meddeb, mailhe, et al., ; gautret, lagier, parola, hoang, meddeb, sevestre, et al., ; magagnoli, ; mathian et al., ; million et al., ; tang, ; yao et al., ) . a post-exposure prophylaxis randomised controlled trial of participants failed to show any benefit of hydroxychloroquine (n= ) compared with placebo (n= ) (boulware et al., ) . at the time of writing, the recovery trial (clinical trial identifier nct ) which is the largest randomised control trial so far conducted for the treatment of covid, has stopped recruiting to the hydroxychloroquine arm ( patients compared with on standard care) because of no beneficial effect either in terms of mortality or hospital stay (p. . there are still many other trials on-going testing the efficacy of hydroxychloroquine for either prophylaxis or treatment. both chloroquine and hydroxychloroquine have been in clinical use for many years for rheumatoid diseases, and thus their safety profile is well established. dose-dependent retinal toxicity has long been recognized as the major ae with long-term use of chloroquine/hydroxychloroquine (marmor et al., ) . besides retinal toxicity, gastrointestinal, liver and renal toxicity have also been reported (giner galvan, oltra, rueda, esteban, & redon, ; michaelides, stover, francis, & weleber, ; mittal, zhang, feng, & werth, ) . as both drugs are mainly metabolised in the liver and excreted by renal clearance, their use in patients with liver or renal impairment may worsen the function of these organs. for chloroquine treatment, prescribing information recommends the full dose at all degrees of renal impairment but suggests that monitoring of renal function may be useful . for hydroxychloroquine, reductions in dosage are advised for patients with impaired renal function, as well as those taking concomitant medications with known risks of kidney damage (concordia pharmaceuticals inc, ) . this article is protected by copyright. all rights reserved. a serious ae associated with chloroquine/hydroxychloroquine is cardiotoxicity, which can take many forms including cardiomyopathy in rare instances. prolonged treatment or high dosage of chloroquine/hydroxychloroquine has been shown to increase of the risk of qt interval prolongation, polymorphic ventricular tachycardia, and sudden cardiac death (chatre, roubille, vernhet, jorgensen, & pers, ) . a large epidemiological analysis in patients with rheumatoid arthritis has recently shown that -day cardiovascular mortality was increased by more than -fold when hydroxychloroquine was combined with azithromycin. the lethal ventricular arrhythmias are primarily due to inhibition of a potassium channel (the inward rectifier kir . channel) and may occur at low µm concentrations (ic = . m) (rodriguez-menchaca et al., ) . while therapeutic doses of chloroquine typically result in plasma concentrations of - µm, much higher concentrations in the heart are expected based on a -fold increase observed in rat pk studies (mcchesney, banks, & fabian, ; walker, dawodu, adeyokunnu, salako, & alvan, ) . both drugs act on various potassium channels including the inward rectifier currents (kir . and kir . ) and rapid delayed rectifier currents (kv . /herg) (ponce-balbuena et al., ; rodriguez-menchaca et al., ; sánchez-chapula, navarro-polanco, culberson, chen, & sanguinetti, ) . the binding of chloroquine to the inward rectifier kir . channel can be stabilized by negatively charged and aromatic amino acids (rodriguez-menchaca et al., ) . to a lesser extent, chloroquine also blocks the rapid delayed rectifier ikr, possibly through cation-π and π-stacking interactions with tyrosine and phenylalanine in the s domain of herg (sánchez-chapula et al., ) . the effect of inhibition of these potassium channels on the heart rate appears to be complex. however, blocking the herg channel has proven to be the most common mechanisms by which drugs cause qt interval prolongation (traebert & dumotier, ) . the binding of chloroquine/hydroxychloroquine to proteins is also stereoselective, but whether one of the chloroquine/hydroxychloroquine enantiomers has a stronger interaction with the kir . channel is not known. caution is needed when hydroxychloroquine is used in combination with other drugs (including azithromycin), which increase the qt interval because of a pharmacodynamic synergistic interaction. given the comorbidities in many patients with covid- , especially those with underlying cardiovascular disease, and the fact that covid- itself is associated with cardiac manifestations, this may increase the risk of cardiotoxicity associated with the use of chloroquine/hydroxychloroquine. indeed, excessive qtc prolongation was observed in % of patients as reported by bessiere at al. and greater qtc prolongation was also seen in patients taking the combination of hydroxychloroquine and azithromycin than those taking hydroxychloroquine alone, highlighting the importance of pharmacodynamic interactions (bessiere et al., ; mercuro et al., ) . furthermore, a phase iib trial in brazil showed that a higher dose of chloroquine ( mg twice daily) in patients hospitalised with covid- had a higher fatality rate ( %) compared with % in the lower dose ( mg twice daily) group (borba et al., ) . qtc interval prolongation > msec was observed in % of the high dose group compared with % of the low dose group. the us prophylaxis randomised control trial however did not show any increase in cardiovascular aes (boulware et al., ) . we await the publication of the recovery trial to determine whether there was an excess of cardiovascular events. however, it is important to note that despite the size of the recovery trial (n = patients), it may still be under-powered to identify an excess number of cardiovascular events when compared with standard of care. remdesivir is an investigational compound that was developed for the treatment of ebola (mullard, ; tchesnokov, feng, porter, & gotte, ) . remdesivir is a monophosphoramidate prodrug and acts as a broad-spectrum antiviral that can be incorporated into viral rna (agostini et al., ; sheahan et al., ; warren et al., ) . many anti-virals are proving to be ineffective against covid- due to the presence of a proofreading exoribonuclease (exon) specific to coronaviruses, encoded in non-structural protein (nsp ) (agostini et al., ) . remdesivir is able to evade this viral proofreading, meaning its incorporation into viral rna results in the inhibition of rna-dependent rna polymerases (rdrps), thereby preventing subsequent viral replication (warren et al., ) . furthermore, arshad et al. suggest that the maximum serum concentration (cmax) of remdesivir is sufficient to inhibit % of sars-cov- replication, a parameter which is suspected to be of vital importance in the treatment of covid- (arshad et al., ) . remdesivir is administered intravenously, with single doses ranging between to mg being well patients receiving remdesivir via the uk early access to medicines scheme (eams) is similar to that which was evaluated for ebola treatment: a loading dose of mg on day , followed by mg daily for - days depending on symptom severity (medicines and healthcare products regulatory agency, b). as such, it is likely that many of the aes observed in the ebola study will translate to covid- patients treated with remdesivir. this article is protected by copyright. all rights reserved. mild to moderate alt and aspartate transaminase (ast) elevations were observed in several ebola patients during the multiple-dose study, thus reflecting observations made in human hepatocytes in vitro (clinical trials.gov, ; world health organisation, ) . this is likely to be due to the high cell permeability of hepatocytes, in combination with the effective intracellular metabolism of remdesivir to its active form within the liver (world health organisation, ) . emerging data has suggested that sars-cov- may target ace on hepatocytes leading to liver injury as evidenced by a significant increase in alt and bilirubin in severe cases of covid- (guan et al., ) . therefore, it is likely that differentiating between covid- -induced transaminase elevations and those induced by remdesivir presents challenges (bangash, patel, & parekh, ; c. zhang, shi, & wang, ) . however, a recent study found that only . % of covid- patients receiving remdesivir treatment suffered serious (grade or ) transaminase elevations, with there being no significant difference between the remdesivir-and placebo-treated groups (beigel et al., ) . this data implies that remdesivir is relatively well-tolerated in sars-cov- -positive patients. regardless, as advised by the drug manufacturer, daily liver function tests are essential in any patients receiving remdesivir, with suggested discontinuation of the drug in patients whose alt levels reach ≥ times the upper limit of normal (uln) (gilead, ) . adhering to these guidelines is of particular importance in patients with pre-existing liver disease, or in those taking other medications which can also induce transient alt and ast elevation (world health organisation, ) . the reported differences between preclinical and clinical data regarding the safety of remdesivir highlight the inadequacies of preclinical models in some contexts. for example, with regards to covid- , a concerning element of theoretical toxicity is that which affects the respiratory system. a study using mice models of middle east respiratory syndrome coronavirus (mers-cov) found remdesivir improved pulmonary pathology in infected mice and rhesus monkeys, and no respiratory toxicity was observed (gilead, ; sheahan et al., ) . in contrast, a respiratory safety study in rats showed that remdesivir had no impact on tidal volume or minute volume, but did increase respiratory rate, which returned to baseline by hours post-dose (world health organisation, ). clearly, increased respiratory rate is a manifestation of covid- , and there would be problems in assessing causality if remdesivir was also likely to cause of respiratory problems in a clinical setting. fortunately, a recent double-blind, randomized, placebo-controlled trial showed there to be no significant differences in adverse respiratory events between the remdesivir-treated and control arms (beigel et al., ) . in addition to this, preclinical safety studies performed in rats and cynomolgus monkeys suggested that the kidney was the target organ for remdesivir-induced toxicity (gilead, ) . this was a significant concern before the initial covid- clinical trials, as it is known that sars-cov- can cause acute kidney failure in severe cases (ronco, reis, & husain-syed, ) . however, this has not this article is protected by copyright. all rights reserved. been reflected in covid- clinical trials, where the presence of biomarkers indicative of renal injury have not differed in patients treated with remdesivir compared to those on placebo (beigel et al., ; gilead, ) . however, due to the inclusion of the solubility enhancer sulfobutylether βcyclodextrin sodium (sbecd) within remdesivir formulations, remdesivir is contraindicated in patients with severe renal impairment (egfr < ml/min) (european medicines agency, ). finally, remdesivir is not exempt from ddis. co-administration of remdesivir with several antibiotics including rifampicin is contraindicated, which could cause problems for any patients being treated concomitantly for tuberculosis (group, ) . this occurs because of enzyme induction which reduces systemic exposure to remdesivir. a similar interaction has also been seen with enzyme-inducing anticonvulsants, including carbamazepine, phenytoin, and phenobarbital (group, ) , where reduction in remdesivir exposure may lead to inadequate treatment of covid- . favipiravir is another broad-spectrum anti-viral prodrug which undergoes intracellular phosphoribosylation to produce its active form, favipiravir-ribofuranosyl- ′-triphosphate (favipiravir-rtp) (yousuke furuta, komeno, & nakamura, ) . it is thought that this anti-viral primarily acts by inducing lethal mutagenesis of rna viruses, although it also selectively and potently inhibits viral rdrp by acting as a pseudo purine nucleotide (dawes et al., ; sangawa et al., ) . favipiravir is currently licensed in japan for the treatment of novel and re-emerging influenza (yousuke y. furuta et al., ) . its extensive spectrum of activity against various rna virus polymerases led to favipiravir being cited as a potentially 'crucial pandemic tool', even before the outbreak of the novel coronavirus, covid- (adalja & inglesby, ) . the pk of favipiravir was initially characterised in healthy japanese volunteers (madelain et al., ) . a cmax of . µg/ml was found to occur hours post-administration, but plasma concentrations decreased rapidly due to the relatively short half-life of favipiravir (between and . hours) (madelain et al., ) . however, both cmax and half-life increase slightly after multiple doses and it has been suggested that favipiravir is capable of reaching a cmax in humans sufficient to inhibit % of sars-cov- replication, thus establishing it as an important compound in the ongoing search for covid- therapies (arshad et al., ) . marked differences in cmax have been observed between japanese and american patients with cmax values in japanese subjects being on average . µg/ml greater than those in american subjects (pmda, ) . this highlights the need for relevant covid- clinical trials to include a diverse range of subjects so that factors such as weight and ethnicity can be considered to optimise dose. the bioavailability of favipiravir is high at . % and only % of the drug is plasma protein-bound, suggesting high tissue penetration would be likely (madelain et al., ; pmda, ) . in vivo work in mice showed that the half-life of favipiravir in the lungs is double that of favipiravir in plasma, indicating slower elimination from the lungs (pmda, ) . this is thought to be of high importance in covid- , where viral load is particularly high in the lungs. for influenza treatment in adults, mg favipiravir is given twice on day of treatment, followed by mg twice daily from days to (pmda, ). however, the dosing period has been extended in ongoing covid- clinical trials: up to days in chictr and days in chictr (guan et al., ) . it is therefore essential that all pk parameters are monitored in these trials as differences, including increased cmax and decreased clearance, are expected during this prolonged dosing regimen which may impact upon safety. favipiravir has been linked to teratogenicity and embryotoxicity, and is therefore contraindicated in pregnancy (yousuke furuta et al., ) . overall, favipiravir is generally thought to have a good safety profile (asrani, devarbhavi, eaton, & kamath, ; group, ; nhs, ) . this is likely to be due to the fact that unlike other antiviral drugs such as ribavirin, favipiravir does not appear to disrupt non-viral rna or dna synthesis. however, very little is known about the long-term safety of favipiravir, as in previous clinical trials patient follow-up has been as little as days . this is perhaps less of a concern in covid- as treatment is time-limited. drug-drug interactions have been reported with favipiravir. for example, coadministration with favipiravir can increase exposure to paracetamol by around %, which may be a concern for patients with pre-existing liver disease as paracetamol is the leading cause of acute drug-induced liver injury (dili) in the uk and usa (asrani et al., ; group, ) . favipiravir can also increase patient exposure to many contraceptives, including progesterone-only pills, combined pills, and several contraceptive implants, which may cause discomfort, prolonged vaginal bleeding, and nausea (group, ; nhs, ) . whether the increased exposure to oestrogens caused by concomitant treatment with favipiravir can enhance the risk of thrombosis is not known but should be monitored, given the overwhelming evidence that covid- increases the risk of blood clots (atallah, mallah, & almahmeed, ; di micco et al., ; spiezia et al.) . interestingly , large clots are most common in patients under the age of ; almost % of women aged between - in the usa currently use either oral or long-acting contraceptives, and thus represent a particular risk group (hurley, ; prevention, ). sars-cov- virus is capable of eliciting an immune reaction in the infected individual. laboratory examinations have revealed that inflammatory factors such as interleukin (il)- , il- , il- and tumour necrosis factor-α (tnfα) are upregulated during infection and can instigate an inflammatory response in the lower airways leading to lung injury in some instances guo et al., ) . additionally, in patients with severe symptoms of covid- , there may be activation of a cytokine storm, which can cause significant tissue damage (mehta, mcauley, et al., ; shi et al., ) . a smaller proportion of patients can progress to a hyper-inflammatory state which in covid- has been suggested to resemble secondary haemophagocytic lymphohistiocytosis (shlh), a rare syndrome characterised by uncontrollable fever, cytopenia, raised ferritin levels and acute respiratory distress (seguin, galicier, boutboul, lemiale, & azoulay, ) . interleukin and tnf-α levels show the greatest increase in those who require admission to the intensive care unit (icu), suggesting that the cytokine storm is instrumental in severe covid- cases (huang et al., ) . therefore, there has been a logical progression towards the use of immunosuppressive agents as potential therapies to alleviate inflammation and hyperinflammation associated with covid- (mehta, mcauley, et al., ) . dexamethasone is a glucocorticoid that can be administered both orally and intravenously. it acts as a glucocorticoid receptor agonist and is over times more potent than endogenous cortisol, thus resulting in dose-dependent suppression of pro-inflammatory genes through a number of pathways in common with other steroids (papich, ; whelan & apfel, ; yasir & sonthalia, ) . low doses of glucocorticoids have an anti-inflammatory effect while higher doses are immunosuppressive (buttgereit et al., ) . dexamethasone can be used for inflammatory diseases such as rheumatoid arthritis (crohn's & colitis foundation, ; freeman, ) , but is recommended for short-term treatment (spanning from one to days) because of the major adverse effects which can occur with long-term treatment. one of the commonest uses of dexamethasone is for reducing cerebral oedema. as of th july , dexamethasone was undergoing evaluation in clinical trials. on th june, the results of the dexamethasone arm of the recovery trial were announced. the trial results, which are available in preprint form, showed that patients had received either oral or intravenous lowdose ( mg) dexamethasone daily for ten days (peter horby et al., ) . when compared to control patients receiving usual care only, it was shown that dexamethasone reduced deaths by one third in sars-cov- positive patients requiring ventilation, and by one fifth in patients receiving this article is protected by copyright. all rights reserved. oxygen. no benefit was observed for patients with milder covid- symptoms who did not require respiratory support (peter horby et al., ) . recent work has found that tissue inflammation and organ dysfunction seen in fatal cases of covid- are not consistent with sars-cov- distribution in tissues and cells (dorward et al., ) . tissuespecific tolerance to the virus may therefore important, and suggests that fatalities arising from covid- may be mainly due to host-mediated immune response rather than pathogen-mediated end-organ inflammation. this is consistent with the dexamethasone result in the recovery trial. dexamethasone has a bioavailability of - % and is % protein bound in plasma (spoorenberg et al., ) . it is -hydroxylated by hepatic cyp a to α-and β-hydroxy-dexamethasone, and can also be reversibly metabolised to -dehydroxymethasone and back to dexamethasone by renal corticosteroid -beta-hydrogenase isozyme (diederich et al., ; diederich, hanke, oelkers, & bähr, ; tomlinson, maggs, park, & back, ) . unlike many glucocorticoids which are predominantly excreted in urine, only about % of dexamethasone is excreted in urine (dexcel pharma technologies ltd.). glucocorticoids are generally safe drugs when given at low doses and for short periods of time (< weeks), with the risk of adverse events increasing with dose and therapy duration (yasir & sonthalia, ). short-term use of dexamethasone can result in increased appetite, mood changes, and insomnia, but most of the adverse reactions are self-limiting (nhs, ). dexamethasone can lead to b and t cell depletion, and hence lymphopenia (marinella, ) , which interestingly is also found in up to % of patients with covid- (liu, blet, smyth, & li, ) . however, despite this, the recovery trial was able to show a mortality benefit in the most severely affected covid- patients. a critical issue may be the dose that is administered -in recovery, mg/day was administered over days, which is a relatively low dose. a recent systematic review and meta-analysis of corticosteroid treatment in patients with coronavirus infection suggested that corticosteroids were associated with higher rates of bacterial infections, longer time spent in hospital and higher rates of mortality (z. yang et al., ) . however, most of the studies analysed in this meta-analysis were retrospective observational studies, generally of poor quality and did not analyse the effects according to steroid dose. other studies which have used low-to-moderate-dose corticosteroids as treatment for diseases such as viral and bacterial pneumonia reflect the results of the recovery trial, with low dose corticosteroids resulting in decreased mortality and morbidity in patients with severe pneumonia (h. li et al., ; stern et al., ) . in these studies, low-to-moderate dose corticosteroids ( - mg prednisolone, which equates to - . mg dexamethasone) were given to patients for between and days (stern et al., ) (national institute for health and care excellence, b). in keeping with the known adverse effects of corticosteroids, the systematic review showed that hyperglycaemia was significantly more frequent in the corticosteroid-treated group (stern et al., ) . dexamethasone can be involved in both pharmacokinetic and pharmacodynamic interactions. combining it with other immunosuppressants may increase the risk of serious infection (national institute for health and care excellence, c). co-treatment with ibuprofen or other nsaids increases the risk of gastrointestinal bleeding (national institute for health and care excellence, c), while its gluconeogenic effects can lead to hyperglycaemia, which in diabetic patients can lead to increased insulin doses being required (consilient health ltd., ). dexamethasone is a cyp a inducer, and may therefore interact with remdesivir, a cyp a substrate, potentially reducing its plasma exposure. although clinicians should be aware of this interaction, the risk is small given that both drugs are indicated for days or less. both tocilizumab and sarilumab are humanised anti-il- receptor monoclonal antibodies used for the treatment of moderate -severe rheumatoid arthritis, whereas siltuximab is a chimeric, human-mouse anti-il- receptor monoclonal antibody used for treatment of multicentric castleman's disease (mcd) (deisseroth et al., ; national institute for health and care excellence, e). due to their long half-life, il- inhibitors do not need to be taken daily; however, given that they are currently indicated for chronic diseases, patients receive il- inhibitor treatments for life or until treatment failure (janssen biotech inc; roche pharma; sanofi-aventis). clinical trials to assess the efficacy and safety of tocilizumab, sarilumab and siltuximab for the treatment of the inflammatory phase of covid- are ongoing. whilst the exact dosing regimens vary between trials, covid- patients will be receiving a single or short course intravenous infusion or subcutaneous injection of the il- inhibitor (clinical trial identifiers nct , nct , nct , nct , nct ). due to their similarity, it is not surprising that tocilizumab, sarilumab and siltuximab have comparable safety profiles. thus far, evidence from clinical trials in patients with rheumatoid arthritis and mcd or post-marketing have revealed that il- inhibitors are generally well-tolerated. participants were enrolled on these trials for a minimum of months and in some cases up to months. individuals with diabetes, a history of recurrent infection, age ≥ and corticosteroid use have been shown to be at an increased risk of developing a more serious infection following il- inhibitor use (jones et al., this article is protected by copyright. all rights reserved. ). whilst adverse reactions were typically seen following chronic il- inhibitor treatment, the potential for covid- patients to develop an adverse drug reaction (adr) following a single or small number of doses should not be ignored. the most common infections reported in patients receiving anti-il therapy include skin infections, respiratory infections, urinary tract infections and in some cases, opportunistic infections ranging from tuberculosis to herpes (emery et al., ; smolen et al., ) . liver injury has also been reported with a liver biopsy from a female patient who had taken tocilizumab for a month revealing focal this article is protected by copyright. all rights reserved. necrosis of hepatocytes with steatosis and early fibrosis (mahamid et al., ) . covid- also has effects on the liver, and again causality assessment may be difficult (guan et al., ) . the prescribing instructions for tocilizumab and sarilumab indicate that liver function tests are required every - weeks following treatment commencement and then every months thereafter (roche pharma; sanofi-aventis). if liver enzymes are - x uln, the dose of tocilizumab and sarilumab can be reduced until alt or ast have normalised and then treatment resumed at the therapeutic dose. where laboratory findings are > - x uln, treatment with il- inhibitors must be paused and then recommendations for - x uln followed. if elevations persist or are > x uln, tocilizumab and sarilumab treatment must be discontinued immediately (roche pharma; sanofi-aventis). whilst sarilumab and siltuximab are associated with abnormalities in liver function tests, they are typically short-lived and asymptomatic (livertox, (livertox, , b . pre-existing liver disease can worsen symptoms of dili, and in some cases increase susceptibility (david & hamilton, ) . tocilizumab, sarilumab and siltuximab are expected to undergo metabolism via catabolic pathways and not cyp processes (mccarty & robinson, ) . therefore, due to the lack of hepatic metabolism, it is assumed that the pk of the il- inhibitors will not be altered in patients with preexisting liver disease (abou-auda & sakr, ). however, tocilizumab, sarilumab and siltuximab have been shown to restore and improve cyp levels (janssen biotech inc, ; roche pharma, ; sanofi-aventis, ). this is of particular importance as cyp levels may remain elevated following treatment discontinuation due to the long half-life of the compounds. therefore, this may be a consideration for further evaluation for any dosing adjustment requirements if patients are taking medication that are metabolised by cyp enzymes. anakinra is a kd, recombinant human il- receptor antagonist that blocks the activity of proinflammatory cytokines il- α and il- β (cawthorne et al., ; dinarello, simon, & van der meer, ) . anakinra is primarily used in combination with methotrexate for reducing the symptoms and slowing the progression of joint damage in rheumatoid arthritis (national institute for health and care excellence, a). it is also used for rare inflammatory conditions such as cryopyrin-associated periodic syndromes and still's disease (national institute for health and care excellence, a). it is administered via subcutaneous injection and is supplied as a single-use, pre-filled syringe containing mg/ . ml (swedish orphan biovitrum ltd, ) . rheumatoid arthritis patients and those with still's disease and a body weight > kg must be administered mg anakinra, while patients with still's disease with a body weight < kg should have weight-based dosing starting at - mg/kg this article is protected by copyright. all rights reserved. (swedish orphan biovitrum ltd, ). the recommended starting dose for patients with cryopyrinassociated periodic syndromes is - mg/kg. if tolerated, the dose can be increased to - mg/kg to a maximum of mg/kg (swedish orphan biovitrum ltd, ) . anakinra has a short terminal half-life of approximately - hours and so must be administered daily, preferably at the same time each day (amgen inc., ) . anakinra is currently not licensed for intravenous administration or treatment of shlh but its use is endorsed by clinicians, where intravenous infusion, as opposed to subcutaneous injection, can achieve quicker and greater maximal plasma concentrations (carter, tattersall, & ramanan, ; la rosée et al., ; mehta, cron, hartwell, manson, & tattersall, ) . thus far, clinical trials have been registered to assess the use of anakinra in patients with severe covid- . additionally, two recent studies have reported positive outcomes with anakinra in covid- induced acute respiratory distress syndrome (cavalli et al., ; clinical trials.gov, c; huet et al., ) . participants were dosed mg twice daily subcutaneously for hours followed by mg daily for days in addition to standard of care (huet et al., ) . this retrospective study found that anakinra reduced rates of mortality and the need for mechanical ventilation in icu patients (huet et al., ) . anakinra was administered either subcutaneously or intravenously in the covid- biobank study (huet et al., ) . participants received subcutaneous injections at a dose of mg twice daily or via slow intravenous infusion at mg/kg per day until there was a % reduction in serum c-reactive protein levels and sustained respiratory improvements (cavalli et al., ) . whilst no safety concerns emerged with anakinra administered subcutaneously, it was discontinued due to a lack of clinical improvement and limited reduction in c-reactive protein (cavalli et al., ) . by contrast, intravenous anakinra was well-tolerated and improved clinical outcomes. notably, % of patients had improved respiratory function in comparison to % within the standard treatment group (cavalli et al., ) . in both studies, cases of alt ≥ x uln were observed in both the anakinra and the standard treatment arms. four cases of bacteraemia following intravenous anakinra were reported in the covid- biobank study, but there were no cases of bacterial infection in the ana-covid study (cavalli et al., ; huet et al., ) . whilst both studies are encouraging, they should be considered proof-of-concept trials and larger randomised trials are still needed (cavalli et al., ; huet et al., ) . subcutaneous administration of anakinra is associated with injection site reactions (kaiser et al., ) . in a review of five rheumatoid arthritis clinical trials, % of participants receiving anakinra therapy reported injection site reactions in comparison to % of participants on placebo (mertens & singh, ) . injection site reactions can range from immediate to delayed. in immediate cases, the reaction manifests as a burning sensation whereas delayed reactions present as a rash, pruritus or swelling (kaiser et al., ) . anakinra has also been reported to lead to infection, neutropenia, this article is protected by copyright. all rights reserved. thrombocytopenia, headache, and blood cholesterol increase when administered subcutaneously (swedish orphan biovitrum ltd, ) . injection site reactions that arise immediately can be eased by placing an ice pack on the injection site before and after anakinra administration and delayed reactions can be treated with topical corticosteroids or anti-histamines (kaiser et al., ) . increases in serious infection rate are common following anakinra use and frequently include upper respiratory infections, sinusitis, urinary tract infection and bronchitis (bresnihan et al., ; cohen et al., ; r. m. fleischmann et al., ) . whilst rare, cases of opportunistic infection have been reported in anakinra monotherapy or in those receiving anakinra in combination with immunosuppressive agents (salvana & salata, ; swedish orphan biovitrum ltd, ) . neutrophil counts must be monitored during the first six months of anakinra treatment and quarterly henceforth (swedish orphan biovitrum ltd, ) . in patients where the anc is < . x /l, treatment must be discontinued immediately (swedish orphan biovitrum ltd, ) . the higher doses being used in covid- trials and the potential for a greater cmax due to intravenous administration potentially raise additional safety concerns. however, earlier detection of aes should be possible since the duration of treatment will be shorter than that used in rheumatoid arthritis, coupled with the fact that patients will already be hospitalised. anakinra is catabolised and eliminated via glomerular filtration (swedish orphan biovitrum ltd, ; b.-b. yang, baughman, & sullivan, ) . caution should be exercised and dose-adjustments may be required in moderate to severe renal impairment (swedish orphan biovitrum ltd, ; b.-b. yang et al., ) . during general infections and inflammatory diseases, cyp enzymes are primarily downregulated (mallick, taneja, moorthy, & ghose, ) . similar to il- inhibitors, it may be possible that anakinra treatment restores cyp levels in infected patients (swedish orphan biovitrum ltd, ) . therefore, caution should be exerted in covid- patients receiving concomitant medications with a narrow therapeutic window drug. mild interactions can occur between anakinra and warfarin, clopidogrel, clozapine and phenytoin (group, ) . baricitinib is an oral disease-modifying anti-rheumatic drug (dmard), traditionally used in the treatment of moderate to severe active rheumatoid arthritis (al-salama & scott, ). by acting as an atp-competitive kinase inhibitor, baricitinib can selectively and potently inhibit janus kinases (jaks) - and - in a reversible manner. jaks are essential in the transduction of intracellular signals for various cytokines involved in the inflammatory and immune responses, and so by inhibiting these kinases, baricitinib is able to relieve symptoms of rheumatoid arthritis for many patients (fridman et al., ) . as described previously, a common characteristic of covid- , much like another beta-coronavirus disease sars, is a profuse inflammatory response (huang et al., ; stebbing et al., ) . increased levels of pro-inflammatory cytokines, such as interferon (ifn) -γ and il- β, have been observed in confirmed covid- cases (huang et al., ; mehta, mcauley, et al., ; russell et al., ) . furthermore, the levels of some specific cytokines appear to be related to disease severity; patients requiring admission to intensive care units show increased levels of tnfα and monocyte chemoattractant protein (mcp ). the rationale behind repurposing baricitinib as a treatment for covid- is centred on this potential for severely ill patients to present with a cytokine storm (mehta, mcauley, et al., ; russell et al., ) . by dampening the inflammatory response, it is postulated that baricitinib will be able to relieve covid- symptoms. data modelled using artificial intelligence techniques suggests baricitinib may work by inhibiting virus entry into cells via an endocytic regulator known to be involved in coronavirus internalisation, ap -associated protein kinase (aak ) (burkard et al., ; richardson et al., ) . baricitinib, as well as being capable of jak and jak inhibition, is a high-affinity inhibitor of aak . patients tend to tolerate baricitinib well, and it has a relatively good safety profile (keystone et al., ) . however, as with tocilizumab and sarilumab treatment, a very common (≥ / ) ae observed in patients taking baricitinib, but not in the placebo arm, is upper respiratory tract infection, which may be related to its ability to suppress the immune system (eli lilly, ) . patients taking baricitinib have the potential to develop respiratory tract infections which may make it difficult to distinguish whether any deterioration is due to covid- or a secondary infection. other opportunistic infections including herpes zoster and urinary tract infections were also more common in the treated arm compared to placebo, and dose reduction is recommended for patients with a history of chronic infections (eli lilly, ; josef s. smolen et al., ) . secondary infections are not uncommon in severe covid- patients and so the use of a drug that may make patients increasingly prone to infections will depend on the harm-benefit ratio for severe cases of covid- (world health organisation, a). baricitinib is currently still being trialled in patients with covid- with a therapeutic dose of - mg once daily which is the same as the recommended dosage for the treatment of rheumatoid arthritis (cantini et al., ; richardson et al., ) . there have been a small number of reports from patients taking this recommended dosage for the treatment of rheumatoid arthritis presenting with deep vein thrombosis (dvt), which was severe in some of these cases (taylor et al., ) . this is a cause for this article is protected by copyright. all rights reserved. concern as there are increasing reports of covid- patients, especially those who are critically ill and in the icu, with thrombotic complications including pulmonary embolism and other venous and arterial thrombotic events (klok et al., ; middeldorp et al.) . as baricitinib has been reported to cause dvt, there is the potential for disease-drug interactions with covid- patients taking baricitinib potentially more likely to develop thrombotic complications. in order to mitigate this risk, alternative jak inhibitors, which have a lower risk of thrombotic events, such as ruxolitinib, may be considered in the context of covid- (alvarez-larran et al., ) . however, unlike baricitinib, ruxolitinib is primarily metabolised by cyp a (l. p. h. yang & keating, ) . this means that prescribing ruxolitinib instead of baricitinib may increase the risk of cyp a -related ddis (ogu & maxa, ) . baricitinib is not predicted to be involved in any problematic ddis. coadministration with both cyp a inhibitors (fluconazole) and inducers (rifampicin) failed to result in any clinically relevant changes to baricitinib exposure (eli lilly, ). emerging reports have revealed that patients with covid- experience renal impairment, which could be attributed ace receptor expression on kidney endothelial cells (varga et al., ) . baricitinib should not be given to patients with renal impairment as the majority of the drug is cleared through the kidneys, and monitoring of renal function will be important to prevent aes related to over-exposure to baricitinib in those with deteriorating renal function (eli lilly, ) . type ifns are a group of cytokines produced during viral infection. notably, ifn-β- a has a leading role in activating genes involved in immunomodulation, suppressing the inflammatory response and anti-viral effects (sallard, lescure, yazdanpanah, mentre, & peiffer-smadja, ) . whilst a variety of type ifns exist, in vitro evidence has shown that ifn-β- a and ifn-β- b are the most potent in the inhibition of sars-cov and mers-cov (chan et al., ; hensley et al., ) . within the lungs, ifnβ- has been shown to upregulate levels of the enzyme cluster of differentiation (cd ), which inhibits vascular leakage, increases the secretion of anti-inflammatory adenosine and preserves pulmonary endothelial barrier function (kiss et al., ; sallard et al., ) . however, in vivo research has revealed that timing of administration of ifn-β- is imperative for positive effects. when administered shortly after mers-cov infection, ifn-β- protected mice from lethal infection, whereas delayed administration failed to effectively inhibit viral replication or pro-inflammatory cytokines, leading to fatal pneumonia (channappanavar et al., ) . interestingly, in vitro evidence has revealed this article is protected by copyright. all rights reserved. that sars-cov- is more sensitive to ifn-β- treatment than mers-cov and sars-cov, and thus supports the tenet that treatment with ifn-β- may be beneficial for covid- patients (lokugamage, schindewolf, & menachery, ; sheahan et al., ; thiel & weber, ) . it is assumed that treatment of covid- patients with ifn-β- will strengthen the host immune response and prevent the worsening of severe respiratory tract manifestations. ifn-β- therapy has been used for the long-term management of multiple sclerosis (ms) and has been associated with a number of aes. when administered subcutaneously in ms patients, the most common aes were flu-like symptoms, injection site reactions, worsening of ms symptoms, menstrual disorders, mood alterations and laboratory abnormalities (walther & hohlfeld, ) . the most common laboratory abnormalities were neutropenia, leukopenia, lymphopenia and raised aminotransferases (walther & hohlfeld, ) . a genome-wide association study of patients with ifnβ induced liver injury showed that rs which has been linked to differential expression of interferon regulatory factor (irf)- is a predisposing factor (kowalec et al., ) . this may be related to the fact that irf leads to apoptosis in the presence of ifn-β. depression is a common ae reported in patients receiving subcutaneous ifn-β- therapy, and thus caution is needed when administering to those with a previous or current history of depressive disorder (biogen) . whilst rare, careful monitoring of clinical manifestations such as new onset hypertension, thrombocytopenia, impaired renal function and fever are required in order to identify cases of thrombotic microangiopathy (tma) (biogen) . tma is rare and has been reported at different time points of ifn-β- therapy (biogen; nishio et al., ; yam, fok, mclean, butler, & kempster, ) . laboratory findings of a decreased platelet count, increased serum lactate dehydrogenase (ldh) and red blood cell fragmentation are suggestive of tma (biogen) . if diagnosed, patients must discontinue ifn-β- therapy and will require plasma exchange (biogen) . sng is an inhaled form of ifn-β- a produced by synairgen. the company have tested the efficacy and safety of the drug for the prevention and treatment of symptoms associated with respiratory viral infection in asthma and chronic obstructive pulmonary disease (copd) (synairgen plc, ). a randomised, placebo-controlled phase trial is currently ongoing to assess the safety and efficacy of inhaled sng for the treatment of patients with covid- (nct ). data from the asthma trials have revealed that when administered via inhalation, high levels of ifn-β- a are achieved within the lungs with lower levels within the circulation leading to improvements in lung function, antiviral responses and better asthma control (djukanović et al., ) . inhaled sng seems to have a good safety profile; patients within the sng arm reported cardiac palpitations whereas no cases were reported in the placebo arm, but symptoms were mild and not considered clinically significant (djukanović et al., ) . this article is protected by copyright. all rights reserved. a clinical trial has been undertaken in hospitalised covid- patients where the triple combination of ifn-β, lopinavir-ritonavir and ribavirin was compared to lopinavir-ritonavir and ribavirin (hung et al., ; shalhoub, ) . patients in the triple combination therapy arm achieved negative tests results faster than those in the control arm, with improved patient symptoms, decreased viral shedding and decreased overall length of stay in the hospital compared to those in the control group (hung et al., ) . aes reported in both groups included nausea and diarrhoea. however, due to polypharmacy in this trial, it was difficult to determine the effect of ifn-β on sars-cov- alone. ifn-β has reported ddis with other covid- therapies including chloroquine and hyrdroxychloroquine, and with anakinra, sarilumab and tocilizumab (group, ) . ddis have also been reported with metamizole (analgesic), linezolid (antibacterial), clozapine (antipsychotic), zidovudine (hiv antiretroviral therapy) and some immunosuppressants (adalimumab, azathioprine and pirfenidone) (group, ) . reviewing the safety of potential covid- treatments (table ) is complex due to the fast-moving pace of research in this field. for example, chloroquine and hydroxychloroquine with or without an accompanying macrolide antibiotic, have consistently been at the forefront of covid- research efforts since the outbreak began. however, the astonishing developments over a week or so have led to retraction of a highly publicised paper, and results from a post-exposure prophylaxis trial and a treatment trial (recovery), both of which have shown no beneficial effect of hydroxychloroquine (boulware et al., ; mehra, ruschitzka, & patel, ) . this highlights that the rapid rate of discoveries surrounding covid- therapies generates the need to update this perspective frequently, in order to ensure that the safety of any newly repositioned therapies, novel developmental compounds, or new therapeutic combinations are investigated. for example, the potential use of heparin in novel forms, including nebulised therapy (clinical trial identifier nct ), as an antiviral agent is currently the subject of several investigational trials. in addition, the potential utility of nitazoxanide is currently the subject of several clinical trials (clinical trials.gov, a; pepperrell, pilkington, owen, wang, & hill, ; rajoli et al., ) . it is clearly essential that the harm:benefit ratio of any pharmaceuticals being considered for use in the treatment of covid- are thoroughly considered. this ratio changes dependent upon the disease stage and is correlated to potential mortality. for example, a higher risk may be accepted for patients in the later stage of severe disease than the same therapeutic agent administered in mild disease. this difference in harm-benefit analysis becomes even more striking when considering the use of such agents to prevent infection. as is the case for many highly contagious viruses, prevention by prophylaxis would be incredibly valuable. some of the agents described in this review, including chloroquine and ritonavir have been suggested as potential prophylactic agents, but to date, data on efficacy have been disappointing (rathi, ish, kalantri, & kalantri, ; spinelli, ceccarelli, di franco, & conti, ) . clearly, treatment duration for prophylaxis is expected to be longer than for treatment of covid- , and this may further alter the harm-benefit ratio, reinforcing the need for safety considerations at the outset of any clinical trials. similarly, the evaluation of therapy risk also applies to long-term recovery. as the current pandemic progresses, it is becoming apparent that being discharged from hospital does not necessarily mean that patients are free from covid- symptoms. large numbers of patients who have survived severe sars-cov- infection may have incurred long-term health problems, including some permanent loss of lung and kidney function (foundation, ; su et al., ; summers, ) . consequently, it is probable that long-term therapies will be required for many patients to maintain, or ideally restore, normal physiological organ function. it is vital that therapies which will be used to treat patients during their long-term recovery are also undergoing evaluation for their safety, particularly as many of these agents may need to be administered over much longer periods of time than initial covid- treatments. the identification and characterisation of biomarkers of disease and safety will be invaluable in the further development and deployment of therapies for covid- . disease biomarkers, for example of lung injury or the hyperinflammatory reponse, may allow the stratification of therapy in order to select the agent best suited to the stage of disease. moreover, biomarkers should be considered to monitor patient safety in cases of known aes. for example, the manufacturer's guidelines for remdesivir recommend daily liver function tests due to the risk of transaminase elevations (gilead, ) . these tests are essential, particularly with regards to covid- where increased alt levels are reported to be common amongst hospitalised patients (bangash et al., ; l. zhang et al., ). looking to the future, improvements in the specificity, predictivity and reliability of drug-induced organ damage, through academic-industry partnerships such as the biomarker qualification program in the critical path institute in the us, and the european innovative medicines initiative consortium transbioline, will help improve clinical assessment of covid- drug safety issues. continued enhancements in the speed, predictivity, and human translation of safety assessment for toxicity of anti-viral compounds is clearly warranted, and this may include animal models of sars-cov- as well as in vitro models, in order to assess efficacy alongside safety. such a full understanding for individual therapies will indicate the combinations that can have the potential to provide the best this article is protected by copyright. all rights reserved. synergy for benefit, while forewarning of the potential for increased risk/harm through pharmacokinetic or toxicodynamic interaction. although outside the scope of this review, a vaccine for covid- remains the greatest hope to end the pandemic and protect the population. as of th july , according to who there are vaccines in clinical trial stages and in preclinical stages of evaluation (world health organisation, b). currently, potential vaccines are only just beginning to be tested for efficacy in humans in early phase studies, and therefore safety data will begin to emerge as larger numbers of individuals are administered the vaccine. safety data regarding preliminary vaccinations against sars and mers are limited, but the available information may be useful during the development of covid- vaccines due to the similarities between the coronavirus strains (padron-regalado, ). one safety concern relevant to coronaviruses is the potential for the induction of antibody-dependent enhancement (ade), a phenomenon which was observed in cats vaccinated against feline infectious peritonitis coronavirus, and has also been seen in patients vaccinated against zika virus and dengue virus (khandia et al., ; padron-regalado, ; vennema et al., ) . ade can occur when nonneutralising antibodies bind to virus particles and increase their uptake into host cells, instead of rendering them non-infectious (padron-regalado, ; tirado & yoon, ) . this caused concern in initial sars vaccine development, but can reportedly be avoided by using truncated versions of the viral s glycoproteins (he et al., ) . acknowledging safety concerns such as this, as well as the ways they can be attenuated, may be paramount in the timely development of a vaccine against covid- . in conclusion, although expanding extremely rapidly, the field of therapies to treat covid- remains in its infancy. safety will continue to play a major role in therapeutic success, as apparent with recent reports of increased cardiac toxicity associated with the use of chloroquine/hydroxychloroquine in the treatment of covid- , despite its long history of use as an antimalarial. above all, this perspective has exemplified the need to view safety concerns in the context of the individual and specific phase of disease in order to formulate a comprehensive harm-benefit balance. importantly, an awareness of potential safety concerns will support the development of the next stage of therapy targeting prophylaxis and recovery post-covid infection. it is imperative that safety scientists look to rise to the challenge of covid- by utilising their expertise in mechanistic understanding, biomarker development and toxicokinetic modelling in order to support the development of covid- therapies that can be used effectively and safely. aa, bkp, cbb, ceg, rlj, rtk, shk, slp and xm declare that that they have no conflicts of interest. ao declares no direct conflict of interest but is director and cso for tandem nano ltd and a co-inventor of patents relating to drug delivery of infectious disease medicines. aec reports no direct conflict of interest but receives research funding for the support of sp and rlj from servier pharmaceuticals and astrazeneca, these are unrelated to the published work. aec receives additional unrelated research funding from janssen pharmaceuticals. ao has received consultancy and /or research funding from viiv healthcare, merck, astrazeneca, gilead, and janssen unrelated to the current paper. db received educational grants and/or consultancy from abbvie, novartis, merck, gilead and viiv healthcare outside the submitted work. mp receives research funding from various organisations including the mrc, nihr, eu commission and health education england. he has also received partnership funding for the following: mrc clinical pharmacology training scheme (co-funded by mrc and roche, ucb, eli lilly and novartis); and a phd studentship jointly funded by epsrc and astra zeneca. he has also unrestricted educational grant support for the uk pharmacogenetics and stratified medicine network from bristol-myers squibb and ucb. none of the funding received is related to the current paper. figure : overview of the mechanisms of action of the repurposed drugs undergoing clinical trials for the treatment of covid- that will be reviewed in this perspective. compounds in red represent those that are viral entry inhibitors, compounds in green represent disruptors of cellular viral processing, compounds in blue are modulators of the hyperinflammatory phase of infection and compounds in yellow stimulate host immunomodulatory and anti-viral activity. abbreviations: ace , angiotensin converting enzyme ; il- , interleukin- ; il- , interleukin- ; jak, janus kinase; rdrp, rna-dependent rna polymerases; 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projection of optimized dosing design of hydroxychloroquine for the treatment of severe acute respiratory syndrome coronavirus (sars-cov- ) liver injury in covid- : management and challenges scientific and regulatory perspectives on metabolizing enzyme-transporter interplay and its role in drug interactions: challenges in predicting drug interactions single-cell rna expression profiling of ace , the putative receptor of wuhan -ncov. biorxiv covid- and the cardiovascular system key: cord- -j l l dx authors: pau, alice k.; aberg, judith; baker, jason; belperio, pamela s.; coopersmith, craig; crew, page; glidden, david v.; grund, birgit; gulick, roy m.; harrison, carly; kim, arthur; lane, h. clifford; masur, henry; sheikh, virginia; singh, kanal; yazdany, jinoos; tebas, pablo title: convalescent plasma for the treatment of covid- : perspectives of the national institutes of health covid- treatment guidelines panel date: - - journal: ann intern med doi: . /m - sha: doc_id: cord_uid: j l l dx in the united states, the efficacy and safety of convalescent plasma for treating coronavirus disease (covid- ) is currently being tested in randomized placebo-controlled clinical trials. treatment of individual patients with covid- with convalescent plasma outside such trials is also now permitted through u.s. food and drug administration emergency use authorization. here, members of the national institutes of health covid- treatment guidelines panel provide their views regarding use of convalescent plasma for treating covid- . c urrently, no food and drug administration (fda)approved therapeutics exist for coronavirus disease . in this context, the pandemic has put considerable pressure on health care providers to prescribe treatments despite limited information about their safety and efficacy. this pressure has exacerbated the tension between the importance of practicing evidence-based medicine and the urgency of providing access to promising therapies before their safety and efficacy are established. as members of the national institutes of health covid- treatment guidelines panel (the panel) ( ), we are charged with providing guidance for u.s. clinicians on the treatment of covid- by reviewing current scientific evidence and providing real-time recommendations based on the strength and quality of the data. on august , the fda issued an emergency use authorization (eua) for convalescent plasma for treating covid- ( ). an eua does not constitute drug approval by the fda. rather, an eua allows the fda to facilitate the availability and unapproved uses of medical products during a public health emergency ( ). the criteria for issuing an eua for medical products include the following: the public health concern must be serious or life threatening; sufficient evidence must exist that the product "may be effective"; the known and potential benefits of the product, when used to diagnose, prevent, or treat the identified disease or condition, outweigh the known and potential risks of the product; and no adequate, approved alternatives to the product are available ( ). a strong scientific rationale and historical precedents exist for the study of passive immunotherapeutic approaches for viral infections ( ). concentrated, virusspecific immunoglobulin preparations are fda approved for the postexposure prophylaxis of such viral infections as hepatitis b, varicella, and rabies ( ). recently, a randomized controlled trial (rct) demonstrated the efficacy of different monoclonal antibody products for treating ebola virus disease ( ). the situation is less clear regarding the safety and efficacy of convalescent plasma, which has been used to treat viral infections from the influenza pandemic to the recent epidemics of severe acute respiratory syndrome (sars), h n influenza, middle east respiratory syndrome, and ebola virus disease ( - ). the only rct demonstrating efficacy of convalescent plasma for an infectious disease was conducted more than years ago, for treating argentine hemorrhagic fever ( ). early in the covid- pandemic, convalescent plasma was used in china to treat hospitalized patients with covid- ( ). shortly thereafter, rcts evaluating convalescent plasma in patients with covid- began in several countries, including the united states ( ) . in march , the fda authorized expanded access to convalescent plasma for treating severe or life-threatening covid- under individual-patient emergency investigational new drug applications. the mayo clinic's expanded access program (eap) was developed in parallel to provide broader access to convalescent plasma; however, it was not designed to generate definitive data on safety or to evaluate efficacy ( ) . one of the requirements for an eap is that it not interfere with pivotal trials ( ) . adequately powered rcts of convalescent plasma in the united states have been slow to enroll patients. given the lack of data from properly powered rcts, and the need to inform regulatory decision making regarding continued access to convalescent plasma, both the fda and the mayo clinic performed retrospective, indirect evaluations of efficacy by using eap data, hypothesizing that patients who received plasma units with higher titers of neutralizing antibodies would have better clinical outcomes. the results of the analyses were used as supporting evidence for the eua. the fda analysis included patients, and donor neutralizing antibody titers were measured by the broad institute, using a sars coronavirus (sars-cov- ) neutralization assay ( ) . the analysis revealed no difference in -day mortality between the patients who received high-titer and those who received lowtiter plasma in the overall population or in the subset of patients who were intubated. however, among nonintubated patients (approximately two thirds of those analyzed), % of those who received high-titer plasma died within days of transfusion compared with % who received low-titer plasma (p = . ) ( ) . in a post hoc analysis of nonintubated patients who were younger than years and treated within hours of diagnosis, -day mortality for those who received high-versus lowtiter plasma was . % and . %, respectively (p = . ) ( ) . a similar efficacy analysis by the mayo clinic included participants who had received a single unit of plasma among the participants who had received plasma through the eap by july ( ) . antibody titers were measured by using the vitros anti-sars-cov- igg assay (ortho clinical diagnostics), and outcomes were compared among patients receiving low-(lowest %), medium-, and high-titer (highest %) plasma. after adjusting for baseline characteristics, the -day mortality rate was . % in the low-titer group and . % in the high-titer group. this difference did not reach statistical significance. the mayo clinic post hoc subgroup analyses also suggested a benefit of high-titer plasma in patients who received plasma within days of covid- diagnosis ( ) . the fda concluded that the totality of data, including additional data from small randomized trials and nonrandomized, observational, and animal studies, met the criteria for eua issuance. despite clearly meeting the "may be effective" criterion for eua issuance, the analyses of the eap data are not sufficient to establish the efficacy or safety of convalescent plasma because of the lack of an untreated control group. for example, the possibility that differences in outcomes are attributable to harm from low-titer plasma rather than benefit from high-titer plasma cannot be excluded. in addition, the eap data may be subject to several confounders, including regional differences and temporal trends in covid- management. there is no widely available and generally agreed-upon best test for measuring neutralizing antibodies, and the antibody titers in convalescent plasma from patients who have recovered from covid- are highly variable. in addition, the analyses focused on early mortality, which may not be clinically meaningful in the context of the prolonged disease course of covid- . the efficacy analyses rely on a subset of eap patients and thus represent only a fraction of patients who received plasma through the eap ( ) . in this regard, additional analyses of the eap cohort and completion of the current rcts will be of critical importance. taking everything into account, the panel has determined that currently the data are insufficient to recommend for or against convalescent plasma for treating covid- ( ) . prospective, well-controlled, and adequately powered rcts are needed to determine whether convalescent plasma and other passive immunotherapies are effective and safe for covid- treatment. although providers have access to this therapy, the panel cannot recommend it as a standard of care for treating covid- at this time. this is consistent with the language of the convalescent plasma eua fact sheet ( ) . the covid- pandemic has intensified the tension between providing rapid access to promising therapies and generating the scientific evidence needed to establish whether those therapies are safe and effective. this tension was also noted during the west african ebola outbreak in to , when several therapies, including convalescent plasma, were claimed to be of benefit. a national academies of sciences, engineering, and medicine review of that response noted that rcts are critical during an outbreak, because they are the quickest way to identify effective therapies ( ) . experience with convalescent plasma, hydroxychloro-quine, and other interventions has taught us that large observational cohorts, eaps, and euas can have a profound impact on our ability to conduct the properly designed rcts necessary to provide definitive evidence of safety and efficacy. conversely, the lack of access to large rcts at many health care centers during the covid- pandemic may exacerbate issues of equity in access to care. expanded access programs continue to be an important mechanism to provide promising therapies for patients who do not otherwise have access to them (that is, through clinical trials). balancing this tension is challenging but imperative to maintaining the ability to generate rigorous and convincing evidence during a public health crisis. despite the challenges of the covid- pandemic, conducting well-controlled, adequately powered rcts is possible. two such trials, actt (adaptive covid- treatment trial) and recovery (randomized evaluation of covid- therapy), recently demonstrated the efficacy of remdesivir and dexamethasone, respectively, for treating covid- ( , ) . collaboration and partnership among governmental agencies, industry, academia, and the public are needed to establish and carry out a robust and coordinated emergency research response, including the rapid development, deployment, and analysis of high-caliber rcts. this approach is the quickest and most efficient way to generate the answers needed to provide the best evidence-based patient care. covid- treatment guidelines list of randomized trials of convalescent plasma. clinicaltrials.gov. accessed at www.clinicaltrials.gov /ct /results? expanded accesss to convalescent plasma for the treatment of patients with covid- [protocol]. version . . accessed at www.uscovidplasma.org/physicians-protocol on food and drug administration expanded access to investigational drugs for treatment use. section eua : emergency use authorization (eua) request. accessed at www.fda.gov/media / /download on food and drug administration. decisional memo. accessed at www.fda.gov/media/ /download on effect of convalescent plasma on mortality among hospitalized patients with covid- : initial three-month experience. medrxiv national institutes of health. the covid- treatment guidelines panel's statement on the emergency use authorization of convalescent plasma for the treatment of covid- . accessed at www .covid treatmentguidelines.nih.gov/statement-on-convalescent -plasma fact sheet for health care providers. emergency use authorization (eua) of covid- convalescent plasma for treatment of covid- in hospitalized patients integrating clinical research into epidemic response: the ebola experience. national academies pr remdesivir for the treatment of covid- -preliminary report dexamethasone in hospitalized patients with covid- -preliminary report author contributions: conception and design analysis and interpretation of the data critical revision for important intellectual content obtaining of funding: h.c. lane. administrative, technical, or logistic support key: cord- -qsx m e authors: tsai, y. c.; tsai, t. f. title: oral disease-modifying antirheumatic drugs and immunosuppressants with antiviral potential, including sars-cov- infection: a review date: - - journal: ther adv musculoskelet dis doi: . / x sha: doc_id: cord_uid: qsx m e there have been several episodes of viral infection evolving into epidemics in recent decades, and severe acute respiratory syndrome coronavirus (sars-cov- ) is the latest example. its high infectivity and moderate mortality have resulted in an urgent need to find an effective treatment modality. although the category of immunosuppressive drugs usually poses a risk of infection due to interference of the immune system, some of them have been found to exert antiviral properties and are already used in daily practice. recently, hydroxychloroquine and baricitinib have been proposed as potential drugs for sars-cov- . in fact, there are other immunosuppressants known with antiviral activities, including cyclosporine a, hydroxyurea, minocycline, mycophenolic acid, mycophenolate mofetil, leflunomide, tofacitinib, and thalidomide. the inherent antiviral activity could be a treatment choice for patients with coexisting rheumatological disorders and infections. clinical evidence, their possible mode of actions and spectrum of antiviral activities are included in this review article. lay summary: immunosuppressants often raise the concern of infection risks, especially for patients with underlying immune disorders. however, some disease-modifying antirheumatic drugs (dmards) with inherent antiviral activity would be a reasonable choice in the situation of concomitant viral infections and flare up of autoimmune diseases. this review covers dmards of treatment potential for sars-cov- in part i, and antiviral mechanisms plus trial evidence for viruses other than sars-cov- in part ii. infections are a common concern of immunosuppressive drugs. however, some immunosuppressants or disease-modifying antirheumatic drugs (dmards) show antiviral activity and may be safely used or even beneficial in patients with selected concomitant viral infections. certain dmards may even be considered as an alternative treatment for recalcitrant infections. moreover, the concomitant use of immunosuppressants and antiviral agents was proved to be more effective than antiviral agent monotherapy in some reports. the antiviral property of immunosuppressants may act through (a) direct virucidal activity, (b) blockage of receptors, (c) inhibition of necessary molecules for viral replication in the hosts, or (d) amelioration of inflammatory symptoms. also, control of inflammation may decrease the susceptibility or enhance host ability to defend against viral infection. the are indicated to treat and prevent malaria. they are also used as dmards for rheumatoid arthritis, lupus erythematosus, and porphyria cutanea tarda. in addition, the application for viral infections in off-label use has recently been investigated vigorously. the antiviral activity is through blocking the virus/cell fusion via increasing endosomal ph and hindering the glycosylation of cellular receptors ( figure ). in vitro cq revealed low half-maximal effective concentration (ec ) and high half-cytotoxic concentration (cc ) for covid- . a preliminary study conducted in china showed benefits in pneumonia image, shortening of disease course, and promoting a virus-negative conversion compared with control group. then, four completed clinical studies demonstrated favorable outcomes in clinical and radiologic amelioration, while another two randomized controlled trials (rcts) illustrated no statistically significant change compared with control arms. [ ] [ ] [ ] [ ] [ ] [ ] based on the inhibitory effect of azithromycin against ebola and zika viruses in vitro, and the possibility of preventing from progressing to severe respiratory tract infections, two french trials which combined the use of azithromycin and hcq revealed better efficacy. , however, further studies are still needed to draw conclusions because most of these studies bear limitations including selection bias, allocation bias, or insufficient case numbers. several multicenter, double-blind, and well-designed controlled trials are already underway to assess the efficacy and safety of cq or hcq in the treatment of covid- pneumonia. in the absence of other confirmed effective therapy specific to sars-cov- , both drugs are currently still listed in the treatment guidelines (table ) . baricitinib, blocking janus kinase (jak) and jak , is approved for rheumatoid arthritis and has been investigated in atopic dermatitis. sars-cov- binds on the angiotensin-converting enzyme (ace ) receptors and enters lung cells through receptor-mediated endocytosis. some of the numb-associated kinase (nak) family members, ap -associated protein kinase (aak ) and cyclin g-associated kinase (gak), are hypothesized to regulate the ace -mediated endocytosis. baricitinib demonstrated high affinity to aak and in one controlled open-label study (n = ), patients were given either baricitinib mg/day plus lopinavir-ritonavir or antiretroviral plus hydroxychloroquine (control group) for weeks. significant improvement of symptoms and laboratory results, no intensive care unit transfer (versus % transfer in control cases), and % discharge from wards (versus % in control) was shown among the baricitinib-treated individuals. in addition to antiviral property, baricitinib has been suggested as an approach for a cytokine storm syndrome, which features hypercytokinemia and multi-organ failure. elevated ferritin and il- in covid- cases were predictive of a high mortality rate according to a china retrospective study. baricitinib inhibits cytokines including il- , il- , il- , interferon gamma (ifn-γ), and granulocytecolony-stimulating factor (g-csf) , and may bring the benefit of immune reconstruction which could be used in rapidly progressive diseases. however, there are competing ideas about the interference of jak inhibitors with ifn-mediated antiviral activities. ifns prohibit viral spreading in the early phase of infections. in animal models of sars and middle east respiratory syndrome (mers), ifn-α and ifn-β showed benefit at the early stage but were harmful at the late phase. patients with severe sars who died of hypoxemia revealed high ifn-α, -γ, while those discharged dmards, disease-modifying anti-rheumatic drugs. journals.sagepub.com/home/tab from hospital had low ifn-α, -γ. therefore, some experts suggested baricitinib's use in the situation of hyperinflammation and cytokine syndrome, rather than in those with mild diseases. in fact, clinical trials have commenced to evaluate the optimal timing, duration, and safety of baricitinib in viral infections, including sars-cov- . [ ] [ ] [ ] cyclosporine a cyclosporine a (csa) is indicated for rheumatoid arthritis, psoriasis, organ transplants to prevent injection, and keratoconjunctivitis sicca. it is also used in severe atopic dermatitis, chronic urticaria, pyoderma gangrenosum kimura disease, acute systemic mastocytosis, and ulcerative colitis. csa inhibits lymphocyte function, mainly t cells, by forming a complex with cyclophilin. cyclophilin-csa complex binds on the calcineurin, which blocks the dephosphorylation of nuclear factor of activated t cells (nf-at). this interferes with entry of nf-at into the t-cell nucleus and further suppresses cytokine production such as il- . severe covid- . experimentally, csa targets cyclophilin d to inhibit mitochondrial permeability transition pore (mptp) opening and rescues mitochondria from apoptosis. [ ] [ ] [ ] moreover, melanoma-differentiation-activated protein (mda ), an rlr helicase and putative cytoplasmic receptor of sars-cov- , is also the target antigen of clinically amyopathic dermatomyositis (cadm). patients with mda plus cadm have higher risks of developing rapidly progressive interstitial lung diseases and respiratory failure, while this could be reversed by calcineurin inhibitors. based on these hypothetical functions, csa was proposed as a modulator for cytokine storm syndrome in covid- infections. mycophenolic acid (mpa), an active metabolite of mycophenolate mofetil (mmf), inhibits inosine monophosphate dehydrogenase (impdh), an essential enzyme in the de novo purine synthesis pathway. impdh inhibition especially influences t and b lymphocytes because they use almost a de novo pathway to synthesize (minimally use a salvage pathway). mmf and mpa are utilized in organ transplantation, crohn's disease, and as steroid-sparing agents for conditions such as pemphigus, behçet's disease, and lupus erythematosus. although they were associated with higher risk of opportunistic infections including herpes zoster, cytomegalovirus (cmv), and bk virus (bkv) nephropathy, literature also revealed its possible benefit for hiv and influenza virus. , in vitro: mmf showed low ec ( . μmol/l) in sars-cov- -infected vero e cells, while the ec of remdesivir, as a positive control, was . μmol/l. besides, mmf probably inhibited sars-cov- through impdh and especially dihydroorotate dehydrogenase (dhodh). dhodh is another essential enzyme for pyrimidine synthesis, and mmf might control viral infection by depleting the intracellular pyrimidine pools. thalidomide thalidomide, a derivative of glutamic acid, is approved for erythema nodosum leprosum and is also used in many conditions such as prurigo nodularis, pyoderma gangrenosum, bechet's disease, lupus erythematosus and erythema multiforme. it exerts anti-inflammatory effect through cereblon e ubiquitin ligase as the primary target and thus inhibits chemotaxis of leukocytes, monocytes as well as the production of tumor necrosis factor (tnf)-alpha, il- , and il- . case report: a -year-old woman with critical symptoms of covid- was treated by thalidomide mg every h. after the first day use of thalidomide, clinical conditions including oxygen index improved. cytokines such as il- , il- , ifn-γ all decreased to normal range. proposed mechanisms are as follows: thalidomide inhibits nf-κb, which further suppresses the production of pro-inflammatory cytokines such as tumor necrosis factor alpha (tnf-α) and il- , and prevents the cytokine surge. it also regulates immune function by activating t cells and t-cell receptors. moreover, the sedative and antiemetic property of thalidomide helps anxious patients calm down, which reduces oxygen consumption. now, at least one clinical trial has been conducted to investigate the efficacy and safety of thalidomide as an adjuvant therapy for covid- pneumonia. part ii: dmards with antiviral potential other than sars-cov- many oral dmards have inherent antiviral activity and could be the treatment of choice for patients with coexisting immune-based diseases and infections. especially when the infection is still in progression, choosing dmards with anti-microbial evidence would bring double benefits for better infection control without sacrificing underlying disease management. the antimicrobial mechanisms of dmards are often distinct from their immunomodulatory pathway, and the efficacy is different in viral species (tables , leflunomide is approved for rheumatoid arthritis and psoriatic arthritis (not in the united states). leflunomide inhibits the synthesis of pyrimidine via acting on the mitochondrial enzyme dhodh; therefore, rapidly dividing cells, especially lymphocytes, are suppressed. on the other hand, leflunomide showed antiviral activity at least for cmv, bkv, and hiv. it works by teriflunomide, the active metabolite of leflunomide, which disrupts nucleocapsid tegumentation, and thus prevents virion assembling, rather than influences the de novo pyrimidine synthesis pathway. herpes simplex virus a case report with perianal hsv- lesions in an acyclovir-resistant hiv patient significantly improved with leflunomide mg, twice a day. another hiv patient with hsv- /hsv- pseudo-tumors on the perineum and scrotum only slightly improved with valacyclovir, foscarnet, and imiquimod. after months of leflunomide, complete regression of the lesions was noted. leflunomide has both immunomodulation and antiviral activities in the hsv pseudotumors because pseudotumor formation is an immune reconstruction phenomenon in hiv patients. human immunodeficiency virus an rct (n = ) demonstrated leflunomide decreased the activation and cycling of cd + t cells. the expression of hiv co-receptors ccr and cxcr was also reduced compared with placebo. three patients with atopic dermatitis treated with azathioprine developed multiple verrucae and molluscum contagiosum. due to treatment resistance, azathioprine was switched to leflunomide ( mg loading days, then mg/day). all the lesions subsided in three patients within months of leflunomide treatment. multiple recalcitrant verrucae in three and molluscum in one of renal allograft recipients cleared after switching from mmf to leflunomide. leflunomide can serve as a potential option for patients with skin warts or molluscum concomitant with immune conditions that require immunosuppressants. leflunomide was regarded as an add-on treatment for multi-drug-resistance cmv infection. in vitro anti-cmv properties of leflunomide were not through blocking the replication of viral dna, so it is effective even in patients with direct antiviral drug-resistance history. disseminates to the urinary-tract system and lives there persistently. a sudden increase of bk-virusassociated nephropathy is related to the administration of potent immunosuppressants such as mmf and tacrolimus. leflunomide is now generally accepted as a second choice after reduction of immunosuppressive agents. however, in a phase ii rct (n = ), viremia was decreased in the group of leflunomide active metabolites, but no significant improvement of renal function was noted. treatment options for rsv are limited to supportive care or ribavirin with only marginal effectiveness. leflunomide showed a potent, dose-dependent anti-rsv activity in cell cultures. also, pulmonary viral loads were prominently reduced in cotton rats, even if there was a -day delay of leflunomide administration after viral inoculation. leflunomide offers a dual benefit of both viral-load reduction and anti-inflammatory effects that attenuate the destruction of cytokine-related diseases. tofacitinib, a jak and jak inhibitor, is indicated in rheumatoid arthritis, ulcerative colitis, and psoriatic arthritis. it is also used off label for vitiligo and alopecia areata. tofacitinib treats inflammatory diseases by interfering with the activation of the jak/signal transducers and activators of transcription (stat) pathway, which inhibits gene transcription, and cytokine production is thereby reduced. htlv- , a retrovirus, has been linked to diseases such as adult t-cell lymphoma/leukemia (atll), htlv- -associated myelopathy (ham), and uveitis. ex vivo and animal studies revealed positive results of tofacitinib for atll and ham. htlv- -encoded tax protein activates il- , - , - , which further trigger jak -stat pathway. accumulating data demonstrated a major role of jak in the pathophysiology of atll. as a result, tofacitinib targeting jak has been suggested as a therapeutic strategy in future studies. hydroxyurea, a deoxyribonucleic acid (dna)synthesis inhibitor, belongs to the antineoplastic medications. however, it may be used as a second-line drug for psoriasis and palmoplantar pustulosis based on the ability to slow down the rapid division of keratinocytes. bone marrow suppression is the major and common adverse effect of hydroxyurea. hydroxyurea demonstrated promising results in reducing hiv rna viral loads in five placebocontrolled clinical trials. among all the trials, hydroxyurea was combined with didanosine, a nucleoside analog reverse-transcriptase inhibitor (nrti). however, one should be reminded that decreased cd counts were noted in some studies. therefore, close follow up of hematologic change is required in daily practice. [ ] [ ] [ ] [ ] [ ] in vitro studies demonstrated the antiviral modes of hydroxyurea. first, hydroxyurea depletes deoxynucleoside triphosphate (dntp) pools, which impedes dna synthesis and in turn slows down the production of viral dna. second, hydroxyurea enhances nrti phosphorylation and reduces resistance to nrtis. this may partially explain the benefits of adding hydroxyurea to nrti for viral control. finally, cytotoxic effect of hydroxyurea makes cellular division of cd + t cells decline. this enables hydroxyurea to block hiv proliferation, because hiv could only replicate in dividing cd + t cells. although the mode of action of hydroxyurea for hcv, hbv, hsv, and b v is unknown, viral replications were inhibited by hydroxyurea in in vitro studies. , [ ] [ ] [ ] small-scaled clinical trials showed significant reduction of hcv rna levels and hbv viral loads in chronic hcv and hbv carriers, respectively. , however, there is a case report of an elderly patient with essential thrombocythemia experiencing reactivation of hbv during treatment with hydroxyurea. a retrospective review of children with sickle cell anemia demonstrated decreased requirement of blood transfusion and attenuation of clinical symptoms when using hydroxyurea in patients with b v infection. minocycline, a second-generation of tetracyclines, is frequently used for bacterial infections, acne, and rheumatoid arthritis. the small size and lipophilic nature facilitate its penetration into blood-brain barrier easily. the neuroprotection and anti-inflammation effects , brought interest in the treatment of virus-induced encephalitis such as hiv, japanese encephalitis virus (jev), and reovirus. the antiviral property is not clearly known but seems to be diverse, including neuroprotective, antiapoptotic, interference of viral protein expression, and anti-inflammatory effects. in microglial cell culture, minocycline reduced viral replication by - %. in vivo, macaque monkeys treated with minocycline showed less destruction of axons and less replication of viruses in the central nervous system. the experiment suggested that the antiviral effect of minocycline was through reducing the activation of monocytes and hence, viral replication was blocked. nevertheless, two double-blind, randomized, placebo-controlled human studies revealed that under minocycline mg twice daily, there was no difference in cognitive function compared with placebo. , japanese encephalitis virus minocycline showed high efficacy in animal models and in vitro studies for the treatment of jev. , four clinical trials showed positive results of hiv control, either in the reduction of immune activation or lowering the vertical transmission. [ ] [ ] [ ] [ ] however, another two trials (one rct, one single-arm) revealed no efficacy. , as for dengue, - chikungunya, [ ] [ ] [ ] influenza a viruses, [ ] [ ] [ ] [ ] and hcv, , paradoxical outcomes were found in the literature. therefore, the utilization of cq in these viral diseases still needs further investigation. the major concern of zika virus infection is that it can transmit from placenta to fetus and cause microcephaly or congenital defects. cq prevented zika virus internalization in cell cultures and reduced morbidity or mortality in mice. in addition, it prevented fetal mice from microcephaly. therefore, cq might be a potential treatment waiting for clinical verification. hcq had been reported to downregulate the expression of ifn genes and reduce the production of type i ifns. this phenomenon was noted in vitro and in human studies of autoimmune diseases. since ifns are crucial in innate immunity to defend viral infections, the usage of hcq may raise concerns about the counter effects in viral control. nevertheless, opposite results were also presented: hcq activated ifnβ signaling pathways in cell studies of dengue virus. betaretrovirus is regarded as one of the environmental factors triggering the recurrence of primary biliary cirrhosis (pbc) after liver transplantation. earlier and more severe recurrence of pbc occurred with tacrolimus compared with csa as an immunosuppressant. this may be partially explained by the antiviral activity of csa. according to an in vitro study, it was suggested that csa interrupted viral replication through inhibiting viral protein synthesis, gag and envelope assembly, and particle budding. the combination of mmf and highly active antiretroviral therapy improved the control of viral replication and delayed viral-load rebound in a randomized pilot study (n = the effectiveness of thalidomide for ks might be related to anti-angiogenesis, and experts hypothesized the modulation of the immune system to trigger an antiviral action. the treatment of immune-based diseases has been revolutionized by the introduction of target therapy, mainly biologics. compared with biologics, conventional synthetic dmards exert broad-spectrum functionality. dmards work through immunosuppressive and antiinflammatory effects with the possibility of higher infection risk. however, many none-biologic dmards demonstrate antiviral activities instead. although in most instances, the antiviral activity of dmards is based on in vitro or small-scale controlled studies, this property would be useful in the choice of dmards for patients with concomitant viral infections. also, the combinational use of antiviral drugs and dmards has been shown to be more effective and less resistant in the control of some viral infections. furthermore, in the face of novel viral infection, such as sars-cov- , screening of existing chemicals, including dmards, may prove to be fruitful. dr tsen-fang tsai has conducted clinical trials or received honoraria for serving as a consultant for abbvie, boehringer ingelheim, bristol-myers squibb, celgene, elililly, galderma, gsk-stiefel, janssen-cilag, leo-pharma, merck, novartis, pfizer inc., and ucb pharma. dr ya-chu tsai has delivered speeches held by abbvie, elililly, janssen-cilag, leo-pharma, novartis, pfizer. the authors received no financial support for the research, authorship, and/or publication of this article. efficacy of combination therapy of antiviral and immunosuppressive drugs for the treatment of severe acute exacerbation of chronic hepatitis b antiviral, immunosuppressive and antitumour effects of ribavirin analysis of therapeutic targets for sars-cov- and discovery of potential drugs by computational methods targeting endosomal acidification by chloroquine analogs as a promising strategy for the treatment of emerging viral diseases remdesivir and chloroquine effectively inhibit the recently emerged novel coronavirus ( -ncov) in vitro breakthrough: chloroquine phosphate has shown apparent efficacy in treatment of covid- associated pneumonia in clinical studies hydroxychloroquine and azithromycin as a treatment of covid- : results of an open-label non-randomized clinical trial a pilot study of hydroxychloroquine in treatment of patients with moderate covid- clinical and microbiological effect of a combination of hydroxychloroquine and azithromycin in covid- patients with at least a six-day follow up: a pilot observational study efficacy of hydroxychloroquine in patients with covid- : results of a randomized clinical trial. medrxiv. epub ahead of print treating covid- with chloroquine hydroxychloroquine in patients with mainly mild to moderate coronavirus disease : open label, randomised controlled trial mechanism of baricitinib supports artificial intelligence-predicted testing in covid- patients baricitinib therapy in covid- : a pilot study on safety and clinical impact thalidomide combined with low-dose short-term glucocorticoid in the treatment of critical coronvirus disease baricitinib as potential treatment for -ncov acute respiratory disease covid- : consider cytokine storm syndromes and immunosuppression jak / inhibition with baricitinib in the treatment of autoinflammatory interferonopathies baricitinib for covid- : a suitable treatment? janus kinase inhibitor baricitinib is not an ideal option for management of covid- baricitinib for covid- : a suitable treatment?-authors' reply why choose cyclosporin a as first-line therapy in covid- pneumonia. reumatol clin. epub ahead of print a novel in vitro cypd-mediated p aggregation assay suggests a model for mitochondrial permeability transition by chaperone systems loss of cyclophilin d reveals a critical role for mitochondrial permeability transition in cell death chloroquine is a potent inhibitor of sars coronavirus infection and spread anti-hiv effects of chloroquine: mechanisms of inhibition and spectrum of activity the additive in vitro anti-hiv- effect of chloroquine, when combined with zidovudine and hydroxyurea hydroxychloroquine treatment of patients with human immunodeficiency virus type effect of chloroquine on human immunodeficiency virus (hiv) vertical transmission reduction of immune activation with chloroquine therapy during chronic hiv infection hydroxychloroquine drastically reduces immune activation in hiv-infected, antiretroviral therapy-treated immunologic nonresponders effects of hydroxychloroquine on immune activation and disease progression among hiv-infected patients not receiving antiretroviral therapy: a randomized controlled trial assessment of chloroquine as a modulator of immune activation to improve cd recovery in immune nonresponding hiv-infected patients receiving antiretroviral therapy chloroquine inhibits dengue virus type replication in vero cells but not in c / cells antiviral activity of chloroquine against dengue virus type replication in aotus monkeys chloroquine use improves dengue-related symptoms a randomized controlled trial of chloroquine for the treatment of dengue in vietnamese adults chikungunya virus: an update on antiviral development and challenges chloroquine phosphate treatment of chronic chikungunya arthritis. an open pilot study on chikungunya acute infection and chloroquine treatment confronting an influenza pandemic with inexpensive generic agents: can it be done? anti-malaria drug chloroquine is highly effective in treating avian influenza a h n virus infection in an animal model influenza a/h n vaccination of patients with sle: can antimalarial drugs restore diminished response under immunosuppressive therapy? chloroquine for influenza prevention: a randomised, doubleblind, placebo controlled trial lysosomotropic agents as hcv entry inhibitors porphyria cutanea tarda in an hcv-positive liver transplant patient: a case report fdaapproved drug, prevents zika virus infection and its associated congenital microcephaly in mice functional association of cyclophilin a with hiv- virions long-term follow-up of hiv positive asymptomatic patients having received cyclosporin a placebo-controlled trial of cyclosporin-a in hiv- disease: implications for solid organ transplantation critical role of cyclophilin a and its prolylpeptidyl isomerase activity in the structure and function of the hepatitis c virus replication complex cyclophilin b is a functional regulator of hepatitis c virus rna polymerase combined interferon alpha b and cyclosporin a in the treatment of chronic hepatitis c: controlled trial cyclosporine inhibits flavivirus replication through blocking the interaction between host cyclophilins and viral ns protein a screen of fda-approved drugs for inhibitors of zika virus infection cyclosporine a inhibits in vitro replication of betaretrovirus associated with primary biliary cirrhosis rationale for the use of hydroxyurea as an anti-human immunodeficiency virus drug combination of a drug targeting the cell with a drug targeting the virus controls human immunodeficiency virus type resistance a placebo-controlled trial of didanosine plus stavudine, with and without hydroxyurea, for hiv infection. the swiss hiv cohort study the hydile trial: efficacy and tolerance of a quadruple combination of reverse transcriptase inhibitors versus the same regimen plus hydroxyurea or hydroxyurea and interleukin- in hiv-infected patients failing protease inhibitorbased combinations activity, safety, and immunological effects of hydroxyurea added to didanosine in antiretroviral-naive and experienced hiv type -infected subjects: a randomized, placebo-controlled trial, actg a randomized trial to investigate the recycling of stavudine and didanosine with and without hydroxyurea in salvage therapy (restart) hydroxyurea as an inhibitor of hepatitis c virus rna replication hydroxyurea suppresses hcv replication in humans: a phase i trial of oral hydroxyurea in chronic hepatitis c patients amazing results with hydroxyurea therapy in chronic hepatitis b: a preliminary report reactivation of hepatitis b virus during treatment with hydroxyurea in an elderly patient with essential thrombocythemia reversible inhibition of herpes simplex virus replication by hydroxyurea hydroxyurea enhances the activity of acyclovir and cidofovir against herpes simplex virus type resistant strains harboring mutations in the thymidine kinase and/or the dna polymerase genes hydroxyurea inhibits parvovirus b replication in erythroid progenitor cells original research: parvovirus b infection in children with sickle cell disease in the hydroxyurea era a novel action of minocycline inhibition of human immunodeficiency virus type infection in microglia neuroprotective and anti-human immunodeficiency virus activity of minocycline minocycline treatment for hiv-associated journals.sagepub.com/home/tab cognitive impairment: results from a randomized trial randomized trial of minocycline in the treatment of hiv-associated cognitive impairment minocycline neuroprotects, reduces microglial activation, inhibits caspase induction, and viral replication following japanese encephalitis minocycline differentially modulates viral infection and persistence in an experimental model of japanese encephalitis minocycline trial in japanese encephalitis: a double blind, randomized placebo study role of oral minocycline in acute encephalitis syndrome in india: a randomized controlled trial drug repurposing of minocycline against dengue virus infection antibiotic minocycline prevents respiratory syncytial virus infection antiinflammatory and antiviral effects of minocycline in enterovirus infections transcriptomic characterization of the novel avian-origin influenza a (h n ) virus: specific host response and responses intermediate between avian (h n and h n ) and human (h n ) viruses and implications for treatment options minocycline inhibits west nile virus replication and apoptosis in human neuronal cells minocycline delays disease onset and mortality in reovirus encephalitis therapy with minocycline aggravates experimental rabies in mice effects of mycophenolic acid on human immunodeficiency virus infection in vitro and in vivo mycophenolic mofetil, an alternative antiviral and immunomodulator for the highly pathogenic avian influenza h n virus infection broadspectrum antivirals for the emerging middle east respiratory syndrome coronavirus treatment with lopinavir/ritonavir or interferon-β b improves outcome of mers-cov infection in a nonhuman primate model of common marmoset inhibition of herpes simplex virus type by the experimental immunosuppressive agent leflunomide successful treatment of acyclovirresistant herpes simplex virus type proctitis with leflunomide in an hiv-infected man leflunomide in the treatment of a pseudotumoral genital herpes simplex virus infection in an hiv patient inhibition of hiv replication by a , the active metabolite of leflunomide, in combination with pyrimidine nucleoside reverse transcriptase inhibitors anti-hiv- activity of leflunomide: a comparison with mycophenolic acid and hydroxyurea the effect of leflunomide on cycling and activation of t-cells in hiv- -infected participants leflunomide: an immune modulating drug that may have a role in controlling secondary infections with review of its mechanisms of action conversion from tacrolimus/mycophenolic acid to tacrolimus/leflunomide to treat cutaneous of four pediatric renal allograft recipients leflunomide for cytomegalovirus: bench to bedside concurrent antiviral and immunosuppressive activities of leflunomide in vivo leflunomide as part of the treatment for multidrug-resistant cytomegalovirus disease after lung transplantation: case report and review of the literature assessment of efficacy and safety of fk in comparison with standard care in renal transplant recipients with untreated bk nephropathy inhibition of respiratory syncytial virus in vitro and in vivo by the immunosuppressive agent leflunomide cp- , , a therapeutic agent, inhibits cytokine-mediated jak activation and proliferation of t cells from patients with atl and ham/tsp activity of thalidomide in aids-related kaposi's sarcoma and correlation with hhv titre activity of thalidomide in aids-related kaposi's sarcoma a prospective evaluation of leflunomide therapy for cytomegalovirus disease in renal transplant recipients ferm domain mutations induce gain of function in jak in adult t-cell leukemia/ lymphoma pustulosis palmaris et plantaris treated with hydroxyurea inhibition of autoimmune encephalomyelitis by a tetracycline minocycline protects pc cells from ischemic-like injury and inhibits -lipoxygenase activation hydroxychloroquine is associated with impaired interferon-alpha and tumor necrosis factor-alpha production by plasmacytoid dendritic cells in systemic lupus erythematosus hydroxychloroquine treatment downregulates systemic interferon activation in primary sjögren's syndrome in the joquer randomized trial hydroxychloroquine-inhibited dengue virus is associated with host defense machinery predictors of major infections in systemic lupus erythematosus previous antimalarial therapy in patients diagnosed with lupus nephritis: influence on outcomes and survival infection risk in systemic lupus erythematosus patients: susceptibility factors and preventive strategies thalidomide in the treatment of kaposi's sarcoma visit sage journals online journals.sagepub.com/ home/tab key: cord- -oigyut k authors: zumla, alimuddin; memish, ziad a; maeurer, markus; bates, matthew; mwaba, peter; al-tawfiq, jaffar a; denning, david w; hayden, frederick g; hui, david s title: emerging novel and antimicrobial-resistant respiratory tract infections: new drug development and therapeutic options date: - - journal: lancet infect dis doi: . /s - ( ) -x sha: doc_id: cord_uid: oigyut k the emergence and spread of antimicrobial-resistant bacterial, viral, and fungal pathogens for which diminishing treatment options are available is of major global concern. new viral respiratory tract infections with epidemic potential, such as severe acute respiratory syndrome, swine-origin influenza a h n , and middle east respiratory syndrome coronavirus infection, require development of new antiviral agents. the substantial rise in the global numbers of patients with respiratory tract infections caused by pan-antibiotic-resistant gram-positive and gram-negative bacteria, multidrug-resistant mycobacterium tuberculosis, and multiazole-resistant fungi has focused attention on investments into development of new drugs and treatment regimens. successful treatment outcomes for patients with respiratory tract infections across all health-care settings will necessitate rapid, precise diagnosis and more effective and pathogen-specific therapies. this series paper describes the development and use of new antimicrobial agents and immune-based and host-directed therapies for a range of conventional and emerging viral, bacterial, and fungal causes of respiratory tract infections. the emergence of diffi cult-to-treat known and novel bacterial, viral, and fungal respiratory tract pathogens with epidemic potential is of major global concern. treatment options are limited by increasing antimicrobialdrug resistance. however, new viral infections causing severe respiratory tract disease with pandemic potential have focused global attention. a substantial rise in the number of patients with multidrug-resistant pulmonary tuberculosis and pan-drug-resistant bacteria has been noted. increasing use of immunosuppressive agents, broad-spectrum antibiotics, and anticancer agents, coupled with resistance to azoles, has led to an increase in the number of invasive pulmonary fungal infections with resultant high morbidity and mortality. successful treatment outcomes for patients with respiratory tract infections across all health-care settings require appropriate, eff ective, and pathogen-specifi c drug or alternative treatments. we describe a range of conventional and emerging viral, bacterial, and fungal causes of respiratory tract infections for which new antimicrobial drugs and immune-based and host-directed therapies are being developed and studied. the outbreak of severe acute respiratory syndrome coronavirus (sars-cov), re-emergence of avian infl uenza a h n , global circulation of oseltamivirresistant seasonal infl uenza a h n , and subsequent emergence of the pandemic infl uenza a h n strain pdm virus (which continues to circulate), have shown the potential limitations of current antiviral treatments for severe respiratory viral infections. epidemic waves of avian infl uenza a h n , sporadic cases of avian infl uenza a h n , the ongoing outbreak of middle east respiratory syndrome coronavirus (mers-cov) infection, and the burden of common respiratory viruses -such as seasonal infl uenza, respiratory syncytial virus, rhinoviruses, and adenoviruses-show that the development of more eff ective therapies to reduce morbidity and mortality is urgently needed. research is focused on the repurposing of available antiviral drugs for generic or specifi c use and for two classes of antiviral drugs are approved for the prevention and treatment of infl uenza in most countries: m inhibitors (amantadine and rimantadine) and neuraminidase inhibitors (oseltamivir, peramivir, zanamivir, and laninamivir; table ). in general, antiviral treatment is indicated as early as possible for any patient with confi rmed or suspected infl uenza who has severe, complicated, or progressive illness or is admitted to hospital, and in outpatients at higher risk of infl uenza complications. , time to treatment after onset of symptoms, illness severity, and extent of viral replication are key variables with respect to response. starting of treatment should not be delayed for diagnostic testing. m inhibitors-also known as adamantanes-are ineff ective against infl uenza b viruses and recently circulating infl uenza a h n and pandemic infl uenza a h n viruses, which are resistant because of an s n mutation in the m ion channel. however, a proportion of avian infl uenza a h n strains will be susceptible, and the combined use of an adamantane and a neuraminidase inhibitor improves antiviral activity for susceptible isolates. two neuraminidase inhibitors are approved for use in most countries: oseltamivir and zanamivir. laninamivir is approved for use in japan only, and peramivir in china, japan, and south korea. several observational studies have shown that when adults admitted to hospital with severe infl uenza are given oseltamivir, mortality falls and clinical outcomes improve, especially when treatment is initiated within days of the onset of symptoms (but positive eff ects are noted when it is begun as late as - days after onset). , , , oseltamivir reduces mortality in infl uenza a h n infection when given before the onset of respiratory failure, and might be benefi cial when started as late as - days after symptom onset. in patients admitted to hospital with severe infl uenza a h n infection, reduction of viral load after treatment with oseltamivir correlated with improved outcome, whereas the emergence of virus resistant to neuraminidase inhibitors that harbours an arg lys substitution is associated with poor outcomes and poor response to oseltamivir and peramivir. the standard duration of oseltamivir treatment is days; longer treatment is recommended for critically ill patients with respiratory failure, who often have prolonged viral replication in the lower respiratory tract despite treatment. whether increased doses provide greater antiviral eff ects in such patients is under investigation. a randomised controlled trial of patients in hospital ( % of whom were children) showed no virological or clinical advantages when a double dose of oseltamivir was given rather than a standard dose. no additional benefi t was noted with high-dose oseltamivir in adults admitted with infl uenza a, although a faster virological response was noted in those with infl uenza b. however, in a randomised controlled trial of critically ill patients with pandemic infl uenza a h n , a triple-dose oseltamivir regimen was associated with signifi cantly higher proportions of viral clearance at days than was standard therapy ( % vs %; p= · ). studies of intravenous neuraminidase inhibitors that are underway should provide further data on the value of high-dose therapy. zanamivir and laninamivir have generally similar profi les of susceptibility. for example, the his tyr mutation confers high-level resistance to oseltamivir carboxylate and reduced susceptibility to peramivir in n containing viruses but does not substantially diminish susceptibility to zanamivir and laninamivir. inhaled zanamivir has not been studied in detail in severely ill patients or those admitted to hospital, in whom eff ective delivery to sites of viral replication and tolerability could be an issue. by contrast, intravenous zanamivir has been used widely on a compassionate basis since the h n pandemic, particularly for late treatment of critically ill adults with pandemic infl uenza a h n virus infection and those with suspected or proven oseltamivir resistance. one trial has shown no drug-related trends in safety measures, and a subset of patients positive at baseline for infl uenza showed a median decrease in nasopharyngeal viral rna load of · log copies per ml after days of treatment. a phase trial in patients who have been admitted to hospital is underway (nct ). a phase randomised controlled trial of inhaled laninamivir in uncomplicated infl uenza failed to show superiority in illness alleviation (primary endpoint) compared with placebo. the trial, involving patients, tested mg and mg doses of the inhaled drug. the median time to alleviate fl u symptoms was · h for the mg dose and · h for the mg dose, compared with · h for the placebo (nct ). das has host-directed receptor-destroying action, which is inhibitory for parainfl uenza and infl uenza viruses, including those resistant to amino adamantanes and neuraminidase inhibitors. when delivered topically, it is eff ective in animal models of lethal infl uenza caused by the h n and h n viruses, including the neuraminidase-inhibitor-resistant arg lys -containing variant. in a phase randomised controlled trial, inhaled das reduced pharyngeal viral replication in uncomplicated infl uenza but did not reduce nasal viral loads or improve clinical outcomes. case reports suggest that inhaled or nebulised das might be eff ective in immunocompromised hosts with severe parainfl uenza lung disease. favipiravir (t- ; -fl uoro- -hydroxy- -pyrazinecarboxamide) is active against infl uenza a, b, and c viruses, including strains resistant to approved antivirals, and a broad range of other rna viruses when given at series somewhat higher concentrations. combinations of favipiravir and neuraminidase inhibitors have additive and synergistic eff ects in preclinical models, but clinical trials have been restricted to uncomplicated infl uenza so far. these clinical trials (combination amantadine, ribavirin, and oseltamivir vs oseltamivir mono therapy [nct ], nitazoxanide vs oseltamivir vs combination vs placebo [nct ], favipiravir vs placebo randomised controlled trial in outpatients [nct , nct ]), which have not been published, suggest that favipiravir has antiviral eff ects similar to those of oseltamivir. a randomised controlled trial showed that favipiravir shortened the time to alleviation of infl uenza symptoms by about hours compared with placebo, and further studies are underway. nitazoxanide is an oral antiparasitic drug with immunomodulatory eff ects, including upregulation of interferon and various interferon-inducible genes and a specifi c infl uenza-inhibitory eff ect related to blockade of haemagglutinin maturation. nitazoxanide inhibits infl uenza replication in vitro and in a phase randomised controlled trial had signifi cant antiviral eff ects ( · log reduction in nasal viral loads) and resulted in a signifi cantly faster time to alleviation of illness (roughly h diff erence in medians from placebo) in uncomplicated infl uenza. a placebocontrolled randomised trial of nitazoxanide versus oseltamivir-and the com bination thereof-in uncomplicated infl uenza and a hospital-based study of its use in severe respiratory illness are in progress (nct ). non-randomly assigned studies and case reports suggest that convalescent plasma with neutralising antibodies is a useful add-on therapy for patients with sars and severe infl uenza pneumonia, including that caused by infl uenza a h n . a recently published systematic review of available sars and infl uenza treatment studies employing convalescent plasma or serum found a signifi cant overall mortality benefi t. a prospective observational study showed lower crude mortality and faster nasopharyngeal viral clearance in plasma-treated patients who were admitted with severe pandemic infl uenza a h n infection, whereas in a randomised controlled trial a reduction in mortality was reported in severe illness when hyperimmune globulin was given within days of the onset of symptoms (table ) . heterosubtypic haemagglutinin stem-neutralising antibodies, which are highly eff ective in animals, are entering clinical evaluation in human beings. the combination of antivirals with diff erent mechanisms of actions (eg, a neuraminidase inhibitor with a polymerase inhibitor such as favipiravir, a broad-spectrum antihaemagglutinin-neutralising antibody, ( ) oral rimantadine and nebulised saline ( ) post-hoc analysis showed faster cough resolution but no signifi cant diff erences in the proportion of patients shedding virus by treatment day ( % zanamivir plus rimantadine, % placebo plus rimantadine), or in the durations of hospitalisation and supplemental oxygen use underpowered because of low enrolment oseltamivir and corticosteroids ( ) more rapid improvement in partial pressure of oxygen, fraction of inspired oxygen, and sequential organ failure assessment scores; shorter ventilator use (median days vs days, p= · ); and faster viral clearance in the sirolimus than in the control group rct=randomised controlled trial. in a retrospective study of critically ill adults, mortality rates did not diff er between those who received a triple combination of antiviral drugs and those receiving oseltamivir only, and a randomised controlled trial sponsored by the national institute of allergy and infectious diseases in higher-risk outpatients is underway (nct ). host-directed therapies aim to reduce the damaging consequences of the host immune response to the pathogen. combinations of antivirals with host-directed therapies such as the immunomodulator sirolimus, an mtor inhibitor that blocks host pathways needed for viral replication (table ) , might also enhance antiviral activity. other host-directed therapies inhibiting cellular targets needed for effi cient viral replication (eg, the raf-mek-erk mitogenic kinase cascade and the ikk-nf-κb module) might provide future options for clinical testing. the role of adjunctive immunomodulatory therapies in severe infl uenza and other respiratory viral infections remains uncertain. several observational studies show that systemic corticosteroids given for pandemic infl uenza a h n -associated viral pneumonia increased the risk of mortality and morbidity (eg, secondary infections), especially when there was a delay in initiation, or absence of, eff ective antiviral therapy. their use might delay viral clearance and increase the risk of the emergence of resistance and fungal infections. other potential adjunctive therapies for infl uenza include intravenous immunoglobulin, n-acetylcysteine, statins, macrolides, peroxisome proliferator-activated receptor agonists, celecoxib, mesalazine, plasmapheresis, and haemo perfusion. chloroquine was eff ective against infl uenza a h n infection in one animal model but was ineff ective in other animal models and one human randomised controlled trial. , interferons mers-cov infection can cause severe respiratory disease, and has higher mortality in those with medical comorbidities. although empirical treatment with a range of antivirals has been tried for severe respiratory tract infections caused by mers-cov and sars-cov, no regimens have been rigorously assessed in clinical trials (panel). , mers-cov elicits attenuated innate immune responses with delayed proinfl ammatory cytokine induction in cell culture and in vivo. , it is also readily inhibited by type interferons (interferon alfa and especially interferon beta), suggesting a potential therapeutic use for interferons. early pegylated interferon alfa therapy was eff ective in a sars primate model, and treatment with interferon-alfa-consensus- plus systemic corticosteroids was associated with improved oxygen saturation and more rapid resolution of radiographic lung opacities than were systemic corticosteroids alone in an uncontrolled study of patients with sars patients. further studies of interferons in mers-cov seem warranted. ribavirin was used extensively in patients with sars without any benefi cial eff ects and was complicated by haemolytic anaemia and metabolic disturbances in many cases. , a combination of interferon alfa b and ribavirin reduced lung injury and moderately decreased viral replication (< · log reduction in lung titres) when given to rhesus macaques within h of inoculation with mers-cov. the treatment combination was given to several severely ill patients with mers, but the infections proved fatal, probably because of late administration in the advanced stage of the disease. , ribavirin has in-vitro inhibitory eff ects against mers-cov. the use of protease inhibitors with lopinavir and ritonavir as initial therapy in sars was associated with signifi cantly less death ( · % vs · %, p< · ) and intubation ( % vs · %, p< · ) than was use of ribavirin alone in a matched historical cohort (n= for lopinavir and ritonavir as intial treatment vs n= for the matched historical cohort). however, one study reported that nelfi navir and lopinavir have high % eff ective inhibitory concentrations (ec ) against mers-cov in vitro, whereas another found inhibition with lopinavir at clinically achievable concentrations. several drugs have shown inhibitory eff ects against mers-cov in cell cultures, including interferons, ciclosporin, and mycophenolic acid. , , mycophenolic acid was inhibitory at clinically achievable concentrations, and the combination of mycophenolic acid and interferon β b lowered the ec of each drug by one-to-three times. dipeptidyl peptidase (dpp ), also known as cd , is a functional receptor for mers-cov, and an anti-cd polyclonal antibody showed in-vitro inhibitory eff ects on mers-cov. by contrast, inhibitors of the enzymatic action of dpp (eg, gliptins) did not inhibit viral replication. timely administration of neutralising antibodies could have a high likelihood of therapeutic success. treatment with convalescent plasma (from patients who have recovered from sars-cov infection) containing high levels of neutralising antibody within weeks of illness onset resulted in a higher proportion of discharges at day than did treatment more than days after onset ( % vs %, p< . ). showed worse outcomes when systemic corticosteroids were given in sars. consequently, their use should be avoided unless a carefully controlled prospective study is done to test their eff ectiveness when combined with an antiviral. several observational studies have shown that systemic corticosteroids given for pandemic infl uenza a h n -asssociated viral pneumonia or acute respiratory distress syndrome increased the risk of mortality and morbidity (eg, secondary bacterial or fungal infections), especially if there is delay or lack of eff ective antiviral therapy. use of systemic corticosteroids has probably contributed to delayed viral clearance and emergence of antiviral resistance in patients with severe infl uenza a h n infection requiring extracorporeal membrane oxy genation. infl uenza increases the risk of invasive aspergillosis, especially among immunocompromised patients, and this is often a silent infection in the early stages, so direct surveillance with aspergillus antigen and pcr testing on respiratory secretions is advisable. patients treated for fungal infections will have to undergo antifungal therapeutic drug monitoring. data are insuffi cient to support routine use of any of the immune therapies. better animal data and careful systematic clinical studies, including serial virological measurements of priority treatments such as convalescent plasma and interferons (and randomised controlled trials if case numbers are suffi cient), are needed. currently, clinical management of patients with severe respiratory tract infections due to mers-cov largely relies on meticulous intensive care supportive treatment and prevention of complications. research done in patients with haemopoietic stem-cell transplants shows that adoptive transfer of antigenspecifi c t cells can restore protective immunity and prevent or reverse disease due to opportunist viral infections such as cytomegalovirus. in transplant recipients, transfer of donor-derived t cells can result in resolution of infection through expansion of virusspecifi c t cells, with associated clinical improvement. transfer of donor t cells is associated with the risk of severe acute graft-versus-host disease, and thus most t-cell therapies have been done in patients who have low lymphocyte counts. lymphopenia enables only a very low number of t cells to be transferred, which then proliferate in lymphopenic hosts, most likely as a result of the interleukins and if the patient does not receive immunosuppressive treatment during t-cell therapy. t-cell therapy targeting cytomegalovirus strains resistant to drug treatment is clinically relevant in lung transplant recipients. t-cell expansion requires time to induce clinical regression of viral infection. several other approaches might be applicable in situations that necessitate fast clinical action-eg, use of synthetic mhc antigens loaded with the relevant peptide from the pathogen of interest (so-called tetramer or multimer mhc-peptide complexes), which engage pathogenspecifi c lymphocytes expressing the pathogen-specifi c t-cell receptors. pathogen-specifi c t cells can be isolated through use of soluble mhc-peptide complexes, and can immediately be transferred into patients for salvage treatments for viral infections. t-cell expansion can also be achieved with several stimuli targeting several infectious pathogens. expansion of t cells targeting several antigens of cytomegalovirus, epstein-barr virus, and adenovirus provides broad antiviral specifi city after stem-cell transplantation. an alternative approach to series become independent of ex-vivo expansion of t cells is the identifi cation of t-cell receptors that would recognise viral infected cells that could be transferred into recipient eff ector cells. t cells can also be engineered to produce an antiviral rna that would block viral infection. synthetic antisense molecules, such as phosphorodiamidate morpholino oligomers, are structurally similar to rna but the phosphorodiester linkage is replaced with a neutral phosphorodiamidate linkage and the ribose ring with a six-membered morpho lino ring. they change gene expression by inhibiting translation, disrupting rna secondary structure, and interfering with pre-mrna splicing. the usefulness of phosphorodiamidate morpho lino oligomers coupled to argininerich cell-penetrating peptides has been repeatedly demonstrated against bacterial pathogens and could be a viable option for any microbial gene of interest. specifi c biological therapy for infectious pathogens targets not only drug-resistant pathogens but also their immune evasion mechanisms. an antibody directed against cd (a b-cell marker) fused to a t-cell signalling molecule can be expressed in t cells and could kill target cells once they encounter their nominal target antigen. such cd chimeric-antigen-receptor cells are used to remove epstein-barr-virus-positive lymphoma cells in the case of post-transplantation proliferative diseases. similar approaches can be used for the eff ective removal of pathogen-infected cells when very specifi c antibodies exist and if target molecules are expressed on infected cells only. the frequency and spectrum of resistance to antibiotics in specifi c bacterial pathogens that cause respiratory tract infections continues to increase worryingly. multidrugresistant streptococcus pneumoniae-with resistance to three or more antibiotics-was initially noted in in south africa and subsequently in many other countries, with alarming rates of - % of s pneumoniae that are multidrug resistant in the usa and spain. [ ] [ ] [ ] the european antimicrobial resistance surveillance system showed that · % of s pneumoniae were intermediate penicillin susceptible, · % were penicillin resistant, and · % were resistant to erythromycin. concerns about multidrug-resistant and pan-antibioticresistant gram-negative bacteria , are focused on klebsiella pneumoniae, enterobacter spp (production of extended spectrum β lactamase, klebsiella pneumoniae carba penemase, ndm , and ampc), acinetobacter baumannii, and pseudomonas aeruginosa. in one survey of us health centres, % of gram-negative bacteria were resistant to all antibiotics except colistin (to which % of acinetobacter spp, % of pseudomonas spp, and % of enterobacter spp were resistant). therapeutic options to treat these infections are limited. , carbapenems are recommended for organisms that produce extended-spectrum β lactamases. in a metaanalysis, [ ] [ ] [ ] [ ] [ ] doripenem was more eff ective for p aeruginosa infections than were comparators in a modifi ed intention-to-treat analyses. polymyxin b and colistin are concentration-dependent bactericidal agents that bind to bacterial cell membranes and have reliable activity against acinetobacter spp. novel β-lactamase inhibitors and antibiotic com bination therapies might provide stopgap measures for fulfi lling clinical need. antibiotic development pipelines remain thin, , and global attention is focused on increasing awareness for investments into the development of new antibacterial agents and other antibacterial innovations, coupled to raising global awareness for more prudent use of available drugs. in , an estimated · million people died worldwide from tuberculosis, of whom had multidrugresistant disease. multidrug-resistant tuberculosis, which is caused by mycobacterium tuberculosis bacilli resistant to at least isoniazid and rifampicin, is now widespread globally, with an estimated half a million cases in . extensively drug-resistant tuberculosisresistance to rifampicin, isoniazid, any fl uoroquinolone, and at least one of the three injectable second-line drugs, amikacin, kanamycin, and capreomycin-has been reported in countries. who recommends use of second-line drugs for - months or longer for extensively drug-resistant or multidrug-resistant disease. , treatment success rates are low in both individualised and standard regimens and new drugs and regimens are needed. in the past years, a promising pipeline of new drugs for the treatment of multidrug-resistant and extensively drug-resistant tuberculosis has emerged. progress has been made by repurposing drugs that are already available, including re-engineering existing antibacterial compounds and redesigning scaff olds, leading to discovery of new compounds. , two new drugs, delamanid (opc- ) and bedaquiline (tmc or r ), have been approved by regulatory authorities. these new drugs are combined with older drugs to treat multidrug-resistant disease. , host-directed adjunct therapies several approaches to rational development of adjunct immune-based therapies for multidrug-resistant tuberculosis have been developed. , non-steroidal antiinfl ammatory drugs can reduce m tuberculosis load and series alleviate lung disease in mice. effl ux pump inhibitors such as verapamil and reserpine reduce macrophageinduced drug tolerance, and thus could be used as adjunct host-directed therapies. , phosphodiesterase inhibitors such as cilostazol and sildenafi l improve mycobacterial clearance and decrease time to sterilisation by reducing tissue infl ammation. a range of adjunct immunotherapy approaches implicating cytokines or their inhibitors and other biological immunomodulatory compounds are being assessed as means to limit damage from infl ammatory responses against m tuberculosis. various cytokine regimens, including interferon c or interleukin , have been assessed, with variable eff ect. , the antiinfl ammatory eff ects of macrolide antibiotics need to be further studied. whole genome sequencing might allow for rapid determination of resistance patterns of m tuberculosis strains, enabling tailored treatment regimens. other immunomodulatory strategies include restoration of eff ective antipathogen-directed immunoresponses-and consequent decreasing of damaging host responses in lung tissues-in multidrug-resistant tuberculosis with infusions of the patient's own bonemarrow-derived stromal cells. a phase trial showed that the procedure is safe, and phase trials are planned to assess the eff ects of mesenchymal stromal cell adjunct therapy on clinical and microbiological outcomes. invasive fungal respiratory tract infections are increasingly reported worldwide (table ) . , the two most common pulmonary fungal pathogens are aspergillus fumigatus and pneumocystis jirovecii. they increasingly represent primary causes of morbidity and mortality in critically ill patients across europe, africa, and asia as a result of more people living with hiv, increased use of immunomodulatory drugs in patients with cancer, transplantations, and use of broad-spectrum antibiotics. some patients with relapsed or micro biologically unconfi rmed multidrug-resistant tuber culosis have alternative diagnoses, including chronic pulmonary aspergillosis, and more com prehensive searches for alternative fungal diagnoses in smear and culture negative cases should be done in patients with multidrug-resistant disease. aspergillus is the most important fungal cause of invasive pulmonary disease, and a fumigatus is the cause in more than % of cases. voriconazole is the most eff ective treatment for invasive aspergillosis but resistance has been noted on all continents except south america. , widespread use of the azoles as fungicides in agriculture has led to the environmental development of pan-azole resistance. resistance can also emerge during treatment, typically to itraconazole, and is possibly linked to a combination of low blood concentrations of the drug and high fungal loads. [ ] [ ] [ ] modelling suggests that more than · million people have severe asthma with fungal sensitisations, as much as % of adults with asthma who attend secondary care have fungal sensitisation, and an estimated · million adults have allergic bronchopulmonary aspergillosis. , people with asthma who are sensitised to a fumigatus have a much higher rate of bronchiectasis than do those who are unsensitised. reclassifi cation of aspergillosis in adults with cystic fi brosis by aspergillus serology (ige and igg) and both pcr and antigen on sputum showed three distinct classes of aspergillosis. % had allergic bronchopulmonary disease, % had aspergillus sensitisation, and % had aspergillus bronchitis; the remaining patients had no disease. long-term oral antifungal therapy is benefi cial for - % of patients with asthma, but is of unproven benefi t in cystic fi brosis. resistance in a fumigatus has been reported throughout europe in roughly % of samples from patients with cystic fi brosis. , a new fungus causing disseminated infections in patients with aids was identifi ed in . molecular identifi cation on the basis of its and its sequencing showed that all isolates of this new species were tightly clustered and were most similar to emmonsia pasteuriana and emmonsia parva, and slightly more distantly related to histoplasma capsulatum. clinical features of infection included fever, loss of weight, anaemia, skin lesions akin to those in disseminated histoplasmosis, and a chest radiograph similar to that noted in pulmonary tuberculosis. the fungus was cultured from skin and blood, but not sputum or csf. signifi cant clinical responses were noted when patients were given intravenous amphotericin b followed by itraconazole. a large combination study series did not reach its primary endpoint of reduced mortality, although patients with positive galactomannan seemed to benefi t most. guidelines for management of invasive aspergillosis still favour voriconazole over all other treatments and combination therapy is not usually recommended. a tablet formulation of posaconazole, which is more bioavailable than the oral suspension, is available and can be given once a day, and the us food and drug administration has approved an intravenous suspension of the drug. the only new drug to be approved is isavuconazole, a broad-spectrum azole, which will be available in intravenous and oral forms (application for approval was submitted in july, ). itraconazole seems safe in the fi rst trimester of pregnancy, whereas fl uconazole increases the risk of fallot's tetralogy by a factor of three to one in . drivers for the development of new antifungal drugs include inadequate response rates, the absence of oral preparations of echinocandins, drug interactions, important drug toxic eff ects (especially amphotericin b and voriconazole), and triazole and echinocandin resistance. several drugs are being repurposed for use as antifungals, and new drugs are under development (table ) . [ ] [ ] [ ] [ ] [ ] [ ] [ ] sertraline, which is used for depression, has synergistic activity with fl uconazole in a murine model of cryptococcal infection. calcineurin and targets of rapamycin inhibitors have antifungal activity, which is synergsitic with that of azoles. hsp inhibitors initially developed for cancer treatment can improve fl uconazole activity in vitro and in animals. enoxacin, a fl uoroquinolone antibiotic, shows activity in a murine candidiasis model. although azoles are important for the treatment of invasive pulmonary aspergillosis, the degree of immunosuppression and other immunological factors have a role in treatment outcomes. antifungal immune responses could be improved by adaptive transfer of pathogen-specifi c t cells directed against invasive and pulmonary fungal infections, particularly infections with candida, aspergillus, and mucormycetes, especially after allogeneic stem-cell transplantation. t-cell responses are mhc class i restricted (for cd positive t cells) or mhc class ii restricted (for cd positive t cells), and thus an eff ective t-cell response needs to match the genetic background of the patient. t-cell transfer was developed on the basis of the promising fi nding that transfer of pathogen-specifi c t-cell clones induces clinically signifi cant responses. , several approaches have been used to obtain these pathogen-specifi c t cells. anti-pathogenspecifi c t cells can be expanded ex vivo under appropriate conditions (usually with the help of recombinant cytokines, synthetic peptides, or cellular components representing the pathogen). responder t cells are identifi ed by interferon-γ production, removed via an interferon-capture assay, and transferred into the patient. this approach requires time for expansion of t cells (either the patient's own or those of an mhc-matched donor). this protocol enabled the expansion of aspergillus spp, candida spp, with the terms "respiratory tract", "pneumonia", "infections", "bacteria", "virus", "fungus", and "mycobacteria". we also combined these terms with the words "antibiotic", "antibiotic resistance", "treatment", "drugs", "drug development", "drug pipeline", "antibiotic development", "host-directed", "therapy", "adjunct therapy", "steroids", and "immunotherapy". we complemented the search with publications from who, the us centers for disease control and prevention, http://clinicaltrials. gov, and google scholar. we also reviewed studies cited by articles identifi ed by this search. and mucor spp-reactive t cells defi ned by interferon-γ production. upon re-encounter with the nominal target antigen, the t cells proliferated and increased the antifungal reactivity of phagocytes. new and antimicrobial-resistant species of bacteria, viruses, and fungi continue to emerge because of the remarkable genetic and adaptable plasticity of the microbiota. respiratory tract infections are among the top two causes of death globally. , microorganisms do not respect international boundaries, and ease of travel and airborne spread make them a threat to global health security. the increasing frequency of antibiotic resistance and limited therapeutic options emphasise the urgent need for more international cooperation to tackle new emerging microbial threats and multidrug-resistant microbes. development of new therapeutic options needs to be coupled to international regulations on the use and prescription of antimicrobial drugs. dsh and az coordinated the writing of this series paper and wrote the draft outline, and subsequent and fi nal drafts. all authors contributed relevant text and tables on their expert sections or sections and contributed to fi nalising the paper. fgh has served as non-paid consultant for multiple companies engaged in marketing and/or clinical development of antivirals for respiratory viral infections including several whose therapeutics are discussed in this review (adamas, biocryst, gsk, genentech, janssen, roche, romark, toyama/medivector, visterra). dwd holds founder shares in f g, a university of manchester spin-out company. he acts as a consultant to trinity group, t biosystems, glaxosmithkline, sigma tau, oxon epidemiology, and has consulted for merck and astellas and he has been paid to give talks on behalf of astellas, gilead, and pfi zer. all other authors declare no confl icts of interest. interspecies transmission and emergence of novel viruses: lessons from bats and birds clinical features and rapid viral diagnosis of human disease associated with avian infl uenza a h n virus history of swine infl uenza viruses in asia writing committee of the world health organization consultation on northern hemisphere infl uenza vaccine composition for - . who recommendations for the viruses used in the - northern hemisphere infl uenza vaccine: epidemiology, antigenic and genetic characteristics of infl uenza a(h n )pdm , a(h n ) and b infl uenza viruses collected from who. avian infl uenza a(h n ) virus 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pharmacology in murine pulmonary coccidioidomycosis preparatory to phase clinical trials in vitro and in vivo antifungal activities of t- , a novel arylamidine advancing antifungal r&d. www.f g.com/f g-ltd-completes- -million-fi nancing-round-to-fund-pre-clinical-and-clinical-developmentof-novel-anti-fungal-compounds/ (accessed may the antidepressant sertraline provides a promising therapeutic option for neurotropic cryptococcal infections signaling cascades as drug targets in model and pathogenic fungi progress and prospects for targeting hsp to treat fungal infections inhibition of candida albicans virulence factors by novel levofl oxacin derivatives restoration of viral immunity in immunodefi cient humans by the adoptive transfer of t cell clones adoptive cellular therapy for early cytomegalovirus infection after allogeneic stem-cell transplantation with virus-specifi c t-cell lines clinical-scale generation of multi-specifi c anti-fungal t cells targeting candida, aspergillus and mucormycetes towards an ecology of the lung: new conceptual models of pulmonary microbiology and pneumonia pathogenesis deaths due to respiratory tract infections in africa: a review of autopsy studies global and regional mortality from causes of death for age groups in and : a systematic analysis for the global burden of disease study key: cord- -hwemigk authors: bhimraj, adarsh; morgan, rebecca l; shumaker, amy hirsch; lavergne, valery; baden, lindsey; cheng, vincent chi-chung; edwards, kathryn m; gandhi, rajesh; muller, william j; o’horo, john c; shoham, shmuel; murad, m hassan; mustafa, reem a; sultan, shahnaz; falck-ytter, yngve title: infectious diseases society of america guidelines on the treatment and management of patients with covid- date: - - journal: clin infect dis doi: . /cid/ciaa sha: doc_id: cord_uid: hwemigk background: there are many pharmacologic therapies that are being used or considered for treatment of covid- . there is a need for frequently updated practice guidelines on their use, based on critical evaluation of rapidly emerging literature. objective: develop evidence-based rapid guidelines intended to support patients, clinicians and other health-care professionals in their decisions about treatment and management of patients with covid- . methods: idsa formed a multidisciplinary guideline panel of infectious disease clinicians, pharmacists, and methodologists with varied areas of expertise. process followed a rapid recommendation checklist. the panel prioritized questions and outcomes. then a systematic review of the peer-reviewed and grey literature was conducted. the grading of recommendations assessment, development and evaluation (grade) approach was used to assess the certainty of evidence and make recommendations. results: the idsa guideline panel agreed on treatment recommendations and provided narrative summaries of other treatments undergoing evaluations. conclusions: the panel expressed the overarching goal that patients be recruited into ongoing trials, which would provide much needed evidence on the efficacy and safety of various therapies for covid- , given that we could not make a determination whether the benefits outweigh harms for most treatments. a c c e p t e d m a n u s c r i p t it is important to realize that guidelines cannot always account for individual variation among patients. they are assessments of current scientific and clinical information provided as an educational service; are not continually updated and may not reflect the most recent evidence (new evidence may emerge between the time information is developed and when it is published or read); should not be considered inclusive of all proper treatments methods of care, or as a statement of the standard of care; do not mandate any particular course of medical care; and are not intended to supplant physician judgment with respect to particular patients or special clinical situations. whether and the extent to which to follow guidelines is voluntary, with the ultimate determination regarding their application to be made by the physician in the light of each patient's individual circumstances. while idsa makes every effort to present accurate, complete, and reliable information, these guidelines are presented "as is" without any warranty, either express or implied. idsa (and its officers, directors, members, employees, and agents) assume no responsibility for any loss, damage, or claim with respect to any liabilities, including direct, special, indirect, or consequential damages, incurred in connection with these guidelines or reliance on the information presented. the guidelines represent the proprietary and copyrighted property of idsa. copyright infectious diseases society of america. all rights reserved. no part of these guidelines may be reproduced, distributed, or transmitted in any form or by any means, including photocopying, recording, or other electronic or mechanical methods, without the prior written permission of idsa. permission is granted to physicians and health care providers solely to copy and use the guidelines in their professional practices and clinical decision-making. no license or permission is granted to any person or entity, and prior written authorization by idsa is required, to sell, distribute, or modify the guidelines, or to make derivative works of or incorporate the guidelines into any product, including but not limited to clinical decision support software or any other software product. except for the permission granted above, any person or entity desiring to use the guidelines in any way must contact idsa for approval in accordance with the terms and conditions of third-party use, in particular any use of the guidelines in any software product. executive summary covid- is a pandemic with a rapidly increasing incidence of infections and deaths. many pharmacologic therapies are being used or considered for treatment. given the rapidity of emerging literature, idsa identified the need to develop living, frequently updated evidence-based guidelines to support patients, clinicians and other health-care professionals in their decisions about treatment and management of patients with covid- . summarized below are the recommendations with comments related to the clinical practice guideline for the treatment and management of covid- . a detailed description of background, methods, evidence summary and rationale that support each recommendation, and research needs can be found online in the full text. in brief, per grade methodology, recommendations are labeled m a n u s c r i p t as "strong" or "conditional". the word "recommend" indicates strong recommendations and "suggest" indicates conditional recommendations. in situations where promising interventions were judged to have insufficient evidence of benefit to support their use and with potential appreciable harms or costs, the expert panel recommended their use in the context of a clinical trial. the guideline panel used the word "only" in recommendations about therapeutic agents with higher uncertainty and/or more potential for harm. these recommendations acknowledge the current "knowledge gap" and aim at avoiding premature favorable recommendations for potentially ineffective or harmful interventions. the panel expressed the overarching goal that patients be recruited into ongoing trials, which would provide much needed evidence on the efficacy and safety of various therapies for covid- . the panel determined that when an explicit trade-off between the highly uncertain benefits and the known putative harms of these therapeutic agents were considered, a net positive benefit was not reached and could possibly be negative (risk of excess harm). the panel acknowledges that enrolling patients in rcts might not be feasible for many frontline providers due to limited access and infrastructure. should lack of access to clinical trials exist, we encourage setting up local or collaborative registries to systematically evaluate the efficacy and safety of drugs to contribute to the knowledge base. each clinician can play a role in advancing our understanding of this disease through a local registry or other data collection efforts. m a n u s c r i p t background the first cases of coronavirus disease (covid- ) were reported from wuhan, china in early december [ ] , now known to be caused by a novel beta-coronavirus, named as severe acute respiratory syndrome coronavirus (sars-cov- ). within a span of months covid has become pandemic due to its transmissibility, spreading across continents with the number of cases and deaths rising daily [ ] . although most infected individuals exhibit a mild illness ( %+), % have serious and % have critical illness. approximately % will require hospital admission due to covid- pneumonia, of which approximately % will require icu care, including invasive ventilation due to acute respiratory distress syndrome (ards) [ ] . while mortality appears to be more common in older individuals and those with comorbidities, such as chronic lung disease, cardiovascular disease, hypertension and diabetes, young people with no comorbidities also appear to be at risk for critical illness including multi-organ failure and death. there has been an expanding number of studies rapidly published online and in academic journals; however, some of these may be of limited quality and are pre-published without sufficient peerreview. critical appraisal of the existing studies is needed to determine if the existing evidence is sufficient to support currently proposed management strategies. given the rapid global spread of sars cov- and the difficulty for the overburdened front-line providers and policymakers to stay up to date on emerging literature, idsa has recognized the necessity of developing a rapid guideline for the treatment of covid- . the guideline panel used a methodologically rigorous process for evaluating the best available evidence and providing treatment recommendations. two additional guidelines on diagnostic testing and infection prevention are also under development. these guidelines will be frequently updated as substantive literature becomes available and will be accessible on an easy to navigate web and device interface at http://www.idsociety.org/covid guidelines. the guideline panel considered making a recommendation for therapeutic agents that were currently available for use. the panel chose not to give a recommendation for remdesivir as it is mostly available in the context of ongoing trials with limited availability for compassionate use and expanded access use. we anticipate data from rcts for remdesivir will be soon available; at that point, we will update the guidelines to provide formal recommendations on its use. there are several ongoing trials evaluating therapeutic agents for the treatment of covid- . as data becomes available from these trials and if there is a preponderance of evidence to suggest the use of a therapeutic agent even in the context of clinical trials is no longer warranted it will be removed from future updates of the guideline (and the removal will be noted in the updated a c c e p t e d m a n u s c r i p t guidelines). if there is emerging evidence on the efficacy or safety of a therapeutic agent not mentioned in the current version of the guideline it will be included in future updates of the guideline. these recommendations are intended to inform patients, clinicians, and other health professionals by providing the latest available evidence. this guideline was developed using the grade approach for evidence assessment. in addition, given the need for an urgent response to a major public health crisis, the methodological approach was modified according to the gin/mcmaster checklist for the development of rapid recommendations [ ] . the panel was composed of nine members including front line clinicians, infectious diseases specialists who are members of the idsa, the hiv medical association (hivma), the society for healthcare epidemiology of america (shea), and the pediatric infectious diseases society (pids). they represented the disciplines of public health, pharmacology, pediatrics, medical microbiology, preventive care, critical care, as well as hepatology, nephrology and gastroenterology. the evidence foundation provided technical support and guideline methodologists for the development of this guideline. the conflict of interest (coi) review group included two representatives from idsa who were responsible for reviewing, evaluating and approving all disclosures. all members of the expert panel complied with the coi process for reviewing and managing conflicts of interest, which required disclosure of any financial, intellectual, or other interest that might be construed as constituting an actual, potential, or apparent conflict, regardless of relevancy to the guideline topic. the assessment of disclosed relationships for possible coi was based on the relative weight of the financial relationship (i.e., monetary amount) and the relevance of the relationship (i.e., the degree to which an association might reasonably be interpreted by an independent observer as related to the topic or recommendation of consideration). the coi review group ensured that the majority of the panel and chair was without potential relevant (related to the topic) conflicts. the chair and all members of the technical team were determined to be unconflicted. m a n u s c r i p t clinical questions were developed into a pico format (population, intervention, comparison, outcomes) [ ] prior to the first panel meeting. panel members prioritized questions with available evidence that met the minimum acceptable criteria (i.e., the body of evidence reported on at least a case-series design, case reports were excluded). panel members prioritized patient-important outcomes such as mortality, development of ards (need for non-invasive or invasive ventilation) and clinical improvement (such as disease-oriented outcomes inferred by radiological findings or virologic cure), and severe adverse events leading to treatment discontinuation. additional drug specific harms were evaluated when clinically relevant, including possible drug-drug reactions, if applicable. the nice highly-sensitive search was reviewed by the methodologist in consultation with the technical team information specialist and was determined to have high sensitivity [ ] . an additional term, covid, was added to the search strategy used in addition to the treatment terms identified in the pico questions (supplementary table s ). ovid medline and embase were searched from through april , . horizon scans were performed daily during the evidence assessment and recommendation process to locate additional grey literature and manuscript pre-prints. reference lists and literature suggested by panelists were reviewed for inclusion. no restrictions were placed on language or study type. two reviewers independently screened titles and abstracts, as well as eligible full-text studies. when acceptable randomized controlled trials of effectiveness were found, no additional non-randomized studies or non-comparative evidence (i.e., single arm case series) were sought. evidence from single arm studies reporting on non-comparative rates of outcomes of interest were included if a historical control event rate could be estimated from the literature. reviewers extracted relevant information into a standardized data extraction form. for several interventions, no direct evidence was available other than case reports or mechanistic considerations. the panel either decided to include plausible indirect evidence and make a recommendation (e.g., from studies of sars-cov) or to provide a short narrative discussion of the intervention. m a n u s c r i p t data extracted from the available evidence included: mortality, clinical progression or improvement as reported in the studies, virologic clearance, and adverse events. where applicable, data were pooled using random effects model (fixed effects model for or less trials or pooling of rates) using revman or openmeta [ ] . cochrane risk of bias tools for randomized clinical trials (rcts) and observational studies and modified domains were used in assessing confounding bias, selection bias, and misclassification bias [ ] . the certainty of evidence was assessed using the grading of recommendations assessment, development and evaluation (grade) approach [ ] . within grade, the body of evidence across each outcome is assessed for domains that may reduce or increase one's certainty in the evidence. factors that may reduce one's certainty include risk of bias (study limitations), inconsistency (unexplained heterogeneity across study findings), indirectness (applicability or generalizability to the research question), imprecision (the confidence in the estimate of an effect to support a particular decision) or publication bias (selective publication of studies). one's certainty in the evidence may be strengthened if the following considerations are present: large or very large magnitude of effect, evidence of a dose-response gradient, or opposing residual confounding. grade summary of findings tables were developed in gradepro guideline development tool [ ] . the panel considered core elements of the grade evidence in the decision process, including certainty of evidence and balance between desirable and undesirable effects. additional domains were acknowledged where applicable (feasibility, resource use, acceptability). for all recommendations, the expert panelists reached consensus. voting rules were agreed on prior to the panel meetings for situations when consensus could not be reached. as per grade methodology, recommendations are labeled as "strong" or "conditional". the words "we recommend" indicate strong recommendations and "we suggest" indicate conditional recommendations. figure provides the suggested interpretation of strong and weak recommendations for patients, clinicians, and healthcare policymakers. for recommendations where the comparators are not formally stated, the comparison of interest is implicitly referred to as "not using the intervention". the guideline panel used the word "only" in recommendations about therapeutic agents with higher uncertainty and/or more potential for harm. for example, the toxicity of hydroxychloroquine/chloroquine plus azithromycin (recommendation ) carries particular risk for patients in the outpatient setting who may not be enrolled in a trial and therefore may have inadequate monitoring; or, for recommendation , there is concern related to tocilizumab shortages for other indications and potential toxicity of worsening infection/drug interactions. these recommendations acknowledge the current "knowledge gap" and aim at avoiding premature favorable recommendations for their use and to avoid encouraging the rapid m a n u s c r i p t diffusion of potentially ineffective or harmful interventions. detailed suggestions about the specific research questions that should be addressed are found in the table (see supplementary table s ). m a n u s c r i p t regular, frequent screening of the literature will take place to determine the need for revisions based on the likelihood that any new data will have an impact on the recommendations. if necessary, the entire expert panel will be reconvened to discuss potential changes. two rcts of patients with confirmed covid- with mild pneumonia (e.g., positive ct scan without oxygen requirement) or non-severe infection admitted to the hospital treated with hydroxychloroquine (hcq) reported on mortality at days, clinical progression (radiological progression on ct scan), clinical improvement, failure of virologic clearance (pcr), and adverse events (both) [ , ] (table ). in addition, we identified four publications describing three trials of combination treatment with hcq plus azithromycin (az) among hospitalized patients with covid- reporting on the outcomes of mortality, failure of virologic clearance (assessed with pcr test), and adverse events (i.e., significant qt prolongation leading to treatment discontinuation) [ ] [ ] [ ] [ ] (table ) . the currently available best evidence failed to demonstrate or to exclude a beneficial effect of hcq on clinical progression of covid- (as inferred by radiological findings; rr: . ; % ci: . , . ; see figure s ), or on viral clearance by pcr tests (rr: . ; % ci: . , . ; see figure s ), although a somewhat higher proportion in the hcq group experienced clinical improvement (rr: . ; % ci . , . ). however, the certainty in the evidence was rated as very low mainly due to small sample sizes (sparse data), co-interventions, and risk of bias due to methodological limitations. in addition, the selected outcomes should be considered indirect, as important patient outcomes (e.g., mortality, rate of progression to ards and need for mechanical ventilation) were unavailable. m a n u s c r i p t studies evaluating the addition of azithromycin to hcq provided indirect comparisons of failure of virologic clearance to historical controls. the observed risk of mortality among patients receiving hcq+az during hospital stay was . % ( / patients). however, an estimated mortality rate in an untreated cohort was not provided in the manuscript. when compared to a lack of viral clearance in historical controls ( % virologic failure), symptomatic patients were compared at day or from a separate hospital in france. patients receiving treatment with hcq+az experienced numerically fewer cases of virologic failure ( % pooled virologic failure; / patients) (figure s ). there is very low certainty in this comparison of treatment effect mainly due to very high-risk selection bias, making any claims of effectiveness highly uncertain. in addition, relying on intermediary outcomes, such as viral clearance to determine patient-important outcomes (including a reduction in development of pneumonia, hospital or icu admission, or need for intubation) add another layer of imprecision. two studies described significant qt prolongation in of treated patients, either resulting in an qt increase to over ms or discontinuation of the hcq/az treatment, illustrating the high risk for clinically relevant arrhythmias for this treatment [ , ] . in addition, several case reports of qt prolongation related to hydroxychloroquine have also been published [ ] [ ] [ ] [ ] . in another prospective cohort study in covid- uninfected patients with sle who received either chloroquine or hydroxychloroquine for routine care, gastrointestinal side effects occurred in % of patients [ ] . several case reports have been published citing the risk of a prolonged qt prolongation, torsades de pointes, and ventricular tachycardia in patients receiving azithromycin alone. in a large cohort study, patients taking a five-day course of azithromycin had an increased risk of sudden cardiac death with a hazard ratio of . ( . - . ) vs. . ( . - . ), compared to patients receiving no antibiotic or amoxicillin, respectively [ ] . given the cumulative effect on cardiac conduction seen with hydroxychloroquine and azithromycin, if this combination was to be used in the context of a clinical trial, baseline and follow-up ecg monitoring would be indicated, as well as careful surveillance for other concomitant medications known to prolong the qt interval. renal clearance accounts for - % of total clearance of hydroxychloroquine, however dose adjustments are not recommended according to package labeling. chloroquine and hydroxychloroquine are metabolized by cytochrome p isoenzymes c , d , and a [ ] , therefore inhibitors and inducers of these enzymes may result in altered pharmacokinetics of these agents. providers are encouraged to visit resources such as the newly created website, https://www.covid -druginteractions.org/ to aid in the evaluation and management of drug interactions with current and emerging investigational agents for covid- . azithromycin is low risk for cytochrome p interactions [ ] ; however additional pharmacologic adverse events including gastrointestinal effects and qt prolongation need to be carefully considered particularly in the outpatient setting where frequent ecg monitoring is not feasible. a c c e p t e d m a n u s c r i p t the panel agreed that the overall certainty of evidence was very low due to concerns with risk of bias, inconsistency, indirectness, imprecision, and publication bias. the guideline panel recommends that, because of uncertainty regarding its risks and benefits, the use of hcq should be in the context of a clinical trial. because of the potential for toxicity, the panel recommends that the hcq+az combination only be used in the context of a clinical trial. this recommendation does not address the use of azithromycin for secondary bacterial pneumonia in patients with covid- . additional randomized controlled trials and prospective outcome registries are needed to inform research for treatment with hcq alone or in combination with azithromycin for patients with covid- (table s . best practices/suggestions for research of treatments for patients with covid- ). one rct and two case studies reported on treatment with combination lopinavir/ritonavir for hospitalized patients with covid- [ ] [ ] [ ] (table ) . cao et al. randomized hospitalized patients with severe covid- to receive treatment with lopinavir/ritonavir in addition to standard of care (n= ) or standard of care alone (n= ) for days. the trial reported on the following outcomes: mortality, failure of clinical improvement (measured using a -point scale or hospital discharge), and adverse events leading to treatment discontinuation. based on a modified intention to treat analysis, treatment with lopinavir/ritonavir failed to show or exclude a beneficial effect on mortality (rr: . ; % ci: . , . ), although failure of clinical improvement was lower in the lopinavir group (rr: . ; % ci: . , . ; itt analysis). nearly % of lopinavir/ritonavir recipients were unable to complete the full -day course of administration due primarily to gastrointestinal adverse events, including anorexia, nausea, abdominal discomfort, or diarrhea, as well as two serious adverse episodes of acute gastritis. two recipients also had self-limited skin eruptions. the risk of hepatic injury, pancreatitis, severe cutaneous eruptions, qt prolongation, and the potential for multiple drug interactions due to cyp a inhibition, are all well documented with this drug combination. the panel elected to inform their decision based on the rct [ ] . the panel determined the certainty of evidence to be very low due to concerns with risk of bias (lack of blinding) and imprecision. in the randomized clinical trial conducted by cao et al, the group that received lopinavir/ritonavir and the group that did not had similar rates of viral decay. this finding suggests that lopinavir/ritonavir is not having a measurable antiviral effect, its purported mechanism of action. the guideline panel recommends the use of lopinavir/ritonavir only in the context of a clinical trial. additional clinical trials or prospective outcome registries are needed to inform research for treatment with lopinavir/ritonavir and other hiv- protease inhibitors for patients with covid- (supplementary table s ) . the panel determined that due to the limitation of direct covid- data, indirect evidence from the sars outbreak and from mers would also be considered. a systematic review [ ] reported on studies, of which were inconclusive to any benefits of corticosteroids. one rct reported that sars-cov- viral loads showed delayed viral clearance associated with corticosteroid use. the same review also reported on a subset of ards patients (three trials). one small rct in patients using a lower dose methylprednisolone for two days showed possible improvement of ards; however, two larger trials showed little or no effect in critically ill patients with pulmonary failure. the authors concluded that despite widespread use of corticosteroids during the sars outbreak, conclusive evidence of benefit was lacking and that administering steroids early in the disease process before viral replication is controlled may lead to a delay in viral clearance. the panel deemed the certainty of the direct evidence as very low owing to concerns with risk of bias, inconsistency, and imprecision. the panel based their decision to conditionally recommend against the use of corticosteroids among patients admitted to the hospital on the indirect findings from the systematic review on sars-cov. m a n u s c r i p t as covid- is a self-limited viral illness in most cases, a small subset of patients progresses from covid- pneumonia to develop ards. based on limited data from other coronaviruses, there is no clear benefit and potential harm from corticosteroids. carefully designed rcts and prospective outcome registries are needed to determine the dose, route, timing, and duration of such treatment on the prevention of clinical deterioration and to better understand the potential harms associated with its use. if a person is on a steroid (inhaled or systemic) for another indication (e.g., asthma), the steroid should be continued. m a n u s c r i p t a c c e p t e d m a n u s c r i p t a c c e p t e d m a n u s c r i p t studies reporting on the pathogenesis of sars and mers-cov suggest a release of proinflammatory cytokines including interleukins- (il- ) [ ] during the clinical illness. our search identified one study [ ] that reported on severe or critical patients with covid- treated with tocilizumab, an il- blocker ( table ). this study had no control group. to estimate a control group rate in patients who did not get treatment with tocilizumab, xu et al. described findings from yang , which suggested a baseline mortality rate of % in critical patients and % in severe patients admitted to the icu [ ] . we estimate that the patients in xu ( patients, critical and severe) would have a baseline mortality risk of % as matched in severity. therefore, treatment with tocilizumab may have reduced mortality since there were no deaths reported out of patients. however, this conclusion remains highly uncertain given the lack of a contemporaneous control or adjustments for confounding factors. out of patients, were discharged from the hospital suggesting a . % rate of failure of clinical improvement in the ct scan findings. xu et al. reported no serious adverse events [ ] . however, patients receiving tocilizumab are often at an increased risk of serious infections (bacterial, viral, invasive fungal infections, and tuberculosis) and hepatitis b reactivation [ ] . cases of anaphylaxis, severe allergic reactions, severe liver damage and hepatic failure, and intestinal perforation have been reported after tocilizumab administration in patients without covid- . tocilizumab is not metabolized by the cytochrome p isoenzyme system, however elevated il- levels seen in inflammatory states have been shown to inhibit these enzymes, thereby slowing the metabolism of drugs through these pathways. as the a pathway is responsible for metabolism of many commonly used medications, administration of il- inhibitors like tocilizumab may result in enhanced metabolism in drugs utilizing the cytochrome p system [ , ] . the panel determined that the overall certainty of the evidence was very low due to concerns of high risk of bias due to confounding, indirectness, and imprecision. m a n u s c r i p t the guideline panel recommended tocilizumab only in the context of a clinical trial. additional clinical trials are needed to inform research on the effectiveness of treatment with tocilizumab for patients with covid- (supplementary table s ). m a n u s c r i p t a c c e p t e d m a n u s c r i p t our search identified two case series of a total of patients reporting on the outcomes of mortality, failure of clinical improvement (as inferred by need for continued mechanical ventilation), and treatment related adverse events among hospitalized patients with covid- (table ) [ , ] . all five patients in shen were mechanically ventilated at time of treatment compared with three out of patients in the duan et al study. duan included a comparison of the treated patients to historical control patients matched on age, gender, and severity of illness. both studies lacked adjustments for critical confounders including co-treatments, baseline characteristics, disease severity, and timing of plasma delivery. compared with a % mortality rate in the historical control ( / ), no deaths were reported among patients receiving covid- convalescent plasma. out of eight patients across both studies on mechanical ventilation at time of treatment, % (n= ) were extubated at time of data collection. among patients, no serious adverse reactions or safety events were recorded following covid- convalescent transfusion. the panel agreed on the overall certainty of evidence as very low due to concerns with risk of bias and imprecision. continuation of mechanical ventilation was used as a surrogate for failure of clinical improvement; however, the panel recognized the importance of the timeframe for extubation when associating it to plasma transfusion. given the limited information provided about time of extubation, the panel recognized an additional knowledge gap with the assessment of this outcome. the guideline panel recommends covid- convalescent plasma in the context of a clinical trial. additional clinical trials are needed to inform research for treatment with covid- convalescent plasma for patients with covid- (supplementary table s ). m a n u s c r i p t in addition to the clinical questions addressed above, the panel identified several treatments currently undergoing evaluation for which additional data are needed to formulate recommendations. narrative summaries for these treatments are provided below. in-vitro antiviral activity of darunavir against sars-cov- showed no activity at clinically relevant concentrations. three randomized, open-label clinical trials are currently listed on clinicaltrials.gov evaluating darunavir/cobicistat as a potential therapeutic option for covid- . janssen, the manufacturer of darunavir/cobcistat has reported that one of these trials [ ] has concluded that darunavir/cobicstat plus conventional treatments was not effective in achieving viral clearance at day seven post randomization, m a n u s c r i p t compared to conventional treatments alone. clinical outcomes of this trial including rate of critical illness and mortality days after randomization, have not been reported to date. lopinavir-ritonavir is a combination of protease inhibitors for the treatment of hiv infection. lopinavir-ritonavir has been shown to have in-vitro antiviral activity against beta-coronaviruses such as sars-cov, and mers-cov [ ] [ ] [ ] [ ] . since lopinavir-ritonavir is not specifically designed for treatment of coronavirus, lopinavir-ritonavir alone may not demonstrate a difference from placebo in reducing viral load when treatment was initiated at a median of days after symptoms onset [ ] . in an open label treatment trial, lopinavir-ritonavir with ribavirin reduced the mortality and requirement of intensive care support of hospitalized sars patients compared with historical control [ ] . many interferons, especially interferon beta have been shown to have modest in-vitro antiviral activity against sars-cov and mers-cov [ , ] . lopinavir-ritonavir or interferon beta- b has been shown to reduce viral load of mers-cov and improve lung pathology in a nonhuman primate model of common marmoset [ ] . lopinavir/ritonavir and interferon-β b alone or in combination are being evaluated in clinical trials. there is a long history of using convalescent plasma as treatment for infectious diseases, including severe viral lower respiratory tract infections [ ] . individuals who have recovered from sars-cov- infection may generate neutralizing antibodies [ , ] that could have application to prevention of infection in certain settings, such as individuals with underlying conditions predisposing to severe disease and those with high-risk exposure. monoclonal antibodies against other respiratory viruses have been shown to be protective against hospitalization in specific high-risk populations [ , ] and animal models have suggested utility in prophylaxis against sars coronavirus infection [ ] . there are some risks associated with the use of convalescent plasma like transfusion-related acute lung injury or a theoretical risk of antibody-dependent enhancement of infection (ade). ade can occur in several viral diseases and involves an enhancement of disease in the presence of certain antibodies [ ] . a trial from patients recovered from sars-cov- infection for use as prophylaxis in adults with a high -risk exposure is expected to begin recruiting shortly [ ] . there are only in vitro data available on the activity of ribavirin on sars-cov- currently. the ec (half maximal effective concentrations) was significantly higher than for chloroquine and remdesivir, so it appears less potent in vitro compared to these agents [ ] . there are limited clinical studies in sars-cov- and mers-cov infections. in a systematic review of ribavirin treatment in patients infected with sars-cov- , studies were classified as inconclusive, and four showed possible harm [ ] . in a retrospective observational study in patients with mers-cov infection, the combination of ribavirin and interferon, compared to no antiviral treatment, was not associated with improvement in the -day mortality or more rapid mers-cov rna clearance [ ] . m a n u s c r i p t oseltamivir oseltamivir is a neuraminidase inhibitor used for prophylaxis and treatment of influenza. given its specificity for an enzyme not found on coronaviruses, it is unclear what the mechanism of action would be against covid- . however, this has been used in combinations of antiviral therapy in wuhan [ ] and continues to be explored as a therapeutic option as part of combination regimens. two trials evaluating combination regimens are underway in wuhan [ , ] as well as a trial in thailand proposing different combinations [ ] . none of the trials or case reports have examined oseltamivir as monotherapy. intravenous immunoglobulin (ivig) has been used as an adjuvant to treat a variety of pathogens either as a pooled product or in a concentrated more pathogen focused (hyperimmune) form. as the community from which a given batch of ivig is derived from includes increasing numbers of individuals who have recovered from sars-cov- , the possibility of protective antibodies being present in the pooled product is increased. however, the potential utility of ivig for the treatment of sars-cov- is unknown at this time. its use has been reported in a few patients with covid- [ ] , but studies are needed to determine if there may be a role for ivig in the treatment of sars-cov- . remdesivir (gs- ) is a broad-spectrum antiviral nucleotide prodrug with potent in vitro activity against a range of rna viruses including ebola virus, marburg, mers-cov, sars-cov, respiratory syncytial virus, nipah virus, and hendra virus [ ] [ ] [ ] . the mechanism of action of remdesivir is premature termination of viral rna transcription [ ] . its use improved disease outcomes and reduced viral loads in sars-cov-infected mice [ ] . the efficacy of prophylactic and therapeutic remdesivir was tested in a rhesus macaque model of mers-cov infection [ ] . prophylactic remdesivir treatment initiated hours prior to inoculation completely prevented mers-cov-induced clinical disease, strongly inhibited mers-cov replication in respiratory tissues, and prevented the formation of lung lesions [ ] . therapeutic remdesivir treatment initiated hours postinoculation reduced clinical signs, virus replication in the lungs, and decreased the presence and severity of lung lesions. a recent case series of patients with severe covid- pneumonia who received remdesivir under a compassionate-use protocol reported clinical improvement in % after a median follow-up of days, with % mortality and a generally acceptable toxicity profile [ ] . however, there was no comparison group of similar patients who received standard care at the participating institutions. because rcts for remdesivir have not been completed, formalized recommendations will be made once the entire body of evidence for remdesivir is available. m a n u s c r i p t should nsaids be stopped in patients infected with covid- ? the role of nsaids in the management of sars-cov has been discussed widely. recent anecdotal reports and subsequent warnings from health officials have suggested against the use of nsaids in the care of patients with covid- ; however, neither fda, ema, or who have identified evidence linking nsaids to covid-related clinical deterioration. human coronaviruses, including sars cov- , use ace to bind to human targets and gain entry into target cells [ ] . it has been theorized that nsaids, due to upregulation in ace in human target cells, may lead to a more severe course of covid- in those taking nsaids. while no causal evidence of adverse outcomes with nsaids in the management of covid- have been published, there are well known risks of nonsteroidal anti-inflammatory agents including cardiovascular, gastrointestinal and renal adverse events [ , ] . in the setting of bacterial pneumonia, nsaids may impair recruitment of polymorphonuclear cells, resulting in a delayed inflammatory response and resolution of infection, however a causal relationship has not been established [ , ] . rcts are needed to better understand the safety of nsaids in the management of patients with covid- . one rct is currently underway to evaluate the role of naproxen in those critically ill with covid- [ ] . should ace and arb's for hypertension be stopped in patients infected with covid ? angiotensin converting enzyme (ace ) is the receptor for sars cov- on human cells. because angiotensinconverting enzyme (ace) inhibitors and angiotensin receptor blockers (arbs) may increase ace expression, the possibility has been raised that these drugs may increase the likelihood of acquiring sars-cov- or may exacerbate the course of covid- . to date, however, there are no clinical data to support this hypothetical concern. for this reason, the american heart association, the heart failure society of america and the american college of cardiology all recommend that ace inhibitors or arbs be continued in people who have an indication for these medications [ ] . during epidemics like the current covid- pandemic, when there are no clinically proven treatments, the tendency is to use drugs based on in vitro antiviral activity, or on anti-inflammatory effects or based on limited observational studies. it is commendable that observational studies are done during an epidemic, but often they do not have concurrent controls, have a significant risk of bias, and use surrogate outcomes like viral clearance rather than patient-important outcomes. medications that were thought to be effective m a n u s c r i p t based on in vitro studies and observational studies for other diseases were later proven to be ineffective in clinical trials [ ] . due to the understandable urgency in producing, synthesizing and disseminating data during the current pandemic, there has been a noticeable increase in fast track publication of studies. in addition to wellestablished concerns that may decrease our certainty in the available evidence, there may be additional issues that will ultimately influence the trustworthiness of that evidence, including: ) circumvention of usual research steps (delay of irb approval [ ] , inclusion of same patients in several studies); ) limited peer-review process (the usual due diligence from editors and reviewers is side-stepped, potentially leading to unnoticed errors in data and calculations, incomplete reporting of methods and results, as well as underestimation of study limitations); ) increased potential for publication bias (in the interest of showing promising data and in the race to achieve recognition, there may be added inclination to publish positive results and disregard negative ones). the extent and impact of these considerations remain currently uncertain but were acknowledged in the development of this guideline. despite these limitations, the recommendations were based on evidence from the best available clinical studies with patient-important endpoints. the panel determined that when an explicit trade-off between the highly uncertain benefits (e.g., the panel was unable to confirm that hcq increases viral cure or reduces mortality) and the known putative harms (qt prolongation and drug-drug interactions) were considered, a net positive benefit was not reached and could possibly be negative (risk of excess harm). the safety of drugs used for the treatment of covid- , especially in patients with cardiovascular disease, immunosuppressive conditions, or those who are critically ill with multi-organ failure has also not been studied. drugs like azithromycin and hydroxychloroquine can cause qt prolongation and potentially lifethreatening arrhythmias. steroids and il- inhibitors can be immunosuppressive and potentially increase risk of secondary infections. steroids may produce long term side effect such as osteonecrosis [ ] . given that the panel could not make a determination whether the benefits outweigh harms for these treatments it would be ethical and prudent to enroll patients with covid- in clinical trials, rather than use clinically unproven therapies [ ] . there are multiple ongoing trials, some with adaptive designs, which potentially can quickly answer pressing questions on efficacy and safety of drugs in the treatment of patients with covid- . we acknowledge that enrolling patients in rcts might not be feasible for many frontline providers due to limited access and infrastructure. should lack of access to clinical trials exist, we encourage setting up local or collaborative registries to systematically evaluate the efficacy and safety of drugs to contribute to the knowledge base. without such evaluations we often attribute success to drugs and failure to disease (covid- ) [ ] . during such a pandemic, barriers to conducting studies and enrolling patients in trials for already overburdened front line providers should be minimized while ensuring the rights and safety of patients [ ] . for clinical trials and observational studies, it is critical to determine a priori standardized & practical definitions of patient populations, clinical syndromes, disease severity and outcomes. observational and non-experimental studies can sometimes answer questions not addressed by trials, but there is still a need for standardized definitions. for clinical syndromes clearly distinguishing between asymptomatic carrier state, upper respiratory tract infection and lower respiratory tract infection is important. illness severity should be reasonably defined using readily available clinical criteria of end organ failure, like the degree of m a n u s c r i p t respiratory failure using sa or fi :pa ratios for lower respiratory tract infection, as opposed to location-based severity determinations such as icu admission, which can lead to bias based on resource limitations (i.e., bed availability) or regional/institutional practice patterns [ ] . for outcomes of prophylaxis trials, the primary endpoint should be prevention of infection and for therapeutic trials patient centered outcomes like reduction of mortality (both short term and long term) [ ] . trials should also study treatments in high risk populations or special populations like immunosuppressed patients, people with hiv, patients with cardiovascular comorbidities and pregnant women. the panel expressed the overarching goal that patients be recruited into ongoing trials, which would provide much needed evidence on the efficacy and safety of various therapies for covid- . this is a living guideline that will be frequently updated as new data emerges. updates and changes to the guideline will be posted to the idsa website. clinical characteristics of coronavirus disease in china world health organization. coronavirus disease (covid- ) situation report - . geneva: world health organization characteristics of and important lessons from the coronavirus disease (covid- ) outbreak in china: summary of a report of cases from the chinese center for disease control and prevention development of rapid guidelines: . gin-mcmaster guideline development checklist extension for rapid recommendations grade guidelines: . framing the question and deciding on important outcomes national institute for health and care excellence. scoping. interim process and methods for developing rapid guidelines on covid- (pmg ). london: national institute for health and care excellence closing the gap between methodologists and end-users: r as a computational back-end cochrane handbook for systematic reviews of interventions grade guidelines: . introduction-grade evidence profiles and summary of findings tables gradepro guideline development tool available at: gradepro.org efficacy of hydroxychloroquine in patients with covid- : results of a randomized clinical trial a pilot study of hydroxychloroquine in treatment of patients with common coronavirus disease- (covid- ) hydroxychloroquine and azithromycin as a treatment of covid- : results of an open-label non-randomized clinical trial clinical and microbiological effect of a combination of hydroxychloroquine and azithromycin in covid- patients with at least a six-day follow up: an observational study no evidence of rapid antiviral clearance or 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clinical trials during pandemics editorial concern-possible reporting of the same patients with covid- in different reports steroid therapy and the risk of osteonecrosis in sars patients: a dose-response meta-analysis the ebola clinical trials: a precedent for research ethics in disasters clinical research ethics for critically ill patients: a pandemic proposal early observational research and registries during the - influenza a pandemic choosing outcomes for clinical trials: a pragmatic perspective key: cord- -rembksdr authors: talwar, shivangi; sood, shivani; kumar, jayant; chauhan, ritu; sharma, mamta; tuli, hardeep singh title: ayurveda and allopathic therapeutic strategies in coronavirus pandemic treatment date: - - journal: curr pharmacol rep doi: . /s - - - sha: doc_id: cord_uid: rembksdr purpose of review: in the last month of , i.e., december, covid- hit wuhan city in china. since then, it has infected more than countries and nearly about . million people with one million deaths globally. it is a viral disease with flu-like symptoms; hence, prevention and management is the best option to be adopted for its cure. recent findings: many healthcare systems, scientists, and researchers are fighting for the cure of this pandemic. ayurvedic and allopathic treatments have been studied extensively and approached for the cure of covid- . in addition to ayurvedic treatments, the ministry of ayush, india, has also recommended many remedies to boost up immunity. allopathic studies involved several antiviral drugs which were used in different combinations for the treatment of covid- . summary: comparative analysis of ayurveda and allopathic treatment strategies were carried out in the present study. depending upon the patient’s conditions and symptoms, ayurveda is useful for the treatment of covid- . allopathic treatments inhibit viral infection by targeting majorly endocytosis, and angiotensin-converting enzyme (ace) receptor signaling. in this article, we summarize different ayurvedic and allopathic medicines and treatment strategies which have been used for the treatment of covid- , a global pandemic. in the last decade, different strains of coronaviruses had presented with challenging health issues to human society. the most popular viruses in this category are severe acute respiratory syndrome coronavirus (sars-cov) and middle east respiratory syndrome coronavirus (mers-cov). with an increase in the population, migration, and social life, these viruses showed an increased rate in the recombination of intra-and inter-species which made them adapt to every recent host [ ] . in , sars-cov was one of the most dangerous emergencies in the world for human infection. in its initial stage of infection, it infected nearly humans with major cases. the severe acute respiratory syndrome coronavirus (sars-cov- ) emerged in in the month of december in wuhan city of china, which again made the life of humans miserable with numerous fatal health issues and slowly and gradually this virus entrapped the whole world [ , ] . the crown-shaped coronavirus leads to serious infections which was a brief part of the human sars virus and affected the whole world which leads to a loss in business, tourism, and human life [ ] . by the end of february and the start of march , sars-cov- was declared as an international pandemic by the world health organization (who). the symptoms of this infection were similar to that of normal flu but included different categories like patients with mild symptoms, asymptomatic patients with no symptoms, and high symptomatic patients. before the doctors, scientists, and researchers could study and come up with a cure for treatment, this virus had already infected more than lakhs of people across the world with the human coronavirus pathogens, i.e., hcov- e and hcov-oc , which affects the upper respiratory tract. in , the other novel pathogen of humans which were diagnosed during the sars-cov pandemic in the netherlands included cov-nl and hcov-hku . this cov-nl (group i) infected children suffering from bronchiolitis and the hcov-hku (group ii) virus infected the adults in hong kong with chronic pulmonary infection. in september , the who diagnosed another coronavirus which was mers-cov, which speeded up in a deadly manner in the middle east, south asia, and africa and more than % of cases were diagnosed in saudi arab. it was identified that the family line of this virus is group betacoronavirus, i.e., tylonycteris bat coronavirus hku (bat-cov hku ) whose primary host is bats and hku -covs pathogen whose primary host is pipistrellus bats which are single-stranded positive rna bat viruses which are widely distributed during the coronavirus pandemic and very close to humans for infection [ ] [ ] [ ] [ ] . bats were the primary host and act as a repository for causing infections not only in sars-cov, but were also a causative agent in the mers cov. additionally, camels were also suspected as a source of infection within the crossed species hindrance to contaminate people [ ] . so it was remarked as bats are the significant supplies of various alpha coronaviruses and its ancestry of different beta coronaviruses [ ] . in china, the common repository of the sars viruses was the horseshoe bats, but bats being the definitive cause of the mers virus species were yet to be discovered [ ] . sars-cov virus is a ribonucleic acid-containing infectious agent, which is transferable from vertebrates to animals. sars-cov infection is mainly developed in people through social contact and migration [ ] . the viral genome has a basic protein named replicase which helps in the replication of the genetic genome in the host cell and is methylated at the ′ end and the polyadenylated tail at ′ end because of which the genetic material gets connected to the ribosome's and then replication starts [ ] . on the other hand, there is a non-basic protein known as protease, used for the isolation of the proteins present in the chain [ , ] which helps in the formation of different types of cytokines that leads to the production of lymphocytes. these lymphocytes act as a barrier and prevent viral genome from replicating which results in an increase in the inflammatory reactions [ ] . this coronavirus is an enormous group with severe infections causing the symptoms like regular cold, fever, and respiratory disorders (shortness of breath), which helps the virus to propagate and leads to the replication and transmission. the basic symptom is common cold, which led to the discovery of six wellknown different species of coronaviruses which were first distinguished from the patients in the s [ ] [ ] [ ] [ ] . the incubation period of this virus is around about . days including the range of almost . to . days [ ] . it is recommended by doctors and health organizations that coronavirus lasts for about days which is the maximum time period and special precautions should be taken like social distancing, sanitization, self-quarantine, and wearing of masks and gloves [ ] . the main target site for this crucial pathogenesis of the sars-cov includes the respiratory system and the main diseases which are related to heart injuries and anemia. the data records received from different hospitals across the world observed that by the end of and at the start of june , it was reported that the covid- crisis leads to patients with the higher plasma level of proinflammatory cytokines like interleukin (il- ), il- , il- , il- , il- , interferons gamma (ifnγ), interferons alpha (ifnα), tumor necrosis factor alpha (tnfα), and transforming growth factor beta (tgfβ) [ ] . there are a large number of treatments and therapies available for this antiviral infection. but until now, there is no suitable vaccination for this pandemic but various pharmaceutical companies and researchers are working on it and human trials are going on. this short review summarizes the role of allopathic and ayurveda in coronavirus infections. each field plays an important role in their respective areas and will definitely prove fruitful in the early management of covid- patients. until now, there is no treatment for coronavirus but our government has issued management and precaution guidelines along with a supporting healthcare system which could provide great relief in the outbreak of covid- . many approaches like social distancing, wearing a mask, and medical grounds are used to control the pandemic disease. the main approach to regulate this disease was allopathic and ayurveda. from the last years in the late s, a german physician named dr. samuel hahnemann founded the homeopathy as a therapeutic medicine which helped to treat many epidemics, fearful, and severe diseases like cholera, fever, chikungunya, hepatitis, and malaria. the preventive measures of homeopathy are eminent and undeniable; as homeopathic medicines act remarkably on a health condition and cure the diseases. the scientific literature related to homeopathy is highly witnessed [ ] [ ] [ ] [ ] . there are numerous confirmations that in the year - , when spanish flu emerged, homeopathy had shown amazing results, during which around about million patients died around the world and about , , in the usa alone. a study revealed that there was a difference in the mortality rate among the patients which were treated by homeopathy and physicians, i.e., - % appeared differently as they were treated by homeopathy as compare to - % of patients who were treated by allopathic [ , ] . in homeopathic treatment, every patient after being fully diagnosed and analyzed received medicines. the medical grounds of homeopathy have a clear protocol of sanitation, antibiotics, and vaccinations to control the infections [ ] [ ] [ ] . in diseases like dengue which causes hemorrhagic fever, homeopathy has helped in improving the platelet count and therefore there is a slowdown in the clinical center for about - days [ ] . likewise, there are many diseases in which homeopathy has acted as a buffer or control to decrease the mortality rate by about - % conversely with the people who got simply institutional management. so, by looking at the past history, it can be observed that there are many instances in which homeopathy had shown extraordinary results and it can be equivalently used for the covid patients but no study has shown its effects on covid- . the homeopathic medicines like belladonna c, eupatorium perfoliatum q, grindelia, calcarea carb, chinimum sulph, bryonia, gelsemium, phosph orus, t hymulin, camph ora, influenzinum, antim tart, and a combination of few tinctures and homeopathic drugs prove to have a high rate of frequency to reduce severe pain, ache, and many more ailments in viral diseases [ ] . there were numerous people who were infected by the virus and showed progressive circulation in their history in china's wuhan village in december [ ] . the name of the homeopathic therapies was previously reported to prevent viral infections that are presented henceforth [ ] [ ] [ ] [ ] . arsenicum album is formed when for continuously - days arsenic is heated with distilled water. on the basis of the fact sheet released by the ccrh (central council for research in homeopathy), arsenicum album can be considered as "prophylactic medicine" covid- [ ] . the inflammatory symptoms shown by covid- , arsenic toxicity, and hiv infection are the same and there is a definite synergy between them and may have the suitable potential to aggravate each other. therefore, arsenicum album may be considered as a suitable remedy for covid- treatment. arsenic is one of the constituents in it which showed its enumerating impact on the different macrophage cells as well on tumor cells. also, it showed decreased nf-κβ hyperactivity (nuclear factor kappalight-chain-enhancer of activated b cells; diminished verbalization of reporter quality of green fluorescent protein (gfp) in transfect ht cells) and decreased tnf-α (tumor necrosis factor-alpha) release in macrophages. arsenic album- was advised to be taken once in a day for days. the tincture of album- is arsenic trioxide which is highly diluted and it works to prevent disease [ ] . the proposed mechanism of action of arsenicum is shown in fig. . until now, there is no furthermore, for more than years, ayurveda, a sanskrit word, originated in india. nowadays, it is considered as a traditional system of medicine which helps in the management of infection and maintains the homeostasis of disease. it also helps in building the strength of the mind and soul, and teaches the body to fight against stress. during covid- , ayurveda is also playing an important role as it has enough possibilities and potential for the prevention of infection and treatment for corona victims. the asymptomatic cases in india help in implementing the role of ayurveda, through the regular use of ayurveda medicines and home remedies. but still, the confirmation imagined by traditional chinese medicine (tcm) cannot be disregarded in china [ , ] . this is directly understood that at the time of the pandemic, approximately tcm-related workers had been passed on to the hubei district. tcm was officially accepted by the chinese guideline on end and used as a cure for covid- [ , ] . this is especially important to observe that specific tcm wards were set up, and quarantine centers were developed which had used chinese drugs for treatment using western medication [ ] . with the accomplishment of tcm in controlling an infectious pandemic, it was reasonable and major to examine how ayurveda can help in treating covid- [ , ] . by this time, it was the ministry of ayush which created a standard to change indian social protection [ ] and to show the power of ayush to build up prosperity [ ] . with this ultimate objective of ayush, ayurveda during the covid- pandemic, people were divided into four specific classifications [ ] along with characters and natural herbs for treatment which is tabulated in table . this classification has huge necessary information which was complete and well managed. subsequently, it is advised that genuine information of factors that are important should be done on each case. these variables should incorporate age, sex, manifestations, topography, and contact history which results in a clear prescription and should be recorded. on the other hand, tcm did not control covid- cases. equivalent philosophy was also adopted and has been used in ayurveda and it should pursue its own skill for finding and coming about remedies optional on roga and rogi bala. in the allopathic approach, treatment in coronavirus included intravenous infusion of fluid, oxygen therapy, and life support chloroquine and hydroxychloroquine have a possibility of curing an intestinal disorder, systemic lupus erythematosus (sle), and rheumatoid joint torment (ra) [ ] . chloroquine and hydroxychloroquine obstruct glycosylation of host receptors, proteolytic, and maturation of endosomes. these mechanisms have immunomodulatory shocks to host cells by bringing down the cytokine level and control of autophagy and lysosomal [ , ••] . in vitro studies revealed that in the low micromolar concentration, chloroquine crushes sars-cov- with a halfmaximal credible center (ec ) and hydroxychloroquine with a lower ec for sars-cov- differentiated, i.e., ec = . μm and chloroquine: ec = . μm the treatment of covid- included the oral dosage of chloroquine ( mg) and hydroxychloroquine ( mg) on daily basis [ ] [ ] [ ] . but still, there is a lack of data which proves the mechanism of chloroquine and hydroxychloroquine. pharmacokinetic studies reviewed that the ideal dose of hydroxychloroquine for treating covid- patients should be replaced by mg twice instead of mg on daily basis [ ••] . unusually, elective outlines are made for mg of total dose step by step by dividing reliant on freedom and clinical experience for whipple's disease [ ] . the food and drug administration (fda), usa, recommended and certified lopinavir/ritonavir, an oral drug for hiv, with in vitro activity against other novel coronaviruses through the control of -chymotrypsin-like protease [ , ] . there is no in vitro study data for lopinavir/ritonavir against sars-cov- [ ] but a review on lopinavir/ritonavir was assessed for the treatment of sars and mers which showed clinical observations and analysis of sars with less mortality rate and incubation rates, along with experimental research. the studies revealed that drugs should be used during the early stages of viral replication, i.e., beginning - days; otherwise, late initiation with lopinavir/ritonavir had no effect on clinical outcomes [ , ] . a guanine basic drug named ribavirin handles viral ribonucleic-subordinate and polymerase whose activity against various coronavirus makes it a challenger for the treatment of the covid- outbreak. in vitro studies of this drug proved to show advancement against sars-cov by blocking the replication of the virus. this mechanism required a high dose of this drug, i.e., . to . g orally as expected along with blend treatment. past studies told that the patients got either endogenous or enteral cooperation [ ] and no data exists in its role with the respiratory syncytial disease in covid- [ ] . the trial on patients confessed questionable results in which out of examinations, were re-evaluated, with assessments exhibiting hematologic and liver toxicity [ ] . on the other hand, in the treatment of mers, ribavirin was mixed with interferons and its clinical studies resulted in no observable and remarkable effect on viral clearance [ , ] . due to a lack of clinical data with ribavirin for sars-cov- strategies, its supportive occupation must be extrapolated from other ncov data. remdesivir (other name gs- ) is a prodrug monophosphate which helps in the absorption of cadenosine nucleoside triphosphate. it was studied that the antimicrobial activity of this drug against rna proved to be contagions especially in the family of coronaviridae and flaviviridae. due to its low ec value, it proved to be therapeutic against the emergence of ebola virus disease based on its selectivity against host polymerase of ebola [ •] . because of broad reach, presently, remdesivir and its in vitro studies against coronavirus help in treating sars-cov- with ec and ec estimations of . μm and . μm, respectively, and are proved to be a fruitful expected treatment for covid- [ dexamethasone is a type of chemically derived corticosteroid which acts as an immunosuppressor. it abridged deaths by / in patients getting invasive mechanical ventilation and by / in patients being delivered oxygen without invasive mechanical ventilation. however, therapy did not decrease the death in patients not getting breathing support at randomization. therefore, dexamethasone abridged -day mortality among those getting invasive mechanical ventilation [ ••] . mechanistically, it inhibits the growth of the cytokines which cause infection and is therefore useful in this covid- -related hyperinflammation or cytokine storm. it has a high rate of activity and also lasts for a longer duration as compared to other cortisone [ ] [ ] [ ] [ ] [ ] [ ] . studies have shown that it is only useful in those cases where the condition of the patient is critical and cannot be used for the generalized treatment of all patients [ ] . the mode of action of various allopathic drugs is summarized in fig. . these above-discussed drugs mainly inhibit angiotensin-converting enzyme (ace ), endocytosis, non-structural protein c-like protease, and nonstructural proteins rna-dependent rna polymerase (rdrp) to stop viral infection and growth. covid- is considered as pandemic worldwide and spreading at an alarming rate. therefore, it has been essential to explore various strategies to overcome the effect of this dreadful viral disease. this review summarizes the utility of currently opted therapies for covid- . no suitable medicine is found to exist currently for this virus infection. the rapidly increasing patient's data of covid- is triggering scientific communities to come forward to develop some possible therapy. the most reassuring treatment is considered to be remdesivir. this drug is known to possess strong antiviral activity as proven by several in vitro studies. oseltamivir has not presented with suitability, and corticosteroids are at present not recommended. on the other hand, homeopathy and ayurveda may be promising, but not applicable towards all types of patients. therefore, the present study concludes that covid- infection can be prevented by following government guidelines and opting immune-boosting ayurveda routes. acknowledgments the authors want to thank maharishi markandeshwar (deemed to be university) for providing the requisite facility. we acknowledge dr. vaishali aggarwal, department of pharmaceutical sciences, university of pittsburgh, usa, for 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review, meta-analysis, and meta-regression potential role of telemedicine in solving st-segment elevation dilemmas in remote areas during the covid- pandemic lymphopenia in severe coronavirus disease- (covid- ): systematic review and meta-analysis dexamethasone for covid- ? not so fast publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations key: cord- -berrojmq authors: burri, christian title: sleeping sickness at the crossroads date: - - journal: trop med infect dis doi: . /tropicalmed sha: doc_id: cord_uid: berrojmq human african trypanosomiasis (hat; sleeping sickness) is a disease with truly historic dimensions [...]. these activities marked the start of incredible efforts of the colonial powers to control the disease, but particularly also of the vertical approach towards disease control, with special programs run in parallel with the public health system-which is now one of the challenges in the elimination "end game" with very few patients remaining requiring an integrated public health approach. the detection of the causative agent, the mode of transmission and the first documented major epidemics coincided with the advent of modern pharmacology. it is, therefore, no surprise that there was an interest to find drugs against this disease. in , the colonial powers, in a joint conference, decided to give drug development a high priority and in course, several molecules were developed. the history of the oldest drug still in use against hat, suramin, is described in the context of the history in the article of madeja et al., not only is the drug still manufactured, but also the continued support of bayer since the year is a major contributing factor allowing us to write about the elimination of hat today. the activity of inorganic arsenic-based compounds had already been recognized in the mid- th century and the treatment of "nagana" (animal trypanosomiasis) was described by david livingstone in and david bruce in . this knowledge led to the development of the first organo-arsenic compound atoxyl ® in by paul ehrlich, who used trypanosomes as a model to screen molecules, but was mainly searching for drugs against syphilis. wolferstan thomas in liverpool subsequently showed that atoxyl ® was effective against t. b. gambiense. however, atoxyl ® , meaning 'non-toxic', caused severe adverse drug reactions particularly affecting the optic nerve; it was only active against early stage hat and was followed by tryparsamide in . tryparsamide was developed in the usa and was the first drug to be active against the late stage, although not very active and also prone to extensive resistance development. tryparsamide was also very toxic, with a dose dependent risk damaging the optic nerve. this is documented in a horrifying report from when a lieutenant of the french army in cameroon doubled the prescribed dose of tryparsamide to speed up the recovery of patients. two days later, all these patients were blind. this event prompted the swiss chemist and physician dr. friedheim to investigate alternative drugs. the introduction of a triazine ring lead to the development of melarsen (disodium p-melaminyl-phenyl arsonate) in , which proved to be a very efficient drug against t. b. gambiense, but was still very toxic. in , friedheim first described the trivalent arsenoxide form of melarsan, known as melarsenoxide. he reported its use in treatment of human sleeping sickness in . the main achievement was the reduction of the duration of therapy to six weeks, with two weeks of seven daily injections of . mg/kg each, spaced by an interval of one month. in a further step, capping the arsenic in melarsen oxide with british anti-lewisite, an antidote to the arsenical warfare agent lewisite, reduced the toxicity by a factor of the order of , but the trypanocidal activity only by a factor . . the new drug was called melarsoprol (mel b; arsobal ® ) [ ] . it remained the mainstay of second stage hat treatment until the early s despite the long treatment duration of days, the known related adverse drug reactions, particularly the encephalopathic syndrome that occurs in about % of the patients treated and leads to their death in about % of cases, and the potential for drug resistance. another line of research was the molecules with a diamidine structure discovered in the s. these molecules were detected by serendipity in the search for hypoglycaemic compounds, with the idea in mind that this effect might compromise the very prominent and particular glucose metabolism of trypanosomes. several compounds, however, proved to have a direct trypanocidal effect with the three compounds stilbamidine, pentamidine, and propamidine identified to have the highest activity [ ] . pentamidine does not penetrate the blood brain barrier so its use is limited to first stage hat; despite this drawback it is still is in use today, for treatment of children below six kilograms. the distinctly better safety profile of the drugs only active against first stage disease (pentamidine and suramin) versus melarsoprol was also the advent of the consistent performance of lumbar puncture to determine the disease stage and make a treatment decision. the need for a lumbar puncture was, for over years, a characteristic of hat treatment, a source of patient distress, stigma and technical limitation of treatment. some years after the discovery of pentamidine, the diamidines again became the focus of drug development, although not successful until today. the development of the organo-arsenicals, diamidines, and also drugs developed much later and still in use like eflornithine and nifurtimox, including their drawbacks related to the potential for drug resistance are described in detail in the contribution of de koning. the "scramble for africa" was an investment with very high political and economic stakes, and sleeping sickness was not just a disease; it had become the colonial disease. besides drug development, the responses of the anglophone and francophone colonial powers to trypanosomiasis differed significantly. francophone countries chose to concentrate directly on the medical problems presented by the disease in humans. this included the introduction of "mobile teams" actively searching and screening population for hat cases. this method of systematic case detection and treatment with the aim of elimination of the parasite reservoir was suggested by the french military surgeon eugène jamot and such activities started in in cameroon ("atoxylisation") [ ] . subsequently, the prevalence of hat declined from as high as % in to . - . % in , leading to an expansion of the methodology to other countries. after the second world war, atoxyl ® was replaced by pentamidine and a regular application of the drug every six months to the population at risk was introduced ("pentamidinisation"). in the s in the belgian congo alone, some two million people were subjected to this preventive mass drug administration [ ] . due to the partial presence of t. b. rhodesiense in their territories, the anglophone countries were confronted with the more widespread problem of disease in domestic livestock, which also presented a reservoir for human disease. their approach included vector control (traps, spraying), bush clearing, and game destruction [ , ] , and later the chemopreventive use of veterinary drugs (diminazene, isometamidium, and homidium). the control measures were overall very successful and progressively controlled the disease, reaching a very low, generalized transmission by the mid- s, with a minimum of cases declared in africa in [ ] . however, the measures taken were very costly, but above all very unpopular in the communities. this led to concealment where possible, and made the longterm goal of elimination by chemotherapy difficult, if not impossible [ ] . we could observe similar tendencies when conducting clinical trials in the s; potential patients were mostly hiding away or fleeing the villages at the beginning of mobile team campaigns for reasons of fear of stigmatization, lumbar puncture, pain, and the possibility of being treated with the dangerous drug melarsoprol. the in-depth understanding of the communities' beliefs, needs, and approaches is therefore key in a successful elimination attempt; insight on these topics are presented in the papers by and falisse et al., lee et al., and palmer et al. a factor mentioned by winslow in , which may still be under-researched today, is the relationship between the disease and poverty, particularly inadequate food supply, as the disease leads to unused land, which creates malnutrition [ ] . such a view would require an even more integrated approach towards disease control and elimination. when the colonial powers withdrew from africa between and , a new era began. the young nations created their own institutions with the goal of continuing research towards the elimination of hat (e.g., kenya trypanosomiasis research institute (ketri), nigerian institute for trypanosomiasis research (nitr), uganda trypanosomiasis research organisation (utro), and programme sur la recherche sur la trypanosomiase in côte d'ivoire (prct)). these institutions were reinforced since the s by internationally funded institutes dedicated wholly or partly to trypanosomiasis research (e.g., international laboratory for research on animal diseases (ilrad) in kenya, international centre of insect physiology and ecology (icipe) in kenya, international trypanotolerance centre (itc) in the gambia). however, in the course of monetary adjustments in the s, the decreasing funds available, and the emergence or increase of other health priorities, institutions devoted to a single disease were no longer sustainable and they were continuously integrated or transformed into multilateral institutions. overall, in the years after the independence process, the expenditures for hat were reduced, and awareness and surveillance of the disease decreased. the number of mobile teams was decreased, and it was attempted to transfer activities to the public health system-without having the respective tools, approaches, and knowledge [ ] . this, together with social instability, conflicts, and insecurity constraining disease control interventions led to a significant resurge of gambiense hat in the s and s [ ] , mainly affecting angola, congo, southern sudan, and the west nile district of uganda [ ] . at the end of the s, the situation was comparable to the one in the and ; the number of reported cases was almost , with , cases suspected [ ] . in , we published a special issue in the journal tropical medicine and international health [ ] , asking ourselves whether there were new approaches to roll back hat. not only was this the time of , hat cases suspected in countries of sub-saharan africa, it was also the time when the organo-arsenic drug melarsoprol was still the only treatment available for second stage hat. treatment with melarsoprol required around days of hospitalization with numerous and very painful injections, very severe adverse drug reactions like an encephalopathic syndrome were common and the mortality rate under treatment was as high as - %. in those days, an oncologist tried to comfort us, saying that a % treatment success rate for a disease with an inevitably fatal course was fantastic. we did not share this view, and rather expressed a dream: to make hat "an ordinary" disease, which follows the usual pattern "test, treat, track"-without the need of a lumbar puncture to make treatment decisions, without a high mortality rate under treatment, without the pain, without the stigma. elimination was a very far-fetched goal at this time, but there were some first positive signals that the dimensions of the problem and its impact on society and development were being recognized. the conclusions adopted by the international scientific committee of trypanosomiasis research and control (isctrc) in reflected a new awareness of the disease. the african union member states were urged to give highest priority ranking to african trypanosomiasis in their development programs, and it was recommended that urgent and particular attention should be given to surveillance and intervention in epidemic areas, to drug availability and resistance, and to the implementation of operational research to respond to the needs of control programs. at their meeting in lomé in july the oau heads of state and governments signed a declaration of intent to eradicate tsetse flies on the african continent-something that will likely not happen, but it was the turning point towards manifold activities which make us today work towards elimination of hat as a public health problem of and the interruption of transmission by . at the same time, médecins sans frontières' access to medicines campaign were able to make a compelling case that society needed to rethink drug discovery paradigms for neglected diseases. aventis (now sanofi) was persuaded to repurpose and develop the failed anti-cancer drug eflornithine for use against hat and to donate it at no cost to the who for distribution in africa. millions of dollars were also provided by aventis/sanofi to the who, who could now develop new screening and intervention programmes [ ] . bayer signed a similar contract with the who, a success story and joint effort which has been renewed by both companies until today, and which is one of the strong drivers in control and now elimination. in , the bill and melinda gates foundation selected hat to be one of the first diseases they targeted through the consortium of parasitic drug development (cpdd) and shortly thereafter, the drugs for neglected diseases initiative (dndi) was founded. the beginning of the century was truly an exciting time for neglected diseases and for hat in particular. the changes and significant impact on funding were later summarized in the landmark publication "the new landscape of neglected disease drug development" [ ] . the changed situation immediately led to the initiation of several large scale activities in drug development and the term "elimination" in the context of hat was mentioned for the first time by dr. jannin, leading the anti-hat efforts at the who in [ ] . drug development had been virtually dormant for about years. although the cultivation and test methods for drug screening for anti-trypanosomal drugs had been developed in the s and s [ ] , the money for pursing lead compounds in preclinical work, translational studies and large-scale trials was too scarce in these days. during the s, some initial limited drug activities were carried out on shoestring budgets: eflornithine, which had initially been developed in the s as a potential anti-cancer drug, was found to be active against second stage gambiense hat. this discovery in the s was a scientific breakthrough [ ] and eflornithine was shown to be much safer compared to melarsoprol. the drug received orphan drug status by the us food and drug administration in ; however, production was stopped after a few years and only resumed after significant public and political pressure. eflornithine, however, was only introduced for treatment in a limited number of centres by msf in , but not until by the national sleeping sickness control programs because of its limited availability, the initial high costs, and particularly the logistical challenge to transport the drug and its associated bottles of sterile water per treatment. the turning point was when who launched a kit format and coordinated training of staff from national sleeping sickness control programs [ ] . furthermore, in the s nifurtimox, developed against chagas disease was used in experimental settings mainly to treat melarsoprol refractory cases [ ] . in the mid- s, the pharmacokinetics of melarsoprol was elucidated. the assessment of a subsequently proposed abridged days regimen in a large scale trial with patients in angola (impamel i) allowed the replacement of the empirically derived complex schemes lasting from - days in [ ] [ ] [ ] . whereas the new regimen had major socio-economic advantages, the disappointment was that the frequency of the worst adverse drug reaction, the encephalopathic syndrome, remained at levels of - % of patients treated, still resulting in death in - % of those in whom encephalopathy developed. the metabolism of melarsoprol was elucidated somewhat later [ ] . the finding that the major metabolite melarsenoxide covalently bound to a midsize protein triggered another large-scale clinical trial, which led to the elucidation of the nature of the encephalopathic syndrome. the early s were dominated by the development of the oral prodrug pafuramidine against first stage hat; the program failed at a late point of development, but it contributed much to the understanding of hat chemotherapy and the conduct of clinical trials against hat, which it is described in detail by the paper of dickie et al. in parallel, several trials assessing combinations of eflornithine, melarsoprol, and nifurtimox were conducted. in all trials, the efficacy was better in the combination arms compared to the monotherapies. however, combinations containing melarsoprol resulted in very high frequencies of severe adverse drug reactions and were rapidly abandoned [ ] . a multiple-centre trial, conducted in the republic of congo and the democratic republic of the congo (drc) compared nifurtimox-eflornithine combination therapy (nect) with the standard eflornithine therapy. nect reduces the number of eflornithine infusions from to , the total amount of eflornithine by half and the hospitalization time by one-third [ ] . based on the favourable results of the trials conducted, nect was included for treatment of second stage gambiense hat into the who's essential medicines list in [ ] , and for children in [ ] . nect can be considered a milestone improvement: under optimal conditions, fatality during treatment is . % compared to - % under melarsoprol [ ] . the complexity of its application still restricts the use to the second stage disease, meaning that the lumbar puncture for diagnostic staging is still required [ ] , continuing until today. to identify better alternatives, the drugs for neglected diseases initiative initiated a major compound mining effort in to explore new and old nitroimidazoles as drug leads against human african trypanosomiasis. one of the compounds screened, fexinidazole, proved to be orally active against t. b. gambiense and t. b. rhodesiense in animal studies and had an excellent safety profile. the development of this orally active compound is described in detail in the papers of neau et al., and dickie et al., fexinidazole received a positive scientific opinion from the european medicines agency for treatment of gambiense hat in late , it was approved by the drug regulatory authority of the drc and added to the who list of essential medicines in , and the first official application in the drc happened at the end of january on world ntd day in a public ceremony. this deliberate coincidence of the date depicts the new integrated thinking of hat control and elimination in the framework of ntds clearly. fexinidazole will be an essential component towards hat elimination. however, it has some limitations, which will hamper its widespread use in the field: its absorption is dependent on simultaneous food intake, or else only subtherapeutic drug levels are reached; based on the observation of a lowered efficacy in patients with advanced disease, a lumbar puncture for staging still is necessary in such patients; and the drug has not been tested yet for children below six years [ ] . hence, the search for "the magic bullet" [ ] continues-with an excellent starting position compared to years ago: for the first time in history, we can speak of a modest pipeline of anti-hat drugs. one most promising candidate is in late clinical development, several compounds are well advanced in pre-clinical stages, and medicinal chemistry and lead selection work is continued as currently, the leading novel class of molecules are the boron-containing benzoxaboroles. one candidate, scyx- , acoziborole, entered phase ii/iii assessment in [ ] . the compound is described in the publication of dickie et al. should the development program be successful, acoziborole would further revolutionize the efforts to eliminate and sustain elimination of hat. due to its long half-life of h, it can be potentially used as a single-dose treatment and should it be well tolerated this would provide further options for decentralized use, and maybe even for "ring-treatment" of patient contacts following the example of ring-vaccinations used, e.g., in the control of the ebola virus. with fexinidazole, and potentially even more with acoziborole, the focus will turn away from the discovery and development of better tools, to the understanding of the implementation, optimal use, including the needs and perception of patients. the clinical research programs have contributed to the reduction of cases: new strong partnerships were formed as described by taylor et al. and the conduct of clinical trials in a number of endemic areas per se has had an impact through staff training, attention to disease, and intensified active case search and treatment of a large number of patients as described by mbo et al. besides the improvements of the renewed interest of governments and improved drug treatment, there are several other reasons for the decrease of hat prevalence: the advances in diagnostics are one of the major factors. the serological card agglutination test for trypanosomes (catt) first published in [ ] had a paramount impact on how patients could be screened by mobile teams. the test was adapted and improved several times, and despite its disadvantages (insufficient specificity to confirm diagnosis, only available in larger batches, cold chain necessary), it has kept its place in hat diagnosis. the mini-anion exchange chromatography for trypanosomes (maect) which increases the sensitivity to detect the parasite in the blood significantly was already published in [ , ] , however, only the increased funding available allowed its more consistent use and therefore detection of cases with low parasitemia. the introduction of rapid diagnostic tests is a true advancement, but also lacks the specificity needed to make a final treatment decision [ ] . additional tools were recently developed but so far only introduced to a limited extent into routine use (e.g., loop-mediated isothermal amplification (lamp) [ , ] ; immune trypanolysis test [ ] ), which will both play a role in the "end-game". the question, however, is how such tests will be used in the future, and in what settings. the currently ongoing research program ditect-hat is set up do exactly that: it seeks to validate the performance of diagnostic tools and algorithms for early and rapid diagnosis of gambiense hat for passive case detection, post-elimination monitoring, and for assessing the therapeutic response [ ] . in addition to the optimization of the technical aspects, however, it is of paramount interest to know about local settings, preferences, and the loss of skills in areas with decreasing patient numbers. the paper by palmer et al. reports on such investigations carried out in uganda. benhamou et al., through a case report on a repeatedly misdiagnosed patient, gives us an insight on future challenges for rapid diagnosis if knowledge and interest in the public health system is not maintained and broadened. another unresolved caveat of diagnosis is that a number of patients are determined to be seropositive, but thereafter hat cannot be confirmed. it will be one of the leading discussions when defining future strategies, and what to do in such cases. nkieri et al. investigated the extent of this phenomenon in the still affected regions of drc. on one hand, relapses have always been a major challenge in the treatment of hat and have made follow-up periods of up months after treatment necessary [ ] . on the other hand, until a few years ago, the dogma was "infected, but not treated inevitably leads to the death of the patient". reports on patients surviving for longer periods despite infection with trypanosomes emerged in the past few years [ ] . one of the compartments where trypanosome may survive seems to be the skin [ , ] . this might also explain how hat can re-emerge in so-called silent foci as illustrated by a nine-year-old child, who was diagnosed with gambiense-hat in ghana in , years after the last detected case [ ] . in this light, the findings of mudji et al. also have importance: over ten years after treatment in the framework of clinical trials, a number of patients revisited presented continued signs and symptoms seen in hat (lymphadenopathy, severe headaches, sleep disturbances); since no trypanosomes could be identified by any means, the implication of these findings remain open at this point. in any case, the existence of such long-term cases has a sudden and dramatic impact on the view of hat epidemiology and hat elimination [ ] . besides further epidemiological, parasitological, and molecular research, mathematical modelling may help to improve our epidemiological knowledge and inform about elimination strategies [ ] and their related costs [ ] . this field has significantly developed against all odds in the past years: trypanosomiasis with its extremely focal distribution and the many external factors influencing its transmission has been a true headache over two decades for all modellers and predictive mappers. studies of existing gambiense-hat models in a few foci (i.e., drc, guinea, and chad) suggest that some type of additional infection reservoir is needed to match the observed dynamics of reported hat cases [ , ] . this could arise from another human reservoir (including undiagnosed and latent infections), an animal reservoir, and/or heterogeneities in human risk exposure and surveillance coverage [ ] . the french colonial forces had completely dismissed the value of vector control due the successes of the treatment strategy proposed by laveran. however, vector control may play a larger role in gambiense hat elimination than anticipated. historical investigations, practical intervention studies, and modelling demonstrate the significant role that vector control can play in the control of gambiense hat. recent models suggest vector control will be essential if we are to reach the set target of elimination of the diseases as a public health problem by and beyond [ , ] . the fact that neither modelling nor vector control are represented in this edition does not represent a valuation of these topics. this special issue comes in a very timely moment, because it is now important to secure what has been achieved, to understand missing pieces, and to finish the work. however, several challenges have to be overcome to not to end up, again, in disaster. in , the world health organization, which has played an instrumental role in the control, set the goal for the elimination of human african trypanosomiasis (hat), caused by trypanosoma brucei gambiense (ghat), as a public health problem for and for the total interruption of transmission to humans for . the efforts to maximise output and optimize innovation by the who has intensified since, and several stakeholders and expert groups have been created and convened [ ] . since , the spectacular decrease of the case number has continued: some , cases were reported in , far fewer than the targeted milestone of cases, and in [ , ] . first of all, "donor fatigue" must be avoided. the elimination to "no transmission" in the drc where over % of the cases are nowadays occurring is a herculean task, which will not happen without considerable and continued funding. the conventional measurements of success (e.g., us$ spent per daly prevented) inevitably fail in an elimination scenario. naturally, the amount of money spent per patient identified and treated will soar, so the question to the health economists is, rather how much money do we lose in case efforts would not be continued, factoring in the needed future efforts to re-start and control the disease again. decisions on priorities will be necessary, too: whereas the total number of patients has massively decreased, the area in the drc they are coming from has not. therefore, a vast area still has to be kept under surveillance; this area has to be gradually reduced by safely "closing" focus by focus in order to not jeopardize the efforts. the elimination of hat, malaria, and guinea worm were all believed at a certain point to only be a matter of time-before new reservoirs became known (guinea worm), pestidicide, and drug resistance set in (malaria), and interest was decreased in a premature belief in success (malaria and hat). secondly, the human factor will start to play a key role: in theory, fexinidazole could be applied in , fixed health facilities ( ) an increase up by % from [ ] , and it will be many more, should acoziborole make it to application in a few years. however, hat is a massively stigmatized disease, linked to many beliefs and bad spirits. traditionally, patients after treatment were excluded from working and sexual intercourse for six months [ ] . therefore, the questions are: "will the disease be recognized by the younger physicians and nurses who have never seen a case of hat?" "is the medical staff willing to recognize a suspected case, given this will create a massive workload including trouble with the relatives of the patient and village, paperwork, an invasion of specialists for diagnosis and follow up activities?" "is the medical staff that was told for over years that hat belongs into the specialized hands of the vertical programs willing to assume this task and challenge?" "are the patients willing to accept hat as a diagnosis anymore?" "can we overcome wrong dogma and information?" and "will patients falling into the respective category accept a lumbar puncture?" these questions can only be addressed through the thorough understanding of beliefs, perceptions, preferences, and decision-making processes. therefore, the social and anthropological science, as well as health economics, will start to play a key role in the "end game". the articles presented in this issue by falisse et al., and lee et al. are contributing to this area. thirdly, peace, stability, and a minimal standard of living for the people in the remote regions most affected are necessary to achieve disease elimination-this condition has not yet been met. there is little the scientific community can directly contribute to this-however, knowing that disease and poverty are inextricably linked [ ] , our efforts have to continue. finally, rhodesiense hat (the east african form of the disease) was reduced to as little as cases in [ ] , goals have been reached and it may be seen as a quantité négligable. however, the disease with a zoonotic reservoir has the potential for spectacular returns, and this real danger still exists as described in the contribution of matovu et al. the surveillance and the knowledge of local medical staff has dwindled, innovation was absent for t. b. rhodesiense for decades, and serological instead of microscopic tests are used for diagnosis of other diseases making accidental diagnosis impossible. from january to october , a total of - cases were reported per month from all treatment centres in malawi; in november to january , this number surged to and higher. the cases were reported from populations around the two geographically separate wildlife reserve areas, vwaza and nkhotakota; the reason for this increase is, so far, unknown (personal communication, world health organization, control of neglected tropical diseases, geneva). this outbreak causes major concern and should be a serious warning to everyone who is of the opinion that sleeping sickness has been conquered. similarly, other unexpected priorities, such as the current sars-cov- epidemic, may at all times derail a fragile health system. as soon as the mental and financial attention and priority is on another disease, signals of a hat resurgence may well be overlooked-we should now be well aware about the consequences and impact of late reactions and exponential transmission. compared to when i wrote the conclusion of the hat special issue in [ ] , we are at a completely different point today. we celebrated several marvellous scientific successes in the meantime, tools were improved, patients numbers down-but to reach the set goals and to get completely rid of this horrible disease, the conclusion is the same again: "the goal must now be to maintain the momentum" and "even the biggest efforts of the research scientists, field workers, development agencies, and companies will fail if they are not paralleled by 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trypanosomiasis in the democratic republic of congo evaluating long-term effectiveness of sleeping sickness control measures in guinea the impact of vector migration on the effectiveness of strategies to control gambiense human african trypanosomiasis human african trypanosomiasis control: achievements and challenges all past events/information related to human african trypanosomiasis monitoring the elimination of human african trypanosomiasis: update to the flipside of eradicating a disease; human african trypanosomiasis in a woman in rural democratic republic of congo: a case report whose elimination? frontline workers' perspectives on the elimination of the human african trypanosomiasis and its anticipated consequences this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license key: cord- -jyktuvyy authors: manski, c. f.; tetenov, a. title: how should clinicians interpret imprecise trials assessing drugs for covid- patients? date: - - journal: nan doi: . / . . . sha: doc_id: cord_uid: jyktuvyy as the covid- pandemic progresses, researchers are reporting findings of randomized trials comparing standard care with care augmented by experimental drugs. the trials have small sample sizes, so estimates of treatment effects are imprecise. seeing imprecision, clinicians reading research articles may find it difficult to decide when to treat patients with experimental drugs. whatever decision criterion one uses, there is always some probability that random variation in trial outcomes will lead to prescribing sub-optimal treatments. a conventional practice when comparing standard care and an innovation is to choose the innovation only if the estimated treatment effect is positive and statistically significant. this practice defers to standard care as the status quo. we argue that clinicians should ignore conventional measures of statistical significance. they should choose treatments that work best in trials, taking side effects into account and recognizing that treatment effects may vary with patient risk factors. to evaluate treatments, we use the concept of near optimality, which jointly considers the probability and magnitude of decision errors. an appealing decision criterion from this perspective is the empirical success rule, which chooses the treatment with the highest observed average patient outcome in the trial. considering the design of covid- trials, we show that the empirical success rule yields treatment results that are much closer to optimal than those generated by prevailing decision criteria based on hypothesis tests. as the covid- pandemic progresses, researchers are reporting findings of randomized trials comparing standard care with care augmented by experimental drugs. the trials to date have small sample sizes, so estimates of treatment effects are statistically imprecise. seeing imprecision, clinicians reading research articles may find it difficult to decide when to treat patients with experimental drugs. we argue that clinicians should ignore conventional measures of statistical significance. they should choose treatments that work best in trials, taking side effects into account and recognizing that treatment effects may vary with patient risk factors. the contributions of this paper are both applied and methodological. we apply to covid- trials the methodology for study of two-arm trials developed earlier in manski ( ) and manski and tetenov ( , ) . moreover, we extend the computational reach of the methodology to enable practical analysis of multi-arm trials. a core objective of randomized trials is to inform treatment choice. when comparing standard care with an innovation, the prevailing statistical practice has been for researchers to conclude that the innovation is better than standard care only if the estimated average treatment effect comparing the innovation with standard care is statistically significant by conventional criteria. equivalently, a conventional statistical hypothesis test must reject the null hypothesis that the innovation is no better than standard care. statistical analysis commonly examines each pre-declared primary and secondary outcome of a trial in isolation from one another rather than the joint effect of all outcomes. articles reporting trials often report subgroup findings only when they are statistically significant. they often discuss side effects of treatments without performing statistical analysis. we will recommend improvements to these practices in section . to illustrate, box summarizes a trial comparing standard-care treatment for severe covid- with standard care augmented by prescription of lopinavir-ritonavir. a clinician might reasonably view the estimated reductions in median time to clinical improvement and in mortality to be suggestive, albeit not definitive, evidence that treatment with lopinavir-ritonavir is beneficial relative to standard care alone. yet the study authors conclude (p. ) "no benefit was observed with lopinavir-ritonavir treatment beyond standard care." this conclusion was reached because the estimated treatment effects were not statistically significant, having confidence intervals that cover zero. subsequently, covid- treatment guidelines issued by the national institute of health (nih) cited the absence of statistical significance when it characterized the study as having negative findings. requiring statistical significance to prescribe a treatment an innovation shows deference to standard practice, placing the burden of proof on the innovation. from a clinical perspective, one might argue that it is reasonable to place the burden on an innovation when standard care is known to yield good patient outcomes. however, this argument lacks appeal in the covid- setting. current standard practice for treating covid- has developed rapidly to cope with an emergency. it has not been shown to yield notably good patient outcomes. how should clinicians act with imprecise evidence such as in the cao et al. study? the nih document states: "the panel recommends against the use of lopinavir/ritonavir (ai) or other hiv protease inhibitors (aiii) for the treatment of covid- , except in the context of a clinical trial. it later remarks: "there was a lower, but not statistically significant, mortality rate (lopinavir/ritonavir . %, on soc . %) and shorter icu stay compared to those given soc ( days vs. days; difference = - days; % ci, - to )." https://covid treatmentguidelines.nih.gov/therapeutic-options-under-investigation/antiviral-therapy/, accessed may , . the statistical analysis of the cao et al. study is not unusual. a much-anticipated preliminary report on a large trial comparing standard care augmented by the drug remdesivir with standard care alone concludes that remdesivir reduces time to recovery, but the report states no conclusion regarding mortality (beigel et al. ) . the report states that remdesivir reduces median time to recovery from days to days and reduces -day mortality from . % to . %. a clinician might reasonably consider both findings to be relevant to treatment choice, but the research team stated a conclusion only for time to recovery. the rationale was that the former finding was statistically significant by conventional criteria and the latter was insignificant. consider the major new recovery trial under development in the united kingdom (https://www.recoverytrial.net/). this trial will compare standard care alone with standard care augmented by various experimental drugs. the statistical analysis plan calls for application of hypothesis tests to compare patient outcomes under alternative treatments. the reported % confidence intervals for the rate ratio for recovery and the hazard rate for death were [ . , . ] and [ . , . ] respectively. the former interval is deemed a statistically significant treatment effect by conventional criteria because the lower bound . is slightly larger than . the latter interval is deemed an insignificant treatment effect because the upper bound . is slightly larger than . the results observed in any randomized trial have random variation. whatever criterion one uses to make treatment decisions based on the results of a trial, there is always some probability that this random variation will lead to prescribing a sub-optimal treatment to patients. considering the probability of error alone is insufficient. the same error probability should be less tolerable when the impact of sub-optimal treatment on patient welfare is larger. to evaluate treatment choice based on trial data, we use the concept of near-optimality (manski and tetenov, , ) , which jointly considers the probability of errors and their magnitudes. box : statistical analysis in a trial comparing treatments for covid- cao et al. ( ) report on a randomized trial in china comparing standard-care treatment of severe cases of covid- with standard-care combined with the drug pair lopinavir-ritonavir. the trial assigned hospitalized adult patients to the lopinavir-ritonavir group and to the standard-care only group. the pre-declared primary endpoint measured time to clinical improvement. a secondary outcome was mortality within days. the authors summarized the primary finding as follows (p. ): "in a modified intention-to-treat analysis, lopinavir-ritonavir led to a median time to clinical improvement that was shorter by day than that observed with standard care (hazard ratio, . ; % ci, . to . ). regarding mortality, of the patients assigned to lopinavir-ritonavir died within days and of the receiving only standard care died. the authors characterized this finding as follows (p. ): "mortality at days was similar in the lopinavir-ritonavir group and the standard-care group ( . % vs. . %; difference, − . percentage points; % ci, − . to . )." they reported raw findings on side effects, but they performed no statistical analysis. they concluded (p. ): in hospitalized adult patients with severe covid- , no benefit was observed with lopinavir-ritonavir treatment beyond standard care. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted june , . . https://doi.org/ . the concept is as follows. consider specified possible values for average patient outcomes under each treatment. presuming the common medical focus on average patient outcomes, the ideal clinical decision would be to prescribe a treatment that maximizes average outcome. trial data do not reveal the best treatment with certainty, so one cannot achieve this ideal. suppose then that one applies some decision criterion to the trial data. the criterion may be a hypothesis test or another one that we will introduce shortly. for every treatment that is not best, we compute the probability that it would be prescribed when the criterion is applied to the results of a trial. we multiply this error probability by the magnitude of the loss from prescribing this treatment, measured by the difference in average patient outcomes compared to the best treatment. this product measures the expected loss from prescribing the inferior treatment, also called its regret. the sum of these expected losses across all inferior treatments measures the gap between the ideal of prescribing the best treatment and the reality of having to prescribe the treatment based on trial data that is subject to random variation. the above calculations are made using specified possible values for average patient outcomes with each treatment. however, trial data do not reveal the true values for average patient outcomes; they only enable one to estimate them. the final measurement step is to look across all a priori possible values for average patient outcomes for all treatments to find the values where the expected loss from prescribing inferior treatments is largest. this measures the nearness to optimality of the proposed criterion for clinical decision making. nearness to optimality is also called maximum regret. see the technical appendix for a mathematical statement. to illustrate how measurement of nearness to optimality works in practice, table applies two different decision criteria to the trial design in cao et al. ( ) , which assigned patients to standard care and to care augmented by lopinavir-ritonavir. we focus on the outcome of -day mortality, presuming that . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . . https://doi.org/ . this is the most important outcome for patients with severe covid- . each column in the table specifies one scenario for average patient outcomes, combining a mortality rate of standard care, fixed at . , with a mortality rate of the new treatment, ranging from . to . . panel a shows what would happen if the trial data were used to make treatment decisions with a conventional two-sided hypothesis test at % level. thus, the new treatment would be prescribed if the results of the hypothesis test show the new treatment to be statistically significantly better than standard care. if the new treatment is better, prescribing standard care is an error. the loss from this error is the difference in average patient outcomes, in this example mortality. the table shows that if the new treatment has a mortality rate of . , compared to . for the standard care, a trial with the design of cao et al. will erroneously reach a negative conclusion about the new treatment in . % of trials, leading clinicians to continue using standard care. the magnitude of the error is . , the difference between . and . . multiplying the probability of error by its magnitude gives an expected loss of . . suppose instead that the new treatment has mortality rate . . then the hypothesis test would reach a negative conclusion about the new treatment in . % of trials. while the error probability in this scenario is higher, it is less consequential for clinical outcomes because the difference in mortality rates between treatments is . . in this case, expected loss is . x . = . . if the new treatment has mortality rate . ( . higher than standard care), the hypothesis test would reach a positive conclusion about the new treatment only in . % of trials, leading to expected loss of . x . = . . expected loss is also extremely low in other scenarios where the new treatment has a considerably higher mortality rate than standard care because the probability of type i error of a hypothesis . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . . https://doi.org/ . test is dramatically lower than its nominal size. the nominal size . of the test is the error probability in the borderline case where the two treatments have the same mortality rate. we measure nearness to optimality by considering all possible scenarios for the average outcomes of treatments in the trial, which can take any values in the [ , ] interval, not just the few scenarios illustrated in table . we report nearness to optimality for treatment choice based on hypothesis tests in two-arm trials with different sample sizes in table . the table shows that choosing treatments based on a hypothesis test following a two-arm trial in which patients receive each treatment (as in cao et al.) achieves nearoptimality of . . specifically, the maximum value of expected loss across all possible values of average mortality rates occurs when the new treatment has mortality rate . and standard care has rate . . then the expected loss ( . − . ) multiplied by the error probability . equals . . hypothesis tests by design treat standard care and the new treatment asymmetrically. an appealing alternative decision criterion is the empirical success rule, which we have previously studied in manski ( ) and manski and tetenov ( , ) . this criterion chooses the treatment with the highest observed average patient outcome in the trial, regardless of the statistical significance of the result. whereas hypothesis testing favors standard care and places the burden of proof on innovations, the empirical success rule assesses the evidence on each treatment symmetrically. the properties of the empirical success rule are illustrated in panel b of table . if the new treatment has mortality rate . and standard care has rate . , using the empirical success rule will result in prescribing the new treatment in . % of trials, whereas the hypothesis testing approach of panel a would only do so in . % of trials. given that the empirical success rule treats both treatments symmetrically, a two-sided hypothesis test rejects the null hypothesis both if the new treatment performs sufficiently better and if the new treatment performs sufficiently worse than standard care. the allowed type i error probability is split between these two cases, but rejection of the statistical null hypothesis only leads to the prescription of the new treatment in the first case. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . . https://doi.org/ . / . . . doi: medrxiv preprint the expected losses in situations when the new treatment is better and when standard care is better are also symmetric. table compares near-optimality of the empirical success rule and the hypothesis test-based decision criterion in two-arm trials for a wide range of sample sizes. these calculations consider all possible values for the average mortality rates of the two treatments. the technical appendix describes the algorithm used to compute near-optimality. the empirical success rule is about times nearer to optimality than the test-based decision criterion. for example, in a trial with patients in each arm (similar to cao et al.) , the empirical success rule achieves near-optimality of . . the maximum value of expected loss occurs when standard care and the new treatment have mortality rates of . and . . in this case, standard care is erroneously prescribed with probability . . the empirical success rule is symmetric, so the same expected loss occurs when standard care has mortality rate . and the new treatment has rate . . then the new treatment is also erroneously prescribed with probability . . good near-optimality properties of the empirical success rule in two-arm trials are well established in the theoretical literature. given any specified sample size, the empirical success rule has been shown to achieve the lowest possible value of near-optimality in trials with binary outcomes that assign an equal number of patients to each arm (stoye, ). it has also been shown to do so asymptotically in general trials comparing two treatments (hirano and porter, ) . what are the implications of near-optimality for clinical decision making and trial design? suppose that a clinician were to choose between standard care and standard care augmented with lopinavir/ritonavir based solely on the results of cao et al., using standard hypothesis testing methodology. then the average mortality rate of these patients could be up to . higher than under the better of the two treatments. (the . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . . https://doi.org/ . / . . . doi: medrxiv preprint average here is taken over different possible outcomes the trial could produce.) given the gravity of the patient outcomes at stake, this may be an unacceptably high expected loss in welfare. there are two ways of reducing maximum expected loss: (i) increase the sample size of the trial and (ii) change the way the trial results are translated into clinical practice. table shows that a trial enrolling patients into each arm, followed by treatment choice using standard hypothesis testing, would achieve nearoptimality of . . about the same level of near-optimality ( . ) could be achieved by using the empirical success rule in a trial with patients in each arm. thus, the empirical success rule yields a dramatic improvement in near-optimality relative to hypothesis testing. medical research evaluating pharmaceuticals has traditionally shown deference to standard care. hence, one might question the empirical success rule on the grounds that it evaluates the treatments in the trial symmetrically, and thus has the same levels of type i and type ii errors. we think symmetric evaluation of standard care and innovations is justified in the covid- setting when considering trials that compare carefully chosen treatments, without a financial conflict of interest, and that report all patientrelevant outcomes. first, standard care for covid- patients has not itself been perfected through clinical trials. hence, it is unclear why it should get the "benefit of the doubt." second, it would be unethical to participants to conduct clinical trials of a new treatment if they were ex ante expected to yield worse outcomes than standard care. this suggests an ex ante ethical symmetry between the possibilities that the new treatment is better, and that standard care is better. it is logical, then, to evaluate the two treatments symmetrically. the specific form of deference differs between superiority trials and non-inferiority trials. the null hypothesis used in the former trials defers to standard care somewhat more than that used in the latter trials. see u. s. food and drug administration ( ). . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . . https://doi.org/ . / . . . doi: medrxiv preprint . near-optimality in multi-arm trials a number of promising pharmaceutical treatments for covid- are currently undergoing clinical trials. most of them are two-arm trials, comparing one experimental treatment with standard care. it is important for clinicians to learn not only which treatments are better than standard care, but also which treatments are the most effective. running multiple two-arm trials has a significant drawback when there are concurrently several treatments under investigation: the performance of alternative treatments cannot easily be compared between trials because the populations from which different trials recruit patients usually are not the same. trials may also differ in the characteristics of standard care they provide and in the outcomes they report. these problems are addressed by multi-arm trials that randomize the same patients either to standard care or to one of several experimental treatments. two large-scale multi-arm trials of treatments for covid- are currently under way. the recovery trial in the united kingdom is comparing standard care with at least four alternatives: lopinavir-ritonavir, low-dose dexamethasone, hydroxychloroquine, and azithromycin. the international solidarity trial organized by the world health organization is comparing standard care with remdesivir, chloroquine or hydroxychloroquine, lopinavir-ritonavir, and lopinavir-ritonavir plus interferon beta- a. we will consider the design of the recovery trial, which assigns patients to standard care and alternative treatments in a : : : : ratio. the standard way to analyze the results of multi-arm trials has been to compute a t-statistic for the difference in average trial outcomes between each new treatment and standard care. each t-statistic is then . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . . https://doi.org/ . / . . . doi: medrxiv preprint compared to a critical value adjusted for multiplicity of hypotheses. the aim of this adjustment is to guarantee that in a scenario when all new treatments have the same true average outcome as standard care, there is only a . probability that any of the differences will be found to be statistically significant in a trial. the protocol of the recovery trial, for example, specifies that its results will be reported this way. the protocol specifically states that dunnett's test of multiple hypotheses will be used. the intention to use dunnett's test may have motivated the study team to assign patients in a : : : : ratio, which has been recommended when applying this test (dunnett, ) . the concept of near-optimality is well-suited to interpret the findings of a multi-arm clinical trial, as it takes into account both the probability and the magnitude of different types of errors: prescribing standard care when one of the new treatments is superior, prescribing a new treatment that is inferior to standard care, or prescribing one new treatment when another new treatment is superior. table illustrates how the near-optimality of a decision criterion is evaluated in a multi-arm trial. we panel a shows what would happen if the trial data were used to make treatment decisions based on a two-sided dunnett's test at % level. we assume that standard care will be prescribed if none of the new treatments has a lower mortality rate that is statistically significantly better. if one or more new treatments is considered statistically significantly better, then the new treatment with the lowest mortality rate among them will be prescribed. treatment a has the lowest mortality rate in this scenario and will be prescribed after . % of trials. standard care will be prescribed after . % of trials. since standard care has mortality rate that is . . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . . https://doi.org/ . higher than the best treatment (a), this error will lead to a loss of . . the expected loss from prescribing standard care is the product of the error probability and its magnitude: . x . = . . treatment b will be prescribed after . % of trials. since its mortality rate is . higher than that of the best treatment, the expected loss from prescribing treatment b is . x . = . . prescribing treatment b does not increase patient mortality rate as much as prescribing standard care and the expected loss reflects that. treatments c and d will be prescribed after fewer than . % trials and the expected loss from these errors is negligible. overall expected loss in this scenario is . , . resulting from prescribing standard care and . from prescribing treatment b. although standard care is only the third-best option, it is prescribed much more frequently than the second-best option (b) due to the status-quo deference inherent in hypothesis testing. panel b shows what would happen if the empirical success rule were used to prescribe treatments based on trial results. treatment a would be prescribed after % of trials. the second-best treatment b would be prescribed after % of trials, resulting in expected loss of . x . = . . standard care would be prescribed only after . % of trials, and treatments c and d after fewer than . % of trials. the overall expected loss when using the empirical success rule in this scenario is . . near-optimality is measured by considering all possible scenarios for the average outcomes of treatments in the trial. the technical appendix describes the algorithm used to compute near-optimality. in table we compare near-optimality of prescribing treatments using standard multiple hypothesis testing approach and of prescribing them using the empirical success rule in five-arm trials with different sample sizes. we report results both for trials with a : : : : treatment-assignment ratio (as in the recovery trial) and for trials with the same total sample size, but balanced assignment of patients to treatments. in each case considered, the empirical success rule is more than times nearer to optimality than the test-based decision criterion. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . the numerical calculations of near-optimality presented in tables through concern relatively simple settings where patients are observationally identical and trial outcomes are binary, such as mortality. in clinical practice, trial outcomes may take multiple values. for example, trials of experimental drugs for covid- may report both mortality outcomes and time to recovery for patients who survive. patients who vary in age, gender, and comorbidities may vary in their response to treatment. it has been common in analysis of trial data to designate primary and secondary outcomes. the latter are often called side effects. research articles focus attention on the primary outcome. this is reasonable when the primary outcome is the dominant determinant of patient welfare or, put another way, when there is little variation in secondary outcomes across treatments. it is not reasonable otherwise. when the secondary effects of treatments are serious, it is more reasonable to consider how the primary and secondary outcomes jointly determine patient welfare. this is easy to accomplish with the empirical success rule. box uses the protocol for the recovery trial to illustrate. methodological research has shown how to compute or bound the near-optimality of the empirical success rule when applied in a broad range of settings. we summarize the findings below. https://www.recoverytrial.net/files/recovery-protocol-v - - - - .pdf , accessed may , . . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . . https://doi.org/ . / . . . doi: medrxiv preprint manski and tetenov ( ) study the near-optimality of the empirical success rule when there are two feasible treatments and patient welfare is a weighted sum of binary primary and secondary outcomes. the primary outcome is patient survival for a specified time period. the secondary one denotes whether the patient suffers a specified side effect of treatment. the protocol for the recovery trial states "for each pairwise comparison with the 'no additional treatment' arm, the primary objective is to provide reliable estimates of the effect of study treatments on all-cause mortality at days after first randomisation . . . . the secondary objectives are to assess the effects of study treatments on duration of hospital stay; the need for . . . . ventilation; and the need for renal replacement therapy. data from routine healthcare records . . . . and from relevant research studies . . . . will allow subsidiary analyses of the effect of the study treatments on particular non-fatal events . . . . the influence of pre-existing major co-morbidity . . . . and longer-term outcomes . . . . as well as in particular sub-categories of patient . . . . ." thus, the researchers intend to study multiple outcomes and to examine heterogeneity of treatment response across patients who vary in co-morbidities and other covariates. the analysis plan calls for pairwise comparison of each experimental treatment with 'no additional treatment;' that is, with standard care. the plan refers to use of hypothesis tests to make these comparisons, particularly the dunnett test for multiple comparisons. we suggest application of the empirical success rule. a simple approach would be to model overall patient welfare as a weighted sum of the multiple outcomes described in the protocol, each outcome weighted appropriately to reflect its contribution to welfare. a clinician might, for example, find it desirable to give large positive weight to survival and some negative weight to duration of hospital stay, the need for ventilation, and the need for renal replacement therapy. considering patients who share similar observed comorbidities and other covariates, each treatment would be evaluated by its empirical success in achieving overall patient welfare in this covariate group. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . . https://doi.org/ . / . . . doi: medrxiv preprint when a patient does not suffer the side effect, we let welfare equal if a patient survives and equal if he does not survive. when a patient experiences the side effect, welfare is lowered by a specified fraction h, whose value expresses the harm associated with the side effect. thus, a patient who experiences the side effect has welfare − h if he survives and -h if he does not survive. in this setting, we develop an algorithm to compute the near-optimality of the empirical success rule, which evaluates trial data by the frequencies of survival and the side effect observed with each treatment. we present numerical findings for alternative values of sample size and the value h expressing the harm of the side effect. exact computation of near-optimality is feasible when trial outcomes are binary or take only a few values, but it becomes more onerous when outcomes can take many values or are continuous. when outcomes are bounded, large-deviations inequalities of probability theory yield upper bounds on the nearoptimality of the empirical success rule. these upper bounds provide conservative measures of nearoptimality. their value is that they are simple to compute and are sufficiently informative to provide useful guidance to clinicians. research of this type was initiated by manski ( ) , who used a large-deviations inequality for sample averages of bounded outcomes to derive an upper bound on the near-optimality of the empirical success rule when used to choose between two treatments. manski and tetenov ( ) extend the analysis to multiarm trials. their proposition extends the early finding of manski ( ) from two to multiple treatments. proposition derives a new large-deviations bound for multiple treatments. let l be the number of treatment arms and let v be the range of the bounded outcome. when the trial has a balanced design, with n subjects per treatment arm, the upper bounds on near-optimality proved . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . . https: //doi.org/ . //doi.org/ . / in propositions and have particularly simple forms, being ( e) -½ v(l − )n -½ and v(ln l) ½ n -½ . the former result provides a tighter bound than the latter for two or three treatments, while the latter result gives a tighter bound for four or more treatments. in both cases, the upper bound decreases toward zero at rate √n as the number n of subjects per arm increases. patient response to treatments for covid- may be heterogenous, varying with observable covariates including age, gender, and comorbidities. hence, a clinician may want to assess the near-optimality of a decision criterion when applied to patients who share similar observed covariates. in principle, this is easy to do. the clinician may view each group of patients who share similar covariates as a separate patient population. accordingly, the clinician may apply the empirical success rule separately to each group, choosing a treatment that yields the highest average outcome among the trial participants who have the group covariates. in this manner, patient care may recognize heterogeneity of treatment response. in practice, the ability of clinicians to differentially treat patients with different covariates is sometimes limited by the failure of medical researchers to report how trial findings vary with patient covariates. a common rationale is concern with statistical significance. stratifying trial participants into covariate groups usually reduces the statistical precision of estimates of treatment effects. research articles often report only findings that are statistically significant by conventional criteria. we think it misguided to tie reporting of research findings to statistical significance. if researchers want to inform patient care, they should study and report observable heterogeneity in treatment response to the extent feasible. the analysis of this paper makes clear that estimates of treatment effects need not be statistically significant to be clinically useful. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . . https: //doi.org/ . //doi.org/ . / . discussion a central objective of empirical research on treatment response is to inform treatment choice. yet researchers analyzing trial data have used concepts of statistical inference whose foundations are distant from treatment choice. it has been common to use hypothesis tests to choose treatments. we recommend evaluation of decision criteria by near-optimality and suggest this way to analyze findings of trials comparing covid- treatments. from this perspective, the empirical success rule performs much better than hypothesis testing. in contrast to hypothesis tests, the empirical success rule views treatments symmetrically. of course, use of the rule does not guarantee that the optimal treatment is always chosen. no decision criterion can achieve this ideal with finite trial data. evaluation of criteria by near-optimality appropriately recognizes how the probability and magnitude of errors in decision making combine to affect patient welfare. for simplicity, we have considered randomized trials having full internal and external validity. internal validity may be compromised by non-compliance and loss to follow up. external validity may be compromised by measurement of surrogate outcomes and by administration of trials to types of patients who differ from those that clinicians treat in practice. the concept of near-optimality is applicable when analyzing data from trials with limited validity, but the specific numerical calculations made in this paper would require modification. a limitation of this paper is that it only considers treatment choice using data from one trial. in practice, a clinician may learn the findings of multiple trials and may also be informed by observational data. the . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . . https://doi.org/ . / . . . doi: medrxiv preprint concept of near-optimality is well-defined in these more complex settings, but methods for practical application are yet to be developed. a further issue beyond the scope of this paper concerns the dynamics of treatment choice when new trials and observational evidence may emerge in the future. the concept of near-optimality should be extendable to such settings. however, methodology for application is yet to be developed. dynamic analysis of treatment choice made with hypothesis tests may be especially difficult to perform, because testing views standard care and new treatments asymmetrically. as new evidence accumulates over time, the consensus designation of standard care may change, leading to a change in the null hypothesis when new trials are evaluated. the implications for patient welfare are unclear. general setup we use concepts and notation like those in manski ( ) and manski and tetenov ( , ) . the clinician must assign one of l treatments studied in the clinical trial to each member of a treatment population, denoted j. denote the set of treatments by t = { , , …, l}, treatment being standard care. each individual j ∈ j has a response function yj(⋅): t → y mapping treatments t ∈ t into individual patientrelevant outcomes yj(t) ∈ y. in general, outcomes could be multi-valued and multi-dimensional. for example, the relevant outcomes for covid- treatment may be survival, taking the value or , and time to recovery for those who survive, measured in number of days. the probability distribution p[y(⋅)] of the random function y(⋅): t → y describes treatment response across the population. the distribution p is unknown. the set of all feasible distributions p is {ps, s ∈ s}, . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . . https://doi.org/ . where s indexes all feasible states of nature. when computing near-optimality in tables and , we include in s all logically possible outcome distributions. we assume that patient welfare is a known function u: y → r of individual outcomes. for binary outcomes y = { , }, with denoting success. in this special case, it is without loss of generality to set u(y) = y. for two-dimensional patient outcomes y = (yp, ys), where yp denotes the primary outcome and ys the side effect, manski and tetenov ( ) considered patient welfare that is a weighted sum of the two outcomes: u(y) = yp − hys, where h expresses the harm of the side effect relative to the primary outcome. now consider data generation. let Ψ denote the sample space; that is, Ψ is the set of data samples that could be generated by the trial. let qs denote the sampling distribution on Ψ in state of nature s. that is, qs is the probability distribution of different trial outcomes. we consider trials that randomize a predetermined number of subjects nt to each treatment t. the set nt the sampling distribution qs is determined by the probability distribution of treatment response ps and the trial design, with qs(yi|ti) = ps(y(ti)). we assume that treatment response is individualistic; that is, patient outcomes are statistically independent of the outcomes of other patients in the trial. a statistical treatment rule maps sample data into a treatment allocation. a feasible treatment rule is a function that randomly allocates persons across the different treatments. let Δ now denote the space of functions that map t into the unit interval and that satisfy the adding-up condition: δ ∈ Δ ⇒ ∑ t ∈ t δ(t, ψ) = , ∀ ψ ∈ Ψ. then each function δ ∈ Δ defines a statistical treatment rule. the mean welfare outcome of treatment t in state of nature s is denoted by μst ≡ es[u(y(t))]. the maximum average patient welfare achievable in state s is max ∈ . after trial data ψ are observed, the fraction δ(t, ψ) . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . . of patients will be treated with treatment t, resulting in mean patient welfare ∑ � ( , )� ∈ . the mean welfare of patients treated according to statistical treatment rule δ over repeated realizations of the trial is is the expected (across potential samples) fraction of persons who will be assigned to treatment t. application of statistical treatment rule δ in state of nature s leads to an expected loss (regret) equal to the near-optimality (maximum regret) of statistical treatment rule δ is the maximum value of (a ) over all feasible states of nature: first, we consider statistical treatment rules based on hypothesis tests for univariate outcomes y. denote specifically, we use the student's t-distribution for two-arm trials and the dunnett's test critical value for multiple comparisons for multi-arm trials. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . . https://doi.org/ . the hypothesis test rule prescribes treatment (standard care) to everyone if all t-statistics are below the critical value.: if some t-statistics comparing treatments ,…,l to standard care exceed the critical value, these treatments are considered statistically significantly better than standard care. we assume that among these treatments the one with the largest mean outcome in the trial will be prescribed (with equal probability if there is a tie). when treatment arms ,…,l have equal sample sizes, as in our table , the t-statistics τt have the same ranking as the sample means � . hence, prescribing the treatment with the largest mean outcome in the trial is equivalent in this case to prescribing the treatment with the largest t-statistic. let � = ∑ ( ) : = denote the mean patient welfare observed in treatment arm t = , , …, l. the empirical success rule considers all treatments in the trial symmetrically and prescribes the treatment with the largest observed mean patient welfare. if there is a tie, all treatments with the largest observed mean patient welfare are prescribed with equal probability. for binary outcomes, we take u(y) = y. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . . https://doi.org/ . computation of near-optimality for two-arm trials with binary outcomes when computing the near-optimality results reported in table , we consider the set of all possible distributions of binary outcomes with means p ≡ e[y( )], p ≡ e[y( )], (p , p ) ∈ [ , ] . let m and m denote the number of positive outcomes in each arm of the trial. for binary outcomes, ψ = (m , m ) is a sufficient statistic for the sample. hence, it is sufficient to consider the sample space Ψ = { , , …, n }×{ , , …, n }. the probability density function of ψ is a product of two binomial density functions. this sample space is sufficiently small, so we compute (a ) exactly. the function (a ) is continuous in (p , p ) but may have multiple global and local maxima. we computation of near-optimality for multi-arm trials with binary outcomes to compute the results reported in table , we consider the set of all possible distributions of binary outcomes with means pt ≡ e[y(t)], t = , …, l, (p , …, pl) ∈ [ , ] l . let mt denote the number of positive outcomes in arm t of the trial. for binary outcomes, ψ = (m , …, ml) is a sufficient statistic for the sample. hence, we consider the sample space Ψ = { , , …, n }×…×{ , , …, nl}. the large size of the sample space makes it impractical to evaluate (a ) exactly. instead, given each value of (p , …, pl) we simulate a large number of trial outcomes to approximate the sampling distribution qs. our computations of the maximum of (a ) proceed in three steps. first, we conduct a grid search using possible values for each parameter pt∈[ , . , …, ]. for each combination of parameters, we approximate the sampling distribution qs by simulating , trial outcomes. the results of this grid search suggest that the largest expected loss for the empirical success rule . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . . https://doi.org/ . occurs when the parameters have the form p = a, p = p = p = p = b, a > b. the largest expected loss for the dunnett's test rule occurs when p = a, p in the second step, we conduct a grid search over these two lower-dimensional parameter spaces using possible parameter values from [ , . , …, ] for a, b, and c. in this step we approximate qs by simulating , , trial outcomes. in the last step, we take parameter combinations yielding the largest estimated expected loss for each decision rule in step and re-compute expected loss by simulating , , trial outcomes. we do this to verify that our results are not affected by bias resulting from approximating qs by simulation. the matlab code used to perform the computations is available from aleksey tetenov. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted june , . table : near-optimality of hypothesis test and empirical success decision rules for two-arm trials with equal number of patients in each arm. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted june , . expected loss given these mortality rates . table : illustrative scenario for a multi-arm clinical trial assigning patients to receive standard care and patients each to four alternative treatments. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted june , . table : near-optimality of multiple hypothesis testing and empirical success decision rules for five-arm trials with specified sample sizes. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted june , . . https://doi.org/ . remdesivir for the treatment of covid- --preliminary report a trial of lopinavir-ritonavir in adults hospitalized with severe covid- new tables for multiple comparisons with a control asymptotics for statistical treatment rules statistical treatment rules for heterogeneous populations sufficient trial size to inform clinical practice trial size for near-optimal treatment: reconsidering mslt-ii minimax regret treatment choice with finite samples non-inferiority clinical trials to establish effectiveness key: cord- -wznzmssz authors: iannitti, t.; palmieri, b. title: therapeutical use of probiotic formulations in clinical practice date: - - journal: clin nutr doi: . /j.clnu. . . sha: doc_id: cord_uid: wznzmssz background & aims: the spreading of gastrointestinal diseases is growing all over the world. although for some of them an effective therapeutic approach has been found, palliation rather than cure is very frequent due to a partial knowledge of their aethiology and pathogenesis. this review, analyzing the main clinical studies, aims at being a state of the art update of the use of probiotic formulations in daily practice. methods: in this review we include all the most significant clinical trials involving the use of probiotic formulations for the treatment of several pathologies. results: dysbiosis has been observed in irritable bowel syndrome patients. probiotics may exert a beneficial effect on crohn’s disease affected patients who have shown gut microbiota antigens and altered wall permeability. moreover some probiotic formulations seem to enhance the therapy for helycobacter pylori reducing its pathogenic potential. intestinal ecology imbalance has been also linked to cancer induction, allergy, skin and urogenital diseases. in addition probiotics administration seems to be particularly useful to ease post-operative complications. conclusion: further future clinical trials, involving large numbers of patients, will be mandatory to achieve definite evidence of the preventive and curative role of probiotics in medical practice. the gastrointestinal (gi) tract starts from the mouth, involves the oesophagus, the stomach, the small and large intestine and ends at the anus (fig. ) . the gi tract has four main functions: ingestion, digestion, absorption, and defecation. in a normal human adult male, the gi tract is approximately . m long and can be divided into the upper tract which is made up of mouth, pharynx, oesophagus and stomach and the lower tract which is made up of the small intestine (duodenum, jejunum and ileum), the large intestine (cecum, colon and rectum) and anus. aerobic and anaerobic bacteria, yeast and fungi live into the gi tract which has more than m of surface area. all these organisms in a healthy intestinal tract live in a natural balance called symbiosis. there are more than species of commensal bacterial organisms within our bodies, the vast majority in the gut. in fact the mammalian gut is considered one of the most densely populated ecosystems on earth with a bacterial load in the region of organisms/g of fecal material in the large intestine. the several species of microorganisms in the adult human gut are known as the microbiota which may contain nearly times the number of genes contained within the human genome. the genome of these collective organisms is called the microbiome. the longitudinal distribution of intestinal microorganisms increases in density progressing from the small bowel to colon (fig. ) . anaerobic bacteria benefit the host by performing metabolic functions including fermentation, providing short-chain fatty acids (scfas), producing vitamins, adding to the trophic action of the epithelium and aiding in the development of the immune system. the stomach harbours only very few bacteria (mainly acidtolerant lactobacilli) because of the acidity due to the gastric juice. in the colon there are about a million times more bacteria than in the stomach due to a higher exposure to nutrients, slow transit, and low-redox potential. about % of feces are made up of bacteria. while new bacteria are produced, the old ones are flushed out of the intestine and they will be finally present in the feces. the different strains of bacteria living in the gi tract are summarized in table . the normal flora which colonizes the gi tract exert several functions: ) synthesizing and excreting vitamins in excess of their own needs, which can be absorbed as nutrients by their hosts (enteric bacteria secrete vitamin k and vitamin b , and lactic acid bacteria produce certain b-vitamins); ) preventing the pathogens colonization by competing for attachment sites or essential nutrients; ) being likely to produce substances which inhibit or kill non indigenous species; ) stimulating the development of certain tissues, i.e., the caecum and certain lymphatic tissues (peyer's patches) in the gi tract; ) stimulating the production of natural antibodies; ) producing a variety of substances ranging from relatively non-specific fatty acids and peroxides to highly specific bacteriocins which inhibit or kill other bacteria. , gut microbiota are also known to influence energy balance and in turn, emerging evidence demonstrates the importance of gut microbiota in the pathophysiology of obesity. the initial acquisition of intestinal microbiota plays a key role in the development of immune processes and protection against pathogens. the human fetus is sterile in utero and microbes colonize it during its passage through the birth canal. the host genotype is important in determining the populations of intestinal organisms which, after birth, are influenced by the baby exposure to numerous bacteria from the environment (e.g., skin, mouth, mother's milk). this initial microbiota is relatively unstable and changes during the initial period of life. reinhardt et al. report that infants are initially colonized by facultative anaerobes such as enterobacteria and gram-positive cocci, which are thought to create a reduced environment favorable for the establishment of obligate anaerobes, including bacteroides, bifidobacterium, and clostridium. tennison et al. report that the type of birth delivery has a significant impact on the development of the gut microbiota in fact vaginal delivery allows infant exposure to maternal bacteria, i.e. the longer the birth process is the greater exposure you have, while infants born by cesarean delivery acquire bacteria by exposure to the mother as well as isolates transferred by nursing staff, other infants, air and equipment. following birth, oral and cutaneous bacteria from the mother will be mechanically transferred to the infant by suckling, kissing and caressing. moreover the authors observed that breast feeding exposes the infant to bacteria, especially bifidobacteria, from milk ducts, nipple, and surrounding skin. breast milk contains antimicrobial components and growth factors that stimulate the development and maturation of the intestinal mucosa. the fig. . picture reported from "dibaise et al. gut microbiota and its possible relationship with obesity". key physiologic and microbiological features of the gut, relative concentrations of bacteria and the ph at various locations within the adult gut are shown (cfu ¼ colony-forming unit). table gi flora components. oral cavity (saliva) authors conclude that the development of infantile intestinal microbiota involves the initial vaginal exposure, transmission during neonatal care, subsequent breast feeding and finally, after the introduction of solid food, the bacterial profiles of breast and formula fed infants become similar to that of adults by the e years of life (conversion to adult microbiota). the gi tract bacteria are all essential for its normal physiology but they are also potentially pathogenic. dysbiosis occurs when the gi bacterial microflora ecology equilibrium is altered leading to an imbalance that can involve metabolic or immunologic feedback of the host. round et al. describe a healthy microbiota as a balanced composition of many classes of bacteria such as symbionts (organisms with known health promoting functions), commensals (permanent residents which provide no benefit or detriment to the host) and pathobionts (permanent residents of the microbiota with the potential to induce pathology). the authors underline that, in conditions of dysbiosis, there is an unnatural shift in the composition of the microbiota, which results in either a reduction in the numbers of symbionts and/or an increase in the numbers of pathobionts (fig. ). this condition can lead to mild subjective discomfort and even disease condition (e.g., dysbiosis can lead to non-specific inflammation which may predispose certain genetically susceptible people to inflammatory disease). the good balance of gi tract microflora is responsible for a lot of functions within the body such as vitamin production, hormonal activities, immunity and detoxification processes. in case of bacterial imbalance a release of toxic metabolic products is induced, followed by flatulence, bloating, intestinal pain and inflammation, cramping and constipation and/or diarrhea. it is important that a correct dysbiosis diagnosis is made because the only treatment of the symptoms will not lead to the solving of the real problem and will bring the patient to develop other diseases. in fact, intestinal dysbiosis should be considered as a possible cause, or a contributing factor in patients who have asthma, bronchitis, allergies, autoimmune disorders, breast and colon cancer, unexplained fatigue or neuropsychiatric symptoms. systemic effects such as halitosis, adrenal stress, diarrhea, candida, leaky gut syndrome, colon cancer and breast cancer can be considered a consequence of dysbiosis. possible factors which can contribute to dysbiosis are: host genetics, lifestyle, exposure to microorganisms and medical practices, diet and stress. birth in the sterile environment of hospitals can protect from exposure to dangerous pathogens, but can also prevent early exposure to health promoting bacteria. overuse of vaccination and antibiotics, which do not distinguish between pathogenic or symbiotic microorganisms, could adversely alter the microbiota. many chronic and degenerative diseases such as irritable bowel syndrome (ibs), inflammatory bowel disease (ibd), rheumatoid arthritis, and ankylosing spondylitis are considered today to be linked to abnormalities in the bacteria microflora ecology (fig. ). the term probiotic derives from the greek/latin word "pro" and the greek word "bios", meaning for life. the concept of probiotic was probably firstly introduced by the russian nobel laureate elie metchnikoff in ("the prolongation of life: optimistic studies") where he proposed the idea that ingesting microbes could have beneficial effects for human beings, especially to treat digestive diseases". the term "probiotic" was firstly used in , by lilly and stillwell, to describe substances secreted by one organism which stimulates the growth of another. the world health organization (who) and the food and agriculture organization of the united nations have defined probiotics as "live microorganisms, which, when administered in adequate amounts, confer a health benefit on the host." probiotics consist of bacteria or yeasts and can be considered functional foods that can re-colonize and restore the microflora symbiosis of the intestinal tract. most probiotics are bacteria similar to those naturally found in people's guts, especially in those of breastfed infants because they are known to have natural protection against many diseases. most often, the bacteria come from two groups, lactobacillus or bifidobacterium. each group involves different species (lactobacillus acidophilus, bifidobacterium bifidus etc.) which include different strains. some common probiotics, such as saccharomyces boulardii, are yeasts. some examples of bacteria used in probiotics formulations are lactobacillus acidophilus, lactobacillus rhamnosus, lactobacillus bulgaricus, lactobacillus salivarius, lactobacillus plantarum, lactobacillus casei, lactobacillus sporogenes, bifidobacterium bifidum, bifidobacteria longum, bifidobacteria infantis, streptococcus thermophilus and homeostatic soil organisms (hso's). a good probiotic must possess the following requirements: ) being able to adhere to cells; ) excluding or reducing pathogenic adherence; ) being able to persist, multiply and produce acids, hydrogen peroxide and bacteriocins antagonistic to pathogen growth; ) being able to be safe, noninvasive, noncarcinogenic and non-pathogenic; ) being able to coaggregate as to form a normal balanced flora. for an adequate amount of health benefits, a dose of billion colonyforming unit (cfu) has been recommended for at least days (  cfu/day). probiotics are available in food and dietary supplements (for example, capsules, tablets and powders) and in some other forms as well. in probiotic foods and supplements, the bacteria may have been present originally or added during preparation. probiotics must survive gastric and bile acids in order to reach the intestinal tract, colonize the host epithelium, and exhibit a beneficial effect. most conventional forms of lactobacilli-type probiotics are nonspore forming and, therefore, are inactivated by bile and low gastric ph. in addition, probiotics selected for commercial use must survive industrial manufacturing and storage to ensure long-term viability and activity. most cells of conventional lactobacilli die at c, while spore-bearing lactic acid-forming bacteria do not show a decrease in viable cells even after heating in saline at c for min. therefore the survival of the gut microbiota shapes intestinal immune responses during health and disease. probiotics through the gi tract is strongly affected by stomach acidity, the length of exposure to acid, the concentration of and length of exposure to bile salts and the level of bile salt hydrolase activity. probiotics must not be confused with prebiotics, nondigestible food ingredients that selectively stimulate the growth and/or activity of beneficial microorganisms already present in people's colons. the term prebiotic was first introduced by gibson and roberfroid in and is defined as "a nondigestible food ingredient that beneficially affects the host by selectively stimulating the growth and/or activity of one or a limited number of bacteria in the colon, and thus improves host health". when probiotics and prebiotics are mixed together, they form a synbiotic. a synbiotic is a supplement that contains both a prebiotic and a probiotic that work together to keep healthy the bacterial microflora of the human intestine. fermented milks (yogurt and kefir) are considered to be true synbiotic products, that is, functional foods, since they contribute to restore the normal bacterial microflora also supplying the food it needs to survive. however not all these products promote symbiosis. the best synbiotic combinations currently available include bifidobacteria and fructooligosaccharides (fos), lactobacillus gg and inulins, and bifidobacteria and lactobacilli with fos or inulins. fos are extracted from fruits and vegetables like bananas, onions, chicory root, garlic, asparagus, barley, wheat, jícama, tomatoes, onion rye, garlic and leeks. the jerusalem artichoke and its relative, yacón have been found to have the highest concentrations of fos. fos are a group of linear fructose oligomers (oligosaccharides), able to escape digestion in the human upper intestine and reach the colon where they are totally fermented mostly to lactate, scfas (acetate, propionate and butyrate), and gas, like dietary fibres. as a consequence of their fermentation, their caloric value is approximately kcal/g. a fecal bulking effect of fos has been observed in humans. an important property of sc-fos is the stimulation of bifidobacterial growth (fos chemical structure is made up of b- - -fructose-fructose which is recognized by the enzyme b-fructosidase which is typical of bifidobacteria that can easily metabolize it; the most of pathogens and putrefactive bacteria are not able to break fos chemical bond making very selective the utilization of these oligosaccharides) specifically while suppressing the growth of potentially harmful species such as clostridium perfringens in the colon. the prebiotic effect of sc-fos is dose dependent and chain length related and is associated with a decrease in fecal ph, an increase in fecal or colonic organic acids, a decrease in the production of nitrogenous end products in urine and stools, a decrease in fecal bacterial enzymatic activities and a modification in fecal neutral sterols. the sc-fos enhance magnesium absorption in humans and have been shown, in animal models, to reduce colon tumour development by enhancing both colon butyrate concentrations and local immune system effectors. buddington et al. studied the effects of dietary fos in healthy adult human subjects fed on a controlled diet for days ( g neosugar/d between days and ). fos caused b-glucoronidase and glycocholic acid hydrolase activities to decrease % and % respectively. the authors found that g neosugar/d alters the fecal flora in a beneficial way decreasing the activities of some reductive enzymes. williams et al. determined changes in the abundance of selected bacteria in anaerobic fecal samples from adult human volunteers who consumed g neosugar (mixture of sc-fos by nutrilite products inc.) daily for two weeks. the presence of fos in the diet acts on the increasing of the growth of the host's existing microbiota encouraging the proliferation of beneficial bacteria groups such as lactobacilli and bifidobacteria. bornet et al. report that in vitro and in vivo studies (in animals and humans) demonstrated that fos are good substrates for the bifidobacteria spp possessing b-fructoisidases and for bacteroides spp and that they are bad substrates for e. coli and c. perfrigens. fos feeding is also related to an increase of bifidobacteria and lactobacilli and to a decrease of c. perfrigens. bifidobacteria are responsible for acetic acid and lactic acid production which reduces the intestinal ph. this ph reduction restricts or prohibits the growth of many potential pathogens and putrefactive bacteria with a reduction of enzyme activities in stools (nitroreductase, decarboxylase etc.) with a deep impact on the metabolism of carcinogenic substances such as n-nitroso compounds, phenolic products of tyrosine and tryptophan and metabolites of biliary steroids. in conclusion fos are able to act on bifidobacteria and could be a protective factor against colon cancer. hidaka et al. performed several clinical studies based on the administration of fos and conclude that these compounds are responsible for cholesterol reduction (reduction in ldl cholesterol contents), suppression of putrefaction, normalization of colon microbial disorders and alleviation of constipation. the authors underline that their usefulness seems to be strictly related to the proliferation of bifidobacteria, to other saccahrolytic intestinal bacteria and scfas produced by these organisms as well. hidaka et al. performed some clinical studies using neosugar g (prepared from sucrose through the action of the enzyme b-fructofuranosidase produced by aspergillus niger), neosugar (a mixture of fos purified from neosugar g by removing the monosaccharides) and disaccharides through a resin treatment. applied foods containing neosugar such as jellies and drinks were also prepared for the clinical studies. the clinical studies showed that fos administration improved blood lipids in hyperlipidemia, suppressed the production of intestinal putrefactive substances and improved the intestinal flora with relief from constipation. aumenta et al. report that nondigestible oligosaccharides (ndos) have been found to stimulate absorption of several minerals and improve mineralization of bone. most of the scientific evidence for the functional effects of ndos is based on animal experiments in which ndos increase the availability of calcium, magnesium, zinc, and iron. this stimulatory effect of some ndos is assumed to be mainly due to their prebiotic character. prebiotics such as inulin, oligofructose, glucooligosaccharide, and galacto-oligosaccharide have been found to stimulate absorption and retention of several minerals, particularly magnesium, calcium, and iron. most of these findings were obtained in studies performed on rats. up to now the number of studies on the effect of ndos on mineral metabolism in humans is limited; positive effects on calcium absorption seem to occur under conditions of increased calcium requirements (adolescence and postmenopause) figs. e . the word probiotics refers to microorganisms that are able to confer health benefits on humans and that have been industrially prepared for nutritional and pharmaceutical use. the consumption of these products is growing very fast all over the world and probiotics are generally considered generally regarded as safe (gras). indu et al. suggest that probiotics are responsible for competitive exclusion of enteric pathogens from the gut lumen. the putative inhibitory mechanism should be the production of lactic acid and bacteriocins. moreover they restore the normal intestinal flora during an antibiotic therapy, trigger cytokines synthesis from enterocytes attaching to their surfaces, produce toxic metabolites like hydrogen peroxide and synthesize butyric acid which increases the turnover of enterocytes and neutralizes dietary carcinogens. probiotics exert several immunomodulatory functions acting on cellular and humoral responses. furthermore they can stimulate type helper t cells (l. casei), mononuclear cells leading to increased clearance of circulating pathogenic bacteria (l. acidophilus), macrophages to produce tnf-alpha, il- and no production, increase clearance of circulating pathogenic bacteria by kupffer cells and they can produce antirotaviral iga and antinfluenza igg antibodies (b. breve). snydman reports three theoretical concerns regarding the safety of probiotics: firstly the occurrence of disease, due to bacteremia, sepsis or endocarditis, secondly the toxic or metabolic effects on the gi tract and thirdly the transfer of antibiotic resistance in the gi flora. the author underlines that, although there are rare cases of bacteremia or fungemia related to the use of saprophytic probiotics, epidemiologic evidence through clinical trials and epidemiologic survey suggests that they can be safely used. wassenaar et al. highlight that bacteria used for probiotics formulation should be completely safe although there could be some flaws: ) sometimes virulence factors have been detected in probiotic bacterial strains; ) horizontal gene transfer can result in acquisition of virulence genes or antimicrobial resistance in probiotic bacteria; ) antimicrobial resistance in these bacteria can possibly aid the spread of unwanted resistance in endogenous bacterial populations. liong et al. observe that some bacteria strains, commonly used in probiotic formulations, such as lactobacillus, leuconostoc, pediococcus, enterococcus, and bifidobacterium have been isolated from infection sites, leading to the problem that these probiotics can translocate. the authors underlined that probiotics translocation hardly occurs in healthy humans (where it happens, detrimental effects are rare) but health-damaging effects of probiotics translocation can occur in immunocompromised patients. in these people probiotics might theoretically cause infections that need to be treated with antibiotics but, unfortunately, the antibiotic resistance of some strains has increased the complexity of their eradication. surely further investigations are required to analyze the mechanisms of probiotic translocation and infection. safety assessments should be focused on these mechanisms so that the negative effects of probiotics do not outweigh the benefits. lammers et al. studied mucosal gene expression of the pleiotropic proinflammatory cytokines (interleukin(il)- beta, il- ), th cytokines (interferon-gamma (ifn-gamma), tnf-alpha, il- ), regulatory cytokines (il- , transforming growth factor-beta), and the chemokine il- . in addition to assess the cytokines gene expression, the presence of polymorphonuclear cells in the mucosal tissue was evaluated. patients who were treated with probiotics had significant lower mucosal mrna expression levels of il- beta, il- , and ifn-gamma compared with placebo-treated patients. a lower number of polymorphonuclear cells was present in the tissue of patients within the probiotic group compared with the number of polymorphonuclear cells in the tissue of patients receiving placebo and patients having an episode of pouchitis. this study highlights that probiotic treatment is able to regulate the mucosal immune response reducing mucosal levels of neutrophilchemoattractant il- and tissue influx of polymorphonuclear cells, and may further act by inhibit t cells activation, reinforce the barrier function and keep a tight control of the potent proinflammatory cytokine il- beta. a randomized double-blind study was designed by marchan et al. probiotic bacteria or placebo were administered for month before delivery to mothers and for months to infants with a family history of allergy. plasma samples were analyzed for c-reactive protein (crp), total iga and ige, foodspecific iga, igg, and ige, il- , il- , il- , il- , tnf-alpha, and ifngamma. the association of crp with a decreased risk of eczema at years of age in allergy-prone children supports the idea that chronic, low-grade inflammation protects from eczema. low-grade inflammation induced by probiotics was characterized by elevation of ige, iga, and il- , a change typically observed in helminth infection associated induction of regulatory mechanisms. this study emphasizes the role of chronic microbial exposure as an immune modulator protecting from allergy. stadbauer et al. in an open-label study involving patients with alcoholic cirrhosis (lactobacillus casei shirota (lcs) ( .  ) times daily for weeks), healthy controls and cirrhotic patients who did not receive probiotics, report that probiotics restore neutrophil phagocytic capacity in cirrhosis, possibly by changing il- secretion and tlr expression, warranting larger randomized controlled and mechanistic studies. kekkonen et al. evaluated the effect of stimulation provided by several probiotic bacterial strains (streptococcus, lactobacillus, bifidobacterium, lactococcus, leuconostoc and propionibacterium) on cytokines production in human peripheral blood mononuclear cells (pbmc). the probiotic s. thermophilus and leuconostoc strains were shown to be more potent inducers of th type cytokines il- and ifn-gamma than the probiotic lactobacillus strains and the use of bacterial combinations did not result in enhanced cytokine production. the first study to investigate the effects of probiotics intervention on global lipidomic profiles in humans was designed by kekkonen et al. the study investigated the effect of three weeks' intervention with lactobacillus rhamnosus on global serum lipidomic profiles and evaluated whether the changes in inflammatory variables (crp, tnf-alpha and il- ) are reflected in the global lipidomic profiles of healthy adults. the authors observed that probiotic lactobacillus rhamnosus intervention may lead to changes in serum global lipid profiles, as reflected in decreased glycerophosphatidylcholines (gpcho), lysophosphatidylcholines (lysogpcho) and sphingomyelins (sm) and in the increasing of triacylglycerols (tags). among the inflammatory variables, il- was moderately associated with changes in global lipidomic profiles, with the top-ranked lipid associated with il- which is the proinflammatory lysogpcho ( : ). there was a weak association between the lipidomic profiles and the two other inflammatory markers, tnf-alpha and crp . takeda et al. in a placebo-controlled crossover trial, observed the effect of lcs on natural killer (nk) cell activity in humans. nk cell activity exhibited a declining trend during the period of placebo ingestion, but nk cell activity increased after intaking fermented milk containing  live lcs for weeks. when human pbmc were cultured in the presence of heat-killed lcs, nk cell activity was enhanced. the ability of lcs to enhance nk cell activity and induce il- production was correlated, and the addition of anti-il- monoclonal antibody reduced the enhancement of nk cell activity triggered by lcs. in addition, the separation of nk cells from lcsstimulated monocytes with membrane filter reduced nk cell activity to the intermediate level and almost deprived monocytes of the ability to produce il- . the authors demonstrated that lcs can enhance nk cell activity in vivo and in vitro in humans, and il- may be responsible for enhancement of nk cell activity triggered by lcs. changes in the composition of the gut microbiota have been implicated in the pathogenesis of allergic disorders suggesting beneficial interactions between the intestinal immune system and specific bacterial strains. ivory et al. designed a double-blinded, placebo-controlled study with seasonal allergic rhinitis (sar) sufferers in each group. the authors observed that volunteers, treated with lcs, showed a significant reduction in levels of antigen-induced il- , il- and ifn-gamma production compared with volunteers supplemented with placebo. meanwhile, levels of specific igg increased and the ige ones decreased in the probiotic group. so changes in antigen-induced production of cytokines were observed in patients treated with probiotics showing that probiotic supplementation modulates immune responses in sar and may have the potential to alleviate the severity of symptoms. twetman et al. randomly assigned forty-two healthy adults with moderate levels of gingival inflammation to one of three parallel arms: group a/p was given one active and one placebo gum daily, group a/a received two active chewing gums, and group p/p two placebo gums. the chewing gums contained two strains of lactobacillus reuteri: atcc and atcc pta (  cfu/ gum, respectively). the authors observed a reduction of proinflammatory cytokines (the levels of tnf-alpha and il- decreased significantly (p < . ) in group a/a compared with baseline after and weeks, respectively) in gingival crevicular fluid that points out that the probiotic approach can fight inflammation in the oral cavity. the skin is able to act as a physical barrier exerting several functions such as fluid homeostasis, thermoregulation, immunologic functions, neurosensory functions, metabolic functions and primary protection against infection. in case of thermal injury the burn can be colonized by several types of pathogens, i.e. primarily gram-positive bacteria such as methicillin-resistant staphylococcus aureus (mrsa), gram-negative bacteria such as acinetobacter baumanniiecalcoaceticus complex, pseudomonas aeruginosa, klebsiella species and fungal pathogens. the prevention of infection include early burn-eschar excision, topical and prophylactic antibiotics, and aggressive infection-control measures. the antimicrobial resistance of bacteria isolated from patients with burns has increased and bacterial colonization and infection remain the major causes of delayed healing and graft rejection following burns. topical treatment is necessary to reduce the incidence of burn wound infection. the ability of the probiotic organism lactobacillus plantarum to inhibit the pathogenic activity of pseudomonas aeruginosa, both in vitro and in vivo, was tested by valdéz et al. in vitro (lactobacillus plantarum whole cultures, culture filtrates acid filtrate and neutralised acid filtrate) and isolated, washed cells were tested for their effects on the production of the p. aeruginosa quorumsensing signal molecules, acyl-homoserine-lactones (ahls), and two virulence factors controlled by signal molecules such as elastase and biofilm. all were inhibited by l. plantarum cultures and filtrates, but not by isolated, washed cells. the acid l. plantarum growth medium itself had some inhibitory activity but the greatest activity was exerted by the whole culture. in vivo (a burned-mouse model was used) burns infected with p. aeruginosa were treated with l. plantarum at , , , and days post-infection. samples from skin, liver and spleen taken after , and days demonstrated that l. plantarum had inhibited p. aeruginosa colonization. there was also an improvement in tissue repair, enhanced phagocytosis of p. aeruginosa produced by tissue phagocytes and a decrease in apoptosis at days. the authors conclude that l. plantarum and/or its by-products are potential therapeutic agents for the local treatment of p. aeruginosa burn infections. peral et al. cultured l. plantarum in de man, rogosa and sharpe medium to provide an alternative method for burn treatment using silver sulphadiazine (sd-ag, a microbicidal agent) as a control. eighty burned patients from the plastic surgery and burns unit were grouped into infected (delayed) second-and third-degree and non infected (early) third-degree burns and treated with l. plantarum or sd-ag. the proportion of patients with delayed second-degree burns was . for l. plantarum and . for sd-ag (relative rate: À . %) in comparison with the decrease in bacterial load (< bacteria/g of tissue), promotion of granulating tissue wound bed and healing. in early third-degree burns, the values were . for l. plantarum and . for sd-ag (relative rate: À . %) in preventing wound infection and promotion of granulation tissue, . in graft taking for both treatments (relative rate: %) and . for l. plantarum and . for sd-ag (relative rate: À . %) in healing. in delayed third-degree burns, values were . for l. plantarum and . for sd-ag (relative rate: þ . %) compared to the decrease in the bacterial load (< bacteria/g of tissue) and providing a granulating tissue wound bed, . in graft taking for both treatments (relative rate: %) and . for l. plantarum and . for sd-ag (relative rate: þ . %) in healing. this study suggests that the l. plantarum treatment could be a valid therapy for the topical treatment of burns. probiotic formulations have been widely studied for the treatment of atopic dermatitis (ad; a type of eczema), a pathology defined as an inflammatory, chronically relapsing, non-contagious and pruritic skin disease which is associated with elevated ige levels and th responses. ad in animal models and human studies has been investigated using different probiotic different strains such as bifidobacterium, lactobacillus, and lactococcus. in several animal studies involving the use of probiotics it was observed suppression of specific or non-specific ige production, reduction of infiltrated eosinophils and degranulated mast cells, potentiation of regulatory t cell cytokines such as il- and tgf-beta relative to il- and il- and potentiation of th /th activity along with reduced symptoms of ad. several well-designed double-blind placebocontrolled human studies showed that some probiotic strains administered during perinatal period prevented the occurrence of ad but they cannot consistently show a reduction in specific or non-specific ige or a change in specific immunomodulatory cytokines. the administration of selected strains of probiotics during the perinatal period may be helpful in the prevention of ad. gueniche et al. designed a prospective, double-blind, placebocontrolled clinical study with a cream containing a % lysate of the non-pathogenic bacteria vitreoscilla filiformis. seventy-five volunteers with ad ( e years of age) were randomized to receive either v. filiformis cream % or vehicle cream daily for days. the therapy efficacy was evaluated by the following parameters: score of atopic dermatitis (scorad), transepidermal water loss (tewl), assessment of microflora and the patient's assessment of itch and loss of sleep. v. filiformis lysate significantly decreased scorad levels (p ¼ . ) and pruritus (p ¼ . ). active cream significantly decreased loss of sleep from day to day (p ¼ . ). v. filiformis lysate reduced staphylococcus aureus colonization of the skin. the skin barrier as determined by tewl also improved significantly with the cream alone. v. filiformis lysate significantly improved ad. this may be in part due to a reduction of s. aureus, but it seems to concern in most parts a direct immunomodulatory effect on skin-associated immune responses. zuccotti et al. analyzed the possible causes related to the increase of diagnosis of allergy related diseases in the last few years. they have noticed firstly a reduced microbial stimulation during infancy and early childhood which results in slower postnatal maturation of the immune system and development of an optimal balance between th and th -like immunity (the hygiene hypothesis) and secondly an altered microflora that promotes the persistence of those th cytokines (il- , il- , il- ) which are predominant at birth and prevent the shift toward a th response with il- and ifn-gamma production. now we are going to report some of the several studies involving the use of probiotic formulations to evaluate their efficacy for the treatment of allergic diseases basing on their ability to change either the composition and/or the metabolic activities of the microbiota or modulate immune system reactivity in a way that benefits health. wickens et al. designed a double-blind, randomized placebocontrolled study in which pregnant women were randomized to take lactobacillus rhamnosus hn (l. rhamnosus), bifidobacterium animalis subsp. lactis strain hn or placebo daily from weeks gestation until months if breast-feeding, and their infants were randomized to receive the same treatment from birth to years (n ¼ ). the infants' cumulative prevalence of eczema and point prevalence of atopy, using skin prick tests to common allergens, was assessed at years. infants receiving l. rhamnosus had a significantly (p ¼ . ) reduced risk of eczema (hazard ratio (hr), . ; % ci, . e . ) compared with placebo, but this was not the case for b animalis subsp lactis (hr, . ; % ci, . e . ). there was no significant effect of l. rhamnosus (hr, . ; % ci, . e . ) or b animalis subsp lactis (hr, . ; % ci, . e . ) on atopy. l. rhamnosus ( . %) was more likely than b animalis subsp lactis ( . %) to be present in the feces at months, although detection rates were similar by months. the authors conclude that supplementation with l. rhamnosus, but not b. animalis subsp lactis, substantially reduced the cumulative prevalence of eczema, but not atopy, by years. abrahamsson performed a double-blind, randomized, placebo-controlled trial involving families with allergic disease. the mothers received l. reuteri atcc (  cfu) daily from gestational week until delivery. their babies then continued with the same product from birth until months of age and were followed up for another year to assess if the oral administration of probiotic l. reuteri may alleviate and even prevent eczema in infants with a family history of allergic disease. the cumulative incidence of eczema was similar, % in the treated versus % in the placebo group. however the l. reuteri group had less ige-associated eczema during the second year, % versus % (p ¼ . ). skin prick test reactivity was also less common in the treated than in the placebo group, significantly so for infants with mothers with allergies, % versus % (p ¼ . ). wheeze and other potentially allergic diseases were not affected. the authors concluded that the treated infants had less igeassociated eczema at years of age and therefore possibly ran a reduced risk to develop later respiratory allergic disease. therefore probiotics may reduce the incidence of ige-associated eczema in infancy. kukkonen et al. studied the effect of a mixture of probiotic bacterial strains (lactobacillus rhamnosus gg (atcc ), l. rhamnosus lc (dsm ), bifidobacterium breve bb (dsm ) and propionibacterium freudenreichii ssp. shermanii js (dsm )) along with prebiotic galacto-oligosaccharides in preventing allergic diseases. one thousand two hundred and twenty three pregnant women carrying high-risk children were randomized to use a probiotic preparation or a placebo for e weeks before delivery. their infants received the same probiotics plus galactooligosaccharides (n ¼ ) or a placebo (n ¼ ) for months. probiotic treatment compared with placebo showed no effect on the cumulative incidence of allergic diseases but tended to reduce ige-associated (atopic) diseases (odds ratio (or), . ; % ci, . e . ; p ¼ . ). probiotic treatment reduced eczema (or, . ; % ci, . e . ; p ¼ . ) and atopic eczema (or, . ; % ci, . e . ; p ¼ . ). lactobacilli and bifidobacteria more frequently (p < . ) colonized the guts of supplemented infants. probiotic treatment showed no effect on the incidence of all allergic diseases for infants aged but significantly prevented eczema and especially atopic eczema. the authors observed an inverse association between atopic diseases and colonization of the gut through probiotics and concluded that the prevention of atopic eczema in high-risk infants is possible modulating the infants' gut microbiota with probiotics and prebiotics. postoperative complications in gi surgery could involve bacteremia and infectious complications. the main causes could be the translocation of the gi bacteria or its toxins as a consequence of bacterial overgrowth, the loss of intestinal epithelial integrity and the immunologic compromising of the host. probiotics could be good candidate to fight against these factors through the competition with potential pathogens for nutrients or enterocyte adhesion sites, degradation of toxins, production of antimicrobial factors, and local and systemic immunomodulation. the aim of this short paragraph is to report some important clinical trials which could help to evaluate the usefulness of probiotics action to ease the complication rate in patients undergoing surgery on the gi tract. some of the main important procedures which have been related to the use of probiotics are: first the ileal pouch-anal anastomosis (ipaa) which involves the removal of the entire colon and rectum, with preservation of the anus and sphincter muscles and is performed to avoid a permanent stoma (opening for collecting waste) in cases where the entire colon and rectum need to be removed usually in patients with chronic ulcerative colitis or pathologies associated with colon cancers; second the pancreaticoduodectomy to treat tumors of the pancreatic head, neck or uncinate process; third the surgical resection for patients with localized tumors affecting the pancreas. falk et al. analyzed the possible role of probiotics for the treatment of pouchitis which is the inflammation of the ileal reservoir and the major complication of ipaa following proctocolectomi for ulcerative colitis (uc). this review reported that patients with pouchitis have an increased number of anaerobes and aerobes, less bifidobacteria and anaerobic lactobacilli and more clostridia than patients not affected by that condition. the authors reported a double-blind study ( patients with chronic pouchitis treated with vsl# , a probiotic bacterial mix containing lactobacilli strains, three bifidobacteria strains and one streptococcus strain) showing that probiotics can prevent relapse of pouchitis. another study combining lactobacillus rhamnosus with fos confirmed the possible use of probiotic formulations to induce remission in this condition. pronio et al. reported that vsl# administration in patients with ipaa modulates the pouchitis disease activity score and expands the number of mucosal regulatory t cells (open-label study in which patients, without signs and symptoms of pouchitis, were randomized in different periods from surgery to sachets of vsl# once daily or no treatment for months). in particular the authors observed a significant reduction in pdai score and a significant increase in the percentage of mucosal cd þcd (high) and cd þlap-positive cells compared with baseline values. tissue samples at different points showed a significant reduction in il- beta mrna expression, and a significant increase in foxp mrna expression. rayes et al. designed a prospective randomized monocentric double-blind trial involving patients following pylorus-preserving pancreatoduodenectomy (pppd). group a received a composition of lactobacilli and fibers; group b received placebo, only fibers, starting the day before surgery and continuing for days. the study proved that early enteral nutrition, supplemented with a mixture of lactobacilli and fibers, reduces bacterial infection rates and antibiotic therapy following pppd. nomura et al. randomly allocated seventy patients with pancreaticobiliary diseases to two groups where the first group received probiotics and the second served as control before pancreaticoduodenectomy. the probiotics used in the study contained enterococcus faecalis t- , clostridium butyricum to-a, and bacillus mesentericus to-a and were first administered immediately after admission, e days before the operation, and then reintroduced on the second post-operative day. they were administered until hospital discharge. this study shows that the use of perioperative probiotics reduces post-operative infectious complications after pancreaticoduodenectomy, making it a promising potential adjunct therapy for patients undergoing high-risk hepato, biliary, and pancreatic surgery. reddy et al. designed a study where ninety-two patients were randomly assigned to one of four groups. group had mechanical bowel preparation (mbp) only, group had neomycin þ mbp, group had synbiotics þ neomycin þ mbp, and group had synbiotics þ neomycin but no mbp. changes in gut microflora were assessed by culturing nasogastric aspirates and polymerase chain reaction (pcr)-denaturing gradient gel electrophoresis of fecal samples. intestinal barrier function was determined by microbiological confirmation of bacterial translocation and measurement of intestinal permeability. the inflammatory response was monitored by measurement of serum crp and il- , and septic morbidity was recorded prospectively. they investigated whether it was possible to modulate gut microflora and preserve intestinal barrier function during elective colorectal surgery by using combinations of oral antibiotics, synbiotics and mbp. the authors did not observe a reduction in inflammatory response or septic morbidity. this study shows that a combination of mbp, neomycin and synbiotics reduces the prevalence of fecal enterobacteriaceae and bacterial translocation. van gossum et al. designed a multicenter clinical trial evaluating the efficacy of an oral administration of the probiotic lactobacillus johnsonii lal on early post-operative endoscopic recurrence of crohn's disease (cd). the study involved seventy patients with cd enrolled prior to elective ileo-caecal resection and randomly assigned after surgery to daily treatment with either (la , nestle, cfu) (group a, n ¼ ) or placebo (group b, n ¼ ) for weeks. the authors demonstrated that oral administration of the probiotic la in patients with cd failed to prevent early endoscopic recurrence at weeks after ileo-caecal resection. sugawara et al. investigated the effect of perioperative oral administration of synbiotics upon intestinal barrier function, immune responses, systemic inflammatory responses, microflora, and surgical outcome in patients undergoing high-risk hepatobiliary resection. patients with biliary cancer involving the hepatic hilus (n ¼ ) were randomized, before hepatectomy, into a group receiving post-operative enteral feeding with synbiotics (group a) or another receiving preoperative plus post-operative synbiotics (group b). lactulose-mannitol (l/m) ratio, serum diamine oxidase (dao) activity, nk cell activity, il- , fecal microflora, and fecal organic acid concentrations were determined before and after hepatectomy. the authors concluded that preoperative oral administration of synbiotics can enhance immune responses, attenuate systemic post-operative inflammatory responses, and improve intestinal microbial environment. these beneficial effects likely reduce post-operative infectious complications after hepatobiliary resection for biliary tract cancer. woodgard et al. focused on the issue of roux-en-y gastric bypass (rnygb) surgery, a treatment for morbid obesity, which is responsible for altering gi flora leading to bacterial overgrowth and dysmotility. the authors randomized forty-four patients undergoing rnygb to either a probiotic or control group; . billion colonies of lactobacillus were administered daily postoperatively to the probiotic group. probiotic administration was shown to improve bacterial overgrowth, vitamin b availability, and weight loss after rnygb supporting the hypothesis that altering the gi microbiota can influence weight loss. urogenital infections not caused by sexual transmission in women are still one of the most important medical issue. recurrent urinary tract infection (uti) is, in most cases caused by the uropathogens e. coli; recurrent bacterial vaginosis (bv) is usually caused by gardnerella vaginalis; recurrent yeast vaginosis is usually caused by candida albicans. the predominant bacteria in the urinary tract of healthy women are lactobacilli. infections are usually treated using antibiotics with the effect of decreasing the number of lactobacilli which cause gi symptoms, raise drug resistance and do not restore the urinary tract natural barrier to infections. zuccotti et al. reported some studies highlighting that probiotics could be a good alternative to antibiotic therapy due to their quality to adhere to uroepithelial cells and produce inhibitors of pathogenic growth and biosurfactant secretion. the same authors reported that oral lactobacilli-based therapy under viable conditions showed that these bacteria are able to colonize the urinary tract after enteral colonization. reid et al. reported that a daily intake of probiotic strains l. rhamnosus gr- and lactobacillus fermentum rc- , resulted in some asymptomatic bv patients reverting to a normal lactobacilli dominated vaginal microflora. the same authors reported other two studies regarding bv: firstly a twice daily use of hydrogen peroxide producing l. acidophilus in a product called vivag for six days led to a % improvement compared to none at all in the placebo group; secondly yogurt containing l. acidophilus, delivered in a tampon to pregnant women, showed to treat bv and prevented infection at months follow-up. reid et al. also reported a study which indicates that the recurrence of uti can be reduced using one or two capsules (l. rhamnosus gr- and l. fermentum b- , replaced more recently by rc- , freeze dried and placed in gelatine capsules, with dosage at per capsule) vaginally per week for one year, with no side effects or yeast infections. the authors also explored the use of probiotics for the treatment of yeast vaginitis reporting that l. rhamnosus gr- and l. fermentum rc- are able to kill and inhibit the adhesion of yeast to vaginal cells. moreover they reported a crossover study involving patients with recurrent vaginitis treated with eight ounces of l. acidophilus supplemented yogurt daily for six months and then switched to a yogurt free diet. the therapy resulted in . breakthrough infections compared with . per study term. czaja et al. performed a phase i trial to assess the safety and tolerance of a lactobacillus vaginal suppository for prevention of recurrent uti involving premenopausal women with a history of recurrent uti. they were randomized to use lactobacillus crispatus ctv- or placebo vaginal suppositories daily for five days. no severe adverse events occurred. mild to moderate vaginal discharge and genital irritation were reported by women in both study arms. seven women randomized to l. crispatus ctv- developed pyuria without associated symptoms. most women had high concentrations of vaginal h -producing lactobacilli before randomization. l. crispatus, lactobacillus jensenii, and lactobacillus gasseri were the most common lactobacillus species identified, with stable prevalence over time. according to this study l. crispatus ctv- can be given as a vaginal suppository with minimal side effects to healthy women with a history of recurrent uti although mild inflammation of the urinary tract was noted in some women. anukam et al. enrolled women diagnosed with bv (it is particularly common condition in black women and in nigeria it is often caused by mycoplasma, as well as atopobium, prevotella and gardnerella sp.) by discharge, fishy odor, sialidase positive test and nugent gram stain scoring. they were randomized to receive either two dried capsules containing l. rhamnosus gr- and l. reuteri rc- each night for days, or . % metronidazole gel, applied vaginally twice a day, in the morning and evening. the follow-up at day , and showed a significant cure for bv in probiotic lactobacilli treated subjects compared to metronidazole treatment. this is the first report of an effective ( %) cure for bv using probiotic lactobacilli. the authors conclude that, given the correlation between bv and hiv, and the high risk of the latter in nigeria, intravaginal use of lactobacilli can provide women with a self-use therapy, similar to over-the-counter anti-yeast medication, for treatment of urogenital infections. martinez et al. designed a study involving sixty-four brazilian women diagnosed with bv. they were randomly assigned to receive a single dose of tinidazole ( g) supplemented with either placebo capsules or capsules containing l. rhamnosus gr- and l. reuteri rc- every morning for weeks. at the end of treatment (day ), the probiotic group had a significantly higher cure rate for bv ( . %) than the placebo group ( . %) (p ¼ . ). in addition, according to the gram-stain nugent score, more women were assessed at "normal" vaginal microbiota in the probiotic group ( . % vs. . % in the placebo group; p ¼ . ). this study shows that probiotic lactobacilli can provide benefits to women being treated with antibiotics for an infectious condition. mastromarino et al. enrolled thirty-nine women with bv in a double-blind, placebo-controlled clinical trial to receive either one lactobacillus-containing tablet or placebo daily for days. after the completion of therapy, all of the patients in the lactobacillus-treated group (n ¼ ) were free of bv, showing a normal ( %) or intermediate ( %) vaginal flora, as compared with only two patients free of bv with intermediate flora ( %) from among the placebotreated women (p < . ). two weeks after the completion of therapy, treatment was successful (score < ) in % of lactobacillustreated patients as compared with % of those ones in the placebo group (p < . ). in the treatment group, the total number of symptomatic patients and the intensity of their symptoms, in particular vaginal malodour, were significantly reduced at both follow-up visits. the previously reported results brought the authors to conclude that intravaginal administration of exogenous selected strains of lactobacilli can restore a normal vaginal microbiota and could be a useful choice for the treatment of bv. larsson et al. investigated firstly if supplementary lactobacilli treatment could improve the initial cure rate after vaginal clindamycin therapy, and secondly, if lactobacilli as repeated adjunct treatment during menstrual cycles could lengthen the time to relapse after initial cure. a hundred bv diagnosed women were offered vaginal clindamycin therapy followed by vaginal gelatine capsules containing either freeze-dried lactobacilli or identical placebo capsules for days during menstrual cycles in a doubleblind, randomized, placebo-controlled trial. the authors concluded that supplementary treatment, combining two different strains of probiotic lactobacilli, does not improve the efficacy of bv therapy during the first month of treatment, but for women initially cured, adjunct treatment of lactobacilli during menstrual cycles lengthens the time to relapse significantly (more women remained bv free at the end of the -month follow up). renal failure can be faced removing waste products and excess fluid using a mechanical method called dialysis. the two forms of dialysis used in medical practice are hemodialysis (hd) and peritoneal dialysis (pd). hd cycles blood through a machine that filters the blood and returns it to the body cleaned of waste. pd cycles fluid into and out of the abdomen using the individual's own peritoneum as a filter. plasma uremic toxins levels such as phenol, p-cresol, and indican are produced in the intestine as bacterial putrefactive metabolites and accumulate to a great degree in the feces of hd patients and cannot be efficiently reduced by hd. intestinal microflora is deranged in hd patients as we can see an increase in aerobic bacteria such as escherichia coli and a decrease in anaerobic bacteria such as bifidobacterium. yangco et al. reported the successful utilization of nitazoxanide and probiotics to treat multirecurrent clostridium difficile infection (cdi) in a pd patient. a -year-old woman was admitted with hypotension, nausea and vomiting attributed to metronidazole therapy for cdi, her third cdi treatment regimen in months. during her admission, the patient developed cdi and was started on a -week regimen of nitazoxanide and probiotics to assist in reestablishing the colonic flora. the regimen was well tolerated and the patient remained disease free at follow up, four months later. hida et al. demonstrated that lebenin, a preparation consisting of antibiotic-resistant lactic acid bacteria, administred orally is able to reduce the levels of fecal putrefactive metabolites to levels comparable with those of healthy subjects. moreover the plasma level of indican also significantly decreased in these lebenintreated patients. an analysis of the fecal microflora revealed that a disturbed composition of the microflora characterized by an overgrowth of aerobic bacteria is restored to normal by oral administration of lebenin in hd patients. the authors demonstrated that oral administration of lactic acid bacteria in uremic patients is effective in reducing the levels of uremic toxins, especially that of indican, in the blood by inhibiting bacterial production by means of correcting the intestinal microflora. taki et al. demonstrated that the oral administration of b. longum in a gastroresistant seamless capsule to hd patients is effective in decreasing the pre-hd serum levels of homocysteine, indoxyl sulfate, and tags. the reduction in the serum level of homocysteine is mainly attributable to the supply of folate produced by b. longum in the human intestines. diverticular disease (dd) is an acquired weakening of the colon wall, and more rarely of the ileum and duodenum causing protrusions of the mucosa and submucosa through the muscular wall. these "pouches" occur in weak areas of the wall where blood vessels penetrate due to the high pressure inside the colon. often they involve primarily the sigmoid region of the colon. the term "diverticulosis" refers to the aymptomatic condition and the term "diverticular disease" refers to the condition associated with symptoms. the term diverticulitis is used to indicate inflammation of the bowel wall. here we report two interesting studies designed by tursi et al. evidencing the possible use of probiotics in the management of this condition. tursi et al. designed a study to investigate whether balsalazide (a novel orally administered prodrug of -asa in which an inert carrier molecule, -aminobenzoil-ß-alanine, has been bonded to a molecule of -asa. after administration, colonic bacteria split balsalazide into -asa and -aminobenzoil-ß-alanine, releasing the active -asa into the colon with minimal systemic absorption) and/or vsl# a probiotic mixture containing several billions of different bacterial strains, mainly lactobacillus and bifidobacteria, is effective in preventing diverticulitis recurrence. thirty consecutive patients ( males, females, mean age . years, range e years) affected by uncomplicated diverticulitis of the colon were monitored. after obtaining remission, the patients were randomly assigned to one of the following groups as follows: group a, balsalazide . g daily for days every month plus vsl# billions/day for days every month and group b, vsl# alone billions/day for days every month. primary endpoint was considered the maintaining of remission throughout a -month follow-up. secondary end-points considered were: firstly the assessment of the overall scores at the end of the follow-up and secondly the effects of the two different treatments with regards to every symptom assessed. the authors found that one group a patient ( . %) showed relapse of symptoms at the th month of follow-up; at the end of follow-up, patients were completely symptom-free ( . %) whilst patients complained of only mild, recurrent symptoms ( %); two group b patients ( . %) showed relapse of the disease at the th and th month of follow-up, respectively; at the end of follow-up, patients were completely symptom-free ( %), patients complained of mild, recurrent symptoms ( . %), patient ( . %) complained of mild but continuous symptoms; no side effects were recorded throughout the follow-up in both groups. this study showed that the combination probiotic/anti-inflammatory drug was found better than probiotic treatment in preventing relapse of uncomplicated diverticulitis of the colon, even if without statistical significance. tursi et al., after the pilot study, designed another study to assess if four different therapeutic schedules with mesalazine and/or probiotics are able to prevent the recurrence of symptomatic dd of the colon. this prospective, dose-finding study was conducted on patients, enrolled in an open fashion: mesalazine mg/ daily (group m ) or mesalazine . gr day/month (group m ); mesalazine mg/daily þ l. casei dg billion/day for day/ month (group lm ) or mesalazine . gr þ l. casei dg billion/day for day/month (group lm ); l. casei dg billion/day for day/ month (group l). seventy one patients completed the study ( . %). sixty six patients ( %) were symptom-free after the th month of treatment: of group m , of group m , of group lm , of group lm and in group l. four patients ( . %) suspended the treatment during the follow-up: all experienced recurrence of symptoms ( %), and two of them developed diverticulitis ( %). this study showed that mesalazine and/or l. casei seem to be effective in maintaining remission of dd for long-time. the authors found recurrence of the disease and complications in all the patients who suspended treatment. in europe and north america ibs is estimated to have an incidence of e %. in sweden, the most commonly cited figure is . %. the prevalence of ibs is increasing in countries in the asiaepacific region, particularly in countries with developing economies. ibs mainly occurs between the ages of and . the estimated prevalence of ibs in children is similar to that in adults. ibs is a common disorder of the intestines associated with cramping, stomach pain, gas, bloating, and changes in bowel habits. ibs can be characterized by constipation, diarrhea or both. diarrhea-predominant ibs (d-ibs) is characterized by an increased intestinal permeability accompanied by persistent low-grade immune activation in the gut presented as increased numbers of t lymphocytes, mast cells and enterochromaffin cells. in its normal condition, gut epithelial lining forms a relatively impermeable barrier between luminal contents and submucosa required for intestinal homeostasis. this barrier is determined by complexes of proteins composing the junctional complexes. tight junctions (tjs) are the most apical organelle of the epithelial junctional complexes and are crucial for the formation and function of epithelial barriers. tjs comprise numerous proteins, with the best characterized being zonula occludens (zo)- and occludin. the diarrhea form is the predominant form and brings the patient to experience abdominal pain, visible abdominal distension (bloating), bowel frequency particularly in association with pain, pain relieved by bowel action, rectal passage of mucous and sensation of incomplete evacuation. spastic colon syndrome is an ibs variant which is mainly characterized by constipation. the constipation ibs variant let the patient experience the same symptoms except for the bowel frequency which is replaced by the constipation which is responsible for the pain. ibs seems to be due to a dysfunction of the muscles of the organs of the gi tract or the nerves controlling the organs. nerves run for the entire length of the gi tract from the esophagus to the anus in the muscular walls of the organs reaching also the spinal cord and the brain. ibs is thought to result from an interplay of abnormal gi tract movements, increased awareness of normal bodily functions, and a change in of the nervous system communication between the brain and the gi tract. although the causes of ibs are not yet known some factors are usually associated to this condition: genetic influences, food intake, endocrine imbalances, malabsorption, post-operative changes, altered gi motility, heightened sensory function of the intestine, or malfermentation of food residues and psychosomatic factors such as a psychological morbidity, stress and an abnormal illness behaviour. ibs has a great negative impact on the patient's emotional health and quality of life especially for those who are facing this disease for their entire life. symptoms can be alleviated by the patient's education, reassurance, and dietary modification but they are not a definitive resolution. before considering the most recent clinical trials for the treatment of ibs it is worth to remember some important studies faced before. in vanderhoof et al. reported a study developed in poland using l. plantarum (lp v). this bacterium is able to synthetize nitric oxide, an important mediator of gut motility, it may displace the attachment of other organisms from the intestinal mucosa and it seems to be able to reduce any inflammatory component associated with ibs. the study results showed a reduction of symptoms of abdominal pain and constipation when compared with placebo. the same author reported another study to support the beneficial effect of lp v. this small double-blinded placebo-controlled crossover study in children with recalcitrant chronic, recurrent abdominal pain of childhood showed a significant reduction in the severity of abdominal pain in lp v-treated patients compared with results in control subjects. tsuchiya et al. realized a study to evaluate the efficacy of a symbiotic containing bifidobacteria ( .  / ml) for the treatment of ibs. the authors found that, after a weeks treatment on patients, the symbiotic was able to significantly reduce the intensity of the symptoms of ibs. o'mahony et al. realized a study to compare the response of symptoms and cytokine ratios in ibs with ingestion of probiotic preparations containing a lactobacillus or bifidobacterium strain. seventy-seven subjects with ibs were randomized to receive either lactobacillus salivarius ucc or bifidobacterium infantis , each in a dose of  live bacterial cells in a malted milk drink or the malted milk drink alone as placebo for weeks. b. infantis alleviates symptoms in ibs; this symptomatic response was associated with normalization of the ratio of an anti-inflammatory to a proinflammatory cytokine, suggesting an immune-modulating role for this organism in this disorder. furrie et al. designed a study based on the use of a symbiotic containing bifidobacteria to treat ibs. the symbiotic was successful in treating the pathology without evident adverse events and modulate the immunological parameters of the same. the treatment based on bifidobacteria and fos improves the intestinal habits and the quality of patients' life. table , adapted from guslandi et al. , summarizes some interesting studies involving the use of probiotics in the treatment of ibs. hun et al. designed a controlled study to evaluate the effects of the probiotic bacillus coagulans gbi- , on ibs symptoms. bacillus coagulans gbi- , (ganeden biotech, inc., mayfield heights, oh) is a patented strain of lactic acid producing bacteria that can sustain the low ph of stomach acid and become active in the intestine. strains of b coagulans produce coagulin, which is a heat-stable, protease-sensitive, bacteriocin-like inhibitory substance with activity against gram-positive bacteria. spores of bacillus are resistant to heat and hostile gi conditions and, therefore, are able to reach the intestine where they can germinate and proliferate within the host. b coagulans gbi- , maintains spore viability after years of storage without the need for refrigeration (unpublished communication, ganeden biotech, inc., mayfield heights, oh), making it particularly suitable for commercial use. this randomized, double-blind, parallel-group, placebo-controlled clinical trial involved subjects who received either placebo or b. coagulans gbi- , once a day for weeks. self-assessments of the severity of ibs symptoms (abdominal pain and bloating) were recorded every day for weeks. because baseline values were significantly different between the study groups, within-group analysis was conducted. all subjects met the rome ii criteria for ibs with diarrhea, i.e. they must have had, during the months prior to evaluation, and for a total of at least weeks (not necessarily consecutively), abdominal discomfort or pain that had of features: relief with defecation, onset associated with a change in frequency of stool and onset associated with a change in appearance of stool. individuals with any organic gi conditions or diseases, previous intestinal surgery, immunodeficiency, or lactose intolerance, or who were pregnant or lactating, were excluded from the study. patients who had taken commercially available probiotic medications within days of the study were also excluded. the authors obtained as results the improvements from baseline abdominal pain and bloating scores in the b coagulans gbi- , group which were statistically significant for all weekly comparisons (p < . ); in the placebo group, only changes in abdominal pain scores at and weeks achieved statistical significance (p < . ); no treatment-related adverse events or serious adverse events were reported during the -week study period. the authors, basing on the previous described results, suggest that the patented b coagulans gbi- , probiotic might be a safe and effective option for the relief of abdominal pain and bloating for patients with ibs. these results justify the design of larger scale, controlled clinical trials to verify these findings. henck et al. performed a clinical trial treating two hundred and ninety-eight patients with lower abdominal symptoms diagnosed as ibs for weeks by the compound symbioflor- (symbiopharm gmbh, herborn, germany), an e. coli product (n ¼ ), or placebo (n ¼ ) in a double-blinded, randomized fashion. patients were seen weekly by the physician, who assessed the presence of core ibs symptoms. both an abdominal pain score (aps) as well as a general symptom score (gss) were used as primary endpoints. responders had to have complete absence of ibs core symptoms at > or ¼ visit during treatment. the results showed that: the responder rate in gss to the drug was / ( . %) in comparison to placebo with / ( . %) (p ¼ . ); the improvement in aps was / ( . %) and / ( . %) for placebo (p ¼ . ); the response was reached from the third visit onwards with both medication and placebo; post-hoc analysis revealed no significant differences in efficacy of the drug between the gender and different age groups. the authors conclude that the probiotic symbioflor- is effective and superior to placebo in reducing the typical symptoms of ibs. barrett et al. aimed at determining whether l. casei strain shirota (yakult) can alter small intestinal bacterial overgrowth (sibo), as tested by the lactulose breath test, and whether it is associated with changes in symptoms in ibs. prior to the breath hydrogen test, dietary restriction (minimising intake of fibre and poorly absorbed short-chain carbohydrates) was advised for h and the subjects fasted overnight. the patients consumed g lactulose, made up to a ml solution with water. breath hydrogen samples were collected at baseline and every min for at least h. the authors recruited patients with ibs (rome ii criteria), who showed an early rise in breath hydrogen with lactulose (erbhal: defined as a rise of breath hydrogen of ppm or greater above the baseline breath hydrogen on two consecutive min samples, before min following the ingestion of lactulose. the time of the first rise in breath hydrogen of ppm or more was recorded). they consumed ml of yakult daily for wks. lactulose breath test was repeated at the end of the treatment period. symptoms were recorded daily using a cm visual analogue scale. fourteen patients completed the study, ( %) had reversal of erbhal, with the median time of first rise in breath hydrogen increasing from to min (p ¼ . ). there was no significant improvement in the symptoms score with probiotic therapy, except for wind (p ¼ . ). patients commencing with at least moderate symptoms and who no longer had erbhal at the end of treatment, showed improvement in the overall symptoms scores [median final score . (iqr . e . ), % reduction; n ¼ ] to a greater extent than those who had had persisting erbhal [final score . ( . e . ), % reduction; n ¼ ; p ¼ . ]. this study shows that yakult is effective in altering fermentation patterns in the small bowel, consistent in reducing sibo. the loss of erbhal was associated with reduced symptoms. this study findings need to be confirmed by a randomized controlled trial. adriulli et al. tested the efficacy of symbiotics in patients with d-ibs. patients were randomized to a prebiotic (n ¼ ), or a symbiotic formulation containing lactobacillus paracasei b (flortec, n ¼ ). primary efficacy was the responder rate for pain and global relief of symptoms in the overall population and in patients with predominant diarrhea (n ¼ ). post hoc time-trend analyses for changes within each treatment were carried out. the following results were obtained: patients with absent/mild pain amounted to . % in the symbiotic group and to . % in the prebiotic group at treatment week , and to . % and . % at the end of treatment; patients with amelioration of well-being were, respectively, . % versus . % at treatment week , and . % versus . % at the end of treatment; within each treatment group, patients with absent/mild pain increased in the flortec and the prebiotic group, but time trend analyses were significant only for flortec (p ¼ . ); in d-ibs, flortec significantly reduced bowel movements, pain, and ibs scores. the authors concluded that: flortec is encouraging in patients with d-ibs and is able to improve the pain and the patient's well-being even if in the future flortec has to be compared with an inert placebo to establish its efficacy for the majority of ibs patients. zeng et al. performed a study to determine the possible effect of lactic acid bacteria on the increased intestinal permeability in d-ibs. this treatment lasted weeks in a randomized single blind placebo-controlled study with d-ibs patients. patients were given either a probiotic fermented milk (streptococcus thermophilus, lactobacillus bulgaricus, lactobacillus acidophilus and bifidobacterium longum) or milk beverage containing no bacteria. the clinical symptoms were scored and intestinal permeability measured by a triple sugar test before and after treatment. small bowel permeability was measured as the ratio of l/m recovery and colonic permeability was measured as the total mass of sucralose excretion (mg). after probiotics treatment, small bowel permeability decreased significantly from . at baseline to . (p ¼ . ), the proportion of patients with increased small bowel permeability was lower than that one at baseline ( . % vs. . %, p ¼ . ). however, colonic permeability improved neither in the probiotics group nor in the placebo group at week . treatment with probiotics significantly decreased the mean global ibs scores compared with the baseline scores ( . ae . vs. . ae . , p < . ). therefore short-term active lactic acid bacteria treatment for d-ibs improves mucosal barrier function. enck et al. re-analyzed a study performed in and according to current ibs standards. two hundred ninety-seven patients with lower abdominal symptoms diagnosed as ibs were treated for weeks with the compound prosymbioflor(r) (symbiopharm gmbh, herborn, germany), an autolysate of cells and cell fragments of enterococcus faecalis and escherichia coli, or placebo in a double-blinded, randomized fashion. patients were seen weekly by the physician, who assessed the presence of core ibs symptoms. responders had at least a % gss and in aps reports at >/ ¼ visit during treatment. the responder rate in gss to the drug was / ( . %) in comparison to placebo with / ( . %) (p < . ), the improvement in aps was / ( . %) and / ( . %) respectively (p ¼ . ). the number needed to treat was . for gss and . for the aps report. kaplanemeier analysis revealed a mean response time of e weeks for active treatment and more than weeks for placebo (p < . ). this study leads the authors to conclude that treatment of ibs with the bacterial lysate prosymbioflor is effective and superior to placebo in reducing typical symptoms of ibs patients. drouault-holowacz et al. investigated the efficiency of a probiotic dietary supplement, containing four strains of lactic acid bacteria, on symptoms of ibs. one hundred and sixteen patients with ibs fulfilling the rome ii criteria were randomized in a parallel group, double-blind study to receive a placebo or a probiotic combination (  cfu) once daily for four weeks. the symptoms that were monitored weekly included discomfort, abdominal pain, and stool frequency and quality. quality of life was assessed before and at the end of the treatment using the sf and fdd-quality-of-life questionnaires. the study showed the following results: one hundred subjects completed the study ( in the probiotic combination group and in the placebo group); the probiotic combination was not superior to the placebo in relieving symptoms of ibs ( . % versus . % improvement); the decrease of abdominal pain between the first and the fourth week of treatment was significantly higher in probiotic treated patients (À . versus À . %, p ¼ . ). interesting findings were also observed from the ibs sub-groups such as a lower pain score at endpoint in patients with alternating bowel habits (p ¼ . ) and an increase of stool frequency in the constipated sub-group from the first week of probiotic treatment (p ¼ . ). the authors conclude that the probiotic combination was not significantly superior to the placebo in relieving symptoms of ibs. despite the apparent high placebo response, interesting findings were observed from ibs sub-groups in the field of abdominal pain and stool frequency. sinn et al. randomized ibs patients into a placebo (n ¼ ) and probiotics group (n ¼ ). lactobacillus acidophilus, sdc and . these two lactobacilli were obtained from infants' feces and examined for their biological and biochemical characteristics. they showed the ability to survive in high acidity and medium containing bile acids as potent probiotics (unpublished data). these two selected strains were freeze dried by a microbial company (culture systems, inc. usa). the freeze-dried bacteria were mixed with an excipient and packed into capsules under good manufacturing processing (gmp) conditions (natural f&p. korea). in this study, the excipient was added to the blend of bacteria to achieve the desired dosage concentrations,  cfu/ml. placebo capsules contained the excipient only. four week treatment with l. acidophilus-sdc , was associated with a reduced score for abdominal pain or discomfort compared to the baseline (p ¼ . ). the percent reduction in abdominal pain or discomfort exceeded the placebo scores by more than % ( . and . % for probiotics and placebo, respectively, p ¼ . ). there was a significant difference in the proportion of responders between the probiotics and placebo groups (p ¼ . ). there was no drop out or adverse events for either group during the study period. bittner et al. designed a study to extend a previous -week assessment of a probioticeprebiotic complex in patients with ibs. prescript-assistÔ (p-a) is a probioticeprebiotic complex reported to be associated with reduced signs and symptoms of several gi disorders, particularly ibs. the probiotic component is a complex of (anthrobacter agilis, a citreus, a globiformis, a luteus, and a simplex acinetobacter calcoaceticus azotobacter chroococcum and a paspali azospirillum brasiliense and a lipoferum bacillus brevis, b marcerans, b pumilus, b polymyxa, and b subtilis bacteroides lipolyticum and b succinogenes brevibacterium lipolyticum and b stationis kurtha zopfil myrothecium verrucaria pseudomonas calcis, p dentrificans, p flourescens, and p glathei phanerochaete chrysosporium streptomyces fradiae, s cellulosae, and s griseoflavus) soilbased microorganisms (sbos), all class i etiologic agents (they present "no or minimal hazard under ordinary conditions"). in this open-label, partially controlled, -year extension study, data were collected from ibs patients who continued treatment following a week study of the efficacy of the probioticeprebiotic complex. data were collected at and approximately weeks after the end of the original study. the authors observed that a total of patients entered the -week extension and completed the approximately -week follow-up study. the results in the control group weeks after crossover to treatment were similar to those from the original study, with reductions in ibs subsyndromes, i.e. general ill feelings/ nausea (p < . ), indigestion/flatulence (p < . ), and marginally colitis (p < . [ -tailed] ). treatment was associated with a continued reduction in general ill feelings/nausea at weeks (p < . ). at > or ¼ -week follow-up, the rate of remissions was . %e % (p < . ). based on these results, treatment with this probioticeprebiotic complex seems to be an option for short-term ( e weeks) and long-term (approximately weeks) reductions in ibs symptoms. guyonette et al. analyzed the effects of fermented milk containing bifidobacterium animalis dn- , and yogurt strains on the ibs in a multicenter, double-blind, controlled trial. the test product was a fermented milk (activia, danone), containing b. animalis dn- , ( .  cfu per pot) together with the two classical yogurt starters, s. thermophilus and l. bulgaricus ( . $ cfu ⁄ pot). the control product was heat-treated yogurt containing non-living bacteria (< cfu/pot). both the test and control products were without flavour, and had a similar appearance, colour, texture and taste. each serving, corresponding to one pot, contained g. both products were specifically prepared for the study and provided by danone research (palaiseau, france). a total of primary care adults with constipation-predominant ibs (rome ii) were randomized to consume for weeks either the test fermented milk or a heat-treated yogurt (control). hrqol and digestive symptoms were assessed after and weeks on an intention-to-treat population of subjects. the previously described results brought the authors to the following results: the hrqol discomfort score, the primary endpoint, was improved (p < . ) in both groups at weeks and ; the responder rate for the hrqol discomfort score was higher ( . vs. . %, p < . ), as it was higher the decrease in bloating score ( . ae (s.d.) . vs. . ae . , p ¼ . ), at week in the test vs. the control group. in those subjects with < stools/week, stool frequency increased (p < . ) over weeks in the test vs. control group. this study suggests a beneficial effect of a probiotic food on discomfort hrqol score and bloating in constipation-predominant ibs, and on stool frequency in subjects with < stools/week. in conclusion, the present large-scale study strongly suggests a beneficial effect of a probiotic food containing b. animalis dn- on hrqol discomfort score and bloating, and also on stool frequency in those subjects with < stools per week. further studies aiming at confirming the results obtained and to elucidate mechanisms of such effects should be of special interest for providing additional scientific evidence to support the use of such probiotic food to alleviate ibs symptoms and improve hrqol discomfort. gawro nska et al. evaluated the efficacy of l. rhamnosus gg for treating functional abdominal pain disorders (fapd) in children. a total of children who fulfilled the rome ii criteria for functional dyspepsia (fd), or ibs, or functional abdominal pain (fap) were enrolled in a double-blind, randomized controlled trial in which they received l. rhamnosus gg (n ¼ ), or placebo (n ¼ ) for weeks. the patients in the l. rhamnosus gg group were more likely to have treatment success (no pain) than those in the placebo group ( % vs. . %, relative benefit (rb) . , % ci: . e . , number needed to treat (nnt) , % ci: e ). for children with ibs (n ¼ ), those in the l. rhamnosus gg group were more likely to have treatment success than those in the placebo group ( % vs. %, rb . , % ci: . e , nnt , % ci: e ) and reduced frequency of pain (p ¼ . ), but not pain severity (p ¼ . ). for the fd group (n ¼ ) and fap group (n ¼ ), no differences were found. the authors conclude that the l. rhamnosus gg appears to moderately increase treatment success, particularly among children with ibs. fanigliulo et al. aimed at investigating the efficacy of rifaximine (a broad-spectrum, poorly absorbable antibiotic) on its own or in association with the probiotic strain of b. longum w in reducing symptoms in patients with ibs. they performed a monocentric, prospective, randomized open trial including patients randomized to two groups: group a ( patients) receiving rifaximin ( cp bid for ten days in a month) followed by a formulation of the probiotic strain of b. longum w (one granulated suspension for days on alternate weeks) and group b ( patients) receiving only rifaximin ( cp bid for ten days in a month). the clinical evaluation was performed at admission and after -months, taking into account the method of visual analogues. the authors observed that at the -month follow-up, group a patients reported a greater improvement of symptoms compared to patients in group b (p ¼ . ) even if the physician's opinion at t did not confirm these results (p ¼ . ). the previously reported results showed an increased colonization by means of b. longum w , after the cyclic administration of rifaximin, which eradicates the bacterial overgrowth of the small intestine and may reduce symptoms, especially those related to bowel habit and stool frequency in patients with ibs. the abnormalities observed in the colonic flora of ibs suggest, in fact, that a probiotic approach will ultimately be justified. colecchia et al. performed a study to evaluate the efficacy and safety of a symbiotic consisting of a probiotic, b. longum w , and the short chain oligosaccharide prebiotic fos actilight, in patients with constipation-variant ibs. six hundred and thirty six patients ( men, women) diagnosed with constipation-type ibs according to the rome ii criteria were enrolled in centers and received the symbiotic at a dose of g/die for at least days. a validated questionnaire investigating symptoms and stool frequency was administered before and after treatment. the results were based on patients' responses to visual scale items; frequency increased significantly after treatment in the "no symptom" class from % to . % for bloating and from . % to . % for abdominal pain (p < . ); in the severest symptoms classes (moderatesevere), symptom frequency dropped significantly from . % to . % and from . % to . % for bloating and abdominal pain, respectively. stool frequency significantly increased from . ae . times/week to . ae . times/week. the authors conclude that the study product can increase stool frequency in patients with constipation-variant ibs and reduce abdominal pain and bloating in those ones with moderate-severe symptoms. whorwell et al. assessed the efficacy of the probiotic bacteria b. infantis on a large-scale, multicenter, clinical trial of women with ibs determining the optimal dosage of probiotic for administration in an encapsulated formulation. after a weeks baseline, primary care ibs patients, with any bowel habit subtype, were randomized to either placebo or freeze-dried, encapsulated b. infantis at a dose of  ,  , or  , cfu/ml for wks. ibs symptoms were monitored daily and scored on to a -point likert scale with the primary outcome variable being abdominal pain or discomfort. a composite symptom score, the subject's global assessment of ibs symptom relief, and measures of quality of life (using the ibs-qol instrument) were also recorded. the authors report the following results: b. infantis at a dose of  cfu was significantly superior to placebo and all other bifidobacterium doses for the primary efficacy variable of abdominal pain as well as the composite score and scores for bloating, bowel dysfunction, incomplete evacuation, straining, and the passage of gas at the end of the week study; the improvement in global symptom assessment exceeded placebo for more than % (p < . ); two other doses of probiotic (  and  ) were not significantly different from placebo; of these, the  dose was associated with significant formulation problems. no significant adverse events were recorded. the authors conclude that b. infantis is a probiotic that specifically relieves many of the symptoms of ibs. at a dosage level of  cfu, it can be delivered by a capsule making it stable, convenient to administer, and amenable to widespread use. the lack of benefits observed with the other dosage levels of the probiotic highlights the need for clinical data in the final dosage form and dose of probiotic before these products are used in practice. ibd commonly refers to two chronic inflammatory diseases of the gi tract: uc and cd. the main difference between cd and uc is the location and nature of the inflammatory changes. cd can affect any part of the gi tract, from mouth to anus, although a majority of the cases start in the terminal ileum. uc affects the colon and the rectum. microscopically, uc is restricted to the mucosa while cd affects the whole bowel wall. the world gastroenterology organization reports that: uc incidence has been increasing in western countries since the second world war and in low-incidence areas in eastern europe, asia and developing countries; cd incidence is < per , in asia and south america, e per , in southern europe, south africa, per , in new zealand and australia, per , in canada, per , in the usa (based on data only from olmsted county, minnesota). the pathogenesis of ibd is not completely understood. genetic and environmental factors such as altered luminal bacteria and enhanced intestinal permeability play a role in the dysregulation of intestinal immunity, leading to gi injury. an abnormal activation of the mucosal immune system driven by the presence of the intestinal microbiota in a genetically predisposed patient seems to play a key role in this pathology. especially in cd the intestinal microbiota is strongly suspected to play a role in initiating and triggering the immune system, leading to a characteristic inflammation. furrie et al. used a synbiotc combining a probiotic, b. longum, isolated from healthy rectal epithelium, and a prebiotic (synergy ), a preferential inulin-oligofructose growth substrate for the probiotic strain to treat uc patients. treatment was employed in a double blinded randomized controlled trial using patients with active uc for a period of one month. clinical status was scored and rectal biopsies were collected before and after treatment, and transcription levels of epithelium related immune markers were measured. the authors conclude that short-term synbiotic treatment of active uc resulted in improvement of the full clinical appearance of chronic inflammation in patients receiving this therapy. sokol et al. determined the composition of the mucosa-associated microbiota of cd patients at the time of surgical resection and months later using fish analysis. they found that a reduction of a major member of firmicutes, faecalibacterium prausnitzii, is associated with a higher risk of post-operative recurrence of ileal cd. this study was conducted as part of a double-blind controlled trial that compared the efficiency of the probiotic l. johnsonii la strain and a placebo to decrease endoscopic recurrence after curative surgery for cd. although the whole human trial included patients, the present study, included only a subset of these patients. f. prausnitzii a e (dsm ), isolated from human fecal stool, was grown at c in lyhbhi medium (braineheart infusion medium supplemented with . % yeast extract (difco) and mg/l hemin) supplemented with cellobiose ( mg/ml; sigma-ealdrich), maltose ( mg/ml; sigma), and cysteine ( . mg/ml; sigma) in an anaerobic chamber. a lower proportion of f. prausnitzii on resected ileal crohn mucosa was also associated with endoscopic recurrence at months. the authors observed the antinflammatory effects in both in vitro (cellular models) and in vivo [ , , -trinitrobenzenesulphonic acid (tnbs)-induced] colitis in mice to evaluate the immunomodulatory properties of f. prausnitzii in caco- cells transfected with a reporter gene for nf-kb activity. the study showed the following results: ) f. prausnitzii had no effect on il- beta-induced nf-kb activity, whereas the supernatant abolished it; ) in vitro pbmc stimulation by f. prausnitzii led to significantly lower il- and ifn-gamma production levels and higher secretion of il- ; ) oral administration of either live f. prausnitzii or its supernatant markedly reduced the severity of tnbs colitis and tended to correct the dysbiosis associated with tnbs colitis, as demonstrated by real-time quantitative pcr (qpcr) analysis. in conclusion these results show that f. prausnitzii is an anti-inflammatory bacterial candidate. this bacterium exhibited anti-inflammatory effects, partly due to secreted metabolites blocking nf-kb activation and il- secretion. in vivo effects were associated with a decrease in proinflammatory colonic cytokine synthesis and with the induction of anti-inflammatory cytokine secretion. counter balancing dysbiosis, using the commensal bacterium f. prausnitzii as a candidate probiotic agent, appears to be a promising strategy in cd treatment. further clinical studies are required to establish the diagnostic tools to define the best population of patients for this probiotic species, and especially whether the clinical benefit is more pronounced in patients with low levels of endogenous firmicutes. vilela et al. evaluated the influence of saccharomyces boulardii on the intestinal permeability in cd. the authors randomized thirty-four patients according to the vienna classification for treatment with either placebo or saccharomyces boulardii. the first group, consisting of patients, received a placebo every h as an oral capsule containing mg cellulose, mg sucrose and . mg magnesium stearate. the second group, consisting of patients, received s. boulardii every h as an oral capsule formulation which contained mg lyophilized s. boulardii (about  cells), mg sucrose and . mg magnesium stearate (floratil Ò ). a third group, consisting of healthy volunteers, aged between and years, (mean age years), who agreed to take part in the study, within the ethical norms of human research, were submitted to intestinal permeability tests in order to establish control values. they were not assigned to any kind of treatment. baseline medications (mesalamine, azathioprine, prednisone, metronidazole and/or thalidomide) were maintained. intestinal permeability (l/m ratio) was evaluated immediately before the beginning of treatment and at the end of the first and third treatment month. the authors obtained the following results in volunteers, the l/m ratio was . ae . , whereas this value was . ae . in patients with cd (p ¼ . ). in the placebo group, there was an increase in l/m ratio by . ae . (p ¼ . ) at the end of the third month. in the s. boulardii group, there was an improvement in intestinal permeability, with a decrease in the l/m ratio by . ae . (p ¼ . ) in the same period. the previously described results bring the authors to the conclusion that patients with cd in remission present alterations in the integrity of the intestinal mucosal barrier according to l/m ratio. s. boulardii, added to baseline therapy, improves intestinal permeability but complete normalization was not achieved. fujimori et al. realized a study to assess the clinical usefulness of combined probiotic and prebiotic therapy in the treatment of active cd. ten active cd outpatients without history of operation for cd were enrolled (cd was diagnosed by established clinical, endoscopic, radiological and histological criteria.). their mean (ae) age was ae years and the main symptoms presented were diarrhea and abdominal pain. patients' initial therapeutic regimen of aminosalicylates and prednisolone failed to achieve remission. patients were thus initiated into a synbiotic therapy, consisting of both probiotics ( billion cfu daily) and prebiotics (psyllium . g daily). probiotics mainly comprised bifidobacterium and lactobacillus. patients were free to adjust their intake of probiotics or prebiotics throughout the trial. chron's disease activity index (cdai), international organization for the study of inflammatory bowel disease (ioibd) score and blood sample variables were evaluated and compared before and after the trial. the duration of the trial was . ae . months. by the end of therapy, each patient had taken a ae billion cfu daily probiotic dose, with six patients taking an additional . ae . g daily psyllium dose. seven patients had improved clinical symptoms following combined probiotic and prebiotic therapy. both cdai and ioibd scores were significantly reduced after therapy ( e , p ¼ . ; . e . , p ¼ . , respectively). six patients had a complete response, one had a partial response, and three were non responders. two patients were able to discontinue their prednisolone therapy, while four patients decreased their intake. there were no adverse events. high-dose probiotic and prebiotic cotherapy can be safely and effectively used for the treatment of active cd. in conclusion, our study shows that synbiotic therapy can safely reduce cd activity and achieve its remission. we found that synbiotic therapy is especially indicated for cd patients with frequent diarrhea. further studies, examining such areas as fecal flora and scfas that compare cd patients with probiotics to cd patients with synbiotics, are expected. larger scale studies and randomized controlled studies on the treatment of cd with probiotic therapy in combination with prebiotics are clearly necessary for a fuller appreciation of the therapeutic value of synbiotics. chermesh et al. designed a prospective multicenter, randomized study. patients were randomized to active treatment or placebo in a : ratio. active treatment consisted of synbiotic , which contains a mixture of prebiotics and probiotics, including lactic acid bacteria and fermentable fibers. the four lactic acid bacteria are pediacoccus pentoseceus, l. raffinolactis, l. paracasei susp paracasei , and l. plantarum ; the fermentable fibers are . g b-glucans, . g inulin, . g pectin, and . g resistant starch. the authors checked if treatment with synbiotic could prevent post-operative recurrence in patients with cd. follow-up consisted of endoscopic, clinical, and laboratory parameters. thirty patients were enrolled. no differences were found between the treatment groups regarding gender, age at diagnosis, age at surgery, weight, smoking status, type of disease, length of the resected segment, or medical treatment prior to surgery. no difference in either endoscopic or clinical relapse rate was found between patients treated with once daily dose of synbiotic or placebo. in our small study, synbiotic had no effect on post-operative recurrence of patients with cd. larger studies in patients with the inflammatory type of cd undergoing surgery, using higher doses of probiotics cocktail, may prove effective. this study highlights that synbiotic had no effect on post-operative recurrence of patients with cd. van gossum et al. designed a multicenter clinical trial evaluating the efficacy of an oral administration of the probiotic l. johnsonii, (la , nestec) on early post-operative endoscopic recurrence of cd. seventy patients with cd were enrolled prior to elective ileo-caecal resection and randomly assigned after surgery to daily treatment with either lactobacillus johnsonii, ( cfu) (group a, n ¼ ) or placebo (group b, n ¼ ) for weeks. the treatment consisted of the probiotic la in freeze-dried form and blended with maltodextrin at cfu/day. the placebo was maltodextrin only. the la powder was supplied in foil sachets (weight g) containing cfu of probiotics. the placebo was a powder of the same appearance and weight, also in individual foil packets. both probiotics and placebo were administered in combination with an enteral formula at ml/day (acd , nunspeet, holland, konolfingen, switzerland). the identity of the treatment sachet was blind to patients, support staff, and investigators (numerical codes). treatment codes were broken only by the statistician after completion of the trial. the primary objective was to assess the effect of la on the endoscopic recurrence rate at weeks. stratification was performed according to smoking status at randomization. seven and patients were excluded in the la and placebo groups, respectively. in intention-to-treat analysis, the mean endoscopic score was not significantly different between the two treatment groups at months (la versus placebo: . ae . versus . ae . , treatment effect: p ¼ . , smoke effect: p ¼ . ). the percentage of patients with severe recurrence (i þ i ) was % and % in the la and placebo groups, respectively (p ¼ . ). using a per-protocol (pp) analysis, the mean endoscopic score was not significantly different between the two treatment groups (la versus placebo groups: . ae . versus . ae . , p ¼ . ). the percentage of patients with severe recurrence (i ae i ) was % and % in the la and placebo groups, respectively (p ¼ . ). clinical relapse rate clinical relapse rate > , with an increase of clinical relapse rate > points or greater from baseline in the la and placebo groups was % ( / ) and . % ( / ), respectively (pp analysis: chi-square test, p ¼ . and log-rank test: p ¼ . ). oral administration of the probiotic la in patients with cd failed to prevent early endoscopic recurrence at weeks after ileo-caecal resection. vasquez et al. analyzed and compared the mucosa-associated bacteria (mab) in non-inflamed and inflamed ileal mucosa of cd patients (n ¼ ). tissue samples from the inflamed ileal mucosa and from the adjacent non-inflamed ileal mucosa were taken from surgical resection specimens. the mab were investigated using fluorescence in situ hybridization with group-specific probes and temporal temperature gradient gel electrophoresis (ttge). samples from both non-inflamed and inflamed mucosa were taken from patients biopsies. the distribution of the bacterial populations was not different between non-inflamed and inflamed mucosa. the bacteroidetes phylum was dominant and accounted for % of mab ( e %) in non-inflamed tissues and % ( e %) in inflamed areas. the proteobacteria represented % ( e %) of mab both in non-inflamed and inflamed areas. the clostridium coccoides group (firmicutes phylum) represented % of mab in non-inflamed tissues versus % in inflamed areas. for most of the patients the similarity index between ttge paired profiles was very high. the authors conclude that the dominant mab do not differ between non-inflamed and inflamed ileal mucosa in cd. this fact argues against a localized dysbiosis to explain the patchy distribution of mucosal lesions. helicobacter pylori (h. pylori) is a small curved to spiral rodshaped bacterium found in the epithelial mucus surface of most patients with active gastritis. h. pylori is strongly associated with duodenal peptic ulceration and it is the main etiologic agent of chronic gastritis and gastric cancer and other gastric malignancies. today the therapy to eradicate this bacterium is based on a combination of antibiotics and proton pump inhibitors (ppi). the ( )c-urea breath test is the commonly used test to diagnose the presence of h. pylori in the stomach. the test also finds application to understand if h. pylori has been eradicated through a treatment with antibiotics. the urea breath test is based on the ability of h. pylori to break down urea, a chemical made up of nitrogen and carbon, into carbon dioxide which then is absorbed from the stomach and eliminated in the breath. for the test, patients swallow a capsule containing urea made from an isotope of carbon. if h. pylori is present in the stomach, the urea is broken up and turned into carbon dioxide. the carbon dioxide is absorbed across the lining of the stomach and into the blood. it then travels in the blood to the lungs where it is excreted in the breath. samples of exhaled breath are collected, and the isotopic carbon in the exhaled carbon dioxide is measured. if the isotope is detected in the breath, it means that h. pylori is present in the stomach. if the isotope is not found, h. pylori is not present. probiotics seem to have a direct antimicrobial effect, as shown through in vitro studies, through competition with h. pylori, inhibition of adherence and production of metabolites and antimicrobial molecules. implementation of probiotics with standard anti-h. pylori regimens can also improve patients' compliance with therapy, reducing the incidence of side effects associated with antibiotic treatment. kim et al. performed a study to evaluate whether the addition of probiotics to ppi-based triple therapy increases the success in the eradication of h. pylori. three hundred and forty-seven h. pylori infected patients were randomized into a triple-plus-yogurt group (yogurt group, n ¼ ) or a triple-only group (control group, n ¼ ). triple therapy consisted of ppi b.i.d., clarithromycin mg b.i.d., and amoxicillin g b.i.d. for days. the yogurt group received triple therapy for week and one bottle of will yogurt per day for weeks, starting on the first day of the triple therapy. will yogurt (a korean brand) contains l. acidophilus hy , l. casei hy , b. longum hy , and streptococcus thermophilusb- . ( ) c-urea breath test was performed for at least weeks after completion of the triple therapy. eradication rates, compliances, and adverse events were compared. with the intention to treat analysis the h. pylori eradication rates in the yogurt group . % ( of ) was similar to that in the control group . % ( of ) (p ¼ . ). however, by means of pp analysis, the eradication rate in the yogurt group, . % ( of ) was higher than that in the control group, . % ( of ) (p ¼ . ). common adverse events were metallic taste ( . %) and diarrhea ( . %). the frequency of adverse effects in the yogurt group . % ( / ) were higher than in the control group, . % ( of ) (p ¼ . ). however, most adverse events were mild to moderate in intensity, and the severities of adverse effects were similar in both groups (p ¼ . ). the authors conclude that, the addition of a yogurt to triple therapy does not decrease the adverse effects of the triple therapy. however it increases h. pylori eradication rate in pp analysis, suggesting a possibility that the addition of will yogurt, commercialized as a kind of food, into triple therapy, might be an option to increase the h. pylori eradication rate. imase et al. examined intestinal microbiota changes during h. pylori eradication therapy and the preventive effect of cbm as a probiotic agent. nineteen patients with gastro-duodenal ulcer were randomly divided into three groups: group a (without probiotics), group b (with regular doses of cbm ) and group c (with double doses of cbm ). cbm is a probiotic agent containing approximately cfu per tablet. the incidence of diarrhea and soft stools during h. pylori eradication therapy was % in group a and % in group b, while none of the patients in group c reported diarrhea or soft stools. both bacterial counts and detection rates of bifidobacteria and/or obligate anaerobe were decreased by eradication therapy. however, bacterial counts of obligate anaerobes in group c were significantly higher than in group a (p < . ). additionally, during eradication therapy, c. difficile toxin a was detected in both group a and group b but not in group c. the authors conclude that side effects associated with h. pylori eradication therapy, including diarrhea and/or soft stools, are considered attributable to disturbances in the composition of intestinal microbiota caused by antibiotics, and to toxin a produced by c. difficile. the results of our study also suggest that these symptoms can be prevented by concomitant administration of a viable bacterial preparation containing cbm . francavilla et al. tested whether lactobacillus reuteri atcc reduces h. pylori intragastric load in vivo, decreases dyspeptic reuteri symptoms, and affects eradication rates after conventional treatment. in a double-blind placebo-controlled study, h. pylori positive subjects were given l. reuteri or placebo once a day for weeks. l. reuteri or placebo were both provided by nóos (biogaia ab, sweden) as chewable tablets and included either l. reuteri each tablet containing cfu of l. reuteri atcc or placebo which consisted of tablets identical in taste and appearance to the active study product except for the absence of freeze-dried l. reuteri (and cryoprotectants). everyone underwent upper endoscopy, ( )c-urea breath test, and h. pylori stool antigen determination at entry and ( )c-urea breath test and h. pylori stool antigen (used as both qualitative and semiquantitative markers) after weeks of treatment. sequential treatment was administered subsequently to everyone. in vivo, l. reuteri reduces h. pylori load as semiquantitatively assessed by both ( )c-urea breath test deltavalue and h. pylori stool antigen quantification after weeks of treatment (p < . ). no change was shown in patients receiving placebo. l. reuteri administration was followed by a significant decrease in the gastrointestinal symptom rating scale as compared to pretreatment value (p < . ) that was not present in those ones receiving placebo (p ¼ not significant). no difference in eradication rates was observed. l. reuteri effectively suppresses h. pylori infection in humans and decreases the occurrence of dyspeptic symptoms. nevertheless, it does not seem to affect antibiotic therapy outcome. the authors report that a -week supplementation with l. reuteri is effective in reducing h. pylori bacterial load in humans and theoretically may help to control gastric inflammation. cindoruk et al. investigated the efficacy and safety of s. boulardii in the prevention of side-effects related to h. pylori eradication. the secondary aim of the study was to define the effect of s. boulardii on the eradication success of anti-h. pylori therapy. one hundred and twenty-four patients with h. pylori infection (male/ female: / , mean age: ae . year) receiving days of triple therapy (clarithromycin mg b.i.d., amoxicillin mg b.i.d., and lansoprazole mg b.i.d.) were randomly assigned to s. boulardii or placebo. dyspeptic symptoms were recorded using modified glasgow dyspepsia questionnaire (gdq). side-effect profile and tolerability were assessed using a symptom-based questionnaire. h. pylori status was rechecked weeks after completion of eradication therapy. h. pylori eradication rate, although higher in the treatment group, was statistically similar in treatment and control groups: % ( / ) versus . % ( / ), respectively (p > . ). nine ( . %) patients in the treatment group and ( . %) patients in the placebo group experienced diarrhea (p < . ). epigastric discomfort was more frequent in the control group [ ( . %) versus ( . %), respectively (p < . )]. diffuse abdominal pain, abdominal gas, taste disturbance, urticaria and nausea symptoms were similar in both groups. gdq scores after treatment were significantly better for treatment group (mean ae sd, range: . ae . ( e ) vs. . ae . ( e ), respectively; p < . ). the authors conclude that s. boulardii improves anti-h. pylori antibiotherapy-associated diarrhea, epigastric discomfort, and treatment tolerability. in addition, saccharomyces boulardii supplement decreases post-treatment dyspepsia symptoms independent of h. pylori status. addition of s. boulardii does not affect the rate of h. pylori eradication. scaccianoce et al. enrolled consecutive dyspeptic patients with h. pylori infection. patients received one of the following therapies: a) standard -day triple therapy; b) standard -day triple therapy plus l. reuteri supplementation; c) the same -day triple therapy plus a probiotic mixture; d) a -day standard triple therapy plus a probiotic mixture. h pylori eradication was checked using a ( )c-urea breath test performed e weeks after treatment. the authors observed that the -day therapy plus probiotic mixture tended to achieve higher eradication rate ( %). the lowest incidence of side effects was observed following the -day therapy plus l. reuteri ( %) and the highest one the -day therapy plus probiotic mixture ( %). the authors underline that there is no significant statistically difference between the therapy regimens. this study shows that e days triple therapy with or without probiotic supplement fails to achieve acceptable h. pylori eradication rates. colon cancer is a multi-factorial and complex neoplasm involving both genetics and environmental factors. there seems to be a strong relationship between colon cancer, diet and intestinal microflora. the rupture of the intestinal microflora equilibrium due to a bad diet seems to be related to an increase in the risk of developing colon cancer. liong underlines the different properties attributed to probiotics and prebiotics in the past years such as anti-carcinogenic, antimutagenic properties, ability of modifying differentiation processes in tumor cells, production of scfas and alteration of tumor gene expressions but he also evidences that, despite all the positive findings, other researchers have also reported insignificant colon cancer protective effects. certain bacterial species in the colon produce harmful substances that seem to be correlated to cancer. that is why it has been thought that probiotics may modulate several major intestinal functions potentially associated with the development of colon cancer preventing the growth of deleterious organisms, producing anticarcinogenic substances and moving the balance of gut bacteria in favour of the ones beneficial for the organism. colon cancer has been correlated to high fat diets and it is thought to be due to colon raised levels of bile acids which help digest fat. these salts are released into the small intestine, and also re-absorbed there, but some may pass into the colon. the break down products of bile may have a cytotoxic effect on the cells lining the colon, increasing cell proliferation and possibly cancer. probiotic modulation of the intestinal microflora may affect the activity of one of the enzymes ( a-dehydroxylase) forming these toxic products but probiotics may also reduce the toxicity of bile salts binding to them. while growing in the colon, probiotics seem to exert different functions such as controlling the growth of potentially harmful bacteria, binding to mutagens, preventing harmful enzyme activity in the gut (b-glucoronidase, nitroreductase), interacting with the cells of the colon, forming conjugated linoleic acid, a compound with antiinflammatory properties that may inhibiting the development of cancer. it may also increase levels of butyric acid in the colon which is an important energy source and growth regulator for colon cells, stimulating the activity of beneficial enzymes that inactivate carcinogens (glutathione s transferase) and the immune system, and produce products that have a beneficial effect on the cells of the colon (lactobacillus and bifidobacterium produce lactic acid and similar scfas increasing the gut lumen acidity). moreover takeda et al. suggest that daily intake of lactobacillus casei strain shirota provides a positive effect on the activity of nk cells which seem to exert a key role in protecting the human organism against cancer. hatakka et al. examined fecal b-glucosidase, b-glucuronidase, and urease activities during administration of l. rhamnosus lc (lc ) together with propionibacterium freudenreichii ssp shermanii js (pjs). thirty-eight healthy men participated in this randomized, double-blind, placebo-controlled, two-period crossover study with treatment periods of weeks. subjects consumed daily bacterial or placebo capsules. bacterial capsules contained viable lc and pjs. lc (dsm ) and pjs (dsm ), which are commonly used in the manufacture of ripened, semi-hard cheeses. the freeze-dried bacteria were filled in gelatine capsules. the subjects consumed daily two capsules containing viable lc and pjs (  cfu of each strain daily) or two placebo capsules. the same amount of this particular bacterial combination had previously shown physiological effects in two human studies. the amount of bacteria in the capsules remained unchanged during the study. in addition to the bacteria, the capsules contained microcrystalline cellulose as a filler. the placebo capsules were of identical composition but without the bacteria. subjects were instructed to take the capsules daily with the first meal of the day. the activities of b-glucosidase, b-glucuronidase and urease, recovery of lc and pjs, and counts of total lactobacilli and propionibacteria were determined from feces. the mean fecal counts of total lactobacilli and propionibacteria as well as lc and pjs strains were significantly increased during the administration of bacteria ( . -, -, -and -fold, respectively). b-glucosidase activity decreased by % (p ¼ . ) and urease activity by % (p ¼ . ) during bacterial supplementation versus placebo. the change in b-glucosidase activity was negatively correlated with the change in propionibacteria counts (r ¼ À . , p ¼ . ), being À . versus . nmol/min/mg protein in subjects with increased and unchanged/decreased propionibacteria, respectively (p ¼ . ). in conclusion, the administration of lc and pjs was followed by an increase in the fecal counts of lactobacilli and propionibacteria and a decrease in the activity of b-glucosidase with increasing counts of propionibacteria. the authors conclude that the administration of lc together with pjs was associated with a decrease in b-glucosidase activity related to the increasing counts of propionibacteria, although we found no significant influence on the activity of three bacterial enzymes, b-glucosidase, urease and bglucuronidase, compared to placebo. to evaluate the effect of the carcinogenic potential of those enzymes and the safety of those strains further studies are warranted. roller et al. investigated whether daily intake of an syn modulates immune functions. in a randomized double-blind, placebo-controlled trial, thirty-four colon cancer patients who had undergone 'curative resection' and forty polypectomized patients participated. subjects of the syn group daily received encapsulated bacteria (  cfu of l. rhamnosus gg and  cfu of bifidobacterium lactis bb (bb )) and g of inulin enriched with oligofructose. controls received encapsulated maltodextrin and g of maltodextrin. prior to intervention (t ), and (t ) and weeks after the start of the intervention (t ), phagocytic and respiratory burst activity of neutrophils and monocytes, lytic activity of nk cells and production of il- , il- and il- , as well as tnf-alpha and ifn-gamma by activated pbmc were measured. in feces, the concentrations of transforming growth factor-b and prostaglandin e were measured. il- secretion by activated pbmc from the polypectomized group increased significantly between t or t and t (p < . ). in the cancer group, syn treatment resulted in an increased capacity of pbmc to produce ifn-gamma at t (p < . ). other immunity-related parameters were not affected by syn treatment, neither in the cancer nor in the polypectomized group. in conclusion, supplementation with this syn has minor stimulatory effects on the systemic immune system of the two study groups. the authors conclude thatno negative effects were observed in cancer and polypectomized patients with daily consumption of this syn for weeks, but more definitive testing is required to indicate conclusively that this product is safe. the syn supplement had only minor effects on the immune system of the subjects in both groups. it is possible that syn supplementation in humans preferentially affects the gut-associated lymphoid tissue rather than the systemic immune system. rafter et al. verified whether the prebiotic concept (selective interaction with colonic flora of nondigested carbohydrates), as induced by a synbiotic preparation oligofructose-enriched containing inulin (beneosynergy ; orafti, tienen, belgium; syn ), l. rhamnosus gg and bb , is able to reduce the risk of colon cancer in humans. the week randomized, double-blind, placebocontrolled trial of a synbiotic food composed of the prebiotic syn and probiotics l. rhamnosus gg and bb was conducted in colon cancer patients and polypectomized patients. treatment consisted of a synbiotic preparation that contained the prebiotic syn and the probiotic strains bb and lactobacillus delbreuckii subspecies rhamnosus strain gg. syn is an oligofructose-enriched inulin preparation. fecal and blood samples were obtained before, during, and after the intervention, and colorectal biopsy samples were obtained before and after the intervention. the effect of synbiotic consumption on a battery of intermediate biomarkers for colon cancer was examined. synbiotic intervention resulted in significant changes in fecal flora: bifidobacterium and lactobacillus increased and clostridium perfringens decreased. the intervention significantly reduced colorectal proliferation and the capacity of fecal water to induce necrosis in colonic cells and improve epithelial barrier function in polypectomized patients. genotoxicity assays of colonic biopsy samples indicated a decreased exposure to genotoxins in polypectomized patients at the end of the intervention period. synbiotic consumption prevented an increased secretion of il- by means of pbmc in the polypectomized patients and increased the production of interferon in the cancer patients. the authors conclude that the synbiotic intervention results in significant alterations in the composition of the colonic bacterial ecosystem, which presumably has consequences for the metabolic activity of the colon. these results also provide indirect evidence that some of the consequences of the synbiotic intervention might be a decreased exposure of the epithelium to cytotoxic and genotoxic agents, a decreased colonic cell proliferation and an improved mucosa structure. diarrhea is an increase in the water content, frequency, and volume of bowel movements. probiotics could be important for the treatment of diarrhea illnesses (viral diarrhea, antibiotic-associated diarrhea, clostridium difficile-related diarrhea, traveler's diarrhea (td)). viral gastroenteritis is characterized by watery diarrhea, vomiting, headache, fever, chills, and abdominal pain. the viruses that may be responsible for this condition are: rataviruses, caliciviruses, adenoviruses, astroviruses, toroviruses, coronaviruses and pestiviruses. citomegaloviruses are responsible for viral colitis. rotavirus is the most common cause of viral diarrhea and can injure the intestinal epithelium leading to malabsorption and can increase the secretion through the epithelium. the rotavirus has several ways of transmission: fecal-oral, through contaminated water supllies, poor hygiene, food and fomites. saavedra et al. reported that lactobacillus gg has been observed to decrease the rate of rotavirusassociated diarrhea and rotaviral shredding. moreover the author reported an interesting study which highlights that % of children treated with lactobacillus gg had an iga specific antibody-secreting cells (sasc) response to rotavirus versus % for placebo. another study performed on infants describes how infectious diarrhea was successfully treated adding a combination of bifidobacteria and streptococcus thermophilus to powdered formula. this study shows that the combination of b. bifidum and s. thermophilus also reduced the rate of rotavirus-associated diarrhea and decreased rotavirus shredding. td is a condition usually due to the ingestion of food and beverages contaminated by fecal matters. % of the cases are bacteria caused. the most common bacteria are enterotoxigenic e. coli and enteroaggregative e. coli, campylobacter jejuni, salmonella species and aeromonas species. some protozoa such as entamoeba histolytica and giardia lamblia or enteroviruses are generally minor causes of td. episodes of diarrhea are frequent side effects of antibiotic therapy. antibiotic therapy leads to an alteration of normal intestinal flora which may cause a loss of colonization resistance and an alteration of the metabolic functions of the normal flora. the first situation is followed by an abnormal growth of pathogenic organisms such as c. difficile, candida albicans, k.caytoca and salmonella spp which are responsible for toxigenic diarrhea. the second situation leads to a diminished digestion of non absorbable carbohydrates followed by osmotic water secretion and a diminished colic absorption of water and electrolytes caused by a diminished production of scfas resulting in diarrhea. dubey et al. conducted a double-blind randomized placebocontrolled study to evaluate efficacy and tolerability of vsl[sharp] (cd pharma india) in the treatment of acute rotavirus diarrhea in children. the patients were randomly assigned to receive days of oral treatment with vsl[sharp] probiotic mixture or placebo in addition to usual care for diarrhea. use of probiotic mixture vsl [sharp] in acute rotavirus diarrhea resulted in earlier recovery and reduced frequency of oral rehydration salt (ors) administration reflecting decreased stool volume losses during diarrhea without side effects. narayanappa et al. evaluated the efficacy and safety of bifilac in reducing the episodes (frequency) and duration of diarrhea induced by rotaviral infection and to evaluate the efficacy of bifilac to ameliorate the associated symptoms like dehydration and duration of rotaviral shedding in feces. the authors enrolled children aged between months and years and divided them into groups, one group received standard therapy þ placebo, the other group received standard therapy þ probiotic (bifilac) randomly. children were assessed for frequency and duration of diarrhea, a degree of dehydration, duration and volume of ors therapy, duration and volume of intra venous fluids and duration of rotaviral shedding. they conclude that synbiotic bifilac appears to be a safe and very effective adjuvant in the management of acute rotaviral diarrhea. henker et al. determined whether the stool frequency of infants and toddlers suffering from acute diarrhea could be normalized more quickly by administering the probiotic escherichia coli nissle (ecn) solution rather than by administering a placebo. the authors also assessed the safety of ecn. a total of children (aged e months) with acute diarrhea (>three watery or loose stools in h) were randomized to either a group receiving the probiotic ecn suspension (n ¼ ) or a group receiving the placebo suspension (n ¼ ) in a confirmative, double-blind clinical trial. depending on the age of patients, e ml per day of verum suspension ( viable ecn cells per millilitre) or placebo were administered orally. the causes of the diarrhea were viral rather than bacterial. ecn was found to be safe and well-tolerated, and it showed a significant superiority compared to the placebo in the treatment of acute diarrhea in infants and toddlers. basu et al. evaluated the role of l. rhamnosus gg as probiotic in acute watery diarrhea (awd). this randomized, controlled, blinded trial involved patients. the intervention group (n ¼ ) received ors with probiotic powder containing million cells of l. rhamnosus gg, while the control group (n ¼ ) received ors alone twice daily for a minimum period of days or till diarrhea ceased. during the study period all patients received ors and/or iv fluids for ongoing losses, and nutritional supplementation. none of them received any antibiotic or antidiarrhoeal medication. rotavirus was isolated in . %. there was no significant difference between treatment groups in the daily frequency or duration of diarrhea or vomiting or in the length of hospital stay. no complication was observed from the use of l. rhamnosus gg. l. rhamnosus gg supplementation did not decrease the frequency and duration of diarrhea and vomiting in children with awd, and does not reduce hospital stay in these patients. the efficacy of a combination of b. longum pl , l. rhamnosus kl a and l. plantarum pl for the prevention of antibioticassociated diarrhea in children was evaluated by szymanski et al. . seventy-eight children (age: months to years) with otitis media, and/or respiratory tract infections, and/or utis were enrolled in a double-blind randomized control trial in which they received standard antibiotic treatment plus a food supplement containing cfu of b. longum, l. rhamnosus and l. plantarum (n ¼ ) or a placebo (n ¼ ) orally twice daily for the duration of antibiotic treatment. patients receiving probiotics had a similar rate of diarrhea (>or ¼ loose or watery stools/day for > or ¼ h occurring during or up to weeks after the antibiotic therapy) as those receiving placebo (relative risk . , % ci . e . ). the mean number of stools per day was significantly lower in the experimental group (mean difference À . stool/day, % ci À . to À . ). no adverse events were reported. concluding the three probiotics do not significantly alter the rate of diarrhea, although they reduce the frequency of stools per day. the authors underline the overall frequency of diarrhea was surprisingly low even though these results should be interpreted with caution. ruszczynski et al. enrolled children with common infections (aged months to years) in a double-blind, randomized, placebocontrolled trial to assess the efficacy of administration of l. rhamnosus for the prevention of antibiotic-associated diarrhea in children. they received standard antibiotic treatment plus  cfu of a probiotic (l. rhamnosus strains e/n, oxy and pen) (n ¼ ) or a placebo (n ¼ ), administered orally twice daily throughout antibiotic treatment. any diarrhea (>or ¼ loose or watery stools/ day for > or ¼ h occurring during or up to weeks after the antibiotic therapy) occurred in nine ( . %) patients in the probiotic group and in ( %) patients in the placebo group (relative risk, rr . , % ci . e . ). three ( . %) children in the probiotic group developed diarrhea caused by clostridium difficile or otherwise unexplained diarrhea compared to nine ( . %) in the placebo group (rr . , % ci . e . ). no adverse events were observed. this study shows that administration of l. rhamnosus (strains e/n, oxy and pen) to children receiving antibiotics reduces the risk of any diarrhea. beausoleil et al. designed a study to assess the efficacy and safety of a fermented milk combining l. acidophilus and l. casei that is widely available in canada, in the prevention of antibiotic-associated diarrhea (aad). this double-blind, randomized study ivolved hospitalized patients which were randomly assigned to receive either a lactobacilli-fermented milk or a placebo on a daily basis. aad occurred in seven of patients ( . %) in the lactobacilli group and in of patients ( . %) in the placebo group (or . , % ci . to . ; p ¼ . ). the median hospitalization duration was eight days in the lactobacilli group, compared with days in the placebo group (p ¼ . ). the study shows that the daily administration of a lactobacilli-fermented milk was safe and effective in the prevention of antibiotic-associated diarrhea in hospitalized patients. hickson et al. designed a study involving hospital patients (mean age ) taking antibiotics. this randomized double-blind placebo-controlled study aimed at determining the efficacy of a probiotic drink containing lactobacillus for the prevention of any diarrhea associated with antibiotic use and caused by clostridium difficile. the patients received g ( ml) drink containing l. casei, l bulgaricus, and s. thermophilus twice a day during a course of antibiotics and for one week after the course finished. the placebo group received a longlife sterile milkshake. / ( %) of the probiotic group developed diarrhea associated with antibiotic use compared with / ( %) in the placebo group (p ¼ . ). logistic regression to control for other factors gave an or . ( % . to . ) for the use of the probiotic, with low albumin and sodium also increasing the risk of diarrhea. the absolute risk reduction was . % ( . %e . %), and the number needed to treat was ( e ). no one in the probiotic group and / ( %) in the placebo group had diarrhea caused by c. difficile (p ¼ . ). the absolute risk reduction was % ( %e %), and the number needed to treat was ( e ). they conclude that the consumption of a probiotic drink containing l casei, l bulgaricus, and s. thermophilus can reduce the incidence of aad and c. difficile associated diarrhea. wenus et al. , to study the preventive effect of a milk drink fermented with multistrain probiotics on aad, designed a doubleblind placebo-controlled study involving patients randomized to ingestion of a fermented milk drink containing l. rhamnosus gg, la- and bb- (n ¼ ) or placebo with heat-killed bacteria (n ¼ ), during a period of days. sixty-three patients completed the study according to the protocol; two patients ( . %) in the treatment group and eight ( . %) in the placebo group developed aad (p ¼ . ). the relative risk of developing aad was . ( % ci: . e . ) when they were given probiotic milk drink. this study proves that a fermented multistrain probiotic milk drink may prevent four of five cases of aad in adult hospitalized patients. koning et al. studied the effect of a multispecies probiotic on the composition and metabolic activity of the intestinal microbiota and bowel habits in forty-one healthy volunteers. they were given mg amoxycillin twice daily for days and were randomized to either g of a multispecies probiotic, ecologic aad ( cfu/g), or placebo, twice daily for days. after collection, feces was analyzed as to the composition of the intestinal microbiota, and betaeglucosidase activity, endotoxin concentration, c. difficile toxin a, scfas, and ph were determined. bowel movements were scored according to the bristol stool form scale. mean number of enterococci increased significantly from log . at day to log . (day ) and log . (day ) cfu/g feces (p < . ) during probiotic intake. although no other significant differences were observed between both intervention groups, within each group significant changes were found over time in both microbial composition and metabolic activity. moreover, bowel movements with a frequency > or ¼ per day for at least days and/or a consistency > or ¼ for at least days were reported less frequently in the probiotic compared to the placebo group ( % vs %, p < . ). this study shows that, apart from an increase in enterococci, no significant differences in microbial composition and metabolic activity are observed in the probiotic compared with the placebo group. however, changes over time were present in both groups, which differed significantly between the probiotic and the placebo arm, suggesting that the amoxycillin effect was modulated by probiotic intake. the intake of a multispecies probiotic significantly reduced diarrhea-like bowel movements in healthy volunteers receiving amoxicillin. sabia et al. focused on plasmid transfer by mating, a process that can occur in the gut microbiota. this process is particularly important when antibiotic-resistant genes are involved. the authors investigated the in vitro capability of two l. plantarum strains (one bacteriocin producer and one non producer) to interfere with the conjugation processes. different matings were performed adding to the donor and recipient cells l. plantarum d bac and l. plantarum / bac as agents of interference. conjugations added with a staphylococcus aureus strain or without any agent of interference were used as controls. both lactobacillus strains were able to decrease mating frequency. statistically significant differences in the viable transconjugants were obtained in the presence and in the absence of the lactobacilli. the effect was almost the same with the two l. plantarum independent of bacteriocin production. in the trial performed with streptococcus aureus, no decrease in mating frequency was observed, confirming that the capability to interfere with r-plasmid transfer ability can be a property of the tested l. plantarum strains. hoesl et al. focused on some interesting studies involving the admnistration of oxalobacter formigenes (discovered in ), a bacterium responsible for the degradation of oxalate in the human body. several studies showed a link between a lack of colonization by o. formigenes and a recurrence of oxalate stone formation. moreover, among the stone formers, a lack of o. formigenes is associated with hyperoxaluria. a higher urinary oxalate excretion in female calcium oxalate formers with recurrent uti may be associated with the application of antibiotics and a subsequent eradication of o. formigenes. a permanent decolonization was also found in cystic fibrosis patients. the authors analyzed some clinical trials involving humans who followed administration of mg of o. formigenes strain; hcl urinary oxalate excretion and oxalate/creatinine ratios were found to be reduced; o. formigenes was used in a first time cinical trial involving children, seven of whom still have functioning kidneys and two with end-stage kidney failure all affected by primary hyperoxaluria type i, an inherited, life threatening disease characterized by recurrent oxalate stone formation, nephrocalcinosis and eventual liver and kidney failure. administering daily teaspoonfuls of a frozen cell paste of live o. formigenes (ixoc- ) oxalate excretion in the urine of the children with functioning kidneys decreased between percent and percent followed by a gradual increase after the treatment was stopped. in the two children on renal dialysis a significant reduction in blood levels of oxalate was observed. in hoppe et al. designed a new study orally administering oxalobacter for weeks as frozen paste, ixoc- or as entericcoated capsules (ixoc- ). nine patients (five with normal renal function, one after liver-kidney transplantation, and three with renal failure) completed the ixoc- study. seven patients (six with normal renal function and one after liver-kidney transplantation) completed the ixoc- study. the preliminary obtained data indicate that oxalobacter formigenes is safe, leads to a significant reduction of either urinary or plasma oxalate, and is a potential new treatment option for primary hyperoxaluria. skovbjerg et al. designed a double-blind pilot/preliminary study involving children with long-standing secretory otitis media (som ¼ a pathology characterized by persistent fluid in the middle ear cavity) who were scheduled for insertion of tympanostomy tubes. they were randomized to nasal spray treatment with streptococcus sanguinis, l. rhamnosus or placebo for days before surgery. clinical evaluation was carried out after days of treatment. middle ear fluid (mef) was collected during surgery for quantification of cytokines and detection of bacteria by culture and pcr. nasopharyngeal swabs were obtained before treatment and at surgery. the authors observed that complete or significant clinical recovery occurred in / patients treated with s. sanguinis compared to / patients in the placebo group (p < . ). in the l. rhamnosus treatment group, / patients were cured or much better (p ¼ . compared with placebo). spray treatment did not alter the composition of the nasopharyngeal flora or the cytokine pattern observed in the nasopharynx or mef, except for a higher level of il- found in the nasopharynx of l. rhamnosus treated children. although the mechanisms for the effect remains to be investigated this study shows that spray treatment with s. sanguinis may be effective against som. probiotics seem to play an important role in the lumen of the gut elaborating antibacterial molecules such as bacteriocins. moreover they seem to be able to enhance the mucosal barrier increasing the production of innate immune molecules, including goblet cellederived mucins and trefoil factors and defensins produced by intestinal paneth cells. some strains promote adaptive immune responses (secretory immune globulin a, regulatory t cells, il- ). some probiotics have the capacity to activate receptors in the enteric nervous system, which could be used to promote pain relief in the setting of visceral hyperalgesia. moreover probiotics exert an important action improving the abnormalities of both the colonic flora and the intestinal microflora. they could be effective for treating various pathologies preventing the dysbiosis which characterizes or is associated with these conditions. further future clinical trials, involving large numbers of patients, will be mandatory to achieve definite evidence of the preventive and curative role of probiotics in medical practice. details about correct formulations in terms of amount of bacteria, viability and associated growth factors, will be required in order to standardize the administration schedule and achieve homogeneous, comparable results on selected cohorts of 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intervention on global serum lipidomic profiles in healthy adults interleukin- is involved in the enhancement of human natural killer cell activity by lactobacillus casei shirota oral delivery of lactobacillus casei shirota modifies allergen-induced immune responses in allergic rhinitis short-term effect of chewing gums containing probiotic lactobacillus reuteri on the levels of inflammatory mediators in gingival crevicular fluid interference of lactobacillus plantarum with pseudomonas aeruginosa in vitro and in infected burns: the potential use of probiotics in wound treatment bacteriotherapy with lactobacillus plantarum in burns probiotics in primary prevention of atopic dermatitis effects of nonpathogenic gram-negative bacterium vitreoscilla filiformis lysate on atopic dermatitis: a prospective, randomized, double-blind, placebo-controlled clinical study probiotics in clinical practise: an overview probiotic study group. a differential effect of probiotics in the prevention of eczema and atopy: a double-blind, randomized, placebo-controlled trial probiotics in prevention of ige-associated eczema: a doubleblind, randomized, placebo-controlled trial probiotics and prebiotic galacto-oligosaccharides in the prevention of allergic diseases: a randomized, double-blind, placebo-controlled trial the treatment of pouchitis e is there a role for probiotics? probiotic administration in patients with ileal pouch-anal anastomosis for ulcerative colitis is associated with expansion of mucosal regulatory cells effect of enteral nutrition and synbiotics on bacterial infection rates after pylorus-preserving pancreatoduodenectomy: a randomized, double-blind trial probiotics reduce infectious complications after pancreaticoduodenectomy randomized clinical trial of effect of synbiotics, neomycin and mechanical bowel preparation on intestinal barrier function in patients undergoing colectomy multicenter randomized-controlled clinical trial of probiotics (lactobacillus johnsonii, la ) on early endoscopic recurrence of crohn's disease after lleocaecal resection perioperative synbiotic treatment to prevent postoperative infectious complications in biliary cancer surgery: a randomized controlled trial probiotics improve outcomes after roux-en-y gastric bypass surgery: a prospective randomized trial urogenital infections in women: can probiotics help? postgrad phase i trial of a lactobacillus crispatus vaginal suppository for prevention of recurrent urinary tract infection in women clinical study comparing probiotic lactobacillus gr- and rc- with metronidazole vaginal gel to treat symptomatic bacterial vaginosis improved cure of bacterial vaginosis with single dose of tinidazole ( g), lactobacillus rhamnosus gr- , and lactobacillus reuteri rc- : a randomized, double-blind, placebo-controlled trial effectiveness of lactobacillus-containing vaginal tablets in the treatment of symptomatic bacterial vaginosis human lactobacilli as supplementation of clindamycin to patients with bacterial vaginosis reduce the recurrence rate; a -month, double-blind, randomized, placebocontrolled study nitazoxanide and probiotics for the treatment of recurrent clostridium difficile infection in a peritoneal dialysis patient inhibition of the accumulation of uremic toxins in the blood and their precursors in the feces after oral administration of lebenin, a lactic acid bacteria preparation, to uremic patients undergoing hemodialysis beneficial effects of bifidobacteria in a gastroresistant seamless capsule on hyperhomocysteinemia in hemodialysis patients diverticular disease of the colon: new perspectives in symptom development and treatment balsalazide and/or high-potency probiotic mixture (vsl# ) in maintaining remission after attack of acute mesalazine and/or lactobacillus casei in maintaining long-term remission of symptomatic uncomplicated diverticular disease of the colon world gastroenterology organisation global guideline clinical trial: effect of active lactic acid bacteria on mucosal barrier function in patients with diarrhoeapredominant irritable bowel syndrome effect of a symbiotic preparation on the clinical manifestations of irritable bowel syndrome, constipation-variant. results of an open, uncontrolled multicenter study use of probiotics in childhood gastrointestinal disorders single blind follow-up study on the effectiveness of a symbiotic preparation in irritable bowel syndrome lactobacillus and bifidobacterium in irritable bowel syndrome: symptom responses and relationship to cytokine profiles is bifidobacterium a more effective probiotic therapy than lactobacillus for patients with irritable bowel syndrome? probiotic agents in the treatment of irritable bowel syndrome bacillus coagulans significantly improved abdominal pain and bloating in patients with ibs randomized controlled treatment trial of irritable bowel syndrome with a probiotic e.-coli preparation (dsm ) compared to placebo probiotic effects on intestinal fermentation patterns in patients with irritable bowel syndrome clinical trial on the efficacy of a new symbiotic formulation, flortec, in patients with irritable bowel syndrome: a multicenter, randomized study a mixture of escherichia coli (dsm ) and enterococcus faecalis (dsm ) for treatment of the irritable bowel syndromeea randomized controlled trial with primary care physicians a double blind randomized controlled trial of a probiotic combination in patients with irritable bowel syndrome therapeutic effect of lactobacillus acidophilus-sdc , in patients with irritable bowel syndrome prescript-assistÔ probiotic-prebiotic treatment for irritable bowel syndrome: an open-label, partially controlled, -year extension of a previously published controlled clinical trial effect of a fermented milk containing bifidobacterium animalis dn- on the health-related quality of life and symptoms in irritable bowel syndrome in adults in primary care: a multicentre, randomized, double-blind, controlled trial a randomized doubleblind placebo-controlled trial of lactobacillus gg for abdominal pain disorders in children role of gut microflora and probiotic effects in the irritable bowel syndrome efficacy of an encapsulated probiotic bifidobacterium infantis in women with irritable bowel syndrome world gastroenterology organisation global guidelines synbiotic therapy (bifidobacterium longum/synergy ) initiates resolution of inflammation in patients with active ulcerative colitis: a randomised controlled pilot trial seksik philippe, langella philippe. faecalibacterium prausnitzii is an anti-inflammatory commensal bacterium identified by gut microbiota analysis of crohn disease patients influence of saccharomyces boulardii on the intestinal permeability of patients with crohn's disease in remission high dose probiotic and prebiotic cotherapy for remission induction of active crohn's disease failure of synbiotic to prevent postoperative recurrence of crohn's disease multicenter randomized-controlled clinical trial of probiotics (lactobacillus johnsonii, la ) on early endoscopic recurrence of crohn's disease after ileo-caecal resection patchy distribution of mucosal lesions in ileal crohn's disease is not linked to differences in the dominant mucosa-associated bacteria: a study using fluorescence in situ hybridization and temporal temperature gradient gel electrophoresis chae jung sung song hyun. the effects of probiotics on ppi-triple therapy for helicobacter pylori eradication takahashi shin'ichi. efficacy of clostridium butyricum preparation concomitantly with helicobacter pylori eradication therapy in relation to changes in the intestinal microbiota vito leonardo miniello. inhibition of helicobacter pylori infection in humans by lactobacillus reuteri atcc and effect on eradication therapy: a pilot study unal selahattin. efficacy and safety of saccharomyces boulardii in the -day triple anti-helicobacter pylori therapy: a prospective randomized placebocontrolled double-blind study triple therapy plus different probiotics for helicobacter pylori eradication effects of a fermented milk drink containing lactobacillus casei strain shirota on the human nk-cell activity the influence of lactobacillus rhamnosus lc together with propionibacterium freudenreichii ssp. shermanii js on potentially carcinogenic bacterial activity in human colon consumption of prebiotic inulin enriched with oligofructose in combination with the probiotics lactobacillus rhamnosus and bifidobacterium lactis has minor effects on selected immune parameters in polypectomised and colon cancer patients dietary synbiotics reduce cancer risk factors in polypectomized and colon cancer patients probiotics and infectious diarrhea drug prophylaxis for traveleres' diarrhea. cid use of vsl[sharp] in the treatment of rotavirus diarrhea in children: preliminary results randomized double blinded controlled trial to evaluate the efficacy and safety of bifilac in patients with acute viral diarrhea the probiotic escherichia coli strain nissle (ecn) stops acute diarrhoea in infants and toddlers efficacy of lactobacillus rhamnosus gg in acute watery diarrhoea of indian children: a randomised controlled trial bifidobacterium longum pl , lactobacillus rhamnosus kl a, and lactobacillus plantarum pl in the prevention of antibiotic-associated diarrhea in children: a randomized controlled pilot trial clinical trial: effectiveness of lactobacillus rhamnosus (strains e/n, oxy and pen) in the prevention of antibiotic-associated diarrhoea in children effect of a fermented milk combining lactobacillus acidophilus cl and lactobacillus casei in the prevention of antibiotic-associated diarrhea: a randomized, double-blind, placebo-controlled trial use of probiotic lactobacillus preparation to prevent diarrhoea associated with antibiotics: randomised double blind placebo controlled trial prevention of antibiotic-associated diarrhoea by a fermented probiotic milk drink the effect of a multispecies probiotic on the intestinal microbiota and bowel movements in healthy volunteers taking the antibiotic amoxycillin interference of lactobacillus plantarum strains in the in vitro conjugative transfer of r-plasmids the probiotic approach: an alternative treatment option urology oxalobacter formigenes: a potential tool for the treatment of primary hyperoxaluria type spray bacteriotherapy decreases middle ear fluid in children with secretory otitis media unraveling mechanisms of action of probiotics the authors contributed equally to this work. this review was not supported by grants. the authors certify that there is no conflict of interest with any financial organization regarding the material discussed in the manuscript. the authors hereby certify that all work contained in this review is original work of tommaso iannitti and beniamino palmieri. all the information taken from other articles, including tables and pictures, have been referenced in the "bibliography" section. the authors claim full responsibility for the contents of the article. key: cord- - cx gnum authors: deng, pengbo; hu, chengping; li, yuanyuan; cao, liming; yang, huaping; li, min; an, jian; jiang, juan; gu, qihua title: bronchial fistula: rare complication of treatment with anlotinib date: - - journal: zhongguo fei ai za zhi doi: . /j.issn. - . . . sha: doc_id: cord_uid: cx gnum background and objective: anlotinib is a newly developed small molecule multiple receptor tyrosine kinase (rtk) inhibitor that was approved for the treatment of patients with lung cancer in china. we aim to report cases of rare complication of anlotinib-bronchial fistula (bf) during the treatment of lung cancer patients and summarize the possible causes. methods: we collected three patients who developed bf due to anlotinib treatment, and conducted a search of medline and pubmed for medical literature published between and using the following search terms: "anlotinib, " "lung cancer, " and "fistula." results: our literature search produced two case reports (three patients) which, in addition to our three patients. we collated the patients' clinical characteristics including demographic information, cancer type, imaging features, treatment received, risk factors for anlotinib related bf, and treatment-related outcomes. the six patients shared some common characteristics: advanced age, male, concurrent infection symptoms, diabetes mellitus (dm), advanced squamous cell and small cell lung cancers, centrally located tumors, tumor measuring ≥ cm in longest diameter, and newly formed tumor cavitation after multi-line treatment especially after receiving radiotherapy. fistula types included broncho-pericardial fistula, broncho-pleural fistula, and esophago-tracheobronchial fistula. six patients all died within months. conclusion: although anlotinib is relatively safe, it is still necessary to pay attention to the occurrence of bf, a rare treatment side effect that threatens the quality of life and overall survival of patients. anlotinib, therefore, requires selective use and close observation of high-risk patients. the application of anti-tumor angiogenesis and growth drugs in the treatment of lung cancer is widely recognized. anlotinib is a newly developed small molecule multiple receptor t y rosi ne k i na se (rt k s) i n h ibitor for ora l medication that targets vascular endothelial growth factor receptor (vegfr) / , platelet-derived growth factor receptors (pdgfr) α/β, fibroblast growth factor receptors (fgfr) - , c-kit and ret [ ] , and has inhibitory effects on tumor angiogenesis. it was approved by china food and drug administration (cfda) for the treatment of patients with both non-small cell lung cancer (nsclc) and small cell lung cancer (sclc) and progression after > lines of chemotherapy. in december and june , anlotinib was certified by the us food and drug administration (fda) for the treatment of ovarian cancer and soft tissue sarcoma. although anlotinib has fewer side effects than other small molecule drugs that target vascular function and inhibit tumor angiogenesis, it still has a % incidence of grade or treatment-related adverse events, and a dose reduction or suspension of treatment is usually required [ , ] . the complications of bronchial fistula (bf) are not stated in clinical trials and cfda labeling, however, we have identified in our clinic several cases of patients with postanlotinib treatment-related bf, from which three cases were selected and combined with three cases reported by others, and their patient characteristics collated and analyzed to guide future clinical applications of anlotinib. case : a -year-old chinese male smoker presented to the local hospital with a persistent dry cough for nine months, hoarseness for two months, and shortness of breath for four days. a computed tomography (ct) scan of the chest showed that the left main bronchus was thickened and occluded, and the left hilar was occupied by a tumor ( mm× mm) associated with the left pulmonary artery and invasion of the left atrium ( fig a) . electron microscopy revealed a left bronchial lesion, and its biopsy revealed a squamous cell carcinoma. electron microscopy guided biopsy of the left bronchial lesion provided a histopathological diagnosis of squamous cell lung cancer in july . the patient refused chemotherapy and was instead treated with anlotinib (orally, mg once daily on day to of a -day cycle). after the use of anlotinib for . mon, the patient' s symptoms improved, and a ct scan identified possible cavitation in the left upper lung tumor ( fig b) . however, another . months later, the patient worsened and displayed the following: shortness of breath, ct indicating the upper left lung tumor was larger than the before ( mm× mm), with cavitation, as well as communication with the left main bronchus and pericardial cavity with large amounts of gas buildup, suggesting the formation of a possible bronchopericardial fistula (bpcf) (fig c) . a second bronchoscopy showed a huge fistula at the left main bronchus, a huge cavity was seen with a visible heartbeat on the inner wall ( fig d-fig f ). the patient was treated with anti-infectives, given nutritional supplementation, and gas drained through a catheter inserted into his pericardium for d, after which his ct showed a significant reduction of gas and his pericardium was partially conglutinated (fig d) . the patient, who was in poor condition, was required to return to the local hospital for supportive treatment, and eventually died due to tumor progression months later. case : a -year-old chinese male smoker diagnosed with squamous cell cancer of the right lung [epidermal growth factor receptor (egfr) del, stage ivb] in , with a history of diabetes mellitus (dm) (poorly controlled), who successively received the following: four series of chemotherapy cycles with gemcitabine (gem)+carboplatin (cbp); four months of targeted therapy (icotinib); gy ( gy× fractions) sequential radiation therapy on the lung tumor and mediastinal lymph node metastasis; and two chemotherapy cycles with paclitaxel (ptx); was started on anlotinib (orally, mg once daily on day to of a -day cycle) in for four months. before initiating anlotinib, the patient's ct scan revealed a tumor in the central right upper lung ( mm× mm) with an invasion of the right main bronchus and obstructive pneumonia in the right upper lung (fig a) . the patient's symptoms were alleviated transiently, and his ct revealed huge cavitation in the upper right lung tumor (fig b) . after four months of anlotinib treatment (in october ), the patient worsened and began coughing pyohemosputum ( ml/d), blood sputum and fever, and his ct displayed a right broncho-pleural fistula (bpf) with liquid pneumothorax formation ( fig c) . staphylococcus aureus and stenotrophomonas maltophilia were cultured in the patient's sputum, and actinomyces cariestus was cultured in the pleural drainage f luid. the patient received closed thoracic drainage and multiple anti-bacterial therapies, after which the fever and drainage decreased. however, the patient died two months later due to tumor progression, failure of the fistula to close, and worsened infection. case : a -year-old chinese male smoker complained of dry cough for three months. a ct scan showed an upper left lung tumor ( mm× mm) with left upper lung atelectasis, along with mediastinal lymphadenopathy (short axis= mm), and multiple thin-walled cavitation lesions in the left lower lung considered to be lung cancer metastases ( fig a, fig b) . bronchoscopy showed an endobronchial lesion in the left upper lobe bronchus, with an invasion of the left lower lobe bronchus and the left main stem. the patient was diagnosed in december with small cell lung cancer by endobronchial biopsy and confirmed to have multiple metastases to the pleura, pericardium, liver, and spleen. meanwhile, the patient was also diagnosed with active viral hepatitis b and poorly controlled dm. the patient received anti-tumor treatment with etoposide (vp- ), cbp, plus anlotinib (orally, mg once daily on day to of a d cycle) while receiving blood glucose regulation and anti-hbv treatment. ten days after completing his first course of treatment, the patient suddenly developed left chest pain, increased shortness of breath, cough, and sputum, without fever. due to the emergence of the coronavirus disease (covid- ) epidemic in china, he did not go to the hospital for examination promptly and continued to insist on oral treatment with anlotinib at home. six weeks later, his ct scan depicted smaller left upper lung tumor and mediastinal lymph nodes but also showed left lower lung atelectasis and a worm-like cavity, with an incomplete cavity wall and communication with the pleural cavity that led to the formation of a liquid pneumothorax ( fig c) . closed thoracic drainage was completed and a large amount of purulent fluid and gas were drained, which was an indication www.lungca.org klebsiella pneumoniae was also cultured in the pleural drainage fluid. the patient died . months later due to tumor progression a n d w o r s e n e d infection. we conduc ted a detailed search of the literature (written in engl ish) published be t we en a nd i n m e d l i n e a nd pubmed usi ng the following search criteria: "anlotinib," " lu ng ca ncer," a nd "fistula". the search ret r ieved t wo ca se reports of three lung cancer patients with f i s t u l a s re l at e d to the use of anlotinib. w e r e a d t h e f u l l te x t s, su m ma r i zed a n d a n a l y z e d t h e general information, t u mor-related data a n d c o m b i n e d t reat ment of t hese t h r e e p a t i e n t s , i n addition to data from ou r t h ree pat ients, and tr ied to der ive s o m e m e a n i n g f u l conjectures. t h e p a t i e n t s ' d e m o g r a p h i c information, cancer t y p e , i m a g i n g features, treatment, r i s k f a c t o r s o f anlotinib related bf www.lungca.org and outcome, etc. are shown in tab [ , ] . among the six cases in this review (including our case report), the mean age was . -year-old (ranging from yr to yr), and . % ( / ) of them are over yr. the ratio of men to women was : . smoking and non-smoking patients were equally divided (ratio : ). in our cases, two of the three patients had poorly controlled dm, and three had concurrent symptoms of infection when the bronchial fistula developed, including fever ( / ) and purulent sputum ( / ). five patients ( . %) were diagnosed with squamous cell nsclc and one ( . %) was diagnosed with sclc, all ( . %) of them were central type. all patients ( . %) had reached stage iiib and above at the start of anlotinib treatment, five of whom ( . %) were in a metastatically advanced stage. the tumors on the ct showed just one case had a tumor with a < cm longest diameter, while the others were ≥ cm ( . %). before anlotinib treatment, only one patient had tumor cavitation, however, after anlotinib treatment, three more patients formed new cavities, with cavity formation rate reached . %. the tumor of the majority of the patients ( . %, / ) measured less than cm from the pleura, except for two patients with esophago-tracheobronchial fistula (etbf). the number of patients treated with anlotinib in st , nd and rd line treatment (or greater) was two, one, and three respectively, indicating . % ( / ) patients received ≥ line treatment. . % ( / ) patients had received thoracic radiation therapy (trt). the types of bronchial fistulas the six patients developed were bpf (three patients), etbf (two patients), and one extremely rare bpcf. after the emergence of bf, all patients ( . %) died within six months, with an average survival time of . months (ranging from . mon- mon). anlotinib is a novel orally administered multi-rtk inhibitor that inhibits tumor angiogenesis and growth [ ] , which was demonstrated to have manageable toxicity, longer circulation times and broad-spectrum anti-tumor potential [ ] . anlotinib was approved by cfda as a candidate drug for third-line treatment of advanced nsclc on may , , and for third-line treatment of sclc on september , . the above is based on a randomized double-blind controlled phase iii clinical trial called alter , whose results confirmed that anlotinib as a third-line treatment for nsclc patients can significantly improve their overall sur vival rate with controllable side effects [ ] . a nother randomized phase ii study called alter indicated that anlotinib appeared to provide significant progressionfree survival (pfs) and disease control rate (dcr) benefits for patients with sclc who progressed after two lines of chemotherapy [ , ] . the above clinical studies found that hypertension, elevated thyroid-stimulating hormone, hand-and-foot syndrome, elevated thyroglobulin, elevated total cholesterol, and diarrhea [ , ] were frequently observed during treatment with anlotinib. w hile hypertension, hyponatremia, and hemoptysis are the most common adverse events reported by patients with squamous cell lung cancer [ ] , bf has not been www.lungca.org bf is a rare, life-threatening condition that seriously affects the quality of life of patients with lung cancer. it includes et bf, bpf, broncho-med iast i na l f ist u la (bmf), and the extremely rare bpcf. it can be caused by a tumor invasion but is more common in tumor patients after chemotherapy, radiotherapy, and inter ventional treatments [ , ] . the incidence of malignant etbf has been reported to be . % to . % for lung cancer [ , ] , with a median survival time (mst) from diagnosis of only weeks in the absence of appropriate treatment [ ] . bpf is more common in lung cancer patients after surgery, directly caused by lung cancer invasion is rarely reported which usually combined with infection [ ] . in recent years, the use of anti-tumor vascular targeting drugs has also been found to cause bf. in the earliest clinical studies of bevacizumab, the first anti-angiogenic drug used in clinics, it was found that bevacizumab used in the treatment of lung cancer often caused bf, of which etbf was the most common [ ] , bpf and bmf [ ] were also have been reported. in phase ii clinical trials of bevacizumab in combination with chemotherapy and radiation for the treatment of sclc and nsclc, both groups had a very high incidence of bf ( / , / respectively), and the death of one patient prompted early trial closures [ ] . they consider that the unique role of bevacizumab in inhibiting angiogenesis and consequently delaying wound healing were likely accounts for this rare and serious effect. therefore, as anlotinib has a similar antiangiogenic effect with bevacizumab, when a patient develops a bf during the treatment of anlotinib, we should carefully consider the correlation between anlotinib and the bf formation. generally, we considered that anti-angiogenic drugs can lead to necrotic cavity formation due to ischemia in the center of the tumor. in our review, five patients ( . %) had a tumor longer than cm in diameter. and four of the five patients with large tumors formed a necrotic cavity after receiving treatment with anlotinib, leading to rupture of the cavity wall after continuous use. suggesting that we need to be highly vigilant when using anlotinib to treat large tumors, especially when new cavities appear. however, there were two cases of etbf that did not appear to display new necrotic cavities, possibly because the trachea is adjacent to the esophagus, similar to the central tumor, so only slight necrosis of the tube wall will form a fistula. therefore, patients with etbf may evade typical necrotic cavities after the use of anlotinib. a case of etbf caused by bevacizumab reported and summarized similar cases, which concluded that trt had been suggested to be the most significant risk factor for bevacizumab-related etbf, also including damage to the esophagus and bulky subcarinal lymph node [ ] . also, in our two cases, two had bulky subcarinal lymph node, and one had a history of trt, indicating trt and bulky subcarinal lymph node, suggesting that these two factors is also related to etbf, caused by anlotinib. acquired etbf should be suspected whenever patients with mediastinal metastasis develop suspicious clinical symptoms, for example, drinking waterwww.lungca.org induced choking cough, especially coughing up food just eaten. the diagnosis relies on an esophagram, ct, and videof luoroscopy. fistulas that occur in the bronchi and its distal end may be difficult to plug with a stent implant and an occlude, and the chance of surgical management for advanced lung cancer patients is almost impossible. however, for etbf, a fully covered self-expandable metallic stent has been demonstrated as a superior alternative treatment owing to its high efficiency, which immediately relieved the patient's symptoms after palliative treatment [ ] . two of t he t h ree bpf pat ient s we ev a lu ated had pathogenic bacteria cultured from sputum or drainage fluid, including staphylococcus aureus, actinomycetes and klebsiella pneumoniae, which can all cause necrotizing pneumonia, lung abscess, and empyema, especially in tumor patients with cavities; this may also be one of the important causes of bf. it has been reported that patients with lung cancer have decreased immunit y after chemotherapy and an actinomycetes infection may finally lead to the occurrence of bpf [ ] . therefore, for lung cancer patients who have a lot of purulent sputum after anlotinib treatment, we need to actively identify the pathogens and utilize anti-infective treatments to prevent infections from aggravating tumor necrosis. meanwhile, two of our three patients have poorly controlled dm, which causes decreased immunity, making them prone to co-infection. as we know, central lung cancer easily causes obstructive pneumonia, and anlotinib causes tumor necrosis. in this situation, once the patients with dm develop pulmonary infections, it will be more difficult to control. this may be one of the possible risk factors for the formation of bf and also needs to be paid attention to. . % ( / ) of our bf patients are over yr, and half of them are over yr, which can be correlated to the higher incidence of lung cancer in people over . also, the incidence of bf is significantly higher in males than in females, and all lung cancer types are squamous cell carcinoma and small cell lung cancer, which was more common in men. from the perspective of cancer type and location, squamous cell carcinoma and small cell lung cancer are more likely to be located at the hilum and easily advance to the mediastinum and trachea, causing an invasion of the airway mucosa, necrosis, and bleeding, leading to the defect of the tracheal wall, and fistulas are also easily formed. five of them were diagnosed by bronchoscopy which further confirmed that the lesions affected the trachea. in our review, four of the six patients ( . %) were undergoing treatment with ≥ lines of therapy, and three were treated with more than four lines ( %). multi-line treatment means that the patient has a difficult to control tumor, has an impaired immune system, is in poor general condition, and may have cachexia. these characteristics of patients in advanced tumor stages may be the reason that the tumor is more easily necrotic, less repairable, and more likely to cause secondary infection when treated with anlotinib. two patients also received trt, which is a recognized risk factor that can cause bf, especially etbf and bmf [ ] [ ] [ ] , suggesting that we need to pay attention to the patient's radiotherapy history before initiating anlotinib therapy. bpcf in lung cancer patient is extremely rare, only a few cases have been reported [ ] . in one case, a patient with squamous carcinoma, stage iiia, acquired bpcf after chemotherapy and trt, after recovered from bpcf, he continued received trt and chemotherapy, subsequently treated with bevacizumab and cetuximab. three months later, the patient reappeared bpcf and died of fatal hemoptysis quickly. in this case, the role of bevacizumab in the recurrence of bpcf needs to be paid attention to. in our patient cases, there was a patient with bpcf, who had the following characteristics which may be the risk factors for bpcf development: the tumor was located in the left hilar, close to the mediastinal pleura and pericardium; the patient had poorly controlled dm; although he was using anlotinib as the st line treatment, he was in poor general condition (ps score ) with cachexia; and a necrotic cavity formed in the tumor after treatment with anlotinib. based on the patient's previously discussed characteristics, when lung cancer patients have exacerbated shortness of breath and chest tightness during the use of anlotinib, in addition to considering other common causes, it is necessary to pay attention to the possibility of bpcf. prompt puncture drainage and active anti-infective treatments can promote pericardial adhesion closure, which is impor tant for improving the prognosis of patients. in general, once a patient develops a bf during the use of anlotinib, the survival time will decrease significantly, and there will no longer be an opportunity for further chemotherapy, radiotherapy, and vascular targeted therapy. most patients die in a short time due to the hard-to-heal fistulas, recurrent infections that are difficult to control, and tumor progression. it has been repor ted that an adenocarcinoma lung cancer patient developed a bmf after st line chemotherapy, radiotherapy, nd line chemotherapy plus bevacizumab, then used nivolumab (an immunecheckpoint inhibitor) as follow-up treatment. to heal the bf, the treatment requires sufficient anti-tumor efficacy, low risk of bacterial infection, and low risk of weakening the airway wall integrity. immune checkpoint inhibition is effective for nsclc but rarely causes necrosis, is less toxic, as well as less likely to lead to infections compared to cytotoxic drugs [ ] [ ] [ ] [ ] . nivolumab successfully controlled the bmf and the tumor of this patient and prolonged the survival time of the patient for months [ ] . a lso, if patients have sensitive gene www.lungca.org mutations, targeted therapy should be considered as one of the alternatives. a lthough the data provided by anlotinib in current clinical trials indicate it is relatively safe, it is still necessary to pay attention to the occurrence of adverse reactions in clinical applications, such as bf. the incidence of bronchial fistula caused by anlotinib in lung cancer is extremely rare, but it seriously affects the quality of life and overall survival of patients. therefore, we need to use it selectively and closely observe high-risk patients. it's possible risk factors include: ( ) ≥ years old male, ( ) dm and infection, ( ) central lung cancer, squamous cell carcinoma or sclc, ( ) advanced stage, ( ) long diameter of tumor≥ cm and cavity formation, ( ) multi-line treatment, and ( ) thoracic radiation therapy. a nlotinib inhibits angiogenesis v ia suppressing the activation of vegfr , pdgfrβ and fgfr effect of anlotinib as a third-line or further treatment on overall survival of patients with advanced non-small cell lung cancer: the alter phase randomized clinical trial anlotinib as a third-line therapy in patients with refractory advanced non-small-cell lung cancer: a multicentre, randomised phase ii trial (alter ) esophago-tracheobronchia l f istula fol low ing treatment of anlotinib in advanced squamous cell lung cancer: two case reports bronchopleural fistula in squamous cell lung cancer following anlotinib treatment: a case report preclinical characterization of anlotinib, a highly potent and selective vascular endothelial growth factor receptor- inhibitor safety, pharmacokinetics, and antitumor properties of anlotinib, an oral multi-target tyrosine kinase inhibitor, in patients with advanced refractory solid tumors anlotinib as third-line or further-line treatment inrelapsed sclc: a multicentre, randomized, double-blind phase trial effect of anlotinib in advanced small cell lung cancer patients previously received chemoradiotherapy: a subgroup analysis in alter trial subgroup analysis of histolog y in a lter : a nlotinib hydrochloride as rd line and further line treatment in refractory advanced nsclc patients (pts) malignant esophagorespiratory fistula: management options and survival tracheal-oesophageal fistula in a patient with lung cancer tracheoesophageal fistula tracheoesophageal fistula due to cancer bronchoepidural fistula in a man with actinomycosis complicated non-small cell lung cancer tracheomediastinal fistula: rare complication of treatment with bevacizumab tracheoesophageal fistula formation in patients with lung cancer treated with chemoradiation and bevacizumab spontaneous pneumothorax due to bronchopleural fistula following reirradiation for locoregionally recurrent squamous cell lung cancer tracheo-parenchymal fistula following concurrent chemo-radiation for stage iii nsclc tracheo-esophageal fistula with bevacizumab after mediastinal radiation nivolumab versus docetaxel in advanced nonsquamous non-small-cell lung cancer nivolumab versus docetaxel in advanced squamous-cell non-small-cell lung cancer pembrolizumab versus docetaxel for previously treated, pd-l -positive, advanced non-small-cell lung cancer (keynote- ): a randomised controlled trial atezolizumab versus docetaxel in patients with previously treated non-small-cell lung cancer (oa k): a phase , open-label, multicentre randomised controlled t r ia l . l a ncet bronchial fistula: rare complication of treatment with anlotinib t h i s m a n u s c r i p t w a s s u p p o r t e d b y n a t i o n a l nat u r a l s c ienc e fou nd at ion of c h i n a (to pen g bo deng pb, cao lm and yang hp conceived and designed the study. deng pb, li yy and jiang j collecting the data. deng pb, li m, an j and gu qh analyzed the data. deng pb, li yy, cao lm and hu cp provided critical inputs on design, analysis, and interpretation of the study. all the authors had access to the data. all authors read and approved the final manuscript as submitted. our study has already approved by examination and approval documents for scientific research projects medical ethics committee of xiangya hospital, central south university. key: cord- -tj ye mx authors: nan title: abstract book date: - - journal: ann allergy asthma immunol doi: . /s - ( ) -x sha: doc_id: cord_uid: tj ye mx nan introduction: the effect of anti ige has been described as a function of complexing free ige to reduce mast cell implantation and consequent reduction of mast cell degranulation upon exposure to antigen. theoretically, as total free ige drops below ng/ml, improvement occurs as free and cell bound ige equilibrate and allergic reactions subside. initial observations ( togias a et al. j allergy clin immunol. ; :s )suggested that prick skin tests consistently reached their low point at days with significant reduction in size. laynadier (leynadier f, doudou o, gaouar h, le gros v, bourdeix i, guyomarch-cocco l, trunet p : effect of omalizumab in health care workers with occupational latex allergy.j allergy clin immunol ; : - ) noted some reduction in skin testing in sixty percent of patients treated over a six month period with monoclonal antiige. but clinicians since approval of the drug in have noted that even in the presence of good clinical response to asthma, skin test reactivity is still obvious, and in many cases unchanged. methods: following the suggestions for standard clinical follow up by lanier and marshall ( annals may ) , routine skin prick skin testing was completed after informed consent on patients at onset of anti-ige therapy, and repeated at - months. in all instances were skin tests done and photographed in a standard manner. in a few cases, skin tests were repeated on patients receiving anti ige for as long as five years. results: photographic evidence will be presented. in of patients on current therapy, prick skin testing remained at an almost identical photographic level to the baseline analysis, but there was a correlation between the patients with the lowest serum ige and the likelihood of apparent reduction. there was no correlation to reduction of skin testing and clinical response to anti ige since all patients had experience significant quality of life improvements. conclusion: anti ige has variable effects on reducing prick skin testing, with a greater likely hood associated with low or extremely low initial total ige levels. skin testing is more sensitive for detection of allergen-specific ige than is immunoassay for allergen-specific ige. for some assay methods, the qualitative cutoff of . ku/l is inappropriately high. this study was conducted in order to determine whether a particular assay system can be used to measure lower levels of allergen-specific ige. the pharmacia unicap system was studied. all reagents were purchased from the manufacturer, and the study was approved by a local human assurance committee. to determine background of the calibration curve, the fluorescent unit (fu) response of replicates of assay diluent measured with an anti-ige solid phase was determined. the background responses of arbitrarily selected allergen solid phases (oak, timothy and short ragweed pollen; cat; peanut; yellow jacket venom; penicillin g) were also measured. lower detection limits (lld) were calculated using the mean background measurement + standard deviations (sd). to examine linearity of a low-range calibration curve, : dilutions to extinction were made, starting with the . ku/l calibrator. the mean background of the anti-ige solid phase was . fu, sd . and coefficient of variation (cv) of %; the lld was . this lld corresponded to a level of approximately . ku/l of ige. the lld of the allergen solid phases ranged from . fu (yellow jacket venom) to . fu (short ragweed); this corresponded to about . ku/l ige. the low level dilution curve exhibited parallelism with a curve constructed using a zero (diluent) calibrator as a th point in the assay's reference curve. a low level method is capable of measuring specific ige levels lower than the manufacturer's . ku/l cutoff. this would seem to be particularly important in research applications, and in the analysis of certain highrisk allergens. the clinical significance of very low levels of specific ige in the serum warrants study. allergists/immunologists are often consulted on patients with rashes or recurrent infections. the differential diagnosis can comprise a variety of disorders, some of which are rare syndromes that require early diagnosis and specific management. a mo old wm developed persistent rash and worsening eczema. later, he had recurrent severe skin infections, skin abscesses, recurrent sinusitis, and chronic otitis media that required multiple placement of tympanostomy tubes, yet had a persistent tympanic membrane perforation. recurrent wheezing was noted from - yr of age. he had several episodes of pneumonia since yr of age affecting different lobes. he failed to shed the primary teeth and had history of periodontitis and oral thrush. he developed scoliosis and multiple fractures of the upper extremities and ribs. at yr he had staphylococcal bacteremia and osteomyelitis of the acetabulum. in spite of antibiotics prophylaxis, he continued to have recurrent skin infections and lymphadenitis. laboratory evaluation revealed eosinophilia (up to /mm ), normal levels of igg, iga, igm & igg subclasses, except for decreased igg ( mg/dl). he had protective levels of anti s. pneumoniae and h. influenzae, but low anti-tetanus and anti-diphtheria titers. at yr, total ige level was , iu/ml which supported the diagnosis of hyper ige (hie) syndrome; it decreased to iu/ml by yr. rast was positive to hd mite, cat, dog, egg, milk, and pollens. flow cytomerty, nbt and phagocytic index were normal; ch was low ( mg/dl). dexa scan showed osteopenia. chest x-ray showed bilateral infiltrate, atelectasis and scoliosis of the thoracic spine. during his hospitalization at yr, his skin was fair, lichenified with widespread maculopapular erythematous rash. the palms and fingers showed open cracks and pustules, but no weeping lesions. in addition to coarse facial features, his face was eczematous. conclusion: hie syndrome is an autosomal dominant disorder that mimics atopic dermatitis but has severe course, multiple infections, and several complications. although a markedly elevated total ige level introduction: mannose-binding lectin (mbl) is a serum protein in the lectin complement pathway. it is important in innate immunity, and is thought to be particularly relevant in young children during the development of adaptive immunity. deficiency in mbl has been reported in population-based studies as a risk factor in children for infection and hospitalization. additionally, age-dependent variability of mbl has been previously noted. this study evaluates the prevalence of mbl deficiency in children with established recurrent infection who were referred for evaluation of immunodeficiency. method: we prospectively evaluated mbl status of children referred for recurrent infection. serum was collected from october to september . children with known primary or secondary immunodeficiencies were excluded. mbl analysis was performed by standardized elisa using mbl oligomer assays. we performed chart and laboratory review for comorbid diagnoses, quantitative immunoglobulin levels and subclasses, and complement function with ch and ah . results: two-hundred thirty five children were evaluated. mean age was . years (range . - years). mean mbl was ng/ml (range - ng/ml). thirty-one of children ( . %) were mbl deficient, levels < , and among this group the mean mbl level was . ng/ml (range - ng/ml). mean age in this group was . years (range . - years). of the children with mbl deficiency, ( . %) children had levels < . the m:f ratio of children with abnormal mbl levels was . . linear regression analysis showed no correlation of mbl level with age. comorbid diagnoses were variable, including asthma, allergy, and atopic dermatitis. none of the children had symptoms compatible with connective tissue disease. no child with an abnormal mbl level was found to have significant deficiency of igg, iga, or igm. several children had low igg , which were within normal physiologic range. no other concomitant complement pathway disorders were detected. conclusions: our study did not reveal any correlation between mbl level and age. in children with recurrent infections, mbl deficiency was approximately twice the estimated rate of the general population. contrary to previous studies, no other significant immunologic disorders were identified. therefore, mbl deficiency alone is a risk factor for infection in children. t.b. fausnight * , hershey, pa. introduction: the incidence of perioperative anaphylaxis is estimated to be between in , and in , procedures. approximately % of cases of perioperative anaphylaxis are attributed to neuromuscular agents. very little information is reported in the literature regarding pediatric perioperative anaphylaxis. i describe a pediatric patient with suspected perioperative anaphylaxis to rocuronium. methods: a year-old girl with a history of sacral agenesis and neurogenic bladder was scheduled to have bladder augmentation surgery. the patient was taken to a latex-free operating room. during induction of general anesthesia, she was found to be difficult to ventilate. she also became hypotensive. examination of the patient revealed urticaria on her right arm. she was given epinephrine, diphenhydramine, and dexamethasone. the procedure was aborted. the reaction was believed to be from either rocuronium or propofol. results: because of the high incidence of anaphylaxis to neuromuscular agents, allergy skin testing was performed for rocuronium, vecuronium, and succinylcholine. the patient had negative percutaneous skin tests ( : ) for rocuronium, vecuronium, and succinylcholine. she had a negative intradermal skin test to rocuronium at the : dilution. she had a positive intradermal skin test to rocuronium at the : dilution. she had negative intradermal skin tests to both vecuronium and succinylcholine at the : , : , and : dilutions. she underwent surgery weeks after skin testing. she received a test dose of vecuronium and had no reaction. she received doses of vecuronium and multiple doses of morphine without any adverse reactions. propofol was avoided. the surgery was completed without difficulty conclusions: this case illustrates the usefulness of skin testing for neuromuscular agents in a pediatric patient. introduction: extrapulmonary pneumocystis jiroveci infection is rare in non-hiv infected individuals and, to our knowledge, it has not been reported before in a patient with good's syndrome. we report a case of extrapulmonary pneumocystis in a patient with good's syndrome. case report: a -year-old african american male patient with a history of good's syndrome presented with left flank pain of months duration. the pain was constant and associated with night sweats, fever, and chills. furthermore, the patient also reported a -pound weight loss. on exam, patient was found to have multiple hypopigmented areas over his abdomen and left lower extremity, bitemporal wasting, sunken eyeballs, and oral thrush. the patient was also found to have left costovertebral angle tenderness with a palpable solid fixed mass along the left mid axillary line overlying the splenic area. computedtomography (ct) scan of the chest and abdomen showed a . x . cm soft tissue mass at the left lateral aspect of the t vertebral body and . x . cm soft tissue parasplenic mass. the parasplenic mass involved the inferior anterior aspect of the left th and th ribs (see figure) . the giemsastained biopsy of the parasplenic mass revealed pneumocystis jiroveci and was confirmed using immunohistochemical stain with monoclonal antipnumocystis antibodies. the patient's symptoms of night sweats and loss of appetite improved within hours following initiation of trimethoprim-sulfamethoxazole therapy. a ct of the chest and abdomen, repeated six months post treatment, confirmed the resolution of both the paravertebral and the parasplenic masses. conclusion: to our knowledge, this is the first case of extrapulmonary pneumocystis presenting in a patient with good's syndrome. although it is rare, extrapulmonary pneumocystis should be considered in the differential diagnosis of patients with good's syndrome and chest or abdominal mass. introduction: t cells are regulated by cellular interactions with the environment during development. they play a critical role in the regulation and development of autoimmune diseases. we report inflammatory myositis in a -year-old caucasian female with primary t cell-deficiency since infancy. methods: at nine months of age, our patient developed lymphoid interstitial pneumonitis. immunologic evaluation revealed isolated t-cell deficiency. during the first years of life, she had failure to thrive, recurrent sinusitis, oral candidiasis, fungal skin infections, and pseudomonas pneumonia. at years, autoimmune conditions, characterized by a purpuric rash over the nose; face and exposure area of elbows; knees and fingers; raynaud's phenomenon; and nasal septum perforation, developed. inflammatory markers were persistently elevated and autoantibodies detected. by age , she developed proximal muscle weakness with distal joint contractures. dry gangrene of the fingers from a thrombotic incident occurred. results: serial immunologic evaluation revealed low cd - %, # - (normal - %, # - cell/mm ), low cd - %, # - (normal - %, # - cell/mm ) , decreased lymphocyte transformation to antigens but appropriate to mitogens. igg - (normal - mg/dl); iga - (normal - mg/dl), and igm - , (normal - mg/dl) with appropriate antibody responses to vaccine antigens. bone marrow and thymus biopsies were normal. further evaluation was not consistent with known primary or secondary immunodeficiencies. several skin biopsies revealed nonspecific dermatitis without vasculitis. mri of lower extremities showed abnormal signals involving bilateral muscles of thighs and calves. muscle biopsy revealed inflammatory myositis with plasma cell predominance, inconsistent with dermatomyositis or polymyositis. aldolase - iu/l (< ), crp - mg/dl (< . ), esr - (< ), rf : (< : ) and type ii collagen ab - ei/ml (< ) . ana, anca and ace were within normal range. antibodies for myositis and myositis related-antibodies were negative. diagnosis of nonspecific plasma-cell inflammatory myositis was made. a trial of monthly ivig gm/kg resulted in clinical improvement. conclusion: this novel plasma cell myositis occurring in a child with primary t cell deficiency underscores the role t cells play in the development of autoimmune diseases. introduction the incidence of hypersensitivity reactions (hr) is increased in patients treated with multiple courses of carboplatin. the purposes of this investigation were to evaluate the effectiveness of a -hour, -step desensitization protocol and to characterize the immune mechanism of carboplatin hr. methods we analyzed ten consecutive patients over a two year period with documented hr to carboplatin who required continued treatment with a platinum agent. the patients were treated with carboplatin using a -hour, -step desensitization protocol. skin tests were performed on five patients. results ten patients successfully completed planned courses of desensitizations to carboplatin, of which were without reactions. four patients had symptoms during their first (n= ) and third (n= ) desensitizations but tolerated the re-administration of infusions without further reactions. for subsequent courses, the protocol was modified for two patients who had extracutaneous symptoms during desensitization and was unchanged for the patient who had mild urticaria. these three patients tolerated subsequent courses of desensitizations without reactions. the fourth patient with symptoms during desensitization no longer required carboplatin. of the five patients who were skin tested to carboplatin, four had positive wheal and flare reactions. in one patient, the skin test response to carboplatin became negative after desensitization. conclusions the -hour, -step desensitization protocol is safe and effective for treating patients with carboplatin hr. positive skin tests to carboplatin suggest a mast cell/ige-mediated mechanism. conversion of the positive skin test to a negative response after desensitization supports antigen-specific mast cell desensitization. hypothesis: there is an association between food allergies and acid reflux in atopic adults study design: a retrospective chart review of patients was conducted. people who tested positive and people who tested negative for food allergy were included. the prevalence of gastroesophageal reflux disease (gerd) in the total group and each of the study arms was compared to population prevalence. methods: results of allergen specific ige tests (pharmacia immunocap, nj) run for food allergies were reviewed to help locate charts of atopic subjects, with positive, and with negative food allergy results. we reviewed charts for history of heartburn and acid regurgitation or the diagnosis of gerd, laryngopharyngeal reflux (lpr) or peptic ulcer disease (pud). population prevalence ( . %; ci . - . ) of acid reflux was estimated from a historical comparison that studied adults in a similar geographical location. results: in the food allergy positive group, . % of the subjects ( % ci . - . ) had either a history of heartburn and/or a diagnosis of gerd, lpr or pud. in the food allergy negative group, % ( % ci . - ) had acid related disorders. in the total study group of atopic subjects, the prevalence of heartburn, gerd, lpr or pud was . % ). on chi square analysis, the prevalence of acid reflux disorders was significantly higher in the total study group when compared with population prevalence (p= . ). the prevalence of acid reflux disorders between the food allergy study group and in the population shows no significant difference (p= . ). the prevalence of acid reflux disorders was significantly higher in the food allergy negative group when compared with the prevalence in the population (p= . ). there was no significant difference in the prevalence of acid reflux disorders between the two study groups with and without food allergy (p = . ). conclusions: the prevalence of acid reflux disorders was higher in people with food allergy when compared to the population, but missed statistical significance. patients without food allergy had a significantly higher prevalence of acid reflux disorders compared to the population. atopic individuals have a statistically significant higher prevalence of acid reflux disorders, but there is no statistically significant difference between atopics with and without food allergy. abstract background: analysis of dispensing patterns of injectable epinephrine offers a method to study the characteristics of school children with allergic or anaphylactic reactions. objective: to analyze the demographics of children prescribed injectable epinephrine in massachusetts school districts with diverse racial and ethnic enrollment patterns. methods: school nurses in schools (grades pk- ) enrolling , students recorded the characteristics of students prescribed injectable epinephrine including the number and racial mix of students in each school, student age, grade level, race, sex, and allergic disorder requiring epinephrine. surveyed school districts were two predominately white ( %) suburban districts enrolling students and one urban area with a minority population of % enrolling , students. the use of epinephrine for peanut allergy was analyzed in detail. results: a total of of , ( . %) students in three school systems were dispensed injectable epinephrine. males outnumbered females ( to ). whites outnumbered non-whites to . two thirds (n= ) of children dispensed epinephrine had peanut allergy. the second most common allergy was stinging insect allergy (n= ). the rate of dispensed epinephrine for peanut allergy was lowest in the urban school district ( . %) versus the two suburban districts, . % and . % respectively. whites with peanut allergy outnumbered nonwhites to . males outnumbered females to . the lowest rate of prescribed injectable epinephrine for peanut allergy in all three school districts was found in non-white school children- . %. eighty-nine of ( %) school children with peanut allergy were enrolled in grades pk through . there were twice as many white versus non-white ( to ) school children in the urban system with prescribed injectable epinephrine for peanut allergy. only eight (. %) of hispanic and asian students in the were dispensed injectable epinephrine for peanut allergy. conclusions: this is the first study to suggest that there may be a racial disparity in the prevalence of childhood peanut allergy. one possible explanation for this disparity is that varied feeding practices in minority infants and children may induce a state of tolerance and lead to a lower incidence of peanut allergy. f.i. hsu * , h.j. burstein, m.c. castells, boston, ma. introduction: trastuzumab is a humanized igg kappa monoclonal antibody specific for human epidermal growth factor receptor protein, her , used in the treatment of her /neu positive breast cancer. we present the first report of desensitization to trastuzumab in a patient with an ige-mediated reaction to trastuzumab and documented igg-anti-igg human antibodies. meth-ods: a year old woman with metastatic invasive ductal breast cancer (er/pr positive, her- strongly positive), unresponsive to conventional therapy, presented with an anaphylactic reaction to trastuzumab and was evaluated for rapid desensitization by skin testing and serum specific igg antibodies. the patient had previously received trastuzumab. results: the anaphylactic reaction to trastuzumab consisted of diffuse erythema, urticaria, respiratory distress and laryngeal edema. premedication with steroids, h and h blockade, and slow infusion did not prevent a subsequent reaction. skin prick testing with trastuzumab ( mg/ml) was positive with negative controls, confirming an ige-mediated mechanism. igg anti-human igg antibodies (haha) to trastuzumab were confirmed by elisa. the patient was desensitized to trastuzumab mg/kg with an intravenous protocol that started at . mcg/h, and increased in rate every minutes until a final rate of mg/h, for a total infusion time of to hours. premedication included diphenhydramine, prednisone, famotidine, and montelukast. desensitization was confirmed by negative skin prick and intradermal tests ( mg/ml and mg/ml), with positive histamine control. the patient tolerated a total of weekly doses of trastuzumab mg/kg. intradermal skin testing prior to her th and th courses showed reactivity, indicating resensitization. serum levels of tratuzumab were undetectable at week after desensitization. conclusion: allergic reactions to trastuzumab are rare but can include anaphylaxis. in patients with documented haha and/or ige-mediated reactions to trastuzumab and clinical symptoms of type i/mast cell mediator-related symptoms, desensitization can allow continued administration of this treatment by providing tolerance. the clinical effectiveness of desensitizations in patients with ige and haha antibodies remains to be defined. in contrast to reports in the medical literature, details of the medical aspects were limited. there were attacks on infants bringing the total to reported infant attacks to date. two of the infants suffered long term morbidity and died. like those reported in the medical literature, the majority of adults were in long term care facilities, although were in hospitals. overall, of the individuals stung died within one week of stings. no significant medical consequences of stings were reported in of of the newspaper reports as opposed to of reports in the medical literature. conclusion: our data suggest that increasing numbers of fire ant attacks are occurring in medical facilities, where chronically ill, frequently immobile patients come in contact with foraging ants. unattended infants in private homes in fire ant endemic areas also appear at risk. the factors that determine why individuals are stung and the severity of injury after attacks remain uncertain. the presence of fire ants inside health care facilities and homes is a harbinger for fire ant attacks of disabled or infant occupants. we hypothesize that morbidity is determined by the number of stings, the condition of the patient and the type of treatment administered. purpose: to determine if gender confers a risk for positive penicillin (pcn) skin test. method: rates of positive pcn skin tests, according to gender, were determined in patients with a history of pcn allergy undergoing an allergy pre-operative evaluation from june to june . during this period, , patients were seen in the pre-operative evaluation clinic in which had a history of pcn allergy and comprise our study population. a univariate logistic regression analysis was employed to calculate the odds ratio (or) and the % confidence interval (ci) for gender differences in the rates of positive pcn skin test and a multivariate logistic regression analysis was used to adjust for age and history of multiple drug allergies. p-value of . or less was considered statistically significant. results: of the patients, underwent skin testing for pcn, patients did not, and charts were not available for review. the mean age of the study group was years. sixtyfour ( . %) patients had a positive skin test to pcn. of these, ( %) were females and ( %) were males (or . , % ci . - . , p = . ). of those with a negative/equivocal pcn skin test, ( %) were females versus ( %) males. in a multivariate logistic regression analysis adjusted for age and history of multiple drug allergies, female gender again was more likely to have a positive pcn skin test (or . , % ci . - . p < . ). patients did not undergo pcn skin testing, ( %) were male and ( %) were female. conclusion: this is the first report showing that a greater risk for a positive skin test to pcn exists in association with female gender. age and a history of multiple drug allergies are unlikely to be confounding factors to the observed gender risk. further studies are needed to identify other possible confounding factors and/or mechanisms that can explain this risk. a. fiocchi * , p.a. restani , s. cucchiara , g. lombardi , g. magazzu' , g.l. marseglia , k. pittschieler , s. tripodi , r. troncone , a. vierucci , . milan, italy; . roma, italy; . pescara, italy; . messina, italy; . pavia, italy; . bolzano, italy; . napoli, italy; . firenze, italy. background: cow milk substitutes for children allergic to cow milk proteins (cmp) include soy-based formula and cow s milk hydrolysates. neither can rule out a sensitisation risk. objective: prospective assessment of clinical tolerance to a rice-based hydrolysate formula by children allergic to cow milk proteins (cmp) who consume rice openly. patients and methods: ninety-seven children aged to months with immediate reactions to cow milk confirmed during dbpcfc were assessed for clinical tolerance to cow milk by spt with whole milk, -lactalbumin (ala), -lactoglobulin (blg), -and -casein ( -cas, -cas) (sigma chemical, st. louis, mo). whole milk, ala, blg and cas specific ige determinations were performed using cap test (pharmacia, uppsala, sweden) . similarly, sensitisation to rice and hrf were investigated by spt and cap test. patients sera were investigated by immunoblotting for cmp, rice and hrf (heinz-plada, milan, italy). dbpcfc was carried our with g rhf powder masked in neocate tm (equivalent to ml reconstituted formula). results: spt: all patients were positive to cow s milk and/or cmp fractions (> mm wheal diameter). ige determinations gave positive results with cow milk and/or cmp fractions ( / patients tested), rice ( / ) and with hrf ( / ). immunoblots (n= ) were positive for -cas (n= ), -cas (n= ), ala (n= ), blg (n= ) and bovine serum albumin (n= ). similarly, although patients sera largely recognized rice ( / ), only one weakly reacted with rhf. challenge with rhf was negative in all cases. conclusions: we conclude that, despite their frequent sensitisation to rice, children with cma tolerate both rice and rhf clinically. hydrolyzed rice formulas may thus represent an alternative protein source for children with cma. r.c. cartwright * , w.k. dolen, augusta, ga. introduction: conventional treatment of human seminal fluid allergy includes abstinence, barrier protection, or subcutaneous immunotherapy with fractionated seminal fluid. treatment using local intravaginal desensitization with unfractionated seminal fluid has recently been described, but experience with this desensitization method is still limited and little has been reported as to its long-term results. methods: a -year-old woman with a history of allergic rhinitis and asthma experienced anaphylaxis following her first unprotected intercourse since the birth of her first child. ige-mediated sensitization was demonstrated through the use of specific ige testing (pharmacia cap system) and skin prick testing using undiluted seminal fluid obtained from the patient's husband. after approval from the human assurance committee, the patient underwent rush intravaginal desensitization with steadily increasing concentrations of seminal fluid, beginning with a : , v/v concen-tration. results: her specific ige level to human seminal fluid was . ku/l. skin prick testing was positive with a wheal of mm diameter with pseudopods and a flare of mm diameter. desensitization was successful and the patient tolerated local application of whole semen without significant reaction. following desensitization, the patient reported that she and her husband engaged in unprotected intercourse without local or systemic symptoms. over the last year since the desensitization, she has not experienced further anaphylaxis, but she has developed local symptoms if her exposure to seminal fluid was delayed past days. the longest time period between exposures has been weeks. she became pregnant months ago and has not had any pregnancy complications. conclusions: local intravaginal desensitization was a safe and effective treatment for human seminal fluid allergy in this patient. a delay in seminal fluid exposure greater than days was associated with the return of symptoms emphasizing the need for frequent seminal fluid exposure to maintain desensitization. l. terracciano, t. sarratud, a. fiocchi * , p. restani, s. guerci, milan, italy. background kiwifruit allergy in children has been seldom reported and the reactions observed are usually mild. anaphylaxis has not been described. we document the case of an infant who developed anaphylacic symptoms within minutes of his mother eating two kiwifruits and initiating breastfeeding. case history in his fourth month, the boy was admitted into an emergency department with dysphonia, breathing difficulties, generalised urticaria and angioedema of the lips and face. this episode was treated as an anaphylactic reaction with epinephrine, chlorpheniramine and hydrocortisone sodium succinate administered via a percutaneous catheter and symptomatic control was achieved within minutes. after days a second anaphylactic episode of similar severity occurred under the same circumstances. neither episode required critical care. the boy presented two months later for clinical evaluation in our paediatric allergy unit. skin prick tests (spt) were positive only with egg white and yolk while negative to cow s milk (and protein fractions), beef, chicken, pork, codfish, rice, wheat, soybean, maize, potato, carrot, tomato, bean, pea, celery, peanut, dermatophagoides pteronyssinus and d. farinae, grass and banana. spt with kiwifruit was specifically ordered because exquisite contact was suspected, and induced a positive wheal (> mm diameter). positive specific ige determinations (cap-feia from pharmacia, sweden) with kiwifruit ( . ku/l), cat dander ( . ku/l) and egg white ( . ku/l) were returned but determinations with other inhalant and food allergens were all below the cut-off point of . ku/l and total ige levels were ku/l. strict avoidance of kiwifruit by the breastfeeding mother proved effective and nothing untoward happened in the intervening year. currently aged . years, the boy is free from food-related symptoms. prick-byprick tests with native allergens and spt carried out with commercial extracts of allergens associated in the literature with kiwifruit allergy were all negative. comment there are no reports of immediate reactions to kiwifruit under two years. in this case, severe reactions via breastmilk in an infant monosensitised to kiwifruit indicate that nursing may represent a hidden source of exposure. in older children monosensitisation without prior sensitisation to pollen has been described as the major risk associated with severity of symptoms. m. sikora * , j.w. sleasman, n. tangsinmankong, st. petersburg, fl. introduction: treacher-collins syndrome (tcs) is an autosomal dominant disorder with an abnormality of craniofacial development during early embryogenesis. there is a known relationship between new bone formation and development of lymphocytes and cytokines. the association of tcs and humoral immunodeficiency has not yet been reported. we present a novel case of a year-old caucasian female patient with tcs and common variable immunodeficiency. methods: our patient presented with midface hypoplasia, micrognathia, microtia, conductive hearing loss and cleft palate with a history of recurrent upper and lower respiratory infections. patient had a -year history of chronic sinusitis, recurrent otitis media and pneumoniae which resulted in bronchiectasis. haemophilus influenza and staphylococcus aureus were persistently isolated from bronchial fluids. laboratory work-up for immunodeficiency was initiated. results: immunoglobulin analysis revealed low igg ( - mg/dl); low iga ( - mg/dl); igm ( - mg/dl); igg ( - mg/dl); low igg ( - mg/dl); igg ( - mg/dl); and low igg < . ( - mg/dl). patient had no detectable response to protein-derived vaccines (diphtheria and tetanus) and to polysaccharide-derived vaccines (pneumococcal) at baseline and at - weeks after immunization. t and b lymphocyte enumeration, ch , ah , and mannose-binding lectin were all within normal limits. laboratory findings were consistent with the diagnosis of common variable immunodeficiency. patient began receiving monthly doses of mg/kg/dose of intravenous immunoglobulin resulting in clinical improvement. our patient no longer requires antibiotic therapy for her respiratory infections; pulmonary function has improved and bronchiectasis resolved months after initiation of ivig. conclusion: our finding shows that tcs can be associated with common variable immunodeficiency which suggests a link between skeletal dysplasia and immunodeficiency. a.s. hartel * , j.w. sleasman, n. tangsinmankong, st. petersburg, fl. introduction: streptococcus pneumoniae is the most common cause of invasive bacterial infection in humans. however, incidence of s. pneumoniae infections in healthy adolescents is low ( / , per year). mannose-binding lectin (mbl) is a c-type lectin which plays a central role in the innate immune response by activating the classical complement pathway and acting as an opsonin by binding c q receptors. several studies have demonstrated an association between invasive bacterial infections, including s. pneumoniae and a homozygous mutation of the mbl gene. however, this association has not previously been described in patients with the heterozygous mutation. methods: a -year-old caucasian female presented with a second episode of meningitis over a -year span. streptococcus pneumoniae was isolated from peripheral blood cultures on both occasions. lumbar puncture revealed wbc , ; % bands; % pmns; glucose mg/dl, protein mg/dl; these results consistent with bacterial meningitis. extensive evaluation for predisposing causes revealed benign arnold-chiari type malformation. further immunological evaluation was initiated. results: evaluation revealed igg mg/dl (normal - ); iga ( - ); igm ( - ), and normal igg subclasses. antibody responses to diphtheria and tetanus vaccines were adequate. antibodies response to pneumococcal vaccine given years prior were protective to all common serotype tests (> . mcg/ml). lymphocyte subset analysis was within normal range. howell-jolly bodies were not detected from peripheral blood smear. evaluation for secondary immunodeficiency was negative, including hiv antibody by elisa. complement analysis showed ch u/ml ( - ); ah % ( - %), and markedly low mbl of ng/ml (> ). genetic analysis of her mbl revealed heterozygous mutation in codon and mutations in two promoter regions (homozygous mutation on h/l variants and heterozygous mutation on p/q variants). conclusion: heterozygous mutation of mbl codon when associated with mutation of promoter regions can result in severe impairment of mbl protein production, and may lead to increased susceptibility to invasive bacterial infections and meningitis. rationale: patients with similar symptoms may have allergic, non-allergic, or mixed rhinitis triggers and can differentially respond to distinct medications. we assessed st in our clinic patient population to characterize factors that influence appropriate diagnosis and treatment of rhinitis type. methods: we used a validated commercial questionnaire and chart review of patients seen in an academic allergy clinic, to assess the number of allergic vs. irritant st and demographic and historical factors (including pharmacotherapy) associated with differences in symptoms. results: the population (n= : female, male) consisted of individuals with a mixed rhinitis history. women had higher st scores than men, including: total scores [ . +/- . vs. . +/- . , p= . (unpaired t-test)]: allergen scores ( . +/- . vs. . +/- . , p= . ); and irritant scores ( . +/- . vs. . +/- . , p= . ). further, patients treated with both azelastine (az) and intranasal steroids (ins) had lower st scores than patients treated with either alone (total st: az . +/- . , ins . +/- . , both . +/- . , p= . ; allergen st: az . +/- . , ins . +/- . , both . +/- . , p= . ; irritant st: no significant difference). conclusions: female patients have significantly higher symptom scores; total, allergic and irritant. rhinitis monotherapy (ins or az) is minimally effective in reducing st but is more effective when used in combination. these data demonstrate rhinitis population heterogeneity and address differential responsiveness to similar medications. increased response to combined drug therapy support the heterogeneous pathophysiology of mixed rhinitis features and may relate to a combination of multiple aeroallergen and air pollution exposure in the houston area. introduction: interaction between eye & nose warrants attention with regard to the propagation and treatment of allergic reactions. the role of topical therapy for rhinitis and conjunctivitis is becoming more widely considered and questions of therapeutic route have been raised. purpose: to elucidate the anatomic and pharmacokinetic interactions of conjunctival & nasal mucosa leading to more rational selection of routes of medication administration. methods:our studies have investigated the effect of ocularly instilled allergen inducing signs and symptoms of rhinoconjunctivitis. study compared effects of allergen administered via conjunctival allergen challenge (cac) or nasal allergen challenge (nac) and analyzed tear & nasal secretions for ecp & tryptase. studies have also used the ability of the cac model to induce rhinitis signs & symptoms to evaluate the relative effects of medication routes: ) ocular v. nasal spray v. systemic; ) ocular + nasal spray v. systemic + nasal spray; ) ocular v. placebo. results: the nac/cac study revealed that, following cac (n= ), significant ocular and nasal signs & symptoms were noted; following nac (n= ), only nasal symptoms were clinically significant. nasal symptom scores between cac & nac differed significantly at timepoint, representing lag in allergen & mediator movement from eye to nose. measurable levels of ecp & tryptase were found in tears and nasal secretions for cac, but only in nasal secretions (with exception of subject) for nac. in cac studies: ) ocular therapy exhibited greater efficacy in ocular itching relief (n= ;p< . ) and was not significantly different from nasal or systemic therapy in nasal symptom relief. ) eyedrop+nasal spray combination exhibited significantly greater prevention of overall rhinoconjunctivitis signs and symptoms than nasal+systemic therapy (n= ). ) ocular therapy offered greater protection from nasal signs & symptoms compared to placebo (n= ;p< . ). conclusion: nac and cac results support the unidirectional flow from eye to nose, the ability of cac to yield nasal symptoms, and the efficacy of topical therapy. tearing, due to inflammation of the inferior turbinate would be the only ocular symptom resulting from nasal challenge. these results offer insight to the nature of the connection between ocular and nasal mucosa and the efficacy of varied medication administration routes for management of rhinoconjunctivitis symptoms. introduction: asthma disease management programs frequently target high utilizers because they are responsible for a large amount of asthma costs. once identified, such "frequent fliers" usually are offered interventions including case management. programs using this approach usually demonstrate reductions in utilization. though the interventions may cause this decline, it could also be due to regression to the mean (rtm) which is a tendency for outliers to become more like the mean over time. in this study we measured rtm in a medicaid hmo asthma population to determine whether targeted case management is effective independent of this phenomenon. we hypothesized that directed case management provides additional utilization reduction beyond rtm. methods: a weighted asthma utilization score was determined quarterly for members of an hmo with asthma from to . rtm was measured by determining how many patients were persistent high utilizers quarterly for year after baseline. to determine the effect of utilization-directed case management, the number of frequent fliers at baseline for each quarter also was determined. results: a total of asthma frequent fliers were identified on january , . by september , only of these individuals continued to be frequent fliers. similar decreases in utilization were seen for frequent fliers identified at the beginning of each quarter of . the mean decrease in the number of frequent fliers is shown in the table. this represents a substantial regression to the mean. the total number of high utilizers at baseline decreased by % after implementation of utilization-directed case management in independent of regression to the mean. this also represented a decrease from . % of health plan members with asthma to . % by the start of suggesting that the decline is not a result of diminishing health plan membership. the benefit appears to be the result of early intervention with members before they become frequent fliers. conclusions: utilization-directed case management can reduce overall asthma utilization by preventing members from becoming high utilizers at an early stage. programs that claim to intervene with plan members who already are high utilizers are likely to be taking advantage of regression to the mean. studies indicate a high incidence of asthma(as) among school-aged children. with the prevalence increasing, significant numbers remain unidentified. they experience morbidity, including school absenteeism, which may be preventable, in part, by adherence to national asthma guidelines. we implemented a pilot study to detect as, as control and initiation of appropriate health care among th grade students in a suburban population. the study was coordinated with the middle school staff and the local county health department. the screen parameters included: student questionnaires, peak flows, exercise with peak flow assessment (frast) , and spirometry as indicated. environmental tobacco smoke (ets) was recorded. results: students screened. no as history and negative screen (d). as history and negative screen (e). as history and positive screen (a). no as history with suggestive written screen and negative screen on exercise (b). no as history and positive screen (c). ets in groups a, b, c: %, %, %. ets in groups d, e: %, %. individual student results were mailed home with medical follow-up recommended for a positive screen. parents of the children who failed the questionnaire or exercise screen (groups a, b, c) were phoned at a - wk interval. no student in-group a or b had medical follow-up. ( %) students in group c had medical follow-up. conclusion: this as screen of th grade students identified ( %) as having significant, undetected as. ( %) with known as had uncontrolled as at the time of screen. ( . %) students with strong suspicion of as based on questionnaire had an acceptable exercise screen. only of the children with a screen suggestive of as or uncontrolled as had medical follow-up. ets was increased in the homes of students with a positive screen and remains a serious health issue. school screening for as has merit, but mail and phone follow-up was insufficient to intervene or initiate acceptable as treatment. references . redline s. et. al. development and validation of school-based asthma and allergy screening instruments for parents and students. ann allergy asthma immunol. ; : - . tsanakas.j.n., et al. free running asthma screening test. arch diseases in childhood. ; : - . american college of allergy, asthma, and clinical immunology screening test ages ( - ) acaai.org. introduction. some laboratory evidence suggests that desloratadine is effective in inhibiting of inflammatory mediators, which play an important role not only in allergic but also in virally induced inflammation. the purpose of this study was to assess its efficacy in acute bronchiolitis developed in young children suffering from concomitant atopic dermatitis (ad). meth-ods. participants were young boys and gilrs aged - who suffered from acute bronchiolitis as established by wheezing, rhinitis and fever. all patients also had concomitant ad as established by hanifin and rafka criteria. patients were allocated to receive syrup formulation of desloratadine (erius, schering plough) , mg/day for days (active group n= ) or no desloratadine treatment (control group n= ) using quota allocation system. we calculated physical global symptom score (combination of cough, wheezing, chest retractions, nasal flaring, blocked nose, runny nose, sore throat - - scale) and respiratory distress assessment instrument (rdai) to examine the patient at baseline and on day th after therapy was initiated, day of normalization of body temperature, respiratory rate, heart beat rate, and use of albuterol. results. both group of patients were comparable on age, gender, family history of asthma, time of onset of the acute respiratory illness, extent of medication taken prior to entering the study, global symptom score and rdai index. all children were evenly treated with oxygen, oral theophylline ( mg/kg/day) and adequately rehydrated. on day th global symptom score of patients receiving desloratadine was , ± , vs , ± , in control group (p= . ). on day th it was also significant difference between active and control groups on rdai index ( , ± , vs , ± , ; p= . ) especially for significant drop in wheezing score in active group. day when respiratory/heart rate normalized, temperature returned to normal, use of albuterol did not differ significantly in these groups. conclusions. our preliminary study is the first to show that desloratadine is an effective agent in viral lower respiratory tract infections of young children suffering from ad. it encourages further gcp trials to explore action of desloratadine in infantile bronchiolitis and concomitant ad. h.j. su * , w.t. lin, p.j. tsai, c.y. huang, p.c. wu, tainan, taiwan. increasing prevalence of childhood asthma has been observed across the world, and found to be associated with, partly, indoor pollution, including bioaerosol exposure. meanwhile, adequate ventilation is shown to be effective in diluting most indoor air pollutants, while only limited data are available addressing directly how the ventilation rate is implicated with childhood respiratory symptoms. this study aimed to examine the concentration distribution of selected indoor air pollutants, including bioaerosols, in domestic environment, and further to assess the effects of ventilation rate, characterized by a co trace gas concentration decay method, on concentration variations of the above-mentioned air pollutants. study subjects were chosen from a prior city-wide questionnaire survey based on positive response to inquiry for physician-diagnosed asthmatic status and wheezing symptoms in the past months. environmental assessments, including ventilation and air quality measurements, were conducted twice, in early winter and the other on early summer. respiratory health diary and pefr (peak expiratory flow rate) were recorded for week concurrent with the sampling activity. increasing ventilation rate is statistically associated with decreasing indoor concentrations of co and tvocs. after adjustment for sex, age, and selected housing characteristics, the or between tvocs concentrations and reporting cough of study children is . , and . between co and nasal congestion. the or between indoor bacterial concentration and the morning pefr less % is . in the similar multivariate logistic regression for data collected from winter study. in summer, the only significant relationship is between ventilation rate and the morning pefr less % of study children, or= . , in a multivariate logistic regression. this study has identified less reporting of childhood respiratory symptoms, especially for coughing and the morning pefr less % are associated with increasing ventilation rate, and higher levels of indoor air pollution appear to be present with greater frequency of the above symptoms. this study suggest quantitatively that proper management of ventilation efficiency may be beneficial for the control of childhood respiratory illnesses. *adjusted for: sex, age, environmental tobacco exposure, use of incense and air conditioner **:p< . ns:no statistical significance with whole model test background: moderate-to-severe allergic asthma can have a substantial impact on a patient's asthma-related quality of life (arql). in addition to asthma symptoms, allergic rhinitis, rhinosinusitis and other related comorbidities are often apparent in patients with more severe disease making it difficult to treat. despite guideline-consistent care, many patients still experience variability in asthma control signaling an unmet need within this population. omalizumab (xolair®) has recently demonstrated clinical efficacy and safety in treating asthma. objective: the aim of this paper is to summarize the arql outcomes associated with omalizumab therapy in moderate-to-severe allergic asthma. methods: we performed a systematic review of arql data from the clinical study reports and published clinical trials on omalizumab. arql was measured by the juniper-asthma quality of life questionnaire (aqlq). results: statistically significant results for arql endpoints consistently favored omalizumab over placebo. the magnitude of the changes in arql were consistently aligned with clinical endpoints. moderate to large effect sizes in the omalizumab groups were maintained throughout the -week clinical trial program and during the -week double-blind extension phase. however, the placebo groups also experienced within-group improvements and moderate effect sizes. a meta-analysis indicated a . to . fold increase in large (> . point) improvements in overall aqlq scores in the omalizumab-treated group compared with placebo during the stabilization and steroid-reduction phases of the clinical trials. conclusions: the consistently positive impact of omalizumab on arql outcomes during the clinical trial program provides evidence of its value as an adjunct therapy in patients with moderate-to-severe allergic asthma. significant differences and large effect sizes were observed despite the fact that the control group received active, guideline-consistent treatment producing a substantial placebo effect. improvements were observed in overall, symptom, activity, emotional and environmental dimensions of the aqlq indicating that omalizumab produced benefits in arql in patients with moderate-to-severe allergic asthma. background: omalizumab, a monoclonal anti-ige antibody, significantly improves asthma-related quality of life (arql) for patients with moderatesevere allergic asthma who express symptoms despite moderate-high inhaled corticosteroids (ics) doses. mean scores can mask underlying variability in arql outcomes. this investigation examined variability in outcomes to elucidate the specific impact of omalizumab treatment. methods: aqlq data (n= ) from two randomized, double-blind, placebo-controlled clinical trials were pooled to assess underlying variability in the mean scores and to identify key drivers of arql treatment-effect differences (juniper-asthma quality of life questionnaire (aqlq)) between omalizumab and placebo (active control) patients. results: correlations between aqlq and other clinical outcomes were low to moderate at best (r= . to r= . ). aqlq assessment captures patient benefit that supplements clinical outcome measures. across all component items of the aqlq patients receiving omalizumab improved more than patients receiving placebo (active control) (p< . ). omalizumab patients reported the greatest improvement for reducing waking with symptoms in the morning (symptoms domain: . vs. . ; p< . ), limitations in all activities done (activities domain: . vs. . ; p< . ), the fear of not having medication available (emotions domain: . vs. . ; p< . ), and symptoms from being exposed to dust (environment domain: . vs. . ; p< . ), compared to placebo (active control) patients. conclusion: arql assessment provides complementary and non-overlapping information on clinical benefit that is distinct from other clinical outcome measures. examination of underlying variability in aqlq mean scores and item-level response extend previously published results on omalizumab treatment effect by showing that aggregate arql improvements for omalizumab patients are strongly influenced by symptom and activity improvement. a. brimer , k. malhi, c. adams, c. dinakar, kansas city, mo. introduction: the desire to belong to a group is a very powerful motivator and is exceptionally strong in the adolescent population. asthma is a disease that makes people feel different. this perception may impinge on patient adherence with medication regimens. we hypothesize that belonging to a club where every member has asthma may encourage identification of the adolescent asthmatic with their peers, and mitigate the perception of being different. objectives: ( ) to investigate the factors that make the asthmatic adolescent feel different ( ) to explore the hypothesis that group activities, such as an asthma club, would help adolescent asthmatics feel less different. methods: as part of an ongoing survey, children with asthma between the ages of - years were offered an anonymous questionnaire in the primary care and adolescent clinics at our hospital. the questionnaire included both multiple-choice and open-ended questions designed to explore the feelings of the respondents. the responses were numerically tallied and reported as percentages. results: at the present time, surveys out of a proposed have been completed. one third of the youth with asthma answering the survey had negative feelings regarding their asthma. nearly forty percent of the respondents reported that their diagnosis made them feel different from their healthy peers. forty-five percent responded that they have felt restricted or excluded from school activities, athletics, and clubs due to their asthma. over one-third of them feel uncomfortable taking their inhaler in front of their friends. most respondents ( . %) indicated that they enjoy group activities. the majority of respondents ( . %) rated playing sports as their favorite group activity. conclusion: almost forty percent of asthmatic youth surveyed indicated that having asthma made them feel different and resulted in restriction/exclusion from school activities, athletics, and clubs. an overwhelming majority expressed a preference for participation in group activities, particularly recreational sports. this social preference towards group activities may be incorporated into an intervention, such as an asthma club, to help asthmatic youth adjust to the disease and its treatment regimen. introduction: airway hyperresponsiveness (ahr) is an exaggerated narrowing of the airways in response to stimuli, such as allergens, histamine, and cold air. ahr is a characteristic feature of asthma linked to chronic airway inflammation. phosphodiesterase (pde ) is an enzyme found in key inflammatory cells involved in the pathophysiology of asthma. inhibitors of pde prevent the breakdown of cyclic adenosine monophosphate, a natural modulator of inflammation. roflumilast is an investigational, oral, once-daily pde inhibitor, which has shown anti-inflammatory activity in vitro and in vivo. this study examined the effect of a single dose of roflumilast on changes in ahr following allergen-induced asthmatic reactions in patients with mild asthma. methods: this double-blind, randomized, crossover study consisted of treatment periods separated by a -to -week washout period. a total of patients (forced expiratory volume in one second [fev ] % predicted) who were hyperresponsive to histamine (provocative concentration causing a % drop in fev [pc fev ] mg/ml) were randomized to receive a single dose of oral roflumilast μg or placebo on day of each treatment period followed by an allergen challenge min after medication. histamine provocation was performed before and h after intake of study drug. results: there was no change in fev min after roflumilast administration, suggesting the absence of direct or acute bronchodilation. allergen challenge elicited early and late asthmatic reactions that were attenuated by a single dose of roflumilast μg. the histamine pc fev in patients treated with roflumilast decreased to a lesser extent than in those patients treated with placebo. the change in pc fev from baseline after challenge was . ± . mg/ml (mean ± sd) with placebo and . ± . mg/ml with roflumilast. the magnitude of the change in pc fev was statistically significantly different between the placebo and roflumilast treatment groups (p= . ). thus, roflumilast decreased the development of ahr by approximately . doubling-dilutions. conclusions: a single dose of oral roflumilast μg attenuated allergen-induced ahr. these data provide further evidence that roflumilast may provide anti-inflammatory activity in vivo and may be an effective treatment for patients with asthma. introduction for the past years we have been tracking pediatric asthma admissions and evaluations at the huntington memorial hospital. during the fall and winter months (oct-march) from to , we noted a . x increase in the number of asthma admissions and evaluations compared with the spring and summer (april -september; , patient encoun-annals of allergy, asthma & immunology ters in years). we have analyzed potential causes for this increase. diesel particulate was estimated in - , and a . -fold increase in the fall versus spring was found in burbank, a city adjacent to pasadena. pollutant particles from the combustion of fossil fuels may act as immuno-adjuvants to allergen exposure as has been demonstrated experimentally in mice and in human nasal exposure studies. methods computerized analysis of asthma admissions and evaluations were calculated according to established codes for acute and chronic reactive airways disease. infectious diseases in patients were analyzed by standard asthma questionnaire. also, pollen and mold counts, as well as diesel particulates and meteorological conditions were studied. results similar numbers of viral infections occurred in the fall of and spring of . among the most prevalent pollens and molds are chinese elm pollen (sept -oct) weed pollens (july -dec), and a newly recognized aureobasidium mold (nov -march). pollen grains can fragment and release respirablesized debris that are loaded with allergens (taylor et al (taylor et al , . the conidia of aureobasidium are also of respirable size and were identified by sequence analysis. fine particulate air pollution (pm . ), containing diesel particles, is increased in the fall and winter in southern california. con-clusions the incidence of asthma outbreaks may vary with air pollution levels in the immediate environment. pollen fragments and particles from fossil fuel combustion can deposit in similar regions of the lower airways. rainfall increases in the fall and winter and this coincides with increased molds and aureobasidium. aureobasidium was recently discovered in high concentrations in pasadena, is known to be allergenic and could be a factor in increased asthma. a mixture of pollens and molds and fine combustion particles may be relevant to this increased incidence of asthma in the fall and winter months in pasadena. background we have previously noted that tree and ragweed pollen grains can be airborne for most if not all daily periods during their respective seasons (aaaai, ) , (acaai, ) . because grass levels are lower than those of trees & weeds (aaaai / nab), we chose a longer daily interval to examine (six hours) that we had for trees (one hour) and ragweed (three hours). methods twenty-four hour microscope slide samples were collected using a burkard day air sampler from / / to / / . the slides were examined @ x along a single longitudinal traverse. the presence or absence of grass pollen was noted per six-hour segment (six successive fields). results the presence of airborne grass pollen during the daily segments was sparse the first two weeks of may. it gradually increased during the next days, and then was detected during most of the daily segments through to the end of june. # ammophila arenaria (aa) is a highly resilient grass with habitat in europe, north america, australia, new zealand, south africa and the mediterranean, used predominantly for dune stabilization. patients with atopic diseases including allergic reactions to pollen are transferred to coastal regions in order to minimize pollen exposure. in spite of the presence of aa pollens, patients experience allergy relief at the coast. our study examines the contradiction between the presence of strong grass allergens and the absence of allergic symptoms in atopic patients, and whether allergic cross-reactions among different types of grass pollen include aa pollen. adult patients presenting symptoms of grass pollen allergy underwent prick testing and rast testing to grass pollen mix and extracted aa pollen. subjects showed positive results in prick and rast testing to aa extracts and were subsequently tested via rhinomanometry for reactions to aa using prick test solutions. subjects showed positive reactions to prick tests for aa extract and grass pollen mix, but did not show specific antibodies. all other sera showed elevated specific ige levels, with specific reactions on protein bands of aa. in sera incubated with grass pollen extract, almost all specific bands previously detected with aa were now inhibited. patients with high levels of total and specific ige to aa showed weak bands after inhibition, demonstrating the allergenicity of aa. comparing data from coastal and mainland weather stations in june and july from to , coastal wind speeds average . to . m/s while inland wind speeds average only . to . m/s. high wind speeds likely dilute pollen concentrations. based on findings of an inverse relationship between wind speed and pollen concentration in the dispersion of ragweed pollen, we hypothesize that concentrations of aa pollens may be similarly influenced. no sensitized patient reported allergic symptoms in coastal areas inhabited by aa plants, indicating that under natural conditions, either the plant modifies its pollen allergenicity or that environmental conditions including salt aerosols, wind patterns, topography or light exposure cause the modification. as such patterns are likely to become more dramatic as the effects of global climate change transform the natural environment, these findings may also become relevant for other grass allergy types. asthma is the most common chronic inflammatory disorders of the airways with increased prevalence in the past decade. it is characterized by airway obstruction, airway inflammation and airway hyperresponsiveness (ahr) to non-specific stimuli. in this study, we examined the effect of a novel class of molecule, ocid , in inhibiting antigen-induced early and late allergic response (ear and lar), ahr, and airway eosinophilia in mouse and guinea pig models of asthma. pulmonary functions were measured in conscious unrestrained animals by whole-body plethysmography. animals were sensitized with ovalbumin (ova; mg, intraperitoneally) with mg alum followed by treatment with ocid ( mg/kg, i.p. twice daily for days). after the last dose, animals were challenged with ovalbumin. pulmonary functions were recorded for ear and lar and hrs later for ahr. this was followed by bronchoalveolar lavage, blood and lung tissue collection. treatment with ocid ( mg/kg) significantly attenuated lar in ova-sensitized and challenged mice or guinea pigs with no effect on ear. ahr to methacholine in mice and to histamine in guinea pigs were prevented by treatment with ocid . ocid attenuated the rise in total number of inflammatory cells in the lung and almost ablated the rise in bal eosinophilia in the lung due to antigen sensitization and challenge. effect of ocid on pulmonary functions and airway inflammation in ova-sensitized and challenged mice were comparable to that of dexamethasone in both models of asthma. these data suggest that ocid prevents the underlying pathophysiological changes in allergic airway inflammation and therefore could prove beneficial in the treatment of bronchial asthma. ma; . madison, wi; . portland, or; . milwaukee, wi; . normal, il; . denver, co; . los angeles, ca; . fremont, ca. introduction. daclizumab (zenapax®), a humanized monoclonal antibody directed against the il- receptor chain (cd ), is approved for prevention of renal allograft rejection and is under evaluation for treatment of asthma. daclizumab inhibits activation of human t lymphocytes by blocking il induced proliferation, and by reducing production of th -and th -associated cytokines. we recently reported that daclizumab improved pulmonary function in a phase ii trial of patients with moderate to severe chronic persistent asthma (jaci, , ( ):s ). we now report additional data from this trial on the possible role of daclizumab as an anti-inflammatory agent that affects asthma outcomes. methods. non-smoking asthmatics age - with baseline fev - % predicted despite use of mcg daily inhaled triamcinolone (taa) or equivalent were enrolled in a randomized, multi-center, double-blind, placebo-controlled trial. patients were randomized ( : ) to i.v. daclizumab ( mg/kg followed by mg/kg every weeks) or placebo added to stable dose taa. starting at week , patients underwent % reduction of taa every weeks while continuing study drug to week . results. patients on daclizumab demonstrated a prolonged time to exacerbation requiring systemic steroid rescue compared to placebo patients (p= . ). exacerbation rates were reduced in the daclizumab group compared to the placebo group for the -week steroid-stable and steroid-taper phases ( . % vs. . %, p= . ). patients on daclizumab demonstrated decreased peripheral eosinophil counts from baseline to week (- ± /mm vs. placebo + ± /mm , p= . ). daclizumab-treated patients with elevated baseline serum eosinophil cationic protein (secp) had a significant reduction in secp from baseline to day compared to placebo patients (p< . ). peripheral eosinophils decreased significantly in daclizumab patients who had no asthma exacerbations compared to an increase in daclizumab-treated patients with at least one exacerbation (p= . ). conclusions. daclizumab reduces time to and frequency of exacerbation in treated asthmatics. the mechanisms of this effect remain to be fully elucidated, but initial findings suggest that associated reductions in circulating eosinophil and eosinophil products may play a role in these therapeutic effects. hae is a genetic deficiency causing a decrease in c esterase inhibitor levels. it is a rare condition (approximate prevalence : to : individuals). it is manifest by acute attacks of swelling which can involve the larynx (a potentially life threatening condition), the gi tract (causing a syndrome similar to an acute abdominal catastrophe) or the skin and soft tissue of the patient including the limbs, face and external genitalia. there is no approved therapy for acute attacks in the usa. pathogenesis of this potentially fatal condition is thought due to excessive activity of plasma kallikrein. dx- is a specific and highly active (ki pm) recombinant inhibitor of human plasma kallikrein undergoing evaluation in hae and cardiopulmonary bypass. it is an animal free product. a double blind, randomised ( : drug to placebo) placebo controlled dose ascending study of dx- in acute attacks of hae was run in the usa and the european union. four dose groups of patients were to be included in the study. the doses were , , and mg/m . the primary outcome variables were proportion of patients achieving a significant clinical response within hours of administration of therapy, and safety. secondary endpoints included site response, dose response, and median time to significant response by site and dose group. dx- met its primary endpoint; % of dx- patients had a significant improvement within hours, (placebo response rate %, difference % p= . ). patients receiving dx- responded in a median time of minutes. there was no difference in proportions of cases that responded within hours between the three anatomical sites. time to significant response did not significantly differ between dose groups and anatomical sites. the safety profile was comparable for patients treated with dx- and placebo, in terms of saes and aes. in conclusion, dx- in this double blind study was shown to be statistically superior by % to placebo and to be at least as safe as placebo. the drug is effective at treating any hae site, including the larynx. dx- represents an important advance in the management of hae. ar is among the most common chronic childhood disorders, and is most effectively treated with intranasally inhaled glucocorticosteroids (ics). recent evidence suggests that intranasal ics therapy may suppress hpa axis function and decrease growth velocity. this study reports -year follow-up data on children ( female, african american), aged to years (mean . years) at entry, enrolled in a long-term growth trial of intranasal taa for treatment of ar. primary measures included height velocity, bone mineral density (bmd), serum osteocalcin and salivary cortisol levels. all subjects followed their expected age-appropriate growth velocities. average growth velocities were . and . cm/year for girls and boys aged < years, respectively, and . and . cm/year for girls and boys aged > years, respectively. mean (+ std) bmd was . + . and . + . gm/cm , mean serum osteocalcin levels were . + . and . + . ng/ml, and mean salivary cortisol levels were . + . and . + . nm/l at entry and -year follow-up, respectively. these results demonstrate no significant effect of one year of intranasal treatment with taa on growth velocity or hpa function in children with ar. patients males, females ranging in age from years to years, received (o) in doses ranging from to injections over to weeks. patients were evaluated with symptoms scores, pulmonary function (pft), blood eosinophil count (bec), medication use, and allergy skin test. st were initially performed by prick and if negative, by intradermal (id) ( / w/v) and if further negative by id ( / w/v). skin tests were performed immediately before and minutes after the administration of o. there was no change in pft or bec. however there were significant reductions in symptom scores, including nocturnal asthma (<. ), exercise tolerance (<. ), sense of well being(<. ). in addition, parenthetically there was a reduction in nasal symptoms (<. ). there were also significant declines in medication use especially for albuterol (<. ). st declined in all patients evaluated and dramatically in many. for several individual allergens st went from prick positive to id ( / w/v) negative. moreover st declined in all instances further, minutes after the administration of o except for patients. in addition to asthma one of the patients had allergic bronchopulmonary aspergillosis and another had allergic fungal sinusitis. three of the patients tested positive on prick test to mouse antigen and in each instance this became negative after administration of o with all patients tolerating o without problem. we conclude: ( .) administration of o is associated with an improvement in symptoms and decreased use of medications ( .) in addition there is a prominent decline in st which is more marked minutes after administration of o compared to immediately prior to administration the explanation of this finding is not apparent. ( .) o appears to be safe to administer to patients even if they demonstrate specific ige to mouse antigen by st a.p. baptist * , t.s. tang, j.l. baldwin, ann arbor, mi. introduction: academic medical institutions are under pressure to shorten or eliminate resident elective rotations due to federal work-hour restrictions. it is unknown if this will affect knowledge and referral patterns for resident and faculty physicians. the objective of this study was to examine the factors associated with resident and faculty perceived knowledge and referral patterns towards allergy/immunology (a/i). methods: a questionnaire was sent to primary care physicians at one academic center. it addressed past history of a/i referrals, referral intentions for conditions that may be seen by allergists, and perceived a/i knowledge. independent variables included history of an a/i rotation, gender, department, years in training/practice, and history of referral to an allergist. results: ( %) completed surveys were returned. using logistic regression with forward selection, we found in the resident physician cohort those with advanced years in training or history of an a/i rotation were more likely to have increased past history of referral to an allergist (or = . , or = . ), increased referral intention for chronic sinusitis to an allergist (or = . , or = . ), and increased perceived a/i knowledge (or = . . for the faculty physician cohort, those with a history of an a/i rotation were more likely to have an increased perceived knowledge about a/i (or = . - . ). in addition, pediatric faculty physicians were more likely to refer asthma (or = . ) and chronic eczema (or = . ) to an allergist than faculty from other departments. finally, faculty physicians with a past history of referral to an allergist were more likely to have refer asthma (or = . ) and allergic rhinitis (or = . ) to an allergist. conclusion: the factors associated with resident and faculty physician perceived knowledge, referral history, and referral intentions towards a/i differ. for residents, senior training level and a history of an a/i rotation appear most important. for faculty, history of an a/i rotation, pediatric department, and past history of referral to an allergist appear most important. given that a history of an a/i rotation may increase perceived knowledge and referral patterns towards a/i, eliminating a/i rotations in medical institutions may have important consequences for patients and the field of a/i. because recent anecdotal reports suggest that hbv may be an effective treatment for patients with multiple sclerosis (ms), there has been a movement of patients to zealous lay practitioners to receive multiple and repeated bee stings. since this practice has real risk of possible fatal allergic reactions as well as emotional and economic costs, properly conducted studies of safety and efficacy are needed. the purpose of the present phase i pilot study was to evaluate the safety of hbv extract in patients with pfms. a total of evaluable bee venom non-allergic patients with pfms ( - years) were enrolled and were randomly divided into groups, each receiving an increasing allergen dose immunization schedule for one year. hyperreactivity to hbv was evaluated by questionnaire, px and hematologic, metabolic and immunologic tests including skin tests. any possible beneficial responses to therapy were evaluated by questionnaire, functional neurologic tests (fnt) and changes in measurement of somatosensory-evoked potentials (seps) prior to and at the completion of the study. no serious adverse allergic reactions were observed in any of the subjects even at the highest doses of bee venom therapy. although of subjects had worsening of neurologic symptoms during the course of bee venom therapy, requiring termination, this response could not be ascribed to side effects of the hbv or to a spontaneous worsening of the neurologic disease independent of treatment since there was no correlation of these events with the bee venom injections. of the remaining , felt that the therapy was beneficial.there were no changes either in fnt or seps measured during the study. the present report represents the first controlled study evaluating the safety of hbv as a possible adjunctive treatment for multiple sclerosis. while this preliminary safety study suggests that administration of repeated injections of hbv in a step-up dosage regimen in appropriately selected non-hbv allergic patients with ms had no serious adverse allergic reactions, because of the small number of subjects studied, it does not permit conclusions regarding efficacy and therefore provides little evidence to support the use of hbv in the treatment of ms. much larger carefully conducted multi-center studies would be required to establish efficacy. i. finegold * , new york, ny. rush immunotherapy (rit) has benefits for inducing immunologic desensitization in shorter periods of time than conventional immunotherapy. however, there is an increased risk of systemic reactions utilizing accelerated schedules. in the past radiocontrast media reactions have been significantly reduced using a standardized protocol. a modification of this protocol was used prior to rit. the oral premedication consisted of mgm prednisone hours, hours and hour prior to rit, fexofenadine mgm at hours and again hour prior to the procedure, and ranitidine mgm, hours prior to rit. patients tolerated the premedications well. a signed consent was obtained prior to rit. patients were desensitized in an office setting with appropriate therapy for anaphylaxis available without an indwelling intravenous line. injections generally began with / dilution of the anticipated maintenance solu-tions and were doubled every - minutes for about - hours and then the patients were observed for hour or more prior to discharge. in this manner patients were desensitized in - half day sessions. the patient was injected again in week, weeks and then weeks. doses were increased if they were not at a full maintenance dose. if reactions occurred this process was appropriately decreased. utilizing this technique patients were treated. the average age was . years old ( - years of age) % were males. % of patients had allergic rhinitis, % asthma, % insect allergy. patients with complicated medical illnesses were excluded. nine patients had systemic reactions requiring an injection of epinephrine. among the symptoms experienced were wheezing, nasal congestion and flushing. no patient required a second injection of epinephrine, intravenous fluids, or hospitalization. the patient reaction rate was % of patients treated or in injections or % of all injections given during the rush protocol. these results are typical of the increased rate of reactions to rit. however, these systemics were mostly very mild and responded to therapy and in only one case was there a delayed hour reaction. thus premedication while not preventing systemic reactions seemed to modify them to make rit in an office setting a practical and effective therapy. we have previously shown that oligonucleotides consisting a novel '- 'linked structure and synthetic immunostimulatory motif cpr (r is a synthetic purine moiety), referred to as second-generation immunomodulatory oligonucleotides (imos), induce potent th immune responses and prevent ovainduced allergic asthma in mouse models. in the present study, we examined local and systemic immune responses of imos following intranasal (i.n.) administration to naive mice. these studies showed that imos produce higher levels of serum and local il- compared with il- . we next examined the ability of s.c. and i.n. administrated imos to reverse ova-induced th immune responses in a murine model of asthma. treatment of ova-sensitized and challenged mice with imos by either route of administration suppressed il- and il- levels with an increase in ifn-gamma secretion in spleen cell cultures and lung homogenates. imos decreased levels of serum ige and igg and induced higher levels of total and ova-specific igg a titers in serum and balf. while both routes of imo delivery showed similar efficacy on serum and balf immunoglobulin levels, s.c. delivery resulted in stronger systemic effects on the spleen cell cytokine production and the i.n. route of administration produced stronger local effects on the lung cytokines. imos also decreased eosinophils in balf and suppressed inflammatory cell infiltration and goblet cell hyperplasia in lungs. these effects in lung were superior with i.n. administration of imo than did with s.c. administration. further studies to understand the effect of low multiple doses against a single higher dose of i.n. administered imos in naive mice suggest that low multiple doses induce strong th responses locally while the single higher dose produces higher systemic responses. these findings suggest that second-generation imos containing cpr dinucleotides potently reverse ova-induced th immune responses with strong th type cytokine induction in ova-sensitized and challenged mice and i.n. delivery is superior to s.c. delivery in reversing ovainduced airway inflammation and mucosal secretion. showed ait was medically inappropriate, lacked documentation of necessity for initiation or continuation and/or had strong contraindications in / ( %) of the reviewed records. method: we audited a convenience sample of our own records for documentation of necessity for (continuing) ait, using a checklist based on the oig report which included the following criteria: an appropriate diagnosis; specific justification; exclusion of strong contraindications; signed, informed consent; a written physician order, and at least annual re-evaluation for continuing ait. results: the first charts in our alphabetized file of total ait charts were reviewed. the patients ( m, f) ranged in age from - yr (mean, yr). the mean duration of ait was . yr (range, . - yr). indications for ait included allergic rhinitis alone ( %) or with asthma ( %) or chronic sinusitis ( %), asthma alone ( %) and venom anaphylaxis ( %). all had initial documentation of necessity. seven charts ( %) had no written order to initiate ait. nine ( %) lacked a signed consent form. no strong contraindication was found. (peak flow documentation showed the asthma cases were well-controlled. three episodes of ait-induced anaphylaxis requiring epinephrine had occurred, but ait was subsequently resumed and well-tolerated.) seventeen ( %) charts had no documentation of re-evaluation during the preceding - months, including with no documented re-evaluation during the previous months or more, of ait. discontinuation of ait was "considered" for patients after . , , and yr of ait, respectively, but all were still receiving maintenance doses. the estimated time for completing this review was - min per chart. inter-pretation: an internal chart review for adherence to ait practice parameters using a checklist such as ours can quickly and easily assess documentation for medicare reimbursement and patient safety. objective(s): immunotherapy is an accepted mode of treatment for children suffering from allergic rhinitis and allergic asthma. this study demonstrates that rapid allergen vaccination (rav) can be as safe as conventional allergen vaccination (cav) in children. rav may also improve patient adherence. study design: pediatric patients, - years of age, diagnosed with allergic rhinitis and/or mild to severe asthma underwent rav over a / hour period in an office-based setting. all patients were premedicated with prednisone and h antagonists for days prior to the procedure. patients were monitored for reactions during the procedure and continued on a cav schedule. adherence was reviewed subsequently. results: a total of pediatric patients underwent rav utilizing a / hour protocol. of the patients, of them were male ( . %) and of them were female ( . %). ( . %) of the patients had allergic rhinitis, ( . %) had asthma, and ( . %) had chronic sinusitis. during the procedure, patients ( . %) experienced systemic reaction, and none experienced true anaphylaxis. seven of the eight patients who suffered a systemic reaction were patients with asthma on inhaled corticosteroids, three of the eight patients were male ( . %) and five of the eight were female ( . %). every systemic reaction occurred within minutes of the injection. treatment usually included one or a combination of the following: nebulized breathing treatment with albuterol, two sprays in each nostril of azelastine, and diphenydramine taken orally or intramuscularly. every patient that was treated was discharged within two hours, and no one required treatment with subcutaneous epinephrine, treatment for recurrent symptoms or hospitalization. all of the patients continued with a conventional allergen immunotherapy regimen following the rapid protocol to reach their maintenance dose. typically, months of build-up period was saved. patients reached efficacious dosages almost immediately. adherence rates were . %, . %, and . % at , , and months respectively. conclusions: effective doses of allergen vaccine can be safely reached using a / hour protocol annals of allergy, asthma & immunology for children. advantages of rav over cav include improved adherence with almost immediate clinical efficacy, and decreased costs. introduction: studies involving allergen immunotherapy (ait) have furthered our understanding of cat allergen, proteases, and dust mite allergen. the impact of these data has not been assessed. objective: to evaluate ait prescribing trends over years ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) focusing on new prescriptions before and after published data regarding specific prescribing recommendations. methods: a retrospective review of , ait prescriptions from a centralized allergy and extract laboratory database was performed with respect to published literature on findings and recommendations regarding the ubiquitous nature of cat allergen, effective dosing of cat antigen, combining protease containing extracts with those susceptible to degradation, dust mite antigen dosing, and the use of house dust versus dust mite antigen. results: ) in , cat allergen was included in % of new allergy immunotherapy prescriptions reviewed; in , it was included in % of new prescriptions, a statistically significant increase (p< . ). ) over the past years, the mean quantity of cat antigen included in new prescriptions has been unchanged at ml/prescription. only % of new prescriptions were written at the manufacturer recommended maintenance dose of ml, significantly less than those written below this level (p < . ). ) there was no significant change in the percentage of extracts combining antigens with proteases with antigens susceptible to degradation. in , % of prescriptions containing alternaria and/or cockroach antigen were mixed with one or more antigens susceptible to degradation; in , % of these extracts were still being combined. ) the mean volume of dust mite mix contained in these prescriptions was between - . ml/ ml. ) prescriptions containing dust mite rose from % in to % in . the use of house dust was unchanged over the same period at . % of prescriptions. conclusions: although the percentage of cat containing extracts has increased significantly, dosing of cat allergen has remained unchanged despite published literature recommending higher volumes. protease-containing allergen prescribing patterns have not significantly changed from [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] young stage of life is a crucial period for aeroallergen sensitization, considering the immaturity of the neonatal immune system which may lead to t-cell anergy or a deviation towards th -type response in mice. the aim of this work was to evaluate the influence of oligodeoxynucleotides containing cpg motif (cpg-odn) on ovalbumin (ova) and blomia tropicalis (bt) immunization in early life compared to adult stage. three days old a/sn mice were immunized with ova in al(oh) and boosted on th and th day after immunization (dai) and bled on th dai. groups of mice received mg of cpg-odn or control-odn associated with ova on immunization and boost. some animals from the three groups (ova, ova+cpg, ova+co) were killed at days old and the spleen was collected and prepared to culture. eight to weeks old female a/sn mice were immunized with ova in al(oh) , boosted on th dai and bled on th dai. groups of mice received mg of cpg-odn or control-odn associated with ova on immunization. animals from the three groups were challenged months after immunization and bled days later. similar protocols were performed using blomia tropicalis (bt) extract in the place of ova. neonate and adult co-administration of cpg-odn with ova or bt were able to significantly decrease specific ige antibody levels and increase igg a production. moreover, cpg-odn decreased specific igg levels in the bt immunization. the co-administration of control-odn in neonates decreased anti-ova igg production. after ova-challenge months later of adult immunization, a similar response was detected in the group that received cpg-odn associated with ova, which showed a decreased anti-ova ige and igg and enhanced igg a levels. analysis of cell division of neonate lymphocytes by flow cytometry showed a decreased proliferation in ova+cpg mice group under ova stimulation. this effect was seen either in b cells and t cells. the results showed that immunization with both allergens, ova and bt, associated with cpg-odn decreased the type i hypersensitivity response. the pattern of antibody production suggests th -type response induced by cpg-odn, and the establishment of memory th response. this findings may imply that the use of cpg-odn in early life seems to be beneficial as an strategy to modulate or to prevent the development of allergic diseases. n. horne * , a. capetandes, m. frieri, east meadow, ny. introduction: it has been shown that dust mite allergens can affect the functioning of airway epithelial cells (winton et. al. br j pharm : , . previous experiments showed ca aggregate in the presence of dermatophagoides pteronyssinus (dp) (capetandes et. al. am j clin path, : , ) . it is hypothesized that epithelial damage is associated with airway remodeling characterized by fibroblast dysregulation. to evaluate the response of fibroblasts to damaged airway epithelial cells, the bioactivity of serum-free conditioned media from dp-treated ca cells (dpcm) was assayed with nhlf. methods: all experiments used insulin-transferrin-selenium supplemented dmem (its). dpcm (generated with ca treated with au/ml dp; alk-abello) was added to % confluent nhlf for hours at oc and % co . its from cultured ca without dp (its cm) was added to % confluent nhlf (control). cell morphology and density were evaluated by microscopy and mtt assay, respectively. data were analyzed by anova followed by student-neuman-keuls (snk) at p< . with power analysis. results: % confluent nhlf treated with dpcm showed decreased cell density (figure ) , and increased aggregation relative to its cm or its alone. nhlf in its alone or with direct addition of au/ml dp to its (dp its) showed no or weak aggregation. aggregated nhlf showed % viability and grew to confluence when subcultured to serum-supplemented media. conclusion: nhlf aggregation was greater, and cell density was lower with dpcm than with its, its cm, and dp its. this suggests that dp-treated ca cells release an unidentified factor or factors that contribute to nhlf aggregation and possible apoptosis. identification of these factors would increase the understanding of the fibroblast response to epithelial cell exposure to dp which may be involved in airway remodeling, a feature of chronic severe asthma. j.t. zimmermann * , y.c. huang, m. frieri, east meadow, ny. introduction: budesonide has been demonstrated to inhibit il- , tgf and gm-csf in ragweed and dust-mite (dm) stimulated human alveolar epithelial cells (j allergy clin immunol : a, ; ann allergy asthma immunology : p , ) . rantes production and expression in dm and il- -stimulated a cells has recently been shown to be inhibited by budesonide (allergy asthma proc, in press ). histamine is known to influence immune response by regulating cytokine synthesis (allergy : - ) . in this study we examined the effect of budesonide in the presence of histamine on il- production and expression by a cells. methods: a pulmonary epithelial cells were cultured in dmem for hours in % co in the presence of : of , au/ml dm, - m histamine and - m budesonide. il- production was measured by a sensitive elisa and il- mrna was measured by qualitative rt-pcr using standardized primers for il- with a gapdh control. results: a cells were stimulated by dm ( - pg/ml) (p< . ). budesonide alone decreased il- levels to pg/ml (p< . ), and in combination with histamine further decreased il- levels to pg/ml (p< . ). relative intensity of il- mrna expression was reduced -fold in dm-stimulated cells and -fold in control cells by budesonide. conclusion: budesonide in combination with histamine showed greater inhibition of il- production by a cells than budesonide alone possibly by increasing cell membrane permeability. c.r. oliveira * , a.e. fusaro, j.r. victor, e.a. futata, c.a. brito, a.j. duarte, m.n. sato, são paulo, brazil. antigen-driven bystander suppression induced by oral tolerance could be an interesting approach in the allergy field, considering the high incidence of new allergens sensitization in atopic individuals. to address the influence of non-related allergen exposure on the type i hypersensitivity response to the mite blomia tropicalis (bt) or ovalbumin (ova) in mice and to verify oral tolerance effect in the bt/ova co-immunization model. groups of mice were immunized with bt extract and two weeks later submitted to ova-immunization, or first immunized with ova or co-injected with bt and ova. ova feeding was performed five days prior co-immunization. ige abs were estimated by means of passive cutaneous anaphylaxis reaction and specific ab and cytokines secretion by elisa. mice sensitized with bt and then exposed to ova developed an enhanced ige response to itself and to ova, but such response has not been observed when ova-immunization was prior to btimmunization. co-injection of bt and ova led to a dominant ige response toward ova over bt and vice-versa for the igg response. ova feeding prior co-immunization decreased ige, igg and igg a ab levels against ova in parallel to a bystander suppression, which avoided the outcome of bt-sensitization. these mice showed increased ifn-?secretion levels induced by antigen-specific stimulus. furthermore, effectiveness of oral tolerance was also related with ova amounts employed in the co-immunization since ova feeding prior co-immunization with low amounts of ova led to inhibition of ige ab response to both allergens, whereas inhibition of specific and non-related antigen igg ab response was broken. the results evidenced that, depending on allergenic potential, new allergen exposure may exert an adjuvant effect on the primary sensitized allergen. the bystander effect to non-related allergen by oral tolerance should be an interesting mechanism to control new aller- rationale. cd + cd + regulatory t cells from patients with atopic asthma undergo apoptosis when stimulated by specific allergen. antihistamines are used to control allergic inflammatory diseases, but their influence on treg cells is currently unknown. the present study investigates the influence of desloratadine (d) on apoptosis of cd + cd + regulatory t cells in atopic patients having dust mite induced allergic disease, including allergic asthma. methods. patients (n= ) with positive skin prick tests to house dust mite allergens and a clinical history of allergic upper and/or lower respiratory symptoms were treated with d mg (schering-plough, usa) once daily for days. no patients used systemic corticosteroids, while theophylline and other medications were stopped at least hours before blood collection. blood was sampled before and after treatment with d. the control group was comprised of individuals without allergic respiratory symptoms and with negative skin prick-tests. peripheral blood mononuclear cells (pbmc) were isolated over a ficoll density gradient and stimulated by specific allergen (dermatophagoides farinae) and in a control series by phorbol myristate acetate (pma). pbmc were labeled with anti-cd , cd , cd , and bcl- monoclonal antibodies. the annex-inv-propidium iodide (anv-pi) test was done. lymphocyte subpopulations and apoptosis were analyzed by flow cytometry. results. after treatment with d, atopic patients had no significant differences in the number of cd + cd + cells. during co-culturing of pbmc from patients treated with d with specific allergen a significant increase in cd + cd + cells was observed. simultaneously, treatment with d led to a significant increase in expression of the antiapoptotic protein bcl- in cd + cells. this data paralleled the decrease of cd expression on cd + cells. there was also a decrease in treg cells in the late stages of apoptosis (anv + pi + cells) in d treated patients. conclusions. the antihistamine preparation desloratadine prevented allergen-specific apoptosis of cd + cd + t regulatory cells in patients with atopic asthma. the type histamine receptor may be involved in the regulation of apoptosis and/or survival of cd + cd + t cells. a.g. palma-carlos * , m.l. palma-carlos, lisboa, portugal. introduction: solar urticaria porphyrin corresponds to sun sensitivity to a a wavelengths and is due to disturbances of posphorin metabolism. photosensitivity can cause urticaria, erythema, polymorphic solar eruption and in more severe cases vesicles and bullae. photosensitivity was confirmed by light test. methods: protoporhyrin in rbc, uro and coproporphyrins in urines, copro and protoporhyrins in faeces and porphyrin precursors have been studied un all the cases of solar urticaria seen in the last few years. results: in patients, female, males, a diagnosis of porphyria has been confirmed by laboratory methods. clinically patients presented solar urticaria and solar erythema or polymorphic solar eruption. patients, female, males ( - ) presented also neuro visceral symptoms: abdominal pains ( ) vomiting ( ) asthenia ( ) constipation ( ) muscle pains and paresia ( ) depression ( ) anesthesic reactions ( ). in cases the symptoms were associated with anticonceptional drugs. the conjunction of clinical history with laboratory data has allowed to confirm the diagnosis of cases of protoporphyria erytheropoietica, one triggered by anticonceptionals, cases of coporporhyria hereditaria and cases of porphyria variegata. this group comprises one case of erythropoietic protoporphyria induced by estrogens not previously reported. conclusions: research of porphyrins must be done in all the patients with solar urticaria and erythema. the incidence of sun sensitivity in mixed hepatic porphyriaalso presenting neuro-visceral symptoms which can be drug dependent suggests that porphyria study must be mandatory in suspected cases. a.r. narayan * , j. kaplan , v. sirvan , a. chandrasekaran , c. goodwin , l. goodwin , l. guida , m. frieri , . east meadow, ny; . manhasset, ny; . bayshore, ny. rationale: our division has reported that nitric oxide (no) from tracheal epithelium can mediate induction of il- (american journal of respiratory critical care medicine : a, ) . increased levels of il- , ltb- , and no in mononuclear cells (mnc) from cystic fibrosis (cf) patients were noted.(pediatric asthma allergy immunology : - ) . no in mnc from cf was increased by stimulation with aspergillus fumigatus (asp) and rhdnase (j. clin allergy immunol : p ). tnf-is produced from bronchial epithelial cells (bec) in the presence of mnc of normal controls (nc). rantes, a chemokine that facilitates leukocyte migration, is associated with airway inflammation in cf, and asp sensitization in cf patients could amplify pro-inflammatory cytokines such as il- , tnf-, and rantes. methods: we studied the mrna and protein expression of tnf-, il- and rantes in a year-old cf patient and a nc. x mncs from the patient and nc were stimulated with μg/ml of asp with bec at x and μg/ml rhdnase. mrna expression was studied by real time pcr (taqman chemistry abi prism ) and protein levels by elisa. results: tnf-production in supernatants of mnc with bec from nc increased from pg/ml to pg/ml with rhdnase. whereas in cf patients the tnf-mrna expression was greatly enhanced over nc but declined in the presence of rhdnase (fold difference: . - . ). there was no difference in expression levels of nc (fold difference: . - . ) with rhdnase treatment. il- expression in mnc with bec of patients increased . fold compared to nc ( . fold). rhd-nase decreased asp stimulated levels to . fold in patients compared to nc ( . fold). mnc and bec rantes production in patients increased from to pg/ml and decreased to pg/ml with rhdnase, but increased from pg/ml to pg/ml in nc. in contrast, rantes mrna expression in all groups was higher in nc but decreased with rhdnase in both cf and nc ( - fold vs. - fold). conclusion: rhdnase can increase no and decrease pro-inflammatory tnf-and rantes in cf patients stimulated with asp. rhdnase could lead to augmented bactericidal activity and epithelial defense by enhancing no production and decreasing the expression and production of tnf-, il- and rantes. this is a case report of two steroid dependent atopic dermatitis patients who both responded to treatment with omalizumab. patient a is a year-old white male who presented with a history of severe atopic dermatitis for years along with concomitant mild persistent asthma and allergic rhinitis. he had previously received monthly triamcinolone injections, methotrexate and doxycycline with limited response. on presentation he had mild improvement on a regimen of alternate day prednisone mg, fexofenadine mg bid, and zafirlukast mg bid. however, attempts at weaning prednisone were unsuccessful. omalizumab was initiated at a dosage of mg every four weeks. the patient remains prednisone dependent yet free from atopic dermatitis. patient a's diagnostic work up determined a total ige of . ku/l. the patient's specific ige tests were positive for grass mix, weed mix, maple, white pine, peanut, strawberry, gluten, soybean, wheat, oat, and dog dander. specific ige tests were negative for cat dander, egg white, milk, goose feathers, chicken feathers, mold mix, dust mix, and fish mix. patient b is a year-old white male who presented with a history of severe full body atopic dermatitis along with mild persistent asthma and allergic rhinitis. he also was receiving triamcinolone injections with limited success. he responded to alternate day prednisone mg, desloratidine mg bid, and zileuton mg bid. attempts at weaning prednisone failed until initiation of omalizumab mg every two weeks. his atopic dermatitis is now under control with once daily desloratidine and omalizumab every two weeks. he was successfully weaned off of corticosteroid medication and has begun an immunotherapy regimen. patient b's diagnostic work up determined a total ige level of ku/l. patient b's specific ige tests were positive for weed mix, tree mix, maple, peanut, strawberry, dust mix, cat dander, dog dander, egg white, milk, oat, wheat, goose feathers, and chicken feathers. specific ige tests were negative for grass mix, white pine, mold mix, gluten, soybean, and fish mix. these two case reports reveal significant response to omalizumab in severe steroid dependent atopic dermatitis. further research is strongly indicated considering the quality of life issues with severe atopic dermatitis and potential side effects to long-term corticosteroid treatment. eosinophilic esophagitis (ee) has been described in children and is characterized by high levels of eosinophils (> - eosinophils/high powered field [hpf]) in the esophageal mucosa. a recent report indicates that the combined prevalence of the eosinophilic gastrointestinal disorders may be higher than that of inflammatory bowel diseases (ibd). the presenting symptoms of ee mimick those of gastroesophageal reflux disease (gerd), and patients of all ages may experience a delay in time from onset of symptoms to diagnosis of ee. there is a paucity of data in the literature regarding the delay in time from symptom onset to diagnosis of ee. we report the data on four children three years of age and under with ee who experienced a significant diagnostic delay. four young children were referred to the pediatric allergy clinic with a diagnosis of ee (table) . three of the patients were male and one was female. the patients were - months of age at the time of diagnosis, and the diagnostic delay was . - months (average delay . months). the most common presenting symptom was vomiting, and three of the four patients had a history of respiratory obstructive symptoms. all of the patients had received conventional treatment for reflux disease, and one had undergone a nissen fundoplication prior to diagnosis. in all four patients the esophageal biopsy revealed > eosinophils/hpf. three out of four patients had a family history of atopy, and two patients had a known history of a food allergy. skin tests to foods were positive in two patients and rast (radioallergoabsorbent) testing to foods was positive in one patient. recent data suggests that the diagnostic delay in ibd is decreasing as much as %. it is hypothesized that this may be due in part to an increased index of suspicion by health care providers. there is little data available regarding the diagnostic lag in children with ee. it is currently believed that chronic ee can lead to progressive esophageal scarring and dysfunction. stricture formation has also been described in children less than two years of age. given the reported increased incidence of this allergic gastrointestinal disease over the past decade, more data regarding the diagnostic delay of these conditions may be instrumental improving health care providers' awareness of this disorder. a. kohli-pamnani * , e. cooney, p. huynh, f. lobo, new haven, ct. introduction: cutaneous hypersensitivity reactions to amprenavir, an hiv- protease inhibitor, are reported in up to % of treated patients, of whom % have severe or life-threatening rashes, with treatment discontinuation required in % of cases. we report a case of successful desensitization to amprenavir, for recurrent maculopapular exanthem, in an hiv-infected patient with late stage disease and limited antiretroviral (arv) agent options. methods: the patient is a year-old caucasian female with late stage hiv disease (absolute cd count cells/mm , hiv rna , copies/ml) and multiple arv intolerances, who developed a severe generalized maculopapular eruption sparing mucous membranes six days following initiation of a regimen comprised of amprenavir, lopinavir/ritonavir, zidovudine, and lamivudine. a similar reaction occurred following re-challenge with amprenavir alone ( mg oral formulation bid via percutaneous endoscopic gastrostomy (peg) tube), despite concurrent administration of oral prednisone mg/day and loratidine mg/day. results: skin prick testing with amprenavir . mcg/ml was negative, whereas intradermal testing with . mcg/ml was positive with a mm wheal and mm flare. percutaneous and intradermal testing with normal saline was nonreactive. the positive histamine control (skin prick only) yielded a mm wheal and mm flare. subsequently, incremental doses of . mg, . mg, . mg, mg, . mg, . mg, mg, mg, mg, mg, mg, and mg of amprenavir oral solution were administered via peg tube at to minute intervals (table) . the patient successfully tol-erated amprenavir desensitization and has remained on therapy without recurrence of rash out to months of follow-up. conclusions: desensitization may permit continued use of amprenavir in patients with a history of amprenavirinduced maculopapular eruptions who have limited alternate treatment options. efforts aimed at characterizing the mechanism of amprenavir cutaneous hypersensitivity reactions seem warranted, given the frequency of reactions and the limited number of arv agents available for patients with late stage hiv disease. doses of oral solution were administered by peg tube at twenty to thirty minute intervals. introduction: beta-lactam (bl) allergy is the most common drug allergy. in most cases, ige antibodies are specific to the bl nucleus. however, sidechain-specific ige (scsige) to bl has been described. despite this, skin testing (st) to bl other than penicillin (pcn) is not commonly performed. we report a case of a year-old female with a selective allergy to pip, and describe the utility of st to this agent to confirm scsige. methods: st to prepen (pp) and pcn g was carried out with percutaneous (pc) testing followed by intradermal (id) testing. st was also carried out with ampicillin (amp; mg/ml), pip ( mg/ml at pc level; mg/ml at id level-a non-irritating concentration), and pip/tazobactam (tbm; mg/ml at pc level; mg/ml at id level) to exclude the possibility of selective allergy to tbm. case report: a year-old white female with crohn's disease was hospitalized for treatment of intra-abdominal abscesses. she had immediate flushing and urticaria during an infusion of pip/tbm approximately years prior. the allergy/immunology service was consulted for pcn st because her primary service preferred to empirically treat with pip/tbm. she had received imipenem approximately months prior without untoward reaction. st to pp and pcn g was performed with negative responses and adequate controls. she subsequently received pip/tbm, but developed flushing and urticaria during her initial infusion, consistent with an ige-mediated reaction. two months later, st to pp and pcn g was repeated. in addition, st to amp, pip, and pip/tbm was performed. she had positive responses to pip and pip/tbm with negative responses to pp, pcn g, and amp, implying selective ige-mediated potential to pip. she tolerated an oral challenge with pcn vk mg immediately following st without untoward reaction. conclusion: we have described a case in which st to pip was useful for diagnosing scsige in our patient, who had prior reactions consistent with ige-mediated pathogenesis. this information will be helpful in identifying antibiotics she can safely receive in the future. this case supports the utility of st to bl in addition to pcn, in evaluation and management of patients with a history of adverse reaction to bl that may reflect presence of scsige. a.r. vaishnav * , b.s. bochner, baltimore, md. we report the case of a -year-old caucasian male with a -year history of asthma, two episodes of eosinophilic pneumonia and chronic peripheral eosinophilia with baseline eosinophil counts around /μl who developed amnesia and elevated cardiac enzymes in february . another physician had added montelukast in january and because of a good response advair was decreased from / to / bid. in february his eosinophil count increased to /μl and soon he developed left arm numbness, diplopia as well as left arm and leg weakness. at his local hospital, he was found to have elevated troponins and cpks. cardiac catheterization showed normal coronary arteries and good left ventricular function. soon after discharge, he developed confusion and global amnesia. brain mri showed diffuse uptake consistent with global inflammation and/or vasculitis. upon hearing this story, we told him to take mg of prednisone and urgently come to our hospital for admission. within hours, his mental status and visual symptoms improved. physical examination was unremarkable except for subungual splinter hemorrhages. montelukast was stopped and gm/day solu-medrol iv was started. endomyocardial biopsy days later showed mild hypertrophy and fibrosis without eosinophils. repeat brain mri and mra were normal. chest ct showed multiple patchy infiltrates with a new central cavitary lesion in the right lobe. other labs included a negative anca, ana of : , normal complements and csf. our differential diagnosis included churg-strauss syndrome (css) versus hypereosinophilic syndrome (ihes) with myocardial, neurological and pulmonary involvement. serum tryptase was normal as was fluorescent in situ hybridization for the fip l -pdgfr fusion gene. based on this, along with the new pulmonary cavitary lesion on chest ct, the diagnosis of css was made. after days of iv steroids, he was switched to mg/day of prednisone. upon discharge his eosinophil count was /μl on mg of prednisone. after all procedures were completed, he was also started on aspirin mg daily to prevent thrombotic and thromboembolic complications. he was seen in follow-up in clinic and cytoxan mg daily was started. his prednisone is being tapered. he is tolerating the treatment well and so far has had an excellent clinical and laboratory response. introduction-c -esterase inhibitor (c -inh) deficiency is a rare disorder classified into acquired and hereditary forms. both entities are distinguished by recurrent angioedema without pruritus or urticaria. the upper airway, head, neck, extremities and gi tract are typically involved. the inherited form usually presents in the first or second decade accompanied by a family history. the acquired form more commonly presents after the fifth decade. in acquired c -inh deficiency, serological evaluation reveals low levels of c , c -inh, and c q and a normal c level. levels of c q are normal in the hereditary form. the acquired form may be associated with lymphoproliferative disorders and autoimmune disease. acquired c -inh deficiency is typically recognized before the underlying malignant condition is diagnosed. clinical regression has been reported in patients whose underlying disorder responds to treatment. methods-a case report of a -year old female who developed repeated episodes of facial angioedema requiring hospitalization preceded by one year of vague abdominal pain and cramping. data-laboratory investigation of this patient revealed c < mg/dl ( - mg/dl), c q< . mg/dl( . - . mg/dl), ch < u/ml( - u/ml), and c -inh at mg/dl( - mg/dl) with a % activity (> % normal). c was mg/dl( - mg/dl). other laboratory evaluation was notable for a normal cbc with diff, comprehensive metabolic panel, amylase, lipase and spep pattern. ige was elevated at ku/l. hematology was consulted. ct of chest, abdomen, and pelvis were nondiagnostic. peripheral blood flow cytometry revealed a small distinct pop-ulation consistent with a clonal b-cell lymphoproliferative disorder. a repeat test showed skewing towards lamba light chain expression. bone marrow biopsy and aspirate were essentially normal except for erythroid hyperplasia on danazol treatment. the physical examination was without any masses or lymphadenopathy. the patient remained asymptomatic after beginning danazol although elevations in rbc, hgb, hct and absolute lymphocyte count have developed. conclusion-acquired c -inh deficiency is rare cause of recurrent angioedema that has been reported in small cohorts and case presentations. we report another case report that reinforces the need for physicians to evaluate for concomitant lymphoproliferative disorders. chronic urticaria is a distressing condition usually associated with poor quality of life and poor response to symptomatic therapy. a wide variety of causes and mechanisms have been described and in some patients the cause remains unknown. rare cases have been associated with thyroid antibodies and some responded to thyroxin, even in the absence of overt thyroid disease. case report: a -yr-old obese white female presented with a history of persistent urticaria/angioedema for mo. urticaria involved various parts of the body and individual lesions usually lasted < hr. it was often accompanied by facial edema. oral diphenhydramine mg qid caused only little improvement. the patient could not suspect any offending factors. review of systems and past medical history were unremarkable, except for hyperthyroidism at age yr that was treated with "medication" for yr. on physical examination there were several urticarial lesions though she has been taking diphenhydramine. the thyroid appeared normal regarding size, shape and texture. various second generation antihistamines and doxepin were of little help. laboratory evaluation revealed total serum ige of iu/ml (normal < iu/ml) and ch of u/ml (normal - u/ml), but high tsh of . iu/ml (normal . - . iu/ml) and low free t of . ng/dl (normal . - . ng/dl). her antithyroglobulin titer was iu/ml (normal < iu/ml) but the antimicrosomal titer was highly elevated at iu/ml(normal < iu/ml) consistent with hashimoto's thyroiditis. thyroxin therapy was initiated at a dose of mcg/d which resulted in marked improvement within one week and the patient was able to discontinue doxepin and other antihistamines. because of marked drop in tsh to . iu/ml, the thyroxin dose was reduced to mcg/d. her thyroid function tests became normal within two months. she did not experience any recurrence of urticaria or angioedema during over mo of follow-up so far. conclusion: patients with chronic urticaria/angioedema, especially women, should be screened for thyroid autoantibodies and if positive, thyroxin therapy might bring impressive remission in urticaria. hypersensitivity pneumonitis (hp) results from an abnormal immunologically mediated response to an environmental antigenic trigger. typically patients with hp experience transient fever, hypoxemia, muscle and joint pain, difficulty breathing, fatigue, weight loss, and cough. there are two clinical presentations of hp differentiated by onset and resolution of symptoms. patients experiencing acute hp experience the onset of symptoms to hours following exposure to a particular antigen and resolve in to days without specific treatment. however, patients with chronic hp experience symptoms that persist for months to years when exposed to a recognized cause of hp. a year-old caucasian male was referred to our practice with acute bronchitis. his referral was secondary to a history of allergic rhinitis, chronic asthma, gastro-esophageal reflux disorder, and sinus surgery. this non-smoking male was a machine operator at a local factory. he was doing well until he began working in the presence of a heat induction machine and metal lubricating spray called multan ea (hinkle surface technologies), i.d. no.: . multan ea is a product containing naphthenic petroleum distillates, amine salts, amine soap, triethanolamine hexyl, hexylene glycol, ethanol, sodium petroleum sulfonate, and triazine. this lubricant is known to irritate the eyes, skin, and respiratory tract. recent studies indicate that thermal decomposition of triazine, which readily occurs during metalworking, results in the production of formaldehyde. formaldehyde is a known carcinogen, as well as respiratory, skin, eye and digestive tract irritant. the patient developed serious respiratory health problems resulting in work absence and eventually hospitalization. while hospitalized he received a high resolution ct scan which showed diffuse ground glass appearance, and multiple attenuation areas of the lung which are consistent with hypersensitivity pneumonitis. the patient was treated with corticosteroids, and antibiotics with eventual normalization of lung parenchyma by chest ct. this represents the first reported case of hypersensitivity pneumonitis resulting from exposure to the metalworking fluid and respiratory irritant multan ea . a.j. ham pong * , f. chan , s.l. bahna , . ottawa, canada; . shreveport, la. sexual intercourse has been known as the route for semen hypersensitivity reactions to the seminal fluid protein or to a contaminating drug or food. we report a case of anaphylaxis to cephalexin-containing semen by ingestion. history of present illness: a -year-old woman developed a systemic reaction after swallowing semen. since the couple frequently practiced fellatio without any reactions, her husband suspected cephalexin that he was taking over days ( mg qid). her reaction began in less than min and peaked over min; first as itchy oral mucosa followed by wheezing, flushing of the face and upper chest, and nausea. diphenhydramine mg was administered po at min and the reaction subsided over hr. past medical history: she had generalized urticaria to oral penicillin more than yr earlier and had positive penicillin skin test. she also had allergic rhinoconjunctivitis, mild intermittent asthma, and positive skin test to house dust mite, cat and dog epidermals, and pollens of grasses, trees, and ragweed. she also had oral allergy syndrome to certain fresh fruits and tree nuts; hazelnuts caused also diarrhea and colic. neither the patient nor her husband ate any nut-containing food on the days preceding the reaction. family his-tory: allergic rhinoconjunctivitis in the mother, sister and brother. eval-uation: the patient sought allergy evaluation about yr after the reaction. she and her husband gave a consent. her serum ige was iu/ml and skin test positive to penicilloyl polylysine x - mol id, but negative to cefazoline mg/ml for prick and mg/ml for id. she had negative prick test to her husband's seminal plasma both before and after his intake of cephalexin mg qid for days. using a cephalexin bioassay sensitive down to . mcg/ml, the medication level in the husband's urine at min post last dose was mcg/ml and in his serum at min was mcg/ml, but was undetectable in the semen collected at min. conclusion: this is probably the first case report of systemic reaction to ingested semen. the reaction occurred in an atopic, penicillin-sensitive woman and seems to be caused by cephalexin excreted in the semen or through urine contamination ( drop = mcg). in addition to her avoiding penicillin and cephalosporins, she was advised to avoid her husband's semen while him taking such drugs and for at least days afterwards. background:asthma causes serious morbidity & mortality all over yet most asthma educational evaluations and programs have an urban rather than rural focus.there is lack of data on rural north dakota(nd). this nd survey aimed to study knowledge & awareness of management strategies for asthma like use of metered dose inhalers, spacer devices and peak flow meters. methods:the qualitative survey addressed attitudes and beliefs on asthma & its triggers;knowledge of medication delivery routes & use of hospitals and provider visits.a simple questionnaire was self-administered at rural clinics in small towns in southeastern north dakota. questions explored asthma knowledge, extent of family history of asthma & factors aggravating asthma.it was voluntary & the population surveyed included patients, family, teachers, employees at nursing homes, the local hospital & clinics. results:of surveys completed % had no asthma in the family.of those with a family history( %), % had person with asthma, . % had & . % had or more.respondents were aged - years & . % were female.see table. discussion:our survey was rural & comparison with urban areas may help in planning for asthma education & resource allocation. % denied asthma in their family. similarly, nonurban alaskan natives have a lower incidence of asthma compared to nonnatives.our results show a lack of awareness in our area.grain dust exposure was perceived as an asthma trigger but without evidence, local research is needed.in our study smoking was considered a trigger by . % & this may be real.there was lack of awareness of peak flow meters & their role in asthma care.a study showed that compared to other areas even rural nurses used peak flow meters less often to assess and monitor asthma.this suggests a need for comprehensive asthma educational programs in rural areas that are based on national guidelines.we had only a moderate followup rate at %.in comparison, one study had % missed scheduled follow-ups. exercise induced asthma was known to only % of our group. conclusion:the need for better patient-provider communication has been highlighted by the lack of awareness of proven strategies to combat asthma.the use of a simple survey has revealed many unknown facts about asthma awareness in rural nd.further study to determine cost effective solutions to achieve national targets for asthma management are essential. aim: in most studies of asthma, the emphasis was on changes in large and middle airways. the aims of this study:( )to observe the morphologic changes in small airways and lung tissue(salt) in guinea pig asthma models(gpam); ( )investigate the role of vcam- , eotaxin, nf-b and ap- in the inflammation of asthma; ( )explore the functional variation of alveolar type cells in asthma; ( )evaluate the effects of inhaled glucocorticoids on the above annals of allergy, asthma & immunology parameters in salt of asthma models. methods: ( )the gpam were established by ovalbumin challenge. five groups were divided: control, asthma day and day , intraperitoneal dexamethasone, and budesonide inhalation group. ( )the expression of vcam- , eotaxin, nf-b and ap- was determined by immunohistochemical technology and rt-pcr; the dna binding activity of nf-b and ap- by electropharetic mobility shift assay. ( )the balf phospholipide concentration was measured by phosphorus detection. results: ( )significant inflammatiom with infiltration of eosinophils and lymphocytes in salt was observed in asthma groups. ( )the protein levels of vcam- , eotaxin, nf-b and ap- expressed in the salt were significantly elevated in asthma groups than those in control. ( )the mrna expression of vcam- and eotaxin of lung tissue homogenate was significantly increased in asthma group. ( )the dna binding activity of nf-b and ap- of lung homogenate was significantly increased in asthma group. ( )the balf surfactant represented by phospholipides was significantly decreased in asthma groups. ( )glucocorticoids in different ways of intake provided significant effects on the inflammatiom of salt. conclusion: ( )widespread and significant inflammation with eosinophilic infiltration existed in the salt in gpam, indicating asthma is a disease involving the whole airway and lung system. not only there were structural changes, but also impaired function of alveolar cells. the role of small airway inflammatiom may be of great importance. ( )eotaxin and vcam- actively mediated the process of inflammatiom, nf-b and ap- played important roles in the regulation of vcam- and eotaxin. the up-regulation of the above mediators in gpam was expressed in salt similar to that in central airways. we have recently reported that immunomodulatory oligonucleotides (imos) consisting of a novel structure and synthetic cpr or r'pg (r and r' are synthetic purine moieties) stimulatory motif effectively prevent ovainduced asthma in mouse models. in the present study we examined whether these novel imos (hyb and hyb ) can reverse established allergic airway inflammation in mice. balb/c mice sensitized and challenged with ovalbumin (ova) were evaluated for airway hyperresponsiveness (ahr) to methacholine. following ova-sensitization, mice were randomized and treated with placebo or mg or mg/dose of hyb or s.c. during the following days. two days after the final treatment, mice were rechallenged with ova and pulmonary functions were recorded. mice treated with either imo were significantly protected from both early (ear) and late (lar) allergic response, airway hypersensitivity and hyperreactivity to methacholine, bal and peribronchial eosinophilia, bal and serum il- , and total serum ige as compared to vehicle-treated ova-sensitized and challenged animals. there was a significant increase in immature lung dendritic cells (cd c+cd r+) together with increase in serum il- levels and significant decrease in lung dc type cells (cd c+ cd b+cd a-) as compared to vehicle-treated ovalbumin-sensitized animals in the lungs following treatment with either imo. these data suggest that both imos are effective and potent in attenuating key features of established allergic airway inflammation in bronchial asthma, and this effect could be mediated via decreasing lung dc cells and increasing immature dendritic cells. additionally, imos contain a novel '- '-attached structure that provides higher metabolic stability and may permit lower and/or less frequent dosing. hyb was evaluated for its safety and immunopharmacology in a phase clinical trial in healthy human volunteers. introduction -hemoglobinopathies are common in southern europe and mediterranean area the more frequent being thalassemia and sickle cell disease. aside of the major hematological diseases of homozygotic patients minor forms are frequent, thalassemia minor and sickle cell trait. in these cases mycrocytosis with decrease of red cell volume and mean corpuscular volume or abnormal erythrocytes are found and can lead to hemorheologic disturbances in bronchial circulation and bronchial hypereactivity. the rationale of this study is to evaluate the incidence of asthma in hemoglobinopatic patients allergic to house dust mites.methods-from patients seen in the last years in an out-patient allergy clinic cases of hemoglobinopathies have been confirmed by red cell count, hemoglobin electrophoresis, assays of hemoglobin a , f, and s, and sickle cell test.all these patients had allergic disease characterized by clinical history, skin prick test to aeroallergens total and specific ige (rast-cap-feia) and respiratory function evaluation. results -hemoglobinopathies: betathalassemia cases, betadelta thalassemia , sickle cell trait , hemoglobin c. . aside of cases of urticaria, all the patients presented respiratory allergy, rhinitis in cases of thalassemia and hemoglobin c, asthma with or without rhinitis in cases of thalassemia and cases of sickle cell trait. therefore asthma was present in , %. in a group of respiratory allergic patients without hemoglobinopathies, % had asthma and % only rhinitis. conclusions -the prevalence of asthma is higher in hemoglobinopathies.(p< square chi test). hemorheological changes probably greater rigidity of red blood cells and capillary bed can contribute to bronchial hypereactivity. detection of hemoglobinopathies must be done in asthmatic patients with slight anemia or mycrocytosis. we investigated the role of aspirin-exacerbated respiratory disease (aerd) as a risk factor for the development of airway remodeling. patients with aspirin intolerance develop hyperplastic sinusitis with fibrosis and nasal polyposis. we speculated that similar mechanisms could be acting in the lower airway and that these individuals would demonstrate more severe asthma and evidence for airway remodeling. the epidemiology and natural history of asthma: outcomes and treatment regimens (tenor) study is a multicenter observational study of subjects with severe or difficult-to-treat asthma. baseline data were compared between subjects years who reported asthma exacerbation following aspirin ingestion and those who did not. the primary measure of asthma remodeling was the maximally achieved post-bronchodilator spirometry. adult subjects with aerd (n= ) were compared with aspirin tolerant subjects (n= ). subjects with aspirin intolerance demonstrated evidence for airway remodeling as shown by lower post-bronchodilator predicted fev . in addition, they were more likely to have physician-assessed severe asthma, to have been intubated, and to have required high-dose inhaled corticosteroids or oral corticosteroids in the previous months. we conclude that aspirin intolerance is associated with remodeling of both the upper and lower airways. asthma is a complex and variable disease with two main components, airway inflammation and smooth muscle dysfunction. according to national and international asthma guidelines, subjects with persistent asthma can be classif ied into one of three categories (mild, moderate, or severe) based upon lung function, symptoms, nighttime awakenings, medications and exacerbations. though it is widely believed that there is a high degree of variability in both pediatric and adult subjects with asthma, few studies have compared variability between them. therefore, an analysis of previously conducted asthma studies was undertaken to evaluate pediatric subjects aged - years (n= ) and adult subjects (n= ) previously receiving short-acting beta -agoinsts alone in seven double-blind, randomized, -week trials. the analysis is limited to subjects who were randomized to placebo in these trials. during the study, subjects exhibited marked fluctuations in asthma severity. despite the fact that all subjects met criteria for moderate or severe asthma at baseline, %, %, % and % of weeks for pediatric subjects and %, %, %, and % of weeks for adults were spent in the intermittent, mild, moderate and severe categories, respectively. a summary of severity classification based upon symptoms and albuterol use is presented below. in addition, based upon pef % predicted, % and % of weeks were spent in the intermittent/mild category for pediatric and adult subjects, respectively. however, fluctuations in pef occurred frequently, with % of pediatric subjects and % of adult subjects experiencing changes in severity based on pef over weeks, indicating more variability in pediatric subjects. this analysis clearly demonstrates that asthma is a variable condition and that both pediatric and adult subjects frequently move between severity categories. furthermore, there are marked differences in severity classifications between pediatric and adult subjects. asthma severity, and consequent optimal therapy, cannot adequately be assessed by discrete, point-intime assessments of lung function, frequency of albuterol use, or asthma symptoms, especially in the pediatric age group. studies suggest that there may be an association between single nucleotide polymorphisms (snps) in the beta -adrenergic receptor gene (adrb ) and the response to beta -adrenergic bronchodilators. polymorphisms at codon have been at the center of this debate. therefore, a retrospective analysis of six large, randomized trials was conducted to evaluate clinical responses to salmeterol administered with fluticasone propionate (fsc) / mcg bid for weeks in patients ( yrs) with moderate or severe asthma and differing adrb polymorphisms at codon . baseline demographics were similar for all genotype subgroups. all measures of asthma improved over baseline and were similar across arg /gly subgroups at weeks. pairwise comparisons were conducted between genotypes and there were no differences other than fev as noted in the table. findings from this retrospective analysis show that regardless of arg /gly genotype, clinical response to salmeterol with an ics was similar during chronic dosing. although prospective studies are needed to fully understand the effect of adrb polymorphisms on response to therapy with a long-acting beta -agonist, this analysis suggests that therapy with salmeterol and an ics together is appropriate for caucasian patients with differing arg /gly genotypes. coronary artery disease(cad) and asthma commonly coexist in adults. iv dipyridamole thallium scintigraphy is considered a safe non-invasive technique in the evaluation of cad when patients can't exercise. dipyrdamole is a purine that blocks reuptake of extracellular adenosine increasing serum adenosine levels after iv administration.this results in a transient coronary vasodilation increasing the sensitivity of the thallium study. methylxanthines reverse the effects of endogenous adenosine by competitively antagonizing adenosine at local purinoreceptors. we report a case of a yr.old female with a year history of stable mild persistant asthma treated with daily salmeterol and low-dose fluticasone. she was referred to cardiology for atypical chest pain. within minutes of a standard iv dose of dipyridamole the patient reported chest tightness, cough, and wheezing. all these symptoms, typical of her past asthma flares, were abolished within minutes of an aminophylline infusion and before albuterol was administered.the stress test was completed and was normal. inhaled adenosine induces bronchconstriction and is used as a probe for bronchial hyper-responsiveness. commercial iv adenosine preparations used in treating supraventricular tachycardia are reported to induce bronchospasm in known asthmatics. since serum levels of adenosine are transiently increased following iv dipyridamole, bronchospastic symptoms during dipyridamole stress tests should not be unexpected. an earlier study found an increased incidence of wheezing in % of patients with known copd/asthma undergoing dipyridamole stress tests despite pretreatment with beta agonists. the marked decline of theophylline use for chronic asthma in recent years may actually be increasing the incidence of this risk. cardiologists performing thallium stress tests are familiar with the risk of asthma flares after dipyridamole. they use iv aminophylline frequently to reverse several types of clinical dipyridamole reactions, including bronchospasm. on the other hand, we are impressed that allergists are relatively unfamiliar with this association. allergists and asthma specialists as well as asthmatic patients should be aware of risk of acute dipyridamole induced bronchospasm during elective cardiac stress testing. it has been shown that adhesive molecules are involved in inflammatory diseases of the lungs such as bronchial asthma. the purpose of the study was to measure and establish possible difference in serum levels of soluble icam- in atopic patients (patients with allergic rhinitis and patients with bronchial asthma) in comparison with patients without atopy (patients with asthma without rhinitis); whether there is a difference in sicam- levels between groups of patients with allergic rhinitis and asthma in comparison with group of patients with allergic rhinitis only and also in comparison with healthy controls. results of the study have substantiated statistically significant difference in sicam- levels between all groups of patients in comparison to healthy control, but no statistically significant difference in sicam- levels between patients with and without atopy (z=- . ) or between patients with allergic rhinitis and bronchial asthma in comparison with group of patients with allergic rhinitis only (z= . ). conclusion: icam- is an important marker of inflammation in patients with allergic rhinitis as well as in those with bronchial asthma. atopic status does not influence differences in sicam- levels. although mean sicam- levels were higher in patients with allergic rhinitis and bronchial asthma ( . ng/ml) in comparison with mean sicam- levels in patients with allergic rhinitis only ( . ng/ml), no statistically significant difference was noted in sicam- levels between these groups of subjects, i.e. asthma itself did not contribute to statistically significant increase of sicam- levels. k. nadarajah * , g.r. green, m. naglak, abington, pa. objective: to study the various clinical outcomes of penicillin skin testing (pst) in a community-based hospital and to determine the percentage of patients who have an antibiotic modification and the choice of antibiotic used following the result of pst. method: this study is a retrospective chart review of all in-patients who were penicillin skin tested during a period of . years(jan to july ). information was collected on patients using a detailed data collection form. data was summarized using descriptive statistics including frequencies and percentages. results: of the patients penicillin skin tested, had a negative test, five had a positive test and in four patients the test was indeterminate(histamine controls were negative). eighty six percent of the patients had a history of penicillin allergy, . % had a history of cephalosporin allergy and . % had a history of both penicillin and cephalosporin allergies. the duration of antibiotic prior to pst ranged from zero to days. there was a . % ( / ) reduction in the use of vancomycin, a . % ( / ) reduction in the use of floroquinolones and a . % ( / ) reduction in the use of aminoglycosides following pst. aztreonam was used in . % ( / ) of patients before pst and in zero patients after pst. use of penicillin-based drugs was % ( / ) after pst and cephalosporin use increased from . % ( / (all third generation cephalosporins)) to . % ( / ( second and third generation cephalosporins)). i.e., % of patients with a negative pst received a penicillin or a cephalosporin. vancomycin usage was higher among pst positive patients. endocarditis was the diagnosis in % of all patients skin tested and staphylococcus aureus ( . %) and enterococcus ( %) were the most common organisms on culture. there were no serious adverse reactions to the use of penicillins or cephalosporins when used following a negative pst, and there were no adverse reactions to penicillin skin testing. conclusion: in the population studied, pst lowers the usage of vancomycin, floroquinolones and aminoglycosides and increases the use of penicillins. third generation cephalosporin usage was increased by pst in our study. overall, pst results in antibiotic modification that could lower the emergence of multi-drug resistant organisms and vancomycin resistant enterococcus. the aim of the study was to find a new marker which could be easily done to predict about possible allergy development in infants. preventive procedure is always economically better than treatment itself.food allergens are able to stimulate lymphocytes even in prenatal period. immunological maturity of newborns is still in the center of our interest because its dependence on many different factors. the question was if cd activity in cord blood and in -year-old children correlates with development or not of allergy? the examined group consists of newborns( , % of boys). breastfed were only children until -months-old and until they were -monthsold. total ige from cord blood and mothers' blood taken at delivery were measured using unicap. immunological detection was done using fluorocytometry(becton nad dako). additionally parents were questionaired( family atopy). our reaults show that positive family atopy history(group a) or elevated level of ige( group b) or symptoms of allergy in first months of life(group c) does not correlate with cd antigenicity. in all subgroups cd frequency was %. our findings show unfortunately that cd cannot be a predictive marker for allergy development. rationale: the etiology of eosinophilic esophagitis (ee) is unknown and the relationship to a type i allergic response is unclear. comparison of patients with positive and negative type i allergy testing may further clarify ee and determine what are the most common food allergens. methods: this is a retrospective chart review of medical records from january to january of children year of age with biopsy confirmed ee (n = ). ee was defined as having eosinophils per high power field on esophageal mucosal biopsy. patients were grouped according to positive (n = ) and negative (n = ) allergic responses on skin or radioallergosorbent testing (cap rast, pharmacia). skin testing with commercial extracts (hollister-stier laboratories and greer laboratories) was performed in an allergist's office. a wheal of mm greater than the negative control on skin testing or ige > . ku/l on rast was considered positive. we performed fisher exact analysis to determine if associations existed between a type i allergic response and factors such as age, symptoms, peripheral eosinophilia, and personal and family history of atopy (asthma, allergic rhinits, and atopic dermatitis). results: ee patients with a positive type i allergic response were significantly younger than those with a negative response (mean . yo, median . yo, range to . yo versus mean . yo, median . yo, range to yo; p = . ). vomiting as a presenting symptom was significantly increased in the allergic population ( %, %; p = . ) and abdominal pain as a chief complaint was significantly increased in the non-allergic population ( %, %; p = . ). personal and family history of atopy and peripheral eosinophilia were similar between groups. the most common allergens were cow s milk ( %), peanut ( %), egg ( %), soybean ( %), and wheat ( %). conclusion: patients diagnosed with ee who present at a young age or who present with symptoms of vomiting may have a type i allergic response contributing to the esophageal eosinophilic inflammation. consistent with food allergies in children, milk, peanut, egg, soybean, and wheat were the most common foods found with allergy testing. because the positive predictive accuracy of food annals of allergy, asthma & immunology testing is only about %, the challenge remains to develop a specific plan to confirm causative foods such as through oral challenges or elimination trials. rationale: the relationship between specific ige and igg levels in atopic individuals is unknown. increasing antigen exposure is expected to increase igg production, however, the influence on ige levels is unclear. to further clarify this relationship the following studies were conducted. methods: three hundred and sixty tandem determinations of specific ige and igg levels in individuals were collected using the immunocap instrument (pharmacia diagnostics) and commercially available reagents. only subjects who had ige levels > . ku/l and igg determinations > mg/l to the same specific allergenic species were included in the study. specific ige and igg determinations were to alternaria alternata, aspergillus fumigatus, penicillium notatum, cladosporium herbarium, felis domesticus, canis familaris, dermatophagoides farina, and periplaneta americana. correlation coefficients were calculated using excel (microsoft). results: the review of this data set yielded tandem determinations of specific ige and igg levels in atopic individuals. the most common ige sensitization was to alternaria. sixtyfour percent of individuals had specific ige directed against alternaria. the lowest ige response rate was for cat and roach. only % of individuals had an ige response to those specific species. correlation coefficients (cc) were calculated between specific ige and igg levels and were positive for all eight species tested. the highest cc was for dog (n = , cc = . ) followed by aspergillus (n = , cc = . ), penicillium (n = , cc = . ), alternaria (n = , cc = . ), cladosporium (n = , cc = . ), cat (n = , cc = . ), and roach (n = , cc = . ). the lowest correlation was for dermatophagoides farina (n = , cc = . ). conclusion: when individuals with measurable specific ige and igg levels are considered, there appears to be a positive correlation between specific ige and igg levels for many allergenic species. factors that influence the correlation are likely to be both genetic and environmental. identifying this link and a clinical application are our next challenge. recently, protein microarray tests are competing with traditional allergenspecific in vitro assays. while the advantages of microarrays in allergy testing are attractive, microarray analysis alone has not been very effective in reducing analysis time and automated microarray equipment typically is much larger than its benchtop counterparts. we have incorporated microarray technology into an automated microfluidic cartridge that provides rapid allergen testing using a compact, low-cost, desktop instrument. the injection molded microfluidic cartridge (fig. a) contains arrays of miniature pumps and valves that direct reagents independently to a solid phase reaction area. standard ige (nibsc) as well as allergens were immobilized within the cartridge to form a protein microarray. a small desktop analyzer actuated the pumps in the cartridge to automatically carry out a chemiluminescence-based elisa reaction. total ige quantitation was performed in a minute reaction. fig.b shows the resultant image of a dilution series of immobilized ige. concentrations ranged from . to iu/ml corresponding to . fg to ng ige per spot. the average cv value for ige quantitation was % showing good linearity (r = . ) and fg sensitivity. this quantitative ige curve is used to eliminate the effects of cartridge variability. specific ige detection was demonstrated using extracts, d. pteronyssinu(dp), a.fumigatus and b. verrucosa(bv). a -step, minute reaction elisa technique was employed. fig. c and d show the resultant images for bv and dp positive serum, respectively. the sensitivity of the dp specific ige test was further investigated using a positive class serum sample confirmed by mast. dilution of the class serum with negative control serum could then be detected on the cartridge down to an fold dilution, resulting in a limit of detection in the range of . - . iu/ml for dp specific ige. we have demonstrated total ige and allergen-specific ige detection with total analysis times less than minutes in a convenient, low cost system using a microfluidic-based microarray cartridge. such rapid diagnosis allows physicians to provide treatment while the patient is still in the office. background: accurate allergen skin tests (ast) are the basis of optimal care of the allergic patient. completing these tests on the first visit can expedite the diagnosis and treatment and offer patients(pts.) efficient use of their time and increase satisfaction. appropriate pre-visit preparation is necessary to reduce the variables that affect ast outcomes. both positive and negative skin test controls are necessary to assure the ast are reliable. methods: we conducted a retrospective chart review of , sequential pts. skin tested at an allergy practice, in order to examine the success of our pre-visit instructions and to identify other medications that may affect ast. pts. were given verbal and written instructions to discontinue antihistamines and other histamine- receptor antagonist medications (h- a) days before their visit. they then underwent ast only if adequate positive (histamine) and negative (saline/vehicle) controls were obtained. results: only ( . %) of the , pts. had inadequate histamine response (ihr). of these pts., ( . %) had used h- a within the prior days. ( . %) pts. had taken h- a in the recent past, but stopped them at least days prior to testing. ( . %) pts. had no exposure to h- a. the use of psychiatric medications in the pts. with an ihr was also examined. of the pts. who discontinued h- a for more than days, ( %) were also taking various medications drugs used in the treatment of psychiatric disorders (ssris, benzodiazepines, atypical antidepressants & antipsychotics) which are not usually associated with h- a. the group of of the pts. with no prior use of h- a included ( %) who were also on various psychiatric medications. the high prevalence of psychiatric medication use in these two groups is in contrast to the to pts. with recent use of h- a in whom % were on psychiatric medications. conclusion: pre-visit patient education about discontinuation of h- a can lead to successful first visit ast in the overwhelming majority of patients ( . %).failure to stop h- a at the appropriate time occurred in only . % of the pts. . % of pts. discontinued h- a for the recommended day interval, but still had ihr. another % of pts. had an ihr yet no obvious use of h- a. a few pts. taking psychiatric medications not normally associated with h- a had ihr. further investigation into this issue is warranted. a. blaziene * , a. chomiciene, l. jurgauskiene, n. ciaponiene, vilnius, lithuania. background: sublingual specific immunotherapy (sit) is accepted as an alternative treatment to subcutaneous sit of seasonal allergic rhinitis. the aim of this study was to evaluate changes in allergen-specific ige and basophil degranulation test (bdt) before and after year of sit with a grass pollen mix. methods: patients ( male and female, aged - years) having sensitization to grass pollen with seasonal allergic rhinitis were treated with standardized grass pollen extracts. the blood samples were collected before and after year of sit assessing allergen-specific ige using an elisa method and bdt using a direct immunofluorescent method employing monoclonal antibodies. results: the sit was well tolerated by all patients. an increase in total ige after sit was observed in all patients. specific ige concentration was increased in ( . %) patients, while the bdt result was greater in ( %) patients after year of sit. conclusions: allergen-specific ige and bdt may serve as markers to indicate the clinical efficacy of sit for seasonal allergic rhinitis patients. a.g. palma-carlos * , s.l. silva, m.l. palma-carlos, lisboa, portugal. introduction -the incidence of primary immunodeficiencies in patients attending an out-patient center for clinical allergy and immunology depends on the recruitment and on patients refered. methods -in the last years patients have been observed in lisbon clinical allergy center reporting allergic diseases or repeated infections or refered by specialists (ent, gynaecology, internal medicine, pediatrics, or gp.). screening for primary immunodeficiencies has been done by electrophoresis, assay of immunoglobulins and complement, igg subclasses and flux-cytometry for t, b and nk cells. results - cases ( , %) of primary immunodeficiencies have been diagnosed. humoral: deficits of iga ( , % of immunodeficiencies), of igg ( , %) of igg subclasses ( , %) of common variable immunodeficiency cvi-( , %), of igm ( , %). complement: cases of c esterase inhibitor deficiency ( , %) cellular: cases of mucocutaneous candidiasis ( , %) in fertile females, cases of cd deficiency ( , %). combined: cases of deficiency of the couple cd /c ligand with igg deficiency ( , %).conclusions -in the present series chronic mucocutaneous candidiasis is the prevalent primary immunodeficiency, due to the number of patients refered by gynaecologists. aside of this group where a decrease of nk cells was the more common immunologic pattern, humoral immunodeficiencies are frequent, mainly cvi, iga, igg and igg subclasses deficiencies. the search for immunodeficiencies must be done in all patients with repeated infections attending immuno-allergology departments. a case of atypical c complement deficiency. c.c. randolph * , waterbury, ct. introduction:c complemennt deficiency occurs in in , individuals .it results in decreased opsonization and chemotaxis with increased prevalence ofsle and other rheumatic disordersas well as enhanced vulnerability to pyogenic infection.there are two types of c complement deficiency :type ( %associated with sle)with no protein translation and type ii with absence of protein secretion.we present a year old white female otherwise healthy with recurrent urticaria and angioedema with c complement deficiency. method:case report:a y/o w/f athlete presented with a two month history of recurrent hives and angioedema which she associated with ingestion of halloween candy .one week before evaluation she had hives with coconut as well.her history was othewise unremarkable except for recurrent uti's, annual sinusitis, pneumonia in as well as migraines.she denied sexual activity.her physical exam was normal.results:an evaluation for autoimmune disease revealed normal esr, ana, dsdna, mono and hepatitis serology as well as lyme titers however her ch was low u/ml(normal - u/ml)and evaluation of complement revealed c mg/dl(normal - mg//dl)and c < . mg/dl(normal . - . mg/dl)with normal c , c -c .her father had nor-malc but c was . mg/dl (normal . - . mg/dl)her sister had c of . mg/dl and normal c and her mother had normal c and c .her workup included positive prick skin test to ragweed, ash and grass and she was started on rhinocort and clarinex seasonally.she has been followed for one year with resolution of hives and is asymptomatic.her diagnosis had been confirmed by a pediatric rheumatologist.conclusion;we present an atypical case of c complement deficiency in an currently asymptomatic individual. background: we diagnosed a month old male with cgd and aspergillus brain abscesses and pulmonary infiltrates. review of the literature suggests he is one of the youngest cases of cgd complicated by cerebral aspergillosis. case report: a ten month old male previously seen for unexplained persistent pulmonary infiltrates since month of age presented to our hospital with lethargy, fevers, and increased irritability. ct scan of the head revealed severe hydrocephalus. multiple brain abscesses were found on surgical exam and cultured for aspergillus fumigatus. he had a history of failure to thrive and hypotonia since birth. family history was significant for parents that were second cousins. there was no family history of recurrent infections or childhood deaths. physical examination was significant for a child with weight and height in the % and %, respectively with persistent fevers > . c, hypotonia, hepatosplenomegaly, and left lower lung field rales. initial immune workup was normal except for elevated total ige of ku/l. cd + ( /m ) and cd + ( /m ) t cells were initially low, but later increased to normal levels without intervention. neutrophil oxidase activity assessed by dihydrorotamine (dhr) oxidation was % of control. superoxide production assessed by cytochrome c reduction was zero. the patient was treated with interferon ? for presumed cgd. his aspergillus brain abscesses improved with intravenous voriconazole and caspofungun. the responsible organism for his recurrent pulmonary infections was not identified, but improved with antifungal therapy and broad spectrum antibiotics. the dhr test of both parents and siblings were normal. antibody testing showed a complete deficiency of the p protein with normal levels of gp , p , and p proteins. evaluation of the exons of the ncf- gene that encodes the p protein were normal. conclusion: mutations due to p protein deficiency are responsible for % of cases of cgd. there has been only one previously reported case of p deficiency without ncf- exon mutations in which a single point mutation in an intron of the ncf-ii gene was identified. fungal infections may complicate cgd, however cerebral aspergillosis is seldom encountered. this case annals of allergy, asthma & immunology reports a month old with cgd due to a p deficiency without exon mutations complicated by cerebral aspergillosis. introduction: lymphoid interstitial pneumonia is an uncommon condition which is considered both as a disease per se or as an inflammatory pulmonary reaction to various external stimuli or systemic diseases; however, at the present time most of the cases remain idiopathic. we present a case of an infant who developed a lymphoid interstitial pneumonia associated to a deficit of interferon-production. methods: we describe a clinical case and review the medical literature. results: we present the case of a five months old male with a history of cough, respiratory distress and four previous hospital admissions regarded as a 'pneumonic' events from two months of age and four siblings dead (two of them with 'abdominal disease' and one of them with candidiasis) during their first year of life. the parents referred no consanguinity. the physical examination showed a malnourished child with signs of bilateral lung consolidation. oxygen supplementation and intravenous antibiotics were started. our patient didn't have neonatal history related to the present compliant. the chest film revealed a diffuse bilateral interstitial pattern which was confirmed by pulmonary ct scan. sweat chloride test, hiv and epstein barr virus serology test were all negative. an initial immunologic evaluation reported slightly increased leukocytic count, hypergammaglobulinemia, lymphocityc flow citometry and nitro blue tetrazolium reduction test in normal parameters. the open lung biopsy showed a thicked pulmonar interstitium with moderate number of lymphocytes with not atypical pattern. our patient was discharged with clinical improvement, ambulatory oxygen supplementation and inhaled fluticasone-salmeterol. in an ambulatory follow-up we evaluated lymphocytic production of cytokines and we found no levels of interferon-. we started weekly administration of oral transfer factor. the patient showed an excellent clinical improvement evidenced by no more oxygen dependence, weight gaining and absence of further hospital admissions. con-clusions: our patient represent a new linkage between lymphoid interstitial pneumonia and primary immunodeficiency characterized by interferonproduction deficit, maybe with a non previously described molecular defect and a probably autosomic recessive inheritance pattern; also we confirmed the transfer factor usefulness to induce gamma interferon endogeous production. objective: marijuana is a schedule class psychoactive control substance more frequently used by the oriental societies( in the event of jubilation) causing altered state of conscience, euphoria, its prolonged use is followed by addiction and dependence.it contains more than chemical entities with over are of the cannabinoid i.e, cannabidiol (cbd), cannabinol (cbn), and delta- , tetrahydrocannabinol (thc) the later on use has been associated with craving for further use of narcotics just to enhance the euphorient effects .the active ingredients i.e, delta- -tetrahydrocannabinolthc) and other cannabinoids(thc) are liquid soluble at high concentrations which alters membrane function, resulting in alterations in immune cell response. cannabinoid has immunosuppressant properties causing impaired cell-mediated and humoral immune system activities, cytokine production, leukocyte migration and natural killer-cell(nk) activity resulting in reduction in the host resistance to bacterial and viral infection, (pms)with hiv infection are at higher risk of developing aids, infection by opportunistic bacteria, fungi, or viruses (pms), when compared to non marijuana smokers, have more respiratory ill-ness.cannabinoids also characteristically as being immunomodulators i.e, generally suppressing but occasionally enhance some immunological responses, some have suggested that the immunosuppressive effects of cannabinoids might be useful clinically; for example, in treating multiple sclerosis.as per clinical response cannabinoids had been found exacerbating existing allergies from antigenic complex (eliciting formation of specific antibodies/metabolites as a hapten, combining with a body proteins). methods .in the follow up studies including individuals(all males age - years) with(pms).of more than months having serum level of tch > um, there have been times reduction in the proliferation of t lymphocytes with a proportionate increase in the proliferation of b lymphocytes, reduction in the cytotoxic activity of t lymphocytes, reduction in macrophage activities i.e, phygocytosis rationale: patients with xla are subject to arthritis and cellulitis. these three relatives have had similar courses, suggesting infectious etiology. methods: two brothers and a cousin, from an african-american family known to carry xla, have been diagnosed with xla and chronically treated with ivig. all three have developed arthritis and cellulitis of a lower extremity. the eldest, now years old, had a -month waxing and waning arthritis and cellulitis that was refractory to the oral antibiotics attempted. his younger brother had not yet accomplished pubertal changes at the age of , and was below rd percentiles for weight and height. he also had several months waxing and waning arthritis and cellulitis refractory to oral antibiotics. he and his cousin have had esophogastroduodenoscopies that show gastritis and duodenitis with heavy growth of an organism visualized by specific staining for h. pylori. the cousin has also experienced more recent weight loss and arthritis/cellulitis. results: the younger brother had a blood culture that grew a curved gram-negative rod. a subsequent culture at the state lab grew a similar organism that was urease-negative. the two brothers are at or near completion of a six-month course of ertapenem and gentamicin; they have had resolution of their arthritis and cellulitis. the younger has gained . kg and experienced his pubertal changes at the age of years. con-clusions: there are prior reports of several different related organisms that can cause arthritis and cellulitis in patients with xla. these include helicobacter, campylobacter, and flexispira species. the urease-negative organism would not be flexispira, but may be a campylobactor species or helicobacter canis. the results from this family suggest that long-term combination iv antibiotics may be indicated for patients with this syndrome. slow virus infections have been reported to affect the central nervous system. parvovirus b , herpes and cmv are usually not included in the diagnosis of cns diseases nor has been associated with cns manifestation in an immuno-compromised patient. in this abstract, we report on a neurological manifestation that can be linked to ebstein-barr/herpes virus and parvovirus-b in an immune deficient patient. a year old female presented to our clinic with a history of chronic fatigue symptoms, daily arthralgias, frequent sinus infections and idiopathic tremors for the past years. the patients neurological evaluation, including mris was found to be within normal limit, despite worsening tremors of her head and arms. a full clinical and labora-tory evaluation was performed which revealed igg subclass, low t-cell numbers and functioning, low response to specific antibodies and positive igm for ebv, parvo and cmv. the patients common immune deficiency coupled with chronic viral infection and worsening tremors led us to try high dose ivig ( g/kg divided over days on cycles of every weeks). within three months of starting ivig, the patient had a large reduction in her tremors and negative igms for parvovirus, herpes and cmv. given our findings, we suggest that ivig may play a role as a neuro-immune modulator, as has been shown in other neuro-immune diseases. we further suggest that the interaction between parvovirus b- , herpes and cmv as part of the slow viruses, combined with underlying immune disorder may lead to neurological presentation and high dose of ivig can reverse the syndrome. purpose: to date, only two patients older than fifty years of age have been diagnosed with velocardiofacial syndrome (vcfs); this case represents the third such patient. methods: physical and laboratory findings of the patient are presented as a case report. results: we describe a sixty-six-year-old male, recently diagnosed with vcfs, confirmed by fluorescent in-situ hybridization (fish), was referred by his psychiatrist for comprehensive care. he had a history of cleft palate and learning disabilities as a child, with the onset of psychiatric illness in his late teens. although there was no history of cardiac disease, the patient had agenesis of the left renal artery as well as other vascular anomalies, including hypoplasia of the left a segement of the anterior cerebral artery. other findings included hypothyroidism, hypoparathyroidism, sensorineural hearing loss, and typical facies. he also suffered from chronic candidiasis. immunologic laboratory studies revealed over a : ratio of cd :cd t cells with a decreased cd percentage, markedly diminished b cell percentage, decreased t cell mitogen responses, and markedly decreased b cell mitogen responses. nevertheless, total serum igg and specific antibody responses remained normal, with a low serum igm. conclusions: this patient meets the criteria for the diagnosis of vcfs; only the third reported case diagnosed over the age of fifty. though his immunologic findings may be consistent with his diagnosis, they may be due in some part to immunologic senescence given his age. background: the classic presentation for patients with xla and mutations in the btk gene includes marked hypogammaglobulinemia, absent b cells, and significant sinopulmonary infections beginning at - months of age. typically, mds presents with anemia, leukopenia, monocytosis, and thrombocytopenia with recurrent infections, skin rash, and hepatosplenomegaly. many of these subjects demonstrate chromosomal abnormalities including monosomy . we describe a case of mds presenting with some features of both conditions. clinical history: we present a year old male with a suspected diagnosis of xla, chronic sinopulmonary disease beginning at mo, diffuse bronchiectasis, and agammaglobulinemia with absent b cells. he had wbc = cells/ul, with % monocytes and platelet count of , /ul. he had no anemia, hepatosplenomegaly, or skin rash. bone marrow biopsy showed mds with absent plasma cells and monosomy in % of his cells. btk expression and sequence analysis were normal. conclusion: while xla is the most likely primary immune deficiency that would present in a male with the clinical picture described above, this case illustrates the importance of maintaining an expanded differential diagnosis in patients with presumed primary immunodeficiency. j. wang * , l. mayer, c. cunningham-rundles, new york, ny. background: chronic granulomatous disease (cgd) usually results in acute or chronic infections with a defined spectrum of bacteria or fungi. other characteristics include inflammatory disorders, including genitourinary or mucosal inflammation resembling inflammatory bowel disease. gm-csf has been used in the treatment of mucosal inflammation in glycogen storage disease ib and crohn's disease with some success. objective: to explore the use of a novel therapy in the treatment of mucosal inflammation associated with cgd. methods: the patient was treated with daily gm-csf ( . mcg/kg/dose subcutaneous injection) along with parenteral antibiotics and total parenteral nutrition. after days on gm-csf, hydrocortisone enemas were added due to continued pain and swelling. results: rectal and abdominal pain significantly improved, blood streaked stools decreased; he tolerated a regular diet and was discharged home days after starting gm-csf. he now has no rectal or abdominal pain and no blood in the stool. conclusions: gm-csf may be a useful therapy for the management of mucosal inflammation in cgd patients. it appears safe and well tolerated and permits avoidance of immune suppressive alternatives. introduction: management of autoimmune cytopenias in patients with cellular immunodeficiency may be very challenging. treatment of these cytopenias with corticosteroids may potentiate the immune dysfunction leading to further infections. methods: we describe a month-old female with a cellular immunodeficiency and autoimmune thrombocytopenia / hemolytic anemia being treated with steroids and ivig without improvement. rituximab, a monoclonal antibody that binds to b-lymphocyte cd surface antigens, was initiated. results: this patient presented at months of age with failure to thrive, eczema and recurrent bacterial pneumonias. she was diagnosed with a t lymphocyte immunodeficiency with decreased absolute numbers of cd ( ), cd ( ), and cd ( ) lymphocytes. t cell function was markedly decreased as measured by pha, cona, and pwm. she developed chronic thrombocytopenia with platelets of less than , and coombs positive anemia with hemoglobin of g/dl. she was placed on mg/kg/day of prednisone with minimal improvement and continued to develop severe pneumonias. rituximab mg/m /week was initiated for doses. her cytopenias improved with an increase in both platelet count ( , ) and hemoglobin ( . g/dl). her absolute cd count fell from to . she was weaned off steroids permanently. she has also continued on ivig, prophylactic antibiotics, and as needed rituximab pending bone marrow transplant. conclusions: rituximab, a monoclonal anti-cd antibody, may be helpful in treating autoimmune cytopenias in patients with cellular immunodeficiency in which steroids need to be avoided. ivig antibody replacement substitutes for the subsequent humoral antibody depletion due to induced secondary b cell lymphopenia. introduction: the patient is a month old male born at full term. during his prenatal course he was noted to have a pulmonary abnormality in his left lower lobe at approximately weeks of age. serial ultrasounds and fetal mri were consistent with the diagnosis of congenital cystic adenomatoid malformation (ccam). histology from elective resection of the lesion performed at months of age revealed no evidence of ccam. silver stain revealed florid pneumocystis jiroveci (carinii) infection. the patient was completely asymptomatic. the differential diagnosis for this infection in the newborn period includes hiv infection, severe combined immunodeficiency, and x-linked hyper-igm syndrome. the infection has also occurred in newborns with apparently normal immune systems. methods: immunology evaluation was performed to evaluate the patient for the listed diagnoses. a complete blood count was performed. lymphocyte subsets were performed by flow cytometry. quantitative immunoglobulins g,a, m and e were measured by nephelometry. specific antibodies to tetanus and diptheria were determined by elisa. hiv status was ascertained by western blot and dna pcr. dichlorofluorescein assay was performed. fluorescenceactivated cell sorter technique was used to evaluate cd ligand. lymphocyte stimulation to mitogens and tetanus were performed. results: the patient had negative hiv / antibodies and a negative hiv dna pcr. the result of the complete blood count was normal with an absolute lymphocyte count of , . the patient had normal percentages and numbers of cd , cd , cd , cd , and natural killer cells. lymphocyte stimulation to mitogens and tetanus was normal. dcf assay was normal. facs revealed normal levels of cd ligand. at months of age he had protective titers to diptheria and tetanus titers of . iu/ml (protective > . iu/ml). at months igg, a, m and e were (normal - ), < , , and < respectively. conclusion: immunologic testing revealed no evidence of severe combined immunodeficiency, hiv infection or x-linked hyper-igm syndrome. the patient remains well clinically with normal growth and development with no subsequent infections. pneumocystis jiroveci pneumonia can be seen in infants with apparently normal immune systems. commercial preparations of igg produced for iv use (ivig), must fulfill regulatory requirements. the method of preparation, however, may produce alterations in the content or function of igg subclasses such as disturbed composition which can be reflected as a lowered clinical effectiveness of the product. we report patients with specific igg immunodeficiency, that, when changed to a new ivig preparation, had lessening of clinical effectiveness of the new product but who also experienced recovery after they were changed to a different ivig product. case . a y/o male with hx of cervical lymphadenopathy associated with recurrent uri, fatigue, cognitive alterations and hypercholesterolemia. he was dx in with a specific igg immunodeficiency for which he was started on ivig infusions mgxkg q/ w which brought his igg levels to normal values mg/dl, ( - mg/dl) with good clinical improvement. when he was changed to a different ivig product with lower iga content his initial symptoms returned with decrease of his igg to mg/dl ( - mg/dl) he was changed to a different ivig product with higher iga content with disappearance of all his previous symptoms. case . a y/o female with history of chronic yeast infection, fatigue, joint pain, asthma, ge reflux, depression, hypothyroidism and shunt for hydrocephaly. she was diagnosed with igg and igg immunodeficiency and started on ivig mg x kg x q/ w. when changed to another ivig with lower iga content she experienced worsening of her symptoms during the months that she was receiving it. she was changed to a different ivig product with a higher iga content with complete improvement of her symptoms. although the content of iga in product ( - ug/ml) was significantly lower than in prod-uct ( ug/ml), the total igg and igg subclass distribution (including igg ) were comparable therefore, the lack of clinical effectiveness of product would appear to be related to qualitative alterations in the product related to methodological preparation possibly in removal of the iga or other physicochemical alterations affecting biologic activity which contributed to a lessened clinical efficacy of the product. we present these cases to alert the allergist-immunologist to these observations when treating patients with igg or igg subclass deficiencies. background: development of atopy has been known to occur in nonatopic recipients of bone marrow transplants ( bmt) from atopic donors. the reverse condition, with atopic recipients losing evidence of specific ige after bmt from non-atopic donors is quite unique. case report: ph is a year old male referred for recurrent nasal congestion. as a teenager, the patient was treated for chronic allergic rhinitis and asthma, atopic dermatitis diagnosed as severe, and multiple food allergy. skin testing done as a teenager showed + reactions to multiple pollen, dog, cat, most seafood, cashew, walnut and pecan. at years of age, he underwent an allogeneic bmt from his non-atopic brother for acute myelogenous leukemia. asthma and atopic dermatitis were observed to clear almost completely and allergic rhinitis improve after the bmt. his blood type changed from + to -. skin testing done on his current visit showed unremarkable responses to all pollen, cat, dog, dust mites and foods with good histamine control. discussion: the negative skin test results suggests that his current nasal symptoms are vasomotor in nature. considering the past severity of his symptoms, it appears unlikely that he lost his specific-ige sensitivity spontaneously. transfer of atopy is known to occur in non-atopic recipients of bmt from atopic donors. in a study of patients undergoing allogeneic bmt for hematologic malignancies, nonatopic recipients developed positive skin tests with profiles similar to atopic donors. a possible mechanism is passive transfer of memory b-cells which initiate specific-ige production with a donor pattern. a reverse of this mechanism could occur with the recipient gaining lymphoid precursors with no atopic tendency leading to clearing of atopy. the literature yielded one report of asthma resolving after high-dose chemotherapy and autologous stem cell transplantation the authors suggested that chemotherapy could have resulted in immune system reconstitution, normalization of the t-cell repertoire and resolution of asthma. introduction: primary central nervous system (cns) lymphomas constitute only a small percentage of central nervous system tumors in adults and are seen more frequently in aids patients and immunodeficiency states. they are extremely rare in children, even those with primary immunodeficiency. we present a -year-old female with combined immunodeficiency who developed an eber+ (ebv-associated) large b-cell lymphoma that was confined to the cns. methods: the patient is a -year-old female that was being evaluated for combined immunodeficiency who presented to our institution with acute fever and seizure activity. results: the patient had a history of recurrent pneumonia, otitis media, sinusitis, and upper respiratory infections. she also exhibited failure to thrive, chronic diarrhea, and sen-sorineural deafness. she was found to have a combined immunodeficiency with severe neutropenia and lymphopenia, low iga, low igm, and poor specific antibody response to protein and polysaccharide antigens. she had no response to a candida delayed hypersensitivity skin test. hiv tests were negative. she was thought to have acute meningoencephalitis causing the fever and seizure activity, however bacterial, viral, and fungal studies were negative. she received multiple anitbacterial, antifungal, and antiviral agents. she died secondary to brainstem compression due to severe cerebral edema. autopsy revealed an eber+ large b-cell lymphoma that involved about % of her brain and spinal cord. no tumor cells were found elsewhere. con-clusions: this case represents a rare manifestation of combined immunodeficiency: the development of a primary cns lymphoma. the tumor cells were found to be eber+ (ebv-associated). ebv is known to be associated with lymphoma, especially in aids and immunocompromised patients. only . % of primary tumor sites in severe combined immune deficiency patients involved the cns in the immunodeficiency cancer registry that was instituted in the s. v. litvinova * , g. muzlaev, krasnodar, russian federation. introduction: glyoma is one of the most prevalent diseases among all brain tumors and more than % of them are malignant. in the previous investigations it has been shown the immune disorders in patients with glyoma tumor. at the same time it was suggested the possible anti-tumor activity of some proinflammatory cytokines (tnf, il , il ), which can penetrate via haematoencephalic barrier and induce the lysis of tumor cells. the aim of this investigation was to study the serum and spinal fluid concentrations of one of the key immunoregulatory cytokines -gamma ifn and il in patients with glyoma tumor. methods: the concentrations of the gamma ifn and il have been studied in serum and spinal fluid of patients with glyoma by eliza method. in control, the same parameters have been studied in patients with brain trauma. results: it has been shown that concentrations of gamma ifn and il in serum and spinal fluid was . - times higher than in trauma patients (p< . ). the serum levels of gamma ifn and il in glyoma patients were . and . pg/ml, accordingly. in trauma patients- . and . pg/ml. the concentration in spinal fluid of the studied cytokines was . time higher than in control patients. conclusion: proinflammatory cytokines gamma ifn and il may be involved in pathogenesis of glyoma and can participate as possible anti-tumor factors of immunity in glyoma patients. a. arrey-mensah * , r.u. sorensen, new orleans, la. rationale: immunodeficiencies need to be ruled out in infants that present with failure to thrive. patients with t-cell lymphopenia, hypogammaglobulinemia and pancytopenia may have a primary immunodeficiency such as scid, or a secondary immunodeficiency that may need to be managed differently. methods: evaluation of cellular and antibody-mediated immunity of a month old aaf admitted with failure to thrive and chronic diarrhea. ohistory of duodenal atresia corrected by creating a blind duodenal loop and anastomosis of the stomach to the jejunum at birth. o mass in hypogastrium. results: immunologic evaluation revealed: " lymphopenia ranging to cells/ul " anemia: hemoglobin . g/dl, retic . " ancs ranging to " thrombocytopenia l to l " cd +: " cd +: " cd /cd r: . " cd : " cd : " mitogen responses were normal: " pha , cpm " con-a, , cpm " pwm, , cpm immunoglobulins: igg mg/dl iga mg/dl igm mg/dl ige iu/ml total protein was . g/dl, albumin was . g/dl the immunoglobulin-g half-life study was days in our patient: metabolic imbalance: hypokalemia ( . mmol/l) hyponatremia ( mmol/l) hypocalcemia ( . mg/dl) blood, stool, urine cultures normal. stool ova, parasite, virus were negative. hiv-pcr (-) radiological evaluation: superior mesenteric vein thrombosis, chronic malrotation and volvulus, dilated duodenal blind loop with possible lymphatic obstruction. the patient improved clinically and all immunological markers normalized after surgical removal of adhesions and obstruction. conclusion: the patient had a secondary immunodeficiency due to lymphangiectasia. lymphangiectasia should be considered in the presence of a lymphopenia with normal lymphocyte function and hypogammaglobulinemia accompanied by hypoproteinemia and hypoalbuminemia. hypogammaglobulinemia and hypoproteinemia were secondary to gastrointestinal losses. the immunological component of q . deletion syndrome (also known as digeorge syndrome;dgs), hypoplasia of the thymus, is quite variable among patients and provides the opportunity to determine the relationship between thymic function and t cell receptor (tcr) repertoire diversity. using a novel measure of repertoire diversity based on cdr length polymorphism called hamming distance, tcrbv repertoire diversity in dgs was found to differ from control subjects by having an overall skewing of receptor expression. as expected from clinical outcomes, there was also great intra-individual variability in dgs tcr repertoires. the degree of repertoire diversity was directly correlated with thymic output as measured by t cell receptor excision circles (trecs), i.e. greater thymic output resulted in more diverse repertoires (see figure below). this result demonstrates a quantitative relationship between thymic function and repertoire diversity in humans and may reflect the balance between thymic output and peripheral expansion to maintain an adequate tcr repertoire. in addition, it may suggest a basis wherein limited repertoire diversity mediates both immune deficiency and autoimmunity. tcr repertoire diversity in dgs, as measured by hamming distance, correlates with thymic output, as measured by trecs (plotted on a logarithmic scale) a. sabra * , s. sabra , h.j. castro , j. malka-rais , j.i. mendez-inocencio , g. santos , j.a. bellanti , . rio de janeiro, brazil; . washington, dc. a major investigative effort of our laboratory has been directed to the study of non-ige mechanisms and their role in the immunopathogenesis of food allergy (fa). we have previously reported th and th cytokine alterations associated with several clinical entities that had overlapping disease manifestations affecting the mucosal-associated lymphoid tissues (malt), of the gi tract (galt), skin (salt), nasal (nalt) and bronchial tissues (balt). the objective of the present study was to evaluate specific immunologic alterations in a group of patients with non-ige fa. peripheral blood cd and cd lymphocyte subset analyses were performed in patients with fa documented by double-blind placebo-control food-challenge (dbpcfc). all patients were treated with an amino-acid based formula (aabf) and then received an open challenge using a panel of commonly offending allergenic food allergens in a normal diet.the clinical picture of all patients with fa were linked to malt-related manifestations; with galt symptoms of diarrhea, vomiting, abdominal pain and ftt, with balt symptoms of asthma, with salt symptoms of eczema, with nalt symptoms of rhinitis and with edema, ascites and anaphylaxis. all subjects had normal serum ige and eosinophil levels, negative ige food rast tests, normal cd (mean + ) and very low cd ( + ) levels in peripheral blood. abnormal cd /cd ratios > . were observed in all patients. age-and gender-matched controls revealed cd /cd ratios ranging from . to . . both patients with anaphylaxis had cd /cd ratios > . all patients responded well to aabf. open challenge to common offending foods from a regular diet (milk, soy, wheat, egg, nuts, beef and chicken), revealed multiple food allergies. after two years of follow-up on an aabf regimen, the patients remain well but allergic to multiple foods. very low cd levels remain as the unique immunological alteration in all patients.these studies suggest that abnormalities of very low cd distribution may play a pathogenetic role in non-ige mediated fa. since cd lymphocytes play a role in immunologic tolerance (it), it is tempting to speculate that the very low cd levels may signal the failure of development of it in our patients predisposing them to the development of allergies to multiple food components. background: mixed connective tissue disease (mctd) is a disease taht have caused controversy, while some authorities consider it a distinct rheumatic disease, others believe that it's an early stage of a fully defined autoimmune disease. the distinctive feature is the presence of the u small nuclear rnp autoantibodies. clinical features involve raynaud's is phenomenon, swollen hands, sclerodactyly, esophageal hypomotility, polyarthritis, and myositis, allof them can be present in others well deined rheumatic diseases. only aew cases have been described in the pediatric population. objetive: to determine the frecuency of mixed connective tissue disease in mexican.children in a tertiary level institution according to kasakawa's criteria, alarcon-segovia's criteria and sharp's criteria and establish if a diagnosis of a well defined autoimmune entity was made during the follow up. methods:medical charts were assessed with the diagnosis of mctd between and in our hospital. results: between and , , cases of autoinmune diseases were treated; with systemic lupus erythematosus(sle), with rheumatoid arthritis(ra), , with scleroderma and , with dermatomyositis. we found only four cases, of them did not complete the kasakawa's criteria but the diagnosis was probable according to alarcon-segovia and sharp's criteria. one of them developed sle after one year of follow up. the case that fulfilled the diagnosis criteria of mctd; raynaud's phenomenon, rnp antibody positive, arthritis, lymphadenopathy, restrictive pulmonary disease, sclerodactily and muscle weakness developed a full blown sle at years follow up. discussion: the disease is extremely rare in children. we conclude that at least in pediatric age the disease may not exist by it's own, but it's an early stage of a defined autoimmune disease, and the terminology "un differentiated connective tissue disease" is more appropriate to define this cases. a. baysan * , h.y. song, s. gupta, l. yel, irvine, ca. hereditary angioedema (hae) is an autosomal dominant disease characterized by episodic angioedema of the skin or mucosa of the respiratory and the gastrointestinal systems. hae is caused by a quantitative (type i) and/or functional (type ii) deficiency of plasma protein c inhibitor, an early component of the classical complement pathway. attacks of hae may be lifethreatening and even cause death when the airway is involved. here, we report a year-old female patient with hae type ii, who has seven affected family members, two of whom died of laryngeal angioedema. the patient had a history of recurrent swelling of the eyelids, lips, tongue and extremities, and respiratory distress since five years of age. she was hospitalized on several occasions one of which required intubation and assisted ventilation. laboratory studies, between the attacks, revealed normal serum ch and complement c levels. complement c level was decreased to mg/dl (n: - mg/dl). c esterase function was impaired, % (n: greater than %) in contrast to normal quantitative c esterase. the patient was on long-term danazol treatment for ten years and experienced side effects, most notably hirsutism. currently, there are limited efficacious and safe treatment options for hae. the treatment of choice for acute attacks and prophylaxis appears to be the c inhibitor concentrate, which is not yet licensed in the us. the present patient emphasizes the need to establish the correct diagnosis and an appropriate management plan in recurrent angioedema. j. hajsam * , l. ponomarjev, krasnodar, russian federation. background: the previous investigations indicate on the positive effects of ncir in different chronic inflammatory and infectious diseases. nevertheless, the mechanisms of the clinical efficacy of ncir remain still unknown. the aim of this investigation is the study of the immune disorders in patients with chronic tonsillitis and the immunomodulatory effects of the complex treatment in combination with ncir. methods: children with chronic tonsillitis in the age from to years old were under the observation. the t cell receptors (cd +, cd +, cd +, cd +, cd +, hla-dr+) have been studied using flow cytometry method. the cytokines (il , gamma ifn and il ) have been investigated by eliza method. the treatment include traditional methods in combination with ncir. control group (without tonsillitis) consists of children of the same age. results: it has been shown that in chronic tonsillitis was dcrease of the number of cd +, cd + and hla-dr+ cells. the decrease of cd + cells was mainly due to decrease of cd + cells. at the same time it has been shown the increase in number of cd + cells. in chronic tonsillitis have been determined the increase in serum proinflammatory cytokine il level in . times (p< . ). at the same time the levels of gamma ifn and il were lower than in control up to - times. the studied treatment method including ncir resulted in increase in the number of cd + and cd + cells. the level of il decreased from pg/ml to . pg/ml. at the same time the serum concentration of gamma ifn and il increased up to . and . times, accordingly. conclusion: in chronic tonsillitis it has been shown the immune disorders in t cell's subpopulations and cytokine production. the efficacy of ncir mainly depends on the normalisation in t cellular subpopulations and increase in the concentration of gamma ifn and il . introduction: viral hepatitis is characterized by suppression of cd +th cell function related to disease severity. the aim of our research was the determination of total ige concentration and anti-c q-autoantibodies levels in patients with viral hepatitis c (vhc) and mixed viral hepatitis (vhb+c) and the investigation of their correlation with t cell parameters. methods: patients with vhc and patients with vhb+c confirmed by pcr were examined. evaluation of serum total ige level was performed by elisa kits produced by "vector-best", russia. immunophenotyping of peripheral blood mononuclear cells (pbmc) was done by cytometry with monoclonal antibodies to cd , cd , cd , cd b, cd , cd , cd , cd and hla-dr-antigens. results: the level of serum total ige in patients with vhc and vhb+c was significantly increased in all groups studied, especially in acute hepatitis c ( . ± . mu/ml, p< . ) compared with the control group. analysis of pbmc subpopulations in patients with vhc and vhb+c was done related to the total ige level: group i - - mu/ml; and group ii -> mu/ml. in patients with viral hepatitis and high total ige level, the content of cd +t-lymphocytes, cd +t-cells and cd /cd ratio were significantly decreased compared with the control group (p< . ). more notable changes were found in patients with acute vhc and vhb+c. the increase in cd +-cell content was seen in groups with both low and high levels of total ige. the content of cd +-cells in patients with high levels of total ige was also increased (p< . ). conclusion: patients with vhc and vhb+c had significantly greater levels of total ige compared with the control group (p< . ). the increase in total ige levels in patients with viral hepatitis is associated with imbalances of t-lymphocyte subpopulations, including a decrease in cd +t-cells, and an increase in b-and nk-cells. title: occupational airway allergy among health care workers (hcw) with latex allergy. introduction: for the last years the frequency of latex allergy has increased. health care workers (hcw) is the risk group of this diseases. latex allergy symptoms occure in different organs -including skin, conjunctive, nose and bronchi. study aim:the aim of this study was to estimate the incidence of airway allergy in group of hcw with latex allergy. materials and methods: the investigations were carried out in a group of hcw, aged - (average age , ). there were two hundred and eight women and forty four men in the group. investigation consisted of questionaire examinations, skin prick tests (latex), patch tests (rubber additives), sige (latex) and spirometry. results: seventy eight ( %) hcw reported undesirable effects after the contact with latex products. fourty ( , %) hcw reported symptoms of airway (nose and bronchi). latex allergy (spt and/or sige and anamnesis positive) was diagnosed in ( , %) cases. the symptoms concerned with: skin, nose and conjunctive ( cases, %); skin and conjunctive ( cases, %); nose and conjunctive ( cases, %); nose and skin ( cases, %); bronchi, skin, nose, and conjunctive ( cases, %) and only skin in cases ( %). conclusions: the incidence of occupational airway allergy in group of health care workers with latex allergy is high ( % of all cases). latex allergy symptoms usually affect skin, but sometimes it includes also other organs -conjunctive, nose and seldom with bronchi. the incidence of anaphylaxis is increasing. the food allergy and anaphylaxis network wishes to expand the use of injected epinephrine by first responders to allergic emergencies. in indiana, there are , first responders, , basic emts, , advanced emts, and , paramedics. the use of injected epinephrine was only permitted by paramedics and advanced emts ( % of all responders). in a bill was introduced to expand the use of injected epinephrine by ems personnel in the event of an allergic emergency. it was sponsored by the indiana allergy asthma and immunology society and the emergency medical services commission of indiana. on july st senate bill no. took effect permitting all first responders to administer, without restrictions, injected epinephrine. once the legislation passed it became the responsibility of the medical director (md) of each ambulance service in the state to implement the change. in an attempt to assess the impact of this legislation we surveyed each of the mds in the state - months after the passage of the bill. mds were notified of the legislation by memo and public meetings. in addition each md received a copy of the legislation. of the mds, ( %) responded to the survey. results: . unaware of the legislation: ( %) . aware of legislation but no implementation: ( %) . aware of legislation with implementation restricted to basic emts: ( %) . aware of legislation and implementation at all levels: ( %) conclusions: twenty-five percent of mds were unaware of legislation. among those that implemented changes the majority ( %) permitted use by basic emts only. allergists, lay organizations, and ems commissioners need to assure implementation of legislation with all mds within the state. a. khadavi * , b. silverman , a. schneider , . great neck, ny; . brooklyn, ny. rabbit anaphylaxis is extremely rare, with one documented case upon inhalation only. we describe a patient with severe anaphylaxis upon consumption of a rabbit. a -year-old female with a -year history of asthma and allergic rhinitis was presented for evaluation. the patient complained of worsening asthma and rhinitis symptoms in the home and upon exposure to outdoor pollen. further history revealed the family had a rabbit as a pet. laboratory testing showed her total ige was ku/l, rast results were normal for tree, ragweed and molds (< . kiu/l). positive results were found for ragweed, dust, cockroach, cat, dog, mouse, peanut and rabbit epithelium ( . kiu/l, class iv). among other environmental control measures, the family was advised to eliminate the rabbit from the home environment, as it could be a potential trigger for their daughters allergy symptoms. two days later, the patient presented to the emergency room with wheezing, coughing and angioedema of the hands and face. she was treated with albuterol, diphenhydramine and oral steroids. the parents said they followed all of our instructions and did not know why anaphylaxis occurred. further questioning revealed that the family consumed the pet rabbit on the same night preceding the anaphylactic reaction. this was the first time the daughter ate rabbit. the parents assumed that only exposure to the live rabbit would worsen her allergy and asthma symptoms, never expecting an allergic reaction via ingestion. they were advised not to feed their daughter rabbit again and were given a prescription for self-injectable epinephrine. this demonstrates either complete identity, partial similarity or cross reactivity between inhaled and food allergens, as has been noted previously with certain other foods such as garlic and crustacean proteins. physicians need to advise food allergic patients that an allergic reaction can develop upon inhalation of the food, as seen with peanuts. but also respiratory sensitization to an allergen can lead to allergic symptoms upon its ingestion. t. nsouli * , j. scheiner , j. malka-rais , j.a. bellanti , . burke, va; . washington, dc. the safety of selective cyclooxygenase- (cox-ii) inhibitors in patients with known nsaid-induced allergic reactions has not been definitely established and is still open to debate. in the present report, we describe two patients with hypersensitivity reactions to naproxen, the first characterized by a systemic anaphylactic reaction and the second by localized urticaria following ingestion of the drug. the first case was a y/o wf with a history of osteoarthritis who, minutes after the ingestion of mg of naproxen, developed generalized pruritus, urticaria, laryngeal edema and hypotension. she was treated in the er with epinephrine, diphenhydramine and iv corticosteroids. epicutaneous and intradermal skin testing to celecoxib revealed negative results similar to a control. an oral challenge with celecoxib was well tolerated by the patient without any adverse responses. the second case was a y/o wf with a known history of chronic urticaria and osteoarthritis requiring regular use of naproxen. a complete allergic and immunologic workup was negative. upon discontinuation of the drug there was resolution of the urticaria. an oral challenge with celecoxib was well tolerated by the patient without adverse sequelae. these two case reports exemplify two extremes in the spectrum of adverse allergic reactions to naproxen, a non-selective cox-i and cox-ii inhibitor, one systemic, the second localized and suggest that the pathogenesis of these symptoms was most likely pseudo-allergic in nature and not immunologically-mediated. the dissimilar chemical structures of naproxen and celecoxib together with their differing mechanisms of action suggest that the absence of allergic reactions to challenge with celecoxib, a cox-ii inhibitor, may be related to a lack of cross-reactivity between the two drugs. although these findings suggest that oral celecoxib could be a possible safe alternative in patients with naproxen-induced drug reactions, it would be prudent to first conduct careful challenges with the drug in a well-equipped medical setting where clinical acceptability and tolerability could be safely assessed. introduction: most fixed and removable dentures are made from casting alloys. many orthodontic appliances are also fabricated from metallic biomaterials. it has been documented in vitro and in vivo, that metallic restorations release metal ions mainly due to corrosion. those metallic ions may be distributed systemically and locally and could pay a significant role in the induction of oral or/and systemic immunoinflammatory conditions. this study determines the frequency of sensitization to metal salts and clinical characteristics in the group of patients with complaints related to adverse effects of dental alloys. methods: patients ( women and men) aged - years with symptoms assumed to adverse effects of dental alloys were studied. all patients were studied with base metal salts, including cu + , co + , cr + , mg + , mn + , ni + , ti + , zn + using patch tests. all patch tests substances were % salts in petrolatum. the patch tests were conducted in accordance with recommendations of the icdrg. occlusion time was days, and patch tests were read when removing the patches (finn chambers on scanpor, epitest ltd oy, tulusa, finland) and to days later. the total number, percentage of irritant and allergic patch test reactions were calculated. results: in of patients ( %) sensitivity to base metals used in dental restorations was noted. symptoms included burning mouth ( %), metal taste ( %), electrical sensations ( %), dry mouth ( %), and taste irritation ( %), but / patients ( %) had no symptoms. local gingivitis ( . %), anomalies of the tongue ( %), stomatitis ( %) and lichenoid reactions ( %) were often seen. the most frequent patch test reactions were caused by ni ( %), cr ( %) and co ( %) . conclusion: this study demonstrated higher frequency of hypersensitivity reactions to ni, cr and co in this group of patients often having symptoms such as burning mouth, metallic taste, electrical sensation, local gingivitis, and anomalies of the tongue. w.y. mak * , s. kearney, b. silverman, a. schneider, brooklyn, ny. the process of intravenous drug desensitization often involves simple but tedious calculations. miscalculations may arise due to human error. for patients who are truly allergic to the drug in question, such errors can be life threatening, if not fatal. we propose the use of a spreadsheet to minimize such calculation errors. spreadsheets, such as microsoft excel, ibm lotus - - , and corel quattro pro, are used extensively in finance for tedious and repetitive calculations. this property of a spreadsheet makes it an ideal tool to assist with any drug desensitization protocol. we chose microsoft excel for its availability at our institution. a general template was initially created with equations in specific cells which were based on the protocols listed in patterson's allergic diseases, th edition and middleton's allergy: principles and practice, th edition. by inputting specific numbers, such as the amount of drug and volume of diluent into key cells of the spreadsheet, the program will automatically calculate the protocol for the given intravenous drug. an example of our pipericillin protocol is listed below. we find that the use of a spreadsheet not only minimizes calculation errors and hence reduces the likelihood of avoidable reactions; but also decreases our preparation time for the desen-sitization protocol. we recommend its use for all allergists performing drug desensitizations. states years ago, the infestation of homes across the northeast, southeast and midwestern states with these insects during the fall and winter months has become increasingly common. in the last years, several investigators have published case reports of patients with allergic rhinitis, conjunctivitis and asthma symptoms associated with suspected inhalational exposure to high levels of proteins from these beetles. we report a series of patients who presented with a spectrum of various allergy complaints ranging from symptoms of allergic rhinitis, asthma, urticaria, angioedema and acute anaphylaxis (with documented elevated serum tryptase) on exposure to high numbers of multi-colored asian ladybeetles(malb.) methods: we performed western blotting with the patients' serum and a whole-body ladybeetle extract made from confirmed h. axyridis obtained from one of the infested homes in that region. results: blots with the patients' serum revealed ige binding to different proteins with molecular weights approximately , and kd. the serum from two patients bound a kd protein possibly similar to the kd protein previously identified by yarbrough et al. jaci ; ; - . ige from four patients bound to an kd protein not previously reported. lastly, serum from two patients revealed ige binding to a kd protein possibly similar to the heavier proteins mentioned in an abstract by magnan et al. jaci ; ; . conclusion: we present five patients with specific ige to malb and allergic symptoms on exposure to high levels of malb. we conclude that malb are likely a significant source of several different allergenic proteins and that malb are increasingly becoming a significant cause of a wide variety of hypersensitivity reactions across the united states. as multiple exposed subjects and several entomologists report that these beetles bite humans, we speculate that a wide range of ige-mediated symptoms including urticaria, angioedema and anaphylaxis can occur by exposure to proteins by inhalation, direct contact and possibly by inoculation of these proteins into the skin by the bite or scratch of this beetle. a case report and literature review. c.s. taylor * , s. ramesh , . getzville, ny; . buffalo, ny. introduction: lentils belong to the legume family and are the staple ingredient of the ethnic indian diet. lentils have been shown to cause allergic reactions and even anaphylaxis. however, little research has been done to distinguish the types of lentils used commonly in the indian diet and their various hypersensitivities. some of these lentils include the black gram (phaseolus mungo), mung bean and split chick peas (bengal gram). case report: we report a -month-old indian boy who presented with severe atopic dermatitis since the age of four months. his dermatitis was exacerbated by the ingestion of peas and beans and resolved with the avoidance of such. at nine months of age, the child was introduced to boiled mung beans and subsequently developed lip swelling within a few minutes. a similar reaction occured with split chick peas. physical exam at consultation revealed severe eczema. skin tests using commercial extract revealed + response to peanut (he had never eaten peanuts), soybean, pea and egg. subsequent skin tests at the follow up visit to prepared reagents revealed much greater than + response to mung bean, chick pea, split chick peas, and black gram. the patient developed a systemic response during testing which required epinephrine. discussion: legume allergy (other than peanut, soy and peas) is rare in the unites states but has been reported in asia and the mediterranean area. it has been reported in one case series that patients with lentil allergy react to more than one lentil. there is a five percent cross reactivity between peanut and other legumes such as soy and peas. however, the extent of cross reactivity between peanut and the other legume sub-groups (ie. lentils) is not well documented. there also appears to confusion in the labeling of the various lentils used in ethnic diets. conclusion: this case has been presented to make allergists aware that there are many differnt types of lentils that can cause hypersenstivity reactions and the importance of considering ethnicity and dietary habits in evaulating for food allergy. background: epinephrine is the drug of choice for the treatment of anaphylaxis however it is frequently underutilized. one possible reason is the fear of adverse cardiac effects. the most common side effects of epinephrine are palpitations, tachycardia, sweating, nausea, vomiting, respiratory difficulty, pallor, dizziness, weakness, tremor, headache, nervousness, anxiety and arrhythmias. a previous study showed that administration of epinephrine, in a small number of healthy adults did not cause any significant cardiac adverse events and vitals sign changes were not clinically significant. the purpose of this retrospective analysis is to determine the safety profile of epinephrine in a large number of patients that were administered epinephrine for treatment of anaphylaxis that occurred in a physician's office. methods: all patients in an allergy office, that were administered epinephrine for acute anaphylaxis between - were selected for this retrospective analysis. a chart review for adverse events and vital was conducted. vital signs and side effects had been monitored every to minutes for minimum of to minutes after the administration of epinephrine. results: patients between the ages of yrs to yrs received injections of epinephrine. after an injections of epinephrine % of the patients had a pulse between - , % between - , and % between - . systolic blood pressure determined % of patients to be between - , with %, between - , and % between - , and % between - . concurrently, diastolic blood pressure was found to have % between - , % between - and % betweem - . the most common reported side effects were tremor, headache and pallor. any rise in blood pressure and heart rate after epinephrine was transient and returned to normal within minutes of observation. there were no serious side effects. all patients responded to the epinephrine and were able to go home. conclusions: this retrospective analysis revealed that the administra-tion of epinephrine is safe and effective for the treatment of acute anaphylaxis in an outpatient setting. the use of epinephrine for treatment of anaphylaxis is life-saving and its use to treat non-cardiac or elderly patients who have anaphylactic reactions should be encouraged. purpose: a clinical pathway was established to decrease the use of vancomycin in surgical patients with self-reported penicillin (pcn) allergy. methods: in , our institution developed a preoperative evaluation (poe) clinic for elective surgical patients. in june , on-site, same-day allergy consultation and penicillin skin testing was made available for preoperative patients with self-reported pcn allergy. we reviewed the antibiotic recommendations, the actual administration of vancomycin, and compliance by the surgeons with our recommendations from july , -september , . results: during this time, , patients were seen for their preoperative medical exam at the poe clinic, and were evaluated for pcn allergy. of these, patients met irb standards to participate in the study. the mean age of the patients was years. the top three surgical specialties represented in the poe clinic were orthopedic ( . %), urology ( %), and neurosurgery ( %). of the patients, underwent skin testing for pcn allergy. eighty-five percent ( %) or of these patients with a history of pcn allergy were recommended to use -lactams such as cefazolin, and ( %) were recommended to avoid -lactams. forty-three ( ) or % had one or more positive skin tests to pcn. of the patients, patients actually received pre-operative antibiotics. of these patients, ( %) of those received cefazolin, ( %) received clindamycin, ( %) received ciprofloxacin, ( %) received levofloxacin. some patients received more than one antibiotic for prophylaxis. only ( %) patients received vancomycin. conclusions: establishment of a clinical pathway in a preoperative clinic that includes allergy testing and consultation reduced vancomycin use to only % in surgical patients with a history of penicillin allergy. h. yarmohammadi * , a. nowak-wegrzyn, new york, ny. introduction: anticonvulsant hypersensitivity syndrome is a potentially fatal drug reaction with cutaneous and systemic reactions to the arene oxideproducing anticonvulsants. in most cases, the hallmark features of fever, rash, and lymphadenopathy are accompanied by multi organ-system abnormalities. fatal outcomes are most often associated with liver failure. recognition of the syndrome, which may have variable presentations, is the key to prompt discontinuation of the drug, close monitoring, and management. case : a y/o male received dilantin for seizure prophylaxis following craniopharyngioma resection. fourteen days later he was readmitted for fever and csf leak from surgical site. he was started on ceftriaxone and vancomycin empirically; an lp and pan culture was done. he continued to have low grade fever and, on the th day of admission, developed a maculopapular rash on trunk. on day th lfts increased and cbc showed eosinophilia. antibiotics were stopped but lfts continued to rise. on day , dilantin was stopped and lfts normalized in days, fever stopped and rash disappeared. case : a y/o girl was admitted to the hospital with generalized rash, facial edema and fever ( degrees c). she developed a pruritic maculopapular erythematous rash over her trunk and face weeks prior to admission. she then developed high fever. three months prior to this visit she had been started on phenytoin ( mg/kg) for control of grand mal seizure. physical exam revealed cervical and axillary lymphadenopathy. she had elevated wbc ( , ), eosinophilia ( %), and elevated lfts. phenytoin was stopped upon admission but hours later she continued to have fever, elevated lfts and devel-oped erythema in her mouth. treatment with ivig and prednisone was initiated and resolution of symptoms was seen within - days after therapy. conclusions: the timely recognition of anticonvulsant hypersensitivity syndrome is important, because accurate diagnosis prevents potentially fatal re-exposure and influences subsequent anticonvulsant treatment options. ivig and prednisone should be considered in situations where prompt improvement of the lfts or clinical symptoms is not observed. the recently published results of a telephone survey about the prevalence of seafood allergy in the us indicate that seafood allergy is a significant health concern. aim of the present study was to retrospectively review our data on the topic. we have interviewed subiects attending our allergy outpatients about any suspected food allergy. over % were years or older. any reaction to food was reported by % of the patients, more frequently by women. of these patients, reported reactions to seafood ( %) with an overall prevalence of seafood reactions of . %: to fish ( . %), to shellfish (including mollusks) ( . %) and to both ( . %). in the case of the reactions to fish it is quite possible that shellfish is also included, as the patients were often unable to tell the role of finfish from shellfish apart. this is most probably due to the fact that seafood dishes or a complete seafood meal in italy generally include both shell and finfish. in only less than half cases there was a convincing relationship between the ingestion of seafood and the reaction. the reactions reported were: gastrointestinal ( ), non life-threatening angioedema ( ), mild oral allergy syndrome ( ), acute urticaria ( ), asthma ( ), rhinoconjunctivitis ( ). the gastrointestinal reactions might not all be true (ige-mediated) allergic reactions, but also toxic. in conclusion, even in a selected population like that attending an allergy clinic and using a broad definition of adverse reaction, seafood allergy appears to be a rare phenomenon and of limited clinical impact, the prevalence of moderate to severe reactions (angioedema and asthma) in the whole selected population being . %. clopidogrel (plavix) is an antithrombotic agent currently used to prevent thrombotic cardiovascular events by inhibiting adenosine diphosphate (adp)dependent platelet activation. clinically, it has been used in patients with aspirin intolerance or who developed neutropenia from ticlopidine. there have been reported cases of clopidogrel causing rash and urticaria. often these patients are told they are allergic to clopidogrel and should not take it again, despite the fact that no workup was ever performed to elucidate whether the reaction was indeed immunologic in nature. a review of the literature revealed no reported attempts at desensitizing a patient to clopidogrel after a presumed immunologic drug reaction. we present the case of a year-old female who initially took clopidogrel ( mg. p.o. daily) for transient ischemic attacks. after tolerating the medicine for five days, it was replaced with an aspirin/warfarin combination, which she took for the next five days. reintroduction of clopidogrel a week later was uneventful, until she developed a pruritic, maculopapular rash on the th, through th days of restarting therapy. at that time, she was not taking any other medications, and had no cardiopulmonary or gastrointestinal complaints. she had discontinued the clopidogrel and was asymptomatic during our consultation. skin testing was done using clopidogrel prepared at concentrations of mg/ml and / mg/ml. at the same time, control skin testing on three non-atopic subjects was performed and produced no reaction to either epicutaneous or intradermal testing. by contrast, the patient had a positive skin reaction at both concentrations on intradermal testing. the patient was hospitalized for an oral desensitization where clopidogrel dilutions were prepared by the hospital pharmacy. the patient tolerated an initial dose of . mg. serial three-fold increases in concentration were given every minutes, until a total cumulative dose of mg. was reached. the patient tolerated the entire procedure and suffered no adverse reactions upon continuation of the treatment. this demonstrates the utility of oral desensitization to clopidogrel in patients with a positive skin test who require this medication. lamotrigine is a non-aromatic anticonvulsant with desirable pharmacological profile. the most common idiosyncratic reaction in children is rash ( - %). severe cutaneous adverse reactions and systemic hypersensitivity reactions are uncommonly reported. method: case presentation an -yearold caucasian female was prescribed lamotrigine in escalating dose for her first generalized seizure. a week later she developed a pink rash on her cheeks gradually progressing to her trunk, hands and feet. three days later she was seen in the er and treated for possible streptococcal-pharyngitis with fever and rash. oral penicillin-v treatment was initiated. the rash continued to spread all over her body with mild pruritis and sores on lips and mouth. few blisters were noted in left ear, hands and feet. later lamotrigine was discontinued. oral steroids were prescribed. she continued to develope new blisters, rash and hemorrhagic plaques and dysuria. she was later transferred to our institute. the physical examination was significant for afebrile girl without pallor and icterus. bilateral conjunctivitis without keratitis evident. tender cervical lymphadenopathy was palpable. multiple ulcers on lips and gingiva were seen. several targetoid lesions on trunk and extremity were noted along with few hemorrhagic plaques on extremities. superficial sloughing of distal fingers and toes was noted. nikolskys sign was not demonstrable. the systemic examination was unremarkable. laboratory tests: hemoglobin . g/dl, wbc-normal range without eosinophilia. normal pt/aptt and inr. liver function tests showed elevated sgpt- iu/ml and sgot- iu/ml with normal bilirubin. urine analysis was normal. serology for cmv, ebv, hsv and hepatitis a and b was negative. skin biopsy showed full thickness epidermal necrosis and sub epidermal clefts. aggressive supportive therapy was initiated. corticosteroids were continued for five more days. prior to being discharged from hospital the rash had dried and most lesions faded. the blisters and oral ulcers had healed. the liver enzymes had decreased. conclusions: we report an occurrence of stevens-johnson syndrome with lamotrigine in a young child. in the literature severe reactions are associated with higher doses or rapid escalation of the dose, and concomitant use of valproate. early recognition and withdrawal of medication is necessary to improve the outcome. introduction: in patients with a history of penicillin (pcn) allergy and negative pcn skin tests to major and minor determinants, - % of patients will tolerate pcn administration without risk of an immediate reaction. in fact, middletons allergy principle & practice reported that no life-threatening false-negative reactions have been reported when pcn was administered after a negative pcn skin test. we describe a case in which a patient with a history of pcn allergy and negative pcn skin tests to the major and minor determinants experienced life-threatening anaphylactic shock when administered piperacillin/tazobactam. case history: a -year-old woman with crohns disease was admitted for treatment of an enterocutaneous fistula. three months before admission, the patient reported a severe reaction to either piperacillin/tazobactam or intravenous (iv) lorazepam needing respiratory support in the intensive care unit. in order to delineate this problem, an allergy consultation was obtained. serum ige antibodies to pcn, measured by a commercial cap system radioallergosorbent test (rast) fluoroenzymeimmunoassay (feia; pharmacia and upjohn, uppsala, sweden), and pcn skin tests to major and minor determinants were negative. a skin test (prick and intradermal) to piperacillin/tazobactam at . mg/ml was also negative. five minutes into receiving . grams of piperacillin/tazobactam iv, the patient reported feeling lightheaded, flushed, nauseated, and diaphoretic. the blood pressure decreased to / from a baseline of / , heart rate /minute and appeared toxic. no wheezing or rash was noted on physical examination. patient was treated with iv epinephrine, diphenhydramine, and dexamethasone and recovered without sequela. serum tryptase, drawn hour after the beginning of the reaction, was elevated at . ng/ml but decreased to . ng/ml hours later. complement levels were normal. conclusion: despite a very high negative predictive value of a negative pcn skin test to the major and minor determinants and reports that no life-threatening false-negative reactions have been reported when pcn is administered after a negative pcn skin test, physicians need to be very cautious in administering piperacillin/tazobactam and other b-lactams in patients with a history of severe reactions such as anaphylaxis to past pcn administrations. a. majmundar * , d.a. khan, dallas, tx. introduction: a variety of adverse drug reactions have been reported after therapy with allopurinol. successful protocols for desensitization to allopurinol have been developed. we report a case of a patient who was successfully desensitized to allopurinol only to develop dress after four months of allopurinol therapy. methods: a year old man was referred to our department with a remote history of rash and fever resulting in hospitalization after initiation of allopurinol. due to severe gouty arthritis unresponsive to colchicine and requirement of chronic steroids, it was recommended to attempt allopurinol desensitization. based on the history of his prior reaction, a slow desensitization protocol was performed beginning with allopurinol μg and increasing the dose weekly to μg, μg, μg, μg, μg, mg, mg, mg, mg, mg, and mg. the patient tolerated the entire desensitization protocol without adverse reaction and was initiated on daily allopurinol at mg per day. results: four months after desensitization and daily allopurinol use, the patient developed fevers and an acute maculopapular eruption on his back and abdomen without mucosal involvement. laboratories demonstrated eosinophilia of cells/mm , elevated ast of , alt of , and ggt of u/l. he was treated with prednisone mg a day which was tapered weekly over weeks with successful resolution of his symptoms, eosinophilia and transaminitis. conclusion: while desensitization to allopurinol can be safely accomplished, allergists need to be cognizant of the potential for delayed serious drug reactions such as dress. wiskott aldrich syndrome is an immunodeficiency characterized by eczema, pyogen infections, and mixed immunodeficiency.we describe a male seven-month old, perinatals antecedents without importance who had an ulcer in site of application of bcg. non-blood relatives, healthy parents. at twomonths-old, he initiated with continuous fever, not quantified, treated with multiples antibiotics without resolution, he was hospitalized, plaquetopenia and anemia were diagnosed, he received a red globules and plateles transfusion, one week after he presented a disseminated dermatosis characterized by erythema and desquamation, at four-month-age presented right axillary adenomegaly, hepatoesplenomegaly and recurrent bilateral media otitis for what was hospitalized in our institute. he was malnutrition, bad general condition, febrile, with disseminated dermatosis affecting the head, trunk and extremities characterized by erythema and desquamation, in addition he had left ankle cellulitis, right axillary adenomegaly, hepatoespenomegaly. during his hospitalization he presented left hand cellulitis, hairy skin abscess, oral candidiasis, required surgical treatment by econdary compartimental syndrome because cellulitis of left ankle. persistent hemogram reported thrombocytopenia with normal platelet volume, blood cultives were positive for grampositive bacterias, isoaglutinines, were normal. immunoglobulines were elevated for the age range, he received antimicrobial and antifungic treatment. but he died. in the autopsy timic alymphoplasia was reported, cortical lymphoid depopulation in lymphatic ganglia and spleen, disease by disseminated cytomegalic inclusion, multifocal pulmonary pneumocystosis, bcgitis, disease graft versus guest. . with the previous features we concluded in a compatible mixed immunodeficiency with wiskott-aldrich syndrome with particular characteristics that make this case interesting. the patient course with cellular immune deficiencie with thrombocytopenia and eczema, even when he didn't have platelet sizing diminished, we consider that the patient had a severe of wiskott s aldrich syndrome and at the moment we are awaiting result of genetic study uasp gene. background : hypersensitivity to mosquito bites (hmb) is a disorder characterized by necrotic skin reaction and systemic generalized symptoms subsequent to mosquito bites. it has been suggested that hmb is associated with chronic epstein-barr virus (ebv) infection and natural killer cell leukemia/lymphoma. we describe here a korean child who had hmb associated with chronic ebv infection and natural killer cell lymphocytosis. case : a -year-old male was admitted with well-demarcated necrotic skin lesions and severe swelling on right ear lobe developed after mosquito bites. he had suffered several similar symptoms since last summer, which complicated as deep scars on skin. hepatosplenomegaly or peripheral lymphadenopathy was not detected. laboratory tests showed wbc , /mm (neutrophil %, lymphocyte %), total eosinophil count /mm , ige by prist above , iu/m. immunoglobulin levels were normal. specific ige for aedes communis by cap was negative. lymphocyte subset analysis demonstrated increased nk cells (cd +cd , %) and decreased cd and cd cells. igm for anti-nuclear antigen (ebna), igm for viral capsid antigen (vca) and igm for anti-early antigen (ea) dr to ebv were negative. but the levels of anti-vca igg (> u/ml), anti-ea dr igg (> u/ml) and anti-ebna igg ( u/ml) were increased. type a eb virus was demonstrated in blood mononuclear cells by dna pcr method, and eber in situ hybridization was negative in necrotic tissues. immunostaining with nk-cell marker (cd ) revealed many immunoreactive cells with the perivascular inflammatory infiltrates in tissue. skin patch tests for mosquito allergen (aedes togoi and culex pipiens) showed positive response to c. pipiens. introduction: scimitar syndrome is a congenital anomaly resulting in anomalous pulmonary venous return from the right lung to the inferior vena cava. recurrent respiratory infections have been associated with scimitar syndrome. methods: we report on a year-old adolescent female who presented to immunology clinic with recurrent pneumonias. results: the patient presented with numerous recurrent pneumonias, multiple er visits, and hospitalizations. she complained of intermittent chest pain, cough, fatigue and exercise intolerance. the patient had a large secundum atrial septal defect surgically corrected at years of age. a cardiac echo obtained at years of age revealed rvh, but was normal at years of age. she was a known atopic asthmatic. previous immunologic workup was normal with iga ( - ), igg ( - ) and igm . at presentation to our clinic pulmonary functions were fvc of % and fev of %. review of previous chest radiographs showed chronic changes with an opacity partially obscuring the right hemidiaphragm. a high resolution chest ct-scan showed a large irregular venous structure extending through the right chest joining the inferior vena cava above the liver consistent with scimitar syndrome. the patient was referred to pediatric cardiology who recommended surgical correction. conclusion: scimitar syndrome may present as recurrent pneumonias and chronic lung disease. a high resolution chest ct scan may be useful in delineating this disorder. background: laryngomalacia is the most common cause of stridor in infants but only rare reports exist of clinically relevant laryngomalacia in adults. objective: to present a case of laryngomalacia in an adult with significant respiratory symptoms initially attributed to asthma. methods: an year-old female with a history of allergic rhinitis and gastroesophageal reflux disease presented to the allergy clinic for further recommendations regarding a prior diagnosis of asthma poorly controlled on inhaled fluticasone, montelukast and albuterol. the patient was clinically diagnosed with asthma at age due exercise related symptoms. the symptoms progressed and intermittent trials of various inhaled steroids provided minimal relief. on evaluation, the patient described constant wheezing which occurred only on inhalation and originated from the throat. symptoms did not respond to albuterol use three to four times a day, rhinitis control and long-term, high-dose, antireflux therapy. baseline spirometry was normal. histamine bronchoprovacation and fiberoptic laryngoscopy were performed for further evaluation. results: histamine challenge was positive with a % decrease in fev with mg/ml histamine. however, laryngoscopy revealed redundant airway tissue most notable over the right arytenoid cartilage, consistent with laryngomalacia, which prolapsed into the laryngeal vestibule significantly obstructing the airway on inspiration only. the patient was referred to otolaryngology and surgical excision using a carbon dioxide laser was performed with subsequent improvement in symptoms and decreased asthma medication use. conclusions: we report an unusual case of laryngomalacia in an adult presenting as asthma, which was successfully treated with laser surgical excision. laryngoscopy of the patient revealing redundant airway tissue most notable over the right arytenoid. c. so * , s. kuhl , . davis, ca; . mather, ca. c. so, s. kuhl u.c. davis medical center, sacramento, ca & sacramento va hospital, mather, ca background: wheezing is an uncommon manifestation of phrenic nerve dysfunction. objective: we offer a description of wheezing attributable to phrenic nerve dysfunction to remind clinicians that dyspnea and wheezing can be caused by cor pulmonale which can be caused by phrenic nerve dysfunction. methods: a -year old male non-smoker presented with chronic dyspnea and occasional wheezing for the last decade. the patient had a remote history of pericardial stripping for presumed tuberculous pericarditis. he also had a non-productive cough and orthopnea. dyspnea was exacerbated by putting his hands over his head and bending over. he had been treated with inhaled corticosteroids and bronchodilators without relief. results: repeated chest x-rays showed a chronically elevated right hemidiaphragm. pulmonary function tests showed a restrictive pattern with: fev . ( %), fvc . ( %), tlc . ( %), dlco/va . ( %) and no bronchodilator response. left heart catheterization was normal while right heart catheterization showed elevated pulmonary artery pressures ( / ) and he was subsequently diagnosed with cor pulmonale. cardiopulmonary exercise testing showed an increase in minute ventilation which was achieved predominantly by an increase in respiratory rate rather than to an increase in tidal volume suggesting restrictive or interstitial lung disease. chest ct showed left ventricular enlargement and no evidence of interstitial lung disease. a fluoroscopic sniff test was performed and showed paradoxical movement of both diaphragms. he was diagnosed as having diaphragmatic dysfunction as a result of phrenic nerve injury from prior pericardial stripping. conclusions: wheezing and chronic dyspnea can be related to phrenic nerve dysfunction. a review and discussion of various causes of phrenic nerve dysfunction, including autoimmune causes, is offered. patients with a history of prior cardiothoracic surgery who present with recalcitrant dyspnea and wheezing may benefit from evaluation for phrenic nerve dysfunction. background: sudden sensorineural hearing loss (ssnhl) is defined by a loss of at least db in contiguous frequencies over a time course of hours or fewer. etiologies of ssnhl include viral infections, ototoxic drugs, autoimmune diseases, trauma, neoplasms, and vascular occlusion, but viral labyrinthitis is the most common cause. in cases of sudden hearing loss, herpes infections can be reported in approximately % of cases caused by viral infections. typically, sensorineural hearing loss is not recurrent. we report a case of recurrent ssnhl is which oral herpes lesion preceded the onset of symptoms on three consecutive episodes. case report: a -year-old male with a history of hypertension, hypothyroidism and chronic tinnitus of the left ear (since a gunshot wound years prior) presented to clinic with a complaint of recurrent episodes of sensorineural hearing loss. the first episode of bilateral hearing loss occurred months prior. an otolarnolgologist treated with a steroid taper and valacyclovir and the hearing loss resolved after one day of therapy. since the initial presentation, the patient reports three subsequent episodes of ssnhl, with two of the episodes responding to prednisone and valacyclovir and one episode responding to steroids alone. oral herpetic lesions preceded at least three of the episodes one day prior to the hearing loss. laboratory data was significant for an elevation of varicella-zoster igg, and of hsv igg. hsv igm was not performed. rpr was non-reactive and ana was negative. a mri of the head was normal. audiogram demonstrated db increase and speech discrimination improved from % to %. the rest of the laboratory data was unremarkable. the patient has been maintained on daily valacyclovir therapy and has had no further episodes of hearing loss. conclusion: our patient experienced hearing loss with concomitant evidence of hsv- stomatitis. this suggests a cause and effect relationship. we found that the antiviral therapy was effective for treatment of the ssnhl in this patient as demonstrated by the absence of further symptoms while on antiviral prophylaxis and conclude the most likely etiology of the recurrent hearing loss was secondary to the recurrent herpes simplex infections. abstract the illness was described for the first time in in the chinese literature by kimm, and szeto, the definitive histological description was published by kimura in , this illness is endemic in asia, but rare, about cases had been reported. kimura disease is extremely sporadic in the rest of the world. the etiology of this disease is ignored but it is believed that there is an aberrant immune reaction to an unknown antigenic stimulus, however epstein barr's virus, human herpes virus and candida albicans had been involved in certain cases. the mast cells had been implicated in its pathogenesis and a th cytokine pattern with the production of interleukin , and rantes which regulate the synthesis of ige and orchestrate the eosinophilic infiltration. on the other hand it is suggested that the eosinophils had undergone an accelerated apoptosis in this illness. case report. it is a year-old boy with a months evolution with the presence of bilateral subcutaneous nodules of x cm in parotid and submaxillary glands, presenting hypereosinophilia ( total eosinophils ) and high ige ( total ige), with normal renal function and negative mycotic and parasitic tests.the histopathologic findings revealed the presence of eosinophilic infiltrates with capillary proliferation and fibrosis. discussion. for the clinical characteristics of the nodules together with the hypereosinophilia, extremely high ige and the characteristic histological lesions the diagnosis is kimura disease. the usual clinical presentation consists on several indolent subcutaneous nodules that grow very slowly in volume, located in the neck and head, accompanied by satel-annals of allergy, asthma & immunology lites adenophaties, and with increment in the salivary glands, there is renal affectation in half of the patients, and the laboratory detects hypereosinophilia and elevation of the total ige. the histological lesions, shows hyperplastic lymphoid tissue with proliferative germinal centers, with infiltration of eosinophils in their interfollicular and perivascular zones sometimes forming an eosinophil abscess and proliferation of poscapillary venules. at the moment he have been treated with prednisone ( mgkdia), with great improvement in the clinical evolution. this is the first case reported in the literature in mexico. introduction: the incidence of cow's milk protein allergy (cmpa) is approximately - % and presents primarily during the first year of life. manifestations of cmpa in the neonatal period include gastroenteritis, colic, lethargy, metabolic acidosis, and hematochezia or melena and appear to be non-ige mediated. ige mediated reactions in the neonatal period, such as urticaria or angioedema, are unusual. case: a -day-old african-american male presented with a day history of rash, swelling, and erythema overlying multiple joints. there was no history of fever, diarrhea, or eczema. he had been on no medications prior to admission. besides mother with a history of childhood asthma, there was no family history of atopy or food allergy. he had been fed cow's milk-base formula (similac ® ) since birth exclusively. physical examination revealed a diffuse erythematous, raised, macular-papular rash, with areas of duskiness and exfoliation. there was angioedema overlying the joints and periorbital areas (figure ). laboratory evaluation included cbc with diff, hgb electrophoresis, lumbar puncture, urinalysis, c q (qualitative and quantitative), c , c , c , and cultures of the blood, csf, and urine which were within normal. percutaneous allergy skin testing for cow's milk allergy was performed revealing a + reaction to cow's milk extract (greer, lenoir, nc) with positive histamine and negative saline controls. rast testing showed . ku/l for -lactoglobulin and . ku/l for cow's milk. he was placed on an elemental formula. skin lesions and swelling resolved completely within hours. at week follow-up the patient was thriving without complaint. conclusion: early sensitization to cow's milk protein in the neonatal period may occur, resulting in ige mediated urticaria and angioedema. the rashes may be misdiagnosed as erythema multiforme or anaphylactoid purpura, since hemorrhagic lesions and cockade pattern are common. physicians should be aware that these reactions may occur so that early recognition and management may be initiated. neonate with periorbital angioedema and exfoliating, urticarial rash. rationale: two patients, presenting with invasive fungal cns infections, were found to have nk cell dysfunction and hypogammaglobulinemia. methods: case reports results: patient # : a year old caucasian male presented with headache, double vision, periorbital swelling, and bilateral sinus disease on ct scan. biopsies showed invasive rhinocerebral mucormycosis. he continued to deteriorate in spite of iv and intrathecal amphotericin b, hyperbaric oxygen, many debridement procedures, and a left orbital exenteration. immune evaluation revealed low igg, low igm and a barely detectable nk cell killing activity. neutrophil respiratory burst was normal. he continued to worsen despite ivig replacement. he had intolerable side effects to ifn-a. gm-csf ( mcg qod) was initiated, in order to boost nk cell activity. this resulted in stabilization of his infection. he was discharged on oral anti-fungal therapy (posaconazole), ivig, and gm-csf. sixteen months later, he continues to remain stable clinically and radiographically on ivig and gm-csf. patient # : a -year-old caucasian male presented with headache, mental status changes, and ataxia. a head ct scan showed a left mass effect and edema. he underwent surgical debridement for ventriculitis and zygomycetes (the same family as mucormycosis) was found. he was started on iv amphotericin b and oral posaconazole. his immune evaluation revealed low igg and igm and low nk cell activity. neutrophil respiratory burst was normal. he was started on ivig and gm-csf after which his nk cell function improved significantly. he remains clinically stable on ivig and gm-csf with persistent radiographic evidence of enlarged ventricles. conclusion: hypogammaglobulinemia is usually not associated with invasive cns fungal infections, suggesting that nk cell dysfunction was likely responsible for the clinical courses of these patients. nk cell deficiency has been reported to be associated with recurrent mucosal candidiasis, suggesting an important role for these cells in the control of some fungi. the spectrum of the clinical presentations of nk cell deficiency is not known since it is not normally included in immune system evaluations. these patients illustrate the importance of including functional nk cell assessment in any evaluation of immune function. introduction: to report a case of successful systemic hydrocortisone desensitization, since allergic reactions and systemic desensitization to corticosteroids have rarely been documented. method: we present a patient with multiple medical problems who has a history of both radiocontrast induced anaphylactoid reaction and corticosteroid allergy. this patient had to undergo cardiac catheterization and corticosteroid desensitization was performed prior to the procedure. results: skin testing to radiocontrast is not considered helpful, therefore patients with suspected reactions to radiocontrast are generally premedicated with corticosteroids and antihistamines to decrease the risk and severity of a reaction. , since this patient experienced an allergic reaction to a corticosteroid previously, she was skin tested to two different corticosteroids. the least reactive skin test revealed a + positive immediate reaction to hydrocortisone. cardiac catheterization with contrast was considered absolutely necessary in this case and corticosteroid desensitization was performed. the half-life of hydrocortisone is the shortest among the tested corticosteroids ( - minutes), so a protocol was developed with short intervals of escalating doses. each dose was diluted yielding a total volume of ml to avoid fluid overload because patient has renal failure. during desensitization, patient developed pruritus and erythema between the rd and th dose that resolved immediately with mg diphenhydramine. after desensitization, the patient continued to be on hydrocortisone mg intravenously every four hours. one hour prior to the procedure, the patient was premedicated with hydrocortisone and diphenhydramine and was administered radiocontrast without any adverse reactions. conclusion: we successfully desensitized our patient to a corticosteroid and premedicated her with hydrocortisone and diphenhydramine before administering radiocontrast. this case illustrates that intravenous desensitization may be a suitable approach to therapy in corticosteroid allergic patients who require systemic corticosteroids administration. autoimmune neutropenia is defined as a decrease in the absolute number of peripheral neutrophils caused by an immunologically-mediated mechanism. autoantibodies directed to neutrophils can lead to the peripheral destruction of neutrophils and/or inhibit myelopoesis in the bone marrow. although recurrent aphthous stomatitis is often the heralding sign of neutropenia, the diagnosis of ain requires the demonstration of specific antineutrophil antibody which acts by promoting the immune destruction and clearance of neutrophils by mononuclear phagocytes. the present case report describes the rare clinical association of ras in an adult. a yr-old black male presented with a year history of recurrent and repeated painful multiple oral ulcers. initially the oral ulcers occurred on a monthly basis then over time the ulcerations on the oral mucosa and tongue began to appear weekly and later continuously. past medical history revealed no drug allergies but a positive history of hypertension. physical exam revealed an otherwise healthy male with no lymphoadenopathy or splenomegaly. laboratory workup revealed : hiv negative, viral culture for h. simplex negative, mild increase in cd , cyroglobulins negative, anti dsdna negative anti-smith and rnp negative, wbc count /ml, neutrophils % (anc ), lymphocytes %, monocytes %, and platelets: , . bone marrow biopsy revealed a normal production of neutrophils. a direct neutrophil antibody assay: revealed an elevated value of , (n= < , ). although following initiation of prednisone ( mg) an immediate increase in anc was seen, the levels fell as the dosage was tapered. the figure below shows the time course and dose-response relationship of anc and prednisone dosage. this case report illustrates the importance of recognition of the relationship of ras and neutropenia, an association that can masquerade as other clinical entities. background: dyspnea, wheezing, and decreased fev are suggestive of asthma. it is essential for the clinician to consider a broad differential diag-nosis as the outcome could be catastrophic if the correct diagnosis is missed. case presentation: we present a case of a y.o. filipino female who was referred to our clinic for the evaluation of cough, shortness of breath, and wheezy respiration associated with changes in voice quality, nasal and palatal pruritus, and postnasal drainage. her initial evaluation revealed mold spore hypersensitivity by prick puncture testing and spirometry with an obstructive pattern with fvc- . l ( %) and fev - . l ( %) predicted and a % reversibility post nebulized albuterol. an initial diagnosis of allergic rhinitis with adult onset asthma was made and she was started on salmeterol, budesonide, montelukast, and pirbuterol. her symptoms persisted and rabeprazole was added to treat possible laryngopharyngeal reflux. repeat spirometry revealed fev - . l prompting treatment with systemic corticosteroids again with no improvement. fiberoptic laryngoscopy was within normal limits. a high resolution computed tomography was obtained and showed a mass in the left side of the trachea which was obstructing % of the airway. bronchoscopy revealed a tumor - cm below the vocal cords with the appearance of adenoid cystic carcinoma which was confirmed by pathology. the tumor was resected by removal of cm trachea with re-anastomosis, followed by a week course of radiation therapy. all medications were discontinued. her symptoms of wheezing, dyspnea, and cough completely resolved. repeat spirometry was within normal limits and she remained asymptomatic. surveillance bronchoscopies have been negative for any recurrence. discussion: adenoid cystic carcinoma (acc) is an uncommon form of malignant neoplasm that occurs within the salivary glands. tracheobronchial acc typically presents with symptoms of cough, dyspnea, and hoarseness. due to its slow growth, acc has a relatively indolent course. in a recent study of a cohort of acc patients, survival was % at years but only % at years. standard therapy is surgical resection often followed by radiotherapy. conclusion: in patients who fail conventional therapies for asthma it is important to entertain other diagnosis and have a systematic approach to establish the correct diagnosis. ipex is an extremely rare, hereditary condition characterized by immune dysfunction, polyendocrinopathy, enteropathy and x-linked recessive inheritance that leads to death without prompt diagnosis. patients usually present by months with severe diarrhea, failure to thrive, and early onset iddm. most children die by one year without a bone marrow transplant. immunologic evaluation is typically normal except for elevated ige, eosinophilia, and autoantibodies. we report a case of ipex in an infant who presented at birth and died at days of multi-organ system failure. this male infant was born at weeks due to chorioamnionitis and prom. at birth, copious green fluid appeared from his rectum and ng tube which evolved into a secretory diarrhea. workup for fistula was negative. at weeks, the patient developed ascites and explorative laparotomy revealed an inflamed appendix. after the laparotomy, the patient had no further stool output and never tolerated enteric feeds. he remained intubated and had problems with apnea and coagulapathy. pathology of the appendix showed an excess of lymphocytes. immune system investigation showed elevated ige ( ) and igg ( ). serum anti-enterocyte igg antibody was positive in the patient and negative in his mother. based on this data, ipex was suspected which autopsy seemed to confirm. autopsies are scarce in patients with ipex. the findings revealed many organs affected by fibrosis but lymphocyte infiltration of only the pancreas and gi tract. the pancreas revealed almost complete loss of the exocrine structure, with invasion of fibrosis and chronic inflammatory cells. the mucosa of the gi tract from the stomach to rectum showed columnar epithelium taken over by fibrosis, capillaries and chronic inflammation. these inflammatory cells were cd + lymphocytes and plasma cells on immunochemistry. the lymphoreticular system was consistent with lymphoid paucity in the thymus, lymph nodes and spleen. preliminary data suggests this patient has a splice mutation of the foxp gene. ipex is an extremely rare disease, often difficult to diagnose while a patient is alive. infants will present in early infancy with diarrhea and endocrinopathies. without prompt diagnosis, death is inevitable. as a result, one must be aware of atypical presentations and considered in patients with total villous atrophy and one other clinical feature such as iddm or autoimmunity. introduction: digeorge syndrome (dgs) is characterized by thymic hypoplasia, parathyroid hypoplasia, and conotruncal cardiac defects, but has a wide variety of clinical manifestations. there is also an increased risk for autoimmune phenomena in later life due to thymic hypoplasia. case report: a year-old aa girl with tetralogy of fallot (repair at age ), developmental delay, asthma, recurrent sinopulmonary infections/skin abscesses, gerd, arthralgias and seizure disorder (due to hypoxic encephalopathy during cardiac surgery) presented to allergy/immunology clinic for immune workup. there was no history of documented hypocalcemia. at age , she developed persistent annular patches on her left leg. a skin biopsy appeared consistent with sarcoid dermatitis. there was no other evidence of sarcoidosis except for slightly elevated ace level. given lack of systemic involvement, the skin lesions were not treated, but resolved spontaneously. at age , she developed swelling of the right mandible, and a bone biopsy revealed garre's osteomyelitis (sterile hyperproliferative osteomyelitis), likely triggered by dental caries, with elevated esr ( ) and polyclonal hypergammaglobulinemia (igg ), but normal crp. immune workup revealed a decrease in cd and cd cells (cd /cd ratio . ), slightly elevated b cells, high-normal range nk cells, normal range t cell cytokine production in response to mitogens and il- , but excessive production of proinflammatory cytokines in responses to lps. in conjunction with facial dysmorphism, dgs was suspected, and fish analysis revealed q . microdeletion. a repeat workup did not reveal evidence of systemic sarcoidosis, and autoantibody screening was negative including lupus anticoagulant. she was treated with a cox- inhibitor, secondary to gerd and mild thrombocytopenia, and her joint symptoms resolved with a concurrent decline in esr (to ) and igg level (to ) after months. conclusion: recurrent infections with fragmented care and resultant chronic inflammation (hence overstimulation of the immune system) may have led this dgs patient to develop atypical autoimmune phenomena and other unusual clinical manifestations. this case illustrates the importance of recognizing the phenotypic features of dgs early in life, and of providing close monitoring and coordinated care. rationale: we report a case of a patient with celiac disease who continues to have symptoms of fevers, nausea, vomiting, night sweats and fatigue despite being on a gluten free diet whose symptoms have been responsive to antihistamines. methods: case report. results: in , this year-old white male suffered from mononucleosis and episodes of prostatitis. he began suffering from fatigue and fevers and was followed at a chronic fatigue syndrome center in . in november , patient was placed on famvir alleviating his sore throat. he was later placed on interferon gamma which was discontinued due to increased fevers, nausea and vomiting. after stopping medication, symptoms abated for sometime. in , patient's father was diagnosed with celiac sprue. in april of , the patient developed a pruritic rash on his right arm. biopsy revealed subepidermal vesicles with pmn's at the tips of dermal papillae. in may of , he developed oral ulcers as well as joint pains. patient underwent endoscopy with biopsies revealing intraepithelial lymphocytosis in the duodenum. patient has been on a strict gluten free diet since october . he reports that some symptoms have improved: skin lesions, itchy eyes, and oral ulcers. however, he has begun to suffer from constipation and continues to intermittently have night sweats, fevers, nausea and vomiting. in february of , he had pruritus that was not alleviated by hydroxyzine. a regimen of benadryl and pepcid was started to aid with the pruritus. the patient reported in the improvement of his symptoms of pruritis, sweats, and emesis. conclusions: diagnosis: celiac disease(cd) patient with persistent nausea, vomiting, sporadic fevers, and fatigue despite maintaining a strict gluten free diet has shown improvement of symptoms with antihistamines. patient has history of chronic infections: prostatitis and chronic ebv. patient also reported alleviation of symptoms after interferon therapy suggesting some autoimmune component to his current illness. cd prevalence in the united states is much higher than once thought . - % of the u.s. celiac disease has been associated with increased risk of lymphoma and malabsorption leading to neurological diseases. this is a rare case of cd associated pruritus responding to antihistamines. rationale: eosinophilic cystitis is a relatively rare condition in children and adults with a varied course. it usually responds to short-term nsaid and steroid therapy. we report a man with a severe case who responded to prolonged oral steroids. case report: a year old caucasian man with a prior esophageal cancer s/p esophagectomy, diabetes, hypertension, allergic rhinitis and chronic obstructive pulmonary disease presented with suprapubic pain, urinary frequency, dysuria, and hematuria. urinalysis showed numerous red blood cells and bacteria but no malignant cells or eosinophils. he was treated with antibiotics with resolution of symptoms. several weeks later he experienced severe suprapubic pain and hematuria resulting in a symptomatic drop in his hemoglobin. he underwent a cystoscopy and biopsy that revealed a chronic cystitis with an inflammatory infiltrate containing numerous eosinophils. he was unresponsive to treatment with nsaid and intravesicular dmso and was then referred to our service. we started prednisone mg/day but the dysuria and hematuria persisted. prednisone was doubled plus a third generation quinolone was added. three weeks later the hematuria and dysuria resolved and he was asymptomatic. the antibiotic was stopped and prednisone was gradually tapered over several weeks. whenever his steroid dose dropped below mg/day he experienced an exacerbation of his symptoms. over the last three years this dose of prednisone has kept his symptoms abated and his renal function stable. conclusion: eosinophilic cystitis is an uncommon diagnosis of unknown etiology. we describe a patient with debilitating suprapubic pain and symptomatic anemia from the hematuria associated with eosinophilic cystitis. for over three years since we first saw him, continued therapy with mg of prednisone/day has prevented exacerbations. this case is unique in the severity of the hematuria experienced and the prolonged relatively low steroid dose needed to suppress exacerbations. we propose that in eosinophilic cystitis patients with severe hematuria who may otherwise be candidates for a cystectomy, a trial of prolonged oral prednisone may be beneficial. rationale: allergic reactions to insulin occurred more frequently in the past, with porcine and bovine preparations. in contrast, allergic reactions to human insulin preparations are now reported in < % of patients treated with insulin. insulin allergy may be manifested as an immediate-type ige-mediated reaction, delayed type hypersensitivity or as serum sickness, varying in severity from mild discomfort to life-threatening events. we present a case to illustrate that an insulin allergy may complicate hospitalization and often be misdiagnosed. methods: a y.o. diabetic female with a history of "insulin allergy" was evaluated. the patient is a long standing diabetic controlled on oral hypoglycemics but required insulin during acute illnesses and hospitalizations. the patient was unable to recall previous types of insulin she had received. during previous hospitalizations, the patient complained of vague symptoms of fatigue, parasthesia, sweating, anxiety, and palpitations. on one occasion the patient had a syncopal episode with hypotension and on another occasion the patient developed a rash and dyspnea after receiving sq insulin. the physcian intrepreted the findings may be due to hypoglycemic. an allergic reaction was not suspected and the patient never underwent any testing. during a recent hospitalization, the patient's history was reviewed and a formal allergy consult was obtained. she underwent epicutaneous and intradermal testing to human insulin preparations. insulin antibody levels were also obtained. results: the patient had negative epicutaneous testing to all human insulin preparations. however, on intradermal testing, the patient had positive reactions to lispro, nph, and lente and negative intradermal tests to insulin glargine and regular insulin. igg and ige insulin antibody test results were < . conclusion: hospitalized patients receiving multiple medications commonly experience pharmacologic, adverse and/or allergic reactions. it is necessary to obtain a thorough history and document all reactions that patients experience to determine what type of event occurred. with a suspicion of drug allergy, skin testing and/or rast assay may provide insight into possible ige mediated reactions. in this case we advised the patient that she may use regular insulin during hospitalizations and that insulin glargine can be used to help achieve optimal glycemic long term control. background: hereditary angioedema type iii (hae iii) is a recently described form of angioedema occurring exclusively in females and characterized by normal c , c inhibitor (c inh) protein and function. hae iii is thought to have an x-linked or autosomal dominant mode of inheritance. we evaluated a year old female with recurrent facial swelling, abdominal pain and laryngeal edema with a family history of similar symptoms in several female relatives. case report: a year old african american female presented with a two year history of recurrent lip, tongue and facial swelling. she also had abdominal pain, diarrhea and shortness of breath. episodes were not associated with hives. her symptoms predated menarche and did not correlate with her menstrual cycle. at the time of presentation she described an increase in frequency of her symptoms that did not respond to antihistamines (diphenhydramine, cetirizine) or prednisone. the patient had no other medical problems. family history was significant for recurrent episodes of facial, lip and tongue swelling in a maternal aunt, grandmother and great grandmother. the patient's great grandmother required tracheal intubation with ventilator support for upper airway compromise. the patient's physical exam was unremarkable. laboratory values drawn during an acute episode of swelling revealed: c inh function = > % (normal > %), c inh protein = mg/ml (normal - mg/ml), c = . mg/dl (normal - mg/dl). dna sequencing at exon to investigate the possibility of an unusual c inh mutation with normal c s binding but abnormal kallikrein inhibition was negative. other lab tests included a normal mast cell tryptase of . mcg/l, a negative rf and ana, a normal angiotensin converting enzyme of u/l (normal - u/l) and positive skin prick tests to a variety of foods which the patient tolerates. based on two case reports of treatment of hae iii with androgens, the patient was started on danazol mg daily with symptomatic improvement. conclusion: hae iii is a rare disease that affects females exclusively. clinically it is indistinguishable from c inh deficiency. the mechanism of inheritance remains to be elucidated. it is unclear why danazol appears to ameliorate symptoms even though there is no evidence for c annals of allergy, asthma & immunology inhibitor dysfunction in this disorder. we believe this to be the first kindred of hae iii reported in the united states. r. dworski * , m. peters, nashville, tn. a four-month-old female identical twin was evaluated for noisy breathing and recurrent cyanosis. she was delivered at weeks of an estimated gestational age after an uncomplicated pregnancy. at birth she was intubated for hours for respiratory distress but the remainder of her neonatal period was uneventful. at age weeks she developed a noisy breathing often associated with cyanosis, particularly in a supine position or while crying. treatments with inhaled albuterol and prednisolone were ineffective. she had no respiratory infections or symptoms of gastroesophageal reflux disease. her growth was normal. her twin sibling was well. the family history was negative for allergies or respiratory conditions. initially she was diagnosed with tracheomalacia. however, the history of cyanotic episodes prompted a search for a definitive diagnosis. she underwent bronchoscopy which showed tracheomalacia when breathing spontaneously and circumferential narrowing of lower trachea likely due to compression. echocardiogram revealed a double aortic arch. the finding was confirmed by computed tomography angiography which demonstrated the presence of a vascular ring composed of double patent aortic arches, each giving rise to the ipsilateral carotid and subclavian arteries. the airway was normal at the aortic inlet, but narrowed markedly at the level of the two arches. a surgical division of the ductus ligamentous and distal anterior vascular arch was performed. aortic arch abnormalities should be suspected in all infants with hoarse coughing or noisy breathing, especially during inspiration but sometimes also during expiration. the diagnosis should also be considered in older children with recurrent bronchitis or pneumonia. respiratory symptoms are more frequent than gastrointestinal manifestations. diagnosis usually occurs in the first year of life. a surgery is often the treatment of choice. postoperative complications are relatively rare. outcome of surgery should be judged after months, including at least one winter season. malacia can delay extubation and recovery following surgery. surgical cure occurs in approximately % of patients. surgery is probably less successful in children with double arches and malacia. a. thatayatikom * , a.j. white, st. louis, mo. background: common variable immunodeficiency (cvid) is the commonest symptomatic primary antibody deficiency syndrome in which b lymphocytes produce low levels of immunoglobulin, leading to recurrent bacterial infection. although hypogammaglobulinemia and susceptibility to the recurrent infection are seen in all patients, other associated conditions such as a non-infectious granulomatous disease have been well described in cvid. corticosteroid therapy has been used with improvement in a subset of cvid with granulomatous disease; however, its treatment remains problematic and a new therapeutic agent is needed. tumor necrosis factor (tnf ) has been demonstrated as a primary mediator in granuloma formation and maintenance. therefore, anti-tnf medications are potentially therapeutic agents of the granulomatous disease. case report: a -year-old caucasian male with cvid and severe granulomatous disease was treated successfully with infliximab, a chimeric anti-tnf monoclonal antibody. the patient initially presented with high fever, chills and abdominal pain; subsequently, he developed acute respiratory failure and adult respiratory distress syndrome. the patient was hospitalized and he required intensive care with ventilatory support. his diagnostic tests revealed elevated sedimentation rate and positive epstein-barr virus (ebv) capsid igm antibody. imaging studies demonstrated bilateral diffuse pulmonary infiltrates and hepatosplenomegaly. open lung and liver biop-sies revealed non-caseating granulomatous lesions without evidence of ebv or other infections. high dose corticosteroid therapy was given with partial improvement, then high dose infliximab ( mg/kg) was given weekly with remarkable improvement. the patient was able to wean off ventilator successfully within weeks and his prednisone dose was dramatically decreased. infliximab infusion ( mg/kg) every weeks and low dose prednisone were continued. a follow-up liver biopsy after months of the infliximab showed no granulomatous lesions. infliximab was discontinued after months of the treatment. there was no serious infection or complication during the period of treatment. conclusion: anti-tnf therapy may be a safe and effective treatment and may allow corticosteroid dose reduction. future clinical studies of anti-tnf therapy in cvid with granulomatous disease are warranted. background: chrug-strauss syndrome is a disorder characterized by hypereosinophilia and systemic vasculitis occurring in individuals with asthma. objetive: to present a pediatric case suffering from a systemic vasculitis. this case fulfilled the churg-strauss syndrome clinical criteria and the histophatology findings were compatible with the diagnosis. case: a year female came to our institution with the diagnosis of severe asthma, chronic sinusisits and polyps requiring high doses of steroids. there was no history of administration of antileukotriene receptor antagonists. months before her admission she presented weight loss, fatigue, cephalea and cough. on physical examination, pallor, respiratory difficulty and signs of bronchospasm were evident. tachycardia and hepatomegaly were also documented. the laboratory test showed anemia, eosinophilia /dl, anca+, sgot , stgop , ige elevated ui/ml. the chest-x ray showed patchy opacities in both lungs and cardiomegaly. pulmonary scintigraphy reported low perfusion in both lungs, predominantly in the left lung.echocardiography demonstrated signs of myocarditis and eyection fraction of %. an open lung biopsy was executed and vasculitis with fibrinoid changes affecting small and medium vessels was reported. treatment was started with oral prednisone mg/kg/d and cyclophosphamide pulses with a satisfactory evolution. discussion: to our knowledge this is the first pediatric case of css reported in mexico. she fulilled the following criteria. asthma, eosinophilia and systemic vasculitis involving the heart, liver and lungs. the disease is extremely rare, specially in mexico. aggressive treatment is necessary as in this case, with a favorable outcome. introduction "all that wheezes is not asthma" is a well-known aphorism among physicians. this same principle exists for patients that present with lip swelling in the allergist's office. we describe a patient who presented with fluctuating lip swelling who was ultimately found to have cheilitis granulomatosa. case history a -year-old male with a history of allergic rhinitis and asthma presented to the allergy clinic with lower lip swelling and occasional upper lip swelling. he was receiving allergen immunotherapy for dust mites and trees. the swelling had been waxing and waning for years, but became more persistent for the previous six months. he denied tongue/throat swelling, dysphagia, respiratory distress, or any triggers for the swelling. chapstick® and vaseline® were used topically on his lips. failed treatments included loratadine, ranitidine, cetirizine, fexofenadine, and montelukast. he was placed on a one-week course of prednisone, which decreased his lip swelling, but it recurred after completion of the treatment. physical exam was significant for diffuse, firm lower lip edema to - times the normal size. there were no oral lesions or tongue swelling. patch testing to a standard panel, preservatives, oral flavors, and dental acrylate was negative. punch biopsy revealed a noncaseating epithelioid granulomatous inflammation consistent with granulomatous cheilitis. he was placed on minocycline mg by mouth twice daily with little benefit. an -week course of oral prednisone resulted in improvement of the lip swelling. conclusion melkersson-rosenthal syndrome (mrs) is a rare syndrome that is characterized by a triad of recurrent facial paralysis, chronic edema of the face and lips, and hypertrophy and fissuring of the tongue. cheilitis granulomatosa is considered a monosymptomatic form of mrs and manifests as a chronic swelling of the lips caused by granulomatous inflammation. the swelling is typically not tender and may be either soft or firm. allergists are often consulted for lip swelling thought due to angioedema. however, as this case illustrates, not all lip swelling is angioedema and one must consider other diagnoses such as melkersson-rosenthal syndrome and cheilitis granulomatosa. progressive multifocal leukoencephalopathy (pml) is a disorder of the nervous system that affects individuals with immune suppression. it has been associated with hiv infection and is present in nearly % of patients with acquired immune deficiency syndrome. the jc virus, a common human polyomavirus, causes this demyelinating disorder. progressive symptoms reflect the multifocal distribution of brain lesions, and include mental deterioration, vision loss, speech disturbances, ataxia, paralysis, and, ultimately, coma. in rare cases, seizures may occur. there is no known treatment for pml. we report a year-old (y/o) male with months weight loss and a sudden onset of confusion, lethargy, and progressive loss of cognition requiring hospitalization. upon questioning he was found to have had recurrent upper respiratory tract infections since infancy successfully treated with antibiotics. as a child he had atopic dermatitis, exercise induced asthma, and myringotomy tubes placed twice. at y/o, he underwent a nasal polypectomy. in , at y/o, a squamous cell carcinoma was removed, and he developed benign cervical lymphadenopathy and common warts. a year later he developed hsv esophagitis. the remainder of his history was unremarkable with normal development and growth and no history of drug abuse, multiple sexual partners, or homosexual contacts. on physical examination, he was thin, ill appearing, with oral ulcers, generalized scanty lymphoadenopathy, multiple common warts on both feet, and occasional ronchi. a brain mri showed a demyelinating process consistent with pml. pcr for jc virus was positive, while hiv pcr was negative; total immunoglobulins and cd counts were low ( we are reporting a year old female with a year history of moderate persistent asthma, who was started on xolair mg sq q wks., and who then presented with a presumed allergic reaction. three hours after her second xolair injection, patient reported developing dizziness, shortness of breath, and felt like she was having an allergic reaction. she was evaluated and observed for two hours in an emergency department. the treating physician reported no wheezing and felt there was no need for treatment. to rule out psychogenic factors, she was given a placebo injection at the next scheduled visit. ten minutes later she reported developing throat tightness and shortness of breath. she had no changes in her peak flows and her lungs were clear. her "symptoms" resolved completely within minutes of receiving placebo epinephrine and nebulized normal saline. patient was informed she had reacted to a placebo injection, as well as placebo epinephrine and albuterol, and counseled. the patient returned to the office every week for the next three weeks to receive blinded injections. she subsequently did not react to either doses of placebo or xolair. she has since tolerated her monthly xolair injections without incident. this case illustrates the importance of ruling out psychologic causes of presumed allergic reactions. introduction :latex allergy, type i ige mediated hipersensitivity, occurs specially in high risk populations, like in patients that have undergone various surgeries. case: a year old boy with asthma and allergic rhinitis since , penicillin allergy and retrospectively, his mother refers lip edema with balloon inflating.at years of age ( ): left orchiorrhaphy because of cryptorchis. between - : surgeries because of sacral giant melanocitic naevus.during the fourth surgical intervention ( ct - ) to collocate a tissue expander, the patient presents perioral and fingertip cyanosis, generalized cutaneous rash and severe bronchospasm.ap: / mmhg, hr x/min. he was treated with iv fluids, steroids, antihistamines and inhaled racemic epinephrine.at the icu his final outcome is satisfactory. laboratory: total ige : . iu/l, skin prick test with glove extract, raw and natural latex extract and purified latex proteins(pseudoeveine, molecular hevein, hev b . and modified hevein)all positive +++. western blot with protein extract of latex positive and elisa with purified latex proteins ( same as above) positive. the last surgery to withdraw the tissue expander was performed with latex free surgical equipment without any problems. discussion: the patient's risk factors for latex allergy are atopy and repetitive exposure to latex articles because of surgery. he presents mild manifestations of latex allergy, till he finally develops full-blown anaphylaxis. diagnosis was made based on clinical history, skin prick test, western blot with protein extract and elisa with purified latex protein. he had a favorable outcome withdrawing latex during the last surgery. introduction: churg-strauss syndrome (css) is a form of primary vasculitis that is a rare diagnosis in an elderly patient. case report: a year old woman presented with a week history of fatigue, vomiting, diarrhea, abdom-inal pain, and right lower leg paresthesia. prior to admission she was being treated for left neck erythema and adenopathy presumed to be cellulitis. she was in good health with no history of atopy until the age of , when she developed both chronic sinusitis, requiring bilateral sinus surgery and polypectomy, * and new onset asthma, * that required systemic steroid control. prednisone was tapered month prior to admission. objective findings included coalescent non-blanching petechiae on her abdomen, peripheral eosinophilia of ( %), * normochromic normocytic anemia, rf= , esr= , ige= , igg= . ana, p and c-anca were negative. ct showed ascites and pleural effusions. egd revealed duodenitis with ulceration and eosinophilic infiltration on biopsy. echo showed pericardial effusion and septal motion abnormality. troponin of without cad was consistent with subepicardial myocarditis. emg confirmed right peroneal neuropathy.* skin biopsy revealed a dense superficial and mid-dermal perivascular and interstitial eosinophilic infiltrate. additional evaluation excluded malignancy, infection, and abpa. treatment with prednisone, mg/kg/day was initiated. a rapid clinical improvement ensued and has persisted. {*acr criteria for css}. discussion: churg-strauss syndrome is a rare form of vasculitis with mean age of onset within the third and fifth decades. it is an uncommon cause (< %) of systemic vasculitis in patients older than . the formes frustes of css is a variant in which early manifestations of the syndrome are hidden by oral and systemic steroids employed in the treatment of worsening asthma often associated with css. this variant makes expedient identification of css more challenging. delayed recognition contributes to a relentless progression of this entity resulting in a systemic vasculitis with multi-organ involvement. early diagnosis, especially in the prodromal and eosinophilic phases, is essential. untreated, css has a high rate of morbidity and mortality. therefore, css and the formes frustes variant must be an integral component in the differential diagnosis of patients presenting with adult onset asthma and/or recurrent sinusitis. common variable immunodeficiency (cvid) is the most prevalent of the primary immunodeficiency diseases. cvid is a heterogeneous group of immunologic disorders of unknown etiology, characterized by impaired antibody responses, hypogammaglobulinemia with normal b cells. the common immunologic defect in patients with cvid is defective antibody formation, and many different immune system defects have been reported in this group of patients. most patients, really, have no identified molecular diagnosis. cvid consists of several different genetics defect. the immunologic defect in cvid is a failure of b-lymphocyte differentiation into plasmacells. b lymphocytes from these patients failed to differentiate into ig-producing cells when stimulated with pokeweed mitogen in vitro, even when cocultured with normal t cells. an overwhelming body of literature suggests that most patients with cvid have intact b lymphocytes of immature phenotype. however the functional classification of cvid patients on the basis of in vitro ig production is time consuming. recently has been proposed a new classification based on the quantitative repartition of memory b cell according to the dual expression of igd and cd . we present a case of a yr old boy. he presented soon in his life frequent infections, of particular severity: pneumonia, meningoencefalitis, sepsis, bronchitis, otitis, linfoadenitis. he also had a -thalassemia intermedia. this clinical manifestations suggested an immunodeficiency. for this reason at years of age serum immunoglobulin and antibody detection showed a reduction in igg subclass and in cd + cells, with normal total igg, iga, igm, normal cd /cd ratio, normal cd , isohemagglutinins and in vitro t cell function. there was also a defective antibody production after tetanus, diphtheria, pertussis immunization. these laboratory findings did not allow, however, a sure diagnosis for cvid. a new immunological evaluation at the age of years old, after the onset of splenomegaly, and enlarged lymph nodes, demonstrated a b memory defect, with a severe deficit of t lymphocytes function in vitro. it was also possible to find a severe deficiency of cd + cells, meaning a defect in memory b cells: we can therfore label this condition as a cvid. in the past two decades there have been conflicting views regarding the clinical importance of igg subclass deficiencies in children. igg subclass plays a vital role in the immune response to polysaccharide antigen. isolated igg subclass deficiency may be widespread and often asymptomatic in children. however, in association with other subclasses and/or other immunoglobulin classes, there may be a significant, symptomatic outcome. the reported patient was diagnosed with familial dysautonomia (fd) at the age of five weeks, presenting with severe hypotonia and tachypnea. hindered by poor pulmonary function, he was hospitalized over fifteen times for recurrent pneumonias, including four lengthy intensive care admissions. daily inhaled-corticosteroids and brochodilator therapies were initiated, along with chest therapy via a high frequency chest wall oscillator. immunoglobulin levels were measured recently and point to low levels of igg , igg and total iga antibodies: igg mg/dl (n - ), igg mg/dl (n - ), igg . mg/dl (n . - . ), igg < . mg/dl (n . - . ), and total iga mg/dl (n - ). since receiving monthly ivig therapy he had no further recurrence of pulmonary infections and was slowly weaned off daily brochodilator therapy. the currently accepted theory is that low igg subclass levels may be associated with increased risk of bacterial infections only in selective groups. fd patients may be in a distinctively susceptible population in which igg levels are critical. the older brother, who was also diagnosed with fd, demonstrated igg , igg and iga levels that were slightly higher but nevertheless on the lower end of the normal range. he suffers from less invasive and less frequent bacterial infections. this may support a genetic association between the fd and hypogammaglobulinemia. alternatively, it may signal that fd patients may have a prolonged variant of transient hypogammaglobulinemia of infancy. follow-up immune profile studies, post-ivig trough levels and broader investigations of the fd population are necessary to determine the severity and prevalence of these findings. pulmonary failure is the dominant cause of death in patients with fd. prompt diagnosis and effective treatment of the associated immune deficiency may be proven essential in the effort to enhance and prolong their lives. s. hassan * , j.a. grant, galveston, tx. rationale: common variable immunodeficiency (cvid), a rare primary immunodeficiency presenting in young adults with repeated sinopulmonary infections as a result of profound hypogammaglobulinemia, was first described by suri et al. (ann acad. med. singapore, ) . we describe a young man with diagnosed but untreated cvid and its eventual course. case description: a -yr-old caucasian male hospitalized secondary to chronic pneumonia and respiratory failure was noted to have non-existent levels of immunoglobulins. history revealed ivig treatment at age , stopped after a year due to non-compliance. although untreated, he denied recurrent sinusitis, otitis media, or bronchitis for almost years but notes a recent inability in keeping up with baseball practice. he is the last of ten healthy siblings. patient started monthly ivig infusions but was noted to have hypertension ( / ), tachycardia ( - ), tachypnea ( - ) on the th month with o saturation of - % and po of % on room air. with a -day history of acute dyspnea, calf muscle and right abdominal pain, he was admitted to the hospital and pulmonary thromboembolism was ruled out. laboratory data: humoral functions (pneumococcal, tetanus toxoid, and hepvac) -undetectable t cell function (mumps, candida, ppd) -normal immunoglobulin (igg, iga, igm) -undetectable flow cytometry -b and nk cell markers normal, mild decrease in the cd /cd ratio high resolution ct thorax -bronchiectasis, bronchial wall thickening, and obstructive changes with airtrapping. minute walk -desaturation to % on l o by nc bnp - echocardiogramestimated ef - %; severe pulmonary hypertension. cardiac catheterization -normal coronary arteries, severe pulmonary hypertension (pa pressure / ). conclusion: cvid patients have a reasonably good prognosis on treatment. untreated cvid is associated with chronic lung infections, bronchiectasis, pulmonary hypertension and right heart failure. although, lung transplant became available during the early eighties (nejm ), this extremely invasive but life saving procedure was undertaken in a patient with cvid and end-stage pulmonary hypertension in (thorax ). lung transplant may be the only way of ensuring survival for this patient. introduction chronic eosinophilic pneumonia (cep) is a rare disorder of unknown etiology characterized as a chronic and relapsing interstitial lung disease with blood or tissue eosinophilia. cep occurs more often in women with preexisting atopic disease. patients with cep respond rapidly to systemic corticosteroids, but often relapse with short, low-dose courses of therapy. while uncommon, extrapulmonary involvement, such as arthralgia, cutaneous purpura, pericarditis, and hepatitis, have been reported. we present a case of a patient who has cep with pericardial effusion. case report the patient is a non-smoking -year-old woman with a past medical history significant for allergic rhinitis and asthma who initially presented with a four-month history of worsening shortness of breath, dyspnea on exertion, dry, non-productive cough, and weight loss (approximately five pounds). her symptoms were refractory to increased dosages of inhaled fluticasone. she then developed intermittent fever up to °c. chest x-ray revealed bilateral apical infiltrates. treatment with levofloxacin for seven days resulted in no improvement of symptoms or roentographic findings. thereafter, she presented with chest and abdominal pain, hypotension, and hypoxia. blood work revealed a white cell count of c/mm with a differential significant for % eosinophilia (absolute eosinophil count of c/mm ). chest ct showed dense consolidation predominantly along the peripheral aspect of the upper and superior segment of the lower lobes, and pericardial effusion. moderate pericardial effusion without evidence of tamponade was confirmed on echocardiogram. left upper lobe wedge biopsy findings included significant tissue eosinophilia, scattered foci of active organizing exudates, and no evidence of granulomatous or necrotizing vasculitis. the patient was treated for cep with a six-month course of prednisone, starting at mg daily, resulting in rapid improvement of her pulmonary and systemic symptoms. background: immunologists are consulted for evaluation of immunodeficiency in patients with recurrent skin infections. disorders of the phagocyte system may be associated with cutaneous infections. methods: case report case: a -month-old african american girl (twin a) presents with recurrent skin abscesses. at months of age, she had her first buttocks abscess, which required incision and drainage with oral antibiotics. a month later, she developed another abscess and was found to be neutropenic, with an absolute neutrophil count (anc) of /μl. cyclic neutropenia was considered and her pediatrician monitored cbcs, which all showed persistent neutropenia (ancs between and ). at months of age, she was hospitalized for fever with neutropenia. immunology was consulted for evaluation of neutropenia. the rest of the past medical history was unremarkable. she was healthy appearing and growth parameters were appropriate for age. her physical examination was unremarkable. immunoglobulins, b-and t-cell markers, nitroblue tetrazolium, complement assay, hemoglobin, platelets and the peripheral smear were normal. antibodies for hiv, cmv, ebv and parvovirus were undetectable. anti-neutrophil antibodies were positive, establishing the diagnosis of primary autoimmune neutropenia (ain). the abscess healed with oral antibiotics. severe neutropenia (anc - ) persisted for three subsequent months without further infections. twin (b) was also found to have persistent severe neutropenia without morbidities, suggestive of primary ain. primary ain is less known among physicians and is typically diagnosed after extensive investigations that exclude other causes of neutropenia. the exact incidence of ain is unknown. it is usually seen in children between and months of age, often with severe neutropenia and self-limiting bacterial infections. the clinical course and presence of antibodies to neutrophil antigens (na , na or cd b/ ) is diagnostic. familial occurrence of primary ain is not reported in the literature. conclusion: primary ain may remain under diagnosed due to lack of characteristic clinical features. although a benign clinical course is likely, severe infections, including pneumonia, sepsis and meningitis, have been reported. genetics may play a role in this disease, as we present primary ain in twins. background: atopic dermatitis (ad) is a chronic inflamatory disease of skin that affects % of the wordl population.the natural history of ad in some patients, evolve to the coexistence with other allergic diseases: allergic rhinitis, allergic conjunctivitis and asthma. the sublingual immunotherapy has demonstrated utility in some patients; however, semi-rush immunotherapy to pollens has only showed utility in one animal case published few years ago. case report: a -year-old infant was referred to us. he began one year before with skin lesions compatible with ad, six months later began perennial rinhorrea and nasal itching. multiple treatments with topic corticosteroids, moisturizing, antihistamines and topic/systemic antibiotics did not demonstrate utility. our evaluation revealed ad lessions that affected % of the total body surface and clinical features of allergic rhinitis (ar).the lab tests revealed eosinophylia ( cell/mm ) in blood cell count, normal levels of total ige but specific ige to dermatophagoides pteronissinus (dpt) was high. the skin prick test reveales the same results. we added environmental control, oral costicosteroids and transfer factor. despite our treatment no improvement was observed. we considered dpt as the principal factor in the maintenance of ad lessions and ar episodes. in the absence of sublingual immunotherapy in our hospital, we decided for semi-rush immunotherapy schedule. we began from . ml of : , w/v concentrations of dpt until , ml of : w/v concentrations in two months receiving three doses per week. no local or systemic adverse events was reported and the ad lesions and ar symptomatology disappeared in the first month of treatment. at this time, no exacerbations have been documented. conclusion: the semi-rush immunotherapy can be useful and safe for treatmente of ad in some patients in whom specific ige to aeroallergens has been demonstrated. introduction: eosinophilic gastrointestinal disorders are a rare group of disorders that can involve the entire gastrointestinal tract. presentations are varied but may include vomiting, dysphagia, abdominal pain, diarrhea and failure to thrive. the diagnosis is made by endoscopic biopsies which reveals eosinophil rich inflammation in the absence of known causes for eosinophilia. peripheral eosinophils and ige may be elevated but can be normal. we report a patient with eosinophilic gastroenteritis associated with an ampullary tubulovillous adnenoma. methods:a -year-old white male with allergic rhinitis and a family history of atopy was admitted for profuse watery diarrhea. he denied any new medications, eating raw foods or recent travels. eosinophils were elevated to . ( % of wbc) and ige was elevated to . multiple stool specimens were negative for ova & parasites and enteric pathogens. serology was negative for strongyloides, trichinella, e. histolytica and toxocara. ast, alt & bilirubin were elevated and a ct scan showed dilated billiary ducts with a possible ampullary mass. biopsy of the ampullary mass revealed a tubulovillous adenoma. biopsies of the duodenum, terminal ileum, colon and rectum were remarkable for focal eosinophilic cryptitis & chronic inflammation in the lamina propria consisting of eosinophils, scattered lymphocytes and histiocytes. all specimens were negative for parasitic infections including duodenal aspirates. he was empirically started on metronidazole and singulair with gradual improvement of symptoms, eosinophils and liver tests. two months after discharge, the patient remained diarrhea free with a normal eosinophil count. conclusion: we report a patient with eosinophilic gastroenteritis and an ampullary tubulovillous adenoma with obstruction of the biliary system. this unique presentation illustrates the diverse nature of gastrointestinal manifestations seen in eosinophilic gastroenteritis. background: zonisamide is an anti-seizure medication chemically classified as a sulfonamide and unrelated to other ant seizure agents. we report a case of hypersensitivity to this agent in a child. method: case report results: this patient is a -month-old girl who developed "peeling of her lips" three weeks after starting zonisamide. one week later she developed a rash that began on her face and generalized over several days to her neck, trunk and extremities. there was no respiratory distress, joint complaints and no angioedema associated with the episode, but fever to prompted referral to our hospital on day of the rash. the rash was macular-papular without discrete urticarial lesions. the rash coalesced with underlying erythema on face, chest and neck. the patient has a known history of seizure disorder, asthma, mild eczema, gastro esophageal reflux, development delay, lactose intolerance and failure to thrive. her other medications were, lansoprazole, topiramate, and albuterol. labs revealed a normal white cell count, an elevated sed rate ( ) and elevated lft's, i.e. sgot and sgpt . the only new medication was zonisamide that was discontinued. she was treated with iv steroids and hydroxyzine. the rash started fading by day and the patient's fever resolved by the third hospital day. liver enzymes returned to normal by day . conclusion: this relatively new anti-seizure agent can be associated with hypersensitivity reactions in children. introduction: kawasaki disease (kd) is an acute chilhood vasculitis. in addition to the diagnostic criteria a broad range of nonspecific clinical features may be observed including aseptic meningitis, vomiting, diarrhea, abdominal pain, sterile pyuria, arthralgia and arthrtis, pulmonary infiltration, pleural effusion and nonspecific paralytic ileum as manifestation of gastrointestinal vasculitis. we describe a child who developed all features of kawasaki disease included the most rarely reported. patient report: a year-old female presented days of high fever, nonsuppurative cervical lymphadenopathy, petequial rash in legs, swelling of feet, distended abdomen, vomiting, obnubilated and hypoactive, incongruent speech, fisured lips and distended abdomen. lab tests showed: anemia ( . g/dl), high wbc count ( , cells/mm ), thrombocytopenia ( , /mm ), hypoalbuminemia ( . g/dl), lactate dehydrogenase (ldh) mcg/l, glutamin transferase (ggt) . csf total proteins , glucose , cells , pm %, mn %, seric complement , cultures were negatives. she developed myocarditis, aneurysms in the right and left coronary arteries. on the th day presented cardiac failure, pleural effusion, paralytic ileum, hydrops vesicular, mechanic ventilatory assistance was required. the first dose of intravenous immunoglobulin (ivig) ( g/k) was infused, heparin and hydrocortisone. on day a second doses of ivig was infused, because of fever, and abdominal vasculitis. steroids ware discontinued, heparin was suspended and aspirin was added as antiaggregant. discussion: our patient presented an unusual and severe presentation of kd with pleural effusion, nonspecific ileum, cardiac failure secondary to myocarditis, aseptic meningitis and thrombocytopenia; all those manifestations had rarely been reported at the same time. she presented with a devastating evolution. complications were resolved. the lastest studies have shown that treatment with ivig plus corticosteroids significantly reduce serum concentrations of proinflamatory cytokines. in this case antiinflamatory doses of aspirin were contraindicated and steroids were used with satisfactory outcome. limited data is available for nonresponding patients to guide therapy. although multiple doses of ivig are sufficient in some patients, some of them remain refractory to therapy and they need corticosteroids to control the vasculitis process eosinophilia is defined by an absolute eosinophil count above . x and can be seen in association with a broad spectrum of disorders ranging from allergic to malignant. idiopathic hypereosinophilic syndrome (hes) should be considered in any patient with an eosinophil count above . x for more than months without commonly recognized causes of eosinophilia and with evidence for organ damage not otherwise explained in the clinical setting. it is potentially an aggressive disease with mean survival of less than a year without treatment. we present a year old male horse breeder, with eosinophilia lasting more than years. prior to coming to our institution, he underwent extensive medical evaluation including bone marrow and gi biopsies, multiple imaging studies with mri and ct scans of the chest and the head as well as detailed evaluation of his cardiac status. all these tests were normal and the patient was empirically started on treatment for possible hes including trials of prednisone, hydroxyurea, interferon alfa, and imatinib, all without lasting resolution of his eosinophilia and causing significant side effects with profound depression of his immune status. finally, in light of the patient's profession, a strongyloides enzyme immunoassay was done and found to be remarkably positive. duodenal drainage confirmed the infestation with this nematode. within a week of starting treatment with ivermectin, his eosinophil count came down by % and eventually normalized. we learn that one should be persistent in excluding all common causes of eosinophilia before considering hes. in case of parasite infestation, premature treatment with immunosuppressors can result in worsening of the infection with potential for poor and even fatal outcome. stool evaluation might not be sensitive enough for detection of parasites and it is therefore necessary to complete a diagnostic work up with appropriate serology. doxil is the pegylated liposomal form of doxorubicin and has been used successfully as a cancer chemotherapy agent in many types of tumors. a hypersensitivity reaction can occur, usually during the first infusion, and appears to be rate related. the symptoms include dyspnea, tachypnea, facial swelling, chills, hives, chest pain, and back pain. we report a case of a hypersensitivity reaction to doxil in a year-old woman with hodgkin's lymphoma. during her first outpatient doxil infusion at mg/min, she developed urticaria, chest tightness, dyspnea, and back pain. these reactions persisted despite being medicated with antihistamines and steroids and immediately resolved during pauses in the infusion. after mg of doxil, the infusion was discontinued. six days later, she was admitted to complete the other half of the dose. she had a negative intradermal skin test to a : dilution of doxil. she was then premedicated with diphenydramine, dexamethasone, acetaminophen, and famotidine. the doxil infusion was started at . mg/min and was soon stopped due to flushing of the hands and face. the infusion was decreased to . mg/min. she was able to tolerate this slow infusion with only mild and tolerable symptoms. when her symptoms worsened, the infusion was stopped for to minutes. she completed the mg infusion of doxil after hours. pre-infusion and post-infusion complement levels were drawn during this second administration of doxil. her pre-infusion c , c , c a, c , c , c a, and bb levels were all normal. her pre-infusion c a and sc b- levels were high, indicating that she might have had some residual or persistent complement activation caused by her first doxil infusion. her post-infusion c , c , c a, c , c , c a, and bb levels were all normal. however, her post-infusion sc b- levels significantly increased, suggesting complement was activated during the second doxil infusion. given her reaction during her first doxil infusion and a negative skin test to doxil, it is highly unlikely that her doxil hypersensitivity was an ige-mediated process. therefore, in patients with a similar doxil hypersensitivity, we suggest a slow rate of infusion of . - . mg/min, toleration of mild symptoms, to minute pauses during more severe symptoms, and continuation of premedication during the entire lengthy infusion. introduction eosiniphilic esophagitis (ee) is an isolated, severe esophageal eosinophilia. patients are usually young males presenting with vomiting, epigastric or chest pain, dysphagia and obstructive respiratory problems. they are often initially misdiagnosed with and treated for gastroesophageal reflux disease (gerd). distinction between the two diseases can be made with biopsies of the esophageal mucosa. while any eosinophils in the esophageal mucosa indicate pathology, gerd typically presents with up to eosinophils per high powered field (hpf, x) while ee most often presents with greater than - eosinophils per hpf. case report the patient is a and one half year old boy who has experienced severe symptoms of gerd from the age of months. he vomits after meals at least - times per day. he coughs when he lies down at night and regurgitates phlegm in the early morning. he has complained of discomfort in his lower chest after eating. his weight has remained at pounds for the last six months. the patient was diagnosed with asthma at age and a half; however, there is no family history of asthma or allergies. the patient initially experienced improvement on lansoprazole, but his symptoms recurred when the medication was discontinued and subsequent courses were ineffective. his physical exam was normal barring slightly edematous nasal turbinates. an endoscopic biopsy showed "numerous eosinphils" (later clarified to eosinophils per hpf) in his distal esophagus. the patient showed allergy to milk and wheat on radioallergosorbent (rast) testing. the patient was started on swallowed fluticasone puffs twice daily and advised to see a nutritionist regarding a wheat and milk elimination diet. conclusion ee is an important differential of gerd-like symptoms in childhood. to avoid misdiagnosis it is critical to evaluate the number of eosinophils present in a biopsy specimen to help differentiate between gerd and ee. children with ee are at increased risk of developing esophageal dysmotility and esophageal strictures. patients often have positive skin prick or rast tests to foods and aeroallergens. alternative treatments such as food elimination diets and glucocorticoids (systemic or topical) are effective in treating symptoms which may not respond to reflux medications. introduction in asherton introduced the term catastrophic antiphospholipid syndrome (caps) to describe patients sharing clinical evidence of multiple (three or more) organ involvement and/or histopathological evidence of multiple vessel occlusions. case report we present a year old female, with lumbar pain, arthralgias, weight loss, fever, malaise, raynaud phenomenom, alopecia, oral ulcers and hepatomegaly. on arrival, she was polypneic with tachycardia, basal hypoventilation, and hepatomegaly was evident. hb: . , leucocytes: . , total lymphocyctes: , , total neutrophyles: , , platelets , . coombs positive. urin exam: proteinuria, leucocyturia and erythrocyturia. creatinine . . diagnosed as sle with pericarditis, cardiac failure and acute pulmonary edema, urinary tract infection and pneumonia, requiring mechanical ventilation and inotropic support, intravenous gammaglobulin and hydrocortisone. acute renal failure and hemodialysis was begun with improvement. suddenly she presented seizures crisis, stuporous, livido reticularis skin and acrocyanosis, external opthamalplexia, bilateral facial diplexia, ocular fundus with arteriolar vasospasm. right facio-corporal hemiparesia, cortical and progressive medular annals of allergy, asthma & immunology segment changes. ct showed multiple left fronto-occipital parietal hypodensities suggestive of lacunar infarcts. diagnosed as neurolupus and caps. initially anti b glp and anti clp were negative with later positivization. urinary tract infection contraindicated high doses of steroids and, intravenous gamaglobulin and anticoagulation were started. with significant improvement. currently the patient is evolving in a satisfactory way. discussion the literature establishes that catastrophic aps is characterized by elevated mortality. in this patient damage was evident to the cns, pns, kidneys and the skin. with the presence of positive antiphospholipid antibodies with an energic antiinflamatory, immunoregulatory and immunosupressive therapy, the function of each affected organ completely recovered. this case exemplifies that the therapy of caps should be undertaken in a sufficient and early manner given the elevated mortality of this syndrome. patient, a -year-old white, male non-smoker physician on high-dose regimen of advair and singulair presents with an -day history of progressive chest tightness. pulmonary function tests showed normal (fev of %) lung function. in the past, whenever inhaled steroid dosages were lowered, patient experienced a reoccurrence of asthma symptoms, despite consistently normal lung function results. to rule out the possibility of a psychologically induced asthma exacerbation, the patient's fractional concentration of exhaled nitric oxide (feno) levels were measured. the patient's feno level was elevated at . ppb. values greater than ppb have been described as consistent with airway inflammation. with an increase in the patient's inhaled steroids, the patient had a remission of symptoms within a week. this case is illustrative of an increasingly common clinical picture where a symptomatic asthmatic may have normal spirometry but elevated feno. as devices for measuring feno become more available in the outpatient clinic setting, elevated feno may be an excellent diagnostic marker in assessing whether airway inflammation is being adequately treated in situations where spirometry values are within normal ranges. introduction the autoimmune thrombocytopenic purpura (atp) is characterized by thrombocytopenia and megakaryocytic hyperplasia. the first choice of treatment consists of intravenous gamma globulin (ivig), corticosteroids and anti-d antibodies and the second line measures are immunosuppressant drugs, splenectomy and danazol. case report a years old male presented in the first year of life ecchymosis in several parts of the body intermittently. in april he presented ephistaxis and lower gastrointestinal bleeding. complete blood count showed platelet count of , /ul. prednisone was started ( mg/kg) with no improvement. at that time, danazol, anti-d antibodies, and ivig ( g/kg) were added. subsequently, the platelet average count diminished to , . the patient was transferred to our hospital. at his admission he presented cushingoid habitus (figure ) and acanthosis nigricans. the immunological tests (aan, ch , c , c , immunoglobulins, anticardiolipins and b glycoprotein) showed no alterations. bone marrow aspirate demonstrated megakaryocytic hypercellurarity. prednisone dose was tampered when the patient presented secondary glaucoma. patient continued his treatment with danazol and ivig ( dosages of g/kg each), hydroxychloroquine and cyclophosphamide with no improvement. thus, months after the immunosuppressant treatment, splenectomy was performed, obtaining partial improvement. at that time ranitidine and hydroxychloroquine were suspended and cyclophosphamide was changed to azathioprine. last platelet count was , /ul. conclusion chronic atp in childhood as the present case account for approximately - % of the total atp patients. chronic atp that does not respond to conventional treatment is a therapeutic challenge. in this patient we used first choice and second choice drugs with no improvement, consequently a splenectomy was indicated, not obtaining the desired response at first. the use of immunosuppressant drugs is not common for this disease, but it could be a good alternative for atp resistant to conventional treatment. this are the most important laboratory test of our patient. background: budesonide is the only corticosteroid available for inhalation by jet nebulizer and is indicated for the treatment of asthma in children. objective: to evaluate the distribution and clinical efficacy of inhaled budesonide administered by nebulization with a modified commercial device. methods: a year old male with severe persistent asthma underwent a lefort procedure for multiple craniofacial abnormalities. the external device maintained his mouth open impeding the proper use of controller medications. as a result he developed an increase in his asthma symptoms. he was subsequently treated with nebulized budesonide delivered with a modified jet nebulizer through the end of a plastic tube in a flow-by manner. we then performed dynamic ventilation imaging after administering . mci of nebulized technetium m-dtpa diluted in two ml of normal saline. images were obtained for five minutes at three seconds per frame. spirometry monitoring was not possible given the obstructive nature of the facial device. results: the patient demonstrated improvement of his asthma symptoms. the ventilation scan showed that the patient breathed the technetium dtpa through the specialized device with delivery to his full lung volumes within seconds. conclusions: we report the successful treatment of a patient unable to use the commercially available methods for administration of inhaled steroids. rationale: hp is a non-ige mediated inflammatory response in the lungs due to a variety of organic antigens, including metal working fluids. the wideranging clinical features include acute, subacute, and chronic forms. elevated antineutrophilic cytoplasmic antibodies and platypnea, defined as dypsnea induced by the upright position and relieved with recumbency, have not been previously reported in patients with hp. case: -year-old white male tool and dye machinist presented with progressive cough, weakness, dyspnea on exertion, and platypnea. symptoms began weeks earlier with coryza and diffuse myalgias. he had lost % of his body weight since symptom onset. examination revealed a pulse of , respiratory rate , and right basilar crackles. resting pulse ox on room air was %, but dropped to % upon ambulation. pft's revealed severe obstruction (fev % predicted) with significant reversibility (fev + %), and a dlco of % (adjusted for va and hemoglobin). hemoglobin was . with a normal leukocyte count and differential. c-anca (anti-pr ) was . (< ), and p-anca (anti-mpo) was . (< ), both performed by elisa. echocardiogram showed an ef of - % with mild pulmonary hypertension; no shunt was present. chest roentogram was normal, but a chest ct revealed a diffuse ground-glass pattern with scattered centrilobular opacities. biopsy was consistent with hp. he was removed from his work exposure to metal working fluids with full recovery of lung function and resoulution of symptoms. conclusions: hp presents as a constellation of symptoms without a single, unique identifying pattern. platypnea and elevated anca's have been observed in a wide range of disorders, all of which were excluded in this patient. platypnea has been associated with hereditary hemorrhagic telangiectasia, pulmonary avm, hepatopulmonary syndrome, recurrent pulmonary emboli, and patent foramen ovale. elevated anca's has been associated with wegener's granulomatosis, goodpasture's syndrome, churg-strauss vasculitis, drug-induced vasculitis, inflammatory bowel disease, and others. elisa is a more specific modality for anca's than indirect immunofluorescence, but it is less sensitive. the possibility of hp should be considered in patients with either of these two abnormalities. rationale: heart disease is the leading cause of death in america and % of persons between and years of age have coronary athersclerosis at autopsy. the presentation in the elderly is commonly atypical. % of myocardial infarctions were silent or unrecognized in the framingham cohort. in patients and older, it is estimated that - % will present with dyspnea without any associated chest pain. we present a case of unstable angina presenting as exercise-induced asthma. case: an year-old white male with moderate persistent asthma, hypertension, dyslipidemia, and a long history of allergic rhinitis presented having had an abrupt increase in his usual exercise-induced asthma symptoms four weeks prior. asthma had been diagnosed at age with spiromety showing moderate obstruction and significant but incomplete reversibility. he had a remote history of pipe and cigar smoking, but had quit at age . he had been well-controlled since that time with his most recent regimen consisting of fluticasone mcg/salmeterol mcg diskus, one inhalation twice daily. his typical exercise-induced asthma symptoms included dyspnea on exertion and chest tightness without radiation, and were relieved with rest and albuterol. the amount of exertion needed to trigger his symptoms, however, was much less than he had previously experienced, and this remained constant during the four weeks prior to his presentation. one week prior he had a normal ecg evaluation by his primary care provider. six months prior he had a normal nuclear cardiac stress test. physical examination was unremarkale except for moderately decreased aeration and + pitting edema of his lower extremities. cardiology performed a nuclear stress test the next day which was abnormal. catheterization revealed % steonsis of his proximal lad. he succefully underwent cabg and is doing well on follow-up. conclusion: the elderly present many challenges to the diagnostician; these include multiple co-morbidities as well as atypical and often late disease presentations. the key to raising suspicion for cardiac involvement in this case was the recognition of the patient's cardiac risk factors in the setting of an abrupt onset of exercise symptoms while lacking other asthma symptoms such as nocturnal cough. cold urticaria is an uncommon form of physical urticaria. this case of a -year-old with cold urticaria and angioedema provides additional information regarding an unusual disorder in the pediatric population. an otherwise healthy -year-old female presented with a complaint of urticaria precipitated by cold exposure over the preceding weeks. she had no recent illnesses and a past medical history significant only for cat allergy. on multiple occasions the patient noted erythema and pruritus of her arms and face after walking through the freezer aisle of a grocery store. urticaria would then develop on regions where she scratched, spontaneously resolving in - hours. on one occasion, urticaria appeared diffusely while taking a shower after the patient had been swimming. the urticaria resolved within a few hours after the patient was given diphenhydramine by her mother. three days prior to presentation the patient experienced upper lip angioedema with erythema, globus sensation and difficulty swallowing after drinking a strawberry slushy. the patient denied any respiratory complaints at that time and her symptoms again annals of allergy, asthma & immunology resolved spontaneously. family history was significant for a maternal history of seasonal allergies. upon physical exam the patient was well appearing. she had - discrete urticaria on each calf. the patient's mother noted that recently these would appear on "cold and rainy" days, attributing them to the fact that the patient's pants left her lower legs exposed. the remainder of her exam was normal and dermatographism was absent. laboratory evaluation consisted of cryoglobulins and strawberry rast, both of which were negative. application of an ice cube to the patient's forearm for minutes resulted in a x centimeter wheal noted minutes after ice removal. a diagnosis of cold urticaria with associated angioedema was made. the patient's mother opted to use diphenhydramine as needed and an epinephrine autoinjector was dispensed. by months after symptom onset, the patient's only complaint was pruritus of her hands if they became too cold. no urticaria were noted. at month follow-up the patient denied any symptoms for the preceding months and had a negative ice cube test. cold urticaria in the pediatric population is a rare entity and not well understood. this case of a -year-old with cold urticaria and angioedema offers additional insight into this unusual disorder. a. khuntia * , m. mcmorris, ann arbor, mi. introduction: chronic granulomatous disease(cgd) is a heterogeneous group of disorders characterized by genetic defects in the ability of phagocytes to generate microbicidal reactive superoxide anions and its metabolites. it manifests early in life, primarily as recurrent infections, caused by catalase-producing bacteria such as staphylococcus aureus, burkholderia cepacia, and serratia marcescens and fungus such as aspergillus fumigatus. the disease may be inherited in an x-linked or autosomal recessive manner, with x-linked disease accounting for - % of cases. the us incidence of cgd is / , live births with an average age at presentation of years for xlinked and . years for autosomal recessive disease. case report: year old male with history of three separate episodes of pneumonia beginning at age . each episode resulted in a hospital admission and intravenous antibiotic therapy after failed oral antibiotic therapy. an extensive pulmonary evaluation was initiated after the third episode of pneumonia, including a chest ct, viral, bacterial and immunodeficiency studies. cbc, complement, immunoglobulins, flow cytometry, viral and bacterial studies were all normal. the ct scan revealed dense nodular opacities in the right upper lobe with surrounding ground-glass opacification and mild bronchiectasis. a subsequent bronchoscopy demonstrated necrotizing granulomatous inflammation. open lung biopsy grew burkholderia cepacia on tissue culture. the clinical history, tissue histopathology and atypical organism found on culture were all suggestive of an underlying immunodeficiency. a neutrophil oxidative burst assay was performed which demonstrated minimal neutrophil activity upon stimulation, suggestive of the diagnosis of cgd. a chemilluscence assay verified the diagnosis of cgd, with minimal fluorescence noted on flow cytometry after neutrophil stimulation. dna analysis demonstrated a p -phox deficiency, resulting in one of the autosomal recessive and less clinically severe forms of the disease. conclusions: this case of cgd is unusual because of the delayed presentation. it demonstrates the importance of a complete immunological evaluation including an evaluation for neutrophil disorders such as cgd in patients of all ages who present with recurrent and recalcitrant episodes of pneumonia, especially when atypical organisms such as burkholderia cepacia are found on culture. autoimmunity may play a role in the development of premature ovarian failure (pof), but the exact mechanism is not well understood. pof is mainly diagnosed after years of age and most women complain of secondary amenorrhea. pof has been reported in combination with presence of ana and autoimmune diseases, but rarely with jra. here we report two cases of pof and positive ana in pediatric patients, one with clinical features of jra. the first patient, an african american -year-old girl, height in th percentile, weight in th percentile, with tenosynovitis of wrists and arthritis of knees and elbows for the past two years, was referred for further evaluation and management. she did not have her menarche yet and laboratory investigation revealed positive ana. the second patient, an african american -year-old girl, th percentile for height and weight, was referred to the immunology clinic with chief complaint of primary amenorrhea and delayed development of secondary sexual characteristics and was found to have positive ana without clinical findings of jra. both patients were tanner stage for breasts and tanner stage - for pubic and axillary hair. both had elevated fsh and lh, karyotype xx and small uterus and small ovaries on pelvic ultrasound. antiovarian antibody was not detected in any of the two patients. the bone age was significantly delayed. pof in karyotypically normal women is frequently seen in combination with elevated serum ana. the clinical spectrum of rheumatoid disease associated with pof ranges from asymptomatic ana positivity to typical presentation of jra. women with pof should be monitored for the emergence of autoimmune disorders including jra, and women with jra should be followed for menstrual irregularities and signs of pof. introduction: many u. s. military personnel deployed to the middle east continue to develop infection with leishmaniasis, a parasite transmitted by the sand fly. pentavalent antimonials have been used as an effective treatment for leishmaniasis for many years. in the united states, sodium stibogluconate (pentostam) is the pentavalent antimonial of choice, and is currently being administered under an ind protocol. side effects of therapy include myalgias, arthralgias, rash, malaise, abdominal pain, pancreatitis, and hypersensitivity reactions. the true incidence of hypersensitivity reactions is not currently known. case reports: two u. s. soldiers receiving pentostam for the treatment of cutaneous leishmaniasis were evaluated in our clinic at walter reed army medical center after experiencing urticaria, angioedema, wheezing and dyspnea after medication infusion during the -day course of daily therapy. due to the concern of a potential ige-mediated reaction, skin testing was performed. after informed consent, skin testing included a prick test at full strength, followed by intradermal (id)testing. soldier # was a -year old male reporting lip swelling, throat tingling, dyspnea and chest pain - hours after treatment # / . skin testing to both lots used during the treatment course showed positive values of x mm and x mm respectively at id : . soldier # was a -year old male reporting diffuse pruritus, hives, dyspnea, and chest pain minutes after infusion # / . skin testing showed positive values of x mm and x mm respectively at id : . due to clinical symptoms and positive skin testing, therapy was discontinued in each case. one control individual showed negative testing to prick at full strength, id : , and id : . conclusion: skin testing with pentostam may provide an objective tool for accurate classification of adverse reactions as igemediated. reliance on skin prick testing alone may not be sufficient to detect pentostam skin test reactivity, as both of these patients reacted to id testing only. a prospective study including pre-and post-treatment skin testing should provide more information on the value of skin testing in providing objective evidence for an ige-mediated process and determining the incidence of hypersensitivity to pentostam. introduction: a -year-old girl with a history of multiple infections was hospitalized with respiratory distress and hypoxia. her past medical history was significant for hypothyroidism, psoriasis, asthma and multiple pneumonias. a cbc revealed an absence of lymphocytes. laboratory: t and b cell subsets showed no b-cells and very low t cells (< cells). inadequate lymphocytes were present for mitogen and antigen studies. serum immunoglobulins were normal and she had antibodies to streptococcus pneumoniae and tetanus. antibodies to rsv, influenza and mycoplasma were absent. chest x-ray revealed interstitial infiltrates bilaterally. a high resolution ct scan revealed septal thickening and confirmed interstitial infiltration. open lung biopsy was consistent with non-specific inflammation with extensive lymphocytic infiltration. bal fluids and biopsy were negative for bacteria, fungi and opportunistic pathogens. clinical course: the patient did not improve with antibiotics and steroids were started. the patient improved rapidly and was discharged to home. biochemical analysis demonstrated a deficiency of adenosine deaminase (ada), a form of severe combined immune deficiency (scid). the patient was started on replacement ada, adagen. a repeat high resolution ct scan showed some improvement. however, the patient continues to be steroid dependant to control her pulmonary symptoms. lymphocyte numbers remain low despite effective ada replacement and the absence of serum datp. she remains clinically stable and receives adagen injection twice weekly. discussion: ada deficiency is a condition, which leads to accumulation of the metabolite datp, which is toxic to lymphocytes. this disease most commonly presents in the first year of life as scid and is fatal unless treated. our case is unusual due to the late onset of severe disease, normal serum immunoglobulin and the presence of some protective antibodies. despite adequate replacement of ada the patient continues to be profoundly lymphopenic, most likely due to steroids. although we do not yet completely understand the underlying lung disease we suspect that the patient has an autoimmune process causing interstitial inflammation. background: atopic dermatitis has a broad range of differential diagnoses. human sarcoptic infestation is characterized by severely pruritic lesions of variable appearance and distribution and may masquerade as eczema. infestation may be difficult to confirm and eradicate. animal transmission has been reported as a source of human infection. objective: to report a case of persistent sarcoptic infestation masquerading as eczema and associated with delusional parasitosis. methods: a -year-old female was referred to allergy clinic for evaluation with a two year history of recurrent, pruritic rash thought to be refractory atopic dermatitis. previous ineffective treatments included topical steroid creams, lindane, topical anti-fungals and multiple otc antiitch preparations. at initial evaluation, she had widespread excoriated papules in various stages of healing over % of her body. she reputed her dog was diagnosed with recalcitrant mange, which necessitated giving him medicated baths twice daily. results: a clinical diagnosis of subacute sarcoptic infection was made and the patient was prescribed two courses of elimite followed by oral ivermectin. her rash quickly resolved except for post-inflammatory hyperpigmentation. three weeks after resolution of primary lesions, she again complained of pruritic eruptions occurring on easily accessible areas and began bringing in medicine bottles of skin debris and scabs for examination. scrapings, koh preparation and skin biopsy examined microscopically showed no evidence of sarcoptic re-infestation. a diagnosis of delusional parasitosis was made. conclusions: the animal to human transmission of sarcoptic infection seen in this patient is rare and responded quickly to appropriate treatment. despite eradication of the infection, she developed delusional parasitosis, a rare psychiatric disorder characterized by fixed, false belief of an infestation by insects or other creatures. she displayed the classic matchbox sign in which samples of skin, scabs and other detritus are brought in for examination. she is currently receiving psychiatric care. background: thimerosal is a mercury derivative that has been used since the s. it is a commonly used preservative in ophthalmic solutions, otic drops, and vaccines due to its bactericidal property. objective: to report the first case of a generalized reaction to thimerosal found in an influenza vaccine. methods: we present a patient who developed a generalized maculopapular eruption after receiving a thimerosal containing influenza vaccine. patch testing was performed to determine if there was an allergy to thimerosal. results: patch testing confirmed a type iv (t cell mediated) sensitivity to thimerosal, further supported by the prior history of a reaction to a thimerosal containing contact lens solution. the patient was asked to avoid thimerosalcontaining products, including vaccinations, unless the benefit clearly outweighed the potential risk of a reaction. conclusion: physicians need to be aware that thimerosal is found in many products including vaccinations. clinicians should also be aware that allergic reactions do occur with exposure to thimerosal even in vaccines. this is the first case report in the literature of a generalized reactions to thimerosal from an influenza vaccine angioedema is a rare condition that has been described in the literature and exists in both inherited and acquired forms. a defect of the innate immune system, more particularly the complement system, is the inciting culprit. the acquired form of c esterase inhibitor deficiency has been divided into two classes and is generally not commonly seen until after the forth decade of life. type acquired angioedema has been described in association with lymphoproliferative disorders, while type is related to excessive complement activation and consumption due to autoantibodies. our case is a -year old man referred from an outside physician for further management of idiopathic edema. he first experienced facial edema in april attributed to sweet myrrh root ingestion. subsequently, in november he developed diffuse swelling of his upper extremities and tongue without airway compromise. a minimal work-up at that time was inconclusive. he fortunately remained asymptomatic until january at which time he experienced two episodes of tongue swelling without etiology. he was seen in his local emergency department and treated with diphenhydramine, corticosteroids, and epinephrine on both occasions with gradual improvement of his symptoms. the patient was not on medications commonly associated with angioedema and did not report insect envenomation. subsequently, he was seen by his primary care physician who ordered a number of laboratory tests including a ch , which was significantly suppressed. in light of this finding, he was referred to our clinic for further evaluation. at the time of presentation to our office, the patient was symptom free. his physical exam was within normal limits. further laboratory evaluation was essentially unremarkable with the exception of comple-ment studies, which are listed in the table. our case demonstrates an elderly patient with evidence of idiopathic swelling. we arrived at our diagnosis of acquired angioedema based on clinical presentation and confirmatory serum complement levels. a low ch at time of presentation allowed us to further delineate the etiology of complement deficiency. the fact that our patient did not present with swelling until after age and the paucity of a family history of idiopathic angioedema makes the diagnosis of acquired angioedema probable. measure of serum c q level confirmed the diagnosis. introduction: certain diseases, widely believed to be of allergic etiology, including atopic dermatitis and episodes of wheezing might be the result of interplay of genetic and environmental factors, at least partially. we describe a child with a rare chromosomal disorder presenting with typical features of atopic dermatitis and recurrent mild wheeze. materials and methods: a new born african-american male was noted to have unusual facial features immediately after birth. the baby was born naturally, without antenatal and neonatal problems. on physical examination, the infant had unusual facial characteristics with tight and taut facial skin, relatively diminished facial pad of fat, pointed chin, and markedly hypertonic extremities. additionally, cardiac exam revealed mumur consistent with uncomplicated asd. frequent reassessments of the infant in the outpatient clinic were done. the child had repeated bouts of wheezing attacks, and facial rashes compatible with the diagnosis of atopic dermatitis. the wheezes were treated in the clinic with nebulaized bronchodilators, and the atopic dermatitis responded reasonably to topical steroid applications and moisturizers as needed. chromosomal analysis of the peripheral blood of the chid confirmed the diagnosis of deletion of long arm (q) of chromosome [ , xy, del ( )(q q )]. karyotypic analyses of the mother and father were normal. the child exhibited features of developmental delay, and seizure activities. anti-epileptic drugs (aed) were instituted. initial eeg was normal and the subsequent eeg showed findings of static encephalopathy. ct scan of the brain revealed absent corpus callosum. neurologic evaluations and physiotherapies were requested for improvement of fine motor skills. he did not seem to suffer from any serious infectious or immunodeficient illnesses. his cbc was normal. he continued to have fair gains in his weight, height, and head circumference. his atopic dermatitis and wheezing episodes remained under control. there were a few hospitalizations for break-through seizures and dehydration from gastroenteritis. a subsequent echocardiography confirmed closure of asd. con-clusion: a child with chromosomal anamoly, atopic dermatitis, and mild intermittent wheeze is reported. despite multiple congenital problems, the child continued to have a stable clinical course. etoposide is a chemotherapeutic agent used to treat many solid tumor malignancies. hypersensitivity reactions have been well described and there are a few reported deaths from anaphylaxis. some suggest that the hypersensitivity is an anaphylactoid type reaction as it may occur during the first dose. case reports of cutaneous complications include stevens-johnson syndrome, radiation recall and diffuse erythema. there are four cases in which diffuse erythematous papules developed after etoposide therapy. all rashes spontaneously resolved within three weeks and biopsies demonstrated keratinocytes in a starburst pattern. we report the first case of an immediate etoposide induced skin reaction that evolved into long lasting hyperpigmented plaques. pretreatement was able to prevent this immediate and late reaction on subsequent exposure to etoposide. a year old female with ovarian cancer was treated with bleomycin, etoposide and vinblastine. three hours after initiation of the third dose of etoposide, patient developed pruritic, erythematous macules on her chest, abdomen, face and extremities. the infusion was stopped and decadron administered. over forty-eight hours, the pruritic macules became hyperpigmented plaques on her chest, abdomen, extremities and face. pruritus resolved after a slow taper of prednisone. the darken plaques were treated with multiple topical preparations but persisted for about three months. biopsies demonstrated superficial perivascular infiltration of lymphocytes and a few eosinophils suggestive of a drug eruption. etoposide was considered essential for this patient so allergy was consulted. the literature supports cautious readministration of etoposide with pretreatment and slower infusion rate to prevent immediate hypersensitivity. we could not guarantee prevention of the late hyperpigmented reaction. the patient was pretreated with prednisone and cetirizine. etoposide was administered in an icu with a slower rate of infusion. etoposide was tolerated without immediate pruritus or erythematous reaction. the patient did not develop the delayed darkened plaques. cautious administration of etoposide after premedication and a slow rate of infusion prevented both the immediate and late reaction previously experienced by this patient. eosinophils normally comprise - % of peripheral white blood lymphocytes. peripheral blood eosinophilia is defined as an absolute eosinophil count > cells/mm and is most often caused by atopy, helminth infections, or collagen vascular diseases. less common causes include adrenal insufficiency and neoplastic processes. eosinophilia can be characterized as mild (< cells/mm ), moderate ( - cells/mm ) or severe (> cells/mm ). although severe eosinophilia has been reported in association with adult hiv infection, studies of hiv-infected children have not shown peripheral blood eosinophilia to be a feature of pediatric hiv infection. we report an unusual case of severe peripheral blood eosinophilia in an adolescent male who was subsequently found to be hiv-infected. a previously healthy -year-old male presented with week history of fever, diarrhea, cough, vomiting, abdominal pain, anorexia and a lb weight loss over the previous months. the patient had recently emigrated from guyana and denied sexual activity, intravenous drug abuse, or other hiv risk factors. there was no known maternal hiv infection. repeated stool specimens were negative for ova and parasites. serologies for e. histolytica, t. canis, and s. stercoralis were negative. an abdominal ultrasound, chest x-ray, serum electrolytes, and liver function tests were all within normal limits. total white blood cell was , with % eosinophils (absolute eosinophil count of , cells/mm ). elisa and western blot were positive for human immunodeficiency virus (hiv- ). cd + tlymphocyte count was cells/mm with an hiv- rna level of , copies/ml. the patients symptoms resolved over the next days without treatment. he was started on combination antiretroviral therapy (zidovudine, lamivudine, abacavir, and efavirenz). absolute eosinophil count continues to slowly decrease with the last count of , cells/mm three months following the introduction of antiretroviral therapy. severe peripheral blood eosinophilia may be a presenting feature of hiv infection in adolescents. hiv testing should be considered in cases where more common causes of eosinophilia such as atopy and parasitic infections are excluded. triad asthma is well described in adults but not in the pediatric literature. this case highlights the successful treatment of a severe pediatric asthmatic with nasal polyps and aspirin sensitivity. a year-old female presented with severe persistent asthma, eib, allergic rhinitis, chronic sinusitis, nasal polyps, and a history of pneumonia. her asthma symptoms were minimal from age until age . she then started flovent and required increasing amounts of inhaled and oral steroids. she required courses of oral steroids per year by age . in addition, she had snoring, fatigue, chronic nasal congestion, rhinorhea, and sneezing despite treatment withallegra and rhinocort. she had received immunotherapy from age to with no clinical improvement. since age she had recurrent sinusitis and had required polypectomies. she noted aspirin caused nasal stuffiness and mild wheezing and therefore avoided it. on exam she had allergic shiners, dennie lines, boggy turbinates, nasal polyps, and diffuse wheezing. on evaluation she had severe airway obstruction. her fev increased from % to % with albuterol. her chest ct had a mosaic pattern due to severe air trapping, and her no level was . a sleep study showed severe hypopneas, and she had pan-sinusitis on ct. she had multiple positive spts, an eosinophil count of and an ige of . she had a normal sweat chloride and ph probe.the differential diagnosis included churg-strauss, abpa, cystic fibrosis, bronchiolitis obliterans, and triad asthma. after a thorough evaluation, she was diagnosed with triad asthma. with weeks of treatment with oral prednisone, her fev improved from % to %. her inhaled controller therapy was increased and she was placed on xolair. she had a polypectomy and then underwent aspirin desensitization. one year after starting treatment her fev remains %. she requires albuterol x/month and has not required prednisone. her eib, allergic rhinitis and congestion are markedly improved. she has had no further episodes of sinusitis, and a repeat sleep study was normal. in conclusion, we treated a severe pediatric asthmatic with nasal polyps and aspirin sensitivity. this is not frequently reported in the pediatric population, and raises questions about the incidence, optimal long term treatment of triad asthma, and the differences from the adult onset of this disease. a.a. white * , r.a. simon, la jolla, ca. background: human disease from mold has traditionally been isolated to infection, allergic disease, or hypersensitivity pneumonitis. specific diseases or pathologic findings other than those listed above have not been well described. we report a case of acute eosinophilic pneumonia related to mold exposure. case presentation: a year old woman developed dry cough and shortness of breath after stachybotrys mold was discovered in her home. a chest radiograph showed bilateral upper lobe infiltrates which worsened two weeks later. treatment with macrolide and flouroquinolone antibiotics was ineffective. a white blood cell count was , /cumm with % eosinophils. an erythrocyte sedimentation rate was mm/hr. aspergillus ige was negative. treatment with prednisone led to complete resolution of the chest radiographic abnormalities and improvement in pulmonary function testing. this patient was given a diagnosis of acute eosinophilic pneumonia with mold as a likely causal factor. discussion: there is dispute amongst health care professionals regarding the significance of environmental mold contamination in the etiology of human disease. this case represents well characterized disease occurring in the setting of mold exposure. while a causal relationship cannot be established, the temporal relationship of mold contamination, symptom onset, and disease progression is compelling. interestingly, a recent report of mold contamination leading to nonspecific interstitial pneumonia/fibrosis has been described. we have observed a patient in our clinic with similar pathology on biopsy and temporal relationship to mold exposure. to our knowledge, acute eosinophilic pneumonia has not been reported in conjunction with mold exposure. conclusion: this case highlights a new condition in which mold may have a causal role. the mechanism is unknown, but likely is through a non-ige mediated immunologic pathway. public awareness of mold as a health concern is increasing. perhaps similar cases will emerge as a history of mold exposure is offered by patients at the time they are evaluated for lung disease. a stronger correlation may then emerge. scuba diving is a commonly practiced activity which normally carries only minimal risks. any severe allergic reaction such as anaphylaxis, however, occurring during this activity could be a particularly dangerous not only because the swimmer is submerged but also because of the lack of proximity to medical care. we report a case of anaphylaxis occurring during scuba diving resulting from an unsuspected hypersensitivity to a latex component of the scuba diving suit. a yr-old white male developed a severe generalized urticarial rash with angioedema of his lips and eyelids, and difficulty breathing within minutes of his applying the suit and entering the water. after being rescued, he was transported to a nearby emergency department where he received epinephrine, antihistamines, corticosteroids and iv fluids with gradual improvement over a hour period. the patient denied being stung by a marine aquatic organism and there was no prior history of allergy or medications usage prior to his reaction. since subsequent investigation revealed that the scuba diving suit contained latex (brazilian rubber), a specific ige rast was found to be strongly positive (class v) to latex. therefore, the patient was advised to use a suit made of neoprene synthetic rubber (polychloroprene) which is a nonlatex containing product. this case report illustrates the importance of a diligent search for hidden sources of latex products which can produce life-threatening allergic reactions in sensitized patients. there has been considerable debate concerning the safety of immunizing egg-allergic children with the combined mmr vaccine. this concern derives from the possibility of an anaphylactic reaction since the mmr vaccine is prepared from attenuated viruses grown on chick embryo fibroblast cell cultures. we have previously reported the safe administration of the mmr vaccine to severe egg-allergic children without development of an adverse reaction (nsouli, tm, et al. ann allergy asthma immunol. ; : ) , a finding consistent with the current report of the committee on infectious diseases, american academy of pediatrics, . the present case report describes an anaphylactic reaction in an egg allergic yr-old-white male consisting of generalized urticaria, angioedema, wheezing immediately following the administration of a second mmr vaccine. the history of hives following ingestion of eggs was confirmed by positive specific ige rast testing. the patient's anaphylactic reaction necessitated emergency treatment including epinephrine, diphenhydramine, and corticosteroids in addition to iv fluids. although the administration of mmr vaccine in egg-allergic children is not considered as an absolute contraindication, the present case report suggests that caution should be observed when administering the mmr vaccine in such patients and that careful medical observation be included together with the ready availability of emergency medical equipment. p. buddiga * , r. turbin, a. baisre, l. bielory, newark, nj. introduction: sarcoidosis is a chronic granulomatous disease of unknown etiology that may have a multi-organ system manifestation and is characterized by the histopathological evidence of nonnecrotizing granulomas. case report: a year old african american woman with a year history of type ii diabetes mellitus, hypertension and sinusitis recalcitrant to multiple courses of antibiotics over months was admitted to the hospital with complaints of right eye proptosis, diplopia, headache and right facial numbness.her exam was consistent with an ipsilateral mild optic neuropathy, complete sixth (vi)nerve palsy, trigeminal, ophthalmic and maxillary division numbness.ct and mri of the face, orbit and brain revealed an extensive process infiltrating ethmoid, maxillary and frontal sinuses;orbits and deep facial structures.chest ct revealed bilateral interstitial nodules and symmetric hilar adenopathy. differential diagnoses included sarcoidosis, lymphoma/tumor, wegener's granulomatosis or fungal infection.labs-purified protein derivative test=negative(neg), antineutrophil cytoplasmic autoantibodies=neg. angiotensin converting enzyme= [ - u/l], fungal & anaerobic and acidfast bacilli culture of sinus secretions=neg.ethmoid, adenoid and maxillary sinus biopsies=multiple nonnecrotizing granulomas. on the basis of compatible clinical and radiographic findings, histopathological evidence and exclusion of other diseases with similar findings, the diagnosis of sarcoidosis was established. she was started on parenteral methylprednisolone and subsequently tapered to oral prednisone after days.concomitantly she was started on methotrexate as a steroid sparing agent.most recent chest x-ray after months of treatment reveals near complete resolution of the hilar lymphadenopathy.at months her optic neuropathy and facial dysesthesia had resolved, and she was left with mild persistent vi nerve dysfunction. conclusion:sarcoidosis that manifests itself as sinusitis is an uncommon presentation and the mechanism involved is thought to be a consequence of the destruction of cilia and mucus producing glands by the granulomatous process.review of the literature indicates that this is the eighth case reported and illustrates that a high index of suspicion of other etiologies must be maintained when there is a refractory response to multiple courses of antibiotics in the treatment of sinusitis. j.b. hein * , p. patel, l. bielory, newark, nj. introduction: cid may result in opportunistic infections such as cryptococcal meningitis. we present an unusual case of cryptococcal meningitis in an hiv-negative patient with severe cd lymphocytopenia. case: a yearold male with a three year history of sarcoidosis presented with acute onset of right-sided body numbness. the patient had been on prednisone mg/day for months prior to presentation. ct and mri scanning showed no vascular defects, meningeal enhancement, hydrocephalus or mass lesions. gallium scanning revealed normal uptake in the liver and spleen, mild uptake in the lungs and nasopharyngeal region, and asymmetric uptake in bilateral kidneys. the patient's initial wbc was , cells/mm , composed of neutrophils/mm , eosinophils/mm , basophils/mm , lymphocytes/mm , and basophils/mm . repeat studies revealed the total lymphocyte count decreased at cells/mm with cd (pan b) cells decreased at cells/mm and cd (pan t) cells decreased at cells/mm . cd count was cells/mm and cd count cells/mm with a cd /cd ratio of . . igg levels were normal at mg/dl. elisa was negative for hiv, and hiv- rna by pcr was not detected. serum ace level was u/l and csf ace level was u/l. csf obtained by lumbar puncture stained positive with india ink and culture revealed cryptococcus neoformans. the patient responded to amphotericin b lipid complex mg/kg/day, and his neurological status eventually returned to baseline. conclusions: the severe lymphopenia in this patient caused predisposition to infection with cryptococcus neoformans. the etiology of the profound lymphopenia likely was multifactorial, including mild sarcoidosis activity (lung uptake on gallium scan) and chronic corticosteroid therapy. however, once cryptococcus became entrenched in the patient's csf, the infection itself likely depressed peripheral lymphocyte numbers even further. this case demonstrates the importance of exploring a broad differential diagnosis when faced with lymphocytopenia. background: isosulfan blue % is a common dye used in sentinel lymph node dissection. the usage of the procedure and dye has increased in numbers, and although rare, several cases of anaphylactic reaction have been reported. objective: we are reporting a patient who had an anaphylactic reaction to isosulfan blue while undergoing breast cancer excision with sentinel lymph node biopsy. methods: the patient is a year-old woman with breast cancer. she underwent breast mass excision with sentinel lymph node biopsy using the lymphazurin % blue dye (isosulfan blue). she has a history of penicillin induced hives but has no other drug allergy. as soon as the dye was injected, she became flushed, hypotensive, and tachycardic. hypotension was refractive to fluid challenge. she was then treated with epinephrine as well as intravenous steroids and cimetidine with relief of symptoms. subsequently, she was evaluated in allergy and skin tests with isosulfan blue % at : , : dilution, and undiluted were performed using histamine as positive control and saline as negative control. this procedure was also performed on two control subjects. results: the patient had a positive skin test (wheal and flare) to isosulfan blue % (undiluted) with the control being appropriately positive for histamine and negative for saline. control subjects had negative response to dye and saline and positive response to histamine. conclusions: isosulfan blue -% dye may cause anaphylactic reactions in patients undergoing sentinel lymph node dissection. . the positive skin test result to the dye plus the negative skin test responses in the controls suggests that the reaction may be immunoglobulin e (ig e) mediated. eosinophilic duodenitis (ed) and gluten-sensitive enteropathy (gse) or celiac disease (cd) are distinct clinical entities with well-defined clinical and laboratory parameters. ed is a rare condition of unknown etiology, which is manifest by eosinophilic infiltration of the gastrointestinal tract and peripheral eosinophilia. gse or cd is a form of non-ige food allergy caused by immune hypersensitivity to ingested gluten. the simultaneous occurrence of the two entities, however, is a rare event. the following presentation is a case report in which both entities were found in the same patient. an y/o white hispanic male presented with severe, chronic, colicky abdominal pain and headache of months duration. hematologic and immunologic studies were within normal limits. serum ige levels were iu/ml (n= < iu/ml), anti-endosomial ab (+), igg antigliadin: u/ml (n=: - u/ml), skin tests for food and inhalant allergens were weakly positive ( +). biopsy of the inferior third of esophagus revealed chronic moderate esophagitis; biopsy of gastric antrum revealed lymphatic hyperplasia; duodenal biopsy showed shortening of the villi with the presence of eosinophils. following treatment with esomeprazole mg bid, famotidine mg qd, montelukast md qd, lactobacillus, a diet free of gluten, rofecoxib mg qd and betamethasone for days, betamethasone the patient improved with partial resolution of symptoms. the presence of duodenal eosinophils persisted despite a gluten free diet, and continued to require repeated bursts of prednisone. since to our knowledge this is rare finding in which ed occurred in association with gse, a high index of suspicion for simultaneous occurrence of ed should be raised in any case of gse that fails to respond to a conventional gluten free regimen. we report the evaluation of a month old male presenting with a pustular rash and choking episodes from birth. by age weeks, he had experienced two pneumonias, one with fleeting infiltrates requiring intubation. persistent eosinophilia ( - /ml) and eosinophils on pustule biopsy were noted. persistence of these and subsequent rsv pneumonia and recurrent draining otitis media led to referral. physical examination showed a thriving male infant with multiple erythematous papules and pustules along the scalp, face, axilla, and trunk. eosinophilia was confirmed. quantitative immunoglobulins were abnormal for igg and ige iu/ml. peanut cap rast was kua/l. hib post-vaccination titer, t cell enumeration/stimulation, and nbt were normal. hiv testing, stool eosinophils, o&p, and hemoccult were negative. cxr, hrct, ekg, and echocardiogram were normal. pustule cultures for bacteria, virus, and fungus were negative. skin biopsy revealed numerous eosinophils in the pustule, dermis, epidermis, and perifollicular region. cd a+ and s- staining were negative for histiocytic infiltration. nemo defect/incontinentia pigmenti were considered but testing was negative and karyotype , xy. bone marrow biopsy revealed numerous eosinophils at different stages of maturation, and no myeloproliferative or neoplastic changes. bronchoscopy was remarkable for % eosinophils on balf. -hour ph probe and impedence evaluation was negative. egd with biopsy was normal except for mild eosinophilic infiltration of the proximal and distal esophagus. with the clinical picture of recurrent pruritic crops of sterile pustules and characteristic skin biopsy demonstrating eosinophil infiltration, the diagnosis of eosinophilic pustulosis (ep) of childhood was made. despite no longterm sequelae or other end-organ involvement in ep, the degree and duration of eosinophilia, and presence of eosinophils in the airways and esophagus, raises the concern for other eosinophilic syndromes. following cardiac, cns, pulmonary, and gi systems is warranted. the infants pneumonias were felt to be due to aspiration, and ear infections the result of humoral immunity nadir or draining pustules in the external auditory canals. immunoglobulin levels will be monitored. this case illustrates the heterogeneity of eosinophilic diseases and raises the question of what drives the mechanisms behind malignant and benign disease. introduction: behcet's disease is a chronic, relapsing vasculitic disease characterized by recurrent oral, genital, and gastrointestinal ulcerations, a wide variety of skin lesions, uveitis, and arthritis. pediatric cases of behcet's disease are uncommon with an estimated prevalence of in , children under the age of . although the disease in children shows similar characteristics as adults, the diagnosis of behcet's disease in the pediatric population remains a challenge. this report describes an year old girl referred to our pediatric immunology clinic for evaluation of recurrent painful oral ulcerations since the age of with no genital ulcerations. the oral ulcers would last for two weeks and heal spontaneously but would reappear to weeks later. the patient had a history of raynaud's phenomenon for the last to years and the recent onset of joint pain. physical examination revealed - white elliptoid lesions - mm in diameter on an erythematous base on the tongue and soft palate. skin examination was significant for hyperpigmented patches over the neck, abdomen, and back. there were erythematous, serpigenous lesions on the palms and punctuated necrotic lesions on the finger-tips. pathergy test was positive. laboratory investigation was unremarkable and cultures from the oral ulcers remained negative. the patient was diagnosed with juvenile behcet's disease. she was started on immunosuppressive therapy with low dose prednisone and responded. conclusion: behcet's disease is a difficult diagnosis to make in the pediatric population. this case demonstrates that in children, recurrent oral ulcerations may be the only initial manifestation of behcet, and an important clinical marker for the disease. rationale: relapsing polychondritis is an uncommon severe inflammatory condition with unknown etiology that can present in a variety of manners. we report a year old patient who initially presented with signs and symptoms of anaphylaxis to shellfish and was later diagnosed with relapsing polychondritis. case report: a year old african-american boy with a year history of asthma and fish and shrimp allergy presented to the pediatric intensive care unit on / / after an episode of severe shortness of breath. his symptoms started shortly after accidental exposure to shrimp. in the intensive care unit, he was noted to be wheezing and stridorous. an initial chest xray as well as subsequent fiber optic laryngoscopy showed sub-glottic stenosis. he was intubated and received mechanical ventilation for greater than a week. after extubation, he stated that he felt fine, but continued to demonstrate audible stridor. pulmonary function tests demonstrated extra-thoracic obstruction, laryngoscopy continued to show sub-glottic stenosis, and esophagogastroduodenoscopy showed erosive esophagitis consistent with reflux. initial lab tests demonstrated a normal eosinophil count, elevated ige ( iu/ml), and positive immunocaps testing to multiple foods. the patient was discharged home with minimal stridor and no wheezing. over the next nine months, the severity of his stridor waxed and waned, but in general it worsened in spite of a strict elimination diet and anti-reflux therapy. on / / he received an emergency tracheostomy. on / / , the patient was again admitted to the hospital. at this time he complained of bilateral knee pain as well as significant weight loss. physical exam demonstrated arthritis with effusions of both knees as well as unilateral auricular chondritis and bilateral episcleritis. antibodies against type ii collagen were positive ( . eu/ml). the diagnosis of relapsing polychondritis was suggested. conclusion: relapsing polychondritis is a rare inflammatory disorder of the cartilage and connective tissue with an unknown etiology. the wide array of presenting complaints as well as the relapsing nature of this disorder often causes significant delay in diagnosis and treatment. in our case there was a period of nine months between the initial presentation and the time when the diagnosis of polychondritis could be made. d.k. geller * , m. ballow, buffalo, ny. introduction: an yo male previously diagnosed with pandas presented to our immunology clinic for ivig. the patient was healthy until age when he developed facial motor tics associated with group a beta hemolytic strep pharyngitis. he was treated with antibiotics and the tics resolved completely. he has had multiple recurrences associated with strep and other viral infections. the tics improve or resolve completely when he is infection free. he has no history of vocal tics, attention deficit/hyperactivity disorder, or obsessional thinking or compulsive behaviors. laboratory: multiple throat cultures positive for group a beta hemolytic strep, positive antistreptolysin and antideoxyribonuclease b titers. discussion: pandas identifies a subgroup of children with an obsessive compulsive disorder and/or tic disorder whose symptoms seem to be triggered by streptococcal infections. the proposed pathophysiology is an immune-mediated mechanism in which antistreptococcal antibodies, antistreptolysin and antideoxyribonuclease b, cross react with the basal ganglia of genetically susceptible hosts. a few studies have looked at immunomodulatory therapies including ivig for neuropsychiatric symptoms including tic disorders secondary to post-streptococcal autoimmunity. we plan a trial of ivig for this patient given the recurrent nature of his tics and the relation to streptococcal and other viral infections. introduction: the chronic granulomatous disease (cgd) is an inheritable disorder of phagocyte cell respiratory burst that result in life-threatening infections. the pulmonary infection is the primary cause of death in greater that % of the cases and the role of surgery in management of this entity remains undefined. case report: a lobectomy was performed in a year-old male who presented a persistent opacity of the medial right lobe with fever, cough, malaise an rapid onset of respiratory failure; skin abcesses were concomitant. his familiar history was unremarkable. a chest tube was placed in a first instance in order to drain empyema, but no progress was observed. a ct scan showed necrotizing pneumonia of the right lung, mediastinal and retroperitoneal limphadenopathy and bronchopleural fistula. a second surgical intervention was undertaken to correct the fistula and pleural debridement was done. at this time, serratia marcenses was isolated from blood culture and lung; a primary immunodefiency was suspected. our evaluation showed nbt reduction on % and dyhidrorhodamine assay (dhra) didn't demonstrate and effective oxidative burst. the subsecuent management was based on specific antibiotic to serratia and prophylaxis with tmp-smz and itraconazole. transfer factor to improve the ifn levels was initiated. the patient's mother showed on dhra two granulocyte populations, with and without oxidative burst. a x linked cgd was consistent. medical progress was observed in the next days. conclusion: despite the poor utility showed by the surgical procedures in the complicated pneumonia in cgd patients in many series, attending to the unusual nature of the pulmonary infections and the high mortality and morbidity associated with thoracic surgery; the management of this case showed that an aggressive approach in the diagnosis combined with some procedures used in immunocompetent patients pneumonia may improve the clinical condition in cgd patients. background: takayasu arteritis is a large vessel vasculitis primarily affecting the aorta and its branches. it is most prevalent in women in the second and third decades of life. initial symptoms are systemic and often self-limited, but the disease may progress undetected over years until signs of vascular insufficiency develop. arteritis is commonly seen in the aortic arch and its branches, although the disease is a panarteritis and vascular compromise can occur in many organs. pathologically, involved vessels show intimal proliferation and fibrosis, and scarring of the elastic lamina. case report: we report the case of a year old southeast asian woman who presented with diplopia, ptosis, dizziness, and progressive dyspnea. past medical history was significant for rheumatic fever complicated by aortic valve insufficiency and hypertension. physical findings on admission included hypertension, asymmetric upper extremity blood pressure (left arm / mm hg, right arm / mm annals of allergy, asthma & immunology hg), wide pulse pressure and a harsh diastolic murmur. admission labs showed anemia (hemoglobin: g/dl, hematocrit %) and an elevated erythrocyte sedimentation rate of mm/hr. transesophageal echocardiography revealed severely dilated aortic root aneurysm with secondary severe chronic aortic valve insufficiency and calcified aortic leaflets not typical of rheumatic heart disease. resection of the aortic valve and aneurysm was performed. pathologic examination of the aortic aneurysm revealed intimal and adventitial fibrosis with focal chronic inflammation and partial loss and fibrosis of media, findings compatible with healed takayasu arteritis. the patient was started on prednisone mg by mouth daily for takayasu arteritis and discharged in stable condition. discussion: this is a case of takayasu arteritis masquerading as rheumatic heart disease. the episode of rheumatic fever was likely the initial presentation of takayasu arteritis, as the systemic symptoms of these diseases can overlap. takayasu arteritis is an insidious disease that often leads to a delayed diagnosis with considerable morbidity for the patient. since takayasu arteritis may go undiagnosed until ischemic symptoms develop, physicians should be alert to the possibility of this disease in young women to avert end organ damage and achieve early remission with drug therapy. we present a fifteen year old boy with disseminated papillomatosis and idiopathic cd + lymphocytopenia (icl). the warts have been present since he was one year old and have progressively worsened. there are more than fifty warts on each of his hands. his legs have multiple warts and about ten warts recently appeared on his lips and around his mouth. his past medical history is significant for no hospitalizations and no blood transfusions. he has never had problems with other infections, and he had a benign course of chicken pox that spontaneously resolved. he has been on cimetidine for six months without improvement. several topical therapies, including imiquimod, have failed. he has a total lymphocyte count of /ul (normal range, - /ul) and a cd + count of /ul (normal range, - /ul). the cd +, natural killer cells, and cd + cells were normal. his hiv test is negative. the serum immunoglobulins were normal as well. lymphoctye proliferation studies reveal an absent response to antigens (candida and tetanus) with a normal response to mitogens. further studies showed no other cause of cd + lymphocytopenia. this case shows that the diagnosis of idiopathic cd + lymphocytopenia should be considered in any patient with widespread viral infection whose hiv test is negative. appropriate evaluation of the cd + count should be pursued. j. ko * , a. nowak-wegrzyn, new york, ny. introduction: approximately % of children with moderate to severe atopic dermatitis (ad) have food allergies. complementary and alternative medicine (cam) is utilized by an estimated - % of patients with allergies. we present a case of a year-old boy with ad referred after receiving a diagnosis of food allergy by a cam practitioner. methods/case: a year-old boy was referred for evaluation of mild ad and possible food hypersensitivity. his ad started at year of age and was limited to the face. he was initially breast-fed and was switched to milk-based formula at months of age. solids were introduced at months of age without difficulty. he had no immediate reactions or noted worsening of ad due to foods. the patient presented to a naturopath for allergy evaluation. based on electrodermal skin testing results, he was reported to be allergic to milk, egg, peanut, rice, and beef (all of which he had tolerated previously). he was restricted from milk and egg for weeks without noticeable change in his ad, which was limited to the cheeks and controlled on topical pimecrolimus. results: his weight and height were both th percentile. physical exam was normal except for - cm dry, erythematous patches on both cheeks and mildly dry skin on flexor/extensor surfaces of both arms. skin prick testing revealed negative tests to milk, egg, peanut, and dust mite. serum ige testing was also negative. since he had no evidence of ige sensitization to commonly allergenic foods, he was recommended to continue an unrestricted diet and discontinue use of a "sippy" cup. his ad subsequently improved on a skin care regimen of postbathing moisturization and topical pimecrolimus prn. asthma and allergies are the # reason for cam use in the us. electrodermal skin testing is a method utilized by naturopathic doctors to detect allergen "sensitivity". however, in two double-blinded trials examining atopic and non-atopic patients, electrodermal testing did not correlate with skin prick testing results, regardless of inter-operator variability. conclusions: allergy patients are seeking cam treatment, and it is important for physicians to be aware of the safety and efficacy of alternative medical practices. the use of electrodermal skin testing has not been proven to detect allergen sensitivity and use of this modality should be discouraged. e.e. mcgintee * , k.e. sullivan, philadelphia, pa. introduction: hematopoietic stem-cell transplantation causes profound tcell immunodeficiency due to the rigorous conditioning involved. following transplant, the t-cell compartment is initially reconstituted through expansion of mature donor-derived t-cells. however, thymopoiesis is necessary to generate naive t-cells with a diverse repertoire. factors affecting thymic function impact the ability of the body to reconstitute the immune system. we report a case of severe t-cell immunodeficiency after two stem-cell transplants for neuroblastoma in a patient with a history of thymic hemorrhage secondary to mediastinal surgery. case: a -year-old female with a history of high-risk neuroblastoma was referred for immunologic evaluation due to a significant infectious history since completing her neuroblastoma therapy. she initially presented at months of age with a right atrial mass that was presumed to be an atrial myxoma. she underwent mediastinal surgery to resect the tumor, which was found to be neuroblastoma extending from her right adrenal gland along the vena cava. a ct scan following her surgery revealed an area of hemorrhage in her right thymus. she subsequently received high-dose chemotherapy and two autologous stem-cell transplants. her infection history was significant for multiple episodes of upper respiratory illnesses, sinusitis, and otitis media requiring myringotomy tube placement on two occasions. immunologic evaluation revealed a dramatically low absolute lymphocyte count with deficits primarily in the t-cell compartment, and reduced proliferation in response to mitogens. immunoglobulin levels were normal; she formed protective titers to diphtheria and tetanus but not to any of pneumococcal serotypes. conclusion: stem-cell transplantation often results in severe t-cell immunodeficiency. the thymus plays an important role in reconstituting the t-cell compartment with naive t-cells generated from hematopoietic stem-cells, which restores tcr diversity. as this case illustrates, damage to the thymus can significantly impair the ability to reconstitute the t-cell compartment. a.k. knight * , c. cunningham-rundles, new york, ny. rationale: this is the first case report of oxcarbazepine induced immunoglobulin deficiency. methods: a y/o white female was referred for further investigation of low serum immunoglobulin found as part of an evaluation for chronic bacterial vaginitis. she was taking oxcarbazepine for chronic pain. this was discontinued and immunoglobulin levels and b cell numbers were tested at intervals. specific antibody responses to pneumococcal vaccine were tested. results: at presentation, on oxcarbazepine, immunoglobulin levels were low [igg , iga < , and igm < mg/dl] and she had a b cell deficiency [ %, b cells (normal - %, - cells/cu mm)]. antibody response one month after pneumococcal vaccine was poor (protective antibody to / serotypes). ( %)] with protective antibody responses to / pneumococcal serotypes. she continued to have iga deficiency. conclusions: the patient's initial evaluation suggested the diagnosis of common variable immune deficiency with hypogammaglobulinemia and specific antibody deficiency. however, these defects reversed when oxcarbazepine was discontinued. it is unclear if persistent iga deficiency was a pre-existing condition, possibly predisposing her to this adverse reaction to oxacarbazepine, or induced by the oxacarbazepine. immunoglobulin deficiency is a known, though rare, reaction to carbazepine, the parent drug of oxacarbazepine; this adverse reaction can occur with its derivative oxcarbazepine as well. secondary hypogammaglobulinemia should be considered before diagnosing primary immunodefiencies such as cvid and committing the patients to lifelong immunoglobulin therapy. introduction: interferon and glatiramer acetate (copaxone) are indicated for the treatment of relapsing-remitting multiple sclerosis (ms). anaphylactic reaction has been reported as a rare complication of interferon and copaxone use. we report a case of interferon - a (rebif) and copaxone hypersensitivity associated with positive skin tests and desensitization to interferon - b (betaseron). case report: the patient is a year-old woman with asthma and allergic rhinitis who was diagnosed with ms in oct ' after an uncomplicated pregnancy and was subsequently placed on rebif. one month after starting therapy, patient developed wheezing and generalized urticaria after receiving a dose of rebif. the symptoms recurred the next day. her neurologist stopped the rebif and started her on copaxone. two months later she developed episodes of generalized urticaria. the patient was then evaluated in our center and underwent skin testing with interferon - a intramuscular (avonex), interferon - a subcutaneous (rebif), betaseron, and copaxone. she had a positive skin prick reaction to copaxone and positive intradermal skin tests to avonex ( : strength), rebif ( : ), and betaseron ( : ) after hrs. the intradermal reactions to all interferon formulations continued to progress upto hrs. her neurologist felt that she would benefit from betaseron therapy. the positive intradermal skin test to betaseron was sufficient to warrant desensitization to prevent immediate hypersensitivity reactions. she underwent subcutaneous desensitization as shown in the table. the desensitization was halted at minutes after the patient developed itching of the hands.* she returned in hrs and we restarted by administering . ml of : strength betaseron. increasing doses were given until the patient received a full therapeutic dose ( . mg in ml). she has since done well with daily doses of betaseron ( . mil units). conclusion: we report a ms patient who developed urticaria and asthma exacerbation in response to rebif and urticaria to copaxone. skin tests confirmed an ige-mediated allergic reaction. she underwent successful desensitization to betaseron. to our knowledge, this is the st report of desensitization to betaseron as well as extension to previous reported cases of systemic reaction to interferon and copaxone. pentoxifylline (ptx) is a phosphodiesterase inhibitor that has been used for ischemic vascular disease because of its effects on red blood cells and platelets. it has been used for systemic inflammatory diseases such as sarcoidosis because of its ability to inhibit production of cytokines such as tumor necrosis factor (tnf-a). we decided to offer a trial to a patient with chronic urticaria since agents that increase intracellular camp have been shown to inhibit mast cell degranulation. we report a case of a year-old female with a history of allergic rhinitis, hypothyroidism, and diabetes mellitus with recurrent episodes of chronic urticaria since adolescence. she had known allergies to various antibiotics but otherwise had an unremarkable history, family history and social history. she was being treated with fexofenadine mg qd, azelastine nasal spray, zafirlukast mg bid, hydroxychloroquine mg bid, levothyroxine mcg qd, doxepin mg qhs, metformin mg bid, and spironolactone mg qd at the time of her initial evaluation. her physical exam was notable only for scattered - cm urticarial skin lesions as well as areas of hypo and hyperpigmentation from previous excoriations. her nasal turbinates were mildly congested with dull membranes. a previous skin biopsy showed only urticaria with increased numbers of mast cells. her workup included normal cbc, urinalysis, spep and complete chemistry profile, as well as negative ana and anti-thyroid antibodies. pentoxifylline mg tid was added to the patient`s regimen. her urticaria resolved within - weeks and was no longer visible at months follow-up. pentoxifylline is a safe medication with few side effects that may benefit patients with chronic urticaria via several mechanisms, including the inhibition of mast cell degranulation and secretion of various cytokines and chemokines. the beneficial effects of pentoxifylline in the treatment of this patient`s urticaria have been seen in other patients. further study is indicated to determine which patients with urticaria are most likely to benefit from pentoxifylline, as well as elucidate the mechanisms of action by which pentoxifylline ameliorates symptoms of chronic urticaria. c.m. mjaanes * , m. boguniewicz, denver, co. we report the case of an -year-old male who since the age of years has suffered from recurrent episodes of left tongue swelling. onset of the swelling is usually abrupt, and generally occurs during the night, awakening him from sleep. he describes a sensation of pain in his tongue but denies any pruritus, throat, lip or eyelid swelling. he has no cough, dyspnea, wheezing, rash, or itchy/watery eyes. the episodes occur infrequently, approximately once every spring . they tend to resolve spontaneously within to hours, however, on occasions, the swelling has lasted for - days. the patient's current episode has been present for weeks and is progressing. today he reports more pain and increased swelling. the child reports no benefit from oral antihistamines. he was treated with dexamethasone during his initial episode and experienced gradual resolution of the swelling. he has never been treated with topical or systemic epinephrine, or additional courses of systemic steroids. there is no family history of angioedema. the child was referred for evaluation of an immunologic/allergic etiology of his unilateral tongue swelling. laboratory studies obtained early in the course of his current episode revealed the following: c level mg/dl; c level . mg/dl; c level . mug/ml; c d level . mug/ml; c esterase inhibitor function % of normal. c esterase inhibitor level . mg/dl; ch units/ml; ana : , negative; beta-tryptase < . ng/ml; total tryptase . ng/ml (all normal). initial evaluation revealed marked swelling along with erythematous and violaceous discoloration of the left lateral and anterior portions of the child's tongue. the remainder of his examination was normal. the patient was referred to the pediatric otolaryngology clinic with a presumptive diagnosis of a glossal hemangioma versus lymphangioma. he underwent a magnetic resonance imaging study which revealed a poorly defined, mass-like enlargement of the anterior and left aspect of the tongue. he was treated with a five day course of prednisolone. after initial regression of the lesion a planned surgical excision was carried out without any complications. in conclusion, this rare case illustrates the unique presentation of glossal hemangioma presenting as recurrent angioedema. highlighted are the differential diagnoses, laboratory studies and clinical features of oropharyngeal swelling. severe tongue swelling. rare skin conditions such as leprosy need to be considered in the differential diagnosis of apparent urticaria and angioedema that is atypical in appearance or response to therapy. a year old male originally from laos presented with chronic recurrent nonpruritic indurated plaques on his face and trunk, and was referred to allergy by his primary physician with a diagnosis of urticaria and angioedema to rule out an allergic reaction to foods. he was otherwise healthy and on no medication, and had a negative personal and family history of atopy. he had moved to the united states from southeast asia in , and visited for several weeks again in . he was treated with prednisone and hydroxyzine without benefit; skin testing to foods was negative, and cbc, differential, sedimentation rate, antinuclear antibody, and liver function testing was normal or negative. a skin punch biopsy from an indurated area on the back showed granulomas with clusters of acid-fast organisms on afb stain consistent with tuberculoid leprosy. as the patient was g pd deficient, he could not be treated with dapsone and was treated alternatively with minocycline mg, rifampin mg, and clofazimine mg daily. he was subsequently started on prednisone as he was determined to be having a reversal reaction; his lesions continue to improve. this patient had a rare condition, leprosy, which was confused with urticaria and angioedema. in patients presenting with atypical apparent urticaria or angioedema, especially if response to standard pharmacologic treatment is poor, a skin biopsy is indicated, and may be diagnostic as in this case. introduction: cutaneous flushing about the face of a toddler within minutes of eating specific foods prompts parents and clinicians alike to pursue food allergy testing. auriculotemporal syndrome, also known as frey syndrome, is an isolated and transient facial erythema about the distribution of the auriculotemporal nerve following mastication. we report a child who was referred for food allergy testing and was diagnosed with auriculotemporal syndrome. case history: a yo wf, prior full-term forceps-assisted delivery, has a history of facial flushing within minutes following ingestion of specific foods. the flushing can be induced by a variety of foods, specifically spaghetti, crackers, potato chips and hard candies, and typically resolves within minutes after eating. the child has no respiratory or gastrointestinal distress during the flushing episode. there is no angioedema, urticaria, or other rash elsewhere on her body. within ten minutes of eating a lollipop in clinic, an erythematous, warm macular eruption appeared in a band-like region anterior to her ear extending from her temporal bone to her mandible. this response occurred bilaterally, with a mildly greater intensity on the right side of her face. no sweating or other symptoms developed, and the flushing began to diminish after thirty minutes of observation. discussion: auriculotemporal syndrome is commonly seen in patients who have undergone facial surgery, specifically about the parotid gland. it is believed to be secondary to a disruption in the fibers of the auriculotemporal nerve. it is theorized that the nerve regeneration following an injury may join the parasympathetic fibers of the salivary gland with sympathetic fibers of eccrine sweat glands. mastication then could result in flushing and sweating over the cutaneous distribution of the auriculotemporal nerve that extends from the temporal region to the mandible, anterior to the ear. although rare in children, auriculotemporal syndrome has been associated with forceps delivery. therapy is seldom of benefit or needed, and the syndrome often resolves spontaneously over many years. conclusion: auriculotemporal syndrome leads to a cutaneous eruption temporally related to the ingestion of foods. allergists should maintain an awareness of this rare syndrome to minimize food allergy testing or eliminate unnecessary food provocation challenges or restrictive diets. m. al-ahmad * , s.s. mace, toronto, canada. introduction: ranitidine is a well-known h -receptor antagonist. anaphylactic reactions are seldom reported despite widespread use of the drug. we report a patient with anaphylactic reaction to ranitidine methods: we report a case of anaphylactic reaction with ranitidine. results: a -year-old female with a history of urticaria over one year period, presented with episodes of anaphylactic reactions of increasing severity over year, after ranitidine ingestion. the first two episodes, occurred one hour after ranitidine ingestion, began with a sensation of burning, and itching in the head followed by dizziness, hypotension and near loss of consciousness. the patient had no significant pulmonary or laryngeal symptoms. the fourth episode, occurred minutes after taking ranitidine tablet, was characterized by severe hypotension. two episodes were managed at the emergency department. a skin prick test with a crushed ranitidine tablet demonstrated a positive mm wheal response, which was negative in a control. investigations for carcinoid syndrome and systemic mastocytosis were negative. conclusion: an ige mediated allergy to ranitidine is possible. anaphylactoid reaction to ranitidine is a well recognized entity. however, to our knowledge, few cases of anaphylactic reaction to ranitidine have been described. hypersensitivity reaction to ranitidine should be considered in patients suspected of having drug-related allergy. introduction: severe combined immune deficiency(scid) and cystic fibrosis(cf) may both present in infancy with a history of failure to thrive, diarrhea, and recurrent respiratory infections. although cf is the most common genetic disease occurring in caucasians with an incidence of in births, scid is a rare condition estimated to occur between in , to in , births. we report a case of x-linked scid where the diagnosis of cf was originally entertained due to similar presentation and misleading laboratory results. case: -month-old caucasian male with month history of recurrent respiratory illnesses, fever, loose stools, thick nasal discharge and failure to thrive. this was his second admission for a respiratory infection. relevant lab results consisted of cultures which grew parainfluenza a virus on np wash and pseudomonas aeruginosa on deep throat culture, chest xray showed patchy infiltrates and a borderline sweat test of mmol/l. despite being treated with broad spectrum antibiotic coverage, albuterol and pulmozyme, his respiratory symptoms were not improving. physical exam revealed a thin infant with palpable though small lymph nodes cervical and groin, diffuse scattered rhonchi and liver edge palpable cm below the costal margin. quantative immunoglobulins were obtained and resulted as an igg of , iga of < , and igm of . review of his chest x-ray was significant for absent thymic shadow. lymphocyte count since admission ranged from - . flow cytometry revealed a cd /cd count of %, cd /cd count of %, cd of % and cd of % of all lymphocytes. t-cell stimulation tests were markedly diminished to both antigen and mitogen. a presumed diagnosis of x-linked scid was made and patient undrewent haploidentical bone marrow transplantation. subsequently, cf gene analysis resulted as negative. discussion: as outlined in the case it is essential to recognize the similarities between the presenting symptoms of cf, a relatively common genetic disease and scid, an uncommon one. although pseudomonas is seen in increased frequency in patients with cf, it is essential to recognize that it is also a leading pathogen affecting patients with antibody deficiency. review of the literature did not reveal any previous cases of individuals with scid reported as having an increased sweat chloride, nor any explanations of why this would occur. while immunodeficiency has previously been associated with some forms of dwarfism, we report the first described case of common variable immune deficiency in a patient with seckel syndrome (bird headed dwarfism). the diagnosis of seckel dwarfism, an autosomal recessive disorder, was made at months of age in this boy based on intrauterine growth retardation, proportional dwarfism, microcephaly, micrognathia, and narrow face with "bird-like" large eyes and beaking of the nose. hematologic abnormalities are reported in an estimated % of such patients, and this child developed thrombocytopenia at the age of years. by age , he had pancytopenia with hypocellular bone marrow. a low cd count ( /ul) was noted and both bactrim and neupogen were begun. his only significant infections, rotavirus and salmonella gastroenteritis, occurred at that time along with frequent otitis leading to pe tube placement at ages and but which subsequently resolved. he has never had opportunistic infections or thrush. by the age of years, he required monthly red cell transfusions for severe anemia. after several months of transfusions, the blood bank reported that he no longer had detectable blood group antibodies during crossmatch; this led to measurement of immunoglobulins. igm was undetectable with low iga ( mg/dl) and low igg ( mg/dl). he demonstrated no protective titers to any pneumococcal serotypes after either conjugated or unconjugated pneumococcal vaccines. response to diphtheria, tetanus, rubeola, and influenza vaccines was adequate. total hemolytic complement was normal. he remains lymphocytopenic (alc = /ul) with low cd ( /ul). after five doses of ivig at mg/kg monthly, platelets have remained between - k/ul and there has not been any improvement in the anemia. although the mechanism for the bone marrow failure in these patients is presumed to be chromosomal breakage, this has not been demonstrated in this child. his karyotype is xy with no chromosomal fragility or deletions detected to date. hypogammaglobulinemia should be investigated in any patient undergoing frequent transfusions who loses blood group antibodies, and suspicion of immune deficiency should remain particularly high in patients with severe growth retardation or dwarfism. n.l. rider * , t. craig, hershey, pa. the objective of this study was to assess the effectiveness of physicians at a university primary care clinic in diagnosing and managing adult patients with asthma. a retrospective chart review of adult patients from this clinic was performed. each chart was evaluated using a survey instrument developed from the national asthma education and prevention program (naepp), which consisted of queries. of the charts evaluated met our entry criteria. overall compliance with the naepp recommendations was %. adherences to the asthma guidelines in the following areas were: diagnosis ( %), treatment/disease control ( %), monitoring ( %), and education ( %). these data suggest that there is an opportunity to improve the care provided to patients with asthma, especially in the areas of asthma education and monitoring, even in a university outpatient facility. these data also suggest that naepp guidelines have not been effectively incorporated into primary care practices. b.m. wahlers * , l. sherwood, t. craig, hershey, pa. objective: our aim was to evaluate adherence to the national heart lung and blood institute (nhlbi), national asthma education and prevention program (naepp) diagnosis and management guidelines, regarding asthma admissions at a teaching hospital. methods: a retrospective chart review of patients over the age of years admitted to the hershey medical center between and with a primary diagnosis of asthma or asthma exacerbation was conducted using a -item questionnaire focused on key aspects of asthma care as outlined in the naepp guidelines. results: overall compliance to the guidelines was . %. maximal areas of compliance were noted in regards to pharmacologic treatments utilized ( %, %). much lower levels of compliance were noted in areas of patient education ( %), instruction in written action plan prior to discharge ( %), provision of peak flow meter for home use ( %), assessment of asthma symptoms and severity ( %), and inhaled steroid prescription on discharge ( %). conclusion: adequate care in terms of pharmacologic treatments is being given but sub-optimal cares in other areas of the guidelines exist. there continues to be room for improvement in regards to asthma management, most notably in the area of education, documentation of triggers, and preparation for discharge with adequate tools to monitor and control symptoms. background: asthma is one of the most common problems of childhood, responsible for a significant proportion of absence from school because of chronic illness. objective: this study was carried out among the school-aged children ( - years) in tehran schools during - , in order to determine the frequency of asthma. methods: according to the recommendation of who, a questionnaire was designed, containing standard questions, and the students were given necessary information to complete the questionnaires. the guidance and high school students completed the questionnaires but the parents of primary school students completed them by themselves. results: seven hundred and eight children out of children had asthma ( . %); this prevalence was higher in the boys ( . %), when compared to the girls ( . %). the prevalence of this disease has been estimated about . % in guidance schools, . % in high schools and . % in primary students. based on this survey, the most common clinical manifestations in asthma were included: prolonged cough lasting more than days ( . %), and exerciseinduced wheezing or dyspnea ( . %), followed by repeated dyspnea or wheezing ( . %). based on the drug responses after receiving solbutamol, the prevalence of asthma was evaluated in the range of . % in primary schools, . % in guidance schools and . % in high schools. conclusions: the prevalence of asthma is high among the students of tehran schools and it needs more careful screening programmes and either more information given to the patients and parents about the disease. in the us, asthma is the most common chronic disease of childhood and affects approximately million children. reasons for inadequate asthma control include: inappropriate therapy, incorrect inhaler technique, poor compliance with treatment, and exposure to environmental triggers. rates for asthma prevalence, hospitalization, and death are highest among children residing in inner cities, and important risk factors for asthma-related mortality include being poor and black. the communities of braddock, north braddock and rankin are among the poorest in allegheny county and are designated areas of greatest health risk. recent statistics have demonstrated an increase in the number of asthma hospitalizations in these communities: . children per , which is double the average for allegheny county and greater than seven-times the overall us rate of asthma hospitalizations. our goals were to assess asthmatic severity and appropriateness of treatment, provide asthma education, and to ensure access to healthcare for asthmatic children living in these medically underserved and predominantly african-american communities. twenty-seven asthmatic children were identified. of the children assessed % were under the age of years, % were aged - years, and % were - years of age. based on nhlbi guidelines the severity of each child's asthma was determined: % had mild-intermittent asthma, % had mildpersistent asthma, % had moderate-persistent asthma, and % had severepersistent asthma. the appropriateness of treatment based on severity was also determined. we found that % of the children with mild-intermittent asthma, % of children with mild-persistent asthma, % of children with moderate-persistent asthma and % of children with severe-persistent asthma were receiving inappropriate treatment. furthermore, of the inappropriately treated children % were undertreated. following the assessment, patients and parents were educated with regard to asthma triggers, pathophysiology, use of peak flow meters, inhaler technique and pharmacologic treatment. patients were also scheduled for outpatient follow-up care. these results demonstrate that inappropriate treatment, especially undertreatment, may be a significant cause of the increased asthma morbidity in this population and underscore the need for aggressive education and innovative methods of ensuring health care. w. li-ling * , t. keng-leong, f.c. stephanie, e. philip, singapore. background: asthma admission is an important indicator of asthma morbidity. little is known about the risk factors associated with asthma admission among high-risk asthmatics. purpose: ) to characterise the profile of high-risk asthmatics who had previous asthma hospitalization. ) to identify predictors and risk factors that are associated with asthma hospitalization. methods: data for consecutive high-risk asthmatics who were enrolled into our asthma program from october to may were retrieved from our prospective database. high-risk asthmatics were defined as patients who had a clinical diagnosis of asthma and who had at least one hospital admission for exacerbation of asthma in the preceding months or at least one severe exacerbation of asthma in the preceding months requiring unscheduled visit for beta -agonist nebulisation. a comparison was made among high-risk asthmatics who had at least one or more hospitalization for asthma in the past months prior to the asthma program enrolment with those who were not hospitalized. statistical analyses were performed using spss version . for windows. results: among high-risk asthmatics, ( . %) had at least one or more asthma hospitalization in the past months prior to the enrolment into the asthma program. hospitalization was significantly associated with female gender ( . % with asthma admission v . % without asthma admnission). a significantly higher proportion of asthmatics with no formal education ( . % v . %), primary education ( . % v . %) and secondary education ( . % v . %) were hospitalized for asthma as compared to the those who had tertiary education ( . % v . %). those admitted were predominantly in lower income group, had poor inhaler technique and have no ownership of an asthma action plan ( . % v . %). those hospitalized were also younger, median age years ( , ) v years ( , ) and had a lower first peak flow reading, l/min ( , ) v l/min ( , ) . conclusion: among high-risk asthmatics, certain population subgroups are at greater risk for hospitalization for asthma. intervention aimed to reduce asthma morbidity should take the above findings into consideration. introduction an association between asthma symptoms and air quality is well established, but controversy exists concerning the role of various air quality indicators. the association of san antonio air quality with emergency department (ed) visits for asthma at our military medical center has not been defined. the objective of this study is to determine the correlation of selected air quality indicators in san antonio with ed visits for asthma for both the general population and for the pediatric population. methods selected air quality indicators were the -hr air quality index (aqi) for ozone, -hr aqi for particulate matter < . μm, pollen counts, mold spore counts, and daily high temperature. the number of daily ed visits coded for asthma was obtained retrospectively. pediatric visits (patients < years-old) were evaluated as a subgroup. pearson correlation coefficients (r) were calculated for all data pairs. results during the days of the study period, there were visits for asthma. of these visits, were pediatric. the number of daily visits ranged from to for all visits and from to for the pediatric visits. r values for all visits were - . , - . , . , - . , and - . ; for pediatric visits, - . , - . , . , - . , and - . for the -hr aqi for ozone, -hr aqi for particulate matter < . μm, total pollen grains/m , mold spores/m , and daily high temperature, respectively. in addition to calculating r values for same-day air quality indicators and ed visits, r values were also calculated for a -day average of air quality indicators with the ed visits. for the -day averages, r values for all visits were - . , - . , . , - . , and - . ; for pediatric visits, - . , - . , . , . , and - . for the -day averages of the -hr aqi for ozone, -hr aqi for particulate matter < . μm, total pollen grains/m , mold spores/m , and daily high temperature, respectively. conclusion there was no significant correlation between the selected air quality indicators and ed visits for asthma, either for the general population or for pediatric visits. this study provides no evidence that air quality is linked to ed visits for asthma in san antonio but the degree to which air quality in san antonio affects asthma symptoms remains unclear. introduction: the aim of this study was to evaluate the level of no in the exhaled air of patients suffering from chronic cough. methods: the study was performed on young (mean age . +/- . years), nonsmoking patients with chronic cough referred to the allergy clinic for evaluation. bronchial provocation challenge with histamine was performed according to the method of ryan. exhaled no was measured on-line using a chemiluminescence analyzer (sievers, usa). all patients had resting spirometry within normal values. results: significant bronchoconstrictive response to histamine at a concentration equal to or lower than mg/ml (pc mg/ml) was found in patients ( . %). these patients had a significantly greater mean concentration of no in the exhaled air ( . +/- . ppb) than those with a pc > mg/ml ( . +/- . ppb; p< . ). receiver operating characteristic (roc) curve analysis revealed that it is possible to identify from among patients suffering chronic cough those who have significant bronchial hyperreactivity (pc mg/ml). using ppb as a cut-off value for the exhaled no concentration, the specificity for bronchial hyperreactivity was . % and sensitivity . %. conclusion: assessment of no concentration is helpful in the assessment of bronchial hyperreactivity in patients having chronic cough. l. abetz * , j. bousquet , e. juniper , e. bateman , h. boushey , w. busse , t. clark , r. pauwels , s. pedersen , . manchester, united kingdom; . montpelier, france; . ancaster, canada; . cape town, south africa; . san francisco, ca; . madison, wi; . london, united kingdom; . ghent, belgium; . kolding, denmark. introduction: the acq has been developed as a measure of asthma control for use in clinical practice or in clinical trials. the reliability, validity and responsiveness have previously been demonstrated for the original item acq, the item (minus fev question) and item (minus fev and short acting bronchodilator use questions) versions. data from the -year gaining optimal asthma control (goal) study was used to assess the predictive value of the acq s , , and item versions in determining asthma control status. method: receiver operating characteristic curves (roc curves), plotting true positive rates versus false positive rates for different acq cut-points, were used to determine optimum cut points for totally controlled and well-controlled asthma. scores for the , , and item versions of the acq were examined at . intervals. results: when predicting totally controlled asthma, the areas under the roc curves (arocc) were . / . / . for the , and item versions, respectively; and when predicting well-controlled asthma the arocc were . / . / . for the , and item versions. in both predictive models, the and item versions provided the best arocc. for the and item versions, the best cut-off point to predict totally controlled asthma was <= . , with arocc of . / . , and corresponding sensitivity of . / . and specificity of . / . , respectively. for the item version the best cut-off point was <= . , with arocc of . , sensitivity of . and specificity of . . the best cut-off points for predicting well-controlled asthma were <= . for the item version (arocc= . ; sensitivity= . ; specificity= . ), and <= point for the and item versions (arocc= . / . ; sensitivity= . / . ; specificity= . / . , respectively). conclusion: results indicate the sensitivity and specificity of the acq in predicting asthma control status. a yo black male with asthma and allergic rhinitis developed gradually worsening cough productive of clear to yellow sputum despite treatment with high dose fluticasone, salmeterol, monteleukast, and prn albuterol. asthma history was significant for an intubation at age and pneumonia at age . physical exam revealed pale turbinates and expiratory wheezes. pulmonary function test showed a severe obstructive lung defect with fev . ( %), improving by % after bronchodilator and fev /fvc ratio %. a chest ct revealed significant bronchiectasis in the right middle lobe, lingula and both lower lobes. evaluation for bronchiectasis showed normal quantitative immunoglobulins, subclasses, and humoral responses, rendering innate immunodeficiency less likely. the diagnosis of allergic bronchopulmonary aspergillosis was entertained, but ige was ku/l and aspergillus titers were negative. a sinus ct failed to show active disease, yet the patient reported chronic yellow nasal discharge despite courses of antibiotics. although he was sexu-ally active with several male partners, hiv testing was negative times, months apart. evaluation for cystic fibrosis (cf) showed no symptoms of malabsorption and a negative sweat test. other tests revealed normal - antitrypsin level, p-anca, esr, ace level, and negative sputum for afb and mycobacteria, helping to exclude other conditions such as -antitrypsin deficiency, vasculitis, sarcoidosis, and chronic infection. with no definitive answer, the diagnosis of cf was pursued, but genetic screening as well as mapping were negative. the diagnosis of primary ciliary dyskinesia was then entertained; however, a mucosal biopsy of the nose did not reveal any structural abnormalities. finally, a sperm analysis revealing azoospermia confirmed the diagnosis of young's syndrome, a rare disease with features similar to cf including bronchiectasis, chronic sinusitis and azoospermia. in young's syndrome however, there is an obstructive process rather than a lack of vas deferens resulting in azoospermia and normal sweat chloride, genetic, and pancreatic testing. this case demonstrates the importance of investigating a persistently productive cough in an asthmatic patient and the differential diagnosis as well as the appropriate work up for bronchiectasis. a final diagnosis is important since appropriate management in each situation may affect long term outcome. a.g. palma-carlos * , m.l. palma-carlos, lisboa, portugal. introduction: bronchial challenges are currently done in allergic asthma with allergen, histamine or metacholine.bronchial reactivity to allergens and histamine can probably be variable. purpose to evaluate if the dose of allergen and histamine triggering a significant bronchial obstruction are always correlated in asthmatic patients. methods: a vitalograph model compact has been used throughout the study. allergen challenge has been done with an acqueous solution of house dust mite. bronchial challenges with placebo (sodium chloride) histamine or allergens have been done in all patients. for the provocations with histamine or allergens the threshold dose, inducing a decrease in fev greater than % has been determined in all the cases, as well for histamine as for allergens. a second challenge has been done in all patients with a supra-threshold dose of histamine or allergen corresponding to the double of the threshold. results: provocations have been done in patients either with histamine or allergen. were allergic and non allergic. the threshold dose for histamine were between and ug. in allergic patients and and ug. in non allergic patients.in allergic patients after histamine threshold challenge mean decrease was for fev , % and for fev /vc , %. for supra-threshold dose fev decreases , % and fev /vc , %. after allergen challenge fev decreases , % and fev /vc , %. with supra threshold doses fev decreases , % and fev /vc , %. in non allergic patients there was no changes after allergen challenge. a good correlation in constriction induced by histamine or allergen either for threshold or supra threshold doses (p< . ) was observed but not between the threshold doses of histamine and allergen. conclusions: these results confirm that bronchial obstruction can be triggered by allergens and mediators that the sensitivity of fev and fev /vc for evaluation are roughly comparable after challenge and points to a better sensitivity of a supra threshold dose of allergen or mediators. allergen and histamine challenges don't give the same information. introduction: peak expiratory flow rate (pfr) and forced expiratory volume in the first second (fev ) are currently used in functional evaluation of asthmatic patients but his degree of correlation in obstructive, restrictive and mixed spirometric ventilatory patterns are not well known. the purpose of this study was to evaluate if the correlation between pfr and fev markers of global airways obstruction is comparable in asthmatic patients with obstruction restriction or both. methods: asthmatic patients, males, females have been studied by spirometry with a vitalograph compact in absence of bronchodilatory or anti-inflammatory therapy. patients have been classified in functional patterns according to vc, and fev /cv: normal : vc greater than % of expected value and fev /vc greater than %, obstructive:vc greater than % and fev /vc greater than % restrictive vc, less than % and fev /vc greater than % and mixed vc less than % and fev /vc less than % presenting a so called functional emphysema. results: according to these criteria patients were normal, restrictive, obstructive and mixed. in all the group the correlation between pfr and fev was statiscally significant (p< ) but the correlation coefficient variable. in functionally normal patients r =+ , in restrictive patients + , in obstructive + , in mixed + , and in the sub-group with functional emphysema + , . for this sub-group the correlation coefficient r allows to define fev = + , pfr. conclusions: the report between the two most usual assays of global bronchial obstruction depends on the balance between restriction, (either by interstial fibrosis or hyperinflation) and obstruction and is more close when a more marked obstruction coexist with a restrictive pattern (functional emphysema). in practice pfr has the same value that fev only in more severe cases of ventilatory failure. the dispersion of values and the standard error or regression do not allow to correlate both data in most patients. introduction: the tenor study longitudinally observes the natural history of subjects with severe or difficult-to-treat asthma. this analysis assessed the association between previous and future asthma exacerbations in tenor. methods: subjects eligible for this analysis were years of age at baseline and had at least one follow-up assessment in year and year . recent asthma exacerbations in the past months were defined as: asthma-related emergency room (er) visits, nights of hospitalization, unscheduled physician office contacts; or as a composite measure of at least one of the previous exacerbation events. relative risks (rrs) and % confidence limits ( %ci) were generated comparing exacerbations in year relative to year . exacerbation rates were defined as the number of events divided by total patient follow-up time. no adjustment was performed for baseline characteristics. results: subjects were eligible for this analysis. rrs in year vs. year were: . ( %ci: . - . ) for unscheduled office contacts, . ( %ci: . - . ) for the composite exacerbation measure, . ( %ci: . - . ) for er visits and . ( %ci: . - . ) for nights of hospitalization. over % of subjects with or more exacerbations (composite measure) in year had a similarly high rate in year compared to % of patients without an event in year who went on to have or more exacerbations in year (see table) . conclusion: tenor subjects who experienced an asthma exacerbation in year were at statistically significantly increased risk of subsequent exacerbations the following year compared to subjects not experiencing an exacerbation in year . this increased risk was consistent for all asthma exacerbation outcomes and most elevated for hospitalizations due to asthma. assessment of recent asthmarelated healthcare use is a critical component of the clinical evaluation of subjects with severe or difficult-to-treat asthma. funded by genentech inc. and novartis pharmaceuticals corp. background: preliminary studies investigating yoga and breathwork for asthma have been promising. several randomized controlled trials have shown a benefit from yoga postures and/or breathing versus control, but the control in these cases involved no intervention other than usual care. this study advances the field by providing an active control. methods: a randomized, controlled, double-blind clinical trial was conducted from october to march to determine the effectiveness and feasibility of a yoga and breathwork intervention for improving clinical indices and quality of life for adult patients with mild to moderate asthma. random assignment was made to either a -week yoga intervention that included both postures and breathwork, or a stretching control condition. outcome measures were assessed at , , and -weeks and included the mini asthma quality of life questionnaire (mini-aqlq), rescue inhaler use, spirometry, symptom diaries, and health care utilization. results: sixty-two participants were randomized into the intervention and control groups, and completed the final follow-up measures. intention-to-treat analysis was performed. significant within-group differences in post-bronchodilator fev and morning symptom score were apparent in both intervention and control groups at and weeks; however, no significant differences between groups were observed on any outcome measures.conclusions: iyengar yoga conferred no appreciable benefit in mild to moderate asthma. circumstances under which yoga is of benefit in asthma management, if any, remain to be determined. in order to investigate asthma mortality trends for the u. s. hispanic population, i have collected and graphed data from the national center for health statistics. mortality data for the hispanic population have been available for the entire united states only since and readily available for asthma only since . these data indicate decreases in deaths from asthma (j -j ) from in to in with decreases in the non-hispanic population from in to in . rates of death from asthma decreased for the hispanic population from . per , in to . in , while that for the non-hispanic population decreased from . to . . rates for non-hispanic whites decreased from . to . in . rates of death from asthma have been twice as high among hispanic women as men. rates of death from asthma for non-hispanic blacks have been more than twice as high as those for non-hispanic whites. (national center for health statistics data dictate racial terminology). data for people of hispanic origin include people of any race. these data are affected by both underreporting of hispanic origin on death certificates and undercoverage in the census and resultant population estimates for a net correction of . %. thus, rates of death from asthma have been lower and have been decreasing faster among hispanics than the rest of the population in the united states. allergic rhinitis and asthma are both highly prevalent diseases and often coexist in patients. rhinitis symptoms have been shown to impact the lower airway. as such, the impact of rhinitis on asthma control may be the greatest in patients with the most severe rhinitis symptoms. therefore, this analysis was performed to determine the impact of baseline rhinitis severity on asthma control in patients with both asthma and allergic rhinitis who received either fluticasone propionate aqueous nasal spray (fpans) or montelukast (mon) added to fluticasone propionate/salmeterol / mcg (fsc). a total of patients (> years) with persistent asthma and seasonal allergic rhinitis received fpans mcg qd, mon mg qd or placebo (pbo) in addition to fsc / mcg bid for weeks. at baseline, total nasal symptom scores (tnss) ranged from to . the analysis was restricted to patients whose pre-enrollment asthma therapy did not include fsc. regardless of baseline rhinitis severity, in patients with both asthma and allergic rhinitis, mon added to fsc resulted in no additional improvements in overall asthma control compared with fsc alone. these data suggest that optimal treatment of the individual conditions should be the goal of treatment for patients with coexistent allergic rhinitis and asthma. (sam ) introduction recent studies have demonstrated that parainfluenza and coronaviruses are as important triggers of asthma. parainfluenza viruses are one of the main triggers of virus-induced asthma at summer. parainfluenza viruses often cause severe low respiratory tract infections in immuncompromised patients and in patients with bone marrow transplantation. a retrospective study found that % of pediatric bmt patients with hpiv infection ( % of viral respiratory infections) developed pneumonia and % died. both viruses contributed to fatal asthma. materials and methods for amplification of these viruses, primers which anneal to specific regions of viral genomes: hn-gene for piv , piv and piv and spike glycoprotein gene for coronavirus oc and nucleocapsid glycoprotein gene for coronavirus e were used. pcrdiagnostics was performed on nasal and throat swabs taken from children with atopic asthma exacerbation. results from / to / a total of samples (including negative controls) were tested by pcr. positive for respiratory viruses samples noted in children having asthma exacerbations including . % of all tested samples. piv was detected in . % of all positive samples, piv in . %, and coronavirus oc in . %. piv and coronavirus e were not detected during this study. for negative controls samples were taken from children with atopic asthma in remission. all controls were found to be negative by viral pcr. conclusions respiratory viruses are an important factor in asthma exacerbations in children. piv was the most frequently detected among the positive samples. although hpiv- was less often positive than hpiv- and hpiv- infections in this study, the frequency of the detected coronaviruses may have been influenced by the seasonal activity of these viruses. introduction. in budapest all children come under the regular supervision of a specially trained paediatrician. each paediatrician is responsible for an average of children, often seen up to the age of years. methods. a questionnaire was sent to the district paediatricians of budapest in budapest in , budapest in and . the total number of children in their practice and the number of the asthmatics was assessed. the diagnosis of asthma in every case was established in a paediatric hospital, or a special allergy or pulmonology outpatient clinic. results. in , replies were received from paeditricians, who were responsible for the supervision of , children, of which . ± . % had been diagnosed as having asthma. in replies were sent by physicians, who had a total of , children under their care, including , asthmatics, a prevalence of . ± . %. at the end of , paediatricians having , children answered, noting , asthmatics, a . ± . % prevalence of asthma. conclusion. the current survey of prevalence of asthma in childhood is by far the largest that has been made. an increasing prevalence of the diagnosis of asthma based on clinical investigations was noted, the differences between the investigated years being highly significant. panel report guidelines for the diagnosis and management of asthma have been available since , to standardize and improve the quality of asthma care. however, asthma remains the leading cause of hospitalization for new york city children. implementation of the guidelines has not been fully embraced in the primary care setting. we attempted to increase primary care practitioners' compliance with the guidelines through extensive training. a hospital based pediatric clinic and school based health clinics in the brooklyn inner city, participated from april to march in the program as part of new york city's education and quality improvement project (equip). initially an asthma physician specialist and asthma educator trained the primary care physicians and nurse practitioners in the guidelines. the training was reinforced during monthly luncheon sessions. clinical exam rooms were also supplied with asthma education materials, peak flow meters, and asthma action plans. goals were to identify asthmatics, document asthma severity, give persistent asthmatics written management plans, and utilize appropriate controller medications. compliance was measured by tracking asthma visits with an asthma intake form. prior to this project no consistent attempt had been made in the clinics to regularly classify asthmatic severity, provide written asthma action plans or to place patients on controller medications. after onset of the project a total of asthma visits were evaluated; were from school based health centers and from hospital based pediatric clinic. severity was classified in %( / ) of asthma visits. patients classified as persistent received updated written management plan during %( / ) of asthma visits and %( / ) were placed on controller medications. this asthma management program demonstrated success in improving primary care practitioners' compliance with the naepp asthma guidelines. further studies are needed to determine if compliance with the guidelines persisted after cessation of the extensive training and if such compliance improves asthma outcomes. numerous studies have associated asthma and obesity. although obesity has been identified as a risk factor for asthma, there is limited information on the impact of obesity on childhood asthma. this study examines the effect of body composition on asthma severity and pulmonary function in children. we retrospectively reviewed charts from asthmatic children ages to years, referred to a community-based pediatric pulmonology practice between and . data were included if asthma was the the primary diagnosis and a baseline spirometry was available. asthma severity was classified and body mass index(bmi) was classified as normal, overweight and obese. spirometry results were reviewed. eighty-five patients were reviewed. thirtyone( . %) patients were normal weight; ( . %) were overweight and ( . %) were obese. baseline characteristics such as age, gender and race/ethnicity were similar. asthma severity classification did not differ between normal, overweight and obese children. overall, % were classified as intermittent, % as persistent mild asthma and % as persistent moderate-severe asthma. % of children with intermittent asthma were receiving controller therapy compared to . % with persistent mild and . % with moderate-severe asthma(p= . ). although healthcare utilization for asthma(emergency room visits/admissions) were significantly different between children with intermittent, persistent mild and moderate-severe asthma(p= . ), there was no difference when normal, overweight and obese children were compared. spirometry results showed comparable peak expiratory flow rates(pfr) in all groups; % of predicted in normal weight and % of predicted in both overweight and obese. mean forced vital capacity(fvc) was . %, . % and % and the mean forced expiratory volume in second(fev ) was . %, . % and . % respectively. there was no difference in fev /fvc; . %, . % and . % and forced expiratory flow in mid-lung volumes (fef - ); . %, % and . % of predicted. in this study we retrospectively reviewed asthmatic children and compared bmi, asthma severity and spirometry. we found no difference in asthma severity classification between normal and overweight/obese patients. regardless of the bmi, all indices of spirometry were similar. further studies are needed to examine the impact of obesity on different asthma related disease outcomes. our objective is to further investigate the effect of budesonide, formoterol, and levalbuterol, alone, and in combination, on tgf- production and expression in ragweed (ra) stimulated a cells. meth-ods: a cells were cultured in duplicate for hours at degrees celcius with % co in serum free dmem with or without the following: μg/ml of ra, . x - m of budesonide, . x - m formoterol, and . x - m levalbuterol. tgf- production and expression was measured by a sensitive elisa and mrna assay in cell supernatants and pellets. results: tgf- production and expression from a cells rose markedly in the presence of ra ( . - pg/ml) ( - amol/ml) with significant inhibition following the addition of budesonide, and the combinations of budesonide and formoterol, budesonide and levalbuterol, and budesonide, formoterol, and levalbuterol (p< . ). combined treatment with budesonide and levalbuterol versus budesonide alone reached significance for production and expression (p< . ). budesonide and formoterol compared with budesonide alone reached significance for tgf- production (p< . ). conclusion: combination therapy with budesonide and a long or short acting beta-agonist showed greater effect of tgf- inhibition compared with budesonide alone. this synergistic effect on the distal airways may prevent a subset of asthmatics from developing airway remodeling. g. tamura * , y. sano , k. hirata , s. ishioka , m. nakashima , t. miyamoto , . sendai, japan; . tokyo, japan; . osaka, japan; . hiroshima, japan; . hamamatsu, japan. tulobuterol tape is the world's first long-acting transdermal preparation of a beta -agonist designed to release tulobuterol in an optimal fashion. when it is applied once daily at bedtime, the blood concentration of tulobuterol peaks early in the morning and is kept at effective levels for hours. tulobuterol tape has milder and less frequent adverse events than conventional oral tulobuterol preparations, and when used at bedtime can prevent marked drop in peak expiratory flow (pef) early in the morning. consequently, tulobuterol tape has been commonly used in japan as a long-acting beta -agonist. in the present study, to evaluate its efficacy as a long-acting beta -agonist and to compare its effects at two different doses, we administered tulobuterol tape at doses of or mg/day to patients with persistent asthma already using inhaled corticosteroids. this study was a randomized, double-blind, double-dummy, parallel-group, multicenter trial of -week duration. mean pef in the and mg/day groups were significantly increased from the baseline value by . and . at week , . and . at week , . and . at week and . and . l/min at week , respectively. the increase in mean morning pef in the mg/day group was significantly higher than that in the mg/day group at every point of determination. the mean evening pef was significantly increased in both treatments groups compared with baseline values at every point of determination. although the increase in the mg/day group was greater than that in the mg/day group at each point of determination, the difference between groups was statistically significant only at week . the safety profiles of the two treatments were similar. in patients with persistent asthma who require inhaled short-acting beta -agonists while receiving inhaled corticosteroids, tulobuterol tape mg/day significantly improved pef compared with tulobuterol tape mg/day. introduction: on an average, % of the children admitted annually for asthma to children s hospital require admission to the pediatric intensive care unit (picu). these admissions are highest in the months of august, september and october. aeroallergens such as alternaria and ragweed predominate during this season, and allergies to these allergens may account for the increased number of picu admissions for asthma. objective: we hypothesized that the seasonal increase in the admission rate could be related to allergen sensitivity, particularly to alternaria and/or to ragweed that predominate during late summer and fall. method: data was collected from a retrospective chart review of all patients admitted to the picu for asthma exacerbation between and . skin prick testing (spt) within one year of picu admission was the criteria for inclusion in this study. results: there was a higher prevalence of admissions to the picu for asthma exacerbation during august, september and october ( out of admissions = % of all admissions, p< . ). sixty-one subjects met the one-year spt criteria for analysis. subjects admitted during august, september and october were categorized as group a, and all others were categorized as group b. sensitivity to a total of aeroallergens (tress, grasses, weeds, ragweed, outdoor molds, indoor molds, alternaria, cat, dog, roach and dust mites) was compared between the two groups. there was no statistical significance in aeroallergen sensitivity to alternaria or ragweed between subjects admitted to the picu in august, september and october (group a) and subjects admitted during the other months of the year (group b). conclusion: asthma exacerbation requiring picu admissions is more prevalent during the months of august, september and october. the increased rated of picu admissions did not correlate with the aeroallergen sensitivity to the prevalent allergens during august, september and october. therefore we suspect other factors such as, viral upper respiratory infections, in addition to aeroallergen sensitivity, which may contribute to severe asthma exacerbation during the late summer and fall months. k. kuzume * , shigenobu, ehime, japan. infantile wheezing may be the result of different phenotypes. the aim of this study was to evaluate the risk factors for allergies and the results of allergyrelated blood tests among infants with different types of allergy symptoms. infants were examined physically at birth and at , , , , and months of age, and questionnaires about number of siblings, the family history of allergy, and feeding methods were given. allergic diseases were diagnosed at months of age, and the subjects were divided into groups: infants with atopic dermatitis (ad) only (a group, n= ), infants with both ad and wheezing (a/w group, n= ), infants with wheezing only (w group, n= ), and infants without allergic symptoms (c group, n= ). risk factors were then evaluated. patients ( from the a group, from the a/w group, and from the w group) were given allergy-related blood tests, total serum ige levels, and rast with egg white, milk, and house dust mites at and months of age. the results of the blood tests in control subjects at months of age were compared to the other groups. as shown in table , there were more male infants in the a/w and a groups than in the c group (p< . , a/w vs. c; p< . , a vs. c). numbers of siblings were greater in the w and a/w group than in the a or c group (p< . , w vs. a and w vs. c; p< . , a/w vs. a; p< . , a/w vs. c). the rate of positive family history of allergic diseases was high in the a and a/w groups, compared to the w or c group (p< . , a vs. c and a/w vs. c; p< . , a/w vs. w). the rate of breastfeeding at months of age was high in the a group compared to the others (p< . , a vs. c). patients in the w group had lower levels of total serum ige at months of age, compared to patients in a or a/w (p< . , w vs. a/w and w vs. a). also patients in the w group had lower levels of rast with egg white at months of age, compared to patients a or a/w (p< . , w vs. a/w and w vs. a). the median of total serum ige levels at months of age was higher in a and a/w but not in w, compared to c (p< . , a/w vs. c and a vs. c). in conclusion, there were two different phenotypes of wheezing in infants before months of age. wheezing with ad might be "allergy-related", while wheezing without ad may be related to other factors. as compared to c group: a), p< . ; b), p< . ; c), p< . ; d), p< . as compared to a group: ), p< . ; ), p< . ; ), p< . ; ), p< . as compared to a/w group: f), p< . ; g), p< . ; h), p< . a group, infants with atopic dermatitis only; a/w group, infants with atopic dermatitis and wheezing; w group, infants with wheezing only; c group, infants without allergic symptoms. rast, radioallergosorbent test, n/a, data not available r. amelio * , c. capristo , a. capasso , m. miraglia del giudice , n. maiello , f. decimo , . naples, italy; . napoli, italy. forced oscillation technique (fot) is considered a sensible and specific method to estimate breathing functionality in asthmatic children aged to years, because it doesn't need special collaboration. the aim of our study was to value baseline respiratory resistances with the fot in preschool-aged children with asthma under high dose of budesonide and flunisolide treatment. at this purpose, asthmatic children aged to years were selected: at a first examination (t ) all the patients showed basal value fot at hz frequency (rr ) changes major or equal than % under mcg of salbutamol treatment. days before the study, children selected didn't take systemic and inhaled steroids, cromons, leukotrienes antagonists, teophylline or anti-histamines and they didn't present upper and lower airways infections; then, two weeks before run-in, all selected patients took beta- -agonists at least times per week. all the patients were divided in two groups: group i ( children) under inhalation of flunisolide mcg/kg/dose + salbutamol mcg b.i.d. for days and, for the following two weeks, under inhalation of flunisolide mcg/kg/dose + salbutamol mcg by pmdi+spacer prn.; group ii ( children) under inhalation of budesonide , mg b.i.d. + salbutamol mcg b.i.d. for days, and for the following two weeks, under inhalation of budesonide , mg b.i.d. + salbutamol mcg by pmdi+spacer prn. moreover, we gave diary-card with a simple symptoms score (at t and t ), to get the real perception of the symptoms in the course of study. however, during the treatment, children have ritired from the study. the results obtained were statistically analysed (t student's test). significant rr pre beta- -agonists and ? value reduction was obtained at t and t vs. t . group i had (at t ) such a quick action than group ii reducing airways resistances (p< , ). children treated with flunisolide had lower frequency of breathless and nocturnal cough at t and lower salbutamol use from t to t than budesonide group (p=n.s.). in conclusion, fot is actually a safety method to value efficacy of inhaled steroids in preschool-aged children with asthma. introduction: approximately . % of u.s. adults and . % of louisiana (la) adults have current asthma, and over % currently smoke cigarettes, according to the behavioral risk factor surveillance system (brfss). the purpose of this study is to compare asthmatic smokers vs. nonsmokers in la and the u.s. here we address whether asthmatic smokers utilize more medical care services in the er and outpatient clinics, and whether they were able to fully participate in activities of daily living compared to nonsmoker asthmatics. methods: brfss is a state-based, telephone survey of u.s. adults. the survey collects self-reported information about modifiable risk factors for chronic diseases. this study analyzed data from the brfss survey using sas software. data: out of the current asthmatics, % are cigarette smokers in the u.s. in louisiana, % of asthmatics are currently smoking, which is significantly higher than the national average (p< . ). within the past year, the average number of emergency room visits due to asthma was similar for both locations (la . , us . , p= . ) . nationally, smokers visited the er significantly more frequently than nonsmokers (s . , ns . , p< . ). in la, smokers visited the er twice as often as nonsmokers (s . , ns . , p< . ) the number of annual routine outpatient checkups for asthma was similar based on location (la . , us . , p= . ). smokers and nonsmokers had a similar number of checkups nationally (s . , ns . , p= . ) and in louisiana (s . , ns . , p= . ). the number of days where asthmatics were unable to perform their usual activities was significantly fewer in la than nationally (la . , us . , p< . ). smokers had a significantly higher number of missed days nationally (s . , ns . , p< . ). in la, there was not a significant difference in the number of missed days based on smoking status (s . , ns . , p= . ). conclusion: even though louisiana has a lower prevalence of asthmatics compared to the national average, significantly more of our asthmatics are smokers. asthmatic smokers in la and the u.s. utilized the er more than their nonsmoking counterparts. smokers and nonsmokers had similar numbers of routine outpatient visits. asthmatic smokers missed more days, but this was only significantly different at the national level. other research has shown that young age is highly associated with improper use in children using a mdi and holding chamber (arch pediatr adolesc med ; : ) . the objective of this study was to compare health outcomes achieved by children with asthma using inhaled corticosteroids (icss) delivered by a nebulizer compared with outcomes of children using icss delivered by non-nebulized device. methods: using a managed care organization database (pharmetrics integrated outcomes database), we identified children aged years with an asthma diagnosis and asthmarelated hospitalization/emergency department (ed) visit (july -june and with a prescription claim for an ics within days of discharge. we compared relative risk of hospitalization/ed recurrence from day - (cox proportional hazards regression, covariates=sex, age, current and prior asthma medications, prior oral corticosteroid and short-acting -adrenergic agonist use, initial type of index event) for patients receiving nebulized ics vs other ics by age groups ( - years and - years). results: of patients with claims for ics, received nebulized ics, of which were aged years; received non-nebulized ics, of which were aged years. postindex hospitalization/ed rates were . %. refill rate was higher for patients using nebulized ics. after model risk adjustment, patients using nebulized ics had a % risk reduction for hospitalization/ed recurrence vs those not using nebulized ics (hr: . , % ci: . , . ). in the -to -year age group, patients on nebulized ics had a % risk reduction compared with patients not using nebulized ics (hr: . , % ci: . , . ). in the -to -year age group, patients on nebulized ics had a % risk reduction (hr: . , % ci: . , . ). conclusion: in actual practice, treatment with nebulized ics after an asthma exacerbation is associated with a significant reduction of recurrent hospitalization/ed visits in young children, possibly due to improved technique and compliance. introduction: tenor is a -year, multi-center, cohort study of patients with severe or difficult-to-treat asthma. the objective of the tenor study is to better understand the natural history of patients with severe or difficult-totreat asthma. this analysis assessed the frequency of skin testing in this population and characterized the differences between the positive (st+) and negative (st ) subjects. methods: subjects were asked whether they had ever been skin tested and, if so, the test results. those who were st+ were compared to both st and those never tested (stnd) using clinical and other asthma-related characteristics. subjects years of age were included in this analysis. results: subjects were eligible for this analysis. . % were skin tested in the past, with stnd frequency of . % from allergist sites and % from pulmonologist/other sites. of those tested, . % were positive (allergist . %, pulmonologist/other . %). baseline ige for st+ subjects was . iu/ml vs. . iu/ml for st ; p< . (table) . as shown, the age at asthma onset, duration of asthma, rate of atopic disorders, and the rate at which asthma was triggered by aeroallergens differentiated the st+ from the st group. disease severity as evaluated by fev , healthcare utilization, and medication use, however, was similar between the two groups. in general, stnd were more likely to have values closer to the st+ group, suggesting that the majority of those not tested would have been st+, if administered a test. conclusions: the prevalence of st+ subjects from both allergy and pulmonary practices was high, demonstrating that the majority of these severe or difficult-to-treat patients have allergic asthma. st+ patients showed differences in clinical characteristics compared to st , including a greater likelihood of their asthma symptoms being triggered by aeroallergens. these data also show that the clinical profile of stnd patients may be similar to that of st+ patients, suggesting the utility of a more universal allergic evaluation in severe asthmatics. funded by genentech and novartis pharmaceuticals corp. background current national guidelines for the diagnosis and management of asthma such as the naepp epr , classify asthma severity based on frequency of asthma symptoms, medication use, and measurements of lung function by spirometry or peak expiratory flow variability. recently, the utility of spirometry measurements for assigning asthma severity has come into question. here we evaluate the correlation of spirometry measurements with asthma severity in school-aged children who are mostly naive to anti-inflammatory therapy. methods children were participants in a school-based lowincome asthma mobile van program, the breathmobile. recruitment was through referrals by school nurses and community public health clinics, parental response to flyers, and asthma screening questionnaires. spirometry was performed on all children greater than years of age as part of a comprehensive asthma evaluation. asthma severity was assigned based on symptoms only, according to the naepp epr . results from april to april of the children evaluated on the breathmobile, patients were diagnosed with asthma. classification of severity by symptom frequency according to naepp epr guidelines resulted in % as mild intermittent (mi), % as mild persistent (mip), % as moderate persistent (mop), and % as severe persistent (sp). the percentage of patients and their mean lung functions at baseline evaluation without bronchodilator challenge are shown in the table. there were statistically significant differences (p<. ) between severity groups which was most pronounced for the fef - % when comparing the severe persistent group and the intermittent group. however, mean values appear to be "normal" for all degrees of asthma given current accepted cut-off values, fvc %, fev %, fev /fvc %, and fef - %. conclusion in our study, airflow impairment did correlate with asthma severity, although it was "normal" (fev %) even in children with severe persistent asthma. therefore, a "normal" lung function measurement may be misleading as sole criteria for asthma severity classification. perhaps a higher cutoff point (fev < %) might be a better indicator of asthma severity in children. asthma is the most frequently chronic disease in childhood.our main was to know the prevalence of bronchial asthma in children ( - and - years) in the north zone of mexico city and to compare the prevalence obtained by the written questionnaire versus the video questionnaire in the group of to years, according to methodology proposed by isaac. material and methods: by means of a validated and standardized questionnaire (isaac) that was applied to children from to years and from to . the questionnaires of and years were filled out by their parents. the group from to years answered a questionnaire and a video questionnaire. according to isaac specification and based on a studied population, it was calculated by statcal program the size of the sample. it was choose a haz-ardous sample of children between - years and of the - group years, both sexes in elementary and high school. measures of central tendency and chi were used. results: the final sample size for both groups was children ( of - and adolescents), . % men and . % women. the prevalence of the asthma diagnosis for teenagers was of % (p< . ic . - . ) and it was . % in children (p< . ic . - . ), wheezing in the last months was . % (p< . ic . - . ) in children and of . % (p< . ic - . ) for - years. wheezing induced exercise appeared in . % (p< . ic - . ) in teenager and . % (p< . ic . - ) in the other group. the severity of asthma showed by nocturnal awakness was . % and . % (p< . ), number of crisis in the last year . % and . % for children and teenagers respectively (p< . ). in the video questionnaire of teenagers . % (ic . - . ) answered affirmative on have displayed a shaken breathing on the last year resting and only . % (ic - . ) in the last month. about exercise question . % confirmed have displayed symptoms, . %(ic - . ) in the last year and . % (ic . - . ) in the last month. wide-awake at night . % (ic . - . ) in the last year and . % ) in the last month. conclusions: the prevalence of asthma by diagnosis was higher in teenagers group than in children group. the prevalence of asthma was higher also in this group. rationale: we investigated the relationship of pet exposure and healthcare utilization (hcu) in a cohort of pediatric patients with severe or difficult-totreat asthma in the epidemiology and natural history of asthma: outcomes and treatment regimens (tenor) observational study. we hypothesized that pet exposure would increase hcu due to increased airway inflammation. methods: tenor is a -year multicenter cohort study of patients with severe or difficult-to-treat asthma. children ages - were interviewed at baseline regarding asthma-related hcu in the previous months. patients with pet exposure (ppe, n= ) were compared with patients with no pet exposure (pnpe, n= ). responses were analyzed using fisher's exact test. results: ppe were less likely to have severe asthma by physician assessment ( % vs. %; p= . ). in addition, ppe were less likely to have an emergency room (er) visit ( % vs. %; p= . ) or to have been hospitalized ( % vs. %; p= . ) in the previous months. more pnpe had an ige level > iu/ml ( % vs. %; p= . ). ppe and pnpe were similar with regard to presence of allergic rhinitis and skin test positivity. compared with pnpe, fewer ppe with two or more pets had er visits and hospitalizations (table) . among ppe, there were no differences in ige levels or in asthma severity related to the number of pets. conclusions: pet exposure was associated with reduced hcu in the tenor pediatric cohort, with the most pronounced effect seen in reduced er visits and hospitalizations needed by those with multiple pets. ppe had significantly lower ige levels compared to pnpe, regardless of the number of pets. these data support the hypothesis that exposure to pets may paradoxically protect individuals from the development of severe asthma. alternatively, these data may reflect a self-selection in patients with severe or allergic asthma who are likely to avoid having a pet. however, there may be other confounding factors in families with pets that confer a protective effect on asthma severity. introduction: in asthma and other chronic obstructive airway diseases, phosphodiesterase (pde ) is involved in the pathophysiology of the disease and is expressed abundantly in key inflammatory cells. inhibitors of pde are investigational, anti-inflammatory agents that prevent the breakdown of cyclic adenosine monophosphate, a natural modulator of inflammation. roflumilast is an investigational, oral, once-daily pde inhibitor with demonstrated in vitro and in vivo anti-inflammatory activity, which may translate into clinical efficacy in asthma therapy. this study examined the ability of roflumilast to exert direct or acute bronchodilatory activity in patients with mild to moderate asthma. methods: this was a double-blind, randomized, placebo-controlled, crossover study consisting of three treatment periods of one day each, separated by a -to -day washout period. during each treatment period, patients with a forced expiratory volume in one second (fev ) of % to % of predicted received either oral roflumilast μg, roflumilast μg, or placebo. the fev was measured twice prior to administration and periodically up to h following treatment. after h, patients inhaled μg salbutamol from a metered-dose inhaler; fev was measured min later. adverse events, vital signs, and electrocardiogram results were monitored throughout the study. results: median baseline fev was similar for the three treatment periods. both doses of roflumilast did not lead to statistically significant differences versus placebo in the time-averaged fev over the first or up to h after drug intake (p > . ). thus, there was no evidence of a direct or acute bronchodilatory effect with either single doses of roflumilast μg or μg. in contrast, inhalation of the short-acting bronchodilator salbutamol led to a distinct improvement in fev versus baseline in all treatments groups with median fev increases of %, %, and % in the roflumilast μg, roflumilast μg, and placebo groups, respectively. roflumilast was well tolerated. conclusions: oral, once-daily roflumilast exhibits no direct or acute bronchodilatory activity in patients with mild to moderate asthma as could be achieved with short-acting -agonists. these data support the proposed mechanism of action of roflumilast as an antiinflammatory agent. south africa; . guadalajara, spain; . munich, germany; . weinheim, germany; . budapest, hungary; . konstanz, germany. introduction: phosphodiesterase (pde ) is found in key inflammatory cells involved in the pathophysiology of chronic obstructive pulmonary disease and asthma. inhibitors of the pde enzyme are anti-inflammatory agents that prevent the breakdown of cyclic adenosine monophosphate, a natural modulator of inflammation. roflumilast is an investigational, oral, oncedaily pde inhibitor with demonstrated in vitro and in vivo anti-inflammatory activity. this study examined the dose-related efficacy of roflumilast in patients with asthma. methods: patients with stable asthma (forced expiratory volume in second [fev ] % to % of predicted) were enrolled in this randomized, double-blind, dose-range finding study. after a single-blind placebo run-in period of up to three weeks, patients received oral roflumilast μg, μg, or μg once daily (n = , , and , respectively) for weeks. efficacy was assessed by change from baseline in spirometric lung function fev and forced vital capacity (fvc), as well as morning and evening peak expiratory flow (pef) recorded in patient diaries. safety and tolerability parameters were monitored throughout the study. results: treatment with roflumilast led to dose-dependent and statistically significant increases in fev , fvc (both p < . ), and in morning pef (p < . ). at last visit, fev improved from baseline by ml ( %), ml ( %), and ml ( %) in patients treated with roflumilast μg, μg, and μg once daily, respectively. similarly, dose-dependent improvements of l/min, l/min, and l/min in morning pef from baseline were reached. roflumilast was well tolerated at all dose levels tested. the most frequent drug-related adverse events were headache followed by gastrointestinal disorders such as diarrhea and nausea. there were no clinically relevant changes in vital signs, electrocardiogram, or laboratory parameters. conclusions: oral, once-daily roflumilast was associated with dose-dependent, clinically relevant improvements of lung function in patients with stable asthma. roflumilast was well tolerated. j.l. izquierdo * , e.d. bateman , p. magyar , u. harnest , p. hofbauer , a. varga , c. schmid-wirlitsch , d. bredenbroeker , t.d. bethke , . guadalajara, spain; . cape town, south africa; . budapest, hungary; . munich, germany; . weinheim, germany; . tatabanya, hungary; . konstanz, germany. introduction: phosphodiesterase (pde ) inhibitors are a new class of anti-inflammatory agents for therapeutic use in inflammatory airway diseases. in several studies, the investigational, oral, once-daily pde inhibitor roflumilast has provided clinically meaningful improvements in patients with chronic obstructive pulmonary disease and asthma. this study examined the long-term safety and tolerability of roflumilast over weeks in patients with asthma. methods: patients with persistent, stable asthma (fev % to % of predicted at randomization) participated in a double-blind, randomized dose-range finding study and were treated with oral roflumilast μg, μg, or μg once daily for weeks. patients completing the -week study per-protocol, then continued treatment in this open-label -week extension study. all patients received oral roflumilast μg once daily during the extension period. adverse events (aes), clinical laboratory parameters, vital annals of allergy, asthma & immunology signs, and ecg were assessed throughout the extension period. results: a total of patients were enrolled in the -week extension study. overall, the most common aes were related to the respiratory system. only a small number of patients ( %) experienced aes that were assessed as at least likely related to study medication. the most frequent drug-related adverse events were headache, diarrhea, and nausea as reported by %, %, and % of patients, respectively. most aes were mild to moderate in intensity and transient in duration; % of patients discontinued the study due to aes. most ( %) of these aes leading to discontinuation were assessed as not related or unlikely related to study drug. out of patients, reported serious aes, which were all assessed as not related or unlikely related to roflumilast. no clinically relevant changes in clinical laboratory parameters, vital signs, ecg, or physical examination occurred. conclusions: oral, once-daily roflumilast μg administered for weeks was well tolerated in patients with persistent, stable asthma. this study provides evidence that roflumilast is associated with a low incidence of aes, which are mostly mild to moderate in intensity and transient in nature, thus, supporting the potential therapeutic use of roflumilast in asthma. paris, france; . madrid, spain; . guadalajara, spain; . harrow, united kingdom; . weinheim, germany; . augsburg, germany; . munich, germany; . kaufbeuren, germany; . konstanz, germany. introduction: in asthma, inhaled corticosteroids (ics) have been the mainstay of maintenance treatment. new therapeutic agents are needed that target key inflammatory processes in asthma as effectively as ics but overcome known limitations of ics. phosphodiesterase (pde ) inhibitors are anti-inflammatory agents that prevent the breakdown of cyclic adenosine monophosphate, a natural modulator of inflammation. roflumilast is an investigational, oral, once-daily pde inhibitor for potential use in anti-inflammatory asthma therapy. this study compared the standard corticosteroid treatment of twice-daily, inhaled beclomethasone dipropionate (bdp) with oral, once-daily roflumilast in patients with asthma. methods: in a randomized, double-blind, double-dummy study, patients (forced expiratory volume in one second [fev ], % to % of predicted) received either oral roflumilast μg once daily (n= ) or inhaled bdp μg twice daily ( μg/day; n= ) for weeks. mean change (lsmean and sem) in lung function parameters fev , forced vital capacity (fvc), and morning and evening peak expiratory flow (pef) from baseline was determined after weeks of treatment. further, symptom score and rescue medication use were assessed. results: both roflumilast μg and bdp μg improved fev from baseline to clinically meaningful levels ( ± ml and ± ml, respectively; both p< . ). similarly, roflumilast and bdp improved fvc ( ± ml and ± ml, respectively; both p< . ) as well as morning and evening pef (p . ). roflumilast μg was statistically non-inferior to bdp μg. roflumilast and bdp led to statistically significant and comparable improvements in asthma symptoms and use of rescue medication. adverse events were generally mild to moderate; the most common drugrelated adverse events reported in the roflumilast group were nausea, headache, and diarrhea. there were no clinically relevant changes in vital signs, ecg, or laboratory parameters. conclusions: roflumilast μg provided clinically meaningful improvement of lung function parameters, reduced asthma symptoms, and decreased the need for rescue medication. oral, once-daily roflumilast was as effective as inhaled, twice-daily bdp in the treatment of asthma. oral roflumilast μg was well tolerated. rationale: evaluation of medical claims from commercial health plans permits assessment of therapeutic interventions on resource utilization. this study investigated the impact of controller therapy in children starting asthma maintenance medications. the risk of obtaining prescriptions for oral corticosteroids (ocs), short-acting beta-agonists (saba) or adding another asthma therapy was evaluated. methods: this was a retrospective observational study utilizing medical and pharmacy claims from a large representative managed care plan from / / - / / . children aged - years old with an asthma diagnosis (icd- , .xx) and an initial pharmacy claim for one of the following regimens: fluticasone/salmeterol in a single inhaler, n= , (fsc), fluticasone propionate alone, n= , (fp), montelukast, n= , (mon), any inhaled corticosteroid plus montelukast, n= , (ics+mon), and an ics plus salmeterol from separate inhalers, n= (ics+sal) were included in the analysis. subjects were excluded if they had received any asthma controller medication in the months prior to the initiation of therapy. regression was used to estimate the incidence rate ratio (irr) for ocs and saba use (negative binomial) and the odds ratio (or) of adding a controller (add) and an ed or hospitalization (ip) event (logistic). all models controlled for demographics, pre-controller asthma-related medications and events, and baseline total health care costs. results: the ratios in the table with a confidence interval excluding unity indicate significantly increased use or likelihood of an event compared to the fsc cohort. controller naïve children started on fsc were less likely to add another controller than mon, fp or ics+sal, and had less use of ocs or saba than the cohorts when studied for months after the initiation of controller therapy. in addition, children treated with ics + mon had a significantly greater or of an ed/ip visit compared to fsc. conclusion: use of fp + sal (fsc) in a single inhaler assures that children are getting more optimal inhaled corticosteroid therapy as well as the benefits from the long acting bronchodilator while avoiding the potential for selective discontinuation of ics in the multiple controller cohorts. a.s. nayak * , r. nathan , j. williams , s. kundu , m. lloyd , d. banerji , . normal, il; . colorado springs, co; . bridgewater, nj. introduction: inhaled corticosteroids (ics) are recommended firstline therapy for severe, persistent asthma. systemic exposure to ics may suppress hypothalamic-pituitary-adrenal (hpa)-axis function, particularly at doses required to control severe asthma. ciclesonide (cic) hydrofluoroalkane (hfa) metered dose inhaler (mdi) is a novel and effective ics that is converted in the lungs to its active metabolite, desisobutyryl ciclesonide (des-cic). previously, in short-term studies, cic has been shown to have no effect on serum or urinary cortisol levels, which may be attributed to the low oral bioavailability, high serum protein binding and high clearance rate of cic and its active metabolite. this hpa axis analysis was part of a long-term study evaluating the safety of cic and beclomethasone dipropionate (bdp) hfa-mdi in patients with severe persistent asthma. methods: this was a multicenter, double-blind, parallel-group, -month extension of a -week double-blind trial of patients years with severe persistent asthma. patients were randomized in a : ratio (cic:bdp) to receive cic ( g bid) exactuator or bdp ( g bid) ex-actuator. after weeks, the doses of both medications could be titrated to g bid as needed for asthma control. hpa-axis function was assessed at selected centers in a subset of patients at baseline and end of study (at month or early termination) by measuring both peak serum cortisol induced by low dose ( -μg) cosyntropin and -hr urinary free cortisol corrected for creatinine. results: data were available for a small number of patients at centers evaluating hpa-axis (table) . mean baseline levels and change from baseline to end of study values in low-dose cosyntropin peak serum cortisol levels for cic and bdp were comparable. likewise, baseline levels and mean change from baseline to end of study values in -hr urinary free cortisol corrected for creatinine were comparable among the two treatment groups. conclusion: these findings demonstrate that cic to μg daily for months is safe and has no significant effect on hpa-axis function. a. long * , a. rahman , . boston, ma; . wilmington, de. introduction: little information is available regarding the relationships between asthma severity, disease control, and compliance with medications. methods: physicians' perceptions regarding these variables were determined by internet-based general asthma medication usage survey and patient-specific asthma medication usage surveys between december and , , for physicians ( pcps, pediatricians, allergists and immunologists, and pulmonologists). the patient-specific surveys were based on chart information of randomly chosen patients per physician on controller medication. results: of patients, %, %, %, and % were categorized by their physicians as having mild intermittent or mild, moderate, or severe persistent asthma, respectively. overall, % of patients were categorized as having "very controlled" asthma and % as being "very compliant" with their current regimen. worse asthma control, decreased compliance, and increased physician visits were all associated with increased asthma severity classification. physicians reported that only % of patients with severe persistent disease (n= ) had "very controlled" asthma in contrast to % of patients with mild intermittent asthma (n= ). patients with mild intermittent asthma, and mild, moderate, and severe persistent asthma, had a mean of . , . , . , and . physician visits for asthma, respectively, within the past year. physician perception of patient compliance varied less across the groups, with % of patients with severe persistent asthma and % of patients with mild intermittent asthma being rated as "very compliant." the incidence of allergic rhinitis was similar among all severity levels (range: %- %), but patients with severe persistent asthma were more likely to have comorbid conditions, including hypertension, chronic obstructive pulmonary disorder, chronic bronchitis, and osteoporosis, compared with patients in other asthma severity levels. conclusions: decreased asthma control and rates of com-pliance, as well as increased physician visits and comorbid medical conditions, may be associated with increased asthma severity classification. rationale: children with asthma frequently have co-morbid allergic conditions requiring medications. the purpose of this study was to assess whether the controller asthma medication selected would reduce the utilization of intranasal steroids (ins) and prescription nonsedating antihistamines (nsa) for children treated for co-morbid allergy. methods: this was an observational retrospective study that utilized the pharmetrics integrated outcomes database that contains administrative medical and pharmacy claims data from over managed care plans across the united states. children age - years old with a new diagnosis of asthma (icd- , .xx) were identified and observed for months after their initial diagnosis and treatment of asthma (post-index). four cohorts were established based on their controller medication dispensed: montelukast, n= (mon), fluticasone propionate, n= (fp), fp+mon n= , fp/salmeterol in a single inhaler, n= (fsc). results: baseline comorbid diagnosis of allergic rhinitis was observed in - % of the children. the patterns of use of ins and nsa were similar in the months before and the months after the initial asthma diagnosis and treatment. children with a diagnosis of allergic rhinitis were nearly twice as likely to receive a nsa or ins. all treatment cohorts used a similar amount of each allergy medication. the presence or absence of a diagnosis of allergic rhinitis did not alter the findings. the adjusted odds ratio ( %ci) of using a nsa or ins relative to the use of fsc in the post-index period was mon: . ( . , . ); fp: . ( . , . ); fp+mon: . ( . , , ). the table below shows the percent of children dispensed a nsa and/or an ins. the number of units of each allergy medication was also similar across all cohorts. conclusion: the use of mon, fp, fp+mon or fsc for asthma did not alter the rate or quantity of either intranasal corticosteroid or nonsedating antihistamines dispensed to children over the -month period. although allergic rhinitis is a common comorbidity of pediatric asthma, the selection of a regimen containing montelukast did not reduce the use of either nsa or ins compared to asthma treatments with fp or fsc. rationale: medication compliance is recognized as a significant challenge in pediatrics.the purpose of this study was to compare inhaled corticosteroid (ics) persistence in pediatric patients using a single inhaler, containing both an inhaled corticosteroid (fluticasone propionate, fp) and an inhaled long-acting beta-agonist (salmeterol, sal) (fsc), to patients receiving fp alone, fp + sal from separate inhalers, or ics + montelukast (mon). methods: retrospective -month pre-post database study utilizing medical and pharmacy claims. a total of subjects - years of age with a diagnosis of asthma (icd ) were grouped into cohorts: fsc [n= ]; fp only [n= ] ics+sal [n= ]; and ics+mon [n= ]. patients were controller naïve for months prior to the index event (the first prescription of the medication of interest). subjects were required to have continuous enrollment of months pre-and months postindex. subjects with cystic fibrosis, copd, bronchopulmonary dysplasia or respiratory distress syndrome were excluded. ics refill rates, as a measure of persistence, were compared between fsc and the ics components of the other cohorts over a -month follow-up period. results: mean refill rates over the -month follow-up period was significantly greater (p=< . ) for fsc ( . ) compared with the mean ics refill rate in the fp alone ( . ) cohort, the ics + sal ( . ) and the ics + mon ( . ) cohort. patients on fsc filled % more ics prescriptions than patients on fp alone, % more than ics+sal and % more than ics + mon. mean refills were generally higher than the median fills as a considerable number of children had only one fill: fsc ( . %), fp ( . %), ics ( . %) + sal ( . %), ics ( . %) + mon ( . %). conclusion: patients using fsc, are likely to fill their inhaled corticosteroids more often over -months compared with patients using ics + sal in separate inhalers, ics+mon, and fp as monotherapy. improved persistence with ics has been shown in other studies to decrease morbidity and mortality of asthma. use of fsc, a single inhaler, assures that children are getting more optimal inhaled corticosteroid therapy as well as the benefits from the long acting bronchodilator while avoiding selective discontinuation of ics that may occur when two medications are dispensed. the national health interview survey (nhis) estimates . million united states residents with asthma. noncompliance with treatment has been estimated as between and %. the consequences of noncompliance include absences from work or school, increased emergency room visits, more severe attacks, increased drug side effects, greater cost of care, and death. we questioned compliance in a yo man with severe, prednisone dependent eosinophilic asthma because he had persistent symptoms despite treatment with fluticasone propionate/salmeterol xinafoate / bid, prednisone mg to mg qd, and budesonide ( mcg/puff) puffs bid. after discontinuation of budesonide and prednisone and initiation of methylprednisolone mg bid for hours and then mg qd and beclomethasone dipropionate puffs ( mcg) hfa bid with a spacer, clinical improvement was unexpectedly abrupt. fev increased from % to % of predicted. sputum eosinophil counts decreased from % to %. because of the sudden improvement with the change to methylprednisolone, compliance to prednisone and fluticasone was questioned. to evaluate compliance, the patient's blood, urine, and sputum were tested for synthetic corticosteroids, without his knowledge, using mass spectrometry. the blood level of methylprednisolone was . mcg/dl and prednisolone was . mcg/dl, documenting use of methylprednisolone and the recently discontinued prednisone. the urine levels were mcg/dl of methylprednisolone, . mcg/dl of prednisolone and . mcg/dl of prednisone that further confirmed recent use of prednisone. the sputum testing revealed . mcg/dl beclomethasone, mcg/dl fluticasone and . mcg/dl methylprednisolone confirming compliance to inhaled fluticasone and beclomethasone at the time of the test. thus, contrary to our clinical suspicion, the patient was indeed compliant with his inhaled glucocorticoids and prednisone and subsequently with the methylprednisolone. to our knowledge, this is the first case report to document compliance to inhaled and oral corticosteroids by analysis of synthetic corticosteroid concentrations in blood, urine, as well as sputum. if compliance could be documented with certainty, it could potentially minimize the adverse effects of needless escalating steroid doses, reduce the cost of treatment, and minimize morbidity and mortality as well. rationale:the burden of pediatric asthma extends beyond those children with an asthma diagnosis. children with wheezing frequently have a delay in the diagnosis of asthma that may impede instituting appropriate therapy and reducing disease morbidity. this observational study was designed to assess the treatment patterns of children - years old receiving asthma medication(s) without a diagnosis of asthma compared with children diagnosed with asthma and children without claims for asthma. methods:this was a retrospective cross-sectional study that utilized the pharmetrics integrated outcomes database containing administrative medical and pharmacy claims data from over managed care plans across the united states. three cohorts were selected: children with an asthma diagnosis (icd- , .xx) (dx cohort), children with prescription claims for asthma controllers or rescue medications without an asthma diagnosis (rx cohort) and children with neither an asthma diagnosis nor prescription claims for asthma medications (control cohort). utilization of asthma medications, asthma specific costs and total costs of care were assessed. results: a total of , children were identified: . % in the dx cohort, . % in the rx cohort and . % in the control cohort. the potential asthma cohort was . %. total annual non-asthma related costs for the dx cohort was $ , for the rx cohort was $ , and for the control was $ . only % and % of the total healthcare charges in the dx and rx cohorts retrospectively were asthma related. non-asthma charges were significantly higher in both the dx and rx cohorts compared with the control cohort. in the rx cohort, the ratio of saba prescription claims to asthma controller claims were . -fold higher than in the dx cohort. conclusion: children treated with asthma medications without an asthma diagnosis consume greater health care resources resembling the pattern of health care utilization of children with an asthma diagnosis more closely than controls. further, children with treatment in the absence of an asthma diagnosis appear to be under-treated with controller therapy as recommended by national and international guidelines. background: a recent retrospective study assessed asthma variability in inner-city patients months before and months after enrollment into an naepp guidelines-directed clinical management and educational program. while guidelines-directed care improved asthma symptoms and outcomes, significant variability in disease indices were observed over the -month period. the present analysis evaluates resource utilization associated with this variability. method: economic end points, including hospital/emergency department (ed) visits, total unscheduled office visits, sick visits, and days lost from work or school, were collected from inner-city patients aged years ( % female, % minority, % treated by primary care physicians) enrolled in a guidelines-directed asthma clinical management and education program aimed at minimizing barriers to adherence. patients were stratified into groups: those with high variability in asthma (n= ) and those with low variability in asthma (n= ), with variability defined as number of fluctuations in naepp symptom class in the -month postintervention period (high variability = patients with fluctuations higher than the mean; low variability = patients with fluctuations lower than the mean). results: guidelines-directed therapy was associated with improvements in asthma during the -month treatment period for both groups. patients in the high-variability group had more ed visits, sick visits, total unscheduled visits, and office visits compared with patients in the low-variability group (see table) . conclusions: despite guidelines-directed therapy and overall improvement in asthma control, patients experienced variability in asthma, indicating that even when their disease is stable, their symptoms continue to fluctuate. as a result, asthma variability may contribute to increased resource utilization. introduction: inhaled corticosteroids (ics) are considered first-line therapy for patients with persistent asthma. ics can lead to oropharyngeal adverse events, which may affect treatment outcomes and adherence. the occurrence of these local adverse events is dependent upon several factors, including dosage and duration of ics treatment. ciclesonide (cic) hydrofluoroalkane (hfa)-metered dose inhaler (mdi) is a novel and effective ics, with relatively low oropharyngeal deposition. cic is converted in the lungs to its active metabolite, desisobutyryl-ciclesonide (des-cic). furthermore, cic undergoes limited conversion in the oropharynx, which may account for its improved safety profile. this oropharyngeal safety profile analysis was part of a long-term study evaluating the safety of cic hfa-mdi vs beclomethasone dipropionate (bdp) hfa-mdi in patients with severe persistent asthma. methods: this was a multicenter, double-blind, parallelgroup, -month extension of a -week double-blind study of patients years with severe persistent asthma. patients were randomized in a : ratio (cic:bdp) to receive cic ( g bid) or bdp ( g bid) (both ex-actuator). after weeks, the doses of both medications could be titrated to g bid as needed for asthma control.) oropharyngeal adverse events were monitored, and suspected oral fungal infections were verified by positive culture. results: the incidence of oral candidiasis was lower in subjects receiving cic ( . %), compared with those receiving bdp ( . %) ( table) . the incidence of pharyngitis and hoarseness was . % and . %, respectively, for the cic group, and . % and . %, respectively, for the bdp group. all local adverse events resolved without sequelae, and there were no withdrawals due to oropharyngeal treatment-emergent adverse events. conclusion: after -months of treatment with cic μg or μg twice-daily, the incidence of oropharyngeal adverse events was low. cic treatment resulted in a much lower incidence of oral candidiasis, compared with similar doses of bdp, reflecting a better local tolerance. objective: to determine the prevalence of asthma and asthma-related morbidity, treatment and asthma-risk factors in a selected population. method: a routine health screening, including tests for asthma, was conducted at the new orleans center for creative arts high school. participants ( ) identified their medications and asthma tools in addition to completing the isaac questionnaire. prevalence data included lifetime wheezing, month wheezing, and previous asthma diagnosis. asthma-related morbidity included sleep disturbance, wheezing with exercise, asthma attack rate and night awakening. results: " participants were aged - years ( . % african american, . % white) with . % male, . % female. " cumulative asthma prevalence was . %, lifetime wheezing ( %), -month wheezing . % with girls reporting . times more often ( % ci: . , . ), and wheezing more than times in months . %. " there was a significant association between race and wheezing in the last months (p < . ) with whites reporting . times more often ( % ci: . , . ). asthma morbidity was reported as follows: a. night cough - . % b. wheezing with exercise - . % " parents with a less education (high school or less) were . times more likely ( % ci: . , . ) to have children who developed wheezing in the past months. " higher body mass index (bmi = ) was associated with wheezing after exercise (p < . ) with a . -fold increase ( % ci: . , . ). " among those with current asthma ( / ), were not on any medication, were using bronchodilators, and were on anti-inflammatory medications. three reported using a spacer and reported using a peak flow meter. conclusion: asthma prevalence is higher in this school population than the national average. less parental education, female gender, and bmi = were associated with greater asthma morbidity. the majority of the participants with current asthma reported receiving episodic and inadequate treatment with inhaled corticosteroids. objectives: to determine the prevalence of asthma and asthma related symptoms; to assess its severity among new orleans school children. methods: seven elementary, middle, and high schools in new orleans participated in the screening of students, % female, % male, ages - in the fall, . the -item questionnaire was designed by the international study of asthma and allergies in childhood (isaac) to determine asthma prevalence and severity in children. the isaac questionnaire is a validated protocol used on over , children in countries. asthma is defined as cur-rent wheezing for the purposes of this study. data was entered using spss and sas software for analysis. results: table: presence of asthma symptoms by ethnicity conclusion: asthma prevalence is significantly higher in inner-city school children in new orleans when compared to the national prevalence ( . % to . % vs. . %). asthma prevalence and severity do not differ significantly between african-american and caucasian children in new orleans even after removing the effect of gender and age. video is an effective method of teaching pollen identification. projected digital images offer three-dimensional views of unique pollen detail similar to focusing a microscope. the national allergy bureau™(nab) currently provides pollen counts to the media. these reported levels are obtained by standardized counting methods rather than forecasts based on historical pollination predictions and weather patterns. the american college of allergy, asthma and immunology and the american academy of allergy, asthma and immunology have an interest in ensuring consistent counting and accurate reporting practices. both organizations offer pollen identification training in conjunction with their annual meetings and have used the video for initial training sessions and for experienced counters in advanced courses. there are certified pollen counting stations in the united states and canada with approximately currently active locations. the nab requires the demonstration of ability to count and accurately identify pollen on test slides. an updated recertification process using an interactive web site is currently being developed. ongoing pollen identification training is essential for the continued success of this aeroallergen network. most observers found that the video provided a quality emulation of microscopic viewing and enhanced the depth and detail of individual pollen characteristics. the video received the highest possible ratings by course attendees. in conclusion the video plays a positive role in pollen identification training and the continuing education of experienced counters. the diagnosis and treatment of mold allergies are complicated by the genetic diversity of individual fungal species and the influence of endogenous fungal proteases on extract compositions and potencies. studies examining the biochemical comparability of mold extracts from different sources and their compatibility with other allergens in immunotherapy mixtures are essential to the clinical effectiveness of these products. compositional comparisons of extracts prepared from alternaria, aspergillus and penicillium source materials by u.s. allergen manufacturers revealed variable sds-page protein banding patterns and noticeable differences in total protein and carbohydrate concentrations. alt a levels in alternaria extracts did not correlate closely with total protein levels or with ige-binding potencies measured by elisa inhibition. immunoblot profiles of fungal extracts were more closely related to one another compared to sds-page patterns, suggesting that similar allergenic or antigenic epitopes may be retained in molecules of varying size. parallel elisa inhibition dose-response curves provided statistical evidence that a repertoire of ige epitopes is conserved in many of these products. variations in the potencies of fungal extracts from different manufacturers may result from differences in source materials and/or conditions of extraction and storage. the stability and compatibility of allergen mixtures containing mold extracts were assessed after storage for up to months at - °c using specific immunoblot and elisa procedures. grass and mite allergens compromised by mixing with mold extracts were stabilized by glycerin. alternaria extracts from different sources produced similar effects on grass allergens when added at comparable strengths. degradative effects caused by aspergillus or penicillium products were more closely related to total fungal protein concentrations than to extraction ratios. structural epitopes on cat, ragweed and fungal allergens were stable after mixing with protease-containing mold extracts, indicating the presence of natural protease inhibitors or allergenic protein sequences distinct from those recognized by these enzymes. allergenic extracts labeled as weight/volume or by pnu have no regulatory requirement for determination of activity. alum-adsorbed allergenic extracts are labeled in pnu and are felt to be depot formulations. the purpose of this study was to develop methods to measure important allergen proteins and specific ige binding capability of these alum-adsorbed allergenic extracts and to begin to assess the potency of these non-standardized extracts. allergen proteins are adsorbed to alum particles making their measurement difficult. in this study allergens were released from center-al ® alum precipitated allergenic extracts using . m citrate buffer, ph . the major allergen contents of several lots of each product were measured using monoclonal antibody elisas for group grasses, cyn d bermuda, bet v birch, ole e olive, and pla l english plantain. these assays were developed and validated by alk-abello and optimized for the citrate releasing buffer. direct binding ige was performed by immobilizing serial dilutions of extract to microtiter plates and then adding specific atopic sera and enzyme labeled anti-ige. the methods used were able to measure in vitro allergen activity in the alum-adsorbed extracts. major allergen content was successfully measured in the extracts and the amount was related to the pnu content. as expected, the variability of the major allergens within a particular extract species was higher than in standardized extracts that are adjusted for potency. the extracts demonstrated specific ige binding ability in the binding assay. the ige binding capability at various dilutions was related to the major allergen content. in conclusion, methods were developed to release adsorbed allergen proteins from alum extracts. the extracts were then analyzed for major allergen pro-teins and the ability to bind ige. major allergen content is currently used to monitor the activity of aqueous and glycerinated extracts and this study demonstrates that implementing these testing procedures will improve the consistency and quality of alum-adsorbed extracts. introduction there are over species of smut and rust fungi. ustilago maydis, or corn smut, is a basidiomycete fungus that infects ears of corn. it is responsible for a percentage of grain loss in the united states but eaten as a delicacy in mexico. it grows into large tumor-like structures, called galls, dispersing soot-like spores responsible for the common name, "smut." it is readily airborne and believed to be a causal agent for allergic rhinoconjunctivitis. "corn smuts" was added to the standard screening panel for patients presenting for evaluation of rhinitis in the region of middle tennessee. methods using greer laboratories™ corn smut extract : w/v, patients were tested by prick/puncture method with the hollister-stier quintip™ device. if negative, intradermal testing was performed. positive and negative controls were assessed. based on current national recommendations, wheals mm greater than negative control were considered positive for prick/puncture testing and wheals mm greater than negative control were considered positive for intradermal testing. results patients were tested between november, and march, . / ( . %) met criteria for prick/puncture positivity. / ( . %) met criteria for intradermal positivity. patients prick positive to corn smut had the following prick positive tests: dust mites / ( . %); cat / ( . %); local grass mix / ( . %); local tree mix / ( . %); local weed mix / ( . %), mold mix / ( . %); cockroach / ( %); and dog / ( . %). discussion allergy testing for aeroallergens is available to a limited number of antigens, of which, only a few are standardized. as time passes, relevant antigens are discovered and their importance further elucidated. this assessment reveals a significant presence of corn smut ige largely accounted for by intradermal positivity which may or may not reflect clinical sensitivity. these numbers are provided so that other clinicians may compare to prevalence in their geographical area. further studies are needed to determine the association of corn smut ige with clinical symptoms. h antihistamines are the mainstay of therapy for allergic disorders, including skin diseases. the most common side-effect of marketed antihistamines is sedation, especially when the clinical symptoms require a higher dose than recommended, a condition commonly encountered in dermatological disorders. the present study describes the pharmacology of a new non-sedating h antihistamine, r (hivenyl™). r binds to the cloned human h receptor with a similar affinity (ki: nm) as the reference antihistamines cetirizine (ki: nm) and loratadine (ki: nm). in vivo, r protects rats and guinea pigs from lethal shock, induced by compound / and histamine, respectively (ed : . and . mg/kg respectively). the compound is at least as effective as cetirizine and loratadine. in rats, r inhibits the histamine-and allergen-induced cutaneous reactions (ed : . and . mg/kg) with a similar potency as cetirizine (ed : . and . mg/kg) and loratadine (ed : . and . mg/kg). even so, in guinea pigs the compound inhibits the histamine-and allergen-induced skin reactions (ed : . and . mg/kg) to a similar extent as loratadine and cetirizine. however, in dogs r is more potent in inhibiting the ascaris allergen-induced wheal reaction (ed : . mg/kg) than cetirizine (ed : . mg/kg) or loratadine (ed : . mg/kg). r fails to occupy central h receptors in the guinea pig cerebellum up to mg/kg, in contrast to loratadine (ed : . mg/kg). in vitro and in vivo cardiovascular safety experiments indicate that r lacks the intrinsic capacity to prolong the qt-interval, even at high doses. as such, r (hivenyl™) is characterized as a potent, non-sedating and cardiosafe h antihistamine. it has been selected for further clinical development, mainly in the field of dermatology. the compound will be a suitable tool to explore the activity of a selective h antihistamine in various indications, without the contamination of the sedative activity often observed with other marketed antihistamines when increasing the dose. ciu represents one of the most clinically perplexing disorders which the allergist-immunologist is faced with. we have previously reported the clinical efficacy of fxt (prozac), an ssri widely used for the treatment of depression, in the management of ciu (nsouli tm, et al. ann allergy asthma immunol ; : ) . in this presentation we report additional cases of ciu which responded dramatically following the use of fxt. a yr-old female and a yr-old male presented with ciu of and months duration, respectively, requiring oral corticosteroid (cs) therapy for control of their ciu after failure of high dose anti-h (hydroxyzine) and anti-h (ranitidine) agents (table) . testing for food and latex allergy, viral hepatitis, autoimmune thyroid disease and parasitic infection were all negative. a skin biopsy performed in subject # was consistent with an urticarial vasculitis. following one week of oral fxt ( mg qd [subject # ] mg qd [subject # ]) a striking and complete resolution of urticaria in each patient was observed within to days during which time it was possible to successfully taper the cs. both patients have been maintained on fxt therapy with complete control of their ciu. the very favorable response to fxt therapy in these patients in addition to our first case report suggests that this drug may have a new therapeutic application in the management of recalcitrant ciu. background: ipratropium bromide nasal spray (ib) is indicated for treatment of rhinorrhea caused by common cold (cc), seasonal and perennial allergic rhinitis (ar) in adults and children age and up. symptoms of rhinorrhea from cc or ar in children are similar to those in adults, yet there is little data on the use of ib in children under years of age. objective: evaluate the safety and efficacy of ib nasal spray . % in - year-old children with symptoms of rhinorrhea from cc or ar. methods: a total of children ( cc and ar) were treated in an open-label, multi-center study. the cc patients received ib nasal spray ( mcg per nostril) tid for days, the ar patients received ib nasal spray ( mcg per nostril) tid for days. effectiveness was measured using a global assessment questionnaire and daily symptom scores reported by the parent. results: from the global assessment questionnaire, % and % of the parents found ib either "very useful" or "somewhat useful" in the cc and ar groups respectively. regarding effectiveness, % (cc) and % (ar) of the parents reported that ib had either a "good effect" or "excellent effect" in treating rhinorrhea. moreover, % (cc) and % (ar) of parents found administration of a nasal spray either "extremely easy" or "very easy." eighty-one percent (cc) and % (ar) of the parents reported they would use ib again for their child's allergy symptoms. the daily symptom score ( = none to = unbearable) for rhinorrhea decreased from . to . (- %, p< . ) for cc and from . to . (- %, p< . ) from baseline compared to the average on-treatment score, with decreases also seen for stuffy nose and sneezing. the nasal spray was well tolerated with adverse events (ae) reported in % of cc and % of ar patients. the aes were mostly mild to moderate and no potentially systemic anticholinergic or serious aes were reported. conclusions: ib nasal spray . % administered at a dose of either or mcg per nostril tid is an easy to use, safe, and effective therapy for control of rhinorrhea in children to years of age with common cold or allergic rhinitis. chronic idiopathic urticaria (ciu) represents one of the most clinically perplexing disorders which the allergist-immunologist is faced with. the pathogenesis of the condition derives from the release of potent vasoactive substances including histamine, and products of arachidonic acid metabolism, e.g., prostaglandins and thromboxanes formed by the action of the enzymes cyclooxygenase (cox) of which cox- is responsible for pseudoallergic and other inflammatory responses. although a number of therapeutic options exist owing to the plethora of mediators produced, treatment has focused largely on the use of h antihistamines and, unsurprisingly, at times without complete resolution of symptoms. in this presentation we report the successful use of a cox- inhibitor for the treatment of chronic urticaria. a y/o white hispanic female presented with a month history of chronic urticaria predominantly on the soles of the feet, with unknown precipitating factors, and fail-ure to respond to prior treatment with: cetirizine, steroids, benadryl, ebastine and epinastine. the patient received a blood transfusion years ago and there was no prior history of allergies. skin testing revealed + reactions to dust mite, pollen, cockroach, shellfish, + reactions to corn, milk and ige = iu (nv < iu), aso = ui (nv < ui). after weeks of treatment with rofecoxib (vioxx) mg, and benadryl, the rash resolved. vioxx was continued for more weeks until complete resolution of symptomatology. this case illustrates that the addition of a selective cox- inhibitor (i.e., rofecoxib) with an h antihistamine may be a more effective regimen for patients with ciu who fail to respond adequately to conventional therapy. introduction: elderly asthmatic patients whose symptoms are controlled by inhaled corticosteroid (ics) therapy may still have breathlessness on exertion. we randomized elderly asthmatic patients stabilized by medium-dose ics therapy into two groups, treated one group with medium-dose ics therapy plus montelukast, a leukotriene receptor antagonist, and the other with increased-dose ics therapy, and compared the effects of the treatment regimens on exercise tolerance. methods:the subjects were patients with bronchial asthma ( males and females, . ± . years) stabilized by ics therapy (with fluticasone proprionate, fp; mg/day) for three months or more with low peak expiratory flow (pef) rates (< %predicted, variability< %). they were randomly divided into two groups ( patients each) to be treated with ics therapy plus montelukast ( mg/day fp + mg/day montelukast; m group) or with increased-dose ics therapy ( mg/day fp; f group). pulmonary function tests, a six-minute walking test, respiratory gas analysis during incremental ( w/min) cycle ergometer exercise were conducted, and exhaled nitric oxide (no) levels were measured before and after two weeks of the study treatment. results: pulmonary function tests showed significant increases in maximal mid-expiratory flow (mmf) and forced expiratory flow at % vital capacity (v ) in the m group (p< . ) but no significant changes in the f group. exhaled no levels decreased significantly in both groups ( . ± . to . ± . ppb in the m group and . ± . to . ± . ppb in the f group; p< . ). the six-minute walking distance extended from ± to ± m in the m group and from ± to ± m in the f group.the peak oxygen uptake (peakvo ) increased significantly in the m group (%peakvo /w from . ± . to . ± . %; p< . ) but not in the f group (%peak vo /w from . ± . to . ± . %). the peak exercise load also increased significantly in the m group ( . ± . to . ± . w; p< . ) but not in the f group ( . ± . to . ± . w). conclusions: the results indicate that concomitant administration of montelukast is more effective than dose escalation of ics on exercise tolerance in elderly asthmatic patients under medium-dose ics therapy. e. meltzer * , y. luo , l. shen , z. guo , c. schemm , y. huang , k. chen , p. king , r. nave , d. banerji , s. rohatagi , . san diego, ca; . bridgewater, nj; . konstanz, germany. introduction: inhaled corticosteroids (ics) are first-line treatment for persistent asthma. ciclesonide (cic) is a novel and effective ics under development. freely circulating, unbound ics is available to cause systemic adverse effects, such as hypothalamic-pituitary-adrenal (hpa) axis suppression. hence, it is important to determine the free fraction of ics in plasma. in separate studies, the protein binding of the active metabolite of cic, desisobutyryl-ciclesonide (des-cic), was evaluated, and the effects of inhaled cic on hpa axis function were determined. methods: human plasma protein bind-ing of des-cic ( . - ng/ml) was determined using equilibrium dialysis. dialyzed samples were analyzed by liquid chromatography with tandem mass spectroscopy to determine free and bound des-cic. in separate clinical studies, the effects of cic (hfa; - μg daily) and placebo (pbo), via metered-dose inhaler (ex-actuator doses), over days, or weeks, on basal hpa axis function ( -hour area-under-the-curve [auc - h] serum or urinary cortisol corrected for creatinine) or stimulated (low-dose [ μg] cosyntropin) serum cortisol were investigated in patients ( years) with persistent asthma. results: the mean % of human plasma protein binding for des-cic was %. in studies measuring serum cortisol auc - h, there was no difference between pbo and cic ( - μg). similar results were observed for -hr urinary cortisol corrected for creatinine. in the rd study measuring low-dose ( μg) cosyntropin-stimulated peak serum cortisol, after weeks of treatment, there was no significant difference in the mean change from baseline versus placebo for either cic (p= . ) or cic (p= . ). conclusions: the favorable pharmacokinetic profile of cic, in particular the high protein binding of des-cic, may explain the lack of hpa-axis suppression. this appears to result in greater systemic safety. purpose: unscheduled office and ed visits for urgent asthma care are an ongoing point of concern. determining preventive variables regarding these unscheduled visits could have a significant impact on asthma costs and quality of life. objective(s): this research addresses the following question: when stratifying by race, gender, age, metropolitan/rural place of residence and comorbidity, do adults with asthma have fewer ed or unscheduled office visits for urgent asthma care if they: a) have an identified primary care provider, or b) have health insurance? method(s): univariate and stratified bivariate contingency table analyses were performed on weighted behavioral risk factor surveillance survey (brfss) data. result(s): adults with asthma who had an identified primary care provider were more likely to have no unscheduled office visits (or= . ) or ed visits (or= . ) for urgent asthma care. this was also true for adults with asthma who had health insurance (or= . for no unscheduled office visits and or= . for no ed visits). these relationships held when stratifying by race, gender and age. the relationships also held for metropolitan residents. the analysis was inconclusive for rural residency and the existence of co-morbidities. conclusion(s): despite race, gender, age and metropolitan residency, having a primary care provider or having health insurance impact whether or not adults with asthma are more likely to have unscheduled office or ed visits for urgent asthma care. further investigations are needed to examine how these factors impact adults with asthma who are rural residents or who have co-morbidities. d. bukstein * , g.a. cherayil , . madison, wi; . brookfield, wi. introduction: costs for plans to process prior authorizations for non-formulary medications, has been estimated to be $ to $ per request. costs for physicians to process these requests has not been extensively studied. methods: dr.bukstein, board certified allergist, developed a data collection tool. the form was utilized by physicians and nurses to document time spent on processing prior authorizations. data collected included, class of medicines requiring the pa, nursing time spent on calling the patient, pharmacist, health plan, nursing time spent completing forms, nursing time clarifying the information for the pa, as well as physician time spent completing pa activities. results: data was collected over weeks in and requests were processed.the class of medicines most often processed was antihistamines, comprising % of requests. nursing calls were tracked and calls to and from patients were the most common call documented. they averaged . +/- . calls per day per nurse. the nurses spent an average of minutes per patient call. calls to health plans averaged . +/- . calls per nurse per day and time spent on these call was . +/- . minutes per call. physician calls documented included calls averaging . +/- . calls per physician per day. these calls averaged . +/- . minutes per call.often the results of the prior authorizations were not known on the day of the request. originally . % of requests were granted the same day. retrospective review revealed . % were approved the first time they were processed. salary and benefits were calculated for nurses and physicians. the hourly rate was defined as $ . per hour for nurses and $ per hour for physicians. the costs for the time spent on the prior authorizations were calculated. during the week study period, over hours was spent by nurses on calls and over hours was spent by physicians on calls during the same time period. the total nursing and physician cost in this specialty practice was $ . per prior authorization. conclusion: there are substantial costs with processing of prior authorization requests for non-formulary drugs on the physician office side of managed care as well as on the insurance side of the process. specialty physicians should have a different process for obtaining non-formulary medications since almost % of their requests are granted. introduction: diabetes mellitus can adversely impact the course and outcome of myocardial infarction (mi). one of the mechanisms underlying this phenomenon is alteration of the course of inflammation and the reparative process following myocardial necrosis. abnormal wound healing, tissue reparation and immune responses in diabetic patients have been intensively studied, but the cellular and the molecular mechanisms are still unclear. transforming growth factor-beta (tgf-beta) is a multifunctional cytokine which plays a critical role in coordination of the course of inflammation and reparation, acting as a potent depressor of inflammation and a stimulator of regeneration. this study investigates the dynamics of serum concentrations of the active form of tgf-beta during the period up to the th day after the onset of a mi in diabetic and non-diabetic patients. results: in non-diabetics a significant increase was observed in tgf-beta on day ( -fold greater than in controls; . ± . and . ± . pg/ml respectively) with further increases reaching a peak on day ( . ± . pg/ml). on day tgf-beta decreased to levels less than on day , but was still greater than in healthy controls ( . ± . pg/ml). in diabetics, concentrations of tgf-beta on days ( . ± . pg/ml) and ( . ± . pg/ml) after mi were similar to diabetics without mi ( . ± . pg/ml). only on day was tgf-beta increased to levels ( . ± . pg/ml) which were fold greater than in diabetics without an mi. thus, in diabetic patients serum concentrations of the active form of tgf-beta are much greater than in non-diabetics. mi in patients with diabetes mellitus is associated with a reduced and significantly delayed increase in tgf-beta . conclusion: tgf-beta deficiency may be a factor associated with low activity of tissue reparation after mi in diabetic patients. introduction helicobacter pylori (hp) is the most common gastrointestinal infection worldwide, but only - % of those infected develop chronic gastritis or peptic ulcer disease. the pathogenesis of ulceration, mechanisms of hp lifelong persistence in gastric mucosa and local immune disturbances induced by this infection are well known, but the mechanisms of resistance and elimination of this infection have not been extensively studied. most study is based only on phenomenological findings, such as absence or low hp colonization in subjects spontaneously producing high levels of il- . the aim of this investigation was the analysis of the efficacy of the recombinant interleukin (ril- ) roncoleukin (biotech, russia) in treatment of hp-associated gastric ulcer disease. methods patients were randomly divided into two groups. the first group of patients was treated with standard therapy including of two antibiotics (claritromycin and amoxicillin), proton pomp inhibitors and h receptor antagonists. patients of the second group were treated with the same therapy, but instead of antibiotics they received . mg roncoleukin into four to six areas submucously using a gastroscopic method and . mg roncoleukin dissolved in ml of . % nacl with ml % human albumin infused intravenously. this procedure was performed three times at an interval of hours. results immunological findings demonstrated that roncoleukin results in an increase of cd +, hla-dr+ and cd +cd + cell levels. there was an increase in the serum concentrations of il ( fold), il ( fold) and ifn (more than fold) while the level of tnf and il profoundly decreased. one month after the end of treatment, the group treated with ril- had hp eradication achieved in . % in comparison to . % of the control patients. in the ril- treated group, the ulcer epithelization period was . ± . days while in the normal treatment control group it was . ± . days (p< . ). conclusion immunotherapy with ril- is a more effective method of treatment of helicobacter pylori-associated gastric ulcer disease when compared with traditional methods of treatment employing only antibiotics. introduction the role of different cytokines and the growth factors is now appreciated in progression of essential hypertension. the participation of et- and tgf in pathogenesis of essential hypertension especially in the process of fibrosis, hypertrophia of vascular smooth muscular fibers, and cardiomyocytes, and the activation of renin-angiotensin system is now recognized, in addition to effects on myocyte cultures. the aim of the investigation was the study of serum et- and tgf levels in patients with essential hypertension. materials and methods patients with essential hypertension ( males and females) with average age . ± . years were studied. all patients suffered from left ventricle hypertrophy documented by echocardiography. the control group consisted of healthy volunteers similar to the investigated patients in sex and age. in all patients the serum concentrations of et- and tgf were determined using elisa (biomedica, biosource). results an increase in the serum concentrations both growth factors were noted in the studied group when compared with the control group. the average concentration of et- in patients with essential hypertension was . ( . - . ) pmol/l. the level of et- in the control group was . ( . - . ) pmol/l (p= . ). the concentration tgf in essential hypertension patients was . ( . - . ) pg/ml and in control group was . ( . - . ) pg/ml (p= . ). there was a positive correlation between the concentrations (spearmen's rank coefficient of correlation was . ; p= . ). con-clusion the increase of the serum concentration of growth factors et- and tgf and their co-influence in patients with essential hypertension, suggests a role of these growth factors in the pathogenesis of arterial hypertension. u. kaza * , c. lauter , . bloomfield hills, mi; . royal oak, mi. introduction: few studies have examined the referral patterns for allergy and immunology inpatient consultations in a community hospital. consequently, an invaluable part of physician and housestaff education is missing. our objective was to examine the number of inpatient allergy and immunology consultations, the reasons for consultations and the outcome of the patients in order to improve physician education. methods:we performed a retrospective chart review of all inpatient allergy and immunology consultations in the years - and in - to determine the reasons for consultation, the recommendations made and if they were followed and the outcomes of the patient. results:we reviewed a total of inpatient allergy and immunology consultations. in the - time period % of inpatient consults were for asthma, % for drug allergy, % for rash. in the - time period % of inpatient consults were for rash, % for drug allergy, % for asthma. the top three reasons for consultations remained the same although the order changed. consultations for immune deficiency, angioedema and rashes increased, whereas consultations for asthma and allergies decreased. there were a total of consultations in - and in - . the number of consultations remained the same despite an increase in overall number of hospital admissions from , in to , in . in greater than % of consultations, allergists' recommendations were followed. in both of the time periods studied, greater than % of patients improved, with less than % having no improvement, in the remainder of cases improvement was not applicable. conclusion:in conclusion, we believe that identifying the reasons for inpatient allergy and immunology consultations and examining the most common recommendations, as well as the outcomes of patients will be a valuable guide in the education of our physicians. by incorporating this information into grand rounds and resident conferences, physicians will benefit from learning about when an allergist can be helpful and how to manage some of the more common allergic and immunologic problems in patients that are hospitalized. the high percentage of providers who follow the advice of allergists indicate that allergists have a great deal of educational value to offer other physicians. while complementary and alternative medicine (cam) has generally experienced increased popularity, its utilization by allergy/asthma patients remains uncertain. our private allergy practice surveyed the use of cam in allergy/asthma patients in ( ). using a similar questionnaire, we assessed the current interest in cam with our allergy/asthma patients and compared the data to our survey. we analyzed completed questionnaires from sequential surveys administered. the results were compared to questionnaires reported in . they indicated that in both study periods ( & ) , the majority of patients wanted to discuss cam ( and % respectively). an equal number ( %) in each study period discussed cam with their primary care provider. sixteen percent ( %) of our respondents sought a cam practitioner for general medical needs in vs. % in . however, there was an increase from % to % of our patients seeing a cam practitioner for their allergies and/or asthma from to . sixty-two percent ( %) would like to consider pursuing cam through our allergy spe-cialty practice or other provider. when asked regarding preferred treatment, % stated combination traditional with cam, % preferred traditional only, % cam only, and % did not know/doctor s choice. more patients are now seeking chiropractic care ( % to %) compared to our results. acupuncture was the first choice cam modality at % in surpassing vitamin/mineral therapy in . currently, the second and third choices were vitamin/mineral therapy and deep tissue massage. while these numbers were small, we were impressed that currently % (two and a half times more since ) of patients in our practice were seeking cam allergy/asthma care from outside of our practice. these results demonstrated that more than half of our patients were interested in pursuing traditional with cam options within our office. given this trend, we have begun discussing the concept of integrative allergy, which to us means integrating evidenced-based cam modalities within our traditional allergy/asthma practice. ( ) introduction: clinical immunization knowledge is complex and demands ongoing training. nationally, basic immunization and vaccine safety education is limited within traditional medical, nursing, and provider education. project immune readiness (pir), a peer-reviewed, web-based, interactive course, was developed in response to this deficit and the need for standardized resources to provide initial and sustainment training for safe and effective immunization services. it is designed for medical personnel with diverse educational preparation. currently, pir offers course modules addressing hours of instruction on specific vaccines, their respective diseases, and general information on immunization healthcare and vaccination procedures. methods: users completed a pre-test (establishes baseline knowledge), an interactive module, followed by a post-test (to observe change from baseline) for each course in sequence. anonymous user and score data were collected as part of a quality assurance and course validation process. learning gain indices (lgi) were calculated based on average mean pre-test and post-test scores for each module lgi of all modules demonstrated substantial increases in user vaccination knowledge. comparing pre and post-testing is an effective method to assess learning gains. the findings support pir as a successful and valid distance-learning tool that establishes and documents core knowledge of medical personnel administering vaccinations. further research is needed to assess the effectiveness of knowledge acquisition and retention, in addition to variance in vaccine delivery after training. this approach to learning may have value as a resource that supports smallpox and influenza pandemic emergency preparedness plans for just in time training. introduction: variances from practice guidelines for the prescription of auto-injectable epinephrine are well documented among practicing physicians, families, and patients. effective patient education requires provider competency. the current study was designed to survey resident physician perceptions regarding auto-injectable epinephrine education, use, and patient education requirements. methods: residents from primary care disciplines at a tertiary care medical center were invited to complete a voluntary, anonymous questionnaire. a total of surveys were distributed and returned: emergency medicine, family practice, internal medicine, and pediatric residents completed the questionnaire. due to the small sample size, responses from physicians in various disciplines were reviewed as a whole. results: respondents ( %) reported that they had previously prescribed auto-injectable epinephrine for allergic emergencies. the majority ( %) of these prescribers reported that their training was inadequate. respondents ( %) reported no training, while respondents ( %) reported that their training was less than that needed to ensure proficiency. respondents ( %) reported that their training was adequate to ensure proficiency. none reported expertise. only of prescribers ( . %) reported that either they or their staff always demonstrated proper medication use to the patient. interestingly, of these providers reported they had not been trained on proper use. the table below summarizes resident training and patient education practices. additional physician knowledge deficits included the proper site of medication administration, the proper interval for replacing medication, and the proper place for medication storage. conclusions: of the residents surveyed, who have previously prescribed auto-injectable epinephrine, % identified training deficiencies. only . % of prescribers reported that the standard of care requirement to demonstrate proper medication use was always met. there is a clear need to improve auto-injectable epinephrine education in all residency training programs. r. bloebaum * , r.k. calabrese , m. . houston, tx; . new york, ny. introduction: pneumocystis carinii pneumonia (pcp) is a major cause of morbidity and mortality in patients with aids. adverse reactions occur frequently to the most effective medication for both the prevention and treatment of pcp, trimethoprim-sulfamethoxazole (tmp-smx). we looked at the immediate safety and efficacy of three protocols for desensitization in aids patients. methods: by retrospective chart review, we identified patients with aids who had experienced previous mild to moderate hypersensitivity reactions to tmp-smx and required desensitization. patients received one of three desensitization protocols based on illness severity or ward attending preference: a -hour intravenous (iv) desensitization, an -day oral desensitization, or a -day oral desensitization. results: of the patients that received desensitization, ( . %) completed successfully. of these, subjects had no reaction during the desensitization process; however, seven of these subjects were on steroids for treatment of other diseases. the remaining five successful patients had mild reactions which were treated symptomatically with acetaminophen, antihistamines or both. eleven patients failed to complete the desensitization: six stopped by the attending physician and four dropped out voluntarily. one patient expired during desensitization from extensive disease complications related to the admitting diagnosis. all protocols were equally successful when comparing the immediate success rates, / ( %) of the hour protocol, / ( %) of the -day protocol and / ( . %) of the day protocol. the -hour iv desensitization protocol was most frequently used in the intensive care unit on critically ill patients. two of these patients, counted as successfully desensitized, died and days post protocol completion secondary to extensive comorbid conditions unrelated to the desensitization. conclusion: given the insignificant differences between the success of the hour iv desensitization and the oral desensitization protocols, we believe that either may be used effectively. further, in patients with mild to moderate hypersensitivity reactions to tmp-smx, an oral desensitization protocol may be used safely in the outpatient setting if given appropriate lab follow up. a. morales * , e. gonzalez, a. contreras, d. lopez, g. lopez, mexico city, mexico. introduction in davis describes job syndrome in two women, in dr buckley reports two children, being known as hyper-ige syndrome (job's syndrome or buckley's syndrome). defined as a primary immunodeficiency, dominant autosomic, characterized by multi-systematic alterations (immunological, skeletal, dermal and dental). it's diagnostic criteria are levels of ige ui/ml, chronic dermatitis, recurring respiratory infections, cold abscesses, pneumatoceles, infections caused by candida, and finally craniofacial alterations. on another front, extraordinary high levels of ige have been reported in patients with allergic illnesses that increase the risk of anaphylaxis, but do not have the job's syndrome criteria. objetive to determine if allergic patients with ige levels higher than ui/ml have diagnostic of job's syndrome. material and methods a retrospective revision was realized from may to april in files of patients treated in allergy services at the instituto nacional de pediatria with a total ige greater than ui/ml, by means of a page with recollected dates. results nine women and men were included with an age range of to years, and an average age to years; ( . %) were diagnosed with allergies; of which . % rhinitis allergy, . % asthma, and . % topical dermatitis of which co-existed in patients. . % presented hereditary antecedents of atopic. the cutaneous tests were positive in ( . %) with a greater reactivity of dermatophagoids. one syndrome of hyper ige was detected. others diagnosed were found as not allergic were hunter's syndrome and toxocariasis. conclusion there are patients with allergies that have total levels of ige as elevated as , ui/ml without correspond to job's syndrome. by which a multi-allergic clinical entity is proposed with levels greater than ui/ml. introduction home monitoring of lung function in asthmatic patients is used extensively in both clinical and research settings, however, little attention is given to device quality control. objective the purpose of this study was to determine the accuracy, precision and usefulness of the airwatch system (enact health management systems, palo alto, ca, usa). methods the subjects included in this study were submitted to spirometry following american thoracic society guidelines (ats ), using collins gs g pft system. afterwards, peak expiratory flow rate (pef) and forced expiratory volume in one second (fev ) were determined using airwatch. fev and pef measures from both devices were compared, by using two sample t-test and pearson correlation coefficient. results a total of patients ( females) were enrolled, and their mean age was . years ( to years). fev measures ranged from . to . l (mean . l), and from . to . l (mean . l), in collins and airwatch, respectively. pef ranged from to l/min (mean l/min) in collins and from to l/min in airwatch (mean l/min). significant difference was noted for pef measures (p< . and pearson correlation r= . ) between the two devices; however, we did not observe this difference when fev measures were concerned. regarless the degree of obstruction (high or low flow rates), these results did not change. conclusion airwatch showed great utility for fev measures when compared to collins spirometer. although airwatch is able to assess lung function at home, on a daily basis, it is not reliable for pef measures. introduction: epidemiologic data show that poorly controlled asthma is a serious public health problem. the degree of implementation of the naepp guidelines in primary care practice remains to be defined. the objective of this survey was to determine if introduction of an assessment tool into primary care practices along with a specially designed program to implement the guidelines would improve diagnosis and therapy. methods: the asthma care network (acn), a program designed to assist healthcare providers in the assessment and management of their patients with asthma, employs a team of specially trained respiratory care associates (rcas), rns and rts, who visit primary care offices to inform staff about various components of the naepp guidelines and assist in their implementation. .a total of primary care providers in sites were recruited as part of the acn program. data from more than , patient visits were collected and analyzed between march and january . the program assessment tool surveyed asthma control and medication prescribing patterns. outcome measures included degree of symptom control, limitation of activity, sleep disruption, use of rescue medication and utilization of urgent care services. these data were collected on an office visit assessment form (ova) completed by both patient and physician. the rcas provided information, education, device training in the use of inhalers and spacers, and a ce course for the staff discussing pathophysiology, assessment and management of asthma. results: a total of , ova forms were completed. among all patient including adults (older than years of age) and children (< - years of age), % (range % to %) reported symptoms consistent with lack of asthma control. approximately % of the survey group had more than markers of uncontrolled asthma. as a result of this assessment, controller medication use increased by over %, % of which was an ics-containing medication. conclusion: the information provided to the primary care health care providers resulted in a considerable increase in prescription of controller therapy, and in particular, increased use of ics controller medication consistent with naepp guidelines. background: patients with allergic rhinitis (ar) demonstrate symptoms of allergy to fruits, vegetables and nuts in - % of cases. oral allergy syn-drome (oas), typical for hypersensitivity to plant food, is based on cross-reaction of pollen-allergen specific immunoglobulin e (ige) antibodies with homologous food proteins. the production of th and th cytokines in allergic rhinitis patients with or without sensitization to food (fruits and vegetables) allergens was assessed. methods: fifty five patients aged - years with allergic rhinitis were observed. group i - patients with ar; group ii - patients with ar and oas. sensitivity to pollen allergens was tested by skin prick tests. the allergic reaction to food in patients with oas was proved by a positive history of oral symptoms caused by eating fruits and vegetables and a positive skin prick test with respective food allergens. blood eosinophil counts and total ige levels were determined during the peak of allergic rhinitis symptoms. il- , il- and -interferon levels were measured by elisa. results: . % of patients were sensitized only to grass pollen, . % only to tree pollen and . % reacted to pollens of grasses, trees and weeds. in patients with oas, skin tests were more often positive to birch ( . %), alder ( . %), and mugwort ( . %). the most common food products implicated in oas were hazelnut ( . %), apple ( . %), carrot ( . %), and peanut ( . %). the allergy to fruits and vegetables was confirmed by positive prick test in . %. during the season blood eosinophil count and total ige levels were elevated in all patients. there was an increase in the production of il- to . ± . pcg/ml in group i and to . ± . pcg/ml in group ii (nor-mal= . ± . pcg/ml). the levels of il- increased to ± pcg/ml in group i and to ± pcg/ml in group ii (normal= . ± . pcg/ml); the level of -ifn decreased to . ± . pcg/ml in group i and to . ± . in group ii (normal= ± pcg/ml). after sit with pollen allergens the clinical manifestations of allergic rhinitis and oas decreased in . % of patients. conclusion: allergic rhinitis patients' sensitivity to food allergens may cause oas in these patients associated with increased functional activity of th responses. patient knowledge and improvement with aller-gen immunotherapy. c.c. randolph * , waterbury, ct. introduction: there is no consensus on objective parameters for improvement in immunotherapy. similarly little is known regarding patient knowledge of immunotherapy. utilizing two published questionnaires ( - ), we assessed clinical improvement based on symptom and medication scoring and knowledge of immunotherapy. methods: the charts of patients of an estimated ( %), ( %) with allergic rhinitis only and ( %) with concomitant asthma, were retrospectively or prospectively reviewed who had been on immunotherapy to inhalants for months to years, mean . years, age range y- y, mean y, male( %), female( %) with caucasian ( %), oriental ( %) and ( %) afroamericans .they completed symptom and medication survey ( ) every months with range of improvement using a decline in likert scale (+) to (-) , mean . ( %) indicated improvement in their symptoms and/or medication . ( %) completed ( ) a question survey of knowledge of immunotherapy. there were questions regarding the outcome of immunotherapy, the years to onset of immunity, the duration until onset of immunity, the danger of immunotherapy and the extract in the vial. the correct responses were recorded to / ( / = . %), ( . %) / , ( %) / , ( %) / , ( %) / . ( %) had a perfect response to all questions. ( %) had no correct responses. conclusion: the majority of immunotherapy patients improved ( %) by symptom and medication scoring over the mean of . years but only % had complete knowledge of the rationale for immunotherapy. further education and repeated surveying of patients on immunotherapy to assure comprehensive knowledge of immunotherapy and achieve better outcomes is recommended by this investigation. as is unique in this study symptom and medication scoring using the rhinitis /sinusitis questionnaire approved by the acaai and a comprehensive questionnaire assessing knowledge should be conducted periodically ie every months to provide objective parameters for improvement. references: .santilli j, nathan r, glassheim j .patient receiving immunotherapy report it is effective as assesses by rhinitis outcomes questionnaire(raq) in private ( )) is a protein involved in the parasite invasion of host erythrocytes and is a leading vaccine candidate for the erythrocyte stage of malaria infection. an increasing number of vaccine clinical trials are being undertaken using various formulations of msp- ( ). comparison of humoral responses among these trials has been limited by the lack of a universal reference standard for specific antibody. the purpose of this study was to develop a human reference standard for msp- ( ) antibody measured in absolute quantity units that could facilitate comparison of interstudy vaccine response. method: we formulated the reference standard by pooling human plasma samples known to contain high titers of msp- ( ) antibody. the specific antibody within the pooled plasma was captured by msp- ( ) adsorbed to nickel resin in a process of immobilized metal affinity chromatography (imac). the intact msp- ( ) antibody-antigen complexes were separated from the nickel resin and total igg in the complexes measured by enzyme-linked immunosorbent assay (elisa). results: our antibody quantitation method yielded a concentration of . mcg/ml of msp- ( ) antibody in the reference standard. conclusion: the reference standard characterized in this study may be useful as a quantitative working standard for msp- ( ) antibody response in future vaccine clinical trials involving msp- ( ). this standardization may facilitate the clinical development of msp- ( ) as a candidate vaccine for malaria infection. background. specific immunotherapy (sit) is currently one of the most effective and widely used treatment methods of allergic diseases including asthma. efficacy of sit depends on the correct choice of patients, severity of asthma and patient's condition when the sit is begun. according to who recommendations, sit is approved for use in patients with mild to moderate asthma. methods. sit with a saline extract of house dust allergen was administered to patients with mild persistent allergic asthma. injections were performed subcutaneously - per day. the course consisted of pnu of allergen and lasted - days. patients were repeatedly surveyed at , and months after sit was completed. dyspnea attacks occurring during daytime and at night were assessed, as was the influence of physical exertion on dyspnea and lung function, and also the number of utilizations of short-acting beta-agonists per day. pulmonary function measurements were performed as was assessment of concomitant allergic rhinitis. % of patients received treatment including cromones, and % utilized inhaled corticosteroids among whom . % had a dose of mcg per day and . % mcg per day. sit efficacy was assessed by clinical symptoms, pulmonary function measurements and amount of concomitant therapy received. results. the number of daytime dyspnea attacks reduced from . ± . per month to . ± . during the months following sit, and . % of patients reduced concomitant asthma therapy. at months, dyspnea attacks increased to . ± . per month, still significantly less then prior to sit. nocturnal symptoms followed the same pattern, occurring . ± . per month prior to sit, . ± . per month months after sit and . ± . per month at the end of the sixth month after sit. . % of patients had no symptoms of bronchial obstruction during the months after sit and their pulmonary function approached normal values, although . % of patients returned to asthma therapy. nasal congestion decreased from . ± . points to . ± . (p< . ), clinical improvement still present for months after sit, but recurring at months after sit. conclusion. sit may be an effective treatment method that improves both asthma and allergic rhinitis for more than months following a brief course, allowing a decrease in the amount of symptomatic treatment. a safe therapeutic vaccine that can alter the allergic response to peanuts would serve a serious unmet medical need. peanut allergy responses are largely associated with downstream events related to antigen specific ige crosslinking of ige receptors and subsequent degranulation of mast cells and basophils. our clinical studies with ragweed have shown that linking immunostimulatory dna (iss) to allergens can decrease ige recognition of the allergen and generate an immunogen that generates protective th responses and reduces harmful th responses. to test this approach to peanut immunotherapy, we focused on the clinically relevant allergen, ara h , as a proof of concept. iss oligonucleotides were linked to ara h at two different ratios: pic ( iss per protein) and hpic ( iss per protein). immunogenicity of pic and hpic was evaluated in c h/hej female mice immunized twice with ug of pic, hpic, or ara h . sera were analyzed for anti-ara h igg and igg a responses. spleens were harvested and ara h -specific ifng and il- responses were measured in vitro. mice were immunized with ara h elicited predominantly igg and il- responses, indicative of a th -type response. animals immunized with pic showed significantly enhanced igg a responses and strong ifng responses, indicative of th -type responses. hpic immunized mice elicited little antibody response, presumably due to iss blocking b cell epitopes, but did induce ifng responses. to assess allergenicity of pic and hpic, histamine release was measured in blood from peanut allergic donors treated in vitro with pic, hpic, and ara h . histamine release was detected at very low concentrations of ara h ( . ng/ml), -fold higher concentrations for pic ( . ng/ml) and was undetectable at concentrations up to fold higher for hpic ( ng/ml). an ige binding competition assay also confirmed reduction in allergenicity following the same trend for the iss-linked allergens. linking iss to ara h increases th responses to the allergen, blocking ige recognition of epitopes on ara h . thus, iss-linked ara h appears to be a promising candidate for a safe immunotherapy product for treating peanut allergic subjects. introduction: immunotherapy has been studied for its adverse effects in some sensitive patients as with worsening of therapeutic response in some amounting to withdrawal of the later. methods: in the allergy center therapeutic trials of immunotherapy(house dust, mixmite) had been undertaken since , in therapeutic dose of . pnu/ml, . pnu/ml, pnu/ml, pnu/ml, pnu/ml pnu/ml, pnu/ml(housedust), . au/ml, . au/ml, au/ml au/ml au/ml au/ml au/ml(mixmite).patients age - years, both sex after diagnostic scratch/prick tests with appropriate antigenic preparations reported for local/systemic adverse effects the details of which were as under, results: please see the attached table for details, in some cases worsening of the existing allergic status was noted, which on analysis revealed initially a slow rise in the allergen -specific ige to be later on fol-lowed by rise of igg & igg & gradual fall of ige.only / patient could not complete immunotherapy for fear of adverse effects. conclusions: with utmost care/follow-up, no incidence of mortality outcome was reported from to late the incidence of adverse effects were significantly lowered on pre-medication with anti-histamines significantly more with elderly than younger age. even with all these documented hazards the beneficial effects far exceeded the harmful effects. background: the prevalence of allergic disease in most human population is steadily increasing. seafood allergy is a serious food allergy, although hypersensitive reactions caused by seafood has long been know, biochemical and immunological studies on seafood allergies had only begun lately. shrimp and abalone are the most frequently reported causes early asthmatic response. objective: to investigate cross-reactivity of shrimp, abalone and derp . methods: shrimp and abalone extracts were prepare from raw seafood. sera from patients from hongkong were studied who had asthma after consumption of seafood. ige elisa analyses comfirmed the combined sensitization to shrimp, abalone and derp . specific-ige elisa assays were accomplished for shrimp and abalone extracts inhibited by derp and derp elisa and immunoblot assays inhibited by shrimp and abalone extracts. results: elisa inhibition showed that most ige antibodies against shrimp and abalone were cross-reactive with derp and the same time, derp elisa was inhibition by shrimp and abalone extract. the elisa inhibition percent (%)of shrimp extract (gm: . %) and abalone extract(gm: . %) by derp were significantly higher than derp by shrimp extract(gm: . %) and abalone extract (gm: . %). (p< . ). furthermore, and there was a significant correlation of elisa inhibition percent between shrimp extract, abalone extract and derp inhibited by each other; sds-page and immunoblot of shrimp and abalone is the and kd allergen respectively. conclusion: this indicates that derp was the sensitive agent. shrimp, abalone and derp demonstrate significant cross-reactivity. these findings confirm that the primary crossreactive allergen of shrimp and abalone is the and kd allergen respectively. b. sun * , a. wu , n. zhong , . guangzhou, china; . hong kong. background: the house dust mites (dermatophagoides farinae (derf) are a major source of aeroallergens implicated in the expression of atopic disorders, including asthma, allergic rhinitis, and atopic dermatitis . in particular, strong circumstantial evidence suggests that house dust mites antigens are important precipitating factors of asthma. many house duse mite allergens are proteases that can elicit airway inflammation by stimulating the release of cytokines in bronchial epithelial cells. objectives: we have investigated whether der f allergen proteases induced cytokine production from the epithelial cell line beas- b. methods: cells were exposed to four different concentrations with serial additions of der f ( . , . , , ug/ml) were incubated for h to h. and compare with those without incubation of allergen. cytokine in the supernatants were assayed by elisa, reverse transcription?pcr was also performed. results: cells treated with der f allergen showed serial changes in the cohesiveness of the monolayer. there was a significant increase in the level of cytokine production compared with the untreaed sample. statistically significantly increased with addition of der f caused the release of il- and il- in time and concentration-dependent manner (p< . , respectively). levels of il- and il- were elevated h and h after allergen exposure, increasing with time, continued increased levels to be present of il- and il- in the supernatants at h and h. at the same time show the concentration dependence of induction of il- and il- expression as well as an increase in the expression of il- and il- mrna. conclusion: hdm-induced airway inflammation may include der f-mediated release of inflammatory mediators, and the proteolytic activity of an allergen may stimulate the release of proinflammatory cytokines from human bronchial epithelium. suggesting that il- and il- production by bronchial epithelial cells may play a role in the pathogenesis of allergic asthma. the purpose of this study is to delineate the immune injury mechanisms that involved in the autoimmune inner ear disease by introducing plasmid dna encoding of th cytokines (inf-g) into the inner ear. b-tubulin is a microtubular protein which we found as an important autoantigenic in meniere's disease as well as other autoimmune hearing loss. hearing loss was induced in mice and guinea pigs when they are immunized with the tubulin molecules. autoimmune hearing loss could be the results of th cytokine responses from autoimmune injury. to test the hypothesis, guinea pigs were immunized with mg of tubulin in cfa and boosted once more. two weeks later, we introduced ug ( ul) of naked dna encoding inf-g was injected into the left side inner ear through round window. same volume of . m pbs was injected into right side as control. abr was recorded before and after the injection. weeks after the injection, the animals were sacrificed and temporal bones were examined with h-e and inf-g immunocytochemical staining. the ears injected with the plasmid dna-inf-g had an enhanced hearing loss ( db), and degeneration of the spiral ganglion was found in these ears. however, the injection of the naked dna encoding inf-g did not change the expression of the inf-g in the inner ears. these results suggest that autoimmune hearing loss could be the result of th responses to inner ear autoantigens. -tubulin is an important molecule in the hair cells supporting cells within the sensory epithelium of organ of corti and found to be an auto autoantigen in autoimmune hearing loss including mèniére's disease. the object of the study is to induce hearing loss in mice with varying doses of antigen and evaluate the pathogenesis of autoimmune hearing loss induced by -tubulin in mice. mice were immunized with , or μg of -tubulin and hearing was evaluated by auditory brainstem responses (abr) and distortion product of otoaccoustic emission (dpoae). all mice had hearing loss by abr and dpoae tests and morphological study of temporal bone showed spiral ganglion degeneration and tunel staining positive cells were noted in these immunized mice. thus this study showed that -tubulin is an autoantigen for hearing loss in animal model as in human autoimmune hearing loss patients including mèniére's disease. supported by nih r dc - introduction: oral polio vaccination (opv) in the united states is currently being replaced with inactivated polio vaccination (ipv) given parentrally. while past studies have looked into the relationship of vaccination and asthma prevalence, none have investigated this relationship with regards to vaccination route namely orally versus parentrally. this study investigates the relationship between vaccination rates for the live attenuated orally administered polio vaccine and parentrally administered vaccines(dtp, mmr)and two potentially dependent factors; asthma prevalence rate and asthma-caused death rate. methods: we looked at data from the national center for health statistics yearly publications of health, united states ( - and the morbidity and mortality weekly report surveillance summaries . two databases were compiled to cover the - age population in the united states since this is the primary period of childhood vaccination. one database contained information for asthma related deaths and vaccination rate (dtp, mmr, opv) covering the years - and the other database compiled information for self reported asthma prevalence and vaccination rates(dtp, measles, rubella, opv) covering the period - . a t-test was used for statistical analysis. results: statistically significant correlation was found between vaccination rates and asthma prevalence rates. data for dtp (p = . ), measles (p = . ), and rubella (p = . ) indicated a statistically significant positive correlation with asthma prevalence. the oral polio vaccine was the only one of the vaccines that failed to display a significant relationship with asthma prevalence rates (p = . ). statistical analysis proved that a correlation between vaccination rates of united states children ages - and asthma-caused deaths was insignificant (p > . ). conclusions: the opv, which is administered orally rather than parentrally, displayed no relationship with asthma prevalence. this could be due to the fact that live attenuated orally administrated polio vaccine may induce mucosal immunity, simulating a normal pathogen route of entry into the body. childhood vaccination had no relationship with asthma-caused death rates. a.s. alfrayh * , riyadh, saudi arabia. introduction: heredity plays a major role in asthma and other allergic diseases, mechanisms underlying the inheritance of these disorders are poorly understood. this study therefore analyzed the risk conferred by family history of asthma and atopy for having childhood asthma. methods : a total of children between - yrs selected randomly in three cities in saudi arabia ( hail, taif and gizan )in - . the questionnaire which is similar to the one used in the international study of allergy and asthma in childhood isaac. were self administerd under medical supervision.apart from the demogrphic details, the questionnaire included questions on symptoms and physician diagnosis of asthma, rhinitis, eczema and family history of these conditions. the family members were grouped as immediate family and relatives. asthma and atopy were defined as ever having had physician diagnosis of such conditions information was also available about exposure to cigarette somke at least one member was a smoker in the household and having pets. relative risk for developing asthma was estimated in terms of odds ratio by bivariate analyses using chi square test and p value was considered significant when less than . . results : history of asthma in the immediate family and relatives conferred a fold and fold risk for development of childhood asthma odd ratio ( or )= . , % confidence interval(ci)= . to . , p= . and or= . , %ci= . to . , p= . respectively. rhinitis in immediate family and the relatives was associated with folds increased risk for childhood asthma or = . , % ci = . to . , p= . respectively whereas history of eczema conferred over folds risk or= . , % ci = . to . , p= . for childhood asthma when present only in the immediate family. history of eczema in relatives was not associated with any risk. of the environmental factors, exposure to cigarette smoke conferred folds risk of developing childhood asthma or = . , % ci = . to . , p= . , whereas exposure to pets was not a significant risk foctor. conclusion : presence of asthma and atopy either in the biological parents or relatives constitute a significant risk for childhood asthma.paricularly in the presence of evironmental risk factors. the murine local lymph node assay (llna) has been developed as an alternative to guinea pig models for the assessment of the contact sensitization potential. however, there is a need to develop a non-radioisotopic endpoint for the llna, because of the radioisotopic method's requiring the use of special facilities. in this study, we investigated to evaluate the lymphocyte subpopulations in the lymph node cells following allergen and irritant treatment. female balb/c mice were treated by the topical application on the dorsum of both ears with sensitizers, , -dinitrochlorobenzene (dncb), toluene diisocyanate (tdi), and a-hexylcinnamaldehyde (hca), and an irritant, sodium lauryl sulfate (sls), once daily for three consecutive days. the lymph node (ln) cells were harvested h after the final treatment. phenotypic analysis of lymphocytes subsets was performed with a flow cytometry. the allergens dncb, tdi, and hca and an irritant, sls increased cell number compared to the vehicle. there was an increase in the percentage of b + cells in mice treated with dncb and tdi compared to the vehicle control, but not in those treated with sls. mice were treated with dncb, hca and tdi showed a preferential increase in the percentage of b +cd + cells compared with vehicle and irritant-treated mice. there was an increase in b +cd + cells of mice treated with dncb, tdi and hca, but no significant increases were observed in mice treated with sls. mice were treated with dncb, and tdi showed an increase in the percentage of b +cd + cells compared with vehicle and irritant-treated mice. these results suggest that analysis of b cell activation marker, cd on b cells may be useful in differentiating allergen and irritant responses in the draining lymph nodes of chemically treated mice. m. frieri * , y.c. huang, east meadow, ny. introduction: nitric oxide (no) is an important biomarker for inflammation in airway epithelial cells and in exhaled breath of asthmatic subjects. we have previously demonstrated no production in antigen-stimulated human bronchial epithelial cells and an effect of omalizumab (monoclonal anti-ige antibody) on no production in those cells [leyko bt et al. j allergy clin immunol ; (suppl ) :a ]. in this study, we investigated the potential role of ige and its receptors on a cells by characterizing the effect of omalizumab on antigen, egf, and il- stimulation of a cells in a medium containing atopic serum. methods: a human alveolar epithelial cells were stimulated with iu/ml of il- , μg/ml of ragweed (ra), au of dust mite (dm), and ng/ml of egf, and exposed to either - m budesonide or . μg/ml omalizumab for or hours. no production was measured in duplicate by a highly sensitive elisa. results: omalizumab but not budesonide inhibited no production at hours in a cells stimulated with il- ( - μm, p<. )and il- +dm ( - μm, p=. ), but not with ra alone. however, at hours omalizumab and budesonide each significantly inhibited no production stimulated by il- ( - μm; - μm), il- +dm ( - μm; - μm), and egf ( - μm; - μm) (p<. ). conclusion: no production is a marker for inflammation. omalizumab demonstrated a significant anti-inflammatory effect in distal alveolar cells by inhibiting no production stimulated by antigen, il- , and egf in a medium containing atopic serum. as persistent inflammation in asthma may play a role in airway remodeling, treatment with omalizumab may have a beneficial effect on chronic airway inflammation in patients with asthma. oral tolerance trigger regulatory mechanisms able to down-modulate antigen-specific t and b cell response. to address the lasting effect of several regimens of oral tolerance to ovalbumin, in naive or antigen primed mice, b-cell function has been focused. furthermore, we analyze specific antibody response up to eight months of post-immunization, proliferative response, b (cd /cd ) expression on b cells and t cell ctla- involvement in oral tolerance. a/sn mice were immunized by intraperitoneal route with μg of ova/ , mg-alum and boost days after priming (dap). ova feeding was done with mg at different days before or after antigen priming. in others protocols, mice were fed twice, before and after priming with a total of mg of ova. all groups were boosted at or or or dap. the results showed that only mice fed at naive status and those fed twice before and after immunization demonstrated a long lasting of ige ab response inhibition up to months of immunization. these mice showed a marked inhibition of antigen-specific proliferative response that was restored with anti-cd mab in vitro stimulation. evaluation by flow cytometry of spleen cells cultured for hours upon ova stimulation, showed an important decrease of b . expres-sion on b cells of naive fed mice, which remained inhibited until months of immunization. after addition of anti-ctla- mab an enhancement of b . expression was detected on b cells of naive fed mice. ctla- molecules expression on cd + t cells of naive fed mice remained unchanged following ova stimulation while a peak of expression was detected at h of ova stimulation in control group. this finding reinforce the t cell anergic status of naive fed mice, due to the less cell division and consequently a low rate of cd +/cd high activated cells. the results showed that antigen feeding before immunization induce a long lasting anergy mediated by an impaired t-b cell cooperation and ab production due to the decrease of costimulatory molecules expression on b cells and negative signaling effects by ctla- expression. introduction: vascular endothelial growth factor (vegf), basic fibroblast growth factor (bfgf) and fibronectin (fn) can promote angiogenesis, a putative component of airway remodeling. (s)-albuterol can exacerbate airway hyperresponsiveness, bronchospasm and release pro-inflammatory cytokines from small airway and smooth muscle cells. our study evaluated the effects of (s)-albuterol ((s))-and (r)-albuterol ((r)) on secretion of these factors on normal human lung fibroblasts (nhlf) and myofibroblasts (myonhlf) in the presence or absence of tgf , il- , or allergens. methods: nhlf were stimulated to differentiate to myonhlf with pg/ml tgf . dose-dependent effects of (s) and (r) [ - to - m] were evaluated for secretion of vegf, bfgf and fn by nhlf and myonhlf with and without au/ml d. pteronyssinus (dp), pnu/ml ragweed (ra), u/ml il- , or pg/ml tgf into serum-free media (its) at o c with % co collected at hr and assayed by elisa. results: in nhlf the following was observed: vegf secretion was -fold higher with - m (r) relative to (s), p< . ; bfgf secretion was increased %- % by - m (s) relative to (r), p< . . a lower concentration of (s) ( - m) in the presence of either dp or il- caused a -fold increase in secretion of bfgf relative to (r), p= . . in the presence of myonhlf the following was observed: - and - m (s) caused a %- % increase in secretion of fn relative to (r). at - m (s), this effect was further increased with the addition of il- , p= . ). conclusion: in a dose-dependent manner, (s)-albuterol stimulated the release of bfgf and fn by nhlf and myonhlf, respectively. this was enhanced by dust mite and/or il- , potentially contributing to the matrix remodeling observed in chronic asthma. vegf over-expression can have a protective effect against chronic hypoxia and can recruit immune cells to the alveoli. increased vegf by (r)-albuterol could contribute to such an effect in vivo in asthmatics. bfgf, in bal and sputum of asthmatics, and fn which contributes to subepithelial fibrosis, can promote angiogenesis. increased bfgf and fn by (s)-albuterol could be detrimental over time by enhancing matrix deposition and remodeling in a subset of asthmatics. o. ozdemir * , c. moore , y. ravindranath , s. savasan , . detroit, mi; . new orleans, la. background: mast cells (mc) have been shown to demonstrate natural cytotoxicity against mouse fibrosarcoma cell line in culture when incubated for - h. this effect has been postulated to be mediated through soluble and/or membranous tnf-. more recently; fasl, mc chymase and serine protease granzyme h with its chymase activity were proposed as mediators of mast cell-mediated cytotoxicity. thus, both 'granule-exocytosis' through chymase, granzyme h and soluble tnf-and 'death receptors' through membrane-bound tnf-and fasl pathways appear to be operative in this process. aims: following our earlier observations on long-term liquid culture-grown human bone marrow mast cell cytotoxicity against human leukemia cells in - h co-incubation experiments, we investigated mast cell-mediated cytotoxicity against natural killer/lymphokine-activated killer cell-sensitive cells in short term ( h) cultures without any stimulation for the first time. methods: human bone marrow mononuclear cells were cultured in methyl cellulose supported with il- , il- and scf. mast cell colonies that developed in six weeks were transferred to liquid medium and maintained for weeks before experiments. cytotoxicity was investigated against k , raji and daudi cells at , and hours of co-incubation by our established flow cytometric cell-mediated cytotoxicity assay. results: after h co-incubation, % ( % early apoptotic and % late apoptotic or necrotic death) and % ( % early apoptotic and % late apoptotic or necrotic death) target cell kill was demonstrated in daudi and raji cells, respectively. daudi cell killing has stayed stable at h ( %; % early apoptotic and % late apoptotic). despite a small numbers of experiments, daudi cell kill was statistically significant at h (p: . ) and h (p: . ) compared to control. however, k cell elimination ( %) has not occurred until h. mast cell-daudi cell conjugates were seen on the wright/giemsa slides (figure) . conclusion: our results demonstrate that human mc can cause cell-mediated cytotoxicity against certain cells in relatively short-term. this further suggests possible contribution of 'granule-exocytosis' pathway to mc natural cytotoxicity, indicating a faster mc response in immune surveillance. o. ozdemir * , m. buyukavci , y. ravindranath , s. savasan , . detroit, mi; . erzurum, turkey. background: the effect of melatonin (mlt) on cellular immunity has been controversial. recently, mlt has been demonstrated to activate t and nk cells through its membrane or nuclear high affinity receptors. it was also shown that pharmacological concentrations of mlt (>nm) could be cytotoxic against different human cancers. aims: our aim was to investigate the effect of mlt alone or in combination with il- on peripheral blood lymphocytes (pbl), lymphokine activated killer (lak) cell generation and its cytotoxicity. methods: pbl were cultured for days in the presence of mlt at different concentrations ( - , - , - m) with or without il- ( u/ml). cell viability was determined by trypan blue exclusion test. cell-mediated cytotoxicity of lymphocytes/lak cells against k- and daudi cells was studied using our established flow cytometric cell-mediated cytotoxicity assay. results: although - m concentration of mlt did not affect cell proliferation much on day , it significantly inhibited proliferation by day (p< . ) consistent with known anti-proliferative effect of mlt. - and - m concentration of mlt also mildly inhibited proliferation on day ; however there was a minimal rebound with - m concentration by day . consistent with the reported mlt-treated pbl's reduced response to mitogens, il- and mlt ( - m) combination suppressed proliferation on days and ; however, with - m mlt concentration pbl counts increased gradually from day to . although mlt treatment alone did not enhance cell-mediated cytotoxicity, il- and mlt combinational treatment at both concentrations ( - and - m) increased it significantly compared to baseline activity (figure) . conclusion: il- and mlt combination at - m concentration resulted in superior lymphocyte proliferation and lak cell-mediated leukemia cell kill. mlt-induced increase in il- r-expression of pbl shown earlier might be the mechanism for our observations. mlt can be considered in immunotherapy as an adjunct to il- treatment. a.e. fusaro * , j.r. victor, c.r. oliveira, c.a. brito, e.a. futata, m. maciel, a.j. duarte, m.n. sato, são paulo, brazil. the maternal exposure to allergens during pregnancy or even in postnatal period may influence the allergy onset to newborns, through antigen or antibody transmission. we sought to verify the effect of maternal antigen exposure before conception, during gestation or in the breastfeeding period on the offspring type i hypersensitivity response. female balb/c mice were immunized or not with ova extract/alum, boosted twice at th and th and mated with normal balb/c male on the th day after sensitization (das). others groups of immunized mothers also received oral administration with ova along pregnancy, or non-immunized mothers received ova only during breastfeeding. offspring from immunized or normal mice were immunized intraperitoneally with ova at do and boosted on the th das. the results showed a important decreased of tgf-levels in the amniotic fluid and milk from immunized mothers before mating in comparison to obtained from normal mothers. ova exposure during pregnancy of immunized mothers decrease significantly the transference of tgf-by breastfeeding, while both tgf-isoforms were founded at high levels in the amniotic fluid. similar levels of tgf-transference by placenta to the newborn was detected in both immunized mother groups. pups from mothers exposed with ag during pregnancy showed an increased spleen cell number, whereas did not produced il- , il- , il- e ifn-secretion induced by antigen neither altered responsiveness to anti-cd or mitogen. maternal ova-immunization induced a marked inhibition of spe-cific ige antibody response in the immunized pups, contrasting to the enhancement of ige responsiveness detected in the immunized pups from mothers which were exposed to ova only at postnatal period. these results showed that preconceptional immunization exert a protective effect on the offspring ige development and an exacerbation of ige responsiveness due to mother antigen exposure during breastfeeding. the findings suggest that rather than in utero antigen priming occurrence, postnatal period may contribute to offspring early life sensitization. financial support: fapesp and lim -fmusp introduction: the reasons for the increased incidence of allergic diseases in westernized countries are still unknown. mercury is an important pollution factor to which humans are increasingly exposed. prior studies on the effect of mercury on mitogen stimulated human lymphocytes indicated a th weighted immune response, but the results were inconsistent and difficult to reproduce. phorbol myristate acetate (pma) is a direct activator of protein kinase c, which has been shown to play a role in mercury induced il- production in animals. therefore we investigated the effect of mercury on pmaactivated human peripheral blood mononuclear cells (pbmc). methods: pbmc from individuals were cultured for days in culture medium containing pma and ionomycin in the presence or absence of mercuric chloride (hgcl ). il- and gamma-ifn concentrations were measured by elisa of culture supernatants. cell death and apoptosis were determined by -aad and annexin staining and fluorescence activated cell sorting (facs). cell-proliferation was assessed by h-thymidin-incorporation. results: after days of culture, pma/ionomycin-stimulated a small amount of il- compared to untreated pbmc ( . +/- . pg/ml versus . +/- . pg/ml). however, mercury induced a more than fold increase in il- production when added to pma-activated cells ( . +/- . pg/ml, p< . ). gamma ifn production was strongly increased in pbmc that were treated with pma/ionomycin (> pg/ml versus +/- pg/ml in unstimulated cells) but dropped markedly in cells treated with mercury plus pma/ionomycin. in addition, mercury induced increased cell death, apoptosis and reduced cell proliferation. conclusions: hgcl strongly stimulates il- production in pma/ionomycin treated pbmc while cell viability and gamma-ifn production drop significantly. these preliminary results suggest that human exposure to mercury may be playing a role in the observed increased incidence of allergic disease in the industrialized world background: mast cells (mc) have been shown to induce natural cellmediated cytotoxicity in long-term ( - hrs.) in vitro assay systems. the cytotoxicity is mediated by at least two pathways: secretory via exocytosis of mc granules containing serine proteases such as granzymes, chymase and soluble tnf-and nonsecretory (cell-to-cell contact) via membranous tnfand fasl. chymase induces apoptosis in neonatal rat cardiomyocytes and human vascular smooth muscle cells. the objective of this study was to investigate mc mediated cytotoxicity against nk/lak-sensitive cells in short term ( hrs.) unstimulated cultures. methods: human bone marrow mononuclear cells were cultured in methylcellulose supported with il- , il- , and stem cell factor. mast cell colonies developed at weeks and were transferred to liquid imdm and maintained for weeks. a flow cytometric cytotoxicity assay was used to determine cytotoxicity against daudi, raji, and k cell lines at hrs., hrs., and hours. the controls consisted of cell lines without mast cells at hrs., hrs., and hours. results: rationale: to establish the antibody response rate in children with recurrent infections and fully immunized with the pneumococcal -valent conjugate vaccine. methods: we have analyzed patients referred to our clinic with recurrent infections despite complete immunization with the pneumococcal -valent conjugate vaccine for age, according to acip guidelines. we assessed the patients by checking their immunization status and the antibody titers to all streptococcus pneumoniae serotypes included in the vaccine ( , b, v, , c, f, f) assessed by standardized elisa. the patients were assembled into groups, a non-immunized group with laboratory data prior to the vaccine, and an immunized group consisting of responders and nonresponders according to their antibody titer (< . or > . iu/ml respectively). the data were analyzed using epi info and spss. results: the mean age was . years for non-responders and . years for responders. there was no significant statistical difference between the groups regarding age, race and sex. ten patients were identified who failed to respond to all serotypes included in the pneumococcal -valent conjugate vaccine. there was no significant statistical difference between the non-immunized and the immunized nonresponders to all serotypes. conclusions: we have identified a special immunological phenotype of specific antibody deficiency (sad) patients with normal total immunoglobulins and normal responses to protein antigens, but who failed to respond to conjugate pneumococcal polysaccharides. a. yates * , r. deshazo , j. butler , g. howell , j. farley , h. liu , n. nanayakkura , g.b.yi , r. rockhold , . jackson, ms; . oxford, ms. introduction: venom from s. invicta consists of % disubstituted piperidine alkaloids and is toxic to insects, birds and farm animals. recent reports of morbidity and mortality in elderly patients after massive fire ant stings suggest the potential for systemic mammalian toxicity. we evaluated the toxic responses to systemic administration of two structurally verified, synthetic s. invicta venom alkaloids, solenopsin a (trans- -methyl- -n-undecylpiperidine) and its cis-isomer, isosolenopsin a, in rats. methods: sprague dawley rats were anesthetized with isoflurane, paralyzed with gallamine, artificially ventilated and instrumented to record arterial blood pressure (bp; mm hg), heart rate (hr; bpm) and % change in left ventricular contractility (lvc; p/ t). in addition, a group of rats was chronically instrumented to record bp and hr while the animals were conscious and freely-moving. results: solenopsin a at to mg/kg iv dose-dependently lowered bp, hr and lvc. at mg/kg iv, hypotension (- ± mmhg), bradycardia (- ± bpm) and decreased lvc (- ± p/ t) were marked. isosolenopsin a, mg/kg iv, produced responses similar to solenopsin a mg/kg iv. solenopsin a mg/kg iv elicited tonic-clonic convulsions and respiratory arrest in conscious, freely-moving rats. hematuria was seen with solenopsin a, but not isosolenopsin a. superfusion of a working, isolated, perfused rat heart with um of solenopsin a elicited a marked, reversible decrease in lvc, and cardiac arrest occurred with um of solenopsin a. conclusion: the results demonstrate that these alkaloids possess significant depressant activity on the cardiac and respiratory systems of rats. the neurologic and cardiorespiratory effects can account for lethality to small mammals in the wild, and may contribute to adverse cardiovascular effects noted in humans after massive fire ant stings. introduction: during asthma attacks, the ph of exhaled breath condensate (ebc) decreases two log orders (ph= . ), returning to normal levels after corticosteroid therapy (ph= . ). ion channels, once thought to participate only in the transport of ions, are now suspected of mediating airway inflammation in asthma as well. to determine whether allergen directly alters airway mucosal ph and ion function, we measured nasal ph and nasal potential difference (pd) before and after nasal allergen challenge (nac). methods: ten allergic rhinitic subjects (mean±sem age . years± . , females) underwent a crossover, single-blinded, placebo-controlled study, where they were challenged with allergen (dust mite, grass, cat) and control diluent in two different occasions in random order via nasal spray. nasal ph was measured on the surface of nasal mucosa with a ph probe. nasal mucosa pd was measured between nasal mucosa and forearm skin. subjects also filled out a nasal symptom scale. measurements were taken at baseline, hour, hours, and hours after nac. results: the nasal symptom score increased significantly immediately after allergen compared to control challenge ( . ± . vs. . ± . respectively, p= . ). there were no statistically significant differences in the nasal ph at h and h, but a significant decrease at h compared with baseline (- . ± . vs. + . ± . , p= . ). the change in ph from h to h correlated significantly and inversely with change in symptoms (r=- . , p= . ) and number of sneezes (r=- . , p= . ) after challenges. nasal pd did not change significantly after challenges. conclusion: allergen decreases nasal mucosal ph in the very late phase after challenge in allergic rhinitic subjects. decrease in airway mucosal ph during asthma exacerbations may be caused by aggravation of allergic inflammation. nasal potential difference does not change after allergen challenge. funding: niaid, acaai foundation introduction: uv induces differentiation of t-and b-lymphocytes, suppresses natural killer cells, renders a tolerogenic effect and induces apoptosis resulting in local and system immunosuppression. methods: lymphocytes were studied using indirect immunofluorescence methods employing monoclonal antibodies to cd-markers cd , cd , cd , cd , cd , hla-i, and hla-ii, from the blood of volunteers (aged - years) before uv exposure (control), after an exposure of blood in vitro to a dose . kj, and after hours of exposure of the medial surface of the elbow joint in vivo (s= cm ), to a dose of . kj. results: the direct exposure of blood results in a significant reduction in the number of lymphocytes, probably due to direct phototoxic effects. significant modifications both of the aggregate number of lymphocytes and amount of t-helpers after uv exposure of the skin were not seen. after uv the number of cells which express the marker cd is sig-nificantly increased. exposure to uv in vitro induces reduced number of cells bearing cd . however on in vivo exposure, a significant increase in number of cells which express cd was observed. uv exposure of blood reduced significantly the hla-i ( . ± . reduced to . ± . ) and hla-ii (dr) ( . ± . reduced to . ± . ) expression. uv exposure of skin increased significantly hla-i to . ± . , while hla-ii (dr) was insignificantly decreased to . ± . . cd expression increased from . ± . to . ± . due to blood uv exposure, while there were insignificant reductions in cd ( . ± . reduced to . ± . ) and cd ( . ± . reduced to . ± . ) expression. conclusion: uv starts a cascade-like response, including apoptosis, leading to changes in nk cell, helper and suppression lymphocyte numbers consistent with an immunomodulating effect of uv radiation. background: previous investigations have shown the involvement of histamine and histamine receptors (h , h , h , h ) in ige synthesis in atopic and lymphoproliferative diseases. ige responses may depend on the concentrations of histamine and histamine receptor antagonists and agonists. the goal of this investigation was to evaluate the role of the concentration of histamine and h /h antagonists along with the importance of pre-existing levels of ige in determining ige responses. methods: ige synthesis was studied in mnc cultures of patients ( - years old) having mild atopic asthma and rhinitis. all patients had high levels of total ige and specific ige to ragweed pollen, house dust mite, epidermal or mold allergens. patients were divided into two groups according to the serum ige and levels of spontaneous ige synthesis: group a -with low levels ( . ± . iu/ml) and group b -with high levels ( . ± . iu/ml). the serum level of total ige in group a was . ± . iu/ml and in group b was . ± . iu/ml. fub hydrogenmaleate was used as an h /h specific antagonist. results: histamine in high concentrations ( - m) suppressed and in low concentrations ( - m) stimulated spontaneous ige synthesis. the h /h antagonist fub activity depends on the pre-existing levels of ige. in high concentrations ( - m), the antagonist increased ige synthesis only in group a, but not in group b having high spontaneous levels of ige synthesis. the synthesis in group a increased . fold (p< . ), but h /h blockade cancelled the ige suppressive effect of high concentrations of histamine ( - m). the addition of histamine into the mnc culture stimulated ige synthesis . fold. fub had no effect on ige-stimulatory effects of low concentrations of histamine ( - m). in allergen (ragweed)-stimulated mnc culture, fub had a co-stimulatory effect on ige synthesis induced by histamine. conclusions: the ige stimulating response depends on the concentrations of histamine and the h /h antagonist as well as pre-existing levels of serum ige and ige spontaneous synthesis. introduction: preliminary data has shown that oral contraceptives can precipitate or worsen attacks of hereditary angioedema (hae). it is thought that estrogens affect the synthesis and degradation of bradykinin with resulting edema. objective: our objective is to determine if there is a difference among the various oral hormonal preparations, namely, combined monophasic, combined multiphasic, progesterone only, and hormone replacement therapy, in regards to their effect on frequency of hae exacerbations. methods: patients in this study consisted of women over the age of diagnosed with hae who receive their care at our institution and women meeting the same criteria who are active in the hae foundation and have access to this association's web page. all patients answered a sixteen item questionnaire about past or present birth control pill or hormone replacement therapy usage and its impact on the frequency of exacerbations. results: of the patients who completed the questionnaire, % had taken or were currently taking oral contraceptive pills or hormone replacement therapy. of the women whom had taken monophasic birth control pills, % worsened with increased number and severity of exacerbations. however, only % of the women that had used combined multiphasic birth control pills worsened. all of the women who had tried progesterone only birth control pills worsened. of those on isolated estrogen for hormone replacement, % had an increased number of exacerbations. when androgens were used concurrently with oral contraceptive pills or hormone replacement therapy, exacerbations decreased to %. conclusion: we are not able to demonstrate a statistical benefit of one oral contraceptive pill preparation over another because of our sample size. however, our preliminary data supports that the oral contraceptive pill which produces less exacerbations and less symptoms is a combined multiphasic pill with concurrent androgen treatment. introduction atopic dermatitis (ad) is associated with multiple immunological abnormalities including imbalances in the subsets of blood circulating lymphocytes forming cellular infiltrates in inflamed skin. many studies of the functional and phenotypic properties of lymphocytes in ad have been limited to either peripheral blood or skin-infiltrating lymphocytes. the purpose of our study was to evaluate and compare the content and phenotypic properties of cd + lymphocytes from blood and inflamed skin of ad patients. materials and methods adult (age - years) patients with chronic ad were selected by the criteria of hanifin. all patients gave written informed consent. the cd + lymphocytes of peripheral blood were phenotyped by flow cytometry. skin biopsies were obtained from eczematous areas, then cryosected and double immuno-histochemistry was performed. for phenotyping of lymphocytes in blood and skin a panel of monoclonal antibodies was used including cd , cd , cd , cd , hla-dr and cla. results immunophenotype analyses of the peripheral blood lymphocytes showed a predominance of cd +cd + cells ( %± . ). most cells were cd +hla-dr+ ( %± . ) and cd +cd + phenotype ( %± . ). double immunohistochemistry of the skin biopsies revealed in the epidermis rare but constant presence of cd +cd +cells ( . ± . cells/mm ) and cd +hla-dr+ cells ( . ± . cells/mm ). in the dermal inflammatory infiltrates the predominant cells were cd +cd + ( . ± . cells/mm ) and cd +hla-dr+ ( . ± . cells/mm ). the dominant inflammatory infiltrate consisted of cd +cla+ phenotype ( . ± . cells/mm ) cells. conclusion in ad skin inflammation is associated with the appearance in the circulation of cd + lymphocytes in activated form (cd +hla-dr+) and lymphocytes with regulatory properties (cd +cd +). these lymphocytes are recruited from the circulation, having the skin homing properties (cd +cla+), and form the main constituent of the dermal inflammatory infiltrate. contact dermatitis (cd) comprises a spectrum of inflammatory skin reactions usually caused by exposure to non-immunogenic low molecular weight substances (haptens). failure to diagnose the condition may result in a chronic and disabling condition with impaired quality of life. a yr-old white male presented with a severe, symmetrically distributed facial maculopapular rash with secondary excoriated lesions. prior to the appearance of the rash, the patient had been applying lubriderm as a skin moisturizer for dry skin. a standardized thin layer rapid use epicutaneous (true) test containing chemical agents suspended in a vehicle and attached to an adhesive backing was applied to the patient's back. at hrs, a positive reaction was observed at the skin site of the paraben mix application. the lubriderm preparation used by the patient contained paraben, in contrast to a newer preparation, advanced therapy lubriderm, which is paraben-free. complete resolution of the facial lesions occurred following discontinuation of the lubriderm and the use of oral and topical corticosteroid therapy. this case report illustrates how a commonly used moisturizer can contain a sensitizing agent that could be detected by standardized patch testing which should be a part of the diagnostic armamentarium of every allergist-immunologist. we report how a commonly used and effective moisturizer (lubriderm) can cause severe allergic cd and that the use of a standardized thin layer rapid use epicutaneous (true) patch test panel can be an effective diagnostic tool for the detection of the offending agent. rationale: this study aimed to establish the possible differences of cutaneous sensitization to common aeroallergens in children under years old. methods:the study was conducted between - and included infants from silesia/southern part of poland/.these infants were refered to our allergy unit due to respiratory symptoms like rhinitis, otitis, pharyngitis, cough, bronchitis recurring;eye's symptoms/ conjunctivitis/ and oral symptoms. the skin prick test/ spt/ to major aerollergens in our environment(hdii, birch, alternaria, cladosporium and trees)were done to -months-old and -yearold children. a spt of mm or larger was considered as positive. patients were classified into three groups: i:positive family atopy ii:smoking ciggarettemother/ or father iii:cat or dog at home iv: coexisting food allergy results: , % of examined children were boys. the prevalence of sensitisation found were as follows:latex , %, birch , %, dpii- , %, grass pollen , %, alternaria- , %. positive spts to latex were first seen in the -months-old group and this prevelance doubled until they finished year. conclusion: in our study, cutaneuos sensitisation start to appear in -months-old chlidren. background: propylene glycol (pg) may induce allergic contact dermatitis (acd) and skin irritant reactions. topical formulations frequently contain pg. it is present in low concentration ( %) in pimecrolimus cream %, a non-steroid inflammatory cytokine inhibitor. objectives: this study was designed to assess the incidence of cutaneous responses to pimecrolimus cream in patients allergic to pg and to determine their nature (acd or irritation) and severity. methods: in this double-blind, randomized, vehicle-controlled, withinpatient study, subjects allergic to pg underwent -hour patch-testing (pg and %, pimecrolimus cream and vehicle) followed by a -day repeated open application test (roat). application sites were assessed by the investigator using a scale ranging from (no reaction) to (spreading bullous reaction) at , , and hours after patch removal and at the completion of the roat. results: pg allergy was confirmed by patch-testing in patients. two patients showed a positive patch-test reaction with pimecrolimus cream and vehicle, indicating an acd. in contrast, no patient demonstrated signs of acd when pimecrolimus cream was applied under normal conditions, i.e. without occlusion (roat). the statistical analysis showed that there were significantly less reactions at pimecrolimus patch-test sites than at the pg patch-test sites (p< . for both pg concentrations, one-sided exact binomial test) and that the median severity was lower with pimecrolimus cream vs. pg (p= . and p< . for pg % and % respectively, wilcoxon signed-rank test). conclusions: this pilot study suggests that pimecrolimus cream %, when applied under normal conditions, can be used safely in patients with pg allergy. introduction: chronic idiopathic urticaria is not always responsive to antihistamine therapy. multiple alternative agents have been tried. we report two cases where tacrolimus has been successful in treating this condition. methods: this is a case report of two patients who have chronic idiopathic urticaria and have been treated with tacrolimus. patient # is a y/o wm who pre-sented with urticaria that had been going on several months. the duration of his urticarial lesions was < hours his urticaria was treated with several medications including: hydroxyzine, cyproheptadine, ceterizine, montelukast, colchicine, and dapsone. he was intolerant to hydroxychloroquine. montelukast seemed to provide some modest benefit but he continued to have daily urticaria with > lesions/day after two months of therapy. tacrolimus was added to montelukast at mg bid. patient # is a y/o wf with a history of biopsyproven urticaria. she had suffered from episodic urticaria since the age of six that was responsive to systemic steroids. after thirty years of having no urticaria, she developed recurrent urticaria at age . at this time, she was treated with hydroxyzine, doxepin, montelukast, loratadine, ceterizine, fexofenadine, colchicine, dapsone, and even prednisone with very little improvement in symptoms. she was then started on tacrolimus mg bid as monotherapy while she was having daily urticaria. results: after one month of treatment with tacrolimus mg bid, patient # had a decrease in the number of urticaria. his dose of tacrolimus was increased to mg/day, and after four weeks, his urticaria resolved. he remained on tacrolimus for a total of six months which was tapered and discontinued. he continues to be in remission from urticaria. patient # had complete resolution of her hives after just two doses of tacrolimus. after two months, she remains free of urticaria on tacrolimus mg bid. conclusion: for patients with severe chronic urticaria unresponsive to multiple therapies, tacrolimus, like cyclosporine, may be efficacious. tacrolimus may also be truly immunomodulatory and capable of inducing remission of urticaria. s.v. gerasimov * , lviv, ukraine. introduction. recent studies suggest that probiotics can be useful in prevention and treatment of atopic dermatitis (ad) in children. as clinical effect of probiotics varies greatly depending on the specific strain, we are currently conduct a search for the most promising probiotic to be used as complementary therapy in infants and young children with ad. methods. we studied infants aged - weeks ( ± ) with ad established using hanifin and rafka criteria. patients were evenly allocated among probiotic (n= ) and nonprobiotic (n= ) treatment groups using quota allocation system. severity of ad was defined using scorad index and infant`s quality of life was assessed using idqol index. patients were examined before and weeks after the treatment with/without probiotic powder formulation (b. infantis, l. acidophilus dds- , billion cfu/day, dds-junior, uas laboratories). we compared pre/posttreatment values of indices above and amount of mometasone furoate ( , %) used employing a paired or unpaired t-test. results. at baseline, infants in either groups were comparable on age, gender, duration of the disease, scorad and idqol indices, and medication taken for the previous weeks. before entering the study all patients were maintained on allergen elimination diet due to milk and egg white allergy. after the treatment with/without probiotics the mean scorad index decreased from , to , (p= , ) and from , to , (p= , ), respectively. however, the mean amount of mometasone furoate used in non-probiotic treatment group was significantly greater ( , g vs , g, p= , ), despite the same recommendation on the use of the drug was given. additionally, parents of children taking probiotics reported an improvement in infant`s quality of life as seen on the decrease of idqol index from , to , (p= , ). in non-probiotic group decrease in idqol was not significant ( , to , ; p= , ) . there were no adverse events in any of the treatment groups. conclusions. our preliminary results suggest that some probiotics may have a corticosteroid-sparing effect and improve quality of life of infants with ad. there is a clear trend towards reduction of scorad index, which did not change significantly, probably due to a limited number of patients involved. introduction : the aim of this study was to analyze the risk factors of severe atopic dermatitis(ad) in the first months of life. methods : the children aged less than months with ad were divided into two groups according to six area six sign in atopic dermatitis(sassad) score. children with score less than was classified as mild ad(n= ) and those with score above as severe ad(n= ). these patients were fed with breast milk or cow's milk formula, and no allergenic food was given except rice and some vegetables. we analyzed the gender, feeding patterns, family history of allergy, number of siblings, total ige and specific ige to common food allergens (egg white, cow's milk, wheat, soy) by cap-feia assay. total eosinophil count was ± /ul in severe ad and ± /ul in mild ad(p< . ). results : ) total ige was . ± . u/ml in severe ad and . ± . u/ml in mild ad(p= . ). specific ige to egg white, wheat and soy ( . ± . u/ml, . ± . u/ml, . ± . u/ml in severe ad; . ± . u/ml, . ± . u/ml, . ± . u/ml in mild ad; p< . ) were associated with severe ad, but cow milk( . ± . u/ml in severe ad, . ± . u/ml in mild ad) showed no difference. ) gender, feeding patterns, family history of allergy and the number of siblings were not significantly associated with severe ad. conclusion : severe ad is associated with sensitization to food allergens in the first months of life, although they are not fed with those foods. background: atopic dermatitis (ad), an inflammatory skin disease diagnosed primarily in children, has been shown to have a negative impact on quality of life (qol). pimecrolimus cream % is a non-steroid, topical calcineurin inhibitor with demonstrated efficacy in the acute treatment and longterm management of pediatric and adult ad. in a -week, double-blind, vehicle-controlled study, a secondary aim was to evaluate the impact on parent's quality of life of a pimecrolimus-based or corticosteroid (cs)-based treatment regimen of children with ad. methods: children aged months to years (mean years) with mild to severe ad were randomized : to receive treatment with pimecrolimus or vehicle cream. emollients for dry skin and pimecrolimus or vehicle bid were applied at the first signs of ad. for severe flares, a mid-potency topical cs (fluticasone or mometasone) indicated for once-daily use in ad replaced the evening study drug application for a maximum of weeks or until all ad resolved. parents completed the parent's index of quality of life-atopic dermatitis (piqol-ad), a -item validated questionnaire, which measures parent's needs-based qol, at baseline, week , and study completion. change in piqol-ad scores at baseline and week were compared between treatments. a negative change indicated improvement. results: parents of patients in both groups reported improvement in piqol-ad scores at week , with greater improvement for the pimecrolimus group. the mean change in piqol-ad score from baseline to week was - . in the pimecrolimus group vs. - . in the cs-based treatment group ( . % vs. . % improvement, respectively). ancova analysis, using treatment and center as main effects and baseline score as a covariate, compared the change in piqol-ad score in two treatment groups. pimecrolimus treatment demonstrated a more favorable change (- . ) which approached statistical significance [p= . ; %ci= (- . , . )]. conclusion: a treatment regimen utilizing pimecrolimus cream % had a beneficial effect on parent's quality of life compared to a corticosteroid-based regimen. this benefit was consistent with other measures of efficacy studied. introduction: atopic dermatitis is a chronic, inflammatory and recurrent skin disorder . its prevalence has increased in recent decades but little is known about it in mexico city. the aim of this study was to evaluate the prevalence and severity of atopic eczema in a pediatric population. methods: a cross-sectional questionnaire survey (isaac phase i questionnaire) was conducted on random samples of schoolchildren aged to years and to years from educational centers of four northern counties from mexico city. those children with a positive response to being questioned about the presence of an itchy relapsing skin rash in the last months were considered to have atopic dermatitis. children whose symptoms resulted in sleep disturbance for or more nights per week were considered to have severe atopic eczema. statistical analyses were done with spss . for windows, chi square . the size of the sample was determined folowing the isaac specifications and calculated with the statcal program. results: complete data was available for children aged to years in schools and children aged to years in high schools. . % males and . % females. response rates were high ( . % for those aged to years and % for those aged to years). the prevalence of symptoms of atopic dermatitis in the last months was . % at age to and % at age to years. medical diagnose of atopic eczema was % and . % for children aged to years and to years, respectively. reported eczema accounted for . % and . % at age to and to years, respectively. children with symptoms of severe atopic dermatitis accounted for % of all those with symptoms of atopic dermatitis. we also found that the majority of the children begun with skin manifestations of atopic dermatitis before the age of years old. conclusions: the prevalence of atopic eczema was very similar for both groups of ages. our results agree with those found in other two studies acomplished in other mexican cities (cuernavaca and chihuahua) and with those from other countries of latin america like brazil, chile and costa rica. although, we found lowest values than those from sweden, japan and australia. studies that include objective skin examination are required to confirm these findings. a. kaplan * , s. meeves , y. liao , s.t. varghese , g. georges , . charleston, sc; . bridgewater, nj. introduction: the symptoms of chronic idiopathic urticaria (ciu) can have a profound impact on patient health and quality of life. the safety and efficacy of fexofenadine (fex) bid for the treatment of ciu has been previously established in two multicenter, double-blind, randomized, placebo-controlled trials. this study evaluated the efficacy and safety of a qd dose of fex hcl mg, as this dosing schedule could offer advantages in terms of patient compliance and convenience. methods: this multicenter, randomized, double-blind, parallel-group, placebo-controlled study consisted of a single-blind placebo run-in period of - days, followed by a (± )-day treatment period. males and females aged years with a diagnosis of ciu and with active disease were enrolled. patients were randomized : to receive either fex hcl mg qd or placebo qd. the primary endpoints were change from baseline in mean daily number of wheals (mnw score) and mean daily severity of pruritus (measured on a -point scale) over the -day treatment period, as assessed reflectively by the patient. secondary efficacy measures included a modified total symptom score (motss), comprising sum of number, frequency, size and duration of lesions, and severity of pruritus. mnw and pruritus severity were also assessed instantaneously at trough drug levels (immediately prior to dosing). results: over the -day treatment period, patients treated with fex (n= ) experienced significantly greater improvements in mnw and pruritus scores compared with the placebo group (n= ) (p< . for both). similarly, over the treatment period, and at individual weekly timepoints, the mean reductions in am reflective, pm reflective and mean daily motss were significantly greater for patients in the fex group compared with those in the placebo group (p . for all comparisons). the mean reductions in instantaneous mnw and pruritus scores were greater with those who received fex than those who received placebo (mnw: p= . ; pruritus score: p= . ). there were no significant differences in the frequency of treatment emergent adverse events between the two treatment groups, and no clinically relevant changes were observed with respect to clinical laboratory data, vital signs or ecgs. conclusion: this study demonstrated that a qd dose of fex hcl mg offers effective and well-tolerated relief from the symptoms of ciu. introduction: the wheals and pruritus associated with chronic idiopathic urticaria (ciu) are often so debilitating that they have a profound impact on patient quality of life. specifically, ciu has been shown to negatively affect patient mobility, sleep, energy levels, social interaction and emotional wellbeing. the purpose of this study was to examine the impact of treatment with fexofenadine hcl (fex) mg on health-related quality of life (hrql) among patients with ciu. methods: as part of a multicenter, randomized, double-blind, parallel-group, placebo-controlled study, designed to evaluate the efficacy and safety of a once-daily dose of fex mg in ciu, the impact of treatment on hrql was also examined. patients were asked to complete the dermatology life quality index (dlqi) and the work productivity and activity impairment questionnaire (wpai) at baseline and at weeks and (final visit or early termination). the primary endpoint was mean change from baseline in dlqi total score, using the mean data of evaluations performed at weeks and as the post-baseline measure. secondary endpoints included change from baseline in individual dlqi domains and wpai scores. additional analyses were conducted to examine the reliability, validity and responsiveness of the hrql measures. results: a total of patients were included in the hrql population: n= fex, n= placebo. patients in the fex group experienced significantly greater improvements in the mean dlqi total score than those in the placebo group (p= . ). this pattern was repeated with respect to the individual domains of symptoms and feelings (p= . ), daily activities (p= . ), leisure (p= . ) and personal relationships (p= . ). both treatment groups reported improvements in productivity, as measured by change from baseline using the wpai. patients randomized to fex experienced significantly less impairment while working (p= . ) and performing activities (p= . ) than those who received placebo. the dlqi was demonstrated to be reliable (cronbach's alpha= . ); both the dlqi and wpai were found to be valid and responsive instruments in this ciu population. conclusion: this study demonstrated that a once-daily dose of fex mg improves the hrql of patients with ciu, as assessed by change in dlqi total score. t. algozzine * , a. lee , s. wong , l. anzisi , . manchester, nh; . centerport, ny; . syosset, ny; . mamaroneck, ny. symptoms of allergic and non-allergic rhinitis may significantly impact a patient's quality of life, by causing fatigue, headache, cognitive impairment and other systemic symptoms. appropriate management of allergic rhinitis is important in the effective management of coexisting or complicating respira-tory conditions (e.g. asthma, sinusitis, or otitis media). in addition, many commonly used over-the-counter (otc) antihistamines can cause performance impairment that may impact daily activities. we designed a brief ten-question allergy survey in an attempt to determine how patients were being treated for their allergies, evaluate a patient's self-assessed impact of their allergies on their daily activities, and identify any difference in treatment outcomes between primary care and allergist practices. patients were invited to complete the surveys anonymously. completed surveys were collected and entered into a microsoft access database for evaluation. minitab was utilized for statistical calculations. four hundred and thirty seven patients completed the survey. fifty-eight percent of survey respondents were women and % were adults (age > ). of those patients surveyed, % (n= ) were under the care of an allergist. compared to primary care, patients treated by allergists reported more allergies ( . vs. . , p < . ) and received more medications on average ( . vs. . , p< . ). pollen was the most common allergy type reported among all patients. while the majority of all patients ( %) received prescription medications, more primary care patients received no therapy or only otc treatment when compared to allergist patients ( % vs. %, p< . ). seventy-four percent of primary care patients reported their allergy symptoms were controlled compared to % of allergist patients (p< . ). patients receiving treatment from an allergist reported less impact of their allergies on daily activities (a lower score signified less impact) compared to patients seen in primary care ( . vs. . , p< . ). the results of our survey suggest that allergists treat more complex patients. these patients had multiple allergies, more uncontrolled symptoms, and utilized more prescription medications. despite these findings, patients treated by allergists reported less impact of allergies on their daily activities. introduction the patogenic mechanism of nasal polyps are unknow.they frecuently are associated with aspirin intolerance, intrinsic asthma, chronic sinusitis, young sindrome, cystic fibrosis, kartagener syndrome and churg-strauss syndrome.chemical mediators found in nasal polyps are as follows: histamine, serotonin, leukotrienes, norepinefrine and possibly pgd .recently, leukotrienes have been implicated in mediation of bronchoconstriction and inflammatory leukotriene levels have also been shown to be elevated in some patients with sinonasal polyposis (figure ) hypothesis antileukotrienes might play a significant role in controlling polyposis and symptoms secundary to sinonasal disease, and they might viable alternative to longterm, oral steroid therapy and repeat surgical debridement purpose this study was undertaken to evaluate the potential role of leukotriene receptor antagonist on recurrent polyposis associated with asthma and improvement of some factor implicated with them design of study:clinical assay, prospective, triple blind. materialsand methods:the study involved patients ( %) males and ( %) women, mean age . years, with a range - years selection criteria:inclusion criteria: nasal polyps associated with astha, allergic or non allergic.exclusion criteria: patients with any concurrent illness, use of sistemic or local corticosteroidsor any kind of antileukotriene within month prior to the beggining of the study.we made an alleatory selection patients recived montelukast ( mgs/day), and nasal steroids, beclometasone ( mgs/day) for months. patients recived loratadine plus pseu-doefedrin mgs/ mgs/day and nasal steroids, beclometasone, patints were operated of fees and transnasal endoscipic polypectomy plus montelukast and nasal steroids, beclometasone ige serum levels .skin prick test .sensitivity in vitro .ct scan . celullarity on nasal lavage (eosinophils and neutrophils) .proinflamatory cytokines (il -il -il ) on nasal lavege by elisa test. results ther was a tendency for more improvement of the group ( surgery-montelukast-local steroid) of symptoms and objective measurments, in second place of improvement the group montelukast-local steroid) and the worse on improvement subjective and objetive was group local steroid and loratadine-pseudoefedrine use as placebo introduction: sensory perceptions of intranasal corticosteroids (ins) vary among products and can be unpleasant and affect adherence to therapy. methods: we conducted a cross-sectional study of patients across allergy and immunology clinics in the united states. respondents were asked to choose between pairs of hypothetical ins that differed by sensory attribute composition. based on prior research, we measured salient sensory attributes: smell, taste, aftertaste, throat rundown, nose runout, and feel of spray in nose/throat. each attribute was described in intensity levels, such as "no taste" (low), "weak taste" (moderate), and "strong taste" (high) ( table) . other outcomes included an importance score for each sensory attribute and patients' willingness to adhere to an ins having the lowest levels of each sensory attribute compared to one with moderate levels. results: preferences decreased with increasing intensity level of each sensory attribute. the most important attribute was aftertaste in % of patients, taste in %, throat rundown in %, nose runout in %, smell in %, and feel of spray in %. only % had more than one attribute tied for most important. if instructed to take ins daily for months, % of patients stated that they would definitely be able to follow their doctor's advice (willing to adhere) if given an ins containing the lowest level of each sensory attribute compared with % for one having moderate levels (p< . ). conclusions: patients' preferences decrease with increasing intensity levels of each sensory attribute and affect patients' willingness to adhere. tailoring ins to patient preferences may lead to improved treatment satisfaction and adherence. introduction:a high prevalence of rhinitis and asthma comorbidity has been persistently noticed in epidemiological studies in last years. our objective was to evaluate the prevalence of rhinitis and asthma comorbidity in a portuguese population including both atopic and non-atopic patients. methods: a retrospective study was performed. clinical records from patients attending an immunoallergology outpatients'clinic during months (from january until june ) were reviewed. data were collected concerning clinical history of rhinitis and/or asthma, aeroallergens'skin prick tests and respiratory function evaluation. results: among the patients attending an appointment during the study period, ( . %) had rhinitis and/or asthma ( . % f; . % m;mean age +/- years). patients with respiratory disease included atopic ( . %) and non-atopic %). diagnosis of asthma, rhinitis or of both diseases was made in ( . %), ( . %) and ( . %), respectively, in atopic patients and in ( . %, ( . %) and ( . %), respectively, in non-atopic patients. rhinitis was diagnosed in . % of atopic asthmatic and in - % of non-atopic patients with asthma. in patients with rhinitis, asthma was also diagnosed in . % of atopic patients and . % on non-atopic patients. conclusions: in this study population rhinitis was frequently diagnosed in patients with asthma and vice-versa, thereby leading to a high prevalence of this comorbodity. this association was more frequent in atopic patients. our data are comparable to those we found in recent literature. these results suggest that clinical investigation of asthma should be mandatory in management of patients with rhinitis as well as asthmatic patients should be routinely submitted to clinical evaluation of rhinitis. introduction: cetirizine hcl (c) has been shown to be more effective than fexofenadine hcl (f) in controlling seasonal allergic rhinitis (sar) symptoms at - hr post-dose, however, the efficacy of c and f was comparable between - hr post-dose. response to treatment in the middle of the dosing interval needed to be addressed. methods: this randomized, double blind, placebo (p)-controlled study was designed to compare the efficacy and tolerability of a single dose of c mg, f mg, and p between - hr postdose in ragweed-sensitive sar subjects. subjects meeting entry criteria were exposed to pre-determined controlled levels of ragweed pollen in the eeu during priming and double blind treatment. subjects assessed rhinitis symptoms at half hr intervals during pollen exposure; at priming, at the qualifying period, at baseline, and from - hr post-dose. the primary efficacy endpoint was the change from baseline in total symptom severity complex (tssc) score at hr post-dose. tssc score was the sum of severity ratings ( =absent to =severe) for symptoms: runny nose, sneezing, itchy nose/palate/throat and itchy/watery eyes. results: a total of subjects (mean age . y; . % females) were randomized: c, ; f, ; p, . baseline characteristics were comparable among groups; tssc: c= . , f= . , p= . . c produced a % greater reduction in tssc score at hr (- . , p= . ) and a % greater reduction overall (i.e., average over the - hr post-dose period) (- . , p= . ) compared with f (- . , - . , respectively). both c and f reduced tssc score more than p ( hr, - . ; overall, - . , p< . ) including all individual symptoms (p< . ). c however, was more effective than f for runny nose and sneezing at hr and overall, itchy/watery eyes at hr, and itchy nose/throat/palate overall (p< . ). rates of discontinuation due to adverse events (aes) were low: c, . %; f, %; p, . %. the incidence of treatmentemergent aes was similar: c, . %; f, . %; p, . %. somnolence occurred in . % of subjects on c, and % on f or p. conclusion: c produced a greater improvement in rhinitis symptoms compared with f and p, at hr post dose and over the - hr post-dose period. all treatments were safe and well tolerated. background: medication utilization patterns of patients suffering from seasonal allergic rhinitis (sar) are not well documented, and although many anti-allergic medications are prescribed for daily use, actual usage is unknown, but recognized to be quite variable. methods: subjects with positive ragweed skin tests were mailed a survey during the third week of ragweed season, soliciting the nature and severity of sar symptoms, usage patterns and reasons for choice of anti-allergic medication. results: subjects completed the survey ( . %). the prevalence of symptoms were, in decreasing order: sneezing ( . %), runny nose ( . %), itchy/gritty eyes ( . %), stuffiness ( . %), itchy nose ( . %), watery eyes ( . %), itchy palate/throat ( . %), post-nasal drip ( . %), red/burning eyes ( . %), headache ( . %), itchy ears ( . %), cough ( . %), shortness of breath ( . %), and wheeze ( . %). sar patients used antihistamines most frequently ( . %), followed by decongestants ( . %), combination (antihistamine/decongestant) products ( . %), and intranasal corticosteroids ( . %). medications were mostly taken intermittently rather than daily (antihistamines . %; nasal corticosteroids . %), conclusion: a constellation of nasal symptoms were the most common seasonal allergic manifestations, followed by ocular, palatal and ear irritation. antihistamines were the most frequently used medication to treat symptoms, succeeded by decongestants (alone or in combination). a significant proportion of subjects took their allergy medication, including nasal corticosteroids, intermittently rather than regularly, underscoring the relevance of single-dose evaluations of drug efficacy. a.k. ellis * , e. rafeiro, j.d. ratz, j.h. day, kingston, canada. background: traditional assessment of seasonal allergic rhinitis (sar) medication efficacy utilizes randomized controlled trials over - weeks in season. an additional study method employs single-dose responses using controlled allergen challenge such as the environmental exposure unit (eeu). a comparison of allergic symptoms generated by controlled allergen challenge to those occurring in ragweed season symptoms has not been done. methods: subjects with known sar to ragweed were mailed a survey during the third week of ragweed season, soliciting the nature and severity of sar symptoms. subjects participating in a subsequent controlled allergen challenge study using the eeu, were again asked to complete a similar survey that documented symptoms generated in this model. those who completed both surveys comprised the primary analysis group. results: subjects completed the ragweed season survey, subjects completed the eeu survey, and completed both. symptoms generated by eeu exposure were similar to those elicited during ragweed season, with the exception of cough ( % vs. %, respectively, p < . ). subjects reported that symptoms were more severe in the eeu than those experienced on a typical ragweed season day, but less severe than those during peak ragweed season days. conclusion: allergic upper respiratory tract symptoms produced during controlled ragweed pollen exposure in the eeu were similar in nature and degree to those expe-rienced during ragweed season, supporting evidence that the eeu is a valid model for studying sar. r. nave , m.a. wingertzahn * , s. brookman , s. kaida , t. shah , . konstanz, germany; . florham park, nj; . princeton, nj; . tokyo, japan. rationale: ciclesonide (cic) is a new corticosteroid under development for treatment of allergic rhinitis (ar). cic is a pro-drug that is hydrolyzed to the active metabolite desisobutyryl-ciclesonide (des-cic) in the target tissue. cic has low oral bioavailability and is highly bound to plasma proteins; therefore cic administered as a nasal spray is expected to have minimal local and systemic effects. objective: the primary objective was to evaluate the safety and tolerability of repeated escalating doses of cic ( - mcg/day) given as a nasal spray for days to healthy and asymptomatic subjects with sar. secondary objectives were to determine pk of cic and des-cic and to evaluate the effect of cic on endogenous cortisol. methods: this was a single-center, randomized, placebo-controlled, double blind, modified sequential dose study. six cohorts were randomized. cohorts i-v consisted of healthy subjects given doses of cic up to mcg bid. cohort vi (asymptomatic sar subjects) received mcg bid. each cohort was comprised of subjects who received cic and subjects who received placebo. safety assessments were conducted by recording adverse events (aes), clinical laboratory, eye, and nasal examination findings. serum and urine samples were taken for evaluation of cortisol levels. cic and des-cic serum concentrations were determined by lc-ms/ms. results: no trend was observed for aes when comparing cic and placebo treatment. additionally, no subject experienced a serious ae or withdrew from the study due to an ae during the trial. cortisol levels showed no differences between the dose groups or between activetreated subjects and placebo-treated subjects. additionally, serum concentrations of cic and des-cic in the majority of serum samples were shown to be below the lower limit of quantification (lloq; pg/ml for cic and pg/ml for des-cic), therefore no descriptive statistics could be calculated. con-clusions: ciclesonide nasal spray, at the doses evaluated, was safe and well tolerated in healthy and asymptomatic sar subjects with no detectable effects of cic on serum or urinary free cortisol concentrations. additionally, no pk parameters could be calculated for cic nasal spray, as it was virtually undetectable in serum despite the use of a sensitive assay. the preferred treatment for allergies is avoidance. air filtration is logical but room air purifiers have been of limited efficacy. zephyr™ is a new device which creates an envelope of air % free of allergenic particles around the head of the sleeping person. allergic rhinitis frequently causes daytime somnolence. this is a pilot study of the effectiveness of zephyr on symptoms of seasonal allergic rhinitis (ragweed hay fever) and on daytime sleepiness. methods: subjects age to with ragweed hay fever were studied in the ragweed season using each subject as his/her own control. usual allergy medicines were not allowed, except loratadine for rescue. outcome measures were a symptom score, juniper rhinitis quality of life questionnaire, a tolerability rating, and epworth sleepiness scale. during the first week subjects qualified by symptom scores, then entered the one-week treatment period with zephyr. the third week was a post-treatment observation period. results: of participants, ( %) showed symptom improvement. the whole group averaged % reduction in morning symptoms and % reduction in evening symptoms. sleepiness scores improved %. rhinitis qol improved %. the zephyr system was well tolerated as evidenced by the response to several statements regarding zephyr use and tolerability: (scoring: = strongly disagree, = strongly agree) "the system did not bother me while i was sleeping." (mean score . ) "the noise level did not affect my ability to sleep." (mean score . ) "the temperature was just fine for me." (mean score . ) "the system did not get in my way during sleep." (mean score . ) conclusions: zephyr significantly reduced seasonal hay fever symptoms and daytime sleepiness, improved quality of life, and was well-tolerated by subjects. zephyr may provide maximal environmental control of bedroom allergen exposure irrespective of ambient airborne allergen levels in the room. nasal congestion is an important symptom that is associated with significant morbidity in the rhinitis sufferer. disrupted sleep leading to daytime fatigue, loss of concentration, and decreased productivity are potential results of this symptom. a study employing online interviews with rhinitis sufferers from harris interactive's online database was conducted in order to understand the symptoms they identify with most and to determine the impact nasal congestion had on their daily activities. respondents were at least years of age and experienced nasal congestion from seasonal allergic, perennial allergic, and/or perennial non-allergic rhinitis. the results showed that % of the respondents agreed nasal congestion is the most bothersome symptom of rhinitis; % experienced nasal congestion daily, while % experienced it several times per week. not surprisingly, sleep was the most important factor affected by nasal congestion. two-thirds ( %) of the respondents felt their sleep had been moderately or significantly impacted by nasal congestion, and more than half ( %) felt it was difficult to get a good night's rest because of congestion. sleep was interrupted or disturbed by nasal congestion approximately nights per week, on average. furthermore, sleep disruption from nasal congestion contributed to daytime fatigue; % of the respondents indicated that they were typically tired or fatigued during the day when they experience nasal congestion. in addition, % felt that activities requiring concentration, such as reading, were moderately or significantly impacted by nasal congestion. this study confirms that nasal congestion causes the rhinitis sufferer significant problems beyond that of just a stuffy nose. consequently, healthcare providers need to ensure that their rhinitis patients who have nasal congestion as their primary complaint are managed effectively. desloratadine (dl, clarinex ® ) is a non-sedating oral antihistamine that is metabolized to -oh dl. however, a phenotypic polymorphism has been observed in some patients that results in reduced formation of -oh dl. the prevalence and safety profiles of such poor metabolizers of dl were examined in pharmacokinetic and clinical trials. a poor metabolizer was defined as a subject having a -oh dl to dl auc ratio of < . , or a dl half-life of hours. in pediatric studies, where a sparse sampling approach was uti-lized to screen for poor metabolizers, a plasma concentration ratio of -oh dl to dl of < . at hours classified a subject as a poor metabolizer. a total of , adult and pediatric subjects ( - years old) were phenotyped with a single dose of dl or loratadine. the overall prevalence of the poor metabolizer phenotype was % ( / ). this prevalence was comparable for adult ( / , %) and pediatric subjects ( / , %), and greater in both populations among blacks ( % pediatric, % adult) than caucasians ( % pediatric, % adult). pharmacokinetic analysis found that exposure to dl was approximately -times higher in poor metabolizers than in normal metabolizers. there was no apparent difference in dl exposure among poor metabolizers in different age groups ( -months to < -years, -to < -years, -to < -years, and -years) when treated with age-appropriate doses. the multiple-dose ( - days) safety profile of dl was examined in pediatric poor metabolizers ( - years) in placebo-controlled trials, and in adult poor metabolizers ( - years) in pharmacokinetic trials. pooled ae rates were low and comparable between the poor metabolizer and placebo subjects, as shown in the table below with all aes that appeared in > % of subjects in any treatment group (or > % in adult poor metabolizers). there was no difference in cardiovascular safety profile or ecg results (including qtc interval) among these groups. in conclusion, ( ) expression of the dl poor metabolizer phenotype is independent of age, but higher in blacks than in caucasians, ( ) exposure to dl in poor metabolizers is independent of age when administered at age-appropriate doses, ( ) the safety profile of dl poor metabolizers is not different from that of placebo at all ages down to at least -years old. these results are consistent with the high therapeutic index of dl. desloratadine (dl, clarinex®) is extensively metabolized to -oh dl and subsequently glucuronidated. the enzyme responsible for the formation of this active metabolite is unknown. poor metabolizers of dl represent a subset of the population that has a reduced ability to form -oh dl. a poor metabolizer was defined as a subject having a -oh dl to dl exposure ratio of < %, or dl half-life of hr. pk parameters from adult and pediatric poor metabolizers following repetitive administration of dl were characterized in clinical pharmacology trials and are summarized in the table below. exposure to dl [auc( - hr)] in poor metabolizers was approximately -fold greater than the corresponding values in normal metabolizers; cmax was to -fold greater. the magnitude of the reduction in the formation of -oh dl and the concurrent increase in exposure to dl associated with the poor metabolizer phenotype was similar in pediatric and adult subjects at age-appropriate doses. despite the increased exposure to dl in poor metabolizers, there was no increase in adverse event frequency or changes in electrocardiographic parameters. a: dose normalized to mg. b: least squares mean ratio: anova of log-transformed data extracting sources of variation due to age group and metabolizer status. the ratio is a contrast of metabolizer status. c: lower and upper % confidence interval based on log-transformed data. introduction: many patients with seasonal allergic conjunctivitis (sac) complain of symptoms of dry eyes. we have previously reported that patients with sac experience discomfort from dry eyes anywhere between to days per week and that the overall severity of the dry eye symptoms tend to range from mild to severe. this preliminary cross over study evaluated the benefits of nedocromil sodium % ophthalmic solution used twice daily, compared with nedocromil sodium % ophthalmic solution used with refresh (ocular lubricant), for the treatment of dry eye symptoms in association with sac during weeks. methods: patients who had a minimum of two-year history of sac and dry eyes, a positive skin prick test towards grass pollen and between the ages of to were enrolled. patients were evaluated on four visits and completed a daily diary, which included scales for grading allergic conjunctivitis and dry eye symptoms. at each clinic visit they completed the osdi and the rqlq (rhinitis quality of life questionnaire). the osdi (ocular surface disease index) was developed to assess dry eye symptoms and the impact on vision related functioning. the rqlq evaluates quality of life in patients with allergic conjunctivitis. at the last visit, both the patient and the physician assessed the treatment and the effectiveness, if any, of the addition of refresh to nedocromil sodium % ophthalmic solution. daily grass pollen counts were preformed using a burkhard sampler. results: patients ( male and female) were enrolled and dropped out. patients experienced minimal symptoms at the start of the season due to low concentration of grass pollen. preliminary analysis carried out using a paired t-test was preformed on the ocular average scores for the two treatment periods. there was no significant difference between the treatment groups for redness, light sensitivity and tearing of the eyes. a reduction in dry eye symptoms was reported in all patients using refresh eye drops and the number of drops required varied between patients. during the treatment periods there was improvement in patients rqlq. conclusion: patients preferred the addition of refresh eyedrops in alleviating sac and dry eye symptoms. further studies need to be carried using refresh eye drops in larger number of patients with sac and dry eye symptoms. c. laforce * , raleigh, nc. introduction: the objective of this study was to determine the ability of azelastine nasal spray to improve rhinitis symptoms and quality of life parameters in seasonal allergic rhinitis patients remaining symptomatic after treatment with fexofenadine. methods: this placebo-controlled, double-blind study began with a -week, open-label lead-in period, during which patients received fexofenadine mg bid. after days, patients who improved less than % to % on fexofenadine were randomized to treatment for weeks with: ( ) azelastine nasal spray, ( ) azelastine nasal spray plus fexofenadine, or ( ) placebo. the primary efficacy variable was the change from baseline to day in thetotal nasal symptom score (tnss), which consisted of runny nose, sneezing, itchy nose, and nasal congestion scores recorded twice daily in patient diary cards. in addition, quality of life was assessed using the rhinitis quality of life questionnaire (rqlq). results: after weeks of treatment, azelastine nasal spray (p<. ) and azelastine nasal spray plus fexofenadine (p<. ) significantly improved thetnss compared to placebo. based on patients with complete tnss and rqlq data, the overall rqlq score also was significantly (p<. ) improved compared to placebo. conclusions: azelastine nasal spray was an effective treatment for patients with seasonal allergic rhinitis who did not respond well to fexofenadine and significantly improved quality of life parameters compared to placebo. the results of this study indicate that azelastine nasal spray is an important alternative to oral antihistamines and should be considered in the initial management of seasonal allergic rhinitis. w. berger * , mission viejo, ca. objective: to evaluate improvement over time with azelastine nasal spray in the treatment of patients with moderate-to-severe seasonal allergic rhinitis (sar) who remained symptomatic after treatment with loratadine or fexofenadine. methods: the studies were -week, multicenter, double-blind, placebo-controlled trials that began with a -week, open-label lead-in period in which patients received either loratadine mg qd (study no. ) or fexofenadine mg bid (study no. ). patients who improved < %- % with loratadine were randomized to treatment with: ( ) azelastine nasal spray sprays/nostril bid, ( ) azelastine nasal spray sprays/nostril bid plus loratadine mg qd, ( ) desloratadine mg qd, or ( ) placebo. patients who improved < %- % with fexofenadine were randomized to treatment with: ( ) azelastine nasal spray sprays/nostril bid, ( ) azelastine nasal spray sprays/nostril bid plus fexofenadine mg bid, or ( ) placebo. the primary efficacy variable was the change from baseline to day in the total nasal symptom score (tnss), consisting of runny nose, sneezing, itchy nose, and nasal congestion. symptom severity was recordedam and pm in diary cards on a -point scale ( =none; =mild; =moderate; =severe). results: in both studies, patients treated with azelastine nasal spray experienced increasing improvement intnss over days of treatment.the improvements were approximately -fold greater than placebo at each day of the study, and the differences from placebo were statistically significant (p<. ) at days , , , and overall. in study no. , % of patients treated with azelastine had > % improvement in tnss compared to % in the placebo group. in study no. , % of patients treated with azelastine had > % improvement in tnss compared to % in the placebo group. conclusions: azelastine nasal spray was effective in treating patients with moderate-to-severe sar who remained symptomatic after treatment with either loratadine or fexofenadine. azelastine demonstrated first-day effectiveness, and patients treated with azelastine experienced increasing improvements in rhinitis symptoms over the -day study periods.azelastine nasal spray is an effective treatment alternative to oral loratadine or fexofenadine and an appropriate first-line therapy in the management of sar. introduction: a large, open-label, azelastine (astelin) nasal spray patient experience trial was conducted in patients with sar, vmr, or mixed rhinitis (allergic rhinitis with nonallergic triggers). this analysis evaluated the effect of azelastine nasal spray in treating rhinitis symptoms in a subset of patients with a history of asthma or sinusitis. methods: patients were entered into an open-label protocol and treated for weeks with azelastine nasal spray at a dosage of sprays per nostril bid. after weeks, the patients completed a questionnaire that assessed onset of action, symptom improvement, satisfaction with therapy, and quality of life. results: from a total of rhinitis patients who received azelastine monotherapy during the -week study period, data were analyzed for patients with asthma (n= ) or sinusitis (n= ). a greater percentage of these patients had severe rhinitis compared to the overall population. nasal congestion and postnasal drip were reported as the most bothersome rhinitis symptoms. after weeks of treatment with azelastine nasal spray, > % of patients with asthma and > % of patients with sinusitis reported some or complete control of congestion and postnasal drip. in addition, > % of patients with asthma reported chest tightness, shortness of breath, and wheezing were somewhat or completely controlled, and > % of patients with sinusitis reported that headache and facial pain were somewhat or completely controlled during treatment with azelastine nasal spray. conclusion: azelastine nasal spray provided effective control of rhinitis symptoms, including nasal congestion and postnasal drip, in patients with a history of asthma or sinusitis. introduction: epinastine is an antihistamine with mast cell stabilization and anti-inflammatory properties. epinastine . % ophthalmic solution was evaluated for treatment of allergic signs and symptoms elicited by feline dander in a cat exposure room. methods: participants (n= ) were aged years, with a history of ocular allergy to cats, a positive skin prick reaction to cat dander, and an ocular itching score of (on a - scale) within minutes of entering the cat room. subjects wore a tb mask while in the cat room to reduce the effects of inhaled allergen. after minutes of exposure, drop of epinastine hcl . % was instilled in one eye, and olopatadine . % was instilled in the fellow eye. environmental exposure to cat dander continued for another minutes. prior to instillation, and at , , , and minutes after instillation, conjunctival hyperemia and chemosis (scales of - ), and ocular itching, tearing, ocular burning, nasal itching and rhinorrhea (scales - ) were assessed. results: instillation of a single drop of ophthalmic epinastine significantly reduced ocular itching from a mean pre-instillation score of . to a mean score of . at minutes after instillation (p<. ), despite continuous exposure to cat dander during the entire period. similarly, ocular burning, tearing, and hyperemia were significantly reduced by epinastine treatment (p<. ). chemosis was only weakly induced by cat room exposure, with a mean pre-instillation score of . ; however, epinastine treat-ment decreased that to (p=. ). instillation of epinastine also significantly reduced nasal itching and rhinorrhea scores (p<. ). results for olopatadine were not statistically different; however, the change from baseline in itching scores in the epinastine-treated eyes was greater than that seen in the olopatadine-treated eyes at the majority of timepoints. conclusion: ophthalmic epinastine is indicated for the prevention of itch associated with allergic conjunctivitis.this study shows that treatment of cat-sensitive subjects with ophthalmic epinastine following environmental exposure to cat dander significantly reduced ocular itching and other signs and symptoms of allergic conjunctivitis. objective: the objective of this study was to evaluate azelastine (astelin®) nasal spray, cetirizine (zyrtec®), fluticasone (flonase®), and placebo in the treatment of patients with symptomatic seasonal allergic rhinitis. methods: this was a double-blind placebo-controlled pilot trial in patients with seasonal allergic rhinitis. the study began with a -week, placebo lead-in period, followed by a -week blinded treatment period (day to day ). efficacy variables were: ( ) change from baseline to day in the total nasal symptom score (tnss; consisting of rhinorrhea, sneezing, itchy nose, and nasal congestion); ( ) onset of action based on tnss over the hours following initial administration of study drugs; and ( ) change from baseline to day ( -hour change) in tnss. tnss was scored twice daily (am and pm) on a -point rating scale ( =none, =mild, =moderate, =severe). patients recorded a minimum -hour tnss of on at least days during the lead-in period, and a congestion score of on at least days to qualify for entry. qualified patients were randomized to treatment with: ( ) azelastine nasal spray sprays per nostril bid plus placebo capsules qd; ( ) cetirizine -mg tablets qd plus placebo nasal spray; ( ) fluticasone sprays per nostril qd plus placebo capsules qd; or ( ) placebo nasal spray plus placebo capsules. results: azelastine significantly (p<. ) improved the tnss compared to cetirizine, fluticasone, and placebo beginning minutes after initial administration; cetirizine significantly improved tnss versus placebo at minutes; fluticasone showed no significant differences from placebo over the -hour evaluation period. azelastine significantly (p<. ) improved the tnss at day ( -hour change from baseline) compared to cetirizine, fluticasone, and placebo. conclusions: azelastine nasal spray improved the tnss in patients with moderate-to-severe seasonal allergic rhinitis. in addition, azelastine nasal spray demonstrated a -minute onset of action and significantly improved tnss versus cetirizine, fluticasone, and placebo hours after initial administration. introduction: epinastine, an antihistamine with mast cell stabilization and anti-inflammatory properties, has been developed for the treatment of allergic conjunctivitis. the efficacy and tolerability of epinastine was assessed and compared with levocabastine. methods: eligible patients for this randomized, double-masked, parallel-group, active-controlled environmental clinical trial were - years old with a recent diagnosis of seasonal allergic conjunctivitis. patients instilled drop epinastine hcl . % or levocabastine . % ophthalmic solution in each eye bid for weeks. patients and investigators assessed efficacy and tolerability at study visits on days (baseline), , , , and , and assessed overall efficacy and tolerability at study exit. adverse events were monitored. results: epinastine provided superior itch relief compared with levocabastine (p=. ; see figure) ; mean ocular itch scores over treatment visits were . for epinastine and . for levocabastine ( - scale; =worst; baseline scores were . for epinastine and . for levocabastine). the mean summed score (ocular itching, tearing, and foreign body sensation) over treatment visits was significantly better for epinastine than levocabastine (p=. ).at study exit, % of epinastine-treated patients rated overall efficacy "very good" (the highest possible rating), versus % of levocabastine-treated patients. at minutes postinstillation, % of epinastine-treated and % of levocabastine-treated patients rated tolerability "very good". at study exit, % of epinastine-treated and % of levocabastine-treated patients rated overall tolerability "very good", with investigator ratings being similar. treatment-related adverse events occurred in . % of epinastine-treated patients (most frequent: eye pain and skin itching, . % each) and . % of levocabastine-treated patients (most frequent: double vision, . %; influenza-like symptoms, . %); most aes were mild or moderate. conclusion: our results confirm the therapeutic potential for epinastine as an efficacious treatment suitable for long-term use throughout the allergy season. ophthalmic epinastine was superior to levocabastine for relief of ocular symptoms in patients with allergic conjunctivitis and was well-tolerated. since chronic inflammation is the histopathologic landmark of otitis media with effusion, clinical observations have led us to believe that the combination of a cysteinyl leukotriene receptor antagonist montelukast with an oral antibiotic may be more efficacious than monotherapy with an oral antibiotic in the treatment of serous otitis media. we studied twenty pediatric patients (age years to years) in a randomized open labeled -week trial to compare the efficacy of the combination montelukast ( mg or mg chewables tablets qd dosed according to patient's age) with an oral antibiotic amoxicillin/clavulanate potassium ( mg/kg/day in divided doses every hours) to a monotherapy with an oral antibiotic amoxicillin/clavulanate potassium for the treatment of otitis media with effusion. the efficacy of treatment options was assessed using pneumatic otoscopy, impedance tympanometry, and audiometry to monitor the clinical course of the middle ear effusion in both treatment groups. in the combination group montelukast and antibiotic a resolution of otitis media with effusion occured at the th day. in contrast in the group treated with monotherapy with the oral antibiotic the resolution of otitis media with effusion occured on the th day. in conclusion, the combination of montelukast plus an oral antibiotic is more effective than monotherapy with an oral antibiotic.the combination of montelukast plus an antibiotic may be a safer and shorter therapy given the safety issues with long term use of systemic antibiotics. introduction: a randomized, double-blind, placebo-controlled study was conducted in an environmental exposure chamber (eec) to compare the efficacy of three doses of olopatadine nasal spray, a topical anti-allergy treatment for seasonal allergic rhinitis (sar), versus placebo spray. methods: patients aged - years old with a history of sar were screened, consented, evaluated for a positive skin test to ragweed allergen, and enrolled in this irbapproved study. a total of "primed" patients were exposed to ragweed allergen in the eec and randomized to olopatadine . % (n= ), olopatadine . % (n= ), olopatadine . % (n= ), or placebo (vehicle) (n= ) spray, sprays/nostril once in the morning. symptoms were self-assessed using a point scale (total nasal symptom score, tnss, comprised of sneezing, runny, itchy and stuffy nose) via diaries at periodic intervals during the -hour study period. safety was also assessed. results: obvious trends indicated a dosedependent response to olopatadine . %, . % and . %, though concentrations were not statistically different from each other. all three concentrations of olopatadine were clearly more efficacious than placebo spray at the first time point, minutes, continuing to the end of the -hour session. olopatadine exhibited a safety profile comparable to placebo. conclusions: olopatadine nasal spray . %, . % and . % exhibited dose-dependent responses. onset of action for all three concentrations of olopatadine was apparent at the first post-dose timepoint, minutes, and efficacy was maintained throughout the next hours. olopatadine nasal spray was safe, well-tolerated, and effective for the treatment of sar in the eec chamber. c. slonim * , tampa, fl. objective: to assess patient subjective responses to the treatment of allergic conjunctivitis using azelastine hydrochloride ophthalmic solution. methods: participating physicians selected patients from their practice to receive azelastine hydrochloride . % ophthalmic solution drop per affected eye twice daily for days. patients on prior ocular allergy medications were allowed to participate. after days of treatment with azelastine hydrochloride, patients (n= , ) rated their experiences with azelastine hydrochloride via a self-administered survey. not all questions were answered by each patient. results: at baseline, % of patients reported that their ocular itching affected their work, school, and/or leisure activities at least "somewhat". after using azelastine hydrochloride, % of patients achieved either "moderate" or "complete" relief from ocular itching, including % who reported "complete" relief from itching. seventy-one percent ( %) of patients had been treated previously with a topical prescription anti-allergy medication for their ocular itching. seventy percent ( %) of patients (n= ) who had not been previously treated with a topical prescription anti-allergy medication treatment and % of previous medication users (n= , ) experienced at least "moderate" relief of itching when treated with azelastine hydrochloride. sixty-five percent ( %) of the previously-treated patients rated azelastine hydrochloride as "somewhat better" or "much better" than their previous medication. conclusions: results suggest that azelastine hydrochloride ophthalmic solution is an effective treatment for the ocular itching associated with allergic conjunctivitis as rated by the patient, regardless of whether they had been treated previously with a topical prescription anti-allergy medication. objective: to determine an association between food allergy and acid reflux in adults. method: we conducted a retrospective chart review of atopic adult patients in an academic otolaryngic allergy practice. adults who tested positive and adults who tested negative for food allergy were included in the study. charts were reviewed for a diagnosis of gastroesophageal reflux disorders (gerd). this included a history of laryngopharyngeal reflux (lpr) and peptic ulcer disease (pud). population prevalence ( . %; ci . - . ) of acid reflux was estimated from a historical study (locke gr et al. prevalence and clinical spectrum of gastroesophageal reflux: a population-based study in olmstead county, minnesota. gastroenterology ; : - ) that had a similar subject population. the prevalence of gerd in each study arm, as well as in the total study group of atopic adults, was compared to the historical control. results: subjects testing positive for food allergy had a diagnosis of gerd in . % ( % ci . - . ) of cases. those subjects who did not demonstrate a food allergy were positive for gerd in % ( % ci . - ) of cases. in the total study group, the prevalence of gerd was . % ( % ci . - . ). on chi square analysis, the prevalence of gerd was significantly higher in the total study group when compared with the historical control (p= . ). those subjects who tested negative for food allergy had a statistically significant higher prevalence of gerd than the control population (p= . ). the prevalence of gerd between the group testing positive and the historical control did not show a significant difference (p= . ). when comparing the study arms to each other, there was no significant difference in the prevalence of gerd (p= . ). conclusions: the prevalence of acid reflux disorders was not higher in subjects with food allergy when compared to a historical control. although a statistical significance was noted between adults who tested negative for food allergy and the control population with regards to the prevalence of gerd, this may reflect the fact that individuals examined in an otolaryngologist's office are more likely to have acid reflux disorders than the general population. overall, the atopic subjects did have a higher incidence of acid reflux disorders, but there was no statistical significance between subjects with and without food allergy. a. suryadevara * , d.l. hamilos, boston, ma. introduction: recent studies suggest that crs without nasal polyposis (crssnp) and crs with nasal polyposis (crscnp) represent distinct pathologic entities. we wished to determine whether these conditions differed in their clinical presentation. methods: over a two-year period, new patients coming to a university based specialty clinic meeting criteria for crs were enrolled in an outcomes study. patients indicated which of four major (facial pain/pressure/headache, nasal obstruction, nasal purulence/discharge, and hyposmia/anosmia) and four minor (fever, halitosis, dental pain, cough) criteria for crs they were experiencing. rhinoscopy was performed to look for nasal polyps or polypoid tissue in any sinus area. the prevalence of each symptom was compared in the groups by chi square analysis. results: the population (n= ) had a mean age of +/- . and was % female, % caucasian, . % african-american, . % asian and . % hispanic. most patients ( %) were non-smokers. all had at least major criteria or major + minor criteria for crs at enrollment. forty-one patients ( . %) had crscnp. the mean number of major criteria was greater in the crscnp than crssnp ( . vs . , p= . ). nasal obstruction and hyposmia/anosmia were more prevalent in crscnp (p= . , . respectively). facial pain/pressure/headache was more prevalent in crssnp (p=). ). the most prevalent symptoms in crscnp were: nasal purulence/discharge ( . %)>hyposmia/anosmia ( . %)>facial pain/pressure/headache ( . %)>nasal obstruction ( %). in contrast, the most prevalent symptoms in crssnp were: facial pain/pressure/headache ( . %)>nasal purulence/discharge ( . %)>hyposmia/anosmia ( . %)>nasal obstruction ( . %). none of the symptoms were absolutely distinguishing of these conditions. no differences were found between the two groups for fever, halitosis, dental pain or cough. conclusion: we conclude that patients with crscnp have a greater burden of symptoms of crs and a much higher prevalence of hyposmia/anomsia. these findings are consistent with other studies showing that, in comparison to crssnp, crscnp tends to be more difficult to treat and have a higher rate of relapse after intensive medical therapy (subramanian et al, am j rhinology ; : ). l.e. mansfield * , e.e. philpot , c. posey , . el paso, tx; . research triangle park, nc. daytime sleepiness is a common complaint in sar. patients often complain of mental slowness, difficulty in concentrating, and thinking. the present study evaluated whether effective therapy of sar would decrease dss and improve an objective measure of cp. dss was measured using the epworth sleep scale (ess). objective cp was measured using the test of variables of attention (tova), a validated test. thirty two adults ( males, females with a year history of sar, a compatible physical exam, and corresponding positive allergy testing) volunteered for this week randomized double blind placebo controlled study. after a one week inf placebo (pl) baseline, the subjects received either active inf or continued pl. they maintained daily nasal symptom dairies and ess. the subjects took the tova test at the end of week and week . weekly nasal symptom scores significantly improved with the inf, but not the pl. w vs. w nasal congestion inf , p=. , pl , p=ns; runny nose inf . , . p=ns; pl . , . p=ns; sneezing inf . , p=. ; pl . , . p=ns. total weekly ess was abnormal and decreased significantly in the inf group, but not in pl group. w vs. w inf . , . p=. , pl . , . p=ns. response time of the tova testing, initially somewhat slow, significantly decreased in inf but not pl treatment. w vs. w inf msec, msec p=. ; pl msec, msec p=ns. these results demonstrate that sar is associated with dss and cp problems. the mechanism is likely to be sleeping disordered breathing associated with nasal congestion and obstruction. effective treatment of nasal congestion with inf led to decreased dss and improved cognitive performance. l.e. mansfield * , c. graham , . el paso, tx; . new york, ny. there is increasing recognition that sleep disturbance and daytime tiredness occur during active ar. the mechanism appears to be nasal congestion and obstruction leading to sleep disordered breathing and resultant poor quality of sleep. in our practice, as part of the initial history, questions regarding fatigue, snoring, sleep problems, and tiredness are addressed. sleep problems and tiredness are graded according to the following scale: effect on daily activity ; =not troubled; = a little trouble; =somewhat troubled ; = trou-bled a lot ; = total disruption. we reviewed consecutive charts of patients with allergic rhinitis documented by history, physical examination and allergy testing. there were females and males; age range y to y. ( %) of patients or parents recognized they commonly snored. ( %) stated they were chronically fatigued. the graded answers concerning sleep problems and tiredness were even more revealing of ar patient's perception of their problems see table in general, the higher sleep problem responses were associated with higher tiredness scores. national surveys of unselected populations suggest that about percent of adults consider themselves to have sleep problems. the high frequency of sleep related problems and tiredness in our sample has prompted us to add more detailed questions regarding sleep related events to our intake history. it is our opinion that questions specifically related to sleep and daytime tiredness should be included in all evaluations for allergic rhinitis. we conclude that sleep related problems and tiredness may be more common in patients with allergic rhinitis than previous reported. r.w. weber * , j. garcia , r. faruqi , d. banerji , g. georges , the study investigator group , . denver, co; . bridgewater, nj; nj. introduction: the intranasal glucocorticosteroid triamcinolone acetonide (taa) is a safe and effective treatment for persistent allergic rhinitis (par). a new hydrofluroalkane- a (hfa) propellant delivery system (taa-hfa) has recently been developed. this study primarily assessed the long-term safety of taa delivered via this new device, as well as its long-term efficacy. methods: patients aged - yrs (mean= ) with par enrolled in this -yr, open-label study at centers in the us. patients received taa-hfa μg once daily for a -week run-in period before adjusting the dose to μg or μg once daily based on symptom severity. doses were standardized to μg once daily across all patients at ~ months to ensure sufficient long-term safety data at the maximum dose. physical exams, including measurement of vital signs and laboratory measurements were taken at baseline, months and study end. independent patient and physician global symptom evaluations were performed at baseline, week and months - thereafter. patients recorded any adverse events (aes) on daily diary cards. results: of the patients included in the study, ( . %) reported aes. the incidence of aes was similar to that of other comparable allergic rhinitis long-term studies. the most frequently reported aes were pharyngitis, rhinitis, local reactions, headache, epistaxis and sinusitis (table ) . most aes were mild-to-moderate in intensity; patients withdrew from the study due to aes. there were no clinically relevant changes in physical exams, vital signs or laboratory measurements. a total of serious aes (saes) were reported; breast carcinoma (n= ), depression (n= ), post-operative spinal fluid leak (n= ) and staphylococcal infection (n= ). saes were thought to be not related to the study drug. at final visit, % of patients had either moderate or marked/complete relief of symptoms using global symptom scores. similarly, % of physicians rated their patients as having either moderate or marked/complete relief. conclusions: long-term administration of taa-hfa μg exhibited a good safety and tolerability profile, while providing moderate-to-complete symptom relief in more than % of patients treated for par. introduction: second-generation, 'non-sedating' antihistamines (ahs) have lower tendency to cross the blood-brain barrier and cause central nervous system side effects than first-generation agents. however, studies have suggested differences between second-generation ahs regarding cognitive function impairment. methods: a medline literature search was performed using the search terms 'antihistamine and impairment', 'antihistamine and psychomotor' and 'antihistamine and central effects', as well as with individual ah names (acrivastine, cetirizine, desloratadine, ebastine, fexofenadine, levocetirizine, loratadine, mequitazine and mizolastine). the findings for second-generation ahs were reviewed and well-designed, placebo-and positive-controlled studies in humans using objective measures of cognitive impairment were included. results: publications were identified as the inclusion criteria. all included objective assessments such as driving performance, critical flicker fusion and divided attention tasks. there was a large variation in the numbers of available well-designed studies; the most rigorously assessed agents were fexofenadine and cetirizine. a number of the ahs (ebastine, acrivastine, loratadine, mequitazine and mizolastine) were not impairing at recommended doses, but were at higher doses. in a small number of available studies, the newer ahs desloratadine and levocetirizine produced no impairment at recommended doses ( mg); however, higher doses were not investigated. cetirizine studies were variable; impairment at the recommended mg dose or higher was seen in a number of studies. in contrast, fexofenadine hcl, up to a dose of mg, was non-impairing in a large number of studies. only one study indicated impairment in one task (critical tracking) and this was only observed with the first doses of fexofenadine hcl ( and mg) and not subsequent doses; however, the authors concluded that doses up to mg/day should be safe for patients who drive. conclusion: while second-generation ahs are less impairing than the first-generation, some newer ahs produce impairment at or above the recommended dose. these differences become important to the patient when agents cause sedation or if patients over use beyond the recommended dose. in conclusion, fexofenadine was the only ah found to be non-impairing in all studies, even at double the recommended us dose. s. shaver , r.b. berkowitz * , c. lutz , p. jones , c. qiu , s. meeves , s.t. varghese , g. georges , . woodstock, ga; . bridgewater, nj. introduction: fexofenadine (fex) is a h -receptor antagonist, with proven efficacy in the treatment of allergic rhinitis (ar). to date, no live cat-room challenge studies have assessed the efficacy of fex in cat-allergen induced ar. this study assessed the efficacy of a single dose of fex hci mg in preventing and controlling cat-allergen induced ar using the cat-room challenge model. methods: this single-center, prospective, randomized, doubleblind, placebo-controlled, two-way crossover study consisted of a screening visit, one or two priming visits and two treatment periods, separated by a (± )-day wash-out. qualifying subjects were randomized to treatment sequence (placebo followed by fex) or (fex followed by placebo). baseline endpoints were obtained prior to study drug administration, and minutes before entering the cat challenge room for allergen challenge. allergen challenges were initiated . hours post-dose, for both treatment periods. the primary endpoint was the change from baseline in total symptom score (tss; sum of rhinorrhea, itchy nose/palate/throat, sneezing and itchy/watery/red eyes) after minutes of allergen exposure at hours post-dose, compared with placebo. other endpoints included changes in individual symptom scores, including nasal congestion. levels of airborne felis domesticus allergen (fel d ) were determined. results: of subjects screened, were randomized and completed the study; and in sequence and , respectively. mean change in tss from baseline was significantly less with fex compared with placebo at minutes after initiation of the cat allergen challenge (p= . ). significantly greater percentage reductions in the individual symptom scores for sneezing (p= . ) and nasal congestion (p= . ) were observed with fex compared with placebo, minutes after challenge. although levels of fel d varied widely, they were balanced between treatment groups. the overall incidence of treatment-emergent adverse events (aes) was low and comparable between groups; no serious aes occurred. conclusion: this study demonstrated that a single dose of fex hci mg is effective and well tolerated as a prophylactic agent for alleviating the ar symptoms induced by exposure to cat allergen. further large-scale clinical trials are warranted to confirm these findings. rationale: allergic rhinitis in children is thought to be associated with several co-morbid disorders. we conducted the following study to assess whether children with diagnosed hypertrophy of tonsils and/or adenoids evaluated by an allergist were more likely to demonstrate objective evidence of allergen sensitization than children similarly evaluated without evidence of these upper airway obstructions. methods: records from the past ten years were identified in the hospital database by presence of an allergy clinic visit and an icd- code for hypertrophy of adenoids and/or tonsils. we reviewed these records to confirm that the diagnosis was accurate. we included subjects if reliable skin prick or in vitro testing for specific ige to aeroallergens was performed. for comparison, we randomly obtained an age and testing-type similar sample. first group subjects were excluded from the second group. skin testing was performed with commercial allergen extracts applied with a dermapik©. in vitro testing was by unicap© feia. positive skin testing had at least a wheal mm or flare mm greater than the negative control. positive in vitro values were . ku/l or greater or a positive pollen mix. additionally, we performed a search in an insurance database to determine how many local children had a code for allergic rhinitis. results: of pediatric allergy patients with adenoid/tonsillar hypertrophy tested, . % ( % ci +/- . %) had at least one positive test. in without adenoid/tonsillar hypertrophy, . % ( % ci +/- . %) had at least one positive test. the observed difference was . % ( % ci +/- . %). the standard error of the difference in percentage was . ; the z score was . . the corresponding p value is . . the percentage of , children with an allergic rhinitis icd- was . % ( % ci +/- . %). conclusion: the number of allergist-referred children with adenoid and/or tonsillar hypertrophy testing positive for an aeroallergen is slightly less than the number of similar children without these diagnoses testing positive. it is not clear that adenoid/tonsillar hypertrophy is associated with a higher risk of allergic rhinitis. a prospective study with allergy testing of all children with adenoid and/or tonsillar hypertrophy might provide information that could alter referral patterns. w.e. berger * , w. storms , s. kimura , m. beck , s. galant , t. westbrook , . mission viejo, ca; . colorado springs, co; . pensacola, fl; . miami, fl; . orange, ca. background: patients having allergic rhinoconjunctivitis are often treated with nasal spray or systemic allergy therapy, forgoing therapy specifically targeting ocular symptoms. the rhinitis quality of life questionnaire (rqlq) and allergic conjunctivitis quality of life questionnaire (acqlq) instruments can be used to quantify the relative benefit of varying medication regimens. objective: to determine the extent of benefit gained in quality of life when an eye drop treatment for ocular allergy (olopatadine) was added to rhinitis patients' preexisting regimen of nasal or systemic allergic treatment. methods: this was a four week prospective, multi-center, open-label crossover, quality of life study occurring during allergy season. at visit , patients completed the rqlq and acqlq questionnaires to assess baseline quality of life. patients were randomized to receive ocular allergy therapy (olopatadine, patanol bid) concomitant with their systemic or nasal rhinitis treatment(s) for weeks between either visit and visit (group a) or between visit and visit (group b). at visit and visit , patients completed the rqlq and acqlq. results: a total of patients completed this study: in group a, in group b. of these, ( . %) experienced eye allergy symptoms at least day during the previous week as reported in the baseline acqlq. baseline scores of the rqlq and acqlq for both groups were comparable. clinically significant improvement from baseline in global rqlq and acqlq was seen following addition of ocular therapy for both groups (rqlq: - . , - . ; acqlq: - . , - . ). similar improvement was seen across all domains of both questionnaires. the acqlq correlated with the rqlq in the applicable domains. conclusion: many allergic rhinitis patients using nasal or systemic medication also suffer from ocular allergic symptoms. for these patients, quality of life improvement is not maximized; the addition of a topical antiallergy eye drop can result in beneficial effects on quality of life. in this study, the addition of olopatadine eye drops to these patients' medication regimens resulted in significant improvement in not only eye symptom related quality of life domains but in overall quality of life. h. milgrom * , r. lanier , f.c. hampel , b. kittner , . denver, co; . fort worth, tx; . new braunfels, tx; . bridgewater, nj. introduction: fexofenadine, a non-sedating, selective h -receptor antagonist, is currently indicated for use in children aged - years with seasonal allergic rhinitis in a number of countries, including the us, and has an excellent safety profile in this age group. this study was designed to assess the safety and tolerability of fexofenadine in children aged - years with allergic rhinitis (ar). methods: the study had a multicenter, double-blind, randomized, placebo-controlled, parallel-group design. children aged - years (n= ) with ar were randomized : to either placebo twice daily (bid; n= ) or fexofenadine hcl mg bid (n= ), for weeks. both treatments were given orally as granulated powders (capsule content) mixed with two teaspoons of apple sauce. treatment-emergent adverse events (teaes) were recorded for all subjects by parents/caregivers and assessed by investigators. clinical laboratory variables, physical examinations, vital signs and ecg evaluations were also assessed in a subgroup of children (placebo, n= ; fexofenadine, n= ). results: baseline demographics were similar in both treatment groups. while approximately % of children in both groups experienced at least one teae, no unusual or unexpected teaes were observed in the fexofenadine group. when the total group was analyzed for teaes by body system, or assessed separately by age groups of -, -, -and -year-olds, no clinically meaningful differences were observed between the two treatment groups. in both treatment groups, the majority of subjects overall and in each age group experienced teaes rated as mild or moderate in intensity. few subjects experienced teaes considered possibly related to study medication (placebo: . % [ / ]; fexofenadine: . % [ / ]). the percentage of discontinuations due to teaes was also comparable between treatment groups (placebo: . % [ / ]; fexofenadine: . % [ / ] ). in the subgroup assessment, no clinically relevant changes were seen from baseline for laboratory variables, vital signs, ecgs or physical examinations in either treatment group. introduction: the efficacy and safety of fexofenadine hcl mg bid has been proven in two large phase iii studies in pediatric subjects aged to years with seasonal allergic rhinitis. in addition, the safety of fexofenadine has been demonstrated in pediatric subjects to years of age with allergic rhinitis (ar). subsequently, two studies (t/ ; t/ ) have assessed the pharmacokinetics, safety and tolerability of fexofenadine and mg bid in pediatric subjects months to years of age. methods: both studies were of multicenter, randomized, double-blind, placebo-controlled, parallelgroup design and enrolled pediatric subjects aged months to < year weighing . kg and aged ± year to < years weighing > . kg. all subjects had a diagnosis of ar as assessed by previous medical history, pattern, or suggestive physical findings. subjects were randomized to receive fexofenadine hcl mg (t/ ), or mg (t/ ) granulation powder twice-daily, or placebo for a minimum of days. safety was evaluated based on adverse events (aes), vital signs, -lead electrocardiograms (ecgs), and physical examinations. results: a total of and subjects were randomized in studies t/ (fexofenadine hcl mg bid: n= , placebo: n= ) and t/ (fexofenadine hcl mg bid: n= , placebo: n= ), respectively. in t/ , . % ( / ) of children receiving fexofenadine and . % ( / ) receiving placebo experienced at least one treatment-emergent ae (teae). in t/ , the incidences of teaes were . % ( / ) and . % ( / ), respectively. in both studies, most of the teaes experienced were mild or moderate in intensity. the incidence of possibly-related teaes was also similar for both treatments in each study. no clinically relevant changes from baseline to study end were observed for vital signs, ecgs and physical examinations. conclusions: the findings of this study show that fexofenadine mg and mg bid are well tolerated and have a safety profile comparable to placebo in pediatric subjects aged months to years. for seasonal allergic rhinitis (sar) patients that remain symptomatic on an h -receptor antagonist, cetirizine, and a nasal glucocorticosteroid, mometasone furoate, the addition of omalizumab, a recombinant, humanized, chimeric, anti-ige monoclonal antibody, may provide additional efficacy in sub-optimally controlled seasonal allergic rhinitis patients. in this open labeled week trial, patients with symptomatic sar currently using cetirizine, mg qd, + mometasone furoate, mcg/nostril qd, were randomized to continue the existing therapy cetirizine + mometasone or to add-on omalizumab subcutaneously (every weeks to weeks) dosed according to patient's weight, and baseline ige levels to the existing therapy cetirizine + mometasone furoate. the endpoints of the trial include: rhinomanometry, nasal symptom score (composite score of nasal congestion, rhinorrhea, sneezing, post nasal drip and itching) and flexible rhinopharyngolaryngoscopy examination. mean efficacy measurements at the end of the -week trial revealed a significant improvements in all parameters examined in the treatment group receiving omalizumab (as add-on to the existing therapy), compared to the other group. in conclusion, the addition of omalizumab to the combination of cetirizine plus mometasone furoate, is more effective than the combination of cetirizine plus mometasone furoate, for the treament of seasonal allergic rhinitis patients. it appears that when omalizumab is added to the combination h receptor antagonist, cetirizine, and nasal corticosteroid, mometasone furoate, the primary end points (rhinomanometry and symptom scores) are significantly improved. background: based on the official statistic data, the prevalence of allergic diseases in russia has increased more than times during the past - years, but still the lowest of all european countries. in some studies done in some regions of russia based on isaac program, it has been shown that the prevalence allergies is significantly higher than indicated in official statistics of health departments. the goal of this investigation was to study the prevalence of allergic diseases, in children of south russian region. meth-ods: this study was done in two steps according to isaac program guidelines. in the first step a questionnaire was given to a total of school children, ages to (group a) and to years old (group b), from the two cities of krasnodar and novorossiysk in southern russia. in the second step a physical exam, skin prick tests with different allergens (pollens, molds, cat, dust mites, foods etc.), and pulmonary function tests were performed. results: wheezing was reported in . % of group a and . % of group b children within the past months. the severity of asthma reported was mild in % (group a)- % (group b); moderate in . % (group a)- . % (group b) and severe in . % (group a)- . % (group b) in studied children). majority of the cases of asthma was noted to be allergic asthma. in both groups of children there was a high incidence of allergies to perennial allergens such as dust mites, cats, molds and other indoor allergens, . % (group a) and . % (group b). the percentage of allergies to pollens was . % and . %, accordingly. allergic rhinitis symptoms were noted in . % (group a) and in , % (group b). atopic dermatitis symptoms with skin itching observed in . % ( - years old)and . % ( - years old). family history of atopy was noticed in . % of group a and . % of group b children. conclusions: the prevalence of allergic diseases in south russia is similar to the ones in most of the european countries. the prevalence of asthma has been associated with increased incidence of allergies, due to indoor and pollen allergens. the prevalence in rhinitis and atopic dermatitis in south russia is parallel to asthma. acknowledgement: we would like to thank hollister-stier lab., greer and antigen lab. for allergen samples. objective: to examine the cost and effectiveness of telithromcyin vs. azithromycin for treatment of mild acute sinusitis under current levels of antimicrobial resistance. methods: we considered an adult with mild acute sinusitis, and symptom duration of days. a decision analytic model was created to compare strategies of st-, nd-and rd-line therapies: azithromycin/amoxicillin-clavulanate/levofloxacin (azi/amc/lev), and telithromycin/amoxicillin-clavulanate/levofloxacin (tel/amc/lev). we considered outcomes: response to initial therapy, cost, and time to completion of all antibiotic therapy. clinical resolution was due to response to antibiotic, or to spontaneous resolution. we assumed bacteria that were resistant in vitro would only be resistant in vivo % of the time. resistance levels were based on the - us protekt surveillance study. model parameters, such as prevalence of bacterial infection, frequency of causative pathogens, and rates of spontaneous resolution, were based on the published literature. those failing to improve after days were switched to next line therapy. we analyzed claims data from managed care organizations to estimate non-drug charges for initial and follow-up care, and applied a % cost-to-charge ratio. drug costs were estimated using the wholesale acquisition cost plus $ for overhead and dispensing. all costs were adjusted to year $us. results: the model predicted the tel/amc/lev strategy would result in . % improving by days compared to . % for azi/amc/lev. the telithromycin strategy had lower mean cost, $ vs. $ . although telithromycin cost more than azithromycin, the tel/amc/lev strategy had slightly lower total drug costs ($ vs $ ) due to less need for additional antibiotic courses. mean time to completion of therapy was . days for tel/amc/lev and . days for azi/amc/lev. sensitivity analyses showed that tel/amc/lev had superior health outcomes even when only % of in vitro resistant organisms were also resistant in vivo. tel/amc/lev also had lower cost if at least % of cases were bacterial, or if in vitro resistant organisms were at least % resistant in vivo. conclusion: based on results obtained using this decision analytic model, initial treatment of mild acute rhinosinusitis with telithromycin may result in improved outcomes and lower cost than initial treatment with azithromycin. rationale: "delta crud" is the term used to describe rhinosinusitis syndromes in the mississippi delta region. local perception is that it is associated with chemical crop dusting, regional produce, especially cotton, or high rates of mold allergy. the climate is extreme with mild winters, hot humid summers, and large volume rain. thirty-five percent of inhabitants live below the poverty level, % are african american. patients from the agriculturally intensive delta suffer from asthma at almost twice the rate of those in the neighboring hills. rates of pesticide use are among the highest in the nation. there are no prevalence estimates for rhinosinusitis in this region. "delta crud" is chronic in many patients with exacerbations occurring in the summer and fall, especially during chemical spraying and defoliation. we conducted this cross-sectional questionnaire based pilot study to begin characterization of rhinosinusitis in this population. method: the sinusitis treatment outcome questionnaire, with two modifications, was given to consecutive patients presenting to the north sunflower regional hospital er and the sunflower outpatient clinic one month prior to the beginning of summer crop dusting. the question, "do you have delta crud?" was added. the survey was anonymous, allowing irb exemption. results: consecutive patients returned completed questionnaires. ( %) admitted to having "delta crud". patients who claimed to have delta crud had significantly more sinus headache, nasal pruritus, conjunctivitis, and chest symptoms (see table) . there was no significant difference in antibiotic prescriptions, er visits, and missed work. six patients with delta crud had been hospitalized for "allergy reasons" compared with three patients without delta crud. despite severe symptoms just patients received sinus ct scans. only / patients were prescribed intranasal corticosteroids. conclusion: in our pilot study, the prevalence of chronic rhinosinusitis symptoms (delta crud) is %, with severe sinus, pulmonary and ocular symptoms. evaluation and treatment may be suboptimal in this economically disadvantaged rural region. further characterization of "delta crud", pollen counts, ige mediated disease, environmental contributions and comparative studies of related regions are needed. introduction: patients with rhinitis commonly experience sinus pain and pressure (sp+p). many patients with recurrent acute bacterial sinusitis (rabs) base the presence of a recurrence on the severity of sp+p and other nasal symptoms. the ability of patients to differentiate between rhinitis and rabs was evaluated by reviewing the subject screening logs of previously reported clinical trials of flonase (fluticasone propionate) nasal spray, mcg (fp). methods: the efficacy of fp was studied in two trials in subjects with sp+p due to allergic rhinitis and in two trials of subjects receiving cefuroxime axetil to treat an acute episode of rabs. sp+p screening logs were examined to determine how many subjects who thought they had sp+p were excluded from the study for an upper respiratory or sinus infection. rabs screening logs were examined to determine how many subjects with symptoms of an acute episode of rabs were excluded from the study for a negative sinus x-ray or ct scan. rabs symptoms experienced at the screening visit by subjects who qualified for the study were also evaluated. results: of subjects screened in the sp+p studies, only ( . %) were excluded for evidence of sinus or upper respiratory tract infections, as clinically diagnosed by the investigator. out of subjects with screening log data in the rabs studies, ( . %) were excluded for a negative sinus x-ray or ct scan. of the subjects who qualified for the rabs study, the most prevalent symptoms included nasal congestion ( %), mucopurulent discharge ( %), facial pain or tenderness in the sinus area ( %), sinus headache ( %) and malaise ( %). only % of subjects had a fever. only one symptom, nasal congestion, was rated by clinicians as severe for greater than % of subjects in either study ( % and %). conclusions: while most subjects can determine when sp+p is due to allergic rhinitis, many cannot determine when symptoms progress to a sinus infection. symptoms experienced by subjects with rabs were consistent with inflammation, but did not include fever as may be expected with an untreated bacterial sinus infection. under appreciation by patients for the role of inflammation in sinus disease may result in over self-diagnosis of sinus infection and the demand for antibiotics. liposomes are small particles consisting of lipid bilayer membranes, which are used to deliver drugs including amphotericin b, more efficiently and with less toxicity. very few cases of allergy to liposomal amphotericin b (lab) have been reported to date. although there is a report on conventional amphotericin b (cab) desensitization, to our knowledge no case of lab desensitization has been described yet. a y/o patient with lymphoma was treated with lab for pulmonary aspergillosis. within minutes of infusion he developed urticaria, hypotension and tachycardia for which he was treated with the appropriate drugs for anaphylaxis. a second attempt to re administer lab resulted in a similar anaphylactic reaction. desensitization to lab was then successfully completed using a modified protocol based on desensitization to cab (jaci ; : - ) : . mg infusion over minutes . mg infusion over minutes . mg infusion over minutes . mg infusion over minutes mg infusion over minutes mg infusion over minutes mg infusion over minutes mg infusion over minutes conclusion: desensitization to lab, a lifesaving drug for invasive fungal diseases, can be performed successfully. adverse events (aes) were recorded throughout the study. therapeutic comparability was defined a priori as a clinical response within % for hfa vs cfc for the primary efficacy measures. results: baseline demographics were similar between treatments for the intent-to-treat population. mean -h baseline symptom scores for nasal stuffiness, nasal discharge and sneezing were . , . and . , respectively, out of a possible score of . all taa-cfc and taa-hfa doses significantly (p< . ) reduced -h, and am and pm -h reflective scores for nasal stuffiness, nasal discharge, sneezing and ni vs placebo (except cfc μg for sneezing). taa-hfa and taa-cfc were statistically comparable (within . and . for the one-sided % confidence interval) at doses of μg and μg for the primary variables of nasal discharge, sneezing and ni for the -h, as well as the am and pm -h reflective assessment, over the -wk period * , * agrawal p , p , , p , p , p , p , p * , p , p , p * p , p , p , p p * finegold, i. * fink p * * sienra monge * , , * so, c. p * soane * , p * staveren, a.m rates of cardiovascular mortality are higher during peak pollen times. (brunkreef, lancet ) . for this reason, mast cell stabilizing agents and leukotriene antagonists are under development for the treatment of myocardial infarction. conversely, ige mediated disease may be protective against sudden cardiac death.(szczeklik, coron art dis ) ar has not been studied in this context. we conducted a retrospective case control pilot study of va patients who were diagnosed with allergic rhinitis and had an acute myocardial infarction. methods:the electronic medical record of a large va hospital was queried for patients diagnosed with an acute myocardial infarction (ami) in the past six years. patients were divided into groups with and without ar. patients with chronic urticaria, asthma, and eczema were excluded from this study. primary outcome was all-cause mortality. secondary outcomes included lv systolic function and peak troponin levels. results: patients were diagnosed with ami, ( %) of which were also diagnosed with ar. patients with and without ar did not differ in terms of age, ethnicity, tobacco status, hypertension, diabetes, or lipid levels. / ( %) patients with ar died, compared to / ( %) control patients, (p-value: . ). ar patients had lower mean peak troponin values ( . vs. . ), but these were not significant. both groups had similar lv function. conclusion: this pilot study suggests an association between allergic rhinitis and a decrease in ami allcause mortality independent of other factors. atopic patients have been shown to have prolonged bleeding times, reduced platelet aggregation, and delayed thrombin generation which can result in delayed clot production. (szczeklik, thromb haem ) possibly, patients in our study diagnosed with allergic rhinitis were more likely to monitor their health symptoms or had physicians who carefully addressed multiple issues. rigorous prospective studies are needed to determine the role of ar in myocardial infarction. purpose and methods. a formulation of olopatadine hydrochloride ophthalmic solution (olopatadine . %) was evaluated in a randomized, placebocontrolled, double-masked, hybrid environmental study intended to determine efficacy and safety in subjects with histories of seasonal allergic conjunctivitis or rhinoconjunctivitis. in this -week trial, subjects regularly assessed their ocular signs and symptoms. additionally, subjects evaluated both the frequency and severity of their nasal symptoms. daily throughout the study, ragweed pollen counts were obtained from each investigative center. repeated measures analysis of variance was used to compare treatment differences in the slopes for nasal symptoms as a function of pollen counts. results. the nasal results are presented herein. specifically, relative to placebo, olopatadine . % significantly reduced the frequency of pollen effects on sneezing (p= . ) and itchy nose (p= . ), and reduced the severity of pollen effects on sneezing (p= . ), itchy nose (p= . ), and runny nose (p= . ). in this study, the most frequent ocular adverse event that was related to therapy with olopatadine . % was ocular dryness, occurring at an incidence of . %. no treatment-related, clinically relevant changes were observed for visual acuity, intraocular pressure, ocular signs, or fundus parameters. conclusion. olopatadine ophthalmic solution, . % is safe, well-tolerated, and effective in reducing some effects of pollen on the nasal symptoms associated with allergic rhinoconjunctivitis. author index key: cord- - mewok l authors: oesterle, tyler s.; kolla, bhanuprakash; risma, cameron j.; breitinger, scott a.; rakocevic, daniela b.; loukianova, larissa l.; hall-flavin, daniel k.; gentry, melanie t.; rummans, teresa a.; chauhan, mohit; gold, mark s. title: substance use disorders and telehealth in the covid- pandemic era: a new outlook date: - - journal: mayo clin proc doi: . /j.mayocp. . . sha: doc_id: cord_uid: mewok l during the current covid- epidemic many outpatient chemical dependency treatment programs and clinics are decreasing the number of in-person patients contact. this has widened an already large gap between patients with substance use disorders (sud) that need treatment and those that actually received treatment. for a disorder where group therapy is the mainstay treatment option for decades, social distancing, shelter in place and treatment discontinuation have created an urgent need for alternative approaches to addiction treatment. in an attempt to continue some care for patients in need, many a medical interventions have transitioned to a virtual environment in order to promote safe social distancing. although there is ample evidence to support tele-medical interventions, these can be difficult to implement especially in sud populations. this article reviews current literature for the use of tele/virtual interventions in the treatment of suds and offers recommendations on safe an effective implementation strategies based on the current literature. we live in an extraordinary time. the covid- (novel coronavirus disease of ) pandemic is a global public health crisis not seen since the influenza pandemic of . social distancing and rigorous infectious disease prevention strategies are the new normal and driving rapid changes in clinical practice. rapid changes and extreme uncertainty resulting from covid- have driven individual fears, grief, and apprehension and a near omnipresent struggle to cope with social isolation, economic tumult and displacement, all of which are all associated with an increase in mental health concerns worldwide. prior to the international public health crisis of covid- , in the united states an epidemic of substance use disorders (sud) had been contributing to an unprecedented rise in deaths of despair from suicide and drug overdoses. in , . million people reported using addictive substances within the past month ( in people or . % of the population) and . million people needed sud treatment. however, only in of those individual ( . %) received treatment due to a significant lack of access to sud providers. there is emerging evidence that the pandemic has worsened substance use and mental health symptoms in the most vulnerable populations. while the need for support is growing, the access to help is diminishing. self-help support options like alcoholics anonymous (aa) and narcotics anonymous (na) have become even less accessible, as most us states have restricted group gathering and social distancing has become the mainstay of infectious disease prevention. many formal group-based sud programs are less accessible in an attempt to mitigate the spread of infection. there is also evidence that with health systems concentrating on covid- patients, access to care for people with sud can be further diminished. emergency rooms, previously, a common first stop for patients seeking help with their sud patients have become less accessible and despite the severity of their condition, patients hesitate to come to the emergency room due to fear of infection. it is now more important than ever j o u r n a l p r e -p r o o f to provide chemical dependency assessment and care through modalities that are safe for the provider and the patient. telehealth, also sometime called telemedicine, is defined as the delivery of health care across a distance using telecommunications technology. telehealth has been shown to improve access to care (especially for rural populations). it can produce similar results to in-person treatment, reduce the burden of travel, and help reduce the perception of stigma. it has been shown to provide substantial patient and provider satisfaction with the delivery of care . , there is also a growing evidence base to support the benefit of telehealth in access to sud related care. although research shows a rapid (approximately -fold), increase in the use of this intervention for sud in the years from to , it still remains underutilized, representing just a fraction of overall tele-psychiatry visits. multiple barriers to the acceptance of tele-mental health services have been identified. these include both patient-based and provider-based factors. however, regulatory barriers have been one of the biggest hindrances so far, including insurance reimbursement and state licensure requirements. in the midst of the pandemic, most of these impediments have been, at least temporarily, removed. on january , , the secretary of health and human services (hhs) declared a public health state of emergency, which included immediate (although temporary) regulatory changes at the federal level. many state legislatures declared similar states of emergency orders which included various measures to loosen restrictions on telehealth. [ ] [ ] [ ] furthermore, department of health and human services office for civil rights (hhs ocr) waived potential penalties for health insurance portability and accountability act (hipaa) violations against health care providers that serve patients in good faith using virtual care technologies, such as facetime or skype. the hhs also announced an easing of practice regulations across state lines "to meet the needs of hospitals that arise in adjoining areas" during the covid- health emergency. the covid- pandemic makes it imperative for clinical practice to adapt rapidly in order to meet patient needs for sud treatment while reducing risk of covid- infection; hence, many providers are now using telehealth for the first time. this manuscript intends to focus on the evidence base for of telehealth services and provides recommendations for evidenced based safely delivered sud focused telehealth visits. the general evidence base for telehealth in medical settings is characterized by significant heterogeneity of study designs, populations, interventions, and outcome measures. , the four most common modes of telehealth in sud treatment programs are computerized assessments ( %), telephone-based recovery support ( %), telephone-based therapy ( %), and video-based therapy ( %). , less utilized tools include texting, smartphone apps, and virtual reality interventions. evidence for each tool will be discussed below. computerized/web-based assessments and treatments with no "live" interaction are the most commonly utilized form of sud virtual intervention; they offer improved ease of access to assessments. these interventions are considered asynchronous (i.e. patients may access them at any time), with the advantage that patients may use them at critical moments in recovery. although there is significant variation in the format, function, and aim of these tools, common features include: screening assessments (e.g. the audit), cognitive behavioral (cbt) modules, motivational therapy sessions, psychoeducation, behavioral skill-building, links to self-help recovery groups, and computerized brief interventions. the majority of studies consistently demonstrate positive effects of these tools in addiction treatment when they focus on the electronic delivery of evidence based strategies . furthermore, these tools demonstrated very few adverse outcomes. for example, in a study of eighty four alcoholic patients, (assessed at , , and months), improvement was noted in the percentage of j o u r n a l p r e -p r o o f days abstinent ( . % to . %), reduced mean drinks per drinking day ( . to . ), and reduced alcohol-related problems. results were similar to traditional face-to-face interventions. notably no safety concerns were identified. however, several reviews of asynchronous online smoking cessation resources show that most programs were of mediocre quality and that the highest quality websites attracted few visitors. this may create risk if individuals are attempting to apply mediocre tools without consulting a physician for advice on quality. further work is needed to determine adequate length (i.e. dose) of treatment, degree of integration needed with traditional treatment, and the sustainability of effects.) [ ] [ ] [ ] telephone-based recovery supports and therapy are the next most commonly used forms of telemedicine. they are labeled as synchronous, requiring real-time contact between patient and clinician. phone calls offer support, link patients to resources, and deliver brief interventions. they are considered minimally resource intensive, in that apart from the capacity to deliver effective brief intervention, cost of infrastructure is low. cost-efficiency however, is limited by lower reimbursement rates which may vary geographically and by payer type. when compared to treatment as usual for alcohol use disorder, the addition of telephone-based services has been shown to improve abstinence rates and reduce binge drinking in the short term but not after the cessation of the interventions examined with no increase in adverse outcomes. current evidence only supports the use of telephonebased telemedicine in continuing care after completion of traditional addiction treatment and may be alcohol specific. , as smartphones and tablets have become ubiquitous over the past decade, the use of synchronous videoconferencing in medical treatment has expanded. according to a systematic review, studies have repeatedly demonstrated that, compared to in-person treatment, videoconferencing for similar modality treatment of suds is no less effective and is associated with significant patient satisfaction and j o u r n a l p r e -p r o o f safety. indeed, the use of videoconferencing for the treatment of alcohol use disorder is associated with reduced drop out, reduced alcohol consumption, higher abstinence rates, and high patient satisfaction compared to treatment as usual. [ ] [ ] [ ] similar results for videoconferencing have been demonstrated for the treatment of opioid use disorder with buprenorphine and methadone. ( ) ( ) ( ) videoconferencing for smoking cessation has also shown similar -month abstinence rates ( %) compared to in-person treatment ( %). several studies support improved one-year retention with videoconferencing compared to in-person treatment, owed partially to the ease of access, perception of reduced stigma, and reduced burden of traveling to appointments. , also owing to the proliferation of smartphones, health care organizations are increasingly utilizing text messages to support health care delivery. most often used as appointment reminders, text messaging has been shown to decrease the frequency of missed appointment. additional texting interventions include craving helplines, automated cbt, relapse prevention skills support, personalized messages delivery based on stage of change, and personalized motivational reminders. importantly, texting interventions can be utilized in vivo at moments of critical decision making. when used for smoking cessation, either as stand-alone treatment or combined with traditional treatment, texting interventions demonstrated improved long-term abstinence rates in rcts with nearly , combined participants. furthermore, a stand-alone texting intervention after an emergency room visit, when compared to controls, demonstrated a reduction in alcohol intake: . fewer heavy drinking days per month and . fewer drinks per drinking day over a three month period. as a simple and cost-effective tool, text messaging is an often underutilized method of supporting sud treatment. smartphone apps and virtual reality are promising new technologies to further improve sud treatment options. rarely out of arm's reach, smartphones represent a nearly continuous opportunity for patients to engage in virtual addiction treatment. smart phone apps represent a rapidly emerging market j o u r n a l p r e -p r o o f attracting the attention of patients, clinicians, and third-party payers. in addition to sharing features with web-based tools (discussed above), apps offer features such as personalized push notifications, direct connections to support persons (i.e. sponsor, family, etc.), in vivo assessments, real-time interventions for cravings, contingency management based rewards and gps-tracking alerting the patient when they approach a high-risk location. such apps have been shown to reduce hazardous drinking and drinks per day. some use predictive modeling to identify patients at high risk for relapse and to deliver personalized interventions. in addition, aa and na have developed free apps that provide a one stop repository for local entities to provide information on location, daily reflections, local meeting guidelines, news etc. although most commonly used as augmentation stratagems to traditional, treatment they appear to be safe ways to enhance skills conducive to maintaining sobriety. virtual reality for sud treatment offers the possibility of both asynchronous and synchronous environments. asynchronous virtual environments are primarily designed to simulate reality for patients to test reactions to environmental cues. by contrast, synchronous virtual worlds allow patients to create digital avatars to interact in real time with peers and clinicians. studies have demonstrated that virtual reality can reliably recreate cravings, although no studies to date have evaluated the effects of a synchronous virtual world in sud treatment. apart from the lack of evidence, these virtual worlds can cost up to $ , -a prohibitive cost for most treatment centers. despite evidence supporting its safe use of all the a for mentioned modalities , there remain limitations many patients with suds have relied upon intrapersonal, face-to-face interactions that may be disrupted by the fluidity of virtual interactions; many may not have reliable phone service or internet access and some lack basic necessities. a analysis showed that < % of sud treatment centers had adopted telemedicine technologies. surveys show clinicians tend to be most concerned about patient outcomes, work efficiency due in part to the implementation of new technology, and reimbursement. widespread implementation of telemedicine has also been hindered by complex reimbursement and regulatory barriers at the state and federal levels. many telemedicine products are now being marketed directly to third-party payers in order to alleviate reimbursement concerns. additionally, patients remain concerned about their privacy in a digital world, and health care organizations must carefully evaluate prospective technology to ensure products meet privacy/security requirements. although most physicians do not provide or facilitate psychosocial interventions, it is important to understand that these treatments are perhaps even more important during viral pandemic restrictions. there is a substantial body of literature supporting the efficacy of both individual and group-based behaviorally oriented treatment components and self-help group intervention in patients with sud. understandably, many patients and providers have concerns about whether video based interactions can provide the same quality of interaction as in person treatment. a number of studies have shown group based treatment by videoconference, both support groups and treatment groups, including those targeting tobacco, alcohol and opioid use disorders have been shown to provide safe intervention, high patient satisfaction and appear to have similar outcomes to in person treatments. , a few studies of group treatment by videoconference (in ptsd and with inmates) have indicated there may be a reduction in patient reported group cohesion and treatment alliance. unfortunately, few studies of group based video treatment have directly assessed specific group therapy process outcomes. nonetheless, virtual groups are a practical alternative to face-to-face treatment limited due to social distancing. patients should be encouraged to participate in virtual -step and other self-help meetings, obtain an on-line sponsor or maintain a virtual connection with their current sponsors. additional care and preparation should be taken regarding safety planning for medical or psychiatric emergencies j o u r n a l p r e -p r o o f during the course of group treatment. , additional research is needed to explore potential limitations of video group treatment, particularly in the area of sud treatment. there is a substantial body of literature supporting the efficacy of face-to-face treatment modalities in helping improve addiction related outcomes and overall symptom burden in patients with sud. general recommendations for a mental health focused primary care telehealth visit based on best practice guidelines include: a quiet space with good lighting, an uncluttered and professional looking environment (home or office). perhaps most importantly an adequate transmission speed and bandwidth of (at least kbps) are needed for videoconferencing. good transmission speed is especially important in behavioral health visits in order to support the detection of facial cues and to prevent fragmented movement because decreased ability of a provider to recognize nonverbal cues can adversely affect rapport building. if possible, the camera should be positioned at eye level as this will what standard of care may mean in this setting, and require creative thinking to address. vital signs and physical exams are difficult to do virtually but despite these limitations even predominantly physical medical complaints like sore throats can be safely assessed without these portions of the visit. observational parts on the physical exam certainly could still be performed and recorded. for a rough assessment of vital signs, patients could procure and use home-based tools (for example, automated electronic blood pressure monitoring cuff, thermometer etc.) at some addition cost. the main goal of the urine drug screen is to objectively assess for substance use. even during restrictions related to the pandemic, most patients are able to access labs where they could provide a urine sample. however, there are also many remote options for monitoring substance use that could be utilized, including oral j o u r n a l p r e -p r o o f fluid and hair analysis in select cases. however, there is high risk for tampering with unobserved collection methods outside of the clinic. observed oral fluid testing for example has been integrated into apps where the patients are observed placing their fluids into the testing cups; other methods of monitoring have been utilized within the criminal justice system. , all of these have their relative strengths and weaknesses and considering urine drug screens performed in certified labs are likely to be the only option reimbursed by most insurance companies, they remain the modality of choice. intoxication/withdrawal during the interview can be assessed by clinical observation and utilizing instruments such as ciwa for alcohol or cows for opioids. home monitoring kits (for example bluetooth enabled breathalyzer) can also be utilized to assess for acute intoxication but these are not widely available for most patients. intoxication with the potential for overdose can be particularly challenging and sometimes difficult to assess remotely. if this is at all suspected then immediate use of emergency services (i.e., local to the patient) would be extremely important. while the covid- public health emergency lasts, urine testing for buprenorphine treatment does not have to be a mandatory part of the treatment. in areas where access to laboratory services are difficult the clinician can consider pausing urine drug testing in clinical practice if they consider the patient at low risk for substance use and restart when patients are able to access laboratory services again. some strategies for risk reduction in a situation where frequent and optimal urine drug monitoring is not feasible include: patient education regarding the risks of overdosing, more frequent clinical encounters, prescribing smaller quantities of medications, prescribing naloxone for individuals on opioid agonist medications and training the patient and any family members engaged with the patient's care to use naloxone. there are many unique features and considerations for providing effective telehealth j o u r n a l p r e -p r o o f visits to sud patients (see table ) and an important research opportunity exists to build a deeper evidence base for best practices in this domain. conducting telehealth medication assisted treatment visits for opioid use disorders represents a unique challenge. prescribing controlled substances like buprenorphine for patients seen exclusively via virtual visits was previously restricted but is possible with temporary emergency legislative changes during the covid- pandemic. however, methadone still requires in-person visits for induction. medications for opioid use disorder (oud) require the greatest supervision and observation due to the risk of misuse and diversion. , , , for new patients seen via telehealth with oud, buprenorphine has advantages over methadone or injectable naltrexone. buprenorphine allows greater prescribing flexibility, and a better safety profile than methadone (greater risk of overdose early in induction, concern for stacking with other opioids, need for lab workup and ecg monitoring). injectable naltrexone requires an office visit which can pose difficulty because of social distancing recommendations but typically can be done quite safely with the appropriate protective equipment. as noted previously, outpatient induction of controlled substances like buprenorphine is currently permissible even if the patient does not have a face-to-face evaluation with the provider. similarly, it became possible to refill a buprenorphine prescription for a patient that has previously not been seen in office, but only via telehealth. . home induction of buprenorphine via a telehealth visit should follow most of the steps that this process would entail during an in office visit (see table )( ) ( ) j o u r n a l p r e -p r o o f to-face evaluation is still needed for methadone induction, however in light of the covid pandemic more flexible take home dosing is possible. the covid- pandemic has brought on unprecedented challenges for the health care system generally, as well as specific challenges for patients coping with suds. fortunately, for patients with internet and wifi access, federal and state agencies have rapidly responded to the crisis by loosening restrictions on telehealth to provide much needed medical care. this has been a necessary and vital step in providing needed services, but presents many challenges for patients and providers. we do not yet fully understand the ramifications of the rapid switch to virtual medical visits. some patients may benefit tremendously by coming to the clinic, meeting with the counseling staff, sharing experiences with other patients in treatments, taking mats, giving a urine test, and getting encouragement and feedback, while other patients may appreciate the convenience of virtual options. many providers have been ill prepared to launch a telehealth practice, often over the course of just a few days leading to a significant delay or potentially even termination in their patient contact. although there are many available resources to guide clinicians in providing a safe and effective video based practice, this is not a substitute for more organized and well-designed training programs. furthermore, these landmark regulatory changes may well be temporary which fuels further uncertainty. this time of crisis has forced a tremendous leap forward in the use of technology to improve quality of care and access to services for patients with suds. telemedicine is a good and required response to the crisis, but its value in the provision of clinical care in post-pandemic healthcare systems will be different depending on unique features of the health systems where it is applied. telemedicine is one means of delivering healthcare and must be contextualized-and perhaps used in conjunction with in-person j o u r n a l p r e -p r o o f and/or asynchronous care delivery-to solve specific care delivery challenges. more randomized trials of in-clinic vs telemedicine will be necessary to evaluate short and long-term outcomes for patients with suds, evaluating retention, overdose, concurrent illness, emergency room visits, urine test results, and return to premorbid function. treatment of suds without independent evaluation of outcomes such a urine testing or interviews with employer, partner, and friends is difficult to evaluate. many longitudinal outcome studies have allowed researchers to look at which aspects of sud treatment patient have deemed most helpful to their recovery. of the various components, group treatment and sharing, was at the top of the list. it is possible but hard to imagine virtual meetings being as compelling over the long term where in-person care may be a viable option. greater implementation experimentation with potential combinations of in-person, asynchronous, and telemedicine options may help define optimal structure of care delivery and clinical communication. telehealth during the covid- crisis is reimbursed at the same rates as in-person care, but may not be reimbursed at these rates going forward. it remains unclear whether the broad capability to provide telehealth without previous restrictions imposed by government and private payers and state licensure will continue beyond the immediate covid crisis period. however, as patients and providers quickly adapt to these new options for treatment, it is likely that telehealth will only continue to be a large component of the health care system overall. it is essential that all health care providers become competent in the use of telehealth including video visits. tele-behavioral health competencies have been developed and should be systematically implemented in training programs across medical disciplines. health care systems and regulatory agencies will need to continue to work together to solve challenges in using telehealth to optimize treatment for individuals with substance use disorders. table j o u r n a l p r e -p r o o f updating the accounts: global mortality of the - " spanish" influenza pandemic generalized anxiety disorder, depressive symptoms and sleep quality during covid- outbreak in china: a web-based cross-sectional survey covid- : the hidden impact on mental health and drug addiction facing addiction in america: the surgeon general's report on alcohol, drugs, and health [internet]: us department of health and human services mental health, substance use, and suicidal ideation during the covid- collision of the covid- and addiction epidemics the role of alcohol, drugs, and deaths of despair in the us's falling life expectancy. missouri medicine the new england journal of medicine best practices in videoconferencing-based telemental health a framework for telepsychiatric training and e-health: competency-based education, evaluation and implications telemedicine-delivered treatment interventions for substance use disorders: a systematic review how is telemedicine being used in opioid and other substance use disorder treatment? health aff (millwood) online recovery resources provided by hpsp trump administration releases covid- medicare tele-medicine healthcare provider fact sheet the role of technology-based interventions for substance use disorders in primary care: a review of the literature telemedicine interventions for substance-use disorder: a literature review use of telemedicine in addiction treatment: current practices and organizational implementation characteristics trends in telemedicine use in addiction treatment mobile technology-based interventions for adult users of alcohol: a systematic review of the literature a web application for moderation training: initial results of a randomized clinical trial a list of the most popular smoking cessation web sites and a comparison of their quality computerized behavior therapy for opioiddependent outpatients: a randomized controlled trial overcoming addictions, a web-based application, and smart recovery, an online and in-person mutual help group for problem drinkers, part : six-month outcomes of a randomized controlled trial and qualitative feedback from participants the drinker's check-up: -month outcomes of a controlled clinical trial of a stand-alone software program for problem drinkers extending residential care through telephone counseling: initial results from the betty ford center focused continuing care protocol extended telephonebased continuing care for alcohol dependence: -month outcomes and subgroup analyses a brief behavioral telehealth intervention for veterans with alcohol misuse problems in va primary care. drug and alcohol dependence metelemedicine: a pilot study with rural alcohol users on community supervision effectiveness of optional videoconferencing-based treatment of alcohol use disorders: randomized controlled trial telehealth-delivered group smoking cessation for rural and urban participants: feasibility and cessation rates the effectiveness of telemedicine-delivered opioid agonist therapy in a supervised clinical setting. drug and alcohol dependence the effectiveness of mobile-health technologies to improve health care service delivery processes: a systematic review and meta-analysis text messaging for addiction: a review text-message-based drinking assessments and brief interventions for young adults discharged from the emergency department examining perceptions of a smartphone-based intervention system for alcohol use disorders results of a pilot test of a self-administered smartphonebased treatment system for alcohol use disorders: usability and early outcomes predictive modeling of addiction lapses in a mobile health application center for connected health policy. state telehealth laws and reimbursement policies report the asam principles of addiction medicine evidence for telehealth group-based treatment: a systematic review a framework of interprofessional telebehavioral health competencies: implementation and challenges moving forward the effectiveness of residential treatment services for individuals with substance use disorders: a systematic review. drug and alcohol dependence variation in quality of urgent health care provided during commercial virtual visits extended-release injectable naltrexone for opioid use disorder: a systematic review validity of transdermal alcohol monitoring: fixed and self-regulated dosing sweat testing for heroin, cocaine, and metabolites caring for patients during the covid- pandemic. asam covid- task force recommendations telehealth tip sheet. pcss faq-treating opioid use disorder via telehealth tips for primary care providers alcoholics anonymous and other -step programs for alcohol use disorder home buprenorphine/naloxone induction in primary care unobserved "home" induction onto buprenorphine • start with a visit to establish • dsm diagnosis • complete history of substance use • full medical, social and psychiatric history • evaluate for current depression or suicidal thoughts (si) • pmp review • provide medications for breakthrough withdrawal symptoms targeting insomnia, nausea, muscle aches, abdominal cramping • warn patient of precipitated withdrawal • the initial prescription should be sufficient for the patient to complete the induction phase, stabalize and return in week or less • most patients will stabilize on - mg of buprenorphine • after hours clinical contact information must be provide to address questions or concerns • it is always a good practice to provide patients with oud a prescription for naloxone kit. table j o u r n a l p r e -p r o o f key: cord- - dltsav authors: trovik, linn hereide; sandnes, miriam; blomberg, bjørn; holmaas, gunhild; ahmed, aymen bushra; tvedt, tor henrik anderson; vintermyr, olav; reikvam, håkon title: hemophagocytic lymphohistiocytosis and miliary tuberculosis in a previously healthy individual: a case report date: - - journal: j med case rep doi: . /s - - -x sha: doc_id: cord_uid: dltsav background: hemophagocytic lymphohistiocytosis (hlh) is a rare heterogenous genetic or acquired hyperinflammatory syndrome associated with a high degree of morbidity and mortality. hlh has clinical manifestations related to abnormal prolonged activation of t lymphocytes and macrophages with an excess of proinflammatory cytokines. the main causes of secondary hlh are malignancies and infectious diseases. case presentation: the patient was a -year-old man, originally from eastern africa, who had lived in northern europe for years. here we describe the clinical features, laboratory parameters, diagnostic workup, management and outcome data of a previously healthy -year-old man diagnosed with hlh secondary to tuberculosis. the patient was initially treated for a community-acquired pneumonia. he developed multiorgan failure with acute respiratory distress syndrome, hypertransaminasemia, and kidney and bone marrow dysfunction. the clinical course together with a simultaneous increase in serum ferritin raised the suspicion of hlh. the patient fulfilled seven out of eight diagnostic criteria for hlh. a thorough diagnostic workup with respect to hlh and a potential underlying disease was initiated. cultivation of bronchoalveolar lavage fluid, stool and urine, and polymerase chain reaction of epithelioid cell granulomas in the bone marrow were all positive for mycobacterium tuberculosis. he was treated for both hlh and tuberculosis, and he survived without any sequelae. conclusions: we present one of few published cases of a patient who survived hlh triggered by miliary tuberculosis. the current case illustrates the need for awareness of these two diagnoses, and the timely initiation of specific and supportive treatment to reduce mortality. hemophagocytic lymphohistiocytosis (hlh) is an uncommon hematologic disorder characterized by an uncontrolled immune response with organ infiltration of lymphocytes and histiocytes, and organ damage caused by excessive production of pro-inflammatory cytokines [ ] [ ] [ ] [ ] [ ] [ ] . hlh is categorized either as primary due to a genetic disorder, or as secondary due to an acquired condition. secondary hlh can be triggered by neoplastic and non-neoplastic diseases [ ] . malignancies associated with secondary hlh are mainly various hematological malignancies such as leukemia or lymphoma, whereas autoimmune disorders and infectious diseases are the most common nonmalignant diseases associated with hlh [ , ] . while active tuberculosis (tb) is rare in the nordic countries, the world health organization estimates million new tb cases globally causing . million deaths every year, thus making mycobacterium tuberculosis the single most lethal infectious agent in the world [ , ] . hlh due to tb is very uncommon, with only a few cases reported, mostly in immunocompromised patients [ , [ ] [ ] [ ] . here we report a case of hlh associated with miliary tb in an apparently immunocompetent healthy man. the case illustrates that the combination of an aggressive diagnostic approach, searching for a broad variety of disorders, combined with an early therapeutic intervention are crucial to securing a successful outcome. the patient was a -year-old man, originally from eastern africa, who had lived in northern europe for years. apart from increased blood pressure, causing mild left ventricle hypertrophy, he was healthy and only taking antihypertensive medication. he contacted his family physician due to nausea and loose, yellowish stools. due to dysuria and microhematuria, he had received treatment with orally administered mecillinam for a suspected urinary tract infection. as this treatment had no effect, he was given doxycycline on suspicion of respiratory tract infection due to dyspnea and fever. eventually, he was admitted to the hospital after days of nausea, anorexia, diarrhea, frequent micturition, dyspnea, persistent fever, increasing c-reactive protein (crp) and elevated liver transaminases. he had no cough, night sweats or weight loss. on clinical examination on admission, he was alert and oriented, but hypotensive (blood pressure / mmhg) and hypoxic with spo of % without supplemental oxygen. the responsible clinician described mild scleral jaundice, but no rashes or palpable adenopathy. pulmonary auscultation revealed bilateral crackles. laboratory test values showed hemoglobin level of . (fig. ) . he had severely reduced partial pressure of oxygen in arterial blood to the inspired oxygen ratio (pao /fio ) at . kpa (ref - ) (fig. ) . computed tomography (ct) scan revealed ground-glass opacities in both lungs, extensive unspecific changes in the colon, multiple enlarged paraaortic lymph nodes, fat tissue reaction in the posterior abdominal wall (fig. ) , an enlarged liver at cm in the midclavicular line with rounded margins, and a slightly enlarged spleen at cm. on admission, the clinical presentation was not clearcut, and the attending clinician considered the possibility of viral or bacterial infections, including pneumonia (fever, dyspnea, auscultatory crackles), possibly due to atypical agents, as well as urinary tract infection, hepatitis, intra-abdominal infection, gastroenteritis with ensuing hemolytic uremic syndrome, and a variety of noninfectious diseases including renal failure due to dehydration, vasculitis, other systemic diseases, heart failure and thromboembolism. broad-spectrum antibiotic (piperacillin-tazobactam) was started to cover for bacterial infection of unknown origin. no clinical improvement was observed the following week, and due to increasing respiratory failure, he was transferred to the nearest regional university hospital for bronchoscopy and further diagnostics. piperacillin-tazobactam was given from admission and meropenem from day , with the addition of azithromycin from day for a suspected bacterial etiology, but without any clinical or biochemical improvement. he developed increasing respiratory failure that required noninvasive ventilation from day , and progressive hypoxemia necessitated intubation at day . continuous renal replacement therapy was initiated from day due to increasing kidney failure as evidenced by decreasing diuresis, metabolic acidosis and increasing serum creatinine levels (figs. , ) . despite lung protective ventilatory support, the pao /fio rapidly deteriorated (fig. ) . on day after admission, the attending clinicians started treatment with high dosages of corticosteroids to cover for a possible autoimmune etiology. at this point, the diagnostic assessment had not revealed the cause of the severe clinical course. standard workup for infectious diseases with culturing of blood, urine and stools did not reveal the etiology. serological tests for human immunodeficiency virus (hiv) and hepatitis a and b were all negative. serology revealed prior but not active infection with epstein-barr virus (ebv) and cytomegalovirus (cmv). since the patient had been back in his homeland year prior to hospitalization, tropical infectious diseases with long incubation time were considered. with fever, pancytopenia and splenomegaly, he displayed the cardinal signs of visceral leishmaniasis, but microscopy of blood and bone marrow aspirate did not reveal visible leishmania amastigotes, serology was negative and polymerase chain reaction (pcr) of blood could not detect leishmania dna. serology for strongyloides was also negative. considering the febrile illness with pulmonary opacities, respiratory failure and subacute deterioration of multiple organ systems, miliary tb was recognized as a possible diagnosis. interferon gamma release essay (igra, quantiferon ® ) taken at admission was positive at a medium level at . iu/ml. upon transfer to the regional hospital, a new igra test was taken with negative/inconclusive results, with a value of . iu/ml, and a repeat test showed a gray zone result of . iu/ml (reference values negative < . , gray zone . - . , low positive . - . , medium positive . - . , strong positive ≥ . ). no immunosuppressive treatment had been given at this point. direct microscopy of bronchial fluid obtained by bronchoscopy did not show acid-fast bacilli, and pcr on the same specimen was negative for mycobacterium tuberculosis. however, these findings could not exclude tb infection. therefore, the patient was given therapy with rifampicin and isoniazid intravenously, and pyrazinamide on nasogastric tube, against possible tb infection at the same time as steroids were started. intravenous levofloxacin was added to cover for other potential bacterial infections. although levofloxacin also has antimycobacterial properties, it is not part of standard first-line anti-tb treatment. an exceptionally rapid improvement of the respiratory failure was seen after initiating treatment with high dosage of steroids and tuberculostatic drugs (fig. ) . the kidney failure continued, however, and the bone marrow failure was worsening, with rapidly decreasing thrombocyte and white blood cell count (wbc) (fig. ). since admission, the patient had persistent fever, increasing levels of serum ferritin to a maximum value of , µg/l (ref - ), splenomegaly and increasing pancytopenia, in addition to hypertriglyceridemia with serum triglycerides of . mmol/l (ref . - . ). based on these clinical and laboratory findings, a diagnosis of hlh was suspected (table ) . two weeks after admission, blood tests were analyzed for soluble il- receptor and natural killer (nk)-cell activity, and bone marrow biopsy was performed. an eliciting cause for hlh was sought. tests for antinuclear antibody (ana) and antineutrophil cytoplasmic antibody (anca) were both negative. immunophenotyping of bone marrow showed no evidence of lymphoproliferative diseases with t-or b-cell clonality. lymphadenopathy of the posterior abdominal wall and wall thickening of the colon seen on ct scan at admission disappeared after initiation of corticosteroid therapy, and biopsy was no longer possible. at day , the patient fulfilled five out of eight diagnostic criteria for hlh (fever, splenomegaly, bi-cytopenia, hypertriglyceridemia and hyperferritinemia), and treatment with etoposide mg/m was initiated according to the hlh- protocol [ ] , although with % dose reduction due to cytopenia and hyperbilirubinemia, and without cyclosporine a (fig. ). over the next days a rapid improvement of the kidney function, decrease in serum ferritin levels and improvement of the general condition were observed (fig. ) . all anti-tb drugs were discontinued, as all tests for tb apart from the interferongamma release assay remained negative, and tb was considered less likely. levofloxacin was continued. three weeks after admission, however, culture of bronchial fluid, stool and urine revealed m. tuberculosis and was also positive on the antigen mpt assay, confirming the diagnosis of tb. results from bone marrow biopsy later revealed an expanded erythropoiesis, increased number of histiocytic cells with phagocytosed lymphocytes and nuclear debris (hemophagocytosis) and granulomas that supported the diagnosis of hlh and tb, respectively (fig. ) . the bone marrow was also later found to be positive for m. tuberculosis by pcr. level of il- receptor was increased to , u/ml (ref - ), and nk-cell [ ] . miliary tb was regarded as the triggering factor. the tb isolate was likely susceptible to rifampicin and isoniazid, the most important first-line anti-tb drugs, as line-probe assay (genotype mtbdrplus, hain lifescience) showed no mutations conveying resistance to rifampicin or isoniazid in the rpob, katg and inha genes. thus, the patient received standard anti-tb treatment with rifampicin, isoniazid, pyrazinamide and ethambutol, in the form of four-drug fixed-dose combination tablets (fdcs) [ ] . treatment of secondary hlh is directed against the underlying disease; however, initial treatment with steroids and/or immunosuppressants is usually required to prevent rapidly progressing organ damage and death. etoposide was discontinued after weeks due to increasing cytopenia, while steroids were continued with tapering doses every days over a -week period (fig. ) . towards the end of the hospital stay the patient received days of additional treatment with intravenously administered ceftriaxone, due to a febrile condition probably related to neutropenia (neutrophils at . /l). his general clinical condition was rapidly improving, and after month of hospitalization he was discharged with biochemical recovery including decreasing serum ferritin. in light of the severe initial disease, the initial-phase anti-tb-treatment with fourdrug fdcs was extended for a total of months, and the subsequent continuation-phase treatment with two-drug fdcs containing rifampicin and isoniazid was given for months, for a total treatment duration of months. on subsequent outpatient visits, the patient's condition has continuously improved, and he is currently without any sequela or signs of active disease. hlh is a life-threatening immune syndrome caused by the massive production of cytokines due to a highly stimulated but ineffective immune response. the pathogenesis of hlh is complicated and not completely understood, but secondary hyperactivation of macrophages and cd + t lymphocytes in the absence of regulatory nk cell activity seems essential. this results in the massive production of proinflammatory cytokines that directly provokes end organ damage [ ] [ ] [ ] [ ] [ ] [ ] . the diagnosis of hlh is challenging and can often be overlooked or delayed. as no single diagnostic test exists, the diagnostic criteria applied in the hlh- trial are currently used to diagnose hlh (table ). hyperferritinemia is often the first clue to the diagnosis. although the diagnostic criteria consider ferritin > µg/l as diagnostic, the ferritin levels are often considerably more elevated [ ] , as was the case for our patient presenting with serum ferritin increasing to > , µg/l. if additional cytopenias are present, involving at least two lines, this should clearly raise the clinical suspicion of hlh. our patient developed thrombocytopenia and anemia, which led to further investigation for suspected hlh. fasting hypertriglyceridemia and/or hypofibrinogenemia can also quite easily be detected, while assays for soluble il- receptor and nk cell activity are often not readily available in standard hospital laboratories. a biopsy demonstrating hemophagocytosis is of considerable help, as in our patient (fig. ) . bone marrow biopsies are easily obtained, and mandatory to rule out secondary causes of hlh such as underlying malignant disorders or visceral leishmaniasis. the etiology of hlh can be categorized as primary and secondary causes ( table ). primary hlh is very rare in adults and is caused by loss of function in genes associated with vesicle trafficking in cytotoxic t and/ or nk cells [ ] . this results in reduction or loss of the cytotoxic potential in nk and t cells, and inability of the immune system to sufficiently eliminate activated macrophages [ , ] . although primary hlh is caused by an underlying genetic immunodeficiency, clinical presentation is usually triggered by a viral infection, most commonly ebv [ ] . secondary hlh can be triggered by both malignant and nonmalignant diseases ( table ) [ ] . malignant disorders often associated with secondary hlh include hematological malignancies such as lymphoma, acute leukemias and myelodysplastic syndrome, but the syndrome has also been observed in relation to solid tumors [ ] . the nonmalignant conditions associated with hlh can be broadly divided into autoimmune disorders and infectious diseases. among autoimmune disorders we find diseases such as systemic lupus erythematosus (sle), systemic-onset juvenile idiopathic arthritis (still's disease) and rheumatoid arthritis. the most common infections reported to be associated with hlh include ebv, leishmaniasis, cmv, hiv and fungal infections [ ] , and most recently sars-cov- [ ] . the association between tb and hlh has been described previously. however, most of the cases described are in immunocompromised patients, including patients with concomitant malignant disorders, hiv, patients on hemodialysis and renal transplant recipients [ ] . diagnosis of pulmonary tb is rapid and straightforward when acid-fast bacilli can be seen on direct microscopy. however, negative microscopy does not rule out tb. extrapulmonary tb is particularly challenging to diagnose, as direct microscopy and pcr have low sensitivity on specimens such as pus, cerebrospinal fluid, biopsies and lymph nodes. although tb bacteria are present throughout the lungs in miliary tb, the majority of these patients have no visible acid-fast bacilli on sputum microscopy. as in our case, definitive diagnosis of microscopy-negative tb relies on a culture for m. tuberculosis, which may take up to - weeks to become positive. while pcr has high specificity and can rapidly identify m. tuberculosis, its sensitivity is far inferior to culture. the classical description of miliary tb is that of hematogenous seeding occurring successively after primary infection and resulting in millet-like grains in various organs, including the lungs, where these grains result in typical findings on chest x-ray. pathological examination typically shows granulomas, as was found on the bone marrow specimen from our patient, and is highly suggestive of the diagnosis. the term cryptic miliary tb is sometimes used to describe similar seeding occurring later in conjunction with reactivated tb ("post-primary" tb), and tending to affect older individuals, often without typical x-ray findings. a third form, nonreactive tb, describes widespread seeding of tb where there is dysfunctional immune response, allowing the bacteria to spread without formation of granulomas, and frequently without "miliary" characteristics on chest x-ray. nonreactive tb often occurs in immunocompromised patients, including hiv patients with low cd (cluster of differentiation ) counts. the term disseminated tb is often used interchangeably with miliary tb, but sometimes reserved for nonreactive tb or widespread tb without typical miliary findings on chest x-ray. the patient's origin in a tb-endemic region suggested that he suffered from cryptic miliary tb due to reactivation many years after primary infection. nonreactive tb was unlikely, as he had granuloma formation on pathological examination, and no underlying immunosuppression could be found. the national reference laboratory for mycobacteria (nrl) at the norwegian institute of public health performed phenotypical drug susceptibility testing using the bac-tec mgit system (becton dickinson, nj, usa), confirming susceptibility to all primary anti-tb drugs, as well as relatedness analysis with comparison to isolates from patients diagnosed with tb in norway during the last years. interestingly, miru-vntr (mycobacterial interspersed repetitive unit-variable number tandem repeat) typing first suggested that the isolate could be related to one obtained from a patient diagnosed with tb in norway years earlier, consistent with relatively recent primary infection causing classic miliary tb. however, whole-genome sequencing (on an illumina platform) excluded relatedness to this isolate (in-house methodology), supporting the initial theory of cryptic miliary tb caused by reactivation decades after primary infection. diagnostics of tb-triggered hlh is particularly challenging, as hlh and miliary tb have several features in common, particularly fever, splenomegaly and anemia, but also lymphopenia, thrombocytopenia and elevated ferritin. while anemia is seen in most miliary tb patients, only up to one quarter have lymphopenia or thrombocytopenia as well [ ] . thrombocytopenia in tb can result from immune-mediated destruction, hypersplenism and infiltration of the bone marrow [ ] . while ferritin is usually moderately increased in tb, values in excess of , ng/ml have been described in miliary tb [ ] . our patient's symptoms and findings coincided with the multiple sites from which m. tuberculosis was recovered, but could also represent organ damage due to hlh. hence pollakiuria and renal failure could be due to affection of kidneys and the urinary tract, history of diarrhea, colonic changes and abdominal fat tissue reaction on ct due to affection of the intestines, and notably, dyspnea, pulmonary crepitation, respiratory failure and ground-glass opacities on ct due to affection of the lungs. the bone marrow biopsy confirmed evidence of both hemophagocytosis and tb. the pathophysiology of hlh related to tb is mainly unknown. phagocytosis of m. tuberculosis by macrophages, and hence th -mediated cytotoxicity, followed by release of a large quantity of cytokines and chemokines are probably involved [ ] . hlh due to tb has a high mortality rate, and most reports describe fatal outcome, particularly if other complicating factors are present [ , , ] . the treatment of hlh is challenging, and simultaneous immunosuppressive treatment for hlh combined with specific treatment of the underlying condition is necessary [ ] . given the rarity of the disease, few studies describing treatment alternatives exist. in most treatment regimens, etoposide is combined with corticosteroids [ , , ] . the greatest obstacle to a successful outcome for individuals with hlh is a delayed diagnosis. as soon as the diagnosis is suspected or confirmed, treatment should be initiated. the major aims for hlh therapy are to suppress the life-threatening inflammation and to treat the underlying cause. therapy based on the hlh- and hlh- protocols consists of a series of weekly treatments with corticosteroids and etoposide, with the addition of intrathecal methotrexate and hydrocortisone for those with central nervous system (cns) involvement ( , ) . for patients with an underlying infection, treatment of the triggering condition should be initiated simultaneously, as treatment of the trigger has the potential to remove the stimulus for immune activation. for the current case, the underlying condition, tb, was treated with rifampicin, isoniazid, pyrazinamide and ethambutol. however, in the case of tb-triggered hlh, it is particularly challenging that the immunosuppressive treatment indicated for hlh can severely exacerbate the course of tb. in the absence of tuberculostatic drugs, the treatment for hlh would have impaired the patient's immunity to an extent that could result in fulminant, disseminated tb. beyond this rare situation of hlh, miliary tb should always be considered before instituting immunosuppressive treatment for febrile illnesses of suspected immunological genesis. while treatment for tb was critical for the survival of the patient, therapy against hlh seemed appropriate as well, and in accordance with generally accepted treatment algorithms. this is supported by the fact that our patient had an improvement of his respiratory failure after treatment with steroids and anti-tb drugs was initiated, but only had improvement in his kidney and bone marrow failure after etoposide was added. to conclude, tb-associated hlh is an exceedingly rare condition, but should be considered for patients with risk factors for tb presenting with severe signs of organ failure, and clinical or laboratory findings consistent with hlh. the incidence of tb is declining globally, but it is still highly endemic in some countries. awareness of hlh as a complication of tb and other chronic infectious diseases such as hiv, leishmaniasis and hepatitis is important for early diagnosis and adequate management. pathophysiology and epidemiology of hemophagocytic lymphohistiocytosis how i treat hemophagocytic lymphohistiocytosis in the adult patient hemophagocytic syndromes-an update how i treat primary haemophagocytic lymphohistiocytosis diagnostic evaluation of patients with suspected haemophagocytic lymphohistiocytosis hypomorphic mutations in prf , munc - , and stxbp are associated with adultonset familial hlh hemophagocytic lymphohistiocytosis: clinical presentations and diagnosis reactive hemophagocytic syndrome in adults: a retrospective analysis of patients global epidemiology of tuberculosis and progress toward achieving global targets- geneva: world health organization tuberculosis-associated haemophagocytic syndrome causes, clinical symptoms, and outcomes of infectious diseases associated with hemophagocytic lymphohistiocytosis in taiwanese adults epidemiology and treatment outcome of mdr and pre-xdr tb in international migrants at two reference centers in the north of italy: a cross-sectional study coordinated by stop tb italia onlus hlh- : diagnostic and therapeutic guidelines for hemophagocytic lymphohistiocytosis. pediatr blood cancer the rationale for recommending fixed-dose combination tablets for treatment of tuberculosis recommendations for the management of hemophagocytic lymphohistiocytosis in adults perforin gene defects in familial hemophagocytic lymphohistiocytosis failed ctl/nk cell killing and cytokine hypersecretion are directly linked through prolonged synapse time hemophagocytic lymphohistiocytosis: pathogenesis and treatment histiocytic disorders: recent insights into pathophysiology and practical guidelines convenient online submission • thorough peer review by experienced researchers in your field • rapid publication on acceptance • support for research data, including large and complex data types • gold open access which fosters wider collaboration and increased citations maximum visibility for your research: over m website views per year • at bmc, research is always in progress. learn more biomedcentral.com/submissions ready to submit your research ready to submit your research ? choose bmc treatment outcomes and prognostic factors in adult patients with secondary hemophagocytic lymphohistiocytosis not associated with malignancy a consensus review on malignancy-associated hemophagocytic lymphohistiocytosis in adults covid- : consider cytokine storm syndromes and immunosuppression high serum ferritin concentration in an aids patient with miliary tuberculosis immune thrombocytopenia secondary to tuberculosis: a case and review of literature tuberculosis-associated hemophagocytic lymphohistiocytosis with initial presentation of fever of unknown origin in a general hospital: an analysis of clinical cases hlh associated with disseminated tuberculosis confirmed efficacy of etoposide and dexamethasone in hlh treatment: long-term results of the cooperative hlh- study etoposide selectively ablates activated t cells to control the immunoregulatory disorder hemophagocytic lymphohistiocytosis chemoimmunotherapy for hemophagocytic lymphohistiocytosis: long-term results of the hlh- treatment protocol publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations we thank paul christoffer lindemann and the department of microbiology and immunology, haukeland university hospital, for permission to use the results of microbiological analyses. we are grateful to anne torunn mengshoel, national reference laboratory for mycobacteria, norwegian institute of public health, for assistance with analysis and interpretation of data from phylogenetic studies and drug susceptibility testing. all health care workers involved in the treatment of the patient are acknowledged. lt initiated the work, treated the patient, and wrote and edited the manuscript; ms wrote the manuscript and was responsible for the layout; bb initiated the work, treated the patient and wrote the manuscript; gh treated the patient and contributed with scientific considerations; abb treated the patient and contributed with scientific considerations; that treated the patient and contributed with scientific considerations; ov was responsible for pathological diagnostics and contributed with scientific considerations; hr initiated and coordinated the work, created the figures, and wrote and edited the manuscript. all authors read and approved the final manuscript. none. not applicable. written consent was obtained from the patient. written informed consent was obtained from the patient for publication of this case report and any accompanying images. a copy of the written consent is available for review by the editor-in-chief of this journal. the authors declare that they have no competing interests. key: cord- -i r bv p authors: hon, kam lun; leung, karen ka yan; leung, alexander kc; qian, su yun; chan, vivian py; ip, patrick; wong, ian ck title: coronavirus disease (covid- ): latest developments in potential treatments date: - - journal: drugs context doi: . /dic. - - sha: doc_id: cord_uid: i r bv p many viral respiratory infections can cause severe acute respiratory symptoms leading to mortality and morbidity. in the spring of , the severe acute respiratory syndrome (sars) outbreak caused by sars-cov spread globally. in the summer of , the middle east respiratory syndrome (mers) outbreak caused by mers-cov occurred in saudi arabia. in the winter of , the coronavirus disease (covid- ) outbreak caused by a novel coronavirus sars-cov- occurred in china which rapidly spread worldwide causing a global pandemic. up until may , there are . million confirmed cases of covid- and , covid- related deaths worldwide, and there has also been an unprecedented increase in socioeconomic and psychosocial issues related to covid- . this overview aims to review the current developments in preventive treatments and therapies for covid- . the development of vaccines for sars-cov- is ongoing and various clinical trials are currently underway around the world. it is hoped that existing antivirals including remdesivir and lopinavir-ritonavir might have roles in the treatment of covid- , but results from trials thus far have not been promising. covid- causes a mild respiratory disease in the majority of cases, but in some cases, cytokine activation causes sepsis and acute respiratory distress syndrome, leading to morbidity and mortality. immunomodulatory treatments and biologics are also being actively explored as therapeutics for covid- . on the other hand, the use of steroidal and nonsteroidal anti-inflammatory drugs (nsaids) has been discouraged based on concerns about their adverse effects. over the past two decades, coronaviruses have caused major epidemics and outbreaks worldwide, whilst modern medicine has been playing catch-up all along. viral respiratory infections such as influenza and measles, which can cause severe acute respiratory symptoms, have been responsible for many epidemics. in the spring of , an outbreak of severe acute respiratory infection (sari) spread globally. , , the world health organization (who) coined the acronym sars (severe acute respiratory syndrome) for this sari and subsequently named the causative coronavirus sars-cov. in the summer of , another sari broke out in saudi arabia, which was found to be caused by a new coronavirus. the who named this respiratory disease middle east respiratory syndrome also known by the acronym mers and called the causative coronavirus mers-cov. in the winter of , another sari outbreak occurred in wuhan, china, which very quickly spread around the world. the culprit was identified as another novel coronavirus, which the who named as sars-cov- due to similarities to sars-cov, and the disease was called coronavirus disease . sars-cov- is a newly emergent coronavirus closely related to sars and mers. covid- is a respiratory tract infection that causes mild symptoms in the majority of cases, but can also lead to issn: - review -coronavirus disease : latest developments in potential treatments drugsincontext.com mortality and morbidity. current reports suggest that covid- causes milder symptoms in children, including fever and cough, but co-infection has also been observed. , however, covid- is associated with severe outcomes in the older population, immunocompromised patients, and those with chronic cardiovascular or respiratory conditions. at present, no pharmaceutical products have been shown to be reliable, safe, and effective for treating covid- . in the midst of the current global pandemic, many research groups around the world are actively developing treatments against this disease to reduce morbidities and mortalities. in the long term, the goal is to develop a vaccine to prevent further infections and future outbreaks. however, an effective vaccine may take years to develop and to manufacture on a global scale. furthermore, it is unknown if newborns and patients already recovered from covid- will need to be vaccinated. it is also uncertain if such a vaccine can protect individuals from this novel coronavirus in the future. in this narrative review, we summarise the latest body of evidence and ongoing research on the development of pharmacological therapies for covid- . the aim is also to review the suggested pathophysiology, prophylactic treatments, and therapeutic modalities for covid- . articles were retrieved using pubmed clinical queries with the search term 'coronavirus covid- ' regardless of the date of publication. there were articles under clinical study categories (category: therapy; scope: broad) and systematic reviews. the discussion is based on, but not limited to, these search results. severe acute respiratory syndrome is a viral respiratory disease of zoonotic origin caused by sars-cov. the sars outbreak between november and july resulted in cases and deaths in countries around the world, giving a casefatality rate of . %. , treatments for sars during the outbreak were mainly supportive, as there were no known effective antiviral agents. the use of broad-spectrum antibiotics to treat secondary bacterial infections was the main treatment regimen. ribavirin, a broad-spectrum purine nucleoside analogue, was empirically used as a broad-spectrum antiviral agent. human immunodeficiency virus (hiv) protease inhibitor lopinavir/ritonavir were also used, as it was found to have weak in vitro antiviral activity on the prototype sars-cov. , other therapies included immunomodulators (e.g. corticosteroid, convalescent plasma, and pentaglobulin), interferons, and traditional chinese medicine (tcm). , the development of vaccines was underway by the end of the epidemic, but no effective vaccine has since emerged. middle east respiratory syndrome caused by mers-cov may have been transmitted to humans through infected camels. the mers outbreak between september and january was reported to have caused laboratory-confirmed cases and associated deaths globally, giving a case-fatality rate of . %. as of , there is still no effective vaccine or treatment for this disease, although a number of antiviral medications have been investigated. a systematic review of therapeutic agents against mers-cov showed that there is still no general consensus on the optimal treatment strategy for mers-cov infection. the miracle trial (mers-cov infection treated with a combination of lopinavir/ ritonavir and interferon-β b) was the first randomised controlled trial to assess the feasibility, efficacy, and safety of a combination of lopinavir/ritonavir and interferon-β b in hospitalised patients with mers. , the trial was started in july and enrolled participants, although results have yet to be published. sars-cov, mers, and sars-cov- are all zoonotic β-coronaviruses that have crossed from animals to humans. the origin of sars-cov is still a mystery and remains a controversial topic. sars-cov is closely related to civet and bat covs, but it is phylogenetically divergent from other coronaviruses associated with human infections, including issn: - review -coronavirus disease (covid- ): latest developments in potential treatments drugsincontext.com oc , nl , e, and hku . the full-length genome sequence of sars-cov- shows that it is similar to sars-cov, sharing . % sequence identity. both sars-cov- and sars-cov use the same cellular receptor, angiotensin-converting enzyme ii (ace ) receptor, to enter into host cells. the pathophysiology of covid- has yet to be confirmed, but it is likely to involve inflammatory processes that can trigger a massive cytokine storm. the cytokine profile of critically ill patients revealed increased levels of interleukin (il)- , il- , il- , granulocyte-colony stimulating factor, interferon-γ inducible protein , monocyte chemoattractant protein , macrophage inflammatory protein -α, and tumour necrosis factor-α. histopathological examination of the lungs of patients with covid- revealed immunopathological changes including diffuse alveolar damage, desquamation of pneumocytes, pulmonary oedema, hyaline membrane formation, and interstitial mononuclear inflammatory infiltrates. according to the limited number of reports of biopsy/autopsy results of patients with covid- , the pathological features resemble those seen in sars and mers virus infections. [ ] [ ] [ ] the similarities between sars-cov and sars-cov- suggest that the development of potential prophylactics and therapeutics for covid- could be based on research on sars. , , , -, an important strategy would be to possibly control the viral replication using an effective antiviral agent to minimise the subsequent inflammation and tissue damage due to high viral loads. immunomodulators could play a rescue therapy role, as pathological findings suggest that there is immunopathological damage. , although the sars-cov- s protein receptor-binding domain has higher affinity than the sars-cov s protein receptor-binding domain, development of vaccines against sars-cov- could still be based on research on sars-cov. [ ] [ ] [ ] therapeutics for covid- the majority of covid- patients, especially children, are either asymptomatic or have mild symptoms, and will likely recover by managing their own symptoms without the need for hospitalisation. the who has also launched the 'solidarity' international clinical trial, which is investigating effective treatments and is currently comparing four of the most promising treatment options: remdesivir, lopinavir-ritonavir, lopinavir-ritonavir plus interferon β- a, and hydroxychloroquine. over countries have joined the 'solidarity' international clinical trial. in the following discussion, we summarise the latest evidence and research progress from the literature, with focus on pharmacological therapies (table ) . empirical antimicrobials should be started within hour after the detection of sepsis based on clinical diagnosis and local epidemiology. for critically ill covid- patients, intensive care treatment can include oxygen therapy, noninvasive mechanical ventilation, invasive mechanical ventilation, and extracorporeal membrane oxygenation. in addition to the standard management for acute respiratory distress syndrome, the literature also suggests lower intubation threshold, early prone positioning, and cautious fluid status management, considering that the incidence of myocardial dysfunction in covid- patients is high. further discussion on the intensive care management of covid- patients is beyond the scope of this review. remdesivir remdesivir (gs- ) is a nucleoside analogue prodrug that inhibits viral rna polymerases, and was developed by gilead science in response to the ebola outbreak in . [ ] [ ] [ ] it is considered to be one of the most promising broad-spectrum antivirals for treating covid- . in vitro antiviral activities of remdesivir have been demonstrated in sars-cov, mers-cov, and sars-cov- . , in early april, a preliminary report describing the clinical outcomes of a cohort of hospitalised covid- patients who received remdesivir, % of patients showed improvement of their oxygen-support status, but % of patients reported adverse events during follow-up. subsequently, a double-blinded randomised controlled trial in adult patients with severe covid- showed that remdesivir was not associated with statistically significant clinical benefits whilst adverse events were reported in % of patients. separately, the results of an interim analysis of the adaptive covid- treatment trial involving patients are more encouraging, as it indicated that patients who received redmesivir had a % faster time to recovery than those who received placebo (median time to recovery was versus days). more recently, a phase simple clinical trial demonstrated that patients receiving a -day and -day treatment course of remdesivir achieved similar improvements in clinical status. reported in the preliminary studies included elevated hepatic enzymes, diarrhoea, constipation, hypoalbuminaemia, rash, renal impairment, anaemia, thrombocytopenia, and hypotension. , potential drug-drug interactions with other medications metabolised through the cytochrome p system were also reported. the safety profile of this drug needs to be further evaluated. randomised controlled trials on remdesivir are still ongoing, and two studies are in phase iii of clinical trials to evaluate the safety and efficacy of remdesivir. [ ] [ ] [ ] [ ] lopinavir-ritonavir lopinavir-ritonavir is a combination therapy used to treat hiv. ritonavir is an inhibitor of cytochrome p and is used to increase the plasma half-life of lopinavir. lopinavir is a protease inhibitor that has been demonstrated to have antiviral effects against sars, mers-cov, and sars-cov- in vitro. , several trials have been investigating the efficacy of lopinavir-ritonavir compared with other drugs as a treatment for covid- . , - nevertheless, the results so far indicate that lopinavir-ritonavir treatment has little benefit as a standalone therapy against sars-cov- infection. in a clinical trial involving patients with laboratory-confirmed sars-cov- infection, lopinavir-ritonavir treatment was not associated with any clinical improvements compared with standard care. furthermore, lopinavir-ritonavir treatment caused gastrointestinal adverse events, and nearly % of the recipients could not complete the full -day course of treatment. other adverse effects included gastrointestinal intolerance, hepatotoxicity, pancreatitis, and qt prolongation. the use of ritonavir can cause severe drug-drug interactions in medications metabolised through the cytochrome system. the tolerance of the side effects might limit the dosage needed, as the concentration necessary to inhibit viral replication is relatively high. other clinical trials have been testing lopinavir-ritonavir combined with different drugs and different combinations such as ritonavir and interferon b. , early use of lopinavir-ritonavir as an additional treatment to ritonavir-methylprednisolone for sars-cov was associated with a reduction in the overall death rate and intubation rate when compared with a matched cohort. a clinical phase ii trial has been investigating the use of lopinavir-ritonavir combined with interferon β- b as a treatment for mers since , but the trial is ongoing and results have yet to be published. ribavirin ribavirin is a guanosine analogue that interferes with the replication of rna and dna viruses. in vitro antiviral activities of ribavirin have been demonstrated in sars-cov and mers-cov. , from the experiences of sars-cov, the use of ribavirin as a monotherapy was limited as it required high concentration to inhibit viral replication, and ribavirin usage was associated with dose-dependent haemolysis and liver toxicity. , in the treatment of sars and mers, ribavirin is used in combination with interferon or lopinavir/ritonavir. , the use of ribavirin in combination with interferon or lopinavir/ ritonavir is recommended in the latest chinese national treatment guidelines for covid- . a recent multicentre randomised phase trial showed triple antiviral therapy of lopinavir/ritonavir, ribavirin, and interferon β- b was superior to lopinavir-ritonavir alone in alleviating symptoms, shortening the duration of viral shedding and hospital stay in patients with mild-to-moderate covid- . chloroquine and hydroxychloroquine chloroquine and hydroxychloroquine are widely used for the treatment of malaria and certain autoimmune diseases. these drugs have an established safety profile and are readily available at relatively low cost. hydroxychloroquine sulphate has been demonstrated to be less toxic than chloroquine phosphate in animal studies. both these drugs have been reported to have antiviral effects against sars-cov and sars-cov- in vitro. their potential mechanisms of action include blocking viral entry into cells by inhibiting glycosylation of host receptors, reducing viral replication, and blocking the export of newly constructed virions. , a trial in china involving more than patients with covid- showed that chloroquine was better able to inhibit exacerbation of pneumonia and improve lung imaging findings compared to the control treatment. a recent small open-label nonrandomised clinical trial showed patients given daily hydroxychloroquine had significantly reduced viral load measured by nasopharyngeal swab on day . however, the results in this study may have been confounded by other factors, as some patients also received azithromycin. the combination of hydroxychloroquine and azithromycin should be used with caution in patients at risk for qt prolongation. the use of chloroquine alone is also a risk factor for qt prolongation. a phase iib clinical trial assessing the safety and efficacy of high-dose chloroquine was terminated early due to prolonged qtc (> ms) and high lethality in the high-dose group compared to the lowdose group. a recent analysis of a multinational registry of , hospitalised covid- patients revealed that hydroxychloroquine or chloroquine was associated with decreased in-hospital survival (mortality of . versus . %) and increased frequency of ventricular arrhythmia. however, concerns have been raised about the veracity of data and analyses in this study and has led to retraction of the article. other adverse effects of chloroquine include retinopathy, rash, nausea, glucose fluctuation and diarrhoea, and use of chloroquine is contraindicated in patients with porphyria. chloroquine or hydroxychloroquine should not be used to treat covid- until they have been tested in clinical trials to determine the optimal dosage to balance efficacy and safety. chloroquine or hydroxychloroquine has been suggested as candidate prophylactics for covid- in populations at high risk of covid- infections, such as italy and new york. other antiviral treatments other antiviral treatments for covid- currently undergoing clinical trials include protease inhibitors (nelfinavir, camostat mesilate, ritonavir, danoprevir, darunavir, flavopiridol, relacatib), nucleoside analogues (galidesivir), fusion inhibitors (umifenovir), rna polymerase inhibitors (favipiravir), and neuraminidase inhibitors (oseltamivir). corticosteroids corticosteroid therapies such as intravenous methylprednisolone are currently being tested as a treatment for covid- . methylprednisolone has already been used in covid- patients in combination with antibiotics, oseltamivir, and oxygen therapy. long and colleagues reported that corticosteroid therapy using methylprednisolone, dexamethasone, and hydrocortisone was beneficial in treating issn: - review -coronavirus disease (covid- ): latest developments in potential treatments drugsincontext.com sars-cov patients, and significantly prolonged survival time in clinical cases. however, other studies reported the use of corticosteroids in early stages of sars infection increased the viral load. furthermore, studies on the use of corticosteroids as an adjuvant therapy against mers-cov infection were unable to prove efficacy because all patients died. based on the recommendation by frontline chinese physicians and local clinical experience during the sars epidemic, a short course of corticosteroids at a low-to-moderate dose is probably justifiable for critically ill patients. , corticosteroids are effective in treating the autoinflammatory cytokine activation syndrome. reported side effects such as osteonecrosis are concerning, but data are still conflicting and recent recommendations against the use of corticosteroids are based on circumstantial evidence. routine use of corticosteroids is not recommended as corticosteroids may prolong or worsen the disease, and were found to prolong viral shedding in mers and sars. based on the current body of evidence, corticosteroids may be justified for certain medical indications (i.e. acute respiratory distress syndrome and sepsis) at the discretion of the physician in charge. convalescent plasma might be promising as a postexposure prophylaxis for covid- and as a potential treatment after infection, as it was also used as a salvage therapy in the sars and mers epidemics. [ ] [ ] [ ] considering the huge number of people exposed to covid- , use of convalescent plasma for post-exposure prophylaxis may not be justifiable, but could still be a treatment option. an observational study during the sars epidemic showed a lower mortality rate in those receiving convalescent plasma as a treatment for sars. studies on the clinical effects and outcomes of critically ill covid- patients treated with convalescent plasma have so far shown encouraging results, although it should be noted that these studies were based on small case series. , furthermore, studies on the use of convalescent plasma in sars patients did not report any significant side effects. , randomised trials on convalescent plasma therapy are still needed to eliminate the effects of other treatments and to investigate the safety and efficacy and optimal timing of administration. highly purified preparations of neutralising antibodies against sars-cov- would be preferable, as it would be safer and have higher activity, but it might be technically difficult to mass produce. several pharmaceutical companies are starting to develop hyperimmune immunoglobulins against covid- . , monoclonal antibodies the use of tocilizumab, a monoclonal antibody against il- , has recently been suggested as a treatment for covid- patients at risk of cytokine storms. tocilizumab is an il- inhibitor that may be effective in treating covid- . the level of il- was found to be correlated with the severity of covid- and levels of c-reactive protein, lactate dehydrogenase, d-dimer, and t cells. a retrospective study of covid- patients receiving tocilizumab found that % of them had decreased oxygen requirement. according to the diagnosis and treatment protocol from the china national health commission and state administration of traditional chinese medicine, tocilizumab can be used in patients with extensive pulmonary lesions and in patients with increased il- levels. clinical trials on the efficacy of intravenous tocilizumab as a treatment for covid- are ongoing. , however, serious adverse effects have been reported including gastrointestinal perforation, anaemia, hepatitis, and infusion reaction. tcm employs phytotherapeutic formulations and cultural concepts that originated more than years ago. the use of tcm as a coadjuvant therapy in the early stage of the sars infection epidemic was reported to increase oxyhaemoglobin arterial saturation. a cochrane review found that chinese herbs combined with western medicines in sars patients could improve symptoms, quality of life, and absorption of pulmonary infiltration, as well as decrease the corticosteroid usage. specific components such as glycyrrhizin, baicalin, and mol were shown to have anti-sars activities in vitro. [ ] [ ] [ ] over % of sars-cov- patients in china received tcm, which has been reviewed by yang and colleagues. the use of tcm was included in the chinese national treatment guidelines for covid- patients and was recommended for different stages and severity of disease (table ) . however, the effectiveness of tcm in treating covid- patients still remains unclear. well-designed, large-scale, randomised, double-blinded, and placebo-controlled studies are necessary to confirm the efficacy of tcm before making any recommendations on their use in the management of patients with covid- . other complementary therapies such as high doses of vitamins, acupuncture, and exercise have been suggested to promote health. however, there are no reports of specific targeted effects on coronaviruses, and there are no randomised trials of complementary therapies as treatments for covid- . several case series reported that combination therapy could be effective in treating patients with covid- patients. a single-centre case series of hospitalised patients with covid- ( non-icu and icu patients) treated with a combination therapy of moxifloxacin, lopinavir, interferon, and methylprednisolone (given to only icu patients) showed good treatment effects and the mortality rate was less than %. , in another study of covid- patients, ( . %) patients treated with a combination of traditional chinese medicine, interferon-a- b, lopinavir, ritonavir, and short-term cold dampness and stagnation lung syndrome raw ephedra g, raw gypsum g, almond g, loquat g, gardenia g, guanzhong g, dilong g, xu changqing g, huoxiang g, peilan g, cangzhu g, yunling g, atractylodes g, jiao sanxian g each, magnolia officinalis g, betel coconut g, yarrow fruit g, ginger g. betel nut g, apple g, magnolia g, zhimu g, scutellaria baicalensis g, bupleurum g, red peony g, forsythia g, artemisia annua g (decocted later), green leaves g, raw licorice g. dampness and stagnation lung syndrome raw ephedra g, bitter almond g, raw gypsum g, raw coix seed g, grass root g, patchouli g, artemisia annua g, polygonum cuspidatum g, verbena g, dried reed root g, gardenia g, orange red g, raw licorice g. cold dampness lung syndrome atractylodes lancea g, chenpi g, magnolia g, aquilegia g, grass fruit g, raw ephedra g, zhihuo g, ginger g, betel nut g. plague poison and lung-closing syndrome raw ephedra g, almond g, raw gypsum g, licorice g, fragrant fragrant g (back), magnolia g, atractylodes g, grass fruit g, pinellia g, poria g, raw rhubarb g (back), mongolian milkvetch root g, gardenia g, red peony g. gypsum (fried first) - g, zhimu g, raw land - g, buffalo horn (fried first) g, red sage g, black ginseng g, forsythia g, paeonia g, chinese goldthread rhizome g, peony g, gardenia g, raw licorice g. all the coronaviruses are similar in nature and have defined clinical presentations. the lower prevalence of coronavirus diseases in children might be accounted for by the lower exposure and relatively mild clinical presentation in the paediatric population. many of the mild and asymptomatic cases are often overlooked and therefore go undiagnosed. comparing the immunopathology of sars-cov- infection between children and adults could reveal the pathology of the disease and might lead to possible treatment strategies for 'recurrent' novel coronavirus infections. there is currently no approved antiviral treatment for patients suspected of or confirmed with covid- . research on the sars and mers epidemics and data from in vitro studies show that antiviral therapy may be beneficial. antiviral therapies and adjunctive treatments should, therefore, be considered in covid- patients with the unstable clinical condition or clinical deterioration or in patients with comorbidities. as the covid- situation develops, we will learn more about the safety and efficacy of specific treatments, and treatment recommendations are likely to change to reflect the latest evidence. at the time of writing, the most urgent issue is to curtail the spread of covid- . vaccines could be the answer to this crisis, but vaccines are likely many months away and will take time to scale-up and manufacture on a global scale. in the meantime, public health officials should be focusing on nonpharmaceutical interventions. measures such as personal hygiene, wearing masks in the general population, social distancing, surveillance programs for testing suspected cases, lung and spleen qi deficiency syndrome french pinellia g, chenpi g, codonopsis g, sunburn astragalus g, stir-fried atractylodes g, poria g, huoxiang g, amomum villosum g, and licorice g qi and yin deficiency syndrome north and south radix salviae g, ophiopogonis g, american ginseng g, schisandra g, gypsum g, light bamboo leaves g, mulberry leaves g, reed root g, salviae miltiorrhiza g, raw liquorice g. one patient died. in a case report of a -year-old woman with covid- treated with thalidomide ( mg orally once a day) and methylprednisolone ( mg intravenously bid for days then reduced to once a day for days), she had overall improved status, increased oxygen index, decreased symptoms of nausea and vomiting, and lower cytokine levels. however, we cannot draw any definitive conclusions from this single case report as there was no control. although sars-cov- is the third re-emergence of a coronavirus in the past two decades and has abruptly put a halt to most social and economic activity around the world, the consequences of which are immeasurable. this pandemic will undoubtedly change our daily habits and social routines and should serve as a huge wake-up call that has shown the vulnerability of the human race. for now, the global battle against covid- continues, and together, we will inevitably defeat the coronavirus. hard lessons will be learned that will better prepare us for the next pandemic. early quarantine, vigilant contact tracing, and preventing healthcare-related transmission are key factors to stopping the covid- pandemic. although a safe and effective treatment has yet to be found, the sheer number of clinical trials that have started since the beginning of the epidemic is nothing short of impressive. combining advanced technologies in the field of genomics and computer science, potential treatments could be identified through machine learning, complex molecular dynamics, and artificial intelligence. with the joint efforts of research communities around the world, we are hopeful that an effective treatment or vaccine for covid- can be developed in the near future. this pandemic should also raise the awareness in governments and pharmaceutical companies contributions: all authors contributed equally to the preparation of this review. all named authors meet the international committee of medical journal editors (icmje) criteria for authorship for this article, take responsibility for the integrity of the work as a whole, and have given their approval for this version to be published. the authors 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with severe acute espiratory failure overview: the history and pediatric perspectives of severe acute respiratory syndromes: novel or just like sars none. key: cord- - fdcu f authors: wu, renyi; wang, lujing; kuo, hsiao-chen dina; shannar, ahmad; peter, rebecca; chou, pochung jordan; li, shanyi; hudlikar, rasika; liu, xia; liu, zhigang; poiani, george j.; amorosa, louis; brunetti, luigi; kong, ah-ng title: an update on current therapeutic drugs treating covid- date: - - journal: curr pharmacol rep doi: . /s - - - sha: doc_id: cord_uid: fdcu f the current pandemic of coronavirus disease (covid- ) caused by severe acute respiratory syndrome coronavirus (sars-cov- ) has presented unprecedented challenges to the healthcare systems in almost every country around the world. currently, there are no proven effective vaccines or therapeutic agents against the virus. current clinical management includes infection prevention and control measures and supportive care including supplemental oxygen and mechanical ventilatory support. evolving research and clinical data regarding the virologic sars-cov- suggest a potential list of repurposed drugs with appropriate pharmacological effects and therapeutic efficacies in treating covid- patients. in this review, we will update and summarize the most common and plausible drugs for the treatment of covid- patients. these drugs and therapeutic agents include antiviral agents (remdesivir, hydroxychloroquine, chloroquine, lopinavir, umifenovir, favipiravir, and oseltamivir), and supporting agents (ascorbic acid, azithromycin, corticosteroids, nitric oxide, il- antagonists), among others. we hope that this review will provide useful and most updated therapeutic drugs to prevent, control, and treat covid- patients until the approval of vaccines and specific drugs targeting sars-cov- . coronavirus disease sars-cov- severe acute respiratory syndrome coronavirus the horrific pandemic outbreak of covid- (coronavirus disease ) around the world caught the health care systems in every country by storm, most if not all were caught off guard without proper defense mechanisms to cope with and to control such a pandemic. covid- , caused by a new and novel coronavirus (severe acute respiratory syndrome coronavirus , sars-cov- ), has recently been identified and characterized [ ••] . coronaviruses are named for their crown-like spikes on their surface and there are four main sub-groupings of coronaviruses, known as alpha, beta, gamma, and delta [ , ] . sars-cov- belongs to the beta sub-grouping, and is one of the seventh coronavirus to date infecting humans [ ••] . some coronaviruses such as e alpha coronavirus [ ] , oc beta coronavirus [ ] , nl alpha coronavirus [ ] , and hku beta coronavirus [ ] were associated with mild clinical symptoms, whereas sars-cov beta coronavirus [ ] , middle east respiratory syndrome coronavirus (mers-cov) beta coronavirus [ ] , and sars-cov- caused severe diseases [ ] . sars-cov- is a positive-sense single-stranded rna virus with , bases, % identical at the whole-genome level to a bat coronavirus, and shares . % sequence identity to sars-cov [ ••] . sars-cov- encodes spike s protein containing receptor binding domain (rbd) that binds to the human angiotensin-converting enzyme (ace ), and promotes membrane fusion and uptakes of the virus into human cells such as the lung by endocytosis [ , [ ] [ ] [ ] . upon entering the human cells, sars-cov- , like other coronaviruses, will takeover or hijack the human cells' protein synthesis machinery to synthesize the viral proteins and assemble the proteins and subsequent viral replication [ •] . once inside the human body, viruses in general will trigger a series of good versus bad host responses including autophagy, apoptosis, stress response, and innate immunity [ ] . fortunately, majority (more than %) of sars-cov- infected individuals are asymptomatic or have mild symptoms, most likely due to the activation of the good response. these good responders would likely activate the body's innate immune system by activating the body's antiviral defense mechanisms including natural killer cells and antiviral t cells, and induction of interferon (ifn) [ ] [ ] [ ] [ ] . unfortunately, in about % of sars-cov- -infected individuals including the immune compromised, elderly, patients with underlying health conditions such as cardiovascular and pulmonary problems, diabetics, hypertension, obesity, chronic obstructive pulmonary disease (or copd, such as emphysema), pulmonary fibrosis, asthma, and interstitial lung disease [ , ] would encounter more severe disease characterized by significant respiratory symptoms leading to acute respiratory distress syndrome (ards) and even death. an important consideration to note is that ards occurs later in disease progression and is preceded by acute lung injury (ali) [ ] . this distinction may inform treatment strategy in terms of drugs directed towards cytokine storm and thrombosis which is described in this manuscript. a study on sars-cov and mers-cov has found that these two coronaviruses appear to have evolved mechanisms to attenuate or delay ifn production, resulting in enhanced inflammatory host responses and severe lung injury [ , , [ ] [ ] [ ] . this aberrant host immune response with the production of powerful inflammatory cytokines, known as "cytokine storm" found in sars-cov-and mers-covinfected patients, would correlate with disease severity and poor prognosis [ , , [ ] [ ] [ ] [ ] . severe covid- patients exhibit profound inflammatory response [ , ] . transcriptomic rna-seq analysis of covid- patients has revealed that several immune pathways and pro-inflammatory cytokines cxcl, ccl , cxcl , ccl , il , and ccl l in bronchoalveolar lavage fluid (balf) and tnfsf , cxcl , il , timp , c , il , areg, and nrg in peripheral blood mononuclear cells (pbmc) were induced by sars-cov- infection, suggesting a sustained inflammation and cytokine storm [ ] . importantly, sars-cov- infection-induced excessive cytokine release correlates with lung tissue injury and covid- pathogenesis [ ] . this estimated % of patients developing more severe disease with sars-cov- infection are most likely due to genetics, epigenetics, and or other factors, with dampened innate immune response to fight the virus coupled with enhanced viral load leading to cytokine storm, severe inflammatory/oxidative stress response, and severe lung injury secondary to ards. while there is clear understanding that the respiratory system is dramatically impacted in covid- patients, evidence suggests that other organ systems are also affected. emerging data show that sars-cov- may lead to damage to other organs including the heart and brain. nearly % of hospitalized patients with covid- have indication of cardiac damage [ ] . furthermore, neurologic symptoms have been reported in patients and infection of sars-cov- has been found in the brainstem of both humans and experimental animals [ , ] . currently, there is no vaccine and/or specific therapeutic drugs targeting the sars-cov- . hence, it remains a major challenge to decide what potential therapeutic regimens to prevent and treat the severely sick covid- patients. effective vaccines are essential to combat against the extremely contagious sars-cov- . at present, a lot of research efforts have been invested to develop vaccines around the world. until we have specific vaccines or therapeutic drugs targeting sars-cov- , "repurposed" drugs that have been approved by the fda in the usa for other indications have been used to treat covid- patients. this review will summarize the most current pharmacotherapeutics prescribed in the treatment of severe cases of covid- patients. these include antiviral therapy, antibiotics, systemic corticosteroids and anti-inflammatory drugs (including anti-arthritis drugs), neuraminidase inhibitors, rna synthesis inhibitors, convalescent plasma, and traditional herbal medicines. in the absence of definitive and specific treatment regimens, strategies including early diagnosis, timely reporting, isolation, and supportive treatments are important line of actions against covid- infections. current social practices including timely release of epidemic information and maintenance of social orders and personal practices such as improving personal hygiene, wearing facial coverings or masks, adequate rest, and keeping rooms well ventilated remain some of first line of actions against covid- pandemic. at present, the treatments of patients with sars-cov- infection are mainly repurposing the available therapeutic drugs and based on symptomatic conditions. considering ards, followed by secondary infections, antibiotics, antiviral therapy, systemic corticosteroids, and anti-inflammatory drugs (including anti-arthritis drugs) are often used in the treatment regimens. in addition to antiviral interferers and antibiotics, neuraminidase inhibitors, rna synthesis inhibitors, convalescent plasma, and traditional herbal medicines have also been utilized in the treatment of covid- [ ] . nevertheless, the efficacy of these treatment regimens remains to be verified by appropriately designed clinical trials. remdesivir is a potential drug for treatment of covid- . it is a phosphoramidate prodrug of an adenosine c-nucleoside and a broad-spectrum antiviral agent synthesized and developed by gilead sciences in as a treatment for ebola virus infection [ ] . remdesivir is metabolized into its active form, gs- , that obscures viral rna polymerase and evades proofreading by viral exonuclease, causing a decrease in viral rna production. the antiviral mechanism of remdesivir is a delayed chain cessation of nascent viral rna. animal experiments indicate that remdesivir can effectively reduce the viral load in lung tissue of mice infected with mers-cov, improve lung function, and alleviate pathological damage to lung tissue [ ] . wang [ ] . in order to evaluate the efficacy and safety of the drug in patients with covid- , a randomized, placebo-controlled, double-blind, multicenter, phase iii clinical trial was launched on february , in china. patients in the experimental group received an initial dose of mg of remdesivir and a subsequent dose of mg for consecutive days via intravenous infusion in addition to routine treatment. patients in the control group received same dose of placebo treatment. the trial is expected to conclude by the end of april . the number of cases planned to be enrolled is and , respectively [ , ]. current recommendation for remdesivir includes a -day regimen of remdesivir treatment: mg loading dose on day , followed by mg once-daily maintenance doses for days in both studies. this regimen of remdesivir therapy is similar to that of former randomized clinical trial against the ebola virus [ , ]. in a summary of subjects receiving remdesivir via compassionate use in the usa, nearly % of patients had improvement in terms of oxygen requirements and many patients that were mechanically ventilated were extubated. this report did not include a control group; therefore, extrapolating these results is difficult. it is too early to conclude the direct antiviral effect of remdesivir on the enhanced clearing of viral loads in the respiratory tract, but it indeed suggests a promising therapeutic effect of remdesivir [ ] . chloroquine and hydroxychloroquine are drugs with a long history of clinical use with similar chemical structures often used in the treatment of lupus erythematosus, rheumatoid arthritis, and malaria [ ] . compared with chloroquine, hydroxychloroquine has a hydroxyl group, which makes it less toxic while maintaining similar activity. one mechanism of action of chloroquine and hydroxychloroquine is targeting lysosome which may be useful to control graft-versus-host disease in humans [ ] . with the accumulation of chloroquine in lysosomes, the ph of lysosomes is significantly changed and the activity of proteases in lysosomes is directly affected, thus affecting the degradation of proteins and glycosaminoglycan [ , ] . chloroquine can inhibit the entry of sars-cov- and prevent virus-cell fusion by interfering with glycosylation of ace receptor and its binding with spike protein, suggesting that chloroquine treatment might be more effective in the early stage of infection, before covid- reduces ace expression and activity [ , , ] . hydroxychloroquine possesses anti-inflammatory effect on th -related cytokines (il- , il- , and il- ) in healthy individuals, and systemic lupus erythematosus (sle) and rheumatoid arthritis (ra) patients [ ] . there is some evidence that chloroquine and hydroxychloroquine can reduce cytokine storm. according to one analysis, the main cause of death of covid- patients is related to the triggering of the cytokine storm, which contributed to acute respiratory distress [ ] . it has been reported that hydroxychloroquine is effective in inhibiting sars-cov- infection in vitro [ , , ] . zinc inhibits sars-covand retrovirus rna polymerase activity in vitro and zinc ionophores block the replication of these viruses in cell culture [ ] . there is also evidence that zinc enhances chloroquine intracellular uptake [ ] . as such, combining zinc with chloroquine or hydroxychloroquine is intriguing and is currently under investigation. overall, more clinical trials are underway to evaluate the safety and efficacy of hydroxychloroquine as a prophylactic and treatment for covid- . the us fda has issued emergency authorization for the use of chloroquine and hydroxychloroquine for the treatment of covid- . a recent study by tang et al. reported that hydroxychloroquine did not lead to higher negative conversion rates, but had reduced clinical symptoms through the anti-inflammatory properties and recovery of lymphopenia [ •] . it has also been reported that high doses of chloroquine ( mg twice daily for days or total dose of g) may be associated with significant cardiac risks and should not be recommended for treating covid- [ • ]. there is still a lack of evidence regarding the safety and effectiveness of these agents in treating covid- . in this regard, clinicians and patients should be made aware of the risk versus benefit profile of these medications [ ] . lopinavir is a protease inhibitor with high specificity for hiv- protease. lopinavir is marketed and administered exclusively in combination with ritonavir. this combination was first marketed by abbott under the brand name kaletra in [ ] . due to lopinavir's poor oral bioavailability and extensive biotransformation, it is co-formulated with ritonavir to enhance its exposure. ritonavir is a potent inhibitor of the enzymes that are responsible for lopinavir metabolism, and its co-administration "boosts" lopinavir exposure and improves antiviral activity [ ] . lopinavir is a peptidomimetic molecule, containing a hydroxyethylene scaffold that mimics the peptide linkage typically targeted by the hiv- protease enzyme but which by itself cannot be cleaved, thus preventing the activity of the hiv- protease [ ] . lopinavir-ritonavir was investigated in an open-label, individually randomized, controlled trial, where patients with covid- received either lopinavir-ritonavir mg/ mg, orally twice daily plus standard of care, or standard of care alone. no benefit was observed with lopinavirritonavir treatment beyond standard care. diarrhea, nausea, and asthenia were the most frequently reported adverse effects in patients receiving lopinavir-ritonavir-based regimen [ ] . interestingly, in a report from korea, lopinavir-ritonavir administration significantly decreased coronavirus titers with no or little coronavirus titers were observed in the follow-up study. however, the analysis included a single patient in the initial phase of outbreak in korea [ ] . umifenovir (branded as arbidol), a derivative of indole carboxylic acids, was first developed in in russia and has since been approved in russia and china for treating prophylaxis and infections associated with influenza a and b, and other arbovirus [ ] . later on, umifenovir demonstrated in vitro antiviral efficacy in widely spreading virus strains such as the ebola virus, human herpesvirus (hhv- ), hepatitis c virus (hcv), and tacaribe arenavirus [ ] . its major mechanism of action is to block the virus-cell membrane fusion as well as virus-endosome fusion through incorporation into cell membranes and interference with the hydrogen bonding network of phospholipids [ ] . in influenza virus, it has been shown to directly interact with virus particles to stabilize hemagglutinin (ha), reducing the likelihood of reaching the low ph threshold required for conformational transition into functional fusogenic ha [ ] . blaising et al. reported the in vitro activity of umifenovir against sars-cov- and sars-cov- [ , ] . a retrospective cohort study has reported that compared with lopinavir-ritonavir (lpv-rtv) only group, combination of umifenovir and lpv-rtv has shown increased negative conversion rate of sars-cov- and improved chest ct scan results [ ] . however, another prospective study (chictr ) has shown that compared with favipiravir, umifenovir has inferior outcome in clinical recovery rate and relief of fever and cough [ ] . there are two randomized and open-label trials ongoing in china, investigating the efficacy and safety of umifenovir against covid- . the effect of umifenovir plus standard treatment versus lpv-rtv plus standard treatment will be evaluated in nct , and the effect of umifenovir plus standard treatment versus standard treatment will be tested in nct . favipiravir (branded as avigan) has been developed by fujifilm toyama chemical in in japan for the treatment of avian influenza or novel influenza resistant to neuraminid a s e i n h i b i t o r s . i t i s a g u a n i n e a n a l o g u e w i t h pyrazinecarboxamide structure, and its antiviral activity is decreased at the presence of purine nucleosides due to the competition [ ] . the prodrug favipiravir first enters the infected cells through endocytosis and is then transformed into active f a v i p i r a v i r r i b o f u r a n o s y l p h o s p h a t e s t h r o u g h phosphoribosylation and phosphorylation [ , ] . the antiviral activity is exhibited through selectively targeting conservative catalytic domain of rna-dependent rna polymerase (rdrp), interrupting the nucleotide incorporation process during viral rna replication [ ] . the dysregulation in viral rna replication results in increased number and frequency of transition mutations including replacement of guanine (g) by adenine (a) and cytosine (c) by thymine (t) or c by uracil (u) which induces destructive mutagenesis in rna viruses [ ] . favipiravir has been used in the treatment of infectious diseases caused by rna viruses such as influenza, ebola, and norovirus [ ] . recent in vitro and human studies have repurposed favipiravir as an experimental agent against enveloped, positive-sense, single-strand rna virus sars-cov- . an in vitro research has investigated seven potential anti-sars-cov- medicines including ribavirin, penciclovir, favipiravir, nafamostat, nitazoxanide, remdesivir, and chloroquine, showing that remdesivir and chloroquine have favorable selectivity index [ ] . in addition, the study showed favipiravir has exerted efficacy in vero e cells infected with sars-cov- with half-maximal effective concentration (ec ) of . μm and half-cytotoxic concentration (cc ) at over μm, implying the high concentration is needed for safe and effective treatment [ ] . clinical trials testing favipiravir against covid- have been carried out vigorously in various countries including china and japan. a randomized control trial (chictr ) has shown that covid- patients treated with favipiravir have superior recovery rate ( . %) than that treated with umifenovir ( . %), and the duration of fever and cough relief time are significantly shorter in favipiravir group than in umifenovir group [ ] . up to mid-april , there are eight undergoing clinical trials in china and two in japan examining the anti-sars-cov- potential of favipiravir. these trials include non-randomized and randomized controlled trials evaluating t h e e f f i c a c y a n d s a f e t y o f f a v i p i r a v i r a l o n e (chictr , jprn-jrcts , jprn-jrcts ) or in conjunction with interferon-α ( c h i c t r ) , b a l o x a v i r m a r b o x i l (chictr , chictr ), tocilizumab (chictr , nct ), or chloroquine phosphate (chictr , nct ). oseltamivir(branded as tamiflu) is a drug approved for treatment of influenza a and b. oseltamivir targets the neuraminidase distributed on the surface of the influenza virus to inhibit the spread of the influenza virus in the human body [ , ] . a study in wuhan reported that no positive outcomes were observed after receiving antiviral treatment with oseltamivir [ ] . several clinical trials are still evaluating the effectiveness of oseltamivir in treating sars-cov- infection. oseltamivir is also used in clinical trials in several combinations, such as with chloroquine and favipiravir [ ] . in the absence of vaccine or specific antiviral drugs been proven against sars-cov- , many adjunctive therapies are used as supportive care for covid- patients. the adjunctive therapies including azithromycin, ascorbic acid, corticosteroids, epoprostenol, sirolimus, tocilizumab, sarilumab, and anakinra are highlighted below. several of these therapies (i.e., tocilizumab and other interleukin-directed therapies) are administered in an effort to blunt the cytokine storm often seen in progressing disease. the optimal timing of administration is yet to be identified. conceptually, blocking cytokine production before it progresses to an exaggerated level would seem to be the most mechanistically idea. elevated serum concentration of il- is associated with worse outcome in covid- and blocking the activity of this pro-inflammatory mediator with directed therapies may be a key target [ ] . other adjuncts are directed at viral replication, viral entry, or through some other alternative mechanisms. azithromycin is an antibiotic that can be used to fight many different types of infections caused by susceptible bacteria, such as respiratory infections, skin infections, and sexually transmitted diseases [ ] . moreover, it has been proven to be active in vitro against zika and ebola viruses and to prevent severe respiratory tract infections when treated to patients suffering viral infection [ ] [ ] [ ] . for the mechanism of action, azithromycin prevents bacteria from growing by interfering with their protein synthesis. it binds to the s subunit of the bacterial ribosome, thus inhibiting translation of mrna [ ] . previously, azithromycin has been used as adjunctive therapy to provide antibacterial coverage and potential immunomodulatory and anti-inflammatory effects in the treatment of some viral respiratory tract infections (e.g., influenza) [ , ] . currently, many trials are testing the effect of azithromycin conjunction with hydroxychloroquine on the course of disease in people with sars-cov- . for example, pfizer has announced positive data for the use of its a z i t h r o m y c i n ( z i t h r o m a x ) d r u g , a l o n g w i t h hydroxychloroquine, in a covid- clinical trial that was performed in france. in brief, the clinical trial was conducted to assess hydroxychloroquine in patients, of which were co-administered with azithromycin. compared with controls and hydroxychloroquine alone group, the patients treated with hydroxychloroquine + azithromycin presented with highest virologic cure rate following -day treatment [ ] . three other clinical studies used azithromycin ( mg on day , then mg daily on days - ) co-treated with day regimen of hydroxychloroquine ( mg daily) in an open-label non-randomized study in france ( pts) [ ] , open-label uncontrolled study in france ( pts) [ ] , and uncontrolled observational study in france ( pts) [ ] . specifically, gautret et al. reported a % viral clearance in nasopharyngeal swabs in their patients after co-treated of hydroxychloroquine and azithromycin [ ] . but the findings reported by molina et al. stand in contrast with those reported by gautret. molina et al. repeated the experiments, thought the rapid and full viral clearance was quite unexpected and found of patients had significant comorbidities [ ] . .based on those results, data presented to date are insufficient to evaluate possible clinical benefits of azithromycin in patients with covid- [ ] . furthermore, one must consider the additive cardiac toxicity of hydroxychloroquine and azithromycin. both agents are known to prolong the qt interval and may potentiate the risk for cardiac events in a population known to have cardiac-related comorbidities. vitamin c is an essential nutrient and plays significant roles within the human body. it can neutralize free radicals and assist to prevent or reverse cellular damage as a potent antioxidant agent. it is also involved in some biological processes, many of which are associated with immune health [ ] . moreover, vitamin c appears to be effective as an antiviral agent, especially against influenza viruses [ ] . many studies showed that vitamin c positively affects the development and maturation of t lymphocytes and nk (natural killer) cells involved in the immune response to viral agents. it also contributes to the inhibition of reactive oxygen species (ros) production and to the remodulation of the cytokine network typical of systemic inflammatory syndrome [ ] . given this background, a phase ii clinical trial (nct ) is initiated in china to evaluate high-dose iv vitamin c in icu patients with severe covid- -associated pneumonia [ ] . some hospitals have reported giving infected patients mg of vitamin c as supportive treatment. high-dose iv vitamin c has been given in the treatment of moderate to severe covid- patients in china [ ] . the doses varied between and g per day, given over a period of -- -h iv infusion. the oxygenation index was improved in real time and all the patients eventually recovered and were discharged [ ] . moreover, high-dose ( . mg/kg body weight) vitamin c has been used for several decades clinically and an nih panel also documented clearly that this dose regimen is safe and has no major side effects [ , ] . as a potent anti-inflammatory and anti-fibrotic drug, low doses of methylprednisolone (depo-medrol or solu-medrol) have the potential to prevent an extended cytokine response and may accelerate resolution of pulmonary and systemic inflammation in pneumonia [ , ] . recently, many medical researchers believe that corticosteroids, especially methylprednisolone, may improve dysregulated immune response caused by sepsis (possible complication of infection with covid- ) and increase blood pressure when it is low [ ] . specifically, in a retrospective cohort study, patients with confirmed covid- who developed ards were treated with methylprednisolone ( - mg/kg daily iv for - days) and the results showed that treatment with methylprednisolone may be beneficial for patients who develop ards in the reduction of the risk of death. briefly, of those patients with ards who received methylprednisolone treatment, of ( %) patients died, while those who did not receive methylprednisolone, of ( . %) died [ ] . in another study, patients with severe covid- that progressed to acute respiratory failure, use of methylprednisolone was associated with improvement in clinical symptoms (i.e., fever, hypoxia) and a shortened disease course in patients who received the drug compared with those who did not [ ] . moreover, according to expert consensus statement from chinese thoracic society, dosage regimen of methylprednisolone should be low to moderate (i.e., ≤ . to mg/kg daily or equivalent) [ ] and the most common regimens of methylprednisolone applied in china were typically - mg iv daily for a course of - days [ ] . the appropriate dosage (low dose versus high dose), place in therapy (early versus late), and role for corticosteroids (cytokine storm or comorbidity management) require additional clarity. there is concern that the use of corticosteroids may have deleterious effects (i.e., inhibition of immune response and pathogen clearance) in patients with covid- [ ] . one study reported no effect on mortality and decreased viral clearance with the use of corticosteroids [ ] . furthermore, the infectious diseases society of american recommends against the routine use of corticosteroids in covid- . however, they do recommend the use of corticosteroids in the setting of ards in the context of a clinical trial [ ] . similarly, the surviving sepsis campaign recommends against corticosteroids in mechanically ventilated patients with acute lung injury in the absence of ards [ ] . however, they provide a recommendation for the use of corticosteroids in patients with ards acknowledging the weak level of evidence. dexamethasone has demonstrated utility on ards by decreasing ventilator days and mortality on severe ards in patients without covid- [ ] . whether the use of corticosteroids provides similar benefit in patients with covid- and ards remains to be seen. ultimately, the clinical utilization of corticosteroids still needs to be established and should be considered on a case by case basis. since patients with pre-existing pulmonary conditions are at higher risk of covid- and should be closely monitored and cared, pulmonary vasodilator agents have been used in some patients for hypoxemia refractory to conventional treatments, but no study has been performed specifically on covid- patients. the surviving sepsis campaign suggested a trial of inhaled pulmonary vasodilator method as rescue therapy in mechanically ventilated adults with covid- , severe ards, and hypoxemia despite optimized ventilation and other rescue strategies. inhaled nitric oxide (ino) and inhaled epoprostenol (iepo, a naturally occurring prostaglandin) are two common pulmonary vasodilators that have been widely studied [ ] [ ] [ ] . experience in patients with ards indicates that ino can substantially reduce mean pulmonary artery pressure and improve oxygenation in such patients. furthermore, in vitro evidence of direct antiviral activity against sars-cov was studied and the genetic similarity between sars-cov and sars-cov- suggests their potential effectiveness against sars-cov- [ ] . for iepo, dosages up to ng/kg per minute have been used [ , , , ] . previous studies reported that to provide a clinically important increase in pao and reduction in pulmonary artery pressure, the most effective and safe dosage appears to be - ng/kg per minute in adults and ng/kg per minute in pediatric patients [ ] . for ino, therapy was given for ≥ days ( ppm on day , followed by and ppm on days and , respectively, then weaned on day ) in a pilot study on sars-cov [ ] . additionally, clinical trials evaluating ino for treatment or prevention of covid- are planned or underway (nct , nct , nct ) [ , ] . and on march , , fda granted emergency expanded access allowing its ino delivery system (inopulse®) to be immediately used for the treatment of covid- . finally, additional studies are needed to evaluate the potential role of iepo and ino in the treatment of covid- patients. sirolimus, also known as rapamycin, is an immunosuppressant that is used to prevent organ transplant rejection and to treat lymphangioleiomyomatosis (lam) by inhibiting mammalian target of rapamycin (mtor) kinase. it was originally isolated from the bacterium streptomyces hygroscopicus found on easter island (rapa nui) [ ] and is commercially available as rapamune (pfizer). mtor, and more specifically a protein complex mtorc formed by mtor, plays a key role in viral replication. in an in vitro experiment, sirolimus has been shown to affect pi k/akt/mtor pathway which inhibited mers-cov activity [ ] . a new randomized double-blind placebo-controlled clinical trial (scope) by university of cincinnati is planned to be conducted between april and september to test the effect of sirolimus on progression of patients hospitalized with covid- to advanced respiratory support [ ] . studies of patients hospitalized with influenza can further shed light on the antiviral effect of sirolimus. in a randomized clinical trial conducted on patients with confirmed h n pneumonia and on mechanical ventilator support, a group treated with corticosteroids and mg/day of sirolimus for days (n = ) showed significantly better clinical outcomes compared with the group treated with corticosteroids only, including shorter median duration of ventilator used [ ] . delayed oseltamivir plus sirolimus treatment in ph n -infected mouse model further suggested a significant association between the sirolimus treatment and improved outcomes [ ] . additionally, a new trial by the chinese university of hong kong is planned to begin in august to investigate the effect of sirolimus and oseltamivir on normalization of respiratory status and changes in biomarkers (viral rna concentration, cytokines/ chemokines and pro-inflammatory mediators) and several other clinical endpoints in influenza patients [ ] . at least one in silico study identified sirolimus as one of the potential candidates for treating covid- patients based on data from other human coronavirus infections using network-based drug repurposing model [ ] . tocilizumab (branded as actemra) is a humanized mab developed by roche and chugai pharmaceutical for treating ra and systemic juvenile idiopathic arthritis patients. at the time of publishing this article, clinicaltrials.gov listed planned studies that included tocilizumab treatment arm, all of them at the recruiting stage or earlier. a study published in april reported that severe or critical covid- patients in china were treated with the compound, with of them recovered at the time of publication and on the way to recovery (but still in icu). encouraged by these results, a larger multicenter clinical trial was launched (chictr ) and had about patients treated with tocilizumab already enrolled [ , ] . sarilumab, (branded as kefraza), a humanized mab, was developed by regeneron pharmaceuticals and sanofi for treatment of rheumatoid arthritis (ra). a phase / randomized double-blind placebo-controlled clinical trial was planned by regeneron pharmaceuticals and sanofi (and in partnership with northwell health's feinstein institutes for medical research) for march targeting to enroll covid- patients, measuring percent change in c-protein (phase only) and time to improvement on a -point scale (based on death and type of hospitalization) in patients with serum il- level above a threshold as primary endpoints. as of the time of this publication, the results of this study have not been made public [ ] . anakinra (branded as kineret by swedish orphan biovitrum) is a modified human il- receptor antagonist (il- ra) approved in in the usa and in in europe for use in ra patients. il- family of receptors triggers innate immune response and was associated with damaging inflammation [ ] . out of approved clinical trials involving anakinra treatment, also have tocilizumab as a comparison: one multicenter open-label non-randomized trial in greece with estimated enrollment of patients [ ] , and another multicenter randomized open-label trial in belgium with estimated patients has been enrolled to date [ ] . angiotensin-converting enzyme (ace ) receptor is regarded as an important target in the pathogenesis of covid- . studies reveal that frequently observed comorbidities, including hypertension and diabetes in patients infected with sars-cov- , are under medication with angiotensin-converting enzyme (ace) inhibitors or angiotensin receptor blocker (arb) [ ] [ ] [ ] [ ] that result in overexpression of ace . it is speculated that sars-covand sars-cov- bind to human cells via interaction with ace receptors [ , ] . the opposing physiological actions of ace and ace in the renin-angiotensin system are reviewed to determine the therapeutic efficacy of ace inhibitors or arbs [ , ] . in hypertensive patients, chronic treatment with angiotensin ii type receptor (at r) antagonists like losartan, lisinopril, or olmesartan facilitates cardiac and renal ace overexpression according to some in vivo studies [ , ] . in contrast, sar viral rna following entry into respiratory epithelial cells downregulates the activity of ace , thereby increasing the levels of angiotensin . this may potentially cause severe lung damage [ , ] . continued treatment with these drugs may be essential for the survival to attenuate the cardiac stress of advancing covid- infection and limit the vasoconstriction and profibrotic effects of angiotensin in alveolar capillaries. some of the anti-inflammatory drugs such as ibuprofen, a nonsteroidal anti-inflammatory drug (nsaid), are activators of ace receptors, same as ace inhibitors or arbs. their usage can lead to increased risk of contracting covid- [ ] . since fatal lung failure induced by sars-cov infections may be controlled by blocking renin-angiotensin pathway [ ] , ibuprofen may not be harmful. however, there is no strong evidence, suggesting a link between intake of an nsaid and worsening symptoms due to infection caused by sars-cov- . the fda considers ibuprofen and the likes as a potentially promising therapeutic agent against covid- [ ] . studies have demonstrated that thiazolidinedione and its derivatives, which are type diabetes mellitus drugs, show efficacious effect against pulmonary disease induced by respiratory syncytial virus (rsv) or h n influenza infection [ , ] . but their role as a therapeutic drug against coronavirus is not yet explored. interestingly, it is known that thiazolidinediones may have the potential to upregulate ace receptor, which is identified as a binding target for sars-cov- in host cells [ ] . however, lack of clinical evidence makes it uncertain to determine its therapeutic efficacy against coronavirus infections. amici et al. have demonstrated that indomethacin, a wellknown nsaid and a potential cyclooxygenase (cox) inhibitor, exhibits antiviral activity against sars-cov and canine coronavirus (ccov). in vitro studies suggest that indomethacin exhibits dose-dependent response in canine a cell monolayers infected with ccov with an ic of um after h of exposure. also, remarkable inhibition against sars-cov-infected vero cells by more than % at concentrations that were non-toxic for uninfected cells is also observed. in addition, indomethacin significantly blocks viral rna synthesis in dogs infected with ccov following oral administration of the drug ( mg/kg) [ ] . this suggests probable efficacy of indomethacin against sars-cov- [ ] . colchicine is an anti-inflammatory drug commonly used for gout management and a variety of other conditions sharing similar pathophysiology. its mechanisms of action are related to interfering with migration of neutrophils to sites of inflammation and blocking the inflammasome complex in both neutrophils and monocytes, thus reducing il- beta activation [ ] . colchicine also has inhibitory effects on macrophages via the inhibition of the nacht-lrrpyd-containing protein (nalp ) inflammasome and pore formation activated by purinergic receptors p x and p x . there may also be beneficial effects on endothelial function due to colchicine's antifibrotic activities. some patients with covid- present with myopathies and colchicine has been shown to reduce inflammation in the cardiac myocytes [ ] . there are several ongoing studies investigating colchicine for cytokine storm (nct , nct , nct ). niclosamide, an anthelmintic drug, has been shown to be an effective sars-cov virus replication inhibitor at dose concentration of . um or higher in vero e cells without interfering with binding of corona virus onto the cells [ ] . another study reveals the efficacy of niclosamide in inhibiting mers-cov replication in verob cells via reduction of skp regulated becn ubiquitination and enhancement of autophagic flux and its ic value is determined to be . um [ ] . thus, the possibility of niclosamide to inhibit sars-cov- cannot be neglected. ivermectin, a potent anthelmintic drug, was first discovered to inhibit interaction between integrase (in) molecule of human immunodeficiency virus (hiv)- and its nuclear transport receptor importin α/β [ ] . further studies exhibit its potential to prevent viral replication of a broad spectrum of viruses, including dengue virus, flavivirus, and influenza [ ] [ ] [ ] .very recently, ivermectin has shown inhibition against sars-cov- up to -fold at h in vitro. inhibition of impα/β -mediated nuclear import of viral proteins is suggested as the probable cause of its antiviral activity [ ] . it will be interesting to know its inhibition effect against sars-cov- in vivo. both nitazoxanide and its metabolite and tizoxanide have shown inhibitory effects against mers-cov in llc-mk cells. besides, inhibition of other corona virus strains, including murine corona virus, mouse hepatitis virus strain a (mhv-a ), bovine corona virus strain l (bcov-l ), and human enteric corona virus (hecov- ) by nitazoxanide is reported via suppression of viral n protein [ ] . nitazoxanide is found to suppress pro-inflammatory cytokines in peripheral blood mononuclear cells (pbmcs) and il- in vivo. however, the relevance of this information is currently unknown [ ] . this treatment option refers to transfusion of plasma loaded with antibodies from individuals after resolution from a specific pathogen. this technique has been used for decades [ ] . transfusion can offer a short-term, immediate immunity for individuals. convalescent plasma can be used prophylactically and for already infected patients to attenuate clinical severity [ , ] . mechanism of action is through binding of the transfused antibodies to the pathogen, resulting in cellular cytotoxicity, phagocytosis, or direct neutralization of the pathogen [ , ] . previously, convalescent plasma was used for two coronaviruses, sars-cov and mers [ ] . one large study in hong kong involving patients with sars-cov supported early administration of antibodies for optimal clinical effect compared to later administration [ ] . limited data from taiwan and south korea showed clinical benefits in severe cases of sars-cov and mers [ , ] . reported dosage varied widely in terms of the amount of plasma transfused and antibody titer [ ] . limited data on covid- patients from china illustrated clinical benefits [ , ] . pilot study reported clinical improvement in terms of fever, cough, tightness of breath, and chest pain while no serious side effects were reported [ ] . there has been considerable attention placed on the role of hypercoagulable state leading to micro-and macro-vascular thrombosis in covid- . disseminated intravascular coagulation and elevated d-dimer level were identified as predictors of worse outcomes in a cohort study of patients with covid- [ ] . patients receiving anticoagulants had a decreased mortality [ ] . heparin has anti-inflammatory properties and may also inhibit viral attachment via conformational changes to the sars-cov- surface receptor (spike) s [ ] . low molecular weight heparin in patients hospitalized with covid- was associated with lower serum il- concentrations, suggesting that there may be an added mechanism besides prevention/treatment of thrombosis [ ] . based on available evidence, it is reasonable to administer venous thromboembolism prophylaxis with either a low molecular weight or unfractionated heparin in hospitalized patients. in patients with rapidly progressing respiratory deterioration or where clinical judgment suggests thrombosis, treatment doses of anticoagulants may be considered. historically, traditional herbal medicines have been used in the past to control and to treat epidemic outbreaks [ ] including the past epidemic outbreaks, such as sars and h n influenza [ , ] . to date, china and south korea have issued traditional medicinal treatment guidelines on the prevention and treatment of covid- [ ] . it is reported that greater than % of sars-cov- -infected patients in china had received some forms of traditional chinese medicine (tcm) treatments [ ] . similar to sars-cov, sars-cov- uses host receptor ace for the cellular entrance; it appears that some traditional medicines may have the capacity to target ace and these show some promises to prevent the infection of sars-cov- [ , ] . due to the high similarity in epidemiologic, genomics, and pathogenesis between sars-cov- and sars-cov, some herbal medicinal products were used for the treatment of patients with infection of sars-cov- in china and korea [ , ] . the top most commonly used tcm herbal medicinal products in china to treat covid- patients include astragalus membranaceus, glycyrrhiza uralensis, saposhnikoviae divaricata, rhizoma atractylodis macrocephalae, lonicerae japonicae flos, fructus forsythia, atractylodis rhizoma, radix platycodonis, agastache rugosa, and cyrtomium fortunei j. sm [ ] . in addition, some tcm herbal products, such as shen fu injection and re du ning injection, could manifest potential immunosuppressive effects and thereby decrease the level of tnf-α, il- β, il- , il- , il- , and other cytokines, resulting in inhibition of lung inflammation or acute lung injury [ , [ ] [ ] [ ] . as discussed above, cytokine storm/inflammatory responses may contribute to the deaths of many covid- patients. thus, anti-inflammatory agents presumably could reduce the severity and mortality rate [ , , ] . it is reported that qingfei paidu decoction could inhibit and alleviate excessive immune response and eliminate inflammation by regulating immune-related pathway and cytokine actionrelated pathway. the herbal formula qingfei paidu decoction was recommended by both chinese and korean guidelines. according to a recent publication, this herbal formula increases immunity and reduces inflammation by targeting the lung and spleen in covid- patients [ ] . li et al. reported that lianhuaqingwen (lh), a tcm formula, significantly inhibited sars-cov- replication in vero e cells and markedly reduced pro-inflammatory cytokine (tnf-α, il- , ccl- /mcp- , and cxcl- /ip- ) production at the mrna levels [ ] . sangju yin and yinqiao san are commonly used in clinical treatment to clear "lung heat," expel phlegm, relieve cough, regulate the patient's lungs, and restore normal lung function [ ] . similarly, yinqiao san may have antibacterial and antiviral functions [ ] . several clinical studies showed that tcm may bring new hope for the prevention and control of covid- [ ] [ ] [ ] . in general, it appears that tcm products were commonly used in covid- patients with mild symptoms to severe symptoms and could prevent or block the diseases progression. although the precise molecular mechanisms currently are unknown, the potential role of anti-inflammatory/antioxidative stress, improving hypoxemia/hypoxia and antiviral activities, among others, could be some of the major drivers. further investigations in the future are needed to uncover the molecular mechanisms. conclusion the covid- pandemic represents the greatest global public health crisis in the past years. hopefully vaccines and or specific therapeutic drugs targeting sars-cov- will be made available in the next few months or years. with the speed and volume of basic and clinical covid- / sars-cov- research to develop potential drugs and therapies for this disease, our hope will be on the horizon. particular interest, published recently, have been highlighted as: • of importance •• of major importance a pneumonia outbreak associated with a new coronavirus of probable bat origin the proximal origin of sars-cov- growth and intracellular development of a new respiratory virus the adaptation of two human coronavirus strains (oc and oc ) to growth in cell monolayers identification of a new human coronavirus characterization and complete genome sequence of a novel coronavirus, coronavirus hku , from patients with pneumonia sars-cov infection in a restaurant from palm civet isolation of a novel coronavirus from a man with pneumonia in saudi arabia bad news wrapped in protein: inside the coronavirus genome structural basis for the recognition of sars-cov- by full-length human ace characterization of spike glycoprotein of sars-cov- on virus entry and its immune cross-reactivity with sars-cov emerging coronaviruses: genome structure, replication, and pathogenesis human coronavirus: host-pathogen interaction t cell-mediated immune response to respiratory coronaviruses viral innate immune evasion and the pathogenesis of emerging rna virus infections the host immune response in respiratory virus infection: balancing virus clearance and immunopathology groups at higher risk for severe illness coronavirus and covid- : who is at higher risk? covid- does not lead to a "typical" acute respiratory distress syndrome middle east respiratory syndrome: emergence of a pathogenic human coronavirus sars-cov and ifn: too little, too late dysregulated type i interferon and inflammatory monocyte-macrophage responses cause lethal pneumonia in sars-cov-infected mice sars and mers: recent insights into emerging coronaviruses clinical features of patients infected with novel coronavirus in wuhan, china epidemiological and clinical characteristics of cases of novel coronavirus pneumonia in wuhan, china: a descriptive study transcriptomic characteristics of bronchoalveolar lavage fluid and peripheral blood mononuclear cells in covid- patients drug treatment options for the -new coronavirus ( -ncov) discovery and synthesis of a phosphoramidate prodrug of a pyrrolo[ , -f][triazin- -amino] adenine c-nucleoside (gs- ) for the treatment of ebola and emerging viruses comparative therapeutic efficacy of remdesivir and combination lopinavir, ritonavir, and interferon beta against mers-cov remdesivir and chloroquine effectively inhibit the recently emerged novel coronavirus ( -ncov) in vitro first case of novel coronavirus in the united states compassionate use of remdesivir for patients with severe covid- antimalarial drugs in the treatment of rheumatological diseases the lysosomotropic amines, chloroquine and hydroxychloroquine: a potentially novel therapy for graftversus-host disease chloroquine inhibits autophagic flux by decreasing autophagosome-lysosome fusion new insights into the antiviral effects of chloroquine hydroxychloroquine, a less toxic derivative of chloroquine, is effective in inhibiting sars-cov- infection in vitro hydroxychloroquine decreases th -related cytokines in systemic lupus erythematosus and rheumatoid arthritis patients covid- : immunopathology and its implications for therapy chloroquine and hydroxychloroquine as available weapons to f i g h t c o v i d - zn( +) inhibits coronavirus and arterivirus rna polymerase activity in vitro and zinc ionophores block the replication of these viruses in cell culture chloroquine is a zinc ionophore hydroxychloroquine in patients with covid- : an open-label chloroquine diphosphate in two different dosages as adjunctive therapy of hospitalized patients with severe respiratory syndrome in the context of coronavirus (sars-cov- ) infection: preliminary safety results of a randomized, doubleblinded, phase iib clinical trial (clorocovid- study) safety considerations with chloroquine, hydroxychloroquine and azithromycin in the management of sars-cov- infection anti-hiv drugs: compounds approved within years after the discovery of hiv a trial of lopinavir-ritonavir in adults hospitalized with severe covid- case of the index patient who caused tertiary 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traditional chinese medicine for covid- treatment network pharmacology-based analysis of the role of traditional chinese herbal medicines in the treatment of covid- publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations funding information this work was financially supported in part by institutional funds, by r ca , from the national cancer institute (nci), r at and r at from the national center for complementary, and integrative health (nccih) of the national institute of health (nih) awarded to dr. ah-ng tony kong. key: cord- -ddulfe authors: ismael, julia; losco, federico; quildrian, sergio; sanchez, pablo; pincemin, isabel; lastiri, jose; bella, santiago; chinellato, alejandro; dellamea, guillermo; ahualli, alejandro; rompato, silvana; velez, julio; escobar, rafael; zwenger, ariel; rosales, cristina; bagnes, claudia; puyol, jorge; niewiadomski, dario; smecuol, edgardo; nachman, fabio; gonzalez, eduardo; ferraris, gustavo; suppicich, juan ramos; price, paola; medina, luis; o’connor, juan title: multidisciplinary approach to covid- and cancer: consensus from scientific societies in argentina date: - - journal: ecancermedicalscience doi: . /ecancer. . sha: doc_id: cord_uid: ddulfe introduction: the world is living through an outbreak of an acute respiratory syndrome caused by a new betacoronavirus known as coronavirus (sars cov- ), which has been declared an international public health emergency by the world health organisation. cancer patients are a very special population in this setting since they are more susceptible to viral infections than the general population. several recommendations have been made on this issue, most of them based on expert opinion and institutional experience. it is essential to gather the evidence available for decision making. objective: to review the evidence available in order to create a multi-institutional position from the perspective of scientific societies in argentina involved in the management of cancer patients. methodology: the review included two phases: ) search and systematic revision of the medical literature; ) consensus and revision of the document drafted by national scientific societies involved in the management and care of cancer patients using the modified delphi method. the final results were presented at a videoconference with all the participants. also, additional comment and recommendations were discussed. the final document was revised and approved for publication by the members of the panel. results: the consensus panel included representatives from scientific societies from argentina who assessed the evidence and then made recommendations for the management of cancer patients in our country. international guidelines (cdc; asco, nccn and esmo) were considered as a background for analysis, as well as institutional guidelines and an open ad hoc survey administered to healthcare professionals from the scientific societies involved in this study. the recommendations are grouped as follows: ) general care interventions—training of the personnel, cleaning and disinfection of the hospital premises and patient scheduling; ) treatment decisions—patient care, surgeries, immunosuppressive therapy, radiotherapy and screening; ) ethical considerations—optimisation of resources, end-of-life care for critically-ill patients; ) management of hospitalised patients; and ) wellbeing of the healthcare team. the general recommendation arising from the study is that the management of cancer patients must adapt to the exceptional pandemic status quo without disregarding treatment or cure options. moreover, healthcare professional accompaniment of all patients should not be neglected. all healthcare professionals must make a significant joint effort to create multidisciplinary teams to discuss the most appropriate measures for each particular situation. conclusions: the scientific evidence available on this topic worldwide is in progress. this together with the epidemiologically shifting scenario poses unprecedented challenges in the management of cancer amidst this global pandemic. furthermore, the key role of the healthcare structural organisation appears evident, such as the drafting of clear guidelines for all the stakeholders, adaptability to constant change and an interdisciplinary shared vision through consensus to provide adequate care to our cancer patients in the light of uncertainty and fast-paced change. the world is experiencing an outbreak of acute respiratory syndrome caused by a new betacoronavirus known as coronavirus (sars-cov- ) [ ] by march, , the rapid spread of the virus had resulted in , confirmed cases and , deaths. cases have been reported in countries. the world health organisation (who) has declared the new coronavirus disease , caused by sars-cov- , is a public health emergency of international concern. in contrast to the severe acute respiratory system, coronavirus and the middle east respiratory syndrome-related coronavirus, covid- has caused more deaths from multiple organ dysfunction syndrome than from respiratory failure [ ] , which could be attributable to the widespread distribution of angiotensin-converting enzyme -the functional receptor for sars-cov- -in multiple organs [ , ] . the authorities from national scientific societies were convened in order to appoint a participating member. his/her function will be to represent the institutional position with a single vote when developing the questionnaire. societies were invited and accepted the invitation to participate. the list of participating societies, representative and conflicts of interest are detailed in appendix i. once the pertinent and relevant evidence was identified, the points or questions of controversy to be developed in relation to the proposed theme were extracted. a list was generated following asco and nccn guidelines. the questionnaire was subsequently distributed among the members of the panel to validate the different aspects of the topic to address, and to modify or add relevant questions not covered in the initial proposal. the final questionnaire set out in this document was eventually agreed upon (appendix ii). consensus methodology: the modified delphi method was used. this is an iterative process, whereby participants must give their opinions or answers anonymously on more than one occasion, via rounds that result in opinion stability. it is characterised by feedback controlled by the coordinating group at each stage, through which a statistical response for the group is reached. a first round of questions was conducted using the survey monkey® tool, outlining a percentage of agreement of greater than %. by decision of the elaboration group, the same survey was carried out with an open and non-nominalised format by the members of the intervening societies, with the aim of finding out the general perception of the subject in different areas of focus. there were participants. the final results were presented in a video conference with all of the participants, where additional comments and recommendations were brought up. the results of the open survey were also shared, for the purpose of enriching the discussion space. in cases where the established percentage was not reached, a second vote was taken in order to come to an agreement during the video conference meeting. a draft document was prepared, which was sent by email for the members of the panel to review and conclude, in order to arrive at a final version of the document. recommendations from asco [ ] , nccn [ ] and esmo [ ] have charted them on six axes, which respond to these questions of healthcare practice for oncology patients, through evidence and the agreement of experts. we have supplemented this with local recommendations in the same order. what are the recommendations for the general care of cancer patients? points of practice may be considered to guide the clinic's preparation and planning: clinic or hospital staff may need additional training to assess patients for possible covid- / other infections [ ] . the procedures for isolating potentially infected patients may need to be reviewed and updated. clinic staff may need additional training on the use of personal protective equipment (ppe). it may be necessary to obtain additional ppe, as staff who do not usually use it may be required to perform tasks where it is appropriate. clinic or hospital staff may need additional training on how to obtain sars-cov- testing for patients according to the current testing guidelines. the recommendation for this is to follow the inter-institutional recommendations to prevent covid- -version / / of the argentine society of infectious diseases (sadi) / argentine intensive care society (sati) / infection control nurses association (adeci) / institute of epidemiology-dr juan h hara [ ] . it may be reasonable to postpone routine follow-up visits for patients who are not undergoing active cancer treatment, or make those appointments by telemedicine. consider calling all scheduled patients day before they visit the clinic in order to detect covid- exposure/symptoms. routine collection of laboratory samples from the patient's home may be considered, instead of having them come into the clinic. treatment planning: ) for patients with a fever or other symptoms of infection, an in-depth evaluation must be carried out according to usual medical practice. ) patientswith covid- currently receiving treatment against cancer must follow standard clinical management plans to delay or modify cancer treatment in a patient with an active infection. current information suggests that patients with cancer are at a greater risk of infection and severe complications from covid- than other patients. for the majority of cases where there is no known covid- infection, it is likely to be more important to start or continue systematic treatment, than delay or interrupt it over concerns about possible covid- infection. however, decisions should be made on an individual basis after considering the age of the patient, the general objectives of the treatment, the present oncological state of the patient and tolerance to treatment, as well as their general medical condition. consider if domiciliary infusion of chemotherapy medication is feasible from a medical and logistical point of view for the patient, medical staff and caregivers. in our country, legal aspects must also be taken into account. given that oncology patients are also at a high risk of serious complications from influenza, they should be vaccinated before starting chemotherapy (at least weeks before if possible), and in cases where chemotherapy has already started, it should be done immediately before the next cycle of treatment [ ] . initially, there was no formal recommendation regarding the use of masks with cancer patients [ ] . in the recommendations for health workers from the department of health in our country, they mention the use of masks by staff who care directly for isolated patients. for example, patients with influenza, coronavirus (including covid- ), respiratory syncytial virus, meningococcus, mumps, rubella and patients with respiratory infections walking around the hospital [ ] . in an update of the guidelines, the cdc recommends the use of masks for healthy people who are going to be exposed to the public, or for patients who must attend health centres; even more so for cancer patients, due to the risk posed by their illness. protection with masks/face coverings is complementary to maintaining distance and isolation as part of preventative measures [ ] . before symptoms are present, the usual early clinical evaluation is recommended [ ] . with respect to systematic covid- testing, there is no conclusive evidence. even though no conclusive increase has been established in the number of infections by covid- in people with an oncological diagnosis, there is evidence that they are more at risk of developing severe forms of the illness, with a higher death rate [ ] . at the moment, only one detailed published report has been identified that compares the spread of the covid- virus in the patients with and without cancer [ ] . this report outlines a prospective cohort of , patients with covid- , of which had a history of cancer. they observed that patients with a history of cancer had more severe complications. this was defined as the percentage of patients admitted to one of the intensive care units who required invasive ventilation or died, in comparison with other patients. according to correspondence from the report, xia et al [ ] , these patients represent a heterogeneous group and are not an ideal representation of the entire population of cancer patients. another recent publication, based on cases of cancer and covid- from three hospitals in wuhan, reports outcomes from patients. in these cases, . % developed severe forms of the illness and . % were related deaths [ ] . the cdc suggests 'elective surgeries' are rescheduled if possible. the american college of surgeons has also given a recommendation. however, doctors and patients should discuss individual cases, evaluating the potential harm of delaying cancer related surgeries; without which they risk missing the window of opportunity for surgical treatment of the patient. in many cases, these surgeries cannot be considered as 'elective [ ] . can immunosuppressive therapy be cancelled, delayed or interrupted? for patients with covid- who are currently receiving treatment for cancer, consider delaying or changing the cancer treatment for patients with active infection. the current information suggests that cancer patients are at a higher risk of infection and complications from covid- than other patients. for patients with no known covid- infection, in the majority of cases, it is likely to be more important to start or continue systematic cancer treatment, than delay or interrupt it over concerns about possible covid- infection. however, decisions should be made on an individual basis after considering the overall objectives of treatment, the current oncological state of the patient and their tolerance to treatment, as well as their general medical condition. at the moment, there is no direct evidence to support the change or suspension of chemotherapy or immunotherapy in cancer patients. therefore, suspending routine anticancer or immunosuppressive therapy is not recommended. the balance of possible harm that could result from delaying or interrupting treatment versus the possible benefits of preventing or delaying covid- infection is very unclear. clinical decisions should be individual considering factors such as the risk of the illness recurring if adjuvant chemotherapy is delayed, modified or interrupted, as well as the number of adjuvant chemotherapy cycles already done and the tolerance of the patient to treatment. however, the following practices should be considered: ) forpatientslargelyinremissionundergoingmaintenancetherapy,stoppingchemotherapymaybeanoption. ) somepatientsmaychangefromintravenoustooralchemotherapy,whichwoulddecreasethefrequencyofvisitstotheclinic,but would require greater care from medical teams to ensure the correct prescription is met. ) decisionsaboutmodifyingorsuspendingchemotherapyshouldconsiderchemotherapyadviceandtreatmentobjectives,aswellas the clinical characteristics of the patient and their tolerance to treatment. for example, the risk/benefit evaluation of continuing with chemotherapy in untreated small cell lung cancer patients is different to patients being maintained with pemetrexed for non-small cell metastatic lung tumours. ) iflocaltransmissionaffectsoneoncologycentreinparticular,reasonableoptionsmayincludeofferingachemotherapybreakfor weeks, organising infusion at a remote unaffected unit, or coordinating treatment with another unaffected centre. ) considerhomeinfusionifitismedicallyandlogisticallyfeasibleforthepatient,medicalteamandcaregivers.insomeenvironments, the delay or change of adjuvant treatment may mean putting infection control at risk, compromising long-term survival. prophylactic growth factors that would be used in high-risk neutropenia chemotherapy regimes, as well as prophylactic antibiotics, can have potential value in maintaining the general health of the patient and make them less vulnerable to possible complications from covid- . in cases where the overall benefit from adjuvant chemotherapy may be small, and where there are no immunosuppressive options available (for example, hormonal therapy in early-stage hormone-dependant breast cancer), the risk of infection from covid- can be considered as an additional factor to evaluate before the different options available to the patient. immunotherapy: it is important in the context of active treatment in cancer patients. it includes the use of agents such as pd- inhibitors, for example, nivolumab and pembrolizumab and anti ctla- therapy such as ipilimumab. on this point, consider aspects [ ]: ) itispossiblethattreatmentrestorestheimmunesystem,creatingasimilarpicturetothatdevelopedinsevereformsofcovid- (caused by a massive release of cytokines). ) considerthesubtypeofthetumourandtheobjectiveofthetreatmenttodecidewhethertocontinueorstarttreatmentwithpd- inhibitors (e.g. melanoma, kidney cancer). ) evenifthealveolitiswasgeneratedwithtoxicitybythepd- inhibitorsisnotafrequentoccurrence,itcanbethecauseofdeathinup to % of cases. in patients with comorbidity or a respiratory disease, it is necessary to consider the increased risk when using pd- inhibitors, mainly when combining pd- inhibitors with anti ctla therapy. in summary, here are recommendations [ ] : ) onlythepatientshouldenterthecentre,wearingamaskandkeepingasafedistancefromothers. ) first-timeandpost-treatmentconsultationsshouldtakeplaceviavideocallortelephone. ) deferstartingtreatmentinearly-stagecasesoftheillness.thesecasesshouldhavebeenpreviouslydiscussedbythetumourcommittee. confirmed cases of covid- : treatment will be limited to urgent cases, such as patients with spinal cord compression, superior vena cava syndrome or bleeding identified by a specialist. in this situation, it is vital to give priority to hypofractionated treatments, especially with a single dose ( gy or gy in fx). for non-urgent cases, treatment will be paused depending on the individualised decision for each patient. individual and group protection is defined accordingly by the rules established by the ministry of health. the last shift of each day will be dedicated to treating patients with suspected or confirmed cases of covid- . diagnoses in which it is feasible to omit starting radiotherapy treatment in breast cancer patients are: hormone receptor-positive ductal carcinoma (dcis, rh+); patients over years who are receiving hormonal treatment after carrying out an individualised evaluation of the risks and benefits of adjuvancy treatment alongside radiotherapy; dcis in patients under years who meet the low-risk criteria (clinically hidden tumour, detected by mammogram, screening or incidental findings during surgery amounting to a mm with a nuclear grade or ). in these hormone receptor-positive cases, endocrine therapy needs to be completed. in cases of stage ia (ct n ) luminal a invasive ductal carcinoma for those over years who receive hormone therapy and palliative cases with a luminal illness with an indication of hormone therapy. prostate cancer: depending on the clinical characteristics and the risk subgroup, the use of neoadjuvant androgen deprivation therapy should be evaluated. in case of low-risk or very low-risk illnesses, it is recommended to continue active surveillance. for intermediate-risk diseases, defer starting treatment during the contingency period. for localised high-risk and very high-risk diseases with positive ganglions, it is not advisable to start treatment during the contingency period when neoadjuvant androgen deprivation therapy is the proposed method of treatment. for advanced illnesses, delay starting treatment within this period. such illnesses are based on the stampede protocol or ablative therapies of metastatic diseases or m . all patients must continue androgen deprivation therapy. for patients with a biochemical recurrence and without a distant disease, it is recommended to begin hormone therapy. consider postponing radiotherapy in treatments with palliative intent in asymptomatic or oligosymptomatic patients, or in response to medical management. brachytherapy: palliative brachytherapy is recommended for skin tumours. should members of the community continue with recommended activities for detecting cancer (e.g., mammograms)? to conserve resources in the health system and limit contact with patients at healthcare facilities, asco recommends that procedures requiring visits to clinics and centres, such as mammograms and colonoscopies, should be postponed for the time being. it is recommended that healthcare teams carefully consider the risks and benefits of continuing elective procedures, such as screening procedures, at this moment. digestive endoscopy generates aerosols [ , ] . the viral load of sars-cov- in the pharyngeal saliva is similar to that in stool, where it can linger for days after respiratory sample results indicate they are negative [ ] . up to % of infections with sars-cov- occur during the presymptomatic phase [ ] . the core recommendations of the spanish association of digestive endoscopy (seed) during the covid- pandemic consist in: endoscopist responsibilities: • under the oath to do no harm that doctors have taken, the seed reminds us that all endoscopic doctors must currently: • suspend all scheduled endoscopic outpatient activity. • without delay, be available to carry out urgent endoscopies. • limit digestive endoscopy to vital hospital activity, such as in: a) p atients with upper gastrointestinal bleeding who suffer from haemodynamic instability, when it is possible to carry out endoscopic treatment. b) patients with oesophageal impaction from foreign bodies. c) patients with obstructive cholangitis who require an ercp. d) cancer patients who require endoscopic treatment. e) specific colonoscopies, where diagnostic yield is urgent. • protect themselves and all personnel by properly using ppe [ , ] . beyond the care of each individual patient, medical oncologists will have to face the reality of limiting care. as the pandemic advances, a point will arrive at which channelling a large number of resources for an individual patient will directly conflict with the greater social good. if a cancer patient at an advanced stage of the illness or with comorbidities, such as cardiac or pulmonary dysfunction, becomes infected with covid- and requires mechanical ventilation, it's possible that it's a bleak prognosis. based on a recent retrospective study from wuhan, china, only one patient survived from the who were all gravely ill with confirmed cases of covid- and required mechanical ventilation [ a large number of sars-related coronaviruses (sarsr-covs]. therefore, it is imperative to have proactive discussions about end of life arrangements and palliative care with cancer patients at risk of infection by covid- . the proactive discussions surrounding these challenging decisions should occur among specific groups of illnesses, between specialists in medical ethics and palliative care teams. in triage procedures, where patients with a shorter life expectancy should not be treated, palliative care teams insist that these patients should not be abandoned, but still provided with the adequate health care needed. in this regard, it is convenient to adapt spaces for patients with a shorter life expectancy. such will avoid overburdening healthcare workers on the front line who will suffer extreme stress seeing patients pass from untreated symptoms and who will at times be unable to exercise their necessary skill and expertise. from an ethical perspective, we can assume the following criteria: ) protection from harm. a flu pandemic and classification system can cause significant physical and emotional distress. it is our obligation to protect those who suffer from the effects of the pandemic and classification system. ) proportionality. the administration of resources in palliative care must reflect the needs of the community and high-quality palliative care must be provided to those who need it. medication, equipment, beds and specialists must not 'accumulate' when they are needed by others in the community. ) obligation to provide access to care. palliative care is a critical component of any pandemic classification plan and the professionals working within palliative care have an obligation to provide care and alleviate suffering. this must be balanced by the obligation to protect the health of oneself and that of their families. reciprocity. palliative resources should be directed more to patients who have greater burden on the classification system, such as critical patients who will not receive life support treatment. these patients (and their families) run a greater risk of feeling abandoned by the healthcare system and should receive care based on the therapeutic objective for comfort by an interdisciplinary palliative care team. we must ensure that high-quality palliative care is available for all patients who may need it, regardless of their ranking on the scale. the argentine association of medicine and palliative care (aamycp) have made the recommendations outlined in this document (see appendix iii), https://aamycp.com.ar/covid /. the priority for oncology units for hospitalised patients has been to prepare for the upcoming bed and resources shortage caused by the expected increase in covid- patients who require beds and acute care in intensive care units (icu). even though some centres have beds or facilities that are allocated for cancer care, the rapid increase in cases may require the reassignment of units, hospital wards or even entire systems for patient care during the pandemic. shortage of blood products due to the drop in blood donors within the community calls for stricter usage guidelines both for clinics and hospitals [ ] . transfer of potentially infected patients from one centre to another requires careful logistics planning in order to reduce both public and staff exposure. due to shortage of supply and increased demand, creative solutions must be developed to preserve ppe, including favouring hand-washing with soap and water over using hand gel in standard precaution wards, limiting the number of team members entering patient rooms and reducing nursing procedures that require ppe, such as measuring urine output. to protect staff, ppe training sessions must be updated and available to all the users. it is recommended to adopt a policy limiting the number of visitors in hospitalised patient departments in order to protect both the public and patients from exposure and reduce the use of ppe, with rare exceptions, such as end-of-life circumstances. these decisions, taken together with patients, are difficult both for patients and families as well as medical personnel, who acknowledge the significant contribution of friend and family support for hospitalised cancer patients. finally, the emotional and physical well-being of our staff requires proactive attention. provider burnout is expected; therefore, priority must be given to protecting the health of frontline staff and ensuring a safe workplace environment. furthermore, human resources should be attended to by developing policies and compensation for leaves of absence and mandatory isolation and creating work support groups. reassignment from clinical tasks to administrative functions must be considered for immunocompromised staff or those having significant comorbidities that put them at higher risk of covid . guidelines for healthcare staff [ , ] • schedule and take short breaks from work to de-stress and attend to your basic needs. a few minutes of rest during your shift can be enough. even a -minute walk can improve your energy and mental focus. • take time each day to do something that brings you joy, even if it is for a brief moment. • maintain a healthy diet; bring your own food to work. • keep your daily activities schedule as regular as you can. • take some sunlight. • try to practice chair yoga or stretch at work. • exercise regularly. try to walk or bike to work if you can. • avoid or limit alcohol and caffeine consumption. • manage excessive fatigue, irritability, lack of concentration or anxiety. • take a moment to breathe slowly before entering a work area or entering or exiting a patient room. this can be difficult while you are wearing personal protective equipment, such as a mask, but breathing is relaxing and helps your body ease the physical symptoms of stress. if you consult regularly with a mental health professional, schedule video appointments or a telephone call. if you do not consult regularly with a mental health professional but do feel that it could be useful at this moment, schedule an appointment or call. • if a spiritual practice is or has been important to you in the past, resume it. the covid- pandemic has posed unique challenges and learning opportunities for oncology centres. the future trajectory of this pandemic is uncertain and we must continue to prepare for its widespread impact. the situation is dynamic and policies and recommendations may change at any point. while we write this document, the health crisis surrounding covid- continues to evolve, and circumstances may change some of our current recommendations. we hope to overcome these uncertain times, even though the long-term economic and emotional impact will be two great future challenges. however, the overall objective is to continue to provide compassionate and safe care to cancer patients. we hope to continue to support our patients and the cancer community while this pandemic continues to spread globally. the the questions were presented to the panel and then distributed to the associates of the different scientific societies, whose responses were anonymous and not identified by name. this constituted a component for the face-to-face discussion, where results of the literature review were presented (sent in due course along with the first delphi round), the survey open to medical professionals who treat oncology patients and the first round of the delphi panel. it is to be noted that the professionals, when responding to the open survey, did not have the document with the analysis and synthesis of the literature review prepared by the revising group, which reflected their usual practice. the analysis of responses concluded that: regarding the question on triage or patient selection for first-time consultations or face-to-face consultations at their centres, there was a satisfactory implementation in % of cases. when asked about an established algorithm at their centres for patients with fever and suspicion of covid- , there was an affirmative response in % of cases. for the question about when cancer patients who had finished their specific treatments would be considered at risk of developing severe forms of covid- , little over half ( %) responded only in those cases less than months from completion of onco-specific treatment. however, % did not take this variable into account and considered all those who had received treatment to be at risk. in relation to the question about adjuvant treatment in patients at risk of developing severe forms of covid- , % revealed inconsistent practices. for example, % decided to delay adjuvant treatment, while the remaining % decided to conduct curative treatment regardless of the covid- situation. on the other hand, % decided to delay treatment in all cases. different comments about this subject were sent, the majority of which agreed on the decision or individualisation of treatment by taking into consideration the risk-benefit ratio, consensus with the patient and also discussions within the interdisciplinary framework. for those deciding to delay treatment, a -day cut-off point was mentioned (two comments). one comment refers to the extreme situation, that is to say the catastrophe, under which it would also depend on the resources of the healthcare system and prioritisation of care. when asked about the use of radiation therapy and prioritising cases, % responded by referring to symptomatic advanced illness or oncological emergencies, preferably with hypofractionated schedules. almost one third of cases ( %) included invasive cancer with curative intent, provided there was no neoadjuvant treatment option. % took no position in relation to radiation therapy. regarding performing elective operations for cancer and the practice adopted in their medical society or care centre, % would not consider delaying surgery, since it would not be elective as it pertained to a serious disease such as cancer. however, one third of cases ( %) envisage postponing all surgical operations, and % consider that postponement should only occur in the context of containment and mitigation due to sars-cov- . responses to this question mention discussing postponement of certain types of surgery on a case-by-case basis, highlighting the importance of not missing the therapeutic window of opportunity-such as in the case of patients receiving neoadjuvant therapy. as a follow-up to the previous question, respondents were asked about the resection of metastases for remedial purposes: % answered that the decision was to proceed with surgery anyway to avoid missing the window of opportunity. nearly half of the cases ( %) favour maintaining systemic treatment and rescheduling surgery. as regards elective surgeries and the health centre's adoption of covid- screening measures for patients in the at-risk category, in % of cases these are conducted through anamnesis and historical exposure records. in % of instances, it is mentioned that all preoperative cases undergo pharyngeal swabbing. in considering the treatment and strategy for cancer patients, % agree that treatment be decided in all cases following discussion by the multidisciplinary team, whereas % are of the opinion that a discussion should only be held in cases where this is warranted at the discretion of the treating physician. concerning the highly sensitive and important matter of ppe, or personal protective equipment, on this subject % of respondents agree or strongly agree with measures taken by their centre. approximately, one third disagree or strongly disagree with measures taken or implemented by their centre. a panel comprising the scientific organisations met to discuss via video conference on april, . global and national epidemiological data were presented, and the definition of risk groups was shared, along with what has been published by the ministry of health on the handling of chronic noncommunicable diseases. review of the document's structure: based on evidence arising from three clinical practice guides (nccn, asco and esmo). an account was made of the methodology used: search, modified delphi consensus. the result of the open-ended and non-standardised survey submitted to the participating organisations' professionals was presented in statistical format. the panel's composition was outlined. question : implementation of a triage system for oncological consultations: % agreement in the open survey, in agreement with the panel. question : organisational algorithm in response to the admissions circuit for patients with suspected or confirmed covid- symptoms: agreement in both surveys. discussion: chemotherapy clinics or oncology day units at hospitals are high-transit areas presenting a higher risk of contagion in the context of the covid- pandemic. patients (actively undergoing treatment and at greater risk of immunosuppression), accompanying persons and health care team members all transit through these areas. implementing safety measures is a priority: implement social distancing in waiting rooms: restrict the number of accompanying persons to one per patient, adhere strictly to the schedule of appointments, establish spacious waiting areas or allow patients to walk around until their treatment begins (e.g., suggest that they leave the waiting room and call them on their phone once it is their turn for treatment). reduce daily patient admissions capacity: to avoid overcrowding in the waiting room and treatment room, assess the feasibility of increasing available days and extending time slots for treatment in order to curb the daily volume of patient admissions. implement a pre-entry triage: looking for symptoms indicative of a covid- infection, carry out or reinforce its implementation if conducted prior to admission to the facility. respect social distancing in the treatment room: configure seats to ensure appropriate distance between patients and accompanying persons, and provide health care practitioners with sufficient room for manoeuvre. conduct methodical cleaning between patients: to this end we rely on the inter-institutional recommendations for preventing covid- , version / / sadi/sati/adeci/ine [ ] . question : in relation to the time interval following the end of treatment taken as a risk variable: open survey: the majority of respondents indicated less than six months. panel: % indicated less than six months. not time-dependent %. discussion: consideration given to assessing patients in line with prescribed monitoring controls. three months and six months following the completion of treatment. even within the month time interval, a stricter approach should be adopted towards the oncological monitoring plan. there is uncertainty regarding immunological recovery, which in some patients can be lengthy (up to months), and should therefore be monitored. the wuhan case study report reveals that oncology patients stand a higher risk of suffering serious complications ( % compared to % in cancer-free patients, p = . ) regardless of the treatment-or illness-free time interval. after adjusting to account for other variables such as age, smoking habits or other comorbidities, the risk was markedly higher (or . ic % . - . ) in the subgroup where chemotherapy treatment had been completed or an operation performed in the preceding month. consequently, the panel recommends that risk be discussed on a case-by-case basis in order to establish monitoring needs. in an open survey, the majority chose to delay the start of treatment, contrasting with the panel's strongly supported choice to follow standard procedure. discussion: possibility of case-by-case discussion linked to the current phase of the pandemic in the country. decisions need to be taken in the context of the pandemic's evolving epidemiological landscape, with a particular focus on rationalising resources. in light of the existing impact of the pandemic on comorbidity-free patients, the panel agrees to recommend that standard oncological treatment may be continued. for patients that are elderly and/or have comorbidities, assessments will be performed using the same criteria as under non-pandemic conditions. the treatment's absolute benefit and potential risks need to be weighed up for each pathology, targeting prioritisation and decision making within a multidisciplinary team context. in an open survey, % pointed to limiting radiation therapy to urgent cases only, preferably through hypofractionation schemes. the panel is in agreement. % have not adopted a formal position on the matter. discussion: certain definitive treatment modalities should be incorporated such as treatment for cancer of the cervix, lung, anus and adjuvant treatment of breast, head and neck cancer. hypofractionated treatment modalities can be envisaged whenever feasible. the timely and proper delivery of radiation therapy is a priority where some of the pathologies mentioned are concerned, in instances where hypofractionation (anal, cervical, and head and neck cancers) and concurrent radiotherapy and chemotherapy treatment modalities are not an option. for such pathologies priority should be given to standard fractionation treatments, following prior multidisciplinary committee discussion. in the open survey referring to non-postponement because of the non-elective nature of surgeries, the panel's view is to delay only in the containment stage and not to postpone. discussion: it must be considered within the context of the current phase of the pandemic, assessing the risk for complications on a caseby-case basis and the need for icu. this extends to human resources, in terms of health care teams and treatment centre resources that are faced with the pandemic's potential to evolve into a catastrophic situation. the natural progression of the illness also needs to be considered (e.g., pancreatic cancer where delaying would not be feasible), provided surgical interventions are curative in scope. prioritising surgeries in pathologies with curative criteria, otherwise refer the patient to concurrent therapies or chemotherapy. multidisciplinary teams should discuss each case individually. furthermore, considering context: the progression of the pandemic compared to available resources in each centre. the aim is to prioritise surgeries for patients who risk missing a therapeutic window (i.e., colorectal cancer patients with metastases after conversion treatment) based on an epidemiological assessment of covid- question : elective surgery and screening patients to detect covid- : open survey, the panel agreed on only screening using clinical criteria. what happens with asymptomatic patients in this community transmission phase? experience and studies from wuhan show that major surgery for covid- -positive patients increases mortality. studies by shaoqing et al. [ ] and other authors [ ] found that patients having major surgery should be swabbed as sars-cov- infection increases mortality. infection also negatively impacts patients at high risk due to age and/or comorbidity as well as underlying oncological disease. these patients need chemotherapy, radiotherapy, or therapies with a high risk of neutropenia or immunosuppression. question : multidisciplinary team discussion: the panel agreed to recommend multidisciplinary team discussion of all cases. question : ppe: there is a consensus that the measures adopted are adequate for institutions. please consider that these recommendations may change. protecting patients must be a priority. advance decisions and support at the end of life. palliative care association document (aamycp). decisions amid scarce resources, such as ventilation criteria. there are algorithms for setting clinical and ethical decision making criteria. isolation at the end of life, crafting communication strategies to promote support. there are common elements in all multidisciplinary discussions that have addressed distinct questions. decisions and recommendations should consider the national epidemiological situation (if it is not catastrophic). measures and their implementation must be considered based on resources, available medical equipment, and care centres in which each professional works. the ideal framework for supporting medical decisions is a multidisciplinary discussion including all involved specialists and relies on the recommendations of scientific organisations. a general recommendation is to provide adequate care to oncology patients in exceptional pandemic circumstances without missing opportunities to treat or cure them. clinicians must also continue to provide professional support for all patients. this recommendation requires health professionals to strive to create multidisciplinary teams that can discuss the best, most timely measures for each situation. discussions continue about how to classify patients at greatest risk of developing severe forms of covid- , for example, patients who will have major surgery, chemotherapy or radiotherapy. is swabbing all patients before these therapies to detect asymptomatic infection adequate? if swabbing is feasible and is implemented systematically, how will it impact patients whom testing identifies as presymptomatic? another unresolved response issue is what some authors call the third wave: measuring the medium-term impact the pandemic has on response measures. for example, the consequences of delaying or interrupting care for chronic, non-communicable diseases, including cancer. the relevant international scientific evidence is still under investigation. incomplete evidence combined with constantly changing epidemiological circumstances poses unique challenges for treating cancer during a global pandemic. it is clear that health systems need organisational frameworks, such as preparation guidelines for all staff. the flexibility to adapt to change and a shared, multidisciplinary vision based on consensus are also vital. institutions need these elements to continue treating cancer patients adequately amid uncertainty and rapid change. cancer patients in sars-cov- infection: a nationwide analysis in china epidemiological and clinical characteristics of cases of novel coronavirus pneumonia in wuhan, china: a descriptive study a pneumonia outbreak associated with a new coronavirus of probable bat origin tissue distribution of ace protein, the functional receptor for sars coronavirus. a first step in understanding sars pathogenesis centers for disease control and prevention information for healthcare professionals: covid- and underlying conditions nosocomial infections in patients with cancer selective depletion of regulatory t cell subsets by docetaxel treatment in patients with nonsmall cell lung cancer features of postoperative immune suppression are reversible with interferon gamma and independent of interleukin- pathways myeloid suppressor cells in cancer and autoimmunity ministerio de salud estadísticas -incidencia managing cancer care during the covid- pandemic: agility and collaboration oward a common goal esmo covid- : supporting oncology professionals sadi recomendaciones inter-institucional para la prevención de covid- sadi / sati / adeci / ine vacunación en huéspedes especiales ministerio de salud recomendaciones para el uso de los epp centers for disease control and prevention how to protect yourself & others clinical characteristics of covid- -infected cancer patients: a retrospective case study in three hospitals within wuhan american college of surgeons covid- : elective case triage guidelines for surgical care controversies about covid- and anticancer treatment with immune checkpoint inhibitors immunotherapy recomendaciones generales de actuacion ante la situación de pandemia por covid- paraservicios de radioterapia de adultos considerations in performing endoscopy during the c- pandemic. ge m coronavirus can persist in stool after its clearance in respiratory tract. faculty of medicine cpra m estimating the generation interval for c- based on symptom onset data medrxiv seed recomendaciones de la seed: protección en unidades de endoscopia frente al covid- endoscopistas digestivos de buenos aires coronavirus: recomendaciones para unidades de endoscopia endoscopistas digestivos de buenos aires recomendaciones para unidades de endoscopia parte ii covid- response tools: seattle cancer care alliance stress management and self-care during covid- : nccn publishes guidelines clinical characteristics and outcomes of patients undergoing surgeries during the incubation period of covid- infection eclinicalmedicine intercollegiate general surgery guidance on covid- update arethemeasuresyourcentrehastakentomanagepersonalprotectiveequipment(ppe)appropriate?indicatetheoptionthatmatches your opinion best national scientific organisation guidelines included in the document • sociedad argentina de terapia radiante dr maría celeste diaz contributed to the methodology of this report. dr federico esteso provided technical support for and participated in the virtual meeting.we would also like to thank the professionals who answered the open survey, providing perspectives of their daily practices. the declaration of conflicts of interest was made by all members of the development group and participants in this consensus. the group of experts states that no sponsorship was received for the development of the document. this document represents the position of the participating scientific societies in the development of this recommendation. the recommendations are the product of a careful evaluation of the available evidence. in no case does it replace the clinical judgment of the treating physician, nor does it substitute for medical judgment in making appropriate decisions for each individual case, the consultation of the patient, the family or the caregivers. key: cord- -pijvvo i authors: peivandi, s.; razavi, a.; shafiei, s.; zamaniyan,; m., orafaie; a., jafarpour; h., title: evaluation of attitude among infertile couples about continuing assisted reproductive technologies therapy during novel coronavirus outbreak date: - - journal: nan doi: . / . . . sha: doc_id: cord_uid: pijvvo i study question: does the fear of the coronavirus disease (covid- ) pandemic reduce the desire of infertile couples to continue treatment? summary answer: most of the participants in this study wanted to continue treatment. what is known already: the effect of the prevalence of infectious diseases including the zika virus on the attitude of infertile couples has been studied in very few studies. however, the effect of the outbreak of covid- on the attitude of infertile couples has not been investigated. study design, size, duration: we conducted a prospective longitudinal study on forty-six infertile couples (n= ) who referred to our infertility clinic from march through june . participants/materials, settings, methods: this study is based on potential infertile couples for treatment with assisted reproductive technology (art) who referred to our infertility clinic, sari, iran (median age of . years). all individuals with primary infertility, as defined by the world health organization (who) and candidates for art, were included in the study. people who did not agree to participate in the study were excluded. subjects were surveyed using a researcher-made questionnaire. this questionnaire has four sections as follows: the first part included demographic information and clinical characteristics, the second part included medical records, the third part included questions related to assessing the level of awareness regarding coronavirus infection, and the fourth part included questions related to the attitude towards continuing infertility treatment. the validity of this questionnaire was assessed by three infertility specialists and was confirmed with cronbachs alpha of . . a p-value of less than . was considered statistically significant. main results and the role of chance: there is no significant relationship between covid- symptoms and the level of awareness (p-value < . ). thirty-two patients ( . %) had decreased motivation to continue treatment during covid- pandemic. fear of transmission to the fetus ( . %) had the highest frequency among the causes of decreased motivation to continue treatment (p-value = . ). confidence in support of the treatment team ( . %) was the most common reason for lack of motivation in people without decreased motivation (p-value < . ). the majority of patients had a very high or high tendency ( . %) to continue or start treatment during the covid- pandemic (p-value < . ). most people had an average fear of getting the disease ( . %) (value < . ). examining the relationship between the presence of covid- symptoms and attitude level variables showed that there is only a significant relationship between the greater desire to have a child and the continuation or initiation of treatment with the presence of covid- symptoms (p-value = . ). limitations, reasons for caution: we were not able to fully assess patients' deep feelings and cultural beliefs, due to the use of questionnaires and the lack of interviews. wider implications of the findings: our results showed for the first time that patients' knowledge about covid- and trust in the treatment staff played an effective role in selecting and continuing infertility treatment. to clarify this issue, studies with the larger statistical community in the form of interviews are needed. study funding/completing interest(s): the study received financial support from the mazandaran university of medical sciences (grant number: ). none of the funders had any role in the study design, collection, analysis, or interpretation of data, writing of the paper, or publication decisions. the authors have nothing to declare. trial registration number: n/a in december , unknown pneumonia was reported in wuhan, china, which belongs to the coronavirus family ( , ) . the most important way of severe acute respiratory syndrome coronavirus (sars-cov- ) transmission is through direct person-to-person contact and respiratory droplets ( ) . in addition, this virus was also detected in urine, feces, and tears, which confirm the possibility of transmission through the fecal-oral route ( , ) . so far, there is no evidence that this disease can be transmitted through sexual secretions and the pregnant mother to the child, but there are doubts and suspicions in this regard ( , ) . bioinformatics analysis has shown that the angiotensin-converting enzyme (ace ), the receptor used by sars-cov- for infectivity, is abundantly expressed in the testes and male reproductive system ( , ) . there are also reports that human coronavirus e (hcov- e), which is a member of the sars-cov- family, has been found in vaginal discharge ( ) . therefore, it is suspected that sars-cov- could be transmitted through sexual secretions ( ) , and such concerns about infectious diseases can affect the process of continuing infertility treatment in infertile couples ( , ) . infertility is a couple's failure to conceive after at least one year of trying ( ) . worldwide, the rate of primary infertility in women aged - is estimated at . %. however, the prevalence of infertility varies from country to country ( ) . according to data collected by the world health organization (who) in , there are million infertile couples in developing countries except for china. however, a large part of the world, including iran, is reluctant to use modern methods of pregnancy ( , ) . on average, about - % of couples in iran have infertility problems ( ) , of which % seek medical treatment, which may initially include medication or surgery ( ) . if these first treatments do not work or are considered inappropriate, about % of these couples are recommended to use assisted reproductive technologies (art). one of these methods is in vitro fertilization (ivf), which accounts for more than % of arts. the success rate of this method is . - . % ( ) . when starting treatment, couples have to endure a variety of treatments, including ovarian stimulation, regular monitoring, egg retrieval, embryo transfer, and the use of progesterone supplements ( ) . examination, research, and injections can severely disrupt a couple's daily routine ( ) . therefore, couples can be expected to suffer from the stressful experience of infertility because they endure the pressure of painful treatment and the fear of failure ( ) . it has also been found that couples seeking ivf approach are more likely than non-ivf couples to report unstable relationship due to length and treatment expectations ( , ) . while the social, ethical, and legal issues regarding art are well documented globally, as well as in asia, many iranians are unaware of the exact application of this technology ( ) . due to the nature of . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted september , . . https://doi.org/ . / . . . doi: medrxiv preprint treatment and pregnancy, objective measurement of psychological, social, emotional, and attitudinal effects on couples using art is limited ( ) . several studies have examined the experiences of infertile couples in ivf treatment ( ) . these studies have mainly focused on the impact of social contexts on infertility, especially in the two weeks waiting for pregnancy outcomes following embryo transfer ( ) and life after unsuccessful treatment ( ) . also, it has been reported that some viral infectious diseases such as zika can cause abnormalities and microcephaly in the fetus ( ) , which has influenced the attitude and decision of infertile couples to continue infertility treatment with art ( , ) . due to the fact that the transmission of sars-cov- through sexual secretions, and through the pregnant mother to the child has not yet been confirmed, during coronavirus disease (covid- ) pandemic, some of these important aspects need to be considered: ) accurate identification infertile women who are sensitive at this time; ) effective personalization of stimulation based on maternal age and ovarian reserve; and ) prevention of art-related risks such as ovarian hyperstimulation syndrome (ohss), complications associated with egg retrieval, and multiple pregnancies ( ) . all of these factors influence couples' decisions to seek infertility treatment. considering that no study has been done on the effect of covid- pandemic on the decision of infertile couples to continue infertility treatment and the importance of investigating this issue in iran, we decided to examine the attitude and knowledge of such individuals regarding the treatment during covid- pandemic. this study is a prospective longitudinal investigation on potential infertile couples for treatment with arts who referred to our infertility clinic from march to june . forty-six infertile couples (n= ) were studied voluntarily and anonymously in this study. this study was all individuals with primary infertility, as defined by the who ( ) and candidates for assisted reproductive technology (art), were included in the study. people who did not agree to participate in the study were excluded. subjects were surveyed using a researcher-made . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted september , . . questionnaire. this questionnaire has four sections as follows: the first part included demographic information and clinical characteristics, the second part included medical records, the third part included questions related to assessing the level of awareness regarding coronavirus infection, and the fourth part included questions related to the attitude towards continuing infertility treatment. the validity of this questionnaire was assessed by three infertility specialists and was confirmed with cronbach's alpha of . . quantitative data were analyzed using kolmogorov-smirnov and shapiro-wilk tests, t-test, and pearson correlation coefficient. data were also analyzed through the q-q (quantile-quantile) plot, as well as skewness and elongation index. a p-value of less than . was considered statistically significant. a total of patients ( couples) were enrolled. the mean age was . ± . years with a minimum age of and a maximum age of years. the mean age of men ( . ± . ) was significantly higher than women ( . ± . ) (p-value = . ). the demographic characteristics of the patients are shown in table . most of women did not have a previous pregnancy, delivery, and abortion (p-value < . ). four women ( . %) had a history of multiple births. none of the people had a history of stillbirth. four and couples had a history of successful and unsuccessful infertility treatment, respectively. fifteen couples with a history of infertility treatment. the treatment methods used by couples with previous treatment history included iui ( . %), embryo transfer ( . %), follicle aspiration ( . %) (p-value < . ). only two patients ( . %) were experiencing symptoms of covid- and no one was hospitalized. table shows the frequency of answers to the questionnaire of the level of awareness of the patients. the highest frequency of information acquisition method was radio and television ( . %) (p-value < . ). the majority of people chose to use a mask ( . %) as the most effective way of prevention (p-value < . ). there is no significant relationship between covid- symptoms and the level of awareness (p-value < . ). . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted september , . . https://doi.org/ . / . . . doi: medrxiv preprint thirty-two patients ( . %) had decreased motivation to continue treatment during covid- pandemic. fear of transmission to the fetus ( . %) had the highest frequency among the causes of decreased motivation to continue treatment (p-value = . ). confidence in support of the treatment team ( . %) was the most common reason for lack of motivation in people without decreased motivation (p-value < . ) ( table ) . to our knowledge, this cross sectional study is the first to investigate the attitudes and consciousness of infertile couples, candidate therapy about continuing treatment during covid- outbreak. the level of knowledge and awareness of infertile couples and their ability to fully respond to covid- in their communities is somewhat limited ( ) . in this study, among patients ( couples), we found that more than % of individuals did not have a reduced motivation to continue treatment. one-third of patients who had a decreased motivation to continue treatment felt the need because of their infection and the transmission of the disease to the fetus and others. also, in the present study, there was no significant relationship between the presence of covid- symptoms and the level of awareness of couples. there was only a significant association between covid- symptoms and a greater desire to have children and . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted september , . . https://doi.org/ . / . . . doi: medrxiv preprint to continue or start treatment. in our patients, subjects with fixed salaries, bachelor's degrees, and shiite religion had the highest frequency. also, the number of individuals who had no history of underlying diseases and lived in the city was significantly higher. in our survey, sociocultural status had an effect on couples' attitudes. these results are reinforced by some studies ( ) . since infertility treatment is very expensive and some couples need years of treatment and also some of them have to travel to another city which is more expensive for treatment, these issues can affect their attitude and it can be claimed that the socio-economic situation may change the couple's attitude ( ) . but in this study, the majority of clients had an income less than $; so, there was not a great difference between their incomes, and there was not a statistical difference between their attitudes. in our study, most people were nulliparas and had no history of infertility treatment. therefore, in this study, no relationship can be imagined between pregnancy history and infertility treatment with patients' attitudes toward continuing treatment. most people wanted to use intrauterine insemination (iui) and embryo transfer for their treatment. iui and embryo transfer are relatively simple, common, and safe procedures, and the risk of serious complications is low ( , ) . although some studies have shown that the process of treating infertility, including art and related tests, is very long and tedious ( , ) , in our study most patients, despite the fear of the covid- pandemic, were tended to perform and continue their treatment. in our study, about % of patients experienced unsuccessful infertility treatment. in some studies, unsuccessful infertility treatment not only led to immediate heart failure and shock, but also to long-term psychological trauma. in these surveys, pregnant women reported experiencing severe anxiety due to previous unsuccessful ivf attempts ( , ) . in addition, we found that more than half of those who wished to continue infertility treatment trusted the support of the treatment team. it seems that trust in the treatment team and the performance of the treatment team members play an important role in increasing the desire of infertile couples to continue infertility treatment. this factor, ie the support of the treatment team for patients, has been studied in some studies. for example, the lack of counseling time in the clinic and the lack of psychological support have been assessed as insufficient in health care providers. in fact, the busy schedule of a clinic makes it difficult for the clinic to provide information and psychological needs to outpatients ( ) . research has shown that the support of health professionals is very effective in improving the stress and anxiety of people with infertility ( ). . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted september , . . https://doi.org/ . / . . . doi: medrxiv preprint in our study, couples' knowledge, and awareness of general information about covid- such as common symptoms, prevention methods, and also about whether sars-cov- is transmitted vertically or sexually ( . %), was evaluated well. many people believed that social distance could help curb this pandemic. the response of many patients was influenced by the information published in the media, so that the role of the media in this result was very significant. in our patients, due to the knowledge of most people in this study that the virus is not transmitted vertically, the majority of people were very, very willing to continue or start treatment during the pandemic of this disease. the highest prevalence of fear among people whose motivation to continue treatment was reduced was due to fear of developing covid- due to being in the treatment environment and feeling afraid of the negative impact of the virus on pregnancy. a noteworthy point in our study was that there was only a significant association between covid- symptoms and a greater desire to have children and to continue or start treatment. some studies have shown that the knowledge gap among infertile women in the pandemic of infectious diseases causes a difference in their attitudes in choosing the type of treatment and its continuation ( ). the sample size of our study was small. although data saturation has been reached, future research with larger sample sizes is needed to address other factors that may affect the experience of infertile couples and reach well-appointed conclusions. another limitation was the use of a questionnaire, which may prevent the deep expression of deep feelings. using interviews to gather information from a couple in person will allow researchers to examine the dual relationships between couples. studying a more homogeneous group allows researchers to gain a deeper understanding of the cultural context and its effects on infertile couples' attitudes toward continuing treatment. studies comparing the differences between infertile couples in different cultural groups in iran can be helpful in the future. given this, the results of this study cannot be generalized to all people who use art or in all regions of iran, although it may be applicable in similar fields. in our study, most patients had acceptable knowledge about covid- and how it was transmitted. due to the knowledge of most people in this study that the virus is not transmitted . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted september , . . vertically, most people in the study wanted to continue their infertility treatment in the covid- pandemic. supplementary data are available at human reproduction online. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted september , . . . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted september , . . https://doi.org/ . / . . . doi: medrxiv preprint is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted september , . . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted september , . . https://doi.org/ . / . . . doi: medrxiv preprint covid- presented with deep vein thrombosis: an unusual presenting hydroxychloroquine-induced stevens-johnson syndrome in covid- : a rare case report covid- in children: a narrative review clinical characteristics of coronavirus disease in china sars-cov- can be detected in urine, blood, anal swabs, and oropharyngeal swabs specimens absence of novel coronavirus in semen and testes of covid- patients † sexual transmission of severe acute respiratory syndrome coronavirus (sars-cov- ): a new possible route of infection? scrna-seq profiling of human testes reveals the presence of the ace a target for sars-cov- infection in spermatogonia rising concern on damaged testis of covid- patients materno-fetal transmission of human coronaviruses: a prospective pilot study infertility treatment for hivpositive women. women's health general psychopathology, anxiety, depression and self-esteem in couples undergoing infertility treatment: a comparative study between men and women assessment of questionnaires measuring quality of life in infertile couples: a systematic review national, regional, and global trends in infertility prevalence since : a systematic analysis of health surveys attitudes of iranian infertile couples toward surrogacy the attitudes of infertile couples towards assisted reproductive techniques in yazd, iran: a cross sectional study in barriers of child adoption in infertile couples: iranian's views. iranian journal of reproductive medicine the experience of infertility: a review of recent literature. sociology of health & illness international committee for monitoring assisted reproductive technologies (icmart) world report: assisted reproductive technology couples facing fertility problems. the psychology of couples and illness: theory, research, & practice infertility counseling: a comprehensive handbook for clinicians psychological characteristics and marital quality of infertile women registered for in vitro fertilization-intracytoplasmic sperm injection in china the interim window: women's experiences during in vitro fertilization leading to maternal embryo attachment transforming hope: the lived experience of infertile women who terminated treatment after in vitro fertilization failure covid- and art: the view of the italian society of fertility and sterility and reproductive medicine the experience of chinese couples undergoing in vitro fertilization treatment: perception of the treatment process and partner support knowledge and attitudes of infertile couples about assisted reproductive technology covid- and art: the view of the italian society of fertility and sterility and reproductive medicine. reproductive biomedicine online analysis of national representative opinion surveys concerning gestational surrogacy in japan safety versus success in elective single embryo transfer: women's preferences for outcomes of in vitro fertilisation stimulated intrauterine insemination: efficient, cost-effective, safe? human fertility time experience during the assisted reproductive journey: a phenomenological analysis of italian couples' narratives medical waiting periods: imminence, emotions and coping. women's health unresolved grief in women and men in sweden three years after undergoing unsuccessful in vitro fertilization treatment the experience of chinese couples undergoing in vitro fertilization treatment: perception of the treatment process and partner support seeking conception: experiences of urban indian women with in vitro fertilisation key: cord- -xjpzhsup authors: sgouros, george; bodei, lisa; mcdevitt, michael r.; nedrow, jessie r. title: radiopharmaceutical therapy in cancer: clinical advances and challenges date: - - journal: nat rev drug discov doi: . /s - - - sha: doc_id: cord_uid: xjpzhsup radiopharmaceutical therapy (rpt) is emerging as a safe and effective targeted approach to treating many types of cancer. in rpt, radiation is systemically or locally delivered using pharmaceuticals that either bind preferentially to cancer cells or accumulate by physiological mechanisms. almost all radionuclides used in rpt emit photons that can be imaged, enabling non-invasive visualization of the biodistribution of the therapeutic agent. compared with almost all other systemic cancer treatment options, rpt has shown efficacy with minimal toxicity. with the recent fda approval of several rpt agents, the remarkable potential of this treatment is now being recognized. this review covers the fundamental properties, clinical development and associated challenges of rpt. the cytotoxic radiation is delivered to cancer cells or to their microenvironment either directly or, more typically, using delivery vehicles that either bind specifically to endogenous targets or accumulate by a wide variety of physiological mechanisms characteristic of neoplasia, enabling a targeted therapeutic approach. unlike biologic therapy, it is far less dependent on an understanding of signalling pathways and on identifying agents that interrupt the putative cancer phenotype-driving pathway (or pathways). notably, the clinical trial failure rate of 'targeted' (that is, biologic) cancer therapies is % (ref. ), which is in part due to the drugs selected for clinical trial investigation targeting the wrong pathway . radionuclides with different emission propertiesprimarily βparticles or highly potent αparticles -are used to deliver radiation. in almost all cases, the radionuclides may be visualized by nuclear medicine imaging techniques to assess targeting of the agent, which provides a substantial advantage over existing therapeutic approaches and enables a precision medicine approach to rpt delivery. patients with cancer with distant metastases continue to have a grim prognosis despite ongoing efforts with new chemotherapeutics, small-molecule inhibitors, biologics, immune checkpoint inhibitors and various combinations of these; novel therapeutic approaches are therefore vital. compared with almost all other systemic cancer treatment options, rpt has shown efficacy with minimal toxicity . in addition, unlike chemotherapy, responses with rpt agents typically do not require many months (or cycles) of therapy and are often observed after a single or at most five injections; side effects such as alopecia or peripheral neuropathy are generally less severe than with chemotherapy, if observed at all. rpt development is a multidisciplinary endeavour, requiring expertise in radiochemistry, radiobiology, oncology, pharmacology, medical physics and radionuclide imaging and dosimetry -most pharmaceutical companies are not familiar with the radiation and radionuclide aspects of rpt and the deployment of rpt agents for cancer therapy is also unfamiliar to the oncology community. it is a therapeutic modality that is not consistently identified with any one group of practitioners and it lacks a constituency. for many decades rpt has been a treatment modality of last resort and available only in small clinical trials or as part of compassionate care from a small number of institutions in europe and even fewer in the usa and the rest of the world. in the sense that rpt has no well-defined community of stakeholders it has been an 'orphan treatment' modality for many years. however, the remarkable potential of rpt directed against primary cancers as well as distant metastases, is now being recognized as an effective, safe and economically and logistically viable treatment modality, receiving renewed attention from both small and large pharmaceutical companies . the recent approval of radionuclides interchangeable with 'radioactive atoms', 'radioactive elements' and 'radioactive isotopes' . although these are all correct, 'radionuclide' (not 'radionucleotide') is the preferred term in the context of nuclear medicine, in general, and radiopharmaceutical therapy, in particular. light, energetic electrons that are either positively or negatively charged and emitted spontaneously from atomic nuclei during a nuclear transformation of many radionuclides. these particles are characterized by a spectrum of energies and associated ranges, typically characterized as the maximum or end-point energy or range. β-particle-emitting rpt agents that act against neuroendocrine cancers and phaeochromocytomas, the approval of an α-emitter rpt for bone metastases of prostate cancer and the highly promising clinical and preclinical preliminary results with rpt agents using other α-particle-emitting radionuclides has reignited interest in rpt. this review provides an overview of the radiochemistry and physics aspects needed to understand the fundamentals of rpt. the different categories of rpt agents in use and in the clinic for the treatment of cancer and the challenges associated with their development and application are discussed. notably, many other rpt agents are in preclinical development, but their discussion is beyond the scope of this review. similarly, while rpt also has applications in non-oncological disorders, such as rheumatoid arthritis and polyarthritis, these will not be discussed here, and the reader is referred to recent reviews on these topics , . the mechanism of action for rpt is radiation-induced killing of cells. investigation into the effects of radiation on tissues and tumours began soon after the discovery of radiation and radioactivity. rpt has the benefit of drawing on the substantial knowledge base of radiotherapy . however, rpt differs from radiotherapy, and it is important to understand how those elements unique to rpt influence therapy. the essential questions for rpt are where does the agent localize and for how long? as noted in the section entitled 'dosimetry' , answers to these questions inform the tumour versus normal tissue absorbed dose and provide a measure of potential treatment success. the biological effects of a given absorbed dose for a tumour depend on the rate at which the dose is delivered [ ] [ ] [ ] . a dose of gy delivered to a tumour over a period of many weeks at a dose rate that is exponentially decreasing, as is typically the case with rpt, will have a very different effect from that of the same amount delivered at the much higher dose rates used in radiotherapy (for example, daily, -gy fractions over days). the difference in biological outcome will depend on the biological repair and radiosensitivity properties of the tumour. dose-rate considerations also apply to normal organs [ ] [ ] [ ] . another fundamental distinguishing feature important for understanding this treatment modality is the diminishing curative potential with reduced target cell number (fig. ) . in radiotherapy the probability of killing all cells for a given absorbed dose increases as the number of target cells decreases -fewer cells to kill for a given radiation absorbed dose increases the chance that all of the cells will be killed. by contrast, fewer cells do not translate into a greater tumour control probability in rpt. this is because the radiation is not delivered uniformly to all cells. if the emitted radiation originates from a radionuclide on the surface of tumour cells, fewer cells leads to a smaller fraction of the emitted energy being deposited into the targeted cells . this is balanced, in part, by the greater concentration that may be achieved in smaller clusters of cells relative to large measurable tumours. one of the hallmarks of rpt is its ability to deliver highly potent forms of radiation directly to tumour cells. three different types of radiation are relevant to understanding rpt: photons, electrons and α-particles . photons come in two 'flavours' -x-rays and γrays. the former are derived from orbital electron transitions and are typically lower in energy than γ-rays. radionuclide photon emissions are useful for imaging the distribution of the rpt but not for localized delivery of cytotoxic radiation. although a wide range of photon energies may be imaged ( - kev), photon emission energies in the range from to kev are optimal for all nuclear medicine imaging cameras (γ-cameras and single-photon emission computed tomography (spect) cameras). a number of radionuclides also emit positrons which lead to the emission of -kev photons that are detected by positron emission tomography (pet) cameras. electron emissions are classified by energy and also by the type of decay. auger electrons, β-particles and a b fig. | tumour cell irradiation: radiotherapy versus radiopharmaceutical therapy. a | an external beam delivers the same absorbed dose per cell regardless of the number of cells. b | in radiopharmaceutical therapy, the absorbed dose delivered per cell by emissions originating from cells is influenced by the range of the emissions, the number of cells that are clustered together and the number of cells that have been targeted. a single cell is very difficult to sterilize with radiopharmaceutical therapy. if the range of the emitted particle is much longer than the dimension of the cell nucleus, a smaller fraction of the total emitted energy will be absorbed in the nucleus. positively charged, heavy particles ejected spontaneously from the nucleus of some radionuclides that are identical to a helium nucleus (mass number of and electrical charge of + ). the dna damage resulting from these short-range particles per unit of energy deposition is greater and more complex than that associated with β-particles. the energy absorbed per unit mass of tissue. abbreviation for the si unit (gray) for radiation dose ( gy= j kg − ). it is the absorbed dose per unit mass of tissue. the corresponding cgs unit is the rad ( rad = gy). the rad is not recommended for use in the scientific literature. www.nature.com/nrd monoenergetic electrons are relevant to rpt. auger electrons are generated from suborbital transitions. they are typically very-short-range emissions, of the order of - nm, depending on their emission energy. if the rpt drug localizes within the cell nucleus, these emissions could be highly cytotoxic , [ ] [ ] [ ] [ ] [ ] . auger electron-emitter rpt has not been widely adopted, however. although preclinical studies have shown substantial therapeutic efficacy, the small number of human investigations did not lead to clinical efficacy [ ] [ ] [ ] [ ] . human studies using locoregional administration showed promise in terms of tumour cell incorporation of the auger emitters , , . the requirement that these agents be incorporated into the dna and also their unfavourable pharmacokinetics are thought to be the reasons underlying the lack of efficacy. encouraged by ongoing technological developments that could overcome the factors listed above, these agents continue to be of interest to the rpt community . β-particles are electrons emitted from the nucleus. they typically have a longer range in tissue (of the order of - mm) and are the most frequently used emission type for rpt agents. this is in part because β-particle-emitting radionuclides are widely available, many of which also emit photons in an energy range that is easily imaged. the β-particle emitters samarium- , lutetium- , yttrium- and i- have been introduced and commonly used over the last years (fig. a; tables , ). the most familiar and frequently used of these is iodine- , which is used to treat thyroid cancer. a number of other β-emitting radionuclides have been investigated or considered - but for several reasonsincluding lack of availability, difficult radiochemistry or perhaps, most prominently, the absence of a commercial justification to overcome the regulatory and financial hurdles involved in their clinical translation -these agents have not been widely adopted . a variety of reasons for the progression and shift to different radionuclides may be invoked to explain the changes and additions of the different β-particle emitters used over time. for example, in an early theoretical evaluation of different radionuclides, yttrium- ranked second to rhenium- in a list of nine radionuclides considered . in that ranking, the main criterion was the tumour to non-tumour-absorbed dose ratio. this was a theoretical calculation obtained for different radionuclides using typical radiolabelled antibody pharmacokinetics for tumour targeting and organ clearance. this optimum reflected the . -hour half-life of yttrium- and its high-energy β-particle, which was deemed favourable for uniformly irradiating tumours. like iodine- , the adoption of yttrium- for rpt is likely based on its history and widespread availability. in the s it was used in colloidal form, primarily to treat rheumatoid conditions , . efforts to conjugate yttrium- , a radiometal, were unsuccessful until a radiometal conjugation chemistry that retained stability in vivo was developed , . clinical trials using yttrium- -labelled antibodies as rpt agents initially focused on ovarian cancer , and subsequently on haematological cancers [ ] [ ] [ ] , as well as radiopeptide therapy . yttrium- continues to be a popular radionuclide for rpt because of the clinical impact of yttrium- -impregnated microspheres that are used for treatment of hepatic metastases [ ] [ ] [ ] [ ] [ ] . although yttrium- has been imaged, imaging generally requires high activities (more than mbq) . such activities are typically achieved only in microsphere therapies. lutetium- gained popularity because it emits photons in the - -kev optimal imaging range and has a β-particle energy that is between that of iodine- and yttrium- , which is appropriate for therapy. these factors, along with a half-life that is compatible with the pharmacokinetics of both antibodies and peptides, make this radionuclide a theranostic in that the same radionuclide may be used to assess tumour uptake and the extent of cancer, and also as a treatment . it is produced in a reactor and is therefore widely available , with a relatively straightforward conjugation chemistry . α-particles are helium nuclei (two protons and two neutrons) that are emitted from the nucleus of a radioactive atom. depending on their emission energy, they can travel - µm in tissue. they are positively charged and are orders of magnitude larger than electrons. the amount of energy deposited per path length travelled (designated 'linear energy transfer') of α-particles is approximately times greater than that of electrons. this leads to substantially more damage along their path than that caused by electrons. an α-particle track leads to a preponderance of complex and largely irreparable dna double-strand breaks , . the absorbed dose required to achieve cytotoxicity relates to the number of α-particles traversing the cell nucleus. with use of this as a measure, cytotoxicity may be achieved with a range of to α-particle traversals of the cell nucleus . the resulting high potency, combined with the short range of α-particles (which reduces normal organ toxicity), has led to substantial commercial interest in developing α-particle-emitting rpt agents . the α-particle emitters introduced and used for rpt over the last years include astatine- , bismuth- , lead- , bismuth- , actinium- , radium- and thorium- (fig. b; tables , ). the α-particle-emitting rpt agent radium- dichloride (xofigo) was approved by the fda in may . at the time it was approved, effective therapies for patients with castration-resistant prostate cancer that had metastasized to bone did not exist. the very encouraging clinical trial results and the subsequent fda approval were instrumental in the renewed interest in rpt, in general, and α-emitter rpt, in particular. subsequently, individual-patient demonstrations of α-emitter potency have reinforced the interest in α-particle-emitting rpt , . overall, there has been an almost sixfold increase in the number of studies related to α-emitters for rpt over the past years. ongoing investigations of radium- in combination with other therapeutics that act against other bone-seeking cancers [ ] [ ] [ ] have led to the recent high prevalence of radium- rpt studies. there are more than radionuclides that are potentially relevant to medicine and biology . table details the subset of these that are rpt agents of current interest, along with properties relevant to their use in rpt. response and toxicity prediction is essential for the rational implementation of cancer therapy. the biological effects of radionuclide therapy are mediated by a well-defined physical quantity, the absorbed dose (d), which is defined as the energy absorbed per unit mass of tissue. the long and well-established cancer treatment experience in radiotherapy has provided ample evidence that absorbed dose may be used to predict biological response . in chemotherapy, targeted biologic therapy and immunotherapy, there is no dosimetry analogue. dosimetry as implemented in rpt may be thought of as the ability to perform the equivalent of a pharmacodynamic study in treated patients in real time. dosimetry analysis may be performed as part of patient treatment to calculate tumour versus normal organ absorbed dose and therefore the likelihood of treatment success. the ability to rapidly assay genetic and epigenetic characteristics of tumour samples comes closest to providing the kind of information that rpt dosimetry provides regarding the potential efficacy and toxicity of a therapeutic agent in an individual patient. the mathematical formalism and tools available to perform dosimetry have evolved over time. the initial impetus for estimating absorbed dose was to assess the potential risks of nuclear medicine diagnostic imaging agents. dosimetry calculations intended to assess risk are performed for an anatomical geometry designed a photon is a quantum of highfrequency electromagnetic radiation that is emitted spontaneously, either during a nuclear transformation (γ-rays) or as a result of orbital electron transitions (x-rays). in the context of radiation delivery, the energy or frequency of photons is sufficient to ionize atoms and lead to potential dna damage. photons emitted as a result of orbital electron transitions. photons emitted during a nuclear transformation of a radionuclide. the abbreviation for a unit of energy (kiloelectronvolts) typically used to represent the energy associated with radionuclide emissions. electrons ejected during suborbital transitions of an atom, typically following spontaneous nuclear transitions (radioactive decay). a measure of radioactivity, typically in the unit of becquerel (bq) or millicurie (mci; the cgs unit). radioactivity corresponds to the number of radionuclide transformations per unit time. the general concept of using a radionuclide-labelled agent that may be imaged to guide radiopharmaceutical therapy; a radionuclide that may be used for both imaging and therapy. www.nature.com/nrd to represent the average patient population rather than any one particular patient. the scheme used to calculate these values is shown in box . this scheme provides the foundation for rpt dosimetry but because the calculation is oriented towards assessing radiation-induced risks of diagnostic imaging, it is not appropriate for toxicity and antitumour efficacy evaluations relevant to rpt. the dosimetry methods summarized in box describe a scheme appropriate to rpt. the implications of adopting such a scheme and necessary extensions, not summarized in box , are briefly described below. image-based, patient-specific dosimetry allows the distribution of the agent in tumours and normal organs to be quantified . the amount of rpt agent that concentrates in the tumour can be increased by increasing the administered activity, which also impacts the tumour-absorbed dose. dosimetry analy sis following a low-activity administration has the potential to inform the amount of activity to administer for subsequent therapy. for example, from radio therapy experience, an absorbed dose of - gy is required to achieve greater than -year tumour control for patients with osteosarcoma , . although such high average tumour-absorbed doses can be achieved with high administered activities, studies have indicated that intratumour variability can be large, with some portions of a tumour meeting and exceeding this dose range, but the overall average being well below therapeutic efficacy . these observations led to a rational, absorbed-dose driven approach for combining radiotherapy with rpt . in the context of rpt, organ toxicity is usually reflected not by a whole-organ absorbed dose but rather by absorbed dose 'hot spots' . this is particularly so if such regions of high absorbed dose correspond to organ subregions that are critical to organ function. for example, some rpt agents (primarily peptides) concentrate and are retained in the renal cortex, so the absorbed dose in the renal cortex better predicts toxicity than the absorbed dose in the whole kidney volume . for certain rpt agents, the biologically relevant region can be microscopic (for example, the kidney nephron or the collecting ducts of the salivary glands , ). the converse is also true. estimates of the average absorbed dose in bone marrow do not predict the very low haematological toxicity of radium- dichloride (lower than that of almost all other rpt agents). in a pivotal randomized clinical trial, the grade or grade haematological toxic effects observed in patients receiving radium- dichloride (xofigo) included neutropenia ( %), thrombocytopenia ( %), leukopenia ( %) and pancytopenia ( %) . this discrepancy could be resolved by a calculation that considered the microscale distribution of radium- in the bone marrow. such an analysis demonstrated that because of the short range of α-particle emissions and the known localization of the rpt agent on the trabecular bone surface, only haematopoietic (bone marrow) cells within µm of the bone surface were irradiated, meaning that most of the bone marrow space was not irradiated and, accordingly, the average bone marrow absorbed dose was not predictive of toxicity . current imaging techniques do not possess the resolution required to resolve activity distributions at the microscopic scale. however, by pairing whole-organ macroscale measurements that can be performed in humans with microscale information that can be obtained from preclinical studies, it is possible to extract microscale information from macroscale measurements. a contour may be drawn on an image obtained with a patient imaging modality such as pet/ct or spect/ct that encompasses the entire organ (for example, kidney) or macroscopic subcompartments within the organ (for example, renal cortex). these macroscale contours may be used to obtain time-versus-activity curves (tacs) for the entire organ or macroscale subcompartments within the organ. microscale structures within these macroscale contours may be obtained in preclinical models by www.nature.com/nrd tissue extraction and high-resolution imaging of tissue sections, for example [ ] [ ] [ ] . these data may be used to obtain time-versus-activity curves for microstructures of interest (that is, those microstructures that govern the organ response to radiation). the integral of each curve gives the total number of radionuclide disintegrations for the whole organ and for each subcompartment. with use of these measurements, a series of apportionment factors may be defined for each subcompartment. these preclinically derived apportionment factors may then be used to convert human whole-organ radionuclide disintegrations to the corresponding number of radionuclide disintegrations for each organ subcompartment in humans. beyond the aspects highlighted above, there is an extensive literature on rpt dosimetry, including technical aspects , , [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] , dose-response studies [ ] [ ] [ ] [ ] [ ] and the rationale for incorporating dosimetry in rpt . in principle, rpt may be applied to any cancer that satisfies the targeting criteria needed for delivery of radionuclides. however, rpt has been investigated for only selected cancers (fig. c) . the type of cancer investigated reflects developments related to the available targets, the availability of rpt agents against the targets, and the expertise and clinical investigators at academic institutions. rpt has had the greatest historical impact for thyroid malignancies and this persists to the present day. haematological malignancies were investigated starting in the early s and continue to be a subject of interest. rpt for hepatic malignancies and prostate cancer has seen the greatest increase since the s. this increase is consistent with the development of new rpt agents, y-loaded microspheres and β-emitter-labelled and α-emitter-labelled small-molecule prostate-specific membrane antigen (psma)-targeting constructs, respectively (see later). the fda-approved α-emitter ra has also driven the substantial increase in interest in rpt for prostate cancer. other solid cancers such as colorectal and breast cancer continue to be of interest but have not had the breakthrough construct development that has driven interest in rpt in hepatic and prostate cancer. neuroendocrine and somatostatin receptor cancers have been an ongoing subject of investigation, and the rpt agents targeting these cancers have probably reached maturity with the fda approval of lu-labelled dotatate. a number of rpt agents are currently on the market, with many more in development (table ) . these include four β-particle and five α-particle emitters. lead- decays to bismuth- and is used as a means to deliver bi, an α-emitter, without being constrained by its -hour half-life. of the rpt agents listed in table , deliver radionuclides that decay by α-particle emission. the interest in α-emitters reflects a potential growth area in rpt. other rpt agents in addition to those discussed below are in preclinical development, but their discussion is beyond the scope of this review. rpt can involve the direct delivery of the radioactive element itself [ ] [ ] [ ] [ ] . a wide variety of 'delivery vehicles' have also been used for rpt (fig. ) , including small molecules that incorporate the radionuclide , , . radiolabelled peptides and antibodies make up the majority of rpt agents investigated clinically [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] . liposomal or nanoconstruct delivery approaches are being investigated preclinically , , but these have not yet been tested in human trials. glass and resin microspheres are relatively well established; these are used in the nuclear or atomic transformations associated with radioactive decay; the term 'radionuclide disintegrations' is also used. one of the earliest advances in establishing a dosimetry formalism for risk evaluation applicable to radionuclides was the reformulation of the fundamental definition (eq. ) of absorbed dose, d, given by the differential of the average energy imparted to matter (ε) divided by the mass (m) that has absorbed ε: equation was reformulated by the medical internal radiation dose committee into a product of two quantities, one that depends on the pharmacokinetics of the radionuclide in the body and one that is a property of the radionuclide and the representative patient anatomy used for the calculation , : gives the absorbed dose, d, for a target region, r t , from the total number of radionuclide transformations or decays, ∼ a r ( ) s , that have occurred in the source region, r s . ∼ a r ( ) s is calculated with eq. . it is obtained by integrating the radioactivity in r s (denoted by a(r s ,t) ) from the time of injection, at t = to a time that is long enough so that all of the radioactivity in a particular tissue has either cleared from the tissue or decayed (in almost all diagnostic nuclear medicine and radiopharmaceutical therapy scenarios this is set to infinity): s s part a of the figure illustrates the different elements involved in calculating the timeintegrated activity for a given source region. the circles correspond to measurements of the radioactivity (for example, by imaging) in the chosen source region at different points in time. the line going through the circles corresponds to a fit to an equation that best matches the measured data. the exponential equation shown in the figure is typically used for tissues that rapidly accumulate some fraction of the administered activity and then clear it over time. a(r s ,t) can be equated to an exponential function representing clearance of the radioactivity from a particular source tissue with a clearance rate that is the sum of the biological clearance rate (λ b ) and the physical decay rate (λ p ). λ b + λ p = λ e , the effective (e) clearance rate; a and f s are the administered activity and fraction in the source tissue (s), respectively, at t = (i.e., back extrapolated from the fit to the y axis). the area under this time-versus-activity curve is the total number of disintegrations, formally known as the time-integrated activity (tia). detailed descriptions of how these measurements should be made using quantitative imaging methods have been published , , . the second quantity, the s value, provides the energy absorbed in the target tissue per unit disintegration in the source tissue. part b of the figure shows eq. with the individual terms making up the s value explicitly identified. the s value incorporates quantities reflecting the total emitted energy per radionuclide disintegration, Δ, the fraction of the energy emitted from a source region (r s ) that is absorbed in a target region (r t ), ϕ ← r r ( ) t s , and the mass of the target, m(r s ). further mathematical details regarding this quantity and s value-based dosimetry, in general, are available in ref. . s, absorbed dose per unit tia nature reviews | drug discovery the treatment of hepatocellular carcinoma or hepatic metastases of colorectal cancer and are administered via the hepatic artery. the differential retention of different rpt constructs in the tumour is important but difficult to generalize. antibody-mediated delivery is bivalent and generally leads to long retention, but the long circulating half-life of antibodies leads to greater normal organ, particularly haematological, toxicity. by contrast, small molecules and peptides have the advantage of rapid targeting and clearance, but exhibit typically shorter tumour retention. in all cases, if the agent is internalized and the radio nuclide retained intracellularly, the target retention time will be very long compared with the clearance kinetics of the agent. furthermore, in all cases, engineered agents can be designed that optimize tumour retention while increasing clearance kinetics [ ] [ ] [ ] [ ] [ ] [ ] [ ] . the prototypical example of rpt is radioiodine treatment of thyroid diseases , - . iodide- , a β-particle-emitting radiohalogen with a half-life of . days, was discovered by john livingood and glenn seaborg following cyclotron bombardment of tellurium . currently, iodine- is produced for commercial use using a nuclear reactor by irradiating either tellurium- ( te(n,γ) te→ i) or uranium- ( u(n,f) i) . radioiodine was initially used to treat hyperthyroidism and thyroid carcinomas . thyroid follicular cells and differentiated follicular thyroid cancer cells concentrate iodine via a sodium-iodide symporter. the iodide is concentrated in iodine-rich thyroglobulin molecules that are cleaved to produce thyroid hormones. these early discoveries led to the widespread and early use of radioiodine for the treatment of patients with thyroid malignancies. radioiodine therapy remains the recommended treatment for patients with metastatic differentiated thyroid cancer . patients with thyroid cancers that originate from cells not involved in concentrating iodine or that are undifferentiated and have lost the molecular machinery to concentrate iodine are not responsive to radioiodine therapy. patients in the latter category, however, can be successfully treated with radioiodine after differentiation therapy . p, y. many of unconjugated rpt agents were first developed for radiosynovectomy (note that none of the radiopharmaceuticals is explicitly approved for this scope, but it is an accepted ('established') practice). in europe these agents continue to be used to treat patients with rheumatoid arthritis and polyarthritis owing to their advantageous faster therapeutic effect and reduced side effects and costs compared with surgical synovectomy , . beyond radiosynovectomy, colloidal chromic phosphate (and glass microspheres) containing phosphorus- have also been used to treat solid refractory cancers. these radiopharmaceuticals are used to irradiate and kill tumour cells and thus inhibit the growth of malignant disease. the major limitation in these applications is the reliance on radiological guidance for particle deposition (for example, ct, x-ray, ultrasonogram or direct inspection of the surgical field) . ra. radium- was the first α-emitter approved by the fda and paved the way to the current development of other α-emitting radiopharmaceuticals. once absorbed into the newly formed bone matrix of osteoblastic metastases, the energetic α-particles emitted by radium- can generate irreparable dna doublestrand breaks in the adjacent osteoblasts and osteoclasts, which can lead to their death. this results in detrimental effects on the neighbouring cancer cells, which then lack their effector of abnormal bone formation, both at a cellular level and at a signalling level (growth factors and box | dosimetry scheme for radiopharmaceutical therapy the dosimetry formalism presented in box entails a number of implicit assumptions that do not apply for dosimetry calculations intended to assess potential toxicity or therapeutic efficacy. in particular, the dosimetry scheme for risk evaluation does not incorporate tumour dosimetry because it relies on reference geometries. the more direct approach of using the measured patient activity distribution from positron emission tomography/computed tomography (ct) or single-photon emission ct/ct images, superimposed over the anatomy as obtained by the ct portion of the imaging scan, has been established. such voxelized dosimetry approaches use monte carlo or point-kernel methods to calculate maps of the spatial distribution of absorbed dose - . these techniques make it possible to calculate the absorbed dose with regard to actual patient anatomy, including tumours, rather than with regard to a reference, population-averaged, geometry. the generic method is illustrated below. the figure depicts integration over imaging-derived activity values and the use of a point kernel to obtain a map of absorbed doses. part a of the figure shows a set of d matrices representing the radioactivity distribution at multiple times (a(x,y,z,t)). integration by volume elements (that is, voxel or a larger discrete structure) is performed over time. this yields a d set of images representing the time-integrated activity ( ∼ a x y z ( , , )) in each volume element (represented by tia i in part b of the figure, where tia is the time-integrated activity). the absorbed dose for a particular volume element, in this example in the kidney, is obtained as the sum of the tia i multiplied by a source-to-target distance-dependent absorbed dose per unit tia (also referred to as a dose point-kernel). the sum over all source volume elements gives the total dose to the target element. alternatively, the order could be reversed, with the dose calculation performed on the series of activity images and the integration performed on dose rate rather than activity images. the dose calculation, itself, could be performed directly by monte carlo techniques. the latter has the benefit of easily accommodating differences in tissue density and composition. this is particularly important for dose estimates in the vicinity of air or bone tissue interfaces (for example, lung or bone marrow dose calculations). radiosynovectomy a treatment for arthritis or, more generally, inflammation that involves injection of radioactivity, typically as colloidal particles into the synovial cavity. www.nature.com/nrd immunomodulators), and ultimately in a negative effect on tumour growth. mechanistic details of this complex interaction are still being evaluated , . the numerous clinical applications of radium- dichloride in men with metastatic castration-resistant prostate cancer culminated in the phase iii placebocontrolled registration alsymca trial, in which radium- treatment prolonged survival ( months versus . months) when added to best standard of care in men with symptomatic bone metastases in the absence of visceral metastases . to increase the significant but narrow margin of increased overall survival over standard of care, radium- is currently being explored in combination with other cytotoxic agents, such as docetaxel (dora trial, nct ), poly(adp-ribose) polymerase inhibitors such as olaparib (nct ) and new androgen axis inhibitors such as enzalutamide and abiraterone citrate (peace iii trial, nct , and era trial, nct , respectively). the first of these trials was recently modified to include bone-protective agents (bisphosphonate) in the treatment regimen , which was found to reduce the incidence of bone fractures. the recommendation was made owing to the observation of an unexpectedly high rate of bone fractures observed in the era trial (radium- plus abiraterone) , which may have been attributable to the inclusion of prednisone needed to ameliorate the glucocorticoid suppressive effects of abiraterone citrate . radium- is also being explored in combination with immuno-oncology agents such as pembrolizumab (nct ) and in combination with external-beam radiotherapy (ravens trial, nct ). sm. samarium- (t / = . hours) is a β-emitting radionuclide used for palliative treatment in patients with osteoblastic and mixed bone metastases in cancers, such as prostate, breast and other primary cancers , . smcl is produced by neutron bombardment of enriched sm o , resulting in sm o , which is dissolved in hydrochloric acid to yield smcl . alone, smcl has poor uptake in bone; however, when chelated with multiple phosphate ligands, the complex accumulates in hydroxyapatite . the affinity of phosphonate for calcium, which is found in rapidly growing bone, is attributed to the accumulation and adsorption of sm in metastatic lesions over normal bone [ ] [ ] [ ] . quadramet is an fda-approved rpt agent that uses the ethylenediaminetetramethylenephosphonic acid (edtmp) chelator, binding samarium- through six ligands (four phosphate groups and two amines) and forming a six-coordinate complex. an alternative formulation of sm has also been described, sm-dotmp ( , , , -tetraazacyclododecanetetramethylenephosphonic acid), which is thought to have a more favourable chelant-to-metal ratio ( . trial of this agent against osteosarcoma has been listed (nct ) but is not yet recruiting. [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] or phosphoramidate-based inhibitors (for example, lu-labelled ctt- ) modified to deliver therapeutic radionuclides [ ] [ ] [ ] . the urea and phosphoramidate functionalities interact with zinc(ii) located in the psma active site; in addition, these small molecules are designed to interact with the s glutamate pocket as well as the entrance funnel of psma (fig. a,b) . the entrance funnel allows a wide variation of modifications to present a pendant group or a chelator for radiolabelling with therapeutic and imaging radionuclides. all three agents are currently in clinical trials: nct , nct and nct , respectively (table ) . lu-labelled psma- is currently in a multicentre ( sites), phase iii randomized trial (vision). in a previous prospective single-centre phase ii trial in men with metastatic castration-resistant prostate cancer in whom standard therapies had failed, patients who showed high expression of the psma target by ( ga-labelled psma- ) pet yielded favourable responses; patients with high [ f]fluorodeoxyglucose (fdg) uptake in low-psma-uptake lesions were excluded. of enrolled patients, met the psma and fdg imaging criteria to advance to therapy. at months after therapy, reductions in tumour dimensions (by ct) and psma uptake and metabolic activity (by pet) were observed in approximately % of treated patients . the imaging-based screening criteria used in this study highlighted the ability to image the distribution of the therapeutic target -a feature that is integral to rpt. although the theranostic (that is, imaging-based patient selection) used in this trial has been discussed as providing a highly favourable patient population and potentially excluding patients who may have benefited from the treatment , , the percentage of screened patients who were treated was higher than for most genomics-based screening criteria that are typically used in trials of biologic agents . the lu-labelled psma-r ligand is in a phase i/ii multicentre dose-escalation study. the eligibility criteria for this study include a positive ga-labelled psma-r pet scan; in contrast to psma- , lesion metabolism by fdg pet is not a screening criterion. preclinical comparison of these two agents suggests similar efficacy . the lu-labelled ctt- anti-psma ligand is an irreversible phosphoramidate-based psma inhibitor that includes an albumin-binding motif , . this agent is in a first-in-human phase i dose-escalation trial. as with the two urea-based agents described earlier, ctt- also incorporates a theranostic paradigm using a companion diagnostic, ctt- , which is a f-labelled pet agent. recent reviews provide more background regarding psma-targeting ligands , . fr is overexpressed in a variety of cancers with limited expression in normal tissue; expression on the luminal surface of the kidneys is the greatest concern for fr-targeted radiotherapeutics , . similarly to psma-targeted radiotherapy, fr-targeted radiotherapeutics have been developed based on the substrates of fr -specifically folate. derivatives of folate have been developed for delivery of radionuclides for imaging and therapy (fig. c) ; however, currently the fr-targeted radiotherapeutics have not been translated to clinical studies [ ] [ ] [ ] [ ] [ ] . early observations of a difference in the membrane composition of neoplastic cells compared with normal cells , led to the development of radioiodinated phospholipid ether constructs that showed rapid and persistent tumour accumulation , . the localization and clearance properties of these low-molecular-weight agents depend on the length of the alkyl chain and they localize to tumours not by a specific receptor but by an overabundance of www.nature.com/nrd lipid rafts present on cancer cell membranes , . these agents have been used for both cancer imaging and cancer therapy , [ ] [ ] [ ] [ ] . as pan-cancer rpt agents they are under clinical trial investigation for a wide spectrum of haematological malignancies and solid tumours (nct , nct , nct , nct and nct ). peptide receptor radionuclide therapy (prrt) with radiolabelled somatostatin analogue peptides (fig. ) was developed in the early s as the next logical step of the somatostatin receptor-mediated radionuclide localization of neuroendocrine tumours (nets). after initial experiences with the diagnostic radionuclide indium- (( in-dtpa -d-phe )-octreotide or in-pentetreotide), in an attempt to exploit the auger and conversion electron emissions of indium- , the past two decades have seen the use of the more suitable β-emitters, yttrium- , and, later, lutetium- , with their longer-range emissions (see below). this therapeutic strategy has been accepted as an effective therapeutic modality in the treatment of inoperable or metastatic gastroenteropancreatic and bronchopulmonary nets, as well as phaeochromocytomas and paragangliomas. the two most commonly used radiopeptides for prrt, y-octreotide ( y-dota-tyr -octreotide) and lu-octreotate ( lu-dota-tyr thr -octreotide), produce disease-control rates of - % (refs , ). these studies culminated in the phase iii registration trial netter- , which demonstrated significantly longer progression-free survival in patients with small-bowel nets treated with lu-octreotate plus mg long-acting-release octreotide than in those treated with mg long-acting-release octreotide . in addition to tumour responses, symptomatic and quality of life improvement is commonly observed and was confirmed in the netter- trial post-hoc analyses , . these results compare favourably with the efficacy of 'cold' somatostatin analogues, chemotherapy and 'targeted' therapies such as everolimus and sunitinib therapies . a major advantage of prrt over conventional treatments is the possibility to identify and quantify the target, the somatostatin receptor, before nature reviews | drug discovery initiation of therapy, in the most classic of the theranostic approaches. recently the prrt strategy against somatostatin receptor-positive cancer was extended to the delivery of the α-emitter lead- (nct ) [ ] [ ] [ ] . in general, prrt is well tolerated with only low to moderate toxic effects on the bone marrow and kidneys in most patients. there is a mild loss of renal function, and subacute and transient haematological toxicity is mild in approximately % of cases. myelodysplastic syndrome and sporadic instances of leukaemias have been reported in approximately % of cases , . prrt with radiolabelled octreotides constitutes a paradigm that in its years of use has still not been outperformed by the introduction of other agents. however, different strategies aimed at improving the outcomes have been proposed. the recently introduced somatostatin receptor antagonists, which are able to recruit also inactive membrane somatostatin receptors, result in a higher irradiation of the net cell, despite the lower internalization. preliminary clinical studies with lu-dota-jr demonstrated an overall response rate of % with a disease-control rate of % with only two therapeutic cycles, as opposed to the standard four cycles of the 'conventional' prrt . an ongoing phase i/ii multicentre study (nct ) will define the optimal therapeutic dose/schedule to be adopted in an upcoming phase iii trial. lastly, octreotide derivatives labelled with α-emitters, such as lead- (nct ) or actinium- are being explored to increase therapeutic efficacy, especially in patients who are refractory to conventional prrt. bombesin analogue peptides. following the success of the somatostatin receptor theranostics, other g proteincoupled receptors with similar binding properties have been explored, including the mammalian gastrinreleasing peptide (or amphibian bombesin) receptors, bb (nmbr), bb (grpr) and bb (brs ) . these receptors are overexpressed in several cancers, mainly in prostate and breast cancers [ ] [ ] [ ] [ ] [ ] [ ] . after initial experiences with agonists, such as the ga/ lu-labelled amba theranostic pair, burdened by a multitude of symptoms related to receptor activation and by poor plasma stability , clinical trials have proceeded with antagonists, owing to their superior targeting properties and their neutral pharmacologic action and resistance to peripheral peptidase degradation . multiple antagonists have been developed for imaging, such as ga-labelled rm (formerly bay ), ga-labelled rm and ga-labelled neobomb (ref. ). therapeutic experience is, however, limited to lu-labelled neobomb and lu-labelled rm . the former has been studied in pc- tumour-xenografted nude mice, demonstrating high tumour uptake and favourable pharmacokinetics, including limited pancreatic uptake, which makes it a suitable candidate for clinical applications . the dosimetry of the grpr antagonist lu-labelled rm was recently studied in individuals with metastatic castration-resistant prostate cancer. the analysis showed high tumour doses ( . ± . gy/gbq), with rapid clearance from normal organs, including the pancreas, which are promising attributes for therapeutic applications . antibody-based rpt. the igg antibody class has been used almost exclusively for rpt. igg antibodies are proteins with a molecular weight of , and which have a long biological half-life in the circulation ( - days, depending on their isotype and structure) and are eventually catabolized by the liver and elements of the reticuloendothelial system , . the ability to generate antibodies possessing well-defined reactivity characteristics against selected antigens (that is, monoclonal antibodies ) was a precondition for the use of antibodies as viable radionuclide delivery vehicles. haematological and lymphoid malignancies have dominated rpt investigations. antibodies to cell-surface differentiation antigens (for example, cd , cd , cd and cd ) were available for radiolabelling and clinical investigations (fig. ) . these early studies used the readily available radionuclide i, which permitted ( ) biodistribution of the radioiodinated antibodies to be imaged using spect , and ( ) therapy [ ] [ ] [ ] . radiolabelled antibodies in this class of targets were used either as molecularly targeted replacements for total-body irradiation in preparation for bone marrow transplantation www.nature.com/nrd (nct ) [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] or for direct targeting of lineages that exhibit uncontrolled proliferation [ ] [ ] [ ] . more recently, the α-emitter astatine- is being investigated with anti-cd as a lower-toxicity alternative to iodine- or radiotherapy for bone marrow ablation in preparation for transplantation , . escalating doses of the iodinated antibody m (anti-cd ) were used to treat ten patients with acute myelogenous leukaemia in a phase i clinical trial . the appending of iodine- to the m antibody allowed detailed pharmacokinetic and dosimetric studies to be performed as well as serial blood and bone marrow sampling and whole-body γ-camera imaging. disease in the bone marrow was specifically and clearly imaged starting within hours after injection. the radioiodinated m was rapidly modulated and internalized into target cells in vivo. importantly, a rapid, specific and quantitative delivery to the bone marrow and the efficient inter nalization of m into target cells in vivo suggested that the delivery of β-emitting and α-emitting radionuclides was feasible. humanization of m (hum , lintuzumab) and access to α-particle-emitting bismuth- and actinium- and β-particle-emitting yttrium- radionuclides expanded the warheads avail able to the anti-cd armament [ ] [ ] [ ] [ ] [ ] [ ] . the pioneering studies using iodine- advanced the utility of the humanized anti-cd with more potent and shorter-ranged energy emissions because the pharma cokinetics and biology of the system were well understood. potent antileukaemic responses have been observed with both of the α-particleemitting lintuzumab drugs with minimal off-target toxic effects , [ ] [ ] [ ] . actinium- -labelled anti-cd targeting multiple myeloma has also been studied , . this α-emitter is also being investigated against solid tumours that express insulin-like growth factor receptor type (nct ) . several antibodies for delivery of a low-dose-rate α-particle emitter, thorium- , are being investigated . thorium- -conjugated antibodies targeting mesothelin , , psma , , and cd (ref. ) are currently in phase i clinical trials (nct , nct and nct , respectively). an anti-her /neu conjugate is under preclinical investigation. this conjugate has demonstrated substantially greater antitumour efficacy compared with a toxin (t-dm ) anti-her /neu conjugate [ ] [ ] [ ] . it has also demonstrated synergy in combination with olaparib in a brca -deficient xenograft model lymphoma radionuclide therapy followed a similar trajectory to that of acute myelogenous leukaemia described earlier. rituximab (anti-cd ) was developed to treat relapsed and refractory follicular low-grade non-hodgkin lymphoma (nhl). when it was used as a single agent, response rates of - % in follicular lymphoma and - % in small b cell lymphoma were reported. these indolent lymphomas are characteristically radiosensitive; however, external-beam radiation is limited by toxic effects on normal tissues. delivery of the radioactive emission source specifically to cancer cells is accomplished via the monoclonal antibody delivery vehicle, providing a potent dose of targeted radiation therapy specifically to tumour cells that express the desired antigen [ ] [ ] [ ] [ ] . there are two intact antibodies directed against the cd antigen which have been conjugated to radionuclides. ibritumomab tiuxetan conjugated to yttrium- yielded zevalin (schering ag, berlin, germany) and tositumomab conjugated to iodine- yielded bexxar (corixa corp, seattle, wa, usa). both y-ibritumomab and i-tositumomab have been compared with their respective unlabelled antibody counterparts in randomized trials. in a phase iii study of patients with relapsed cd positive nhl, those who received y-ibritumomab had a higher overall response rate than those who received the 'cold' unlabelled rituximab (response rate of % compared with %, respectively) . complete response rates of % and %, respectively, were reported. reversible myelosuppression was associated with y-ibritumomab therapy. in addition, in a randomized trial designed to treat relapsed low-grade or transformed indolent nhl, patients receiving the 'hot' i-labelled tositumomab drug exhibited response rates of %, while those receiving 'cold' unlabelled tositumomab exhibited only a % response rate. the complete response rates reported were % and %, respectively . the amount of i-tositumomab prescribed to patients was determined by assessing the whole-body clearance rate, so that the amount administered was adjusted to deliver the same whole-body absorbed dose in all treated patients , making it the first rpt agent whose package insert specified an absorbed dose-based treatment planning procedure. such an approach was, in part, necessitated because the radioiodine in iodine- -labelled antibodies is cleaved antibodies to a variety of tumour-associated targets may be raised, including leukaemia-associated and lymphoma-associated targets (for example, cd , cd and cd ), targets expressed on solid-tumour cancer cells (for example, carcinoembryonic antigen (cea), prostate-specific membrane antigen (psma) and gd ) and targets expressed on their supporting microenvironment (for example, fibroblast activation proteinα (fapα)). aml, acute myelogenous leukaemia; apc, antigen-presenting cell; baff-r, b cell-activating factor receptor; caix, carbonic anhydrase ; dr, death receptor; sig, secretory immunoglobulins. adapted from ref. , springer nature limited. (due to dehalogenation) from the antibody if the radiolabelled antibody construct is internalized. as mentioned already, there are a number of antigenic targets for antibody-based rpt for solid tumours (fig. ) . however, antibody-mediated rpt for solid tumours has not provided the clinical impact of antibody-mediated rpt for haematological and lymphoid malignancies. this may be explained by the substantially greater absorbed dose required to effectively treat solid cancers - - gy compared with as low as gy for some lymphomas . radiolabelled antibodies must overcome a number of barriers before they can effectively irradiate solid tumour targets. they must extravasate and diffuse across an interstitial fluid space that is characterized by pressure gradients opposing macromolecular transport [ ] [ ] [ ] and penetrate throughout antigen-positive tumours, wherein a high antigen concentration itself presents a binding-site barrier [ ] [ ] [ ] . these barriers, along with the long circulation half-life of antibodies, lead to high bone marrow absorbed doses and insufficient dose delivery to tumours. a number of strategies that retain the exquisite specificity and high binding affinity of antibodies have been examined to overcome these limitations , . the most widely investigated of these is 'pretargeting' , in which delivery of the radionuclide is temporally dissociated from tumour targeting. the original pretargeting paradigm involved administration of a radiolabel-free streptavidin-conjugated antibody. this was followed by administration of lower molecular weight biotin which is radiolabelled . the initial construct localizes to tumours without irradiating the bone marrow. the subsequent radiolabelled biotin has a lower molecular weight and is not susceptible to the pharmacokinetics and barriers of intact radiolabelled antibody delivery. antibody engineering has eliminated the requirement for bacterial-derived elements (with their attendant immunogenicity), and a large number of novel approaches have been developed that are founded on the basic concept of temporal dissociation . yttrium- radioembolization is a technique that targets radiolabelled microspheres to liver tumours associated with unresectable hepatocellular carcinomas or metastatic liver tumours from primary colorectal cancer. liver tumours derive their blood supply from the hepatic artery, whereas the normal liver derives its blood supply from the portal vein, allowing targeted delivery of y-loaded microspheres via intra-arterial injection [ ] [ ] [ ] . the commercially available y-loaded microspheres are either glass based (therasphere) or resin based (sir-spheres), differing in size, number of microspheres injected and activity per microsphere , . both agents were approved by the fda and are marketed as devices. we include these as rpt agents because they better fit the broad definition of rpt agents provided earlier. the findings of studies comparing y-loaded glass-based and resin-based microspheres are conflicting and further investigation is needed. for example, while one study in patients with unresectable hepatocellular carcinomas found a significantly higher overall survival for treatment with y-loaded glass microspheres compared with y-loaded resin microspheres , another study found a similar outcome in terms of progression-free survival and overall survival between patients treated with y-loaded glass-based microspheres and patients treated with y-loaded resin-based microspheres . additional transarterial radiotherapeutics are being explored, including phosphorus- glass microspheres and holmium- microspheres (nct ) [ ] [ ] [ ] , as well as i-labelled or re-labelled iodized oil [ ] [ ] [ ] . initial clinical trials of i-labelled iodized oil ( i-labelled lipiodol) were completed in the late s/ early s [ ] [ ] [ ] [ ] , and clinical investigations of this treatment modality continued until (nct , nct and nct ). administration of i-labelled lipiodol in the adjuvant setting, after resection or radiofrequency ablation for hepatocellular carcinoma, yielded a -month increase in recurrencefree survival and a -month increase in median overall survival . in a prospective randomized -patient trial, adjuvant treatment of patients with hepatocellular carcinoma led to a significant increase in overall survival at years of . % in the treated group versus . % in the control group . at both the -year follow-up and the -year follow-up, actuarial overall survival in the treated group was statistically significantly greater than in the control group ( . % versus . %, respectively, and . % versus . %, respectively). the difference in overall survival lost statistical significance years after randomization . rpt has proven to be an effective cancer treatment when other standard therapeutic approaches have failed. however, despite more than years of clinical investigation, rpt has not become a part of the cancer treatment armamentarium in the same way as other therapies . 'targeted' cancer therapies are associated with clinical trial failure rates of % (ref. ), partly because the agents targeted a pathway that was not involved in promoting the cancer phenotype . by contrast, rpt has been unsuccessful owing to a failure to adopt and rigorously evaluate this treatment modality, which may be explained in part by the multidisciplinary nature of the treatment. additional challenges facing the development and application of rpt include public perception and fear of radioactivity as well as the perceived complexity of the treatment. until very recently, the > years of experience with these agents was largely ignored or presented as a burdensome multidisciplinary endeavour in the medical literature. a review of the management of painful bone metastases highlights this, implying that the efficacy, low toxicity, minimal side effects and non-addictiveness of rpt for bone pain palliation is trumped by the complexity and need for a multidisciplinary implementation. the lack of a medical constituency for rpt suggests the need for a new specialty or subspecialty to provide the multidisciplinary training needed to safely and effectively administer rpt agents to patients and subsequently manage them. such a specialty or subspecialty would require training in nuclear medicine, radiation oncology and also general oncology. www.nature.com/nrd as delivery of radiation is involved, the participation of medical physicists familiar with both imaging and radionuclide dosimetry is important. radionuclide supply, in particular for α-particleemitting radionuclides (such as actinium- ), is considered a potential obstacle for growth of the field. technological efforts to address the radionuclide supply are ongoing by both the public sector , and the private sector. these developments suggest that supply issues are transient technical issues that will be resolved with greater investment if rpt is adopted as a mainstream cancer therapy. assuming that the early dramatic results obtained with α-particle rpt continue to be borne out in rigorous clinical trials, the growth of α-emitter rpt is likely to accelerate. however, the development of biological resistance to these agents -likely due to outgrowth of cancer cells with low or no target expression -must be considered. accordingly, combination treatment will be necessary. identifying the optimal combination cancer therapy is currently largely a trial-and-error effort. by incorporating molecular imaging to assess the impact of other therapeutics on rpt delivery and calculation of the target and normal tissue absorbed doses, the trial-and-error effort needed to optimize combination therapy for rpt agents can be substantially reduced. furthermore, preclinical models to assess changes in radiosensitivity arising from combination therapy can also be used for optimization. in contrast to biologics or chemotherapeutics, both radiation delivery and the biological response to radiation may be mathematically modelled and used to understand the parameters of a treatment that are most important in influencing efficacy and toxicity . in this sense, the trial-and-error process can be further attenuated by modelling to reduce the 'parameter space' that needs to be clinically investigated. finally, as a radiation delivery modality, one may envision widespread adoption of treatment planning that combines rpt with external-beam radiotherapy; the former to target disseminated cancer and the latter to target bulky disease that is less effectively treated by rpt. such a combination strategy would expand patient eligibility for both rpt and external-beam radiotherapy. the systemic delivery of short-ranged potent radiation is an effective approach to treating patients with cancer, exhibiting a number of advantages over current therapeutic strategies. these advantages include the ability to image and calculate quantities that directly impact efficacy and potential toxicity such as absorbed dose, the ability to deliver radiation that is impervious to almost all conventional resistance mechanisms and the ability to combine rpt with radiotherapy in a rational and absorbed dose-driven manner so as to reduce the level of empiricism in clinical trials. the field of rpt has been active and growing for nearly years, and is attracting a high level of recognition and commercial interest (table ) . aside from establishing trained practitioners, the future growth of rpt will be fuelled by continued discovery of more-specific tumour-associated targets, improvements in radiochemistry, increased and low-cost availability of radionuclides (particularly α-particle emitters) and expanded preclinical and clinical investigation of combination therapy with agents and treatment modalities that are complementary to rpt. the ability to image and quantitatively characterize the likely biological outcome of rpt through dosimetry and treatment planning is a major and unique strength of this treatment approach. the question to be addressed is how does the field strike the right balance between using those features of rpt -imaging, dosimetry and treatment planningthat can help guide and optimize patient treatment and that provide an advantage over other cancer therapies versus the more expedient approach of adopting a chemotherapy dosing paradigm? the former is seen as too complicated, while the latter is already in use, is thought to work well enough and has already introduced commercially viable and beneficial agents to patients. the answer lies in early-stage clinical trials that incorporate imaging and dosimetry so that the value of these unique aspects of rpt may be rigorously evaluated and compared with existing therapeutic approaches. published online xx xx xxxx estimation of clinical trial success rates and related parameters off-target toxicity is a common mechanism of action of cancer drugs undergoing clinical trials targeted radionuclide therapy in 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imaging of folate receptor-positive cancer radioimmunotherapy of human tumours a schema for calculating the absorbed dose from biologically distributed radionuclides. mird pamphlet no. mird pamphlet no. : joint eanm/mird guidelines for quantitative lu spect applied for dosimetry of radiopharmaceutical therapy three-dimensional radiobiologic dosimetry: application of radiobiologic modeling to patient-specific -dimensional imaging-based internal dosimetry three-dimensional imaging-based radiobiological dosimetry treatment planning for internal radionuclide therapy: three-dimensional dosimetry for nonuniformly distributed radionuclides imaging-based patient specific dosimetry for rpt treatment planning g.s. acknowledges nih grants r ca and r ca . g.s. is a founder of and holds equity in radiopharmaceutical imaging and dosimetry llc (rapid). he serves as a member of rapid's board of directors; this arrangement has been reviewed and approved by the johns hopkins university in accordance with its conflict of interest policies. m.m. was a consultant for actinium pharmaceuticals, regeneron, progenics, bridge medicine and general electric. memorial sloan kettering has filed for ip protection for inventions of m.m. related to alpha particle technology. l.b. was a non-paid consultant for advanced accelerator applications (aaa), ipsen, clovis, itm and curium, and receives research support from aaa. johns hopkins university has filed for ip protection for inventions of j.n. related to alpha particle technology. springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. supplementary information is available for this paper at https://doi.org/ . /s - - - . key: cord- -i jslrae authors: visca, dina; beghè, bianca; fabbri, leonardo michele; papi, alberto; spanevello, antonio title: management of chronic refractory cough in adults date: - - journal: eur j intern med doi: . /j.ejim. . . sha: doc_id: cord_uid: i jslrae cough is a common respiratory symptom that is considered to be chronic when it lasts more than eight weeks. when severe, chronic cough may significantly impact an individual's quality of life, and such patients are frequently referred for specialist evaluation. current international guidelines provide algorithms for the management of chronic cough: in most cases, treatment of the underlying disease is sufficient to improve or resolve cough symptoms. severe chronic cough may significantly affect patients' quality of life and necessitate frequent referral for specialist evaluations. in this narrative review, we summarize non-pharmacologic and pharmacologic management of adult patients with chronic cough of known cause that persists after proper treatment (chronic refractory cough, crc) or chronic cough of unknown cause in adult patients. if chronic cough persists even after treatment of the underlying disease, or if the chronic cough is not attributable to any cause, then a symptomatic approach with neuromodulators may be considered, with gabapentin as the first choice, and opioids or macrolides as alternatives. speech pathology treatment and/or neuromodulators should be discussed with patients and alternative options carefully considered, taking into account risk/benefit. novel promising drugs are under investigation (e.g. p × inhibitors), but additional studies are needed in this field. speech pathology can be combined with a neuromodulator to give an enhanced treatment response of longer duration suggesting that non-pharmacologic treatment may play a key role in the management of crc. cough is a physiological response to mechanical and chemical stimuli due to irritation of cough receptors located mainly in the epithelium of the upper and lower respiratory tracts, pericardium, esophagus, diaphragm, and stomach. a complex reflex arc through the vagus, phrenic, and spinal motor nerves to the expiratory musculature generates an inspiratory and forced expiratory effort to clear the airways [ ] . under pathological conditions of known and unknown etiologies, chronic refractory cough (crc) may become a major medical problem because patients may need to undergo repeated examinations before reaching a diagnosis, and/or try several treatments with sometimes poor symptom control, worsening their quality of life and increasing economic burden. cough is one of the most common respiratory symptoms to result in outpatient clinical referral. the initial assessment aims to classify duration and severity of the clinical presentation with guidelines from the american college of chest physicians (accp) listing three categories based upon duration: acute cough, lasting less than three weeks; subacute cough, lasting between three and eight weeks; and chronic cough, lasting more than eight weeks [ ] [ ] [ ] . in the acute phase, when life-threating features are present, such as acute worsening of dyspnea, increased sputum production, hemoptysis, fever, and weight loss, management of underlying etiologies is an urgent priority. subacute or chronic cough may become a bothersome symptom that significantly impairs quality of life, sometimes persisting for months or years after treatment. in order to optimize and select a treatment for chronic cough, and particularly crc, current guidelines suggest applying a diagnostic algorithm to identify possible underlying diseases [ ] [ ] [ ] . in the majority of cases, a number of associated conditions are identified [ ] , most commonly upper airway cough syndrome (formerly named postnasal drip), asthma, gastroesophageal reflux, eosinophilic bronchitis, and intolerance to drugs such as angiotensin converting enzyme inhibitors. other well known triggers and diseases associated with cough include cigarette smoking, occupational irritants, foreign bodies, chronic https://doi.org/ . /j.ejim. . . received april ; received in revised form july ; accepted september obstructive pulmonary disease (copd), chest neoplasms, bronchiectasis, cystic fibrosis, and interstitial lung diseases. after excluding these causes, triggers and diseases, some patients may experience chronic cough of unclear etiology, which is called 'chronic idiopathic cough' or 'unexplained chronic cough'. the term crc has also been introduced, which includes cough that persists despite optimal treatment of the underlying disease(s) [ ] [ ] [ ] . in this review we focus on the management of crc of known or unknown cause in adults. over the past decade, international guidelines have been developed to help physicians in clinical practice to diagnose, assess the severity of, and manage cough -particularly chronic cough [ , ] . these guidelines recommend identifying the potential causes of chronic cough and then suggest specific treatments for any underlying disease. moreover, they address the treatment of cough in patients whose underlying disease remains unknown. the prevalence of chronic cough has been estimated as up to % of the general population, and may be associated with significant impairment of quality of life, together with anxiety and depression [ ] [ ] [ ] . this is especially common in patients who undergo numerous consultations and/or unsuccessful therapeutic trials before getting the diagnosis unexplained chronic cough or crc. therefore, there is increasing interest in understanding possible mechanisms for these clinical conditions. in a previous perspective, we reviewed the definitions, mechanisms, and diagnosis of chronic cough in adults [ ] . in this perspective we review the pharmacologic and non-pharmacologic management of chronic cough of known or unknown cause in adult patients. the european respiratory society (ers) task force introduced the term 'cough hypersensitivity syndrome' in , and defined it as a 'clinical syndrome characterized by troublesome coughing triggered by low levels of thermal, mechanical or chemical exposure' [ ] . in pathological conditions, inflammation of central and/or peripheral components of the cough reflex may be triggered by innocuous stimuli resulting in excessive coughing due to neuroinflammation defined as 'cough reflex hypersensitivity'. assuming cough hypersensitivity syndrome represents a common mechanism responsible for troublesome persistent cough of known or unknown causes, peripheral and central neural pathways for cough signal and receptors become new target for treatment and may help to understand clinical aspects of 'difficult to treat cough'. the concept of cough hypersensitivity syndrome includes both chronic troublesome cough of known cause that remains troublesome even after treatment of the underlying cause (crc), and chronic idiopathic cough with no identifiable cause. most chronic respiratory diseases can manifest with chronic cough as one of the symptoms, although chronic cough is rarely the dominant symptom and it usually responds to treatment of the underlying disease. unfortunately, with the exception of asthma, in which respiratory symptoms including cough are largely reversible upon treatment, chronic cough due to other chronic respiratory diseases, such as copd or bronchiectasis, only partially responds to specific treatment. however, unless the cough remains hacking and troublesome, this partial response is usually sufficient, and does not require additional speech pathology and/or neuro-modulatory treatment. in fact, in most cases (including chronic respiratory infections, pneumonia, bronchiectasis, interstitial lung diseases, cystic fibrosis or productive cough in copd) cough should be reduced but not abolished as it is an important defense mechanism. in contrast, such additional treatment should be considered for patients with one or more of these diseases when chronic cough remains hacking and troublesome even after adequate treatment of the underlying disease, and in those with chronic hacking and troublesome cough of unknown origin [ ] [ ] [ ] . this additional approach to treatment may be non-pharmacologic and/or pharmacologic. the two most influential guidelines for the management of cough, and particularly crc, are: ) those developed [ ] and updated [ ] by the accp, and ) those developed by the ers [ ] . the definitions, classification, diagnosis and differential diagnosis, assessment of severity, and management (non-pharmacologic and pharmacologic) are similar in these guidelines, and we refer the reader to the original documents for a detailed description. in this review we focus on the management of crc of known and unknown origin, describing all available approaches, but highlighting whether or not they are recommended by guidelines. as mentioned above, coughing is the sudden expulsion of air from the lungs through the upper airways when the vocal cords are open [ , , ] . the increased tension in the larynx is involved in phonation, respiratory function as part of the conducting airways, and swallowing, with laryngeal motor dysfunction at any point potentially leading to dysphonia and triggering chronic cough [ , ] . voice problems and vocal cord dysmotility have been estimated in up to % of adults with chronic cough [ ] . singing, talking and shouting are the activities most frequently associated with increased tension of the larynx and may be identified as a trigger of chronic cough. phonation may be associated with a decreased lower esophageal sphincter tone, which in turn can promote acid reflux from the stomach and stimulate pressure receptors in the larynx, resulting in chronic cough [ ] , which, together with stimulation of pressure receptors in the larynx, may lead to chronic cough. the most common laryngeal motor dysfunction is vocal cord dysfunction (vcd), which consists of an involuntary vocal fold adduction during inspiration [ ] . the link between voice problems and chronic cough is the rationale for the speech pathology approach in refractory cough [ ] . indeed, speech therapy, breathing exercises, cough suppression techniques, and patient counseling have been tried in the management of chronic cough. a systematic review reporting five studies of such interventions showed improved cough severity and frequency, although few studies used validated cough measurement tools [ ] . the identification of specific components of this non-pharmacologic approach and its effectiveness on chronic cough was described by vertigan et al. in a single-blind, randomized placebo-controlled trial [ ] . ninety-seven patients with refractory chronic cough were randomly assigned to the speech pathology intervention or placebo. intervention consisted of four sessions over a two-month period by a qualified speech pathologist. the components of speech pathology treatment were education, vocal hygiene, cough suppressant strategies, and psychoeducational counseling. chamberlain et al. conducted a multicenter randomized controlled trial in patients with crc, and observed an improvement in cough-specific quality of life (leicester cough questionnaire) and cough frequency (leicester cough monitor) as a consequence of implementing a combined physiotherapy and speech and language therapy intervention [ ] . the educational component should determine the reasons for coughing and outline the possible negative consequences of ongoing chronic cough. patients should understand the goals of therapy, which are to suppress cough despite the triggering sensation, and enhance patients' ability to voluntarily control the cough. patients are taught to substitute a competing response, such as a distraction technique, cough suppression swallow, or relaxed throat breathing in order to reduce laryngeal constriction. psychoeducational counseling should support patients and their control over their cough, emphasizing that cough is a response to irritating stimuli rather than a phenomenon outside of their control. vocal hygiene education aims to reduce or prevent laryngeal irritation by avoiding passive smoking, avoiding mouth breathing, and behavioral management of gastroesophageal reflux. broaddus-lawrence et al. documented that strategies to reduce coughing and throat clearing in individuals with voice disorders improved voice quality [ ] . in addition, solomon et al. found a beneficial effect on the larynx of adequate hydration, including attenuating or delaying elevation of phonatory threshold pressure [ ] . further, vertigan et al. found that speech pathology management was effective in terms of the global clinical assessment, symptom response and analysis of voice parameters [ ] . in a non-comparative study, ryan et al. evaluated the presence of vcd in their participants and investigated the efficacy of speech pathology management for crc in those with vcd. subjects with vcd received speech pathology therapy from a speech pathologist in sessions every four weeks, which included education, vocal hygiene, cough suppression strategies, relaxed throat breathing techniques, and psychoeducational counseling [ ] . the terminology of breathing exercises varies among studies, but breathing control/diaphragmatic breathing and relaxed breathing control techniques have all been described as aiming to relax the throat, neck, and shoulder muscles whilst increasing abdominal excursion and reducing upper chest movement. a non-comparative retrospective study by murry et al. was the only one to include breathing exercises as a sole intervention rather than a composite package of care [ ] . sixteen adults with chronic cough underwent - sessions of respiratory retraining exercises over a - -week period. patients with (vcd) and chronic cough reported an aberrant laryngeal sensation which tended to normalize following a limited course of respiratory retraining, with improvement in patients' symptoms. ryan et al. documented a reduction in cough frequency following intervention using a validated objective outcome measure, the leicester cough monitor [ , ] . seventeen adults with chronic cough were assessed before, during, and after speech language pathology intervention by a qualified speech language pathologist over a period of - weeks.. this intervention also reduced laryngeal irritation, with subsequent lower cough sensitivity and lower urge to cough, whereas the cough threshold increased. patel et al. evaluated the effectiveness of outpatient-based cough physiotherapy in a pilot prospective observational study [ ] . this study reported a significant reduction in cough frequency and an improvement in cough-related quality of life from the intervention, which consisted of education, counseling, cough control, breathing retraining, and vocal hygiene. according to current ers guidelines, multi-component physiotherapy/speech and language therapy interventions should be considered for crc patients who wish an alternative to drug treatment [ ] . the accp guidelines recommend identifying patients with oral-pharyngeal dysphagia, or the presence of conditions associated with high risk of aspiration, as they are potential candidates for speech pathology treatment [ ] . despite the efficacy and advantages of speech pathology intervention, there is limited guidance in the literature as to when patients should be referred for treatment. patients suitable for speech pathology intervention are those whose cough has persisted despite medical management. speech pathology intervention may be particularly beneficial for patients with coexisting laryngeal disorders such as muscle tension dysphonia or inducible laryngeal obstruction [ ] . pathological mechanisms may affect central and peripheral neuromodulators or cause a hypersensitivity of the cough reflex. most studies in crc have focused on pharmacologic treatment or speech pathology treatment individually; few studies have evaluated the effectiveness of combined treatment. a randomized, double blind placebo-controlled trial by vertigan et al. showed that combined treatment with pregabalin and speech pathology was more effective than speech pathology alone in terms of cough frequency, cough severity and cough-related quality of life [ ] . in addition, the effect of the combined approach was still beneficial for the four weeks after cessation of pharmacological treatment ( fig. ) [ ] . a number of agents, both opioid and non-opioid, are thought to suppress cough via activity on the central cough center [ , , , ] . they modulate the enhanced neural sensitization, which is the key component of crc. codeine is the opiate traditionally used for cough, but despite widespread use data are limited (and conflicting) regarding efficacy in chronic cough, and a range of side effects have been reported. in a double-blind, placebo-controlled crossover study by smith et al., patients with copd were randomly assigned to codeine mg twice a day or placebo for one day [ ] . no significant difference was noted between the groups in cough counts or subjective cough scores, although the study size was small and the dose of codeine low [ ] . while codeine is not effective in chronic refractory cough, and not recommended by ers guidelines (table ) [ ] , it may be useful in prolonged cough persisting after acute respiratory infections, including covid- [ ] . morphine is effective in some but not all patients, and limited data are available from prospective studies. in a double-blind crossover trial by morice et al., patients who had a persistent cough of greater than three months duration and who had failed specific treatment were randomly assigned to receive slow-release morphine ( mg twice daily) or placebo for four weeks. morphine improved daily cough severity scores, although the cough reflex was unaltered [ ] . somnolence and constipation are common side effects, yet despite this morphine is recommended by guidelines (table ) [ , ] . tramadol is an opioid similar to codeine and morphine. a pilot prospective study by dion et al. on patients with neurogenic cough highlighted the antitussive properties of tramadol [ ] . however, tramadol is neither recommended nor discouraged by guidelines (table ) gabapentin and pregabalin are gamma aminobutyric acid (gaba) analogs that bind to the voltage-gated calcium channels and inhibit centrally neurotransmitter release. they are neuromodulators commonly used to control pain and epilepsy. lee et al. reported data from patients with chronic cough on the effectiveness of gabapentin: % had a clinically positive response, especially when laryngeal neuropathy was present; however, . % complained of dizziness or somnolence [ ] . in addition, mintz et al. described six cases in which gabapentin was administered for intractable cough; complete resolution or a significant improvement in cough was observed in five of these cases [ ] . fatigue and drowsiness were reported as side effects [ ] . further, in a randomized trial by ryan et al. in patients who had experienced crc for more than eight weeks, treatment with gabapentin for weeks significantly improved cough-specific quality of life (leicester cough questionnaire score), cough severity (visual analogue scale) and cough reflex sensitivity (defined by quantity of capsaicin needed to induce five coughs) with limited side effects, most commonly nausea, confusion, dizziness, dry mouth and fatigue (fig. ) [ ] . after withdrawal of gabapentin, there was reduced effectiveness, in terms of leicester cough questionnaire and mean cough severity, further supporting its antitussive effect. in a recent randomized clinical trial by dong et al. gabapentin was compared to baclofen in the treatment of suspected refractory gastroesophageal reflux-induced chronic cough [ ] . two hundred and thirty-four patients who failed an eight-week course of omeprazole and domperidone were recruited and randomly assigned to receive either gabapentin or baclofen for eight weeks. the authors concluded that the two drugs had similar therapeutic efficacy, but that gabapentin was preferable because of fewer side effects. these findings suggest that gabapentin does not act by reducing peripheral sensitization, but additional placebo-controlled randomized controlled trials are needed to explore how long a patient with crc should remain on gabapentin to achieve resolution of symptoms. gabapentin is recommended by current guidelines as a potential pharmacologic treatment for crc (table ) [ , , ] . administration of pregabalin decreases levels of neurotransmitters such as glutamate, noradrenaline, and substance p [ ] . in a case report by li et al., pregabalin prescribed to alleviate postherpetic neuralgia also relieved the patient's chronic cough, with no serious adverse events reported after two years of follow-up [ ] . halum et al. documented its effectiveness on laryngeal sensory neuropathy through a retrospective study in consecutive patients [ ] . the risk/benefit of pregabalin versus gabapentin for the treatment of crc needs to be carefully considered. the magnitude of change in the leicester cough questionnaire and cough severity in this pregabalin study was greater than the gabapentin study [ , ] , however, adverse effects were more common with pregabalin than with gabapentin. some aspects of the study design may have amplified the differences between gabapentin and placebo. first, the known cns effects of gabapentin might have impacted treatment masking, thus favoring gabapentin. second, baseline cough frequency was higher in the gabapentin group, although not significantly, providing more 'space' for a positive effect. third, the population examined was highly selected, possibly identifying the optimal target population, but limiting the use of gabapentin to very few patients in real life. in addition, pregabalin has a greater abuse potential than gabapentin, most likely due to its more rapid absorption and faster onset of action. pregabalin is a treatment option recommended by current guidelines (table ) [ , , ] . dextromethorphan is probably the most commonly used non-opioid agent for cough; it is considered to have opiate properties [ ] . however, few studies have evaluated the efficacy of dextromethorphan in chronic cough, and those available were conducted in adults and used small sample sizes ( - patients in each study), with conflicting results [ , ] . due to the absence of appropriately designed and powered randomized clinical trials, dextromethorphan is neither recommended nor discouraged by guidelines [ , , ] . amitriptyline is a tricyclic antidepressant and inhibitor of serotonin reuptake that has been investigated by jeyakumar et al. for the treatment of crc due to post-viral vagal neuropathy [ ] . in this prospective, randomized, controlled study in patients, the majority of patients receiving amitriptyline achieved a complete response, whereas none of those receiving the combination of codeine and guaifenesin responded [ ] . the authors do not report whether any patients experienced side effects during the study. secondly, bastian et al. conducted a prospective uncontrolled cohort study in consecutive patients [ ] . all patients were treated with a single dose of open label mg of amitriptyline for days. at least a % reduction in selfreported symptoms was recorded, suggesting that a trial of amitriptyline mg (or of other anti-neuralgia type medications) may be helpful in chronic cough [ ] . finally, a retrospective case series by norris et al. in patients with recurrent laryngeal nerve sensory neuropathic symptoms documented improvement in neuropathic symptoms when treatment with amitriptyline over two months [ ] . four patients with no response or intolerable side effects were prescribed gabapentin [ ] . amitriptyline is neither recommended nor discouraged by guidelines (table ) [ , , ] . taking into account all the studies mentioned so far, several neuromodulators with at least one positive randomized controlled trial were evaluated. these therapies seem promising for the treatment of chronic cough. the chest expert cough panel recommends only gabapentin (table ) [ ] , the risk-benefit profile to be reassessed after six months before continuing the drug. ers guidelines recommend a trial of low dose slow-release morphine ( - mg twice daily) in adults with crc. they also suggest a trial of gabapentin or pregabalin in adults with crc [ ] . in conclusion, there are few effective treatments for cough with an acceptable therapeutic ratio; more selective agents with a more favorable side effect profile are needed. a possible role of inhaled drugs in the management of crc has been also investigated. local anesthetics (e.g., lidocaine or bupivacaine) are currently used in the palliative management of cough associated with malignancies. in addition, an older study with ipratropium bromide reported a significant reduction in cough severity and a good safety profile in patients with chronic persistent cough, although the sample size was small (n = ) and results have not been subsequently replicated [ ] . subsequent preclinical research suggests that tiotropium can directly modulate airway sensory nerve activity and thereby the cough reflex, through a mechanism unrelated to its anticholinergic activity [ ] . the recognition that chronic cough is characterized by hypersensitivity of the peripheral and central neural pathways involved in cough has expanded the range of potential therapeutic targets currently under evaluation. a novel approach is to focus on molecular pathways rather than neural mechanisms [ ] . the primary vagal fibers mediating cough are a-fibers and c-fibers, which are responsive to mechanical and chemical stimuli, respectively [ ] . p × receptors are expressed by airway vagal afferent nerves and contribute to the hypersensitization of sensory neurons [ ] . based on laboratory studies, increased sensitivity of p × receptors on the airway sensory nerve fibers (e.g., vagal afferent c fibers) could mediate sensitization of the cough reflex and could therefore be a potential cause of refractory cough [ ] . adenosine triphosphate (atp) plays a significant role in the activation of sensory c fibers, and this activation is inhibited by blockade of p × and p × / receptors. in a randomized, cross-over trial of patients with refractory cough, an investigational p × antagonist, gefapixant, previously known as af- , decreased cough counts during the two-week study blocks by % compared with placebo [ ] . however, taste disturbance was noted in all patients taking gefapixant and caused six patients to withdraw from the study; nausea was also common ( %). in a phase , double-blind, two-period study by morice et al. there was a reduction in the cough reflex in patients treated with gefapixant mg [ ] . two randomized, double-blind, placebo-controlled, two period crossover, doseescalation studies by smith et al. of gefapixant at lower doses has reported efficacy with fewer side effects [ ] . finally, in a multicenter randomized placebo-controlled parallel trial smith et al. investigated the effect of gefapixant on chronic cough [ ] . data are available only as an abstract, in which the authors describe a significant improvement in the cough frequency when compared to placebo [ ] . these results support a promising therapeutic target in development for p × receptor hypersensitivity in refractory cough, but further study is needed to determine safety and efficacy in a larger number of patients. transient receptor potential (trp) channels are present in abundance in the airways and are expressed in many cell types of the airway including primary sensory afferent nerves, epithelial cells and smooth muscle cells [ ] . several agents for pain are in development that target these receptors. however, since trp channels are directly activated by changes in temperature, chemicals, mechanical stimulation, ph and osmolality, and may evoke cough, they been proposed also as treatments for chronic cough. of particular interest in relation to cough are members of the vanilloid (trpv , trpv ), anykrin (trpa ) and melastatin (trpm ) families. to date, pharmacologic modulation of trp channels for the treatment of cough has been disappointing and remains to be investigated as a potential target for chronic cough. trpv was the first channel to be considered as a key regulator of cough, but two phase , double-blind crossover studies by belvisi et al. and khalid et al. on trpv failed to show improvements in spontaneous cough frequency [ , ] . the trpa channel is activated by a range of physical and chemical factors including cold temperatures, mechanical stimulation, inflammatory mediators and acrolein (a component of cigarette smoke). although animal studies demonstrated effectiveness of trpa antagonists in reducing cough in response to tussive challenges, in a double-blind placebo-controlled study in patients there was no reduction in cough frequency over h, or no reduction in citric acidinduced cough [ ] . trpv is recognized as an osmosensor and responds to diverse stimuli including non-noxious temperatures, shear stress and mechanical stimulation. a clinical trial with the trpv antagonist, gsk , was terminated early, presumably due to lack of efficacy [ ] . finally, trpm is activated by cooling compounds such as menthol, icilin and eucalyptol [ ] . voltage-gated sodium channels (nav) mediate the initiation and propagation of action potentials in afferent sensory nerves and represent a potential therapeutic target for cough. lidocaine, a non-selective nav channel blocker, has been used clinically to alleviate cough and has been reported to be safe [ ] . however, a phase double-blind crossover study using a novel blocker targeting a subtype selective inhibition of the nav . (gsk ) failed to illustrate an antitussive response [ ] . the tachykinins, substance p, neurokinin a and neurokinin b are released both from the peripheral endings of afferent nerves (predominately c-fibers) and from central neural structures. the tachykinin receptor, neurokinin receptor, has gained attention as a target for chronic cough treatment. in a phase , double-blind study (volcano- ) by smith et al. on patients, significant improvements in objective cough frequency and sustained reductions in daytime cough frequency were documented [ ] . nicotinic acetylcholine receptors, or nachrs, respond to the neurotransmitter acetylcholine and to nicotine and are found in the central and peripheral nervous system. dicpinigaitis et al. studied the alpha (α ) subtype of the nachrs, which is responsible for the antitussive effect of nicotine through the activation of gabaergic interneurons in the brainstem [ ] . azithromycin belongs to the class of macrolide antibiotics. it is commonly used in the treatment of a variety of infections, including community-acquired respiratory tract infections and mycobacterial infections, and macrolide antibiotics also have anti-inflammatory actions. hodgson et al. investigated the potential effects of azithromycin on chronic cough in a randomized, double-blind, placebo-controlled study [ ] . treatment with azithromycin for eight weeks failed to improve health status in patients with chronic cough when compared with placebo. erythromycin was studied by yousaf et al. in a randomized, doubleblind, placebo-controlled parallel trial; the authors documented no difference in the change in cough frequency between the erythromycin and placebo group, although there was a significant difference in the change in sputum neutrophils over a week period (a reduction with erythromycin and an increase with placebo) [ ] . pa- is a novel formulation of cromolyn sodium and thought to act as a mast cell stabilizer. in a randomized placebo-controlled trial by birring et al. pa- was delivered via a high efficiency eflow nebulizer to patients with idiopathic pulmonary fibrosis and chronic cough [ ] . no treatment benefit was observed for pa [ ] . in conclusion, there have been important developments in elucidating pathophysiological mechanisms underlying chronic cough. additional information regarding neurobiology has introduced a number of novel pharmacological treatment options, including drugs targeting the p × receptor, which seems to be the most promising. cough is one of the most common respiratory symptoms, and is defined as chronic when it lasts for more than eight weeks. in the majority of cases, it represents the most troublesome symptom of common respiratory and non-respiratory diseases. if chronic cough persists even after treatment of the underlying disease, or if the chronic cough is not attributable to any cause, then a symptomatic approach with neuromodulators may be considered, with gabapentin as the first choice [ , , ] , and opioids or macrolides as alternatives. speech pathology treatment and/or neuromodulators should be discussed with patients and alternative options carefully considered, taking into account risk/benefit. novel promising drugs are under investigation (e.g. p × inhibitors), but additional studies are needed in this field. speech pathology can be combined with a neuromodulator to give an enhanced treatment response of longer duration suggesting that non-pharmacologic treatment may play a key role in the management of crc. international guidelines, based on consensus opinion and observational data, provide detailed investigation and treatment algorithms [ , , ] . however, there are broad national and international differences in the delivery of health care resulting in differences in available diagnostic tests and management strategies, both in primary and specialist care. quality of life is frequently impaired in patients with chronic cough, who often also have increased economic burden. smith et al. provides a simplified approach through four steps: identification and treatment of obvious causes; focused testing for, and treatment, of asthma, gastroesophageal reflux and rhinosinusitis; investigations to rule out rarer causes of cough; and management of idiopathic or refractory chronic cough [ ] . the lack of knowledge or limited economical resources in several areas may be handled by identification of referral centers for multidisciplinary management (respiratory physician, ear, nose and throat specialist, gastroenterologist, psychologist, lung function and molecular biology lab, respiratory physiotherapist and speech therapist) of chronic refractory cough and the feasibility of clinical trials to implement this field. none. what is chronic cough? terminology chest expert cough panel. classification of cough as a symptom in adults and management algorithms: chest guideline and expert panel report ers guidelines on the diagnosis and treatment of chronic cough in adults and children diagnosis and management of cough executive summary: accp evidence-based clinical practice guidelines changing the paradigm for cough: does "cough hypersensitivity" aid our understanding? treatment of unexplained chronic cough: chest guideline and expert panel report development of a symptom specific health status measure for patients with chronic cough: leicester cough questionnaire (lcq) the global epidemiology of chronic cough in adults: a systematic review and meta-analysis the impact of chronic cough: a cross-sectional european survey chronic cough in adults expert opinion on the cough hypersensitivity syndrome in respiratory medicine chronic cough chronic cough as a neuropathic disorder voice and upper airway symptoms in people with chronic cough and paradoxical vocal fold movement manometric evidence for a phonation-induced ues contractile reflex speech pathology for chronic cough: a new approach nonpharmacological interventions for refractory chronic cough patients: systematic review efficacy of speech pathology management for chronic cough: a randomised placebo controlled trial of treatment efficacy physiotherapy, and speech and language therapy intervention for patients with refractory chronic cough: a multicentre randomised control trial the effects of preventive vocal hygiene education on the vocal hygiene habits and perceptual vocal characteristics of training singers effects of a vocally fatiguing task and systemic hydration on phonation threshold pressure chronic cough and laryngeal dysfunction improve with specific treatment of cough and paradoxical vocal fold movement laryngeal sensory deficits in patients with chronic cough and paradoxical vocal fold movement disorder cough reflex sensitivity improves with speech language pathology management of refractory chronic cough the leicester cough monitor: preliminary validation of an automated cough detection system in chronic cough improvement in health status following cough-suppression physiotherapy for patients with chronic cough an update on speech pathology management of chronic refractory cough pregabalin and speech pathology combination therapy for refractory chronic cough: a randomized controlled trial effect of codeine on objective measurement of cough in chronic obstructive pulmonary disease covid- : nice advises against using nsaids for fever in patients with suspected cases opiate therapy in chronic cough treatment of neurogenic cough with tramadol: a pilot study chronic cough as a sign of laryngeal sensory neuropathy: diagnosis and treatment gabapentin in the treatment of intractable idiopathic chronic cough: case reports gabapentin for refractory chronic cough: a randomised, double-blind, placebo-controlled trial randomised clinical trial: gabapentin vs baclofen in the treatment of suspected refractory gastro-oesophageal reflux-induced chronic cough a new treatment option for laryngeal sensory neuropathy effect of pregabalin for the treatment of chronic refractory cough: a case report a review on the efficacy and safety of gabapentin in the treatment of chronic cough the antitussive effect of dextromethorphan in relation to cyp d activity efficacy and tolerability of treatments for chronic cough: a systematic review and meta-analysis dextromethorphan and codeine: objective assessment of antitussive activity in patients with chronic cough effectiveness of amitriptyline versus cough suppressants in the treatment of chronic cough resulting from postviral vagal neuropathy sensory neuropathic cough: a common and treatable cause of chronic cough management of recurrent laryngeal sensory neuropathic symptoms chronic persistent cough: use of ipratropium bromide in undiagnosed cases following upper respiratory tract infection tiotropium modulates transient receptor potential v (trpv ) in airway sensory nerves: a beneficial off-target effect? therapeutic targets for the treatment of chronic cough vagal afferent innervation of the airways in health and disease in pursuit of p × antagonists: novel therapeutics for chronic pain and afferent sensitization p × receptor antagonist (af- ) in refractory chronic cough: a randomised, doubleblind, placebo-controlled phase study the effect of gefapixant, a p × antagonist, on cough reflex sensitivity: a randomised placebo-controlled study gefapixant in two randomised dose-escalation studies in chronic cough mk- , a p × receptor antagonist, reduces cough frequency in patients with refractory chronic cough: results from a randomized, controlled, phase b clinical trial xen-d , a novel transient receptor potential vanilloid antagonist, does not reduce cough in patients with refractory cough transient receptor potential vanilloid (trpv ) antagonism in patients with refractory chronic cough: a double-blind randomized controlled trial long-term safety of nebulized lidocaine for adults with difficult-to-control chronic cough: a case series effects of a novel sodium channel blocker, gsk , in patients with refractory chronic cough the neurokinin- receptor antagonist orvepitant is a novel antitussive therapy for chronic refractory cough: results from a phase pilot study (volcano- ) the antitussive effects of alpha (α ) nicotinic receptor agonists the effects of azithromycin in treatment-resistant cough: a randomized, double-blind, placebocontrolled trial long-term low-dose erythromycin in patients with unexplained chronic cough: a double-blind placebo controlled trial a novel formulation of inhaled sodium cromoglicate (pa ) in idiopathic pulmonary fibrosis and chronic cough: a randomised, double-blind, proof-of-concept, phase trial editorial support (in the form of critically reviewing the content written by the authors, and editing for grammar and journal style) was provided by david young of young medical communications and consulting ltd. key: cord- -hsgsuor authors: constantinou, constantina; kolokotroni, ourania; mosquera, maria‐cecilia; heraclides, alexandros; demetriou, christiana; karayiannis, peter; quattrocchi, annalisa; charalambous, andreas title: developing a holistic contingency plan: challenges and dilemmas for cancer patients during the covid‐ date: - - journal: cancer med doi: . /cam . sha: doc_id: cord_uid: hsgsuor during the first quarter of the world is experiencing a pandemic of severe acute respiratory syndrome‑coronavirus‑ (sars‑cov‑ ), a novel beta coronavirus that is responsible for the novel coronavirus disease (covid‐ ). the covid‐ pandemic revealed that healthcare systems around the world were not prepared to deal with either the direct effects of the pandemic or with the indirect effects that are imposed on the health of patients with chronic disorders such as cancer patients. some challenges and dilemmas currently faced during the pandemic include the management of cancer patients during the treatment and follow‐up phases, the assessment of the safety of treatments currently used for the management of sars‑cov‑ for use in cancer patients, the development of psychoeducation and emotional support for cancer patients and the safe conduct of clinical trials involving participation of cancer patients. evidence from the literature supports the need for the urgent development of a holistic contingency plan which will include clear guidelines for the protection and comprehensive care of cancer patients. the implementation of such a plan is expected to have many beneficial effects by mainly minimizing the increased morbidity and mortality of cancer patients that could result as an adverse consequence of the covid‐ or future pandemics. during the first quarter of the world is experiencing a pandemic of severe acute respiratory syndrome-coronavirus- (sars-cov- ), a novel beta coronavirus that is responsible for the novel coronavirus disease . , it all started when at the end of december , healthcare authorities reported unidentified cases of pneumonia in a seafood market in wuhan, china. on the last day of january , the world health organization (who) announced a public health emergency of international concern (pheic) and on th march , the who formally declared the covid- outbreak a pandemic. , according to a who situation report through th april , covid- was responsible for a total of confirmed cases and , deaths. sars-cov- is an enveloped virus with a single-stranded rna genome of positive polarity. [ ] [ ] [ ] the most common symptoms are fever, dry cough, and fatigue. some patients may present with headache and/or muscle pain but may have no upper respiratory symptoms. [ ] [ ] [ ] [ ] [ ] men have a higher risk than women of being infected with the virus and patients with pre-existing comorbidities such as diabetes, hypertension, and cardiovascular disease are among those at highest risk of not only acquiring the infection but also of having worse outcomes. , there is also concern that cancer patients may also be of higher risk which is exceedingly concerning from a public health perspective since cancer is amongst the most prevalent diseases worldwide. cancer development is associated with a state of immunosuppression. , in addition, the management of the disorder (eg chemotherapy, immunotherapy, surgery, and hematopoietic transplantation) also leads to defects in the adaptive and innate immune systems. , for example, some conventional chemotherapies eliminate the function of t cells whereas some immunotherapeutic agents eliminate the function of b cells. , therefore infection with sars-cov- can be a life-threatening event for a cancer patient. preliminary evidence in the literature supports that cancer patients infected with sars-cov- have a higher risk of disease severity and mortality compared to sars-cov- infected patients without cancer. a study by liang et al, provided evidence that cancer patients (that had received chemotherapy or surgery within the past month) and cancer survivors (in routine follow-up) who were infected with sars-cov- had a higher risk of severe events (defined as the percentage of patients being admitted to the intensive care unit requiring invasive ventilation, or death) ( %) compared to patients without cancer with sars-cov- ( %) adjusting for age and other known risk factors. in this study the mortality rate was significantly higher in cancer patients ( . %) compared to the virus' overall case fatality proportion which appears to be about % in china. , globally, about . % of reported covid- cases died up to march rd, . in another retrospective cohort study, the mortality of cancer patients infected with covid- was . % whereas in covid- infected patients without cancer (of the same age group of - years) the mortality was reported to be between . %- . % and . %. , the most comprehensive data available to date is the report of the who-china joint mission on coronavirus disease published on february th, . the report indicated that the case fatality rate for patients with cancer as a comorbid condition and laboratory confirmed infection with sars-cov- was . % compared to patients with no comorbid condition and laboratory confirmed infection with sars-cov- which was . %. an important factor associated with covid- disease severity and complications in patients with cancer and covid- is whether cancer patients are undergoing treatment at the time of infection. zhang et al, reported that patients who had their last anti-tumor treatment (including chemotherapy, immunotherapy, and radiation) within days prior to infection with sars-cov- had a significantly increased risk of developing severe events (hr = . , % ci . - . , p = . ). the results of another study found that cancer patients had an estimated twofold increased risk of covid- infection compared to the general population. of the cancer patients examined, were infected with sars-cov- and two of these patients died ( . %), though one of the two patients died due to an unrelated cause. they also reported that of the patients were undergoing treatment at the time of contracting the virus, and it is possible that hospital visits for treatment were responsible for the increased incidence of covid- in cancer patients. consequently, the researchers proposed that protocols should be developed to offer treatments to cancer patients in proper isolation to prevent the risk of sars-cov- infection. many of the studies described are retrospective and the number of patients included in the studies was small. in addition, it has been proposed that smoking history and increased age may explain the increased susceptibility and severity of covid- in cancer patients compared to healthy individuals. [ ] [ ] [ ] in addition, the studies were carried out in china where the prevalence of specific cancers may be different than in the rest of the world. furthermore, patients in china receive cancer therapy in hospitals, whereas in other countries treatment is provided in outpatient settings. lastly, in these studies the cancer patients were treated in hospitals which were also covid- referral centers treating a high number of covid- patients, and this could lead to the cancer patients being exposed to a higher risk of infection with sars-cov- than if they had been treated in other healthcare centers. in the uk, nice has developed the 'covid- rapid guideline: delivery of systematic anti-cancer treatment', a generic guideline for all cancer patients. in the usa, guidelines have also been developed with regards to the management of cancer patients during the pandemic but these are specific to different types of cancers. some examples include the guidelines developed by the american society of clinical oncology (asco), the american society of breast surgeons (asbs), and the american college of surgeons (acs). however, currently, there are no international guidelines with regards to the management of all aspects of care of cancer patients during the covid- pandemic. multiprofessional healthcare teams therefore need to be constantly evaluating the facts related to the covid- pandemic in order to make the most appropriate decisions for their cancer patients. some of the questions addressed are the following: should the cancer patients' management be continued or deferred and under | which conditions? should any specific measures be taken during treatment? are there any specific measures to prevent infection? how will the pandemic affect ongoing or planned clinical trials, access to medication and hematopoietic cells. the purpose of the current review is to shed some light on the impact of the covid- pandemic on cancer patients and some challenges and dilemmas faced by the healthcare teams in their effort to continue to provide high quality healthcare to these patients. cancer is a life-threatening event and treatment should be offered at the appropriate periods and frequency as required by protocols. in addition, the provision of care to cancer patients requires good coordination between multiprofessional healthcare teams. interruption of care can be life threatening and may have detrimental effects on the patients' physical and mental well-being. , during periods of epidemics one of the issues that arise is that there is an increased need for healthcare professionals to provide care to patients infected with the specific infectious agent. the latter may lead to deprivation of the necessary resources that are needed to treat patients with chronic disorders including cancer patients. for example, it has been estimated that since january , more than medical workers travelled from areas around wuhan to wuhan to help manage covid- patients and contain the outbreak. this phenomenon affected healthcare services outside wuhan since there was a decrease in the number of doctors and other healthcare professionals in those regions. in addition, enforced quarantine, as was the case in wuhan, caused complications in terms of attendance of cancer patients for scheduled appointments and continuity of care. there were also reported issues with severe complications or emergencies particularly in patients with advanced cancers due to their inability to access required healthcare. similar to china, italy has also been severely affected by the covid- epidemic. hospitals of affected areas had to re-allocate resources for the epidemic. treatments for cancer patients were postponed so that medical teams could deal with the overwhelming number of covid- patients in the intensive care units (icus). in italy, specific protocols within the emergency medical system were applied to increase the capacity of intensive care units. , in order to achieve this, in the most affected areas medical specialists, including oncologists, were asked to provide their assistance in managing patients suffering from covid- requiring hospitalization in icus or in the departments of infectious or respiratory diseases or general internal medicine. in addition to the organized re-allocation of resources, in areas where covid- is widespread, physicians may be limiting in-person contact with cancer patients due to concerns of being asymptomatic and exposing the patients to covid- . in addition, physicians may limit exposure to patients because they may not have personal protection equipment (ppe) especially in areas and times when ppe is in shortage or is being redirected to covid- treating hospitals. access to healthcare services for cancer patients may also be limited because lockdown measures may have affected the social determinants of health. for example, in certain countries such as the usa where healthcare is provided by insurance, the processing or renewal of insurance paperwork may delay the onset or continuation of treatment. furthermore, in parts of the world where transport is affected by lockdown (ie closing of roads and airports), patients may be restricted from travelling to other cities or countries for treatment to receive the necessary care. moreover, it is important to bear in mind that in certain parts of the world, where patients have to pay for cancer services, lockdown may have affected their finances enough that they may either delay or may not be able to seek treatment. currently, there are no official reports of how the treatment of cancer patients has been affected by the lack of resources and limited access to healthcare due to the covid- pandemic in most afflicted countries. yet this is an important issue that should be carefully analysed and reported. no studies are yet available that have investigated the risk of untreated malignancy while waiting for covid- to subside vs the risk of exposure to the virus during cancer treatment. usually the decision as to whether treatment should be offered or deferred is left to the judgment of multiprofessional healthcare teams and particularly oncologists who are responsible for the management of cancer patients. in making decisions regarding whether treatment should be offered as usual or deferred to reduce the risk of infection with covid- , a number of factors should be considered since not all cancer patients fall under the same category or urgency for treatment (ie there are differences for each case with regards to the patient's age, type of cancer, stage of cancer, and the presence of other comorbidities). in addition, the risks vs benefits posed by the hospital setting need to be considered. therefore, decisions with regards to patients' treatment are usually taken on a case by case basis which is time consuming further straining the limited resources available. some healthcare settings and guiding bodies seem to be in favor of deferring treatments they deem to be 'less urgent' for cancer patients. some organizations such as the american college of surgeons are giving guidance regarding breast cancer treatment based on the number of covid cases in the area and the availability of hospital resources. for example, they are deferring surgeries in early stages of cancer. researchers have also proposed delaying chemotherapy treatment and surgeries in stable cancer patients in places where covid- is endemic. , more specifically, yu et al, suggested that if surgery is required for the management of colorectal cancer patients, it should be done as soon as the hospital can accept admissions and that surgeons should use laparoscopic surgery vs open surgery under these conditions. in the uk, up until march , even though england, scotland, and wales cancelled 'less urgent' surgeries, the policy was to continue to treat cancer patients in the same way as prior to the start of the covid- epidemic. in fact the uk government introduced specific guidelines for cancer patients on the st march strongly advising them to stay at home and avoid person to person contact. however, the latter recommendation could not be applied in the case of cancer patients on active treatment plans such as chemotherapy and radiotherapy which is offered in hospitals. evidence in the literature supports that, for example in the case of colorectal cancer, the - year survival is lower if treatment starts beyond days from diagnosis and that the ideal time for colon resection is between - weeks. yet the latter is unlikely to be achieved for most colon cancer patients during the covid- pandemic and particularly in countries which are severely affected by the virus. a delay in treatment may have detrimental effects for the patients' prognosis and quality of life. in addition, a delay in the treatment of cancer is associated with an increased cost of care. , therefore, by delaying the treatment of cancer, financial and healthcare resources are wasted which could have been used more effectively in developing a vaccine or treatments for covid- and/ or better treatments for colon or other types of cancer. in a paper by cortiula et al, the researchers expressed their concern regarding how re-allocation of healthcare personnel to the covid- triage and management may leave uncovered some vital activities for cancer patients such as treatment and surgeries in italy. they emphasized how delayed treatment may have detrimental effects for cancer patients since it may lead to disease progression particularly in patients in the most advanced stages of cancer. they proposed that patients with advanced disease, and no suggestive symptoms of covid- , should continue to receive chemotherapy or radiotherapy treatment, without unnecessary delays. cortiula et al, also mentioned that even screening appointments should be kept or re-scheduled shortly after cancellation, whereas others proposed the need to postpone planned cancer screening procedures. cortiula et al, also expressed concerns that during the pandemic it may not be possible to deliver palliative care to patients unable to move from their homes to sites of treatment due to the quarantine. the italian association of medical oncology (aiom) in collaboration with the boards of academic oncologists (comu) and the oncology unit directors (cipomo) have recently proposed some important recommendations for cancer patients. , , for patients currently receiving active treatments, the recommendations propose that oncologists should consider the possibility of a delay in treatment on a case-by-case basis. the decision should be based on the cancer type and stage, the clinical condition of the patient, the treatment indicated for the condition, the patient's response to anticancer therapy, and the potential risks for an infection with sars-cov- . for patients that have completed their treatment and are in the follow-up phase, the recommendations propose that oncologists should avoid asking patients to come to the hospital for routine follow-up visits. instead they should try to use telephone calls or telemedicine for patient consultations. oncologists should limit consultations at the hospital to cases of patients who report new symptoms or signs of disease progression. regarding admission to the hospital, outpatients scheduled for treatment should attempt to go alone and avoid the assistance of a caregiver except for cases when the latter is unavoidable. in addition, triage of patients with fever and/ or respiratory symptoms should be applied to prevent possible exposure to other patients and healthcare providers. , , in the usa, even though until march there was no suggested interruption of care for cancer patients, researchers started proposing the postpone treatment for some cancer patients. for example, ganatra et al, proposed that for patients with stable cancer it may be advisable to consider postponing anti-neoplastic therapy or 'less urgent' surgery in areas with high transmission of sars-cov- . they emphasized that the decision should be made on a case-by-case basis after consideration of the overall health of the patient and the type of anti-neoplastic therapy needed. patients with a recent history of stem-cell transplantation in areas of high transmission, should 'self-quarantine' to avoid exposure to the virus. also, carers of such high-risk patients should also try to 'self-quarantine' or obtain testing if they have any concerning symptoms. ganatra et al, also proposed that in-person visits could be substituted with telehealth visits and any nonurgent procedures should be deferred. due to the increasing burden of covid- in the usa since march , as of th may several guiding bodies have published guidance on different types of cancer. the american society of breast surgeons has published brief, high level guidance on prioritization of care in breast cancer. the american college of surgeons has published guidance on triage of patients with breast cancer for surgery. overall, the guidance provides recommendations to delay cancer treatment including surgeries based on the type/risk of the cancer patient and the risk/burden to healthcare in the area. , in addition, an american multiorganizational panel has published recommendations on the triage, prioritization, and treatment of breast cancer and an international group has also published recommendations on the same topic. currently, cancer type specific guidance has been developed for a number of cancers including gastrointestinal cancer, neuroncology, and skin cancer. the society of surgical oncology has published a brief guidance on surgery which is specific for each type of cancer. another matter to be addressed is whether special measures should be implemented before, during, and after surgeries for cancer patients. wen and li recommended full assessment of the patient for infection in order to detect asymptomatic cases, history of recent travel and contact with covid- infected people, body temperature measurement and chest ct scan. in addition, li et al, recommended a -week isolation of the patient and checking body temperature twice daily as well as testing the patient for the virus. yu et al, proposed complete examinations of cancer patients for covid- before operation and using an operating room with a negative pressure system. in addition, they emphasized the importance of following the sterilization and disinfection protocols for surgical equipment and the use of general anesthesia with tracheal intubation. the authors also proposed that the protocols for handling infected specimens should be used for handling all surgical specimens. some cancer patients may have to undergo planned allogeneic stem cell transplantation which poses certain challenges for both the healthcare team and the patients. it has been recommended that stem cell transplantation could be reasonably delayed in view of covid- , particularly in a situation where the disease is controlled with conventional treatment. in addition, visitors to post-transplant patients should be restricted in order to reduce the risk of infection of the immunosuppressed patients with sars-cov- . another issue related to stem cell transplantations is the supply of stem cells for patients in need which have been reported due to travel restrictions. stem cells need to be transplanted within hours and the latter is risky given the new developments with travel restrictions. dkms is a collection of charities working in seven countries around the world to recruit donors for people in need of blood stem-cell transplants. since the covid- outbreak dkms started exploring the possibility of having the stem cells transported in cargo flights. in addition to ensuring that stem cells are available to patients at the right time, the outbreak itself has complicated the process of donations. the process requires donors to attend hospital for preparation and blood tests and the donation can take a couple of days and donors have concerns with regards to their safety. it is therefore expected that in the next few months the supply of stem cells may be affected dramatically, and actions should be taken immediately to address this matter which may have detrimental effects for a high number of cancer patients across the globe. in addition to the need for access to medical treatment (such as chemotherapy and hormonal therapy, radiotherapy and surgery), cancer patients and survivors need to have access to supportive services such as physical therapy and occupational therapy. evidence in the literature suggests a significant role of physical therapy and occupational therapy in decreasing the symptom burden and improving the strength, endurance, and physical functioning of cancer patients therefore, supportive care involving physiotherapy and occupational therapy ameliorates the multiple physical and psychosocial challenges faced by many cancer patients and survivors. , due to the fact that these therapies improve the cancer patients' and survivors' quality of life, it is important to consider how access to such services may have been affected during the covid- pandemic. it is well-known that in-person appointments of occupational therapy and physical therapy have been interrupted or significantly reduced in most countries. however, some national organizations have provided recommendations with regards to the provision of physical therapy and occupational therapy during the covid- pandemic. for example, cdc has asked physical therapists to assess if each of their patients would be a good candidate for physical therapy via telehealth/telemedicine, if a patient's therapy could be delayed, or if the patient would be a good candidate for physical therapy in the home. , despite the lack of availability of published data on this matter, future publications may provide evidence on the impact of the interruption of physical and occupational therapy, with or without the development of alternative ways of therapy, during the covid- on the cancer patients' quality of life. it is generally considered that children are less likely to develop severe covid- illness compared to adults. nevertheless, a study has highlighted that infants and younger children (ie ≤ years) are more likely to develop severe clinical manifestations compared to older children (ie ≥ years) possibly due to the immaturity of the immune system of the former. , one problem with pediatric cancers is that they are usually aggressive and need intensive treatment with a combination of chemotherapeutic agents which induce severe immunosuppression to these patients. therefore usually there is no option to delay treatment of pediatric cancers as suggested for other types of cancers. even though some patients are hospitalized and are in isolation, many children are treated as outpatients. the latter places a certain risk for these patients since during their treatment appointments they may be exposed to sars-cov- . the latter has caused anxiety in young cancer patients and their families and this has led to the development of specific recommendations by national authorities to prevent the spread of sars-cov- in this vulnerable population. these recommendations are of major significance since they provide a reference to healthcare teams and caregivers. through these recommendations, efforts have been made to protect pediatric cancer patients by minimizing the number of patients visiting the oncology clinics, reducing visits, and using telehealth when possible. in addition to the usual questions with regards to the delivery of care to cancer patients, oncologists are being called to look into the specific biology of the cancer and address specific concerns. for example, many patients undergoing cardiotoxic chemotherapy may be on an angiotensin-converting enzyme inhibitor (acei) or angiotensin receptor blocker (arb). whether treatment with an acei or arb increases the risk associated with covid- is controversial but should be investigated. , in addition, covid- seems to predispose patients to thrombotic disease, both in the venous and arterial circulations. this is particularly important in cancer patients who are at higher risk of thrombotic events and some of whom may have a history of thrombotic events. there is no clarity yet over whether any medication should be used for the prophylaxis of cancer patients or for the management of cancer patients infected with covid- . last but not least, it is important to consider any possible shortages in cancer medication. in the uk no shortages of cancer medication were reported. as time progresses, it is likely that there will be effects in terms of the manufacture, supply, and shipping of drugs used in cancer treatment. currently, there is neither a vaccine nor a direct acting antiviral that can be used for the management of covid- . therefore, there is an urgent need to develop both a vaccine and drugs to manage covid- . it is believed that the first vaccine will be available months after the outbreak. currently, the disease is managed by symptomatic therapy and the intensive care unit is used for the management of patients with severe disease and those that have organ involvement or require intubation. currently there are more than clinical trials in an effort to find the most appropriate coronavirus treatment. some of the drugs currently used for the management of covid- include chloroquine, remdesivir (gs- ), , lopinavir/ ritonavir, , , and favipiravir. given that clinical trials are at the early stages, it is difficult to assess if the drugs are safe to use in cancer patients or whether there are any contra-indications for these group of patients based on their immunosuppression or other ongoing treatments. as the results of clinical trials are analysed it will be important to evaluate any possible safety issues and side effects imposed by these medications on cancer patients. drug-drug interactions remains a possibility which has not been fully investigated yet. currently, there is no evidence regarding the use of prophylactic antiviral therapy for covid- in immunosuppressed patients such as cancer patients. in the ongoing clinical trials the treatments have been used in patients with confirmed infection and not for prophylactic use. therefore, at the current time there is no recommendation to offer any of these pharmaceutical agents in immunocompromised patients, including cancer patients, to protect them from getting infected with covid- . this, however, could be a possibility in the future since there is an additional need to protect this group of patients due to their immmunompromised state. in a recent study by henry et al, the researchers reported on a cohort of french cancer patients who were treated with different drugs and methylene blue. during the covid- epidemic, none of the patients developed influenza-like illness. while this lack of infection could be by chance, it is possible that methylene blue had a preventive effect for covid- infection in this group of patients. this is in line with the antiviral activity of chloroquine, which is a | constantinou et al. methylene blue derivative. this is another area that could be further studied in the future in larger randomized control trials in order to clarify if indeed such an agent could be safely used in cancer patients. based on the increased vulnerability of cancer patients, special efforts should be put in place to educate cancer patients with regards to their personal protection. the who and centers for disease control (cdc) have advised that every individual should frequently wash their hands, avoid touching their face, and practice social distancing. , while these are important general guidelines for the entire population, cancer patients should strictly follow these guidelines given that they may be more likely to acquire the infection and develop severe disease. however, there are no specific guidelines regarding the use of face masks in cancer patients and this should be explored. it is likely that the covid- pandemic causes increased anxiety to cancer patients with regards to their risk, what they can do to protect themselves and how their treatment may be affected. therefore, psychoeducation of cancer patients via a variety of different mechanisms is of critical importance at this time, and cancer treatment centers, in collaboration with cancer patient societies, should do their best to offer advice and support for cancer patients. virtual informational sessions, telephone support lines, social media, and webpages could do a lot in providing a forum where each patient can express their concerns and receive detailed and up to date information with regards to how covid- affects their treatment. the seattle cancer care alliance in collaboration with the fred hutchinson cancer research center, and the university of washington have developed patient handouts and a website to educate and support cancer patients and their family on how to prevent infection with sars-cov- . in addition, they have developed a telephone triage line for patients with mild symptoms in the community to minimize exposures at the clinic. testing at a drive-up site was also coordinated when appropriate. this provides an example of how healthcare organizations, together with research institutes and patient groups, can work together to provide better education and thereby prevent cancer patients from getting infected with sars-cov- . there is no doubt that in addition to the effects of covid- on people's physical health, the virus has affected the emotional status of people around the world. patients suffering from chronic disorders, such as cancer patients, are extremely vulnerable since they are commonly psychologically strained and the emotional aspect of their disorder may not be sufficiently managed as part of their care. a study by zheng et al, assessed depression in cancer patients during the covid- epidemic. a survey was conducted in patients of zhejiang cancer hospital through social media platforms. the self-rating depression scale (sds) was used to evaluate the effect of covid- on cancer patients. in this study, the incidence of depression in cancer patients during the coronavirus pandemic was found to be . % ( . % had mild depression and . % had moderate depression). the covid- pandemic had an impact on mood, sleep, and stress in . %, . %, and . % of the cancer patients respectively. while few studies have been carried out thus far to investigate the effect of the pandemic on cancer patients, preliminary evidence suggests that psychological support should be provided to these patients. despite the common constraints of physical interactions, consultations could be replaced by virtual or telephone consultations to ensure the holistic continuity of care for this group of patients during a difficult period in their lives which imposes another level of stress to their previous strained psychology. , in addition, further research is needed to determine the best way to utilize virtual platforms to effectively conduct such psychological individual or group support. covid- is hindering research in all disciplines, including cancer research. oncology trials are resource-intensive, and approved protocols frequently require in-person contact between participants, researchers, and the medical team. cdc has provided recommendations for cancer patients participating in clinical trials. they have proposed screening patients for fever/symptoms, postponing nonessential in-person visits, and arranging for telemedicine interactions when possible. in addition, they are proposing that efforts should be made to provide personal protective equipment with the aim to protect both the immunocompromised participants and also the medical and research teams. the national institutes of health has recently released several helpful notices regarding funded human subject research trials during the covid- pandemic in the usa. these include encouraging investigators to consider limiting study visits to those needed and to conduct virtual visits when possible. in addition, it is very important to be respectful of the participants' right to withdraw from a clinical trial if they feel that their participation in the trial poses an increased risk to their health. in the uk, trusts are making decisions around clinical trials by following government advice and on a case-by-case basis. in certain cases, this prevented the start of new trials or the recruitment of existing trials, but attempts were made to continue existing clinical trials. for example in certain cases there was delivery of medication to people's homes to avoid increased traffic at hospitals. the european commission, the european medicines agency (ema) and the head of medicines agency (hma) as well as the food and drug administration, and the italian medicines agency have issued special guidance for the conduction of clinical trials during the covid- emergency. , the guidance includes a harmonized set of recommendations to ensure the safety of the trial while preserving the quality of the data generated by the trials. the guidance provides information on changes and protocol deviations which may be needed in the conduct of clinical trials to deal with extraordinary situations, eg if trial participants need to be in self-isolation or quarantine, access to hospitals is limited due to the risk of spreading infections, and healthcare professionals are being reallocated. , the experiences of the covid- pandemic have shown that the healthcare systems in most countries around the globe were not ready to deal with the effects of the pandemic. in addition, while efforts are still focused on the management of covid- infected patients, it is important to also address the needs of patients suffering from chronic disorders such as cancer patients who may be affected either directly or indirectly by covid- . multiprofessional heathcare teams address the needs of different cancer patients (ie from patients on active treatment to patients on a follow-up phase). cancer is a very heterogeneous disease which is why oncologists routinely review each patient individually by taking into consideration a number of different factors, such as the stage of the disease, type of cancer, clinical outcome, and response of the patient. during the covid- pandemic, there have been some attempts for the development of recommendations for the management of cancer patients during this extremely difficult period. , it is important that more specific guidelines are developed as a collaboration between infectious disease doctors, epidemiologists, oncologists as well as other members of the multiprofessional heathcare teams who are directly involved with the care of cancer patients. the guidelines should be specific to particular types and stages of cancer (from diagnosis to active treatment to palliative care to survivorship) and to particular treatments (eg chemotherapy, radiotherapy, surgery) and there should be specific guidelines for pediatric patients. in conjunction with guidelines, the details of each individual patient should still be reviewed, and a final management plan should be developed for each patient. once the management plan is developed, it should be clearly communicated to the cancer patients. physical consultations could be replaced by telephone or telemedicine consultations whenever it is considered safe to do so. the patients should receive clear explanations with regards to their management but also with regards to their personal protection and safe practices. further research should be conducted on the best way to ensure optimal and effective care of cancer patients using virtual platforms. in addition, although the evidence may not be available yet, in a few months data will be available that should be analysed to evaluate the impact of covid- on cancer patients. the results of such analyses are necessary to contribute toward the development of evidence-based guidelines for the management of cancer during the covid- pandemic. in addition to developing guidelines for the management of cancer patients during covid- , the most promising medication(s) that will eventually be used for the management of covid- will need to be evaluated in cancer patients. in addition, more specific guidelines will need to be developed on the conduct of clinical trials, and the possibility of future pandemics should be included in the design of future clinical trials. in addition, psychological support should be continued to be provided to cancer patients and adapted to address their increased anxiety during the covid- pandemic. in summary, the covid- epidemic has revealed that the healthcare systems have difficulties not only in dealing with the direct 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authors: scanderbeg, daniel j.; yashar, catheryn; ouhib, zoubir; jhingran, anuja; einck, john title: development, implementation, and associated challenges of a new hdr brachytherapy program date: - - journal: brachytherapy doi: . /j.brachy. . . sha: doc_id: cord_uid: gny xkx developing any new radiation oncology program requires planning and analysis of the current state of the facility and its capacity to take on another program. staff must consider a large number of factors to establish a feasible, safe, and sustainable program. we present a simple and generic outline that lays out the process for developing and implementing a new hdr brachytherapy program in any setting, but with particular emphasis on challenges associated with starting the program in a limited resource setting. the sections include feasibility of a program, starting cases, machine and equipment selection, and quality and safety. brachytherapy is an important and often necessary component in the management of patients with various types of cancer across the globe. cervical cancer is the fourth most common cancer in women worldwide, with most cases occurring in developing countries, and there have been multiple publications regarding the necessity of brachytherapy in the treatment of cervical cancer ( e ). other cancers might not necessarily require brachytherapy, but it could be a highly effective treatment option that is convenient and cost-effective. in the rapidly evolving world of radiotherapy, there has been an increased utilization of hypofractionation. when given the option, most patients would opt for convenience and a shorter treatment course. today, the fractionation schedule for accelerated partial breast irradiation using brachytherapy has seen movement from day, fraction courses, to day, fraction courses ( ) . this reduces the number of trips the patient must make, which can be particularly attractive if the patient must travel far or has other transportation issues. with the covid- pandemic, fewer treatments decrease contact interactions with others (public, patients, and staff), thereby reducing infection risk. despite factors and motivation to start a brachytherapy program, many centers are intimidated by the challenges presented with starting a program from scratch. this article is intended to be a practical framework for developing and implementing a new brachytherapy program and, in particular, highlights challenges associated with development and implementation in resource-limited settings. the sections of this framework include feasibility of starting a program, starting cases, machine and equipment selection, and quality and safety. the decision to start a brachytherapy program requires in-depth analysis and determining factors for success. these include significant patient caseload, sufficient space, appropriately trained personnel and acknowledgment of the increased time commitment required to deliver brachytherapy treatments. if any of these are missing, or insufficient, the program will either be unsafe or unsustainable. in this section, we will discuss these requirements in more detail. although brachytherapy can be used to treat a number of malignancies including prostate cancer, breast cancer, skin cancer, and others, by far the most common malignancy treated around the world with brachytherapy is carcinoma of the cervix. brachytherapy use has been shown to improve both local control and overall survival in this disease ( , ) . in fact, it is the requirement for brachytherapy in cervical patients with cancer that often leads to the decision to start a brachytherapy program. typically, in the united states, treatment centers operate with a hub-and-spoke system for providing brachytherapy. this is a health care system with multiple centers where patients requiring brachytherapy are typically sent to a central site that has the equipment and expertise to deliver the treatment. this is both economical and leads to consolidation of expertise and higher quality treatment ( ) . however, with only , cases of cervical cancer per year in the united states ( ), for a brachytherapy program to thrive, it will be necessary to treat other types of malignancies. the incidence of carcinoma of the cervix is much higher in parts of the developing world, including eastern and central africa, where it is the most common malignancy ( ) . in these countries, a single high-dose-rate (hdr) afterloader can easily be overwhelmed by treatment of this single disease. because brachytherapy is both a surgical procedure and a radiotherapy treatment, it requires a multidisciplinary approach involving gynecologic oncologists, urologists, surgical oncologists, radiologists, and pathologists to plan and deliver effective treatment and manage situations or morbidity afterward. having the input of other services will lead to a more coordinated treatment approach and likely better outcomes. moreover, involvement of other specialists outside of radiation oncology will increase the visibility of the service and likely lead to a greater case load. in , the average cost of an hdr afterloader ranges from usd , to usd , with ongoing annual service/source exchange costs of well over usd , / year. considerations of cost are quite different in the united states as compared with low-and middle-income countries (lmics) and are beyond the scope of this article. careful consideration to cost and case load in the evaluation of sustainability is essential. radiating hope, a charitable organization that provides radiation therapy equipment and training to clinics in the developing world, has donated a number of hdr units across the globe. it is tempting to think that these facilities will not have the same financial pressures and required case load to sustain the equipment. however, the cost of ongoing maintenance of the afterloader, source exchanges, and replacement of applicators are expensive endeavors and sources of funding such as charitable donations, home country support, or clinic buyin must be in place to cover these expenses to avoid jeopardizing the entire program. consideration of the hdr suite is very important in the planning process. an hdr afterloader requires a stable power supply and the room requires sufficient shielding. shielding requirements depend on the isotope (greater for co- than for ir- ). although it is convenient to install the unit in an existing ebrt room due to the substantial cost of building, a separate hdr vault doing so may limit the growth of the program because of limited treatment time. a high-volume brachytherapy center should have a separate hdr treatment room. this room should have sufficient space for the patient gurney, brachytherapy team, and any surgical or anesthesia equipment. it should also be equipped with emergency equipment such as a shielded source storage container (pig) and it should contain, or be located in close proximity to, the imaging equipment appropriate for the type of treatment planning being performed. appropriately trained personnel are often a prohibitive factor in the development of an hdr program. the american association of physicists in medicine (aapm) task group- report recommends that the treatment team consist of a radiation oncologist with special expertise in brachytherapy, preferably hdr; a medical physicist with expertise in brachytherapy who receives at least vendorsupported onsite training on the treatment machine and planning system; and a treatment-unit operator who could be either the physician, physicist, dosimetrist, or a radiation therapist ( ) . the international atomic energy agency (iaea) also indicates that nursing staff is among the minimum personnel required ( ) . we strongly endorse this recommendation as these are surgical procedures that require substantial patient monitoring. in lmics that do not currently have hdr brachytherapy, the radiation oncologist will often have training and experience in low-doserate brachytherapy and the placement of applicator devices may be straightforward. however, additional training is required to obtain expertise in dose prescription, radiobiological differences between low-dose-rate and hdr, and emergency procedures. it may also be difficult to find a physicist with sufficient experience in countries where hdr is not currently being performed. physicists who perform brachytherapy require training in afterloader procedures, treatment planning, and quality assurance procedures. all members of the treatment team should be trained in emergency procedures. competency assessment should be included as part of the training of personnel for new procedures and will be discussed further in section : quality and safety. any time a new treatment site is added, additional expertise is needed. for example, a center that treats gynecologic (gyn) cases regularly may wish to add prostate brachytherapy or another disease site. although training in afterloader use, quality assurance protocols and safety procedures is likely universal to all disease sites, expertise in treatment planning, treatment techniques and dose constraints may require additional training. because of the substantial time commitment required, it would not be possible to start an hdr brachytherapy program without a dedicated team whose time is not already occupied with external beam radiation therapy. a gyn brachytherapy procedure can take from min up to e h. it is impossible for team members to be involved in other unrelated tasks during that time. any center planning to implement hdr brachytherapy should understand that it will put a substantial demand on resources. this is the same reason we recommend that the afterloader not be installed in an existing, active ebrt vault. key points on feasibility of starting a program: it is essential to perform a careful analysis of the current state of the clinic and factors needed to start a new program. physical space, financial resources, personnel, time, and training are all important factors in determining feasibility. any weakness in these components represents a serious impediment to starting or sustaining a program. when beginning the program and picking the first patient/case, choose a reasonable time frame for equipment acquisition, training, acceptance and commissioning, and other tests or practice runs. even patient selection for the first few treatments is important, and our recommendation is to start with relatively simple cases. one of the most straightforward and best treatments for beginners is the vaginal cylinder (fig. ) . these are used for postoperative endometrial cases to treat the vaginal cuff and are very common in the united states where endometrial cancer cases outnumber cervical cancer cases. the vaginal cylinder is composed of a single channel that is inserted in the vaginal canal. with fixed geometry applicators like a cylinder, computer template plans can be used to deliver a standard dose with a combination of active length, cylinder diameter and depth of prescription. this type of treatment allows the center to gain experience with an hdr procedure, planning, and patient management, paving the way to more complex treatments in the future. the next step would be to implement tandem and ovoids/ring (fig. ) for cervical cancer as these patients comprise a large portion of the patient population, especially in lmics. a tandem and ring (t&r) is composed of an intrauterine tandem and a ring that sits against the cervix in the vaginal fornices. most t&r applicators have a rectal retractor that allows the user to push the posterior vaginal wall posterior and add space between the applicator and rectum, reducing rectal wall dose. the t&r has a fixed geometry, so with proper training, template plans can also be used when treatment planning is limited in lmics. in dakar, senegal, where hdr was installed without a functioning treatment planning system, the cervical cancer brachytherapy program was developed around the t&r applicator with a library of plans and doses prescribed to point a. isodose overlays were created for d radiographs to estimate bladder and rectal doses for determination of adequate geometry and normal tissue sparing ( ) . the tandem and ovoid (t&o) is another applicator that can be used for cervical cancer treatment, which gives more flexibility in implant geometry, but requires packing instead of the rectal retractor. the simplest t&o treatment planning process is filming -dimensional radiographs and locating point a and rectum and bladder points. this does not require expertise in contouring and the treatment dwell times are relatively standard. a center could start with this technique until they have enough experience and training in contouring to begin image-guided brachytherapy utilizing the gec-estro guidelines for contouring and prescribing dose to the high-risk ctv and contouring and calculating dose to organs at risk (oars) including the rectum, bladder, and sigmoid colon ( ) . this approach was utilized at the kathmandu cancer center in kathmandu, nepal where an hdr until was donated by radiating hope in . the first t&o treatments were in may of and doses were prescribed to point a. over implants were done in a -month period until, with additional training, the physicians began image-guided brachytherapy in november of . any program transitions require careful follow-up to ensure efficacy and toxicity are acceptable. interstitial and hybrid implants offer the most flexibility and best dosimetry; however, they are also the most technically challenging and labor intensive. the hybrid implant can be used as a transition from applicator based implants to full interstitial. often, the t&o or t&r implant can be supplemented with several needles that can improved dosimetric coverage of the target while decreasing dose to oars. this technique can allow users to gain more experience with needles before moving to a full interstitial implant. other types of brachytherapy, such as skin, prostate, breast, could be added as the program grows and gains experience depending on the resident patient population. machine and equipment requirements for treatment sites are outlined in the following. key points on starting cases: incremental steps to more complex procedures avoid potential anxiety, frustration, and errors. plan the program for success from the start with procedures that are easy to implement and build confidence. use dry runs and end-to-end tests during the commissioning process so the team may familiarize themselves with the procedure(s) and gain comfort and experience. one of the most important aspects in developing and setting up a new brachytherapy program is choosing the appropriate equipment. imaging equipment is necessary for visualization of the implant as well as treatment planning. a treatment delivery machine (afterloader) is needed, similar to a linear accelerator in ebrt. it is necessary to have applicators compatible with the afterloader for the planned treatments. the clinic will need methods for applicator cleaning, disinfection, and sterilization. proper delivery of high-quality brachytherapy requires a commissioned treatment planning system and equipment. as pointed out previously, brachytherapy requires a multidisciplinary treatment team that includes physicians, physicists, nurses, therapists, and dosimetrists (depending on resources and staffing models). therefore, machine and equipment selection for brachytherapy should be a collaborative team effort to ensure that all needed items and their functionality have been evaluated carefully in terms of cost, physical space requirements, clinical applicability, compatibility with any existing technology (hardware and/or software), any history of reported medical events associated with hardware/software components, and any limitations including dependability, cleaning and reusability or end-of-life standards. in addition, equipment should be appropriate for the patients and procedures identified in the feasibility assessment of program development with adequate education available for proper use. the equipment selection section can be further subdivided into five categories: imaging, treatment devices, treatment planning, applicators, and calibration/qa. gynecological brachytherapy. gyn procedures can use a variety of imaging devices: portable x-ray, computed tomography (ct), ultrasound (us), and magnetic resonance imaging. some of these devices can be used during insertion such as transrectal or transabdominal us to ensure accurate placement of the applicator and prevent any undesirable outcome such as perforation or incorrect applicator depth, location, and orientation, whereas others are used after implant for dosimetry calculations like ct. however, using us requires experience and expertise in both using the modality and interpreting the imaging. in general, this does not require a radiologist to be involved but rather comes from the acquisition of this experience during training. there have been many publications regarding transition from d to d brachytherapy for gyn implants as there are many advantages to ct imaging for gyn procedures with reconstruction of applicators, use of applicator libraries, and d visualization of the target(s) and oars with dvh metrics ( e ). prostate brachytherapy. for hdr procedures, it is a necessity to have a us unit with a transrectal probe that can provide an enhanced contrast/resolution throughout the image and all the anatomical details to perform a safe and accurate implant. this unit is used for target volume acquisition and applicator insertion. again, it is generally not necessary to have a radiologist involved to interpret the imaging as it is relatively straightforward to learn. a biplanar unit with variable frequency probes that provide good flexibility for the user is essential. in addition, a reliable stabilization system is very important in providing a secure setup for the probe. a ct scanner is required for hdr needle position verification and treatment planning, when not using a us-based intra-op technique. breast brachytherapy. fluoroscopy, us, and ct are typical imaging modalities used for breast brachytherapy. these can be used for accelerated partial breast irradiation procedures (balloon-based devices, strut-based devices, and interstitial implants). images taken are used for applicator insertion, verification of its location and integrity before each treatment, and treatment planning. hdr afterloaders are versatile because they are able to treat many types of cancer with use of the appropriate applicator. the most common isotope used is ir- , which has a half-life of approximately days, and most sources come at an activity of about ci. in limited resource settings, it is important to consider replenishing the radioisotope in the afterloader as treatment time increases with a decaying source. treatment time with a source that has decayed to about ci could be over h in duration. some vendors offer co- as an alternative to ir- because of its long half-life (~ years) and it might be a suitable alternative to ir- for a clinic if it is impractical to ship, receive, and install a new source on a frequent basis. most brachytherapy procedures utilize treatment planning software to generate a therapeutic dose to the target while minimizing dose to oars. some procedures still rely on the use of tables and nomograms, as it is the case for conical skin treatment, where treatment planning is not yet available. however, as most treatments transition to d imaging with ct, computer-based planning is necessary and it offers some advantages such as applicator reconstruction through the use of a built-in applicator library that allows a user to ''snap an applicator into place'' quickly and without risk of manual digitization errors. a variety of applicators can be used in brachytherapy. common applicators for hdr interstitial implants are stainless steel, plastic, or titanium needles. gyn procedures are performed using a variety of shielded and unshielded applicators including cylinders, t&os, t&rs, tandem and cylinders, hybrid applicators, and interstitial needles. considerations for limited resource settings are the number of applicators necessary to treat the expected patient volume while considering the availability of cleaning and sterilization for reuse of an applicator. it may be necessary to consider buying sterilization equipment if none is available. it is also necessary to consider the lifetime of the applicators and if applicators become broken or destroyed, if the program can either continue treatments without an applicator or afford to replace it, or if it will not be sustainable in the long run. before the implementation of a new brachytherapy program, or using a new device, applicator, or software, commissioning is essential to ensure safe introduction into the clinic. while most publications regard commissioning as key to safe implementation, many are nondescript in their approach, and some offer more prescriptive processes ( ) . every center performs commissioning after acceptance of a new treatment device, so there is ample knowledge on how to perform this task. many vendors can connect users that have experience and have previously commissioned equipment as they might be willing to share their experience and reports. this can be a good option for centers with little experience in a particular area. most regulations require that all radiation sources used, such as ir- , co- , must be verified (air kerma strength, activity, dose rate, etc.) before use in the clinic as well as periodic spot checks. a calibrated electrometer, well chamber, ionization chamber suited for the energy, thermometer, barometer, solid water phantom, d water tank, and film dosimetry (densitometer and software) are the most common equipment needed to perform these tasks. commissioning of the treatment planning software is required before its use and can be verified after each upgrade using a variety of standard cases that have been previously planned and saved. key points on machine and equipment selection: it is paramount to select the correct equipment for the clinic and patient population to maintain a successful program. because brachytherapy has recurring costs associated with source and applicator replacement, careful consideration should be taken on funding for these items. overly costly or complex equipment, especially if rarely used, should be avoided if there is not adequate funding to repair or replace broken equipment or if lack of training and expertise could lead to improper use. a key component to the development and implementation of any new program is the foundation of a robust quality and safety plan. a minimum requirement, usually set by most regulatory agencies, requires a radiation safety program to be established before licensing for any type of radioactive isotope usage. however, this program is often generic, or nonspecific in many facets, and may include a bare minimum set of tests for a clinic to perform to maintain compliance. programs should view literature from organizations such as the iaea and aapm for guidance on good practice ( , ) . in the united states, the nuclear regulatory commission regulations ( cfr ) state that an application for a license for medical use of byproduct material is required to have a radiation safety program as well as specific information on radiation safety precautions and instructions ( ) . similarly, the iaea has published radiation protection and safety of radiation sources: international basic safety standards that states ''principal parties shall establish and implement a protection and safety programme'' ( ) . licensing regulations will be dependent on local and national regulations. one of the challenges for developing countries could be working with the government to establish a program, especially if it is the first program in the country. if the program is not the first in the country, then communication to other clinics with programs and site visits may help in gathering information. if it is the first program in the country, then the iaea is a good resource with both reference materials and personnel that can help assist a clinic. alternatively, vendors often have regulatory affairs personnel who can assist with regulatory compliance and interfacing with the government. in the past decade, there have been a number of highprofile articles highlighting errors during medical application of radiation ( ). there are multiple publications available on the internet outlining best practices with links to those articles on both the american society for therapeutic radiation oncology (astro) and american brachytherapy society websites ( ). there are a wide variety of reasons to explain the ongoing occurrence of these errors. some causes include increased complexity of advancing technology, poor teamwork or communication, staff fatigue, compressed time frames and stress, or too much reliance on computer technology. however, another major cause is lack of proper education and training. the international commission on radiological protection published report on prevention of accidents to patients undergoing radiation therapy in and then publication in entitled preventing accidental exposures from new external beam radiation therapy technologies ( , ) . in both publications, it states that ''purchasing new equipment without a concomitant effort on education and training and on a program of quality assurance is dangerous''. proper training for a new program is key to its success. training for physicians in the united states is accredited by the accreditation council for graduate medical education and involves a -month residency program that requires, at a minimum, the physician to perform seven interstitial brachytherapy cases and intracavitary cases of which must be uterine tandem-based insertions ( ) . certification in the united states is through the american board of radiology that requires graduation from a program that is accreditation council for graduate medical education accredited, thus ensuring some experience in brachytherapy implants. it should be noted that this is a minimum requirement and proficiency often requires additional experience. typically, a health care system that hires the physician may require a period of preceptorship for the first e cases performed after residency. however, in the absence of a residency program, it can be challenging to obtain this experience especially in limited resource settings. many organizations, such as the iaea, aapm, as-tro, estro, and radiating hope offer live training programs, whereas there are many other organizations that have begun to offer online distance education, such as rayos contra cancer (https://www.rayoscontracancer.org/ ), and vendors offer user training on new equipment. although all these programs are a great educational opportunity, they are often limited and cannot fully encompass all aspects of starting a brand-new program. in addition, many of these programs are offered in a small variety of languages, despite it being preferential to have a highly technical education program in one's native language. site visits to other centers performing treatments similar to those that will be implemented are a valuable opportunity and should be used when possible. when planning and developing a new program, it is important to research education and training options and whether they will be adequate for safe implementation and sustainability of a program. another aspect of education is competency assessment. there can be a difference between attending a training course, learning concepts, and then attempting to apply those concepts in practice. in , the world health organization published a technical manual on radiotherapy risk profile ( ) . in this report, it was stated that competency assessment is one of the top three interventions that is likely to be an effective safety barrier. competency assessment can take many forms such as quizzes, supervised observation of tasks or supervised observation of dry runs. these are highly effective and should be part of the ongoing training and education plan for implementing a new program. not only are these useful for training new staff or adjusting to changes in a program, but they are beneficial in keeping staff familiar with a procedure, especially if it is performed with a low frequency. peer review is another critical component of the quality and safety program for any center. there have been a number of publications and recommendation regarding peer review including those by the american college of radiology and astro and aapm ( e ). peer review can allow for the discovery of inaccuracies that may often go overlooked without a formal review process. this is especially true in small centers with single physician or single physicist staffing. challenges in limited resource settings might be lack of in-house expertise to establish a robust internal program or even recruiting peers for the peer review process; however, with more resources becoming available online, such as web-based programs, such as chartrounds, or just email dialog with colleagues and experts internationally, or through societies such as the american brachytherapy society or gec-estro, it may be easier for centers to find others that can participate in online, remote reviews ( ). external audits are another form of peer review that can add value through external validation of the treatment delivery process. every effort should be made to collect data from all patients to track outcomes and analyze this information for evaluation of efficacy of a program. the quality management plan for a new program should follow all local and governmental regulations as well as implement standards published in guidance documents from organizations and societies. although preparation for the safest brachytherapy practice is paramount, errors or complications may still happen. medical complications during or shortly after brachytherapy can occur including acute bleeding, oversedation, reactions to medications, visceral perforation, and infection. the brachytherapy team should consider instituting protocols and policies to manage these before starting a program. if a radiation delivery error occurs, disclosure and mitigation of risk to the patient is necessary. error evaluation should commence expeditiously and necessitates an honest, nonjudgmental evaluation of the factors that lead to the error so that safeguards can be put in place to prevent future errors. key points on quality and safety: as hulick and ascoli stated in their article ''quality assurance in radiation oncology'', ''quality assurance (qa) means being certain that things are done right'' ( ) . it is a very simple, yet eloquent statement. when developing a program, it is essential to formulate a comprehensive education and training plan that will ensure competency before treatment of the first patient while also ensuring continuous education and ongoing competency evaluations. in addition, peer review should be implemented as part of the overall quality and safety program. world fact sheet trends in the utilization of brachytherapy in cervical cancer in the united states curative radiation therapy for locally advanced cervical cancer: brachytherapy is not optional three-fraction accelerated partial breast irradiation (apbi) delivered with brachytherapy applicators is feasible and safe: first results from the triumph-t trial predictors of quality of care and survival in a three-state cohort of locally advanced cervical cancer patients and development of a predictive model to identify women at risk of incomplete treatment national cancer institute. surveillance, epidemiology and end results globocan estimates of incidence and mortality worldwide for cancers in countries high dose-rate brachytherapy treatment deliverty: report of the aapm radiation therapy committee task group no. implementation of high dose rate brachytherapy in limited resource settings implementation of a high-doserate brachytherapy program for carcinoma of the cervix in senegal: a pragmatic model for the developing world recommendations from gynaecological (gyn) gec estro working group (i): concepts and terms in d image-based treatment planning in cervix cancer brachytherapy- d dose volume parameters and aspects of d image-based anatomy, radiation physics the transition from -d brachytherapy to -d high dose rate brachytherapy recommendations from gynaecological (gyn) gec-estro working group (ii): concepts and terms in d image-based treatment planning in cervix cancer brachytherapy- d dose volume parameters and aspects of d image-based anatomy, radiation physics american brachytherapy society consensus guidelines for locally advanced carcinoma of the cervix. part i: general principles a consensus-based, process commissioning template for high-dose-rate gynecologic treatments code of practice for brachytherapy physics: report of the aapm radiation therapy committee task group no. nuclear regulatory commission icrp publication acgme program requirements for graduate medical education in radiation oncology world health organization. radiotherapy risk profile acr-astro practice parameter for radiation oncology aapm task group report on peer review in clinical radiation oncology physics enhancing the role of case-oriented peer review to improve quality and safety in radiation oncology: executive summary strategies for effective physics plan and chart review in radiation therapy: report of aapm task group quality assurance in radiation oncology key: cord- -jh klbg authors: sivapalan, pradeesh; ulrik, charlotte suppli; bojesen, rasmus dahlin; lapperre, therese sophie; eklöf, josefin viktoria; håkansson, kjell erik julius; browatzki, andrea; tidemansen, casper; wilcke, jon torgny; janner, julie; gottlieb, vibeke; meteran, howraman; porsbjerg, celeste; madsen, birgitte lindegaard; moberg, mia; pedersen, lars; benfield, thomas lars; lundgren, jens dilling; knop, filip krag; biering-sørensen, tor; ghanizada, muzhda; sonne, tine peick; bødtger, uffe christian steinholtz; jensen, sidse graff; rasmussen, daniel bech; brøndum, eva; tupper, oliver djurhuus; sørensen, susanne wiemann; alstrup, gitte; laursen, christian borbjerg; møller, ulla weinrich; sverrild, asger; jensen, jens-ulrik stæhr title: proactive prophylaxis with azithromycin and hydroxychloroquine in hospitalised patients with covid- (propac-covid): a structured summary of a study protocol for a randomised controlled trial date: - - journal: trials doi: . /s - - - sha: doc_id: cord_uid: jh klbg objectives: the aim of this randomised gcp-controlled trial is to clarify whether combination therapy with the antibiotic azithromycin and hydroxychloroquine via anti-inflammation/immune modulation, antiviral efficacy and pre-emptive treatment of supra-infections can shorten hospitalisation duration for patients with covid- (measured as "days alive and out of hospital" as the primary outcome), reduce the risk of non- invasive ventilation, treatment in the intensive care unit and death. trial design: this is a multi-centre, randomised, placebo-controlled, -arm ratio : , parallel group double-blind study. participants: participants are recruited at the trial sites/hospitals, where the study will take place in denmark: aalborg, bispebjerg, gentofte, herlev, hillerød, hvidovre, odense and slagelse hospitals. inclusion criteria: • patient admitted to danish emergency departments, respiratory medicine departments or internal medicine departments • age≥ years • hospitalized ≤ hours • positive covid- test / diagnosis during the hospitalization (confirmed). • men or non-fertile women. fertile women* must not be pregnant, i.e. negative pregnancy test must be available at inclusion • informed consent signed by the patient *defined as after menarche and until postmenopausal (no menstruation for months) exclusion criteria: • at the time of recruitment, the patient uses > lo /min (equivalent to % fio if measured) • known intolerance/allergy to azithromycin or hydroxychloroquine or hypersensitivity to quinine or -aminoquinoline derivatives • neurogenic hearing loss • psoriasis • retinopathy • maculopathy • visual field changes • breastfeeding • severe liver diseases other than amoebiasis (inr> . spontaneously) • severe gastrointestinal, neurological and hematological disorders (investigator-assessed) • egfr < ml/min/ . m • clinically significant cardiac conduction disorders/arrhythmias or prolonged qtc interval (qtc (f) of> / ms). • myasthenia gravis • treatment with digoxin* • glucose- -phosphate dehydrogenase deficiency • porphyria • hypoglycaemia (blood glucose at any time since hospitalization of < . mmol/l) • severe mental illness which significantly impedes cooperation • severe linguistic problems that significantly hinder cooperation • treatment with ergot alkaloids *the patient must not be treated with digoxin for the duration of the intervention. for atrial fibrillation/flutter, select according to the cardiovascular national treatment guide (nbv): calcium antagonist, beta blocker, direct current (dc) conversion or amiodarone. in case of urgent need for digoxin treatment (contraindication for the aforementioned equal alternatives), the test drug should be paused, and ecg should be taken daily. intervention and comparator: control group: the control group will receive the standard treatment + placebo for both types of intervention medication at all times. if part or all the intervention therapy being investigated becomes standard treatment during the study, this may also be offered to the control group. intervention group: the patients in the intervention group will also receive standard care. immediately after randomisation to the intervention group, the patient will begin treatment with: azithromycin: day - : mg x day - : mg x if the patient is unable to take the medication orally by themselves, the medication will, if possible, be administered by either stomach-feeding tube, or alternatively, temporary be changed to clarithromycin mg x (this only in agreement with either study coordinator pradeesh sivapalan or principal investigator jens-ulrik stæhr jensen). this will also be done in the control group if necessary. the patient will switch back to azithromycin when possible. hydroxychloroquine: furthermore, the patient will be treated with hydroxychloroquine as follows: day - : mg x main outcomes: • number of days alive and discharged from hospital within days (summarises both whether the patient is alive and discharged from hospital) ("days alive and out of hospital") randomisation: the sponsor (chronic obstructive pulmonary disease trial network, cop:trin) generates a randomisation sequence. randomisation will be in blocks of unknown size and the final allocation will be via an encrypted website (redcap). there will be stratification for age (> years vs. <= years), site of recruitment and whether the patient has any of the following chronic lung diseases: copd, asthma, bronchiectasis, interstitial lung disease (yes vs. no). blinding (masking): participants and study personnel will both be blinded, i.e. neither will know which group the participant is allocated to. numbers to be randomised (sample size): this study requires patients randomised : with in each group. trial status: protocol version . , from april , . recruitment is ongoing (first patient recruited april , ; final patient expected to be recruited october , ). trial registration: clinicaltrials.gov identifier: nct (registered march , ) full protocol: the full protocol is attached as an additional file, accessible from the trials website (additional file ). in the interest in expediting dissemination of this material, the familiar formatting has been eliminated; this letter serves as a summary of the key elements of the full protocol. the study protocol has been reported in accordance with the standard protocol items: recommendations for clinical interventional trials (spirit) guidelines (additional file ). the drug is approved and marketed in denmark for the prevention and treatment of malaria, for the treatment of rheumatoid arthritis, discoid and systemic lupus erythematosus and juvenile idiopathic arthritis. manufacturing, packaging and labelling of imp: the trial drugs (imp) are manufactured by glostrup pharmacy by pharmacist kristian Østergaard nielsen. placebo capsules are thus made similar to the intervention medicine. the drug (and placebo) are labelled, according to appendix . glostrup pharmacy has a key for blinding. therefore, it will always be possible to unblind a patient if indicated. investigator must notify sponsor on grounds if a patient is unblinded. medical professionals dispense the imp daily during hospitalization, except for patients preferring to handle their medication themselves. in the latter case, patient will fill in a medication diary (provided at randomisation). for all patients who are discharged during the intervention period, a medication diary will be provided. the medication diary is subsequently collected. exactly the amount of medication or placebo that the patient is required to take during the study periode will be provided, but for patients who do not take all the medication (protocol deviation), the remaining medication will be collected by the study staff. the patient will receive a follow-up phone call to check whether they have adhered to the medication schedule according to the trial protocol. proactive prophylaxis with azithromycin and chloroquine in hospitalised patients with covid- (propac-covid) . hypothesis: in patients with acute hospital admission, a positive test for -ncov and symptoms of covid- disease, treatment with virus-modifying agent hydroxychloroquine as well as virusimmunomodulatory and antibacterial drug azithromycin can lead to shorter hospitalisation and fewer admissions to the intensive care unit. the aim of this randomised gcp-controlled trial is to clarify whether combination therapy with macrolide azithromycin and hydroxychloroquine via anti-inflammation/immune modulation, antiviral efficacy and pre-emptive treatment of supra-infections can shorten hospitalisation duration (measured as "days alive and out of hospital"as the primary outcome), reduce the risk of non-invasive ventilation, treatment in the intensive care unit and death. in the ongoing coronavirus pandemic, covid- , with its origin in wuhan, china, there is still sparse data on the course, risk of various complications, and the best possible treatment of patients admitted to hospital to ensure best possible survival and reducing length of stay at hospital. the most frequent symptoms are fever (> %) and cough ( - %), together with radiologically fingdings of "ground-glass infiltrates" or "patchy infiltrates" in the patients with the most severy ill patients ( %), compatible with severe viral pneumonitis ( , ) . the length of hospitalisation is observed to be relatively long, - days ( ) , which in itself is a problem as hospitals can quickly reach the maximum capacity for hospitalisation and the proportion of patients who become critically ill have, based on the observations reported so far, had a mortality rate of> % ( ), and overall mortality for admitted patients in china with covid- infection is apparently unusually high for viral respiratory tract infections with an estimate of % ( ). only specific data on patients with chronic obstructive pulmonary disease (copd) have been reported in a few studies, but the risk of in-hospital death appears to be very high (or . [ % ci . - . ]) ( ) . proactive prophylaxis with azithromycin and chloroquine in hospitalised patients with covid- (propac-covid) despite the rapid spread of the disease globally, there is no solid data yet to recommend any specific treatments, and by that, symptomatic, organ supportive therapy is recommended, and in case of progression to severe acute respiratory failure mechanical ventilation ( ) . a high incidence of bacterial super-infections has been reported in patients with covid- who died ( %) compared to survivors ( %) (p < . ), and likewise, an incidence of septic shock of % and %, respectively ( ) . thus, there is an urgent need for treatments that can improve the course of the diseases in the individual patients, including positive impact on risk for hospital admission, duration of hospitalisation, risk of secondary infections and death. azithromycin is a macrolide antibiotic that has shown convincing efficacy in several studies in recent years to reduce hospitalisation-related exacerbations in copd ( , ) , and to reduce exacerbationrate in asthma ( ) and non-cystic fibrosis bronchiectasis ( ) . at the same time, it has been shown that azithromycin has a distinct effect by down-regulating airway inflammation by reducing cxcl , tnf-alpha, il- and il- p ( ) . furthermore, a strong association has also been reported between survival from acute respiratory distress syndrome (ards) and administration of azithromycin (hr for days of death for all causes: . [ % ci . - . ] in a well-conducted study ( ) . furthermore, it has been consistently observed in several recent publications that azithromycin itself appears to have an antiviral effect on a number of several viruses causing respiratory tract infections, such as respiratory syncytial virus (rsv) ( ) , rhinovirus ( ) and zika virus ( ) . hydroxychloroquine has been marketed since , originally developed for prophylaxis and treatment of malaria, but has for years also been used an anti-inflammatory agent for rheumatic diseases. large daily doses (up to mg a day) of hydroxychloroquine are prescribed over many years to patients with arthritis such as systemic lupus erythematosus and rheumatoid arthritis for anti-inflammatory purposes, which is generally well-tolerated ( ) . but in addition to these effects, it is well described that the drug has an antiviral effect especially against flavivirus, retrovirus and coronavirus by inhibiting a number of low-ph-dependent steps in virus replication, as well as by inhibiting the ph-dependent endosomal mediated viral uptake in cells ( ) . the drug is well tolerated even with high dosage, for up to five years and there is no signal for birth defects with usage of the drug summarised by savarino et al. ( ) . cell studies with primate cells infected with the coronavirus that induced sars- (formerly called sars) have shown that chloroquine, in a dose-dependent manner, inhibits the ability of the corona virus to infect cells and to spread among cells ( ) . thus, several researchers and health care professionals have, during the present sars-cov- pandemic, have proposed studies examining hydroxychloroquine/chloroquine as treatment for patients with covid- disease ( , ) . proactive prophylaxis with azithromycin and chloroquine in hospitalised patients with covid- (propac-covid) the study will clarify whether treatment with azithromycin in combination with hydroxychloroquine for days from the time of hospital admission with diagnosed covid- disease may reduce the length of hospitalisation, the risk of admission to the intensive care unit, treatment with non-invasive ventilation and death. the study will also clarify whether this treatment can reduce the need for oxygen supplementation (time for breathing on its own without oxygen supplementation) or for regular long-term oxygen therapy oxygen supplementation ("home oxygen"). if the treatment also improves the course of covid- disease in patients with pre-existing lung disease, a very large number of patients could benefit from the treatment immediately. the study originates from the danish national non-commercial lung research network cop:trin (chronic obstructive pulmonary disease: trial network). . design: randomised, good-clinical-practice-monitored, placebo-controlled, double-blind study. see point . inclusion criteria: interactions should be taken into account if the patient is taking other medications. for azithromycin, this includes antacids, ergotamine derivatives, colchicine and cyclosporine. for hydroxychloroquine, these include antidiabetic agents, tricyclic antidepressants, antipsychotics, halofantrine, cyclosporine, mefloquine, antiepileptic drugs, praziquantel and agalsidase. as there is no specific treatment for covid- , standard assessment and treatment is based on organ supportive therapy such as oxygen therapy (central), fluid therapy, antibiotic therapy for secondary infections. if the disease progress to severe acute respiratory failure, the patients will often require referral to an intensive care unit for mechanical ventilation. in addition, danish national guidelines for handling of in-hospital covid- patients can be obtained from www.lungemedicin.dk or from the open access journal european respiratory clinical journal (at present in press). the sponsor generates a randomisation sequence. randomisation will be in blocks of unknown size and the final allocation will be via an encrypted website (redcap), where also inclusion and exclusion criteria are required to be filled in correctly in order to randomise a patient. allocation will be stratified for age (> years vs. <= years), site of recruitment and whether the patient has any of the following chronic lung diseases: copd, asthma, bronchiectasis, interstitial lung disease (yes vs. no). the primary daily project management is carried out by the project manager. in addition, a project group (investigators), consisting of doctors from the departments involved, is trained to assist the project manager with the recruitment, sampling and follow-up of patients. all medical decisions regarding patients will be taken by a physician. data is collected in case report forms (crf) for each individual patient. prior to consent to participate in the trial, we will only assess the specific information needed to assess inclusion and exclusion criteria. no other information will be accessed. it is the attending physician who asks if patients are interested in hearing more about the trial. if yes, an investigator is contacted, who will inform the patient about the trial. as part of the study, all patients will be regularly monitored for oxygen saturation, heart rate, blood pressure, respiratory rate and temperature during hospitalisation. the following information will also be obtained: all this information is passed on to the investigator. the information from the medical records is required to calculate demographic data, medication data and outcomes in the trial. no information that is not required according to the protocol will be obtained. case report form is archived at the departments involved for years. a separate database is created in redcap (www.projectredcap.org) for data management. *the blood samples include haemoglobin (hb), leukocytes + differential count, thrombocytes, creactive protein (crp), na+, k+, albumin, creatinine, urea, amylase, alkalic phosphatase, beta- -microglubulin, fibrinogen, glucose, tsh, inr, billirubin, d-dimer, aptt, calcium, triglycerides, ferritin and lactate dehydrogenase (ldh). these blood tests will also be recommended daily for covid patients outside studies in the recommendation of the danish lung medicine association. **when screening for the study, any ecg from within the last days can be used. ***a follow-up ecg can be recorded during any remaining days of the hospital admission. ****only in patients with copd. neither patients nor study staff will know which group the patient is allocated to. the medicine will be marked neutral, e.g. "azithromycin group a" and "azithromycin group b" and the same for hydroxychloroquine. note: if the patient is receiving azithromycin prophylaxis, common practice is followed: the prophylaxis is paused and then restarted as usual. control group: the control group will receive the standard treatment + placebo for both types of intervention imp at all times. if part or all the intervention therapy being investigated becomes standard treatment during the study, this may also be offered to the control group. intervention group: the patients in the intervention group will also receive standard care. immediately after randomisation to the intervention group, the patient will begin treatment with : azithromycin: if the patient is unable to take the medication orally by themselves, the medication will, if possible, be administered by either stomach-probe, or alternatively, temporary be changed to clarithromycin mg x (this only in agreement with either study coordinator pradeesh sivapalan or principal investigator jens-ulrik staehr jensen). this will also be done in the control group if necessary. the patient will switch back to azithromycin when possible. hydroxychloroquine: furthermore, the patient will be treated with hydroxychloroquine as follows: follow-up is done on days , , and days, by accessing the electronic medical record system. the specific information obtained, and its purpose can be found in section . . . the summary of product characteristics for azithromycin suggests mg/day for three days or mg/day for one day and then mg daily for four days. however, other clinical studies have found a positive effect of a daily dose of mg for prolonged periods as prophylactic treatment. mortality among hospitalised patients with covid- is quite high and the median time for hospitalisation is - days, so it seems reasonable to give patients prophylactic dose for days. the dosing of hydroxychloroquine follows the summary of product characteristics. regarding other treatment with antibiotics: if antibiotic therapy is deemed indicated to the patient due to e.g. pneumonia or if it becomes standard therapy, piperacillin-tazobactam should be given as an empirical treatment at a dose adjusted to renal function. in case of penicillin allergy, cefuroxime is also given at a dose appropriate to renal function, weight and age. when positive microbiology is available, immediately switch to targeted treatment. if specific suspicion of atypical pneumonia is raised, ciprofloxacin is administered at a dose of corresponding to kidney function and concomitant examination for atypical pneumonia will be performed. if negative, ciprofloxacin is discontinued. if positive, ciprofloxacin treatment is continued for the duration of treatment corresponding to the microorganism detected. if there is a specific need for treatment with macrolide and where other options are not available (e.g. allergy to fluoroquinolones, or when there is an estimated need for combination treatment of e.g. legionella pneumonia), consult with an investigator, and in this case it may be decided to discontinue azithromycin (active) or azithromycin placebo. in this case, treatment stops without unblinding. furthermore, ecg recordings during the treatment period will be analysed with focus on qtc. at qtc (f)> / ms for respectively women and men, imp will be discontinued for safety reasons (but the patient remains in the study). primary endpoint: this requires patients randomised : with in each group. this is a fixed sample size. it is assumed that most patients complete the intervention. however, for interim analysis, the data and safety monitoring board (dsmb) may recommend the steering committee to expand sample size. frequency and depth are determined by the gcp units. initiation visits and the first monitoring visits to all centres will be conducted off-site, i.e. without a physical meeting, due to the sars-cov- pandemic. consent sheets will be scanned into an online system (redcap or journal system) that can be accessed by gcp monitors. after recruiting half the sample size (approximately patients), an interim analysis will be performed focusing on safety. an external data and safety monitoring board is appointed. the interim analysis will be prepared and presented by physician josefin eklöf. the groups will be presented as "group a" and "group b" and dsmb will only be unblinded if they ask the steering committee for the study on this. as part of ususal care, blood samples are taken daily from the time of inclusion and as long as the patient is admitted. blood samples include haemoglobin (hb), leukocytes + differential count, thrombocytes, c-reactive protein (crp), na+, k+, albumin, creatinine, urea, amylase, alkalic phosphatase, beta- -microglobulin, fibrinogen, glucose, tsh, d-dimer, aptt, calcium, triglycerides, ferritin, bilirubin, alat, inr, and lactate dehydrogenase (ldh), see table . these blood samples are analysed at the hospitals. in addition, supplemental blood tests and material obtained with nasal swaps will be performed according to the sub-study protocols. material from this will be included in a research biobank for the trial, and after completion of the trial in another regional biobank. the trial is expected to end in february , and the material will then be transferred to the regional biobank. for the present trial, the results of blood tests are collected from the patient record. the treating physician may at any time discontinue intervention with imp if, in clinical and/or paraclinical assessment, it is deemed contraindicated. serious side effects to regular blood sampling (venous puncture) are rare. frequent ( - %) can be seen transient discoloration of skin around the insertion site. chest x-rays correspond to a radiation dose of approx. . millisievert (msv). this should be compared with the average background radiation in denmark of approx. msv per year. there are no documented adverse effects of the radiation dose received by chest x-rays in the literature. therefore, we believe that the study is not associated with any risks or side effects. • with pigment change requires careful dosing and careful control. when using rheumatologic doses, eye examination by an ophthalmologist is recommended before starting treatment and with follow-up to check for any eye manifestations that may arise. annual monitoring after years of treatment is recommended, however in risk patients initially annual control, see also chloroquine derivatives (inflammatory rheumatic diseases), side effects. • with cardiomyopathy can be fatal. • with macular degeneration is seen and may be irreversible. • with reversible corneal changes with oedema and blemishes can cause blurred vision or photophobia. • with blurred vision accommodation is dose-dependent and reversible. • in malaria treatment and prophylaxis, fewer and milder side effects occur. **prolonged qt interval has been seen in patients with particular risk factors for it. ***acute generalized exanthematous pustulosis must be distinguished from psoriasis. psoriasis exacerbation may occur. may be associated with fever and hyperleukocytosis. an adverse reaction (ar) is defined as any adverse and undesirable reaction to a trial drug regardless of dose. an adverse event (ae) is defined as any adverse event in a patient or subject in a clinical trial following treatment with a drug, without necessarily linking this treatment to the adverse event. since the trial drugs are well known and have been used for many years, we will only record side effects not mentioned in the respective drug summary of the trial drug. a severe adverse reaction or event (sar/sae) is defined as an event or adverse event that, regardless of dose, results in death, is life-threatening, results in hospitalization or prolongs hospitalization, results in significant or persistent disability or incapacity, or leading to a congenital anomaly or malformation. investigators must immediately (= within hours) report serious incidents and serious adverse reactions (saes and sars) to the sponsor regardless of whether they are described in the respective product summary. this allows the sponsor to assess the benefits and risks along the way in the study. events and adverse events recorded during the period from the patient have received the first dose of trial medication up to and including day . recording and reporting of all events and adverse events will end when the trial drug is stopped. a high degree of comorbidity and death is seen in this patient group and therefore it is also expected that prolonged admissions, re-admissions, niv, respirator treatment and death will occur in this patient group. therefore, these parameters will not be considered as a sae. all incidents and registered side effects are reported at the end of the trial in a final report to the danish medicines agency. all serious suspected adverse reactions must be reported annually together with a report on the safety of the subjects and sent to the the danish medicines agency (lmst) and the danish national committee on health research ethics (vek). the product summary of the trial drugs is used to assess whether a serious adverse event is unexpected and thus possibly a suspected unexpected serious adverse reactions (susar). in the event of a fatal or life-threatening susar, this must be registered and reported to lmst and vek within days of the sponsor becoming aware of it. no later than days after the report, the sponsor must provide lmst and vek with all relevant information about the sponsors and investigators' follow-up on the event. all other susars are reported to lmst and vek within days of the sponsor becoming aware of them. the report must be followed up by a detailed written report, and in both the immediate report and the subsequent report, the investigator must identify the subjects with a personal code number. when reporting deaths, the investigator must provide any additional information that the sponsor may request. the research project is (investigator) initiated by cop:trin. funding has been obtained from the novo nordisk foundation of dkk . million for sponsor, remuneration of auxiliary personnel, payment of laboratory tests and equipment, as well as for manufaction of imp treatment and placebo. the sponsors and investigators are not financially linked to private companies, foundations, etc. in this research project. medical expenses are covered, if not obtained from other sources, by the section for respiratory medicine research, gentofte hospital. to the extent possible, the section for respiratory medicine research, gentofte hospital supports follow-up for endpoints and otherwise by appointment. patients are not paid for participation in the trial. the consent gives the primary investigator, monitor and any control authority direct access to obtain information in the patient's medical record, etc., including electronic record, in order to see information about the subject's health conditions which are necessary as part of the implementation of the research project and for control purposes, including self-monitoring, quality-control etc. the project group that has designed and conducted this study has the right to data and the right (and duty) to publish based on data. project management manages data and invites members of the study group to publications. all sites that recruit patients are entitled to at least one authorship on the primary publication, and for every patients recruited, the site is entitled to an extra authorship. sites that have not participated in the design of the study are entitled to a maximum of authorships. it is the opinion of the steering committee that knowledge sharing creates more and better scientific results. requests for knowledge sharing from other groups may be submitted to project management (jens-ulrik jensen, charlotte ulrik, pradeesh sivapalan) who will evaluate primarily and who, if the project is found suitable, will discuss it with the cop:trin steering committee. project management has the first right to undertake sub-studies but may well assign projects to other contributors. in that case, the following considerations will be significant in the assessment: ) participation in the design phase of this rct and at what level, and ) number of patients recruited at a site. if the hypothesis to be investigated is not planned to be examined by our group, we will allow the use of our data if the steering committee finds the project scientifically sound and, if appropriate, a collaboration with members of the cop:trin steering committee will be proposed. however, it should be emphasized that data is used for a specific purpose, not for future purposes in general. this becomes conditional by the steering committee for data to be used in a sound way to test hypotheses with relevant scientific content. information regarding subjects are processed and stored in accordance with the data protection regulation (gdpr), the data protection act and the health act and the project is properly notified in accordance with applicable rules and laws to the appropriate authorities. all project results will be sought published in scientific contexts, including international journals. this will happen regardless of whether the result is positive, negative or inconclusive. the study is conducted in accordance with the declaration of helsinki and is carried out in accordance with the rules of the personal data act and the health act. the study has been registered at the danish data protection agency. recruitment and inclusion will take place as previously described (section . . ). participation requires a signed statement of consent. patients can withdraw their participation consent and withdraw from the research project at any time without this having any effect on their right to current or future treatment. furthermore, the patient is entitled to bring a bystander to the information interview and is entitled to reflection time before any declaration of consent is signed. the important objective of the study is to investigate whether pro-active and pre-emptive treatment against covid- can reduce the length of hospitalisation and the risk of intensive care and improve the survival of patients -an area that has so far been poorly researched and where the need for evidence-based guideline for handling and processing is large and very urgent. potential disadvantages and side effects are described in the separate section . among other things, it appears that the likelihood of serious adverse reactions to both treatment and examinations is rare. in addition, the treating physician can always discontinue treatment if it is considered contraindicated. placebo is given patients allocated to the control group as no specific standard medical treatment is available. the experimental method and statistical analyses have been carefully considered in order to be able to disseminate and apply relevant and secure research results to clinical practice. based on the above considerations, we believe that the experiment is sound ethically sound and can be conducted without exposing the test participant to unjustifiable risks. at each trial centre, screening of patients admitted with a positive sars-cov- test is performed. patients are assessed against the inclusion and exclusion criteria of the attending physician who receives the patient's consent to contact the investigator. the investigator then contacts the patient for recruitment to the study. disclosure of information about the study and obtaining informed consent may also be undertaken by other healthcare professionals. this includes research assistants (medical students), clinical nursing specialists and project nurses (see below for specific requirements). these are all separately trained in the task and have the opportunity to call a physician should any medical issues arise. they can also contact the coordinating investigator as well as a hotline team for the trial should any questions arise about informed consent. this hotline is available hours a day. all patients are offered a consultation with a physician if they ask for it. for project nurses, the following applies specifically: i) must have at least years of seniority. these requirements are verified by primary investigator from each site that afterwards creates a document for these individuals from which the above specific requirements are verified. this document is dated and signed. if a patient is considered suitable, the person will be invited to participate in the project. participation in the trial is voluntary. informed consent is obtained from the participants of the trial acc. to executive order no. of september on information and consent for participation in health science research projects and on notification and supervision of health science research projects. the first contact with the the potential participant in the trial will be at admission to one of the participating departments. participant information is provided both orally and in writing, and the patient is informed that they are entitled to hours of reflection time before consent is given for participation in the trial. participants who wish to do so themselves after the period of reflection time may give consent in connection with the information meeting. the right to a bystander is ensured by the patient being able to bring a bystander, however, subject to covid isolation rules. if no bystanders come to the first call, they are ensured afterwards to a bystander, when the patient is out of isolation. it is ensured that the conversations are undisturbed by using the patient's isolation room. if the doctor carries a "pager" or telephone, these are handed in prior to the call. the trial participant will be provided with the document "the research subject's rights in a health science research project", which contains information about confidentiality, access to documents and access to complaints. the subjects are protected under the personal data processing act. the trial has been reported to the regional science ethics committee, the danish medicines agency and the danish data protection agency. it must be ensured at all times that subjects have consented to participate in clinical trials. if an isolated subject with covid- can sign consent declaration via electronic tool, this can be used instead of consent with signature. this can be, for example, a mobile phone, an ipad, a laptop with secure identification, for example by an easy id (or other solution that meets the oces standard). if the above described solution is not possible, the following solutions can be used as temporary documentation for the consent: • copy of signed consent declaration -e.g. using camera: the subject can sign the consent form as usual. since the signed form must not leave the isolation room, the signature can be documented in the form of a photograph of the signed form, for example through a window. • if the test subject cannot sign the consent declaration himself, e.g. due to problems with having electronic equipment in the room, or obtaining documentation for the consent out of the room, the witness can sign on behalf of the subject: if the subject verbally consents, a witness can on behalf of the subject sign the consent form. for both of the above solutions, documentation (photo and witness signature) will be filed in the investigator's section of the trial master file (tmf). furthermore, it is ensured that the data protection regulation and the data protection act are complied with, although documentation of the consent is temporarily different than it usually is. if the situation is normalised, the correct signed consent form must be obtained from the subject as soon as possible. regular monitoring and quality control of the study will be carried out. if the physician responsible for the study deems it necessary, the physician may during treatment take the subject out of the study. the physician may also terminate the study at any time if there is a medical justification (such as the development of allergies to medicines), a safety risk or a requirement from the authorities. the test subject may also withdraw their informed consent and withdraw from the investigation at any time, as mentioned in the above paragraph. patients who participate in these studies and who believe they have suffered injury can seek compensation through the patient compensation (http://patienterstatningen.dk/) cf. danish law. common ( - %) powerlessness, decreased appetite. vomiting, taste disorders. decreased lymphocyte count. decreased serum bicarbonate. arthralgia. headaches, paraesthesia, dizziness. skin itching, rash uncommon ( . - %) pain. hepatitis, oral candidiasis. dyspnea, pneumonia, oedema. eosinophilia, leukopenia, neutropenia. elevated serum bicarbonate, hyperchloremia, hyperglycaemia, hyperkalaemia, hypernatremia, hypokalaemia, hyponatraemia. arthritis, back pain. nervousness, somnolence. facial oedema liver impact. agitation. acute generalized exanthematous pustulosis*, allergic reactions*, angioedema*, hypersensitivity. not known fulminant hepatitis, hepatotoxicity, hepatic insufficiency, pancreatitis, pseudomembranous colitis. arrhythmias, extended qt interval, hypotension, torsades de pointes tachycardia. haemolytic anaemia, thrombocytopenia dress -drug reaction with eosinophilia and systemic symptoms, erythema multiforme, stevens-johnson syndrome, toxic epidermal necrolysis. anaphylactic reaction. acute renal failure *in case of allergic reactions, including acute generalized exanthematous pustulosis and dress, azithromycin should be discontinued. hydroxychloroquine: very common (> %) abdominal pain common ( - %) eating refusals. diarrhoea, vomiting. emotional lability, headaches. skin itching, rash. accommodation difficulty aggravation of porphyria, hypoglycaemia. myopathy. extrapyramidal genes, cramps, neuropathy, palsy, psychosis, suicidal behaviour. acute generalized exanthematous pustulosis***, exfoliative dermatitis, erythema multiforme, photosensitivity, stevens-johnson syndrome, toxic epidermal necrolysis. allergic reactions (including dress syndrome proactive prophylaxis with azithromycin and chloroquine in hospitalised patients with covid- clinical characteristics of coronavirus disease in china clinical course and risk factors for mortality of adult inpatients with covid- in wuhan, china: a retrospective cohort study clinical characteristics of refractory covid- pneumonia in wuhan, china clinical course and outcomes of critically ill patients with sars-cov- pneumonia in wuhan, china: a single-centered, retrospective, observational study care for critically ill patients with covid- azithromycin maintenance treatment in patients with frequent exacerbations of chronic obstructive pulmonary disease (columbus): a randomised, double-blind, placebo-controlled trial azithromycin for prevention of exacerbations of copd effect of azithromycin on asthma exacerbations and quality of life in adults with persistent uncontrolled asthma (amazes): a randomised, double-blind, placebo-controlled trial proactive prophylaxis with azithromycin and chloroquine in hospitalised patients with covid- (propac-covid) effect of azithromycin maintenance treatment on infectious exacerbations among patients with non-cystic fibrosis bronchiectasis: the bat randomized controlled trial randomised, double-blind, placebo-controlled trial with azithromycin selects for anti-inflammatory microbial metabolites in the emphysematous lung adjunctive therapy with azithromycin for moderate and severe acute respiratory distress syndrome: a retrospective, propensity score-matching analysis of prospectively collected data at a single center azithromycin attenuates airway inflammation in a mouse model of viral bronchiolitis azithromycin induces anti-viral responses in bronchial epithelial cells azithromycin protects against zika virus infection by upregulating virus-induced type i and iii interferon responses effects of chloroquine on viral infections: an old drug against today's diseases? the role of antimalarial agents in the treatment of sle and lupus nephritis chloroquine is a potent inhibitor of sars coronavirus infection and spread chloroquine for the novel coronavirus sars-cov- breakthrough: chloroquine phosphate has shown apparent efficacy in treatment of covid- associated pneumonia in clinical studies key: cord- -n n ii k authors: singh, thakur uttam; parida, subhashree; lingaraju, madhu cholenahalli; kesavan, manickam; kumar, dinesh; singh, raj kumar title: drug repurposing approach to fight covid- date: - - journal: pharmacol rep doi: . /s - - - sha: doc_id: cord_uid: n n ii k currently, there are no treatment options available for the deadly contagious disease, coronavirus disease (covid- ). drug repurposing is a process of identifying new uses for approved or investigational drugs and it is considered as a very effective strategy for drug discovery as it involves less time and cost to find a therapeutic agent in comparison to the de novo drug discovery process. the present review will focus on the repurposing efficacy of the currently used drugs against covid- and their mechanisms of action, pharmacokinetics, dosing, safety, and their future perspective. relevant articles with experimental studies conducted in-silico, in-vitro, in-vivo, clinical trials in humans, case reports, and news archives were selected for the review. number of drugs such as remdesivir, favipiravir, ribavirin, lopinavir, ritonavir, darunavir, arbidol, chloroquine, hydroxychloroquine, tocilizumab and interferons have shown inhibitory effects against the sars-cov in-vitro as well as in clinical conditions. these drugs either act through virus-related targets such as rna genome, polypeptide packing and uptake pathways or target host-related pathways involving angiotensin-converting enzyme- (ace ) receptors and inflammatory pathways. using the basic knowledge of viral pathogenesis and pharmacodynamics of drugs as well as using computational tools, many drugs are currently in pipeline to be repurposed. in the current scenario, repositioning of the drugs could be considered the new avenue for the treatment of covid- . drug repurposing is the process to identify the new indications for existing drugs and considered as an efficient and economical approach [ ] . it is also known as repositioning, re-profiling, re-tasking and rescue of drugs [ ] . it has been considered that % of known drugs could be repositioned for various diseases [ ] . outbreaks of novel emerging infections such as coronavirus disease (covid- ) have unique challenges in front of the health professionals to select appropriate therapeutics/pharmacological treatments in the clinical setup with very little time available for the new drug discovery [ ] . further, development of a vaccine for any disease including covid- takes time and even if the process is put on accelerated mode it would take - months to introduce it as ready-to-use product. currently, no specific treatment is available against the new virus severe acute respiratory syndrome coronavirus (sars-cov ). hence, the search for effective therapeutic agents to tackle covid- is vital and urgent. the discovery and licensed use of a drug come with a long-gestation period. the cost of the new drug development process amounts to more than a billion dollars extending for a period of - years [ ] with the success rate of only . % [ ] . this creates a lag in the productivity of pharmaceutical research to develop a new drug which results in a persistent gap between therapeutic needs and available treatments [ ] . considering the time and cost required for coming up with new therapies, probing the existing antiviral and other drugs against sars-cov is cost-effective. in recent times, repurposing of available drugs for the management of several disease conditions is increasingly becoming a popular strategy as it uses de-risked compounds with known preclinical, pharmacokinetic, pharmacodynamic profiles which can directly enter phase iii or iv clinical trial making the drug development process potentially a low-cost and relatively rapid [ ] . therefore, reassessing the efficacy of licensed and experimental drugs has become go to choice of world health organization (who) and other health agencies to treat emerging health problems. drug repurposing follows mainly two concepts. one is that a single drug interacts with multiple targets, which paves the way for searching new target sites of action for the known compound [ , ] . the other concept is that targets associated with a disease are often relevant to a number of biological processes of pathogenesis [ , ] which paves the way for designation of a new indication for the known target. notionally, a drug that acts on these common elements can, in principle, be useful for several disorders. broadly, there are three kinds of approaches which are widely used in drug repositioning: computational approaches, biological experimental approaches, and mixed approaches. data such as gene expression, drug-target interactions, protein networks, electronic health records, clinical trial reports, and drug adverse event reports has become accessible in standardized forms. the repository of knowledge and omics data available in pharmaceutical research leads to the rise of some computational methods which are novel and exciting in the field of drug repositioning. these computational methods are capable to make a high-level integration of all the knowledge and data and help in understanding the new signaling pathways and generate novel insights into drug mechanisms, side effects, and interactions which further speed up drug discovery. a recent study presented integrative network-based systems pharmacology, methodology which quantifies the interplay between the coronavirus-human cell interactome and drug targets in the human protein-protein interaction network which help in rapid identification of repurposable drugs against sars-cov . a study using this kind of approach was able to identify potential repurposable drugs against covid- [ , ] . the sars-cov mainly spreads through the respiratory tract [ ] and affects alveolar cells. unlike, middle east respiratory syndrome coronavirus (mers-cov) which employs dipeptidyl peptidase (dpp ) [ ] , sars-cov and sars-cov adopt angiotensin-converting enzyme (ace ) as receptor for entering the cell. attachment, fusion and entry of the virus are aided by spike protein which makes it an interesting target for the development of antibodies, entry inhibitors and vaccines [ ] . anti-viral agents including ritonavir, lopinavir, ribavirin, interferons have been used against sars-cov and mers-cov clinically, however, clinical data is still limited [ ] . currently, with the lack of effective agents against sars-cov as well as public-health emergency, who has identified some therapies which doctors and researchers believe are the most promising, such as a combination of two hiv drugs (lopinavir and ritonavir), anti-malarial drugs (chloroquine and hydroxychloroquine), and an experimental antiviral compound remdesivir. further, many available drugs with the intention of repurposing against covid- have been subjected to clinical trials [ ] ( table ) . however, the search for other agents cannot pause while waiting for the results because the demand for new effective agents is huge. human population of the twenty-first century is suffering a large-scale epidemic of highly pathogenic coronaviruses such as severe acute respiratory syndrome coronavirus (sars-cov) in - [ ] , middle east respiratory syndrome coronavirus (mers-cov) in [ ] and severe acute respiratory syndrome coronavirus (sars-cov ) in - . coronaviruses are pleomorphic, enveloped, positive sense, - kb large rna viruses with typical crown-shape glycoprotein spikes (peplomers) that cause respiratory and enteric diseases in humans and other animals [ ] . very high recombination rates lead to constant transcription errors and rna-dependent rna polymerase (rdrp) jumps in coronaviruses [ ] give them a chance to develop into diverse zoonotic pathogens such as sars-cov . sars-cov is a positive-sense single-stranded rna virus classified as a strain of the species sars-cov, (genus beta-coronavirus; subgenus sarbecoronavirus; subfamily orthocoronavirinae; family coronaviridae) which earlier in - caused an outbreak of sars in guangdong, china [ ] . overall genome sequence of sars-cov showed . % similarity with sars-cov and interestingly, . % similarity with bat coronavirus ratg , suggesting its origin from a bat virus [ , ] . though not certain, yet it is suspected that the introduction of this new coronavirus to humans might have been facilitated by an intermediate host, the pangolins [ ] . as per who report, a case of pneumonia of unknown causative pathology from wuhan city of china was first time reported to the who country office on december . the outbreak of the coronavirus-associated acute respiratory disease throughout the world was named as covid- and it was classified as -ncov (sars-cov ) [ ] . the classification and naming of the virus were done by the coronaviridae study group of the international committee on taxonomy of viruses. novel coronavirus genome sequencing by china was publicly available on the global in the current scenario of lacking efficient and specific treatments for sars-cov infections and the urgent need to restrain the pandemic, drug re-tasking appears to be the most suitable tool to find out the best therapeutic option for covid- [ ] . the mechanisms of infection by the sars-cov are not clear yet, however, it is genetically similar to sars-cov and other coronaviruses [ ] . hence the common mode of pathogenicity is being explored for targets of treatment. the therapeutic targets depending on the common mode of pathogenicity can be classified as virus-related targets and host-related targets. replication of sars-cov depends directly on the key enzyme rdrp. it is interesting to note that potential drug targets protease and polymerase for sars-cov and sars-cov are highly conserved with % and % overall identity. therefore, blockers developed against the sars may act as good therapeutic candidates to bind protease or polymerase sites against sars-cov (gisaid, ) ( fig. ). on the basis of current knowledge about the use of remdesivir in sars-cov infection, remdesivir is considered as the potential drug candidate for repurposing against the covid- . remdesivir (gs- ) is a nucleoside analog originally developed against ebola viruses by gilead sciences inc, a usa based biopharmaceutical company ( table ) . though the drug failed to show effect against ebola, the preliminary results from in-vitro and in-vivo preclinical studies as well as case reports indicate its efficacy against sars-cov . recently, in vero e cells, remdesivir has been shown to block the viral infection at low concentration (ec = . μm) with high selectivity index (si > . ). the ec value ( . µm) was also low enough to be achieved in non-human primate models [ ] . it also efficiently inhibited sars-cov infection in human liver cancer huh- cells [ ] . in rhesus macaques, the drug showed therapeutic and prophylactic efficacy against both sars and mers coronaviruses, indicating its potential against diverse coronaviruses including sars-cov [ ] . similarly, in a ces c-knockout mouse model of sars-cov infection, remdesivir in both prophylactic and therapeutic use significantly reduced lung viral titers, though the survival and lung pathology were not improved [ ] . treatment with intravenous remdesivir on day of hospital admission, clearly improved the clinical condition from the next day in a -year-old covid- patient in washington, usa [ ] . in italy, remdesivir has been used ( mg every h as a loading dose followed mg every h for days thorough intravenous route) with other supportive therapy in the clinical management of covid- patients presented with a range of modified early warning score (mews) from less than to more than [ ] . in a recent report, clinical improvement in of patients ( %) of severe covid- patients has been observed with the compassionate-use of remdesivir in a cohort study [ ] . according to another study remdesivir was superior over the placebo in shortening the time to recovery in adult patients hospitalized with covid- . in the trial that was conducted at sites and subsites in different parts of the world, mortality rate was . % with remdesivir and . % with placebo by days in patients in which were in remdesivir group and were in the placebo group [ ] . another trial, however, suggests differently, that remdesivir has no such statistically significant clinical benefits, although, patients who were administered with remdesivir showed a faster clinical improvement in numerical terms, with symptom duration of days or less in a study of patients in which patients received remdesivir and (one withdrew) were on placebo in a randomised, double-blind, placebocontrolled, multicentre trial at ten hospitals in hubei, china [ ] . another clinical trial done with remdesivir in severe covid- patients without mechanical ventilation support indicated no significant difference between -day and -day course of remdesivir therapy, however, by day , a clinical improvement was noticed in % of patients in the -day group and in % in the -day group at points or more on the ordinal scale out of -point ordinal scale [ ] . being a nucleotide (adenosine) analog, remdesivir gets incorporated into the replicating genome of the virus after being converted into its triphosphate form. the triphosphate forms compete with adenosine triphosphate (atp) to act as a substrate of rdrp and have been found to cause significantly efficient incorporation as compared to atp. remdesivir adds three more nucleotides before terminating the growing rna chain [ ] . the extra three nucleotides may protect the inhibitor from removal by the viral ′- ′ exonuclease activity [ ] , contributing to the lack of acquiring resistance. the pharmacokinetics, metabolism and distribution of remdesivir have been studied in non-human primates, previously. in rhesus monkeys, mg/kg dose yields a half life (t / ) of . h with fast systemic elimination. the active metabolite of remdesivir, ′-cyano-substituted adenine c-nucleoside ribose analogue (nuc) then appears which produces antiviral activity [ ] . however, the drug is parenterally administered through intravenous route and is not expected to be given to mildly infected patients, though potent action is expected in mild infection. it is under clinical trial in china and usa against covid- by th of april, (nct and nct ). however, seven clinical trials are underway on remdesivir to evaluate its efficacy on sars-cov infection (https ://www.gilea d.com/purpo se/advan cing-globa l-healt h/covid - /remde sivir -clini cal-trial s). the results of nct clinical trial showed that intravenous remdesivir was adequately tolerated by covid- patients [ ] . in the third trial (nct ) with the severely infected covid- patients, with the use of remdesivir, common adverse effects were observed such as nausea, acute respiratory failure, increased alanine aminotransferase (alt) and constipation [ ] . in all these studies ramdesivir was administered intravenously as mg sid on day and followed by mg sid for the subsequent period. virus enters the cell by fusion of the viral spike proteins with cellular ace receptor, followed by ace downregulation. angiotensin receptor blockers (arbs), angiotensin-converting enzyme inhibitors (aceis) and statins increase ace expression, hence may have efficacy in this condition. . fusion is followed by endocytosis of the virus, where low endosomal ph helps in lysis of the viral structural proteins. disruption of this acidic environment by diprotic bases like chloroquine and hydroxychloroquine may produce an antiviral effect. , . release of nucleic acid (na) into the cytoplasm and translation of the viral proteins using host ribosomes, . proteolysis by viral main protease enzyme makes functional proteins e.g. rna dependent rna polymerase (rdrp). thus, inhibition of the main protease enzyme by inhibitors like lopinavir, ritonavir and darunavir, may have efficacy against the virus. . rdrp is essential for replication and transcription of the virus. rdrp inhibitors, remdesivir, favipiravir, ribavirin and arbidol may be effective against coronaviruses. , . subsequent translation and proteolysis into structural proteins followed by packaging makes intact virions, which get exocytosed ( ) from the cell as per the information obtained from the chinese news channel by dong and co-workers, this drug got an approval against the sars-cov infected patients in china on th february, since it had drastically attenuated the illness of the sars-cov infected patients [ ] . favipiravir ( -fluoro- -hydroxy- -pyrazinecarboxamide, t- also table chemical structure of pharmacological agents reviewed marketed as avigan) was developed by a japanese firm, toyama chemical co., ltd. and has been approved in japan for influenza since ( table ). the drug effectively inhibits the enzyme rdrp. in vero e cells this drug showed an ec of . µm and selectivity index of more than . against sars-cov [ ] . though this concentration against sars-cov is very high, the drug may be tested in an animal model based on its performance against ebola virus. remarkably this drug had shown % efficacy against ebola in a mice model although it had a very high ec in vero cells [ ] . randomized trials are being conducted for this drug in combination with other drugs against coronaviruses (favipiravir + interferon-α, chictr , favipiravir + baloxavir, chictr ). favipiravir is a nucleoside precursor which inhibits the broad range of influenza virus strains, however, it shows antiviral activity through its ntp form (converted into an active phosphoribosylated form, t- rtp) via direct inhibition of the rdrp activity of influenza a virus polymerase and it has also shown lethal mutations within the viral genome [ ] . nevertheless, the exact mode of action, precise molecular mechanism and its interaction between the nucleotide and the viral polymerase could be investigated in the sars-cov infection. favipiravir exerts its antiviral action in a dose-dependent manner [ ] . its oral bioavailability is close to % and has a short half life of - . h [ , ] . in humans, the plasma protein binding of favipiravir is %. favipiravir undergoes metabolism in the liver mainly by aldehyde oxidase (ao) and partially by xanthine oxidase (xo) and the inactive oxidative metabolite (t- m ) is excreted by kidneys. a study reported that in pichindé arenavirus infection the kinetics of absorption, elimination and time to maximum drug concentration is altered. the t- m levels were higher in the infected animals [ ] . further, favipiravir concentration may be increased by drugs those undergo metabolism through ao such as raloxifene, tamoxifen, estradiol, cimetidine, felodipine, amlodipine, verapamil, propafenone, amitriptyline, zaleplon, citalopram, sulindac and famciclovir. concomitant administration of acetaminophen and favipiravir showed increased area under curve (auc) of former drug possibly due to inhibition of the sulfate transferase by the latter drug [ ] . the drug did not show any toxicity at the oral dose of mg/kg/day for days in guinea pigs [ ] . this can be converted to mg/kg of human equivalent dose [ ] which is far greater than the dose prescribed for covid- on first day i.e. mg/kg/day ( mg bid on the first day) (https ://www.clini caltr ialsa rena.com/comme nt/influ enza-favip iravi r-covid - /). however, use of this drug may be approved with the availability of more number of clinical results. ribavirin, a broad-spectrum antiviral drug, is a guanosine analog approved for treating hepatitis c virus in combination, and respiratory syncytial virus as monotherapy. effect of this drug has been assessed in patients with sars [ ] and mers [ ] (table ) . against sars-cov , it has very high ec of . μm and selectivity index more than . in vero cells. ribavirin in its monophosphate form inhibits host inosine monophosphate dehydrogenase (impdh) enzyme that controls intracellular guanosine triphosphate (gtp) pools [ ] . exhaustion of intracellular gtp pool indirectly inhibits viral rdrp enzyme. it also interferes with mrna capping. ribavirin at a dose rate of mg - times/day in combination with other drugs such as lopinavir/ritonavir or interferon (ifn)-α through intravenous route for not more than days made the sars-cov infected patients more resistant to respiratory distress syndrome as well as death [ ] . the oral bioavailability of ribavirin is %, which is due to modest first-pass metabolism in liver [ ] . estimated halflife is . h [ ] . ribavirin-induced hemolytic anemia is a most commonly reported adverse effect and frequently it requires dose reduction [ ] . further, close monitoring of renal impairment in terms of creatinine clearance during therapy is required. old age, decreased renal function, low body weight and female gender are other risk factors to be considered during ribavirin therapy [ , ] . animal studies have shown teratogenic potential of ribavirin. therefore, exposure during pregnancy should be avoided. other less common yet pertinent adverse effects are bronchospasm and pulmonary edema on inhalation [ , ] . neutropenia, thrombocytopenia, skin rashes, anorexia and depression are some minor adverse effects of ribavirin that need to be monitored in the sensitive patients [ ] . in a recent clinical trial with combinations of ribavirin + interferon-alpha, lopinavir/ritonavir + interferon-alpha and ribavirin + lopinavir/ritonavir + interferon-alpha in patients with mild to moderate covid- showed that ribavirin plus lopinavir/ritonavir combination showed a significant increase in gastrointestinal adverse effects [ ] . the viral rnas get translated into polypeptide chains which get cleaved into functional proteins before packing into virions. the viral main proteases are responsible for the cleavage of these polypeptide chains [ ] . sars-cov protease has % overall similarity with sars-cov [ ] . protease inhibitors used in hiv- therapy are shown to be effective against sars-cov [ ] . in-silico and in-vitro approaches have been used to validate the inhibition of sars-cov protease by hiv- protease inhibitors [ , ] . numerous protease inhibitors are approved by fda for use in hiv therapy. the agents available from this class include saquinavir, amprenavir, indinavir, nelfinavir, ritonavir, and lopinavir. few of them are being considered against sars-cov (fig. ). this drug combination is available under brand name kaletra and was developed by abbott laboratories, usa. this drug was approved by fda in the year as an anti-retroviral for the treatment of hiv patients. lopinavir is rapidly degraded in the human body by the host proteases, hence is given with ritonavir (another protease inhibitor) at a lower dose, which helps lopinavir remain active for a longer time by inhibiting the metabolizing enzyme cytochrome p [ ] (table ) . coronavirus main proteases are cysteine proteases whereas hiv main proteases are aspartic proteases. nonspecific protease inhibition by protease inhibitors used in hiv therapy has been found effective against sars-cov. lopinavir has comparable binding energies against the sars-cov and hiv- proteases [ ] . in sars-cov patients treated with lopinavir-ritonavir, a significant virus clearance has been achieved [ , ] . a -year old patient, who failed to respond to methylprednisolone and interferon therapy, got quick improvement with additional lopinavir and ritonavir tablets therapy [ ] . in paediatric patients between the age of - years with confirmed covid- from three hospitals in zhejiang, china, use of lopinavir-ritonavir (syrup twice a day) along with interferon α to patients ( patients needed oxygen inhalation but not sure whether it included lopinavir-ritonavir group) showed a mean of hospital stay time of days and all were cured [ ] . based on these initial successful reports, sars-cov main protease has been docked for . billion protease inhibitor compounds [ ] . also, lopinavir-ritonavir has been included in solidarity trial (nct ). however, in a recent clinical trial with severely ill patients with confirmed sars-cov infections, lopinavirritonavir treatment did not improve the time to clinical improvement and mortality rate beyond standard care and further, some patients also showed adverse drug effects such as gastrointestinal disturbances [ ] . in a study on four covid- patients treated with western (lopinavir mg/ ritonavir in a ratio of mg to mg for q h through oral route), arbidol ( . g, three times in a day through oral route), and chinese traditional medicine shufeng jiedu capsule (sfjdc, . g, three times in a day through oral route) combination for - days, it has been observed that out of the two mild and two severe sars-cov -infected pneumonic patients, three patients showed significant improvement in pneumonia associated symptoms and the remaining patient with severe pneumonia has also shown signs of improvement till the date of reporting [ ] . most hiv protease inhibitors show poor bioavailability. they are extensively metabolized by microsomal cyp a enzymes. other agents that induce or inhibit these metabolizing enzymes influence their effectiveness. side effects associated with the use of protease inhibitors include diarrhea, vomiting, diabetes, hypertriglyceridemia, and hypercholesterolemia. it also could cause severe hepatic damage [ ] . therefore, a lot of clinical and experimental study regarding the use of lopinavir-ritonavir is required to reach a conclusive statement. the most common adverse effect of ritonavir/lopinavir is diarrhea and gastrointestinal disturbance. elevated liver enzymes, dyslipidemia, asthenia, headache and skin rashes are some minor side effects [ ] [ ] [ ] . ritonavir/lopinavir coadministration causes mild hepatotoxicity (elevated alanine aminotransferase, alt) [ ] . however, sole use of ritonavir at a higher dose ( mg/bid) may increase the risk of severe hepatotoxicity [ ] . a rarely observed adverse effect with ritonavir is retinal pigment epitheliopathy. the risk factors for the retinopathy are high dose and hepatic impairment [ ] . darunavir is a second-generation non-peptide protease inhibitor effective against hiv- . it has a distinct chemical structure that enhances binding affinity and reduces dissociation rate, making it more potent than the other protease inhibitors [ ] (table ). using computational drug design methods, darunavir was identified as one of the promising hits for inhibition of chymotrypsin-like protease of sars-cov [ ] . results of a structural analysis showed no binding of darunavir to sars-cov protease (https ://www.eacso ciety .org/home/covid - -and-hiv.html). anyhow, recently in shanghai, in-silico and an enzyme activity test based drug screening revealed agents with potential antiviral activity against sars-cov including darunavir (https ://www. simm.ac.cn/xwzx/kydt/ /t _ .html). interestingly, therapeutic doses of darunavir are reported to be too low to cause cytotoxic effects, affording a wide margin of safety [ ] . in an in-vitro study, darunavir at micromolar concentration was found to inhibit sars-cov virus replication by times in comparison to the untreated group (https ://www.sd.china news.com/ / / / .html). further, darunavir has been used ( mg tablet every h) along with other anti-viral drugs and supportive therapy in the clinical management of covid- patients presented with a range of mews from less than to more than in italy [ ] . darunavir is rapidly absorbed after oral administration and has a terminal elimination half-life of h. approximately % of the drug is plasma protein bound and metabolized exclusively by cyp a . therefore, co-administration of small doses of ritonavir (cyp a inhibitor) increases the bioavailability of darunavir. combination therapy with other cyp a inhibitors (e.g. statins) with darunavir/ritonavir requires caution or is even contraindicated [ , ] . a recent study correlated the daurnavir use with increased risk of myocardial infarction in hiv patients and concludes that cardiovascular disease (cvd) risk increases with darunavir exposure. therefore, it may be used cautiously in patients with underlying cardiac diseases [ ] . before, regular use of this drug, more pharmacological profile may further be investigated during the use in covid- patients. the pattern recognition receptors in immune cells recognize the viral pathogen-associated molecular pattern (pamps) to stimulate antiviral interferon responses in the host [ ] . the secreted interferons activate hundreds of interferon-stimulated genes which encode proteins with profound effects against the virus (fig. ) . the interferons (ifns) are antiviral molecules classified into type i (ifnα, ifnβ, ifnω, and ifnτ) and type ii (ifnγ). ifnα plays a critical role in innate immunity against viral infection which prompts its use in the treatment of many clinical viral infections. the recombinant ifnα is interferon alfacon- . the pegylated types are pegylated ifnα- a and pegylated ifnα- b [ ] . pegylated interferon alfa- b acts to target b cells through host interferon receptor, ifnar signalling and enhances immune response against viral infections [ ] . recombinant human ifnα- b has been shown to possess wide antiviral spectrum, low toxicity and high therapeutic index in vitro. quantitative reverse transcriptasepolymerase chain reaction (rt-pcr) results revealed antiviral effect of recombinant human ifnα- b on respiratory viruses such as influenza b virus, parainfluenza virus, respiratory syncytial virus and coronavirus which was stronger in comparison to the effect of ribavirin [ ] . in another study, ifnα- b administered by nasal spray reduced positive rates of immunoglobulin m (igm) antibody against all four respiratory viruses (parainfluenza virus, influenza b, adenovirus and respiratory syncytial virus) possibly suggesting the lower virus titre due to ifnα- b [ ] . in the rhesus macaque, ifnα- b with ribavirin showed very good effect against beta-coronavirus emerged in saudi [ ] , however, was unsatisfactory in humans [ ] . in china, intranasal ifnα ( × u) twice a day in combination with ribavirin is one of the guidelines for the treatment of covid- patients [ , ] . it was further showed that the infection rate of sars-cov was decreased by ifnα- b sprays [ ] . ifnα- b has demonstrated potent anti-viral activities against respiratory viruses and may serve for the prevention and treatment of sars-cov as well. nevertheless, thorough evaluation in appropriately designed randomized trials is recommended before forging on. peg-ifnα- b is a linear kda molecule and susceptible to hydrolysis. it is absorbed quickly and distributed widely. after administration peg-ifnα- b gets hydrolysed and the free ifnα- b circulates in the body. most of the free ifnα- b excreted solely through kidneys. therefore, it requires dose adjustment in patients with renal impairment. further, the clearance of peg-ifnα- b decreases after repeated dosing. therefore, it is administered according to body weight. conversely, the peg-ifnα - a is a kda branched chain molecule which is absorbed more slowly and has poor tissue distribution. peg-ifnα - a has long half-life. therefore, it is used at a fixed dose of μg per week for the treatment of hepatitis c virus infection. peg-ifnα- a is metabolized by both the kidneys and liver, therefore this drug does not require a major dose modification [ ] . number of adverse events was recorded with peg-ifnα therapy. dizziness, headache, depression, fatigue, insomnia, alopecia, myalgia, arthralgia, pyrexia, anorexia are the most common constitutional symptoms observed with peg-ifnα- a and peg-ifnα- b therapy in various other diseases. hematologic adverse events such as leucopoenia, thrombocytopenia and myelosuppression, thyroid disease, lung disease and retinopathy are the other adverse events recorded in the patients receiving peg-ifnα- a/ peg-ifnα- b [ ] [ ] [ ] . dose limiting, mild injection site reactions/inflammations were observed commonly in peg-ifnα - b therapy [ ] . most of the adverse events are well tolerated and become less severe during the progression of therapy. the neuropsychiatric adverse effects were observed in patients undergoing interferon-α therapy and may require timely medical interventions [ ] . in the case of severe events, discontinuation and dose reduction will help to overcome these adverse events [ ] . lopinavir-ritonavir along with interferon beta is undergoing clinical trial (miracle) against mers in saudi arabia wherein a total of patients have enrolled till jan [ ] . interferons are the antiviral weapons of the body and coronaviruses are known to reduce the host antiviral immunity by suppressing the production of interferons. so, replacement therapy with interferons or interferon inducers has the potential to reduce the viral load in the body. they augment the host response to the viral infection. lopinavir-ritonavir-interferon-β b treatment improved the clinical findings and lowered the lung viral load in mers-affected common marmosets [ ] . results of a recent clinical trial (nct ) on covid- patients showed the safety and efficacy of this combination. adverse events like selflimited nausea and diarrhoea were recorded in this study. however, there was no significant difference in the adverse effects between the combination group and ritonovir/lopinavir alone (control group) [ ] . the coronaviruses enter the cell by two ways, ( ) endocytosis, virus is taken up into the cell along with the endosomes, ( ) fusion of the viral spike protein with the cell surface receptor ace [ ] , the latter being the predominant pathway of virus entry [ ] . blockade of entry pathways may be effective targets for treatment (fig. ). chloroquine, primarily known for its anti-plasmodium actions, has antiviral activity as well. this drug originally derived from cinchona plant is now largely a synthetic drug ( -amino quinoline) discovered by bayer laboratories. chloroquine and its analogs are potent inhibitors of most coronaviruses [ ] (table ) . chloroquine and hydroxychloroquine are weak diprotic bases. these drugs take a similar pathway like the virus and concentrate in the endosomes increasing the ph of the endosomal fluid. the acidic ph of the endosomes is necessary for the optimal activity of viral enzymes responsible for proteolysis and post-translational modification of nascent proteins. disruption of acidic ph thus blocks the replication and lifecycle of the virus [ ] . in addition, the drug is known to interfere with the glycosylation of the host receptor for the virus, ace . faulty terminal glycosylation may affect the binding and subsequent entry of the virus into host cells [ ] . cell culture studies in african green monkey vero e cells indicate significantly higher potency for chloroquine compared to hydroxychloroquine [ ] . chloroquine has ec value of . μm against the sars-cov in vero e cells, which can be clinically achievable after administration of mg as shown in rheumatoid arthritis patients [ ] . a safe dosage of - . mg/kg per day of hydroxychloroquine could yield serum levels of . - . μm in humans [ ] . it is speculated that with a safe dosage, hydroxychloroquine could achieve concentration in the above tissues to inhibit sars-cov infection. hydroxychloroquine phosphate ( mg tablet every h as a loading dose followed mg tablet every h for days) or chloroquine phosphate ( mg of two tablet every h for days) along with other anti-viral drugs and supportive therapy have been used in the clinical management of covid- patients presented with a range of mews from less than to more than in italy [ ] . chloroquine and hydroxychloroquine have been considered for solidarity trial (nct ). hydroxychloroquine has shown side effects such as prolonged qt interval and heart failure, though controversy exists. recently, who stopped hydroxychloroquine arm of the solidarity trial to find an effective covid- treatment. this recommendation was developed on the basis of data obtained from solidarity trial (including the french discovery trial data and uk's recovery trial data). these trials showed that hydroxychloroquine did not result in the reduction of mortality of covid- patients who were hospitalized when compared with standard care (briefed on june by who). use of chloroquine for sars-cov asks for a high dose but an overdose of chloroquine has been reported to cause poisoning and death [ ] . in comparison, hydroxychloroquine is safer with % less toxicity in animals [ ] . oral absorption of chloroquine and hydroxychloroquine in humans is efficient. both the drugs distribute similarly in different tissues with high concentrations in the liver, kidney, lungs and spleen [ ] . chloroquine is two to three times as toxic in animals as hydroxychloroquine [ ] . the acute toxicity of chloroquine causes death due to cardiac and respiratory arrest [ ] . adverse effects of chloroquine/hydroxychloroquine therapy at the therapeutic doses include retinopathy, myopathy, electrocardiographic changes, bleaching of hair, pruritus, headaches, dizziness and gastrointestinal upset [ ] [ ] [ ] . hydroxychloroquine retinal toxicity in the patients is far more common in patients taking this drug for greater than years with the overall prevalence of . % [ ] . a study showed even with the recommended therapeutic dose of hydroxychloroquine produced bilateral maculopathy and it was attributed to the differential susceptibility of the retinal epithelium to hydroxychloroquine [ ] . hydroxychloroquine and chloroquine are orally well absorbed and show - % oral bioavailability. chloroquine is % bound to plasma proteins and distributed extensively. following administration, chloroquine is rapidly dealkylated to pharmacologically active desethylchloroquine and bisdesethylchloroquine. metabolism of hydroxychloroquine is similar to chloroquine except for a third metabolite desethylhydroxychloroquine which is also produced during metabolism. both hydroxychloroquine and chloroquine have prolonged half-lives, between and days, and low blood clearance by kidneys and liver. for both chloroquine and hydroxychloroquine, approximately - % is excreted as an unchanged or metabolized drug through the kidneys, - % is excreted in an unchanged or changed form in the feces, % is sloughed off through the skin, and - % is stored long term in lean body tissues [ ] [ ] [ ] [ ] . hydroxychloroquine should be cautiously used in patients with known hepatic or renal dysfunction. the co-administered drugs with hydroxychloroquine excreted via liver/ kidney may interact with hydroxychloroquine and modulates its pharmacokinetics and toxicity. hydroxychloroquine has been reported to cause severe hypoglycaemia when coadministered with oral hypoglycaemic drugs. there have been few reports of mild to severe hepatic failure in patients with hydroxychloroquine treatment [ ] . racial difference in toxicity has also been reported wherein the incidence of pericentral maculopathy was common in asian ( %) than caucasian ( %) patients [ ] . further, the use of chloroquine and hydroxychloroquine may be warranted in prophylaxis strategy as well as in covid- patients with more number of clinical trials. arbidol, an indole-derivative, also known as umifenovir is a potent broad-spectrum antiviral agent. this drug has shown activity against a wide range of enveloped and nonenveloped viruses [ ] (table ) . it is effective against numerous pathogenic respiratory viruses and relatively very safe for use [ , ] . arbidol is an approved therapeutic agent against influenza in russia and china [ ] . arbidol and arbidol mesylate were reported to act directly on viral replication of sars-cov at an early stage in vitro [ , ] . the anti-viral mechanism of arbidol against influenza a and b involves viral fusion inhibition by hindering the hemagglutinin fusion machinery with the membrane, thus blocks virus entry into the cell [ ] . arbidol is one of the drugs in clinical trial phase for pharmaceutical interventions of covid- and treatment of covid- patients with arbidol leads to a reduction in the mortality rate and increase in the recovery rate [ , ] . arbidol treatment coupled with lopinavir/ritonavir reckoned to retard the development of pulmonary lesions concurrently reducing the respiratory and gastrointestinal covid- viral load thus lowering the transmission [ ] . encouragingly, seasonal prophylaxis with arbidol reduced influenza morbidity in patients with asthma and copd during epidemic [ ] . four cases with mild to severe sars-cov pulmonary symptoms were subjected to antiviral therapy consisting of arbidol, lopinavir/ritonavir, and shufeng jiedu (traditional chinese medicine) along with supportive care. following medication, three patients showed a notable reduction in pneumonia-related manifestations and two of them were discharged after testing negative for sars-cov [ ] . in covid- patients, reduction in fever and cough; improvement in chest computed tomography (ct) and clinical status among the arbidol, lopinavir/ritonavir and control group remained statistically indifferent. however, arbidol was better tolerated by patients whereas test subjects administered with lopinavir/ritonavir experienced adverse events during the follow-up period [ ] . the half-life of arbidol is between and h and % of the total drug excreted unchanged in feces. arbdiol conjugation with glucuronide and sulfonation is evident. the major phase i enzyme involved in its metabolism was cyp a , therefore, a possible interaction with cyp a inducers/ inhibitors may happen [ ] . the drug has oral lethal dose (ld s) of - mg/kg in mice, and > mg/kg in rats and guinea pigs. intravenous ld s are mg/kg in mice and mg/kg in rats. in long term animal studies, it showed no adverse effects with - times of human dose and no developmental toxicities were observed [ ] . it has been noticed that sars-cov binds the ace receptors similar to the sars coronavirus [ ] . covid- is associated with the acute respiratory distress syndrome (ards) and higher activity of ace leads to attenuation in ards [ , ] . ace expression is downregulated in covid- patients [ ] . it is a general observation throughout the world that aged persons affected with covid- suffer from high mortality. association between covid- infection and the process of chronological aging has been understood with the presence of two host receptors cd and ace which are associated with senescence. the major pathway of virus entry into the host in case of sars-cov and sars-cov is through the target cell ace . spike proteins of the virus attach to the cell surface ace expressed in epithelial cells of the oral mucosa, lungs, intestine, blood vessels and kidney. angiotensin receptor blockers (arbs) which inhibit the action of ace, an isoform of ace , are known to increase the expression of ace [ ] (fig. ; table ). the patients with diabetes and cardiovascular diseases regularly take ace inhibitors and arbs. hence, they remain under continuous risk of sars-cov infection. however, experimental studies with ards indicate a higher level of ace reduces the severity of the disease [ ] . increased ace /ace ratio may improve the host response to viral infection by correcting the endothelial dysfunction common to most viral infections [ ] . experimental and clinical studies are needed urgently on this aspect for repurposing of commonly used arbs or ace inhibitors (aceis). arbs are well-tolerated drugs with minimal side effects in the population. however, a lot of patients from south america, central america and spain, had stopped or intended to interrupt their treatments with anti-hypertensive drugs like aceis such as enalapril or arbs such as losartan fearing the risk of sars-cov infection [ ] . however, another school of thought provided alternative suggestions about the use of renin-angiotensin-aldosterone system (raas) inhibitors. they suggested that though ace expression may be enhanced with the use of raas inhibitors, sudden withdrawal of these drugs may be responsible for higher risk in patients of covid- already affected with cardiovascular illnesses. therefore, the use of raas inhibitors should continue in patients with covid- under continuous observation [ , ] . out of covid- patients taking antihypertensive drugs, patients who were treated with aceis/arbs showed less mortality in comparison to patients taking drugs other than aceis/arbs in shenzhen third people's hospital, china [ ] . aceis and arbs may improve the clinical condition of the covid- patients in a clinical setting by maintaining a low level of il- level in peripheral blood and through increment in a cluster of differentiation cd and cd t cell counts in peripheral blood and decreased the peak viral load [ ] . contrary to the previous report, another retrospective study from the union hospital of wuhan, china done on patients suggested that acei/arbs medication has no difference in the critical group and general group and further, did not show any effect on the morbidity and mortality of covid- patients associated with cardiovascular diseases [ ] . it is reported that ace inhibits the formation of ang ii in the presence of aceis; therefore, these prevent the negative effects induced due to at r as well as positive effects derived from the ang ii binding with at r and further, its transformation into ang-( - ) [ ] . therefore, it could be assumed that the use of aceis leads to the protective effects in the lung in covid- patients. angiotensin receptor blockers are the most commonly used drugs for hypertension and related cardiac problems. in general, aceis and arbs have few interactions with ritonavir [ , ] . generally, arbs are well tolerated and the frequency of adverse reactions is less than %. there are no specific considerations for use in patients with hepatic and renal impairment [ ] . arbs are structurally related to losartan (except eprosartan) but the individual members exhibit diverse pharmacokinetic properties. their bioavailabilities vary from - % and half-lives are between and h. they are highly plasma protein bound ( - %) and mostly metabolized and eliminated by the liver and, therefore, can be safely used in mild to moderate renal failure without any dose adjustment. however, losartan should be started with a lower dose in hepatic impairment and telmisartan should be avoided in case of renal impairment and congestive heart failure/digoxin therapy [ , ] . statins, the lipid-lowering drugs, have shown pleiotropic activity through anti-inflammatory and immunomodulatory properties to prevent acute lung injury in different experimental and clinical conditions; therefore, it may be used as re-tasking drug for the covid- patients [ ] (table ) . statins are commonly taken for a lifetime to prevent coronary artery diseases. studies have reported that these drugs increase the ace expression [ ] . ace cleaves ang ii, a peptide which promotes endothelial dysfunction and cardiovascular diseases, and produces ang-( - ) which counters the effects of ang ii [ ] . stimulation of ace /angiotensin-( - )/mas and angiopoietin/tie- signaling axes help restoring viral infection-induced endothelial dysfunction and maintain the homeostasis of the patients [ ] . ace activity has shown to be up-regulated with the use of arbs and atorvastatin [ , ] (fig. ) . statins being immunomodulatory have been hypothesized to work against mers coronaviruses [ ] . however, in animal models of sars and mers infections, reduced expression of the adapters, tirdomain-containing adapter-inducing interferon-β (trif) or myeloid differentiation primary response protein (myd) causes severe respiratory disease leading to death. hence, the use of statins, which can further suppress myd signaling, may exacerbate the disease condition [ ] . fungus derived statins (lovastatin, pravastatin and simvastatin) have elimination half-lives of - h and other synthetic compounds have elimination half-lives ranging from h for fluvastatin to h for rosuvastatin. bioavailability of statins varies from - % and - % of the absorbed statins. majority of satins are metabolized by the liver and the biliary excretion is the predominant route of excretion. pravastaitn and rosuvastatin are excreted mostly unchanged by liver and kidneys. all statins are extensively bound to plasma proteins (> %) with the exception to pravastatin which is only % bound to plasma proteins [ ] . myopathy and rhabdomyolysis are the most frequent adverse effect of statins. other common adverse effects include hepatotoxicity, peripheral neuropathy, cardiac toxicity, cognitive dysfunction, cataracts, diabetes mellitus and autoimmune necrotizing myopathy [ , ] . most of the statins are cyp a substrates and the inhibitors of this enzyme may increase blood levels of statins and therefore associated with adverse effects [ ] . statins have potential interactions with the protease inhibitor drugs and they are contraindicated in combination therapy [ ] . usfda warns using atorvastatin, lovastain, rosuvsatin, pravstatin, simvastatin with antiviral protease inhibitor drugs (for list please see https ://www.fda.gov/drugs /drug-safet y-and-avail abili ty/fda-drug-safet y-commu nicat ion-inter actio ns-betwe en-certa in-hiv-or-hepat itis-c-drugs -and-chole stero l#dose). in this case dose reduction and therapeutic drug monitoring will reduce the occurrence of adverse effects. tocilizumab is a drug used against rheumatoid arthritis as well as cytokine release syndrome/systemic inflammatory response syndrome. this drug was introduced in japan in the year and subsequently in the european union (trade name roactemra) in the year . later in the year , it was used in the usa (actemra) and this drug is an antihuman monoclonal antibody of the immunoglobulin g k subclass [ ] . this drug does not act on the virus but it acts to reduce the cytokine response of the host. tocilizumab is a recombinant humanized monoclonal antibody which is responsible to bind the human il- receptor and inhibiting its signal transduction pathway [ ] (fig. ) . a -year old man of wuhan, china developed symptoms of chest tightness without fever and cough on st february and confirmed to be the first case of covid- with multiple myeloma. the case was successfully treated with humanized anti-il- receptor antibody, tocilizumab. the patient was administered mg/kg tocilizumab through iv route for one time from day to day upon hospital admission and a decrease in il- level was recorded, however, a rebound phenomenon of il- level was observed, may be due to the recovery of the normal t cells and the patient was cured on day . the patient, however, had also received other therapies like mg dose of umifenovir (arbidol) tablets orally for three times daily as antiviral treatment and mg of moxifloxacin iv daily for three days [ ] . however, in another years old covid- patient of end-stage renal disease (esrd) in the usa treated with tocilizumab, hydroxychloroquine and broad spectrum antibiotics, the patient remained in critical condition throughout the study period [ ] . a years old woman from switzerland suffering from systemic sclerosis (ssc) was on tocilizumab treatment for arthritis and ssc-associated interstitial lung disease (ssc-ild) @ mg/kg body weight every weeks intravenously. on the basis of observation it has been reported that tocilizumab treatment given for chronic autoimmune diseases may prevent the development of severe covid- [ ] . a case of years old patient with a respiratory failure linked to covid- from france showed a rapid favourable outcome after two infusions of the tocilizumab at a dose rate of mg/kg through intravenous route along with other therapy like lopinavir-ritonavir [ ] . tocilizumab treatment in of the patients showed improvement in terms of oxygen intake, lung lesion opacity (in patients), lymphocytes in peripheral blood ( patients), c-reactive protein ( patients) and further, all patients were discharged on average . d after giving tocilizumab in a study conducted in china between and february [ ] . a study on covid- patients with severe pneumonia treated with tocilizumab and other supportive therapy from - march in italy, the respiratory condition was improved or stabilized in patients in days. of these patients had shown clearing of diffuse bilateral opacities on chest x-ray and were discharged from the hospital; however, respiratory condition of patients was worse during the treatment and died out of patients [ ] . in another clinical study, tocilizumab administration showed a reduction in serum il- level in patients out of patients, however, it could not decrease il- level in four patients. still, observations suggest that tocilizumab is a good treatment option in patients who have a risk of cytokine storms [ ] . however, it is difficult to reach on a conclusion regarding the use of tocilizumab in covid- patients with the limited number of clinical sample size. the absolute bioavailability of tocilizumab following subcutaneous administration was estimated to be . % [ ] . tocilizumab is eliminated from the body in a concentrationdependent manner. therefore, its half-life is directly proportional to its serum concentration. at higher serum concentration, it shows linear elimination and has the terminal half-life of . days (https ://www.acces sdata .fda.gov/drugs atfda _docs/label / / s , s lbl.pdf). the notable adverse effect of tocilizumab is liver toxicity. steatosis, steatohepatitis and focal hepatocellular necrosis were seen in this drug-induced hepatotoxicity. other common adverse reactions observed were skin and soft tissue infections, dyslipidemia, transient neutropenia, headache, nausea and flu-like symptoms. therefore, a full assessment for liver injury and dose adjustment is required in patients administered with tocilizumab [ , ] . tocilizumab also showed good efficacy in long term dosing for rheumatoid arthritis with similar adverse reactions and few malignancies also were reported [ ] . in a recent study, it has been demonstrated that an antiprotozoal agent nitazoxanide has shown antiviral activity against a number of viruses which include human and animal coronaviruses. it is used orally and chemically, this drug is nitrothiazoly-salicylamide, a broad-spectrum anthelmintic and antiviral prodrug which is metabolized to an active compound tizoxanide [ , ] (table ). it had shown inhibitory potential against sars-cov at a low-concentration with % effective concentration of . μm in vero e cells. it has been observed that antiviral activity of this compound may be due to interference with host-regulated pathways which are involved in viral replication rather than virus-specific pathways [ , ] . nafamostat is an anticoagulant in nature and further, its activity was also evaluated in the vero e cells infected with sars-cov . this drug is a synthetic serine protease inhibitor and inhibited the sars-cov at % effective concentration of . μm in vero e cells. further, it is speculated that it may act through the inhibition of membrane fusion by reducing the release of cathepsin b. as this agent has previously shown potential against the mers-cov through prevention of membrane fusion, it could also be recommended for further in-vivo evaluation against covid- [ ] (fig. ; table ). ivermectin is a broad-spectrum anti-parasitic agent and has also shown efficacy against some viral infections. this drug is basically a macrolide endectocide macrocyclic lactone derived from streptomyces avermitilis with anthelmintic activity (table ) . recently, this drug has been investigated against sars-cov in in-vitro cell culture system in australia. it reduced the viral rna of sars-cov at two hours post infection in vero-hslam cells with the addition of single dose and its reduction intensity was approximately -fold. this study hypothesized that ivermectin may act through inhibition of importin (imp) α/β -mediated nuclear import of viral proteins similar to other rna viruses, however; further investigation is required to understand the precise mechanism of action in sars-cov [ ] . it is also important to conduct the trials in in-vivo animal models and further, the pre-clinical trials in human beings are also required with fast pace if in-vivo models results have potential to mitigate the covid- infection (fig. ) . cepharanthine, a naturally occurring plant alkaloid, is an anti-inflammatory and anti-neoplastic and is approved for leukopenia treatment (table ). cepharanthine showed the most potent inhibition of gx_p v infection and decreased the viral rna yield in the pangolin coronavirus gx_p v workable model, therefore, this therapeutic agent may also be a potential candidate for repurposing against covid- [ ] . further, it has been speculated that this drug may target host cell pathways [ ] . a gold-containing triethyl phosphine coated drug, auranofin, is used as therapy for the arthritis and approved from fda for this treatment (table ) . previously, this drug has shown effects against viral, bacterial and parasitic infections. recently, auranofin has shown inhibitory effect against viral rna in huh cells infected with sars- cov fig. overview of the drugs with potential for repurposing against covid- . the drugs being considered for primary therapy of covid either acts on targets of the virus or on the targets of the host as well as a reduction in proinflammatory cytokines in an in-vitro study [ ] . endoplasmic reticulum (er) stress and unfolded protein response (upr) activation are responsible for the viral replication and pathogenesis in coronavirus infection [ , ] and high levels of upr activation has been recorded in the cells which have higher expression of sars-cov spike protein [ , , ] . therefore, it is speculated that auranofin may act through the inhibition of redox enzymes such as thioredoxin reductase and induction of er stress, however, its confirmatory investigation is required [ , ] . janus kinase inhibitors have anti-inflammatory and antiviral effects and may have a purported advantage over other immunomodulatory strategies in covid- [ ] . jak / inhibitor ruxolitinib, baricitinib, jak / inhibitor tofacitinib and pan-jak inhibitor td- are presently under different phases of clinical trial and being investigated for covid- treatment (https ://www.pharm aceut ical-techn ology .com/comme nt/incyt e-eli-lilly -jak-inhib itor-covid - /). a phase-i clinical study showed improvement in covid- inflammation score with clinical improvement by ruxolitinib. however, it has toxicity on the liver and hematopoietic system. but in this study with the short term dosage, it did not show any major adverse events [ ] . baricitinib is presently under phase-iii clinical trial (https ://www.clini caltr ialsa rena.com/news/lilly -baric itini b-covid - -trial /). initial studies showed the drug baricitinib corrected the immune dysregulation and improved clinical disease outcome with no serious adverse events [ , ] . all the above drugs are under different phases of clinical trials and none have been approved for the treatment of covid- . dexamethasone is a corticosteroid and it has been used in some clinical trials. the preliminary results of recovery trial conducted in patients showed dexamethasone @ mg once daily for up to days showed improvement in recovery with . % mortality in the dexamethasone group compared to the . % mortality in the usual care group [ ] . however, few concerns have been raised on recov-ery trial outcome in choosing the correct steroid and dose. in another study, methylprednisolone reduced the mortality rates in covid- patients with ards. further, the effect of dexamethasone in geriatric patients and effects on viral load are not mentioned in the recovery trial [ ] . theoharides and conti have also suggested restricting the use of dexamethasone during the initial phase of disease in severely ill patients for shorter period. using this drug in recovery phase may lead to reduced viral clearance and nosocomial infections [ ] . as it suppresses immunity and it may aggravate some latent infections whose occurrence is of no importance to the developed countries. therefore, region-specific study is required before incorporating into covid- therapy [ ] . a chemotherapeutic fluoroquinolone antibiotic, prulifloxacin, with broad-spectrum activity, and some anti-hiv drugs such as tegobuvir, (a novel non-nucleoside inhibitor of human coronavirus rna replication), nelfinavir (a protease inhibitor which inhibits the cleavage of the polyprotein gag-pol) and bictegravir (hiv- integrase inhibitor) have protein binding sites of the proteases which have been shown using the high throughput screening as molecular docking with bioinformatics analysis and would be considered the potential candidates for re-tasking against covid- in future [ ] and in-vitro and in-vivo animal models may provide a lead against this disease. according to another recent molecular docking study based on rdrp modelling and multiple sequence alignment (msa) showed a binding capacity to rdrp against sars-cov by various antiviral agents such as sofosbuvir (fda approved against hepatitis c virus), ribavirin, remdesivir and idx- ; (under clinical trial against hepatitis c virus) [ ] . elbasvir, an antiviral drug, (approved for the treatment of hepatitis c) has shown predicted multiple binding sites at rdrp, papain-like proteinase and helicase of sars-cov using the docking simulations and computational modelling [ ] (fig. ; table ). in a recent review, it has been stated that azithromycin, quercetin, rapamycin and doxycycline may have senolytic activity and azithromycin and doxycycline are used to inhibit viral replication and il- production, therefore, these therapeutic agents may be potential re-tasking agents against covid- in future with proof of sufficient invitro and in-vivo studies [ ] (fig. ; table ). peptide (ek ), tdf, tc (rna synthesis inhibitors), shufeng jiedu and lianhuaqingwen capsules (chinese traditional medicine) are screened using standard bioassays, chemical screening and genome and biophysical understanding of the targeted virus for being the potential drug candidates against sars-cov infection as described in a recent review. however, the efficacy and safety of these drugs for sars-cov still need to be further confirmed by clinical experiments [ ] (fig. ) . covid- is a pandemic and has no treatment till date including vaccine and drugs. however, there are number of available drugs with approval of fda for treatment of other diseases which could be used on the basis of the trial against covid- and considered as the repurposed drugs. these are antivirals, antimalarials, aceis, arbs, statins and monoclonal antibodies. it has been noticed that remdesivir, favipiravir, ribavirin, lopinavir-ritonavir combination, arbidol, tocilizumab have shown benefits in various clinical studies done on the basis of compassionate use to save the life of covid- patients; therefore, in future, these drugs could be the potential drug therapy against this deadly disease. however, the use of chloroquine and hydroxychloroquine has shown the controversial results in the different trials, therefore, who also stopped their solidarity trials recently. in future, chloroquine and hydroxychloroquine require a large number of research studies to reach a conclusion for its use in covid- patients. further, aceis and arbs could be the potential supportive therapy against this infection. some drugs are in the early phase of investigation like ivermectin and auranofin to be used against the covid- and these agents could be potential therapeutic agents in future. molecular docking would be the central technique to identify the probable therapeutic agents 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treatment date: - - journal: front environ sci eng doi: . /s - - - sha: doc_id: cord_uid: r a vxl chromium (cr) typically exists in either trivalent and hexavalent oxidation states in drinking water, i.e., cr(iii) and cr(vi), with cr(vi) of particular concern in recent years due to its high toxicity and new regulatory standards. this account presented a critical analysis of the sources and occurrence of cr(vi) in drinking water in the united states, analyzed the equilibrium chemistry of cr(vi) species, summarized important redox reaction relevant to the fate of cr(vi) in drinking water, and critically reviewed emerging cr(vi) treatment technologies. there is a wide occurrence of cr(vi) in us source drinking water, with a strong dependence on groundwater sources, mainly due to naturally weathering of chromium-containing aquifers. challenges regarding traditional cr(vi) treatment include chemical cost, generation of secondary waste and inadvertent re-generation of cr(vi) after treatment. to overcome these challenges, reductive cr(vi) treatment technologies based on the application of stannous tin or electron-releasing titanium dioxide photocatalyst hold extreme promise in the future. to moving forward in the right direction, three key questions need further exploration for the technology implementation, including effective management of residual waste, minimizing the risks of cr(vi) re-occurrence downstream of drinking water treatment plant, and promote the socioeconomic drivers for cr(vi) control in the future. • wide occurrence of cr(vi) in us source drinking water. • a strong dependence of occurrence on groundwater sources. • elucidate redox and equilibrium chemistry of cr (vi). • sn(ii)-based and tio -based reductive treatments hold extreme promise. • key challenges include residual waste, cr(vi) regeneration and socioeconomic drivers. the future. exposure to cr(vi) through respiratory, oral and dermal pathways induces cancers and other terminal illnesses. chromium mainly existing as hexavalent cr (vi) and trivalent cr(iii) are the two stable forms in the aquatic environment. at circumneutral phs, cr(vi) exists as an oxyanion, i.e., chromate cro -, whereas cr(iii) exists as different low-soluble solids depending on the coexisting constituents such as hydroxide, iron and copper. cr(iii) is considered non-toxic, a micro-nutrient in mammalian diets and aids in the metabolism of glucose and lipids. both anthropogenic activity and natural occurrence lead to cr(vi) in the aquatic environment, and natural occurrence plays a more substantial contribution. the occurrence of cr(vi) in the aquatic environment was historically driven by anthropogenic release from chemical and manufacturing industries, including paints, pigments, paper, electroplating and leather tanning (jacobs and testa, ) . one notable example is the disastrous cr(vi) release from an industrial site in hinkley, calif. between s and s , which garnered an international attention four decades later through the blockbuster oscar-winning movie erin broachvich (izbicki and groover, ) . however, as the manufacturing industry sets more stringent standards on wastewater treatment in recent decades, the contribution of industrial wastewater discharge to cr(vi) occurrence becomes less of a routine concern. in contrast, natural release of cr(vi) driven by geochemical sources makes a more substantial contribution to the wide occurrence of cr(vi) in drinking water (coyte et al., ; oze et al., ; vengosh et al., ) . one major source of natural-occurring cr(vi) is from groundwater and aquifer materials. chromium is widely embedded in aquifer minerals as the st most abundant element in the earth's crust (oze et al., ) . the naturally geological weathering of aquifer materials releases cr(vi) via a slow oxidation of cr(iii)-containing iron minerals fe x cr ( -x) (oh) (s) in the aquifer by co-existing manganese (iv) minerals (eary and rai, ; pan et al., ) : where x is the molar fraction of chromium in the mixed phase of iron-chromium hydroxide solid, and its value varies between and . an analysis of a recent us epa database on chromium -unregulated contaminant monitoring rule round (ucmr ) showed that hexavalent chromium is widely present in drinking water sources across the us . drinking water systems using groundwater as the main source water report much higher percentages of cr(vi) occurrence than those using surface water as the main source, especially for cases with elevated levels of cr (vi) higher than µg/l (fig. a) . this dependence clearly indicates the strong influence of naturally geological weathering process in the natural occurrence of cr(vi) in source waters, which preferentially impacts groundwater sources. furthermore, chromium accumulated in urban drinking water infrastructure, namely the drinking water distribution systems risks to become another geochemical source of hexavalent chromium. recent surveys have discovered that chromium accumulates in the corrosion scales of drinking water distribution systems. the level of chromium observed in the corrosion scales has exceeded the level observed in earth crust (peng et al., ) . under oxidative conditions in drinking water and in scenarios with abrupt changes of source water and associated water chemistry, the accumulated chromium can release back into drinking water and increased cr(vi) level at the tap. for example, an analysis of the us epa ucmr database showed that the hexavalent chromium level at the exit point of the drinking water distribution systems was statistically higher than the level at the entrance to the distribution system . a synthesis of the database also showed that a considerable percentage of public water utilities in the us detects cr(vi) at the exist point to the drinking water distribution systems, range from sub-µg/l to higher than µg/l (fig. b) . us epa currently regulates total chromium, i.e., a combination of cr(iii) and cr(vi), at µg/l in treated drinking water. a new standard specifically for cr(vi) was established at µg/l in california in but was subsequently withdrawn (us epa, ) . considering the public health risks of cr(vi) and a tightening regulatory perspective in the future, it is urgent and important to understand chromium chemistry that drives cr(vi) occurrence in drinking water, and develop efficient treatment technologies to minimize risks. because cr(vi) is redox reactive, its redox chemistry drives the fate of cr(vi) in drinking water, and dictates the development of effective treatment processes. consequently, it is imperative to examine the redox chemistry of chromium in typical drinking water conditions. from a chemical speciation perspective, cr(vi) can undergo protonation and bimolecular combination via chronic acid h cro , and exists in different soluble species depending on the solution ph (fig. ) . within the typical ph range of drinking water, i.e., neutral to slightly basic (ph of - ), cr(vi) predominately exists as the deprotonated oxyanion chromate cro -, the protonated hcro only accounts for a small fraction, and other soluble species including cr o are negligible. in contrast, trivalent cr(iii) exists as different solid phases with a low low solubility in typical drinking water chemical conditions. for example, various cr(iii) minerals exist in corrosion products in drinking water distribution systems liu, , ; choi et al., ) . the redox potential of these cr(iii) solids coupled with cro ranged between - . and . v in typical drinking water chemical condition (fig. ) . meanwhile, common disinfectants used in drinking water, e.g., free chlorine (hocl), possess a higher redox potential (e = . v) than any of the cro -/cr(iii) solid couple; therefore, chlorine can oxidize cr(iii) and affect the mobility of cr in drinking water liu, , ) . taking cr(oh) (s) as an example: the reactions of cr(iii) solids oxidation by free chlorine residuals can take place in drinking water distribution systems, as supported by statistical analysis of epa ucmr database. the accumulation of even non-toxic cr(iii) in water distribution systems may be inadvertently converted to cr(vi) by residual chlorine in the distribution systems. this transformation could seriously jeopardize the benefits of upstream treatment. meanwhile, several reductants exists a redox potential lowered than that of cr(vi)/cr(iii) couple and can serve as a reductive reagent to convert toxic cr(vi) to benign cr (iii) end products. for example, ferrous ion with the fe (oh) (s) /fe + redox couple has a redox potential of . v, and divalent tin sn(ii) with the sno (s) /sn + redox couple also has a very low redox potential of - . v in typical drinking water conditions (fig. ) . these reductants provides possibilities for reductive treatment of cr(vi) in drinking water. cr(vi) drinking water treatment technologies . traditional drinking water treatment technologies traditional cr(vi) treatment technologies that have been applied at full scale drinking water treatment plants include ion exchange and ferrous iron fe(ii)-based reduction coagulation (seidel et al., ) . the treatment principle of ion exchange is based on the physical separation of cr(vi) anions using quaternary amino functionalized ion exchange resins, and has been employed in small drinking water treatment systemsmostly groundwater based systems. the handling and disposal of concentrated cr (vi)-containing ion exchange brine is very challenging and costly, which hinders the wide application of ion exchange to large-scale drinking water treatment. in addition, the application of effective ion exchange treatment needs to avoid the competitive exchange in co-existing anion in the source drinking water sources, including sulfate, nitrate, arsenic and radioactive uranium, which can potentially decrease the cr(vi) treatment efficiency or increases the operational complexity (plummer et al., ) . fe(ii)-based reductive cr(vi) removal is another existing technology that has been applied at pilot-scale for cr (vi) drinking water treatment in california (blute et al., ) . this process applies ferrous chloride as a reductant to convert cr(vi) to non-toxic cr(iii) particles, followed by a coagulation step to promote the formation of cr(iii) and fe(iii) particles, and a final filtration step to remove the particles, therefore achieving a total chromium removal. this technology is proven viable at full-scale; however, it also brings operational challenges to deal with, including a long treatment time, high chemical dosage requirement and large secondary solid waste. for example, to ensure a complete conversion of cr(vi) to cr(iii) particles via fe(ii) reduction, this process requires a large over-stoichiometric molar ratio of fe(ii)-to-cr(vi) (between and ) to achieve a desirable reaction kinetics in a continuous treatment mode. the long reaction time for reductive reaction requires min or more. in addition, the over-stoichiometric dosage of fe(ii) requires a subsequent re-oxidation stepachieved by either aeration or chlorinationto convert residual fe(ii) to fe (iii) particles prior to filtration step. this results in the formation of a large quantity of iron sludge waste that is operationally complicated to handle (seidel et al., ) . redox-driven cr(vi) treatment technologies are more promising and cost-effective than physical separation technologies (for example, ion exchange), because cr (vi) is chemically reduced to non-toxic cr(iii) solids in the presence of a reductant and subsequently removed as cr (iii) particles, eliminating the need for additional brine disposal (eary and rai, ) . the challenges to overcome for a full-scale application in drinking water treatment include operational complexity, high chemical dosage requirement and secondary waste generation. to overcome the disadvantages of over-stoichiometric addition of chemicals and secondary waste generation, a new chemical reductive treatment has recently been developed based on divalent tin sn(ii) addition as the chemical of stannous chloride sncl . the following redox reaction takes place (henrie et al., ; kennedy et al., ) : upon the completion of reaction, divalent tin is oxidized to tetravalent tin solid sno (s) and removed together with cr(iii) solids by a filtration unit. compared to fe(ii), using sn(ii) as the reductant is advantageous in multi-fold. first, the reaction kinetics between sn(ii) and cr(vi) is extremely fast, i.e., reaction in typical drinking water condition typically completes within seconds, whereas the reaction kinetics between fe(ii) and cr(vi) is much slower and takes more than min to completion. this inherent advantage of fast reaction kinetics enhanced the easiness of continuous sn(ii)-based treatment operation. second, stannous addition requires a much lower stoichiometric molar ratio of sn(ii)-to-cr(vi) compared to fe(ii)-to-cr (vi) in ferrous-based approach ( - vs. - ). therefore, the formation of solid residual waste is minimized and the secondary waste generation is not a concern when sn(ii) is employed as the reductant. due to the small amount of solid formation as the end product, additional coagulation and flocculation are not required. instead, a simple treatment step utilizing cartridge filtration or porous- medium sand filtration typically follows the addition of sn (ii) to remove residual particles (fig. a) . for example, a pilot-testing conducted in coachella valley, calif. showed that the cost of sn(ii) reductive treatment would substantially decrease capital and operation/maintenance costs, as well as minimizing waste residuals, compared to fe(ii) reductive treatment. third, residual tin in the treated drinking water acts as a corrosion inhibitor and benefits drinking water distribution systems. a recent study has demonstrated that residual tin is sequestered in the corrosion scales of distribution systems. cr(iii) solidsthe end products of sn(ii) reductive treatmentalso exhibited a low risk in re-oxidation to cr(vi) when the treated drinking water enters a distribution system in the presence of chlorine as the residual disinfectant. another promising reductive treatment technology harnesses electrons as a strong reductant for cr(vi) removal via photocatalysis. differing from other chemical reductive treatment technologies, photocatalytic reduction does not require consumable chemicals, and converts photon energy to reactive electrons via catalysts to drive the reduction of cr(vi) to cr(iii). titanium dioxide (tio ) photocatalysts are popular materials because of its high stability, low toxicity, low cost, large surface areas and good optical properties (loeb et al., ) . upon uv irradiation by photons with energy equal or greater than its bandgap, tio undergoes a hole-electron separation process, generated holes on the valence band (vb) and electrons on the conduction band (cb), and induces reductive conversion of cr(vi) when electrons migrate to the surface of tio catalyst (fig. a) . thermodynamically, cb-associated electrons (e = - . v) can be utilized to reduce cr(vi) to cr(iii). however, with conventional tio (e.g., commercial p tio ), the holes on the valence band quickly oxidize surface adsorbed h o to hydroxyl radicals (ho ) and creates a highly oxidative environmental that is detrimental to reductive cr(vi) treatment. in addition, the migration of the electrons takes random pathway, which make it a high probability for electrons to recombine with holes, and interfacial electron transfer is much slower than holeelectron recombination rate and interfacial hole transfer. these facts make electrons from conventional tio materials unavailable for cr(vi) reduction. to fully utilize photogenerated electrons and make tio reductively reactive, polyol molecules as hole scavengers are applied to covalently bond onto the tio surface via bridged o atoms is a promising strategy (fig. b ). this surface modification can be realized simply via thermal hydrolysis, which induces the occupied energy state inside the tio band gap, and significantly improve the hole trapping efficiency (chen et al., ) . polyols reacts with holes, prevents ho generation and effectively releases electrons for cr(vi) reduction. a recent study has shown that using diethylene glycol (deg) as the polyol molecule, the surface modified tio photocatalyst exhibited a much faster kinetics on reductive cr(vi) conversion in comparison to the non-reactive conventional tio material (chen et al., ) . the tio -based photocatalytic cr(vi) treatment process is also cost-effective and safe. conventional tio photocatalysts such as degussa p @ is widely available, and food-grade tio has been frequently used as a pigment for food production. these low-cost traditional tio materials can undergo a simple surface fabrication with polyols and convert into reductive tio tailored for cr(vi) treatment. in addition, the modified tio can be recycled for multiple rounds of treatment without losing its reductive capacity. pilot-scale photocatalytic water treatment reactors are already available in the market (e.g., photocat system @ ) and a full-scale application is possible. both sn(ii)-based and photocatalytic reductive cr(vi) treatments hold extreme promise as well as challenges in the future. future research focused on solving these challenges is necessary. to moving forward in the right direction to minimize the occurrence of chromium in drinking water, the following three important questions needs to be considered: ) what are the challenges on residual waste management during treatment? ) are there hidden risks of cr(vi) re-occurrence downstream of drinking water treatment plant? ) what are the socioeconomic drivers for cr(vi) control in the future? . what are the challenges on secondary waste management during treatment? all reductive cr(vi) treatment inevitably generates cr(iii) solids as the end product of chromium. because cr(iii) is also redox reactive and can participate in an oxidative reaction to re-generate hexavalent chromium, the handling of cr(iii) residual is a major challenge that dictates the success of the treatment. although cr(iii) itself is nontoxic at low dose, an excessive presence of cr(iii) in the treated water can violate total chromium regulatory standard in the us at µg/l. the presence of dissolved oxygen does not pose the risk of re-oxidizing cr(iii) solids. instead, the addition of a secondary disinfectant (e.g., free chlorine) in the treated water can induce the oxidation. therefore, the removal of cr(iii) solids as a subsequent treatment step should be integrated into the cr(vi) treatment train. during the sn(ii)-based treatment, cr(iii) solids are precipitated out together with sno (s) and generate a mixed phase solid product. a cartridge filtration unit with pore sizes of . µm has been demonstrated to successfully remove cr(iii) residual solids. in the final treated drinking water coming out the filtration unit, the addition of free chlorine with a contact time of days did not generate cr(vi), indicating the combination of sn(ii) reductive treatment and subsequent microfiltration or porous media filtration is effective in removing cr(vi) and total chromium (henrie et al., ) . regarding the photocatalytic cr(vi) treatment option, the separation of cr(iii) solids and regeneration of tio photocatalysts are critical to the success of the technology. the reductive tio photocatalysts are typically in nano-to micro-size range. as cr(iii) solids are generated, they deposited on the surface tio particles and results in a composite particle size in the range of - nm (chen et al., ) . accordingly, a membrane ultrafiltration unit can be added to remove tio and cr(iii), and produce crfree drinking water (fig. b) . the combination of a photochemical reactor and an ultrafiltration unit as a treatment train has been commercialized (e.g., photocat @ system by purifics), and the process can be readily scaled up into the design of future full-scale treatment. furthermore, the reductive tio recovered by membrane separation can undergo mild acid washing to dissolve cr(iii) solids and renew its surface (fig. b) . although the polyols coated on the catalyst surface are eventually consumed during the cr(vi) reduction, the catalysts can be re-dispersed in polyol solutions, subsequently heated to replenish the hole scavengers, and regenerated for the next cycle of treatment. in addition to the implementation of treatment technologies, any risks involving a potential release of cr(vi) downstream of the treatment needs to be considered and minimized. the average residence time of water staying in the downstream distribution systems can be up to several days compared to hours in the upstream treatment facility, thus providing ample time for reactions. as an in situ source, cr can potentially be leached from plumbing materials (e.g., cast iron and stainless steel) in water distribution systems (choi et al., ; gonzalez, et al., ; percival, et al., ) . in addition, pipe corrosion scales can accumulated chromium from its trace level in drinking water over decades (hering and harmon, ; peng et al., ) , thus creating in situ sources of chromium in drinking water distribution systems. theoretical redox potential calculation suggests the oxidation of common cr(iii) solids, including chromium oxides, copper chromite and iron chromite by free chlorine are all thermodynamically favorable (fig. ). recent kinetics model also predicts that cr(iii) oxidation by free chlorine can result in a cr(vi) concentration at the tap (i.e., the exit of the distribution system) exceeding µg/l, a possible benchmark for future cr(vi) regulatory standard (henrie et al., ) . in addition, the kinetics of cr(iii) oxidation process driven by free chlorine is catalyzed by bromide, a conservative anion typically existing in source water originated from seawater desalination, water reuse or impacted by wastewater discharge from hydraulic fracking. water utilities need to incorporate source water protection and distribution system corrosion control as part of the mitigation strategy for cr(vi) control in drinking water. . what are the socioeconomic drivers for cr(vi) treatment in the future? the incentive for future cr(vi) treatment and control will first comes from regulatory perspective. currently only total chromium in drinking water was regulated in the us without differentiating cr(iii) and cr(vi); therefore, no mandate to specifically treat cr(vi) exists in the us in the state of california, a recent drinking water standard specifically targeting cr(vi) at µg/l was established in but was subsequently challenged in the court and invalidated in . the withdrawal of the new cr(vi) regulation was partially driven by the huge economic cost of upgrading treatment to comply with the new regulation. however, the economic cost calculation was based on traditional cr(vi) treatment options available back then, i.e., ferrous reductive treatment or ion exchange treatment. in contrast, the newly developed sn(ii)-based or photocatalytic treatment would significantly reduce the cost of water utilities and become economically feasible. combined with the convincing evidence of the toxicological effects of cr(vi), it is reasonable to expect that a new cr (vi) regulatory standard specifically on cr(vi) will be reintroduced in the future. furthermore, the importance of redox processes taking place in drinking water distribution systems should be considered when establishing new cr(vi) standards in drinking water. in the future, climate change adaptation strategies (including water reuse, desalination and water conservation) and associated changes on water chemistry including bromide enhancement will pose challenges for water distribution systems, alter redox chemistry at the pipe-water interface, affect the corrosion behaviors of piping materials, and change the stability of cr-containing corrosion scales. to address this cascade of changes on water distribution infrastructure, future regulatory standards on cr(vi) should incorporate drinking water distribution systems into considerations. for example, in an approach similar to the us epa lead and copper rule, samplings of cr(vi) at the tap should be considered and distribution system corrosion control strategiesespecially for water systems with cast iron pipes and using groundwater as the source watershould be part of the mitigation. more broadly speaking, more cities in the future will deal with aging water infrastructure. although distribution systems might be functional when operating as they have been for decades, the risks are going to come when source waters are abruptly switched in response to droughts or a decision to use a new water supply. these universal challenges needs to be addressed and to prevent another flint crisis with hexavalent chromium from distribution systems. . what is the future outlook of cr(vi) drinking water treatment technologies? sn(ii)-based reductive technology can offer immediate benefit to water systems that are experiencing elevated cr (vi) levels in their source water, and an implementation of this technology will be a cost-effective and easy retrofitting to the existing water treatment infrastructure. although questions regarding the stability of sn and cr residual products need to be better understood through more careful laboratory-scale research and pilot-scale testing, this technology is expected to be a widely considered candidate in the future when new cr(vi) drinking water regulatory standard is established, and used as a benchmark to compare against other new technologies. meanwhile, recent advances in nanotechnology lead to the development of new photocatalysts with tailored surface reactivity for cr(vi) treatment. new photocatalysts that are based on semiconductor materials exhibited a high reduction efficiency for cr(vi). there are ample promising opportunities to further optimize these photocatalysts in areas including enhanced stability, materials longevity, and ease to separate and recover catalysts. in addition, advancement in cr(vi) removal technologies tested at laboratory-scale or tailored for industrial wastewater treatment and environmental remediation, including electrochemistry, nanomaterials and photochemistry can guide the future design for drinking water treatment (chen and liu, ; pan et al., ; pan et al., ) . for example, the introduction of magnetic property and doping of cocatalyst can offer enhanced catalytic capacity and easy reuse after treatment. however, challenges need to be overcome prior to their wide application associated with cost, complex fabrication process and release of nanomaterials to the environment. despite the unresolved issues, these nanomaterial based cr(vi) treatment technologies are promising next-generation technologies for cr(vi) removal in drinking water treatment. water chemistry hexavalent chromium treatment implementation in glendale, calif frontier review: occurrence and speciation of chromium in drinking water distribution systems kinetics and mechanisms of cr(vi) formation via the oxidation of cr(iii) solid phases by chlorine in drinking water oxidation of cr(iii)-fe(iii) mixed-phase hydroxides by chlorine: implications on the control of hexavalent chromium in drinking water photocatalytic removal of hexavalent chromium by newly designed and highly reductive tio nanocrystals photochemical removal of hexavalent chromium and nitrate from ion-exchange brine waste using carbon-centered radicals corrosion behavior of low alloy steels containing cr, co and w in synthetic potable water occurrence and distribution of hexavalent chromium in groundwater from north carolina kinetics of chromium(iii) oxidation to chromium(vi) by reaction with manganese dioxide chromate removal from aqueous wastes by reduction with ferrous iron presence of metals in drinking water distribution networks due to pipe material leaching: a review full-scale demonstration testing of hexavalent chromium reduction via stannous chloride application geochemical controls on chromium occurrence, speciation, and treatability natural and man-made hexavalent chromium, cr(vi), in groundwater near a mapped plume, hinkley, california-study progress as of may , and a summative-scale approach to estimate background cr(vi) concentrations stannous chloride reduction-filtration for hexavalent and total chromium removal from groundwater the technology horizon for photocatalytic water treatment: sunrise or sunset? genesis of hexavalent chromium from natural sources in soil and groundwater chromium geochemistry in serpentinized ultramafic rocks and serpentine soils from the franciscan complex of california rates of cr(vi) generation from cr x fe -x (oh) solids upon reaction with manganese oxide dynamics of chromium (vi) removal from drinking water by iron electrocoagulation cr (vi) adsorption on engineered iron oxide nanoparticles: exploring complexation processes and water chemistry occurrence of trace inorganic contaminants in drinking water distribution systems biofilms, mains water and stainless steel optimization of strong-base anion exchange o&m costs for hexavalent chromium treatment national and california treatment costs to comply with potential hexavalent chromium mcls unregulated contaminant monitoring rule (ucmr ) origin of hexavalent chromium in drinking water wells from the piedmont aquifers of north carolina she joined the department of biochemistry at uc riverside as a postdoctoral researcher in . she is interested in environmental sustainability, bioremediation and state-of-the-art detection technologies including biosensors he completed his b.s. at sichuan university, china, m.s. and ph.d. at university of washington, usa, and a postdoctoral training at uc berkeley, usa. his research group focuses on water chemistry acknowledgements this work was supported by the us national science foundation career program (cbet- ). we thank current and former members of the liu group at uc riverside who have contributed to this effort, as well as the emotional support from jacob y. liu to complete this article during the covid- pandemic. key: cord- - m bc authors: aquino, yves s j; cabrera, nicolo title: hydroxychloroquine and covid- : critiquing the impact of disease public profile on policy and clinical decision-making date: - - journal: j med ethics doi: . /medethics- - sha: doc_id: cord_uid: m bc the controversy surrounding the use of hydroxychloroquine (hcq), an antimalarial drug, for covid- has raised numerous ethical and policy problems. since the suggestion that hcq has potential for covid- , there have been varying responses from clinicians and healthcare institutions, ranging from adoption of protocols using hcq for routine care to the conduct of randomised controlled trials to an effective system-wide prohibition on its use for covid- . in this article, we argue that the concept of ‘disease public profile’ has become a prominent, if not the sole, determinant in decision-making across various healthcare responses to the pandemic. in the case of covid- , the disease’s public profile is based on clinical and non-clinical factors that include contagiousness, clinical presentation and media coverage. in particular, we briefly examine the dangers of a heightened public profile in magnifying the inequality of diseases and undermining three key ethical concepts, namely ( ) evidence-based practice, ( ) sustainable allocation and ( ) meaningful consent. the controversy surrounding the off-label use of hydroxychloroquine (hcq) for covid- is just one among numerous ethical problems raised by the current pandemic. in this article, we examine hcq for covid- as a case study in highlighting emerging ethical dilemmas. in particular, we document the role of disease public profile as the most prominent, if not the sole, determinant of decisionmaking that potentially undermines ( ) evidencebased practice, ( ) sustainable allocation and ( ) meaningful consent. we acknowledge that although there are justifiable variations among national policies, practice guidelines and institutional protocols as a response to the outbreak, it remains important to identify both tacit and implicit values that underlie the decision-making in healthcare settings. hcq, along with chloroquine, belongs to a group of antimalarial agents known as -aminoquinolines. as more was learnt about hcq's immunomodulatory effects, its use expanded from the prevention and treatment of malaria to the treatment of various rheumatological and autoimmune conditions. hcq putatively increases intracellular vacuolar ph to modify the processing of antigens within macrophages and other antigen-presenting cells. this mechanism likely pre-empts inflammatory responses that could be maladaptive and lead to the symptoms of autoimmune disease. data from randomised controlled clinical trials (rcts) have established the efficacy of hcq for the treatment of specific rheumatological conditions such as systemic lupus erythematosus and rheumatoid arthritis. a potential role of hcq in the treatment of covid- has been suggested. in vitro data have demonstrated activity against severe acute respiratory syndrome coronavirus (sars-cov- ), likely through the inhibition of nucleic acid synthesis, viral protein glycosylation, virus assembly, virus particle transport and viral release. clinical data on its use in covid- are sorely limited. a nonrandomised open-label clinical study conducted in france included patients treated with hcq and controls. researchers reported a greater decline in viral load on day of treatment compared with untreated patients, particularly when hcq was combined with azithromycin. the conclusions of the study have been thoroughly scrutinised owing to its methodological limitations. [ ] [ ] [ ] in contrast, a small randomised controlled study in china that included patients and compared hcq with standard care did not demonstrate a difference in viral clearance on day of treatment. systematically collected data on clinical outcomes over a reasonable follow-up period have yet to be reported but may have emerged by the time of this publication. in the face of limited data, the us food and drug administration (fda) has opted to grant limited emergency use authorisation, though not approval, to the use of hcq in the treatment of covid- . hcq as well as many other drugs being repurposed to treat covid- are not without risk of serious adverse events, including potentially fatal cardiac abnormalities (eg, arrhythmias). these risks may be heightened in critically ill patients with comorbidities that place them at high cardiovascular risk. in the wake of widespread use in healthcare facilities across the world, the infectious disease society of america has issued recommendations to use hcq only in the context of a clinical trial. the american thoracic society-led international task force issued guidelines of their own that suggested considering the use of hcq for hospitalised patients with covid- pneumonia on a case-by-case basis, taking into account shared decision-making, collection of valid data and the severity of the patient's condition. regulatory boards, healthcare institutions and clinicians are now involved in a contest on whether hcq is appropriate for one medical condition but not for another. the pandemic demonstrates the role of covid- 's public profile in magnifying the inequality of diseases. here, we discuss clinical and non-clinical factors that underpin disease public profile that potentially privileges one medical condition over others. first, contagiousness is a key factor that causes one disease to be deemed or perceived as far more important than others. contagiousness, including ease and mode of transmission, of a disease determines the imperatives to intervene. in the case of covid- , the transmission is through the transfer of respiratory droplets between persons who are in close contact (within m). other modes of covid- transmission include direct contact with infected individuals, as well as contact with surfaces used or touched by the infected individual. worse, studies have shown that sars-cov- , the novel coronavirus causing covid- , has a higher transmissibility rates than other viruses such as middle east respiratory syndrome coronavirus (mers-cov) and h n . concerns have also been raised regarding transmissions from asymptomatic and presymptomatic persons that are expected to challenge containment efforts. thus, unlike in malaria and lupus, contagiousness in covid- entails a sense of larger scale, more sense of urgency and greater threat. second, the clinical presentation (ie, acuity, prognosis and case-fatality rate) determines the perceived importance of some diseases over others. accumulating clinical experience documented in case reports [ ] [ ] [ ] and relayed in anecdotes among treating clinicians contribute to the sense that patients may deteriorate rapidly and dramatically, making covid- distinct from most viral types of pneumonia. the case-fatality rate for covid- has varied widely, reflecting differences in multiple factors such as testing practices, containment efforts or demographic structure. estimates have ranged from as low as . % in germany and . % in china to as high as % in spain and . % in italy. in contrast, the united states centers for disease control and prevention (cdc) has estimated that from october to april , there have been - million cases of illness and - deaths from influenza, which translates to a case-fatality rate of only up to . %. third, media coverage is another factor that informs the inequality of disease conditions. although media coverage of a disease is a non-clinical factor, it is correlated with the contagiousness and clinical presentation of the disease in question. public profile due to media coverage is best exemplified by conditions in two extremes of perceived worthiness as a cause: breast cancer and (any type of) orphan disease. breast cancer has a high public profile mainly due to effective awareness campaigns across the globe that often involve celebrities who encourage regular examination and support for research. on the other extreme are orphan diseases, so-called because they are so rare that drug companies are not inclined to adopt them to develop treatments. in the current scenario, lupus (and to some extent malaria) are closer to the orphan disease side of the spectrum and covid- in the other extreme. unlike breast cancer, the worthiness of covid- as a cause is not due to any corporatised awareness campaign. rather it is due to the / coverage, the grim picture in countries like italy and iran, the daily updates on incidence and fatality rates and the extreme social interventions (eg, lockdowns) among others. increased public profile in itself is not problematic, as some rare or unknown diseases have received increased research funding through this route. a famed example is the 'ice bucket challenge', involving celebrities dumping ice water on their heads to promote awareness of and research on amyotrophic lateral sclerosis, a rare motor neuron disease. the danger of increased public profile of disease is demonstrated by the tendency of public officials with no medical expertise, such as us president donald trump and french president emmanuel macron, to explicitly recommend drug treatments and prophylaxis against covid- . one harmful result of president trump's pronouncements is the death of a man from arizona who ingested a cleaning cocktail that contains the same active ingredient as hcq. furthermore, increased public profile heightened by unfounded treatment recommendations have negatively impacted the academic and medical community, with scientific publications accelerating dramatically at the expense of academic rigour that validates the integrity of the research. as a result, several published articles have been retracted by elite medical journals the lancet and the new england journal of medicine following revelations of questionable data sources. in the next three sections, we elaborate the ways in which one disease's public profile, such as covid- 's, can become so extraordinary that it undermines evidence-based clinical practice, drives unsustainable resource allocation and authorises structural forms of coercive consent. the heightened public profile of disease appears to increase the imperative to resort to off-label treatments, both for therapeutic and prophylactic purposes. in the case of covid- , various drugs are proposed or currently under investigation as potential off-label treatments. however, at the time of this writing, there was still no standard of care. off-label use refers to the use of treatment (medication or device) for regimens not stated in the approved labelling or package insert. off-label use is considered a common practice and sometimes clinically appropriate in cases when there are no alternatives and potential benefits outweigh potential risks. however, off-label use has raised longstanding debates on whether it is morally justified. by its very definition, off-label use entails treatments that are not yet fully supported by evidence. in response to the potential harms of unproven treatments, national medical associations have stated some guidelines on off-label treatments. for example, the american medical association's code of ethics states that off-label and other innovative treatments must be based on 'sound scientific evidence and appropriate clinical expertise'. the australian medical association similarly recommends that off-label use should be based on 'sufficient evidence to support its efficacious and safe use and overall favourable harm:benefit ratio'. although there are several morally justifiable reasons for off-label use in general clinical practice, our analysis focusses on the influence of disease public profile on the unapproved or emergency use of hcq for covid- without sufficient scientific evidence. but what counts as scientific and/or sufficient evidence? despite the good intentions of these practice guidelines, it seems that off-label use will remain in a 'catch- ' situation given the contradicting regulations. on one hand, a common regulation states that drugs can only be used for indications of which they are approved by authorities such as the us fda. on the other hand, drug authorities do acknowledge and to some extent permit the use of drugs for unapproved or unproven indications granted the best available evidence supports this unapproved use. if there were evidence deemed by authorities to be sufficient to support use for the indication in question, this labelling would be approved and the use no longer off-label. it is widely accepted that the strongest evidence for adopting a treatment comes from well-designed randomised controlled trials, or a meta-analysis of such well-designed trials if study designs are sufficiently similar. anecdotes are powerful, but they have a limited ability to make fair comparisons between any two treatment options. outside a controlled setting, observed differences in outcomes may be due to the differences in the treatments. but they are just as likely due to pre-existing differences in the risks of patients themselves for developing a poor outcome, and these are misattributed to the treatments received. variables that are readily or quickly measured (eg, laboratory test results such as persistent detectability of viral particles) may be used to compare the two treatments, but they do not necessarily translate to the clinical outcomes that are directly experienced by patients (eg, resolution of symptoms, discharge and death). thus, good clinical trial design, ideally including the randomisation of patients to different treatment arms, is the key to producing interpretable data that best inform the care of patients. however, when such data do not yet exist, clinicians nevertheless must make patient care decisions using the best available evidence. any evidence that falls short of an rct can be classified into supported, suppositional and investigational. the classification relies on the availability of non-rct evidence and expert opinion. among the three, the investigational off-label use has the lowest level of certainty. at the time of this writing, a search in clinicaltrials. gov yielded studies on the use of hcq to prevent or treat covid- in various stages ranging from prerecruitment to completed. though there is much disagreement on the merits of hcq as a treatment, most researchers and clinicians likely at least agree that equipoise exists. though we are uncertain, the probability that hcq works is at least enough to merit investigation through rcts that will either affirm or debunk its role in care. while awaiting the results of these rcts, treating clinicians have taken a wide range of positions on the off-label use of hcq in treating covid- . for the sake of this discussion, we can consider two: the treating clinician should consider the off-label use of hcq in a closely monitored inpatient setting for patients at increased risk of an adverse outcome from covid- versus the treating clinician should provide supportive care alone and not consider any targeted off-label therapy outside the context of an rct. the position to consider off-label use has been described as the compulsion to 'just do it', or the drive to do something rather than nothing. in contrast, the position to refrain from off-label use outside the context of an rct has been presented as a necessary measure to protect patients from adverse consequences of treatment that might later prove to lack efficacy anyway. in this light, the position to offer and use hcq off-label (ie, to 'just do it') may be perceived as instinctual or irrational. nevertheless, it must be recognised that the position to refrain from offlabel hcq use to avoid serious adverse events from unproven therapy is based on an alternate instinct as well. the latter position instinctively presupposes that death from a serious adverse event from hcq that is later proven ineffective for covid- must be a worse outcome than death from covid- if hcq is later proven effective but was not tried. the former position presupposes the opposite. given the heightened public profile of covid- , it is conceivable that some next of kin of deceased patients would find greater comfort or less regret in thinking, 'we tried', or, 'we did everything we could', whereas others by, 'we did not know it could have worked'. however, when experts determine that off-label use outside of an rct (of an agent that has enough potential to be investigated in an rct) should be discouraged when managing an individual patient with their own preferences, they do make an inadvertent claim that one value or preference is objectively superior to another. however, these preference hierarchies are by nature subjective and, thus, requiring continued ethical scrutiny. the impact of covid- 's public profile on evidentiary concerns trickles down to issues regarding resource allocation based on government policies, hospital protocols and norms of clinical practice. in the case of hcq, one issue is regarding the fair distribution of the drug among its indicated uses (eg, malaria and lupus) and off-label use for covid- . as a consequence of the interest in hcq for covid- , no doubt fuelled by president trump's endorsement, demand for the drug has skyrocketed. the precarity of supply has prompted diverging responses at the level of the state and healthcare organisations or at least varying opinions from different stakeholders on how to manage the scarcity. a patient with lupus has reportedly been issued a letter by her healthcare network explaining that the hcq supply was being conserved in favour of those critically ill with covid- . the covid- global rheumatology alliance highlighted the major risk of disease flare and organ damage in patients with lupus who might be unable to refill their hcq prescriptions. in their statement, they discouraged off-label use until further efficacy data emerge in favour of its use in covid- and the supply is bolstered. at least until before the us fda's emergency authorisation, certain states had opted to restrict dispensing hcq for conditions outside the proven indications. as various expert panels and bodies have highlighted the threat to the hcq supply for lupus patients generated by hcq use in the treatment of covid- , media reports of unusual prescribing patterns on the part of healthcare providers have emerged. there is suspicion that physicians, dentists and other licensed providers are issuing themselves or family members prescriptions of hcq to stockpile them, ostensibly to take them prophylactically or to use them should they develop symptoms. the magnitude of this practice is unclear, but it does pose an ethical concern that treatment practices surrounding patients hospitalised with covid- are being influenced by an allocation problem generated by some prescribers hoarding for themselves or significant others who are not or only mildly symptomatic. bioethical debates regarding medical resource allocation generally involve two main competing positions: the maximising utility view and the equity view. the former follows the utilitarian precept of promoting the greatest good for the greatest number of persons, whereas the latter highlights the need to redress social injustice and socioeconomic inequalities that result in unfair distribution of goods. using the utility view, the competition among diseases means that governments and health institutions should focus on the disease where treatment will result in the greatest good for the greatest number. the key criticism against utility view is that the greatest good is often at the expense of a vulnerable minority, whether in terms of persons or diseases. in contrast, the equity view recognises that certain groups of people are already at a disadvantage. the equity view can be useful in demonstrating that in a public health crisis, some disease conditions are vulnerable to neglect as resources are diverted disproportionately to the disease that receives high public attention. in the example of breast cancer, there has been a growing criticism against the 'pink ribbon' campaign as receiving excessive attention at the expense of other types of cancer. the case of hcq for covid- demonstrates a problematic allocation of resources that cuts across various domains of healthcare. intensive care unit beds, mechanical ventilators and human resources are now largely diverted toward covid- . arguably, diverting resources toward a highly contagious disease during a pandemic is justifiable. however, such a strategy can have unintended harmful consequences. for example, health experts warn against the surge of polio, measles and other infectious diseases as covid- efforts trigger the suspension of worldwide vaccination campaigns. a patient with lupus who is unable to fill their hcq prescription could end up requiring hospital care from a life-threatening lupus flare, but be unable to receive optimal care from a system now primed to focus on covid- . hence, the trend of allocating resources, including hcq, toward covid- is not only disproportionate but may also prove to be unsustainable or counterproductive in the long run. the public profile of a disease similarly impacts the creation of undue influence on patient consent to participate in research trials. when the us fda granted emergency authorisation for hcq, there was concern that offering off-label therapy outside rcts leads to a squandered opportunity to enrol these patients in them. if off-label therapy is offered outside the context of an rct, there is reduced motivation or incentive to participate in one. however, if they could be persuaded to participate, their outcomes would provide clarity to the treating clinician in their care of future patients. in bioethics, consent is deemed meaningful and informed if the person giving it is 'competent to act, receives a thorough disclosure, comprehends the disclosure, chooses voluntarily and consents to the intervention'. competence, comprehension and voluntariness can be compromised by coercion and undue influence, which are two overlapping concepts. although coercion is generally understood as direct use of threat of violence, undue influence occurs when there is an excessive and inappropriate reward to obtain compliance. for some authors, coercion can occur when there is a substantially asymmetric power dynamic between the physician/researcher and the patient/participant. patients and potential research participants may be coerced to consent if they fear they have something to lose by not complying with the request. in a less pessimistic light, coercion may occur when patients overly trust their physicians so that a physician's invitation to participate may be viewed as a recommendation rather than a request. concerns regarding potential coercion of participants have been demonstrated in clinical trials for cancer treatments, hiv cure and treatment for psychiatric disorders, among others. authors argue that therapeutic clinical trials tend to collapse the two roles of a clinician as providing clinical care and performing research, and this collapse can contribute to patients' misconception that participation in the trial is a matter of necessity if not an obligation. clinicians and future patients with covid- would be best served by the participation of current patients with covid- in these rcts. nevertheless, one of the cornerstones of modern ethical codes governing clinical research is preserving the participant's ability to provide meaningful consent. withholding an ff-label agent (with sufficient potential to warrant rct investigation) in the course of care functions as an inducement to consent to join the study. study participation might entail being randomised to placebo (ie, supportive care alone) when the patient would otherwise not have agreed to be. understandably, in practice, many rcts often involve incentives, but these are closely scrutinised precisely because of the risk of compromising meaningful consent. a conflict, therefore, arises between future patients on one side and the current patient whose only access to off-label therapy is through an rct. although the informative findings of an rct might serve the 'greater good,' this must be carefully weighed against protecting the meaningful consent of patients being recruited. the controversy surrounding hcq further demonstrates that undue influence and coercion can be structural. wider social, economic and political contexts can undermine understanding and voluntariness as components of consent. structural and indirect forms of coercion can be shaped by social disparities that perpetuate unequal access to resources that help people make healthier and more informed choices. for example, us reports show that the pandemic has highlighted the disparity in access to technology and online information from reputable websites such as the us centers for disease control and prevention, leading to hoax and conspiracy sites that promote unfounded and harmful covid- treatments. moreover, structural forms of coercion are demonstrated by the ways in which the public profile of covid- magnifies the impact of political, social and institutional influence on participants consenting to ongoing hcq trials. on a political level, some state leaders, such as president trump and president macron, have been vocal in their confidence with hcq, putting demands on researchers and clinicians who are already under intense pressure to develop treatments for covid- . consequently, political faith on a treatment that is not supported by evidence has spurred greater society's demand to have access to hcq, either as a prophylaxis or treatment against covid- . the hype may play a role in influencing patients' decision to participate in trials or to seek treatments that are at best not proven to be effective or worst associated with potentially fatal side effects. in this article, we argued that the case of hcq being touted as potential covid- treatment demonstrates the dangers of a disease's public profile becoming the overarching influence in healthcare decision-making. the public profile of a disease, which is based on a combination of clinical features and media coverage, not only magnifies the inequality of diseases but also potentially undermines the ethical concepts of evidence-based medicine, sustainable allocation of resources and meaningful consent. given the rapid progression of the pandemic, we acknowledge the need for quick clinical and policy responses. although we do not advocate for a particular outcome of decision-making, we wish to highlight the need for ethical deliberation to make explicit the values that are informing widespread and immediate responses to the pandemic. we need to strike a balance between matters of urgency and matters of equity, with some medical conditions becoming vulnerable to neglect and ethical concepts being dismissed, as resources and attention are diverted towards covid- . the key claims during the development stage; responsible for the ethical discussion raising specific ethical concepts in the manuscript. nc is responsible for the technical details of the drugs and the diseases discussed. funding the authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors. competing interests none declared. provenance and peer review not commissioned; externally peer reviewed. data availability statement there are no data in this work. this article is made freely available for use in accordance with bmj's website terms and conditions for the duration of the covid- pandemic or until otherwise determined by bmj. you may use, download and print the article for any lawful, non-commercial purpose (including text and data mining) provided that all copyright notices and trade marks are retained. yves s j aquino http:// orcid. org/ - - - hydroxychloroquine: from malaria to autoimmunity mechanism of action of hydroxychloroquine as an antirheumatic drug hydroxychloroquine in systemic lupus erythematosus: results of a french multicentre controlled trial (plus study) a long-term study of hydroxychloroquine withdrawal on exacerbations in systemic lupus erythematosus. the canadian hydroxychloroquine study group hydroxychloroquine compared with placebo in rheumatoid arthritis. a randomized controlled trial in vitro antiviral activity and projection of 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doctors stockpile trial coronavirus drugs for themselves, states say the new york times ethics of resource allocation equity and population health: toward a broader bioethics agenda backlash against "pinkwashing" of breast cancer awareness campaigns allocation of scarce resources during the covid- pandemic: a jewish ethical perspective polio, measles, other diseases set to surge as covid- forces suspension of vaccination campaigns science the ethics of consent: theory and practice expanding the frame of "voluntariness" in informed consent: structural coercion and the power of social and economic context consent to clinical research--adequately voluntary or substantially influenced? seeking informed consent to cancer clinical trials: describing current practice informed consent to hiv cure research the ethics of clinical trials research in severe mood disorders the routledge companion to bioethics. abingdon-on-thames ethical issues surrounding forced, mandated, or coerced treatment how health disparities are shaping the impact of covid- pandemic response lays bare america's digital divide. the guardian coronavirus: the spread of misinformation the authors would like to thank the journal of medical key: cord- - gp mjen authors: garwood, tyler j.; lehman, chadwick p.; walsh, daniel p.; cassirer, e. frances; besser, thomas e.; jenks, jonathan a. title: removal of chronic mycoplasma ovipneumoniae carrier ewes eliminates pneumonia in a bighorn sheep population date: - - journal: ecol evol doi: . /ece . sha: doc_id: cord_uid: gp mjen . chronic pathogen carriage is one mechanism that allows diseases to persist in populations. we hypothesized that persistent or recurrent pneumonia in bighorn sheep (ovis canadensis) populations may be caused by chronic carriers of mycoplasma ovipneumoniae (mo). our experimental approach allowed us to address a conservation need while investigating the role of chronic carriage in disease persistence. . we tested our hypothesis in two bighorn sheep populations in south dakota, usa. we identified and removed mo chronic carriers from the custer state park (treatment) population. simultaneously, we identified carriers but did not remove them from the rapid city population (control). we predicted removal would result in decreased pneumonia, mortality, and mo prevalence. both population ranges had similar habitat and predator communities but were sufficiently isolated to preclude intermixing. . we classified chronic carriers as adults that consistently tested positive for mo carriage over a ‐month sampling period (n = in the treatment population; n = in control population). . we failed to detect mo or pneumonia in the treatment population after chronic carrier removal, while both remained in the control. mortality hazard for lambs was reduced by % in the treatment population relative to the control (ci = %, %). there was also a % reduction in adult mortality hazard attributable to the treatment, although this was not statistically significant (ci = % reduction, % increase). . synthesis and applications: these results support the hypothesis that mo is a primary causative agent of persistent or recurrent respiratory disease in bighorn sheep populations and can be maintained by a few chronic carriers. our findings provide direction for future research and management actions aimed at controlling pneumonia in wild sheep and may apply to other diseases. heterogeneity in infectiousness of individual hosts may dramatically affect pathogen transmission, as illustrated by the role of human superspreaders in the emergence of the severe acute respiratory syndrome-associated coronavirus (sars-cov), a zoonotic virus responsible for an acute human epidemic during (lloyd-smith, schreiber, kopp, & getz, woolhouse et al., ) . less is known about the importance of individual variation in infectiousness among diseases associated with chronically carried bacterial pathogens. chronic carriage/shedding is common features of several pathogenic bacteria, so understanding infection risks posed by chronic carrier individuals is relevant to management of infectious diseases across human, domestic animal, and wildlife health sectors (buhnerkempe et al., ; coyne et al., ; wertheim et al., ) . bighorn sheep (ovis canadensis) populations declined precipitously following the mid- s (buechner, ) , and bacterial pneumonia is a primary impediment to recovery (cassirer et al., ) . bighorn pneumonia frequently manifests as an initial allage outbreak causing %- % mortality (cassirer et al., ; enk, picton, & williams, ; spraker, hibler, schoonveld, & adney, ) , followed by annual epizootics among juveniles and sporadic pneumonia mortality among adults smith, jenks, grovenburg, & klaver, ) . pasteurellaceae (bibersteinia trehalosi, mannheimia haemolytica, leukotoxigenic pasteurella) and parasites (protostongylus sp.) (dassanayake et al., ; foreyt, snipes, & kasten, ; miller et al., ) . while mycoplasma ovipneumoniae (mo) is more strongly associated with pneumonia than previously targeted pathogens (besser et al., , no vaccines or efficacious antimicrobial treatments for mo currently exist. interventions for any pathogen(s) are also constrained by inaccessible terrain, as well as the complex movement patterns of bighorn sheep (cassirer et al., ; george, martin, lukacs, & miller, ) . we conducted our study in the south dakota black hills from august to may . this study site includes elevations of - , m (brown & sieg, ) , average annual precipitation (rapid city) of . cm rainfall and . cm snow, and temperatures of − to °c, with an average high of °c and an average low of the control population inhabited public and private land in pennington county and contained three subherds that rarely interacted (rapid creek, spring creek, and hill city, figure ; ° ′ ″ n, ° ' " w). this population utilized canyons for summer range and residential lawns during winter (smith, grovenburg, monteith, & jenks, ) . an all-age die-off occurred in , and pneumonia remained a major mortality source . the we captured bighorn sheep via chemical immobilization (bam; . mg/kg butorphanol, . mg/kg, azaperone, . mg/kg medetomidine, wildlife pharmaceuticals) delivered through dart injection or by aerial net-gunning (quicksilver air, inc. and hells canyon helicopters). we fitted sheep with very high-frequency (vhf) collars (m ob; advanced telemetry systems) with mortality sensors, which were activated if the collar was motionless for ≥ hr. after confirming pregnancy with ultrasonography (e.i. medical imaging), we fitted ewes with vhf vaginal implant transmitters (vits; m ; advanced telemetry systems; smith, walsh, et al., ) . during capture, we collected information on sex, age, mo carrier status and antibodies, and presence of other pathogens. we aged individuals up to . years old using tooth eruption (valdez & krausman, ) and classified adults > . years old as a single age group. we collected mo mucosal samples via three swabs, which were consecutively inserted deep into each of the nares and rotated around the cavity wall during removal (drew et al., ) . we returned two swabs to their sheath and immersed one in tryptic soy broth with % glycerol (hardy diagnostics; butler et al., ) . to sample for other aerobic bacteria that could contribute to respiratory disease, we rotated swabs along each tonsillar crypt and stored them similarly to nasal swabs. we collected blood for serum, held all samples at °c, and shipped them on ice to the washington animal disease diagnostic lab (waddl) or dr. thomas besser's lab (washington state university). we used real-time polymerase chain reaction (rt-pcr) to detect mo on nasal swabs (ziegler et al., ) . samples were positive if fluorescence generation exceeded the threshold before the th rt-pcr cycle, indeterminate if between the th and th cycles, and negative if not exceeded through cycles. we determined serum mo antibody presence by competitive enzyme-linked immunosorbent assay (c-elisa; ziegler et al., ) . we documented other pathogens on swabs through aerobic culture and pcr (besser et al., ) . we determined mo strain type using genomic dna extracted from m. ovipneumoniae broth cultures or swabs using dneasy blood and tissue kits (qiagen inc.), following manufacturer's instructions, or pcr-positive dna extracts obtained directly from waddl. mycoplasma ovipneumoniae extracts were genotyped using a multi-locus sequence typing approach that targets four loci. the targeted loci are partial dna sequences from the s- s intergenic spacer region (igs), the small ribosomal subunit ( s), and housekeeping genes encoding rna polymerase b (rpob) and gyrase b (gyrb). protocols and primers for pcr amplification of these loci were described previously ). commercial service laboratories (amplicon express and eurofins genomics) conducted bidirectional sanger dna sequencing of amplified pcr products using the same primers used in pcr reactions. we began mo testing in the treatment population in august . we obtained ≥ tests from every adult alive in the population before or shortly after chronic carrier removal (table and table s ). we classified individuals as chronic carriers (consistently positive), intermittent carriers (negative and positive tests), or noncarriers (all negative tests). we immobilized and relocated all chronic carriers from the treatment population to south dakota state university (sdsu). postremoval, we tested most individuals in both populations annually (table s and s ). f i g u r e a conceptual depiction of our experiment, where chronic carriers of mycoplasma ovipneumoniae are identified in two populations, but only removed in one. bighorn sheep can be classified as chronic carriers, intermittent carriers, and noncarriers; only chronic carriers need to be removed under our operating hypothesis. if chronic carriers are removed, the population should rebound as lamb recruitment improves. without intervention, the population will continue to decline indefinitely due to low lamb recruitment we monitored vit radio signals daily using handheld directional radio telemetry (telonics, inc.) starting april and . we located the dam to verify lamb presence when a vit was expelled. budgetary constraints prevented vit implantation in some pregnant ewes in the control population, so we visually monitored females without vits along with ewes that expelled their vits prematurely. if we observed a lamb, we attempted to hand capture it. we immobilized lambs we failed to capture as neonates at - months old. we weighed captured lambs, determined sex, and fitted them with expandable vhf collars (m ; advanced telemetry systems). we wore latex gloves and minimized handling of neonates to avoid abandonment (smith, walsh, et al., ) . the sdsu institutional animal care and use committee approved capture and handling procedures (approval number - a). we monitored adult collars for mortality signals times/week from march to may and lamb collars daily from capture until november; thereafter, we monitored lambs similarly to adults. when a collar indicated mortality, we located the carcass and examined the site for predator presence (scat, tracks, scrapes) and the cadaver for caching, hemorrhaging, and skeletal disarticulation (stonehouse, anderson, peterson, & collins, ) . we performed necropsies on adults in the field and shipped swabs to waddl for pathogen testing. when possible, we shipped lamb cadavers to waddl for necropsy. cause of death was sometimes uncertain; therefore, we used the knowledge gained from necropsies, evidence at the site, and behavioral observations to assign the likelihood of each individual's cause of death. cause-specific mortality categories for lambs and adults were "predation," "pneumonia," and "other," and, in addition for adults only, "human-caused." we created a probability for each category, and the resulting vector of prior predictive probabilities summed to one for each individual. if cause of death was certain, the vector contained a single, nonzero entry for the appropriate causeof-death category (walsh, norton, storm, van deelen, & heisey, ) . as an example of this process, a carcass might be scavenged shortly after dying, and movement of the collar could delay detection of the mortality by a week. the lack of disarticulation might rule f i g u r e ranges of study populations of bighorn sheep in the black hills, south dakota, usa, - out predation, but the carcass's desiccated state would make it difficult to tell whether pneumonia or another internal malady caused death. if we had previous behavioral evidence that indicated pneumonia, in this example we would assign a % predictive probability to "pneumonia," % to "other," and % to all other categories. we modeled weekly survival rates, incorporating covariates for treatment, strain type exposure , testing pcr positive for mo, biological year (gaillard, festa-bianchet, yoccoz, loison, & toigo, ) , sex (jorgenson, festa-bianchet, gaillard, & wishart, ) , and age (loison, festa-bianchet, gaillard, jorgenson, & jullien, ) as factors affecting survival. we coded the treatment, sex, and an individual's positive test effects as binary variables (treatment population = , control population = ; males = , females = ; ≥ positive = , no positives = ). we treated an individual's age as a time-varying, categorical variable separated into groups ( = - years old, = - years old, = + years old). our adult global model calculated log unit cumulative hazard as the baseline log unit cumulative hazard rate. for the i th individual during the j th week, we denoted β treatment as the treatment effect, β positive test as the positive test effect, β strain as the strain type effect, β year as the year effect, β age as the individual's age effect, and β sex as an individual's sex effect. we signified the week effect with ρ j . we modeled daily survival rates, incorporating treatment (i.e., population identity), year (gaillard et al., ) , strain type exposure (cassirer ta b l e summary of bighorn sheep pathogen testing results and survival estimates in the treatment and control populations, we coded treatment and individual sex effects as with adults. we designated year as a binary variable ( = , = ) and birth timing consisted of three groups: lambs born within ± days of the median date of lamb births in a given year, those born > days before the peak period, and those born > days after the peak period . we coded strain type exposure as categorical (exposure to introduced strain = , exposure to resident strain = , exposure to neither = ). based on strain typing data, lambs in the spring creek subherd were exposed to the introduced strain in , and the resident strain in . all lambs in rapid creek and hill city subherds were classified as only exposed to the resident strain for the duration of the study. since we removed all carriers of mo in the treatment population in january and there were no mo-positive tests postremoval, we classified treatment lambs as being exposed to neither strain for the entire study. birth weight was measured to the nearest . kg. for late-caught lambs, we imputed missing birth weight and birth timing values using the empirical distributions of these variables for lambs caught as neonates (gelman et al., ) . our global model calculated daily log unit cumulative hazard as ln(Λ i,j ) = γ + β treatment × treatment i + β strain [strain type i ] + β year × year i + β sex × sex i + β birth timing [birth timing i ] + β birth weight × birth weight i + ρ j . the γ, β treatment , and β sex parameters were included in the model in the same way as in the adult model. for the i th individual during the j th day, we denoted the year effect as β year , β strain as the strain type exposure effect, β birth timing as the birth timing effect, and β birth weight as the birth weight effect. we signified the day effect with ρ j . we then calculated cause-specific mortality while incorporating observer uncertainty into parameter estimation (walsh et al., ) . specifically, we treated the true cause of death for each individual as a latent, unknown variable with an assigned vector of prior predictive probabilities. as described above, these priors specified the observer's belief that each cause of death was the true cause of death given their assessment of the available evidence (table s ) . we imputed the true cause of death, using a data augmentation approach that generated a cause of death at each markov chain monte carlo (mcmc) iteration (gelman et al., ) , based on a categorical distribution with a parameter vector equal to the prior predictive probability vector specified for that individual. using random starting values, we ran three mcmc chains for , iterations and removed the first , repetitions for burn-in. we looked for evidence of nonconvergence of the chains via graphical checks, and none was observed for any of the following analyses. we calculated watanabe-akaike information criteria (waic) from each model to identify models that best described the evidence in the data (gelman et al., ) . we considered models differing by ≤ waic as alternatives to the top ranked model but preferred the simplest model (burnham & anderson, ) . we based our conclusions on parameter estimates from the best model. we radio-collared adult bighorn sheep between august and may : in the treatment ( rams, ewes) and ( rams, ewes) in the control population. this constituted % and ~ % of adults in the respective populations by the study's end. categorized by age at the end of the study, we collared ( treatment, control) - year olds, ( treatment, control) - year olds, ( treatment, control) - year olds, and ( treatment, control) ≥ year olds. we tested all treatment population adults that survived long enough to be tested ( rams, ewes) for mo over sampling events (table ) . fifty-one ( %) swabs tested negative with rt-pcr, ( %) tested indeterminate, and ( %) tested positive. two females were classified as chronic carriers of the bh- strain (n = positive tests). the other adult that tested positive subsequently tested negative and died before experimental manipulation. we classified all other individuals tested twice as noncarriers (n = individuals). we removed the two chronic carriers on march . after removal of chronic carriers, we did not detect mo in samples ( negative and indeterminate) collected from individuals ( males, females) in the treatment population (table and table s ). we collected serum from individuals, and antibodies were detected in ( %); ( %) tested indeterminate, and between january and may , we collected samples from control population bighorn sheep (table and table s ). we obtained mo-positive samples ( %), indeterminate samples ( %) and negative samples ( %). we were able to strain type of the positive samples. we found that samples were the resident bhs- strain also detected in the treatment population, but samples were typed as bhs- (introduced and ( %) tested negative. we lacked serum from individuals. we we monitored survival of radio-collared adults march - may . we documented mortalities ( males, females, % of adults) in the treatment population and ( males, females, % of adults) in the control population (figure a ). our best survival model was ln(Λ ij ) = γ + β treatment × treatment i + ρ j , which we used to calculate log weekly cumulative mortality hazard estimates (w = . , table s ). the model indicated chronic carrier removal reduced adult hazard by %, but was not statistically significant with the % credible interval (ci) including zero (ci = % reduction, % increase; table , figure s ). an analysis that excluded the spring creek subherd, which was exposed to multiple mo strains, produced similar estimates (hazard reduction = %, ci = % reduction, % increase). this corresponds to a % annual survival rate (ci = %, %) in the treatment population and % (ci = %, %) in the control population (table ) . hazard of pneumonia-induced mortality for adults in the treatment population was significantly lower than in the control population (probability difference = − %, ci = − %, − %; figure c ). no pneumonia was detected in the treatment population, and the probability of pneumonia-induced adult mortality was lower ( %, ci = %, %) than in the control herd ( %, ci = %, %). conversely, predation was more likely to be assigned as cause of death in the treatment population ( %, ci = %, %) than in the control ( %, ci = %, %; probability difference = %, ci = %, %). we our best lamb survival model was ln(Λ ij ) = γ + β treatment × treat- table s ). lamb birth weight (mean = . kg, se = . , n = ), sex, and birth timing were not supported as predictors of survival. we calculated log daily cumulative hazard measurements based on this model ( figure s ) and determined that chronic carrier removal had a negative effect on daily lamb hazard ( % reduction in the treatment population, ci = %, %; table ). this corresponds with a % annual survival rate (ci = %, %) in the treatment population and % (ci = %, %) in the control (table ) . we observed higher lamb mortality in than in (β year = . , ci = . , . ). pneumonia-caused mortality was significantly less likely in the treatment population (probability = %, ci = %, %) than in the control population (probability = %, ci = %, %), with a probability difference of − % (ci = − %, − %) (figure d ). lambs that died had a % probability of dying from predation in the treatment population (ci = %, %), which was significantly higher than the control population ( %, ci = %, %; probability difference = %, ci = %, %). we found that pneumonia can be maintained in bighorn sheep populations by a few individuals chronically carrying mo. after removing these individuals, we detected no deaths attributable to pneumonia and % of lambs survived to months of age, similar to other healthy populations in our study region ( . %- %; parr et al., ; zimmerman, ) . in contrast, we detected pneumonia-induced mortality in adults and juveniles in a control population where mo carriers remained. average lamb survival to months in the control population was %, which is similar to other unhealthy populations ( %- % of collared lambs surviving; cassirer et al., ; grigg et al., ; . we detected other pneumonia-associated pathogens in both populations, but their presence failed to induce pneumonia in adults or lambs in the absence of mo (table ) . this finding makes physiological sense: while other pathogens contribute to disease , mo appears necessary, by disrupting mucociliary clearance, for bighorn sheep to establish lung infections (cassirer et al., ; niang et al., ) . although leukotoxigenic pasteurella was detected in the treatment population before removal and not afterward, the three individuals harboring it were not removed (table s and table s ). our results indicate that mo is warranted as a focal pathogen in efforts to eliminate pneumonia in wild sheep populations. we found intermittent carriers in our control population but none in our treatment population (table ) . strain typing of samples from intermittent carriers in the control population revealed that eight changed from noncarriers to carriers when infected with a strain previously found in bighorn sheep in deadwood, south dakota and western nebraska (kamath et al., ) . these individuals therefore were not intermittently carrying a single strain of mo. more likely, they lacked strain-specific immunity and were acutely carrying the introduced strain of mo . importantly, they were not contributing to the persistence of the original strain. the role of intermittent carriers in population-level dynamics of mo is not known ; however, our assumption is that chronic carriers are necessary for persistence. our study indicates that in some cases intermittent carriage can be attributed to the introduction of a new strain type. future studies could consider invasion of new strains as a potential factor influencing mo carriage patterns. although our study demonstrates improved lamb survival resulting from removing chronic carriers, the impact on adult survival is not as pronounced. we detected a statistically significant reduction in pneumonia-induced adult mortality in the treatment population relative to the control, but other sources of mortality in the treatment population offset this effect. for adults, our best survival model included a treatment effect and was significantly better (i.e., ≥ Δwaic) than models lacking this effect; however, the effect was not statistically significant. this finding may indicate that the treatment effect was biologically important, but a larger sample size is needed to assess statistical significance given the overall high survival rates of both the treatment and control populations. previous studies found that adult survival generally rebounded to or above previous levels in the years following all-age die-offs (manlove, cassirer, cross, plowright, & hudson, ; plowright et al., ) . clarifying it remains unclear which host factors contribute to chronic carriage and how to minimize the number of tests necessary to identify chronic carriers. plowright et al. ( ) found that age and homozygosity at a specific locus were associated with persistent carriage of mo in bighorn sheep, suggesting possible host factors that might contribute to variation in infectious period and carriage rates among populations. coinfections, underlying disease, and high exposure frequency and/or dose may also shape host resistance to infection and increase likelihood of chronic or intermittent carriage (fox et al., ) . chronic carriers might also be individuals that adopt a strategy of tolerance (limiting the harm caused by a given parasite burden) rather than resistance (limiting parasite burden) to combat mo. this predisposition for tolerance has a genetic basis and is variable among individuals within a species (råberg, graham, & reed, ) . identifying factors associated with carriage status would provide insight into temporal variation in disease dynamics and population response to infection. the ability to determine the likelihood of intermittent versus chronic carriage at an individual or population level would also help minimize the sampling effort required to efficiently identify chronic carriers. our results indicate the minimum required sampling intensity will vary across populations. given the cost of identifying chronic carriers, wildlife managers might question whether complete depopulation followed by repopulation is preferable to selective removal. however, complete depopulation of wildlife is not always feasible, especially in rugged or remote terrain (courchamp, chapuis, & pascal, ) . furthermore, while depopulation removes the pathogen along with its host, ensuing reintroductions may fail (griffith, scott, carpenter, & reed, ) depends on how the disease is spread and maintained within and between populations. as infectious disease outbreaks increase globally (jones et al., ) , broadening our understanding of various transmission patterns will be integral to mitigating disease outbreaks and conserving at-risk wildlife populations. wieseler, j. jenson., and b. felts were integral to completing field work. any use of trade, firm, or product names is for descriptive purposes only and does not imply endorsement by the u.s. government. none declared. tyler j. garwood https://orcid.org/ - - - x daniel p. walsh https://orcid.org/ - - - association of mycoplasma ovipneumoniae infection with population-limiting respiratory disease in free-ranging rocky mountain bighorn sheep (ovis canadensis canadensis) bighorn sheep pneumonia: sorting out the cause of a polymicrobial disease historical variability in fire at the ponderosa pine -northern great plains prairie ecotone, southeastern black hills bighorn sheep in the united states detecting signals of chronic shedding to explain pathogen persistence: leptospira interrogans in california sea lions model selection and multimodel inference: a practical information-theoretic approach ( nd assessing respiratory pathogen communities in bighorn sheep populations: sampling realities, 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techniques for capturing bighorn sheep lambs south dakota bighorn sheep management plan pathologic changes and microorganisms found in bighorn sheep during a stress-related die-off approaches to field investigations of cause-specific mortality in mule deer mountain sheep of north america using expert knowledge to incorporate uncertainty in cause-of-death assignments for modeling of cause-specific mortality the role of nasal carriage in staphylococcus aureus infections. the lancet infectious diseases heterogeneities in the transmission of infectious agents: implications for the design of control programs safety and immunogenicity of a mycoplasma ovipneumoniae bacterin for domestic sheep evaluation of an augmentation of rocky mountain bighorn sheep at badlands national park, south dakota. phd dissertation key: cord- -phsr jp authors: nan title: abstracts tps date: - - journal: allergy doi: . /all. sha: doc_id: cord_uid: phsr jp nan (either in men or women) between metabolic syndrome and incident asthma. conclusion: this study confirmed the significance of obesity as a risk factor for incident asthma. moreover, obesity appeared to be a stronger risk factor than metabolic syndrome. | relationship between helminth infection, blood eosinophils and asthma symptoms in a rural community from the tropics peñaranda d; alvarez l; sierra n; lopez j; zakzuk j; caraballo l institute for immunological research. university of cartagena, cartagena, colombia background: immune response to helminths shares many features with the allergic response. in tropical regions where helminths are highly prevalent, asthma is still a major public health burden. large clinical cohorts suggest that high blood eosinophils (hbe=> cells/ mm ) are associated with asthma exacerbations. however, the association between hbe and asthma severity in rural communities with prevalent helminthic infections is unclear. method: patients with wheezing symptoms in the last year living in a rural tropical community (santa catalina, colombia) where helminths are highly prevalent, were recruited for this study. blood eosinophils were assessed by complete blood count. parasitic infection was evaluated with two serial coprological exams (kato-katz method) and skin prick tests were conducted to determine reactivity to ascaris. results: seventy-three patients (mean age: ; range: - years old) were recruited in this study. a. lumbricoides and t. trichuria active infection ( . % and . %, respectively) were not related to age or gender. a positive spt to ascaris extract, aba- and d. pteronyssinus was observed in %, . % and . %, respectively. mean eosinophil count was cells/mm ; . % had hbe. rate of patients with at least one emergency department visit was . % and hospitalization, . %. blood eosinophil counts (as a continuous variable) were inversely associated with age (p = . ) and higher in helminth infection (p = . ). in crude univariate analysis, exacerbations (er and/or hospitalization) were associated with age (or: . ; % ci: . - . , p < . ) and hbe (or: . ; %ci: . - . , p = . ), but not with helminth infection. for a better definition of asthma, multivariate analysis done in those > years old indicated that hbe, helminth infection and positive ascaris spt were not associated with asthma exacerbations. conclusion: uncontrolled asthma is common in rural places of the tropics. since helminth infection influences eosinophilia, the clinical value of hbe to predict exacerbations is limited in helminth-endemic populations. castro mc ; ferreira j ; sarmento d ; carvalho c ; matos a ; bicho m chln-immunoallergy; lisbon medical school-genetic department, lisboa, portugal; lisbon medical school-genetic department, lisboa, portugal background: the bioavailability of no and endothelial homeostasis depends on the functional polymorphism of -bp del/ins within intron- of dhfr (dihydrofolate reductase enzyme) (rs ) that could interfere in the regeneration of bh (tetrahydrobiopterin) from bh ( , -dihydrobiopterin) and contributes to endothelial dysfunction in asthma. method: asthmatics (n = ) compared with control group (n = ).the polymorphism was analyzed by pcr. control of asthma assessed by (acq and paqlq). statistical analysis with spss . establishing a significance level of p < . . results: there are women and males in asthmatics and women and males in controls (p = . ). in asthmatics: age ( x ± sd): . ± . ; and in control group: age ( x ± sd): . ± . . the genotype frequencies in asthmatics are: dd ( . %); id ( . %); ii ( . %); in control group: dd ( . %); id ( . %); ii ( . %); there is no statistical difference between groups (p = . ). the allelic frequencies in asthmatics are: allele d ( . %); allele i ( . %); in control group: allele d ( %); allele i ( %); there is no statistical difference between groups (p = . ). the genotype frequencies in the uncontrolled asthmatics are: dd ( . %); id ( . %); ii ( . %) ; in the controlled asthmatics are: dd ( . %); id ( . %); ii ( . %); there is statistical difference between groups (p = . ). genotypes id and ii are more frequent in the uncontrolled asthmatics. the allelic frequencies in the uncontrolled asthmatics are: allele d ( . %); allele i ( . %); in the controlled asthmatics are: allele d ( . %); allele i ( . %); there is a trend to have differences between groups (p = . ). allele i is more frequent among uncontrolled asthmatics. the uncontrolled asthmatics are older than the controlled asthmatics (p < . ). there is no differences in gender distribution (p = . ). the genotype ii confers a risk of being uncontrolled asthmatic of . times when compared with controlled asthmatics and adjusted for age: or b : . [ . - . ]; p = . . physiopathology and the emergence of evidence-based clinical guidelines. however, variation still exists among some diagnostic aspects of asthma in real life. it is unknown to what degree diagnosis is affected by the treating physician's medical specialty. results: a total of gps, pediatricians, allergists, pulmonologists and otolaryngologists (orls) replied. although for general application of diagnostic clinical criteria all physicians rated similarly, in general accordance with the mag suggestions, a third of non-pulmonologist practitioners don't recognize chest discomfort as one of the clue symptoms of asthma, but they erroneously believe crackles are (p = . ). we found agreement in almost half of all physicians to erroneously believe that viral illness' induced wheezing in non atopic children predisposes asthma. conversely, - % are aware that allergic sensitization predisposes to asthma. most specialists -except pulmonologists (p = . )-incorrectly listed fev as the best parameter to identify airflow obstruction (ao) and fev /fvc to assess ao severity. % of gps do not know peak expiratory flow (pef) measurements could be valuable, and % of all specialists are not aware that changes in pef can also be used to confirm ao reversibility. to classify asthma, only pulmonologists adequately considered the level of control in similar proportion than severity ( % and %, respectively), which is uniformly the preferred method by most other specialists. conclusion: although in general many clinical aspects of asthma diagnosis seem to be accurately assessed, there is a wide specialityspecific variation regarding some aspects of phenotyping and classification, diverging from mag's recommendations. as such, our results can help to detect knowledge-gaps and to guide the development of more focused specialty-specific learning tools to improve clinical impressions, process medical evidence, and apply it to patient care. | issues, continuous medical education on treatment of acute asthma, exercise induced asthma and asthma in pregnancy should include, per medical specialty background: to unify and improve the management of asthma, including asthma exacerbations, the mexican guideline on asthma ( . %) of employees who stated increased symptoms with flour exposure. among all workers ( . %) employees were diagnosed as asthma and ( . %) workers were diagnosed as ba. conclusion: wheat flour sensitivity is high among workers who are exposed to wheat flour, however the prevalence of ba is similar to the previous data in the literature. johnsen cr ; callesen kt ; jensen bm ; poulsen lk clinic of allergy, dept. of dermato-allergology, gentofte hospital, copenhagen, denmark; laboratory of allergy, gentofte hospital, copenhagen, denmark background: enzymes are well known as sensitizers and causes of occupational allergy primarily in the industries producing and using the products. we present a case of occupational contact urticaria, rhino-conjunctivitis and asthma in a year male chef who was using a transglutaminase enzyme powder obtained from fermentation of streptomyces mobaraense as meat glue in processing of fine culinary dishes. this transglutaminase has been used for protein food preparation in industrial settings since to improve the texture of protein rich foods such as surimi or ham. in this case it was used in small scale in a gastronomy restaurant kitchen spraying enzyme powder with a sieve over raw meat without any protective equipment in contrast to the producer's recommendation. the chef was also found allergic to dried, edible mushrooms also forming part of the meat dish prepared with the transglutaminase enzyme powder. in one occasion he experienced an oral reaction with itching and swelling of the mucosa in the mouth, stridor, angioedema of the face, and urticaria after ingestion of beef meat treated with transglutaminase and rolled in horn of plenty dried mushroom powder. no other symptoms of food allergy were reported but a known cat allergy was. background: formaldehyde and xylene are occupational skin and respiratory irritant and/or sensitizer, exposure to those may be associated with dermatitis, rhinitis and asthma. health care workers, as nurses, laboratory technicians, doctors could be exposed in different tasks in operating rooms, endoscopy and in pathology laboratory. we describe three cases of work-related rhinitis in technicians employed in the same unit of hospital pathology . first case: a woman of years old underwent medical examination in our occupational allergy unit because allergy respiratory symptoms. she has been working for years in pathology laboratory and was exposed to xylene and formaldehyde. she developed rhinitis, rhinosinusitis, hyposmia and cough with sputum after years started work. she had negative skin prick test for common aeroallergens. lung function was normal with a fev /fvc ratio of % of predict. blood cells count reveled % of eosinophils ( /mmc) with total leucocytes. second case: a woman of years old was affected by moderate persistent allergic rhinitis with positive skin prick tests to house dust mite, dog and cat. in the last year rhinitis symptoms worsened in relation to work and improved during vacation. when she was exposed mostly to formaldehyde during shift at the end of it she usually experienced face skin and conjunctival erythema. she developed work-related symptoms after years of exposure in the pathology unit. third case: a woman of years old, who has been working for years in the pathology unit and was exposed to formaldehyde and xylene, in the last year developed moderate-severe persistent rhinitis with hyposmia and chronic cough. she referred to otorhinolaryngologist and an irritant induced rhinitis was diagnosed. she had negative skin prick test for common allergens and normal lung function. results and conclusion: the workers experienced respiratory symptoms in relation to work exposure to formaldehyde and xylene. the suspected causal agents were monitored in the work environment and an exceeding of the recommended limit values was found. preventive measure were adopted with a reduction of exposure and symptoms improve only in the second and third case. challenge test with mannitol is considered to be more specific than test with methacholine. also, duration of procedure is shorter and safer. therefore the study aim was to compare the usefulness of these two tests in monitoring of sict. method: four bakery workers with suspicion of oa underwent single-blind, placebo-controlled sict with workplace allergens accompanied by evaluation of nsbhr with mannitol and methacholine before and after sict. clinical examination, spirometry, skin prick tests (spts) to common aeroallergens and occupational allergens, serum specific ige antibodies to occupational aeroallergens were also performed. results: positive spts results to occupational aeroallergens were found in all bakery workers, specific ige to flours were detected only in two subjects. three out of the four patients displayed positive sict reaction (in two cases early spirometric response). in all of these patients, airway response to methacholine increased significantly. in the first two patients also airway reaction to mannitol was significant, whereas in one subject with early reaction there was no increase in nsbr after mannitol inhalation. the patient with negative sict results did not reveal any changes in nsbr before and after the test, neither to methacholine nor mannitol. | rice-induced occupational anaphylaxis and socio-economic impact-case report method: in this prospective study, a total of students completed a self-administrated questionnaire that comprised different questions and gave information about the participants and their glove use, working habits, signs and symptoms related to these gloves, precautions taken to minimize it, etc. skin prick test is performed through commercial extract latex gloves (stallergenes), while patch test is prepared through latex gloves and adhesives. two types of gloves are used: gloves that contain latex and gloves without latex (vinyl gloves), which are used also as e negative control. results: questionnaire items and diagnostic tests revealed that one-fourth of subjects were suspicious for latex gloves hypersensitivity. their mean value for skin reactions like irritant or allergic dermatitis or contact urticaria was between % and %, while for other symptoms the mean value was under %. logistic regression analysis revealed an association between different questionnaire items and positive allergy tests among suspected cases and diagnosed cases of latex allergy. approximately % of people who work with laboratory animals experience some allergic symptoms and about % of animal technicians go on to develop serious symptoms of asthma. uk government guidelines state that employers must prevent or adequately control exposure of employees to animal allergens and should undertake monitoring to ensure that suitable controls remain effective. the most widely used monitoring method is personal iom filters. however, these need to be attached to a pump and carried by the technician which can be cumbersome and awkward. previous data has demonstrated that allergens from dust mite, cat, dog and pollen could be captured and quantified by a novel type of nasal filter. in this current study, we sought to assess the feasibility of using the nasal filters for the assessment of exposure to mouse allergen in a laboratory facility. method: technicians working in a laboratory animal facility were asked to wear the filters during normal routine work. for comparison, they were also asked to wear an iom filter for the same duration. allergen was extracted from nasal and iom filters by gentle rocking in pbs-tween for two hours. levels of the major mouse urinary protein (mus m ) were quantified using our multiplex array technology, which is highly sensitive and allows for quantification of mus m down to . ng/ml. results: significant levels of mus m were detected in the nasal filter extracts and these levels correlated with the type of activity that was being performed by the technician, as well as the housing environment of the mice. levels were compared to the suggested 'safe' limit of allergen exposure of ng/m . we also found that the technicians grew accustomed to the nasal filters quickly and found them far more practical for every day monitoring that wearing the iom filter and pump. conclusion: these data indicate that nasal filters may be considered a simple and easily wearable method for monitoring laboratory animal allergen exposure. future studies are planned to assess the feasibility of wearing the filters for analysing exposure to other laboratory animal allergens from rat and guinea pig. havana university lower co emission, water and feed consumption and limited waste production. insects are currently allowed both for human and animal feeding in some eu countries, including italy and the risk profile related to production and consumption of insects as food and feed, including risk of allergenicity, is currently under evaluation by efsa. both food and feed products derived from insects require multiple manipulations by the breeder and/or by the workers who transform the insect into the commercial products, thus the occupational exposure have to be considered too. the aim of this work is to evaluate the allergenicity of tenebrio molitor, one most used species for animal feeding. method: t. molitor proteins were extracted from intact dried larvae and from flour of dried larvae. the protein extracts were separated in one-dimensional electrophoresis conclusion: according to these results, the larva flour seems to be less immunoreactive than the intact counterpart, probably due to the processing that causes the degradation of protein bands over kda. working in gastronomy is associated with exposure to many factors with an irritating and allergic potential influencing respiratory system. food products and organic dust are the source of inhaled allergens which may cause sensitization during apprenticeship. the study aim is a prospective observation of incidence of sensitization to selected environmental and occupational allergens among culinary school apprentices and identification of work-related allergic diseases in this group. method: the cohort comprised apprentices. they were examined in the first and the second year of education. questionnaire and allergological tests [(skin prick test) spt to common and occupational allergens, ige level evaluation (total and specific for occupational allergens) and pulmonary tests] were performed]. results: the most frequent symptoms reported by examined apprentices were rhinitis ( . %), conjunctivitis ( %), skin symptoms ( . %), dyspnea ( . %) and cough ( . %). subjects developed nasal symptoms during the second year of education, while in cases the skin symptoms and in subjects conjunctivitis appeared. in cases the work-related symptoms were reported. the most frequent positive results of spts were obtained with dermatophagoides pteronyssinus . %, dermatophagoides farinae . %, grass pollens . %. positive spt to rye and barley flour were found in respectively . % and . % apprentices. . % of apprentices had specific ige to flours. the preliminary results indicate that work-related allergy symptoms and hypersensitivity to occupational allergens are rarely found among culinary school apprentices in the first years of education. the further observation will allow to evaluate the trends in incidence of allergy to occupational allergens, as well as the clinical presentation of allergy in that group. | how multifaceted the clinical presentation and etiology of allergic diseases could be? method: the study was done in children from west georgia randomly and on based of questionnaire of representative cohort. ( ) ( ) ( ) . the cohort was children, - years old, risk factors were studied by way of interviewing, clinical-laboratory dates. for assessing the risk factors, was used 'case control' method. the statistical processing of material was done with computer program sps/sv . inclusion criteria for enrolment were: collectors of dust, gender, existence of moisture and mold consuming of tabasco, atopic dermatitis and seasonality. results: the groups, which we have studied, prevalence of acute respiratory viral infection was %, bronchitis − . %, allergic rhinitis . %, atopic dermatitis . %, food allergy . %. the reliability was high (p < . ) in families with bronchial asthma compared with healthy population. bronchial asthma was detected in . % of population. the hereditary load of allergic diseases in patients with bronchial asthma was . % and in healthy cohort it was . % (p < . ). conclusion: based on the results, we can conclude that, ecological factors and genetic predisposition significantly influences on prevalence of sensibilisation of house dust mite, molds and formation of bronchial asthma. as the genetic and environmental factors that act on an immune system are better elucidated and their roles established, the implementation of more enduring preventive efforts will be developed. however, at present, the best approach to the child at high risk for the development of allergies is to institute dietary and environmental control measures early to decrease sensitization, and to recognize and appropriately treat the evolving signs and symptoms of allergic disease. background: plantation of road-side avenue trees has become a major part of the urbanization programme in kolkata metropolis of india for megacity beautification and environmental management. due to evergreen habits, gulmohor (delonix regia) and chhatim (alstonia scholaris) are frequently selected for plantation programme to generate green belts. however, an increasing incidence of seasonal pollinosis was observed among the inhabitants living in close vicinity to these trees suggesting a possible link between the airborne pollen load and the concomitant respiratory hazards. this prompted us to investigate the allergens in the pollen of these two dominant avenue trees. method: aerobiological surveys were conducted at multiple sites of kolkata for a period of two years using seven-day volumetric burkard sampler to record the pollen concentration in the outdoor ambient air. clinical data and residual blood of pollinosis patients were collected from a public hospital. allergens were detected in the pollen proteome fractionated in d gel by ige-serology. the major igereactive proteins were partially purified by ammonium sulphate fractionation followed by ion-exchange chromatography. the allergenic activity of the fractions was tested by histamine release assay. results: a clear correlation was observed between the pollinosis related morbidity and the aeropollen load especially during the peak flowering period of these two trees. about % and % of the patients displayed positive spt response and ige-reactivity using pollen extracts of gulmohor and chhatim respectively. immunoproteomic analyses revealed the presence of - ige-reactive components in the d pollen proteome of these species. hierarchical cluster analysis with patient immunoblot data identified a kda and a kda protein as major allergens of gulmohor and chhatim respectively. the purified fractions containing each of these two major allergens induced histamine release from granulocytes within a range between and %. method: immortalized human keratinocyte cell line (hacat) and primary normal human epidermal keratinocytes (nheks) were differentiated with calcium chloride for and days, respectively. following the differentiation, the cells were treated with il- ( ng/ml), il- ( ng/ml), and/or hcho ( × ^- %) for hours. the mrna expression of flg, ivl, lor, dsg , dsg , dsc , dsc , as well as tslp was analyzed using quantitative real-time pcr. results: hcho exposure decreased the mrna expressions of structural components (flg, ivl, and lor) and cell adhesion molecules (dsg , dsg , dsc , and dsc ) in a short-period time of exposure ( hours). we also found that hcho exposure significantly enhanced il- -and/or il- -induced tslp production in nheks as well as hacat. interestingly, exposure to hcho alone is enough to increase the tslp mrna expression in both cells. conclusion: our results suggest that hcho exposure might synergistically damage the skin barrier function with il- and il- by increasing tslp expression and decreasing structural components as well as cell adhesion molecules. | skin prick test reactivity to aeroallergens in adult allergy clinic in a tertiary hospital: a -year retrospective study results: five different human sera were screened for specific ige level against different allergen sources using test methods of three different suppliers. the sensitivity of the three different methods can be arranged in the ascending order manufacturer a < manufacturer c < manufacturer b. with the test of manufacturer a, % of the measurements were below the detection limit ( . ku/l), with the test of manufacturer c, % of the measurements were below the detection limit, whereas the test of manufacturer b leads to values below the detection limit in % of the cases. in terms of variation coefficient, the test system of manufacturer c had the best performance. test systems of manufacturers a and b exhibited comparable variation coefficients, which were considerably higher than that of manufacturer c. conclusion: based on these test results, only the test of supplier c is recommendable for determination of levels of specific ige for diagnostics of allergic patients. with the test of manufacturer a, elevated levels of specific ige antibodies for many allergens cannot be detected due to the poor sensitivity of the test system. the test system of supplier b exhibits a good sensitivity but the coefficient of variation is rather high for a diagnostic test. this drawback could be circumvented by multiple determination of one test parameter. although this is an advisable strategy in general, the routine in diagnostic laboratories is incompatible with this approach, since throughput would decrease while costs would increase. this study is another good example for the need of the implementation of a characterized standard material with known values of sige, as demanded by wojtalewicz et al. method: cd c and cd expression on basophils were monitored upon exposure of whole blood samples (< hours) to anti-ige and/or allergenic extracts. staining was conducted on exposed samples using dry room temperature stable antibody panels (dura innovations format) coated in well plates, eliminating all antibody pipetting steps from the workflow. red blood cells were lysed and data was acquired (without further wash steps) on a cytoflex flow cytometer (beckman coulter). staining and lysing were automated using a biomek (beckman coulter). results: the described no-wash preparation protocol, already established for manual preparation mode in tubes, could be trans- conclusion: the hr-test was significantly less likely to be positive, if a patient suffered from monosymptomatic ae than in ae patients with concomitant urticaria. this could signify a higher likelihood of treatment response to antihistamine and other anti-allergic medication in the latter group. background: pathogenetic mechanisms of allergy are polymorphic. they include ige-dependent and ige-independent, allergen-specific granulocyte-mediated and lymphocytic reactions, as well as nonspecific hypersensitivity, which are realized through a variety of mediators: histamine, tryptase, etc. allergen bucal challenge mimics the natural situation and is useful for understanding the mechanisms of allergic airway inflammation and airway hyperresponsiveness (ahr).saliva used as a non-invasive readily available bio-sample for diagnosis instead of blood. biomarkers in saliva are associated with the pathogenesis and clinical outcome of allergic diseases method: aim: to examine mediators for ahr with buccal(mucosal) challenge tests. we examined patients with allergic asthma(the history, positive skin prick test, serum specific ige) and healthy volunteers. saliva were collected. then, both groups were subjected to buccal(mucosal) allergen challenge by a water-salt solution of the mite allergen dermatophagoides pteronyssinus. saliva was recollected in minutes and hours after the provocation. the level of myeloperoxidase, elastase, tryptase in saliva were determined by the elisa. that provocative test did not cause clinical symptoms development or reduction in nasal bronchial patency in any patient. results: in patients with allergopathology, an initially increased level of myeloperoxidase and tryptase in minutes after the provocation, elastase increased in hours (table ) . tryptase in saliva after minutes increased till . ( . ; . ) (me, pg/ml (lq;uq)), p = . . increased tryptase is presence of increased cellular inflammation, e.g. mast cells. its ige-dependent hypersensitivity, because there was the correlation between the elevated level of tryptase and positive prick tests. elevated levels of myeloperoxidase and elastase in saliva may be the criteria for the neutrophil hypersensitivity and ige-independent reactions. in healthy volunteers this increase was not observed. the identification of tryptase, myeloperoxidase, elastase can be used for diagnosis of types of ahr. tryptase is a mediator of early (immediate) response to allergen. increased myeloperoxidase and elastase indicates the involvement of the eosinophils and neutrophils in the oral mucous membrane in the allergic process. these mediators have additional roles in the late phase response. elevated levels of myeloperoxidase and elastase in saliva may be the criteria for the neutrophil hypersensitivity. conclusion: safe and acute in vitro methods allow to conduct early etiological diagnosis of allergy, which contributes to the effectiveness of therapy; the detection of polyvalent sensitization dictates the need for molecular diagnostics to single allergens, which has a higher prognostic level and the clinical significance of predicting the appropriateness and effectiveness of allergen-specific therapy; laboratory diagnostics of the allergy allows to reveal sensitization at the ( , ) ( , ) ( , . ) *p = . ; **p = . ; ***p = . . subclinical level, which increases early diagnosis and identify persons with a predisposition to allergy; the establishment of causal aller- background: antibacterial chemicals like parabens and triclosan have been associated with allergic disease in children. parabens are also suspected to affect metabolic functions, possibly due to their weak endocrine disrupting properties. furthermore, a possible link has been suggested for eczema and adiposity, and thus, how body burden of chemical exposures affect both of these outcomes are of interest. we aimed to describe the association between exposure to parabens and eczema and body mass index (bmi) in an adult population in norway. method: urine biomarkers of butyl-, ethyl-, methyl-and propylparabens were quantified by mass-spectrometry in adult participants (median age= years) from the rhinessa study in bergen, norway. linear regression models adjusted for gender, age and bmi (for eczema outcomes) and with clustering for siblings, were applied to model possible association between specific gravity standardized urine biomarker concentrations of parabens with bmi and eczema. results: propyl-(ppb) and methyl-parabens (mpb) were detected in % of the urine samples; ethyl (epb) in % and butyl (bpb) in % of the samples. in women, epb and bpb were detectable in % and %, respectively. participants with current eczema ( %) had lower level of several parabens compared to those without eczema (bpb for both genders; epb in women only and sum of all parabens in men only). body burden of epb (geometric mean (gm)) was . μg/l in women with current eczema compared to . μg/l in women without eczema (p = . ). body burden of parabens (mpb and epb) were inversely associated with obesity (bmi> , ( . %) ), as compared to normal range bmi (bmi= . - ( . %)) in both men and women. the concentration of mpb for obese women was gm= μg/l compared to μg/l in women with normal range bmi. for men, the gm for mpb was . μg/l in obese compared to . μg/l in normal weight men (p = . ). conclusion: person with eczema or obesity had lower paraben levels in urine. we speculate that these chemicals might be stored in adipose tissue, and therefore excreted in urine in lower levels among the obese. eczema and obesity was not strongly associated in the current study. method: we retrospectively analysed medical records of patients who were patch-tested with our dental screening series of substances. adverse reactions to dental materials were suspected based on subjective complaints in the oral cavity and/or objective conditions of the oral mucosa. square plastic chambers on hypoallergenic tape were used. patch tests were applied to the upper back and removed by the patient after hours. readings were performed and days after application (d and d ). results were evaluated according to the international contact dermatitis research group guidelines. positive patch test reactions fulfilled the criteria of at least a one plus (+) reaction on d and/or d . the term »contact allergy« is usually used for such reactions. we prefer the term »contact sensitization«. clinical relevance of positive reactions to dental materials was not systematically assessed in this analysis. conclusion: we report a high frequency of positive reactions on d that were not seen on d . this finding demonstrates the importance of an additional late patch test reading in patients with suspected contact allergy to dental materials. background: psoriasis is a chronic inflammatory skin disease. its etiopathogenesis is not exactly known. it is believed that the disease occurs in people with genetic tendency with the effect of a triggering factor. in some studies it is observed that contact dermatitis in psoriasis is increased with respect to normal population. for this reason it is proposed that allergen materials could trigger psoriasis. in this study it is aimed to determine contact allergy frequency in psoriasis cases using patch test. results: of the cases were plaque, of them were guttate, of them were palmoplantar and of them were inverse type. more positivity rate is observed in psoriasis cases ( . %) than control ( %). the positively responsed materials with respect to decreasing number of patients are found as follows: nickel sulphate ( . %), thimerosal ( . %), peru balsam( %), p-phenylenediamine( . %), colophony( . %), n-isopropyl-n-fenil- -fenilendiamin( . %), mercaptobenzothiazole( . %), benzocaine( . %), most frequently plaque type and following guttate type positive responses are observed in evaluations with respect to clinical types. no statistical significance is found between patch test results and pasi values in psoriasis cases. conclusion: patients with psoriasis should be carefully evaluated. sometimes some materials may trigger psoriasis. the composition of the pigments that professional tattooists use are varied inorganic salts of metals or organic vegetable pigments. red tattoos, especially those that contain mercury, are the most common cause of late reactions. method: year-old male patient with no previous allergy history known, who gets a tattoo on his right leg and develops within months, cutaneous erythema and pruritus on the same location as the tattoo. true test ® for skin allergy patch epicutaneous testing is performed. results: and hours reading: showed positiveness for mercury ++, with no late positive reactions after that. conclusion: as allergists we should be familiar with the different types of tattoos available, and know the possible cutaneous complications that each of these decorative techniques can present. it is our responsibility to be able to diagnose any complications at an early stage, establish the most appropriate treatment and, if possible, prevent them by informing the possible users. background: within otorhinolaryngological pathology chronic eczematous otitis externa is one of the most common, usually treated with topical medication successfully; however, there are cases in which the poor response to treatment, or the recurrence thereof, may be due to causes secondary to the medication itself, as observed in cases of allergic contact dermatitis caused by these drugs. case report: we present a -year-old male patient without relevant pathological antecedents or known allergies, who consulted the otorhinolaryngology service of our center for otorrhea of days of evolution, bilateral external otitis is diagnosed and a topical otological combination is recommended (beclomethasone dipropionate . % and clioquinol %, excipient: macrogol) with improvement. however, during the following years the patient presents exacerbations and remissions of the condition, with negative or inconclusive microbiological studies. during all that time he was using the prior topical treatment and other combination treatments of topical antibiotics, corticosteroids and local antiseptics. more aggressive causes of external otitis such as malignant external otitis were ruled out. during the third year of follow-up, a clear relationship of exacerbations was observed with the use of the first combination of topical drugs, so it was decided to investigate allergic sensitization. material and methods: we perform patch tests using true test ® , standard spanish series (geidac -spanish group for investigation of contact allergy dermatitis), topical corticosteroid battery, antiseptic, as well as topical medications used by the patient. results: from the first reading on day two, positivity was observed for: mixture of quinolines ++ patient's otological combination ++ and chlorquinaldol ++; being confirmed in the reading at day four. eczematous external chronic otitis is diagnosed with allergic sensitization to quinolines (clioquinol, chlorquinaldol). we conclude that in the case of chronic external otitis, allergic contact dermatitis should also be investigated as a possible cause, and it is important to perform epicutaneous tests with the patient's own products to evaluate non-common or hidden allergens that may be relevant to their current pathology. most common causes of acd. it is important to distinguish local findings of infection from acd caused by topical antibiotic treatments. here we present a patient with acd with topical use of bacitracin and neomycin combination therapy due to recurrent blepharitis. an -year-old male patient presented with the complaints of itching, redness, swelling of the eyelids and facial edema. he had used various topical ophthalmic antibiotherapy and eye shampoo for years due to recurrent blepharitis. five days ago, due to the redness of the eyelids, burning sensation in the eye, itching of the eyes; he was examined by an ophthalmologist. the eyelids and eyelashes were scaly and dry. the patient was treated with warm water soaked cloth dressing, mechanical eyelash cleaning and topical antibiotherapy (neomycin-simple combination therapy). after the second day of treatment, the patient's topical ophthalmic antibiotherapy was discontinued due to an augmentation of the redness in the eye- | contact allergy after exposure to ivy (hedera helix l) potent steroid treatment associated with systemic antihistamines, but with no improvement. on dermatological examination a small, well delineated, eczema-like plaque was noticed on a digital finger, as a new finding striking with her old burn scars. she denied any symptoms and was in good health condition. a mm punch biopsy was performed and histological report established the diagnosis of squamous cell carcinoma. the patient was transferred to oncology department for further investigation and treatment. conclusion: early diagnosis and prompt surgical therapy are recommended to all patients with chronic wounds and scars who develop malignant transformation. *written informed consent for the publication of potentially identifiable personal details of patient (gender, age, illness, location) was obtained. **in relation to this presentation, i declare that there are no conflicts of interest. ertugrul a; hizli demirkale z; bostanci i dr sami ulus maternity and children training and research hospital, ankara, turkey introduction: the incidence of contact sensitization among adolescent has been increasing. nickel is one of the important causes of allergic contact dermatitis (acd) in this age group. increased exposure to nickel and deterioration of the skin barrier are among the important risk factors in children. the gold standard for diagnosis is skin patch test. we report here an adolescent patient who has allergic sensitization to nickel and cobalt. case: a -year-old female patient admitted in our clinic with a complaint of edema on her face. the patient had applied chickpea water to her face at least once a day for one week because of her acnes. her medical history revealed that she had experienced similar edema on her face after applications of clay mask one year ago. she was diagnosed with cellulitis and she had been treated with antibiotics for five days. on her physical examination, angioedema was observed on her face, especially on the glabellar region. eosinophilia was not found on her laboratory data. c-reactive protein (crp), c and c esterase inhibitor protein levels were also normal. the skin prick test was performed with aeroallergens, chickpea, lentil, bean and nuts, and no reaction had been observed. the patch test was performed with 'thin-layer-rapid-use-epicutaneous' (t.r.u.e) test and chickpea. the patient had positive reactions to nickel and cobalt. detailed questioning disclosed that the patient was preparing the chickpea water in a metal pot. result: chickpea water and clay mask contain varying amounts of nickel. it was thought that the edema of the patient is due to nickel allergic contact sensitization. an increased exposure to nickel and cobalt raises the frequency of sensitization. nickel allergy can cause different clinics ranging from localized lesions to systemic reactions. we want to emphasize that a detailed medical history and the patch test would enable clinicians to demonstrate hidden allergens and then make a correct diagnosis. case report: autoimmune progesterone dermatitis is a condition of hypersensitivity to progestogens. it is not an easy diagnosis given the variety of clinical presentations it may have, ranging from eczema, urticaria, erythema multiforme, folliculitis, to angioedema or even anaphylaxis. manifestations are cyclical, occurring when the levels of progesterone are higher, this is, at the luteal phase of the menstrual cycle, and disappear during menses, with the physiological decrease of the hormone. it can also be triggered by exposure to exogenous progestins. we report the case of a -year-old woman with a cyclical erythematous and violaceous rash related to the menstrual period. the symptoms typically began - days before the onset of menses and ended - days before. the diagnosis was based in the clinical history and intradermal skin tests: skin prick testing with levonorgestrel and medroxyprogesterone were negative, but the intradermal skin test with medroxyprogesterone was positive at a concentration of mg/ml. we performed intradermal testing with the same concentration in three other women with no symptoms to exclude an irritative reaction, which were negative. autoimmune progesterone dermatitis is, perhaps, not so rare, but rather poorly recognized and reported, and thus, underdiagnosed. clinicians should be aware and include always this condition in the differential diagnosis, especially in cases of atypical or intractable skin eruptions. case report: a year old male was referred to a community allergy clinic for assessment of chronic urticaria (cu). allergy assessments for foods, inhalant and inducible physical triggers revealed no association. an autoimmune workup followed, with treatment consisting of standard dose antihistamines (h and h ). blood work revealed a persistently low hemoglobin with low-normal ferritin. hematology consulted and followed attempted iron replacement to no avail. skin biopsy revealed neutrophilic rich urticaria with the presence of eosinophils. serum protein electrophoresis (spep) revealed a monoclonal gammopathy with elevated igm, felt to be of undetermined significance (mgus). c-reactive protein (crp) was consistently elevated ( , ) in conjunction with anemia. rheumatology consulted and cleared of any evidence of vasculitis. hematology considered the anemia to be of chronic disease linked to cu. the cu was resistant to treatment including high dose antihistami- background: isolated head and neck angioedema (ae) can be mediated by bradykinin (bk) or histamin (hi) . the objective of our study was to determine which etiology was most frequent in cases of death by asphyxiating ae in france. we sought all cases of death by isolated asphyxiating ae reported in france between and via death certificates and/or the national pharmacovigilance database. results: the overall mortality by asphyxiating ae for all causes was . / million inhabitants. the death rate of bkae per million inhabitants was . and lethality of . per thousand patients per year. the death rate of hiae per million inhabitants was . and lethality of . per thousand patients per year. we found a times higher risk of death in case of bkae than hiae. conclusion: consequently, particularly severe episodes must be initially considered as bradykinin mediated and quickly reassess any first-line treatment that is inappropriate. case report: we present the case of a -year-old man who suffered recurrent abdominal pain since age of eight, leading to unnecessary emergency surgical interventions and endoscopies before hereditary angioedema due to c inhibitor deficiency (c -inh-hae) was diagnosed at the age of . rare subcutaneous swellings were considered allergic reactions preventing proper diagnosis. family history, positive for recurrent abdominal pain and swellings was totally neglected until diagnosis of c -inh-hae type i was established through appearance of severe oro-facial symptoms in the propositus' grandson. the diagnosis was suggested by the boy's mother, directed by educational materials available in the international hae patients' association website (www.haei.org). this report highlights and emphasizes the importance of accurately evaluated personal and family history to suspect condition that are scarcely known to the majority of physicians. highlights: diagnostic delay in hae and iatrogenic procedures are an underestimated problem, hiding undefined consequences, possibly destructing an entire lifetime. correct, publically available information provided by patients' associations raise awareness about the disease and could put the milestone of establishing correct diagnosis. de luque v ; lara p ; guardia p ; jimenez ar virgen macarena hospital, seville, spain; hospital virgen macarena sevilla, seville, spain background: in the protocol for the study of patients who consult for recurrent acute angioedema with facial involvement, the contactant battery is included (epicutaneous test). we review the results in our patients with facial angioedema to evaluate the contactants to which these patients present sensitization, some of them coexisting with contact dermatitis clinic. we reviewed the patients referred to the clinic for recurrent acute angioedema with facial involvement and to whom a standard battery epicutaneous test was requested. in all these patients, other habitual triggers included in the diagnostic protocol (food, medications, autoimmune diseases, bradyinergic aea/complement deficit …) were ruled out. conclusion: it seems to be profitable to continue including in the diagnostic battery of patients who consult for aea with facial affectation, study of epicutaneous with standard battery. it is a small sample, but the data correlate with what has been published, being more frequent the sensitization to contactants in women and the contactant more frequently involved nickel sulphate. | ace inhibitor-related angioedema-the value of history taking background: angioedema is a well-recognized side effect of angiotensin-converting enzyme (ace) inhibitor therapy. although it occurs in < % of the patients who take these drugs, it seems to be responsible for % of the episodes of angioedema. this entity is underdiagnosed and failure to recognize it leads to recurrence of episodes, with an impact on morbidity and increased risk of serious reactions. our objective is to analyze the clinical, therapeutic and orientation approach of patients diagnosed with ace inhibitor-related angioedema, evaluated at the outpatient consultation (oa) of immunoallergology (ia). a -year retrospective study was performed by analyzing the clinical files of all patients diagnosed with angioedema observed in oa of ia. the following variables were analyzed: gender; age; clinical data; evaluation in emergency department (ed); therapy in the episode; evolution and orientation. the chi-square test was used to study the association between categorical variables: "established therapy"/"disease evolution" and "place of reference"/"withdrawal of ace inhibitor". results: review of cases of patients referred for angioedema. only in % the final diagnosis was "ace inhibitor-related angioedema". the mean age of the patients was . years and % were male. the location of angioedema occurred in the tongue in % and in the remaining sites (lip, hemiface, tongue and hemiface, tongue and lip) appeared in the same frequency, %. none of the patients had airway obstruction. during the episode of angioedema, % of patients were not referred to ed and the therapeutic approach was done with antihistamines in %. in patients who were referred to ed ( %), antihistamines and corticosteroids medications were administered in %. regarding the evolution, it was verified that the duration of the episode was independent of the established therapy (p > . ). regarding the place of reference, % of the patients were referred form hospital (ec or ed) and, in these, the ace inhibitor was suspended in %. in patients referred from general practitioners ( %), in none of them the ace inhibitor had been withdrawal. a causal association between the use of ace inhibitors and the episode of angioedema becomes crucial, since drug withdrawal is indicated. a reference for ai oa should be weighed. therapy with antihistamines and corticosteroids has no proven efficacy. hereditary angioedema (hae) seen by physicians belonging to the hae scientific committee of the aaaeic background: patients with c -inh-hae frequently suffer from anxiety and stress. the impact of prophylactic treatment on anxiety and stress in c -inh-hae patients is largely unknown. here, we analyzed data from the apex- study, a phase ii study that investigated the effects of the oral kallikrein inhibitor bcx . method: c -inh-hae patients with a history of at least hae attacks per month were randomized to receive four different doses ( , , , . mg) of bcx or placebo for days. the depression anxiety stress scale (dass) was administered at baseline and at day . the dass consists of three self-reported scales designed to measure the negative emotional states of anxiety and stress. subjects used a -point severity/frequency scale to rate the extent to which they have experienced each state. results: baseline dass total scores as well as anxiety and stress domain mean (sd) scores for the mg treatment arm (n = ) were . ( . ), . ( . ), and . ( . ) points respectively. placebo scores were generally similar or slightly lower at baseline than for the mg treatment arm. the dass questionnaire data showed statistically significant improvements in total score vs. placebo at day (− . method: a two-phase mixed methods approach was used to develop the hae-rt tool including: phase : delphi study [hae specialists (n = ) and national patient advocacy group members (n = )] was conducted to reach consensus ( % agreement) on predictor variables to include in the tool. phase : retrospective chart review was conducted to assess the predictive findings of the decided variables. a convenient patient sample presenting with angioedema (with and without hae) between january -january were included in the study. results: nine of invited experts ( %) participated in the delphi study. of hae-specific predictive variables, reached consensuses including: (i) recurrent angioedema; (ii) absence of urticaria; (iii) recurrent abdominal pain/swelling; (iv) lack of response to allergic therapy. the retrospective study included patients (n = with hae; n = non-hae; overall % female). hae patients were significantly more likely to have a family history of hae ( % vs %; p < . ); previous recurrent angioedema ( %; p < . ); present with no hives ( %; p < . ); previous recurrent abdominal pain ( %; p < . ); and % responded to allergy treatments (p < . ). a regression analysis categorized observed frequencies (actual patient outcomes from chart review) versus predicted (by model); plotted on a by table and calculated the sensitivity and specificity of the hae-rt which resulted in one hundred percent for both. conclusion: our study demonstrated that expert involvement led to the identification and prioritization of variables that when included an hae-rt tool, were associated with a high level of sensitivity and specificity when applied to known patients. the next step is to observe the effect of the hae-rt tool on patient care in the ed. method: evaluation of cardiovascular manifestation included morphology, serum level of troponin t, electrocardiography (ecg) and echocardiography. evaluation of pulmonary manifestation included spirometry, diffusing capacity of the lung for carbon monoxide (dlco) and evaluation for mastocytosis included bone marrow biopsy and serum total tryptase measurements. results: in the study there were patients - women and men between and years old (the average age was ). there were ( . %) patients with mpcm, ( . %) with bmm, ( . %) with ism and ( . %) with ssm. the average level of serum tryptase was . μg/l ( . - ) . troponin levels was within the normal range in all patients. one patient had lowered the ejection fraction (eflv= %). no one patient had restriction. the average value of a forced lung capacity was . l ( %) and a total here, we describe a case series of twelve mis patients seen at our department over a -year period and report how many of these patients have sm. common phenotypical manifestations of acute hae episodes in this region, to review therapeutic challenges in a rural setting in comparison with world standards, and lastly to evaluate the socio-economic burden inflicted by the disease. method: a sample of individuals from a total of . the exclusion criteria was the inability to attend booked appointments more than times in year ( ). the following methods were used: an interview to formulate a family tree identifying affected individuals in contiguous generations, and review of the acute presentations in the past year ( ) . a questionnaire to obtain the relevant hae associated socio-economic burdens. a chart review to identify the therapeutic strategies in this region. c inh levels, and complement c to confirm the diagnosis. results: polygamy as a local culture was found to be an important factor that perpetuated the genetic burden of the disease. c inh and c levels confirmed hae in all participants individually. clinical features during acute attacks included swelling of extremities ( %), facial swelling ( %), neck swelling ( %), and laryngeal swelling ( %). therapeutic strategies for acute attacks included fresh frozen plasma or fresh dried plasma. danazol was used for prophylaxis. hae has had a significant negative impact upon the socioeconomic status of the affected individuals. conclusion: hae is a newly identified disorder in the broad spectrum of allergy medicine in kwazulu-natal. the diagnosis is simple to confirm but requires an initial high index of suspicion, and therapeutic management still poses a challenge in this region due to lack of resources. genetic counselling is of paramount importance during intervention since polygamy forms part of most cultures in this region. a support strategy is highly recommended in order to help alleviate the socio-economic burden posed by the disease in this region. the socio-economic burden secondary to hae ( participants/ identical questions each) question ( - points) question ( - points) question ( - points) question ( - points) question ( - point) method: a total of medical faculty senior year students were included to study on a voluntary basis. students are divided into two groups. one group was given visual user guide that has not been modified, and a visual user guide on which we have modified to the other group ( figure ). then they were asked to show how to use the inhaler spacer. results: the mean age of the volunteers was . ± years and ( . %) were male. there were students in the group without modification of the visual user guide and students in the other group with modified the visual user guide. sixty-four per cent of the modified user guide group showed correct use of the inhaler spacer, while % of the unmodified group showed correct use (p = . ). the group that given modified visual user guide was more successful in all of the display steps of the inhaler spacer. conclusion: modification of the currently available visual user guide of inhaler spacer in our country will increase the correct usage rate. results: mean fev , fvc, fev /fvc z-score were . ( . - . ), . ( . - . ), . ( . - . ), respectively. restriction had ( . %) and obturation ( . %) patients. fev (p < . , r = . ) and fvc (p = . , r = . ) decreased with age (%pv and z-score). background: children who were treated for leukemia are known to have developed long term impairment of lung function. the reasons that complication are only partially known. the aim of this study was to asses pulmonary function in children treated the lower dlco is the most frequent abnormality in childhood leukemic survivors. hsct and pulmonary infection (in particular cmv pneumonia) is a strong risk factor for impairment of dlco in children. clinical manifestation of dlco impairment is poor exercise tolerance. a screening for respiratory abnormalities in survivors following treatment for childhood haematologic malignancies, seems to be of significant importance. | phenotyping allergic respiratory diseases: an unsupervised classification using latent class analysis allergen groups was significantly associated to uawi (aor[ % ci]: . [ . - . ] ), compared to uasi. results: . % of br and % of py were women, median age was years, % br and % py reported having more than four years of training. although they recognized the main symptoms of ar, % br and % py never asked whether the patient had a medical diagnosis of ar; . % br and . % py did not ask whether the symptoms occurred when close to animals or allergens; % br and % of py did not ask if the patient had a medical diagnosis of asthma; % br and % py did not ask if rhinitis worsens asthma symptoms and . % br and . % py did not ask whether symptoms of rhinitis interfere with their daily activities. results: there was a predominance of female (br: %, py . %, uy: %) median age years old, / worked in the community and / in the emergency departments, % of the br had more than years of education, % from py had between and years, and % from uy had been graduated for less than year. br/uy recognize the main symptoms of ar, however % of those from uy do not ask: if the patient has physician diagnosis of ar, % present shortness of breath, and % a medical diagnosis of asthma, % if rhinitis worsens asthma symptoms and % if symptoms of rhinitis interfere with the patient's daily activities. the prescribed treatment varied a lot, the intranasal corticosteroid use rate was: bd: %, pd: % and ud: %. % of doctors in py, . % in br and % of uy never refer the patient to the specialist. . % of pcd of br, % of py and . % of uy are aware of aria guideline. conclusion: although ar is largely attended by pcp, recognition of symptoms and their impact on asthma, as well as the knowledge about aria guide is low and treatment is not always prescribed according to best practice. allergy education programs, with an emphasis on ar and aria guide, need to be directed to pcp in la for the better assistance of ar patients. | assessing knowledge of allergic rhinitis among final year medical and pharmacy students in croatia-curriculum change necessity? the two factor structured questionnaire was formed by the authors regarding the topics mentioned. t-test was used for statistical analysis. the global results were formed as composites of ( ) ar general characteristics, ( ) ar treatment approach, and ( ) the participants' overall knowledge. of the respondents, ( . %) were female and ( . %) were male (p < . ). medical students had a median score of of correct answers on ( ), of on ( ), and of on ( ), whereas pharmacy students had median score of of correct answers on ( ), of on ( ), and of on ( ). there were no significant differences in knowledge between two student groups. the results indicate an inadequate level of knowledge of ar in both groups, especially regarding the therapy approach. since general practitioners and community pharmacists have a major role in providing treatment to patients suffering from ar, it is important to develop advanced knowledge on this topic during medical and pharmacy degree courses. despite a relatively small study population, it would be advisable to introduce change by improving the core curriculum regarding ar with more emphasis on treatment, but additional research on this topic is necessary. tan r ; cvetkovski b ; kritikos v ; price d ; yan k ; smith p ; bosnic-anticevich s woolcock institute of medical research; university of sydney, sydney, australia; observational pragmatic research institute pte ltd, singapore, singapore; royal prince alfred hospital, sydney, australia; clinical medicine, southport, australia; griffith university, sydney, australia background: people with allergic rhinitis symptoms frequently selfselect over-the-counter medications from community pharmacies without seeking advice from a health care professional. this increases the incidence of complications due to delayed diagnosis and suboptimal treatment. this study aims to (i) compare the demographics, clinical characteristics and medication selected, between pharmacy customers who choose to self-select and those who interacted with a pharmacist when purchasing medication for allergic rhinitis symptoms, and (ii) identify the key factors associated with allergic rhinitis patients' medication self-selection behaviour. a cross-sectional observational study was conducted in a convenience sample of community pharmacies from the sydney metropolitan area. data were collected using a researcher administered questionnaire that included: demographics, pattern of allergic rhinitis symptoms, their impact on quality of life, factors triggering allergic rhinitis symptoms and medication(s) selected. logistic regression was used to identify key factors associated with participants' medication self-selection behaviour. results: of the recruited participants, were identified with allergic rhinitis, of which . % were female, . % were aged more than years old, . % had a diagnosis of allergic rhinitis, and . % self-selected medication(s). significant differences were noted in allergic rhinitis symptoms, impact of allergic rhinitis on quality of life and medication(s) selected between participants who chose to self-select and those who interacted with a pharmacist. participants who experienced moderate-severe wheeze were times more likely to self-select allergic rhinitis medication(s), and those who had allergic rhinitis symptoms impacting on their quality of life were . times less likely to self-select allergic rhinitis medication(s). conclusion: there is a high incidence of self-selection of over-thecounter treatments for allergic rhinitis symptoms in community pharmacy, with the majority of allergic rhinitis sufferers failing to seek pharmacist advice. this research identified predictors of medication self-selection behaviour in community pharmacy among people with allergic rhinitis, which can inform the design of tools/strategies and targeted interventions, aimed at improving pharmacist engagement and future practice in optimising allergic rhinitis management. the weir family health clinic, cork, ireland; university college, cork, ireland background: allergic rhinitis is a common condition that is predominantly managed in primary care. the incidence of allergic rhinitis is increasing. it is frequently under diagnosed, misdiagnosed and mistreated. it has a significant impact on patients' health related quality of life and represents a huge cost both to healthcare systems and society. the aim of this study was to implement appropriate guidelines regarding the management of allergic rhinitis in primary care and evaluate the effect on patients' health related quality of life. method: patients with a history of allergic rhinitis were selected from three general practice bases in west cork, ireland and quality of life of patients was assessed initially in year one and followed up one year later in a general practice setting using the standardised rhinoconjunctivitis quality of life questionnaire (rqlq). allergic rhinitis and its impact on asthma (aria) guidelines and appropriate prescribing were implemented during this year and patient education and structured follow up was arranged in the intervention group. this was compared with the control group who received usual care. results: valid responses were received, from the control group and from the intervention group. the study demonstrated a statistically significant difference in quality of life in the intervention group. in the adult intervention group the quality of life score decreased between and representing an improvement in their quality of life, (t = . ; df= ; p < . ). the difference in the score between the control and intervention groups in was also statistically significant.(t = . ; df= ; p < . ). the numbers in the adolescent groups and paediatric group also demonstrated an improvement in quality of life but the sample size was too small to demonstrate a statistically significant difference. conclusion: as the majority of patients rely on their general practitioners for treatment and diagnosis of allergic rhinitis, primary care represents an important area to target in the management of allergic rhinitis to improve patients' quality of life. the implementation of guidelines has been shown to improve patients' quality of life. this study demonstrates this care can be delivered in a primary care setting with an improvement in patients quality of life but substantial investment in education and resources available to primary care physicians is needed. | the predictive value of allergy tests in the diagnosis of peanut allergy in adults rey-garcia h; gunawardana n; wheeler k; scadding g; durham s; skypala i royal brompton hospital, london, united kingdom background: adults presenting with either new-onset symptoms attributed to peanuts or with early-onset peanut allergy, often wish to know whether they should continue to avoid peanuts. clinical history and standard tests may be sufficient to provide an answer, but for many the tests are inconclusive and an oral food challenge is required. this review was undertaken to determine the most accurate tests. conclusion: these data suggests that peanut spt and ara h provide the most accurate prediction of the outcome of oral food challenge in adults. should components not be available, then spt would be the test of choice being more accurate in all aspects than sige. combining spt and sige improves the sensitivity and negative predictive value of spt alone. however, the best combination is spt and ara h , which increases the overall accuracy to %. further studies are needed before it can be determined whether peanut diagnostic tests can replace the oral food challenge in adult patients. method: retrospective chart review was carried out in a community allergy clinic. patients with rap, bloating and altered stools who underwent bt were characterized by age, gender and atopic status. a separate study to assess patients' outcome post-dietary counselling was carried out to determine impact on symptom management. results: thirty-four patients were assessed for fi from january to december . female gender predominated ( / , %) with an average age of years at presentation. results of fi were positive in / ( %), borderline in / ( %) and negative in / ( %). the average age of patients with a positive, borderline and negative tests were , and , respectively. of the patients who tested positive for fi, ( . %) had comorbid inhalant allergies alone, ( . %) had comorbid (unrelated) food allergies alone, ( . %) had inhalant and food (unrelated) allergies, and ( . %) were non-atopic. of the patients who tested negative for fi, ( . %) had comorbid inhalant allergies alone, ( %) had comorbid (unrelated) food allergies alone, ( . %) had inhalant and food (unrelated) allergies, and ( . %) were non-atopic. conclusion: patients investigated for carbohydrate intolerance with rap, bloating and altered stools were predominantly female ( %). fi was confirmed in half. atopic status did not help differentiate between the fi positive or negative groups. results of a fod-map elimination diet are separately reported. conclusion: post-bt, % of patients reported symptom improvement. patients who implemented fructose or fodmap avoidance reported symptom improvement. one patient who tested negative for fi reported symptom improvement with a low fodmap diet. patients suspected as being fructose intolerant may benefit from a fructose restriction or fodmap diet, while awaiting bt confirmation. this form of dietary intervention may assist and shorten the natural history of non-specific chronic gi symptoms. inappropriate referrals to a uk paediatric tertiary allergy clinic demonstrate lack of allergy education and knowledge in primary care marriage de bristol royal hospital for children, bristol, united kingdom background: up to % of children have a food allergy. allergy has become an explanation for all manner of nebulous symptoms and self-diagnosis is common. sham allergy tests are easily available giving incorrect results and resulting in unnecessary, potentially harmful abstracts | parentally-imposed dietary exclusions. there are million allergyrelated google searches per year. the rising prevalence of perceived allergic disease has led to an increase in health service utilisation, including increased referrals to secondary care. clinic waiting lists are long and children with severe food allergies have to wait longer than necessary to be seen method: uk paediatric tertiary allergy clinic referrals were prospectively reviewed over three months. five inappropriate referrals deemed most reflective of poor knowledge in primary care were selected as case summaries to highlight this gap in knowledge. results: : schoolchild referred for investigation of allergic cause for a red, watery eye after splashing juice in her eye whilst cutting a kiwi, despite having a co-existent dendritic ulcer. : schoolchild referred for peanut allergy testing after inhaling a peanut and developing wheeze, with all respiratory symptoms resolving following peanut removal. : young child referred for peanut allergy testing after developing a rash on leg following skin contact with faeces hours after ingestion of peanut butter. : teenage boy referred for investigation of likely peanut allergy despite eating peanut butter and tree nuts almost every day. the family were concerned he was allergic to peanut butter. : toddler referred for milk allergy investigation after developing urticaria lasting hours minutes after drinking a bottle of milk. the child had consumed cow's milk formula since birth, and continued to consume milk daily for a further five months following the episode of urticaria. conclusion: provision of allergy services in the uk is poor and lack of investment in allergy services has led to suboptimal recognition and management of food allergy in primary care. allergy education provision for primary care practitioners is inadequate and fails to empower healthcare professionals to discern between allergy requiring full investigation and management, parentally-diagnosed allergy or symptoms which clearly have no association with allergy. progress to improve primary care training for allergy needs to be optimised to prevent further unnecessary referrals and lengthening clinic waiting lists. background: in case of allergic reactions to food or insect venom, quick and adequate treatment, based on clear instruction for use of emergency medication and calling for help, is necessary. however, daily practice shows that patients do not use the prescribed emergency medication because they are afraid to use the epinephrine auto-injector or they do not know how to use it. information and instruction offered by a reliable app could be a useful aid. we aim to develop an app for adult patients and children older than years with allergy to food or insect venom, which offers a step-wise approach to support patients, their relatives or acquaintances in case of an allergic reaction. method: first, the content of the app, including a step-wise approach to treat the allergic reaction has been determined, based on literature, a survey about needs of patients and on consultations of healthcare professionals. subsequently, a web-based prototype has been developed with an adult profile and children profile. the content and flow of this prototype was tested by the project group, as well as by selected healthcare professionals and patients and improved according to the test results. next, the revised prototype was submitted to representatives of patient and professional organizations for final approval. currently the procedure for ce approval is ongoing. finally, the app will be built and offered to the market for ios and android. results: a web-based prototype of the allergy app is available with two profiles: adult and older children. the app is useful for patients with a doctor's diagnosed allergy to food or insect venom, who received emergency medication and instructions to use prescribed medication in case of an allergic reaction. based on severity of complaints, the user is informed about the steps to treat the allergic reaction. in case of a moderate to severe reaction, the patient is advised to use an epinephrine auto-injector, to call the emergency number and, if prescribed, to use medication such as antihistamines, prednisone or inhaler. besides that, the app provides links to websites of expertise centres and patient organisations and includes instructions how to use the epinephrine auto-injector. conclusion: the allergy app will help patients, their relatives or acquaintances to adequately treat an allergic reaction to food or insect venom. involving patients and professionals in the development of the app will contribute to its acceptability and usability. | electronic documentation of drug allergies in a tertiary hospital in singapore: are we relying too much on it? choo kjl; garuna murthee k; naing cs singapore general hospital, singapore, singapore background: singapore has hospitals shared between public and private healthcare system. its healthcare system, ranked # in the world by who in serves a multi-racial population of . million of which % are above years old. drug allergy alert cards (medik awas) were started in s by singapore medical association to improve patient safety. work on computerisation of drug allergy and medical alerts started in the s, a precursor to today's critical medical information system (cmis). cmis serves as a platform across all public hospitals in singapore. it promotes uniform reporting of drug allergy and notification of adverse drug events to the health science authority. yet, we found that there is a lack of awareness of one's own drug allergies. method: all patients admitted to ward (general medicine ward) at singapore general hospital from july to oct were screen for any previously documented drug allergies. consenting patients who had previously documented drug allergies on cmis were interviewed to document their demographics, education level, current medications, knowledge of their own drug allergies and possession of a drug medication alert card. the answers were then compared with their electronic documentation of drug allergies for accuracy. we interviewed patients aged - with documented drug allergies during the recruitment period. % had secondary school education or higher. the majority ( %) spoke english and ( . %) mandarin. almost half had medical problems and are on long term medications (mean . medications); hypertension and diabetes being the top two common diseases. % of the patients could accurately relay their drug allergies; antibiotics and analgesia being the most labelled. only % had a drug allergy alert card while the rest both rely on the hospital's electronic documentation and/or their caregivers to record and relay their allergies to future prescribers. about % received prescription from multiple healthcare sites in both the public and private healthcare system. we found patients' knowledge of their own drug allergies dismal. the cmis electronic documentation provided a false sense of security. unfortunately, the cmis platform is not available to all private hospitals, increasing the risk of mis-prescription due to the lack of information. unless this is made available nationally, patients with drug allergies should be given some written documentation, either a letter or medik awas. how frequent are they and how are they treated? method: for this cross-sectional study, participants were recruited in the waiting rooms of local doctors in the rural bavarian forest region of southern germany (q / ). a paper questionnaire was handed out to the participants, asking for allergies (pollen, animal hair, bee and wasp venom, drugs, food, house dust mites, contact allergies and other allergies) and how or rather by whom (e.g. general practitioner, specialist, self-treatment) these allergies are treated. results: participants with a mean age of . years (sd= . ) and % women were included in this study. . % indicated to have at least one allergy, including pollen allergy most frequently ( . %). women had significantly more often at least one allergy than men (rr= . ; ci [ . ; . ] ) and for almost all examined allergies a significant higher risk of disease. younger age groups indicated more often to have at least one allergy ( - [. ; . ]) seemed to be affected less. participants indicated most frequently that their allergy was treated by a general practitioner ( . %), except of the - -yearold young adults who indicated "no treatment" most frequently ( . %). conclusion: there is a high self-reported prevalence of allergies in the examined rural bavarian region, that increases with decreasing age and is significantly higher among women. moreover, the data on the absence of an appropriated treatment for allergies is alarming. therefore, medical care needs to be improved in rural regions to lower the burden of allergies. | the prevalence of the burnout syndrome among medical professionals involved in allergology education programmes astafieva n ; kobzev d ; gamova i ; perfilova i ; udovichenko e ; skuchaeva l ; michailova i ≥ ) and rpa (low ≥ - , subscales were calculated and analyzed. results: on average students demonstrated: moderate/high ee scores ( - ); moderate/high dp scores ( - ) and moderate rpa scores ( ); higher rpa scores were common ( . %) among junior students, which is also linked with their levels of engagement, and lower ( %) among senior students. junior specialist (starting specialization) had very low scores in all subscales and expressed a very high motivation in their course and new profession. clinical allergologists with significant experience demonstrated moderate / high ee scores ( - ); low dp ( ) ( ) ( ) ( ) ( ) and rpa (below ) scores. high ee scores associated with pressures of service were compensated by a substantial loyalty to their profession and positive assessment of the outcomes of their work. clinical academics demonstrated the highest level of ee scores ( + among + % of the group) with low to moderate dp and rpa scores, the latter being associated with a loyalty to their profession. it was also possible to identify a correlation between engagement in research activities and lower rpa scores. conclusion: burnout is a complex and multifaceted phenomena, which requires further investigation. however, this research identified that students and junior specialists involved in allergology and clinical immunology programmes with higher levels of engagement and motivation to acquire new specialist knowledge had lower levels of ee, while loyalty to the profession and positive assessment of the outcomes of clinical and research work allows to compensate high levels of ee among experienced practitioners and clinical academics and to reduce burnout effects overall. | appeal (allergy to peanuts impacting emotions and life): the first pan-european study to evaluate the psychosocial burden of living with peanut allergy deutscher allergie-und asthmabund (daab)/german allergy and asthma association, mönchengladbach, germany; food allergy italia, padua, italy; aepnaa asociación española de personas con alergia a alimentos y látex, madrid, spain; afpral association pour la prevention des allergies, paris, france; asthma-allergy denmark, roskilde, denmark; anaphylaxis campaign ireland, cork, ireland; brainsell ltd, london, united kingdom; aimmune therapeutics, london, united kingdom background: peanut allergy, one of the most common and rapidly growing food allergies, is most frequently a lifelong condition. current management is limited to avoidance and symptomatic treatment of allergic reactions when accidental exposures occur. peanut allergy can affect the quality of life (qol) of individuals and also that of parents/caregivers and family members. appeal was designed to assess the impact of peanut allergy on qol in peanut-allergic individuals and their parents/caregivers and families. method: the first, quantitative part of appeal is described here and consisted of a pan-european, cross-sectional online survey of approximately minutes in length. the study was conducted in the uk, republic of ireland, france, spain, germany, italy, the netherlands and denmark. over participants were recruited via patient advocacy groups or directly through a specialist survey recruitment panel. ethics committee approval was obtained and all participants provided their informed consent. eligible participants were: ( ) parents or caregivers of a child/adult with peanut allergy; ( ) parents or caregivers responding as a proxy for a child aged under ; ( ) adults. all allergic subjects had self-reported diagnosed peanut allergy. after several screening questions, eligible participants answered a set of clinical questions about their (or their child's) allergies and other conditions, details on the peanut allergy diagnosis, contact with healthcare professionals, worst allergic reaction to date and use of emergency medicine. depending on whether they were an allergic adult, a parent responding on behalf of the child, or a parent/caregiver recounting their own experience, they then answered specific questions on restrictions on life choices, coping strategies and the impact of peanut allergy on feelings and emotions of families, friends and other people. sociodemographic questions completed the questionnaire. the results of the survey are being summarized using descriptive statistics and the data are being analysed on a pan-european level, by country, and according to the participant's perspective (parent, caregiver or individual). conclusion: this comprehensive, pan-european online survey has been specifically designed to uncover the psychosocial burden and effect on qol of peanut allergy in terms of individuals' lives and those of their families. results: pediatric patients were included in the study. . % (n = ) were male. the median age of onset of symptoms (interquartile range) was months ( - ).the median age (interquartile range) of diagnosis was months ( - ). initial reactions associated with cmpa were observed in . % of patients before months old. patients' diagnoses were atopic dermatitis ( %), urticariaangioedema ( %), anaphylaxis ( . %), proctocolitis ( . %), atopic dermatitis and urticaria ( . %), food protein induced enterocolitis ( . %) and eosinophilic esophagitis ( . % method: the study involved patients, who are two years old (and above), diagnosed with cow milk allergy and are observed for at least six months in our hospital. socio-demographic features of the patients, their symptoms, symptom-start ages, age of diagnosis, clinical findings at diagnosis and during observation were recorded in data collection questionnaires. results: the samples were ( . %) boys. the average symptomstart age was observed to be months , average diagnosis age months ( - ) and average age of final check months . when symptoms at entry were observed, . % of the patients had dermal system, . % gastrointestinal system, respiratory system disorders, and % were detected to have developed anaphylaxis. among the patients diagnosed with cow milk allergy, . % showed food reaction to nutrients with lge agents, . % to mixed types, and % to nutrients with non-lge agents. it was also observed that, in the end of . ± . -month observations, sensitivity to cow milk was observed to continue in ( . %) of our patients. when tolerance improvement rates among the patients were compared, anaphylaxis (p < . ) during entry were observed to be influential in continued allergic state. ( . %) patients were able to consume yoghurt, ( . %) patients could consume dairy products and ( . %) patients could not consume dairy products. conclusion: in the end of our investigation, it was observed that ( . %) of the patients developed cow milk tolerance before the age of . when the factors enabling the continuation of sensitivity in cow milk allergy were investigated, anaphylaxis during entry, entry specific lge and pasteurized milk antigen as well as high skinprick test results were detected to be significant. | initial lower threshold was a risk factor of severe adverse reaction during oral immunotherapy for cow's milk anaphylaxis results: before oit, median age was . years old, median threshold to induce initial reaction was . ml, to induce anaphylaxis was . ml of cm and median milk specific ige was . ku/l. twentyseven subjects ( %) dropped out from the protocol, subjects | investigation of heat and matrix effect on milk proteins' allergenicity and the development of hypoallergenic food products reduce some milk proteins' allergenicity (ß-lactoglobulin) . in this project we aimed to investigate the effect of heat and matrix on different milk protein fractions through maillard reaction and eventually develop hypoallergenic food products that have milk protein with low reaction risk. method: milk cake matrix is prepared in different flour/sugar (f/s) ratio ( f/ s, f/ s, . f/ s) and baked minutes at °c. proteins that cake contains are separated using sds page and stained with coomassie blue to check total protein. in parallel specific proteins are detected by western blotting using pooled sera from patients with milk specific ige> ku/l for incubation results: in normal milk cake recipe ( f/ s) ß-lactoglobulin bands are disappeared but casein bands did not differ in size. in order to investigate the matrix effect f/s ratio is changed and it is found that when this ratio decreases, with the affect of heat and maillard reaction, milk casein bands' intensities also decrease in sds gel coomassie staining. in western blot experiments it is also shown that milk specific ige bound weakly to casein bands in low f/s ratio cake ( . f/ s) whereas in cakes that have high f/s ( f/ s) ratio it bound significantly higher. and ß-lactoglobulin proteins' structure and lower the milk specific ige bindings to milk proteins in low f/s ratio cake through maillard reaction. | extensively hydrolyzed formulas for the management of cow's milk protein allergy in infants: is extensive hydrolysis sufficient to guarantee success? method: to better understand the range of ehfs, we aimed to analyse samples of commercially available ehfs from countries and various manufacturers, with a focus on suitability for cmpa management. samples were de-identified and coded for the analyses. molecular weight (mw) distribution of hydrolysates and residual proteins and peptide profiling were assessed with sds-page gel and size exclusion-high-performance liquid chromatography (se-hplc), as they reflect both the design of the formula and the quality management applied during production. osmolarity, nitrogen fractions, lactose content, total and free amino acids, β-lactoglobulin, and casein content were quantified and β-lactoglobulin residual allergenicity was assessed. results: peptide mw distribution displayed significant variation, with the percentage of peptides with mw > . kda varying from % to %. mw distribution was shown to be positively correlated with β-lactoglobulin specific in vitro degranulation. twenty % of samples had non-measurable β-lactoglobulin content (smaller than or at the limit of quantification (loq): . mg/kg); however, % of samples had β-lactoglobulin content greater than the loq, with high variability from . to mg/kg. surprisingly, even in samples featuring a high degree of hydrolysis, significant levels of residual β-lactoglobulin were quantified. conclusion: lack of consensus over the definition of 'extensively hydrolysed' is reflected in the wide range of degree of hydrolysis in commercially available ehfs, and can result in products that are mislabelled as 'extensively hydrolysed' and may be high-risk or even unsuitable for the management of cmpa. results of these analyses also highlight that degree of hydrolysis alone is not sensitive enough to characterise ehfs, and that whilst a high degree of hydrolysis is desirable, further quality control measures are essential to ensure clinically safe and suitable products. actionable guidelines to better define hypoallergenic formulas based on extensively hydrolysed milk proteins are warranted. background: assessing the effect of baked milk products on accelerating unheated milk tolerance in patients with cow's milk allergy. method: a randomized clinical trial was done on patients ( months- years old) divided randomly to case and control groups matched for age and sex. baked milk in form of muffin for months followed by baked cheese in form of pizza for next months was given to the patients in case group. skin prick test and serum ige (sige) levels (immunocap) of milk, casein and betalactoglobulin were measured before and after the study. the ones having milk sige less than ku/l and being asymptomatic during the study underwent oral food challenge test for evaluating unheated milk tolerance. chualalongkorn university, bangkok, thailand; kk women's and children's hospital, singapore, singapore; university of the philippines, philippine general hospital, manila, philippines background: problems in recognising cow's milk allergy (cma) and lactose intolerance (li) in infancy may lead to a delayed or incorrect diagnosis, as well as inappropriate dietary interventions. method: between january and november , a survey was conducted online in china, india, singapore, thailand, mexico, kuwait, united kingdom, australia, and paper-based in the philippines. the survey consisted of multiple-choice questions on cma and li in infants aged under months, two case scenarios (non-ige cma and anaphylaxis) and questions on educational needs (likert scale [ ] [ ] [ ] [ ] [ ] . data on the type of medical practitioner and clinical setting were collected. responses were summarised as percentages and categorised by country. results: responses were received from general practitioners ( . %), paediatricians ( . %), paediatric allergists ( . %), paediatric gastroenterologists ( . %) and other specialities ( . %). there were significant misconceptions about the clinical importance of primary li in infancy. while primary li rarely manifests before years of age, . % of participants felt it was a significant clinical problem in the first year of life. regarding secondary li, % of respondents recommended lactose restriction for viral gastroenteritis, and % for cow's milk protein-induced enteropathy. while the management of ige cma was relatively well understood, there were greater knowledge gaps for non-ige cma. % of practitioners appropriately identified extensively hydrolysed formula (ehf) as first-line treatment of cma in formula-fed infants. however, the distinction between lactose-free and lactose-containing ehf appeared to be an area of uncertainty. in india, . % used soy-based formulas as first- results: patch tests were positive in ( . %) and negative in others. positivity to milk was seen in patients ( . %), to soy in ( . %), to egg white in / ( . %), to wheat in / ( %), to potatoes / ( . %), to corn (maize) in / ( . %), to rice in / , and to peanut in / ( . %). patients were requested to withdraw the suspected food(s) from their diets during a months period. preliminary follow-up data show the improvement of one or more symptom in / patients (gastroesophageal reflux in , appetite in , stool consistency in , respiratory symptoms in , pain in , eczema in ). conclusion: patch tests are informative, easy to use tools in order to identify potential causes of common lasting symptoms in children with negative or weak rast results and introduce beneficial changes in the daily diet. longer follow-up is necessary in order to refine and assess the benefit of such strategy. background: currently in the us, in children suffer from food allergies. at present, there is no cure and strict avoidance of the relevant foods is the only way to prevent allergic reactions. elimination diets put infants and children at risk for nutritional deficiencies and impaired growth. we examined the role of the registered dietitian (rd) in advising patients and families of food allergic children. method: a retrospective review of clinical notes was performed for the first consecutive children who required a dietetic consultation in a dedicated food allergy clinic. we examined common questions from parents that were addressed by the dietician during the consultation. results: patients were aged months - years (median: months) and were diagnosed with the following food allergies: cow's milk: . %, egg: %, tree nut: %, peanut: %, wheat: %, soy: %, fruit/vegetable: %, legume: %, fish: %, sesame: %. the most common questions for the dietitian included: ways to meet nutritional needs following a prescribed allergen-restricted diet ( %), meeting vitamin d and calcium requirements on a milk protein-free diet ( %), suitable oral supplements and recommended serving sizes ( %), appropriate order of solid foods introduction in food protein-induced enterocolitis syndrome (fpies) ( %), cautionary food ingredient statements ( %), baked milk protein introduction ( %), cross-reactivity risk of milk protein with soy ( %) and crossreactivity of nuts in retail bakeries ( %). conclusion: parents of children with food allergies have multiple questions with regards to nutrition. dietetic input in the food allergy clinic addresses important issues for children and families including successful avoidance of allergen-containing foods while ensuring optimal nutrition, decreased exposure to high-risk situations and avoidance of allergen cross-contamination. | multicenter prospective study of a stepwise single dose oral food challenge of egg background: oral food challenges (ofcs) are necessary for allergy management. we previously reported that a low-dose ofc can avoid complete elimination, even if patients react to higher doses of causative foods. nevertheless, this approach has only been validated in a retrospective single-center trial. we have previously reported that the median time for initial symptom onset is minutes for egg ofc using a single exposure. therefore, this study aimed to confirm the safety and effectiveness of a stepwise single-dose ofc in a multicenter, prospective study. who showed a positive reaction to low-dose ofc, only patient ( %) showed a severe reaction: barking cough immediately improved with adrenaline inhalation. among patients with a positive reaction to medium-dose ofc, none had a severe reaction. the median times to symptom onset were and minutes following low-dose and medium-dose ofc, respectively. patients in the three groups, divided according to threshold doses, differed significantly in sige levels against egg white and ovomucoid. conclusion: this multicenter prospective study confirmed that stepwise single-dose ofc to egg will help to clarify the severity of egg allergy, and will contribute to improved food allergy manage- method: the study design was a retrospective cohort study extracting data from the electronic chart of children older than years who visited our out-patient clinic for egg or milk allergy and who underwent an oral food challenge test (ofc) twice within months between november and december . the patients were divided into five groups according to their treatment schedule, which consisted of those who: a) started from / of the first ofc reaction threshold and maintained / till the end of oit; b) started from / of the threshold and maintained / ; c) started from / of the threshold and maintained / , d); conventional slow oit (started from just below the first ofc reaction and increased . - . times every few weeks); or e) continued elimination. we determined the presence or absence of an increase in threshold reacted to the allergen, any adverse events during oit, and food-specific ige reduction. results: the number of participants was and their median age was years. the number of patients in groups a, b, c, d, and e was , , , , and , respectively. the percentage of patients in groups a, b and c showing an increase in reaction threshold to the allergen was higher than that in group e (p < . ), and that in group b was higher than that in group d (p < . ). the number (percentage) for group a, b, c, d, and e was ( . %), ( . %), ( . %), ( . %), and ( . %), respectively. there was a significant difference in the frequency of adverse events during oit between group a-c and d, which was as follows: ( . %), ( . %), ( . %), and ( . %), for the respective groups (p < . ). there was no significant difference in the percentage of patients showing a decrease in food-specific ige in each group. conclusion: the regimen starting from / of the ofc reaction threshold and maintaining the dose at / was safer and more effective for increasing the threshold reacted to the allergen than the 'conventional slow oit' regimen. elimination continuation was not effective for increasing the threshold reacted to the allergen. legumes allergy was presented in different clinical features; urticaria and angioedema in ( %) patients, anaphylaxis in ( . %) patients, atopic dermatitis in ( . %) patients, eosinophilic esophagitis in ( . %) patients and as food-related enterocolitis in ( . %) patient. thirteen ( . %) of the patients had asthma, ( . %) had allergic rhinitis. fourteen ( . %) of the patients with single legume allergy showed improvement. the patients who developed tolerance, of these ( . %) had peanut allergy, ( . %) had lentil allergy and ( . %) had chickpea allergy. two of patients with multiple legumes allergies, it developed tolerance to all the legumes they are allergic. conclusion: peanut and lentils were the most frequent legumes that displayed allergic reactions in our study. in these patients the rate of allergy to non-legumes food is high. in patients who were allergic to single legumes, the symptoms were ameliorated in . %. conclusion: cashew nut is a potent allergen and can cause quite severe reactions. avoidance of pistachio nut and other related allergens should be advised to patients after allergologic investigation. in the majority of the patients, presence of atopic dermatitis with food allergy is noteworthy. therefore, it would be useful to investigate these patients for cashew and other tree nut allergy before they present with a serious clinical reaction. and jellyfish sting. serum allergen-specific ige test was negative; skin prick test was positive for natto and pork. we performed an oral food challenge with natto, pork, crustaceans, and wheat, and she developed a general itchy rash after hours of eating natto. h blocker was administered and she recovered soon. however, the general itchy rash relapsed after hours. hence, we intramuscularly injected epinephrine, h -blocker, and steroids; then, her symptoms did not relapse. based on these findings, we inferred that anaphylaxis caused by natto could be associated with a jellyfish sting. discussion: although association between japanese fermented soybeans (natto) allergy and jellyfish sting has been previously reported, its anaphylaxis is a rare event. in this case, we suggest that anaphylaxis was caused by natto allergy, which was perhaps related to jellyfish sting. hence, further investigation is essential to elucidate the association between fermented soybeans allergy and jellyfish sting. introduction: non-celiac gluten sensitivity (ncgs) is a syndrome characterized by intestinal and extra intestinal symptoms related to the ingestion of gluten-containing food, in subjects that are not affected by either celiac disease (cd) or wheat allergy (wa).once the gluten-containing foodstuff is removed from the diet, the patients will have relief of their symptoms. case: a -year-old girl was referred by his general practitioner with history of occasional constipation and abdominal pain (especially after main meals and defecation), short stature and low weight. the growth indices were proper for her age till she was . then after there was a stunting. she had short stature and low weight. despite different types of supplementation, there was no improvement in growth indices, so she was referred to a pediatric endocrinologist for gh therapy. primary investigations and anti-ttg, iga, anti-ema all were normal. after a consultation with a pediatric gastroenterologist, a genetic study of hladq and were done because of the highly suspicion of celiac disease. the results were also negative. at last she was referred to immunology-allergy clinic for evaluation of probable food allergy. ige level was checked and a prick test was performed which they were not indicative of any suggestive food allergy. because of the history of the abdominal pain and constipation which was more prominent after meals, negative results of genetic study, spt to wheat, and serologic markers, a gluten free diet was suggested for her with the suspicious of non celiac gluten sensitivity. a significant improvement in her symptoms was noticed within weeks of starting gluten free diet. she has kg of weight gain and height improved from cm to cm in months. she continued to improve on a gfd and when seen in the follow-up clinic months later reported complete resolution of symptoms and another cm and kg gain in her height and weight. conclusion: non-celiac gluten sensitivity syndrome is a diagnosis made by excluding celiac disease and wheat allergy. it should be taken into consideration especially in patients who have the suspicious symptoms of celiac without supporting lab data, and also negative spt to wheat. the young man in question along with his parents were keen to proceed, so with some hesitation we proceeded to a hazelnut oral provocation challenge, having very carefully explained the risks of undertaking such a challenge. he successfully completed the challenge and experienced no allergic symptoms and is now able to have hazelnuts in his everyday diet. discussion: this young man wanted to confirm if indeed he was allergic to hazelnuts. not being hazelnut allergic would mean that he would be no longer allergic to any nut and would not have to take precautions prior eating products. positive results to both cor a and cor a , hazelnut storage proteins are associated with the patient possibly experiencing systemic reactions, at a higher risk of experiencing anaphylaxis it they were to ingest hazelnut. these facts in conjunction with his specific ige to hazelnut would have prevented us from proceeding to challenge was it not for this young man's persistence that he wanted to proceed to challenge despite the risks. conclusion: appearances are deceptive, as this case demonstrates; allergen-specific ige and component testing can only predict the probability of an allergic reaction, the final test in the diagnostic process is the oral provocation challenge. the patient and his family were happy for me to share the above with other health care professionals. method: we present the case of a female of years old diagnosed of acu with poor control of the symptoms at maximum doses of antihistamines. we decided to associate omalizumab treatment. the patient had a good control of the symptoms with omalizumab at dose of mg/ weeks, but in the th month she presented an erythematous, raised and pruritic lesion in the area of injection together with localized abdominal edema at hours of the administration, with two weeks of evolution without symptomatic treatment. we decided to discontinue omalizumab alter a second episode with half doses. results: we performed a skin biopsy of the lesion and epicutaneous tests with the drug. immediate hypersensitivity tests were not taking due to the impossibility of stopping antihistamines. skin biopsy showed a perivascular lymphocytic inflammation of the superficial and deep dermis with frequent presence of perivascular and interstitial eosinophils, suggestive of a hypersensitivity reaction. results: nine months before presentation at our clinic, the patient had been hospitalized and treated with imipenem and tmp/smx for pulmonary nocardiosis. once discharged, she had been prescribed oral tmp/smx alone, according to antimicrobial susceptibility. at our first evaluation, the patient presented with fever, macular erythematous non-pruritic (vasculitic-like) skin lesions on the upper limbs, polyarthralgia and bilateral ankle arthritis. tmp/smx was transiently stopped. after four days, there was a dramatic improvement, with resolution of all signs and symptoms. she was tentatively diagnosed with a viral infection and thus tmp/smx was started again. however, after three days, the symptoms (fever, arthritis and skin lesions) recurred. laboratory investigations showed increased levels of inflammatory markers. complete blood count with differential, serum creatinine, urinary sediment, liver enzymes, rheumatoid factor, antinuclear antibody, c , c , immune complexes, serology for rickettsia, borrelia and coxiella were all negative. hence, tmp/smx was stopped again and cutaneous lesions, fever and arthritis resolved spontaneously in five days. conclusion: given the clinical course and the resolution after the withdrawal of tmp/smx, we diagnosed a sslr due to sulfonamides. to the best of our knowledge, this is the first case of sslr occurring after a nine-month therapy with tmp/smx and allergists/immunologists should be aware of the possibility of such a reaction even after months. case report: * we received written informed consent for publication of these clinical details and/or clinical images included in my abstract was obtained from the patient. drug rash with eosinophilia and systemic symptoms (dress) syndrome is a severe adverse cutaneous reaction that usually appears - weeks after treatment with the causative drug. this syndrome is characterized by severe dermal rash, fever, eosinophilia, and internal organ involvement, and clinically, diffuse maculopapular eruption, exfoliative dermatitis, and facial edema are often observed. we performed blood tests and laryngeal fiberscopy for the diagnosis of the patient. intradermal test with delayed reading and patch test were performed months after the end of treatment. a -year-old man had begun treatment with carbamazepine for epilepsy. after weeks of treatment, he observed skin rash with pruritus on both lower extremities, and after weeks, his skin lesions had begun to spread over his whole body, and he complained of several new symptoms, including hoarseness, dyspnea at rest, and dysphagia. an examination revealed maculopapular rash, facial edema, and bilateral cervical lymphadenopathy. laryngeal fiberscopy revealed both arytenoid and epiglottic swelling. laboratory studies revealed eosinophil counts of /μl and increase in alanine aminotransferase level to u/l. a diagnosis of dress syndrome was definite according to the regiscar group criteria. carbamazepine, the suspected culprit drug, was withdrawn, and systemic corticosteroid was initiated. the patient experienced rapid improvements in hoarseness, dyspnea, and dysphagia. after days of treatment, laryngeal fiberscopy revealed complete resolution of both arytenoid and epiglottic swelling. to the best of our knowledge, our case is the first reported case of dress syndrome to manifest with laryngeal edema. case report: bortezomib (velcade Ⓡ ), a targeted therapy works by blocking the action of proteasomes in side cells, is commonly used to treat newly diagnosed as well as relapsed/refractory myeloma. bortezomib has been reported to have gastrointestinal symptoms, peripheral neuropathy, neuropathic pain and thrombocytopenia as its most common side-effects. although several cases of skin lesion caused by bortezomib have been reported, severe cutaneous adverse reaction (scar) such as stevens-johnson syndrome (sjs) is very rare. we here report a case of bortezomib induced sjs. a -year-old female patient, who was diagnosed with multiple myeloma, received bortezomib and melphalan /dexamethasone therapy. after the th dose of bortezomib, she presented with fever and maculopapular skin rashes spreading from face to the trunk. erosive lesions in the oral mucosa and corneal ulceration with conjuntival injection were observed. she was diagnosed as sjs. the symptoms of sjs improved after bortezomib was discontinued and systemic steroids and intravenous immunoglobulin were administered. drug patch test was performed, the result was positive in bortezomib. this is the first case report of bortezomib induced sjs in this country, which was diagnosed by a patch test. although the scar by bortezomib is generally considered very rare, we suggest that clinicians be aware of potential adverse reactions, including sjs. case report: we report the case of a healthy -year-old woman with history of red erythematous macules in both hands, one hour after taking a fluconazole ( mg) tab for a vaginal candidiasis. it faded spontaneously. she didn't recall if she had ever taken that medicine, but denied known drug allergies. although fde is primarily a clinical diagnosis, we conducted an oral challenge test with fluconazole ( mg). two hours after intake of the drug the patient started complaints of pain and erythema in both hands and the challenge was stopped. two days after the challenge, she developed red painful erythematous macules on the same sites of the first episode. due to the specificity of the challenge, local patch testing was not performed. introduction: the classic form of a fixed drug eruption is one or more anular or oval erythematous patches as a result of systemic exposure to a drug. these skin lesions normally resolve with hyperpigmentation and may recur in the same location with re-exposure to the drug. other types of fixed drug eruptions have been described, being fixed drug urticaria a rare form of presentation. ( , ) case report: in the last years, a year old woman has developed more than episodes of a wheal in the right supraciliary region minutes after taking mg of oral ibuprofen. the symptoms resolved in less than hours without treatment and without leaving residual lesion. after the last episode, she refers good tolerance to g of oral paracetamol. she denies local traumas. she also refers mild spring rhinoconjunctivitis well controlled with antihistamine, and sneezing with house dust. a -year-old-m patient had psoriasis vulgaris for years, and had been using methotrexate at intervals of years. despite the addition of phototherapy, he underwent a new treatment with biological agent (antitumor-necrosis-factor; anti-tnf), since the disease control was insufficient. before anti-tnf, preventive treatment against latent tuberculosis (tb) activation was indicated with positivity in tuberculin skin test ( mm). he was given inh mg/day, and at the th day of treatment, desquamation, erythema, and subsequent exfoliation developed in his hands and foots dorsum. inh was withdrawn. in order to distinguish the lesions from psoriasis attack, skin biopsy was performed and reported as erythema multiforme-like dermatitis with no relation to psoriasis. the lesions were completely improved at weeks of topical steroids, and inh was re-initiated at the same dose. a week after the initiation of the drug, skin lesions similar to previous reoccurred with more severity and progression from distal to proximal extremities. cell counts, renal and hepatic function tests, and hepatitis markers in blood were in normal limits. skin lesions were retracted after weeks of topical steroids, and withdrawal of inh. there was positivity in skin patch test with inh at hours. finally, for tb prevention an alternative drug rifampicin ( mg/kg/day) was given, and the patient successfully completed with no adverse event. his psoriasis lesions were improved with anti-tnf which was started after month of tb prevention with rifampicin. in these days which the use of biologic agents is increasingly widespread, inh use will be more prevalent than the past. even tough, it is effective and safe in most of the patients, its adverse event dermatitis may be a reason to withdraw in patients with dermatological diseases. in this case, diagnostic drug allergy evaluation should be performed to optimize the second-line treatment of tb infection, in addition to early withdrawal of the culprit drugs. background: around % of cancer patients will receive radiotherapy (ionizing radiations) as a treatment, either as a single therapy or as an adjuvant to chemotherapy and surgery. several side effects have been described due to radiotherapy, of which we can mention erythema multiforme and stevens johnson syndrome, but in lower prevalence. erythema multiforme can be described as an acute skin condition and may be present within a wide spectrum of severity. erythema multiforme minor represents a localized eruption of the skin with minimal or no mucosal involvement. the papules evolve into pathognomonic target or iris lesions that appear within a -hour period and begin on the extremities (see the following image). lesions remain in a fixed location for at least days and then begin to heal. it is considered to be a type iv hypersensitivity reaction associated with certain infections, medications, and other various triggers precipitating factors and complex interactions may trigger the appearance of signs and symptoms. these include especially recurrent herpes simplex virus (hsv), epstein-barr virus (ebv), histoplasmosis, alcohol, systemic diseases and immunological factors. method: -year-old male diagnosed with prostate adenocarcinoma who underwent transurethral resection and was taking trinomia (ramipril, atorvastatin, acetyl-salicylic acid) after his th rte external radiotherapy session, he presented erythematous maculo-papular lesions in the suprapubic area with some vesicles. therefore, withdrawal of treatment was decided and the performance of a skin biopsy. days later, regarding the improvement of the lesions, rte was continued, presenting incipient exacerbations of the lesions but it allowed us to end the cycle of treatment. results: skin biopsy results (anatomical pathology): basal keratinocytes, which blur the dermoepidermal interface, with lymphocyte exocytosis at this level, associated with isolated images of spongiosis. the dermis shows a superficial perivascular lymphocytic inflammatory infiltrate of moderate intensity. compatible with erythema multiforme. conclusion: radiotherapy is a technique of increasing use, so it is important to recognize the associated cutaneous lesions that appear less frequently and are sometimes underdiagnosed. diagnosis is both clinic and pathological and is usually late in most cases so it is vital to take into account this skin disease complication in order to be properly managed. including chinese herbal medicine is usually considered to be without any allergic and adverse reaction. method: visits were made to pharmacies in hong kong and luoyang, china and a martial art monastery/temple in dengfeng, china. some cam were found to have ingredients with potential allergic and adverse reaction. results: three cam, one from hong kong ( ), one from shaolin martial art monastery/temple in dengfeng ( ) and one from luoyang ( ), china were found to contain chinese herbal medicine with potential allergic and adverse reaction. ( ) cordyceps ling-zhi complex ingredients: cordyceps sinensis "caterpillar fungus", tremella fuciformis "snow fungus", ganoderma lucidum (ling-zhi) "reishi mushroom" and others years old female patient who has ulcers in oral mucosa and purple, itchy lesions on her right hand palmar area, little finger, index finger, on her left hand palmar area, pollex finger. in her history, she has relapsing vaginal yeast and she hasn't any hypersensitivity reaction with fluconazole before month ago she started to take fluconazole because of vaginal candidiasis. after using fluconazole she started to itch from described areas and dark redpurple eruptions appeared. she was prescribed oral methylprednisolone and topical pomade which included corticosteroid for four days but she didn't aware of fluconazole related drug reaction. lastly four days ago she took fluconazole and metronidazole for severe vaginal yeast. hours later pruritus, same eruption appear on the same area, lip and tongue angioedema than she had dyspnea, dizziness, hypotension, arrhythmia and consciousness. she had admitted to the emergency department and performed adrenalin. after a day bullae and ulcers came into existence in her oral mucosa. in her blood analysis there was mild increase in white blood cell count ( . /mm ), eosinophil count was normal ( /mm ), biochemistry parameters were in normal limits, crp and sedimentation rate were in normal limits, total ige was iu/l. introduction: tuberculosis is a disease that most commonly affects the lungs, which is transmitted by the respiratory tract and drugs are the most important factor in the treatment. non-resistant tuberculosis infection is usually treated with hrze. in rare cases, a hypersensitivity reaction may develop against one or more of the drugs during treatment. case: a -year-old female patient was diagnosed with culturepositive pulmonary tuberculosis and hrez treatment was started by the related department. seven days later she referred to the policlinic with edema and itchy erythematous lesions which are common in her extremities, which developed after hours of taking her medication. liver and kidney function tests and eosinophil count were normal. drug eruption was considered with current physical examination findings. the treatment was interrupted, short time systemic corticosteroids and antihistamine treatment started. desensitization planned. there was no feature in the prick and patch tests with drugs. desensitization was performed with isoniazid, no reaction was observed during the procedure. six hours after the procedure, the patient applied to the emergency department with painful edema and pruritic erythematous lesions in the extremities. desensitization procedures with rifampicin, ethambutol, pyrazinamide were performed without any problems after the lesions were regressed. isoniazid was withdrawn from the treatment protocol. outcome: we would like to present on this case that drug eruption may develop in the form of maculopapular rash after desensitization. this study aims to compare ethmoid mucosa and nasal polyp regarding density of tissue eosinophil and its sensitivity, specificity, and correlation with clinical characteristics for diagnosing ecrs. method: patients with crs with polyps scheduled for endoscopic sinus surgery were enrolled. specimens were collected from polyp apex, polyp pedicle and ethmoid mucosa. tissue eosinophil from these three sites in the same patient were compared. using eosinophilic mucin as a reference, sensitivity, and specificity of each site for diagnosing ecrs was assessed. correlations between tissue eosinophilia (defined as greater than / hpf) and clinical characteristics of ecrs including asthma, serum eosinophilia, and eosinophilic mucin were analyzed using each site of specimens. results: thirty patients with crs with polyps were enrolled. polyp apex, polyp pedicle and ethmoid mucosa gave similar results regarding tissue eosinophilia in patients ( . %). eleven ( . %) patients were ecrs (having tissue eosinophilia at all sites) and five ( . %) were non ecrs (no tissue eosinophilia at any sites). median tissue eosinophil was significantly greater in polyp apex ( , and polyp pedicle ( , iqr: - ) than ethmoid mucosa ( , iqr: - ), p = . . sensitivity of polyp apex, polyp pedicle and ethmoid mucosa for diagnosing ecrs were %, % and % respectively. specificity were %, % and % respectively. correlations between tissue eosinophilia and asthma were significant when assessing ethmoid mucosa (p = . ), and polyp pedicle (p = . ) but not polyp apex (p = . ). correlations with serum eosinophilia, and eosinophilic mucin were not significant (p > . ) when assessing any specimens. gov/pubmed/) was performed using the following key words: "obstructive sleep apnea syndrome"; "allergy rhinitis"; "hypoxia"; "intermittent hypoxia"; "fluctuating hypoxia"; "cyclic hypoxia"; and "hif- α" results: osas may affect the prognosis of ar patients based on the following evidence: ) ar is thought to be a cause of osas. ) exposure to hypoxia could mediate immune activation in ar and affect the response to treatment. ) hif- α expression may be a risk factor for ar. ) intermittent hypoxia can induce robust expression of hif- α. conclusion: first, improvement of ventilation during sleep represents an efficient strategy for treating ar. therefore, continuous positive airway pressure or nasal surgery to resolve a nasal obstruction could be added to ar treatment. finally, medications that target hif- α, such as digoxin, can be tested as adjuvant therapy. method: forty patients diagnosed with allergic rhinitis and olfactory dysfunction were recruited in current study in the group and . patients of group were administered with no treatment and patients administered with the traditional chinese acupuncture therapy were incorporated into the group . before the treatment, all of them underwent t&t olfactory testing, nasal sinus computer tomography scanning and visual analog scale (vas; - ), and repeated the assessment after four-week treatment. results: improved total t&t olfactory testing scoring averages and vas scoring averages was observed in eleven patients treated with traditional chinese acupuncture compared with four patients in the observation group. no side effect was found. no significant differences in olfaction recovery were found according to age, gender, or duration of disease between the two groups. the observation group underwent nasal endoscopic sinus surgery and the control group underwent external approach surgery, and the therapeutic effect of the two groups were investigated. results: the total effective rate was % in observation group and % in control group, the total effective rate of observation group is significantly higher than control group (p < . ). the recurrence rate was % in observation group and % in control group, the recurrence rate of observation group is significantly lower than control group (p < . ). complication occurrence rate of observation group was % which is significantly lower than control group % (p < . ). the therapeutic effects of endoscopic sinus surgery on chronic sinusitis in geriatric patients are better than conventional external approach surgery which is worth clinical application. results: (descriptive). the equick app is user-friendly even for vkc patients with sub-optimal reading ability. home use between clinic appointments allows responsive temporal data gathering of qol, symptoms, medication scores and impact of medical interventions. equick may be used in future as a research tool in gathering outcome data following interventions for vkc. ectoine, a substance deriving from halophilic micro-organisms, is a strong water structure forming solute exerting cell protective antiinflammatory and antiallergic properties. method: purpose of our study was to assess the efficacy of the preventive administration of % ectoine eye-drops ( times a day for months) to shorten the duration of vkc relapses (which begin, in our country, very early in spring and usually end in october), or to mitigate the attacks, which are only controlled by topical corticosteroids or cyclosporine resulting in an important burden of side-effects. in this retrospective study, we included children of both sexes ( males and females), under the age of years (mean age . years), affected by vkc from more than years/seasons and treated for more than months during a year, with cyclosporine eye-drops. these patients underwent, from february to september , the additional-to-the-usual protocol treatment with % ectoine eyedrops. results: % of the included subjects astonishingly had no relapse of vkc, % needed topical cs or cyc treatment but it was started months later compared to previous years, % needed the topical drugs months later and % had a similar to previous years course (no ectoine efficacy). the treatment was well tolerated and only child had to stop it because of local allergy to the eye-drops. the preventive administration of % ectoine eyedrops was able to stabilize and to delay vkc attacks in more than % of the selected patients showing the importance of anti-inflammatory and anti-allergic properties of this product. following international criteria we considered normal levels of vitamin d the levels between nmol/l ( ng/ml) and nmol/l ( ng/ml), a potential deficiency between nmol/l and nmol/l and a severe deficiency less than nmol/l. results: . % ( children) of akc group patients presented vitamin d low levels, among them children showed a potential deficiency and a severe deficiency. . % ( subjects) of vkc patients suffered a deficiency in vitamin d which was mild in and severe in patients. . % ( children) of sac group showed a deficiency in vitamin d which was potential in and severe in subjects. conclusion: our study shows that in different forms of allergic conjunctivitis many children are suffering a vit. d deficiency and it can be supposed that a correlation between the severity of the allergic form and the level of vit. d deficiency exists. we recommend allergists and ophthalmologists to check vit. d levels in children suffering from allergic conjunctivitis because its deficiency is very common and many are unaware of it; in case of a vit. d insufficiency it is fundamental to give a vit. d suitable-to-the-case supplementation. method: children ( males and females, mean age . ± months) affected by vkc and allergic rhinitis from more than years were treated with mometasone furoate nasal spray spray bid × weeks in a month, for consecutive months as a co-seasonal treatment at the beginning of eye allergic symptoms. other systemic or topical treatments did not vary compared to the previous years. results: a quick questionnaire administered to children and their care-givers showed that nasal symptoms regressed after a mean period of . days from their beginning but, impressively, in more than % of them, these patients did not show a vkc typical relapse along the months of mometasone treatment, moreover the following summer period was milder in subjective ocular symptoms in more than % of the patients. our experience pointed out that incs adjunctive treatment was positively associated with a regression of eye and nose symptoms in children suffering from vkc, confirming previous literature data which concern milder forms (seasonal allergic conjunctivitis or allergic rhino-conjunctivitis) compared to the severe forms (like vkc) we analyzed in our work. one of the involved mechanisms of action can be the alleged effect on the reduction of substance p in tears; it is supposed to reflect the neuropeptides levels in ocular tissues. | patient response to mp-azeflu in an allergen exposure chamber onset of action (ooa) timing may impact treatment adherence. mp-azeflu, intranasal azelastine hydrochloride (aze) and fluticasone propionate (fp) in a single device, has proven to have greater efficacy and faster ooa than a combination of oral loratadine and intranasal fp (lora/infp), but the clinical relevance for patients is unclear. this single-center (ontario, canada), randomized, double-blind, double-dummy, three-period crossover trial examined by which extent mp-azeflu provides clinically relevant symptom improvements according to different efficacy parameters. method: ar symptoms were induced in asymptomatic, ragweedsensitive patients via ragweed pollen challenge in an environmental exposure chamber. patients received a single dose of mp-azeflu, lora/infp, or placebo and were monitored for hours. symptoms were assessed using total nasal symptom score (tnss) and total ocular symptom score. responder analyses included the number of patients to achieve relevant response (rr) to therapy ( % or % reduction in tnss), time to rr (ie, first time point at which rr was reached), and minimal clinically important difference (mcid) in ooa. background: nasal allergen provocation test (napt) is a standardized diagnostic tool indicated in the diagnosis of allergic rhinitis, to design and monitoring allergen immunotherapy, and to study the pathophysiology of airway allergy. unfortunately, until now very few studies have evaluated its reproducibility and safety. in this study we wanted to analyse the safety and reproducibility of napt in a large group of rhinitis patients and healthy controls. unit until december . a bilateral saline challenge followed by a bilateral napt were performed in symptoms-free individuals. the response was assessed by nasal-ocular symptoms and acoustic rhinometry. all subjects signed a written informed consent. the safety of napt was checked by the occurrence of extra-nasal/ ocular reactions (enor), severe adverse events (sae), and use of rescue medication (rm). enor was assessed by clinical symptoms, physical examination, cardiopulmonary auscultation, spirometry, and oxygen saturation. the reproducibility of napt was tested by comparison of the results in or more sessions with≥ -month interval. background: nasal hyperreactivity (nhr) is self-reported by a majority of patients with allergic rhinitis (ar) and is likely mediated by neural-immune interactions. the combination of fluticasone propionate (fp) and azelastine (aze) hydrochloride administered in a single spray (mp-azeflu) has been shown to be superior to fp or aze alone in patients with seasonal ar (sar). we hypothesize mp-aze-flu may reduce neuro-immune mediators in ar with nhr. in a post hoc analysis of three pivotal studies of mp-azeflu, we analyzed the efficacy of mp-azeflu, fp, and aze in patients with ar with and without nonallergic triggers. method: in three randomized, double-blind, controlled trials, patients with sar were randomized : : : to mp-azeflu, fp, aze, or placebo (pbo). patients self-reported sensitivity to nonallergic triggers. change from baseline in total nasal symptom score (tnss) and treatment differences between active agents and pbo were calculated. results: across patients in three studies, mean age was . years and mean age at ar symptom onset was . years. overall, % reported ≥ nonallergic trigger, which included sudden temperature/humidity change ( %), tobacco smoke ( %), perfumes/fragrances ( %), incense/candles ( %), and cleaning products ( %). change from baseline in tnss for patients with ar and nonallergic triggers was greater with mp-azeflu than with fp or aze (table) , and patients with nonallergic triggers improved slightly less than patients without nonallergic triggers in both the mp-azeflu and fp groups. background: in low-income countries (lics), assessment of phenotypes, prevalence and risk factors for allergy-related diseases (ards) using allergen-specific ige may be complicated by environmental exposures such as helminths. these exposures may also induce cross-reactive carbohydrate-specific ige profiles that could inhibit allergic effector responses. we sought to elucidate the molecular basis of ige sensitisation among individuals in uganda, using a component-resolved approach to ige measurement. we employed the isac ® allergen microarray to assess plasma ige reactivity to purified natural and recombinant allergen components in participants of three studies: a trial of intensive versus standard anthelminthic treatment in the rural helminth-endemic lake victoria islands (n = ), a parallel urban survey of allergy outcomes in a lower helminth exposure community (n = ) and a study on asthma risk factors in children from the urban setting and from nearby rural schools (n = ). data on sensitisation to crude allergen extracts were obtained by skin prick testing (spt) with cockroach and house dust mites (hdm), and by immunocap ige testing (cockroach, hdm, and peanut). results: the rural setting was characterised by high prevalence (≥ %) of sensitisation to crude extracts (immunocap ige> . ku/ l) but low sensitisation to the major, established, allergenic components on the microarray (≤ %, ige> . isu). however, sensitisation to cross-reactive carbohydrate determinant (ccd)-bearing components and venoms was more common in rural (up to %) versus urban (up to %) individuals, and was associated with helminth infection. urban individuals mounted higher responses to allergenic components of dust mites but responses to other components were similar between the two settings. sensitisation to allergenic components was higher among asthmatics and spt+ children but ccd sensitisation profiles were similar between asthmatics and nonasthmatics, and between spt+ and spt-school children. conclusion: we show that, in lics, ige to crude allergen extracts (detected in standard immunocap assays) reflects sensitisation to a myriad of environmental exposures (absent in more developed countries), such as ccds expressed by helminths, and may not accurately define ard phenotypes in this setting. however, our data does not seem to indicate that ccd-specific ige detected by isac ® microarray protects against ards. considered minor allergens. due to their sequence homology and conserved structure, they show a high cross-reactivity. the objectives were to study the ige/igg binding properties of polcalcin in relation to the calcium ions, and the ige cross-reactivity between purified polcalcin from olea europea (ole e ) and two recombinant polcalcins (rphl p and rbet v ). method: ole e was purified by immune-affinity chromatography using polyclonal antibodies anti-rche a . serum samples were obtained from patients allergic to grasses recruited at hospital de guadalajara (spain), all of them positive to phl p with sige values ranging from . to . ku/l. equal volumes of all sera were used to prepare a pool. calcium binding assay was performed either by addition or not, or depletion of ca + . ole e was incubated with . mm cacl or with mm egta ph . (ca + chelator agent) at the same time as the antibody in immunoblot or elisa assays with the pool of sera or with anti-che a polyclonal antibody. crossreactivity assay was performed by immunocap inhibition. aliquots of the pool of sera were previously incubated with amounts of ole e ranging from . to . ng. the same dilution of the pool of sera without ole e was used as a control. after hours of incubation, sige (ku/l) binding to rbet v or rphl p was determined. results: a kda protein was purified from the o. europea extract and identified by lc/ms-ms as ole e . in the calcium binding assay there were no differences between the samples with or without ca + . however, the addition of egta to the reaction completely inhibited the binding of the polyclonal antibody by immunoblot and also produced a . % reduction of ige binding by elisa. in the cross-reactivity assay, a % inhibition of ige binding was obtained with . ng of ole e for rbet v and . ng for rphl p . the maximum rate of achieved inhibition was . % for rbet v and . % for rphl p . conclusion: native purified ole e contains the ca + necessary to bind to the specific antibodies and the depletion of ca + inhibited this binding. high cross-reactivity of ole e with rphl p and rbet v was demonstrated. | effect of glutathione-s-transferase pi on the cysteine protease activity of the house dust mite allergen der p background: environmental proteases have been proposed to be involved in the pathogenesis of allergic disorders via different mechanisms, such as the disruption of epithelial tight junctions, the cleavage of surface proteins, the activation of damage and pathogen-associated molecular patterns receptors, and the alteration of redox status. der p from house dust mite is one of the most clinically relevant indoor allergens worldwide, which exhibits cysteine protease activity and has been linked to allergenic rhinitis and asthma. however, it is unknown whether the host microenvironment could regulate der p activity once it reaches the mucosal surface. glutathione-s-transferase pi (gstpi) is an anti-oxidant and detoxification enzyme. gstpi is the predominant gst in human lung epithelial cells, where it is expressed in high levels. polymorphic variants of gstpi have been associated to various inflammatory lung disorders such as allergic asthma. more recently, gstpi has been identified as a redox regulator through protein s-glutathionylation, a post-translational modification where glutathione (gsh) is conjugated to cysteine residues. method: this work aimed at determining if gstpi affects the cysteine-protease activity of der p , compared to gstmu -a different gst isoform-by using different in vitro approaches. results: we found that gstpi increased der p -activity, but not gstmu. our results suggested a potential role of gstpi in upregulating the protease activity of der p allergen. however, the clinical implications of these findings in allergic airway diseases needs for further investigations. | cari p , a novel polygalacturonase allergen from papaya acting as respiratory and food sensitizer biswas sarkar m; sircar g; ghosh n; das ak; jana k; dasgupta a; gupta bhattacharya s bose institute, kolkata, india background: papaya was globally reported to elicit ige-mediated hypersensitivity. certain papaya sensitive patients with food allergic symptoms were found to experience recurrent respiratory distresses at peak flowering period of papaya even after quitting the consumption of papaya fruits. the immunoreactive protein present both in pollen and fruit proteome was detected by ige-serology and identified by mass spectrometry. one such allergen, designated as cari p was cloned, and purified as recombinant protein. the ige-reactivity of rcari p was examined by immunoblot using patient sera. the allergenic activity of rcari p was evaluated by histamine release assay from ige-sensitized granulocytes. the aggregation and folding pattern of rcari p was assessed by size exclusion chromatography and circular dichroism spectroscopy respectively. the presence of cari p in papaya fruit was searched by igg-immunoblot using allergen-specific rabbit antisera. a mouse model of papaya allergy was established to study the role of rcari p in eliciting respiratory and food hypersensitivity. results: a kda ige reactive protein commonly present in pollen and fruit proteome of papaya was identified as endopolygalacturonase. recombinant cari p remained monomer and the cd-spectra revealed predominantly β-sheet characters. the melting curve of the allergen showed partial refolding from a fully denatured state indicating the possible presence of conformational ige-epitopes in addition to the linear ige-epitopes of food allergens. out of papaya allergic patients displayed ige reactivity to rcari p . rcari p at μg/ml, induced histamine release from challenged granulocytes within a range of % to % (i.e. ± . %; n = patients). expression of cari p was detected in the peel and pulp tissues of papaya fruits at two edible stages of fruit maturation. in mouse model, rcari p exhibited a comparable level of eosinophil infiltration and goblet cell hyperplasia in lung and duodenum histology. conclusion: cari p the first major allergen reported from papaya with a dual role in respiratory sensitization via pollen inhalation and sensitization of gut mucosa via fruit consumption. the recombinant allergen can be used as marker allergen for molecular diagnosis and immunotherapeutic management of papaya allergy. background: lipids can be potent stimulators of the immune system, and their role in allergy is highly investigated and debated. since many allergens bind lipids, one question that arises is the relative importance of the lipids versus the lipid-allergen complex in eliciting the immune response. also of interest is an evaluation of the importance of the allergen-lipid complex. in our characterization of the structure of the cockroach allergen bla g , we discovered that it could promiscuously bind a variety of lipids in a large central cavity. this suggested that bla g could be used as a prototypical allergen and lipid delivery vehicle to test in various models of sensitization. method: cd spectroscopy. nmr spectroscopy. molecular modeling. we have developed an hplc procedure to strip the phospholipids derived from the e. coli-based expression system, and reconstitute the allergen with a variety of lipids. using cd spectroscopy and nmr, we have verified that the protein conformation is highly similar in the presence and absence of lipids. temperature dependent cd spectroscopy revealed that unloaded bla g is the least stable, and the melting temperature increased with increasing fatty acid chain length up to c . similar cd melting experiments revealed that bla g could bind lipoteichoic acid (lta) from gram positive bacteria, but did not interact with lipopolysaccharide (lps) from gram negative bacteria. molecular modeling studies have suggested that the stoichiometry of phospholipid binding is likely phospholipids per bla g and give insight as to the different binding characteristics that would allow bla g to bind lta but exclude conclusion: these biophysical studies will allow the design of bla g -lipid systems to test a variety of sensitization models. | sal k , a new allergen from salsola kali sola jp; pedreño y; fernández j; cerezo a; peñalver m probelte pharma, murcia, spain background: the polcalcin from salsola kali was identified and sequenced (genbank kt ) and the recombinant protein was characterized as a minor allergen with a prevalence of % of patients with a spt positive to s. kali. the objective of this study was to purify the polcalcin from s. kali pollen and to include the allergen in the website for the systematic allergen nomenclature (www.allergen.org). method: the native polcalcin from s. kali (npsk) has been purified from pollen after a first step of protein extraction and then diverse chromatographic steps: a size exclusion chromatography to remove particles minor than kda, an ionic exchange chromatography, a hydrophobic interaction chromatography and a final step of size exclusion chromatography to obtain the purified sample of polcalcin. the purity of the npsk has been determined by sds-page and the binding capacity to a specific polcalcin antibody from rabbit serum was tested by immunoblot. the specific antibody had previously been obtained by immunization with the recombinant polcalcin from s. kali. the allergenicity of the npsk has been assayed by immunoblot with a pool of sera of patients sensitized to s. kali. the identity of the purified npsk has been analyzed by peptide footprint in hplc-ms/ms after digestion with trypsin. all the information about the polcalcin from s. kali was sent to who/iuis allergen nomenclature sub-committee. the npsk showed a high purity in sds-page with a molecular weight of approximately kda and this purified protein reacted with the specific polcalcin antibody from rabbit serum. the ige binding capacity of the npsk was confirmed by immunoblot using a pool of sera from patients sensitized to s. kali. the analysis of peptide footprint confirmed that the purified protein is a polcalcin. the who/iuis allergen nomenclature sub-committee included the polcalcin from s. kali in the website for the systematic allergen nomenclature as a new minor allergen named sal k . conclusion: the polcalcin from s. kali has been purified from pollen and tested for its ige binding. it is included in the website for the systematic allergen nomenclature as the new allergen sal k . background: alt a protein is the major allergen from the fungus alternaria alternata and responsible for chronic asthma, yet little is known about its physiological role and immunological activity. our main purpose was to investigate the mechanism through which alt a induces an allergic response in bronchial epithelium. method: although alt a has a unique topology, we studied the structural relationship by in silico procedures consisting of three distinct structural alignment methods in order to understand its nature. the immunological properties of the allergen were investigated by using monocyte cell line thp and human peripheral blood mononuclear cells. results: its crystal structure has been recently reported and claimed to be exclusively in fungi without equivalent in the protein data bank. data obtained in silico show that this allergen shows some structural relationships with a number of other β-barrel proteins such as human lipocalin (lcn ). besides, our experimental data demonstrate that alt a is also able to interact with lcn , human lipocalin. in this way, the results obtained from several immunological assays showed that alt a is able to produce a response of the immune system through different immune innate receptor pathway inducing the th cytokines. background: increasing evidence of cross reactivity syndromes between pollen grains and fruits, with immediate or delayed reactions, has been reported. while some syndromes such as the birch pollen/apple syndrome are well documented, some other such as the cypress pollen/peach syndrome remain to be understood. for the latter, significant progress has recently been made with the discovery of a new allergen family, the gibberellin regulated proteins (grps), which has been shown to be responsible for the observed cross reactivity i.e. pru p and bp ( , ) for the peach and the cypress pollen respectively. grps are small cationic proteins with anti-microbial properties and have been shown to be over produced in response to a stress. herein, the case of a patient, born and raised in the south of france but currently living in paris, has been studied. this patient has been suffering since childhood from allergic rhinoconjunctivitis to cypress pollen and from some oral symptoms to peach and other fruits (including pomegranate). method: in addition to the clinical exploration and cutaneous tests, a very thorough biological characterization of the patient samples has been performed through various specific ige quantitation techniques, western blotting after one and two-dimensional gel electrophoresis and flow cytometry based basophil activation testing (bat). results: specific iges to cypress pollen, birch pollen, peach, orange and apple have been found. pr allergenic proteins are recognized by iges but no ltps. the presence of specific iges to cypress pollen bp , peach peamaclein (pru p ) and a cationic kda protein from pomegranate has been shown through western blotting after gel electrophoresis separation of the protein extracts. the use of bat finally enabled to demonstrate that the basophils of this patient were, ex vivo, strongly activated with protein extracted from orange and cypress pollen and also with purified proteins such as bp and pru p . conclusion: these results unambiguously show that the cypress pollen grp, bp , is clinically relevant, similarly to its homologous protein in peach, pru p . it can be proposed that these two allergens are at the basis of the observed cross-reactivity syndrome. the search for new cross-reactive allergenic grps in pollen, fruits or vegetables may enable to better understand other pollen/food associated syndromes that still remain unexplained. background: nine allergens of phleum pratense have been described until now (iuis database) and classified into groups based on their function and cross-reactivity. group and allergens are considered the most immunodominant, due both to their greater ige-binding capacity and the number of patients ige-reactive to them. previously published studies have estimated that group is recognized by almost % of grass pollen-allergic patients, and group by %. however, until now a comparative of the ability of these allergens to provoke an immune response has not been performed. the objective was to study the immunogenicity of the major allergens phl p and phl p , by analyzing the ability of the recombinant forms (rphl p and rphl p a) to induce a humoral immune response. method: five mice were immunized with the same amount of each recombinant protein: rphl p and rphl p a (indoor biotechnologies) ( μg plus two boosters of μg). the specific igg antibodies produced by each mouse were tested against the recombinant proteins by direct elisa and the title of each of them was determined by optical density (o.d.). additionally, the recognition of both allergens in native and depigmented-polymerized (dpg-pol) extracts of p. pratense was studied by direct elisa using these generated antibodies. results: preimmune sera were negative. all mice produced antibodies against the corresponding recombinant protein. the immune response (sigg) was statistically significant higher in mice immunized with rphl p than in those immunized with rphl p ; it was needed times more rphl p serum than rphl p a serum to obtain the same o.d. values. the difference in responses was higher in the group of mice immunized with rphl p than with rphl p a. differences in the recognition of phl p and phl p in native and depigmented-polymerized extracts of phleum pratense was also observed. it was necessary times more rphl p serum to produce the same signal than rphl p a serum in native extract and it was necessary times more rphl p serum to produce the same signal than rphl p a serum in dpg-pol extract. conclusion: rphl p a is more immunogenic than rphl p , which was also probed with native and dpg-pol extracts. background: glioblastoma (gbm) is an incurable primary malignant brain tumour with a median life span of less than months despite multimodal treatments. therefore, there is a serious need for the development of innovative medications. several epidemiological studies underlined an inverse correlation between pre-existing igemediated allergy and gbm risk, where having such an allergy decreased the odds of developing gbm by to %. we aim to delineate the intrinsic immuno-biological and molecular mechanisms that can be responsible for these correlations, based on the hypothesis that allergies may promote a state of increased immuno-surveillance in the brain through the presence of immunological factors such as immunoglobulins, cytokines and cells involved in th -driven allergic reactions. we consider that as the major immune cell type of the brain, microglia should be implicated in this beneficial association and may favour the elimination of the nascent tumour in brain parenchyma in an allergic context. we implemented a long term allergic airway inflammation by repeated nasal instillation of house dust mite (hdm) extract in a syngeneic orthotropic mouse model of gbm. we followed animal survival and the tumour growth by mri. in addition, we purified microglia from allergic vs non-allergic mice in order to assess their cytotoxic function against the gbm cell line ex vivo and their secretory capacities. finally, we investigated immunoglobulin reactivity against gbm antigens in the context of allergic reactions by reverse phase protein array (rppa). we demonstrated an increase of the animal survival that was correlated with a delayed tumour engraftment and a reduced tumour growth. these phenotypes were associated with functional modification of microglia from sensitized mice. indeed, these microglia showed a rise in the production of il- and tnf-a as well as an increase in cytotoxic functions against a gbm cell line ex vivo. in parallel, we observed an increase in serum igg reactivity against gbm antigens in mice sensitized with hdm compared to control mice. results: in patients ( %) with cvid we recorded at least one temporary platelet count decrease below × /l compared to only patient ( %) with xla (p = . ). more importantly in patients ( %) with cvid this decrease was observed in a period longer than months compared to patient ( %) with xla (p = . ). in patients ( %) with cvid we recorded at least one temporary platelet count decrease below × /l and only in patients ( . %) with cvid this decrease was observed in a period longer than months. we did not record any platelet count decrease bellow × /l in patients with xla however the difference with cvid did not reach statistical significance. no thrombocyte count decrease bellow × /l was observed in either group. none of patients required immunosuppressive treatment for immune thrombocytopenia (itp). conclusion: although the statistical significance was documented only in temporary platelet count decrease below × /l it is obvious that numbers of thrombocytes commonly fluctuate in some patients with cvid. the mechanism leading to these temporary decreases is unclear. monitoring of complete blood count is a basic follow-up investigation in patients with cvid. introduction: wegener's granulomatosis (wg) is a systemic disease that may affect all organs, most frequently the ears, noses, throats, sinuses, lungs and kidneys. it is a rare autoimmune disease, also called granulomatosis with polyangiitis, and characterized by necrotizing granulomatous inflammation in small and medium sized blood vessels. anti-neutrophil cytoplasmic antibody against to proteinase (c-anca) is thought to be responsible for autoimmune inflammation. the coexistence of wg and common variable immunodeficiency (cvid) is extremely rare. in this report, we describe a patient with wg and cvid who was treated with immunosuppressive drugs and intravenous immunoglobin concomitantly. case report: a twenty-four-year-old male patient was referred to our clinic for immunological evaluation due to recurrent infections, fever of unknown origin and neutropenia. the patient had been diagnosed with wg and taking immunosuppressive therapy for three years. he had chronic renal failure due to wg and had also been on peritoneal dialysis for three years. serum igg, iga levels, peripheral blood cd + b cell percentage and absolute count of the patients were found to be low according to reference limits. he was diagnosed with cvid after excluding secondary reasons for hypogammaglobulinemia and he started to receive mg/kg intravenous immunoglobulin (ivig) therapy once in a month. also, the treatment that consists of mycophenolate mofetil (mmf) and glucocorticoids was continued to decrease c-anca levels in serum. he has been accepted as a candidate for kidney transplantation, and prepare for this purpose. discussion: the management of the patient with cvid and wg may be complicated. it is considerably difficult and needs competency and courage. moreover, the cases similar to ours, are extremely rare. therefore, the authors should share their own experiences on cvid and discuss them by comparing the data obtained from other cases. background: leukocyte adhesion deficiencies (lads) are a group of three genetic disorders leading to defective leukocyte adhesion to the endothelium and as a consequence decreased leukocyte recruitment and immune defense. lad-i is caused by mutations in the gene encoding the ß -integrin cd on chromosome .lad-iii is a rare primary immunodeficiency syndrome, characterized by homozygous mutations in the kindlin- gene (official symbol fermt ). we have aimed to evaluate our patients who were followed up with lad for the last years, retrospectively. method: all data of the cases were obtained from the file records of age at diagnosis. results: seven patients from separate families were included in the study. four patients were lad-iii and patients were lad-i. the female to male rate was / . the age of diagnosis is ranged from days to years. the median umbilical cord detachment was days ( - days groups: up to times ( people) and from to times ( people). healthy donors were examined as a control. flow cytofluorometry method was used to study peripheral blood and assess the parameters of innate and adaptive immunity results: it was found that at a frequency of edema up to times a year there are changes in the t-system of adaptive immunity, which are shown by a decrease in the expression of late activation markers (cd + hladr+ . ± . %, in control . ± . %), an increase in the number of cd + cd + cytotoxic lymphocytes ( . ± . x /l, in control . ± . x /l) and as an increase in their functional activity (cd + gr+ . ± . x /l, in control . ± . x /l). the nature of disorders of cellular factors of the innate immunity is manifested by decrease in the adaptive resources of neutrophils (kstnbt . ± . u.e., in control . ± . u.e.). patients with hae with a frequency of edema up to times a year, we observed the disorders of the humoral link of adaptive immunity, which consist in an increase in the number of circulating b lymphocytes ( . ± . x /l, in control . ± . x /l). in addition, with the strengthening of the hae clinic, changes in the system of innate immunity progressed very fast and consisted in increasing the amount (cd + . ± . x /l, in control . ± . x /l), and functional activity (cd + gr+ . ± . x /l, in control . ± . /l) of natural killer cells results: we included children, mostly males ( %), aged between month and years. . % of patients (n = / ) showed abnormal absolute results of lymphocyte count for age. we found more patients evaluated in the age group of to years ( . %), followed by - years ( . %), lymphopenia was found in . % of patients. b lymphocyte deficiency was the most common pattern ( %) followed, in decreasing order, by low cd , t cd , tcd and nk. many patients have more than one affected population ( . %) . some patients were affected in all three series ( . %). the cd / cd ratio decreased in . % of the patients. the majority of the children were males between the ages of month and years. . % of patients showed abnormal absolute lymphocyte count for age. b-cell deficiency was the most common pattern followed, in decreasing order, by low cd , t cd , tcd and nk. many patients have more than one affected population. | indicators of the humoral immunity in the mechanical jaundice of benign genesis the aim of the investigation was to study the indices of humoral immunity in patients with benign mj, depending on the level of bilirubin. method: patients with mj and practically healthy volunteers were examined. patients with a level of bilirubin less than μmol / l - , with a bilirubin level of - μmol / l - and with a bilirubin level of more than μmol / l - patients. the concentration of immunoglobulin classes a, m, e and g in serum was determined by enzyme immunoassay. the statistical significance of the differences was determined using the ranked mann-whitney test. the critical level of significance in checking statistical hypotheses was assumed to be p < . . results: of the contacted dermatologists, participated ( women, men; mean age . ± . ) which results in a response rate of . %. the guideline compliant prescription rate of biologicals in patients with csu was . %. the most prevalent barriers in the prescription were the high cost of the treatment ( . %), low reimbursement for doctors ( . %) and the fear of a recourse claim ( . %). however, a lack of evidence or an insufficient efficiency were not con- case report: eosinophil associated gastrointestinal disorders (egids) including eosinophilic colitis are commonly associated with atopy. aeroallergen sensitization may accompany food allergy in these patients. a case with eosinophilic colitis responsive to anti-ige monoclonal antibody (omalizumab) treatment is presented. an eleven-year-old boy had bloody diarrhea lasting nearly one month in autumn for last years. this year diarrhea lasted more than months. colonoscopic biopsy revealed lymphoplasmacytic inflammatory cells including eosinophils leading to a diagnosis of ulcerative colitis. corticosteroid and mesalazine treatment was started with a good clinical response. recurrence of diarrhea during corticosteroid dose reduction suggested corticosteroid dependent ulcerative colitis. eosinophilic/allergic colitis was an alternative diagnosis when seasonal recurrence, lack of weight loss, eosinophils in biopsy and high serum ige level were considered. colonoscopy done after cessation of therapy for one month, revealed exudative ulcerous lesions, lacerations, loss of haustration compatible with colitis (inflammatory/allergic?). presence of significant mucosa associated lymphoid tissue in biopsy supported any inflammatory, reactive process. he had recurrent bronchiolitis until age six and allergic rhinitis in spring for three years. total ige and mix aeroallergen specific ige were high ( iu/ml, . kua/l), absolute eosinophil count was normal ( /mm ). food skin prick and patch tests were negative. he had positive skin reactions with dermatophagoides, grass and olea pollens (induration diameter: , , mm, respectively). pulmonary function test was normal. he was considered as eosinophilic/allergic colitis and omalizumab was started according to manufacturer's dosing table ( mg/ weeks). rectal bleeding decreased after first dose and ceased after the second dose. early colonoscopy examination after rd month of therapy showed that exudations disappeared and haustrations became evident. microscopy revealed mild nonspecific colitis. few patients with eosinophilic colitis improved with omalizumab were reported before. ige-mediated processes are responsible from eosinophilic inflammation in egids, making anti-ige therapy as a promising treatment option. | design of liposomal carriers modified by glycoconjugates for liver cell delivery of nucleic acids used. the surface of liposomal nanoparticles can be modified to increase the selectivity of intracellular delivery. it is well known that asialoglycoprotein receptors of hepatocytes have a strong affinity to galactose carbohydrate. therefore, the aim of this study was to assess the effect of the modification of the liposome surface by glycoconjugates on the selectivity of intracellular transport of nucleic acids into the liver cells. method: liposomes based on ornornglu(c ) were chosen previously as the effective nucleic acid delivery system. we modified liposomes with novel lactose-based derivatives. every of four glycoconjugates was added to ornornglu(c ) in an amount of , and %. as a result, variants of modified liposomes were obtained. to determine the cytotoxicity, an mtt test was used. using luciferase test, the selectivity of penetration was evaluated on nonspecific t (human embryonic kidney) and specific hepg (human liver cells) cell lines. results: modified liposomal compositions ornornglu(c ) - + lacc ( %) and ornornglu(c ) - + lacggg ( %) had the lowest cytotoxicity similar to that for unmodified ornornglu(c ) . the ic , calculated based on the data of mtt test, was . and . , vs. . mg/ml, respectively. ornornglu(c ) - + lacggg ( %) showed a . -fold increase in transfection activity on the nonspecific t cells, compared to unmodified ornornglu(c ) , whereas the modification of ornornglu(c ) - + lacc ( %) resulted in a -fold decrease in transfection activity. however, the ability of these variants to penetrate the specific liver hepg cell was significantly higher by and times, respectively, than for unmodified ornornglu(c ) . results: the greatest inhibitory effect of sbfhd was observed in mdm infected with hiv- bal: % and % suppression of hiv replication was achieved at concentrations of . μg/ml and . μg/ ml, respectively. the activity in pbmc and dc was less pronounced (the respective ic values were . μg/ml and . μg/ml). studies in endometrial hec- a cells demonstrated that sbfhd suppressed cd -independent entry of hiv- ( tcid /ml) by %, %, and %, respectively, at , , and μg/ml. the effect was also observed after increasing the dose of the virus. at tcid /ml, sbfhd suppressed hiv infection by % ( μg/ml) and % ( μg/ml). the cytotoxicity of sbfhd in this system was low. similar results were obtained with colorectal caco- cells. sbfhd exhibited no spermicidal activity at concentrations of up to mg/ml. combining within a single microbicide two agents that target distinct steps of hiv life cycle will maximize its efficacy (via synergistic effects and/or interference with multiple stages of the transmission). we therefore explored the synergistic potential of combinations of sbfhd and azt, the classical nucleoside rt inhibitor. in these experiments, % suppression of hiv infection was reached at concentrations of sbfhd and azt, which were significantly lower than the respective ic values of each component (determined in parallel experiments). the synergistic effect was most pronounced for the combination of . μg/ml sbfhd (which is times less than the ic ) and . nm azt (which is times less than its ic ). cd expression was increased after the co-culture with reishi, shiitake and boletus mushrooms (c - . ( . - . )%; pma - . ( . - . )%; )%; shiitake - . ( . - . )%; boletus - . ( . - . )%). method: the study included men (mean age ± . years) before and immediately after staying in countries with a hot climate. results: the development of lymphopenia observed in the first week of observation. this was accompanied by a decrease in the number cd + lymphocytes expressing the markers of late activation (cd + hladr+ . ± . x /л и . ± . x /л). revealed significant decrease of cd + cd + foxp + regulatory cells in the first week after returning from the area of adverse climatic conditions, as well as a significant sustained decrease in the number cd + cd + hladr+(p < . ). change of the effector link of innate immunity was determined in significant reliable decrease in relative (cd + . ± % and . ± . %, respectively, p < . ) and absolute (cd + . ± . x /l and . ± . %, respectively, p < . ) in the number of a population of natural killer cells in the first week of observation. in the context of acute stress marked a significant increase in relative and absolute numbers of b lymphocytes ( ± . % ( . ± . × /l) before a trip to countries with a hot climate and ± . % ( . ± . × /l) in the first week after returning, p < . ). the activity is the production of antibodies was not changed. (ast) which is the intramuscular injection of patients own serum, is a promising therapy with a substantial efficiency on ciu patients. in this study we aim to assess the efficacy of ast on chronic urticaria patients by dlqi questionnaire. method: this was a single-blind randomized clinical trial which evaluated the efficacy of autologous serum therapy compared to oral antihistamines in patients with ciu. ciu patients received the ast. every session cc of each patient's blood was centrifuged at the speed of rpm for minutes and . cc of the serum was injected intramuscular into the patient's deltoid muscle weekly for weeks. the control group consisted of ciu patients took mg of cetirizine daily for weeks. patients answered the dlqi questionnaire at the first session of treatment as baseline and weeks after the last session(week ) as response to treatment. the mean baseline score of dlqi for ast group was conclusion: pharmacotherapeutic and inpatient costs for patients with prevalent ar and asthma were lower in those prescribed ait than in those not prescribed ait in all years, both with and without including the cost of ait itself. this indicates that treatment with ait is associated with lower cost burden for health services. background: immunotherapy with peptides rather than conventional whole allergens is being developed to improve the benefit/risk balance of subcutaneous immunotherapy (scit). lolium perenne peptides (lpp) demonstrated reduced allergenicity following ex-vivo analyses, allowing higher doses to be given over a shorter period to improve treatment adherence and compliance. such treatment resulted in significant reduction in symptoms and rescue medication intake during the grass pollen season. here we report the safety of lpp immunotherapy in adults. background: a new allergoid from alternaria alternata was characterized to determine its reduced allergenicity in vitro. the objective of this study was to determine the skin response to the allergoid and to evaluate the clinical tolerance of the immunotherapy with the allergoid product using a rush schedule. method: to assess the skin response (sr) two groups of patients were included: group with patients sensitized to a. alternata and with respiratory disease caused by this mold; group (control) with patients sensitized to others allergens and non-atopic patients. the sr was determined by spt using three concentrations of the allergoid: p (lowest concentration), p (four times higher than p ) and p (estimated to obtain a wheal area similar to histamine mg/ml). in spt was also used a native extract of a. alternata (n) and histamine mg/ml (h). all products were tested in duplicate in all patients and the sr was evaluated by comparing the median of the wheal area produced by different products. to evaluate the clinical tolerance to immunotherapy the patients of group were treated with the allergoid product using a rush schedule consisting in a dose of . + . ml the first day and . ml after one month (maintenance dose). the clinical tolerance was determined as the percentage of adverse reactions (ar) to the treatment and the classification of ar was established according to eaaci. the number of patients included to evaluate the sr was (group : ; group : , atopic and non-atopic) with an average age of . (range . the spt data from group were expressed as median and interquartile range of wheal area (mm ): h: . ( . - . ); n: . ( . - . ); p : . ( - . ); p : . ( - . ); p : . ( . - . ). it was determined that sr of allergoid was reduced in % respect to the native. the products n, p , p and p did not produce any response in patients of group . to evaluate clinical tolerance, patients of group were treated with the allergoid product with a rush schedule and only two ar were registered ( . % of doses). these were retarded local reactions with a wheal diameter higher than cm. no systemic reactions were registered and all patients continued the treatment. the allergoid from a. alternata produces a significant reduced response to spt due to its reduced allergenicity. the treatment with an allergoid product in a rush schedule is safety and clinically well tolerated. background: in our study we aim to determine the more effective, the total cost of years of patients using scit was tl per person whereas the total cost of years of patients using slit was tl per person. when we compare the total cost data of both groups, we found that they are close to each other. while the greatest portion of the cost data of patients with scit treatment was direct costs associated with the treatment itself ( %); the remaining part of the total cost was indirect ( %) with non-medical expenses such as transportation ( %). in the slit group, direct costs including drug expenditures have a larger percentage ( %) and it was significantly more costly compared to the direct costs of the scit group ( %). transportation costs were found to be more costly in the scit group ( %) when compared to the slit group ( %). similarly loss of parent work days in the scit group(% ) was found to be significantly more expensive compared with slit group ( %). our study results show that slit is a similar treatment for clinically and laboratorially and has a similar efficacy to scit to reduce the patients' complaints and to the need for medication. for cost-effectiveness however medicines for treatment of scit are less costly; when long term total treatment costs are calculated slit and scit treatment are economically close treatments. the protein content of the new acd was . μg/mg and the protein profile in sds-page and sec-hplc confirmed the presence of proteins with high molecular weight and the absence of smaller proteins. the content of free lysine in acd, involved in glutaraldehyde modification, was reduced in . % respect to ncd and it can be considered as the polymerization degree. regarding to the allergenic profile, through elisa inhibition was determined a reduction of times in the capacity to bind ige of the proteins in acd respect to ncd, whilst the igg binding capacity was maintained. in immunoblot there was no reaction of acd proteins to specific ige from sera. the analysis by peptide footprint determined the presence of fel d and others allergens in acd. the content of major allergen fel d in acd was determined as . μg/mg. the new developed and characterized allergoid from cat dander has an excellent safety profile and will allow a safer immunotherapy to treat the allergy to felis domesticus. results: the protein content of the new aaa was . μg/mg and the protein profile in sds-page and sec-hplc confirmed the presence of proteins with high molecular weight and the absence of smaller proteins. the content of free lysine in aaa, involved in glutaraldehyde modification, was reduced more than % respect to naa and it can be considered as the polymerization degree. regarding to the allergenic profile, in immunoblot there was no reaction of aaa proteins to specific ige from sera and by elisa inhibition was determined a reduction of % in the capacity to bind ige of the proteins in aaa respect to naa. the igg binding capacity in aaa was maintained. the analysis by peptide footprint determined the presence of alt a and others allergens in aaa. the content of major allergen alt a in aaa was determined as . μg/mg. a. alternata shows an excellent safety profile and allows a safer immunotherapy to treat the allergy to this mold. she was an otherwise healthy woman: she took no drugs and she did not have any remarkable concomitant diseases. the distribution and appearance of the remaining body hair was normal and the hormonal level profiles (lh, fsh, estrogens, progesterone and testosterone) did not show any significant alteration according to her age. a year old woman with allergic rhinitis underwent sq glutaraldehyde-modified ait to house dust mites (d pteronyssinus and g domesticus) without any incidences and complete tolerance to maintenance dose without local reactions during a year period. two years after ait discontinuation, patient first experienced a local urticarial reaction with multiple hives at previous sq ait injection sites minutes after mg of ibuprofen intake. these symptoms recurred at least in seven occasions when patient was exposed to ibuprofen (in five) and metamizol (in two). results: case : dermatologist diagnoses localized hypertrichosis. case : a single blind, placebo controlled oral challenge (sbpcoc) with ibuprofen mg was performed and elicited multiples hives in the circumscribed area in the arm where ait was conducted. subsequently, sbpcoc with aspirin was carried out showing the same reaction although a controlled challenge with celecoxib was negative. conclusion: local hypertrichosis is a very rare injection-disease associated with injected allergen vaccine treatment. we also firstly described a recall urticaria phenomenon after allergen immunotherapy which has been only elicited after different nsaids intake. results: there were included patients, in five spanish hospitals. following aria guidelines, . % of patients were diagnosed of persistent moderate/severe rhinitis. the mean age was . ± . years, being . % female. moreover, . % of the patients had concomitant mild/moderated asthma. the period between the diagnosis of rhino-conjunctivitis and the informed consent signing was . ± . years. according to international guidelines, eight systemic reactions were registered, representing . % of the administered doses: five reactions grade , (described as nonspecific ocular pruritus, nasal herpes, general discomfort, localized non-specific pruritus plus nausea and non-specific pruritus in throat), a grade i reaction described as rhinoconjunctivitis and two reactions grade ii, registered as generalized urticaria and asthma. all reactions were classified of mild or moderate intensity and only two required symptomatic treatment. there were five clinically significant delayed local reactions, which were higher than cm or involved modifications in next dose. regarding efficacy parameters, immunoglobulin titers between baseline and final visit according to specific igg and igg significantly increased. cutaneous reactivity also decreased significantly in the dose response skin prick test. results: patients were included, to accelerated and to polymerized cluster group schedules. according to aria criteria, . % of patients presented persistent moderate/severe rhinitis. the mean age was . ± . years, being . % male. moreover, . % had concomitant mild/moderated asthma. immunoglobulin titers method: the quantification of total proteins in the products was carried out by means of a colorimetric technique using the bradford reagent (sigma-aldrich™, us) in accordance with the manufacturer's instructions. the absorbances of each standard and samples were obtained in a scinco™ s- spectrophotometer (seoul, korea) at nm. all samples were analyzed in duplicate. the electrophoretic profile of the proteins in the tested allergens was obtained according to the procedure described by laemmli, under denaturing conditions in a polyacrylamide gel at . % concentration and stained in silver. in each lane approximately μg of total proteins were applied. commercial extracts of the main allergens marketed in mexico were obtained, rossel ® , alk ® , alerquin ® , alergomex ® , allerstan ® , ipi asac ® ; and they were assigned randomly with the numbers , , , , and . results: the following protein concentrations were found in the various extracts analyzed: see table conclusion: differences were found in the protein profiles ana- background: a new allergoid from cat dander was developed and characterized to determine its reduced allergenicity in a % and the maintenance of igg binding capacity. the objective of this study was to develop an immunogenicity assay in mice with the new allergoid and a native extract from cat dander. the study included female balb/c mice separated in three groups of mice each: group , immunized with a mold allergen extract (control); group , immunized with a native extract from cat dander with a fel d content of . μg per dose; group , immunized with the new allergoid from cat dander with a fel d content of . μg per dose. all mice were immunized four times by subcutaneous injections with a volume corresponding to / of the recommended human maintenance dose with an interval between injections of weeks. one week after the last injection the mice were sacrificed and the serum was obtained. to determine the specific antibody title indirect elisa were performed using a cat dander extract as antigen, sera from mice as primary antibody and antimouse igg or igg as secondary antibody. elisa assays were performed using serial dilutions of sera or a simple dilution by duplicate to determine the specific antibody title as arbitrary units/ml (au/ml). the data were analyzed by one-way anova and tukey hsd test to compare the averages of specific antibodies in each group. results: the immunization with both the native extract and the allergoid from cat dander produces specific igg and igg . regarding to igg, a higher title was observed in group respect to group in a curve obtained after elisa with serial dilutions of sera. the specific igg title obtained in terms of au/ml was . ± . in group , . ± . in group and . ± . in group . concerning to igg the au/ml obtained was . ± . in group , . ± . in group and . ± . in group . the increase of specific igg or igg in mice from group respect to mice from group and control group was statistically significant (p ˂ . ). the safety profile of the allergoid from cat dander allows a treatment with higher dose of allergens to produce a greater response to immunotherapy to induce formation of specific this was an open, multicenter clinical trial, in patients aged between to years with rhinoconjunctivitis with or without concomitant mild asthma sensitized to house dust mites (hdm). the aim was to evaluate the safety and tolerability of the vaccine. secondary endpoints included were: changes in immunoglobulin levels (specific ige, igg and igg ) versus d. pteronyssinus and d. farinae and changes in cutaneous reactivity. patients were under study treatment for weeks: five for the induction phase (weekly injections) and for the maintenance phase (monthly injections). results: patients were included. there were withdrawals from the trial; no one was related to treatment. the patients mean age was . years, being % female. . % were diagnosed of persistent moderate/severe rhinitis according to aria guidelines and . % presented concomitant mild asthma. regarding to safety results, systemic adverse reactions were registered which corresponded to . % from a total of administered doses. the most of systemic reactions were grade i, ( . %) described as rhinitis or urticaria, grade or nonspecific ( . %) and reaction ( . %), was grade ii. all of them were mild or moderate and only needed treatment. among local reactions, ( . %) were clinically relevant late local reactions, meaning a wheal at injection site > cm and /or requiring a dose readjustment in the next administration; ( . %) were clinically relevant immediate local reactions meaning a wheal > cm. concerning the efficacy parameters, cutaneous reactivity at the final visit versus baseline was, in average, significantly decreased, and specific titers of igg and igg against tested hdm increased significantly at final visit. patients completed the study. mean values in rqlq questionnaire (total score) decreased from . to . points ( . % score reduction) in final visit, reflecting a statistically significant improvement (p < . ). annual episodes of rhinoconjunctivitis decreased from . to . (p < . ). . % of patients improved from persistent to intermittent rhinoconjunctivitis (p < . ) and . % from moderate/severe to mild intensity (aria) (p < . ). moreover, . % of asthmatic patients at baseline, did not have any bronchial symptoms after -year treatment (p < . ). mean value of treatment satisfaction was . (sd= . ) and . (sd= . ) for patients and physicians respectively. | evaluation of safety and tolerability of "allergovac poliplus" in polysensitized patients with allergic rhinitis-rhinoconjunctivitis with or without asthma: an observational prospective study (apolo) background: the objetive of this study was the safety and tolerance assessment of "allergovac poliplus" scit treatment, with allergen combination-mixtures in polysensitized patients, as well as the evaluation of the clinical improvement and patients' satisfaction after treatment. method: this is a prospective observational clinical study. allergovac poliplus treatment is being administered in a " -day" or in an abbreviated schedule. polysensitized patients (to pollens or mites), with rhinitis or rhinoconjunctivitis, with or without asthma, and between - years have been included. all adverse events are being recorded. visual analog scales (vass) are being used to evaluate clinical improvement, tolerance and satisfaction after treatment ( months). results: a total of patients have been included, with an aver- results: in all groups prevailed severe forms of the disease and the phenotype of frequent exacerbations. groups were comparable in age composition and structure of severity. observations in the group of vaccinated pcv continue the dynamics of decreased dyspnea up to . ( . ; . ) results: of a total of pts under scait, were excluded due to data unavailability, and included (♀ ( %), mean age ± years (minutes: max md ), age range [ - ] being most prevalent ( %). the most frequent diagnosis was rhinitis/rhinosinusitis ( %), followed by asthma ( %), diagnosis coexisting in abstracts | pts ( %). other diagnosis such as conjunctivitis ( %), atopic eczema ( %) and food allergy ( %) were also found. mite sensitization occurred in patients ( %) of which ( %) were monosensitized. the pollen sensitization was verified in ( %) with monosensitized pts ( %). the double sensitization mitespollens was displayed in ( %). sensitization to epithelia and fungi occurred respectively in ( %) and pts ( %). it was found that pts ( %) presented sensitization to the groups of allergens (mites, pollens, fungi, dander). an average of ± pts started this treatment per year. prescription included laboratories with the following %: a- . ; b- . ; c- . ; d- . ; e- . ; f- . ; g- . ; h- . ; i- . ; j- . . option for extract of physical modification ( %), physical-chemical ( %) and chemical ( %). table shows the frequency of distribution of scait composition. conclusion: in this population sensitization to mites was predominant being the most prescribed scait followed thru sensitization to grasses with the respective scait. the majority of the population was polysensitized. however, in composition preference the choice of group of allergens prevailed and only % had more than one sort of pollen and % pollen+mites. polysensitization is a reality, nonetheless the choice of ait composition should be guided thru scientific criteria and not through the availability of mixtures encouraged by laboratories. background: allergen immunotherapy (ait) has been proven to be an effective treatment of allergic diseases in numerous studies. however, its use in seniors remains limited and questionable, due to common comorbidities and limited evidence of efficacy and safety of ait in aging population. the aim of presented study was to assess the safety of ait in patients over years of age undergoing subcutaneous immunotherapy (scit) and analyze the potential risk factors of adverse reactions in this population, compared to younger adults. we followed subcutaneous immunotherapy in a group of patients treated in the outpatient clinic of medical university of lodz, of whom were aged and older ( between the age of - , aged - and patients above the age of ). we recorded detailed information of each administration and corresponding adverse reactions over the period of years. we compiled results of our observations with patients' medical records to compile a database, which we then analyzed using statistical software. method: a total of cases with seasonal allergic rhinitis undergoing pre-seasonal immunotherapy and cases followed with conventional drug treatment were included in the study. immunotherapy and control groups were divided into monosensitized (only pollen) and polysensitized (at least additional allergen except pollens) patient groups according to skin prick test reactivity. all patients were followed between march-september with symptom and medication scores, and visual analogue scale (vas). the quality of life was assessed using the mini-rqlq questionnaire. phleum pratense (phl p) specific ige and specific igg (uni-cap , phadia) measurements were performed before and after weeks of immunotherapy in all patients. gramineae pollens were counted during the grass pollen seasons. results: mean age was . ± . and . ± years, female/ male ratio was / and / , the number of monosensitized/polysensitized patients were / and / in immunotherapy and control groups, respectively. in the immunotherapy group, june-july symptom scores, may-june-july-august vas scores and june combined symptom-medication scores were lower than the control group (p = . ). furthermore, improvements in activities-practical problems and other quality of life scores were significantly different between two groups (p < . ). in immunotherapy group, phl p specific ige and phl p specific igg levels measured after immunotherapy were significantly higher compared to those before immunotherapy (p < . , p < . , respectively). phl p specific igg levels measured after immunotherapy were also significantly higher in the immunotherapy group than in the control group (p < . ). there was no difference in terms of clinical and immunologic parameters in monosensitized and polysensitized patients (p > . ). conclusion: clinical improvement with pre-seasonal allergoid immunotherapy is accompanied by an important increase in specific igg blocking antibodies despite short-term injections. our findings show that pre-seasonal allergoid immunotherapy has similar clinical efficacy and b cell response in polysensitized subjects compared to monosensitized patients. | the safety trial of sequential sublingual immunotherapy with japanese cedar droplet and house dust mite tablet matsuoka t ; kuroda y ; igarashi s ; fukano c ; natsui k ; ohashi-doi k ; masuyama k university of yamanashi, yamanashi, yamanashi, japan; torii pharmaceutical co. ltd., tokyo, japan background: sublingual immunotherapy (slit) is recognized as the only treatment option with the potential to provide long-term posttreatment benefits. in japan, the prevalence of japanese cedar (jc) pollinosis is very high, about % of the population, of which the majority are co-sensitized to hdm. slit is now well established, safe and convenient treatment form for allergic disease, and recently, jc slit-droplet and hdm slit-tablet products were approved in japan for treatment of jc and hdm induced allergic rhinitis, respectively. however, the safety of sequential jc slit-droplet and hdm slittablet has not yet been investigated. therefore, we investigated the safety trial on slit combined with jc droplet and hdm tablet in allergic patients. method: eleven subjects with jc pollinosis and hdm rhinitis were enrolled. patients were treated once-daily with jc slit-drops for weeks, followed by weeks of sequential slit treatment where the jc slit-drops and the hdm slit-tablets were administered daily with a minute interval ( st: jc-slit drops, nd: hdm slit-tablet). the primary endpoint was the frequency and severity of adverse events (aes) during sequential slit by common terminology criteria for adverse events (ctcae) v . and slit grading system. serum antibodies were measured as the secondary endpoint. results: eleven patients were recruited. aes after jc slit-drops administration were found in patients out of cases ( %). aes after sequential slit were found in patients out of cases ( %). all aes were graded or . no severe aes were observed during the study period. the levels of jc-and hdm-specific ige and igg in serum were increased during treatment. conclusion: sequential-administration of jc slit-drops and hdm slit-tablets was well tolerated by patients suffering from both jc pollinosis and hdm rhinitis. background: according to the ema guideline on the clinical development of products for specific immunotherapy products should be tested in phase ii at different doses in several study-arms to establish a dose-response relationship for clinical efficacy before confirmatory trials can be initiated. allergen exposure in an aec may be used as primary endpoint. the study was a single-center, randomized, double blind, placebo-controlled, phase ii trial, treatment duration months. grass pollen allergic patients ( - years of age) with seasonal rhinitis/rhinoconjunctivitis (arc) with (mild, gina i) or without concomitant asthma were randomized to three different dosages of a liquid phase iii study is in preparation. as part of an effort to prepare the analysis plan using the csms as primary endpoint, the grass pollen data of the european aeroallergen network (ean) was used to identify the window within the grass pollen season (gps) with optimal correlation between the grass pollen counts and the csms. method: ean currently includes information from more than active and historical pollen-monitoring stations in europe including countries. the ean database used for analysis included grass pollen data collected during - . the daily allergy symptoms and medication were recorded spontaneously using an app questionnaire on the subject's smart phone. the csms was re-calculated using the ean database, using the recorded symptom scores with estimation of the medication score using similar methods as recently published. the correlation between the daily grass pollen count and the daily csms was analyzed with a mixed effects model accounting for patient-specific correlations and symptom levels. conclusion: these results confirm a statistically significant correlation between grass pollen counts and the csms. importantly, these findings suggest that the optimal window to observe treatment effects after immunotherapy may be a short interval after start of the gps and during the peak gps, due to generally higher csms values. this provides sufficient basis to consider additional sensitivity analyses to evaluate the treatment effect of grass mata mpl scit on the primary csms endpoint during a shortened window after the start of the gps and to consider excluding the overlapping period between the bps and gps from the primary analysis. | combo-vas as a tool to assess efficacy of allergen immunotherapy ciprandi g ; silvestri m ; olcese r ; tosca ma ospedale policlinico san martino, genoa, italy; istituto g. gaslini, genoa, italy background: allergen immunotherapy (ait) is at present the unique cure for respiratory and venom allergy. usually, ait lasts for some years, but its efficacy is longstanding. criteria for assessing ait efficacy are mainly based on symptom severity improvement and saving of symptomatic medications. in this regard, there are different score grading for both measuring symptom severity and drug use. visual analogue scale (vas) is a well-defined and validated method widely used in many diseases, including allergic disorders. vas is a psychometric tool measuring the patient's perception of symptoms, emotions, pain, drug use, etc. recently, it has been published an eaaci position paper concerning the recommendations for the standardization of clinical outcomes used in ait trials for allergic rhinoconjunctivitis, but it is complex. so we would propose a simpler way to measure ait efficacy by vas, in particular a combo-vas based on one vas for symptom and one for medications. results: globally patients were retrospectively evaluated. all of them were treated with a -year ait course: were defined as responders and as non-responders. in responders group the combo-vas mean value was (iqr - ) at baseline and (iqr - ) after ait treatment. in non-responders group combo-vas mean value was at baseline and (iqr - . ) at the end of ait. the difference was significant (p = . ). the d combo-vas was − . % in responder group and − % in non-responders group (p < . ). conclusion: combo-vas, i.e. the sum of vas for symptoms and medications, could be an easy and quick tool for assessing ait efficacy and reflects the patient's perception. therefore, it could be very fruitful in clinical practice. | rapid up-dosing in sublingual specific immunotherapy is safe, well-tolerated and effective in patients suffering from tree pollen allergic rhinitis background: an optimised up-dosing period of specific immunotherapy (sit) is desirable for better patient compliance because a long or complicated up-dosing scheme is sensitive to disruption. the aim of this study was to compare the safety, tolerability and effectiveness of an optimised up-dosing scheme with two preexisting schemes of sublingual sit (slit) in patients under standard medical care. method: this was a prospective, open, active controlled, multi-center non-interventional study in germany and austria to document the treatment of children and adults with allergic rhinoconjunctivitis and/or allergic asthma treated with a slit containing purified, aqueous extracts of birch, alder and hazel pollen. the investigators were free to select an up-dosing scheme for included patients: scheme a consisted of an up-dosing period of up to days at the patient's home using three different solution strengths to reach the maximum dose; ultra-rush scheme b performed only with the highest solution strength at the physician's office within hours, and the optimised scheme c which was initiated at the physician′s office and continued at home using exclusively the highest solution strength within (long-term) or (pre-seasonal) days. data on up-dosing and maintenance treatments were documented by physicians during patient visits and by patient diaries. the study was approved by ethic committees, and all patients or parents gave their informed consent. results: in total, patients aged - years were included into this study. scheme a was applied by patients, patients decided on regimen b, and patients on the optimised scheme c. conclusion: one-day ur-scit conducted in an outpatient clinic was safe and well-tolerated in patients with ad sensitized to hdm. ur-scit can be a safe and useful option to start a subcutaneous allergen immunotherapy for ad. | factors affecting on adherence to allergen specific immunotherapy results: among enrolled patients, ( . %) patients failed to complete at least years of ait, which were regarded to be nonadherent in this study. univariate analysis revealed that male, younger age group less than years, cluster and ultra-rush schedules, atopic dermatitis, the absence of associated diseases, and follow up of other department were found to be associated with nonadherence to ait. in multivariate analysis, younger age group less than years (or . , % ci . - . ), cluster ( . , . - . ) and ultra-rush schedules ( . , . - . ) , and absence of follow up of other department ( . , . - . ) were independently associated with non-adherence to ait. no association was found in gender, diagnosis of allergic diseases, kind of allergen extracts, and patients' distance from hospital. conclusion: various factors are related with ait non-adherence to interfere the effectiveness of immunotherapy. clinicians need to be aware of the factors associated with non-adherence to ait and consider them when choose to maximize ait adherence. | cost-effectiveness of allergen immunotherapy to grass in patients with allergic rhino-conjunctivitis and asthma background: allergen immunotherapy (ait) has been shown to reduce symptoms and medication use in subjects with rhino-conjunctivitis and asthma. however, long-term cost effectiveness of this therapy needs to be evaluated. our aim was to assess cost effective of ait, both subcutaneous immunotherapy (scit) and sublingual immunotherapy (slit), vs. pharmacotherapy alone in subjects with rhino-conjunctivitis, with or without allergic asthma, to grass pollens. method: a markov cohort state-transition model with a time horizon of years was used to assess the costs and effects of -year ait in adults. relative efficacy of the treatments expressed as standardized mean difference was estimated using an indirect comparison on symptom and medication score extracted from available meta-analyses. the rhinitis symptom utility index was used as a proxy to estimate utility values for symptom score. the societal perspective, through the human capital technique, was used to estimate indirect costs, to represent the scenario of a country with nationalized medicine. data on drug and other medical costs were derived from published sources as well as ait duration and asthma occurrence. additional sensitivity analyses were performed to test the robustness of our results. results: in the base case analysis, using italy clinical practice patients with moderate-to severe allergic rhino-conjunctivitis (ss ranging from to points) and a mean age at entry of years, both scit and slit were associated with increased cost but superior efficacy compared to pharmacotherapy alone. the results were most sensitive to variation in efficacy estimates and ait persistence rates. conclusion: this analysis suggests that ait is cost effective relative to pharmacotherapy alone. scit, despite significantly higher indirect cost burden, seems to be the most cost effective option. the results should be interpreted in the context of the data input and modelling assumption used. | ielisa as a tool to measure ige binding towards single modified peanut allergens background: immunotherapy has shown to be a potential treatment for food allergies but needs further research to improve safety. modification of peanut allergens to reduce their allergenicity is a promising approach to develop a safe and effective immunotherapy as shown by the successful completion of a first-in-human safety and tolerability study using hal-mpe in adult patients with peanut allergy (eudract - - ) . in order to assess the impact of modification on individual peanut allergens and to assess its impact on ige binding by individual patient sera, we have developed peanut allergen-specific inhibition elisas. with this methodology we are able to identify patients with residual ige binding to modified peanut allergens. method: ige inhibition elisas (ielisas) were developed and performed to test ige binding towards purified ara h and ara h and their reduced and alkylated (modified) versions, using the individual responses of single patient sera. results: ara h -specific ielisas showed that modification of ara h results in > % reduction in ige-binding for all individual sera tested. ara h -specific ielisas showed that modification of ara h also results in > % reduced ige-binding for most of the sera, but some sera were identified which showed residual, %- % ige binding to mara h . in some of the latter sera, the presence of ige binding to a linear hydroxyproline-containing peptide could be confirmed as a possible source for the residual ige binding to mara h . we have developed a methodology to assess residual ige binding to modified peanut allergens. the sensitivity of the allergen-specific ielisas allowed us to discriminate between patient sera in which ige binding to mara h and to mara h was virtually completely absent and sera in which - % residual ige binding to ara h was observed. the clinical importance of these observations is yet unknown. future clinical studies will need to reveal whether the patient-specific ige binding profiles to individual modified peanut allergens do correlate with the adverse events profile of immunotherapy with modified peanut extract. | design of a phase ii allergen immunotherapy study to determine the optimally effective and safe dose of subcutaneously administered tyrosine adsorbed modified grass allergen+mpl (mpl) adjuvants for the treatment of allergic rhinoconjunctivitis (arc) due to grass pollen. there is increasing evidence that the effectiveness of allergy immunotherapy to control arc symptoms is related to the cumulative allergen (or allergoid) dose administered. previously, two clinical studies have been conducted using a conjunctival provocation test (cpt) as primary efficacy measure for a similar scit mata mpl product for birch allergy [eudract - - and - - ] . these studies showed a . fold increase in cumulative dose to achieve~ % increase in efficacy, with a relative reduction in total symptom score (tss) of . % compared to placebo and no safety signals of concern. the shape of the dose response curve was curvilinear, where this high dose almost reached plateau. method: this is a multi-center (~ clinical study centers across europe), randomized, double-blind, placebo-controlled, parallel-group study in~ adult patients with moderate to severe seasonal arc with or without mild asthma. a positive cpt is to be achieved at screening and verified prior to randomization. the primary outcome is the post-treatment tss following cpt. a wide range of cumulative dose regimens is used ( , , and su) applied over weekly injections to establish the shape of the dose response to support dose selection for phase iii. the design of the current phase ii grass allergoid scit study will be discussed, including the rational of using cumulative dose regimens and placebo and the pre-selected shapes of the dose response curves. in addition, the number of patients screened and randomized will be presented by country, gender and/or age category and screen failures will be categorized. conclusion: this phase ii study was initiated to establish the dose response of a grass mata mpl scit product, using cpt to measure the effect of a wide range of cumulative dose regimens. the achievement of its aim will be an important milestone in the development of an efficacious and safe state-of-the-art grass scit. conclusion: we observed that the specific nasal challenge with house dust mite generates an inflammatory response within the first hours, but we did not demonstrate any correlation with the response to immunotherapy after six months. | tolerability of a two week rush updosing with modified allergens in pollen allergic subjects in the day-to-day practice background: in two phase iv studies the tolerability of a subcutaneous rush up-dosing, using three injections in two weeks, has been tested and proven to be save in adults. in the course of a non-interventional study (nis) now the tolerability of this treatment scheme was tested in the day-to-day practice. conclusion: over % of the patients could reach the highest dose of . ml. the overall tolerability is very good. the data from daily practice confirm the data that were previously obtained in two phase iv studies. siges from patients, evaluated during the st semester of at an outpatient clinic. all patients presented persistent moderatesevere allergic rhinitis, in pollen season and had not been submitted to it. all patients had positive spt for grasses (grass) and olive (olea). sige-tot for phleum pratense and olea europaea and some sige-crd (rphl p , rphl p , rphl p , rphl p , role and nole ) were determined. physicians were divided into groups (group if < years of practice and group if≥ years of practice) and were asked to choose which it to prescribe for each patient (none, only grass, only olive or both grass and olive), according to spt and sige results. results: fifteen physicians ( % with ≥ years of practice) participated in the survey. considering only the sige-tot results, the it choice (group / ) was: no vaccine in %/ %; grass vaccine %/ %; olive vaccine %/ % and both grass and olive vaccines in %/ % of the patients (p = . ), the intergroup agreement was % (kappa . ). according to the sige-crd results the physicians chose (group / ): no vaccine at %/ %; grass vaccine in %/ %; olive vaccine in %/ % and both vaccines in %/ % of patients however, data on control of allergic rhinitis (ar) after discontinuation of therapy are insufficient. the aim of our study was to assess sustained control of ar in three consecutive years after grass-pollen slit discontinuation. method: a total number of patients [ ( . %) males; mean age years, age range - ] well-controlled after a three-year course of slit with grass pollen extract were prospectively evaluated in three consecutive years after discontinuation of therapy. conclusion: a three-year course of grass-pollen slit seemed to have a long-term effect on control of symptoms in patients with ar. the authors declare no conflict of interest. results: all patients showed a positive sensitization profile by skin prick test to either betula and/or alnus. in % of patients this profile was furtherly confirmed with serum specific ige levels to betv , (mean . ku/l). allergic symptoms in patients with birch/alnus pollen allergy after ingestion of certain food can result from crossreactivity of bet-v -specific ige to homologous pathogenesis-related proteins, particularly the pr- protein. conclusion: within the allergy history we emphasize on focusing on sao symptoms as many patients under-recognize them. among the sensitization profile of these patients it is quite important to highlight cross reactivity between bet v and alnus. the other patient suffered from anaphylaxis(grade ii) induced by minimum amount of lettuce consumption without co-factors. both patients suffered from oral allergy syndrome to peach and allergic rhinitis. spts to foods and pollens were performed with commercial extracts, prick-through-prick with fresh plant foods, while specific ige was determined accordingly. ltp syndrome was defined as a sensitization to pru p and symptoms elicited by at least unrelated plant foods. co-factors were also investigated. results: the first patient was sensitized to lettuce, peanut, hazelnut, sunflower's seed, peach and banana, and plane tree, olive tree, grasses, parietaria and mugwort. sige to lettuce was . kua/l, to pru p was . kua/l and total ige was . u/ml. co-factors, such as exercise, were involved. the second patient was sensitized to peanut, walnut, hazelnut, almond, sunflower's seed, cashew, lettuce and peach, and, plane tree, olive tree, grasses, parietaria, mugwort and willow. sige to lettuce was . kua/l, to pru p was and total ige was . ku/l. no co-factors were identified. background: garlic (allium sativum) is a vegetable that belongs to amaryllidaceae's family. hypersensitivity to garlic is not very common. it has been mainly reported in occupational allergy but it also may cause contact dermatitis, rhinoconjunctivitis, asthma, urticaria, gastrointestinal symptoms and anaphylaxis after its ingestion. some studies have identified alliin lyase, a kda protein, as a major garlic allergen and it seems to be a heat-sensitive allergen. we report on a -month-old infant who presented, minutes after an accidental ingestion of garlic sauce, generalized erythema and cough. she was still breastfeeding and she had never abstracts | eaten garlic before (although the mother usually consumed garlic). the patient had never tasted other vegetables belonging to amarylidaceae's family either but zucchini, with good tolerance. we performed skin tests and specific ige (sige) to different vegetables. a raw garlic extract was also carried out and analysed in the patient by sodium dodecyl sulfate polyacrylamide gel electrophoresis (sds-page). results: prick by prick with garlic was positive ( mm) and negative to onion, leek, asparagus, zucchini and saffron. skin prick tests to commercial extracts of mugwort, grass pollen, peach ltp and profilin were negative as well. specific ige to garlic was . ku/l (out from a total ige ku/l) and ku/l to onion and asparagus. sds-page immunoblotting assay with patient′s serum revealed ige reactivity with proteins of kda and kda. conclusion: we report a garlic ige-mediated anaphylaxis case in an infant with proteins of and kda as the relevant allergens. the mechanism of sensitization in the present case remains unclear. the authors hypothesized that breastfeeding, cutaneous contact or inhalation might be possible mechanisms involved. chong kw ; saffari se ; chan n ; seah r ; tan ch ; goh sh ; goh a ; loh w allergy service, department of paediatric medicine, kk women's and children's hospital, singapore, singapore; centre for quantitative medicine, office of clinical sciences, duke-nus medical school, singapore, singapore; yong loo lin school of medicine, national university of singapore, singapore, singapore background: the predictive decision points for both peanut skin prick test (spt) wheal size and serum ige concentrations, in peanutsensitized children, have not been evaluated in singapore. we aim to assess these for purposes of risk stratification and prediction of oral food challenge (ofc)s' outcomes by means of a retrospective chart review. results: the number of patients evaluated was , of which had clinical diagnosis of peanut allergy based on recent immediate reaction to peanut (pa group) and were tolerating peanuts regularly (pt group). the mean age of both groups were similar, . ± . and . ± . years in pa and pt groups respectively. there was a high prevalence of atopic diseases in both groups, with atopic dermatitis ( . % in pa, . % in pt), and other food allergies ( . % in pa, . % in pt). presence of rhinitis was statistically higher in the pa group compared to the pt group, with odds ratio of . ( % ci: . - . ) . a wheal size of ≥ mm and a peanutspecific ige of ≥ ku/l provided for a % positive predictive value. the larger the wheal size on spt, the higher the probability of a clinical reaction to peanuts. the results will help us in deriving preliminary cut-off values when conducting future prospective studies with ofcs in our peanut-sensitized cohort (whom had no prior peanut exposure), and to eventually reduce the need for expensive and potentially risky food challenges. | ginger: flavory, spicy …allergenic? a report of four patients with allergy to ginger background: ginger (zingiber officinale) belongs to the family zingiberoidae, along with cardamom and turmeric. the edible portion is the horizontal rhizome, and it is very appreciated for its aroma and spicy flavor. it also presents great interest for its therapeutic and culinary use. hypersensitivity to ginger is rare and has been scarcely reported. we report cases (p , p , p , p ) of adverse reactions to ginger after its ingestion and with good tolerance to cardamom and turmeric. method: skin prick tests (spt) to environmental allergens and prick-by-prick with ginger were carried out. total ige, and specific ige to ginger were also determined. a raw ginger extract was prepared. this extract was analyzed in all the patients by sodium dodecyl sulfate polyacrylamide gel electrophoresis (sds-page). background: food allergy is divided into groups according to pathophysiology: ige-mediated, ige-and non-ige (mixed type), and non-ige (cellular type). however, in clinical practice, patients who fall under more than one group may be observed. method: patients who were diagnosed with food allergy at our clinic from january to december were included in the study. the medical files of patients were retrospectively evaluated, their symptoms and findings after consumption of foods were recorded, and they were categorized into groups (ige-mediated type, non-ige type, and mixed type) according to their symptoms and findings. results: a total of patients ( . % male) with food allergies were included in the study. according to categorization via symptoms and findings, the distribution of patients was as follows: ( . %) ige-mediated type, ( . %) non-ige type, ( . %) mixed type. the remaining ( %) patients were found to show various combinations of symptoms and findings that fit more than one group. in this study, we observed that food allergy symptoms and findings were distributed in a broad range which caused difficulties in the categorization of more than one-third of our patients. background: fish allergic patients suffer a lifetime of strict dietary restrictions. crocodile meat is a nutritious alternative choice in many countries around the world; however, it has recently been reported to also trigger severe allergic reactions. in these two case reports from pediatric patients were sensitised to the major fish allergen parvalbumin (pv), a potential cross-allergen. bony fish contain predominantly pvs of the β-lineage, which are the most common trigger of allergic reactions in fish allergic patients. in most other vertebrates, pvs of the α-lineage are most abundant, which have been reported as a causal allergen in frog, cartilaginous fish, and chicken allergies. we aimed to evaluate the allergenicity of crocodile meat in fish allergic children, with focus on pv. method: over children with clinical history of ige-mediated fish allergy were identified, skin tested to commonly consumed fish species using commercial and in-house preparations, and serum samples were collected. a sub-cohort was skin tested to crocodile using heat-treated tail muscle tissue from saltwater crocodile (crocodylus porosus). extracted proteins and purified pvs were analysed by sds-page, immunoblotting, and mass spectrometry. serum from all fish allergic children was analysed for ige reactivity to the crocodile pv. this reactivity was compared to those of raw and heated crocodile protein extracts as well as protein extracts and purified pvs from frequently consumed fish species. results: more than fish allergic children were positive on skin testing to crocodile (wheal size> mm), demonstrating its clinical reactivity. in vitro analyses revealed ige reactivity to crocodile pv in serum from more than half of all patients. two βand one α-crocodile-pv isoforms were identified. pvs constituted approximately % of total proteins in heated crocodile extracts, with β-pv ( kda) being times less abundant, but up to times more ige-reactive than α-pv ( kda). αand β-pvs from crocodilians, including alligators and crocodiles, share more than % and % of their amino acid sequence, respectively. conclusion: crocodile pv is a new allergen as per the iuis guidelines. fish allergic patients may be at risk of severe allergic reactions upon ingestion of crocodile meat due to strong ige cross-reactivity of β-pvs. this study suggests that fish allergic individuals and health professionals need to be aware of potential allergic reactions to meat from crocodilians, termed 'fish-crocodile syndrome'. background: we present a -year-old nonatopic woman that in december after eating a seafood paella with green pepper presented asthenia, nasal obstruction, incoercible vomiting and diarrhea. later she ate a grilled loin sandwich in a bar and she had the same symptoms (she asked the waiter at the bar and the chef had cooked her sandwich in the same pan where he had cooked green pepper just before). after that, she suffered from abdominal pain, nausea, abdominal distension without diarrhea two hours after she ate an omelet sandwich with certain flavor of green pepper. at present even the casual smell of pepper causes her nausea. the woman eats everything including spices and just avoids pepper. method: skin prick tests were performed using extracts from food (nuts, fish, mollusk, fruits, vegetables, legumes), aeroallergens (mites, abstracts | pollens and epithelia) and purified proteins (pru p , profilin, polcalcin, alfalactoalbumin, betalactoglobuline, casein). we also performed prick by prick to raw and cooked green pepper. sds-page immunoblotting according to laemli under reducing conditions (with -mercaptoethanol) was performed to study the molecular mass of the ige-reactive proteins. extracts from green pepper and green pepper seed were used. the prick tests were all negative and the prick by prick test to raw and cooked green pepper was positive in both cases. blond was taken from all patients to specify the levels of allergenspecific ige against allergen components of immunocap isac test, the result≥ . isu-e was assumed as positive. results: in the study group, in patients ( %) specific antibodies against ltp were detected, the isu-e level range . - average . isu-e on average, in patients with detected ltp ige was detected for . components belonging to the ltp, however the highest number % patients were detected ige only for ltp. in subjects ( % of respondents with detected ltp), ige was detected against art v and this is the only ltp component whose occurrence was statistically significant (p = . ). in patients ige was detected against pru p , jug r , pla a ,; patients ige to ara h ; patients cor a ; patients ole e , patients tri a , and in person para j . background: the birch pollen-associated oral allergy syndrome (oas), an ige-mediated local allergic reaction, is the most common manifestation of pollen-associated food allergies. its origin is explained by cross-reactions between birch pollen-and food-allergens belonging to the pathogenesis-related protein subfamily (pr- ). [ ] so far, there is no marker available for its detection and no standardized test established to evaluate objectively the subjective feelings experienced by oas. the diagnosis is based on a characteristic history and on detecting the sensitization to triggering allergens in skin prick test (spt) and laboratory examination. method: the aim of this study was to evaluate whether the food skin prick test could be a helpful marker in the diagnosis of a birch pollen-associated oas. for this exploratory study, data from - was collected retrospectively at the dermatological outpatient department of the ordensklinikum linz elisabethinen. patients with positive spt results for birch pollen were included. the variables age, gender, tree pollen-(birch, alder, hazel) and food-spt, laboratory tests (ige, bet v , bet v , gly m ) and symptoms (oas, rhinoconjunctivitis allergica, atopic dermatitis, anaphylaxis) for statistical analysis. results: there was an association between food-spt and oas but also between the negative oas patients and food-spt (p = . - . ). all of the bet v sensitized patients with positive gly m results had also a positive food-spt result. conclusion: there was no evidence for a possible role of food-spt as helpful markers in the diagnosis of birch pollen associated oas. maybe gly m could be a helpful marker, but more data are needed. bet v seems to be the cause of birch-pollen associated oas, due to the dominant sensitization pattern to major allergens in austria. background: eggs are among the foods most frequently causing allergy. the most common one is hen egg, although we may consume other bird's eggs such as duck's, those of goose, quails and seagulls. clinical and serological crossreactivity between hen egg proteins and those of other birds eggs have been described. allergy to other species eggs are less frequent and are usually described in patients allergic to hen eggs. we report a case of food allergy after ingestion of duck egg in an adult patient without hen egg allergy. the patient was a year-old man who had symptoms of generalized itching, swelling uvula, erythema neck and deglutition difficulty immediately after he ate eggs from duck and hen. he claimed to have eaten hen eggs almost daily without clinical symptoms and he had not previously ingested duck egg. he denied allergic reactions to any other food but did complain of seasonal allergic rhinoconjunctivitis in the spring. we performed skin prick test with extracts of egg and feathers, prick by prick test with cooked and fresh yolk and white from duck and hen egg and oral challenge with hen eggs. specific serum ige was measured to hen proteins and we carried out a western blot with the proteins of allergenic extracts from different eggs (white and yolk of quail, chicken, goose and duck) and an inhibition of western blot with ovalbumin as inhibitor allergen. results: skin test with extracts of eggs and feathers, cooked and fresh hen and duck eggs were positive. total serum ige was . ku/l. specific ige to hen's egg was class two for hen egg white, ovoalbumin and class one for yolk and ovomucoid. oral challenge with heated egg yolk negative and with egg white was positive. the patient's serum recognized mainly and intensely several proteins of white and egg yolk of quail and duck with a molecular mass around to kda respectively. on the other hand a protein around and - kda was unique recognized in white eggs of hen and goose. the western blot inhibition revealed ovalbumin inhibited the protein recognized in the egg white but not egg yolk involved in. background: management of tree nut allergy is usually based on the avoidance of the suspected tree nut (tn), as well as peanuts and seeds, either because of the risk of cross-reactivity and/or contamination, or due to the clinical severity. objective: to assess the sensitization pattern and clinical reactivity patterns to different tn, peanut and sesame seeds (ss) in patients with a history of reaction to at least one of these foods. results: a total of patients with confirmed nut allergy were included; % female, median age [interquartile range] of years; % were atopic. the most frequently involved foods were walnuts ( %), hazelnuts ( %), almonds ( %) and peanuts ( %). anaphylaxis was the clinical presentation in % of the patients. in those with a history of reaction to only one nut ( ), the most prevalent was peanut ( %). in the patients that reacted to more than one nut, the most frequent combinations were walnut/hazelnut ( ), walnut/almond ( ) and almond/ hazelnut ( ). of these patients, tolerated other nuts. two had sesame seed allergy, one reacted only to ss. nine patients ( %) were sensitized to foods that they tolerated. fourteen ( %) patients were sensitized to ltp and of them reacted to more than one nut. conclusion: these data concur with the existence of different sensitization profiles (primary, concomitant or cross-reactive), which may predict different clinical reactivity patterns and therefore, influence dietary recommendations. background: buckwheat (fagopyrum esculentum) is a polygonaceae weed, not a cereal, which is increasingly been consumed and used as an alternative food in the diet of celiac patients. despite its wide use, allergy to buckwheat has unfrequently been reported in our setting. method: two female patients, aged and , suffered an immediate severe allergic reaction after eating a bread and a pancake containing buckwheat among its ingredients. the first patient presented generalized urticaria, palpebral angioedema and pharyngeal occupation. the second one showed those same symptoms, as well as abdominal pain, nausea, dyspnea, dizziness, hypotension and loss of consciousness. skin tests and specific ige determination to aeroallergens and food allergens were carried out, including prick-prick test with buckwheat and all other components contained in the food involved. buckwheat allergens were studied by sds-page and ige-immunoblotting of one of the patients. results: prick-prick tests yielded strongly positive results to the food itself and buckwheat, and negative to the remaining food components in both cases. cap was positive to buckwheat ( . ku/l and > ku/l, respectively). basal serum tryptase levels were normal. both patients were not sensitized to cereals, ltps, profilins or pr- proteins. for the first patient, the skin tests were negative for other foods, seeds and nuts. the cap was negative for ltps, profilins and storage proteins of peanut and other nuts. the second patient who had the most severe reaction, was also sensitized to hazelnut(cap . ku/l), pistachio ( . ku/l), almond( . ku/l), walnut( . ku/l) and sesame( . ku/l), which were not included in the pancake. the buckwheat immunoblot of the first case, under non-denaturing conditions, revealed a ige-binding protein of -kda. ige-immunoblotting under reducing condition showed protein bands of , , and kda in the buckwheat extract. conclusion: two cases of anaphylaxis by buckwheat flour contained in two frequently consumed foods are presented. the absence of sensitization to ltps, together with the pattern of specific ige binding in the immunoblot in one of the cases suggests that the responsible allergen could correspond to a storage protein of buckwheat, without cross-reactivity with other seed and nut allergens. buckwheat must be taken into account as an unsuspected food allergen capable of causing severe allergic reactions. background: allergy to linseed (linum usitatissimum) has infrequently been reported despite of its wide use in bread and in a range of "health food" products. linseed contains potent allergens which have not yet been characterized. we studied three patients who presented allergic reaction after eating different foods which contain linseed. two of them (patient p and patient p ) had anaphylaxis and the third one (patient p ) had oral syndrome, abdominal pain and diarrhoea. p was also allergic to mustard and p to sesame seed. all of them tolerated the remaining seeds, nuts and food. baseline tryptase levels were in normal range in all patients. skin tests and specific ige determination to inhalants and food allergens were carried out. linseed allergens were studied by sds-page and ige-immunoblotting. skin tests: patient : prick tests were positive to pollens and linseed, and negative to ltp, profilin, nuts, seed and the remaining food; patient : prick tests were positive to linseed and mustard and negative to other food and inhalants; patient : prick tests were positive to linseed, pollens, sesame and nuts (peanut, hazelnut, almond, pistachio). we present three cases of severe allergic reactions to linseed. the pattern of specific ige binding in the immunoblot seems to lead to storage proteins as the responsible allergens. | pr- sensitization-looking it up in food allergy background: pr- protein group sensitization is found in patients with respiratory allergy, mainly in areas inhabited by trees of the betulacea or fagacea families. its role in food allergy is, however, more frequently described in the context of cross reactivity. our aim was to characterize the pattern of molecular sensitization of food allergic patients sensitized to pr- protein group with immu-nocap isac ® (isac). the remaining patients, with more severe reactions, were all co-sensitized to either ltp and/or storage proteins (sp). only of the patients without pfa were co-sensitized to ltp or sp versus of with pfa (p < . ). conclusion: pr- sensitization is rare in our population. approximately half of the patients had allergy to plant foods, but the majority were co-sensitized to ltp and/or sp. the few patients only sensitized to pr- had minor reactions. among the patients without plant food allergy, co-sensitization to ltp and sp was significantly less common. according to these results, in our population, pr- seems to be less relevant to food allergy, when compared to reported results from other european countries. gür Çetinkaya p; uysal soyer Ö; esenboga s; sahiner Üm; sekerel be hacettepe medical school, ankara, turkey background: pistachio is a tree nut belonging to "anacardiacea" family, and constitutes % of tree nut allergies. this nut most often abstracts | cross-reacts up to % with cashew which is located in the same family. pistachio allergy is mostly seen in iran, turkey, the united states, and china where this tree nut is frequently consumed. in this study, we analyzed age and cut-off values for development of tolerance to pistachio. method: children who had reported allergic reactions with pistachio, and who have not consumed pistachio, but had positive spt and/or specific ige levels were enrolled into the study. spt and specific ige levels were measured in all patients. oral provocation(op) tests with pistachio were performed by patients, and of them had positive test result. the median age of tolerance development was months (iqr: . - . months). the most commonly involved systems during op tests were skin ( %, n = ), gastrointestinal system ( %, n = ), and lower respiratory tract ( %, n = ). concomitant allergic diseases were atopic dermatitis ( %), asthma ( %) and allergic rhinitis ( %). there was a positive correlation between skin prick test diameter (spt) and specific ige levels (spige) (r = . , p = . ). spt of≥ . mm to pistachio nut was found as highly predictive of clinical allergy (auc: . , %ci: . - . , p < . ). any relation was not determined between eosinophil, basophil counts, triptase levels, and op test positivity. conclusion: pistachio allergy is one of the frequently seen nut allergies in turkey which may cause serious allergic reactions including anaphylaxis. op test showed that tolerance was achieved by the median age of months, and a cut-off level of . mm was best predictor for positive reaction. in an oral challenge test, the patient responded with generalized urticaria, swelling of the lips and difficulty breathing at a cumulative dose of . g peanut protein, however, without blood pressure drop. (grade , moderate symptoms). the patient was treated with anti-ige for months (with mg every weeks sc). oral desensitization began with ingestion of μg peanut, escalating to mg, on the first day and escalating weekly doses of peanut from mg to mg ( peanuts). then anti-ige was discontinued while the patient ingested peanuts every day. we have followed the patient's sensitivity to peanuts from before anti-ige treatment to after anti-ige washout with basophil testing. results: the patient completed desensitization without side effects, and continues to ingest peanuts a day. basophil sensitivity was reduced -fold by anti-ige treatment, but returned to baseline levels after anti-ige washout. conclusion: anti-ige allows rapid desensitisation of peanut allergic subjects with peanut oral immunotherapy. in the majority of subjects, this desensitization is sustained after anti-ige is discontinued. additional studies will help clarify which patients would benefit most from this approach. the return of basophil response to pre-treatment levels suggests that the patient is desensitised, and depends on the daily ingestion of allergen. what do we (not) know? background: the use of biologic prosthesis is a well-established surgical procedure. acute and delayed complications may occur, but accurate epidemiologic data about allergic reaction to graft tissue is lacking. methods: a years old boy referred to our unit for urticaria and gastrointestinal symptoms which developed a few years before. he received a biologic porcine vascular duct during a cardiovascular surgery at days of life. at the age of urticarial episodes occurred, and a diagnosis of beef allergy was made. after the exclusion of beef meat from the diet, most symptoms resolved, but the child began to complain about occasional episodes of vomit and diarrhoea. results: skin prick tests confirmed the beef meat sensitization and prick-prick test resulted positive against raw pork meat but not against cooked pork meat. in vitro tests demonstrated the presence of pork meat specific iges ( . kua/l). component-resolved diagnostic tests revealed allergy sensitization toward bos d (bovine serum albumin, bsa; porcine serum albumin was not tested due to lack of a specific test). after accurate exclusion of pork meat from diet, a complete remission was achieved, and the diagnosis of pork meat allergy was confirmed. conclusion: bsa is a major beef allergen, responsible for the raw beef-cow milk cross-reactivity but with a scarce importance in milk allergy. it is highly homologous with human serum albumin and other mammalian serum albumins, including porcine albumin. porcine albumin is also highly homologous with cat serum albumin and therefore responsible for cross-reactivity in patients affected by cat-pork syndrome. we hypothesize that the implanted porcine tissue was the trigger for pork meat allergy in our patient, as this condition is exceptional in childhood and that our patient never owned a cat. few cases of pork allergy due to porcine tissue implantation have been reported so far. of interest, pig sensitization was recognized as a rare but possible cause of blood-culture negative endocarditis in patients with porcine bioprosthesis according with anamnesis, increased ige level against pork, tissue eosinophilia during autopsy. background: desensitization to foods is assuming a new paradigm in food allergy. this technique is becoming widespread especially for patients with egg and milk allergy, but the effect of desensitization on the consumption of similar but not identical foods is still uncertain. material and methods: we describe the case of a -year-old patient, with a history of chicken egg allergy, who had been successfully desensitized tolerating cooked and raw chicken eggs for a year. the patient came to the office after presenting an episode of anaphylaxis immediately after eating fried quail eggs. an immunological study was carried out. we performed skin prick test with chicken egg′s proteins (white, yolk, ovoalbumin and ovomucoid). an immunoblotting to detect specific ige to egg proteins was also performed. for this purpose, the following extracts were used: chicken egg white and yolk (commercial extract form alk) and quail egg white and yolk prepared following a similar procedure (extracted in % phosphate buffer (w/v)). conclusion: we present the case of a patient with specific allergy to quail egg white and yolk, probably through ovotransferin, but not to chicken egg. the desensitization against chicken eggs does not allow the consumption of eggs of other species of birds, such as quail eggs, and this indication must be made specifically to patients after a protocol of desensitization against chicken′s eggs. case report: seven years ago we presented the case of a year-old male, who suffered two acute episodes of oral pruritus, lip angioedema, epigastric pain, generalized urticaria and dizziness after ingesting lettuce. he previously tolerated salads (including lettuce). he was later diagnosed with non-ltp-dependent lettuce anaphylaxis and an aspartyl protease was identified as a new lettuce allergen with cross-reactivity with other members of the compositae family. since the diagnosis he has avoided lettuce and all the other compositae. we present the patient's curious outcome after years of follow up. methods: total ige, basal tryptase, specific ige to lettuce by immu-nocap, prick-prick and oral challenge tests with lettuce and other compositae. sds-page, immunoblotting and molecular characterization of ige binding bands by mass spectrometry. skin prick tests and specific ige to lettuce were repeated on several occasions in the following years. after years an oral challenge test with lettuce was carried out. results: prick-prick test was positive to fresh lettuce ( × mm) and to other compositae (raw endive, chicory, thistle, artichoke and chamomile). prick-prick test was negative with these boiled compositae. basal tryptase was . μg/l. total ige in serum was ul/ml. specific ige by immunocap was positive to lettuce ( . ku/l) and negative to profilin, ltps and thaumatin. oral challenge test with endive was positive and negative with cooked compositae (artichokes and thistle). sds-page and immunoblotting detected an intensely binding ige band about kda, common for endive and chicory, which was identified by mass spectrometry as an aspartyl protease. no bands were detected at ltp ( kda) and profilin ( kda) . in the first two years after the diagnosis, prick-prick test and specific ige to lettuce remained positive (cap . ku/l and . ku/l, respectively). after years, prick-prick test and specific ige to lettuce became negative (cap . ku/l). with this findings a new oral challenge test with lettuce was carried out which result turned out negative. we report the first case of spontaneous tolerance to lettuce in a patient who previously presented lettuce anaphylaxis and identify an aspartyl protease as the causative allergen. introduction: eosinophilic esophagitis (eoe) is an emergent allergic inflammatory disease that is triggered by food allergens and characterized by progressive esophageal dysfunction. recently, it has been seen that eoe develops in up to . % of patients with ige-mediated food allergy undergoing oral immunotherapy (oit). ingestion of baked milk and egg was associated with increased development of tolerance to regular milk and immunologic changes have been reported in subjects ingesting baked milk and egg, similar to those seen in food oral immunotherapy studies. case description: we present the case of a -year-old girl, with history of ige mediated cow′s milk allergy and rhino conjunctival and bronchial asthma symptoms. prick test against milk proteins showed: milk mm, alpha-lactalbumin mm, casein mm and to beta-lactoglobulin: negative. total ige: ku/l. specific ige to milk: , alpha-lactalbumin: , ku/l; casein: ku/l and beta-lactoglobulin: . ku/l. we performed an oral food challenge with baked milk which was well tolerated. then, we performed an oral food challenge with fresh milk and she presented facial urticaria and pharyngeal pruritus. after months eating baked milk every day, she had symptoms of dysphagia and esophageal food impaction. for this reason, we performed an esophagogastroduodenoscopy (egd) and biopsies which showed white exudates and vertical furrows. the histological study showed eosinophil count> per high-power field. eosinophilic esophagitis was diagnosed and she started treatment with esomeprazole mg. the egd was repeated weeks later with similar results in the biopsy. she was treated with a comprehensive diet free of cow′s milk proteins. after weeks she was asymptomatic and endoscopy and biopsy findings were normal. we report the case of a cow′s milk allergic patient who developed eoe after introduction baked cow′s milk which apparently was tolerated in her diet. the avoidance proved efficacy in inducing the remission of eoe. method: we examined bottle-feeding infants with food allergy aged from to months. serum vitamin levels were measured by immunoassay methods (retinol binding protein (rbp), vitamin b , hydroxy vitamin d), biochemistry methods (vitamin c, vitamin e) and microbiology methods (vitamin b , vitamin b ). as criteria for complete sufficiency standards adopted in the russian federation were used (the lower limit of normal levels: rbp - . μmol/l; b - ng/ml; -hydroxy vitamin d- ng/ml; vitamin c - . mg/dl, vitamin e - . mg/dl; vitamin b - μg/ml; vitamin b - ng/ ml). results: complete sufficiency were observed in infants ( . % cases), one vitamin deficiency in infants ( . %), two vitamins deficiency in infants ( . %), three and more vitamins deficiency in infants ( . %). should be used after vitamin status asses, mainly using monovitamin medication. results: patients were followed with the diagnoses of cma and asthma. age at the beginning of symptoms and start of oit were in the range of - months and - years, respectively. they had high total ige ( - iu/ml), milk spige ( . - kua/l), casein spige background: food allergies may affect up to % of school-aged children. it has been shown that approximately % of all anaphylactic reactions caused by food allergy are firstly presented at (pre) school. therefore, it is of high importance that (pre)schools have a policy on food allergy management and the use of an epinephrine auto-injector (eai). to our knowledge, limited is known on the policies of food allergy management at (pre)schools. the aim of this study was to investigate the policy on food allergy management in preschools and primary schools in the northern part of the netherlands. results: we included preschools and primary schools in this study. we showed that . % of the preschools and . % of the primary schools had a child(ren) with food allergy. only . % of the participating preschools and . % of the primary schools had a policy on allergen avoidance and only . % of the preschools and . % of the primary schools had a policy for the use of an eai. the majority of the pre-and primary schools in the northern part of the netherlands have children with food allergy. however, only a limited number of (pre)schools do have written guidelines for food allergy management in (pre)schools. additionally, there is limited experience how to use an eai at (pre)schools. therefore, an evidence-based policy on food allergy management in (pre) schools is needed. background: food allergies are the most common cause of anaphylaxis in childhood. here we present cases had anaphylaxis due to cow 's milk allergy, and treated with specific oral tolerance induction (sotİ) to cow' s milk. method: soti protocol was administered according to previously published by longo et al. skin prick test were performed according to standard methods with allergens. cow's milk specific ige was investigated with immunocap system. in all cases, the wheal size of the cow's milk in skin prick tests or the specific ige levels was higher than level of positive predictive value of %. results: case : a years old male patient who had anaphylaxis after milk consumption. soti treatment was started one year ago. there was no complications during the dose increasing phase. however, he had two episodes of anaphylaxis during the maintenance phase. in the final visit, we observed that he could drink ml milk and could consume dairy products. case : eight-year-old male patient has an intensive care-of-hospitalization story due to anaphylaxis three times after milk consumption. his accordance to strict diet was bad, and had frequent asthma attack. anaphylaxis developed times during the dose increasing phase in soti protocol. after soti treatment, he could consume ml cow's milk and dairy products without problems. case : a -year-old male patient followed-up for asthma and cow's milk allergy. it was learned that anaphylaxis developed times after milk consumption. he was fed in accordance with the milk-free diet. he has used fluticasone nebules, montelukast, mometasone nasal spray, and cetirizine. anaphylaxis developed times during the dose increase phase of soti administration. there were many mild to moderate anaphylactic episodes during the maintaining phase. after the soti treatment, he could consume ml milk and dairy products. background: cow's milk protein allergy (cmpa) is one of the most common food allergies in early childhood. small dietetic group sessions for parents of infant with non-ige mediated cmpa were held to meet increasing demands and reduce waiting times. parents were given information on cmpa, advice on weaning and milk reintroduction using a locally designed milk ladder. parents were also advised to contact the dietitians via telephone if they had further questions. we aim to evaluate the sustained effectiveness and patient satisfaction of the group sessions. method: parents and carers who attended the group dietetic sessions held between november and july were included in the survey. feedback were obtained via a self-designed questionnaire using a likert-type scale, rating several questions from (least satisfied) to (most satisfied). initial feedback was obtained directly after the session. we followed these patients up a year after the initial session via telephone and postal questionnaire. results: overall attendance rate of the group sessions held was % (n = ). during the initial survey, participants found the group session useful (mean score . out of ) and felt more confident in managing cmpa (mean score . ). we successfully obtained follow up feedback from participants. majority agreed that the group sessions have been informative (mean score . ). they also said they felt confident weaning their child on milk-free diet (mean score . ), and in reintroduction of cow's milk in diet (mean score . ). % (n = ) said that they would have preferred an individual session. % (n = ) have contacted the dieticians via telephone after the initial session, and % (n = ) had requested individual consultations. % (n = ) have attempted reintroduction of cow's milk in their child's diet using our local milk reintroduction guide. the mean age at first challenge was months (age range to months), with average of two attempts. % (n = ) have been successfully challenged and are managing well on a normal diet. we recognised the limitation in obtaining feedback via telephone and postal questionnaire, which resulted in the poor follow-up response rate. overall, parents felt more confident in managing cmpa and the positive responses were sustained a year on, highlighting the success of these group sessions. follow up opt-in sessions could be offered to provide additional support and allay parental anxiety in challenging their child with cow's milk at an appropriate age. results: goats and rabbits were immunized with specific allergoids, the allergoid-specific igg titer determined and sera pools produced. the allergoid reference material was comprehensively characterized. while ige reactivity of the allergoids was not detectable anymore, igg reactivity was maintained. allergoid-specific assay parameters as serum dilution, reference dilution and sample dilution factor to obtain at least six data points within the pseudo-linear range of the inhibition curve were determined. with these set parameters the evaluation of the analytical method was performed. the assay showed very good results in terms of linearity, accuracy, precision, reproducibility and robustness for all investigated allergoids as well as aluminum-adsorbed allergoid-preparations. conclusion: with the developed immunological inhibition assay, it is possible to determine the specific igg reactivity of allergoids in different preparations. the performance of the analytical method met all pre-defined acceptance criteria, which will be confirmed in the next step by a validation procedure according to ich-guidelines. case report: we present the case of a -year-old patient, diagnosed with rhinitis and asthma due to sensitization to pollens, as well as dyshidrosis and allergic contact dermatitis to cobalt. the patient presented a cutaneous pattern consisting of erythematous papules, some scaly, very pruritic, of initial appearance in the upper limbs - days after initiation of administration of specific immunotherapy extract (depigoid forte grasses, leti ® ). subsequently generalize lower limbs and neck. she presented them repeatedly and late after - days of the first doses administered. she referred partial control of pruritus with oral antihistamines, without total resolution of lesions for weeks. immunotherapy was suspended persisting the skin lesions for more weeks. according to the personal history of sensitization to metals, and the clinic presented in a temporal relationship with the use of an extract of immunotherapy with aluminum hydroxide, a study was requested with epicutaneous tests with aluminum hydroxide as well as with epicutaneous tests with immunotherapy extract. aluminium hydroxide and depìgoid forte grasses extract epicutaneous test were negative. in subsequent visits the patient reported that coinciding with the start of immunotherapy, presented at home and mainly in her bedroom a plague of cimex lectularius, popularly known as bedbugs, proving that they had been the cause of bites on their skin, and later skin reaction. patient reported that with the elimination of said pest the skin lesions disappeared. the administration of its immunotherapy extract was tolerated. cimex lectularius, commonly known as bed bugs, is a hemiptera insect of the family cimicidae. the clinical picture usually corresponds to multiple pruriginous lesions from the prurigo type, to multiple erythematous plaques, some infiltrated and others with a urticarial appearance, or even bullous. the lesions last for to weeks without treatment, and while the older ones heal, new ones may appear. in our patient it was not considered as an initial diagnosis, having considered immunotherapy as an etiological factor, but we must not forget that although in our country it is not a reason for frequent consultation, either due to underdiagnosis, because of the transitory nature of the pathology or because of scarce number of causative agents, it is important to consider insect bites in the differential diagnosis of dermatosis. di cara g; salvatori c; testa i; pacitto a; bizzarri i; isidori c; tarsia m; esposito s università degli studi di perugia-dipartimento di scienze chirurgiche e biomediche, perugia, italy background: house dust mites (hdm) are one of the most important allergens involved in childhood respiratory diseases, and the most frequently prescribed extract for sublingual immunotherapy in children (slit). despite the improvement of standardization methods for the production of slit, the differences in cultivation and purification processes used to produce raw materials for specific immunotherapy extracts may still impact on the final composition of mite allergen extracts. our study investigated the total protein and main allergen content of five commercial hdm sublingual immunotherapy extracts using sds-page and immunoblotting. recombinant allergens of group and group major allergens were used to test the immunogenicity of such extracts. method: hdm slit extracts were purchased from five italian suppliers (alk-abellò, allergy therapeutics, anallergo, lofarma, stallergenes). the protein composition of extracts was evaluated analysing equal volumes ( ml/lane) by sds-page ( % separating gel) and subsequent immunoblotting. for identification of allergens in the extracts, western blot analyses were performed with rabbit monoclonal antibodies (raybiotech) against der p and der p . the total protein content in the five tested commercial extracts showed a relevant variability. the protein contents ranged from . to . μg/mg for what concerns der p , while der p showed a greater variability, ranging from . to . μg/mg. sds-page showed a similar pattern of distribution in of the tested extracts, which showed protein bands of comparable intensity, while extracts showed a lower total protein count. extract showed a higher intensity band corresponding to the molecular weight of tropomyosin. western-blotting showed a similar concentration of der p in most extracts, while der p was more variable. conclusion: our analysis of five commercial extracts commonly used for sublingual specific immunotherapy against hdm showed important variations in term of total protein content. a less evident but still relevant difference was also evidenced when testing the major allergen content, with up to % variation in der p and up to a -fold variation in der p concentration. this differences, likely related to the different production and extraction methods, could still be responsible of a different immunological response in children who underwent slit. method: we evaluated children who had completed their immunotherapy treatment. along with demographic data we were able to record skin prick test (spt) results and mrqlq at start and end of treatment. we only included patients who had completed pre and post treatment questionnaires in the study to allow a comparison. the scores were evaluated using a student t test. results: patients' starting age ranged from to years (mean years). of the children had completed pre and post treatment questionnaires. all had grass pollen allergy confirmed on spt at the start of treatment. patients ( %) had isolated grass pollen allergy on spt and ( %) had multiple allergies. mean start treatment score for all patients was on mrqlq. mean score at end of treatment was , indicating a % reduction in total mrqlq score (p value < . ). for those with multiple allergies the mean total mrqlq scores were at start of treatment and at end of treatment, indicating a % reduction (p value . ). for those with isolated grass pollen allergy scores were at start of treatment and at end of treatment indicating a % reduction (p value < . ). conclusion: for children with uncontrolled symptoms of allergic rhinoconjunctivitis, grass pollen immunotherapy is associated with statistically significant improvement in quality of life. this improvement is most beneficial for patients with isolated grass-pollen sensitivity on spt. those with multiple aeroallergen sensitivities on spt did show an improvement (not statistically significant) post-treatment. grass-pollen immunotherapy is an effective treatment for rhinoconjunctivitis to offer patients in a rural dgh setting. background: allergic asthma is a common clinical refractory disease, most patients with asthma are accompanied by varying degrees of allergy. in clinical practice, treatment of this disease using specific immunotherapy has proven effective. in the current study, we examined the effectiveness of specific immunotherapy in a total of patients admitted to our hospital from to . method: to investigate the clinical efficacy of allergic asthma-specific immunotherapy. patients were selected, of which were males, aged to years, females, aged between to years old, all patients were clinically diagnosed only as allergic asthma. the patients were randomly divided into two groups, including the observation group containing cases, the control group of cases. all patients were first treated with conventional basic treatment. the observation group was subsequently treated with specific immunotherapy. both groups were followed-up and the treatment efficiency were analyzed. results: after treatment, both two groups of patients showed improvement, in the observation group, the effective rate was %, while for the control group, the effective rate was %. observation group showed significantly better outcomes than the control group. conclusion: in allergic asthma treatment, adding specific immunotherapy on the basis of routine treatment is beneficial and could be widely used in clinic. case report: atopic dermatitis(ad)is the most common itchy dermatosis that affects millions of children and adults. during recent years, diagnosis and treatment based on component resolved diagnostics (crd)is recommended. we report a -year-old boy with severe atopic dermatitis. he had positive family history of atopy. the atopic dermatitis was developed since infancy. he was referred to our clinic when he was years old. he had generalized xerosis with ulcerative eczematous lesions on his neck, popliteal and antecubital areas. he had mild eosinophilia and his serum total ige level was iu/ml. daily bleach bath, moisturizing agents, topical steroids and systemic antibiotics in addition to antihistamine were prescribed. he had multiple food and aeroallergen sensitization in skin prick test (spt). he started to eliminate some foods according to the spt results. he was suffering from recurrent relapse even after strict food avoidance; so treatment with cyclosporine was initiated for him, with partial response. crd showed sensitization to alternaria alternata (alt a specific ige: . ku/l). allergen immunotherapy by alternaria alternata was started. after accomplishment of buildup phase, he had significant improvement and we were successful to taper and finally discontinue cyclosporine. now he is on maintenance phase of immunotherapy, his skin is in optimal condition only by hydration and moisturization. result: a -year-old thai girl is a known case of severe asthma since one year old. her asthma was uncontrolled asthma even treatment with high dose combination of inhaled corticosteroid and long acting beta agonist (ics/laba), montelukast and omalizumab. spirometry revealed the force expiratory volume in one second (fev ): % predicted, fev /forced vital capacity (fvc): % predicted and % improvement of fev after salbutamol ug inhalation. allergic sensitization showed specific ige to cat: . kua/l. slit with cat allergen started at the dose of au per month and increased to au per month (scit dose is au per month) for three-year-and-six-month course. after slit, her asthma symptom improved significantly. she can exercise without exacerbation and plays sport at school. her last episode of asthma exacerbation was . year ago. her fev (% predicted) was improved from % predicted to % and the fev bronchodilator response decreased from % to %. conclusion: an improvement of pulmonary function and asthmatic symptoms of the presenting case would support the efficacy of slit of cat allergen in a patient with severe asthma. ra developed during pollen scit in this case might be related with immunomodulation effect of immunotherapy. background: we report a case of -year-old woman with allergic rhinoconjunctivitis and mild persistent asthma due to sensitisation to seasonal pollens and molds with bad clinical evolution and not response to conventional drug therapy. we decided to start subcutaneous allergen specific immunotherapy with alternaria extract in our immunotherapy unit in accordance with the guidelines of the european academy of allergology and clinical immunology (eaaci) and we used a cluster regimen. the immunotherapy was not well tolerated: the patient had two grade systemic reactions with the first dose in two attempts. method: sensitisation was diagnosed through skin prick test with aeroallergens standard panel and serum specific ige by elisa. due to the bad tolerance to immunotherapy, molds molecular diagnosis by immunocap, study of the molecular weight to specific ige binding proteins by sds-page ige immunoblotting, and cross-reactivity study by means of immunoblotting-inhibition assay were performed. a. fumigatus extract was able to produce a total ige binding inhibition on the kda band of a. alternata extract when ige immunoblotting assay was performed. conclusion: respiratory allergic disease due to alternaria is difficult to control, the use of subcutaneous specific immunotherapy could be of significant benefit. most of the allergic patients to a. alternata are sensitized to alt a , major allergen from a. alternata. however, our patient is sensitized to a kda alternaria protein due to cross-reactivity with a. fumigatus allergens, this sensitization could explain the bad tolerance to the alternaria immunotherapy. background: the association between natural pollen exposure, clinical symptoms as well as allergen-specific immune responses has not been investigated at a molecular level. our aim was to monitor the effect of seasonal birch and grass pollen exposure on clinical symptoms as well as specific b cell and t cell responses to defined allergen molecules in sensitized subjects during two consecutive years. method: grass pollen sensitized (n = ) and birch pollen sensitized (n = ) subjects were included in this study and were followed for two consecutive years ( ) ( ) . subjects were taking part in a clinical trial for the recombinant grass pollen vaccine (bm ) but did not receive immunotherapy for the allergen they were sensitized to. before, during and after the respective seasons ige and igg levels as well as t cell responses to the major birch pollen allergen bet v and the major grass pollen allergens phl p , , and were measured. pollen counts were recorded throughout the year and patients kept a daily diary including symptom medication score (sms) and visual analogue scale (vas). results: we noted that ige levels specific for bet v and the grass pollen allergens increased most in the seasons in which patients experienced the highest peak symptoms according to vas and sms but not depending on cumulative pollen counts. increases in allergen-specific t cell responses were observed in the pollen seasons as compared to shortly before the pollen seasons in the grass pollenallergic patients also in association with vas and sms but not in the birch pollen allergic subjects. no relevant changes of allergen-specific igg levels were observed during the two years observation in grass and birch pollen allergic patients. we found an association of increases of allergen-specific ige increases shortly after the pollen season with clinical symptoms in the pollen season as reflected by vas and sms which was not necessarily reflected by cumulative pollen counts in the season. these results may be important for the analysis of allergen-specific immunotherapy trials. background: the morbidity and mortality of severe asthma is much higher than that of mild to moderate asthma. this study was performed to understand the clinical characteristics of severe asthma in korea. results: data from the questionnaire showed that bronchial asthma was diagnosed before pregnancy only in women ( . %). patients ( . %) were diagnosed with chronic bronchitis at the pregestation stage. asthma attacks were experienced repeatedly during a lifetime in . % of patients, . % of patients noted long periods of dry cough at night, among them . % had wheezing. the cold did not precede the wheezing breathing in . % of patients. difficulty in breathing on waking was noted in . % of patients, at night- . %. after examination, the diagnosis of asthma was confirmed in . % of the respondents ( people). symptoms of rhinitis are noted in % of women surveyed, % of rhinitis was allergic. before examination, the diagnosis of ar was only in . % of patients. the incidence of symptoms of asthma and ar in pregnant women is significantly higher than the reported cases of these diseases, which leads to untimely initiation of treatment. method: a total of nonsmoker asthmatic patients without concomitant pulmonary pathology are recruited to our study. all patients underwent spirometry tests, measurement of fraction of exhaled nitric oxide and sputum induction to asses sputum cell counts, demographic features and current medications were recorded. using the variables of age at onset, bmi, allergy status, fev %, fev /fvc, asthma severity and induced sputum cytology cluster analysis is performed. results: clusters are identified. cluster : (n = ) early onset atopic asthma, consists of mild asthmatics with a good asthma control and lower bmi. cluster : (n = ) severe atopic asthma, consists of lowest spirometry measurements with a least act scores. induced sputum cytology shows a neutrophilic character, while having also the highest percentage of eosinophils. cluster (n = ) late onset obese asthma, nonatopic asthmatics having high spirometry measurements, with a lower act scores. cluster (n = ) nonatopic mild asthma, consists of patients with the best respiratory functions and least inflammation in means of lowest total ige, feno, sputum cell counts. conclusion: identification of asthma phenotypes in different countries will improve our understanding on the heterogeneity of the disease among the different geographies. results: results and discussion. in the course of analysis, obesity was more common in children with bronchial asthma − % than in the comparison group-in . %. obesity of the st degree was diagnosed in patients of the main group, ii degree-in , and iii degree- and iv degree-in patients e diagnosis of obesity, the sds indices of body mass index (bmi) were determined. obesitymore than + . (i degree: sds bmi . - . , ii degree: sds bmi . - . , iii degree: sds bmi . - . , iv degree: sds bmi ≥ . ). conclusion: thus, the results obtained indicate a high prevalence of constitutional-exogenous obesity in children with bronchial asthma and precedes the formation of the underlying disease e diagnosis of obesity, the sds indices of body mass index (bmi) were determined. obesity-more than + . (i degree: sds bmi . - . , ii degree: sds bmi . - . , iii degree: sds bmi . - . , iv degree: method: postal questionnaires were distributed to an unselected group of asthma patients (n = ). healthy non-asthmatic volunteers were recruited amongst university and hospital co-workers (n = ). the presence of self-reported nhr, the type of triggers evoking nasal symptoms, asthma phenotype, medication use and environmental factors were evaluated. results: patients and controls completed the questionnaire (responder rate of % and % respectively). nhr was reported in % of asthma patients and % in non-asthmatic controls (p < . ), with changes in temperature being the most important inducer of nasal symptoms ( % of asthmatics), followed by strong odours ( %) and cigarette smoke ( %). interestingly, nhr was more prevalent in patients with severe ( %) compared to mild ( %) asthma symptoms (p = . ), and more prevalent in atopic ( %) compared to non-atopic ( %) asthmatics (p = . ). most asthma patients reported more than one trigger evoking nasal symptoms, with % of patients reporting or more triggers evoking nasal symptoms. results: the mean score of cbcl questionnaire in case group with . ± . was significantly higher than in comparison with a control group with . ± . (p = . ). the mean scores of the subscales of social isolation (the case group: . vs control: . , p = . ), anxiety-depression ( . vs , p = . ), intellectual problems ( . vs . , p = . ), and aggressive behaviors ( . vs . , p = . ) were significantly higher in children with asthma than in healthy children. the study showed a significant correlation between the mean duration of asthma and a general score of cbcl (p = . , cc= . ). moreover, there was also a significant correlation between asthma severity and cbcl scoring (p = / , cc= . ). conclusion: behavioral disorders in children with asthma are significantly more than healthy children. the duration of asthma and the severity of asthma, are related to and can predict behavioral disorders in children with asthma. background: assessment of asthma control is an integral part of the management of asthma. whilst asthma control test (act) is a commonly used questionnaire to assess symptom control, its utility in predicting long term risk of exacerbation has not been well studied. aim: to analyze the factors associated with uncontrolled asthma symptoms using act and its impact on predicting future exacerbation. method: severe asthma patients on at least step background: most of the asthma-scoring tools detect the asthma severity from patients' symptoms but there is no scoring tool using parameters to define risk of asthma exacerbation. thus, this study use factor analysis to evaluate the relationship of parameters in childhood asthma. method: the descriptive study using factor analysis in asthmatic children aged less than years old, who attended thammasat university, the center of excellence for allergy, asthma and pulmonary diseases, thailand. the participants or caregivers were inter- the factors which have the major impact on asthma control are changing bed sheets less than once per month and using dust mite-proof bed sheets. this study is supporting non-pharmacological strategies but further studies are needed to create a more efficient asthmatic symptom checker. were not different between the controlled and uncontrolled group. the act score in the controlled group was significantly higher than the uncontrolled group (p < . ). the study showed that cigarette smoke is one of the significant factors that can trigger asthma exacerbation (p < . ) and mosquito repellent coil smoke is also significantly associated with asthma exacerbation (p < . background: experimental studies have demonstrated that tumor necrosis factor family member (tnfsf /light) plays an important role in airway remodeling. there is little data available concerning in vivo regulation of tnfsf /light expression in humans. the aim of this study was to evaluate serum concentration of tnfsf / light in different subsets of asthmatic patients. the study was performed on nonsmoking asthmatic patients (a), including mild-moderate-severe asthmatics controlled on inhaled corticosteroids (aics) and asthmatics evaluated twice during asthma exacerbation (aex) and during subsequent remission (arem). in addition age and sex matched nonsmoking healthy controls were included (hc). serum tnfsf /light concentration was evaluated using elisa method. in asthmatic patients lung function tests, exhaled nitric oxide concentration (feno), serum total ige concentration (t-ige), allergen-specific ige concentration (s-ige) and peripheral blood eosinophilia were evaluated. ( + /- pg/ml) was significantly greater than that in hc ( + / - pg/ml; p < . ). among all asthmatic patients studied the greatest tnfsf /light serum concentration was demonstrated in aex ( + /- pg/ml), which was significantly greater than that in aics ( + /- pg/ml p < . ). during resolution of asthma exacerbation a significant decrease in serum tnfsf /light concentration ( + /- pg/ml; p < . ) was demonstrated. in arem the mean serum tnfsf /light concentration was comparable to that seen in aics (p = . ) but was still significantly greater than in hc (p < . ). no significant correlation could be demonstrated between serum tnfsf /light concentration and baseline lung function parameters, exhaled nitric oxide concentration, serum t-ige or s-ige concentration or peripheral blood eosinophilia. conclusion: enhanced production of tnfsf /light seen in asthmatic patients, which is further upregulated during asthma exacerbations may play an important role in asthma pathogenesis. method: two models of aspergillus fumigatus-induced allergic airway inflammation were used in the study: long terms ( weeks) and short terms ( weeks background: chalcone is identified as an inhibitor of the interaction between cxcr or cxcr and their ligand cxcl . therefore it is called a neutraligand. the chemokine cxcl , interacting with the cxc-receptor (cxcr ) can play a role in the progression and development of bronchial asthma. asthma is defined as a chronic disease characterized by episodes of obstructive events which affects about million people over the world. the aim of this study is to approach the mechanism of the anti-inflammatory effect of the cxcl neutraligand chalcone and also to assess its impact on the migration of dendritic cells in a murine model of allergic airway inflammation. method: chalcone is administered intranasally to balb/c ovalbumin (ova) asthma mice and control groups as well. our results indicate that the cxcl neutraligand chalcone can modify the inflammatory reaction in an airway allergic hypereosinophilia model. furthermore, found out that cxcl neutraligand chalcone prevents dc migration to the airways and airway jnc ganglia during allergic airway inflammation. the detection of the cxcr -cxcl pathway and its role in the pathophysiological actions of asthma offers a promising target for allergic diseases treatments. method: four groups of balb/c mice were defined: control and asthmatic, with and without treatment. asthmatic groups were sensi- overexpression of ptgdr in pulmonary cells associated to a generalized increase of cytokine expression. conclusion: in a mouse model we confirmed the involvement of ptgdr in allergic asthma by the increase of its expression levels after ovalbumin sensitization. we also identified a reduction of ptgdr levels in response to dexamethasone treatment. the in vitro model suggests that ptgdr induces an inflammatory response, increasing the cytokines levels. | immune imbalance between transcription factor t-bet/gata and allergic asthma results: t-bet mrna expression of peripheral blood lymphocytes in patients with allergic asthma was lower than that of the normal control group, and the expression level of gata- mrna was higher than that of the normal control group (p < . ). the th percentage of peripheral blood lymphocyte subsets was lower than that of the normal control group (p < . ), the percentage of th cells was significantly higher than that of the normal control group (p < . ), and the changes in t-bet/gata expression and th /th ratio was highly correlated. our objectives were to assess the changes of bmp and bmp serum levels in the response to allergen and methacholine challenge tests and the correlation between bmp and bmp serum levels and fev before and after allergen and methacholine challenge tests. method: study group consisted of patients with asthma and healthy volunteers. spirometry, skin prick tests, allergen and methacholine challenge tests were performed in compliance with eaaci, ers and ats guidelines. personalized clinic surveys including act ™ were performed. venous blood was collected before and after hour, and hours afterwards the provocation to edta-ke-filled test tubes. evaluation of bmp and bmp serum protein levels was performed using specific elisa immunoassay kits according to the manufacturer's protocol. results: the increase in bmp and bmp serum level hours after provocation test correlates significantly with the concentration methacholine during provocation time (p < . ). bmp serum level before the provocation, hour and hours after provocation, correlates negatively with fev change (p < . ). the median bmp level hours after provocation was significantly lower in patients with negative methacholine challenge test compared to the control group (p = . ). the median bmp level hours after provocation was higher in patients with positive allergen provocation test than in patients with negative test results (p = . ). the bmp serum level hours after positive methacholine test is lower and correlates inversely with fev change in every time point, which could indicate that serum level of bmp is a predictive factor of fev change. the higher bmp serum level, the lower fev change was observed. this could suggest the protective influence of bmp in patients with obstructive pulmonary disease, i.e. asthma. the higher bmp serum level hours after positive allergen provocation test result shows that the bmp could be an indicator of the response to a specific trigger. background: inflammation and coagulation are closely linked events. thrombin is the key enzyme in coagulation system. besides its well-known functions in hemostasis, thrombin plays a role in inflammation. the aim of our study was to evaluate thrombin generation in children with mild asthma and demonstrate associations between thrombin levels and control of asthma. method: forty-two children with mild asthma and forty-nine healthy children included in the study. asthmatic children had no asthma exacerbation during the last months. patients (n = ) who had mild persistent asthma, were using either inhaled steroid or montelukast. all patients performed spirometry. thrombin levels were measured by thrombin generation test. thrombin peak levels, endogenous thrombin potential, thrombin lag time, time to thrombin peak and thrombin tail time were recorded. results: thrombin lag time was significantly longer in children with asthma ( . ± . ) compared to those in control group ( . ± . ) (p < . ). children with asthma also had longer thrombin tail time compared to control group ( . ± . vs . ± . , p = . ). thrombin peak was inversely correlated with fef - (- . , p < . ). thrombin lag time was inversely correlated with fef - (- . , p < . ). thrombin generation parameters did not show difference according to asthma control treatment, asthma control scores and having atopy. conclusion: coagulation/anticoagulation balance is disturbed in mild asthma but this disturbance may not be as strong as to increase thrombin levels. factors increasing inflammation may cause an increase in lag time, and increase in inflammation and excessive fibrin deposition may contribute to airway narrowing. background: cytokines represent key mediators in the onset and persistence of inflammatory process, in both asthma and copd. il- , which belongs to il- family, it might act in a similar way with il- at the beginning of the inflammatory process. its role in atopic skin diseases has already been demonstrated, but there are conflicting results related to its role in respiratory allergic diseases. the aim of the study was the evaluation of il- plasmatic level in patients with asthma and copd and the its correlation with clinical and lung function parameters. method: fifty consecutive patients with bronchoobstructive diseases were included in the study. thirty-two patients presented asthma and patients had copd. the evaluation included: number of exacerbation in the last year, disease's severity, spirometry. plasmatic levels of il- and il- were determined in all patients. results: the mean age was higher in patients with copd dermatophagoides pteronyssinus [house duste mite (hdm), ug/ mouse] were administered oro-tracheally on days , , , , , , and . at was performed in a treadmill during weeks in moderate intensity, from day until day . results: at inhibited hdm-induced total cells (p < . ), eosinophils (p < . ), neutrophils (p < . ) and lymphocytes (p < . ) in bronchoalveolar lavage (bal), and eosinophils (p < . ), neutrophils (p < . ) and lymphocytes (p < . ) in peribronchial space. at also reduced bal levels of il- (p < . ), il- (p < . ), il- (p < . ), cxcl (p < . ), il- (p < . ), il- (p < . ), il- (p < . ), while increased il- (p < . ). airway collagen fibers (p < . ), elastic fibers p < . ) and mucin (p < . ) were also reduced by at. at also inhibited hdm-induced airway hyperresponsiveness (ahr) to methacholine . mg/ml (p < . ), . mg/ml (p < . ), mg/ml (p < . ) and mg/ml (p < . ). mechanistically, at reduced the expression of stat (p < . ), stat (p < . ), stat (p < . ) and jak (p < . ), similarly by peribronchial leukocytes and by airway epithelial cells. socs expression (p < . ) was upregulated in leukocytes and in airway epithelial cells, socs (p < . ) was upregulated in leukocytes and socs down-regulated in leukocytes (p < . ) and in airway epithelial cells (p < . ). conclusion: at reduces asthma phenotype which is followed by positive modulation of socs-jak-stat signaling in peribronchial leukocytes and in airway epithelial cells. rodolfo a ; paciência i ; rama t ; leão l ; silva d ; rufo j ; mendes f ; padrão p ; oliveira fernandes e ; moreira p ; delgado l ; moreira a porto, portugal; potentially irritating chemicals that may have a cutaneous drying side effect. this study aimed to evaluate if skin barrier function, as measured by transepidermal water loss (tewl), is affected by a training session in swimmers compared with football players. environment impact on the human respiratory health (clinicaltrials.gov identifier: nct ) and football players were invited to participate. due to the lack of prior information no sample size calculation was possible and all athletes that provided informed consent were included in the analysis (n = , females, aged to years). tewl was measured using the tewameter ® tm before, immediately after, and minutes after a hours training session. the probe was held on the dorsum of hand, the volar forearm and the antecubital flexure for s. the average of two consecutive measurements was recorded. non-parametric statistic was used were appropriate. ethical approval was obtained from the university clinical research ethics committee and informed consent provided. results: mann-whitney u test showed significantly higher baseline median tewl level on football players hand's dorsum compared with swimmers, median (p -p ) respectively . ( . to . ) and . ( . to . ); p = . . friedman test revealed a significant effect of swimming on tewl on the hand's dorsum, volar forearm and antecubital flexure (p < . ) while football training affected only the hand's dorsum (p = . ). differences in changes after swimming and football training were significant only for tewl in volar forearm (p = . ). in conclusion, our exploratory findings do not provide support for a specific deleterious effect of swimming, compared with football training, on the training induced changes in tewl. background: exercise-induced bronchoconstriction (eib) is defined as transient, reversible airway narrowing occurring during or after exercise, is common among elite athletes and associated with epithelial damage. however, little is known about the existence of eib in young athletes. the goal of this study is to investigate the presence and to evaluate potential (bio)markers of eib in young high-school elite athletes in different sport disciplines versus age-matched control subjects. method: high-school selected elite athletes ( - years) from different sport disciplines: basketball (n = ), football (n = ) and swimming (n = ) performing at least hours of sport per week (median= h) and control subjects (performing less than hours of sport per week) were recruited. the eucapnic voluntary hyperventilation (evh) test was performed according to ats guidelines and adapted for this age group. lung function was measured before, immediately after and , , minutes after the evh test. the test was considered positive if a maximal fall in fev of % was measured on at least one time point and exhaustion was excluded. a blood sample was obtained at baseline. sputum induction and skin prick test for the most common allergens were performed after the evh test. results: fifteen swimmers had a positive evh test ( . %), which is higher than in basketball players ( . %), football players ( . %) and controls ( . %). . % of the swimmers were atopic which is also higher than in basketball players ( . %), football players ( . %) and controls ( . %). serum clara cell secretory protein (cc ) levels are significantly higher in swimmers ( . ± . ng/ml) compared to indoor athletes ( . ± . ng/ml) and controls ( . ± . ng/ml). a significant positive correlation was found between the magnitude of maximal fall in conclusion: young elite swimmers have a higher prevalence of eib compared to basketball and football players. atopy and/or chlorine is a risk factor for the development of eib in young elite athletes. cc levels and sputum uric acid levels are increased in athletes compared to control subjects suggesting the presence of epithelial damage already at young age. this is especially observed in young elite swimmers, pointing to a probable role of exposure to chlorineby-products in combination with intensive exercise. results: data from subjects ( females, . %) were analyzed. frast was positive in ( . %) patients ( females, median age of years (iqr - )). in this group, ( . %) had a previous diagnosis of asthma, ( . %) practiced federated sports, ( . %) had smoke cigarette exposition and ( . %) had a bmi > kg/m . . % of patients showed a Δfev % > % in the first minutes after finishing the challenge. median fev reduction was . % ) and ml . frast was more frequently positive in patients with previous diagnosis of asthma (p < . ). there were no differences related to conclusion: frast is an important tool to diagnose exerciseinduced bronchospasm without asthma (eib wa ), as well as to diagnose asthma. in our study, frast was fundamental to access eib wa in % of patients with rsee, and confirmed asthma diagnosis in % of cases with previous asthma diagnosis and negative sbt. there was no difference in the prevalence of atopy between patients with positive and negative frast. patients older than years-old presented higher Δfev % compared to younger patients (p = . ). higher levels of feno were observed in patients with positive frast (p = . , p = . ), both in patients with and without previous diagnosis of asthma. a positive correlation was observed between feno levels and Δfev % in the whole sample (r = , p = . ); when these data were analyzed considering a previous diagnosis of asthma, only patients with this condition showed a positive correlation of feno and Δfev % (r = . , p = . ). conclusion: our results evidenced that higher feno was associated with atopy and a positive frast, both in patients with and without previous diagnosis of asthma. higher feno seems to correlate with Δfev % in patients with previous diagnosis of asthma. background: specific immunotherapy is the casual treatment for allergic rhinitis. a year old professional footballer suffer from severe allergic rhinitis since two years. during may, june and july his level of playing, concentration and durability decreased about %. patient was complaining of runny nose, nasal blockage, each eyes, sneezing, tearing. method: we did skin prick tests -which showed greatest allergy to grass pollen. we confirmed the allergy by specific ige and nasal provocation tests. spirometry was done-fev %. the patient was qualified to undergo specific immunotherapy. however, because of his profession, it was hard to find a day without trainings to get the vaccine. after long discussion, patient decided to start specific immunotherapy-scit. results: the patient start the immunotherapy. he was attuning very irregularly, because of matches, injuries, trips, trainings, and lack of time. several times we had to call the patient to remind him about the immunotherapy. after one year of scit the patient felt big improvement. during grass pollen season he suffered from mild allergic symptoms, and just for few days. after next year of immunotherapy, the patient had no symptoms of allergic rhinitis during the grass pollen season. however, it was the reason for him, to stop sit, before rd year of immunotherapy. conclusion: such a treatment-specific immunotherapy-is a burdensome method for both, for professional athletes and doctors. such a patients need to be on special observation, and cooperation with trainers must be obtained, if we want to see results. to improve compliance we have to keep in touch with patients, to remind them about next visit. gherasim a ; choual i ; radu c ; khayath n ; beck n ; jacob a ; schoettel f ; domis n ; de blay f alyatec, strasbourg, france; hôpitaux universitaires de strasbourg, strasbourg, france background: late allergic response (lar) is a good asthma model. it has been shown, in individual challenge tests that mite allergen induces more frequently late allergic responses (lar) than cat allergen. the aim of this study is to compare the frequency of lar in asthmatic subjects allergic to mite with asthmatic subjects allergic to cat. method: asthmatic subjects allergic to mite were compared to subjects allergic to cat (gina or ). the subjects had prick tests≥ mm compared to the negative controls and specific ige ≥ . ku/l. the dose selected for the mite and cat allergen was the airborne allergen concentration inducing the most frequently early asthmatic response (ear) (a % drop in fev ) and lar (a % drop in fev ). results: the frequency of lar with mite allergens was . % and % with cat allergens (p = . ). the frequency of ear for mites was . %; of . % for ear or lar, and % for ear and lar. in contrast, with cat allergens, % of patients had an ear, % had ear or lar and % had an ear and lar. no significant differences was observed between cat and mite allergen regarding the severity and the time necessary to obtain an ear and lar. no significant differences was observed between cat and mite allergen regarding the severity and the time necessary to obtain an ear and lar. the frequency of lar in asthmatic subjects allergic to dust mite exposed in alyatec ® eec was higher than in asthmatics sensitized to cats. our results confirmed previous results with individual bronchial challenge. therefore, it appears that the mite model is more interesting in the study of asthma. exposure chamber in strasbourg (alyatec ® ) in asthmatic patients allergic to cat allergens gherasim a ; choual i ; radu c ; khayath n ; beck n ; jacob a ; schoettel f ; domis n ; de blay f alyatec, strasbourg, france; hôpitaux universitaires de strasbourg, strasbourg, france background: as recommended by the task force on environmental exposure chamber (eec), allergenic and non-allergenic exposure must be better controlled in eec. it is the aim of alyatec's eec. the aim of the study is to validate alyatec's eec by determining the concentration of fel d inducing % of early asthmatic response (ear) and/or late phase asthmatic response (lar) in subjects sensitized to cat. method: it was a randomized, double blind, cross-over study including group a: asthmatic subjects allergic to cat and group b: asthmatic subjects allergic to another allergen. all subjects were first exposed to placebo. group a was exposed to fel d concentrations. the number and size of particles were recorded online during the exposure. group b was exposed to the concentration of fel d which fulfills the objective of the study. the mean age of subjects was years (± ). for the concentrations of fel d , we obtained more than % ear and/or lar. the mean time necessary to obtain an ear was: . ± minutes and . ± minutes for the lar. the mean fall in fev during ear and lar was − . % and − . % respectively. we didn't observe any severe reaction. no subjects in group b experienced any symptoms during exposure. we have validated alyatec's eec in asthmatic subjects allergic to cat allergens. we also demonstrated its specificity. background: the best test and strategy for diagnosing asthma especially in those patients with negative bronchodilator reversibility tests still remains unclear. in this study we aimed to investigate the diagnostic yield of peak expiratory flow (pef) variability for the patients with symptoms suggesting asthma but negative bronchodilator reversibility tests. method: subjects referred to our outpatient clinic with suspicion of asthma were enrolled in this study. demographics and referral symptoms were recorded, asthma control test (act) scores and health related quality-of-life scores (aqlq, sf ) were calculated. monitoring of pef variability during -weeks and bronchial challenge test with methacholine (bpt) were analyzed. asthma was diagnosed by having pef variability ≥ % and/or positive bpt. results: thirty out of enrolled patients were diagnosed as having asthma. when we compare asthmatic patients with nonspecific respiratory symptomatic subjects there were statistically-significant differences regarding to wheezing (p = . ), activity limitation (p = . ), total symptom score (p = . ) and basal fef (p = . ) in the favor of asthma cases. multiple logistic regression analysis revealed that lower basal fef - was an independent predictive factor of asthma diagnosis (p = . ). when the bpt positivity was assessed as gold standard for the diagnosis of asthma, the sensitivity and specificity of pef variability for different cut-offvalues (≥ %, > % and >% ) were . - . %, . - . % ve - . %, respectively. conclusion: fef - is an important diagnostic parameter for asthma. although current guidelines recommend pef variability of % for the diagnosis of asthma in general, this cut off level may not be appropriate for this defined group of subjects. our results suggest to use a cutoff level of > % while excluding asthma and ≥ % while confirming the diagnosis of asthma for patients with asthma suspicion but without shown reversibility. de barayazarra s background: in recent years obesity has been considered as a factor that contributes to the development of asthma, increases exacerbations and leads to poor control of it due to resistance to drugs to control this pathology. it is known that obesity produces chronic systemic inflammation; one of the markers that are affected is the levels of c-reactive protein (crp), which are increased. objective: evaluate, lung function, the use of medications to control asthma and systemic inflammation, after bariatric surgery. results: obese asthmatic patients with surgery, non-asthmatic obese patients with surgery, obese asthmatic patients without surgery. a significant difference was found between the severity of obesity and forced expiratory volume in patients with asthma and without asthma of second (fev ) before surgery with an average of . % at the beginning of the study and . % at months (p: . ). in the non-operated group, fev at the beginning was % and . % at months (p: . ). the crp, before surgery in all operated patients had crp: , at months after surgery they became negative, crp: (p: . ). in obese asthmatics with surgery at the beginning, % used medication, and at months only % in obese asthmatic patients without surgery, . % used the medication at the beginning, at months . % (p: . ). method: patients with asthma aged to and a predetermined positive methacholine pc were recruited and underwent a single challenge to cause bronchoconstriction of~ % comparing the outcome of the device with spirometry. the subjects were monitored at baseline, after a~ % fall in fev and after bronchodilation back to baseline. the study protocol allowed for an interim analysis of the initial subjects at which point the sensor was calibrated to optimise sensitivity. a further subjects were studied using the optimised sensor. results: all subjects successfully completed the study. the device was found to be straightforward to use by both operator and subject with no concerns regarding safety. the initial sensitivity of the device was found to be suboptimal in the first eight patients to reliably detect changes in lung function. after adjustment to the device the tests results of the remaining subjects were analysed. . % of subjects were female. the mean age of all subjects was . years. an average baseline fev value of . (s.d. . ) was observed. changes in lung function were detected in % of subjects. a baseline value, drop in lung function and reversal were measured in % of subjects. the mean percentage drop observed in % of subjects using the investigational device was . %. the mean percentage increase observed using the investigational from drop to reversal was . %. the device (using ebc ) was able to detect changes in lung function tracked using fev . this provided proof of concept that the device could potentially be used to monitor lung function more effectively in the home than peak flow and supports further development to optimise the device and demonstrate functionality in clinical asthma. method: ninety four patients under years of age seen in the allergy department due to common asthma symptoms (wheezing, dyspnea, cough, chest tightness) with normal spirometry and negative bronchodilator response, underwent mct during and . the variables studied were: sex, age, body mass index (bmi), asthma symptoms, exercise symptoms, rhinoconjunctivitis, family history of atopy, sensitization to respiratory allergens, spirometric data and fractional exhaled nitric oxide (feno). results: of the total sample, half were women ( . %) and the other half were males ( . %). mean age was . years. bmi was normal in most of them (with an average of . kg/m ). the most common symptom among the patients with positive mct was cough ( . %), followed by dyspnea ( . %), wheezing ( %) and chest tightness ( . %). . % had symptoms of asthma with exercise and . % had rhinoconjunctivitis. . % had a family history of atopy. . % were sensitized to aeroallergens, mainly to pollens (grass and olive tree). . % of the mct′s were positives, with a mean pc of . mg/ml. . % had a moderate-severe result (pc ≤ mg/ml), . % mild (pc - mg/ml) and . % bordering (pc - mg/ml). the mean feno was . ppb. conclusion: in our series, the completion of a test of hrb was decisive to confirm the diagnosis of asthma in most patients of a pediatric population with symptoms of suspicion (cough, mainly), normal spirometry and negative bronchodilator response (with normal feno in most of them). therefore, we consider it important to include in the routine clinical practice hrb tests in the pediatric population with suggestive symptoms of asthma, despite normal functional and/or inflammation tests. | cut-points of the ′control of allergic rhinitis and asthma test′ (carat) asthma subscale based on an international survey patients with asthma) in kashan, iran. the data collection tool was a questionnaire with questions, designed to gather information on demographic asthma patients, the current use of mobile functionalities, and the willingness to use these functionalities to receive selfmanagement services, which was distributed among patients with informed consent. the collected data were analyzed by descriptive statistics method using spss software. results: the most use of patients from mobile phone functionalities was to receive information about asthma symptoms and allergens and irritants via mobile internet ( . %). patients were most likely to use social networking ( . %) in comparison with other mobile phone functionalities, to receive reminders about appointments and medication. the respondents were most likely to use social networks through mobile phone functionalities, to receive asthma self-management information ( . %), to communicate with other patients ( . %), to receive reminders about medication use, and to perform a peak flow meter test ( . %) and to get an alert when the asthma is not controlled ( . %). the findings show that asthma patients are currently using the internet search for educational information and they have a tendency to use social networks to receive asthma-related services. patients believe that mobile health is an appropriate intervention for providing educational information, reminders, and alerts and communication with other patients. | concordance between the determination of asthma control through the gina guidelines and the act questionnaire-results of the efimera study background: the exacerbation of asthma, progressive worsening of acute episodes, is one of the most frequent attending reasons at hospital emergency unit . several factors causing poor control of asthma, such as inadequate therapy, have been described. in the present study, estimations of asthma severity by researchers were assessed by comparing the concordance between the assessment of asthma control through the gina guidelines and the act questionnaire method: cross-sectional observational study on the evaluation of factors related to treatment that influence the poor control of asthma was assessed through the gina guidelines and the act questionnaire. patients referred to a pneumologist or allergist by a primary care for the first time were evaluated. two variables were collected for the assessment of asthma control: one derived from the gina guidelines and another derived from the act questionnaire. regarding the gina assessment, researchers' evaluations guidelines were compared with the scoring calculated from the variables registered in the crd. both measures were compared in terms of sensitivity-specificity to determine their ability to classify patients. the patients included in this study (n = ) had a mean age of ± years, with a % of women and an average disease evolution of . ± . . the control of asthma according to "gina results: pts were reasonably representative of those in sls asthma (at sls baseline: . % male; mean age . yrs; mean asthma control test [act] score . ) . the most frequently reported symptoms during sls asthma for these pts were cough/ breathlessness, followed by wheeze, phlegm and chest tightness; breathlessness and wheeze were perceived as the biggest impactors on pts' lives. the aspects of daily life most impacted by asthma were reported as walking at a hurried pace, strenuous physical activity, and asthma-related frustration. since sls began, % of pts in this subset reported improvements in overall asthma ( % no change; % worsening). perceived changes in symptoms are shown (table) . most pts ( . %) reported avoiding places with dust, smoke or fumes. most pts ( . %) perceived no change in overall qol; . % reported improvement. being an act responder during sls (total act score ≥ or ≥ change at end of sls) was associated with reported improvements in overall asthma symptoms, lower impact of asthma on qol, and higher perceived confidence/control in managing asthma. more pts ( . %) in the ff/vi arm reported an overall improvement in asthma vs uc ( . %); the most evident differences between treatment groups were for breathlessness, wheezing and chest tightness. improvements in confidence/control in managing asthma were reported by . %/ . % of pts (ff/vi) vs . %/ . % (uc). conclusion: breathlessness and wheezing were key symptoms in sls asthma and had the biggest impact on pts' daily lives. this patient-centred study enriches the findings of sls asthma. funding: gsk (study ) | asthma and copd treatment adherence and breach using tai questionnaire suarez-vergara m; fuentes-soltero f; garcia-nunez i; ignacio-garcia j background: adherence is defined as medication (inhalator) intake following the dosage and schedule prescribed. adherence mistakes are a public healthy problem according to the big morbi-mortality presented in patients with an incorrect intake. our aim is to evaluate the adherence level and fulfillment in patients with asthma or copd using tai (inhalators adherence test) questionnaire. method: patients with a diagnosis of persistent asthma or copd were selected. we used to size adherence and breach type the tai questionnaire. adherence is defined as good when patient′s test reaches points, medium ( - points) and bad (less than points). breach type is defined as erratic when points between questions to are less than , deliberate when questions to are less than , and unconscious when questions and are less than points. a correct fulfillment is defined when questionnaire reaches points plus points of conscious fulfillment. results: fifty-five patients more than years old (mean age . years and . % males) were selected. a . % of them were asthmatics, . % copd and . % a mix phenotype. a . % presented a correct fulfillment with conscious fulfillment, and the other . % presented good, medium or bad adherence with a breach type. according to adherence level, a medium adherence was defined in patients ( . %), with an erratic mistake in patients ( %). bad adherence was seen in patients ( . %) , with the three breach types in patients ( %). good adherence with unconscious breach type was defined in patients ( . %). conclusion: tai questionnaire confirms a good adherence and fulfillment in less than % patients. an erratic mistake is the most frequent breach type defined in our patients. educational protocols should be applied to improve adherence and fulfillment. | what is adhesion to treatment of asthmatic patients like in argentina according to the tai questionnaire? background: asthma is a chronic inflammatory disease of the airways, which requires an adequate treatment and control. the adhesion of a patient to an asthma treatment is a critical factor in order to achieve and maintain control. this adherence arises from a consensual agreement of the doctor-patient relationship; it is a complex multifactorial variable in which the variability in human behaviour in relation to its environment influences. background: the association between ambient pollen and asthma has been studied intensively with inconsistent results, attributed to differences in study population, geographic factors (geoclimatic features), data sources, measurement of pollen (different types of traps), and different outcome occurrence (hospitalizations or emergency department visits). we investigated the associations between daily sales of short-acting β -agonists (saba) and outdoor pollen concentrations in the central france area. the relationship between daily changes in pollen concentrations and daily saba sales obtained from the social security database was analysed with generalized additive models, taking into account confounding factors such as air pollution, weather conditions, and day of the week. results: the daily saba sales (mean, sd) rose from . ( . ) conclusion: this study indicates that outdoor pollens contribute to asthma morbidity in the general population. it confirms the highly allergenic role of fraxinus, betula and quercus pollens, but also shows a relatively unknown association between treated asthma and carpinus and platanus pollens, despite their counts being less than % of overall pollen concentration. results: of asthma patients (mean age . years, female . %), regular ocs use was identified for patients ( . %), periodic ocs use for patients ( . %), and no ocs use for patients ( . %) -year post-index. regular ocs users had a greater mean age, were more often male, and had greater eosinophil counts, lower lung function, and greater prevalence of comorbidities than did the periodic and no ocs users (p < . ). total yearly cost was greatest for the regular ocs users (€ ), followed by periodic ocs users (€ ) and no ocs users (€ ) (p < . ). among regular ocs users, hospital admissions were the main cost driver ( . % of total cost), while gp consultations were driving the total cost in periodic and no ocs users ( . % and . % of total cost, respectively). conclusion: in this sample of patients with asthma in sweden, the total yearly cost of health care resource utilization for a regular ocs user is twice as high as for a patient with no ocs use, demonstrating substantial economic and clinical burden in asthma patients on regular oral steroid treatment. method: children with physician-diagnosed asthma who attended to an outpatient pediatric allergy and asthma center were enrolled in the study along with control subjects. asthma severity and control status of the patients were evaluated according to recent gina guidelines. laboratory investigations including skin prick tests, complete blood counts with differential, total ige levels, serum periostin levels and pulmonary function tests were performed. results: a total of children ( with asthma and age and sex-matched control subjects) with a median age of . years (range . - . ) were enrolled. asthma severity was mild in ( . %), moderate in ( . %) and severe in ( . %) children. children with asthma had significantly higher periostin levels than controls ( . ± . vs . ± . ng/ml; p < . ). the mean serum periostin levels of children with severe asthma ( . ± . ) were significantly higher than in children with moderate asthma ( . ± . ) and mild asthma ( . ± . ) (p < . ). serum periostin levels were found to be significantly correlated with asthma severity (spearman's rho [r]=. , p < . ). analysis using roc curves identified the role of periostin levels in determining children with severe asthma (auc: . , % ci: . - . , p < . ]. conclusion: serum levels of periostin, a novel asthma biomarker, were higher in asthmatic children, and were associated with asthma severity. adam i ; selevestru r ; rogut v ; sciuca s background: nowadays, data from several epidemiological studies confirm the important role of fungi in respiratory disease in the indoor as well as in the outdoor environment. in general, exposure to fungi occurs via inhalation, skin contact, or ingestion. alternaria alternata is one of the most common fungi associated with presence asthma and persistence and severity of asthma. although exposure to a. alternata is also may represent a risk factor for development of asthma. in ukraine has been an increase in the number of the mold sensitized children for the last few years. at the same time we can see increasing frequency ba at the children of pre-school age. method: thirty five children aged - years with allergic rhinitis and high level of asthma predictive index (api) sensitized to a. alternata were included in a -year cohort study of the efficacy and safety of slit (diater laboratories, spain) using standardized sublingual extracts containing molds (alternaria alternata). treatment efficacy was analyzed using the score of symptoms such as difficulty in nasal breathing, rhinorrhea, sneezing, itching of the nasal mucosa (upper palate) and discharge from the nose and recurring wheezing. we also have analyzed the level api during the period investigation. symptoms were measured before starting treatment, and at , and months after starting immunotherapy. results: slit significantly reduced both symptoms and medication score: nasal symptoms ( % vs. control group) and the use of rescue medications ( % vs. control group), and improved fev (in children aged≥ years). in the slit group, api decreased by % for the first year, by % for the second year. no patient had a systemic reaction during therapy. our results have shown that slit is an effective treatment in pediatric patients suffering from allergic rhinitis and high api with significantly improved clinical outcomes (less symptoms and less medication intake) in comparison with children treated with symptomatic drugs only. in this study, large and statistically significant differences in symptom and medication scores were demonstrated in patients receiving slit compared to control group. sublingual immunotherapy is effective for allergic rhinitis in children especially early age and is generally advantageous because of the convenient administration and safety profile and ensure prevention of developed ba. bednarek a background: the classification of asthma based on the severity of its clinical course has been recommended by gina since . this division is useful for the patient's initial assessment when asthma is being diagnosed and essential decisions concerning an appropriate therapy are made. the objective of the work is to evaluate the influence of a clinical form of asthma on vaccine immunity in preschoolers following three years after the programme of mandatory vaccination has been realised. the study encompassed preschool children (mean age of . ± . years old) with asthma being newly diagnosed, including patients with mild asthma and ones with moderate asthma, whose vaccine immunity (igg specific antibody titer) was assessed after the mandatory early childhood vaccines had been administered. monovalent vaccines (hbv+ipv+hib) along with a three-component combined vaccine (dtwp) were given to children while a six-component vaccine (dtap+ipv+hib+hbv) was given to the remaining children. the vaccine doses were consistent with the polish immunisation programme and manufacturers' recommendations. the elisa immunoenzymatic method was applied to assess titer of specific antibodies to diphtheria, tetanus, pertussis, poliomyelitis and h. influenza type b. the level of hbv antibodies was measured chemiluminescently. the immunity class for particular vaccinations was assessed according to the test manufacturers' instructions. results: children suffering from mild asthma had considerably more frequently vaccinations on time (p < . ) and the type of vaccines (monovalent, highly-combined) administered to them did not have a significant influence on a clinical form of asthma in the children examined (p > . ). apart from the vaccines against hepatitis b and rubella where considerably more frequently a high antibody titer occurred in children with mild asthma, the titers of antibodies to other vaccines, namely diphtheria, tetanus, pertussis, hib and mumps, were not associated with a clinical form of asthma. the protective antibody titers in the children with asthma were found in % after vaccinating them against poliomyelitis (≥ u/ ml) and measles (≥ ml u/ml). significantly higher current weight was solely found in the children with mild asthma (m = . , sd= . ; p < . ). conclusion: there are some clinical and cultural differences among the four southern chinese cities within the canton province. this study identifies potentially modifiable environmental and treatment factors associated with poor asthma control and qol for healthcare interventions. having a smoker in the family is independently associated with poor asthma control and qol. were classified into two groups (levocetirizine group (l) and montelukast group (m)) and we treated each group for another week. to evaluate the therapeutic effectiveness, we used symptom score (ss) and ebc leukotriene e (lte ). ebc samples were collected with rtube. each parameter was checked at , , week therapeutic period. results: most ar patient showed clinically improvement with and week fluticasone therapy ( wk ss= . , wk ss= . , wk ss= . p < . in l group; wk ss= . , wk ss= . , wk ss= . p < . in m group). lte levels of ar were higher than control ( wk vs. pg/ml), and were reduced after week fluti- mic were: md allergic rhinitis, wheezing apart from colds, eosinophilia ≥ %. outcome was defined as md asthma and at least episode of asthma during the previous year or more than episodes of wheezing during the months regardless of asthma diagnosis. results: from a total of of parents approached, ( %) agreed to participate in a phone interview. ( %) children were diagnosed with asthma. the age at the time of admission (mean, abstracts | (sd)) was . ( . ), at the time of phone survey . ( . ) months, respectively. positive loose api at - years of age had sensitivity of . %, specificity %, positive predictive value (ppv) . %, negative predictive value (npv) . %. positive stringent api at - years of age had sensitivity of %, specificity %, ppv . %, npv %. background: asthma is the most common chronic airway disease in childhood, with a high unmet need for new treatments due to insufficient symptom control in a relevant percentage of patients. ethics and resource factors limit the feasibility of large, long pediatric trials required to assess outcomes such as exacerbations and symptoms. for diseases like asthma, where the disease process is largely similar in children and adults, with the same expected therapy outcome, the international council for harmonisation advise extrapolating adult data to those of a younger age, reducing unnecessary pediatric trials. here we assess the partial extrapolation used in the clinical development of tiotropium. phase trials in adults (aged - ), adolescents (aged - ) and children (aged - ) with symptomatic severe (primotina-/pensie-tina-/vivatina-asthma) or moderate asthma (mezzotina-/rubatina-/ canotina-asthma), respectively. trials lasted - weeks, all with tiotropium respimat μg add-on vs placebo as two puffs once daily. results: in adult trials, lung function, symptoms and exacerbation endpoints were evaluated in a confirmatory manner: tiotropium significantly improves lung function and asthma control, and reduces risk of exacerbation, vs placebo ( conclusion: based on similarities in disease profile and magnitude of treatment responses between age groups, it is reasonable to expect tiotropium add-on to produce clinically meaningful improvements in exacerbation and symptom endpoints in children and adolescents, as in adults. the robust tiotropium clinical program supports using a partial extrapolation to avoid overly long and large trials in pediatrics. | clinical state of treatment and examination during last years before remission about asthmatic children in long-term remission cases method: remission cases (no symptom and no therapy) for years of asthmatic children were studied. clinical background and treatment (drugs) was studied during last years before remission annually. acetylcholine inhalation test by standard method was performed, and respiratory threshold of acetylcholine (rt-ach) was obtained. fev %, and serum ige also examined. these data were compared before remission with years after remission. results: mean age of cases at year before remission was . years old. male to female ratio was . . severity of asthma was all mild type, and number of attack was to times in a year. there was no admitted case during this study. the long-term therapeutic drugs were leukotriene receptor antagonist (anti lt) in cases, and/or inhaled corticosteroids (ics) in cases, but cases had no treatment for the control. geometric mean of rt-ach (after then: years before and after remission) was μg/ml and μg/ml. the mean fev % was % and %. geometric mean of serum ige level was iu/l and iu/l. complicated cases of atopic dermatitis decreased after remission, but the incidence of allergic rhinitis increased slightly. conclusion: characteristics of asthmatic children during last years before remission were mild type, had several times of attack in a year, and the treatment was mainly anti lt and/or ics. fev % was within normal range, and serum ige level was not changed after remission. rt-ach had the tendency to improve during years before and after remission. these data is supposed that airway hyperresponsiveness is one of the indicators for quitting treatment. | clinical aspects of polyvalent mechanic bacterial lysate (pmbl) treatment in children with uncontrolled asthma our results indicate that long-term treatment with omalizumab in children can help to achieve better asthma control and reduce the amount doses of basic therapy. method: allergic rhinitis (ar) and allergic rhinoconjunctivitis (arc) diagnosed-patients' demographic information, accompanying-asthma, the allergic history of the family, the onset of symptoms, types of aeroallergens sensitivity were noted from patients' files in our hospital's pediatric allergy clinic. results: in this study, patients were evaluated. the mean age of the patients were . ± . years and % (n = ) were male. ( %) patients had ar and ( %) patients had arc. background: allergic rhinitis (ar) is a disease characterized by symptoms of nasal discharge/congestion, sneezing, and pruritus, and is caused by an ige-mediated immunological response to inhaled allergens. we aimed to evaluate pollen season and out of pollen season pulmonary function tests (sft) of patients with ar in our study. method: in our study, the demographic characteristics and aeroallergens were recorded from patients' files with ar diagnosed. in addition, pollen season and out of pollen season sfts were evaluated and compared. conclusion: in patients with ar, fev and fvc values are seen to be lower during the season even though there is no lower respiratory symptom. therefore, sfts of patients with ar should be evaluated during pollen season. results: among the clinical manifestations, the most common combination of allergic rhinitis (ar) and conjunctivitis (ac) is noted in . % of adults and . % of children, but in children aged - , the combination of ar and ac is observed only in . %, among - years old- . %, while in the remaining age groups it is encountered in more than %. higher percentage of isolated ar is also observed among young children- . %, and those of the results: allergic rhinitis was a main symptom in . % of children with pollen-food sensitization. in all of them concomitant allergic disorders were noticed: bronchial asthma ( . %), atopic dermatitis ( . %). only in . % temporal association between ingestion of pollen-related foods and nasal symptoms was observed (mainly apple and peanuts); occurring also outside the pollen period. the simultaneously sensitization to animal origin food allergens was stated in . % of children with sar, but only in two of them milk and white egg proteins were an additional exacerbation factor of nasal symptoms. in . % anaphylactic reactions to food allergens were registered. . % of children were asymptomatic despite pollen-food sensitization. the statistically significant differences were noticed in comparison to the control group. conclusion: . allergic rhinitis in children, similar to adults, is a common manifestation of pollen-food syndrome and this type of sensitization should be taken into account regardless to age. . children with pollen-related food allergy have the predisposition to multiorgan clinical manifestation. . the lack of association of symptoms with plant-origin foods in the majority of cases and the asymptomatic course of food sensitization in more than one third of patients indicate the need for follow-up. | clinical benefit of the screening of suspected food allergen using multiple allergen simultaneous test in the patient with pollen-food allergy syndrome (pfas) background: the quantitative fluoresce enzyme immunoassay immunocap (ic) system has been widely used for detection of allergen-specific ige for the diagnosis of allergy. however, the system can only detect ige against a single allergen, the multiple antigen simultaneous tests has been developed such as the fluorescence enzyme immunoassay view allergy (va) or chemiluminescent enzyme assay mast iv (ma) and both assay detect more than allergen-specific ige. in this study we examined the diagnostic capability of these two systems for screening test in the patient with pfas. method: total number of participants are (male/female: / ), aged . ± . (range ~ ) years old. all the patients showed oral allergy syndrome (oas) to rosaceae family plants (apple, peach) and/ or kiwi and/or banana, also showed tree pollen allergy. specific ige assay were performed using ic, ma or va. results of greater than class were to be regarded as positive, and the concordance rates between the assays were assessed. results: the correlation of sensitivity between pr- (rbet v , rmal d , rpru p , measured by ic) and specific ige to apple (measured by va), specific ige to peach (measured by ma) in oas patients to rosaceae family plants were assessed. rbet v , rmal d , rpru p were found to be . %, . %, . % positive measured by ic while the specific ige to apple (supposed to be including pr- ) were found to be % positive measured by va. on the other hand, the specific ige to peach (supposed to be including pr- ) were found to be only . % positive measured by ma, this detection rate was lower than that of va (p < . ). also, the correlation of sensitivity between pr- (ract d , measured by ic) and specific ige to kiwi in patients with oas to kiwi were assessed. ract d were found to be . % positive measured by ic while the specific ige to kiwi (supposed to be including pr- ) were found to be . % and . % measured by va and ma, respectively (p < . ). additionally, all the oas patients to banana found to be positive for the specific ige to banana measured by va, but only patient was detected as positive measured by ma. conclusion: in this study, we found that va showed better agreement of sensitivity and specificity with ic compared to ma in the oas patients to rosaceae family plants, kiwi, or banana. therefore, it may be clinically useful for screening of allergen specific background: the hygiene hypothesis for autoimmune and allergic diseases, which exists nowadays, shows that human immune system is dependent on various environment factors. we consider the effects of humic substances (hs) to be important in understanding the hygiene hypothesis. due to urbanization, the amount of human interaction with hs found in soil has significantly dropped. the goal of our work was to study allergenic potential and antimicrobial activ- conclusion: hs appear to be exogenous immunocorrectors, and also to have an ability of suppressing propagation of allergic reactions and sensibilization, which leads to conclusion that they seem to play a major role in hygiene hypothesis. moreover, hs selectively interact with bacterial cell wall, and this effect could be used in order to create antimicrobial drugs based on hs. background: peach tree pollen has been identified as having relevant allergens (the third most prevalent after olive tree and grass pollen) in areas of high cultivars (murcia, east-spain). when analyzing molecular components in sensitized patients, along with pru p , we have identified other relevant inhalant allergens one of which was named pru p x. because pollen of different species share allergens and with plantderived food, we have also studied peach tree pollen sensitization in a non-exposed population (madrid, central-spain). the aim was to study the association between peach tree pollen and several panallergens, as well as the relevance of pru p x in our area (madrid). method: a total of patients who came to our allergy unit in those patients with positive spt to at least one pollen we also performed peach tree pollen spt. if positive, we tested pru p , pho d , pho d and pru p x. to study the clinical relevance of these findings, we also performed nasal provocation test (npt) with peach tree pollen and pru p x. results: a total of patients were sensitized to peach tree pollen. from these, % had also positive spt to pru p and none of them to pru p x. positive spt to polcalcin were found in the % of the cases and to profilin in the %. in patients sensitized to peach tree pollen npt was performed being cases positive to peach tree pollen and none to pru p x. conclusion: peach tree pollen sensitization in non-exposed patients with allergy to other pollens is high although primary sensitization is unlikely. these patients present clinical response when exposed to that pollen that needs further evaluation. in our study, one third of the patients were also sensitized to polcalcin and pru p and none to pru p x. we have not found clinical response to this new inhalant allergen identified in highly exposed peach tree pollen population. results: the bet v elisa . -ep complete kit format (including pre-coated plates and all buffers and reagents) allowed for the consistent measurement of bet v in birch pollen extracts within the same lab (intralab cv= . %) and between different labs (interlab cv= . %). the average recovery from matrix spiked samples (crs in birch pollen extracts) ranged from - %, with an average recovery of % (n = ). assay time was reduced from several days to two hours compared to the original method. the performance of the bet v elisa . -ep kit was comparable to that of the stallergenes greer candidate standard method and has been successfully cross-validated. this will enable allergen manufacturers and regulatory authorities to adopt a standard method for bet v determination, which, ultimately, may be included in the european pharmacopoeia. the development of a certified elisa represents a major step forward in the standardization and quality control of allergen products. | an isoform of the ole e allergen assembled by proteomics could explain the cross-reactivity with pollen and food nsltps results: a total of peptides were obtained by de novo sequencing. ten of them allowed the completion of the full-length amino acid sequence of the allergen. after purification, role e was obtained with a yield of . mg/l of cell culture. immunological assays confirmed that the recombinant isoform of ole e shared most of the allergenic and antigenic properties of the natural allergen. moreover, we observed its implication in cross-reactivity with pollen extracts, and plant-derived food extracts. conclusion: these results suggest that the presence of this isoform in the olive pollen could explain the co-sensitization observed in some allergic patients between ole e and nsltps from foodderived extracts and might be used for a more effective clinical diagnosis of olive pollen sensitized patients. background: penicillium oxalicum, one of the prevalent airborne fungi in india, was selected to detect its spores as potential source of allergens and also to identify and characterise its major ige-reactive component. the airborne spores of penicillium oxalicum was detected by andersen -stage air sampler at different parts of west bengal. the allergenic potency of p.oxalicum was tested by spt, elisa and immunoblotting. total protein was resolved in -d and -d gel electrophoresis and allergens were identified by -d and -d immunoblots. identification of major ige-reactive protein spots was made by mass spectrometry based maldi-tof-tof. major allergen was partially purified by ion exchange chromatography. results: aerobiological investigation clearly indicated the predominance of p. oxalicum spores ( cfu m − ) in the air of west bengal, india. sensitivity of patients to spore antigens was highly correlated with rhinitis. in sds-page, bands were detected with molecular weight range of - kda. the allergenic potency of spores was confirmed by skin-prick test, elisa and dot-blotting. eleven ige-reactive proteins were detected as allergens by -d and -d immunoblots, of which % patients were sensitized to kda allergen. this kda protein was found to be the major allergen which was further characterized by mass spectrometry based maldi-tof-tof. this major allergen (pi . ) was partially purified by ion exchange chromatography. the eleven allergens were identified from spore of penicillium oxalicum fungi for the first time from india. immuno-proteomic identification of major ige-reactive protein ( kda background: airway epithelium (ae) is one of the largest cellular surfaces exposed to the environment. ae constitutes a physical barrier due to the presence of intercellular apical junctional complexes between neighboring cells. in the past years evidence indicates an association between epithelial airway dysfunctionality and allergic asthma. it is still unclear if an impaired epithelial barrier could be the cause of allergy development as opposed to the consequence. one of the most common comorbidities of asthma is house dust mite (hdm) allergy. it has been shown that hdm allergen der p can disrupt the epithelial airway due to its protease action against cellular apical junction complexes damaging the epithelial monolayer. in the last decade, metabolomics has been successfully employed as a new approach to describe metabolic changes in biological systems. metabolomics focuses on describing and identifying small molecules to explain complex biological processes. we theorized that metabolomics could be used as a new tool to detect damage of epithelial barrier in vitro after der p exposure. method: human cell line calu- cultured at air-liquid interphase (ali) was used as an in vitro model of bronchial epithelium. ali culture system allows establishing different compartments, mimicking the conditions found in the human airways: a basolateral compartment in which basolateral surface of the cells is in contact with the culture medium, and an apical compartment where the apical cellsurface is exposed to air. after days in ali, the cells were exposed to either der p or pbs as a control in the apical side for hours. then, apical and basolateral media were collected and processed for metabolomics analyses. results: metabolic profiles from samples were obtained, these were composed by and features for apical and basolateral media, respectively. of these, using mann-whitney unpaired test as statistical analysis, and features were found changed within the apical and basolateral compartments, respectively. specifically, in the apical compartment there were signals significantly increased and decreased after der p exposure; whereas for the basolateral compartment, signals were found to be significantly decreased and increased after exposure. background: mites are one of the major causes of allergies. it is known that allergen concentration varies depending on the species of mites and the degree of allergy induction is different, but the difference in microbiota according to mite species is not known. in addition to allergen, endotoxin or bacterial dna, adjuvants of allergen derived from the microbiota in the mites, are also present in the feces. bacterial endotoxin is found in gram-negative bacteria, acting on tlr and acting as an adjuvant to allergies. method: three species of mites (d. farinae, d. pteronyssinus, and t. putrescentiae), known to cause allergies, are cultured in same condition(autoclaved media, %rh, °c)and analyzed for microbiota of each species. using the next generation sequencing that complements the existing sanger sequencing, we analyze the difference of microbiome according to the dust mite species and measure the level of endotoxin. method: six hundred and thirty five patients ( . % males and . % females, mean age . years old, range to years old) were included. all of them referred respiratory symptoms (rhinitis, conjunctivitis or bronchial asthma) and had skin prick tests positive with any pollen. patients were skin prick tested with a battery of common pollens in our area, including three species of chenopodiaceae: chenopodium album, salsola kali and salsola oppositifolia. results: three hundred and forty tree ( %) patients were sensitised to pollen of any chenopidaceae species: ( . %) to chenopodium album, ( . %) to salsola kali and ( . %) to salsola oppositifolia. the prevalence of skin sensitisation to pollen of salsola oppositifolia was . % in the population studied and . % in patients sensi- results: in patients aged - years of age in . % of the cases ige reactivity was at least to one allergen tested. the majority of patients (more than / ) had a complex sensitization profile and reacted on average to more than allergens. the highest frequency of sensitization in ukraine among patients who turned to the clinic among adults was found phl p ( . %), amb a ( . %), fel d ( . %), bet v ( . %) and children ( . %, . %, . %, . %), respectively. when analyzing the results of tests for the source of the allergen, most often among house dust mites (hdm) allergens in adults and children is sensitization to fel d ( . %), as well as to hdm: in adults (der f - . % der p − . %, der f - . %, der p - . %) and in children ( . %, . %, . %, . %), respectively. among fungal allergens the most common is sensitization to alt a and varies from . % in adults to . % in children. among pollen allergens in adults is sensitization to phl p ( . %), amb a ( . %), bet v ( . %), cynd ( . %), art v ( . %), bet v ( . %) and in children ( . %, . %, . %, . %, . %, . %), respectively. tests for food allergens in adults and children are more common on pr- proteins. in children, sensitization to milk and egg proteins is more common than in adults. conclusion: most patients who came to the clinic have a complex ige reactivity profile in which pollen sensitization predominates. among hdm allergens, more than / of the examined have sensitization to the cat's proteins. sensitization to mold alternaria alternata in children occurs times more often than in adults. results: total children were examined, aged - years (median years). % children were sensible to two and more components . %to and more components. the frequency of sensitization to inhalation components was . %, to food abstracts | components- . %. among the most frequent inhalation components were feld - %, betv - %, amba - %, phlp - %, alta - %, the sensitization to house dust mites (hdm) was most often observed to der p - %. however, the analysis of these protein by the level of isu showed that the highest levels were for der f median (iqr . - . ), whereas for fel d - . (iqr . - . ). among food allergens, sensitization was most commonly observed to pr- proteins - %. children sensitized to pr- proteins were in most cases sensitized to -mal d ( %), cor a . ( %), pru p ( %).this co-sensitization was accompanied by a high correlation of isu levels among these components. sensitization to celery and kiwi was less common, the level of these proteins was also low. the frequency of sensitization to storage proteins was %, among which the highest level of isu was in ara h median . sensitization to ltp proteins was detected in % of children, among which the most commonly detected pru p protein was . %. the sensitization to profilins, which was evaluated at the level of bet v , was found in % of children, but the levels of these proteins were not high. among the food products of animal origin, the most frequent was sensitization to egg component gal d − . %, however, isu levels were the highest to milk component bos d − . (iqr . - . ). the most frequent causative inhalation allergens were epidermal allergens and weed pollen, however, the highest level of isu was to hdm and mould. among food allergens, the most commonly observed sensitization was to pr- proteins. hypereosinophilia of peripheral blood was observed in children under study, which was % ( . %). as a result of testing patients with a wide panel of allergens, % of the patients had diagnostic levels of antibodies to allergens siged , . %to allergens siged . in % of cases, a significant level of antibodies to plantain allergens sige w was detected, . % to dandelion allergens sige w , . % to evergreen trees sige t , to maple sige t to . %, to allergens of olive tree sige t - %, to the banana allergens sige f - . %, to the egg protein sige f in . %, in % to the milk allergens sige f , to the food mixture sige f x - . %, to allergens of mold fungi mx − . %. among the leading household allergens were registered in the st group and in the nd group of the investigated children -d pteronyssinus ( . %, . %), and d. farinae results: the prevalence results are expressed in the table . we have not observed any significant association in allergic rhinitis patients group with any ltp or pr- molecules. for atopic dermatitis only rara h (or with % ci - . ( . - . ) and njug r (or with % ci - . ( . - . )) were associated significantly. for asthma, the most important molecules were rbet v , raln g , rcor a . , rcor a . , rmal d , rpru p and rapi g (p-values for or less than . ). conclusion: future studies focusing on the evaluation the association of cross-reactive molecules with allergy phenotype should be done. background: the fuzzy/green kiwifruit (actinidia deliciosa), widely grown commercially, contains various pulp allergenic molecules, including the major allergen cysteine protease actinidin. methods. this case report is about a -year-old male patient with house dust mite allergic persistent rhinitis and intermittent asthma, presenting a convincing history of anaphylaxis immediately after eating a kiwifruit on empty stomach, followed, a few months later, by a severe oral allergy syndrome after licking a slice of raw kiwi. previously, the patient ate kiwi without any problems and had no manifestations of pollen or latex allergy. skin prick testing was done with commercial allergen extracts, while prick-prick testing was performed with raw kiwifruit, avocado and banana. molecular approach consisted in assessment of serum specific ige to native extracts and molecular allergen components using patient-friendly allergen nanobead array multiplex test and singleplex capsule-enclosed activated cellulose solid phase fluorescence enzyme immunoassay. results. regarding kiwifruit allergy, the patient presented positive prick-prick tests with raw edible kiwifruit components: outer pericarp and inner pericarp (each mm wheal) and columella/core ( mm wheal) and negative with kiwifruit whole seeds, avocado and banana, and pollen extracts. serum specific ige to kiwifruit were detected ( . ku/l), but specific ige values were negative (≤ . fiu/ml) for actinidin act d , thaumatin act d , kiwellin act d , nsltp type act d , bet v -like major latex/ripening-related protein act c , act c chitinase_iv, act d cross-reactive profilins bet v (birch pollen profilin) and hev b (latex profilin), and also negative (< . ku/ l) for pr- ract d . moreover, specific ige to avocado were nor found (≤ , fiu/ml). although ige against seed proteins cupin/ s globulin act d and s albumin act d were not determined, this was not considered of great importance since allergic symptoms were also induced by licking kiwi pulp, in which abundantly expressed actinidin enzymatically degrades seed storage proteins, and prick-prick test was negative to kiwifruit seeds. conclusion: in a patient with anaphylaxis to kiwifruit, positive skin tests to its pulp and detectable serum specific ige to actinidia deliciosa, a detailed molecular allergy diagnosis is necessary, including assessment for act d glycoallergen or other molecules, not performed in this patient. | is pr- sensitization a portuguese phenomenon as well? background: bet v , a major allergen found in birch pollen, belongs to the pr- protein group. in our practice, some bet v sensitized patients have been identified, residing in areas without this tree genus in its flora. our aim was to characterize a portuguese patient population with pr sensitization. method: a group of patients in whom immunocap isac ® (isac) study was performed, between january and june , were analyzed. all subjects with one or more pr- sensitizations were selected, and their clinical records reviewed. a sequential sample of the last subjects (n = ) who underwent isac study, was then used for comparison. results: out of isac studies performed, only were positive for pr- protein group. median age was . years, % (n = ) were male. pr- sensitized individuals were more likely to live in portalegre district compared to the control group ( / vs / ; p < . ). patients were positive for pr- family pollens ( . %), frequently bet v (n = ), followed by aln g (n = ) and cor a (n = ). out of the patients were sensitized to pr- foods, mostly cor a . (n = ) and mal d (n = ). skin prick tests revealed birch as the main sensitizing pollen as well ( / ). moreover, only four patients were skin prick tested for fagaceae trees which were positive for oak ( ), chestnut tree ( ) and cork tree ( ) . all patients were co-sensitized to other pollens, namely grass and all had respiratory allergy. nine patients were food allergic, although seven of them were co-sensitized to other cross reactive (ltp/profilin) or species specific proteins. conclusion: although pr- sensitization is known to be rare in our population, mostly alto alentejo inhabitants showed sensitization to this protein family in our sample, either by in vitro and/or in vivo methods. this phenomenon is consistent with the native plant species of this region, which should be taken into account when studying the allergic profile of these patients. in our sample, all pr- sensitized patients had respiratory allergy while this protein didn't seem to be relevant when it comes to food allergy. further studies are needed to characterize which plant species belonging to this protein family are more significant for our country's aerobiology context and to determine its clinical relevance. included. allergic asthma, rhinitis, conjunctivitis and eczema allergic symptoms were diagnosed. all patients were tested by immunocap with mugwort pollen extract and the natural components nart v , nart ar , nart v , and nart an . results: the positive frequency and sige levels of the four components in the artemisia allergic patients from southwestern china were significantly lower than that from the north. art v and art an were the highest recognized allergens, followed by art v and art ar . patients from northern china were more likely to have abstracts | asthma ( %) than patients from southwestern china ( %), and being sensitized to more than two allergens increased the risk of asthma. sensitization to art v , art v and art an played a significant role in the development of asthma. artemisia pollen allergic patients is helpful to assess the potential risk of asthma. conclusion: a small but significant part of the population react to ragweed pollen extract and are not identified as disease-positive by standard sige tests. there is a need for targeted tests towards a larger spectrum of allergen molecules. in ragweed allergic individuals, this allergy can be the main cause of overall sige levels and also of in vivo reactions (tested by spt). | molecular profile of pollen sensitization of tashkent residents with respiratory allergy background: in paediatric cohorts, a correlation between specific ige (sige) levels to house dust mite extract or allergen components and the occurrence of asthma has been shown. higher levels of sige to mite extract were associated with a higher risk of wheezing. moreover, asthmatic children recognized more allergens and had higher sige levels to nder p as well as rder p , and . we sought to investigate potential differences in sige levels or sensitization patterns between asthmatic and non-asthmatic patients in a mixed paediatric and adult house dust mite allergic cohort. method: total ige and specific ige against house dust mite extracts (dermatophagoides pteronyssinus and farinae) and allergen components (rder p , , , and ) were determined in house dust mite allergic patients. patients had diagnosed asthma ("asthmatic", % females, mean age ± years, % younger than years), whereas had rhinitis (and conjunctivitis) without respiratory symptoms ("non-asthmatic", % females, mean age ± years, % younger than years). results: total ige levels were markedly higher in asthmatic compared to non-asthmatic patients ( vs. ku/l, p = . ). positivity to rder p ( vs. %, p = . ) as well as rder p ( vs. %, p = . ) differed between both groups. specific ige levels to house dust mite extracts and allergen components (rder p , , , and ) and positivity to rder p and did not differ between both groups. conclusion: in contrast to previously published data, sige levels to house dust mite extracts or allergen components were not statistically different between asthmatic and non-asthmatic patients in our mixed paediatric and adult house dust mite allergic cohort. only higher total ige levels and a higher reactivity to rder p and were found in asthmatic patients. however, larger studies are needed to confirm clinical relevance of these findings. results: prior treatments reported at baseline (bsl) included: . % of pts were receiving or more second-generation h -ah at approved dose (recommended first-line), . % were receiving them at increased dose (second-line); . % were receiving omalizumab (third-line); . % had no treatment. the majority of pts ( . %) had uncontrolled csu (uct< ) at bsl (table) . treatment changes were most evident at the bsl visit, with an increase in pts receiving omalizumab ( . %) and a decrease in those receiving no treatment ( . %) vs. prior therapy. these changes were associated with improvements in rates of hives and/or angioedema, uct and qol scores at month , but only modest improvements thereafter (table) . a sub-analysis of pts with uct< and who were receiving the approved ( . %) or increased dose h -ah ( . %), revealed that few pts had recommended escalation from the approved to increased dose h -ah ( . - . %) or from increased dose h -ah to omalizumab ( . - . %) (table) . conclusion: poor physician adherence to guidelines was evident throughout aware. initial improvements in disease activity and qol plateaued after month , possibly owing to fewer changes to recommended therapies. greater physician adherence to guidelines is needed for better symptom control in pts with uncontrolled csu. results: we revealed that in russians urticaria is associated with rs *arg/gln genotype of the il gene (p = . ) and rs *cc genotype of tlr (p = . ) gene polymorphism. in tatars the association with disease development was shown for rs *tt genotype of tlr gene snp (p = . ). the rs *c allele of tlr gene polymorphism is associated with acute and chronic forms of urticaria (p = . and p = . , respectively) and rs *c allele of il gene polymorphismwith acute urticaria (p = . ). method: csu patients from the urtica cohort (clinicalttrials.gov number: nct ) participated in the study. a questionnaire was carried out evaluating the triggers identified by the patients, the comorbidities and the treatments received. patients with a self-report of skin exacerbation by foods, nonsteroidal antiinflammatory drug (nsaid) or physical triggers were subjected to a controlled provocation test with the suspect food, medication or physical stimuli report by the patient. the levels of anti-tpo ige were measured during a period of clinical control and during two exacerbations in all patients. results: % of the patients had at less one inducible urticaria demonstrated by provocation tests ( % dermographism, % cold, % pressure). self-reported exacerbation for a food ( %) or medication ( %) were high, but positive provocation tests were low ( % and % respectively). patients had (+) anti-tpo ige during the baseline period. among them, % presented a significant elevation of anti-tpo ige during at less one of the two exacerbations. . % of patients (n = ) with (−) anti-tpo ige, presented elevation of anti-tpo ige one of the two exacerbations. conclusion: foods, drugs and physical triggers must be verified by challenge tests to avoid unnecessary lifestyle restrictions in patients with csu, nevertheless self-report is usually greater than positive provocation tests. increase concentrations of anti-tpo ige seems to be implicated in urticaria exacerbations in some patients with csu. brzoza z ; adamczyk k ; wcislo-dziadecka d ; zbiciak-nylec m ; brzezinska-wcislo l adipokines. the aim of the study was to evaluate the possible contribution of leptin to chronic spontaneous urticaria pathophysiology. the study included chronic spontaneous urticaria patients and healthy subjects. the leptin level in both examined groups was measured. results: no statistically significant difference in leptin level was determined between the studied subgroups. we are among the first to present the effects of exploration aimed at assessment of the possible role of adipokines in chronic spontaneous urticaria pathogenesis. in this study we did not prove any difference in leptin level. in our opinion it is valuable to perform further studies in this area. the microorganisms were inactivated with phenol, and the concentration was adjusted to microbial cells/ml (labeled as a / ). dilutions / and / were made from the product labeled / . the dot blot technique was used to detect the presence of specific ige to the different microbial antigens and controls (anti ige / and fold dilution ½ and ¼). the dot blot images were processed with a documentation system (gel doc ez, bio-rad), and the different microbial antigens in different dilutions were compared with the positive anti-ige controls. results: all patients have specific anti ige to microbial antigens (see table below). the presence of microorganism-specific ige could explain, the relationship between the infections and / or microorganisms in ciu, as well, the urticaria control by omalizumab, even when it has not been detected ige sensitizations to common allergens. finally, these findings, showed that the bacterial allergy could be one line of research to understand the unresolved etiology of urticaria. background: dermographism is the most common form of inducible urticaria. it shows itself as hives made by scratching or rubbing on the surface where it has been produced and with the same morphology. the pathogenesis has not been clarified nor has it been associated until now with the sensitization to allergens. we have studied the relationship between the presence of dermographism and domestic mites sensitization. we have selected patients older than years old. all of them had symptoms compatible with dermographism at the moment of medical evaluation. at least one third of patients additionally showed rhinitis and/or asthma symptoms. we performed:: -skin prick tests with our basic neumoalergens (mites d. pteronyssinus y lepidoglyphus destructor, pollen, molds, dog, cat and horse dander, latex and anisakis simplex). -determination of specific ige levels for dermatophagoides pteronyssinus, lepidoglyphus destructor, and anisakis were measured in serum by using the immunocap (thermo fisher scientific). -blood count, serum immunoglobulins, antithyroid antibodies, serine tryptase and proteinogram. results: blood count, serum immunoglobulins, antithyroid antibodies, serine tryptase and proteinogram were normal. we divided patient in different groups. background: urticaria results from the appearance of pruritic papules and/or erythematous plaques caused by substances from mastocytes present in the skin, notably histamine. chronic urticaria is defined as flare-ups that occur at least two or three days per week over a six-week period. in addition, affected subjects are often prone to an atopic or auto-immune profile that promotes urticaria [ ] . the association of polyphenols (ambora, green tea) and the soothing active ingredients slow down the itching biological process from the outset by reducing the release of pruritic mediators (e.g. histamine, cytokines, etc.) of immune cells such as mastocytes and lymphocytes, involved in urticaria. in this context, the purpose of the study was to evaluate the efficacy and the tolerance of an anti-pruritic spray containing the polyphenols and the soothing ingredient. the tested product aims to quickly calm the itching in subjects with chronic urticaria. results: on average, the product was applied . times per day with a significant decrease of d-pruritus scale (- %) and sensations of itching (- %) between d and d . in terms of quality of life, a significant decrease of the skindex score was observed (- %). the product soothed the pruritus within seconds for all subjects and the anti-pruritic effect lasts at least hours for % of subjects. the product also showed very good cosmetic properties and was well tolerated; no intolerance case was reported. showed near complete remission. in the week before omalizumab and for a few days after, her urticaria flared but on of weeks she was largely asymptomatic (uas - ). after years of successful treatment she reported an increase in csu activity. no trigger factors could be identified. add-on treatment with cyclosporine was refused, montelukast showed no, and prednisolone only transient benefit. over a period of months wheals occurred almost daily and a maximal score of was achieved on uas . we replaced omalizumab with cyclosporine but this was subsequently discontinued due to side effects. months later the patients' csu remained poorly controlled with up to wheals occurring almost daily despite rupatadine mg/d. due to the good initial response to omalizumab and lack of good treatment alternatives, a trial of re-treatment was considered. results: within week of re-commencing omalizumab she once again achieved near complete remission of csu with uas ≤ on of weeks. the mechanism of action of omalizumab and the development of resistance to it in csu, are incompletely understood. our case shows that some csu patients developing resistance to omalizumab may benefit from a subsequent trial of re-treatment, particularly if treatment alternatives are poorly tolerated. manipulate and store data by electronic means. this includes e-mail, sms text messaging, video chat and online social media as well as all the different computing devices that perform a wide range of communication and information functions. a rapid increase in the use icts in recent decades is an enormous contributing factor in the development of a number of novel clinical and public health intervention strategies. the aim of the present study is to assess the level of ict use and to examine patterns of preferences among patients with chronic urticaria (cu). method: we will conduct an anonymous multicentre cross-sectional study, starting from january , to investigate the use of icts in patients with cu, using a questionnaire as a survey method. this questionnaire will assess the frequency of use of social media and icts in patients, and their preferences for receiving and asking disease-related information. the survey will consist of items, evaluating demographical information, time with disease, medication currently used, and additional aspects of social network use. results: we will use a chi-squared test to assess the association between internet access or owning a cell or smartphone, and age, gender, type of urticaria, educational level and number of years since diagnosis. we will employ the same test to assess the association between the independent variables previously introduced and the frequency of use of each ict type (short messaging service [sms], facebook, twitter, youtube, email, internet, linkedin and skype) as well as agreement in receiving and seeking information (i.e. asking questions to the practitioner) through such icts. we will perform adjusted regression analyses between categories of age, gender, educational level, type of urticaria, years since diagnosis and the use and level of interest shown in communicating through icts. our aim is to report on remarkable findings from a registry of a large sample of patients, potentially providing clues for its approach and results: patients with a median length of months suffering from urticaria were registered, being % women; mean age . years. in % of patients no causal agent was identified. parasites were found in . % and thyroid peroxidase antibodies in . %, while autologous serum skin test was positive in % and igg to mycoplasma in % of evaluations. two thirds of patients reported wheals on uas , with just / having concomitant angioedema. almost / reported significant affection on quality of life because of itch by cu-q ol. just % of patients achieved total control on first anti-histamines provided, and less than half had good control of urticaria. cetirizine was the first choice in %, followed by fexofenadine ( %) and first generation anti-histamines ( %). method: cases at - years of age which were being followedup in our clinic with diagnosis of chronic urticaria and were not receiving any antihistaminic medication for last one month were included in the study. cu-q ol, uas- , psqi and psg results of the patients were evaluated. correlation of data with each other in regard to sleep disturbances was evaluated. results: patients were included in the study. patients' mean total score in cu-q ol was . ± . . patients' mean uas- value was . ± . . mean total psqi was . ± . , the ratio of total scores ≥ and those with poor quality of sleep was . %. mean epworth sleepiness scale (ess) score was . ± . , with total score ≥ in . %. in psg, mean apnea-hypopnea index (ahi) was . ± . , with . % of the patients having ahi ≥ . when patients having ahi< were compared with patients having ahi ≥ , no significant difference was determined in regard to total cu-q ol score, mean score for questions concerning status of sleep, uas- and psqi. when correlation analysis was performed between cu-q ol and total score for questions concerning status of sleep, a positive correlation was determined with psqi (p = . ). conclusion: it was demonstrated in our study that patients with chronic urticaria had poor quality of sleep and this disturbance was independent from ahi. omalizumab was discontinued due to absence of improvement in csu symptoms after three consecutive doses. the plasmapheresis without intravenous immunoglobulin replacement was initiated. results: the symptoms were relieved during the first procedure and the disease improved shortly thereafter. the following weeks the symptoms still occurred but with lower intensity and severity. (angioedema was gone). the second attempt with omalizumab was successful after this course ( procedures of plasmapheresis). case report: rosacea is a chronic skin disorder associated with flushing, erythema, dryness, burning and stinging, and inflammatory papules and pustules. new treatments available or in development target the inflammatory and erythematous components of the disease. these agents include the selective alpha- receptor agonist brimonidine. allergic contact dermatitis to brimonidine is an unusual condition. in addition to this, urticarias due to brimonidine are rarely reported. we report on a -year-old woman who, immediately after apply a thin layer of brimonidine gel as preparation for a rosacea treatment on her face developed facial urticaria, which reverted in approximately four hours with systemic steroids. she had previously tolerated this product without any problems, but has not use it again ever since. skin prick-tests with brimonidine ( . mg/ml) and latex were realized in the patient. skin prick-tests with brimonidine were realized in eleven healthy control subjects. results: skin prick-tests with latex was negative in the patient. skin prick-tests with brimonidine were positive in the patient ( x mm). the prick-test with brimonidine was negative in teen healthy control subjects. we report on a case of immediate urticaria due to brimonidine and triggered by an immediate, probably ige-mediated, hypersensitivity mechanism. we highlight this case because it is the only case described in the literature with a positive prick-test. method: the study was in accordance with the helsinki declaration and was previously approved by the national comity of ethics. this was a one dose study conducted on fasting young healthy volunteers, of which were females and five males. the mean age was ± years old and the body weight . + . background: cetirizine is a potent h -receptor antagonist indicated in the treatment of allergic rhinitis and urticaria. cetirizine is widely used due to its potent antihistaminic effects in yielding strong and fast relief of itchy sensation, sneezy and rhinorrhea and its unlikely probability to manifest anticholinergic side effects in therapeutic doses. histamine flare and wheal inhibition by anti-h are widely used as a standard to test and compare the effect intensity and duration. our study aimed to test these effects of cetirizine in young healthy adults. method: this was a double-blind, single dose study in healthy young adults, previously approved by the national comity of ethics. eleven females and five males with a mean age ± years participated in this study. histamine skin pricks were tested before and after they received a tablet of mg cetirizine as previously scheduled. twenty minutes after each test flare and wheal were drawn in a transparent paper which was then scanned and measured with a software. wilcoxon signed ranks test two-sided with significance at % level was used to analyze the differences. claims that the preparation relieves itch within seconds of its application. we performed a simple study to verify this claim. we used irp in consecutive subjects, males, median age , range - years, whose workup implied ast. their preliminary diagnoses were "asthma" ( subjects), "allergic rhinitis" ( subjects), "atopic dermatitis" ( subjects) and "food allergy" ( subjects). all of them had refrained from systemic antihistamines for at least one week. standard skin prick tests (spt) were applied as appropriate, including histamine controls to assess the level of their skin sensitivity. subjects were asked to mark their sense of itch in the area of the skin to be tested on mm visual-analogue scales (vas) starting from " "-"no itch" to " "-"unbearable itch". vas assessments were repeated minutes after ast was done; then irp was applied according to the manufacturer's instructions, and the vas assessments were repeated after seconds and minutes. results: there vas assessments are shown in table format: table irp did not affect the wheal and flare of the histamine control, nor did it abolish positive spt. no differences were outlined between subjects with different diagnoses. the commercially available itch relieving preparation not containing defined pharmacological antihistamine is effecting in relieving itch associated with allergen skin testing. before ast ( ) . ± . vs ( ) p < . represent the first-line treatment for osteoporosis-related mastocytosis. we report a case of sm with bone pain and with an area of osteolysis in the femur as first sign and symptom. we had to consider the risk of adverse reaction when we decided to treat the patient with bp, but the patient was under antihistaminic treatment and also we made a premedication to reduce the risk. the pk/pd model available was informed by data from clinical trials. the pd endpoint data was available from two studies and used to characterize the effect of bilastine on wheal and flare. moreover, food effect had been characterized in pk studies and the data was used to model the effect of food in the pk of bilastine. the pk parameters relative to the fed state were then used to simulate the temporal evolution of the wheal effect using the pk/ pd model. all analyses were conducted by nonlinear mixed effect modeling (nonmem v . ). using the pk model developed (food effect model) and the pk/pd model already available, monte-carlo simulations for plasma concentrations and pd over time were performed for both the fed and the fasting states. results: . a reduced bioavailability (f) and a slow absorption constant characterized the pk of bilastine when administered concomitantly with food (f = % relative to the fasting state and ka = . hour − , a -fold reduction compared to fasting conditions). the rest of the pk parameters remained unchanged. onset of action was hour for bilastine both in fed and fasted conditions. maximum wheal inhibition occurred at . hours (fasted % and fed %). from to hours, the percentage reduction with bilastine for both fasted and fed was between % and % after the third day of treatment. a % inhibition in wheal effect was maintained during hours for both conditions after the third day. the results of the simulations show that even if the pk is altered with food, the pd is maintained unchanged. conclusion: even if a significant food effect was described for bilastine at a pk level, the difference is not translated directly into the pd. therefore, the antihistaminic effect of bilastine remains unaffected by the concomitant administration with food. the results of these simulations will be further confirmed in a dedicated clinical trial. results: we also found no correlation between the different tgt parameters and other clinical and analytical parameters associated with uc (table ) results: both cetirizine products have no differences in respect to the pharmacodynamic and pharmacokinetic parameters analyzed. the % confidence interval of the mean ratios of the auc - , auc -inf , cmax, auce - , and e max , between the test and the reference, were within the bioequivalence ranges ( %- %) in both cases. no statistical difference was revealed when comparing the respective t max and te max too. the two cetirizine products tested were bioequivalent. the bioequivalence was evident even when tested with the pharmacodynamic parameters. there is strong evidence that supports the use of histamine skin prick test for the bioequivalence evaluation of different cetirizine products. | bradykinin-mediated angioedema associated with combination of angiotensinconverting enzyme and dipeptidyl peptidase iv inhibitors: a disproportionality analysis from the who database method: we performed a disproportionality analysis using data from the who pharmacovigilance database by a case-noncase study, until the / / . we extracted all individual cases safety reports (icsrs) included in the high level term "angioedemas", according to the medical dictionary for regulatory activities classification. given the absence of term "bma", we selected only the icsrs of angioedema without associated symptoms evoking another underlying mechanism, such as histamine angioedema (e.g. pruritus, urticaria, rash, etc.). drug class exposure was "acei" and "dpp i", considered suspect or concomitant, using the atc classification. we results: there was no correlation between mother's disorders such as periodontitis, rhinitis, diabetes etc. and the onset of ar (p > . ). a multivariate analysis showed, neonatal jaundice (p < . ), respiratory system infection (p < . ), diarrhea (p < . ), eczema (p < . ) in the first months of life and home environmental factors (house decoration (p < . ), mold environment (p < . ), keeping flowers (p < . ), passive smoking (p < . )) increased the risk of ar. besides, there was no significant difference in current height and birth weight of the participants between ar and control group. however, ar group had significantly lower current weight (p = . ) and age (p < . ) compared with the control group. paternal age and maternal age in the ar group were significantly higher than the control group (p < . ). conclusion: diseases in the first months of life and home environmental factors increased the risk of sequential ar. the older parents increased the possibility of ar in the offspring. the data of general characteristics of participants were statistic analysis by z text analysis. *significance at p < . . results: anosmia was more frequent in crs than in rhinitis ( . % vs . %, p < . ) and in crswnp than in crssnp ( . % vs . %, p < . ). lms was higher in crs than in rhinitis ( [ - ] vs [ - ], p < . ) and in crswnp than in crssnp ( [ - ] vs [ ] [ ] [ ] [ ] [ ] [ ] [ ] , p < . ). in addition, lms was associated with loss of smell in patients with hyposmia (or = . [ . , . clinics. patients were submitted to confirmatory exams including oral provocation test with aspirin. nasal polyps were removed by functional endoscopic sinus surgery and eosinophils in this tissue were quantitated. eosinophil counts in peripheral blood was obtained. serum periostin was measured by elisa and total ige was determined using immunocap. as control groups, ( f/ m) patients with par and healthy subjects ( f/ m) were selected. samples of nasal tissue and blood were collected from these subjects during elective surgery for correction of anatomical variations, and compared with the patients with aerd. results: ar symptoms were significantly improved in the treatment group compared with the control group ( . % ( / ) vs . % ( / ); p < . ). furthermore, the mean total vas score for patients in the treatment group was reduced from . ± . before treatment to . ± . after treatment (p < . ). moreover, the reduction in free ige levels was greater in the treatment group than in the control group. the results of this study suggest that the chinese herbal medicine ber may be effective for improving the symptoms of ar. a multicenter clinical trial is needed to confirm this finding. results: in patients with "eosinophilic" polypoid rhinosinusitis, mucociliary transport was . ± . minutes, ph . ± . , suction- . ± . minutes, excretory- . ± . mlg and in patients with "neutrophilic" polypous rhinosinusitis, mucociliary transport was . ± . minutes, ph . ± . , suction- . ± . minutes, excretory- . ± . ml. the study showed that disruption of the transport function, changing the concentration of hydrogen ions method: this prospective controlled study was carried out on crs patients underwent ess. patients participating in the study were divided into two groups-group : partial middle turbinectomy (n = ) and group : partial middle turbinectomy and middle turbinate fenestration (n = ). objective assessment of olfactory function using the university of pennsylvania smell identification test (upsit) and subjective assessment of symptom using visual analogue score (vas) were performed before and months after surgery. results: there were significant improvement comparing postoperative and preoperative upsit in both group ( . ± . vs . ± . , p = . ) and group ( . ± . vs . ± . , p = . ). the vas were also significantly improved postoperatively compared to preoperatively in both group ( . ± . vs . ± . , p = . ) and group ( . ± . vs . ± . , p = . ). patients undergoing partial middle turbinectomy and middle turbinate fenestration were more likely to show improvements in upsit ( . ± . vs . ± . , p = . ) and vas ( . ± . vs . ± . , p = . ) compared to those with only partial middle turbinectomy. conclusion: partial middle turbinectomy and middle turbinate fenestration during ess is an effective method for improving postoperative olfactory function. | nasal irrigation for the alleviation of nasal symptoms in pregnant women with allergic rhinitis we sought to determine specific ige responses to bacterial pathogens in sera from cystic fibrosis patients and analyze their kinetic during disease course. genes, respectively. in contrast, most of healthy donors had normal homozygous genotype with tt- . ± . %(n = ) and cc- . ± . %(n = ) with low frequency of mutations; gg- . ± . %(n = ) and tt- . ± . %(n = ) and heterozygous genotype tg- . ± . %(n = ) and ct- . ± . %(n = ) for il- and il- genes, respectively. following a month treatment, there was a significant reduction of cytokine levels in the il - . ± . and increased in the il - . ± . , when compared to the beginning of therapy and after months (p < . ) results: at baseline the st group had serum levels of il- ( . ± . ) pg/l; il- ( . ± . ) pg/l and ifn-γ ( . ± . ) pg/ l; nd group had il- ( . ± . ) pg/l; il- ( . ± . ) pg/l and ifn-γ ( . ± . ) pg/l vs il- ( . ± . ) pg/l; il- ( . ± . ) pg/l; ifn-γ ( . ± . ) pg/l in the control group. after months, there was a significant decrease in pro-inflammatory cytokine levels in the st (il- : ± . ; ifn-γ: . ± . ) pg/l and nd group (il- : . ± . ; ifn-γ: . ± ) pg/l, respectively. conversely, il- increased in st and nd groups to . ± . pg/l and . ± . pg/l (p < . ). conclusion: prior to the study initiation patients with tuberculosis had higher il- , ifn-γ and lower il- content than healthy controls. two-month chemotherapy produced significant reduction in proinflammatory cytokines and increase in anti-inflammatory il- , with levels approaching those of healthy controls. thus, tuberculosis drugs appear to have the anti-inflammatory effect in tuberculosis patients, which was predictive of positive clinical outcome. | antibiotic resistance: ligands of innate immunity take the challenge in this work, we aimed to perform an ex vivo hrsv infection in precision-cut lung slices (pcls) from human, rhesus, and cynomolgus macaques, comparing whenever possible the response with the viral surrogate poly i:c. method: pcls containing airways were prepared from lung sections of human, rhesus, and cynomolgus macaques. the slices were inoculated with hrsv-a iu/ml, uv-inactivated hrsv, or vehicle control for hours. macaque slices were also incubated with poly i:c μg/ml with and without the immunosuppressive dexamethasone μg/ml. viral replication, tissue viability, and immune response assays were assessed in supernatants, lysates, or slices. the inoculum infectivity of iu/ml as well the uv-inactivation were confirmed by plaque-assay on hep- cells. immunofluorescence staining using a fitc-labeled anti-rsv showed the presence of infected macrophages in pcls, but not in mock infected samples. hrsv stimulation slightly decreased tissue viability, as seen by live/dead staining and ldh assay. the viral infection increased ip- production in pcls of human, rhesus, and cynomolgus macaques, reaching respectively . , . , and . fold-increase in comparison to the vehicle controls. poly i:c stimulation caused ip- response comparable to hrsv in rhesus and cynomolgus pcls. the ip- production ratio comparing hrsv/poly i:c was . in rhesus and . in cynomolgus pcls. conclusion: hrsv infects ex vivo pcls of human and non-human primates, inducing the release of the pro-inflammatory chemokine ip- . this response is comparable to the viral surrogate poly i:c. in the future, these systems can be used to further investigate host response to hrsv, especially in the context of asthma development. however, a relatively small number of reports are related to the association of ebv with allergic diseases, in particular atopic ones. we found that among patients with activated ebv infection, polysensitization was found to be . times more frequent, chest syndrome was . times more common and hyper-ige syndrome occurred . times more frequently. in most of these patients, atopy was not detected in medical history. method: we evaluated the laboratory test results of five boys ( . %) and six girls ( . %), children ( with hbov and with cov). their average age at the study time was . ± months. nasal swab specimens were taken from these patients who admitted to our hospital with respiratory symptoms between - . patients are recalled after an average of ± . months. isaac questionnaire and skin prick test to common inhalated allergens were performed. results: only one patient had family history of atopy. forty percent of the patients with cov and % of the patients with hbov developed rhinitis. one patient with cov and one patient with hbov developed recurrent wheezing. one patient with cov developed atopic dermatitis. all skin prick tests were negative. it was noteworthy that . % of the patients were passive smokers. conclusion: hbov and cov may be associated with rhinitis but there is a need for more patient groups for a clear result. rna_lig (ccg-agg-aug-cga-ggc-uug-uu) . to study chemotaxis in vitro, a boyden chamber was used -wellfiltrationplatemultiscreentm -mic with a pore size of μm (millipore, usa). chemotaxis was studied in dynamics after , minutes and a day using the above ligands. as control, rpmi- medium without glutamine was used (paneco, russia). the statistical analysis was carried out using the computer statistical program biostat conclusion: with all the data provided, a drug induced hypersensitivity was diagnosed. we present a case of immediate allergic reaction with eosinophilia due to carbapenems, with tolerance to other beta-lactams antibiotics. written informed consent of patient has been obtained in the two cases. discussion: the first case shows cutaneous immediate hypersensitivity response to infbeta a. literature reports a few cases of urticaria and anaphylaxis but this is the first for the pegylated formulation. polyethylene glycol (peg) confers to a drug modified pharmacokinetics, solubility and immunogenicity. immediate reaction to peg (macrogol) have been described when combinated in vaccines or drug pils. dmf is a known cause of contact dermatitis related to footwear, wallets and furniture. flushig is a reported side effect of dms in ms managed with dose reduction. this case shows the possibility to immediate sensitization to dmf. as the armamentarium to treat ms now combines immunomodulatory and biologic drugs, the avaliability of diagnostic and desensitization protocols for hypersensitivity reactions must be keeped in mind. case report: drug rash with eosinophilia and systemic symptoms (dress) syndrome is an uncommon but serious hypersensitivity drug reaction, manifested with rash, fever, lymphadenopathy and visceral organ involvement. table) . drug withdrawal and prednisolone treatment leaded to attenuating of mentioned skin symptoms within days, associated by occurrence of a exfoliative dermatitis. one week after admission, the patient developed fever that lasted for days with enlarged lymph nodes on submandibular, paracervical, axillar and inguinal regions. a preventive antibiotic therapy is started and weeks later, the lymph nodes were not palpable and the skin got the normal appearance. corticoid therapy is reduced gradually according to symptoms resolvement. case : a -year old woman presented to our department with a -day history of pruritic, macular rash, periorbital swelling, cheilitis and fever. she had started some weeks ago the allopurinol for asymptomatic hyperuricemia, had longer history for treatment of arterial hypertension and type- diabetes mellitus (olmersartan, nitrendipine, methyldopa, furosemide, regular and glargine insulin), and experienced nephrectomy and cholecystectomy. the patient was febrile, while blood tests revealed eosinophilia, increased seric creatinine/urea levels (due to nefrectomy), and severely-altered liver parameters (see table) . the allopurinol withdrawal, topical and systemic corticoid therapy, and the liver protectors attenuated serologic transaminases levels and patient's skin lesions within few days, followed by substantial improvement of laboratory findings one week after therapy start. the treatment dosage was gradually tapered and finally stopped within a period of months in accordance with attenuating and complete resolvement of the clinical and laboratory abnormalities. our case demonstrated that dress syndrome is a severe drug reaction, but the immediate introduction of treatment and supportive measures can improve disease's outcome even after a temporary exacerbation or severe affection of internal organs. case report: a -years-old woman, diagnosed of ischemic cardiopathy, developed an anaphylactic shock minutes after the administration of ml sulphur hexafluoride intravenous during an echocardiogram. she was treated in emergency room with a total recovery. months earlier, she had developed an extensive erythematous-maculopapular rash converging in plaques in relation with adhesive dressings which had been placed during a hospitalization due to thoracic pain. an allergic contact dermatitis was suspected and recommendations thereon were given. interestingly, an arteriogram with iodixanol (icm) was carried out one week before skin reaction with good immediate tolerance. methods: blood test: blood count and serum chemistry were done during both reactions to contrast media. serum tryptase level was not measured during the anaphylaxis, but its baseline level was quantified later. conclusions: we present a patient with a double sensitization to parenteral contrast media: an anaphylactic shock due to sulphur hexafluoride and an atypical delayed exanthema related to iodixanol, and diagnose was obtained with st in both cases. this is the first documented case with a positive immediate st to sulphur hexafluoride. with the culprit drugs mixed with % and % petrolatum resulted negative. patient was suspected to have behcet's disease, and consulted to rheumatology department. oral colchicum dispert twice a day was prescribed. afterwards, patient achieved to take oral amoxicillin-clavulanate for a week without any hypersensitivity; and has been following by oral colchicum dispert maintenance therapy since then. the reported patient had one anaphylactic perioperative reaction to morphine and another anaphylactic reaction to tramadol during her diagnostic investigation. remain the question if this patient had two allergic anaphylactic reactions with cross-reaction between morphine and tramadol, or two non-allergic anaphylaxis due to "hypersensitive" mast cells. case presentation: a -year-old female was diagnosed with rectal adenocarcinoma. one year after radical surgery, progression with pulmonary metastasis was shown. in first line of systemic therapy she received premedication with pantoprazole, metoclopramide, clemastine and dexamethasone, followed by cetuximab infusion. during first minutes of infusion, grade anaphylactic reaction occurred. a reaction started with generalized pruritus, urticaria, rhinitis, followed by hypotension, bradycardia and loss of consciousness. she was treated with fluids, clemastine and methylprednisolone. next day she received same premedication followed by panitumumab. during first minutes she had grade reaction with generalized urticaria. the third day she had generalized urticaria minutes after metoclopramide application. skin prick tests with cetuximab ( mg/ml) were negative, but intradermal test were posi- bat response was highly positive for both cetuximab and alpha-gal, with comparable values and dose response curves. thus, we showed %, %, %, % and % of cd positive basophils for stimulation with cetuximab ( - . μg/ml), and %, %, %, and % for stimulation with alpha-gal ( . - . ng/ml). bat response to panitumumab was negative (< %; - . μg/ml). drug provocation with panitumumab was negative and patient received treatment with panitumumab. in the operating theatre, the skin is disinfected using povidoneiodine and pupil dilation is carried out with tropicamide (showing no immediate reaction in the surgery). method: as we are dealing with a late cutaneous reaction, the study of the medicine involved is carried out by means of epicutaneous medicine testing. in order to do the study of aflibercept, we wore gowns, two sets of gloves, a mask, eye protection and in a containment hood in the outpatients hospital. the patient diagnosed himself with dermatitis when in contact with povidone-iodine and despite the fact that the cutaneous provocation was negative, it is known that when there is surgery involved, there needs to be moistness and occlusion for it to show up clinically. the application of this antiseptic seems to lose its irritation and allergic properties when it dries on the skin and therefore tends to give a negative result in these patients, but this does not mean that they are not allergic to this antiseptic. we report the case of a year old man who experienced erythema and pruritus immediately after an intravenous injection of ranitidine and hyoscine butylbromide given for gastric pain treatment. results: spt and idt were performed for ranitidine ( mg/ml and . mg/ml respectively) and hyoscine butylbromide ( . mg/ml and . mg/ml respectively) being exclusively positive for ranitidine at idt dose with a × mm papule (histamine control × mm). oral provocation test for hyoscine butylbromide was negative. bat for ranitidine and famotidine were carried out, being negative for both drugs. conclusion: skin tests for h ra are the best option when studying a suspected reaction to h ra and are also useful for assessing cross-reactivity between other h ra. the sensitivity for bat in diagnosis of drug allergy is about %, and the specificity up to %, although these percentages make reference to the common drugs studied (beta-lactams, quinolones, pyrazolones, etc). specific studies for h ra are still to be done. in our case we had a negative result for the bat test, although we proved ranitidine was responsible for the reaction. conclusion: gentamicin is an aminoglycoside antibiotic used systemically for septicemia and as prophylaxis during surgery. immediate type allergy (type i) to gentamicin is rarely reported. since , approximately only five cases have been reported in literature. in our case, initial theories were pointed towards cefazolin as beta-lactams report a higher rate of allergic reactions. after an exhaustive allergological study, results disproved our initial theory indicating gentamicin as the responsible drug. giangrande n ; bobadilla-gonzález p ; garcía-menaya jm ; cámara-hijón c allergy department, infanta cristina university hospital, badajoz, spain; clinical immunology department, san pedro de alcántara hospital, cáceres, spain background: polyethylene glycol (otherwise known as macrogol or peg) is a polymer with a wide application as an excipient, solvent and dispersing agent in food, cosmetic and pharmaceutical industry. it presents distinct length polymer chains with a molecular weight from to g/mol conferring them specific properties. macroglol with a molecular mass between and g/mol is commonly used as osmotic laxative previously to colon endoscopy and radiologic examinations. after the introduction, anaphylactic reactions to macroglol are rarely reported, considering it safe and well tolerated. we report on a -year-old man who, immediately after of the topical application of benzindamine in left inferior limb developed acute urticaria in this limb, which reverted in approximately hours with systemic steroids. she had previously tolerated this product without any problems. skin prick-tests with benzindamine ( . mg/ml) and latex were realized in the patient. skin prick-tests with benzindamine were realized in eleven healthy control subjects. results: skin prick-test with latex was negative in the patient. skin prick-test with benzindamine was positive in the patient ( × mm). the prick-tests with benzindamine were negative in eleven healthy control subjects. we report on a case of contact urticaria due to benzindamine and triggered by an immediate, probably ige-mediated, hypersensitivity mechanism. some of the drug used in daily clinical practice can cause allergic contact urticaria and should therefore be borne in mind. background: the use of new oral anticoagulants which act as direct inhibitors of activated factor x is constantly increasing, due to lower rates of serious and fatal bleeding events than warfarin/acenocoumarol. rivaroxaban, the first commercialized drug in this group, is the most used for prevention of thromboembolic events. however, < cases of hypersensitivity reactions have been described so far, most of them delayed and severe. to present a case of delayed hypersensitivity to rivaroxaban, diagnosed by a positive ltt (lymphoblastic transformation test). a year old woman with hypertension and chronic atrial fibrillation (af) was referred to our clinic for suspected drug allergy. she reported that months before, for af she was started on oral amiodarone and rivaroxaban, presenting on the seventh day with both of them generalized erythema, pruritus, micropapular rash and facial angioedema. no oral or other mucosal were observed, neither pustules, vesicles or blisters. blood eosinophilia, enlarged lymph nodes, renal and hepatic injury were discarded in emergency, where the new drugs were discontinued and replaced by acenocoumarol. the rash subsided one week later, with oral antihistamines. before and after the episode the patient also has been taking losartan and hydrosalurethyl, with good tolerance. she denied other adverse reactions. in allergy department we performed skin prick tests and intradermal tests with amiodarone ( . mg/ml and . mg/ml) and rivaroxaban ( . mg/ml and mg/ml), and a ltt with both drugs, months after the reaction. background: patients with history of beta lactam allergy, often self-reported, are commonly encountered in the hospital setting. this frequently leads to increase use of broad spectrum and more expensive antibiotics that may be unnecessary or even less efficacious at times due to fear and concerns about potential disastrous outcomes. nonetheless, with increasing awareness, many patients are now being referred to allergy service for formal evaluation. we aim to look at patients who underwent evaluation for beta-lactam hypersensitivity and determine the number of patients that were successfully de-labelled. method: a retrospective analysis was conducted with patients referred for evaluation of questionable beta-lactam allergy to the allergy service in our institution from the years - . initial evaluation process included a thorough history to determine the type of hypersensitivity reaction and suitability for further testing. patients underwent skin prick test (spt) and intradermal (idt) with either (a) both major and minor determinants of penicillin, benzyl penicillin, amoxicillin and ampicillin, and/or (b) the culprit drug itself. if skin testing was negative, oral or intravenous (iv) drug challenge was then performed after informed consent. clinical details and reactions were documented. patients were also contacted post challenge to ensure no delayed reaction had occurred. results: a total of patients were evaluated for beta-lactam allergy in the year period, of these were females and were males. of the referred patients had presumed penicillin group allergy and had cephalosporin group allergy ( patients had both penicillin group+cephalosporin allergy). cases ( %) were successfully de-labelled. beta-lactam allergy was confirmed in patients ( %); identified by positive spt in two patients, positive idt in six patients and positive drug challenge in patients ( patients developed rash/urticaria, had respiratory symptom and patients developed anaphylaxis). patients were referred before any drug allergy labelling was done, out of which were confirmed not to have beta-lactam allergy. conclusion: in our study, % of patients were confirmed not to have true beta-lactam allergy. we were able to successfully remove beta-lactam allergy label from the electronic record for % of the patients. results: a total of % referred amoxicillin-clavulanic acid (ax-clv) as trigger for the hypersensitivity reactions (hrs), followed by ax ( %), penicillin ( %) and cephalosporins ( %). almost % of hrs were immediate (< minutes). positivity of skin tests was observed in % subjects, of bat in % and of rast in %. in conclusion: the label of penicillin allergy is quite often erroneous. this involves using of more expensive and less effective therapeutic alternatives, which also facilitate the emergence of multi-resistant micro-organisms. hence the importance of confirming the diagnosis of allergy. finally, we did not find differences in the study of penicillin allergy in patients older than years compared with the general population. background: severe cutaneous delayed drug reactions (toxic epidermal necrolysis -ten-, stevens-johnson syndrome -sjs-, acute generalized exanthematous pustulosis -agepand drug reaction with eosinophilia and systemic symptoms/drug-induced hypersensitivity syndrome -dress/dihs-) among others, are a rare but potentially fatal complications of drug treatment. although its epidemiology has been described in different latitudes, it is unknown in latin america. our aim was to describe the epidemiological characteristics of severe cutaneous reactions to drugs in countries of latin america. method: an online questionnaire was designed to report new and old cases (since ). it was a modified and adapted version of enda questionnaire for drug allergy interesting group. sociodemographic data, type of reaction (ten, sjs, dress-dihs, agep), culprit drug (s), treatment, complications, mortality and sequelae, were described. three centers from colombia, one from argentina, one from brazil and one from paraguay were included. an excel database was created, in which cases were recorded and analyzed. results: thirty seven cases were reported. ( %) were women. the median age was years. ( %) had dress/dihs, ( %) ten, ( %) sjs, ( %) agep, ( %) other not classified scars, and ( . %) overlapping ten/sjs. the main culprit drugs were aromatic anticonvulsants in cases ( %), beta lactam antibiotics in ( %), non-beta lactam antibiotics in ( %) and allopurinol in ( . %). in % of the patients the suspect drug was withdrawn. thirty one patients ( . %) received systemic corticosteroids. complications occurred in cases ( %) and death in one patient ( . %). seven patients ( %) had some type of sequelae. countries, dress/dihs was the most frequently reported clinical entity, and the anticonvulsants were the main triggers. complications were frequent, but mortality was low. | drug-induced cough: analysis of nationwide spontaneous reports in korea over ten years using who-adverse reaction terminology (who-art) indicative of cough. results: from cases of spontaneously reported adverse drug event cases, a total of cases ( . %) were identified as drug-induced cough. most cases occurred in adults ( . % of the subjects) and females were more common than males ( . % vs . %). regarding severity, only cases ( . %) were classified as serious based on who criteria. the most common causative drug category was antineoplastic and immunomodulating agents ( . %), followed by cardiovascular drugs ( . %). the most common causative drugs were ace inhibitors including perindopril and ramipril. conclusion: in the nationwide spontaneous reports of adverse drug events, many cases of drug-induced cough have been reported so far. much attention is needed to find new causative drugs of cough in the future. background: allergological assessment to determine the mechanism of the perioperative reaction and to identify the agent responsible and recommendation of a range of drugs or agents likely for future surgery is essential, but it often poses a significant challenge. in this study, we analyze our experience in the investigation of adverse reactions during anesthesia in the last years. method: a total of patients who attended our allergy unit with suspected perioperative reactions between january and december were reviewed retrospectively. the severity of the perioperative allergic reactions was graded according to ring and messmer system. results: grade iii, ii and i reactions were observed in , and patients, respectively. in patient we didn't know the reaction suffered. tryptase measurements were available for patients. of those, and patients had elevated and normal levels respectively and suffered grade reaction. ige mediated reactions was diagnosed in patients ( %): for ßlactam antibiotics ( . %), for patent blue ( . %), for neuromuscular blocking agents-nmbas ( . %), for latex ( . %), for colloids ( . %) and for ranitidine ( . %) . cefazolin was the ß-lactam antibiotics causing the largest number of reactions. non-ige-mediated reactions was diagnosed in patients ( %). the allergy tests were negative and tryptase levels were normal. conclusion: in our series, among the patients who suffered allergy reactions during anaesthesia and the cause was subsequently identified, ß-lactam antibiotics were the most common causative agent ( . %), followed by patent blue ( . %), nmbas, latex, colloids and ranitidine ( . % each agent). in contrast, data from other authors indicated that nmbas were the most common cause of anaphylaxis, followed by latex, hypnotics, antibiotics, plasma substitutes and opioids. these differences might be due to the small size of our study, which was limited to our centre over the last years and thus may not be representative. diagnostic evaluation. all patients signed an informed consent. we made a retrospective analysis of their clinical records and excluded patients whose records were missing or incomplete. it was analyzed each patient's medical history (focusing allergic disease) and clinical reaction to the suspect drugs. signals/symptoms at pcc were characterized. we also studied the variation of the dpt's results when it was performed after a pcc. aim: to define and quantify the ongoing pharmacy needs in sustaining a large drug allergy assessment program. method: a retrospective review of pharmacy files was used to identify and quantify the drugs and dosages most frequently used and to determine prescription trends within the allergy testing program over the last years. results: initially, this reaction was thought to be a result of a drug allergy, but upon further review and the onset of fever, we determined that it met the diagnostic criteria of jhr. his twin brother was diagnosed with penicillin and betalactamic allergy. neutrophilia % was to be underlined in the blood test. after this, drug oral challenge with penicillin was performed, ruling out penicillin allergy. conclusion: it is not uncommon to confuse drug allergy with jhr. jhr should be an anticipated reaction to early doses of antibiotic treatment for treponemal diseases, such as syphilis. antibiotic treatment should be continued; it is not a warrant to stop treatment. clinicians should be aware and anticipate jhr as a potential complication to early doses of antibiotic for spirochetal diseases such as syphilis or lyme, leptospirosis. the patient was unresponsive in oral drug provocation tests with amoxicillin-clavulanic acid, clarithromycin and trimethoprim sulfamethoxazole for months. the patient could use these drugs. results: chronic abacterial inflammation of the prostate gland was accompanied by a significant increase in concentration of slpi, il- , tnf-α, il- in the seminal plasma and serum concentration, and a decrease in the concentration of il- and tgf-β compared to healthy men (p < . ). there was no statistically significant difference between slpi, il- , tnf-α, il- , il- , and tgf-β in the ejaculate of patients with inflammatory and non-inflammatory forms of cap (p < . ). the concentration of il- in ejaculate of patients with inflammatory forms of cap was significantly greater than in patients with non-inflammatory form of cap (p = . ). the inflammatory and non-inflammatory forms of cap are pathologically similar with changes in the concentration of the studied cytokines except for il- in both forms with signs of inflammation. the terms "leukocytic" vs "non-leukocytic" chronic abacterial prostatitis are more correct than "inflammatory" and "non-inflammatory" when describing chronic abacterial prostatitis. results: the status of all patients after dc immunotherapy was evaluated as satisfactory. heart rate, blood pressure in patients remained within the age norm. skin had normal color without rash or peripheral edema. there were no local or systemic allergic reactions. the body temperature after the injection did not exceed °c. conclusion: these results show, for the first time, that among mastocytosis patients, besides the already known periodontal disease risk factors that include diabetes, age, osteoporosis and alcohol consumption, the bone marrow mast cell burden is also associated with increased periodontal disease severity. results: metformin at relatively low doses ( - μm) was shown to mildly suppress ige-mediated responses, including degranulation ( % reduction, p = . ), tnf-α ( % reduction, p = . ) and il- ( % reduction, p = . ) secretions in bmmcs. importantly, metformin at the same doses potently inhibited mast cell responses in all parameters ( % reduction, p < . for degranulation; % reduction, p < . for tnf-α; % reduction, p < . for il- ) in mast cells treated with an ahr ligand, , -dihydroindolo[ , -b]carbazole- -carbaldehyde (ficz). mechanistically, its inhibitory effect was mediated through the suppression of ficz-induced mapk activation, intracellular calcium release and ros generation. metformin also blocked ahr-mediated pca in vivo ( % reduction, p < . ). conclusion: metformin, a common anti-diabetic agent, was shown to exert inhibitory effect on ahr-mediated mast cell activation in vitro and in vivo, suggesting its potential utility as a newer form of therapy for asthma and allergic diseases; this is particularly relevant when considering the adverse effect of the exposure to environmental polycyclic aromatic hydrocarbons. gasser p ; brigger d ; zbären n ; jardetzky t ; pennington l ; eggel a results: in one of affected family members, we were able to identify the c. a>g mutation in the plasminogen (plg) gene that was recently described to be associated with hereditary angioedema. this mutation leads to a missense mutation with an amino acid exchange p.lys glu in the rd kringle domain of plasminogen. there is no direct relationship between the earlier described cases with this mutation and the family we report here. in all affected members of the family, the symptoms manifested in early adulthood, with swelling of the face, the tongue and the larynx. the frequency of attacks was variable, between once in a year to once in a month. in one of the three family members, we found a slightly decreased level of coagulation factor xii and of plasminogen. icatibant proved to be very effective for the treatment of acute attacks in the affected family. the occurrence of the same c. a>g (p.lys glu) mutation in the plg gene in many families with no or only unknown distant relationship suggests that the disease might have been inherited through the generations without being purged from the population. the mutated amino acid exchange appears to be significant for the function of plasmin or plasminogen. we found a decrease in plasma levels of coagulation factor xii and plasminogen, which may be beneficial markers for diagnosis and monitoring of this disease. several biomarkers are useful in the diagnosis (fibrin degradation products (fdps), d dimer (dd), and fragments of prothrombin + ). also, a correlation between the levels of biomarkers and activity phases of the disease has been detected. alterations in coagulation parameters have an etiopathogenic role in the ae attack, but have not been considered as biomarkers of activity phases. tgt is a global coagulation test which quantifies in vitro the ability of plasma to generate thrombin and estimates alterations in coagulation parameters. the objective is to assess the usefulness of the thrombin generation test (tgt) to characterize patients with hereditary angioedema (hae). method: seventeen hae patients from hospital la fe were recruited to obtain blood samples in remission and during ae attacks. none of them experienced thromboembolic events. plasma was collected in citrate tubes to obtain platelet rich plasma. hemostatic parameters were analyzed:. tgt was conducted using a calibrated automated thrombogram (cat) method and a fluoroskan ascent as a reader. results were analyzed via thrombinoscope v . citrated plasma was incubated with calcium, tissue factor, phospholipids and a fluorogenic substrate. a thrombin generation curve is generated, obtaining parameters: latency time (lagtime), thrombin generation maximum speed (vo), maximum peak of thrombin generated (peak), time to generate the maximum peak of thrombin (ttpeak), total quantity of generated thrombin (etp), and the end time of thrombin generation (starttail). tgt parameters from healthy donors were used as controls. results: thirty-eight samples were collected from seventeen hae patients ( . % female). fifteen ( . %) samples were collected during ae attacks. tgt parameters and fdps were significantly higher in hae patients compared with controls (p < . ), although no significant differences were found in tgt between acute attacks and remission. a decrease trend in tgt is observed in ae attacks. fdps were increased during ae attacks, but normalized at remission periods. these results support the involvement of coagulation in the pathophysiology of hae, although no increase in prevalence of thrombosis is observed during acute attacks. method: the repeated measures design study included patients in two groups: the slit group, patients- follow-ups per allergen (p), and the vit group, patients- p. the slit group had patients treated for hdm ( p), and patients on pre-coseasonal pollen ait (grass p, ragweed p, birch p). the vit group had patients on rush protocol ( for bee and for wasp) and patients on conventional protocol ( bee, wasp, and for both). the ige and igg levels were measured by the immunocap method. the friedman test was used to compare data. results: when compared to placebo group, slit+vitamin d group therapy was more effective in the reduction of nasal symptoms (p = . ), asthma symptoms (p = . ) and combined symptommedication score (p = . ); there was no significant difference between groups in medication and ocular scores. we observed a significant improvement of fev (vitamin d group p = . , placebo group p = . ) and fev %vc levels (vitamin d group p = . , placebo group p < . ), within both groups, between visits. feno results did not differentiate statistically significantly the study participants in terms of receiving slit along with vitamin d or placebo. significant increase in the percentage of cd + cd + foxp + and in tlr positive cells in children receiving slit+ vitamin d was observed compared to placebo group. increase in cd + cd + fox-p + induction, and in tlr positive cells recruitment were independently associated with better clinical effect of slit in children. conclusion: overall, ait with a high-polymerized ash pollen extract was well tolerated. as ash pollen are supposed to be an important allergen during spring time, it is recommended to include spt and npt with ash pollen in the test panel for allergological diagnostic. additionally, determination of ash pollen specific ige could be applied. furthermore, appropriate ait should be considered for ash pollen allergic patients. a | impact of sublingual immunotherapy with a five-grass pollen tablet on grass pollen allergic rhinitis and asthma: a real-life, long-term analysis in france background: data on the fulfilment of prescriptions of symptomatic medications in patients with grass pollen allergy were analysed to evaluate the long-term effectiveness of sublingual immunotherapy (slit) on allergic rhinitis (ar) and asthma. method: by using data in the lifelink ™ treatment dynamics database (iqvia, paris, france), we compared two cohorts of patients with ar: a group treated with oralair® (stallergenes greer, antony, france) slit tablets (n = ), and a matched control group having received symptomatic medications only (n = ). oralair®'s effectiveness was assessed as the change in symptomatic medication fulfilments between the pre-index period (before the initiation of slit) and the follow-up period (after slit), and as the onset of asthma or the progression of pre-existing asthma (based on fulfilments of prescriptions for asthma medication). the number of fulfilments per year was calculated for each patient and each period. results: in line with prescribing guidelines, the mean duration of treatment with oralair® was . months per season for either seasons or seasons. the mean number of symptomatic medications for ar fulfilled per patient and per year in the pre-index period was . ± . in the slit tablet group and . ± . in the control group. in the follow-up period, this value fell for the slit tablet group (to . ± . ) but did not change significantly in the control group ( . ± . ). when considering individuals not taking any asthma medications in the pre-index period, asthma onset during the treatment period was observed in . % of those in the slit tablet group and in . % of those in the control group. the corresponding values for the follow-up period were . % in the slit tablet group and . % in the control group. when considering individuals already taking asthma medications in the pre-index period, the mean ± sd number of asthma medication fulfilments in the pre-index period was lower in the slit tablet group ( . ± . ) than in the control group ( . ± . ). the corresponding values for the treatment period were . ± . and . ± . , respectively. in the follow-up period, the number of asthma medication fulfilments fell more in the slit tablet group (to . ± . ) than in the control group ( . ± . ). oralair® tablets have long-term effectiveness by relieving allergic rhinitis and slowing a progression to asthma. b | a real-life, retrospective analysis evidencing slower long-term progression of asthma in grass pollen allergy patients treated with sublingual immunotherapy tablets | an examination of the reasons for treatment discontinuation and non-compliance to allergen immunotherapy background: allergic rhinitis (ar) patients treated with subcutaneous immunotherapy (scit) and sublingual immunotherapy (slit) may be non-compliant or discontinue treatment too early, which can negatively impact efficacy. therefore, understanding the reasons for non-compliance and treatment discontinuation is vital to help improve compliance, persistence and thus outcomes. this study reported reasons for treatment discontinuation to scit and slit and non-compliance to slit in patients with ar in published real-world studies. method: a literature review was conducted in embase, medline, ebm reviews, psycinfo and econlit ( - ) using key search terms for allergic rhinitis, scit, slit, non-compliance and non-persistence. across all studies,~ % of patients were non-compliant, and -year drop-out rates ranged from % to %. reasons for noncompliance and treatment discontinuation in this subset of patients were stratified according to the who dimensions for adherence (patient-related, treatment-related, or socio-economic). results: from the publications identified, six studies reported reasons for non-compliance to slit (n = ) or treatment discontinuation (n = ) to scit or slit, and the results were grouped for analysis. the majority of patients cited treatment-related factors as the primary reason for discontinuation ( % for slit, % for scit). common reasons were a length of treatment for slit and frequency of injections for scit. % of patients discontinued scit due to patient-related factors such as travel to doctors and waiting time for administration. only % of slit patients discontinued due to patient-related factors. socio-economic reasons for discontinuation were low for both therapies ( % slit and % scit). conversely, for non-compliance to slit, socio-economic factors were the most frequently cited reasons ( %), and included taking time off work and financial concerns. conclusion: of patients who discontinued therapy, treatmentrelated factors were the most cited reasons for scit and slit, reflecting concerns with administration and treatment length. noncompliant slit patients cited socio-economic factors as common reasons for non-compliance, suggesting financial concerns over a long treatment course. differences in reasons for non-compliance and treatment discontinuation may be due to patients assigning differing importance for compliance (a day-to-day decision) compared to the long-term decision to discontinue treatment. results: % of patients had monosensitization to rbet v component. the rest % had combinations ige to rbet v and ige to one, two or even three minor allergens ( %, %, % accordingly). after courses of slit by standardized pollen extracts symptoms of arc and pfas decreased in % and % patients accordingly. in group patients with monosensitization to rbet v : patients had a reduction of arc ( % had - degree by ado); patients had reduction of pfas. patients hadn't finished treatment due to allergic reactions. among patients with sensitization to rbet v /v : patients had a reduction of arc ( % - to degree by ado); had reduction of pfas. patient hadn't finished treatment due to allergic reactions. in patients with sensitization to rbet v /v : patients had a reduction of arc ( % - to degree by ado); had reduction of pfas. patients with sensitization to rbet v /v /v showed the similar results: patients had a reduction of arc ( % - to degree by ado); had reduction of pfas. patients had sensitization to all cra, and only patient who also received slit with grass allergens had reduction of arc only ( degree by ado). as the result of the study it was identified that beneficial effect of slit is highest in patients with monosensitization to rbet v . the increase of sige sensitization profiles to minor birch allergens caused less efficacy of slit treatment. dermatophagoides pteronyssinus immunotherapy is independent of sensitization to blomia tropicalis among children with allergic rhinitis and asthma method: children ( - years old) with allergic rhinitis and asthma sensitised to both dp and bt received years dp-scit. clinical symptom and medication scores, serum specific ige and specific igg were evaluated during dp-scit. in order to investigate whether the treatment outcome was dependent on the sensitisation pattern between dp and bt, patients were further grouped into dp and bt co-sensitisation and cross-reaction, according to positive or negative ige against bt major allergen (btma) blo t and blo t . btma+ group, with specific ige to either blo t or blo t , was defined as the co-sensitized group; btma-group, with no detectable ige to both blo t and blo t , was defined as the cross-reactive group in this study. results: all the recruited patients completed year of dp-scit, ( %) patients completed years of treatment. after years of dp-scit, compared to baseline, all patients had significant reduction in symptom and medication scores. lung function (fev ) was significantly improved as well. % of the patients were free of medication use and asthma symptoms, % of them were free of rhinitis symptom, and the fev % in all patients were higher than % of predicted. dp-scit induced significant increases in dp and bt specific igg . in % of patients, dp specific igg increased more than fold and bt specific igg increased more than . fold. further investigation in btma groups showed moderate correlation (spearman r = . , p = . ) between specific ige against dp and bt in the btma-group (n = ), indicating specific ige cross-reactivity. no specific ige correlation (spearman r = . , p = . ) was found in the btma+ group (n = ) indicating co-sensitisation to both dp and bt. the two groups showed almost identical change in clinical responses. dp and bt specific igg significantly increased during dp-scit, no difference was found between the two btma groups. conclusion: dp-scit can induce specific igg cross-reacting with bt allergens. patients with specific ige sensitisations to both dp and bt may have clinical benefit from dp-scit treatment. moreover, the clinical benefit of scit was independent of ige cross-reactivity or co-sensitisation to dp and bt. method: we investigated allergic rhinitis children who were basically sensitized to house dust mite and received house dust mite slit for year and months. among patients, patients were mono-sensitized to house dust mite (group ) and patients were poly-sensitized aside from house dust mite (group ). we also assigned another allergic rhinitis children who were only treated by medication as control group. nasal symptoms (rhinorrhea, sneezing, nasal obstruction, nasal itching, sleep disturbance) and anti-allergic medications use were assessed at every -month visit. results: the symptoms of allergic rhinitis started to improve after months of slit and significantly improved after a year and a half in group and group compared with control group. there was no significant difference between group and group . anti-allergic medication use in group and group significantly decreased after a year and a half compared with control group and there was no significant difference between group and group . conclusion: house dust mite slit was more effective than treatment only by medication. the effect of house dust mite slit was similar between mono-sensitized and poly-sensitized allergic rhinitis children. house dust mite slit could also be recommended to polysensitized allergic rhinitis children. method: a prospective, randomized, double-blind, controlled, multicenter phase ii study was conducted with four different concentrations of cluster allergoid clustoid wiesenlieschgras (group : tu/ml; group : tu/ml; group : tu/ml; group : tu/ml). out of patients screened, grass pollen allergic patients ( - years) were randomized. the cluster build-up phase was followed by four monthly maintenance injections of . ml. the efficacy was evaluated by the change of the threshold concentration step needed to induce a positive reaction in a titrated nasal provocation test (tnpt) before start and after end of the study (pre-post analysis). the safety profile was assessed for each treatment group by analyzing treatment-related adverse events. background: allergen immunotherapy relies on the consistent administration of allergen extract, therefore compliance to these treatments (subcutaneous immunotherapy (scit) and sublingual immunotherapy (slit) tablets and drops) is vital for efficacy. as scit is administered as an injection by a healthcare professional, and slit is self-administered, compliance to scit may be perceived as superior. therefore, a review of real-world studies investigating compliance to scit, slit-tablets or slit-drops was conducted. real-world studies, instead of clinical trials, were included in this review as they are more likely to reflect actual clinical practice and patient compliance. method: a literature review was conducted in embase, medline, ebm reviews, psycinfo and econlit ( - ) using key search terms for ar, scit, slit-tablets and slit-drops, and real-world compliance. compliance was reported according to ispor medication compliance and persistence work group definitions. results: from the publications identified, eight studies (seven slit [one slit-tablets, two slit-drops, four unspecified], one both scit+slit-tablets) reported compliance rates and were included in the analysis. real-world compliance rates ranged from % to % for slit administration and % for scit administration. only one study compared compliance of slit to scit, with similar rates reported over three years ( % and % respectively). three studies reported "good" compliance (physician-reported or patients consuming > % of allergen extract) to slit-drops or slit-tablets. the good compliance rates were higher for slit-drops ( %- %) compared to slit-tablets ( %- %). observed compliance to slit-drops or slittablets did not vary by country or geographical region. the percentage of patients defined as having "good" compliance to slit-tablets or slit-drops did not vary by study length or patient population. conclusion: whilst compliance to scit may be perceived as superior to slit-tablets and slit-drops, comparable compliance rates between scit, slit-tables and slit-drops were identified across real-world studies. differences between perception and real-world results may be explained by a lack of direct comparisons between scit and slit administration. limitations included discrepancies in definitions of compliance, as well as methodology between studies. however, these are common to reviews analysing compliance, regardless of therapy area. conclusion: in the allergic rhinitis patients, successful compliance for -year slit compared with control was approximately %. method: igg inhibition elisa: rabbit igg antibodies specific for grass allergen allergoids are pre-incubated with different concentrations of alum-adsorbed grass pollen allergoid. the mix is added to an allergoid coated microtiter plate. unbound igg will bind to the allergoid coat and is subsequently incubated with anti-igg hrp labeled conjugate and stained with tmb. results are expressed as percentage inhibition relative to the uninhibited value. the concentration of alum-adsorbed allergoid that is required to inhibit % igg is used as read-out. circular dichroism: far-uv cd spectra ( - nm) were recorded on a j- spectropolarimeter. a cuvette with a stirring compartment was used to keep the suspension homogeneous during measurement. results: the igg inhibition elisa assay is specific for grass pollen allergoids (not for other allergen allergoids), has a good inter-and intra-assay precision and is robust for assay variation. thermally stressed alum-adsorbed grass pollen allergoids were used to show that the igg inhibition assay can be used as a stability indicating method. severe thermal stressing resulted in a higher % inhibition value, indicating a loss of igg epitopes. furthermore, far-uv cd analyses showed that there is a close relation between the decreasing igg binding capacity ( % inhibition values) and the loss secondary protein structures by unfolding (cd-ratio / nm values). the igg inhibition assay was demonstrated to be a valuable method to determine the stability of alum-adsorbed grass pollen allergoid preparations. in addition, a relation was shown between the igg binding capacity and the change in secondary protein structures. | design of a pivotal phase iii trial of allergen specific immunotherapy (ait) using a high-dose house dust mite (hdm) allergoid in patients with allergic bronchial asthma method: male and female outpatients (age - years) asthmatics allergic to hdm are enrolled. during the baseline phase, the patient's minimal dose of ics required to achieve asthma control will be assessed. after the baseline period, approx. patients will receive double-blind placebo-controlled treatment for approx. months, followed by a nd period of weeks to assess the minimal ics dose and further months of observation for the assessment of asthma exacerbation. based on the results of the dose finding study regarding the efficacy endpoints and the safety profile, the optimal allergoid dose is considered to be pnu. results: competent authorities and ethic committees in all participating eu countries, serbia, russia and ukraine approved the study design. the primary endpoint of the trial is the change in predefined dose steps of the minimal daily ics dose required to achieve asthma control after approximately months of subcutaneous ait. all efficacy data will be determined using daily questionnaires and the acq by e-diary for months from october to january. the aim of this clinical trial is to demonstrate efficacy and to evaluate safety of ait with an allergoid preparation of major allergens of dermatophagoides pteronyssinus in patients suffering from allergic bronchial asthma caused by house dust mites. asthma increases the burden of allergic disease and health care costs, especially when uncontrolled. with the development of a high-dose preparation we intend to treat asthmatic patients highly efficiently. romantowski j; jassem e; lata j; wasilewska e; chelminska m; specjalski k; niedoszytko m background: specific immunotherapy (sit) is the only causal treatment in patients allergic to airborne allergens. it has been proven to be widely effective in allergic populations, but individual patients vary in terms of response to the therapy. the aim of the study was to assess the factors that might affect the efficacy of sit. method: patients treated with sit for grass pollen or house dust mites were included. the efficacy of sit was assessed with the use of allergy control score (acs), performed before and at least after one year of sit. the following variables were assessed as potential risk factors for a poorer response to sit: age, gender, type of allergy, type of allergen, type of vaccine, type of sit and smoking history. background: specific immunotherapy (sit) is a suitable treatment option for asthma and allergic rhinitis (ar), but it is not commonly used in korea. in the achievement of the treatment, it is important that immunotherapy is applied with ideal dose and regular intervals and it is essential for the patient compliance. the aim of this study is to investigate evaluate compliance with immunotherapy protocols of patients who were treated with sit in clinic and their satisfaction of the treatment. we performed a multicenter, cross-sectional survey using a specially designed questionnaire that was given to allergy specialists and patient in korea. a member of the trained research group conducted face-to-face questionnaire interviews with each respondent. conclusion: this study shows that most patients are ar with asthma. in our study sit compliance and satisfy are found to be high in both groups. aim: to identify the frequency of regress claims in a dermatological setting and to assess its impact on general prescription behaviour and immunotherapy. method: all physicians of the psoriasis-praxisnetz süd-west e.v. (n = ) were invited to participate in a web based questionnaire study on the topics of dermatology and medical law. the survey was separated into two sub-polls which were carried out after a first poll deciding whether the topic of medical law is of any interest for the dermatological practice. the topic of interest was located in the second poll. results: overall, dermatologists participated in this study. most participants were form bavaria, baden-wuerttemberg or rhineland-palatinate and had more than years of experience as a dermatologist. out of the participating physicians . % (n = ) already experienced a previous regress claim. of these, . % (n = ) stated, that the experienced regress claim changed their prescription behaviour. half of these participants (n = ) further stated, that the fear of a possible recourse affects their prescription behaviour, whereas only out of the other participants declared a possible influence. missing values excluded, this leads to a substantial hesitation in physicians who experienced a prior recourse ( . % vs . %). nevertheless, this seems not to affect the usage of allergen immunotherapy, as all physicians who already experienced a regress claim, stated to use allergen immunotherapy. the fear of a possible regress can change physicians' prescription behaviour but does not seem to have an effect on the prescription of allergen immunotherapy. therefore, the topic should be addressed from another perspective such as providing trainings on relevant regulations for physicians who experienced a prior recourse claim. this approach could also improve patient centred care related to modern treatments. results: the sds were significantly reduced in patients subjected to slit (p < . ) year after the onset it. vas also was significantly reduced (p < . ) with satisfied control of sar and the same time with translation from moderate-severe to mild-moderate sar, after slit. nbh was also significantly reduced (p < . ) year after the onset slit. in patients receiving pht only, sds, vas and severity of sar did not change and significantly higher (p < . ) from the value obtained in the experimental group. nbh also remained unchanged and significantly higher (p < . ) then in experimental group. precoseasonal slit added to pht shows short-term beneficial clinical effects in polysensitized patients with sar and scuad phenotype. results: ten studies ( children, adults; median sample size, ) met the inclusion criteria. the risk of bias was moderate to high in all but one studies. low strength evidence supports the assumption that ait is effective in reducing symptoms and medication use, with only out of studies reporting higher benefit in the ait group vs comparator group. subgroup analyses of studies sharing similar characteristics did not explain inconsistency. safety does not appear was not major concern for alternaria ait. conclusion: this is not enough strength of evidence to suggest that mold ait is efficacious for the treatment of respiratory allergies. high-quality studies with an adequate sample size are needed. abstracts | | tolerability of a two week rush updosing with modified trees, modified grasses or modified grasses/trees mixture in pollen allergic subjects in the day-to-day practice table) severe systemic reactions (grade iii and iv) did not occur. conclusion: rush immunotherapy is an effective therapeutic method for patients with allergic rhinitis. it seems that in cases requiring faster response to treatment, this immunotherapy can be considered as a substitute for conventional immunotherapy. | design of a pivotal phase iii allergen immunotherapy study to assess the efficacy and safety of subcutaneously administered tyrosine adsorbed modified birch allergen+mpl results: the design of this study, including sample size and primary and secondary endpoints, will be discussed based on prior experience gained in two dose finding studies. in addition, the number of patients screened and randomized will be presented by country, gender and/or age and screen failures will be categorized. results: the primary analysis showed an absolute difference in tcs between placebo and du of . ( %, p < . ). the odds of experiencing a severe day during the bps were approximately doubled in the placebo group compared to the du group (or = . , p < . ) and the odds of experiencing a mild day were halved (or = . , p < . ). similar results were seen for the tree pollen season (tps), covering both alder, hazel and birch pollen seasons. the total rqlq score was improved for du compared to placebo during the bps and tps (p < . , except for the last week of the tps), with the most pronounced effects during week - of the bps (absolute difference: . - . , p < . ). treatment was well tolerated. the most frequent adverse reactions were mild or moderate local reactions related to the sublingual administration. no deaths were reported and no serious adverse events were assessed as related to the sq tree slit-tablet. conclusion: treatment with the sq tree slit-tablet improved arc symptoms and need for symptomatic treatment. the du group had less "severe days" and more "mild days" during the pollen seasons. the quality of life was similarly improved. these findings substantiate the clinical relevance of the sq tree slit-tablet for patients with arc induced by pollen from the birch homologous group. nagaraju k ; nagaraju k ; katare s ; kapatkar v ; shah a ; rathod r results: total n = subjects (mean age . ± . years, . % males) completed entire study. the mean incidence of artis reduced from . ± . episodes at baseline to . ± . (p < . ), with . % subjects not suffering from any episode. the mean duration of episodes reduced from . ± . to . ± . days (p < . ). % of episodes (vs % at baseline, p < . ) required antibiotics for mean duration of . ± . days (vs. . ± . days, p < . ). none of arti episodes in follow-up period required hospitalization as against . % episodes, (mean duration ± . days; p < . ) before pidotimod therapy. the number of school days lost & work days lost showed reduction of . ± . days(p < . ) & . ± . days(p = . ) respectively. the average expenses incurred in treatment of artis shows significant reduction of rs. ± (p < . ). adverse events were reported in ( %) subjects, which were mild in nature. a statistically significant increase in absolute counts of t-& nk cells was seen in explorative assessment of immune markers. the study shows pidotimod to be well-tolerated effective therapy in reducing the incidence and severity of recurrent artis, thereby providing additional benefit of reduction in discomfort & healthcare cost due to recurrent artis. thus, pidotimod can be considered as potential therapeutic option for treatment of recurrent artis in children. martignago i ; ridolo e ; incorvaia c department of medicine and surgery, university of parma, parma, italy; cardiac/pulmonary rehabilitation, asst pini/cto, milan, italy background: two registered sublingual immunotherapy (slit) products are available to treat grass-pollen induced rhinoconjunctivitis, consisting of the -grass (phleum pratense) and the -grass pollen tablets. no study of direct comparison of the efficacy of the two products was performed. we report the case of a patient who was treated in different years with the -grass or the -grass tablets with contrasting efficacy. the patient was a -year old woman suffering from years of grass pollen induced rhinoconjunctivitis. in slit was started with the -grass pollen tablets, but in , due to unavailability of the product, slit was performed by the -grass pollen tablets. in the third year of treatment slit with the -grass pollen tablets was resumed. for the -grass tablets slit was initiated before the pollen season and stopped after months of treatment, while for the -grass tablets the treated was prescribed to be continuous. the efficacy of slit was evaluated by symptom-medication scores as reported in diary cards by the patient during the month of may, when the grass pollen usually reach the higher concentration in the atmosphere in lombardy, where the patient lives. results: the mean symptom-medication score in the first year of treatment ( -grass tablets) was . , compared with a mean score of . in the second year ( -grass tablets). the patient was unsatisfied of the symptoms control and asked to resume for the last year of slit the -grass tablets. the mean symptom-medication score in such year was . . no clinically relevant adverse event was reported with any slit product. conclusion: based on the momentary unavailability of the -grass pollen tablet, it was possible to assess in a same patient the clinical outcome associated to either of the two registered slit products. a significantly different efficacy of slit with the -grass tablets compared with the -grass tablets was observed. | fusion proteins consisting of bet v and phl p form ige-reactive aggregates with reduced allergenic activity najafi n ; hofer g ; gattinger p ; smiljkovic d ; blatt k ; selb r ; stoecklinger a ; keller w ; valent p ; niederberger v ; thalhamer j ; valenta r ; flicker s background: bet v and phl p representing major allergens in birch and grass pollen, occur as monomeric proteins with high allergenic activity as assessed by clinical provocation testing in patients. she did not suffer more hymenoptera stings after the last reaction. one bee sting several years before bst resulted in no reaction. she has no symptoms with honey, vegetable or other food ingestion. methods: total ige and specific ige were determined using inmu-nocap system (thermofisher, scientific inc). apis, vespula and polistes (hørsholm, denmark) were also performed. prick tests showed negative results for all extracts tested. intradermal skin tests were positive for apis at μg/ml, but negative for vespula and polistes. our patient was diagnosed of anaphylaxis due to apis venom, thus bst was contraindicated and an epinephrine autoinjector was prescribed. she rejected hymenoptera venom immunotherapy. conclusion: to our knowledge, this is the first case of anaphylactic reaction after bee sting therapy. bee sting therapy should be considered a risk factor for anaphylaxis. patient reported good control of their disease, improved their quality of life, tolerating contact and exposure to numerous horses as well as contact with clothes of people who had been exposed. although ita is absolute contraindication on uncontrolled asthma with a degree of evidence ia, our case had only "transitory" con- and immunocap among wasp allergen components-i , i , i were %; . , %; . and %; . respectively and honey bee allergen components-i , i , i were %; . , %; . and %; . respectively. agreement between polycheck and immuno-cap i and i allergen components were %; . and %; . respectively. agreement between polycheck and euroline i and i allergen component were %; . and %; . respectively. based on wasp and bee components in all three systems, sensitization pattern was analyzed. similar test results were found between euroline and immunocap systems. the comparative studies carried out showed a markedly higher compliance of results with the euroline tests compared to polycheck with the immunocap system. percent agreement was extremely high and kappa value was substantial or almost perfect in the case of bee venom allergy between euroline results: a total of patients were included; ( %) males, with a mean age of (± ) years; ( %) beekeepers, ( %) were atopic, ( %) had asthma, ( %) rhinitis and ( %) cardiovascular disease, and of these patients were on ace/beta blockers. vit with honeybee was proposed in ( %), wasp ( %) and polistes ( %). the mean duration of vit was (± ) months. however, completed less than months. of the total, patients ( %) were not treated with vit. eighty-eight patients ( %) participated in the telephone interview: completed vit ( %), were still on vit ( %) and did not undergo vit ( %). of those who completed vit, ( %) were restung and went to the emergency department (er). twenty-four patients ( %) were stung while still on vit. of those never on vit, ( %) were re-stung and went to er. the severity of the reactions according to mueller of the patients who completed vit (mean follow-up time was months ( - months)) and were stung again was: local reaction in ( %), grade i in ( %); grade iii in ( %). one had a toxic reaction after multiple stings. in those who were stung during vit, ( %) had local reactions, ( %) grade i and ( %) grade iii. of those who were not treated and were re-stung: ( %) had grade i, ( %) grade iii and ( %) grade iv. in this series, the patients who did not undergo vit presented a greater number of systemic reactions when re-stung as well as more severe reactions (p < . ). conclusion: in this group with indication for vit, the reactions of the re-stings were less severe in the patients who had completed or who were on venom immunotherapy, as expected. three quarters of those who did not undergo treatment had severe anaphylactic reactions when they were stung again. this study reinforces the importance and the efficacy of immunotherapy in the treatment of hymenoptera venom allergy. method: this is a retrospective, descriptive study of cases diag- method: data were issued from the reference centre in mastocytosis of toulouse university hospital. ms diagnosis was determined using world health organization diagnostic criteria. hymenoptera venom immunotherapy was performed with an ultra-rush protocol (table) . results: seven patients were included ( women, men), median age years old. during the anaphylactic reaction, cutaneous signs missed in all cases. the reaction was most often severe: grade (n = ), grade (n = ), grade (n = ). three patients suffered from digestive symptoms and one from respiratory manifestations. basal tryptase in serum reached . - . μg/l. hymenoptera venom specific ige were low ( . - . kui/l) except for one patient ( . kui/l). ait was initiated with vespula venom in patients, polistis in patient, apis mellifera and vespula in patient, vespula and polistis in patients. no reaction was observed during ait. four restringing accidents led to increase the cumulative dose to μg and μg in patients. in these patients, the diagnosis of mastocytosis was made due to the resting. conclusion: hymenoptera venom ait using ultra-rush protocol seems well tolerated in patients with systemic mastocytosis. specific studies are necessary to determine the real tolerance profile of this protocol. collaboration with reference centres for mastocytosis should be considered for all patients with mastocytosis associated to hymenoptera venom allergy. dose (μg/ml) results: see table. conclusion: there is a shift or immunomodulation in terms of sige to vespids. even in patients double sensitised who were receiving venom of only one of the vespids. albanesi m background: slit has been suggested as an alternative route for allergen-specific immunotherapy. aim of this study was to investigate allergen-specific antibody responses in birch pollen allergic children who had received slit for two years using recombinant allergens. method: children (n = ; - y o) with respiratory symptoms of birch pollen and oral allergic syndromes (oas) were studied. ten children received slit with staloral, were treated by slit with microgen, and children received only symptomatic therapy (control group). sige and sigg levels to rbet v , rbet v , rbet v were measured twice (before therapy started and after two years) using quantitative immunocap and a panel of more than microarrayed allergens using immunocap isac technology. clinical efficacy of slit was evaluated by recording symptoms upon allergen contact and need of rescue medication. results: all children were sensitized to the major birch pollen allergen, bet v and one patient from each of the groups showed to bet v , no patient had sige to bet v . after two years of slit clinical improvement was observed in the slit patients. in the staloral group there were no respiratory symptoms in patients and a decrease of symptom severity in the other cases as well as a partial or complete tolerance to pr allergen-containing food in the patients. microgen treatment had no influence on oas symptoms but decreased of pollinosis severity in children. however, there were no statistically significant differences of bet v -specific levels measured before and after treatment in the slit and control groups (mann-whitney, p > . ). in this real-life study we found that birch allergic children who had been treated with slit showed a reduction of clinical symptoms but we did not find a significant induction of allergen-specific igg levels in the slit-treated group when compared with children who had only symptomatic treatment. conclusion: our study confirms the scarcity of food additives allergy. it also suggests that even when the diagnostic of allergy was excluded with a negative oral food challenge, families remain suspicious about industrials feeding products containing food additives. these results should reassure health professionals and parents who incriminate too frequently food dyes and conservators when a manifestation which mimics allergic reactions occurs. background: autumn/winter birth has been reported to be a risk factor of food allergy (fa) development. a putative mechanism is that dry/cold weather causes and exacerbates infant atopic dermatitis (ad), which is a major risk factor for food sensitization through inflamed/damaged skin. we investigated prevalence of fa among infants under well skin care in relation with seasons of birth (sob). we recruited full-term newborn infants without perinatal diseases at an obstetric/pediatric clinic. participants were followed up for skin status and food allergy symptoms until months of age. sob were defined as spring (march-may), summer (june-august), autumn (september-november) and winter (december-february). ad was diagnosed based on the united kingdom working party's criteria. use of moisturizer (mo) and topical corticosteroids (tcs) was recorded. primary outcome was fa based on apparent immediate allergic reaction after ingestion of causative food. we classified infants who avoided any food because of sensitization or mother's anxiety as suspected fa. results: six hundred and thirty-one infants were screened for month-period and infants were enrolled in this study. of them, infants were born in spring-summer (s-born) and infants were born in autumn-winter (w-born). fa developed in ( . %) infants and ( . %) infants had suspected fa. there was no difference (p = . ) in prevalence of fa and suspected fa between s-born and w-born. multivariate analysis revealed ad at and months of age was a significant risk factor for fa with or= . ( %: . - . ) and or= . ( % ci: . - . ), respectively. prevalence of ad at months of age was higher in w-born than s-born but prevalence promptly decreased thereafter and stayed low with early use of mo and tcs. prevalence of ad was rather higher at months in s-born than w-born. results: cases and controls were included. the median age was years, (q -q - ). men and women were almost equally represented ( . % males). alcohol consumption associated with the intake of mammalian meat or innards as the trigger factor. the overall prevalence of a positive result of sige to α-gal was abstracts | . % ic % ( . , . ); cases _ . % ic % ( . , . ) controls _ . % ic % ( . , . )_. among cases sige anti α-gal positivity rate ranged from . % (rural), to . % (half-urban) and . % (urban). the rates of positivity were . %, (northern) . % (center) and % (mediterranean). a positive result of sige to α-gal was more frequently observed among men ( . %) than women ( . %) and associated with history of tick bites, practice of outdoor activities, pet's ownership and the antecedent of having eaten mammalian meats or innards previously to the development of symptoms background: a special challenge in the st century for allergists is allergy to food, which is considered "the second wave" of epidemics of allergic diseases. panallergens occur in unrelated organisms and perform a similar function in them. in their structure, they have highly conserved amino acid sequence regions and a similar three-dimensional structure, and thus meet the requirements for cross-recognition by ige. results: in patients ( %) isac test has been shown to have specific ige for panallergen components. mostly, the presence of ige for pr- proteins has been shown in patients. in patients ige to ltp; patients ige to ccd; patients to profilin; patients to tropomyosin; patients to serum albumin, person to tlp. an important aspect is undoubtedly the occurrence of simultaneous sensitization to several panallergens. analysis of data from the study group showed that isolated sensitization to one panallergen concerned only pr proteins ( patients), tropomyosin ( patients) and profilin ( patient). in the remaining patients, the analysis of the isac test results showed that two or more panallergens were allergic. in the study group, asige for the component responsible for the occurrence of real food allergy was detected in ( %) patients. mostly, the presence of ige for jug r has been shown in patients. in the study group, panallergens were more likely to be responsible for food intolerance than specific food allergens. results: of children, children had peanut allergy only, children had tree nut allergy only, and children had both. the mean age was . ± . years in peanut allergy, . ± . years in tree nut allergy, and . ± . years in both. male to female ratio was significantly higher in tree nut allergy ( . %) than peanut allergy ( . %). among tree nut allergens identified, walnut ( . %) was most frequent, followed by almond ( . %), hazelnut ( . %), pine nut ( . %), chestnut ( . %), cashew ( . %), pistachio ( . %), and macadamia ( . %). mean serum total ige level was kua/l in tree nut allergy and kua/l in peanut allergy. mean serum specific ige level to peanut, walnut, almond, hazelnut, and pine nut was . , . , . , . , . , and . kua/l, respectively. children with peanut allergy had higher rate of co-sensitization with soybean and higher soybean-specific ige levels than children with tree nut allergy. however, there was no difference in co-sensitization rate with tree pollen between peanut and tree nut allergy. children with peanut allergy showed significantly increased co-sensitization rate with egg white and wheat compared to children with tree nut allergy. a . % of the children with peanut allergy and . % of tree nut allergy showed co-sensitization with aeroallergens. a total of % of the children with peanut allergy showed decreased specific ige levels within - years. conclusion: prevalence of peanut and tree nut allergy is similar. tree nut allergy develops later than peanut allergy and more common in male. children with peanut allergy showed higher co-sensitization rate with soybean, egg white and wheat compared to children with tree nut allergy. | natural history of egg allergy in a large cohort of infants with food allergy shows its high prevalence but also its transient nature in a months of follow-up background: the cohort of infants ( boys, girls, - months) with the food allergy has been followed for months. as more than % of infants manifested atopic dermatitis (ad), a condition closely linked to egg sensitisation, we focused our attention on egg allergy, following its natural history as well as a development of atopic march. method: the diagnosis of food allergy was based on a personal history, clinical examination, skin prick tests and/or atopy patch tests with native foods. laboratory tests were performed within year of age the latest. the specific ige levels against food allergens were measured using immunocap or immulite. patients with ad were scored according to scorad system. the oral food challenges (ofcs) with cooked/baked egg were done in children at the age of months except for children at risk of anaphylaxis. results: within the whole cohort the allergy to cow milk proteins was confirmed in pts ( . %), to egg in pts ( . %), to wheat in pts( %), to lentil in pts ( . %) to banana in pts ( . %), to soya in pts ( . %) and to potatoes in pt ( . %). in a cohort of egg allergy patients we found out that: % of pts presented the early onset of allergy-up to months of age, % of pts presented severe ad (scorad > ), % of pts showed cosensitisation to peanuts, % of pts had early sensitisation to inhaled allergens, and majority % of pts presented with early onset allergic rhinitis and/or asthma. we proved that egg allergy is closely linked with the early onset of allergy symptoms, with severe forms of ad, co-sensitization to peanuts, early sensitisation to inhaled allergens and an early onset of allergic rhinitis and/or asthma. we also proved that the egg allergy in infancy is transient. the tolerance to baked/cooked egg was achieved in about % of pts at the age of years, unlike previously published results claiming the reach of tolerance in % of pts at the age of years. in these patients we studied: sex, personal history, type of reaction they presented, time of onset of symptoms and food involved. results: out of a total of patients over years of age (from to years old) who have been attended the consultation for the first time during these period, patients ( . %) ask about possible allergic food allergies. of these patients who came for possible allergic pathology, patients ( %) presented positive results. these are the other item we have studied: . sex of patients: % of the patients are women. these patients because of that, it is important to remember that food allergy can also appear in old people. the food that is mainly involved in our population is fish and seafood. a much higher percentage than in other populations, probably due to the mediterranean diet of spain. the symptoms mainly involved are itching and skin lesion, which is the characteristic symptom of a mild allergic reaction. in our population, there was patients with a anaphylactic shock, a much higher percentage than in other studies. the experience with this group of patients is still limited. more studies are needed to know better this patient profile. background: cow's milk allergy (cma) is the first atopic disease in children. diagnosis suspicion in the emergency room (er) is increasingly frequent, however, further assessment by an allergist is often difficult to schedule. therefore, screening for cma through a blood test (specific ige) while the infant is still in the er has gained momentum in recent years. we set out to analyse (a) symptoms which had led the emergency physician to prescribe specific ige, (b) the prevalence of confirmed cma among infants screened in the er, and (c) the long-term outcome of the screened infants. method: a retrospective study of medical records and laboratory results was performed. patients were infants under months, without a previous diagnosis of cma, attending one of the two pediatric er of the university hospitals of marseille, france. allergy blood tests were specific ige to cow's milk extract (immuno-cap, thermofisher, sweden). in infants with specific ige to cow's milk extract of . kua/l or higher, ige directed to the main three individual proteins (casein, alpha lactalbumin et beta lactoglobulin) were also measured. results: infants were included from december to june . the sex ratio was . . % of infants were atopic et % were currently or had been breastfed. the most prevalent symptoms were vomiting and reflux. one third of infants were hospitalized after the er visit. following the er visit, % of infants attended a specialized consultation with an allergist. % of infants with a follow-up visit were diagnosed with an ige mediated cma. infants with cma developed further food allergies (egg, nuts, cashew…). it is difficult to diagnose it. the emergency pediatrician are increasingly confronted to infant with symptoms evoking cma. thus they prescribe sige and extensively hydrolysed proteins because they know that ige-positive infants can be ige-negative during the interval between the er visit and the follow-up one. after bad results interpretation of blood assay after er visit, cma was probably over diagnosed without prick test for ige positive allergy and no eviction/ reintroduction test for non ige. the lack of allergist is probably leading to over prescription of blood assay in er to diagnose cma and prolonged eviction of milk. results: a total of patients were included ( % female) aged from to yo with an average . ± years. % of patients had history of atopic disease: % rhinitis, % asthma, % prior food allergy, % eczema, % drug allergy, % eosinophilic esophagitis (ee) and % chronic urticaria. mean serum total ige was . ui/ml. sensitization to aeroallergens was present in % of patients, the most common were dust mites ( . %), pollen ( . %) or both ( %). in ( %) patients, first symptoms of fa appeared ≥ yo, with an average age of ± . yo. in this group, were diagnosed with ee, with eosinophilic colitis and with eosinophilic gastritis. from the remaining patients, had history of reaction with more than food group (fg). cutaneous reactions were referred in % of patients followed by anaphylaxis ( %) and gastrointestinal symptoms ( %). the fg most commonly implied were: fresh fruits (n = ), seafood (n = ) and tree nuts (n = ). fa diagnosis was confirmed in % of patients, the remaining had negative ofc. in ( %) patients, their symptoms started under yo, with an average age of . ± yo. from this group, ( %) were diagnosed ee. from the remaining patients, cutaneous complaints were the most frequent ( %) followed by gastrointestinal ( %) and respiratory symptoms ( %). the most common fg implied were: fresh fruits(n = ), seafood(n = ) and tree nuts(n = ). only one anaphylaxis was referred. fa was confirmed in %, the remaining had negative ofc. in patients with history of anaphylaxis of had positive st and/ or sige; one had negative sp and sige, with ofc positive. the blood donors were classified based on their clinical symptoms related to possible as contact via fish intake: allergic to as ( %), chronic urticaria ( . %), unspecific dyspepsia ( . %) and asymptomatic ( . %). the prevalence of sensitization (anti-as ige > . kua/l) were . % (ic: . - . %; mean . kua/l; median . kua/l) with a maximum value of . kua/l. raw fish consumption was the only variable associated with statistical significance (p < . ) to as sensitization ( . % vs . %, respectively). albacore and codfish were the most consumed species associated to seropositive results ( %), followed by hake ( %). coastal population ( . % vs . %), non-previously frozen fish consumption ( . % vs . %) and > times per week fish consumption ( . %) were other seropositive associated factors. background: oral allergy syndrome (oas) is an ige-mediated allergy caused by raw fruits and vegetables in patients with pollen allergy, which is known as the most common food allergy in adults. however, there has been no nation-wide study on oral allergy syndrome in korea. the aim of this study is to investigate the prevalence and clinical manifestations of oas in korea. method: twenty two investigators from hospitals and private clinics participated in this study. the patients with allergic rhinoconjunctivitis and/or bronchial asthma with pollen allergy were enrolled to the survey. the questionnaires include demographics, a list of fruits and vegetables, and clinical manifestations of food allergy. pollen allergies were diagnosed by positive results of one or more pollen allergens including birch, alder, hazel, beech, oak, willow, poplar, bermuda, meadow, orchard, rye, timothy, mugwort, ragweed, hop japanese on allergy skin prick tests (allergen/histamine ratio ≥ +) and/or serum specific ige levels using multiple allergen simultaneous tests (mast ≥ +) or immunocap (≥ . ku/l). conclusion: this is the first nation-wide study for oas in korea. the prevalence of oas in korea was . %, in which substantial proportion had anaphylaxis. these results will provide useful information for clinicians to apply in clinical practice. we conducted a self-administered, questionnaire-based survey in - during the -month checkup. children were considered to have food allergies if they were diagnosed by a physician or if they had been instructed to avoid a causative food after medical examination by interview. we divided the year into three periods. the months of march-june were considered spring, july-october as summer/fall, and november-february as winter. while the season of onset for the boys occurred in . %, . %, and . % in spring, summer/fall, and winter, respectively, it was . %, . %, and . %, respectively, for the girls. thus, the onset rate was the highest in winter for both genders. in boys whose mothers did not consume folic acid (fol − ), the food allergy onset rate was significantly higher for boys whose mothers ate no eggs and for boys whose mothers ate - eggs per week than for those whose mothers ate eggs daily according to the dunnet multiple comparison test. however, no relationship was observed with egg intake if the mother had consumed folic acid (fol + ). on the basis of seasons, fol − and egg intake by mothers affected only children born in winter, with a significant difference in the dunnet multiple comparison. among mothers who did not eat eggs, fol + was . % and fol − was . %; for mothers who ate - eggs per week, fol + was . % and fol − was . %; and for mothers who ate eggs every day, fol + was . % and folwas . %. thus, consumption of folic acid seemingly annulated the effects of eating eggs. however, for girls, neither folic acid nor eating eggs had any effect on the onset rate. conclusion: since this effect varied according to the birth season, consumption of folic acid, a methyl group donor, appeared to affect the allergy onset in children. results: skin prick test with commercial extracts of tuna ( mm), cod ( mm), rooster ( mm), hake ( mm), salmon ( mm), trout ( mm) and anisakis ( mm ige to shrimp, lobster, crab and mixed seafood were all undetectable. dermatophagoides pteronyssinus , to assess for tropomyosins was negative. outcome: the patient continues to react to both hdm and shrimp, despite undetectable ige levels to tropomyosin associated components. this is the only testing available in south africa currently and hence we are unable to look at other proteins. the relationship between tropomyosins in shellfish allergy and mite allergy has been well documented and investigated, but other allergens are now also being implicated in cross-reactions. we also established the level of ige specific to allergen components using the immunocap isac method. allergen-specific ige was not elevated to any shrimp allergens available in immunocap isac: n pen m (tropomyosin), n pen m (arginine kinase) and n pen m (calcium binding sarcoplasmic protein). the patient was diagnosed with a shrimp allergy. the molecular diagnostics used did not explain which allergen component is the patient allergic to. it is possible that the patient is allergic to hemocyanin, which can also cross-react with house dust mite allergens, but confirmation of this diagnosis requires further investi- results: the groups were identical in terms of the age and sex (table ) . ara h ige correlated (spearman test) with the cumulative protein dose (threshold dose) r = − . (p = . ) but not with reaction severity r = . (p = . ), or the use of adrenaline r = . (p = . ). patients with ara h ige < ku/l had higher threshold doses ( vs mg) than children whose ara h ige was ≥ ku/l (p = . ). there were no significant differences in severity of the reaction or in use of adrenaline (table ) . the level of ara h ige is relevant in predicting the threshold dose at peanut exposure. a low reaction threshold dose increases the risk of reaction at an accidental exposure leading potentially to a severe reaction. flaxseed allergy is uncommon and most of the cases reported involved anaphylaxis. cross reactivity has been described with other seeds. case report: a -year-old atopic girl diagnosed with egg allergy and rhinoconjunctivitis and asthma due to pollens. when she was eight, she presented two reactions consisting of conjunctival, periorbicular, malar erythema and abdominal pain after eating egg free french toasts cooked with flaxseed. she was treated with oral antihistamines. the allergic workup included prick-by-prick test with flaxseed which was positive and skin prick tests with mites, molds, cockroach, cat, dog, profilin, ltp and pollens with positive results for olive and grass pollens. the serum total immunoglobulin (ig) e was u/l, and specific ige to flaxseed was . kua/l. the flaxseed extract was resolved with sodium dodecyl sulfate polyacrylamide gel electrophoresis (sds-page) and an ige immunoblotting was performed under nonreducing conditions. the patient's serum showed specific recognition of a -kda band in the immunoblot. proteins were identified using mass spectrometry (maldi-tof) that showed results highly consistent with conlinin, a s storage protein of flaxseed. we described for the first time a patient with allergy to flaxseed due to conlinin, a s storage protein of flaxseed. background: cyperus esculentus is an herbaceous plant that has edible tubers called tiger nuts. in spain, they are used mainly in the elaboration of the well-known "horchata" or tiger nut milk, which is obtained by macerating tiger nuts with water and sugar. tiger nut allergy has rarely been reported, despite of its widespread consumption. case report: we present the case of a -year-old male with a history of oral syndrome allergy with several fruits (peach, melon, banana, kiwi, apple, pear and plum) and seasonal allergic rhinoconjunctivitis due to grass pollen. he reported oral pruritus, vomiting and cutaneous itching in both arms and hands immediately after drinking tiger nut milk. he became asymptomatic without treatment after - hours. the allergic workup included skin prick tests with profilin, ltp, latex and fruits that were positive to melon and watermelon and negative to profilin, ltp, latex and the rest of the fruits. prick-by-prick tests with melon, banana, kiwi, apple, pear, tiger nut and tiger nut milk were positive. the serum total immunoglobulin (ig) e was . μg/l, and specific ige was negative to profilin, ltp, bet v and all the tested fruits. background: specific blood ige tests for food allergens are mainly used to confirm a suspect food allergy than to diagnose such an allergy. this is due to the low positive predictive value and the high negative predictive value they have. nevertheless, they are very helpful when they are interpreted in the context of medical history by an experienced allergist. we analyzed the prevalence of sige in children with suspected food allergies. we retrospectively analyzed the all the consecutive laboratory tests of sige for food allergens during the two-year period ( ) ( ) ( ) . tests were of children diagnosed or suspected to have food allergies. a quantitative immunoblot assay was used to measure the circulated different sige. t-test, wilcoxon signed rank test, and chi-square were used to make comparisons. results: fifty-six ( . %) men and ( . %) females, . + . years old with a maximum of years and a minimum of months old were part of children whose tests were analyzed. one-third of the tests ( . %) reveals more than one sige present and . % of the tests resulted negative for the sige for the allergens tested (table) . only ( . %) children have very high concentrations (> iu/ml) of egg whites sige, and ( . %) have egg yolk sige. concentrations of . % of sige positive cases were . - . iu/ml. in our study more than half of the children suspected of food allergies resulted negative for sige for most common food allergens. seventy-nine percent of the positive cases had relatively low sige. only a few positive cases have higher sige than iu/ml. our data support the recommendation that sige couldn't be decisive in food allergic diagnosis, but they may help if they are interpreted cautiously. method: seven patients with a mean age of . years and female to male ratio of: : , with a background history of hypertension treated with an acei presented with oro-pharyngeal irritation (itch, tingling), face and tongue angioedema and laryngeal constriction, on ingesting fresh fruits (cherries, apples, plums, peaches, apricots, strawberries, grapes), vegetables (parsnips) and/or nuts (peanuts, hazelnuts). two patients required admission to emergency department and three received adrenaline auto-injector. six out of seven patients underwent skin prick testing to common aeroallergens and the index foods. in five cases, immunocap/isac testing was undertaken. in one case the diagnosis was based on the history and in one other case it was based on history and skin prick tests. results: a diagnosis of pfas was confirmed in all patients through the clinical history, spt and/or specific ige serology to the offending food confirming predominant sensitisation pr- allergens. primary food allergy and spontaneous angioedema was excluded in all patients. in the cohort studied, the pfas symptoms were unusually severe. we therefore postulate that this was secondary to concurrent use of acei. the management of these patients to sensitization to a β-casein with high homology between only the first milks. more precisely, the allergen candidate could be γcasein, which is derived from β-casein by proteolysis, whose abundance increases during cheese production from fresh milk, and which is absent in cow's milk. a lactoglobulin specific to buffalo's milk may also be responsible. in case of ewe's and goat's milk allergy without cow's milk allergy, sensitization to buffalo's milk should systemically be seeked out. we recommend inclusion of all mammalian milks in the list of the mandatory allergens for declaration on food products. method: prick tests with fruit battery, ltp and profilin was made. analytical with blood count, immunoglobulins, triptasa, total ige and specific ige to banana, apple and orange. finally, open oral provocation with fruits was performed. the diagnostic key was given by the mother of the patient who attended consultations because the infant had erythema in the temporary zone after drinking sea water on the beach. associated with salivation, the patient presented erythema in the malar area lasting a few seconds many times. the prick tests with fruits, ltp and profilin were negative. hemogram: eosinophils/μl, total ig e: . iu/ml, specific ige to fruits were negative. triptase: . μg/l. method: here we describe a variety of cases of nsltp allergy presenting to a tertiary allergy centre in the north west of england. results: nsltps have been found to be major allergens in various foods and they are likely to produce severe and systemic allergic reactions. this is reflected in the cases we present here. these proteins are highly cross-reactive due to extensive sequence homology and are panallergens. nsltps are remarkably heat stable and retains its allergenicity in processed foods. it is assumed that nsltps may sensitise both by inhalation and ingestion. an intriguing aspect in nsltp hypersensitivity is the extreme variability of its clinical expression. co-factors are often needed for the clinical expression of nsltp hypersensitivity. conclusion: patients regardless of where they are from, presenting with multiple severe/systemic food allergies need to be investigated for nsltp allergy. these patients require specific dietary advice on foods to avoid and a tailored management plan on how to deal with their allergic reactions. cow's milk as well as cow's milk products are tolerated. material and methods: skin prick tests with different sorts of milk, cheese and milk proteins were performed, specific ige antibodies were measured, a basophil activation test with cow's and goat's milk was performed and an oral provocation test (opt) with cow's milk, cow's milk cheese, raw milk and raw milk cheese was conducted. results: skin prick tests were positive for sheep's milk, goat's milk, goat's milk casein, feta, pecorino and parmesan cheese. elevated specific ige against goat's milk ( . ku/l) and sheep's milk ( . ku/ l) were detected. activation of basophil granulocytes after incubation of the patient's blood with cow's milk and goat's milk was measurable but also in the non-incubated control blood. all cow's milk products were tolerated in the opt. conclusion: despite consistent homologies between whey and casein proteins of mammals and high cross-reactivity between cow's, goat's and sheep's milk an isolated goat's and sheep's milk allergy with tolerance of cow's milk is possible. skin testing and specific ige help to distinguish from allergy against cow's milk proteins. diet counseling is possible after opt. introduction: salmon roe's allergy, without concomitant fish allergy, is rarely described in western countries. there are few studies on its allergenicity. objective: to report of a case of salmon roe allergy without concomitant fish allergy in a western country. case report: a -year-old male with house dust mite allergic rhinitis and asthma, describes for the st time, in , an acute episode of dyspnoea, rhinorrhoea, ocular pruritus, epigastric pain and nausea, a few minutes after the ingestion of a sushi meal with rice, salmon, salmon roe, wasabi, soy and ginger. these complaints motivated observation in the emergency room, where it was still documented uvular oedema. he was prescribed intramuscular adrenaline, intravenous steroids and anti-histamines with complete symptoms resolution. the patient declares not had eaten other foods, taken any drugs including nsaid, been infected or practised exercise. skin prick tests with food extracts (salmon and other fish, shellfish, soy, rice, egg total, egg white, egg yolk, ovalbumin and ovomucoid) were negative. skin prick-prick tests were positive for salmon roe ( × mm) and negative for egg (white and yolk), ginger, salmon, flying fish roe (tobiko), sturgeon roe (caviar) and black scabbard fish roe. specific-ige (sige) to salmon roe extract was . kua/l (immu-nocap-phadia) and negative against extracts from salmon fish and other fish (< . kua/l). sds-page immunoblotting with salmon roes extract showed a kda-ige binding band, that may correspond to a lipovitelin. after the allergic reaction the patient have tolerated abstracts | salmon fish and other fish roes (tobiko, caviar and black scabbard fish). no oral provocation test with salmon roes was performed given the severity of the reaction. conclusion: this report is an example of a severe allergic reaction to salmon roe without concomitant fish allergy, where the clinical history and the in vivo and in vitro tests were important to an accurate diagnosis. the authors believe this is the first report of a salmon roe anaphylaxis in our country and highlight the importance of this allergen in the western countries, given the increase of sushi consumption in these countries. case report: the prevalence of food allergy is increasing worldwide and consumer habits are changing. pomegranate (punica granatum) was commonly consumed in the mediterranean area but in the last few years became also popular in the different parts of europe. a -year-old boy was admitted to our emergency department suffering from allergic reaction within minutes after consumption of pomegranate. he presented with skin pruritus, generalized urticaria and eyelid edema. symptoms resolved within an hour after oral intake of cetirizine. prick-to-prick test with pomegranate was positive (wheal diameter × mm). he had a history of anaphylaxis with egg (urticaria and wheezing) at the age of month, meanwhile consumption of egg is well tolerated. an episode of anaphylaxis with unknown origin appeared at the age of years (urticaria, wheezing and abdominal pain). skin prick tests with aeroallergens revealed birch pollen allergy and he was diagnosed with allergic rhinoconjunctivitis. dietary elimination of pomegranate was suggested and adrenaline auto-injector was provided. we have analyzed omalizumab effectiveness and safety in patients with csu from our database. clinical response was categorized as: no response, partial or complete response by using the urticaria activity score (uas ). furthermore, the dosage, administration frequency and any side effects were recorded. results: effectiveness: out of patients ( %) achieved complete response. ( . %) after a single dose of mg ( patients) or mg ( ); patients ( . %) after two doses of mg ( patients) or mg ( ) results: multi-ethnic adolescents accounted for approximately . % of the total sample of adolescents. prevalence of asthma was significantly higher in multi-ethnic group than non multi-ethnic group. we examined if maternal or paternal foreign born status had a differential effect: in multi-ethnic family with foreign-born father, prevalence of asthma was significantly higher. parental region of country at birth had a significant influence on the prevalence of asthma. adjusted logistic regression analysis was used to determine risk factors for occurrence of allergic disease. residential area, perceived household economic status, parental region of country at birth, and body mass index (bmi) had a significant effect on prevalence of asthma. conclusion: population admixing appears to have significant effect on the prevalence of asthma. further study will be needed to clarify the effect of population admixing on prevalence of allergic disease. several studies have aimed to explore the possibility of mirs as biomarkers for various diseases. in our study we examined six different mirs, previously shown to be involved in eosinophil development and other immune responses, in serum from non-allergic and allergic asthmatics and healthy control subjects in order to determine their potential ability to be used as biomarkers for varying forms of asthma. method: serum from healthy individuals as well as age matched non-allergic asthmatics (naa) and allergic asthmatics (aa) were utilized. additionally, the naas and aas subjects had high eosinophila (≥ . × cells/l) compared to healthy controls (≤ . × cells/l) and eosinophil cationic protein (ecp) in serum was measured. asthmatic subjects were included irrespective of inhaled corticosteroid usage. rna was extracted from serum, reverse transcribed and subjected to qpcr analysis. expression changes in six candidate mirs, mir- , - , - a, - , - , and - , were investigated. results: two mirnas, mir- and mir- a, were significantly upregulated in aas as compared to naa or healthy subjects. additionally, mir- was upregulated in naa, but not aa or healthy subjects. furthermore, the expression change observed in the aa mirs appeared to correlate with the use of inhaled corticosteroids, but not in the naa mirs. finally, mir- and mir- expression levels were altered based on the number of eosinophils, which correlated to ecp levels, in naa subjects. conclusion: using six mirs found in the literature to be involved in eosinophila or immune responses, we were able to detect expression changes in the serum of healthy and asthmatic individuals. moreover, were able to distinguish between healthy individuals, aas, and naas on inhaled corticosteroids or with differing eosinophil levels, leading to the possibility that these mirs may be valuable future biomarkers for asthma. background: some studies report that certain sensitization profiles may increase the risk of a more serious allergic respiratory disease. the aim of this study was to describe the sensitization patterns to major allergens of dust mites in our area and investigate the association of these patterns with a specific clinical picture. method: multicenter study performed in hospitals for months. we recruited patients older than years with rhinitis and/or bronchial asthma, with a history of allergy to dust mites and both skin test and specific ige to d. pteronyssinus, d. farinae or l. destructor positive. der p and der p were determined to all of them. we analyzed patients with an average age of . years, . % women, . % smokers, . % rhinitis and asthma, . % only rhinitis and . % only asthma. % of patients presented sensitization to d. pteronyssinus, . % to d. farinae and . % to l. destructor. the detected sensitization patterns were: both der p /der p positive . %; der p positive . %, der p positive . % and both der p /der p negative . %. it was observed that patients with higher specific ige levels had more severe forms of respiratory disease, with isolated asthma or associated with rhinitis. for d. pteronyssinus, d. farinae, der p and der p > ku/l there is a greater number of cases of asthma associated with rhinitis, while for l. destructor > . ku/l greater number of cases of asthma. no relationship was observed between a specific sensitization pattern and an increased risk of asthma. conclusion: . specific ige values greater than ku/l for d. pteronyssinus, d. farinae, der p and der p , were significantly associated with a higher probability of asthma and this association was significant for l. destructor> . ku/l (class ). . there are four well-defined sensitization patterns in our population that are influenced by geographic location, being the double sensitization to der p and der p the most prevalent and allowing the correct characterization of % of the cases. none of them increased the risk of asthma. kobori t ; nagao m ; ekenkrantz t ; borres m ; sjölander a ; fujisawa t national mie hospital, tsu-city, japan; thermo fisher scientific, uppsala, sweden background: reliable biomarkers for diagnosis and management of asthma in young children are needed since pulmonary function test and exhaled no measurement, good biomarkers for asthma in older children and adults, are difficult to perform in young age. we have developed a sensitive and stable assay system to measure eosinophil-derived neurotoxin (edn), an eosinophil granule protein, that is released upon activation, and that may serve as a marker for eosinophilic inflammation also in young children. method: volunteer children from - years old were recruited and an isaac-based questionnaire was filled out by their caregivers. venous blood was obtained to measure serum and plasma edn and eosinophil count. edn was measured with a research assay developed on the immunocap ® platform. conclusion: blood edn may be a reliable biomarker for diagnosis of asthma in preschool children. conclusion: feno measurement as an add-on option in asthma management to identify asthma patients with th driven airway inflammation is less costly than the use of standard diagnostic methods. new biologics may have an additional impact on overall asthma treatment costs. our model demonstrates that incorporating feno measurement may help to optimize asthma medication and reduction in physician visits as well hospitalizations due to severe exacerbations. | peripheral airway inflammation assessed by fractional measurement of the exhaled breath temperature is a leading feature of asthma background: airway inflammation is considered to be a hallmark of asthma. the potential clinical benefits of assessing it non-invasively has led us to develop a method and device for measuring the temperature of the exhaled breath (ebt=exhaled breath temperature) reflecting the thermal state of the airway mucosa. studies have demonstrated that ebt is increased in asthma, proportionately to the level of control of the disease. in an attempt to further increase the usefulness of this approach, we have further developed a device to allow the assessment of the relative contribution of the central and peripheral airways (caw and paw). now we present the frebt data gathered from patients with suboptimal control of their asthma and from healthy subjects. method: in this cross-sectional study we included volunteers: patients with suboptimally controlled asthma of mild to moderate severity (median age , range - years, men) and nonsmoking subjects without respiratory disease (median age , range - years, men). we measured the fractions corresponding to caw and paw sampled with a fast reacting inflatable balloon valve system operated by a computer during a single breathing cycle. it allows steering of the expired airflow through channels with sensitive temperature sensors. during an initial deep inhalation, the inspired volume is measured and the sequence of valve openings is adjusted so as to yield volumes of air characteristic of caw or paw during expiration. the ratios between [pawebt-cawebt] over the total ebt [%] measured during the same manoeuvre (fractional ebt, frebt) were calculated and compared between asthmatics and controls. results: there was high statistically significant difference between the frebt ratios of asthmatics and controls: . ± . (mean ± sem) vs . ± . , p < . . as the magnitude of the ratio depends on the difference between pawebt and cawebt, higher values of the frebt ratio point to bigger contribution of the peripheral lung tissues, presumably indicative of peripheral inflammation. multiple regression analysis with frebt ratio as dependent variable identified only asthma diagnosis as significant predictor (p < . ) and excluded all other anthropometric indices. conclusion: peripheral airway inflammation assessed by frebt measurement appears to be a leading characteristic in asthmatics compared to healthy subjects. method: we examined outpatients ( % male, aged - year, mean age . years) with severe asthma according to ers/ ats ( ) definition treated with high dose of ics/laba± tiotropium, antileukotrienes and omalizumab. some patients (n = ) had orally steroid-dependent asthma. they referred to our secondary care center by gps. pulmonary function tests were measured by dry spirometer ( , vitalograph ltd., uk). skin prick tests or serum specific ige to common inhalant allergens (house dust mite, animal dander, pollen) were used to assess atopic status. results: seventy five percent (n = ) of patients with severe asthma had fao in % of those was diagnosed concomitant copd. duration of asthma was . years in patient with reversible airway obstruction (rao) and . years in those with iao (p > . ). early (before age years) onset of asthma was established in % of patients with rao and in % of patients with fao (p > . ). prevalence of atopy did not differ between both groups ( % vs %, p > . ) but total ige level in serum was higher in severe asthmatics with rao than fao ( me/ml vs me/ml respectively, p < . ). most of atopic patients with severe asthma both with fao ( %) and roa ( %, p > . ) were sensitized to house dust mites (d. pteronyssinus and d. farinae). hypersensitivity to pollen was diagnosed in % patients with foa and in % with rao (p > . ), to cat and dog dander in % and % respectively (p < . ). the majority ( %) of patients with severe asthma had fao. hypersensitivity to house dust mites was most common in severe atopic asthmatics with foa and roa where as sensitization to animal danger was associated with presence of foa. | loss of smell as a clinical marker of severe asthma and its association with upper airway inflammatory diseases background: asthma is frequently associated with rhinitis and chronic rhinosinusitis (crs) while severe asthma is more associated with crs with (crswnp) than without (crssnp) nasal polyps. loss of smell (los) is associated with crs, mainly with crswnp. we aimed to assess loss of smell as a clinical marker to discriminate crs from rhinitis and severe from non-severe asthma. method: in a cross-sectional multicentric study, asthmatic patients (n = ) were evaluated by pulmonologists and ent specialists using gina, aria, and epos definitions. los was evaluated by severity [vas scale, - mm, median (iqr,inter-quartil range)] and by prevalence of anosmia (hyposmia vas > - mm, anosmia vas> mm). results: los was present in . % of asthmatics (hyposmia . %, anosmia . %). los was more severe [ mm ( - ), p < . ] and anosmia more frequent ( . %, p < . ) in severe persistent asthma than in moderate [ mm ( - ); . %] mild [ mm ( - ); . %], or intermittent [ mm ( - ); . %] asthma. in addition, los was more severe [ mm ( - ) vs mm ( - ), p < . ] and anosmia more frequent [ . % vs . %, p < . ] in crs than in rhinitis patients. in those asthmatic patients with crs, los was even more severe [ mm vs mm ( - ) p < . ] and anosmia more frequent ( . % vs . %, p < . ) in crswnp than in crssnp. conclusion: loss of smell and specially anosmia may clearly discriminate severe from non-severe asthma and crs (specially with np) from rhinitis alone in asthma patients. thus, los may be considered a significant clinical marker of severe asthma and its association with upper airway inflammatory diseases. | last station in the eosinophilic asthma with chronic rhinosinusitis and/or nasal polyposis march: eosinophilic asthma with radiological findings associated with blood eosinophilia yilmaz i ; nazik bahçecioglu s ; türk m ; tutar n ; oymak fs ; gülmez i erciyes university school of medicine, kayseri, turkey; department of chest diseases, kayseri, turkey; division of immunology and allergy, kayseri, turkey background: eosinophilic asthma with chronic rhinosinusitis and/or nasal polyposis (eacrs/np) is a subphenotype of adult-onset eosinophilic asthma. blood eosinophil levels are shown to be highly elevated in patients with ea-crs/np and have potential for tissue infiltration. we aimed to demonstrate the clinical features of the patients who have a blood eosinophil level above % and have thorax computed tomography findings due to blood eosinophilia. results: we identified patients who met the above criteria. we defined this group as "eosinophilic asthma with chronic rhinosinusitis and/or nasal polyposis with radiological findings related to blood eosinophilia" (earr). the mean age was . ± years and % was female. nasal polyps, aspirin exacerbated respiratory disease and atopy was present in %, % and % of the patients, abstracts | respectively. the mean blood eosinophil count was . cells/mm ( %). the majority of earr patients had upper lobe dominant ground-glass opacities. the mean follow-up period was . ± . years. earr patients did not evolve into eosinophilic granulomatous polyangiitis in the follow-up. method: we aimed to identify features more probably associated with asthma in a unselected group of patients with diagnostic criteria for aco. we consecutively selected the first consecutive patients with diagnostic criteria for aco. all patients were evaluated by accurate clinical history interview, assessment of asthma control test (act) and copd activity test (cat), lung function and exhaled nitric oxide (fe no ) measurements, sputum cytology, blood eosinophil count, serum total ige and periostin levels, methacholine and adenosine-mono-phosphate (amp) bronchial challenges. all these measures were repeated after an oral corticosteroid (ocs) trial of methylprednisolone mg/day for days. we defined parameters that we expected improved after the ocs trial, and therefore considerable as markers of asthma: fev , fef - , fev /fvc, fe no , act, sputum and blood eosinophilia, methacholine and amp challenges. patients with improvement of at least of these parameters after ocs trials were defined as "responders" to the treatment, and therefore more likely to be asthmatic than copd or aco. results: five ( %) patients were classified as responders and they were characterized by having basal higher fe no values ( . ± . vs . ± . ppb, p = . ), greater bronchial reversibility basal values of serum periostin and total ige, and blood eosinophils were higher in responders but without reaching the statistical significance. conclusion: fe no and the degree of bronchial reversibility (and possibly also the degree of response to an amp challenge) are reliable biomarkers to distinguish asthmatics among those with suspect aco. method: the preliminary case-control study included obese persons with asthma who were matched for age and sex and nonobese asthma subjects. non fasting serum levels of adiponectin, and leptin were measured by commercially available immune assay kits, and routine biochemical parameters were analyzed in both the study groups. the results show statistically significant lower levels of serum adiponectin and higher serum leptin levels in obese asthma subjects with respect to non-obese asthma patients (p < . ). moreover, an inverse correlation was also observed between serum adiponectin and serum leptin in obese asthma subjects (p < . ). our results indicate the association of these hormones might act as a significant predictor in the progression of asthma. moreover, the role of serum adipokines is promising and might potentially act as a meaningful drug target in the pathogenesis of asthma. background: overweight/obesity is known to be a possible factor for poor asthma control. the aim of the study is to determine the serum concentrations of leptin in atopic asthmatic patients and its relationship with body mass index (bmi), asthma severity defined by medical treatment and asthma control defined by the asthma control test (act). method: we randomly selected adult patients previously diagnosed with allergic asthma based on gina (global initiative for asthma) guidelines, returning for follow-up to an outpatient allergy/ immunology clinic during november . following an informed consent, the patients were asked to fill act, their bmi was recorded, and elisa blood assays for leptin were drawn. exploratory data analysis, spearman's correlation ( % ci by bootstrapping), and partial correlations were performed. results: female/male ratio was / , mean bmi was . ± . conclusion: leptin was significantly associated with overweight/ obesity in asthmatic subjects, and showed higher values for women. leptin inverse correlation with act did not reach statistical significance, likely owing to underpowered estimates, in a small sample characterized by an elevated mean bmi and severe allergic asthma. background: immunoglobulin lowering may be associated with recurrent wheezing symptoms and clinic by increasing the tendency to viral respiratory tract infections. in this study, it was aimed to investigate the frequency of immunoglobulinemia in preschoolers with wheezing. the study was conducted between . . and . . between. university of health sciences, ankara child hospital, the children allergy and immunology clinic included patients who had been followed up and treated for at least one year with recurrent wheezing attacks within younger than months. the immunoglobulin (g, a, m) values of the patients were retrospectively analyzed. immunoglobulin levels were determined to be normal and low according to age limits. the study included patients ( . % male, . % female) under the age of years with a mean age of . months. the mean follow-up period of the patients is . years. in . % of these patients, at least one immunoglobulin was found to be low. none of these patients had any signs or symptoms of immunodeficiency. immunoglobulin a was low in % of the patients, immunoglobulin g in %, and immunoglobulin m in . % of all patients. conclusion: immunoglobulin was found to be low in these patients when there was no immunodeficiency and preschool wheeze was diagnosed. this should be etiologically investigated as to whether if this is a special group in preschoolers with recurrent wheezing and hypogammaglobulinemia combination. method: asthma severe unit is formed by allergists, pneumologists, pediatricians and otorhinolaryngologists. hematologists and immunologists make specific collaborations. we present the partial results of our data collection, which include patients with severe asthma according to ers/ats task force, selected by peripheral eosinophils > according to wagener et al. we followed them up to assess control for year. we obtained cellularity in sputum using induced sputum technique. values of il of th , th , th pathway, periostin and ilc were not yet available. results: median age was ± , feno ± , exacerbations previous year . ± . , act . ± , fev % ± and dose of inhaled corticoids (budesonide equivalent) ug ± . most of the patients were sensitized ( %) and . % were polysensitized. the most frequent sensitization was dust mites ( %). % had received immunotherapy of whom . % with lack of response. not sensitized patients were older. sputum cell analysis of patients was performed, % had sputum eosinophils> %, mean sputum eosinophil value was . ± . and peripherally ± . correlation among sputum and peripheral eosinophilia was . (p = . ). the peripherally eosinophil value > had a sensitivity of % and a specificity of % for the detection of sputum eosinophils > %. no differences were observed in sputum cell count depending on allergic sensitization. % had an uncontrolled asthma. presence of polysensitization, rhinitis or polyposis were not statistically related with the control. different patterns were observed in function of cause of poor control: patients with obstructive pattern (fev < %) were older and received more inhaled treatment. patients with high rate of exacerbations had more sputum eosinophilia and neutrophilia. both groups had worse act and received more oral steroids. patients who received oral steroids were more often sensitized to fungi in some follow-up visits. not significant differences were observed in control according to the act. asthma had more sputum neutrophilia, were older, received higher inhaled steroids dose and had adult onset asthma. the only control variable related with sputum eosinophilia was exacerbation. fungi sensitization was more frequent among patients with oral steroids. method: a randomized, double blind, placebo controlled study with patients from the de la salle university medical center with a mean age of with partly or uncontrolled asthma. they were assigned to either cm glucan or placebo group for two months. act score and %fev postbronchodilator were assessed at the st visit, th week follow up, and th week follow up visits. an independent and paired t-test were used to determine mean changes in act scores and %fev between the groups. results: in the two treatment groups, those in the cm glucan group had a greater % fev mean change of − . compared to placebo which had only − . , a mean difference of − . , and a trend toward significance with a t-test p value of . . in terms of changes in act score, those in the cm glucan group had a mean change of . and . for placebo, a mean difference of . and was not significant at t test p value of . . the result of the emanuel trial showed a trend of improvement among patients on both groups in terms of act score and %fev postbronchodilator. however, it was not statistically significant. | lung function improvements with tiotropium in patients across all ages: impact of episodes of asthma worsening during phase trials vogelberg c ; casale tb ; bleecker er ; goldstein s ; szefler s ; engel m ; el azzi g ; dewberry h ; hamelmann e method: post hoc analyses involved phase iii, randomized, double-blind, placebo-controlled trials: in patients aged - years (rubatina-/canotina-/vivatina-/pensietina-asthma) who received tiotropium ( or . μg) or placebo, as two puffs once-daily via the respimat, as add-on to ics ± other controllers; and in adults (pri-motina-asthma replicate trials) who received once-daily tiotropium μg or placebo, as add-on to ics/laba ± other controllers. we analyzed change from baseline for peak fev ( - h) and trough fev at week in vivatina-and pensietina-asthma, and week in pri-motina-/rubatina-/canotina-asthma, comparing patients with and without episodes of asthma worsening during the trials. asthma worsening was defined as an episode of progressive increase in dayto-day asthma symptoms (recorded by patients and confirmed by the investigator) or a decrease of patient's best morning pef ≥ % from mean for ≥ consecutive days. as a post hoc analysis, p values are nominal. results: there were no differences in baseline disease characteristics between those who experienced episodes of asthma worsening and those who did not, within specified age and asthma severity groups. placebo-adjusted lung function improvements were observed with tiotropium μg in patients who experienced episodes of asthma worsening and those who did not during the trials (table ) . there was some variability in subgroups with low numbers of patients. conclusion: once-daily tiotropium add-on had a similar efficacy in adult and pediatric patients with symptomatic asthma, irrespective of whether they experienced episodes of asthma worsening or not during the trials. these data support the broad efficacy of tiotropium and show largely consistent improvements in lung function even in patients who experience episodes of disease worsening. | cochrane review of the use of antibiotics for acute exacerbations of asthma method: we searched the cochrane airways trials register, trial registries and reference lists of primary studies. we extracted outcome data and assessed risk of bias in duplicate and used current cochrane methodology throughout. our primary outcomes were intensive care unit (itu) admission, duration of symptoms/exacerbation and adverse events. we included six studies, including a total of adults and children. trials were of varied methodological quality and we were able to perform only limited meta-analysis. one study reported a single itu admission but no other studies reported admissions to itu. two studies investigating macrolides reported diary card symptom score and showed antibiotics improved symptoms (md − . , % ci − . to − . ). one study including participants reported more symptom-free days in the macrolide group than usual care. one study of a penicillin including participants reported asthma symptoms at hospital discharge; the between group difference was reported as non-significant. serious adverse events were rare; events were reported across the three trials (n = ). the pooled effect estimate for all adverse events from three studies was imprecise (or . , % ci . - . ). no deaths were reported. conclusion: our results confirmed that omalizumab significantly improves disease control and is a safe add-on therapy. also in appropriate patients with controlled disease over time, efforts to stepdown other asthma medications will be appropriate. ( ) aerd: aspirin exacerbated respiratory disease; sd: standard deviation. data are n (%), mean ± sd or n/n (%). c-act: asthma control test for children, fev : forced expiratory volume in one second; fev /fvc: the ratio of forced expiratory volume in one second to forced vital capacity, pef: peak expiratory flow; feno: fractional exhaled nitric oxide, vas: visual analogue scale *these included allergic rhinitis, asthma, eczema, atopic dermatitis, food allergy, etc. **there were , and missing data in treatment a, b, and c, respectively. this study examines the potential treatment effects of sq ® hdm slit-tablet on qol measured by sf- v in people with aa and ar. the analyses are based on data from the mt- trial (eudract no. - - ) and utilize data from the sq-hdm treatment group ( subjects) and the placebo group ( subjects). throughout the trial, qol was measured at each of visit - via sf- v . this yielded psychometrically-based physical and mental health summary measures, as well as a sf- v total score. according to trial design, the use of inhaled corticosteroid (ics) was reduced by % for a three months period (visit and ) and completely withdrawn for the last three months of the trial (visit and ). results: by estimating a simple regression on differences in sf- v total score from baseline measurements (visit ), a positive and statistically significant treatment effect on the overall qol of the sq-hdm treatment compared to the placebo group in visit and was found. further analyses show that the qol improvements are mainly driven by increases in the general mental health score, which are carried through to visit . in particular, the mental health and role emotional domains show statistically significant improvements. the results show that the sq ® hdm slit-tablet improves qol measured by sf- v in patients with hdm induced aa and that this effect is driven by improvements in the mental health domains. | impact of treatment prescription, adherence to treatment and use of inhalers in asthma control-results of the efimera study method: cross-sectional multicenter observational study conducted with patients who use any type of medication with inhaler devices. patients referred from primary care and seen by a pneumologist or allergist for the first time were evaluated. the following data was collected in a single visit: adequate prescription according to gina guidelines (gina); specific and general treatment adherence using morisky-green questionnaire (mg) and inhaler adherence test (tai); disease control with asthma control test (act) and assessment of inhaler use technique were measured with the extended tai. results: patients included in this study (n = ) had a mean age of ± years, an average disease evolution of . ± . years, % of which were women. according to gina recommendations, . % of patients have insufficient or inadequate prescription. when measured by the mg test the . % of patients showed bad adherence, meanwhile measured by the tai test adherence was . % measurements of inhaler use technique resulted in % of patients having one or more mistakes regardless of whether the device was a mdi or dpi. several factors showed to be related with bad asthma control: inadequate prescription (or: . [ . - . background: it is well known that the constant and prolonged tobacco smoking affects the natural history of asthma. vaping is the act of inhaling and exhaling the vapor produced by an electronic device called e-cigarette (e-cig), whose basic structure includes a power source and an atomizer. two types of vaping are the most popular ("mtl" and "cloud chasing"). we have created a web-survey with questions concerning epidemiological data, quality of life and symptoms worsening in asthmatic vapers. the survey has been advertised through various social networks and local press. people responded, including asthmatics ( %). the asthmatics were: males %, under %, - years %, - years %, - years % and over %. % used ecig-only, % smoked and vaped together, %. those who preferred mtl-type of vape were % and "cloud chasing" were %. results: to the question: "has vaping ever worsened asthma symptoms?" % answered no, % yes. to the question: "as asthmatic, would you suggest to an asthmatic smoker to start vaping instead of smoking?" . % answered no, . % yes. to the question: "how much nicotine do your vaping liquids have?" % answered mg/ml, % . mg/ml, % mg/ml, % mg/ ml, % mg/ml, % mg/ml and % mg/ml. to the question: "do you take medications for your asthma?" % declared to use a drug as needed, % used a single drug daily, % used more than one drug daily and % declared "i don't take any asthma medication". we related (χ test) the worsening of asthma symptoms with the nicotine content (p = . ), the type of vaping (p = . ), the current therapy (p = . ) and we did not find a statistically significant correlation. vaping has undoubtedly shown an advantage in terms of improvement of symptoms compared to cigarette smoking (p = . ), in particular . % subjects who smoke and vape did not have a worsening of symptoms, while . % of them had a worsening. the vaper-only users who never worsened were ( . %) and ( . %) had a worsening. conclusion: despite the limits related to the online survey as a data source, e-cigs seem to be a useful tool in the pathway to quit smoking. in fact, % of the asthmatics who smoked traditional cigarettes would recommend switching to e-cig and % did not worse their asthma symptoms. background: despite the success of pharmacotherapy, more than half of patients with persistent bronchial asthma (ba) do not achieve disease control. in recent years, the issue of approaches to treatment based on the identification of phenotypes of the disease has been increasingly discussed. this approach becomes the key to optimizing therapy for asthma, allowing the personification of treatment. anti-ige-therapy using omalizumab is one of the most researched variants of phenotype-specific treatment. method: aim of our study was to investigate of the causes of uncontrolled predominantly atopic asthma, the frequency and effectiveness of the personalized therapy in real clinical practice. patients with uncontrolled severe atopic asthma were examined in outpatient department of the city hospital during . all patients underwent physical examination, pulmonary function testing, and total serum ige evaluation. results: % of patients had uncontrolled asthma due to inadequate basic therapy of the disease. the change in therapy allowed them to achieve control of the disease. obstructive sleep apnea syndrome (osas) was revealed in . % of patients. these patients underwent cpap (continuous positive airway pressure) therapy. % of patients had gastroesophageal reflux disease (gerd). % of patients had an elevated level of serum ige level and needed anti-ige therapy. in . % of cases, the initial serum ige level was more than iu/ml which was a contraindication to therapy of omalizumab. patients received omalizumab therapy. this therapy led to relief of symptoms and decreased frequency of asthma exacerbations. results: it was found that the prevalence of obesity among the patients with asthma and being treated in inpatient conditions in - was . % of patients, which is comparable to the prevalence of obesity among the population in general. the data of the patients suffering from asthma and obesity treated both in inpatient and outpatient conditions, was analyzed and it is set that obesity does not affect the severity of the clinical course of asthma. it is shown that obesity does not affect the control of symptoms of asthma. thus, the control of asthma symptoms depends on timeliness of diagnosis, the adequacy and terms of appointment of basic asthma therapy, the presence, severity and adequate treatment of concomitant diseases, psychoemotional background of patients, their compliance and adherence to therapy. results: the causes of smoking in asthmatics were not significantly different from the control (p > . ). patients most often used smoking as "support for emotional stability". the motivation to smoking cessation was higher in the asthmatics group ( %) than in the control group. the main reason for smoking cessation was a deterioration in health - %. the majority of smokers - %, performed attempts for smoking cessation. low level of br was revealed in % asthmatics ( % non-smoking asthma patients and . % of cases in the control group, p < . ), cf had low values and was lower in asthmatics group in compare to the control group (p < . ). the pac values correlated with the level of br: a low level was determined in % in smoking asthmatics, in % in nonsmokers with asthma and . % in smokers of the control group obstructive sleep apnea (osa). all of the patients were on regular treatment with low dose inhaled corticosteroids for at months and start treatment with continuous positive airway pressure (cpap) .to assess quality of life, we used asthma symptom control tools (asthma control test) .patients performed daily peak flow meter and spirometry (once a week) during period of weeks after start using cpap. results: during the study, of the followed patients had no exacerbation of asthma. four of patients during this period had exacerbation, due to upper airway infection so they were excluded from study. results of following showed that there was improvement in quality of life in all patients included in study but there no statistically significant improvement in pulmonary function tests fpt. huang y ; yao t ; huang y ; chiu c ; tsai z ; kao p ; lu k ; fang h ; lin c ; gau c ; lee w ; tsai h results: the rate of preterm birth among the study subjects was . %. the prevalence of physician-diagnosed rhinitis was . %. there was no significant association between preterm birth and physician-diagnosed rhinitis (p = . ). when stratifying by atopy status, we found that preterm birth was associated with physiciandiagnosed rhinitis among children without atopy (adjusted or [aor] = . , % ci = . - . , p = . ), but not among children with atopy (p = . ). when further classifying by gender, greater protective effect of preterm birth on rhinitis was only found in boys without atopy (aor = . , % ci = . - . , p = . ). the results suggest that preterm birth may have a protective effect against the development of childhood rhinitis in our study population. the protective effect is only observed in boys without atopy. further investigations will be merited to confirm these findings and to investigate underlying mechanisms. background: folic acid supplementation (fas) during pregnancy has been suggested due to its protective effect against neural tube defects. at present the effect of fas during pregnancy on childhood rhinitis has remained unclear. we aimed to investigate the relationship between fas during pregnancy and childhood rhinitis. logistic regression analysis with covariate adjustment was performed. adjusted covariates included sex, age, number of older siblings, breast feeding duration, maternal smoking during pregnancy, maternal allergy, maternal education level, maternal age and socioeconomic status results: the prevalence of physician-diagnosed rhinitis was . %. there is a significant association between fas and physician-diagnosed rhinitis (adjusted odds ratio [aor] = . ; % confidence interval [ci] = . - . for fas ≥ months) compared to the group of never use. in the stratified analysis by atopy status, maternal fas during pregnancy was significantly associated with physician-diagnosed rhinitis in the atopic group (aor = . , % ci = . - . for fas < months; and aor = . , % ci = . - . for fas ≥ months), but not in the non-atopic group. when further stratified by gender, significant association between maternal fas during pregnancy and physician-diagnosed rhinitis was only found in boys with atopy (aor = . , % ci = . - . for fas < months; and aor = . , % ci = . - . for fas ≥ months). the results demonstrate that maternal folic acid supplementation during pregnancy might increase the risk of childhood rhinitis, especially among boys with atopy. further investigation will be needed to validate our findings and to understand potential underlying mechanisms. according to sequence data from detected adv (in all groups of patients) belongs to species f type and samples to species c type (rei group). bv type was identified in strongly positive (ct ≤ ) swab samples in ari group. conclusion: simultaneous testing of respiratory and stool samples together shown that at least . %/ . % of study subjects had dual/mixed infections, respectively, including %/ . % of respiratory disease patients, . %/ % of gastroenteritis patients and . %/ . % of patients with combined respiratory/enteric infections. we found no virus combination specific for different groups of patients. | neonatal respiratory supports and future asthma-like presentation in prematurity with bronchopulmonary dysplasia results: of all the tests analyzed . % were males and . % females with a mean age . ± . years old. half of the tests ( . %) reveals positive specific-ige to more than one allergen and . % ( ) have no serum specific-ige for the tested allergens (table ) . sixteen patients ( . %) have very high concentrations (> iu/ml) of derm. pteronyssinus specific ige, ( . %) of derm. farina, ( . %) of rey pollen and ( . %) of oak and timothy grass pollen. further studies are needed in order to elucidate the effect of these cytokines on allergy development and protection. shinohara m ; matsumoto k department of pediatrics, ehime university hospital, toon, japan; department of allergy and clinical immunology, national research institute for child health and development, tokyo, japan background: probiotics consumption during perinatal and postnatal periods reportedly reduces the risk of atopic dermatitis in the offspring, whereas such probiotics consumption did not affect ige levels or the risks of other allergic diseases; the precise mechanism how probiotics consumption reduces the risk of atopic dermatitis remains unknown. we hypothesized that probiotics consumption may reduce skin hypersensitivity to histamine. to test this hypothesis, we investigated whether perinatal/postnatal consumption of yogurt associates with skin hypersensitivity to histamine or not. method: this was a cross-sectional study enrolled motherinfant (≥ -months-old) pairs. physician-diagnosed allergic diseases and food consumption, such as milk, fermented drinks, and yogurt, by mothers during the third trimester of pregnancy and by infants during the first months of life were assessed using self-questionnaires. skin prick tests (spts) to saline and mg/ml histamine were performed using bifurcated needles, and wheal sizes were measured minutes after the puncture. the spt wheal sizes in infants with eczema/atopic dermatitis (n = ) were significantly larger than those in infants without eczema/atopic dermatitis (n = ; . ± . mm vs . ± . mm, respectively, p = . ), and thus these infants were excluded from the further analyses. the spt wheal sizes to histamine in infants with daily yogurt consumption during the first the aim of this study was to evaluate the prevalence and clinical relevance of sensitization to profilins in atopic patients with food allergy. the study was performed on a group of children age - years with sensitization to at least one plant-derived food allergen (ige > . ku/l). the included patients had never been treated with allergen immunotherapy before the study. the presence of ige to recombinant (r) rbet v , rart v and ramb a in serum was evaluated using elisa method as previously described (jbc ; : ) . in addition serum level of igg to rbet v , rart v and ramb a was also evaluated. results: sensitization to profilins was found in out of ( . %) patients (p+). sensitization to all studied profilins was demonstrated in each p+ patient. the remaining children, with pollenfood sensitization, were not sensitized to any of the studied profilins and they served as a comparator group (p−). analysis of the clinical status revealed that asymptomatic patients in regard to plant-derived food hypersensitivity were found more frequently among p+ ( %) than p− ( . ; p < . ) patients. sensitization to profilin was associated with positive ige to the same food allergens as in the control group. clinical manifestation of pollen-food sensitization expressed as allergic rhinitis, bronchial asthma and atopic dermatitis was comparable between groups, except of oral allergy syndrome, which was not seen among p+ children. similarly, history of anaphylaxis to plant-derived foods was registered only among p− ( . %) patients. interestingly, all patients with sensitization to profilins had also elevated level of serum igg against rbet v , rart v and ramb a . results: no significant difference of physician-diagnosed eczema (p = . ) or current eczema (p = . ) was observed between children born full-term and preterm. after stratifying by atopy status, we found that children born preterm had a more than three-fold higher risk of having physician-diagnosed eczema (adjusted or (aor) = . ; % ci = . - . ; p = . ) and current eczema (aor = . ; % ci = . - . , p = . ) than their counterpart in the non-atopic group. no statistical significance was observed for the association between preterm birth and eczema in the atopic group. no association between preterm birth and eczema was found when stratifying by gender. our results reveal that non-atopic children born preterm have a higher risk of developing eczema. the results suggest potential modifiable effect of atopy on the association between preterm birth and eczema. further studies with a larger sample size are needed to validate the findings in this study. background: there is a need for more knowledge about factors of importance for a successful transition from childhood to adulthood among adolescents with allergic disease and especially those with severe allergy. therefore the aim of this study was to describe experiences of living with severe allergy from the adolescents and their parent's perspective and thereby identify factors of importance for transition from pediatric to adult care. method: a qualitative study was performed based on six focus groups interviews, two with adolescents and four with their parents. in total adolescents (age - years old) and parents participated. the interview guide contained questions about experiences of living with severe allergy. the transcribed data was analysed using systematic text condensation. results: in total four themes were presented, two themes occurred in both the adolescent and the parent's focus groups, to be special and to be prepared. for two themes there was a difference between the adolescents and their parents. the theme, the importance of the parents, only occurred in data from the adolescents and the theme the meetings with health care only occurred in the parent's data. the adolescents felt that they had low priority in the class and several stated they were teased at school and their parents felt that focus on their child often was in a negative way. the adolescents described that they took responsibility for their diseases while their parents expressed a need to protect. the adolescents stated that one of the parents were always present or had been during the years, the reason being safety and security. only the parents mentioned experiences from healthcare. parents who described that they had continuity in healthcare meetings and where met by high competence and with a professional approach were more satisfied with the support from the health care. one factor that was felt to be important was whether the doctor involved the youth in the conversation or not. the teenagers in this study relied on their parents while also taking responsibility for their illness at the same time. parents, on the other hand, showed a tendency to overprotect their adolescents. for healthcare professionals it is important to involve the adolescents in the care to facilitate the transition. results: . % of the children used antibiotics currently and . % out of them used antibiotics ≥ times yearly. current wheeze (w) was established in . %, sleep-disturbing w in . %, exerciseinduced w in . %, dry night cough apart from a cold in . %, and asthma in . %. current antibiotics use ≥ times yearly was positively associated with current w (aor: . ; . - . ; p < . ), sleep-disturbing w (aor: . ; . - . ; p < . ), exercise-induced w (aor: . ; . - . ; p = . ), dry night cough (aor: . ; . - . ; p < . ), and diagnosed asthma (aor: . ; . - . ; p = . ) while antibiotics use < times yearly was positively associated only with current w (p = . ) and dry night cough (p = . ). the results suggest an aggravating role of antibiotics use on asthma in school age thus further supporting the recommended restriction of antibiotics exposure. results: after questioning . % % ci, . - . were suffering from respiratory diseases, having symptoms of chronic disease: cough- . %, wheezing- . %, tightness in the chest- . %. the risk factors (passive smoking, open fire house warming and no air conditioning) were commonly met in major cases at ill children rather than healthy ones ( . % % ci, . - . ). as a result of studies made of the equal to . ± . , comparative the end of lessons equal . ± . (p ≤ . ); air relative humidity varies during lessons equal with . ± . (norma toilet %- %); co concentration exceeds allowable limits − . ± . (mac − . %). conclusion: respiratory morbidity in high school examined has a tendency to increase. we noticed deviations from the hygienic norms: the indoor temperature and relative humidity was lower and the co level was twice higher than the normal one. the "asthma ever" outcome was reported in cohorts. cohorts defined this as parental reported asthma (with or without specifying that it was doctor-diagnosed), cohorts used gp records as the only source of diagnosis, and used parental report or gp records. the "current asthma" outcome was reported in cohorts. there was little consistency with how current asthma was defined or worded, with different definitions used. the most common definition of current asthma, reported times, was "asthma ever and either asthma symptoms in the last months or asthma medication in the last months". other criteria included in asthma definitions were bronchial hyper-responsiveness, reversible airway obstruction, positive exercise test, and asthma symptoms reported at a previous questionnaire. only one "current asthma" definition was based exclusively on prescription data: "dispensed two asthma medication during the past year". nine cohorts reported asthma outcomes without specifying how it was defined, and were categorized as "asthma unspecified". conclusion: "asthma ever" and "current asthma" are two main asthma outcomes used to define asthma in child cohort studies. definitions of asthma vary substantially across cohorts. case report: thereby we present two case reports of two children with impairment verbal communication as part of asd and allergic diseases. the first patient was a year old boy with sneezing, rhinorrhea night cough and eye redness. he had been suffering for almost years from the above mentioned symptoms. he had family history for atopic diseases and was for month breastfed. specific ige revealed sensitization to birch, alder, hazel, oak, mugwort pollen and dog epithelia and dermatophagoides farinae. specific ige resulted positive for nuts and rye flour. the second patient was almost year of age in the tame that he presented in our hospital. he cried and screamed all the time because of severe atopic dermatitis and typical symptoms such as itching all over the body and his impairment of verbal communication. specific sensitization showed sensibilization to egg white and egg yolk, to nuts, rye and wheat flour. the food specific ige leaded to positive results to alder, birch, hazel and oak pollen, but also to grasses, ragweed and mugwort. prick by prick test showed positivity to egg white and egg yolk. atopy patch test to pollens resulted negative. results: the first patient symptoms were well controlled after treatment with antileukotrienes. his verbal communication was also improved after a year or more. the second three year old patient after required a combination of specific treatment with antihistamines, corticosteroids, immunosuppressive drugs and diet recommendation. afterwards he had a reduced level of itching and anxiety but compared to other children he had a severe eczema. erythema multiforme (em) is an acute, immune-mediated, mucocutaneous condition that is most commonly caused by infection and drugs. it is characterized by targetoid lesions, sometimes accompanied by oral, genital or ocular mucosal erosions. there was no pediatric patient that had previously been reported in the literature with development of type reaction after omalizumab treatment. we presented a case who developed em to omalizumab therapy. an year-old female patient was admitted to pediatric allergy clinic with complaints of fever and rash. she had been diagnosed with chronic spontaneous urticaria (csu) years ago and she was planned to treat with omalizumab ( mg, subcutaneously every week) because of the inadequate response of antihistamines at a medical center. her complete blood counts, liver, renal, thyroid function tests and serum c ,c ,c esterase inhibitor protein levels introduction: celiac disease is an autoimmune disease triggered by exposure to gluten in genetically predisposed individuals and characterized by chronic inflammation of the small intestine. chronic urticaria is a skin disease, characterized by the appearance of pruritic wheals with or without angioedema, whose underlying mechanism cannot be identified. objective: to report a sporadic case of an -year-old boy with chronic urticaria associated with celiac disease. methods: an -year-old boy(weight kg, rd- th percentiles) was admitted to our clinic with a -year history of chronic urticaria. during the first three years, he was under antihistamine treatment(of incremental doses)and occasionally received preparations of cortisone according to the eaaci guidelines. he was asymptomatic for years until treatment was discontinued. eight months earlier, after a viral infection, a recurrence of urticaria, involving the trunk and extremities without angioedema was noted. subsequently, he was under antihistamine treatment with cetirizine but had an uas- score of . total laboratory investigations were performed. results: laboratory control was negative except for positive antibodies to celiac disease(anti-transglutaminase > u/ml, anti-endomysial, gliadin antibodies).further control with colonoscopy and biopsies (from duodenum and stomach) were obtained. the histopathological findings along with the clinical findings indicate celiac disease, type b marsch-oberhuber and grade b corazza-villanacci. in the past, similar cases have been reported. efforts have been made to associate chronic urticaria with celiac disease, although the mechanism remains unclarified. evidence suggests that the duration of gluten exposure, among otherwise asymptomatic patients with celiac disease, is related to the development of other autoimmune mechanisms. this can be explained by resolution of urticaria manifestations after the onset of gluten-free diet. in our case, three months after gluten-free diet, an improvement of urticaria with decreased uas- score of was observed. conclusion: he specific case of subclinical diagnosis of celiac disease in a child with chronic resistant urticaria further reinforces the suggestion that screening for celiac disease should be included in the diagnostic approach of chronic urticaria. | allergy to gingival balm in an infant with cow's milk protein allergy we report a case of an infant with a diagnosis of cmpa with an allergic reaction to a gingival balm caused by the presence of cmp in its constitution. furthermore, it is important to reinforce that milk proteins were labeled in an unusual form which might increase the risk of misunderstanding. these findings illustrate the difficulty in implementing total avoidance of common food allergens as well as the need to improve their labeling, particularly in non-food products. bakiri ah results: after specific treatment with corticosteroids, antihistamines, emollient creams, disinfectants and antileukotriens he was feeling better, he was smiling again and wished to have the chance to play with his classmates again. conclusion: this case report shows an association between level of stress and risk for atopic dermatitis. as previously showed children with low educational level parents and boys with higher stress have increased risk of having severe atopic dermatitis as compared to "no stress" boys. so early treatment and diagnoses are key important factors improving the children`s social life. results: the data cover immigrants (mean age . , range - ) and locals (mean age . , range - ). a slight difference in male prevalence ( . % vs %, p = . ), and pet possession ( . % vs . %, p = . ) were found between immigrants and locals, respectively. no differences were find in term of age and symptoms at presentation. the pattern of sensitization to the different allergens showed no statistically significant differences between migrants and controls. the rate of monosensitization resulted slightly higher in migrants ( . %) than controls ( . %). pollen-only sensitization was statistically higher among migrants than control ( . % vs . %, p < . ). monosensitization was more frequent among patients who have been living in italy for less than years ( . % vs %, p = . ). the opposite phenomena can be seen among polysensitized patients. conclusion: migrants are more frequently monosensitized than locals and tends to cluster towards either a pollen or dust mite sensitization. sensitization to house dust mite tends to appear early (< years of stay). pollen or mixed sensitization is more frequent the longer the residence time. | allergenonline.org: update of comprehensive allergen and celiac protein searchable databases for risk assessment of novel food proteins goodman re ; baumert jl ; taylor sl ; ebisawa m ; ferreira f ; bohle b ; van ree r ; kleine-tebbe j ; abdelmoteleb m ; koning f ; amnuaycheewa p conclusion: allergen and cd databases have been updated following a described review process. they can be used to identify proteins that might represent risks of food allergy or cd for affected consumers. han dh ; lee jw ; yim hj ; ko yk ; kim d ; rhee c seoul national university hospital, seoul, south korea; seoul national university bundang hospital, seoul, south korea background: stress can change the immune response and aggravate various allergic diseases. we already demonstrated in previous allergic rhinitis cohort (arco) kids study that stress might be a risk factor for pediatric allergic rhinitis (ar). the aim of this arco study is to investigate relationship between stress intensity, symptoms severity and quality of life as well as allergic markers in adult ar patients. results: as stress intensity increased, the proportion of moderatesevere ar patients was significantly increased. ar patients in high stress group was likely to belong to moderate-severe group (or, . ; % ci, . - . ). global vas of ar symptom was . ± . in high stress group and . ± . in low stress group, respectively. the each rqlq domain score was significantly higher in high stress group than in low stress group. total rqlq scores were . ± . in high stress group and . ± . in low stress group, respectively. however, as the level of stress increased, there were no significant changes in serum levels of allergic markers. our results suggest that stress may affect ar symptom severity and quality of life in ar patients. | skincare and synbiotics for the prevention of atopic dermatitis or food allergy in newborn infants: a × factorial randomized non-treatment controlled trial dissanayake e ; tani y ; sahara m ; mitsuishi c ; nagai k ; sato y ; suzuki y ; nakano t ; yamaide f ; shimojo n (n = ). the skin care group was advised to apply an emollient - times/day especially on cheeks and peri-oral area. the synbiotics group consumed a mixture of fos ( g) and bifidobacterium bifidu-mol ( × )/day. the last group received both. emollient application was not prohibited in the no-intervention group. interventions were carried out from birth to months of age. the development of ad was assessed at month, months and months by a pediatrician and at year by a questionnaire. ad was diagnosed using guidelines of the japanese society of dermatology. sensitization to food allergens was assessed by allergen-specific ige levels at months of age. results: skin care and synbiotics, alone or in combination, did not prevent the development of ad at year of age or the sensitization to food allergens at months of age. conclusion: our data suggest that skin barrier protection using emollients may be insufficient to prevent the development of ad as other factors affecting skin barrier integrity and trans-epidermal water loss such as the method of skin washing may have an additional effect. the probiotic bacterial species used may also affect the outcome as lactobacilli have been shown to be more beneficial. more studies are required to confirm the effects of skin care and synbiotics on ad. results: in the population number of girls exceeded the one of boys (p < . ), especially within the age group from to years. questioning, for months, symptoms of allergic rhinitis (rhinorrhea, sneezing, nose itch, nasal obstruction and eyes' itch) were identified in . (p < . ); symptoms of bronchial asthma (wheezing ( %), episodes of cough at night ( . %), intolerance to physical load ( . %), indoor and outdoor ( . %), coughing and rales in response to stimulus ( . %)) in . % of the population; atopic dermatitis (dermatitis, itch, revelation in early age, involvement of large areas in early age, damage of extremities bending and stretching surfaces in adults)- . % (p < . ); food allergy- . % (p < . ) etc. at the second stage of clinical studies, on the basis of prick-testing, average ige, in our case, was - times greater than normal level. results of study of allergens showed sensibilization to domestic dust (d.f. and d.p.) ( , %) (p < . ). in . % of cases there was stated sensibilization conditioned by cat and dog epidermal allergens results: among the women with available serum, . % were sensitized of whom . % were monosensitised, and . % polysensitised (to two or more allergens). sensitisation to inhalant allergens dominated ( . %), with grass being most common ( . %). only . % were sensitized to food allergens, most often to peanuts ( . %), while among the . % who reported ddfa, ige reactivity to foods were identified in . %. compared to women with no asthma, women with dda ( . %) were in a significantly higher background: regular exercise has been known as beneficial that it reduces the risk of chronic diseases including allergic diseases. however, little has known regarding the relationship between exercise and allergic diseases in korean adolescents. we analyzed the national data whether exercise is related to the prevalence of allergic diseases in the population of korean adolescents method: data from sixth korean national health and nutrition examination survey ( - ) that included adolescents from to years old was analyzed. we defined regular exercise according to physical activity guidelines for americans. multivariate regression analysis was performed to find whether lack of exercise could be a risk factor for allergic diseases. results: the prevalence of asthma, allergic rhinitis (ar) and atopic dermatitis (ad) were . %, . % and . % in korean adolescents, respectively. after adjusting for factors, lack of exercise was not associated with asthma and ar, but was significantly related to ad in korean adolescents (adjusted odd ratio . , . - . , results: it was found that over % of ch up to y.o. having the ad within allergic disease (ads). the most significant symptom was a long-lasting itchy rash lasting for month in . ± . % of g and . ± . % of g. the first morbidity of ad was noticed at the age of up to y.o. among . ± . %. at the age of ch - y.o. and older than y.o. the skin ads onset was noticed for . ± . % and . ± . % accordingly. the ad sl was determined as follows: %moderate (mo), %severity (s), % were ± kua/l, ± iu/l respectively. skin prick tests were positive in . % of the patients ( . % multiple allergens). grass pollens ( %) and dermatophagoides ( . %) were the most common allergens. average vitamin a and d levels were . ± μg/l ( - ), . ± . ( - ) respectively. thirty percent of the patients vitamin d levels were mildly low, . percent was low. in control group % was mildly low, vitamin a levels was low in . % of the patients. none of the children in control group had low vitamin a levels. we didn't find any statistical significant difference for both vitamin levels between patient and control groups. vitamin a deficiency was mostly found in asthma patients whereas vitamin d deficiency was mostly in allergic rhinitis and asthma groups. passive smoking and vitamin d deficiency was significantly related (p = . ). there wasn't any relation between asthma attacks and vitamin levels. conclusion: in conclusion vitamin a and d levels weren't found significantly related with allergic diseases but was found lower than control group. patients having chronic diseases are one of the population groups that are chronically exposed to drugs. this study aims at evaluate the impact of this factors in developing drug allergies in the medical staff. method: this was a cross-sectional study that included nurses from the uhc "mother theresa" of tirana. they were asked to fill up a questionnaire where questions about chronic diseases and drug allergies were included. . % were females and the mean age was . (+ . ) years old. relative risks with % ci were calculated for different groups. results: . % ( ) nurses reported to have at least a chronic disease. the most common non-atopic disease was hta followed by the groups of autoimmune and thyroid diseases. nurses who had one chronic disease have a rr of . ( % ci = . - . , p < . ) to develop a drug disease higher than those who didn't had any chronic disease, and those who have more than one chronic disease have a rr of , p < . ) to develop a drug disease. the presence of chronic diseases can be a risk factor to develop a drug allergy probably through the increased risk to drug exposure. these patients may be exposed to drugs not only through therapy but also through hospitalizations and other forms of health care. lapeere h ; oosterlinck p ; vermeir p ; vermeire i ; coppens m ; gevaert p ghent university hospital/ghent university, ghent, belgium; ghent university hospital, ghent, belgium; ghent university hospital/ghent university, ghent, belgium background: the key to managing latex allergies in healthcare professionals and patients lies in correct recognition and appropriate action. . million people are employed in the health care sector. while there are no overall statistics on the prevalence of latex allergy in that work force, studies do indicate that %- % of health care workers regularly exposed are sensitized, compared with %- % of the general population. latex allergy is defined as an immune mediated reaction to latex products (e.g. balloons, contact dermatitis for gloves, condoms, surgical catheters); these encompass immediate and delayed hypersensitivity reactions. method: based on the experience of the belgian dutch pathway network, a -phase method to develop, implement, evaluate and continuously follow up a care pathway for latex allergy was designed and implemented. the purpose of the study was to develop and implementation of latex allergy clinical care pathways to provide all staff at ghent university hospital with appropriate knowledge and skills to identify and manage patients who have a known latex allergy or those at risk of developing latex allergy. results: care pathways, also known as clinical pathways, are used all over the world to implement and monitor patient-centered care processes in a transparent way. care pathways are defined as a complex intervention. -phase method consists of: ) screening phase; ) project management phase; ) diagnostic-and objectification phase; ) development phase; ) implementation phase; ) evaluation phase and ) continuous follow-up phase. this phased approach is based on the deming cycle, better known as the "plando-study-act" (pdsa)-cycle. conclusion: this method can offer support to multidisciplinary teams (re)designing and implementing safe, efficient, effective, person-centered, timely, equitable, continuous and integrated care processes. however, the method is no guarantee to success. the key to success is the collaboration and critical attitude of the entire multidisciplinary team when implementing pathways. background: cord blood ige (cb-ige) were considered to be a useful predictive tool for allergic symptoms especially in early childhood. there is only sparse knowledge about their importance for health in later life. the aim of our work was to determine the importance of cb-ige for allergic symptoms in young adults. we also studied the possible modifying factors for cb-ige concentration. results: resutls shown as daily mean, pollen grains/m³: table . the daily means of pollen concentrations of cupressus arizonica, platanus acerifolia and plantago lanceolata in our area differs from other sites in madrid city. although cupressus arizonica and platanus acerifolia counting were lower, plantago lanceolata counts were higher, representing a relevant pollen in our area. the clinical relevance of these findings is under evaluation by our group. method: grass pollen counts were performed since - using a burkard days spore trap located in our allergy center in madrid. the beginning of the algid period of pollination was considered the first of three consecutive days with more than grains/m and the end, the last day of three consecutive days with more than grains/m . madrid, barajas meteorological station data, was used. skin prick tests (pt) to grass pollen was also studied in comparison conclusion: total grass pollen concentration did not suffer any increase or decrease in its counts despite the dramatic increase of the temperature. an advance at the beginning and the end of the season was seen. these changes significantly correlate with the temperature increase during may and july. discrete decrease in the sensitization prevalence. since several years, the reference method to monitor the biological particles concentrations has been the hirst method: a volumetric pollen trap, located on the roof of building for background measurements, sucks continuously l of air per minute, particles depositing by impaction on a coated tape. the tape is then analyzed by optical microscopy. the hirst method produces accurate but past data. nowadays, many researches are focused on the development on new devices to get real time information. method: rapid-e from plair sa is a device using red laser beam to determine the size and the shape of sucked particles and an ultraviolet ray to measure the fluorescence of these particles. the results: the correlation coefficients got between rapid-e and hirst trap are higher than % for most of calibrated pollens, this correlation reaching % for all pollen taxa: • plane % • pine % • birch % • oak % • plantain % • dactylus % • urticaceae % conclusion: new calibrations are planned for and a real time information will be set up. results: the quinquennial media concentrations since - were . ; . ; . ; . ; . ; . ; . and . grains/m . the quinquennial media temperatures were . ; . ; . ; . ; . ; . ; . and . °c. increase of . °c (r s = . p < . ). the beginning and the end of the actual season advanced days respectively in regard to the period from to . the annual prevalence of positive pt to platanus in was % an % in . the quinquennial media from to was , , and %. conclusion: platanus pollen counts had a dramatic increase that meaningfully correlates with the dramatic increase of the temperature. a discreet advance at the beginning and the end of the season was seen. these changes did not influence in a longer duration of the season. we observed a significant increase in platanus pollen sensitization prevalence whiting madrid pollinosis patients. results: the quinquennial media concentrations since - were , , , , , , and grains/m . the quinquennial media temperatures were . ; . ; . ; . ; . ; . ; . and . °c. increase of . °c (r s = . p < . ). the actual season beginning advanced in days and the end has results: over % of house dust samples collected between april and may from central european countries were found to contain bet v allergen at levels well above the limit of detection of . μg/g for elisa . ep kit and . μg/g on maria. samples were found to have much higher levels of bet v allergen from midto-late april, particularly those that were collected in germany, belgium and hungary. samples taken from outside of the pollination season were tested and found to be negative for bet v . in conclusion, we found that bet v allergen can be detected and quantified in house dust samples. these data suggest that household dust is a source of pollen allergen and could therefore be contributing to asthma and allergic rhinitis symptoms in individuals affected by pollen allergy. household dust may also be considered as a source of bet v allergen which could contribute to allergic sensitization. | cupressaceae pollen in the atmosphere of alentejo: disruption of pollen grain during air transport spring, depending on the temperature. despite being considered moderately allergenic, it might be responsible for winter allergic outbreaks. as ornamental trees, they are found scattered throughout the territory but are more abundant in pockets of wild forest, outside alentejo. despite being more common in mountain, this pollen type is captured in considerable amounts in alentejo, portugal, where its aerobiological features and allergenic impacts are poorly characterized. the aim of this work is to characterize the aerobiology of cupressaceae pollen, to evaluate the effect the meteorological conditions and the source of this allergenic pollen type in the atmosphere of evora, alentejo. method: pollen were collected using a hirst type -day pollen trap and pollen was identified following standard methodology. background: allergic rhinitis caused by pollen is one of the most common allergic diseases. the presence of pollen in the air is currently centrally monitored at roof top levels, and not in the direct living environment of sensitized subjects. in the current project we aimed to develop a handheld pollen sampler, called pollensniffer, that can collect pollen in the living environment of the allergic subjects. as a first step this device was validated against the standard burkard pollen sampler and used to monitor local pollen concentrations at street level in the city of leiden. method: rooftop level pollen were monitored routinely by a hirst type pollen sampler (burkard, uk). the pollensniffer ( | does the allergy risk due to pollen exposure information is useful for the allergy sufferers? sindt c; oliver g; thibaudon m background: in france the information for the allergy sufferers is not made with pollen counts, which have not a real signification, but with the allergy risk due to pollen exposure. method: since more than years, rnsa (réseau national de surveillance aérobiologique), the french aerobiology network, has measured the pollen exposure in the main cities of france, using background: the effect of environmental factors on allergic sensitizations is still unclear. rural areas vs cities have different exposure levels to pollutants and aeroallergens. these differences could give clues on the causes of higher allergic sensitization rates in children exposed to city air. method: two studies with children aged years old were initialized to analyse the airborne drives of allergic sensitization: seal (günzburg, children) and ae r kids (munich, children). capillary blood was collected and the parents filled in a questionary. sensitization rates were quantified using the immunocap ® isac sige array. pollen data were measured at both locations. results: in günzburg more children were sensitized to aeroallergens, however munich children showed significant higher sensitization to phl p (p < . ), despite the lower concentration of pollen. in günzburg % children had no sensitization at all compared to % in munich. % of the children in munich spend at least hour per day outside and % of the total have no animals at home. % felt symptoms of hay fever in the last months, the majority between march and june, which correlated with the pollen flight. results: the total rate of atopy in crd patients was . %, and asthma patients was the highest ( . %). the positive rate of phadiatop in urban asthma patients ( . %) was significantly higher than that in rural areas ( . %, p < . ) and the phadiatop positive rate of office staff ( . %) was significantly higher than that of outdoor workers ( . %, p < . ). the total rate of atopy in copd patients was . %, and in patients with acute exacerbation was . %. beside, atopy is a risk factor for dyspnea (or = . , p < . ), and the fvc levels in copd patients with atopy were significantly lower than those without ( . l vs . l, p < . ). optimal scaling analysis show that, there were a correlation between the tige and smoking coefficient (cronbach's alpha = . %). in addition, the correlation between the level of tige and phadiatop sige was so strong in the patients with mild to moderate asthma (r s = . , p < . ), but it was weak in severe asthma patients (r s = . , p < . ), and up to . % of the gold iii iv patients with low phadiatop level (≤ ku/l) had a high level of tige (≥ ku/l) compared gold i ii ( . %). conclusion: the rate of atopy in patients with crd is high, and atopy is an important factor affecting the process of crd. the patients with severe copd or asthma is likely to has high serum tige level but the level of common allergen sige is low, so the allergy screening strategy should be adjusted and we should pay attention to those patients, therefore, it is necessary to screen the sensitization situation of crd patients at first, and the results can guide the treatment, management and prevention of crd. background: due to a limited amount of epidemiological data [ ] it has been thought that many severe allergic asthmatics in germany remain unidentified and are therefore not adequately treated. a pilot project demonstrated that more than % of patients, having been mean total ige (sd) was . ( . ) ku/l. . % of the patients had no sensitization towards any of the specific iges tested, whereas % were positively tested on - allergens and further . % showed sensitizations towards > allergens. conclusion: approximately % of online recruited (severe) asthmatics had a total ige level of > ku/l and ≥ sensitization (allergen-specific ige) towards atopic allergens. this further supports the high prevalence of atopy in asthma. results: patients (mean age: ± . years, range - years, m/f ratio: . ) who suffered from allergic rhinitis or allergic rhinoconjunctivitis enrolled in this study. highest rate of skin sensitivity was for weeds/grasses pollen including salsola kali, amaranthus retroflexus, chenopodium album and compositae family ( . %, . %, . % and . % respectively). among tree's pollen; ash ( %), walnut ( . %) and mesquite ( . %) were the most common. less than % of patients showed skin reactivity to indoor allergens and storage mites, mix of cockroaches and house dust were the most common ( . %, . % and . % respectively). the results of current study confirmed the importance of weed/grass and trees pollen as the major source of allergic sensitization in our area. interestingly the rate of sensitization to indoor allergens was low which can be explained by geo-climatic situation. background: there are few studies of cutaneous sensitivity to gramineae in our region. mostly of them use allergens of foreign species. the study aims to estimate the prevalence of skin sensitivity to widespread grasses in our region. method: this is a retrospective observational study of patients with seasonal allergic rhinitis. patients were studied using skin tests with pollens extracts from pooideae, chloridoideae and panicoideae grass species. results: the prevalence of positive reaction to pollen from pooideae subfamily was . % (ic: . %- . %). in turn, prevalence of allergy to panicoideae subfamily pollens was . % (ic: . %- . %) and positive reaction to chloridoideae subfamily reach . % (ic: . %- . %). cochran test suggests that prevalence in those three groups is different (χ = . , p < . ). when comparing just the groups of allergens from pooideae and panicoideae differences are also significant (χ = . , p < . ). in particular, . % (ic: . %- . %) of patients were allergic to paspalum notatum. regarding cross-reactivity between subfamilies, we find a no crosscorrelation between pooideae and panicoideae (χ = . , p = . ). conclusion: in bahia blanca, patients with seasonal rhinitis are sensitive to pooideae, chloridoideae and panicoideae. paspalum notatum, belonging to panicoideae, has a significant prevalence, high reactivity and low cross-reactivity within the group of species studied. this last species is relevant because it is a native grass from the northwest region of our country, paraguay and the south of brazil. prevalence of grass positive skin tests in patients with seasonal rhinitis by species. allergen frequency percentage % ci results: correlation analyzes were performed between sige and spt and area results. the concentration with the highest correlation by diameter and area for blo t was μg/ml and for der f of μg/ml. in the case of der p the concentration with the highest correlation for the diameter was μg/ml and for the area of μg/ml. when evaluating the reproducibility of the results according to the area and the greater diameter of the spt, a strong agreement was observed for blo t in the concentrations of μg/ml and . μg/ml. results: among the patients, the majority of allergens-positive was t , accounting for . %, followed by f ( . %), f ( . %), ds ( . %) and ccd ( . %). the prevalence of plant-related allergens (t , w , f , f , w and u ) in ccd-positive patients were significantly higher than those in ccd-negative patients (all results: with our new point-of-care methods using a selected recombinant protein e other markers, we were able to detect the disease early as days post-infection and more than % of positive cases from chronic and low endemicity areas (which are characterized by hard to detect patients with extremely low parasite load, < eggs per gram of feces) were obtained. plus, chromatography poc-cca ® test was improved by our group with a urine concentration step that turned its sensibility from % to %. conclusion: monoclonal antibody and recombinant protein technologies allowed superior detection methods when comparing it to the conventional ones. in conclusion, data showed % of sensitivity of chronic patients and % of acute patients. marton c county hospital, oradea, romania background: allergic rhinitis is a disease that affects about a quarter of the population, a disease with an important negative impact on daily activities, both on learning and working ability, as well as spending leisure time or sleeping. in the western part of romania, the most popular and blamed allergen is ambrosia, in the late summer months. it is a plant of the compositae/asteraceae family, along with goldenrod, sunflower, dandelion, cocklebur, chamomile, wormwood, daisy, etc. allergen identification is important for applying prophylactic measures, but especially for determining the allergen to be desensitized. considering the possible cross-reactivity within the compositae plant family, as well as the possibility of co-sensitization, as well as the number of patients sensitized to these pollens, which is steadily increasing, i considered is necessary a broad screening for a more precise identification of the allergen and increase chances for a successful desensitization. method: the observational study includes patients who presented on october for testing with standardized allergen extracts, as recommended. criteria for inclusion: patients with specific symptoms of rhinoconjunctivitis in august and september, with or without asthma symptoms, who returned for allergic prick test after the end of treatment. criteria for exclusion: patients who disagreed with cutaneous testing, who did not discontinue antihistamine treatment or who had been treated for other diseases with drugs that influence skin testing. background: in recent years, cationic liposomes are thought to be the most effective and non-toxical nucleic acids`transport system, so most of gene therapy drugs are developed on their base. however, lipoplexes are quickly captured by reticuloendothelial system cells after the injection and taken out of a blood stream. there are many modification methods of liposomal surface for liposomes with prolonged pharmacokinetic properties production. addition of hydrophilic polymers (peg) is seemed to be the most promising approach, that is able not only to create steric barrier on the particle`s surface and prevent the interaction with blood plasma lipoproteins, but also inhibits the protein adsorption, opsonisation and subsequent degradation in human body. the aim of this study is the evaluation of liposomal surface modification by hydrophilic polymers influence on nucleic acids`lipoplexes conjugation and on their physico-chemical and biological properties. method: liposomes preparation (including peg-modified liposomes), size determination by photon-correlation spectroscopy, examination of transfection efficacy by luciferase assay. (c h ) ) were obtained. also the modified liposomes were produced by addition of % of peg (by mass) during thin lipid layer preparation step. the size distribution was analysed by photon-correlation spectroscopy. it was shown that peg addition does not increase the par- conclusion: it can be noted that addition of peg can change the lipoplex formation but the cationic liposomes still remain an effective rna delivery system. and peg modification will be able to impart prolonged properties for the vehicle in bloodstream. foundation (grant № - - ). ory c may cause a cross reaction with fel d (cat), can f (dog), equ c (horse), mus m (mouse) and rat n (rat). february eight patients that were treated at our institution were diagnosed with rabbit allergy. results: all eight patients with the diagnosis of rabbit allergy presented with signs of upper respiratory involvement. two patients had itching teary eyes, watery nasal discharge and sneezing while feeding farm rabbits. one of those also presented with dyspnea. four patients developed problems whenever in contact with domestic rabbits. one patient developed allergic rhinoconjunctivitis whenever she was home-her parents own a rabbit, but while away in her college room she had no problems. another patient had dyspnea whenever visiting his girlfriend's house. she owned a rabbit. two patients developed asthma-like symptoms, one also presented with angioedema. the other two had developed allergic rhinoconjunctivitis. two patients have problems in contact with cats, one of them also with cows, however skin prick tests were also positive to rabbit. three out of eight patients developed allergic asthma with a positive methacholine test. six patients had a positive house dust mite prick test. all patients were diagnosed with a positive prick tests to rabbit allergens. all were treated with a nasal steroid and antihistaminesic. they were also advised to avoid contact with the animal. conclusion: domestic rabbit-induced asthma and/or allergic rhinoconjunctivitis is possible, however it is still rare in our environment. it is very important to always ask the patient about their pets in general, not just focusing on cats or dogs. only with a thorough examination and history we can find the true cause of the patient's allergy where pets play an important role. korea. changes of protein and major allergen concentration were measured over one year by bradford assay, two-site elsia, and sds-page after reconstitution of the lyophilized allergen extracts in various buffer (normal saline, . % phenol saline, and or % glycerol with saline) and stored at room temperature (rt, ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) or refrigerated ( °c). results: more than % of the initial protein concentration in all four extracts examined was detected over one year when % glycerol was added and refrigerated, whereas . %- . % remained in the extracts at rt. the addition of % glycerol to the storage buffer was found to prevent protein degradation at rt. all four extracts were found to be stable when reconstituted in % glycerol. amb a , a major allergen of ragweed, was almost completely degraded in weeks at rt when reconstituted in a buffer without % glycerol. however, . %- . % of amb a content was detected after one year of incubation at °c in all buffer conditions except . % phenol. conclusion: addition of % glycerol as well as refrigeration was found to be the important to increase the shelf-life of allergen extracts from pollens of allergenic importance. results: this is the first genetic study of the bulgarian hae patients. genetic defects were identified in hae families are: nonsense, splice-site defects, frameshift mutations, indel non frameshift, missense, and large deletion of exon . novel mutations, not previously reported in human gene mutation databases were discovered, and were predicted to be deleterious due to the expected effect on dna transcript and protein. descriptive statistics were used to summarize the eq- d-y descriptive system responses and vas scores by treatment and visit. results: twelve patients with hae type i and a median (range) age of . ( ) ( ) ( ) ( ) ( ) years were enrolled, ( . %) of whom were female. during bop, treatment with u c inh, and u c -inh, ≤ . %, ≤ . %, and none of the patients, respectively, reported having problems with mobility, self-care, doing usual activities, pain or discomfort, and feeling worried, sad or unhappy. the mean [sd] eq- d vas scores increased from . ( . results: overall, the model-derived median exposure and peak concentration across all weight ranges in paediatric patients is predicted to be higher with wb vs weight-based dosing (table) . the effect was most pronounced in patients aged - years, where the wb dosing achieved approximately % higher values than weight-based dosing for median auc - ( ng hour/ml vs ng hour/ml, respectively) and c max values ( ng/ml vs ng/ml, respectively). the wb levels are closer to those in adults receiving mg icatibant (median auc - ng hour/ml; median c max ng/ ml) but never exceed them. results: samples from patients were analysed. lanadelumab concentrations in plasma increased with higher doses and dosing frequencies. steady state was reached around week (range week to week as evaluated by predose concentrations). at baseline, mean (sd) chmwk levels were . % ( . ), . % ( . ), . % ( . ) and . % ( . ) for patients in the placebo and lanadelumab mg q wks, mg q wks and mg q wks treatment arms, respectively. by week , mean (sd) chmwk levels decreased to . % ( . ), . % ( . ), and . % ( . ) following treatment with lanadelumab mg q wks, mg q wks, and mg q wks, respectively, and remained reduced throughout the treatment period. conversely, chmwk levels remained elevated at . % ( . ) at week in patients who received placebo. patients in the placebo group had the highest attack rates over the -week treatment period (mean . attacks/month), whereas the rates were markedly lower in patients treated with lanadelumab mg q wks ( . attacks/month), mg q wks ( . attacks/month) and mg q wks ( . attacks/month). dose-and frequency-dependent manner. exposure to lanadelumab was associated with decreased chmwk levels (indicating inhibition of plasma kallikrein activity) and lower hae attack rates, corroborating the efficacy findings and utility of chmwk as a bioactivity marker in the help study. with cyklokapron (tranexamic acid) since she was years old and took the medication very irregularly due to lack of efficacy. one year before presentation at our clinic, she married and moved to vienna. we started a treatment with the bradykinin- receptorantagonist icatibant sc at the beginning of the menses and if needed a second time at the time of ovulation. she responded well until she got pregnant. during pregnancy, she developed weekly attacks with increasing severity. therefore, a weekly treatment with humanplasma-derived, pasteurized, nanofiltered c -inhibitor (inh)-concentrate, units iv once a week was started and had to be increased to twice per week after one month of therapy due to increasing number and severity of attacks. results: with this treatment attack frequency and severity attenuated. in january she had a normal delivery at term and gave birth to an otherwise healthy son. treatment had to be continued during year of lactation period and also thereafter due to persistent attack severity. conclusion: there are only limited data for the use of humanplasma-derived, pasteurized, nanofiltered c -inh concentrate during pregnancy and lactation period. this case confirms the safety and efficacy of the named drug during these periods. wheals are yet classified. the best characterized stem from hereditary or acquired c inhibitor deficiency (c -inh-hae and c -inh-aae) . last year, the french angioedema network (creak) joined the registry of angioedema without wheals (cloud-r hae). here we present the contribution of the grenoble alpes university hospital (chuga) to this disease registry. the study population is composed of patients with a proved diagnosis of c -inh-hae/aae. the following items are collected: patients' personal-demographic data, clinical/laboratory/genetic characteristics, major comorbidities, treatments (prophylaxis/acute attacks). data from existing registries at chuga are merged into cloud-r hae and missing data obtained at follow-up visits. as from cloud-r hae structure, patients can directly provide information on angioedema attacks and their treatment through a dedicated electronic app, web connection or paper support, which is then transferred into the registry at chuga. method: in a retrospective study, we included a total number of patients, suffering from a chronic skin disease, whose lesions did not improve or even worsened under immunosuppressive treatment ( chronic ulcers/pyoderma gangrenosum, bullous autoimmune diseases, skin lymphomas). ffpe tissue was examined for the presence of cmv dna by pcr. next, within the framework of a small prospective study (n = ) we analyzed the seroprevalence of cmv as well as the presence of cmv dna in lesional skin in patients that had been diagnosed with a chronic skin disease and in whom longterm immunosuppressive therapy had been initiated. results: in the retrospective study cmv dna could only be detected in / chronic ulcers/pyoderma gangrenosum ( . %), but not in bullous autoimmune diseases and skin lymphomas. / patients ( . %) of the prospective study group were seropositive for anti-cmv-igg, as compared to / patients ( . %) in an ageand sex-matched control group. anti-cmv-igm could be detected in method: in this study, we aimed at testing the diagnostic potential of skin function measurements in ss. sixteen patients with conformed diagnosis ss were enrolled in the study. skin fibrosis was assessed by conventional rss and involvement of inner organs and serum inflammation parameters were determined. four objective criteria, namely transepidermal water loss (tewl), corneometry, ph and elasticity, were assessed at nine predefined sites of the body. results were compared to patients with atopic dermatitis (n = ) and acne vulgaris (n = ). method: a multicenter prospective observational study was conducted to investigate the clinical significance of serum scca in children as a biomarker for ad. patients with ad younger than years old and age-matched healthy children without any allergic disease were enrolled in this study. the severity of ad was evaluated using the objective scorad (o-scorad). the serum levels of scca , tarc and total ige were also measured. results: in total, patients with ad and non-allergic healthy children were recruited. the serum levels of scca had the strongest significant correlation with o-scorad, compared with tarc and ige (r = . , and . , respectively). after standard treatment with topical steroids and emollients resulting in an improvement of symptoms, the serum levels of scca and tarc decreased significantly. the area under the curve (auc) for the roc curve was higher for scca ( . ) than for tarc ( . ) or ige ( . ). the difference in aucs between a single cut-off value and age-dependent cut-off values was not significant for scca , compared with that for tarc ( . and . , respectively). conclusion: scca is a more reliable biomarker than tarc for the diagnosis of ad and for determining the clinical severity of ad in children. challenges in predicting severity of atopic eczema patients results: before modeling, we checked for significant differences between patients and controls. these were detected for the levels of ccl , ccl , cxcl , ige and ldh. next, we assessed whether single serum proteins already explain disease severity by calculating correlations. twelve of the proteins, namely gcsf, il- , il- , il- , ccl , il- ra, cxcl , ifng, ccl , il- ß, ccl , and il- , significantly correlate with severity (r range: . - . ). finally, we built a model for the severity of ae based on all measured serum proteins. ten of the proteins are included in the best-fit model (adjusted r = . ). the overall correlation between original and predicted severity scores is high (r = . ) nevertheless the cross validation prediction error is substantial with %. conclusion: applied in daily practice, a prediction error of % translates to a possible miscalculation of scorad points in both directions and therefore the model is of no practical use. aside from using model-based quality measures like cross validation prediction errors to infer the usefulness of predictive models, testing them in independent cohorts could validate these models. collaborations among scientists working on similar approaches would lead to an increase in statistical power and ideally to more robust models. only robust and validated models are going to have the chance to take the step forward from being a result of computational modeling to being applied in the clinical practice of assessing disease severity in patients. jargosch m ; lauffer f ; pätzold k ; krause l ; garzorz-stark n ; schmidt-weber c ; eyerich s ; eyerich k preclinical studies in cell cultures, mice, guinea pigs and rabbits, comprising sterility, cytotoxicity, systemic toxicity, skin irritation, delay contact sensitization and phototoxicity tests, demonstrated safety of this therapeutic agent. we next conducted a single-blinded, intra-individually controlled, phased clinical trial on patients with keloids. the aim was to determine the effects of -month therapy on keloid volume and symptoms of pain and itch. two similar keloids on each subject were selectedone was treated with once-daily, self-administered application of triamcinolone-loaded ( . mg/patch) microneedles for weeks, while the other served as control with no intervention. outcome measures were (a) keloid volume using a -dimensional high-resolution ( . mm) scanner and (b) pain and itch scores on - numerical rating scales. evaluations were performed at baseline, and weeks. in phase of the trial, the whole process was repeated using microneedles loaded with a higher dose of triamcinolone ( . mg/patch). case report: a -year-old girl was admitted to our department with a single round-shaped lesion in the popliteal fossa which spread to extremities, trunk and face and persisted for several weeks and then faded slowly to residual hyperpigmented patches. courses of antihistamines, antibiotics, cyclosporine a, fluconazole, hydroxychloroquine, prednisolone and topical steroids were ineffective. also patient has had history of itchy urticarial rash and angioedema since -year-old, suffered from the flares triggered by physical exertion, stress, cold air and water, spicy food, which resolved within - hours. the patient's father and -year-old brother also had chronic urticaria induced by the same stimuli. the physical examination revealed multiple pink-to-red non-scaly, non-pruritic papules coalescing into annular, arcuate, polycyclic plaques ( - cm) with central clearing, centrifugal spread, indu- | the role of humoral immunity in the pathogenesis of psoriasis results: we found significantly increased levels of iga in the serum of treatment-naïve psoriasis patients correlating with disease score. however, iga was only observed in dermal vessels of skin sections. we next performed in-depth analysis of peripheral b cell subsets using flow cytometry. among all investigated subsets, we only found a moderate positive correlation of cd + plasma cells with iga levels and disease score in untreated psoriasis patients. however, in the group of treated psoriasis patients, neither did iga levels drop nor did plasma cells correlate with iga levels and disease score, rather hinting at an epiphenomenal finding. confirming our hypothesis that psoriasis can develop in the absence of proper humoral immunity, we present a patient who suffered concomitantly from both psoriasis and a hereditary common variable immune defect (cvid). conclusion: here, we provide new insights in the immunology of psoriasis, demonstrating the clear dominance of t cells over shifts in b cell subsets. conclusion: allergic diseases show an increasing incidence in geriatric age. this is partly due to the growing emphasis on a more accurate and careful diagnosis of the aging population. we must also take into consideration the influence of other factors, besides comorbidities and therapeutic regimens in elderly that might affects the immune response, such as environmental pollution as well as food contamination and changing dietary habits of elderly such as easy access to exotic food. one of the challenges in the decades to come is recognizing and fulfilling the need for accurate and timely diagnostics of allergic manifestations in elderly patients, as important part of achieving the best possible quality of life for this growing age group. method: sixty-eight patients with various forms of psoriasis and healthy subjects (healthy control group) were assessed after informed consent was obtained. all subjects were asked to complete a questionnaire including age, gender, duration of psoriasis, concomitant diseases and medications. in the group of patients psoriasis was with only skin involvement with skin plus joints involvement ranging from moderate to severe. psoriaticplaques were evaluated by a specialized medical team using the psoriasis area and severity index (pasi). all patients were seen by a dermatologist and clinical immunologist, who collected data considering the demographic, health status and any other relevant details. blood samples included serum levels of -hydroxycholecalciferol and tnf-α using an elisa kit (germany). method: % ethanolic extract of sp (sp etoh ) and its five major chemical constituents are prepared. to elucidate whether human orai modulated by sp etoh and its chemical constituents, conventional whole-cell patch clamp performed in horai -overexpressing hek t cell. we also assessed whether sp etoh and its constituents could inhibit mast cell degranulation and t cell activation. results: in jurkat t lymphocytes, we found that mg/ml sp etoh inhibited orai current (i orai ) by . ± . %, while one of its constituents (compound v (com v ); μm) inhibited i oria by . ± . %. investigation of human primary t cell proliferation induced by co-stimulation with antibodies to cluster of differentiation and , and of rbl- h mast cell degranulation following ige-antigen complex stimulation, revealed that μm com v inhibited both t cell proliferation (by . ± . %) and mast cell degranulation (by . ± . %); these effects were concentrationdependent, and no cytotoxicity was observed. conclusion: considering that most regional plants have not been investigated chemically or pharmaceutically, they remain as untapped potential sources of topical agents for drugs and other application. our findings suggest that com v , which derived from sp etoh , represents a promising candidate compound for the development of therapeutic agents for the prevention and treatment of allergic diseases. results: the cohort consists of caucasian patients. eight of them ( %) are women. the mean age (and range) at the clinical presentation of disease was years ( - years). the mean age at diagnosis for men was years and years for women. all patients have a positive history of recurrent and/or persistent lip swelling, of them ( %) report oral ulceration, cases ( %) have history of previous or current facial palsy and patients ( %) present tongue fissuring. concurrent cd has been diagnosed in one patient. biopsy reports were available for patients ( %); in cases ( %) non-caseating granulomas were seen. various therapeutic approaches have been described: intralesional corticosteroids had a good response in patients, infliximab was partially effective in cases; oral corticosteroids and/or methotrexate seem to cause a partial symptoms improvement. conclusion: this is the first attempt, in our knowledge, to (a) centralize all data of patients with ofg in a national registry with the aim of carrying out epidemiological data and (b) develop italian guidelines including a diagnostic-therapeutic flow chart, shared by the participating centers. the registry will guide the clinicians in the identification and management of the ofg patients, reducing the diagnostic delay and hopefully improving quality of life. case report: a -year-old girl without personal history of atopy, got a temporary tattoo with henna. after three days, she developed a local exudative, erythematous eruption with painful blisters lesions that followed the contours of the tattoo. she had neither fever nor other lesions. she was treated with topic methylprednisolone-gentamicin showing an important improvement days after. as a liquenoid scar remained in tattoo area, trofolastin ® (centella asiatica, αtocopherol, hydrolysed collagen, elastin) patch was prescribed to be placed on the scar. forty-eight hours later, the patch was removed and was newly observed an exudative, erythematous and painful wound that required oral treatment with amoxicillin-clavulanic. after three days, the girl developed on a maculopapular, generalized and itching rash. she was treated with dexchlorpheniramine and methylprednisolone with a complete resolution in days and she was referred to our allergy unit to be studied because of a suspicion of drug allergy to amoxicillin-clavulanic acid. an allergy workup was performed after obtaining an informed consent. case report: it may be sometimes difficult to find the causing allergen in allergic contact dermatitis. face is a region on which various materials contact. in this manuscript a woman case is presented who shows patch test positivity to her husband's shaving product. a years old woman applied because of allergic contact dermatitis on her face. it is learnt that lesions have been continuing for a long time, occasionally getting well with corticosteroid creams; but continuing again. patch test was performed with european standard series and cosmetic products she was using. negative result was observed. following, patch test was performed for the products her husband was using. positive results were obtained for the shaving cream of her husband was using. in detailed anamnesis, it is learnt that the lesions developed approximately month after her husband started to use this cream. it is advised not to use this product to her husband. the disease did not repeat again. it should not be forgotten that cases with allergic contact dermatitis could get in touch with allergenic materials via individuals in close contact. gül Ü akdeniz university faculty of medicine, department of dermatology, antalya, turkey case report: tnf-alpha plays role in etiopathogenesis of allergic contact dermatitis (acd). in mice which lack tnf-alpha, the response of late type hypersensitivity is spoiled. in addition, tnfalpha blocker are also used in some cases with acd. in this poster the results of european standard patch test is given in which acd is observed and tnf-alpha blocker are used without dermatological indication. cases who use tnf-alpha blocker applied because of acd: there was lesion in one case on face, in other case on face and hand, and in the last case only on hand. european standard patch test was performed to patients who were continuing to use tnf-alpha blocker. in one case no positive response was observed, while in two cases positive response to more than one allergen were obtained. in conclusion, tnf-alpha blockages cannot suppress the response of delayed type hypersensitivity. | case of allergy to nickel on the background of its intake in food peredelskaya m case report: nickel is one of the most commonly used metals; it is used for the manufacture of jewelry, plates and dishes, and medical products. a patient n, years old, female, complains of pruritic rash on the body skin with the itch intensity up to - points and the number of lesions more than . allergic background: for quite some time now the patient noted occasional eruptions on her skin after a contact with jewelry made of non-precious metals. previously patch skin tests with nickel showed a positive reaction. the patient sought emergency medical care with complaints of a number of itchy lesions erupted on her whole body during the last hours. on admittance: state of moderate severity, the patient was emotionally labile, focused on her body sensations, tearful. on the skin of face, upper and lower extremities and torso a punctuate purpura with lesions up to . cm diameter, prone to confluent. a physical status was within normal limits. in order to control the itching, as well as to sedate the patient, antihistamines of the first generation were administrated parenterally; but the eruptions kept to progress and to intensify; lesions were spread throughout the whole body, merged in gigantic areas. system glucocorticosteroids therapy was administrated, with mg of prednisolone, but then new lesions kept appearing in a large number, including after-meal rash. water, tea, bakery products, thin yoghurts did not impact the skin condition, whereas the intake of pasta, cereals, and similar products provoked intensifying of eruptions. the patient observation revealed a sharp increase in the rash after such manipulations as intravenous injections or blood sampling from the vein, the process spreading from the injection site to the entire arm. a detailed anamnesis of the disease: on the eve of the start of hives, the patient purchased a coffee machine (with metal nickel-plated parts) and started to use it. diagnosis: a systemic contact dermatitis. an allergy to nickel. the injection treatment was discontinued and a therapy with per oral gcs and antihistamines of the second generation was administrated. a recommendation was given to cook and to eat food using ceramic or wooden utensils. three days later marked positive dynamics of the skin process has been noted. the episode of systemic contact dermatitis has developed due to exposure to nickel from ingestion in food, as well as during the parenteral treatment. background: anaphylaxis reactions during anesthesia can have a mortality of %- %. / of the anaphylaxis in the operating room are due to the use of neuromuscular blockers. rocuronium is frequently involved because is oftenly used. we present a case of a years old man with an anaphylaxis shock due to the administration of rocuronium. method: years old man with no personal history of interest that is going to undergo vertebral surgery. minutes after anesthetic induction with fentanyl, propofol and rocuronium he started with lowering of oxygen saturation. orotracheal intubation is performed and, with the suspicion of anaphylaxis shock, adrenaline, antihistamines and corticoids were administered. after minutes without improvement, mg of sugammadex was administered, given the possibility that the condition was secondary to the use of rocuronium. tryptasa level was . results: skin test to fentanyl, propofol, látex and rocuronium were done weeks after and only rocuronium test was positive. conclusion: in summary, the occurrence of anaphylactic shock after neuromuscular blockers is widely described in medical literature. there are conflicting data about the use of sugammadex as coadjutant treatment in case of anaphylaxis due to the use of rocuronium. we believe is a good option when conventional treatment is not useful. case report: a -year-old woman with past history of allergic rhinitis and hypertension was admitted to the obstetrics service in labor of first child in april . epidural anesthesia with ropivacain and sufentanil was administered. as there was no labor progression, eighteen hours later she was admitted to undergo cesarean section and epidural anesthesia was re-administered. metoclopramide, ampicilin and ranitidine were given intravenously. during ranitidine perfusion, the patient presented general cutaneous erythema and pruritus, tongue, lips and eyelids angioedema and dyspnea. perfusion was suspended and hydrocortisone and supplementary oxygen administered. she denied any type of previous adverse reaction to drugs and any symptoms with use of latex-containing material. allergic evaluation revealed negative latex skin prick test (spt) and negative penicillin, amoxicillin and ampicillin specific ige assay. skin prick and intradermal tests with sufentanil, ppl, mdm, amoxicillin and ampicilin were negative. oral amoxicilin and metoclopramide provocation challenge were negative. spt and subcutaneous provocation challenge with ropivacain were negative. spt with ranitidine was negative but skin intradermal test proved to be positive. the patient was taught to avoid histamine h receptor antagonists and use as a safe alternative proton pump inhibitors. conclusion: anaphylaxis during anesthesia is an unpredictable, severe, and rare reaction. the identification of responsible drugs is a complex task. we report a case in which a commonly used and generally safe drug caused a severe reaction, which demonstrated that even the least obvious culprit should not be disregarded. epidemiologic data suggest that the number of cases of chx allergy appears to be increasing. background: chlorhexidine is a synthetic chemical with excellent antiseptic and disinfectant quality frequently used in everyday products and medical devices. the prevalence of allergic reactions towards chlorhexidine is rare, though there is increasing evidence for its allergenic potential. in this case we report about a patient with serious perioperative anaphylaxis. next to multiple potential allergens that he was exposed to, a chlorhexidine containing lubrication gel has been used for urinary catheterisation. within minutes post-exposure, the patient developed generalized urticaria, bronchospasm, tachycardia and hypotension. material and methods: we performed skin prick tests and intradermal tests with all substances documented in the anaesthesia chart, further we analysed specific immunoglobulin e (sige) antibodies and performed oral provocation challenges for exclusion. results: in the skin tests all substances except for chlorhexidine (spt: mm wheal diameter/ mm erythema) were negative. a sensitization for chlorhexidine was further corroborated by chlorhexidine-specific ige antibody ( . ku/l) in the patient's serum. in addition, the challenges for the drugs without sensitization (cefuroxime, lidocaine) were tolerated. considering all potentially relevant allergens that the patient was exposed to and the proof of specific sensitization, we diagnosed an immediate-type allergy towards chlorhexidine. conclusion: with the ubiquitous use of chlorhexidine an increase in hypersensitivity reactions including immediate-type allergic reactions is observed. anaphylactic reactions are rare, but potentially life-threatening, the diagnosis is crucial. as a warning declaration in medical devices is missing, the diagnosis of chlorhexidine allergy might be easily under-recognized or misdiagnosed. unfortunately, until now validated provocation tests are not existent, but the evaluation of combined skin tests and sige is sensitive and specific. | an approach to incidence of death due to anaphylaxis in spain ( spain ( - background: reports about death due to anaphylaxis are still scarce because of its rarity and limited information to few countries. also, data source analysis is usually not included. we report incidence of death due to anaphylaxis in spain using two databases. method: we used a hospital series of anaphylaxis deaths from the spanish hospital system and a series from the national institute of toxicology and forensic sciences (intcf) predominantly formed by extra-hospital deaths. deaths from the spanish hospital system were extracted using codes from icd- -cm, related to anaphylaxis among all deaths occured in the - period. for extracting deaths due to anaphylaxis at the intcf in the same period, two allergist researchers identified these deaths among cases with suspicion of anaphylaxis cause. a regression logistic was run to discriminate the probability of anaphylaxis death belonging to each database. incidence rates were calculated for the different groups (age, sex) using the spanish population as the denominator. temporal trends were calculated from the hospital database using poisson regression models with the number of cases of anaphylaxis detected each year as the dependent variable, and age and sex as covariates. results: there were four positive predictors of fatal anaphylaxis after the logistic model (usual allergen, positive specific ige, suggestive symptoms and previous reaction to the same allergen case report: we were informed that a girl was admitted to the pediatric endocrinology department due to early breast development. she had been diagnosed as central precocious puberty (pp). later, triptorelin acetate (ta) therapy had been started monthly. within minutes after first sc injection of ta at home, she had developed shortness of breath, decreased air entry, and coughing for ten minutes and lastly she had developed vomiting for minutes. her symptoms were accompanied by a pruritic blanchable maculopapular rash on her ears, cheeks, lips, and eyelids approximately for two hours. although they had applied emergency department of the local hospital. based on the diagnosis of anaphylaxis she was immediately treated with adrenalin. she was subsequently hospitalized for possible recurrence and discharged next day without any further events. treatment with another preparation, leuprolide aseptate(la-lucrin), as an alternative treatment was started with premedication against anaphylaxis risk only at first time and the patient did not develop any reactions. the patient is still on this treatment with no complications. anaphylaxis is diagnosed in the presence of a detectable allergen accompanied by symptoms of two systems. our patient had symptoms of the three systems as described above, that is, dyspnea with coughing, hives, nausea, and vomiting. main treatment of anaphylaxis is the epinephrine use. early usage maximizes the likelihood of survival. diagnostic tests with culprit drug were not performed in our hospital if the patient had the anaphylactic drug reaction and grouped as "physician diagnosed anaphylaxis". there has been only one report regarding anaphylaxis to ta treatment in cpp in turkey. in the literature, anaphylactic reactions against ta have been reported only in few pediatric cases. gnrh analogues are important to ensure the physiological growth in precocious puberty. because anaphylaxis can be lethal, and gnrh analogues are similar structure; the present case suggests that one should bear in mind the possibility of anaphylaxis in all patients who receive gonadotropin-releasing hormone and anologs and monitor such patients carefully as needed. furthermore, we must provide sufficient information of adverse reactions, including anaphylaxis, to patients. hence, managements against anaphylactic shocks should be recognized and treatment should be given immediately. | an anaphylactic shock induced by the rocuronium anesthesia: a case report cabrera v; barrios j; callero a; gonzález ce; pérez e; martínez ja hospital universitario nuestra sra de la candelaria, santa cruz, spain background: the anesthetic act is a unique pharmacological situation, where the patient is exposed to a multitude of substances.among them, neuromuscular blocking agents are the leading cause of preanesthetic anaphylaxis, with a frequency of between %- %.followed by latex in second place and antibiotics in third place. among the neuromuscular relaxants, most reactions are due to suxamethonium or succinyl-choline in . %, followed by atracurium, rocuronium and verocuronium.the one that produces the least reactions is cisatracurium. method: a -year-old woman presented a type iii anaphylaxis of the brown classification during the anesthetic induction in a surgery scheduled for laparoscopic cholecystectomy. for which adrenaline, dexchlorpheniramine, hydrocortisone, ranitidine and sugammadex was administered and was transferred with orotracheal intubation to the anesthetic resuscitation room. due to good evolution of the patient, she was extubated within three hours. the drugs involved in the reaction were: rocuronium, amoxicillin-clavulanic, fentanyl, propofol, midazolam, lidocaine and atropine. there was a high suspicion by the anesthesiology and resuscitation service that the abstracts reaction could have been due to the neuromuscular relaxant used, in this case rocuronium, since the reaction was reversed with sugammadex. the patient had undergone surgeries under general anesthesia previously without incidents. a specific allergy study was performed with laboratory tests with tryptase, skin tests with drugs and basophil activation test for rocuronium, sugammadex-rocuronium mixture and cisatracurium. • serial measurement of serum tryptase: . u/l, . u/l y . u/l there is no activation of basophils for sugammadex-rocuronium mixture and cisatracurium. the patient is diagnosed with rocuronium allergy. sugammadex not only acts as an antidote to reverse the neuromuscular block against rocuronium, but also has antiallergic properties by inhibiting mast cells. as an alternative for future interventions, the patient can use cisatracurium, as the skin tests and the basophil activation test are negative. unal d yedikule chest disease, istanbul, turkey case report: tetracycline hydrochloride may rarely cause hypersensitivity reactions. (hrs). immediate type reactions are at the level of case presentations and anaphylaxis is reported. we report a patient with late onset anaphylaxis caused by tetracycline. a -year-old woman referred to our allergy outpatient clinic because of urticaria due to an antibiotic that she does not remember the name of. the patient reported that many years before she had presented urticaria on her arms and legs one hour after taking the drug. to confirm drug allergy invivo and invitro testing have to performed. for many drugs there was no validated skin test. for all that invitro tests are often less sensitive and more expensive. therefore single blind placebo controlled drug provocation tests (sbpcdpt) is the gold standard in the diagnosis of drug hypersensitivity reactions. we did not know which group of antibiotics were allergy to the patient. because the patient had history of asthma and atypical pneumonia we were performed the allergy tests with clarithromycin and she had tolerated. it was necessary to use tetracycline because of patient had vaginal infection. skin tests have not yet been validated for tetracyclines. for skin prick tests of tetracycline that is only available as tablet, not in a soluble form. therefore, the tablet was smashed and diluted with . % nacl. it was also tested. healthy controls to exclude irritation. because of skin prick tests with tetracycline negative. sbpcdpt was planned. sbpcdpt was performed by progressively increasing four divided doses at minute intervals. two hours after last dose the patient experienced dyspnea, palpitations, and hypotension. as the reaction was considered to be anaphylaxis, she was given . mg of intramuscular epinephrine, intravenous mg of pheniramine, and mg of methylprednisolone. the reaction resolved within hours. blood tryptase level was . ug/l taken at the nd hour of the reaction approximately months after the anaphylaxis, serum tryptase level was . ug/l the serum tryptase level and the patient's clinic confirmed anaphylaxis due to tetracycline. we had proved late onset anaphylaxis due to tetracycline with the patient's clinic and serum tryptase level. anaphylaxis due to tetracycline is limited to case reports and small series but to our knowledge, there is no previous report of late onset tetracycline anaphylaxis. | case series of ige mediated anaphylactic shock due to polysorbate case : an -year-old male patient with hypertension, hypothyroidism and episodes of sustained monomorphic ventricular tachycardia (smvt), developed an anaphylactic shock after the administration of injectable amiodarone due to smvt. serum tryptase levels reached . μg/l during the reaction (baseline . μg/ l). skin tests were positive to injectable amiodarone (prick mg/ ml, intradermal . mg/ml) and polysorbate and (prick-prick). skin prick-prick to amiodarone and dronedarone tablets were negative. the patient tolerated oral amiodarone. we report an anaphylactic reaction during the first intravenous administration of amiodarone in a female patient being treated for supraventricular tachycardia. bat was positive, suggesting a direct effect on basophil activation, as the patient was not previously exposed to the drug. | anaphylaxis during labor: don't forget to think of an amniotic fluid embolism case report: a -year old primigravida ( weeks of gestational age) was admitted with signs of pre-eclampsia and labor was induced. benzylpenicillin and ropivacaine (epidural anesthesia) was administered > hours before the event. eighteen minutes after starting an infusion with oxytocin ( ml/h) and a vaginal toucher, the patient developed a decreased level of consciousness, generalized edema/erythema and thoracic pain, followed within minutes by fetal bradycardia and maternal collapse. after resuscitation, an urgent sectio was performed, and a baby girl was born. patient was extubated the same day. serum tryptase, hours after the event, was . μg/l (basal tryptase level . μg/l). allergy workup demonstrated negative specific ige and skin tests for latex and chlorhexidine, negative skin and provocation testing for ropivacain. however, skin testing was hampered by dermographism: intradermal (idr) testing of benzylpenicillin ( iu/ml, / - / ) and oxytocin ( ie/ml, / - / ) showed extensive erythema. idr testing of oxytocin in healthy volunteers showed pallor around the injection site (n = ). intravenous provocation with benzylpenicillin was uneventful. a basophil activation test with oxytocin (patient and control) was negative. an additional bone marrow evaluation showed no evidence for mastocytosis. although clinical criteria for anaphylaxis were fulfilled, a diagnosis of an amniotic fluid embolism (afe) was concluded. no drugs were prohibited. patient gave consent for publication. conclusions: afe is one of the most devastating conditions in obstetrics, occurring typically during labor and delivery or immediately postpartum. the pathogenesis remains incompletely understood, however, it has been suggested that afe involves an anaphylactic reaction to fetal tissue exposure associated with breaches of the maternal-fetal physiological barrier, supported by transiently increased serum tryptase levels. the diagnosis is primarily clinical, and generally one of exclusion. no specific antemortem diagnostic tests are available to confirm afe. postmortem identification of fetal squames in the maternal pulmonary circulation gives final diagnosis. differential diagnosis includes drug-induced anaphylaxis or mastocytosis, which were ruled out in our case. method: the patient presented after hymenoptera stings dyspnoea, generalized erythema with pruritus, edema of the face that required emergency therapy in episodes. results: an angio-ct was performed at the inferior limbs with optiray and minutes after the end of the investigation, the patient presented an anaphylactic shock requiring admission to the icu for days. conclusion: the patient's progression was slowly favorable. results: thirty seven cases were reported. ( %) were women. the median age was years. ( %) had dress/dihs, ( %) ten, ( %) sjs, ( %) agep, ( %) other not classified scars, and ( . %) overlapping ten/sjs. in % of the patients the suspect drug was withdrawn. thirty one patients ( %) received systemic anti-inflammatory treatment. twenty six patients ( %) received intravenous (iv) corticosteroids alone, ( %) iv corticosteroids plus ivig, ( . %) iv corticosteroids plus ivig, infliximab and colchicine, and ( . %) iv corticosteroids plus infliximab and cyclosporin. there were complications in cases ( %), and death occurred in the patient with overlapping ten/sjs who had received corticosteroids plus immunoglobulin. in this study, our aim was to evaluate severe ihr to icm. method: we retrospectively analysed patient who consulted to our allergy unit between july and july reporting symptoms within hour after icm administration. from a total of patients, we selected eight that had suffered an anaphylactic reaction. a written informed consent had been obtained for diagnostic procedures. introduction: immediate type hypersensitivity reactions to pemetrexed have been reported as very rare case reports. as limited availability of alternative therapies in chemotherapeutic allergy, desensitization plays an important role in ensuring reuse of the culprit drug. we report a case of pemetrexed anaphylaxis and successful desensitization. case: years old female patient with lung adenocarcinoma had been treated with cisplatin-pemetrexed as second-line therapy. during the th cycle within minutes after the end of pemetrexed infusion she had chest pain, shortness of breath, cough, swallowing difficulty, erythema on face and body, nausea and vomiting. she was diagnosed as anaphylaxis and adrenaline was administered besides antihistamine and methylprednisolone. symptoms and findings of the patient were improved within minutes. oncologists decelerated no suitable alternative therapy for the patient. although skin tests (prick test with / concentration, intradermal test with / - / concentration) were negative with pemetrexed, taking into account the severity of the reaction, pemetrexed desensitization was applied with the consent of the patient. no reaction was observed during the procedure result: desensitization is a successful and safe method of reusing the culprit drug. successful desensitization of pemetrexed with immediate type hypersensitivity reaction is described. the years old man was admitted emergency department with fever, rash (maculo-papular) and pain in joints. it was the th day of taking of amoxicillin. the hematological abnormalities were revealed -eosinophilia, increased erythrocytes sedimentation rate. the level of serum ecp was μg/l. the liver functional tests were increased too. hepatomegaly and cervical lymphadenopathy were observed. the patient was treated as a dress syndrome (infusion therapy, systemic steroids) and discharged after weeks with improvement. all hematologic parameters were in normal limits. lymphadenopathies were resolved. the level of ecp was retaken - μg/l. patient was prescribed oral steroids till normalization of limits of ecp. it lasted weeks after discharging. the serum level of ecp can play key role in the management of dress syndrome and in the making of diagnostic processes. until now, allergic or anaphylactic reactions to peg have been rarely reported. although patient with hypersensitivity to peg should avoid peg-containing drugs or products, patient who needs colonoscopy has few alternative bowel cleansing methods. no successful desensitization to peg has been reported to date. we report a case of successful desensitization and subsequent safe colonoscopic examination in patient with allergic reaction to peg. method: a -year-old woman developed generalized urticaria, pruritus, throat swelling, and shortness of breath immediately after taking a bowel preparation solution for colonoscopy. she had the first symptoms years ago, and has had more experiences so far. the symptoms appeared within - minutes of taking cleansing solution, and the endoscopy was no longer possible. seven years ago, she underwent endoscopy with no specific symptom. when the last symptom occurred a year ago, she was treated at emergency room because of severe dyspnea and dizziness. the patient came to our clinic for the proper diagnosis of allergy reaction and possible colonoscopic evaluation. objectives: to describe a successful desensitization to vedolizumab in one patient diagnosed with ulcerative colitis, refractory to infliximab and intolerant to azathioprine and sulfasalazine. methods: our patient was a year old woman receiving treatment with intravenous vedolizumab ( mg/cycle). cycles and were well tolerated, but in cycles , and she experienced hypotension and dyspnea, in spite of premedication with oral dexamethasone and metoclopramide. during cycle , she also showed facial angioedema, systemic urticarial reaction and oropharyngeal pruritus treated with methylprednisolone and ebastine. the results of prick (vedolizumab concentration mg/ml) and intradermal skin tests ( : and : ) with vedolizumab were negative in our patient and in ten healthy controls. total ige level was . ui/ml and specific ige against dermatophagoides were positive, being negative for hamster epithelium and latex. since vedolizumab was the only therapeutic alternative, the patient was planned to undergo vedolizumab desensitization according to an -step protocol. patient informed consent was obtained previously. premedication consisting of ebastine, acetylsalicylic acid, montelukast and methylprednisolone one hour before desensitization was administered. desensitization protocol was performed with a total duration of hours and minutes and a total dose of mg. dose steps were . , . , . , . , . , , and . mg. conclusions: our -step protocol desensitization to vedolizumab resulted safe and effective in our patient and it has allowed the continuation of treatment with vedolizumab for her ulcerative colitis. montelukast, anti h and h blockers were used for the pretreatment of desensitization. all procedures (skin and blood tests, desensitization) were carried out with the informed consent of the patient. we present an exceptional, non-immediate case of fever after cisplatin and etoposide infusion with positive skin test. case report: a -year-old man, recently diagnostic of lung cancer stadium iv, in first line of treatment with cisplatin and etoposide, started hours after finishing the nd infusion: facial erythema that becomes generalized after - hours from infusion. twelve hours later, developed warmth sensation, shivering and fever ( °c) that persisted despite the use of several oral antipyretics treatment. infectious disease was discarded, so he was referred to our department in order to assess further administration of cisplatin and etoposide. methodology: skin testing was performed days after the last reaction to minimize false-negative results, as follows (a) cisplatin prick test ( mg/ml) and intradermal tests ( . mg/ml); (b) etoposide prick test ( mg/ml) and intradermal tests ( mg/ml); with histamine as the positive control and nacl-diluent as the negative control. the results of skin test were negative for immediate reading. but two hours later, intradermal test for cisplatin turned into red and itchy and hours later, still associated a wheal. the patient was classified as high-risk (lung diseases, forced expiratory volume in second < l) and underwent programmed inpatient desensitization according to the standardized birmingham women's hospital protocol. desensitization was performed in the medical intensive care unit. the patient received only standard oncology premedication. he tolerated the final dose of cisplatin with no breakthrough reactions followed by etoposide standard infusion. two additional desensitization procedures were performed, with no breakthrough reactions. therapy ended when the disease worsened. the importance of this case, lies in the fact that fever has not been described as a clinical hypersensitivity reaction for cisplatin but for oxaliplatin. although a non-immediate reaction at the nd infusion of cisplatin could scarcely suggest a hypersensitivity reaction, the positive skin test and successful desensitization with this drug, could suggest it. introduction: propylthiouracil is commonly used as the first treatment option in patients with hyperthyroidism. although it is generally a well-tolerated drug, it may lead to some side effects including liver damage, leucopenia and skin rash. among skin rash findings, urticaria is considerably common. nevertheless, in cases that developed urticaria, a rapid desensitization protocol specific to propylthiouracil has not been encountered. we represented a case in which we applied successful oral desensitization via a scheme in accordance with general desensitization principles in a case that developed propylthiouracil-induced urticaria. case report: propylthiouracil at a dose of mg/day was initiated for a year-old female patient with diagnosis of hyperthyroidism in internal diseases clinic. the patient developed widespread itching and swelling in the body - hours after she took the first dose of the drug. she had experienced a similar reaction with use of propylthiouracil in . the patient who was breastfeeding a baby and did not have any treatment option other than propylthiouracil was referred to us with pre-diagnosis of drug allergy. the patient was thought to have propylthiouracil-induced hypersensitivity reaction and desensitization was planned. we prepared a desensitization scheme in accordance with general desensitization principles (table ). in accordance with this prepared scheme, we successfully applied the desensitization protocol with propylthiouracil for the patient. the patient gave informed consent before testing and desensitization. results: spt was negative, but idt reaction was positive at : method: we present a desensitization protocol to intravenous etoposide used in a -year-old male for non-hodgkin's lymphoma who was referred to the department of allergy at sotiria general hospital of athens. within minutes after receiving the first dose of the drug, the patient complained for flushing, retrosternal pain, difficulty in breathing and weakness. the infusion was ceased immediately and the patient received proper treatment with gradual recovery of the symptoms. the next day, skin prick test (spt) and intradermal test (id) were performed with etoposide at dilution : ( mg/ml). both of the tests, spt and id, were negative. histamine and nacl . % were also used as positive and negative controls, respectively. a desensitization protocol of three-day cycle with intravenous etoposide was conducted. premedication for days was administered including methylprednisolone, cetirizine, ranitidine, paracetamol and montelukast. results: the desensitization protocol of the first day consisted of steps of rapid pulses administered at increasing infusion rates every minutes, and step of drip infusion at a final rate of ml/hour ( mg/ . ml) until completion of the infusion. the following days, the patient received a modified rapid protocol consisting of the administration of the calculated dose of mg in only one step of infusion rate of ml/hour completing in only hours and minutes. the same protocol was applied in another three-day cycle with no adverse reactions. conclusions: hsrs to etoposide are rarely described in the literature. we propose a three-day modified rapid desensitization protocol to intravenous etoposide that could be particularly useful compared to other time-consuming desensitization protocols. case report: imatinib, a tyrosine kinase inhibitor, sometimes causes cutaneous reactions that can be of various severity. we present a case of a patient who was started on imatinib mg daily and after months developed diffuse mildly pruritic rash with some desquamation of palms of the hands. the dose of imatinib was reduced to mg daily and therapy with prednisone mg was started. after resolution of rash, the dose of prednisone was tapered to mg daily, but the rash reappeared, although milder in intensity. the dose of prednisone was increased and levocetirizine added and rash resolved. prednisone was slowly discontinued and rash did not appear. in the case of reactions to imatinib the dose of drug can be reduced and short course of oral corticosteroid given. milder reactions can be treated with antihistamine or topical corticosteroid. therefore, when adverse skin reaction to imatinib occurs, induction of tolerance to this important drug should be attempted. method: the exosomes were collected from in vitro primary human sinonasal epithelia cell, which derived from three different groups (normal control, chronic rhinosinusitis and chronic rhinosinusitis with asthma). generation of exosomes in epithelia was confirmed by nanosight, tem and western blot. the proteins of exosomes were identified by proteomics analysis. the cellular proliferation and ciliogenesis were analyzed by cck and qpcr.the ciliary beat frequency was detected by sava system. we found that epithelial cellular exosomes from chronic rhinosinusitis and chronic rhinosinusitis with asthma could reduce the multiplication rate of normal epithelial cell at a certain concentration (≥ μg/ml).we found that exosomes from chronic rhinosinusitis with or without asthma could interrupt the cellular ciliogenesis and ciliary beat frequency. using mass spectrometric analysis we demonstrated that the epithelial exosomes contained different proteins in different disease states. conclusion: our findings first identified that exosomes could be secreted by nasal epithelial cells. we also demonstrated exosomes from chronic rhinosinusitis with or without asthma could be a pathogenic factor in the remodeling of sinonasal mucosa. it could be considered as a significant biomarker for detecting the progress of chronic rhinosinusitis and a alternative therapy target. background: mucociliary transport (mct) is a major respiratory tract host defense mechanism and chronic exposure to allergen can deteriorate the these defense mechanism. the aim of this study was to investigate the effects common allergen (dp/df) on human nasal mucociliary transport in allergic rhinitis patients, and to determine the pathophysiology of ciliary beat frequency (cbf) during allergeninduced change method: allergic nasal mucosa cells of allergic rhinitis patients were exposed to common allergen (dp/df), and cbf was analyzed using an optical flow technique with the peak detection method results: the allergen(dp/df) exposed group showed a decreased cbf when compared to the control group. in the cytotoxicity assay, difference in survival rates was not found between the two groups. in the allergen(df/df)-exposed group, protein kinase c (pkc) activity was increased during a pkc activity assay. the broad pkc inhibitor, calphostin c abolished the allergen(dp/df)-induced decrease of cbf. the allergen-induced decrease of cbf was abolished by gf x, a novel pkc (npkc) isoform inhibitor, whereas the decrease was not attenuated by g€o- , a specific inhibitor of conventional pkc (cpkc) isoform. conclusion: allergen may inhibit cbf via an npkc-dependent mechanism. therefore, we have confirmed that chronic exposure to allergen could decrease cbf by increasing pkc activity. method: ova-alum allergic rhinitis mouse model (ar model) and poly(i:c) induced il- dominant mouse model (neutrophil dominant model) were used. both mouse models were exposed to tio particles for hours twice daily for days, while the controls (n = ) were not. sirius red staining for eosinophil infiltration, immunohistochemistry for neutrophil and il- a, serum immunoglobulin (ig) g and e were assayed by using enzyme-linked immunosorbent assay. in addition, the expression of interleukin (il)- , il- , and interferon (ifn)-γ in the nasal mucosa and cervical lymph nodes was measured by immunohistochemistry, and real-time reverse transcription-polymerase chain reaction (rt-pcr), il- monoclonal antibody (secukinumab) was administered in vivo to evaluate il- a dependency. results: tio exposure did not influence eosinophil infiltration in both ar and neutrophil dominant model. however, tio exposure increased neutrophil infiltration in both models and neutrophil infiltration was correlated with il- expression in the nasal mucosa. serum igg and ige levels were changed significantly in the tio exposed group. th cytokines (il- , il- ) and th cytokine, ifn-γ were not changed significantly in both models after tio exposure, however, il- were increased in tio exposure group. and these increased type pathway and neutrophil infiltration were reversed after il- monoclonal antibody administration. conclusion: exposure to airborne tio induced neutrophil infiltration in the nasal mucosa. the type response seems to play a dominant role in the nasal immune response following airborne tio exposure. | toll-like receptor ligands increase type i interferon induced b-cell activating factor expression in chronic rhinosinusitis with nasal polyposis results: first: paf-r mrna expression was very low in fibroblasts from nm and np (data not shown). paf-r mrna expression was detected in whole sinonasal tissue, submerged and ali epithelial cell cultures from both controls nm and np. paf-r mrna was also detected in peripheral blood eosinophils. although no differences were found between nm and np tissues and cultures, paf-r mrna expression was significantly higher (p < . ) in eosinophils than in upper airway tissues and cells. second: protein paf-r was found expressed in whole tissue (predominantly in the epithelium and submucosal glands), submerged and ali epithelial cell cultures from both nm and np. peripheral blood eosinophils also showed paf-r protein expression. conclusion: both paf-r mrna and protein expression was found in sinonasal nm and np tissues (epithelium and submucosal glands) and in peripheral blood eosinophils. these findings suggest the paf/ paf-r system could play a pathophysiological role in crswnp through the modulation of structural and inflammatory cell functions. "this study was funded with a research grant from uriach group". background: allergic rhinitis (ar) is an increasingly more common nasal inflammatory disease in which an antigen such as pollen or dust mites triggers symptoms such as itching, sneezing, and rhinorrhea, which can lead to nasal obstruction. ar is mediated by thelper type cells together with mast cells, eosinophils, and several inflammatory cytokines and chemokines. for example, recent abstracts | research indicates that hypoxia-inducible factor α (hif- α) is involved in the mechanism of ar development. the anti-heart failure drug digoxin has a specific inhibitory effect on hif- α, and thus, the aim of the present research was to explore the anti-hypertensive effect and mechanism of digoxin in ar. method: an animal model of ovalbumin-induced ar was established in guinea pigs. the experimental group was treated with digoxin through the tail vein. for the comparison of symptoms between the experimental and control groups, the incidence of sneezing was recorded, and the eosinophilic interleukin il- and il- levels in nasal secretions were measured by enzyme-linked immunosorbent assays. western blotting and reverse transcription polymerase chain reaction analyses were conducted to evaluated hif- α expression in guinea pig nasal mucosa. results: the ar symptoms of guinea pigs in the experimental group were significantly improved after administration of digoxin. specifically, the experimental group exhibited a significantly lower numbers of sneezing times(average . ± . vs . ± . , p < . ) and lower il- and il- secretion levels (p < . ) compared with the control group. moreover, guinea pigs of the experimental group showed less severe nasal mucosa edema, lower hif- α production, and reduced eosinophil infiltration in nasal mucosa compared with the control group. conclusion: the anti-heart failure drug digoxin may ameliorate the symptoms of ar by inhibiting hif- α production. campo p ; eguiluz i ; bogas g ; gomez f ; ariza a ; espino t ; torres mj ; rondon c allergy unit-regional hospital of malaga-ibima, malaga, spain; allergy laboratory_regional hospital of malaga-ibima, malaga, spain background: similarly to what has been described in allergic rhinitis, there is an important association of local allergic rhinitis (lar) with lower airway symptoms suggestive of asthma, being selfreported in . % of lar patients after five years of follow-up, and increasing to . % after years. however, clinical suspicion alone it is not enough for asthma diagnosis and could overstate its real prevalence. the aim was to evaluate the real prevalence of asthma in lar patients based on validated objective methods. method: seventy-five patients ( with lar, with non-allergic rhinitis (nar), with allergic rhinitis (ar)), and healthy controls (hc) were included. all patients had perennial history of rhinitis and bronchial symptoms suggestive of mild-moderate asthma for at least two years. non-specific airways hyperresponsiveness (methacholine challenge test, using tidal breath method following ats guidelines) was performed in all subjects. results: subjects were mostly young females, non-smokers. median μg/day of inhaled corticosteroids (budesonide/equivalent dose) was similar in all groups. median fev % in ar group ( . %) was significantly lower compared to lar ( %, p = . ), nar ( %, p = . ) and hc ( %, p = . ). in the lar group, / ( . %) had a positive methacholine, / ( %) in the nar, / ( . %) in ar group and / ( %) in hc. patients with lar had a significant lower percentage of confirmed asthma than ar (p = . ) and similar to nar (p = . ). no differences were detected between ar vs nar (p = . ). conclusion: presence of objectively demonstrated asthma was lower in lar compared to ar, and with better lung function. conclusion: ambient air pollution influenced the hospital visit of patients with rhinitis, even, the level of pollutants, below the national standard. so , o , no , and pm could increase an incidence of rhinitis and/or induce an aggravation of rhinitis symptoms. health care provider might expect upraising patients with rhinitis in the clinic with increase of air pollutants, even under the standard levels. results: during relapse of erosive oral lichen planus mononuclear cells obtained from peripheral blood of patients showed increased number of nk-cells cd + cd + in acute ( . ± . %) and chronic ( . ± . %) disease periods, and cd + grb cells in acute ( . ± . %) and chronic ( . ± . %) disease periods, p < . . in patients with the non-erosive forms of olp there were cd + cd + and cd + grb cells in acute ( . ± . %) and ( . ± . %) and chronic disease ( . ± . %) and ( . ± . %), p < . . the number of cd + cd + and cd + grb cells in the controls were ( . ± . %) and ( . ± . %), p < . . conclusion: acute relapse of erosive oral lichen planus, unlike nonerosive forms, is characterized by increases in the number of cd + cd + and cd + grb cells. chronic disease in patients with erosive oral lichen planus showed a steady increase in the number of cd + cd + killer cells and cd grb lymphocytes. bite", were observed in patients ( %). typical hyper-and hypopigmentation were observed in six patients mainly on the fingers and the cheekbones. fibrosis of the skin of the fingers often leads to flexion contractions, which we observed in patients. we were watching two-sided swelling of the fingers, but it was very pronounced in patients ( %). % of our patients have impaired motility of the esophagus. accelerated esr and c-reactive protein were found in patients as follows- intensively accelerated and moderate. in our patients with positive ana, we observed patients -at low titer : at and titration : in patients. the spectrum of ana found by us in raynaud's syndrome patients is closer to scleroderma than to lupus. we underline the importance of ana ( %) and anti-cc antibodies ( %) for the early diagnosis of raynaud's syndrome and scleroderma, which is also seen in our patients. anti-scl- antibodies were observed in patients coinciding with other publications describing about % of the patients. low levels of complement were observed in patients. low hemoglobin levels were observed in patient, with no iron deficiency. conclusion: . we observed a typical fibrinoid necrosis and polymorphonuclear infiltration, and collagen accumulation in the walls of small and medium-sized blood vessels. results: statistically significant increase of il level ( . pg/ml [ . ; . ]; . pg/ml [ . ; . ] respectively) was determined in patients with uc both in acute stage and remission compared to controls ( . pg/ml [ . ; . ] , (p = . ; . respectively). statistically significant increase of il a level ( pg/ml [ . ; . ] ); . pg/ml [ . ; . ] respectively) was also observed in patients both in acute stage and remission compared to controls ( . pg/ml [ . ; . ], p = . , p = . respectively). besides statistically significant increase of ifnγ both in acute stage ( . pg/ml [ . ; . ] ) and remission ( . pg/ml [ . ; . ]) compared to controls ( . pg/ml [ . ; . ], p = . ; . respectively) was revealed. background: the presence of antinuclear antibodies (ana) is commonly associated with a broad spectrum of connective tissue diseases. low titres might be detected rarely also in healthy individuals, especially in higher age. an indirect immunofluorescence (iif) detection of ana antibodies on hep- cells is the most frequently used laboratory method in this respect. the method is quite reliable regarding sensitivity, however the specificity of this test is lower. we would appreciate a biomarker for clinical discrimination of ana- other autoantibodies were tested in relation to basic diagnosis. results: a cohort of patients was divided into groups according to main diagnosis: immunodeficiency, connective tissue diseases, bronchial asthma and allergic rhinitis, recurrent infectious diseases, gastrointestinal diseases, endocrinopathy and others and the last group was generated from healthy subjects. the presence of anti dfs antibodies was highest in the group of recurrent infections, mostly in females. in these subjects homogenous pattern of ana antibodies by iif was also detected quite often, probably induced by non-specific activation of immune system. on the other hand, in a group of connective tissue diseases, we have not found any anti dfs positive patient. the clinical impact of anti-dfs antibodies is not yet finally confirmed, but their low frequency in connective tissue diseases and presence in %- % of healthy subject suggests their potential role as a new biomarker to be used as a negative predictive factor in non aard. confirmation of presence or absence of anti-dfs antibodies seems to be helpful to exclude potential diagnostic errors in iif ana positive patients. background: multiple sclerosis is a debilitating autoimmune and degenerative condition of the central nervous system, that predominantly affects young adults. both genetic and environmental factors are associated with increased risk for this disease. we propose that the effect of environmental factors, particularly latitude of childhood, is mediated through epigenetic mechanisms. specifically, we propose that unfavourable gene methylation predisposes individuals to multiple sclerosis, that this is set in childhood and adolescence, and transmitted from haematopoietic stem cells to progeny. method: cd + , cd + and cd + cell subsets were isolated from peripheral blood of healthy controls. libraries enriched for cpg islands and promoter regions were generated using modified reduced representation bisulfite sequencing and subjected to next generation sequencing. site specific methylation profiling of genome wide cpg islands, including ms susceptibility genes was conducted using methpipe software. results: genomic coverage was consistent with other published methylomes using modified reduced representation bisulfite sequencing. the methylation signature of peripheral blood derived subsets showed greater differences in methylation compared to buccal cells than with each other. individuals displayed differences in cd + methylomes, and these were recapitulated in the progeny cd + and cd + cells for those individuals. methylation of specific genes regions (e.g. prf ), were consistent with the known biological function of these genes and their potential contribution to ms risk. the vast majority of cpg islands interrogated show recapitulation of their methylation signature from cd + to progeny. however, individual differences and cell subset differences identified, likely reflect the known biological function of these genes in progeny cells. our preliminary results are consistent with the hypothesis that the epigenetic signature (that predisposes to ms risk) is set in childhood and adolescence. the physiological basis underlying the setting of this epigenetic signature is still to be elucidated, but may involve uv light and/or vitamin d, and may provide novel therapeutic targets, especially at a personalised level, for treatment of ms. background: auto-inflammatory diseases are rare disorders characterized by recurrent episodes of fever/inflammation affecting serosal surfaces, joints, eyes and skin without autoantibody production or an underlying infection. innate immunity is implicated in their pathogenesis and the underlying genetic defect has been identified in a fraction of the syndromes. during last years, the increased knowledge about auto-inflammatory diseases and the difficulty in their characterization aroused great interest to better understand these pathologies. the acidic soluble fraction of salivary proteome of patients and controls (hc) were analyzed by rp-hplc-esi-ms. known salivary proteins (salivary acidic proline-rich phosphoproteins (aprps), histatins (hst), salivary cystatins s, sn and sa, statherin, p-b peptide, α-defensins - , cystatins b, c, thymosin β- , s a , s a , s a , and s a proteins) and several derivatives (acetylated, glutathionylated, phosphorylated, and oxidized forms) were searched in the chromatographic profiles by xic (extracted ion current) procedure. adult patients (mean age ± sd: . ± . ; f, m) were enrolled and compared with sex/age matched healthy controls (mean age ± sd: . ± . ; f, m). patients are classified on the base of clinical manifestations as follows: patients with fmf (mean age ± sd: ± . ; f, m), and with unclassified fever syndrome (uc) (mean age ± sd: . ± . ; f, m). results: fmf patients showed low levels of α-defensins , and , this last was absent, with respect hc, and high levels of the glutathionylated proteoforms of cystatin b, and s a , and of antileukoproteinase (slpi). similar results were obtained on saliva of unclassified patients, which showed also levels of cystatin c higher than controls. interestingly, proteins and peptides typically secreted by salivary glands (cystatin c, histatins, statherin, aprps) were found more abundant in uc patients than in controls, and in some cases also than fmf patients (see table) . an evaluation of relative abundance of phosphorylation of phosphorylated proteins/peptides highlighted a significant hypophosphorylation of hst- , prp- and prp- in uc patients with respect to controls, probably due to a less active fam c kinase responsible for their phosphorylation conclusion: we show by a top-down proteomics approach a wide salivary modification, highlighting dysregulation in neutrophil-derived proteins and significant differences between fmm and uc patients. the control group consisted of healthy donors aged - years. immunological methods of investigation included determination of membrane antigens b cells: cd − cd + cd + , cd + cd + cd + , cd + cd + cd , cd + cd + cd + , cd + cd + cd + , cd + cd + cd + , cd + cd + cd l + cd + , cd + cd ra + cd + cd + , by flow cytometry. results: in the study subpopulation composition of lymphocytes in seropositive variant form of ra visceral a statistically significant increase in relative amount as b -cells with immunophenotype cd + cd + cd + ( . ± . % . ± . %) and b lymphocytes with the phenotype cd + cd − cd − cd + ( . ± . % and . ± . %). in the analysis of the processes of maturation and differentiation of b cells detected statistically reliable increase of the relative number of mature cd + cd − cd + naïve b cells cd + cd ra + cd number of mature cd + cd − cd + naïve b cells cd + cd ra + cd − cd + ( . ± . % and . ± . %) compared to the control group. in the study of surface markers b lymphocytes revealed an increase of expression of costimulatory cd + cd + ( ± . % and . ± . %) molecules and increasing the relative amount of cd l . ± . % ( . ± . %) ligand on cd + cd + cd + subpopulation of t-lymphocytes. analysis of surface antigenic receptor b cells in the visceral form of ra showed an increased expression of early markers of cd + cd + cd + ( . ± . % and . ± . %), cd + cd + cd + ( . ± . % . ± . %) activation in comparison with the control group. case: a year-old male patient who works as a dental technician with a history of lung silicosis and recurrent sinusitis applied to an orthopedics clinic for left hip pain and difficulty in walking. he has a history of keeping a dog during childhood. hip mri revealed a × cm sized mass on left iliac wing extended to gluteus muscle and subcutaneous tissue. incisional biopsy was reported as chronic granulomatous osteomyelitis. the lesion was considered as tuberculous abscess. despite anti-tuberculous (fourdrug regimen) treatment for one year, the lesion showed no regression. excisional biopsy was carried out by the same orthopedics clinic. chronic inflammatory reaction and fibrosis was considered to be due to cyst hydatid in the detailed evaluation. antiechinococcus igg and igm was performed with elisa and found positive. no other lesion was detected in lungs and liver. albendazole mg twice a day was initiated and substantial regression observed after three months. atypical and sustained infections made us think of primary immunodeficiency disorders. immunoglobulin subgroups were as follows: iga: < mg/dl ( - case description: year-old male was firstly admitted to gastroenterologist due to intermittent diarrhea, abdominal pain and reactive lymphadenopathy. celiac disease was suspected as genetic test showed hla dq (hla-dqa * and hla-dqb * ), histological evaluation of duodenum biopsy provided picture of lymphoid hyperplasia and marsh iiia variant. however, laboratory testing for celiac disease showed very low amount of antibodies against transglutaminase. gluten free diet for almost one year was ineffective as patient had a continuous problem of gaining weight due to chronic diarrhea. additional questioning revealed recurrent respiratory tract infections with a need of antibiotics more than two times/year during last decade. lymphocyte phenotyping by flow cytometry showed that cd , cd , cd , cd are in normal ranges, but amounts of all immunoglobulins are low: igm < . g/l, igg . g/l and iga . g/l. based on clinical symptoms and immunological evaluation diagnosis of cvid was confirmed, and replacement therapy with subcutaneous immunoglobulin ( mg/kg/month) was initiated. after six months of treatment patient affirmed reduction of gastrointestinal symptoms; he gained kg of weight, has no more infections and stable sufficient level of igg ( . g/l). conclusions: this clinical case shows the importance of immune testing for primary immunodeficiency in all subjects (despite age) with unusual symptoms of autoimmune and/or infectious disorders. cvid may have manifestation of various symptoms, which can lead to misdiagnosis, as well as inadequate treatment. results: in our sample, all patients who progressed to hypogammaglobulinemia were receiving lymphomas. there is no immunoglobulin dosage record prior to treatment. of the cases, mean age was years ( men and women), lost follow-up, and of them also presented neutropenia. seventeen patients who continued in followup required ivig replacement, due to infectious exacerbations, mainly pneumonia and sinusitis. the mean serum igg dosage at the time of onset of ivig replacement was g/dl. the mean time between the first dose of rtm and the need for ivig replacement ranged from to years, with an average of years. the iga dosage was used as a parameter for the recovery of hypogammaglobulinemia, and it was observed that only of the patients presented recovery of the condition up to the moment. conclusion: given the data, we considered the immunoglobulin dosage to be important before initiating rtm treatment and periodically, in order to indicate the replacement of ivig or igsc in a timely manner avoiding complications such as potentially serious infections. background: steinert's disease, also known as type myotonic dystrophy (md ), is the most common dystrophy of the adult. it is inherited with an autosomal dominant mechanism. it causes myotonia, progressive muscles atrophy, muscular weakness, and problems at the heart's conduction tissue and at the respiratory muscles. in patients with myotonic dystrophy, hypogammaglobulinemia is frequently described. the associations and the pathogenesis between those affections are not totally clear, but it is recognized an increased catabolism of the immunoglobulin in these patients. in most of the cases, hypogammaglobulinemia affects only the igg class and does not become clinically manifest. however, replacement treatment is not always successful in these patients. we report the case of a patient with myotonic dystrophy and hypogammaglobulinemia. case report: a -years-old man with md came to our attention for a history of recurrent infections of the upper respiratory tract and persistent infection by helicobacter pylori. at the laboratory tests, we documented low serum igg levels ( mg/dl), normal igm and iga levels and protective antibodies against tetanus consisting with the diagnosis of hypogammaglobulinemia. due to the recurrent infections, he started replacement therapy with ivig ( . g/kg/ months), switched one year ago to facilitated subcutaneous ig (fscig) with achievement of protective serum igg levels (> mg/dl) and significantly reduction of infectious episodes. conclusion: hypogammaglobulinemia is frequently reported in patients with md . in literature most of the cases described does not become clinically manifest, but in our case, the patient was symptomatic with recurrent infections. the replacement therapy with fscig showed both clinical effectiveness and safety. | real-world experience of a novel, highly purified % liquid iv human immunoglobulin for the treatment of antibody deficiencies guidelines for immunoglobulin use (july ). a highly purified % liquid iv human immunoglobulin (ig), with low levels of iga, anti-a and anti-b haemagglutinins, factors xia, xiia, kallikrein and aggregates (i e) was recently approved for use in the uk. here i report our centre's experience in using this novel % i e in three patients with antibody deficiencies. case presentations: a patient who presented in clinic with a first diagnosis of pid, was initiated on % i e at g infused every four weeks. after starting i e, they experienced a decrease in the rate and frequency of infections, in line with expectations for igrt. a young patient on home therapy with a % subcutaneous ig for pid presented in clinic with low trough igg levels. non-compliance was identified as the cause of these low trough levels and therapy was switched to % i e at g infused every four weeks in a clinical setting. both the rate and severity of infections reduced and trough igg levels normalised. an older patient on igrt for sad was reviewed in clinic due to discontinuation of their current igrt product. they were switched to % i e at g infused every four weeks. the efficacy and tolerability of i e was comparable to their previous therapy. a detailed analysis of patient, clinical and safety parameters associated with the initiation of % i e will be presented, including infection rates, white cell counts, c-reactive protein levels, tolerability and infusion-related adverse events. conclusion: these cases highlight the real-world use of % i e in two patients with pid and one patient with sad. they show that i e was well-tolerated and efficacious in one treatment-naïve, and two previously-treated patients. method: prospective study of families with one or more members with c -inh-hae followed in hospitals in the northern area of spain. a cohort of patients from families with c -inh-hae was evaluated for familiar diagnosis of c -inh-hae one or several patients from the same family were chosen and were given a questionnaire to identify the total family members from the family branch affected by c -inh-hae that had been already studied (members with diagnosis of c -inh-hae and healthy members) and those that had not been previously studied. we also register the difficulties for obtaining these data. family members not previously studied and that consent to be contacted were asked for study of c -inh-hae. for c -inh-hae screening we use c blood levels results: we have studied families with c -inh-hae, ( %) type and ( %) type ii; families had all their known members already studied for c -inh-hae ( %): families have all their members studied ( . %), families have % or their known members studied ( . %) and families had less than % of their total known members studied. we have identified members from unrelated families that had not been previously studied for hae, healthy, had low c levels and had presented symptoms of hae; had not presented symptoms of angioedema, had normal c levels, and low antigenic and functional c -inh levels. difficulties for a complete family testing study have been: family dispersion, scarce or no family relationship, do not wish to know their possible pathology conclusion: it is crucial to insist on the study of the relatives of patients with hae. we propose to include a questionnaire to identify all patient's relatives at medical reviews of hae patients. case: a- year old boy was admitted to our clinic with the history of recurrent respiratory tract infections. his all immunoglobulins were low (igg < mg/dl, iga < . mg/dl, igm < . mg/dl) associated with the absence of b cells. his aunt cousin also had xlaa missense point mutation, c c>t in exon of the btk gene was identified in both affected cousins. the patient was commenced on regular ivig treatment every weeks. at the age of , he suffered from intermittent fever attacks, abdominal pain and weight loss. tests for giardia lamblia, clostridium difficile and cryptosporidium, noro virus or parasites were negative. mr-enterography revealed intra-abdominal fluid and thickened walls of his jejunum and cecum. histopathological examination of the biopsy material obtained from terminal ileum, colon and cecum showed crohn disease. initially, he was treated with prednisolone and infliximab. because of the lack of response, infliximab treatment was switched to adalimumab. terminal ileum was resected to relieve obstruction complication. although he had been treated with adalimumab for year, a significant improvement was not observed. vedolizumab (entyvio ™ ), is a humanized monoclonal antibody α β integrin-receptor antagonist, was commenced. induction dosing was mg infusions at , , and weeks followed by a maintenance phase at week intervals. at the month of the treatment, fever and abdominal pain attacks reduced, while his weight and oral intake increased. no side effects were observed. discussion: vedolizumab is effective for inducing and maintaining remission in adults with inflammatory bowel disease (ibd); however, there is limited pediatric data. this is the first immunocompromised child treated with vedolizumab. the symptoms of the patient receded and no side effect observed during months of the treatment. results: louis-bar syndrome is a multisystem progressive disease with polymorphic manifestations which varies by age. the locomotor disability of these children is determined by neurological disorders, the exitus being caused by respiratory infectious and malignancies. the children involved in the study, had frequent episodes of respiratory infectious (bronchitis, pneumonia, atelectasis, empyema, lung abscess), ent infections (otitis, mastoiditis, sinusitis), chronic pulmonary disease (pulmonary fibrosis, bronchiectasis). index of death in this group is high ( . %). in one of the boy, the pulmonary ct showed lymphadenopathy, later was confirmed non-hodgkin lymphoma, with subsequent death. another child died from pulmonary and systemic infectious complications. results: in this paper we present the clinical and morphological analysis of children with nezelof syndrome diagnosed post-mortem. clinically were predominantly the generalized intrauterine infections or their development in the postnatal period. at macroscopic examination all patients had thymic hypoplasia. later on the microscopic study of the thymus specimens determined dysplastic changes, defined by the presence of concentrically arranged epithelial cells. in all patients, was determined the total lack of hassall corpuscles and its predecessors. besides the above-mentioned modifications in all specimens, there was no cortico-medullary segregation. thymic parenchyma outside pseudorrhagia was made up of a reticular stroma with total lymphocyte depletion. conclusion: nezelof syndrome is a severe primary immunodeficiency associated with thymic dysplasia and alymphocytosis, which is manifested early with generalized infections and major risk of death in neonatal and infant. background: the study was aimed to evaluate the cytokine profile in nasal secretion and blood serum in patients with seasonal (sar) and perennial allergic rhinitis (par) with a potential for additional sensitization with microbial allergens. method: the inclusion criteria for ar were as follows: a diagnosis of ar for more than years, the absence of nonallergic disorders of the nasopharynx, age of patients from years to years.control group: healthy volunteers at the age of - years without any allergic disorders at examination.in order to evaluate the innate and adaptive immunity, the cytokine profile of blood serum (il- , il- , and tgf-β) and nasal secretion (tslp, il- β, tnf-α, and gm-csf) was determined. to determine tslp, tgf-β, il- , and gm-csf concentrations, enzyme-linked immunosorbent assay kits were used (ebioscience, bender medsystems, r&d systems, mn, usa). we have noticed a significant correlation (r = , p = ) between the tslp concentration in nasal secretion and as-ige level to staphilococcus aureus enterotoxin (allergen component m ) in patients with par. there was a significant correlation conclusion: staphylococcal superantigens might be one of the stimuli of local tslp hyperproduction by the epithelium. there was a significant correlation between gm-csf concentrations in nasal secretion and the intensity of sensitization to a staphylococcal enterotoxin (seb) in the patients with ar. seb is one of the polyclonal t cells activators, which may account for increased concentrations of cytokines such as gm-csf locally within the system of mucosal immunity. the patients with ar and additional high sensitization to ses demonstrated a higher tnf-α production profile due to macrophage and tcell activation by these toxins. | evaluation of circulating osteopontin level as potential biomarker of allergic asthma in patients with caucasian and south-east asian ethnicity background: osteopontin (opn) is a pleomorphic cytokine known to influence a wide range of immune cells; allergic asthma was previously associated with high circulating opn levels. in the present study, we aimed to verify if opn may qualify as biomarker of activated immune response in allergic patients belonging to two different ethnic groups: caucasians and south-east asians. method: serum opn levels were measured by elisa test (human osteopontin duoset, r&d systems) in a series of italian adult patients affected by extrinsic asthma, allergic rhinitis, hymenoptera venom allergy, food allergy, allergic contact dermatitis and ige mediated hypersensitivity to beta lactams. healthy subjects served as controls. ethnic chinese subjects were recruited at the national university of singapore (nus) as cross-sectional cohort of an ongoing epidemiological study on the national prevalence of allergic diseases, and opn levels were detected by luminex (milliplex map, merck) and elisa assays (r&d systems). results: in the italian cohort, opn levels were significantly higher in cases compared to controls (p = . by the mann-whitney test). statistically higher opn levels were found in asthma (p = . ) and food allergy (p = . ) groups in comparison to controls. no significant differences were found (p = . ) between singaporeans with lifetime asthma and healthy controls, only the highest opn levels were heterogeneously found to correlate with asthma. however, a strong gender effect was shown, in both cases (p < . ) and controls (p < . ), with males presenting higher opn levels in comparison to females. consequently, we checked the mrna expression levels of opn gene (spp ) with illumina chips in whole blood of males and females, and no difference was found (p < . ). several experiments with western blots and different gel types were performed to verify if possible post-transcriptional/posttranslational modifications of opn could explain these findings. conclusion: opn seems to be a promising biomarker for current, active allergic asthma in caucasians even though technical difficulties, due to opn intrinsically disordered structure, the complex enzymatic metabolism, and the low circulating levels, significantly affect the experiments. further studies are needed to confirm these data. | mortality, intubation, and healthcare cost in patients with allergic bronchopulmonary aspergillosis in a hospital setting: a nationwide study fan x; luo y; yue b background: abpa is a complex hypersensitivity reaction to aspergillus fumigatus that colonize in airways, it is almost exclusively seen in patients with asthma or cystic fibrosis(cf). this study is to estimate hospitalization outcomes and healthcare cost of hospitalized patients with abpa. method: we conducted the study using data from national inpatient sample(nis) from to . diagnosis were identified using icd- -cm codes. hospitalization with a primary diagnosis of abpa and hospitalization with a primary diagnosis of acute respiratory failure/acute and chronic respiratory failure/respiratory distress/ asthma/cf and a secondary diagnosis of abpa were included. the study population was divided into groups including abpa with asthma, and abpa with cf. mortality and intubation rate were the primary outcomes; length of stay and total hospitalization cost(adjusted to cost in based on medical care cpi) were secondary outcomes. student t-test and chi-square were used for univariable analysis, linear and logistic regression were used for multivariable analysis. results: a total of hospitalizations with abpa were included, with hospitalizations with abpa and asthma, and hospitalizations with abpa and cf. the overall mortality rate was . % ( % ci: . %- . %), the mortality for abpa with asthma was . % ( % ci: . %- . %) and for abpa with cf was . % ( % ci: . %- . %). the overall intubation rate was . % ( % ci: . %- . %); the intubation rate for abpa with asthma was . % ( % ci: . %- . %) and . % were early intubation (< days); the intubation rate for abpa with cf was . % ( % ci: . %- . %) and . % were early intubation. the overall mean length of stay(los) was . ( % ci: . - . ) days, while the los for abpa with asthma was . ( % ci: . - . ) days and the los for abpa with cf was . ( % ci: . - . ) days. the overall total cost was million usd, the total cost for abpa with asthma was . million usd with a mean of , while the total cost for abpa with cf was million usd with a mean of . conclusion: mortality among hospitalized patients with abpa is low< %. intubation rate is relatively low, intubation, especially early intubation (< days), is more common in patients with asthma. although abpa is not a common disease in inpatient population, it does have a high health care cost and despite lower intubation rate, patients with abpa and cf generally have a longer hospital stay with a higher hospitalization cost. | frequent exacerbations of bronchitis with wheezing in adults: is it possible to predict and prevent asthma? case report: frequent episodes of bronchitis, accompanied by wheezing and dry with a prolonged duration in adults, the clinical course may be similar to bronchial asthma. the aim is to assess the risk of asthma in adult patients with or more episodes of acute bronchitis per year, had a prolonged duration and accompanied by a dry wheezing. for years in two regional clinical pulmonology centers were observed in patients ( men and women) with average age ± . years. each had at least episodes of acute bronchitis per year, which was accompanied by prolonged cough and presence of wheezes. average number of acute episodes per year was . ± . . in the course of the observation the patients were divided into equal groups. the first group consisted of persons treated in acute episodes of the disease symptomatic therapy, including inhaled β -agonists short-acting short course. in the second group to the corresponding treatment added montelukast mg per day lasting for month. in all cases of exacerbation had a viral nature. held in the period of remission of allergic sensitization, the survey revealed. starting from the first year of follow-up all patients were vaccinated against influenza annually. by the end of the fifth year of observation in the first group in cases was diagnosed of bronchial asthma- cases easy persistent asthma and case moderate. the diagnosis was exhibited in accordance with the gina criteria. in the second group, the diagnosis of bronchial asthma were exposed to patient (hazard ratio of . ). prospective observation suggests that the use of anti-inflammatory potential antileukotriene medicines in complex therapy of recurrent acute episodes of bronchitis accompanied by a dry wheezing in adults may be a factor preventing the development of asthma. for more conclusive results require more extensive research. background: chemokine receptors play an important role in regulating the migration of t lymphocytes, monocytes and neutrophils from the peripheral blood into inflamed tissue, such as lung. however, little is known about their expression on natural killer (nk) and natural killer t (nkt) cells in patients with chronic obstructive pulmonary disease (copd). therefore the aim of the study was to determine the chemokine receptor profile of peripheral blood nk and nkt cells of copd patients. method: for analysis of lymphocytes subtypes the flow cytometry method was used. the study population consisted of smokers with copd, healthy smokers and healthy non-smokers. results: we observed an increase in blood nk cells expressing cxcr receptors in smokers with copd compared to healthy smokers (p = . ) and healthy non-smokers (p < . ). the percentage of nkt cells containing cxcr receptors was also significantly higher in blood of smokers with copd compared to healthy smokers (p = . ) and healthy non-smokers (p < . ). copd smokers had significantly higher proportion of ccr + nk cells than smokers without copd (p = . ) and healthy non-smokers (p < . ). increased proportion of blood nkt cells expressing ccr on their surface was observed in smoking copd patients compared to healthy smokers (p = . ) and healthy non-smokers (p < . ). there were no significant changes in the percentage of cxcr + and ccr + nk and nkt cells between healthy smokers and non-smokers. in addition, no differences were seen in the proportion of nk and nkt cells expressing cxcr , cxcr , ccr and ccr among all studied groups. method: patients with copd in stable condition (gold stage ) aged - years old, smoking history of ≥ pack-years, were studied. bmi of patients were divided into groups: obese (n = ) (bmi- . - . kg/m ) and non-obese (n = ) (bmi- . - . kg/ m ). ten subjects with normal lung function and bmi were the control group. the level of il- assessed in induced sputum (pg/ml) was measured using an elisa (raybiotech ® ). serum levels of crp were measured using the "vector-best" (russia federation). spirometry was performed according to american thoracic society and the european respiratory society (ats/ers) guidelines. results: obese copd patients had significantly increased concentrations of il- compared with healthy subjects and non-obese copd patients by . fold ( . ± . pg/ml vs . ± . pg/ ml) (p < . ) and . fold, ( . ± . pg/ml vs . ± . pg/ml)(p < . ), respectively. non-obese copd patients had higher levels of il- by . fold compared with healthy subjects ( . ± . pg/ml vs . ± . pg/ml) (p < . ). results: among these three groups, the level of cer in lung cancer patients ( . ± . g/l) was significantly higher than that in ild patients ( . ± . g/l) and healthy individuals ( . ± . g/l) (p < . ). meanwhile, the levels of c and c in healthy individuals, which are . ± . g/l and . ± . g/l respectively, were both significantly higher than that in lung cancer patients (c : . ± . g/l, c : . ± . g/l) and ild patients (c : . ± . g/l, c : . ± . g/l), (c : p < . , c : p < . ). results from optimal scaling demonstrated that lung cancer was closely associated with immune factors including crp, cer, c and c (cronbach's alpha = . %). conclusion: for ild patients, when the level of crp and cer is increased and the level of c and c is decreased simultaneously, the risk of the development of lung cancer should be considered for these patients. results: among pbmc subpopulations, endurance exercises impacted the number of nkt and activated t cells with nkt cell numbers greater in male bobsledders vs bullet shooting and biathlon ( . % and . %, respectively). the number of activated t cells (cd + ) was greater in bullet shooting and bobsleigh athletes vs the biathlon group ( . % and . %, respectively). in female athletes the number of cd + cells in the shooting and bobsled groups was greater by . % and . %, respectively vs the biathlon group (p < . ). increased il- occurred in bobsleds in comparison to bullet shooting and biathlon: % and % in male and . % and % in female, respectively (p < . ). the concentration of il- in male bobsledders and biathlon was % and % greater, respectively, compared with bullet shooting (p < . ). serum concentrations of ifnγ in male as well as female athletes showed an increase of . % and . %, respectively vs biathletes (p < . ). increased il- occurred in the male biathlon group by . % and %, respectively, vs the bullet shooting and bobsleigh athletes (p < . ). il- was increased in the male biathlon group, compared to bullet shooting and bobsledders by . % and . %, respectively (p < . ). conclusion: prolonged endurance exercises impacts secretion of pro-and anti-inflammatory cytokines in athletes of different sport specializations. concentrations of studied cytokines did not exceed reference values perhaps due to specialized sport nutrition, which may restore immune function during endurance exercises. background: oral immunotherapy (oit) is a promising therapeutic approach to treat food allergic patients. recently, we have shown that the use of a mixture of short-chain-and long-chain fructo-oligosaccharides (scfos/lcfos) improves the efficacy of oit in cow's milk and peanut allergic mice. however, concerns with regard to safety and long-term efficacy of oit remain and there is a need to identify novel biomarkers (panels) that predict, monitor and/or evaluate the effects of oit. here we present a method for the selection of candidate biomarkers by using the computational approaches bayesian networks (bn) and topological data analysis (tda). method: data were used from scfos/lcfos diet-supported oit studies performed in independent cow's milk allergy (cma) and independent peanut allergy (pna) experiments in mice. first, a subset of the data was used for learning the data structure and their interactions in terms of a bn. this bn was used to compare the key parameters in both experimental food allergy models. finally, the relations within the dataset in combination with the bn were explored to identify and rank candidate biomarkers for the effect of oit by applying tda. the bn was able to predict the efficacy of oit in the cma and in the pna model with % and % accuracy respectively, thereby identifying a set of parameters (allergen-specific ige and igg , body temperature, mmcp- , earswelling) being key in the mechanisms involved in both scfos/lcfos-aided oit food allergy models. the tda zoomed in on the full set of previously analyzed parameters and identified clusters of biomarkers closely linked to biologically relevant clinical symptoms but also unrelated and redundant parameters within the network. taken together, this enables the prioritization of candidate biomarkers. moreover, the tda indicated differences between pna and cma models in how the data are related to each other. here we provide promising bioinformatics methods to compare mechanistic features between two different food allergies and to determine the biological relevance of biomarker (panels) of oit for food allergy. we have shown that the key drivers that influence pna and cma are similar, but that these phenotypically similar diseases show mechanistic differences in their subnetworks. these new insights provide excellent starting points to generate new hypotheses to explain why cma has a different disease pattern than pna and to select biomarkers that are useful in future clinical studies. | functional and immunoreactive levels of igg correlate with clinical responses during the maintenance phase of house dust mite immunotherapy basophils were identified as ssc low cd high , and cd was used as an activation marker. reactivity was confirmed by anti-ige as a positive control. results: in patients, basophil reactivity and sensitivity was comparable for grass pollen extract and recombinant phl p , while phl p only caused a lower basophil activation. in one patient, recombinant phl p did not cause any basophil activation, while phl p elicited an even higher sensitivity and reactivity than grass pollen extract. conclusion: in patients, basophil reactivity was comparable for grass pollen extract and recombinant phl p , while phl p only caused a minor basophil activation. in one patient, recombinant phl p did not cause any basophil activation, while phl p elicited an even higher sensitivity and reactivity than grass pollen extract. reactivity of extract and the main sensitizing components correlated, while sensitivity did not. | in vitro assessment of hypersensitivity to allergen before and after allergen immunotherapy with whole blood basophil histamine release assay wbbhr assay in these patients was performed - days before and - days after ait. heparinized whole blood samples ( ml) of each patient after substitution of plasma with pipes buffer were incubated one hour at °c with different concentrations of birch pollen extract (t ) in u-shape -well micro-titer plates. after incubation plates were centrifuged and supernatants from each well of the plate were directly analyzed for histamine content by reversedphase high performance liquid chromatography with electro-spray ionization mass-spectrometry (rp-hplc-esi-ms). results were expressed as ng/ml released histamine. sensitivity (limit of quantification) was - ng/ml. to compare results of histamine release in patients before and after ait data were calculated as area under the curve (auc) values. results: in contrast to pre-immunotherapy activity of blood basophils there were significant decreases in hr induced by t extract after ait. according to auc values all patients demonstrated decrease in hr after ait in compare to hr before ait in a range of %- % demonstrating a decrease of hypersensitivity to birch allergens. analysis of basophil hr in patients received s.c. or s.l. the asthma and rhinoconjunctivitis symptom scores during and after pollination season decreased significantly and showed correlation with histamine release by t . | immunotherapy with the recombinant b cell epitope-based grass pollen allergy vaccine bm induces a biphasic allergen-specific igg and igg response background: immunotherapy with the recombinant b cell epitopebased grass pollen allergy vaccine has been shown to reduce symptoms of grass pollen allergy in a multicenter, double-blind, placebocontrolled study. aim of this study was to investigate the levels and kinetics allergen-specific igg responses in a double-blind, placebocontrolled phase iib combined field and exposure chamber trial studying the effects of three, four and five pre-seasonal injections of bm as compared to placebo. method: a quantitative elisa assay based on purified human monoclonal allergen-specific igg as well as igg antibodies as standards was developed to measure allergen-specific igg and igg concentrations induced by ait with bm . results: we found rises in levels of both tested allergen-specific igg subclasses in the actively but not placebo-treated patients. phl p -and phl p -specific igg levels up to μg/ml and μg/ml, respectively and phl p -and phl p -specific igg levels of up to μg/ml and μg/ml, respectively were measured in bm treated patients. five pre-seasonal injections induced the highest allergen-specific igg levels. interestingly, allergen-specific igg and igg antibodies showed a biphasic response with early rises of allergen-specific igg which declined quickly after the pollen season and a delayed but very sustained allergen-specific igg response. conclusion: treatment with bm induces a biphasic allergen-specific igg response consisting of an early igg and a sustained allergen-specific igg response which may be responsible for early and sustained protection against allergic symptoms. | t reg cd + cd high in peripheral blood in patient with grass pollen allergy during sublingual specific immunotherapy slit the aim of this study was to evaluate t reg cd + cd high in peripheral blood in patients with grass pollen allergy during sublingual immunotherapy slit. method: we examined adult patients, aged - , female and male. patients were qualified to slit after confirmation of allergy-by skin prick tests, specific ige and nasal provocation tests. we determined t reg cd + cd high from blood sampling of those patients (by flow cytometry method), before the slit, after reaching the maintenance dose, before the grass pollen season, during the grass pollen season, and after one year of slit. results: during slit the percentage of t reg cd + cd high increase after reaching the maintenance dose, then it decreased before and during the grass pollen season, and again increase after one year os slit. we observed, that in the group with significant improvement of symptoms, t regcd + cd high decreased during grass pollen season, comparing to group without clinical improvement. conclusion: slit as a method of immunotherapy influence on levels of t reg cd + cd high cells. the observed decreased levels of these cells during the grass pollen season might be consider as a prognosing marker of clinical improvement. | t reg cd + cd high from peripheral blood during subcutaneous specific immunotherapy (scit) for grass pollen hofman a; hofman j; hofman t centrum alergologii, poznan, poland background: specific immunotherapy is the only causal method for grass pollen allergic rhinitis. however, we don't observe in every patients satisfying clinical effects. because the treatment of allergic rhinitis takes - years, and is quite expensive, everyone is constantly looking for a perfect parameter, which may prognose the effectiveness of specific immunotherapy (sit). the aim of this study was to evaluate t reg cd + cd high lymphocytes from peripheral blood in patients during subcutaneous specific immunotherapy (scit) for grass pollen . method: we examined adult patients ( female, male), age - , who undergo scit for grass pollen allergy. we have done skin prick tests and specific ige in those patients. additionally, we confirmed the allergy by nasal provocation tests. we have determined lymphocytes t reg cd + cd high from blood sampling from those patients, with flow cytometry method: before immunotherapy, after reaching the maintenance dose of scit, before and during the grass pollen season, and after one year of scit. our control group was represented by adult healthy volunteers. after one year of scit we divided patients into two groups-with and without clinical improvement. results: in allergic patients we have observed decreased levels of t reg cd + cd high compared to control group before the start for scit. during immunotherapy, the percentage of t reg cd + cd high increased after reaching the maintenance dose, however it did not reached the level of healthy volunteers. again, levels of t reg cd + cd high decreased before and during the grass pollen season, and increased after one year of scit. we compared also patient with significant improvement of clinical symptoms, and without. and we observed that the level of t regs cd + cd high decreased during pollen season in improved group, and increased in the group without clinical improvement. conclusion: in patients with grass pollen allergy, during the grass pollen season, decrease of t reg cd + cd high cells might be con- results: in the group of patients treated with sit gene expression analysis revealed significant change in ifng expression (p = . ) (comparison between sample a and b). comparison between samples a and c showed significantly different expression in genes: afap l (p = . ), commd (p = . ), pik cd (p = . ), and twist (p = . ). duncan's multiple range test confirmed difference between sample a and c for commd (p = . ) and also revealed new significant difference in tbx in samples a and b (p = . ; in wilcoxon's test p = . ). k nearest neighbors algorithm was built based on ifng, pik cd, commd expression. the results of the study indicate, that there is a significant change in the expression of a few genes during the build-up phase of sit. it may be suspected, that this change contribute to the mechanisms involved in the building tolerance to allergen. k nearest neighbors algorithm may be useful for sit efficacy prediction. | regulation of cytokine thymic stromal lymphopoietin (tslp) in modulating tgf-ß induced interstitial inflammation and cellular fibrosis background: thymic stromal lymphopoietin (tslp) has previously been linked to allergic inflammatory diseases, tissue fibrosis and organ dysfunction. it remains unclear, however, whether tslp plays any role in the occurrence of renal fibrosis, so this study investigated that underlying mechanism. method: an in vitro fibrosis model was established by treating normal rat kidney fibroblast (nrk- f) cells with transforming growth factor-β (tgf-β ), after which the levels of various fibrogenic markers (e.g., fibronectin) and downstream fibrogenic signal proteins (e.g., smad ) were investigated. also, tslp shrna was used to silence the effects of tslp, while an elisa was conducted to evaluate the fibronectin secretions. results: the level of fibronectin in the nrk- f cells was doseand time-dependently increased by the administration of exogenous tslp (p < . ). tslp also significantly increased the level of fibrosis signaling, in addition to inducing a marked decrease in the down-regulation of smad . interestingly, the application of tslp shrna caused a dramatic reversal of the tgf-β -induced cellular fibrosis while simultaneously leading to the suppression of fibronectin and fibrogenic signal proteins. conclusion: taken together, these observations provide insights into how extracellular matrices develop and could lead to potential therapeutic interventions for the suppression of renal inflammation and fibrosis. abstracts | | effects of two years treatment with the recombinant b cell epitope-based grass pollen allergy vaccine bm on allergen-specific b and t cell responses background: bm contains recombinant fusion proteins of nonallergenic peptides from ige-binding sites of the four major timothy grass pollen allergens phl p , , and and pres protein from the hepatitis b virus as a carrier. in a multicentre, double-blind, placebocontrolled trial, grass pollen allergic subjects were treated for two years either with bm or placebo. here we investigated in detail the effect of immunization with bm on allergen-specific t and b cell responses. during the study from subjects treated in the vienna centre (bm : n = , placebo: n = ) were investigated regarding proliferation using h thymidine incorporation and cytokine production in response to various recombinant allergens at different time points. grass pollen allergen-specific ige, igg and igg levels were determined by immunocap and elisa. results: a significant increase of allergen-specific igg and igg levels was found in the bm -but not in the placebo group in both years (year > year ) after treatment. there was no difference regarding t cell proliferation in response to phl p and phl p after first grass pollen season between actively and placebo-treated patients whereas proliferation in particular of phl p -specific responses seemed to be blunted in the active group in the second year. no significant differences regarding allergen-specific th , th and tolerogenic (i.e., il- ) cytokines were observed between bm and placebo-treated patients. the findings indicate that the bm induces high levels of allergen-specific blocking antibodies which may reduce allergen-specific t cell proliferation but does not induce significant increases of regulatory cytokines in t cells. this study was supported by grants f , f and dk -b of the austrian science fund (fwf). hospital universitario ramón y cajal, madrid, spain; department of immunology iis-fundación jiménez díaz, uam, madrid, spain background: shiitake mushroom (sm) (lentula edodes) is an edible fungi native to east asia. it is traditionally cultivated and used in many asian countries and its consumption is increasing worldwide. direct skin exposure to sm can cause cutaneous reactions, including allergic contact dermatitis and urticaria, while its oral intake may prompt "shiitake flagellate dermatitis" (sfd), which is a distinctive itching linear erythematous eruption. sfd is usually considered a toxic reaction to lentinan, a thermolabile polysaccharide that increases interleukin- . we report cases (p , p , p ) of shiitake flagellate dermatitis studied in our centre. method: skin prick tests (spt) to environmental allergens-including moulds -, prick-by-prick and patch test with raw and cooked sm were carried out. total ige and specific ige to mushroom, white mushroom and environmental moulds were also determined. a raw and cooked shittake mushroom extracts were prepared. both extracts were analyzed in all the patients by sodium dodecyl sulfate polyacrylamide gel electrophoresis (sds-page). results: skin prick tests, prick-by-prick, patch tests and specific ige were all negative except for p , who had positive prick-by-prick to raw shiitake mushroom. sds-page ige immunoblotting assays with the patient's sera revealed ige-reactivity with proteins ranging from kda to kda for p , p and p . we report cases of shiitake flagellate dermatitis with demonstrated ige-sensitization. physicians should take into account that some cutaneous reactions considered as toxic might be allergic reactions. vorozhko i ; sokolnikov a ; sentsova t ; donnikov a ; ilyenko l ; denisova s background: allergic diseases such as asthma, rhinitis and food allergy have increased in recent decades in tropical countries. the tropics has climatic, environmental and ecological peculiarities that allow us to emit several hypotheses that could explain this phenomenon. in one of them, it is postulated that the increase of the sensitization to food, is due to the presence of lower serum levels of vitamin d, product of the adoption of a western lifestyle, with lower sun exposure, which in its turn diminishes the immunomodulatory action of this vitamin at intestinal level, favoring the sensitization against food antigens. we evaluate differences between the titers of serum antibodies against food antigens between two populations with african ancestry but different environment (rural vs urban) and investigate the influence of vitamin d levels. method: an observational, cross-sectional and descriptive study was carried out on afro-descendant children living in san basilio de palenque (rural) or in the city of cartagena, bolivar (urban). the sensitization was determined by a positive skin prick test to allergen extracts, including foods, and, specific ige, iga and igg to egg, milk and peanut extract, as well vitamin d, were measured by elisa. antibody and vitamin d titers were correlated by spearman's test and comparisons between groups were done using the wilcoxon rank sum test. a p < . was considered significant. results: atopy was more prevalent in the urban population ( % vs %, p < . ). however, none participant tested was positive for food allergens. regarding vitamin d levels, these were found to be higher in the rural population compared to the urban group (p < . ). among the antibodies analyzed, only ige against peanut showed differences, which were higher in rural population (p < . ) as well as those of iga to peanut, which were higher in the urban population (p < . ). we observed only a significant correlation between peanut specific ige (rho . , p < . ) and iga (rho - . , p < . ) response and vitamin d. conclusion: in our study, we found differences between the peanut specific ige and iga response in urban and rural populations. the correlation between the levels of specific ige and iga to peanut and vitamin d, suggest that this vitamin may influence peanut sensitization in this population, besides other components like diet and genetic and environmental factors. | evaluation of inhaled allergen sensitivity in patients with food allergies younger than two years of age kulhas celik i ; aldemir es ; buyuktiryaki b ; ginis t ; toyran m ; dibek misirlioglu e ; kocabas cn ; civelek e carbohydrates and pyruvate was observed in the severe group compared to the rest of allergic groups. in addition, an increment in lactate was noticed. these metabolites were closely associated with the energy metabolism. other metabolic changes included increased levels of fatty acids such as myristate, palmitate and laureate. these fatty acids might be precursors of arachidonic acid, a key molecule in inflammation. finally, alterations in some amino acids and adenosine were found method: to evaluate these critical processes, five-week old germ-free c h/hen mice were split into two groups; were intraperitoneally sensitized to the peanut allergen ara h and remained ns. upon reaching weeks of age, mice were intragastrically challenged with purified ara h . mice were harvested in two groups: -minutes and -minutes post-gavage. upon harvest, the left lobe of the liver was collected and sera were removed. sera and livers were evaluated for drp-ara h using an in-house quantitative sandwich enzyme-linked immunosorbent assay (elisa). a sample of the proximal small intestine was monitored for drp-ara h using immunohistochemistry (ihc) and for mast cell degranulation using toluidine blue stain. results: sensitization does not have a large effect on the concentration of allergen present in the sera or liver. however, s mice allowed to digest ara h for -minutes were more likely to display tissues positive for detection of drp-ara h than ns mice at the same time point. conclusion: there is drastic biological variation among mice in their capacity to absorb and transport allergens. the elisa used in these analyses proved effective in the quantitative detection of drp-ara h in both liver and sera samples, while ihc provided inconsistent results for the detection of drp-ara h in tissues. however, in positive ihc samples, staining was indicative of paracellular transport across the epithelial barrier. | eczema induces a high ovalbuminspecific ige/igg ratio and affinity maturation during the lactation period irahara m; kido h; shinahara w inst. for enz. res., tokushima university, tokyo, japan background: recent articles have revealed that ingestion of foods induces oral tolerance and cutaneous sensitization induces food allergy. relationships with levels of immunoglobulin subclasses, affinity of allergen-specific ige, and development of food allergy have also been indicated. however, relationships with levels and affinity of specific immunoglobulins and eczema during early infancy remain poorly understood. therefore, the present study aimed to elucidate these relationships. method: this study enrolled women who visited naruto hospital (tokushima prefecture, japan) in late pregnancy and their children. blood samples and information on skin condition were taken every months from neonate to months old. egg white and milk allergen-specific immunoglobulin subclasses and affinity of ovalbumin (ova)-specific ige levels were measured using the densely carboxylated protein (dcp) microarray with μl of serum. results: this study included infants whose parents agreed to join this study. of these, infants ( %) were diagnosed with eczema by months old. egg white (ew) and milk-specific igg were detected in a few subjects at months old. however, these specific ige and igg were detected in some subjects at that time ew-and ova-specific ige levels and ige/igg ratios were significantly higher in participants with eczema than in those without eczema at months old. moreover, subjects with high ova-specific ige/igg ratios showed higher affinity ova-specific ige antibodies than subjects with low ova-specific ige/igg ratios. these results were not reflected in milk-specific ige levels. the milk-specific ige level differed between breast feeding and formula-fed infants, with no difference in the ige/igg ratio. conclusion: eczema contributed to high ew-and ova-specific ige levels and ige/igg ratios. high ova-specific ige/igg ratios involved high affinity ova-specific ige antibodies. however, the milk source during early infancy had no effect on the specific ige/igg ratio with eczema. these results suggest different sensitization routes provoke different results in levels and affinity of immunoglobulins. | purification and characterization of naturally occurring post-translationally cleaved ara h , an allergen that contributes substantially to the peanut allergome background: the s albumin ara h is one of the most important peanut allergens. a post-translationally cleaved ara h isoform has been described in the past but had not been characterized in detail, nor had its relevance for peanut allergy been investigated. method: post-translationally cleaved ara h (para h ) and intact ara h (intact ara h ) were purified from virginia type peanuts and the cleavage site was mapped using high-resolution mass spectrometry. biochemical characteristics were determined by sds-page, uv absorbance spectroscopy, far uv cd spectroscopy, and immunochemical reactivity of both forms of ara h was compared by igg immunoblotting and ige-elisa using sera from individuals sensitized to peanut. reversed-phase liquid chromatography was applied to study the occurrence and abundance of para h in various peanut types. results: compared to intact ara h , para h lacks a -amino acid stretch, resembling amino acids - (uniprot accession number q g ) in the non-structured loop. consequently, para h consists of chains; a n-terminal chain of approximately kda, and a c-terminal chain of approximately kda, held together by disulfide bonds. intermediate post-translationally cleaved products, in which this stretch is cleaved but not removed, are also present. the secondary structure and ige-binding of para h resembles that of intact ara h , indicating that the loss of the non-structured loop is not critical for maintaining conformational ige-epitopes. both forms of ara h were reactive with several commercially available igg antibodies. the peanut cultivars runner, virginia, valencia, and spanish contained para h at equivalent levels, suggesting para h is a consistent and important constituent of the peanut proteome. conclusion: a post-translationally cleaved form of ara h is abundant in the main peanut market types, and has ige-binding comparable to intact ara h . this should be taken into account when ara h is investigated in peanut-containing products. | release of major peanut allergens from their matrix at various ph and at saliva conditions; ara h and ara h are quickly bioaccessible background: the oral mucosa is the first immune organ that encounters allergens upon ingestion of food. peanut is often consumed in solid form, and it is not known if peanut allergens are released from the food already in the mouth. we set out to investigate the solubility of individual peanut allergens at conditions that mimic the first exposure site, i.e. the mouth. method: light roast peanut flour was suspended in buffers of various ph mimicking saliva. protein concentration was measured in supernatant, and release of major allergens ara h , ara h , ara h , and ara h was assessed by sds-page. also, the allergen profile of un-dissolved material was assessed. results: peanut protein solubility is poor in the ph range - , while at low ph ( . ) and at moderately high ph (> ), the solubility is higher. at all conditions tested, there was a substantial amount of un-dissolved protein. this indicates that the ph range of saliva, between . and . in healthy individuals, may be critical for the release of peanut protein from its matrix. in this ph range from . to . , ara h and ara h are readily released, while ara h and ara h are poorly released. increasing the ph from . to . slightly increased the release of ara h and ara h , but still the recovery was low (approximately % for both ara h and ara h ) compared to that of ara h and ara h (approximately % and %, respectively). this remarkable difference in extraction kinetics suggests that ara h and ara h are the first allergens an individual is exposed to upon ingestion of peanut-containing food. conclusion: based on our observations, we conclude that the peanut allergens ara h and ara h are quickly bio-accessible in the mouth upon ingestion of peanut. this new insight may contribute to the understanding of the extraordinary allergenicity of ara h and ara h compared to other peanut allergens. background: in proven cases of non-ige mediated cow's milk allergy clinical response can be partial even when treated with amino acid formulae e.g pain in infants. residual intestinal symptoms can be related to ongoing nerve hypersensitivity, changes in microbiome or motility disturbance. mast cells are thought to play crucial role in non-ige mediated food allergy. ketotifen is a first generation h antihistamine which has mast cell stabilising properties with pain blocking and anti tnf-a effect. hence ketotifen could have important role in symptom resolution where diet elimination has not been successful. we aim to find out effectiveness of ketotifen to unresponsive/partially responsive symptoms such as pain in non-ige mediated cow's milk allergy infants. method: children who presented to single specialist centre over years had their case notes reviewed retrospectively. inclusion criteria were those children with confirmed non-ige mediated cow's milk allergy by elimination of cow's milk with improvement of symptoms and worsening of symptoms on reintroduction of dairy. where symptoms partially responded e.g pain, ketotifen was used at . - mg once at night for weeks and symptoms were reassessed. statistical analysis was performed using r v . . with significance was set at p = . . results: patients were identified with patients excluded due to unconfirmed non-ige mediated allergy. of the case ( males, age - months), atopic co-morbidities were found in % children. common symptoms were abdominal pain ( %), vomiting ( %), back arching ( %), constipation ( %), bloating ( %), food aversion ( %) and diarrhoea ( %). we compared the children who had symptom improvement on ketotifen and cow's milk elimination against children who improved on cow's milk elimination alone. significant difference of symptom improvement was found with abdominal pain; % using ketotifen compared to % who did not use results: a total of analysis for ttgiga have been performed for a total of patients during the study period ( , , , ) . patients showed at least once a positive ttgiga. among these, had a negative result at first testing, and were positive at the second (n = ) or third testing (n = ). despite an increasing number of ttgiga requests, the number of positive results decreased. wige were rarely requested but were positive in about % of tested sera (table a and b). the amount of laboratory requests for ttgiga has increased, while those for wige remains stable and is rare. wheat allergy seems to be rarely investigated in our center and may deserve more attention. case report: eosinophil-associated gastrointestinal disorders (egids), including eosinophilic gastroenteritis (eog), are a inflammatory diseases, characterized by gastrointestinal symptoms and eosinophilic infiltration. patients with eoe have an increased incidence of allergy, with increased ige mediated food and inhalant sensitivities. use of either a targeted food allergen avoidance approach (based on allergy testing) or untargeted approach (based on food allergen avoidance) results in the resolution of eosinophilia in the gastrointestinal tract of %- % of adult. we describe a case of a -year-old patient diagnosed with eosinophilic enteritis, associated to protein-losing enteropathy. the patient experienced severe diarrhea, nausea, vomiting and weight loss, that caused a severe dysproteinaemia and electrolytes abnormalities. an upper and lower endoscopy was performed, showing an ulcerative ileitis. the histological pattern was characterized by eosinophilic infiltration of ileum and duodenum> hpf. she presented also high levels of total ige ( k/ui), high serum tryptase ( μg/l, n.v. ≤ . ) and sensitization to the lipid transfer protein (ltp) of peach. the patient was prescribed to a six-food elimination diet (sfed) and underwent high doses of oral and intravenously corticosteroids, but a satisfactory therapeutic response was not achieved. we hypothesized that ige has a role in the mechanism of aeg and that blocking ige would have improved disease symptoms and reduced allergic inflammation, as measured by a decrease in intestinal tissue eosinophilia. we started off-label administration of omalizumab mg/month subcutaneously, the same dosage schedule used in allergic asthma and, by other authors, in eosinophilic gastrointestinal disease after achieving informed consent by patient. except for an exacerbation of symptoms occurred months after starting the therapy, when a further endoscopy, showing a gastrointestinal eosinophilic infiltration> hpf, was performed, a significant improvement of both gastrointestinal and cutaneous symptoms was observed during therapy, together with a normalization of laboratory parameters. after months a clinical remission of disease was obtained and administration was stopped. although a histological remission during the first few months of treatment was not obtained, in a subset of aeg patients, ige plays a role in the pathophysiology of the disease and that anti-ige therapy with omalizumab may result in disease remission. | fullerene c reduces the allergic inflammation in food allergy mouse model background: a food allergy (fa) is an abnormal immune response to food. the signs and symptoms may range from mild to severe. they may include itchiness, swelling of the tongue, vomiting, diarrhea, hives, trouble breathing, or low blood pressure. food allergy is becoming increasingly common. fullerene c has the unique electronic properties making it an attractive candidate for allergic diseases therapy. the main purpose of our research was to assess therapeutic effect of fullerene c in a mouse model of fa. method: new efficient method for producing a water-soluble fullerene c has been developed. fa experimental model was induced in balb/c mice by the intragastrical (ig) ova administration after subcutaneous (sc) sensitization. fullerene c was administrated ig once a week, or twice a week, or daily. ova-specific antibodies were assessed by elisa. splenocytes cytokine production upon ova in vitro stimulation was detected by elisa. samples of jejunum of the small intestine were removed for histological examination immediately after the last ig allergen administration. results: it was shown that ova-specific ige and il- level were significant decreased in groups treated with water-soluble fullerene c . the greatest effect was observed in mice receiving fullerene c daily. the ifn-gamma level was significantly higher in ig c treated groups. the histologic analysis of jejunum of the small intestine samples showed that c -therapy improved the histologic picture. the greatest effect was observed in mice receiving fullerene c daily too. conclusion: taken together, these results demonstrate that the water-soluble fullerene c exhibits a significant anti-inflammatory effect in a mouse model of fa, and possesses a high therapeutic potential. background: a -year-old male reported eight episodes of anaphylaxis after exercise. all the ingested food eight hours before each episode was analyzed. before each episode, he had always eaten chicken or turkey meat, and he tolerated these foods without exercising. in one of the episodes the patient had taken a tablet of dexketoprofen a few hours before. since several years, he referred chest tightness after eating some fish (emperor, salmon and whiff), however he tolerated others. the patient denied having eaten fish before any of the episodes of anaphylaxis. method: commercial skin prick tests (spts) and prick by prick tests (pp) with all food ingested and fishes were performed. tryptase, total serum ige (ige) and specific ige (sige) (immunocap. thermo-fisher scientific, uppsala, sweden) to the foods involved were determined. a controlled oral provocation test (opt) with dexketoprofen was performed. results: spt was positive to tuna extract ( mm) and negative ( mm) for the rest of fish extracts. it was also negative for chicken meat extract and other foods tested. pps were positive for raw and cooked turkey meat ( mm), raw and cooked tuna ( and mm), raw emperor ( mm), raw and cooked whiff ( and mm) and raw hake ( mm). pps were negative to raw and cooked chicken meat. ige was ui/ml and tryptase . ng/l. sige was slightly positive to hake, cod and chicken meat. dexketoprofen opt was negative. at that moment, we recommended the patient to avoid chicken and turkey, as well as the fishes which he had symptoms with. since then, he has not suffered any new episode of anaphylaxis despite exercising daily. protein extracts from turkey meat, tuna, emperor, salmon, hake and whiff were prepared and analyzed by sds-page. conclusion: recently, triosephosphate-isomerase ( kda) has been identified as a new chicken meat allergen. this allergen could be responsible for the cross-reactivity between bird and fish meat and the episodes of anaphylaxis after exercise in our patient. the triosephosphate-isomerase has not been implicated previously as a cross-reactive allergen involved in the fish-chicken syndrome. results: twenty-three patients were included, % male, median age years (iqr . ), % atopic, % asthmatic. non-specific lipid transfer proteins (nsltp) were implicated in % (n = ) and ω- -gliadin in % (n = ). eighteen ( %) patients referred anaphylaxis in the reaction with co-factor, ( %) urticaria/angioedema, had both depending on the co-factor. all patients in which ω- -gliadin was the allergen involved had anaphylaxis in the presence of co-factor, with tolerance to wheat without it. in patients in which nsltp was the allergen involved, ( %) had anaphylaxis in the presence of co-factor. reaction with co-factor was more severe than without in ( %) patients; patients had no previous history of reaction and subsequently tolerated the culprit food. only patient had anaphylaxis in the absence of co-factor; the remaining presented oral allergy syndrome and/or urticaria. exercise was the main co-factor, present in patients. nonsteroidal anti-inflammatory drugs (nsaids) were the only co-factor in patients; all of them had anaphylaxis, with allergy to ω- -gliadin, to nsltps. all subsequently tolerated the nsaids involved. conclusion: nsltps and ω- -gliadin were the most frequently involved allergens in cefa, with exercise being the most frequent co-factor. nsaids were relevant co-factors, even when ω- -gliadin was the allergen involved. several patients subsequently tolerated culprit foods and nsaids, difficulting the diagnosis and further emphasizing the importance of a correct cofactor evaluation. molecular allergens had an important role in the diagnosis, avoiding unnecessary ofc. information about co-factors must be included in all patients with allergy to nsltps and ω- -gliadin. | allergy to wheat-dependent exerciseinduced anaphylaxis (wdeia) proteins, without? -gliadins as responsible ferreira a ; castillo m ; martins s ; pineda f unidade de imunoalergologia hospital das forças armadas., lisbon, portugal; departamento de aplicaciones. diater laboratorios, madrid, spain background: the second well-characterized form of allergy to wheat proteins is wheat-dependent exercise-induced anaphylaxis (wdeia), with the ω -gliadins (part of the gluten protein fraction) being the major group of proteins which are responsible, but other forms of food allergy have also been reported, with the proteins responsible including gluten proteins, cm proteins and non-specific lipid transfer proteins. the patient was a -year-old man who visited the hospital with acute urticaria just eat bread before run ( minutes). according the components of bread. it was formed by a mixture of wheat, rye and barley. with a history (for several years) of episodes of severe urticaria after intake a mixture of cereals and/or different kinds of beer. results: prick test and specific ige with wheat, rye and barley were negative and the proteins from allergenic extract from these cereals, and also the gliadins and glutenins fractions were transferred onto a pvdf membrane to carried out a western blot technique with the patient's serum. the patient's serum recognized several proteins from wheat and millet gliadins not compatible in molecular mass with a ω -gliadins. the association of w gliadin as responsible for the symptoms produced after the intake of products containing wheat and exercise is well referenced but in the case of this patient could have other proteins involved as triggers of their symptoms. suksawat y phramongkutklao hospital, bangkok, thailand background: food-dependent, exercise induced anaphylaxis (fdeia) is an anaphylactic condition that develops in patients who ingest specific food followed by exercise. a variety of foods have been described to be the cause including shellfish, wheat and vegetables. the mechanisms of fdeia is believed that exercise increases allergen absorption or decreases threshold of mast cell. the investigations such as skin prick test or specific ige for food are useful because food sensitization is demonstrated. however, a challenge test including ingestion of suspected food followed by exercise is the only method to diagnose this disease. we report a case of fdeia in a -year-old adolescent male. result: he presented with generalized urticaria and hypotension after eating a barbecue buffet which was one hour followed by playing taekwondo. after treatment with intramuscular adrenaline, antihistamine and systemic steroid, his condition was improved. the barbecue buffet consists of many kinds of food including shrimp, squid, salmon and pork meat which were previously tolerated. he had no past history of anaphylaxis or drug allergy. he was referred to our allergy unit for investigation. we performed skin prick test with food allergens and many kinds of fresh foods that he ate on that day and the result was positive to shrimp ( mm. in diameter). three-day challenge protocol was set up a month after recovery and we used aspirin as a cofactor. on the first day, open challenge for gram of shrimp was administered and the result was negative. on the second day, exercise challenge test based on the american thoracic society guideline was also negative. however, on the last day, he developed generalized urticaria five minutes after the same exercise challenge test which was hour preceded by aspirin intake and gram of shrimp ingestion. but his vital signs appeared to be stable. the patient was administered intramuscular adrenaline and antihistamine with full recovery. he was strongly advised to avoid shrimp for - hours before exercise and carry an adrenaline autoinjector. the-three day challenge protocol is a definite tool to confirm the diagnosis of fdeia. a correct diagnosis is important to avoid unnecessary restricted diet. | food dependent exercise induced anaphylaxis in peach allergic patient-case report consumption of different types of food (pancakes with cream cheese and fruit, peach, chinese dish, sandwiches-all eaten on other occasions without symptoms) and co-occurring physical exercise (dancing, shopping, walking). during diagnosis we performed spt with inhaled and food allergens (allergopharma), prick by prick tests with peach, banana, apple, pear and bread. we established the concentration of allergen specific ige (peach, wheat flour, peanuts, hazelnuts) and the level of ige specific to allergen components (immunocap isac). we performed exercise provocation test and open food challenge with peach. results: spt were negative with all tested food and inhaled allergens (inc.egg; milk; cocoa; tomato; carp; apple; banana; strawberry; rye flour; wheat flour; peanuts; hazelnut; citrus, d. farinae; d. pteronyssinus; grass; weeds; clad. herbarium; alt. tenuis; dog; cat; poplar; hazel; alder; birch; mugwort). prick by prick tests were positive with fresh peach. concentration of peach specific ige was . ku/l. in immunocap isac we found elevated levels of ige specific to ltps from different allergen sources (jug r - . ; pru p - . ; pla a - . ; tri a - . [isu-e]). open food challenge with a medium size peach was negative. exercise provocation test without allergen exposition was negative. exercise provocation test after eating a medium size peach concluded with severe lip and eyelids edema, followed by whizzing, dyspnea and urticarial. patient received adrenaline . mg im, steroids and antihistamines with good clinical effect. conclusion: patient was diagnosed with food dependent exercise induced anaphylaxis (fdeia) due to ltp allergy. she was advised to eat peeled fruit and vegetables, avoid cofactors of allergic diseases and carry rescue set (adrenaline, steroids and antihistamines). cases reports: we report case of fdeia and cases of wdeia. case : -year-old woman with intermittent severe allergic rhinitis and food allergies since childhood. in the last years she registered weekly episodes of fdeia (urticaria, angioedema, wheeze, drop of bp) especially when during effort and after alcohol intake. prick tests were positive for grass pollen, mugworth, ragweed, dust mites, celery, soy, sesame, pistachio, mango, honey and shellfish. she followed years of subcutaneous immunotherapy for grasses pollen. the fdeia episodes frequency and severity diminished during it. provocation test for celery and mango were positive, for alcohol, soy, sesame, pistachio, honey and shellfish were negative. case : -year old man with a -year history of acute gluten induced urticaria, recently developed episodes of wdeia (flushing, severe urticaria and angioedema, wheeze) when he went for gym. skin test was highly positive for wheat flour and dust mites, in vitro tests for omega gliadin and wheat-specific ige were positive. food challenge for wheat was positive. he followed oral immunotherapy for wheat. the wdeia episodes were rare and mild. case : -years old female with mild allergic rhinitis and controlled asthma, with wdeia (urticaria, angioedema, wheeze, drop of bp) in the last years. skin tests showed positive results for wheat flour, dust mites and dog hair. omega- gliadin and wheat specific ige were high, but the provocation test for wheat was negative meanwhile combined wheat and effort provocation test was positive. -year-old female athlete, otherwise healthy, experienced three episodes of fdeia following running sessions. two reactions were preceded by intake of salad containing lettuce, tomato and sunflower seeds and the third one occurred after eating celery salad. the patient denied occurrence of any symptoms with physical exertion or food ingestion alone. physical examination and blood testing did not reveal any abnormalities. the differential diagnosis was performed. in skin prick test and specific serum ige antibodies sensitization to house dust mite, grass and mugwort were found. the spt and specific ige assay to culprit and most common food allergens were negative. the molecular diagnostic has been applied (faber, caam, rome, italy). the test scored positive for art v, blo t, der f, der p, eur m, lol p, phl p. no positive results for available food molecules including celery, tomato, sunflower seeds and lettuce were found. the detection of culprit food in fdeia is of crucial meaning as the syndrome can be life-threatening. the molecular diagnostic has been applied already in diagnosis of wheat-dependent exercise-induced anaphylaxis (wdeia) proving ω- -gliadin sensitization in the majority of the cases. as the presented case did not reveal sensitization to culprit food in traditional allergy tests the molecular diagnostic was performed. this test did not show sensitization to culprit food either. however, not all of the molecules are available in molecular assays yet. cross-reactivity reaction to mugwort and grass has to be considered. the pathophysiological components of physical exertion has to be taken into consideration as well. this could contribute to the assessment of reasonability of molecular approach in diagnostic work-up for fdeia and to the establishment of standardized protocols for diagnosis and management of that syndrome. case report: food allergy to wheat is rare in adults, often reported in exercise-induced anaphylaxis. food-dependent exercise-induced anaphylaxis (fdeia) is a form of food allergy induced by exercise. fdeia symptoms can include urticaria/angioedema, respiratory and gastrointestinal manifestations and hypotension/shock. a -year-old male patient presented to the emergency department, was admitted after an episode of hives, hypotension and loss of consciousness. his consciousness was restored after treatment with epinephrine, glucocorticoids as well as fluids, and thereafter, the patient reported that the anaphylactic episode occurred when he started rapidly walking hour after eating a slice of pizza. he mentioned that the offended food was tolerated always when it was not followed by a physical exercise. review of his past medical history and family one were non-contributory with respect to this episode. the allergy skin prick testing for common foods revealed a positive response only to wheat, while and other laboratory test values were within normal ranges. the patient is discharged after instructions on the use of epinephrine auto-injector. he was also advised to avoid wheat containing products up to hours prior to physical exercise. our case demonstrated that fdeia can be characterized by the onset of anaphylaxis soon after physical exercise, when preceded by the ingestion of the responsible food. avoidance of the combination of the exposure to respective allergen and exercise is the most efficient precautive measure toward subsequent fdeia episodes. | residual exercise-induced allergic reactions after successful rush oral immunotherapies for milk and wheat method: we conducted roit for children (median . years old) with milk allergy and children (median . years old) with wheat allergy during - . after - days of the rush phase in the hospital and a slow-increasing phase at home, patients consumed the maintenance dose ( . g milk protein or g wheat protein). after at least three months of the maintenance phase without allergic symptoms, we conducted an exercise provocation test (ept) after eating the target food. if the ept was positive, we repeated it after a couple of years to check for remission. the presence or absence of eiars was based primarily on the results of epts but also on the clinical history in some cases. results: as of december , milk-and wheat-allergic patients were able to continue ingesting the maintenance dose (desensitization). in these patients, milk-and wheat-allergic patients underwent the first ept at a median of ( - ) days after roit, and the result was positive in ( . %) and ( . %) patients, respectively. among these ept-positive patients, milk-and wheat-allergic patients conducted a second ept at a median of ( - ) days after the first ept. the result of the second ept was positive in milk-and wheat-allergic patients. in addition, clinical histories of eiars were subsequently observed in milk-and wheat-allergic patients after negative results on an ept. altogether, ( . %) milk-and ( . %) wheat-allergic patients still had eiars even after getting desensitization as of december conclusion: patients with persistent milk and wheat allergy often have residual eairs even after three to five years of desensitization due to the administration of successful roit. abstracts | | anaphylaxis caused by omega- -gliadin initially diagnosed as idiopathic anaphylaxis: a case report tziotou m ; syrigos k ; syrigou e ; sinaniotis a department of allergy,, athens, greece; gpp,, athens, greece case report: we report the case of a -year-old man who experienced two episodes of wheat dependent exercise induced anaphylaxis, initially diagnosed as idiopathic anaphylaxis. first episode: the patient woke up in the morning and drove to his resort. while driving, he ate a piece of cheese and ham pie. when he arrived, he walked some meters to the garden and started feeling pruritus and dizziness. he lost consciousness and recovered by himself. he was carried to hospital where his vital signs were normal. the patient has a history of atrial fibrillation and has been on flecainide bid and aspirin at noon for the last four years. a month after the first episode he visited an allergist. skin prick tests to aeroallergens and prick to prick tests to the ingredients of the pie were negative. tryptase levels were within normal limits and skin biopsy was negative for mastocytosis. an endocrinology workup was also negative. the patient was prescribed an epinephrine autoinjector and was asymptomatic for eight months. second episode: that morning he had a cup of milk and two slices of toast for breakfast and started working in the garden. two hours later he experienced pruritus and urticaria and fell unconscious. his wife had to administer two epinephrine autoinjectors before he regained consciousness. after the second episode it was decided to start treatment with omalizumab. two months later he experienced an episode of urticaria while working in the garden. he could not recall what he had eaten before. based on history, we thought that a cofactor might contribute to the occurrence of anaphylaxis. we performed skin prick tests with peach (ltp) and gliadin, allergens associated with food dependent exercise induced anaphylaxis in our region. the test to gliadin was positive. specific ige in serum to omega- -gliadin was also positive, while specific iges to all ltps tested were negative. the patient was advised to avoid wheat and has been asymptomatic ever since. cases diagnosed with idiopathic anaphylaxis may actually be cases in which the culprit allergen has not been identified. detailed history and extensive workup may contribute to the successful management of these patients. written informed consent has been obtained from the patient. | wheat-dependent exercise-induced anaphylaxis (wdeia) and nsaids: clinical history is crucial conclusions :we present a case clinically compatible with wdeia with nsaids intake as augmenting factor. this case emphasizes that a carefully and thoroughly taken medical history is of crucial importance, otherwise wdeia can easily be unrecognized. as a result, non-allergic hyperreactivity to nsaids could be excluded and the diagnose of selective allergy to arylpropionic acids was made. exercise challenge test could not be performed in our case. case report: kounis syndrome (ks) has been defined as an acute coronary syndrome that manifests as unstable vasospastic or non-vasospastic angina, and even as acute myocardial infarction. it is triggered by the release of inflammatory mediators following an allergic insult. a -year-old woman with type ii diabetes and hypertension, and unstable angina pectoris as cardiovascular risk factors, has consumed chamomile tea. thirty minutes later, she developed generalized itching, skin rash, swelling of the face and the throat, chest tightness, dyspnea and syncope. the patient was transferred immediately to the emergency department, and sodium chloride, mg prednisolone, mg dexamethasone, mg methylprednisolone, ui heparin, mg voltaren were intravenously administered along the subsequent minutes under simultaneous treatment with oxygen therapy. an ekg examination is performed based on the patient disease's history, showing a . - mm st-depression on d -d leads, mm on v , and . mm on the v -v ones. in addition, . mm st-elevation on the avr and mm on the v derivation was observed, associated by a negative t-wave on the v , v , and avr leads. blood tests revealed a normal troponin i level (of . ng/ml). five hours later in the ekg was noticed: isolined st-segments, and negative t waves on the d , avr, and v leads. ultrasound examination revealed normal heart kinetics and function. following the heart changes, the patient was administered sol. heparin ui twice i.v., nebivolol mg, plavix mg, atorvastatin mg, abstracts | monocinque mg, ordinary insulin ui s.c., glargine insulin ui s.c., and sol. furosemide mg i.v. the patient progressed favorably, and four days after the anaphylactic episode the ekg revealed a . mm st-depression on leads v , and v , negative t-wave on avl lead, and normalized one on the v one. this case emphasizes the role of serious allergic reactions as cause of acute coronary syndrome in patients with altered coronary arteries and food intake as cause of kounis syndrome. | recall urticaria in two young patients with alpha-gal-syndrome after tick bites case report: patient a (m, age ) had suffered from - anaphylactic reactions (hives, nausea, dyspnea and dizziness) within the past months. all episodes occurred - hours after ingestion of red meat, once with alcohol as a co-factor. all episodes started with a wheal measuring about . cm in exact the same spot where he had been bitten by a tick one year before. specific ige to galactose-alpha- , -galactose (alpha-gal) was positive ( . ku/l). skin prick testing using raw pork kidney suspension and intradermal testing with gelafundin ® % diluted : also showed positive reactions. we performed an oral challenge with cooked pork kidney under careful monitoring being able to reproduce the recall urticaria as described above with a cumulative dose of g pork kidney. we stopped the challenge and treated the patient with antihistamines and corticosteroids. patient b (m, age ) reported on several anaphylactic reactions within the past years with symptoms including abdominal pain, diarrhea, as well as dyspnea and loss of consciousness in one of the episodes. all episodes occurred several hours after ingesting food. furthermore the patient remembered a tick bite about years before the first anaphylactic reaction, which repeatedly became inflamed and only healed completely over months. every episode started with pruritus and a wheal in the area of the former tick bite (in loco). specific ige to galactose-alpha- , -galactose was positive ( . ku/l) as well as the skin prick testing with cooked pork kidney and intradermal testing with gelafundin ® % diluted : . this patient refused performance of oral challenge tests. an elimination diet of red meat for months resulted in the absence of the symptoms as described. the diagnosis of alpha-gal-syndrome with recall urticaria in loco was made in both cases. this symptom may also be useful in evaluating results of oral challenge tests as well as an important clinical sign in medical history. pali-schöll i ; meinlschmidt p ; purschke b ; hofstetter g ; einhorn l ; mothes-luksch n ; jensen-jarolim e ; jäger h background: insects have gained interest as alternative nutrient source for humans and animals. however, being a "novel food" in the industrialized part of the world, several safety aspects, like allergenicity, need to be thoroughly addressed. in the present work we evaluated the cross-recognition of ige from patients allergic to crustaceans, house dust mite or stable flies, using house cricket acheta domesticus (ad), desert locust schistocerca gregaria (sg) and mealworm tenebrio molitor (tm). we further investigated changes of immune-recognition in terms of ige-binding in differently processed insect extracts. method: migratory locust locusta migratoria (lm) was subjected to different extraction methods, enzymatic hydrolysis or thermal processing, whereas tm larvae (tml) were evaluated after different centrifugation modes and ph levels. results: we revealed that ige from patients with crustacean allergy shows cross-recognition of acheta domesticus, schistocerca gregaria and stable flies. ige from house dust mite allergic individuals binds to acheta domesticus and schistocerca gregaria. importantly, the cross-reactivity to lm can be deleted by enzymatic hydrolysis with different enzymes or heat treatment (cooking, autoclaving), but not by different extraction methods. changes of ph and varying centrifugation steps are not sufficient to reduce ige-binding to tml. our results show that patients allergic to crustaceans, house dust mite or stable flies-allergic patients cross-recognize desert locust and house cricket proteins, and crustacean-allergic patients also flies proteins. furthermore, we confirm that the appropriate food processing method of insect proteins can reduce the risk of cross-reactivity for crustaceans-and house dust mite-allergic patients. the study was supported by the austrian science fund fwf (grant sfb f -b to ejj). results: the mean age at diagnosis was years in children and years in adults, more frequent in males ( : ). in the pediatric group, three had first-degree relatives with eoe and three had celiac disease. two children had performed milk oral immunotherapy and five adults aeroallergens subcutaneous immunotherapy. most of them were atopics with sensitization to aeroallergens ( . % of children and . % of adults) and food allergens ( % of children and . % of adults), without statistically significant differences. the most frequent foods were fruits and nuts in both groups. we found significant statistical differences in fruits ( % of children abstracts | and . % of adults; p = . ) and cereals sensitization ( % of children and . % of adults; p < . ). in the clinical presentation we observed significant statistical differences in impaction ( . % of children and . % of adults; p < . ), dysphagia ( . % of children and . % of adults; p < . ) and abdominal pain ( % of children and . % of adults; p = . ). in the endoscopic findings children had more frequently exudates ( . %; p < . ) and adults had esophageal trachealization ( %; p < . ). significant statistical differences were found in the treatment with topical corticosteroids ( % of children and . % of adults; p < . ) obtaining a variable positive response. . % of patients in both groups received food elimination diet, % with four or more foods. conclusion: eoe presents differences in the sensitization profile, clinical manifestations and endoscopic findings according to the age of presentation. the response to pharmacological treatment is variable and a high percentage of patients receive food elimination diets. it is a pathology difficult to control, therefore new non-invasive techniques would be useful in order to facilitate its management. | modulation of gut microbiota in patients with nickel allergy and ibs after diet and probiotics supplementation mb ; garcía-figueroa be department of allergy department of allergy fang l united states | bcx improves health-related quality of life in hereditary angioedema with c -inhibitor deficiency bygum a fang l former yugoslav republic of; division of clinical immunology huissoon a bygum a ; panovska vg united states callejas fdb alobid i ; muñoz-cano r izquierdo i icahn school of medicine at mount sinai method: the case report form was developed by experienced allergists, and the web-based registry was established in cooperation with a professional medical software team. twenty-two departments from hospitals took part during the first year %), whereas in adults, drugs ( . %) were more common than foods ( . %). the most common food triggers were eggs ( . %), milk ( . %), and walnut ( . %) in children, and shrimps ( . %), wheat ( . %), and crab ( . %) in adults. among drug triggers in adults, antibiotics ( . %) were the most common cause followed by nsaids ( . %), and h -blockers ( . %). the onset time was≤ minutes in . %. in children, home was the place of occurrence in more than half of the cases, whereas adults experienced anaphylaxis in out-of-home settings more often than children. cofactors were present in %. among the cases registered via the emergency department of participating hospitals, epinephrine was administered in . % ( . % in adults, . % in children) and the route of administration was im in . %, iv in . %, both im and iv in . %, and subcutaneous in . %. the number of epinephrine administration was single in % conclusion: this multicenter prospective registry would provide a better understanding of anaphylaxis, and provide visionary modalities to improve the management and prevention of anaphylaxis in future a case of kounis syndrome after chamomile tea consumption characterized by symptoms related to esophageal dysfunction and esophageal mucosal infiltration by eosinophils objective: characterize patients (pts) with eoe diagnosis and analyze the differences between pts with diagnosis at pediatric (ch, < years old) and adult age epicutaneous tests(epict)], serum total ige and eos, findings in upper digestive endoscopy (ude) and biopsies. the correlation between food sensitization, clinical severity (visits to er services or hospitalization due to complications of eoe, sclin) or severe histology results: pts ( % male, average age ± years) ad and , respectively. % ch and % ad were atopics. the most frequent symptoms of eoe were dysphagia ( %) and gastroesophageal reflux( %) in ch; impaction( %) and dysphagia( %) in ad. % ch and % ad had aeroallergens sensitization. % ch and % ad had food sensitization. the most frequent positive tests were for ch: spt to milk( %) and shellfish( %), epict to shellfish( %) and meat( %); for ad: spt to milk( %), fresh fruits and nuts both %), epict to shellfish( %) and meat( %). ude showed: % striation and white plaques in % ch shist ( %) was associated with sclin ( %), p = . in ch; but this was not observed in ad group there was no correlation between food sensitization and sclin or shist in both groups(p > . ). the average values of serum total ige (kua/l) were in ch and in ad; eos were and , respectively in ch and ad allergy unit-fondazione policlinico universitario a. gemelli, università cattolica del sacro cuore conclusion: ltp with a fixed dose ( iu in ml) of ready-touse shp led to fewer severe attacks, a higher proportion of attack-free patients, and a clinically meaningful and statistically significant reduction in cumulative attack severity and daily severity in hae patients relative to placebo. background: c -inh-hae is a rare, potentially life-threatening disease characterized by episodes of subcutaneous and/or submucosal swelling. apex- was a phase , double-blind, placebo-controlled study to evaluate the prevention of attacks with bcx , a once daily oral kallikrein inhibitor, in patients with c -inh-hae.method: patients with c -inh-hae with a history of at least hae attacks per month were randomized to receive four different doses of bcx ( mg, mg, mg, . mg) or placebo for days. blood samples for bcx concentrations and kallikrein inhibition were obtained from patients before dosing and for hours post-dose on day . pk analyses and pk-pd modeling were done in phoenix winnonlin v . and sas v . . the pk population included , , , and subjects in the mg, mg, mg, and . mg groups respectively.after daily dosing achieved steady state, c max was reached at a median of - hours after dosing. there was a greater than dose proportional increase in exposure (auc tau and c max ) over the . -mg to -mg dose range, with an approximate -fold increase in exposure with a . -fold increase in dose. at doses ≥ mg, which showed statistically significant and clinically meaningful reductions in hae attack rates, geometric mean plasma trough concentrations (c tau ) were maintained at or above the minimum target concentration ( -fold ec ) estimated to be required for adequate plasma kallikrein inhibition. percentages of study subjects at steady-state with bcx plasma concentrations> -fold ec were %, %, % and % in the . , , , and mg dose groups, respectively. a -mg dose provided a mean c tau of slightly above . fold ec , with a corresponding reduction in hae attack rate of % (p < . ) compared with placebo. consistent with the exposure data, a dose dependent inhibition of kallikrein was observed with bcx treatment over the dose range. the drug effect on kallikrein inhibition was highly correlated with exposure (r = . ). in patients with c -inh-hae, bcx treatment at doses ≥ mg resulted in clinically meaningful reductions in the mean weekly hae attack rate. concentrations of bcx at doses ≥ mg were maintained at or above a c tau of -fold the kallikrein inhibition ec in most patients, and kallikrein inhibition was highly correlated with bcx plasma concentrations.background: c -inh-hae is a rare, life-threatening disease characterized by recurrent episodes of subcutaneous and/or submucosal swelling that lead to considerable morbidity and a poor quality of life (qol). apex- was a phase , double-blind, placebo-controlled study to evaluate the prevention of attacks with bcx , a once daily oral kallikrein inhibitor, in patients with c -inh-hae.method: patients with c -inh-hae with at least hae attacks per month were randomized to four different bcx doses ( mg, mg, mg, . mg) or placebo. subject-reported qol assessments were conducted at the start and end of treatment using the disease specific angioedema quality of life (ae-qol) questionnaire that measures domains (function, fatigue, nutrition, fear/ shame) and has minimal clinically important difference (mcid) of points. the changes from baseline in total and domain scores was compared between the treatment and placebo groups. modified angioedema activity score (aas) values across domains (daily activities, appearance, physical discomfort, overall severity) were calculated for each attack and a total score was derived for each subject by summing scores from each attack. total scores were compared to placebo using an ancova model with adjustment for qualifying attack rate. reduction of attacks was statistically significant for all top doses and there was a dose related increase in adverse events.results: in the mg dose group, qol assessed by ae-qol was significantly improved after weeks of treatment compared to placebo for ae-qol total score (- . , p < . ) as well as across all domains (function: - . , p = . ; fatigue: - . , p = . ; fears/shame: - . , p < . ; nutrition: - . , p = . ). all other treatment groups showed a trend towards improvement. qol improved the most in the mg group, and % of subjects in the mg group showed ae-qol reduction of more than points. disease activity as assessed by the aas was significantly reduced in the mg, mg and mg dose groups as compared to placebo, whereas there was no significant reduction in the . mg dose group. results: there were no marked differences in the age, sex, total ige titer, comorbidity of bronchial asthma and atopic dermatitis or the starting dose of rush oit among the groups. all patients in the low-bmfi group achieved ≥ % of the target dose, whereas . % of the middle-bmfi group and % of the high-bmfi group failed to achieve the target dose (p < . ). results: a total of infants were diagnosed with food allergy (ige-mediated and mixed type) at our center during the study period, of these patients underwent prick test for inhalant sensitivity, and ( . % male) of these were younger than years of age. conclusion: sensitivity to inhaled allergen were found in of ( . %) patients with food allergy. therefore, we believe that inhalant sensitivity should be evaluated in these patients. there is also a requirement for further studies to identify the influence of inhaled antigens on the disease activity of patients with allergic conditions. method: in this study, we aimed to perform the metabolic profiling of severe profilin mediated food allergic patients looking for biomarkers that might both, predict the prognosis of the disease and understand the molecular mechanisms of inflammation underneath. other allergic patients (mild and moderate) and non-allergic were recruited in the study as comparative groups. the allergic patients class was predicted using a mathematical algorithm from non-allergic vs severe model results: plasma samples from non-allergic subjects, mild, moderate and severe allergic patients were measured using gas chromatography coupled to mass spectrometry (gc-ms). the samples were from different hospitals in spain covering the areas with the highest pollen exposure. the metabolic profile was composed of metabolites for each sample. results after the statistical analysis showed differences between the groups. firstly, a clear reduction of several abstracts conclusion: we found, as expected, a predominance of males with eoe diagnosis. ch were more frequently atopic and had aeroallergen and food sensitization. impaction and esophageal stenosis were more frequent in ad than ch. shist was associated with sclin only in ch. method: three children with ee, boys aged . - years, were assessed over months to years. results: cases developed in infancy. one had dyspepsia and low weight gain in infancy soon after feeding began. another had symptoms in infancy but not diagnosed until age with dysphagia and esophageal stricture.. the third case was diagnosed at years old after episodes of food impaction in the esophagus beginning at age . all cases had allergic comorbid diseases including atopic dermatitis in all and allergic rhinitis in . skin prick tests were positive to several food allergens (cow's milk, egg protein) in , to dust mite in and to pollens in . serum total ige levels ranged from to iu/ml. eosinophils in peripheral blood were elevated in all , reaching %- %. treatment included restricted diet and topical budesonide - mg daily depending with periodic endoscopic biopsy.in all cases clinical improvement occurred by one month of treatment, with endoscopic confirmation. morphological improvement fol- the study aimed to evaluate the effects of probiotic supplementation, in addition to diet, in ibs and snas patients, in terms of modulation of faecal microbiota population, reduction of gi and cutaneous symptoms, increase of patient's quality of life and modification of gut dysbiosis.method: forty patients aged between and years, affected by ibs, ni sensitization and ltp sensitization were enrolled to evaluate gut dysbiosis. dna extraction method (next generation sequencing) with commercial kit (microbiopassport ® ) was performed on stool samples. ibs patients were divided in two groups, according a gluten free diet prescription or a low fodmaps diet prescription for three months. similarly, (suspected) snas patients (confirmed by % ni sulfate in petrolatum patch test) were prescribed a low ni diet ( μg/kg nickel content during the first four weeks and then up to μg/kg up to three months). two ltp (lipid transfer protein) sensitized patients underwent a ltp free diet.gut dysbiosis was re-assessed after a fixed probiotic supplementation. a sex-age matched group of individuals without history of ibs, snas or any gastrointestinal disease was considered as control.gastrointestinal symptoms were evaluated using the visual analogue scale before and after treatment. conclusion: our preliminary findings suggest that probiotic implementation could be useful in patients with snas on a low-ni diet to increase population diversity, which could contribute to restore the intestinal homoeostatic conditions. key: cord- -whne l authors: anderson, victoria l.; miskinis-hilligoss, dianne title: choosing the right antibiotic in ambulatory care date: - - journal: j nurse pract doi: . /j.nurpra. . . sha: doc_id: cord_uid: whne l the goal of this article is to be a quick guide for the nurse practitioner practicing in an ambulatory setting for making the right antibiotic choice for the right infection. with the use of a system-based approach, this article defines the most common infections seen in ambulatory care and their most common causative organisms and gives antibiotic options with respect to efficacy, common side effects, and cost. we provide recommendations for length of therapy and follow-up, as well. approximately -to -m thick.the dermis, lying deeper to the epidermis, houses sweat glands, nerves, blood vessels, and lymphatics. diagnoses of skin infections, rashes, or both are made by history and examination, and at times a skin biopsy is needed.the medical history and the history of the injury will help in choosing what organisms might be involved or to what extent one or both of these structures are involved. nurse practitioners can diagnose and manage most of these skin infections; however, in the case of necrotizing fasciitis this is a surgical emergency and requires immediate referral and hospitalization.the following clinical entities most commonly seen in outpatient care are described: cellulitis, impetigo, folliculitis, furuncles and carbuncles, necrotizing fasciitis, paronychia, onychomycoses, lice, scabies, and lyme disease. definition. an acute inflammatory spreading response of the skin characterized by superficial swelling, pain, erythema, and warmth that often extends in the subcutaneous tissues. diagnosis. rapidly spreading cellulitis, evidence of systemic response, or association with asplenia, neutropenia, cardiac or renal failure, cirrhosis, preexisting edema, or immunodeficiencies are indications for admission and treatment with an intravenous antibiotic (cefazolin or vancomycin for patients allergic to penicillin). in a diabetic host, a clinician should consider broader coverage to include gram-negative and anaerobe coverage that includes an intravenous (carbapenem, meropenem, or imipenem-cilastatin) and a penicillinase-penicillin such as ampicillin-sulbactam. differential diagnosis. • contact dermatitis: intense pruritus and a history of an exposure help to differentiate this usually erythematous rash that can spread from the point of exposure. • erysipelas: superficial, red, and tender,"st.anthony's fire" rash with well-demarcated edges caused mostly by group a ␤-hemolytic streptococci. • panniculitis: defined as an inflammation of the adipose layer of the skin and can be septate or lobular and includes such entities as erythema nodosum (multiple, scattered erythematous lesions that are painful), erythematous nodules of idiopathic or varied cause such as infection, drug reaction, sarcoidosis, ulcerative colitis. • sweet's syndrome or acute febrile dermatosis. • insect bites or stings: the history, pruritus, and lack of response to antimicrobials may help to distinguish this from cellulitis. • kerions of the scalp because of tinea capitis can appear erythematous, indurated, and painful but is caused by a fungus instead of bacteria so will not respond to antibiotics, and cultures from drainage will be negative for bacteria but may be positive on the wet mount. • folliculitis: see discussion below. • superficial thrombophlebitis and deep vein thrombosis (dvt): a tender cord and a history of venous catheter will help with the differential for superficial thrombophlebitis. engorgement of superficial veins in the extremity of a dvt and a history of risk factors toward a dvt and a lowerextremity ultrasound scan will help to differentiate this from cellulitis. cause. usually trauma related. most common sites are legs and digits; rarely seen are the face, hands, torso, neck, and buttocks. common bacterial organisms. gram-positive organisms: streptococcus pyogenes, staphylococcus aureus. if saltwater or brackish water injuries lead to cellulitis, consider vibrio vulnificus. treatment. heat and elevation of an extremity; support hose for patients with chronic edema, analgesics (acetaminophen or ibuprofen), and antibiotics. antibiotics. duration is typically to days. • ␤-lactamase-resistant penicillin.augmentin: adult, mg orally every hours; pediatric, to mg/kg divided every hours. • first-generation cephalosporin. keflex: adult, mg every hours or mg every hours; pediatric, to mg/kg per day in divided doses every hours. • azithromycin (zithromax): adult, mg day and mg days to , may increase to days depending on host and extent of disease; pediatric, mg/kg day , followed by mg/kg days to . • fluoroquinolones. levofloxacin: adult, mg orally every day; pediatric use is not approved for those aged younger than years. a primarily pediatric entity, this superficial infection of the corneal layer of the dermis presents as a unilocular, vesicular rash that often erupts, leaving a serous drainage that is golden yellow and crusting. occurs mostly on the face or cheek and chin and is usually associated with trauma but can be a secondary infection from a herpetic lesion or angular chelitis. it can be bullous or nonbullous and is highly infectious, often in families and institutional childcare settings. differential diagnosis. • varicella: crusts of varicella are darker and harder. • herpes simplex: fluid is more turbid and lacks the golden yellow hue. • acute palmar pustulosis: palms and soles are more commonly affected and are sterile and self-limited associated with pharyngitis. causative organisms. s aureus, gram-positive organism commonly found in the environment. treatment. hand washing, topical bactroban, and systemic antibiotics. • azithromycin: adult, mg day and mg days to ; pediatric, mg/kg day , followed by mg/kg days to . ation. diagnosis is made by physical examination, because lesions often are pustular with a hair follicle in the center. most common causative organism. s aureus. treatment. folliculitis usually resolves spontaneously; however, in significant cases or in immune-compromised or diabetic patients, you may want to treat with topical agents and watch closely. • topical therapy with cleansing with hibiclens or antibacterial soap, application of topical anti-infective agent such as benzoyl peroxide. if needed, you can use an application of topical erythromycin, clindamycin as cleocin, mupirocin, or bactroban. follow-up. if there is a change in the rash or development of systemic symptoms, follow-up is immediate; otherwise, it is as needed. definition. folliculitis that extends beyond the hair follicle creates a furuncle, a walled off mass with pustular material inside. multiple furuncles that coalesce into a large mass is a carbuncle.a carbuncle will drain through multiple sinus tracts. most common causative organisms. s aureus. treatment. incision and drainage are usual in an otherwise healthy host and addition of a systemic antibiotic. any evidence of associated cellulitis with an ill-appearing patient or one who has an immune defect, diabetes, cirrhosis, chronic steroid use, burns, or obesity should lead to a high index of suspicion toward a necrotizing fasciitis. antibiotics. • first-generation cephalosporin. keflex: adult, mg every hours or mg every hours; pediatric, to mg/kg per day in divided doses every hours. • augmentin: adult, mg orally every hours; pediatric, to mg/kg divided every hours. follow-up. if change in rash or development of systemic symptoms, the follow-up is immediate; otherwise, it is to days for a compromised host or as needed in a healthy host. definition and cause. this surgical emergency is described as a necrosis of the fascia and the subcutaneous tissue. it may occur from an injury to the skin or from a preexisting skin rash, but in most cases it has no identifiable cause. evidence suggests that predisposing factors, such as age older than years, diabetes, cirrhosis, immunosuppression, chronic renal failure, or cardiac disease, may attribute to developing necrotizing fasciitis. diagnosis. it can occur on any part of the body, but the perineum, extremities, and truncal areas are most involved. presenting symptoms are swelling that may evolve into tense erythema that may progress to a dusky blue and pain out of proportion to what is visible. palpable crepitus from air formation and soft tissue air on x-ray is also pathogonomic but not always present. local symptoms may be accompanied by systemic symptoms of sepsis and shock. common bacterial organisms. usually the cause is polymicrobial with both anaerobic and aerobic gram-positive and gram-negative organisms to include vibrio, group a and b streptococci, enterococci, staphylococci, escherichia coli, pseudomonas, proteus, serratia, clostridium, and rarely fungal organisms, including aspergillus, zygomycetes, and candida. treatment. treatment is immediate referral for surgical debridement and hospitalization for intravenous antibiotics and supportive treatment for sepsis. definition and cause. scabies is a highly contagious dermatosis caused by a mite, sarcoptes scabiei. diagnosis and differential diagnosis. common diagnoses include atopic dermatitis, dyshidrotic eczema, urticaria, pityriasis rosea, impetigo, and contact dermatitis. symptoms are intense pruritus caused by the immune response of the mites' excretions and their burrowing in the skin.the pathognomonic sign is the burrow of the scabies that can be linear, curved, or sshaped and pink-white to gray colored in appearance. lesions are often in web spaces of fingers and wrists, in extensor surfaces of the elbows and knees, sides of hands and feet, axillary areas, buttocks, and waistline. skin scraping to look for mites and eggs using mineral oil on a glass slide under microscopy is helpful, but without a positive finding it is not conclusive. treatment. all household members and close contacts should be treated whether they are symptomatic. • permethrin (elmite or acticin) cream % is applied from head to toe and everywhere in between for an -to -hour period and then washed off.this treatment should be reapplied in week.all household bedding should be washed in hot water the journal for nurse practitioners -jnp and dried on a hot cycle or dry cleaned. once cleaned all bedding should not be used for hours. follow-up. if there is a change in rash or development of systemic symptoms, the follow-up is immediate; otherwise, it is to days for a compromised host or as needed in a healthy host. definition and cause. infestation of the hairy parts of the body with of the species of arthropods that suck blood and feed on mammals. pediculus humanus and phthirus pubis are those species that cause human lice. diagnosis. clinical observation of nits or lice. treatment. • malathion (ovide) available by prescription is the most effective treatment, and no evidence shows development of resistance to this product to date, whereas resistance to permethrin or nix has been shown. use of these products on dry hair (as lice can hold their breath under water for to hours) for minutes and follow by combing the hair with a fine-tooth comb to remove the nits. use of wet-combing or use of petroleum, mayonnaise, and pomades is alternative to insecticides to kill lice but must be reapplied every weeks until all nits hatch and can be removed. follow-up. most schools will exclude children with lice, so letters may need to be written to explain when children can return, usually after the first treatment despite the presence of nits. definition. infection of the skin bordering the nail.the infection will lead to swelling, erythema, and pain. paronychia can be acute or chronic. cause. acute paronychia is most readily caused by nail biting, nail trauma, and thumb sucking, whereas chronic paronychia is caused by chronic exposure to water or irritants. causative bacterial organisms. acute paronychia is caused by s aureus, streptococci, pseudomonas, and anaerobes; chronic paronychia is caused by atypical mycobacteria, candida, and gram-negative rods. treatment. acute paronychia: warm soaks, incision, and drainage as needed, and antibiotics. chronic paronychia: avoidance of overexposure to water or irri-tants by wearing rubber gloves, emollients, topical steroids, soaks in acetic acid, or occasional oral antibiotics used for acute paronychia or referral to a dermatologist or surgeon for chronic paronychia for nail removal or eponychial marsupialization. • antibiotics for acute paronychia.augmentin: adult, mg orally every hours; pediatric, to mg/kg divided every hours. • clindamycin: adult, to mg orally four times a day; pediatric, to mg/kg per day orally divided three times a day or four times a day. follow-up. if change in rash or development of systemic symptoms, follow-up is immediate; otherwise, it is as needed. definition. fungal infection in the nail beds, nail matrix, or plate. although mostly a cosmetic problem, mobility can be affected, indirectly adding to morbidity of persons with diabetes and venous stasis. causative bacterial organisms. trichophyton rubrum and trychophyton mentagrophytes differential diagnosis. psoriasis, lichen planus, contact dermatitis, trauma, nail bed trauma, yellow nail syndrome. treatment. • fluconazole: one mg tablet each week for months. • itraconazole: mg/day for weeks for toenails and mg/day for weeks for fingernails, or pulse dosing of mg/day for first week of the month for to pulses for fingernails and to pulses for toenails. • terbinafine: mg/day for weeks for toenails and weeks for fingernails. follow-up. special note:these drugs all have significant drug interactions in that they induce the cytochrome p- enzymes, changing the metabolism of many concomitant drugs. laboratory evaluation of liver enzymes is warranted at baseline and then at weeks for terbinafine. definition. multisystem inflammatory disease caused by an infection, which is spread by a tick bite. causative organisms. spirochete borrelia burgdorferi. diagnosis and differential diagnosis. the diagnosis of lyme disease is often made clinically and occasionally www.npjournal.org the journal for nurse practitioners -jnp supported by appropriate laboratory testing (serum antibodies to ␤ burgdorferi). lyme disease has been described using phases of infection. • early localized disease: erythema migrans (em), often called a bull's-eye rash and associated symptoms • early disseminated disease: multiple em and associated symptoms, lyme carditis, neurologic features, including facial palsies, lymphocytic meningitis, and radiculoneuropathies • late disease: neurologic features, including peripheral neuropathies, chronic encephalopathies, arthritis, and migratory polyarthritis or monoarthritis (sigal) the transmission of disease from tick to human can take place only after the tick has been attached to the host for to hours and has had at least one blood meal.this is important to know because many patients will want antibiotic treatment after finding a tick.there are several different approaches to treatment. empiric antibiotic prophylaxis is not recommended for patients who are not symptomatic. persons who develop a skin lesion or other illness within month after removing a tick should be instructed to seek medical attention to rule out any tick-borne diseases (lyme disease, rocky mountain spotted fever, ehrlichiosis, tularemia, babesiosis, or colorado tick fever). lyme disease is the most common and is endemic to the mid-north atlantic states and in areas of the great lakes. the infectious diseases society of america has published guidelines to assist clinicians in the decisions about the treatment of patients diagnosed with possible lyme disease. one option is to treat with antimicrobials only if the person is at risk because of a prolonged attachment. another option is to treat only if the person develops or presents with em or other systemic symptoms. all persons who exhibit late disease symptoms, seroconvert from negative to positive (serum antibodies to b burgdorferi), or both should be treated with a full -day course of antibiotics and receive follow-up evaluations. the respiratory system infections discussed herein include upper and lower respiratory tract infections, including otitis media, pharyngitis, sinusitis, bronchitis, and pneumonia. most of these infections are usually viral in nature; however, they often become secondarily infected with a bacterial organism.we strongly recommend culture verification (as feasible) to determine organism and resistance patterns to guide antibiotic choices and changes but understand that empiric regimens must be started at the time of visit, and it is in that frame we make recommendations for empiric antibiotics regimens. definition. inflammation or infection and fluid in the middle ear accompanied by acute signs and symptoms of illness. causative bacterial organisms. most common are streptococcus pneumoniae, haemophilus influenzae, moraxella catarrhalis. diagnosis and differential diagnosis. a large percentage of aom is caused by viruses (respiratory syncytial virus [rsv], rhinovirus, influenza virus, and adenovirus). because of this, one treatment option recommended by the american academy of pediatrics (aap) and the american academy of family physicians (aafp) is an observation period of to hours and limiting treatment to only symptomatic relief. symptomatic relief may consist of pain management and antihistamines or decongestants.this decision should be based on the child's age (must be older than months), severity of illness, and diagnostic certainty. a clinician should confirm a history of acute onset, identify signs of middle ear effusion, and evaluate for the presence of signs and symptoms of middle ear inflammation. treatment. analgesics, antihistamines, decongestants, and antibiotics. hiv) . gas is the most common bacterial cause and requires treatment with antibiotics; therefore, the main objective in evaluating a patient in the primary care setting is to identify, rule out, and treat gas. many clinicians use the "centor criteria," which include fever, tonsillar exudate, tender anterior cervical lymphadenopathy, and absence of cough.all adult patients with pharyngitis should be clinically screened using these criteria. patients with none or one of these criteria should not be cultured or treated with antibiotics. patients with or more of these criteria should have their throat cultured for gas, and antibiotics should be reserved for those with positive results. patients with or of these criteria should be treated with antibiotics without the need for throat culture results. definition. characterized by inflammation of the bronchi causing cough, usually with sputum production, and evidence of concurrent upper airway infection. causative bacterial organisms. m pneumoniae, c pneumoniae, and bordetella pertussis. it is suspected that the bacterial pathogens that cause pneumonia can also cause acute bronchitis (s pneumoniae, h influenzae, s aureus, group a streptococcus, m catarrhalis, anaerobes, and aerobic gram-negative bacteria), but no evidence is convincing to support this concept of "acute bacterial bronchitis." diagnosis and differential diagnosis. the usual causes of acute bronchitis are viral infections that affect the upper airways (influenza a and b virus; parainfluenza type , , and ; coronavirus; rhinovirus; rsv; and human meta-pneumovirus). cough is the most common symptom. fever is relatively unusual.a chest x-ray can distinguish pneumonia from bronchitis. patients that complain of a chronic cough, defined as lasting for longer than weeks, can include noninfectious entities such as postnasal drip, asthma, and gastroesophageal reflux.the indications for a chest x-ray in patients with an acute cough to rule out pneumonia are patients with abnormal vital signs (increased respiratory rate, difficulty in respiratory effort, stridor or tachypnea, and oxygen saturations below %) or crackles on chest examination.the main treatment issue in cases of acute bronchitis is the use of antibiotics. multiple studies indicate that patients with acute bronchitis do not benefit from antibiotics because bacteria are not usually responsible. treatment. analgesics, decongestants, antipyretics, antitussives, vaporizers, ␤-agonist inhalers, and antibiotics. antibiotics for suspected or proven m pneumoniae, c pneumoniae, or b pertussis include • azithromycin: adult ( -day regimen), mg once daily for day, then mg orally for days; pediatric, mg/kg per day for day, then mg/kg per day for days. • doxycycline: adult, mg orally twice daily for to days; pediatric (< kg), . mg/kg every hours for to days. • levofloxacin: mg orally once daily for to days; not recommended for pediatric patients, follow-up. no follow-up is necessary unless symptoms do not resolve; immediate follow-up is needed if the patient develops worsening complaints. , [ ] [ ] [ ] [ ] community-acquired pneumonia (cap) definition. acute infection of the lung parenchyma in a patient that has acquired the infection in the community rather than the hospital setting. causative bacterial organisms. typical organisms are s pneumoniae, h influenzae, s aureus, gas, m catarrhalis, anaerobes, and aerobic gram-negative bacteria.atypical organisms include c pneumoniae, legionella, m pneumoniae. diagnosis and differential diagnosis. viruses such as influenza, rsv, parainfluenza virus, rhinovirus, adenovirus, varicella, and severe acute respiratory syndrome (sars) are estimated to be the cause in up to % in adult patients with cap, and, in young children, viruses are the most common cause.the diagnosis of cap is based on the following clinical criteria: acute symptoms november/december the journal for nurse practitioners -jnp associated with infection of the lower respiratory tract (fever, cough, tachypnea), presence of acute lung infiltrate on chest x-ray, auscultatory findings consistent with pneumonia, and lack of hospitalization or residence in a long-term facility in the past weeks before infection. choosing between inpatient and outpatient treatment is a crucial decision that will influence the medication choice. clinicians should use clinical judgment and mortality prediction tools (ats, infectious disease society of america [idsa], or both) to determine whether a patient should be hospitalized or is able to receive outpatient therapy safely with scheduled followup care (need follow-up chest x-ray in to weeks). hospitalization should depend on patient age, presence of comorbidities, and severity of presenting disease. treatment. analgesics, antipyretics, inhalers, antibiotics, and prevention with immunizations (adult: pneumococcal vaccine and yearly influenza vaccine) are used. pneumonia is a known complication of rubeola, varicella, pertussis, and h influenzae type b (hib), which are all part of routine childhood vaccinations. antibiotics for outpatient treatment include this section discusses infections of the genitourinary tract, including vaginitis, cervicitis, cystitis, and epididymitis with specific reference to the diagnosis and management of sexually transmitted diseases (stds). definition. bladder infection is usually caused by bacteria that ascend from the urethra, often with presenting symptoms of dysuria, pyuria, bacteriuria, urinary frequency, and urgency often associated with suprapubic tenderness. differential diagnosis. urethritis is defined as a lower urinary tract infection or the urethra; symptoms can encompass those of cystitis but may include discharge, burning on urination. pyelonephritis is defined as infection of the kidney(s) with symptoms of cystitis, flank pain, and fever. common causative bacterial organisms. e coli, proteus mirabilis, pseudomonas species, klebsiella pneumoniae, enterobacter species, candida species. treatment. increased fluid intake, cranberry juice, and antibiotics. for uncomplicated cystitis, defined as episodes occurring in healthy nonpregnant females with functionally and anatomically normal urinary tract, antibiotics include • tmp-smx (sulfamethoxazole) (bactrim-septra): adult, ds ( / ) tablet every hours for days. • for sulfa allergy.tmp: mg every hours for days. • ciprofloxacin mg every hours for days or ciprofloxacin mg extended release (er) daily for days. follow-up. no follow-up is needed unless symptoms do not resolve; immediate follow-up is needed if the patient's complaints worsen. special situations. pediatric: neonates, uncircumcised boys, and children with functionally or anatomically abnormal urinary tracts are susceptible to urinary tract infections.their presentations are remarkably different from adults.young children aged to years may have abdominal complaints with nausea and vomiting and fever. infants may present with poor feeding, fever, irritability, and malodorous urine. after age , typical symptoms will present. be suspicious of an std in a sexually active man. rule out a functional or anatomic urinary tract defect. the journal for nurse practitioners -jnp • amoxicillin: to mg/kg per day divided every hours. • tmp-smx (bactrim): mg/kg per day as trimethoprim divided every hours. definition. vaginal discharge with vulvar itching and irritation. diagnosis and differential diagnosis. diagnosis is made on clinical history and physical examination of the vagina and its secretions.testing of vaginal secretions for ph and with potassium hydroxide for amine testing for bacterial vaginosis and presence of pseudohyphae for candida and motile protozoa for trichomonas. cervicitis may be asymptomatic or present with abdominal pain, dyspareunia, and abnormal menstrual bleeding.the pelvic examination will reveal mucopurulent exudates in the endocervical canal and a friable cervix when touched by a cotton swab. causative organisms, treatments, and special situations are given in table . definition. painful scrotal swelling that is often unilateral and can be associated with trauma, urinary tract infection, and stds.acute bacterial epididymitis is rare and is often accompanied by prostatitis. differential diagnosis. testicular torsion, appendiceal torsion. stds are of high suspicion in patients with penile discharge and strong history of unprotected sexual exposure. common bacterial organisms. pseudomonas and streptococci, organisms that are common if std is suspected, n gonorrhoeae and chlamydia trachomatis. treatment. antibiotics. rule out urinary tract functional or anatomic abnormality and stds. • ciprofloxacin: mg orally every hours for days. • levofloxacin: mg orally daily for days. • sexually transmitted diseases. ceftriaxone: mg intramuscularly; doxycycline: mg orally every hours for days. diarrhea is discussed in this section, because it is likely to be the most encountered chief complaint in regard to the gastrointestinal system. diarrhea's cause is first and foremost viral; however, we will present in this section all the common bacterial pathogens and their treatment. of note, we recognize that many pathologic entities still are not mentioned here, such as acute appendicitis, pancreatitis, or cholecystitis, whose causes could be infectious and are likely to be seen in an ambulatory care setting. however, because most of these entities are very likely to result in a hospital admission, we elected not to discuss them. national ambulatory medical care survey lippincotts prim care pract common bacterial skin infections practice guidelines for the diagnosis and management of soft-tissue infections available at: www.bmj scabies and pediculosis common acute hand infections treating onchomycosis diagnosis of lyme disease the sanford guide to antimicrobial therapy misconceptions about lyme disease: confusions hiding behind illchosen terminology diagnosis of lyme disease. available at: www.uptodate tick-borne disease the emergence of lyme disease practice guidelines for the treatment of lyme disease acute otitis media practice guidelines: aap, aafp release guidelines on the diagnosis and management of acute otitis media treatment of acute otitis media. available at: www.uptodate practice guidelines: principles of appropriate antibiotic use: part iv. acute pharyngitis approach to acute pharyngitis in adults. available at: www.uptodate acute sinusitis and rhinosinusitis in adults. available at: www.uptodate macrolides for the treatment of chronic sinusitis, asthma, and copd american academy of pediatrics: clinical practice guidelines: management of sinusitis available at: www.uptodate practice guidelines: principles of appropriate antibiotic use: part v. acute bronchitis guidelines for the management of adults with community-acquired pneumonia. diagnosis, assessment of severity, antimicrobial therapy, and prevention diagnosis and treatment of community-acquired pneumonia community-acquired pneumonia in infants and children urinary tract infections: management rationale for uncomplicated cystitis pediatric urinary tract infections us department of health and human services evaluation of the acute scrotum in adults. available at: www.uptodate important bacterial gastrointestinal pathogens in children: a pathogenesis perspective infectious disease society of america. practice guidelines for the management of infectious diarrhea acute infectious diarrhea principles and practices of infectious diseases principles and practices of infectious diseases principles and practices of infectious diseases rifamycins and macrolides, clindamycin and ketolides tetracyclines and chloramphenicol sulfonamides and trimethoprim principles and practices of infectious diseases what are restricted duty, light duty, and transitional duty, and the implications of each for case management practices? disability prevention principles in the primary care office temporary work restrictions: guidelines for the primary care provider work restrictions and outcome of non-specific low back pain minnesota workers' compensation system report. minneapolis, minn: mn department of labor and industry occupational medicine practice guidelines $ indicates no more than $ /dose; $$, = $ -$ /dose; $$$, $ -$ /dose; $$$$, more than $ , [ ] [ ] [ ] common antibiotics used in ambulatory care and comparison of their cost, side effects, and spectrum of activity are given in table . the online home for all titles in the clinics of north america series, the most trusted sources for clinical reviews. access to the full text online version of the clinic is included with your individual print subscription. abstracts and other features for all clinics are available at no cost.activate your online subscription today. simply visit the url printed below and click the online access button. continued from page key: cord- -wyz jyjh authors: bai, li; yang, dawei; wang, xun; tong, lin; zhu, xiaodan; zhong, nanshan; bai, chunxue; powell, charles a.; chen, rongchang; zhou, jian; song, yuanlin; zhou, xin; zhu, huili; han, baohui; li, qiang; shi, guochao; li, shengqing; wang, changhui; qiu, zhongmin; zhang, yong; xu, yu; liu, jie; zhang, ding; wu, chaomin; li, jing; yu, jinming; wang, jiwei; dong, chunling; wang, yaoli; wang, qi; zhang, lichuan; zhang, min; ma, xia; zhao, lin; yu, wencheng; xu, tao; jin, yang; wang, xiongbiao; wang, yuehong; jiang, yan; chen, hong; xiao, kui; zhang, xiaoju; song, zhenju; zhang, ziqiang; wu, xueling; sun, jiayuan; shen, yao; ye, maosong; tu, chunlin; jiang, jinjun; yu, hai; tan, fei title: chinese experts’ consensus on the internet of things-aided diagnosis and treatment of coronavirus disease (covid- ) date: - - journal: clinical ehealth doi: . /j.ceh. . . sha: doc_id: cord_uid: wyz jyjh abstract the aim is to diagnose covid- earlier and to improve its treatment by applying medical technology, the “covid- intelligent diagnosis and treatment assistant program (ncapp)” based on the internet of things. terminal eight functions can be implemented in real-time online communication with the “cloud” through the page selection key. according to existing data, questionnaires, and check results, the diagnosis is automatically generated as confirmed, suspected, or suspicious of novel coronavirus ( -ncov) infection. it classifies patients into mild, moderate, severe or critical pneumonia. ncapp can also establish an online covid- real-time update database, and it updates the model of diagnosis in real time based on the latest real-world case data to improve diagnostic accuracy. additionally, ncapp can guide treatment. front-line physicians, experts, and managers are linked to perform consultation and prevention. ncapp also contributes to the long-term follow-up of patients with covid- . the ultimate goal is to enable different levels of covid- diagnosis and treatment among different doctors from different hospitals to upgrade to the national and international through the intelligent assistance of the ncapp system. in this way, we can block disease transmission, avoid physician infection, and epidemic prevention and control as soon as possible. the aim is to diagnose covid- earlier and to improve its treatment by applying medical technology, the ''covid- intelligent diagnosis and treatment assistant program (ncapp)" based on the internet of things. terminal eight functions can be implemented in real-time online communication with the ''cloud" through the page selection key. according to existing data, questionnaires, and check results, the diagnosis is automatically generated as confirmed, suspected, or suspicious of novel coronavirus ( -ncov) infection. it classifies patients into mild, moderate, severe or critical pneumonia. ncapp can also establish an online covid- real-time update database, and it updates the model of diagnosis in real time based on the latest real-world case data to improve diagnostic accuracy. additionally, ncapp can guide treatment. front-line physicians, experts, and managers are linked to perform consultation and prevention. ncapp also contributes to the long-term follow-up of patients with covid- . the ultimate goal is to enable different levels of covid- diagnosis and treatment among different doctors from different hospitals to upgrade to the national and international through the intelligent assistance of the ncapp system. in this way, we can block disease transmission, avoid physician infection, and epidemic prevention and control as soon as possible. the novel coronavirus ( -ncov, officially known as severe acute respiratory syndrome coronavirus ) was detected in wuhan at the end of in cases of unexplained pneumonia. , the -ncov, which is a new coronavirus strain that has never been previously reported in humans, , has aroused concern. on february , , -ncov-induced pneumonia was officially named as novel coronavirus pneumonia in china. on february , , the world health organization named the disease caused by -ncov as coronavirus disease (covid- ). the number of patients with covid- has rapidly increased, with nearly , reported cases currently. the virus is transmitted mainly through infected respiratory droplets and on close contact with the infected person. the incubation period can be as long as weeks or even longer, and it is highly contagious. the main target organ is the lung. some patients with severe infection gradually develop respiratory failure, even acute respiratory distress syndrome, multiple organ failure, and ultimately death. , therefore, it is important to identify, report, isolate, and treat individuals at the early stages of the disease to control its spread. however, the current diagnosis of covid- is mainly dependent on viral nucleic acid testing. the accuracy of current nucleic acid testing is approximately - %. a large number of suspected or suspicious cases may be missed, which is not conducive to the isolation and treatment of patients. the national health commission of the people's republic of china promulgated the ''diagnosis and treatment scheme for pneumonia of covid- (interim version )", which proposed clinical diagnostic criteria based on chest imaging, and proposed version . however, considering the different levels of diagnosis and treatment among doctors in different regions and hospitals, some cases are still missed or misdiagnosed, especially when the nucleic acid test has a negative result. additionally, patients suspected of having this disease have not been identified in the interim version. a study conducted at the mount sinai hospital in new york revealed that changes observed in computed tomography (ct) can precede the detection of nucleic acid tests in some patients. to control this epidemic in various regions, it is important to appropriately manage patients suspected of having the disease, immediately identify and isolate the source of infection, cut off the transmission route, and prevent viral transmission from these potential patients or virus carriers. therefore, we have formulated consensus version by convening clinicians with rich clinical experience, clinicians supporting front-line work in wuhan, and biomedical, statistical, and information technology engineers through the internet. we aimed to apply the covid- intelligent diagnosis and treatment assistant program (ncapp) based on the internet of things (iot) medical technology to conduct clinical work during the covid- epidemic, especially for outpatients, and quality control (qc) will assist the diagnosis and treatment, and achieve early identification, isolation, and treatment of patients with covid- . this consensus is appropriate for different specialists at all levels of hospitals and even managers at all levels of hospitals, local community development corporations, and public health centers. this will enable them with intelligent assistance to work in the timely discovery, isolation, and management of patients who are confirmed, suspected, and suspicious to have the disease through the ncapp. after the consensus version was published, it was warmly welcomed. however, some improvements were required while applying this consensus. hence, we have revised the consensus based on these valuable opinions and published it in english to meet more requirements. the iot was originally referred to as radio-frequency identification technology and equipment combined with the internet based on the agreed communication protocol to achieve intelligent management of item information. today, this concept has been expanded and deepened, that is, the use of communication technologies such as local networks or the internet to connect sensors, machines, people, and things to achieve the connection between people and things, things and things, people-oriented informationization, and remote control and intelligent management. the most basic functional feature of the iot is ''ubiquitous connectivity." its three basic processes are comprehensive perception ? reliable transmission ? intelligent processing. the application of the iot to medicine is referred to as the medical iot (miot), [ ] [ ] [ ] [ ] which aims to establish a decision-oriented big data analysis model supported by information technology such as communication, electronics, biology, and medicine. miot can also be used for the prevention and control of covid- . we can establish a three-level linkage ncapp system based on the medical theory and technology of the iot to diagnose and treat covid- . the iot ncapp cloud medical system platform contains the basic functions of the iot and has a core graphics processing unit (gpu). cloud computing systems connected to existing electronic medical records, image archiving, and picture archiving and communication can better assist in deep mining and intelligent diagnosis. the ten functions of the iot (table ) are considered beneficial time assistance, supervision, and control of medical quality. [ ] [ ] [ ] [ ] among them, the functions of online monitoring, location tracking, alarm linkage, and follow-up scheduling are conducive to online discovery, monitoring, management, and treatment assistance for covid- . plan management, remote maintenance, command management, and statistical decision-making functions can expand the massive information mining of covid- and complete management and timely treatment of covid- by applying preset guidelines or standardized criteria. security privacy and online upgrade functions are ncapp guarantee that can ensure the normal operation of the iot cloud plus terminal system. it can also assist in asking questions; registering patients' details; coordinating with patients, community doctors, and experts; and providing safe diagnosis treatment programs and two-way referrals (fig. ) . simultaneously, the three-linkage iot cloud plus terminal ncapp covid- diagnosis and treatment system uses the fifth generation ( g) technology, network performance characteristics and advantages, combines with the overall system's network requirements for network liquidity, efficiency, high load, and high capacity platform. g technology is an important part of the overall technical support of the platform to ensure the normal and efficient operation of the three-linkage iot cloud plus terminal ncapp intelligent assisting the diagnosis and treatment system of covid- . , compared with the previous generations of mobile networks, the abilities of g networks are significantly better. for example, the peak downlink data rate can reach gbps, and the peak uplink data rate can exceed gbps. additionally, g will significantly reduce latency and improve overall network efficiency. the simplified network will provide terminal-to-terminal latency of less than ms. the mobile beyond giga, real-time world, and all-online g will provide an era of opportunities, an attractive operating model for iot healthcare can efficiently provide various ncapp can coordinate the division of labor in the diagnosis and treatment of covid- in one-, two-, and three-tier hospitals and perform three-level linkage among experts, primary doctors and service providers. this model contributes to prevent and control of covid- and other sudden respiratory infectious diseases in china. . . introduction of the ncapp assisted covid- diagnosis and treatment system to reflect the three basic processes of ''comprehensive perception ? reliable transmission ? intelligent processing" of the iot technology and assist the gpu to manage the ncapp assisted three-level linked cloud plus terminal platform, we designed easy-to-use questionnaires and nucleic acid detection information for deep mining and intelligent processing (fig. ) . the diagnosis and treatment recommendations are automatically generated and transmitted to doctors and experts for reference. physicians and experts can use smartphone ncapp assistant software to participate in the three-linkage iot cloud plus platform according to their needs (fig. ) . , , the three-cascade iot ''cloud plus terminal" ncapp can assist in the intelligent management, command, and diagnosis of covid- . ''cloud" is a general term for cloud technology, which can be further subdivided into network technology, information technology, integration technology, management platform technology, and application technology based on the application of the cloud computing model. the terminal is a physician's smartphone that can implement the following eight functions in real-time online communication with the ''cloud" through the page selection key (fig. ) : ( ) patient registration. the basic information of the patient is registered online. ( ) start the consultation. after the patient is admitted, the page will display the item-by-item questions (fig. ) , and the patient selects the answer button, which transfer the data back to the cloud online. ( ) intelligent assisted diagnosis. diagnostic suggestions are automatically generated for reference. ( ) intelligent assisted treatment. treatment recommendation based on the severity of the disease are provided. ( ) talent experts. relevant information of local relevant experts and first-line experts and clinicians is provided. ( ) self-control. relevant information about self-control is provided. ( ) map positioning. information about covid- cases around the user's area is provided. ( ) related information. relevant guidelines, diagnosis and treatment specifications, expert lectures, research papers, and links are provided. additionally, ncapp can also be used by visualization techniques. the data visualization method of the system, with the cloud plus augmented reality brm all-in-one (fig. ) , make doctors and patients communicate in an augmented reality way, thus reduces cross infection. physicians use the data transmitted on their smartphones to automatically respond to the prompts generated by ncapp to assist patients in their diagnosis and treatment, ensuring their safety and effectiveness. when the data exceed the normal value range or an emergency occurs, the monitoring system will issue an alarm to remind the physician to take corrective measures quickly. [ ] [ ] [ ] [ ] this system makes the diagnosis and treatment more convenient and also enhances the efficiency of remedial measures in emergency situations, guarantees the safety and effectiveness of the diagnosis and treatment of covid- , and improves the medical service capabilities of hospitals in preventing and controlling covid- . simultaneously, as the ncapp intelligent assisted covid- diagnosis system collects a large amount of clinical diagnostic data from patients with covid- , through data feature engineering and statistical methods, the data can be further clustered and analyzed to achieve a more intelligent distinction between suspected and suspicious cases in patients with a negative nucleic acid test result. compared with the traditional medical model, the application of ncapp assisted management of covid- can better meet the requirements of p medicine (predictive, preventative, personalized, and participatory). ncapp can conduct the online monitoring, location tracking, alarm linkage, command and dispatch functions, in favor of online and full-time monitoring of changes in symptoms and diseases severity and guiding treatment. plan maintenance, remote maintenance, management command, and statistical decision-making functions can expand the deep mining and management of big data, subsequently achieve management and timely intervention on acute infectious diseases and improve the effect of detecting and managing covid- . . the process of cloud plus terminal internet of things ncapp assisting the diagnosis and treatment of covid- according to consensus, patients must register the necessary information when making an appointment or in the outpatient department, including the following: ( ) history of residence or visits in the epidemic area, ( ) history of contact with people in the epidemic area, ( ) history of contacting patient with cough in last weeks, ( ) history of contacting covid- patients, and ( ) whether the -ncov nucleic acid test was conducted. it is advisable to provide the information available online before the visit. at the time of appointment registration (recommended) or at the outpatient clinic, the patient or his guardian answers the following in the questionnaire : ( ) whether the patient has chronic obstructive pulmonary disease, ( ) whether the patient has any other medical history (e.g., coronary heart disease, hypertension, diabetes, tumor), ( ) whether the patient has a high fever or whether his/her body temperature is . °c, ( ) whether the patient has a dry cough, ( ) whether the patient's body temperature does not decrease with antibiotics, ( ) whether the patient manifests weakness, and ( ) whether the patient has dyspnea. additionally, to establish a differential diagnosis, the following test results must be obtained: ( ) respiratory frequency times/min, ( ) blood oxygen saturation %, ( ) oxygenation index mmhg, ( ) normal or decreased white blood cell count in the early stage of the disease, ( ) decreased lymphocyte count (in this consensus, registration of specific data is recommended, and the cloud will automatically generate results indicating a decreased or increased lymphocyte count), ( ) presence of lymphopenia (registration of specific data in this consensus is recommended, and the cloud will automatically generate results indicating a decreased or increased lymphocyte count), ( ) presence of pulmonary opacity or thickened lung texture based on chest radiographs (ct equipment is not available), ( ) presence of inflammatory opacity on ct, and ( ) increased c-reactive protein (crp) level. according to the registration information and questions, ncapp generates the following automatic prompts at the doctor's terminal : . . . . confirmed diagnosis. according to the ''novel coronavirus pneumonia diagnosis and treatment program (interim version )," a patient with the positive nucleic acid testing of ncov is considered the confirmed case. when meeting the diagnostic criteria, ncapp automatically generates a prompt ''confirmed diagnosis," and the patient needs to be reported and transferred to the designated hospital. a patient with any one in a or any three in b is considered the suspected case: a (history of residence or visit in the epidemic area), a (history of contact with the people in the epidemic area, a (contact with the confirmed cases of novel coronavirus infection), b (high fever or temperature . ℃), b (normal or decreased white blood cell count in the early stage of the disease), b (presence of lymphopenia), and b (characteristic ct manifestations such as conspicuous ground-glass opacity lesions in the peripheral and posterior lungs on ct images). when meeting the criteria of suspected diagnosis in the ''novel coronavirus pneumonia diagnosis and treatment program (interim version )," ncapp automatically generates a prompt ''suspected diagnosis". the patient needs to be isolated and observed, and a doctor should collect specimens for the detection of new coronavirus nucleic acid to establish a clear diagnosis as soon as possible. for a patient with suspicious diagnosis of -ncov infection, the epidemiological history is unclear. however, a patient who has been exposed to patients with cough in the past weeks and who also manifests any of following is also suspicious of -ncov infection: fever with dry cough, fatigue, fever persists after antibiotic treatment, characteristic ct manifestations such as conspicuous ground-glass opacity lesions in the peripheral and posterior lungs on ct images and increased crp level. according to the expert consensus of shanghai quality control center or the requirements of local hospitals, ncapp automatically generates a prompt ''suspicious diagnosis," and the patient needs to be isolated and observed for days. according to the registration information and questions, if ncapp automatically generate a prompt ''confirmed diagnosis," and the patient needs to be transferred to the designated hospital. subsequently, the physician establishes a severity of ''mild, moderate, severe, and critical pneumonia" based on symptoms and oxygenation index. . . . . mild. for mild, the clinical symptoms are slight, and there is no sign of pneumonia on ct images. for moderate, patients with pneumonia on ct images do not meet the criteria of severe and critical cases. this will be reported automatically to the qc cloud after the diagnosis. for severe, patients with pneumonia on ct images meet one of the following criteria: respiratory rate times/ min, resting oxygen saturation %, and oxygenation index mmhg. after the establishment of the diagnosis, the case will be automatically reported and transmitted to the qc cloud. for critical, patients with pneumonia on ct images meet one of the following criteria: respiratory failure requiring mechanical ventilation, shock, other organ failures requiring intensive care unit treatment, and oxygenation index mmhg (proposed by the authors of this consensus). after confirming the diagnosis, it will be automatically reported and transmitted to the qc cloud. . . . intelligent assisted treatment for patients with mild and moderate pneumonia ncapp automatically generates treatment recommendations in accordance with the guidelines of the ''novel coronavirus pneumonia diagnosis and treatment program (interim version )". in case of treatment difficulties, doctors can request the assistance of a cloud link to interact with experts or front-line experienced physicians online. the patient should rest on bed, be monitored for vital signs (heart rate, pulse oxygen saturation, respiratory rate, and blood pressure), and provided with nutrition support to ensure sufficient energy intake. moreover, the amount of water consumed by the patient, his/her electrolyte and acid-base levels, and other internal environmental factors should be comprehensively monitored. furthermore, the patient should undergo blood cell count, urine test, crp, organ function (liver enzyme, myocardial enzyme, and renal function), and coagulation function tests, arterial blood gas analysis, and chest imaging. if possible, the patient's blood cytokine level should be determined. the patient should be provided with effective oxygen therapy, including nasal catheter therapy, mask oxygen therapy, and highflow nasal oxygen therapy (hfno). . . . . antiviral treatment. at present, there are no effective antiviral drugs against ncov. the a-interferon atomization inhalation can be considered ( million u per time for adults in -ml sterile injection water, twice a day). lopinavir/ritonavir ( mg/ mg per capsule) orally, capsules each time, twice a day, can also be considered. ribavirin ( mg/time, intravenous infusion to times a day, no more than days) in combination with interferon or lopinavir/ritonavir is recommended. chloroquine phosphate ( mg for adults, twice a day, no more than days) and abidor ( mg for adults, three times a day, no more than days) can be also considered. we should pay attention to the adverse reactions of lopinavir/ritonavir, such as diarrhea, nausea, vomiting, and liver dysfunction, and the interaction with other drugs. using three or more antiviral drugs simultaneously is not recommended. in case of intolerable side effects, the relevant drugs should be discontinued. . . . . antibacterial treatment. avoid inappropriate use of antibacterial drugs, specifically the combination of broad-spectrum antibacterial drugs. traditional chinese medicine treatment. traditional chinese medicine treatment is recommended according to the ''novel coronavirus pneumonia diagnosis and treatment program (interim version )". . . intelligent assisted treatment for patients with severe pneumonia ncapp automatically generates a prompt treatment recommendations in accordance with the 'novel coronavirus pneumonia diagnosis and treatment program (interim version )'. in case of treatment difficulties, doctors can request for the assistance of doctors can request for the assistance of a cloud link to interact with online experts or front-line experienced physicians on line. treat the patients to ease the symptoms and treat underlying diseases, actively prevent emergence of potential complications including secondary infection, and provide organ function support in a timely manner. oxygen therapy. severe patients should be provided with effective oxygen therapy, including nasal catheter and mask oxygen therapies. physicians should timely assess whether respiratory distress and/or hypoxemia is relieved. hfno or noninvasive ventilation (niv). when respiratory distress and/or hypoxemia cannot be relieved after standard oxygen therapy, hfno or noninvasive ventilation (niv) can be considered. if respiratory distress still exists or even worsens dramatically within a short time ( - h) , endotracheal intubation and invasive mechanical ventilation should be implemented as soon as possible. invasive mechanical ventilation. lung protective ventilation should be implemented to reduce ventilator-associated lung injury by decreasing the tidal volume ( - ml/kg) and plateau pressure (< cmh o). sedation and muscle relaxation strategies should be administrated while patient-ventilator asynchrony occur, for an adequate fluid resuscitation, vasoactive drugs that improve microcirculation should be administered and hemodynamic status should be monitored if necessary. glucocorticoids can be administered in a short period ( - days) for patients with rapid reduction of oxygenation index, rapid progression of the disease based on ct images and activation of inflammatory response. the recommended dose of glucocorticoid is equivalent to - mg/kg methylprednisolone per day. because of the immunosuppressive effect of glucocorticoids, virus clearance will be delayed. xue bi jing ml/time can be administered intravenously, twice a day. intestinal microecological regulators can be used to maintain intestinal microecological balance and prevent secondary bacterial infections. for patients with critical pneumonia with high inflammatory reactions, extracorporeal blood purification technology, such as plasma exchange, adsorption, perfusion, and blood/plasma filtration, can be considered. patients frequently experience anxiety and fear; thus, psychological counseling should be adopted. traditional chinese medicine treatment. traditional chinese medicine treatment is recommended according to the ''novel coronavirus pneumonia diagnosis and treatment program (interim version )". . . intelligently assisted treatment for patients with critical pneumonia ncapp automatically generates a prompt treatment recommedations in accordance with the 'novel coronavirus pneumonia diagnosis and treatment program (interim version )'. in case of treatment difficulties, doctors can request for the assistance of a cloud expert link to interact with experts or front-line experienced physicians online. treat the patients to improve the symptoms and underlying diseases, actively prevent emergence of potential complications including secondary infection, and provide organ function support in a timely manner. . . . respiratory support hfno or niv: when respiratory distress and/or hypoxemia cannot be relieved after standard oxygen therapy, hfno or niv can be considered. if respiratory distress still exists or even worsens dramatically within a short time ( - h), endotracheal intubation and invasive mechanical ventilation should be implemented as soon as possible. invasive mechanical ventilation. lung protective ventilation should be implemented to reduce ventilator-associated lung injury by decreasing the tidal volume ( - ml/kg) and plateau pressure (< cmh o). sedation and muscle relaxation strategies should be administrated while patient-ventilator asynchrony occur. salvage treatment: for patients with severe acute respiratory distress syndrome, lung expansion is recommended. if possible, prone ventilation should be performed for more than h per day. in patients with poor prone ventilation, extracorporeal membrane oxygenation should be considered as soon as possible. circulatory support: for an adequate fluid resuscitation, vasoactive drugs that improve microcirculation should be administered and hemodynamic status should be monitored if necessary. glucocorticoids can be administered in a short period ( - days) for patients rapid reduction of oxygenation index and rapid progression of the disease based on ct images, and activation of inflammatory response. the recommended dose of glucocorticoid is equivalent to - mg/kg methylprednisolone per day. because of the immunosuppressive effect of glucocorticoids, coronavirus clearance will be delayed. xue bi jing ml/time can be administered intravenously, twice a day. intestinal microecological regulators can be used to maintain intestinal microecological balance and prevent secondary bacterial infections. for patients with critical pneumonia with high inflammatory reactions, extracorporeal blood purification technology, such as plasma exchange, adsorption, perfusion, and blood/plasma filtration, can be considered. patients frequently experience anxiety and fear; hence, psychological counseling should be adopted. traditional chinese medicine treatment: traditional chinese medicine treatment is recommended according to the ''novel coronavirus pneumonia diagnosis and treatment program (interim version )". . . ncapp intelligent assisted treatment and management for patients suspected of covid- ncapp automatically generates prompt diagnosis according to the national guidelines, and patients who meet the criteria are suggested to be reported or transferred to the designated hospitals. to avoid missed diagnosis, these suspected patients should be isolated and monitored until a confirmed or excluded diagnosis is established in the designated hospitals. the patients' body temperature should be normal for more than days, and the respiratory symptoms should improve significantly. during the treatment, superior doctors and high level hospitals are well informed about the patients' status by using ncapp. doctors can continue the original treatment which focuses on relieving symptoms from fever and cough. in case of treatment difficulties, doctors can request for the assistance of a cloud expert link to interact with experts or front-line experienced physicians online. the ''novel coronavirus pneumonia diagnosis and treatment program (interim version ) " has not yet defined suspicious patients and has not explained how to manage suspicious patients. however, if these patients are misdiagnosed, it will lead to serious consequences. hence, suspicious patients can be defined as those whose epidemiological history is unclear and whose clinical manifestations and ct images are similar to covid- , but do not meet the suspected criteria. in case of treatment difficulties, doctors can request the assistance of a cloud expert linkage to interact with experts or front-line experienced physicians online. to avoid misdiagnosis, suspected patients should be isolated and monitored for days. the patients' body temperature should be normal for more than days, and the respiratory symptoms should significantly improve. clinicians should be trained about how to prevent and treat respiratory infectious diseases. due to the lack of protective equipment and awareness at the beginning of the epidemic, doctors were accidentally infected in wuhan at the outset of the epidemic. medical institutions should standardize the process of disinfection, isolation, and protection, reserve qualified and sufficient protective materials, such as disinfection products, medical surgical masks, medical protective masks, isolation gowns, and eye masks, to ensure the personal protection of medical personnel. based on the strict implementation of standard prevention, medical institutions should strengthen measures to prevent and control viral transmission through contact, infected droplets, and airborne transmission. wearing of masks and hand hygiene are key measures for infection prevention and control. the main purpose of ncapp is to improve the diagnosis and treatment, management, and command with different levels to a national standard, quickly identify and isolate infectious sources and cut off the transmission, and win the fight against covid- as soon as possible. to achieve these goals, the close cooperation of intelligent assisted diagnosis and treatment and on interaction with experts or front-line experienced physicians online is provided by ncapp. to achieve the accurate diagnosis and management, the following scientific and accurate ncapp technologies are required: ( ) accurate intelligent assisted diagnosis including confirming of the diagnosis. with the registered data and answer results, ncapp can automatically generate a prompt ''confirmed, suspected, or suspicious." regarding typing, with the registered data and answer replies, ncapp can determine the severity of the patient, including mild, moderate, severe, or critical. the first online update of the ncapp patients database with covid- in china, through automatic data upload, update, and intelligent maintenance, was established. it can update and optimize the intelligent diagnosis model in real-time, and improve diagnostic accuracy. ( ) precise and intelligent treatment. according to the severity of disease, treatment and long-term follow-up recommendations are provided. to achieve this, users are required to perform qc on the three-linkage cloud platform. this requires not only the understanding of iot medical equipment but also the cooperation among primary care physicians, experts, and patients in the process. in addition to general training, qc (homogenization) is required in clinical practice. it needs to monitor and supervise the authenticity and reliability of the data uploaded to the cloud. the ncapp currently used has been a scientific and accurate technology. however, it also requires close cooperation between users and managers to ensure the authenticity and reliability of the uploaded data, and continuous training and correction should be performed not only for the clinical diagnosis and treatment but also for professional qc center and even the intelligent system of command and management. ncapp can improve the management of suspected and suspicious patients, early control of covid- , and even can be applied to prevent and control emerging infectious diseases that may occur in the future. ( ) ncapp assists in identifying experts ncapp assists in identifying volunteer experts for expert consultation (assist in checking the outpatient time of interested doctors in each hospital), online consultation (expert consultation of volunteers, only limited to the questions of the doctors instructed), and lecture training, including training guide consensus, diagnosis and treatment technology, qc consensus, science education, and expert forum. ( ) ncapp auxiliary map positioning. for details, please scan fig. . ( ) ncapp provides relevant information. for details, please scan fig. . early transmission dynamics in wuhan, china, of novel coronavirus-infected pneumonia clinical characteristics of novel coronavirus infection in china clinical management of severe acute respiratory infection when novel coronavirus (ncov) infection is suspected. interim guidance pathological findings of covid- associated with acute respiratory distress syndrome national health commission of the people's republic of china. diagnosis and treatment scheme for pneumonia of covid- (interim version ) national health commission of the people's republic of china. diagnosis and treatment scheme for pneumonia of covid- (interim version ) chest ct findings in coronavirus disease- (covid- ): relationship to duration of infection internet of things-aided diagnosis and treatment of covid- chinese experts group of clinical of ehealth prospect and application of internet of things technology for prevention of saris beijing: people's medical publishing house co medical internet of things grading diagnosis manual. beijing: people's medical publishing house co g and intelligence medicine-how the next generation of wireless technology will reconstruct healthcare? the multipurpose application wechat: a review on recent research shanghai expert consensus for respiratory clinic quality control during epidemic -ncov time the authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. key: cord- - tapkjb authors: nan title: th escp-nsf international symposium on clinical pharmacy: clinical pharmacy tackling inequalities and access to health care. oslo, norway, – october date: - - journal: int j clin pharm doi: . /s - - - sha: doc_id: cord_uid: tapkjb nan pharmacy, sint maartenskliniek, ubbergen, pharmacy, radboud university medical centre, nijmegen, clinical pharmacy and toxicology, maastricht university medical centre, maastricht, netherlands please specify your abstract type: research abstract background and objective: according to literature adherence to statins ranges from to %. medication adherence is affected by both practical barriers and patient's beliefs about medication. however, physicians also have their beliefs about medication. several studies have shown that these beliefs also impact the decision of patients to agree with a particular treatment or not. as current published interventions on medication adherence (which focus predominantly on patients) are not or just partly effective, physicians' beliefs might be a promising target for interventions to improve adherence. however, there is currently no information available on physician's beliefs about statins and whether these beliefs affect patient's beliefs and adherence. therefore, the objective of this study is to examine whether physicians' beliefs about statins influence the beliefs and adherence of patients using a statin. setting and method: this cross-sectional study was conducted in gp practices and community pharmacies, between september , and march , . physicians' and patients' beliefs about statins were assessed with the beliefs about medicine questionnaire (bmq) specific. patients' adherence on statins was assessed with both the mars- and the morisky- questionnaires. please specify your abstract type: research abstract background and objective: nhs highland and nhs western isles are the most remote and rural health boards in the united kingdom, with high numbers of dispensing medical practices. a pilot is underway in dispensing practices with clinical pharmacists undertaking targeted medication reviews. a previous quantitative service evaluation demonstrated its value, with pharmaceutical care issues identified in almost all patients, the vast majority of which ( . %) were managed by the pharmacist without any need for general practitioner (gp) referral. the objective was to undertake a qualitative exploration of the service. setting and method: all patients and staff involved in the service were invited to participate. a semi-structured interview schedule was developed and piloted. telephone interviews were conducted with all consenting staff and a purposive sample of consenting patients recruited to the point of data saturation. interviews were audiorecorded, transcribed verbatim and analysed thematically. nhs ethics and research and development approvals were obtained. were the most confident with doacs (range from . to . %) please specify your abstract type: research abstract background and objective: patients are at risk of drug-related problems (drps) at transition points during hospitalization. the community pharmacist (cp) is often the first healthcare professional patients visit after discharge. cps lack sufficient information about the patient and so they may be unable to identify problems in medications, which may lead to dispensing the wrong drugs or dosage, and/or giving wrong information. we aim to assess the impact of a complex intervention comprising of medication reconciliation performed at discharge by a hospital pharmacist (hp) with communication between the hp and cp on drps during the days following discharge. setting and method: cluster randomized crossover trial involving medical and surgery care units (each unit corresponding to a cluster) in french hospitals during two consecutive -day periods, randomly assigned as 'experimental'(e) or 'control' c (usual care) periods. during the experimental period, the hp performed a medication reconciliation that was communicated to the patient's cp. main outcome measures: the primary outcome was a composite outcome of any kind of drp (prescription/dispensation, gap or patient) during the days following discharge assessed at day seven post-discharge by phone from patient and cp. the secondary outcomes were /unplanned hospitalizations assessed by phone contact at day after discharge and /the iatrogenic potential exposure scale from to for each patient established by a clinical team. analysis was conducted in intention to treat. results: hospitals corresponding to clusters enrolled patients ( e group v/s c group). no difference was observed on age, sex, autonomy, and number of drugs in home medication at admission and discharge. at day ; ( . %) patients in e group had at least one drp v/s ( . %) in c group (or . ; ic % [ . ; . ] p = . ). intervention was especially efficient for patient discharged from surgery unit (or . ic % [ . ; . ]) and aged less than years (or . ic % [ . ; . ] . although intervention decreased patient exposure to drp with high iatrogenic potential (from . to . % p \ . ), un-planned hospitalizations at day weren't different between groups ( . vs. . % p = . ). conclusion: medication reconciliation associated to communication between hospital and community pharmacists is efficient to decrease patient exposure to drp but not sufficient to decrease un-planed hospitalization. hp-pc : clinical pharmacists bridging health care levels by medication reviews in primary care katherine wendelbo *, , kristine lundereng namsos hospital pharmacy, central norway hospital pharmacy trust, namsos, levanger hospital pharmacy, central norway hospital pharmacy trust, levanger, norway please specify your abstract type: descriptive abstract (for projects) background and objective: nord-trøndelag county is sparsely populated and many inhabitants live far from the hospital. additionally, only half ( of ) of the municipalities have a local pharmacy. traditionally, namsos and levanger hospital pharmacies have performed quality audits of the implementation of drug administration procedures in primary care units. since , a service where clinical pharmacists participate in multidisciplinary medication reviews in municipalities throughout the county has been established. the objective of this poster is to describe the practical approach and design of the service. design: a descriptive report of an implemented clinical pharmacy service in primary care where clinical pharmacists, as part of multidisciplinary teams, perform medication reviews. results: medication reviews are performed on patients admitted to nursing homes and patients in home care, receiving help with handling of their drugs. primary care nurses prioritise patients (by selecting frail elderly with multiple co-morbidities and polypharmacy), usually five patients in each meeting. prior to the review, nurses collect medical information using a checklist including; diagnosis, drug-related symptoms, standard laboratory tests and an updated medication list. the clinical pharmacist receives de-identified medical information by postal mail or e-mail before the meeting. based on this information the pharmacist identifies possible drugrelated problems (drps) and provides recommendations on how to solve them. this is performed in a structured approach according to the integrated medicine management (imm) model. subsequently, the pharmacist visits the municipality and discusses the medication reviews in a multidisciplinary team meeting with nurses and physicians. in addition, the pharmacist gives lectures in a medication related topic (e.g. treatment of insomnia and anxiety, oral anticoagulants and cognitive side effects). following the meeting, the pharmacist reports the drps and suggested interventions to the multidisciplinary team, for further follow-up. during , totally medication reviews were performed in municipalities. in the same period, lectures were given by the clinical pharmacists. conclusion: this clinical pharmacy service enables multidisciplinary medication reviews even in municipalities with limited health professionals and resources. as a part of multidisciplinary teams, the clinical pharmacists contribute with medical competence. camille castel , arnaud de la blanchardière , vincent cattoir , guillaume saint-lorant *, pharmacy, infectious and tropical diseases, microbiology, chu caen, caen, france please specify your abstract type: research abstract background and objective: antimicrobial stewardship have clearly demonstrated their efficiency towards a more adequate use of antibiotics. since , the use of daptomycin, a ''critical last resort antibiotic'' has intensified in our hospital, occasionally outside the scope of its approved indications. this situation has led to the implementation of an antimicrobial stewardship and the drafting of local guidelines. the aim of this study is to analyse the evolution and pertinence of daptomycin prescriptions, after distribution of these guidelines within our institution. setting and method: a monocentric prospective study was conducted between july and november in a -bed university hospital. each daptomycin prescription recorded by pharmacy department was analysed by an infectious diseases specialist in the presence of the prescriber and considering local guidelines and the patient's clinical conditions. main outcome measures: the indicators chosen to determine prescription pertinence were: treatment indication, prescribed dose and other antibiotics associated with the daptomycin prescription. results: daptomycin prescriptions were analysed. observed indications were: sepsis ( %), infective endocarditis ( %), bone and joint infections ( %) and vascular prosthetic infections ( %). identified pathogens were: mrsa ( %), methicillin-resistant coagulase-negative staphylococci ( %), methicillin-sensitive staphylococcus aureus ( %), enterococci ( %) and methicillinsensitive coagulase-negative staphylococci ( %). daptomycin was prescribed as first-line treatment in % of cases. the mean dose was mg/kg/day [ - mg/kg/day] for a mean duration of days [ ; days] . local guidelines were followed in % of cases. daptomycin use was relevant for % of prescriptions. the irrelevant prescriptions triggered the modification or stoppage of antibiotic therapy in % of cases, respectively, generating an % decrease in consumption and an economy of over € for our institution. conclusion: this study shows the efficiency of antimicrobial stewardship in adequately using antibiotics, limitating ecological impacts, improving patient care and decreasing healthcare costs. it also shows that guidelines alone are insufficient to ensure a proper use of antibiotics. without a close prescription follow-up, constant reminders and sustainable evaluations, guidelines only affect a few prescribers. within the context of an ''antimicrobial crisis'', further development of guidelines and antimicrobial stewardship is essential to fight increasing bacterial resistances and requires a close collaboration between all healthcare professionals including pharmacists. interviews were transcribed verbatim and data were analysed using systematic text condensation. results: three major themes were identified: benefits, unrealised potential and criteria and barriers for success. ( ) benefits described by physicians included increased patient safety, increased awareness on drugs, and an ease of workload. drug interaction management was emphasized as one of the clinical pharmacists' most important work tasks, as well as being a resource for collaborating healthcare professions and to the patient himself. ( ) the clinical pharmacists expressed that they had an unrealised potential and could contribute to a greater extent in the multidisciplinary team than they did already. they mentioned education towards physicians and nurses, contribution in treatment decision-making and patient counselling as examples for possible extended work tasks. ( ) as criteria to succeed as a clinical pharmacist, physicians highlighted the importance of oral communication and physical presence on the wards. as barriers for integration in the team, the clinical pharmacists identified the physicians' lack of knowledge about the clinical pharmacists' skills as well as unclear expectations regarding their responsibilities. conclusion: physicians agreed that the clinical pharmacist represent a valuable contribution to the multidisciplinary team, where patient safety and drug interaction management are highlighted as main benefits. clinical pharmacists should to a greater extent educate healthcare professions in drug related topics and provide patient counselling. continuous effort on making the clinical pharmacist a natural part of the multidisciplinary team is crucial for the development of clinical pharmacy. by gathering perceptions from the collaborating professions as well as educating them on what clinical pharmacists can provide, we can develop a multidisciplinary team that enhances patient safety. hp-pc : assessment of dual antiplatelet therapy following acute coronary syndrome using grace and crusade sadeer fhadil * , paul wright, sotiris antoniou please specify your abstract type: descriptive abstract (for projects) background and objective: mortality and morbidity benefits of dual antiplatelet therapy (dapt) following acute coronary syndrome (acs) have been unequivocally demonstrated in a large body of evidence. with the availability of more potent antiplatelet agents, balancing ischemic and bleeding risks to prevent adverse outcomes is an on-going challenge, in particular, recognising that patients with high bleeding risk were excluded from clinical trials. grace and crusade scores stratify risk of mortality and in-hospital major bleeding post acs respectively. these tools should be used to support antiplatelet choice in light of newer more potent agents that equally pose a greater risk of bleeding. design: grace and crusade scores were calculated for patients presenting with acs. clopidogrel was recommended for patients with a high or very high crusade score (greater bleeding risk). ticagrelor was recommended for patients presenting with st-elevation myocardial infarction (stemi) or those with nsteacs with a grace score of intermediate or above (greater ischemic risk) and a crusade score of moderate or less (low bleeding risk). in either case, treatment was at the discretion of the clinician and patients received concomitant aspirin. a registry was collated of risk scores, diagnosis and choice of antiplatelet therapy. results: patients were included in the registry, of which ( %) presented with stemi and ( %) presented with nsteacs. of ( %) patients with a greater ischemic risk received ticagrelor as part of their dapt regime. advanced age, concomitant anticoagulation and those awaiting surgery were the most common reasons for patients with a greater ischemic risk to receive clopidogrel. ( %) had a high or very high crusade score. of these, ( %) received clopidogrel as part of their dapt regime. conclusion: risk stratification was streamlined using the data collection tool and useful to support choice of dapt. european society of cardiology (esc) guidance recommends use of established risk scores for prognosis and bleeding; however evidence to correlate to choice of dapt is lacking. outcome data is currently being reviewed and will provide further evidence to correlate choice of dapt to grace and crusade scores. please specify your abstract type: descriptive abstract (for projects) background and objective: in europe, approximately % of the patients with the human immunodeficiency virus (hiv) infection are co-infected with the hepatitis c virus (hcv). treatment recommendations in hiv/hcv co-infected patients are identical to those in patients with hcv mono-infection. however, potential drug-drug interactions (ddis) between antiretroviral agents and new direct-antiviral agents (daas) imply the need of a careful selection of the hcv treatment regimen. the aim of the present study was to evaluate the need of a change in the antiretroviral therapy (art) due to potential ddis in patients with hiv/hcv co-infection who started treatment for hcv with new daas. we also assessed the effectiveness of hcv treatment weeks after hcv treatment completion. design: we retrospectively registered clinical data about hcv and hiv management: hcv genotype, fibrosis metavir score, initial hcv viral load, hcv treatment and previous art regimen. we recorded the changes in art prior to starting hcv treatment and the reason of this switch (ddi, simplification or duplication of the therapy). results: between february and january , hiv/hcv coinfected patients started hcv treatment with a daas regimen. of them, had advanced liver disease (fibrosis score: f /f ) and were infected with hcv genotype . prior to starting hcv treatment, patients needed a switch in art regimen due to potential ddis with daas. simeprevir and the co-formulation ombitasvir/paritaprevir/ritonavir were the daas most frequently implicated in ddi with protease inhibitors or non-nucleoside reverse transcriptase inhibitors: / and / , respectively. also, we observed some changes of art due to other causes. five switches occurred to adequate the regimen (discontinuation of ritonavir in candidates to take the co-formulation ombitasvir/paritaprevir/ ritonavir or art improvement to decrease pill burden). as for hcv treatment effectiveness, / ( %) patients achieved sustained viral response weeks after therapy completion. conclusion: a large proportion of patients with hiv/hcv co-infection who initiate treatment with daas for hcv need to switch art due to potential interactions that may impact on effectiveness and safety of both treatments. additionally, some changes in art treatment are made to facilitate therapeutic adherence. these results highlight the need of a multidisciplinary approach in which interactions between art and hcv treatments should be carefully assessed. please specify your abstract type: descriptive abstract (for projects) background and objective: the potential impact of polymedication, iatrogenic events and medication error is a serious concern in hospitalized patients. clinical pharmacists can limit these risks by identify high risk. the aim of this study are to identify in six medical units high risk patients by using three predictive scores of rehospitalisation ( ps) , early mortality (charlson) and drug related problems (drp) . design: clinical and therapeutic variables in patients were collected through medical records and prescriptions by clinical pharmacists. scores were calculated during months in six units (internal medicine, n = ; nephrology, n = ; geriatrics, n = ; rheumatology, n = ; cardiology, n = and endocrinology, n = ). the data were analysed by mann and whitney test for the continuous variables and chi square test for the qualitative variables. the coefficient of correlation between the three scores were calculated by a pearson test for normal distribution and by a spearman test for non normal distribution. patients were considered at a high risk for re-hospitalization ( ps [ ) , early mortality (charlson [ ) and iatrogenic events (drp c ) . results: in the general population, the average age was . ± . years old and the sex ratio was . . the average treatment used was . ± . charlson scores were higher in geriatric unit ( . ± . ) follow by medical interne unit ( . ± . ). the ps and drp scores were higher in nephrology unit respectively . ± . and . ± . follow by internal medecine unit . ± . and . ± . . on contrary the rheumatology unit presented the lower level for the three scores. patients were considered at high risk for three scores, % (n = ) in nephrology unit (almost % of unit), % (n = ) in geriatric unit, % (n = ) in internal medicine unit, % (n = ) in cardiology unit, % (n = ) in endocrinology unit and % (n = ) in rheumatology unit. conclusion: knowledge of the variables associated with these predictor scores could help clinical pharmacists to prioritise various medicine units and target those at risk. we identified especially three units at risk: nephrology, geriatric and internal medicine. thanks to these results, clinical pharmacists can rapidly and efficiently target patients who present iatrogenic and/or re-hospitalization risks. design: a retrospective observational analysis was conducted in our hospital, based on medical records of patients presenting atrial fibrillation (af) and treated by doacs from january to may . to identify patients hospitalized due to severe bleeding, we analysed prothrombin complex concentrates (pccs) and activated pccs prescriptions, as well as pharmacovigilance declarations. results: patients were treated with doacs: with rivaroxaban ( . %), with dabigatran ( . %) and with apixaban ( %). fifty-nine ( . %) patients experienced at least one bleeding leading to hospitalization: with rivaroxaban ( . %), with dagibatran ( . %) and with apixaban ( . %). thirty-eight severe bleeding were identified ( . %): occurred with rivaroxaban ( . %), with dabigatran ( . %) and with apixaban ( . %). they included intracranial bleeding ( %) and gastro-intestinal bleeding ( %). seven haemorrhages resulted in hypovolemic shock (dabigatran: , rivaroxaban: , apixaban: ) and of them were fatal (dabigatran: ). rates of bleeding (p = . , v test) and of severe bleeding (p = . , v test) were not statistically different for the three molecules. in case of major haemorrhage, the recommended factor concentrate in our protocols differs between the anticoagulant. with dabigatran, the antidote idarucizumab ( g, intravenously) should be administered, without waiting for plasma concentration results. with rivaroxaban, apixaban or unknown doacs, pcc ( - units/kg) is indicated. in case of pcc failure, activated pcc ( - units/kg) is suggested. pcc, activated pcc or idarucizumab ( ) were used in / patients ( %). in rivaroxaban and apixaban-related haemorrhages, patients received activated pcc: two had a ui/kg dose and one had a ui/kg dose. regarding dabigatran-related bleeding, one patient received pcc instead of idarucizumab. compliance with local recommendations was % ( , p [ . , v test) . pharmacovigilance reports were issued. conclusion: management of doacs-associated severe bleeding in our hospital respects local protocols. it should also be pointed out that patients with life threatening bleeding may benefit from pcc. however, the risk of thrombosis associated with pcc must be weighed against the risk of haemorrhage. since specific antidotes are emerging, like idarucizumab or andexanet alpha, new guidelines for doacs-related haemorrhage are expected. please specify your abstract type: descriptive abstract (for projects) background and objective: this project is part of a prospective quasi experimental proof-of-concept investigation of a clinical pharmacist intervention to reduce drug-related problems among people admitted to a ward in a rural hospital in northern sweden. the aim of this particular study is to explore doctors' and nurses' expectations of having a ward-based pharmacist providing clinical pharmacy services in a rural hospital. design: eighteen face to face semi-structured interviews were conducted with a purposive sample of doctors and nurses working on the ward were the clinical pharmacy service was going to be implemented. semi-structured interviews were digitally recorded, transcribed and analysed using thematic analysis. results: the majority of participants had limited experience or a vague idea of what pharmacists are able to do in a ward. most participants described traditional roles such as inventory, drug distribution and dispensing. most respondents were unaware of the pharmacists' knowledge, skills and competences. for some it was unclear how having a clinical pharmacist in the ward was going to impact on their workload this was particularly important for the nurses. some doctors (mainly experienced) were concerned that having a pharmacist may mean losing or not gaining competence on drugs. for others it was unclear how the pharmacists' will work with patients or what clinical skills they have. however most participants were positive about the implementation of the new service. conclusion: this study provided a rare opportunity to explore the doctors' and nurses expectations of the role of clinical pharmacists before a clinical pharmacy service was implemented. the results showed that the participants' expectations of the clinical pharmacist role were unclear. to successfully implement clinical pharmacy services in a clinical pharmacy ''naïve'' setting; roles, clinical competence and responsibilities should be clearly described. furthermore, it is important to focus on inter professional collaborations between doctors, nurses and pharmacists. practical for the local hospital setting. seven out of experts agreed with pharmacist prescribing for the conditions identified. pharmacists (n = ) were more willing to prescribe antihypertensive and antidiabetic medication ( . %) when compared to oral anticoagulants ( . %). these values are higher than those obtained by vella in . the majority of pharmacists ( . %) recommended that pharmacists should take up further studies to a master or doctorate level degree in a clinical aspect in order to be authorised to prescribe. conclusion: the developed framework for pharmacist prescribing and the guidelines developed for pharmacist prescribing of oral anticoagulants and pharmacotherapy of hypertension and diabetes mellitus were shown to be reliable and were accepted by pharmacists and physicians. please specify your abstract type: research abstract background and objective: valproic acid (vpa) and its derivates and mycophenolate mofetil (mmf) and mycophenolic acid used during pregnancy increase risk of congenital malformation and cognitive impairment. thus, the french national agency for medicines and health products safety (ansm) decided to establish new conditions of prescription and dispensation of drugs containing vpa (may ) and mmf (april ). a signed care agreement and a co-prescription of contraceptives are now mandatory in the drug dispensation for reproductive-age adolescent girls and adult women. this study will describe the impact of these new guidelines on our practice. our objective is to compare the vpa and mmf media coverage and the impact on the prescriptions. setting and method: we compared the mass communication between vpa and mmf on social media, webpages and journal article (public and professional journal) on google and googletrends in the first months around these new rules. we combined different keywords such as ''accord de soins'' and the drug name. in the same time, we collected and analysed vpa and mmf prescribing and dispensing data and compared it to the data for the first months. main outcome measures: results: just before the vpa rule, the vpa was presented in the general press as the new health scandal after benfluorex mediator°w ith google searches in march compared to searches usually per month. simple research combining keywords reveal always more than twice more webpages concerning vpa than mmf. at the same time, a patients association (renaloo for renal failure) wrote to the ansm to contest the new rule with the double contraception and without any consultation of patients association. in our daily practice we also faced some physician reluctant to sign this prescription agreement with patient (too many agreements already asked, decision of ansm without any consultation of learned societies). the care agreements are kept in the patient records, a statement ''care agreement signed'' is reported in the electronic prescription of vpa and mmf. the overall consumption of mmf and vpa increase for respectively the first and months after rule implementation (from + to + %) except for the micropakin mg. the months mmf data will be presented for the final communication. conclusion: the media pressure and the new regulation have an impact on prescription trends. these new prescription and dispensing rules concerned two different contexts: pathology, media coverage, possible drug alternatives. we were faced to some difficulty in implementing the new guidelines, which reveals a certain reluctance of the prescribers or the patients represented by associations. tdmp : vancomycin trough serum concentrations are frequently subtherapeutic in a population of critically ill patients: a prospective observational study please specify your abstract type: descriptive abstract (for projects) background and objective: to design and characterise a framework of international pharmacy standards for pharmaceutical care application on oral anticoagulation for prevention of atrial fibrillation (af) related strokes. design: literature review (including existing international guidelines and quality measures) was conducted to characterise the standards and design an international framework for pharmaceutical practice application on oral anticoagulation for prevention of af-related strokes. expert opinions were sought through a delphi method to reach consensus on the framework domains and standards. results: the framework consisted of twelve overarching standards, which were defined and grouped into four domains as follows; ([personal care package]:-communication with patients, support decision making process, education and counselling, adherence. [medicines optimisation]:-clinical review and therapy optimisation, initiation and control, maintenance, supply and transfer between care settings. [workforce]:-workforce planning, training and development, analysing information; and [governance]:-assurance of service provision) specific to oral anticoagulation in prevention of af-related stroke. each standard was also categorised within dimensions and supporting statements to describe what a quality pharmacy service should deliver. a total of forty-five dimensions and twelve statements were incorporated into the framework. conclusion: a clearly defined framework of international standards was developed as a clinical tool and quality assurance to optimise the delivery of care for oral anticoagulation in prevention of af-related strokes. it will support pharmacists and their teams to develop their professional practice, improve services, and deliver safe and high quality patient care across all pharmacy settings. poster discussion forum i: community pharmacy and public health cp-pc : nurses' and pharmacists' learning experiences from participating in inter professional medication reviews in primary health care: a qualitative study hege t. bell *, , anne gerd granås , ragnhild omli , ingela enmarker , aslak steinsbekk nord university/ntnu, trondheim, hioa, oslo, nord university, namsos, norway, department of nursing, Østersund, sweden, ntnu, trondheim, norway please specify your abstract type: research abstract background and objective: traditionally, drug prescription and follow up have been the sole responsibility of physicians. however, interprofessional medication reviews (imrs) have been developed to prevent drug discrepancies and patient harm. what participating nurses and pharmacists learn from each other during imr is poorly studied. the aim of this study was to investigate nurses' and pharmacists' perceived learning experience after participating in imrs in primary health care for up to years. setting and method: a qualitative study with semi-structured focus group interviews and telephone interviews with nurses and pharmacists with experience from imrs in nursing homes and home based services. the data was analysed thematically by using systematic text condensation. main outcome measures: a qualitative method is useful when looking at objects from the perspective of how they are experienced. results: sixteen nurses and four pharmacists were interviewed. the nurses' perception of the pharmacist changed from being a controller of drug management routines towards being a source of pharmacotherapy knowledge and a discussant partner of appropriate drug therapy in the elderly. the pharmacists became more aware of the nurses' crucial role of providing clinical information about the patient to enable individual advice. increasingly the nurses learned to link the patient's symptoms of effect and side effect to the drugs prescribed. with time both professions jointly spoke of an increased awareness of the benefit of working as a team and the perception of contributing to better and more individual care. conclusion: imrs in primary health care meet some challenges especially concerning how to ensure participation of all three professions and how to get thorough information about the patient. possible solutions might be to use shared communication tools like internet based communication programs and to introduce the patient as a participant at the imrs. please specify your abstract type: research abstract background and objective: international good pharmacy practice guidelines describe how pharmacists should counsel the patients about their medicines, offer additional services where needed, and intervene at drug related problems. daily practice often differs from theory. this study aimed at illustrating the whole process of prescribed medicines dispensing in daily community pharmacy practice. part b of the project focuses on pharmacists' opinions. setting and method: community pharmacies in basel, switzerland, were invited in random order for study participation. one master student in pharmacy performed non-participant observations during day at each included community pharmacy. at dispensing of prescribed medicines, patient data, content of counselling, communication style, and provision of further services (e.g. follow-up offer) were documented on a checklist with predefined themes. interventions were documented systematically. a semi-structured interview on the pharmacists' opinions about the counselling, triggers, facilitators and barriers, and the documentation of interventions was conducted at each community pharmacy. main outcome measures: counselling content at prescription dispensing by numbers and by pharmacists' opinions; barriers, facilitators, and triggers for counselling at prescription dispensing. results: in march and april , of invited community pharmacies participated in the study. out of documented observation periods, encounters were analysed (first prescription: /refill prescription: ). counselling was provided to ( . %) clients with an average of . (± . ) themes per encounter. a total of clients refused counselling. themes most counselled at first and refill prescription dispensing were: drug intake ( / ), dosage ( / ) , and administration ( / ). for the pharmacists (n = ), most important themes to be discussed at first prescription dispensing were indication ( ), administration ( ), and anamnesis ( ); for refill prescription dispensing they were adherence ( ), therapy benefits ( ), and adverse effects ( ). the majority of pharmacists ( ) felt that it was their obligation to ask questions about patients' health during the dispensing of prescription medicines and named trigger (e.g. patient knowledge gap, patient motivation, interactions), but one-third reported difficulties with it. barriers were refusal by patients ( ), communication problems (language, ), lack of medical data ( ) , and lack of time ( ) . conclusion: a discrepancy in counselling content by observation compared to pharmacists' opinions was revealed. this might indicate that pharmacists are aware but hindered by barriers to practice according to good pharmacy practice guidelines. please specify your abstract type: research abstract background and objective: the workforce vision in scotland envisages 'making more and better use of technology …to increase access to services and improve efficiency' across the healthcare interface. services offered by community pharmacy remain limited by lack of shared access to patients' clinical information. in scotland, every patient has a unique identifier, their chi (community health index), which facilitates identification of/searching for patient records. the aim of this research was to explore the experiences of community pharmacists granted clinical portal access to patients' records. setting and method: from april , community pharmacists across nhs tayside (n = ) who had completed technical and information governance training were invited to maintain a portal log of their experiences of using the clinical portal to access patient records. each was asked to record when/why they considered accessing a patient's record and whether their information needs were met. portal logs were subject to independent summative content analysis by two researchers. this study gained ethical approval from robert gordon university. main outcome measures: not applicable. results: clinical portal logs were received from most participating pharmacists (n = / ). two were unavailable (moved to hospital setting; maternity leave). a third had not had occasion to access the clinical portal which he speculated was due to not working at weekends but also raised concerns about gaining patient consent. frequency of seven identified themes provided a partial indication of balance of reasons for usage. firstly (# ), to confirm a patient's prescription (n = ), secondly (# ), for additional information (n = ). less frequently (# ), portal access was to check repeat medications (n = ). other reasons for access were (# ) to check hospital discharge (n = ) followed by (# ) check on multi-compartment appliance aid status (n = ) or (# ) check the emergency care summary (n = ). there were also instances (# ) when portal access was not found to be helpful (n = ) so traditional offline routes were followed. conclusion: preliminary findings indicate mainly positive experiences with no technical issues raised and community pharmacists' information needs largely met. although limited to a small number of pharmacists in only one health board, findings support scottish policy aims, including 'prescription for excellence.' further work is underway around patients' perspectives of community pharmacist access. please specify your abstract type: research abstract background and objective: multicompartment compliance aids (mcas) such as the multidrug punch cards pharmis Ò are used to support patients in the daily management of their medication. solid oral medicines are unpacked from their original packaging and repacked in mcas although controversy exists about the stability of repackaged medicines. different countries published contradictory lists of medicines not recommended for repackaging. we aimed to define and apply criteria able to assess visual alteration of medicines repackaged in mcas. setting and method: eight criteria describing physical alteration of tablets/capsules were retrieved from the who international pharmacopoeia : chipping, swelling, capping, rough surface, cracking, crushing under pressure, mottling, and discoloration. absence of one criteria gives point. a maximum score of points can be obtained. twenty-two critical medicines and three half tablets were repackaged in the multidrug punch cards pharmis Ò and stored at accelerated conditions ( °c/ % rh) for weeks. original blisters of medicines were stored at room temperature as control. each tablet/capsule was visually inspected after , , and days. main outcome measures: score according to eight criteria. results: after weeks, tablets/capsules including of the half tablets showed no visual alteration and were identical to controls. a reduced score ( - points) was given to seven repackaged medicines and one half tablet within weeks: madopar Ò ( ), pravastatin sandoz Ò ( ), carvedilol mepha Ò ( ), plavix Ò ( ), pantoprazol nycomed Ò ( ), adalat Ò cr ( ). swelling and rough surface were the most frequent. chipping and capping were not observed. conclusion: our eight visual criteria are able to detect physical alteration of repackaged solid oral medicines under stress conditions. in absence of reliable data we suggest to apply this simple quality control for repackaged medicines in pharmacy practice. because chemical stability testing is not feasible in practice, pragmatic solutions are sought. further studies are needed for storage at room temperature. cp-pc : drug-related problems and symptom burden in nursing home residents kerstin bitter *, , ulrich jaehde , christina pehe , gabriela heuer , manfred krü ger clinical pharmacy, university of bonn, bonn, aok rheinland/ hamburg, pharmacists' association north rhine, düsseldorf, germany please specify your abstract type: research abstract background and objective: drug-related problems (drp) are common in the elderly due to polymedication. community pharmacies supplying drugs to nursing homes may play an important role in detecting and solving drp in nursing home residents. this project aims to evaluate whether community pharmacists can enhance the medication safety of nursing home residents by solving drp by means of a simple medication review (mr). furthermore, the applicability of a new tool to detect symptoms as potential adverse drug reactions in elderly patients should be tested. setting and method: nursing home residents at the minimum age of years insured by aok rheinland/hamburg and regularly taking at least five drugs per day were invited to participate. pharmacists performed a mr based solely on the patients' medication data, including dosage regimens of the nursing home and self-medication data. the detected and solved drp were counted. additionally, a simple questionnaire (sympel) was distributed to the patients periodically in order to assess their symptom burden. main outcome measures: frequency and type of the patients' drp as well as their symptom burden before and after the mr. results: after testing the feasibility of this intervention in a pilot study, patients were included in the main study so far. in average, the pharmacists identified two drp per patient and reported to the responsible general practitioner (gp) . as in the pilot study, most frequent drp documented by pharmacists were drugdrug-interactions ( %). % of the pharmacists' recommendations were accepted by the gp. % of the patients took at least one drug considered as potentially inadequate in the elderly. out of six different symptoms, patients reported dizziness and bruises most frequently. conclusion: pharmacists can detect many drp in nursing home residents by means of a simple mr. however, the full potential of this service to solve drp can only be exploited if the cooperation with the gps is improved. please specify your abstract type: research abstract background and objective: medicines for rare diseases (rd) are costly and have limited efficacy evidence but they represent around % of all innovative medicines. therefore, countries are facing challenges in providing patient access to them. the purpose of the study was to assess the patient access for slovenia and compare it with other european countries in the last decade. setting and method: the medicines for rd that obtained marketing approval between and via centralised procedure were included in the study based on the orphanet list from january . using the quarterly ims health database, sales data were analysed for slovenia and other european union countries, norway and switzerland. patient access was assessed for each country and comparisons between the countries were made using the three main outcome measures. main outcome measures: the number of medicines for rd available; time to first continuous use after marketing approval; total pharmaceutical expenditure for medicines for rd in euros. results: altogether, medicines for rd were approved between and . complete sales data were available for medicines which were included in the comparison. for germany and the united kingdom the continuous use of ( %) and ( %) was observed, respectively. the following italy, france, denmark and sweden use - % of all the medicines. in slovenia, ( %) medicines for rd were introduced. germany and the united kingdom times to first continuous use were the shortest (median time - months after marketing approval). median times below months were observed for norway, sweden, austria, the netherlands, france and switzerland. other countries were slower in enabling first continuous use (median time from to months). germany, france, switzerland had the largest pharmaceutical expenditure per inhabitant in ( . , . and . euros/inhabitant) while slovenia amounted to . euros/inhabitant. in slovenia more than a half of the medicines for rd approved in europe are used which ranks it in the middle of all the countries in comparison. comparing to the important european pharmaceutical markets like germany, united kingdom, france and italy, slovenia's median time to first continuous use is longer and pharmaceutical expenditure per inhabitant for these medicines is lower. pec : mapping of the dlqi scores to eq- d utility values using ordinal logistic regression and monte carlo simulations: is it plausible? please specify your abstract type: research abstract background and objective: converting dermatology life quality index (dlqi) scores to generic measure data would allow utility calculations and enable cost-effective analysis. this would meet the needs of health technology assessment agencies (htas) such as nice, who preferentially use the general health measure eq- d. the dlqi is a specialty-specific measure unlike the eq- d, a generic measure from which utility values can be derived. often several measures are implemented in studies with increased cost and patient burden. ordinal logistic regression (olr) was used to develop a model to convert dlqi scores to eq- d based utility values for use in economic appraisal of medicines. setting and method: data from patients were randomly divided into estimation and validation sets to fit and test the model. a series of ordinal logistic regressions were fitted in spss v for the five eq- d dimensions based on age, sex and all individual items of the dlqi as predictors. the model produced three estimated probabilities per subject per eq- d domain. using these estimated probabilities, a series of monte carlo (mc) simulations were run for each subject resulting in predicted domain responses. from these, utility values were calculated and compared to actual patient values. main outcome measures: conversion of dlqi scores to eq- d domain data results: there are conceptual overlaps between items of the dlqi and eq- d. the validation data set (which was not included in the creation of the model), demonstrated that the models were highly predictive compared to actual responses, except for minor differences for the pain/discomfort domain. for example, for the eq- d ' mobility' domain, patients answered 'no' (predicted and patients answered 'some or extreme' (predicted ) . we examined the model's latent variables, which also demonstrated high predictability at individual level. for example for the 'usual activities' domain the mean latent variable scores were - . , - . and - . for those responding 'no', 'some' and 'extreme' respectively, showing a clear increase in the scores with response. after excluding subjects with missing variable data there were patients in the estimation set and in the validation set. the model was shown to be highly predictive and repeated simulations demonstrated a stable model. the average predicted utility value for the entire validation set ranged from . to . across the mc simulations compared to the actual average utility value of . . conclusion: using olr, we have developed a method of mapping the disease-specific dlqi onto the eq- d: utility values may then be derived for population data sets, and possibly for individuals. the olr technique could be used to convert data from other disease-specific quality-of-life measures to generic utility data for incorporation into cost-effective analyses, greatly enhancing the potential value of such information. tomi laptoš *, , tanja kersnik levart hospital pharmacy, the division of paediatrics, department of nephrology, university medical centre ljubljana, ljubljana, slovenia please specify your abstract type: descriptive abstract (for projects) background and objective: having to take medication during time in school may present certain discomfort for some children. suboptimal dosing regimens (i.e. dosing more frequent than determined by drug's trough:peak ratio) can be prevented by a clinical pharmacist's overview and therapy optimization. the aim of the study was to review and evaluate dosage regiments in paediatric patients on antihypertensive therapy. dosage regiments are defined as schedule of doses of a therapeutic agent per unit of time and the amount of a medicine to be given at specific time. design: electronic health records (ehr) review, evaluation of actual dosage regiments against regiments recommended in smpcs and clinical database (uptodate Ò ), a consecutive case series study. results: ehrs of patients, admitted to or discharged from the department of nephrology of the division of paediatrics, umcl in with suspected icd- diagnoses from i to i were reviewed. patients were excluded (diagnosis not confirmed or lifestyle-change disease management only). the remaining patients (average age . years (range - )) received daily on average . medications (range - ) in . individual doses (range [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] . most frequently used drugs were perindopril (n = ), ramipril (n = ), amlodipine (n = ), bisoprolol (n = ) and doxazosin (n = ). patients received ex tempore oral suspensions. dosage regimen was not optimized in % (n = ) of the patients, among those % (n = ) receiving one medication only and % (n = ) receiving more than one medication where at least one was not optimized. furthermore, % (n = ) patients on stabledosage therapy (no dosage change of either medication in last months with satisfactory clinical outcomes) were eligible for fixeddose combination medication. with optimized dosage regimens patients would receive daily on average . medication (range - ) (- %) in . individual doses (range - ) (- %). the difference was statistically significant ( % ci, p \ . ) in both cases. conclusion: our data show that the majority of the paediatric patients on antihypertensive therapy ( %) received their medication in optimal dosage regimens. however, with an estimated every fifth patient not being on optimal dosage regimen, a multidisciplinary approach is crucial to assure that the individual patient achieves the best clinical, humanistic and economic therapy outcomes. ph : polypharmacy management programmes in the elderly: a case study in greece dimitra gennimata *, , christos kampolis , aggelos vontetsianos , jennifer mcintosh , alpana mair , on behalf of simpathy consortium please specify your abstract type: descriptive abstract (for projects) background and objective: polypharmacy management and medication adherence in the elderly are significant public health issues throughout the european union (eu). simpathy (stimulating innovation management of polypharmacy and adherence in the elderly) is a consortium of organizations representing eight european countries, aiming at stimulating innovation around management of appropriate polypharmacy and adherence, ultimately providing tools for eu policy makers to develop and/or improve, implement and evaluate programs addressing these issues. design: a mixed-methods case study was carried out in greece, to identify policies on the management of polypharmacy and adherence issues in the elderly. a desk review of the polypharmacy and adherence policies at the government, regional and institutional level has been completed. key informant interviews were conducted with policymakers and health professionals responsible for developing and implementing strategies. focus groups consisting of policymakers, clinicians and patients validated the research findings. results: although e-prescription implementation is widespread (& % coverage nationwide) and disease-specific guidelines have been developed, polypharmacy management is only associated with direct economic indicators. no formal policies or programmes are identified. significant contributions are coming from different health professional organizations that have chosen to provide expanded services to their patients, aiming at optimising drug therapy and thus polypharmacy management and medication adherence in the elderly. community pharmacists offer pharmaceutical care to patients, which includes management of prescribed medication, otc remedies, vitamins and supplements and food-drug interactions. hospital pharmacists in some state (public) hospitals review medication for inpatients and out-patients, communicate with prescribers and confirm the ''benefit-no harm'' principle in the prescribed medication (e.g. incompatibilities, side effects, -rights of medication). medical doctors, mostly general practitioners and some specialized ones, usually in primary healthcare settings, keep health records of their patients and have an overview of all administered medication. however, key barriers still remain the lack of coordination of institutions and authorities and overlap of their responsibilities, healthcare workforce and infrastructure shortages and several cultural issues. conclusion: all initiatives to medication management and medicines optimisation are provided without directive from national policies or guidelines. therefore, these activities rely on the goodwill of the health professionals to address pharmacotherapy and therefore polypharmacy management but they are not necessarily representative of what is happening nationwide. a national policy to implement the management of polypharmacy nationwide could mobilise the willingness of health professionals and ensure consistency of care. development and implementation of this policy should build on the grassroots efforts currently underway in this area. ph : clinical profile and treatment discontinuation in a tuberculosis control state programme in brazil: preliminary results from sinan database simone s. bezerra , mara guerreiro *, , , nathany pessoa , maria paula athayde , rodrigo auad , joão josé gomes , josé lamartine soares sobrinho post graduation program in therapeutic innovation, federal university of pernambuco, recife, pernambuco, brazil, centro de investigação interdisciplinar (ciiem), instituto superior de ciências da saúde egas moniz, monte de caparica, please specify your abstract type: research abstract background and objective: challenges remain in tuberculosis (tb) control. discontinuing treatment can leave patients infectious and contributes to the emergence of resistance. this study aimed to describe the clinical profile and cure and discontinuation rates of tb patients enrolled in the pernambuco tuberculosis control programme (pect). setting and method: the study was conducted in three sites in recife, brazil, designated a (one polyclinic plus eight general practice units), b (one hospital for medium-complexity patients) and c (one hospital for high-complexity patients). data were extracted from the notifiable diseases information system (sinan) for all pect outpatients, from / to / (n = ). analysis was performed with the aid of action for excel; there is on-going analysis to further explore differences across sites. ethical approval was granted. main outcome measures: clinical form of the disease, hiv testing, new cases, cure and treatment discontinuation. results: sociodemographic data were available for sites a and b only. most patients were male ( %, n = ), with age raging from to years old ( . %, n = ); most had a low education level ( %, n = ) and low socioeconomic status ( %, n = ). the most common clinical presentation was pulmonary tb. most cases were new ( . %, n = ); recurrence and enrolment after discontinuation were respectively . and . % (n = and n = ). with respect to hiv, . % of patients were seronegative (n = ); about a third ( %; n = ) had not performed hiv test. rates for cure were respectively . % (n = ), . % (n = ) and . % (n = ) in the sites a, b and c. correspondent rates for treatment discontinuation were . %(n = ), . % (n = ), . % (n = ), respectively. tb-related mortality ranged from in site c to . % in site b. conclusion: missed hiv tests may represent undetected tuberculosis/ hiv coinfection. site b presented the highest rates of intrapulmonary plus mixed tb forms, discontinuation of treatment and tb-related mortality; additionally, it had the lowest rate of enrolment after treatment discontinuation. patients co-infected with tb and hiv are firstly referred to this site, which may explain this finding. our findings may help managers allocating resources and assist clinical pharmacists in planning their interventions. findings also suggest the need of more intensive interventions in tb patients, such as pharmaceutical care programmes. please specify your abstract type: research abstract background and objective: pharmacists working in primary health clinics have various roles. pharmaceutical care is one of them. how to provide this service varies across countries and settings. the most optimal way to provide pharmaceutical care is important to define when developing clinical pharmacy services in a new setting such as primary care practices. general practitioners are key stakeholders in this endeavour. the aim of this study was to find the most optimal approach to providing pharmacist-led pharmaceutical care in primary health care clinics in iceland in collaboration with general practitioners. setting and method: action research provided the framework for this research. data was collected from pharmaceutical care interventions with patients, field observations, field notes, and interviews with general practitioners over the period of the study. the study ran from september to june . three separate semi-structured in-depth interviews were conducted with five general practitioners from one primary health care clinic in iceland at different time points throughout the study. pharmacist-led pharmaceutical care was provided to patients (n = ) before and between general practitioners' interviews. the study settings was a primary health care clinic in reykjavik area and the patients' homes. main outcome measures: how to provide pharmaceutical care in collaboration with general practitioners in the icelandic health care environment. results: direct contact between pharmacists and general practitioners over short distances are essential to providing optimal pharmaceutical care services. pharmacist's access to medical records is necessary even though face-to-face communication between pharmacist and patients are most effective in providing pharmaceutical care. pharmacist-led clinical service was deemed most needed in dose dispensing polypharmacy patients. patients require more information about drugs prescribed to them coupled with an accurate drug list with greater detail. conclusion: the most efficient collaboration when pharmacist and general practitioner is obtained when they work side by side at the primary health care clinic. when new services are developed it is vital to identify different requirements of the primary health care clinics to optimize the running of a clinical pharmacist service. ph : accompaniment of patients treated with oral chemotherapy: a survey on patients' experience laure napoly *, , pascal paubel , , sylvie burnel oncorif -regional cancer network, health law and health economics deparment, health law institute, inserm, umr s , paris descartes university, sorbonne paris cité, paris, france please specify your abstract type: descriptive abstract (for projects) background and objective: antineoplastic agents taken orally are more and more used in cancer care. these medicines confer autonomy to patients. although, they may cause adverse effects that can lead to treatment adherence issue, unjustified hospitalizations, or premature treatment interruption. proper accompaniment of patient can prevent these issues. in order to define how to organize this accompaniment, we conducted a survey on patients' experience. the objective is to describe patients care pathway and identify their needs. design: a descriptive, qualitative, prospective, survey was conducted using self-administered questionnaires, in hospitals of ile-de-france region. inclusion criteria were: having being treated with oral neoplastic agents during minimum months, age [ , solid tumor, no concomitant iv chemotherapy. collected data were: patients' sociodemographic and clinical profile, their insight about different steps of care pathway (information, treatment delivery, follow up), their behaviours and interactions with healthcare professionals, and their overall opinion. results: patients were recruited in six hospitals. their sociodemographic and clinical characteristics were variable. % were treated with targeted therapy, % with cytotoxic agent, and % with endocrine therapy. patients showed high satisfaction for given information at the beginning of the treatment. principal source of information identified was the oncologist ( %). while the delivery of treatment, % of patients beneficiated of advices from the pharmacist. accompaniment of patients during treatment seemed unequal, with: a frequency of visits with the oncologist ranging from less than - months; % of patients not knowing any telephone number they can call in case of worries or questions about their condition or treatment; % not remembering any particular accompaniment treatment (visits or calls from nurses or doctors for example). for adverse effects management, three principals actors were identified: oncologist ( %), general practitioner ( %) and pharmacist ( %). regarding the use of oral chemotherapy, patient are satisfied with: it's comfort ( %); being more actively involved in their cancer care ( %); and state not having any anxiety taking chemotherapy home ( %) . asked openly about their concerned and needs three major concepts were identified: high concern about adverse effects, positive feedback about maintaining contact with health professionals between cures and difficulties of communication between health professionals. conclusion: there is a high satisfaction regarding oral chemotherapy and health professionals. the oncologist has a primordial place in patient pathway, whereas implication of pharmacist and general practitioner stays variable. adverse effects are a major concern that needs proactive accompaniment. the variability of our results suggests that accompaniment must be flexible and adapted to the needs of each patients. the key to flexibility could be good coordination and communication between healthcare professionals. ph : general beliefs about medicines among independent elderly adults in sweden: data from an rct lina hellström *, , , victoria throfast the pharmaceutical department, kalmar county council, ehealth institute, linnaeus university, kalmar, sweden please specify your abstract type: research abstract background and objective: there is a need to improve prescription and use of medications by the elderly. the objective of a recent rct was to investigate the effects of e-learning about medicines among elderly adults. a positive impact on the primary outcome measure, knowledge about medicines, is reported elsewhere. a secondary outcome measure, general beliefs about medicines, is reported below. setting and method: the study was a randomized controlled trial in elderly people (aged c years). participants were recruited from patient associations and pensionerś associations. participants were randomized to either an intervention group that participated in the e-learning, i.e. internet modules with video and audio, or a control group that did not take part in the e-learning. post-intervention data was collected using paper-based questionnaires, completed within two weeks after agreeing to participate in the study. the general beliefs about medicines questionnaire (bmqgeneral), comprising the subscales necessity, harm and overuse, was used to elicit beliefs. higher scores indicate stronger endorsement of scale constructs (range [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] . main outcome measures: bmq-general subscale scores. results: a total of elderly people were included in the study, in the intervention and in the control group. the mean age in the total population was . years and % were women. eleven percent did not use any prescribed drugs while % used more than five prescribed drugs. the patients' scores were very similar in the two groups for all three bmq subscales. the median ''overuse'' score was in the intervention group versus in the control group, the median ''harm'' score was (iqr - ) in both groups and the median ''necessity'' score was in both groups. in the total population the most commonly expressed negative beliefs referred to overuse of drugs. . % of respondents agreed with the statement ''if doctors had more time they would prescribe fewer medicines'', . % stated ''doctors prescribe too many medicines'', and . % stated ''doctors place too much trust in medicines''. a majority of the respondents agreed with the four items on the ''necessity'' scale. for example ''medicines help people to live a better life ( . % agreed)''. conclusion: the studied e-learning intervention was not shown to have any impact on general beliefs about medicines. beliefs about medicines have been associated with a number of background variables which might explain why increased knowledge about medicines alone cannot change such beliefs. in general, respondents in the study had highly positive beliefs about the necessity of medicines. nevertheless, the results indicate that overuse of medicines is regarded as a problem. ph : maf-plus: pharmacists' contributions to provision of financial assistance for medications ian wee * , charlene ong, niron naganathar changi general hospital, singapore, singapore please specify your abstract type: descriptive abstract (for projects) background and objective: the medication assistance fund plus (maf-plus) is a government scheme introduced in singapore in to provide financial assistance to needy patients who meet pre-set criteria based on means testing. unlike previous schemes, maf-plus provides broader discretion to institutions when providing financial assistance. in our institution, pharmacists reviewed patients' case and medication histories, and filed recommendations to a multidisciplinary committee tasked with approving deserving maf-plus applications. the pharmacists' contributions to the committee, and the outcomes of the applications, are presented in this study. design: all maf-plus applications received between st october and st december were reviewed. pharmacists' comments for each application, where provided, were noted, as well as the range of medicines applied for, review approval rates, and cumulative percentage of available funds utilised. the effect of a recent widening of the scheme's scope to include notable high-cost items was also evaluated. results: between and , maf-plus applications were reviewed, of which ( . %) were approved. of the rejected applications, ( . %) were channelled to alternative financial assistance schemes on the recommendation of the pharmacists. the medicines most commonly applied for were intended for the treatment of cardiac ( . %), respiratory ( . %), and psychiatric ( . %) conditions. pharmacists' recommendations also led to a gradual expansion of our institution's list of pre-approved medicines-from in - to by end- . from onwards, pharmacists previewed increasing numbers of applications for high-cost medicines, particularly those for treatment of retroviral disease, hepatitis c, and rare diseases. cumulative utilisation of maf-plus funds (inclusive of annual replenishment) rose from . % in - to . % by end- , representing an average year-on-year growth of . %. conclusion: using a process of judicious previewing of maf-plus applications, and recommendations to the maf-plus committee, pharmacists contributed to a high percentage of patients receiving financial assistance for medications. despite a steep growth in the number of applications received between and , this approach helped to prevent over-extension in fund utilisation. pharmacists will likely be increasingly relied upon due to an anticipated rise in the number of applications for high-cost medicines. please specify your abstract type: research abstract background and objective: adolescents often treat themselves and take medications without parental supervision. lack of experience and knowledge of medicines in this age group frequently leads to inappropriate use of medicines and adverse drug reactions. data about the use of medicines among slovak adolescents and their knowledge of medicines have not been studied yet. setting and method: for our study we used the questionnaire method. the questionnaire contained multidimensional items with closed-ended and open-ended questions, which focused on the characteristics of the adolescentś health status, use of medicines, also in relation to parents and adolescentś knowledge and perception of medicineś risk. we distributed validated questionnaires for adolescents aged from to at secondary schools in all regions of slovakia. response rate was . %. questionnaires were finally analysed. the differences in the distribution of categorical variables between groups were evaluated using the chi square test. sas . . was used as statistical software. main outcome measures: to determine adolescentś knowledge of medicines in terms of efficacy, self-medication, safety of therapy and analyse which medicines are the most frequently used by adolescents. to compare adolescents with chronic disease and healthy ones from the perception of pharmacotherapy point of view. results: in the analysed group . % (n = ) of adolescents are treated for chronic disease. mostly they suffer from allergy ( . %, n = ) and skin diseases ( . %, n = ). adolescents with chronic disease use regularly prescription medicines ( . %, n = , p \ . ) and over the counter medicines ( . %, n = , p \ . ). this group of adolescents better accept the pharmacotherapy with parental supervision ( . %, n = , p = . vs. healthy adolescents) and they believe in effectiveness of prescription medicines ( . %, n = , p = . vs. healthy adolescents). most frequently prescribed medicines were azithromycin, levocetirizine, ofloxacin and over the counter medicines were ibuprofen, paracetamol, ascorbic acid. we found out in all group of adolescents that . % (n = ) prefer self-medication without check-ups, . % (n = ) used drugs in the last months without a prescription, . % (n = ) take over the counter medications independently without the supervision of parents, . % (n = ) buy medicines themselves in the pharmacy, . % (n = ) do not take medications as recommended, . % (n = ) believe that they have enough knowledge of medicines which they take, . % (n = ) resp. . %, (n = ) believe that prescription medicines resp. over the counter medicines are safe. conclusion: questionnaire analysis pointed out that slovak adolescents have not enough knowledge of medicines. the study provides new information in the field of risk perception and adolescentś knowledge of medicines in the slovak republic and highlights the areas that need to be studied in the future in terms of adolescentś education. federal university of pernambuco, state technical school prof. agamenon magalhães, recife, pernambuco, brazil please specify your abstract type: research abstract background and objective: the effectiveness of tuberculosis (tb) control programmes depends critically on patients completing appropriate treatment. this study aimed to outline the cure and discontinuation rates of patients enrolled in the pernambuco tuberculosis control program (pect), based on dispensing data. setting and method: the study was carried out in three sites in recife public health system, brazil, designated a (one polyclinic plus eight general practice units), b (one hospital for medium-complexity patients) and c (one hospital for high-complexity patients). data were collected between - / , through reports from the stock management software for public pharmacies (horus) for pect outpatients. reports corresponded to a total of patients ( , and in sites a, b and c, respectively). horus defines ''cure'' as medicines collection for three, six or nine consecutive months without interruption, depending on the treatment scheme; discontinuation is defined as non-sequential collection of medicines or treatment interruption for two consecutive months or more. patients were assigned an ''undetermined'' status if treatment was ongoing. data were inputted onto an excel spreadsheet and checked for accuracy. quisquared test, fisher's exact test and bootstrap analysis were performed with r statistical computing. ethical approval was granted. main outcome measures: cure and discontinuation rates for pect outpatients. results: demographic data are not available for the sample. rates for cure were respectively . % ( ), . % ( ) and % ( ) in the sites a, b and c, while rates for treatment discontinuation were . % ( ), . % ( ) and % ( ), respectively. discontinuation rates were significantly different among the sites a, b and c (p \ . ). bootstrap analysis showed that overall the proportion of patients with an ''undetermined'' status in each site did not significantly change these differences. conclusion: only site a had an acceptable discontinuation rate, in light of the world health organization recommendations. this deserves attention as default treatment leaves patients infectious for longer, increases the risk of poor outcomes and fosters resistance to antibiotics. pharmacists could use dispensing data to signal tb patients at-risk of discontinuation, and subsequently tailor interventions addressing its causes. site b had the greater number of patients which discontinued treatment. patients co-infected with tb and hiv are firstly referred to this site, which may explain this finding. our findings suggest the need of more intensive interventions in patients co-infected with tb and hiv, such as pharmaceutical care programmes. please specify your abstract type: research abstract background and objective: many efforts are done to organise good quality and safe pharmaceutical care. in general, the involvement of a hospital pharmacist or hospital pharmacy personnel in the process of medication reconciliation results in a reduction of the number of medication discrepancies. however, in case of emergency admissions this topic is still insufficiently studied. the introduction of good medication reconciliation on the emergency department (er) requires firm logistical and organisational efforts. we investigated the effects of a drug reconciliation intervention by pharmacy personnel during emergency admissions in order to identify discrepancies between medication lists taken by er physicians and by pharmacy personnel. setting and method: this observational, comparative, non-randomised intervention study was performed in . we calculated that a population size of patients was sufficient to perform reliable measurements. inclusion criteria: all patients presented at the er and admitted to a hospital ward \ after presentation with usage of one or more prescription drugs. exclusion criteria: age \ years, residency outside the region delftland, inability to undergo an oral interview, absence of a medication list of the public pharmacy (ozislist), decease of the patient during er-stay and patients undergoing surgical procedures. discrepancies between both medication lists taken by an er physician or pharmacy technician were classified in four categories of increasing severity ( = no discrepancy to = clinical relevant discrepancy) using the index of the national coordinating council for medication error reporting and prevention (www.nccmerp.org). discrepancies were categorised by a panel consisting of a pharmacy technician, a (senior) hospital pharmacist and a th year pharmacy student. statistical analysis was carried out with a statistical software package (spss ) using the mann-whitney u test and chi squares test. main outcome measures: during the intervention measurement we analysed the reconciliated medication by comparing the er's physician's list with the list of the pharmacy technician after a medication verification interview. the number of discrepancies were measured and judged by the panel. discrepancies were given a category , , or as defined. results: during the intervention measurement patients were admitted to the er. sixty-five ( ) patients ( . %) met the in-and exclusion criteria. the number of medication discrepancies decreased significantly after intervention of the pharmacy technician by %, from to discrepancies. the average number of discrepancies per patient after intervention decreased by . %, from average . to . discrepancies per patient. conclusion: medication verification by pharmacy personnel in the er reduces the number of medication discrepancies by half. medication lists generated with a standard interview by pharmacy technicians in combination with an ozis-list on admission of patients at the er is more complete and accurate than the current method. hp-pc : discharged patients: a problem for community pharmacists? information transfer, as well as the role, needs, and objectives of pharmacists when they care for recently discharged patients. setting and method: a focus group was conducted with a sample of six community pharmacists from personal contacts to represent different characteristics. the focus group consisted of different questions and the recording was transcribed, fragmented and categorised. based on these results, a nationwide online-survey was created with the following questions: a) responder's characteristics, b) number and origin of prescriptions, c) role fulfilment of the joint-who/fip-guideline on good pharmacy practice, rated with a -point likertscale, d) information items derived from the focus group discussion grouped into four categories and evaluated for their availability and for their usefulness by likert-scales, e) goals for discharge optimisation, f) additional comments. the questionnaire was piloted and translated forward and backward to french and italian by native speakers. it was sent to all managers of pharmacies belonging to the swiss pharmacist's association in summer (n = ). main outcome measures: conclusions from focus group discussion and responses to questions a-f from the nationwide questionnaire. results: the focus group participants ( . ± . years, % female, % employees) emphasised the importance of an expanded information transfer, especially for medication changes, unclear prescriptions, and information about a patient's medication acquisition. they were concerned about their extensive workload of discharge prescriptions, and mentioned treatment continuity as one of their goals. the questionnaire was answered by pharmacists (response rate . %, . ± . years, . % female). there were . % of responders who reported to fulfil their role (to manage a patient's therapy, function b) not satisfyingly. unavailable but essential information were allergies and the specification of off-label use prescription. unavailable although desired information were the reasons for therapy changes, indications, appointments, contact information, or compounding formulations. concerning design and transfer, information should be written in a structured way but no clear preference for a transfer method was found. goals of community pharmacists were: improved treatment continuity, patient safety, and pharmaceutical care. conclusion: swiss community pharmacists rarely receive sufficient information on discharge prescriptions. appropriate pharmaceutical care is therefore impeded. the knowledge and application of the findings enable directed optimisation of discharge. hp-pc : patients attitude for using antipsychotic medication in the norwegian early intervention in psychosis, tips study rafal yeisen *, , stein opjordsmoen , , , inge joa , , jan olav johannessen , , jone bjørnestad on behalf of centre for clinical research in psychosis, psychiatric division, stavanger university hospital, stavanger, norway background and objective: poor drug adherence in patients with psychosis leads to relapse, re-hospitalization, poor outcome and increased consumption of health services. pharmacoclinical studies have demonstrated that the treatment response decreases with each relapse. it is estimated that % of patients suffering from chronic illness are not taking medication as prescribed after months. the purpose of this study is to investigate which experiential factors that potentially might affect adherence with medication in adults with psychotic disorders. setting and method: in a descriptive qualitative sub-study in the ongoing norwegian early intervention in psychosis, tips study, where twenty-first episode patients ( male, female) participated in semi-structured interviews years after inclusion. they were still using or had used antipsychotics during the last years. data were analysed using interpretative phenomenological analysis. main outcome measures: adherence to antipsychotics. results: the data suggested four main themes, reflecting the patients' subjective experiences and their impact on the desire to adhere to antipsychotics: ( ) admission experience as a psychotic's patient; ( ) information from healthcare staff; ( ) limited involvement in decision-making; ( ) attitude to antipsychotics. conclusion: a number of factors had a positive influence on adherence to antipsychotics. pleasant admission/stay experiences, feeling that antipsychotics had therapeutic effects, mild or no side effects, and believing that antipsychotics are necessary and useful, were typical statements. please specify your abstract type: research abstract background and objective: the hospital-to-home transition is a vulnerable stage in a patient's care. patients can experience problems with medication supply, which possibly lead to therapy interruptions. the objectives of this study were to investigate medication supply after discharge, and patients' and physicians' opinions about the current discharge process and possible optimisations. setting and method: a telephone interview was conducted with discharged patients from the surgical and internal medical wards from the cantonal hospital in baden (switzerland). inclusion criteria were: patients c years old, discharged home with a discharge prescription. patients were called between the nd and th day after discharge and a piloted, structured interview was performed, consisting of questions on experiences and optimisations. afterwards, semi-structured interviews were conducted with five physicians from the study hospital. results from patient interviews and the general discharge process were discussed. main outcome measures: proportion of filled prescription, frequency and type of supply problems including therapy interruptions. opinions of physicians and patients on current discharge process and possible optimisations. results: discharged patients were . ± . years old, % female, % from internal medicine, and % regularly visit the same pharmacy. of the interviewed patients, have not filled their prescriptions yet and had their prescription filled when they were called. of these, % of them visited the pharmacy on the day of discharge, but it took up to the th day until all of them received their medication. supply problems were encountered by patients ( %), mainly because of the medication not being in stock in the community pharmacy. only four patients experienced therapy interruptions, which took up to the rd day post-discharge. patients discharged from internal medical wards had more supply problems compared to surgical wards (relative risk = . , p = . ). patients experiencing supply problems had statistically significant more medicines on a daily basis ( . ± . vs. . ± . , p = . ). physicians were surprised about the late prescription filling and worried about the disease outcomes. however, interruptions were interpreted as unfrequent. when asked if, in future, hospitals should transfer prescription to the community pharmacy prior to discharge, % of patients refused and physicians were undecided, mainly because of a questionable benefit. but both groups indicated that giving some bridging supply would be welcome. conclusion: this study showed that patients discharged from a swiss hospital encounter supply problems, but therapy interruptions are seldom. giving some bridging supply was preferred over an early information transfer by patients and physicians. interventions should consider these opinions and focus on internal medicine patients with high number of medication. please specify your abstract type: research abstract background and objective: adherence to secondary prevention evidence-based medical (ebm) therapies for patients with st-segment elevation myocardial infarction (stemi) is essential to reduce long-term rates of major adverse cardiovascular events. current guidelines recommend the long-term use of low-dose aspirin, highintensity statins, angiotensin-converting enzyme inhibitors (acei)/ angiotensin receptor blockers (arb) and beta-blockers (bb), in addition to p y inhibitors for year. we aimed to assess the adherence to secondary prevention ebm therapies from discharge to one-year follow-up among patients with stemi undergoing primary percutaneous coronary intervention (pci) in contemporary practice. setting and method: observational single-centre study including consecutive patients with stemi undergoing primary pci in a tertiary hospital in switzerland over a one-year period. secondary prevention ebm therapies were assessed at discharge and at one-year follow-up. main outcome measures: prescription of key secondary prevention ebm therapies (aspirin, p y inhibitors, statins, acei/arb and bb) from discharge to one-year follow-up after stemi. bb was recommended only for patients with heart failure or left ventricular ejection fraction (lvef) \ %. results: a total of patients were included. ebm drug prescription at discharge was . % for aspirin (n = ), . % for p y receptor inhibitor (n = ), . % for statin (n = ), . % for acei/arb (n = ) and . % for bb (n = , among patients with lvef \ %). ticagrelor ( . %) was the major p y inhibitor prescribed. overall, ebm drugs were missing at discharge, with of these missing drugs having no justification for no-prescription (contraindications, allergy or intolerance). at one-year follow-up (median . months, n = ), aspirin, statins and acei/ arb prescription rates were . % (n = ), . % (n = ) and . % (n = ) respectively. out of patients ( . %) with lvef \ % received a bb. among patients treated with ticagrelor at discharge, ( . %) were receiving ticagrelor at follow-up, whereas ( . %) were switched to another p y inhibitor. among patients who discontinued ticagrelor (n = , . %), duration of dual antiplatelet therapy was months for % (n = ) and discontinued prematurely (\ year) for % (n = ) patients. reasons for ticagrelor early discontinuation or switch were not specified. conclusion: in a real-world cohort of patients with stemi undergoing primary pci, prescription of recommended secondary prevention medications at discharge is excellent. adherence to ebm therapies at year remains high with more than % of patients receiving all ebm drugs. early discontinuation of dual antiplatelet therapy was observed in % of patients, whereas ticagrelor was switched for another p y inhibitor in . % of patients. these observations highlight key opportunities to improve longitudinal use of secondary prevention therapies after stemi in routine clinical practice. although side effects are less common than traditional chemotherapies, certain ones such as pain, fatigue, nausea and vomiting can still be bothersome. in oncology outpatient clinics, side effects are monitored by oncology nurses; however due to high patient turnover and limited numbers of nurses, the assessment of side effects might not be performed adequately. therefore, aim of this study was to determine side effects of immunotherapy and targeted therapy and to compare the severity assessment of side effects by clinical pharmacist and nurses. setting and method: the study was conducted in the hacettepe university oncology hospital outpatient clinic. the patients who have been taking ipilimumab, nivolumab, pembrolizumab, bevacizumab, panitimumab or cetuximab during october -march were included. the assessment of side effects were undertaken by a clinical pharmacist and nurses separately on each visit using the common terminology criteria for adverse events version- toxicity assessment scale. an independent clinical pharmacist compared the side effects' assessments by pharmacist and nurses for analysis. ethical approval was obtained from hacettepe university ethics committee. main outcome measures: to compare the severity of side effects of targeted drug therapies which were assessed by a clinical pharmacist and nurses. results: during the study period visits of patients were evaluated. a total of side effects assessments were recorded. among those assessments ( . %) was assessed in different ranking by nurses and pharmacist. the differences in the number of assessments were mainly seen in criteria related to pain (n = ; ), sensory loss (n = ; ), fatigue (n = ; ), stress (n = ; ), insomnia (n = ; ) which was performed by nurses and pharmacist respectively. other side effects detected only by clinical pharmacist were oedema, cough, gastrointestinal complaints (heartburn, cramp) and sensitivity of odour which require close monitoring and in-depth counselling by clinical pharmacist. conclusion: this study explores the differences in assessment of side effects by pharmacist and nurses in targeted therapies. routine assessment of side effects between chemotherapy cycles might yield to misinterpretation or inadequate assessment due to workload of outpatient clinic. therefore, inter-professional interactions in outpatient clinics might close the communicational gaps and improve patient care. hp-pc : implementation of clinical pharmacy in the acute psychiatric wards: improving quality of medical treatment across health care sectors amila zekovic *, , signe kristensen , lisbeth lund pedersen clinical pharmaceutical services, capital regional pharmacy, head of clinic, mental health services, copenhagen, denmark please specify your abstract type: descriptive abstract (for projects) background and objective: a study from shows that people with a mental disorder had a two-to threefold mortality compared with the general population in denmark. life style diseases are the major reason for the excess mortality, partly due to undertreatment of physical disease and well known side effects from medicines such as obesity, diabetes, and heart disease. in may , a clinical pharmacy service (cps) was implemented in all acute psychiatric wards (apw) in the capital region as a part of a three-year project funded by the danish health authorities. the objective is to illustrate how the implementation of clinical pharmacy in the apw in copenhagen increases the focus on drug related problems, rational pharmacotherapy and side effects, increasing the quality of medical treatment and patient safety across health care sectors. design: data was collected at the apw in copenhagen which consists of three wards and has a total capacity of beds. inclusion criteria were patients to which two or more of the following apply: • c years of age • c drugs • high risk drugs (clozapine, sertindole and opioids) • combination of antipsychotics and benzodiazepines • diagnosed with liver/kidney disease the secondary inclusion criteria were all patients receiving c drugs as a single criterion. to obtain a valid medication history and secure medication reconciliation, the pharmacist interviewed included patients. the patients were also asked about side effects, compliance, and perceived effects of treatment. a medication review was conducted based on the patient interview, screening for interactions in an interaction database, and consideration of biomedical data in order to evaluate if treatments should be adjusted, initiated or discontinued. the pharmacist's input was discussed with the doctor, as inputs are more likely to be considered if they are communicated orally. finally, all inputs were documented in the patient's journal as a pharmacist note. the model for improvement was used as a tool for implementing the cps and is being used continuously for improving the service. results: between may th and june th , patients were screened at admission to the apw, of which . % met the inclusion criteria ( patients). in this period the pharmacist conducted notes, indicating that . % of the included patients were seen by the pharmacist. in april , patients were in average admitted with . drugs and . inconsistencies between the hospital's medication orders and the medications that the patient had been taking. regarding patients who are discharged to community care shortly after admission, the pharmacist note is sent to their general practitioner for follow up. conclusion: overall, the implementation of a cps in the apw has been successful. medication reconciliation ensures that the patient is provided with correct medicine at admission, transfer or discharge. by performing a thorough medication review based on a consultation with the patient, the service contributes to an increase in quality of medical treatment. please specify your abstract type: descriptive abstract (for projects) background and objective: the importance of the role of a clinical pharmacist resident in the operating room during months, in a private hospital belonging to a group devoted to healthcare for over years. the hospital is recognized as a reference centre of excellence of hospital care in portugal. it has inpatient beds, two surgical blocks with rooms and beds in the intensive care unit. the aim of the clinical pharmacist in the operating room is to ensure compliance with good clinical practice, safety and pharmacotherapeutic effectiveness, as well as optimization of drug costs. design: . logistics restructuring of pharmaceutical services and the need of the physical presence of the pharmacist in the operating room. . furthermore, the workstation of the pharmacist is moved to the operating room and the in-depth study of all medicines used in the operating room. . in compliance with the joint commission, definition, optimization and adjustment of drug stocks to the needs of the service itself. in close collaboration with the nursing staff, consumer kits were created for registration of drugs by type of surgery in order to facilitate registration and ensure billing efficiency. control of the analgesic drug's dispensation circuit in hospitalized surgical patients that stay less than h in the hospital. ensure compliance with the project through which the health regulatory authority evaluates several hospitals in the country, creating a national ranking among hospital specialties. . clinical phase: creation of prescription protocols by type of surgical intervention based on national clinical guidelines. validate prescriptions in the intra-surgical block in compliance with antibiotic prophylaxis, antiemetic and thromboembolic, checking deviations in therapy according to good practice. identify pharmacologic hypersensitivities of patients by consulting the clinical process and anaesthesiology records. provide information on drugs, drug efficacy monitoring and adverse drug reactions in risk management platform. check off label use of drugs. results: of a total of interventions, relate to revenue optimization and relate to clinical interventions. there was an increase of approximately % in billing. on what regards to clinical interventions, the majority of them showed deviations from good clinical practice. the physical presence of a clinical pharmacist in the surgical block is essential as the prescription and administration of drugs is carried out simultaneously, allowing immediate therapy validation, in order to increase the safety and efficacy. the pharmacist has the ability to interact with the multidisciplinary team, as well as monitoring the patient's clinical process, the pharmacotherapeutic profile and drug allergies, allowing the detection of any adverse drug reaction on-time. all these interventions are possible in the pre, intra and postoperative phases. results: counselling (av.(±sd) duration: ± min) was performed in patients ( . % female; av.(±sd) age: . (± ) years; av.(±sd) medicines at discharge: . (± . )). in % of patients mrps were intercepted. the five most common mrps (%) were: need for organisational support ( . , e.g. proper prescriptions' writing), therapy-related discussions ( . ), untreated indications ( . ), errors in documentation ( . ), and medicines without an indication ( . ). patients ( . %) classified for study inclusion, of whom ( . %) consented to be followed-up and ( %) provided data. roughly % of patients report having received information about medicines at discharge, of which three-fourths remember being informed by the pharmacist. more then every second patient ( . %) reported having received valuable new information. changes in chronic-use medicines occurred in . , . , and . % of patients at -, -, and -month, respectively. at -month, in . % of patients chronic-use medicines were newly prescribed, in . % discontinued. medical specialists initiated these changes in . % of patients. one out of five patients couldn't recall the reasons for changes in medication. nearly % of patients showed moderate to little medication adherence at -month. it did not significantly change during the follow-up period. conclusion: clinical pharmacists' counselling prevents mrps at the transition from hospital to home. follow-up data show that changes occur in one out of three patients. medication adherence remains stable, but generally needs to be improved. please specify your abstract type: research abstract background and objective: until , prescription analysis was based in our hospital pharmacy. clinical pharmacy has been deployed in care units since . many clinical pharmacy services were developed: medication reconciliation, patient's therapeutic education and counselling, and prescription analysis unit based. the purpose of this study is to assess the impact of the clinical pharmacist as a direct patient-care team member on prescription analysis. setting and method: we collected pharmaceutical interventions (pis) of the first months of and at the same period of the year in the neurology unit when the pharmacist was unit based. we studied and compared type of pis (medication, drug related problem-drp), rate of pis acceptance and clinical impact. focus was made on high alert risk medications and potentially inappropriate medications. . % in versus none in . when prescription analysis was based in the pharmacy unit, % of drp detected by the pharmacist had a potential clinical impact versus % when the pharmacist performed prescription analysis in the care unit (p \ . ). three drp detected in had serious potential harm. results: ward-based prescription analysis allowed detecting five more times drp with a significant more important clinical impact than pharmacy unit based prescription analysis. the clinical pharmacist as a direct patient-care team member is more efficient in detecting serious potential harm. indeed, the pharmacist has a greater knowledge of the patient's clinical condition. nevertheless the global rate of acceptance of pis was greater when the prescription analysis was based in the pharmacy unit even if the difference is not significant. but prescription analysis is more complex when performed in the care unit, taking account adherence of the patient, and potentially inappropriate medications resulting in much higher risk-taking by the ward-based pharmacist. conclusion: this study showed that unit based prescription analysis is the best way to detect drug related problem. it must be competed by medication reconciliation and medication review to improve medication safety process. hp-pc : qt-prolongation in an acute psychiatric setting: fact or fiction? eva jacxsens *, , hans van den ameele , jü rgen de fruyt , yves vandekerckhove , frank vancoillie , veerle grootaert pharmacy, psychiatry, cardiology, az sint-jan brugge-oostende av, bruges, belgium please specify your abstract type: research abstract background and objective: several psychotropic drugs can induce qt-prolongation, which is a well-known risk factor for developing torsade de pointes (tdp) and sudden death. the clinical relevance of this side effect of psychotropic medication remains unclear, especially in patients hospitalized in an acute hospital. to interpret the clinical importance of psychotropic drug induced qt-prolongation, we investigated the prevalence of these electrocardiographic changes. setting and method: a prospective study was conducted on four psychiatric wards in a general hospital: two acute, short-term psychiatric units (asp and asp ), one addiction service unit (asu) and one geriatric-psychiatric ward (gpw). all adult patients admitted between october st and march th on a psychiatric ward were eligible for inclusion. at admission, an ecg (ecg ) was performed and creatinine and potassium levels were measured. a second ecg (ecg ) was performed at least days after the start of a psychotropic drug associated with a risk of qt-prolongation. qtcprolongation was defined as ms for males and ms for females. clinically relevant qtc-prolongation was defined as c ms. statistical analysis (r software) was done as appropriate. main outcome measures: prevalence of psychotropic drug induced qtc-changes and correlating factors. results: patients (mean age years, %female) were enrolled in the analysis. in patients, an ecg was performed. qtc + were prolonged in . %( / ) of females and . %( / ) of males. no clinical relevant prolongation (c ms) was registered. higher qtc intervals were measured in the geriatric population. . %( / ) of all measured qtc were situated between [ c qtc + b ms] in gpw versus . %( / ) in the other units. significant difference in qtc-changes was associated with sex (p = . ). there was no correlation assessed between qtc-prolongation and age, number of psychotropic drugs or a specific single psychotropic drug (p [ . ). conclusion: in this study qtc-prolongation due to psychotropic drugs is less common than previously described. ecg monitoring may be unnecessary in the follow up of patients without risk factors and could reduce hospital and community costs. however, considering the potential harm associated with tdp, qt-prolongation should be avoided. we recommend recording an ecg before the start of a qt-prolonging psychotropic drug in risk patients: patients with a chronic alcohol or drug addiction, a cardiac history, on concomitant therapy with at least two qt-prolonging psychotropic drugs, or geriatric patients ([ years). hp-pc : implementation of medication reconciliation aase m. raddum *, , anne-lise sagen major sykehusapotekene i midt-norge, sjukehusapoteket i Å lesund, avd. volda sjukehus, volda, sykehusapotekene i midt-norge, sjukehusapoteket i Å lesund, Å lesund, norway please specify your abstract type: descriptive abstract (for projects) background and objective: a correct and accurate medication list should accompany patients at transitions in care from one setting to another, including admission to hospital. complete information on drug use is a prerequisite for all hospital treatment, whereas incomplete information represents a potential patient safety risk. medication reconciliation is defined by the world health organization (who) as ''…the formal process in which health care professionals partner with patients to ensure accurate and complete medication information transfer at interfaces of care.'' the objective of this study was to investigate the quality of the medication history obtained for admitted patients. furthermore, measures to improve the quality of medication histories, i.e. implementation of medication reconciliation, were initiated. design: the study included patients admitted to the internal medicine ward. a comprehensive medication history was determined by performing a standardized patient interview and/or by using relevant sources of information. the primary endpoint was discrepancies between the medication history obtained on admission and the one determined prospectively by a clinical pharmacist. the clinical relevance of the discrepancies was not determined, but sorted according to six major categories, such as: medication not in chart, but patient reports using (omission) and medication in chart, but patient reports not using (commission). further on, in order to minimize the risk of discrepancies, it was focused on implementation of medication reconciliation. a campaign was initiated, where a clinical pharmacist held information meetings regarding the medication reconciliation procedure. for the next weeks, the degree of medication reconciliation was recorded. to spur the degree of medication reconciliation, each ward's weekly numbers were published and the ward with the highest degree of medication reconciliation won a prize. results: among the patients included, a total of discrepancies were revealed. in summary, patients had at least one discrepancy in their medication history, resulting in discrepancies in the medication lists of % of the included patients. at the start of the study, the level of medication reconciliation varied among the wards ( - %), while at the end of the study the levels were increased ( - %). conclusion: all the included wards improved their level of medication reconciliation during the study period. however, these new combinations have potential drug-drug and herb-drug interactions which can affect the safety and effectiveness of the treatment. in our clinical practice, the clinical pharmacist provides patient education about direct acting antiviral drugs (daa) based-regimens, promotes medication adherence and manages potential interactions with hcv treatment. the aim of the present study was to determine the prevalence of use of herbal products in the patients on hcv treatment, and to describe the potential hepatotoxicity of the herbal products and their interactions with hcv treatment. design: we included all adult patients on daa treatment for hcv who were dispensed drugs from / / to / / . we retrospectively recorded demographic data (age and gender), clinical data related to hcv infection (hcv genotype, fibrosis stage, daa regimen and treatment outcomes) and type of herbal products consumed. we then assessed the presence of herb-drug interactions and the potential hepatotoxicity of herbal products. results: we obtained data from patients on daa-based treatment for hcv. the prevalence of consumption of herbal products prior to starting the treatment was . % ( / ). the most consumed herbal products were (prevalence [ % among herbal products users): milk thistle, green tea, chamomile, valerian, pennyroyal, boldo and artichoke. we detected four herbal products with potential hepatotoxic effects according to the literature: milk thistle, green tea, pennyroyal and aloe vera. the prevalence of consumption of these hepatotoxic plants among herbal products consumers were, respectively: . , . , . and . %. we detected herb-drug interactions or potential for hepatotoxicity in out of patients who consumed herbal products. the management of these potential interactions consisted of stopping the herbal product before starting the hcv treatment. conclusion: the consumption of herbal products in our hcv patients was frequent. the management of potential interactions was conservative, recommending to stop herbal products. clinical pharmacists have an important role in the counselling, detection and management of potential herb-drug interactions and herbal products-related hepatotoxicity. poster discussion forum iii: hospital pharmacy and pharmaceutical care please specify your abstract type: research abstract background and objective: anaemia is a common comorbidity of chronic kidney disease. intravenous (iv) iron is used when oral iron formulation became insufficient or to reduce the use of erythropoiesis-stimulating agents (esas) in haemodialysis (hd) patients. the lack of generic group for iv iron sucrose (is) preparations leads to a controversial issue about their clinical effectiveness. in this study, we evaluated the effectiveness of original is compared to is similar (iss) in hd patients. setting and method: a retrospective monocentric observational cohort study was conducted from / / to / / , in a stable hd population to compare is and iss. the follow-up periods lasted weeks and were separated by a one-month wash-out period. original is and iss were administered respectively during the first (p ) and the second (p ) periods. the comparisons were performed using the paired student's t test or the paired wilcoxon test for continuous data and the fisher's exact test for categorical data. main outcome measures: the main endpoint was the difference in haemoglobin (hb) levels between p and p per patient. anaemia parameters (serum iron, serum ferritin, transferrin saturation ratio), the number of transfused patients, the doses of iv is and the doses of erythropoiesis stimulating agents (esas) were compared before and after the switch from is to iss, as secondary endpoints. results: a total of patients were included. there was no significant difference in mean hb value between p and p ( . ± . mmol/l versus . ± . mmol/l p = . ). anaemia parameters were significantly different between p and p (mean serum ferritin, serum transferrin and transferrin saturation ratio) with p \ . , except to the mean serum iron. the mean monthly dose of iv iron per patient and the mean dose of esas were respectively in p and in p : . ± . mg versus . ± . mg (p = . ) and . ± . ui/kg/week versus . ± . ui/kg/ week (p = . ). transfusions occurred less frequently in p than in p (p = . ). conclusion: this study showed that iss was as effective as original is regarding hb levels. however anaemia parameters appeared to be in favour of is; the mean dose of esas seemed to be higher after switching from is to iss. these outcomes should be further explored using prospective comparative clinical studies. please specify your abstract type: research abstract background and objective: the pharmacy residents are sometimes up to deliver chemotherapy when they are on night or week-end duty at the hospital. a dispensation's error (delivery of metoject Ò (methotrexate) for intrathecal (it) injection whereas it doesn't have the indication for this use), led us to test the pharmacy residents' knowledges about the it access in order to underscore the points to be improved. the final aim of this work is to secure the pharmaceutical care of the patient h a day, days a week. setting and method: an online and anonymous survey of questions was sent to the residents of our area. it was composed of three parts: specific general information, questions about the chemotherapy specifically (indication, maximum dose and volumes, molecules used), illustrated questions about real situation for the dispensation on duty. the answers were collected over a two weeks period. main outcome measures: we studied the rate of good answers in global and by respondent. results: twenty-five residents answered the survey, among them % never achieved any internship in a centralized unit of reconstitution of chemotherapy (urc). all the levels of internship are represented: st year (n = ), nd year (n = ), rd year (n = ) and th year (n = ). only % know where a medicine is injected intrathecally on the spinal column, % know on which level of the meninges. three residents think that a nurse can inject intrathecally. they also had to select the molecules which can be injected by this access: % answered vincristine, % vinblastine, % bortezomib; despite these three molecules are mortals if they are injected intrathecally. the majority know the indication of the it chemotherapy: prevention and treatment of cancers' meningeal localizations. sixty percent do not know that several molecules can be injected for the same patient in the same time. the maximum dose of methotrexate is known for half of the respondents, but only % for the cytarabine'one. only residents out of know that ml is the maximum volume allowed to be injected for an adult. six residents would have delivered metoject Ò mg in pre syringe filled if a doctor had asked for an it during a night. lastly, there are only two people who know that aracytine Ò (cytarabine) mg must be reconstituted with sodium chloride for it use and not with the provided solvent containing benzylic alcohol. the score of the residents having already done an internship in an urc is . / compared with . / for those who never did. the respective scores per year of internship are . ( st year), . ( nd year), . ( rd year) and . ( th year). conclusion: results and answers have been presented in a meeting and sent to the residents. we initially note many gaps in knowledge. the residents who already worked in an urc and the elders got better results. all the residents could be on duty at the hospital and all must be formed. a second session will be organized in a month to evaluate the formation's impact. it also has been presented to the assistants during an interactive lesson. this formation is essential to guarantee the dispensation of the adequate product and a secured medical care of the patient. please specify your abstract type: descriptive abstract (for projects) background and objective: patient adherence to prescribed medications is crucial for reaching metabolic control goal. to better understand the impact of polypharmacy on medication adherence, we undertook a detailed survey of medication use among patients with endocrinologic diseases. the aim of this study was to determine medication adherence in a cohort of patients with endocrinologic diseases and to test the hypothesis that adherence decreases with increased number of medicines prescribed. design: we conducted structured interviews to determine self-reported adherence of patient on a scale of (high) to (low observance) (srap- ) and a measurement using morisky medication adherence scales . demographic and medication information were collected from medical record. for statistical analysis, mann-whiney u-test for continuous variables, with chi square for categorical variables and kendall test for correlation were used. results: our cohort included patients, % were women and % were diabetic ( % suffering from type diabetes). the mean age was ± years, the average number of medication was . ± . . ( %) patients were not able to estimate their adherence. patients reported srap- scale with an average of . ± . , this estimation was significantly higher than mmas- with an average of . ± . (p \ . ). the proportion of adherence level were identical between srap- and mmas- with respectively and % of high, and % of medium and and % of low adherence. a significand correlation between srap- and mmas- scales (r = . , p \ . ) was found. however no correlation between adherence scale and number of treatment (r = . for mmas- and . for srap- scale) nor number of daily doses (r = . for mmas- and . for srap- scale). on the medications, % presented difficulties with observance. cardiovascular ( . %), diabetes ( . %) and psychiatric ( . %) treatment are the three most involved drug classes in nonadherence. conclusion: in this cohort, patients reported high medication adherence. we highlighted a correlation between srap- and mmas- scales. surprisingly, we didn't find correlation between adherence scales and number of treatment or dose by day. the next step of this work will be the identification of risk factor of nonadherence using logistic regression analysis. hp-pc : the office of access to healthcare: how to optimize secured access to treatments? claire chatron, adeline flatres, claudine hecquard, guillaume saint-lorant * , alexandra muzard pharmacy, chu caen, caen, france please specify your abstract type: research abstract background and objective: office of access to healthcare (oah) is an organization which offers a medical and social coverage to people who can't access to care and to medication because of the absence of social welfare, living conditions, or financial difficulties. medications are free dispensed thanks to retrocession activity in hospitals pharmacies. the aim of this study is to analyse this activity and to improve communication with patients and access to treatments by an adapted pharmaceutical interview. setting and method: this study includes all dispensations of year . in order to get medications in our hospital, a social worker and the patient come at the hospital's pharmacy. one people of retrocession team (four assistants, two externs, two residents and two pharmacists) dispenses necessary drugs to the patient according to hospital drug formulary and operating protocol. a switch or a special order can be purposed if the drug is not available. then, we give the patient a medication management plan (mmp) to explain him how to take his treatment at home. retrocession team filled a quiz about this activity and ways to improve it. main outcome measures: the main topics included in the quiz and evaluated were: dispensation organization, english talking, feeling during the interview and evaluation of the mmp. results: three hundreds and ten patients were admitted in oah . these patients come mainly from the eastern europe and do not speak french in most of cases. social workers, who can help for communication, are not always present because these patients can come during on-call duty. quiz results showed that weak points occurred during the interview: explanation of the mmp, languages barriers, mention '' if needed '' not understood by the patient. explanation of the order for a particular drug was difficult to operate too. mmp were only drafted in french which was not convenient for foreign people. however, modalities of dispensation were well understood by the retrocession team. following quiz results, mmp was translated into english by the retrocession team. mentions '' if needed '', '' number of maximum tablet a day: … '', ''your medication is in order, thank you for coming to look for this treatment back to the hospital on … '', '' … is the same as …, prescribed by your doctor on your medication list '' have been added and translated. results of the study and new mmp will be presented to the pharmaceutical team and to social workers in staff. an index card for ''communication in english with a patient'' has also been drafted. it contains sentences meadow drafted in english. conclusion: access quality health care service is important to achieve health equity and to increase the quality of everyone's life. these documents improve communication with patients and by the way their understanding about their treatment. the use and the impact of these documents on well understanding will be soon evaluated with social workers and patients. hp-pc : improve the medication in an associated to general hospital nursing home luisa alonso * , marta vidal iglesias, lucia gómez carrasco, guillermo goda, laura garcia, laura marin, ana hernandez, alvaro moreno please specify your abstract type: descriptive abstract (for projects) background and objective: in order to improve the medication reconciliation and to implement training programs for the medical team in an associated to general hospital nursing (asnh) home we measured the discrepancies between pharmacy registered treatments (prt) and medical prescriptions (mp), and we analysed potentially inappropriate prescriptions according to ''american geriatrics society beers criteria'' and ''stopp-start criteria. design: retrospective observational study that included patients admitted in the asnh. the ''consensus document on terminology and classification in medication reconciliation'' was considered for discrepancy classification. data collected: discrepancies between mp and prt. in patients from the original group of , we reviewed potentially severe drug interactions, potentially inappropriate mp and drug classes to avoid in older adults and medications to be used with caution in older adults (according to stopp-start and beers ) . all data were registered, measured and analysed in excel Ò . results: patients and a total of mp were reviewed. discrepancies ( . %) were found between the medical order and the prt, those discrepancies included errors of omission in prt ( . %), absence of discontinuation of medication ( . %), incorrect dosage ( . %). potentially moderate to severe interactions: the most frequent drug groups were proton pump inhibitors (ppis) ( . %), benzodiazepines (bzds) ( . %), oral hypoglycemiants ( . %), other groups with frequency over %, oral antihistaminic, statines, low molecular weight heparine (lmwh), laxatives, calcium salts and iron salts. stopp criteria were identified that affected to mp and the distribution was as follows: laxative combinations ( . %), long term ppis ( . %), cns depressants combinations ( . %), long half life bzds combinations ( . %), aspirin incorrect drug strength ( . %) and other groups with lower frequencies, nsaids and prokinetics. start criteria: being all of them by omission of the drug at the time of admission. beers criteria: prescriptions in the ''avoid prescription in adults'' group of which corresponded largely to concomitantly cns depressants and long term use of ppis in no risk patients. conclusion: the difficult working conditions, the excessive workload and the high staff turnover, where doctors have a patient ratio over / , make difficult to update treatments according to patient daily needs. a clear communication problem between the hospital pharmacy and the asnh prescribers exists due to lack of infrastructures, and it has been demonstrated with the high percentage of discrepancy, that implies an important logistic problem (not a safety problem) since the nurse team works directly with the original medical orders. the analysis of prescriptions showed the need for updating the medical knowledge. the high volume of stop and beers criteria and lack of doctors time made impossible the individual acting upon each patient, so short summaries of continuous training related to most frequent problems have been designed. please specify your abstract type: descriptive abstract (for projects) background and objective: our french university hospital is one of the most active centre for liver transplant ( transplants annually). various professionals are involved in the graft patient care and education. much information and education sessions are exempted before and after the transplant. the objective of this work was to realize a short movie for patients ( ) to get them ready for transplant ( ) to give the key messages to support their transplant ( ) to make family understanding the process and to promote the life behaviour changes. design: three members of the pharmaceutical team with nurses-led care coordination and a surgeon wrote the scenario. we requested two directors for days of shooting. we defined the key points for the patient and places to film, and fixed the duration ( - min). the scenario was validated by the chief of the liver transplant unit and nurses-led care coordination. after the days of film shooting, we selected sequences. results: the movie was a succession of six parts. ( ) the movie has been burned onto cds, put on flash-drives and will be uploaded on the internet. because of the international origin of our patients, the video will be subtitled at least in english. the video will be broadcast to hospitals which do not transplant patients and refer them to our hospital. since the medical team was involved in a collaborative project, the making of the video has permitted to strengthen the cohesion. indeed, this work would not succeed if everybody did not express himself. patients understood the interest to testify about their lived experience with the liver transplant, because they wished to have such information when they were waiting for the graft. conclusion: this movie is very useful for patients and families who are looking for information before and after liver transplant. it is a tool to get them into condition patients. this video presents the advantage of being personalized (local and caregivers that the patient will encounter are filmed). furthermore, it maintains a dynamic involvement of the pharmacy (already well established with clinical pharmacy, patient education and medication reconciliation) in the liver transplant unit. the making of the film has been an opportunity to bind the members of the team together, by valuing the work of everyone. the film could be screened if this abstract is selected for an oral communication. please specify your abstract type: descriptive abstract (for projects) background and objective: numerous procedures on medication management at oslo university hospital aim to minimize the risk of medication-related errors. error reports and observations show great variation in the use of these procedures, primarily due to difficulties in their implementation and maintenance. our aim was to assess the effect of a novel teaching strategy, the impala project, on doctors and nurses compliance with the medication management procedures. design: the project was carried out at general medicine wards at oslo university hospital for a period of weeks at each ward. assessment of medication-related error reports yielded the following areas of focus: (i) correct medication prescription, (ii) specification of doses for medications given on an ''as required''-basis, (iii) double control of medication dosing, (iv) correct and documented generic substitution. weekly presentations by pharmacist(s), lasting for a maximum of min, were given to doctors and nurses as part of daily ward routines. this was repeated over weeks. data on medicationmanagement procedure compliance were recorded before the start of the intervention, during and after each intervention period. the results were presented and made available to both leaders and employees throughout the project period both as an incentive to improvement and as a motivation factor for continued effort. results: there was a marked increase in medication-management procedure compliance among the nurses, especially after the second week of intervention. the most marked increase was shown for double control. increase in medication-management procedure compliance was also present among the doctors, but was less prominent. the data presented gave an extra motivational kick according to the participants. the leaders and the employees stated that the impala strategy was easy to follow and gave results without much organizational effort. conclusion: fifteen minutes presentations given by a pharmacist(s) as part of daily ward routines, combined with presentation of results demonstrated considerable improvement in medication-management procedure compliance. please specify your abstract type: research abstract background and objective: high unexpected serum vancomycin concentrations (svcs) were observed in patients without impaired renal function during the therapeutic drug monitoring (tdm) in our pharmacokinetic service. the aim of this study was to analyse the evolution of the svcs and its relationship with the markers of renal function. setting and method: retrospective study conducted at a university hospital with a follow-up period of months. only adult patients having at least two tdm were selected. trough svcs were measured by cmia (architect i- analyser, abbott Ò ) and fitted to a two-compartment model by using bayesian analysis (pks Ò , abbott). clinical and demographic data and daily dose, as well as timings of vancomycin administration and of blood sample collection were accurately recorded. spss Ò , version . was used to compare data from both tdm by student t-test (parametric data) and wilcoxon (nonparametric data). main outcome measures: concentration-to-dose ratio (cdr: trough concentration * /daily dose); glomerular filtration rates (gfr) estimated by cockroft-gault formula; measured and predicted svcs levels. results: adult patients were included (females: %); median age [ - ] years).the first and the second tdm were carried out after . [ . - . ] and [ . - . ] days from the beginning of the treatment, respectively. in the first tdm, no difference was found between the measured concentrations ( . ( . ) lg/ml) and those predicted ( . ( . ) mg/l. however, predictions were less accurate in the second tdm and predicted concentrations were significantly higher svcs ( . ( . ) mg/l vs. . ( . ) mg/ml, p \ . ). the median cdr in the second tdm was significantly higher than that calculated in the first one ( . [ . - . ] l - vs. . [ . - . ] l- ; p \ . ), indicating a lower clearance and a drug accumulation. however, no statistically significant differences in the glomerular filtration rates were found ( [ - ] ml/min vs. ml/min) in the first and second tdm, respectively. conclusion: although the markers of renal function did not change during the treatment, a decrease in vancomycin clearance was observed. the pharmacokinetic model does not accurately predict evolution of the svcs over the treatment. the introduction of covariates such as the length of treatment or the cumulative dose in the pharmacokinetic model could improve its predictive performance. please specify your abstract type: descriptive abstract (for projects) background and objective: genetic polymorphism or major physiological changes have to be considered in patient therapeutic management. clinical pharmacists have a role to evaluate and optimize the appropriateness and effectiveness of patient's medications. we report here the impact of the clinical pharmacist and his collaboration with the clinical pharmacologist in the therapeutic management of a patient suffered from anorexia nervosa, a psychiatric disorder leading to body composition change that may influence drug pharmacokinetics and efficacy. design: case report. results: the patient was a -year old woman hospitalized for chronic pulmonary aspergillosis previously treated by voriconazole, posaconazole and itraconazole. her medical history included anorexia nervosa since with a body mass index of . kg m - , pulmonary tuberculosis in with relapse in , and chronic pulmonary aspergillosis since . at admission, a treatment by oral voriconazole at mg/ h was introduced. the trough concentration of voriconazole at steady state was . mg/l (therapeutic range - mg/l) despite taking drug on empty stomach. although the voriconazole dosage increased in mg/ h, the trough concentration did not increase significantly ( . mg/l). we hypothesized anorexia led to a significant mucosal atrophy and accordingly, a significant decrease in intestinal absorption surface which is a major determinant of the level of drug absorbed. thus, a switch from oral to intravenous route was performed (voriconazole mg/ h). according to subtherapeutic voriconazole concentrations (trough concentration: . mg/l) despite the use of intravenous route, we decided to perform genotyping to look for mutations of cytochromes p a * , c * and c * , particularly implicated in voriconazole metabolism. the presence of an ultrarapid metabolizer genotype ( * allelic variant of the c isoenzyme) in our patient should lead to increase drug dosage from to %. finally, the patient was treated by intravenous voriconazole at mg/kg/ h (i.e., increase by %). the maximum concentration performed h after iv route initiation was at . mg/l, suggesting a better efficacy. conclusion: this case report highlights the potential complexity of therapeutic management in some patients given anatomical and functional changes or genetic polymorphism, which can affect drug efficacy. clinical pharmacists in collaboration with clinical pharmacologists have to be able to help physicians in this type of situations. please specify your abstract type: research abstract background and objective: posaconazole (pcz) is widely used for invasive fungal infections as prophylactic, pre-emptive or curative therapy in lung transplantation. recently, a new formulation of pcz has been available in enteric-coated tablets. this new formulation improves pcz bioavailability, as compared to the oral suspension, which leads to increase pcz plasma trough concentrations (c min ) in haematological patients. no data related to pcz exposure and its effects on tacrolimus (tac), an immunosuppressant with narrow therapeutic index widely used, exists in lung transplantation. we aimed to assess the consequences of the treatment by pcz entericcoated tablets on pcz and tac exposure in lung transplant patients. setting and method: a single-centre retrospective study was conducted among lung transplant patients receiving tac and either enteric-coated pcz or both galenic forms. main outcome measures: pcz and tac exposure were estimated by the measurement of c min . to overcome the influence of dose (d), c min were adjusted on dose (c min /d) for both pcz and tac. a spearman test (nonparametric distribution) was performed to assess the correlation between pcz c min /d and tac c min /d. results: eighteen lung transplant patients (median age [q ; q ] = . [ . ; . ] years; % female) were included between june and march . eight patients received only pcz entericcoated tablets. pcz enteric-coated tablets were associated to an increase in pcz c min /d as compared to oral suspension ( . ± . l - vs. . ± . l - , p \ . ). overall, pcz therapy initiation led to an increase in tac c min /d ( . ± . l - before initiation vs. . ± . l - after initiation, p = . ). tac c min /d was significantly higher with pcz enteric-coated tablets, as compared to pcz oral suspension ( . ± . l - vs. . ± . l - , p \ . ). a weak correlation was observed between pcz c min /d and tac c min /d, independently to pcz galenic form (r = . , p = . with pcz enteric-coated tablets and r = . , p = . with pcz oral suspension). conclusion: this pilot study in lung transplantation confirms the better bioavailability of pcz enteric-coated tablets as compared to oral suspension. our results show a more important increase in tac exposure with pcz enteric-coated tablets compared to pcz oral suspension, suggesting a concentration-dependent cyp a inhibitor effect of pcz. these findings are of interest in clinical practice to monitor transplant patients treated by the new formulation of pcz. further analyses, including the consideration of confounders, will be conducted. please specify your abstract type: descriptive abstract (for projects) background and objective: within months, two patients receiving apixaban developed agranulocytosis. based on temporal and clinical plausibility as well as published literature, the objective was to determine the causal relationship between agranulocytosis and apixaban. design: description of two agranulocytosis cases reported in our hospital. results: first case is an years old male, admitted to the neurology unit (d ) for ischemic stroke. at admission, blood count showed no abnormalities. four days after admission, treatment administered consisted in: dextrose % infusion iv, sodic heparin iv, acetaminophen, atorvastatin, metoprolol. neutrophils count was normal ( . g/l). heparin was stopped at d and replaced with apixaban according to following dose regimen . mg twice a day. at d , patient presented with hyperleukocytosis (neutrophils count g/l) and high crp ( mg/l). thus, a cytobacteriological urine test was performed. at d , patient presented with hypothermia followed by hyperthermia related to acute sepsis. blood count showed agranulocytosis (neutrophils count . g/l). broad spectrum antibiotherapy was started (ceftriaxone and gentamycin). despite treatment, death of patient occurred at d . the suspected cause of death was septic shock added to severe febrile neutropenia. following haemocultures confirmed sepsis (e. coli) possibly originating from urinary tract infection. second patient is a years old male, admitted to the cardiology unit (d ) for bronchopneumopathy associated with tachycardia and atrial fibrillation. a treatment with heparin was immediately started in association with patient usual treatment (bisoprolol, valsartan, rosuvastatin, hydrochlorothiazide and manidipine). in addition, broad spectrum iv antibiotherapy was started with ceftriaxone and spiramycine followed at d by an oral treatment with cefixime and spiramycine until d . heparin was replaced by apixaban at d ( . mg twice daily). antihypertensive treatment was adapted throughout patient's stay. patient presented neutropenia at d (neutrophils count . g/l), followed by agranulocytosis at d (neutrophils count . g/l) when it was decided to replace treatment with apixaban by fluindione. the following day, neutrophils count was about . g/l and patient received filgrastim. a myelogram showed a possible peripheral neutropenia. in the absence of other confounding factors (hiv, hbv, hcv, cmv), an iatrogenic agranulocytosis related to apixaban was suspected. conclusion: causal association with heparin is unlikely as neutropenia is not an adverse drug reaction known included in the smpc of this drug having a well-established safety profile. since the two patients were taking their usual treatment for a significant period of time, a causal relationship is deemed unlikely. temporal and clinical plausibility seem to indicate a possible relationship between agranulocytosis and apixaban. as this medicine has been recently approved, this might explain why no case has been reported in the literature and the absence of agranulocytosis as an adverse drug reaction of apixaban. please specify your abstract type: research abstract background and objective: taste is tightly connected to children's acceptability of medicines. two ways to overcome lack of acceptability are to administer solid formulations which are easier to taste mask and change to better tasting medicines. dicloxacillin is an antibiotic known for its unpalatability, and taste studies suggest that this might jeopardize its adherence. the aim of this study was to explore if prescription data can be used to estimate acceptability of antibiotics among children on a population level using dicloxacillin as an example drug. the research questions were: when comparing dicloxacillin with other antibiotics commonly used in children, ( ) is there a difference in the age of conversion from liquid to solid formulation and ( ) is there a difference in re-prescription rates on day and after the initial prescription? setting and method: we included all initial prescriptions of oral dicloxacillin, phenoxymethylpenicillin, amoxicillin and erythromycin for children - years registered in the norwegian prescription database (norpd) - due to dicloxacillin mixture being discontinued from the norwegian market in . the age of conversion was defined as the age where half of the children were prescribed liquids and the other half prescribed solid formulations. re-prescription rates were defined as re-prescriptions of a different antibiotic or formulation on day and after the initial prescription, divided by the total number of prescriptions. main outcome measures: age of conversion and re-prescription rates of dicloxacillin compared with other common antibiotics. results: the age of conversion for dicloxacillin was . years, compared to years for other common antibiotics. the average represcription rate for dicloxacillin was . % for children - years and . % % for children - years. the highest re-prescription rate of . % was found in -year olds. corresponding numbers were . , . and . % for common antibiotics. conclusion: the lower age of conversion from liquid to solid formulation and higher re-prescription rate of dicloxacillin mixture compared to common antibiotics indicates that prescription data can be used to identify antibiotics with low acceptability for children - years. further studies are needed to investigate if this also holds true for other antibiotics. please specify your abstract type: research abstract background and objective: attention deficit/hyperactivity disorder (adhd) or hyperkinetic disorders (hkf) is among the most common mental disorders in children, and may persist through adolescence into adulthood. pharmacotherapy used for treating the disorders also has potential for misuse/abuse. the aim was to describe the prevalence and magnitude of use of stimulant drugs and atomoxetine, and compare consumption in the nordic countries. setting and method: a descriptive pharmacoepidemiological study from the * million inhabitants of the five nordic countries in the period - . data were collected from national prescription registers, public drug reports and by correspondence with public health institutions. population data were obtained from official statistical databases or by correspondence with public health institutions. main outcome measures: trend over time, comparison between countries, type of pharmaceutical, gender, age, comparability of data. results: the annual consumption has been increasing from to , both in volume and prevalence of use. denmark had the largest increase in volume, from . to . ddd/ inhabitants/day. sweden had the highest increase in prevalence of use over the period, from . to . users/ inhabitants. iceland had the largest consumption of adhd medications in , . ddd/ inhabitants/day. prevalence data was not available for iceland but sweden was highest in prevalence of use among the other countries in : . users/ inhabitants. males aged - years had the largest volume and prevalence of use in , but females' consumption had been increasing faster both in terms of numbers of users (* . faster) and in volume (* faster) than men's consumption. conclusion: variation in consumption is considerable and cannot be explained by diagnostic and prescription guidelines, as these are similar in the five countries. consumption has been increasing fast in the period in all the countries, and faster for women than for men, although men still consume larger volumes than women, and are more frequent users. please specify your abstract type: research abstract background and objective: in and , regulatory bodies in usa (fda) and europe (ema), issued warnings on use of metoclopramide due to an increased risk for serious adverse drug reactions (adr), especially neurological adrs. ema recommended that metoclopramide only should be prescribed for up to days while fda concluded that treatment longer than weeks should be avoided. metoclopramide is commonly used to treat nausea and vomiting in pregnancy (nvp) and deficient breast milk production ( days course). ema did not make any recommendations concerning use during pregnancy and lactation. the objective of this study is to assess the disproportionality of reporting of adr from metoclopramide, with special emphasis on neurological adrs and women in reproductive age. setting and method: data from whos global adr database vigibase Ò for the time period november to may was used. the measure of disproportionality of reporting calculated was the proportional reporting ratio (prr), and % confidence intervals (ci). analyses were performed according to gender and age. time-toonset of adr was calculated. main outcome measures: proportional reporting ratio (prr) results: vigibase contains over million adr reports. metoclopramide is a suspected/interacting drug in of the reports, most common ( %) are neurological adrs. the majority ( %) of the metoclopramide adrs occurred within the first days of use. a total of % of the reports was received the last years ( ) ( ) ( ) ( ) ( ) . the reporting of neurological adrs was higher for metoclopramide than other medications in vigibase. women in reproductive age ( - years) reported higher proportion of neurological adrs (prr = . , % ci . - . , n = ) than women + years (prr = . , % ci . - . , n = ) but a similar proportion as men - years (prr = . , % ci . - . , n = ). conclusion: there is a . to three fold higher proportion of all reports regarding neurological adrs for metoclopramide than for other drugs. patients initiating treatment with metoclopramide should be informed about risks of adrs and that most adrs occur within days, and instructed to contact health care personnel and stop treatment if adrs occur. please specify your abstract type: descriptive abstract (for projects) background and objective: self-induced drug intoxications (sidi) are one of the most frequent reasons of hospitalization in emergency service ( %) with around - / inhabitants and represent around % of admissions in intensive care unit (icu). it is the most frequently used method of suicide attempts (sa) and the leading cause of hospitalization for young people under . the main objective of our study was to analyse, stratify and pharmaceutically map the different sidi identified in our icu. design: this is a prospective study over months, including all icu patients following sidi from june to january . we have collected psychiatric history and previous sa by sidi, usual treatment, state of consciousness, incriminating drugs, drug classes stratified according to the clinical severity score igsii, evolution, transfer in a specialized centre and average cost of stay. results: ninety-two cases were reported, representing % of icu admissions. the average hospital stay was days for an average cost of . €. this amount is low compared with the average cost of all stays gone through the icu for the period ( , €). ninety percent of patients had a psychiatric history and % a previous sa. the usual treatment was involved in % of sidi. half of the patients arrived conscious with an average of severity score igsii of / , being the highest found for a patient who had swallowed simultaneously pregabalin and nitrazepam. clinical severity of these patients is less than that found on average for all patients in the icu in this period ( / ). eighty-seven percent had a favorable evolution. only one death was observed after ingestion of propranolol. fifty-six and a half percent of patients were then hospitalized in a specialized centre. the great family of psychotropic is the most frequent with benzodiazepines %, neuroleptics %, antidepressants . % and antiepileptic . %. the main drugs involved are oxazepam %, alprazolam %, cyamemazine %, bromazepam % and quetiapine %. antihypertensives then arrive and represent % of sidi. the stratification of severity scores does not appear to show significant differences between drug classes, nor between mono or polydrug ingestions. conclusion: sa by drug ingestion are very common and are often linked to risky behaviours. for these epidemiological and economic findings, it is necessary to continue and develop prevention strategies avoiding the appearance of intoxication (primary), limiting the consequences (secondary), and reducing the risk of recurrence (tertiary). please specify your abstract type: research abstract background and objective: interpretation of quality of life scores to render them meaningful to aid clinical decision-making is an ongoing challenge. interventions often result in statistically significant quality of life (qol) improvement, but may not reach the threshold of clinical importance. the minimal clinically important difference (mcid) is the minimal score change of relevance clinically. the aim of this systematic review was to assess the impact on quality of life of topical, systemic and biologic treatments for psoriasis in randomised controlled trials (rcts). setting and method: prisma guidelines were followed. all available articles describing rcts of therapies for psoriasis that included qol measurements published up to november were identified. six databases were examined with search terms. abstracts of articles were reviewed independently by two assessors: a third adjudicator resolved any opinion differences. risk of bias was assessed using the jadad scale. main outcome measures: reporting of the use of qol endpoints and impact of interventions in psoriasis. results: of screened article abstracts, articles were selected for detailed review: trials met the eligibility criteria, describing research on a total of , patients. reports of psoriasis interventions that fulfilled inclusion criteria have gradually increased over time : - = , - = , and - = ( ) to evaluate the relationship between the use of different therapeutic agents and the severity of osa, and ( ) to determine the effects of commonly used medications on continuous positive airway pressure (cpap). setting and method: patient medical records (n = ) of patients, that underwent sleep studies between the years and were collected over an eight-month period from the sleep laboratory department at mater dei hospital using a random sampling technique. data collected included body mass index, gender, age, epworth sleepiness score (ess), drug history, apnoea hypopnoea index (ahi) and cpap therapy prescription. likelihood ratio chi square test, paired samples t-test and multinomial logistic regression were the statistical tests used for data analysis. main outcome measures: assessment of the drug history in response to osa control using the ess and ahi scores. results: one hundred and seventy ( . %) patients of the patients ( males, females) were diagnosed with osa. forty-five ( . %), ( . %) and ( . %) patients suffered from mild, moderate and severe osa respectively. patients had a mean age of years. angiotensin ii receptor antagonists (arbs) (p-value = . ), sulphonylureas (p-value = . ), insulin therapy (p-value = . ) and non-benzodiazepine sedating agents (p-value = . ) were found to be associated with the presence of osa. a decline in the use of the arbs (p-value = . ), angiotensin converting enzyme inhibitors (p-value = . ) and non-benzodiazepine hypnotics (pvalue = . ) was observed over the study year period. reduction in the cpap therapy benefit was detected with the use of histamine (h ) antagonists (p-value = . ), b-adrenergic blocking agents (pvalue = . ) and antiplatelets (p-value = . ). conclusion: it is confirmed that hypertension and diabetes mellitus type ii are the main co-morbidities associated with the presence of osa. reduction in the use of certain therapeutic agents is observed secondary to cpap therapy use. patients using specific drugs have been identified as being at risk of a reduced cpap therapy benefit. please specify your abstract type: research abstract background and objective: people are using increasingly more common of social networks such as facebook, twitter and youtube for different purposes. many people are using these networks with the aim of getting information and knowledge sharing. there are many groups that pharmacist is a member in social networks at turkey. the largest of these groups has , members. pharmacists are shared common problems, information and experiences in these groups. but the accuracy of the information shared on social networks are not always conclusive. the study aim to evaluate the impact of social network information sharing in the knowledge and attitude of pharmacists. setting and method: clinical pharmacy group has been created to share information on facebook. pharmacist joined this clinical pharmacy group. the group was fed by information which include new drugs, fda alerts, adverse event and case report and also drug related problems during the months. pharmacists were assigned in two major groups, group a active pharmacist who becomes a member of our clinical pharmacy group, share and discuss information through the network and group b who is not a member. a knowledge measurement survey (ams) was given to both of them. main outcome measures: acknowledge measurement survey (ams) was developed and the difference in the score was used to evaluate the difference between the two study groups. results: pharmacists participated in the study, . % of the participants were a member of our facebook group and . % of participants were not. . % of the participants have doctoral degree or student, . % have master degree or student, % have bachelor degree from year-pharmacy faculty, . % have bachelor degree from year-pharmacy faculty. the education level distribution between the two groups was not statistically significant. while . % of the ams questions were answered correctly in the member group only . % were answered correctly in the non-member group. conclusion: the study emphasizes the importance of social network in providing the accurate and fastest information for the daily use of the pharmacists, there is a significant difference in knowledge between the pharmacist who join, share and discuss information on the social network and the one who do not join. cp-ce : impacts of a community pharmacy practice experiences on student professionalism yunn-fang ho , , hung-wei lin *, , fang-ju lin , , sheng-ping chang , yen-ming huang graduate institute of clinical pharmacy, school of pharmacy, college of medicine, national taiwan university, taipei, taiwan, r.o.c please specify your abstract type: research abstract background and objective: professionalism is valued globally and pharmacy schools are expected to nurture competent practitioners to better serve the public with humanity attitudes and behaviours. the study aims: ( ) to understand possible differences in professionalism between pharmacy students and potential community pharmacist preceptors, and ( ) to evaluate student changes in professionalism upon completing the community pharmacy practice experiences (cppe) at the end of the third (p ) year. setting and method: a modified chisholm's pharmacy professionalism instrument ( -item, -point likert scale) was administered to p students, pre-cppe and hopefully post-cppe in september, and community pharmacist practitioners who participated in a two-day preceptor training workshop. participants also provided their significance ratings toward ten traits, namely altruism, accountability, excellence, duty, honor and integrity, respect for others, communication, ethics, humanism, and teamwork. main outcome measures: differences or changes in chisholm professionalism scores. results: thirty-two students and fifty pharmacists participated in the survey. honor and integrity ( . ± . ) and communication ( . ± . ) were recognized by students ( . %) and pharmacists ( . %), respectively, as the most significant trait. humanism was rated the lowest in both groups (students, . ± . ; pharmacists, . ± . ). the -item professionalism scores ranged from . ± . (''i do not expect anything in return when i help someone.'') to . ± . (''i am respectful to individuals who have different backgrounds than mine.'') in the student group; whereas . ± . (''i do not expect anything in return when i help someone.'') to . ± . (''it is wrong to cheat to achieve higher rewards (i.e., grades, money).'') in the pharmacist group. in general, pharmacists' professionalism scores were higher and, in certain items, statistically significant differences were achieved. conclusion: professionalism might grow with professional competency and practice experiences as demonstrated by potential pharmacist preceptors. upon completion of cppe, students could probably exhibit gains in professionalism. more investigations are still underway. please specify your abstract type: descriptive abstract (for projects) background and objective: in france, a significant consumption of benzodiazepines (bzd) is observed in prisons. they are widely used during incarceration to treat or prevent anxiety and insomnia. furthermore, it is known that, an important traffic exists with these drugs because of the releasing properties of bzd in case of misuse. based on these observations, the pharmacist has set up a plan to improve the use of bzd in prison. the purpose of the study was to evaluate the impact of these measures after year of implementation. design: in january , we shared with physicians in a meeting to explain our plan for a better use of bzd and to set up new rules of prescription in prison: • regularly reducing the dose to limit drug tolerance • promoting the use of long half-life molecules which allow reducing addiction and misuse • advising sedatives anti-histaminics to treat insomnia • providing information to patients about addictives risks of bzd on the tv channel please specify your abstract type: descriptive abstract (for projects) background and objective: some drug combinations (described in thesaurus of national agency of drug) are contraindicated because they appear to increase the risk of torsade de pointes. the aim of this work is to standardize our pharmacists' intervention and to propose guidelines for doctors and pharmacists, depending on the situation and drugs, to limit these combinations and to reduce this risk at our hospital centre ( beds). design: a prospective survey was realized over a period of months to identify the drug combinations prescribed in medical prescription software, from the national drug agency thesaurus, that might be inducing torsade de pointes. a multidisciplinary staff was then constituted composed of a cardiologist, a geriatrician, a paediatrician, an anaesthesiologist, a psychiatrist and pharmacists to identify the different situations and to establish guidelines. results: from the survey drug combinations were found to be contraindicated due to increased risk of inducing torsade de pointes on a list interventions realized by pharmacists. the work group identified three drugs with a therapeutic alternative: hydroxyzine, domperidone, escitalopram, the other drugs can't be switched because they are vital or have no alternative. the work group decided to maintain hydroxyzine but only on premedication and child anxiety, to eject domperidone from our therapeutic index and substitute it with metoclopramide or metopimazine, to not initialize escitalopram but to keep it if the patient has no have others risk factors associated or no contraindication. if the patient has a contraindication with a risk factor the doctor could prescribe other ssri. in addition, pharmacists alert doctors about the risk of torsade de pointes on medical prescription software if some contraindications are identified. conclusion: the contraindications identified must not be underestimated. this work allows identification of torsadogenic drugs commonly prescribed and provides guidance for doctors and pharmacists regarding drug combinations. the collective decision will be disseminated to sensitize all the doctors in the establishment. some treatments could not be substituted despite the contraindication; these must be retained but with clinical monitoring. conclusion: a substantial proportion of medication waste in the community pharmacy could have been prevented. unused medicines in the community pharmacy are generally of low economic value, making it unlikely that the costs that pharmacies will make with the redispensing of unused medicines will be covered. therefore, other actions to decrease medication waste in the community pharmacy, such as preventing that too much medicines are dispensed, should be considered. please specify your abstract type: research abstract background and objective: flaws in usage technique for inhalationmedicines is common, as much as half of the users may need some correction measures, to get the active substances down to the lungs and provide the intended effect. inadequate compliance, especially for regular-use preventive medications, is common. good guidance in pharmacies enhances correct use of medicines. the new norwegian pharmaceuticals policy (legemiddelmeldingen) from opened up for paid cognitive services, leading to the first such service being implemented in march . the service can contribute to a more correct use of the medicines and, as a consequence, lead to better control of the symptoms for patients with asthma or copd. our objective was to map the variation in pharmacies' handling of an inquiry regarding lack of effect of an inhalation-medicine. the study was done prior to the implementation of the standardized service ''inhalation-guidance'' in norwegian pharmacies. setting and method: simulated patient (mystery shopper) visits in pharmacies in oslo, akershus and buskerud in november/december . the mystery shopper expressed just having started to use an inhaler because of her asthma, but not experiencing effect. structured data collection sheets were used to register the handling immediately after the visit. main outcome measures: scoring of the quality and contents of the information based on the products' patient information leaflets. results: the issue of inhalation-technique was mentioned in of the pharmacies, whereof asked the ''patient'' to show their inhalationtechnique, in order to correct and advice and used an inhaler or demo-inhaler as an aid in the guidance. going through the instructions or watching a video-demonstration with the simulated patient also occurred, or referring the patient to read the instructions and/or watch the video-demonstration on his own. half of the pharmacies discussed the difference between use for preventive treatment of asthma and inhaler that is being used for treatment of attacks. sixty-five pharmacies gave no information about the importance of regular use of the preventive treatment. conclusion: there was considerable variation in how the pharmacies guided, which indicates a potential for improvement. the new guidance-service, implemented in norwegian pharmacies in march , will contribute to better guidance. please specify your abstract type: research abstract background and objective: in portugal, tobacco addiction was responsible for over , deaths in ( % of the total deaths). the community pharmacist's contribution to control this public health problem is insufficiently documented. the aim of this study is to assess the contribution of the community pharmacist for smoking cessation. setting and method: a retrospective and longitudinal study of a convenience sample of patients integrating quit tobacco consultations, as part of a pharmaceutical care programme implemented by an outsourced pharmacist was performed at several community pharmacies. the smokers, aged or over, were invited to join the programme. patients signed an informed consent and were submitted to a comprehensive approach by face-to-face consultations and telephone contacts. richmond and fagerström tests were used to evaluate motivation and nicotine dependence, respectively. the therapeutic plan (pharmacotherapy and behavioural counselling) was personalised to each smoker. the quit rates were evaluated by patient selfreport and confirmed by carbon monoxide measurements. the continuous variables are expressed as mean ± standard error of the mean. main outcome measures: quit rates at , , and months. results: between january and june , smokers joined the programme, dropouts ( . %). the remaining smokers, ( . %) were male, with mean age of . ± . years. on average, each smoker consumed . ± . cigarettes per day. the mean age of initial tobacco use was . ± . years with . ± . years of consumption. about % reported moderate or high motivation and % medium or high dependence. a total of consultations were held and, on average, each patient received . ± . interventions. all smokers received non-pharmacological interventions (e.g. motivational approach) and ( . %) also accepted pharmacological interventions, usually nicotine replacement products. the quit day was achieved by patients ( . %). a month after quit date, patients were abstinent ( . %). the number reduced to after months ( . %), to after months ( . %) and to after year ( . %). these data upgrade and are consistent with our previously published results ( ). the smoking cessation consultation in the scope of a pharmaceutical care programme in community pharmacy seems to effectively contribute to the reduction of tobacco addiction in portugal. cp-pc : patient counselling at dispensing of oral anticancer drugs in european countries from the pharmacists' perspective andreja eberl * , on behalf of epic working group pharmacy, institute of oncology ljubljana, ljubljana, slovenia please specify your abstract type: research abstract background and objective: the number of oral anticancer drugs (oads) available on the market grows constantly. consequently the number of patients, which have to manage the complex treatment with oads at home is increasing. the pharmacists present an important member of healthcare team, since they are dispensing oads to the patients, which need a high quality information at that crucial moment. therefore, our aim was to evaluate pharmacists perceived confidence and needs for specific continuing education in connection to oads dispensing in european countries. setting and method: we used an electronic mailing approach and a standardized online survey to ask practicing pharmacists in european countries about their experience with dispensing of oads. main outcome measures: frequency of patient counselling and fields of counselling, assessment of knowledge and skills. results: the frequency of patient counselling varied widely in participating countries between ''never'' and ''more than %'' at initial fill of an oad. at following refills the frequency of counselling was generally even lower. counselling mostly encompassed directions of use, the proper use of antiemetics and side effects. however many pharmacists stated, that they do not feel comfortable counselling patients of oads ( %) and even more acknowledged that they were uncomfortable with managing patients' side effects ( %). on the other hand only % of pharmacists believed, that they have received adequate knowledge of oads through undergraduate program, continuing education (ce) events and professional practice. many of pharmacists ( %) have not attended any of ce events related to oncology in last years. pharmacists' responses differed little between the countries. conclusion: the proportion of pharmacists who regularly counsel their patients on oads is insufficient in view of importance of the patients' needs to manage their therapy at home. however the pharmacists seems to be aware of their knowledge deficits and educational needs. the field of oads needs better coverage in under-and postgraduate education. the number of ces has to be increased in order to improve the knowledge and skills in the areas of oads counselling. please specify your abstract type: research abstract background and objective: treatment guidelines for diabetes recommend that patients are well-informed about their disease, treatments and treatment goals, e.g. glycosylated haemoglobin (hba c). the objective was to describe diabetes patients' self-monitoring of blood glucose (smbg) and potential need of guidance. please specify your abstract type: descriptive abstract (for projects) background and objective: in , the international pharmaceutical federation collected data of remuneration models for community and hospital pharmacy and identified large variations between remuneration models and highlighted that the focus is largely on products and not on cognitive services. the aim of the study is to map the remuneration models of different pharmacist-led cognitive services in primary care across europe, with a special interest on medication reviews and to update a prior survey by bulajeva (bulajeva a et al. medication review practices in european countries. res social adm pharm ; : - .). the definition of terms is pivotal for such a european survey to avoid results based on pseudoconceptions. hereafter we present the development of the survey and we will present first results from pilot tests. design: pharmacist-led cognitive services were selected based on a previous study by our group and by searching the literature, official government websites, the pcne wiki and arising links. the definitions of the terms of these services were based on searches in the mesh browser, medline and google scholar. additionally, a search in grey literature and in the internet was conducted to find appropriate foundation for the formulation of the definitions. the questionnaire will consist, of a first part about the remuneration of the pharmacist-led cognitive services. the focus is on country-specific differences in remuneration and the different levels of supply across europe. the second part of the survey is about the different types of medication review services with a focus on e.g. the implementation level, addressed issues, eligibility criteria. this survey will have a cross-sectional study design with an online questionnaire specific for invited participants across europe. to achieve the best quality of answers we will send this survey to at least two researchers with references in pharmacy practice, in each european country (purposive sample). the answers from each country will be checked for discrepancies and these potential discrepancies will be solved by a discussion with the responders. results: by the end of the pre-pilot phase, different pharmacist-led cognitive services were identified and the correlating definitions of the terms were developed. conclusion: at the time of submission the pre-pilot phase has been finished and the pilot will start july . please specify your abstract type: research abstract background and objective: medication adherence is one of the key aspects in assuring optimal health outcomes in majority of chronic diseases. the aim of the study was to evaluate copd patients' medication adherence in slovenia and its association with health outcomes. setting and method: patients were recruited by community pharmacists at the time of dispensing medication for copd. medication adherence was evaluated by using morisky medication adherence scale (mmas- ). patients who scored b points, . - . points and points were regarded to have poor, moderate and good adherence, respectively. quality of life was evaluated by saint george's respiratory questionnaire (sgrq) and the impact of disease by copd assessment test (cat). the study was conducted in september and february . the association between potential predictors and copd impact or quality of life was estimated using multiple linear regression in ibm spss statistics version . main outcome measures: medication adherence rate (mmas- ), quality of life (sgrq total score) and impact of disease (cat score). results: of patients, majority were men ( %) with mean age years. in average, patients were prescribed . medicines for copd and . medicines for other diseases. good, moderate and low adherence to copd medication regimens was found in . , . and . % of patients, respectively. mean cat scores and sgrq scores were . (range - ) and . (range - ), respectively. thirtyeight percent of patients experienced an exacerbation in the past year. linear regression showed no statistically significant association between medication adherence and quality of life or copd impact on patient. factors that statistically significantly predicted patients' quality of life were exacerbation in the past year, education level and number of concomitant medicines for other diseases. the latter was found to be the only factor associated with copd impact. conclusion: the study showed half of the copd patients to be optimally adherent to their treatment and only a small proportion of patients not taking their medicines regularly. due to the nature of the disease medication adherence does not seem to play the most important role in assuring optimal health outcomes in copd patients. please specify your abstract type: descriptive abstract (for projects) background and objective: intermediate care units (imcu) are designed to serve patients in need of more advanced medical care than the ordinary nursing home units can provide. the aim of this study was to see; ( ) how medication information follows patients in and out of icmu and nursing home short-termcare units (stcu) ( ) the type and amount of drug related problems (drp), focusing inappropriate drugs, and ( ) if there are differences between the icmu and stcu in drug use and drps. design: patients c years old admitted and submitted at the imcu or stcu in the study period ( weeks) were included. transfer of medication information were evaluated and given a score. the clinical pharmacist provided medication reconciliation upon admission, medication review and monitoring, and presented identified drps and a suggestion for solving the problem, to the multidisciplinary team. inappropriate drugs, identified by screening tools (stopp/norgep), and systematic medication reviews, were recorded. results: patients from imcu and five from stcu were included. a hospital discharge summary including medical history followed mostly all patients. the score of the medication history was . points out of . by submission from either imcu or stcu, the score was . . systematic drug review identified . drp in the imcu and . in the stcu. imcu patients used . drugs, stcu patients . in the icu, % of the identified drps was inappropriate drugs, none in the stcu. the clinical pharmacist in the multidisciplinary team presented % of the identified drps. the doctors agreed in % of the suggestions for solution, and started immediate changes in %. conclusion: a hospital discharge summary followed the patients, but the medical history part needs improvement. although few patients, the results suggest that imcu patients had more complicated medication and more inappropriate drugs than stcu patients did. clinical pharmacist in a multidisciplinary team provides useful contribution to identify, solve and prevent clinical relevant drps, including inappropriate drugs. please specify your abstract type: research abstract background and objective: lack of clinical effects of medication review on health-related quality of life of older people may be due to insufficient focus on health-related complaints. goal attainment scales (gas) are an instrument to formulate specific health-related goals. the objective of this early process-evaluation of the dreamer-study (drug use reconsidered in the elderly using goal attainment scales during medication review) is to investigate if pharmacists are able to formulate gas during a medication review of older people with polypharmacy. setting and method: older patients aged years or older using or more medicines are included in this study. half of the patients were randomized into the intervention group, where they received a medication review. during the patient interview, the pharmacist formulated gas in concordance with the patient. recommendations were made to reach these goals in collaboration with the gp. main outcome measures: number of performed medication reviews, total number of formulated gas and the three most frequent types of gas. results: until now patients have been included in the drea-mer study ( % of the target). half of them ( ) were randomized into the intervention group. by now ( %) of these patients have received a patient interview. goal attainment scales were formulated yet. the number of gas ranged from to per patient. the four most frequent gas were: polypharmacy-reducing the number of medicines ( ), reducing pain ( ), increasing mobility ( ), reducing fatigue ( ). conclusion: gas seem to be a feasible approach during medication review that increased focus on patient's needs and health-related complaints. cp-pc : oral transmucosal fentanyl citrate: a regional survey of dispensing practices in community pharmacy please specify your abstract type: descriptive abstract (for projects) background and objective: oral transmucosal fentanyl citrate (otfc) is an opioid analgesic indicated for management of breakthrough cancer pain in patients with malignancies who are already receiving and who are tolerant to opioid therapy for their underlying persistent cancer pain. otfc are usually use off-label prescription, especially in noncancer patients or patients without opioid maintenance treatment. this practice can expose to iatrogenic risks, lack of efficacy, abuse and addiction. the observatory of drugs, medical devices and therapeutic innovation of upper normandy, conducted a study to assess the knowledge of pharmacists on these medications and assess dispensing practices (pharmaceutical analysis and advice to patients). design: between june and september , two quizzes were sent to the pharmacists and pharmacies in upper normandy: one included questions of knowledge and general practice, the other assess dispensing practices of otfc prescriptions received at the counter, regarding indication, dosage and associated opioid medication. results: of the pharmacists who participate in the survey, % know the all of the oftc specialties, % of them confuse transdermal and transmucosal fentanyl specialties. indication, dosage, titration methods and the main interest of oftc are known by , , and % of them. only % have dispensed oftc more than times over the past months, % never have. they already have dispensed oftc in noncancer patients ( %) or without opioid maintenance treatment ( %). they consider not know enough about these drugs to be able to provide the necessary advice to patient ( %) and would like specific training on oftc ( %). of the analyzed prescriptions, only % are consistent with the marketing authorization: otfc medicines are prescribing in noncancer patient ( %) and/or dosage is higher than four units per day ( %) and/or there is no prescribed opioid maintenance treatment ( %). only two prescriptions have been discussed with the prescriber, and all were approved and dispensed. conclusion: otfc specialties are occasionally dispensed and often misunderstanding by pharmacists. a good knowledge of otfc is necessary to achieve the pharmaceutical analysis and provided appropriate advice to patients, in order to guarantee the good use of these medicines. support tools for dispensation, recalling indication, . the most frequent interventions were drug substitution (n = ), dose adjustment (n = ), and clarification of information (n = ). common services were reconstitution of suspension (n = ), provision in advance for continuing supply (n = ), and follow up offers (n = ). conclusion: the observation of the dispensing process in community pharmacies revealed a broad range of tasks performed by the pharmacy and identified several variables likely to influence the counselling. in addition, pharmacy activities could be pictured by the documentation of pharmaceutical interventions. please specify your abstract type: descriptive abstract (for projects) background and objective: medication reconciliation (mr) is a multidisciplinary process to correct medication errors resulting from miscommunicated information at transitions of care. development of this activity is essential but it is hindered by the time required for its implementation. we must carefully choose which services can develop this activity. as it was recently introduced in cardiac surgery unit, this study aims to evaluate impact of this process to hospital admission (severity of potential harm of medication error intercepted) and to determine the relevance of this activity in this unit. design: prospective study conducted from january to april . the data is recorded in an excel table, filled after each mr. there are five items: patient's age, best possible medication histories (bpmh), implementation period of the mr, inadvertent discrepancies (ids) and clinical impact. to assess the severity of ids, a scoring method was used (doerper et al. ) with the cooperation of surgeon and pharmacist. results: eighty-two patients (mean age ± years old) were included in the study, which represents % of the patients hospitalized in this service. the mean number of drugs per patient was ± . the bpmh were obtained within h to h of admission to hospital. a total of ids were detected, with a mean of . ids per patient. the most frequent type of ids was omission ( %, n = ), error of dose ( %, n = ). the three most common classes involved in ids were hypolipaemic drug (n = ), antidiabetic drugs (n = ) and the drugs for acid related disorders (n = ). the mean of ids per patient ( . ) as well as the percentage of patients affected by a ids ( %) are less important in cardiac surgery than those observed in other services of the institution and in the literature. about clinical impact, % of patients presented with ids considered as minor, % significant and % major. among the major ids, none was evaluated as critical or catastrophic. in our study, this process remains retroactive. conclusion: one of challenge experienced when implementing mr process in hospitals is demonstrating its clinical impact. in order to address this concern, we found that the little ids with a serious clinical impact in this unit. mr is an interesting process to detect drug errors. to optimize our study we will improve our organization in order to be closer to the patient and to strengthen the doctor-pharmacist collaboration. please specify your abstract type: research abstract background and objective: special packaging like multidose drug dispensing (mdd) may optimize medication use in patients with a decreased ability to manage their own medication. however, it remains unclear how a 'decreased ability to manage medication' is defined. the objective of this study is to assess potential medication problems that contribute to a decreased ability to manage medication in patients starting with mdd compared to patients who use manually-dispensed drugs. setting and method: patients starting with mdd (cases) and patients using manually-dispensed drugs (controls) were interviewed in community pharmacies. questions to assess potential medication problems covered three domains; medication adherence ( ), practical management issues ( ) and medication knowledge ( ) . every potential medication problem was scored with one point. cognition was assessed with the mini-cog and frailty with the groningen frailty index (gfi). main outcome measures: mean scores of potential medication problems on the domains medication adherence, practical management issues and medication knowledge. results: patients starting with mdd and patients using manually-dispensed drugs were interviewed. patients starting with mdd scored more potential medication problems on all domains: adherence . versus . , practical management issues . versus . , medication knowledge . versus . . on the three domains together, patients starting with mdd scored . [ . - . ] potential medication problems compared to . [ . - . ] for patients with manuallydispensed drugs. forty-two percent of the patients starting with mdd might be cognitive impaired and % was classified as frail compared to and % respectively of the patients using manually-dispensed drugs. conclusion: patients starting with mdd reported significantly more potential problems on three domains that may contribute to a decreased ability to manage their medication. cp-pc : fifteen key questions to assess patient knowledge on new oral anticoagulants corina metaxas * , valerie wentzky, sonja luginbü hl, kurt e. hersberger, isabelle arnet please specify your abstract type: research abstract background and objective: knowledge on new oral anticoagulants (noacs) is crucial for their safe and effective use. validated tools that assess patient knowledge exist for vitamin k antagonists, but not for noacs. we aimed to identify which questions are relevant for patient knowledge on noacs. setting and method: based on a systematic literature search, questions were compiled for the assessment of noacs knowledge. key questions were selected through three rounds of ranking by an expert panel (four physicians, four pharmacists, four nurses). round (online survey; importance): the questions grouped into the nine educational topics of wofford,adapted for noac (disease, mode of action, risk-benefit, adherence, accessing healthcare professionals, diet/life-style, lab-monitoring, medication interactions, self-care) were to be rated as important/not important and educational topics were to be ranked according to decreasing importance. round (online survey; relevance): the questions were to be ranked according to decreasing relevance. round (focus group): number of questions was reduced by voting. main outcome measures: ranking of educational topics and questions ( = most important/relevant) in march/april . results: experts ranked adherence ( . ± . ) as the most important topic, followed by risk-benefit ( . ± . ), disease ( . ± . ), accessing healthcare professionals ( . ± . ), self-care ( . ± . ), lab-monitoring ( . ± . ), medication interactions ( . ± . ), diet/life-style ( . ± . ) and mode of action ( . ± . ). one question was judged as unimportant by all experts. out of the remaining questions, ( . %) were selected as relevant for basic knowledge, ( . %) were combined into four questions and one new question was generated. a total of key questions remained after the focus group discussion. conclusion: a multiprofessional expert panel was able to select key questions retrieved from literature and ensured content validity. the selected questions will be compiled into a tool to assess patient knowledge on noacs. background and objective: medicines use review (mur) was defined by the slovene chamber of pharmacies in december and an education program was set to assure pharmacists competencies. in june the first pharmacists were certified and implemented the service in the community pharmacies. additionally, an online database was established to collect mur reports and provide feedback on pharmacists' performance. the aim of the study was to evaluate identified drug related problems (drp) as well as pharmacists' interventions from mur documentation. setting and method: a preliminary retrospective analysis of documentation for mur services provided in the first year after implementation was performed. drps were classified using a slovenian drp classification system, which is based on the pcne classification v . [ ] . data were analysed with descriptive statistics measures. main outcome measures: number and type of identified drp and pharmacists' intervention. results: a preliminary analysis was performed on mur cases, performed by certified pharmacists. in total drps were identified: ( . %) manifested and ( . %) potential. patient had on average two drps, however patients had none. main risk factor for potential drps was inappropriate use of medicines. adverse drug events (ades) presented . % of manifested drps; the main risk factor was again inappropriate use. in two cases ades happened due to an allergic reaction. different medicines were the cause of ades; mainly statins resulting in muscles pain and sleeplessness. another frequently manifested drp was insufficient effectiveness of treatment. drug interactions were risk factors in cases of manifested drps, mainly in connection with antidepressants: serotonin syndrome due to escitalopram, bleedings in concurrent use of escitalopram and ginkgo, sleepiness, etc. pharmacist intervened independently in . % of cases; times recommendations were given to physicians. however, in . % of cases the outcome of intervention is unknown. the preliminary results of the first mur cases points to a high number of identified manifested drps. however, the knowledge of intervention outcomes is lacking and therefore more attention has to be put on establishing adequate follow up on this issue. official definition represented harmonisation of several similar activities that have already been performed in slovenian pharmacies and also provided an educational program to assure pharmacists competencies. in may the first pharmacists were certified and implemented the service in the community pharmacies. therefore, the aim of the research was to get an insight into the implementation of mur in slovenia from the perspective of the first community pharmacists that provide the service in practice. setting and method: a focus group with seven community pharmacists, that provide mur in practice, was run in february . guided discussion included three main themes: the development and assurance of competencies, experience with the provision of service in practice and the future of the service. the discussion was voice recorded and analysed with the nvivo . written consent from included participants was obtained. main outcome measures: views, challenges and opportunities for the medicines use review service in slovenia. results: in total themes were identified and organized in three main categories: competencies for quality provision of mur, mur's recognisability and organizational aspects of mur provision. participants emphasized broad knowledge in pharmacotherapy is pharmacists' key competence and advantage in performing mur when compared with other healthcare professions. recognisability of mur among other health care professions as well as participants' work environments is low. hence a comprehensive approach in marketing of the service is needed. positive patient's feedbacks were reported, however persuading patients to attend mur presented a challenge. another barrier was the time to perform mur, which could be overcome by suitable work organization and special time intended for mur. conclusion: participants of the focus panel had positive experience with the development of competencies and implementation of the service in the practice. several challenges were presented connected with the recognition of the service by patients, physicians and health care payer. they strongly believe that continuing professional development forms the base for quality of the service in the future. cp-pc : evaluation of rational antibiotic dispensing in the community pharmacy setting: a simulated patient study betul okuyan * , mehmet ali savan, fikret vehbi izzettin, mesut sancar please specify your abstract type: research abstract background and objective: in the present study, it is aimed to evaluate rationale antibiotic dispensing without prescription in the community pharmacy setting; this will be done by using a simulated patient methods. setting and method: this study was conducted in malatya, located in the east part of turkey. the simulated patient visited the community pharmacies to meet the pharmacist, posing as the husband of a patient with acute uncomplicated rhinosinusitis. the simulated patient was trained regarding the standard information to be provided by the researchers and informed about the privacy of all information that would be gathered during the present study. the sample size was sixty-seven pharmacies, with a confidence interval of % and error of margin of %. the study was conducted over a total of pharmacies. all the pharmacies were listed alphabetically and were randomly selected and allocated random numbers by a computerbased program. main outcome measures: after each community pharmacy was visited, the simulated patient filled the check list which had been drawn up for the purpose of the present study. due to ethical concerns, no audio or video records were used during the study. any suggested medications were not purchased from the community pharmacy. results: of the total community pharmacies that were visited . % of them had female pharmacists and . % were run by male pharmacists. the mean number of questions asked by pharmacists to the simulated patient was . ± . . only eleven pharmacists did not suggest any medication for the simulated patient. however, thirty-two ( . %) pharmacists recommended various medication regimens, including antibiotics. of them, . % referred the simulated patient to a physician. conclusion: in conclusion, it was observed that dispensing antibiotics without prescription was still high, pharmacists did not take comprehensive medical or medication history from patients, and pharmacists provided insufficient medication information to the patient regarding suggested medications at community pharmacy setting. to avoid irrational antibiotic dispensing, it is essential to educate both health care providers and the general population. although dispensing antibiotics without prescription is illegal in some countries, it is necessary to actualize new regulations to avoid antibiotic dispensing without prescription. please specify your abstract type: research abstract background and objective: the medication adherence is an important part of active (as well as passive) attitude of a patient to the disease treatment. it represents the level of keeping the treating procedure as well as the recommendations of doctors, pharmacists and other healthcare professionals. this study deals with the adherence in patients with hypertension. the hypertensive patients are a substantial part of patients, daily visiting the community pharmacy to pick their prescriptions. these patients represent group of patients with typical asymptomatic disease. this means that they do not take the medicines or use them according to their own will. the result of their non-adherence could lead to later complications. the aim of the study was to evaluate the level of adherence and its relation to the clinical outcome-the blood pressure in hypertensive patients. setting and method: the methodology was based on a single anonymous questionnaire survey combined with the blood pressure measuring in a community pharmacy in slovakia. the modified morisky -item medication adherence tool was used in this study. main outcome measures: the results of medication adherence were evaluated as follows: - points = full adherence, points = partial adherence and - = non-adherence. each participant should use at least one antihypertensive agent and fulfil the anonymous questionnaire in the community pharmacy. the pharmacist measured the blood pressure in each participant twice, within the interval of min and used the average value in data sheet. results: the research included hypertensive patients ( . % females and . % males). the results showed that almost % of the respondents were non-adherent to the prescribed pharmacotherapy ( . % of those were males and . % were females). the group of partially adherent patients consisted of . % of the respondents ( . % of those were female). only . % respondents were fully adherent according to modified morisky score ( . % of those were women). fully adherent patients reached an average blood pressure . / . mmhg; partially adherent hypertensive patients recorded an average blood pressure . / . mmhg; and in the non-adherent patients has been observed the average blood pressure . / . mmhg. the results showed an alarming situation, and confirm the published data. non-adherent patients could not goal the good clinical outcomes. this leads to adding of another medications, raising the risk of interactions and adverse drug reactions, complications of undertreated disease, and finally, to pharmacotherapy costs increasing. please specify your abstract type: research abstract background and objective: in psychology, depression is a mental state characterized by feelings of sadness, dejection, inner tension and indecision. in psychiatry, the depression is defined as a severe mental affective disorder which paralyzes clarity of thought, psychomotorics, sleep cycle and raises pessimistic and depressing emotions often lead to pathological changes of personality. during treatment of depression is often needed psychotherapy and pharmacotherapy as well. using of antidepressants requires the sufficient level of medication adherence in patients. non-adherence to antidepressant medication significantly contributes to the undertreatment of depression in primary care populations. the aim of this study was to evaluate the level of medication adherence to antidepressants to better understand the socio-behavioural factors associated with non-adherence. setting and method: the anonymous, face-to-face questionnaire survey was set in the community pharmacy in slovakia. questionnaire obtained questions on socio-behavioural factors and adherence tool-modified -item morisky score (mmmas- ). main outcome measures: respondents were patients ( males, females) using at least one antidepressant. the results were evaluated as follows: points = full adherence, - points = partial adherence and - = non-adherence. results were evaluated in relation to socio-behavioural factors. results: average level of the medication adherence in our group was , which means the line between partial and full adherence. the results showed non-significant higher medication adherence level in males ( ) compared to females ( ). the highest level of medication adherence ( ) has been shown in patients - years old, the lowest average adherence level (non-adherence) was observed in patients up to years old ( ). patient living in the city were more adherent to their medication ( ) compared to patients living in countryside ( ). the highest level of the partial medication adherence has been shown in secondary educated patients ( ). partial adherence level was higher in patients with monthly income over € ( ) compared to non-adherent patients with monthly income up to € ( ). in patients using no other medications, only antidepressant, we have observed the highest partial adherence ( ). conclusion: our survey showed the partial antidepressant medication adherence levels in our study group. poor adherence results in low stabilization of clinical state in patient, in using more types of therapy and in increasing costs. there might be very important role of the community pharmacists and other health care professionals to improve the medication adherence and persistence through counselling and education patients on importance and need of antidepressant medication. ( ) and medication regimen complexity was assessed by using the medication regimen complexity index (mrci) ( ) . five and more medication usage has been defined as polypharmacy. results: a hundred and two elderly subjects ( . ± . ; male) were included in this study. of them, . % had two and more chronic diseases. the most common chronic diseases determined in study population were cardiovascular diseases (especially hypertension), diabetes and hyperlipidaemia. the polypharmacy has been defined in . % of them. the mean of mrci per elderly patient was . ± . . one or more pims use was observed in seventy-four elderly subjects ( . %). of all elderly subjects, . % were dispensed one and more medicines with a potential for drug-disease/ syndrome interaction. pims use was more frequently determined in patients with polypharmacy ( . vs. . %, p \ . ). the total score of mrci was significantly increased with elevated number of pims (r = . , p \ . ). conclusion: this study highlights a significant association between utilization of pims and both polypharmacy and higher total score of mrci in elderly patients. pharmacists could be evaluated utilization of pims in especially elderly patients with used five or more medications and/or higher total score of mrci. please specify your abstract type: research abstract background and objective: nursing home patients with multimorbidity often use multiple drugs simultaneously, which makes these patients more susceptible to adverse drug events. several studies have pointed to a need to increase the quality of prescribing to this population. to achieve this there is a need for reliable information about patients' diagnosis, and what is recorded as the drug's indication in different electronical and handwritten health records. the aim of this study was to examine the registered diagnoses, and indications for drug use in nursing home patients. we also wanted to study the extent to which diagnoses are untreated with drugs, as well as the extent to which drugs have a registered indication for use and a suitable recorded diagnosis. setting and method: data was collected for long-term patients, on average years old, and % females from four nursing homes in tromsø municipality, norway. we retrieved information about patients' diagnoses and indication for drug use from the electronic health record and written drug charts. two pharmacists conducted the linkage between the reported diagnoses and drug use. main outcome measures: percentage of untreated diagnoses and the percentage of drugs with a registered indication for use. results: as considered by the pharmacists, % of the registered diagnoses was untreated with drugs. dementia, gout and osteoporosis were the most commonly untreated diagnoses with, , and %, respectively. in comparison, the indication for use listed on the patients' drug charts was reported for % of the drugs. the drugs with the highest percentage of recorded indications were acetylcysteine (n = ), oxycodone (n = ) and zopiclone (n = ), where , and % had a listed indication, respectively. conclusion: a high percentage of nursing home patients' diagnoses seem to be untreated. however, most drugs that patients received were listed with indication for use in the drug charts. to increase quality of drug prescribing, one should put emphasis on improving the recorded information in electronical health records. cp-pc : personal changes in drug regimen: dangerous for health system? inga urtane, raivis pastars, dace bandere please specify your abstract type: research abstract background and objective: patient compliance is a key factor for a successful treatment and lack of it is the main reason for predicting treatment failure. in multiple researches patient adherence is determined to be as low as %. therefore it is important to identify the reasons of patients not following their drug regimen. objective. to analyse the patient comprehension of their drug regimen depending on the duration of hypertension and received treatment. setting and method: during the period from december to march a quantitative survey was conducted to include respondents who have been diagnosed with arterial hypertension and whose regimen includes at least one fixed dose combination drug. main outcome measures: in an anonymous survey data was collected about their demographic information, co-morbidity, other prescribed medication, intake regime, the average blood pressure during treatment, and patient's assessment of the prescribed therapy. collected data was analysed with spss. results: the study included participants, most of whom ( . %) were women. participants average age was . ± . years and the median arterial hypertension duration was ( ; ) years. the study participants, who sometimes consciously adjusted dosing regimen, observed arterial hypertension for a longer period of time compared to the group, which follows the prescribed regimen according to their doctor's recommendation, respectively, ( ; ) vs. ( ; ); p = . . group of respondents (n = ) receiving c prescription drugs, more often deliberately adjusted treatment regimen compared to respondents (n = ) treated with b prescription drugs, respectively . versus . %; p = . . respondents who deliberately adjusted drug were more often not satisfied with the number of longterm daily use of tablets (n = ) compared to the group (n = ), which had to intake fewer tablets every day, respectively, . versus . %; p = . . conclusion: arterial hypertension duration was associated with more frequent conscious adjustment of therapy without consulting a doctor. more individual prescriptions (c ) and an increase in the number of tablets per day at the same time also increases the risk of patients deliberately changing their dosing regimen. long-term drug users should receive additional attention during pharmaceutical care process to their respective treatment schedule in order to promote proper use of medication. please specify your abstract type: research abstract background and objective: diabetes is a health issue and real burden for in belgians. better adherence to the treatment could potentially reduce complications, decrease morbidity and mortality, and have a beneficial economic impact due to fewer consultations and hospitalizations. setting and method: a one-year program was started in belgian pharmacies to accompany diabetes patients taking dpp- inhibitors and encourage them to be compliant with their treatment. this study concerns of these pharmacies, all part of the same cooperative group. all pharmacists received prior training in motivational techniques and reviewed the bases of diabetes therapy with an e-learning program. materials developed for the patients included brochures on diabetes and its treatment, nutritional advice, physical exercise, foot care and tips and tricks for diabetics. main outcome measures: the impact on pharmacological adherence was measured using mmpr and pdc. two control groups were included: a historical control group and a group of patients that were not included in the project. non-pharmacological adherence was assessed using questionnaires. results: in the subgroup of pharmacies, patients were included in the program. by the end of april , only of them had completed the program; patients came only once to the pharmacy. they either stopped their treatment after one prescription, or were occasional clients. adherence rates were found to be high in all groups ( . - . % of patients with mmpr b %). only for the pdc, a statistically significant difference was measured between the intervention and control group ( . vs. . %; p = . ). no other statistically significant impact was measured (neither pharmacological, nor non-pharmacological). conclusion: adherence was very high in all groups. the underlying reasons still need to be investigated (choice of adherence measure, healthy user effect, etc.). however, both patients and pharmacists were very pleased with this type of program. this new role of the pharmacist will definitely be more developed in the future. please specify your abstract type: research abstract background and objective: oral anticoagulants (oac) have a beneficial effect on the long term survival of patients with atrial fibrillation and venous thromboembolism. however oacs have also side effects such as bleeding, especially when used inappropriately. pharmaceutical care interventions aim to optimize medicines use and improve patient health outcomes. the literature lacks a review on the impact of pharmaceutical care interventions in patients using oac. therefore, we systematically assessed the impact of pharmaceutical care interventions on the effective and safe use of oac compared to usual care. setting and method: a systematic review was performed in pubmed and embase with synonyms/detailed specifications of the terms oral int j clin pharm ( ) . it was motivate for the need to sort the instruments for urm, including professional participation, and on the basis of the clinical management unit, and reduce variability in decisions. the p&t or ''multidisciplinary commission rational use of medicines'' is constituted by people: one hospital medical director (president), head of pharmacy (secretary), and three directors of healthcare centre, three directors of department of specialities, one epidemiology, one hospital pharmacy, one primary care pharmacy and one paediatric. because some of these members are far between them, and normally dose not have too much time, we create an online platform to work, discuss and download all the necessary documents. setting and method: we used the facilities of the andalusian agency for healthcare quality (www.acsa.junta-andalucia.es), and as a base the law of the administrative decision. we have organized a session to discuss methodology with the participation of all members. main outcome measures: number of meeting and number of internal discussion emails. drug or protocol decisions. design of the platform. results: the design platform consists of five tabs: ( ) has the member information, position, telephone and address, ( ) email forum, following a subject line, ( ) a place for meeting requests and then hang up the meeting minutes. ( ) a tool allows you to upload documents to the portal ( ) a search engine. two sessions are schedules and total of mails. we have of members who have never participated online. at this moment we have adopted two decisions. conclusion: it is an online experience of one andalusian p&t committees, the low turnout makes go slower than expected, therefore physical meetings are necessary in this moment. we are working how to get more participation and involve in the project the committee members. please specify your abstract type: research abstract background and objective: liver cirrhosis can have a major impact on drug metabolism, requiring evaluation of drug safety and dosage in individual patients. currently, there are no guidelines on safe prescribing for medications in patients with liver cirrhosis, and these patients have many questions about safety and side effects of medication. the objective of this study is to explore the patient's needs on information about medication. setting and method: qualitative, semi-structured interviews were performed in patients with a (history of) liver cirrhosis. the patients were approached through an item in the newsletter of de dutch association of liver patients. topics in the interview guide were preferences about information about medication, side effects, safety, drug dosage, and how patients preferred to receive this information. interviews were audiotaped and transcribed verbatim. interviews were analysed using thematic content analysis. main outcome measures: the experiences and needs of patients with liver cirrhosis concerning information about medication. results: patients indicated they had received sufficient information about the indication, possible drug-drug interactions and the duration of treatment. they preferred (more) information about how medications work, what adverse drug reactions could be expected and practical aspects concerning intake of medication. informational needs were related to questions 'how to act': patients with more informational needs took a more active role in responsibility for their own medication management. patients needed information to know what to do, e.g. in case of adverse drug reactions or when a dosage was forgotten. the doctor and internet were the preferred sources of information: doctors because of the personal contact and internet because of the accessibility. facilitating factors were 'taking time' in healthcare provider-patient contact and 'everyday language' for texts on the internet and in package leaflets. a combination of verbal information by the healthcare professional and written information was preferred. conclusion: patients with liver cirrhosis need information about medication to take an active role in their drug management. comission for medicines and medical devices, chu de toulouse, toulouse, france please specify your abstract type: descriptive abstract (for projects) background and objective: due to its common use, insulin is often considered as a harmless medication by lots of health professionals while an overdose can lead to dramatic consequences and death. between january and june , in our university hospital, % ( out of ) of the declared adverse drug events have involved insulin: were caused by prescription errors and by administration errors. all were discovered after the medicines have been administered but thankfully none had serious consequences. the british national health service (nhs) and the french medication safety national agency (ansm) made a list of ''never events'': avoidable events which should never happen and misadministration of insulin is among them. the objective was to increase patient safety in the hospital by setting different actions to promote and improve the appropriate use of insulin and warn health professionals about the real dangers of this medicine. design: different actors participated in the implementation of these actions: the commission for medicines and medical devices (which is composed by doctors and pharmacists) directed a group made by physicians and clinical pharmacists from the department of cardiological and metabolic diseases'. results: in addition of the usual analysis of any adverse event linked to medication declared in the hospital, several actions were set up: • a didactic document summarizing all the ''sensitive'' steps during the prescription, stocking, dispensation and administration of insulin has made the front page of the hospital's intranet and was also diffused throughout the establishment. • a chart resuming all the different insulins commercialized in france has also been diffused. it contains their types, durations and onsets of action, conditions of storage and pictures of their packaging. • the computerized protocols involving insulin are going to be reviewed in order to lower their numbers and harmonize their content. • a revision of the list of insulins available at the hospital is in progress to reduce their number and avoid any confusion between the different products. • an evaluation of insulin's computerized prescription practices will be made via a data request. : this topic about insulin shows a greater willingness to secure the medication circuit in the hospital. other action plans such as this one will be set up involving other medications among the never-events list. meanwhile, the commission for medicines and medical devices pursues its actions of promoting the appropriate use of medication. please specify your abstract type: descriptive abstract (for projects) background and objective: one of the hospital pharmacist tasks is to suggest substitutions to ensure conformity of medical prescription with the hospital formulary. indeed, when an eye drop isn't available at the hospital, there is a specific supply circuit which has to remain exceptional: it's ordered directly to the pharmaceutical wholesaler. in this context, ophthalmologists and clinical pharmacists created a table proposing therapeutic equivalencies with eye drops available at the hospital. after approval by the commission for medicines and medical devices, this tool has been diffused within the establishment via the intranet website since the beginning of to the medical and paramedical staff. the purpose of the study is to evaluate professional practices concerning the use of the eye drops' equivalence chart. design: in the study, we compared eye drops' orders made to the pharmaceutical wholesaler before and after the table's diffusion, thus between january and december . for each order, we used the table available at this time to determine if equivalencies could have been proposed or not. if so, we identified the hospital ward and the pharmaceutical specialty. market changes have also been considered. results: we noticed a decreased frequency of eye-drops ordered despite available equivalencies: % in (before the table's diffusion), % in (after its diffusion), % in and % in . prisons units are responsible of % of these orders: they have the lowest rates of substitutions. their most ordered pharmaceutical specialties are ophthalmic glaucoma agents: % ganfort Ò (bimatoprost . mg/ml/timolol . %), % xalacom Ò (latanoprost + timolol . %), % azopt Ò (brinzolamide) for which the authorized substitutions are for the first two specialties: monoprost Ò (latanoprost) + ophtim Ò (timolol . %) and for the third: dorzolamide Ò . conclusion: equivalence table diffusion throughout the hospital has facilitated and improved the prescription and substitution of eyedrops. orders of pharmaceutical specialties despite authorized equivalencies available have declined by half. probably for practical reasons regarding long-term treatments, prison units make less substitutions but an awareness campaign will be carried out to reduce these rates. please specify your abstract type: research abstract background and objective: the patient's education and information is a mean to reduce medicine misuse and it can be performed with support of a leaflet or informative material about medicines. in brazil, there is a lack in regulation about this type of informative material to compounded medicines. the aim of this study was to evaluate the quality and effectiveness of leaflets developed to compounded medicines' users through knowledge's level and medicine treatment adherence. setting and method: analytical and quantitative study; month prospective study through interviews, at time zero (t ) and after days (t ) in a university pharmacy in goiás, brasil; fisher's exact test to measure effectiveness; ethics committee number / . main outcome measures: categorization into high adherence and low adherence by morisky test; categorization into sufficient, regular or insufficient knowledge about medicine prescription; perceptions and suggestions about delivered leaflet in medicine dispensing process. results: of patients ( . % female, mean = . years), . % considered as relevant the leaflet's content, as well . % of them kept it and . % of them read it. suggestions of . % included a desire in increase font size, more emphasis on drug interactions and images. there was a predominance of regular knowledge in both analysed times ( . % e . %), however there was a decrease in high adherence to medicine treatment ( . - . %). among patients who read the leaflet, no statistically significant association was found on these two variables at t and t (p = . and p = . , respectively). knowledge about ''administration schedules'' showed a significant improvement after intervention (p = . ). . % of patients considered that there was no need to obtain more information. conclusion: this study demonstrates the evaluated leaflets had relevance to patients and demonstrate clinical relevance. however was not observed statistically significance. this highlights the need of using different ways to measure the effectiveness of an informative material to promote rational use of medicines and depth studies and stimulation of greater attention from the health professionals to the topic. di : chlormethine gel: effectiveness and tolerance to treat mycosis fungoides françois dugre *, , anne lefebure , sonia martelli , marion pin , eve maubec , philippe arnaud pharmacy, dermatology, bichat-claude bernard hospital, paris, france please specify your abstract type: descriptive abstract (for projects) background and objective: to determine the effectiveness and tolerance of chlormethine gel in treating mycosis fungoides. design: mycosis fungoides is the most common form of cutaneous t-cell lymphoma (mf-ctcl). early stages (ia and ib) can be controlled by skin-directed therapies such as chlormethine and carmustine. these drugs which are solutions for injection are usually used for skin application. chlormethine or mechlorethamine gel is an alkylating agent representing an alternative for previously treated patients diagnosed with mf-ctcl, in case of therapeutic failure and intolerance, or in case of chlormethine and carmustine solutions supply disruption. a retrospective observational analysis was conducted based on medical records of all patients treated by chlormethine gel in our hospital from the first of july to the first of september . the following data were collected with an excel table: body surface area or bsa affected by disease, location of the lesions, therapeutic management, effectiveness and treatment tolerance. results: fourteen patients ( women, men, mean age [min ; max ]) were treated with chlormethine gel in our hospital. twelve ( %) were treated three times per week, ( %) once a day. before treatment by chlormethine gel, ( %) patients were treated by dermocorticoids, ( %) by dermocorticoids and phototherapy, and ( %) by bexarotene, all of them stopped their treatment on account of inefficacity. one ( %) patient was treated by carmustine and dermocorticoid, and ( %) by only carmustin, all of them stopped it because of supply disruption. one ( %) patient received it in first line therapy. ten ( %) patients showed a response (partial or complete), one ( %) experienced a stabilization of his disease. before treatment with topical chlormethine, seven patients ( %) had an involved bsa [ % and four of them ( . %) experienced adverse effects. seven patients ( %) had an involved bsa \ % and three of them had ( . %) side effects. a total of seven patients ( %) presented at least one adverse effect. five patients ( %) stopped the treatment on account of adverse effects; two of them ( %) interrupted it temporarily. reported side effects were: irritant dermatitis and erosive toxicity ( ), rash ( ) and telangiectasia ( ) . conclusion: our results indicate that chlormethine gel can be effective to treat mycosis fungoides. however, it involves side effects that seems to be more frequent than those observed with chlormethine solution (used for skin application). indeed, the french national authority for health reports % of adverse effects for chlormethine solution versus % in our study for chlormethine gel. moreover, telangiectasia was never documented with chlormethine. this significant number of side effects of chlormethine gel can be explained by the gel formulation which induces patients to apply more product, especially in patients with plaques affecting more than % of the bsa. it is important to explain to patients to apply a thin film of chlormethine gel to involved skin areas and allow the skin to dry completely. sophie dumas *, , capucine devaux , nathalie le guyader diaconesses croix saint-simon hospital, diaconesses croix saint-simon hospital, paris, france please specify your abstract type: descriptive abstract (for projects) background and objective: aprepitant, a neurokinin- receptor antagonist, prevents nausea and vomiting due to high and moderate emetogenic chemotherapy in combination with other antiemetic agents. it induces cytochrome p (cyp) c and moderately inhibits cyp a . drug-drug interaction could occur with intravenous anticancer or antiemetic drugs metabolised by these isoenzymes. it may lead to adverse effects or loss in efficacy. regarding recent international antiemetic guidelines, emergence of new intravenous chemotherapy and lack of bibliographic data, a report on aprepitant interactions is performed in oncology. the aim of this study is to review pharmacokinetic interactions with aprepitant in order to prevent potential toxic effects of intravenous anticancer or antiemetic agents and provide the best patient care. design: anticancer and antiemetic agents metabolised by cyp a and c were identified. pharmacokinetic literature review was performed using medline Ò database and laboratory data. clinical assessment and non-aprepitant pharmacokinetic studies were excluded. a table was established to summarize data. results: ten intravenous anticancer agents used in oncology are identified as cyp a substrates. pharmacokinetic assessments are achieved for docetaxel, cyclophosphamide, vinorelbine, irinotecan and trabectedin. studies dealing with the five other drugs are strictly clinical assessments. among the different pharmacokinetic studies, only trabectedin showed relevant interaction with aprepitant. in this association, aprepitant dose needs to be adjusted. cyp c catalyses the cyclophosphamide activation pathway with minor contribution. however, it would have few repercussions on cyclophosphamide pharmacokinetic. corticosteroids and hydroxytryptamine type ( ht- ) receptor antagonists are also metabolised by cyp a . aprepitant significantly increases corticosteroid plasma concentrations. in this case, corticosteroid dose adjustment should be applied. furthermore, no interaction has been found with ht- receptor antagonist. conclusion: regardless of the emetogenic level of anticancer agents, all drugs have been studied because of theirs potential combinations. two relevant pharmacokinetic interactions have been demonstrated leading to dose adjustment recommendation. corticosteroids doses, in association with aprepitant, should be reduced one-fourth for intravenous form and one half for oral form. aprepitant first dose should be decreased to mg when it is co-administrated with trabectedin. these two results lead us to re-evaluate our prescription practices. please specify your abstract type: research abstract background and objective: nsaids are associated with serious adverse reactions which in turn are responsible for significant risks of morbidity and mortality. the aims of this project is to identify risks involved in nsaid administration including over-usage and significant drug interactions, and to analyse occurrence of side-effects. the trends of nsaid prescribing by physicians and pharmacists are also determined. setting and method: a pharmacy from each electoral district was chosen by stratified sampling. a sample population (n = ) was obtained from pharmacies in malta. data was collected through the completion of questionnaires carried out by the patients. the trends of nsaid prescribing were determined by another questionnaire directed to pharmacists and physicians that was available online. main outcome measures: use of nsaids by patients and prescribing trends. results: back pain (n = ), muscular pain (n = ), headache (n = ) and arthritic pain (n = ) accounted for the most frequent use of nsaids. diclofenac accounted for the most commonly administered nsaid, taken by of the patients, of which use the mg dose. chronic disorders of symptoms experienced by the patients included hypertension (n = ), heartburn (n = ), dyspepsia (n = ), asthma (n = ) and a history of helicobacter pylori infection (n = ). other disorders suffered by single individuals include epilepsy, crohn's disease and renal dysfunction. more than half of the respondents (n = ) admitted to self-prescribing regardless the fact that the majority of nsaids are prescription-only medications. epigastric pain ( . %), stomach ulcers or gi bleeding ( . %) and elevated blood pressure ( . %) were the most common sideeffects that pharmacists and physicians come across. nsaids were frequently found to be co-administered with antihypertensives ( . %) and ssris ( %) regardless of their significant risks of interacting with nsaids. . % of the pharmacists and doctors believe that nsaids are being over-used and . % state that closer monitoring of nsaid adverse effects is necessary. conclusion: the risk involved with nsaid administration due to over-usage and drug interactions is identified, and healthcare professionals are aware of this risk. pierre leduc, antoine lanneluc, christophe gellis * , sylvie poux, dominique plats, regine larnaudie corrèze, ch brive la gaillarde, brive la gaillarde, france please specify your abstract type: research abstract background and objective: proton pump inhibitors (ppi) are widely prescribed in hospital while their long-term use may be responsible of many potentially serious long-term side effects (hypomagnesemia, neutropenia, gastric cancer) and drug interactions (ppi are inhibitors of cyp c ). the objective of this study was to assess the appropriateness of ppi prescriptions in a geriatric department in order to optimize their conditions of prescriptions. setting and method: this prospective study involved patients hospitalized between january and april in a geriatric department. the accordance of the prescriptions with the marketing authorization indications and the french guidelines was analysed. data collection was done using a table excel. main outcome measures: collected information were related to patients (age, sex) and ppi prescriptions (active substance, administration route, dosage, duration of therapy, therapy indication and reassessment of ppi therapy). results: ninety-one patients were included: sr: . , mean age: . years [ ; ]. ppi therapy prevalence over the period was %. the ppi were prescribed in the geriatric department in patients (mostly esomeprazole) whereas patients had ppi therapy (mostly esomeprazole) at the admission, for more than years in patients. oral route was the most frequent one (n = ). ppi were administered once a day and only three ppi were administered in the morning. % of ppi prescriptions were considered unjustified; the indications were prevention of haemorrhage with antiplatelet therapy (n = ), prevention of haemorrhage with corticoid (n = ), prevention of haemorrhage with anti-vitamin k (n = ), dyspeptic disorders (n = ), gastralgy (n = ) and others reasons (n = ). % of ppi prescriptions were considered relevant. the reassessment of ipp therapy (n = ) lead to prescribe another dosage (n = ), to stop therapy (n = ) or no change (n = ). conclusion: the study showed that the majority of ipp prescriptions were not in accordance with french guidelines. limiting the prescription to the indications, reassessing the therapy or respecting the therapy duration should reduce the risk of long term side effects and the economic burden of ppi in a long term use. please specify your abstract type: descriptive abstract (for projects) background and objective: to evaluate the effectiveness and safety of the use of high dose of tigecycline ( mg followed by mg every h) a tertiary care hospital. design: retrospective observational study. period: january to december . inclusion criteria: episodes use of tigecycline ( mg followed by mg every h. exclusion criteria: time less than days treatment. data source: corporate program stories electronic health. results: we identified episodes in patients ( men, mean age: years ( - )). treatment was directed to multidrug-resistant organism infection in cases (seven klebsiella pneumoniae oxa- , two enterobacter cloacae, two enterococcus faecium and one methicillin resistant staphylococcus aureus. in one episode they coincided e. cloacae and e. faecium). in cases had severe sepsis or septic shock (seven abdominal focus, six respiratory focus and one unknown focus). the median number of days of treatment was ( - ). tigecycline was administered as monotherapy in three cases, bitherapy and triple combination therapy in . the antibiotics were associated were: beta-lactam ( ), aminoglycosides ( ), quinolones ( ) colistin (three, two inhaled cases), cotrimoxazole ( ) and vancomycin ( ) . in episodes produced clinical and/or microbiological resolution and antibiotics are rotated by progression picture or lack of improvement, death occurred in three cases and was suspended on suspicion of hepatotoxicity. among the seven episodes of klebsiella pneumoniae oxa- infection there were four pneumonias, three with favourable evolution and one patient died, two bacteraemia, both with resolution clinical and microbiological, and one urinary tract infection resolved. among the episodes in severe/ septic shock were five cures, six cases of antibiotic rotation progression or lack of improvement and three deaths while patients receiving therapy tigecycline. patients showed an adverse effect possibly related to therapy tigecycline: diarrhoea after days of treatment and case of liver toxicity after days of tigecycline and piperacillin-tazobactam which led to their withdrawal. int j clin pharm ( ) : - conclusion: tigecycline has been used in double dose defined in data sheet especially in situations of severe sepsis or septic shock and infection multiresistant microorganisms. the effectiveness is conditioned by the clinical situation patient, being worse in severe/septic shock sepsis. tigecycline high dose was well tolerated and there was only a case of stopping the medication for suspected damage hepatic. di : wikipedia and medicines: who edits medicine articles on the english wikipedia? kristian husvik skancke , kristian svendsen *, department of history, uit -the arctic university of norway, hospital pharmacy of tromsø, tromsø, norway please specify your abstract type: research abstract background and objective: the medical profession and pharmacists are divided on the usability of wikipedia for looking up health information. nevertheless wikipedia is widely used, more than half of us physicians and percent of all medical students use wikipedia as a source of health-related information. there is a potential for incorrect and biased information being added by the pharmaceutical industry. the aim of this project was to examine who edits wikipedia articles on medicines and to investigate whether the pharmaceutical industry edits these articles. setting and method: two different groups of articles has been examined; the top ten bestselling medicines (substances) in the world in and the ten most recently approved medicines on the european market (until december ). the top ten medicines were selected from a consultancy report by evaluatepharma/ep vantage. the ten most recently approved medicines (new substances) were found on the european medicines agency webpage. we queried the english wikipedia on january and information from the edit history and the editors' user information were extracted. unregistered editors were checked using a whois service. for the new medicines all editors were checked, while for the bestselling medicines large edits and initial edits was checked. main outcome measures: edits suspected of being made by the pharmaceutical industry. results: ten bestselling medicines: there are many users editing these articles and/or watching them, limiting the risk of misinformation from the industry. there was no indication that the pharmaceutical industry had edited any of the articles. ten most recent medicines: no article existed for dasabuvir. for the nine other substances there were relatively few editors and watchers. in four out of the nine articles we found evidence of edits from the pharmaceutical industry. these edits, were done by registered editors with very few edits except for the medicine in question and they had made large additions to the articles sometimes even before the medicine was marketed. conclusion: the pharmaceutical industry seems to edit articles about medicines on english wikipedia however we found no evidence of harmful edits and bestselling medicines have many editors monitoring the quality of articles. please specify your abstract type: research abstract background and objective: the pharmaceutical professional service of the monitored dosage systems (mds) tries to improve the adherence of the patients to the treatment. the aim was to analyse the relevance of the repackaging of the most sold medicines in our country being used by patients included in the mds professional service and to determine the information discrepancies according to the source used by the pharmacist. setting and method: cross-sectional descriptive study. community pharmacy and healthcare institutions. all the patients included in the pharmaceutical professional service of mds on june , . data source: patients' records in the professional service, database of medicines ranked by sales in units in our country to december ( medicines), information sources on medicines: ( ) vademecum of medicines and ( ) the centre of drug information of our agency of medicines. main outcome measures: number of institutionalized and ambulatory patients included in the professional service of the mds and demographic characteristics, sum of different repackaged medicines belonging to the studied patients, analysis of the repackaged medicines of major use, number of discrepancies on the repackaging of the medicines according to the information source. results: patients were included in the professional service of the mds. of them were institutionalized (average age: . years, . % men, . % polymedicated defined as using c prescribed chronic medicines) and the remaining were ambulatory (average age: . years, . % women, . % polymedicated). different medicines prescribed in the institutionalized patients were taken into account, of them included in the sales ranking in our country. according to the first source, of medicines were eligible for repackaging, medicines could be repackaged according to the laboratory manufacturer and the remaining ones could not be repackaged. according to the second source, of medicines could be repackaged, and the remaining ones could not. different medicines prescribed in the ambulatory patients were taken into account, of them included in the sales ranking in our country. according to the first source, of medicines could be repackaged, medicines would depend on the laboratory manufacturer and the remaining ones could not be repackaged. according to the second source, of medicines could be repackaged, and the remaining ones must remain in the original package. discrepancies were observed in the information for ( . %) and ( . %) medicines in institutionalized and ambulatory patients, respectively, based on the sources used. conclusion: a considerable number of discrepancies in the information on the relevance of the repackaging of medications in the mds were found between two analysed sources. these findings have already improved the quality of this professional service. it would be necessary to alert the pharmacist of the existence of the above mentioned discrepancies to be able to prevent errors from occurring at the time of repackaging the medicines in the mds and, thus, increasing patient safety. please specify your abstract type: research abstract background and objective: despite the global advances of pharmacy practice and subsequently pharmacy education, students experience insufficient opportunities to practice the activities, tasks and processes essential to deliver pharmaceutical care. objective: to describe the development, implementation, and assessment of a clinical pharmacy practice (cpp) experience course in internal medicine, cardiovascular, respiratory clinics and drug information centre that is newly integrated into pharmacy curriculum at a university in north cyprus. setting and method: a weeks structured pharmacy practice experience was designed for fifth year students. student competence was assessed using formative osces and summative written exams before and after the course, and mapped in eight main cpp competences. the course utilized a wide variety of learning and practical activities including rounds participation, morning case reports, interdisciplinary activities, carrying interventions, role-play, direct patient care, formal case presentations, journal clubs and answering drug queries. competencies tested and strengthened include: taking medication history, response to the symptoms, pharmacotherapy knowledge application, comprehensive patient assessment, data interpretation using evidence-based approach, public health counselling, drug related problems management, patient counselling and communication skills. student perceptions and experience was assessed using semi-structured group interview and a questionnaire. main outcome measures: student scores in osce; student's perceptions. results: student reported that the course met pre-set objectives with substantial learning in different areas of cpp. students scored best in communication skills ( . ± . %), public health promotion ( . ± . %) and patient counselling ( . ± . %) than in resolution of drps ( . ± . %) and pharmacotherapy application ( . ± . %), while they significantly enhanced in di manipulation ( . ± . %) compared to baseline assessment ( . ± . %)(p = . ). conclusion: the course provided a rich experiential learning environment rather than just theoretical knowledge of clinical pharmacy. students well perceived the course structure assessment and knowledge attained. this could be implemented in other faculties of pharmacy through turkey. please specify your abstract type: descriptive abstract (for projects) background and objective: clinical pharmacy and clinical pharmacology have many similar aspects. both areas present professionals who have groundings in drug therapy principles and who aim to optimize the efficacy and safety of therapies for patient's benefits. however, there are clear distinctions. clinical pharmacologists are in general doctors with an additional education in clinical pharmacology. many of these are prescribers of drugs in practice but are in usual connected to academic parts responsible for education and research. they belong to a well-recognized but small sub-specialty of medicine. in contrast, clinical pharmacists are part of a much greater group of professionals working in most hospitals in developed countries. while the former one is restricted and subordinate to distributing the drugs requested by the medical prescribers, the role of the pharmacist has increasingly developed to encircle monitoring outcomes of medicine treatment and report management, patient safety and budgetary responsibilities. pharmacists are currently capable to take on prescribing responsibilities in developed countries and have been actively involved in collaboration in practice of prescribing with doctors. they also take on a great part in education related to rational prescribing that was once thought the area of the clinical pharmacologist. given the difference in size of the two areas there is understandably increasing confusion in the minds of managers in health services as to the continuing role and identity of clinical pharmacology. this may illuminate, in part, the diminishing in numbers and visibility of clinical pharmacologists in certain countries. in fact, some might see the continuous development of clinical pharmacy as a direct danger to the viability and future existence of the specialty of clinical pharmacology. however, clinical pharmacy and clinical pharmacology working synergistically would serve for the well-being of the public. design: . results: . conclusion: . maxime apparuit *, , lea boissinot , ngauv melodie , stephanie charles weber , isabelle lopez , françois chast pharmacy, hopital cochin, pharmacy, hopital hotel-dieu, paris, france please specify your abstract type: descriptive abstract (for projects) background and objective: hereditary angioedema (hae) is a rare disease characterized by episodic attacks of swelling which can be life-threatening. treatment for hae involves prophylaxis and management of acute attacks. the objective of this study was to evaluate patients' knowledge of their disease and their treatment. design: a questionnaire about the disease and drug treatment has been implemented. it was distributed to patients through either a pharmacist during patients stay at the hospital, or the french association des malades souffrant d'angioedèmes (amsao). answers were collected by electronic or conventional mail. results: patients completed the questionnaire. the average patients age is . ± . years. all of those interviewed could name their disease. for % of patients, the crisis happened unpredictably but in most cases a triggering factor was described, such as stress ( %), fatigue ( %) or an emotional shock ( %). oedema were located mainly in extremities ( %), abdomen ( %), ent sphere ( %) or face ( %). patients ( %) reported having more than crisis each year (eligible to prophylaxis), among them, patients ( %) said they had no preventive treatment. all patients knew the difference between prophylactic and curative treatment of crisis. among the patients receiving treatment for crisis, were able to define which treatment to be used depending on the intensity and location of the crisis. the majority of patients used icatibant during a crisis, but the most frequently cited prophylaxis treatments were tranexamic acid ( %) and danazol ( %). for injectable drugs to treat acute episodes, icatibant (subcutaneous) and c esterase inhibitor (intravenous) were self-administrated respectively in and % of patients. conclusion: this study showed that patients generally knew their disease and its treatment. however, they are insufficiently informed on drugs to be used according to the clinical situation and especially intravenous self-administration. therefore, it seems necessary to increase pharmacist involvement in patient's information about therapeutic strategy and drugs routes of administration. this for a major objective: an optimal self-care in a skilled patient. please specify your abstract type: descriptive abstract (for projects) background and objective: hospital pharmaceutical educations (hpe) on patients with oral anticoagulant (oa) can improve their overall management by providing skills on proper use. an ambulatory monitoring is necessary to ensure good compliance and understanding of the treatment. our study aimed at the establishment of hpe for patients with oa, the establishment of a hospital-city link in burgundy, and an evaluation of the expectations of ambulatory health professionals (ahp). design: the development of hpe has been performed in our centre for patients with oa and assessed between may and september . in order to ensure continuity in their support, patients then received a binding document to the attending physician, pharmacist and nursing home stating the treatment and acquired skills. a satisfaction survey, with anonymous electronic questionnaire circulated by the representative boards evaluating the expectations of ahp, took place in order to improve and make the programme more attractive. results: two hundred and ninety-one patients could benefit from hpe and came out with an oa. one hundred and forty-three answers were collected: officinal pharmacists and nurses. ninety-seven percent of ahp have judged relevant the following stated security goals: the name of the drug, its use, its risks and to be able to inform all ahp. ''associated pathologies and treatments,'' ''the last coagulation test'' and ''potential factors for non-adherence'' seem necessary for the binding document. more than % of participants found that this action will facilitate the establishment of pharmaceutical anticoagulant educations in cities, the dialogue around the oa with the doctor, patient's compliance and will secure the treatment. conclusion: hpe certainly help patients. its implementation for patients with oa in our hospital has generated a real interest. the addition of an ambulatory link allows continuing at best their support. the questionnaire has also allowed us to know the opinions of ahp involved and some improvements to the binding document may have been done. participants were asked to associate the task to the profession by determining whether each profession had the main responsibility for undertaking the task, a supportive responsibility, or whether they should not be involved at all. data was analysed using spss Ò, version . the chi squared test was used to assess any significant association between categorical variables. main outcome measures: perception of the oncology pharmacist's role by healthcare professionals. results: from a total of completed questionnaires, it was found that for tasks listed as ''patient education and counselling'', % were considered as the pharmacists' main responsibility, whereas % were believed to be supportive roles. main tasks included educating the patient regarding which medication to avoid during their treatment. for tasks listed as ''drug related problems'', and % of tasks were found to include pharmacists as having main and supportive roles respectively. supportive tasks included dose calculation of anti-tumour therapy required per patient. in the ''authorisation of medication'' category pharmacists' main roles carried a total of % and supportive that of % of the total number of tasks. this included ordering anti-tumour medication. further analysis of data revealed that years of experience did not have a significant association with results obtained (p-value = . ); however physicians, pharmacists and allied healthcare professionals were found to involve the pharmacist most extensively (pvalue = . ). conclusion: tasks associated with the pharmacist were representative of the current role they possess within the oncology setting; however this association was limited to professionals having a close working relationship with pharmacists. this may be due to the lack of an established multidisciplinary team approach within this scenario thus limiting the perception of the oncology pharmacist's contribution. an implemented multidisciplinary team may improve communication between the professionals involved and optimises patient care. the aim of the study is to analyse from a qualitative and quantitative point of view the pharmacy resident's activity in pneumology service. setting and method: the study included all the daily prescriptions of three units of pneumology from january to april . pi and data were extracted from the software pharma Ò and collected in a summary excel Ò table: nature of potential errors, nature of the proposals offered by residents, way of transmitting pi, and rate of pis' acceptance. main outcome measures: potential errors are collected by following the validated and standardized criterions of french society of clinical pharmacy. results: over months, lines of prescriptions from patients aged years old (median [ - ]) were evaluated. sex ratio (m/f) was . . one hundred and two medication problems have been found: overdose ( . %), contraindication (ic) ( . %), under dosage ( . %), wrong rhythm of administration ( . %), forgotten treatment ( . %), dose unit error ( . %), antibiotic indication missing ( . %), drug not listed in the hospital formulary ( . %), potassemie unchecked ( . %), dose unadapted to renal function ( . %) or to inr ( . %), treatment not indicated ( . %), wrong administration route ( . %), antibiotic unreevaluated ( . %), redundancy ( . %). the proposals made to the doctors were: stopping treatment ( . %), posology adaptation ( . %), substitution ( . %), dose unit modification ( . %), adding information about the indication ( . %), treatment renewal ( . %), administration modalities changing ( . %), biological monitoring ( . %), therapeutical monitoring ( . %), antibiotic treatment reevaluation ( . %). all pi were made by informatical way. all medicinal classes were found in this study. hydroxyzine, cyamemazine and escitalopram were often found in contraindication errors. they are involved in cardiac disorders with qt extension. pis' acceptance rate was %. conclusion: this study shows the importance of pharmaceutical analysis on the quality of access to healthcare. the statement of pi allows us to identify the most frequent errors, warn and prevent doctors from these potentials errors by proposing solutions. the rate of acceptance is high which means that doctors agree with our proposals. pharmacists' implication in clinical pharmacy activities and their participation to medical rounds will improve this activity and by the way optimization of the management of the patient. please specify your abstract type: descriptive abstract (for projects) background and objective: ppis consumption is largely practiced in europe, because of their excellent tolerance in short time, and their misuse with regard to indications, dosage and treatment duration (in , france was the nd,ppi consumer in eu). the result is drug iatrogenic disease and unjustified expenses in health insurance. objectives: assess the ppis consumption and appreciate conformity according to the latest recommendations for relevant prescriptions of ppis. design: prospective study via an audit (model created internally), every hospitalized patients with a ppis prescription, in two hospitals, on a given day. data collected through the patient's medical record. prescriptions conformity defined, by taking account of indication level ( : approved by the ma (marketing authorization), : non-valid but certified by international publications or learned society, : nonvalid without scientific proofs, : non-indicated), dosage and treatment duration. analysed situations with no conformity (inappropriate dosage despite conform indication, treatment duration unjustified and ppis prescribed in wrong indications ( and ) . results: patients have ppis prescriptions ( male, £ years] among patients ( %). % ppis prescriptions began during the hospitalization. ( %) of the ppis prescriptions are in accordance with the experiment (indication + dosage +treatment duration), as well in community than in hospitals. details: indication level ( . %), indication level -gi bleedings-( . %). of the ppis prescription aren't in accordance. details: treatment duration ( %), dosage ( %), indication level -prevention of iatrogenic bleeding risk without nsaids prescription-( %), indication level ( %). regarding level indications, ppis are always taken with anticoagulant and/or platelet aggregation inhibitors and/or corticoid. conclusion: the part of ppis prescriptions in this study is high. the majority of non-conformity is caused by ppis prescribed with an indication level . the improvement program will involve feeding back ppis' good use, to educate physicians (junior and senior) about the relevant ppis prescription and give advice in complex situations (indication and ). in collaboration with prescribers, shutdown protocol of ppis, prescribed in long term, could be implemented in order to avoid the acid rebound effect after brutal treatment discontinuation. hp-ce : impact of a self-management program on inflammatory bowel disease patient in a university hospital caroline egon * , xavier pourrat please specify your abstract type: descriptive abstract (for projects) background and objective: inflammatory bowel disease (ibd) is a group of chronic inflammatory diseases that affects the colon and the small intestine. crohn's disease and ulcerative colitis are the principal types of ibd and involve severe diarrhoea, pain, fatigue and weight loss. ibd affects young adult with an increasing annual incidence ( . million concerned people in europe). patients with ibd are affected by somatic or psychosocial problems and patient education may contribute to their well-being. since september , individual educational sessions have been set up and since september , collective educational sessions. these sessions have been developed to improve patient's understanding of treatment options and medical adherence. the aim of this study was to demonstrate that a therapeutic education program (tep) could have a significant effect on ibd patient's skills with regards to their disease. design: after individual education sessions with a nurse, a group education session was introduced for outpatients with ibd. the collective session include approximately six to ten patients and is organized in a half day workshops (about disease and treatment) conducted by a multidisciplinary team. the workshops were performed by an education nurse, two hospital gastroenterologists, two hospital pharmacists and a community pharmacist. these sessions were wrapped up by a short satisfaction and knowledge questionnaires. results: in total, ibd outpatients participated to the educational program, patients with crohn's disease and patients with ulcerative colitis ( . % male; median age: ). for the individual educational sessions, two competence questionnaires were performed about anti-tumour necrosis factor alpha (tnfa) therapy: one about general knowledge, another one about self-administration subcutaneous injection. patients completed these questionnaires. for the collective educational session, the competence questionnaire developed consisting of six questions covering few items: disease, symptoms, treatment and complications. patients completed this questionnaire. after the questionnaire, each participant received a summary document about drugs, side effects, therapeutic and medical advice. conclusion: the patient education program contributes to the improvement of self-management skills when it comes to ibd. pharmacists joining medical specialists and nurses provided pharmaceutical care with a positive impact on compliance, which is a determining factor for the success of the treatment and the quality of life in patients living with an ibd. this program will be continued and a new program for teenagers is to be established as well. hp-ce : desensitization study of paclitaxel and carboplatin drug in the ovary tumor protocol in cuf descobertas hospital miguel  . freitas * , daniela brites, ana bota pharmacy, hospital cuf descobertas, lisbon, portugal please specify your abstract type: descriptive abstract (for projects) background and objective: the hospital pharmacy should be an integral part of the multidisciplinary team and implement strategies that meet the patient's needs. pharmacy, in oncological area, is in constant renewal. josé de mello saúde uses paclitaxel/carboplatin protocol as first line in ovarian tumor. although the antineoplastic agents are essential for the treatment of cancer, they can also cause hypersensitivity reactions, which may carry serious consequences. both immunoallergologist and oncologist create a desensitization protocol, which allows the reintroduction of the drug with greater security. the desensitization protocols involves the gradual administration of small quantities of the drug, resulting in a refractory period of the white blood cells (mastocytes) and a lower production of cytokines until the dose has been totally administrated. objective:to evaluate the efficacy of methods used to prevent and treat hypersensitivity reactions of carboplatin and paclitaxel, in order to carry on the treatment. design: a retrospective review of the patient files was performed in the day hospital between and . we included only patients with moderate to severe immediate hypersensitivity reactions (b h) receiving carboplatin and paclitaxel. the desensitization protocol brigham and women's hospital was applied using three solutions with increasing concentrations (dilution : , : and : ) in twelve successive steps for about h. results: in the period - were desensitized five patients with platinum group drugs, carboplatin (n = ) and paclitaxel (n = ) and the total elapsed six desensitization. almost all patients reached the scheduled daily dose, except a patient, which suspended the desensitization program for disease progression. conclusion: the desensitization protocol allowed the successful reintroduction of antineoplastic drugs in patients with a history of hypersensitivity reactions, in order to treat the disease. please specify your abstract type: research abstract background and objective: in the context of harmonization of clinical pharmacy activities within our region, a common medication reconciliation project was developed between two general hospitals. the objectives of this study were to initiate, a common medication reconciliation activity in the two hospitals, to analyse the results, and to communicate to all professionals in the area. setting and method: a working group composed of pharmacists of each hospital was formed to develop analytical documents. a -month prospective study was conducted in two general hospitals: in the first one, in an emergency department, and the other one, in a medicine department. patients included in the study were either elderly and/or had polypharmacy and/or were hospitalized for iatrogenic reason. at int j clin pharm ( ) : - the point of admission and discharge for each patient, the pharmacist has completed a conciliation record, and has detected potential discrepancy. unintentional discrepancies were reviewed and corrected by doctors. at the discharge, medication changes were sent to general practitioner and community pharmacies. a satisfaction survey about this process was sent to healthcare professionals (gp, pharmacist and nurses). a medication reconciliation's workshop was organized for a hundred healthcare professionals in the area. main outcome measures: at the point of admission, the conciliation record included the list of patient's home medication, admission medical orders, and the types of discrepancies. at the discharge, drugs prescribed were compared to admission medical orders. the satisfaction survey included seven questions to assess the process. results: during the study period, patients were included corresponding to prescription lines. reconciliation process required about min per patient. we identified at admission unintentional discrepancies. the most common unintentional discrepancy was the omission of medication ( %). % concerned alimentary tract and metabolism group. at the discharge, no discrepancies were found; the process required min per patient. % of healthcare professionals answered to our satisfaction survey to date. % are satisfied and believe that the process of medication reconciliation secures the patient medicinal treatment. healthcare professionals were present at the medication reconciliation's workshop, indicating an interest in the process. conclusion: in this experience of medication reconciliation, due to unintentional discrepancies observed, we had better implement this activity in the two general hospitals. a pharmacist devoted to this activity will be hire in each hospital. this relevant practice is well accepted by clinician. thus, we will improve communication with gp and community pharmacies. please specify your abstract type: descriptive abstract (for projects) background and objective: the sickle cell disease (scd) is a genetic, chronic disease, paroxystic in its unpredictable and polymorphic acute events. this most frequent genetic illness in the world is a major public health concern in french overseas territories. haute autorité de santé (has) recommendations for the care of scd advocate the development of therapeutic patient education (tpe). in martinique (french west indies), we consider the population of patients with scd in among which are followed in the adults sickle cell centre (ascc). one of the actions carried out by the ascc of our hospital is the tpe. the objective is to set up an original (because specific in the scd) tpe method, which enables the patient to live better with his disease on a daily basis, by teaching him and his family to recognize prematurely certain complications. design: we analysed needs from the outcomes of a national french survey has which one participated martinique and retained the following themes: the red blood cell, the genetic transmission, the main symptoms, the role of the water, the medicinal treatments and the questions of everyday life. we chose the innovative educational tools called the ''malles des savoirs Ò **'', a set of unusual experiments, accessories and models, which, by using a method of active pedagogy ''omca*: observer, manipuler, comprendre, agir ***'', value the learner by offering to him to manipulate and to experiment by himself. results: in , healthcare professionals (doctors, pharmacists, nurses) and a president of patients with scd association followed one week of formation in the omca* method for the animation of six workshops for - teenagers and adults. every ''malle des savoirs Ò **'' contains the necessary material for the animation and a guide of the organizer, including, for every tackled issue, a generic introduction, a presentation of the themes, the index cards of educational animations proposing the activities and one time of synthesis grouping the approaches concepts. the interactive manipulation allows the appropriation of the discoveries become then long-lasting experiences. a final evaluation allows to spot the problems met by learners to understand, to analyse the difficulties and to proceed to the useful adaptations during the next activity. conclusion: this tool, playful and perfectly adapted to the scd, engages, accompanies and helps patients in the construction of their own knowledges to return them actors of their disease. in , we shall estimate the impact of the development of this specific tpe programme of the patient with scd. please specify your abstract type: research abstract background and objective: to investigate the frequencies and clinical relevance of unintentional medication discrepancies, between preadmission medication lists and discharge medication lists, at discharge from hospital. a discrepancy is considered unintentional if there is no documentation explaining the intent of the medication change or if it is unintentional according to the prescribing physician. setting and method: systematic literature review. main outcome measures: frequency of unintentional medication discrepancies per patient and per medication; frequency of clinically relevant medication discrepancies. results: of the patients included - % experienced at least one unintentional medication discrepancy. of the medications used by the patients, - % were involved in unintentional medication discrepancies. of unintentional medication discrepancies found in five studies, - % were clinically relevant. conclusion: the review documented a high frequency of medication discrepancies, of which many were clinically relevant. ensuring sufficient communication of correct and complete medication information in transitions of care is a process which should be better implemented, to enhance patient safety. please specify your abstract type: research abstract background and objective: to investigate the frequency of medication changes not documented in the discharge letter, at discharge from hospital, for both regular, as needed and over-the-counter medications, supplements and herbal remedies (otc). secondary, differences between variables and patients with undocumented medication changes were investigated. setting and method: the patients included were all part of the intervention groups from an intervention study, conducted by one of the authors (tg), from april to december . the best possible discharge medication list was compared against the medication list in the discharge letter and any discrepancy between the two lists was noted, taking into account the text in the discharge summary. main outcome measures: the proportion of patients affected by at least one undocumented medication change at discharge and proportion of medications with undocumented changes. the proportion of patients was compared using a test according to gender, age, number of preadmission/discharge medications and length of hospital stay. results: two hundred patients were included in the study. the proportion of patients experiencing at least one undocumented medication change for the three subgroups: regular medications; as needed; otc, were , and % respectively. the proportion of medications involved in undocumented changes for the three subgroups were , and % respectively. the proportion of patients experiencing undocumented medication changes was significantly higher in patients with more than five regular medications at admission, (p \ . ) and at discharge (p \ . ). in both regular and as needed medications, the proportion of patients experiencing undocumented medication changes was higher in patients hospitalized longer than days (p \ . and p: \ . respectively). for otc, the rate of patients experiencing undocumented medication changes, was higher in females (p: \ . ). conclusion: a high proportion of patients are affected by at least one undocumented medication change and many medications are involved in undocumented changes. correct and complete medication information at admission and discharge may resolve many of these errors, ensuring patent safety at transitions of care. hp-ce : participation in courses at learning and mastery centre and the impact on patients' beliefs about medicines merethe nilsen *, , erik oie , kirsten k viktil diakonhjemmet hospital pharmacy, department of internal medicine, diakonhjemmet hospital, oslo, norway please specify your abstract type: descriptive abstract (for projects) background and objective: patients with chronic diseases are referred to learning and mastery centre (lmc) where the main objective is to support patients to cope with chronic diseases. education about the disease(s) (by a physician) and the medication treatment (by a clinical pharmacist) are important elements of these courses. little is known about how the participation at lmc influences the patients' beliefs about medicines. design: patients c years participating at a days course at lmc regarding acute coronary disease or atrial fibrillation were included in the period september -december . the patients filled out 'beliefs about medicines questionnaire'(bmq) before and immediately after the course, and also months after the course to evaluate their concern (bmq-concern) and necessity (bmq-necessity) of their cardiovascular medications. the bmq scores were dichotomized at scale midpoint (scale - ) to evaluate high and low concern and necessity, and these scores were combined to calculate the 'ambivalence'and 'acceptance', 'sceptical', and 'indifferent'rate to medications, and also the mean scores of the bmq were calculated. results: fifty patients were included, mean age years, % were women, using a mean of . cardiovascular drugs taken regularly. fifty-eight percent of the patients had high concern prior to the course, whereas and % had high concern immediately after and months after the course, respectively. ninety-nine percent of the patients assessed their medication as highly necessary before the course, % immediately after, and % months after the course. the mean score for bmq-necessity was . (sd . ) prior to course and . ( . ) and . ( . ) immediately after and months after the course, respectively. the corresponding scores for bmq-concern were . ( . ), . ( . ), and . ( . ), respectively. the proportions of patients classified to be 'accepting'were , , and % at the three time points, respectively, and the corresponding numbers for patients classified as 'ambivalent'were , , and %, respectively. conclusion: the lmc course had an immediate positive influence on the patients' concern about their medicines and on 'acceptance'. however, the effect seems not to persist over time. a closer follow-up could be discussed. please specify your abstract type: research abstract background and objective: the narrative-based medicine was intended primarily for health care professionals, and the use of narratives can be applied in any settings to better understand the meaning of own profession, to rediscover/strengthen the motivation to work as a team. the italian society of hospital pharmacist (sifo) promotes a qualitative study aimed at getting the real picture of pharmacist's role within the national health system (nhs), the interaction with other health professionals and patients through the narratives of under specialization pharmacists (ui) and pharmacists already working in the nhs (hp). these data can be further investigated to increase the perceived value/role of the pharmacist. setting and method: sifo hps and uis joining the national pharmacy school specialization network were invited to participate. all pharmacists participating to the study were given a semi-structure interview. the methodology was developed within the conceptual framework of the grounded theory (gt) a research methodology that arises in the context of qualitative research. gt is a systematic methodology involving the construction of theory grounded in data systematically gathered and analysed. main outcome measures: analysis of narratives. narratives were analysed according to the classifications of kleinman, frank and launer and robinson together with transitional analysis (ta). results: a total number of narratives were collected ( ups and hps). narratives from both group of participants show the need of strengthening the professional identity already in the early years of the pharmacy curriculum and more effectively during the years of specialization as well as the need of being educated to deliver patientcentred care as members of an interdisciplinary team. conclusion: this is the first step of a study that also includes patient's contribution to the definition of pharmacist's professional identity. hp-ce : impact of pharmaceutical counselling on cancer patients' information desire and treatment satisfaction stephanie wuyts *, , jacques de grève , veerle foulon , hilde collier , pieter-jan cortoos pharmacy, medical oncology, university hospital brussels, brussels, faculty of pharmaceutical sciences, catholic university of leuven, leuven, belgium please specify your abstract type: research abstract background and objective: appropriately educating onco-/haematological patients is a prerequisite to improve patient empowerment, satisfaction and outcomes. objective: to quantify patients' information need and satisfaction on cancer drug therapy and how this can be improved by clinical pharmacist's counselling. additionally, the pharmacist's impact on therapy quality and costs is assessed. setting and method: setting: prospective, randomised study in the ambulatory ( beds) and in-hospital onco-/haematology unit ( beds) in a tertiary hospital. inclusion criteria: adult patients on intravenous or oral cancer therapy, with informed consent. methods: all patients were asked to complete standardised surveys (extent of information desired, eid; patient satisfaction with cancer treatment education, ps-cate and cancer satisfaction of treatment questionnaire, ctsq) on three occasions (at the start of a new therapy, during the second cycle and after months). patients in the intervention group received additional counselling by a clinical pharmacist including medication reconciliation and review. control patients received standard of care (information on drug therapy was provided by the onco-/haematologist, followed by limited administration instructions by nursing staff). main outcome measures: patient information desire and satisfaction on cancer treatment results: patients were included over a period of months (control (n = ); intervention (n = )). no significant differences were found between contact moments or patient groups for eid, ps-cate and ctsq-scores. however, scores for ps-cate on medication side effects were positively correlated with contact moment (r s = . ; p = . ). multiple linear regression analysis showed a similar trend (b = . ; p = . ). patients receiving first-line therapy (b = . ; p \ . ) and ambulatory patients (b = . ; p = . ) were more satisfied on treatment education. the clinical pharmacist documented more drugs than were recorded in the patient file ( vs. . drugs/patient; p \ . ). on average, each patient required two pharmacist's interventions per occasion. intervention acceptance rate on drug related problems was high ( %). during the study, interventions shifted from therapy adjustments towards advice on supportive measures ( st contact: %; rd contact: %). improved medication stock control on the ward led to a savings of € , . conclusion: the clinical pharmacist can play an important role on the onco-/haematological ward, leading to improved drug reconciliation, patient counselling and cost savings. hospitalised patients and patients receiving salvage therapy appear to have higher educational needs, making them possibly overlooked target groups. finally, pharmaceutical counselling should be repeated and primarily focused on side-effect management to have a meaningful impact on patient satisfaction. please specify your abstract type: research abstract background and objective: europe is ahead of the usa and canada on approval, regulatory and marketing aspects of biosimilars. however, there is still uncertainty about interchangeability and substitution of biosimilars. the aim of the study is to assess pharmacists' perceptions about biosimilar interchangeability. setting and method: a cross-sectional study was carried out in june-july . hospital pharmacists from quebec and france were invited to respond to an online survey of nine questions (surveymonkey Ò , palo alto, ca, usa). the survey focuses on pharmacist's exposition to biosimilars (general knowledge, dispensing) and their perceptions about biosimilar interchangeability. a -item likert scale was used to answer to statements based on key issues about biosimilar interchangeability. main outcome measures: levels of agreement on biosimilar interchangeability key issues. results: a total of pharmacists responded ( % in quebec vs. % in france). the global response rate is: % ( % quebec vs. % france) (n = / ). % attended at least to one conference on biosimilars ( vs. %). % had already dispensed biosimilars ( vs. %). more than % of the pharmacists knew that: biosimilars can cause immunogenicity, clinical studies are requested for their approval, automatic substitution is not permitted. % considered that post-marketing surveillance for biosimilars should be reinforced. pharmacists considered that biosimilars are cheaper than the reference product ( vs. %). there was no difference between the level of agreement of french and quebec pharmacists for the statements. pharmacists agree that a list of biosimilar and interchangeable biologic products is necessary ( vs. %), using the international nonproprietary name to prescribe a biological product can create confusion between the reference product and its biosimilar ( vs. %), pharmacists should check if patients already experienced an immunogenic reaction before dispensing a biological product ( vs. %). pharmacists disagree that a biosimilar can be used for all the indications of the reference product ( vs. %). conclusion: perceptions of quebec and french hospital pharmacists about biosimilar interchangeability issues are very similar. this study highlights the need to deal with the lack of clarity of national guidances. clinical studies on biosimilar interchangeability must be conducted in the future to help pharmacists and physicians to take clear-headed decisions. please specify your abstract type: research abstract background and objective: analgesics are essential drugs in hospitals and especially in emergency units. medical and nurse staffs are used to the narcotic status of opioids. for some drugs, a regulatory change to narcotic status can discourage their use. for others, it could limit their access particularly in developing countries; that's why who did not recommend ketamine to be placed under international control (http://www.who.int/medicines/access/controlled-substances/ recommends_against_ick/en/). yet, the french drug agency has recently considered to register drugs containing ketamine as narcotics. the aim of this study was to assess the impact of this possible regulatory change on the pharmaceutical and medical practices in some paediatric french hospitals. setting and method: the survey was conducted in january-february in four parisian paediatric hospitals: four pharmacies, paediatric neurology and anaesthesia departments, intensive care units and pain management services. main outcome measures: pharmacists, clinicians, health managers and nurses were interviewed, using a standardized questionnaire with closed and opened questions, on the drug circuit including ordering, storage, distribution, prescription, administration and destruction. results: all the health professionals (five pharmacists, ten clinicians, five nurses) indicate that the change to narcotic status would not preclude the use of an analgesic drug. they consider that the pharmaceutical aspects (dispensation, storage and transport, etc.) are not limiting, provided that clinical usefulness is demonstrated: short action onset allowing rapid efficacy, short duration of action allowing the replacement by another drugs if needed, and moderate clinical monitoring. change to narcotic status was rather seen as advantageous since allowing better traceability, use and prescription. half of the pharmacies (n = / ) had a computerized register of narcotics and % of care units (n = / ) had a drug staffing in addition to nominative prescriptions, which was used in all care services. the drugs were kept into secured rooms. none of the emergency units (n = / ) had a computerized secured cabinet. conclusion: according to this survey, narcotic status is not a limiting factor for a drug use in paediatric hospitals, when its clinical usefulness is clearly demonstrated. to promote its use, it is important to inform medical and nurse staffs and include it into care protocols. beyond the nominative prescription, implementation staffing is a key step. please specify your abstract type: research abstract background and objective: port-a-cath is an implanted venous access device most commonly used for frequent or continuous chemotherapy administration. however, the procedure and its subsequent maintenance are not free of complications and requires additional intervention by the clinical pharmacist who can provide further patient care to make a positive impact on. to assess the effective provision of appropriate patient counselling offered by a clinical pharmacist on reducing port-a-cath relatedcomplications in cancer patients. setting and method: a controlled prospective observational study carried out on patients newly diagnosed with cancer eligible for chemotherapy administration at the oncology unit. assessment of port-a-cath related-complications were assessed at regular schedule of chemotherapeutic protocols administration. main outcome measures: to assess, reduce and solve port-a-cath related-complications. results: the most significant port-a-cath related complications were skin rash . % (p \ . ) with occurrence in males (n = ) and females (n = ), skin erythema . % with equal occurrence in both genders, followed by skin discharge . % with also equal occurrence in both genders. a high occurrence of skin rash . % occurred among diabetic cancer patients. a significant improvement in port-a-cath related complications after the provision of patient counselling by the clinical pharmacist was observed as skin rash ( . %), skin discharge ( . %), and skin erythema ( . %). conclusion: results of this study pointed out the essential role of clinical pharmacist in argumenting patient care and improving port-a-cath related-complications in cancer patients. please specify your abstract type: research abstract background and objective: polytherapy, frequently used in the elderly, is associated to an increased risk of potential drug-drug interactions (pddis) and adverse drug reactions (adrs). literature demonstrated that medication reconciliation and medication review performed by hospital pharmacists are correlated to drug related problems (drps). aim: to define a structured and feasible model where hospital pharmacists support clinicians identifying drps and promote the safe use of medicines. setting and method: prospective, feasibility study conducted in four internal medicine wards of a hospital in northern italy. inpatients (c years old, treated with c drugs) were consecutively included; the recognition/reconciliation process was performed by pharmacists in order to identify changes between prescription profile at home and during the admission (active principles, dose, administration route). these changes were classified as intentional documented discrepancies (id), not documented (ind), not intentional (ni). prescriptions during the first -hours of hospitalisation were analysed to retrieve drps (ddis, inappropriate medications for elderly, off-label, over/ under dosage, duplications, adrs) then discussed with clinicians. based on literature, referring almost drp in % of patients, a sample size of patients should allow an estimate of drp rate over % (need of intervention) with a % power and a confidence interval of % (software stata version . ). main outcome measures: rate and type of: discrepancies, drps at admission and discharge, pharmacists consultations accepted by clinicians. results: ad interim results are presented. between october/ -february/ , inpatients ( male, . mean age) were included. overall, patients were admitted with drugs used at home and prescribed during the first -hours; pharmacists retrieved discrepancies ( %id, %ind, %ni) and drps, of which % ddis, % off-label, % overdoses, % duplications, % inappropriate drugs, % not notified adrs. the % of drps was known to clinicians and % considered clinically relevant for the patients. please specify your abstract type: research abstract background and objective: hypertension is a major risk factor for cardiovascular morbidity and mortality worldwide, for which management is based on two principal, complementary approacheslifestyle modification and lifelong treatment with antihypertensive medication. adherence to hypertension therapy is a major public health challenge, despite the availability of multiple classes of antihypertensive agents. factors contributing to non-adherence are multifactorial and include intolerances to drugs at standard doses that result in therapy discontinuation. medication intolerance (mi-htn) refers to patients who experience adverse drug reactions (adrs) to at least one antihypertensive medication, without a known immunological mechanism and the need to discontinue them. we sought to determine factors associated with mi-htn and to identify patients' beliefs and concerns about their antihypertensive treatment and medication in general. setting and method: a cross sectional survey consisting of selfreported questionnaires including beliefs about medicines questionnaire (bmq), perceived sensitivity to medication (psm) and quality of life was undertaken in an unselected patients attending a hypertension centre of excellence out-patient clinic based in london. main outcome measures: to determine factors associated with mi-htn and the impact of health beliefs and self-reported perceived sensitivity to medications on mi-htn and bp control. chi squared tests for comparisons between cases/controls and multiple logistic regression analysis were used for statistical analysis. results: participants were included, of which ( %) participants had mi-htn. two-thirds were female (p = . ) with a mean age of ± years (p . ), of whom . % had uncontrolled hypertension (p = . ). calcium channel blockers were the most commonly reported intolerance by drug class followed by diuretics. being female and age [ were statistically associated with a greater likelihood of reporting medicines intolerance (p \ . ). patients who believed that medicines are harmful were [ -times more likely to report mi-htn (p = . ) and -times more likely to have uncontrolled bp ([ / mmhg) (p = . ). patients with high self-perceived sensitivity to medication was -times more prone to mi-htn (p = . ). conclusion: our findings suggests the need for greater focus on behavioural change interventions to both improve patients' perception of the necessity to persist with lifelong antihypertensive medication and allay concerns regarding harmful effects of drugs may help with long term control of hypertension. please specify your abstract type: research abstract background and objective: today, the number of medical problems in heart transplant recipients has increased due to aging and complications common to immunosuppressive drugs. the co-existence or emergence of other disease states such as renal dysfunction, infection, diabetes, obesity, hypertension, hyperlipidaemia, malignancies, and osteoporosis necessitates the use of other medications. the use of these medications in combination with immunosuppressive agents increases the risk of drug-drug interactions. the aim of this study is to identify the frequency and significance of drug-drug interactions for the patients who received cardiac transplantation. setting and method: this retrospective study was conducted at a cardiovascular specialty hospital. all patients who received cardiac transplantation from the same surgery team between and ( years) were included in the study. all data were collected from the medical records of the patients. only the most recent prescription before discharge was analysed for the presence and significance of drug-drug interactions. drug-drug interactions were checked using micromedex(r) interaction checker. main outcome measures: main outcome measures were the frequency and significance of drug-drug interactions. results: a total of patients met the inclusion criteria and prescriptions were analysed. each prescription contained an average of drugs. a total of drug-drug interactions were identified: . % was classified as moderate; . % as major and . % as contraindicated. almost half of all interactions (n = ) included immunosuppressive agents ( . % was classified as moderate; . % as major and . % as contraindicated). conclusion: cardiac transplant recipients were found to have a high number of drug-drug interactions. in order to advise on these interactions which increase with poly-pharmacy, drugs with narrow therapeutic index or drugs that require intensive monitoring, it is recommended to include a transplantation pharmacist in the transplantation team. please specify your abstract type: research abstract background and objective: the aim of our study was to assess the impact of patient education provided by the pharmacist on gylcemic control, medication knowledge level and medication adherence of patients with type diabetes. patients who were diagnosed with type diabetes for at least one-year time and were receiving at least one antidiabetic medication, attending to the outpatient diabetes clinic for the control visit were informed about the study and invited to participate in the study. patients who gave their informed consent were included in the study. setting and method: the setting is a diabetes outpatient clinic of a state hospital. the medication knowledge levels, medication adherence scores, fasting blood glucose levels, hba c levels and blood pressure of the patients were measured before pharmacist's education. after provision of standard information and individualized patient education all these parameters were measured again after monthstime and the impact of the education was assessed. main outcome measures: main outcome measures are change in the clinical parameters (hba c; fasting blood glucose; blood pressure), as well as improvements in medication knowledge and adherence levels. results: the study was conducted on patients who met the inclusion criteria; none of the patients were lost to follow-up. majority ( %) of the patients was female and the mean age was . years. pharmacist intervention resulted in positive outcomes at all clinical parameters. systolic blood pressure decreased by mmhg, while diastolic blood pressure decreased by . mmhg (p \ . ). hba c level decreased by . % (from . to . %; p \ . ) and fasting blood glucose level by . mg/dl (p [ . ). on the other hand, the number of patients reaching the blood pressure goal increased from to ; and those reaching to hba c goal increased from to (p \ . for all). similarly, the medication knowledge level [usual range - ] increased from . to . (p \ . ); and the medication adherence score [usual range - ] increased from . to . (p \ . ). conclusion: it can be concluded that pharmacist's contribution results in positive outcomes in glycaemic control and management of co-morbid conditions of type diabetic patients by improving medication knowledge and adherence levels of the patients. pharmacists should take active role in management of chronic diseases. hp-pc : impact of a pharmaceutical care program on glycemic control, medication knowledge and medication adherence levels of type diabetic patients residing at a nursing home nimet saglam *, , sule apikoglu-rabus , betul okuyan , fikret v. izzettin , nuran yildirim clinical pharmacy department, marmara university faculty of pharmacy, darulaceze nursing home, istanbul, turkey please specify your abstract type: research abstract background and objective: the aim of our study was to assess the impact of pharmaceutical care provided by the pharmacist on glycaemic control, medication knowledge level and medication adherence of patients with type diabetes residing at a nursing home. setting and method: this prospective cohort study was conducted in a state nursing home (darülacaze nursing home) in istanbul, turkey on patients who completed the whole study. all the patients received pharmaceutical care provided by the pharmacist. this pharmaceutical care program was held for months. it consisted of an initial visit, followed by ''care and control'' visits and a final control visit; each visit was held at two-week time intervals. at the initial visit, demographic and general clinical data were collected and medication knowledge and medication adherence levels of the patients were also assessed. pharmaceutical care needs were identified for each patient and recommendations addressing these issues were structured. education regarding the medications of the patients was provided in both verbal and written forms using the standard patient education leaflets prepared by the pharmacist. at each visit pharmaceutical care needs are assessed and pharmaceutical care is tailored accordingly. main outcome measures: main outcome measures are change in the clinical parameters (hba c; fasting blood glucose), as well as improvements in medication knowledge and adherence levels. results: majority ( %) of the patients was male and the mean age was . years. pharmacist intervention resulted in positive outcomes regarding hba c levels. hba c level decreased by . % (from . to . %; p \ . ) and fasting blood glucose level by mg/dl (p [ . ). similarly, the medication knowledge level [usual range - ] increased from . to . (p \ . ); and the medication adherence score [usual range - ] increased from . to . (p \ . ). conclusion: it can be concluded that pharmacist's contribution results in positive outcomes in glycaemic control of type diabetic patients by improving medication knowledge and adherence levels of the patients. pharmacists should take active role in management of type diabetes at the nursing home setting. please specify your abstract type: research abstract background and objective: haemoglobin variability is related to mortality and morbidity in haemodialysis, renal transplantation and pre-dialysis patients. some demographic, haematological and pharmacological variables may affect hb variability. but there are some controversies about the influences of different erythropoiesis stimulating agents (esa).the objective of this study is to determine the influence of different esa on haemoglobin variability in pre-dialysis patients. setting and method: we conducted a prospective observational study with chronic kidney disease patients recruited from outpatients of nephrology department of a tertiary university hospital (from january to june ). exclusion criteria were: stage i and ii, not treated with esa, haemodialysis, peritoneal dialysis, renal transplantation, thalassemia, and deficit of glucose- -phosphate dehydrogenase . main outcome measures: patients included were treated with esa in maintenance phase (stable months prior).hb variability was calculated by standard deviation (sd) and residual standard deviation (residual sd) of hb levels. statistical analysis was performed with spss . (spss inc, chicago). observation period was months and data were recorded from the clinical records. ( ) . %, sofosbuvir/daclatasvir/ribavirin ( ) . %, sofosbuvir/simeprevir ( ) . %, sofosbuvir/ledipasvir ( ) . %, sofosbuvir/ledipasvir/ribavirin ( ) . %, dasabuvir/ombitasvir/paritaprevir/ritonavir ( ) . %, dasabuvir/ombitasvir/pari taprevir/ritonavir/ribavirin ( ) % ombitasvir/paritaprevir/ritonavir/ ribavirin ( ) . %, sofosbuvir/ribavirin ( ) . %. viral load at week was \ iu/ml in patients and at the end of treatment . conclusion: the results of rapid viral response at end of treatment were similar to those obtained in studies published to date. due to its recent access to these treatments it is necessary to continue monitoring these patients to assess virologic sustained response at weeks after end of treatment. please specify your abstract type: research abstract background and objective: fragile patients are considered those vulnerable patients with a certain degree of complexity in their care (polypharmacy, multi-pathological, palliative and/or residents in social and healthcare institutions). to ensure their continuity of care and safety in the use of drugs we applied a medication reconciliation process at admission, transition of care and/or hospital discharge. objective: to analyse the results of the medication reconciliation process of a fragile patient. setting and method: we developed a list of current medication with the following sources of information: medical history, clinical databases and information provided by the patient (interview). clinical case: -year-old woman admitted through emergency department due to severe dyspnoea. no known drug allergy. background: heart failure, chronic hypertension, hypercholesterolemia, hyperthyroidism, hyperuricemia, gouty arthritis, chronic kidney disease and cognitive impairment by alzheimer disease. exploration and complementary tests: echocardiogram and analytical control. clinical judgment: acute decompensated heart failure. acute myocardial infarction. prerenal acute kidney injury. main outcome measures: medication reconciliation made at admission with the detection of discrepancies and deprescribing criteria at hospital discharge. results: fragile patient (high-risk) with medicines as home treatment. patient was hemodynamically stable during the hospital stay. discrepancies were detected between the prescribed medication and the home treatment. discrepancies justified ( ): five by omission of medication (two new clinical situation, two therapeutic exchanges to adapt to the pharmacotherapy guide and one wrong drug) and two beginning of medication. discrepancies unjustified ( ): by omission of medication. to discharge: one antiplatelet therapy was. after the comprehensive review, we made the following recommendations of deprescription: suspend one non-steroidal anti-inflammatory drug-nsaid (by risk of bleeding in association with concomitant antiplatelet and antidepressant therapy) and one benzodiazepine (central nervous system-cns side effects); modify treatment: reduce doses of diuretics (blood pressure lowering effect). pharmacotherapeutic recommendations were accepted. conclusion: detection of discrepancies in the medication reconciliation and deprescription process are effective and safe strategies that allow optimization of pharmacotherapy in fragile patients. the use of drugs such as nsaids (gastrolesive effect), the combination of drugs with cns side effects and hypotensive action (associated with falls) in elderly patients constitute situations of risk that should be reviewed in fragile patients, as an essential part of the clinical evaluation. please specify your abstract type: descriptive abstract (for projects) background and objective: there are no positions for clinical pharmacists at the hospital, so we are dependent on projects to be able to show how pharmacists can contribute in the clinical team. our aim in this project was to introduce pharmaceutical knowledge by implementing medication reconciliation and medication review in different hospital wards. we wanted to show that many patients have discrepancies in their medication lists during hospital stay and that some of the drugs or doses given can cause drug related problems for the patient. our final goal was to get the physicians to be more aware of these issues when treating their patients. design: the method used was based on the two first parts of the integrated medicines management. the pharmacist conducted a standardized drug interview with patients who prior to admission were responsible for their own drugs. for patients who could not be interviewed or were not responsible for administering their own drugs, a current medication list from relevant care level was obtained. the medication lists obtained were compared to the documentation in the patient's drug chart and discrepancies communicated to the physician. during the hospital stay, a medication review and monitoring was also conducted by the pharmacist. results were presented to the patients physician and discussed. results: a total of patients were included and of these % had c discrepancy identified by the process. the most frequent type of discrepancy was the use of a drug that was not registered on admission (omission discrepancies). other discrepancies were wrong dose, dosage or formulation and registration of a drug the patient didn't use. drug-related problems were discovered in % of the patients and the most frequent were use of anticholinergic drugs in elderly, interactions, lack of treatment and monitoring and too high doses regarding kidney function. many of the detected drug related problems results in change in medication, other times the physician addresses the problem to the gp. the physicians were surprised of the high numbers of discrepancies in medication lists and drug related problems discovered. almost all the physicians considered that the pharmacist could be an important part of the treatment team and they wanted the participation of the pharmacist to be permanent. conclusion: the project led to increased awareness of the importance of medication reconciliation and medication review and showed the importance of pharmaceutical knowledge in the treatment team. unfortunately this was not sufficient to create positions for pharmacists in our hospital. new projects will focus on pharmacists teaching interns to improve the reconciliation at admission. please specify your abstract type: descriptive abstract (for projects) background and objective: we aimed to assess the quality of fluoroquinolones (fq) prescriptions at the toulouse university hospital emergency department as part of significant increase in consumption. design: retrospective mono-centric study of fq prescriptions written to adult patients managed at the emergency department (february th, -march th, . a pair consisting of a biologist pharmacist and a clinical pharmacist has analysed them using tools provided by the centre de coordination de lutte contre les infections nosocomiales (cclin). various criteria (pertinence of prescription, choice of antibiotic, dosage, duration of treatment, method of administration…) were faced with the guidelines issued by the société de pathologie infectieuse de langue française (spilf). results: about files were examined, contained fq prescriptions for systemic use. the most frequently prescribed antibiotic was ofloxacin ( %) and the most frequent indications were urinary tract infections ( %). among the prescriptions of fq, the establishment of fq was justified in % of cases and the antibiotic chosen was always the most suitable. nonconformities of dosage and/ or treatment time were found in a quarter of cases. overall, % did comply with guidelines. the prescriptions, due to the particularity of emergency were still permormed probabilistic. however, a reassessment of them was scheduled for two-third of outpatients. conclusion: this study highlights the conformity of less than half of the prescriptions. this demonstrates that there are still actions to ensure the accuracy of fq prescriptions. and it is in this sense that this audit should be registered under the impetus of the committee on anti-infectives. it will raise awareness among doctors in the proper use of this family of antibiotics. please specify your abstract type: descriptive abstract (for projects) background and objective: the number of persons suffering from end-stage renal disease (esrd) is growing worldwide, mainly due to the aging of the population. esrd incidence has been increasing by - % per year for years. it is estimated that worldwide, more than . million patients with established renal failure are being treated with haemodialysis (hd). water for haemodialysis must meet the physicochemical and bacteriological compliance standards defined by the european pharmacopoeia. as a medicine, this water is placed under the responsibility of hospital pharmacists. addressed to hospital pharmacists, this methodology guide will enable them not only to validate controls of haemodialysis water as well as drug prescriptions for dialysis patients, but also to familiarize themselves with the best currently existing dialysis techniques and medical devices. we have tried to simplify and synthesize existing circulars and guidelines so as to render them more readily understandable for the pharmacist in charge of a haemodialysis service, and thereby help to ensure optimally safe treatment of haemodialysis patients. design: the themes developed in this guide are: • a review of the different existing dialysis techniques, • a review of the different sampling points for controls of hd water, • a review of the physicochemical and bacteriological standards of these controls according to the latest recommendations of the european pharmacopeia, and of appropriate conduct for exceeding established thresholds, • a review of the main international recommendations with regard to clinical signs of chronic kidney disease: anaemia, mineral and bone disorders (ckd-mbd), high blood pressure. • a review of the various medical devices used in haemodialysis and haemodiafiltration. results: the recommendations of good practices summarized in this guide are integrated perfectly adapted to the concept of quality assurance and its role in the accreditation process. they are focused on improving patient safety by harmonizing pharmaceutical haemodialysis practices in different dialysis centres. conclusion: these types of recommendations may be transposable to other pharmaceutical fields and/or be used as a training tool for pharmacy students or young pharmacy school graduates. the format of this guide makes it convenient, easy to use every day. it will be revised regularly to ensure the sustainability of quality plans. please specify your abstract type: descriptive abstract (for projects) background and objective: combination antiretroviral therapy (cart) has strongly improved disease control in hiv-infected patients. however, aging and comorbidities are becoming a major problem in this group of patients. most hiv-infected patients are treated with five or more medications, and harms by polypharmacy increase proportionally with number of medications. possible risks include: poor medication adherence and consequently inefficient care, increased risk of drug interactions and adverse events, with prolonged hospitalization. the problem is worsened when patients are of nonnative language and so their comprehension and adherence to drug therapy can be very poor, compromising efficacy. the hivig study is designed to evaluate the impact of the interventions promoted by the clinical pharmacist in the optimization and comprehension to personal drug therapy, favouring compliance, in a cohort of patients, hiv infected with comorbidities like cancer; the cohort includes a high number of non-native italian language individuals. design: hivig is a randomised, parallel groups clinical trial. in april the study protocol was approved by the local ethical committee, aviano. the project is scheduled to start in autumn . main objective: evaluation of the impact of a series of tools-''drug therapy setting interventions'' (dtsis) applied by the clinical pharmacist on a cohort pf hiv-infected patients with comorbidities, afferent for care at cro aviano. the treatment arm will be submitted to dtsis. dtsis interventions (treatment group) consist in: motivational interview, sharing and delivery of printed, explanatory material in the patient's native language, reconciliation of patients medications at hospital admission and at discharge; identification of potential risks due to drug-drug interactions; monitoring of compliance to drug therapy, and finally detection of adverse drug reactions (adrs) occurring in the course of care. the control group will undergo only to scheduled standard medical visits at cro. results: we expect to recruit a total patients for a -months period of follow-up. statistical analysis will be performed by intention-to-treat and by protocol. at cro aviano, the italian cooperative group on aids and tumors (gicat) has studied malignancies in hiv-positive patients since and has a leading role for studies conducted in italy (vaccher, ) conclusion: previous collected data from the previous trial performed at cro aviano (target-vig), showed a positive impact in the optimization of individual drug therapy and in the reporting of adrs. hiv has an enormous impact on life of infected patients and represents a priority issue for the entire community. we consider the method of dtsi, combined with a close monitoring of patients by means of telephonic motivational interviews, the best added value performed by the profile of the clinical pharmacist in optimizing drug therapy and personal awareness about medicines. please specify your abstract type: research abstract background and objective: the world health organization reports that ''one in four people in the world will be affected by mental or neurological disorders at some point in their lives. around million people currently suffer from such conditions, placing mental disorders among the leading causes of ill-health and disability worldwide». to review the evidences published about the roles and the impact of pharmacists in psychiatry. setting and method: literature review. a literature search was conducted using pubmed and the following terms: pharmacists, clinical pharmacy, pharmaceutical services, pharmaceutical care, pharmacy, mental illness and psychiatry from january st until june th . manual search was also conducted using selected articles. the selection of articles was based on abstracts. selected articles were reviewed, analysed and entered in impactpharmacie.org website according a standard operating procedure. relevant key data were extracted for each article including the type and the description of pharmaceutical interventions and descriptive and outcomes indicators with their results. no statistical analysis was conducted. main outcome measures: proportion of outcome indicators associated to pharmaceutical interventions with a positive impact in psychiatry. results: a total of articles were included. described pharmaceutical interventions included patient-pharmacist relationship ( ), medication reconciliation ( ), patient care needs assessment ( ), drug therapy assessment ( ), patient follow-up ( ), interdisciplinary work ( ), knowledge transfer ( ), competencies maintenance ( ). the impact of pharmacists interventions was studied using a total of indicators from which ( %) had outcome measures. of these outcome indicators, ( %) were positive, neutral and negative (knowledge transfer strategy). positive impacts of pharmaceutical interventions were identified in the following areas: morbidity ( ), patient adherence ( ), patients or clinicians satisfaction ( ), side effects management ( ), medication errors prevention ( ), mortality ( ) please specify your abstract type: research abstract background and objective: the world health organization reports that . million people die each year from cancer, an estimated % of all deaths worldwide and that there is a % increase in new cases of cancer expected over the next two decades. to review the evidences published about the roles and the impact of pharmacists in cancer. setting and method: literature review. a literature search was conducted using pubmed and the following terms: pharmacists, clinical pharmacy, pharmaceutical services, pharmaceutical care, pharmacy, neoplasms from january st until june th . manual search was also conducted using selected articles. the selection of articles was based on abstracts. selected articles were reviewed, analysed and entered in impactpharmacie.org website according a standard operating procedure. relevant key data were extracted for each article including the type and the description of pharmaceutical interventions as well as descriptive and outcomes indicators with their results. no statistical analysis was conducted. main outcome measures: proportion of outcome indicators associated to pharmaceutical interventions with a positive impact in cancer. results: a total of articles were included. described pharmaceutical interventions included patient-pharmacist relationship ( ), patient care needs assessment ( ), drug therapy assessment ( ), drug compounding/dispensing ( ), patient follow-up ( ), interdisciplinary work ( ), knowledge transfer ( ). the impact of pharmacists interventions was studied using a total of indicators from which ( %) had outcome measures. of these outcomes indicators, ( %) were positive, ( %) neutral and ( %) negative. positive impacts of pharmaceutical interventions were identified in the following areas: morbidity ( ), patient adherence ( ), patients or clinicians' satisfaction ( ), side effects management ( ), medication errors prevention ( ), mortality ( ), costs ( ) setting and method: literature review. a literature search was conducted using pubmed and the following terms: pharmacists, clinical pharmacy, pharmaceutical services, pharmaceutical care, pharmacy, myocardial infarction, acute coronary syndrome from january st until june th . manual search was also conducted using selected articles. the selection of articles was based on abstracts. selected articles were reviewed, analysed and entered in impactpharmacie.org website according a standard operating procedure. relevant key data were extracted for each article including the type and the description of pharmaceutical interventions and descriptive and outcomes indicators with their results. no statistical analysis was conducted. main outcome measures: proportion of outcome indicators associated to pharmaceutical interventions with a positive impact in myocardial infarction. results: a total of articles were included. described pharmaceutical interventions included patient-pharmacist relationship ( ), medication reconciliation ( ), patient care needs assessment ( ), drug therapy assessment ( ), drug compounding/dispensing ( ), patient follow-up ( ), interdisciplinary work ( ), knowledge transfer ( ). the impact of pharmacists interventions was studied using a total of indicators from which ( %) had outcome int j clin pharm ( ) : - measures. of these outcome indicators, ( %) were positive, ( %) neutral and ( %) negative. positive impacts of pharmaceutical interventions were identified in the following areas: morbidity ( ), patient adherence ( ), side effects management ( ), mortality ( ) and others ( ). conclusion: the role and the impact of pharmacists have been studied in myocardial infarction and % of outcome indicators used in these studies show a positive impact of pharmaceutical interventions. pharmacists should pay attention to these evidences to improve their practice, contribute to prevention or insure treatment of patients with potential or found myocardial infarction. hp-pc : impact of pharmaceutical care in vaccination: a review of literature please specify your abstract type: research abstract background and objective: the world health organization reports that ''immunization is the process whereby a person is made immune or resistant to an infectious disease, typically by the administration of a vaccine and a proven tool for controlling and eliminating lifethreatening infectious diseases and is estimated to avert between and million deaths each year. it is one of the most cost-effective health investments, with proven strategies that make it accessible to even the most hard-to-reach and vulnerable populations». to review the evidences published about the roles and the impact of pharmacists in vaccination. setting and method: literature review. a literature search was conducted using pubmed and the following terms: pharmacists, clinical pharmacy, pharmaceutical services, pharmaceutical care, pharmacy, vaccination and immunization from january st until july th . manual search was also conducted using selected articles. the selection of articles was based on abstracts. selected articles were reviewed, analysed and entered in impactpharmacie.org website according a standard operating procedure. relevant key data were extracted for each article including the type and the description of pharmaceutical interventions and descriptive and outcomes indicators with their results. no statistical analysis was conducted. main outcome measures: proportion of outcome indicators associated to pharmaceutical interventions with a positive impact in vaccination. results: a total of articles were included. described pharmaceutical interventions included patient-pharmacist relationship ( ), medication reconciliation ( ), patient care needs assessment ( ), drug therapy assessment ( ), patient follow-up ( ), interdisciplinary work ( ), knowledge transfer ( ), competencies maintenance ( ). the impact of pharmacists interventions was studied using a total of indicators from which ( %) had outcome measures. of these outcome indicators, ( %) were positive, ( %) neutral and negative. positive impacts of pharmaceutical interventions were identified in the following areas: cost ( ), errors ( ), morbidity ( ), patient adherence ( ), patients or clinicians satisfaction ( ) please specify your abstract type: descriptive abstract (for projects) background and objective: evaluating the appropriateness and effectiveness of the patient's medications by analysing prescriptions is pharmacist side work. bedside drug administration and computerised drug administration traceability (cdat) in nursing care plan (ncp) are nurse's one. however, in order to check adherence, efficiency and tolerance of a drug, pharmacist has to ensure that the patient takes the medication appropriately. therefor ncp could be a useful tool. the aim of this study is to evaluate the effectiveness of cdat, and if not, define causes of divergences with real life situation. design: • comparison between unused drugs remained in individual patients' seven daily pill dispensers (considered as not taken) which come back from the evaluated service to the pharmacy, and their cdat status completed by nurses (taken, not taken or no status) • two recorded data, each collecting a three-week period, separated by a period of discussion with nurses: first results presentation, analysis of divergences by taking into account their feedbacks, and actions to raise their awareness about the importance of cdat. • pill dispensers' cdat is correct only if all returned drugs' status in ncp is ''not taken''. results: during the first period (n = pill dispensers), . % of pill dispensers had an incorrect cdat status. on average, . drug per pill dispenser didn't have an appropriate status in ncp (taken or no status). major causes of divergences were the lack of time and insufficient human resources, the fact that they often are interrupted in the middle of this task, a software which isn't ''user-friendly'' and a deficit of information about the issue. corrective actions were implemented, prior to the second recorded data period, targeting human factor of divergences (oral and written reminders about cdat with didactic memorandum on computers). after awareness actions, results (n = ) were . and . respectively. conclusion: efforts about cdat have been done but not enough to observe a significantly improvement in short terms. ncp's level of reliability is not optimal yet and still dependent on nurses' practices. this study allowed us to strengthen the relationship between clinical service and pharmacy, and opens the way for further works particularly through corrective actions targeting material and organizational causes of divergences. please specify your abstract type: descriptive abstract (for projects) background and objective: in , our teaching hospital has participated to a worldwide survey (global point prevalence survey (global-pps)) aimed to explore antimicrobial consumption and resistance in hospitals. because broad spectrum antibiotics have to be followed with the attention of resistance prevention, we focused our analysis on these antibiotics in our hospital (carbapenems, piperacillin/tazobactam and amoxicillin/clavulanic acid). design: the survey was performed by pharmaceutical team (senior and resident) with help of microbiologists and referring physicians. all wards of the hospital were included. hospitalized patients treated with antimicrobial agent (j , j , j a, p ab, a , j ah, p b from the atc classification) prescribed at a.m. on the day of the survey, were involved. from those who were treated by carbapenems, pip/taz or amx ac, following data were collected: age, gender, weight, doses, indications (probabilistic? documented? and if documented microbiological data), and mention of stop/review date of prescription. results: the survey was carried out from april to june in wards. among the patients included, patients ( . %) were treated with antimicrobial agents. patients ( . %) were treated with broad spectrum antibiotics: ( . %) with amx-ac, with pip-tz, with imipenem and with meropenem. the mean age of patients was . ± . and the weight was . ± . kg. their prescriptions were concentrated in three types of wards: ( . %) in icu, ( . %) in medicine, ( . %) in surgery. moreover, we observe that bsa were used to treat ( . %) community acquired infections, ( . %) nosocomial infections, ( . %) used as medical prophylaxis, or surgical prophylaxis (n = , . %). in relation to the type of treatment: were empirical treatment (including prophylaxes) and were targeted treatments ( bacteraemia, joint and bones infections, cardiovascular system infection, urinary tract infections, lower respiratory tract infections, skin and soft tissues infections and others infections). finally, extended spectrum beta-lactamase (esbl) producing enterobacteriaceae and third generation cephalosporin resistant enterobacteriaceae non-esbl producing were targeted by bsa regimen. conclusion: in this survey, use of bsa is globally compliant to french guidelines and we identified no improper prescription: multidrug resistant bacteria infections, several diseases and empirical treatments with limited duration of regimen. this shows that control of the proper use of antibiotics especially those with a broad spectrum is efficient in our hospital and has to be continued. this has been made possible due to a multidisciplinary approach including physicians, bacteriologists and pharmacists. please specify your abstract type: descriptive abstract (for projects) background and objective: in , our teaching hospital has participated to a worldwide survey (global point prevalence survey (global-pps)) aimed to explore antimicrobial consumption and resistance in hospitals. from these results, we observed that sulfamethoxazole/trimethoprim (tmp/smx) was largely prescribed in our hospital. we focused then our analysis on these results with the attention of check of its proper use. design: the survey was performed by pharmaceutical team (senior and resident) with help of microbiologists and referring physicians. all wards of the hospital were included. hospitalized patients treated with antimicrobial agent (j , j , j a, p ab, a , j ah, p b from the atc classification) prescribed at a.m. on the day of the survey, were involved. from those who were treated by tmp/smx, following data were collected: age, gender, weight, doses, and indications (probabilistic? documented? and if documented microbiological data), and mention of stop/review date of prescription. please specify your abstract type: research abstract background and objective: in france, benzodiazepine (bzd) is frequently prescribed in elderly people (ep). long-term efficacy is often questioned, and treatment has to be regularly re-examined, especially in ep. in our geriatric day-hospital for assessment of frailty, a multidisciplinary team evaluates the patients and gives them preventative measures against the loss of autonomy. medication evaluation is part of these measures. the aim of our study was to evaluate the impact of a standardized intervention on the optimization of bzd treatment. setting and method: after a short interview and the delivery of an information booklet about bzd, patients were proposed an optimization of their bzd treatment (dosage reduction, occasional medication, switch to a short half-life bzd, or total discontinuation). patients were followed up monthly by a phone-interview over a -months period. main outcome measures: the main outcome measure was the prevalence of bzd optimized treatments after a months follow-up. results: patients were included. among them, % have been taking a bzd for more than years, and % were prescribed a long half-life bzd, which can be qualified as inappropriate in ep. % of the subjects were frail and % pre-frail according to the fried criteria. at the end of the study, % of the patients had their bzd treatments optimized, including % of total discontinuation. conclusion: in frail or pre-frail elderly population, a standardized intervention can be useful to improve bzd treatment. an extension to this intervention would be the creation of an organisation tasked with routinely monitoring the patients withdrawal over a month period. hba c and weight were significantly reduced by . ± . %, p \ . and . ± . kg, p \ . , respectively; systolic bp ( . ± . mmhg, p \ . ), diastolic bp ( . ± . mmhg p \ . ) and triglycerides ( . ± . mg/dl, p . ).genital-and urinary tract infections were reported by . % patients. any diabetic ketoacidosis case was reported. conclusion: sglt- inhibitors added to other oral antidiabetic drugs or insulin in patients with uncontrolled t dm significantly improved glycaemic control, reduced weight, blood pressure and triglycerides, and was generally well tolerated. in conclusion, sglt- inhibitors, appears to be an important addition to the therapeutic options for the management of type diabetes, particularly when used as add-on therapy. ( ). treatment safety takes part of the decision to undergo bariatric surgery. during multidisciplinary team meetings, the clinical pharmacist must rely on guidelines to limit drug-induced iatrogenesis. this review aims at assessing influence of bariatric surgery on the clinical impact and pk of cardiotropic drugs so as to document pharmacists' notifications. setting and method: literature review on medline- to may -with terms: cardiovascular drugs and bariatric surgery or malabsorption syndrome. related articles were reviewed. main outcome measures: pharmacokinetic or pharmacodynamic data and clinical impact of cardiotropic drugs. results: a total of titles, and abstracts when necessary, were screened for eligibility. after reviewing process, studies were included: nine concerning digoxin, five beta-blockers (bb) and one amiodarone. published studies varied in methodology: five case report, seven case control and three cohort studies. studies reported variations of digoxin plasmatic concentrations among patients versus , suggesting liquid oral form are preferred. no clinical event was notified. more the bb is liposoluble (propranolol), the higher the toxicity is, such as heart rate and blood pressure decreasing, with potential fatal outcomes. a case of amiodarone-induced hyperthyroidism is described after bariatric procedure showing an increase plasma concentration adjusted to weight. conclusion: while the impact on narrow therapeutic range drugs is documented, others cardiotropic drugs may cause serious patient injury justifying their monitoring. therefore, risk must be identified for all patients undergoing bariatric surgery to setting up closely therapeutic monitoring. further studies are still expected to lead to recommendations about posology and treatment withdrawal to improve patient safety. please specify your abstract type: research abstract background and objective: the issue of non-compliance to prescribed medical treatment has been reported to be a crucial problem in psychiatric outpatients. the aims of this study were to assess the extent of non-compliance in a cohort of psychiatric outpatients in malta and to investigate the applicability of using a -day multi-dose pill box in terms of practicality, ease of use and impact on compliance within this patient group. setting and method: the study was conducted at mount carmel hospital, a psychiatric hospital in malta. twenty outpatients were recruited by convenience sampling. the study was divided into two phases. during phase , patient compliance was assessed using the medication adherence rating scale (mars) survey and patients were administered part a of a questionnaire entitled 'assessment of the -day multi dose pill box'. this questionnaire evaluated the patients' opinion regarding the -day multi dose pill box before and after its use. in phase , the chosen patients were given a demonstration on how to use the -day multi dose pill box and the device was given to them to use at home for one week. after one week, part b of the questionnaire was completed and compliance was re-assessed using mars . main outcome measures: evaluation of adherence before and after use of the compliance aid device. results: of the patients recruited, were male and were female. the mean age was years (range - ) and the mean number of daily medications (range - ). upon initial scoring using mars, patients were adherent and patients were nonadherent. a higher adherence was observed in patients taking or more medications daily. ten patients accepted to move on to phase of the study and took the device home to use for one week. out of these patients, felt that the way they take their medication improved following use of the device and out of patients would consider buying the device since they found it practical and easy to use. statistical analysis of mars score before and after use of the device showed no significant improvement in compliance (p [ . ). there was no significant association between level of adherence and type of psychiatric condition (p [ . ). furthermore, results did not indicate increased adherence in patients who have a carer in-charge of their medication administration or in patients using a compliance aid device (p [ . ). conclusion: the use of a compliance aid device in psychiatric patients is challenging due to difficulty in establishing patient communication and motivation. the pharmacist is in a position to identify patients who would benefit from the compliance aid device. adrien borowik * , anne fratta, fabien hernandez pharmacy, ap-hp, armand trousseau paediatric hospital, paris, france please specify your abstract type: descriptive abstract (for projects) background and objective: enoxaparin, a low molecular weight heparin, is the most prescribed anticoagulation treatment in paediatric indications. however, the marketing authorization mentions that due to the lack of data, the use of enoxaparin is not recommended to children nor anyone weighing less than kg. thus, expert recommendations described specific dosage for the paediatric use: we aimed to compare these with our hospital practices. ( ), sofosbuvir/ledipasvir ( ), ombitasvir/ paritaprevir/ritonavir ( ), ombitasvir/paritaprevir/ritonavir + dasabuvir ( ), simeprevir + ifn ( ) . twenty-six patients ( %) were treated for weeks ( week pay-back policy). twenty pharmacists' interventions were carried out with an acceptance rate of %. the interventions included treatment adjustments due to drug interactions ( ), inappropriate treatment according to genotype ( ), duration of treatment ( ) and switch to a more cost-effective therapy ( ). seven pharmacists' interventions concerning treatment switch were applied ( %) resulting in a cost saving of € , . . all assessable patients ( ) have a negative serum hcv rna weeks after the end of treatment (svr = %) while patient died during follow-up (due to the disease). conclusion: the hospital pharmacist, as an active member of the multidisciplinary team, has an essential role in guaranteeing optimal care for hcv patients at the best cost. monitoring has also shown to be fundamental to evaluate the real world effectiveness of these drugs approved with surrogate endpoints. hp-pc : are hospital pharmaceutical staff educated on the criticality of thermosensitive drugs? camille castel, guillaume saint-lorant * please specify your abstract type: research abstract background and objective: in the use of thermosensitive drugs, the safety of patient care involves compliance with allowed temperatures. having the right information at time of care is essential. the aim of this study is to assess, within a french university hospital, pharmaceutical staff knowledge on the criticality of thermosensitive drugs and to educate them accordingly, including associated patient risks. setting and method: an assessment of knowledge using a questionnaire was led in january among pharmaceutical staff in a -bed hospital ( pharmacists, pharmacy residents, pharmacy technicians). evaluation criteria were: storage temperature of refrigerated drugs and frozen drugs, thermosensitive drug retention period after removal from the refrigerator, highest risk situation for a thermosensitive drug (t [ °c or t \ °c) and action to be taken during a temperature excursion. main outcome measures: to determine shortcomings in the management of thermosensitive drugs in order to adapt appropriate tools. results: completed questionnaires were collected. collected questionnaires included % from pharmacists (n = ), % from pharmacy residents (n = ) and % from pharmacy technicians (n = ). regulatory variations in storage temperatures of refrigerated and frozen drugs are known in respectively and % of cases. % of pharmaceutical staff are aware of thermosensitive drug retention periods after removal from the refrigerator and % of the highest risk situation for a thermosensitive drug (t \ °c). the measures to adopt during a temperature excursion are understood in % of cases. conclusion: this study highlights the lack of knowledge on the management and criticality of thermosensitive drugs and the lack of information available to pharmaceutical staff. dissemination of data and questionnaire reponses have been beneficial for the pharmacy department and have reduced inequalities in available information among pharmaceutical staff. subsequent to the study, thermosensitive drug management procedures have been revised. the deployment of this questionnaire is continuing via the university hospital intranet in order to train all health professionals in good patient care. please specify your abstract type: research abstract background and objective: temocillin is a beta-lactam antibiotic exclusively active against gram-negative pathogens. its use can avoid that of broad spectrum antibiotics, such as carbapenems, for the treatment of infections due to extended-spectrum beta-lactamase producing enterobacteriaceae. however, the absence of recommendations by learned societies on temocillin use could lead to misuse and the emergence of resistance. the aim of this study is to identify the role of temocillin in a french university hospital arsenal in order to limit ecological risks. setting and method: a retrospective study was conducted in a -bed university hospital. all adult patients having received at least days of treatment between june and april were included. data collected for the study were: age, sex, treatment indication (type of infection, identified pathogen, dosage and treatment duration), previous antibiotics and therapeutic outcomes. main outcome measures: the indicators chosen were: treatment indication, prescribed dose and treatment duration. results: two patients were included. in july , temocillin was used in a year old female as first-line treatment of intraperitoneal haematoma infection due to multiresistant klebsiella pneumoniae. prescribed at a dose of g twice daily by an infectious diseases specialist, treatment was continued at the same dose for up weeks with therapeutic success. in august , temocillin was used in a year old male for the treatment of bacteraemia due to multiresistant enterobacter aerogenes. previously treated by imipenem/cilastatin, temocillin was prescribed as second-line treatment at a dose of g twice daily by an infectious diseases specialist. treatment was continued at the same dose for up weeks with therapeutic success. conclusion: the dissemination of antibiotic resistance among gramnegative enterobacteriaceae continues to be an increasing threat for healthcare worldwide. within this context, temocillin could be an interesting alternative. determining the role of temocillin in a therapeutic arsenal is essential. our hospital considers temocillin as a ''critical antibiotic'' although its use is not exclusively limited to the new drug application. therefore, temocillin prescriptions are monitored permanently by infectious diseases specialists, microbiologists and pharmacists in order to improve the good use of this antibiotic and to optimise patient safety. please specify your abstract type: research abstract background and objective: drinkable solutions are more susceptible to deterioration and can lead to a potential risk for patient care. having the right information at time of care is essential. the aim of this study is to assess nursing staff knowledge in a french university hospital on the management of drinkable solutions to elaborate tools to help health professionals and to enhance equality of information in order to optimise patient care. setting and method: an assessment of practice using a questionnaire was conducted in may among a share of the nursing staff in a int j clin pharm ( ) results: completed questionnaires were collected. % of nursing staff replied that the period-after-opening is the same for all of drinkable solutions. this period is estimated at month in % of cases, weeks in % of cases and days in % of cases. % of nursing staff do not know how to store drinkable solutions after opening. the date of opening or the date of expiry after opening are specified on the medicine bottle in respectively and % of cases. only % of nursing staff have tools pertaining to the management of drinkable solutions. these observations led the pharmacy to create and distribute appropriate tools. storage methods for the drinkable solutions available in our hospital were collected directly from pharmaceutical laboratories. this information has been made available to nursing staff via drug control software (pharma Ò , computer engineering, paris). conclusion: this study highlights the lack of knowledge on the management of drinkable solutions and the lack of information available to nursing staff. in our hospital, the dissemination of appropriate data reduced inequalities in available information between care units. data will soon be integrated within the drug prescription software (mc kesson usv Ò , crossway, san francisco) in order to homogeneously train all health professionals in good patient care. please specify your abstract type: descriptive abstract (for projects) background and objective: medication reconciliation (mr) is a process which allows prevention of iatrogenic injuries during patient's hospitalisation and transfers. since , a clinical pharmacist has been integrated into the orthopaedic surgery care. he has performed mr at patients' admission. the aim of this study was to evaluate the impact of medication reconciliation performed by a clinical pharmacist. design: a prospective monocentric study was conducted on patients admitted in an orthopaedic surgery care (elective or unplanned surgery), during months. the clinical pharmacist established the best possible medication history (bpmh) from at least three sources of information (including patient interview when possible). then, it was compared to the admission medication order (amo) (from anaesthetists when elective or orthopaedists when unplanned). unintended medication discrepancies (umd) detected were discussed with prescribers in order to be corrected. epidemiological data, number and type of umd, therapeutic classes involved and the percentage of corrected umd were collected and their potential clinical impact was assessed. results: in this study, patients were included during months. elective surgeries were concerned in % of the cases. at least one umd was identified in patients ( %) (median age: . years old; male/female ratio: . ). of these, ( %) were older than years old. finally, umd were detected, being . by patient. main therapeutic classes concerned cardiovascular system ( %), nervous system ( %) and digestive system ( %). of the umd detected by mr, there were % of omissions, % of inappropriate dosing and % of renewal prescriptions stopped by the patient. finally, % of umd were corrected. of these umd, % were major errors (i.e. causing potential harm), % were significant errors (i.e. monitoring or intervention potentially required to preclude harm) and % were minor errors (i.e. without potential harm to the patient). conclusion: medication reconciliation process performed by a clinical pharmacist allows detection and correction of umd on half of patients in surgery care particularly on elderly patients. the high proportion of umd can be explained by the multiplicity of actors involved in medication management. health information technology could help to focus mr on patients at high-risk of adverse drug events. please specify your abstract type: research abstract background and objective: darunavir plus ritonavir (drv/r) have shown optimized results in simplification strategies (monotherapy (mt) or dual therapy (dt)) for selected hiv + in randomized clinical trials and real life experience. recent introduction of one pill drv plus cobicistat co-formulation (drv/c) may be particularly suited for both mt/dt allowing once daily administration optimizing dosage and adherence. the objective of our study is to evaluate efficacy and security of drv/c in mt and dt. setting and method: all hiv + adults with antiretroviral change to drv/c in mt/dt at a reference hospital in the northwest of spain were included in this retrospective study. a statistical analysis was performed using the spss v. .software. main outcome measures: epidemiological, clinical, antiretroviral regimen, serum creatinine, lipids and inmunovirological data (rna-hiv and lymphocytes cd ) were compared previous and after change to drv/c. results: hiv treatment-experienced patients have received drv/c in dt ( ) or mt ( ). . % were men with a mean age of years. main risk factors were: . % heterosexual, . % msm, . % injection drug users, . % mother-to-child transmission, . % transfusion in haemophiliac patient and . % unknown. cdc category distribution was . % a, . % b, . % c and . % unknown. overall mean nadir cd counts were . ± . cells/mcl. mean time since drv/c prescription to discontinuation or until analysis was . days [range - ]. . % drv/c mt were prescribed to patients with prior drv/r mt in order to simplify treatment and the mean time of the duration of these prior therapies were . years. in case of dt, . % were prescribed on patients with prior drv/ r + tc with a mean duration of . years. serum creatinine increases ( . vs. . ; p \ . ) and cd decrease ( . vs. . ; p = . ) when patients move to drv/c. no significant change in the other analytical parameters and all patients maintained undetectable. patients discontinue drv/c due to intolerance and inability to swallow in each case. conclusion: this preliminary study concludes that drv/c in mt or dt is efficacy (no viral rebound) and safety. although an increase in creatinine was observed, it would not be considered clinically significant. of note, lymphocytes decreased significantly and it will be important closely monitored to check that maintain effectiveness during the follow up. hp-pc : developing clinical pharmacy in emergency department setting up a medication reconciliation process marion collignon *, , antoine gantier , florent lapacherie , hélène dewaele , laura foucault , anne-laure raso , emmanuel cirot , said laribi , xavier pourrat pharmacy, emergency department, chru tours, tours, france please specify your abstract type: descriptive abstract (for projects) background and objective: in emergency department (ed), if a drug related problem (drp) happens at the patient admission, the risk is the error remains until discharge. one part of drp may be avoided with using medication reconciliation (mr). the objective of this study was to evaluate the feasibility of setting up a medication history (mh) of patients in ed in an acceptable lap of time before they were transferred in another unit or discharged. design: a months prospective study was conducted in ed in a university hospital in france. two junior pharmacists coached by a senior pharmacist, after a months training for mr, were in charge of the data and mh collection. for all patients, we collected age, mh according to number of sources, discrepancies identified, adherence to treatment (according to the social security questionnaire), type of sources. mh were established according to community pharmacies, patients, previous electronic patient files, prescription sheets, patient's family, packs of pills and to the general practitioner (gp). for patients from long term care facilities (ltcf), the mh was established only by communication with the ltcf. then, the current prescription was compared with the home medication regimen. mh and discrepancies (omitting medication, incorrect dose, ambiguous name) were recorded in the electronic patient files to be available during hospitalization. because ed does not have a pharmaceutical review of prescriptions, only major discrepancies were transmitted to physicians. results: we collected mh ( from ltcf), with a sex ratio of . and a medium age of . years old. it represented an average of . mh per day or min per mh. among patients who did not come from ltcf, sources used by pharmacy students were patient's community pharmacy ( , % of cases), patient ( , %), previous electronic patient file ( , %), prescription sheets ( , %), call to gp ( , . %), gp mail ( , . %), patient's family ( , . %), packs of pills ( , . %), community nurse ( , . %). finally, patients ( %) had been hospitalized, others were discharged. we analysed mh for patients: at least one drp occurred for patients ( %). among patients, ( %) had an immediate pharmaceutical intervention because of the risk due to discrepancy. among patients who did not come from ltcf and who could communicate, were good adherent to treatment ( %). conclusion: this study highlights the great interest of the mh by pharmacists at ed, which avoids many drp. the presence of pharmacists in ed contributes to maintain a safe environment for medication and to assist prescribers in the continuity of treatment between home and hospital. spending min by mh, we identify one drp every min. nevertheless, it could be benefit to develop this activity because of the satisfaction of the emergency physicians. currently, mr is the first step to develop clinical pharmacy in the ed. please specify your abstract type: research abstract background and objective: emerging evidence in the literature suggests a high prevalence of suboptimal vitamin d (vitd) and an association between lower serum levels and higher mortality in cancer. the objective of this study was to quantify vitd deficiency in patients after surgery for head and neck cancer, and to determine the effect of one cholecalciferol intramuscular dose. setting and method: intervention study with a follow-up period of months (november -february ) performed on patients followed by the nutrition support unit after surgery for head and neck cancer. demographic and physiopatological data, including admission diagnosis, age, gender, calcium, magnesium and phosphate were collected. nutrition screening by conut index was carried out. a single intramuscular dose of . ui cholecalciferol (vitamine d bon Ò ) was administered to vitd-deficient patients and serum -hidroxy-vitamin d (s ohd) records after the administration, including primary carés records after discharge, were evaluated (reference range - ng/ml). main outcome measures: s ohd (\ ng/ml: deficiency; - ng/ml: insufficiency; c ng/ml: sufficiency). results: data from patients with a mean (sd) age of . ( . ) years were collected (males: %). the admission diagnosis was laryngeal squamosis cell carcinoma (n = ), glottis carcinoma (n = ) and nasopharynx, tongue and skull base cancer (n = ). at baseline, , and patients were considered have high, medium and low risk of malnutrition, respectively. the mean (sd) serum ohd was . ( . ) ng/ml (deficiency: patients; insufficiency: patient). despite the role of vitd in mineral balance, calcium, magnesium and phosphate mean (sd) serum levels were between the normal range . ( . ) mg/dl, . ( . ) mg/dl, and . ( . ) mg/dl, respectively. s ohd records were available week after the administration (mean (sd) = . ( . ) ng/ml). and patients still showed deficiency and insufficiency, respectively. primary care's records from patients were available after discharge ( . , . and . ng/ml). conclusion: poor nutritional status and high prevalence of suboptimal vitd in patients with head and neck cancer were found. a single dose of intramuscular cholecalciferol slowly raises s ohd. follow-up after discharge is essential to evaluate the achievement of the therapeutic objective. setting and method: this is a descriptive retrospective study. it took place in a teaching hospital. antifungal broad spectrum therapies (liposomal amphotericin b, caspofungin, micafungin, posaconazole, voriconazole) used between st january and st december were included. main outcome measures: indications, type of combination and patients specifications were analysed. results: only patients ( . % over all patients receiving antifungal therapy; n = / ) received an antifungal combination therapy during the study period. majority of patients presented risk factors: % of patients had an organ transplant (n = ), % suffered from malignant blood disorders (four acute myeloid leukaemia, two chronic lymphoid leukemia, one non-hodgkin's lymphoma, one hodgkin's lymphoma and two refractory anaemia with excessive blast), % suffered from solid cancer (one lung cancer and one breast cancer) and % suffered from chronic obstructive bronchopneumopathy (n = ). antifungal combination therapy was used against invasive aspergillosis in % of cases (n = ) among which complications such as brain and cardiac impairment were found in % of patients (n = ). the six remaining patients ( %) were co-infected with candidiasis for three patients and mucomycosis for three patients. voriconazole was logically the most used in combination, and just one patient received oral form. it was in majority prescribed with caspofungin ( %, n = ) and intravenous liposomal amphotericin b ( %; n = ). combination including liposomal amphotericin b and caspofungin (n = , %) or posaconazole with liposomal amphotericin b (n = ) were found in our study. five patients deceased during the hospitalization of the fungal infection ( %) which shows the gravity of these cases. majority of patients ([ %) was treated less than days with these combinations. conclusion: this retrospective study shows that patients who received antifungal combination therapy were mostly immunocompromised, co-infected or experienced a severe infection with severity factors. the antifungal combination was in majority initiated because monotherapy failed to cure the patient. all prescriptions were discussed with a mycologist who tried to shorter the combination treatment duration. this multidisciplinary approach is a major key in the process of these type of treatments. please specify your abstract type: research abstract background and objective: because of its broad spectrum and the risk of resistance mutation, delivery of posaconazole is nominative and controlled by hospital pharmacists. the aim of this work was to describe the use and pharmaceutical follow-up of posaconazole tablets over a -months period. setting and method: this is a descriptive retrospective study over a -months period from november to may in a teaching hospital. all patients who received posaconazole tablets were included. main outcome measures: indications and dosage were reported. results: patients were included in the study. posaconazole tablets were used for: fungal invasive infection prophylaxis in case of stem cell transplantation ( %; n = ), fungal invasive infection prophylaxis if a chemotherapy was started to treat a chronic myeloid leukaemia or a myelodysplasic syndrome ( %; n = ); treatment of invasive aspergillosis ( %; n = ); mycetoma ( %; n = ); zygomycosis or mucormycosis while patient had renal impairment ( %; n = ). all of these indications were approved for posaconazole (marketing authorization and local guidelines). only patients ( %) received a loading dose ( milligrams twice a day) as recommended in approval authorization. posaconazole blood levels were monitored by pharmacologists: % of patients (n = ) did not need dosage modulation which shows that variability is not so important. but three patients did not have any assay to monitor posaconazole blood concentration. patient received a loading dose and was switched to intravenous voriconazole after icu transfer. patients needed increase and/or reduction dose to obtain optimal posaconazole blood levels. conclusion: this study describes the use and the follow-up of posaconazole tablets during the first months after its approval in europe. all indications are approved for posaconazole but this analysis shows that pharmacist have to remind the necessity of a loading dose. dosage can be adjusted according to assays results. please specify your abstract type: research abstract background and objective: due to the acute, hectic environment in a fast-paced work-flow emergency department (ed) it is a challenge to verify the correct and updated medication list for the admitted patients. when performing medication reconciliation (mr) in this environment, these challenge has to be taken into account and prioritizing patients for mr could be necessary. the objective of this study was to identify risk factors correlated to clinical relevant medication discrepancies (crmds) among patients admitted to ed, and based on these revealed risk factors, develop a model for prioritizing patients for mr in the fast-paced work-flow at the ed. setting and method: patients continuously included at the ed, diakonhjemmet hospital (dh), oslo, norway. trained pharmacists and emergency nurse conducted mr. patient specific factors and revealed crmds, between hospital admission records and information about prehospital medication use, were recorded. binary linear regression was used to identify risk factors correlated to crmds. the prioritizing model was built using statics and clinical experiences. main outcome measures: what risk factors is correlated to crmds and how precisely do the prioritizing model classify the patients as high-and low-risk patients. results: % of the patients had c crmd. the following were identified as risk factors correlated to crmd and were suitable for inclusion in the prioritizing model; gender (woman), age (c ), c admission to hospital last months, admission causes; surgical, malfunction, cancer. the model correctly classified . % of the patients with crmds as high risk. further, . % of the patients with crmds were classified by the model as low-risk patients (false negatives). the model classified . % of the patients who did not have a crmd as high-risk patients (false positives). conclusion: the prioritizing model developed can be helpful in identifying what patients are at increased risk of having crmds in the fast-paced work-flow at the ed. identifying these patients will result in using the resources available in the ed in the most efficient manner and utilizing the full potential of the mr method. as a consequence of this, patient safety would be increased. hp-pc : intravenous potassium chloride: quick audit of prescribers knowledge and recommendations regarding safe practice and proper usage asmaa damou * , vincent zaugg, martine postaire please specify your abstract type: descriptive abstract (for projects) background and objective: our hospital has established methods that try to ensure the safe use of high alert medications. intravenous potassium chloride (kcl) was the subject of preventive measures: separation of different dosages (kcl . % vials reserved for paediatric services and kcl % vials reserved for adult services); creation of an advice record for doctors and nurses; specific labelling of storage areas; double-check the prescription and administration. the objective of this study was to evaluate the knowledge of the safe use of intravenous kcl by prescribers. design: multiple-choice questions were developed for prescribing recommendations established by our hospital with the collaboration of the doctor who is chairman of the central committee of vigilance and risk associated with care (cvris). a link to the online survey was sent by email to physicians practicing in departments (eight paediatric services and six adult services). the results were extracted and interpreted in excel Ò . results: % of physicians responded to the survey ( medicine residents, hospital doctors). in paediatric services, % of doctors know that only the kcl . % should be used. % know the unit of prescription to be used (mmol/kg or meq/kg), and % know that the maximum recommended infusion rate is . mmol/kg/hour (or mmol/kg/h in recovery unit). in adult services, the recommended maximum rate of infusion ( g/h) is known to all prescribers, but only % know that the concentration of kcl must be less than g/l. % of paediatric doctors say that their kcl prescriptions are checked by a second doctor, but the answers in the same service area are sometimes contradictory. in adult services, only % of physicians say that the prescriptions are double-checked. the information brochure available on the intranet of the hospital is known by % of prescribers. the response rate of physicians to the survey was satisfactory. therefore, the recommendations are rather well known by prescribers, except the value of the maximum concentration of infusion for adults. the results of this audit were returned to the doctors, accompanied by a reminder stating the need to double-check the prescription and the existence of advice records on the website of the hospital. conclusion: this audit is an approach to increase the safety of the use of high alert medications. it will be completed a second time, by an evaluation of prescriptions collected and the storage conditions of potassium chloride in the care units. please specify your abstract type: research abstract background and objective: data listed behind each unit dose of a primary packaging of a pharmaceutical product are essential for a safe identification for the patient. however, the last medical services of the lausanne university hospital where nurses remove the solid form drugs (sfd) from their blisters when they prepare in advance the week container were in the vaud's prisons. the aims of the study were: ( ), quetiapine ( ) and ibuprofen ( ) and were psychotropics ( . %). part . the four data identified as essential: brand name, dosage [mg], batch number, expiration date. the sfd unit doses were classified as green when the blister included four data, yellow with two or three and red with less than two. of the sfd in cupboards, were green ( %), yellow ( %) and red ( %); an infovigilance was sent to each manufacturers. part . potential barriers identified: trays' sizes and space in drug's cupboards; preparation time to cut versus to remove the blisters; risks of self/hetero-aggression with pre-cut blisters; drugs packaged in bulk; multidose liquid medications. using containers larger than is usual was rarely necessary; space in cupboards was sufficient. the preparation time gradually decreased during the study. ingestion or aggression with pre-cut blisters was considered as limited, based on literature and experiences of two others prisons (geneva; lyon). for bulk sfd and multidose liquid drugs: proposals to the pharmacy to store some alternatives blistered sfd; blistering expensive bulked drugs; availability of the entire package delivered to inmates. the pilot phase was initiated in may . conclusion: a majority of inmates takes a drug treatment. half of sfd unit dose is identifiable (trade name and dosage) but an effort from manufacturers would better secure the drug supply chain. the study of the barriers helped to further implement the pilot phase. since early , none of the five prisons medical wards are removing the blisters and no incident was reported. please specify your abstract type: research abstract background and objective: nefopam is a widely used antalgic in hospital. its use is contraindicated in the epileptic patient as it results in lowering the epileptogen threshold and is likely to trigger epileptic seizures. the clinical pharmacist should systematically warn the prescriber against this contraindication when analysing prescriptions. following the onset in our establishment of an epileptic condition in a patient treated with nefopam, who had not been subject to any pharmaceutical intervention (pi), we set about analysing the validation practices regarding this contraindication and possibly implementing actions designed to improve those practices. setting and method: retrospective collection over a period of months of prescriptions for patients hospitalized in hospital beds with clinical pharmacy service (associating med-reconciliation, checking prescription according to medical file and participation to medical rounds): orthopaedic surgery, hepatic-gastro-enterology, general surgery, liver transplant and chest surgery. records of patients with nefopam prescription associated to medication belonging to the therapeutic class of antiepileptics were consulted with a view to finding cases of epilepsy. the pharmaceutical alerts were extracted from the pharmaceutical software. main outcome measures: number of epileptic patients treated with nefopam, number of pharmaceutical interventions issued when prescribing nefopam in epileptic patients. the study focused on , patients. ( . %) of them were prescribed nefopam, and ( . %) of them were prescribed nefopam associated to medication belonging to the therapeutic class of antiepileptics. after analysis of the patients' records has shown that of them were really epileptic. only pi's were effected ( . % of problematic prescriptions), and ( %) of them had an immediate prescription change. . % ( / ) of the patients have a pi in medicine services compared to . ( / ) in surgery services (p \ . ). the results of this study show that % of the contraindications related to the use of nefopam in epileptic patients are not reported to the prescriber. these results will be presented to our pharmacists so they can take them into account. subsequently a new study will be conducted to measure the relevance and efficiency of this program. hélène dewaele * , anne-laure raso, emmanuel cirot, marion collignon, laura foucault, xavier pourrat please specify your abstract type: descriptive abstract (for projects) background and objective: medication reconciliation (mr) has been demonstrated to reduce drug-related problems in inpatients. in our university hospital, mr has been performed for beds for years at the same time as prescriptions review. the aim of this study was to assess the impact of mr on pharmaceutical interventions (pi) during prescriptions review. design: a -month prospective study in orthopaedic surgery, hepato-gastro-enterology, general surgery, liver transplant and chest surgery was conducted. during medication review all pis were collected and those related to mr (rpi) were identified. thereafter for each patient we collected age, type of hospitalization unit (med or surgery) and for pis the drug associated and its acceptance by the medical team. results: during the study patients had a daily prescription review. patients ( %) had at least one drug-related problem. lines of prescriptions were mentioned to have at least one rpi. rpi represent % of drug-related problems. ( %) discrepancies were corrected by prescribers. the age of the patient was significantly different between patients with rpi (mean age: years old) and with pi (mean age: years old; p \ . ). the type of unit did impact the percentage of prescriptions with drug-related problems (medicine: . ; surgery: . ; p \ . ), the rate of corrected pi (medicine: %, surgery: %, p \ . ), but did not impact the rate of corrected rpi (p = . ). in surgery units the rate of corrected rpi ( / ) is significantly higher than corrected pi ( / ; p \ . ). medicines belonging to the four classes of: digestive and metabolism system, blood and blood flow, cardiovascular system, neurological system represent more than % of all the medication concerned by a resolved pi or rpi. the proportion of medicines from the digestive and metabolism class is the only class among those four that is not significantly different between resolved pi and rpi. conclusion: mr highlights a large number of discrepancies in inpatients. a modification of prescriptions due to mr occurs in % of the patients. in surgery units, these rpi are more frequently taken into account than drug-related problem warned by pis. indentifying patients for whom mr has the bigger impact could help us to reinforce our actions. please specify your abstract type: research abstract background and objective: diabetes is very frequently causing cardiovascular complications, thus impairing various systems and organs. therapy for these multiple conditions has to be revised and improved constantly. the aim of this closed retrospective study lead in bucharest emergency clinical hospital was the assessment of some of the diabetes mellitus (dm) complications and the related medication. setting and method: data was collected from cardiology, neurology, gastroenterology, internal medicine wards from bucharest emergency clinical hospital. only patients diagnosed with type dm were included in the study. there were analysed records from patients aged - of whom were men, following the presence, signalling and monitoring of diabetic nephropathy and arteriopathy. main outcome measures: we investigated the relationship between diagnosis and/or biochemical signs of kidney disease (serum urea, serum creatinine levels), diagnosis of arteriopathy, and the drug therapy administered in the respective cases. we also assessed the sex and age distribution of the patients diagnosed with diabetes mellitus and facing at least one of its complications. results: kidney disease, as a dm complication, was present in % of cases, patients aged - , of whom % were men. patients received diuretic treatment, of them being given hydrochlorothiazide, contraindicated in dm because of its hyperglycaemia-inducing effect. of the patients, had high serum urea levels ([ mg/dl), had high levels of serum creatinine ([ . mg/dl), and presented risen levels for both, but only were also diagnosed with kidney disease. patients with kidney disease were given furosemide, known for altering the renal function. circulatory failure was found in % of the patients, aged - and % of subjects, aged - , had both diabetic complications. conclusion: the present study emphasizes the role of the clinical pharmacist in adapting the medication of the diabetic patient, an inappropriate pharmacotherapy worsening dm complications. this is essential especially for elders, where polypathology and polymedication lead to a significant increase of dm complications risk. hp-pc : epileptic seizure after treatment with thiocolchicoside: discussion about a case report valérie dobremez *, , adeline martin-dupray , jacqueline berlioz , pierric giraud pharmacy, neurology, centre hospitalier annecy-genevois, metz-tessy, france please specify your abstract type: descriptive abstract (for projects) background and objective: thiocolchicoside is a semisynthetic derivate of naturally occurring colchicoside, which is largely used in humans as a centrally acting muscle relaxant. this compound also has anti-inflammatory and analgesic effects. the objective of this work is to report a recent case of serious adverse effect of thiocolchicoside occurring in context post traumatic brain damage without sequalae. design: a -year-old woman suffered from headaches and neck pain since days, she was treated with thiocolchicoside. she took mg in the evening and mg the next morning. five generalized tonic-clonic seizures, without recovery of normal consciousness between seizures, have occurred suddenly - min after the second administration. the patient was admitted to intensive care unit in order to control the epileptic seizures. a status epilepticus was diagnosed requiring intravenous drugs with clonazepam, phenobarbital and propofol. the patient was controlled and transferred in neurologic unit in order to complete paraclinical investigations. its main antecedent was a severe head injury at the age of years following a public road accident. the brain scan revealed an old frontal hypodensity. rest of etiological assessment was negative (lumbar puncture, no infectious disease), numbers were normal. the definitive diagnosis was a status epilepticus on post-traumatic sequelae, sensitized by taking a proconvulsant drug. a treatment with levitiracetam was initiated at mg twice a day. outcome was favourable with no recurrence months later, a recommendation was requested to pharmacovigilance. results: the muscle relaxant activity of thiocolchicoside results of an agonist action on glycinergic receptors located primarily in the brain stem and spinal cord. however, thiocolchicoside also acts as an antagonist of the gaba-a receptor (mainly located in the cerebral cortex), this pharmacological action can cause a proconvulsant effect. epilepsy is a very rare adverse effect, only few cases have been reported in literature. the epileptogenic activity of thiocolchicoside occur mainly in patients with a history of epilepsy, acute brain injury or possible blood-brain barrier disruption. the chronology is consistent with the responsibility of the drug as a promoting factor. pharmacovigilance retains after analysing drug causality. conclusion: the case history indicates that thiocolchicoside has a powerful epileptogenic activity. thiocolchicoside can precipitate seizures in predisposed patients, and that its use should be avoided in patients with brain diseases (and therefore lower seizure thresholds) or blood-brain barrier disruption. pharmacists could warn physicians and should verify the absence of notable history before dispensing thiocolchicoside. hp-pc : acute exacerbation generalized myasthenia after red yeast rice use: a case report valérie dobremez *, , amélie serra , déborah grosset-janin , jacqueline berlioz , aymeric dopter , jean-henri ruel pharmacy, neurology, centre hospitalier annecy-genevois, metz-tessy, nutrivigilance, french agency for food, environmental and occupational health and safety, paris, france please specify your abstract type: descriptive abstract (for projects) background and objective: many drugs can induce acute exacerbations or reveal myasthenia gravis. self-medication or complementary and alternatives medicines expose patients. the objective of this work is to report a recent case of acute exacerbation of myasthenia gravis because of a dietary supplement use. design: intermittent vertical diplopia and ptosis of the left eye settled in a -year-old man. its main antecedent is hypertension treated with perindopril. the neurovascular origin was ruled out. the electromyogram (emg) found a significant decrement ( %) of a postsynaptic block in the tongue and right orbicularis muscle. acetylcholine receptor-antibodies were positive. myasthenia gravis was diagnosed (osserman score / ) and the patient was treated with pyridostigmine. the identification of carotid atheroma required a treatment with a statin that the patient refused. he preferred a cholesterol lowering dietary supplement, containing red yeast rice. six days later, he was hospitalized for an acute decompensation of myasthenia with bilateral ptosis, oculomotor paresis, drooping head, int j clin pharm ( ) : - chewing trouble and dysphagia (osserman score / ). the patient is treated with high-dose intravenous immunoglobulins then corticosteroids. the dietary supplement is stopped. an opinion was requested to the clinical pharmacist of neurology. the osserman score gradually increases to / . results: red yeast rice contains a range of compounds known as monacolins, of which monacolin k-renamed lovastatin, which was found to be an inhibitor of cholesterol synthesis and the progenitor of the statin family. a literature review has highlighted the responsibility of statins in acute exacerbations or reveal myasthenia gravis occurrences. in this case, the chronology is consistent with the responsibility of red yeast rice. the case was reported to the french system of nutrivigilance, which retained after analysing a probable intrinsic imputability score. conclusion: dietary supplement with red rice yeast are not recommended in case of myasthenia gravis. this is the first case of acute decompensation of myasthenia recorded with red yeast rice in the french system of nutrivigilance. multidisciplinary collaboration (neurologists, clinical pharmacist) has optimized the patient management. fanny durand * , camille lambert, antoine dupuis please specify your abstract type: descriptive abstract (for projects) background and objective: development of computerized prescription highlights the need to harmonize pharmaceutical analysis practices. the aim of this study is to analyse the antibiotics prescriptions in the treatment of urinary tract infections, to develop a pharmaceutical validation tool. design: a prospective observational study was conducted for one week, in care units. pharmacists, interns, and pharmacy students were trained on spilf (french society of infectious pathology) recommendations, on pharmacist's role in the management of urinary tract infections, and on the data collection. all patients with antibiotic prescription for urinary tract infection were included. some data were collected: reason for hospitalization, clinical signs, results of susceptibility testing, risk factors for complications (organic or functional abnormality of urinary tract, male, pregnancy, elderly, severe immunodeficiency, severe renal impairment) and signs of severity (severe sepsis, septic shock, interventional surgical drainage). then, the treatments prescribed to the patient, probabilistic on the one hand and documented on the other hand, were compared to spilf recommendations. finally, during a multidisciplinary meeting (pharmacist, expert in infectious diseases), we selected the relevant pharmacist interventions. results: twenty-three patients were included ( women, men), % had a urinary catheter. . % of prescriptions were concordant with spilf recommendations: probabilistic and documented treatment, and duration. among the non-conforming prescriptions, nine pharmacist interventions have been formulated: four prescriptions did not specify the duration of treatment, one antibiotic was prescribed on an insufficient period, two cases of severe acute pyelonephritis without prescription of aminoglycoside, one prescription was not reassessed according to results of susceptibility testing, one pregnant woman with urinary colonization without clinical signs, was treated before obtaining results of susceptibility testing. three cases of poor management are identified: two cases which treatment began only after results of susceptibility testing (a urinary tract infection linked to care, an acute pyelonephritis with complication risk), and a cystitis treated with nitrofurantoin while the germ was resistant. conclusion: a synthetic tool was created. there are three elements for helping pharmaceutical analysis: the questions to ask oneself facing a prescription of antibiotic for urinary tract infection, a flowchart to identify the recommendation adapted to the case, and finally a summary table showing spilf recommendations. this tool will be distributed and evaluated. hp-pc : off-label use of rituximab in refractory antisynthetase syndrome (as) through a long-time experience in a neuromuscular diesases center lise durand * , carole metz, patrick tilleul, helga junot pharmacy, gh pitié salpêtrière, paris, france please specify your abstract type: descriptive abstract (for projects) background and objective: as is an idiopathic autoimmune inflammatory myopathy, characterized by presence of antisynthetase antibodies: anti-jo , anti-pl , anti-pl . patients are usually first treated by corticosteroids (cs) or immunomodulating drugs. rituximab (rtx) has become another option for refractory as, supported by few uncontrolled studies . because of its off-label use, our hospital pharmacy has implemented a controlled drug delivery. this work assesses a -years follow-up of patients treated by rtx and the resulted drug costs. design: patients registered in our database since december who received c injections of rtx to treat as, were analysed to describe their eligibility criteria, conditions of management and the clinical and biological effects of the treatment (creatine kinase (cpk) used as biomarker). patient files were consulted to collect all individual data and pharmaceutical software was used to review deliveries. drug costs were also reckoned based on prices from french health insurance. results: for months, patients (median age (min-max): ( - ), % women) have been treated with rtx for refractory as, the majority with anti-jo antibodies ( ). all patients suffer from muscular and lung affections, particularly interstitial pneumonia. many are also living with arthropathies ( ) or cutaneous disorders ( ). cardiac involvement is seldom ( symptomatic patients). the mean age of diagnostic is . years and the mean treatment period is . years. the common treatment is g at day (d ) and d , then g all months. before rtx treatment, seven patients received c other drugs such as cs ( %), azathioprine ( %), methotrexate or mycophenolate mofetil ( %). prednisone and azathioprine are also prescribed with rtx respectively for and %. treatment is associated with cures of intravenous immunoglobulins for four patients. to date, median number of administrations per patient is ( - ), d and d included. all patients have presented positive effects on both clinical and biological markers, mainly during the first months after treatment induction. wilcoxon tests show a significant difference in cpk level between d and m , also between d and the last known result. today, three complete remissions are specified in patient file; only one hepatitis b virus reactivation is reported. since , budget impact due to drug cost amounts to €. conclusion: whereas the use of rtx is controverted for treatment of all types of myopathy, as could have one of the best response . our cohort shows real clinical results and positive effect on usual biomarker. our experience demonstrates the safe and successful use of repeated administrations in refractory as. however, there is a need for further controlled studies to assess the efficacy/safety of rtx and to define its place in the strategy in view of its cost-effectiveness ratio. the pharmaceutical controlled drug delivery has to be continued to supervise, support and document its proper off-label use. please specify your abstract type: descriptive abstract (for projects) background and objective: as a part of the national patient safety program, the northern norway regional health authority are implementing new procedures for medication reconciliation (mr) in hospitals in the region. the procedure defines that mr is the doctor's responsibility and describes how it should be performed. the aim of this study was to investigate whether the implementation of the procedure reduces medication discrepancies (mds) in the charts at bodø hospital. and . % ( / ) of the patients died before discharge. parenteral nutrition was administered an average of . days ( % ci . - . ), of which . ( % ci . - . ) were with ipn. previous spn had been administered in . % ( / ) of the patients. before beginning ipn, the average triglycerides level was . mg/ dl ( % ci . - . ) but at the end of the ipn it was . mg/ dl ( % ci . - . ), which lead to a mean reduction of . mg/dl ( % ci . - . ; p = . ). regarding to the total amount of lipids provided with parenteral nutrition, with ipn there was a mean reduction of . g ( % ci . - . ; p = . ) comparing to those administered with spn. conclusion: usage of ipn in critically ill patients with htg permits to adjust parenteral nutrition formulations to meet specific nutrition needs, enables to reduce the total amount of lipids administered and, therefore, it allows to significantly decrease triglycerides levels. jennifer a. esteban gonzález * , elisabet nogué pujadas, angels andreu crespo, xavier bonafont pujol, nuria romero pascual please specify your abstract type: descriptive abstract (for projects) background and objective: the incidents involving patient misidentification (pm), or wrong patient medical errors (wpme), are medication errors (me), near-miss or close-call situations which can pose a considerable threat to patient health. pm may be under-reported due to the unawareness of the error or the difficulty of identifying them. the aim of this study is to describe the incidence and categories of wpme in a university hospital. design: observational, retrospective analysis of the voluntary reported wpme in the pharmacy database since march until june . these were classified in prescription, transcription, dispensing, administration and drug system errors. in addition, the national coordinating council for medication error reporting and prevention (nccmerp) taxonomy was used for classifying me according to the severity of the outcome. results: of me registered, of them were wpme ( . %). . % of them were due to prescription errors, which consist on wrong labelled medical orders, intermingled patient prescriptions or patient misidentification in computerized physician order entry (cpoe). the administration errors supposed a . % of the total amount of wpme and dispensing errors were . %. % of wpme were transcription errors, which occurred previously to the implementation of cpoe, and the remaining . % were system errors after cpoe. the wpme reported took place in the hospitalization wards ( . %), pharmacy ( . %), outpatient services ( . %), intensive care unit ( . %) and day-care hospital unit ( . %). . % occurred at working days and . % at the weekends. wpme were notified by pharmacists ( . %), nurses ( . %) and physicians ( . %). referring to the classification according to nccmerp, . % of wpme didn't reach the patient (category b) whereas . % reached the patient but didn't cause harm (category c) and . % required patient monitoring (category d). the remaining wpme ( . %) caused harm to patients and required medical intervention (category e). finally, in int j clin pharm ( ) : - more than half of wpme ( . %), reporters suggested measures to prevent these errors. conclusion: wpme represents near % of total me reported in our hospital. given that more than % reached the patient, safety measures must be implemented to reduce the risk of hazardous events. additionally, further encouragement in notification is necessary in order to improve patient safety. results: two men diagnosed with rrms aggressive evolution were included in the study. age: and . both of them without any treatment by the time they started being treated with alemtuzumab (previously one of the patients had been treated with fingolimod, suspended by inefficiency). the protocol design for the elaboration and control of alemtuzumab in the pharmacy service ensures greater safety and represents a saving strategy. in addition, the development of the protocol in the electronic prescription system (silicon Ò ) facilitates the prescription, proper administration and standardization of treatment among patients. the protocol includes daily alemtuzumab infusion for days and other necessary medications including premedication (metylprednisolone, omeprazole, paracetamol and metoclopramide) and anti-infective prophylaxis (aciclovir). developed adverse effects during infusion were skin erythema, pruritus and fever. it was not necessary to stop the alemtuzumab infusion in any patient. during treatment, one patient developed a severe lymphopenia and upper respiratory tract infection (influenza a). conclusion: the role of the pharmacist is critical at various stages, from the preparation and the administration guidelines, to detection, monitoring and reporting of adverse effects. alemtuzumab is presented as an alternative for those patients who do not respond to standard therapies or who have rapidly evolving severe rrms. because of its mechanism of action it is important to closely monitor patients, with particular emphasis on prophylaxis of possible infections. hp-pc : descriptive analysis of patients receiving oral anticoagulation following acute coronary syndromes sadeer fhadil * , paul wright, sotiris antoniou please specify your abstract type: descriptive abstract (for projects) background and objective: triple therapy with concomitant anticoagulant and dual antiplatelet therapy (dapt) following acute coronary syndrome (acs) increases bleeding risk by % compared to patients on dapt. bleeding post acs increases mortality and reinfarction risk; balancing ischemic and bleeding risks is particularly challenging in this population. european society of cardiology (esc) produced a consensus document, providing guidance for patients presenting with acs requiring concomitant anticoagulation; however optimal duration of triple therapy and safety and efficacy of novel oral anticoagulants (noacs) and more potent antiplatelet agents requires further evidence. design: a registry was collated of patients presenting with acs requiring concomitant anticoagulation. baseline characteristics, bleeding and ischemic risk scores, periprocedural treatment and antiplatelet/anticoagulant choice and duration was recorded and analysed for trends in prescribing. results: patients have been included in the registry between oct and june , of which ( %) were naïve to anticoagulation prior to admission, ( %) were taking warfarin and ( %) were on noacs. atrial fibrillation (af) accounted for ( %) cases, (average chadsvasc score of , hasbled score of ), and ( %) were for lv thrombus. of those naïve to anticoagulation, ( %) were initiated on warfarin and ( %) on a noac (last patients all received noacs). of those on a noac for af, ( %) were dose reduced on triple therapy; apixaban being the most commonly prescribed ( % apixaban, % rivaroxaban, % dabigatran). background and objective: solid oral formulations are more convenient than liquids to manufacture, store and administer for most adults. given this superiority, one would think that children were prompted to use solid formulations when available in an eligible dose. there are indications, however, that the conversion from liquid to solid formulation in children is influenced by characteristics of the liquid medication, rather than the child's ability to swallow solid medications. the aim of this study was therefore to explore if the proportion of oral liquid formulations differed between antibiotics commonly used for upper respiratory tract infections (urti) in hospitalized children. setting and method: we collected the sales data for for the children's department of the five university hospitals in norway. the three most common oral antibiotics used for urti in children were included: penicillin v, amoxicillin and erythromycin. the proportion of oral liquids was calculated by dividing the number of defined daily doses (ddd) of liquids by the total oral ddds for each substance. main outcome measures: the proportion of ddds of oral liquid antibiotics. results: a total of ddds of common oral urti antibiotics were sold in , distributed as % erythromycin % amoxicillin and % penicillin v. amoxicillin had the highest proportion of liquid with %, followed closely by erythromycin at %. in contrast, only % of the ddds sold of oral penicillin v were liquids. conclusion: higher proportions of liquid amoxicillin and erythromycin compared to penicillin v were sold to children's departments in hospitals. there are several limitations regarding the quality of sales data, as we lack information of the administered doses as well as the child's age, gender, infection and specific needs. infections in hospitals often require initial intravenous treatment, and oral switch will often be based on the initial treatment. despite these limitations, the results fit well with earlier findings which indicate that children prefer liquid amoxicillin and erythromycin to penicillin v. hp-pc : proactive medication reconciliation: a preliminary study to identify barriers before its implementation in surgery departments laura foucault * , marion collignon, hélène dewaele, anne laure raso, emmanuel cirot, xavier pourrat please specify your abstract type: descriptive abstract (for projects) background and objective: it's well known that medication reconciliation (mr) decreases drug-related problems at patient admission (pa). in surgery departments, for planned hospitalizations, mr is performed - h after the pa (pourrat x and al, ). during this period, some chronic treatments are unintentionally not prescribed to patients. the aim of proactive mr (pmr) is to anticipate the pa by collecting their medication history before their hospitalization. the objective of this study was to identify the barriers preventing pmr implementation in our hospital. design: one week prospective study in digestive and orthopaedic surgery units in a beds' university hospital. the main outcome is to identify which barriers prevent the collection of mr before pa including the evaluation of time required to collect the relevant information, reconcile any discrepancies after the pa and identify the right sources from which to perform the mr. results: eighteen patients with a median age of years old ( - ) were contacted by phone one week before their scheduled surgery. these calls were conducted by pharmacy residents mainly between and p.m. (a more practical time for patients and at the end of pharmacist's routine tasks). an average of . ( - ) calls per patient were conducted. one patient was unreachable by phone. the average duration of the calls was min ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . twelve community pharmacy (cp) were contacted. in all cases, cp have accepted to share information about the patient's prescriptions by phone and sending it by fax during the day. five pharmacists were not contacted because patients had no chronic treatment and consequently no regular cp. on lines of prescriptions, discrepancies between the patient's information and prescriptions were identified and between prescriptions and the anaesthesia records. drug history was reported in the patient's records by pharmacy students on the day of pa in order to be used immediately by prescribers. surgery was cancelled for one patient. conclusion: the first step of an mr is made by a hospital anaesthetist some weeks before hospitalization but we have demonstrated that this step is not able to avert all potential errors. our study highlights that the time necessary to perform an mpr appears to be shorter than for an mr. in fact, it's sometimes difficult to properly interview patients during hospitalization (patient in operating room, drug-induced drowsiness). additionally, a key hurdle is to obtain any necessary modification of the prescriptions by surgeons. pmr can be expected to produce time saving efficiencies given that at pa, prescribers will have their full medication history. this study also allowed us to highlight the good cooperation between patients, cp and the hospital. it is worth noting that efforts were made to accommodate the schedules of a majority of working patients. however, as we would expect pharmacy student to perform the pmr, they will most likely attempt to contact patients during standard working hours which may impact the number of patients they are able to reach. laura foucault * , hélène dewaele, marion collignon, emmanuel cirot, anne laure raso, xavier pourrat please specify your abstract type: descriptive abstract (for projects) background and objective: the french legislation has clearly defined and integrated the therapeutic education of patient (tep) for healthcare professionals. the pharmacist is invited to get involved in tep as a caregiver around the patient. in our study, we are investigating how the pharmacist's role is viewed by patients with chronic diseases that are included in a tep program. design: prospective study on patients included in a tep program (chronic inflammatory bowel diseases, rheumatoid arthritis, ankylosing spondylitis) between september and april . in july , the participants of group sessions (gs) conducted with health professionals, including a pharmacist, were interviewed on the phone. the principal outcome of the interviews was to evaluate how their view of the involved health professional's roles evolved before and after gs; to evaluate if they would consider being followed by their pharmacist for individual sessions (is) in a community pharmacy (cp); and if the information supplied by the pharmacist during gs was understandable. to health care. however, discussions between patients appear to be essential to facilitate their acceptance of a chronic condition. some patients also questioned the cp's skills and knowledge when it comes to their particular disease. nevertheless, . % of patients have found that the vocabulary and documents used by pharmacist during gs was adapted and that the information supplied was very useful. conclusion: this study highlights that although the pharmacist is the drug's specialist, a majority of patients will more likely ask their physician about medication. their participation to the gs hasn't changed their habits even if the pharmacist intervention was relevant and understandable. the fact that the pharmacists took into account the level of health literacy of each participant was an appreciated aspect. cp should be more proactive in their relationship with the patients in order to highlight their skills and the assistance they can provide in a chronic disease. however, it's important to take in consideration that in some cases, patients have lived with their disease since childhood. the role of is is likely to be much more limited than in other situations given their key need is to interact with patients afflicted with the same condition. hp-pc : use and safety of trastuzumab emtansin in her + metastatic breast cancer in a tertiary hospital c. chaguaceda galisteo * , alba manzaneque gordon, héctor josé del río torres, natália creus baró please specify your abstract type: descriptive abstract (for projects) background and objective: novel anti her drugs have changed the management of her + metastatic breast cancer patients. the aim of this study is to describe the use of trastuzumab emtansin (tdm- ) in clinical practice in a tertiary hospital and to evaluate its safety profile. design: we performed a retrospective study of patients who started tdm- between january and december . we recorded demographic data, clinical and treatment variables, number of doses received, reasons for discontinuation, progression-free survival (pfs) and adverse effects (aes). data were obtained from the chemotherapy prescription program and medical records. aes were classified according to the common terminology criteria for adverse events version . of the national cancer institute. results: eleven female patients with a median age of . years [ . - . ] and an ecog ( / ) were included. tdm- was prescribed as a third or further line treatment in / patients and as firstline in one patient who develop disease recurrence within months of completing adjuvant therapy. median number of tdm- cycles was . . all treatments discontinuations were due to disease progression ( / ). pfs was . [ . - . months] (patients that received less than three cycles were excluded (n = )). most frequent aes were plaquetopenia, neutropenia and transaminitis but only grade in three patients (two transaminitis and one neutropenia). conclusion: the lower pfs obtained comparing to the pivotal study ( . vs. . months) could be explained by the later use of tdm- in clinical practice ( / patients received tdm- as third or further line while % in the pivotal study were first or second line). tdm- safety profile was according to the summary product characteristics. few data are currently available regarding the use of tdm- in clinical practice. further data are required to position this drug in clinical practice. please specify your abstract type: descriptive abstract (for projects) background and objective: the hospital pharmacist for their specialized training in the area of medicines, possess a greater responsibility in the detection and reporting of adverse drug reactions (adrs), as well as other problems related to treatment, which may be subject to monitoring and reporting to the regulatory authorities and the respective laboratories. thus, the pharmaceutical services of the cuf infante santo hospital has implemented a pharmacovigilance program, with two main objectives: . optimization of the detection and reporting of problems related to therapy; . implementation of corrective and/or risk minimization measures. the pharmacovigilance program is based on the following methodology: . detection of adrs/problems related to therapy/medical device: the detection can be performed by the pharmacist or other health professional that guides the process to the pharmaceutical services. . information processing by the pharmaceutical services and realization of spontaneous reporting: the notification is performed both for the portuguese regulator (infarmed) as to the appropriate laboratory (if applicable). after evaluation by both entity, the conclusions are communicated to the pharmaceutical services, which has the responsibility to share it with all the other hospital services. . report of the event in the internal risk management platform: when applicable, the pharmaceutical services internally report the adverse event to the hospital's risk management department, leading to an internal evaluation of the current process. . completion of the process and implementation of corrective measures: when the regulatory authority and/or the laboratory sends the report/technical advice about the notification, the pharmaceutical service in partnership with the risk management team perform a reassessment of the whole process. if needed, corrective and/or monitoring measures are implemented. . monitoring of implemented measures: after the implementation of corrective and/or monitoring measures there is a period of evaluation. results: the implementation of this program for the period of year, has led to a total of fourteen spontaneous reports. from all of these notifications, seven were related to quality defect of medicines, four were of adr, one was due to suspected lack of therapeutic efficacy, and lastly, one of the notifications was medication error derived. conclusion: the obtained results, over a year period, by the pharmacovigilance program were satisfactory but the aim of the pharmaceutical services is to consolidate and optimize the same program with a view to achieving better results. the pharmaceutical services will continue to take responsibility for the pharmacovigilance circuit management in this hospital, by promoting a proactive approach to monitoring the safety, quality and efficacy of medicines, which possess the primary objective to patient safety assurance. please specify your abstract type: descriptive abstract (for projects) background and objective: for prematures, parenteral nutrition (pn) is essential for medical care but is complex (specific needs, daily change of intakes…). now, the software logipren Ò , developed by the french society of neonatology, allows the prescription of pn as well as all the childish therapeutics. it is also in link with our production robot (baxa pomp) for individual pn bags. our objective was to integrate this software while optimizing our pharmaceutical validation process. design: the software implementation was lead by a physician/ pharmacist collaboration with several preliminary steps: • identification of pharmaceutical validation settings (pertinence of individual pn vs. industrial bags, parenteral approach, elements…). before the life-sized use of logipren Ò , a base test has been experimented to identify possible difficulties and to realize some correctives actions of the software or our process. results: logipren Ò leads us to a change in our pharmaceutical validation process, by introducing new elements: • the pharmaceutical validation of pn bags is done in collaboration with the physician, during the prescription step. • all the therapeutics are known, which allow the pharmacist to take into consideration all the intakes (micro-nutrients, vitamins…). • remove the transcription step of pn bags in our production software (abacus Ò ) thanks to an interface with our production robot. • less production problems because of the coverage of those pharmaceutical aspects during the prescription. since months, this reorganization helped us to propose pharmaceutical notices for prescriptions: • omissions (remove lipids, levocarnyl Ò , micro-nutrients, electrolytes, remove industrial bags…) • modification (reduce proteins according to urea level, micronutrients and electrolytes posology, duration of lipids infusion…) conclusion: the implementation of logipren Ò enabled us to reorganize of the pharmaceutical validation process with a consolidation of the role of the pharmacist during the prescription step, in the paediatric ward. it had a beneficial aspect by the reduction of the validation and production time, a decreased risk of error (suppression of job interrupts and better communication) and an improved production by the end of transcription step to abacus Ò . furthermore, during our experimentation, we could bring to the software editor new ways to improve it and make it more efficient. % ( . % in ) , difficulties in swallowing/psycho-behavioural distress in . % ( . % in ) , and rejection of oral drug in . % ( . % in ) . physicians and nurses indicate the reason in the medical record in . % of case versus % last year. this year, drug were crushed versus drugs in : % concerned nervous system group (vs. % in ), % concerned cardiovascular system group (vs. % in ) , and % concerned alimentary tract and metabolism group (vs. % in ) . nurses use guideline in % of cases versus . % last year. as the previous year, in % of cases, washing hands before preparation and after administration are met. last year, none of them was wearing mask and gloves during this operation while this year, % was wearing mask and gloves. finally, in the two assessment, for each patient, drugs are systematically crushed together and then mixed with the patient's meal. conclusion: this study shows that crushing drugs is still problematic in our units. however, best practices were observed, such as the indication of the reason of crushing in the medical record, or the consultation of guideline. a new training for nurses will be conducted to create awareness about risks of crushing drug. please specify your abstract type: research abstract background and objective: in invasive candidemia, three echinocandins are indicated: caspofungin, mycafungin and anidulafungin. the aim of this work is to establish which echinocandin to prescribe in a french university hospital, given the scarcity of available clinical data in the literature regarding obese patients. setting and method: in a french uhc with beds, a multidisciplinary working group composed of a microbiologist, an infectious disease specialist and a pharmacist has been set up to analyse the various therapeutic options. main outcome measures: analysis of the literature, pharmacoeconomic study. results: four medications have been identified as possible therapeutic options. their adverse effects are similar and their administration rhythm is the same. according to recommendations by the esmid ( ) and the idsa ( ), the level of evidence for these three echinocandins in initial treatment of candidemia is equivalent. concerning obese patients, no weight limit is mentioned, int j clin pharm ( ) : - despite recommended dosage adjustment. caspofungin must be prescribed at a dose of mg/day for patients weighing over kg. micafungin must be administered at a dose of mg/day regardless of patient weight. in the case of persistence of cultures or if clinical condition does not improve, the dose may be increased to mg/day. anidulafungin, which is not referenced in our establishment, must be prescribed at the same dose regardless of patient weight. from an economic point of view, in our hospital, micafungin at a dose mg/day remains the least costly therapy. however, if its posology is doubled as indicated, caspofungin then becomes the most economic therapy. amphothericin b, an optional treatment, is never the most economically advantageous therapy. conclusion: as a result of this study, the chosen prescribed therapy for obese patients is caspofungin at a dose of mg/day. this work has improved access to healthcare for obese patients. pharmacokinetics and survival data must be collected on the basis of various patient weights in order to predict clinical efficacy. kristin f. heier * , liv czynski please specify your abstract type: descriptive abstract (for projects) background and objective: the aim of this study was to develop a system to prioritize patients for medication reconciliation by pharmacists in the emergency department. it also proved a useful setting for evaluating how other health care professionals perceived the role of the pharmacist performing medical reconciliations within the emergency department. design: the study was located in the Østfold municipal hospital, located in kalnes, norway. pharmacists used a prioritization model to identify ''high-risk patients'' having clinically relevant prehospital medication discrepancies between hospital admission records and the information obtained via medication histories, general physician referrals and nursing homes. pharmacists registered patient information such as age, gender and drug-related problems (drps). seventeen physicians and thirty nurses in the emergency department answered structured questionnaires anonymously. main outcome measures: • number of patients with medication reconciliation performed by a pharmacist. • number of drug-related problems denoted in the electronical journal and presented to the physician. • the overall experience physicians and the nurses had with pharmacists when located in the emergency department. results: pharmacists performed medication reconciliation for patients, identifying drps and potential drps in total. fourteen of the physicians had read the journal notes from pharmacist and found them helpful (n = , %) or greatly beneficial (n = , %). most physicians (n = , %) and nurses (n = , %) reported a good cooperation with the pharmacist in the care of the patients. some of the physicians (n = , %) and most nurses (n = , %) wanted more information about the pharmacists work in the emergency department. the majority of ed staff ( % of physicians and % of nurses) found pharmacist as a good academic resource in the emergency department. conclusion: the physicians reported an improvement regarding the quality in the medication reconciliation made by pharmacists in the emergency department and both physicians and nurses expressed a need that pharmacists work in the emergency department on a more permanent basis. more information in general and especially better communication with nurses regarding the care of the patients are important actions need to optimise collaboration with pharmacist in the emergency department. results: a total of patients were included in the study, median age was years and % were males. they used in average four drugs regularly (range - ). almost three-quarters ( %) of the patients reported high or moderate adherence to all their regularly used drugs (mmas- c (max )). of the patients using oral spasmolytics, % reported high or moderate adherence to these drugs. the majority ( % of the patients) had high perceptions of necessity to their treatment (bmq [ . (max )), and % had a high level of concern (bmq [ . (max )). logistic regression analysis showed that there was no association between adherence and pain, nor between adherence and spasticity. younger age was found to be associated with higher risk of nonadherence. conclusion: even though overall adherence was high, the patients were more concerned to take their medicines compared to other patients with other chronic conditions. further studies are required for understanding adherence and attitudes toward medication in this population, and to help the patients feel safe about their medication regime. please specify your abstract type: descriptive abstract (for projects) background and objective: errors in medication lists often emerge in transition between health care levels, and there is need for strategies to communicate medication information. therefor we aimed to describe reasons why medication discrepancies (md) occurs in the transfer of patients between hospital and primary care service. design: in conjunction to a study based on use of structured medication report at transition from hospital to primary care service, we observed different reasons to why mds occurs. our observations and experiences linked to communication between health care levels is outlined. results: we observed that many md's disclosed at discharge could most likely be attributed to lack of medicines reconciliation at admission to hospital. for instance, several medicines were prescribed in primary care service prior to admission, but not at admission to the hospital. in addition, at admission, some medicines were listed as prescribed medications although not found in the medication lists in primary care service. we also observed that newly started and discontinued medicines were documented in the hospital discharge letter, but not implemented in primary care service. according to health care personnel in primary care service, insufficient communication about the patients' medications at discharge from hospital, led to corrections in the medication lists based on their previous knowledge about the patients. in addition, justified medication changes at discharge from hospital were not always implemented in primary care service due to professional disagreement. some stated that lack of trust was one reason for not always taking changes into account, often based on earlier experience. conclusion: these observations indicated that mds occurred both with and without intent when patients from primary care service were admitted to hospital and returned back due to poor communication. medication errors during hospitalisation and unproven intentional changes may be the consequences. due to this, it is important to improve the communication and confidence between professionals in the hospital and primary care service in order to reduce the number of mds and to enhance patient safety. please specify your abstract type: descriptive abstract (for projects) background and objective: intravenous human immunoglobulins (iv igs), plasma protein products, may cause in patient to a range of adverse side effects (headache, skin rash, kidney failure, thromboembolic event). in the framework of securing medicinal care, an assessment of professional practices has been conducted within our university hospital. the overall goal of this study is to evaluate the process of intravenous administration of human immunoglobulins done by the nurse staff. design: this prospective study has been carried out in three departments of neurology. an observation grid was established on the basis of guidelines on good practices. all in all, criterions have been examined resuming: prerequisites before administration, patient setup, iv igs administration, monitoring, traceability of drug delivery and management of adverse side effects. results: during the course of this investigation, administrations were observed. only % of nurses deliver information about the treatment to their patients before administration and % question patients about previous hypersensitivity reaction. the presence of spontaneous diuresis is verified in % of cases. emergency cart is not reachable in % of all cases. % of nurses ask patients to decline their identity. the use-by date on the bottles is checked in % of cases. at the time of preparation of perfusion, labelling does not mention either patient's name ( %) or date and hour of perfusion ( %). int j clin pharm ( ) : - during perfusion, only % of nurses follow diuresis and % watch rate of administration. hydration is not always kept min after the end of perfusion ( %). patient monitoring varies between min and h after perfusion's end. in % of cases, diuresis is monitored after the end of administration. % of nurses explain to patients side effects that may occur remotely. finally, administration traceability is was conform in % of all cases and in the event of adverse side effects, statement was made in % of cases. conclusion: best compliance scores have been achieved in myology department where patients are fewer than in the two others departments ( vs. and ). a presentation of those results will be given in theses three departments in order to improve patient management and securitization of iv igs administration. this audit will be carried out soon in other departments. please specify your abstract type: descriptive abstract (for projects) background and objective: a new human polyvalent immunoglobulins dose ( g) for intravenous administration is available on our establishment since . in order to secure the administration, this new dosage was initially reserved for the healthcares using administration pumps (being four health-care). the aim of this survey was to evaluate the satisfaction of the nursing staff already user of the new g dose and to estimate the motivation of the nonuser nursing staff by the audit date. design: this satisfaction survey was carried out with the most igiv consumer services (being internal medicine, neurology, cardiology and haematology). the questionnaire was structured in two sections: the first section regarding igiv in general, the second section concerning the new g dose. the survey included multiple choice questions or questions with answers based on a four levels evaluation scale (not satisfied, mildly satisfied, satisfied, and very satisfied). results: the audit was realized on eight health-care, involving nurses. among the interviewed, ( %) have already used the g dosage. in % of cases, users were very satisfied and % were satisfied. the most positive points noted were: gain of time provided ( . % of satisfaction), less manipulation needed ( . % of satisfaction), and reducing of infectious risk ( . %). moreover, the influence of the injection technique on users' satisfaction was further reported. indeed, according to nurses interviewed, the use of an injection pump is safer and improves the job comfort of nursing staff, unlike the injection by gravity (used in % of cases), which seems to slow down the use of this new dosage. in two cases, a positive opinion given by patient was also reported. finally, negatives points noted were related to administration instruments (use of pump or not) and to less flexibility in daily dose regulation. among the % not-user of this new dose, the % showed a strong interest for the product apart from services making the igiv administration by gravity. conclusion: in light of these results, the use of g dose will be spread to other services. the general diffusion of this dosage will provide a gain of time also at the pharmacy, during the unitary delivery and the computer-based administration of every units. a second survey will be soon effected within patients involved in the switch g/ g. the capital region pharmacy, clinic of neurology, rigshospitalet, blegdamsvej, copenhagen, denmark please specify your abstract type: research abstract background and objective: the clinic of neurology, rigshospitalet, copenhagen, denmark experience continuous medicine-related patient safety incidents (psi) related to newly admitted patients and patient transfers between wards. in order to prevent drug related problems (drp), the pharmacists increased their focus on these patients and provided systematic medication reconciliation. thus, the objective of this pilot study was to investigate if the intervention would help identify drug discrepancies (dd) and prevent drp. four wards were included in this study; two neurological, one neuro-anaesthetic (icu), and one neurosurgical ward(s). three wards use electronic medication module (epm), whereas the icu uses critical information system (cis). furthermore, all patients' prescriptions are registered on shared medication record (smr), which provides an overview of prescribed medicine. prescriptions cannot be transferred from smr and epm to cis and vice versa. we suspected that psi resulted from these system incompatibilities. setting and method: patients admitted or transferred from may nd to june rd were included. medication reconciliations using smr, epm and cis were conducted by a pharmacist on weekdays. dd were presented to a physician orally and documented. only dd accepted by physicians led to drug prescribing change. main outcome measures: number of identified dd. results: the study included patients, of which ( %) were newly-admitted. patients ( %) were transferred between wards. of the transferred patients, ( %) were transferred from the icu to other wards and ( %) were transferred from other wards to the icu. of the newly-admitted patients, ( %) were admitted to the icu and ( %) were admitted to other wards. the pharmacists identified dd; dd ( %) in the transferred and dd ( %) in the newly-admitted patients. in the transferred, dd were all related to the icu. in the newly-admitted, dd ( %) was related to the icu and dd ( %) to other wards. of the dds, ( %) were accepted by the physician. an example of a severe dd identified was an omission of prednisolone to a patient admitted to the icu. conclusion: most dd were identified in patients admitted to or transferred from icu, which uses the incompatible system cis. pharmacist systematic medication reconciliation helps identify these dd and prevent drp. please specify your abstract type: research abstract background and objective: antibiotic related drug interactions are more likely in intensive care unit patients due to common polypharmacy and antibiotic usage. the aim of this study is to determine the antibiotic related drug interactions with three different online databases (micromedex-paid, medscape-free and drugs.com-free) and to evaluate these interaction information by clinical pharmacist. setting and method: a retrospective, descriptive study was set up in hacettepe university hospital's intensive care units, between november and december , . patients who use at least one antibiotic were involved in this study. all drugs were assessed by each three databases and only antibiotic drug interactions were evaluated. clinical significance of identified drug interactions were evaluated by clinical pharmacist. main outcome measures: clinical pharmacist's assessment in significance of drug interactions indicated by three online databases. please specify your abstract type: research abstract background and objective: an implementation of clinical pharmacy practice by postgraduate students in intensive care units is a new way of learning in postgraduate education which creates opportunities in multidisciplinary collaboration in clinical pharmacy research, and also has influence on clinicians' routine patient care process. this system in educational program was ongoing in the department of clinical pharmacy since . as a part of this educational program, drug related problems in intensive care units were described and analysed, an influence of clinical pharmacy postgraduate students on patient treatment process was sought. setting and method: a prospective, cross-sectional study was performed between the march-june in hacettepe university hospitals, department of internal diseases intensive care units which consists of beds. three postgraduate pharmacy students from the department of clinical pharmacy, faculty of pharmacy conducted medication reconciliation in order to identify any problems in patients' medical orders. drug related problems (drps) were identified by the students and recommendations for management were approved by a supervisor of clinical pharmacy department before they were directed to physicians for approval. the students were not authorized to undertake any action in patient care process, therefore all required interventions for drp were undertaken by physicians and the acceptance ratio of the interventions were recorded. the pharmaceutical care network europe foundation classification system (v. . ) was used to asses drps. main outcome measures: determination of drps by pharmacists and evaluation of their interventions' acceptance by physicians in intensive care units. results: during the study period, patients were admitted to the intensive care units. each patient's medication orders were evaluated and interventions were recommended by postgraduate students. the number of interventions per patient was . . the acceptability rate of interventions by physicians was . %. in addition, physicians were provided drug information on seven different occasions. recommendations regarding drug therapy were mainly related with treatment effectiveness and adverse reactions. the common causes of drps were requiring dose adjustment due to pharmacokinetic problems ( . %), no therapeutic drug monitoring ( . %), inappropriate timing of administration and/or dosing intervals ( . %), requiring dose adjustment due to deterioration/improvement of diseases ( . %), inappropriate drug selection ( %) and new indication for drug treatment presented ( %). the most common drugs responsible for drps were ranitidin, levothyroxine, allopurinol, pantoprazol, piperacillintazobactam and vancomycin. the study showed that the most common drps was dose-related, therefore close monitorisation of the intensive care unit patients by students in clinical pharmacy postgraduate program can help physicians in terms of detecting, preventing and minimizing drps in order to improve patients' health outcomes. please specify your abstract type: research abstract background and objective: antibiotic stewardship is the process of salvaging important antibiotic agents from becoming ineffective due to bacterial resistance. this is important because throughout the world antibiotics continue to be one of the most important classes of therapeutic agents due to their vital role in saving patient lives. key goals of antimicrobial stewardship are to improve clinical outcomes, prevent antibiotic resistance, promote patient safety, and reduce health care cost. pharmacist are in the frontlines because they perform antibiotic stewardship activities, such as selecting the most optimal antibiotic agent, adjusting drug-dosage, and stopping use of unnecessary antibiotics. as a result of the continuous rise in antibiotic resistance and decline in development of new antibiotics, antibiotic stewardship programs are proving to be indispensable in a health care settings. setting and method: adult and paediatric inpatients receiving antibiotic therapy in the hospital medipol university has been evaluated. patients were selected randomly in the hospital system. patients were evaluated for antibiotic susceptibility results and compliance with antibiotic management guidelines. main outcome measures: to evaluate the antibiotic therapy in patients with culture results and to determine according the treatment guidelines. results: it was observed different pathogens in blood culture results of inpatients out of patients who were treated with antibiotics in hospital. antibiotic susceptibility results for acinetobacter spp, staphylococcus spp, enterococcus spp, pseudomonas aeruginosa, klebsiella spp, e. coli spp, streptococcus spp, corynebacterium spp, streptococcus pneumonia and enterobacter spp are evaluated in the study. klebsiella spp was the most isolated pathogen at total of culture results. most frequently resistance were int j clin pharm ( ) results: a total of ( %) questionnaires were completed. of these, approximately % were answered by hospital nurses, the remaining mainly by physicians ( %) and % ''other''. on the question ''what is your general perception of the benefit of the clinical pharmacy service; for collaborating health professionals? for the patient?'' the total benefit was ranked . and . respectively (scale from (''no benefit'') to (''beneficial to a very large extent''). the open questions: ''what disadvantages/advantages have you experienced by the introduction of clinical pharmacist into multidisciplinary teams?'' received / comments respectively. physical obstacles regarding office space, interference with the decision making process, more time consuming processes and the issue of relying too much upon the advices given was reported as possible disadvantages. respondents answered ''none'' to this question. the comments regarding advantages dealt mainly with general increased patient safety and quality assurance. in addition, advantages as work-load relieve, time saved, collegial support, practical help, and learning interchange between professions, were highlighted. conclusion: health-professionals assessed the clinical pharmacy service as highly beneficial. the advantages outlined were higher patient safety and quality regarding medication, in addition to collegial support, practical help and learning interchange. please specify your abstract type: descriptive abstract (for projects) background and objective: in june , the french health authority, the «has», published an index resuming the recommendations of benzodiazépines (bzd) prescriptions and proposing an approach to stop using it. indeed, it has been established that there is a too high and too long consumption of bzd in france. a study of prescriptions' prevalence has been done in our hospital centre. the aim of this study was to know our situation regarding the use of bzd in order to set up some improvements and take part in their proper use. design: a prospective study has been done on a months period in different services: geriatric, post-op and rehabilitation facilities, endocrinology, internal medicine, pneumology and cardiology services. the data were raised on a given day in each services and recovered thanks to the prescriptions software but also through interviews with the patients and their doctors. it was examined whether there was a bzd prescription (hypnotic or anxiolytic), whether the duration was superior or not to the duration of the amm and whether the prescription was done in our hospital centre. if the prescription was already part of the patient treatment, we looked if it was possible for the patient to stop using it, according to the has criteria. on their discharge, the letters and bzd prescriptions were also analysed and some patients' general practitioner were contacted after their discharge. results: patients (median age years old) were included from november to march . . % ( / ) of the patients had at least one bzd prescription the day we collected the data. we found only one bzd in prescriptions ( . %) and among them . % ( / ) were anxiolytic bzd. among those prescriptions, . % ( / ) already existed before the hospitalization and . % ( / ) were given during the hospitalization ( were prescribed automatically). . % ( / ) of the prescriptions did not respect the legal duration of the amm ( pieces of data were not found). . % ( / ) already exceeded this duration limit. among the patients who already had a bzd treatment before going to hospital, . % ( out of ) could consider stopping their use of bzd. by the end of this study, patients were discharged from hospital, among them . % ( / ) with a prescription of bzd. . % ( / ) of the prescriptions established during the hospitalization had been renewed when the patient came out of the hospital, we managed to contact ten general practitioners (approximately . days after their discharge), nine patients carried on their bzd treatment, among them one patient had reduced his consumption. conclusion: this study is an example of the high proportion of bzd prescriptions in france which the majority doesn't respect the legal length of the amm. the prescriptions of bzd in the hospital are generally systematically renewed by the general practitioners. the patients must be informed about the risks of using those molecules. in order to ameliorate this practice in the hospital, a proper use leaflet, reminding the prescriptions of bzd, has been created and distributed in each services to make people aware. main causes of admission were infections ( %) (respiratory disease ( %) and other ( %)), hepatic disease ( %) and neoplasias complications ( . %). patients died during their admission; due to hepatic disorder, due to neoplasia, and due to infections. conclusion: last diagnosis of hiv or no art treatment are causes of admission. immunovirological situation is related with their adherence but isńt with admissions. coinfection with hcv or hbv or others infections are risk factors for admission. center for psychopharmacology, diakonhjemmet hospital, oslo, norway please specify your abstract type: research abstract background and objective: complex medical history and treatment can potentially cause problems. the objective of this study was to investigate the prevalence of drug-related problems (drps) and medication discrepancies in internal medical patients with complex treatment at hospital admission. further, to investigate to which extent drps were identified as a result of medication reconciliation, and to which extent drps could be associated to the hospitalization. setting and method: patients with at least four regular medicines from two different therapeutic groups were consecutively included at admission to an internal medicine ward at a university hospital in norway in the period . . - . . . pharmacists used the integrated medicines management (imm) model for medication reconciliation and medication reviews at admission. a medication discrepancy was defined as any discrepancy between the recorded medication list at admission and the patient's actual use of medications, as revealed by medication reconciliation. the patients' actual use of medications, medical journal and laboratory results, were used to perform a medication review at admission time and identify drps. the proportion of drps revealed due to medication reconciliation was calculated. moreover, the project group retrospectively assessed possible drp-induced hospitalizations based on clinical history, cause(s) of admission and identified drps. main outcome measures: the main outcome was the median number of drps per patient at admission. the proportion of drps revealed due to medication reconciliation, the proportion of patients with drps possibly associated to the hospitalization, and the median number of medication discrepancies, were included as secondary outcomes. results: patients were included, . % women. median patient age was (range - ) and most of the patients were home-living before admittance ( . %). in total drps were identified at admission, with a median number of (range - ) per patient. drps ( . %) were identified due to medication reconciliation. for patients ( . %) a causal relationship between the hospitalization and the drps was assessed as ''possible''. medication discrepancies were revealed in of the included patients ( . %), with a median number of (range - ) per patient. conclusion: internal medical patients with complex drug regime are frequently exposed to drps and medication discrepancies at hospitalization. medication reconciliation could be essential to identify drps, which is likely a common cause of hospitalization in the studied patient population. hp-pc : assessment of oral anticoagulant prescriptions and pharmaceutical analysis at the hospital by regional audit damien fuss *, , clélia monchablon , anaïs breteau , marie lefebvre-caussin , rémi varin , jean doucet , mikael daouphars , doreya monzat omedit normandie -chu rouen, chu rouen, please specify your abstract type: descriptive abstract (for projects) background and objective: oral anticoagulants (oa) are the most common drug class associated with preventable adverse drug events in hospitalized patients that require optimizing the pharmaceutical analysis (pa) process. in this context, a regional audit was conducted on pa of prescriptions oral of oa. the aim of this study is to provide an overview of the treatment by oa in the hospital by evaluating the consistency of the oa prescriptions compared with national and european guidelines and evaluate the pharmaceutical interventions. design: this study is based on the collection of pa data (demographics, indication, posology, drug interactions, monitoring) as well as the collection of pharmaceutical interventions and discordance int j clin pharm ( ) : - between guidelines recommendations and clinical practice. the inclusion criteria were any patient treated with oa (vitamin k antagonists (vka), non-vitamin k antagonist oral anticoagulants (noacs)). included patients were followed minimum months. the primary outcomes include description of baseline characteristics of patients, the number of inappropriate prescriptions compared to the different clinical recommendations, the number of pharmaceutical interventions, the number of adverse drug reactions (adrs) related to oa use and the assessment of patient monitoring. results: during the -months study period, patients were included in six health institutions. the average age was years ( % of patients over years old) and % of the patients were women. % of patients had renal impairment. % of patients were treated with vka, and % with noacs. it was the first prescription of oa for % of patients ( % with vka; % with noacs). the most common indication was the non-valvular atrial fibrillation ( %). in this indication, % of patients had cha ds -vasc score c , and nearly % had a high risk of bleeding (has-bled score c ). drug interactions were observed, and adrs occurred related to oa. % of patients with an adrs had a has-bled score c . . % of prescriptions were considered inappropriate, including % noacs (no monitoring renal function in % of patients over years initiating treatment, inappropriate posology in %, and % of contraindications). the rate of pharmaceutical interventions was %. nearly % of the prescriptions were already adapted when the pharmacist was starting analysis. conclusion: prescribers are sensitized of the risks on the oa prescriptions, which explained the delay upon pa and low rate of pharmaceutical interventions. however, the high number of inappropriate prescriptions shows the necessity to improve the pa process on these drugs, particularly by actions on therapy initiation and patient monitoring, especially for noacs. for this class, the impossibility of assess the level of anticoagulation by laboratory monitoring requires appropriate initiation and monitoring, especially an assessment of baseline renal function. please specify your abstract type: descriptive abstract (for projects) background and objective: the development of bacterial resistance these last years is a public health major problem in the world and needs to implement actions. in france, the national drug safety agency has defined a list of ''critical antibiotics''. this list includes antibiotics particularly generator of bacterial resistance (amoxicillinclavulanate, cephalosporine, fluroquinolone) and antibiotics called ''last resort'' (antibiotics against gram-positive cocci, car-bapenem…). at our regional level, an evaluation of prescription of these critical antibiotics was proposed to all medical centers. the aim was to evaluate the quality of prescription of these critical antibiotics. design: the regional working group (pharmacists, infectious diseases physicians and biologists) had developed a collection grid including data on patients, antibiotics and four criteria: adequate molecule, compliance with medical prescriptions, duration of antibiotic therapy and reassessment at h. this is a prospective study proposed to all health institutions (public and private), which had to be completed on a given day in all care units and had to be conducted by a team of multi-professional evaluators. the study included a quantitative part (number of patients hospitalized in the audited units, number of patients receiving antibiotics and number of critical antibiotic prescriptions) and a qualitative part (adequate to the four criteria). results: response rate was of %. the study investigated on patients hospitalized in the audited units, including patients ( %) receiving antibiotics. among the patients, % were hospitalized in medical, surgery or obstetrics units we recorded prescriptions of ''critical antibiotics particularly generator of bacterial resistance'' ( % amoxicillin-clavulanate, % ceftriaxone, % fluoroquinolone and % other third-generation cephalosporine) and prescriptions of antibiotics called ''last resort'' ( % carbapenem). the average age of the population was . years (± years). sex ratio was . . % corresponded to curative use and % to prophylactic use. the expertise of infections diseases physician was requested in only % of the cases. the antibiotics were prescribed in majority to treat bronchopulmonary infections ( %), urinary tract infections ( %) and intraabdominal infections ( %). ninety-two percent of the prescriptions had a proper indication. % of the prescriptions complied to the guidelines. the duration of antibiotic therapy was adequate in % of the cases. only % of the prescriptions were correct according to these three criteria. forty-four percent of the prescriptions were reassessed and adapted by the physician. conclusion: this study is original because of its regional dimension and antibiotic analysis. the number of analysed prescriptions was significant with an overall proper prescription in adequate with the guidelines. however, actions must be implemented on duration and reassessment and adjustment of treatment. these results were presented to the participating hospitals. these three points will be reevaluated during a new regional audit. the criterion «no more psychotropic drugs» has been met in . % of assessment. otherwise, or more psychotropic drugs are prescribed in . % of assessment from the point of admission. the criterion «no more a benzodiazepine drug» has been met in . % of assessment. otherwise, more than one benzodiazepine drug is prescribed in . % of assessment from the point of admission. no contra-indication is detected in . % otherwise, a contra-indication between two drugs causing torsade de pointes is detected from the point of admission in this department. no more anticholinergic drug is prescribed in . % of assessment. according to the french criteria, one or more inappropriate drug is prescribe in . % of assessment. the most common inappropriate drug group prescribed was alimentary tract and metabolism drug ( . %) (the hospital at home team needs these class of drug) followed by nervous system ( . %) (prescribed at the point of admission) and by cardiovascular drugs ( . %) (prescribed at the point of admission). finally, the criteria «no more one non-steroidal anti-inflammatory drug» and «no illogical association» have been met in all cases. conclusion: this analysis shows that most of criteria for «assessment of prescription among elderly in a «hospital at home» department have been met. when one has not been met, either the hospital at home team needs the drug prescribed, or this drug have been yet prescribed from the point of admission in this department. this study could be used for the next certification. hp-pc : access to health care: case of autologous serum eye drops batiste martel, fabien lindenberg, camille castel, guillaume saint-lorant * please specify your abstract type: research abstract background and objective: autologous serum eye drops (ase), prepared from patient's serum, are indicated in the treatment of severe dry eye syndrome and defective epithelial healing. its in-hospital preparation within a controlled-atmosphere zone unable it to be dispensed by non-equipped hospital pharmacies. the aim of this study was to implement security measures to allow transport towards distant hospital pharmacies and all patients even those residing far from a regional university hospital (uh). setting and method: this study was conducted in a -bed french university hospital. patient blood samples were taken within the university hospital every weeks. serum was then biologically controlled (negative tests for hiv, hbv, hcv, tpha, vdrl). preparation was conducted days after blood sampling. sterile preparations were then stored at a temperature of - °c. studies showed that eye drops were stable days after being thawed. transport of eye drops to distant hospital pharmacies requires to be conducted under controlled temperature i.e. below °c, to ensure the stability of eye drops. these pharmacies are located close to patient's homes. the entire process was examined by a pharmacy team in order to study and secure each step, transport in particular. main outcome measures: validation of each step of the autologous serum eye drop dispensing process, from sampling to receipt by different hospital pharmacies, transport in particular. results: patients benefitted from the preparation. all patients resided more than kilometres from a uh. a follow-up form was completed to qualify dispatching and to trace each step during transport. a temperature sensor was placed inside the box. the receiving agent was required to stop and control the sensor. a double retrospective control was performed by a pharmaceutical team via the recording of temperature sensors. a second follow-up form was drafted in order to track dispensation reviews, ongoing dispensation and future planning. a patient information booklet was distributed to hospital pharmacies to inform patients about good practice concerning eye drops. conclusion: technological necessities concerning autologous serum eye drop preparation and transport limit access to health care. in this study, the role of the pharmacist consisted in reducing inequalities among patients residing at a distance from the only regional uh. the role of the pharmacist is to ensure absolute quality of preparation between the uh and the patient. hp-pc : computerized medication reconciliation: overview of pharmaceutical software used and support for development of integrated modules julie mocquard, anaïs berthe, elise rochais * , nicolas prévost, jean-claude maupetit, on behalf of centre de ressources régional en conciliation médicamenteuse omedit pays de la loire, nantes, france please specify your abstract type: descriptive abstract (for projects) background and objective: medication reconciliation aims to improve continuity of care for patients. in , a national survey identified barriers for implementation of this activity in france, among which computerized systems were judged unsuitable for hospital practices. in the absence of appropriate hospital information systems (his), medication reconciliation remains a time consuming process implying manual transcriptions, potentially leading to a lack of traceability and medication errors. the objective of the study was to assess the current his used in a french region including the integration of medication reconciliation into the software and to define courses of action to assist this integration. design: an online survey conducted in may was addressed to head pharmacists of the health facilities in the region, giving a total of head pharmacists concerned. it included questions on the software used by the health facility, the development of medication reconciliation and its traceability, formulation of operational requirements to the editors of software and availability of a module integrating medication reconciliation provided by the software. results: seventy-eight pharmacists ( %) participated in the study, with all types of health facilities represented: public hospitals, clinics, home health agencies, haemodialysis structures and after care and rehabilitation facilities. thirty different software were identified in the region. ( %) pharmacists planned to develop medication reconciliation in their health facility and ( %) were already carrying out this activity. within these %, medication reconciliation was conducted on paper only for ( %) of them, while ( %) were using a computerized system (patient file, pharmaceutical software, other) for traceability. the most widely used software in the region contains a module enable for computerized medication reconciliation, and three other editors are currently developing one. no development is scheduled for another three editors nonetheless commonly used in the region. ( %) pharmacists had contact with the editor of the software, and had given thought to the preparation of requirement specifications to the editor to develop an integrated module of medication reconciliation. conclusion: despite the interest attributed to medication reconciliation and despite the need of a fully integrated module of medication reconciliation to his, only a few health facilities of the region possess an appropriate computerized system to develop this activity. this study underlines the approaches already made by pharmacists to editors in order to integrate medication reconciliation to the his. subsequently, retrieving these approaches and writing specifications common to all health facilities is scheduled, in order to assist them in providing a strong incentive for the editors to integrate medication reconciliation to existing his. please specify your abstract type: descriptive abstract (for projects) background and objective: medication reconciliation (mr) is an interactive and multiprofessional process that ensures the continuity of care by integrating the ongoing treatment to the new hospital prescription. this helps securing the patient's care pathway particularly at transition points. the objective is to initiate the mr process in our medical institution with a pilot study in the department of internal medicineemergency downstream to validate a methodology and adapted tools. design: the mr takes place in three steps performed by a pharmacy student: ( ) realization of best possible medication histories (bpmh), combining at least three sources of information and using sources' collection form. this research begins with a patient interview done in pairs with a medical student using an interview guide. ( ) comparison bpmh with the initial hospital prescription in the department (after passing through the emergency department) on the treatment reconciliation form. a status is assigned to each line of drugs and then the differences are identified (stopped, changed or added). these two steps are validated by a pharmacist. ( ) discussion and characterization of observed differences (intentional/unintentional and documented/undocumented) with the senior physician. results: twenty-six mr were performed over weeks in . the mr is performed within days after admission. on average, . information sources per patient were used for the bpmh: mainly drug prescription (dispensed in pharmacies community); analysis of emergency medical records and patient interview. for the patients included, drugs were listed. discrepancies were observed and were studied (status stopped or changed only): one documented intentional discrepancy, undocumented intentional discrepancies and unintentional discrepancies (ud). these uds affected patients ( - medication errors per patient) and corresponded to a non-prescribed drug in % of the cases. vitamins, antihistamines, anti-reflux and proton-pump inhibitors were involved in % of cases; cardiovascular drugs in % and antiinfectious in %. through this pilot study, the methodology was validated: (a) need to have a minimum of three sources to achieve a relevant bpmh and to confirm each information with two sources; (b) need for a dedicated time with trained staffs; (c) development of tools to improve the traceability of information obtained from each source and traceability of medication reconciliation activity. conclusion: the mr establishment in the internal medicine department was helpful in identifying medication errors that have been corrected. it is proposed to archive the treatment reconciliation form in the patient file to contribute to the traceability of information on treatment. this study strengthens the deployment of this method and mr tools to other services of the hospital. alma mulac * please specify your abstract type: research abstract background and objective: clinical pharmacists have an important role in improving healthcare services. there is lack of knowledge of clinical pharmacists' experiences in interprofessional collaboration. our objective was to explore the challenges and barriers experienced by clinical pharmacists in interdisciplinary teams in norway and incorporation of expanded pharmacist roles in hospital settings. setting and method: this qualitative study was conducted using semi-structured interviews. a total of clinical pharmacists from four (government) hospitals were included in the study. the interviews were audio recorded using a digital recorder. the recordings were transcribed verbatim. main outcome measures: challenges and barriers clinical pharmacists experience in interdisciplinary teams in hospital setting. results: the main findings are that the pharmacists' role is little known to other health care professionals, particularly at hospitals with short tradition for clinical pharmacy services. clinical pharmacists have great motivation from being able to influence drug treatment for patients. from the perspective of the participating pharmacists they succeed in interdisciplinary cooperation when their professional knowledge solves the patients' drug-related problems. communicating recommendations to physicians with professional credibility has great importance for the intervention to be implemented. using the theoretical framework of communicating tensions, we argue that the pharmacists in our study use indirect communication to prevent physicians defensiveness to recommendations. lack of education in interprofessional cooperation and communication is apparent in this study. the participants also stated that there should be some form of quality assurance or education requirements before one can work as a clinical pharmacist. conclusion: training in communication for graduates and interprofessional collaboration during the undergraduate pharmacy education, can possibly help pharmacists with integration in interdisciplinary teams. increased attention to teamwork from the hospital leadership is essential for the implementation of interprofessional collaboration in a larger context. please specify your abstract type: descriptive abstract (for projects) background and objective: antifungal therapy in the icu, particularly therapy targeting resistant aspergillosis, mucormycosis and systemic candida, is often of lifesaving importance. posaconazole and voriconazole are the antifungal agents of choice. our aim was to compile a tool that can be used at the icu to address aspergillosis, mucormycosis and systemic candida in an optimal manner. design: female patient, age + , liver transplant, crp [ mg/ l, creatinine [ lmol/l. abdominal x-ray imaging revealed four large abscesses and laboratory analyses confirmed mucormycosis. posaconazole intravenous ( mg one times daily) and liposomal amphotericin b ( mg/kg/day) were initiated. the inflammatory markers remained unchanged days following initiation of therapy with no change in size or number of abscesses and the patient developed sepsis. amphotericin b dose was increased to mg/ kg/day. after week the inflammatory parameters and size of abscesses began to fall. the dosage form of posaconazole was switched from intravenous to mixture. the dose remained the same and within h the crp rose to mg/l. results: pharmacist intervention revealed a missing loading dose of intravenous posaconazole as well as incorrect dosage of the per oral form due to bioavailability variation. posaconazole mixture dose was increased to mg two times daily. through serum concentration analysis of posaconazole was suggested prior to the dose increase. the serum concentration was . mg/l (range [ . - . ) . through serum concentration days later was . mg/l. both crp and abscess size were on the decline. a dosage and tdm pocket card for posaconazole therapy of mucormycosis, aspergillosis and candida was compiled. conclusion: optimal systemic fungal infection therapy is essential, especially in the critically ill. of special importance is tdm and correct dose adjustment when dosage-form changes occur. please specify your abstract type: research abstract background and objective: potentially inappropriate prescriptions and omission of prescription, respectively ip and op, are common issues in the pharmacotherapy, especially in vulnerable population, such as elderly and children. there are many available tools detecting ip and op for geriatrics, however, similar tools are less common in paediatrics. therefore, a first target tool for paediatric population: popi «paediatrics: omission of prescriptions and inappropriate prescriptions» was created and was validated by delphi method in . we aim to evaluate inter-rater reliability between health care professionals, who apply popi. our study also assessed their satisfaction and the accessibility of this tool. setting and method: twenty cases with or without ip or op were selected. these cases were identified in a previous retrospective ip-op prevalence study on . patients. these patients were admitted to the emergency department of a university mother and child hospital, between october and march . one doctor and one pharmacist, who participated in the creation of popi tool, identified ip and op in cases and composed ''standard answers''. these cases were then reviewed independently by eleven clinicians (including generalists, paediatricians, pharmacists, residents, general practitioners), who did not experience this tool before. inter-evaluator agreement was calculated by using the agreement kappa test. the satisfaction of users was also evaluated. main outcome measures: inter-evaluator agreement, the median time of use and the satisfaction of users. results: a high level of agreement of ip and op detection was recorded (ip: k median = . ; op: k median = . ). the easy use of popi was approved by % evaluators. the median time of use was min s per case (quartiles : . - . ) . as a result, there were % of clinicians satisfied with the provided popi and they would like to apply this tool in their daily practice. conclusion: popi demonstrated a good interrater reliability and is easy to use. this strong validation by many specialists prove popi is a reliable tool. it can be applied daily at work in paediatric section by doctors and pharmacists. other multicentre and prospective study should be conducted to evaluate economical and clinical impacts of popi. please specify your abstract type: descriptive abstract (for projects) background and objective: drug dosing during cvvh is challenging due to changes in pharmacokinetic parameters brought about by the patients' deterioration in health and factors associated with the physical process of filtration. this is of particular significance in the icu. in addition, there is the issue of the patients' diuresis or lack of such. this will affect the total clearance (cl total ) of the drug. the dose of antibiotics must therefore be calculated individually taking into account all of the above as well as changes of filtration parameters. our aim was to illustrate how such dosage calculations can be undertaken. design: a -year-old male patient, weight kg, diagnosed with stenotrophomonas maltophilia infection. the trimethoprim/sulfamethoxazole dose was . mg trimethoprim/kg/day every h as specified for anuric patients on cvvh. patient was initially anuric for days after which diuresis was started. the dose was recalculated. results: creatinine clearance (crcl) related to cvvh during the anuric period was calculated accounting for ultrafiltration rate, sieving coefficient, blood-flow, haematocrit concentration and pre-dilution. the value was ml/min. following diuresis on day , remaining kidney function was assessed by measuring urine and serum creatinine. the value for crcl renal ( ml/min) was added to the extracorporeal clearance, and gave a total clearance of ml/min. this warranted dose adjustment of trimethoprim/sulfamethoxazole since this drug requires normal dosage at crcl [ ml/min. conclusion: during cvvh, the presence or absence of diuresis must be taken into consideration when dosing antibiotics. in anuric patients, the cvvh-machine set up constitutes crcl total , but in patients with diuresis, the remaining crcl renal should be added. please specify your abstract type: descriptive abstract (for projects) background and objective: the aim of the study is; to evaluate patients' home (prescribed and non-prescribed) and hospital medication during hospital admission by computing medication regimen complexity index and investigating possible drug-drug interactions. design: patients (aged and older) who applied internal service during months ( days/a week) were included to the study. patients' medical profile were obtained from patients' file. their home medication and hospital medication were calculated with medication regimen complexity index ( ) and checked drug interactions with micromedex drug interaction program. results: a total of from of patients who applied to the internal service (male . %, female . ; the mean age of patients was . ± . .) were included to this study during months. of them, . % had low education level (\ education years), . % had and more chronic diseases of them, % hospitalized last months before this hospital admission. the most prevalent diagnoses documented at admission were kidney disease ( . %), cardiovascular disease ( . %) and cancer ( . %). the mean of patients' home medication number was . ± . and the mean of their mrci scores was . ± . . % in patients hospitalized in the last months. at least one possible drug-drug interactions were found in . % of patients at home medication and in . % of patients at hospital medication, respectively. the mean number of possible drug-drug interactions at patients' home medications was . ± . , while the mean number of possible drug-drug interactions at patients' hospital medications was . ± . . of them, . % had polypharmacy at home medication. the frequency of possible drug-drug interactions and the score of medication complexity index was found high among patients' hospital medications when compared with their home medications. conclusion: the potential role of pharmacist including medication reconciliation and medication review could improve rationale drug use during hospital admission. coronavirus. experts' local committee has approved to use oral ribavirin for the treatment of these respiratory viral infections. we aimed to assess the effectiveness and safety of oral ribavirin as main treatment in respiratory viral infections. setting and method: from may to october , we performed a retrospective monocentric study including patients who received oral ribavirin for non-hcv infections. main outcome measures: viremia negativation was used to determine the response rate to oral ribavirin. specific toxicities (anaemia, cytopenia, liver dysfunction) and renal function were assessed biologically. results: thirty-five immunocompromised patients (f/m: / , age: ) were included. underlying conditions were lung transplant (n = ), heart transplant (n = ), pulmonary fibrosis (n = ) and acute myeloblastic leukaemia (n = ). the median duration between transplantation and infection was . years ( . - . ). nine patients were exclusively infected by rsv, by hpiv ( hpiv- ; hpiv- ; hpiv- ; hpiv- ; non-identified hpiv), by hmpv and by coronavirus. there were six co-infections: rsv/ hpiv- , rsv/coronavirus, hpiv- /hpiv- and hpiv- or /coronavirus ( patients). all the patients were admitted in pulmonary division, except for the patient with heart transplant who was in cardiac intensive care unit. the administered dose was mg tid or mg tid if there was renal insufficiency ( patients). the median duration of the treatment was days . four patients prematurely discontinued the treatment due to severe toxicity or therapeutic change; three didn't respond to the treatment (no data for the last one). four patients were re-treated despite having a virological response to the first cure. one patient treated for a hpiv- /coronavirus coinfection had an hpiv- relapse days after ribavirin discontinuation. concerning the three other patients, they received a second cure to treat a new infection (coronavirus, hpiv- and hmpv, in opposition to hpiv- twice and hpiv- respectively). virological response rate was % ( / for rsv, / for hpiv, / for coronavirus and / for hmpv). two non-negative viremia patients (rsv and hpiv- /coronavirus) received intravenous ribavirin after oral ribavirin therapy. no patient died from viral infection. twelve patients presented specific toxicity: one hepatic cytolysis and cholestasis, eight haemoglobin decrease, two pancytopenia and one mucositis. conclusion: despite the poor number of patient, our study shows that oral ribavirin seems to be efficient to treat hpiv, hmpv and coronavirus in immunocompromised adults. we observed known side effects that could generally be managed. oral ribavirin may thus represent a therapeutic strategy in several respiratory viral infections. please specify your abstract type: descriptive abstract (for projects) background and objective: reconciliation of medicine lists is important to ensure correct medical treatment of patients both in hospital and other healthcare levels. while reconciliation upon admission is part of the normal routine at surgical ward b, molde hospital, there has been less focus on reconciliation at discharge. as such, this study aimed to ensure reconciliation and correct transfer of medical information at discharge. design: medicine lists of all patients discharged from surgical ward b, molde hospital between week and in (n = ) were investigated. the forms were gathered and counted based on the tasks signed for to ensure completed reconciliation and sufficient information given to the patient. the count was performed every - weeks, and the forms in each count was pooled together as one point of measure. the quality of medicine lists in discharge lists was evaluated based on the norwegian patient safety program criteria. medicine lists in discharge lists from week to (n = ) were pooled together and compared to medicine lists in weeks - (n = ). results: the results of reconciliation was divided into the subsections of surgical ward b, and represent the number of completed tasks as signed for in the reconciliation form. the surgical subsection showed a significant increase in patients with pre-checked medicine lists and reconciled medicine lists over the measured time period. similar results were not found in the orthopaedic subsection. as for the quality of medicine lists in the discharge lists, significant improvement was seen in all set criteria, with the exception of ''source'' in the surgical subsection. in the orthopaedic subsection however, no significant improvement was seen in any of the criteria other than ''indication for use''. conclusion: the implementation of reconciling medicine lists at discharge was successful. however, both subsections need to work further to ensure continuation and improvement of the process. furthermore we found varying results in the writing of medicine lists depending on subsection. still, regardless of the individual results of the two subsections there is big room for improvement to ensure that sufficient medical information is included in the discharge papers. please specify your abstract type: descriptive abstract (for projects) background and objective: from july clinical pharmacists began conducting medication histories and reviews (pharmacist notes) at the emergency surgical ward (esw), north zealand hospital (nzh). inclusion criteria are acute patients using c drugs or c risk drug (antidiabetics, anticoagulants, antipsychotics, benzodiazepines, opioids and digoxin). the aim of the service is to identify drugrelated problems and secure correct medication reconciliation between the medicine the patient is admitted with and the medicine in the electronic medication system (ems) in the hospital. the service ensures that the patients' medication follows across healthcare sectors. the objective is to determine if the discrepancies between the medicine the patient is admitted with and the medicine in ems (documented in the pharmacist notes) are used by the physicians. in addition to determine if the pharmacist interventions increase the physicians' acceptance rate of the discrepancies. design: data were collected at the esw at nzh (capacity of beds). data consist of pharmacist notes conducted from august to may . pharmacist notes were compared to the patient record and ems to identify if the pharmacist notes were considered by the physicians. in order to increase physicians' acceptance rate of the discrepancies suggested in the pharmacist notes, interventions were made according to the model for improvement. throughout the period, the focus was on oral delivery of the pharmacist notes. in december the pharmacist optimized the clinical relevance of the discrepancies, by creating and testing a list of products (including vitamins, herbal drugs, glucosamine etc.) which the pharmacist should not intervene on. in december the pharmacist also started to follow up on the pharmacist notes not considered by a physician the previous day to ensure that the physician considered the discrepancies. results: there were identified discrepancies between the patients' actual medication at admission and ems at the hospital in patient records ( . discrepancies per patient). in total discrepancies were accepted by the physicians ( . discrepancies per patient). the physicians' acceptance rate was based on the acceptance of one or more of the discrepancies in the pharmacist note. baseline data were collected from august to november , where out of pharmacist notes were accepted by the physicians resulting in an acceptance rate of . %. from december to may the interventions made by the pharmacist contributed to an increase in acceptance rate to . % ( out of notes accepted). if the pharmacist notes were not delivered orally to the treating physician the acceptance rate was % ( out of notes accepted). conclusion: the pharmacist interventions contributed to an increase in the physicians' acceptance rate of discrepancies from . to . %. a result indicating that the pharmacist notes contributes to an increase the quality of the medication process across sectors. hp-pc : how the centralization of medicines manufacturing enable to generalize the pharmaceutical validation? samantha oses * , soizic vandierdonck, vincent servant, dominique breilh please specify your abstract type: research abstract background and objective: the centralization of the reconstitution of injectable anti-infective drugs enhance to decrease costs and several risks. this minimization of the risks operates at several levels such as i) reduction of the staff exposure and external contamination of preparations during the reconstitution phase (with controlled atmosphere areas, isolators, etc.), ii) improvement in the quality of the management of infective diseases thanks to a pharmaceutical validation systematically performed after the prescription and before the reconstitution phase. the main objective of the study was to describe and quantify pharmaceutical validation on injectable anti-infective drugs prescriptions restored in a pharmaceutical reconstitution unit. setting and method: an observational descriptive study was carried out on each prescription with at least one injectable anti-infective drug that has to be reconstituted before administration. the process was as follows: -prescription by the physician on an electronic prescription software, -pharmaceutical validation and if necessary pharmaceutical intervention (pi) made by phone call, -reconstitution at the pharmacy, -administration to the patient. the pharmaceutical validation methodology followed the french society of clinical pharmacy (sfpc) guidelines ''prescriptions screening and analyses level'' published in the good practices of clinical pharmacy and one resident and one pharmacist were devoted to the activity every day. main outcome measures: the pharmaceutical validation was quantified by the number of pi by patient, which were categorized according to the sfpc guidelines. results: during months, a total of pi were collected. they concerned patients with an average of . pi per patient. among them, . % ( ) concerned paediatric population. antibiotics were involved in . % ( ) then followed by . % ( ) cases ( . % ( ) biological assessment issues, . % ( ) absence of therapeutic drug monitoring (tdm) and . % ( ) the drug hasn't been adapted to the weight), dosage adjustments in . % ( ), information missing concerning the treatment indication in . % ( ) and miscellaneous pi in . % ( ) such as wrong clinical service on the prescription, etc. approval rate of physicians was . % ( ). conclusion: this study has shown that even if prescriptions were secured by electronic prescription software, the pharmaceutical validation remains essential. in that case, the centralization of the reconstitution of injectable anti-infective drugs enabled to generalize this activity on all prescriptions of the hospital. however, the pharmaceutical validation was focused only on anti-infective drugs, that was not fully efficient and must be extended to the whole prescription. it is a priority to develop a comprehensive and exhaustive validation on every medical prescription; however, this activity is highly time consuming and needs larger and more trained staff. hp-pc : the start/stopp criteria as a helping tool to the pharmacists' medication review in the acute admissions unit of the regional hospital in horsens hans pedersen * please specify your abstract type: research abstract background and objective: polypharmacy occurs often increasing the need for patients' medications to be reviewed. the start/ stopp criteria help detects potentially inappropriate prescriptions in older people. in this study we aimed to measure and categorize the different start/stopp criteria found in medication reviews in the acute admissions unit of horsens and the acceptance rate. setting and method: patients admitted to the acute admissions unit were selected based on their age and the number of prescriptions in a period of months. patients years or more which received six or more drugs were included in the study. only patients who later were transferred to another medicine ward were included in the study. the pharmaceutical medicine review was performed by a clinical pharmacist using minimum two different sources; the electronic medical record and medication-lists. the guideline of pharmaceutical medicine review in the hospital pharmacy central denmark region was used as the standard-guideline. in addition, thestart/stopp criteria version was used. main outcome measures: the number of start/stopp criteria found in medication reviews. the different start/stopp criteria were scored equally with one point each. results: patients, males and females, out of , were included. the mean age was years and the patients received in average prescribed drugs. at admission the average number of stopp criteria were . ± . and . ± . for the start criteria. in average, % of the purposed stopp criteria were accepted by the physicians. the most frequently accepted stopp criteria were in the category of drugs that predictably increases the risk of falls in older people. the benzodiazepines where the most common drugs to be discontinued. in the start category, % of the suggested start criteria were accepted, which included: calcium and vitamin d supplement, beta- agonist and bisphosphonate. conclusion: the present study demonstrates that it was possible to integrate the start/stopp criteria as a helping tool in the medication reviews in the acute admissions unit of horsens. the start/stopp criteria were found within the different categories, however only a minor part of the registered start/stopp criteria were accepted by the physician. please specify your abstract type: research abstract background and objective: the objective of this work is to assess prescribing practices of somatostatin analogues in a surgery department, and to analyse the conformity of switching from immediateacting octreotide to the long-acting release (lar) form, in accordance to laboratories' guidelines. setting and method: retrospective observational study. a focus was realized on patients admitted in a digestive surgery unit between january and december , . the patients' medical records were reviewed for clinical features, diagnosis workup and treatment strategies. main outcome measures: medical records for patients with diagnosis of gastro-entero-pancreatic or endocrine tumors who had received injections of lar octreotide during hospitalization were reviewed and the economic impact of prescriptions errors has been evaluated. results: of the evaluated patients, ( %) were hospitalized in surgery digestive unit; mean age at first administration of octreotide was years and % were male. the male and female ratio was . : . reasons for hospitalization were: digestive system neoplasms ( %), fistula ( %), intestinal obstructions ( %) and other pathologies ( %). of the patients treated with octreotide, ( %) received a lar form. only four patients received doses in accordance with guidelines: one at mg/month lar form and three at mg/month lar form, after having respectively been treated by intravenous octreotide at and mcg/day during - days. medical prescriptions of the remaining patients did not comply: all patients received mg/month after an intravenous treatment of mcg/day, instead of mg/month. from a financial perspective, these misuses have led to an additional cost of . euros for the hospital, excluding tax ( mg: . €/unit and mg: €/unit). conclusion: despite the publication of octreotide release form proper use recommendation in our hospital, % of patients of digestive unit are not right treated. a new guideline will be written added by doses of long-acting release and economic data. this work will be transmitted to specialists by clinical pharmacists. hp-pc : pharmaceutical process for intrathecal analgesia in clinical oncology practice vivien pigeon * , guillaume binson, claire grignon, antoine dupuis please specify your abstract type: descriptive abstract (for projects) background and objective: in some cases, patients with cancer pain remain painful despite the use of high dose of intravenous opioids and intrathecal analgesia becomes the ultima recourse to manage acute pain. until , intrathecal syringes were prepared by nurses in the unit care which involve a risk for patients. therefore, the aim of this work is to describe the set-up of the prescription and preparation process with the potential benefits for the safety. design: multidisciplinary concertation took place between pharmacists, physicians and surgical teams and several points were discussed to secure the process: • identification of patients with high level of infection risk; • identification of critical points of the pharmaceutical process; • validation of quality control and drug stability studies regarding drug compounding involving morphine, ropivacaine, baclofen and clonidine, alone or in admixture. results: multidisciplinary concertation lead us to define the most important points to set up the pharmaceutical process for intrathecal analgesia: • chosen patients are cancer patients; • implementation of a prescription software to secure the prescription step; • production of syringes by the pharmacy department implying several criteria: • preparation in controlled atmosphere area; • training of pharmacy technicians; • implementation of quality control and drug stability studies at °c in syringe over h and at °c in pumps over month; • microbiological control and bacterial endotoxin level. the implementation of a pharmaceutical process for intrathecal analgesia gave us the opportunity to reorganize the care of cancer patients tolerant to high dose of opioids. in this process, the pharmacy department plays a major role leading to decrease the risk of infections and errors of dosing. ingrid plessala *, , xavier deviot , thomas sidibe , zohra mostefaï , michèle minvielle , marta wyrtwal , roselyne gervais pharmacy, geriatrics, saint-denis hospital centre, saint-denis, france please specify your abstract type: descriptive abstract (for projects) background and objective: proton pump inhibitors (ppis) are indicated in gastro-oesophageal reflux and peptic ulcer disease. they are widely prescribed, often in off-label indications. the objective of this work was to reassess ppis prescriptions in collaboration with geriatricians. proton pump inhibitors (ppis) are indicated in gastro-oesophageal reflux and peptic ulcer disease. they are widely prescribed, often in off-label indications. the objective of this work was to reassess ppis prescriptions in collaboration with geriatricians. design: prospective study in three geriatric wards. the study included ppis treated patients from these three geriatric wards. dose, indication of the ppi, age, gender and duration of treatment have been recorded for each patient. the relevance of each ppi treatment has been reassessed by a geriatrician, a pharmacist and a junior pharmacist, regarding the indication and the patient's clinical condition. following this re-evaluation, three situations arose: • to maintain ppi at the same dose ( mg or mg) • to maintain ppi but half dose (from mg to mg) • to stop ppi corrective actions have been recorded in patients' files to allow their traceability. results: patients were included in the study. % of ppis prescriptions were off-label, % had no indication mentioned in patient's file and % were conform to the marketing authorization. % of patients have been on ppis medication longer than months, which is the recommended treatment' duration in france, % longer than a year and % longer than years. in collaboration with the geriatricians, ppi prescriptions were maintained for % of patients. we reduced the dose in % of cases. finally, we decided to stop a third of the ppis prescriptions. conclusion: ppis prescriptions are often longer than recommended. this can lead to side effects for patients. in france, lack of new recommendations since may explain this frequent misuse of ppis. there is also a reserve from doctors to stop these treatments, especially with fragile patients. in our case, the relevance of each ppi treatment was re-evaluated in three geriatric wards and we succeeded in shortening and stopping ppis medications in half of the situations. to assess the impact of this action on our geriatricians, a new review of ppis prescriptions relevance is programmed in . ppis prescriptions are often longer than recommended. this can lead to side effects for patients. in france, lack of new recommendations since may explain this frequent misuse of ppis. there is also a reserve from doctors to stop these treatments, especially with fragile patients. in our case, the relevance of each ppi treatment was re-evaluated in three geriatric wards and we succeeded in shortening and stopping ppis medications in half of the situations. to assess the impact of this action on our geriatricians, a new review of ppis prescriptions relevance is programmed in . hp-pc : oral anticoagulants and heparin for children: standardized protocols for prescription, dispensation and administration alexandra liauzu , marie-françoise hurtaud-roux , ronan bonnefoy , caroline farnoux , philippe sachs , theresa kwon , olivier bourdon , sophie ajzenfisz , sonia prot-labarthe *, pharmacy, hématologie clinique, ap-hp hôpital robert-debré, cardiologie, néonatologie, ap-hp hôpital robert debré, réanimation pédiatrique, ap-hp hôpital robert-debré, néphrologie, pharmacy, ap-hp hôpital robert debré, coordonnateur de la gestion des risques associés aux soins/ responsable du système de management de la qualité de la prise en charge médicamenteuse, ap-hp hôpital robert-debré, paris, france please specify your abstract type: research abstract background and objective: high-alert medications (ham) are medications that are associated with a high risk of serious harm if used improperly. we already identified paediatric ham used in our institution to identify safety measures for their use. anticoagulants and heparin were part of these high-alert medications. we aim to write standard protocol of use for low weight heparin and oral anticoagulant used in our mother-child teaching hospital. our secondary objectives were to decrease medication errors, anti-xa and inr unexplained variability and to help nurses to administer the drugs (standard dilution, oral solution available) setting and method: we carried out a literature search on pubmed Ò , on websites of several learned or professional societies and agencies. the results of the literature search were compiled on written protocol and presented to our institute drug safety-steering committee composed of four doctors, two head nurses, two pharmacists, and one risk manager. main outcome measures: not applicable. results: the protocols concerned enoxaparin, tinzaparin, warfarin but we chose to also include protamine. the most difficult issue was to have standardized dilution and protocol for all ages and weight: from premature to adolescents and all units of care (from cardiology to intensive care unit, nephrology and neonatology). we took into account the administration errors we had in our hospital and the preexisting protocol to avoid any drastic error-prone change. the final version of these protocols will be presented on the final communication with web link to upload them. conclusion: for now we did note evaluate the impact of these protocols but a before/after analysis of error reports and users evaluation will be done. however, these protocols can help all health professionals working in paediatric units for benchmarking. hp-pc : does a hospital formulary system impact timely medication administration and quality of inpatient care? anne-valérie putallaz *, , vera jordan-von gunten , pierre-auguste petignat , pierre turini , johnny beney division of pharmacy, institut central des hôpitaux, division of internal medicine, medical coordinator for quality of care and patient safety, hôpital du valais, sion, switzerland please specify your abstract type: research abstract background and objective: the prevalence of drug omissions is often underestimated but their impact can be clinically relevant. we hypothesized that delays in the administration of non-formulary/nonstored drugs could impair the quality of care. the aims of this study were: °to determine the time between the prescription and the administration of the first prescribed dose and, if applicable, to calculate how many doses were omitted. °to analyse the clinical relevance of the identified delays. setting and method: three months retrospective study of electronic records of patients hospitalized on the internal medicine wards of a network of hospitals supplied by a centralized pharmacy. this pharmacy is located in one of the sites; other sites are - km apart. main outcome measures: . for the main hospital site and the three distant sites: • median time between the prescription and the administration of the first prescribed dose • mean number of omitted doses for formulary and non-formulary/ non-stored drugs. . categorization of patient's harm caused by the delays of timecritical drugs, according to the ncc-merp taxonomy of medication errors. results: ' prescriptions were analysed. calculated delays for non-stored/non-formulary drugs were longer than for formulary drugs. however, the median time to administration is less than h for both formulary and non-stored/non-formulary drugs; and more than % of formulary drugs and around % of non-stored/non-formulary drugs were administered within h following their prescription. there was no significant difference in the mean number of omitted doses or in the delays between the site where the centralized pharmacy is located and the other sites, except for one of them. a delay representing . or more omitted doses was found for ( . %) prescriptions. among them, only were considered potentially clinically relevant. none of them caused severe harm to the patients involved. conclusion: in our setting, non-stored/non-formulary drugs take more time to be delivered than formulary drugs, but more than % of formulary drugs and around % of non-stored/non-formulary drugs are administered within h following their prescription. none of the patients who experienced delays underwent severe harm. our study showed that delays also occur for formulary drugs but no systematic cause of omission was identified; further studies should focus on all dose omissions during hospitalization. penelope randuineau *, , roger jeremy , lauriane cornuault , anne lecoeur , franck lemercier , isabelle javerliat , thomas tritz service de pharmacie à usage intérieur, service de chirurgie vasculaire, hôpital ambroise paré, boulogne-billancourt, france please specify your abstract type: descriptive abstract (for projects) background and objective: a french national survey of inpatient adverse events reveals that nearly half of adverse drug events (ade) are preventable. medication errors behind these ade occur mainly during the transition steps of care pathway. in this context, medication reconciliation process has been implemented in our vascular surgery department. the objective of this study is to identify unintentional discrepancies (uid) and assess their potential clinical impact design: a pharmacy resident or a pharmacy student reconciliated patients: aged older than or with at least five chronic treatments at admission or suffering from chronic diseases. patients were considered reconcilable if at least two reliable sources on usual patient's treatment were available. these many sources of data (patient interview, prescription or interview of general practitioner, reference dispensary, drug box …) were compared to the admission prescription during the first h of hospitalization to detect and correct uid. based on gravity scale promoted by the french high authority of health, two pharmacists (a resident and a senior) and a vascular surgeon reviewed every uid in order to define their potential clinical impact. the uids were considered minor if it leads to no consequence for the patient, clinically significant if it leads to essential monitoring, major if it could cause temporary clinical consequences, and critical if it could result in permanent clinical consequences or the involvement of the prognosis. results: between february th and may st , a total of patients have been reconciled. patients were excluded due to a lack of reliable sources. mean age was . years old (± . ) and sex ratio m/f was . . % of the reconciliated patients' admissions were scheduled. the mean number of medication was . (± . ). patients ( %) had at least one uid and the mean uids per patient was . (± . ). the most common types of uids were omission ( %), incorrect dose ( %) and incorrect administration frequency ( %). more than % of these uid presented a potential clinical impact: an adverse effect (high blood pressure, hyperglycaemia) was observed for nine patients and lead to therapeutic optimization and monitoring; uid were considered to have potential clinically significant impact ( %), a potential major impact ( %) and a potential critical impact. conclusion: these results appear consistent with those reported in literature. vascular surgeons have appreciated the approach and would like systematic medication reconciliation before surgery. as a major part of admissions were scheduled, we would like to establish the reconciliation before the patient's hospitalization every time it's possible. this new organization should facilitate the care pathway before surgery and decrease preventable postoperative adverse events. hp-pc : delirium in elderly patients: successful use of melatonin gaëlle jouin , aurélie reiter-schatz , pierre bentzinger , fatem-zohra laalou , bénédicte gourieux *, pharmacy-sterilization, orthopedic's intensive care unit, university hospital of strasbourg, strasbourg, france please specify your abstract type: descriptive abstract (for projects) background and objective: postoperative delirium happens to about one-third of elderly patients and is a major cause of morbidity and mortality. it is reported that haloperidol, an antipsychotic, has been the agent of choice for managing delirium. however, it induces cerebrovascular adverse effects and greater mortality. the hyperactive type of delirium is known to be associated with a low melatonin level and the loss of a normal melatonin secretion rhythm. the postoperative administration of melatonin to elderly could decrease the symptoms of delirium. the purpose of this study was to evaluate melatonin effectiveness in a cohort of patients suffering from postoperative delirium. design: a retrospective study of melatonin prescriptions has been conducted over a months period. medical background, type of surgery, symptoms of delirium, use of antipsychotics and benzodiazepines have been studied in all patients who received melatonin in an orthopaedic surgery unit. length of hospital stay, time between delirium and melatonin administration and the effect of melatonin had been evaluated. results: a total of patients were included: average age was . years ( - ), sex ratio m/f = . twelve patients ( %) were hospitalized because of an infection (prosthesis or osteoarticular). in % of cases (n = ), the prescription of melatonin was started when the patients were hospitalized in our intensive care unit. nine patients ( %) were under chronic treatments like benzodiazepines or antipsychotics. the average length of hospital stay was days ( - ). melatonin was started on an average of days after surgery , and administered at the dose of mg xr in the evening, during an average of days ( - ). cognitive impairments requiring a prescription of melatonin were: confusion ( %, n = ), agitation ( %, n = ), daytime sleepiness ( %, n = ), temporal-spatial disorientation ( %, n = ), nocturnal awakening ( %, n = ), hallucination ( %, n = ), difficult falling asleep ( %, n = ). the average time to recover from confusion was days, agitation days, daytime sleepiness days, temporal-spatial disorientation days, nocturnal awakening days, hallucination days and falling asleep days. melatonin treatment helped stopping benzodiazepines treatment in six patients ( %). conclusion: after administration of melatonin, delirium symptoms were improved for all patients and benzodiazepines treatment stopped for six patients. earlier prescription of melatonin could regulate sleep-wake cycle and reduce the duration and incidence of delirium. please specify your abstract type: research abstract background and objective: denosumab (xgeva Ò ), a fully human monoclonal antibody targeting rankl, which inhibits bone resorption, is indicated to prevent skeletal complications in patients with solid tumors and bone metastases. about % of patients develop hypocalcaemia, a common adverse event that may induce spasms, muscle cramps, paraesthesia, prolonged qt interval, tetany, convulsions… we report the management of ionic supplementation and physicochemical incompatibilities in a case of hypocalcaemia due to denosumab. setting and method: the clinical case was analysed with the pharmacovigilance regional center. main outcome measures: a year old patient, with nodal and bone metastasis in prostate cancer, was treated with denosumab (stopped with the last injection months before, on the th of march). he went to emergency on the th of may with asthenia, anorexia, nausea, diarrhoea, qt prolongation. biological results showed hypocalcaemia (corrected calcaemic = . mmol/l) and hypophosphatemia (phosphorus \ . mmol/l). concomitant calcium and phosphorus intravenous supplementation started with loading doses ( g of calcium and . g of phosphorus) and then a week of following daily intakes: phosphorus ( g iv and . g oral); calcium ( g iv and . g oral). however, low-serum corrected calcium and phosphorus levels persist at . mmol/l and . mmol/l. results: incompatibility between phosphorus and calcium by formation of soluble or not-soluble complexes is described in literature. in our case, calcium and phosphorus were mixed in a same infusion. after a week of supplementation, calcium infusion is continued with increased dose ( g/day) and phosphorus infusion is stopped. phosphorus oral supplementation remains stable ( . g per day); calcium oral supplementation is increased ( . g per day). h between intakes is applied to avoid digestive complexation. h later, corrected calcium levels are normalized at . mmol/l and phosphorus levels are still low. therefore, as hypocalcaemia due to denosumab induced a secondary hyperparathyroidism and thus hypophosphatemia; phosphorus levels are expected to increase subsequently. conclusion: this case report shows that recurrent hypocalcaemia with denosumab is possible few months after administration. supplementation with large amount of calcium is needed and administration methods may impact the effectiveness of supplementation. indeed, it seems that the incompatibility between phosphorus and calcium did not allow an effective supplementation. gunnhild langdal *, , , ida rudberg , lone holst , anne-lise sagen major , central norway hospital pharmacy trust, Å lesund, centre for pharmacy, university of bergen, bergen, møre og romsdal health trust, Å lesund, norway please specify your abstract type: descriptive abstract (for projects) background and objective: drug interactions (dis) can cause side effects and lack of therapeutic effect. the objective of this study was to describe the prevalence of dis at the medical department of Å lesund hospital, and to investigate how dis were managed by clinical pharmacists and physicians. design: at the medical department, Å lesund hospital, clinical pharmacists serve seven out of ten wards, from which patients were included during a five weeks period. the clinical pharmacists selected patients for screening for potential dis (www.interaksjoner.no) as int j clin pharm ( ) : - usual (= pharmacist group). detected dis were classified according to a predetermined classification system, and it was registered whether the physician implemented suggested changes in prescription. for patients not selected by clinical pharmacists (= non-pharmacist group), a pharmacy student performed the search for dis. results: in total patients were admitted. on average, each patient had . dis, and . % of the admitted patients had at least one di. the prevalence of dis was significantly higher among the patients in the pharmacist group compared to the patients in the non-pharmacist group (median@@@ vs. , respectively, p \ . ). the groups differed significantly regarding number of drugs used, age, duration of hospital stay and number of warfarin users. . % of the dis detected in the pharmacist group were discussed with the physician. the remaining . % were considered not necessary to discuss for various reasons e.g. because they were considered not clinically relevant ( %) or already adjusted for in clinical practice ( %). for dis the clinical pharmacist suggested a change in prescription, and of these suggestions ( %) were implemented by the physician. conclusion: just over half of the patients were selected by the clinical pharmacist for screening of dis, and the pharmacist seemingly made a reasonable priority of patients with many drugs, old age, a long hospital stay and users of warfarin. only of dis was discussed with physicians. this indicated that pharmacists do a considerable work in assessing the relevance of dis before discussing with the physicians. it also seemed that changes in prescription suggested by the clinical pharmacist were reasonable. hp-pc : securing the paediatric use of oral chemotherapy: a proactive risk assessment samia mouffak *, , linda an , anne fratta , anne auvrignon , , nadia marquis , karine morand pharmacy, risk management committee, hematology, armand trousseau hospital -aphp, paris, france please specify your abstract type: descriptive abstract (for projects) background and objective: oral chemotherapy is an important part of the therapeutic strategy in childhood cancer or haematological malignancy. it also represents an emerging risk area in oncology practice. several medications errors involving oral chemotherapy were reported in children of our onco-haematology department, fortunately without clinical consequences. nevertheless, the potential severity of such errors led us to implement a failure analysis of the paediatric oncology care pathway in order to identify and prevent potential risks, and secure the paediatric use of oral chemotherapy. design: we conducted a failure modes, effects and criticality analysis (fmeca) which is a proactive risk assessment approach. first, process maps were detailed for each step of the oncology care pathway. it was performed by a multi-disciplinary group composed of physicians, coordinating nurse, hospital pharmacists and pharmacy resident. then, for each step of the medication-use process, the team identified the failure modes, their main causes and effects. finally, participants rated the expected severity, frequency and detectability for each failure mode, assigning a score on a five-point scale. a risk priority number (rpn) was then calculated by multiplying those three indexes. the risks getting a high rpn were categorized as critical risks and have been the object of safety improvements. results: failure modes were identified, including critical risk failure modes. critical failures were related to hospital discharge prescriptions and were about the dispensation of oral chemotherapy by pharmacy assistants. most failures were due to prescriptions heterogeneity, lack of clinical information reported on prescriptions, and lack of training of pharmacy assistants in reading oral chemotherapy prescriptions and in mistake detection. two improvement strategies were implemented. first, physicians' awareness led to the harmonisation of practices and to the standardisation of discharge prescriptions. then, to enhance pharmacy assistants' abilities, an educational program on oral chemotherapy dispensation was planned. conclusion: the implementation of a fmeca has highlighted the most critical risks of oral chemotherapy medication-use process. the awareness of all caregivers and the targeted changes in our practices allowed us to improve the safety of the paediatric oncology care pathway. please specify your abstract type: descriptive abstract (for projects) background and objective: the purpose of this study was to investigate if medication reconciliation and medication review, by using the integrated medicines management (imm) model, were suitable to assure the quality of patients' medical treatment at a gastrointestinal surgical ward. furthermore, to analyse frequency, type, handling and clinical relevance of medication discrepancies (mds) and other medication related problems (mrps). design: patients, above years of age, from two departments at a gastrointestinal surgical ward at a norwegian university hospital were included consecutively. medication reconciliation was performed at admission by a clinical pharmacist. the resulting medication histories were compared with the medications documented in the medical records. mds were detected and categorized. thereafter the clinical pharmacist identified mrps by reviewing the medical records systematically and categorized the revealed mrps. mds and mrps were presented for the physician with proposed solutions. the physician's actions to manage the mrps were registered. later a multidisciplinary team assessed the clinical significance of mds and mrps in a subset of patients. results: a total of patients were included. overall, mds and mrps were identified. at least one md was revealed in % of the included patients, whereas at least one mrp was identified in % of the patients. the most frequent type of mds was omission, whereas mrps most often were related to medications that were considered unnecessary. totally, % of the mds and mrps were discussed with the treating physician. the physicians followed the pharmacist's input in % of the discussed md-cases and % of the mrp-issues. longterm consequences of mds and mrps were considered more serious than short-term consequences for the patients. conclusion: medication reconciliation and medication review revealed, solved and prevented a large number of mds and mrps in this study. the results emphasize that pharmacist involvement, by using the multidisciplinary imm-model, contributed to more correct medical records and furthermore to quality assurance of the patients' medical treatment at a gastrointestinal ward. hp-pc : prevention and management of drug interactions in oncology day-hospital: results from a months study involving drug assessment and pharmaceutical report to oncologist pauline-saraï zeller *, , chloé hugard , céline mongaret , , juliette vella-boucaud , antonin maréchal , olivier bouché , dominique hettler , florian slimano , pharmacy, oncology day hospital, university hospital reims, clinical pharmacy, faculty of pharmacy, reims, france please specify your abstract type: research abstract background and objective: quality during transitions of care is a major concern in drug safety for patients. traditional hospitalization allows to reconciliation medication but there is not possible for dayhospitalization (patient's hospitalization short time and no outpatient medication prescribe by oncologists). however, lack of communication between health professionals may expose patients to drug-drug interactions (ddi). while ddi between oral antineoplastic and other drugs are well known, there is a lack of knowledge about ddi between parenteral antineoplastic (ak) and other drugs. in this pilot study, we aim to investigate prevalence and characteristics of ddi between ak and other drugs in real life and to propose a pharmaceutical report model to enhance patient's drugs safety. setting and method: during months, all new oncologic patients (thoracic and digestive) receiving chemotherapy in day-hospital have been recruited by clinical pharmacist. first it was conducted a patient-clinical pharmacist interview and carried out the best possible medication history (bpmh) by contacting at least three different sources of drug information. then, the bpmh has been confronted with oncologic treatment (including concomitant medications such as like antiemetic) with support at least with two different database of ddi analysis. finally pharmaceutical recommendations in order to manage potential relevant ddi were reviewed with oncologists then reported and inserted in personal health record (phr). main outcome measures: prevalence and description of potential clinically relevant ddi in an ambulatory oncology population. results: from november, to april, n = oncologic patients were included with following characteristics: mean age of . , sex ratio : , majority of oncologic thoracic localization ( %). number of oncologic concomitant medications per patient was . ± . (mean ± standard deviation). patients present an average of . ± . comorbidities (excluding cancer) and . ± . linked medications per patient. pharmaceutical analysis revealed potential clinically relevant ddi ( . ± . per patient): % of them concern antiemetics (ondansetron and aprepitant): pharmaceutical interventions were formulated (including recommendations to adapt chronic treatment) and % of them involved biological monitoring (for renal function, inr, potassemie or magnesemie). conclusion: our pilot study confirms high prevalence of ddi between oncologic and non-oncologic drugs. clinical pharmacy services with bpmh performing and pharmaceutical recommendation appears to be useful to enhance patient' drug safety in oncology dayhospital. we currently are deploying our study in order to convey a pharmaceutical letter to general practitioner and community pharmacist. hp-pc : loading dose of anti-infectives: elaboration of a tool helping pharmaceutical analysis julie soyer *, , cécile sanchez , guillaume beraud , nicolas venisse , pauline lazaro , antoine dupuis pharmacy, infectiology, pharmacokinetics, university of poitiers, poitiers, france please specify your abstract type: descriptive abstract (for projects) background and objective: the recent data on vancomycin and ceftazidime confirm that continuous infusion is the best way of administration of these antibiotics. moreover a loading dose before the administration is required for the antibiotics to prevent from the infratherapeutic period at the start of infusion and limiting the risk of resistance emergence. long half-life antibiotics and antifungals also require a loading dose to be effective. the aim of this study is to analyse the prescriptions of anti-infective requiring a loading dose in order to develop a tool to help pharmaceutical analysis. design: a prospective observational study was carried out during days in units. initially, pharmacists, residents and students were trained (role of the loading dose, drugs concerned). then, all patients with anti-infective requiring loading dose were included. some data were collected: weight patient, creatinine clearance, loading dose or not, dose, administration mode, monitoring of steady state concentrations (vancomycin and ceftazidime) and dose adjustment. the results were analysed and compared to bibliographic research before discussion during a multi-disciplinary meeting (pharmacists, infection control specialist and pharmacokinetic specialist). finally, a list of relevant pharmacist interventions was selected. results: out of the patients, were enrolled for prescription of anti-infective requiring loading dose. twenty-six prescriptions including vancomycin, ceftazidime, the others fluconazole, caspofungine, voriconazole and posaconazole. concerning vancomycin, the loading dose was prescribed in % of case, monitoring of steady state concentrations was performed in % of case and dose adjustment after first dosage was required in % of case. selected pharmacist interventions were: • to favour continuous infusion (excepted paediatric) • to keep loading dose at full dose even in patient with renal failure • to monitor steady state concentrations after the first h in patient with renal failure or obesity • to adapt dosage when the target concentration is not reached concerning ceftazidime, the interventions were: • to recommend continuous infusion: g/ h after loading dose of mg/kg • to monitor steady state concentrations in patient with renal failure a total of interventions (dosage, adaption of posology at the monitoring, patients with renal failure, obese, paediatric patient, administration…) were identified by the group of experts. conclusion: this study allowed creating a recap data sheet for students and hospital pharmacists. the selected interventions will allow the harmonization of practices. these recommendations have been validated by the commission of the anti-infective. finally, this study shows that the pharmacist has a key role in the management of antiinfective requiring loading dose. hp-pc : assessment of potentially inappropriate medications in orthogeriatric patients using the rasp list the detection of inappropriate prescribing. the objective of this study was to investigate if the rasp list (rationalization of home medication by an adjusted stopp list in older patients), an explicit screening method adapted to the belgian context, can be used to reduce the number of potentially inappropriate medications (pims) in orthogeriatric patients. setting and method: single-centre, interventional study conducted at the orthogeriatric department of the uz brussel, a -bed university hospital. the rasp list was first applied by a last year pharmacy student to the admission medication of orthogeriatric patients hospitalised in october . after potential adaptations to the medication by a liaising geriatrician, the rasp list was additionally applied by the same pharmacy student to the discharge medication of these patients. main outcome measures: detection and reduction of the number of pims. results: in total, orthogeriatric patients, from whom an informed consent was obtained, participated in this study. on admission, a total of pims were detected in this population. at discharge, the number of pims decreased to . the median number of pims per patient decreased from (on admission) to (at discharge). this difference was statistically significant (p \ . ; wilcoxon signed rank test). drugs of atc class n (nervous system) were responsible for the highest number of pims. conclusion: pims can be detected and reduced in the hospital using the rasp list. a structured and collaborative medication review between (student) pharmacists and physicians appears a good approach to reduce the number of potentially inadequate drugs. nevertheless, more research is necessary to substantiate this further as well as to assess the clinical impact of the findings. hp-pc : impact of implementing ward based dispensaries across a hospital site on both service delivery and patient care michelle sullivan, paul wright, christopher watson, malcolm smith, sotiris antoniou * please specify your abstract type: descriptive abstract (for projects) background and objective: waiting for medication at discharge is often quoted as a key factor for delaying patients leaving hospital. feedback from service users (patients and healthcare professionals) was for a more patient facing pharmacy service. this led to a phased installation of remote dispensaries on wards within the hospital to supply medicines. this new and innovative service enabled the supply function to be fully co-ordinated on the ward. this model was initially implemented on wards, which coupled with one-stop dispensing meant % of discharges require nothing to be supplied at the point of validation, % of discharge prescriptions meeting key performance indicator of being dispensed and ready within h with average turnaround time of min for a discharge prescription and a reduction in missed doses- . % in september to . % in march . this success prompted further installation of remote dispensaries in all clinical areas on site. design: implementation included; purchasing hardware, pharmacy labellers, locating appropriate computer terminals and stock cupboards. the main pharmacy labelling and stock control system was fully integrated at ward level, enabling the automatic reordering of replacement stock. identification of items and quantities to stock for remote dispensaries was also needed prior to role out. there was a need to scope staffing requirements including the redeploying of roles from a main inpatient pharmacy to patient facing areas. results: over items are supplied at ward level each month via satellite pharmacies for all wards, equating to more than % of the total dispensing workload for the site allowing for pharmacy staff to be redistributed from dispensary to the ward. this offered the benefit of being more patient facing and supporting other initiatives such as patient counselling and medicines reconciliation. the project has impacted the pharmacists as it has enabled them to focus on clinical aspects of service delivery, including attendance of ward rounds as well as supporting a ward team approach with the pharmacy technician. results of missed dose audit from june shows across the site % ( ) wards scored below the national . % target and ( %) wards had no unintentional missed doses. conclusion: ward based dispensing has led to pharmacists and pharmacy technicians being % ward based. as a constant presence on the ward, the team offer consistency within the pharmacy service for patients, nursing and medical staff. impact of pre-discharge planning has been beneficial to nurses, patients and work flow of the pharmacy teams. ward based dispensing has improved supply at discharge as well as promoting a more patient facing pharmacy service that has seen the pharmacy team instilled as integral to service delivery at ward level. kutay demirkan * , nursel surmelioglu, aygin bayraktar-ekincioglu clinical pharmacy, hacettepe university, ankara, turkey please specify your abstract type: research abstract background and objective: hacettepe university hospitals clinical pharmacy unit was established in april . this unit runs its services by clinical pharmacy postgraduate students under the supervision of two qualified clinical pharmacists as part-time and oncall basis, in adults, paediatrics and oncology hospitals. the aim of this study was to identify drug related problems and describe its management strategies in inpatient and outpatient settings by pharmacists in clinical pharmacy postgraduate education program. setting and method: during a total of months study period (period i: february-july , and period ii: november-february ), clinical pharmacy postgraduate students followed patients for - times in a week in different services in hospitals (internal medicine, internal medicine intensive care, infectious diseases, neurology intensive care, paediatric bone marrow transplant/haematology unit, paediatric intensive care, geriatrics and nutrition units) and drug related problems were identified and pharmacists' recommendations were listed. main outcome measures: determination and evaluation of drug related problems by pharmacist in hospital. results: a total of recommendations was provided for patients. those recommendations were classified as alteration or discontinuation of drug treatment ( . %), dose adjustment ( . %), change in drug administration time ( . %), inadequate treatment ( . %), healthcare staff training/consulting ( . %), patient education ( . %) and error/deficit in therapeutic drug monitoring ( . %). a majority of recommendations (n = ) were related with alteration or discontinuation of drug treatment provided mainly in departments of internal medicine (n = , geriatrics (n = ), neurology intensive care (n = ) and infectious diseases service (n = ). the following main reason for pharmacist's recommendation was related with dose adjustment (n = ) which were provided in departments of internal intensive care (n = ), infectious diseases service (n = ), neurology (n = ) and internal medicine (n = ). conclusion: clinical pharmacy practices are being carried out effectively in many services, particularly in internal medicine services, internal medicine intensive care unit and infectious diseases services. a collaborative and bed-side education in postgraduate programs in clinical pharmacy help to increase the knowledge and skills of students in real life circumstances and also maintain safe and effective drug therapy by an involvement of clinical pharmacists in hospital services. hp-pc : development of a tool to help pharmaceutical analysis in patients with hepatic failure barbara troussier *, , eric gautier , astrid bacle , florian charier , christine silvain , pauline lazaro pharmacy, gastroenterology, hepatology and gastroenterology, university hospital of poitiers, france, poitiers, france please specify your abstract type: descriptive abstract (for projects) background and objective: hepatic impairment can cause significant changes in the pharmacokinetics of many medicines. however hospital pharmacists can be helpless in performing pharmaceutical analysis behind the lack of precise guidelines. we need a strategy to first detect accurately patients with hepatic impairment, then lead us in dose adjustments. the objectives of this project were to develop a helping tool for hospital pharmacists in the pharmaceutical analysis of patients with hepatic failure's prescription and to select relevant pharmacist interventions. design: we first planned an investigation of patients with hepatic failure's management, with multidisciplinary experts groups. the study was conducted during one week in post-surgical, gastro-enterology, endocrinology, cardiology, pulmonology, geriatric departments and reanimation care units. a flowchart based on hepatic's biomarkers helped us including patients. criteria used to assess hepatic impairment could be: a stage c child-pugh score, prothrombin score inferior to %, bilirubin superior to micrograms per millilitres of blood without haemolysis, aspartate and alanin aminotransferases superior to three times the high normal value, and presence of a vitamin k antagonist interfering with those results. after a review of each included patient's prescription, we checked the major pharmacokinetic elimination pathway of each prescribed molecule (biliary or renal) and if hepatic biotransformation was expected. we also checked if the molecule could cause hepatic side effects. results: out of patients, patients were included for liver failure ( . %) and for a cholestasis ( . %) mainly in reanimation care units ( . %) and gastro-enterology ( %). among the lines of prescribed medicines, the main pharmacological classes encountered were cardiology, ( %) pain ( %), psychiatry ( %), haemostasis ( %) and antibiotics ( %). at the end of the investigation, the expert group decided on the relevant pharmacist interventions. these were based on dose adjustment of anti-infectious, psychotropic drugs, painkillers, oral anti-diabetics, anti-coagulants and corticosteroids. alternatives are proposed for each class. conclusion: to conduct a better pharmaceutical analysis, steps are necessary. first, any liver failure or cirrhosis must be detected thanks to the patient's biological results and medical record. then the patient's prescription can be analysed in order to highlight drugs that need a dose adjustment in a context of hepatic impairment. finally, the physicist and the pharmacist discuss about dose adjustments or alternatives if presence of contraindication with the drugs prescribed. soon the designed tool will be available to all pharmacists to harmonize clinical pharmacy practices. please specify your abstract type: research abstract background and objective: data regarding adherence rates to oral chemotherapy in lymphoma patients is limited. the aim was to assess pharmacist intervention on adherence to oral chemotherapy in patients suffering from hodgkin's (hl) and non-hodgkin's lymphoma (nhl). setting and method: following ethics approval, hl and nhl patients attending chemotherapy sessions at the medical investigations and treatment (mitu) at mater dei hospital accepted to participate. a questionnaire was compiled to evaluate adherence to oral chemotherapy and to assess pharmacist intervention. the questionnaire was divided into sections (a-c). the same questionnaire was used for both the first interview (t = ) and after weeks (t = ). an additional section (d) was incorporated at t = to evaluate pharmacist intervention. section a consisted of questions regarding patient management of lymphoma. section b incorporated the morisky -item medication adherence scale (mmas- ) to evaluate adherence to oral chemotherapy. a total mmas- score of zero indicates high adherence, a score between and indicates medium adherence and a score between and indicates low adherence. section c consisted of additional questions regarding medication adherence. between t = and t = , pharmacist intervention involved providing each patient with an information leaflet which was developed in this study, an individualised treatment chart and verbal advice. ibm Ò spss version and the wilcoxon signed-rank test were used to assess changes in medication adherence between t = and t = . main outcome measures: evaluation of pharmacist intervention on adherence to oral chemotherapy in patients suffering from hl and nhl. results: out of the patients with hl at t = , 'never' missed a dose, missed a dose 'once in a while' and 'sometimes' missed a dose. for the patients with nhl at t = , 'never' missed a dose, missed a dose 'once in a while' and 'sometimes' missed a dose. the reason for missing a dose was forgetfulness. all nhl and hl patients indicated the haematologist as their source of information about the management of lymphoma. of the nhl patients, scored low adherence and scored medium adherence at t = and after weeks (t = ) all nhl patients who participated scored medium adherence. of the hl patients, scored low adherence and scored medium adherence in the first interview (t = ) and after weeks (t = ) all hl patients who participated scored medium adherence. there was a statistically significant increase (p \ . ) in the number of patients who scored medium medication adherence between t = and t = for both nhl and hl patients. conclusion: this study shows how pharmacist intervention and extended professional services could be implemented in the clinical setting to impact on the management of hl and nhl patients. please specify your abstract type: descriptive abstract (for projects) background and objective: in may , an activity of medication reconciliation was implemented in the gastroenterology service to carry on the optimization of the medication care of patients due to the recent computerization of their prescriptions. design: this project, worked in collaboration with the gastroenterology service has been introduced in two medical committees. this activity gathers pharmacy students, the pharmacist, senior and junior doctors. reconciled patients are selected according to several criteria (advanced age, poly pathological, poly-medicated and those for whom a drug background is difficult to retrieve for the medical team). a minimum of information sources is used for the collection of the drug background. all information are synthetized on a paper, validated by the pharmacist and discussed again with the prescriber. results: on a -month period, patients were reconciled with on average age of . the reconciliation is executed on average . days after the entry in the service. . % of reconciliations are retroactive. the main sources of information used for the collection of the drug background are: in . % of the cases an oral interview with the patient and/or the family; in % of the cases the prescriptions, the hometown pharmacist ( . %) and a medical letter ( . %). . drugs are on average on the hospital prescription, and . % ( / ) of the patients are concerned with at least one non intentional divergence (nid). on average there are . nid/patient and . intentional divergences (id)/patient. the main types of nid are omissions ( . %), drug dose errors ( . %) and errors in administration frequency ( . %). after the detection of nid, the proposed modifications to the prescribers are accepted in more than % of the cases ( / ). the average time of a reconciliation is min. exchanges on the id and nid are made with the junior doctors in . % of the cases. conclusion: some nid are occurring for . % of the reconciled patients. it is therefore necessary to extend this new activity to reconciliation in other services in order to increase the interception of eventual medication mistakes and allow their correction. please specify your abstract type: research abstract background and objective: diuretic therapy is routinely used in the management of congestive heart failure (chf).,compliance with clinical practice guidelines is reported to result in improved outcomes for patients with chf such as reduced exacerbations. the aim was to assess the effect of pharmacist intervention on adherence to diuretic treatment in a hospital and community pharmacy scenario. setting and method: the study was undertaken at karin grech hospital (kgh), a geriatric and rehabilitation hospital, and in one community pharmacy. inclusion criteria for patients recruited from kgh were age over years, suffering from chf and on bumetanide therapy. the validated -item morisky medication adherence scale (mmas- ) was administered to patients on admission (t = ), repeated after two weeks hospital stay (t = ) and again one-month post-discharge (t = ). a total mmas- score of zero indicates high adherence, a score between and indicates medium adherence and a score between and indicates low adherence. in the community setting patients on diuretic therapy were chosen by convenience sampling. the same adherence scale was administered prior to pharmacist intervention (t = ) and one-month after pharmacist intervention (t = ). pharmacist intervention in the community setting involved dissemination of an informative leaflet regarding chf and diuretic therapy developed for the purpose of this study. main outcome measures: impact of pharmacist intervention on adherence to diuretic therapy in chf patients. results: a total of patients were recruited from the hospital setting, of whom were female and were male with a mean age of years (range - years). on admission (t = ), patients scored high adherence, scored medium adherence and scored low adherence to bumetanide therapy. following weeks at the hospital (t = ), the number of patients scoring high adherence increased from to and the number of patients scoring low adherence decreased from to . one-month post-discharge (t = ), patients scoring high adherence decreased from to and patients scoring low adherence increased from to (p \ . ). a total of patients were recruited from the community pharmacy, of whom were female and were male, with a mean age of years (range - years). after pharmacist intervention (t = ), the number of patients scoring high adherence increased from to , while the patients scoring low adherence decreased from to (p [ . ). conclusion: pharmacist intervention in the hospital setting improved adherence to bumetanide therapy. in the community pharmacy setting, there was a slight improvement in the compliance. pharmacist monitoring and patient support is important post-discharge to ensure patient compliance to therapy. conclusion: surveillance of aeds may be followed by combination of data from adverse drug reaction databases and drug utilisation data from prescription databases. focus on reporting adverse reactions is important for pharmacists and clinicians, especially for newly approved drugs. awareness of increased exposure of aeds to new groups of patients followed by data regarding safety aspects is important and contributes to improved pharmacovigilance. please specify your abstract type: research abstract background and objective: the medication review of polymedicated patients is a priority shared among all healthcare professionals. a multidisciplinary approach of these patients is necessary to achieve the best results for their treatment ( ) . the objective was to analyse the rate of acceptance of the recommendations made by the primary care pharmacist (pcp) to the general practitioner (gp) regarding the treatment of polymedicated patients. setting and method: setting: a primary health care centre ( , population). method: a review of the medical records of polymedicated patients (c chronic drugs for c months). the patients' data were collected from january to june from their clinical records. statistical descriptive analysis of data was performed. main outcome measures: drug related problems (drp) for each patient: interactions, contraindications, inadequate dosages, nonindicated drugs, omission of a necessary drug, duplications, medication with low therapeutic effect, and inappropriate medication for patients c years old. treatment alternatives proposed to gp's by pcp were also measured. results: patients were included in the study (average age: . ± . , % women). out of the patients, interventions were laid out to reduce the risks of drp's and to improve the efficiency of treatments. % of patients presented some drp or some intervention to improve the efficiency of their treatment, this mean an average . interventions for patient. the prevalence of intervention proposals were: non-indicated drugs ( %), interventions for improve the efficiency of treatments ( %), interactions ( %), inappropriate medication for patients c years old ( %), contraindicated drugs ( %), duplications ( %), medication with low therapeutic effect ( %), inadequate dosages ( %) and omission of a necessary drug ( %). % of these intervention proposals were accepted by the gp: % of the accepted proposals were carried out and from the remaining , . % led to a prescription from a specialist physician. in % of the cases, the patient did not accept the changes. . % were not carried out due to other issues. the main drug related problem was the prescription of non-indicated drugs and the most involved drug was omeprazole. conclusion: acceptance by gp's to changes proposed by primary care pharmacists was high. a significant number of changes was not accomplished due to the negative response by some patients and led prescriptions from a specialist physician. the gp greatly values the multidisciplinary aid in approaching the complexity of polymedicated patients. background and objective: case-reports provided evidence that influenza infections, particularly severe episodes, may exert neuronal damage in the cns and thereby increase the risk of depression. it was the aim of this study to analyse the association between influenza infections and the risk of developing incident depression. setting and method: we conducted a case-control analysis using the large uk-based primary care database clinical practice research datalink (cprd). this database contains anonymous longitudinal data from primary care. at present, it contains over million person-years of data from some million active patients. the study encompassed , patients below the age of years with an incident major depression diagnosis between and , and we matched each case to one control patient on age, sex, general practice, number of medical encounters, and years of history in the cprd prior to the index date. main outcome measures: major depression diagnosis was identified by read-codes based on icd- codes (f ), with a minimum of three prescriptions for antidepressant drugs recorded after the diagnosis. we calculated relative risk estimates of developing depression in association with previous influenza infections, stratified by the number, timing and severity of such events, and we adjusted for a variety of comorbidities, smoking status, alcohol intake, body mass index, use of oral corticosteroids, and benzodiazepines. results: patients with a previous influenza infection had an increased risk of developing depression (or . , % ci . - . ) compared to patients with no history of influenza infections. a recent influenza infection recorded within - days prior to the index date yielded an adjusted or of . ( % ci . - . ), and an increasing number of previous influenza infections was associated with increasing odds ratios (c recorded influenza infections, adjusted or . , % ci . - . ). we did not see any differences in the relative depression risk associated with influenza with regard to a previous influenza vaccination. conclusion: this study suggests that influenza infections are associated with a moderately increased risk of developing depression. please specify your abstract type: research abstract background and objective: warfarin is known for its interactions with many drugs. elderly patients are particularly sensitive to warfarin interactions. to evaluate the incidence of potential drug interactions when prescribing new drugs to elderly patients on warfarin, a prospective observational study was conducted. setting and method: patients on warfarin older than years were included and monitored for months in community pharmacies in croatia. data regarding new prescribed drugs was obtained from pharmacy records at the moment of dispensing or by patient selfreporting. the potential interacting drugs were identified using the lexicomp Ò lexi-interact online software. only the clinically significant (levels c, d, x of clinical significance as classified by lexicomp Ò lexi-interact online) interactions were included in this analysis. main outcome measures: number of new proscribed drugs, level of interaction with warfarin, mechanism of interactions. results: we included elderly patients with an average age of years. in the follow-up period, new drugs were prescribed to patients ( . %). there were prescriptions of new drugs and ( . %) of those were drugs with a clinically significant interaction with warfarin. there were prescriptions of drugs with level c of interaction ( . %), and ( . %) with level d. there were no drug interactions of level x. in the group with level c the most prescribed drugs were antibiotics with prescriptions: amoxicillin/clavulanate %, clindamycin %, ciprofloxacin %, norfloxacin %, azithromycin %, cefuroxime %, clarithromycin %, doxycycline %. the remaining prescriptions included tramadol with paracetamol %, rosuvastatin %, simvastatin %, fluvastatin %, levothyroxine % and torasemide %. the dominant mechanism of the potential interactions was pharmacokinetic. in the group with level d the most prescribed drugs were nonsteroidal anti-inflammatory drugs with prescriptions-diclofenac %, ibuprofen %, indomethacin %. among other drugs, prescriptions were antibiotic sulfamethoxazole with trimethoprim %, fenofibrate %, miconazole %, and fluconazole %. the dominant mechanism of the potential interactions was pharmacodynamic. conclusion: pharmacists should actively monitor prescribing of new drugs to elderly patients on warfarin in order to reduce the risk of clinically significant drug interactions. please specify your abstract type: research abstract background and objective: explicit criteria of potentially inappropriate medications in the elderly (pims) have been published in the usa, canada, australia and many eu countries. there is a lack of studies describing prevalence of pim use in central and eastern europe. the aim of the eu cost action initiative wg b ( wg b ( - is to evaluate the registration rates and use of pims in central and eastern europe compared to other eu countries participating in this initiative. this abstract describes preliminary findings on different registration rates of pims in different eu countries. setting and method: researchers/members of the eu cost action initiative from the czech republic, serbia, hungary, spain, turkey and portugal were asked to fill in evaluation tables for the list of pims in the period - / . items available in these evaluation tables related to: registration of individual pims on the pharmaceutical market, registered doses, drug forms, availability of pims on prescription or as otc drugs, prescription limits and the most frequently used brand names. data were evaluated using comparative descriptive statistics. main outcome measures: overall prevalence of registered pims in different countries, cross-country differences in availability of individual pims. results: of pims . % were registered in at least participating country. for the czech republic ( . %), turkey ( . %), spain ( . %) and hungary ( . %) overall prevalence rates of registered pims were found to be similar. however, these prevalence rates substantially differed in serbia (low prevalence- . %) and portugal (high prevalence- . %). substantial differences were found also in the lists of individual pims registered in different countries. these lists were similar in spain and portugal compared to the czech republic, hungary, serbia and to turkey. conclusion: although overall prevalence rates of registered pims were similar in the majority of evaluated countries (except serbia and portugal), availability of individual pims was substantially different. our pilot results confirmed that there are substantial geographical/ regional differences in europe in the lists of pims available (in spain and portugal compared to central and eastern europe and compared to turkey). please specify your abstract type: research abstract background and objective: inappropriate prescribing is a common circumstance found in polymedicated patients. screening tools for identifying potentially inappropriate prescription (pip) and pharmacist interventions for evaluating them have been developed to decrease this ( ) . the aim of this study was to evaluate the effectiveness of a pharmacist provided intervention to reduce pips in polymedicated patients. setting and method: the design was a quasi-experimental study focusing on a single group before and after intervention. the study took place from july to december of at three primary care centres ( , population). polymedicated patients were those using c chronic drugs for c months. main outcome measures: reduction in the rate of pip per polymedicated patient (number of pips found divided by the total number of polymedicated patients) before and after intervention, and the influence of the following variables: type of pip (inappropriate medication for patients c years old, medication with low therapeutic effect, duplication of benzodiazepines (bzd) or angiotensinconverting enzyme (ace) inhibitors, combination of anticoagulant and antiplatelet, combination of non-steroidal anti-inflammatory drug (nsaid) with a diuretic and ace inhibitor, nsaid in cardiovascular disease, chronic antipsychotic in dementia, chronic bzd, or chronic nsaid), gender and age of patients with at least one pip, and the main prescribed drugs involved in the pips based on atc classification system of world health organization. results: there were and polymedicated patients before and after intervention, respectively. . % (n = , before) and . % (n = , after) of the total patients had at least one pip. the number of pips was reduced from to , while the rate of pip per polymedicated patient decreased from . to . , achieving the limit established by the regional health authority. . % (before) and . % (after) of patients had more than one pip at the same time, up to pips per patient. before and after intervention, more than half of patients with at least one pip were c years old, and approximately out of were c years old. also before and after intervention, out of patients with chronic nsaid and with bzd duplication were women. out of patients with combination of anticoagulant and antiplatelet were men. the main pips before and after intervention were, respectively: chronic prescription of bzd ( . vs. . % of the total pip), medications with low therapeutic effect ( . vs. . %) and inappropriate medication for patients c years old ( . vs. . %). the main atc group involved in the total of pips was drugs for the nervous system, and the five most prescribed drugs were all bzd (lorazepam being the first). conclusion: pharmacist provided intervention was able to reduce pip in polymedicated patients. gender, age and atc classification of drugs involved were factors in the pips. please specify your abstract type: research abstract background and objective: up to % of women are exposed to selective serotonin reuptake inhibitors (ssris) during pregnancy. information on their effect on birthweight and gestational age remains conflicting. the aim of this sibling-controlled prospective cohort study is to address shared genetic and family-level confounding to investigate the effects of prenatal ssri exposure and maternal depression on birthweight and gestational age. setting and method: we used the norwegian mother and child cohort study (moba) and the medical birth registry of norway (mbrn). our study population consisted of siblings; were prenatally exposed to ssris and were unexposed to any antidepressant medication. random and fixed effects analysis with propensity score adjustment was used to evaluate the effects on birthweight and gestational age. main outcome measures: birth weight. gestational age. results: ssri exposure during two or more trimesters was associated with a decrease in birthweight of g [ % confidence interval (ci) to ] and a decrease in gestational length of . days ( % ci . to . ). neither maternal ssri use in one trimester, lifetime history of major depression nor depressive symptoms during pregnancy were associated with these pregnancy outcomes. conclusion: prenatal exposure to ssris during two or more trimesters may decrease birthweight and gestational length. our results indicate that neither maternal depression nor shared genetics and family environment fully explain this association. please specify your abstract type: research abstract background and objective: the drugs burden index (dbi) is a tool to evaluate the burden of medications with anticholinergic and sedative effects and this exposure has been associated with poorer physical and cognitive function in older people. objectives were; to determine the cumulative burden of anticholinergic and sedative medicines in older adults with intellectual disability (id) using the dbi, to examine the relationship between dbi score with demographics and comorbidity. setting and method: data from wave of the intellectual disability supplement to the irish longitudinal study on ageing (ids-tilda), a nationally representative study of ageing people with id in ireland. dbi scores were calculated for all participants with available medication data (n = ). bivariate associations between dbi and demographic and clinical characteristics were examined with a significance level of . main outcome measures: dbi scores of participants categorised into low ( ), medium ( - ) and high (c ). dbi score categories were related to demographics, cognitive effects and to a modified functional comorbidity index (fci), which is associated with physical function in older adults. results: of participants, . % ( ) had dbi exposure; . % were exposed to any anticholinergic medication, . % to any sedative medication; mean number of dbi medications . (± . ), mean dbi score: . (± . ). ( . %) participants had dbi score , ( . %) - , and ( . %) c . antiepileptics accounted for the greatest contribution to cumulative score ( . %), antipsychotics ( %) and antidepressants ( %). there was no significant association between higher dbi score and sleep difficulties (p = . ). there was a significant age gradient associated with higher dbi score (p = . ) and significant association between higher scores and increased comorbidity scores; mean fci of . in those with dbi c , . in dbi - and . in those with dbi . conclusion: cumulative exposure to sedative and anticholinergic medicines was high in older adults with id. higher dbi scores were associated with higher comorbidity and associated poorer physical function. optimising use of medications with anticholinergic and sedative effects through medicines review by pharmacists as part of multidisciplinary teams using a tool such as the drug burden index may reduce functional decline and improve quality of life among older adults with id. please specify your abstract type: research abstract background and objective: poor adherence to pharmacotherapy may have considerable consequences for the patients' health and for healthcare costs to society. there was observed that diabetes patients have higher risk of later health complications development. it is necessary to be adherent to non-and pharmacological recommendations as well, to improve the clinical outcomes and decrease the cardiovascular risk (cvr). the aim of this study was to evaluate the medication adherence and cvr in group of patients with diabetes, and to find an association between them. setting and method: the methods were based on a questionnaire survey using a modified -item morisky score and score charts ( ). medication adherence and cvr were evaluated in the whole group (n = , males and females, range - years) as well as in subgroups according to age, gender, (no-/ex-) smoking, level of education, residence, number of used medicines, exercises, compliance to the diabetic diet, and total cholesterol levels. the survey was realized in three ambulatory diabetic centres in slovakia. the study has been approved by ethics committee of university hospital bratislava -ruzinov. all participants signed an informed consent. main outcome measures: the results of medication adherence were evaluated as follows: points = full adherence, - points = partial adherence and - = non-adherence. the cvr (estimating -year cardiovascular attack risk) was evaluated according to score charts using data from questionnaire and medical records-gender, age, smoking, total cholesterol levels and blood pressure. the results showed a partial medication adherence in the study group in average ( . ± . ). the average value of cvr in the study group was . %. the highest average medication adherence has been observed in males b years ( . ), with elementary education ( . ), in ex-smokers ( . ), in patients with regular physical activity-at least times a week ( . ), in patients non-adherent to the diabetic diet ( . ), in patients using medications ( . ), and in patients with satisfactory ( . - . mmol/l) total cholesterol levels ( . ). the lowest cvr has been observed in females b years ( . %), in no-smokers ( . %), with elementary education ( . %), in patients with irregular physical activity ( . %), in patients adherent to the diabetic diet ( . ) , in patients using medications ( . %) and in patients with satisfactory ( . - . mmol/l) total cholesterol levels ( . ) . on the other hand, the highest cvr has been observed in males [ years ( . %), smokers ( . %), secondary educated patients ( . %), without any physical activity ( . %), in patients partially adherent to diabetic diet ( . %), using medications ( . %) and, surprisingly, in patients with satisfactory (\ . mmol/l) total cholesterol levels ( . %). conclusion: our survey has showed that medication adherence in our study group has been decreased and cvr has been increased. cvr and adherence to pharmacotherapy in the study group did not correlate with each other. the medication adherence, cvr and their relationships are specific in every patient. please specify your abstract type: research abstract background and objective: studies show that quality of life (qol) of patients with diabetes mellitus can influence medication adherence, satisfactorily improving clinical outcomes and reducing the morbidity and mortality rates and disease progression. this applies even upside down-medication adherence could significant contribute to improving patient qol. the aim of this study was to evaluate the medication adherence in group of patients with diabetes, to evaluate their qol and find a correlation between them. setting and method: the methodology was based on a questionnaire survey using a modified -item morisky score and questionnaire eq- d- l, including visual analogue scale (vas). medication adherence and qol were evaluated in the whole group (n = ) as well as in subgroups according to age, gender, level of education, monthly income, number of used medicines and type antidiabetic treatment. the survey was realized in three ambulatory diabetic centres in slovakia. the study has been approved by ethics committee of university hospital bratislava-ruzinov. main outcome measures: the results of medication adherence were evaluated as follows: points = full adherence, - points = partial adherence and - = non-adherence. the qol in levels of dimensions results were evaluated as follows: the lowest qol in every dimension = point, the highest = points. the highest vas evaluation has been points and every patient should mark number on the scale - to indicate his/her health on current day. results: the results showed a partial medication adherence in the whole group in average ( . ± . ). the average value of the qol in the study group was . and vas . . the highest medication adherence has been observed in males ( . ± . ), patients \ years old ( . ± . ), with primary education ( . ± . ), with monthly income over € ( . ± . ) and in patients using medications ( . ± . ). the highest qol and vas (qol; vas) has been observed in males ( . ; . ), patients \ years old ( . ; . ), university educated ( . ; . ) , with monthly income over € ( . ; . ) . qol has been highest in patients using medications ( . ), vas has been highest in patients using medication ( . ). we have observed the highest level of medication adherence in patients treated with combined therapy-with oral antidiabetic agents and insulin ( . ), the lowest in patients treated with only insulin therapy ( . ). highest qol was recorded in patients treated with oral antidiabetic agents ( . ), and the lowest qol in patients with insulin therapy ( . ). the highest vas has been observed in patients using only oral antidiabetic agents ( . ), the lowest in patients using combined therapy ( . ). conclusion: survey has showed that medication adherence and qol in our study group has been decreased. qol and adherence to pharmacotherapy in the study group did not correlate with each other. the medication adherence, qol and their relationships are specific in every patient. the role of health care professionals should be in education and counselling with patients to improve qol and medication adherence as well. please specify your abstract type: research abstract background and objective: to assess the appropriateness of antibiotic prescriptions used for urinary tract infections (uti) in the elderly. setting and method: we included patients aged years and older, hospitalized in the geriatric department and for whom a urine culture was performed between march and may . a prescription was qualified as inappropriate: when the antibiotic prescribed was not the narrowest compared to the culture result, or when there was a contra-indication, or when the treatment duration was shorter or longer than recommended. prescriptions were consistent with the guidelines when they were identical to those adopted by the french society for infectious diseases in december . main outcome measures: appropriateness of antibiotic prescription (type and duration) results: elderly patients were included (women: . % (n = ), mean age: . years). % of antibiotic choices were appropriate and % of treatment durations were consistent to the guidelines. urinary clinical signs were mentioned in the medical files for . % of the cases (n = ). patients received an empirical antibiotherapy ( . %). . % (n = ) of urine cultures were positive with bacteria, escherichia coli being the most prevalent (n = ). the urine culture results led to a change in antibiotics for . % of the cases. for cystitis, . % of the antibiotics chosen were appropriate (n = ). the main reasons of non-conformity were the lack of deescalation (to amoxicillin or pivmecillinam), and the prescription of ciprofloxacin when the bacteria was in vitro resistant to other fluoroquinolones. the average duration of effective antibiotherapy for cystitis was . days (appropriateness: . % (n = )). for pyelonephritis, . % of the antibiotics chosen were appropriate (n = ). the average duration of effective antibiotic treatment was . days (appropriateness: . % (n = )). . % of the patients had a transurethral catheterization (n = ). another infection was diagnosed for . % of the patients (n = ). conclusion: according to these results, it appears important to reemphasize to the prescribers the guidelines around the uti diagnosis and treatment in order to improve the prescriptions appropriateness in elderly patients. it is particularly necessary to promote the de-escalation of antibiotherapy (with pivmecillinam for example which has recently become available in our hospital) and to insist about the recommended durations of treatment. please specify your abstract type: research abstract background and objective: to measure the use of potentially inappropriate medications (pim) in the general elderly population several criteria lists exist, e.g., beers criteria. last year, a set of explicit criteria for assessing pharmacologically inappropriate medication use in nursing homes was developed; the norwegian general practice-nursing home criteria (norgep-nh). the aim of this study was to investigate the prevalence of pims in nursing home patients using this new assessment tool. furthermore, we studied possible associations between the use of pims and factors like gender, age, geographical area and the number of drugs used. setting and method: cross-sectional study comprising nursing home patients from two geographical different regions in norway; tromsø city (n = ) and lofoten islands (n = ). data was collected from november to january . pims were identified by norgep-nh. we used logistic and poisson regression to examine possible associations between the use of pims and factors like gender, age, geographical area and the number of drugs used. main outcome measures: number of pims per patient, and odds ratios (or) and marginal effects for associations. results: nursing home patient used a mean (sd) of . ( . ) drugs; . ( . ) regularly and . ( . ) as needed. at least % of patients used one pim. concomitant use of three or more psychotropic drugs was the criterion most commonly identified ( %), followed by the use of antidepressant ( %) and hypnotics ( %). an increasing number of regularly used drugs increased the odds of having pims (or: . ), as well as it lead to . more pims per extra drug used. on average, patients c years had . fewer pims than patients \ years. no statistical significant associations were seen between having pims and gender, nor geographical area and the use of as-needed medication. yet, statistical significant differences were identified in some criteria. conclusion: this is the first study that explicit uses norgep-nh. our results confirm that nursing home patients often use potentially inappropriate medications. this is an area where further work is necessary, not to measure the prevalence of pim, but to develop interventions in order to prevent pims from being used. pe : use of pharmacy dispensing data to measure adherence and identify nonadherence with oral hypoglycaemic agents please specify your abstract type: research abstract background and objective: a framework for calculation of adherence for oral hypoglycaemic agents (ohas) based on data from health-insurance claims is available. pharmacy dispensing data aid identification of nonadherent patients in pharmacy practices. however, use of these data for calculation of oha adherence requires additional methodological categories. we examined the impact of different methodological choices on estimation of oha adherence using pharmacy dispensing data. setting and method: a framework for adherence calculation for pharmacy dispensing data was developed from health-insurance claims. a basic scenario was developed from methodological categories. consequences of choices for different parameters within these categories on the scores of the three adherence measures were calculated from dispensing data. main outcome measures: for oha use between july and july , three adherence measures were calculated: ( ) average medication availability (ama); ( ) mean rate of adherent patients with an ama c % (mrap ); ( ) please specify your abstract type: research abstract background and objective: ulcerative colitis (uc) is a chronic inflammatory disease usually affecting young adults and impacting on patient's quality of life. although many biological agents (bas) have been approved for the treatment of moderate-to-severe uc in patients who have responded inadequately to conventional therapy, the selection of bas is controversial due to the lack of head-to-head trials. indirect economic comparisons of these costly drugs are available from national healthcare perspectives that are not the italian ones. therefore, the objective is to evaluate cost-utility of bas for the treatment of refractory moderate-to-severe uc both in italy and in the lombardy region. setting and method: a markov model (considering transition states: remission, clinical response, relapse) was constructed using the software r . . markovchain-package to evaluate incremental cost-utility ratios (icur) of adalimumab, infliximab, infliximab biosimilar, golimumab and vedolizumab treatments of patients over a ten-year time horizon from the perspective of the italian (n) and lombardy region (r) healthcare system. clinical parameters were derived from clinical trials. costs (which have been actualised- . %) were obtained from the national database and regional public tender. utility was expressed as qaly (quality adjusted life years). main outcome measures: icur. results: costs per treatment were different from a n and r perspective (adalimumab - %; infliximab - . %; infliximab biosimilar - . %; golimumab - . %; vedolizumab - %). direct healthcare costs (treatment cost, visits, lab tests, hospital admissions) were calculated over years of treatment per patient: adalimumab (n: € , . , r: € , . , - . %), infliximab (n: € , . , r: € , . , - %), infliximab biosimilar (n: € , . , r: € , . , - . %), golimumab (n: € , . , r: € , . , - . %), vedolizumab (n: € , . , r: € , . , - . %) with associated qaly respectively of . , . , . , . , . . from a n perspective, infliximab biosimilar was dominating compared to all other treatments. the icur of vedolizumab/infliximab biosimilar was € . for years (willingness to pay (wtp) € . /qaly). from a r perspective, adalimumab was dominating compared to all other treatments. the icur of vedolizumab/adalimumab was € , . for years (wtp € , . /qaly). conclusion: national and regional cua produced different results. as regional price discounts can occur, local analyses are needed to estimate the economic impact of therapies to ensure optimal choice. please specify your abstract type: research abstract background and objective: automated dispensing systems (ads) have been implemented to reduce overall medication errors related to picking, preparation and administration of drugs. costs of drug storage between ads and classic dispensing system (cds) had not been yet performed in france. our objective was to assess economic impact of ads compared to cds. setting and method: retrospective quasi experimental study was conducted in university hospitals in , one with ads ( beds, ads) and one with cds ( beds, cds ( ) for ads and ( ) for cds (p \ . ). mean number of costly drug per system was for ads and for cds. the global stock value in the wards was , € in ads and , € in cds representing respectively . and . % of total pharmacy stock value. conclusion: our data demonstrate that despite the same storage capacity, ads allow the storage of more expensive drugs such as innovative drugs fully reimbursed up to national reimbursement prices, due to the lower risk of pilferage. this preliminary study was focused mainly on stock value. subsequently, another study is conducted to evaluate cost of these two drug storage systems, satisfaction of pharmaceutical technicians and nurses and time allowed for systems reloading. please specify your abstract type: descriptive abstract (for projects) background and objective: in france, pharmacists are not entitled to substitute an original biological drug with its biosimilar, due to specific issues of efficiency, safety, and patient monitoring. our hospital referenced a biosimilar of infliximab on january . according to the french medication safety national agency's recommendations, it has been decided that naïve patients would be treated with biosimilars, and changes between specialties would be proscribed. the objective is to compare prescribing practices between infliximab and its biosimilar, year after its introduction. design: a database tracking patients treated with infliximab was set up. data comparing prescribing practices of biosimilar and reference treatment were analysed between june and may . regional and national infliximab consumption between january and february were used to compare the practices of our hospital with other hospitals. the past and future savings were estimated from repayments data of the regional health agency. results: infliximab was administered to patients, of which ( %) were naive. patients were treated with biosimilar (i.e. . % of all patients), of which were naive. in the end, nearly % of naive patients actually received the biosimilar and . % of patients treated with infliximab switched specialties during treatment. in % of cases, biosimilar prescriptions were consistent with the recommendations (vs. % for infliximab). in % of cases the off-label prescriptions of the biosimilar were explained in the patient record (vs. % for infliximab). in february , the share of biosimilars was % in france, % at regional level and % locally. in year, infliximab and its biosimilar's consumption in our hospital have increased by % in quantity and only % in expenditure (+€ m expenditure). negotiating a lower purchase price and costs has enabled the hospital to save € , (vs. € , during the previous year). because of the decline of refund rates, the gains would have been zero without using the biosimilar but € , if it had been prescribed to every naive patient. conclusion: current data from the literature on security and effectiveness of infliximab biosimilars are very reassuring and the french medication safety national agency doesn't exclude the possibility of changing specialties during treatment. in our hospital, there is room to improve the efficiency of treatment with infliximab. feedback on prescribing practices will be given to prescribers and a campaign to widespread prescriptions of biosimilars will be made. the arrival of biosimilars on the market is a real economic opportunity for hospitals, which are increasingly financially constrained in particular by the arrival of therapeutic innovations which are more and more expensive. setting and method: the study used health claims data on prescription ppis from st january to st july obtained from the health insurance institute of slovenia. to assess medicine use and costs before and after trp implementation data were aggregated into four periods: jan-dec , pre-baseline period; jan-dec , baseline period; jan-sept , transition period between announcement and introduction of trp; oct to jul , period after trp enforcement. main outcome measures: medicine costs; defined daily doses (ddds) dispensed per inhabitants per day; market share; herfindahl-hirschaman index (hhi); number of active substance switches; number of exceptions when medicine is fully reimbursed since physicians may choose option ''not to switch medicine'' when adverse consequences are predicted. results: average monthly cost of ppis declined from € , , in pre-baseline period to € , in period after trp introduction although the consumption increased from . to . ddds/ inhabitants/day. cost of ppis decreased the most in baseline period ( %), however trp induced . % cost reduction compared to the transition period. the reference pantoprazole was market leader already in the transition period, but its use increased significantly after trp introduction and represented % of total ppis consumption. manufacturers' market shares were constant before trp, whereas trp caused decrease of the largest market share for %. still, this resulted in the minor market concentration change; hhi was on average . before and . after trp introduction. further, at least one active substance switch was detected in approx. and % of patients before and after trp introduction, respectively. similarly, the proportion of exceptions when medicine was fully reimbursed increased from . % in transition period to . % in period after trp introduction. conclusion: enforcement of trp for ppi contributed to approx. € m annual cost savings. from the payer's perspective the new policy was proven to be effective in reducing pharmaceutical expenditure; however trp also affected physician prescribing pattern and use of ppis. pec : blood coagulation factor: improvements of the supply chain samantha oses * , serri traore, sonia caroline sorli, lea damery, philippe cestac, sylvie pomies, julien tourel please specify your abstract type: descriptive abstract (for projects) background and objective: most of the antihemophilic factor (ahf) must be held by a teaching hospital to face serious bleeding events. to ensure better availability, offsite-stocks at critical points are required (emergency unit, intensive care unit, etc.). however, this management system increases the risk of economic loss and alteration of the quality due to expired products. in this context, we carried out an optimization of the supply and management system of the ahf. to identify critical points of the supply and management system and to implement improvement solutions. design: a multidisciplinary working group belonging to a regional management centre of haemophilia was set up. two lines of improvement were discussed: i) optimization of stocks ii) optimization of the supply system. results: the optimization of stocks has led to the modification of the threshold of the lowest stock (ls) for ahf out of . in % of cases, this stock modification has exceeded %. the overall cost of ls has been reduced by . % ( , €) for the general stock at the central hospital pharmacy (hp) and by . % for offsite-stocks ( , €). the ahf mainly involved in this reduction was fvii mg ( , €), then followed by the strengths of mg and mg ( , € for each). in order to improve the ahf management, several propositions have been implemented: ( ) developing an online, easily accessible and monthly updated spreadsheet that displayed several accurate data such as the shortest expiry date and the storage location. this operative tool is shared between all pharmacists involved in ahf management in order to facilitate a stock rotation and decrease economic losses, ( ) regular reminders to physicians and health care staff concerning the guidelines for inventory management and the importance of checking the drug expiry date, ( ) presentation of the financial results and raising awareness on ahf costs to the medical consultant[ppip ] and ( ) optimizing stock distribution based on consumption on the different hospital sites for better patient care management (pcm). conclusion: this optimization of stocks and improvement of the supply chain have led to a direct cost saving of , €. however, a more accurate assessment has to be performed to quantify the direct and indirect impact on pcm and cost saving. this work has been done in a context of a sharing operative network at a regional level. the aim of such project is to share, to optimize and to improve practices, knowledge, human and medical health resources at a widespread level to enhance the security and quality of health services and to promote cost and time saving. please specify your abstract type: descriptive abstract (for projects) background and objective: the overall pharmaceuticals consumption in hospitals is rising, which has led to an increasing expenditure, challenging health care professionals and threatening patients safety. clinical trials in hospitals have increased over the past few years and currently play an important role, giving access to new investigational medicinal products and also avoiding costs with standard treatments. the objective of this study is to evaluate the savings of centro hospitalar do porto, a central university hospital with beds and currently clinical trials, with patients included in clinical trials between january and may . design: retrospective observational study over months. all the clinical trials ongoing between january and may were analysed and the data was collected based on: pathology and doses established; number of treatments per patient and the medium prices of standard treatments that patients would be receiving if they were not in the clinical trial. results: there were clinical trials ongoing between january and may , but only were selected to be included in this study. the total number of patients included was . the clinical trials selected for this study were conducted in medical specialties: in dermatology, in immunology clinical unit, in hemato oncology, in gastroenterology, in ophtalmology and in neurology. during these months, with all ongoing clinical trials, centro hospitalar do porto was able to save, in medical products, more than million euros. conclusion: during the period of time established, of the clinical trials ongoing, were not selected due to: not including patients or not having an alternative treatment. hospitals and patients can benefit from clinical trials not only financially but also by preserving resources and medication. on centro hospitalar do porto, the pharmacists specialized in clinical trials, as members of the study team, are more and more required to perform specific tasks, their contribution has been increasing over the years and also have become more aware of all the advantages from participating in clinical trials. these savings can be used to provide a better assistance and contribute, in general, to a higher quality health care. please specify your abstract type: descriptive abstract (for projects) background and objective: several studies show a misuse of opioid maintenance treatment (omt) in detention. in fact, buprenorphine (bup) when it's misused, could present the same effects as heroine. in order to reduce misuses, the pharmacist decided to switch all the patients under bup to buprenorphine/naloxone (bup/nlx). bup/ nlx prevents patients from misusing by a withdrawal syndrome when it's issued by another route of administration than sublingual route. in france, bup/nlx is more expensive than bup which may explain why this therapeutic strategy is not often observed. the purpose of this study is to evaluate the extra cost after switching patients from bup to bup/nlx in order to decide if this choice could be maintained. design: to identify our population, we used the administration reports drugs written by nurses. please specify your abstract type: research abstract background and objective: haemophilia b is an x linked genetic disorder characterized by spontaneous or prolonged haemorrhages due to factor ix (fix) deficiency . within the next few years, new treatments are willing to hit the market. among them are recombinant extended half-life products that will reduce by half the number of injections and will potentially improve the patient quality of life. the aim of the study is to describe the development of haemophilia treatments market between and and to forecast the potential impact of these new therapies on the haemophilia market. setting and method: national and french hospitals of paris (aphp) consumption data of fix between and have been studied. new therapies in development or soon to be marketed have been identified. potential benefits and interest in the therapeutic care of these new products were discussed with haemophilia's medical experts. main outcome measures: quantity (ui) and value (euros) of fix aphp and national consumption. results: in , recombinant (rfix) and plasma-derived factors (pfix) were on the french market. the ap-hp's purchases of these factors represent almost million ui and million euros, which comprise % of national fix expenditures. in france and aphp, ambulatory care is a major part of the use of these treatments with nearly % of the fix purchases in . french rfix consumptions are higher than pfix consumptions ( % against %). in the ap-hp hospitals, rfix even account for % of consumptions against % for pfix. both national and ap-hp rfix purchases have steadily increased between and . the added competition arising from new treatments may lead to more competitive market procedures in hospitals and may reduce costs of haemophilia treatments. according to haemophilia doctor, long-acting (la) fix would offer obvious benefits like fewer infusions and presumably fewer bleeds. these treatments will mainly be used in a prophylactic wayin ambulatory care-than in a curative way (such as surgical use). conclusion: the therapeutic extent of these new treatments is still hard to define. the choice of treatment must remain consensual between physicians and patients. please specify your abstract type: descriptive abstract (for projects) background and objective: good practice about medicines imposes to health institutions a close monitoring of prescriptions, especially off-label prescriptions. patient care should take into account clinical profile, respect of guidelines and health expense control. we report here a case highlighting the significant role of the clinical pharmacist in care units to ensure medication good use in a castleman syndrome, a rare disease due to human herpesvirus (hhv- ) and associated with human immunodeficiency virus (hiv) infection. design: case report. results: our patient, a years old man (creatinine clearance rate (crcl): ml/min), was diagnosed with hiv infection in february (cd at ui/l), leading to introduce a therapy by emtricitabine-tenofovir, darunavir, and ritonavir. the evolution was hampered by repeated episodes of acute renal failure (arf; crcl: ml/min) and pancytopenia (hemoglobinemia at . g/dl, leucopoenia at . g/l, and thrombopenia at g/l). because of hhv blood pcr at copies/ml, transient crises with pancytopenia, arf, and hiv infection, a diagnostic of kaposi sarcoma herpesvirus (kics), an atypical castleman syndrome, was retained. given the lake of data in literature for this rare disease, a multidisciplinary team (medical specialists and clinical pharmacists) was gathered to choose an appropriate therapeutic strategy. treatment regimen consisted of: day , intravenous etoposide at mg; day , rituximab at mg/ m ; following one week later by rituximab day and oral etoposide at mg the day after. good communication between medical specialists and pharmacists enables the patient to get an optimal and personal treatment. relaying the information by clinical pharmacists in care units to pharmacists in charge of good practice facilitate the reimbursement. conclusion: clinical pharmacists in care unit help to optimize therapeutic strategies according to their experiences and scientific works. cooperation with physicians is improved, as well as prescriptions follow-up of off-label drugs, and health patients fully respected. quality and relevance of prescriptions are strengthened, with a better control of economic expenses. please specify your abstract type: research abstract background and objective: the maltese government launched the hpv vaccination scheme in and the national healthcare system (nhs) has since provided the cervarix Ò vaccine free of charge to girls aged . the aim of this study was to assess the cost of the administration of hpv vaccines in the healthcare system of malta. this study was based on the scheme provided by the nhs. the number of girls born per year was used to estimate the annual cost for vaccinating year old girls, based on the wholesale price and tender price respectively. the estimated yearly cost using the wholesale price was approximately € , while the average estimated cost based on the tender price was approximately € , . this signifies that cost savings based on the tender price compared to wholesale costs were of approximately € , . the cost for the cohort who completed the three dose schedule using the tender price on average was of € , per year. this result proved to be more than the anticipated cost. a reason for this could be that the number of girls aged increased possibly due to an influx of immigrants. including boys in the vaccination scheme would increase costs by an average of € , per year. conclusion: this study shows that procuring branded vaccines using the tendering process reduces expenditure for the government and the tax payer. wholesale prices were found to be more expensive than tender prices. this proves that the tendering system in malta is a potent system with many advantages for the tax paying public. the impact of the tendering process must therefore, be safeguarded. please specify your abstract type: research abstract background and objective: with the old age, presence of comorbidities, and overcrowding in mass gatherings such as the annual hajj pilgrimage in saudi arabia, there is a high risk of spreading infectious diseases among pilgrims and then within their country of origin. knowledge and application of hygiene principles in such an environment is therefore important to reduce the transmission of infectious diseases. up to date, there have been no studies to evaluate pilgrims' knowledge, attitude and practices toward mers-cov during the annual hajj pilgrimage in order to see whether there is a need for these aspects to be improved. setting and method: a cross-sectional survey study was conducted with a convenience sample of participants. participants were pilgrims, aged over , and able to speak arabic or english. a selfadministered structured questionnaire was distributed during hajj season in mecca. descriptive and multiple linear regression analysis were used in data analysis. main outcome measures: assessing pilgrims' knowledge, attitude and practices regarding mers-cov. results: two hundred and fifty-seven participants completed the study, % of whom were female, and the median (iqr) age was ( . - . ) years. pilgrims had moderately correct knowledge and accurate attitudes towards mers-cov with median scores of (iqr - ) and (iqr: - ) respectively. they were less educated about management ( %), hallmark symptoms ( %), high-risk individuals ( %) and source of coronavirus ( %). almost % of participants showed a negative attitude towards the use of protective measures such as avoiding food prepared under unsanitary conditions and contact with live animals. some participants ( %) were unable to comply with hygiene practices, particularly washing hands with soap and water or disinfectant after sneezing/coughing and wearing a face mask in crowded areas. educational level and employment status were significantly associated with knowledge whereas gender and age were significantly associated with attitude and practices respectively (p \ . ). the correlation between knowledge, attitude and practices was significant (correlation coefficient: . ; p \ . ). better knowledge was found to be a predictor for positive practice. conclusion: these findings aided in the assessment of the adequacy of current pilgrims' educational measures. they will also provide insight when designing future interventions to promote specific messages to improve knowledge, change attitude and improve practice regarding mers-cov. please specify your abstract type: research abstract background and objective: the prevalence of type diabetes significantly increased in the paediatric population, which is affected by obesity worldwide. today, type diabetes accounts for % of all cases of new-onset diabetes in adolescents. preventive health care particularly taking place at community pharmacies may involve risk assessment for the children and the adolescents, early referral for seeking relevant medical care and patient education on healthy lifestyle choices. the aim of the study is to conduct a type diabetes risk assessment program for the kids b years of age of whose parents visited the community pharmacies involved in the study and also to identify the behavioural parameters that might be associated with this risk. setting and method: the study was conducted in community pharmacies. all patients with kids aged b years who visited the study pharmacies during one-week period were informed about the study and invited to participate in the study. patients who gave their informed consent were included in the study. all data were provided by the parents. demographic data, height and weight of the kid, as well as data regarding the behavioural features (eating habits, exercising, time spent in front of a screen, etc.) of both the children and the parents were collected using standardized forms. type diabetes risk test consisted of questions and identified subjects at risk. the parent of the kid who was identified to have risk for type diabetes was referred to a physician for further examination. also, information regarding type diabetes and the importance of preventive measures such as converting to a healthy life-style was provided. main outcome measures: main outcome measures were the percentage of kids identified to be at risk of developing type diabetes and the behavioural parameters associated with type diabetes risk. results: the study involved subjects. of the subjects % were identified to be at risk of type diabetes. more girls than the boys had the risk ( vs. . %). those with type diabetes risk were older, taller, heavier and had higher body mass index. they were spending more time in front of a screen (tv, pc, tablet, smart phone); . % were spending more than h a day. although the kids' eating habits were similar for those with and without risk, the parents' of the kids with risk ate out more frequently, consumed rice, pasta and pastry more frequently. both the kids with risk and their parents exercised more regularly and frequently. conclusion: this study shows that pharmacist have a vital role in identifying children and adolescents at risk for type diabetes; thus at early management of this condition. identifying and addressing the behavioural parameters associated with the risk will be helpful in lifestyle modification interventions. please specify your abstract type: descriptive abstract (for projects) background and objective: analyse and promote the reporting of adverse drug events (ade), to improve the quality and safety of care to be able to control the risks. design: a software is available on the intranet website of the institution, to enable health professionals to report ade. the drug and medical devices commission (comedims) of the hospital, centralizes these statements and always makes a multidisciplinary and overall analysis of the event, using a collection sheet which is based on the pdca model (plan, do, check, act). it proposes the nursing and medical teams axes of improvement. results: in , only ade were reported and analysed by the comedims, including from the paediatric centre ( %), particularly sensitized to this issue. health professionals are divided as follows: healthcare executives ( %), nurses ( %), pharmacists ( %), residential students ( %), doctors ( %) and others ( %). the main impacted steps of the drug circuit are: administration ( %), prescription ( %) and the use or implementation of a sterile medical device ( %). identified causes include related following factors: operational tasks and procedures ( %), health professionals ( %), work environment ( %), organization and management ( %), drugs or associated medical devices ( %). the number of ade reports, taking into account the size of the institution, remains very low. in january , the comedims decided to broadcast a communication campaign to promote ade reporting, on the hospital website via the intranet. three months after the release, this document was viewed times, and the number of reports increased by % compared to the same period in . conclusion: in front of the low number of returns of adverse drug events, and relying on the charter of non-punishment, the come-dims wants to increase health professionals' awareness. in our hospital, where e-learning about drug-related iatrogenesis is already available, the communication campaign with poster and analysis of adverse events seems to be a useful complementary tool to enhance awareness of medication safety concerns. please specify your abstract type: research abstract background and objective: the migration of modern social networks to the internet has facilitated the transition of traditional pharmacy networks online. the ubiquitous nature of social media (some) combined with merging of personal and professional personas have led to organisations publishing guidance on online behaviour and responsible use of social media. the research to date on the use of social media as a support for professional practice in general is limited. as the pharmacy profession evolves to embrace the technologies which underpin core services and mainstream online daily social activities, it is important that research tracks and evaluates its use and impact within the profession. the objective of this research was to explore and describe how and why pharmacists interact with hosted networks on social media. setting and method: two one-hour online hosted micro-blogging twitter chats were held in december via the #weph network. topic guides were developed around 'exploring the use of twitter and wepharmacists' in line with the wenetwork guidelines (#wecommunities), informed by existing literature, discussion with the #weph moderator after review by an expert panel. all research was carried out in accordance with university governance processes and association of internet researchers guidelines. themes were inducted from analysing the textual content of the chats using the topic guide as a framework. the research was approved by the school of pharmacy and life sciences ethics committee. main outcome measures: tweets per chat results: each of the chats had over million impressions with participants representing international pharmacy practice. themes of e-professionalism and online privacy emerged as concerns; however, the benefits included using social media for education, networking, support mechanisms and career development. tweets highlighted personal experiences of 'trolling' (angry, offensive behaviour) and the effect on user interaction with social media. twitter was also recognised as a career development tool and, in particular, collaborative outcomes around mentorship networking early career pharmacists with more experienced colleagues. conclusion: results support the responsible use of social media as a force for inclusion, breaking down geographical barriers in support of pharmacy practice. further research is underway including a systematic review of guidance on the use of social media by registered healthcare professionals. please specify your abstract type: research abstract background and objective: it is estimated that half of the , persons with diabetes in norway have not been diagnosed. with early treatment, life expectancy can be increased and the incidence of longterm complications and health costs reduced. community pharmacies may be able to help uncover undiagnosed diabetes, but being diagnosed with diabetes can lead to strong emotional reactions, and how the diagnosis is given may influence the experience. the aim of this study was to explore how norwegian people living with type diabetes (t d) experienced being diagnosed, and what led up to the diagnosis. in addition, their attitudes towards a planned community pharmacy service to identify undiagnosed t d was investigated. setting and method: three focus group interviews with people with t d were conducted using a semi-structured interview guide. eleven participants were recruited through a course about type diabetes. the interviews were audio-taped and transcribed in modified verbatim form and analysed in accordance with malteruds principles of systematic text condensation. the study was approved by the norwegian data protection authority, and did not require approval from the regional committee for medical and health research ethics. main outcome measures: how people with t d describe their experiences of being diagnosed with t d, how the disease was revealed and reactions towards using community pharmacies to perform risk assessment for t d. results: none of the participants were diagnosed due to their own suspicion of having diabetes. some saw their doctor because of unspecific symptoms such as fatigue and thirst, and were thereafter diagnosed with t d. others were diagnosed through a routine checkup. negative reactions like shock, discontent and denial were commonly used to describe the experience of being diagnosed with t d, but some participants also expressed a more relaxed attitude, especially if they were familiar with the disease through family members. participants expressed a strong wish for more and better information following the diagnosis. ''it's a jungle out there'' was used to describe how difficult they felt it was to find trustworthy and understandable information. they described change of lifestyle, side effects from drug use, and stigma as challenges following the diagnosis. while in general the participants were positive to using community pharmacies to uncover undiagnosed diabetes as this could help reduce the number of people who were undiagnosed, some were sceptical. they questioned whether the pharmacy staff had the necessary competence of the for this type of service, and saw it as the doctor's responsibility. conclusion: more information and support when people are diagnosed with diabetes may lead to that the experience being diagnosed will be more adaptable and that the challenges living with diabetes are reduced. community pharmacies are important healthcare providers, and risk assessment of t d at the pharmacy can be valuable. however, the pharmacies may also be helpful to reduce the information gap. please specify your abstract type: research abstract background and objective: chemotherapy-induced nausea and vomiting (cinv) is a disruptive and unpleasant side effect in chemotherapy patients and is associated with decline in patients' quality of life and decrement in the adherence to effective chemotherapy regimens. setting and method: chemotherapy naive patients were included in this study. consistency with guidelines were assessed according to mascc/esmo . flie questionnaire was administered to patients before chemotherapy, and days after receiving chemotherapy to assess the difference in the quality of life due to chemotherapy administration. main outcome measures: patients were categorized into two groups as consistent with guidelines group (acute (gcga) and delayed (gcgd)) and inconsistent with guidelines group (acute (giga) and delayed (gigd)). flie score differences between the two groups were assessed. results: the median flie score for patients prior to chemotherapy was and a dramatic decline was noticed post chemotherapy (flie score ; p \ . ). the post-chemotherapy score were for nausea and for vomiting ( . , respectively). although the flie score differed significantly between gcgd and gigd (p \ . ), these differences were not significant in gcga and giga. conclusion: the significant drop in flie scores in the study ( pre-to post-chemotherapy) reflected substantial declination in patients' quality of life. the lower postchemotherapy flie score of nausea emphasized the negative impact of nausea, and to a lesser extent vomiting on the patients ability to complete normal daily activities such as enjoying meals and maintaining social activities. although there were no significant differences in flie scores between giga and gcga groups for acute cinv prevention, significant differences were noted between gigd and gcgd (p \ . ). the flie score was lower for gigd patients. this result implied guideline inconsistency associated with high incidence of nausea which negatively affect patient quality of life. as for the degree of compliance with gp, the results are expressed as percentage of compliance compared to the ideal of %. prescription criterion was fulfilled to %: all requirements of pntb were performed using standardized procedure. in what concerns validation, % of pntb prescriptions were validated by a pharmacist. the invalidated prescriptions were made outside opening hours of the pharmacy service, which is open monday to friday from : to : and on weekends and holidays from : to : . % of the dispensations were individualized and not pntb stocks were found in hospital wards. as for preparation, % were supplemented with micronutrients. pntb of kabiven peripheral administration ml are not supplemented in our centre. of the remaining prescriptions central administration, % were supplemented. in all cases, the addition of micronutrients was performed in laminar flow hood in pharmacy service and the corresponding galenic validation was performed. finally, in the process of administration, % of pntb identified with a complete label: name of the patient, medical record number, type of pntb, qualitative and quantitative composition, date of administration and infusion rate. conclusion: use practices of pntb of our centre are far from those recommended by the sefh standards. this initial evaluation will serve for improvement measures that increase the quality of prescribing and safe use of pntb, in order to minimize errors that can occur with the use of this therapeutic modality. please specify your abstract type: research abstract background and objective: methadone maintenance treatment was developed in malta in and is provided to patients by sedqa, the national agency against drug and alcohol abuse. methadone is the most frequently prescribed opioid in opioid substitution treatment and is dispensed through a centralised service through the substance misuse outpatients unit. in , patients were in opioid substitution treatment, of who were on methadone. in , the government introduced a take-home methadone program. the prescribing, purchasing and dispensing of methadone are regulated by subsidiary legislation . . the objectives were to determine whether community pharmacists in malta would be willing to dispense and supervise the consumption of methadone and to investigate the involvement of community pharmacies in the development of a regionalised methadone dispensing service. setting and method: the study was set in community pharmacies. a cross-sectional study, through the use of a questionnaire, was performed to quantitatively analyse whether pharmacists in malta would be willing to dispense methadone. the questionnaire consisted of questions divided into sections, with each section assessing a particular aspect of community pharmacists' attitudes towards methadone dispensing. community pharmacies were then chosen via a systematic sampling procedure. a hard copy of the questionnaire, addressed to the managing pharmacist, along with a cover letter, instructions on how the questionnaire was to be returned, and a prepaid self-addressed envelope was distributed via postage to community pharmacies. an online format of the questionnaire was also circulated to community pharmacists through the pharmacy council. data was analysed using spss version . main outcome measures: community pharmacist's attitudes towards methadone dispensing. results: a total of responses were obtained and a response rate of . % was achieved. eighteen percent of the pharmacists (n = ) who responded to the questionnaire worked in a community pharmacy located in the north of malta, % in the centre, % in the south, % in the southeast and % in gozo. thirty-two percent of community pharmacists were willing to dispense methadone to drug misusers. the number of community pharmacists who are willing to dispense methadone increased to % if they were provided with appropriate education and support. twenty-nine percent of community pharmacists were prepared to handle the duty of supervising the consumption of methadone while % had never learnt about methadone and its clinical application within opioid substitution treatment. conclusion: community pharmacists should be provided with education and training regarding methadone substitution treatment before embarking on a new regionalised methadone dispensing service within community pharmacies. this would allow more community pharmacists to become involved in a new dispensing methadone service. pt : evaluation of regorafenib in patients with colorectal cancer please specify your abstract type: research abstract background and objective: the colorectal cancer is the second more frequent cancer in europe and the third in the world. regorafenib is only approved in adult patients with metastatic colorectal cancer who are previously been treated with available therapies or are not considered suitable candidates to these treatments. regorafenib is an oral anti-tumor drug that blocks the kinases involved in the tumor angiogenesis (vegfr , - , - , tie ), the oncogenesis (kit, ret, raf- , braf, brafv e) and the tumor microenvironment (pdgfr, fgfr).in this study, we are reviewed the reports of the patients with colorectal cancer who are been treated with regorafenib in our hospital and analysed the information in order to evaluate the efficacy and safety of regorafenib. setting and method: descriptive and observational study about the use of regorafenib from april to the present day. the variables studied, obtained from the software applications archinet and diraya, were: sex, age, pathology, location of metastasis, posology and adverse effects of regorafenib, tumor markers (cea y ca . ) before and after the treatment with this drug and the mutational state of kras. main outcome measures: the tumor markers cea and ca . only decreased in the . % of the patients after the regorafenib treatment. results: regorafenib was taken by patients ( %men).the average age of these patients was . ± . years old. the patients took regorafenib to treat: metastatic and non-intervened gastrointestinal stromal tumors (gist) e-iv that progressed with the previous treatment of imatinib and sunitinib ( . % patients), intervened colon adenocarcinoma e-iv ( . % patients), sigma adenocarcinoma e-iv ( . % patients) and unresectable and non-intervened rectal adenocarcinoma e-iv ( . % patients).all patients presented metastasis in different locations on the body: liver ( . % patients), diaphragm ( . % patients), intestine ( . % patients) and lung ( . % patients).the % of the patients started the treatment with mg of regorafenib, administrated once a day for weeks followed by one week without this drug; while the . % of the patients started the treatment with mg. however, the . % had to decrease the initial dose and the . % of the total patients had to get off the treatment because of the development of side effects. the most frequent adverse effects were: hypertension associated with headache, hyperbilirubinemia, elevation of ast and alt, intense asthenia. the . % of the patients presents native kras. the native kras was presented in the % of the patients treated with regorafenib who had an appropriate development of the illness (decrease of cea and ca . ) conclusion: the decrease of cea in the . % of the patients and the high development of side effects reveal that regorafenib has low effectiveness and security in the control of the progression of colorectal cancer. in addition, it is supposed that this drug has better results in native kras patients. however, more studies are necessaries in order to demonstrate the effectiveness of regorafenib in this pathology. pt : evaluation of nintedanib in patients with non-small-cell lung carcinoma (nsclc) please specify your abstract type: research abstract background and objective: the nsclc means a high rate of mortality in developed countries. patients diagnosed with nsclc who debut with advanced or metastatic disease have a median survival of months. one of the innovative drugs approved to improve survival in nsclc is nintedanib: an inhibitor of multiple tyrosine kinases, which can be found in some receptors on the surface of cells involves in the growth and spread of cancer cells (''pdgfr'', ''fgfr'' and ''vegfr''). nintedanib is not yet marketed in spain. hospital pharmacists are responsible for applying this treatment as ''expanded drug'', only after the elaboration of an exhaustive report. in this study, we have reviewed all the reports and classified the information in order to present our clinical practice. the objective of this study is to evaluate the effectiveness and safety of nintedanib in patients with nsclc treated in a tertiary hospital. setting and method: descriptive observational study of the use of nintedanib from november to september . sex, age, body mass index (bmi), pathology, smoking habits, line of treatment, posology and adverse reactions of the treatment with nintedanib and tumor markers (cea an ca . ) before and later the treatment with nintedanib were collected from medical history through archinet informatic application. main outcome measures: the tumor marker cea decreased in % of the patients and ca . no decreased in any patient after nintedanib treatment. results: nintedanib was used in patients ( % men and % smoker).the average age of these patients was years old. the average bmi was kg/m ( - ).all patients received nintedanib together with docetaxel for metastatic nsclc with adenocarcinoma histology and with non-mutated egfr and alk in third line treatments. posology: all patients started the treatment with nintedanib mg/ h from day to day every weeks; but patients had to reduce the initial dose to mg/ h ( patient) and mg/ h ( patient) because of some adverse reactions. the side effects were: asthenia, diarrhoea, alteration of transaminases, muscle pain and cramps, weight loss and mucositis. conclusion: the decrease of cea in % of the patients reveals that nintedanib is effective in controlling nsclc progression which involves an increase of the survival and the quality of life of these patients. however, more studies are required to demonstrate the efficacy of nintedanib in this illness. please specify your abstract type: research abstract background and objective: patients with sore throat symptoms often seek fast, meaningful relief when presenting to their local pharmacy. flurbiprofen is a non-steroidal anti-inflammatory drug, which has been developed as a spray and lozenge to provide targeted relief for the main underlying process responsible for the symptoms of sore throats, inflammation. to study the relief provided by flurbiprofen . mg delivered as a spray or lozenge, we conducted a multicentre, randomised, double-blind, double-dummy, parallel group, activecontrolled, single-dose, non-inferiority study. setting and method: adult patients with acute sore throat were randomly assigned to take one dose of either flurbiprofen . mg spray plus a placebo lozenge, or flurbiprofen . mg lozenge plus placebo spray at sites across russia. main outcome measures: patients rated sore throat relief using the sore throat relief rating scale (strrs; a -point scale, = no relief, = slight relief, = mild relief, = moderate relief, = considerable relief, = almost complete relief, = complete relief) at timed intervals throughout h starting from min post completion of first dosing ( min after administration of the spray, and min after the lozenge had fully dissolved). adverse events (aes) were recorded over h post-dose. results: patients were assessed (n = for spray, n = for lozenge). [ % of patients in either treatment group experienced some relief (a score of [ on the strrs) at min post-dose, which increased to % of patients by h. - % of patients reported 'at least moderate relief', which is a well-recognised measure of a clinically meaningful effect at min post-dose, which increased to - % of patients by h. over the h post-dose, a total of drugrelated aes were reported by patients across both treatments and no severe adverse events were reported. conclusion: flurbiprofen . mg delivered as a lozenge or spray provides fast, clinically meaningful relief from sore throat. pt : analising antiangiogenics prescription in an ophtalmology service after a protocol implementation silvia cornejo-uixeda * , ivan de la vega-zamorano, celia aparicio-rubio, olga carrascosa-piquer, manuel prieto-castello, agustin sanchez-alcaraz pharmacy, hospital universitario de la ribera, alzira, spain please specify your abstract type: descriptive abstract (for projects) background and objective: after some years using antiangiogenics in our hospital, we observed a large variety of use. considering the high cost of these treatments, we proposed ophthalmology service to develop a protocol of use, attending efficiency criteria. in this paper, we analyse the protocol implementation repercussion. design: a protocol of use was designed with the main of unify criteria and to use the most efficient treatment depending on the specific situation on each patient. once it was implemented, we compared two periods, the period after the implementation (january-may ) and the period before of it (january-may ). the protocol designed is the following: the cost for each injection and patient was the following: aflibercept €, bevacizumab €, ranibizumab €. results: in the period, patients were treated with antiangiogenics. ( %) with aflibercept, ( %) with bevacizumab and ( %) with ranibizumab. in the period, patients were treated, ( %) with aflibercept, ( %) with bevacizumab and ( %) with ranibizumab. the consumption of aflibercept decreased a %, bevacizumab consumption increased % an ranibizumab increased a %.we also observed, some patients had more than one diagnostic at the same time. once the protocol was implemented, the percentage of use was the following: % . please specify your abstract type: research abstract background and objective: drug prescribing is the most common medical intervention in the elderly. however, elderly patients are more sensitive to the drug's effects due to pharmacokinetic and pharmacodynamic changes associated with aging. chronic diseases and co-morbidities often require the use of a large number of medications. therefore, when prescribing drugs for the elderly, the choice of suitable drugs, dosage and duration of treatment should be carefully considered as well as clinically significant drug interactions. inappropriate prescribing is often associated with an increased risk of adverse drug reactions, increased morbidity and mortality, and health care costs. the aim of this study was to determine the incidence of potentially inappropriate medications (pim) prescriptions in the elderly (c years) using the original protocol developed by mimica matanovic and vlahovic-palcevski. setting and method: we enrolled patients hospitalized in clinic of internal medicine. data about patients' medications was collected during patient interview taken by the pharmacists on hospital admission. pharmacotherapy was analysed using the original protocol developed by mimica matanovic and vlahovic-palcevski in order to detect pims. main outcome measures: number and type of potentially inappropriate medications, potential clinically significant interactions. results: the average age of patients was years (range - ), and the average number of drugs per respondent was . (range - ). a total of patients ( . %) were taking at least one pim. the most common pim were long-acting benzodiazepines, central antihypertensive moxonidine and non-steroidal anti-inflammatory drugs (nsaids) in patients with hypertension. in the study population, patients ( . %) have taken at least one combination of drugs that could result in a clinically significant interaction. the most common combinations included application of nsaids and antihypertensive drugs or diuretics, concomitant use of multiple medications with effects on the central nervous system and drug combinations that can cause hyperkalaemia. conclusion: this study revealed the high prevalence of inappropriate prescribing. clinical application of this protocol could be an effective method for improving and optimizing drug prescription with the aim to reduce the number of side effects and the morbidity and mortality associated with the drug use in the elderly. please specify your abstract type: research abstract background and objective: to reduce adverse effects of conventional amphotericin b formulation (deoxycholate or d-amb) it can be infused in intralipid Ò (a fat parenteral nutrition), or lipid-based formulations can be used (i.e. amphotericin b lipid complex (ablc), amphotericin b colloidal dispersion (adcd) and liposomal amphotericin b (l-amb)). studies evaluating safety profiles present conflicting results. the aim of our study was to gather evidence on nephrotoxicity rates of d-amb versus lipid-based formulations in immunosuppressed patients susceptible to invasive fungal infection. setting and method: a systematic review, including randomized controlled trials (rcts) that compared the use of d-amb and amphotericin b lipid-based was performed. a search was conducted in pubmed, scopus, web of science and scielo. results were synthetized and meta-analysis was performed using software review manager . . main outcome measures: nephrotoxicity rates. results: eighteen rcts were identified (n = participants). the result from the meta-analysis favours the treatment with the lipidbased amphotericin b formulations (or: . ( . , . ) and presents a low heterogeneity (i = %). about % of patients from lipid-based treatment group presented an increase in serum creatinine of one to two times, which corresponds to stage one or two of acute renal failure (arf). and % presented an increase of tree times in serum creatinine achieving a stage three in arf (severe) which will require dialysis. while in group treated with conventional formulation int j clin pharm ( ) all of these patients, except one whose treatment adherence was inadequate, were cirrhotic ( / ), liver transplanted ( / ) and/ or presented hepatocellular carcinoma ( / ). / patients were coinfected with hiv. / patients ( %) were genotype . the total genotype patients treated with daas (svr /relapsed) were , which means that . % ( / ) of all genotype patients has had a relapse. / patients ( %) were treated with ledispavir/sofosbuvir ( . % of a total of patients (svr /relapsed) treated with this option). % of patients who suffered a relapse were treated with daas sofosbuvir, simeprevir, daclatasvir, previously to the introduction of the newest antivirals (dasabuvir + ombitasvir/ paritaprevir/ritonavir, ledispavir/sofosbuvir), which represents . % of the total of patients treated with the older option. conclusion: relapses rate was . %, slightly lower than reported in other studies. according to the references, these results show that genotype is the one presenting more relapses. all the patients presented a deteriorated performance status, except for one whose treatment adherence was inadequate. patients treated before april , when the newest daas where introduced, showed more relapses. more studies have to be developed in the near future since other daas will appear, the treatment options will be amplified and the number of relapses is expected to decrease. please specify your abstract type: research abstract background and objective: the inappropriate use of antibiotics remains a major issue since it causes bacterial resistance, longer hospital stay and increased mortality. antibiotic prescriptions must be monitored: the clinical pharmacist has a key role in ensuring patient safety and quality of pharmaceutical care. therefore, an antimicrobial stewardship program has been implemented as part of a national project of the italian society of hospital pharmacy (sifo). the objective is to describe the results obtained at the hospital. setting and method: a multidisciplinary antimicrobial management team has been implemented including clinical pharmacists, microbiologists and infectious disease specialists. the pharmacist examines drug charts on a daily basis in the department of medicine and supports clinicians to improve the appropriate use of antibiotics. data from time-points were extracted from medical records and collected in an excel database: t (november -january ) and t (february -april ). main outcome measures: type of infection, antibiotic consumption data, type of isolated pathogens, patient allergies, clostridium difficile infection assessment and adverse drug reactions (adr). results: records were analysed (t -t ), of which contained at least one antibiotic prescription. the most frequent infections were urinary tract ( %), respiratory ( %) and gastro-intestinal ( %). antibiotic therapy was started in . % of cases due to aspecific increase of c-reactive protein (crp). ddds were calculated for each treatment and were grouped by type of infection and setting (empiric vs targeted): ceftriaxone, meropenem and metronidazole were the most widely used antibiotics for empiric therapy. at t , an increase in the use of piperacillin-tazobactam instead of meropenem was observed. the ddd of ceftriaxone for targeted therapies decreased significantly, while an increase was observed for carbapenems, levofloxacin, glycopeptides and, in case of mdr bacteria, tigecycline. three allergies to antibiotics were reported in medical history. there were clostridium difficile infections ( relapses), confirmed by antibiogram. a total of adrs were identified: of these were related to antibiotics. conclusion: antimicrobial stewardship is a fundamental step to optimise antibiotic management, ensure patient safety and improve quality of care. the results obtained so far demonstrate the added value of a multidisciplinary team in controlling bacteria resistance and in the improving the use of antibiotics. please specify your abstract type: descriptive abstract (for projects) background and objective: the aim of this study was to analyse effectiveness and safety of pirfenidone, an anti-inflammatory and antifibrotic agent used for treatment of idiopathic pulmonary fibrosis. design: a retrospective, descriptive, observational study including all patients treated with pirfenidone at the hospital between march and june ( month) was carried out. to identify patients and collect data the outpatient medication dispensation software farhos Ò and the electronic medical record software hcis Ò were used. statistical analysis was carried out using microsoft excel Ò . demographic (age and sex), clinical (forced vital capacity (fvc), diffusing co capacity (dlco) and six-minute walk test (wt m)) and therapeutic (dosage and adverse reactions) variables were collected. results: throughout the study period, a total of patients ( males) started treatment with pirfenidone, with a median age of . years ( - ). during this period patients were excluded for lack of monitoring. the median fvc, dlco, wt m values prior to pirfenidone therapy, were % ( [ %), . % ( [ %) and m ( - m) respectively. all patients met the inclusion criteria of capacity trial according to fvc and wt m; however of them didn't meet the dlco criteria (at least %).'' all patients were monitored every months. the median in fvc percentage change at the end of the study was - % (- % to + %). patients ( %) showed an improvement on fvc during treatment with a median change of %. in the other eight patients fvc value decreased with a median of - %. only one patient would be candidate to discontinue treatment due to a lack of efficacy, according to discontinuation criteria established at the hospital (absolute decrease of c % in fvc during first year of treatment). dlco percentage was measured in patients, with a median change of % (- % to + %). dlco decreased in patients. wt m was monitored in patients, with a median change of - . m (- m to + m). adverse effects related to pirfenidone were gastrointestinal disorders ( / ), increase of hepatic ggt ( / ), and dermatologic toxicity ( / ). six patients ( %) required a dose reduction because of gastrointestinal adverse effects. five patients ( %) discontinued treatment with pirfenidone due to hepatotoxicity ( ), gastrointestinal ( ) and dermatologic effects ( ). one patient died. conclusion: half of the patients improved fvc during the period of the study. the other half, showed a decrease in fvc value which was similar to the median obtained in capacity trial. gastrointestinal disorders were the most frequent adverse effects and cause of discontinuing treatment. treatment monitoring is important to achieve therapeutic benefit and control the adverse effects. the national centre for epilepsy, oslo university hospital, oslo, norway please specify your abstract type: research abstract background and objective: systematic medication reviews in interdisciplinary teams can help to identify potential and actual drugrelated problems (drp). the centre for development of institutional and home care services in oslo, norway, conducted medication reviews for polypharmacy patients with mental disabilities in - , based on a lack of knowledge about drug-related problems in this patient group. the objective was to examine prescribing patterns, frequencies and types of drp in patients with mental disabilities. setting and method: the forms for medication reviews were developed by the national patient safety campaign in norway. the nurse/social educator recruited eligible patients, observed them, and ordered test if needed. the clinical pharmacist (jwa) reviewed the medications to identify drps. the interdisciplinary case conference took place at the different general practitioners' offices being responsible for the individual patients. the general practitioner, the nurse/social educator and the pharmacist were present, and in some cases, also patients took part. main outcome measures: an independent researcher (aqm) collected and analysed the data based on the drp-forms containing information on the prescribed medicines, strength, dose, indication, a description of drp and suggested interventions to resolve them. results: overall, patients with mental disabilities, aged - years, consented to have a medication review. they used on int j clin pharm ( ) : - average medicines (range - ). the team identified drp in of the patients (average . , range - ). overall, % of all drp were resolved. for one-third of the medicines, an action was taken to improve the prescribing. the most commonly medicines were analgesics ( %), antiepileptics ( %) and anxiolytics ( %). the most frequent drps were unnecessary drug choice ( %), side effects ( %) and too low dose ( %). drps were most common in antipsychotics ( %), antidepressants ( %) and anxiolytics ( %). conclusion: patients with intellectual disabilities take more medicines and have many drps compared to other patient groups. they are also more prone to taking combinations of cns-active medicines and therefore more at risk of side effects and drug interactions. pt : protocol feasibility and patient findings when using a dry extract of zingiber officinale roscoe (ginger extract gr ) during pregnancy please specify your abstract type: research abstract background and objective: there is limited information about the use of dry extracts of ginger root. the objectives of this study are ( ) to evaluate the feasibility of a pilot study with a food supplement among pregnant women ( ) to learn what the patient findings are when using the dry extract of ginger during pregnancy. this abstract deals with the intermediate evaluation of a study conceived to investigate the safety of the ginger extract gr during pregnancy. setting and method: a prospective, interventional and real life pilot study with pregnant women between and weeks of gestation and having symptoms of nausea and vomiting or digestive complaints. the included patients can use the ginger extract gr for digestive comfort during pregnancy when needed. during the use, the score of digestive discomfort is noted and the researcher reports adverse events. main outcome measures: ( ) number of included patients as an indicator of feasibility: including a number of patients was taken as a target ( ) analysis (qualitative and quantitative) of the patient diaries, more particularly patient behaviour, wellbeing and impressions. results: within twelve weeks, patients were included with an average age of . years and a median age of ( - ) years. patients used gr : patients were dissatisfied, patients had a neutral opinion and patients were satisfied to very satisfied. one miscarriage occurred at a gestational age of almost weeks (only tablets of gr were used, with no relevant medical history in preceding pregnancies). two patients were hospitalized, of which with hyperemesis gravidarum. one patient complained about heartburn and one patient experienced a bad taste and heartburn. three patients have indicated that they experienced more nausea after taking the tablets. patients experienced no adverse events. the remaining patients were not yet evaluated. of the included patients, six patients decided not to use the product: because their gastrointestinal complaints were not serious enough, because problems of swallowing (using ginger gums instead). one patient was afraid for the negative consequences for her unborn child. the last of the nonusers indicated that she had no confidence in the product. conclusion: conducting a pilot study with the ginger extract gr in case of pregnancy is feasible. the majority of the evaluated patients were satisfied. signing the consent form does not guarantee the intake of the product. pregnant women remain very cautious in the use of unknown products during their pregnancy, even though it concerns a food supplement and not a drug. the severity of symptoms does not give a good indication whether or not and how often the product will be used. please specify your abstract type: descriptive abstract (for projects) background and objective: to analyse effectiveness and safety of ibrutinib, an oral inhibitor of bruton tyrosine kinase, in patients with mantle cell lymphoma (mcl) who have received at least one prior therapy. design: a descriptive observational study was carried out. all patients with relapsed or refractory mcl who started treatment with mg of daily ibrutinib between september and june were included. patients were identified and followed through electronic medical record. demographic and baseline clinical characteristics of patients were collected: age, sex, ecog (eastern cooperative oncology group scale), number and type of prior regimens, simplified mipi status (mantle-cell lymphoma international prognostic index), and disease stage (relapsed or refractory). progression free survival (pfs) and response to treatment were recorded to evaluate effectiveness. adverse effects related to ibrutinib and possible interactions with concomitant medication were documented to measure safety. statistical analysis of the data was carried out using microsoft excel Ò and spss Ò . results: throughout the period of study a total of patients ( males and female) with a mean age of . ± . years started treatment with ibrutinib. the median of previous treatments were ( ) ( ) ( ) ( ) ( ) including first-line treatment with high dose chemotherapy ( %), steam-cell transplantation ( %), rituximab ( %), bortezomib ( %) and lenalidomide ( %). the median ecog value prior to ibrutinib therapy was (range - ). the mipi status was intermediate risk in patients and high risk in , the disease stage was relapsed in % of the patients. partial response was reported in patients. the mean pfs estimated at the end of the study period was months ( % . - . ). adverse effects related to ibrutinib were: fatigue ( %), diarrhoea ( %) leucocytosis ( %) and infections ( %), including upper respiratory and urinary tract infections, sinusitis and pneumonia. one possible interaction between ibrutinib and everolimus was found in a liver transplant patient. close monitoring of everolimus plasmatic levels was recommended. conclusion: the mean pfs estimated in our study was similar to the median obtained in the pivotal phase ii trial. infections were the most frequent adverse effects. concomitant medication to ibrutinib should be checked, as ibrutibib is metabolised by cyp a and interactions may be frequently present. pharmacy, hiv unit, germans trias i pujol hospital, badalona, spain please specify your abstract type: descriptive abstract (for projects) background and objective: dolutegravir (dtg) is one of the preferred options for initial antiretroviral therapy (art) due to its high efficacy, good tolerability and low potential for drug-drug interactions. nevertheless, an unexpectedly high rate of dtg discontinuation (up to %) due to adverse events in the clinical practice has been recently reported. therefore, we aimed at assessing the dtg discontinuation rate and reasons for discontinuation in our hospital. design: single-centre, retrospective study from september to june of patients cohort with art both naive and pretreated. patients who had started dtg-based art containing regimen were identified and the reasons for the discontinuations were analysed. data were collected using the primary care service program and the electronic prescription program. results: out of patients attended by pharmacy department in our hospital, patients ( males, mean age years (range - )) had started a dtg-based art. out of them, patients were art naive and art-experienced. at the moment of starting dtg, mean cd cells were cell/mm (range - ) and hiv- rna load in plasma was detectable in patients. treatment discontinuation was reported in / patients ( . %) with a median treatment time of days (range - ). / patients ( . %) were naïve and / patients ( . %) pre-treated. most of the patients ( ) were in single tablet regimens (str) containing dtg in combination with abacavir and lamivudine, whereas the rest were in combination with other antiretroviral drugs. the main reason for treatment discontinuation was toxicity in / patients ( . %). the rest of the patients discontinued due to other motives (clinical trial inclusion ( / ), treated in another hospital ( / ), exitus ( / ) and others ( / ). reasons for the discontinuation were classified in different side effects: / ( . %) related to central nervous system (cns) (insomnia, psychiatric disorders such as anxiety, nightmares and depression), / ( . %) gastrointestinal effects, / ( . %) headaches, / ( . %) musculoskeletal effects, / ( . %) fatigue, / ( . %) allergy and / ( . %) for other reasons. some patients reported various toxicities at once. conclusion: more than % of patients treated with dtg discontinued by toxicity reasons. it is important to note that half of these patients had cns adverse effects. please specify your abstract type: research abstract background and objective: hcv therapy has been revolutionised recently by the approval of antiviral agents direct-acting (daa) facilitating the treatment of patients coinfected with hiv/hcv. however, potential drug interactions and overlapping toxicities of both treatments represent the major challenges in adapting therapy. to analyse the prescription profile of direct acting antivirals (aad) in patients coinfected with hiv/hcv. setting and method: retrospective observational study from january to january in a specialty hospital. the data were collected from the hospital program of clinical stories, archinet Ò , and the outpatient program farmatools Ò . the results were analysed using the statistical program r-commander. main outcome measures: inclusion criteria: adult patients coinfected with hiv/hcv with undetectable viral load. the following variables were collected: age, gender, hcv genotype, degree of fibrosis, patient type (naïve or pre-treated), baseline cd count, cd levels end of treatment, sustained viral response (svr) and hcv treatment. results: patients, of whom were men, mean age years were included. patients received daclatasvir and sofosbuvir for hcv, patients had genotype a and b respectively, patients genotype and patient genotype . patients had fibrosis f f , . of the patients they had not received previous treatment (naïve) and had failed to treatment. hiv treatment was modified in patients, patients achieved svr. the cv was undetectable to hiv treatment change for all patients. cd levels increased in all patients at the end of treatment for hcv with a median of cells/ul and at the beginning and end respectively. patients received ombitasvir/paritaprevir/ritonavir and dasabuvir, who had a genotype a. these two patients had received previous treatment and had a f and f fibrosis. none of them was modified hiv treatment and only one got svr. cv remained undetectable and cd slightly increased after the treatment. patients received ledipasvir and sofosbuvir, patients had genotype a, patients genotype b and patient genotype . patients had f fibrosis and had f . patients had received previous treatment (naïve). the hiv treatment was modified only in one of the patients, patients achieved svr. cv increase in patients after the treatment while cd followed the trend of increasing. conclusion: the aad that caused fewer changes in the hiv treatment were ombitasvir/paritaprevir/ritonavir and dasabuvir followed by ledipasvir/sofosbuvir. sofosbuvir and daclatasvir present a greater number of interactions with hiv drugs so they behaved to a major change. more patients are needed to assess more accurately the aad leading to a minor modification. please specify your abstract type: research abstract background and objective: the simplification strategies reduce the amount of tablets and the toxicity in order to facilitate adherence in patients with virological suppression. the strategy more studied is monotherapy with a ritonavir-boosted protease inhibitors (pi/r). to analyse the effectiveness of monotherapy with pi/r in pre-treated patients infected with hiv. setting and method: retrospective observational study. selected hiv patients treated with pi/r monotherapy at any time of pharmacotherapeutic history to / / , with at least one clinical and analytical control months before the beginning. data were collected from the medical record archinet Ò and outpatient farmatools Ò program. variables included were age, sex, duration of monotherapy, virological failure, treatment failure, cd % during monotherapy. main outcome measures: inclusion criteria: virological suppression for year prior to the start of monotherapy, no previous ip virological failure, high cd count ([ cell/ml) and a high level of drug adherence. the effectiveness is defined as the percentage of patients without virological failure ( consecutive plasma viral load (vl) [ copies/ml) and without treatment failure (any event causing retirement monotherapy). results: patients with monotherapy, which represent % of patients with antiretroviral therapy (art) at our institution were identified. were excluded ( co-infected with hepatitis virus, with insufficient data and no had more than months included), including patients in the analysis, with a mean age of years and % were men. the median of time monotherapy treatment was . years ( . days), ( . %) patients received darunavir/r and ( . %) lopinavir/r. the effectiveness of monotherapy treatment during the follow up period was % with undetectable pvl at follow-up. the median of cd % over the treatment time was cell/ml ( %). conclusion: the effectiveness of treatment with ip/r monotherapy in our hospital obtained good results. according with our results treatment adherence plays a very important role. this is a current and valid strategy that brings benefits to the patient and to the healthcare system. please specify your abstract type: research abstract background and objective: the access to investigational drugs for patients who are not included in a clinical trial and without authorized therapeutic alternatives is known as compassionate use. the incorporation of the evidence-based medicine in the area of oncohaematology has implied that an important part of clinic therapy validated by evidence that could not be controlled from an administrative point of view. this is due to the continuous and progressive development of investigation and information on cancer treatment and the delay of the administration regulation. the use of drugs in this way is regulated by royal decree / ( / ). the objective of the study is to describe the use of cancer drugs through compassionate use in the last years in a specialty hospital. setting and method: descriptive retrospective study on a specialty hospital. all the applications for a compassionate use drugs were analysed from january until october . the data were obtained from medical records programme diraya Ò and from an excel database of medicines in compassionate use of the pharmacy service. main outcome measures: the following variables were registered: • number of patient clinic history • authorized medicine • authorization date • applicant service results: we recorded requests of cancer drugs in compassionate use during the years of study. oncology was the service that recorded more authorizations with %, followed with gynaecology with . % and finally endocrinology and haematology with . %. drugs of the requests were approved ( %) and unauthorized ( %) in the years of study. the year in which more applications were received was ( . %) and the least requests were received in ( . %), being the year where all requests were authorized. in fewer applications were authorized, %. in the years , and were authorized . , and . %, respectively. a total of different active drugs were received during the study, the most requested bevacizumab ( %) for grade iii oligoastrocytoma, ovarian cancer (monotherapy), metastatic gall bladder cancer and metastatic platinum-resistant ovarian cancer, everolimus ( %) for indications of neuroendocrine carcinoid tumour and metastatic breast cancer, nab-paclitaxel ( %) for invasive lobular carcinoma indications of high-grade and metastatic pancreatic cancer, ipilimumab ( %) for the indication of metastatic melanoma, and regorafenib for indications of colorectal cancer and metastatic gist i pre-treat with imatinib ( %). the solicitude of drugs through compassionate use needs effective commissions of pharmacy and therapeutics, along with the medical management to establish an agile and faster requesting circuit and the consequent use monitoring. please specify your abstract type: research abstract background and objective: to describe the standard procedure for the elaboration and control of a magistral formula (mf) to assess their effectiveness in two patients with cutaneous metastases of malignant melanoma refractory to other treatment. setting and method: medication for compassionate use was requested for two patients of and years with histopathologic diagnosis of cutaneous metastases of malignant melanoma in the left thigh and left heel in which the lack of response to first-line treatments made to be valued to start with adesleukina intralesional therapy. the first week was infiltrated mu ( ml) in lesions less than cm, mu ( ml) in the larger lesions and repeating each week until complete remission of the lesions. in the nd patient we proceed in the same way but the second week was infiltrated mu ( ml). the following week, infiltrated mml, in metastases and we turn to weekly infiltrations. the response was assessed by clinical disappearance of the lesions treated. complete response (cr) is defined as a clinical disappearance of lesions and partial response (pr) greater than % reduction of the lesion diameter. main outcome measures: we performed a literature search (pubmed, trissel, spc) for all studies published to determine the standard procedure for preparing and monitoring the mf (processing, preservation, stability, dose and indication). results: the standard procedure of preparation and quality control was carried out following the rules established in rd / . it was made in a vertical laminar flow cabinet. the aldesleukin vial was reconstituted with . ml api ( mu/ml) and then diluted with . ml of a solution of . % albumin, % glucose as stabilizer, to avoid aggregate formation, preparing ml syringes ( mu/ml). it was obtained a homogeneous and clear solution without precipitate or opalescence appearance. stable days in a refrigerator ( - °c), protected from light. initially patients had approximately a total of injuries. after months of treatment it was obtained a cr of most lesions in the first patient and rp of the second patient injuries. treatment was well tolerated. the side effects presented were only a flu-like syndrome in the second patient. conclusion: intralesional administration aldeslukina has been effective in treating malignant melanoma skin metastases in our patients, allowing the extension of its use in patients with the same involvement refractory to other primary treatments. the results are similar to those of the publications consulted. please specify your abstract type: research abstract background and objective: chronic infection with hepatitis virus c (hcv) affects about million people worldwide and is a leading cause of liver cirrhosis and hepatocellular carcinoma. the new direct acting antivirals against hcv have revolutionized the treatment of this disease. due to the high cost of these drugs it is necessary to assess their use in clinical practice. to evaluate the effectiveness of daclatasvir in combination with sofosbuvir in patients with hcv monoinfected in a specialty hospital. setting and method: retrospective observational study of patients who began treatment with the combination of daclatasvir and sofosbuvir from january to january in a specialty hospital. the data were collected from the hospital program of clinical stories archinet Ò and the outpatient program farmatools Ò . the results were analysed using the statistical program r-commander. main outcome measures: the sustained virologic response (svr) was considered the primary endpoint of the study. as secondary variables were analysed: sex, duration of treatment, naïve patients or pre-treated, degree of fibrosis, hcv genotype, concomitant use with ribavirin, viral load (vl) before treatment and medical service. results: there were included patients of whom were men. baseline characteristics were: patients with genotype , genotype b, with genotype a and genotype . the degree of fibrosis in the study was patients with f , f and to f . among the patients infected with hcv genotype , had not received prior treatment (naïve) and had failed therapy. the duration of the treatment was weeks to patients and weeks for patients. only patients receiving ribavirin of these had genotype and genotype b. from ribavirin patients it was greater the number of patients in whom the treatment duration was weeks ( patients versus with p-value = . ). the digestive service attended to patients while patients were followed by infectious. the median cv was , , iu/ml. svr was achieved in . % of patients with hcv genotype in . % with genotype b and % with genotype and a. after weeks of treatment % of patients achieved svr and % after weeks. only one patient died during treatment. the results are similar to those obtained in clinical trials. svr has not been influenced by hcv subtype, duration of treatment, degree of fibrosis, pre-treatment or by concomitant use of ribavirin. further studies are needed to evaluate the efficacy of this treatment. please specify your abstract type: research abstract background and objective: the safety and efficacy of medications can vary significantly between patients as a result of genetic variability. as genomic screening technologies become more widely available, pharmacists are ideally suited to utilize this tool to optimize medication management. the objective of this study is to evaluate the feasibility of implementing personalized medication services into community pharmacy practice and to assess the number of drug therapy problems identified as a result of pharmacogenomic screening. setting and method: the study was designed as open-label, nonrandomized, and observational. two community pharmacies in toronto, ontario offered pharmacogenomic screening as part of their professional services program. prior to initiation, participating pharmacists received structured, comprehensive training in pharmacogenetics. pharmacists then facilitated voluntary subject enrolment among patients who they believed would benefit from screening and met inclusion criteria. eligible patients received a simple buccal swab followed by dna analysis using pillcheck Ò . pillcheck Ò is a genotyping assay that translates genomic data and generates a personalized, evidence-based, report that provides insight into patients' inherited drug metabolic profile. upon receiving the report, pharmacists invited patients back to the clinic for interpretation of the results. clinically significant drug therapy problems were identified and recommendations for medication optimization were forwarded to the primary care physician. main outcome measures: number of clinically significant drug therapy problems identified by pharmacists as a result of pharmacogenomic testing. results: patients were enrolled in the study. average age was . years and patients were taking a mean of . chronic medications. pharmacists cited the most common reasons for testing as ineffective therapy ( . %), to address an adverse reaction ( . %), and to guide initiation of therapy ( . %). an average of . drug therapy problems were identified per patient. pharmacist recommendations included change in therapy ( . %), dose adjustment ( . %), discontinuation of a drug ( . %), and increased monitoring ( . %). generally, physician feedback was positive but did reveal an opportunity for a broader understanding of the technology. conclusion: these results highlight the readiness of community pharmacists to adopt pharmacogenetic screening into practice and their ability to leverage this novel technology to positively impact medication management. community pharmacists are ideally suited to both offer personalized medication services and interpret genomic results. please specify your abstract type: descriptive abstract (for projects) background and objective: visual impairment is a common geriatric syndrome and glaucoma/miotic eye drops treatment is a frequent therapeutic option. pharmacist's role in medication reconciliation is an effective process for reducing medication errors and supporting safe medication use. we observed that mentioned medication reconciliation was occasionally not performed during hospital stay and could be cause of delirium because of visual impairment. the aim of this study was to evaluate the influence of omission errors of eye drops treatment on incidence of acute confusional state. design: we conducted an observational, descriptive and retrospective study in an orthogeriatric unit with an average of patients with hip fractures per year ( % surgically treated). data collection was performed from june to march . reconciling medications at admission was performed by implementing the tools and resources of the canadian patient safety institute (cpsi). we extracted from our electronic database (filemaker pro Ò ): • demographic patient data (age and gender). • name and posology of the glaucoma/miotic eye drops treatment. • medication reconciliation performed and identification of professional in charge (pharmacist, geriatrician or orthopaedic surgeon) registration during hospital stay. • protocolar management of delirium with tiapride occasional intramuscular administration performed if necessary was also registered to establish the incidence of acute confusional state. results: thirty-two patients ( women and men) were included, median age year-old . in patients, eye drops reconciliation treatment was performed by the pharmacist in of the patients, the geriatrician in cases and the orthopaedic surgeon in . in patients, the mentioned medication reconciliation was not performed (pharmacist absentism). considering the patients on eye drops treatment during hospital stay, ( . %) of them suffer from acute confusional state. on the other hand, among the patients without medication reconciliation, delirium was registered in cases ( . %). concerning ocular topic treatment, . ± . active principles per patient were observed, being the most frequent timolol ( . %), brinzolamide ( . %) and latanoprost ( . %). conclusion: we consider of paramount importance the pharmacist evaluation availability at an orthogeriatric unit, minimizing the impact of acute confusional state during hospital stay by medication reconciliation. please specify your abstract type: descriptive abstract (for projects) background and objective: to report the therapeutic management of haemorrhagic rectocolitis onset in a lung-transplanted patient with mycophenolate-induced diarrhoea. design: case report. results: a -year-old-man lung transplant patient for alpha -antitrypsin deficiency in receiving mycophenolate mofetil, tacrolimus and corticosteroid developed chronic diarrhoea worsened by sigmoid and cecal necrosis in , and treated successfully by sigmoidectomy. severe diarrhoea attributed to mycophenolate mofetil reappeared in april , which motivated a switch to mycophenolate sodium. the absence of clinical improvement in june led to stop mycophenolate sodium and introduce azathioprine at mg/day (absence of mutation for the thiopurine methyl transferase gene). one month later, the patient presented melena, diarrhoea, bloating, nausea, and knee pain, attributed to azathioprine. this latter was stopped and mycophenolate mofetil was rechallenged associated with symptomatic treatment (i.e., diosmectite and loperamide). in january , a colonoscopy, performed in a context of profuse chronic diarrhoea with mucus during months, highlighted haemorrhagic rectocolitis. therefore, the patient initiated sulfazalasine therapy with no clinical improvement, and then high doses of oral corticosteroids. because high-dose of oral corticosteroids was not recommended as a long-term treatment, mercaptopurine was proposed as a new therapeutic option. mercaptopurine has no indication as an immunosuppressive treatment in solid organ post-transplant supportive care. however, as the active metabolite of azathioprin, an immunosuppressive drug widely used in transplantation, mercaptopurine has immunosuppressive functions towards t-lymphocytes. after multiprofessional collaboration between gastroenterology, pneumology and pharmacy specialists, it was decided to stop mycophenolate mofetil and introduce mecaptopurine at . mg/kg/day, as immunosuppressant for haemorrhagic rectocolitis as well as lung transplantation. this unusual lung transplant immunosuppressive therapy, associated with tacrolimus, improved digestive disorders and patient's quality of life. currently, mercaptopurine is biologically and clinically well tolerated. the dosage of blood residual concentrations of purinethol metabolites ( -thioguanine and -methylmercaptopurine) is going to be performed. conclusion: immunosuppressive therapy in solid organ transplantation is a real challenge for patients who have comorbidity onset. despite a lack of data in the literature, a multidisciplinary collaboration based on comprehensive pharmacology skills is essential to choose the best therapeutic option in this type of patients. please specify your abstract type: descriptive abstract (for projects) background and objective: the use of complementary medicines (cm) in oncology is the subject of broad but still controversial interest. a large part of patients with cancer uses cm, including complementary drugs, during their treatment period. indeed, according to different studies, this proportion ranges from to %. importantly, the risk of interaction between cm and anti-cancer drugs is not negligible; hence we need to identify these cm to ensure the security of our patients and the success of their treatment. design: to achieve this purpose, a monocentric retrospective analysis was conducted with collection of data by pharmacy students during medication reconciliation of hospitalized patients from january to june . collected data are patients' characteristics, prevalence of cm use and potential cm-anticancer drug interactions. results: patients were included in the study ( men- women); median age was [ - years]. a total of . % (n = ) were using a least one cm, most frequently homeopathy ( %, n = ) or phytotherapy ( %, n = ); some patients were using a combination of two cm ( %, n = ). cm are mainly used by women in comparison to men ( . % versus . % and p = . , chi square test). for phytotherapy, at least different herbs were described by patients and among them the most frequently used were mistletoe (viscum album), propolis and fireweed (epilobium angustifolium). data analysis showed that % (n = ) of patients were at risk of potential cm-anticancer drug interaction. moreover this risk was increased to % if we considered only patients taking phytotherapy. interactions included pharmacokinetic ( %, n = ), such as altered hepatic metabolism, and pharmacodynamics ones ( %, n = ). conclusion: in conclusion, our work clearly demonstrates that the use of cm by patients is associated with high risk of relevant drug interaction with their anti-cancer treatment. even if further investigations are necessary to clarify the clinical impact of these interactions, the use of cm must be considered during prescribing process. please specify your abstract type: research abstract background and objective: since their reimbursement, the direct oral anticoagulants (doacs) are increasingly used for stroke prevention in atrial fibrillation (af). the objective of this study was to identify the proportion of real life patients with af eligible for doac therapy, based on the inclusion and exclusion criteria used in the clinical studies and based on the officially approved indications as mentioned in the summary of product characteristics (smpc). setting and method: data for this retrospective cross-sectional study was extracted from the uz brussel stroke registry, containing anonymized data of patients with a suspected stroke. characteristics of patients with documented af were compared with the patient characteristics in clinical trials and the approved indications in the smpc. main outcome measures: proportion of real life patients with af eligible for doac therapy. results: data of patients with af was analysed. based on the selection criteria of the clinical trials, significantly less patients were eligible for treatment with rivaroxaban compared to dabigatran etexilate ( . % versus . %; p = . ), but not compared to apixaban ( . %; p = . ). based on the indications and contraindications in the smpc, significantly fewer patients were eligible for apixaban compared to dabigatran etexilate and rivaroxaban ( . % for apixaban, . % for dabigatran etexilate and . % for rivaroxaban; p \ . and p \ . , respectively). significantly more patients were eligible for doac therapy based on the indications and contraindications in the smpc compared to the inclusion and exclusion criteria of the clinical trials ( . % versus . %; p \ . for dabigatran; . % versus . %; p \ . for rivaroxaban and . % versus . %; p \ . for apixaban). conclusion: when taking into account the selection criteria from the pivotal clinical trials with doacs for stroke prevention in af, less than half of real life patients are eligible for therapy with one of the doacs. however, the indications mentioned in the smpcs of these drugs are less strict. please specify your abstract type: research abstract background and objective: idiopathic pulmonary fibrosis (ipf) is a disease in which tissue deep in the lungs becomes thick and stiff, or scarred, over time. the formation of scar tissue is called fibrosis. pirfenidone is an anti-fibrotic and anti-inflammatory agent, thus offers a new hope for treating progressive fibrotic diseases. int j clin pharm ( ) : - our objective is to set a description of idiopathic pulmonary fibrosis patients treated with pirfenidone, as well as the adverse reactions observed. setting and method: descriptive study in which all patients have received pirfenidone. the data were obtained through the dispensing program of outpatient (farmatools) and review of medical records of the hospital database (archinet) and clinical station (diraya). main outcome measures: we have extracted from each patient baseline data, comorbidities, dose received, reported adverse reactions and data about haematology and biochemistry. results: we have a total amount of patients treated with pirfenidone, all diagnosed with idiopathic pulmonary fibrosis, including women and men. the age of patients is between and years, with an average of . years. all patients are ex-smokers and one of them is also ex-alcoholic. concerning concomitant pathologies, patients have diabetes mellitus, have arterial hypertension, and one of them has ischemic heart disease. another has upper gastrointestinal bleeding prior, among others chronic pathologies. pirfenidone dose received was the usual dose in of the patients: days - mg every h, days - mg every h and a maintenance dose of mg every h. in one patient due to its low imc the dose received was smaller ( - days mg every h, days - mg every h and maintenance dose of mg every h). in relation with the adverse effects, digestive discomfort were observed in of the patients, causing the interruption of the treatment in one of them (with prior gastrointestinal bleeding). in the other patient it was relieved by lowering the dose received. also, one patient has experienced photosensitivity. alterations in transaminase levels were observed in patients but that didn't force to discontinue the treatment. no alterations were observed in the blood count. conclusion: treatment with pirfenidone is being generally well tolerated by patients. it has improved their life-quality and reached the objective data of a slowdown in disease progression. currently, the number of patients is no enough to give conclusive information in relation to the drug effectiveness. please specify your abstract type: research abstract background and objective: to describe the total amount of patients treated with a magistral formula of sodium cromoglycate mg without excipients: indications, concomitant therapy and the response to therapy. setting and method: we run a descriptive study in which we included the totality of patients in treatment with a magistral formula of sodium cromoglycate mg without excipients in a tertiary hospital. the data were obtained through paracelso (development of magistral formulas program), as well as with farmatools (dispensation program of outpatient) and the review of medical records from the hospital database (archinet), and diraya clinical station. main outcome measures: from each patient we extracted data relative to sex, age, diagnosis, time in treatment with the formula, dose received, response to therapy, concomitant antihistamines treatments and adverse effects. results: a total of patients in treatment with a magistral formula of sodium cromoglycate mg without excipients were reviewed: women and men with a mean age of . years old (range - years). regarding the indication of the prescription, patients have been diagnosed of indolent systemic mastocytosis and the remaining were diagnosed of mast cell activation syndrome. in all cases, the diagnosis was established by examination of the bone marrow in the mastocytosis studies institute of castilla la mancha (spain). on average, patients took the treatment . months, with a range between months and months. the dose received was mg every h in patients, having to be increased to mg times daily in a case with poor response to the therapy. in the remaining patients, the treatment response has been optimal. in relation to the concomitant anti-allergic treatment received, patients took fexofenadine daily during the study. no cases of adverse effects related to the therapy received have been reported. conclusion: both indolent systemic mastocytosis and mast cell activation syndrome are considered rare diseases, and we should indicate that in spain there are no commercial medicines available of sodium cromoglycate without excipients for its treatment. the treatment with this magistral formula of sodium cromoglycate mg without excipients has been effective and well tolerated in all patients, improving the symptoms associated with their condition as well as their quality of life, and also, assuming a solution to the lack of marketing of the drug currently in spain. please specify your abstract type: research abstract background and objective: to analyse the prescription profile, safety and effectiveness of new therapies available for the treatment of hcv genotype b in a tertiary hospital. setting and method: we run a retrospective observational study in which we included a total amount of patients infected with hcv genotype b treated with the new therapies against hcv from february to december in a tertiary hospital. the data were obtained through the outpatient dispensing program farmatools and the review of the medical records from the hospital database, archinet and prescription hepatitis c portal of the andalusian health service. main outcome measures: from each patient the following information was collected: sex, age, viral genotype (gen.), naive/nonnaive, hiv coinfection, presence of cirrhosis, degree of hepatic fibrosis measured by fibroscan, treatment prescribed and duration, adverse effects, sustained viral response (svr) and the service that made the prescription. results: a totality of patients with hcv gen. b were reviewed which . % of them were men with a mean age of . years (range - years). of the patients were naive and only of them were hiv co-infected, there were a . % of cirrhotic patients. regarding the degree of hepatic fibrosis, patients had grade f , f grade patients, patients grade f and f grade patients. the most commonly therapy prescribed was lepidasvir + sofosbuvir in patients ( without ribavirin and with ribavirin ) using a treatment schedule of weeks in of them. the treatment was discontinued in one case because of the adverse effects, achieving svr in the remaining patients. the combo treatment with paritaprevir/ombitasvir/r + dasabuvir was prescribed in times ( without ribavirin and with ribavirin) choosing only in one of them for a treatment period of weeks. there were no treatment discontinuations and svr was achieved in all patients treated in this way. patients received simeprevir + sofosbuvir for weeks ( without ribavirin and with ribavirin), one patient of the left the treatment due to adverse effects. svr was found in the remaining patients who completed treatment. sofosbuvir + daclatasvir was prescribed to patients, associating ribavirin in only one case. a treatment duration of weeks was used in patients and weeks in the remaining two. one patient failed rvs without any incidences of adverse effects in any case. interferon + ribavirin sofosbuvir + was prescribed to patients in -week regimen which was well tolerated achieving svr. digestivo service treated the % of the total amount of patients. conclusion: new therapies for hcv have been used in all the treated patients and the older drugs have been relegated. about the effectiveness, svr was achieved in . % of patients. regarding the safety, only patients have discontinued the treatment due to adverse effects representing less than % dropout rate of the therapy. please specify your abstract type: descriptive abstract (for projects) background and objective: thanks to pharmacogenetics we can identify and predict different responses to the same drug among different individuals. during these last years we have noted a big increase of dosing guidelines and advices about the use of several drugs due to the influence of different polymorphisms. the aim of this study is to describe and evaluate the use of pharmacogenetics in our hospital from april , when we started our first research about pharmacogenetics, to the actual time, using these information in our daily clinical practice; and indeed quantify the number of different tests and the number of different clinical advices done because of pharmacogenetic information, by different healthcare specialty areas and drugs. design: we reviewed all the pharmacogenetic test requests in our hospital from april to april , noting which health specialty and for which drug was asked the test. polymorphisms were genotyped using taqman Ò genotyping assays technology by independent laboratories to confirm the results. results: from april we were asked for pharmacogenetic tests from different healthcare specialty areas: rheumatology ( . %), infectious diseases ( . %), oncology ( . %), cardiology ( . %), vascular surgery ( . %), neurology ( . %), ophthalmology ( . %); this information was asked about different drugs: clopidogrel ( . %), trastuzumab ( . %), ranibizumab ( . %), azathioprine ( . %) and tocilizumab ( . %). from all the genotypes, ( . %) were done after using the drug (study phase) and ( . %) were done previous to the use of the drug in daily clinical practice to make a ''clinical recommendation''; from these recommendations affected to the prescription of clopidogrel. conclusion: during the last years we could implement the use of pharmacogenetics in the daily clinical practice in our hospital in different healthcare areas affecting drugs and we started research studies previous to its use on the clinical practice for other three different drugs. please specify your abstract type: descriptive abstract (for projects) background and objective: the drug burden index (dbi) is a tool used to quantify the anticholinergic and sedative burden of medication on an individual. it has been independently associated with poor physical and cognitive performance in community-dwelling older people. objectives were: to create an inventory of medications used in ireland with clinically significant anticholinergic and/or sedative activity and to decide upon the minimum daily dose (mdd) for each medication. design: medications with potential anticholinergic and/or sedative burden were identified by literature review and examination of the summary of product characteristics (smpc) for all medications registered in ireland. each medicine was classified as anticholinergic or sedative. drugs with both anticholinergic and sedative properties were classified as primarily anticholinergic. the mdd, a key component of the dbi score calculation, was selected by reference to the irish smpc. other options which were also considered for this value include the defined daily dose (ddd) of a medication, as available from the world health organisation (who), and the mdd as outlined in the british national formulary (bnf). mdds were decided upon regardless of indication as the lowest effective therapeutic dose as specified in the smpc for the medication. the final list of medicines and mdds to be included in the inventory was then defined by consensus of three pharmacists. results: in total, medicines with potential anticholinergic and/or sedative activity were considered for inclusion. a final list of medications was identified by consensus ( anticholinergic, sedative). of these, ( %) were agents which act primarily on the nervous system. the three main therapeutic groups contributing to the inventory of dbi medications were antipsychotics ( medications), antidepressants ( medications) and antiepileptics ( medications). conclusion: creation of an inventory of medications with anticholinergic and/or sedative properties, in combination with the individual mdds, was achieved. this is a useful resource for use in analysis of drug burden in an older population. it could help in both identifying patients who would benefit from medication review as well as analysing population medication data. please specify your abstract type: research abstract background and objective: vancomycin is an antibiotic widely used to treat infections such as bacteraemia, infective endocarditis, osteomyelitis, meningitis and pneumonia. nowadays, optimal trough concentration is stablished between and mg/l to avoid development of resistance or - mg/l to improve penetration in complicated infections. some articles have been published explaining the methodology to calculate an expected trough level in steady state. our aim was to compare the trough serum value estimated by the mathematical method with a two-compartimental bayesian forecasting model. setting and method: observational retrospective study carried out in a tertiary hospital from january to december . non obese adult patients with creatinine clearance (crcl) \ ml/min and who have achieved steady state level were included. vancomycin serum values were measured using a chemiluminescence's immunoassay (cmia) and bayesian analysis was performed with abbottbase pksystem Ò (pks Ò ). the statistical analysis was made with medcalc software Ò . bland-altman plot and passing-bablok regression were used to compare both methods. main outcome measures: sex, age, weight, dose, creatinine, and size were collected from clinical history. serum trough values (cminr) were collected from cmia. trough values were estimated using two methods: mathematical method (cminf) and bayesian calculations (cminb). results: patients were included, with a mean age of (± . ) years. % were male and % female. they received a median dose per h of ( - ) mg. the mean of cminr was . mg/l ( % ci . - . ), cminb . mg/l ( % ci . - . ), cminf . ( % ci . - . ) . correlation coefficients (r) comparing both methods were significantly different: r between cminf and cminr was . ( % ci . - . ), while r between cminb and cminr was higher: . ( % . - . ). bland-alman plot analysis showed both methods cannot be used interchangeably. the regression equations estimated by passing-bablok regression were y = - . + . x and y = - . + . x. conclusion: bayesian method has demonstrated better correlation with real measures than mathematical method. most part of our patients could be underestimated or overestimated using mathematical methods which could cause toxicity or lack of efficacy, so this method is unsuitable for clinical use. bayesian estimation remains the best option for optimal dosing of vancomycin. please specify your abstract type: research abstract background and objective: combination therapy with digoxin and acenocoumarol is common in patients with atrial fibrillation (af). getting optimal concentrations of digoxin leads an appropriate response; taking into account its narrow therapeutic range and all the factors which can affect to its pharmacokinetics. interaction between them has been studied, even though its mechanism is not clear yet. patients who are taking both drugs need higher doses of digoxin; because they get lower concentrations by using the same dosage. the objective of this study was to analyse digoxin concentrations in patients treated with this combination compared to expected concentrations according to population parameters. setting and method: retrospective observational study from december to march performed by pharmacokinetic unit. patients included had chronic treatment with acenocoumarol and digoxin, which determination were realized in the steady state before the next dosage. patients with toxics concentrations of digoxin, or who were suspected nonadherence, were excluded. the plasma digoxin concentrations were determined through the autoanalyzer architect c- Ò (petinia). dosage adjustment was realized by the program abbot pharmacokinetics system (pks). a comparative between the real measured concentrations in patients and estimated concentrations were realized based on population parameters. finally, in order to get optimal concentrations, some dosage changes were proposed based on pharmacokinetic monitoring. data collected: population characteristics (gender, age, weight, and height), analytical data (potassium, urea, creatinine and clearance). main outcome measures: digoxin serum concentrations (optimal range . - ng/ml). results: data from patients, . % women with a mean (sd) age of . ( . ) years were included in the study. at baseline, potassium, urea, creatinine and clearance mean (sd) was . ( . ) mmol/l; . ( . ) mg/dl; . ( . ) mg/dl; . ( . ) ml/min. . % of the patients had lower concentrations than expected according to population parameters. finally, digoxin dosage was increased in . % of patients, it was maintained in . %, and it was decreased in . %. conclusion: digoxin concentrations in patients with af in combination therapy of digoxin and acenocoumarol are lower than would be expected in most cases. it is important monitoring digoxinaemia to achieve optimal concentrations and a good clinical response. further studies are needed to determine the relevance of this interaction in clinical practice. please specify your abstract type: research abstract background and objective: tocilizumab (tcz) is a humanized monoclonal antibody inhibitor of il- receptor, indicated in combination with methotrexate in the treatment of rheumatoid arthritis (ra) in patients with inadequate response or intolerance to prior therapy. interleukin is involved in the pathogenesis of rheumatoid arthritis via its broad effects on immune and inflammatory responses. previous studies have shown that c-allele at the - g[c (rs ) polymorphism is related with a bad response to tocilizumab (according to eular criteria). the aim of our study was to explore the potential role of il- genetic polymorphisms as a predictor of tocilizumab efficacy in rheumatoid arthritis (ra) patients and check this association depending on the genotype. setting and method: the il- (g[c) (rs ) genetic variant was genotyped using predesigned taqman Ò genotyping assays technology and analysed on a viia Ò real-time pcr system. main outcome measures: clinical response was evaluated at , , and months according to the eular criteria. patients were classified as ''responders'' (good and moderate response according to eular criteria) and ''non-responders''. the statistical analysis was performed using spss v. . results: we recruited patients with ra treated with tocilizumab, these were aged . ± . (mean ± sd), ( %) were women. the mean das at baseline was . ± . . of these patients, the il- g[c genetic polymorphism was significantly associated with ''responders'' at months after the baseline (cc vs non-cc p = . , or . , % ci . - . ) but not at (p = . ), (p = . ) and (p = . ) months. conclusion: the il- g[c may be useful as a genetic marker of tocilizumab efficacy at months. other polymorphisms, clinical parameters and other pharmacological treatment during the follow-up may be checked about their influence on the response to tocilizumab. tdmp : daptomycin pk/pd profile in neutropenic cancer patients with beta-lactam-resistant gram-positive infection nancy perrottet *, , frederic tissot , laurent decosterd , thierry buclin , guy prod'hom , christina orasch , oscar marchetti , farshid sadeghipour , , thierry calandra , véronique erard pharmacy service, infectious diseases service, laboratory and division of clinical pharmacology, service of biomedicine, institute of microbiology, lausanne university hospital, lausanne, school of pharmaceutical sciences, university of geneva, university of lausanne, geneva, switzerland please specify your abstract type: research abstract background and objective: the pharmacokinetics (pk) and pharmacodynamics (pd) of many antibiotics are modified in neutropenic patients and few data are available on daptomycin in this population. this prospective study aimed to assess the pk/pd profile of daptomycin in the treatment of neutropenic patients with beta-lactamresistant gram-positive cocci infections. setting and method: this substudy was performed in the context of a prospective pilot study on daptomycin versus vancomycin in adult hemato-oncological patients with febrile neutropenia and proven or suspected infection with methicillin-resistant staphylococci or betalactam-resistant enterococci. patients received daptomycin mg/ kg/day ( mg/kg/day for enterococci) for c days as a -min infusion. main outcome measures: pk analysis using a published non-linear mixed effect model with nonmem Ò , followed by comparison of parameters with values published for healthy subjects. pd analysis based on auc/mic (area under the concentration-time curve/minimal inhibitory concentration). according to eucast, an auc/mic ratio [ is required for bacteriostatic effect against staphylococci and [ for a two-log reduction in bacterial count. for e. faecium, an auc/mic ratio of . has been suggested for bacteriostasis and . for a -log bacterial count reduction. results: model-derived mean auc observed in patients was . ± . mg h/l, maximum concentration (cmax) ± mg/ l, minimal concentration (cmin) . ± . mg/l. clearance was . ± . l/h and volume of distribution at steady sate . ± . l, both values found higher than those reported in healthy subjects. all patients ( / ) with a staphylococcal infection achieved auc/mic values predictive of bacteriostatic effect on staphylococci, and out of values associated with two-log bacterial killing. of note, infection relapse occurred in the only patient with suboptimal daptomycin exposure (auc/mic of ). the pd targets were also reached in the two patients with e. faecium infection. an asymptomatic elevation of creatine phosphokinase was reported in two patients ( u/l and u/l) with cmin of . and . mg/l, respectively. conclusion: daptomycin pk profile in neutropenic cancer patients indicated higher total clearance and volume of distribution, along with lower total exposure, compared to healthy subjects. despite this, standard dosages allowed attainment of pd targets in / patients with a staphylococcal infection (two-log drop) and / with e. faecium infection ( -log drop) . please specify your abstract type: research abstract background and objective: individual clinical response to infliximab can be influenced by their pharmacokinetics and immunogenicity, so therapeutic monitoring of drug levels (tdm) can guide these biologic treatments. the objective was to analyse the suitability of serum infliximab trough levels (sitls) in patients with inflammatory bowel diseases (ibd) receiving dose schemes based only on clinical response. setting and method: prospective and descriptive study of patients with ibd treated with infliximab and under tdm. medical records were reviewed. dose schemes were established according to clinical guidelines ( mg/kg every weeks) and optimized based on an index of clinical response (mayo, pcr…). sitls (therapeutic range - mcg/ml) and anti-drug antibodies (ada) were measured in all of patients by elisa (promonitor Ò ). ada presence was considered as a therapeutic failure indicator. informed voluntary consent was obtained from all patients. main outcome measures: sitls and ada. results: a total of patients, with a median age of years (range ), were included in the analysis. infliximab standard dose according to clinical guidelines were administered to patients: . % showed sitls under the therapeutic range ( . % with ada). in eight patients with maintained good clinical response, dose decrease or interval elongation had been implemented: % of these patients showed sitls below the therapeutic range ( % with ada). it had been necessary to increase the dose or shorten the interval in patients due to inadequate clinical response: . % of these patients with sitls below the therapeutic range ( % with ada). conclusion: optimization based on clinical response of infliximab treatments in patients with ibd is not always an effective strategy, since it leads to a high percentage of patients with sitls below the therapeutic range and adas. tdm together with clinical response should guide the optimization of infliximab treatments. please specify your abstract type: research abstract background and objective: in addition to its anticonvulsive properties, valproate is also used as a mood stabiliser in bipolar disorder and as augmentation treatment of other psychiatric disorders. the unpredictable relationship between dose-plasma valproate concentrations and correlation between concentrations-efficacy suggest therapeutic drug monitoring (tdm) of plasma valproate concentrations might be useful. the aim of our study was to evaluate the rationale of a new protocol for measuring valproate concentrations and the incorporation of a clinical pharmacist in the process of valproate tdm service, compared to pre-existing standard measuring. setting and method: in the retrospective study we analysed the process of measuring plasma valproate concentrations at the department of psychiatry and at the unit for forensic psychiatry of a large teaching hospital in slovenia before the enrolment of a clinical pharmacist. for the prospective study we created a protocol for tdm of valproate in adults based on literature research. the protocol included reference range, sampling time, indications for sampling and schedule of other laboratory tests that have to be monitored during valproate therapy. main outcome measures: percentage of plasma valproate concentrations in reference range (c trough = - mg/l) before/after the enrolment of a clinical pharmacist, percentage of measured valproate c trough . results: in the retrospective study randomly chosen patients with measured plasma valproate concentrations were included ( % male, age ± years, length of hospital stay ± days). plasma valproate concentrations were measured . ± . times per patient, % were in the reference range (other % subtherapeutic), % were drawn at c though , . % were drawn for assessing compliance (nontrough). in the prospective study patients were included ( % male, age ± years, length of hospital stay ± days). plasma valproate concentrations were measured . ± . times per patient, % were in the reference range (other subtherapeutic), % were drawn at c trough , . % were drawn for assessing compliance. conclusion: the inclusion of a clinical pharmacist in valproate tdm service increased the number of valproate plasma concentrations in the reference range by almost % and increased the number of concentrations drawn at c trough , when indicated. including a clinical pharmacist in valproate tdm is beneficial and the new protocol is useful for optimising valproate therapy. concurrent and predictive validity of a self-reported measure of medication adherence the effect of pharmacist-led interventions in optimising prescribing in older adults in primary care: a systematic review aflibercept: . neovascular membranes with visual acuity higher than . . one eye affection severe cardiovascular pathology (severe episodes in the last months) non-responders to other anti-vegf bevacizumab: . diabetic macular edema macular edema secondary to vascular pathology setting and method: a longitudinal study was carried out in primary care centres. participants: patients aged c , under treatment with or more drugs and belonging to primary care areas in different towns. patients should have at least one of the following potential safety problems: (a) concomitant use of a non-steroidal anti-inflammatory drug (nsaid) with an antihypertensive drug, anticoagulant or antithrombotic drug; (b) use of two or more benzodiazepines. two clinical management units (cmu) were randomized per area to be included in the study. thirty patients per cmu were randomized to be enrolled and monitored during months number of adverse effects ( . ; p \ . ) and number of clinical problems ( . ; p \ . ).with each year increase in age ) and a significant rise in physician ( . ; p \ . ) and nurse ( . ; p \ . ) home visits. women compared to men resulted in a significant decrease ) but a significant increase in visits to nurses ( . ; p \ . ), hospital admissions ( . ; p \ . ) and hospital visits ( . ; p \ . ). age, sex and npsp had no significant effect on falls, fractures or cardiovascular events. conclusion: the npsp in elderly patients contributes to an increase in the use of health services and comorbidity. effective interventions should be addressed to general practitioners to reduce inappropriate prescriptions bpa was found in the dialysate ( ng/l) and ls ( ng/l) wherein the concentration of bpa decreases over time to reach ng/l at the end of a session. finally, bpa was present in all tested dialysis at concentrations of up to . ng/dialyzer in the compartment mimicking the blood and to . ng/dialyzer in the dialysate despite prior rinsing with l of . % nacl. conclusion: our study is the first one to show the risk of exposure to bpa and bpa-clx hdf-ol. while assessment of the impact of this exposure in a patient under treatment remains to be done, it is now possible to better master contamination by bpa and its four chlorinated derivatives through better practices (choice of medical devices) and improvement of the overall water treatment process san cecilio university hospital, genomic unit san cecilio university hospital, genomic unit, genyo, centre for genomics and oncological research the aim of this study is to compare the apparition of stroke, acs, cardio-vascular death and the need of surgery in patients after percutaneous transluminal angioplasty (pta) or stroke depending on the presence of cyp c * * polymorphisms. setting and method: retrospective cohort study. we recruited patients treated with clopidogrel after a pta of the lower limb or stroke (without surgery) from to in our hospital. data collected: age, sex, cyp c * (rs ) and cyp c * (rs ) genotypes and the primary end-point: stroke, acs, cv death and surgery of the affected vessel during months after discharge. polymorphisms were genotyped using taqman Ò genotyping assays technology. main outcome measures: we recruited patients with stroke ( . % men; mean age . ) and patients after pta ( . % men; mean age . ) treated with clopidogrel after discharge %) suffered the primary end-point during months after discharge; of these patients had the cyp c * allele. among patients with pta of the lower limb: % of them had the cyp c * allele and no one a cyp c * allele; ( . %) of these patients suffered the primary end-point during months after the discharge and of these had the * allele of the cyp c isoenzyme * allele and treated with clopidogrel have a higher risk of the primary end-point than those patients not carrying it spain please specify your abstract type: research abstract background and objective: the engagement of fcgrs by tnf antagonists could affect to macrophage-mediated clearance of immune-complexes. the aim of our study was to evaluate the potential role of fcgr a (a[c) (rs ) single nucleotide polymorphism (snp) as a predictor of tocilizumab efficacy in rheumatoid arthritis (ra) patients. setting and method: the fcgr a (a[c) (rs ) snp was genotyped using predesigned taqman Ò genotyping assays technology and analysed on a viia Ò real-time pcr system. the statistical analysis was performed using spss v the mean age of the patients was . ± . years and % were women. the mean das at baseline was . ± . . we found no statistically significant association between our end-point and the genetic polymorphisms studied tdmp : therapeutic drug monitoring of infliximab biosimilar and anti-infliximab antibodies in inflammatory diseases patients with dermatological conditions and inflammatory bowel disease being treated with ifx-b ( mg/kg/ weeks after the induction dose) were included. the concentrations of ifx-b and ati-b were quantified by two sandwich-type elisa immunoassays (triturus Ò analyser). main outcome measures: plasma levels of ifx-b and ati-b, clinical response and infusion reactions. the clinical response was assessed according to pathology of each patient (based on specific clinical variables for the pathology into the electronic history) pharmacokinetic results (% assessments): (a) . % no ifx-b detection (c \ . mcg/ml) and positive ati-b (c [ ua/ml) ( assessments/ patient). atis = , y ua/ml. no clinical response (nr) in . % assessments. (b) . % ifx-b and ati-b (c b ua/ml) no detection ( assessments/ patient). nr %. (c) . % ifx-b detection (c [ . mcg/ml) and negative ati-b ( assessments/ patients) weight: ( - ) kg. twenty assessments, . ( - ) assessments per patient, ( - ) ifx-b doses, % concomitant treatment ( / -azathioprine, / -corticosteroid) the incidence of ati-b was low. a correlation was observed between the presence of ati-b and loss of clinical response, as infliximab original. tdmp : serum concentration of non-vitamin k antagonist oral anticoagulants (noacs) in older hip fracture patients ina linnerud , mette i martinsen estimation of t of noacs by t / = ln /kel [kel; elimination constant] using two s-concentration measurements. results: we included patients (median age years, . % women). noac use was detected be serum analysis in patients ( . %; % coherent with mr), while patients ( . %) used warfarin. of the noac users ( . %) had s-concentrations of noacs above the reference range at admission, and five patients ( . %) had s-concentrations within the reference range before surgery. patients using noac had significantly longer median waitingtime for surgery than warfarin-users ( vs h, p = . ). blood transfusions were given to . % of noac-users vs . % of warfarin-users (p = . ). mean estimated t of noacs were , . and . h for dabigatran (n = ), apixaban (n = ) and rivaroxaban (n = ), respectively. conclusion: mr is effective in detecting noac use in older hip fracture patients, but importantly s-concentrations are higher than expected in this population. this might reflect the significantly longer waiting-time for surgery this column is supplied with packing material made of totally porous spherical silica coated with a silicone polymer monolayer containing octadecyl (c ) groups. the mobile phase was composed of . % na po h o (ph . ), acetonitrile, and methanol ( : : , v/v/v), which was degassed in an ultrasonic bath prior to use. the flow rate was . ml/min at ambient temperature and sample detection was carried out at nm. plasma samples were obtained from patients with cml receiving nilotinib treatment. sampling was performed at the steady state. blood samples were collected by venipuncture h after oral administration of nilotinib. plasma was separated by centrifugation at g for min and stored at - °c until analysis. plasma samples ( ll) were then extracted as described above. the same samples were also sent to a commercial laboratory (bml, inc.) for assaying nilotinib concentration by liquid chromatography-tandem mass spectrometry (lc-ms/ms). in addition, we applied this method to tdm of cml patients receiving nilotinib at our hospital. main outcome measures: the calibration curve exhibited linearity over the nilotinib concentration range of - ng/ml at nm, with relative standard deviations (n = ) of . , . , and . % for , , and ng/ml, respectively. the detection limit for nilotinib was ng/ml due to three blank determinations (q = ). in addition, we compared the results with those measured by lc-ms/ ms at bml, inc. (a commercial laboratory). as a result, a strong correlation was observed between the nilotinib concentrations measured by our hplc method and those obtained by lc/ms-ms (r = . , p \ . ). in addition, tdm of nilotinib was performed to six cml patients. there was the case which participated in dosage adjustment of nilotinib in hepatic dysfunction and poor glycaemic control. results: we have developed a simple ultraviolet detection method for the determination of nilotinib, which has high sensitivity and large dynamic range please specify your abstract type: research abstract key: cord- - dannjjm authors: nan title: research abstract program of the acvim forum denver, colorado, june – , date: - - journal: j vet intern med doi: . /j. - . . .x sha: doc_id: cord_uid: dannjjm nan clinics Ãà also see infectious disease abstracts id- -id- (thursday, june , : pm - : pm) Ãà also see pharmacology abstracts p- -p- (thursday, june , : pm - : pm) Ãà also see gasteroenterology abstracts gi- - june , hypertrophic cardiomyopathy (hcm) is the most commonly observed myocardial disease in cats. beta-blockers and calcium channel inhibitors are frequently administered drugs to cats with preclinical hcm despite the fact that neither drug category has been proven to slow disease progression or improve survival. ivabradine (procorolan s , servier, france) is a novel negative chronotropic agent used in the treatment of ischemic heart disease in people. little is known about its efficacy and safety in cats. the purpose of this study was to determine the short-term effects of ivabradine on heart rate (hr), blood pressure, left ventricular (lv) systolic and diastolic function, left atrial (la) performance, and clinical tolerance in healthy cats after repeated oral doses. ten healthy laboratory cats were involved in the present study. physical examination, systolic blood pressure measurement, and transthoracic echocardiography were performed in all cats at baseline and after oral administration ( weeks each) of ivabradine ( . mg/kg, q h) and atenolol ( . mg/cat, q h; . - . mg/kg) in a prospective, double-blind, randomized, active-control, fully crossed study. a-priori non-inferiority margins for the effects of ivabradine compared to atenolol were set at % (f . ) based on predicted clinical relevance, observer measurement variability, and in agreement with fda guidelines. variables were compared by use of -way repeated measures anova. ivabradine was clinically well tolerated with no adverse events observed. hr (ivabradine, po . ; atenolol, po . ; ivabradine vs. atenolol, p . ) and rate-pressure product (ivabradine, p o . ; atenolol, p . ; ivabradine vs. atenolol, p . ) were not different between treatments. at the dosages used, ivabradine demonstrated more favorable effects than atenolol on echocardiographic indices of left ventricular (lv) systolic and diastolic function and left atrial performance. ivabradine is non-inferior to atenolol with regard to effects on hr, rate-pressure product, lv function, la performance, and clinical tolerance. clinical studies in cats with hcm are needed to validate these findings and further assess safety. the aim of this study was to compare outcome from cpa in dogs following initial administration of either epinephrine or vasopressin during cardiopulmonary resuscitation (cpr). dogs having cpa in the er or icu of a university hospital were randomized to receive either iv epinephrine ( . - . mg/kg) or vasopressin ( . - . u/kg) in a blinded fashion immediately following establishment of iv access and again three minutes later. a standardized cpr protocol was followed. other vasopressors were not permitted during the six minute study period, at the end of the study period additional cpr interventions were at the discretion of the managing clinician. the primary end point was return of spontaneous circulation (rosc) within the study period; secondary end points included rosc at any point, survival to minutes, and survival to one hour. sixty dogs completed the study, received epinephrine and received vasopressin. rosc within six minutes was % ( vasopressin, epinephrine p . ), rosc at any time was % ( vasopressin, epinephrine p . ). survival to minutes was % ( vasopressin, epinephrine p . ), survival to one hour was % ( vasopressin, epinephrine p . ). five dogs survived to hours, one survived to hospital discharge. of animals dying after rosc, / were euthanized and / rearrested. no advantage of routine substitution of vasopressin for epinephrine was seen for rosc, a small survival advantage at one hour was seen in the group receiving epinephrine. the study also demon-strated that prospective clinical cpr research in animals is both possible and practical. three dogs were evaluated in phases. phase- : single-dose diltxr at approximately mg/kg po. phase- : same dose q h for . days. phase- : after a day wash-out the single-dose protocol was repeated using cut tablets to assess affect on extended release properties. blood pressure (bp), -lead ecg, echocardiogram, and h-ambulatory ecg were performed at baseline, and conclusion of phase- . blood samples and bp was obtained , , , , , , and h after final dosing. peak median plasma diltiazem concentrations (mcg/ml) measured by hplc for each phase were . , . , and . respectively. diltiazem concentrations were below the limit of detection in the majority of samples in phase- . median diltiazem concentration reached purported therapeutic concentrations ( . - . mcg/ml) by h post-pill in phase- and h post-pill in phase- . therapeutic concentrations were maintained for h in phase- , but only h in phase- . median bp (mmhg) was . at baseline and . at peak concentration in phase- . median heart rate (bpm) was . at baseline. h-ambulatory ecg analysis revealed the median hourly heart rate was . at baseline and during phase- . median heart rate at peak concentration in phase- was . . lack of detectable plasma diltiazem during phase- may be due to up-regulation of drug metabolism via p-glycoprotein (abcb - ) mutations. ongoing data collection and analysis will include mutation testing. adiponectin (adpn) is a cytokine produced by fat cells which has been shown to be correlated with adverse cardiac conditions in humans. in the heart, adiponectin activates several pro-survival reactions, including the ampk pathway and cox receptors, which protect the heart following ischemic injury. recent studies have shown that higher levels of adpn influence cardiac remodeling signaling, inhibiting protein synthesis and suppressing pathological cardiac growth. in humans, adpn plasma levels rise with decreased activity of the sympathetic nervous system and b-adrenergic agonists inhibit adpn at the level of gene expression. in contrast c-reactive protein (crp), a marker of systemic inflammation is elevated in humans with congestive heart failure (chf) and correlates to the severity of disease. first, we hypothesized that dogs with chf would have reduced adpn and elevated crp compared to normal dogs and that cytokine concentrations would predict severity of chf. second, we hypothesized that adpn receptor- (r ) and adpn protein would be elevated in the myocardium of chf dogs reflecting a compensatory process. we collected serum from dogs ( healthy and chf). circulating adiponectin and crp levels were quantified using a mouse/rat adiponectin elisa and a canine crp elisa. we found lower mean crp concentrations in normal dogs ( . ae . mg/ ml) than dogs with chf ( . ae . mg/ml), however, the results were not statistically significant due to the large variability seen among the chf dogs (p . ). we found greater mean adpn concentrations in normal dogs ( . ae . mg/ml) than chf dogs ( . ae . mg/ml) (p . ). in general, the greater the severity of the heart failure, the lower the level of serum adpn. when the tests the purpose of this study was to determine if there are any clinically important differences between the approaches (including devices) used in non invasive transvascular (interventional) closure of patent ductus arteriosus (pda) in dogs in our institution. initial and follow up records from all dogs (n ) that underwent attempted transvascular pda occlusion from january -december were examined. dogs were placed into groups depending on the device and route of vascular access (transvenous or transarterial). group : amplatz s canine ductal occluder (acdo) (transarterial) - dogs; group : gianturco s or mreye flipper s detachable embolization (flipper) coil (transarterial) - dogs; group : amplatzer s vascular plug (avp) (transarterial) - dogs; group : flipper coil (transvenous) - dogs. statistical comparisons were made using the kruskal-wallis test with mann-whitney tests to compare pairs of groups when significance was detected. p o . was considered significant. there was no significant difference in ages between the groups. there was a significant difference in body weight between groups with dogs receiving a coil either transarterially or transvenously (groups and ) being significantly smaller than dogs receiving an acdo or avp. this was by design since the acdo and avp cannot be used in small dogs. overall, the success rate of the total procedure (including vascular access and satisfactory pda occlusion) was high ( %) with success rates being comparable between groups ( - %). there was a significant difference in complication rate between groups (p o . ) with the acdo group having a markedly lower complication rate than the remaining groups ( % for acdo versus - % for the other groups). total fluoroscopy time ranged from - minutes (median minutes). fluoroscopy time for the transvenous method was significantly longer (median minutes; range - minutes) than in the remaining groups (median minutes; range - minutes) (p o . ). number of dogs with residual flow immediately following the procedure and hrs later was significantly less in the acdo group than in the remaining groups ( dogs from group and from group had moderate persistent flow while dog from group and from group had severe persistent flow hours after the procedure). the acdo appears superior in ease of use, complication rate, completeness of occlusion and fluoroscopy time than other devices. the remaining limiting factor with this device is patient size. until a smaller acdo device is marketed, coils remain the only choice for interventional closure in very small dogs ( o . kg). previously presented at the university of california davis, house officers seminar day. subvalvular aortic stenosis (sas) is one of the most commonly reported canine congenital heart defects and is inherited in newfoundland dogs and human beings. the golden retriever and rottweiler are breeds over-represented in dogs with subvalvular aortic stenosis; however, a genetic cause of this disease in these breeds has not been described. we performed genome wide association analysis in both normal and sas affected rottweilers and golden retrievers to identify chromosomal regions of interest that could implicate a causative mutation by high density single nucleotide polymorphism (snp) array. ( unaffected/ affected) adult golden retrievers and ( unaffected/ affected) adult rottweilers were included in this study. criteria for affected included a subcostal continuous-wave doppler aortic velocity ! . m/s and presence of a left basilar systolic ejection murmur; criteria for unaffected included a doppler aortic velocity . m/s. dna samples were obtained from anticoagulated blood. genotypes were obtained using high density ( , ) snp arrays, and genome wide association with sas was evaluated for each breed. significance cut-off was set at p  À , and all snps meeting this criterion were plotted within each breed and compared across breeds using plink. affected golden retriever data implicate the most significant region of genetic variation on chromosome at location (p .  À ; odds ratio . ) with other significant surrounding snps . affected rottweiler data also implicate the most significant region of genetic variation on chromosome at location (p .  À ; odds ratio . ) with other significant surrounding snps . other regions of statistical significance were on chromosomes and in the golden retriever and and in the rottweiler. genome wide association with subvalvular aortic stenosis in the golden retriever and rottweiler implicate overlapping chromosomal regions of interest for causative mutations on chromosome . the different secondary chromosomal regions of interest (chr , in golden retrievers and , in rottweilers) supports the known familial nature of this disease within different breeds and may suggest the presence of multiple mutations or breed specific disease modifiers. these data highlight the need for candidate gene evaluation on chromosome in golden retrievers and rottweilers with sas. heart valves share developmental signaling pathways with bone and cartilage. degenerative aortic valve disease in humans is characterized by valve stenosis and calcification. recent evidence suggests that degenerative aortic valves are undergoing pathologic processes that mimic osteogenesis. degenerative mitral valves in dogs and humans are characterized by valve regurgitation, and rarely undergo calcification. we tested the hypothesis that canine and human degenerative mitral valves might be undergoing pathologic processes that mimic chondrogenesis. to test this hypothesis, expression of bone morphogenic protein (bmp ), a chondrogenic growth factor; sox , a chondrogenic transcription factor; aggrecan, a proteoglycan abundant in cartilage; and type ii collagen were evaluated utilizing immunohistochemistry. normal canine mitral valves, different stages of canine degenerative mitral valves (early, intermediate, and late), and late-stage human degenerative mitral valves were studied. canine and human degenerative mitral valves showed focal areas that co-expressed all four markers of chondrogenic signaling and phenotype. valve interstitial cells and surrounding extracellular matrix in these focal areas adopted a morphologic appearance reminiscent of cartilage. focal chondrogenesis was present in all stages of canine degenerative mitral valves, but not normal canine mitral valves. focal areas of chondrogenesis did not coincide with nodular areas of glycosaminoglycan accumulation on the leaflet edge, but rather seemed to occur at points of chordae attachment to leaflets. in conclusion, canine and human degenerative mitral valves undergo pathologic processes that mimic chondrogenesis. this finding suggests that mitral valve degeneration may be recapitulating developmental signaling pathways shared by heart valves and cartilage. the triggering events for chondrogenesis in mitral valves remain unknown; as does the reason why aortic and mitral valves appear to be undergoing different pathologic processes. the fact that humans exhibit degeneration of both the aortic and mitral valve, and that dogs commonly exhibit only the latter could eventually provide insight into both processes. arrhythmogenic right ventricular cardiomyopathy (arvc) is a familial cardiomyopathy characterized by right ventricular fibrofatty infiltration and ventricular ectopy of left bundle branch block morphology (vpc) . a deletion in the striatin gene has been associated with arvc in at least some boxer families. syncope and sudden death (sd) occur in some affected dogs, although many affected dogs survive for years. the objective of this study was to define clinical characteristics of arvc in boxers that experienced sd, and compare them to those of a contemporaneous group of arvc boxers that had not died suddenly (nsd). data for both groups were collected from adult boxers enrolled in a long term prospective study of arvc in which echocardiograms and hour ambulatory ecg (aecg) are evaluated annually. aecg are quantitated for vpc numbers and arrhythmia grade ( - ). arvc diagnosis requires at least vpcs/ hours in the absence of other disease. forty three adult boxers that entered the study had died suddenly at the time of analysis (sd defined as the absence of observed clinical signs within hours prior to an unexpected and unexplained death). striatin genotype was available for of the sd dogs ( heterozygotes, homozygotes); were female ( intact) and were male ( intact). sd occurred at a mean age of years (range, - ); sd dogs ( %) had no prior history of syncope. twelve sd dogs ( %) were on antiarrhythmics at the time of death (metop-p oooooooooooprolol ( ), sotalol ( ), amiodarone ( ), procainamide ( ), mexiletine & atenolol ( ), atenolol ( )). eleven sd dogs ( %) had decreased myocardial systolic function defined by a shortening fraction (%fs) o % (range - , mean ) on the most recent echocardiogram prior to sd. median vpcs/ hours on annual aecg was , (range - , ) with a median arrhythmia grade of (range - ). twenty one contemporaneously entered arvc boxers that had survived to at least the median age of the sd group with nsd were available for comparison; / were genotyped ( heterozygous, homozygous, negative), were female ( intact) and male ( intact). twelve nsd dogs ( %) had no prior history of syncope. median nsd group age was years (range, - ); / ( %) were on an antiarrhythmics (sotalol ( ), mexiletine & sotalol ( ), mexiletine & atenolol ( )). one nsd dog had decreased %fs (nsd group %fs range - , mean ). the nsd median number of vpcs was , (range - , ), median arrhythmia grade was (range - ). striatin genotype was significantly associated with sd. no significant differences were found between groups with respect to vpc numbers or arrhythmia grade. shortening fraction was significantly lower in the sd group (p o . ). sd in arvc appears to be associated with the presence of the striatin mutation and reduced % fs, it does not appear to be associated with number of vpcs or arrhythmia grade. coughing in the small breed dog may be related to cardiac causes associated with myxomatous mitral valve degeneration (mmvd) including pulmonary edema and compression of the mainstem bronchus by a severely enlarged left atrium, or due to respiratory causes such as tracheal and/or bronchial collapse or chronic bronchitis. the purpose of this study was to evaluate the association between left atrial enlargement and large airway collapse in dogs with mmvd and chronic cough. we hypothesized that airway collapse was independent of degree of left atrial enlargement. twelve dogs with mmvd and a chronic cough in the absence of congestive heart failure were prospectively evaluated with thoracic and cervical radiography, echocardiography, fluoroscopy, bronchoscopy and bronchoalveolar lavage (bal). group dogs (n ) had moderate to severe left atrial enlargement based on an echocardiographically calculated left atrial:aortic surface area [la:ao(a)] . group dogs (n ) had no to mild left atrial enlargement [la:ao(a) ]. the site and severity of airway collapse was graded on bronchoscopy and bal cytology was assessed for evidence of inflammation or infection. the occurrence of bronchoscopic abnormalities was compared between groups using fisher's exact test. p o . was considered significant. age and body weight did not differ between groups. left atrial size was interpreted radiographically as moderately to severely enlarged in of dogs in group and as moderately enlarged in of dogs in group . fluoroscopy revealed variable degrees of airway collapse during normal respiration and induced cough in both groups. radiography and fluoroscopy were not accurate in identifying site and degree of collapse in either group when compared to bronchoscopy. cervical tracheal collapse was identified during bronchoscopy in both group ( of ) and group ( of ) dogs but was subjectively less severe in group dogs. bronchial collapse % was evident at multiple sites in both groups of dogs with no difference between groups. all dogs had suppurative and/or lymphocytic inflammation on airway cytology. infection was not present in either group of dogs, although non-specific light bacterial growth was detected in of group dogs and of group dogs (p . ). preliminary results failed to identify an association between left atrial enlargement and airway collapse in dogs with mmvd but did suggest that airway inflammation is common in affected dogs. further studies are needed to identify factors contributing to airway collapse in dogs with and without mmvd. atenolol is often used empirically in cats with asymptomatic hcm, even though clinical and experimental evidence of efficacy is lacking. cardiac biomarkers play a critical role in the early detection of subclinical cardiac disease, in the prediction of long-term prognosis, and in monitoring the response to therapy in humans. we hypothesized that serum concentrations of the biomarkers, nterminal pro-brain natriuretic peptide (nt-probnp) and cardiac troponin i (ctni), would improve following the chronic administration of atenolol po to asymptomatic cats with hcm. six maine coon or maine coon cross cats with severe hcm from the research colony at ucdavis were administered atenolol ( . mg po twice a day) for days. no cat had severe left ventricular dynamic outflow tract obstruction due to systolic anterior motion of the mitral valve. the concentrations of nt-probnp and ctni were assayed prior to drug administration and on the last day of drug administration. there was no statistically significant difference identified in nt-probnp [median before: pmol/l (range: - pmol/l), median after: pmol/l (range: - pmol/l); p . ] or ctni [median before: . ng/ml (range: . - . ng/ml), median after: . ng/ml (range: . - . ng/ml); p . ] concentrations before and after drug administration using the wilcoxon matched pairs test. the ctni finding suggests that atenolol does not reduce chronic myocyte death in cats with hcm. the lack of improvement in nt-probnp suggests that atenolol does not improve myocardial wall stress in cats with hcm. a clinical trial is warranted to confirm or refute the findings from this study. therefore, leptin-gene expression was investigated in blood samples of dogs with congestive heart failure (chf; n ) in comparison to dogs presented for cardiac screening (n ) without abnormalities. additionally myocardial samples (interventricular septum, right and left atrium and ventricle) of dogs with no cardiac abnormalities (controls), seven dogs with acquired and three with congenital cardiac diseases were investigated using quantitative rt-pcr. leptin blood levels were significantly higher in dogs with chf in comparison to dogs without diseases (p . ). there was an association with gender with higher myocardial leptin levels in female dogs with cardiac diseases (p . ). differences between cardiac regions were present (p o . ) and cardiac diseases resulted in an increase in atrial leptin levels in both sexes (p . ). interestingly, a significant reduction of myocardial leptin was present in dogs with congenital cardiac diseases (p . ), whereas acquired cardiac diseases resulted in an increase in leptin (p . ) in comparison to controls. these results suggest that the heart might be a target of leptin action in the dog and myocardial leptin production might play a role in regulating cardiac function in an auto-and paracrine manner. predicting risk of chf in asymptomatic dogs with mitral valve disease (mvd) is challenging. we examined ability of nt-probnp to identify asymptomatic dogs at high risk for chf. dogs with isachc- b (la:ao . ) were prospectively recruited; dogs with current or previous chf or diuretic therapy were excluded. physical examination, radiography, echocardiography, and nt-probnp were performed at - mo intervals for dogs (median follow-up d, range, - d). thirty-one patients reached a study endpoint of radiographic pulmonary edema; remained asymptomatic. parameters from the visit immediately previous to onset of chf (future-chf) or prior to the most recent visit without chf (remain-asympt) were analyzed. median nt-probnp of future-chf ( pmol/lpmol/l, iqr - ) was significantly different from remain-asympt ( pmol/l, - ; p . ). median time to chf of future-chf was d (iqr, . groups also differed in median la:ao (future-chf . [ . - . ]; remain-asympt . [ . - . ], p . ); vhs (future- ]; remain-asympt . [ . - . ], p . ); and lvidd:ao ]; remain-asympt . [ . - . ], p . ). roc analysis to predict if chf would occur prior to the next visit yielded auc . ( %ci, . - . ). sensitivity was . % or . % and specificity . % or . % for nt-probnp pmol/l or pmol/l, respectively. mean increase in nt-probnp between penultimate visit and two visits prior to endpoint: future-chf . pmol/l vs. remain-asympt . pmol/l. within mo, . %, . %, . %, and . % of dogs with nt-probnp o , , and pmol/l developed chf. nt-probnp and heart size helped assess risk of chf in asymptomatic mvd. increasing the assay's upper limit of detection would likely improve utility of nt-probnp. piiinp is a serum biomarker of collagen biosynthesis and is described as a marker of myocardial fibrosis in human patients. we hypothesised that piiinp concentrations would vary according to the degree of remodelling demonstrable in dogs with naturallyoccurring myxomatous mitral valve disease (mmvd). serum piiinp concentrations (mg/ml) were measured in dogs with mmvd and healthy controls using a validated commerciallyavailable radioimmunoassay. results are reported as (mean ae sd). non-normally distributed variables were logarithmically transformed. comparisons of continuous variables were made between groups using t-tests and one-way anovas with tukey's post-hoc comparisons. univariable analyses were used to evaluate associations between piiinp and clinical characteristics (age, breed [cavalier king charles spaniel (ckcs) yes/ no], sex, weight, heart rate [measured from ecg], treatment with acei [yes/ no], treatment with diuretics [yes/ no] and echocardiographic measurements [la/ao, lvedd/ lvfwd, lveddn, lvesdn]). multivariable analysis was initially performed with all dogs included and then repeated excluding all dogs receiving therapy. dogs with mmvd were divided into those with no cardiomegaly (nc) (la/ao o . and lveddn o . ), those with cardiomegaly (la/ao ! . and/ or lveddn ! . ) but no clinical signs (c) and those dogs with cardiomegaly requiring treatment for congestive heart failure (chf). one hundred and fifty-four dogs with mmvd and control dogs were studied. there was no difference in age (p . ) or weight (p . ) between the mmvd and control groups. there was a significant difference in serum piiinp (p . ) between normal ( . ae . ), nc ( . ae . ), c ( . ae . ) and chf ( . ae . ) groups. post-hoc comparisons demonstrated a difference between nc and chf groups (p . ). there was no difference in serum piiinp between genders (p . ). in the univariable analysis ckcs (yes/ no) (p . ) was positively associated with serum piiinp. age (p o . ), log (la/ao) (p . ) and lveddn (p . ) were negatively associated with serum piiinp. in the multivariable model including all dogs, lveddn (p o . , b À . ( %ci À . to À . )), age (p . , b À . ( %ci À . to À . )) and ckcs (yes/ no) (p . , b . ( %ci . to . )) were independently associated with serum piiinp. in the multivariable model including only dogs not receiving therapy (n ), lveddn (p . , b À . ( %ci À . to À . )), age (p . , b À . ( %ci À . to À . )) and ckcs (yes/ no) (p . , b . ( %ci . to . )) were independently associated with serum piiinp. in conclusion, serum piiinp decreases with age and with increasing lveddn. ckcs have higher serum piiinp measurements independent of age and lveddn, which may reflect a difference in collagen turnover in this breed. left atrial (la) chamber dilation and congestive heart failure (chf) are common consequences of cardiac conditions in cats. in some cases chf is manifest as right-sided chf (r-chf) or pleural effusion, in other cases chf manifests as left-sided chf (l-chf) or pulmonary edema. it is not always readily apparent as to which cats will develop what form of chf. a general impression has been that la enlargement is associated with the average burden of elevated filling pressures, but little attention has been paid to the function of the la chamber itself. since chf is classically preceded by abnormal atrial chamber dilation and alterations in atrial chamber function, we want to understand how these changes may help us manage or predict chf in the cat. we hypothesized that cats manifesting r-chf have la failure with the la acting primarily as a conduit, resulting in greater pulmonary hypertension, whereas l-chf cats maintain some booster pump and reservoir function. we measured la maximum and minimum areas from right parasternal long axis four-chamber views on d echo, and la m-mode dimensions at maximum, minimum, and beginning of atrial contraction. la area change, fractional shortening, active emptying fraction, and expansion index were calculated from these measurements. right ventricular internal diastolic diameter was also measured on m-mode views. preliminary data revealed that maximum left atrial size is not significantly different between r-chf and l-chf cats on d or m-mode measurements due to high variability. however, total left atrial fractional shortening is significantly reduced in r-chf cats ( . % ae . ) compared to l-chf cats ( . % ae . )(p . ), and r-chf cats have reduced left atrial active emptying fraction ( . % ae . ) as compared to l-chf cats ( . % ae )(p o . ). left atrial expansion ability is poorer in r-chf cats ( . % ae . ) than in l-chf cats ( . % ae )(p . ). these findings may suggest that atrial stiffness and poorer atrial function is associated with a greater degree of pulmonary venous and thus secondary pulmonary arterial hypertension resulting in pleural effusion (r-chf). right ventricular diameter on m-mode was increased in r-chf cats ( . mm ae . ) when compared to l-chf cats ( . mm ae . )(p . ) and normal cats ( . mm ae . )(p . ), which may also be evidence for a greater degree of pulmonary arterial hypertension in these cats. episodic weakness and syncope are common in boxer dogs. reported causes include rapid ventricular tachycardia (vt) and exertion-excitement triggered neurally-mediated bradycardia (nmb) .the purpose of this retrospective study is to describe the features of presumed nmb in boxers. to be included in the study, each dog must have been overtly healthy with a history of exertion-excitement triggered syncope or presyncope; had a normal echocardiogram (ec); had absence of vt and fewer than ventricular premature complexes (vpc) on an initial and subsequent hour holter recordings; and been alive and overtly healthy for at least six months following the initial evaluation. a total of boxers were identified. sixteen were male and were female. most ( %) dogs were either less than or more than years of age. most dogs had multiple, but infrequent, episodes and heart rhythm was documented at the time of an episode in only ( %) and only once (bradycardia) on the first holter recording. owners were instructed to attempt to precipitate episodes. bradycardia related episodes were subsequently recorded in : during the nd ( ), rd ( ) or th ( ) day of hour holter recordings and during the th day of an event recording ( ). collapse and bradycardia were documented during auscultation in additional dogs. the heart rate during syncope was never documented in ( %) dogs. a presumptive diagnosis of nmb was based on the absence of initial and follow-up of ec abnormalities and the presence of no or few vpc during extended ecg monitoring. multiple holter recordings ( - hours) were performed in of ( %) dogs and event monitoring of days ( ) and days ( ) was performed in additional dogs. in conclusion, documentation of the heart rhythm during episodes of collapse was difficult, accomplished in only % and was unlikely during the first holter recording. in boxers with suspected nmb, extended ecg monitoring and implantable loop recorders may be best for hr documentation. arrhythmogenic right ventricular cardiomyopathy (arvc) is an inherited myocardial disease with high prevalence in the boxer dog population, and is associated with sustained monomorphic ventricular tachycardia, sudden cardiac death, and replacement of myocardium with fatty or fibro-fatty tissue. though several genes have been linked to the disease both in humans and in boxers, the etiology of arvc is still unclear. several mechanisms for the development of arvc have been suggested, including dysfunction of the canonical wnt pathway, which results in an arvc phenotype in the mouse. the canonical wnt pathway has been linked to many cellular functions, including growth and differentiation of adipocytes. with the recent discovery that the gene encoding striatin, a protein involved in wnt signaling, may be involved in the development of boxer arvc, we hypothesized that changes in the wnt pathway may also play a role in the etiology. here, we show changes in the localization and decreased amount of proteins affiliated with the canonical wnt pathway. afflicted boxers were identified by -hour holter monitoring and histopathological examination of the heart. samples from the right ventricle rv) of arvc afflicted boxers, and unafflicted dogs ( beagle, mongrels, and german shepherds) were collected, fixed in % formalin, processed, treated with antibodies recognizingcatenin, striatin, and calnexin, and examined using confocal microscopy. western blots were performed on unafflicted rv samples, and arvc afflicted rv samples. frozen tissue samples were homogenized in laemmli buffer, and mg of protein was loaded into each well of a - % gradient gel. -catenin, an integral modulator of the wnt pathway, and striatin were colocalized with the endoplasmic reticulum (er) marker, calnexin. in the unafflicted animals, -catenin localized at sites of cell-to-cell apposition, and striatin localized in a diffuse intracellular pattern, with no detectable localization in the er. in contrast, in the arvc boxers, bothcatenin and striatin were colocalized with calnexin in an er pattern. in the afflicted samples, -catenin and striatin were not visualized to the intercalated disc and intracellular space, respectively. western blots of striatin and -catenin revealed no changes in the amount of protein. interestingly, a western blot for the wnt protein revealed a decrease in the amount of protein in arvc samples, compared to unafflicted samples. our preliminary data suggest that disturbances of the canonical wnt pathway may play an etiological role in the development of arvc in the boxer dog. there are numerous benefits of omega- fatty acid supplementation in human heart disease, including reduction in arrhythmias, decreased incidence of sudden death, and improved survival in heart failure. antithrombotic effects of omega- fatty acids have been demonstrated in people, which may have particular benefit in cats given their risk of thromboembolic complications with cardiac disease. benefits also have been found in canine heart disease, and reduced serum concentrations of the omega- fatty acids, eicosapentaenoic acid (epa) and docosahexaenoic acid (dha) have been found in dogs with congestive heart failure (chf) secondary to dcm. to the authors' knowledge, no studies to date have investigated fatty acid concentrations in cats with cardiomyopathy. the purpose of this study was to measure serum fatty acid concentrations in normal cats and cats with cardiomyopathy. serum fatty acid concentrations were measured in normal cats and cats with cardiomyopathy using gas chromatography. cats with cardiomyopathy and at least mild left atrial (la) enlargement (la to aortic ratio . on two-dimensional echocardiography from a right parasternal short axis view) were candidates for study. normal cats had a normal history, physical examination, echocardiogram, packed cell volume, total solids and platelet count. cats with evidence of other systemic disease or those receiving anticoagulants were excluded from the study. normally distributed and skewed data were compared between the cardiomyopathy and control groups with independent t tests or mann whitney u tests, respectively. statistical significance was set at p o . . thirty cats with cardiomyopathy ( neutered males and neutered females) and healthy controls ( neutered males and neutered females) were enrolled. median age was yr (range, - yr) in the cardiomyopathy group and yr (range, - yr) in the control group (p . ). cats in the cardiomyopathy group were classified in the international small animal cardiac health council stage b (n ), (n ), a (n ) and b (n ). compared to control cats, cardiomyopathic cats had higher concentrations of palmitic acid (p . ) and dha (p o . ), and lower concentrations of linoleic acid (p . ). among cats with cardiomyopathy, there was no significant correlation between any serum fatty acid concentration and left atrial size or age. these findings warrant further investigation into the role of fatty acids in cats with cardiac disease. platelet mapping is an application of thromboelastography that relies on the generation of at least three tracings: ma thrombin (maximum platelet activity),ma fibrin (fibrin activity only), an-dma aa or adp (platelet activity not inhibited by arachidonic acid or adp receptor antagonists, respectively). using these three tracings, the % inhibition of platelets can be calculated. the purpose of this study was to evaluate the platelet mapping assay in normal cats and assess platelet inhibition in cats receiving clopidogrel. employee-owned cats with normal history, physical exam, echocardiogram, thromboelastography, packed cell volume, total solids and platelet count were eligible. clopidogrel ( . mg po q h) was administered for days with platelet mapping performed on days and . platelet mapping values were compared using a paired t test, with significance set at p o . . seven cats ( fs, cm, aged - years) were enrolled. compared to day , ma adp (p o . ) and ma fibrin (p o . ) were lower on day . the latter unexpected result prompted measurement of fibrinogen concentrations at day and in the last of these cats. fibrinogen was not different from day to in these cats. these results suggest that platelet mapping may be a simple, outpatient clinical tool to measure antiplatelet activity in cats receiving clopidogrel. this clopidogrel dose resulted in significant platelet inhibition as measured by ma adp in all cats. further studies correlating antiplatelet effects measured by platelet mapping with clinical outcomes in cats with cardiomyopathy are warranted. this study investigated the hemodynamic effects of application of an itd in a canine model of cardiopulmonary arrest. laboratory beagles which were part of a separate terminal study were anesthetized and instrumented for continuous measurement and recording of right atrial pressure, arterial pressure and carotid blood flow. following euthanasia, cpr was performed for one minute, then a pause of one minute followed by a second one minute period at a compression rate of - /minute, ventilation with % oxygen was delivered at eight breaths/min and ml/kg tidal volume. cpr was performed with the itd in place (itd-cpr) and without the itd (s-cpr) for one period each in a randomized fashion with the rescuer blinded to its application. baseline, s-cpr and itd-cpr data were assessed for normality, a kruskal-wallis one-way anova on ranks was used (baseline v cpr). when appropriate a pairwise multiple comparison procedure (dunn's method) was used. percentage of baseline s-cpr v itd-cpr was assessed using the student t-test. the right atrial diastolic pressure was significantly more negative with the itd attached than without (p . ), the coronary perfusion pressure and carotid blood flow were significantly higher during cpr with the itd than standard cpr (p . , p . ). no significant differences in diastolic, mean or systolic arterial pressure or end tidal co were seen. application of the itd resulted in significantly improved hemodynamics during cpr in dogs. clinical evaluation of the device is warranted to examine whether this translates into improved success in resuscitation and survival. left ventricular (lv) systolic dysfunction is a common problem in dogs and can be due to a variety of etiologies. one potential etiology for systolic dysfunction is persistent or paroxysmal tachyarrhythmias, leading to tachycardia-induced cardiomyopathy (ticm). in humans, ticm carries a relatively good prognosis in that remodeling may be reversible with normalization of heart rate. differentiating between primary and secondary tachyarrhythmias in dogs with systolic dysfunction is critical for prognostic purposes as primary tachyarrhythmias may be associated with a better outcome. the goal of our study was to describe a population of dogs with ticm and to determine if treatment of arrhythmias was associated with reversible cardiac remodeling as indicated by standard echocardiographic parameters. medical records of dogs referred to the cardiology service of ksu vmth from to were reviewed. ticm was defined as the presence of severe tachyarrhythmias that were reversible with treatment, systolic dysfunction or ventricular enlargement that improved with treatment of the arrhythmia, or dogs with severe tachyarrhythmias and systolic dysfunction of breeds with that are atypical for idiopathic dilated cardiomyopathy. exclusion criteria were dogs with congenital heart disease, severe mitral regurgitation, and endocarditis. transthoracic echocardiography, thoracic radiographs and electrocardiography (ecg) were performed in all dogs. ventricular enlargement and systolic dysfunction were defined according to standard echocardiographic parameters. arrhythmias were confirmed with a holter monitor in dogs. a total of dogs were included in the study. mean age was years (range - years) with males ( intact, castrated) and females ( spayed, intact). four dogs had pulmonary venous congestion or pulmonary edema and two dogs had ascites. at initial presentation, the meanaesd values were as follows: heart rate ae bpm, m-mode fractional shortening (fs) . ae . %, ejection fraction (ef) using the area-length method . ae . %, and left atrial to aortic root ratio (la/ao) . ae . . initial meanaesd m-mode derived lv internal dimensions corrected for body weight were as follows: diastolic . ae . and systolic . ae . . at least one of the following tachyarrhythmias were identified in each dog: atrial fibrillation ( ), supraventricular tachycardia ( ), junctional tachycardia ( ), and ventricular arrhythmias ( ). ten dogs were available for follow up. seven dogs improved in at least one of the following parameters: resolution of tachyarrhythmia ( ), improved systolic function ( ) antidiuretic hormone (adh) has been shown to be elevated in humans with congestive heart failure (chf). recently, antidiuretic hormone antagonists were successful during investigational treatment of refractory congestive heart failure in humans. adh levels have been only modestly investigated in dogs with cardiac disease, primarily due to the technical difficulty in measuring adh levels via radioimmunoassay. based on the homologous structure of canine and human adh, we aimed first to determine the feasibility of measuring adh in dog plasma using a human elisa kit, and secondly to investigate the level of adh in dogs with congestive heart failure due to acquired cardiac disease. elisa assay kit validation was performed using six healthy dogs with normal clinical and echocardiographic examinations. pooled canine plasma was spiked with synthetic adh and intra-assay precision, dilutional parallelism, and linearity were assessed. to address the second aim of the study, samples were collected from normal dogs and dogs with heart failure due to one of two types of acquired cardiac disease: chronic degenerative valve disease (cdvd) or dilated cardiomyopathy (dcm). patients underwent clinical, radiographic, and echocardiographic examination to confirm diagnosis, assess severity of disease, and determine presence of pulmonary edema. whole blood was collected into edta tubes containing protease inhibitors, cold centrifuged, and plasma was stored at À until analysis. following ether extraction, plasma adh in each sample was measured in duplicate using a human elisa kit. statistical analysis included a d-agostino and pearson test for normality; group results were compared using a nonparametric mann-whitney test. adh was measured in canine plasma using the human elisa kit with acceptable intra-assay precision, linearity, and dilutional parallelism. intra-assay coefficient of variation was %. twenty-four dogs were recruited for the second phase of the study. six normal dogs and twelve dogs with radiographic evidence of pulmonary edema due to either cdvd or dcm were selected for participation. the remaining six dogs were excluded due to lack of definitive radiographic evidence of congestive heart failure. median adh values were . ae . pg/ml for the normal group (n ) and . ae . pg/ml for the heart failure group (n ). median adh values for the two groups were statistically different (p . ). our preliminary results indicate that measuring canine adh using a human elisa kit is feasible and provides results with an acceptable coefficient of variation. we also showed that dogs with congestive heart failure due to cdvd and dcm have elevated adh levels in comparison to normal dogs. our findings motivate further investigation to assess the degree of plasma adh level elevation and the possible use of adh antagonists as an adjunct treatment for refractory congestive heart failure in dogs. aortic thromboembolism (ate) occurs in both cats and dogs. whereas ate in cats is strongly associated with structural heart disease and typically has an acute catastrophic presentation; the pathogenesis and presentation of ate in dogs is less well known or understood. further, an effective antithrombotic strategy for ate in dogs has not been reported. medical records of dogs diagnosed with ate between and were examined retrospectively. diagnosis of ate was based on ultrasonography, doppler flow studies, and diminished or absent femoral pulses. dogs were treated with various acute and chronic antithrombotic therapies. the severity of ambulatory dysfunction was graded as none, mild, moderate, severe, or non-ambulatory at presentation and after therapy. a cohort of dogs in this study received a standardized protocol of chronic warfarin therapy with or without antiplatelet drugs. target international normalized ratio for warfarin therapy was to . twenty-six dogs were diagnosed with ate. all had an apparent mural aortic thrombus caudal to the renal arteries with most having evidence of embolization to the iliac and femoral arteries. none had structural heart disease at diagnosis. twenty dogs ( %) were still ambulatory at diagnosis. the median duration of ambulatory dysfunction prior to presentation was . weeks (range day - weeks). a majority of dogs ( %) had no concurrent conditions at diagnosis. nine dogs ( %) had protein-losing nephropathy. four dogs ( %) were hypothyroid. fourteen dogs were treated with a standard warfarin protocol for a median period of . months (range . - months). eight dogs were treated concurrently with aspirin, dogs were treated concurrently with clopidogrel, and dogs were treated with warfarin only. ambulatory function improved between and grades in dogs treated with chronic warfarin. the median period until clinical improvement was . days (range - days). two dogs treated with chronic warfarin therapy had documented resolution of ate, and dogs had complete resolution of ambulatory dysfunction. none of the dogs treated with chronic warfarin became nonambulatory, died, or underwent euthanasia because of ate. the median period of freedom from an adverse event was . months. no serious hemorrhagic events were reported. four dogs were treated with tpa. three of these had an unfavorable outcome. two dogs were ambulatory before tpa and become non-ambulatory after treatment. two dogs underwent surgical thrombectomy. one had a favorable outcome until ate recurred months after surgery. in conclusion, the pathogenesis of ate in dogs is not associated with structural heart disease or left atrial thrombus formation. the presentation tends to be for chronic ambulatory dysfunction. most dogs are still ambulatory at presentation. warfarin, with or without concurrent antiplatelet therapy, is an effective antithrombotic treatment strategy for dogs with ate. information is known. through previous work, investigators have encountered norfolk terriers (nt) with echocardiographically apparent dmvd in the absence of a heart murmur. in order to more fully understand dmvd in this breed of dog, we sought to characterize findings from the physical and echocardiographic exam, biochemical, biomarker, and nutritional profile, and select environmental variables from a cohort of apparently healthy nt. overtly healthy nt ! yrs old were recruited by different veterinary hospitals and underwent historical, physical, ecg, and d/color-flow doppler echocardiographic exam. anterior mitral valve length, maximal thickness, area, and prolapse were measured from d images. presence of dmvd was defined as thickened, prolapsing, or flail mitral valve leaflets in the presence of color flow doppler evidence of mitral regurgitation. blood samples were obtained for serum biochemistry and serotonin, plasma nt-probnp, amino acid profile, c-reactive protein, and cardiac troponin-i. forty-eight dogs were entered into the study (median age, yrs iqr [ - ]; gender, f, m; median bcs, ). of the dogs, ( %) had murmurs, ( %) had mid-systolic clicks, ( %) had ecg p-pulmonale, and ( %) were deemed to have echocardiographic evidence of dmvd, including nt without a murmur. seven ( %), ( %), and ( %) dogs were classified as isachc , a, and b, respectively. mean indexed echocardiographic mitral leaflet length (p o . ), thickness (p . ), prolapse (p . ), and la:aod (p . ) were significantly different between isachc a/b vs . between isachc a/ b and , there were no differences in serum amino acids, c-reactive protein, troponin, diet, or environmental factors; however different amino acids (ala, gly, phe, pro, trp, tyr) were significantly higher in isachc b vs. a. median serum serotonin was increased in dogs with a/b vs. (p . ). dogs whose diets contained some canned food (p . ) and dogs residing in suburban environments (p . ) had higher serotonin concentrations. nt-probnp tended (p . ) to be higher in isachc a/ b vs. . dmvd appears to be relatively common in nt and echocardiographic changes consistent with mild dmvd can be seen in dogs without a heart murmur. the results of this study establish a foundation of useful information upon which additional prospective studies can be developed. left ventricle (lv) evaluation is one of the most important contributions of echocardiography in the assessment of cardiac function. however, lv analysis can be made from images obtained by different modes and views of the heart. the aim of this study was to compare lv measurements, shortening fraction (sf) and ejection fraction (ef) obtained from four methods: m mode in short-axis and in long-axis, bidimensional mode in short-axis and in long-axis views of the heart. forty normal adult german shepherds were selected. echocardiographic study of lv of each animal was performed by the four methods described above. ancova test was used to examine the effects of axis, mode, weight and gender over lv measurements. isolated effect of the axis was observed for lv end-diastolic diameter (lvedd), with greater values obtained from short-axis views. there was isolated effect of mode over ef and sf, with greater measurements derived from bidimensional mode methods. weight correlated with all linear lv measures at least in one method, but not with ef and sf. weight had positive effect over lv endsystolic diameter and lv end-diastole posterior wall thickness in all methods, except from m mode in short axis in the last one. gender had isolated effect over lvedd, males showing greater values than females in bidimensional mode in short and long axis. the combined effect of axis, gender and weight was identified in interventricular septal end-diastolic thickness. we concluded that normal reference values obtained by different echocardiographic modes and planes should not be used interchangeably. abstract c- assessment of left ventricular diastolic func-tion by color tissue doppler imaging echo-cardiography in maine coon cats tested for mypbc-ap mutation hypertrophic cardiomyopathy (hcm), characterized by increased cardiac mass and diastolic dysfunction, is the most common feline heart disease. myocardial analysis by color tissue doppler imaging (tdi) is more sensitive than conventional echocardiography. this study evaluated diastolic dysfunction in various stages of feline hcm. maine coon cats (n ) were screened for the mybpc-a p mutation and examined with both echocardiography and tdi. then, were phenotypically classified in: normal (n ), suspects for hcm (n ) and hcm group (n ); and genotypically classified in: negative (n ), heterozygous (n ) and homozygous group (n ). myocardial velocities, measured in the basal and mild ventricular segment of the interventricular septal wall (ivs), left ventricular free wall (lvw) and in radial segment of left ventricular wall, was compared among different groups. a significant decreased (p , ) longitudinal em/am at the basal segment of ivs was observed in hcm cats compared with suspects and normal cats. a significant increased (p , ) longitudinal e/em at the basal segment of ivs was observed in hcm cats compared with suspects and normal cats. and a significant decreased (p , ) longitudinal sm at the basal segment of the lvw was observed in heterozygous cats compared with negative cats, both without hypertrophy. there was a significant positive correlation between summated early and late diastolic velocities (emam) and heart rate (p o , ); and a positive correlation between sm and em velocities and heart rate (p o , ). the mybpc-a p mutation is not consistently associated with ventricular hypertrophy and negatives cats can also develop hcm. the tdi alone is not able to identify cats with mutation before myocardial hypertrophy. diastolic dysfunction occurs in many cats with hypertrophic cardiomyopathy (hcm) but less is known about systolic function in various stages of hcm. myocardial strain analysis by tissue doppler imaging is a noninvasive echocardiographic method to assess systolic function. this study evaluated systolic function in various stages of feline hcm. maine coon cats (n ) were screened for the mybpc-a p mutation an examined with both echocardiography and strain. then, were phenotypically classified in: normal (n ), suspects for hcm (n ) and hcm group (n ); and genotypically classified in: negative (n ), heterozygous (n ) and homozygous group (n ). peak myocardial strain, measured in the basal and mildventricular segment of the interventricular septal wall (ivs), left ventricular free wall (lvw), left ventricular anterior wall (lvaw), left ventricular posterior wall (lvpw) and radial segment of left ventricular wall, was compared among different groups. whereas conventional echocardiography demonstrated an apparently normal contractile state based on fractional shortening, myocardial strain (at mildventricular segment of ivs) in hcm cats was significantly decreased compared with normal group (p , ). myocardial strain (at basal segment of lvaw) also was significantly decreased in heterozygous cats compared with negative group (p , ); and was significantly decreased in heterozygous cats compared with negative group, both without ventricular hypertrophy (p , ). there was a significant negative correlation between strain values and wall thickness (p o , ). this method allows detection of abnormal systolic deformation in maine coons cats with hcm mutation despite apparently normal systolic function. the abnormal systolic deformation already can be present in heterozygous cats without hypertrophy and increased with progressive ventricular hypertrophy. recently, multiple advanced resting electrocardiographic (ecg) techniques have been applied in humans for detection of cardiac autonomic and repolarisation function. this has improved the diagnostic and/or prognostic value of short-time ecg in detection of common human cardiac diseases even before onset of symptoms or changes in the standard ecg. therefore, this study investigates, if advanced ecg can predict the severity of mitral regurgitation (mr) in dogs with myxomatous mitral valve disease (mmvd) and thereby improve the diagnostic value of ecg. the study included privately owned cavalier king charles spaniels (ckcss) (age . ae . years; males and females). all dogs were examined by echocardiography and a short-time ( - min) high-fidelity -lead ecg, with the dog in a resting position and in sinus rhythm. dogs were divided into groups according to the degree of mr estimated as the percentage of the left atrium area using color doppler mapping ( %; % o jet %; % o jet %; jet %; jet % and with clinical signs of congestive heart failure). ecg recordings were evaluated via custom software programs to calculate different parameters, including heart rate variability (hrv), qt variability (qtv), t-wave complexity, wave morphology and -d ecg. one-way anova determined ecg parameters, which were significantly different (p o . ) between the dog groups. principal component factor analysis identified a factor model with . % explained variability. qrs dipolar voltage and two repolarization indices of qtv increased significantly with mr severity, whereas total power of the frequency spectrum of rr interval and the standard deviation of qtv decreased significantly with mr severity. for the selected parameters the prediction of mr jet value was tested by multiple linear regression. a correlation coefficient (r) of . indicated that the prediction value was significant (p o . ). if age was included in the multiple linear regression the prediction value was further increased (r . ). our results indicate that for a cut-off criteria of mr ! % jet the five selected ecg parameters could predict the severity of mr caused by mmvd in ckcss with sinus rhythm with sensitivity % ( % with age inclusion) and specificity % ( % with age inclusion) (p o . ). nt-probnp concentration is increased in canine patients with heart disease. relatively little is known about the stimuli for release of nt-probnp in dogs. physical activity independent of cardiac disease and the stress of being in the hospital could influence nt-probnp release and affect diagnosis and management of patients. we hypothesized that nt-probnp concentration in healthy dogs would not exceed the normal reference value ( pmol/l) following a period of exercise. the goal of this study was to examine whether physical activity could elevate plasma nt-probnp and cause false positive results in healthy dogs. the study population included healthy dogs yr of age without heart murmur or known systemic disease, and normal d/color flow echocardiographic exam. plasma samples for nt-probnp were obtained before, immediately after, and hour after a standardized -minute submaximal exercise regimen. the study included dogs with a median age of . yrs and included females and males. there was no statistical difference in median plasma nt-probnp concentration across the three time points (baseline median, [iqr, immediately post, ; p . ). the average coefficient of variation of nt-probnp concentration across the exercise regimen was . ae . %. in of dogs ( . %), nt-probnp increased from to pmol/l immediately after exercise. the results of this study demonstrate that submaximal exercise does not significantly change median nt-probnp concentration and the incidence of false positive results is low. further studies should investigate effects of exercise on nt-probnp concentrations in dogs with heart disease. obesity is an increasing problem in veterinary medicine. obese human patients are shown to present lower levels of natriuretic peptides, regardless of an increased volume and pressure load, what raises the possibility that the natriuretic response is impaired in these individuals. considering the controversial findings in obese humans, and the lack of studies reported in dogs, this study proposed the evaluation of nt-proanp concentration in obese dogs. nt-proanp concentration was determined prospectively in obese dogs ( females; males; - months) and in non-obese dogs (controls; females; males; - months) from a veterinary hospital population. obesity was determined by body condition score [ ( / ); ( / ); ( / ); ( / ); ( / ); ( / )]. dogs were excluded if they had any primary cardiac disease, renal insufficiency, endocrine disease, or if they were receiving diuretics, vasodilators, antiepileptic drugs or corticosteroids. commercial kits were used (vetsign s canine cardio screen nt-pro-anp vc -guildhay/biomedica). mann whitney test was used for group comparison. results are presented as median; interval; p and p ). nt-proanp was significantly lower in obese dogs [ . fmol/ml ( . - . ); p . ; p . ] than in controls [ . fmol/ml ( . - . ); p . ; p . ]; (p . ). results were similar to what has been found in obese humans. lower levels of natriuretic peptides are also seen in obese heart failure patients. this study provides important information regarding nt-proanp concentration in obese dogs, which should be better explored characterizing the behavior of natriuretic peptides after weight loss, and also in obese dogs with primary heart disease. left-to-right shunting patent ductus arteriosus (pda) is one of the most common canine congenital cardiovascular defects. human studies have shown that bnp and nt-probnp concentrations are elevated in patients with pda, and can be used to detect hemodynamically significant pda. the purpose of this study was to measure nt-probnp concentrations in dogs with pda, and to assess whether additional indicators of hemodynamics correlate with ntprobnp. we hypothesized that nt-probnp will serve as a simple non-invasive marker of hemodynamic significance in dogs with pda prior to and following transcatheter ductal occlusion. nt-probnp was measured in client-owned dogs with echocardiographically normal hearts. ten dogs with pda were initially evaluated with thoracic radiographs, transthoracic and transesophageal echocardiography, pulmonary capillary wedge pressure (pcwp) and nt-probnp. nt-probnp and echocardiography were repeated at day and months following ductal occlusion. pcwp was repeated at months. baseline nt-probnp was significantly higher in pda dogs compared to control ( ae pmol/l (mean ae sd), ae ; p o . ). at day and months following ductal occlusion, nt-probnp was ae and ae , respectively. the following decreased significantly from baseline: pcwp ( . ae . to . ae . mmhg; p . ), and indexed left ventricular internal dimensions in diastole ( . ae . to . ae . ; p . ) but not significantly in systole ( . ae . to . ae . ; p . ). nt-probnp is elevated in dogs with pda and transductal closure is associated with a reduction in nt-probnp, pcwp and left ventricular size. cardiac biomarkers, particularly nt-probnp, are becoming more commonly used in dogs and cats as part of a diagnostic work up. multiple studies already have documented the correlation of this peptide with cardiac disease status and potential clinical implications. in a portion of these reports the manner in which samples were handled was placement of whole blood into an edta tube, followed by centrifugation and decanting of the supernatant that was ultimately stored at À c or À c prior to shipment, either with or without protease inhibition. our objective was to compare the nt-probnp concentrations in feline plasma collected using the previously reported methods to the california animal hospital (cah) collection method using tubes containing a protease inhibitor. this study compared nt-probnp concentrations using the protease inhibitor tubes vs. edta tubes from privately owned feline patients, with confirmed cardiac disease, and control feline patients. for all study participants, we performed a full history and physical examination, a hematology and chemistry panel, thoracic radiographs, ecg, and echocardiogram. in each study participant, at least ml's of whole blood was drawn from a peripheral vein, and transferred to a plastic edta tube. the sample was centrifuged within hour after collection. ml of plasma was then transferred to a tube containing a protease inhibitor, which was stored at c until being shipped within hours of collection. the remaining plasma was placed into separate microtubes, which did not contain a protease inhibitor. one microtube was then stored and shipped as previous studies have reported (À c, styrofoam container, shipment within hours), and the second microtube was frozen at À c. all samples were shipped, received and analyzed within hours of collection. results of this study showed that no difference was found between the frozen sample methods ( pmol/l and pmol/l p . ). it was determined that both frozen methods had lower nt-probnp levels ( and pmol/l) when compared to plasma samples shipped in protease inhibitor tubes ( and pmol/l). the findings of this trial demonstrate that the nt-probnp levels are significantly different between samples placed in edta tubes vs. contain protease inhibitor (p . and p . ). utilizing protease inhibitor tubes allows more accurate measurement of plasma nt-probnp. as for its relevance for future research and publications, authors should take care to investigate the manner in which blood samples were handled and the conclusion/results of these studies should be taken in light of the methodologies used in collecting, storing, shipping and analyzing the samples. degenerative mitral valve disease (dmvd) is one of the most common heart disease and is present approximately % of the canine heart disease. although the high prevalence exists in small dogs, the underlying molecular mechanism of its pathophysiology is rarely known. dmvd is functionally and pathologically similar in humans and dogs, thus, there will be a common pathogenesis in human and dogs with naturally occurring dmvd. serotonin and serotonin-related mechanisms have been implicated as a cause of valvular disease in human and animals, including spontaneous dmvd in dogs. increased circulating ht concentration as a potential source of heightened ht signaling is demonstrated in small dogs with dmvd. the aim of this study was to investigate whether serum ht concentrations were associated with severity of naturally occurring dmvd in small dogs and to investigate potential associations of dog characteristics on serum ht concentrations in our study population. forty-eight dogs were included in this study and were classified into control and dmvd groups according to the results of physical and echocardiographic examinations. based on the la:ao ratio, dogs with dmvd were classified as follow: control (la:ao ratio . and no mr), mild (la:ao ratio . and mr), moderate ( . o la:ao ratio . and mr), severe (la:ao ratio . and mr). serum serotonin concentrations were measured by elisa. an overall significant difference (p o . ) was found among groups and ht concentrations (control, . ng/ml [ . - . dmvd, ). significantly higher ht concentrations were observed in dogs with moderate (p o . ) and severe (p o . ) dmvd, compared with concentration in control group. additionally, ht concentration in dogs with moderate dmvd were significantly higher (p o . ) than concentration in dogs with mild dmvd. also, dogs with severe dmvd had significantly higher ht concentration than dogs with mild (p o . ) and moderate (p o . ) dmvd. there was no significant association of age, platelet, and lvidd, on serum ht concentration, however, weak correlation between serum ht increased significantly and la:ao ratio (r . , p o . ) was observed. the results of this study indicate that serum ht concentrations were higher with increasing severity of spontaneous dmvd, which may be the potential cause to advance the progression of dmvd. further studies should be performed to reveal the role of ht in inducing and accelerating spontaneous dmvd and to investigate if lowering serum ht concentration could alter the progression of dmvd. the objective of this prospective study was to evaluate the utility of cardiac troponin i (ctni) in differentiating between underlying etiologies of pericardial effusion in the canine patient. patients were prospectively recruited at time of diagnosis of novel pericardial effusion. serum samples were collected prior to pericardiocentesis. patients were evaluated by echocardiography and classified with the diagnosis of hemangiosarcoma (hsa), heart base tumor (hbt), or unknown etiology at the initial evaluation based on established characteristic echocardiographic findings. idiopathic pericardial effusion (ipe) was defined by histopathology, echonegative for a mass lesion with no recurrence of pericardial effusion months, or symptom free months from time of enrollment. patients were excluded from analysis if a diagnosis could not be established based on above criteria or concurrent moderate azotemia (creatinine . mg/dl) was present at time of sample collection. serum samples were frozen and analyzed in batches within days of collection by a ctni assay with a . ng/ml lower limit sensitivity. sixty-three patients were recruited over a one year period with patients excluded due to lack of diagnosis ( ) or azotemia ( ). median ctni levels of dogs with hsa (n ), hbt (n ), and ipe (n ) were . ng/dl (interquartile range (iqr) o . - . ), . ng/dl (iqr o . - . ), and o . ng/dl (iqr o . -o . ) respectively. concentrations of ctni differed significantly between dogs with hsa and hbt (p . ) and ipe (p . ). there was no difference between ctni concentrations between hbt and ipe dogs (p . ). receiver operating curve analysis to determine the optimal cutoff for differentiation of dogs affected with hsa and both hbt and ipe revealed a significant (p o . ) area under the curve ( . ). a cut-off point of ctni of . yielded a sensitivity of % ( % ci, - %) and specificity of % ( % ci, - %). utilizing a higher cut-off point of . yielded a lower sensitivity of % ( % ci, - %), but a higher specificity of % ( % ci, - %) which may have more clinical utility given the disparity in prognoses of the etiologies compared. in conclusion, this study supports the diagnostic utility of ctni concentrations to delineate between patients with hsa and other etiologies of pericardial effusion, but does not reliably differentiate between dogs with ipe and other neoplastic etiologies. the pathogenesis of degenerative mitral valve disease (dmvd) in dogs remains to be fully elucidated. the high sheer stress caused by mitral regurgitation damages the endothelial surface of the valve, and a previous study demonstrated increased transcription of intercellular adhesion molecule- (icam- ) and e-selectin in affected mitral leaflet tissue. we hypothesized that this may be responsible for platelet recruitment and adhesion, and initiation of a proliferative cascade, resulting in further myxomatous changes. the goal of this study was to compare plasma levels of icam- and e-selectin in healthy dogs and those with dmvd. the study population included dogs with echocardiographic evidence of dmvd and healthy control dogs year old with no heart murmur or known systemic diseases. dmvd dogs underwent d/color-flow doppler echocardiographic exam. blood samples were obtained for plasma icam- and e-selectin analysis using commercially available elisa kits. the study included dogs, of which had dmvd and were normal. the dmvd group had a median age of . yrs ) and included females and males. two ( %), ( %), ( %) and ( %) dogs were classified as isachc a, b, and a, respectively. of the control dogs, median age was . yrs [ - . ], with females and males. there was no statistical difference in plasma e-selectin between control dogs (median . [ . - . ]) and those with dmvd ( . [ . - . ]); p . . plasma icam- concentrations were higher in dmvd dogs ( . [ . - . ]) than controls (median . [ . - . ], but this difference did not reach statistical significance (p . ). linear regression analysis showed no significant correlation between icam- or e-selectin and serum serotonin level, nt-probnp or echocardiographic measures of dmvd severity (la:ao, lvidd:ao, lvids:ao). the results of this study demonstrate no significant difference in circulating adhesion molecules icam- and e-selectin in dogs with dmvd as compared with healthy controls. further studies investigating adhesion molecules within the mitral valve tissue itself are likely needed if icam- and e-selectin play a role in the pathophysiology of dmvd. the rate of glucose utilization in the heart is greater than in other tissues, and impaired glucose uptake may play a major role in the pathogenesis of heart failure (hf). glucose uptake across the sarcolemma is regulated by a family of membrane proteins called glucose transporters (gluts), which includes glut- , the major cardiac isoform, and glut- , a recently discovered isoform, the role of which is unknown in the heart. in addition, despite the wellknown regional differences in myocardial structure and function, potential regional patterns in glucose transport have not been investigated. thus, we hypothesized that glut- and - protein and gene expression would be chamber specific in healthy dogs and during chronic hf. using a canine model of tachypacing induced chronic hf, glut protein and messenger rna in both ventricles and atria were investigated by immunoblotting and real time pcr. in control dogs, glut- , but not glut- , protein expression were significantly higher in the atria compared to the ventricles, with the highest content in the right atrium (ra, p o . ). glut- and - mrna were homogeneously expressed in all the cardiac chambers. during chronic hf, glut - and - expression was highest in the left ventricle (lv, by . and . fold, respectively, p o . ), with a concomitant increase in glut- and - mrna (p o . ). glut - , but not glut- , was decreased in ra during chronic hf (p . ). our data suggest that glut- protein was differentially expressed across the cardiac chambers in the healthy heart. during chronic hf, lv was the primary site dependent on both glut and glut -mediated glucose transport, which was transcriptionally regulated. in addition, the paradoxical decrease in glut content in ra may induce perturbations in atrial energy production during chronic hf. some obese dogs are suspected to have cardiac disease because they have enlargement of the heart on thoracic radiograph. it has been reported in cats that the fat increases the cardiac silhouette, while echocardiograms revealed normal cardiac dimensions. the purpose of this study was to determine whether obesity overestimates cardiac dimension in radiographs compared to echocardiographic findings in dogs. twenty three obese dogs and controls were included based on a - body condition scoring (bcs). computerized radiography was obtained and vhs measurement was performed as previously described. echocardiographic measurements were interpreted based on reference values according to lean body weight regression equations. results for echo and vhs measurements were classified in scores as normal, mild, moderate or severe increase. student's t test was used for comparison of vhs between groups. mann-whitney rank sum test was used to assess echocardiographic scores between groups. spearman rank order correlation was used to assess relationships between any pairs of variables between echo and vhs scores, echo vs bcs and vhs vs bcs. groups were similar regarding age [obese ( ae ); control ( ae ); p . ], breeds and gender distribution. obese dogs had significantly higher vhs and echo scores compared with controls [vhs: ( . ae . ) vs ( . ae . ); p o . ; echo score: range ( - ) vs ( - ); p . ]. there were no relationships between any pair of variables analyzed. these results show that there are changes both in echo and radiographic appearance of the heart in obese dogs, but vhs overestimates cardiac silhouette compared to echo, probably related to pericardial fat accumulation. heart rate variability (hrv) is an indirect measurement of the autonomic modulation of heart rate (hr). reduced hrv measured from short-time electrocardiography is seen in dogs with heart failure (hf) secondary to myxomatous mitral valve disease (mmvd). however, hrv is suggested to increase with disease severity at early stages of mmvd. the aims of this study were ) to associate hr and hrv with severity of mmvd in cavalier king charles spaniels (ckcs) and ) to compare hr and hrv between ckcs and other dog breeds in a group of dogs in hf secondary to mmvd. one-hundred dogs were examined by echocardiography and hour electrocardiography. the dogs were divided into five groups: ) ckcs with no/minimal mitral regurgitation (mr) (mr jet % of the left atrial area using color doppler mapping) and no murmur, ) ckcs with mild mr ( % o jet %), ) ckcs with moderate/ severe mr (jet %) and no clinical signs of hf, ) ckcs in hf (hf defined as left atrium to aortic root ratio (la/ao) . , clinical signs of hf and furosemide responsiveness) and ) non-ckcs in hf. dogs in hf were allowed hf therapy. both hr and hrv were analyzed over a -hour period, while hrv were also analysed over a -hour nightly period. analyses of variance were performed with hr or hrv as response variables and the explanatory variables dog group and echocardiographic indices of mmvd were included separately. all p-values were bonferroni corrected. minimum-and mean hr were significantly higher in ckcs with moderate/severe mr and in hf compared to ckcs with no/ minimal and mild mr (all p o . ). seven out of hrv variables were significantly decreased in ckcs with moderate/ severe mr and in hf compared to ckcs with no/minimal and mild mr (all p o . ). another hrv variables showed the same groupwise differences (all p o . ), except that the difference between ckcs with mild mr and ckcs with moderate/severe mr did not reach statistical significance. mminimum hr, mean hr and the hrv variables ( and ) differing between dog groups, also consistently decreased with increasing mr, la/ao and the proximal isovelocity surface area in ckcs. non-ckcs in hf had a lower minimum hr compared to ckcs in hf (p . ) and a higher triangular index measured in both periods (all p o . ). in conclusion, hr increased and most hrv variables decreased with increasing severity of mmvd in ckcs, even prior to the development of hf. other breeds in hf secondary to mmvd had lower minimum hr, but higher triangular index compared to ckcs in hf. although the cells in the specialized conduction system in the heart are capable of initiating their own impulse, the rate in which those impulses are generated can be influenced by autonomic nervous system. different types of respiratory patterns can stimulate autonomic nervous system in different manners. thus, non-sedated rabbits were studied during forced respiration aiming to evaluate the influence of this breathing pattern on heart rate. twenty male, one-year-old healthy new zealand rabbits were enrolled in the study. animals were set in right lateral recumbency and maintained that way by physical contention. chemical sedation was not used. partial nasal obstruction by digital compression was applied to those rabbits for five seconds, eliciting a forced inhaling and exhaling against semi closed nostrils. heart rate was obtained by measurement of two consecutives rr intervals in the computerized electrocardiography, recorded continuously prior and during the maneuver. heart rate before the intervention was ae bpm (mean ae standard deviation). all rabbits submitted to the maneuver showed a dramatic reduction in this parameter. after nasal partial obstruction, heart rate was ae bpm. data was submitted to statistical analysis by paired student's t test and a significant difference between the heart rate before and after the maneuver was observed (p o . ). although the exactly mechanism involved in this response was not elucidated, the presented data support the applicability of this maneuver as an efficient method for non-pharmacological heart rate reduction in rabbits. obesity can affect cardiac function due to effects on cardiac rhythm, ventricular volume and blood pressure. the purpose of this study was to determine the effects of obesity and overweight on noninvasive systemic blood pressure and doppler echocardiographic parameters in cats without others causes of cardiac hypertrophy. the study groups comprised fifteen obese cats with mean body score index (bsi) of , , seven overweight cats (bsi , ) and seven cats with ideal bsi ( , ). the blood pressure was measured by doppler method and the doppler echocardiography was performed in conscious animals. the statistical analysis was performed by analysis of variance followed by tukey's test and pearson's correlation. the blood pressure values of the obese cats were superior ( , ae , mmhg, p o , ) than in overweight ( , ae , mmhg) and normal cats ( , ae , mmhg) and % of the obese cats had blood pressure higher than mmhg. there were observed differences on the ratio of early (e) and late (a) left ventricular filling velocity (p , ) of obese animals (e/a , ae , ) compared to overweight ( , ae , ) and normal cats ( , ae , ). seven obese cats ( %) had inversion of e/a compatible with diastolic dysfunction and there were negative correlation (r À , , p , ) between the e/a ratio and blood pressure values. other differences observed were increases in left ventricular septum in diastole (p , ) and in free wall in diastole (p , ) and systole (p , ) of the obese animals compared to overweight and normal cats. these results demonstrate the possibility of cardiovascular effects related to obesity in cats, such as systemic arterial hypertension and secondary diastolic dysfunction. diuretic therapy reduces preload, and relieves congestion secondary to cardiac dysfunction. torsemide (torasemide) is a loop diuretic with longer duration of action, less diuretic resistance, and adjunctive aldosterone antagonism as compared to furosemide. we hypothesized that torsemide was no less effective than furosemide at diuresis, control of clinical signs, and maintenance of quality of life in dogs with congestive heart failure. a double-blinded, randomized, crossover clinical trial was performed in dogs with stable heart failure receiving bid furosemide and adjunctive medications. dogs were randomized to their current furosemide dose or torsemide (calculated as / of the daily furosemide dose divided into bid dosing). crossover occurred at day and the study ended on day . clinical, laboratory, radiographic, and owner-perceived quality of life variables were evaluated on days , and . no dog developed recurrent heart failure during the study. average furosemide dose on day was . mg/kg/day (range, . - . ). following torsemide treatment, blood urea nitrogen (p . ), albumin (p . ), and albumin:globulin ratio (p . ) were significantly increased, and urine specific gravity (p . ) and chloride (p . ) were significantly decreased as compared to baseline and/or furosemide dosing (one-way anova with bonferroni correction). no differences in qol were found. results indicate that torsemide is equivalent to furosemide at controlling clinical heart failure in dogs, and might in fact, achieve greater diuresis vs. furosemide. larger clinical trials evaluating furosemide resistance and/or torsemide as a first-line loop diuretic for congestive heart failure in dogs with heart failure are warranted. the purpose of this study was to investigate the feasibility of speckle tracking echocardiography (ste) in healthy cats and to determine whether or not it can detect myocardial dysfunction in cats with diseased heart. radial and circumferential strain and strain rate were measured by ste using left ventricle short-axis view in clinically healthy cats. eighteen cats with hcm whose lv thickness at end-diastole with mm or more were evaluated with ste analysis, and compared with healthy cats. index of left ventricular synchrony (trs-sd) was also assessed in cats with hcm, and compared to healthy subjects. ste resulted in technically adequate images in % of the cats. fusions of early and late diastolic (e and a) wave in strain rate were seen in of cats. percent errors in analysis with or without simultaneous ecg monitoring were . - . % in all parameters. inter-and intraobserver variability of ste parameters in healthy cats was minimal ( . - . %) except for the systolic circumferential strain rate. sedation using buprenorphine and acepromazine did not affect any ste parameter. e wave in radial and circumferential strain rate of hcm cats was significantly decreased compared with healthy cats. no significant difference was seen in trs-sd. ste analysis was considered clinically feasible to assess cardiac function in cats, and could detect myocardial dysfunction in cats with hcm. further study is warranted to investigate to assess whether or not ste can differentiate the etiology of left ventricular concentric hypertrophy since it is clinically important. carvedilol, a rd generation non-selective beta-blocker with ancillary alpha -blocking and antioxidant properties may have therapeutic implications for multiple diseases in cats; however, pharmacokinetics and bioavailability of commercially prepared oral carvedilol has not been determined. hplc for carvedilol measurement in feline plasma was validated and standardization curves created. the pharmacokinetics (pk) of carvedilol was evaluated in apparently healthy male neutered adult cats (average weight of kg) following single dose intravenous (iv) of . mg/kg and single dose oral administration of . to . mg/kg. concentrations of the active parent compound, carvedilol, were detected in plasma using hplc analysis. lower limit of quantification was ng/ml. the mean peak concentration after iv administration of carvedilol was ng/ml (range, to ), elimination half-life was . hours (range, . to . ), and clearance was . l/hr/kg. the volume of distribution was . l/hr. after a single oral administration of carvedilol, the time to peak plasma concentration was minutes (range, to minutes) and the mean residual time was . hours. the half life was . hours. maximal concentration ng/ ml and the mean bioavailability was . % with a median of . % (range, . % to %). these data demonstrate a low bioavailability of oral carvedilol and a wide variation in cats. all cats tolerated the oral dose of carvedilol with no major adverse effects. also, a mean residual time of . hours would suggest that a more frequent dosing schedule may be required to maintain therapeutic plasma levels. pharmacodynamic studies investigating beta-adrenergic blockade duration may provide a more accurate dosing interval of carvedilol. abstract c- effects of sildenafil citrate on dogs with ei-senmenger's syndrome. k nakamura, m yamasaki, h ohta, m takiguchi. department of veterinary clinical sciences, graduate school of veterinary medicine, hokkaido university, sapporo, hokkaido, japan. sildenafil has shown to be effective for dogs with pulmonary hypertension; however, its efficacy for dogs with eisenmenger's syndrome (es) and secondary erythrocytosis has not yet been determined. the objective of this study is to determine the effect of sildenafil for dogs with eisenmeger's syndrome and secondary erythrocytosis. this was a prospective, single arm, open-label study. five clinical dogs with es and secondary erythrocytosis were included. new york heart association (nyha) functional class, pcv, and pulmonary artery acceleration time to ejection time ratio (pa at : et) were evaluated before and after sildenafil therapy ( . mg/kg, bid). nyha functional class was significantly improved after (median ; range - , p . ) and months (median ; range - , p . ) of sildenafil therapy, compared with the baseline (median , range - ). pcv was significantly decreased after month ( . ae . %, p . ) and months ( . ae . %, p . ) of therapy, compared with the baseline ( . ae . %). at : et was significantly increased after month of therapy ( . ae . , p . ) from the baseline ( . ae . ). sildenafil resolved the clinical signs and secondary erythrocytosis in dogs with es. sildenafil therapy could be the treatment of choice for dogs with es. sepsis is the number one cause of mortality in neonatal foals. the role of the raas and hpaa in systemic inflammation and response to stress is well documented in critically ill human neonates, but limited information exists in foals. we hypothesized that in septic foals the raas and hpaa will be activated by systemic inflammation and hypoperfusion and the degree of activation will be associated with severity of sepsis and mortality. blood samples were collected on admission from septic (sepsis score ), sick non-septic (sns), and healthy foals of o days of age. blood concentrations of corticotropin-releasing hormone (crh), adrenocorticotropin (acth), cortisol, aldosterone, angiotensin-ii (ang-ii), arginine vasopressin (avp) and plasma renin activity were determined by radioimmunoassays. acth, cortisol, aldosterone, ang-ii and avp concentrations were higher while crh was lower in septic and sns foals compared to healthy foals (p o . ). septic non-survivor foals had higher concentrations of aldosterone, cortisol, acth and avp and lower concentrations of ang-ii and crh than survivors. avp was associated with ang-ii in septic, and with acth in septic and sns foals (p o . ). there was no difference in renin activity and ang-ii concentrations among foal groups. septic foals had a higher acth:aldosterone ratio than healthy foals (p o . ). this study shows that in response to sepsis there is raas and hpaa activation in critically ill foals. we propose that in sick foals avp is more important than crh in regulating acth secretion. the increased acth:aldosterone ratio further supports relative adrenal insufficiency in septic foals. this prospective, cohort study aimed to characterize alterations in coagulation and blood-derived inflammatory biomarkers in adult horses that developed diarrhea during hospitalization. physical and hematological parameters were evaluated at times (onset of diarrhea), , , and h, then every h until resolution of diarrhea or death. each hematological analysis included a complete blood count (cbc), thromboelastography (teg), partial-thromboplastin-time (ptt), prothrombin-time (pt), plasma concentrations of lactate, tumor necrosis factor alpha (tnf-a), interleukin (il)- , il- , il- and nt-proc-type-natriuretic peptide (pcnp). horses were categorized into three groups based on the duration of diarrhea and evidence of systemic inflammation. group : diarrhea o h without systemic inflammation (si); group -diarrhea ! h without si; group -diarrhea with si. assessment of vital parameters and cbc established a diagnosis of si as previously described (levy, ) . descriptive and univariate outcome analyses were based on data normality. horses were enrolled, of which ( . %) survived to discharge. the mean age was . /- . years. eight horses ( . %) were categorized as group- , ( . %) as group- and ( . %) as group- . two horses developed thrombophlebitis. based on the results of teg, / ( . %) were normocoagulable, / ( . %) were hypocoagulable and / ( . %) were hypercoagulable, at one or more time points. of these, / ( . %) group- horses were coagulopathic. additionally, group- horses had a significantly lower ma than group- horses at baseline ( . ae . vs. . ae . ) and h ( . ae . vs. . ae . ). biomarker analyses are pending. in conclusion, si was associated with coagulation disorders in horses with hospital acquired diarrhea. clostridium difficile and clostridium perfringens are commonly associated with colitis and diarrhea in equines but asymptomatic carriers exist. reported carrier rates of toxigenic c. difficile and c. perfringens strains in feces range between - % and - % respectively. toxigenic c. difficile has also been isolated from the small intestine of diseased foals and is implicated as etiologic agent of duodenitis/proximal jejunitis in adult horses however scarce information is available on prevalence in gastrointestinal compartments other than feces in healthy horses, and it is unclear whether fecal samples are good predictors of the status of proximal intestinal sites. the objectives of this study were to investigate the presence of c. difficile and c. perfringens in various intestinal compartments of healthy adult horses and to molecularly characterize isolates. intestinal contents were collected from the stomach, duodenum jejunum, ileum, cecum, right dorsal and left ventral colon, small colon and rectum of euthanized horses free of apparent gastrointestinal disease. enrichment culture was performed for c. difficile and c. perfringens and c. difficile isolates were further characterized via toxin gene detection and ribotyping. c. difficile was isolated from / ( %) samples from / ( %) horses. between zero and three sites were positive per horse, and multiple sites were positive in three horses. isolates were recovered from duodenum (n ), right dorsal colon (n ), small colon (n ) and rectum (n ). in one horse, the rectal sample was negative but c. difficile was isolated from a proximal site, all other horses were positive on the rectal sample if a more proximal compartment was positive. in three horses multiple compartments were positive however different strains were always present within the same horse (n ). all isolates possessed genes encoding toxins a and b. five isolates were ribotype and also possessed genes encoding the binary toxin. the other isolates were ribotype and were negative for the genes encoding the binary toxin. despite using a method with a detection level as low as cfu/g of feces, no c. perfringens was recovered. rectal samples were a good predictor of overall c. difficile carrier status ( / horses), however rectal samples were not always representative for the ribotype carried in more proximal compartments. the presence of variable strains within the same horse suggests transient passage of the bacterium through the gastrointestinal system rather than actual colonization although further study testing multiple colonies per site is needed. the predominance of ribotype is consistent with recent emergence of this strain in this region, as earlier studies found other strains ( , ) to be more prevalent and a variety of ribotypes were typically recovered from horses. interestingly ribotype has recently emerged as a hypervirulent strain in humans in our area. clostridium difficile, clostridium perfringens and salmonella are important enteric pathogens in horses, however some healthy animals also harbour these pathogens. point prevalence studies have reported these carriage rates, but there are no data regarding longitudinal prevalence of these enteric bacteria, information that would be useful to better understand the epidemiology of these pathogens. additionally, antimicrobial resistance is a pressing concern. commensal e.coli is often used as an indicator organism to evaluate antimicrobial resistance of enteric bacteria, yet there are limited data from horses on farms. the objectives of this study were to longitudinally investigate the above enteric pathogens over the course of one year, molecularly characterize obtained isolates and determine the antibiotic susceptibility profile for e. coli. fecal samples were collected from adult horses from five farms on a monthly basis over the course of one year. selective cultures were performed for c. difficile, c. perfringens, salmonella and e. coli. c. difficile isolates were characterized via toxin gene pcr and ribotyping. broth microdilution was performed to assess antimicrobial susceptibility profiles of e. coli. clostridium difficile was isolated from / ( . %) samples from / ( %) horses. four horses were positive on more than one occasion, three were positive in two consecutive months. different ribotypes were found in two of the latter horses. most isolates were ribotype (n ) with ribotype (n ) and ribotype c (n ) also identified. ribotypes and c possessed genes encoding toxins a, b and binary toxin, while ribotype only possessed toxin a and b genes. despite a detection threshold of cfu/g feces, c. perfringens was not detected in any samples, nor was salmonella. e coli was isolated from / ( %) samples. resistance to ! antimicrobial was present in only / ( . %) isolates. multidrug resistance (! antibiotics) was present in / ( %). most commonly, isolates were resistant to sulfisoxazole ( / ) and trimethoprim sulfamethoxazole ( / ). the overall detection rate for toxigenic c. difficile in fecal samples of healthy horses was . % which is consistent with previous studies. the cumulative prevalence of % was striking but only one horse shed the same strain for more than one month, indicating c. difficile shedding is a transient and dynamic state. the predominant isolation of ribotype is consistent with the suspicion that this strain has emerged and become widely disseminated in this region in recent years. the low prevalence of c. perfringens and salmonella is in agreement with some other studies. the low prevalence of antibiotic resistance in commensal e. coli was encouraging and suggests that healthy horses on pleasure horse farms are not likely a major reservoir of resistance in enteric bacteria. type polysaccharide storage myopathy (pssm) in horses is associated with a dominant missense mutation (r h) in the skeletal muscle glycogen synthase gene (gys ). since disease severity varies between affected horses, we hypothesised that some clinical variability could be accounted for by the underlying genotype. belgian / percheron horses were genotyped using a validated restriction fragment length polymorphism assay enabling grouping of horses as homozygotes (hh), heterozygotes(hr) or normal (rr). subsequently, semimembranosis muscle samples were biopsied from each of six matched sedentary horses from each group; one sample was formalin-fixed and one fresh frozen. sections were stained using haematoxylin and eosin, periodic acid schiff /diastase. anti-dystrophin, nnos and myosin heavy chain immunohistochemistry was performed to examine sarcolemmal intregrity, there were significant differences in resting ck activity (p . ) (median hh u/l interquartile range(ir) - ; hr u/l ir - ; rr u/l ir - ) and ast activity (p o . ) (ast mean hh u/l sd ; hr u/l sd ; rr u/l sd ) and muscle pathology between the groups, with severity increasing rr o hr o hh. there were significantly more type a (p . ) and fewer type x fibres (p . ) in homozygotes ( a % sd . ; x % sd ) compared with the other groups (hr a % sd . , x % sd . ; rr: a . % sd . x % sd . ). more type a fibres contained polysaccharide inclusions in homozygotes ( % sd . ) than in heterozygotes ( . % sd . ) (p o . ). both dystrophin and nnos expression was normally localised to the sarcolemma in pathologically normal and vacuolated fibres from mutant horses. in conclusion, sedentary homozygotes have more severe skeletal muscle pathology and higher resting plasma ck and ast activities than heterozygotes, and pssm is associated with a fibre type shift towards type a. although subsarcolemmal vacuolation likely disrupts the contractile apparatus's attachment to the sarcolemma, the latter's integrity appeared intact. the recumbent horse presents a logistic, diagnostic, and therapeutic challenge to the equine practitioner. there is currently very little data available on the prognosis and outcome of horses that are recumbent. therefore, the purpose of this study was to investigate the outcome of hospitalized horses that had been recumbent in the field or in the hospital and the factors affecting their survival. records of horses admitted to the school of veterinary medicine, university of california davis from january of to december of with a history of recumbency or horses that became recumbent while hospitalized were evaluated. a horse was defined as recumbent if it was unable to stand on its own. the medical record was examined for the following criteria: history pertaining to the current illness including treatment by the rdvm, breed, age, weight, date of presentation, physical and neurological examination findings, cbc and biochemical profile results, initial drugs administered on arrival, time spent recumbent, time spent in a sling, diagnosis, and hospitalization costs. statistical analysis correlating factors associated with survival was performed using logistic regression. overall there were non survivors and survivors. factors that favored survival included early initiation of treatment in the field by the rdvm, horses that tolerated a sling and spent more time in a sling, increased duration and costs of hospitalization, horses that were recumbent post anesthesia, and those recumbent due to disease of the musculoskeletal system. factors that increased likelihood of non survival included horses that were ataxic on presentation, horses with increased bun, horses that spent more time recumbent, those that did not tolerate a sling, and horses diagnosed with botulism and spinal cord disease. in conclusion, this retrospective study demonstrated that both the cause of recumbency and the ability of horses to tolerate a sling had a direct effect on survival. abstract e- plasma peak and trough gentamicin concentra-tions in hospitalized horses receiving once daily gentamicin. jr read , pa wilkins , rd nolen-walston . university of pennsylvania, new bolton center, kennett square, pa. university of illinois, champaign-urbana, il. gentamicin is often used to provide gram negative antimicrobial coverage in horses at . mg/kg iv every hours. therapeutic drug monitoring in our hospital suggests larger doses are required in many clinical cases to achieve the desired concentration ( -  minimum inhibitory concentration) for common bacterial isolates (peak target range - mg/ml). the aim of this study was to determine the correlation between gentamicin dose and plasma concentration in hospitalized horses receiving gentamicin treatment in order to identify an optimum dose range for this population. review of records ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) identified horses ! months old receiving once-daily gentamicin with peak and trough assays performed (n sets). spearman rank correlation coefficient analysis revealed a weak (r . ) but statistically significant correlation (p . ) between gentamicin dose and peak plasma concentration. horses receiving . - . and . mg/kg gentamicin (groups and ) had higher median peaks ( mg/ml) than horses receiving . - . mg/kg (group ; . mg/ml). higher doses were more likely to result in peaks mg/ml ( and %, groups and respectively) than horses receiving . - . mg/kg (group ; %). all hour post-gentamicin administration trough values were o mg/ml. no correlation was found between dose and change in plasma creatinine during treatment, nor dose and trough level. these data suggest that gentamicin dosage in horses should be individually determined by therapeutic monitoring. additionally, these data support an initial dose of . - . mg/kg iv every hours in order to achieve desired peak concentration and an appropriately low trough concentration. heaves is a common respiratory inflammatory disease, characterized by a pulmonary neutrophilia. this disease is also characterized by an activation of circulating neutrophils after antigen challenge but their specific role in heaves is not well understood. also, there are anecdotal studies concerning heaves-affected horse to be more susceptible to infection. however, to our knowledge, the antibacterial host defense role mediated by circulating neutrophils was not investigated in heaves-affected horses. the objective of this study was to compare phagocytosis activity and bacterial killing by circulating blood neutrophils of heaves-affected and control horses. peripheral neutrophils were isolated from heaves-affected (n ) and control (n ) horses using a density gradient technique. the killing capacity was assessed by incubating neutrophils with streptococcus equi spp equi and spp zooepidemicus. after h of bacterianeutrophil coculture, total viable bacterial cells were measured by quantitative plating. the phagocytosis was evaluated by flow cytometry using fluorescent beads and gfp-transformed streptococcus suis suilysin-negative mutant strain. circulating neutrophils from heaves-affected horses showed a significant decrease in their killing capacity toward s. zooepidemicus (p . ). a reduced, although not significant (p . ), killing capacity of s. equi by these neutrophils was also observed. the phagocytosis activity was not different between groups. this impairment of blood neutrophil bactericidal activity in heaves-affected horses could contribute to an increase susceptibility to infection. obesity is a common disorder of the horse, with current prevalence estimated at %. in people, obesity is associated with dyslipidemia, insulin resistance, mitochondrial dysfunction and downregulation of lipid and glucose metabolic pathways. in the horse, obesity is similarly associated with insulin resistance and alterations in lipid profiles; however, metabolic regulatory gene expression profiles have not been fully characterized. we hypothesized that obese horses have decreased expression of metabolic regulatory genes and decreased mitochondrial content in skeletal muscle compared with non-obese horses. sixteen light breed horses, - years of age were included. body condition score (n ) and neck circumference (n ) were recorded. post-mortem biopsy samples of the semi-membranosus muscle were obtained. dna and rna were isolated. relative expression of the metabolic genes, peroxisome proliferator activated receptor g (pparg), pparg coactivator- a (pgc- a), fatty acid translocase (fat) and estrogen related receptor a (erra) was determined by quantitative polymerase chain reaction (qpcr). mitochondrial content was assessed by determining mitochondrial dna/nuclear dna ratio by qpcr, using nadh-dehydrogenase subunit and cytochrome oxidase subunit as mitochondrial genes and beta actin as the nuclear reference gene. non-normal data was log transformed for analysis and a pearson coefficient of correlation was calculated for relative gene expression, body condition score and neck circumference. a value of p o . was considered significant. body condition score was strongly correlated with neck circumference (n , r . , p . ). relative expression of erra and glut- increased with body condition score (erra: n , r . , p . ; glut- : n , r . , p . ). copy number of the mitochondrial genes (nadh-dh and cox- ) was not related to body condition score or metabolic gene expression. expression of glut- , erra, pparg, and fat were strongly correlated to each other, but not pgc- a. there was a strong trend towards correlation between pparg and pgc- a in horses with body condition score (n , r . , p . ). in this study, there was no change in mitochondrial content in obese horses. assessment of mitochondrial function in obese horses and horses with ems is under way. the strong correlation between pparg and pgc- a observed only in horses with high body condition scores suggests this pathway is activated with obesity. the role of pparg and pgc- a in equine obesity should be further investigated to determine their potential as therapeutic targets. upregulation of erra and glut- in horses with increasing body condition score is unexpected, and may indicate a compensatory response to dysfunction of a downstream pathway. further studies to better define the role of metabolic regulatory gene expression in obese horses and those with ems are ongoing. previously presented at the th annual harold hamm diabetes center research retreat, oklahoma city, ok. inflammatory bowel disease is a cause of weight loss, decreased performance, and colic in horses. this condition is difficult to diagnose and clinicians rely upon absorption tests to document malabsorption. the purpose of this study was to compare glucose and xylose absorption tests in normal horses and determine the repeatability of these procedures. eight horses received mg/kg dextrose or d-xylose powder mixed as a % solution in water or water alone via nasogastric intubation on three different occasions within the same week for three consecutive weeks ( tests/horse). a crossover design was employed and the order of treatments was randomized. blood samples were collected at time , , , , , , and min. data were analyzed by repeated measures anova and t-tests. results showed that the xylose response over time differed significantly from the glucose response over time (test  time; p o . ). mean time to maximum concentration differed (p o . ) between tests (glucose min; xylose min). within-horse area under the curve, maximum concentration, and time to maximum concentration values for dextrose and xylose did not differ significantly when tests were repeated. results indicate that glucose and xylose absorption tests are repeatable within the same horse, but plotted curves differ between tests, with peak concentrations occurring at a later time point for the glucose absorption test. we conclude that both tests provide repeatable measures of intestinal absorption, but glucose and xylose appear to differ in their rates of absorption and clearance. the purpose of this study was to examine the records of a population of thoroughbreds with cervical vertebral malformation (cvm) and to determine which factors have an effect on these horses achieving athletic function. this was a retrospective case study of thoroughbreds with cvm treated medically from to . forty-one were euthanized after diagnosis, while the remaining were discharged for treatment. racing records were reviewed to determine which horses raced after treatment. horses were separated into groups based on whether or not they raced. medical records were reviewed, and results of neurologic examination, radiographic and laboratory findings, treatments, and outcome were assessed and compared between groups. twenty-one of horses treated medically ( %) improved enough to race. median neurologic grade between groups was significantly different (p o . ), with a hind limb grade of . (range - ) for the raced group and . (range . - ) for the unraced. intravertebral sagittal ratios measured from standing lateral cervical radiographs were equivocal between groups. radiographs of all horses were examined for kyphosis, dorsal over-riding arch, caudal epiphysitis, degenerative joint disease, cystic bone lesions, and cranial stenosis of the vertebral canal. horses with kyphosis (p . ), degenerative joint disease (p . ), or cranial stenosis (p . ) at any site were less likely to return to racing. racing prognosis for horses with cvm treated conservatively is equivalent to that of those treated surgically as reported by rush moore et al (javma, ) . radiographic changes and neurologic grade may help serve as indicators for whether a horse will respond to conservative therapy. since pain assessment is vital for management of colic, a valid, reliable and feasible tool for assessing the severity of acute abdominal pain in horses is urgently needed. our aim was to construct and validate a behavior-based pain scale by methodology utilized in construction of pain scales in non-verbal humans. the project consisted of four stages. firstly, behaviors to include in a scale were empirically identified. thirty equine clinicians noted behaviors in each of random film clips of horses with colic using a checklist. nine behaviors (e.g. rolling, pawing, and flank watching) demonstrated good inter-observer agreement without bias (multi-rater kappas: . - . ). secondly, the clinical judgment of experts was utilized to identify and to weight behaviors. six expert clinicians independently expressed opinions as to which of behaviors to include and the severity of pain they indicate. two contending scales (equine acute abdominal pain scales (eaaps) & ) were constructed based on both the empirical and the judgmental approaches. each included identical behaviors with a - point score range; eaaps- with gradations to some of the behaviors and eaaps- without. in the third stage, blood cortisol and lactate levels and heart rate were shown to only approximate pain since they correlate poorly with degree of pain as assessed by visual analog scale (vas) in horses with colic and controls (spearman rho; lactate . ; cortisol . ; heart rate . ). finally, reliability and validity of the pain scales were evaluated including constructs of pain; face validity, convergent and discriminate validity and extreme groups. thirty of films of horses with colic were randomly presented to expert equine clinicians internationally who were randomly allocated into three groups to score pain; one group by both vas and numerical rating scale (nrs)), and two groups, each by one of the two eaaps scales. inter-observer reliability of both eaaps scales was excellent (intraclass correlation . ). intra-observer reliability based on scores given for identical films demonstrated; % and % agreement, kappa . and . , and spearman's rho . and . for eaaps- and , respectively. both scales varied by score between observations. face validity; each group reported their scale to be valid ( % & %). convergent validity; the scales compared favorably with vas/nrs scores (spearman's rho: . - . ). discriminate validity; correlation to heart rate, lactate and cortisol levels was predictably low (rho . - . ). extreme group validity; colic horses scored significantly higher than control horses; scores of . - . in controls versus . - . in cases. in conclusion, methodology established in human medicine but novel in veterinary medicine was used to construct and validate two clinically feasible equine abdominal pain severity scales that showed excellent reliability and validity. further refinement of the eaaps scale is advised prior to introduction into clinical practice. aortic valve prolapse (avp) is a common echocardiographic finding in horses, but when compared with mitral valve prolapse in dogs, little is known about the natural progression of this condition. previously published data has shown that echocardiographic identification of avp in horses is reliable, diagnostic criteria have been established and that development occurs with training. the aims of this study were to evaluate the different rna and protein expressions of smooth muscle actin (sma), transforming growth factor-b (tgf), nitric oxide synthase (nos) and the concentrations of elastin and collagen in normal, prolapsing and diseased cusps to evaluate what structural changes may predispose them to prolapse. valve cusps were harvested and processed from a group of horses at a commercial abattoir following disease classification using echocardiography. horses were aged . ae . years, weighing ae kg and with a median body condition score of / . cusps were collected in rnalater s and stored at À c prior to processing. cdna was produced from half a valve using a standard protocoland qrt-pcr performed to assess relative rna expression of sma, tgfb , endothelial (enos) and inducible nos (inos) and compared with the housekeeping gene s. a quarter of cusp was processed using an adapted commercial protocol to evaluate protein expression of sma, tgf b , enos and compared to vimentin. specific antibody binding was assessed with western blotting and protein expression evaluated using dot blots. the remaining quarter cusp was used to measure soluble collagen and elastin concentrations using commercial assays . statistical analyses included one way anova with post-hoc bonferoni, paired student's t-test, linear and logistic regression. there was no effect of gender or age on any of the measurements. valves from animals with avp had lower expression of sma and elastin compared to normal and diseased valves, increased expression of tgfb and enos, whereas inos expression was greater than normal valves (table ) . collagen content of valves from horses with avp was increased compared to normal but lower than horses with valve disease. prolapsing cusps appear to be a different phenotype from diseased cusps. further studies will help to elucidate the significance of these findings in vivo. a clear association between heart rate (hr) and body mass has been observed across a wide range of mammalian species. furthermore, it is well known that electrocardiographic (ecg) time intervals vary with heart rate and body mass. within the equine species, small breeds are generally thought to have higher heart rates than large breeds. however, despite the large differences in size among different equine breeds, there is little information about normal heart rates and normal ecg time intervals in horses and ponies of different body size. similarly, the relationship between hr and body mass in dogs of various breeds and sizes is still under debate. the goal of this study was to investigate the relationship between heart rate and ecg time intervals to body mass in apparently healthy horses and ponies and to calculate normal ranges for different weight groups. adult horses and ponies at an age of . ( - ) y [median (range)] and a body weight of ( - ) kg were included in the study. all animals were considered clinically healthy based on history and physical examination. a standard base-apex ecg was recorded at a speed of (n ) or mm/s (n ) using a multiparameter monitor (datascope passport). during the procedure, the horses were unsedated, standing quiet in a box stall. mean hr over sec was determined for each recording. the following ecg time intervals were measured in triplicate and averaged for further analyses: pq interval, qrs duration, qt interval, and difference between qt and qrs (qt-qrs duration). the relationship between hr, ecg time intervals, and body mass was assessed using linear regression analyses. normal ranges ( . % to . % percentile) were calculated for different weight groups. the level of significance was p . . heart rate was inversely related to body mass (p o . , r . ). the pq interval (p o . , r . ), qrs duration (p o . , r . ), qt interval (p o . , r . ), and qt-qrs duration (p o . , r . ) were directly related to body mass. normal ranges for hr, pq, qrs, and qt within the different weight groups were - bpm, - ms, - ms, - ms (o kg); - bpm, - ms, - ms, - ms ( - kg); - bpm, - ms, - ms, - ms ( - kg); - bpm, - ms, - ms, - ms ( - kg); and - bpm, - ms, - ms, - ms ( kg). we conclude that in healthy horses there is a significant but weak relationship between body mass and hr and between body mass and ecg time intervals, respectively. this study therefore supports the hypothesis that within the equine species, small breeds have faster heart rates and shorter ecg time intervals than large breeds. therefore, body mass has to be considered when comparing hr and ecg time intervals to normal ranges in horses. horses with pituitary pars intermedia dysfunction (ppid) often have elevated plasma acth concentrations. however, ppidaffected horses rarely have resting serum cortisol levels above the reference range or adrenal hyperplasia. we hypothesized that this apparent dissociation between plasma acth levels and adrenal response in horses with ppid is due to the secretion of acth that is less biologically active than that from normal horses. to test our hypothesis, a bioassay to evaluate acth activity was developed. adrenocortical explants were harvested aseptically from normal horses at euthanasia and stimulated with plasma from healthy (n ) and ppid-affected horses (n ). the assay was performed three times with explants obtained from different horses. cortisol secreted by the explants and plasma acth levels were measured with commercially available radioimmunoassays. cortisol secretion stimulated by each sample was standardized to the respective explant protein concentration. cortisol data was normalized for acth concentration in each plasma sample and expressed as a cortisol:protein:acth ratio. ratios from horses with ppid and normal horses were compared by unpaired t-test. horses with ppid had significantly lower cortisol:protein:acth ratios compared to normal horses. (assay : . ae . vs. . ae . , p o . ; assay : . ae . vs. . ae . , p o . ; assay : . ae . vs. . ae . , p o . ). these results suggest that plasma acth from ppid horses is less biologically active than plasma acth from normal horses. our findings give further insight into the pathophysiology of ppid and may aid in the development of novel diagnostic testing protocols. an online survey was conducted to determine perceived needs of potential employers of new acvim-laim diplomates. the survey was designed as the first step in determining what is needed for success in the various sectors of practice employing acvim-laim diplomates. demographic and background data were collected using questions and drop-down menus on the first page. the survey evaluated skills or concepts in areas of veterinary practice. participants answered questions about each skill or concept using drop-down ranked lists. those participants that had completed an acvim-laim training program were asked additional questions about whether they were taught the skill or concept during their own residency. data were collated and descriptive statistics calculated. the mean scores or frequencies of use for each skills or concepts were ranked to determine which of the skills or concepts were most important for an entry-level diplomate. eighty-eight individuals participated in the survey with respondents being acvim diplomates, respondent was not board-certified and respondent was an act diplomate. nineteen respondents were diplomates of acvim and an additional specialty. eighty-three respondents had completed an acvim residency. the majority of respondents were in academia ( %) with % being in private practice. equine specialists prevailed ( %) followed by mixed large animal ( %) and then food animal only specialists ( %). the distribution of years post-residency was slightly skewed toward younger diplomates, but overall there was a good distribution of diplomates across years of experience. most respondents stated that they did not make hiring decisions in their practice. competency in disciplines other than internal medicine was expected with ultrasonography and radiology being the most desirable followed by theriogenology and lameness. surgical skills, both equine abdominal ( %) and food animal general surgery ( %) were considered important by some respondents. thirty-six per cent of respondents thought that a new diplomate should expect to make o $ , per annum, while only % of respondents thought that a new diplomate should expect to make ! $ , per annum. not all respondents answered questions on all skills or concepts. the mean number of skills or concepts evaluated was (sd ) with only respondents answering all . all skills or concepts evaluated were found to be at least somewhat important, were estimated to be used at least occasionally, were recommended for inclusion in training programs as core or elective, and some level of knowledge was expected. at least some of the respondents were taught each of the skills or concepts during their residency, practiced the skill or concept at least occasionally during their residency, and some degree of competency was expected at the time of completion of their residency. these data will provide a framework for designing future laim residency programs. abstract this study evaluated pharmacokinetics and clinical safety of an oral paste formulation of a commercially available cox -sparing nsaid in clinically healthy pony foals in a randomized controlled clinical trial. values for complete blood count, serum chemistry profile, urinalysis, pharmacokinetic assay, and gastric endoscopy were evaluated in eighteen shetland pony foals treated with firocoxib ( . mg/kg, po, q h) or placebo for days. foals were divided into treatment groups. group and foals received firocoxib while a rd group was administered an oral placebo. gastric endoscopy was performed on group and foals prior to treatment and on days and to monitor for the presence of gastric ulcers. group and foals had blood and urine samples taken sequentially for pharmacokinetic analysis, cbc, serum chemistry evaluation, and urinalysis. physical examinations were performed prior to treatment and daily for days. data were analyzed using anova and paired t-tests (p o . ). none of the foals presented adverse clinical effects. there were no significant changes in cbc, biochemical profiles within groups, or differences between groups. pretreatment gastric endoscopy scores were not significantly different from evaluations at and days. firocoxib was quickly absorbed with an observed maximum concentration at hr, the first sampling interval, for the majority of animals. firocoxib plasma concentrations decreased in a log-linear manner after reaching the maximum concentration and steady state concentrations were achieved by the th dose. based on the sampling times after the final and th dose, an average half life of . days was estimated. administration of firocoxib did not cause any adverse effects on gastrointestinal, or hematological or serum biochemical variables, appears to have been well tolerated, and follows a predictable pharmacokinetic pattern in - week old foals. equine herpesvirus (ehv- ) is highly prevalent in most horse populations. horses are routinely vaccinated against ehv- , and neutralizing antibodies have helped to prevent disease. however, the usda has recently classified ehv- myeloencephalopathy (ehm) as an emerging disease, in response to the apparent increase in incidence, morbidity, and mortality of ehm that suggests a change in virulence of the virus. it has been reported that cellular immune mechanisms, in particular cytotoxic t-cells (ctls), are important in controlling ehv- viremia. interferon-alpha (ifn-a) has a key function in innate immune regulation by inducing the differentiation and maturation of ctls. here, we investigated the influence of abortogenic (racl , ny ) and neuropathogenic (ab ) ehv- virus strains on ifn-a, il- and il- secretion in equine pbmc. equine pbmc were infected with racl , ny or ab ehv- strains or kept in medium for hours. ifn-a, il- and il- secretion was detected in the supernatants by a fluorescent bead-based cytokine assay. the production of ifn-a increased with increasing viral doses and similarly for all three ehv- strains. the production of the antiinflammatory cytokine il- was significantly decreased after ab infection compared to racl and ny strains at viral infection doses of moi . - . at high doses (moi ), il- production was suppressed by all three ehv- strains. the results suggested that abortogenic and neuropathogenic ehv- strains equally induce antiviral ifn-a production in equine pbmc. they also illustrated the differences in the ability of ehv- strains to modulate anti-inflammatory il- . neuropathogenic ab strain had an increased potential to down-regulate il- production suggesting specific viral mechanisms that interfere with the control of inflammation in the host. the variations in innate il- secretion might influence the development of protective immunity and might offer an explanation why neuropathogenic ab induces more severe disease, including myeloencephalopathy, than abortogenic ehv- strains. previously presented at a conference of research workers in animal disease. rhodoccocus equi is the major cause of pneumonia in foals during the first six months and control measures are frequently ineffective. treatment protocols are long, expensive and do not always produce good results. rhodococcosis prevention through immunization of foals using a safe and efficient vaccine is still a challenge. recent studies are based on the use of the virulence associated protein a (vapa) which has been described as an important inducer of immunity against r. equi. the present study evaluated the clinical and immune response of foals vaccinated with an attenuated strain of s. enterica typhimurium expressing vapa antigen (test group) or s. enterica typhimurium without the vapa gene (control group), previous to and following experimental challenge. two experimental phases were established according to the immunization route: intranasal or oral vaccination up to hrs following birth and at days of age. the experimental and control groups were challenged on day with a virulent stain of r. equi. clinical examination, cbc and image complementary exams were used to evaluate the development of clinical signs. immune response patterns were evaluated though immunoglobulin dosage, cytokine expression, lymphocyte proliferation assays, isolation of r. equi and cytological profiles of tbw. clinical manifestation was less intense in the test group during the second experimental phase, and death occurred only in the control group ( / ) and was due to r. equi pneumonia. the test group produced a more intense iggb response when compared to controls however no statistical difference was observed. lymphoproliferation and th cytokine expression were higher in the test group. in contrast, controls produced an il- response. local iga was significantly higher in animals immunized with salmonella carrying vapa. immunization protocols produced no severe toxic effects. the vaccination of neonatal foals with s. enterica typhimurium expressing vapa was considered safe, produced efficient modulation of the immune response and is apparently able to protect against experimental r.equi infection. this study was conducted to test the hypothesis that the kd protein, myristolated alanine-rich c-kinase substrate (marcks), is involved in equine neutrophil migration and adhesion. in other species, marcks phosphorylation and dephosphorylation causes the protein to cycle between the cell membrane and cytosol, respectively. to investigate marcks phosphorylation in horses, neutrophils were isolated from whole blood and stimulated with platelet activating factor (paf), leukotriene b (ltb ) or phorbol myristate acetate (pma). western blot was performed using specific phospho-marcks and total marcks primary antibodies. these results determined marcks phosphorylation is maximal seconds following stimulation and that dephosphorylation occurs within minutes. to investigate the requirement for marcks in equine neutrophil chemotaxis, isolated neutrophils were pre-treated with mans (a cell permeant peptide identical to the n-terminal amino acids of marcks), rns (a control peptide) or vehicle control (vc) prior to a migration assay toward known neutrophil chemoattractants (ltb or paf). pre-treatment of equine neutrophils with mans significantly inhibited migration while rns pre-treatment had no effect. to investigate marcks requirement in equine neutrophil adhesion, mans, rns or vc treated cells were stimulated to adhere to immulon plates coated with % fbs. pre-treatment of equine neutrophils with mans significantly inhibited adhesion while rns pre-treatment had no effect. inhibition of marcks using a cell permeant peptide identical to the protein's n-terminus significantly inhibited equine neutrophil adhesion and migration. these results indicate that marcks is an important regulator of equine neutrophil chemotaxis and represents a potential target for anti-inflammatory therapy. amongst other tests, a thorough neurologic examination of horses may include walking with the head elevated and during blindfolding, in order to help differentiate normal from abnormal and to help with neuroanatomically localising any lesion(s) i.e. in the ataxic horse. consensus amongst equine neurologists suggests that gait abnormalities associated with these specific tests are often exacerbated in horses with underlying proprioceptive deficits however the effect of these tests on temporal gait characteristics in normal horses has not previously been assessed quantitatively. we hypothesized that head elevation or blindfolding, in comparison with walking in a straight line would result in a compensatory decrease in lateral (left front-on to left hind-on and right front-on to right hind-on) and diagonal coupling intervals (left front-on to right hind-on and right front-on to left hind-on) in normal horses. four thoroughbreds without any history or clinical signs suggestive of neurological disease (age range to years) were included in the study. retroreflective markers were applied to the withers, to the sacrum and to left and right tuber coxae; for each limb, lateral fetlock markers and dorsal and lateral hoof wall markers were used. a minimum of trials each with - walk strides for each task were analysed as horses walked across an -force-plate runway i surrounded by a -camera kinematic system. ii force-plate data were processed with semi-automated custom written matlab iii scripts. data were analysed with a mixed model using the statistical software r. there was a significant fixed effect of normal walk on a straight line and head elevation on left and right lateral coupling intervals (p o . ) and of the left and right diagonal coupling intervals (p o . ). there was no significant effect of blindfolding on neither lateral nor diagonal coupling intervals. the random effect of horse had no influence on the coupling intervals. the decrease of the lateral coupling intervals indicates a tendency towards a pacing gait during head elevation. we conclude that there is a significant change in temporal gait characteristics of non-neurologic horses when the head is elevated but not during blindfolding compared to normal walking. current results suggest that pacing and increased variation in foot-placement during head elevation should be interpreted with caution however further work is required to determine whether the change differs between horses with neurological disease and non-neurologic disease. hereditary equine regional dermal asthenia (herda) is an autosomal recessive connective tissue disorder associated with a mutation in cyclophillin b that leads to impaired collagen folding, aberrant wound repair, and corneal abnormalities. it affects young quarter horses, appaloosa, and paints. herda shows similarities to the human hereditary connective tissue syndrome ehlers danlos (eds). many eds patients suffer from joint pain and osteoarthritis (oa) as adults. the similarity between eds and herda raises the question whether horses suffering from herda develop oa. in oa, excess production of inflammatory mediators such as prostaglandin e (pge ) activate enzymes that degrade cartilage as well as impede wound healing. the present study examined articular cartilage from yearling horses afflicted with herda. we hypothesized that chondrocytes from these horses are continually activated to produce inflammatory mediators. to test this hypothesis, articular cartilage from carpal and tarsal joints of herda horses were evaluated using histology. pge production by chondrocyte cultures was measured by elisa and analyzed by one-way anova, tukey post-hoc test, p o . significance. we also determined the antiinflammatory effects of an avocado/soybean unsaponifiables (asu), glucosamine (glu), and chondroitin sulfate (cs) mixture (ingredients found in cosequin s asu) and phenylbutazone (pbz) on chondrocytes. cosequin s asu and pbz are used alone or in combination for the management of oa. chondrocyte cultures were incubated for hrs with control media alone, a clinically relevant concentration of pbz ( mg/ml), or the combination of asu (nmx s , . mg/ml) glu (fchg s , mg/ml) cs (trh s , mg/ml). articular cartilage from joints of five herda-afflicted horses showed gross and histologic evidence of osteoarthritic lesions. chondrocyte cultures from cartilage of horses suffering from herda spontaneously produced greater pge than chondrocytes from normal horses ( -fold). pbz significantly decreased pge production by $ % (p o . ). the combination of asu -glu cs also significantly reduced pge production by $ % (p o . ). the present study supports anecdotal findings that horses suffering from herda are likely to develop oa. the inhibition of pge synthesis by asu glu cs suggests that this combination may be beneficial for the management of oa in herda. research supported by nutramax laboratories, inc. equine inflammatory airway disease (iad) is a common condition often treated empirically with corticosteroids. gene expression analysis in the bronchoalveolar lavage fluid (balf) may help understand the effects of corticosteroids in iad. the first part of the study aimed at identifying reference genes in the balf of iad horses treated with corticosteroids. the second part of the study investigated the effects of dexamethasone and fluticasone propionate treatments on the mrna expression of il- b, il- , il- and il- . the expression stability of seven candidate reference genes was determined in balf taken pre-and post-treatment with dexamethasone and fluticasone propionate in horses with iad. primers' efficiencies were calculated using linregpcr. normfinder, genorm and qbaseplus softwares were used to rank the genes according to their stability. gapdh was the most stably expressed gene whereas b m was the least stable gene. in addition, genorm analysis revealed that the number of genes required for optimal normalization was four (gapdh, sdha, hprt, rpl ). in the second part of the study the mrna expression of il- b, il- , il- and il- was measured in balf samples from seven iad horses treated in a randomized cross-over design with dexamethasone ( . mg/kg sid, days) or inhaled fluticasone propionate ( mcg bid with aerohippus, days). the balf samples were taken at baseline and after each treatment period. there was no significant effect of the corticosteroids treatment on the mrna expression of il- b, il- and il- in the balf. the mrna expression of il- was suppressed by dexamethasone and fluticasone propionate treatments. pneumonia is observed in horses after long distance transportation in association with confinement of horses' head position leading to a reduction in tracheal mucociliary clearance time (tmct). we hypothesize that clenbuterol, a beta- agonist shown to increase tmct in the horse, will ameliorate the affect of a fixed head position on large airway contamination and inflammation in a long-distance shipping model. six adult horses were enrolled in a cross-over design prospective study. horses were housed with their heads in a fixed position for hours to simulate long distance transport, and treated with clenbuterol ( . ug/kg po q h) or a placebo starting hours before simulated shipping. tmct was measured using a charcoal clearance technique. data were collected at baseline and hours, and included tmct, tracheal wash cytology and quantitative culture, rectal temperature, cbc, fibrinogen, and serum tnfa, il- and il- levels. there was a -week washout between study arms, and each horse served as its own control. the data was analyzed using regression analysis and wilcoxon rank-sum tests. no statistically significant difference was seen between treatment and placebo groups for any of the variables investigated. tmct did not differ after treatment ( . ae . cm/min) versus placebo ( . ae . cm/ min; p . ), and intratracheal bacterial counts were similar for treatment (  ae  cfu; p . ) and placebo (  ae  cfu) groups. a reduction of tracheal b hemolytic streptococcus. spp. after clenbuterol versus placebo was also nonsignificant ( % versus %; p . ). in conclusion, treatment with clenbuterol does not appear to combat the deleterious effects of this long-term shipping model. breathing cold air during strenuous exercise is associated with airway inflammation. under these conditions, warming and humidification of inspired air occurs in the lower respiratory tract resulting in mucosal cooling, desiccation, and hyperosmolarity. the purpose of this research was to test the hypothesis that airway hypertonicity causes inflammatory cell migration and alterations in cytokine expression associated with exercise induced airway inflammation. horses (n ) were examined in a randomized crossover design after exposure to hypertonic aerosols ( minute nebulization with solutions of either isotonic or hypertonic mannitol). airway leukocytes were harvested and hours post aerosol challenge via bronchoaveolar lavage, and were used to determine total and differential nucleated cell count and expression of cytokinespecific mrna. hypertonic aerosol challenge resulted in an increase in total number of cells hr after challenge, characterized by increased macrophage (p . ) and neutrophil (p . ) concentrations, but there was no effect on airway leukocyte concentrations hours after nebulization. no significant changes in the relative quantity of mrna for airway cytokines were noted at either time point. these data demonstrate that transient airway hypertonicity can cause airway leukocyte influx and may be responsible for the airway inflammation commonly found in athletes that exercise in cold conditions. however, our data do not support the hypothesis that hypertonicity is the sole initiating cause of changes in cytokine expression secondary to cold weather exercise. it is likely that factors such as airway temperature, shear stress or epithelial damage also play a role in this phenomenon. we studied the importance of abdominal sonograms in neonatal foals suffering from gastrointestinal conditions. we hypothesized that there would be a subgroup of neonates with sonographically detectable pneumatosis intestinalis (pi) as a reflection of a necrotizing component of the disease. records of foals days of age hospitalized between and with signs of gastrointestinal disease were evaluated (n ). the association of sonographic, clinical, pathological and clinicopathological signs with outcome and severity of disease was determined. pneumatosis intestinalis was imaged in foals. twenty-seven foals were classified as having necrotizing gastrointestinal disease based on the presence of gastrointestinal signs (colic, diarrhea, gastric reflux or abdominal distension) and pi detected sonographically ( ), surgical ( ) or pathological ( ) evidence of gastrointestinal necrosis. there was a difference between overall survival rate ( %) and survival rate in foals with necrotizing disease ( %, p . ) or foals with pi detected sonographically ( %, p . ). pneumatosis intestinalis was the only sonographic finding associated with outcome. sonographic abnormalities in peritoneal fluid, stomach, duodenum, jejunum, cecum, umbilicus or the presence of meconium were associated (p o . ) with surrogates of severity of disease (hospitalization cost or days of hospitalization). hypoproteinemia was associated with pi (p . ). the presence of blood in the feces, reflux and abdominal distension was associated with necrotizing gastrointestinal disease (p o . ). abdominal sonograms have prognostic value in neonatal gastrointestinal disease. pneumatosis intestinalis was a common sonographic sign that worsened the prognosis. the therapeutic implications of detecting a necrotizing component of the gastrointestinal disease deserve further study. the interaction of insulin and the microvascular endothelial insulin receptor (irc) plays an important role in the normal and insulin resistant (ir) individual. while endothelial irc signaling is normally vasodilatory, this effect is well-documented to reverse in the ir individual, resulting in vasoconstriction. although vascular dysfunction has been reported in sepsis-associated equine laminitis, the role of the laminar microvasculature in endocrinopathic laminitis remains poorly characterized. the purpose of this study was to characterize the pattern of irc expression in digital laminae in ponies subjected to a dietary carbohydrate challenge that mimicked abrupt exposure to pasture rich in nonstructural carbohydrates (nsc). mixed-breed ponies (body weight . /- . kg) received a diet of hay chop (nsc $ % on a dm basis) for weeks prior to initiation of the experimental feeding protocol. following conditioning, ponies either remained on the control diet (n ) or received the same diet supplemented with sweet feed and oligofructose (total diet $ % nsc; n ) for a period of days. serum insulin concentrations were measured prior to and after completion of the feeding protocol. at the end of the feeding protocol, sections of numerous tissues, including dorsal digital laminae, were collected immediately following euthanasia. the samples were formalin-fixed for hours, transferred to % ethanol, and paraffin-embedded. laminar sections were stained immunohistochemically for irc using a commercially-available antibody (abcam); the number of irc ( ) cells was quantified in x light microscopy fields (n ) for each section. the total number of irc ( ) cells was greater in the laminae of challenged ponies than control ponies (p . ), and there was a significant correlation between the change in serum basal insulin concentration and number of laminar irc ( ) endothelial cells (r . ; p o . ). while the number of irc ( ) endothelial cells was significantly greater in the dermal laminae of challenged ponies (p . ), there was no difference in the number of interstitial irc ( ) cells (p . ). no epithelial irc ( ) cells were observed in any laminar section, and irc ( ) cells were conspicuously absent from the deep dermal tissue (including vessels). up-regulation of irc expression in the laminar vasculature occurs acutely in response to dietary carbohydrate challenge and accompanies hyperinsulinemia in ponies. the dramatic increase in endothelial irc expression in the laminar microvasculature in nutritionally challenged ponies, with no apparent epithelial irc present, suggests that hyperinsulinemia associated with exposure to increased dietary nsc may induce laminar injury by causing a similar vasoconstriction in ir equids as described in the microvasculature of ir humans. glucose transport from the blood stream into cells, the limiting step in whole-body glucose utilization, is regulated by a family of glucose transporter (glut) proteins in insulin-sensitive (i.e., muscle and adipose) tissues. we previously demonstrated that glut , the major isoform, is a key factor in the pathogenesis of equine insulin resistance (ir). while it has been recently demonstrated that glut (a newly discovered isoform) increases insulin-stimulated glucose transport in human muscle, its role in other tissues, particularly in the setting of ir, is not well characterized in any species. in addition, as has recently emerged as a key downstream signaling molecule regulating translocation of glut to the cell surface, the rate-limiting step in glucose uptake. we hypothesized that glut content would be differentially expressed across tissues and that ir would induce alteration in glucose transport by affecting active cell surface glut . biopsies of skeletal muscle, and subcutaneous and visceral adipose tissue were collected from light-breed horses, characterized as either insulin sensitive or compensated ir, based on the results of an insulin-modified frequently-sampled intravenous glucose tolerance test (n /group). we specifically quantified active cell-surface glut in these biopsies, using an innovative exofacial bismannose photolabeled assay, which has not been previously applied to glut . total glut protein expression was measured by western blots, as well as total and phosphorylated (indicating activation of) as . glut was expressed in all the depots with a significant regional effect. total glut protein content was increased (p o . ) in visceral (omental and mesenteric) compared to subcutaneous (nuchal ligament and tailhead) adipose tissue and skeletal muscle of healthy horses. ir did not induce alterations in active cell-surface and total glut content nor in total and phosphorylated as in any of the tissues evaluated. our data suggests that glut is abundant in visceral adipose tissue and is therefore likely to play a substantial role in the regulation of glucose transport. however, neither glut translocation nor as activation are impaired in insulin-sensitive tissues of ir horses. it is concluded that, in contrast with glut , glut does not appear to contribute to glucose transport alterations during naturally-occurring equine ir. insulin resistance (ir), characterized by exaggerated glycemic or insulinemic responses to glucose challenge, is a key metabolic disturbance in horses that develop obesity-associated laminitis. in addition to obesity, diet and age have been demonstrated to affect tissue sensitivity to insulin in other species but these factors have received limited investigation in horses. we hypothesized that there would be greater glycemic and insulinemic responses to a sweet feed meal in aged horses, as compared to adult horses, as well as in horses adapted to a forage-only diet. three diets, grass hay only, grass hay plus sweet feed (starch and sugar-rich, ss), and grass hay plus a fat and fiber (ff) feed, were fed to mares, adult ( - yr) and aged ( yr), for a -week adaptation period in a randomized design. glycemic and insulinemic responses to a standardized meal of sweet feed ( g/kg bw offered for hour) were determined for hours from the onset of feeding. peak glucose and insulin concentrations and areas under the glucose or insulin vs. time curves (auc-g, mg/ dl/ min, and auc-i, mu/ml/ min) were determined and data were analyzed by one-and two-factor repeated measures anova. there were no differences between age groups in glycemic responses to any of the diets. however, in aged horses peak glucose concentration (p o . ) and auc-g (p o . ) were greater after adaptation to the forage-only diet, as compared to the other two diets. in contrast, aged horses had a greater peak insulin concentration (p o . ) and auc-i (p o . ) than adult horses on all diets but no differences in peak insulin concentration or auc-i was found between diets within age groups. as hypothesized, the insulin response, but not the glycemic response, to a sweet feed meal was greater in aged horses, regardless of background diet. further, the glycemic response was greatest after adaptation to a forage-only diet, but this finding was only significant in aged horses. morbidity, mortality, and economic loss to the equine industry. in obese humans and rodent models of nutritional obesity, systemic insulin resistance and hyperinsulinemia are followed temporally in a majority of individuals by decreased glucose tolerance, pancreatic bcell failure, and type ii diabetes mellitus. in stark contrast to humans, obese horses and ponies chronically remain in what is termed a ''prediabetic'' state in human ir, characterized by hyperinsulinemic euglycemia. few data exist describing the biology of the equine endocrine pancreas in the chronically ir animal that may both: ) explain this unique equine endocrine physiology and ) characterize the animal at-risk for hyperinsulinemia-associated laminitis. the purpose of the study reported here was to characterize the morphology and physiology of the equine endocrine pancreas in response to a dietary carbohydrate challenge. twenty-two mixedbreed ponies (body weight . ae . kg) were conditioned to a diet of chopped hay (nsc $ % on dm basis) for weeks; following conditioning, ponies either remained on the control diet (n ), or received the same hay supplemented with sweet feed and oligofructose (total diet $ % nsc; n ) for days. serum insulin concentrations were measured prior to and after completion of the feeding protocol. at the end of the feeding protocol, sections of numerous tissues, including pancreas, were collected immediately following euthanasia. the samples were formalin-fixed for hours, transferred to % ethanol, and paraffin-embedded. immunohistochemistry was performed on pancreas sections using a commerciallyavailable anti-insulin antibody (abcam), and measurements of islet surface area and b-cell surface area were performed (n islets per tissue section) using a commercially-available computer software program (image j). there was a trend for greater total islet surface area in pancreatic tissue from ponies fed the high nsc diet when compared to the ponies on the hay diet (p . ); however, no difference was noted in b-cell surface area between diet treatments (p . ). the change in serum insulin concentration was significantly greater in the high nsc-fed ponies than in controls ( . /- . miu/l vs. . /À . miu/l; p . ); however, this variable was not correlated with total islet surface area (r . ; p . ) or b-cell surface area (r . ; p . ). due to the relatively modest changes in pancreatic islet surface area that accompany marked increases in serum insulin concentrations in ponies fed a high nsc diet, it is important to assess both b-cell function and insulin clearance mechanisms in future studies to delineate the mechanism(s) of hyperinsulinemia in this model. humans that suffer from obesity show exaggerated inflammatory responses and this may be relevant to the association between increased adiposity and laminitis in horses with equine metabolic syndrome (ems). this study was performed to test the hypothesis that inflammatory responses to endotoxemia differ between healthy horses and those affected by ems. six healthy adult mares and horses with ems received an intravenous infusion of lipopolysaccharide (lps; ng/kg in ml sterile saline) or saline alone. a crossover design was employed with a -day washout period. physical examinations were performed hourly for h and whole blood was collected at , , , , , and min for assessment of inflammatory cytokine gene expression. a liver biopsy was performed between and min postinfusion. data were analyzed using mixed model anova. mean rectal temperature, heart rate, and respiratory rate increased following lps infusion (treatment  time; p o . ), with higher heart (group  treatment; p . ) and respiratory rates (group; p . ) detected in ems horses. lipopolysaccharide infusion significantly increased whole blood gene expression of tumor necrosis factor a (tnfa), interleukin (il)- b (p o . ), il- (p o . ), il- (p o . ), and il- (p . ), and hepatic gene expression of il- (p o . ), il- (p o . ), and il- (p . ). inflammatory gene expression did not differ significantly between groups, so our hypothesis was not supported. heart rates tended to be higher when lps was administered to horses with ems. elevated serum concentration of cardiac troponin i (ctni) is a biomarker for myocardial damage in horses. preferred times to test blood for ctni levels following athletic performance or other events that may cause myocardial injury are not yet established and would be affected by time of release from the myocytes, location of release within the myocytes, duration of release and half-life of ctni in the horse. this information would be necessary to more accurately and reliably test horses for myocardial injury. the aim of this study was to determine the elimination half-life (t / ) of equine ctni. to establish the t / of equine ctni in horses, ctni was recombinantly expressed in e.coli. two healthy ponies received intravenous injections of recombinant equine ctni and plasma ctni concentrations were measured with a point-of-care ctni analyzer at multiple time points after injection. standard pharmacokinetic analysis was performed to establish the elimination half-life of ctni. for comparative purposes, data were subjected to pharmacokinetic models describing a single versus biphasic elimination profile. elimination of recombinant equine ctni following intravenous administration exhibits a short half-life. establishing the t / of troponin provides critical information in understanding the clinical application of this cardiac biomarker in clinical practice. this study describes a true biological ctni t / , which has not been documented in any species thus far. stall-side assessment of this cardiac biomarker in horses should enhance the ability of clinicians to detect myocardial damage and aid in the management and treatment of horses with cardiac disease. the objective of the study was to evaluate the between-pony, within-pony, between-analyser and within-analyser variation of flow-mediated vasodilation (fmd) measurement in healthy ponies, to investigate the hypothesis that fmd occurs in healthy ponies. six healthy, native breed, unrelated pony mares of varying weight ( - kg), body condition score ( / - / ) and age ( - years) were used. the median artery was occluded for minutes. twodimensional ( d) ultrasonographic images of the artery were recorded for seconds prior to and for minutes after occlusion. the peak luminal diameter was compared to baseline diameter to calculate the relative percentage increase in luminal size (fmd). images were obtained from six ponies on one occasion and from one pony on six occasions. analysis of images was performed by two independent analysers and by one analyser twice. the mean (sd) fmd in ponies was . % ( . %) and in pony ( occasions) was . % ( . %). coefficients of variation were . % and . % respectively. agreement between analysers was fair (icc . ) and within analyser was poor (icc . ). fmd is used to assess endothelial function in humans and has recently been assessed for its use in canine subjects. fmd occurs and measurement is feasible in ponies. fmd could be used to assess endothelial function, in the context of laminitis or other cardiovascular diseases. current state-of-the-art technique for measuring blood pressure (bp) in the horse is invasive and involves cannulation of the facial artery. indirect techniques, such as oscillometry, have proven useful in the anaesthetised horse, but have not become routine in the standing horse. monitoring bp can be indicated for the diagnosis and treatment of the hypotensive patient (ie. caused by endotoxemia, hypovolemia, systemic inflammatory response syndrome and cardiac failure) or the hypertensive patient (ie. due to equine metabolic syndrome or pain). the objective of this study was therefore to a) describe the methodology for application of oscillometric bp using a cuff applied to the tail in the standing horse and b) and to determine accuracy and precision of this method applied to the normotensive standing horse. the oscillometric method is simple to apply in a clinical setting. a pneumatic cuff is snugly applied to the unclipped tail-base with the cuff bladder centered over the middle coccygeal artery. the tail circumference must match the manufacturers description of the cuffs diameter range. the oscillometric apparatus inflates the cuff and obtain systolic, diastolic and mean arterial bp (sap, dap and map). at least consecutive measurements must be obtained. a correction of . mmhg/cm vertical distance between cuff and heart level is added to the measurement to correct for hydrostatic pressure difference. for determination of accuracy and precision of indirect sap, dap and map, eight healthy horses (age to years), was equipped with an intra-arterial catheter ii in the facial artery and a commercial tail-cuff oscillometric apparatus. i measurements were recorded every minutes for minutes. the data were analysed with the statistical software r using a mixed model with repeated measurements and a bland-altman analysis corrected for repeated measurements. oscillometric bp was accurate and precise for map (mean bias, lower confidence level, upper confidence level, variation in difference, all mmhg) (À . , À . , . , . , respectively) in the conscious horse but not for sap (À . , À . , . , . , respectively) and dap ( . , . , . , , respectively) . there was no significant contribution to the statistical model of either horse or measurement number. all horses tolerated the tail-cuff well and the method was simple to apply. only map could be measured with acceptable accuracy and precision in the normotensive standing horse using the described oscillometric method. reference intervals for thyroid hormone (th) concentrations have not been established for donkeys. therefore, clinicians must use reference ranges from horses, potentially leading to misdiagnosis of thyroid diseases. we hypothesized that th concentrations are different between donkeys and horses. the purposes of this study were: a) to compare th concentrations between donkeys and horses and, b) to determine whether the age may influence th concentrations. thirty-eight healthy donkeys ( . ae . years), mixed breeds, and healthy andalusian horses ( . ae . years) were used. donkeys were divided into three groups: o years (n ), - years (n ), and years (n ). serum concentrations of total triiodothyronine (tt ), free triiodothyronine (ft ), total thyroxine (tt ), free thyroxine (ft ), reverse triiodothyronine (rt ) and thyroid-stimulating hormone (tsh) were quantified by radioimmunoassay. all blood samples were collected the same day. neither horses nor donkeys had received any treatment for days before sampling and both farms had similar production conditions. total t , ft , ft and tt concentrations were higher (p o . ) in donkeys than horses. in contrast, no statistical differences were found for rt and tsh concentrations. young donkeys ( o years) had higher ft , tt and rt concentrations compared to other donkey groups (p o . ). old donkeys ( years) had lower tt and ft concentrations than both younger donkeys groups (p o . ). this study shows that there are differences in th concentrations between donkeys and horses, raising awareness on the possibility of misdiagnosis of thyroid gland dysfunction when using values from horses, being necessary to determine exclusive reference intervals for donkeys. ovariectomy is associated with alterations of responses to many hormones, not just those associated with reproductive function. in humans and rats, ovariectomy leads to insulin resistance, increased adiposity and altered fat mobilization. the effects of ovariectomy on energy metabolism have not been reported in horses. ovariectomized mares have been shown to respond normally to an acth stimulation test, but the response to suppression of the hypothalamo-pituitary-adrenal axis has not been previously described. the aim of this study was to evaluate the effect of ovariectomy on insulin response in mares and to determine if mares exhibit alterations in response to dexamethasone administration after ovariectomy. six healthy mares underwent an intravenous glucose tolerance test (ivgtt), an insulin sensitivity test (ist) and a dexamethasone suppression test (dst) before and weeks after bilateral ovariectomy. body weight, cortisol values at baseline, and hours after dexamethasone injection and acth values at baseline, and hours after dexamethasone injection, basal insulin/glucose ratio, time to reach a % decrease in blood glucose in the ist, time to reach baseline glucose concentration in the ivgtt and area under the curves plotting blood glucose and time to injection of glucose or insulin were compared before and after ovariectomy using a paired t-test or an anova for repeated measures. significance level was p o . . average body weight was decreased after surgery ( kg ). the injection of dexamethasone resulted in a serum cortisol concentration of less than mg/dl in all mares before ovariectomy, whereas after ovariectomy, dexamethasone injection resulted in a serum cortisol concentration of less than mg/dl in out of mares. in all cases, acth concentration was within the reference range ( - pg/ml) before and after ovariectomy. however, acth concentrations at t and at t were significantly higher after ovariectomy. each mare had a normal ivgtt, both before and after ovariectomy. additionally, no significant differences were observed in basal blood glucose ( ae mg/dl before and ae mg/dl after) or in the time to reach glucose baseline ( ae min before and ae min after). serum basal insulin concentration and insulin/glucose ratio was not significantly different before or after ovariectomy ( . ae . miu/ml and . ae . miu/ml and . ae . and . ae . , respectively), nor was the average time to reach a % decrease in blood glucose after insulin injection ( ae min and ae min, respectively). these findings suggest that, as reported in other species, the shortterm effect of ovariectomy may modify dexamethasone response in mares and that, contrary to other species, it may not modify insulin response. equine gastric ulcer syndrome (egus) is a common medical problem in horses. the high prevalence of gastric ulcers, vague clinical signs and negative effect on performance make it a significant clinical and economic problem within the horse industry. current pharmaceutical treatments are expensive and alter the acidic environment of the stomach. berries and pulp from the seabuckthorn plant (hippophae rhamnoides) are a rich source of vitamins, trace minerals, amino acids, antioxidants, and other bioactive substances and have been used successfully to treat stomach ulcers in man and rats. the purpose of this study was to evaluate the efficacy of a commercially sold, liquid extract of seabuckthorn berries (seabuck tm sbt gastro-plus) for treatment and prevention of gastric ulcers in horses. eight thoroughbred and thoroughbred-cross horses ( - years of age, geldings & mares, - kg) were used in a blinded two-period cross-over study. treatments consisted of control (untreated) and treatment (seabuck tm sbt gastro-plus) twice daily mixed with the grain meal. horses were treated for weeks followed by a week alternating feed-deprivation period to induce or worsen existing ulcers. gastroscopies were performed on all horses on day , week , and week (at the end of the alternating feed-deprivation period). gastric juice was aspirated and ph was measured. during gastroscopy, gastric ulcer scores were assigned to each stomach based on lesion number and severity. horses acted as their own controls, and between each treatment period the horses had a -week washout period. data was analyzed by anova for repeated measures via the glm procedure (sas inst. inc., cary, nc). when significant differences (p o . ) were observed, a post-hoc tukey's test was used to determine differences. non-glandular gastric ulcer scores significantly increased in all control and sbt-treated horses from week to week , after the feed-deprivation phase of the study. there was no significant difference in the non-glandular gastric number (p . ) and nonglandular gastric severity (p . ) scores in sbt-treated horses compared to non-treated controls. glandular ulcer number (p . ) and glandular ulcer severity (p . ) was significantly lower in the sbt-treated horses compared to the control horses. there was no significant difference in the ph (p . ) in sbt-treated horses compared to non-treated controls. thus, seabuck tm sbt gastro-plus, mixed in the feed twice daily, may be efficacious in controlling the severity of glandular ulcers in horses during stress, without increasing stomach ph. the availability of rapid and accurate quantitative fibrinogen measurements may be useful for evaluation of hospitalized equine patients. the abaxis vspro analyzer was evaluated for precision using two levels of human fibrinogen controls ( mg/dl and mg/dl), four different vspro machines, and two different lots of cartridges, assessed over subsequent days. the coefficients of variation of the assay ranged from % ( mg/dl) to % ( mg/ dl). we subsequently evaluated the abaxis vspro fibrinogen assay compared to fibrinogen concentration measured using the beckman coulter acl- in equine samples of varying fibrinogen concentrations obtained from horses with gastrointestinal disease. all samples were measured in citrated plasma. fibrinogen samples measured on the acl- ranged from to mg/dl (median mg/dl). vspro samples were run in duplicate, and the mean compared to the acl values. pearson correlation coefficient analysis generated an r value of . (p o . ). duplicate measurements on the vspro were strongly correlated to each other with an r value of . (p o . ). bland-altman analysis of these samples for the vspro compared to the acl- noted a bias of À ae mg/dl the results of this study indicate that the vspro benchtop fibrinogen analyzer provides accurate and precise fibrinogen data compared to the acl- reference analyzer. the immune response of foals to r. equi is incompletely understood and believed to be responsible for clinical disease caused by this pulmonary pathogen. in a recent study foals receiving a large inoculum exhibited th skewing with pneumonia and a small inoculum exhibited th skewing without clinical disease. we hypothesized that cytokine/chemokine production by pulmonary alveolar macrophages, in vitro, would increase with the infective dose and that the magnitude of the response would differ between foals and adults. alveolar macrophages were obtained by bronchoalevolar lavage from healthy mares and their -week-old foals. macrophage cultures were infected with r. equi ( or -) at a multiplicity of infection (moi) of or . total rna was harvested and hours post-infection, reverse transcribed and used as template for quantita-tive pcr. the ddct method was used to calculate relative gene transcripts for il- , il- p , tnfa and cxcl . cellular infections at moi resulted in significantly higher expression of il- , il- p and tnfa mrna transcripts compared to moi . however, the dose-effect was reversed for cxcl with significantly lower expression at the higher moi. there was no difference in magnitude of cytokine/chemokine responses by the alveolar macrophages between adults and foals. dose-dependent responses of alveolar macrophages may represent a novel mechanism by which r. equi could modulate immune responses and therefore disease. significant down-regulation of cxcl mrna transcripts associated with a higher dose is of particular interest as this chemokine plays a role in development of protective th responses. the intent of this study was to develop likelihood ratios (lrs) for infection attributable to corynebacterium pseudotuberculosis in horses based on synergistic hemolysis inhibition (shi) test titers. medical records for horses presented to the uc davis veterinary teaching hospital with serum submitted for shi titer determination were evaluated and cases met study inclusion criteria. these cases were grouped based on evidence of internal and/or external infection attributable to c. pseudotuberculosis and likelihood ratios with % confidence intervals determined. results showed increasing lrs indicating increasing odds for any form of active disease as titer increased with all cases considered. lrs for internal infection were for titers ! overall and for titers with external abscess cases excluded. no difference from (and therefore no significant change in pre-test to post-test odds) was seen in any lrs for internal disease when only cases with external disease were examined (external and internal disease vs. external only). overall, the shi test results showed usefulness in determining internal c. pseudotuberculosis infection in horses with no evidence of external abscessation. overall, however, higher titers were more indicative of active external or internal disease than internal disease specifically in contrast to previous reports. the shi test was unable to distinguish internal infection when external abscesses were present. salmonella enterica is a zoonotic pathogen that has tremendous impact on many different animal production and management systems. rapid detection of s. enterica in fecal samples may facilitate effective infection control practices. current detection methods require - hours (polymerase chain reaction or pcr) or - hours (enriched aerobic culture) to obtain results. alternatives have been developed, lateral flow antigen detection systems (lfads), which are currently marketed for salmonella detection related to food safety microbiology. the objective of this study was to evaluate two commercially available rapid salmonella detection systems in equine feces. fecal samples collected from repeatedly culture-negative horses were inoculated with known concentrations of salmonella enterica serotype typhimurium (five uninoculated control samples, and samples of each -fold dilution [ .  - .  cfu/gram of feces]). all samples were aerobically cultured using a standard enrichment technique. in a blinded fashion, samples were tested using two different lfads as well as plated on agar media for confirmatory testing. at hours of incubation, using bacterial culture as the reference method, test was correctly identify % of samples ( bacterial contamination of stalls with salmonella sp. is a serious problem in equine hospitals. salmonella sp. exposure to horses in the facility can result in nosocomial infections which results in temporary facility closure, until the organism is eradicated. hospital closure can result in loss of revenue, damage to reputation and interference with patient care. the purpose of this study was to evaluate three stall cleaning methods on eradication of salmonella sp. at an equine veterinary teaching hospital (vth). horses admitted to the vth were assigned to salmonella sp.negative stalls within areas of the vth during the study period (september -january . when the horses were discharged stalls were randomly assigned to one of three cleaning methods (pressure-washing only [pw] , pressure washing and hand scrubbing [pws] , or hand scrubbing only [s]) in a single period, non cross-over design. all stalls were stripped of bedding and surfaces sprayed with tap water and cleaned with a disinfectant quaternary-ammonia solution (super hdq neutral, spartan chemical co., inc, maumee, oh). the pressure-washing system (psc cleaning systems, inc., toronto, canada) used, provided a pressure of psi and a temperature range of - f. following cleaning, each stall was allowed to air dry and within hours, stall surfaces were sampled using three  sponges moistened with sterile saline. the person collecting the samples was masked to the method of cleaning. sponges were submitted to the louisiana animal disease diagnostic laboratory (laddl) for culture of salmonella sp. a chi-squared analysis was used to determine significant differences (limit p o . ) between cleaning methods and salmonella sp. isolation. during the study period, stalls (pw [n ]; pws [n ]; s [n ] were included. all stalls had negative environmental salmonella sp. cultures prior to beginning the study. for pw cleaned stalls, / ( . %) were salmonella sp.-positive, for pws cleaned stalls, / ( %) were salmonella sp.-positive, and for s cleaned stalls, / ( . %) were salmonella sp.-positive. although, there were fewer salmonella sp.-positive stalls ( . %) in the handscrubbed stalls, cleaning method did not significantly (p . ) affect the isolation of salmonella sp. from the stall environment. in conclusion, power washing alone, power washing and hand scrubbing, and hand scrubbing alone, using a quaternary-ammonia solution did not significantly affect environmental isolation of salmonella sp. from stalls surfaces in the vth during this study. the objectives of this study were to determine the plasma and pulmonary disposition of gamithromycin in foals and to investigate the in vitro activity of the drug against streptococcus equi subsp. zooepidemicus (s. zooepidemicus) and rhodococcus equi isolates. a single dose of gamithromycin ( mg/kg of body weight) was administered intramuscularly. concentrations of gamithromycin in plasma, pulmonary epithelial lining fluid (pelf), bronchoalveolar lavage (bal) cells, and blood neutrophils were determined using hplc with tandem mass spectrometry detection. the minimum inhibitory concentration of gamithromycin required to inhibit growth of % of r. equi and s. zooepidemicus isolates (mic ) was determined. additionally, the activity of gamithromycin against intracellular r. equi was measured. mean peak gamithromycin concentrations were significantly higher in blood neutrophils ( . ae . g/ml) and bal cells ( . ae . g/ml) compared to pelf ( . ae . g/ml) and plasma ( . ae . g/ml). mean terminal half-lives in neutrophils ( . h), bal cells ( . h), and pelf ( . h) were significantly longer than that of plasma ( . h). the mic of s. zooepidemicus isolates was . g/ml. the mic of gamithromycin for macrolide-resistant r. equi isolates ( g/ml) was significantly higher than that of macrolide-susceptible isolates ( . g/ ml). the activity of gamithromycin against intracellular r. equi was similar to that of azithromycin and erythromycin. intramuscular administration of gamithromycin at a dosage of mg/kg would maintain pelf concentrations above the mic for s. zooepidemicus and phagocytic cell concentrations above the mic for r. equi for approximately days. eight western stock yearling horses were infected with ehv- (ab ) by nasopharyngeal instillation. venous blood samples for collection of plasma were collected in na-citrate tubes on the day prior to infection (d - ) and on d through d . in addition, clinical data, nasal swabs and peripheral blood mononuclear cells (pbmc) for detection of viremia were collected on the day before infection (d - ) and on d through d post-infection. d-dimer concentrations were determined in citrated plasma samples using a latex agglutination test (minutex d-dimer, biopool, ireland). viral load in pbmc was determined using quantitative pcr. all horses showed bi-phasic fevers typical for ehv- infections. one horse developed acute ehm on d and was euthanized after samples were collected. in all horses d-dimers were undetectable on d - and on d , and . in contrast, all horses had increased ddimer concentrations for to consecutive days starting on day post-infection. d-dimer concentrations in horses increased to ug/ml and one of these horses was the horse with acute ehm. interestingly, mean increased d-dimer concentrations showed timely overlap with the mean fever curve and, delayed by day, with the mean viremia curve. because plasma samples for d-dimer measurements were not collected during the first days post-infection, which are typically associated with a primary fever, conclusion on the association of d-dimers with fever of viremia await analysis of a second study currently conducted in our laboratory. in conclusion our data indicates that during ehv- infection with neuropathogenic strains activation of the coagulation cascade and production of cross-linked fibrin is wide-spread; not limited to horses with clinical signs of ehm, and can be expected between days and post-infection. lawsonia intracellularis is an emerging pathogen in horses and the causative agent in equine proliferative enteropathy (epe). the goal of this study was to evaluate the exposure of pre-weanling foals and broodmares to lawsonia intracelluaris on several farms in louisiana with a history of epe and compare the results to several farms with no known clinical cases of epe in foals. an additional goal of the study was to identify whether a relationship exists between lawsonia intracelluaris and other gastrointestinal pathogens in foals. whole blood and fecal samples were collected from mares and foals from four breeding farms in louisiana. farms a and b had no known clinical cases of epe, while farms c and d had previous know cases of epe in . serum samples were examined for the presence of antibodies against lawsonia intracellularis using an immunoperoxidase monolayer assay (ipma). dna was extracted from fecal samples using a commercial dna kit and molecular detection of lawsonia intracelluaris was assayed using real-time pcr. fecal ova were determined using quantitative sucrose floatation. the presence of fecal clostridium difficile toxin was measured using a commercial enzyme linked immunosorbent assay (elisa). three of the farms examined had foals and mares with exposure to l. intracellularis as evidenced by serum antibodies against the organism. of the total population sampled, foals ( . %) and mares ( . %) had evidence of antibodies to l. intracellularis based on serology. three foals ( . %) tested positive for l. intracellularis organism by fecal pcr, and all of these foals were located on farm c. of these, one of the foals was seronegative, while the other two were seropositive. farm c also had the highest percentage of mares ( . %) serologically positive for l. intracellularis, while farm a had the highest percentage of foals ( . %) with antibody titers against l intracellaris. farm c also had the only pairs (n ) of serologically positive mares with seropositive foals. while farm a and b had seropositive mares and/or foals, none of the foals were positive for l. intracellularis fecal shedding by pcr. all serum and fecal samples were negative for evidence of l. intracellaris on farm d. ten foals ( %) had fecal egg counts greater than egg per gram and foals ( %) were positive for c. difficile toxin. this study demonstrated evidence of natural exposure to l intracellularis on farms both with and without a history of epe in louisiana. further, this study failed to establish a relationship between l intracellularis and other gastrointestinal pathogens. the objective of this study was to examine the clinical, hematological, biochemical, and outcome data from equids infected with anaplasma phagocytophilum presented to a primary care field setting in southeastern pennsylvania. computerized medical records from febrile equids with confirmed anaplasma phagocytophilum infection were reviewed. confirmation of anaplasma phagocytophilum was defined by the presence of granular inclusion bodies seen within leukocytes or eosinophils on microscopic blood smear evaluation and/or a positive polymerase chain reaction (pcr) for anaplasma phagocytophilum. horses and donkey presented with a mean fever of . f and mean fever duration of hours. the mean age at presentation was . years and the mean pack cell volume was . %. / cases were diagnosed in the months of may to december. equids ages to years had significantly lower platelet counts. / cases were positive on blood smear for inclusion bodies and / cases were positive for anaplasma phagocytophilum on pcr. treatments included intravenous oxytetracycline, oral doxycycline, or both. mean treatment duration was . days and mean treatment cost was $ . / cases were normothermic within hours. the treatment used in the two remaining cases was changed from oral doxycycline to intravenous oxtetracycline and was successful. this is the first case series of equine granulocytic anaplasmosis in the mid-atlantic states. all cases were examined and treated in the field. in order to make a definitive diagnosis, some cases required pcr. treatment failures were documented with the use of oral doxycycline alone. % of the cases survived. a high incidence of clinical and possibly genetic abnormalities has been reported amongst friesian horses including dwarfism, hydrocephalus, dissecting aortic aneurism and esophageal dysfunction. the purpose of the current study was to develop a new electromyography (emg) method to assess neurophysiological function of the esophagus especially for friesian horses. five friesian horses with esophageal dysfunction were included (ranging in age from . - years and comprising mares and a stallion) and two friesian control horses (a -and -year-old gelding). all five horses with esophageal dysfunction had a history of recurrent esophageal obstruction and were examined histopathologically post-mortem. barium contrast radiography was used as the gold standard to distinguish the diseased from the control horses. an endoscopically-guided percutaneous needle emg procedure (viking quest r ; software version . ) was performed just caudal to the larynx and just cranial to the thoracic inlet (to monitor striated and smooth muscle, respectively) to visualize esophageal motility. esophageal contractility in both control horses was predominantly reflected by interference patterns associated with longer duration and lower amplitude in smooth muscle compared to striated muscle. mean (ae sd) values were . ae . ms and . ae . mv (n readings) and . ae . ms and . ae . mv (n readings), respectively. in diseased horses, aperistalsis in smooth muscle was the most remarkable finding suggesting a loss of inhibitory neurogenic input resulting in aperistalsis and thus esophageal dysfunction. preliminary findings suggest that endoscopically-guided percutaneous needle emg might become a valuable method in elucidating the pathophysiology of dysfunction of esophageal motility especially in friesian horses. lymphoma affects horses of all ages. unlike in humans, no etiologic agent has been discovered. a year old thoroughbred/warmblood cross mare presented with signs of upper and lower respiratory disease and was subsequently diagnosed with lymphoma and equine multinodular pulmonary fibrosis (empf) and was positive for equine herpes virus (ehv- ) in both the pulmonary tissue and the lymph nodes. retrospective polymerase chain reaction (pcr) testing of six lymphoma cases found that of of the cases were positive on pcr for ehv- ( . %, p . , rr . ). electron microscopy was performed on one sample and herpes virus particles were identified. of the samples in which immunohistochemistry was performed ( of ), only t-cell rich b-cell lymphoma was identified. samples of mesenteric or submandibular lymph nodes from clinically healthy horses were submitted for ehv- pcr analysis; % were positive. gamma herpesviruses in humans have been associated with lymphoproliferative diseases such as kaposi's sarcoma and burkitt's lymphoma. equine herpesvirus , also a gamma herpesvirus, is found in association with equine lymphoma; although the exact role this virus plays in the initiation or perpetuation of lymphoproliferative neoplasia remains unknown. pathologic events reported to occur in the digital laminae in early stages of sepsis-related equine laminitis include leukocyte extravasa-tion into the laminar interstitium, pro-inflammatory cytokine expression, and epithelial stress. while these events have been documented early in the disease process at both a developmental stage and at the onset of obel grade (og ) lameness in the carbohydrate overload (cho) model of laminitis, the later events occurring at the onset of obel grade lameness(og , time point at which structural failure of the laminae usually occurs) have not been determined. we hypothesized that the inflammatory events described above are sustained through og lameness, likely playing an injurious role culminating in laminar failure. our objectives were to determine pro-inflammatory gene expression, leukocyte extravasation, and epithelial stress at og induced using the cho model. archived laminar tissue samples (snap frozen and paraffin embedded sections) were used from a previous cho study at louisiana state university (control group [n , water], cho group [n , corn starch]. calprotectin (cp) immunohistochemistry (ihc) was used to assess both laminar myeloid leukocyte numbers and epithelial stress; rt-qpcr was used to assess inflammatory gene expression. minimal inflammatory changes were present at og compared to published values at og stage in the cho lameness model including decreased mrna concentrations of cytokines (i.e. -fold increase in il- at og vs. -fold increase at og , no increase in il- b at og vs. -fold increase at og ), chemokines (no change in mcp- at og vs. fold increase at og , -fold increase in il- at og vs. fold increase at og ) and adhesion molecules (no change in e-selectin at og vs. -fold increase at og ). laminar leukocyte emigration was also decreased at the onset of og lameness compared to previously reported leukocyte infiltration at og . interestingly cox- , underwent a greater increase at og (approx. -fold) compared to that reported at og lameness ( -fold). finally, epithelial stress at og evidenced by cp ihc did not follow the uniform widespread distribution reported at og lameness, but instead was present in focal areas in which secondary epidermal laminae on either side of a common primary dermal vascular supply demonstrated increased cp signal. overall, laminar inflammation appears to be subsiding at og lameness, with epithelial stress possibly more dependent on vascular dysregulation instead of inflammatory events. the sustained increase in cox- , central to the induced production of vasoactive prostanoids in disease processes, may play a role in vascular dysregulation. this study was conducted to characterize clinical, laboratory and postmortem findings associated with oleander toxicosis in equids and to determine factors predictive of survival in these cases. retrospective analysis of medical records from our veterinary medical teaching hospital from january , to july , was completed. records of equids demonstrating detectable oleandrin in serum, plasma, urine or gastrointestinal fluid samples or detectable serum digoxin in the absence of pharmaceutical cardiac glycoside administration were included. descriptive statistics were used to evaluate the history, physical examination, and laboratory and postmortem data of affected individuals. logistic regression analysis was used to detect physical examination and laboratory factors significantly associated with survival. thirty equids met inclusion criteria of the study. three of subjects were dead on arrival or died immediately upon arrival ( %). of the remaining equids, % presented with gastrointestinal abnormalities, % were azotemic and % had cardiac arrhythmias. mortality was % for all subjects and % for those treated. the predominant cause for non-survival was cardiac dysfunction. factors significantly associated with survival included relatively decreased hematocrit and serum glucose, relatively increased serum chloride, absence of cardiac arrhythmias, and increased duration of hospitalization. equids with oleander toxicosis frequently present with gastrointestinal upset and may develop cardiac and renal disturbances. patients with cardiac arrhythmias and relatively increased hematocrit and serum glucose and decreased serum chloride are significantly less likely to survive. oleander intoxication is a differential diagnosis for colic in endemic areas, particularly with concurrent azotemia or cardiac dysrhythmia. the quantitative physicochemical approach emphasizes the importance of strong ions (na, k, cl, lactate), pco , and the plasma protein concentrations in determining plasma ph. serum concentrations of strong ions, proteins, and total co are reported on modern biochemical profiles. we hypothesized that the results of serum biochemical analysis can be used for acid-base interpretation in horses. the objective was to determine whether blood ph, anion gap, and strong ion gap could be quantitatively estimated and clinically used based on the results of serum or plasma biochemical analysis. horses ( adults and foals) presented to the isolation unit of our veterinary teaching hospital for suspected infectious diseases were prospectively enrolled. a venous serum sample was analyzed using a hitachi or copas c automated machine. measured parameters included strong ion difference (sid {na k}-{cl lac-tate}), total protein concentration (tp), and total co (tco ), with lactate being measured by blood gas analyzer. a second venous blood sample was collected into a na-heparin blood gas syringe and analyzed for ph (ph m ), pco and concentrations of na, k, cl, and lactate using a radiometer flex blood gas analyzer; sid was calculated from the measured values, and total solids (ts) were estimated using refractometry. serum/ plasma ph (ph calc ) was calculated using stewart's factor equation from the results of serum or plasma biochemical analysis, assuming pco mmhg for serum and pco accurate for plasma. anion gap (ag) was calculated as: ag (na k)-(cl tco ). strong ion gap (sig) was calculated as: sig . x[total protein, g/l]/ ( {pka-ph} )-ag. linear regression analysis was used to compare ph calc to ph m, as well as ag and sig to blood lactate concentrations. measured ph ranged from . to . ( . ae . ). measured sid from serum biochemistry (sid sb ) ranged from . to . meq/l ( . ae . meq/l) and sid from blood gas analyzer (sid bg ) from . to . meq/l ( . ae . meq/l; r . ; sid bg .  sid sb ). sid sb and sid bg showed small variability in measurements. tp ranged from to g/l ( . ae . g/l) and ts from - ( . ae . g/l; r . ; ts .  tp). using sid sb and tco values with constant pco , ph calc was poorly associated with ph m (r . ; ph calc . . ). in contrast, using sid bg with accurate pco , ph calc was closely associated with ph m (r . ; phcalc . . ) and the equation was not different from the line of identity. anion gap and sig (meq/l) calculated were significantly linearly correlated with lactate concentrations (mmol/l); ag .  [lactate] . (r . ), and sig À .  [lactate] . (r . ). we conclude that ph calc using sid sb , tco and constant pco values is not accurate. however, variability of measured biochemical parameters between machines was small, permitting use of serum biochemistry for clinical metabolic acid-base abnormalities interpretations of patients. these results reemphasize the importance of strong electrolytes and proteins in acid-base balance. metalloproteinases (mmps) are critically important in remodeling processes and in wound healing. however, excessive activation of mmps by pro-inflammatory mediators including cytokines, prostaglandin e , and nitric oxide lead to tissue breakdown. this is observed in osteoarthritis (oa) which is characterized by erosive lesions in articular cartilage. in hereditary equine regional dermal asthenia (herda), afflicted horses exhibit collagen abnormalities and can have associated chronic inflammation and aberrant wound repair. herda affects horses with quarter horse bloodlines and is similar to the human hereditary connective tissue syndrome ehlers danlos (eds). many adult eds patients suffer from joint pain and oa. we hypothesized that chondrocytes from articular cartilage of herda horses have increased activity of mmps. to test this hypothesis, chondrocytes were retrieved from articular cartilage of homozygous herda carpal and hock joints. chondrocytes from normal horses were also obtained for comparison. chondrocytes were seeded at x /ml into -well plates and incubated at c, % co for up to seven days. activity of secreted mmps was determined by zymography using equal amounts of proteins for loading. secreted mmps were analyzed by western blot. zymography showed that normal chondrocytes secreted two major bands with gelatinolytic activity observed at and kda suggestive of the latent form of mmp- and mmp- , respectively. less intense bands of gelatinolytic activity were observed at about and kda suggestive of the active form of mmp- and mmp- . another band of activity was also seen at kda which is suggestive of a dimer of mmp- that has been reported when mmps are in excess of tissue inhibitors of metalloproteinases (timps). chondrocyte cultures from homozygous herda cartilage showed a similar profile but with decreased activity by % at kda and - % increased activity at kda compared to normal chondrocytes. western blot analysis detected mmp- and mmp- immunoreactivity in chondrocyte culture media of herda-afflicted and normal horses. the present study demonstrates for the first time that horses suffering from herda have increased mmp activity which may predispose them to the development of lesions in articular cartilage. research supported by nutramax laboratories, inc. equine polysaccharide storage myopathy (pssm) type is a dominantly inherited glycogenosis caused by a mutation in the gene coding for skeletal muscle glycogen synthase type (gys- ). the disease has been reported to affect the haflinger breed but so far its prevalence is unknown. aim of this preliminary study was to estimate the occurrence of the gys- mutation in austrian haflingers and establish which of the seven haflinger sire lines appear mostly affected. gys- genotyping of randomly chosen haflingers was performed with a validated restriction fragment length polymorphism assay. resting and post-exercise muscle enzyme activities (creatine kinase (ck), aspartate aminotransferase (ast), lacate dehydrogenase (ldh)) and blood lactate concentrations were compared between horses with and without the mutation. among the horses were heterozygous (hr) carrier of the mutation. no homozygotes (hh) were identified. all horses with the gys- mutation were descendents of the a-or w-sire lines. the estimated hr prevalence was % ( % ci: . - . %). ck activity after exercise (p . ) was significantly higher in hr horses compared with horses not carrying the mutation (rr). ast activity was significantly higher in the hr group at rest and after exercise (p o . ). there was no statistically significant difference in resting ck, resting and post exercise ldh activity or blood lactate between hr and rr. results suggest that the prevalence of hr in the austrian haflinger population is higher than in the overall quarter horse population and might be as high as %, similar to some draft horse breeds. further research is needed to establish the prevalence within the different breeding lines. hereditary equine regional dermal asthenia (herda) is an autosomal recessive connective tissue disorder affecting quarter horse lineages. although a mutation in the gene encoding cyclophilin b has been genetically linked to herda, its causal association with the disease is not yet documented. previously, we demonstrated reductions in ultimate tensile strength (uts), modulus of elasticity, and energy to failure (toughness) of skin from many corporal regions of herda animals. given the presumed relationship between her-da and abnormal collagen structure, and the predominance of type i collagen in skin, we hypothesized that altered biomechanical properties would be detected in tendons which are rich in type i collagen. to evaluate this hypothesis we compared the uts, modulus of elasticity, and energy to failure of forelimb deep digital flexor tendons (dft) from six herda horses to six age-matched controls. isolated dft was secured and pulled to failure on an instron s universal testing instrument using purpose-built cryogenic clamps. analysis of variance was executed using sas . proc glimmix program (sas institute, ). p-values . were identified as significant. uts and modulus of elasticity were significantly lower in herda dft when compared with controls (p o . ); energy to failure did not differ between groups. these findings document abnormal biomechanics in herda tendon, leading us to postulate that lower uts and modulus of elasticity associated with the herda defect could convey a competitive advantage in the athletic disciplines in which this defect has segregated. (references on request). a proprietary herbal biocontamination product (bios) approved for cosmetic use in france, inhibits proliferation of medically relevant bacteria, mold, and viruses. these properties make bios potentially useful as a topical wound medication, prompting us to compare bios to silver sulfadiazine (ssd) in a distal extremity wound healing model in horses. using general anesthesia, two . cm wounds were aseptically created on the dorsomedial aspect of all limbs. for the duration of the study, two contralateral limbs were randomly chosen to be bandaged; the other two limbs were un-bandaged -with one limb of each group being treated with % bios and the other with ssd. for each limb the most proximal wound served as an untreated control. every hours wounds were evaluated, digitally photographed, and perimeter and area determined using morphometric software (imagej, nih). analysis of variance did not identify significant differences between ssd or bios treatment for wound perimeter (p . ) or area (p . ). at individual time points the effect of bandaging was significant when area was evaluated (p . ) and trended toward significance for perimeter (p . ) comparisons, substantiating published reports that bandaging modifies wound healing. difference in perimeter and area between control and treatment were highly significant (p o . ), substantiating the importance of topical treatment. over the study duration, effects of bandaging (p o . ) and topical treatment (perimeter p o . ; area p . ) continued to be highly significant. bios performance in the equine distal extremity wound model was equivalent to ssd. both bandaging and topical treatment significantly impacted wound healing. this effect was compounded when both variables were evaluated over time. radiolabeled leukocytes are the only scintigraphic method currently available for identifying sites of infection and/or inflammation in horses; however the clinical applicability of this technique is limited by expense and poor efficacy. this pilot study compares the accumulation of m tc-labeled igg, peg-liposomes and leukocytes in an equine muscle abscess model. three mixed breed adult horses had  cfu s. equi zooepidemicus inoculated into the right semitendonosis to create an abscess. peg-liposomes were prepared via the film hydration method and labeled using mci m tc-hexamethyl-propylene-amine-oxime ( m tc-hmpao). autologous leukocytes were obtained from ml whole blood and labelled using mci m tc-hmpao. commercial equine polyclonal igg was conjugated with the chelator hydrazinonicotinamide (hynic) and labelled with mci m tc. radiopharmaceutical administration was initiated hours after inoculation. horses and received mg m tc-igg, . mmol/kg m tc-liposomes and m tc-leukocytes, with a hour interval between each radiopharmaceutical. horse received only m tc-leukocytes. scintigraphic examinations were performed at and hours post injection (p.i.) with each radiopharmaceutical. after the final study, horses were euthanized and tissue samples collected. the percentage of injected dose per kilogram of tissue (%id/kg) was calculated for the region of the abscess, normal muscle and multiple organs. scintigraphic examinations demonstrated increased radiopharmaceutical in the region of the abscess with all three techniques at both time-points. at hours p.i. abscess-to-background ratio was highest using m tc-igg ( . ae . ). at hours p.i. abscess to background ratio was highest using m tc-liposomes ( . ae ). tissue biodistribution data revealed abscess to muscle ratios of ( m tc-igg), ( m tc-liposomes), and . ( m tc-leukocytes). this preliminary data demonstrates that m tc-liposomes, m tc-igg and m tc-leukocytes exhibit long circulating characteristics and accumulate at inflammatory/infectious foci after intravenous injection in horses. m tc-igg and m tc-liposomes appear to be superior to m tc-labelled leukocytes in this model. due to its low cost and ease of preparation, m tc-igg has great potential for clinical use where identification of infectious or inflammatory foci is necessary. digital hypothermia is used clinically to decrease the incidence of sepsis-related equine laminitis, a disease causing structural failure of digital laminae resulting in crippling lameness. due to the fact that hypothermia was recently reported to effectively decrease laminar expression of inflammatory molecules including pro-inflammatory cytokines, chemokines and cox- in equine laminitis, our laboratory is investigating the effect of hypothermia on central upstream signaling cascades which may induce expression of these diverse inflammatory molecules. the p mapk pathway has recently been reported to be a central component of inflammatory signaling in multiple diseases including human sepsis, and is currently being assessed as a therapeutic target. we thus hypothesized that ) p mapk is upregulated and activated in affected laminae in equine laminitis and ) digital hypothermia inhibits inflammatory mediator expression by blocking p mapk phosphorylation (indicator of p mapk activation). western hybridizations using both a total p mapk and a phospho-p mapk antibody were performed on archived pooled laminar samples from black walnut extract (bwe) model ( control, developmental (dev) groups [ . h & h post bwe administration] and the onset of obel grade lameness (og ) [n each]) and carbohydrate overload (cho) models (con [n ], dev [n ], og [n ]) of laminitis, and individual laminar samples from two groups of horses from a digital hypothermia (dh) study. in the dh study, one forelimb of each horse was kept at approximately c in ice water and the other at ambient temperature following administration of g/kg oligofructose (of). dorsal laminae were harvested for snap freezing at either hours after of administration (dev, n ) or at the onset of lameness (og , n ) using protein extracted from treated and untreated digital laminae of each horse. increased laminar concentrations of phospho-p mapk were present in the developmental periods ( . h and h) in the bwe model, and in both the dev and og periods in the cho laminitis models. however, digital hypothermia had no effect on laminar phospho-p mapk concentrations. thus, p mapk is activated in affected laminae in multiple models of laminitis, but does not appear to be the central signaling cascade through which hypothermia works to block the expression of inflammatory molecules. therefore, p mapk is not likely to be a viable therapeutic target as a sole source for blocking the multiple inflammatory signaling mechanisms inhibited by local hypothermia. abstract e- does cefquinome penetrate the blood brain barrier in the normal horse? hollis ar duggan ve and corley ktt . scott dunn's equine clinic, berkshire, uk; university college dublin, dublin, ireland; anglesey lodge equine hospital, the curragh, ireland. meningitis is a rare but serious condition that occurs in both foals and adult horses. there is currently a restricted choice of antimicrobials that are both safe to use in horses and penetrate the blood brain barrier. cefquinome is a fourth generation cephalosporin that has activity against streptococcus, the most commonly reported causative organism in adult horse meningitis. therefore, if cefquinome were to achieve therapeutic concentrations in cerebrospinal fluid following routine administration, this would be an exciting advance for the treatment of meningitis in the horse. mature, healthy horses were used on separate occasions, seven days apart, in a crossover design. each horse was administered either cefquinome ( mg/kg) or saline (equivalent volume). cerebrospinal fluid was collected via atlanto-occipital puncture under general anaesthesia and hours after administration of cefquinome or saline placebo. blood samples were collected prior to, and and hours after administration of cefquinome or placebo. all samples were analysed for the presence of cefquinome by a laboratory masked to treatments administered. cefquinome was detectable in the cerebrospinal fluid in all horses hours after intravenous administration, and in horses hour after administration. cefquinome penetrates the blood-brain barrier and it is therefore a potential treatment for equine meningitis. further investigation of the pharmacokinetics and pharmacodynamics of cefquinome in the cerebrospinal fluid is warranted to establish the optimum intravenous dose. the purpose of this study was to determine if enrofloxacin alters the pharmacokinetics of firocoxib in the horse. firocoxib is a coxibclass nonsteroidal anti-inflammatory drug (nsaid) approved for use in horses to control pain and inflammation associated with osteoarthritis. dosages of firocoxib are species dependent, with the recommended dose for horses being . mg/kg as an oral paste every h. the main elimination pathway of firocoxib is hepatic; however the effects of concurrent administration of drugs that may inhibit its metabolism have not been evaluated. enrofloxacin is a synthetic antibacterial agent from the flouroquinolone group developed for veterinary use. it is primarily used for gastrointestinal, urogenital, skin and respiratory tract infections in various animals. a well acknowledged problem associated with flouroquinolone usage is their effect on the metabolism of other drugs. co-administration of multiple drugs can result in unpredictable therapeutic outcomes. often it is either diminished therapeutic efficacy or increased toxicity of one or more of the administered drugs. various pharmacokinetic interactions between antimicrobials and nsaids have been described. six healthy, adult mares were administered . mg/kg of firocoxib orally. samples were collected by direct venipuncture of the jugular vein at (control), , , and min, , , , , , , , , and h after administration. after a day washout period the six horses were pretreated days with enrofloxacin mg/kg intravenously every h then on the fourth day given . mg/kg of firocoxib orally. samples were collected at (control), , , and min, , , , , , , , , and h after administration. all samples were stored at À c until analysis using a validated hplc method. the t / , c max , t max , auc - and auc -f after firocoxib administration were . angiotensin converting enzyme (ace) inhibitors improve survival and quality of life in humans and small animals with cardiovascular and renal disease. there is limited information regarding their effects in horses. the purpose of this study was to determine the pharmacokinetics of quinapril and its effects on ace inhibition in horses. six healthy horses were administered quinapril at mg iv, mg po or mg po in a -way crossover design. blood was collected at predetermined times for measurement of quinapril and quinaprilat concentrations using high pressure liquid chromatography, as well as ace concentrations using a radioenzymatic assay. normally distributed data were analyzed with one way repeated measures analysis of variance (rm-anova) and non-normally distributed data were analyzed using friedman rm_anova on ranks. significance was set at p o . . no adverse effects were observed during the study period. plasma quinapril concentrations were low and rapidly declined after iv administration. quinaprilat concentrations were below the limit of quantification ( . mg/ml). ace activity was significantly decreased from baseline at . and hour after iv dosing and at all timepoints after oral dosing. maximum % ace inhibition was , and % with the iv, high and low oral doses, respectively. these results suggest that, despite low plasma concentrations, quinapril has sufficient oral absorption and results in inhibition of ace in healthy horses. controlled studies in clinically affected horses are indicated. this study determined the pharmacokinetic profile of firocoxib in healthy neonatal foals. foals are more sensitive to the side effects of nsaid, primarily due to immature renal clearance mechanisms and ulcerogenic effects on gastric mucosa. firocoxib, a novel, second generation nsaid, is reported to have reduced side effects due to cox- selectivity. the pharmacokinetic profile of firocoxib in neonates has not been established. we hypothesized that firocoxib given po to neonatal foals would achieve therapeutic concentrations in plasma. seven healthy foals of mixed gender were administered . mg/kg firocoxib po q h for nine consecutive days, commencing at h old. blood was collected for firocoxib analysis at (dose # only), . , . , , , , , and h after doses # , and . for all other doses ( , , , , and ) blood was collected immediately prior to the next dose ( h trough). elimination samples were collected after dose # . plasma was stored at À c until analysis. physical examinations were performed on foals daily and body weight obtained every two days during the sampling period. analysis of plasma samples by liquid chromatography-mass spectrometry revealed firocoxib was rapidly absorbed. after the initial dose, a maximum plasma concentration was reached in min, minimal accumulation after repeat dosing occurred and steady state was obtained after approximately four doses. after the final dose, plasma drug concentration decreased in a linear manner with an estimated terminal t / of h. seventy-two hours after the final dose, firocoxib was not detectable (o ng/ml). erythrocytosis is reportedly a rare finding associated with hepatocellular carcinoma in horses. the purpose of this study was to determine the relative frequency of erythrocytosis and the clinicopathologic abnormalities and hepatic histopathology associated with erythrocytosis in horses with liver disease. ninety-seven horses aged ! year with clinicopathologic or clinical signs of liver disease, a complete blood count (cbc), and hepatic histopathology were included. information on cbc, biochemical variables, and hepatic histopathology was collected from records. data from horses with erythrocytosis (packed cell volume %) were compared to those without using the mann-whitney rank sum test with significance set at p o . . there were no differences between groups in white blood cell count, gamma-glutamyl transferase, sorbitol dehydrogenase, aspartate aminotransferase, and alkaline phosphatase activities, total protein, albumin, globulin, blood urea nitrogen, or glucose concentrations. fibrosis ( %), biliary hyperplasia ( %), inflammatory infiltrate ( %), megalocytosis ( %), degeneration ( %), necrosis ( %), cholestasis ( %), anisocytosis and anisokaryosis ( %), and lipidosis ( %) were observed in livers of horses with erythrocytosis. neoplasia ( %) was observed rarely. this study reports a high frequency of erythrocytosis in horses with liver disease. erythrocytosis is associated with higher total bilirubin and serum bile acids concentrations. common histopathologic changes include fibrosis, biliary hyperplasia, and inflammatory infiltrate. hepatic neoplasia was rare. this study was performed to determine if horses diagnosed with equine proliferative enteropathy (epe) from lawsonia intracellularis (li) infection had long term effects from disease based on their sale price as yearlings and race earnings. a retrospective review of medical records of thoroughbred horses that were treated for lawsonia intracellularis infection between january , and january , at hagyard equine medical institute in lexington, kentucky was performed. three criteria were used for inclusion in this study. first, each horse had presumptively been diagnosed with li based on physical examination findings such as ventral edema, diarrhea, lethargy, or poor body condition. second, horses had hypoalbuminemia of less than . mg/dl (normal reference range: . - . mg/dl). third, each horse had a positive fecal polymerase chain reaction (pcr) for li, a positive serum immunoperoxidase monolayer assay (ipma), or both. an ipma titer greater than or equal to was considered positive for disease. horses met the initial criteria. of the horses sold at public auction as yearlings. the sale price of these horses was compared to the average sale price of all yearlings by the same sire as the affected horse (control group). of the horses raced in the united states. their monetary earnings from racing were compared to the average monetary earnings of all progeny by the same sire as the affected horse (control group). earnings of horses that were between and years of age ( / horses) at the conclusion of the study were compared to the lifetime average earnings of the stallion's progeny. earnings from horses that were two years of age ( / ) at the end of the study were compared to the two year old average earnings of the stallion's progeny. monetary earnings from all races prior to december , were included in the study. horses both sold at public auction and raced. as well as being included in the total number of horses that sold and raced, their sale records and monetary earnings were compared to the averages from their respective sire as a separate group. this retrospective study indicated that yearling horses previously infected with li do not sell for as much at public auction as their herdmates, but their monetary earnings from racing are not significantly different from other horses. these results should assist practitioners in guiding owners in determing if treatment of horses with epe is appropriate and it may aid in reassuring owners that despite the poor condition of the horse during and shortly after the course of disease, horse may still have future athletic potential. this abstract was presented at the aaep in december . bronchopneumonia caused by streptococccus equi subsp. zooepidemicus (s. zooepidemicus) is one of the most important causes of morbidity in weanling foals. ceftiofur crystalline free acid (ccfa) is a long acting third-generation cephalosporin antimicrobial recently approved for the treatment of bronchopneumonia associated with s. zooepidemicus in adult horses. the objective of the present study was to determine the disposition of ccfa in plasma and pulmonary epithelial lining fluid (pelf) of weanling foals. six healthy -to month-old weanling foals were administered a single intramuscular injection of ccfa at a dose of . mg/kg of body weight. concentrations of desfuroylceftiofur acetamide (dca) and related metabolites were measured by use of ultra-high performance liquid chromatography and tandem mass spectrometry. following im administration, median time to maximum plasma and pelf concentrations was h ( - h) . mean (ae sd) peak dca concentration in plasma ( . ae . mg/ml) was significantly higher than that in pelf ( . ae . mg/ml). terminal half-life of dca in plasma ( . ae . h) was not significantly different from that of pelf ( . ae . h). time above the therapeutic target of . mg/ml was significantly longer in plasma ( ae h) than in pelf ( ae h). based on the results of the present study, intramuscular administration of ccfa at a dose of . mg/kg would be appropriate for the treatment of bronchopneumonia caused by s. zooepidemicus and other susceptible pathogens in weanling foals. fgf- is secreted by osteocytes and osteoblasts in response to hyperphosphatemia. fgf- enhances phosphaturia and is postulated to have a central role in the development of secondary renal hyperparathyroidism. hyperthyroid cats have elevated plasma phosphate and parathyroid hormone concentrations, which may in part be associated with underlying chronic kidney disease (ckd). the aim of this study was to determine if plasma fgf- concentrations were associated with the presence of underlying ckd in hyperthyroid cats, and to investigate the changes in plasma fgf- concentrations that occur following treatment of hth. hyperthyroid cats were recruited from two london-based first opinion practices between and . cats that were azotemic at diagnosis were excluded. hth was treated with anti-thyroid medication alone or in combination with thyroidectomy. cats were included in the study if they had a plasma total thyroxine concentration o nmol/l documented for a six month period following commencement of treatment. cats were classified as having azotemic ckd if they developed renal azotemia within six months of establishment of euthyroidism. otherwise cats were deemed to have normal renal function. stored edta plasma samples were assayed for fgf- using a recently validated elisa. the mann-whitney u test and the wilcoxon signed rank test were used to compare between the groups and assess the response to treatment respectively. results are reported as median [ th , th percentiles]. correlations were made using spearman's correlation coefficient. thirty one cats with hth ( azotemic and non-azotemic) were included in the study. plasma phosphate concentrations decreased following treatment in cats that did not develop azotemia ( . [ . , . ] mg/dl vs. . [ . , . ] mg/dl; n , p . ) whereas plasma phosphate concentrations did not change significantly following treatment in cats that did develop azotemia ( . [ . , . ] mg/ dl vs. . [ . , . ] mg/dl; n , p . ). plasma fgf- concentrations were significantly higher in cats that developed azotemia than cats that did not at both pre treatment ( . [ . , . ] pg/ml vs. . [ . , . ] pg/ml; p . ) and post treatment ( . [ . , . ] pg/ml vs. . [ . , . ] pg/ml; p . ) timepoints. plasma fgf- concentrations increased following treatment in both azotemic (p . ) and non-azotemic groups (p . ). plasma fgf- concentrations and plasma phosphate concentrations were not correlated at baseline (r s . , p . ) or following treatment (r s . , p . ). plasma fgf- concentrations were higher in pre-azotemic cats than non-azotemic cats and increased following treatment of hth. the reason that fgf- concentrations increased following treatment, particularly in the face of decreasing plasma phosphate concentrations in cats that remain non-azotemic, is unclear but may be related to the decline in glomerular filtration rate. hyperthyroidism is a disorder resulting from the excessive production and secretion of t and t by the thyroid gland. although the disorder and its pathological lesions have been well studied and described the cause remains illusive. whole blood and solid tissue samples from non-diseased, severe disease and mild disease cats based on t levels and thyroid histology were used in this study. whole blood samples from non-disease cats, severe disease cats and mild disease cats as well as solid thyroid tissue samples from non-disease cats, severe disease cats and mild disease cats were collected and processed. the resulting total rna samples were used for genechip analysis using our custom feline gene chip designed by affymetrix. data analysis was performed using the partek s gs software for gene expression data. the robust multichip average algorithm was used for background adjustment, normalization, and probe-level summarization of the raw data. anova analysis was performed to find significant differentially expressed genes with a minimal false discovery rate control of . and a fold change of . in each direction. during the mild disease state, pathways associated with dna damage and apoptosis are most prominent. at later stages when the histopathological disease is more severe in addition to the aforementioned pathways others associated with tgf-beta signaling, cell adhesion and extracellular matrix remodeling take more prominence. the analysis of this unique data set generated from the use of our proprietary genechip revealed molecular mechanisms that are associated with the transition from non-disease, to mild disease to severe disease, in the thyroid tissue as well as the blood. these mechanisms could provide insights into the causes of the disease and identify potential new therapeutic and diagnostic targets. although it is well established that concurrent chronic kidney disease (ckd) develops in about % of hyperthyroid cats, no one has reported the use of the iris staging system for ckd before and after treatment of these hyperthyroid cats. the purpose of this study was to compare the effects of treatment in hyperthyroid cats with known stage and ckd in order to determine the effects of restoring euthyroidism or inducing hypothyroidism has on the iris stage in these cats. we evaluated hyperthyroid cats (median age, years) in this study. one day prior to treatment, serum t concentration, serum chemistry analysis, complete urinalysis, and urine protein-to-creatinine ratio (upc) were measured. all cats were again evaluated with the same parameters again months after treatment with i. prior to treatment, ( %) of the cats had no evidence of azotemia (serum creatinine o . mg/dl), whereas cats ( %) had stage ckd (serum creatinine, . - . mg/dl). in the cats, iris staging revealed proteinuria in cats ( %), with borderline proteinuria (upc, . - . ) and with overt proteinuria (upc . ). hyperthyroidism was cured in all cats (median post-t , . mg/dl). all cats had a good response to treatment; there were no signs of ckd except for polyuria and polydipsia in some cats. a significant (p o . ) increase in median values for both serum urea nitrogen ( mg/dl to mg/dl)) and creatinine ( . to . mg/dl) occurred after treatment. nine of the cats ( . %) classified as nonazotemic or iris stage prior to i progressed to stage ckd after i. all cats with stage ckd before treatment remained azotemic after i, with cats remaining in stage ckd, and cats progressing to stage ckd (serum creatinine, . - . mg/dl). there was a significant inverse relationship (p . ) between pretreatment urine specific gravity (usg) and post-treatment serum creatinine in the cats. of the cats with post-treatment serum creatinine values . mg/dl (stage to ckd), ( %) had pretreatment usg of o . . in contrast, in the cats with post-treatment serum creatinine values o . mg/dl, only ( %) had pretreatment usg of o . . a significant (p o . ) decrease in median upc from . to . occurred after treatment, but there was no relationship between degree of proteinuria and iris stage in these cats. two cats developed iatrogenic hypothyroidism after i, diagnosed by finding low serum t and high ctsh concentrations. both hypothyroid cats had progressed from stage before treatment to stage and ckd, respectively, after i; after thyroxine replacement, serum creatinine decreased to near pretreatment concentrations in both cats. conclusions: ) iris stage ckd is common in untreated hyperthyroid cats. ) progression to next higher iris stage is common after treatment, but most cats with remain relatively asymptomatic for ckd. ) usg may be helpful in predicting which cat's iris stage will progress after i. ) iatrogenic hypothyroidism worsens azotemia, an effect that appears reversible with replacement therapy. home blood glucose monitoring (hbgm) of diabetic pets is likely to result in superior glycaemic control, minimizing episodes and impact of dangerous hypoglycaemia and reducing costs. nevertheless, it has proven difficult to objectively establish a clear benefit of hbgm using biological parameters (clinical signs, blood glucose, fructosamine). the current study aimed to assess the impact of hbgm on owner perceived quality of life (qol) aspects of diabetes mellitus (dm) treatment, using the recently validated psychometric tool diaqol-pet. owners of insulin treated diabetic cats were recruited to complete the -item tool, evaluating areas affecting the cat's and owner's qol, including: worry about pet's dm, hypoglycaemia, costs, owner's desire for autonomous control over the pet's dm, etc. item-weighted-impact-scores (iwis), reflecting frequency and importance ratings of each item, were calculated, as well as averageweighted-impact-scores (awis; average iwis of all items), as an overall measure of diabetes dependent qol. frequencies, iwis and awis were compared between owners practising hbgm and those who did not using mann whitney u test (significance p o . ). two hundred and eleven owners of insulin treated diabetic cats completed the diaqol-pet; owners practised hbgm, whereas the remaining did not practise any form of home monitoring (including urine glucose). iwis for 'excessive drinking' and 'owner wanting more control' were significantly different between the hbgm-group (mean /-standard deviation: À . /À . and À . /À . ) and the non-hbgm-group (À . /À . and À . /À . ). there was no significant difference between the groups with regards to the iwis for other items, including 'worry about hypoglycaemia' or 'worry about pet's dm'. polydipsia was reported significantly more frequently in the non-hbgm-group and this was the reason for the difference between groups in this item's iwis as it was considered of equal importance. frequency and iwis of reported occurrence of hypoglycaemia signs were not significantly different. awis for both groups was not significantly different (hbgm: À . /À . ; non-hbgm: À . /À . ). the current study suggests that hbgm is predominantly practised by owners who desire more autonomous control over their cat's dm. the frequency of polydipsia was lower in the hbgm-group perhaps suggesting superior control. however, hbgm did not detectably affect the impact of the majority of qol-items, nor the frequency of hypoglycaemic episodes. overall diabetes dependent qol of diabetic cat and owner, as measured per diaqol-pet, was unaffected by hbgm. these data argue for the use of hbgm in selected pet-owner combinations rather than as part of a practice's standard dm management protocol, although further studies are indicated. insulin resistance is associated with impaired activation of the insulin signaling pathway in peripheral tissues such as skeletal muscle, visceral and subcutaneous (sc) adipose tissue. high plasma glucose, fatty acid and endotoxin levels are three major causes of insulin resistance in feline and human obesity and in type diabetes mellitus. however, the mechanisms by which these factors influence insulin action are still unclear. therefore, our aim was to investigate the tissue-specific expression of crucial mediators of insulin action such as the insulin-receptor substrate (irs ), the serine/threonine protein kinase b (pkb/akt) and of the principal insulin-dependent glucose transporter protein (glut ) in feline models of hyperglycemia, hyperlipidemia and subacute endotoxemia. healthy cats were infused through the jugular vein with glucose (n ), lipids (n ) or lipopolysaccharide (lps; n ) for days to clamp their blood concentrations at the approximate level found in untreated feline diabetes (glucose: - mmol/l; triglycerides: - mmol/l) or to induce a systemic low-grade inflammation (lps; rectal temperature: . - . c), respectively. healthy control cats were infused with saline (n ). on day , specimens were collected from skeletal muscles, visceral and sc fat and processed for irs mrna expression, total and phosphorylated pkb/akt and glut protein expression. gene transcripts of irs were not different between the groups. compared to controls, skeletal muscle pkb/akt phosphorylation was % lower in cats infused with glucose (p o . ); lipid-infused cats showed a trend for a decrease in pkb/akt phosphorylation ( % lower than saline) and had decreased glut expression (p o . ) in muscle. total (p o . ) and phosphorylated (p o . ) pkb/akt protein expression were decreased in the sc adipose tissue of lps-infused cats compared to controls. in these cats, phosphorylation of pkb/akt protein was also decreased in visceral fat (p o . ). sustained hyperglycemia and, to a lesser extent, hyperlipidemia impaired insulin signaling and glucose transport pathways primarily in skeletal muscle; endotoxemia reduced insulin sensitivity mainly in adipose tissues. thus, the development of insulin resistance in response to hyperglycemia, hyperlipidemia or endotoxemia might be affected by tissue-specific mechanisms in cats. separately used, single photon emission computed tomography (spect) and computed tomography (ct) both lack sensitivity and are additionally hampered by a poor anatomical location capacity and a lack of specificity, respectively. these drawbacks suggest an interest in the fusion of images obtained by the techniques. the aim of this study is to test spect/ct fusion performance in dogs with insulinoma. inclusion criteria were: / a biological diagnosis of insulinoma; / an examination by high resolution ct scan and in-pentetreotide spect followed by spect/ct fusion; / a surgical or post mortem examination completed by histopathological analysis. spect examination showing abnormal foci and ct scan showing pancreas, lymph nodes (ln) or liver abnormalities were considered positive. in case of double positivity, presence (imp ) or absence (imp-) of superimposition of abnormal images was noted. ten dogs were included. in / dogs, superimposition of abnormalities couldn't be tested. ct scan detected abnormal images [ pancreatic nodules (pn), enlarged ln (eln)] while spect failed to show any abnormal uptake. both dogs became euglycemic after removal of pn and ln designed by ct scan. in / , all abnormal images were classified as imp [ pn, eln and diffuse hepatic infiltration (dhi)]. surgery performed on / resulted in euglycemia in ; dog remained hypoglycemic after partial removal of pn. pn localization and dhi were confirmed after necropsy in the th dog. in / dogs imp and imp-images were both recorded. in dog, a dhi was classified as imp but pn localization was imp-: localized in the left lobe by ct scan and in the corpus by spect, the latest localization being confirmed after necropsy. in the other dog pn localization was imp but a diffuse spect signal superimposing to the liver considered as normal on ct scan was noted. hepatic biopsy confirmed spect results. this study confirms an imperfect sensitivity of both ct scan and spect. it confirms that ct scan can be associated with unspecific abnormal images. subject to a confirmation on a larger cohort of dogs, it indicates that imp images provide specific detection and accurate localization of canine insulinomas' primary lesions and metastasis. the majority of dogs with primary hypoadrenocorticism (ph) reveal clinical and laboratory abnormalities of gluco-and mineralocorticoid deficiency. in some of them sodium and potassium levels are normal, a phenomenon currently called atypical addison's. it has been postulated that in those cases adrenal destruction is confined to the zona fasciculata/reticularis, resulting in isolated glucocorticoid deficiency. however, there are no histological studies confirming a normal zona glomerulosa and in most reported cases diagnosis was based solely on low post-acth cortisol levels. the aim of the study was to evaluate aldosterone (aldo) levels in dogs with ph with and without electrolyte abnormalities. seventy dogs with newly diagnosed ph were included. aldo concentrations (ria, coat-a-count s , siemens) were measured before and min after administration of mg synthetic acth (synacthen s , novartis) iv. results were compared to those of healthy dogs and dogs with diseases mimicking ph. to confirm that peak concentrations were not missed aldo was additionally measured , and min after acth in dogs ( with ph, with ph mimicking diseases). results were analysed by means of non-parametric statistical methods (p o . ). post-acth aldo was significantly lower in dogs with ph ( - pg/ml, median pg/ml) than in healthy dogs ( - pg/ml, median pg/ml) and in dogs with ph mimicking diseases ( - pg/ml, median pg/ml). low post-acth aldo was found in / dogs with ph, in / of them levels were below the detection limit of the assay. normal sodium and potassium levels were found in / dogs ( %), / dogs ( %) had hyponatremia and normal potassium, / dogs ( %) had hyponatremia and hyperkalemia. electrolyte abnormalities ranged from mild to severe. there was no correlation between post-acth aldo and sodium and a weak correlation between post-acth aldo and potassium (r À . ). aldo concentrations were not different , and min after acth. the results demonstrate that aldo levels are low in most dogs with ph independent of the degree of electrolyte abnormalities. this implicates that all three zones of the adrenal cortex are compromised and that there are mechanisms which allow maintenance of a normal electrolyte balance without aldo. definitive diagnosis of canine hypoadrenocorticism (ha) is based on inadequate cortisol secretion following adrenocorticotropic hormone (acth) administration. an abnormal serum sodium to potassium (na:k) ratio can be used to determine whether an acth stimulation test is warranted. the aim of this study was to examine the utility of combining the na:k ratio with white blood cell counts to determine whether an acth stimulation test is warranted. a retrospective review of medical records of dogs examined between and was performed. dogs diagnosed with ha and control dogs, in which a diagnosis of ha was excluded during the study period, were included. inclusion criteria for all dogs were hospitalization with intravenous fluid therapy, a complete blood count, and serum na and k measurements at the time of initial examination. dogs were included in the ha group if they also had pre and post acth stimulation serum cortisol concentrations . mg/dl. dogs were included in the control group if they had resting or post acth stimulation serum cortisol concentration . mg/dl. exclusion criteria were recent administration of glucocorticoids, prior treatment of hyperadrenocorticism, or serum cortisol concentration . mg/dl but . mg/dl. continuous variables were compared between groups using the mann-whitney u test. receiver operating characteristic (roc) curves were produced to assess the sensitivity and specificity of detecting ha with various cutoffs for each variable. data is presented with % confidence intervals (ci) and statistical significance was defined as p o . . the na:k ratio, neutrophil count and neutrophil:lymphocyte ratio were significantly lower in dogs with ha than in dogs without ha (p o . for each). lymphocyte and eosinophil counts were significantly higher in dogs with ha compared to dogs without ha (p o . for each). the areas under the curve by roc analysis were largest for na:k ratio ( . , ci: . - . ) and lymphocyte count ( . , ci: . - . ). a na:k ratio . was % sensitive (ci: - %) but only % specific (ci: - %) for detecting ha. a lymphocyte count ! . x cells/ml was % sensitive (ci: - %) and % specific (ci: - %). conversely a na:k ratio . was % sensitive (ci: - %) but % specific (ci: - %) and a lymphocyte count ! .  cells/ml was % sensitive (ci: - %) but % specific (ci: - %). a na:k ratio . was % sensitive (ci: - %) and % specific (ci: - %) for detection of ha and a lymphocyte count ! .  cells/ml was % sensitive (ci: - %) and % specific (ci: - %) for detection of ha. a combination of this na:k ratio ( . ) and lymphocyte count (! .  cells/ml) was % sensitive (ci: - %) and % specific (ci: - %) for detection of ha. these results indicate that the combination of lymphocyte count and na:k ratio results in a better screening test for ha than the use of the na:k ratio alone. pheochromocytoma is a malignant, catecholamine-producing, adrenomedullary tumor. clinical signs resulting from excessive catecholamine secretion are typically non-specific, making differentiation from other adrenal tumors a challenge. elevated plasma concentrations of the catecholamine breakdown products metanephrine (mn) and normetanephrine (nmn) are used to identify pheochromocytoma in humans. this study tested the hypothesis that plasma metanephrine concentrations are greater in dogs with pheochromocytoma than in dogs with other adrenal neoplasms, healthy dogs and dogs with non-adrenal illness. edta plasma was collected from healthy dogs and unwell, hospitalized dogs with non-adrenal illness, pheochromocytoma and cortical tumors between april and october . samples were stored at À c before measurement of free mn and nmn concentrations using high pressure liquid chromatography at the central laboratory for clinical chemistry at the university of groningen ( samples) or the mayo clinic, rochester, minnesota ( samples). kruskal-wallis tests followed by dunn's multiple comparison analysis were used to compare results between groups. significance was set at p o . . results are reported as median [range] . eight dogs with pheochromocytoma, healthy dogs, dogs with non-adrenal illness and dogs with cortical tumors were sampled. pheochromocytoma was diagnosed histologically ( dogs) or cytologically ( dog). cortical tumors were diagnosed histologically ( dogs) or by response to trilostane treatment after obtaining consistent endocrine test results ( dogs occult hyperadrenocorticism (hac) has been theorized to exist in which excess adrenal sex hormone secretion induces the clinical signs and laboratory changes associated with classic hac. however, the ability of sex hormones to cause such alterations has never been closely evaluated. if sex hormones can cause a syndrome similar to classic hac, they should be able to induce expression of classic glucocorticoid-induced genes. the purpose of the study was to determine if in vitro expression of the gene for corticosteroid-induced alp (cialp) could be induced by clinically relevant concentrations of cortisol and sex hormones believed to cause occult hac. canine hepatocytes were purchased from a commercial source (cellzdirect or invitro) in -well plates. upon arrival ( - plates per shipment), the cells were allowed to recover in general media per supplier recommendations. after hrs, media was changed to william's e media (-l-glutamine) containing concentrations of cortisol or sex hormones that have been documented in the literature in dogs with hac or with purported occult hac. each plate was treated with a different hormone (cortisol, -hydroxyprogesterone [ ohp], progesterone, estradiol or androstenedione), and each well contained a different concentration (starting with no hormone added as a negative control) to evaluate a dose response. media was changed daily. after days of hormone exposure, rna was extracted. reverse transcription was performed and the product used for quantitative pcr for cialp and beta-actin (roche lightcycler) using a gene-specific fluorescent probe for detection. standard curves were created for each gene. all samples and standards were run in duplicate. using the lightcycler software (vers . ), cialp expression was normalized to that of beta-actin. fold change in expression was determined relative to the negative control. each sex hormone was used to treat plates; one plate in each shipment was treated with cortisol as a positive control. for cortisol, a dose response was seen in expression of the cialp gene. compared to no cortisol, , , , , and nmol cortisol increased expression . , . , . . . , . and . fold, respectively. a -fold increase is considered significant (j.vandesompele et al genome biol ). expression of cialp was not significantly induced in response to any concentration of ohp ( nm maximum), progesterone ( nm maximum), estradiol (max pm maximum) or androstenedione ( nm maximum). we conclude that in vitro these sex hormones do not induce expression of the cialp gene which is classically induced by cortisol in vivo; indeed, elevated serum cialp activity is a hallmark of classic hac. thus, the ability of the sex hormones to induce the gene in vivo must be questioned and evaluated. measurement of sex hormones has been advocated as an adjunct means for diagnosing typical hyperadrenocorticism (hac), i.e. disease due to excess cortisol secretion, as well as for diagnosis of atypical hac, i.e. disease due to excess adrenal sex hormone secretion. however, measurements in either setting have not been widely studied. therefore, our objectives were: . to determine the sensitivity of -hydroxy-progesterone ( ohp) and estradiol concentrations pre-and post-acth for diagnosis of typical hac. . to determine the specificity of ohp and estradiol concentrations preand post-acth for diagnosis of occult hac. dogs that had pdh (n ), dogs that were suspected to have hac but proven not to (had non-adrenal illness [nai, n ]) or dogs that were healthy (n , used to establish reference ranges [rr]) were enrolled. acth stimulation tests were performed ( mcg/kg cosyntropin iv); blood samples were drawn pre and min post; ohp and estradiol were measured by previously validated radioimmunoassays. a kruskal-wallis rank sum test was used to compare values between the groups. significance was set at p o . . for basal and acth-stimulated ohp concentrations, the rr were determined to be . - . ng/ml (mean ae s.d.; range . - . ) and . - . ng/ml (range . - . ), respectively. in pdh dogs, and had basal and post-acth ohp concentrations above the rr, respectively; in the nai group, and dogs had concentrations above the rr, respectively. thus, the sensitivity of basal and post-acth ohp measurement for diagnosis of hac is % and %, respectively. specificity of diagnosis is % and %, respectively. post-acth ohp concentration was significantly different between groups. for basal and stimulated estradiol concentrations, the rr were determined to be - pg/ml (range - ) and - pg/ml (range - ), respectively. for both basal and stimulated estradiol, pdh dogs (n ) had concentrations above the rr; for those with nai (n ), and had concentrations above the rr, respectively. thus, the sensitivity of estradiol measurement for diagnosis of hac is % for both pre-and post-acth. specificity of estradiol for diagnosis for hac is % and % for pre-and post-acth, respectively. overall, dogs with nai had at least one elevated estradiol concentration (total specificity %). post-acth estradiol concentration was not significantly different between groups. we conclude that use of ohp and estradiol concentrations for diagnosis of hac can be problematic. sensitivity and specificity are relatively low, potentially leading to misdiagnoses. diabetes mellitus is one of the most common feline endocrinopathies and is considered to have a similar pathophysiological basis to human type diabetes. several studies have identified risk factors for development of diabetes mellitus in cats, which include age, obesity, inappropriate diet and physical inactivity. however, to date, no specific genetic risk factors have been identified. genome-wide association studies in humans have identified several genes that predispose to obesity and/or diabetes mellitus, one of which is the melanocortin receptor (mc r) gene. the aim of the current study was to identify polymorphisms (snps) in the feline mc r gene and to use these to perform a case:control study to determine whether these candidate gene snps were associated with diabetes mellitus in cats. genomic dna from cats ( domestic short hair [dsh], burmese) was initially analysed by pcr and direct sequencing using felmc r-specific primers, which identified a missense mutation (mc r:c. c t) in the region encoding the extracellular domain of the receptor protein in dsh cats only. one hundred and nineteen dsh cats were subsequently recruited into the case:control study. fifty nine cats were obese diabetic ( male, female), mean age . years (range - y); mean weight . kg (range . - kg). sixty lean cats were used as controls ( male, female), mean age . years (range - y), mean weight . kg (range . - . kg). the t to c base change alters a restriction site in the sequence recognized by the enzyme bstoi, such that dna from cats with the mutant (c) allele can be cut, whereas that from the wild-type (t) allele cannot. primers were designed that flanked the mutation to allow pcr amplification of this region of mc r from genomic dna obtained from edta blood. the pcr products were purified and subject to restriction fragment length polymorphism (rflp) analysis. bstoi digestion products were then analysed by agarose gel electrophoresis. of the diabetic cats, ( %) were homozygous for the mutation (cc), compared to ( %) of control cats. statistical analysis (two tailed fisher's square test) revealed that this difference between groups was statistically significant (p . ). in conclusion, this pilot study has identified a missense mutation in the coding sequence of mc r. this could be an important predisposing factor for development of diabetes and/or obesity in dsh cats. polymorphisms in a similar region of human mc r predispose to obesity, which in turn is a major risk factor for type diabetes. hyperadrenocorticism (hac) is one of the most common endocrine disorders of dogs. the two most effective medical treatments are trilostane (vetoryl s ) and mitotane (lysodren s ). previous studies evaluating the effect of treatment on aldosterone secretion measured the hormone at min post-acth administration. however, the optimal sampling time would be at the time of maximal secretion, which occurs minutes after the mg/kg dose commonly used for the test (carlson et al, jvim, ). thus, the true effect of either medication on aldosterone secretory capacity is unknown. our objectives were: ) to assess and compare the effect of treatment with trilostane and mitotane in dogs with pituitarydependent hac (pdh) on aldosterone secretory reserve at min post-acth stimulation and ) to determine if changes in aldosterone concentration at that time correlate with changes in serum sodium and potassium concentrations. forty-six dogs being treated for pdh with either mitotane (n ) or trilostane (n ) have been enrolled. the dogs could be treated for any length of time. all had acth stimulation tests performed ( mcg/kg cosyntropin iv); blood samples were drawn before and at and min post-acth for monitoring of cortisol and aldosterone concentration using previously validated radioimmunoassays. ten historical normal controls were also included. serum sodium and potassium concentrations were measured in the basal samples. a kruskal-wallis rank sum test was used to compare values between normal dogs and those treated with mitotane or trilostane. linear regression analysis was used to determine if a correlation existed between electrolyte and aldosterone concentrations or between cortisol and aldosterone concentrations. significance was set at the p o . level. acth-stimulated aldosterone concentrations in mitotane-treated but not trilostane-treated dogs were significantly lower than that in normal dogs at both the and min time points. no difference was detected between aldosterone concentrations at and min after acth injection in either treatment group. a positive correlation existed between the -min cortisol and -min aldosterone concentrations in the trilostane-treated group (r . ), i.e. the peak post-acth concentration for each hormone, but not in dogs treated with mitotane. basal serum sodium and potassium concentrations were not correlated with the basal aldosterone concentration in either treatment group. in conclusion, treatment with mitotane resulted in decreased aldosterone secretory reserve, but this did not correlate with hyperkalemia or hyponatremia. measurement of aldosterone concentrations is not predictive of electrolyte concentrations. previously presented at the auburn university phi zeta research emphasis day, november , . antioxidant depletion is documented in humans with hyperthyroidism, and is reversible with treatment. in addition, antioxidant depletion has been shown to increase the risk of methimazole toxicity in rats. the primary aim of this study was to determine whether deficiencies in glutathione (gsh), ascorbate (aa), or vitamin e, along with increases in urinary -isoprostanes, were present in hyperthyroid cats, and were reversible after radioiodine treatment. a secondary aim was to determine whether antioxidant abnormalities were associated with a prior history of methimazole toxicity. ongoing prospective, controlled, observational study. otherwise healthy client-owned hyperthyroid cats presenting for radioiodine therapy (n to date) and healthy age-matched controls (n to date) were recruited. all cats were screened with cbc, biochemical panel, urinalysis, and t , as well as red blood cell (rbc) gsh, plasma aa, plasma vitamin e, and urinary -isoprostanes. hyperthyroid cats were re-evaluated months after radioiodine treatment. unlike in humans, median blood antioxidants were not significantly different in hyperthyroid cats (gsh . mm; aa . mm, and vitamin e, g/ml) compared to controls (gsh . mm; aa . mm, and vitamin e, g/ml). results for urinary isoprostanes are pending, and associations with methimazole toxicity will be investigated after full recruitment. rbc gsh concentrations did increase significantly (to . mm; p . ) after radioiodine treatment. however, this modest change is unlikely to be clinically significant. preliminary data do not indicate clinically significant blood gsh, ascorbate, or vitamin e deficiencies in hyperthyroid cats. with appropriate insulin therapy and a low carbohydrate diet, up to % of newly diagnosed diabetic cats are eventually able to maintain euglycemia without insulin administration, and these cats are considered to have achieved remission. there are currently no published data reporting the glucose tolerance status of cats classified as being in remission, and it is unknown whether these cats are truly in diabetic remission, or should be classified as non-insulin dependent diabetics, or having impaired glucose tolerance, and/or impaired fasting blood glucose. the aim of this study was to determine fasting blood glucose concentrations and glucose tolerance status of cats in remission. the study was a prospective study in a feline-only clinic. for inclusion, diabetic cats had to have achieved remission through insulin therapy, and insulin withheld for a minimum of two weeks. five diabetic cats in remission and five matched non-diabetic cats were enrolled in the study. blood samples were obtained via the ear vein but where the cat's temperament precluded this, from the jugular.glucose concentration was measured using a meter calibrated for feline blood (abbott alphatrak). a simplified glucose tolerance test was performed after food was withheld for hours. a g catheter was placed in a cephalic vein three hours before the gtt was commenced, to minimize the effects of stress on blood glucose concentration. blood glucose concentration was measured at time and then a g/kg dose of glucose was administered slowly via the intravenous catheter. further blood glucose measurements were made at hours and then hourly until glucose had returned to o mg/dl (o . mmol/l). in the control group, all cats had a fasting blood glucose below mg/dl, and following glucose administration, glucose had returned to o mg/dl by hours. fasting blood glucose in the remission group was o mg/dl ( mmol/l) in all cats except one, which had fasting blood glucose of mg/dl ( . mmol/l). following glucose administration, all five cats in remission had blood glucose above mg/dl ( . mmol/l) at three hours, four were o mg/dl at four hours, and one returned to o mg/dl at five hours. the cat with impaired fasting glucose subsequently became diabetic after steroid administration. the results of this study show that these cats, while no longer diabetic, have mildly impaired glucose tolerance compared to nondiabetic cats, and a minority have impaired fasting glucose. the objective of this study was to determine the role of iodine restriction in the nutritional management of cats with naturally occurring hyperthyroidism. five domestic shorthair cats ranging in age from - years were confirmed to have hyperthyroidism based on persistently increased serum total thyroxine concentrations (tt ), palpable thyroid nodule and weight loss. serum tt concentrations ranged from - nmol/l (reference range - nmol/l). the cats were then fed a low iodine containing food ( . ppm iodine dmb, as measured by epiboron neutron atomic activation). serum tt concentrations were measured every weeks. biochemistry parameters were also evaluated at weeks , and . at weeks, serum tt concentrations had decreased in all cats with of cats ( %) being euthyroid (mean nmol/l; range - nmol/l). the remaining hyperthyroid cat had an initial serum tt of nmol/l, which decreased to nmol/l after being fed the iodine-restricted food. mean decrease in tt for all cats was nmol/l (range - nmol/l). renal parameters remained stable in all cats. these cats along with additional newly diagnosed hyperthyroid cats were transitioned to a similar food that contained less iodine ( . ppm dmb). baseline serum tt concentrations in the new cats ranged from - nmol/l. serum tt and other biochemical parameters were monitored every weeks for weeks, and then every weeks for an additional weeks. with the . ppm iodine food the four new cats became euthyroid with a mean tt concentration of nmol/ (range - nmol/l). the euthyroid cats from the earlier feeding study had a further decrease in tt concentration (mean tt nmol/l, range - nmol/l). the single non-euthyroid cat from the first study had a serum tt concentration of nmol/l, a decrease from the baseline concentration of nmol/l. the average decrease in serum tt for all cats was nmol/l (range - nmol/l). finally, of the cats were fed a third iodine-restricted food ( . ppm dmb) along with one other newly diagnosed hyperthyroid cat ( nmol/l serum tt ) and evaluated every weeks. all cats in this evaluation were euthyroid (mean tt nmol/l; range - nmol/ l). this result included the cat whose serum tt remained in the hyperthyroid range in the first two evaluations. the average decrease in tt was nmol/l (range - nmol/l). biochemical features of renal function remained stable and no other biochemical abnormalities were observed. in summary, the results of these three feeding studies demonstrate that feline hyperthyroidism can be managed effectively with dietary iodine restriction. we have shown previously that restriction of dietary iodine (i) is a safe and effective method for decreasing serum thyroxine concentrations (tt ) in cats with hyperthyroidism. the objective of this study was to determine the maximum level of iodine in a nutritionally balanced feline mature adult food required to maintain normal serum tt concentrations in hyperthyroid cats currently being controlled on a food containing . ppm i (dmb) as measured by epiboron neutron atomic activation. all cats were previously diagnosed at least months prior to the start of the study and their tt concentrations were maintained in the normal range by dietary iodine restriction for a minimum of months (range months- years). serum tt concentrations ranged from - nmol/l (reference range - nmol/l) at the beginning of the study. the cats were divided into two groups each containing cats. groups were similar in age and gender distribution (mean age . years, range - years). one group (group a) was placed on a food that was formulated for mature adult cats containing . ppm i (dmb). the other group (group b) was placed on a similar food that differed only in that it contained . ppm i (dmb). blood was collected from all cats every three weeks and analyzed for serum tt concentration. biochemistry parameters were also evaluated at weeks , and . all group a cats exhibited increases in serum tt concentration (mean increase of nmol/l above baseline, range - nmol/l). seven of the cats remained in the euthyroid range (mean serum tt nmol/l, range- - nmol/l). two cats exceeded the upper limit of the reference range ( and nmol/l respectively). the cats in group b also exhibited increases in serum tt concentration but to a greater degree than the cats in group a (mean increase nmol/l, range - nmol/l). four cats remained in the euthyroid range (mean serum tt , range - nmol/l). the five remaining cats all exceeded the upper limit of the reference range (mean serum tt nmol/l, range- - nmol/l). all cats returned to a euthyroid state within month of being returned to a diet containing . ppm i (dmb). it was determined that serum tt concentrations are not ideally controlled in the normal range in hyperthyroid cats fed a food containing ! . ppm i (dmb). hyperthyroidism is a common disease in old cats. excessive production of thyroid hormones is the hallmark of the disease. three main treatments for feline hyperthyroidism include radioactive iodine, thyroidectomy, and antithyroid drugs such as methimazole. previously we have shown that limiting dietary iodine to or below . ppm induces euthyroidism in cats with hyperthyroidism compared with a similar diet containing . ppm iodine. the objective of this study was to test whether dietary iodine at . ppm would induce euthyroidism in cats with naturally occurring hyperthyroidism. fourteen cats with hyperthyroidism confirmed by serum tt and ft measurements were stratified into two groups based on gender and age. one group (control: males and females, age ranged from to years) was given a positive control dry cat food ( . ppm iodine) while the other group (test: males and females, age ranged from to years) was fed a commercial dry cat food ( . ppm iodine) for at least weeks before the study. afterwards (week ), the control cats continued to receive the same food while cats in the test group were given a test food ( . ppm iodine) for additional weeks. all cats had free access to their food and deionized water during the study. blood samples were collected during weeks , , , and of the study. the control cats maintained euthyroidism during the study. the test food significantly reduced serum tt ( ae , ae à , ae à , ae à nmol/l in weeks , , and , respectively; à : p o . compared with week , dunnett's t test). it also significantly reduced ft at the end of the study ( ae vs. ae pmol, week vs. week ; dunnett's t test, p o . ). serum ft was within the reference range ( - pmol/l) in cats in both groups. serum tt , ft , and tsh were not affected by the test food and were within the reference ranges (tt : . - . nmol/l, ft : . - pmol/l, and tsh: - mu/l) in cats of both groups during the study. this study demonstrates that dietary iodine at or below . ppm provides an effective and inexpensive therapy for cats with naturally occurring hyperthyroidism. radioactive iodine ( i) is a widely used treatment for feline hyperthyroidism. prior to i administration, many cats receive methimazole therapy. it has been suggested that recent withdrawal of methimazole prior to i may increase the risk of hypothyroidism, inhibit the response to therapy, or have no effect. to further address this question, a retrospective medical records search was performed to identify hyperthyroid cats that received i therapy after methimazole treatment. inclusion criteria included documentation of the time interval between discontinuation of methimazole and i administration, and measurement of thyroxine (t ) at - days after i. cats were divided into groups: those receiving i within day of stopping methimazole, and those receiving i treatment or more days after stopping methimazole. sixty cats met the inclusion criteria. forty received i within day of stopping methimazole. of those, ( %) had a low t (o . mcg/dl), ( . %) had a normal t ( . - . mcg/dl), and ( . %) had an elevated t ( . mcg/dl) at - days after i therapy. fourteen cats received i or more days after stopping methimazole: ( %) had a low t , ( %) had a normal t , and ( %) had an elevated t at - days after i therapy. the results were compared with a fisher's exact test and there was no difference between the groups (p . ). these findings indicate that stopping methimazole therapy within day of i therapy does not inhibit the response to therapy. pharmacokinetic studies evaluating synthetic insulin analogs such as glargine necessitate the ability to measure the blood concentrations of glargine without cross-reactivity to endogenous insulin. although the cross-reactivity between endogenous human insulin assays and synthetic analogs is often known for commerciallyavailable assays, the degree of cross-reactivity of human insulin assays with feline insulin is not. the purpose of this study was to evaluate the cross-reactivity of feline insulin with a commerciallyavailable human insulin elisa with known cross reactivity to several synthetic analogs. pre-and post-prandial blood samples were collected from four healthy cats immediately prior to and approximately minutes following a meal, for a total of samples. dextrose was added to the meals given to two of the cats. blood samples were immediately centrifuged and the serum was collected, aliquoted, and stored at À c until analysis. serum insulin levels were determined in parallel with commercially-available feline insulin and human insulin elisas. the elisas were run in duplicate and according to the manufacturer's instructions. concentrations of serum insulin measured by the feline insulin elisa ranged from . ng/l to ng/l. despite the wide range of concentrations of feline insulin, all samples evaluated with the human insulin elisa yielded absorbance readings equal to or lower than the absorbance of the negative control, indicating no crossreactivity between the evaluated human insulin assay and feline insulin. since this assay is reported to cross-react significantly with glargine, it is a great candidate for determination of serum glargine concentrations in cats. the aim of this prospective, controlled study was to compare the efficacy of two trilostane protocols for treatment of canine pituitary-dependent hyperadrenocorticism (pdh). among the client-owned dogs diagnosed with pdh, only the dogs weighing o kg were selected (n ). group a (n ; low-dose treatment group) and group b (n ; high-dose treatment group) received . ae . mg of trilostane/kg orally every hours and mg of trilostane/ body orally every hours, respectively. all of the dogs were reassessed at , , , and weeks after the initiation of treatment. the improvement in post-acth stimulation serum cortisol concentration, as well as clinical signs in group a, required more time than group b; however, of dogs in group b had clinical signs and abnormal laboratory findings consistent with hypoadrenocorticism after treatment for weeks. twenty-four weeks later, all of the dogs of both groups improved the abnormal clinical findings. the present study suggests that twice daily, low-dose administration of trilostane is effective in the management of canine pdh and may be safe without the potential adverse effects of once daily, high-dose treatment. however, because this study involved only a small number of dogs, a population-based control study will be needed to clarify the efficacy of low-compared to high-dose trilostane treatment. cobalamin is essential for a variety of metabolic processes in many tissues and organs, and has effects on cell growth and peripheral and central nervous system function. chronic distal small intestinal disease in humans, cats, and dogs has been shown to cause cobalamin deficiency. an immunoassay for the measurement of serum cobalamin concentration in these species is being used in routine practice for the diagnosis of cobalamin deficiency. in pigs, the role of cobalamin has not yet been extensively investigated. thus, the aim of this study was to analytically validate an immunoassay, labeled for use in humans, for the measurement of cobalamin in porcine serum samples and secondly to determine serum cobalamin concentrations in weaned pigs. for the analytical validation of the assay, serum cobalamin concentrations were measured using the commercially available immulite s cobalamin immunoassay (siemens healthcare diagnostics ltd., deerfield, il, usa) in surplus porcine serum samples from a variety of studies. validation of the assay consisted of determination of dilutional parallelism, spiking recovery, and intra-and inter-assay variability. additional surplus serum samples from piglets from four litters at a texas a&m university farm were obtained. each piglet had been bled twice, the first at weaning ( days of age) and the second one days later. to investigate results in comparison between age groups, serum cobalamin concentrations were compared using a wilcoxon matched pairs test. significance was set at p o . . observed to expected ratios (o/e) for serial dilutions ranged from . to . % (mean ae sd: . ae . %) for four different serum samples at dilutions of : , : , and : , and from . to . % (mean ae sd: . ae . %) for one serum sample at dilutions of : , : , and : . o/e for spiking recovery ranged from . to . % (mean ae sd: . ae . %) for five different porcine serum samples that had been spiked with each other in a : dilution. intraassay coefficients of variation (%cv) for five different serum samples were . , . , . , . , and . %. inter-assay %cvs for five different serum samples were . , . , . , . , and . %. serum cobalamin concentration was significantly lower in piglets post weaning (median: ng/l) compared to those at the time of weaning (median: ng/l; p . ). the immulite s cobalamin immunoassay labeled for use in humans is linear, accurate, precise, and reproducible for measurement of serum cobalamin concentrations in pigs. this study also showed that piglets that differ in age by only days have significantly different serum cobalamin concentrations. further investigations of cobalamin concentrations in both sows and piglets at different stages of weaning are warranted. primigravid dairy heifers can be infected with mastitis pathogens during the periparturient period. the prevalence of intramammary infection (imi) ranges from - % of quarters pre-partum and - % at parturition. some pre-partum infections self-cure before parturition, however a number of these imis persist into early lactation. these imis may impact milk production and quality and may serve as a reservoir for contagious pathogens. no study has specifically investigated the risk of an imi persisting from the prepartum period into early lactation. the objectives of this study were to describe the prevalence of mastitis pathogens in heifers on a grazing dairy before and after parturition and calculate the relative risk (rr) and attributable fraction of population (afp) for the association between a post-partum and pre-partum imi. two-hundred-ninety-four heifers were systematically assigned to of groups: g ) pre-partum secretions from all mammary quarters (n ), g ) no pre-partum secretions collected (n ) and g ) pre-partum secretions from two diagonal quarters (n ). group assignments were designed to assess whether pre-partum sampling increased the likelihood of imi at calving. mammary quarter secretions were collected for bacterial culture approximately weeks prior to expected calving date. quarter milk samples were collected for bacterial culture once weekly during the st -weeks of lactation. bacterial isolates were classified as staphylococci, non-agalactiae streptococci and gram-negatives. mammary quarter samples yielding different bacteria were classified as mixed infections and those yielding ! bacterial types were classified as contaminated. bacterial isolates were speciated using gene sequencing methods and strain-typed using pulse-field-gel-electrophorysis to evaluate the relatedness of bacteria isolated from pre-and post-partum samples from the same mammary quarter. relative risk and afp were calculated using  tables. forty-five percent of mammary quarters had a pre-partum imi. during the st weeks of lactation the mean prevalence of imi was . % of quarters. staphylococci were most frequently isolated bacteria from pre-partum secretions and milk with s. chromogenes and s. aureus being the most common species. using data from mammary quarters, the rr and afp for the association between a post-partum and pre-partum imi were and %, and %, and and % for all staphylococci, s. aureus only and cns only imis, respectively. mammary quarters sampled pre-partum were no more likely to have a post-partum imi than those not sampled (chisquare, p ! . ). these data demonstrate that pre-partum imis persist into early lactation and that pre-partum secretion cultures may be a useful, not only in predicting imi at calving, but also in assessing risk of introducing new contagious mastitis pathogens, e.g., s. aureus, into the lactating herd. despite concerns about antimicrobial resistance and clostridium difficile in food animals, there has been little study of the prevalence or mechanisms of resistance. this study evaluated the impact of tetracycline treatment on c. difficile shedding in veal calves and the impact on resistance. calves arriving on veal farm received oral oxytetracycline for days as per farm protocols. calves were sampled at arrival and days later. selective culture for c. difficile was performed. isolates were ribotyped, and tested for tetracycline susceptibility and the presence of tetracycline resistance genes. multivariable logistic regression models were used to determine the relationship between tetracycline resistance and the presence of tetracycline resistance genes. clostridium difficile was isolated from % ( / ) and % ( / ) calves, at the first and second samples, respectively. the percentage of tetracycline resistant isolates increased from % to %. isolates from the second sample were times more likely to be tetracycline resistant (p . ) and times more likely to possess tet(m) (p . ). tet(m) was detected in % ( / ) and % ( / ), tet(o) in % ( / ) and % ( / ) and tet(w) in % ( / ) and % ( / ) of isolates from first and second samples, respectively. tet(l), tet(k) and tet(s) were not detected. resistant isolates were not carrying any of the genes investigated. routine tetracycline use may have had an impact on both the prevalence of c. difficile, as well as the strain distribution and resistance patterns. this is the first report of presence of tet ( the objectives of this study were to ) estimate the prevalence of antimicrobial resistance in the study population and ) to investigate the associations between exposures to antimicrobial drugs and antimicrobial resistance in fecal non-type specific e. coli (ntsec) recovered from individual feedlot cattle. two-stage random sampling was used to identify cattle for enrollment at western canadian feedlots. a fecal sample was collected per rectum from each individual at arrival and in the middle of the feeding period when cattle were rehandled as part of standard feedlot protocol. from samples collected at this second time point, a total of , ntsec isolates were tested for susceptibility to antimicrobial drugs by disk diffusion. parenteral and in-feed exposures to antimicrobial drugs were recorded for each individual enrolled in the study. the least square means estimates and % confidence intervals for the prevalence of resistance at each time point were modeled using poisson regression. multivariable logistic regression was used to investigate associations between antimicrobial resistance and exposure to antimicrobial drugs. regression models were adjusted for clustering of observations among individuals and pens. the most common resistances identified in arrival samples were sulfisoxazole ( . %; %ci: . - . ), streptomycin ( . %; %ci: . - . ) and tetracycline ( . %; %ci: . - . ). at the second sampling point, resistance prevalence was . % ( %ci: . - . ) for sulfisoxazole, . % ( %ci: . - . ) for streptomycin, and . % ( %ci: . - . ) for tetracycline. logistic regression modeling identified weak associations of exposures to tetracycline and macrolide classes of drugs with antimicrobial resistance at the second time point. abstract fa- premature/dysmature syndrome in cria: a ret-rospective study of cases ( ) ( ) ( ) ( ) ( ) ( ) ( ) . c. gerspach, d. anderson. the ohio state university, columbus oh. prematurity is widely acknowledged as risk factor for subsequent morbidity and mortality in llama and alpaca cria. a review of medical records for premature cria alive at the time of admission to the veterinary teaching hospital between and was performed to determine risk factors of prematurity and to report the outcome and related conditions or diseases in affected cria. medical records for premature or dysmature cria were included in this study. of these cria, were alpaca and llama, were female and were male. reasons for referral were prematurity, failure of passive immunity, dyspnoea, weakness and failure to gain weight. cria were presented at a mean age of . days and were premature by a mean estimated time of . days. overall survival rate was . %, with all llama cria surviving. a multivariate logistic regression model was used to identify risk factors associated with not surviving. cria receiving camelid colostrum had a significant better outcome than cria receiving no colostrum or colostrum from different species. dyspnea and tachypnea was associated with a poor outcome. all cria that were able to nurse, without assistance prior to referral, survived. clinical pathology parameters most commonly associated with death were hyperphosphatemia and acidosis. enrofloxacin is approved for the treatment of swine respiratory disease, however there are no published studies describing the pharmacokinetics of enrofloxacin at the approved dose and route in pigs ( . mg/kg subcutaneously). furthermore no studies have assessed the unbound concentrations of enrofloxacin at its site of action, the extracellular tissue fluid. therefore the objective of this study was to use an in-vivo ultrafiltration method to measure the active fraction of enrofloxacin, and the metabolite ciprofloxacin, at tissue sites relevant to pigs, and to compare these concentrations with plasma concentrations collected at similar time points. six healthy pigs were used in this study. pigs were recently weaned and weighed an average . kg. on the day before the experiment, pigs were anesthetized for the placement of jugular vein sampling catheters and interstitial fluid collection probes. three ultrafiltration probes were placed in each pig in a subcutaneous site near the right shoulder, an intramuscular site along the epaxial muscles, and in the pleural space of the chest cavity. each pig received an injection of enrofloxacin (baytril , bayer animal health) at a dose of . mg/ kg subcutaneously behind the left ear. plasma and interstitial fluid samples were collected at pre-determined time points, and enrofloxacin and ciprofloxacin concentrations were measured using hplc with fluorescence detection. protein binding was determined with a microcentrifugation system. pharmacokinetic data was analyzed using a one compartment model. the analysis of plasma and isf showed that only a small fraction of ciprofloxacin was produced in these pigs, therefore ciprofloxacin concentrations were not used in pharmacokinetic measurements. the plasma half-life (t / ), volume of distribution, clearance, and peak concentration (c max ) for enrofloxacin was . hr (ae . ), . l/kg (ae . ), . l/kg/hr (ae . ), and . mg/ml (ae . ), respectively. the concentrations from each of three tissues were not different in each pig. when pharmacokinetic values from all tissues were combined for the isf, the t / was . hr (ae . ) and the c max was . mg/ml (ae . ). the enrofloxacin plasma protein binding was . % (ae . ) and . % (ae . ) at a high and low concentration, respectively. this study has demonstrated that the concentration of biologically active enrofloxacin in tissues exceeds the concentration predicted by the unbound fraction of enrofloxacin in pig plasma. the half-life of enrofloxacin is longer in tissues and plasma than has been reported in previous studies. the high tissue concentrations and long half-life produce an auc/mic ratio sufficient for the pathogens that cause respiratory infections in pigs. ceftiofur crystalline free acid (ccfa), a long-acting ceftiofur formulation labeled for use in cattle, pigs, and horses for treatment of respiratory disease has been used for treatment of ovine respiratory infections in clinical practice. pharmacokinetic data, however, do not exist for ccfa administered subcutaneously in sheep. the present pharmacokinetic study evaluated the single dose subcutaneous administration of ccfa in sheep (n ) at . mg/kg body weight. concentrations of ceftiofur free acid equivalents (cfae) in plasma were measured by high performance liquid chromatography for days following drug administration. pharmacokinetics of subcutaneous ccfa in sheep were best described using a single compartment model with the following average (ae sd) parameters: area under the concentration time curve ! ( . hÃug/ml ae . ), observed maximum plasma concentration ( . ug/ ml ae . ), and observed time of maximum plasma concentration ( . h ae . ). no significant adverse drug reactions were observed. adequate cfae plasma concentrations were attained to effectively treat respiratory tract pathogens associated with pneumonia in sheep. the purpose of this study was to assess, using thoracic ultrasonography, the prevalence of lung lesions in pre-weaned dairy calves. subsequent aims were to describe ultrasonographic changes within the lung, clinical respiratory score, and treatment of respiratory disease. a longitudinal study was performed using female dairy calves from commercial dairy farms in new york state. calves were enrolled based on age. thoracic ultrasound and clinical respiratory scoring were performed on each calf at time points. a standard mhz linear ultrasound probe was utilized to evaluate intercostal spaces through of each hemi-thorax with the calf in lateral recumbency (us ) or standing (us ). lesion appearance, size, and location were recorded. respiratory score (rs) was assigned based on a previously published protocol incorporating fever, nasal discharge, cough, ocular discharge and ear droop, with a higher numerical score corresponding to more severe disease. abnormal lung on ultrasound was defined as one or more areas of ! cm width or depth of non-aerated lung. farm records were evaluated to identify treated calves. calves were treated for respiratory disease at the farm manager's discretion, not based upon ultrasound findings or rs. non-parametric methods were used to evaluate the data. ninety-one calves were enrolled into the study, with lost to follow-up. an average of minutes was spent performing the rs and ultrasound on each calf. the median ages at first (us ) and second (us ) examination were (interquartile range - ) and (interquartile range - ) days, respectively. the majority of calves had a low rs (o ) and only . % of calves had a rs high enough to warrant treatment based on previous recommendations (rs! ). the prevalence of calves that had abnormal lungs on ultrasound but a low rs (o ) was . % (us ) and . % (us ). the prevalence of calves that had abnormal lungs on ultrasound and a high rs (! ) was % (us ) and . % (us ). of the calves that had abnormal lungs on ultrasound but a low rs, % were treated with antimicrobials within days of examination. none of the calves with high rs and abnormal lungs on ultrasound were treated with antibiotics within days of examination. this study demonstrates a high prevalence of abnormal lungs, as detected by thoracic ultrasonography, without significant clinical signs in pre-weaned dairy calves. the relatively low treatment rate in these calves may suggest an area of opportunity for improvement in calf health, welfare, and herd longevity. further studies and follow up are needed to elucidate the significance of these findings and whether or not treatment is indicated. literature regarding diseases causing lameness in beef cattle is limited. this retrospective study was undertaken to examine beef cattle presented for lameness. medical records of beef cattle having a lameness examination done during the period to were reviewed and descriptive statistics generated. lameness was classified based on clinical diagnosis. the medical records of beef cattle were reviewed of which . % were male and . % were female. beef cattle presented for lameness most often during the summer months ( %) and least during autumn ( %). causes of lameness were categorized as infectious ( . %) or non-infectious ( . %) and infectious lameness subcategorized as either a primary disorder or a secondary infection. all cases of a primary infectious disorder were interdigital phlegmon. secondary infections diseases included sole abscess ( . %), septic arthritis ( . %), tenosynovitis ( . %), and pedal osteitis ( . %). non-infectious lameness included proximal limb lameness ( . %), foot trauma ( . %), hoof horn cracks ( . %), hoof defects ( . %), interdigital fibromas ( . %), overgrown hooves ( . %), sole bruise ( . %), subclinical laminitis ( . %), white line disease ( . %), osteoarthritis ( . %), heel erosion ( . %), sole ulcers ( . %), and sole hemorrhage ( . %). the most frequently affected claw was the lateral digit of the hind limb ( . %), followed by the medial digit of the front limb ( . %), lateral digit of the front limb ( . %), and the medial digit of the hind limb ( . %). the findings of this study suggest significant differences in the frequency of disease causing lameness in beef cattle compared to published reports for dairy cattle. in people, endoscopic ultrasound (eus) has become the technique of choice for assessing pancreatic disease and eus-guided fineneedle aspiration (eus fna) has proven a useful and safe modality for characterizing pancreatic lesions. reported complications include infections, bleeding and acute pancreatitis. in dogs, laparoscopic-assisted pancreatic biopsy has been suggested to be a safe procedure, however eus and eus fna have not been evaluated in dogs so far. thus the aim of the present study was to assess the practicability and safety of eus examination of the abdominal cavity as well as pancreatic eus fna in healthy dogs. this study was approved by the cantonal committee for the authorization of animal experimentation, zurich, switzerland. the study population consisted of healthy beagle dogs with a median bodyweight of . kg ( . - . ). eus was performed with an olympus gf-uc p-echoendoscope and fna were performed using g needles (cook echotipultra). after completion of the eus-examination of the abdominal cavity from the stomach (liver, gallbladder, bile ducts, kidneys, adrenals, pancreas), the scope was advanced into the duodenum and eus fna of the pancreas was performed. fna tissue acquisition was made applying negative pressure and to needle passes were made. all dogs received mg/kg metimazole im after eus fna and were re-checked ultrasonographically minutes post eus fna. postoperative activity was assessed using a standardized scoring system. a cbc, serum biochemistry, urinalysis and spec cpl s were measured before, as well as and h after eus fna. the eus examination was complete in / dogs, the pancreas could not be visualized in dog. the pancreas was hypo-( / ) to isoechoic ( / ) to the surrounding mesenterium in all cases. in / dogs parts of the pancreas presented hyperechoic. the mean measured thickness was . cm. the pancreas was aspirated in dogs using a transgastric approach ( ) or transduodenal approach ( ). duodenal transmural puncture was not accomplished in dog where a re-sterilized needle was used. a minimal amount of peripancreatic fluid was observed in / dogs after eus fna. all dogs recovered uneventfully and required no further analgesia. all laboratory results including the spec cpl s measurements were within reference ranges on all three time points. cytologically, conglomerates of exocrine pancreatic cells were seen in / cases, duodenal villous epithelial cells were seen in / cases. in dog the aspirated pancreatic material was sufficient for a histological assessment. the aspirates with exocrine pancreatic cells on cytology were obtained by transgastric ( ) and transduodenal ( ) aspirations. in conclusion, ( ) eus examination of the abdomen is feasible in medium-sized dogs, ( ) the healthy canine pancreas can be difficult to visualize completely, and ( ) eus-guided pancreatic fna using a g needle is a safe procedure in healthy dogs. studies evaluating its use in dogs with pancreatic disease are warranted to assess its clinical utility. miniature schnauzers have a high prevalence of idiopathic hyperlipidemia, which is characterized by an increased serum triglyceride (tg) concentration, with or without an increased serum cholesterol (chol) concentration. a common initial therapeutic approach for the management of hyperlipidemia is the use of a low-fat diet. also, it is believed that low-fat diets may be beneficial in the treatment of pancreatitis in dogs. however, the efficacy of this approach has not been evaluated for either condition. the aim of the present study was to evaluate the effect of a commercially available low-fat diet on serum concentrations of tg, chol, and canine pancreatic lipase immunoreactivity (cpli; measured as spec cpl s ) in apparently healthy miniature schnauzers with hypertriglyceridemia. blood samples were collected from apparently healthy miniature schnauzers with hypertriglyceridemia (serum triglyceride concentrations mg/dl). common causes of secondary hyperlipidemia were excluded based on historical information, physical examination findings, and the measurement of serum glucose, total t , and free t (by ed) concentrations. the owners of the dogs were asked to switch their dog to the study diet (royal canin gastrointestinal low fat s ; fat content: . g/ , kcal) and have a second blood sample collected weeks after their dog had been on the new diet. all blood samples were collected after food had been withheld for hours. serum tg, chol, and spec cpl concentrations were measured both before and after the diet change. results were compared between the two time-points using the wilcoxon signed rank and fisher's exact tests. serum tg concentrations were significantly higher before (median: mg/dl) than after the diet change (median: mg/dl; p . ). the proportion of dogs with hypertriglyceridemia was significantly higher before ( / ) than after the diet change ( / ; p . ). also, the proportion of dogs with serum tg mg/dl was significantly higher before ( / ) than after the diet change ( / ; p . ). serum chol concentrations were significantly higher before (median: mg/dl) than after the diet change (median: mg/dl; p . ). the proportion of dogs with hypercholesterolemia was significantly higher before ( / ) than after the diet change ( / ; p . ). finally, the difference in serum spec cpl concentrations before (median: mg/l) and after the diet change (median: mg/l) approached but did not reach significance (p . ). also, the proportion of dogs with high serum spec cpl concentrations before ( / ) and after the diet change ( / ) was different, but this difference was not significant (p . ). in summary, a commercially available low-fat diet was effective in reducing serum tg and chol concentrations in miniature schnauzers with hypertriglyceridemia. toll-like receptor (tlr ) is an extracellular pattern recognition receptor which recognizes flagellin present in motile bacteria. we have previously demonstrated a significant association between three non-synonymous single nucleotide polymorphisms (snps) in the tlr gene (g a, c t and t c) and inflammatory bowel disease (ibd) in german shepherd dogs (gsds). recently, we have confirmed that two of these tlr snps (c t and t c) are significantly associated with ibd in other canine breeds. to further substantiate the role of tlr in canine ibd functional analysis of these polymorphisms would be needed. therefore the aim of this study was to determine the functional significance of the tlr snps by transfecting wild-type and mutant receptors in to human embryonic kidney cells (hek) and carrying out nuclear factorkappa b (nf-kb) luciferase assay and il- elisa. the tlr gene containing the risk haplotype for ibd (acc) and wild-type haplotype (gtt) as determined by the case-control analysis in gsds with ibd were cloned into plasmids expressing yellow-fluorescent protein (yfp). these were then stably transfected into hek cells. nf-kb activity was measured by transiently transfecting the cells with nf-kb firefly and hsv-thymidine kinase promoter (prl-tk) renilla plasmids. the cells were then stimulated with various ligands ( . mg/ml flagellin, . mg/ml flagellin, mg/ml lps, mg/ml pam csk and media control). firefly and renilla luciferase activities were measured using the dual-glo luciferase assay system (promega, uk) according to the manufacturer's recommendations. the supernatants were harvested and used in an il- elisa (r&d systems). human tlr transfected hek cells (invivogen) served as positive controls in all experiments. independent t-test was used to determine the significance of relative luciferase activity and il- concentration between wild-type and mutated tlr cells. although there was no significant difference between the wild-type and mutated receptor when they were stimulated with . mg/ml of flagellin (p . ), there was a significant increase when the cells with mutated tlr were stimulated with . mg/ml of flagellin compared to the cells expressing wild-type tlr (p . ). similarly, there was a significant increase in il- concentration in the supernatants in the cells with the mutated tlr receptor when stimulated with . mg/ml flagellin compared to the wild-type (p . -one-tailed, . -two-tailed) but not with . mg/ml flagellin (p . ). we show for the first time that polymorphisms associated with ibd are functionally hyper-responsive to flagellin compared to the wild-type receptor. this suggests that tlr may play a role in canine ibd and that blocking the hyper-responsive receptor found in susceptible dogs with ibd may alleviate the inappropriate inflammation seen in this disease. however, further in-vivo functional analysis of tlr , especially at the intestinal mucosal level would be needed to confirm these findings and predict the usefulness of any future therapeutic interventions. tlr has been shown to play a role in the inappropriate inflammation seen in human inflammatory bowel disease (ibd). similarly, we have recently demonstrated a significant association between three non-synonymous single nucleotide polymorphisms (snps) in the canine tlr gene (g a, c t and t c) and inflammatory bowel disease (ibd) in german shepherd dogs (gsds). therefore the aim of this study was to determine the functional significance of the tlr snps in the breed of gsds. the tlr gene containing the risk haplotype for ibd (acc) and wild-type haplotype (gtt) were stably transfected into hek cells. nf-kb activity was measured by transiently transfecting the cells with nf-kb firefly and hsv-thymidine kinase promoter (prl-tk) renilla plasmids. the cells were stimulated with various tlr ligands ( . mg/ ml flagellin, . mg/ml flagellin, mg/ml lps, mg/ml pam csk and media control). firefly and renilla luciferase activities were measured using the dual-glo luciferase assay system (promega, uk). the supernatants were harvested and used in an il- elisa (r&d systems). peripheral whole blood from dogs carrying the wild type and mutant tlr genes was cultured and stimulated with tlr ligands as above. canine tnf-alpha was measured in the supernatant by commercially available elisa (r&d systems). t-test was used to determine differences of relative luciferase activity, il- concentration and tnf-alpha concentration between wild-type and mutated tlr cells. there was a significant increase in nf-kb activity when the cells with mutated tlr were stimulated with . mg/ml of flagellin compared to the cells expressing wild-type tlr (p . ), which correlated with il- expression in the supernatant (p . ). similarly, in the whole blood assay the tlr risk haplotype for ibd in gsds (acc) was significantly hyperresponsive to flagellin at a concentration of . mg/ml compared to the tlr wild-type haplotype (gtt) (p . ). we show for the first time that polymorphisms associated with canine ibd in gsds are functionally hyper-responsive to flagellin compared to the wild-type receptor. blocking the hyper-responsive receptor found in susceptible dogs with ibd may alleviate the inappropriate inflammation seen in this disease. proton pump inhibitors (ppi) are widely used in human and also veterinary medicine. side-effects of ppi treatment reported in people are atrophic gastritis, gastric and esophageal cancer, and rebound hyperacidity following cessation of treatment, which has been speculated to be due to a sustained increased in circulating gastrin concentration. moreover, long-term ppi treatment has been associated with an increased risk for osteoporosis in people. little is known about the effect of ppi treatment on serum gastrin concentration or calcium metabolism in dogs. eight healthy adult research dogs ( males and females) were enrolled into the study. the dogs received an average dose of . mg/ kg of omeprazole orally twice daily for days. blood samples were collected prior to initiating the treatment and every days during the days of treatment and during the days after discontinuation of treatment for determination of serum gastrin, ionized calcium, pth, and oh vitamin d . gastric fluid was collected via gastroscopy after an overnight fast for measurement of gastric ph prior to, during, and after the omeprazole treatment period. normally distributed data were compared with a repeated measures anova and post hoc dunnett's test. data that were not normally distributed were compared with a friedman's test and a post-hoc dunn's test. gastric fluid ph was significantly higher (p o . ) at the end of the treatment period (median: . ; range: . - . ) when compared to pretreatment values (median: . ; range: . - . ). serum gastrin concentrations increased significantly from a median baseline of . ng/l (range: . - . ) to a maximum median of . ng/l (range: . - . ) at day of treatment (p o . ). serum gastrin remained significantly increased above baseline values from day to day of the treatment, but was not different from pre-treatment values days after the end of the treatment. omeprazole treatment had no effect on ionized calcium or pth for the duration of the study. marginal, but significant changes of oh vitamin d were observed at day (end of the treatment period -increased by . %) and day ( days after the end of the treatment -decreased by . %). this study shows that treatment with omeprazole for weeks results in a profound and sustained increase in serum gastrin concentration in dogs. this effect is rapidly reversible after cessation of the treatment. no effect on calcium metabolism was observed. however, this study documents only the effect of short-term treatment and it is possible that the effects of long-term administration are different. omeprazole treatment has been associated with small intestinal bacterial overgrowth and a higher risk for infectious enteropathies in humans. using a semi-quantitative sequencing approach, we have previously shown that omeprazole treatment may lead to alterations in both duodenal and gastric bacterial populations in healthy dogs (acvim ). however, a sequencing approach can only estimate relative proportions of genomic bacterial targets. therefore, significant changes in the total number of bacteria could not be evaluated. the aim of this study was to quantify gastric and duodenal bacterial populations in dogs undergoing omeprazole treatment. eight month-old healthy research dogs ( males and females) were enrolled. the dogs received an average dose of . mg/kg of omeprazole orally twice a day for days. endoscopic gastric and duodenal biopsies were harvested and days before starting omeprazole treatment, on the last day of treatment (day ), and days after the end of treatment (day ). all biopsies were fixed in % formalin for hours, processed, and embedded in paraffin blocks. fluorescent in situ hybridization was used to quantify mucosa-associated bacteria using fluorescently-labeled probes targeting the s ribosomal rna. statistical analysis aimed to compare changes in helicobacter spp. in gastric biopsies and total bacteria in both gastric and duodenal biopsies using the glimmix and npar way procedures in sas s . . bacteria were counted in , and microscopic fields ( Â) obtained from and gastric and duodenal biopsies, respectively. in the stomach, omeprazole treatment led to a decrease in helicobacter spp. (log of average counts ae standard error: . ae . at day ) when compared to the counts ( . ae . , p . ) and ( . ae . , p . ) days before treatment. after completion of omeprazole treatment, helicobacter spp. increased and returned to baseline counts ( . ae . at day , p . vs day ). also, in the stomach, non-helicobacter spp. bacteria were observed more often during omeprazole treatment (median: , range: - ) than on days (median: , range: - ) and (median: , range: - ) before and days after (median: , range: - ) omeprazole treatment; however, statistical comparison across time points did not reach significance. in the duodenum, while the median number of bacteria for all time points was zero, non-parametric comparison of median scores (number of points above median) revealed significantly higher numbers of bacteria during omeprazole treatment (p . ). our results suggest that omeprazole treatment for weeks leads to a lower abundance of helicobacter spp. organisms in the stomach of healthy dogs. also, this transient decrease in helicobacter spp. was accompanied by a higher abundance of other bacteria in both the stomach and the proximal duodenum. the smartpill ph.p s capsule (the smartpill corporation) is a wireless motility capsule that measures ph, pressure, and temperature as it passes through the gastrointestinal (gi) tract. analysis of this data allows the calculation of gastric emptying time (get), small and large bowel transit time (slbtt), and total gi transit time (tgtt). this study evaluated the variability associated with repeated measurement of gi transit times and the effect of oral administration of ranitidine (zantac s ) on gi transit times in dogs using this system. it was hypothesized that ranitidine would reduce gi transit times. six privately owned healthy adult dogs weighing between . kg and . kg were used. on occasions each dog was fed a standard meal followed by oral administration of a capsule. data were recorded until the capsule had passed in the dog's feces. on a th occasion each dog was given mg of ranitidine po q hrs starting hrs prior to testing. the dogs were then fed the test meal and the capsule was administered as above. ranitidine was given until the capsule had passed in the dog's feces. proprietary smartpill software was used to calculate get, slbtt, tgtt, and the median gastric ph (mgph). mean intra-individual and inter-individual coefficients of variation (cv%) were calculated for get, slbtt, and ttt for the first time points. transit times and gastric ph recorded at all time points were compared using a repeated measures anova. where significant differences were identified, post-hoc testing was performed using a bonferroni's multiple comparisons test. significance was set at p o . . a sharp rise in ph indicating exit of the capsule from the stomach was identified in each experiment. mean (ae sd) get, slbtt, and tgtt without ranitidine were ae , ae , and ae min, respectively. mean get, slbtt, and tgtt during treatment with ranitidine were ae , ae , and ae min, respectively. mean intra-individual cv% before ranitidine for get, slbtt, and tgtt were . , . , and . %, respectively. mean inter-individual cv% before treatment with ranitidine for get, slbtt, and ttt were . , . , and . %, respectively. no significant differences in get, slbtt, or tgtt were found at any of the time points. the mean mgph during treatment with ranitidine (ph . ) was significantly higher than at all other time points (overall mean ph for the time points: . ; p o . ). the smartpill system is an easy to use, ambulatory, non-invasive, non-radioactive method for assessing gi transit times in medium to large breed dogs. measurements of gi transit times, especially slbtt, were subject to considerable intra-individual and interindividual variation. no significant effect of oral ranitidine on gi motility was identified in this group of dogs. however, as expected, oral ranitidine caused a significant increase in gastric ph. the intestinal microbiota has been implicated in the pathogenesis of various gastrointestinal disorders in both humans and dogs. recent metagenomic data suggest that specific bacterial groups, including bacteria within the clostridium clusters iv and xiva (i.e., faecalibacterium spp., ruminococcaceae, and lachnospiraceae) and bifidobacterium spp. are decreased, while proteobacteria are increased in dogs with clinical signs of gastrointestinal disease. the objective of this study was to establish quantitative polymerase chain reaction (qpcr) assays for these specific bacterial groups and evaluate their abundance in healthy dogs and dogs with clinical signs of gastrointestinal disease. fecal samples were collected from healthy dogs ( females and males) and dogs with clinical signs of gastrointestinal disease ( females and males). novel quantitative pcr assays were established for faecalibacterium spp., ruminococcaceae, and lachnospiraceae by aligning respective group specific sequences against canine specific sequences obtained from s rrna gene clone libraries and sequences available from the ribosomal database project. primers for bifidobacterium spp. and proteobacteria were selected from previously published studies. the specificity of the qpcr assays was confirmed by sequencing of obtained qpcr amplicons. the bacterial dna abundance in fecal samples was compared between healthy dogs and dogs with clinical signs of gastrointestinal disease using a mann-whitney u test. significance was set at p o . . a significantly lower abundance of faecalibacterium spp. (p o . ) and ruminococcaceae (p . ) was observed in dogs with clinical signs of gastrointestinal disease when compared to healthy dogs. proteobacteria were more abundant in dogs with clinical signs of gastrointestinal disease, but this difference did not reach statistical significance (p . ). there was no significant difference in the abundance of lachnospiraceae (p . ) and bifidobacterium spp. (p . ) between both groups. in conclusion, we established novel qpcr assays for faecalibacterium spp., ruminococcaceae, and lachnospiraceae. we observed significant decreases in the abundance of faecalibacterium spp. and ruminococcaceae in dogs with clinical signs of gastrointestinal disease. these bacterial groups are considered major short-chain fatty acid producers and studies are warranted to determine if a decrease in these bacterial groups is associated with decreases in short chain fatty acid production. further studies are also needed to determine if these bacterial shifts are associated with specific gastrointestinal disorders. the pathogenesis of chronic enteropathies (ce) in dogs likely involves complex interaction between the mucosal immune system and the intestinal microbiota. while the application of bacterial s rdna sequence-based analysis has shown an association between altered microbial composition and duodenal inflammation in dogs, relatively little is known about alterations in non-invasive mucosal and luminal bacteria seen with diseases involving the ileum and colon. the present study sought to evaluate the relationship of enteric bacteria to type and severity of mucosal inflammation affecting the ileum and colon of dogs with ce. eleven client-owned dogs with ce involving both the small and large intestines were prospectively enrolled. ce was diagnosed on the basis of a history of chronic gastrointestinal signs, exclusion of identifiable underlying disorders, and histopathologic evidence of intestinal inflammation. mucosal bacteria were detected in formalinfixed ileal and colonic tissue sections with fluorescence in situ hybridization (fish) using s rdna-targeted probes directed against all bacteria, enterobacteriaceae, e. coli, eubacterium rectale-clostridium coccoides group, bacteroides/prevotella, and helicobacter spp. sections were examined by epifluorescence microscopy and the number of bacteria and their spatial distribution (luminal, superficial mucus, epithelial adherent, within mucosa) was determined in ten x fields of each section. microbial composition in ce dogs was compared to the ileal/colonic microbiota of healthy control (hc) dogs using a mixed effect anova model. p values o . were considered significant. the final diagnoses for dogs with ce included ibd (n ) and lymphosarcoma (n ). when compared to hc dogs, dogs with ce showed regional (ileum versus colon) imbalances in microbiota composition characterized by selective enrichment of mucosa-associated populations. evaluation of colonic biopsies in dogs with ce showed that the total number of bacteria (p o . ), clostridium (p o . ), enterobacteriaceae (p o . ) and e. coli (p o . ) were increased in the adherent mucus regions of dogs with ibd as compared to hc dogs. total bacteria (p o . ) and e. coli (p o . ) were also more numerous in dogs with lsa versus hc and ibd dogs (p o . for e. coli). ileal biopsies from ce dogs similarly showed variable dysbiosis with increased total bacteria (p o . ) but decreased helicobacter spp (p o . ) and bacteroides (p o . ) observed within inflamed intestines as compared to hc tissues. the spatial distribution of these bacteria was also appreciably different from hc dogs, with higher numbers of bacteria generally found within the adherent mucus compartment as compared to other ileal regions. our data demonstrate that dogs with ce affecting the ileum and colon have altered microbiota composition that may be a cause or consequence of mucosal inflammation. recognition of these microbiota imbalances may provide new opportunities for therapeutic intervention. trichomonads have been rarely reported in the feces of dogs and their pathogenicity remains uncertain. although pentatrichomonas hominis (ph) is considered to be a commensal that may overgrow in dogs with other causes of diarrhea, little is known regarding the history, clinical presentation or prevalence of concurrent gi infections in dogs with trichomonosis. the aim of this study was to determine whether dogs with diarrhea and trichomonosis could be distinguished from dogs having diarrhea without trichomonosis on the basis of clinical signs or presence of concurrent enteric infections. fecal samples from dogs were submitted to ncsu from - for trichomonas spp. pcr testing. dna was extracted using a zr fecal dna mini-prep kit and absence of pcr inhibitors verified by amplification of bacterial s rdna. pcr for ph and tritrichomonas foetus (tf) was performed as well as real-time pcr assays for possible concurrent enteric infectious agents. obtainable medical records were reviewed. all submitted fecal samples were submitted from dogs with diarrhea that was variably described as soft, mucoid, hemorrhagic, or watery. mean age of the dogs was . years (median . ; range: . - months) and represented a total of breeds. ph, tf, or concurrent ph and tf were diagnosed in , , and dogs respectively (group a). the remaining dogs were negative for ph and tf by pcr no dogs were identified as infected with canine distemper virus or parvovirus. five samples from each group had insufficient quantity or quality of dna for concurrent infectious disease testing. in this large study of canine trichomonosis, no differences in age, clinical signs, or prevalence and identity of concurrent enteric infection between diarrheic dogs with or without ph were identified. thus, these findings do not appear to support a primary pathogenic role for ph as a causative agent of diarrhea in dogs. gastrointestinal motility disorders are a common clinical problem in domestic animals. many of the g.i. motility disorders have been treated previously with -ht agonists although limited availability of drugs in this classification have stimulated interest in the use of new (and old) drug therapies. the dopaminergic antagonists are a group of drugs with well-known anti-emetic effects at central dopamine d receptors, and putative gastrointestinal prokinetic effects at peripheral d receptors. domperidone has been shown, for example, to reverse gastric relaxation induced by dopamine infusion in the dog. similar studies have not been reported in the cat or rabbit, two species at risk for distal gastrointestinal motility disorders. our aim was to study the effects, mechanisms, and sites of action of domperidone in feline colonic and rabbit gastrointestinal smooth muscle contraction. portions of stomach (fundus and antrum), intestine (duodenum and ileum), cecum (rabbits only), and colon (ascending and descending) were obtained from healthy cats and rabbits from - months of age. longitudinal and circular smooth muscle strips from each site were suspended in physiologic (hepes) buffer solution, attached to isometric force transducers, and set to optimal muscle length (l o ) using acetylcholine (ach; À m). muscle strips were treated with domperidone (d; À to À m) in the presence or absence of ach ( À to À m), and maximal force output (p max ) was normalized for cross-sectional area (n  newtons/m ). domperidone (d) had a minor direct effect of inducing feline and rabbit gastric, cecal, and colonic smooth muscle contraction. direct effects were similar whether in the longitudinal or circular muscle orientation. the direct effect of domperidone was dose-dependent and maximal (feline colon p max . - . n; rabbit colon p max . - . n) at a dose of À m. domperidone had a much greater indirect effect in augmenting cholinergic (ach; À m) contractions in feline and rabbit gastric, cecal, and colonic smooth muscle. domperidone-augmented cholinergic contractions were - % (feline colon p max . ae . n ach only; feline colon p max . ae . n ach d) of baseline cholinergic contractions. domperidone contractions were of a similar magnitude to those induced by cisapride. domperidone effects were similar in mucosaintact and mucosa-dissected preparations. domperidone contractions were unaffected by prazosin (a receptor antagonist), yohimbine (a receptor antagonist), or terbutaline (b receptor agonist), but were somewhat attenuated by dopamine (d receptor agonist) and a non-specific cholinergic antagonist (atropine). in vitro studies show for the first time that domperidone has minor direct and major indirect effects in augmenting cholinergic contractions of feline and rabbit gastrointestinal (stomach, cecum and colon) smooth muscle. as recognition of acute and chronic pain in dogs has increased, so too has the use of non-steroidal anti-inflammatory drugs (nsaids) often in conjunction with tramadol. in people and rats, co-administration increases the risk of perforation and gastric injury over nsaids alone. using an ex vivo model of acid injury in canine gastric mucosa, we examined the effects of indomethacin and tramadol on gastric permeability and concentrations of gastroprotective prostaglandin e (pge ). mucosa from the gastric antrum was harvested from shelter dogs immediately after euthanasia, and mounted on ussing chambers. the tissues were equilibrated for -minutes prior to addition of acidic ringer's solution (ph, . ). after -minutes of injury, the acid was replaced with neutral ringer's and the tissues were treated with indomethacin, tramadol or both. tissues were maintained for minutes total, during which time permeability was assessed electrically. prostanoid concentrations were quantified using a commercially available elisa. western blots were performed for cox- and À . recovery of gastric barrier function after acid injury was inhibited by co-administration of tramadol and indomethacin ( figure ) but not by tramadol or indomethacin alone (data not shown). prostaglandin e increased with acid injury. the increase in pge was inhibited by co-administration of indomethacin and tramadol (in pg/ml: acid injury . ae . , indo tramadol . ae . ). there was no significant effect of treatment on cox- or À expression. co-administration of tramadol with a non-selective nsaid inhibits the return of gastric mucosal barrier function after acid injury in canine tissue, suggesting that caution is required in prescribing concurrent use of these drugs in dogs at risk for gastric ulcers. these drugs may exert this effect by decreasing levels of gastroprotective prostanoids. further study is needed to understand the mechanism of this drug interaction. an increased intestinal permeability (ip) has been suggested to be both cause and consequence of gastrointestinal (gi) disease, such as inflammatory bowel and celiac disease, in people. a novel tight junction regulator, larazotide acetate (alba therapeutics, baltimore, md) has been shown to significantly decrease ip in rats and in humans with celiac disease. the purpose of this study was to determine if larazotide acetate reduces ip in soft coated wheaten terriers (scwt) and norwegian lundehunds (nl) with chronic gi disease and ameliorates clinical signs. four nl ( females, males; median age: . yrs, range: . - . yrs) and scwt ( females, males; median age: . yrs, range: . - . yrs) were enrolled based on presence of clinical signs of gi disease and hypoalbuminemia, increased fecal alpha proteinase inhibitor (a -pi) concentrations, and/or hypocobalaminemia. scwt with protein-losing nephropathy were excluded. dogs were fed q hrs and received . mg ( nl and scwt) or . mg ( scwt) of larazotide acetate po before each meal for days. prior to start of treatment (day ) and at the end (day ), ip was evaluated by calculating the lactulose/rhamnose (l/r)-ratio in serum samples obtained at , , , and min after oral dosing. also, consecutive fecal samples each were collected prior to day and day for n-methylhistamine (nmh) measurement. pre-and post-treatment data were compared using a wilcoxon signed rank test. the . mg vs. . mg dose groups were compared using a mann-whitney u test. statistical significance was set at p o . . l/r-ratios (medians) for the min sampling time point were significantly lower on day ( . ) than on day ( . ; p . ). dogs treated with . mg q hrs had significantly lower min l/r ratios on day than dogs treated with . mg ( . vs. . ; p . ). no difference was found between breeds. fecal nmh concentrations were not different between time points, treatment groups, or breeds. fecal a -pi concentrations were available for of the dogs and were significantly higher on day compared to day (p . ). no differences were found between pre-and post-treatment serum albumin or cobalamin concentrations. weight gain was seen in all nl. resolution of diarrhea, vomiting, hyporexia, as well as an increased activity was seen in scwt. another scwt had resolution of diarrhea and a decrease in pruritus. no changes in clinical signs were reported in the remaining scwt. this study indicates that larazotide acetate might be able to reduce ip in dogs. this effect may be dose-dependent. however, not all dogs showed an improvement in clinical signs, suggesting that factors other than increased ip might have been responsible for the clinical signs in these dogs. breed-related effects cannot be ruled out, and further studies are warranted to determine the efficacy of larazotide acetate in dogs of other breeds with gi disease. to analyze different biochemical markers, calculate clinical activity scores, and assess survival in dogs with ple and compare them with those in dogs with food-responsive diarrhea (frd) without protein loss. dogs with ple and dogs with frd, referred to the university of bern, ch, were enrolled. selection criteria included a history of chronic diarrhea ( weeks), exclusion of identifiable underlying causes, and histopathologic evidence of intestinal inflammation, but not neoplasia. underlying disorders were excluded based on cbc, chemistry profile, urinalysis, fecal analysis, trypsinlike immunoreactivity, cobalamin, folate, and transabdominal ultrasound. also, canine pancreatic lipase immunoreactivity (spec cpl s ), c-reactive protein (crp), calprotectin and alpha -proteinase inhibitor (a -pi) were measured in serum from dogs and compared with dogs with frd without ple. all dogs were scored using the canine ibd (cibdai) and the canine chronic enteropathy (cce) clinical activity index (ccecai). total protein, albumin ( - . g/l), and total calcium ( . - . mmol/l) were decreased in all dogs. cobalamin was decreased in all but dogs ( o - ng/l). spec cpl was mildly increased in / dogs with ple and normal in / ple and all frd dogs. crp was normal in / dogs with ple ( / frd), mildly increased in / ( / frd), and moderately increased in / ple dogs ( / frd). calprotectin was slightly higher in dogs with ple, but all ple and frd dogs yielded values in the normal range. serum a -pi was significantly lower in dogs with ple than in those with frd (p o . ), with / ple dogs below the reference range ( / frd). cibdai ranged from to and ccecai from to . at the end of the study, / dogs were still alive with survival times between and days. / dogs died with a median survival of days (range - days). dogs with mildly increased crp died earlier than dogs with a normal or moderately increased crp (p . ), whereas albumin, calcium, spec cpl, calprotectin, cibdai, and ccecai had no significant impact on outcome and survival. in conclusion, dogs with ple have a significantly lower a -pi in the serum than dogs with frd. furthermore, most dogs with ple have an increased crp and a decreased cobalamin. a mild increase in crp appears to be a poor prognostic factor. while hypoalbuminemia is a common finding associated with chronic enteropathies, its impact on survival in this population is poorly defined. the aim of this study was to compare dogs with chronic enteropathies on the basis of their serum albumin concentration at the time of presentation. we hypothesized that dogs with a protein losing enteropathy (ple) have a significantly shorter survival time compared to dogs with chronic enteropathies which are not hypoalbuminemic (controls). information obtained from the medical records included signalment, duration and characteristics of clinical signs, physical examination findings, clinicopathologic data and survival time. one hundred seventeen cases fit the inclusion criteria; in the ple group and controls. there was no statistical significance between groups for age (p . ), weight (p . ), weight loss (p . ) and body condition score (p . ). compared to control dogs, ple dogs had decreased serum concentrations of cobalamin (p . ), total calcium (p o . ), globulin (p o . ), cholesterol (p o . ) and ionized calcium (p o . ). survival analysis revealed a significantly decreased survival time for ple dogs (p . ); median survival was days for ple dogs and , days for controls. while the ple group did not survive as long, survival was not directly associated with severity of hypoalbuminemia; patients with albumin concentration o . g/dl survived longer than those with mild hypoalbuminemia ( . - . g/dl). this study supports the observation that chronic enteropathy patients have decreased survival time when presented with hypoalbuminemia; however this study suggests the severity of hypoalbuminemia is not a reliable indicator of survival. cobalamin (vitamin b ) deficiency in the chinese shar pei (shar pei) is suspected to be hereditary. inherited causes of cobalamin deficiency have been reported in humans and may affect absorption, transport, or cellular processing of cobalamin. based on human and veterinary studies, an increased serum methylmalonic acid (mma) concentration has been suggested to reflect cobalamin deficiency at the cellular level. in this context, it has been shown in humans that mma concentrations are higher in patients with genetic disorders affecting intracellular processing than in patients with genetic defects affecting gastrointestinal processing and extracellular transport of cobalamin. therefore, the aim of this study was to evaluate serum mma concentrations in shar peis and dogs of six other breeds with cobalamin deficiency. from in conclusion, serum cobalamin deficient shar peis had a times higher median serum mma concentration compared to cobalamin deficient dogs of six other dog breeds. further studies are needed to investigate the intracellular processing of cobalamin in shar peis with cobalamin deficiency. chinese shar peis (shar peis) have a high prevalence of cobalamin deficiency. two other conditions reported frequently in this breed are shar pei fever and cutaneous mucinosis. shar pei fever is an autoimmune disorder causing periodic flare-ups and is associated with increased serum concentrations of c-reactive protein (crp), a nonspecific marker of inflammation. cutaneous mucinosis is characterized by excessive deposition of mucin in the dermis. also, hyaluronic acid (ha), the main component of mucin, was shown to be significantly higher in serum from shar peis with cutaneous mucinosis than in healthy controls. to date, a possible association between shar pei fever and/or cutaneous mucinosis on one side and cobalamin deficiency on the other has not been investigated in shar peis. thus, the aim of this study was to compare serum concentrations of ha (an indicator of cutaneous mucinosis) and inflammatory markers (crp, calprotectin, and s a ), assumed to be increased in episodes of shar pei fever, in shar peis with and without cobalamin deficiency. serum samples from shar peis, collected from to , were analyzed. serum ha and crp (reference interval (ri): . - . mg/l) were quantified by using commercial elisa kits (echelon biosciences, salt lake city, ut, usa and tridelta, maynooth, ireland; respectively). serum calgranulin concentrations were measured using an in-house elisa (calprotectin; ri: . - . mg/l) and ria (s a ; ri: . - . mg/l), respectively. mann-whitney u tests were used to compare serum ha, crp, calprotectin, and s a concentrations between shar peis with and without cobalamin deficiency. significance was set at p o . . fourteen shar peis were severely cobalamin deficient, defined by an undetectable serum cobalamin concentration ( o ng/l). in the remaining dogs, serum cobalamin concentrations were within the reference interval ( - ng/l). serum concentrations of ha, crp, calprotectin, and s a were not significantly different between cobalamin deficient shar peis (medians: . ng/ml, . . fifty percent of cobalamin deficient shar peis had serum calprotectin concentrations above the upper limit of the reference interval, and % had serum s a concentrations above the suggested upper reference limit. in this study, serum concentrations of ha, crp, and the calgranulins did not differ between cobalamin deficient shar peis and shar peis with a normal serum cobalamin concentration. this finding leads us to speculate that increased ha and/or inflammatory markers are not associated with cobalamin deficiency in shar peis. further studies are needed to investigate serum cobalamin concentrations in patients with shar pei fever or cutaneous mucinosis. cobalamin deficiency (cd) has been associated with gastrointestinal and pancreatic disease in dogs. hereditary cd has been demonstrated in giant schnauzers and single case reports have suggested congenital cd in the border collie (bc) breed. clinicopathologic findings of cd vary and can be unspecific as cobalamin acts as a co-factor for a multitude of enzymatic reactions. the two most important reactions concern the conversion of methylmalonyl-coa to succinyl-coa and the re-methylation of homocysteine (hcy). these two metabolites increase when cobalamin is lacking and act as markers for cobalamin availability on a cellular level. preliminary data from dogs suggested that measurement of methylmalonic acid (mma) may be a better diagnostic test for cd than serum cobalamin concentration. therefore the goals of the study were ( ) to establish reference values for serum cobalamin, urine mma and plasma hcy in healthy pet dogs, ( ) to screen a larger bc population from switzerland for cd, and ( ) to perform genomic analyses on bc with cd. for determination of reference values healthy pet dogs were used. serum cobalamin was measured using an automated chemiluminescence assay (immulite ), urine mma was determined using gas chromatography and expressed as a ratio to urine creatinine and plasma hcy was measured using high pressure liquid chromatography and fluorimetric detection. to calculate reference ranges the th and th percentile were used. data were analyzed using non-parametric tests. reference ranges for cobalamin, hcy, and mma were: cobalamin . - . ng/l; urine mma - . mmol/mol creatinine; and plasma hcy . - . mmol/l. the screened bc population comprised purebred dogs and bc (median . months; range - ) suffering from congenital cd could be identified. clinical signs differed and consisted of tiredness ( ), stunted growth ( ), anemia ( ), dysphagia ( ) and persistent fever ( ). median (ranges) results for healthy bc and bc with cd were: for cobalamin ( - ) and . ( - ) ng/l; for urine mma ( - ) and ( - ) mmol/mol creatinine; for hcy . ( . - . ) and . ( - . ) mmol/l. strikingly, healthy bc with cobalamin concentrations well within the reference range had significantly higher urine mma concentrations compared to control dogs. under the assumption that the four affected bc are inbred to a single founder animal, first results of genotyping on the k illumina canine_hd snp chip suggest that mutations in the cubn and amn gene can be excluded to cause the observed cd in these dogs. we conclude that cd is a rare familial disease in bc with variable clinical signs. to define the genomic region responsible for cd further genetic analysis is in progress. it remains to be determined why some bc have high urine mma concentrations despite a serum cobalamin concentration within the reference range. calprotectin is a protein complex that plays an important role in the innate immune response. preliminary data suggest that canine calprotectin (ccp) is a useful marker for the detection of inflammation in dogs. recently, a radioimmunoassay for the measurement of ccp has been developed and analytically validated, but this test requires the use of a radioactive tracer. therefore, the aim of this study was to develop and analytically validate an enzyme-linked immunosorbent assay (elisa) for the quantification of ccp in serum and fecal specimens from dogs. canine calprotectin (ccp) was purified, antiserum against purified ccp was raised in rabbits, monospecific antibodies were purified by affinity chromatography, and a sandwich-elisa was developed. purified antibodies were used for capturing and, after coupling with horseradish peroxidase (hrp), for reporting. a hrp substrate was used for color development. the assay was analytically validated by determination of analytical sensitivity and specificity, dilutional parallelism, spiking recovery, and intra-and inter-assay variability. control intervals for serum and fecal ccp were established from and healthy pet dogs, respectively, using the central th percentile. sensitivity of the assay for serum samples assayed in a : dilution and for fecal extracts assayed in a : , dilution was . mg/l and . mg/g, respectively. over a wide range of the assay, there was no cross-reactivity with cs a , the closest structural analogue of ccp available. observed to expected ratios (o/e) for serial dilutions ranged from . - . % (mean ae standard deviation [sd]: . ae . %) for four different serum samples, and from . - . % (mean ae sd: . ae . %) for five different fecal extracts. o/e for spiking recovery ranged from . - . % (mean ae sd: . ae . %) for four different serum samples and different spiking concentrations, and from . - . % (mean ae sd: . ae . %) for different fecal extracts and different spiking concentrations. intra-assay coefficients of variation (cv) for different serum samples were . , . , . , and . %, and . , . , . , and . % for different fecal extracts. inter-assay cv for different serum samples were . , . , . , and . %, and . , . , . , and . % for different fecal extracts. the control intervals for serum and fecal ccp were established as . - . mg/l and . - . mg/g, respectively. we conclude that this new elisa for the measurement of ccp is analytically sensitive, linear, accurate, precise, and reproducible, and does not cross-react with canine s a . further studies evaluating the clinical usefulness of measuring serum and/or fecal ccp are currently under way. the syndrome of hemorrhagic gastroenteritis (hge) is characterized by a peracute onset of hemorrhagic diarrhea, vomiting, depression, and anorexia, and can be associated with a high mortality if untreated. the etiology of hge is unknown, but it is speculated that an abnormal response to bacterial endotoxins, bacteria, or dietary components may play a role. hge is characterized by an increased vascular/mucosal permeability, thought to represent a type i-hypersensitivity reaction, whereas inflammation and necrosis appear to be rare. however, markers of gastrointestinal (gi) inflammation and changes in the intestinal microbiota have not been studied extensively in dogs with hge. therefore, the aim of this study was to evaluate fecal canine calprotectin (cp) and s a (a ), a -proteinase inhibitor (a -pi, a marker of gi protein loss), and bacterial groups that have previously been shown to be decreased (i.e., faecalibacterium spp., ruminococcaceae, bifidobacterium spp.) or increased (i.e., proteobacteria) in fecal samples from dogs with hge. fecal samples from consecutive days were collected from dogs with hge. fecal cp, a , and a -pi concentrations were measured by in-house immunoassays. bacterial dna was extracted from each fecal sample and was analyzed for faecalibacterium spp., proteobacteria, rumino-coccaceae, and bifidobacterium spp. using quantitative pcr assays. concentrations of fecal cp, a , and a -pi, and the abundance of bacterial dna were compared using a friedman test with dunn's post-hoc tests. significance was set at p o . . at the time of diagnosis (day ), fecal cp, a , and a -pi were above the suggested reference intervals in , , and of the dogs, respectively. until day , this number decreased to , , and , respectively. decreases in concentrations were significant between days and for a (p . ), and between days and for a -pi (p . ), but not for cp despite a trend (p . ). no differences in the abundance of faecalibacterium spp. (p . ), bifidobacterium spp. (p . ), or proteobacteria (p . ) were observed. however, the abundance of rumino-coccaceae was significantly lower on day when compared to day (p . ). in this study, fecal markers of inflammation and gi protein loss were increased in dogs with hge. although the number of patients was small, following initiation of treatment, two of the markers decreased significantly. these results suggest a loss of protein into the gi tract at the onset of hge. the lack of significant increases of faecalibacterium spp., bifidobacterium spp., and ruminococcaceae, and decreases in proteobacteria may suggest gi dysbiosis. further longitudinal studies are needed and are currently under way to evaluate gi dysbiosis in canine hge patients. the most recent antiemetic approved for use in dogs is maropitant citrate (cerenia s , pfizer animal health). maropitant is a selective nk receptor antagonist that acts by blocking the binding of substance-p within the emetic center and chemoreceptor trigger zone. label dosage recommendations for maropitant citrate are mg/ kg sc or mg/kg orally once daily for up to consecutive days (acute emesis) and mg/kg orally once daily for up to consecutive days (motion sickness). the study objective was to determine when steady-state is reached and the pharmacokinetics of maropitant administered at label oral dosages once daily for consecutive days. two groups of eight healthy beagles were administered maropitant citrate at or mg/kg orally once daily for days. concentrations of maropitant and its metabolite were measured in plasma using a lc-ms/ms assay. pharmacokinetic parameters were estimated using non-compartmental pharmacokinetic techniques and a modeling approach was used to estimate steady-state. the accumulation ratio for maropitant was . (auc - ) and . (cmax) for the mg/kg dose; and . (auc - ) and . (cmax) for the mg/kg dose after days. the model estimate for the number of doses required to reach % of steady-state was . for mg/kg and . for mg/kg. three dogs experienced a single episode of vomiting. dosing maropitant citrate beyond the label duration was well tolerated by healthy dogs. steady-state was reached after approximately doses for daily mg/kg and doses for daily mg/kg oral dosing. previously presented at the veterinary cancer society, november . cobalamin (vitamin b ) is involved in a variety of metabolic processes. altered serum cobalamin concentrations have been observed in dogs with gastrointestinal disorders, such as exocrine pancreatic insufficiency (epi) or severe and longstanding ileal disease. this study was conducted to identify breeds with a higher proportion of a decreased serum cobalamin concentration that were submitted to the gastrointestinal laboratory. the study was also aimed at investigating serum trypsin-like immunoreactivity (tli) concentrations that were diagnostic for epi in the dogs with a decreased serum cobalamin concentration. except for csp, breeds identified here, have not previously been identified to have a higher rate of a decreased serum cobalamin concentration. also, a possible association between an undetectable serum cobalamin and a decreased serum tli in ai needs to be further investigated. calprotectin (cp) is a widely used marker for the diagnosis and monitoring of gastrointestinal (gi) inflammation in humans. studies in humans usually report fecal cp concentrations based on a single stool sample although considerable day-to-day variability of fecal cp was found in patients with gi disease and in healthy controls. intra-individual variation of canine cp (ccp) was also substantial in a small number of healthy dogs but has not been determined in dogs with chronic gi disease. thus, the aim of this study was to compare the day-to-day variation of fecal ccp in dogs with chronic gi disease before and during treatment to that in healthy dogs. we hypothesized that fecal ccp would be less variable in patients with chronic gi disease than in healthy controls, and thus collection of a single fecal sample would be sufficient. fecal samples from consecutive days were prospectively collected from dogs (group a; median age: . years) referred for diagnostic work-up of chronic signs of gi disease, from dogs (group b; median age: . years) with stable gi disease while being treated, and from healthy adult dogs (group c; mean age: . years). fecal samples were extracted and ccp was measured by an in-house immunoassay. mean ccp, standard deviation, coefficient of variation (cv), and difference between maximum and minimum ccp for the -day sample collection period were calculated for each dog and were compared among groups using a kruskal-wallis test. fecal ccp ranged from . - . mg/g (median: . mg/g) in dogs with gi disease (group a), from . - . mg/g (median: . mg/g) in dogs of group b, and from . - . mg/g (median: . mg/g) in healthy controls (group c). cvs were - . % in group a (median: . %), . - . % in group b (median: . %), and - . % in group c (median: . %), respectively. patients in group a appeared to have less variable fecal ccp than dogs in group b and c, but this difference was not significant (p . ). the difference between maximum and minimum ccp for the -day sample collection ranged from - . mg/g in group a (median: . mg/g), from . - . mg/g in group b (median: . mg/g), and from - . mg/g in group c (median: . mg/g), and were not significantly different between any of the groups (p . ). in this study, considerable day-to-day variation of fecal ccp was found in dogs with chronic gi disease (regardless of treatment) and was comparable to that in healthy dogs. results of this study suggest that for evaluating fecal ccp in dogs with clinical signs of gi disease, three consecutive fecal samples rather than a single fecal sample should be analyzed. because we did not intend to evaluate the clinical usefulness of fecal ccp as a marker of gi disease in dogs, disease severity, quality, and location differed among dogs in groups a and b. the diagnostic utility of fecal ccp in dogs with gi disease is currently being investigated. it has been suggested that diagnosis of clostridium perfringens related enteropathy should be based on the detection of the c. perfringens enterotoxin gene (cpe-gene) by pcr and/or c. perfringens enterotoxin (cpe) by elisa in feces. however, the prevalence of the cpe-gene and cpe in dogs and especially cats with gastrointestinal disease has not yet been reported. also, there is limited information about the stability of cpe in fecal samples at various storage conditions. the aim of this study was to evaluate the prevalence of the cpe-gene and cpe and the stability of cpe in fecal samples from dogs and cats. to evaluate the prevalence of the cpe-gene, a total of fecal samples from dogs and cats with clinical signs of gastrointestinal disease ( dogs and cats) and fecal samples from those without such signs ( dogs and cats) were examined using pcr. to evaluate the prevalence of cpe, a total of fecal samples from dogs and cats with clinical signs of gastrointestinal disease ( dogs and cats) and dogs without such signs were evaluated using a commercially available elisa kit (techlab, blacksburg, va). the results were analyzed using a fisher's exact test. significance was set at p o . . to evaluate the stability of cpe, fecal samples from dogs and from cats with clinical signs of gastrointestinal disease that were positive for cpe were examined. also, cpe negative samples from dogs were evaluated as negative controls. each sample was subdivided into aliquots and evaluated on day ; on days , , and after being stored at room temperature (rt) or c; and on day after being stored at À c. the prevalence of the cpe-gene was not significantly different between dogs with signs of gastrointestinal disease ( / ; . %) and dogs without ( / ; . %; p . ). also, the prevalence of the cpe-gene in cats with signs of gastrointestinal disease ( / ; . %) was not significantly different compared to cats without ( / ; . %; p . ). pcr and elisa results were available for samples. of the pcr positive samples, only ( . %) were elisa positive. of the pcr negative samples, only ( . %) was elisa positive. the prevalence of cpe was not significantly different between dogs with clinical signs of gastrointestinal disease ( / ; . %) and those without ( / ; . %; p . ). the prevalence of cpe in cats with signs of gastrointestinal disease was / ( . %), but no samples from cats without such signs were available. when evaluating the stability of cpe, results for all aliquots were consistent with the initial result, except for one sample (on day , stored at rt, which was initially cpe positive). these results indicate that only a small proportion of samples that are pcr positive for the cpe-gene are also positive for cpe. studies are warranted to further compare the prevalence of cpe among animals with gastrointestinal disease and those without. furthermore, the results indicate that cpe is relatively stable in fecal samples at various storage temperatures. clostridium perfringens has been implicated as a cause of diarrhea in dogs. the main study objective was to compare two culture methods for the identification of c. perfringens. a secondary objective was to evaluate c. perfringens toxin genes a, b, b , e, ı and cpe from canine isolates using a multiplex pcr and determine their prevalence in a group of normal and diarrheic dogs. fecal samples were collected from clinically normal (nd, n ) and diarrheic dogs (dd, n ) at a primary care veterinary facility. isolation of c. perfringens was performed using direct inoculation of feces onto % sheep blood agar (sba) as well as enrichment of stool in bhi broth followed by inoculation onto sba. isolates were tested by multiplex pcr for the presence of a, b, b , e, ı and cpe genes. c. perfringens was isolated from % ( / ) of nd fecal samples using direct culture and . % ( / ) with bhi enrichment (p . ). in the dd, corresponding isolation rates were . % and . % (p . ). all isolates possessed a toxin gene. b, b , e, ı and cpe toxin genes were identified in . %, . %, . %, . % and . % of nd isolates, respectively. in the dd group, b and b were identified in %, e and ı were not identified and the cpe gene in . % of isolates. bhi enrichment did not significantly increase the yield of c. perfringens compared to sba but increased time and cost involved. c. perfringens (p . ) and c. perfringens toxin genes were present in equal proportions in nd and dd groups (p ! . ). culture of c. perfringens and pcr for toxin genes are of limited diagnostic utility due to the high prevalence of c.perfringens in normal dogs and the lack of apparent difference in toxin gene distribution between normal and diarrheic dogs. endoscopic biopsies are a relatively convenient, non-invasive test for feline infiltrative intestinal disorders. commonly, only the duodenum is examined due to cost, risks and time required to prepare the colon using lavage solutions, cathartics and/or enemas. the purpose of this study was to evaluate the consistency between endoscopic biopsies of the duodenum and ileum in cats. endoscopic biopsies from cats which had duodenal and ileal tissue specimens were evaluated retrospectively. all slides were randomized and reviewed by a single pathologist (jm) for quality, number of biopsies, and diagnosis according to wsava standards. no information regarding history, clinical signs, endoscopic findings, or previous histological diagnosis was made available to the pathologist. statistical comparison of the diagnosis of sc-lsa and ibd by intestinal location was conducted using fisher's exact test (p o . significant). of cats ( . %) were diagnosed with sc-lsa in the duodenum and/or ileum. of these cats, ( . %) were diagnosed with only duodenal sc-lsa, ( . %) were diagnosed with only ileal sc-lsa, and ( . %) had sc-lsa in both duodenum and ileum. in cats with only ileal sc-lsa, had severe ibd in duodenal biopsies, possibly consistent with early sc-lsa. of these had duodenal biopsies without evidence of sc-lsa. our results suggest there is a population of cats in which diagnosis of sc-lsa may only be found by evaluating ileal biopsies. clinicians should consider performing both upper and lower gi endoscopic biopsies in cats with suspected infiltrative small bowel disease. periodontitis is one of the most common diseases in cats and is mainly due to the presence of plaque and calculus. in this study, we investigated putative correlations between dental tartar and gingivitis and also between gingivitis and subgingival bacteria in cats. twelve cats (median age: years; range: - years; dsh and persians; females and males) were enrolled. dental tartar was obtained during scaling for a dental prophylactic procedure. all cats were negative for felv and fiv infection as assessed by a commercial elisa test (snap s fiv/felv combo test). severity of gingivitis (scores: - ; normal, mild, moderate, and severe) and dental tartar (scores: - ) were scored in each cat. endodontic paper points were applied for collecting a bacterial sample from the subgingival area and transferred to thioglycollate transporting media for bacterial culture. the relationship between gingivitis and tartar thickness scores was analyzed by spearman correlation. a student's t-test was used to compare the mean differences (gingivitis and tartar thickness scores) between upper and lower teeth. the association between severity of gingivitis and bacterial type was tested by chi square test. the spearman correlation coefficient for the average gingivitis score and the average tartar thickness score was . (p o . ). interestingly, the average tartar thickness scores from the upper jaw were significantly higher than those from the lower jaw (p o . ). the highest scores were found for the molar teeth in all cats. bacterial culture revealed . % anaerobic bacteria species (i.e., bacteroides spp., peptostreptococcus anaerobius, and eubacterium aerofaciens) and . % aerobic bacteria species (i.e., pasteurella multocida, streptococcus spp., enterococcus spp., staphylococcus spp., bacillus cereus, escherichia coli, and pseudomonas aeruginosa). anaerobic bacteria were found mostly in cats with higher gingivitis scores ( - ; chi square: p o . ), while pasteurella multocida was found mostly in cats with lower gingivitis scores ( - ; chi square: p o . ). antimicrobial sensitivity testing indicated that all of the anaerobic bacteria were sensitive to clindamycin, chloramphenicol, metronidazole, cefoxitin, or tetracycline, % were sensitive to erythromycin, and % were sensitive to penicillin. the most abundant aerobic bacterial species, pasteurella multocida, was sensitive to cefoxitin in all cases in which it had been cultured. these results suggest that anaerobic bacteria may be associated in the pathogenesis of severe gingivitis. these data warrant further studies of the prophylactic use of antibiotics in cats undergoing dental prophylactic procedures. inflammatory bowel disease is the most common cause of vomiting and diarrhea in dogs. although it can occur in any canine breed, certain breeds are more susceptible. we have previously shown that polymorphisms in the tlr and tlr gene are significantly associated with inflammatory bowel disease (ibd) in the german shepherd dog (gsd), a breed at risk of developing this disease. it would be useful to determine if these polymorphisms are significant in other canine breeds as this may allow the development of novel diagnostics and therapeutics to be applied to all canine breeds with ibd. therefore the aim of this study was to investigate whether polymorphisms in canine tlr and tlr genes are associated with ibd in other non-gsd canine breeds. four non-synonymous snps in the tlr gene; t c, g a, a t and g a and three non-synonymous snps in the tlr gene; g a, c t and t c previously identified in a mutational analysis in gsds with ibd were evaluated in a case-control study using a snapshot multiplex reaction. sequencing information from unrelated dogs with ibd consisting of different non-gsd breeds from the uk were compared to a breed-matched control group consisting of unrelated dogs from patients treated for noninflammatory disease at the royal veterinary college, london, uk. as in the gsd ibd population the two tlr snps; c t and t c were found to be significantly protective for ibd in other breeds included in this study (p . and p . respectively). this study confirms the protective effects of the two tlr snps (c t and t c) in other canine breeds with ibd. this highlights the importance of tlr in the pathogenesis of canine ibd and may represent common pathological pathways of ibd in different canine breeds due to the high degree of haplotype sharing seen among breeds. this may allow for the future expansion of novel diagnostics and therapeutics to be applied to all canine breeds with ibd. further functional studies looking at the role of tlr in the pathogenesis of canine ibd are needed to confirm these findings. toll-like receptor (tlr ) is an extracellular pattern recognition receptor belonging to the innate immune system. we have recently shown that three non-synonymous single nucleotide polymorphisms (snps) in the tlr gene (g a, c t and t c) are significantly associated with inflammatory bowel disease (ibd) in german shepherd dogs. in addition, we confirmed that two of these tlr snps (c t and t c) were significantly associated with ibd in a population consisting of different dog breeds. in order to determine if other novel snps exist in the tlr gene in addition to the ones identified in the gsd population, mutational analysis was carried out in seven boxer dogs with ibd. polymerase chain reaction was carried out to amplify the tlr coding region in the seven dogs with ibd. sequencing was carried out using sequence based typing with the abi prism sequencing kit (applied biosystems, uk) and analyzed using an abi automated sequencer (pe applied biosystems). sequencing information from seven boxer dogs with ibd from the uk were compared to the reference sequence published on the ensemble webserver (www. ensembl.org/canis_familiaris). in addition to the three snps identified previously in the tlr gene, a novel non-synonymous snp; t c was identified in the boxer dog population with ibd. this snp has never been reported before and was present as the homozygote genotype in three dogs with ibd and in one dog as the heterozygote genotype. using the simple modular architecture research tool (smart) web server (http:// smart.embl.de/) we were able to map the t c snp to the leucine rich repeat domain of the tlr protein. the leucine rich repeat domain is involved with ligand binding and therefore a change in the amino acid in this region may affect function, especially as the t c snp results in a change in the amino acid from non-polar to polar. our study further confirms the role of tlr in the pathogenesis of canine ibd. our results suggest that in addition to shared risk polymorphisms amongst breeds, individual breeds may harbor unique snps arising after breed formation which may further affect their susceptibility to this disease. however, a case-control study would be needed in the boxer dog to confirm the significance of the tlr t c snp and further functional data would be needed to elucidate the exact role of this polymorphism in canine ibd. an automated power driver device (oncontrol, vidacare) has recently become available for bone marrow aspiration (bma) and bone marrow biopsy (bmb) in humans. the purpose of our study was to compare this automated technique to the traditional manual technique for bone marrow sampling in cats. twelve healthy research cats were anesthetized using a standardized protocol on different occasions, days apart, to have bmas and bmbs performed by the same operator. on day , half of the cats were randomized to have a bma performed at both the proximal humerus and the iliac crest, and a bmb performed at the iliac wing, using the oncontrol device ( -gauge needle for bma; -gauge needle for bmb). the other half of the cats had the same procedures performed using a manual technique ( -gauge illinois needle for bma; -gauge jamshidi needle for bmb). on day , each cat had bma performed at the opposite humerus and iliac crest, and a bmb performed at the proximal humerus using the opposite technique from day . for each procedure, the operator was given a maximum of attempts to successfully collect a sample. the rate of success, as well as the number of attempts were recorded. the ''ease of use'' of the device was rated by the operator on a -point scale after each procedure. using previously determined criteria, the macroscopic and microscopic qualities of the bma and bmb samples were assessed by a board-certified pathologist, blinded to the technique used. the level of pain experienced by each cat was evaluated , , , , and hours following each set of procedures, using a previously validated pain scoring system. two sample t-tests were used to compare the automated technique to the manual technique and to compare the humerus to the iliac crest site for bmas and the humerus to the iliac wing site for bmbs. for all procedures, at all sites, the ''ease of use'' was better for the automated technique than for the manual technique (p o . ). the duration of the procedure and the number of attempts to collect a sample were significantly lower with the automated technique for bma at the proximal humerus (p o . ). there was no significant difference in the level of pain at any time point following each set of procedures with either technique. performing bma at the proximal humerus was associated with a higher rate of success (p o . ), a lower number of attempts (p o . ), a shorter duration of the procedure (p o . ), a higher-rated ''ease of use'' of the technique (p o . ), and a better quality sample (p o . ) when compared to sampling from the iliac crest, in conclusion, we found the automated bone marrow sampling technique suitable for use in adult cats. this technique was easier to use than the manual technique for both bma and bmb, and reduced the duration of the procedure and the number of attempts for successful bma at the proximal humerus. performing bma at the proximal humerus was faster, easier and allowed collection of better quality samples than at the iliac crest, independently of the technique used. the fractious nature of some feline patients sometimes makes sedation or general anesthesia necessary for routine procedures such as blood collection for hematologic analyses. it has been anecdotally reported that sedation or general anesthesia could induce variations in hematologic parameters in cats, making it important for the clinician to be able to anticipate potential changes on hematologic parameters that could result from chemical restraint. this study evaluated the effects of a standardizecd anesthetic protocol using ketamine ( mg/kg, iv), midazolam ( . mg/kg, iv) and buprenorphine ( mg/kg, im) on the hematologic parameters of healthy adult research cats. each cat had blood samples collected before and after induction of anesthesia on different occasions, days apart. in total, pairs of complete blood counts were obtained. analyses were performed at a certified veterinary laboratory. paired sample t-tests were used to determine whether there were any statistical differences between hematologic parameters before and after induction of general anesthesia, for each cat, on different occasions. compared to preanesthetic values there was a significant decrease in red blood cell count, hemoglobin concentration, hematocrit, lymphocyte count and plasma total protein concentration after induction of anesthesia. there was no significant difference in the segmented or band neutrophil, eosinophil, basophil, monocyte and platelet counts between the samples taken before and after induction of anesthesia. on average, there was a . % decrease in the red blood cell count ( .  /l to .  /l) (p o . ), a % decrease in hemoglobin concentration ( . g/l to . g/ l) (p o . ), a . % decrease in the hematocrit ( . l/l to . l/l) (p o . ), a . % decrease in the lymphocyte count ( .  /l to .  /l) (p . ), and a . % decrease in the plasma total protein concentration ( . g/l to . g/l) (p o . ) when samples taken before and after induction of anesthesia were compared. if only the hematocrit was considered as a marker of anemia, % of the samples from these healthy cats, taken while they were under general anesthesia, would have been misinterpreted as belonging to anemic patients (hematocrit o . l/l), using the reference interval established in our laboratory. none of the cats would have been considered anemic before induction of general anesthesia. in practice, the decrease in lymphocyte count following anesthesia is unlikely to be of clinical relevance, as all the samples except had a lymphocyte count that was within the reference interval for cats established by our laboratory. this study suggests that complete blood counts performed on blood taken under general anesthesia with this combination of anesthetic drugs in cats should be interpreted cautiously in order not to make a false diagnosis of anemia. the mechanism responsible for the decrease in circulating red blood cell mass following anesthesia induction in cats is unknown and requires further investigation. rivaroxaban is an oral inhibitor of activated coagulation factor x (xa). it is expected to have similar coagulation effects as low molecular weight heparin, without the need for injection, making it an attractive alternative for long-term anticoagulant therapy in cats. citrated blood obtained from five healthy adult cats was exposed in vitro to varying concentrations of rivaroxaban, followed by coagulation testing. the rivaroxaban was extracted from commercially available tablets (xarelto s ) and dissolved in dmso prior to addition to the blood. tests performed included kaolin-activated thrombelastography (teg), prothrombin time (pt), dilute pt (dpt), activated partial thromboplastin time (aptt), and anti-factor xa (axa) activity. dose-dependent prolongations were seen in all coagulation parameters. similar to human data, therapeutic axa levels (between . - . axa units) were achieved at in vitro concentrations between and mg/l. at mg/l, dpt measurements were clinically prolonged in all cats ( . ae sec vs. . ae . sec, p . ), while aptt values were only mildly prolonged from baseline ( . ae sec vs. . ae sec, p . ). significant prolongations were seen in dpt at ( . ae ec, p . ). teg r time did not prolong from baseline values until concentrations of mg/l were reached ( . ae min compared to . ae . min, p . ). rivaroxaban has similar coagulation effects in the cat as in other species and may play a role in feline thromboprophylaxis. kaolinactivated teg does not appear to be sensitive to low concentrations of rivaroxaban in the cat. anticoagulated blood is required for platelet function studies. sodium citrate, a calcium chelater, is the most commonly used anticoagulant to measure coagulation parameters including platelet aggregation but it may have a negative effect on platelet responsiveness. dogs are generally considered moderate responders to collagen on platelet aggregation and are notorious for being poor or inconsistent responders to adp-induced platelet aggregation using citrated whole blood. hirudin, a selective thrombin inhibitor, can also be used as an anticoagulant for coagulation assays and is the anticoagulant of choice for certain assays including the multiplate s platelet function analyzer. ten adult healthy dogs were used to compare whole blood platelet aggregation between citrated and hirudinated blood samples. venous blood was collected atraumatically from the external jugular vein directly into tubes containing . % trisodium citrate or hirudin. whole blood platelet aggregation was performed (whole-blood lumi-aggregometer, chrono-log corporation, havertown, pa, usa) with collagen ( mg/ml) and adp ( mm) as agonists. maximal platelet aggregation (ohms) was recorded. there was a significant increase in collagen-induced platelet aggregation from the hirudinated samples compared to the citrated samples ( . ae . vs. . ae . o, p o . ). there was also a significant increase in adp-induced platelet aggregation from the hirudinated samples compared to the citrated samples ( . ae . vs. . ae . o, p . ). the results of this study show a significant difference in platelet responsiveness between citrated and hirudinated whole blood using the chrono-log impedance aggregometer. while both collagen and adp-induced platelet aggregation was attenuated from citrated blood samples, this was most notable for adpinduced aggregation where almost all samples had no objective measurable platelet aggregation. it is suggested from this data that future whole blood platelet aggregation studies performed on the chrono-log impedance aggregometer should use hirudinated blood samples although new reference limits would need to be established. low-molecular-weight heparin (lmwh) is now used to prevent thrombotic complications in dogs. a functional assay such as the calibrated automated thrombogram (cat) may provide a new approach for monitoring lmwh therapy. we hypothesized that cat would detect decreased endogenous thrombin potential (etp) in healthy dogs receiving lmwh (fragmin s ). twenty-four healthy adult beagles were included in this study and divided equally in four groups. one dose of u/kg, u/kg or u/kg of lmwh were given subcutaneously to healthy dogs and compared to a control group. platelet poor plasma (ppp) was collected over a hour period. using a repeated-measure linear model, effect of lmwh on etp was time and dose dependent with a significant interaction (p o . ). compared to control dogs, significant differences were obtained for group u/kg at t (p . ), for group u/kg at t (p . ) and between t -t minutes (p o . ) respectively, and for group u/ at t (p . ), between t -t minutes (p o . ) respectively and at t (p . the cat assay can be employed to measure the effects of lmwh at different doses in healthy dogs, resulting in significant time and dose-dependent decreases in etp and warrants further investigation as a tool for monitoring lmwh therapy in dogs. the purpose of this study was to determine the effects of prednisone and prednisone plus ultralow-dose aspirin on coagulation parameters in healthy dogs, with an emphasis on thromboelastography (teg). this was a prospective, randomized, blinded study utilizing fourteen dogs determined to be healthy based on normal physical examination, complete blood count, biochemistry, urinalysis, and fecal floatation. dogs were evenly divided into either prednisone plus aspirin (pa) or prednisone plus placebo (pp) groups. baseline values for teg parameters (r, k, angle, ma, ly , ly , g, ci) were measured twice two days apart, and thrombin-antithrombin complexes (tat), and traditional coagulation parameters (prothrombin time, activated partial thromboplastin time, d-dimer, antithrombin (at), fibrinogen) were measured once. each dog received mg/kg/ day of prednisone, and either . mg/kg/day of aspirin (pa group) or placebo (pp group) for days. a complete blood count, biochemistry profile, teg, tat, and traditional coagulation parameters were then repeated on each dog. day to day variation was calculated for the teg parameters using the two baseline measurements. the change from baseline between and within each group were compared using t-tests, or wilcoxon sample test where appropriate, for teg, tat, traditional coagulation parameters, and hematocrit. day to day variation in teg was acceptable ( %) for ma, g, and angle, unacceptable ( %) for r, k, ly and ly , and not meaningful for ci. within both groups, ma, g, ci and fibrinogen significantly increased from baseline (p o . ). within both groups, ly and at significantly decreased from baseline (p o . ). for the pp group, ly significantly decreased from baseline (p . ), and approached significance for the pa group (p . ). all other within group changes from baseline were not statistically significant (p-values . ). for all parameters, there was no difference between groups for change from baseline (p values . ). day to day variation in some teg parameters is high and may preclude their clinical utility. prednisone causes hypercoagulability in healthy dogs based on increased g, ma, and ci. the addition of ultra-low dose aspirin to prednisone has no effect on the parameters measured in this study. 'aspirin resistance' has been identified in people and dogs that develop thrombi despite low dose aspirin therapy. variability in platelet cyclooxygenase (cox) isoform expression is one proposed mechanism for aspirin resistance in people. two isoforms (cox- and cox- ) have been identified in canine platelets. high (antiinflammatory) dose aspirin inhibits platelet function and alters expression of both cox isoforms in most dogs. this study evaluated the effects of low dose aspirin on platelet function and cox expression in normal dogs. twenty-five healthy client-owned dogs were evaluated before and at two time points (days and ) during aspirin therapy ( mg/kg po sid). platelet response to aspirin (siemens pfa- s ; collagen/ epinephrine cartridges), was stratified into one of three groups [aspirin responders ( dogs), non-responders ( dogs), or inconsistent responders ( dogs)]. flow cytometry identified platelet cox- and cox- expression. an elisa was used to measure urine -dehydro-thromboxane b ( -dtxb ). there were no significant differences between groups for cox- , cox- or -dtxb at any time point. when all dogs were considered as a single group, there was a significant increase (p o . Ã) in cox- and cox- mean fluorescent intensity (mfi) from baseline to day , . % ae . (mean ae sd) and . % ae . , respectively. there was a significant decrease in mean urine -dtxb :creatinine on day and by . % (p . à ) and % (p o . à ). as with our previous high dose studies, cox- expression was increased with aspirin exposure. however, there was a significant increase in cox- expression with low dose aspirin in contrast to the decrease seen at higher doses. our study suggests that levels of platelet cox- and cox- expression do not influence aspirin response in dogs. although thromboxane levels decreased in most ( of ) dogs on low dose aspirin, platelet function was consistently affected in only % of dogs, suggesting that differences in response to thromboxane may play a role in the variable affects of low dose aspirin on canine platelet function. delayed postoperative bleeding is common in retired racing greyhounds (rrgs), despite normal results of routine hemostasis assays. the excessive postoperative bleeding in the rrgs is not due to primary or secondary hemostatic defects, and may be due to enhanced fibrinolysis or to a clot maintenance dysfunction. providing a method to prevent or minimize the severity of postoperative bleeding in rrgs will not only have major economic impact for owners, but also will markedly decrease the associated complications of minor or major surgeries in the breed. epsilon aminocaproic acid (eaca) is a potent inhibitor of fibrinolysis that also supports clot maintenance due to unknown mechanisms. the objective of this double-blinded, prospective, randomized study was to evaluate the effects of eaca versus placebo on the prevalence of bleeding in rrgs, and to investigate its mechanism of action by using thromboelastography (teg). we compared the effects of eaca and placebo in rrgs that underwent elective ovariohysterectomy or orchiectomy at the veterinary medical center, the ohio state university during years. the main endpoint was bleeding (prevalence and severity); minor endpoints included most teg parameters. thirty percent ( / ) of the rrgs in the placebo group had delayed postoperative bleeding starting to hours after surgery, compared to % ( / ) in the eaca group (p . ). on the teg parameters, the r time (clot formation time) was significantly different between treatment groups (p . ). the postoperative administration of eaca significantly decreased the prevalence of postoperative bleeding in rrgs. thromboembolism associated with protein losing nephropathy (pln) has been long recognized as a serious and unpredictable complication in dogs, however its prevalence remains unknown. in humans, surrogate indicators are frequently used to assess thromboembolic risk. this study aimed to investigate the prevalence of hypercoagulability in pln dogs based on thromboelastography (teg), and to determine whether hypercoagulability in these patients could be predicted by clinical assessments that identify systemic hypertension (systolic blood pressure mmhg), hypoalbuminemia (serum albumin o . mg/dl), antithrombin activity (o %), and degree of proteinuria (urine protein:creatinine ratio [upc] ! ). between march -september , twenty-seven dogs were identified with pln at the animal medical center. the prevalence of hypercoagulability based on a teg g-value . was . %. there was no statistically significant relationship, either categorically or continuously, in univariate as well as multivariate analyses of all variables. univariate logistic regression (odds ratio; lower and upper confidence limit; p value) for hypertension was À . ; . , . ; . ; for albumin - . ; . , . ; . ; and for antithrombin activity - . ; . , . ; . . thus, in this patient population, in the absence of teg, prediction of hypercoagulability using abnormalities in commonly measured clinicopathologic variables was not helpful. however, given the documented high prevalence of hypercoagulability in patients with pln, early institution of prophylactic anti-platelet or anticoagulant therapies should be considered. thromboelastography (teg) is a test of global hemostasis. due to the effects of extrinsic factors on whole blood coagulation, sample collection method (scm) may influence results. the purpose was to determine if scm influenced teg using kaolin-activated citrated whole blood (wb). healthy dogs with normal platelet counts were prospectively enrolled. three wb samples were obtained from each dog at least hours apart from alternating jugular veins in a randomized order of three methods: ) vacutainer s into citrated tube (vac), ) citrated syringe with transfer into plain tube (cit), or ) plain syringe with transfer into citrated tube (plain). draw time was recorded in seconds. kaolin-activated teg was performed, with measurement of reaction time (r), clot formation time (k), maximum amplitude (ma), and alpha angle. eleven dogs were enrolled. there were no significant differences in teg indices between vac samples and either cit or plain samples. cit samples had a significantly higher k value (p . ) and a lower alpha angle (p . ) compared to plain samples. draw times ranged from - seconds. a longer draw time was significantly correlated (p . ; r À . ) with a shorter r time. higher platelet count was significantly correlated (p . ; r . ) with a higher ma. scm did not have a significant effect on teg parameters when comparing vac samples to either cit or plain samples. minimizing sample collection time and trauma during venipuncture may be important in minimizing hypercoagulable changes in teg indices. liquid plasma (lp) is defined as either plasma collected and refrigerated immediately after collection or fresh frozen plasma (ffp) that is thawed and stored refrigerated until use. stability studies in people have shown that adequate clotting factor activity is preserved for at least days. lp is transfused in human level i trauma centers to critically ill people requiring rapid infusion of clotting factors as the time required to defrost ffp is considered prohibitive. the use of lp has not been described in veterinary critical care. the purposes of this study were to ) determine the length of time required in a water bath for a unit of canine ffp to thaw and ) describe the use of lp in a busy university emergency room (er). for part : six units ( ml) of canine ffp were individually thawed in a c water bath. the duration of time (in minutes) to thaw was recorded. for part : the transfusion log was reviewed for dogs receiving lp in the last months. the indications and outcome were recorded. the mean time ae sd thaw time was . ae . minutes. ten units of lp were transfused to critically ill or injured dogs during the study time. indications for lp transfusion included hypovolemic shock due to intra-abdominal hemorrhage in dogs ( traumatic, non-traumatic) and rapid correction of hemorrhage following parenteral tissue plasminogen activator administration in dog. lp volume transfused ranged from . to . ml/kg. no transfusion reactions were identified. effect on coagulation was not consistently evaluated. time required to thaw a unit of ffp is greater than minutes which could be detrimental in a bleeding, coagulopathic dog. lp was transfused without incident to critically ill and injured dogs and represents a potential new addition to the armamentarium of treatments in a veterinary er setting. further investigation of canine lp is warranted including evaluation of in vitro factor stability and in vivo efficacy in correcting coagulopathy. immune mediated thrombocytopenia (imt) is associated with increased morbidity and mortality. large prospective research studies in dog platelet antibodies and clinical utilization of platelet immunoglobulin assays are limited. potential explanations include limited availability and low specificity due to nonspecific binding. the focus of this study is to evaluate optimized direct and indirect platelet surface associated immunoglobulin (psaig) and staining with anti-cd antibodies (cd ab) for the utilization in classifying thrombocytopenic dogs. one hundred clinically ill and apparently healthy dogs were prospectively evaluated. data collected included a history of hemorrhage, physical examination evidence of bleeding, complete blood count, and measurement of psaig and cd ab. the psaig assay utilized polyvalent antibodies with correction for non-specific binding by subtraction of background fluorescence with control antiserum. thrombocytopenia was defined as o , /ml and all dogs were clinically classified into of groups (g): g imt, n , g thrombocytopenia from non-immune mediated diseases, n , g ill with normal platelet counts, n , g healthy dogs, n . median platelet counts, by groups, were g , , ; g , , ; g , , ; and g , , /ml. for the direct and indirect psaigs in dogs with itp (g ), more dogs (n and n ) with clinical evidence of bleeding had antibodies compared to those who were not bleeding (n and n ). considering only direct psaig the sensitivity and specificity was % and %, respectively for the diagnosis of imt. for indirect psaig the sensitivity and specificity was % and %, respectively, for the diagnosis of imt. when considering both direct and indirect psaig together, the sensitivity was % with a specificity of %. in g interference from high control antiserum background staining was noted in . % of dogs and resulted in a negative direct psaig classification. minimal background interference was noted in g , g , or g . the percentage of platelets stained with cd ab was significantly less in g (median , p . ) vs. g (median , p . ) vs. g (median . , p . ) and g (median . ). these findings indicate the optimized platelet surface associated immunoglobulin assay has a high specificity, however poor sensitivity, for the diagnosis of imt. the decreased cd staining in g (imt group) may reflect decreased surface gpiiia expression, blocking by anti-gpiiia antibodies or other proteins, clearance by macrophages, or increased non-platelet debris and has potential applications in the diagnosis and treatment of imt. greyhounds have lower serum concentrations of a-globulin than other breeds, explained by negligible levels of haptoglobin (hp) measured using different methods (colorimetric, immunoturbidimetric and protein electrophoresis). the purpose of the present study was to characterize the hp gene in greyhounds. we isolated dna and rna from blood samples of akc-registered and retired racing greyhounds (akcg, rrg), and a german shepherd dog (gsd). we sequenced the hp exons and splice sites, and conducted array comparative genomic hybridization to identify associated dna structural variation (custom m agilent oligonucleotide array). additionally, we tested for the presence of one or multiple haplotypes spanning hp in greyhounds using a high density snp array ( k illumina hd). sequencing results of hp in both dna and cdna revealed three synonymous snps in the racing greyhound. we did not identify structural variation overlapping or near the hp gene. notably, we detected that the rrg and akcg do not appear to share a specific haplotype spanning hp. despite having low or undetectable serum concentrations of hp, we did find that rrg hp mrna is expressed and lacks amino acid variation. this suggests that the clinical absence of the hp is attributable to post-transcriptional hp effects or to an unknown physiological interaction. finally, given the existence of distinct rrg and akcg haplotypes spanning hp, it is important to characterize serum levels of hp in akcg in follow on studies. we reported that hemoglobin in retired racing greyhounds (rrg) has higher oxygen carrying properties and affinity than other breeds. surprisingly, very little is known about canine hemoglobin genetics. the purpose of this study was to characterize genetics of canine beta globins. using computational blast analysis of the dog genome, we identified five beta globin genes in a single locus: two human hbelike followed by three hbb-like genes. we isolated dna and rna from blood of rrgs, akc registered greyhounds (akcg), and german shepherd dog (gsd). all beta globin exons and splice sites were sequenced, and the beta globin locus was examined by array comparative genomic hybridization (custom m agilent array). additionally, we determined the number of common haplotypes that span this locus in rrgs and akcgs using high density snp array ( k illumina hd). expression and sequence analysis of cdna showed all five beta globin genes are actively expressed in adults. canhbb and were created by relatively recent segmental duplication and have identical protein sequence. canhbb / are abundantly expressed in adults; canhbb is expressed at greatly reduced levels. sequencing results revealed one rare non-synonymous single nucleotide polymorphism (snp) in hbe of rrgs, but no variation that could explain their abnormal hemoglobin. we did not detect structural variation overlapping or near the beta globin locus. notably, rrg and akcg do not share haplotypes spanning the beta globin locus. this is the first characterization of canine hemoglobin genetics, and the first report of canine embryonic hemoglobins and their expression in adults. sampling of the bone marrow in the dog from the costochondral (cc) junction can be performed with minimal to no sedation and readily available equipment but is not in widespread use in the united states. the aim of this study was to compare the number of attempts needed to successfully obtain a sample, the time needed for the procedure, and the sample quality between aspirates obtained from the cc junction and more traditional sites (humerus or femur) in healthy dogs when performed by novice and seasoned practitioners. samples were obtained from healthy anesthetized laboratory reared adult dogs after undergoing terminal endoscopic surgery. paired samples from separate dogs were obtained by each practitioner using either a gauge needle and cc syringe at the cc junction or an gauge rosenthal needle and cc syringe from either the proximal humerus or femur (clinician preference). three small animal veterinary interns, one experienced technician and one boarded internist were monitored for number of attempts to success and length of time needed for success of each procedure. slides were prepared by a single investigator and read by a blinded clinical pathologist. data were compared using the paired t-test for normally distributed data and wilcoxen signed rank test for non-gaussian distributions. five pairs of samples from three dogs were evaluated. two dogs had two pairs drawn from opposite limbs and ribs. mean number of attempts to success for traditional sampling sites ( . /À . ) and time to success ( . minutes /À . ) did not differ significantly from attempts ( . /- . , p . ) or time ( . /- . , . ) needed when aspirating from the cc junction. subjectively, samples were of similar quality with regards to cellularity and number of particles present when compared within practitioners. myeloid: erythroid ratio and percentage of lymphocytes were also not significantly different between sites (m:e ratio p . , lymphocyte % p . ) and were within normal limits. while there were no significant differences between the two sites in terms of number of attempts or time to success, it should be noted that the ''seasoned'' practitioners had never performed an aspirate at the cc site and had an increased number of attempts compared to the traditional sites. if the number of attempts needed for success decreases with experience, it is likely the time required would decrease as well. both subjectively and objectively, there were no significant differences in quality or cell populations between the two sampling sites in healthy dogs. based on this data, bone marrow aspiration from the cc junction appears to be equivalent to more traditional sampling sites in healthy dogs. larger studies in clinically ill dogs should be performed before routinely using the site in the clinical setting. recent research on iron homeostasis has elucidated the tightly controlled intestinal uptake of iron. hepcidin, the major hormone limiting iron absorption and release from macrophages, is downregulated by matriptase- , a transmembrane serine protease (tmprss ) produced by the liver. while iron deficiency is commonly caused by chronic blood loss anemia and rarely dietary deficiency or intestinal disorders in dogs and other species, we report here the clinical to molecular investigations of a dog with iron-refractory iron deficiency anemia (irida) caused by a matriptase- deficiency homologous to a recently described autosomal recessive disorder in humans. the proband, a spayed female cocker spaniel without any clinical signs except for recent occasional idiopathic seizures, exhibited a lifelong history of microcytosis and hypochromasia but not anemia. there was no evidence of any blood loss and the dog was receiving an appropriate meat-based diet. mean values of complete blood cell counts, performed from . - years of age, were: hematocrit % (normal reference range - ); rbc count .  /ml ( . - . x ); mcv fl ( - ); mchc g/dl ( - ). serum iron parameters revealed severe iron deficiency with serum iron mg/dl ( - ); total iron binding capacity mg/dl ( - ); serum iron saturation o % ( - %), and ferritin ng/dl ( - ). prolonged courses of oral ferrous sulfate supplementation and several short courses of intramuscular (dextran) injections and intravenous iron infusions did not result in improvement of any red cell or serum iron parameters. however, this dog was never anemic and the partial seizures could not be directly related to the iron deficiency status. no family members were available for further studies. genomic dna was extracted from the proband's edta blood and the exons of the tmprss gene were amplified with flanking primers and then sequenced. in comparison to the normal canine tmprss sequence and that of a sequenced control dog we found a homozygous missense muation, r h, toward the c-terminal end of the protein in the proband's gene. in conclusion, the severe microcytosis and hypochromasia, low serum iron parameters and lack of a response to oral and parenteral iron therapy led to the diagnosis of irida. the missense mutation in the matriptase- at position from an arginine, which is conserved across all species currently deposited in the genbank, to a histidine is likely the disease-causing mutation. this is the first report of an irida in the dog with features very similar to those observed in humans. dogs with naturally-occurring irida may be helpful in developing and assessing novel therapies. accidental ingestion of copper-coated zinc pennies minted after is the most common causes of zinc toxicity anemia in the dog. zinc toxicity anemia may also be seen with ingestion of zinc from other sources as ingestion of metallic foreign material other than pennies, medicines containing zinc, and zinc supplements. the purpose of this study was to determine if there is a weight below which dogs are more susceptible to zinc toxicity anemia secondary to metallic foreign body ingestion. records of dogs presented to the internal medicine service at the veterinary medical center of long island for metallic foreign body ingestion were reviewed for signalment, weight, presenting pcv, and type of metallic foreign body ingested. eighteen dogs met the inclusion criteria and were compared. of the dogs, there were cases of coin ingestion ( %), with ( %) involving ingestion of or more pennies. the other cases involved ingestion of a metallic object ( ), decorative garland ( ), and bb pellets ( ).of the dogs exposed to zinc, ( %) were less than pounds ( . kgs). of those cases ( %) had ingested one or more pennies. eleven out of the ( %) zinc exposure dogs were anemic at presentation. the average weight of the dogs was . pounds ( kg). this study showed that dogs less than pounds appear to be more susceptible to developing anemia secondary to zinc toxicosis, with the majority of cases due to ingestion of pennies minted after . zinc toxicity anemia secondary to penny ingestion is more commonly seen in small dogs. we suspect larger dogs are able to pass pennies through the pyloric sphincter and thus not develop clinical signs. although thrombocytopenia is common in hospitalized dogs, canine cryopreserved platelet concentrate (pc) is used infrequently. data suggest in vitro efficacy of pc and when administered to research dogs, but efficacy is unknown in clinical patients. study objectives were to determine clinical characteristics of dogs receiving pc as well as safety and efficacy of pc in thrombocytopenic dogs. medical records were evaluated retrospectively to identify dogs that received pc. information evaluated included patient characteristics, platelet count, acute transfusion reactions, and survival. twenty six dogs met study criteria. dogs receiving pc ranged in age from - years (mean . years) and / ( . %) were spayed or intact females. hemorrhage was reported in / dogs ( . %) prior to pc transfusion. platelet counts prior to transfusion ranged from to  /ul (mean . /À .  /ul). change in platelet count was measured in dogs and the mean change was . /À .  /ul. dose of pc administered ranged from . to ml/kg with a mean of . /À . ml/kg. no acute adverse reactions were reported. there was no correlation between transfusion dosage and platelet count change post transfusion. survival to discharge occurred in / ( . %) of dogs. the only variable correlated with survival was age with survivors being younger than non-survivors ( . years-old ae . vs. . years-old ae . .; p . ). efficacy of cryopreserved pc transfusions for improving clinical outcome in dogs with thrombocytopenia is yet to be determined; however, pc is well tolerated in clinical patients. fresh frozen plasma (ffp) is used to treat coagulopathies in dogs. current transfusion guidelines recommend that ffp be administered within hours of thawing to avoid decreasing clotting factor function and bacterial contamination. the purpose of this study was to assess clotting factor activity and bacterial contamination of ffp that had been thawed and refrigerated for days. blood was collected from client-owned healthy dogs with no known history of coagulopathy or of administration of drugs affecting coagulation. plasma was separated from whole blood and frozen (À c) within minutes of collection. thawed plasma was maintained at c ( /À c). aerobic and anaerobic bacterial culture, prothrombin time (pt), activated partial thromboplastin time (ptt), and factor ii, vii, ix, and x analyses were tested at time of whole blood collection, ffp thaw, hours post-thaw, hours post-thaw, and hours post-thaw. there were no statistically significant differences in pt and ptt at any of the measured time points. statistically significant differences occurred between initial measurements of factors ii, vii, ix, and x and subsequent time points, but there was no difference in activity levels of the factors once ffp was thawed. one bacterial colony was grown from each of two samples from post-thaw plasma. thawed plasma protocols do not significantly decrease the function of factors ii, vii, ix, and x or prolong pt and ptt. bacterial contamination of the plasma supply seems unlikely, but strict aseptic technique should be used when obtaining plasma for patient use. erythrocyte pyruvate kinase (pk) deficiency is the first and most common erythroenzymopathy described in dogs, cats, and humans. the pk enzyme plays a crucial role in the erythrocyte energy metabolism and its absence causes severe hemolytic anemia, often misdiagnosed as autoimmune hemolytic anemia. the disease is inherited as an autosomal recessive trait and affected dogs also develop osteosclerosis. in dogs, the enzymatic diagnosis is complicated by the anomalous expression of malfunctioning m -pk expression, but breed-specific r-pk mutation tests have been reported for basenjis, west highland white terriers (whwt), and beagles. we report here on a survey of canine pk deficiency studied at the penngen laboratory. a biased group of samples were received for screening from dog breeds with known mutations as well as from dogs with chronic, prednisone-and antibiotic-resistant hemolytic anemia and their relatives. edta blood samples and/or cheek swabs as well as medical record information were received and genomic dna and/ or enzyme activity testing were performed. among the whwts % and % were found to be homozygous deficient dogs or carriers, respectively, with a mutant allele frequency of . . the average age at the time of diagnosis was . years ranging from months to years of age; some samples came from europe and south america. of the beagles studied, % were affected and % were carriers (mutant allele frequency . ). the average age at the time of diagnosis was years ranging from months to years. surprisingly, very few samples from basenjis were received for screening, and none showed the mutant allele. while pk-deficient basenjis lived o years, whwt and beagles often show milder signs and can reach years of age. several dogs from other breeds were also examined because of chronic regenerative anemia and none had any of the known mutations seen in the other breeds. however, based upon pk enzyme activity studies, chihuahua, dachshund, miniature poodle, spitz, eskimo toy, and labrador retriever dogs were found to be affected; they also had osteosclerosis and at least one labrador retriever developed severe hemochromatosis (hepatic iron , ppm; normal o , ppm, analyzed on a dry weight basis). moreover, sequencing of the r-pk cdna from a pk-deficient labrador retriever revealed a new nonsense mutation in exon . in conclusion, pk deficiency appears to be a common cause for hemolytic anemia in certain breeds, and mutation testing makes screening simple. pk deficiency should also be considered in dogs of other breeds which may require the more cumbersome enzyme testing. studies to identify new mutations will confirm and simplify the diagnosis. supported in part by nih grant rr . immune-mediated hemolytic anemia (imha) is a common hematological condition observed in dogs. the diagnosis is based on clinical history, presenting signs and hematological evidence of imha such as regenerative anemia, leucocytosis and presence of spherocytes. the definitive diagnostic procedure is the coomb's test (direct antiglobulin test, dat) which is known to be highly specific but lacks diagnostic sensitivity. direct flow cytometric assay (fca) for igg, igm or c coated red blood cells (rbcs) detection might be more sensitive and thus could be introduced as an alternative diagnostic tool. to investigate the usefulness of fca for imha diagnosis, evaluation of igg, igm or c coated rbcs was performed from dogs presented at the veterinary hospital at usp that fulfilled clinical and hematological criteria for imha. thirty eight healthy dogs were included as controls. dat was performed with polyvalent and monovalent anti-dog sera with twofold serial dilutions of each one, incubated with % rbcs suspension at c and c. for fca, % rbcs from anemic and healthy dogs were incubated with fitc anti-dog igg, anti-dog igm and anti-dog c and submitted to flow cytometry evaluation. specific software and mann whitney u test were used for data analysis. five dogs showed positive results for dat with polyvalent coombs reagent at c (titer to ) and c (titer to ) but only three of them had agglutination titer for anti-igg at c ( to ) and c ( to ). no positive results were observed for anti-igm and anti-c dat. by fc, percentage of igg, igm and c coated rbcs in normal and anemic dogs were, respectively, , % and , % (p o , ); , % and , % (p o , ); , % and , % (p o , ). igg coated rbcs percentage were higher in dogs showing dat positive results (min. , %; max. , %; median , %). direct flow cytometric erythrocyte immunofluorescence assay is more sensitive than dat for detection of antibodies coated rbc in anemic dogs and may provide quantitative data useful for laboratorial diagnosis of imzha. bone marrow aspirates from cats are typically obtained from the ilium, humerus or femur, but may be difficult to obtain and/or of poor quality. in this study the feasibility, safety, and nature of sternal aspiration in cats was investigated. under general anesthesia, bone marrow aspirates were obtained in a randomized order by a single investigator from the sternum and ilium of healthy cats weighing . - . kg, with body condition scores of - (on a scale of - ). for sternal aspirates, cats were positioned in sternal recumbency and a -inch, - ga hypodermic needle attached to a cc syringe was inserted into the cranial manubrium and directed caudally along the long axis of the sternum. aspirates were also obtained from the right iliac crest using an ga illinois needle attached to a cc syringe. difficulty of site localization, needle insertion and advancement, and specimen aspiration, were scored from (easiest) to (hardest). bone marrow smears were prepared by one investigator and reviewed by a pathologist blinded to aspiration site and cat. sample quality was scored from (no marrow particles) to (excellent) based on the number of wellsmeared marrow particles on the slide. particle cellularity was scored from ( % fat) to (o % fat). post-procedure, cats were treated with tramadol ( - mg/kg, po, q h) for days, and assessed for post-biopsy pain (colorado state university feline acute pain scale, range [no pain] - [maximum]) and site swelling (range [none] - [marked]). data were analyzed by ancova accounting for effects of weight and body condition score. pneumothorax was not identified. it was significantly easier to perform sternal than iliac aspiration, but the quality of the sample was significantly better for iliac than for sternal aspirates. because of limitations due to sample quality, bone marrow morphology in sternal samples could not be compared to iliac samples in all cats. for samples that could be compared, cellularity was identical for sternal and iliac samples from cat but underestimated in the sternal sample from another cat. myeloid:erythroid ratios and lymphocyte numbers were the same for sternal and iliac samples in and cats, respectively. megakaryocyte numbers were the same in one sample, less in sternal samples compared to iliac samples from cats, and overestimated in the sternal sample from cat. bone marrow cell morphology was normal in all acceptable samples. it was concluded that sternal aspiration of bone marrow using a - ga hypodermic needle is ) easier to perform than iliac aspiration; ) safe; but ) provides samples of lower quality than iliac aspiration in cats. the diameter of - ga jamshidi-type needles makes bone marrow core biopsy difficult in cats. in this study, biopsies of the left humeral head were taken under anesthesia using a -inch, ga needle (ez-io s intraosseous infusion system, vidacare) from healthy cats weighing . - . kg with body condition scores of - (on a scale of - ). humeral biopsies were compared to biopsies taken from the left iliac crest using a -inch, ga jamshidi needle. biopsies were performed in randomized order by one investigator. biopsy was repeated to a maximum of attempts until a specimen ! mm long was obtained. difficulty of site localization, needle insertion and needle advancement were scored from (easiest) to (hardest). specimens were wrapped in tissue paper and placed in davidson's fixative for min and then transferred to formalin. biopsy sections were reviewed by a pathologist blinded to biopsy site and cat. biopsy length on the slide was measured, and biopsy quality was scored from (no hematopoietic tissue) to (! intertrabecular spaces free of artifact). post-procedure, cats were treated with tramadol ( - mg/kg, po, q h) for days, and assessed for postbiopsy pain (colorado state university feline acute pain scale, range [no pain] - [maximum]) and swelling of biopsy sites (range [none] - [marked]). data were analyzed by ancova accounting for effects of weight and body condition score. there were no significant differences between ga and ga biopsies except for post-biopsy swelling, and there were no significant effects of body weight and body condition. six ( %) of ga and ( %) of ga biopsies were considered acceptable specimens for assessment of bone marrow architecture and morphology; all intact spaces in these biopsies had normal hematopoiesis and cell morphology. comparison of acceptable ga to ga biopsy specimens from cats showed no significant differences for cell density and lymphocytes/plasma cells, while cellularity, assessed as high in of the ga biopsies, was assessed as medium in corresponding ga biopsies; and megakaryocytes, assessed as - /low-power field in one ga biopsy, were assessed as /low-power field in the ga biopsy. myeloid:erythroid ratios were greater in ga biopsies compared to ga biopsies in cats, and less in the ga biopsy in one cat. discordant results between biopsies were not related to differences in quality. in conclusion, ga bone marrow biopsy of the humerus was as likely to yield a specimen of acceptable quality as was ga biopsy of the ilium, and resulted in less post-biopsy swelling. reports on canine acute liver failure (alf) include individual or small case series of animals with a specific diagnosis. the aim of this study was to describe the clinical course, outcome and etiology of alf in dogs presenting to a referral hospital. medical records ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) were reviewed for a diagnosis of alf (elevated serum bilirubin or icterus with concurrent coagulopathy or hepatic encephalopathy (he)). fifty cases were identified representing breeds: labradors retrievers, golden retrievers, german shepherds, and cocker spaniels. median age was years ( m to humerus, ga . ae . . ae . . ae . . ae . à ( . - . ) ( - ) ( - ) ( - ) ilium, ga . ae . . ae . . ae . . ae . . ae . . ae . à ( . - . ) ( - ) ( - ) ( - ) ( - ) ( - ) yrs). presenting signs included anorexia ( / ), vomiting ( / ), polydipsia ( / ) and neurologic signs ( / granulomatous hepatitis (gh) is a histopathological diagnosis characterized by focal aggregations of activated macrophages mixed with other inflammatory cells that is usually part of a systemic disease process (wsava). published case reports describe many potential infectious causes, but only one retrospective study involving nine dogs with gh has detailed clinically relevant findings. the aims of this study were to describe the clinical and clinicopathologic findings in dogs with a histopathological diagnosis of gh, and to identify infectious agents using differential staining techniques, pcr, and fluorescence in-situ hybridization (fish) in archival paraffin-embedded tissues from dogs with gh. medical records of dogs with a histopathological diagnosis of gh (n ) were reviewed and signalment, historical toxin exposure or evidence of other systemic diseases, clinical signs, physical exam findings, clinicopathologic test results, imaging findings, concurrent diagnoses, treatments administered, and case outcome, when available, were extracted and summarized. twelve archival formalin-fixed, paraffin-embedded hepatic tissue samples were available for special staining and molecular diagnostic testing. two of these samples had sufficient tissue for only pcr. the mean age of dogs with gh was years (median . years; range to years) and included males and females representing different breeds. common presenting complaints included inappetance or anorexia (n ), weight loss (n ), lethargy (n ), fever (n ), and vomiting (n ). high mixed liver enzyme activity ( / ) was the most common clinicopathologic abnormality. leukemia was diagnosed in one dog and copper-associated hepatopathy in dogs. no infectious agents were identified using differential staining techniques. bartonella species dna was not pcr amplified from the extracted archival tissue. furthermore, no bacteria were identified by means of fish using a universal eubacterial probe. these data suggest a possible role for copper accumulation in the genesis of gh in dogs and support further evaluation of dogs with gh for evidence of copper-associated hepatopathy. future studies should include detailed environmental histories, the collection of adequate sample volumes for quantification of hepatic copper content and the examination of frozen tissues using novel molecular diagnostic platforms. hepatocyte copper and iron accumulation contribute to cell loss, inflammation, and fibrosis. the purpose of this study was to compare copper and iron accumulation in feline liver samples with different disease processes. liver biopsies (n ) submitted between july , and june , were evaluated using wsava guidelines and categorized as non-hepatic/normal, congenital, inflammatory/infectious, neoplastic, and other. copper (by rubeanic acid) and iron (by prussian blue) accumulation were graded by increasing amounts ( - ) and location (centrilobular cl, midzonal mz, periportal pp, random r). associations between metal scores and diagnosis category were assessed using the kruskal-wallis test. histologic diagnoses were non-hepatic/normal (n ), congenital (n ), neoplastic (n ), infectious/inflammatory (n ), and other (n ). ninety-two samples were negative for copper; remaining samples were graded (n ), (n ), and (n ). histologic diagnoses (pattern) for positive samples were congenital ( cl), infectious/inflammatory ( : cl, mz, pp, r), neoplastic ( pp), and other ( cl). iron staining was negative in samples; remaining samples were graded (n ), (n ), and (n ). distribution was primarily cl (n ) or r (n ), though mz (n ) and pp (n ) distribution occurred. there were no significant differences by kruskal-wallis analysis for amount or location of hepatocellular iron or copper for the different disease categories. in this study, copper accumulation was rare, had variable distribution and occurred primarily in samples with inflammatory/ infectious disease. in contrast, iron accumulation was common and did not correlate with disease category. further prospective evaluation of copper and iron accumulation in feline liver disease and association with outcome may be warranted. chronic hepatitis (ch) in dogs is a progressive condition without clearly defined treatment. glucocorticoids are commonly used to stop progressive inflammation and fibrosis but are associated with significant side effects including a steroid hepatopathy that complicates enzyme monitoring. cyclosporine is proposed as an alternative therapy, but there are no published reports of its use for canine ch. patient records at the csu veterinary teaching hospital were searched for histologically confirmed cases of ch treated with cyclosporine. data were compiled on cyclosporine dosing, concurrent medications, clinical course and biochemical parameters. patients over a -month period were identified. serum alanine aminotransferase (alt) decreased by an average of % in dogs. the alt normalized completely in of dogs treated for days. in of dogs on mg/kg/day, the alt also normalized. five of the patients that exhibited clinical signs prior to treatment showed measurable improvement (weight gain, fewer gastrointestinal signs). eight patients had hyperbilirubinemia or ascites prior to treatment; these resolved in . post-treatment histopathology, available in one patient, revealed decreased severity of ch. five patients exhibited adverse effects including gastrointestinal signs ( ), gingival hyperplasia ( ), and papillomatosis ( ). cyclosporine was discontinued in dogs with gastrointestinal signs. cyclosporine was an effective therapy for many cases of ch and should be considered for patients who are refractory to or cannot tolerate glucocorticoids. prospective clinical trials with histological documentation are needed to better define cyclosporine's effectiveness in ch. insertion of the veress needle and establishment of pneumoperitoneum is associated with to % of all laparoscopic complications in humans. the purpose of this study was to determine the accuracy of interpretation of tissue impedance measurements for veress needle location. two laparoscopists, blinded to impedance measurements, placed reusable veress needles in cadaverous dogs euthanized for reasons unrelated to the study. placement order was randomized. a third individual evaluated impedance measurements using a handheld device (sensormed, knoxville tn) to determine correct versus incorrect needle placement. veress needle locations were marked using contrasting colors of india ink; tissues were dissected to determine ink locations. impedance measurement interpretation identified / correct and / incorrect placements, respectively. sensitivity, specificity, accuracy, and precision for correct veress needle placement are listed below. agreement was moderate (kappa . , p . ) for placements by operator and very high (kappa . , p o . ) for placements by operator . results for tissue impedance measurement interpretation are superior to published data for currently available tests. impedance measurements accurately detected all incorrect needle placements. comparison of needle placement with and without tissue impedance feedback will be necessary to determine whether it increases operator detection of inappropriate veress needle placement and decreases installment phase complication rates. delayed detection of intestinal perforation during veress needle insertion is associated with high mortality. the purpose of this study was to evaluate the accuracy of tissue impedance measurement interpretation for veress needle location. two laparoscopists, blinded to impedance measurements, placed reusable veress needles in cadaverous cats. placement order was randomized. a third individual evaluated impedance measurements (sensormed, knoxville, tn) to determine placement location. needle locations were marked using india ink; tissues were dissected to determine ink locations. impedance measurement interpretation identified / correct and / incorrect placements. all undetected incorrect placements were located within the retroperitoneal fat pad. sensitivity, specificity, accuracy, and precision for correct veress needle placement are listed below. correlation was absent (kappa À . , p . ) for placements by operator and substantial (kappa . , p o . ) for operator . there was no association between correct or incorrect placement and operator on chi-squared analysis. failure of impedance measurements to identify placement in the retroperitoneal fat pad resulted in poor accuracy and discordant kappa statistics. small cat size limited the number of appropriate placement sites, perhaps resulting in excessively dorsal placement. comparison of needle placement with and without tissue impedance feedback will be necessary to determine whether impedance measurements increase detection of inappropriate veress needle placements or decrease installment phase complication rates. best clinicopathologic tests detecting portosystemic shunting (pss) in dogs remains controversial. this retrospective study examined performance of single random "fasting" and paired serum bile acids (sba; pre-and -hr post-feeding) in a large population of non-icteric dogs with confirmed pss (abdominal ultrasound, colorectal scintigraphy, radiographic or spiral-ct portography, laparotomy, or necropsy). sba were measured by enzymatic colorimetric method with normal o mmol/l. dogs meeting inclusion criteria (n ) included portosystemic vascular anomalies (psva; extrahepatic [e-psva], intrahepatic [i-psva]), and acquired pss (apss). signalment and laboratory parameters were recorded. non-parametric statistical analyses were used, two-tailed p o . applied with bonferroni corrections. median age and weight of breeds were . ( . - ) yrs and . ( . - ) kg, with equal gender distribution. random "fasting" sba detected % psva and % apss, whereas post-feeding sba detected % psva and % apss. low protein-c (o % activity) occurred in % psva and % apss. low mcv and creatinine occurred in % and % of psva dogs, respectively; other tests were less helpful. in apss, post-feeding sba was superior. compared to apss, psva had significantly (p . ) lower mcv, cholesterol, bun, creatinine, glucose, and protein-c. compared to e-psva, i-psva had significantly (p . ) lower post-feeding sba, mcv, albumin, urine specific gravity, and protein-c but higher cholesterol and glucose. post-feeding sba reflect physiologically provoked bile acid challenge and should be the preferred sba test in non-icteric dogs for pss detection. protein-c assists in identifying psva but its utility in apss may be complicated by concurrent coagulopathies and inflammation. this study compared outcomes of treatment with adjunctive nonsteroidal anti-inflammatory drugs (nsaids) or anti-inflammatory glucocorticoids in dogs with severe pulmonary blastomycosis. medical records were reviewed for dogs diagnosed with blastomycosis at the university of illinois veterinary teaching hospital between and . dogs with a presenting pao of mmhg, and clinical or radiographic signs of respiratory blastomycosis were included. all dogs were treated with either itraconazole, fluconazole, amphotericin b, or a combination of these. group (g ) dogs were treated with nsaids and group (g ) dogs were treated with glucocorticoids as anti-inflammatory adjunctive therapy. the following comparisons were made: days of oxygen supplementation, days in hospital, survival to discharge, and long term patient survival. mann-whitney u tests and chi-squared tests were performed on continuous and categorical data, respectively. p o . was considered significant. sixty-eight dogs fit the inclusion criteria. g consisted of dogs and g consisted of dogs. the two groups were found to be similar in weight, age, and sex distribution. there was no significant difference between the two groups with regard to duration of oxygen supplementation, duration of hospitalization, survival to discharge, and patient survival. there does not appear to be a difference between the clinical course or patient outcomes between groups of dogs with severe pulmonary blastomycosis treated with nsaids or anti-inflammatory glucocorticoids. further studies need to be performed to fully evaluate the impact these adjunct treatments have on prevention of ards and additional respiratory complications. diagnosis of feline histoplasma capsulatum infection traditionally relies upon identification of organisms in circulating monocytes or affected organs. in recent years, an antigen assay (aa) was developed for the diagnosis of disseminated histoplasmosis in human patients, but there is little information describing this test in cats. the goal of this study was to determine the sensitivity and specificity of h. capsulatum aa in cats with clinical disorders suggestive of histoplasmosis. urine and serum h. capsulatum aa results for feline patients from veterinary hospitals were evaluated. medical records were reviewed for confirmatory evidence of histoplasmosis (based on cytological or histopathological findings) or an appropriately supported alternate diagnosis. aa results were available for cats; initial testing was performed on urine samples, serum samples, and unspecified sample. of these cats, / had a definitive diagnosis of histoplasmosis based on organism identification, and had a definitive alternate diagnosis (e.g., neoplasia, other infection) based on necropsy findings (n ) or other clinical data (n ). an additional cats had a clinical alternate diagnosis with no cytological or histopathological evidence of histoplasmosis in the affected body system(s). the remaining cats had unverified histoplasmosis (n ) or an open diagnosis (n ). of the cats with confirmed histoplasmosis, were positive on initial urine aa. one cat (with rectal involvement) was negative, indicating a test sensitivity of %. one cat was positive on urine aa but negative on serum aa. all of the cats with definitive or clinical alternate diagnoses had negative results on the aa, suggesting an excellent specificity ( %). however, this result should be interpreted with caution, as the possibility of primary or concurrent histoplasmosis was only definitively excluded in the patients who underwent necropsy examination. these findings suggest that the aa for h. capsulatum is a reliable diagnostic tool in this species. a positive result appears to reliably support the presence of infection, but a small percentage of infected cats may be negative on aa. in addition, tests performed on urine may be more sensitive that those performed on serum. the purpose of this study was to evaluate the sensitivity and specificity of an aspergillus galactomannan antigen enzyme immunoassay (ga-eia) for the diagnosis of canine systemic aspergillosis. serum and urine samples were collected from sick dogs at hospitals (ucd and tamu). group dogs were diagnosed with systemic aspergillosis using culture (sterile site) or microscopy and culture (non-sterile site). group dogs had clinical findings suggestive of aspergillosis but an alternate diagnosis was established. group dogs were not suspected to have aspergillosis. samples were tested using the ga-eia and results expressed as a galactomannan index (gmi). gmis . were considered positive. comparisons were performed using the mann-whitney test. there were dogs in group , in group , and in group . serum was collected from all dogs, and urine from , , and dogs, respectively. serum gmis did not differ from urine gmis across groups. serum gmis of group dogs were higher than those of group and group dogs (p o . ). results from dogs in group did not differ from those in group (p . ). two dogs in group tested negative, but had localized pulmonary infections. one dog in group , which had paecilomycosis, tested positive. two dogs in group tested positive. one was being treated with plasmalyte. the other had a cutaneous opportunistic mycosis. these data support the utility of this assay to aid in the diagnosis of systemic aspergillosis in dogs. anaplasma phagocytophilum, an ixodes tick transmitted rickettsial bacterium has a wide mammalian host range that is not commonly reported in cats. clinical signs in humans, dogs and cats are often vague and include lethargy, anorexia and malaise. the purpose of this retrospective study was to describe the clinical signs, laboratory data and response to treatment in cats that tested positive for a. phagocytophilum on a commercially available pcr of peripheral blood (fastpanel tm ). this study describes and reports the appearance of intracellular morulae in feline neutrophils contributing to the diagnosis of a. phagocytophilum. the a. phagocytophilum real-time pcr (rt pcr) assay consists of four multiplexed primer systems designed to detect a total of three distinct genes. amplicons were confirmed as a. phagocytophilum by dna sequencing. clinicopathologic data was obtained by review of medical records and interview of primary veterinarians. complete blood counts were available from / cats and / blood smears were reviewed. the cats included in this study were all positive for a. phagocytophilum by real-time pcr. the cats ranged from months to years of age with an average age of . years. fifteen of cats had a history of tick exposure and lived in the northeastern region of the us, an ixodes endemic area. all cats presented with lethargy, / were anorexic and / had a fever (temperature o f). other clinical findings included hepatomegaly, splenomegaly, ataxia and ocular changes of conjunctivitis and elevation of the nictitating membrane. hematologic findings included leukopenia ( / ), neutropenia ( / ) and lymphopenia ( / ). thrombocytopenia was not noted in any case. morulae were seen within neutrophils in / cases. all cases in this report responded to treatment with doxycycline. this is the first report of the identification of morulae within neutrophils via peripheral blood smear review in cats confirmed by rt pcr to be infected with anaplasma phagocytophilum in north america. infection with anaplasma phagocytophilum should be considered in a clinically ill cat with tick exposure, living in an ixodes endemic area that presents to a veterinarian for lethargy, anorexia and fever. the spectrum of disease manifestations and the accompanying clinicopathological abnormalities indicative of bartonellosis in dogs have not been thoroughly characterized. the objective of this unmatched case-control study was to compare signalment, clinical and pathologic findings in clinically-ill dogs suspected of a tick-borne disease that were negative for bartonella sp. dna (controls) as were the dogs diagnosed with bartonellosis by pcr amplification, dna sequencing and the bapgm (bartonella alpha proteobacteria growth medium) enrichment culture approach. both groups were tested under the same laboratory conditions and in the same time frame. medical records were reviewed for information regarding signalment, medical history, physical examination findings, clinicopathological abnormalities, microbiological data and treatment. the study population consisted of bartonella-infected dogs and non-infected dogs. healthy dogs with no historical illnesses, such as blood donors, were excluded. the following species were amplified: b. henselae (n , . %), b. vinsonii subsp. berkhoffii (n , . %), b. koehlerae (n , . %), b. volans-like (n , . %), b. bovis (n , . %). nineteen ( . %) bartonella-infected dogs were febrile and lethargic and ten ( . %) had neurological signs. laboratory abnormalities for both groups are summarized below (number of affected dogs provided in parenthesis): multivariate logistic regression using confounding factors was performed to establish potential associations between specific variables and bartonella sp. infection. there were no differences in signalment, age, sex, body weight and duration of clinical signs between the two groups. compared to the control population, infection with the genus bartonella was associated with a diagnosis of endocarditis (p . , or . , %ci . - . ) and hypoglobulinemia (p . , or . , % ci . - . ). controls were more likely to have joint effusion (p . , or . , % ci . - . ) and azotemia (p . , or . , %ci . - . ) than were the bartonella sp. infected dogs. bartonella was detected in dogs with signs such as fever, anemia, thrombocytopenia, hyperglobulinemia and proteinuria that are typically associated with tick-borne diseases. when endocarditis or hypoglobulinemia are detected, testing for bartonella should be prioritized. likewise, the detection of bartonella should prompt further testing for endocarditis, if not already investigated. surveillance studies in other species depend on detection of antibodies to the highly conserved influenza a nucleoprotein (np); however, no such antibody detection assay is approved for canine use in the u.s. the purpose of this study was to determine the diagnostic accuracy of a commercial blocking elisa used for avian species in detecting influenza a np antibody in dogs. since the blocking elisa is not a species-specific or viral subtype-specific format, we hypothesized that it would detect np antibodies in dogs infected by influenza a virus. serum samples from uninfected dogs (n ) and dogs naturally infected with canine influenza h n (n ) were tested using the idexx flockchek blocking elisa for influenza a np antibody according to manufacturer instructions. the sample/negative control (s/n) absorbance ratios for infected dogs ranged from . to . compared to . to . for uninfected dogs. a receiver operating characteristic (roc) curve analysis determined optimum diagnostic sensitivity ( . %) and specificity ( . %) at a s/n cutoff ratio of . . using this cutoff ratio, the overall diagnostic accuracy was . %. coefficients of variation for intra-assay ( . %) and inter-assay ( . %) testing demonstrated good repeatability with canine sera. the excellent diagnostic accuracy of the commercial blocking elisa makes it a suitable tool for large-scale surveillance of influenza a virus exposure in dogs. upper respiratory disease (urd) can affect a majority of cats in shelters and is one of the leading reasons for euthanasia of otherwise adoptable cats. the purpose of this study was to determine prevalence and risk factors for upper respiratory pathogens in four different models for managing unowned cats: short-term animal shelters (shel), long-term sanctuaries (sanc), home-based foster care (fost), and trap-neuter-return (tnr) programs. conjunctival and oropharyngeal swabs were collected from cats, half of which had clinical signs of urd, and tested for feline herpesvirus (fhv), feline calicivirus (fcv), chlamydiophila felis, bordetella bronchiseptica (bb) and mycoplasma felis by real-time pcr. management model, vaccination, sex, age, body condition, and clinical signs were evaluated as risk factors for infection. a majority of cats in all management models carried one or more organisms capable of causing urd. in many cases, prevalence was similar in cats with or without clinical signs. unlike diseases that can be controlled by segregation of symptomatic animals, the lack of strong correlation between the presence of pathogens with the presence of clinical signs suggests that feline urd control should be managed by vaccination before or at the time of intake ,biosecurity protocols that presume all cats may be shedding pathogens, and minimizing stressful conditions that contribute to disease susceptibility. depending on geographical location, sex, age and environment, - % of cats worldwide are infected with the feline immunodeficiency virus (fiv). knowledge of the fiv status of cats is important to limit the spread of disease and to institute appropriate health management. however, like all lentiviruses, fiv is highly variable in nucleotide sequence, and viral load in cats is variable during different disease stages. detection of antibodies is the most widely employed diagnostic approach, but does not distinguish fiv-infected from fiv-vaccinated cats. in this study, samples from fiv-seronegative cats, fivseropositive cats, and fiv-historically seronegative but vaccinated cats, were analyzed by a commercial quantitative pcr (qpcr) assay and virus isolation. replicate blood samples were coded, and then submitted for ) qpcr (idexx); and ) mononuclear cell isolation with -day culture and viral p antigen detection by elisa. for the p antigen elisa, cutoff absorbance values were established from analysis of fiv-negative samples. fiv infection status was pre-determined based on antibody-elisa results and vaccination history. results indicated that qpcr had a sensitivity of % for samples from fiv-seropositive cats, and a specificity of % and . % for samples from fiv-seronegative and fiv-vaccinated cats, respectively. at a cutoff value of standard deviations above the mean absorbance for p antigen elisa, results from fiv-negative samples yielded a sensitivity of . % for samples from fiv-seropositive cats, and a specificity of . % and . % for samples from fiv-seronegative and fiv-vaccinated cats, respectively. conclusions from this study are ) the commercial fiv qpcr assay has high specificity but limited sensitivity for diagnosis of fiv infection; ) -day virus culture has limited sensitivity and specificity. hence, detection of antibodies remains the most reliable test for diagnosis of fiv infection, but qpcr may be suitable to rule out infection. oral disease is an important clinical problem in feline medicine and includes common painful conditions such as oropharyngeal inflammation (formerly known as gingivostomatitis) and tooth resorptive lesions. a number of infectious agents have been associated with private veterinary clinics in the u.s. were recruited to test feline patients presenting with oral disease. presenting cases included cats with plaque, calculus, gingivitis, stomatitis, periodontal disease, tooth resorptive lesions and other oral diseases as defined by the practitioner. all cats were tested using a commercially available point-of-care elisa test (idexx snap combo). confirmatory tests were not performed as part of the study. seroprevalence was calculated as the percentage of positive tests in the study population for each virus. a total of , cats were tested. seroprevalence for felv was . % and for fiv was . %. of these, cats ( . %) were infected with both viruses. seroprevalence was higher in cats with inflammatory oral disease than in cats characterized with other types of oral disease. of , cats with gingivitis, seroprevalence for felv was . % and for fiv was . %, with . % of cats co-infected. of , cats with stomatitis, seroprevalence for felv was . % and for fiv was . %, with . % of cats co-infected. the seroprevalence for felv and fiv reported in this population of cats with oral disease was higher than in a recent large study where samples from u.s. cats not specifically selected for oral disease were tested (felv . %, fiv . %). results of this study indicate that further investigation of the role of retroviruses in cats with oropharyngeal inflammation is warranted. reliable tests and preventive vaccines and medications for feline retroviral and heartworm (hw) infections are available, but compliance with protocols to reduce transmission is unknown. no largescale longitudinal studies evaluating prevalence over time have been reported. the purpose of this study was to determine the prevalence and risk factors for infection compared with a similar study completed for the first time years previously. veterinary clinics and animal shelters in the us and canada submitted results of testing using a point-of-care elisa for felv antigen, fiv antibody, and hw antigen (idexx snap triple) and risk factor information for cats tested during march-september . bivariable and multivariable analyses were used to evaluate risk factors for infections. a total of , cats were tested. only % of owned cats were prescribed hw preventive. risk of retroviral infections was increased by outdoor access, adulthood, and male gender. the most important risk factor associated with all infections was clinical disease; in particular, respiratory and oral diseases and abscesses or bite wounds. multivariate analysis revealed differences among geodivisions and across infection types. feline retroviral and heartworm infections are easily prevented, but difficult to treat. despite availability of effective management protocols, compliance remains inadequate to reduce the prevalence of these infections. improved use of preventive care and testing to identify and segregate contagious cats, particularly those at high-risk, is required to reduce the morbidity of these preventable infections. infectious disease outbreaks are common in animal shelters and are frequently managed by depopulation when risk-assessment tools are not available. during a canine distemper virus (cdv) and parvovirus (cpv) outbreak in sheltered dogs, we used a cdv/cpv point-of-care antibody titer elisa, a cdv quantitative rt-pcr test, and a cpv fecal antigen test as risk assessment tools to guide release of exposed dogs from quarantine and euthanasia of diseased dogs. serum samples (for antibody titers) and swabs of the conjunctiva and upper respiratory tract (for cdv pcr) were collected from asymptomatic dogs starting on day of the outbreak. dogs with positive cdv pcr tests were retested every weeks until euthanized for progressive disease or released following recovery from infection. dogs with clinical signs of parvoviral infection were tested using a cpv fecal antigen test. for dogs ! months old, protective antibody titers correlated with resistance to clinical disease, but % of dogs shed cdv. lack of protective cdv antibody titers correlated with susceptibility to clinical infection, but most dogs recovered. risk assessment and outcome in dogs ! months of age feline herpesvirus (fhv- ) is a common ocular and respiratory pathogen of cats that can have clinical illness exacerbated by stress. cyclosporine (csa) is commonly used for the treatment of a number of inflammatory diseases in cats and can induce immune suppression. a small number of cats administered csa to block renal transplant rejection have developed clinical signs of upper respiratory tract disease that may have been from activated fhv- . in this study, young adult cats experimentally inoculated with fhv- several months previously were divided into three groups and administered methylprednisolone acetate ( cats, mg/kg, im, day and day ), csa ( cats, . mg/kg, po, daily for days), or a placebo ( cats, corn syrup; . ml/kg, po, daily for days). each cat was assigned a daily individual clinical score by a trained, masked observer using a standardized score sheet during the initial pre-treatment time period (day - to day ) and throughout the day treatment period. each individual clinical score (conjunctivitis, blepharospasm, ocular discharge, sneezing, nasal discharge, nasal congestion, and body temperature scores), the total clinical score (sum of all parameters), the total ocular score (sum of conjunctivitis, blepharospasm, ocular discharge), and total respiratory score (sum of ocular discharge, sneezing, nasal discharge, nasal congestion) were analyzed using sas proc glimmix with 'treatment', 'time', and the two-way interaction 'treatment by time' all as fixed effects. statistical significance was defined as p o . . on day of the study, all of the csa treated cats had detectable concentrations of csa in serum (mean . ng/ml; standard deviation . ng/ml; median . ng/ml). when group mean values for clinical signs were compared over time as described, significant differences in individual clinical score measurements, in total score, total ocular score, or total respiratory score were not detected over time among any of the treatment groups. while clinical signs of activated fhv- occurred in some cats administered methylprednisolone or csa, disease was mild and self-limited in most cats and there were no significant csa sideeffects. these results suggest that the csa protocol described here is unlikely to reactivate latent fhv- infection and cause significant clinical illness. the purpose of this study was to determine the prevalence and risk factors for enteropathogens in four different models for managing unowned cats: short-term shelter, long-term sanctuary, home-based foster care, and trap-neuter-return (tnr) programs. fecal samples were collected from cats, half with diarrhea (d) and half with normal feces (n), and tested for a panel of feline and zoonotic enteropathogens by polymerase chain reaction, antigen, and fecal flotation. risk factors for infection evaluated include management practices, fecal consistency, and signalment. a majority of cats had at least one enteropathogen of feline or zoonotic importance, regardless of management model or preventive healthcare protocol. for most enteropathogens, the presence or absence of diarrhea did not correlate with infection, the exceptions being t. foetus in sanctuary cats and fcov in foster cats. prevalence of specific enteropathogens varied between management models, reflecting differences in preventive healthcare and housing conditions. management protocols for unowned cats were inadequate for elimination of infections present at the time of intake and for prevention of transmission of enteropathogens among shelter cats. improved compliance with effective vaccination, deworming, sanitation, and housing protocols is needed to reduce zoonotic and feline health risks. several allergic diseases of cats, including atopy and gingivostomatitis, can be resistant to glucocorticoids but responsive to cyclosporine. toxoplasma gondii infection occurs in approximately % of cats and the effect cyclosporine therapy has on the t. gondii oocyst shedding period is unknown. the objective of this study was to determine whether administration of cyclosporine before or after t. gondii infection influences the oocyst shedding period. the young adult cats were t. gondii seronegative when administered , t. gondii tissue cysts orally on day . group cats (n ) were never administered cyclosporine; group cats (n ) were administered cyclosporine ( . mg/kg, po) daily on days - ; and group cats (n ) were administered cyclosporine ( . mg/kg, po) daily from days - . available feces from individual cages were collected daily and fecal flotation by sugar centrifugation was performed for days after t. gondii inoculation. group shed oocysts for a significantly shorter period than groups or and had a significantly lower oocyst shedding scores than groups and on days - after t. gondii inoculation. group cats had completed the oocyst shedding period prior to being administered cyclosporine and repeat oocyst shedding was not detected during administration of the drug. administration of cyclosporine prior to t. gondii infection lessened oocyst shedding which is likely from the anti-t. gondii effects of the drug. administration of cyclosporine using this protocol is unlikely to induce repeat t. gondii oocyst shedding in client-owned cats. à group with diarrhea significantly different than group with normal feces p o . known about its metabolic pathways or mechanism of pathogenicity and whole genome sequencing of feline hemoplasmas has not yet been reported. the aim of this study was to completely sequence the genome of m. haemofelis to further characterise this important pathogen. mycoplasma haemofelis genomic dna was purified and subjected to whole shotgun roche sequencing. gaps were closed using targeted pcr and amplicon sequencing. ribosomal genes and potential open reading frames (orfs) were predicted in silico. putative orfs were annotated and orthologous groups identified. analysis showed a circular genome of . mbp with a gc content of . %. thirty-one transfer rnas (trnas) were identified, accounting for all amino acids, including a tryptophan trna for the opal codon (uga). of the , putative proteins identified, ( . %) matched to proteins from other bacterial species. in common with the pneumoniae group of mycoplasmas, the closest phylogenetic relatives of the hemoplasmas, genes involved in carbohydrate metabolism were limited to enzymes of the glycolytic pathway, with glucose appearing to be the sole energy source for m. haemofelis. the majority of the pentose phosphate pathway genes present in other cultivatable mycoplasmas appear to be incomplete or absent in m. haemofelis, suggesting an alternative mechanism for sourcing purine and pyramidine bases such as scavenging from the host. a gene encoding a glyceraldehyde- -phosphate dehydrogenase homolog of the immunogenic msg protein of mycoplasma suis was present. of the uncharacterized hypothetical proteins, , were arranged in series of orthologous repeats, or comprised fragments there-of, encoding putative proteins of approximately amino acids. the predicted motifs of the majority of these putative proteins were consistent with these proteins being presented on the cell surface; an n' terminal signal peptide or transmembrane region followed by a non-cytoplasmic tail. these data have provided valuable information as to why this pathogen remains highly fastidious; it lacks some of the metabolic pathways found in cultivatable mycoplasmas. we have also identified a homolog of a known m. suis immunogenic protein, and identified a potential mechanism for host immune system evasion by way of highly repetitive, putatively surface-expressed hypothetical proteins with variable sequences. canine leptospirosis has been recognized as a re-emerging disease in the u.s. over the past years, and several serosurveys of the prevalence of leptospiral antibodies in dogs have been published during that time. the role of cats in the epidemiology of leptospirosis has received little attention. serosurveys of cats for exposure to or infection with leptospires have been published from other geographic areas, but none for cats in the u.s. in the past four decades. the new england states have been found to have a high incidence of canine leptospirosis. the purpose of this pilot study was to determine the prevalence of leptospiral antibodies in a population of feral cats in central massachusetts. blood was collected from sexually intact feral cats presented to a spay and neuter program. microagglutination titers to leptospira serovars autumnalis, hardjo, bratislava, icterohaemorrhagiae, canicola, pomona, and grippotyphosa were determined. three of cats ( . %) had a positive titer to one or more serovars, with autumnalis being the most common. these results are consistent with previously published prevalence rates in feral cats. further studies are required to determine the role of leptosporosis in clinical disease in the domestic cat. since years the rivalta's test is routinely used in several european countries as a tool to diagnose feline infectious peritonitis (fip) in cats with effusion. it is inexpensive and easy to perform in private practice. there is, however, only little information about mode of action or its diagnostic value. the objectives of this study were to evaluate sensitivity, specificity, positive (ppv) and negative predic-tive values of the rivalta's test to diagnosis of fip and to examine if there is a correlation with any effusion or blood parameters. medical records of cats with effusion in which the rivalta's test was performed between and were reviewed concerning diagnosis, blood and effusion parameters, and survival time. effusion and blood parameters were compared between rivalta-positive and -negative effusions using the mann whitney u test. prevalence of fip in cats with effusion was . %. the rivalta's test showed a sensitivity of . %, a specificity of . %, a ppv of . %, and a npv of . % for the diagnosis of fip. the ppv improved, when cats with lymphoma or bacterial infection were excluded (ppv . %) and also, when only cats younger than years (ppv . %) or year (ppv . %) of age were included. the most important significantly different parameters between rivalta-positive and -negative effusions were specific gravity as well as cholesterol, triglyceride, and glucose concentration in the effusion. the rivalta's test in general is a useful tool to diagnose fip, but its sensitivity and specificity are not as high as previously assumed. if the rivalta's test, however, is performed in young cats or if certain diseases have been ruled-out, its diagnostic value is high. effusion total protein is not highly correlated with test outcome. therefore, it is still unclear, which components in the effusion of cats with fip lead to a positive rivalta's test. canine parvovirus (cpv) and canine distemper virus (cdv) infections are relatively common in animal shelters and are important population management issues since the immune status of incoming dogs is usually unknown. our study aimed to determine the antibody protection status of dogs at the time of admission into an animal shelter (pre-vaccination) and over the following weeks after vaccination. serum samples were obtained from incoming shelter dogs aged months and older with no known history of vaccination. immediately following serum collection, the dogs were vaccinated against cpv and cdv using a modified live vaccine (mlv). cpv and cdv antibody protection status was determined using synbiotics titerchek. dogs with unprotective serum antibody levels against cpv and/or cdv were retested at - days post-vaccination and again at - days post-vaccination, if antibody levels were still unprotective against cpv and /or cdv. at the conclusion of the study, stored duplicate sera were submitted for batch 'gold standard' testing to determine canine distemper virus serum neutralization and canine parvovirus hemagglutination inhibition antibody titers. based on the synbiotics titerchek results, / dogs ( . %) were protected against cpv and / ( . %) were protected against cdv at intake. older incoming dogs were more likely to be protected against cpv (p o . ) and cdv (p . ). dogs that were spayed/neutered were more likely to be protected against cpv on intake than intact animals, although this result was not statistically significant (p . ). the number of dogs with protective titers against cpv/cdv was increased at - days post-mlv (cpv - / , . %; cdv - / , . %) and further increased at - days post-mlv (cpv - / , . %; cdv - / , . %). we conclude that incoming shelter dogs often do not have protective antibody titers against cpv and cdv, but older shelter dogs are more likely to be protected against cpv. based on this population, we further conclude that a large percentage of dogs develop protective antibody titers to cpv and cdv within to weeks when vaccinated with a mlv. mycoplasma spp. are common inhabitants of the feline oral cavity and so likely contaminate many cat bite abscesses. mycoplasma spp. are cell-wall deficient and so do not respond to beta-lactam class antibiotics, the class most commonly use for the treatment of cat bite abscesses. the objectives of this study was to determine whether mycoplasma spp. are common contaminants of cat bite abscesses and are associated with beta-lactam resistant clinical disease. privately owned cats with clinical evidence of an acute abscess suspected to be from a cat bite were included in the study. participants were given a free aerobic and anaerobic culture as well as mycoplasma spp. culture and polymerase chain reaction using mycoplasma genus specific primers. mycoplasma spp. amplicons were sequenced to determine the species. all cats were initially treated with appropriate wound management, were administered an antibiotic in the beta lactam class (amoxicillin-clavulanate or cefovicin), and were rechecked in person or by phone days after beginning treatment. of the cats entered into the study to date, mycoplasma spp. were amplified from cats ( . %). of the positive samples with adequate dna for sequencing, one was consistent with m. felis and the other was consistent with m. equigenitalium. of the cats, responded by day to the initial treatment, including of the mycoplasma spp. positive cats. the cat that failed initial treatment was positive for m. equigenitalium on both day and day and ultimately responded to administration of a fluoroquinolone. the results suggest that while mycoplasma spp. commonly contaminate cat bite abscesses, routine wound management and antibiotic therapy is adequate for control. however, as mycoplasma spp. infections do not respond to beta lactam class antibiotic therapy, these organisms should be on the differential list for cats with abscesses that fail treatment with this antibiotic class. molecular diagnostic assays are frequently used in clinical practice to aid in the diagnosis of suspected infectious respiratory diseases in dogs. however, most currently available assays cannot distinguish strains of the organisms used in vaccines from naturally occurring strains. our prior studies demonstrated that previously immune adult dogs are unlikely to shed nucleic acids of vaccine strains of adenovirus , parainfluenza, or bordetella bronchiseptica. however, whether this is true for puppies is unknown. puppies (n ) at a breeding facility were moved into area without other dogs at weeks of age. swabs of the nasal and pharyngeal mucosa were collected prior to vaccination and on days , , , , , , , , , , , , , and after vaccination with an intranasal adenovirus , parainfluenza, and b. bronchiseptica vaccine (intratrac , schering plough). the swabs were shipped on cold packs by overnight express for dna/rna extraction and assay in the fastpanel tm pcr canine respiratory disease profile at antech diagnostics. all puppies were negative for the infectious agents prior to vaccination. after vaccination, positive assay results for parainfluenza and b. bronchiseptica were first detected on day and on day for adenovirus . by day , dna or rna of the agents were amplified from all puppies from both sample sites and most samples were positive for all agents through day . by day , only one dog was still positive for b. bronchiseptica. the results indicate that intranasal administration of adenovirus , parainfluenza, or bordetella bronchiseptica vaccines commonly leads to positive molecular diagnostic assay results for a short time period after primary vaccination. these findings should be considered when assessing the results of these assays in client-owned puppies with respiratory disease. antimicrobial resistance in escherichia coli is an increasing concern in both human and veterinary hospitals' patients. the choice drug for treatment in dogs is enrofloxacin, a second generation fluoroquinolone (fq) whose activity reflects, in part, ciprofloxacin. among the difficulties in effective e. coli treatment is rapid detection of fq resistance. the purpose of this study was to determine the specificity and sensitivity of a fret based assay for the rapid detection of urinary tract infections caused by fq associated multi-drug resistant e.coli. clinical e. coli isolated from canine urine and clinical veterinary urine samples being examined for e. coli were subjected to susceptibility testing for drugs representing drug classes. pure isolates were designated ndr (no drug resistance), sdr (single drug resistance) and mdr (multi-drug resistant) (n mdr, sdr and ndr). minimum inhibitory concentration (mic) for enrofloxacin ranged from . mg/ml to mg/ml, with high mic generally associated with mdr. extracted dna from culture and from urine were subjected to fret-pcr targeting single nucleotide polymorphisms in gyra. the resulting product was sequenced to detect other polymorphisms. further, to determine the level of detection, microbial free canine urine was inoculated with to cfu/ml of isolates characterized by variable susceptibility to enrofloxacin (mic enro . , . , . , , , , mg/ml). of pure isolates, were confirmed positive for enrofloxacin resistance (mic enro mg/ml), of which were positively identified by the fret-pcr assay giving a sensitivity of . %. only isolate that was resistant was not detected (specificity of . %). however, of the isolates expressing high level resistance (mic x breakpoint [ mcg/ml]), and mdr (n ), sensitivity . %. of the urine samples contained e. coli of which determined to be fq-resistant by the assay. colony dilutions of e. coli confirmed the assay able to detect enrofloxacin resistance at as low as cfu/ml. the relationship between cfus and the peak of the -(d/dt) fluorescence of the melting curve was r . . these results conclude that the assay is capable of detecting not only the presence of escherichia coli in clinical samples, but also detecting severity of fluroquinolone resistance and infection. the fluoroquinolones (fqs) are a key class of synthetic antimicrobial agents with an established history in both humans and companion animals of efficacy for treatment of urinary tract infections (utis) caused by e. coli, and fluoroquinolones are common therapy. among the commonly used fqs in dogs and cats are the nd generation drugs, enrofloxacin, marbofloxacin, orbifloxacin (all veterinary approved) and the human drug ciprofloxacin; no rd and th generation fq is routinely used. the purpose of this study was to assess the in vitro activity of different generation fqs toward e.coli uropathogens whose phenotype ranges from no resistance to multidrug resistance. a total number of canine uropathogenic canine or feline e.coli isolates had been subjected to susceptibility testing to drugs classes ( drugs) and phenotyped as to resistance: none (ndr, n ), single (sdr, n ), or multiple, mdr (resistance to - drug classes; n ). mdr included isolates susceptible (enr s -mdr, n ) or resistant (enr r -mdr) to enrofloxacin. the minimum inhibition concentrations (mics) for quinolones ( - st generation, - nd generation, - rd generation and - th generation) were determined for these isolates using broth microdilution methods according to clsi guidelines (e. coli atcc s served as a negative control). mic statistics were generated for each drug among phenotypes. the results showed that companion animal e. coli expressing ndr or sdr are largely susceptible to nd to th generation fqs. however, isolates expressing resistance to st or nd generation quinolone also express high level resistance based on the mic to rd and th generation fqs. the overall potency (mic) for the drugs for isolates not expressing enr resistance (that is, ndr, sdr and enr s -mdr) is gat canine leproid granuloma (clg) was first reported in brazil in . over the past years, cases of clg were diagnosed in sa˜o paulo, brazil, and clinical and epidemiological findings were similar to those reported in australia. all dogs presented with one or more, uni or bilateral, ulcerated or not, papular, nodular or tumoral lesions, mainly observed in the dorsal surface of the ear, site usually more affected. in general, the lesions are painless and confined to the subcutis and skin, and it does not involve regional lymph nodes, nerves or internal organs, and systemic clinical signs frequently are absent. short-coated breeds show a marked predisposition for this disease. the definitive diagnosis of clg was obtained by histological examination of skin biopsies that were stained with acid fast (ziehl-neelsen) and diffquik s . thirty one ( . %) of the dogs were purebred; in this study the breed pattern comprised ( . %) boxers, ( . %) german shepherd and labrador retriever, ( . %) dobermann, ( . %) brazilian terrier, ( . %) golden retriever, ( . %) bulldog, ( . %) american pitbull, ( . %) mastiff, ( . %) fila brasileiro and ( . %) cocker spaniel, ( . %) were of unknown breed. nineteen ( . %) of the thirty seven dogs were males. twenty ( . %) dogs were - years old. in most cases, dogs presented with unilateral or bilateral ear lesions, but rarely thoracic, foot and caudal lesions. the animals were successfully treated by use of rifampicin orally (''the brazilian protocol'') or enrofloxacin orally and topical rifamicin. anaplasma phagocytophilum is being recognized more frequently in dogs in endemic areas. currently, most suspected cases are evaluated for a. phagocytophilum antibodies by immunofluorescence assay (ifa) or elisa. since a. phagocytophilum is an acute disease, detection by antibody measurement may be negative on initial evaluation. it is possible that a. phagocytophilum dna can be amplified from blood or synovial fluid prior to seroconversion. wild caught ixodes scapularis adult ticks from rhode island were allowed to feed on young adult ( - years), mixed sex beagles for up to days. blood (weekly for weeks), serum (weekly for weeks), and synovial fluid (radiocarpal joint; alternating arthrocentesis weekly for weeks) were collected prior to tick attachment and then weekly after tick attachment. joint fluid cytology was performed and total dna was extracted from blood and synovial fluid and assayed in a proprietary real time pcr assay (fastpanel tm ) that amplifies the dna of anaplasma phagocytophilum, a. platys, ehrlichia canis, e. chaffeensis, and e. ewingii. serum was assayed for a. phagocytophilum antibodies by ifa. time to first positive results for serology and pcr were compared by paired student's t test. none of the beagles developed clinical evidence of disease, and no major changes in synovial fluid cytology were detected over time. of the beagles, were positive for a. phagocytophilum dna in blood or synovial fluid or ifa antibodies in at least one sample after tick attachment. antibody titers appeared in of dogs from weeks to (median to st positive weeks ae ). titer magnitude ranged from : to : , . anaplasma phagocytophilum dna was amplified from the blood of of dogs with positive test results ranging from to weeks (median to st positive weeks ae . ). anaplasma phagocytophilum dna was amplified from synovial fluid from of dogs between weeks to (median to st positive weeks ae ). of the dogs, were pcr positive for only one week and dog was pcr positive for two consecutive weeks. of the dogs, were positive for a. phagocytophilum in both blood and joints by dna analysis. anaplasma phagocytophilum dna was amplified from blood more quickly than seroconversion was detected by ifa antibody titer (t À . , p o . ) or dna was amplified from synovial fluid (t . , p o . ). anaplasma phagocytophilum dna can be amplified from the blood prior to development of detectable antibody titers by ifa. amplification of a. phagocytophilum dna from synovial fluid does not occur in all dogs, appears to be transient in most dogs, and a negative test result does not preclude a diagnosis of a. phagocytophilum infection. canine granulocytic anaplasmosis and granulocytic ehrlichiosis are tick-transmitted infections caused by anaplasma phagocytophilum (aph) and ehrlichia ewingii (eew), respectively. both organisms induce an acute clinical disease, frequently accompanied by fever, polyarthropathy and thrombocytopenia. however, aph and eew have different tick vectors, i.e. ixodes scapularis and ambylomma americanum, respectively, with different, but overlapping geographic distributions. in addition, infection outcome may be affected by other regional ticktransmitted pathogens, such as borrelia burgdorferi (mn) or ehrlichia chaffeensis (ar). therefore, we compared serology and pcr results derived from dogs examined at two private practices located in highly endemic areas for either aph or eew. serum collected between april-december, from minnesota dogs (n ) was tested by snap s dx s and whole blood was tested by aph pcr. serum collected from arkansas dogs (n ) for year beginning in august was tested using microtiter plate elisas for antibodies to eew, e. canis, and e. chaffeensis (ech) while whole blood was tested by ehrlichia pcr. comparisons were evaluated using chi square (Ã) and binomial (w) tests with an alpha of %. the above results indicated that dogs are frequently exposed to both aph and bb in mn, whereas ar dogs are often exposed to eew, but less frequently to ech. antibodies to e. canis peptides were found infrequently in both mn and ar with only seroreactive dogs detected in both locations. active eew infection, as determined by pcr, was four times more frequent in ar pet dog seroreactors as compared to active aph infections among aph seroreactors. although both organisms induce acute disease, the number of aph and eew pcr positive dogs that were also seropositive was relatively high suggesting that both organisms induce persistent infections or that dogs are frequently re-infected, despite the presence of a measurable humoral immune response. additional studies are needed to determine regional infection profiles in other areas that are endemic for these pathogens. anaplasma phagocytophilum and ehrlichia canis are two of the most common vector borne disease agents that infect dogs and cats. while pcr assays that amplify the dna of these agents from blood are currently available, there is minimal information concerning the performance of these assays in different commercial laboratories that utilize different techniques. the purpose of this study was to compare the e. canis and a. phagocytophilum results of two different laboratories on the same samples collected from client-owned animals. veterinarians in states (az, md, ct) were recruited to participate in the study based on high prevalence rates for e. canis or a. phagocytophilum infection. blood in edta was collected from dogs or cats with fever, thrombocytopenia, or clinical evidence of polyarthritis and an equal volume of the same blood sample was simultaneously shipped on cold packs by overnight express to colorado state and to antech diagnostics. standard operating procedures at each laboratory were followed for total dna extraction and amplification of gapdh as the dna control. at colorado state university, a previously published pcr assay that amplifies the dna of ehrlichia spp., anaplasma spp., neorickettsia spp., and wolbachia was performed on each sample with positive amplicons sequenced to determine the species. at antech diagnostics, a proprietary real time pcr assay (fastpanel tm ) that amplifies the dna of anaplasma phagocytophilum, a. platys, ehrlichia canis, e. chaffeensis, and e. ewingii was performed. in the study to date, samples from animals ( dogs and cats) have been assayed at both laboratories. dna of a. phagocytophilum ( cats and dogs) and e. canis ( dog) were amplified at both laboratories with a percentage agreement between laboratories of %. the results to date suggest that the assay results of the two laboratories for a. phagocytophilum and e. canis are comparable. ehrlichiosis and bartonellosis are zoonotic diseases caused by extremely small, obligate intracellular bacteria that require a mammalian reservoir and a blood sucking arthropod vector. human ehrlichiosis is present in peru, with a seroprevalence as high as % in the highlands. bartonella species in humans were also identified in peru since (b. bacilliformis). recently, a new species (b. rochalimae) was isolated from an american woman who became febrile after travelling to peru. dogs can become infected with the same ehrlichia species, and the majority of bartonella species that affect human beings. the role of dogs as reservoirs for human infections has not been clearly established, but exposure and/or infection in dogs has been used to monitor human exposure to tick-borne disease (tbd), since they share the same environment. the objective of this study was to determine the serological and molecular prevalence of anaplasmosis, ehrlichiosis and bartonellosis in rural dogs in the highlands of peru. a total of healthy adult dogs were enrolled in this study from four communities in the central highlands of peru: ondores, pachacayo, san juan de pachayo, and canchayllo. edta-blood samples were collected from dogs, whereas serum samples were available from dogs. serum samples were tested for ehrlichia canis, anaplasma, borrelia burgdorferi and dirofilaria immitis infections using a qualitative dot-elisa (snap s dx). the edta-blood samples were screened by conventional pcr for the groel gene of the genus anaplasma and ehrlichia, and for the intergenic transcribed spacer of the genus bartonella. speciation was conducted by nucleotide sequencing. bartonella genus dna was detected from seven of the dogs ( . %) and ehrlichia canis dna was detected and sequenced from one dog ( . %). four of the bartonella positive samples were identified by dna sequencing as b. rochalimae (genbank accession numbers hq and hq ). the other three bartonella positive samples were identified as b. vinsonii subspecies berkhoffii, the causative agent of endocarditis in dogs and humans. no dog was infected with anaplasma species by dna amplification, but one dog was seroreactive for this genus ( . %). no specific antibodies against ehrlichia canis and borrelia burgdorferi and no antigens of dirofilaria immitis were detected. this study expands the current knowledge about tbd in peru and describes for the first time the infection of b. rochalimae in dogs in peru. the results suggest that dogs may play an important role in the epidemiology of this infection in humans, since they can be asymptomatic but bacteremic. bartonella spp. dna is commonly amplified from the blood of cats exposed to ctenocephalides felis. in previous work, it was shown that cats administered imidacloprid and experimentally exposed to b. henselae infected cats and c. felis did not become pcr positive for b. henselae whereas untreated cats all developed infection. the purpose of this study was to determine if administration of imidacloprid to clientowned cats likely to be exposed to bartonella spp. and c. felis in the field lessens prevalence of bartonella spp. infection. veterinary students in tennessee and florida that owned cats that spent at least days per month outside and that were willing to apply imidacloprid to their cats monthly for six months were recruited for the study. blood for bartonella spp. pcr assay was collected from the cats seven months after starting imidacloprid administration and assayed at colorado state university. to serve as a control group that was unlikely to have been administered flea control products in the previous months, blood was collected from feral cats during tnr programs in each of the two cities and assayed for bartonella spp. dna. the bartonella spp. dna prevalence rates between the groups were compared by chi square analysis with significance defined as p o . . the overall prevalence rates for bartonella spp. dna in the blood of veterinary student cats ( . %) and the feral cats ( . %) were significantly different (p o . ). the distribution of results is shown in table . the results suggest that florida feral cats were more commonly exposed to c. felis than tennessee feral cats. while the cats in the groups were not exactly matched, the student cats were allowed outdoors for approximately days per month and lived in the same cities as the feral cats, so c. felis exposure rates were likely similar. as previously shown in experimentally-exposed cats, the use of imidacloprid monthly may influence transmission rates of bartonella spp. amongst naturally-exposed cats. in an endemic area for leishmaniosis and filariosis, coinfection can occur and immunomodulation produced by wolbachia might influence the clinical signs and progression of both diseases. the aims of the present study were ) to determine the prevalence of wolbachia in dogs infected with dirofilaria immitis (di) and other filarial nematodes, ) to evaluate the level of coinfection of leishmaniosis and filariosis by molecular assays and ) to evaluate any associations between leishmania infantum (li) infection, filariosis with or without wolbachia and clinical presentation and outcome. statistical differences between groups were tested for significance by the fisher exact test using spss v. . software (significance: p-value o . ). one-hundred and eighteen owned dogs from southeastern spain presenting for clinical evaluation were included in the study. criteria the results of this study highlight the increased sensitivity of pcr for diagnosis of filariosis, confirm the presence of wolbachia in dogs from the mediterranean basin, show the increased severity of hwd when li-filaria coinfection is present and suggest that wolbachia could play a protective role for leishmaniosis. wolbachia antigens can stimulate a th -type immune response, as has been previously described. however other factors (as treatment with doxycicline) might be responsible for the lower prevalence of wolbachia among filaremic dogs infected with li and further studies must be done to clarify this interaction. the purpose of the present study was investigate the occurrence of leishmaniasis in cats in the municipality of arac¸atuba, sa˜o paulo, brazil, an endemic area for canine visceral leishmaniasis. animals were evaluated by direct parasitological examination of lymphoid organs and serology for visceral leishmaniosis by immunosorbent assay (elisa) and indirect immunofluorescence (ifat). thirteen ( . %) out of cats studied were diagnosed with visceral leishmaniasis; eight ( %) by parasitological diagnosis through cytological examination of lymphoid organs, six ( %) were considered positive by elisa and one ( . %) by ifat. only two ( . %) out of the thirteen infected cats had clinical signs, characterized by the presence of crusty lesions on the dorsal cervical region and hepatosplenomegaly. regarding age five cats ( . %) had between six months and two years, being the others older than years ( . %). only one cat ( . %) was positive for the three employed methods. pcr confirmed leishmania sp infection in nine ( . %) cats, of which six were diagnosed previously by cytological examination, two by elisa and one by the three techniques employed. since its first description in feline leishmaniosis has been reported in several countries. the purpose of this study was to assess the prevalence of leishmania chagasi infection in cats showing dermatologic lesions from an endemic area for visceral leishmaniasis in brazil. animals were evaluated by direct parasitological examination of lymphoid organs, immunohistochemical technique for detection of amastigotes in lesioned skin and serology for visceral leishmaniosis by immunosorbent assay (elisa) and indirect immunofluorescence (ifat). twenty seven ( . %) out of the cats studied were diagnosed with visceral leishmaniosis. twelve ( . %) were positive by parasitological diagnosis; amastigote forms of leishmania sp were identified in lymphoid organs from / ( . %) infected cats, and immunohistochemical technique allowed the identification of nine ( . %) positive animals. the seroprevalence of leishmaniosis was . % ( / ) by elisa and . % ( / ) by ifat. fiv specific antibodies were found in / cats ( . %), of which / ( . %) had leishmaniosis. real time pcr confirmed leishmania chagasi infection in three cats. based on the evidence of the high occurrence of leishmaniosis in cats in this study, this disease should be included in the differential diagnosis of skin diseases of felines living in endemic areas. blastomyces dermatiditis is a dimorphic fungus that commonly affects large-breed hunting dogs. a recent advancement in diagnosis has come with the advent of a urine antigen screening test that has both high sensitivity and moderately high specificity. therapy for the disease involves use of antifungal agents, usually itraconazole, and length of treatment is based chiefly on resolution of clinical and radiologic signs. with the new urine antigen test, however, a noninvasive route of monitoring treatment progress is available and could be an adjunct device utilized to determine treatment efficacy and may even reveal a need for prolonged treatment. therefore, the purpose of this study was to determine if monitoring the blastomyces urine antigen test and comparing to pulmonary radiographic signs would elucidate the necessity for prolonged antifungal therapy, even after resolution of radiologic signs. to this end, a retrospective case review was performed that identified a series of client-owned animals with naturally occurring blastomycosis. the inclusion criteria were radiographic pulmonary parenchymal signs consistent with fungal disease and urine antigenconfirmed blastomycosis with repeated testing of both radiographs and urine antigen quantification as monitoring parameters until negative results achieved in each. ideally, intervals between testing dates would be between two and five months. radiographs were considered negative if all radiographic changes had resolved or if repeated radiographs separated by at least one month were considered static after documented improvement had occurred from original diagnostic radiographs (suspected scarring). urine antigen testing was considered negative if concentrations were less than . enzyme immunoassay units, a reference interval set by the testing laboratory. preliminary data analysis reveals resolution of radiographic signs of blastomycosis occurred earlier in many of the cases presented than did attaining a negative urine antigen concentration. ceasing treatment month after radiographic resolution of signs as has been recommended in the past might have resulted in premature discontinuation of therapy in many of the cases. monitoring of urine antigen concentrations may be of additional clinical use for determining when cessation of treatment should occur in cases of blastomycosis. persistent elevation of urine antigen concentrations after radiographic resolution of infection may account for apparent recrudescence of blastomycosis after suspected clinical resolution. giardia spp. and cryptosporidium spp. are both known to cause infections in dogs and humans in the united states. nevertheless, prevalence rates for dual infection in dogs had not been widely reported. in this study, fecal samples from dogs housed in a northern colorado animal shelter (n ), dogs owned by veterinary students in northern colorado (n ), and dogs from the pine ridge reservation in south dakota (n ) were collected. each sample was assayed with a commercially available fluorescent antibody assay that detects giardia spp. cysts and cryptosporidium spp. oocysts. those samples that were positive for giardia spp. or cryptosporidium spp. with adequate dna available for sequencing were genotyped by the glutamate dehydrogenase [gdh] and by the heat shock protein- [hsp- ] genes, respectively. overall, ( . %) of the dogs had current evidence of a protozoal infection ( table ). the dogs from pine ridge reservation had the highest prevalence rates for giardia infection and also for dual infections. from the student dogs, sequencing was successful for the three giardia isolates (assemblage d from dogs; assemblage c from one dog) and one cryptosporidium isolate (c. canis). from the reservation dogs, sequencing was successful for nine giardia isolates (assemblage d from dogs; assemblage c from dogs) and one cryptosporidium isolate (c. canis). cryptosporidium and giardia co-infections are commonly detected in dogs; in this study dual infections were more common than cryptosporidium infections alone. further studies will be required to determine the clinical importance of this finding. although the giardia and cryptosporidium isolates that were sequenced were the dog specific assemblages/genotypes, more samples should be analyzed in order to assess the potential for zoonotic transmission of either parasite. the current study was conducted to determine the prevalence of intestinal parasites in dogs visiting the veterinary teaching hospital, chiang mai university, northern thailand. fecal samples (n ) were collected and submitted by owners between august to february . demographic and geographic data were recorded. intestinal parasitic infection was diagnosed by both microscopic examination after zinc sulfate centrifugation flotation and commercially available ifa for giardia spp. and cryptosporidium spp. polymerase chain reaction and dna sequencing were performed on all giardia and cryptosporidium positive samples to provide genotyic information. overall prevalence of intestinal parasitic infection in dogs in chiang mai was . %. the most prevalent parasite was giardia spp. ( . %) followed by ancylostoma spp. ( . %), cryptosporidium spp. ( . %), cystoisospora spp. ( . %), toxocara canis ( . %), trichuris vulpis ( . %), coccidian-like ( . %), toxascaris leonina ( . %), and strongyloides spp. ( . %). the prevalence of having at least one parasite in dogs o year, - years, and years were . %, . %, and . %, respectively. of these infected dogs, . %, . %, . %, and . % were infected with one, two, three, and four organisms, respectively. available dna sequences from giardia spp. positive samples were shown to be dog specific. only one adequate dna sequence was available for cryptosporidium spp., which was shown to be c. canis. the findings suggested that intestinal parasitic infection was common in dogs in chiang mai, thailand. dogs could be potential source for zoonotic intestinal parasitic infection since dogs in this area are allowed for free roaming. regular deworming program is indicated to prevent not only transmission among dogs but also to human. a retrospective study was conducted on parasite positive fecal specimens consisting of canine, feline, equine and from other host species, comparing recovery of eggs, protozoan cysts and coccidian oocysts using standardized methods of parasite concentration: the formalin/ethyl acetate (f/ea) sedimentation concentration and the commercial fecalyzer (flotation) kit procedures. specimens were processed by each technique either according to manufacturer's instructions or according to standard laboratory procedures. formalin/ethyl acetate concentrations used at a ratio of ml normal saline to ml ethyl acetate for extraction of lipophilic material from pelleted stool samples, previously fixed in sodium acetate/acetic/acid/formalin (saf) solution. flotations with the fecalyzer kit were performed with concentrated zinc sulfate solution (s. g. . ) . the range of parasites recovered from these specimens included flagellate cysts ( total), coccidian oocysts ( total), ova and larvae of nematodes ( total), and ova of trematodes ( total) , and cestodes ( total). recovery rates by fecalyzer flotation were good for protozoan cysts, coccidian oocysts and nematode eggs and larvae, but very poor for cestode and trematode eggs. formalin/ethyl acetate concentration showed excellent recovery of all parasites and consistently outperformed fecalyzer in recovery rates. recoveries by f/ea concentrations were higher by . % for giardia, by . % for coccidia and by . % for nematode eggs and larvae. with the exception of coccidian oocysts, based on z-test analyses, recovery rates were significantly higher, at a confidence level of at least %, for all parasites, using formalin/ethyl acetate sedimentation concentration. although capc recommends the use of flotation with centrifugation methods for standard fecal ova and parasite examination for veterinary patients, sedimentation concentration methods are widely and effectively used in human diagnostic parasitology laboratories. these results provide good evidence for the use of f/ea concentration as a preferred method to flotation procedures for stool ova and parasite examinations in veterinary laboratories. cyclosporine and glucocorticoids are powerful immunosuppressive agents used to treat many inflammatory diseases. cyclosporine inhibits calcineurin-dependent pathways of t-cell activation and the resultant cytokine production, and glucocorticoids directly inhibit genes coding for cytokines. little work has been done comparing the effects of these agents on cytokine production in dogs. our study assessed these effects by measuring t-cell cytokine production using flow cytometry, and cytokine gene expression using quantitative reverse transcriptase polymerase chain reaction (qrt-pcr) in activated canine t-cells treated with cyclosporine and dexamethasone. for flow cytometric assays, peripheral blood mononuclear cells were separated using density gradients and cultured for hours in the presence of cyclosporine ( , , or ng/ml), dexamethasone ( À , À , À m), or cyclosporine plus dexamethasone. for qrt-pcr, whole blood was cultured for hours with the same drugs at the same concentrations, and rna was then extracted from leukocytes. expression of cytokines il- and ifn-g was analyzed in pma/ionomycinactivated t-cells by flow cytometry, and gene expression for il- and ifn-g in activated t-cell populations was assessed via qrt-pcr. flow cytometry and qrt-pcr both demonstrated inhibition of il- and ifn-g that was generally dose-dependent in response to both cyclosporine and dexamethasone. flow cytometry results from the average of samples collected from different dogs are shown in figure a . similar results were achieved using qrt-pcr ( figure b ). suppression of il- and ifn-g in activated t-cells has potential as an indicator of the efficacy of cyclosporine and glucocorticoids in suppressing canine t-cell function in vivo, and may therefore be of value for characterizing the immunosuppression induced by these drugs in clinical patients. idiopathic eosinophilic diseases are described in several breeds, but are over represented in rottweilers. the immunopathogenesis of idiopathic eosinophilic disorders is poorly characterised. studies in people highlight the importance of cytokines, particularly interleukin- (il- ), in mediating eosinophil maturation, differentiation, egress from the bone marrow, migration and polyclonal expansion. eotaxin- and eotaxin- also appear important for induction of chemotaxis and release of reactive oxygen species from eosinophils. the aim of the current study was to establish whether definable differences in specific cytokines associated with mediation of eosinophil production and survival are present between healthy rottweilers, non-rottweilers and rottweilers with non-parasitic eosinophilia. secondly, by evaluating cytokine profiles the study aimed to improve understanding of the pathophysiology of eosinophilia therefore assisting development of potential molecular treatment options. quantitative real-time reverse transcriptase polymerase chain reaction (qrt-pcr) assays were used to quantify messenger rna (mrna) encoding cytokines il- , il- , il- , il- p , il- p , il- p , il- , interferon gamma (ifn-g) and chemokines eotaxin- and eotaxin- from peripheral blood mononuclear cell (pmbc) samples obtained from healthy non-rottweiler dogs with normal eosinophil counts (n ) and rottweilers with normal (n ), mildly increased (n ) and high (n ) eosinophil counts. quantification of serum ifn-g was also performed using a commercially available canine-specific elisa. all samples were positive for housekeeping genes and all cytokines could be quantified with the exception of eotaxin- and - . results were normalised using three stably expressed housekeeper genes (rpl a, sdha and ywaz) and a relative copy number was calculated for each sample with the sample with the fewest copies given a value of . no significant differences were found between groups but there was a tendency for ifn-g mrna expression to be lower in the rottweilers with moderate to severe eosinophilia versus control dogs (p . ). this trend was not seen in the concentration of serum ifn-g quantified by elisa as there were no significant differences between normal and diseased animals. in conclusion, there were no significant differences in cytokine mrna profiles between normal dogs and rottweilers with varying degrees of eosinophilia. additional studies including larger numbers of affected dogs are warranted before any accurate conclusions can be made. the presence of large amount of antibody on erythrocyte membrane can accelerate red blood cell (rbc) removal process by the mononuclear phagocyte system. an antigenic stimulus such as the one promoted by vaccines, for example, can induce hypersensitivity reactions and may accelerate rbc destruction. the study objective was to evaluate the erythrocytic membrane potential in inducing lymphocyte proliferative response of recently immunized dogs. healthy adult dogs (n ) were immunized with multiple antigens (commercial vaccine with eight antigens: distemper virus, parvovirus, coronavirus, parainfluenza virus, adenovirus, infectious hepatitis virus and leptospire; and anti-rabies). blood samples from each animal were collected into edta tubes in two moments: pre (immediately before vaccination) and pos ( to days after vaccination). mononuclear cells were separated by gradient, marked with cfse-fitc and cultured. the stimuli for lymphocyte proliferation used were autologous erythrocytic membrane (aem) and concanavalin a (cona). aem was obtained by hypotonic lysis and tested in two concentrations (m : . ug/ ul; m : . ug/ ul). the proliferation assay was evaluated by flow cytometry and analyzed with specific software. the proliferation index (pi) was calculated dividing the fluorescence intensity of the basal sample by the stimulated one. statistical analysis was performed using paired t-test for parametric samples and wilcoxon test for non-parametric samples (a . ). the for the tested concentrations, autologous erythrocytic membrane does not constitute a stimulus for lymphocyte proliferation in vitro, either before or after vaccination procedure. additionally, there was no evidence of self-reagent lymphocytes to erythrocyte membrane after vaccination. e. coli is a common cause of canine urinary tract infection. current treatment emphasizes eradication of established infection rather than infection prevention but increased antibiotic resistance necessitates strategies to prevent infection. proanthocyanidins found in cranberry juice inhibit e. coli attachment to human uroepithelial cells, impairing bacterial adherence and colonization. we hypothesized that purified cranberry extract (ce) inhibits bacterial adhesion to canine uroepithelial cells. five healthy female dogs received an oral ce supplement (vetoquinol; mg ce/tablet) according to body weight for days. voided urine collected from each dog before (pre) and after ( -day) completion of the protocol was membrane filtered ( mm) and stored frozen (- c). bacterial adhesion was determined using an in vitro assay. briefly, urine samples were incubated with an uropathogenic e. coli strain that had been subcultured to promote fimbriae expression. urine samples containing e. coli were next incubated in -well plates containing methanol-fixed madin-darby canine kidney (mdck) cells for -hr ( c) to permit bacterial attachment. after incubation, plates were washed to remove nonadherent bacteria and fresh media added. plates were incubated ( c) for -hr to grow attached bacteria to detection level. bacterial concentration in each well was determined using a spectrophotometer ( nm). results were analyzed using the chi-square test. ce significantly reduced bacterial adhesion by % (n ; p . ) in -day urine samples compared with pre samples. the results show that ce supplementation can reduce adhesion of uropathogenic e. coli to canine uroepithelium and suggests one mechanism by which ce might improve urinary tract health. the purpose of this study was to determine prevalence of urovirulence factors (uvfs) and antimicrobial resistance in canine uropathogenic e. coli (upec) and to evaluate associations between uvfs and antimicrobial resistance. two hundred and twenty-one upec isolates from samples collected from different canine patients submitted to the university of tennessee microbiology laboratory in were evaluated. a multiplex pcr assay was used to detect cnf, hlyd, sfa/foc, and papgiii in dna lysate. in vitro susceptibility was evaluated and if the isolate was resistant to any antimicrobial in a class, it was considered resistant to that class. of the samples, the number of uvf expressed per isolate was: / ( %), / ( %), / ( %), - / ( %), and / ( %). expression of uvf was sfa ( %), hly ( %), cnf ( %), and pap ( %). presence of uvfs was associated with less resistance (p o . ). the combination of hly, cnf, and sfa was associated with less resistance (p o . ). when sfa was present alone, resistance was less (p o . ). average resistance to antimicrobial class by number of uvfexpressed was: uvf . ae . classes, uvf . ae . classes, uvf . ae . classes, uvf . ae . classes, and uvf . ae . classes. urovirulence factors were present in a moderate number of upec and correlated negatively with resistance. neither individual nor combinations of uvfs were associated with increased resistance. obesity is associated with several comorbidities in dogs including pancreatitis, osteoarthritis, oral disease, neoplasia, and lower urinary tract disease. investigator observations led to the hypothesis that morbidly obese dogs are more likely to have asymptomatic bacterial urinary tract infections (abuti) than overweight and moderately obese dogs. therefore, a pilot study was conducted to screen for abuti in obese dogs. urinalysis with urine culture and dual energy x-ray absorptiometry (dxa) were performed on fortythree dogs with body fat (bf) percentages ranging from to %. following dxa, subjects were categorized as obese (o)(bf - %, n ) and morbidly obese (mo)(bf %, n ). no dogs had owner-reported symptoms indicative of uti. the prevalence of abuti in o dogs was % (n ) and % (n ) in mo dogs. the dog in the o group with abuti was close to being mo with a bf equaling . %. of the nine dogs with positive cultures, were neutered males and were spayed females. the prevalence ratio of abuti in mo dogs was . , indicating dogs with % or greater bf are . times more likely to have the condition then dogs o % bf. the results of this pilot study coincide with other surveillance data describing an increased prevalence of lower urinary tract disease in obese dogs. in conclusion, dogs with body fat percentages greater than % are at risk for abuti, and veterinarians should consider screening all morbidly obese patients for urinary tract infections. calcium carbonate (cac) is recommended to decrease phosphate intake in chronic kidney disease. however, its effect is poorly documented in dogs. our objectives were to assess within-day, postprandial and cac effects on phosphatemia variations in healthy dogs. phosphatemia was measured every hours for hours in eight adult healthy beagle dogs in i) fasted condition and ii) a  crossover design. one group received cac mixed with maintenance diet ( . % phosphorus), while the second group received the diet alone. after a -week wash-out period, groups were switched. a general linear model was used to test the period, sequence, treatment, dog and time effects on phosphatemia and the area under the phosphatemia versus time curve (auc - ). a significant (p o . ) circadian variation existed in fasted dogs. the maximum difference (mean: À . mg/dl; % c.i.: À . mg/dl; À . mg/dl) was observed between a.m. and midnight. the auc - with cac ( ae mg.min/dl) was mildly but significantly lower (p . ) than without cac ( ae mg.min/dl). however, it was similar to the auc - in fasted conditions. feeding, with and without cac, has minor effect on phosphatemia. however, circadian variation of fasted phosphatemia might affect its interpretation. gfr measurement permits diagnosis of kidney injury prior to development of azotemia, and is the gold standard for kidney function assessment. accurate and rapid (o min) gfr measurement has been performed in rats by simultaneous transcutaneous assay of two intravascular fluorescently-labeled markers. a recently developed analyzer assays fluorescence via a fiberoptic cable introduced through a peripheral catheter, and thus should also allow rapid gfr determination in larger species. the purpose of this study was to determine correlation and agreement between fluorescent ratiometry (fr) and iohexol plasma clearance (ipc) in dogs over a range of gfrs. acute kidney injury (aki) was induced in female hound-type dogs ( mg/kg gentamicin iv q h), and fr and ipc gfr were simulta-neously determined on days , , and . a -sample, -hr protocol was used for ipc; fr was determined following bolus injection of a dextran conjugate mixture ( -sulfohexamine rhodamine-carboxymethyl kd dextran, -aminofluorescein-carboxymethyl kd dextran) with fluorescence measured over min. gfr was calculated using -compartment model concentration-vs.-time curves for both techniques. correlation was determined via spearman's rho; agreement was analyzed via bland-altman plots. ipc gfr and serum creatinine confirmed progressive aki in all dogs. correlation between fr and ipc was . (p o . ). bland-altman plots confirmed good agreement between techniques with slight underestimation of gfr by fr across most observed values. these results suggest fr is suitable for gfr determination in dogs with aki. importantly, the portable analyzer allowed for point-of-care gfr determination in o min using a peripheral vein. previously presented at the american society of nephrology renal week (related but not identical abstract). dogs with protein-losing nephropathy (pln) are at risk of thromboembolic disease, but the mechanism of hypercoagulability and the population of dogs at risk are unknown. the purpose of this study was to characterize thromboelastography (teg) in dogs with pln. twenty-eight client-owned dogs with pln (urine protein:creatinine ratio (upc) . ) and control dogs were enrolled. teg parameters, antithrombin activity, serum biochemical profiles, and upc were measured. teg analyses were run in duplicate with kaolin activation; reaction time (r), clot formation time (k), maximal amplitude (ma), and g (global clot strength) were analyzed. a wilcoxon sum rank test was used to evaluate differences between groups. twelve pln dogs ( . %) were azotemic. nineteen pln dogs ( . %) were hypoalbuminemic [serum albumin (salb) o . g/dl]; had salb o . g/dl. dogs with pln had higher k (p o . ), ma (p o . ) and g (p o . ) than controls. r was similar between the two groups. pln dogs with salb o . g/dl had higher g (p o . ) values than dogs with salb . g/dl; however, even pln dogs with normal salb ( . g/dl) had significantly higher g values than controls (p o . ). no significant relationship between upc and g, salb and g, antithrombin and g, or salb and antithrombin was noted using linear regression analysis. these results indicate that antithrombin, salb, and upc cannot be used alone to predict hypercoagulability as assessed by teg in dogs with pln. a comprehensive evaluation of the coagulation system in individual patients may be necessary to predict the point at which to initiate anti-thrombotic therapy. cystinuria is a hereditary renal tubular reabsorption defect of cystine, ornithine, lysine and arginine (collectively, cola). the low solubility of cystine in acidic urine predisposes to the formation of uroliths. type i cystinuria in newfoundland and labrador retriever dogs is an autosomal recessive trait caused by mutations in the slc a gene, whereas in other breeds, the cause of cystinuria has not yet been determined. we report here on the clinical, biochemical and molecular features of cystinuria in irish terriers. urine and edta blood were collected from irish terriers from europe and australia. a nitroprusside screening test was used to identify increased cystine in urine. urinary amino acid concentrations were determined by high-pressure liquid chromatography. cystinuric dogs were defined as having cystine calculi, a positive nitroprusside result, urinary cystine ( mmol/g creatinine) and/ or a cola concentration of mmol/g creatinine. all females tested nitroprusside negative and had normal urinary cystine (o mmol/g creatinine) and cola (o mmol/g creatinine) concentrations. the intact males that formed calculi as adults exhibited cystine concentrations ranging from - and cola from - mmol/g creatinine. an additional males had similarly high cola values with cystine levels from - mmol/g creatinine. among the affecteds tested, % were nitroprusside positive. the negative nitroprusside results and/or low urinary cystine levels of affecteds may be due to precipitation of cystine in acidic urine. sequencing the coding regions of the slc a and slc a genes from edta blood identified no mutations. the mode of inheritance remains undetermined. however, castration appears to lower the urinary cystine and cola concentrations and to prevent cystine calculi formation, while diet changes have lesser effects. in conclusion, non-type i cystinuria in irish terriers (and several other breeds like mastiffs and scottish deerhounds) is a unique form characterized by increased aminoaciduria only in males, with lower cystine and cola excretion and fewer and later urolith formation compared to type i cystinuria. castrating cystinuric irish terriers lowers their cystine and cola excretion and thus their risk for calculi formation. cats and dogs that are diagnosed with acute kidney injury (aki) and resultant uremia that is not responsive to standard medical therapy are likely to benefit from renal replacement therapies, such as intermittent hemodialysis (ihd). the purpose of this study was to evaluate the long-term outcome of patients with aki treated with ihd, and to establish whether renal function, as determined by serum or plasma creatinine concentrations, is associated with longterm survival. medical records of cats and dogs that were diagnosed with aki, treated with ihd, and survived longer than days following the last ihd treatment were retrospectively analyzed. standard methods of survival analysis using kaplan-meier product limit curves and the log-rank test were performed. for all-cause mortality, the median survival time was days ( % confidence interval: , ) for cats and days ( % confidence interval: , ) for dogs. when only renal-related causes of death were taken into account, the median survival time was not reached for cats or dogs. survival time for all-cause mortality was inversely associated with the lowest creatinine concentration within the to day period following the last ihd treatment (p o . for cats, p o . for dogs). this study demonstrates that veterinary patients that are diagnosed with aki, treated with ihd, and survive greater than days after the last ihd treatment have a good longterm prognosis and frequently die from causes that are unrelated to renal impairment. renal fine-needle aspiration (r-fna) is oftentimes attempted during evaluation of dogs and cats with renomegaly, mass lesions, or suspected infiltrative processes. diagnostic utility of fna is dependent upon the organ being sampled; additionally, in some organs, certain diagnostic imaging findings are associated with improved concordance of fna with final diagnosis. objectives of this study were to evaluate the diagnostic utility of r-fna and determine whether concordance with final diagnosis is associated with specific clinicopathologic or diagnostic imaging findings. we hypothesized that r-fna is most useful in patients with diagnostic imaging results suggestive of renal neoplasia (i.e. masses or suspected infiltrative processes). dogs and cats that had undergone r-fna from jan , to dec , were identified by database search. patient signalment, serum creatinine and blood urea nitrogen concentration, urine specific gravity, dipstick protein, r-fna result, and final diagnosis were recorded. patients were excluded if abdominal radiographs or sonographic images were not available for review, or if diagnostic test results were insufficient for determination of final diagnosis. a single coauthor blinded to final diagnoses interpreted all abdominal images using a pre-set list of descriptors and grading criteria. radiographic kidney shape, margin distortion, and ventrodorsal kidney-to-l ratio were evaluated. sonographic kidney margin distortion, cortical echogenicity, and corticomedullary junction distinction were described, and presence of nodules or masses, peri-renal effusion, or a peripheral sonolucent rim was noted. concordance of r-fna and final diagnosis was determined, and the chi-squared or fisher's exact test were used to determine association of concordance with the above variables; p o . was considered significant. dogs and cats ( animals) met all inclusion criteria. r-fna results were concordant with the final diagnosis in ( . %) patients, discordant in ( . %) patients, and inadequate for cytologic interpretation in ( . %) patients. neoplasia or fip were the final diagnoses in of ( . %) and of ( . %) patients with concordant results, respectively. renal lymphoma (p . ), renal carcinoma (p . ), and renal neoplasia in general (p . ) were not associated with a higher likelihood of r-fna and final diagnosis concordance. there was no association noted between likelihood of r-fna and final diagnosis concordance when patients were stratified by species, serum creatinine or blood urea nitrogen concentration, urine specific gravity, dipstick proteinuria, or any diagnostic imaging variables. this study failed to identify concurrent clinicopathologic or diagnostic imaging findings that enhanced the diagnostic utility of r-fna. future studies should use standardized criteria to prospectively identify patients in which r-fna will be performed, evaluate additional variables that may be associated with increased r-fna diagnostic utility, and directly compare the utility of r-fna with that of other diagnostic techniques. feline lower urinary tract disease (flutd) is a disease with increasing prevalence in private practices and veterinary teaching hospitals. although several underlying causes can cause the obstructive form in male cats, the idiopathic form (feline interstitial cystitis) often is diagnosed as underlying reason in cats o years. the goal of this retrospective study was to identify possible predisposing factors in order to optimize the therapy of these patients. as a study group, cats hospitalized with obstructive flutd at the veterinary university of vienna were examined during a year period ( ) ( ) ( ) . as a control group cats presented for other reasons were randomly chosen during the same time period. the data were examined concerning the signalment and history. furthermore, the long-term outcome was evaluated with a questionnaire. based on assumptions a student's t-test or a chi-square test was used. there were no significant differences in age and breed. the body weight was significant higher in the flutd group than in the control group (p o . ). we could observe a significant risk for the disease of a weight of kg (p o . ). there were significant less cat toilets in the flutd group compared to the control group (p o . ). furthermore we could observe that in the households of flutd cats there was significant less than one toilet per cat (p o . ) and more cats diseased on flutd lived strictly indoor than outdoor (p . ).there were no significant differences at the time of hospitalization in age, breed, number of cats per household or season of the year between the two groups. in summary, we could observe that cats over kg body weight kept indoor with less than one toilet per cat have a significant higher possibility to be affected by obstructive flutd. further studies with an extensive history of animal husbandry are needed to identify risks predispoing cats to this frequent and cost-intensive disease. although purine uroliths (ammonium urate, sodium urate, xanthine, uric acid, etc.) represent the third most common stone type in cats, purine uroliths have the highest rate of recurrence ( % in months). in dogs, mutation of the urate transporter (slc a ) and portovascular anomalies are common risk factors. however the underlying cause(s) for purine urolith formation in cats is unknown. the purpose of this study was to test the hypothesis that hyperuricosuria without alterations in liver function is common in cats with urate uroliths. urine concentrations of purine metabolites were measured by high-performance liquid chromatography in cats with ammonium uroliths (cases), clinically healthy, breed and gender matched cats (negative controls), and cats with naturally occurring xanthine uroliths (positive controls). prior to urine collection, all cats were fed a standard maintenance food (protein g/ kcal) for weeks. urinary xanthine, uric acid, and allantoin concentrations and concentration to creatinine ratios were calculated and compared between groups. also, serum pre-and post-prandial bile acid concentrations were measured. when compared to control cats, urinary uric acid concentration was significantly higher in case cats (p . ). xanthine was not detected in the urine of cases or negative controls. a significant difference in fasted and post-prandial serum bile acid concentrations was not detected in cases or controls (p . , . ).hyperuricosuria without increased concentrations of urinary xanthine or allantoin appears to be a risk factor for ammonium urate urolith formation in cats. an association between portovascular shunts and purine urolithiasis was not observed in this population of cats. studies indicate that proteinuria is predictive, on a population basis, of those cats at risk of developing azotemia. seldi-tof-ms is a sensitive, high-throughput, proteomic technique utilising chromatographic surfaces to facilitate separation and detection of proteins and peptides within biological fluids such as urine. individual low molecular weight (lmw) urinary proteins have been considered as potential biomarkers for renal damage but provide only a limited representation of the urinary proteome; seldi-tof-ms may provide a more global assessment. normotensive, non-azotemic geriatric cats ( years) were recruited prospectively from two first-opinion clinics for routine health screening. at entry cats received a full physical examination, plasma biochemistry, evaluation of total t concentration and urinalysis including urine protein to creatinine ratio. re-examination was offered at and months. cats were divided into two groups based on clinical status at the month re-examination (azotemic; creatinine concentration ! . mg/dl and non-azotemic). optimisation studies were performed to facilitate the automated preparation (biomek ) of cm (weak cation exchange) arrays for seldi-tof-ms analysis (ciphergen enterprise ) of urine samples from cats at entry to the study. results are reported as median [ th , th percentile]. mann whitney u-test and wilcoxon signed rank test were used to compare variables between groups and between timepoints, respectively. ciphergen express ( . ) software was used to analyse spectral data and a mann whitney u-test was used to identify clusters which differed significantly between groups (p o . ) at entry to the study. twenty non-azotemic cats were recruited, of which cats developed azotemia by months. no significant differences in age, body weight, biochemical or urinalysis variables were identified between groups at entry to the study. as might be expected creatinine increased significantly ( . mg/dl [ . , . ], . [ . , . ], p . ) between study entry and months in the cats that developed azotaemia and there was a commensurate increase in phosphate concentration ( . mg/dl [ . , . ], . [ . , . ], p . ). creatinine and phosphorus did not change significantly over time in the cats that did not develop azotaemia. seven clusters with m/z values of , , , , , were found to differ significantly between groups at entry to the study. the low protein concentration of feline urine makes the use of proteomic techniques challenging. however, this pilot study indicates that seldi-tof-ms can be utilised to examine the feline urinary proteome and that differences in low molecular weight protein patterns may be useful to differentiate those cats which are at risk of the development of azotemia. further work is necessary to identify these proteins/peptides. fibroblastic growth factor (fgf- ) is a phosphotonin with an important physiological role in the regulation of phosphorous and vitamin d metabolism, and may therefore play a part in the development of renal secondary hyperparathyroidism. previous studies in cats have shown parathyroid hormone (pth) to be elevated prior to the development of azotemia. the study objectives were to explore the hypothesis that fgf- is a mediator of the development of renal secondary hyperparathyroidism in the nonazotemic stages of feline ckd. healthy, non-azotemic (plasma creatinine concentrations (cr) o . mg/dl) geriatric cats were recruited into the study prospectively and followed for months. at the study end point cats were categorised into the following groups: group (n )-cr . mg/dl, group (n )-cr ! . mg/dl but did not meet the criteria for group and group (n )-cr . mg/dl in association with reduced urine concentrating ability (usg o . ) or demonstration of persistent azotemia (cr . mg/dl). plasma samples were subjected to routine biochemical analysis, intact pth, calcitriol and intact fgf- assay. variables were compared between the groups at the baseline time point. gfr was measured in an additional group of cats ( non-azotemic, iris stage ii, iris stage iii) using a corrected slope-intercept iohexol clearance method. relationships were explored using linear regression analysis and determining the coefficient of determination (r ). results are presented as median [range] . at the baseline time point fgf- concentrations were significantly higher in group ( . [ . - . ], p . ) and group ( . [ . - . ], p . ) compared to group ( . [ . - . ] ). weak positive relationships were identified between fgf- and pth (r . , p . , n ) and fgf- and cr (r . , p . , n ). however, the positive relationships between fgf- and phosphate (r . , p . , n ) and fgf- and calcitriol (r . , p . , n ) were not significant. the additional group of cats in which gfr measurement was performed there was an inverse relationship between fgf- and gfr (r . , p . ). in conclusion, fgf- was elevated in cats prior to the development of azotemia. the role of fgf- in the development of feline renal secondary hyperparathyroidism remains to be determined and should be explored through interventional studies. however, considering the relationship between fgf- and gfr, it cannot be excluded that the phosphotonin is simply a marker of reduced filtration. chronic kidney disease (ckd) is common in geriatric cats and hypoxia might contribute to the progression of this disease. the aim of this study was to evaluate urinary vascular endothelial growth factor (vegf) as a marker of renal hypoxia. cats were recruited through geriatric clinics held at two first opinion london practices. vegf was measured in stored samples using a canine elisa kit validated for use on feline urine and indexed to creatinine concentration to yield a vegf to creatinine ratio (vcr). two studies were undertaken -firstly a cross-sectional analysis of clinical variables associated with vcr in cats with ckd. diagnosis of ckd was based on concurrent findings of plasma creatinine ! mg/dl and usg . , with persistence of azotemia for ! weeks. only patients receiving no medical therapies were included. normotensive and (pre-treatment) hypertensive cats were included, but borderline cases (mean systolic blood pressure - mmhg on the date of sampling) were not. hyperthyroid cats were also excluded from this cross-sectional study. associations between vcr and clinical data were initially assessed using the spearman's coefficient and mann whitney test. linear regression was then used for multivariate analysis. the second study used samples from a trial in which hypertensive cats that had been treated with amlodipine for at least months were entered into a randomised cross-over study where they received placebo or benazepril ( . to mg/kg daily) for weeks in turn. vcr on placebo was compared with that on benazepril using the wilcoxon signed ranks test. cats with well controlled hyperthyroidism were included in this intervention study. results are reported as median [ th, th percentile]. vcr was higher ( . [ . , . ] vs. . [ . , . ] fg/g, p . ) in untreated hypertensives (n ) than normotensives (n ). vcr was correlated with pcv (r À . , p . , n ), upc (r . , p o . , n ), plasma phosphate (r . , p . , n ), and usg (r À . , p . , n ), but not plasma creatinine concentration. in the best multivariate model, pcv was associated with vcr independently of upc (r . , n ). vcr was significantly reduced by benazepril therapy ( . [ . , . ] fg/g) compared with placebo ( . [ . , . ] fg/g; p . , n ) with a reduction seen in % of cases. these results suggest urinary vegf excretion is associated with proteinuria in cats with ckd and might be a marker of renal hypoxia induced by low pcv. ace inhibitor therapy might reduce urinary vegf excretion because angiotensin ii causes constriction on efferent arterioles resulting in tubular hypoxia. fgf- is a phosphaturic hormone. fgf- concentrations increase with declining renal function in humans. the objectives of this study were to validate a method for fgf- quantification in feline plasma and to assess the association between fgf- concentration and plasma creatinine or phosphate concentration in cats with chronic kidney disease (ckd). non-azotemic and azotemic (plasma creatinine concentration (cr) . mg/dl) geriatric ( yrs) cats were recruited into the cross-sectional study from two london first opinion practices. cats were excluded from the study if they were fed a phosphate restricted diet, or had evidence of concurrent disease. the cats were categorized, using a modified iris staging system, into the following four groups: group (cr . mg/dl), group (cr . - . mg/dl), group (cr . - . mg/dl), group (cr . mg/dl). groups and were further subdivided based on the iris targets for plasma phosphate concentration (po ): group a (po . mg/dl), group b (po . mg/dl), group a (po mg/dl), group b (po mg/dl). fgf- concentrations were measured in feline edta plasma using a human intact fgf- elisa, validated by intraand inter-assay variability and assessment of dilutional parallelism. comparisons between groups were made using the kruskal-wallis test and mann-whitney u test, with statistical significance defined as p o . . bonferroni correction was applied where appropriate (statistical significance then determined as p o . ). results are reported as median [ th, th percentiles]. fgf- concentrations ! pg/ml (upper limit of quantification) were assigned the value of pg/ml. intra-and inter-assay variability of fgf- measurements were o . % and dilutional parallelism between feline samples and the calibration curve were demonstrated. plasma fgf- concentrations increased with increasing creatinine concentrations (group : [ , ] , n , group : [ , ] , n , group : [ , ], n , group : [ , ], n ). fgf- measurements were significantly different between all groups (p . to o . ) except between groups and (p . ). fgf- concentrations were significantly higher in cats with higher plasma phosphate concentrations (group a: [ , ] , n vs. group b: [ , ], n ; p . ) and (group a: [ , ] , n vs. group b: [ , ], n ; p . ). in conclusion, fgf- concentrations were higher in cats with more severe ckd or higher plasma phosphate concentrations as would be predicted from its known biological actions. further work is warranted to explore the role of fgf- in the development of renal secondary hyperparathyroidism by measuring parathyroid hormone (pth) and calcitriol in cats at different stages of ckd. progressive non-cardiogenic edema and lung dysfunction are common complications of acute kidney injury (aki) in people. pulmonary abnormalities have not been systematically reviewed in dogs with renal azotemia, but anecdotal reports of dogs with aki and concurrent non-cardiogenic pulmonary edema are suggestive of uremic pneumonopathy (up), a centrally-distributed pulmonary edema syndrome associated with kidney disease in people. we therefore hypothesized that pulmonary-associated clinical signs or thoracic radiograph abnormalities are more common in dogs with renal azotemia than in non-azotemic dogs, and that this association is more likely in dogs with aki than dogs with chronic renal failure (crf). our study objectives were ) to describe thoracic radiograph and lung histopathologic abnormalities in dogs with renal azotemia, ) to compare the occurrence of these findings in dogs with aki, crf, or non-systemic illness, and ) to determine if these abnormalities are associated with shorter survival times. records of dogs with renal azotemia evaluated from / / to / / were reviewed; dogs which could be classified as having aki or crf and which had complete thoracic radiograph studies available for review were included. dogs with primary intracranial disease and normal serum creatinine and a complete thoracic radiograph study were selected as controls. signalment, weight, presence of pulmonary-related clinical signs, azotemia duration and severity at time of radiography, and leptospirosis antibody titer were noted. alveolar, bronchial, interstitial, or nodular lesions were described using a -point scale, and lung tissue collected at time of necropsy was reviewed; both the radiologist and pathologist were blinded to final diagnoses. significance was p o . for all analyses. the final study population included aki, crf, and control dogs. crf dogs were older (p o . ) than aki and control dogs. pulmonary-related clinical signs were more commonly diagnosed at first evaluation in aki dogs ( / dogs, . %) than in crf ( / , . %; p . ) or control dogs ( / , . %; p o . ). presence of an alveolar pattern was the only radiographic finding which differed amongst groups (more common in aki [n , . %, p . ] and crf [n , %, p . ] dogs than in control dogs [n , . %]). there was no association between presence of an alveolar pattern and any other variable. alveolar mineralization was the most common lesion in aki dogs ( / dogs; . %), with concurrent alveolar space concretions or mineralization of vessels or bronchioles noted in dog each. necropsies had not been performed in any of the crf dogs, but mineralization was not seen in lung tissues from any control dogs (n ). neither pulmonary-associated clinical signs nor alveolar pattern were associated with median number of days from discharge until death in dogs with aki (p . and . , respectively) or crf (p . and . , respectively). in this group of dogs, presence and type of radiographic pulmonary abnormalities were associated with renal azotemia but not with median time until death. the association between and clinical relevance of alveolar mineralization in aki dogs were not determined, but both the radiographic and histopathologic abnormalities reported here differ from up in people. chronic kidney disease (ckd) is a common cause of morbidity and mortality in cats. the purpose of this study was to investigate the effects of chinese rhubarb (rheum officinale) supplementation on the progression of feline ckd. cats with stable iris stage ii or iii ckd and without comorbidity were included in the study. cats were divided into treatment groups and administered rhubarb extract (group , rubenal s , vetoquinol, mg tablet po q h), benazepril as a positive control (group , . mg/kg po q h), or both (group ). cats were fed a commercial renal specific diet and enteric phosphate binder as appropriate. body weight, laboratory data, and blood pressure were recorded every months for up to months. variables between groups at enrollment and within groups over visits were compared with anova and repeated measures ano-va, respectively. a treatment by visit interaction term was included in all repeated measures models. significance was set at p . . except for body weight there was no significant differences between treatment groups at enrollment. there was no significant change in body weight, hematocrit (hct), upc, or creatinine over time as compared to baseline within any group. there was no significant difference between groups over time in regards to change in weight, hct, upc, or creatinine. the treatment by time interaction was non-significant in all models. although there was no benefit associated with combination treatment, the results for rhubarb treatment alone were not different from benazepril treatment. azodyl, an encapsulated, enteric-coated probiotic/prebiotic nutraceutical, is marketed for reduction of azotemia (bun & creatinine) in dogs and cats. cat owners often sprinkle contents onto cat food to facilitate administration. however, exposure to air and stomach acid are thought to inactivate the lyophilized bacteria within the product. therefore, we examined the ability of foodsprinkled azodyl to reduce azotemia in cats with ckd. cats with ckd were enrolled in the study and randomized receive azodyl or placebo. owners were provided with - capsules of azodyl prior to enrollment to ensure compliance with administration. baseline blood samples were obtained month apart, and then & months after beginning therapy. clinicians and owners were masked as to medication assignment. we hypothesized that a % decrease in bun and/or creat in the azodyl group would be significant, and set a . . in order to maximize the probability of detecting a difference, we determined the % change as being the difference between the maximal baseline analyte concentration and minimal therapeutic concentration. we compared the % change between groups by mann-whitney u test. bun and creatinine did not differ between groups. based on these results, azodyl, applied by sprinkling onto food fails to reduce azotemia in cats with ckd. whether intact capsule administration reduces azotemia in cats with ckd remains unknown. lower urinary tract disease (lutd) occurs commonly in cats, and idiopathic cystitis (fic) and urolithiasis account for over % of cases in cats less than years of age. although several strategies have been recommended, a common recommendation is to induce dilute urine resulting in more frequent urination and to dilute calculogenic constituents. in addition to conventional therapy using modified diets, traditional chinese and western herbs have been recommended, although only one, chorieto, has published data. we evaluated commonly used herbal treatments recommended for use in cats with lutd including ( ) san ren tang, ( ) wei ling tang, and ( ) alisma. we hypothesized that these chinese herbal preparations would induce increased urine volume and decreased urine saturation for calcium oxalate and struvite. six healthy, spayed female, adult cats were evaluated in a placebocontrolled, randomized, cross-over design study. cats were randomized to of treatments including placebo (p), san ren tang (srt), wei ling tang (wlt), or alisma (a). treatment was for weeks each with a week washout period between treatments. at end of each treatment period, a -hour urine sample was collected using modified litter boxes. urine volume and biochemistries were measured, and urine saturation for struvite and calcium oxalate was estimated using equil . b. analysis of variance (anova) was used to analyze data statistically if distributed normally and kruskal-wallis was used to analyze data statistically if data were not distributed normally. a p o . was considered significant. body weights were not different between treatments. no differences were found in -hour urinary analyte excretions, -hour urine volume, urine ph, or -hour urinary saturation for calcium oxalate or struvite between treatments (table) . urolithiasis is a multifactorial disease, frequent and recurrent in dogs in the worldwide, in which breed, sex, age, diet, some anatomical abnormalities, urinary tract infection, urine ph and some geographical and hereditary features in the populations studied have been implicated as risk factors. the effective long-term management of urolithiasis depends on identification and control of the pathophysiological mechanisms involved, which, in turn, depend on accurate knowledge of the mineral composition of the uroliths. the aim of this study was to determine for first occasion the main epidemiological data of canine urolithiasis in mexico. this study was developed with dogs with urolithiasis from of the states of the country. chemical composition of the uroliths was determined by stereoscopic microscopy, infrared spectroscopy, scanning electron microscopy and x-ray microanalysis. urolithiasis affected nearly the same number of males and females; with ages ranging from two months to years with a median age of years. adult animals were the most affected. breeds more affected were schnauzer miniature, poodle, dalmatian, yorkshire terrier, scottish terrier, chihuahua and bichon frisee´. uroliths were found in the lower urinary tract in . % of the cases. mineral composition of the uroliths was: struvite . %, followed by calcium oxalate . %, purines . %, silicate . %, others . %, mixed . % and compound uroliths . %. struvite uroliths affected females in most cases, whereas calcium oxalate, purines and silicate uroliths, were mainly observed in males. our results are similar to studies developed in other countries and continents, though we found a higher frequency of uroliths containing silicate, either pure, mixed or compounds uroliths ( . %); in mexico city the frequency reached %. this high frequency may be due to high consumption of silicate in home-made food or in the groundwater derived from aquifers. acknowledgments: this work has been partially supported by a project of waltham foundation in mexico and the consejo nacional de ciencia y tecnologı´a (conacyt) of mexico. voiding urohydropropulsion is a non-invasive method for removing small urocystoliths from the dog, most commonly used in females due to the relatively wider and shorter urethra. this procedure is typically performed under general anesthesia to allow complete relaxation of the urethra, however, anesthesia results in longer procedure times and difficult endotracheal tube stabilization due to the vertical positioning of animals, especially in larger dogs. the aim of this study was to devise a novel injectable sedation protocol for urohydropropulsion when cystoscopy was not concurrently required. an intravenous catheter was placed, and a combination of medetomidine ( to mg/kg iv) and hydromorphone ( . to . mg/kg iv) was administered, with the addition of ketamine ( mg/ kg iv) in fractious animals; atipamezole (double volume of medetomidine, administered im) was used as a reversal agent upon procedure completion. this protocol was considered in cardiovascularly healthy, non-diabetic dogs without evidence of urinary obstruction. monitoring equipment included electrocardiography, blood pressure measurement, and pulse oximetry, and supplemental flowby oxygen was provided. two dogs received the proposed sedation protocol in order to perform urohydropropulsion. dog one was a year old female spayed shih tzu cross, and dog was a year old female spayed standard poodle. ultrasonography revealed a moderate number of urocystoliths present in both dogs, measuring up to mm in dog and . mm in dog . urohydropropulsion was performed and resulted in retrieval of urocystoliths in dog , and approximately urocystoliths in dog . repeat ultrasonography revealed no uroliths present after urohydropropulsion in both dogs. the time from administration of sedation to administration of reversal agent was minutes for dog , and . minutes for dog . records were obtained from dogs that had traditional general anesthetic protocols for urohydropropulsion with cystoscopy for confirmation of urocystolith removal, performed within the last years, and the average anesthetic time was minutes. subsequent to the use of medetomine-based sedation protocols for the above dogs, cystoscopy was performed in a year old neutered male golden retriever with prostatomegaly. medetomidine ( ug/kg iv) and butorphanol ( . mg/kg iv) were administered; atipamezole (double volume of medetomidine, administered im) was used as a reversal agent upon procedure completion. this sedation allowed adequate immobilization for cystoscopy of the urethra and urinary bladder, and endoscopic biopsying of the prostatic urethra and urinary bladder. the time from administration of sedation to administration of reversal agent was minutes for this dog. in conclusion, a novel sedative protocol for urohydropropulsion is proposed which allows for an appropriate level of sedation along with a short procedure time and rapid recovery. this sedation protocol may also be useful for certain cystoscopic procedures. analysis may be delayed for a variety of reasons, including the need for sample batching within the laboratory or shipping to an outsourced location. therefore, it is important to know how storage of the sample may affect enzyme activity. we hypothesized that urinary nag and ggt activity would be affected differently in samples stored by refrigeration vs. freezing. thirty-four canine urine samples submitted to the clinical pathology laboratory at kansas state university were included. samples were collected from clinical patients with a variety of medical/surgical disorders and were selected based on the day of the week and a minimum volume of ml. a complete urinalysis was performed on each sample; however there were no exclusion criteria based on urinalysis results. nag and ggt activity in the urine supernatant was assessed by colorimetric assay. aliquots of each supernatant were refrigerated for days and frozen at À c for and days at which time enzyme activity was re-assessed. compared to baseline values, enzyme activity for both nag and ggt were stable after days of refrigeration, however there were significant (p o . ) declines in ggt and nag activity when urine supernatants were frozen for and days. treatment for canine urinary tract infections (uti) typically consists of - days of antimicrobial drugs in primary care veterinary practice. compliance with this drug regimen can be difficult for some clients. enrofloxacin is a veterinary approved fluoroquinolone antimicrobial and is useful for treatment of canine uti. fluoroquinolones are often used in human medicine to treat uncomplicated utis in women and can be prescribed for as little as days. the primary objective of this study was to determine if dogs with naturally occurring uncomplicated uti have equivalent microbiologic cure with a high dose short duration protocol of enrofloxacin, compared to a standard antimicrobial protocol. client-owned adult dogs with naturally occurring, uncomplicated uti were prospectively enrolled in a multi-center clinical trial and assigned to of groups in a randomized blinded manner. group received treatment with - mg/kg oral enrofloxacin once daily for consecutive days. group dogs were treated with . - mg/kg oral amoxicillin-clavulante twice daily for days. both groups had urinalyses and urine cultures submitted on day , , and . at the time of this interim analysis, thirty-six dogs have completed the trial. bacteriological cure was achieved in dogs ( %) treated with enrofloxacin and dogs ( %) treated with amoxicillinclavulante, respectively. these data suggest that the high-dose, short-duration enrofloxacin protocol was equally effective to the standard protocol in treating uncomplicated canine uti in the sample patient population. and may represent a viable alternative therapeutic regimen for similar patients. azotemia is frequent in dogs with dmvd (nicolle et al; jvim ; : - ) and could result from renal hemodynamic alterations. renal resistive index (ri) allows assessment of renal vascular resistance. the aim of this prospective study was to assess ri in dogs with different dmvd stages. fifty-five dogs with dvmd were used (isachc class (n ), (n ), and (n )). physical examination, renal ultrasonography and echo-doppler examinations were performed in awake dogs by trained observers. plasma creatinine, urea and nt-probnp were measured. statistical analyses were performed using a general linear model. whereas ri of renal and arcuate arteries were unaffected by isachc class, left interlobar ri increased (p o . ) from . ae . (mean ae sd) in class to . ae . in class . left interlobar ri was also higher (p o . ) in azotemic ( . ae . ) than in non azotemic ( . ae . ) dogs. similar findings were observed for right interlobar ri. a positive effect of nt-probnp (p . ), urea (p o . ), creatinine (p . ), urea-to-creatinine ratio (p o . ), left atrium-to-aorta ratio (p o . ), regurgitation fraction (p . ), systolic pulmonary arterial pressure (p o . ) and shortening fraction (p . ) on ri was also observed. in conclusion, interlobar ri increases with the severity of dmvd and azotemia. a cause-effect relationship remains however to be established. antibodies against alpha-enolase are associated with immunemediated nephritis in people. it was previously shown that vaccinated cats commonly develop antibodies against alpha-enolase. the purpose of this study was to assess for associations between alphaenolase antibodies and azotemia in privately-owned cats. clinically stable privately owned cats ! years of age, with and without azotemia (creatinine mg/dl), and with an available vaccine history for ! years were recruited for the study. sera were assayed for creatinine concentrations and alpha-enolase antibodies by use of previously validated techniques. results from cats with and without azotemia were compared by student's -tailed t test or fisher's exact test with significance defined as p o . . median ages were years (range: - ) and years (range: - ) for cats with (n ) and without azotemia (n ), respectively. there was no significant difference in vaccine events (number, type, or route of administration) between groups. azotemic cats ( . %) were more likely than normal cats ( . %) to be positive for antibodies against alpha-enolase (p . ). in addition, alpha-enolase antibody concentrations were greater (p . ) in azotemic cats (mean % elisa . %) than cats with normal creatinine concentrations (mean %elisa . %). results of this study suggest that antibodies against alpha-enolase in cats may be associated with renal disease. additional prospective evaluation in a larger number of cats is indicated. aki is used in human medicine as a predictor of mortality based on the akin (acute kidney injury network) scoring system which utilizes relative increases in creatinine to determine stage. with this scheme, mortality has been shown to increase as the stage of kidney injury (indicated by akin score) increases. accordingly, we hypothesized that this system would improve predicting prognosis in dogs and cats. we retrospectively evaluated dogs and cats ( ) ( ) ) that had ! creatinine measurements within days, and whose first creatinine was o . mg/dl. patients were categorized as: level (no aki); level (second creatinine value o . mg/dl, but creatinine increased ! . mg/dl); or level (second creatinine . mg/dl with a creatinine increase ! . mg/dl). thirty and day survival for each level was compared to level . adjusted odds ratio (or) in dogs for day survival was . for level (ci %, . - . ) and . (ci %, . - . ) for level ; or for day survival was . for level (ci %, . - . ) and . (ci %, . - . ) for level . for cats, or at days was . (ci %, . - . ) for level and . (ci %, . - . ) for level ; or for day survival was . (ci %, . - . ) for level and . (ci %, . - . ) for level . thus, detecting increasing stage of aki helps predict mortality in dogs and cats. abstract n/u- feline urate urolithiasis: cases ( - . j dear , r shiraki , a ruby , j westropp . william r pritchard veterinary medical teaching hospital, university of california, davis, ca, gerald v. ling urinary stone analysis laboratory, university of california, davis, ca and the department of veterinary medicine and epidemiology, university of california, davis, ca. feline urate urolithiasis accounts for % of the feline stones our laboratory analyzes each year; little information is known about this disease, particularly the incidence of those cats with hepatopathies. the objective of the study was to characterize the signalment, clinicopathologic data, and diagnostic imaging of cats with this disease as well as the salts of uric acid present. a retrospective analysis of feline urate uroliths submitted to the stone lab between january -december were included. from these data, primary veterinarians were solicited to submit records. furthermore, all records from cats with urate uroliths from the vmth were analyzed separately. records were received from the primary care veterinarians. sixteen cases were identified from the vmth. median values for the cbc and chemistry panels available were within the reference ranges provided, with only a few outliers present. of the cats with radiographic reports, ( %) had visible evidence of uroliths. two external cases had confirmed pss; five cases from the vmth had a pss. cats with urate uroliths and pss were younger than cats without a documented hepatopathy ( years vs. years). the siamese breed was overrepresented. all stones were ammonium hydrogen urate. the pathogensis of urate uroliths in cats is poorly understood. most cats were not completely evaluated for pss, however, there were few clinicopathologic parameters which indicated hepatopathies were present. further studies are warranted to evaluate genetics and purine metabolism in cats with urate uroliths to help tailor proper management and breeding strategies. -indoxyl and p-cresyl sulfate (is, and cs, respectively), small protein-bound molecules derived from gastrointestinal protein metabolism, are among the most important uremic solutes affecting morbidity and mortality in human chronic kidney disease (ckd). in the blood stream, these compounds are predominantly bound to protein, but their debilitating effects on prognosis and quality of life in ckd appear to be driven by the free fraction. the objectives of the present study were to assess the normal, physiological levels of is and cs in healthy cats and to evaluate the correlation of the respective free and protein-bound levels. blood samples were taken from clinically healthy adult cats enrolled at five participating veterinary practices in germany. after centrifugation, the serum was deep frozen until transport on dry ice to the analytical laboratory. serum creatinine and urea levels were quantified by vettest s (idexx laboratories, inc.). total and free is and cs, respectively, were quantified by turbulent flow chromatography coupled with a tandem mass spectrometry detector. statistical analysis of the results comprised i) a descriptive report of the median with upper and lower bounds of the % confidence interval for reference values of is and cs, ii) a calculation of various pearson correlation coefficients r, also tested with reference to the null hypothesis of no relationship, and iii) wilcoxon-mann-whitney utest for an estimation of the effect of hemolysis on serum is or cs levels. six animals with serum creatinine or urea levels outside the reference range were excluded from the calculation of reference values. median levels of is in cat serum were . mg/l with upper and lower bound % confidence intervals at . and . mg/l, respectively. the corresponding median levels of cs were . mg/l (median) and . vs . mg/l (upper vs lower bound levels, respectively). these values showed a low, non-significant correlation with serum creatinine or urea levels. however, is and cs serum levels were moderately correlated (total levels r . , p o ). their respective free levels constituted about % of the total serum levels (r ! . , p o . ). non-hemolytic samples tended to yield lower values than hemolytic samples. due to the low number of hemolytic samples (n ) , the group difference could, however, not be statistically confirmed. the results indicate that it is sufficient to determine total levels of either is or cs in serum while studying the effects of therapeutic or dietetic interventions on the evolution of these parameters in feline ckd. reference values are provided for orientation towards clinically relevant changes. disrupted urothelial differentiation has been implicated in the pathogenesis of feline idiopathic cystitis (fic). studies of cultured human urothelium have shown that abnormalities in urothelial differentiation and repair may be mediated by persistent -hydroxy-prostaglandin dehydrogenase (pgdh) activity and subsequent metabolism of cytoprotective prostaglandins. the goal of this study was to confirm persistent pgdh expression in fic bladders compared to desmoplakin i ii expression, a marker of urothelial differentiation. urinary bladder biopsy specimens were obtained by cystotomy from symptomatic cats with chronic fic. cats with a history of another major disease, previous cystotomy, or recent treatment with corticosteroids, nsaids, antihistamines, antidepressants, or glycosaminoglycans were excluded. urinary bladder tissue specimens were also obtained from untreated clinically normal specific-pathogen-free cats. tissue specimens were fixed in buffered % formalin and embedded in paraffin. tissue sections were deparaffinized and subjected to citrate buffer microwave antigen retrieval. tissues were stained for pgdh using a rabbit anti-pgdh antibody, an isotype negative control or goat anti-desmoplakin i ii and developed using the avidin-biotin peroxidase complex method. all fic ( / ) and normal ( / ) cat bladder samples showed similar staining of urothelial cytoplasm for pgdh. however, desmoplakin i ii staining, found on the luminal cell surface in / normal tissues, was disrupted in / fic bladder samples. desmoplakin i ii staining confirmed altered urothelial differentiation in fic cats. however, pgdh expression remained intact in fic samples. we hypothesize that pgdh expression in fic may contribute to its pathophysiology due to breakdown of prostaglandins essential for urothelial healing. additional studies will explore this hypothesis. the university of tennessee college of veterinary medicine's picture archiving and communication system was searched over a month period for cats that had undergone both abdominal radiographs and ultrasound during the same visit. one hundred and three cats were identified (age range o to yrs; median yrs). kidney size was determined based on radiographic and ultrasound findings. of the included cats, . % had two normal sized kidneys, . % had one small and one normal, . % had one large and one normal, . % had two small, . % had two large, and . % had one small and one large kidney. the presence of mineralization, uroliths and hydronephrosis was also noted. medical records were reviewed for clinical chemistry data and historical information concerning previous urinary disease. no significant differences were found between kidney size and renal function, kidney size and the presence of uroliths, renal mineralization and function or the presence of uroliths and function. the presence of uroliths was significantly associated with hydronephrosis. of the cats with at least one large kidney, ( %) had hydronephrosis. of the cats with current or previously diagnosed uroliths, urinary tract infections or other uropathies, ( . %) had at least one small kidney. small kidneys were commonly found in older cats, however, this correlation was not statistically significant. based on these findings, small kidneys are more likely to be the result of urinary disease as opposed to being either congenital or due to aging. this study aimed to evaluate ife, which has been advocated for treatment of lipid-soluble drug intoxication, in the treatment of clinically-occurring canine ivermectin toxicosis. one australian shepherd and two miniature australian shepherds were included. all three dogs were homozygous for the mdr- gene mutation. two dogs roamed on horse ranches where ivermectin-based deworming products had recently been used. ivermectin was administered to the third dog ( mg/kg po). all three dogs exhibited tremors, ptyalism, and cns depression, which progressed over several hours to stupor in two dogs, and to a comatose state requiring mechanical ventilation in the remaining dog. a % formulation of ife (liposyn ii, hospira) was administered as a bolus ( . ml/kg) followed by a slow iv infusion ( . - ml/kg over minutes). no change was observed in the neurologic status of any patient. lipemia visible upon blood sampling persisted for hours in one dog. no other adverse effects were noted. serum ivermectin levels confirmed ivermectin exposure in each case. in this study, ife administration did not result in clinical benefit in cases of ivermectin toxicosis. brain ivermectin concentrations in mdr mutant/mutant genotype dogs may be too high to be overcome by ife. additionally, these dogs may lack p-glycoprotein-mediated biliary clearance mechanisms needed for optimal ife function. further investigation is needed to determine the utility and optimal dosing of ife in canine toxicoses, to characterize its safety, and to determine how mdr- status may alter the efficacy of ife in treatment of canine ivermectin intoxication. rufinamide is a recently approved antiepileptic drug used for the treatment of seizure disorders in human patients. rufinamide is administered at a dose of mg/kg divided twice daily to achieve therapeutic concentrations of mg/ml. the objective of this study was to determine the pharmacokinetic properties and short-term adverse effects of single-dose oral rufinamide in healthy dogs in preparation for a possible clinical trial evaluating the efficacy of rufinamide in the treatment of canine epilepsy. six healthy adult dogs were included. the pharmacokinetics of rufinamide were calculated following administration of a single mean oral dose of . mg/kg (range . - . mg/kg), extrapolated from the dose used in human patients. dogs were monitored by repeat physical examinations, electrocardiograms and blood pressure assessments during the course of the study. plasma rufinamide concentrations were determined using high-performance liquid chromatography. pharmacokinetic data were analyzed using winnonlin version . . no adverse effects were observed. the mean terminal half-life was . /À . hours. the mean maximum plasma concentration was . /À . mg/ml and the mean time to maximum plasma concentration was . /À . hours. mean clearance was . /À . l/hr. auc inf was . /À . mgÃh/ml. results of this study suggest that rufinamide given orally at mg/ kg twice daily in healthy dogs should result in a plasma concentration and half-life sufficient to achieve the therapeutic level extrapolated from humans without short-term adverse effects. further investigation into the efficacy and long-term safety of rufinamide in the treatment of canine epilepsy is warranted. the aims of this study were to investigate the abg for (i) the prevalence of skull abnormalities; (ii) the prevalence of sm; (iii) an association between lateral ventricular size, cerebellar size and sm; and (iv) associations between sm, skull abnormalities, csf pleocytosis and clinical signs. seventy-six abgs, recruited as part of a larger epidemiological and genetic study, underwent brain and spinal mri evaluation ( . t general electric signa hdx, milwaukee, wi). all dogs were evaluated neurologically, recording deficits and the presence of spinal pain. sequences acquired included t w, t w pre-and postcontrast, and t w flair, sagittal and transverse. cervical spinal cord central canal (cc) and or syrinx size and its percent area of spinal cord was measured using osirix s . the presence of chari-like malformation (cm) was assessed by recording the presence of caudal cerebellar deviation and/or foramenal vermal herniation. lateral ventricle and cerebellar volume was expressed as a percent of the cerebrum and intracranial volume qa respectively. forty-five dogs underwent atlanto-occipital cerebrospinal fluid tap at the time of mri and the white blood cell (wbc) count was recorded. student's t-tests were used to compare the measured variables between groups with and without skull abnormalities, spinal pain and neurological signs. the mean age of the males ( intact) and the females ( intact) was . months (range - ; median months). neurological deficits and neck pain were noted in ( %) and ( . %) of dogs respectively; dogs ( . %) exhibited both. cerebellar deviation and vermal herniation were present in ( . %) and ( . %) dogs respectively; twenty-three dogs ( . %) had both. mean height of the cc was . mm ( - . mm). forty ( . %) ccs were greater than mm in height; the mean length of these lesions was . vertebrae ( . - ). mean csf wbc count was . /ml ( - ). syrinx height and extent were significantly higher in dogs with neurological signs (size p . ; extent p . ). there were no significant differences in syrinx sizes and extent in dogs with or without skull abnormalities or spinal pain. there were no associations of syrinx height or extent with csf wbc count or age of dog. intact females had a significantly lower syrinx extent than intact males (p . ). there were no significant differences in presence of spinal pain or neurological signs between dogs with or without skull abnormalities. there was a significant negative association of ventricular percentage and cerebellar percentage (p o . ). there was a significant association of ventricular percentage with syrinx percentage (p . ) and height (p . ). this study suggests that sm and cm are prevalent in abgs. syrinx size and extent are associated with neurological signs and ventriculomegaly is associated with both small cerebellar size and large syrinx size. however, sm may not be associated with cm as defined by cerebellar herniation and deviation and is not associated with csf inflammation. the power tissue resection device (ptrd) is a hand-piece comprised of an outer cannula with motor driven vacuum-assisted inner cutting blade. this device was designed and is marketed for human neurosurgical brain/spinal cord tumor resection. the purpose of this study is to describe the use of the ptrd for intervertebral disc fenestration and to compare the effectiveness of manual fenestration to that of the ptrd. fifteen cadaveric lumbar spines were randomly placed into three study groups: group was the control group on which no fenestrations were performed, group was the manual fenestration group and group was the ptrd fenestration group. the effectiveness of fenestration via both manual and ptrd was assessed by calculating the ratio of remaining nuclear weight post fenestration to total nuclear volume. discs with lower ratios were more effectively fenestrated. results showed a smaller ratio of post fenestration remaining nuclear weight to nuclear volume following fenestration with the ptrd ( . ae . ) as compared to manual fenestration ( . ae . ). these results did not show statistical significance. when fenestrated samples were compared to control samples ( . ae . ), there was a statistically significant reduction in ratios. in conclusion, the ptrd is easy to use and is as effective as the manual technique for canine intervertebral disc fenestration. according to the human who classification gliomatosis cerebri (gc) is a rare astrocytic tumor affecting at least three lobes of the brain with extensive infiltration, but relative preservation of brain architecture. gc has not been reported to occur as a hereditary disease, neither in man nor in animals. here, we report the temporally clustered occurrence of gc in a family of bearded collies. a years old female bearded collie with forebrain signs was presented. differentials included inflammatory/ infectious, metabolic/ toxic, and neoplastic diseases. within a time period of months, offspring of this bitch were presented with similar clinical signs. two dogs were full siblings ( males). the remaining female dog originated from a match with a different male dog. mri was performed in all dogs and revealed a diffuse and extensive intra-axial lesion with moderate mass effect and midline shift. the ill defined lesion showed mainly a white matter distribution with hyperintense signal in t -w and flair images and iso-to hypointense signal in t -w images without contrast enhancement. the lesion was bilateral in all cases, continued along the white matter extending partially into the gray matter with contact to the brain surface. neuropathology revealed a diffuse and extensive infiltration of the brain and spinal cord by a neoplastic glial cell population involving white and gray matter of both hemispheres, thalamus, brainstem and cerebellum in all dogs. based on the cell morphology and immunoexpression of glial fibrillary astrocytic protein by neoplastic cells diagnosis of gc was made. this is the first report of familial occurrence of gc, which is likely the result of a germ-line mutation. several human hereditary cancer syndromes are associated with cns tumors including amongst others the li-fraumeni cancer family syndrome (p mutation), neurofibromatosis (type and ) (neurofibromin, merlin mutation), and tuberous sclerosis (hamartin, tuberin mutation). furthermore, familial clustering of human gliomas unassociated to the known inherited cancer syndromes has been described. in the dog, hereditary cns tumors are not known. the exact mode of inheritance and putative gene mutations of gc in this bearded collie family are currently under investigation. preliminary results are consistent with a monogenic autosomal dominant mode of inheritance, although a recessive inheritance cannot be completely ruled out at this time. mutations in the tp gene were not found following amplification and sequencing of exons - in affected dogs. previously presented at the ecvn annual meeting in cambridge, uk. the gm gangliosidoses are characterized by a deficiency of bhexosaminidase. there are two isoforms: hex a composed of an a and b subunit encoded by hexa and hexb genes respectively and hex b with two b subunits. hex a requires an activator encoded by gm a. two japanese chin dogs with confirmed gm gangliosidosis showed elevated total hexosaminidase and normal hexosaminidase a activity, a pattern associated with the ab variant in humans and consistent with prior reports in the breed. this study was performed to identify the mutation responsible using resequencing with an applied biosystems xl dna analyzer as previously described (awano ). mutations in gm a cause the ab variant in humans, but resequencing gm a revealed no mutation that could account for the disease. resequencing hexa and hexb revealed a c. g a mutation in hexa which was homozygous in both affected dogs. sixty-five normal japanese chin dogs were screened for the mutant allele; were homozygous for the ancestral allele and heterozygous. this mutation predicts a p. e k substitution affecting one of two primary active-site amino acids that participate in the hydrolysis of gm ganglioside. substitution of a lysine residue at this site is likely to eliminate subunit a enzymatic activity. the apparently normal levels of hexosaminidase a activity in affected dog samples may be a result of b subunit overexpression. human hex b possesses low levels activity against the artificial substrate used to assess hex a activity, but specificity of activity of the canine enzyme is not known. previously presented at the american society for neurochemistry: additional data in this abstract. phenytoin (pht) is the intravenous drug of choice in humans for seizure emergencies following benzodiazapines. iv fosphenytoin (fos) is a pht pro-drug which causes less administration related adverse events. while the short half-life of pht is not suitable for chronic oral therapy in dogs, iv fos has not been studied. two dogs received mg/kg phenytoin equivalent (pe) and two dogs received mg/kg pe of fosphenytoin intravenously at a rate of mg pe/min. blood for plasma levels were drawn at time-points over hours; total and unbound drug levels were measured by hplc. vital signs including ekg, blood pressure, and neurological examination were monitored. the half-life of metabolism of fos to pht was $ min, with % of fos metabolized to pht by minutes. eighty to % of pht was protein-bound during the first minutes after dosing, compared to - % in humans. the elimination half-life for total pht ranged from . - . hours and for unbound pht ranged from . - . hours. dogs receiving mg/kg pe intravenously achieved unbound pht plasma maximum concentrations of . - . ug/ml at minutes, consistent with human loading dose levels. adverse events observed in some dogs included vomiting, mild ataxia, and short lived tremors, the severity of which appeared dose dependent. all dogs were clinically normal within minutes of all doses. a mg/kg pe dose of iv fos appears adequate for production of pht levels predicted to be effective for the treatment of canine seizure emergencies. further studies in clinical canine patients are warranted. acquired myasthenia gravis (mg) is caused by antibodymediated inactivation of the acetylcholine receptor on the neuromuscular endplate causing focal, regional or generalized muscle weakness. many medical treatments have been reported; however, responses to therapy and outcomes are unpredictable and death often results from aspiration pneumonia. therapeutic apheresis is an extracorporeal procedure that separates blood into its components for removal or specific alteration prior to return to the patient. therapeutic plasma exchange (tpe) is an apheresis treatment in which plasma (containing pathologic antibodies) is removed and exchanged with donor plasma. tpe is used routinely to treat mg in human patients with severe disease or disease unresponsive to conventional therapy. we report the successful use of tpe to treat large breed dogs with confirmed mg (aceytlcholine receptor antibody concentration: . and . nm/l, respectively; normal concentration: o . nm/ l) that was severe and not adequately responsive to traditional therapies. both dogs were non-ambulatory, recumbent, and demonstrated megaesophagus and aspiration pneumonia. three tpe treatments ( plasma exchange each) were performed over and days, respectively, in each dog without complication. both dogs became ambulatory within days of starting tpe treatment with subsequent resolution of regurgitation and megaesophagus. pyridostigmine was continued during tpe sessions and discontinued in both dogs within - months. both dogs remain asymptomatic and have had no recurrence of mg during and months of follow-up, respectively. tpe is a viable treatment option for dogs with mg that have severe disease, life-threatening complications or that remain unresponsive to traditional therapies. tpe may alleviate clinical signs more rapidly, and improve long-term outcomes when compared to historical experiences in patients with comparable disease. clinical findings, clinicopathologic data, imaging features, and treatment of canine spinal meningiomas have been described in the veterinary literature, but histological characteristics and tumor grading have less commonly been reported. the aims of this retrospective case series were to describe the clinical, imaging, and histologic features of seven canine spinal meningiomas including a cervical spinal cystic meningioma that had imaging and intraoperative features of a subarachnoid cyst. medical records from dogs with a histopathological diagnosis of spinal cord meningioma presented to the veterinary teaching hospital between and were reviewed. signalment, presenting clinical signs, physical and neurologic examination, clinicopathologic data, surgery reports and available images were reviewed. all meningiomas were histologically classified and graded following the international who human classification for cns tumors. seven dogs were included, males and females. median age at presentation was . years (range, . - . years), and median weight was kg (range, - kg) . median time between onset of clinical signs and diagnosis was days (range, days - year). cerebrospinal fluid (csf) analysis was performed in dogs, showing increased protein concentration in cases, and being normal in the other . spinal radiographs revealed vertebral canal widening in one case. myelography ( / ) showed intradural/extramedullary lesions in three cases, one of them consistent with a csf-filled subarachnoid cavity, and an extradural lesion in one case. magnetic resonance imaging (mri) was performed in all cases and revealed mild to marked hyperintensity on t w and precontrast t w images and homogeneous contrast enhancing (ce) intradural/extramedullary masses ( cervical and thoracic) in six cases, with one of these showing an additional intramedullary ce pattern. a dural tail was identified in two dogs. one dog had a fluid-filled subarachnoid enlargement located dorsally to the spinal cord. this lesion was hyperintense on t w, hypointense on t w and flair images, and did not enhance. it was diagnosed as a spinal subarachnoid cyst, but the histopathological study of the surgically resected mass revealed a grade i cystic meningioma. five other cases underwent cytoreductive surgery, two transitional meningiomas (grade i) that survived (alive at the time of writing) and months; and three anaplastic meningiomas (grade iii) that survived - . months before neurological deterioration and euthanasia. another anaplastic meningioma was euthanized right after diagnosis. there are few reports grading canine spinal meningiomas, with most being grade i or ii. of the few grade iii tumors reported, only one had been treated surgically and was euthanized days later because of neurological deterioration. we report four grade iii (anaplastic) meningiomas, three of which surgically treated and with longer survival times. finally, cystic meningioma should be considered in the differential diagnosis of cases with imaging features consistent with arachnoid cyst because of their similar appearance, making histopathological analysis essential for a definitive diagnosis. head trauma is a common veterinary emergency, but few prognostic indicators have been studied in dogs, making it challenging for clinicians to counsel clients about the odds of recovery. a recent meta-analysis showed that higher plasma glucose, lower plasma ph and lower hemoglobin at admission were associated with increased risk of death in human head trauma. the goal of this retrospective study was to investigate the association between admission point of care blood gas parameters and survival to discharge in dogs with head trauma. fifty one dogs presenting to the cornell university hospital for animals with head trauma from to that had a blood gas analysis done within hour of presentation were eligible for inclusion. parameters assessed included glucose, base excess (be), anion gap (ag), ph, hemoglobin, and sodium. biochemical data were found to be normally distributed using the kolmogorov-smirnov test. t-tests or welch tests were used to compare parameters between survivors (s,n ) and non-survivors (ns, n ). of glucose, be, ag, ph, hemoglobin, and sodium, only mean glucose (s mg/dl, ns . mg/dl, p . ) was significantly different between groups, although there was a trend for a difference in mean be (s À . , ns À , , p . ). logistic regression analysis showed that of the parameters, only be was independently associated with outcome (odds ratio . , % ci . - . , p . ). these results suggest that two easily measured biochemical parameters (glucose and be) may yield useful prognostic information in dogs with head trauma, but further studies are needed to further elucidate these findings. type i intervertebral disc disease (ivdd) commonly affects chondrodystrophic dogs. neurological recovery and outcome following surgical decompression may be unpredictable due to suspected ischemic neuronal injury. hyperlactatemia has been associated with spinal cord injury in humans and experimental animals. the purpose of the study was ) to determine the relationship between serum and csf lactate levels and ) to compare lactate levels with neurological outcome following decompressive surgery in dogs with ivdd. healthy, chondrodystrophic dogs diagnosed with ivdd localized to the t -l spinal cord were included. serum lactate levels were obtained at: anaesthetic induction, skin incision, muscle dissection, and extubation. in patients with hyperlacatemia at extubation, additional samples were obtained. csf was analyzed for lactate concentration. neurological status was recorded at presentation and multiple times during the recovery period. dogs were included in the study ( - years old). / dogs had normal lactate levels throughout the study. / dogs had serum hyperlactatemia prior to anaesthetic induction; / dogs returned to normal during anaesthesia and / dogs had continued hyperlactatemia until the end of the observation period. neurological status of the dogs varied similarly between all groups. in / dogs where csf lactate levels were measured, initial serum levels were lower than csf lactate levels; in / dogs where csf and serum were collected simultaneously, serum lactate concentration was consistently lower than csf lactate. no association between presenting neurological status or neurological outcome and serum or csf lactate concentration was made. neither serum nor csf lactate concentration is useful for predicting neurological outcome in dogs with ivdd. chiari-like malformation (cm) has been associated with syringomyelia (sm) in cavalier king charles spaniel (ckcs) and is postulated to result from a mismatch between the volume of the caudal cranial fossa and the brain parenchyma contained within. the objective of this study was to assess the role of cerebellar volume in caudal cranial fossa overcrowding and syringomyelia. three dimensional models were created using t -weighted transverse magnetic resonance images in the commercial software package mimics s . volumes of cerebellar parenchyma were analyzed as percentages of caudal cranial fossa volume (cerebellar caudal cranial fossa percentage) and total brain parenchyma volume (cerebellar brain percentage). data was assessed for normality and the appropriate statistical test was used to compare means/medians between groups. forty-five small breed dogs (sb), ckcs and labradors (ld) were compared. as sm is thought to be a late onset disease process, two subgroups were formed for comparison: ckcs younger than years with sm (group ) and ckcs older than years without sm (group ). ckcs had a larger cerebellar caudal cranial fossa percentage than the other groups . %] vs. sb . % [ . - . %] and ld . % [ . - . %]; p o . ). the cerebellar brain percentage was also larger in ckcs compared to the other groups (ckcs . % [ . - . %] vs. sb . % [ . - . %] and ld . % [ . - . %]; p o . ). group had a significantly larger cerebellar caudal cranial fossa percentage than group ( . % ae . vs. . % ae . , p . ) and a significantly larger cerebellar brain percentage ( . % ae . vs. . % ae . , p . ). our findings show that the ckcs has a relatively larger cerebellum than small breed dogs and labradors and there is an association between increased cerebellar volume and sm in ckcs. chiari-like malformation (cm) is nearly omnipresent in the cavalier king charles spaniel (ckcs) breed. the mis-match of the caudal cranial fossa and the parenchyma within is thought to lead to syringomyelia (sm). there is currently a lack of information if the morphological changes seen in ckcs with cm are progressive or non-progressive. in this retrospective study we used established measurements of cerebral volumes, foramen magnum height and cerebellar herniation length to assess if there is a significant difference between subsequent magnetic resonance (mr) imaging of the brain of the same dog. electronic patient records were reviewed for ckcs with cm which had two separate mri scans, which were a minimum of months apart. ckcs with diseases affecting measurements were excluded. for the volumetric measurements three-dimensional models were created using t -weighted transverse mr images in the medical imaging software (mimics v . , materialise n.v, ) . volumes of the caudal cranial fossa parenchyma were analyzed as percentages of caudal cranial fossa volume and caudal cranial fossa volume was analyzed as a percentage of total cranial cavity volume. the volume of the ventricular system was recorded as a percentage of total parenchymal volume. data was assessed for normality and the appropriate statistical test was used to compare means/medians. twelve ckcs were included with a median scan interval of . months ( - months). the size of the foramen magnum increased significantly between the first and second scan ( . ae . cm vs. . ae . cm; p . ), as did the length of cerebellar herniation ( . ae . cm vs. . ae . cm; p . ) and the caudal cranial fossa percentage ( . % [ . - . %] vs. . % [ . - . %]; p . ). there was no significant difference noted between the two time points in any of the other volumetric measurements ( this work could suggest that overcrowding of the caudal cranial fossa in conjunction with the movements of cerebrospinal fluid and cerebellar tissue secondary to pulse pressures created during the cardiac cycle causes pressures on the occipital bone. this leads to a resorption of the bone and therefore an increase in caudal cranial fossa and foramen magnum size allowing cerebellar herniation length to increase. the cord dorsum potential (cdp) is a stationary potential arising in dorsal horn interneurons after stimulation of sensory nerves. cdps have been recorded in normal anesthetized dogs previously, and normal latency values have been determined for tibial and radial nerves. this study was undertaken to determine whether cdps could be reliably recorded from the caudal nerves in normal dogs, thus allowing electrophysiological assessment of the cauda equina, and whether neuromuscular blockade improved recording quality. ten adult dogs weighing from . to . kg were anesthetized and cord dorsum recordings were compared before and after administration of atracurium. recording needles were placed onto the dorsal lamina at intervertebral sites from l /s to l / . stimulations were made on the lateral aspect of the caudal vertebrae approximately - cm from the tail base. recordings from stimulations were averaged. cdps were recorded successfully in all dogs. onset latency varied from . to . ms. the cdp was largest when recorded closest to the site of entry of the stimulated nerve into the cord, as determined by post-mortem examination immediately after testing in dogs. administration of atracurium did decrease muscle artifact, and in some cases helped isolate the origin of the cdp. these data show that cdps can be readily assessed from the caudal nerves of anesthetized dogs, with or without atracurium. cord dorsum potentials from caudal nerves may add important information about the integrity of the cauda equina in dogs with suspected degenerative lumbosacral stenosis. canine intracranial glial tumors and many human brain tumors express heat shock proteins (hsps) associated with their degree of malignancy. the up-regulation of hsps during tumor cell growth helps keep tumor proteins stable and therefore makes them a reasonable target for therapy. ki expression and ec have been strong indicators of cell proliferation and dedifferentiation, respectively.the aims of this study were to determine (i) if canine meningiomas express hsp and/or hsp ; (ii) whether the expression of the hsps was associated with ki and/or e-cadherin (ec) expression; and (iii) whether peritumoral edema was associated with hsp, ki and/or ec expression. forty-one formalin-fixed, paraffin-embedded canine intracranial meningiomas underwent immunohistochemical staining using anti-hsp , or antibodies. these tumor samples were also immunohistochemically stained for ki and ec expression. canine mammary carcinoma and squamous cell carcinoma tissues served as the control samples, as both have previously been shown to express hsps. skin was used as control for ki and ec. four non-overlapping high power fields of each stained sample were selected and cell staining was analyzed using a semi-quantitative method for hsps and ki ; a qualitative assessment was used for ec. all analyses were performed using sas v . (cary, nc). descriptive statistics of staining percentages were calculated for all tumors tested. simple pearson's correlation was used to test for correlations of ec area with hsp areas and ki- percent positive cells and of ec intensity with hsp intensities and ki- percent positive cells. all hypothesis tests were sided and the significance level was a . . thirteen meningiomas had mr images quantitatively evaluated for peritumoral edema using t flair sequences. the edema index (ei) was evaluated for an association with hsp , hsp , ec and ki expression. hsp was expressed in % (mean . % of cells; range - %), hsp in % (mean . % of cells; range - %) and ec in % of meningiomas. there was no association demonstrated between either hsp expression variable and ec or ki- expression. there was also no association between the ec expression variables and ki- . however, there was a significant negative association between hsp extent (p . ) and area (p . ) with ei. in conclusion, hsp and expression was demonstrated in canine intracranial meningiomas but was not associated with ki- or ec expression. this study suggests that hsps may not have a significant role in the maintenance of canine meningiomas and so do not represent a novel treatment target for this group of tumors unlike canine glial cell tumors. however, hsp may be involved in the pathogenesis of peritumoral edema in meningiomas and warrants further investigation. an extended release (xr) formulation of levetiracetam, a second generation antiepileptic drug, was recently approved for human use on a once daily basis. although levetiracetam is clinically effective for seizure control in dogs, it requires a three times daily administration. the potential benefits of the xr formulation include reduced daily dosing leading to improved compliance and relatively constant plasma concentrations. the aim of this study was to compare the pharmacokinetics of levetiracetam xr tablets with immediate release (ir) tablets following single dosing in dogs. five clinically and neurologically normal mixed breed dogs were used in a cross-over design. all dogs (mean body weight . kg; range . - . ) had normal hematology, serum chemistry and urinalyses. following a hour fast, each dog was administered oral ir levetiracetam ( mg; mean dose . mg/kg; range . - . ). heparinized blood for drug analysis was taken from each dog prior to administration and . , . , . , , , and hours after. blood was immediately centrifuged and supernatant plasma was stored at À c until analysis. after a day wash-out period, each dog was administered mg oral xr levetiracetam and blood samples were taken at identical timings. plasma samples were thawed at room temperature before preparation by solid phase extraction for hplc analysis. reverse phase chromatographic separation was performed. levetiracetam and an internal standard were detected using ultraviolet spectroscopy at nm. concentrations of levetiracetam were determined by peak area comparison to the internal standard. mean data were fit to a one compartment pharmacokinetic model with first order elimination and absorption and included a lag-phase for xr formulation. no adverse clinical effects were noted in any of the dogs. the auc associated with xr was hr ug/ml, a . fold increase over that with ir ( . hr ug/ml). the absorption half-life was . hr with xr and . hr with ir, a . fold difference. the elimination halflife was . hr with xr and . hr with ir, a . fold difference. the tmax associated with xr . hr and . hr with ir, a . fold difference. the cmax associated with xr was . mg/ml and . mg/ml with ir, a . fold difference. the plasma concentration of ir levetiracetam was not detectable at hr after administration whereas it was greater than mg/ml at hr after xr administration. based on the auc data, there is an approximately fold increase in bioavailability of the xr compared to the ir formulation. the cmax was approximately times greater following xr administration and a high plasma level in excess of the suggested canine therapeutic concentration ( mg/ml) for at least hours. although specific dosing recommendations cannot be made from this data, the favorable pharmacokinetics of xr over ir suggests that single, daily administration could be efficacious. thoracic and lumbar vertebrae are frequently affected by fractures and or luxations in dogs following trauma. surgical repair is part of the emergency treatment described for this disorder but does not guarantee improvement of the associated clinical signs. multiple surgical repair techniques have been described but have not been compared in terms of their success and the factors associated with a positive outcome. the aims of this study were to retrospectively evaluate the effect of different types of vertebral repair, injury type and injury location on outcome in dogs with thoracolumbar (tl) and lumbosacral (ls) spinal trauma. medical records were searched for dogs with radiographic evidence of a tl or ls vertebral fracture and or luxation ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ; signalment, body weight and duration of disease were recorded. dogs were retrospectively scored neurologically ( - ; normal to plegic with absent pain perception) on admission and at re-evaluation following surgery. lesion location was classed as t -l and l -s ; dogs were evaluated as one group and as two separate groups with respect to outcome. a subset of lesions were classed as cord compression or not based on advanced imaging. three repair techniques were evaluated (i) pins and polymethylmethacrylate (pmma); (ii) screws and pmma; and (iii) spinal stapling. regression analysis was applied to test for an association between the type of surgery and a successful outcome (non-painful and ambulatory). simple bivariate analyses were performed to investigate for variables predictive of a successful outcome. fifty-nine dogs were included. twenty-eight dogs were classed as t -l and were l -s . there were dogs with fractures and with luxations; dogs had both. thirty-one of dogs evaluated had spinal cord compression. ten dogs were repaired with im pins and pmma, dogs with screws and pmma and dogs with spinal stapling. overall, there was a . % success rate; there was no significant difference in outcome between the anatomic sites (p . ). all dogs initially graded as - pre-operation were classed as a successful outcome after at least one week following surgery; % of dogs initially graded as (plegic with pain perception) were classed as successful recovery. one dog ( . %) initially as graded as (plegic with no pain perception) had a successful outcome. a low admission score was statistically predictive of a successful outcome (p o . ). surgery type was not associated with a successful recovery (p . ). signalment, body weight, location of injury, injury type (fracture, luxation or both), presence of compression, and duration of disease did not predict outcome. from this study, the successful recovery of dogs following surgical fixation is high and is only dependent on the neurological score at the time of admission. the choice of surgical technique does not seem to influence outcome although a prospective study comparing two surgery types is warranted to further investigate this issue the results of which can be confounded by surgeon experience and variable follow-up. cranial thoracic intervertebral disc disease (ivdd) is extremely rare due to the presence of the intercapital ligament, although anecdotic data suggest german shepherd dogs (gsd) can share some predisposition for this disorder. the objective of the study was to retrospectively evaluate through mri if cranial thoracic ivdd is significantly more common in gsd compare to other large breed dogs. a search was done through database of the ontario veterinary college. any gsd were a spinal mri including t -t spine was performed was recruited. a group of large-breed non-gsd was used as a control. in the midsaggital t wi plane, three variables were assessed and graded for each intervertebral disc space t -t : spinal cord compression (scc), disc degeneration (dd), and herniation. wilcoxon sign rank test was used to assess if scores were different between groups. exact conditional logistic regression was used to determine whether any intervertebral disc space was a risk factor. gsd and large breed non-gsds were recruited. the gsd group had significantly higher scores than the non-gsd for scc, and herniation. regarding the individual intervertebral discs, in the gsd group t - , t - , t - discs had significantly an increased risk for scc, and t - for herniation. the results of this study show that gsd have a higher risk of cranial thoracic disc ivdd than other large breed dogs. that risk was higher in discs t -t , t - , and t - , particularly in t - . genetic and/or conformational factors, such as weakness of the intercapital ligament, may predispose gsd to this lesion. diskospondylitis is a common disease of the canine spine; however, few reports of mr imaging findings in dogs are available. the purpose of this study was to describe the signalment, clinical and mr imaging features in affected dogs. twenty-three dogs with a diagnosis of diskospondylitis based on clinical signs, mr imaging, and urine, blood, csf and/or intervertebral disk cultures were included. large breed dogs ( kg) accounted for of the cases. the mean age was . years with males and females equally represented. most dogs ( / ) were ambulatory with varying degrees of pain and paresis. mr imaging characteristics of sites were reviewed. on t w images, vertebral endplates were of mixed signal intensity ( / ) while the vertebral body was hypointense ( / ). the intervertebral disk space was hyperintense on t w ( / ) and stir ( / ) images and mixed signal intensity ( / ) on t w images. paravertebral soft tissue hyperintensities were noted on / t w and / stir images. contrast enhancement occurred at / endplates and / intervertebral disk spaces. only / vertebral bodies and / parvertebral soft tissues contrast enhanced. intramedullary spinal cord t w hyperintensity was noted at / sites. spinal cord or cauda equina compression occurred at / sites. based on the spearman correlation coefficient, a significant direct correlation was found between the degree of spinal cord or cauda equina compression and the patient's neurologic status (p . ). the incidence and severity of spinal cord compression in canine diskospondylitis may have prognostic value and may have been previously underestimated using other imaging modalities. hemilaminectomy and pediculectomy are both well described and commonly utilized techniques to access the spinal canal. these procedures are most often performed to approach a compressive lesion, such as intervertebral disc disease and neoplasia, the goal being adequate visualization of the spinal canal and access to the offending lesion. a proposed benefit of pediculectomy is preservation of the articular facets and thus better maintaining stability of the vertebral column, but at the cost of reduced access to the spinal canal. the purpose of this study was to describe standardized anatomical limits of each technique and report any observed differences that could be considered during presurgical planning. ten canine cadavers had both procedures performed on opposite sides to access the t - , t -l , and l - spinal canal. measurements were obtained after performing a computed tomography study of the spine and recorded from the transverse slice most representative of the defect. the surgical technique, vertebral site, and side of vertebral column were compared with the mean spinal canal and defect height using a covariate model. dorsal and ventral remnant lamina heights were also compared. the height of the defect relative to the spinal canal was - % with hemilaminectomy and - % with pediculectomy. the observed difference in defect height of - % (p o . ) and varied with spinal canal height. dorsal remnant lamina height was . - . % of spinal canal height with hemilaminectomy and - % with pediculectomy. ventral remnant lamina height ranged from - % and . - . %, respectively, though the difference was not statistically significant. while a larger defect is expected with a hemilaminectomy procedure, our results demonstrate that this difference increases with increasing spinal canal height. interestingly, the proportion of exposed spinal canal decreases with increasing canal height for both procedures. the difference in defect height between techniques was due to greater removal of the dorsal spinal canal, possibly making the hemilaminectomy technique better suited for more dorsal lesions, while no statistically difference in access to the ventral canal is observed. no effect of vertebral site was detected. of note was the involvement of articular facets in half of the pediculectomy defects, involving an average of % of the articular facet height. this result questions the suggested benefit for the vertebral stability, but further biomechanical studies would be required. low level laser therapy (lllt) is a treatment used in human and veterinary medicine for a variety of clinical syndromes. some uses in human medicine include acute pain associated with osteoarthritis, rheumatoid arthritis, tendonitis, tmj disorders, chronic joint disorders, and wound healing. research is currently on-going to determine the adequate wavelengths to promote effective treatment results with lllt in these conditions. it is purported that lllt acts via the mitochondria to increase cellular metabolism promoting wound healing and a decrease in pain and inflammation. in this study, we hypothesized that dogs treated with lllt in conjunction with hemilaminectomy would display quicker recovery times regardless of the presence or absence of deep pain sensation. seventeen dogs ( dachshunds, chihuahuas, french bulldogs, lhasa ahpsos, and each of a pembroke welsch corgi, and a miniature poodle) were selected and divided into two groups. the dogs ranged in age from to years old, weighed between and pounds, and underwent hemilaminectamies after acute onset of paraplegia secondary to intervertebral disc disease (surgically confirmed). one group received laser treatments on days through of hospitalization. the second group did not receive lllt, but followed the same peri-operative medication protocol. the laser used in this study was an erchonia laser model pl ( nm). the hertz setting was similar for each patient using the previously established protocol for intervertebral disc disease (ivdd) with pulse rate ranging from hz to hz. all dogs received advanced imaging pre-operatively with myelogram or mri. results of the study revealed that treatment with lllt of nm wavelength did not shorten or improve recovery times for dogs with acute onset paraplegia secondary to ivdd after hemilaminectomy procedures. dogs that showed recovery to ambulation at the two week recheck were consistently dogs that were deep pain positive on presentation. a lengthened recovery time or no recovery was seen in the majority of those dogs with absent deep pain on presentation as has been revealed historically in past studies. lllt did not appear to have an effect on this result. however, there are few data describing normal glucose uptake of the canine brain for comparison with suspected or confirmed disease. thus the purpose of this study was to assess the normal distribution of fdg uptake of canine brain structures using a high-resolution research tomography-pet and t-magnetic resonance imaging (mri) fusion system. fdg-pet and t -weighted mr imaging of the brain were performed on healthy laboratory beagle dogs. acquired pet and mr images were automatically co-registered by the image analysis software. on mr images, regions of interest (roi) were manually drawn over intracranial structures, including gross structures (whole brain, telencephalon, diencephalon, mesencephalon, dorsal metencephalon, ventral metencephalon and myelencephalon). a standard uptake value (suv) and relative suv ratio (rsuv suv of roi/suv of whole brain) were calculated for each roi. t-mr images compensated the low anatomical resolution of pet qj;by proving good spatial and contrast resolution for the identification of the clinically relevant brain anatomy. among gross structures, mesencephalon and ventral metencephalon had the highest (suv: . ae . ; rsuv: . ae . ) and the lowest (suv: . ae . ; rsuv: . ae . ) fdg uptake respectively. when suvs were calculated on detailed regions, rostral colliculus and corpus callosum had the highest (suv: . ae . ; rsuv: . ae . ) and the lowest (suv: . ae . ; rsuv: . ae . ) value respectively. these data acquired from normal dog brain will be used in clinical neurology to investigate various intracranial diseases such as inflammation, neoplasm and behavioral disorders. degenerative lumbosacral stenosis (dlss) is a multifactorial condition affecting predominantly large breed dogs. the combination of stenosis and compressive neuropathy cause lumbar pain, lameness and neurologic dysfunction. previous reports describe urinary and fecal incontinence in severely affected dogs. the objectives of this retrospective case series were to describe the clinical signs associated with dysuria and eventual diagnosis of dlss in dogs, and to describe factors associated with regained micturition following prompt diagnosis and treatment. medical records from the university of georgia and the university of missouri between and of dogs were reviewed. inclusion required observation of dysuria, urine retention, absence of structural lower urinary tract disease and concurrent presumptive diagnosis of dlss. dysuria was defined as inability to initiate or sustain a urine stream. urine residual volume was evaluated postvoiding. dysuria was further evaluated using urethral contrast studies, urodynamic testing (urethral profilometry ( ) and cystometry ( )), ultrasonography ( ), and urine culture ( ). presumptive diagnosis of dlss was based on imaging using plain radiography and epidurography ( ), computed tomography ( ) or magnetic resonance imaging ( ). breeds represented included the german shepherd dog (n ), golden retriever (n ), burnese mountain dog (n ), and each labrador retriever, weimaraner, rottweiler and mixed-breed. all dogs were male. were intact at onset of clinical signs. median body weight was . kg (range . - ) and median age was years (range - ). median duration of clinical signs prior to admission was months (range . - ). other pertinent presenting clinical signs included dyschezia ( ), fecal incontinence ( ), general proprioceptive ataxia ( ), weakness ( ), and difficulty rising ( ). physical examination findings included pelvic limb muscle atrophy ( ) and prostatomegaly ( ). abnormal neurologic examination findings included postural reaction deficits ( ), hyporeflexia ( ), decreased tail tone ( ) and lumbosacral hyperesthesia ( ). neurologic examination was normal in dogs. dorsal laminectomy was performed and diagnosis confirmed in dogs; recovery was monitored for a median of . months (range . - ). three of the dogs ( %) regained normal micturition within . - . months of surgery. though not statistically significant, dogs that regained micturition tended to have a shorter duration of clinical signs (median . months, range . - ) versus dogs that remained dysuric (median months, range - ). two of the dogs that regained micturition were neutered at the onset of clinical signs, but only of dogs that remained dysuric was neutered. signs improved in all dogs with postural reaction deficits and decreased tail tone. hyperesthesia resolved in of dogs ( %) and fecal continence returned in of dogs ( %). these findings suggest that following prompt diagnosis and surgical decompression, normal micturition could be regained in dlss affected dogs presenting with signs of dysuria. glycogen storage disease type ia (gsdia; von gierke disease) is an inherited metabolic disorder resulting from a deficiency of glucose -phosphatase-a (g pase). previous reports indicate that clinical manifestations of gsdia occur only in individuals with homozygous expression of a p.i l mutation. heterozygote dogs (het) have been previously reported to exhibit an overall normal outward phenotype. the purpose of this report is to briefly describe some differences that have been observed between het and homozygous wild type (wt) dogs. a colony of dogs at the university of florida contains a mix of affected, wt, and het individuals. in the course of studies designed to determine the effectiveness of gene therapy for correction of gsdia in dogs, both wt and het dogs have been utilized as controls. available information about body weights, clinical pathology tests, fasting studies, and liver biopsies was retrieved from records for both wt and het dogs and compared. although birth weights are similar, het dogs have a slower average rate of weight gain than wt dogs and this difference is especially prominent during the first few months of life (figure ) . in contrast to affected dogs, both wt and het dogs are able to maintain normal blood glucose concentrations for up to - hours of fasting, however, after longer fasts of - hours, het dogs have lower glucose and higher lactate concentrations (table ). in addition, liver biopsy samples from het dogs had greater apparent levels of glycogen suggested by pas staining than did samples from wt dogs, and this correlated with the results of proton magnetic resonance spectroscopy which demonstrated . times greater glycogen content in a liver biopsy sample from a het dog compared to a sample from a wt dog. together, these findings suggest that the level of g pase activity in heterozygote dogs does not provide a completely normal physiological, biochemical, or histological phenotype as previously reported. the glucokinase gene (gck) encodes an enzyme involved in cellular glucose-sensing mechanisms in pancreatic beta cells and hepatocytes. gck mrna is present in feline pancreas but the gene is not expressed in feline liver. hepatic gck expression is abundant in omnivores so its absence may reflect an evolutionary adaptation of strict carnivores, like feline species. we hypothesized speciesspecific features in the gck hepatic promoter may underlie the gene expression pattern observed in cats. the putative feline gck (fgck) promoter region was located using bioinformatic software to identify homology with human gck (hgck). genomic dna from a dsh cat was subjected to direct sequencing using a series of pcr reactions with speciesspecific primers. dna clones thus obtained were aligned to generate the feline sequence. direct sequencing yielded . kb of genomic dna sequence with high homology with sequences (acbe , acbe ) archived in the feline genome project. the feline sequence had six regions homologous with non-coding regions of hgck; four of these conserved regions are upstream of the putative fgck start. a . kb segment immediately upstream of feline hepatic exon is not present in hgck. the . kb insert is the reverse complement of a conserved sequence located downstream of exon in feline and human sequences. in conclusion, the putative hepatic promoter of fgck shares extensive homology with the hgck promoter but contains a . kb insert not found in hgck. functional studies are needed to confirm the role of the unique insert in regulation of fgck gene expression. deuterium oxide (d o) dilution has been proposed for quantifying body water content, but remains difficult to perform routinely. the objective of this study was to assess if the volume of distribution (vd) of creatinine could be proposed as an alternative in dogs for such a measurement. creatinine and d o vd were measured before (c) and after induction (o) of obesity (by giving an hypercaloric diet ( kcal/ kg) for months) in six healthy adult beagle dogs. creatinine ( mg/kg) and d o ( mg/kg) were simultaneously injected by bolus iv. blood was collected before administration and then at , , , , , , , , and min post-injection (creatinine), and , , , , , , and min (d o) . plasma concentrations of both markers were determined. vd was calculated using pharmacokinetic equations. the body weight increased from . ae . (c) (mean ae sd) to . ae . kg (o). d o vd decreased from ae (c) to ae (o) ml/kg. similarly, creatinine vd decreased from ae (c) to ae (o) ml/kg. the individual difference between creatinine and d o vd (expressed in % of d o vd) ranged from À . to . % (c) and from À . to À . % (o). in conclusion, creatinine vd provides a good estimate of d o vd in both normal and obese conditions. a wk double blinded study was conducted comparing the affect of two foods on mobility in dogs. all work was approved by an iacuc. healthy beagle dogs ( - years old, mixed gender) were used. affected (a) and non-affected (na) dogs were identified based on orthopedic examination and radiography as having or not having evidence of naturally occurring joint pathology (presence of osteophytes, dysplasia, effusion, pain on manipulation etc) in one or more joints. a and na dogs were evenly distributed between two locations. foods had nutrient profiles adequate for maintenance according to the aafco official publication. the test food contained greater amounts of methionine, manganese, carnitine, vit. e,, vit. c, alpha linolenic acid (ala), and eicosapentaenoic (epa) acid: the food provided mg n fatty acids and mg n fatty acids per kcal. all dogs were fed the control food for wks followed by a wk feeding period where a and na dogs consumed the test food and a and na dogs the control. blood and urine were collected at weeks , , and and analyzed for serum fatty acids and urine thromboxane:creatinine ratios were determined. evaluators in this study were different than those making the original diagnosis and so were blinded as to treatment and diagnosis. orthopedic exams were performed by two veterinary surgeons at each site on weeks , , and . the same two evaluators examined the same dogs throughout. the data was evaluated for the difference between a and na dogs and between foods with age, gender and location as covariates. body weight, disease status, age and gender were blocked. analysis included anova repeated measures mixed procedure (sas version . ) to determine treatment effects over time.serum epa was greater and arachidonic acid lower at weeks , and in the test food fed dogs (p o . ). urine thromboxane:creatinine ratios were decreased in the a dogs fed the test food compared to the a dogs fed the control food at wks (p o . ). lameness score was significantly improved (p o . ) within and between groups of dogs fed the test food. a significantly greater proportion of a dogs fed the test food had improvement in total het (n ) blood glucose (mg/dl) (ae ) (ae ) blood lactate (mmol/l) . (ae . ) . (ae . ) joint score, lameness, functional disability and overall assessment score at wks compared to a dogs fed the control food. % of a dogs had an improved overall assessment score on the test food after wks and at wks compared to % at wks and % at wks of a dogs consuming the control food. this study shows that a food with moderate amounts of added linolenic acid and epa can have a positive impact on systemic inflammation and mobility in - weeks. a similar abstract will be presented at the orthopedic research society meeting in january to an audience largely of orthopedic researchers interested in human orthopedics. fat is an important dietary component, serving both as a source of energy and as a supplier of essential fatty acids (fa). medium-chain triglycerides (mct) contain intermediate length fa that do not rely on l-carnitine for transport across the inner mitochondrial membrane, bypassing this rate-limiting step in fa oxidation. longchain (n- ) polyunsaturated fatty acids (pufa) from fish oil (fo), and in particular eicosanoids derived from eicosapentaenoic acid (epa), may protect against excessive inflammatory reactions, which may be exacerbated by eicosanoids derived from (n- ) arachidonic acid (aa). this study investigated the effects of adding mct:fo and l-carnitine to a control diet (prescription diet s k/d s ) on lean body mass, and serum fa and metabolites. forty healthy beagles ( . to . y) were fed one of three foods (n to dogs each) for mo. the study protocol was reviewed and approved by iacuc, hill's pet nutrition, inc. all foods were complete, balanced, and sufficient for maintenance of adult dogs; and had similar concentrations of moisture, protein, and fat (approx. . %, . %, . %, respectively). composition of serum fa was determined by gas chromatography of fa methyl esters. metabolomic profiles of serum samples were determined from extracted supernatants that were split and run on gc/ms and lc/ ms/ms platforms, for identification and relative quantification of small metabolites. body composition was determined by dual energy x-ray absorptiometry. serum concentrations of lauric and myristic fa increased; epa and dha increased in a dose-dependent manner; and aa decreased in dogs fed treatment food (proc-mixed procedure in sas; all p . ) when compared to dogs fed treatment foods or . serum concentrations of acetylcarnitine and succinylcarnitine increased, indicating lcarnitine incorporation, in dogs fed treatment foods and . thus, a diet enriched with mct:fo significantly altered serum fa composition, enriching (n- ) pufa and lowering aa concentrations. there was no change in lean body mass for any of the diets compared to baseline values, and no difference between treatments, showing that all three treatment foods met protein requirements. ten owned dogs, obese for more than months (body condition score [bcs] of ; fat mass [fm] . ae . %) were studied. these dogs had their weight reduced by % (bcs ; fm . ae . %; p o . ) being designated weight reduced (wr) group and then were fed to maintain constant body weight during days (bcs . ; p . ), designated maintenance (main) group. a control (ct) group of beagles was also included (bcs . ; fm . ae . %; p o . ). in all groups the glucose postprandial response test was performed after hours of fasting. blood samples were taken prefeeding and after , , , , , , , , , and minutes of the consumption of cooked rice enough to the ingestion of g of starch/kg body weight. tnf-a and il- were dosed in milliplex tm map panel, insulin and leptin by radioimmunoassay. statistical analysis included paired or non-paired t-tests and wilcoxon (p o . ). the regimen normalized meal glucose response, the area under the curve (auc) of glucose for wr was lower than for obese (p o . ) and similar to main and ct (p . ). insulin secretion did not normalize immediately, as obese and wr exhibited similar auc of insulin and higher values than for ct (p o . ). main, however, presented similar auc of insulin than ct, with lower values than obese and wr (p o . ), suggesting that dogs require some time to adapt their metabolism. leptin, tnf-a, and il- presented significant reductions after weight loss (p o . ), without differences between wr, main and ct (p . ), suggesting an improvement of the pro-inflammatory state consequent to obesity. studying food base excess (be) modification, methionine intoxication was described. in a basal kibble dog diet (be meq/kg; . g/kg of s) two dosages of ammonium sulphate and methionine was added, resulting in diets with be of meq/kg ( . g/kg of s) and À meq/kg ( . g/kg of s), or be of meq/kg ( . g/kg of s) and meq/kg ( . g/kg of s), respectively. a  factorial plus a control diet design, resulting in five treatments, and adult health beagle dogs were used, in a completed randomized design with six dogs per diet. a -d adaptation phase followed -d of total urine collection (in bottles with mg of thymol). urine were pooled by dog and analyzed for density, volume and ph. food macroelements were determined by standards methods (aoac, ) and used for be calculation. dog's acid-basic status was studied by blood gas analysis of venous blood, at : h (pre feeding) and hours after meal. a dose-dependent reduction of urinary ph was verified for both compounds (p o . ). blood bicarbonate (r . ; p o . ), and blood base excess (r . ; p o . ) were highly correlated with food be. acidemia and reduced blood be were verified in diets with be close to zero (higher dose of both compounds, or . g/kg of s), resulting in daily or each other day vomiting episodes in the dogs. ataxia, seizures, and vomiting were previously describe in dogs fed g/kg of methionine, but our results suggest that a much lower value ( . g/kg) was toxic and that the safe upper limit should be between this value and . g/kg (the lower evaluated dose). in people with chronic kidney disease and heart failure, obesity is associated with longer survival times. this association, called the "obesity paradox," also has been recognized in dogs and cats with heart failure. excess weight appears to modulate the serious deleterious effects of muscle loss in these diseases. the purpose of this study was to determine the effects of body condition and body weight changes in dogs with naturally-occurring chronic kidney disease (ckd). dogs diagnosed with ! iris stage ii ckd between and at iowa state university and tufts cummings school of veterinary medicine were eligible for the study. dogs o year of age and those with acute renal failure or suspected congenital renal diseases were excluded. medical records were reviewed using a standardized data form, and data were collected for initial body weight and body condition score (bcs, - scale), clinicopathologic values, changes in body weight and bcs, comorbidities, and treatments. dogs were classified as underweight (bcs - ), moderate weight (bcs - ), or overweight (bcs - ). a change in body weight was defined as . kg. survival times were determined for all dogs that were discharged from the hospital and lived day. associations between survival and bcs or body weight changes were analyzed using cox proportional hazards models. one hundred two dogs were enrolled in the study. at the time of diagnosis, dogs were classified as iris stage ii, dogs were stage iii and dogs were stage iv. median body weight at baseline was . kg (range, . - . kg). for dogs with body condition scores recorded (n ), were underweight ( %), were moderate ( %), and were overweight ( %). for dogs that had at least two body weights recorded over the course of their disease, gained weight, lost weight, and had no change in weight. changes in body weight were not associated with survival; however, bcs at the time of diagnosis was significantly associated with survival. dogs classified as underweight had a significantly shorter survival time compared to both moderate (p o . ) and overweight dogs (p o . ). these results suggest that body condition is an important consideration in dogs with acquired chronic kidney disease. further studies are warranted to evaluate the relationship between obesity and longer survival in dogs with ckd. protein restriction is the cornerstone of dietary management of kidney disease. the national research council recommends % crude protein and the american association of feed control officials (aafco) recommends a minimum of % crude protein for maintenance for healthy adult cats. protein requirement is unknown for adult cats with kidney disease. most commercially produced cat foods for adult maintenance contains % or more crude protein on a dry matter basis. a typical therapeutic food for cats with kidney disease contains about % crude protein. the objective of the present study was to investigate whether dietary crude protein at . % would be adequate for the maintenance for adult cats with impaired kidney function. seven adult cats, female and male, with age ranging from to . years old (mean: . years) were used in the study. all cats had elevated serum creatinine concentration ( . mg/dl, range: . - . mg/dl) and reduced glomerula filtration rate (mean: % reduction; range: - % reduction) during the study. they did not have other systematic diseases, e.g., hyperthyroidism, at the beginning of the study. cats were fed an expanded dry food made with ingredients commonly used in commercial dry cat foods. the food contained . % crude protein (chemical analysis) and kcal/kg (calculated) on a dry matter basis, or . g protein/ kcal. each essential amino acid in the food was at least % of that recommended by aafco. other nutrients in the food also exceeded aafco's recommendations for maintenance for adult cats. cats were fed the food for weeks. lean body mass (dual x-ray absorptionmetry; hologic, hologic, inc, ma) and serum albumin concentration were measured periodically to monitor protein status of cats. the average lean body mass (mean ae sd) was . ae . kg, . ae . kg, . ae . kg, and . ae . kg in weeks , , , and of the study, respectively. paired t-test did not detect statistical difference (p . ) when comparing the lean body mass in weeks versus weeks , , and , respectively. serum albumin concentration were within the normal reference range during the study (mean ae sd: . ae . %, . ae . %, . ae . %, and . ae . % in weeks , , , and , respectively) . these data show that . % dietary crude protein in a dry food with kcal/kg on a dry matter basis, or . g protein/ kcal, is adequate for maintenance for cats with impaired kidney function. in humans, several disease conditions exist that involve abnormal patterns of polyunsaturated fatty acids and similar abnormalities may be present in companion animals. indeed there have been reports of decreased plasma arachidonic acid and reduced delta- desaturase activities in dogs with atopy and other skin disorders. the present study investigated serum fatty acid profiles in dogs and cats presented to the texas a&m university veterinary teaching hospital, clinical pathology laboratory over the past one year period. results were compared with normative data generated among dogs and cats from earlier feeding studies. sera used were residual samples submitted to the laboratory for other diagnostic procedures and stored frozen for no more than months after collection. the samples were grouped according to presenting disorders involving liver, kidney, digestive, and cardiac diseases. total lipids were extracted using chloroform:methanol ( : v/v) and fatty acid methyl esters were prepared for capillary gas chromatography. relative percentage distribution of individual serum fatty acids for each animal were then compared with average normative serum phospholipid fatty acid values (dogs, n ; cats, n ) by calculating the ratio of the value in the diseased individual to the normal mean value and used as an index of normalcy. normalcy ratios were then plotted on a logarithmic scale with normal at . . the ratio was then compared to changes greater than , and standard deviations of the normal mean values. in this way a graphical presentation of resultant values was obtained. although the animals had been fed various commercial diets and some home-prepared foods, a number of noteworthy patterns emerged from this analysis. dogs showed increased linoleic acid, decreased arachidonic acid, increased total monounsaturated and decreased saturated fatty acids at p o . ; oleic acid was increased at p o . . remarkably, these findings were similar for all canine disease categories evaluated (n , heart; n , kidney; n , liver, and n digestive disorders). in cats, a slight decrease in arachidonic acid and large decrease in : was observed but only in heart disorders. by contrast, modest elevations of arachidonate were observed in kidney, liver, and digestive disease groups but at p o . . sample sizes of the feline sera were considerably smaller (range of - per group). a limitation of this analysis is that variability of normal data may exist depending on diet fed making comparisons less reliable however, these preliminary data suggest that metabolic diseases of dogs may depress plasma arachidonic acid independent of diet fed suggesting either reduced conversion from linoleic acid or increased utilization of arachidonate for eicosanoid production during times of metabolic stress. conversely, in cats, increases in arachidonic acid may be associated with diet arachidonate or other mechanisms. additional studies to verify these findings are warranted. the objective of this study was to determine whether or not lalanyl-l-glutamine (ala-gln) supplementation in dogs with parvoviral enteritis improves the survival rate and ameliorates clinical signs without side effects. this randomized, double-blinded, placebo-controlled clinical trial included client-owned dogs. the dogs were randomly assigned into two groups and administered ala-gln solution (dipeptiven; . g/kg) or an equivalent volume of placebo orally twice a day. all of the dogs (ala-gln group [n ] and placebo group [n ]) received standard treatment while hospitalized and were monitored daily according to a clinical scoring system and diagnostic evaluation for days. among the dogs, (ala-gln-treated group [n ] and placebo group [n ]) were vaccinated and (ala-gln-treated group [n ] and placebo group [n ]) were not vaccinated. the population consisted of purebreds and mixed breed dogs, with a mean age of . ae . weeks. the survival data were compared statistically by means of a log-rank test for the kaplan-meier survival curves. the clinical scores of ala-gln-treated dogs improved significantly relative to the placebo group. there was a significant difference between the two groups in the survival distribution (p . ); specifically, of the ala-gln-treated dogs ( . %) died, whereas of the dogs in the placebo group ( . %) died. no side effects were associated with the administration of ala-gln. these results suggest that the oral administration of ala-gln is effective in improving clinical signs and survival rate in dogs with parvoviral enteritis. bleeding disorders, thrombocytopenia and alterations in platelet function have been documented in humans receiving lipid-containing parenteral nutrition formulations. despite a lack of evidence in the veterinary literature, it is believed that parenteral lipids are contraindicated in critical illness when the development of bleeding disorders is likely. the objective of this study was to determine if there is an in vitro effect on platelet function and thromboelastography (teg) in normal dogs with varying concentrations of a % soybean oil emulsion (intralipid s ). twelve clinically healthy dogs were used for this study. whole blood platelet aggregation, using adp and collagen agonists, was measured using multiple electrode aggregometry in hirudinated blood with final lipid concentrations of , , , and mg/ml. the teg parameters r, k, a-angle, and maximum amplitude (ma) were evaluated from citrated whole blood with equivalent final lipid concentrations as platelet aggregation. there was no significant difference between groups with collageninduced platelet aggregation. there was a significant increase in the area under the curve (auc) with adp-induced aggregation at a lipid concentration of mg/ml (p . ). the ma was significantly reduced at both the mg/ml (p o . ) and mg/ml (p o . ) lipid concentration. there was no statistical difference between groups evaluating the other teg parameters. while platelet aggregation appeared enhanced at the highest concentration evaluated, this concentration is not clinically relevant. the reduction in ma seems discordant but both fibrinogen and platelets contribute to the ma. therefore the higher lipid concentrations may be interfering with fibrinogen kinetics or fibrinogenplatelet interaction. in vivo studies are indicated to determine if any of these changes are clinically significant. rosiglitazone is a peroxisome proliferator-activated receptor gamma (pparg) agonist and an fda-approved anti-diabetic agent in humans that has been investigated for its ability to reduce tumor cell growth. specifically, the combination of rosiglitazone and carboplatin has demonstrated enhanced tumor control. the purpose of this study was to determine the peak plasma concentrations and side effect profile of rosiglitazone after oral administration in dogs with spontaneously occurring cancer. all dogs received carboplatin intravenously concurrently with oral rosiglitazone. ten cancer-bearing dogs with normal pre-treatment hepatic and renal function were enrolled. complete pre-treatment hematological and biochemical parameters were available in ten dogs and post-treatment parameters in nine dogs. peak plasma concentrations varied with dose and ranged from . - . ng/ml and occurred between minutes and hours post administration and rapidly declined after the peak. the dose limiting toxicity was hepatic at a dose of mg/m . there was one grade iii, two grade i alt, and one grade iii ast elevations noted. no changes in total bilirubin, alkaline phosphatase, or ggt values were noted. blood glucose values remained within normal limits. mild, self-limiting gastrointestinal and hematologic toxicities were observed when rosiglitazone was administered in combination with carboplatin. based on this study, the recommended dose of rosiglitazone in cancer-bearing dogs with normal hepatic function is mg/m orally once daily. side effects of the combination appear similar to side effects noted with carboplatin alone. further study is needed to determine efficacy of this combination and if more frequent dosing is required to maintain plasma concentrations. carboplatin has shown little activity as a single agent for the treatment of canine transitional cell carcinoma (tcc). however, gemcitabine has shown synergism with carboplatin in human cell lines. the purpose of this study was to evaluate the activity of gemcitabine against canine tcc cell lines alone or in combination with carboplatin. we hypothesized that gemcitabine in combination with carboplatin would have synergistic effects in vitro. the results of this study could provide a rationale for treatment of canine tcc with the combination of these drugs. tcc cell lines tcc-kiss, tcc-knapp-js, tcc-axa, tcc-hxc, and tcc-sh were treated with gemcitabine, carboplatin, or the combination. cell proliferation was assessed using cyquant assay, cell cycle was evaluated using propidium iodide staining, and apoptosis was assessed by measuring caspase- / activation. synergy was quantified by combination index analysis using compusyn software. treatment of canine tcc cell lines with carboplatin or gemcitabine decreased cell proliferation, induced cell cycle arrest, and apoptosis. when tcc cell lines were treated with gemcitabine and carboplatin in combination at a therapeutically relevant concentration (gemcitabine o um, carboplatin o um), a significant decrease in cell proliferation was observed compared to gemcitabine or carboplatin alone, and the drug combination was synergistic in of cell lines, and additive in the remaining lines. gemcitabine exhibits biologic activity against canine tcc cell lines and carboplatin combined with gemcitabine exhibits synergistic activity at biologically relevant concentrations. our results support further evaluation of these drugs in dogs with tcc to determine the clinical efficacy of this combination. metronomic chemotherapy has been shown in murine models and humans to improve tumor control by inhibiting tumor angiogenesis and suppressing regulatory t cells (treg). treg are a subset of t lymphocytes demonstrated to be increased in humans and dogs with cancer and are thought to suppress cellular immune responses against tumors. the purpose of this study was to determine whether metronomic cyclophosphamide therapy depletes treg and/or exhibits antiangiogenic activity in dogs with soft tissue sarcoma. client owned dogs with histologically confirmed grade i or ii soft tissue sarcoma were administered cyclophosphamide at . mg/m or mg/m orally once daily for days. whole blood and tumor biopsies were obtained on days , , and . flow cytometric analysis of blood was performed to assess changes in t lymphocyte subsets, including cd and cd cells as well as cd foxp treg. tumor microvessel density (mvd) was assessed by performing immunohistochemistry for cd . five dogs were enrolled in the . mg/m /day dose cohort and six dogs were enrolled in the . mg/m /day dose cohort. in patients that received cyclophosphamide at . mg/m /day, the mean number of treg decreased from day to but there was no change in the mean percentage of treg or mvd. for patients that received . mg/m /day, both the mean number and percent of treg as well as mvd decreased over the day time period. cyclophosphamide at . mg/m /day or greater selectively depletes treg and inhibits angiogenesis in dogs with soft tissue sarcoma. arsenic trioxide (ato) is used to treat leukemias, multiple myeloma, and relapsed lymphoid malignancies in humans; its use has not been explored in veterinary oncology. prior therapy with glucocorticoids decreases likelihood and duration of remission for dogs with lymphoma treated with chemotherapy. we hypothesized that ato will re-sensitize glucocorticoid-resistant canine lymphoma cells to glucocorticoid-induced apoptotic death. the osw canine lymphoma cell line was cultured with um dexamethasone. remaining viable dividing cells were considered resistant. resistant cells were exposed to . um and . um of ato without dexamethasone, after which cells were washed and re-exposed to um dexamethasone. after , and hours of dexamethasone exposure, cells were counted using trypan blue stain. apoptosis was assessed by tunel assays on cytospin preparations collected at , , and hours from ato-exposed and control groups. statistical analysis was performed using way anova and tukey's test. the proportion of dead cells increased over time in both . um and . um ato exposed groups. the proportion of dead cells was greater for . um ato (p o . ) and . um (p o . ) groups compared to control. apoptosis increased with increasing ato concentration and duration of dexamethasone exposure compared to control. these results support the effectiveness of ato at re-sensitizing glucocorticoid-resistant canine lymphoma cells to apoptotic death following re-exposure to glucocorticoids. ongoing gene expression studies aim to elucidate this mechanism. additional studies to determine if this effect is seen with other chemotherapeutic agents are warranted. lymphoma is the most common hematopoietic tumor of dogs. protein disturbances may be associated with this disease including monoclonal gammopathies in a low percentage of cases. serum protein electrophoresis (spe) is routinely used to aid diagnosis of various canine diseases including lymphoma when total protein concentration is elevated. the purpose of this study was to compare spe changes in lymphoma patients without elevated total proteins with a population of healthy dogs. agarose gel electrophoresis was performed on residual serum from healthy control dogs and untreated dogs with multicentric lymphoma (stage iii -v) after measuring total protein (tp) using the biuret method. densitometric traces of the protein bands were obtained using computer software (totallab ) and the albumin, alpha- , alpha- , beta- and gamma globulin subfractions were identified by visual inspection. the total protein concentration, the number of subfractions and the relative and absolute protein subfraction concentrations were then compared statistically between the two populations. in lymphoma dogs, tp, absolute albumin, beta- and gamma globulin concentrations and both relative and absolute concentrations of the alpha- globulins were significantly lower however relative and absolute alpha- globulin concentrations were significantly elevated. no monoclonal gammopathies were identified in any of the dogs and not every patient with lymphoma had the above changes in their electrophoretogram. this study has demonstrated that significant changes occur in the albumin and globulin fractions of canine lymphoma patients despite no obvious increase in tp. further investigation is required to identify the proteins responsible for these changes. it is well known that immunophenotype has a prognostic value for the outcome of canine lymphoma, with t-cell lymphomas having a worse prognosis than b-cell lymphomas. the recent advent of flowcytometric techniques allowed easy detection of many different markers on lymphoma cells and therefore, not only distinguish between t and b cells, but also estimate possible aberration on immunophenotype. in human oncology, although some controversy persists, it seems that non-hodgkins lymphoma and acute leukemia carrying aberrations have a worse prognosis. the aim of this study was to evaluate the role of immunophenotype aberration in canine high-grade lymphoma considering outcome and time span to achieve complete response under chemotherapy. samples of bone marrow, blood and lymph node suspensions from twentythree dogs were evaluated with flow-cytometry. eleven dogs had aberrant expression of neoplastic lymphocytes and twelve were non-aberrant. the most common aberrations found were: positivity to cd , biphenotypes, double expression of tantigens (cd , cd ), diminished expression of cd . all dogs were treated with a chop-based protocol. there was a significant difference for the time to achieve response to chemotherapy (partial or complete). / non aberrant lymphomas went into cr or pr after the first treatment (l-asparaginase), while aberrant lympho-mas needed more than treatment to reach cr or pr. there was a trend for a prolonged disease free interval with non-aberrant versus aberrant, although it was not statistically significant. aberration of immunophenotype may be a prognostic factor for canine lymphomas, but further studies with larger groups are needed. class ii major histocompatibility expression is a significant and independent predictor of prognosis in human b cell lymphoma. low class ii mhc is consistently associated with poorer outcome. the mechanism underlying this relationship is not clear, but one hypothesis is that high class ii mhc allows for better antigen presentation and tumor-specific immune responses. in the this study, we investigated whether that class ii mhc expression in canine b cell lymphoma was associated with remission and survival times. a total of patients were categorized by level of class ii mhc,expression of cd and cell size for on neoplastic b cells. multivariable cox-proportional hazard analysis was used investigate this research question using a randomly selected subset of the data, and the predictive ability of this model was validated on the remaining / of patient data. results suggested that low class ii mhc expression was associated with decreased times to relapse and death as is seen in human b cell lymphoma, and that large neoplastic cells were associated with decreased survival time. cd expression was not associated with patient outcomes. these findings have implications for the use of dogs to model human lymphomas, for the study of tumor vaccines, and for prediction of mortality in dogs with b cell lymphoma with a high level of specificity. one of the reasons for the failure of canine lymphoma treatment is related to the resistance of tumor cells against chemotherapy drugs. the major form of this resistance is provide by multidrug resistance abc transporters. abc transporters proteins comprise a large superfamily of transmembrane proteins, atp-dependent, that extrude a large variety of drugs from the cells. multidrug resistance phenotype in cancer cells is associated with overexpression of these transmembrane proteins. abcg , also known as bcrp, is a residue half-transporter protein that protect hematopoetic stem cells against toxic compounds. the aim of this study was to investigate the expression of bcrp (abcg ) in canine multicentric lymphoma. samples were collected by fine needle aspiration of an enlarged lymph nodes, from dogs with multicentric lymphoma (stage iii to v) at diagnosis, and normal lymph nodes (control). dogs that were previously treated with prednisone or chemotherapy were excluded from the study. quantitative rt-pcr was used to measure the mrna expression level of bcrp and flnb expression as a endogenous reference canine gene. a widely range expression value for abcg expression was found for canine multicentric lymphoma. high gene expression was observed in % ( / ) canine lymphoma, but % of dogs had a lower expression when compared with normal lymph node. gene expression was not associated with clinical staging, complete or partial remission, relapse and survival time. in conclusion, abcg was expressed in canine lymph node and canine multicentric lymphoma at the diagnosis, and it was not correlated with clinical response. osteosarcoma (osa), the most frequent primary malignant bone tumor of dogs, is both locally aggressive and highly metastatic. prognostic factors for canine osa include tumor location, distant metastatic disease, and serum alkaline phosphatase (alp) concentration. an increased serum alp concentration is associated with poor prognosis; however the mechanisms underlying this phenomenon are currently unclear. during normal bone development alp may be used as a marker for osteoblasts. additionally, alp is a downstream target of activated canonical wnt/b-catenin signaling. therefore, we hypothesized that increased serum alp would be associated with increased expression of b-catenin in canine osa. the goals of this study were: ( ) characterize and compare cellular alp expression in osa tissue from patients with normal and high serum alp; and ( ) assess b-catenin expression in those same patient populations. we used frozen osa samples collected from patients with either high alp (n ) or normal alp (n ). total rna was isolated from the frozen tissue, converted to cdna, and analyzed using quantitative reverse-transcriptase polymerase chain reaction (qrt-pcr) with either target gene alp (aim ), or target gene b-catenin (aim ). additionally, b-catenin expression was analyzed by western blot. qpcr data for bcatenin and alp expression were normalized to s, and relative expression was calculated by the ddct method. the relative expression of cellular alp was higher in high serum alp samples compared to normal serum alp samples: . ae . (mean relative expression ae standard deviation; p o . ). further, the relative expression of b-catenin was also increased; b-catenin expression of high serum alp samples relative to low serum alp samples was . ae . (p o . ), which is also seen by western blot. this study begins to clarify the mechanism behind high serum alp in canine osa, and suggests the wnt signaling pathway may be active in this population of patients. further work will focus on elucidating the role active wnt signaling plays in the biology of osa. in the future, serum alp status of osa patients may help identify patients that would benefit from therapies targeting this pathway. accurate assessment of abdominal lymph node status is of vital importance for appropriate treatment planning and determining prognosis in dogs with apocrine gland adenocarcinoma of the anal sac (agaas). pretreatment knowledge of lymph node status is helpful for determining prognosis and planning the optimal extent of lymphadenectomy. in addition, pretreatment knowledge of lymph node status may help in selecting patients who might benefit from adjuvant chemotherapy and radiation therapy. abdominal ultrasound is currently the most commonly employed test to screen for abdominal lymphadenopathy in dogs with agaas. imaging studies in people indicate that magnetic resonance imaging ( to determine and compare the plasma concentration of cyclophosphamide and its metabolite -ohcp, within the plasma of lymphoma bearing dogs being treated with either oral or intravenous cyclophosphamide. in this prospective study, patients were randomly assigned to either receive oral or intravenous cyclophosphamide, at a dose of mg/m . based on a priori power calculation eight patients per treatment group were enrolled. plasma was obtained at times , , , minutes, and then at , , , , hours post administration for evaluation of -ohcp concentrations by liquid chromatography-dual mass spectrometry (lc/ms/ms). average values were obtained for both cyclophosphamide and -ohcp concentrations within the plasma of both groups. the following values were obtained, half life (hl), time to maximum concentration (tmax), maximum concentration (cmax), and area under the curve (auc). the mann-whitney statistical test was used to compare the groups. the auc for cyclophosphamide was statistically significant (p o . ) when compared between the two groups. the auc for -ohcp was not statistically significant between the groups. the difference between cmax for cyclophosphamide and -ohcp was statistically significantly (p o . ) between the groups. although the auc for cyclophosphamide was statistically significant between the two groups, the auc for the active metabolite -ohcp was not different when administered intravenously or orally. thus drug exposure to the active metabolite of cyclophosphamide is the same when administered intravenously or orally. previously the percentage of successful intraosseous (io) catheter insertions, insertion times, and ''ease of use'' scores using the ez-io g power driver by a wide spectrum of novice participants in feline cadavers were evaluated. novice users' mean io catheter insertion time using the ez-io g driver was also compared to the mean iv catheter insertion time in normovolemic feline and canine patients presented to the western college of veterinary medicine (wcvm) small animal hospital. novice users included wcvm personnel ( technicians, veterinary students, interns, residents, clinicians). after watching a -minute ez-io g training video, each participant inserted io catheters using the ez-io g driver. site (proximal humerus or trochanteric fossa of the femur) and side of cat (right or left) were randomized for each attempt for each participant. a gauge x mm long needle and a gauge x mm needle were used for io catheter insertion in the humerus and femur, respectively. participants then graded the ''ease of use'' of the ez-io g device on a visual analog scale (vas) that was converted to a -point scale. twenty-six iv catheter insertions in normovolemic feline and canine patients performed by wcvm small animal hospital personnel ( technicians, veterinary students, intern, resident, clinicians) were then timed and compared to the mean io catheter insertion time in feline cadavers by study participants using the ez-io g device. the io catheter was inserted correctly on every attempt by % ( / ) of participants. no difference was found between participant groups for mean io catheter placement confirmation percentage (p . ). percentage of io catheter ''slippage off the bone'' at the time of placement did not vary across participant groups (p . ). mean io catheter insertion times were all less than seconds and did not differ significantly as a function of attempt number (p . ) or as a function of participant group (p . ). participants rated the ez-io g 's ''ease of use'' favorably and subjective scores did not differ across participant groups with varying levels of clinical experience (p . ). compared to the mean insertion time for iv catheterization ( sec), mean io catheter insertion by participants using the ez-io g ( sec) was significantly faster (p . ). regardless of their level of clinical experience, participants rated the ez-io g device favorably in terms of its ''ease of use'' and their willingness to use the device in the future. regardless of their level of clinical experience, study participants successfully placed io catheters using the ez-io g device and did so significantly faster than the reported iv catheter insertion time in normovolemic feline and canine patients in the wcvm small animal hospital. intraosseous catheterization using the ez-io g has the potential to provide very rapid vascular access and is a skill that can be easily learned. previously presented at the western college of veterinary medicine undergraduate poster competition. multicavitary effusion is a common cause of presentation for dogs to emergency medical centers. the goal of this study was to identify common underlying causes of multicavitary effusion as well as determine their relative importance. a retrospective analysis of cases of multicavitary effusion admitted to the icu of a tertiary referral center (ontario veterinary college) from to was performed. twenty-three different breeds, with golden and labrador retrievers ( . % and %, respectively) being most commonly seen, were included in the study. ages ranged from to years with a median age of years and a mean of . years. . % of cases were males ( / cases). most common presenting signs included lethargy ( . %), anorexia ( . %), vomiting ( %) and dyspnea ( %). cavitary effusion was detected by either ultrasonography (pericardial, pleural or abdominal) or radiographs (pleural). bicavitary effusion was present in cases ( . %) whereas cases ( . %) had tricavitary effusion. neoplasia was found to be the most common underlying cause overall ( . %), with hemangiosarcoma being the leading type ( . % of neoplasia cases), followed by congestive heart failure ( . %), gastrointestinal lymphangectasia ( . %), peritonitis/pancreatitis ( . %), cirrhotic liver disease ( . %) and acute renal failure ( . %). in cases ( . %), no underlying cause could be found. of these, ( . % of all cases) were diagnosed as having idiopathic pericardial effusion. taken together, these findings suggest a strong association between multicavitary effusion and diseases carrying a guarded prognosis in dogs. infection control practices in veterinary clinics and hospitals are becoming increasingly important, with rising client expectations, growing concern about the spread of antimicrobial-resistant pathogens, and the potential for zoonotic transmission of disease. surgical patients are at increased risk of developing infections, and can serve as sources of these pathogens for other animals and people with whom they have contact within and outside the clinic. taking all reasonable precautions to reduce the risk of surgical site infections, beginning with preoperative preparation of the surgeon and patient, is therefore an important part of any infection control program. while guidelines are available for preoperative preparation procedures, there has been no objective investigation of compliance with these guidelines in veterinary practices. the objectives of this pilot study were to describe a range of preoperative hand scrub and surgical site preparation practices in veterinary clinics, and to determine if there were any areas that consistently require improvement. observation of preparation practices was performed in each of ten clinics over - days using - small wireless surveillance cameras. data was coded for surgical patients, and surgeons performing a total of hand scrubs. patient hair removal was most commonly performed after induction of the animal ( / , %) and using clippers ( / , %) . steps in surgical site aseptic preparation ranged from - . contact time with soap ranged from - s (mean s, median s), and with alcohol from - s (mean s, median . s). application of alcohol or antiseptic using a ''cleanest to dirtiest'' pattern was infrequent ( / ( %) and / ( %), respectively). potential contamination of the surgical site occurred most frequently when the animal was moved to the surgery table after initial preparation ( / , %). preoperative alcohol hand rub was used in / facilities, but soap and water hand scrub was still more commonly used even at these clinics. proximal-to-distal scrubbing was noted in / ( %) of soap and water scrubs. contact time during surgeon hand preparation ranged from - s (mean s, median s) for soap and water and from - s (mean s, median s) for alcohol-based hand rub. approximately % of the variation in contact time was due to inter-surgeon variation. no significant changes in practices were identified over the course of the observation period. some preoperative preparation practices were fairly consistent between clinics in this study, while others varied considerably. contact times with preparatory solutions were often far shorter than recommended, and there was a high frequency of non-sterile contact with the surgical site during movement of patients to the surgical suite. the camera system used to perform this study did not have a significant time-dependent effect on the behavior of participants, and could be useful for performing similar field-based observational studies in the future. this prospective randomized study compared the percentage of successful intraosseous (io) catheter insertions, insertion times, and ''ease of use'' scores using the ez-io g power driver to manual io catheterization in feline cadavers. the io catheter insertion time in cadavers using the ez-io g device was also compared to iv catheter insertion time in normovolemic feline and canine patients. after a purposely limited training period, a preclinical veterinary student was timed and video-recorded as she performed io catheter placements in feline cadavers ( io insertions by placing an illinois needle manually and io insertions using the ez-io g ). order of technique (manual or ez-io g ), site of io placement (proximal humerus or trochanteric fossa of the femur), and side of cat (right or left) were randomized for each attempt. when using the ez-io g , a gauge x mm long needle and a gauge x mm needle were used for io catheter insertion in the humerus and femur, respectively. after each attempt, the student graded the ''ease of use'' of each technique on a visual analog scale (vas) that was converted to a -point scale. twenty-six iv catheter insertions in normovolemic feline and canine patients performed by western college of veterinary medicine (wcvm) small animal hospital personnel ( technicians, veterinary students, intern, resident, clinicians) were then timed and compared to the student's mean io catheter insertion time using the ez-io g .median io catheter insertion times for the techniques were significantly different (manual io technique sec; ez-io g sec) (p o . ); the manual method took seconds longer ( % confidence interval of to seconds) than the ez-io g method. insertion time was more variable for the manual technique than for the ez-io g . percentage of catheter ''slippage off the bone'' and extravasation around the inserted catheter were significantly higher for placement of the manual io catheter compared with placement of the ez-io g catheter (p o . ). student's subjective ratings were more favorable and more consistent for the ez-io g technique compared to the manual technique for io catheter insertion. compared to the mean insertion time for iv catheterization in the wcvm small animal hospital, io catheter insertion by the student using the ez-io g was significantly faster (iv catheter sec; ez-io g io catheter sec) (p o . ). intraosseous catheter insertion using the ez-io g can be said to be significantly faster, less traumatic, more user-friendly, and as effective as io catheter placement using the manual technique. vascular access via io catheter insertion using the ez-io g device may be suggested to be faster than iv catheter insertion. previously presented at the western college of veterinary medicine undergraduate poster competition. computed tomography (ct) has been widely investigated and applied as a means for non-invasive quantitative bone mineral determination in human medicine. the aim of this study was to assess age-related changes and anatomic variation in bone mineral density (bmd) using quantitative ct in normal cats. seventeen normal cats were included in this study and divided into the following age groups: o year (n ); - years (n ); and years (n ). a computed tomographic scan of each vertebra from the th thoracic to the th lumbar spine, and the pelvis, was performed with a bone-density phantom ( , , and mg/cm , calcium hydroxyapatite, cirs phantom s ). on the central transverse section, the elliptical region of interest (roi) was drawn to measure the mean hounsfield unit value. those values were converted to equivalent bmd by use of the bone-density phantom and linear regression analysis (r . ). the mean bmd value of the thoracic vertebrae ( . ae . mg/cm ) was significantly higher than of the lumbar vertebrae ( ae . mg/cm ). the maximum bmd occurred at the t , t , and l levels in all age groups. there was a statistically significant difference in the mean bmd value among the age groups at the t (p o . ), t (p o . ), and l levels (p . ), respectively. in addition, there was no significant difference between the mean bmd value of the left and right iliac bodies ( . ae . mg/cm and . ae . mg/cm , respectively). the present study suggests that age-related changes and anatomic variation in bmd values should be considered when assessing bmd using quantitative ct in cats with bone disorders. dynamic contrast-enhanced computed tomography (dce-ct) is a rapid and widely available method of cerebral perfusion imaging. however, there is no established reference value of cerebral blood flow (cbf) measured by dce-ct according to a dog's age. the purpose of this study was to identify the correlation between regional cbf and aging in clinically normal dogs using dce-ct. fourteen dogs with no evidence of hemodynamic disorders and central nervous system dysfunction were included in this study. dogs were assigned to the following age groups: o year (group ); - years (group ); and o years (group ). dce-ct scans were performed at the level of the third ventricle and mesencephalic aqueduct. cbf in the gray and white matter was calculated using stroketool-ct s software. the overall mean ae standard deviation quantitative estimate for regional cbf in clinically normal dogs was . ae . ml/min/ g, . ae . ml/min/ g, and . ae . ml/min/ g in groups , , and , respectively. there was no significant regional cbf difference between the right and left sides of the brain in each group. also, a statistically significant difference in the regional cbf was observed between groups and (p o . ). thus, aging affects the regional cbf in normal dogs and the values should be considered assessing the results of dce-ct. according to several clinical behavior guidelines, ''toileting'' type inappropriate urination (i.e. large amounts of urine deposited in horizontal surfaces) can arise in cats suffering from a medical problem (typically lower urinary tract disease). by contrast, ''spraying'' type behaviour (i.e. possibly smaller amounts of urine deposited on vertical areas) is more typically associated with anxiety brought about by a threat to local resources, arising from either a change in the physical environment or threat to these resources from another cat. however, there is some evidence that ''sprayers'' may also be presented with a medical problem, which might be linked to the disease (e.g. painful voiding associated with crystalluria may lead to a standing posture being adopted and small amounts eliminated at a given time). this might be associated with an apprehensive state or simply a co-morbid state. as part of a larger research project aimed at investigating behavioral and physical aspects of cats presented with inappropriate urination, owners of ''spraying'' and ''toileting'' cats with appropriate control subjects from the same households were recruited throughout local media coverage and the internet. the case-control dyads were brought by the owners to the veterinary hospital of the university of sa˜o paulo, at the same time, for a medical work-up (i.e. physical examination, complete blood count, biochemical profile, urinalysis, urine culture and abdominal ultrasound). no significant differences between the ''sprayers'' and ''toileters'' regarding the occurrence of medical problems were found. both groups had a similar proportion of cats affected by medical illnesses (sprayers: . %, toileters: . %; chi , p . ), directly or indirectly relating to the urinary system (e.g. diabetes, chronic kidney disease). in both groups, control cats also had a relatively high occurrence of medical concerns ( . % and . %, respectively for each control group). these results emphasize the importance of careful medical evaluation of cats presented for a urinary housesoiling problem. the relatively high prevalence of medical concerns among apparently healthy cats in multi-cat households may have arisen, at least in part, as a result of an inability/failure of owners to monitor individuals, thus allowing some early signs to pass unnoticed. the way in which medical and behavioral elements are linked (if at all) remain unknown but deserve further investigation. considered as a semi-social species, domestic cats appear to be highly sensitive to the effects of social stress, especially when living in high density populations. cats are capable of adapting to live ingroup; nonetheless, they do not appreciate living in close proximity with others as result of an environment lacking of great opportunities of escaping and hiding. this study aimed at testing the following hypotheses: (a) owners' perceived quality of life affects cats' global levels of stress; (b) cats' global levels of stress are influenced by cats' personality; (c) cats' living style (single housing versus large group housing) does affect stress levels in cats. to our knowledge, this is the first study investigating stress levels of domestic owned cats, under natural conditions, throughout measurement of faecal glucocorticoids metabolites concentration, and taking into consideration cat personality, cat living style and owner's subjective life quality. in this study, adrenocortical activity, as a valuable physiological indicator of emotional stress, was evaluated throughout the measurement of faecal glucocorticoids metabolites in fourteen single and sixteen in-group housed cats. cat personality as well as owners life quality was evaluated by self reported questionnaires given to the owners to answer. significant differences in mean glucocorticoids metabolites concentrations (mgcm) between the two populations (i.e. single versus in-group cats) were not detected (random effect model, p . ). however, when mgcm were taken as a function of cat personality, there were differences regarding single catstimid cats showed higher levels in comparison to easy-going (random effect model, p . ) and bossy (random effect model, p . ) cats. as to owner subjective life quality, a direct association between the scores given by the owners to the social dimension and mgcm was found for single cats only (i.e. the better the owner felt itself social wise the higher the mgcm of the cat; random effect model, p . ). social stratification may compensate the stress resulting from spatial restriction in large in-group living cats. other underexplored factors such as feline personality and owner life style seem to play an equally important role in domestic cats' day to day levels of stress, especially in the cats kept as single pets. in dogs, raas activation is a major feature of congestive heart failure (chf). benazepril (fortekor s ) is a potent ace inhibitor with well-documented effectiveness in canine chf. although ace activity (ace a ) has been used in preclinical studies as a surrogate marker of efficacy, some authors have reported a poor correlation between plasma ace a and changes in angiotensin ii (aii) or aldosterone (al). the purpose of this study was to investigate the effect of benazepril on canine plasma renin activity/concentration (pra/prc), angiotensin i (ai), aii, al, and fractional excretion of potassium (ufek), sodium (ufena) and aldosterone (ufeal). sixteen beagle dogs were fed a low-sodium diet and dosed with placebo or benazepril tablets ( mg po, q h) for days. blood and urine samples were collected on day (d ) and day (d ) over -hour periods. data were analyzed by repeated measures anova of baseline corrected values, and anova of auc hours . compared with placebo, benazepril induced a significant increase in pra and ai at d (p-value [pra] : . , p-value [ai] : . ) and d (p-value [pra] : . , p-value [ai] o . ). no differences in prc were noticed. based on auc hours, aii levels were % lower in the benazepril group at d (p-value [aii] : . ). ufeal and al decreased by up to % and % at d and d , respectively, though differences did not reach statistical significance. benazepril markedly influences raas dynamics in dogs. decreased exposure to aii and al are likely to be the key events required to counteract pathological remodeling of the heart in chf. this study compared two intravenous anesthetic agents, alfaxalone (alf) (alfaxan s , jurox pty. ltd.) and propofol (ppf) (rapinovet s , schering plough animal health) and their effects on spontaneous ventilation after induction of anesthesia in dogs at various doses. this randomized, crossover, dose-escalation study used six dogs in weight and gender-matched pairs ( m- f). for each drug, each dog was dosed incrementally at , , , and times the labeled anesthetic induction dose rate (alf mg/kg, ppf . mg/kg) or until a dose was reached that rendered the dog apneic. a minimum of three days was allowed between doses. for each dose administration, the entire calculated dose was delivered constantly over min. the primary variable was apnea, defined as an absence of spontaneous ventilation for minute. apneic dogs were manually ventilated with oxygen until they resumed adequate spontaneous ventilation. once the apneic dose was determined for an individual dog for one drug, the dog began incremental doses with the alternate drug. for each anesthetic episode times were recorded from completion of induction dose to; removal of endotracheal tube, dog lifting head, dog attaining sternal recumbency and dog standing. pulse rate, respiratory rate, spo and etco were each measured every min. within-dog comparisons were made using the paired student's t-test. for both alf and ppf all dogs respired voluntarily at the labeled ( x) dose. for ppf at and x doses, and dogs respired voluntarily respectively. for alf at , and x doses, all , and dog respired voluntarily respectively. for all six dogs to become apneic required x dose of ppf and x dose of alf. the mean no observable adverse effect dose (noael) expressed as a multiple of the labeled dose was higher for alf ( . x) than for ppf ( . x) (p . ). there were no significant differences between times to extubation, head lift or attaining sternal recumbency after alf and ppf at , and x doses. at the x dose, dogs took longer to stand after alf ( . ae . min) than ppf ( . ae . min). we concluded that based on anaesthetic duration, the manufacturer's labeled dose rates of mg/kg for alf and . mg/kg for ppf were equivalent. however, based on the dose escalation, the number of dogs becoming apneic at each dose-multiple is consistent with ppf having a narrower safety margin, i.e., ppf caused more respiratory depression than alf. parenteral levetiracetam (lev) has been shown to rapidly attain therapeutic levels in dogs when given iv or im, and has been used offlabel for the treatment of seizure emergencies. the purpose of this study was to determine the safety and pharmacokinetics of subcutaneously administered levetiracetam in healthy dogs. potential application of these results would be use of sq lev instead of or in addition to rectal diazepam for the treatment of cluster seizures at home. lev was administered sq between the shoulder blades to healthy, purpose-bred hound dogs, at a dose of mg/kg (undiluted). blood samples were collected at , and minutes after lev administration via jugular venipuncture. plasma lev concentrations were measured by high pressure liquid chromatography. none of the dogs became sedated, nor was there pain evident on palpation of the injection site. mean (standard deviation) lev concentration was . ( . ), . ( . ) and . ( . ) mg/ml at , and minutes, respectively. administration of sq lev was well tolerated, and exceeded the suggested therapeutic range ( - mg/ml) within minutes of administration, and remained above the range for at least hours. these data indicate that sq lev administration may be an alternative for the at-home treatment of cluster seizures in dogs, and prospective studies in epileptic dogs are warranted. the purpose of this study was to assess the effects of cyp inhibitors (ketoconazole, chloramphenicol, fluoxetine, trimethoprim, cimetidine, and medetomidine) in varying combinations on the bioavailability of oral methadone in healthy greyhound dogs. the iacuc approved this study. cyp inhibitors were administered po for hours prior to methadone administration. methadone hydrochloride was administered po at a targeted dose of mg/kg. blood was obtained for the determination of methadone plasma concentrations by mass spectrometry. the area under the curve (auc) of methadone for each treatment group was compared statistically to the auc of methadone administered without inhibitors using the mann-whitney rank sum test. significant increases (p o . ) in the methadone auc occurred in all treatment groups which included chloramphenicol, including chloramphenicol as the only inhibitor. the magnitude of increase was at least fold. mean concentrations of methadone exceeded ng/ml for at least hours in all groups administered concurrent chloramphenicol. no significant increases in the auc occurred in any of the groups which did not include chloramphenicol. in conclusion, chloramphenicol significantly inhibits the metabolism of methadone in greyhound dogs. as a result, the oral bioavailability of methadone is significantly increased and plasma concentrations are achieved that are reported to be effective in humans for - hours after a single oral administration. doxycycline hyclate is used frequently in small animals, horses and exotic animals for treatment of a wide variety of infections. because doxycycline hyclate tablets may not be suitable for oral administration in some animals, particularly horses and cats, it has been compounded into liquid suspensions. the commercially available doxycycline calcium mg/ml oral suspension, vibramycin s (pfizer) is not suitable for use in animals due to its low concentration and flavoring that animals find unpalatable. because of the known inherent instability of doxycline in aqueous vehicles under storage, this study was conducted to determine the potency of two formulations stored in dark and light conditions. a high pressure liquid chromatography (hplc) assay with uv absorption at nm was developed for analyzing doxycycline in formulations, in comparison to a reference standard from the united states pharmacopeia (usp). doxycycline hyclate mg tablets were first tested for potency. the tablets were then crushed and mixed with a pharmaceutical vehicle to make two concentrations: . mg/ml and . mg/ml. the vehicle used was a : mixture of a vehicle for oral solution (ora-sweet, usp-nf) and vehicle for oral suspension (ora-plus, usp-nf). the suspensions were prepared in replicates of . each replicate was divided, with one aliquot stored at room temperature in lighted conditions, and the other aliquot stored at room temperature in the dark. doxycycline was extracted from the formulations and measured by hplc at day , , , , , , and . each replicate was tested and the potency reported as the percent doxycycline relative to the usp reference standard. on day , , , and , the potency of each formulation was within - % of the reference standard (range . - %). this value is within the accepted range cited in usp o on pharmaceutical compounding-non-sterile preparations. however, starting at day , the potency declined dramatically and remained low for the tests performed on day and . the potency on day , , and was below % of the reference standard (range - %). there was also a noticeable change in the quality of the formulation starting on day , and a change in the color of the formulation to a dark brown. these results indicate that when doxycycline hyclate tablets are compounded as a suspension in an aqueous vehicle as described in this study, at . and . mg/ml under the storage conditions used in this study, potency of the formulation cannot be assured beyond days. we recommend a beyond-use-day (bud) of days for formulations prepared and stored at room temperature in light or dark conditions. therapeutic options for multidrug resistance (mdr) escherichia coli urinary tract infections (uti) are limited. fosfomycin (fos) tromethamine is an oral, broad-spectrum, cell-wall active, bactericidal drug approved for treatment of uncomplicated uti in humans. the purpose of this study was to determine time dependency of fos and the disposition of fos tromethamine in dogs. using a randomized, double crossover design, client-owned dogs received fos sodium iv ( mg/kg) and fos tromethamine (po, mg/kg) either with (n ) or without food (n ). serum and urine were collected for hr; fos was quantitated with a bioassay (atcc e. coli , serum or atcc proteus vulgaris , urine). in-vitro killing curves (cell counts through hours) were performed at (control), . , , , , and x mic for mdr e. coli canine fos susceptible (e-test s ) uropathogens. killing curves indicated fos to be time dependent. after iv administration, clearance (mlÃkg/hr), volume of distribution (l/kg), elimination half-life (hl; hr) and mean residence time (mrt, hr) were (mean ae sd): ae , . ae . , . ae . , . ae . and . ae . , respectively. for po, c max , hl and mrt were ae , . ae . and . ae . , respectively. serum fos exceeded the mic reported for multidrug resistant (mdr) e. coli ( . mg/ml) for hr (iv; . mg/ml) and hr (po, mg/ml diminazene is an aromatic diamidine, anti-protozoal drug that has shown promise in a small number of cases of cytauxzoonosis. in a noncontrolled case series, of cats with clinical cytauxzoonosis given mg/ kg of diminazene aceturate survived infection. dosage frequency was two intramuscular injections given one week apart. commercial formulations contain the diminazene diaceturate salt. the active base is diminazene with the salt consisting of two aceturate molecules. currently there is no data available on the pharmacokinetics of either diminazene compound in cats. the objective of this study was to determine the pharmacokinetics of diminazene diaceturate in healthy cats. four purpose bred cats with normal physical examination, cbc, chemistry and urinalysis were used. a powdered commercial drug formulation (veriben s , ceva sanet animale) was freshly reconstituted with sterile water to a concentration of mg/ml prior to administration and sterile filtered solution. heparinized blood samples were collected just before (hour ) or . , , , , , , , , , , , , and hours after intramuscular administration of mg/kg ( . mg/kg of diminazene base) diminazene diaceturate. the plasma was separated by centrifugation within minutes of collection and frozen (À c) until analysis. concentrations of diminazene were measured by hplc analysis using uv absorption and ion-pairing conditions. the pharmacokinetic profile was analyzed using a simple one-compartment model. in these cats, diminazene had a mean terminal half life (t / ) of . ( /- . ) hrs and mean peak plasma concentration (c max ) . ( /À . ) mg/ml. the mean residence time (mrt) of diminazene was . hrs ( /À . ). systemic clearance (cl/f) was . ( /À . ) l/kg/hr. the volume of distribution per fraction absorbed (vd/f) was . ( /À . ) l/kg. a single intramuscular dose of diminazene diaceturate was well tolerated by all cats. without knowing the concentration required to inhibit or kill cytauxzoon felis, it is not yet possible to make suggestions regarding optimum dosing schedules for this drug. additional toxicology data and studies to assess clinical efficacy for the treatment of cytauxzoonosis are indicated before routine clinical use can be considered. meloxicam has been shown to accumulate in areas of inflammation in both the rat and human. the objective of this study was to investigate the concentration of meloxicam in synovial fluid of inflamed joints versus that of non-inflamed joints in dogs. eight male dogs were treated with . mg/kg of meloxicam on day one and . mg/kg of meloxicam on day two. all treatments were administered orally. on day three reversible acute synovitis was induced in one stifle by aseptic, intra-articular administration of ml sodium urate crystal suspension ( mg/ml). in four dogs synovitis was induced in the l stifle and in four dogs the same procedure was used in the r stifle. in each dog the stifle without induction of synovitis served as the ''normal'' joint sample. a synovial fluid sample was collected from both the r and l stifle of each dog. sample collection occurred eight hours after administration of sodium urate and twenty four hours after the last administration of meloxicam. synovial meloxicam concentration was analysed using high performance liquid chromatography-mass spectrometry (hplc/ ms-ms). the concentration of meloxicam in the inflamed versus non-inflamed joint in each dog was compared using the paired t-test. the results indicate that meloxicam preferentially accumulates in inflamed joints in the dog as meloxicam concentrations are statistically significantly higher in inflamed joints than in non-inflamed joints. no national surveillance system exists for monitoring emergent resistance in companion animals. however, e. coli resistance is an increasing therapeutic and public health concern in these in dogs and cats. the purpose of this study was to describe current resistance patterns of canine and feline pathogenic e. coli throughout the united states and identify risk factors of antimicrobial resistance. isolates (n ) of clinical e. coli collected from dogs or cats from may through may located in different regions. susceptibility was determined to drugs ( drug classes) by broth microdilution methods. pharmacodyamaic statistics were described regionally. phenotypes were determined and type of resistance was based on the number of drug classes to which resistance was expressed: none (ndr), single (sdr) and multi (mdr). the majority of isolates were from urinary tract ( . %) and dogs ( . %). the proportion of resistance type for each drug was: ndr ( . %), sdr ( . %) and mdr ( . %). the proportion of mdr was greatest in the southwest ( . %) and least in the northwest ( . %) (p o . ). for all regions, the proportion of resistance was: cephalothin (cph, . %) amoxicillin-clavulanic acid (amx, . %), ampicillin (amp, . %), tricarcillin-clavulanic acid (tcx, . %), doxycyline (dxy, . %) cefoxitin (cfx, . %), cefpodoxime (cpx, . %), chloramphenicol (chp, . %), enrofloxacin (enr, . %) , ciprofloxacin (cif, . %), trimethoprim-sulfamethoxazole (tmx, . %), ceftazidime(cfz, . %), gentamicin (gtm, . %), cefotaxime (cft, . %) meropenem ( . %) (p o . ). the mic exceeded the resistant breakpoint for amp, amx, cpx, cph, cif, cfx, dxy and enr whereas mic did not surpass the susceptible breakpoint. beta-lactams ( . %) was the most and aminoglycosides the least ( . %) sdr. the drug class most frequently involved in mdr was beta-lactams ( . %) and least, gen ( . %). resistance differs regionally, being greatest in the southwest. cph is the most and meropenam is the drug least associated with resistance; these patterns are consistent with current drugs used by veterinarians. the fluoroquinolones (fqs) are common choices for treatment of e. coli urinary tract infections (utis) in animals and humans. nd generation drugs approved in animals include enrofloxacin (enr), marbofloxacin (mar), orbifloxacin (orb); human drugs include ciprofloxacin (cip). rd and th generation fq for humans include moxifloxacin (mox), gatifloxacin (gat) and ofloxacin, (ofl]), its lisoform levofloxacin (lev). for animals, pradofloxacin (pra) is approved for use in europe. the purpose of this study was to assess the in vitro activity of st (naladixic acid [nal] through th generation fqs (n ) toward dog or cat e.coli uropathogens (n ). isolates were subjected to susceptibility testing to drugs classes ( drugs). isolate phenotypes included no (ndr; n ), single (sdr; n ) or multidrug (to more than drug classes; mdr; n ) resistance (including enr resistant [enr r -mdr; n ] or enr susceptible (enr s -mdr, n ). the minimum inhibition concentrations (mics) were determined for each isolates using broth microdilution (e. coli atcc s served as a negative control). mic statistics were generated for each drug among phenotypes. the overall potency (mic ) for all enr susceptible isolates (ndr, sdr and enr s -mdr) was gat pra, mox, mar, lev, cip sar, orb, ofl enr nal. each e. coli isolate expressing ndr or sdr was susceptible to all fq. however, isolates expressing resistance to st or nd generation fq were also resistance to later generation drugs. glucocorticoids (gc) are standard therapy for allergic asthma but do not reverse the underlying type i hypersensitivity. allergenspecific immunotherapy (asit), a process of ''desensitization'', is potentially curative but requires identification of offending allergens. the purpose of this study was to determine if oral or inhaled gc administered at routinely used dosages would interfere with allergen identification. we hypothesized that oral but not inhaled gc would interfere with accurate identification of allergen-specific ige using skin and serum testing in experimentally asthmatic cats. asthma was induced in eighteen cats using bermuda grass allergen (bga). cats (n /group) were randomized to receive oral gc ( mg prednisolone q hr po), inhaled gc ( ug budesonide q hr) or placebo (gelatin capsule q hr po) for one month. intradermal skin testing (idst) and bga-specific ige amounts were measured prior to, during (weeks one and four) and every two weeks after treatment until both tests were positive. a paired t test was used to compare serum ige among groups pre-and post-treatment (p o . significant). idst reactivity was eliminated in / cats on oral gc, / on inhaled gc, and / placebo-treated cats. within two weeks after stopping treatment, idst was again positive in all cats. contrary to our hypothesis, serum ige reactivity to bga was not significantly diminished by any treatment. in conclusion, a two week withdrawal from gcs is adequate for idst identification of allergen but no withdrawal is required prior to serum ige testing to identify the sensitizing allergens. previously in people, increasing severity of asthma is associated with low serum concentrations of -hydroxyvitamin d ( -oh-d). -oh-d is thought to ameliorate lower airway inflammation primarily by decreasing the production of pro-inflammatory mediators, and by increasing the production of the anti-inflammatory cytokine il- . in people, serum -oh-d concentration is associated with sunlight exposure as well as dietary intake. cats do not rely on sunlight for vitamin d synthesis; all vitamin d comes from dietary intake. cats have a naturally occurring lower airway disease syndrome (lad) that shares many features with human asthma. the goal of this study was to evaluate serum -oh-d concentrations in cats with lad. cats with naturally developing lad were enrolled. criteria for a diagnosis of lad included a history of cough, wheeze or respiratory distress, radiographic evidence of a bronchial pattern and hyperinflation, negative heartworm antigen and antibody test, and a resolution of clinical signs in response to glucocorticoids. dietary history was obtained. -oh-d concentrations were determined on serum samples by a commercial laboratory. twelve cats with lad were enrolled. all cats ate commercial cat food. the median -oh-d concentration was nmol/l with a range of - nmol/l which is within the reported reference range of - nmol/l. in contrast to human asthma, lower airway disease in cats is not associated with low serum concentrations of -oh-d. interstitial lung diseases (ild) are uncommon in dogs, with the most commonly recognized ild idiopathic pulmonary fibrosis (''westie fibrosis''). in human medicine, ild represent a large umbrella of pulmonary diseases, with ipf only a subset. other, more treatable, ilds are also identified, and may respond to either the removal of a stimulus (hypersensitivity) or steroid therapy. the goal of this report is to describe the clinical course, including outcome, computed tomography and histopathology of dogs affected with an ild. the computed tomography (ct) log was reviewed for dogs that underwent thoracic ct scanning for evaluation of respiratory signs, and had changes consistent with ild as the primary abnormality, including the presence of diffuse disease in all lobes, and at least of the following: reticulation, ground glass opacity, consolidation, or traction bronchiectasis. survival time from ct date was calculated. the presence of moderate pulmonary hypertension [phtn] ( mmhg) as estimated by tricuspid regurgitant jet, was also reported and survival times were compared with a mann-whitney rank sum with p o . considered significant. thirteen dogs were identified. terriers and chihuahuas were the most commonly affected breeds. two dogs were adolescents, the remaining dogs ranged from - years, with a median of years. histopathology results (n ), including moderate to severe interstitial fibrosis ( ) alveolar proteinosis with fibrosis ( ), and interstitial eosinophilic pneumonia ( ). one had suspected cryptogenic organizing pneumonia and had a good response to glucocorticoids. eight dogs died of respiratory failure, with a median post ct survival time of days (range - ), two dogs died of non-pulmonary disease, dogs had severe lower respiratory infections as puppies with persistent respiratory signs, and both are still alive at years since diagnosis, terrier is alive at months and was lost to follow up. dogs had phtn, with a median survival of days ( - ), while the dogs without had a survival of days (range - ), [p . ]. interstitial lung disease in dogs is not just idiopathic pulmonary fibrosis. following respiratory infection, young dogs may develop an ild with a relatively indolent course and rare ild is steroid responsive. ct is useful to identify ild but further research correlated with echocardiography and histopathology is advised to use it to prognosticate. idiopathic pulmonary fibrosis (ipf) is an interstitial pulmonary disease, mainly described in west highland white terriers (whwt). identification of molecular pathways important in the pathogenesis of ipf would improve our understanding of this disease and may help identify therapeutic targets. the aim of the present study was to investigate gene expression in lungs of whwt with ipf using oligonucleotide microarray. total rna was extracted from post-mortem pulmonary samples from five whwt with ipf and five control dogs (ctrl) without pulmonary disease. the rna was pooled from each group (ipf and ctrl) and analysed using the canine specific affymetrix microarray technology. genes with a minimum of a two-fold difference in expression between the two groups were selected for further analysis. the most significant biological functions for these genes were identified using ingenuity pathways analysis. more than genes were identified as having greater than twofold difference in expression. the significant biological functions associated with these genes were related to cellular movement, cellular proliferation and apoptosis. most notable among these were genes encoding the leukocyte chemotactic proteins: ccl (fold change . ), ccl ( . ) and il ( . ); the proteins involved in fibroblast migration; and the matrix metalloproteinases (mmps) involved in matrix degradation: mmp (À . ), mmp (- . ), mmp (À . ). this study has identified genes which may be important in pathogenesis of ipf, e.g. proteins involved in leukocytes chemotaxis, fibroblast recruitment and activation, regulation of apoptosis, and extracellular-matrix turn-over. however, real-time quantitative rt-pcr studies are needed to confirm these results before any definitive conclusions can be drawn. idiopathic pulmonary fibrosis (ipf) is an interstitial disease, mainly described in west highland white terriers (whwt). defini-tive diagnosis ultimately relies on lung histopathology. identification of specific biomarkers would be very helpful. expression microarray is a powerful screening tool to study local gene expression in a disease state. the aim of the present study was to measure gene expression profiles in lungs of whwt with ipf to identify potential blood or bronchoalveolar lavage fluid (balf) biomarkers. total rna was extracted from post-mortem pulmonary samples from five whwt with histopathologically confirmed ipf and five control dogs (ctrl) without pulmonary disease. the rna was pooled from each group (ipf and ctrl) and analysed using the canine specific affymetrix microarray technology. ipa-biomarkers analysis (ingenuity system) was used to filter and prioritize biomarkers candidates using the three following criteria: a minimum of a two-fold difference in expression between ipf and ctrl; expression of the gene in lung tissue; possible detection of the protein in blood or in balf. fifty-four molecules met all the criteria. based on difference in expression, promising proteins included ccl (fold change . ), a -actinin ( . ), ccl ( . ), serum amyloid a ( . ), il ( . ), plunc (À . ), mmp (À . ). some are well-known biomarkers of ipf in humans either for diagnosis (mmp , il ) or prognosis (ccl ). these results provide novel potential biomarkers of canine ipf. measurement of these proteins in blood and balf of healthy dogs, dogs with ipf and with other respiratory diseases is needed to assess their use as biomarkers of canine ipf. heliox is a mixture of helium and oxygen that has been used therapeutically in human medicine for treatment of airway obstruction. helium's low density and other physical properties have been shown to reduce the work of breathing by limiting turbulence. the purpose of this study was, therefore, to evaluate respiratory parameters in response to inhaled heliox in dogs with meso-and brachycephalic conformation. eleven healthy dogs were recruited, five were mesocephalic and six were brachycephalic. flow-volume loops were collected using commercial software (buxcor) while breathing : helium: oxygen (heliox) and : nitrogen:oxygen (nitrox) in a randomized order via a low dead-space face mask. due to the intrinsic gas properties, gas flow rates and volumes were corrected in-vitro by a conversion factor for the effect of helium on the pneumotachograph. respiratory rate, tidal volume (ml), minute ventilation (l), inspiratory time (ti), expiratory time (te), peak inspiratory flow (pif) and peak expiratory flow (pef) were recorded while breathing heliox or nitrox. values were compared using a paired sample t-test, with p o . considered significant. all dogs cooperated with testing. there was no significant difference in respiratory rate, tidal volume, minute ventilation, inspiratory or expiratory times, or peak inspiratory flow. peak expiratory flow was significantly higher (p . ) while breathing heliox than when breathing nitrox in brachycephalics but not in mesocephalics (p . ). heliox is well-tolerated in healthy dogs and results in an increased expiratory flow rate in brachycephalic dogs. further investigation of heliox is warranted in dogs with airway obstruction. of this prospective multicentric study is to assess the effects that surgical correction has on the severity of clinical signs and levels of acute phase proteins (c-reactive protein [crp] , haptoglobin [hp]) and cardiac troponin i (ctni). thirty three brachycephalic dogs with boas were included and evaluated before and, approximately two months, after surgical correction. the most common components of boas found were elongated soft palate ( / ; %), stenotic nares ( / ; %) and everted laryngeal saccules ( / ; . %). staphylectomy was performed by means of two different surgical techniques: laser (n ) or electrical scalpel (n ). there were significant differences between dogs depending on the surgical technique used, with a higher reduction of respiratory signs (p o . ) and a better postsurgical improvement (p o . ) with the use of laser. the levels of crp, hp and ctni were categorized into normal or elevated. before surgical treatment three ( . %), six ( . %) and thirteen ( . %) dogs had elevated values of crp, hp and ctni, respectively. two months after surgical correction, five ( . %), eleven ( . %) and fourteen ( . %) dogs had elevated values of crp, hp and ctni, respectively. there were no statistical differences between values of crp and ctni before and after surgical correction but the levels of hp increased significantly after surgical treatment (p o . ), probably due to postsurgical treatment with corticosteroids. as previously suggested by others, there was a statistically significant reduction of respiratory and gastrointestinal signs in dogs with boas submitted to surgical correction (p o , ). according to the results obtained in the present study, the determination of crp, hp and ctni before and two months after surgical treatment do not have a prognostic value in dogs with boas. even though, near half of the dogs studied had elevated levels of ctni ( . %) that persisted after surgical treatment ( . %), suggesting some degree of myocardial damage is present. further studies are needed considering the influence of breed and age. to the authors' knowledge, this is the first description of crp, hp and ctni determination in dogs with boas. overweight and obesity are common conditions that lead to alterations in respiratory mechanics, airway resistance, pattern of breathing and gas exchange in humans. the objective of the present study was to investigate if there are significant differences on respiratory parameters and arterial gas analysis of obese and overweight cats, in conscious state and under general anesthesia. twenty nine adult cats were arranged in three groups: obese (n ), overweight (n ) and with ideal body score index (bsi) (n ). mean of bsi in the groups were: , (obese), , (overweight) and , (ideal bsi). cats did not had respiratory, cardiac or others systemic diseases. the respiratory parameters were evaluated with a ventilometer equipment coupled to facemasks in conscious cats and directly to the endotracheal tube in anesthetized cats under spontaneous respiration. the anesthesia was performed with propofol ( ae , ml/kg) and the cats were maintained in the same anesthetic plan. the three groups were compared by analysis of variance followed by tukey's test and conscious and anesthetized cats were compared by student's t test, with a % significance level. there were not observed differences on the respiratory parameters evaluated on ventilometry (tidal volume, expiratory and inspiratory times and peak pressures, respiratory rate and partial pressure of end tidal co (petco )) and on arterial gas parameters (pao e paco ) in the three groups. the pao of cats with ideal bsi was , ae , mmhg, although was not significantly different (p , ) from overweight ( , ae , mmhg) and obese cats ( , ae , mmhg). comparison of anesthetized to conscious cats, it was detected decreases in tidal volume, expiratory and inspiratory times and peak pressures and increase in petco in respiratory rate in the anesthetized cats. only petco , inspiratory time and respiratory rate in overweight cats did not differ in anesthetized cats. these results suggest that obesity and overweight did not result in impairment of respiratory function in cats and propofol induced respiratory depression. osteosarcoma (osa) is the most common bone tumor in dogs, however, little is known regarding the mechanisms underlying malignant transformation in these tumors. breeds such as rottweilers and greyhounds are at higher risk for developing osa, suggesting that heritable factors play a role in this disease. mirnas have tumor/tissue specific roles in regulating gene expression and dysregulated mirna expression is found frequently in cancer. we hypothesize that canine osa is characterized by a unique mirna expression profile(s) with dysregulation of some mirnas being associated with specific breeds. mirna expression profiling of primary osa tumors from greyhounds and rottweilers was performed using the nanostring technologies ncounter mirna expression assay kit, interrogating the mirna expression profile of human mirnas, of whose mature sequences are % conserved between human and dog. mirnas were differentially expressed in greyhound versus rottweiler tumors (p o . ), suggesting that breed-specific dysregulation of mirnas may contribute to the development and progression of spontaneous osa. hierarchical clustering revealed distinct mirna expression signatures in greyhound osa tumors as compared to rottweilers. based on these preliminary results, we are evaluating a larger cohort of osa tumor samples including greyhounds, rottweilers, golden retrievers, and a mixed population of other breeds. statistical analysis will be performed to determine the association of mirna transcript levels with specific breeds and overall outcome. characterization of mirna expression in canine osa will facilitate our understanding the biology of this disease and has the potential to identify targets for therapeutic intervention. originally combination therapies using drugs with documented single-agent activity and lack of overlapping toxicities could potentially improve outcome. the hypothesis intended to be tested is that palladia s can be safely administered concurrently with a standard weekly protocol of vinblastine (vbl), at dosages known to have activity against mast cell tumors. dogs with histologically confirmed measurable mast cell tumors were evaluated for eligibility to enter a standard phase i dose-finding trial ( cohort), at a starting dose of . mg/m iv vbl (weekly for a total of treatments) and . mg/kg po palladia s eod, concurrently. dose escalation of palladia s was scheduled in . mg/kg increments until mtd was established or fda label dose completed ( . mg/kg). safety evaluation was performed weekly throughout the week study period. dose-limiting toxicities were described following established vcog-ctcae(v . ) criteria. while antitumor response is not a primary endpoint of phase i trials, activity was documented prior to vbl treatments - , and monthly thereafter, based on recist criteria. nine dogs have been enrolled; cohort is filled and approaching completion of the evaluation period. hematologic dose limiting toxicity led to de-escalations of vbl. the current safe combination appears to include vbl at . mg/m every other week and palladia s at . mg/kg eod. response was seen in all but one dog. without head to head trials comparing efficacy of bi-weekly vbl combined with palladia s and vbl alone, choice of therapy should remain at the clinician's discretion. originally prostate specific membrane antigen (psma) is a transmembrane protein expressed by tumor-associated neovasculature, but not normal blood vessels. based upon its selective expression in endothelial cells associated with cancer, psma may serve as a conserved angiogenic target shared by macroscopic solid tumors of various histologies. to investigate the feasibility of targeting a homogenous population of psma-expressing endothelial cells as a novel anticancer strategy, we have investigated psma expression in several canine hemangiosarcoma (chsa) cell lines, and subsequently developed self-assembling nanoparticles containing diagnostic (near infrared dyes) and therapeutic (doxorubicin) cargo which selectively bind to psma by means of the a aptamer, a commercially-available oligonucleotide. the expression of psma by chsa cells was confirmed transcriptionally and translationally by real time pcr and immunohistochemistry, respectively. selective binding and endocytosis of a decorated nanoparticles was studied by fluorescent microscopy. the ability of a decorated nanoparticles encapsulating doxorubicin to exert in vitro cytotoxic effects in chsa cells was assessed by colony forming assays. using a chsa xenograft murine tumor model, clinically-relevant anticancer effects of a decorated nanoparticles encapsulating doxorubicin were tested. all chsa cell lines expressed psma mrna and protein. a decorated nanoparticles were selectively endocytosed by psma-expressing cells, and when these nanoparticles encapsulated doxorubicin, significant cytotoxic effects were exerted in vitro. finally, a decorated nanoparticles encapsulating doxorubicin significantly reduced the size of macroscopic chsa tumor burdens in transplanted mice. diagnostic and therapeutic nanoparticles can be targeted to psma-expressing endothelial cells, and chsa provides a comparative model for the future study of nanoparticle therapeutics. canine transitional cell carcinoma (tcc) is the most common tumor of the urinary tract, and is similar to human invasive tcc in histopathologic characteristics, molecular features, sites of metastasis, and response to medical therapy. prevalence is increasing, and novel therapies and strategies are needed to effectively treat this aggressive form of cancer in both species. personalized medicine techniques intend to improve treatment outcome by using patient tumor profiling to identify potential and individualized therapeutic targets. a genomic algorithm has been developed termed ''coexpression extrapolation'', or coxen, that aims to use expression microarray data to predict drug activity in patient tcc samples. the utility of this predictive methodology has been established in other types of cancer in vitro, however its clinical utility has not yet been determined. validation studies of coxen in canine tcc cell lines were conducted. the goal was to determine the value of coxen in predicting baseline sensitivity of canine tcc to chemotherapy agents (gemcitabine, mitoxantrone, carboplatin, vinblastine and cisplatin) that would then be used in a proposed clinical trial. additionally, expression data from canine treatment-naı¨ve primary tumor samples were generated on an affymetrix array platform (canine genome v . ). both the expression data and tcc cell line data (antiproliferative effects, % growth inhibition or gc ) were used to establish a canine specific predictive coxen algorithm. coxen scores for canine tcc cell-line drug activity were then analyzed. scores predicted the activity of cisplatin, gemcitibine, and mitoxantrone in all cell lines, and of carboplatin in cell lines. because all of the cell lines were sensitive to vinblastine (gi o . mm), the coxen score was not predictive of its potency. interestingly, coxen fails to predict vinblastine response in human tcc cell line data as well. in concurrent work, comparative genomic studies to define and compare the gene expression signatures of tcc in dogs and humans provides further evidence that canine tcc is a valuable genomic model of the human disease. current studies involve testing the chemo-predictivity of this derived canine coxen algorithm in additional canine tcc cell lines. canine tcc offers an excellent model for in vitro and in vivo studies of the coxen approach. this preclinical work will be used to guide the feasibility of future coxen clinical trials in dogs and humans with tcc. a small molecule complex (aminoact) isolated from bovine milk is a natural peptide mixture with multi-kinase inhibitory effects against epidermal growth factor receptor (egfr) and insulin-like growth factor receptor- (igfr- ). ingestion of aminoact in people with cancer results in lower serum tnf-alpha, an increase in antioxidant superoxide dismutase (sod) enzyme activity, and subjects' blood serum causes apopsotis in cancer cell lines. this study was designed to first assess safety and secondly the efficacy of three dosage levels of ax- in sustaining progression free survival (pfs) for dogs with refractory advanced and/or metastatic cancer. the prospective, open label study included dogs of different breeds with naturally occurring histologically confirmed malignancies. the first dogs received aminoact at g/m ; the second group of dogs subsequently received the same dosage mg of aminoact; and the third group of dogs subsequently received g/ m . each dog was treated orally daily for six weeks along with mg betaine hcl, that aids in peptide absorption. all patients were evaluated for toxicity using the vcog-ctcae and efficacy using the recist criteria via assessment of clinical parameters, blood work and client questionnaires. no toxicity other than mild, transient (grade i) nausea was noted, nor were there any changes in hemograms or biochemical profiles in any patient. dogs with tumors that were confirmed as responders ( % reduction in size) include pulmonary adenocarcinoma, mast cell tumor, trichoepithelioma and soft tissue sarcoma. it appears in limited studies that the response rate may be more durable at higher dosages. the response to aminoact is dose dependent and only transient mild toxicity was observed, which suggest the maximum effective dosage has not been reached. further clinical studies will be valuable in determining the effective dosage and response duration. treating cancer in dogs with aminoact offers a unique opportunity as a model for human cancer biology and translational cancer therapeutics. stereotactic radiation therapy (srt) combines patient immobilization, image guidance, and intensity modulated delivery to achieve ablative radiation doses within the tumor, while preferentially sparing surrounding normal tissues. the purpose of this study was to evaluate the efficacy of srt as a means of achieving local tumor control for canine nasal tumors. retrospective analysis was performed on dogs with a nasal tumor confirmed by histopathology and computed tomography, no previous surgical or radiation therapy, at least six months of follow-up, and completion of three fractions of srt at csu.srt was administered via the varian trilogy linear accelerator once daily for three consecutive days. the varian eclipse treatment planwas reviewed to determine the planned target volume (ptv) and dose to % of the ptv. kaplan-meir survival analysis was performed for disease free interval (dfi) and overall survival (os). sixteen patients with nasal tumors ( adenocarcinoma/carcinomas, squamous cell carcinomas, chondrosarcomas, osteosarcomas, and undifferentiated sarcoma) were treated with srt. a median dose of . gy was administered to % ptv with a median ptv of . cc. srt was well tolerated by the normal tissues with minimal, manageable side effects. to date, the median dfi is days, while the median os is days. based upon the initial clinical experience, stereotactic radiation therapy is an emerging modality in the management of canine nasal tumors. canine leptospirosis can vary from subclinical infection to illness that ranges from mild to severe, including death, depending on the susceptibility of the dog, virulence of the organism, and route and degree of infection. the objective of this study was to evaluate the ability of a canine leptospira bacterin to prevent infection and disease following challenge with virulent leptospira canicola, l. pomona, l. grippotyphosa, or l. icterohaemorrhagiae. groups of week-old beagles were vaccinated (day ) and boosted (day ) with placebo (n ) or the -way bacterin (n ! ) and subsequently challenged with each serovar. the results demonstrated that blood and various tissue samples from placebo-recipients became reliably infected, and the dogs developed typical clinical signs of leptospirosis including loss of appetite, ocular congestion, depression, dehydration, jaundice, hematuria, melena, vomiting, petechiae, and death. in addition, placebo-recipients developed kidney and liver dysfunction. in contrast, some vaccine-recipients became infected, but the organisms were cleared quickly from the blood. vaccinated dogs failed to develop severe clinical disease requiring medical intervention, and no animals died (p ! . ). a few of the vaccinated dogs developed clinical abnormalities, but the clinical signs remained mild and were self-limiting (p o . for each serovar). administration of the bacterin also prevented thrombocytopenia ( ciprofloxacin, a synthetic fluoroquinolone antimicrobic, is not fda-approved for veterinary use. however, due to recent availability of less expensive generic formulations, extra-label use of ciprofloxacin by veterinarians appears more common. although ciprofloxacin crystalluria and uroliths have been reported in humans, we are unaware of any published reports in dogs. this is surprising since mean urine ciprofloxacin concentration ( . mg/ml) in dogs following a modest iv dose ( mg/kg) was times higher than the solubility of ciprofloxacin in water ( . mg/ml). to identify the occurrence of ciprofloxacin uroliths in dogs, records from the minnesota urolith center were reviewed. between january and december , ciprofloxacin was identified in uroliths from dogs; uroliths were composed of % ciprofloxacin in , mixed uroliths containing ciprofloxacin were identified in , a shell of ciprofloxacin was observed in , and ciprofloxacin surface crystals were identified in . based on an experimental study in which % of human volunteers consuming mg of ciprofloxacin with nahco exhibited ciprofloxacin crystalluria (urine ph . ), while no volunteers consuming mg of ciprofloxacin and nh cl to acidify urine formed crystals; we postulated that ciprofloxacin uroliths could be dissolved in acidic urine. to test this hypothesis, canine uroliths composed of % ciprofloxacin from a single source ( -yr-old male, english bulldog receiving mg/kg of ciprofloxacin po, q hr to manage superficial pyoderma; turbulent flow chromatography/tandem mass spectrometry detected mg of ciprofloxacin/g of urolith) were incubated in urine at selected ph's and monitored for dissolution. urine obtained from multiple dogs not receiving fluoroquinolones, was pooled and divided into aliquots. aliquots were adjusted with hcl or naoh to a ph of , , , , or . aliquots were capped and preserved by refrigeration; ph was monitored and readjusted weekly. ten uroliths of approximately equal weight were randomly assigned to individual flasks containing mls of urine. flasks were constantly agitated and maintained at c. every hours, urine was discarded and replaced with mls of urine of identical ph until stone dissolution was complete. ciprofloxacin urolith dissolution times at each urine ph are reported below. ciprofloxacin uroliths are a newly recognized disease and a potential adverse effect of ciprofloxacin administration in dogs. in vitro dissolution of ciprofloxacin uroliths was achieved in canine urine, supporting the premise that in vivo dissolution is possible. urolith dissolution times were shortest at lower and higher ph's, which is consistent with the pka ( . and . ) of this amphiprotic antimicrobic (more soluble at ph below the acidic pka and above the alkaline pka). foods designed to promote struvite urolith dissolution may be designed for short term feeding facilitating rapid dissolution or may be formulated with a more moderate target urine ph to allow for dissolution and then life-long maintenance feeding minimizing recurrence. the purpose of this study was to compare the efficacy and rate of dissolution of a maintenance food with a struvite dissolution food. sixteen client-owned adult cats ( fs, mc) with naturally occurring struvite urocystoliths (mineral composition based on history, radiographs, urinalysis, urine culture and physical examination) were randomized to either a dry maintenance food (test) or a dry food known to dissolve struvite uroliths (control). the clinical care team and owner were blinded to treatment assignment. the test food was formulated to provide . % mg (dm), . % p, % protein, and a calculated target urine ph value (uph) of . - . . the control food was formulated to provide . % mg (dm), . % p, % protein, and a targeted urine ph of . - . . owners were advised to feed the assigned diet exclusively in an amount to maintain body condition. after diet assignment radiographs were performed at eight weekly intervals until there was no evidence of uroliths or until there was evidence that the uroliths were the same size or larger. a physical examination, complete blood count, serum chemistry profile, urinalysis and urine culture were repeated at the conclusion of the study. statistical analysis was by anova. all uroliths dissolved in all cats and both foods were palatable. radiographs of cats fed the control food indicated the uroliths dissolved in a significantly shorter time (mean ae std dev of . ae . weeks) compared to cats consuming the test food (mean . ae weeks; po . ).). cats in the control group finished the study at (n ), (n ) and weeks. cats in the test group finished the study , , (n ), , , , and weeks. all the minnesota urolith center occasionally receives uroliths for analysis that are immersed in formalin. results of quantitative analysis of these uroliths revealed that some submitted in formalin consisted of newberyite (magnesium hydrogen phosphate trihydrate). because newberyite is uncommonly found in uroliths formed by cats and dogs, we hypothesized that this mineral was an in vitro artifact caused by exposure of struvite (magnesium ammonium phosphate hexahydrate) to formalin. the purpose of this study was to determine if formalin alters the mineral composition of uroliths. urolith submissions containing stones of either % struvite (n dogs and cats), % calcium oxalate (n dogs and cats), % calcium phosphate apatite (n dogs and cats), % cystine (n dogs and cats), % ammonium urate (n dogs and cats), and % silica (n dogs) preserved by only air drying were tested. one urolith from each submission was quantitatively analyzed by polarized light microscopy or infrared spectroscopy. a subsequent urolith from the same submission was immersed in ml of % buffered formalin for hours at room temperature. uroliths were then air dried for minutes and the analysis was repeated. after exposure to formalin, portions of all struvite uroliths were transformed into newberyite. three ( dog and cats) of ammonium urate uroliths were completely dissolved. newberyite was not detected in any of the remaining uroliths. likewise quantitative mineral analysis of non-struvite uroliths remained unchanged. to avoid misdiagnosis of mineral composition, uroliths should not be immersed in formalin prior to analysis. we previously reported that transfusion to normal dogs of autologous erythrocyte concentrates (prbcs) that had been stored for days causes a profound inflammatory response ( x increase in leucocyte count and fibrinogen, x increase in c-reactive protein). we speculated that inflammation was due to cytokines produced during the storage period, and hypothesized that transfusion of fresh (f) prbcs would elicit less inflammation than would stored (s) prbcs. a whole blood unit was collected from healthy dogs (n ) for prbcs on day , then again on day . on day dogs received an autologous transfusion of prbcs stored for either days (s, n ) or days (f, n ). cbcs and in-tem thromboelastometry (ct:coagulation time, cft:clot formation time, a:alpha, mcf:maximum clot firmness) were evaluated on blood samples collected at (pre) and , , , , and hours after transfusion. fresh prbcs did not elicit any change in leucocytes, platelets, or thromboelastometry. stored prbcs elicited a degenerative left shift ( hr) followed by a regenerative left shift ( - hr), thrombocytopenia ( % decrease at hr), and marked hypocoagulability characterized by prolonged ct ( , , hr) and cft ( , hr), and decreased a ( , hr) and mcf ( , , hr). data are mean(sd). a: p o . between groups f and s by t test. b: p o . compared to '' '' by rm anova. transfusion of autologous stored prbcs elicits a greater inflammatory response than fresh prbcs, and results in hypocoagulability on thromboelastometry. clopidogrel is a potent antiplatelet drug that is gaining popularity in veterinary medicine for antithrombotic therapy. the parent molecule is an inactive prodrug that must be converted by hepatic isozymes to an active metabolite. the majority of the parent molecule is directed to the formation of inactive metabolites with only an extremely small proportion of parent molecule directed to the formation of the active metabolite. there are multiple hepatic isozymes responsible for the formation of the active metabolite. a non-specific hepatic isozyme inducer such as rifampin could increase the formation of the active metabolite of clopidogrel thereby increasing the pharmacodynamic response which may allow a reduced drug dose to achieve a clinical effect. we have previously presented data supporting the increased pharmacodynamic response of clopdiogrel after rifampin therapy. the goal of this study was to demonstrate an increased pharmacokinetic response of clopidogrel after rifampin induction of hepatic isozymes. six healthy, purpose-bred dogs were used for this study. the pharmacokinetics of clopidogrel were determined by measuring the parent molecule, primary inactive metabolite and active metabolite through lc/ms/ms. the pharmacodynamics of clopidogrel were determined by measuring collagen-induced whole blood aggregation. blood samples were collected prior to clopidogrel administration (baseline), after days of mg/kg clopidogrel po q hrs, and after days of mg/kg clopidogrel po q hrs mg/ kg po q hrs rifampin. given the absence of a known standard for the active metabolite, only a semi-quantitative assessment of active metabolite concentration can be made. there was no identifiable active metabolite peak noted at baseline or after clopidogrel treatment. however, with clopidogrel and rifampin combined administration there was an active metabolite peak identified in all dogs with a mean area of . ae . . the development of the active metabolite peak was associated with an increase in the pharmacodyamic response of clopidogrel in the dogs. this is the first study in any species to document the increased formation of the active metabolite of clopidogrel in response to a strong, non-specific hepatic isozyme inducer. this increased pharmacokinetic response was associated with an increased pharmacodynamic response of clopidogrel. this data provides supportive evidence to develop therapeutic protocols to improve the pharmacodynamic response to clopidogrel in dogs that may reduce dosing requirements or correct subtherapeutic pharmacodynamic response. critical illness-related corticosteroid insufficiency (circi) has been identified in humans, foals, dogs and cats with lower-thanexpected circulating cortisol concentrations, and/or by a blunted cortisol response to acth stimulation. our purpose was to determine if circi exists in critically ill horses. endogenous plasma acth and serum cortisol concentrations, and cortisol at t and t min after . mg/kg cosyntropin, were measured by radioimmunoassay from horses with colic or systemic illness on admission, and days , and of hospitilization. horses were divided into mild, moderate, or severe illness groups based on clinicopathologic data. inappropriately low cortisol was defined as endogenous cortisol o mean- sd achieved after administration of . mg/kg cosyntropin to normal horses ( o nmol/l). inadequate delta cortisol was defined as o mean delta cortisol in normal horses after . mg/kg cosyntropin ( o nmol/l). cortisol, acth and delta cortisol were compared using anova between groups, with p o . considered significant. fifty-eight horses classified as having mild ( ), moderate ( ) and severe ( ) disease at admission had survival rates of %, % and % respectively. admission acth and cortisol concentrations were highest in severely ill horses ( ae pg/ml, ae nmol/l) compared to moderate ( ae , ae ) and mildly ill horses ( . ae . , ae ). admission cortisol concentrations were higher overall in severely ill horses (p . ), but were low in % ( / ). admission delta cortisol was low in % ( / ) of severely ill horses, and was associated with marked adrenal hemorrhage in non-survivors. severely ill horses have high cortisol and acth, but low cortisol and delta cortisol may indicate circi secondary to adrenal hemorrhage. equine pituitary pars intermedia dysfunction (ppid) is a common endocrinopathy of aged horses that results from neurodegeneration of the dopaminergic periventricular neurons that innervate the intermediate lobe of the pituitary. factors that initiate spontaneous dopaminergic neurodegenerative disease remain elusive, however accumulation of misfolded a-synuclein protein and dysfunctional protein clearance have been implicated. misfolded protein accumulation occurs due to increased protein production or decreased clearance of damaged macromolecules through the process of autophagy. while have previously demonstrated that horses with ppid have increased asynuclein in the periventricular neurons compared to controls, it remains unknown whether the protein accumulates due to increased production or decreased clearance. we hypothesized that autophagy is decreased in the pituitary neurointermediate lobe from horses with ppid compared to controls. neurointermediate lobe pituitary tissue was from collected from horses with ppid (n ) and healthy horses (n , - years). realtime pcr was used to determine the relative expression of autophagy genes (mtor, beclin , atg , atg , atg , pink, lamp ) and a-synuclein relative gene expression from horses with ppid were compared to healthy horses by t-test following log transformation. a pearson coefficient of correlation was calculated comparing a-synuclein expression with autophagy gene expression. the expression of a-synuclein, autophagy-related genes (atg , beclin, lamp ), and mtor was greater in horses with ppid than in healthy horses. age was not correlated to a-synuclein or autophagy gene expression. there was a significant positive correlation between expression of a-synuclein and beclin , atg , atg , atg , and pink, but not mtor expression. accumulation of a-synuclein protein in horses with ppid may result from increased a-synuclein expression. autophagy genes are upregulated in horses with ppid, suggesting a compensatory response, although these findings need to be confirmed by demonstrating an increased functional response. asynuclein expression was positively correlated to expression of autophagy genes except mtor, suggesting a-synuclein may stimulate autophagy in an mtor independent manner. acvim forum session a efficacy of delayed antiviral therapy against ehv- challenge. lk maxwell , ll gilliam , n pusterla , r carmichael , rw eberle , jw ritchey , tc holbrook , t gull , gb rezabek , d mcfarlane , cg macallister . oklahoma state university, stillwater, ok. university of california, davis, ca. equine herpes virus type- (ehv- ) outbreaks are often not recognized until exposed horses are at immediate risk for developing equine herpes myeloencephalopathy (ehm). the objective of this study was to determine whether delayed therapy with the antiviral drugs valacyclovir or ganciclovir could protect those horses most at risk for ehm. eighteen aged ( years) mares were randomized to treatment: no therapy (control), oral valacyclovir therapy, or intravenous ganciclovir therapy. drug administration was initiated at the onset of the second febrile phase, between days - after ehv- inoculation (pi), and continued for one week. neurological examinations were performed prior to the study and for three weeks pi. one horse was excluded from the study for failure to become febrile. body temperature was significantly lower in the ganciclovirtherapy horses as compared to control horses on days - pi (p o . ), whereas valacyclovir-therapy horses did not differ from control horses. viremia in whole blood, as determined by pcr, was also lower in the ganciclovir-therapy horses on days - pi and on day pi in the valacyclovir-therapy horses (p o . ). although antiviral drug administration did not reduce the risk of ataxia (p . ) or nasal shedding, ganciclovir therapy did decrease the severity of ataxia (p o . ) as compared to valacyclovir-therapy and control horses, where / , / , and / horses, respectively, developed at least a two grade change in ataxia. in summary, ganciclovir administration provided better protection against ehm than did valacyclovir when therapy was initiated just prior to the onset of neurological disease. equine vaccination is amongst the most important method of prophylaxis against equine influenza virus (eiv), a pathogen in which continuous antigenic drift can lead to vaccine failure. a month duration of immunity (doi) challenge infection study was conducted using commercial inactivated vaccines containing different strains of a/equine/ /influenza virus's, including innovator tm , containing kentucky/ (pfizer animal health, new york, ny), and calvenza, containing a combination of ohio/ , kentucky/ , and newmarket (boehringer ingelheim vetmedica, st. joseph, ms) . the challenge virus strain was colorado/ , the most contemporary challenge strain currently in use. the study design was a blinded, randomized challenge trial. three groups of yearling ponies, with no history or serological evidence of eiv infection were established. each group received one of three treatments: vaccination with innovator tm ; vaccination with calvenza tm ; or injection with a saline placebo. each treatment was administered times, at intervals of month between the first two treatments, and months between the second and third treatments. all ponies were challenged by nasal nebulization of x eid influenza virus a/eq/ /colorado/ months after the third treatment. clinical signs of disease, including rectal temperature, nasal discharge, anorexia, coughing, and depression, were recorded daily for days prior to challenge infection, and days post-challenge. nasal shedding of eiv was measured on the same days, using a realtime pcr test procedure. eiv-specific antibody responses were measured by elisa. differences between groups were analyzed by non-parametric repeated measures anova, and differences were declared significant when p o . . all control group ponies demonstrated clinical signs of disease consistent with eiv infection post-challenge infection, including pyrexia, nasal discharge, inappetance and partial anorexia. these signs were significantly lower in both vaccine groups; mean body temperature was elevated ( . f) for days in controls, but only days in vaccine groups. nasal shedding of eiv was detected in all ponies in all groups: over the duration of the study the calvenza group shed significantly less virus than innovator and control. over time antibody titers were significantly higher in the calvenza than the innovator group, and both were significantly greater than controls. this study demonstrated that both current commercial inactivated eiv vaccines have a duration of clinical protection of at least months after a highly pathogenic challenge with a recent eiv isolate. both antibody responses and virological protection differed between the vaccines. formulation difference between the vaccines, including the eiv antigens employed, may have contributed to this performance difference. degenerative myelopathy (dm) may be homologous to a form of amyotrophic lateral sclerosis in humans which has excitotoxic and immunologic pathogeneses described. the aims of this study were to determine (i) presence or absence of abnormalities in concentrations of csf amino acid (aa) neurotransmitters (glutamate, glycine and gÀaminobutyric acid (gaba)) and cytokines in dogs with dm and if present (ii) investigate associations with disease severity. twenty-two dogs histopathologically confirmed for dm and dogs with suspected dm based on thorough diagnostic investigations and clinically normal age-matched control dogs were included in the study. the neurological severity of the dm dogs was graded ( - ) using an established scale. csf was evaluated for presence of glutamate, glycine and gaba by high performance liquid chromatography and for gm-csf, ifn-g, il- , il- , il- , il- , il- , il- , il- , il- , ip- , kc (keratinocyte chemoattractant), mcp- (monocyte chemotactic protein- ) and tnf-a using a commercially available, canine multiplex immunoassay (millipore, billerica, ma). all data analyses were performed using sas v . (cary, nc). analyte levels were compared between dm confirmed, dm suspected and control dogs by an analysis of variance (anova). spearman correlation was used to test for correlations of analyte levels and neurological grades. all hypothesis tests were -sided with a . . there were no significant differences between individual csf analytes in dm confirmed and dm suspected dogs. glutamate levels were not significantly different between dm affected (mean . mg/ ml; range . - . ; sd . ) and control dogs (mean . mg/ ml; range . - . ; sd . ). control dogs (mean . mg/ml; range . - . ; sd . ) had significantly higher levels of gaba (p o . ) than dm dogs (mean . mg/ml; range . - . ; sd . ). control dogs (mean . mg/ml; range . - . ; sd . ) also had significantly higher glycine concentrations (p o . ) than dm dogs (mean . mg/ml; range . - . ; sd . ). dm-affected dogs also had significantly higher levels of il- (p . ), kc (p o . ) and mcp- (p . ) than control dogs. neurotransmitter levels were not significantly associated with neurological grade. kc levels were significantly higher in the least affected dogs (p . ). there were no associations with disease severity and analyte concentrations. dm affected dogs have an imbalance of csf aa concentrations creating a relatively excitotoxic environment. reports in human als confirm an imbalance between csf excitatory and inhibitory aas suggesting a pathogenic role for excitotoxicity in als. it also appears that dm affected dogs have increases in csf cytokines and chemokines suggestive of an immunologic component to the pathogenesis as is similar to als. further prospective analysis of dm is warranted to evaluate the role of treatment on csf variables. the pathogenesis of neuropathic pain (np) and syringomyelia (sm) in association with chiari-like malformation (clm) in dogs has focused on the anatomical anomalies and secondary cerebrospinal fluid (csf) flow abnormalities. neuropathic pain in humans has been associated with abnormalities of neurotransmitters such as glutamate and serotonin as well as immunologic mechanisms. the aim of this study was to investigate the csf neurotransmitter and cytokine levels in brussels griffon dogs (bgs) with clm, sm and np. as part of an mri study investigating the prevalence of sm in bgs, atlanto-occipital csf was acquired from dogs and stored at - c until analysis. all dogs underwent a neurologic exam prior to mri; osirix s software was used to measure sm and the presence of cerebellar herniation and deviation were recorded. deproteinized csf samples were analysed for presence of serotonin (ng/ml), glutamate, glycine and gaba (mg/ml) by high performance liquid chromatography. all csf samples were evaluated simultaneously for gm-csf, ifn-g, il- , il- , il- , il- , il- , il- , il- , il- , ip- , kc, mcp- and tnf-a. a commercially available, canine multiplex immunoassay (millipore, billerica, ma) was used for the cytokine analysis (pg/ml). student's t-tests were used to compare the means of neurotransmitter and cytokine values between groups with and without skull abnormalities or spinal pain. simple pearson's correlation was used to test for correlations of neurotransmitter and cytokine values with syrinx dimensions and correlations of neurotransmitter with cytokine values. all hypothesis tests were -sided and the significance level was a . . np was detected in dogs ( %); sm was present dogs ( %); and cm was detected in dogs ( %). ifn-g levels were significantly lower in dogs with np than without (p . ). there were significant positive correlations between syrinx size and il- (p . ), kc (p . ) and mcp- (p . ). there were significant negative correlations between ifn-g and syrinx height (p . ) and extent (p . ). there was a significant negative correlation between il- and syrinx height (p . ). neurotransmitter levels were not associated with skull abnormalities or spinal pain, but there was a positive correlation of glycine with il- (p . ) and mcp- with glutamate (p . ) and serotonin (p . ). the size of the syrinx in bgs with sm is associated with several cytokine elevations but only a decrease of ifn-g was associated with np. based on this study it does not appear that excitotoxicity plays a role in either sm development or np. further work is justified on the role of the immune system in cm, sm and np. current knowledge about the conservative management of disk associated cervical spondylomyelopathy (da-csm) is rather limited and mainly based on retrospectively retrieved data. the goals of this study were to prospectively evaluate the evolution of clinical signs in dogs treated conservatively for da-csm. additionally, several potential prognostic parameters and the correlation of initial clinical signs with magnetic resonance imaging (mri) and transcranial magnetic stimulation (tms) were investigated. twenty-one dogs were included. after neurological evaluation, neurological status was graded from ( normal) to ( tetraplegia). all animals underwent low-field mri and tms with measurement of onset latencies and peak-to-peak amplitudes from the extensor carpi radialis and cranial tibial muscles. from the mr images, the following dimensions were calculated: remaining spinal cord area; compression ratio; vertebral occupying ratio of the spinal cord; canal height to body height ratio (cbr); canal height to body length ratio (cblr); and the canal compromise ratio. intraparenchymal intensity (isi) changes were graded from to . all dogs were reevaluated by the same person after , , , , and months. eight of dogs ( %) experienced a positive clinical evolution with improvement of clinical signs or stabilization of mild clinical signs. all dogs with a negative clinical evolution month after diagnosis experienced a further progression of clinical signs resulting in a poor outcome. the opposite was true for all dogs with a positive clinical evolution after month. outcome was further significantly associated by the remaining spinal cord area and the vertebral canal compromise ratio. prognosis was not significantly affected by clinical presentation or tms. progression of clinical signs, in unsuccessfully treated dogs, was generally characterized by a rapid and dramatic deterioration of neurological status. there were no significant correlations between clinical presentation, mri and tms. two dogs underwent necropsy and histopathological examination. this revealed in both cases chronic wallerian degeneration and segmental myelomalacia. the results of this study suggest that conservative treatment of da-csm is associated with a rather guarded prognosis. clinical evolution month after diagnosis and selected mri parameters can be considered as prognostic indicators. the lack of correlation between clinical presentation and outcome, medical imaging and electrophysiological evaluation is disturbing and warrants further investigation. a mri-guided stereotactic brain biopsy system has not been clinically evaluated in dogs. the purpose of this study was to determine the ability of the brainsight tm system to obtain histologically diagnostic samples and access the impact of this procedure on neurologic status for hours after the biopsy. five dogs with mri definable lesions in the brain have been enrolled. breeds included a pitbull mix, pembroke welsh corgi, french bulldog, border terrier and west highland white terrier. age ranged from - years. weight ranged from . - . kg.dogs presented with seizures (n ), ambulatory paresis(n ), unilateral blindness(n ) and head tilt(n ). one dog had a normal neurologic exam. lesions chosen for biopsy were in the olfactory and/or frontal lobes (n ), parietal lobe(n ), and pyriform lobe(n ). lesions were between - mm in diameter. all lesions were well-circumscribed and contrast enhancing except for one. histologic diagnosis of meningioma(n ) and granulomatous meningoencephalitis(n ) were made. the poorly-circumscribed, non-contrast enhancing frontal mass yielded non-specific necrosis. following biopsy, three dogs returned to pre-biopsy neurologic status within hours. the french bulldog took hours to return to previous neurologic status due to brachycephalic syndrome that required oxygen support. one dog had acute respiratory arrest hours post-biopsy. necropsy is pending. these results suggest that this mri-guided biopsy system can provide an accurate histologic diagnosis of brain lesions. biopsies of poorly-circumscribed and non-contrast enhancing brain lesions may be less diagnostic. further evaluation is on-going to determine the true diagnostic yield and complication rate of this procedure. concurrent malformations of the craniocervical junction are commonly identified in humans with chiari type i malformation. recent evidence suggests such craniocervical junction abnormalities (cjas) also occur in dogs suspected of having chiari-like malformation (clm). the purpose of this study was to objectively describe morphometric features of the craniocervical junction region of dogs with suspected clm and to investigate for associations between these features and the occurrence of other malformations in this region. magnetic resonance (mr) and computed tomographic (ct) images from dogs with clm were evaluated. three regions of neural tissue compression were assessed: cerebellar compression (cc); ventral compression at the c /c articulation, termed ''medullary kinking'' (mk); and dorsal compression (dc) at the c /c articulation. a compression index (ci) was calculated for all abnormal regions for each dog. multiple logistic regression analysis was performed (p o . ) to ascertain whether ci values for the different regions of compression were associated with the incidence of other craniocervical junction abnormalities. % of dogs had mk and % of dogs had dc. % of dogs also had evidence of atlanto-occipital overlapping (aoo medical infrared imaging (mii) is a non-invasive diagnostic imaging technique that measures skin surface temperature and generates thermal pattern maps based on predetermined color scales. because skin temperature, dependent on regional perfusion, is under direct control of the sympathetic nervous system, mii provides information about the function of the autonomic nervous system. because of recent advances in technology and lack of sedation needed to image patients, mii has potential use as a screening test for a variety of conditions that may result in autonomic dysregulation like chiari-like malformation in dogs (clm). the purposes of this study were to establish a mii protocol for dogs suspected of having clm, to identify thermal imaging patterns for various regions of interest (roi), to evaluate changes in thermal patterns and compare the results to those of mri findings, considered the standard for diagnosing clm in dogs. one hundred and five cavalier king charles spaniel dogs with clinical signs attributable to clm and confirmed clm with mri were evaluated with a complete blood count and chemistry profile, examination by a board certified surgeon/neurologist, multidetector ct scan of the craniocervical junction, whole body mri and mii. the protocol for thermal imaging included cranial and caudal views of the body, full lateral right and left body views, dorsal views of the head and body, and right and left lateral views of the head. thermal patterns were assessed with custom image recognition software. after each dog was imaged awake, general anesthesia was administered and the dogs re-imaged using the same protocol. mri findings in dogs with severe or moderate cerebellar compression and cerebellar herniation were compared with mii results. the top of head and front of head roi were . % and . % successful in identifying dogs with clm. based on these preliminary findings, mii may be a viable screening tool to detect clm in dogs. medical infrared imaging (mii) is an imaging technique that measures skin surface temperature derived from cutaneous perfusion and generates thermal pattern maps based on color scales. mii has been used as a test for a variety of conditions that cause autonomic dysregulation resulting in altered cutaneous perfusion. acute thoracolumbar intervertebral disk disease (tlivdd) is common in dogs. the purpose of this study was to: ) determine the success of mii in identifying dogs with tlivdd, ) compare the mii localization with mri results and surgical findings ) determine if the mii pattern returns to that of normal dogs following decompression surgery. small breed chondodystrophic dogs with tlivdd confirmed with mri and dogs with no tlivdd were evaluated with mri and mii. regions correlating with the intervertebral disk spaces were analyzed for average temperatures and thermographic patterns. thermal patterns were assessed with computer recognition pattern analysis (crpa) software. dogs were re-evaluated weeks after surgery using the same protocol. when analyzing temperature averages over a region, no significant difference was found between control and affected dogs. crpa was % successful in differentiating normal from affected dogs. crpa was % successful in identifying the intervertebral disk space when compared with mri and surgical findings. based on these findings, mii may be a viable screening tool to detect tlivdd in dogs. microglia physiologically shows regional topographical differences in immunophenotype and function within the central nervous system indicating the endowment for a prompt response to pathological stimuli such as trauma. spinal cord injuries (sci) consist of a primary injury encompassing the mechanical impact and the ''secondary wave'' of injury occurring minutes to weeks later and comprising various consecutive effects such as increased production of free radicals, excessive release of excitatory neurotransmitters and inflammatory reactions. activated microglia has the potential to perform some of these reactions, their contribution to the secondary wave is therefore controversially discussed. it has to be considered a double-edged sword as both, beneficial and deleterious effects have been attributed to these cells. the purpose of the presented study was to assess microglial involvement, particularly in the ''secondary wave'' following sci. microglia from dogs with sci was isolated and characterized ex vivo in terms of morphology, immunophenotype, and function by flow cytometry. the results were compared to region-specific findings obtained from healthy control dogs (n ). the histopathological exam confirmed the diagnosis of sci in the cervical (n ) and thoracolumbar (n ) spinal cord, and revealed a significant activation of microglia/ macrophages and upregulation of myelinophagia in dogs with sci days or longer prior to euthanasia. microglial ex vivo examination showed significantly increased expressions of b - , b - , mhc ii, cd c, icam- , cd , cd , and cd , and significantly enhanced phagocytosis and generation of reactive oxygen species (ros) in sci compared to healthy controls. microglial cells seem to be highly activated following sci with an immunophenotype indicating their active role in co-stimulation of t cells, in leukocyte adhesion and aggregation, and in lipid and glycolipid presentation. microglial phagocytosis might play a pivotal role in removal of injured or damaged cells and initialize subsequent healing processes. however, as ros can be directly neurotoxic an enhanced microglial generation might lead to bystander damage of the traumatized spinal cord and might therefore add to the deleterious effects of the secondary wave. modulating the microglial response in sci might be a valuable novel therapeutic strategy alleviating further damage to the spinal cord. thymidine kinase (tk) is a soluble biomarker present in s-phase of a salvage pathway for dna synthesis, and can be measured in serum. tk activity correlates with stage, prognosis, and relapse in canine and human lymphoma. we previously reported the results of a pilot study evaluating tk activity in archived canine osteosarcoma, transitional cell carcinoma, and hemangiosarcoma (hsa) sera, and found elevated tk activity in % of canine hsa sera evaluated. the purpose of this study was to prospectively evaluate serum tk activity in a large number of dogs presenting to emergency clinics with hemoabdomen and a splenic mass, to determine if tk activity could be used as a noninvasive means to distinguish hsa versus benign conditions in this population. dogs presenting with hemoabdomen and a splenic mass identified on ultrasound examination were studied. serum was collected prior to anesthesia, euthanasia or surgical intervention and frozen until batch analysis. tissue from all patients was evaluated histologically by a single pathologist. sera from age-matched normal dogs comprised a control population. an elisa using azidothymidine as a tk substrate was used. comparisons between groups were made using -tailed student t-tests, and receiver-operator characteristic (roc) curves were generated. sixty-two patients and normal controls were studied. there were dogs with hsa, dogs with other splenic neoplasia, and dogs with benign diseases. using a training set of normal dogs, a cutoff of . u/l was established from the roc curve. tk activity was significantly higher (p o . ) in dogs with hsa than in the validation set of normal dogs (mean /Àsd . /À . and . /À . respectively), but not between dogs with hsa and benign splenic disease (mean /Àsd . /À . , p . ). using a cutoff of . u/l, tk activity demonstrated a sensitivity of . , specificity of . , positive predictive value of . and negative predictive value of . for distinguishing hsa versus benign splenic disease. when interval thresholds of o . and . u/l were used together, diagnostic utility was markedly increased for distinguishing both hsa versus normal and hsa versus benign disease. in conclusion, serum tk evaluation may assist in detection of canine hsa, and may also discriminate between benign disease and hsa in dogs with hemoabdomen and a splenic mass. t cell chronic lymphocytic leukemia (cll) is a heterogeneous disease that affects a number of dog breeds. cll patients have variable disease outcomes. the objectives of this study were to use gene expression profiling of cd t cell leukemias with variable outcomes in order to identify markers that can be used in routine diagnostic tests to distinguish good from poor prognosis disease, and to identify potential targets for novel therapy. gene expression profiling of cd t cell leukemias ( good, poor prognosis) was conducted. samples from normal dogs were also profiled. several differentially expressed genes were found including cd , cd , and cd . these were selected for further study using flow cytometry to determine expression of protein on the cell surface. seventy nine cases of cd t cell leukemia were screened for cd expression. forty seven had associated outcome information. based on analysis to date, cd expression as assessed by flow cytometry does not appear to provide prognostic information. a monoclonal antibody to cd was recently made available. to date patients with cd t cell leukemia have been profiled. cd is variably expressed on t cell leukemias compared to normal cd t cells. cd is the receptor for interleukin . cyclosporin, a commonly used immunosuppressive drug, inhibits il- production, and has been used to treat a subset of t cell leukemias in people. thus, the finding that cd is up regulated on t cell leukemias compared with normal t cells suggests a possible new therapeutic avenue. recent molecular studies have revealed a highly complex bacterial microbiota in the intestine of dogs. there is mounting evidence that microbes play an important role in the pathogenesis of acute and chronic enteropathies of dogs, including idiopathic inflammatory bowel disease (ibd). similarly, compositional changes of the intestinal bacterial ecosystem have been associated with ibd in humans. the aim of this study was to characterize the bacterial microbiota in dogs with various gastrointestinal disorders using a next generation sequencing technique. fecal samples were obtained from healthy dogs (n ), dogs with acute uncomplicated diarrhea (n ), dogs with acute hemorrhagic diarrhea (ahd; n ), and dogs with active (n ) and therapeutically controlled ibd (n ). the bacterial composition was analyzed by massive parallel s rrna gene -pyrosequencing. differences between groups were analyzed using mann-whitney u tests and kruskal-wallis tests followed by dunn's multiple comparison tests. statistical significance was set at p o . . significant differences in the proportions of several bacterial groups were identified between healthy and diseased dogs. dogs with gastrointestinal disease had significantly higher proportions of proteobacteria (p o . ). proportions of firmicutes were lower in diseased dogs, but this difference did not reach significance (p . ). within the firmicutes the most notable findings were decreases in bacterial groups belonging to clostridium clusters iv and xiva (i.e., ruminococcus, dorea, and faecalibacterium spp.; p o . for all). dogs with ahd had the most profound changes of the microbiota, followed by dogs with acute uncomplicated diarrhea, and dogs with active ibd. faecalibacterium spp. was the bacterial group most prominently depleted in dogs with active ibd, but was not significantly different between healthy dogs and dogs with therapeutically controlled ibd (p . ). results of this study revealed bacterial dysbiosis in fecal samples of dogs with various gi disorders. bacterial changes were more profound in dogs with severe disease, but were not identified in dogs with therapeutically controlled ibd, suggesting that the microbiota is stable in non-active disease. the bacterial groups identified are considered to be important short chain fatty acid producers and may serve as candidates for the diagnosis or therapeutic monitoring of gi disease. future studies are necessary to determine if these microbial changes correlate with functional changes in the intestinal microbiota. ciprofloxacin oral tablets, available in a generic formulation for people, are widely used for treatment in dogs. oral absorption data for ciprofloxacin in dogs has been variable, and too limited to guide accurate dosing. subsequently, published doses for dogs in veterinary formularies have varied from to mg/kg. this study was undertaken to explore the factors that may affect oral absorption of generic ciprofloxacin in dogs, and to derive a pharmacokinetic-based dose for treating susceptible bacteria. six healthy adult beagle dogs were used for the study ( . kg mean weight). after placing jugular vein catheters for collecting blood samples, these dogs were administered either a single oral dose of ciprofloxacin ( mg tablet; mean dose mg/kg), or an intravenous (iv) dose ( mg/kg; mg/ml solution). a randomized crossover design was used with a washout time between treatments. blood was collected for plasma drug analysis for hours. ciprofloxacin concentration in plasma was analyzed using high pressure liquid chromatography (hplc) and pharmacokinetics analyzed using a computer program. oral absorption was also evaluated via deconvolution analysis. the oral dose was well-tolerated, but the iv dose produced transient vomiting and depression in some dogs. after the oral dose, the peak plasma concentration (c max ) was . mg/ ml (cv . %), terminal half-life (t / ) . hr (cv . %), auc . mg Á hr/ml (cv . %), and systemic absorption (f) . % (cv . %). after the iv dose, the t / was . hr (cv . %), systemic clearance . l/kg/hr (cv . %), and volume of distribution . l/kg (cv . %). after examining the pharmacokinetic results from the oral dose, it was apparent that oral ciprofloxacin was absorbed well in some dogs (approximately %), but poorly in others (approximately %). to explore the factors that may have affected oral absorption, two high absorbers and two low absorbers were administered an additional oral dose as a mg/ml solution ( mg total dose) via gastric tube. after administration of the oral solution, the plasma concentrations were more uniform and consistent among dogs. absorption of the oral solution of ciprofloxacin was . % (cv %) with a t / of . (cv . %) hr and c max of . mg/ml (cv . %). therefore, it appears that inconsistent oral absorption of ciprofloxacin in some dogs may be formulation-dependent, and affected by tablet dissolution in the canine small intestine. doses were calculated using the data for oral tablets in these dogs. the pharmacokinetic-pharmacodynamic (pk-pd) target was an auc/ mic ratio of . because of the wide range in oral absorption of tablets, a dose to reach the pk-pd target ranged from canine distemper (cd) is a highly contagious, acute or subacute systemic viral disease of dogs and other carnivores which can be controlled efficiently by the use of modified live-virus (mlv) vaccines. however, mlv strains do cross-react with molecular diagnostic tests and cause significant confusion for clinicians. the purpose of this study was to use quantitative real-time pcr viral load information to differentiate between vaccine virus used in mlv vaccines and wildtype infections in dogs. a real-time pcr test for cd virus (cdv) based on the p gene for phosphoprotein was used to determine viral loads in vaccinated and wildtype infected animals. a total of respiratory mucosal swab samples from mlv vaccinated and asymptomatic dogs were obtained within the first weeks after mlv vaccination. based on the viral load in vaccinated animals, a cutoff value was established for the differentiation of dogs with clinical signs of respiratory distress and presumably infected with a wildtype strain of cdv. two hundred clinical cases with known clinical and vaccination histories were analyzed to validate the cutoff value. the cdv real-time pcr proved to be of high analytical and diagnostic sensitivity: a standard curve was established using known numbers of cdv molecules to allow absolute quantitative cdv viral load data. the limit of detection was in the single molecule range while the limit of quantitation was established at around molecules per pcr reaction. a comparison to ifa showed real-time pcr to be % more sensitive. the cdv viral load in vaccinated animals averaged , viral particles per swab. a cutoff value of , viral particles was calculated by adding standard deviations to the average value. this cutoff value correctly detected . % of the vaccinated samples. acutely infected dogs with cdv compatible clinical signs have high viral loads normally several logs higher than the cutoff value. in dogs with clinical distress, recent cdv mlv vaccination but viral loads below the cutoff value, other infectious agents were detected by using a panel of real-time pcr tests. testing additional infectious agents in clinical settings is important in order to explain clinical signs when viral loads below cutoff values indicate that cdv is not the cause of clinical signs. in conclusion, quantitative real-time pcr is a sensitive, rapid and reliable test regardless of recent vaccination. the use of a cutoff value will be of significant help to discriminate between vaccine interference and wildtype infection in clinical settings. feline ureteral obstructions are a common urinary dilemma and traditional therapy is associated with substantial morbidity/mortality. feline nephrostomy tubes are reported as being effective when pelvic drainage is required. the biggest limitation is externalized drainage, requiring careful management to prevent infection/dislodgement. the development of an indwelling ureteral bypass using a combination locking-loop nephrostomy/cystostomy tube was modified from humans, resulting in permanent indwelling drainage, reduced complications, and improved quality of life. the objective is to describe the technical and clinical outcome using a novel device called a subcutaneous ureteral bypass (sub) in cats with ureteral obstructions. fifteen cats ( kidneys) had a sub placed for: ureterolithiasis ( ), ureteral stricture ( /À stones) ( ), and ureteral stent rejection ( ). the median pre-and post-procedure creatinine was mg/dl (range: . - ) and . mg/dl (range: . - ), respectively. the median pelvis diameter pre and post-procedure were (range: - ) and mm (range . - ), respectively. six french tubes were placed in , and fr. in . the bypass remained indwelling for a median of days (range - ). there were major complications resulting in nephrostomy tube dislodgement ( ) and port leakage ( ) days after surgery. one patient with severe coagulopathy developed a clot which resolved with tpa infusion through the port. no sub got occluded/obstructed long-term. overall, the use of a sub for cats with ureteral obstructions can be considered a functional option when other therapies have failed or are contraindicated, but shtime. oxidative stress is considered central to the pathogenesis of many systemic diseases. in humans, biomarkers of oxidative stress, antioxidant depletion and lipid peroxidation, have been correlated with disease severity and associated with poor clinical outcomes. therapeutic antioxidant supplementation with nac in glutathione (gsh)-deficient patients has shown clinical benefits, including repletion of intracellular gsh levels. we have shown that clinically ill dogs are gsh-deficient, and that gsh deficiency correlates with mortality, but it is not clear whether there are direct benefits of antioxidant intervention in these patients. the purpose of this randomized, investigator-blinded, placebo-controlled, prospective study was to evaluate the effect of nac to normalize blood antioxidants (rbc reduced gsh (rbc gsh), plasma cysteine (cys), serum vitamin e (vit e), and whole blood selenium (se)), reduce lipid peroxidation (urine isoprostane/creatinine ratio (u i/ c)), and improve illness scores (spi ) and outcome (survival to discharge) in clinically ill dogs. clinically ill client-owned dogs, admitted to the uw veterinary medical teaching hospital that did not receive blood transfusions, tpn, vitamins, or antioxidants were eligible for the study. dogs enrolled in the study were randomized to receive iv infusions q. h. of either nac (  mg/kg and  mg/kg) or equal volumes of % dextrose (placebo) over hours. at the time of enrollment, and hours following the final hour infusion, blood and urine were collected to quantify rbc gsh, cys, vit e, and se concentrations; u i/c ratios; and calculate spi scores. rbc gsh and cys concentrations were quantified by hplc. commercially available hplc, atomic absorption spectroscopy, and eia were used to quantify vit e, se, and u i/c ratios, respectively. nonparametric statistical analyses were used, with results reported as medians and p o . considered significant. sixty-one ill dogs were randomized to either nac (n ) or placebo (n ). overall this group of ill dogs had significantly decreased rbc gsh ( . vs. . mm; p . ), vit e ( vs. mg/ml; p . ), and se ( . vs. . mg/ml; p . ) levels and elevated u i/c ratios ( vs. pg/mg; p . ) in comparison to healthy control dogs. dogs in the placebo group showed a significant further decrease in rbc gsh over the next hours ( . to . ; p . ). nac supplementation significantly increased plasma cys levels ( . to . mm; p o . ), and prevented a further decline in rbc gsh ( . to . mm; p . ). however, serum vit e ( vs. mg/ml), se ( . vs. . mg/ ml), u i/c ratios ( vs. pg/mg), spi scores ( . vs. . ), and outcome ( % vs. %) were not significantly different between the nac and placebo groups after treatment. the results of this study further support that clinically ill dogs experience oxidative stress, and suggest that antioxidant supplementation with nac within the first hours of hospitalization prevents further rbc gsh depletion. further studies are necessary to investigate whether longer duration or combined antioxidant supplementation normalizes the redox state and impacts long-term outcome. diabetes mellitus in cats is very similar to type ii diabetes in humans, preceded by a period of insulin resistance. evaluating insulin resistance in a cat is a time consuming, expensive, and difficult procedure. there is a need for a simple biomarker based test predictive of insulin resistance. there is a biomarker based assay predicative of insulin resistance in humans. the purpose of this study was to evaluate the utility of this assay in overweight cats and show improvement in insulin sensitivity following weight loss and weight maintenance. the insulin resistance assay is based on the quantitative analysis of metabolites ( -hydroxybuterate, creatine, palmitate, decanoylcarnitine, and oleoyl-lpc). a proprietary algorithm (metabolon, inc, durham nc) was used to generate a predictive rd (rate of disposal) value (normal range in cats . - . ). individuals with an rd value less than will have a greater than % chance of being insulin resistant and an rd value less than will have a greater than % chance of being insulin resistant. initial studies demonstrated that the rd values indicating insulin resistance in cats correlated with age, obesity and severity of diabetes as determined by histopathology and blood glucose levels. in a feeding study of cats ( % vs. o % body fat) rd values improved from . ae . to . . (p . ). during weight maintenance, % body fat for months, further improvement was observed (rd, . . (p . e- )). these results demonstrate that long term weight maintenance following weight loss is critical for increasing insulin sensitivity in cats. the use of monoclonal antibodies and antibody fragments to directly target tumor antigens and neutralize their growth factors has shown promising results in human clinical trials. however, these targeted approaches have not been possible in dogs since specific tumor antigens have not been identified, monoclonal antibodies of canine origin are not available and the efficacy of xenogeneic antibodies in the dog is limited by neutralizing antibody responses. to overcome these obstacles, we have generated canine antibody phage display libraries from canine splenocytes. these libraries consist of single chain variable fragments (scfv) comprised of canine variable heavy (vh) and variable light (vl) immunoglobulin chains displayed on the surface of bacteriophage (fig. ) . the antigen specificity within these libraries is diverse and recapitulates the antigen-experienced immunoglobulin repertoire of the dog. we can now use simple panning techniques to isolate scfv of canine origin that bind to either known targets or unknown targets which can then be identified using standard molecular techniques. canine hsa is a highly aggressive malignancy of vascular endothelial cells that affects large breed dogs. although there are no confirmed immunological targets for hsa, serum levels of vascular endothelial growth factor (vegf) are elevated in these patients and, as in many human cancers, vegf may represent an important therapeutic target for neutralization. we used simple panning techniques to screen canine scfv libraries generated from the spleens of dogs with hsa against canine vegf and successfully isolated scfv clones that bind and neutralize canine vegf in vitro. these scfvs are now being taken into a murine model of canine hsa to determine whether they can inhibit tumor growth and metastases. in addition, we have panned the same antigen-experienced scfv phage display libraries against allogeneic primary canine hsa cells of low passage number to isolate canine-derived antibody fragments that can target malignant endothelial cell surface molecules. early results demonstrate enrichment of scfv phage libraries for malignant endothelial cell binders. these scfv can be readily linked to chemotherapeutic agents or other toxins and used to deliver high doses directly to the malignant cell. this novel approach aims to reduce side effects of systemic chemotherapy and augment therapeutic response. calcitriol, (vitamin d ), has antineoplastic activity and acts synergistically to potentiate the antitumor activity of a diverse array of chemotherapeutics. ccnu, vinblastine, corticosteroids, and tyrosine kinase inhibitors, are used to treat canine mast cell tumors (mct). vitamin d receptor is expressed in the majority of canine mcts, suggesting a role for calcitriol in the management of dogs with these tumors. the purpose of our study was to examine the in vitro effects of calcitriol in combination with ccnu, vinblastine, imatinib, or toceranib on canine mastocytoma c cells. also, we evaluated the antitumor activity of dn , a highly concentrated oral formulation of calcitriol, as single-agent treatment in dogs with naturally occurring mcts. c cells were incubated with serial dilutions of calcitriol ( . - nm). twenty-four hours later, cells were then treated with vehicle control or serial dilutions of ccnu ( . - um), vinblastine ( . - nm), imatinib ( . - . nm), or toceranib ( . - nm). cell viability was assessed with an mtt assay after hours and data was used to derive a combination index (ci: values o , , indicate synergism, additivity, antagonism, respectively). in the phase ii clinical trial, dogs were eligible if they had at least measurable, histologically confirmed, mct. calcitriol was administered orally. recist criteria were used to assess tumor response. calcitriol, ccnu, vinblastine, imatinib, and toceranib each suppressed c cell viability in a dose-dependent manner. ci values o were obtained for calcitriol ( . - . nm) combined with ccnu ( and um), vinblastine ( . and nm), imatinib ( . - . nm) and toceranib ( . - . nm). due to the occurrence of toxicity (vomiting, anorexia, hypercalcemia), the phase ii trial was terminated early; only of planned patients were treated. one dog with a metastatic muzzle mct had a complete response that lasted days. three dogs achieved partial response lasting from - days. in summary, our in vitro data demonstrate that calcitriol combined with ccnu, vinblastine, imatinib or toceranib has synergistic effects on c mastocytoma cells. antitumor responses were observed in dogs with spontaneously occurring mcts treated orally with single-agent calcitriol, but the frequency of adverse effects was high. together these results suggest calcitriol combination therapies might have significant clinical utility in the treatment of canine mcts but refinement of the calcitriol-dosing regimen must be done. cyclosporine is a potent immunosuppressive agent used to treat many canine inflammatory and immune-mediated diseases. cyclosporine has gained popularity as an immunosuppressive agent because of a favorable toxicity profile compared to many other immunosuppressive agents. optimal dosing regimens for cyclosporine in the dog remain unclear, primarily because standard methods that monitor effectiveness of immunosuppression have not been established. pharmacokinetic testing is currently used during treatment with oral cyclosporine to adjust doses based on measurement of blood drug levels. individual patients, however, often demonstrate marked variations in blood drug levels while on similar oral doses of cyclosporine, and can also demonstrate different clinical responses even at comparable drug levels, making correlation of blood cyclosporine levels and degree of disease control extremely difficult. pharmacodynamic testing offers an alternative method for regulating cyclosporine dosing by objectively measuring the effects of cyclosporine on t-cells, the drug's main cellular target in the body. our acvim foundation-funded research has focused on developing and evaluating a comprehensive panel of biomarkers of immunosuppression that can be utilized for pharmacodynamic monitoring during treatment with cyclosporine and other immunosuppressive agents that affect t-cell function. we have completed several studies using flow cytometry to evaluate activated t-cell expression of surface molecules (cd & cd ) and cytokines (il- , ifn-g & il- ) as potential biomarkers. our first study was an in vitro study evaluating expression of surface molecules and cytokines in canine t-cells exposed to varying concentrations of cyclosporine. this study established consistent drug-associated suppression of the cytokines il- , ifn-g and il- . our second study was an in vivo study in normal dogs evaluating the effects of two doses of oral cyclosporine, a high dose considered to be reliably immunosuppressive (starting dose mg/kg bid, titrated upwards as needed to attain trough drug blood levels of at least ng/ml) and a lower dose used to treat atopy ( mg/kg sid), on t-cell expression of these three cytokines. significant suppression of il- and ifn-g expression was seen at the high cyclosporine dose, while at the lower dose only ifn-g expression was suppressed. because tcell expression of il- was not significantly suppressed at the high cyclosporine dose, il- was not evaluated at the lower drug dose. because of specialized sample handling requirements, flow cytometry is not as practitioner friendly as other assays (such as pcr) for routine use in pharmacodynamic testing. we have therefore conducted an in vitro study comparing the effects of cyclosporine on activated t-cell expression of il- and ifn-g using flow cytometry and qrt-pcr, and demonstrated dose dependent and comparable suppression of il- and ifn-g using either methodology. we are currently evaluating, using qrt-pcr, the effects of oral cyclosporine on t-cell expression of il- and ifn-g in normal dogs prior to moving on to pharmacodynamic trials in our clinic patients. effect of hypothyroidism on reproduction in bitches. dl panciera , bj purswell , ka kolster , sr werre . departments of small animal clinical sciences, large animal clinical sciences, and laboratory for study design and data analysis, virginia-maryland regional college of veterinary medicine, virginia tech, blacksburg, va. numerous reproductive abnormalities, including irregular interestrous period, anestrus, and infertility have been attributed to hypothyroidism. we previously documented reduced fertility and lower birth weight and increased periparturient mortality in pups born to bitches with experimentally-induced hypothyroidism for a median duration of weeks. the purpose of this study was to evaluate reproductive function in these same bitches after hypothyroidism was treated with a replacement dose of levothyroxine. twelve multiparous bitches were studied. hypothyroidism was induced in dogs by administration of mci/kg i. hypothyroidism was confirmed by finding serum t concentrations before and hours after iv administration of human recombinant tsh that were o nmol/l. levothyroxine ( . mg/kd q h) was administered to all hypothyroid bitches. six bitches served as euthyroid, untreated controls. dogs were evaluated daily for signs of estrus and were bred by of males when serum progesterone was ! ng/ml. interestrous interval, gestation length, strength and duration of contractions during whelping, time between pups, number of live pups and stillbirths, viability of pups at birth, weight of pups, and periparturient mortality were recorded. the student's t-test and anova were used to compare differences between control and hypothyroid bitches for continuous, normally distributed data. the wilcoxon rank sum test was used to analyze data between groups that was not normally distributed. the mean duration of hypothyroidism prior to levothyroxine administration was ae . weeks. breeding took place after levothyroxine treatment for ae . weeks in the hypothyroid group. all dogs in the hypothyroid group and / control dogs were pregnant, while / hypothyroid and all control bitches became pregnant prior to levothyroxine administration. no difference in interestrus interval or gestation length was noted between groups. during whelping, no difference in strength of contractions, contraction duration, interval between pups, or viability scores of pups was found between groups. litter size, birth weight and peirparturient mortality were similar between groups. levothyroxine administration reverses the detrimental effects of hypothyroidism on fertility and neonatal health. racing sled dogs have a high prevalence of exercise-induced gastric erosions/ulcers, with reports ranging from - % of dogs running at least miles in a day or less. omeprazole reduces the severity of, but does not completely prevent, gastritis under racing conditions, and can be difficult to administer under these conditions. famotidine can be administered in food, but has only demonstrated efficacy under less intense training conditions. the purpose of these studies was to evaluate different acid suppression strategies under racing conditions for the prevention of exercise-induced gastritis. experiment # was a randomized placebo-controlled study using sled dogs ( - years) competing in a mile race over - h. treatment groups were famotidine (approx mg/kg qd) or no treatment, beginning days prior to the start of the race and proceeding until gastroscopy was performed h after the race. experiment # was a randomized positive-control study using sled dogs ( - years) running a mock race of miles in h. dogs were divided into omeprazole (approx mg/kg qd, administered min prior to a meal) or famotidine (approx mg/kg bid) groups beginning days prior to the exercise challenge and continuing for h after completion. gastroscopy was performed immediately prior to the start of dosing and h after completion of the exercise. in all cases, mucosal appearance during gastroscopy was blindly scored using previously described scoring system. famotidine ( mg/kg qd) reduced the prevalence of clinicallyrelevant, exercise-induced gastric lesions compared to no treatment ( / vs / , p . ). compared to famotidine at mg/kg bid, omeprazole significantly decreased the severity ( . vs . , p . ) and prevalence ( / vs / , p . ) of gastric lesions. although famotidine provides some benefit in the prevention of exercise-induced gastric lesions, neither the recommended dose nor the higher dose were considered acceptable in the prevention of exerciseinduced gastritis as between - % of the dogs receiving famotidine had clinically significant lesions. a previous study examining omeprazole under racing conditions, but without careful administration on an empty stomach, resulted in a % prevalence of clinically significant gastric lesions. however, the bioavailability of omeprazole is reduced in the presence of food, and when the daily administration of the drug is carefully scheduled to coincide with an empty stomach, the resulting prevalence of clinically significant lesions induced by racing-intensity exercise is reduced to just over %. the conclusions of these studies are that omeprazole is superior to famotidine in preventing gastritis in racing sled dogs during competition. routine administration of omeprazole is recommended to prevent stress-associated gastric disease in exercising and racing alaskan sled dogs. mares may be an important source of environmental contamination with rhodococcus equi on breeding farms. attempts to reduce fecal shedding of r equi by the mare and the effects of the mare's fecal r equi concentration on airborne concentrations in the foaling stall have not been previously reported. twenty-one arabian mares were treated daily with either oral gallium nitrate or placebo in a randomized double-blind study. fecal samples were collected at day of gestation (time ), the week before foaling (time ), and the week after foaling (time ). airborne concentration of r equi were measured in the stall within hours post foaling using a microbial air sampling system into which standard ( -mm) culture plates with a media selective for r. equi have been loaded. concentration of total r equi were determined by morphological characteristics. the concentration of virulent r equi was determined using a modified colony immunoblot method. concentrations of total and virulent r equi were compared among mares to examine effects of treatment, time, and treatment by time interaction. there were significant (p o . ) effects of treatment that depended on time of sample collection. at sample times and there were no significant differences between groups in the fecal concentration of virulent r equi. at time concentrations of virulent r equi were significantly lower among mares in the treatment group (p o . ) compared to control. effects of time depended significantly on groups: for the control group, there were no significant effects of time. for the treatment group, concentrations tended to decrease over time, and concentrations at time were significantly (p o . ) lower than those at time . no other differences among times for concentrations in the treatment group were statistically significant. there were no significant effects of treatment, sample time, or their interaction on the concentration of total r equi between groups; however, the pattern for these data was similar to that observed for the virulent isolates. no significant differences were determined between treatment groups for airborne concentrations of virulent or total r equi. treatment of mares with oral gallium nitrate significantly reduced the fecal concentrations of virulent r equi over time, but had no impact on the airborne concentration of r equi shortly after foaling. the purpose of this study was to evaluate the protein profile of bronchoalveolar lavage fluid (balf) in horses affected with recurrent airway obstruction (rao) and in control horses using proteomics and western blot techniques. rao-affected (n ) and control horses (n ) were subjected to an experimental exposure trial; when the rao-affected horses showed clinical signs of disease, balf was collected from all horses. balf was also collected from client-owned rao-affected horses (n ) with naturally-occurring clinical signs of disease and client-owned control horses (n ) from the same environments. the balf from the experimental exposure trial horses was subjected to trypsin digestion and proteomics analysis with mass spectrometry (ms). peaks detected with ms were identified using tandem ms analysis and database searches. western blot was used to confirm the identity and expression levels of two proteins identified using proteomics techniques in the balf of all horses. data from ms experiments were analyzed with the student's t-test to compare peak intensity between rao-affected and control horses. western blot band density data was analyzed with the kruskal-wallis anova for comparison between groups of horses. significance level was set at p o . . with ms proteomic analysis of the balf from the experimental exposure trial horses, total peaks (peptides) were identified. of these peaks, were differentially expressed between the rao-affected ( over-expressed) and control horses ( over-expressed). identifications were made for balf proteins. transferrin and secretoglobin were chosen for validation with western blot. proteomics indicated that secretoglobin was not differentially expressed between the experimental exposure trial group; this was confirmed with western blot analysis. western blot also showed that clientowned rao-affected horses had lower secretoglobin expression than client-owned control horses and control horses before experimental exposure. according to the proteomics data, transferrin was over-expressed in control horses after experimental exposure compared to rao-affected horses. while the western blot analysis did not show a statistically significant difference in this comparison, transferrin was significantly over-expressed in control horses before experimental exposure compared to client-owned rao-affected horses. in addition, both secretoglobin and transferrin band densities on western blot were negatively correlated with airway obstruction and neutrophilic pulmonary inflammation. this study demonstrates that proteomics techniques can be used in the investigation of equine balf proteins. the proteins identified as differentially expressed between rao-affected and control horses in this study including, but not limited to, secretoglobin and transferrin should undergo further evaluation for their use as biomarkers of rao, and as potential targets of new therapeutic agents for rao. cardiotoxic effects of rattlesnake venom in the horse are not well defined. the first aim of this study was to document cardiac damage in naturally envenomated horses. twenty horses with clinical diagnosis of snake bite were included. a snake venom elisa was utilized to confirm envenomation when possible. serum and plasma were collected at selected intervals. plasma was assayed for cardiac troponin i (ctni) using a flurometric assay (stratus cs s , dade behring). holter monitors (zymed s , philips) were placed at admission, week and month post presentation. echocardiography was performed on available horses - months after envenomation. the second aim of this study was to investigate potential mechanisms of the cardiac damage. serum samples were assayed for tnfalpha using a commercial assay (endogen). antibody titers to crotalus atrox venom were measured at admission, week and month after natural envenomation and compared to titers in vaccinated horses (crotalus atrox toxoid, red rock biologics). a significant number of horses showed elevations in ctni (p o . ) at one or more time point indicating myocardial damage. holter readings revealed the presence of arrhythmias or persistent tachycardia in horses. five of twenty horses were available for echocardiography; no abnormalities were noted. horses with increased ctni tended to have greater tnfalpha concentrations compared with horses without increased ctni. peak venom titers in bitten horses were significantly higher than peak titers in vaccinated horses (p o . ). rattlesnake envenomation was associated with evidence of cardiac damage in a significant proportion of bitten horses. further studies are needed to determine the cause as well as mechanisms to treat and/or prevent its occurrence. little is known about the gastric mucosal flora in healthy horses and its role in gastric disease has not been critically examined. our laboratory previously reported that a diverse microbial flora with a predominance of streptococcus spp. and lactobacillus spp. exists in healthy horses using fluorescence in situ hybridization (fish). the present study sought to further characterize the gastric mucosal flora of healthy horses using massive parallel srrna bacterial tag encoded flx-titanium amplicon pyrosequencing (btefap). biopsies of the squamous, glandular, antral and any ulcerated mucosa were obtained from healthy horses via gastroscopy after a -hour fast and horses immediately post-mortem. dna was extracted from the mucosal biopsies and btefap and data processing was performed. hierarchical cluster analysis based on relative abundance data on the genus level were performed to look for trends in bacterial diversity among the individual horses. pyrosequencing yielded between , and , reads per horse with , , reads in the antrum, squamous and glandular regions, respectively. the microbiome segregated into two distinct clusters: cluster comprised of horses that were stabled, fed hay and sampled at post-mortem and cluster consisted of horses that were pastured on grass, fed hay and biopsied gastroscopically after a -hour fast. samples from different antomic regions clustered by horse rather than region. despite being very similar at the higher taxonomic level (phyla) differences in the distribution of bacteria were seen at the genus and species level. the dominant bacteria in cluster horses were firmicutes ( % reads/sample) consisting of mainly streptococcus spp., lactobacillus jensenii, l. fornicalis and sarcina maxima. cluster had more diversity with a predominance of proteobacteria, bacteroidetes and firmicutes and genera identified such as streptococcus spp., moraxella spp., actinobacillus spp., and others. though the relative abundance of the individual taxonomic groups was significantly different between individual horses, no significant differences in the overall diversity could be found (as assesed by shanon weaver, ace and choa i diversity indices). helicobacter spp. sequences were not identified in any sample (out of , reads). the ulcerated mucosa from horse (group ) had lower diversity and higher numbers of bacteria predominated by lactobacillus equigenerosi. this data shows that the equine gastric mucosa harbors an abundant and diverse microbiome which is unique to each individual and differs by sampling method, fasting prior to sampling and diet. seasonal pasture myopathy (spm; atypical myopathy [am] in europe), typified by nonexertional rhabdomyolysis, occurs in pastured horses during autumn or spring. clinical signs rapidly progress from muscular weakness to recumbency and frequently death. extensive myonecrosis and intramyofiber lipid storage occur in highly oxidative respiratory and postural muscles. recently, a defect of lipid metabolism called madd has been identified in european horses with am. this report documents the first cases of equine madd in the united states. six midwestern us horses suspected of having spm in the spring or fall of were evaluated for madd by urine organic acids, plasma acylcarnitines and/or muscle carnitine and histopathology. five horses had clinical signs and clinicopathologic data consistent with severe rhabdomyolysis. one horse was found dead on pasture after days of rear limb stiffness and inappetance. urinary organic acid profiles revealed markedly elevated ethylmalonic and methylsuccinic acids, butyrylglycine, isovalerylglycine, and hexanoylglycine, consistent with equine madd. plasma acylcarnitine profiles from horses had marked elevations of short chain acylcarnitines, while the third horse and only survivor had minor elevations of short chain acylcarnitines. affected muscle showed extensive degeneration with intramyofiber lipid accumulation, a marked decrease in free carnitine, and high levels of carnitine esters. spm appears to be a highly fatal emerging disease of pastured horses in the us characterized by weakness, colic-like signs and myoglobinuria. the disease is associated with a defect in muscular lipid metabolism that can be diagnosed by performing lipid staining of muscle samples and urine organic acid profiles. candidatus mycoplasma haemolamae (cmhl) is a common red blood cell parasite of new world camelids. the high degree of parasitemia that develops in an infected splenectomized animal allows for the efficient collection of parasitic dna. this dna can then be used in the development of genetically-derived tools such as pcr and in-situ hybridization. thus, one splenectomized animal can replace many immunologically intact animals within a research setting. the purpose of this study was to track the natural progression of cmhl parasitemia and associated clinical signs in a splenectomized alpaca. an intact, -month-old, . kg male alpaca was used in this study. he had tested positive via pcr for cmhl on three different occasions, although no organisms were seen on peripheral blood smears. the alpaca was placed under general anesthesia and a ventral midline incision was made. the spleen was located, the vessels ligated, and the organ removed. buprenorphine and flunixin meglumine were given for and days after surgery respectively. body weight, attitude, rectal temperature, blood glucose, and pcv were recorded daily. in addition, a peripheral blood smear was examined daily and the percent of red blood cells that were infected with mycoplasma organisms was determined. the alpaca was not parasitemic prior to surgery. one percent of the rbc's contained mycoplasma on days and after splenectomy. parasitic bloom developed on day with % of the red blood cells infected, and over % containing or more organisms. the alpaca was treated with mg/kg oxytetracycline i.v. on day . on postoperative day no parasites were seen in the peripheral blood. the peripheral blood remained free of parasites for days. on the morning of the th day, % of the peripheral red blood cells contained mycoplasma. by late that afternoon, % of the observed rbc's contained - organisms. the alpaca again received oxytetracycline. there were no more parasites observed from that time until the alpaca was euthanized days later. the alpaca lost . kg between days À and after surgery. his weight fluctuated between . and . kg for the remainder of the study period. blood glucose ranged between and mg/dl there was no major change in pcv (range - %), a finding that was expected as the spleen was not available to remove infected red blood cells. body temperature ranged between . and degrees celsius except for days and when more than % of red blood cells contained parasites. on those days rectal temperature reached . and . degrees respectively. this study confirmed that a non-parasitemic, yet pcr positive alpaca did indeed harbor cmhl. the time from splenectomy to parasitic bloom was shorter, and the length of oxytetracycline suppression longer than has been observed in other species. gastro-intestinal (gi) disease frequently results in increased wall thickness in many species. identification of changes in gi wall thickness using ultrasound has proved to be a useful diagnostic tool and is widely used in human patients, small animals and horses. although gi motility has been evaluated in cattle, normal reference ranges for wall thickness has not been reported in ruminants. the aims of this study were to report normal values for wall thickness of various gi structures and to assess the repeatability of this technique in adult dairy cows, sheep and goats. eight healthy adult holstein friesian (hf) cattle ( ae kg), eight jersey (j) cattle ( ae kg), thirteen adult sheep ( ae kg) and eleven adult goats ( . ae kg) were recruited and examined on three consecutive days. ultrasonographic images were optimised for the structure of interest. structures were identified based upon appearance and anatomical position. a minimum of three cineloops were obtained of the abdominal organs per intercostal space (ics) and three along the ventral midline in each ics; images were analysed offline. data were analysed using anova and post-hoc bonferoni, student's ttest and intra-class correlation coefficients. each structure was measured per ics per species; if no differences were noted for structures in different ics, then measurements were pooled. no differences were noted between hf and j cattle so data were pooled. data are displayed in table . good repeatability (icc . ) was obtained for all measurements and no differences were noted between animals of the same species or between days. these measurements for assessment of normal gi thickness are repeatable and may allow valuable additional information to be gained from ruminants with gi disease. ocular infections with the infectious bovine keratoconjunctivitis (ibk) agent moraxella bovis (m. bovis) are associated with significant economic loss in the cattle industry.although antibiotic therapy is the treatment of choice for ibk, treatment failures are common and current vaccines are not optimally effective mainly due to antigenic variation. as a result, our laboratory has been actively investigating the therapeutic potential of bdellovibrio bacteriovorus j (b. bacteriovorus); a predatory bacterium capable of attacking and inducing lysis of gram-negative bacteria, as a new treatment for ibk. we have previously shown that b. bacteriovorus can reduce the number of m. bovis attached to bovine epithelial cells in an in vitro model of ibk and that b. bacteriovorus can be trained to kill m. bovis as effectively as e. coli using serial passages. in this study, we hypothesized that b. bacteriovorus can remain viable in bovine tears without its prey for up to hours. this hypothesis was addressed by incubating inocula of active b. bacteriovorus in its preferred media peptone yeast extract (pye) and comparing b. bacteriovorus viability in bovine tears or phosphate buffered saline (pbs) at time , , , , and hours. using a plaque assay to quantify the mean amount of plaque forming units (pfus) of b. bacteriovorus exposed to each treatment, it was determined that viability of b. bacteriovorus over time was comparable between treatment groups. overall, the results supported that b. bacteriovorus can remain viable in tears for up to hours in the absence of prey bacteria. further studies are needed to determine the therapeutic potential of b. bacteriovorus in an in vivo model of ibk. correction of the measured ionized calcium concentration (cca ) to a ph . is routinely applied in experimental studies in order to assist in the interpretation of measured values relative to a reference range. the equation most commonly used for ph correction in bovine plasma is: cca ph . cca  (- . Â{ . -ph}) . the validity of this equation for bovine plasma is unknown. accordingly, our first objective was to characterize the in vitro relationship between cca and ph for bovine plasma. feeding rations with a low dietary cation-anion difference (dcad) during late gestation mitigates periparturient hypocalcemia in dairy cows, particularly when chloride containing acidodgenic salts are fed. the mechanism for this beneficial effect remains unclear. our second objective was to determine whether hyperchloremia displaces calcium from binding sites to albumin, thereby increasing cca . the in vitro relationship between plasma log(cca ) and ph in was investigated using lithium heparin anticoagulated blood from healthy holstein-friesian calves. plasma was harvested and tonometered with co at c over a ph range of . - . . plasma chloride concentration (ccl -) was altered by equivolume dilution of plasma with electrolyte solutions of varying ccl -( ae , ae , and ae meq/l; mean ae sd). the slope of the linear regression equation relating log(cca ) to ph for tonometered plasma samples from the calves was - . ae . at normal values for cca ( . ae . meq/l), albumin concentration ( . ae . g/l), and ccl -( . ae . meq/l). the experimentally-determined value for the slope for bovine plasma was identical to that determined previously for human plasma. the formula for correcting cca in bovine plasma for change in ph from . is therefore: cca ph . cca  (À .  { . -ph}) . this equation is only valid at normal concentrations of albumin and chloride in plasma. equivolume dilution of plasma by electrolyte solutions of varying cclindicated that cca ph . increased by . meq for every meq/l increase in ccl -. in other words, plasma cca at a given ph increases directly in response to an increase in plasma ccl -, presumably because the additional chloride displaces calcium that is electrostatically bound to albumin. furthermore, the increase in cca is independent to the change in plasma ph induced by an increase in ccland decrease in plasma strong ion difference. our finding that hyperchloremia directly increases plasma cca provides an additional mechanism by which ingestion of high chloride (acidogenic) rations prevents the clinical signs of periparturient paresis. our finding is consistent with the results of other studies that indicate acidogenic salts that contain chloride as the predominant anion (ie, nh cl, cacl ) are more effective in increasing cca than equimolar quantities of acidogenic salts such as mgso . coagulase negative staphylococci (cns) are among the most common bacteria isolated from the bovine mammary gland. historically, these bacteria were lumped together as minor mastitis pathogens. modern molecular techniques have allowed accurate speciation and fingerprinting of the cns species. these methodologies have recently been applied to the study of cns in bovine mastitis. the aim of the studies presented here was to evaluate the role of individual cns species on milk somatic cell count (scc) and duration of intramammary infection (imi). in the first study, mammary quarter foremilk samples were aseptically collected from all lactating cattle ($ head) at the university of missouri dairy research center once monthly for months for bacterial culture and milk scc. staphylococcal isolates were speciated by sequencing the rpob gene and strain-typed using pulsed-field gel electrophoresis (pfge). using species and fingerprint data along with published definitions for staphylococcal imi, cns imis were identified. overall, species of cns were identified with staphylococcus chromogenes, s. cohnii, s. epidermidis, and s. simulans being most prevalent. duration of imi and scc data were analyzed using regression models accounting for repeated measures. mean milk scc and duration of imi were found to differ between cns species (p o . ). although most imis were of short duration ( month), staphylococcus capitis and s. chromogenes imis had longer mean durations of infection than or more of the other species isolated. mean sccs were under , cells/ml in most cases. however, staphylococcus simulans and s. xylosus imis were more inflammatory (mean , cells/ml) and had a higher mean scc than s. cohnii, s. epidermidis, and s. haemolyticus. to examine the relationship between cns imi and milk scc in a larger population of cattle, cns isolates from the canadian bovine mastitis research network (cbmrn) culture collection were obtained for speciation. speciation and fingerprinting were performed as above. isolates were from subclinical imi from before and after the dry period and from subclinical imi during lactation. data associated with each isolate were obtained from the cbmrn database. nine-hundred-thirty-eight isolates from mammary quarters in herds were successfully speciated. twenty-two different species of cns were identified. staphylococcus chromogenes was the most frequent species identified accounting for % of the infections. three species, s. chromogenes, s. xylosus, and s. simulans accounted for % of all infections. data were analyzed using a linear hierarchical repeated measures mixed model. differences in mean scc were found between some cns species and culture negative control quarters and also between different species of cns (p o . ). overall, our data demonstrate potential differences in pathogenicity between strains of cns that cause bovine mastitis. passive transfer of maternally derived antibodies via ingestion of good-quality colostrum within the first hours of life is crucial for the health and future productivity of dairy calves. however, infectious diseases can be transmitted via colostrum feeding, which may require use of a colostrum replacement product or pasteurization to decrease disease transmission. while pasteurization of colostrum is effective for sterilization, heating during pasteurization can alter the viscosity of colostrum, destroys important nutritional biomolecules, and has been shown to decrease colostral igg concentrations. the purpose of this study was to investigate the effect of high pressure processing (hpp) on the viscosity, igg concentration, and bacterial contamination of bovine colostrum. first milking colostrum samples were collected from cows from different farms, and ml aliquots of each sample were pooled for analysis. pooled colostrum was processed in triplicate using an isostatic press at mpa ( , psig) for , , , , and minutes. samples were tested for the effects of hpp on the viscosity, bacterial load (cfu/ml), and igg concentration. there was a significant decrease (p o . ) in bacterial load at each time point when compared to time . no significant difference in igg concentration was found between any time points. subjectively, the colostrum viscosity appeared to increase with the processing time, though the rheologic assessment has not been completed at this time. hpp appears to be an effective method to decrease bacterial contamination of colostrum while maintaining appropriate igg concentrations. minimizing the processing time or pressure may be necessary to maintain an acceptable viscosity of the colostrum. based on these results, additional studies are justified in order to determine the optimum combination of processing time and pressure and the effect of hpp on specific bovine pathogens. the heme-associated iron-binding apoprotein lactoferrin (lf) is known for its, anti-inflammatory, anti-parasitic, antimicrobial and bactericidal effects. lactoferrin demonstrates ubiquity throughout mammalian host biological fluids: saliva; tears; mammary secretions, as well as at mucosal surfaces. it is also released from immune cells under pathogenic stimulation. the purpose of this study which has been approved by western university's institutional animal care and use committee is to further characterize the mechanisms through which lf modulates inflammation in the face of bacterial endotoxin. it was hypothesized that lf would inhibit p phosphorylation. numerous studies speak to the ability of lf to alter leukocyte function, inhibit cytokine production, and bind lipopolysaccharide (lps); mechanisms through which it is believed to achieve its anti-inflammatory effects. recently, investigators demonstrated its ability to interact with host dna while others describe regulation of granulocyte adhesion and motility; elucidating its roles in the apoptotic signaling. in earlier studies, dawes me, et al. demonstrated lactoferrin's ability to limit the expression of inducible cyclooxygenase- and the gelatinase, matrix metalloproteinase - by lps-induced macrophages. the generation of these inflammatory mediators is modulated by pro-inflammatory cytokines such as interleukin- b (il- b) and tumor necrosis factor-alpha (tnf-a), the production of both being dependent on signaling through the p mitogenactivated protein kinase (mapk) pathway. peripheral mononuclear cells (  )isolated from buffy coat cells of healthy neonatal to -month old holstein calves were cultured in the presence and absence of lf ( ng/ml), lps ( mg/ml), anisomycin ( mg/ml), a known p activator -the positive control, and mm of sb , a known p inhibitor -the negative control. sample lysates obtained post culture was subjected to immunoprecipitation and kinase reactions. reactions were terminated under reducing conditions and evaluated using western immunoblotting. phosphorylation of activated transcription factor- (atf- ) by phosphorylated p served as the marker of investigation. immunologically reactive atf- expression by lps and anisomycin-treated cells was compatible with a prominent band at kd. evidence of lf-induced inhibition of lps-induced p- activation was observed in lanes representative of co-cultures of lf lps; lf anisomycin; and anisomycin sb , which was demonstrated by decreased immunological reactivity at kd. the findings here, suggest that lf interferes with lps-induced p- activation of transcription factor atf- , in vitro. this serves as additional proof of its potential use in attenuating the systemic effects of lps. six ( ) clinically normal, purpose-bred cats of similar age and body condition were imaged with [ f] fluorodeoxyglucose ([ f]fdg) and [ f]ftha by using dynamic cardiac-gated fused pet/ct for kinetic assessment of myocardial glucose and fatty acid uptake and metabolism, respectively. kinetic tracer uptake within the myocardium was achieved by initiating image data acquisition simultaneously with tracer injection. pet data were acquired over a hour period with the heart in the center of the scanner field of view. regions of interest were drawn in the left ventricular wall and thoracic aorta for the purpose of measuring the kinetics of tracer redistribution. serial blood samples were also taken during pet imaging for comparison with image data. the equilibrium biodistribution of both tracers was documented hour post-injection in a whole body pet/ct image. standard echocardiographic examination of cardiac structures was also performed. both radiotracers remained in the plasma fraction; however, [ f]ftha was cleared from the more rapidly than [ f]fdg (t / $ and $ min, respectively). the tracers were readily visualized within the feline myocardium in dynamic pet images and analysis of the blood pool clearance from the kinetic image data agreed with blood sampling data. myocardial uptake of each tracer was best described by a double exponential analysis and was rapid but variable among animals (range - bq/cc/min), although blood glucose levels were similar in all cats during image acquisition. physiologic [ f]fdg was observed in the brain, salivary tissue, gastrointestinal tract, renal pelves and urinary bladder, with [ f]ftha seen in the myocardium, liver and renal cortex. all cats were normotensive with normal echocardiographic parameters. this study demonstrates the utility of kinetic imaging using the left ventricle (lv) shape has been suggested to change from elliptical to more globular in response to chronic volume overload. real-time three-dimensional echocardiography (rt de) offers new modalities for lv assessment. the aim of the study was to investigate left ventricular changes in shape and volume occurring in response to different severities of naturally acquired myxomatous mitral valve disease (mmvd) in dogs using rt de. privately owned dogs were classified by standard echocardiography into: healthy ( ), mild ( ), moderate ( ) and severe mmvd ( ). a lv cast was obtained using semi-automated endocardial border tracking from rt de dataset, from which global and regional (automatically acquired basal, mid, and apical segments based on lv long-axis dimension) end-diastolic (edv) and endsystolic volumes (esv), lv long-axis dimension and rt de sphericity index, were derived. global and regional edv and esv increased significantly with increasing mmvd severity, assessed by mmvd group-wise comparisons and linear regression analyses using left atrial to aortic root ratio, and lv end-diastolic and end-systolic dimensions. all three segments contributed to the overall increased global volumes, but the mid edv segment was strongest associated with increasing lv end diastolic dimension (p . ). furthermore, lv long axis distance and lv sphericity index increased with increasing mmvd severity. the basal and apical edv segments were strongest associated with sphericity index (p o . ). in conclusion, this rt de study showed that increased lv edv, primarily in the mid segment, leads to rounding of lv apical and basal segments in response to increasing mmvd severity in dogs. dogs from shelters in florida with naturally acquired di infection were euthanized and necropsied. all adult di in each dog were sexed using morphological features. total worm burdens and numbers of males and females were recorded. no other information was available for any dog. all data, raw and transformed, were examined visually and descriptively. raw numerical data were further examined by a paired t-test; log-odds transformed data were examined by logistic regression. we also conducted a binomial distribution goodness of fit analysis assuming a null hypothesis of a m:f . . worm intensities ranged from to di per dog. eight dogs had unisex infections: / had all-female infections. dogs with lowintensity dual-sex infections were more likely to have greater numbers of female di. overall, sex ratios were equal (paired t-test, p . ). however, logistic regression demonstrated that the probability of being female is strongly affected by the total worm intensity, with lower intensities increasing the probability of having a predominance of female worms. our data show that di sex ratios in naturally-infected dogs equal when examining the entire dog population, but deviate to favor female worms at low worm intensities. these data could impact adulticide treatment strategies. the reasons for sex ratio distortion in di are unknown. we evaluated cardiac reverse remodeling after mitral valve repair under cardiopulmonary bypass (cpb) for mitral regurgitation in small breed dogs. fifty dogs (body weight . - . kg, age - years) with mitral regurgitation were treated between august and november . the cardiac murmur was grade / - / . the preoperative chest x-rays showed cardiac enlargement (vertebral heart scale (vhs) . - . ). echocardiography showed severe mitral regurgitation and left atrium enlargement (la/ao . - . ). after inducing anesthesia, a thoracotomy was performed in the fifth intercostal space. cpb was started by using a cpb circuit connected to carotid artery and jugular vein catheters. after inducing cardiac arrest, the left atrium was sectioned and chordae tendineae rupture confirmed. the chordae tendineae were replaced with expanded polytetrafluoroethylene. a mitral annulus plasty was also done, and the left atrium was closed. after de-clamping for restarting the heart, the chest was closed. heart rate decreased from - bpm to - bpm. the grade of cardiac murmur was reduced to / - / three months postoperatively, and the heart shadow was reduced (vhs . - . ) in the chest x-rays. echocardiography confirmed the marked reduction in mitral regurgitation and the left atrial dimensions (la/ao . - . ). mitral valve repair reduced enlarged cardiac size by reduction of regurgitant rate. pulmonary arterial hypertension (pah) is a well recognized condition in dogs leading to considerable morbidity and mortality. the majority of therapeutics has focused on endothelial dysfunction causing reduced production of vasodilators, such as nitric oxide and prostacyclin, coupled with overproduction of vasoconstrictors, such as endothelin- . more recently, it has been shown that the mitochondria play an important role in the development of pah as oxygen sensors and regulators of cellular proliferation. in pah, pulmonary artery smooth muscle cells undergo a metabolic shift from oxidative phosphorylation in the mitochondria to glycolysis in the cytoplasm as the major energy source and this leads to suppression of apoptosis and increased proliferation. dichloroacetate (dca) inhibits pyruvate dehydrogenase kinase to activate pyruvate dehydrogenase which catalyzes the rate limiting step for entry of pyruvate into the krebs cycle, thus increasing mitochondrial respiration. in three different rat models of pah, dca has been shown prevent and reverse pah by normalizing molecular pathology, stimulating apoptosis of pulmonary artery smooth muscle cells, and reducing pulmonary artery hypertrophy. dca has known toxic effects, including reversible hepatotoxicity and peripheral neuropathy, and has not been studied in any species with naturally occurring pah. the objective of this open label pilot study is to evaluate the therapeutic and toxic effects of dca in naturally occurring canine pah. three dogs with pah diagnosed by doppler echocardiography and no correctable underlying cause are enrolled in the study. dogs are orally administered mg/kg of dca divided daily for weeks, and then . mg/kg of dca divided daily for the remainder of the study. at baseline, , , , and weeks, an echocardiogram, cbc, serum chemistry profile, urinalysis, nt-probnp, blood uric acid, blood lactate, noninvasive blood pressure, nerve conduction study, and trough dca level ( hr post-dose) are obtained. the measured echocardiographic parameters include peak and mean tricuspid regurgitant flow velocity and pressure gradient, peak and enddiastolic pulmonary regurgitant flow velocity and pressure gradient, pulmonary valve flow velocity acceleration time and ejection time, pulmonary valve flow velocity time integral, right ventricular myocardial performance index, tricuspid annular plane systolic excursion, and systolic tricuspid annular tissue velocity. variables are inspected for normalcy and equality of variances and a two-sided paired t-test is used to compare the variables before and after treatment at each evaluation time. the basis for the role of the mitochondria in pah and the results of this pilot study will be presented to determine if dca warrants further study as a therapy for dogs with pah. study produced the strongest associations between the ncl phenotype and cfa markers. all ncl-affected tibetan terriers were homozygous for the same haplotype which extended for consecutive snps spanning . mb. none of the annotated genes within this target region had previously been associated with human or rodent ncl. we used dna from ncl-affected tibetan terriers to resequence the coding regions and intron-exon borders of several genes harbored within the target region and found a single base pair deletion, c. delg, in exon of positional candidate atp a . this deletion produces a frame shift and a predicted premature termination codon. we genotyped all tibetan terrier dna samples in our collection and found all ncl-affected tibetan terriers to be homozygous for the c. delg allele. eleven additional c. delg homozygotes were either less than years old, or lost to follow up. there were no known cases of ncl in the remaining tibetan terriers which were either heterozygous (n ) or homozygous for the ancestral allele (n ). atp a is a member of group of ion transport genes and has been associated with lysosomes. mutations in human atp a cause kufor-rakeb syndrome (krs), a rare neurodegenerative disorder with clinical features that include parkinsonism plus spasticity, supranuclear upgaze paresis, and dementia. post-mortem findings in krs have not been reported. we conclude that ncl in tibetan terriers is caused by a mutation in atp a . our results suggest that krs may be a form of adult onset ncl in humans. niemann-pick type c (npc) disease is a progressive neurological disorder characterized by dementia and ataxia, hepatic and pulmonary disease, and death typically within the first or second decade. despite the identification of causative mutations, the pathogenesis is not clear and therapies to successfully treat npc disease have been ineffective to date. the recent use of intravenously administered -hydroxypropylbeta-cyclodextrin (hpbcd), an fda-designated orphan drug (may ), in a small number of children with npc disease is based on favorable treatment outcome data in subcutaneously treated mouse and cat models. to rigorously evaluate the mechanistic, pharmacologic, and toxicity issues associated with hpbcd therapy in npc disease, we have utilized the spontaneous feline npc model harboring a missense mutation in npc (pc s), orthologous to the most common mutation in juvenile-onset patients. the feline npc model has clinical, neuropathological and biochemical abnormalities similar to those present in juvenile-onset patients making this model homologous to the most common disease form seen in human patients. we identified that intrathecal administration of hpbcd ameliorated all clinical aspects of neurological disease at least up to weeks of age (an age when untreated cats die) but had no effect on hepatic disease. we identified that while subcutaneous therapy with hpbcd at all doses ameliorated liver disease, only mg/kg substantially affected neurological disease but also resulted in early death due to pulmonary toxicity. finally, we identified a dose-related toxic effect of hpbcd on hearing function that had not been described in any other species. leukodystrophies are disorders of myelin synthesis and maintenance that affect cns myelin. they are subdivided as leukodystrophies, hypomyelinating disorders and spongy degenerations. although infrequently seen, several forms have been described in various dog breeds. we present a novel form of complex leukodystrophy consisting of hypomyelination and spongy degeneration that presents primarily with hind end tremors in border terrier puppies. three border terriers from two different litters (and lineages) are described here that presented with a history of shaking movements. the youngest dog was a -week old male. it was the only dog affected in the litter. the other two dogs were -week old female littermates. there were two unaffected males in the same litter. physical examination revealed no abnormalities. on neurological examination, the affected dogs displayed severe hind end tremors, with a characteristic swinging side-to-side movement (best described as ''rumpshaker''). the tremors also involved the head and thoracic limbs but to a lesser degree, and disappeared when the dogs were asleep or at rest. severe cerebellar ataxia was observed when the dogs ambulated. proprioceptive positioning was delayed in the pelvic limbs of all dogs. spinal reflexes and nociception appeared normal. necropsy was performed in all puppies. no macroscopic changes were observed. histologic evaluation of the cns revealed spongy degeneration and hypomyelination in all funiculi of the cervical and thoracic spinal cord. white matter of the frontal, temporal and parietal cortices had mild multifocal spongy degeneration and hypomyelination, whereas white matter of the cerebellum, medulla and pons showed severe diffuse spongy degeneration and hypomyelination with gliosis. the combination of reduced myelin formation combined with spongiform white matter changes in the absence of microglial responses suggest a complex pathogenesis affecting both oligodendrocytes' capacity to synthesize myelin and the stability of the myelin that was formed. the number of oligodendrocytes and axons appeared subjectively normal indicating a primarily hypomyelinating process. the clinical and pathological features of this disease have not been described in any other canine leukodystrophy. the primary and most striking clinical feature is the presence of severe tremors in the hind end, causing the ''rumpshaker'' pheynotype. genetic studies are underway to determine if the disease is inherited and the inheritance mode. a syndrome of border collie collapse (bcc) appears to be common in dogs used for working stock. this syndrome has also been called malignant hyperthermia, heat intolerance, exerciseinduced collapse and ''wobbles''. a presumptive diagnosis of bcc can only be made by eliminating other causes of exercise intolerance and weakness. the purpose of this study was to describe the clinical features of collapse in affected dogs and determine if there were characteristic clinical or laboratory features at rest or after exercise that could aid in diagnosis. seven adult border collies with a history of collapse during sheep herding (affected) and adult border collies regularly used for sheep herding but showing no signs of exercise intolerance (normal) were evaluated before and after participating in a videotaped minute exercise protocol consisting ofa series of continuous short outruns and fetches of three sheep in an outdoor pen. exercise was halted at minutes or earlier if there were signs of gait or mentation abnormalities. pre-exercise evaluation included physical examination, orthopedic and neurological exam. pre and immediate post exercise rectal temperature, pulse and respiration, patellar reflexes, ecg, cbc, serum biochemistry profile, cortisol, arterial blood gas and plasma lactate and pyruvate concentrations were measured. clinical parameters (gait, temperature, reflexes) and lactate and pyruvate concentrations were evaluated at intervals up to minutes after exercise. additional testing in affected dogs included measurement of acetylcholine receptor antibodies (achrab) and dna testing for dynamin-associated exercise induced collapse (deic) and the ryanodine receptor mutation associated with canine malignant hyperthermia(mh). one week after exercise affected dogs had thoracic radiographs and echocardiography performed and were anesthetized for emg and muscle biopsies. there were no significant differences in temperature, pulse, respiration, or any laboratory parameter at any time point between normal and affected dogs. no arrhythmias were detected. affected dogs were negative for the dna mutations tested and for achr ab. thoracic radiographs, echocardiograms, emgs and muscle biopsies were normal. the normal dogs had no alterations in mentation or gait during or after exercise. three of the affected dogs had exercise halted early ( min- min) because of altered gait or mentation. all of the affected dogs were abnormal in the minutes following exercise. abnormalities seen in all dogs included disorientation, dull mentation, swaying, falling to the side, exaggerated lifting of limbs each step, choppy gait, delayed limb protraction, scuffing of rear and/or forelegs, and crossing legs when turning. all dogs returned to normal by minutes. bcc appears to be an episodic nervous system disorder that can be triggered by exercise. genetic testing excluded deic and the described canine mh mutation. common causes of exercise intolerance were eliminated, but the cause of collapse in bcc was not determined and no clinical or biochemical marker to aid diagnosis was established. equine cushing's disease (ecd) is common in older horses. the purpose of this study was to determine the frequency of diagnosis, identify prognostic factors and assess owner satisfaction with treatment. the study was a retrospective cohort design evaluating equine accessions reported to the veterinary medical data base (vmdb) and the ohio state university from - . proportional accessions, annual incidence and demographic characteristics of horses with ecd were compared with all accessions in the vmdb. medical records for a subset of horses were extracted and owners contacted to obtain long-term follow up information. two hundred seventeen new cases of ecd were reported to the vmdb. incidence increased from . / , in to . / , in . eighty-one percent of horses were ! years of age. average delay from onset of signs to diagnosis was days (range to , days). hirsutism ( %) and laminitis ( %) were the most common clinical signs. improvement in one or more signs months after diagnosis was reported by / ( %) of horse owners. none of the clinical or laboratory data were associated with survival and, % of horses were alive, . years after diagnosis. / ( %) of horses were euthanatized and / ( %) were euthanatized due to conditions associated with ecd. twenty-eight of ( %) of horse owners said they would treat a second horse for ecd. ecd is becoming a more frequent diagnosis. fifty percent of horses survived . years after diagnosis and owners were satisfied with the horse's quality of life. supported by centers of excellence in livestock diseases and human health, college of veterinary medicine, university of tennessee. the role of the hypothalamic-pituitary-adrenal (hpa) axis in sepsis has been a subject of a great deal of research. the role that the somatogenic axis plays in sepsis is less well understood and how these two axes interact during critical illness is not clear. the purpose of this study was to assess inter-relationships of adrenocorticotropin (acth), cortisol, and insulin-like growth factor-i (igf-i), in septic and non-septic term foals. blood samples were obtained from term septic foals less than days of age (n ) admitted to texas a&m university veterinary medical teaching hospital or mid-atlantic equine hospital. the foals were classified as septic by a sepsis score ! and/ or a positive blood culture. non-septic term foals less than days of age (n ) and having a sepsis score o and a negative blood culture, were obtained from texas a&m university veterinary medical teaching hospital and mid-atlantic equine hospital. plasma and serum were processed from whole blood collected by jugular venipuncture upon admission, at hours post admission and at days post admission or at the time of discharge. plasma concentrations of acth, and serum concentrations of cortisol and igf-i were determined by specific rias. data were analyzed using linear mixed-effects modeling with foal modeled as a random effect and day of admission modeled as an ordered categorical variable; post-hoc testing of pair-wise comparisons was made using the method of sidak. significance was set at p o . , and analyses were performed using s-plus software (tibco, inc., seattle, wa). plasma concentrations of acth were not significantly different between septic and non-septic foals whereas septic foals had greater serum cortisol ( ae ng/ml vs ae ng/ml) but lower serum igf-i ( ae ng/ml vs ae ng/ml) relative to non-septic foals pooled overall sampling times. the positive association of the peripheral blood concentrations of acth and cortisol depended on disease status of the foals. specifically, cortisol and acth were positively correlated for the septic foals (p . ) but not significantly correlated in the non-septic foals. peripheral concentrations of acth and igf-i were not significantly correlated whether data were pooled overall or stratified by sepsis status. however, peripheral concentrations of cortisol and igf-i were negatively associated (p . ); disease status did not influence this association, although it appeared to be a stronger association for the septic than the non-septic foals. the negative correlation between serum concentrations of the adrenal axis steroid cortisol and the somatogenic axis peptide igf-i may reflect interactions of these homeorhetic hormones. further studies of these and other metabolic hormones in a greater number of foals are warranted to better understand how these factors contribute to survival or non-survival of critically ill foals. botulism is a potentially fatal paralytic disorder which definitive diagnosis is difficult. the purpose of this study was to investigate if repetitive stimulation of the common peroneal nerve will aid in the diagnosis of suspected botulism in foals. four healthy foals were used for its comparison with foals with suspected botulism. controls were anesthetized and affected foals were sedated to avoid risks of anesthesia. the common peroneal nerve was chosen for its superficial location and easy access. stimulating electrodes were placed along the common peroneal nerve. for recording, the active and reference electrodes were positioned over the midpoint and distal end of the extensor digitorum longus muscle, respectively. repeated supramaximal stimulation of the nerve was performed utilizing a range of frequencies ( to hz). amplitude, area under the curve and percentages of decrement or increment for each m wave over subsequent potentials for each set of stimuli were analyzed. baseline m waves were decreased in affected foals compared to controls. a decremental response was seen at all frequencies in control foals. decremental responses were also observed in affected foals at low frequencies. however, an incremental response in amplitude and area under the curve was seen in all affected foals at hz. reduced baseline m waves with incremental responses at high rates are supportive of a presynaptic neuromuscular disorder which botulism was the most likely cause in these foals. repetitive nerve stimulation is a safe, simple, fast, and non-invasive technique that can aid in the diagnosis of suspected botulism in foals. this study examined the frequency with which dogs are exposed to e. chaffeensis and e. ewingii relative to e. canis, which is transmitted by the more ubiquitously distributed brown dog tick (rhipicephalus sanguineus). a total of , canine serum samples, ranging from to from each of the participating institutions, collected at random from clinical accessions, diagnostic laboratories and/or shelters were evaluated. all serum samples were tested by three microtiter plate elisas using species-specific peptides for antibodies to e. canis, e. chaffeensis and e. ewingii. zip code information for sample origin was provided by the collaborator and was used to assess seroprevalence by region. comparisons were evaluated using the chi-square test. seroreactivity for at least of ehrlichia spp was found in samples from every institution both mississippi and oklahoma had greater than a % samples from ohio had the lowest aggregate seroprevalence ( . %) with only dogs e. canis seropositive, one e. ewingii seropositive and no e. chaffeensis seroreactors. the geospatial pattern of e. chaffeensis and e. ewingii seropositive samples was similar to that previously reported based on modeling seroreactivity to e. chaffeensis in white-tailed deer as well as the distribution of human monocytic ehrlichiosis (hme) cases reported by the cdc. this study provides the first large scale regional documentation of canine exposure to these three ehrlichia spp., highlighting where infections most commonly occur and thus identifying areas where heightened awareness about these emerging vector urinary incontinence (ui) occurs in approximately % of spayed female dogs. the most common cause is urethral sphincter mechanism incompetency (usmi). pharmacological agents are effective, however, not all dogs respond, and dogs may become refractory to treatment over time. urethral bulking, where a compound is injected submucosally in the urethra, has been used in women and in female dogs with urinary incontinence. new synthetic compounds have been used in human medicine; the most promising is polydimethylsiloxane (pdms), which has been shown to be more effective than glutaraldehyde cross-linked collagen. the purpose of this descriptive clinical trial is to evaluate the safety and effectiveness of pdms urethral bulking agent (pdms uba) in client-owned, spayed female dogs with naturally-occurring ui due to usmi.twenty-two, spayed female dogs were included. dogs had a median age of years ( to years). eighteen dog breeds were represented, and dogs weighed a median of . kg ( . to . kg). average length of time of ui was . ae . years; / dogs had been treated medically, of which / were continent, / were improved, and / had no improvement. dogs were deemed healthy based on results of physical examination, complete blood cell counts, plasma biochemical analysis, and urinalysis; urine cultures were negative.dogs were anesthetized, positioned in dorsal recumbency, and cystoscopy performed using a . mm, -or -degree, cm rigid cystoscope. urethral bulking was performed with pdms uba. on average, . ae . ml were injected in to locations approximately to . cm distal to the trigone submucosally in the proximal urethra. good coaptation was achieved in all dogs. the procedure took on average . ae . minutes. one dog experienced urethral obstruction after the procedure; a foley catheter was inserted for approximately hours and removed at which time she urinated normally and was continent. three dogs experienced an acute allergic reaction characterized by blepharedema and urticaria treated successfully with diphenhydramine. dogs were discharged on day of procedure except for the one dog that experienced urethral obstruction. all dogs were treated with meloxicam ( . mg/kg po q h for days).owners were contacted on day after discharge and / dogs were continent; / dogs was improved. dogs were re-evaluated week after discharge and / dogs were continent and / dogs polyneuropathy in large breed dogs is a relatively common clinical problem for which the genetic basis is generally unknown. the first cases of polyneuropathy in the leonberger breed (leonberger polyneuropathy or lpn) were identified in by one of the authors (gds) and a report published in (musclenerve : - ) . in this report a spontaneous, distal and symmetrical polyneuropathy with onset between to years of age was described and characterized clinically, electrophysiologically, histologically and morphometrically. there were striking similarities between lpn and the charcot-marie-tooth group of human inherited sensory and motor polyneuropathies, which have many known genetic mutations.a genome-wide case-control association study for lpn was performed with cases and controls on high-density k canine snp arrays and revealed a significantly associated region on cfa (p raw .  À p genome .  À ). a clear association of an approximately mb cfa haplotype with cases (p .  À ) was observed, particularly with those cases that were affected more severely and at a younger age (p .  À ). a positional candidate gene, arhgef , which has previously been associated with peripheral nerve abnormalities in humans, was sequenced, revealing a deletion that results in a frame shift and premature stop codon. of all leonbergers with young onset lpn (before years), . % ( of ) have two copies of this deletion, and, of all young onset leonbergers that are nerve biopsy positive for lpn, . % ( of ) have two copies of this deletion. importantly, nearly all dogs carrying two copies of the deletion ( of or . %) are affected with lpn by the age of years.the leonberger breed was generated from crossing several breeds, including the st. bernard, and a polyneuropathy clinically and histologically similar to lpn occurs in this breed. to determine if the arhgef mutation was associated with polyneuropathy in the st. bernard, dna was extracted from archived frozen muscle biopsy specimens from clinical cases (n ). the identical arhgef startle disease or hyperekplexia is caused by defects in mammalian glycinergic neurotransmission resulting in an exaggerated startle reflex and extensor hypertonia triggered by noise or touch. in humans and animals, startle disease is typically caused by mutations in one of three genes (glra , glrb, and slc a ) encoding postsynaptic glycine receptor subunits (a and b) or a presynaptic glycine transporter (glyt ). a litter of seven irish wolfhounds was recently identified in which two puppies developed muscle stiffness and tremor beginning at - days of age post-partum. signs were dramatic when the puppies were handled and resolved when the puppies were relaxed or sleeping. both puppies were euthanized due to ongoing stiffness, tremor and breathing difficulties. necropsies were performed, but no microscopic pathological abnormalities were identified in the peripheral or central nervous system.based on the clinical signs, exons from the three candidate genes were amplified from genomic dna isolated using pcr and directly sequenced. no deleterious polymorphisms were identified in either glra or glrb. however, difficulties were experienced in amplifying slc a exons and from affected animals, although control samples were positive, suggesting that the pcr primer designs and conditions were not at fault. further pcrs revealed that the reason for this anomaly was the presence of a homozygous . kb deletion encompassing exons and of the glyt gene in both affected animals. this deletion is predicted to result in the loss of part of the large cytoplasmic n-terminus that is vital for trafficking of glyt to synaptic sites, and a loss of all subsequent transmembrane domains via a frameshift. this genetic lesion was confirmed by defining the deletion breakpoint, southern blotting and multiplex ligationdependent probe amplification (mlpa). this analysis enabled the development of a rapid genotyping test that revealed heterozygosity for the deletion in the dam and sire and three other siblings, suggesting recessive inheritance of this disorder. wider testing of related animals has identified a total of carriers of the slc a deletion and enabled the identification of non-carrier animals to guide future breeding strategies. insulin resistance (ir), obesity, and type diabetes affect glucagon-like peptide (glp- ) concentrations in humans and rodents, but this incretin hormone has not been examined in horses. we therefore hypothesized that glp- concentrations would change in horses as obesity and ir were induced or exacerbated by overfeeding. six horses previously diagnosed with equine metabolic syndrome were provided with twice the amount of digestible energy required for maintenance as sweet feed and hay for weeks. intravenous and oral glucose tolerance tests (ogtts) were performed at and weeks. effects of time and period ( and weeks) were assessed by repeated measures anova.mean body weight increased from ae kg (range, to kg) to ae kg (range, to kg) over weeks, with individual horse weight gain varying from to %. mean body condition score increased (p . ) from ae (range, to . ) to ae (range, to ). three horses developed mild laminitis. glucagon-like peptide concentrations increased over time during ogtts (p . ), but the period  time effect was not significant (p . ). area under the glp- curve remained unaffected by weight gain, whereas area under the insulin curve increased (p . ) over time, indicating a reduction in insulin sensitivity. obesity and ir were induced or exacerbated when horses previously diagnosed with ems were overfed, but glp- concentrations did not change as a result. hypertonic saline solution ( . %) (hss) is an intravenous fluid used for the emergency treatment of intravascular volume deficits. the use of this fluid in horses with severe dehydration is controversial. the purpose of this study was to compare the use of hss and isotonic saline solution ( . %) (iss) for the emergency treatment of endurance horses.endurance horses eliminated from competition and requiring intravenous fluid therapy were eligible for enrollment in the study. twenty-two horses were randomly assigned to receive ml/kg of either hss or iss along with l lactate ringer's solution (lrs). following this bolus, all horses were treated with an additional l of lrs. blood and urine samples were collected before, during and after treatment. data was compared using two-way anova with repeated measures.as compared to iss, hss horses showed a greater decrease in pcv (p . ), total protein (p . ), albumin (p . ), and globulin (p . ). hss horses showed a greater increase in sodium and chloride (p o . ) as compared to iss horses. horses receiving hss had a shorter time to urination (p . ) and lower specific gravity (p o . ) than those receiving iss.results of this study indicate that hss may provide faster restoration of intravascular volume deficits than iss in endurance horses receiving emergency medical treatment. more profound electrolyte changes should be expected with hss however. b -adrenergic receptor agonists have been shown to increase erythrocyte carbonic anhydrase activity, which may stimulate the jacobs-stewart cycle and increase pulmonary circulation transvascular fluid fluxes during exercise. increase in pulmonary transvascular fluid fluxes (j v-a ) and consequent increase in the pulmonary interstitial fluid would be detrimental for alveolar o exchange during the fast erythrocyte transition time across the pulmonary capillaries. therefore, we hypothesised that treatment with inhaled b -adrenergic receptor agonist will increase j v-a and the alveolar-arterial po difference (aado ) during exercise.six stb horses were exercised on a high-speed treadmill at % vo peak until fatigue. horses were randomly assigned to treatment with salbutamol (sal: mcg) or placebo (control: con) inhalation via aeromask à min prior to exercise, with cross over treatment used at the repeated exercise test ( days later). arterial and mixedvenous blood, as well as co elimination and o uptake, were sampled simultaneously at rest, during exercise at sec intervals until fatigue, and into recovery. blood gases were analyzed. aado was calculated using the inspired po ( mmhg), and blood partial pressure of o and co . blood volume (%) changes across the lung were calculated from changes in hemoglobin and hematocrit values in venous and arterial blood. cardiac output (q) was calculated using the fick equation. j v-a was calculated using q and blood volume changes across the lung. variables were analyzed using two-way repeated-measures anova (p o . ).the duration of exercise to fatigue was . ae . min and . ae . min in both con and sal, respectively. at rest sal had no effect on j v-a , oxygen consumption (vo ), blood oxygen saturation (so ) or aado (p . ). at the onset of exercise j v-a increased in con and sal (p o . ) and at fatigue reached . ae . l/min and . ae . l/min, respectively. treatment with sal had no effect on j v-a during exercise (p . ). at the onset of exercise so and vo increased in con and sal (p o . ). treatment with sal had no effect on so or vo during exercise (p . ). aado increased during exercise in con and sal (p o . ) and at fatigue reached . ae . mmhg and . ae . mmhg, respectively. treatment with sal had no effect on aado during exercise (p . ).inhaled b -adrenergic receptor agonist salbutamol at the dose of mcg given min before exercise did not affect the duration of exercise to fatigue, j v-a , vo , so or aado . therefore, it had no detrimental effect on alveolar-capillary diffusion distance and the ventilation/perfusion mismatch in exercising horses. inflammatory airway disease (iad) and recurrent airway obstruction (rao) represent two classes of equine lung inflammatory diseases that may share some similar immunologic mechanisms. there is evidence that th cytokines and il- play some role in rao. iad is a common condition in horses, but its pathophysiology is still not understood. the aim of the present study was therefore to determine the mrna expression of th , th and th inflammatory cytokines, to understand the immunological mechanisms of iad.the mrna expression of ten inflammatory cytokines and chemokines was measured in the bronchoalveolar fluid (balf) of seventeen horses with iad and compared with ten control horses. the horses were selected based on -their clinical signs, -the inflammatory cells count in the balf, -their physical examination and -their medical history. the mrna expression of il- , il- b, il- , il- and il- was significantly up-regulated in balf from horses with iad.furthermore, the balf samples were subdivided in two groups based on the differential cells count -balf with increased mast cells (iad-mast) and -balf with increased neutrophils (iad-neutro). il- was significantly down-regulated in the iad-neutro group compared to the iad-mast group. il- , il- and il- were significantly up-regulated in the iad-neutro group compared to the iad-mast group.the present study shows that iad in horses is characterized by a th and a th mrna inflammatory expression profile and that different immunological mechanisms are involved in mast cells or neutrophils accumulation in the balf of horses with iad. b -adrenoreceptor (b -ar) agonists are a class of medications that promote smooth muscle relaxation and bronchodilation in horses and humans with airway disease. activated human peripheral blood lymphocytes (pbls) also respond to b -ar agonist stimulation by attenuating the production of cytokines associated with the pathogenesis of asthma and recurrent airway obstruction (rao). the aim of this study was to develop an in vitro technique for measuring the response of equine pbls to stimulation with salbutamol, a b -ar agonist. this method was then used to compare the response of pbls from rao-affected and non-affected horses to b -ar agonist stimulation. pbls from rao and nonaffected horses were cultured ( x /ml) in rpmi complete media with concanavalin a (cona, ug/ cells) for , , or days then stimulated with salbutamol ( minutes). using flow cytometric techniques, response was measured by detecting protein kinase a phosphorylation of vasodilator stimulated phosphoprotein (vasp). results were verified by western blot analysis. activated pbls were then incubated with cona for one day were pre-incubated with b or b-adrenoreceptor antagonist (ici , , sigma s ; atenolol, sigma s ) for minutes, followed by minutes salbutamol ( nm) stimulation. results were analyzed by anova or ancova and differences were considered significant when p o . .response to b-antagonist was only observed in activated pbls (pre-cultured with con a) and was greater in cells from rao horses as compared to cells from non-affected horses. the addition of b-antagonist attenuated the response of pbls to salbutamol while the addition of a b -antagonist had no effect. these findings indicate that activated pbls from rao-affected horses have a greater response to salbutamol as compared to pbls from non-affected horses, and this response is mediated mainly through the b -ar.human b -ar are known be polymorphic and this polymorphism results in a variable response to b -agonist binding that affects long term outcome in human asthmatics. further studies are required to determine if the difference in response of pbls from rao affected as compared to non-affected horses is due to genetic polymorphism in the equine b -ar, and whether this difference is associated with a propensity for horses to develop equine rao. key: cord- -ak pq authors: nan title: th european congress of intensive care medicine athens - greece, october – , abstracts date: journal: intensive care med doi: . /bf sha: doc_id: cord_uid: ak pq nan objectives: evaluate the levels of tnf, il- and pai-i in different moments of the ards and the possible relationships among them. methods: septic patients with ards were studied. also significant differences for: tnf, pai-i and il- in septic patients and both evaluations of ards with control gropup; pai- between septics and nd evaluation in ards, and between the ist and nd evaluation in ards; il- between septics and both evaluations in ards; and il-~ in both evaluations in ards patients in relation to mortality. conclusions: i) elevations of tnf, pai-i and il- , with clinical signs, are suggestive of infection; ) the persistent and progressive elevation of pai-i with any clinical criteria may suggest evolution to ards; ) due to its own kynetics, il- takes part later in the acute phase, its levels being related to the magnitude of the injury in the tissues. objectives: the influence of long-term volume therapy with different solutions on plasma levels of circulating adhesion molecules was studied. methods: according to a randomized sequence, patients with sepsis secondary to major surgery exclusively received either hydroxyethylstarch solution ( % hes, mean molecular weight (mw) , daltons, degree of substitution (ds) . ) or human albumin % (ha) for volume therapy for days. plasma levels of circulating (soluble) adhesion molecules (endothelial leukocyte adhesion melecule- [selam -i] , intercellular adhesion molecule- [sicam -i] , vascular cell adhesion molecule- [svcam -i] , and p-selectin ) were serially measured on the day of admission to the intensive care unit (='baseline ' value) and during the next days. results: selam-i, sicam-i, and svcam-i plasma levels were markedly higher than normal at baseline in both groups. in the hes-patients, selam-j decreased to normal range, whereas it further increased in the ha-group (from • to • during the study period, sicam-i and svcam-i plasma levels remained unchanged in the hes-patients, but further increased in the ha-group (from • to , • sgmp- increased significatly only in the ha-group ( • to • only pao /fio was significantly correlated to plasma levels of adhesion molecules. conclusions: sepsis is associated with markedly elevated plasma levels of adhesion molecules indicating endothelial activation or damage. by long-term volume therapy with hes, these levels remained unchanged or even decreased, whereas volume therapy with human albumin did not have any beneficial effects on soluble adhesion. central venous catheters are frequently used in the care of the critically ill patient. the incidence of catheter related sepsis varies in the literature. we investigated the occurrence of contamination and sepsis compared to results of the epic study as part of quality assesment in our intensive care unit. from january until august all removed central venous catheters were examined for microbiological culture. the patients who showed signs of sepsis were also registered. the results of the contaminated catheters and septic patients were compared with results from the epic study. during the month period , patients were hospitalized on our intensive care unit. central venous catheters were examined for microbiological culture. specimens appeared to be possitive ( %). patients showed clinical signs of sepsis. the incidence of sepsis due to contaminated central venous catheters was / ( %). the incidence of sepsis due to the presence of all central venous lines was / ( %). the microorganisms responsible for the sepsis syndrom were : stapylococcus aureus (n= ), escherichia colt (n= ), others (n= ). in the epic study the percentage for sepsis on the icu was . % for the netherlands and . % for europe. despite a high number of positive culture from removed intravascular lines, a low percentage of sepsis was seen compared to results of the epic study. we recommend routine bacteriological culture of all removed central venous lines and recommend to look at colonization and sepsis due to intravascular lines as a measure of quality control in the intensive care unit. objectives: prognostic assessment of simplified acute physiology score (saps) in granulocytopenie patients with septic shock (ss). methods: the medical records of admissions to an intensive care unit (icu) of granuloeytopenic patients with ss are reviewed. fiftytwo patients had haematological malignancies. seven patients had aplastie anaemia. patients were categorised as survivors (discharged from icl and non-survivors (died in the icu). saps index was calculated for patients daily during their stay in icu. all patients were severe granulocytopenic (total white cell count less than , ] ] ). results: five patients ( , %) were discharged from icu. fifty-four patients died in icu. non-survivors had saps on admission higher than survivors ( . + . and . + . , respectively, p< , , mann-whitney u test). no patient with a saps greater than survived. mortality among the patients with saps from to was , %o. the evolution of ss was rapid. the mean stay in icu among non-survivors was only hours. an analysis of the saps index on admission of non-survivors showed an inverse correlation with the duration of their stay in icu (r=- , , p= . ). all survivors recovered from granulocytopenia. they had normal white cell counts at the time of discharge from icu. there was inverse correlation in survivors between saps and white cell counts, when these parameters were evaluated daily. however, the saps index alone cannot be considered to be on individual predictor factor of mortality. patients who had failure of the malignancy to respond to chemotherapy and who had persistent granuloeytopenia died in icu despite saps index on admission and recovery from ss. conclusion: saps index greater than , failure of the malignancy to respond to chemotherapy and persistent leueopenia all point to a poor outcome of granulocytopenie patients with ss. introduction: antipyretics sometimes are used for fever control in febrile neutropenic patients with hematological malignancies(hm). we observed a dramatic fall of blood pressure(bp) and development of septic shock(ss) in some of the patients who received antipyretics. aim: to clarify can antipyretics provoke ss in neutropenic patients with infection. methods: retrospective review of medicat records of neutropenic(wbc < , / )patients with hm, admitted to the intensive care unit for ss, was performed. there was selected group of patients receiving antipyretics shortly before a fall of bp. results: there was a definite causal relationship between receiving antipyretics and fall of bp in from patients. all patients had fever due to infection and had normal level of bp before receiving antipyretics. hypotension developed within minutes up to , hours after administration of antipyretics. three patients received , g of metamisol and one , g ofparacetamol per os. in all cases we observed dramatic diaphoresis and the temperature fall to subnormal level ( . + . ~ accompanied'by hypotension. but in - hours the fever was coming back without blood pressure elevation. the fluid replacement was controlled by central venous or wedge pressures. there were required + ml colloid and cristalloid solutions for volume loading. in spite of fluid administration the hypotension persisted and all patients required inotropic therapy. only one patient survived and is alive now. conclusion: it seems to us that our data offer to state that antipyretics administration can initiate ss in febrile neutropeuic patients with infection. objectives: to assess the agreement between cardiac output (co) measured by odm t and by other methods used in icu patients. methods: we prospectively studied adu t patients requiring hemodynamic monitoring with a pulmonary artery catheter. an esophageal doppler monitor provided measurements of co (odm), stroke volume and flow time (ft) used as an indirect evaluation of patient's volume status. patient hemodynamic status was evaluated by a modified fast response pulmonary artery catheter (baxter health care corporation, santa ana, ca), allowing co measurements by thermodilution "d) and an evaluation of right ventricular ejection fraction and end diastolic volume (rvef and rv-edv). in the last six patients co was measured by transthoracic echocardiography (echo) and oxygen consumption was measured by a deltatrack ii metabolic monitor (datex) allowing co calculation according to the fick formula (fick). the agreement between methods measuring co and their reproducibility, were evaluated by bland and altman analysis. results: agreement between co measurements is expressed as bias (d) and % limits of agreement (l of a = d_+ sd . td-fick - . - . to . fick-echo . - . to . there was no correlation between ft and rv-edv. conclusions: although co measurements by odmil had the best reproducibility, the limits of agreement between the four methods tested were unacceptable for clinical purposes. further investigation is required in order to improve the accuracy of co measurement in the icu. phd, a. paltzev, v.bajbikov, b.dobryakov d.sc., a.ostanin phd, o.leplifia phd, h.chernykh phd munieip. hosp. n l, n ; inst. of clin. immunol., novosibirsk, russia objectivies: efficiency of native cytokines used in the treatment of patients with severe surgical infections has been studied. methods: for two years patients were treated with cytokine mixture (ssp) obtained by arterio-venous perfusion of swine spleen and contained the following cytokines: il- , il- , il- , tnfa, ifny, gm-csf. results: ssp intravenous infusions were shown to accompany with mortality decrease from . % to . % in patients with abscessed pneumonia and lung abscesses and from % to % if disease course was complicated with sepsis. in patients with purulent peritonitis and sepsis efficiency of ssp was decreased due to endotoxieosis. thus, we used adoptive immunotherapy with mnc activated in vitro with ssp or recombinant il- . intravenous infusions of such cells resulted in transformation of a pathologic process from destructive into productive one. moreover, clinical manifestations of sepsis were controlled in % and mortality was decreased from % to %. conclusions: the use of eytokines themselves as well as cytokine-treated lymphoeytes permits to control the disease and leads to the mortnlity decrease owing to stimulation of host defence mechanisms. background: although red blood cell transfusions (rbct) are used to increase oxygen availability in septic patients, several lines of evidence suggest that rbct may actually worsen tissue hypoxia. thus, rbct may negatively influence outcome of septic patients. objectives: to determine the association of ) rbct ; ) number of units transfused; and ) mean age of the units transfused on the first day of transfusion with mortality of critically ill septic patients. methods: we prospectively identified patients who met strict criteria for sepsis syndrome (ss) seen in the icu of st. paul's hospital from to and excluded patients who died in the first days after the onset of sepsis. we recorded clinical characteristics, multiple system organ failure score, and apache ii at onset of sepsis. then, we retrospectively recorded the total number and age of rbc units transfused during the first days after onset of sepsis. overall -day mortality was %. results: the main results are shown in the table. the mortality of patients who received rbct was nearly double the mortality of those who did not receive rbct even after adjusting for severity of illness using apache ii. objectives: gastric mucosal acidosis is frequently observed in patients with sepsis. the aim of this study was to determine whether volume infusion using pentaspan| decreases abnormal gastric mucosal pco (pico ) in patients who have sepsis syndrome (ss) who have already been resuscitated using clinical endpoints. methods: we prospectively identified patients who met strict criteria for ss, had a pulmonary artery catheter and a gastric tonometer in place, and pico > mmhg. pentaspan| ( ml) was infused in rain. measurements of hemodynamics, hemoglobin, arterial lactate, blood gas analysis, and pico were performed before and repeated miff and hr after pentaspun| infusion. we calculated the pico -arterial pco' difference (pico -paco ) and phi (using henderson-hasselbach equation). anova was used to assess statistical significance. results: all patients werereceiving adrenergie drugs. map was : : mmhg and lactate . : : . mmol/l. pentaspan| increased ci by % (p< . ) but did not change pico ( and increase m oxygen o* wery were simimny achieved in both groups. nevertheless, epinephrine was associated with a lactic acidosis and increased laetate/pyruvatemia ratio (l/p) that evoke a dysoxia rather than a metabolic effect. an higher gastric mucosal pco in the ep group compared to nor-rob suggests the hypothesis of an anaerobic production of co in favor of a splanchnic hypoxia. in both group, arterial ketone body ratio that reflects hepatic mitochondrial redox state, compared to a control group without shock was decreased but increased between and hours after restoration of arterial pressure. the association norepinephrine-dobutamine seems to be better for splanehnic circulation than epinephrine and should be used for dopamine resistant septic shock. moreover, the increase in arterial pressure with nor-dob improved gastric mueosal ph and hepatic mitochondrial redox state and argue to reconsider arterial pressure as a significant goal for resuscitation in septic shock. conclusion: significantly higher malondialdehyde and ghitathione levels and glutathione-peroxidase activity in group ns at the end of icu stay were related to mortality these findings indicate an increased generation of free oxygen radicals together with increased anfioxidant activity in this group and sapport the employment of antioxidant interventions in critically ill patients. oblecfives: to determine the role of nitric oxide (no) in the mechanism of septic shock induced by isolated limb perfuslen with recombinant tnfcr methods: we have measured tnfr~ and metebo~ites of no in patients with signs ot septic shock following treatment with isolated limb perfusion for nonresectable soft tissue tumors and melanomas of a limb. perfuslen was carried out with melphalan (burroughs wellcome) and recombinant tnfcr (boehringer). tnfc~ was determined by specific radiometric assay (medgenix diagnostics), nitrate and nitrite were measured with a modification of the guess reaction ~. results: results are shown in the table. conclusions: during isolated limb pedusion with recombinant tnf~ very high levels of tnfcr were measured in arterial blood in patients. they all showed signs of severe sepsis syndrome with shock from vasodilafion, probably due to leak of recombinant tnft~ from the peduslen circuit to the systemic circulation. tnfc~-induced vasodilation was not accompanied by a rise in serum no-metsbolites. our findings do not confirm the widely accepted theory, mainly based on animal experiments, that genera• of no is the key pathogenefic mechanism in septic vasodilafion , nor that tnfrt invariably induces forreafion of no. the precise mechanism of shock in these patients remains to be elucidated. references: . moshage h, kok b, huizenga jr, jansen plm nitrite and nitrate determinaiions in plasma: a critical evaluation. clin chem : / . . moncada s, higgs a. the l-argioine-nitrio oxide pathway. n engl j med ; : - ec is a commonly used for prolonged, stable animal anesthesia. noting that the hypotension after iv lps was attenuated by ec, we hypothesized ec also protects against lps toxicity. sprague-dawley rats received ip saline (s), thiobutabarbita mg/kg (tb), or varied doses of ec, followed hours later by bolus mg/kg iv lps. -day survival is shown below: group: s tb ec( . gmikgi ec( .sgm/kg) ec(i. gm/kg) alive (n) t ~ total (n) s s "signiflcant;y different from all other groups, p< . s / rats given lps followed hours later by ec ( . gm/kg) also died. additional rats were treated with s (n= ) or gm/kg ec (n= ) followed by mg/kg lps, then sacrificed at hours. blood glucose (bg, mg/dl),.hematocrit (hct), leukocyte count (wsc/mm~ platelet count (pltxl ~/mm ), bicarbonate (hco, mg/dl), gross bowel hemorrhage (bh, - scale) and lung myeioperoxidase activity (mpo, ~vmirvgm wet lung) are shown below ( we conclude that ec reduces the lethality and multiple organ toxit;~ty of lps. its diverse effects suggest asite of activity upstream from the cytokine cascade. these results are important for studies of lps which may use ec anesthesia and may have potential in the therapy of septic shock. [zo = hz impedance (z; {dyn.sec.cm " }); zl = first harmonic z; zc = characteristic z; z ph. = t'trst harmonic phase angle {radians}; f, #, * at least p < . between fio . and . , fio . and fio . &no - . _+ . - . _+ . # - . + . m - . + . * - . + . * - . + . * - . _+ . * in hyperoxia, compared to dogs at the same q, minipigs had a higher ppa ( + rnmhg versus + mmhg; p < . ). hypoxia increased (ppa-ppao) at all levels of q by an average of mmi-ig in minipigs and mmhg in dogs. inhaled no inhibited hypoxia-induced (ppao-ppa)/q changes in both species. conclusions: we conclude ~ that the minipig is an animal model of elevated pulmonary vascular resistance and impedance, and ~ that hypoxia-induced alterations in pvz spectrum are due to changes of resistance in small arteries. objectives: ) to determine the toxicity of ng-monomethyi-larginine (nma) administered by intravenous bolus to patients with refractory septic shock. ) to investigate the biologic activity of nitric oxide synthase inhibitors in septic shock. methods: from august to january , thirteen patients with vasopressor refractory septic shock received nma intravenously in escalating doses from to mg/kg. results: no hepatic, renal, gastrointestinal, or hematologic toxicity was observed at doses of nma as high as mg/kg. significant biological activity was observed at all dose levels consisting of increased blood pressure (systolic blood pressure from . mm hg + . to . _+ . s.e.m., p= . , systemic vascular resistance ( + to + dyne.sec/ cm s, p=. ), and a decrease in vasopressor requirements. the magnitude and duration of these effect were dose dependent. decreased cardiac output ( . _+ . to . _+ . i/min p=. ) and increased pulmonary artery pressure ( . _+ . to . _+ . mm hg; p=. ) were also observed. no significant effects on heart rate, pulmonary capillary wedge pressure, or central venous pressure were observed. four of patients survived for more than days, patients died of cancer complications (all patients had maintained blood pressure for h on nma) and patients died of complication attributable to septic shock (mods, ards, dic, refractory hypotension), and patient was unevaluable. conclusions: no adverse clinical effects have been observed in patients receiving bolus doses of nma as high as mg/kg. the increased pulmonary artery pressures observed in septic shock patients is further augmented by nma and may limit the dose which can be administered by intravenous bolus. other schedules of drug dosing may attenuate this effect. glucose-insulin-potassium (gik) solutions have been shown to improve cardiac contractility and increase oxygen availability in experimental and clinical settings of septic shock. several mechanisms have been proposed to explain these effects including a direct improvemeut of the energy balance by glucose, a direct influence of insulin on cardiac performance or an increase in intravascular volume due to the hyperosmolarity of the solution. to explore the role of hyperosmolapity, we compared the effects of gik to those of a isoosmolar hypertonic saliue solutiou in endotoxin shock in dogs. methods : the study included mongrel dogs ( • pentobarbitalanesthetized aud mechanically ventilated with air. thirty minutes after the intravenotls administration of mg/kg of e. coli endotoxin, the dogs were randomized to receive a ml/kg infusion in rain of a hypertonic ( mosm]l) solution iucludiug either a mixture of glucose % with u insulin and meq kcl/l (glk-group ) or hydroxyethyl starch . % in naci . % (hes-group ). in each dog, a . % saline infi~sion was continued to maintain the puhnonary arlery occluded pressure at baseline level. hemodynamic, blood gas aualysis and laboratory data were collecled at baseline and miu, rain, rain, and nunutes later.. results : eudotoxin administration was followed by a fall in mean arterial pressure (map) aud cardiac index (ci) and a rise in blood lactate levels. resuscitation with either gik or hes hypertoaic solutions resulted in similm increases in map, ci, oxygen delivery and left ventricular stroke index (table ) . we conclude that during resuscitation from endotoxic shock the use of gik solutions is not superior to hypertouic hes solutions. the higher blood lactate levels observed in the dogs receiving gik can be attributed to the glucose metabolism. , for group , for group ) were drawn and immediately analysed at ~ using the abl radiometer for po , pco and ph, and the osm radiometer for hbo %, hbco% and methb%. psost (i.e. the ps at ph= . , pco = mmhg and temperature at ~ c) was calculated automatically by the instruments on mixed venous blood, as was the ps "in vivo" (i.e. the ps at the patient's value of ph, pcoz and temperature), using siggaard-andersen's algorithm. the data were compared by the one-way anova test and by the t-test for paired and unpaired samples. results: the mean resulting values (in mmhg) with the statistical differences are shown in table i. in addition, the time series analysis shows the mean ps~st values as statistically below the psin vivo" in the septic patients while the opposite is shown for the cardiac patients. no differences in the time analysis are demonstrated for the second group. a possible clinical significance may be drawn from these different behaviours. objectives:toxemia degree and humoral immunity condition have been studied in patients aged from to with progressive course of sepsis and polyorganic insufficience. methods: such toxemia and humoral immunity findings as lencositlcindex of toxication (lii), level of oligopeptides of the middle molecular mass registered at the wave length of nm(mmi) & nm (mm ), distribution index (id), immunoglobulins a,m,g, concentration of circulating immunocomplexes (cici & cic ) and also some clinical and biochemical findings on the , , day after the operation serve as criteria for treatment effect. results: it was founded that in intensive therapy and detoxication, level of lii is successively decreased from . ~ . to . +. on the -th day after the operation. true decrease of the level mm from . ~. to . +. un & optimal density and increase of distribution index from . to . are argued. conclusions: in studlng the dynamics of the immunoglobulin's spectrum and the true increase of immunoglobulin g level from . +. g/i to i . +. g/i on the -th day after the operation simultaneously with the decrease of cic from . ~ to . ~ . (p . ) were founded. some stages of the investigation true increase of lymphocytes from . + . % to . + . % was noted and it appeared to be a favourable prognosis finding for disease outcome. high correlation dependence between bacillus-and segmentonuclear neutrophils and immunoglobullns g & m (r=. -. in p<. ) was discovered and it also showed positive dynamics of the course of the disease. a year old male patient was admitted to the icu with severe paraquat poisoning. treatment consisted of gastic lavage and oral administration of fullers earth. because of very high plasma levels hemodialysis together with charcoal hemoperfusion was started within one hour after admission. this treatment was further continued by continuous veno-venous hemofiltration in order to remove the circulating paraquat and also circulating cytokines. nevertheless patient s condition worsened necessitating artificial. ventilation and hemodynamic support. patient died hours after admission of acute multiple organ failure due to paraquat poisoning. serum levels of paraquat were determined by colorimetric method (table) . levels of interleukin (il ) and (il ), tumor necrosis factor (tnf-alpha), interleukin i receptor antagonist (il ra) were determined both in plasma and ultrafiltrate ( q~!ectives : evaluate in critically ill patients the effects of tow-dose dopamine on gastric mucosal blood flow (gmbf) using laser-doppler flowmetry, a continuous non invasive method of assessing microcirculation. methods : patients requiring both mechanical ventilation and pulmonary artery catheterization for multiple trauma (n= ), ards (n= ) and pancreatitis (n=l) were included. in each patient, the laser-doppler (ld) probe was inserted through a naso-gastric tube. the ld signal is proportional to the number of red blood cells moving in the measuring volume and the mean velocity of these cells. when the ld signal was satisfactory, an aspiration was created into a catheter which was fixed in parallel to the ld probe, to maintain the tip of the probe against the gastric wall at the site of measurement. data (systemic hemodynamic parameters and gmbf) were obtained at the end of a rain resting period (baseline), then min after dopamine ( mcg/kg/min) infusion, and finally rain after the end of dopamine infusion (recovery gmbf _+ (perfusion units) gmbf ~a% vs baseline) * p < . vs "baseline" and "recovery". conclusions : ) despite a slight increase in co (+ %), the dramatical increase in gmbf (+ %) with dopamine, strongly suggests a selective vasodilator effect of low-dose dopamine on gasaic mucosal perfusion. ) laser-doppler flowmetry appears a promising method to assess gastric microcircalation in critically ill patients. increasing evidence suggests that the activation of inos is the final common pathway for vasodilation in human sepsis associated with endotoxic shock. activation of the cellular immune system induces the excessive release of the pteridines neopterin (n) and , -dihydroneopterin (nh ) by human macrophages/monocytes. besides the well established diagnostic value of pteridines in several inflammatory diseases, it is speculated that these substances per se exhibit biochemical functions. thus we hypothesize that pteridines can modulate inos gene expression in vascular smooth muscle cells (vsmc) in vilro. cdtured rat aortic vsmc from female wistar kyoto rats were incubated with n ( pm), nh ( ilm), lipopolysaccharide (lps, ~g/ml), and interferone-~/(ifn-~/, u/ml) for h, respectively, inos gene expression was measured by competitive reverse transcription polymerase chain reaction. the results are summarized in the table. the present study demonstxates a neopterin induced increase in inos mrna expression at the transcriptional level in vsmc. while coincuhation of cells with n + lps resulted in an additive effect on inos gene expression, n + ifn- seem to have a more than additive effect nh did not alter inos mrna synthesis, but it suppresses the lps as well as the ifn-yinduced augmentation of inos gene expression. we speculate that this pteridine-mediated modulation of inos gene expression is involved in the regulation of the vascular tone in endotoxic septic shock. the relationship of sepsis and coagulation abnormalities is well known, mainly in severe sepsis and septic shock. still farther, the extreme expression of hemostasis abnormalities (disseminated intravascular coagulation) in sepsis, has been extensively described. we studied the changes in several coagulation and fibrinolysis markers in septic patients, trying to correlate them with the evolution of the sepsis phenomenon, with an emphasis in its early stages, where therapeutic intervention might be more drastic. in patients, with sepsis, with severe sepsis and with septic shock, as well as in healthy volunteers (control group) we measured : platelet (ptl), coagulation markers [fxii, fvii, fviii, fvw, fibrinogen (fibr) we conclude that all parts of the coagulation system are gradually changed during the evolution of sepsis phenomenon , even in the earliest stage of sepsis. the expression of an inducible nitric oxide (no) synthase (inos) plays a major role in the pathophysiology of septic shock (ss). inhibition of inos could therefore be of therapeutic value. however, such an inhibition has been shown to be detrimental, increasing tissue anoxia (and end-organ damage), possibly through the simultaneous blockade of constitutive nos (cnos). thus, selective inhibition of inos might be more suitable. we evaluated the effects of l-canavanine (can), a more potent inhibitor of inos than cnos, in an animal model of ss. method: in anesthetized rats, catheters were placed in the femoral vein and artery. rats were given an iv bolus of lipopolysaccharide (lps, mg/kg), at baseline (to). after h (t ), rats received at random an infusion of either can ( mg/kg/h; can group, n=l ) or an equivalent volume of . % naci ( cc/kg/h; nac group, n= ), giyen over h (t -t ). a third group (sham group, n= ) received . % nac in place of lps, and then was treated like the nac group. mean blood pressure (mbp), blood lactate and nitrates (no ) were measured each h. glucose, creatinine and asat were also measured in rats (n= in each group). the can _+ * + "t . + . "~ . +_ . "t + " + " *p< . can vs naci ?p< . vs sham can suppressed the hypotension, reduced the hypoglycemia and hyperlactatemia, and attenuated the biological signs of renal and hepatic dysfunction induced by endotoxemia. these effects were associated with a lesser elevation of blood no , confirming a partial inhibition of inos. conclusion: l-canavanine attenuates the hemodynamic and metabolic consequences of endotoxemia in the rat. these effects may be related to a partial inhibition of inos. they contrast with the deleterious effects described with non selective inhibitors of nos. l-canavanine could become a new tool for the treatment of septic shock. rocalc tonin :marker of sepsis, ii~flammaiiur% t~ boifi .cheval*~ jf.timsit*, m.assicot**, b.misset*,/.carlet*, c.bohuon** saint joseph heap, paris**biochemistry institut g roussy, villejuif, ce bi~)l~i~ttectives_: high serum levels of procalcitoaln (proct) have been shown to be ~ss-ocinted with bacterial infection. however, few data exist about the ability of proct to differenciate septic shock and shock from other origin in which an activation of intlmmamtory mediators has been also demonstrated. methods: thirteen patients with bacterial septic shock (ss), patients with non septic shock (nss), patients with bacterial infection without shock ( nf) and icu patients without shock and without infection (control) were compared for proct levels at dayl, , , , . patients were classified blindly and independently fi'om proct results. twelve patients were excluded because any classification was impossible due to mixed pathology. proct was measured with ebemoluminescenee (brahms diagnostica-berlin). results: dayl, proct levels are significantly different between the four groups. dayl proct levels are correlated with saps (p= . ), infection ( . +_ vs _+ ,p= . ), shock ( _+ vs +.- ,p= . ), death at day ( _+ vs _+ ,p= . ). when shock and infection are introduced in multifactor &nov& only infection remains correlated with day proct levels ( = . ) in patients with shock, dayl proct levels are correlated with saps, infection and death at day , but not with arterial lactate levels (p= . ), white blood calls (p= . ) or fever (p= . ). proct levels remain higher i~i septic shock patients at day , and ( figure) . i c edpsion: procalcitonin levels in the first three days of shock are differen[" between septic and non septic shock patients. in patients with diseases known to induce acute an inflammatory process, procaldtonin seems to be a marker o~ infection. obiectives-to evaluate the effect of endotoxic shock on the distribution of blood flow between the mucosal and the muscular layer of the intestinal wall. methods: in fasted pigs, mean aortic pressure (map, mm hg), cardiac output (co, ml/min-kg),superior mesenteric artery flow (q sma, ml/min.kg), and phi, where measured before (control) and after i.v. endotoxin ( gg/kg). the blood flow to the mucosal and the muscular layer was measured in regions (proximal jejunum (pj), mid-small intestine (mi) and terminal ileum (ti)) by colored microspheres, using adjacent samples in each region. the muscular layer was separated from the mucosa by blunt dissection, and the flow determined independently in each layer. results: endotoxin with fluid resuscitation induced the expected decrease in map ( . _+ . vs . -+ . , p< . ), and phi ( . !-_ . vs . _+ . , p< . ), with a constant co ( _+ vs _+ , p= . ) and qst, aa ( . _+ . vs . _+ . , p= . ). the results of regional pertusion are presented in the table. (flow in ml/rain g of tissue; mean _+ sem ; * p< . vs control by two-way anova) conclusions-these data indicate that the mucosal flow increased during septic shock. they suggest that a decrease in phi may be due to hypoper~usion of the muscular layer or to metabolic alterations within the mucosa, despite a % increase in flow. acute increase in wbc count (from a mean of lo.oo mm a to o /mm~), between the rd and the th day of therapy. there was a decline of the wbc count to an average of about . mm a after decreasing the daily dose of the medication to mcg there was no increase in tile absolute number of the eosinophils during the whole course of the medication. there was a slight decrease in the c complement between . to . g/i. normal values . to . g/i there was no change in c values. conclusions : an early increase in wbc count was observed ( rd day) without subsequent increase in the number of immature types from bone marrow, probably due to the mobilization of wbc from the periphery and this increase was dose dependent. there was a slight decrease in c fraction of complement, probably due to the consumption of this fraction in the process of opsonization. no adverse effects of the medication were observed, during the treatment with the above dose. these data sugest that cm csf may be a useful complement to tile main antimlcrobial treat,nent ~ of septic [cu patients. objectives: as part of a large multicentric, placebo-controlled, randomized clinical trial investigating the effects of interleukin- receptor antagonist (ii-lra) in the treatment of severe sepsis and septic shock, this substudy evaluated in dem.il the acute hemodynamic effects of ii-lra in patients who were invasively monitored. methods: in a total of evaluable patients in whom vasoactive support was little altered, hemodynamic measurements were performed at baseline (twice), and i hour, h, h, h, h, and h after the administration of mg/kg (n= ) or mg/kg (n= ) of i - ra or the corresponding placebo (n = ). / patients ( %) were treated with adrenergie agents and / ( %) with mechanical ventilation. data were analyzed by a kruskal-wallis test. results: during the study, there was no significant difference with time or between groups in arterial pressure, cardiac filling pressures, cardiac index or left ventricular stroke work (figure). burmester, "~ man and h. djonlagic medical university (internal medicine, "cardiology, *'microbiology) and "**southern city hospital, lfibeck, germany obiectives: evaluation of the incidence of bacteremia and sepsis in patients with nontyphoidal salmonella (s.) infections, specification of risk factors, need of icu treatment, clinical course, and mortality in the group of the patients who developed septic complications. methods: data of all patients with microbiologically proven s. infections hospitalized in the medical university of lobeck and in the southern city hospital of l beck from to . results: within the observation period s. was isolated from the stool cultures of patients. in patients (g m, f, median age yrs) s. could be detected in blood cultures ( s. enteritidis, s. typhimurium). in addition, in of these patients s. was also isolated from other specimens (urine, liquor, and tissue fluids derived from abscess punctures). in all patients with positive blood cultures the clinical course of s, infection was complicated: ? patients developed mof (acute renal failure, ards, hemodynamic instability, dic) and required icu treatment for at least up to days, of the patients died. the predisposing disorders in the patients with s. bacteremia were (n=): aids ( ), immunosuppressive drugs ( ), chronic alcoholism ( ), malignancies ( ), none ( ). septic complications in patients with nontyphoidal s, infections are relatively rare (in this study < % of all hospitalized patients with microbiologically proven salmonellosis) but severe (mortality of approx. %). patients at risk for a complicated clinical course are predominantly those with predisposing disorders but occasionally also patients without evidence for an underlying disease. age (yr) + + death (n) duration of shock (h) + + noradrenaline (rag/h) , _+ + temperature (~ , + , + pvr (dynxsecxcm - ) + + co (ljmin) , _+ , , + , lactate (mmol/l) + , , + interleukin- (pg/ml) _+ + interleukin- (pg/ml) , _+ , , + , tnf-alpha (pg/ml) , + , + neopterin (nmol/l) , + , + crp (rag/l) _+ +_ pro-ct (ng/ml) , + , , + there was no positive correlation between serum lactate levels, degree of shock, hypoxemia and pro-ct positivity. pts with septic shock of bacterial origin entirely developed hyperprocalcitoninemia, whereas pts with cardiogenic shock, who expired within h did not. however, in late cardiogenic shock (> h) all pts developed fever of unknown origin and consecutive hyperprocalcitoninemia. these data suggest bacterial inflammation and/or mucosal translocation of bacterial products in pts with prolonged cardiogenic shock. the use of a loading dose of quinine ( . mg/kg base in h) is recommended in previously untreated patients (pts) with sfm, particularly in multi-drug resistance areas. this protocol is difficult to validate, since the viability of microorganisms is not assessed routinely in parasitology laboratories. objectives: to examine the evolution of parasite viability during the early phase of therapy of sfm. methods: from / to / , pts with sfm (who ) treated with iv quinine for less than h were included prospectively. blood samples were collected at o, , , , , and h viability was assessed by culturing parasitized red blood cells in the presence of h-hypoxanthine, and radioactivity was determined at h by scintillation counting. viability was expressed as the percentage of radioactivity compared to the initial sample. plasma quinine was determined by liquid chromatography. tile ratio plasma quinine (pmol/ )xlo /icso for quinine (nmo]/]) was called the parasiticida/ index. results: pts were included, • saps . -+ . . the initial parasitemia was t. + . %. complications of malaria were coma ( pts), shock ( pts), renal failure ( pts) and acute lung injury ( pts). all strains were sensitive to quinine (icso -- nmol/ ). in pts who were not given a loading dose, parasite viability increased by and %, with concomitantly low quinine levels ( and #mow] at h); pt died. in pts that received a loading dose (serum quinine at h = . -- . ~mol/]) a marked decrease of parasite viability (by +_ % at h) was shown. viability was inversely correlated with plasma quinine (r=. , p-.o ) and parasiticidal index (r=. , p-.o ). conclusions: even with fully sensitive strains, the use of a loading dose of quinine seems warranted in severe falciparum malaria in order to reach rapidly adequate plasma quinine ]evels, necessary to inhibit significantly parasite viability. l nkka, e ruokonell j takala. critical care research program, department of intensive care, kuopio univ hospital, finland objective: to determine the incidence of positive blood cultures, their microbial subgroups and to evaluate the outcome of icu patients with different bacleremias. material and methods: we analysed all positive blood cultures in consecutive admission to a university hospital icu in - and the icu and hospital survival of the bacteremia patients. during these years patients had positive blood cultures that were considered as clinically relevant, excluding colonizations or contanfinations. results: patients with positive blood cultures had an icu survival of . % (vs. , % in all icu patients) and six month survival of . % (vs. . % in all icu patients). the most common bacteria were enterobacteriaceae ( , %), staphylococcus aureus ( , %) , coagulase negative staphylococci ( . %), pseudomonas ( . %) and slieptococci ( . %). obiectives: to evaluate prognostic factors and mortality in consecutive patients (pts) with hiv infection and septic shock. methods: from - to - , records of consecutivepts with septic shock (crit care med , : - ) admitted to the icu were reviewed retrospectively. results: among pts with septic shock admitted during the study period, had hiv infection- of whom had aids-(gr. i) and were hiv-negative (gr. ill. ten gr. ii pts ( %) were irnmunosuppressed because of neoplastic or immune dlsease. mechanica] ventilation was required in % gr. i and % gr. ii pts in gr . i pts ( %) a multivariate analysis demonstrated that hiv infection and sap i were independently predictive of death in pts with septic shock. ~onclusions: evidence of increased mortality, number of organ failures and higher severity scores (saps i does not take into account immunosuppression) is demonstrated in hi v-positive pts, infection with hiv appears to be an independent prognostic factor in pts with septic shock. the frequency of opportunistic infections (often responsible for delayed diagnosis and treatment) may contribute to the poor prognosis in this population. obiectives: to determine interleukin (il)-i levels in plasma of patients with sepsis and septic shock. to analyze the relationship between plasma il- and the proinflammatory mediators, tumor necrosis factor-aifa (tnf) and il- , the underlying severity of the disease and the evolution of patients with sepsis. methods: we studied critically ill patients ( men, women; - years old) in three diferents groups. group i: patients without evidence of infection, group i : patients with sepsis and with septic shock (group iii). we measured plasma il-lo, tnf and il- levels in the first hours of diagnosis. severity of illness was estimated with the acute physiology and chronic health evaluation (apache ii) scoring sytem. results: plasma levels of il- were higher in group iii (median, pg/ml; range, - pg/ml) than in group ii (median, pg/ml; range, - pg/ml; p <. ) and group i (median, pg/ml; range, - pg/ml; p <. ). median il- concentrations did not differ among patients who survived (median pg/ml; range, - pg/ml) and those who died during the overall follow-up period ( days) (median, ; range, - pg/ml); but patients who died in short-term (< hours) with catecholamine-refractory hypotension showed the highest concentrations of il-io (median, pg/ml; range, - pg/ml). in patients with bacteriemia ( %), levels of il- were higher (median, pg/ml; range, - pg/ml) than in those with negative blood culture (median, , pg/ml; range - . pg/ml; p< . ). there was a good correlation between plasma il-io concentration and levels of tnf (r= . ; p < . ) and il- (r= . ; p < . ). the correlation between levels of il- and the apache ii score was significant only in the septic shock group (r= . ; p <. ). conclusions: in septic shock, il-io and proinflammatory citokines are released in high concentrations. the significant correlation observed in patients with septic shock between il- levels and apache ii, short-term death and bacteriemia can possibly be explained by the massive inflammatory response in septic shock with fulminant course. intensive care department -calmette hospital - lille -france. in septic shock, inadequate splanchnic blood flow may play a prominent role in the pathogenesis of multiple organ failure. measurement of gastric phi has been propose to evaluate tissue oxygenation in splanchnic organs. objectives: to compare gastric phi values with hepatic icg clearance, an index of liver blood flow and function ; to determine if one of these two methods could be proposed to assess the entire splanctmic peffusion in septic shock. methods : patients (age : • years ; saps ii : • were prospectively investigated (septic shock : bone criteria). following parameters were collected during hours : systemic hemodynamic parameters (swan ganz catheter a h -ref computer -baxter lab.), calculated systemic oxygen transport (do ), oxygen consumption (vo ) by indirect calorimetry (deltatrac datex lab.), gastric intramucosal pco (pco ss) and phi (trip -ngs catheter -tonometrics lab.) and plasma disappearance rate of icg (pdr dye) (femoral artery fiberoptic/thermistor catheter , cold z computer -pulsian medizintechnik, germany). correlations were performed using a linear regression. elevated in all days with the highest value in second and third days of treatment. nonsurvivors had higher values of these parameters than survivors but differences did not reach statistical significance. another trend of changes were observed in selectin p (gmp- ) concentration. in all patients concentrations measured were elevated but in survivors after not significant decrease this parameter in second day another one had simmilar values. in patients who died we noted significant decrease in third day (p < . ) whereafter prominent increase, significant after seventh day, in comparison to third day value and value in survivors group. icam- concentrations in all patients reached high levels and in nonsurvivors after four day of treatment significant increase in comparison to survivors we found. conclusions: multiple trauma complicated with sepsis induce rapid elevation of concentrations of il- , il- and increased expressior of adhession molecules (selectin e, p, icam- ) measure of icam- and selectin p concentration determine lung injury severity and prognosis as to health and life. (clp) .pathophysiology of cip is unclear, but changes in regional bloodflow may be a ~ignificant factor. nerve blood flow (nbf)is reduced in rat models of hemorrhagic shock (g),but no information is available in sepsis. we studied the comparative effect of acute endotoxemic shock {etx)& h on perfusion of rat sciatic nerve. methods: male sprague-dawley rats were anesthetized with pentobarbital (ip), instrumented with a tracheostomy, carotid arterial & venous catheters and mechanically ventilated (fi = . ). the left sciatic nerve was surgically exposed. monitored variables included: a) mean arterial pressure (map,mmhg) ,b) nbf (ml/ o g/min) by laser doppler flow meter,c) nerve internal arterial diameter (id ~ m) by video image shearing and splitting method. after stable baseline measurements were obtained, acute hypotension was induced by randomly assigning the rats to etx ( . b , difco) in saline at mg/kg or h. both interventions produced % reduction in map within min., which recovered to baseline values spontaneously in etx group, & by reinfusion of heparinized withdrawn blood in m. data were analyzed by linear regression, two-way repeated measures analysis of variance followed by bonferroni-t method. experimental stages were:( )baseline, ( ) mid-point of map reduction; ( ) nadir of hypotension, ( )midpoint of map recovery, & ( ) after stable recovery of map. both etx & h induced shock result in similar reduction in nbf consistent with lack of autoregulation in peripheral nerve vessels independent of etiology. since cip is primarily associated with sepsis, it is not likely that acute reduction in nbf alone causes cip. direct & indirect neurotoxic effects of mediators of sepsis need to be evaluated. .':_.~::::o o:oc ., objectives : evaluate the relationship between il- , a cytokine which inhibits tnf, production and protects mice from endotoxin toxicity, and the other proinflammatory cylokines, tnf~, il and ils in severe sepsis and septic shock. methods : twenty-eight icu patients ( m, f, mean age + y) were studied as soon as they developped a severe sepsis (n = ) or a septic shock episode (n= ) as defined by a conference consensus in ( ). tnf~, il , il s and il- plasma levels were measured by immuno-radiometrie assays from medgenix (fleurus, belgium). lc mean and range. results : the comparisons between cytokine levels in severe sepsis versus septic shock were made using the logarithm of the value in order to normalize the distribution of data, and student test. il- plasma levels were higher in patients with septic shock than in patients in severe sepsis. there was a significant correlation (p < . ) between il- and tnf a (r= . ), il- and il~ (r = . ) and il- and il s (r = . ) as well as between il- and apache n score (r= . ). patients who died (n = ) had il- levels higher than patients who survived but this difference was not statistically significant ( pg/ml vs . pg/ml; p> . ). conclusions : during severe sepsis and sepsis shock, il- seems at least to follow the same evolution (increase in plasmatic level) with the severity of sepsis as the other cytokines. reference : ( ) crit care med ; : - . objectives: to evaluate the effects of steroids on hemodynamics and mortality in septic patients with konwn levels of cortisol concentration. methods: retrospectively we analyzed data ofpatients with documented septic shock who received steroids after assessment of adrenal function. in all patients hemodynamic parameters as well as the necessary vasoactive medication were assessed, before and hours after corticosteroid medication. immediately before administration of corticosteroids adrenal function was evaluated with cortisol levels before and after synthetic corticotropin ( . mg). finally we studied mortality. we defined a positive respons on corticosteroids as an elevation of map of at least mmhg and/or a decrease in the necessary vasoactive medication of at least % within hours. adrenal insufficiency was defined as a cortisol level after stimulation of less than nmol/l. results: of patients were found to respond to steroid medication, did not. mean cortisol levels before and after corticotropin were • and • nmol/l in the responder group (rg) and • and • nmol/l in the non responder group (nrg). in the rg out of ( %) were found to have an adrenal insufficiency, in the nrg out of ( %). in the rg -weeks mortality was . % (l out of ), the overall mortality % ( out of ). mortality in the nrg was % ( out of ) (p < . ) and % ( out of ) (p < . ) respectively. conclusions: in patients in septic shock there is a beneficial effect of steroids in case of adrenal insufficiency, but also in a subgroup with normal adrenal f{unction. obiectives: intercellular adhesion is a critical step in the accumulation of leukocytes. postischemic cardiac lymph has the capacity to stimulate icam-i. in the coronary microcirculation neutrophils can be trapped and in many cases obstruct capillaries, previously we found that troponin t (s-tnt) a marker for myocardial iechemia, was increased in septic patients. the aim of the study was to follow slcam- and s-tnt levels continuously starting at the beginning of sepsis. methods: patients were ingluded in this institutionally approved study after relatives had given their informed consent. all patients were included within hrs following the beginning of sepsis. blood was drawn every hrs in the first ;~ hrs, after hrs, followed once per day for days. s-tnt, icam- , elam (elisa's, boehringer mannheim inc, r&d systems ltd.) arterial and venous blood gases were determined, an ecg and a complete hemedynamir measurement including cardiac output were obtained. all patients received adequate volume and catecholamine therapy (norepinephrine, dopamine, dobutamine; median (range) . ( . - . ), . ( . - ), . ( . - . ) pg/kg/min, respectively). statistical analysis: wileoxon signed rank-sum test. . ( . - . ) . patients had s-tnt levels > . pg/l. of these died, whereas only of patients died with s-tnt values < . pg/l (p= . ). all patients that died had elevated sjcam- levels ( ilg/l:cut-off ) whereas in the survivor group only % had elevated icam- levels (p= , ). conclusions: increased slcam- and s-tnt levels were found during early sepsis in the majority of patients, a high sicam- and s-tnt value was associated with a higher mortality. the research of the noninvasive haemodynamic monitoring accelerated recently all over the world. the aim of our study was to test whether the changes of the haemodynamk parameters measured by impedance cardiography (icg) were corresponded to clinical changes in septic patients. investigations were performed on critically ill postoperative septic patients (their multiple organ failure score was - /with icg monitor. in cases the investigation~ were performed in septic shock. the measured parameters were: heart rate (hr), mean arterial pressure (map), cardiac output (co), peripherial resistance (svr),preejection period (pep), and ventricular ejection time (vet). these parameters were measured during - hours in every minutes, depending on the patients cl~tnical condition. results: at the septic patients the hr and the co ]~reased. in septic shock the co was significantly higher the svr lower than in the septic group. in the hr there was no difference between the two groups. in septic shock noradrenalin influenced more effectively the measured parameters than dobutamin. conclusion: the trend of the measured icg parameters correlated with the clinical changes of septic patient's state. the noninvasive haemodynamic monitoring by impedance cardiography helps the planning and leading the adequate intensive therapy of these critically ill septic patients. to evaluate the development of sirs, sepsis and septic shock in hospitalized patients with fever, a prospective study was performed on patients using previously defined criteria. methods: normotensive patients with fever (temperature > . ~ axillary), admitted to the department of internal medicine were evaluated for the existence of sirs during the first three days of the study and sepsis at inclusion. during a follow-up period of days the patients were daily evaluated for the development of sepsis or septic shock. results: most patients ( %) had or developed sirs within the first three days, patients ( %) did not. sepsis was present in % at inclusion. in patients with sirs, % did not progress to sepsis or septic shock, % progressed to sepsis (mean interval . • . days), and patient (< %) directly progressed from sirs to septic shock. in patients with sepsis, % progressed to septic shock (mean interval . • . days). sepsis was preceded by sirs in %. septic shock was preceded by sepsis in % and by sirs in %. conclusions: % of patients with fever in an internal medicine department develop sirs, or sepsis. furthermore, progression from sirs to sepsis or septic shock is poorly predicted by fever or sirs. nevertheless, all patients with septic shock were preceded bysirs or sepsis. taken together, this may indicate a severity hierarchy of the syndromes. however, fever, sirs and sepsis are relatively poor indicators of development of septic shock. this supports further research on additional predictors of septic shock. b. m.manuylov, v.b.skobelsky (moscow) in recent years sodium hypochlorite (sh) has been successfully used to eliminate pyo-septic complications. moreover, the mechanism of the sh effect on the immune system has not been sufficiently studied. the aim of the present investigation was to study the mechanism of sh effect in inflammatory pulmonary diseases. patients with double pneumonia were subjected to the evaluation. sh in the concentration of mg/l in the volume of - m / hours was administered by drop infusion into the central vein. to evaluate one of the defence systems the leukocytes activity by the chemoluminescence technique was studied. in all the patients baseline secondary immunodeficiency which was indicated by the decrease in the luminescence level was established. even hour after the sh administration the leukocytes activation exp-ressed by the enhancement of their chemoluminescence . - times was observed. this supports the available findings that accumulation and liberation of the oxygen active forms (ol'oh, ' , h ) are accompanied by the increased phagocytosis, i,e. the signs of "the oxydation explosion" testify to the favourable sh effect on the course of inflammation processes. the use of sh permitted to decrease the percentage of lethality in double pneumonia by % in the intensive care unit over the year. at the same time, excessive activation of free radical oxygen may be a damaging factor. therefore, precise individual control over the choice of concentration, dosage and the preparation administration rate is required. prospective, double-blind, placebo-controlled, trial of atiii substitution in sepsis r. a. balk objective: pilot study to evaluate the efficacy and safety of atiii substimtion therapy in patients with sepsis. efficacy assessed using change in mortality or organ failure/dysfunction. adult patients meeting a definition of sepsis and cared for in a tertiary care academic medical center in chicago were identified and prospectively randomied to receive either atiii (kybernin p) or placebo in a double-blind treatment protocol. all other therapy and patient management were under the direction of the patient's attending physician. all patient's were followed for days and the organ dysfunction/failure were scored using published scoring systems (jordan et al crit. care med. , goris et al arch. surg. , kuaus et al ann. surg. colldusions:wha~ we met the shomaeker objectiv% the mortality and the pro~os[s were i~ttc*. those criteria were obtained with file tradititmal t~ctor likr doht~mme, hut c.~vh ~,as ca in~aertam measure. they ac~s smxergically in the optimizatic~l of the fell vmtrictdar work index, tad fimdameatally cavh seox~s to have an impo.aat role in the better respiratory ev-altmtioa, leaving yet the possibility to coltrol the flui& r althou~l eomproved it's not aec~pt~xl file importmlce h* the diminution, of the sepsis modiat~lrs llke fnt and il- with h~wmotiltrafi(al, stopphlg the evolution to nmltiorganic failure mid de~easethe mortality. with ours clhlicals results, we could saythat cavii in multiol~atlie disfut~oa septic patieats, se~r~ to be an c xilna] supoa or troatmeat maesure. of anaesthesia and intensive therapy, medical university of prcs, p~csf hungary. objectives: since some biological effects of bacterial endotoxin require an interaction between the lps molecule and a serum factor(s), we hypothesized that lps-induced no production and cgmp accumulation in vascular smooth muscle cells (vsmc), a mechanism ~thought to underlie cardiovascular collapse associated with septic shock, is modulated by serum factor(s). methods: cultured vsmc from rat aorta were challenged with e. coli lps for - hours either in the presence or absence of fetal calf serum (fbs), and no production was monitored by radioimmunoassay determination of cgmp content of hci extracts. results: in the absence of serum, o ng/ml lps was required to increase cgmp levels, whereas the presence of % fbs shifted the lps concentration curve i times to the left. similarly to fbs, human serum also potentiated lps-induced cgmp accumulation. in contrast to lps, serum had no effect on cgmp accumulation elicited by sodium nitroprusside, a no releasing agent, suggesting that the sensitivity of vsmc to generate cgmp in response to exogenous no is not modulated by serum. heat inactivation (> ~ min) but not removal of small molecules (< , d) from the serum by dialysis, reduced the potentiation of cgmp accumulation by serum. time course studied indicated that serum is required within the first min of lps exposure to increase cgmp levels. to investigate whether the effect of serum is specific for lps, we treated the cells with increasing concentration of interleukin -~ (il-i). % fbs shifted the il-iinduced cgmp responses five times to the left. conclusions: our study suggests that lower concentrations of e. cell lps and il-i require a heat labile macromolecule in the serum in order to elicit no production. this factor is present in the human serum and it may play a potentially important role during no synthesis induction in vsmc. objective: to evaluate the factors of acquisition and the outcome of methicillin resistant staphylococcus aureus (mrsa) bacteremia in an intensive care unit (icu). methods: all patients in which bacterermia due to staphylococcus aureus developed > hours following admission to our icu, during a year period ( january through january ) were reviewed. patients (pts) were included, mean age , y (sd , ), saps , (sd , ), mac cabe ( and ) %, mortality directly due to sepsis %. pts had mrsa bacteremia and methicillin susceptible staph. aureus (mssa) . both groups were compared using the chi square (with correction of yates), fisher's exact, student's t or wilcoxon test. results: there was no statistically significant difference between mrssa and mssa regarding at age ( , + , vs , + , ) , saps ( , + , vs , + , ), use of vancomycin ( % vs %), mechanical ventilation ( % vs %), number of days (d) before the drawing of the first positive blood culture (median d, range - d vs median d, range - d). more mrsa than mssa pts had previous use of nonsteroidal anti-inflammatory drugs (nsaid) ( % vs % p< , ), central venous catheter infection due to staph.aureus ( , % vs % p< , ), but previous use of antibiotics was not significantly different ( , % vs %). the outcome of the bacteremic pts was not statistically different: saps at the first day of bacteremia ( , +_. , vs , + , ), severe sepsis and septic shock ( % vs %), persistence of the bacteremia ( % vs %), mortality directly due to bacteremia ( % vs %). conclusion: previous use of nsaid, infection of venous central catheter are more frequently associated with mrsa bacteremia. thus, similar to others studies (hershow infect control hosp epidemio ; : - ) , these results do not indicate that mrsa is associated with increased virulence. objectives: to closer definition of mosf formation mechanismes in nosocomial sepsis (ns) the complex clinicobiochemical, microbiological, immunological, functional exaroination of cases with ns had been done. methods: examination of cellular and humoral immunity, nonspecific immunologic reactivity, systemic and hepatic circulation, microbiological examination of blood,electro-and echocardiography, sonography and computer tomography of chest and abdomen organs were obligatory. autopsy findings of dead cases had been analized. results: in cases ( , %) opportunistic pathogen microscopic flora ( staphylococcus anreus,staphylococcus epidermidis, staphylococcus saprophyticus) had been found out in blood inoculations. in cases ( %) side by side with destructive process in lungs the bacterial endo-and myocarditis with blood circulation failure had been determined.in cases ( %) simultanious lesion of three organs (heart,lungs,liver) had been found. morphologic examinations of dead cases ( %) internal revealed involvement of them in mosf-syndrome.hyperplasia of adenohypophysis;sclerosis of adrenal glands cortical layer;perivascular brain oedema,paralysis of brain capillaries and plasmorrhagia, cerebral thrombosis and cerebral abscess,necrobiosis of epithelium tubules of the kidney,pletora of hepar, fatty and granular degeneration of hepatocytes had been found.atrophy of white pulp and hyperplasia of red pulp, supress of lymphoid tissue, plethora and formation of infarctious had been found in spleen. mentioned changes in spleen were indispensable in ns. conclusion: in ns spleen can not secure it functions to support and appropriate detoxication potencial of organism,elimination of microbes,toxines,antoallergenes. insolvency of immunological link of antimicrobic defence is the starting mechanism of mosf developmentin ns. %neviere, jl. chagnon, b. vallet, d. mathieu, n lebleu, f. wattel ] ept of intensive care, hop calmette, lille, france ~everal studies have described tiypoperfusion of intestine during sepsis. owever, it is unknow whether the mesenteric blood flow is associated with nucosal hypoperfusion. additionally, the effects of resuscitation on the ntestinal microcirculation remain controversial. bjectives : to describe the effects of endotoxin in a porcine model during ~hock and resuscitation. ~ethods : ten pigs ( kg) were anesthetized and instrumented for "neasurement of cardiovascular variables. gastric and gut oxygenation vere assessed by intra-mucosal ph and microvascular laser doppler lowmetry. after baseline data collection, a minute intravenous infusion )f escherichia colt (serotype h , sigma, st. louis, mo) was begun ~t a rate of pg/kg. an infusion of either saline at . ml/kg/min (group ; n= ) or saline and dobutamine at a rate of pg/kg/min (group ii; n= ) vas begun mn after the end of the endotoxin infusion. tesults : to td t ~ fl w fluid ioadin,q alone sfyras d, k perreas, e douzinas, k spanou, m pitaridis and c roussos critical care dpt, evangelismos hosp., athens univ, school of medicine. obiectives: much controversy exists concerning the beneficial effects of cvvh on sepsis. we studied the effects of cvvh application on septic patients with reference to the following parameters: i) survival rate ii) cytokines' removal and iii) timing of cwh onset. methods: patients with sepsis (criteria according to accp/sccm, ) underwent cvvh as soon as they developed renal failure or dysfunction (urinary output< ml/ h, cr> . mg/dl and bun> mgd'dl ). specimens were collected: blood samples before cvvh and therafter both blood and ultrafiltrate (uf) samples on , and hours. cytokines tnfa, i - and ii- were measured by the immunoassay method in all specimens (uf and plasma -p) and sieving coefficient ([uf]/[p]) and h solute mass transfer of tnf and i - were calculated (v h x [uf] ). the apache ii score before cvvh onset, the duration of icu stay and the timing of cwh application related to the sepsis onset in days (ta) were recorded.with respect the mortality two groups were formed, i.e. group a (survivors) and group b (non-survivors) . the morbidity period in days of those septic patients who died in the past year and were not subjected to cwh (group c) was compared to that of group b. results: group a included pts and group b pts with mean+sd age ( _+ vs _+ , ns) and apache scores( _+ vs -+ . , ns). the mean ta-+ sd was . + vs -+ , p< . . the mean_+se morbidity period of group b vs group c was _+ vs _+ . p< . . the mean values of cytokines are presented in the following figures. the sieving coefficient for tnf was . and for i - was . . the solute mass tranfer was -fold the actual plasma content at a given time. . o conclusions: i) early application of cvvh seems to favourably affect the outcome of septic patients, ii) cytokine plasma levels do not decrease although cytokine removal is substantial, iii) it seems that cwh application in sepsis of any stage helps to buy time for further treatment. the most commonly monitored variables in shock stages idclude : arterial pressure, heart rate, central venous pressure, pulmonary artery wedge pressure and cardiac index. with vigorous therapy it is possible to bring these values back into the normal range in both survivors and nonsurvivors. therapeutic goal in septic shock stages is to maximize the values of cardiac index, delivery (do ) and consumption (c ). objectives: the main purpose of this article is to determine the relationship betwee~ delivery an consumption as a sign of hypoxia. fifteen patitents with septic shock were treated with intention to maximize the value of ci,d and v . we compared the levels of these parameters between the survivors and nonsurvivors and found no significant differences after hours. high levels of do and v may not guarantee against tissue hypoxia in early stage of septic shock. zjar~iic, dj janjic, lj. gvozdenovic, a.komareevic. t.petrovic, &marjanovic, institute of surgery, novi sad, yugoslavia objectives: evaluation and mutual comparison of clinical signs, laboratory data and microbiological monitoring in the patients with burn sepsis. method: retrospective analysis of the recorded data of all burn patients treated in our department between january and december . specially attentions were given to data considering wound infection, positive haemocultures, positive urinocultures and characteristics of septic state. results: out of patient there were ( , ~) adults and ( , ( ~) children. almost two thirds of the patients ( - , ~) were males. the predominantly cause ( , ~) of children's burns was scalding b~y hot liquids and flame burns ~ , ~) in adult patients. the most frequdntly species isolated from surface swat~ were pseudomonas aeruginosa ( " in adult patients) and staphyloccocus epidermidis ( , % in children). in only five patients ( , ~ the haenmcultures were positive -pseudomonas aeruginosa was isolated in three and staphyloccocus aureus in two patients. urine infection was diagnosed in , % of all patients. the treatment protocol included use of imipenem and polyvalent pseudomonas vaccine again~ pseudomonas aeruginosa and vancomycin and aminoglycosides against staphylococcus aureus. total mortality rate in this group of burned patients was , ~, but the mortality rate caused of sepsis was low (i %) . conclusions: early detection of any signs of wound infection and symptoms of septic state is a foundation for prevention and treatment of burn sepsis. the burn sepsis could be reliable detected by continuously monitoring the patient's status and by systematic microbacteriological monitoring of the burned patients. hyperdynamic vasoplegic septic shock p.f. laterre, p. goffette, j. roeseler, j.p, fauville, a. poncelet, p. lonneux, m.s. l~eynaert. dept. of intensive care, st. luc univ. hospital, brussels, belgium. splanchnic ischemia is described as a common feature of septic shock and could determine the development of msof. therapy such as noradrenaline (na) aiming at improving blood pressure is expected to worsen splanchnic ischemia by its vasoconstrictive effect and subsequent reduction in intestinal blood flow. ob[ective: evaluate the effect of na on splanchnic blood flow. material and method : in a patient admitted for variceal bleeding, ards and sepsis with positive blood culture, a fiberoptie catheter was positionned in the portal vein after recanalisation of its portosystemic stent shunt. blood pressure (bp-mmhg) , ci, svr, do (vigilance ~ baxter), v (indirect colorimetry), arterial, mixed venous and portal vein blood gases, phi were determined before (to) and during (t ) na infusion ( , to , hcg/kg/min.) . changes in splanchnic flow were assessed by changes in portal oxygen saturation (sp ) and arterio-portal oxygen saturation gradient (sao, -spoe laterre, ,lp. pedgrim, th. dugernier, v. delrue, ph. hantson, p. mahieu, m.s. reynaert. dept. of intensive care, st. luc univ. hospital, brussels, belgium. aim of the study : prospective determination of plasma levels of in patients with ss and their correlation with the type of microorganism and outcome. material and methods : in patients (pts) with ss and severe sepsis, plasma levels of tnfti, ill-b, il and il were determined every hours for days and on day after fulfilling the criteria of ss and severe sepsis. results : in pts, sepsis was caused by a gram (-) microorganism, in pts by a gram (+) and in pts no microorganism was identified. there were survivors ( %) (s) and non-survivors ( %) (ns) . cytokines profiles and levels were not different between gram (+) and gram (-) sepsis. ill-b levels were seldom elevated whatever the group studied. tnfot and il- were significantly higher in ns than in s ( objective: to evaluate the effects on the nitric oxide synthase inhibitor l-n~ hcl ( c ) on myocardial performance in human septic shock. method: septic shock was defined as severe sepsis with either persistent hypotension (mean arterial pressure; map< mmhg) or the requirement for a noradrenaline (na) infusion >_ .i ]tg/kg/min with a map _< mmhg. cardiovascular support was limited to na _+ dobutamine (db), c was administered for up to h at a fixed dose-rate of either , . , , or mg/kg/h iv. during c infusion, na was to be reduced and if possible withdrawn, whilst maintaining map above mmhg and the cardiac index (ci) as clinically appropriate. assessments were made at baseline (t = ); at i h from the start of treatment (t = ); and at the end of treatment (t = ) with c . conclusions: c can restore systemic vascular tone in patients with septic shock enabling na therapy to be reduced and/or removed. the ci tends to fall whilst lv performance is sustained over time. c is a novel vasoacfive agent for the treatment of septic shock, which is undergoing further clinical evaluation. laterre, f. thys, e. danse, j.p. pelgrim, e. florence, z roeseler, m.s. r eynaert. dept, of intensive care, st. luc univ, hospital, brussels, belgium. therapy aiming at improving blood pressure and cardiac index in septic shock (ss) might have deleterious effects on regional blood flow. objectives : compare the influence of volume loading (vl), dobutamine (dobu) and noradrenaline (na) on sushepatic oxygen saturation (shoe) and svoe-sho, gradient in treated ss. material and methods : in patients with ss, ci (thermodilution) , doe, svo,. sho,, svoe-sho e gradient and lactate (l) were determined before (to) and after (t ); vl, dobu and na. results: in patients with treated ss, tests were performed (vl n= ; dobu n= ; na n= method: septic shock was defined as severe sepsis with either persistent hypotension (mean arterial pressure; map< mmhg) or the requirement for a noradrenaline (na) infusion ~> . ~g/kg/min with a map _< mmhg. cardiovascular support was limited to na + dobutamine (db), c was administered for up to h at a fixed dose-rate of either i, . , , or mg/kg/h iv. during c infusion, na was to be reduced and if possible withdrawn, whilst maintaining map above mmhg and the cardiac index (ci) as clinically appropriate. assessments were made at baseline (t = ); at h from the start of treatment (t = ); and at the end of treatment (t - ) with c . conclusions: c is a novel vasoactive agent that can sustain map in patients with septic shock, enabling na support to he reduced and/or removed. there is a tendency for the ci to fall during treatment, which may be reflex in response to the increase in systemic vascular tone. c is a promising new therapy for septic shock, which will now be evaluated in a randomised, placebo-controlled safety and efficacy study. k. guntupalli objective: to evaluate the acute effects of the nitric oxide synthase inhibitor l-n~ hc ( c ) on selected indices of organ function in patients with septic shock. method: septic shock was defined as severe sepsis with either persistent hypotension (mean arterial pressure; map < mmhg) or the requirement for a noradrenaline (na) infusion --> . [xg/kg/ min with a map _< mmirlg. cardiovascular support was limited to na + dobutamine. c was given for up to h at a fixed dose-rate of either , . , , or mg/kg/h iv. during c infusion, na was to be reduced and if possible withdrawn, whilst maintaining map above mmhg and the cardiac index (ci) as clinically appropriate. indices of organ function were assessed at baseline (t = ); at the end of treatment (t = ); and h after treatment (t = ) with c . results. -median values (* assessment made at h or when c discontinued). conclusions: there was no appareut dose-dependent adverse effect on these indices of organ function either during or after exposure to c . the plmelet count tended to fall whilst creadnine appeared to increase over time in all dose cohorts. this novel and promising therapy for septic shock will now be evaluated in a randomised, placebo-controlled safety and efficacy sludy. pharmacokinetics of c in patients with septic shock preliminary results z. hussein, b. jordan, c. fook-sheung, k. guntupalli objective: to evaluate the pharmacokinetics of the nitric oxide synthase inhibitor l-n~ hc ( cg ) given by continuous infusion for h in patients with septic shock. method: septic shock was defined as severe sepsis with either persistent hypotension (mean arterial pressure; map < mmhg) or the requirement for a noradrenaline (na) infusion --> . ~tg/kg/min with a map _< mmhg. cardiovascular support was limited to na • dobutamine. c was administered for up to h at a fixed dose-rate of either , . , , or mg/kg/h iv. plasma was collected from each patient over a h period and analysed for c . pharmacokinetic parameters were derived from plasma concentration-time profiles using non-compartmental pharmacokinetic analysis. results: the (cm~ -maximum plasma concentration; auc -area under curve; cl -plasma clearance; v,, s -steady state volume of distribution; t'/ -plasma elimination halflife). conclusion: the pharmacokinetics of c in patients with septic shock are dose-independent at infusion rates up to . mg/kg/h. at higher rates, clearance of c decreases without any marked change in volume of distribution. c metabolism may be partially saturable at dose-rates above . mg/kg/h. obiectives: investigate the effect of the no synthase inhibitor, l-nt-methylarginine hc ( c ) on the haemodynamics and survival rate in a conscious mouse model of endotoxin shock. methods: female cd- mice ( - g) were instrumented under gaseous anaesthesia (isofluorane, %) and connected to a swivel tether system for continuous monitoring of blood pressure and drug administration. results: after h recovery, endotoxin administration (e. col• :b , - . mgkg - i.v.) elevated the plasma concentration of nitrite/nitrate (nox) and caused a progressive fall in mean arterial pressure (map) from + to + mmhg (n= , p< . ) at h, with a survival rate at h, h and h of %, % and % respectively. c administered as a h continuous infusion ( mgkg-th -t i.v., n= ), h after endotoxin, inhibited the elevation of plasma nox and attenuated the fall in map from + to + mmhg (n= ) at h, with an improved survival rate at h, h and h of %, % and % respectively. conclusions: this study suggests that overproduction of no is involved in the hypotension and mortality characteristic of septic shock. inhibition of no synthase using c represents a novel and promising treatment for septic shock. cultures of e.coli ( , %) and candida( , %) were olso received from autopsy material of children;p.aeruginosa,unspored anaerobes,proteus sp.,s.aureus,b.pneumonia were found in the few cases. in adults the spectrum of bacterioflora was mo~ re limited speaking about the number of species and cultures. in generalized forms of bacterial pyo-septic pathology a wider specific spectrum of causative agents was revealed usua fly with associations. e.coli and k.pneumonia played the leading role in children as well as in adults. in general,k.pneumonia ( , %cultures) and common e.coli( , %)prevailed according to the date of microbiological investigations of authopsy material in pyo-septfc pathology in . objectives: .in spite of all clinical exertion sepsis is still the reason for high clinica! lethality. this study is characterizing the group of patients which survived a septi~ shock. methods: during a period of months all surgical patients on icu were registrated prospectively, more than parameters for each of them were documented'daily in a paradox file. results (see table ): of patients fulfilled the criterion of a septic shock (r. bone, ) , of them died at the lth day, while the surviving group of patients stayed almost days at icu. obiectives: to compare the effects of and % pentastarch solutions to a human albumin solution on oxygen delivery (do ) in septic patients. methods: this stud}, included septic patients with fever (t > ~ tachycardia flqr > /rain), tachypnea (rr > /min) or mechanical ventilation, leukocytosis (wbc> /mm ) or leukopcnla (wbc< ()/mm ) and a clinical source of infection, who required a fluid challenge. in each patient the pulmonary arterial occlusion pressure (paop) was < mmhg. patients were randomized to receive ml of % albunun (n:i ), hydroxyethyl starch (hes -mw /d.s. . ) % (n: ) or t % (n=i ); patients were also treated with adrenergic agents. results cardiac index (c ) increased significantly only in % lies (table) hemoglobin (hb) decreased significantly at min in the same group. there was not significant change in oxygen delivery ( do ). baseline ci alb . :: . (l'min/m ) hes % . = . hes % . polyneuropathy of the critically ill (pci ) is a well recognized complication, acquired in the course of severe illness. we undertook a prospective study, to estimate the severity, extension and time of onset of pci in a selected group of patient with established septic shock ( bone's criteria ). all patients received inotropic circulatory support and were mechanically ventilated. none received relaxants or aminoglycosides. pci was diagnose<by clinical investigation and by emg, and repeated weekly ( axonal degeneration ). after days ( day = onset of septic shock ) in % of the patients pci was demonstrable. after days % of the patients had pci. there was a strong correlation between pci and other mof and between pci and encephalopathy ( eeg ). we conclude that i. pci is a common complication after septic shock. . pci develops early in the course of illness ( % after days ). . pci can be considered as a part of mof, suggesting a common pathogenesis. objectives: we addressed two questions: ) can serial measurements of vapco and avph also reflect the onset of tissue hypoxia during endotoxemia? ) are whole body changes in vapco and avph associated with parallel changes in regional circulation? methods: in anesthetized, mechanically ventilated dogs exhaled gases were sampled for determination of oxygen consumption (vo ). a catheter was positioned into the pericardial cavity to induce cardiac tamponade. ultrasonic flow probes were placed around superior mesenteric, left renal and left femoral arteries, and the corresponding veins were cannulated. group l served as control (n= ), group (n-- ) received mg/kg of endotoxin. thirty min later, tamponade was induced to gradually reduce do . results: systemic do crit was higher ( . _+ . vs . + . ml/kg.min, p < . ) and critical oxygen extraction ratio (o ererit) was lower ( . +_ . vs . +_ . %, p< . ) in the endotoxie than in the control group. meslenteric and femoral do crit were higher in the endotoxic than in the control group ( . _+ . vs . _+ . mlll g tissue.min and . _+ . vs . _+ . ml/min, respectively, both p< . ). regional o ercrit were lower in we endotoxic than in the control group (mesenteric: . _+ . vs .i_+ . %, renal: . + . vs . -+ . % and femorah . -+ . vs . _+ . %, all p< . ). vapco and avph followed a similar pattern in both groups, increasing slightly before do crit was reached, but dramatically wh,en do fell below do crit. in the presence like in the absence of endotoxin, systemic and regional do crit calculated from vo , from vapco , or from avph were similar; do crit was also significantly higher in the mesenteric and the femoral beds of the endotoxic than the control dogs. systemic and regional do crit could be calculated from the blood lactate levels only in the control group. conclusions: during an acute reduction in blood flow i) vapco and avph can reflect hypoxic threshold in the presence like in the absence of endotoxemia. ) alterations in organ oxygen extraction capabilities induced by endotoxin can be reflected by regional changes in vapco and avph. objectives: enhanced nitric oxide (no) release has been incriminated in the vasodilation and myocardial depression characterizing septic shock, but the administration of no blockers has yielded equivocal results. the present study explored the systemic and regional effects of a no donor linsidomine (sin-i) during endotoxic shock. methods: anesthetized dogs received endotoxin ( mg/kg iv), followed min later by a saline infusion to keep cardiac filling pressures constant. oxygen uptake (vo ) was derived from the expired gas analysis. regional blood flow was measured by an ultrasonic flowmeter (transonic). results: the control endotoxie group (n= ) maintained low arterial pressure and systemic vascular resistance. the dogs receiving a continuous infusion of , , ~ug/kg.min of sin- starting min following initial fluid resuscitation (each dose for h), had a higher cardiac index ( . -+ . vs . _+ . l/min.kg, p< . ) and lower systemic and pulmonary vascular resistance than the control group ( -+ vs -+ and -+ vs -+ dyne.sec/cm , respectively, both p< . ). arterial pressure and pulmonary artery pressure were not influenced. sin- significantly increased the mesenteric blood flow from -+ to + % of baseline levels and renal blood flow from -+ to -+ % (both p< . ) but did not influence femoral blood flow. the relative blood flow was increased in the mesenteric bed (at all doses), and reduced in the femoral bed (at highest dose). systemic oxygen delivery, vo , oxygen extraction and blood lactate levels had similar course in the two groups. conclusions: in fluid-resuscitated endotoxic shock dogs, the no donor sin- increased cardiac index without deleterious effects on arterial pressure, and increased splanchnic blood fl w. objectives: sepsis syndrome is associated with the release of a variety of inflammatory mediators, such as interleukins, tumor necrosis factor and platelet-activating factor (paf). administration of paf, a naturally occuring phospolipid, to laboratory animals has been demonstrated to resullt in pathological changes that closely resemble those found in sepsis. in addition, paf antagonists of various origins have been demonstrated to attenuate cardiovascular collaps and to protect against lethality in endotoxemia. in the present study the efficacy and safety of the paf-antagonist tcv- g was investigated in sepsis syndrome patients. in addition, the putative inflammatory parameters tumor necrosis factor (tnf), interleukin il) - il- , and soluble (s) e-selectin were measured in both tcv- and placebo treated patients. metho.~a randomized, double-biind, multi-center study was undertaken to compare the safety and efficacy of intravenously administered tcv versus placebo (takeda chemical industries ltd., osaka, japan). tcv- was used as add-on to conventional therapy in the treatment of patients with severe sepsis and septic shock ( . mg/kg body weight intravenously over hrs, twice a day for one week). day mortality was registered, as well as vital signs, laboratory parameters, hemodynamic parameters, apache ii score and mof score. plasma samples for the determination of inflammatory parameters were collected twice a day for one week. the study was approved by each institutional review board and written informed consent was obtained for each patient. results: a total of patients were included in the study. one patient had to be excluded as a result of protocol violation of the remaining patients patients were randomised to receive tcv- and to be treated with placebo. there were no significant differences between the treatment group with respect to age. gender, and apache i~ score on admission. however, admission levels of il- and il- , considered to reflect severity of disease, tended to be higher in tcv treated patients: . . vs . ng/ml for il- (p. ) and . vs . ng/ml for il- (p. ) in tcv- and placebo treated patients, respectively. a remarkable difference in survival, however not significant, was observed at day i.e. the end of tcv treatment (mortality: out of in the tcv group and out of patients in the placebo group). the inc;dence ui ~-,~verse events, 'n both treatment groups were comparable. plasma il- and plasma il- levels tended to decrease more rapidly in tcv treated patients compared to controls (p=. and p=. , for il- and /l- respectively) conclusions: tcv- is safe as add-on treatment in sepsis syndrome patients. the data presented indicate that tcv- may enhance survival of sepsis syndrome which will be assessed in a phase ill study. objective: oxidation of lipids by free oxygen radicals playes an important role in sepsis. an important source of oxygen radicals is the respiratory burst of phagocytic leukocytes, especially~ polymorphonuclear leukocytes. clinically the hallmark of sepsis is the capillary leak, which is mediated in part by oxyradicals. the adult respiratory distress syndrom (ands} represents the most studied capillary leak phenomenon in sepsis. methods: in ii patients (df,~m, aged - y.) with verified septicemia had been included in this study. beginning from day oxidisable lipidautoantibodies (club), ~opterin and crp were determined in the patients serum and compared against the apache ii score during the days - . patients, f and m died @u= ring their stay at the icu, of them in less than h~urs: after admission. at the begin surviving patients showed olab values between - %, non-survivors between - %, com= pared to neopterin values of - m~ol/l in survivors and - ~mol/l in non-survivors. apache ii score didn t show any difference. during the following days olab sbowed an in= crease in survivors, while in non-survivors olab stayed equal or showed a decrease. no difference between both groups was found in neopterin, crp and apache ii score. as result we conclude, tbat lipidperoxidation playes an important role during septicemia. olab as a marker of this process are predictive for the outcome of patients. obiectives : to evaluate the influence of cardiopulmonary bypass ongastrointestinal transit. meth~xls; gastrocoecal transit time (gtt) in consecutive children on day after uncomplicated open heart surgery was compared to gtt in children after closed heart thoracic surgery and to healthy controls. gtt was measured by hydrogen breath testing, using lactulose (o, g/kg in a % aequous solution) as nonabsorbable marker. exspiratory hydrogen content was measured using a electrochemical system (stimotron). patients in both groups had continuous infusion of morphine and midazolam and were comparable in respect to catecholamine dose. children with a history of toddler's diarrhoea and children with elevated central venous pressure were excluded. results: gastrocoecal transit was delayed in all patients after cpb, no transit was achieved within minutes in / . after closed heart surgery gtt was delayed (+- ) min vs. (+- ) compared to controls, but transit was achieved in all aptients within rain. mean dopamine dose was , mcg/kgmin after cpb and , meg after closed heart surgery.. conclusions: after uncomplicated cpb gastmcoecal transit is extremely delayed. the degree of delay is not explained neither by the use of analgetic and sedative drugs neither by the use of catecholamines. factors directly related to cpb (e.g. low flow perfusion, hypothe,mia) may be responsible. these findings are of limited clinical relevance in ancomplicated cases. in critically ill patients delayed enteral feeding may contribute to infectious complications. studies of therapentic measures to accelerate gastrointestinal transit therefore are warranted. neonatal ecmo -czech experience. nekvasil r., penkova z, vasek l., plier p., bobula a novotna e., pavlicek v., hnilicka m. nicu and ecmo center brno and dept. pediatric surge ', children's hospital brno, czech republic. introduction. in spite of the fact that neonatal ecmo has been gradually considered a standard method of solving uncontrollable respiratol t failure in newborns in most countries of the western europe, the introduction of this sophisticated method in countries of the former communist block meets a lot of problem. material methods. in the course of two years, only newborns, b.w. - g, were reffered to neonatal ecmo because of uncontrollable respiratow failure. at the admission the average values of oxygenation index were + , and aado , -+ , kpa. results. newborns ( %) died shortly alter" admission or during transport without possibity to further is newborns ( , %) were treated using high-frequency ventilation (hfo or hfjv), one for conspicuous airway resistance paradoxically with low-frequency ippb. all ventilated newborns survived. ecmo was applied in newborns ( , %) and of them survived the mortality rate of group mentioned was %. conclusion. the fact that in the czech republic ( mil. population with natality rate of about . newborns/year) only small part of patients was reffered to neonatal ecmo has a number of causes. the most important are: unacquaintance of prognostic and indication criteria at forwarding workplaces and the aversion of neonatologist to all new.therapeutic interventions. last but not least, a negative role is also played by current change of health service systems when, under the influence of health-service insurance companies a newborn in serious condition given only a standard intensive care in primary and secondary nicu is literally "the golden calf", and therefore these workplaces either do not send him or send him too iate ~o an ecmo center. stndy aim: urfactant, which is being applied into the lungs for treatment of respiratory distress syndrome, can reach the circulatory blood system by absorption. it refinances local fimctiun of macrophages and lymphocytes and increases the accumulation of nentrophils into the hmgs this eunld influence the local acute phase reactiml in the hmgs after surfactant application. "ilia aim of the stud), was to investigate the influence of oatural and artificial surfactaat onto the acute phase reaction and the blood elottiog system. material :and methods: a) measurement of tnf-a, - , ltb and thromboxane b release in whole blood: each of . ml hepariaised blood of healthy adult volunteers was iucubated lbr hears with eillier ill ug/ml lps, mg/ml b&,ine smfactant (alveulhct/themae), rag/nil artificial surfactant (exosurf/wellcome), og lps + i mg/ml bovine surfactant or i ug lps + i mghal artificial sorfactant, tleparinised bhx-,d without additions was used for controls. ' e concentration of e)lokines and eicosanoids ".van measured semiquantilatively by eijsa or eia (dimmva/hamburg) after ceatrifagalion, b) measurement of platelet aggregation: each of . ml haparinised hltxxl of healthy adult vohmteers was inculmled lbr hours with eilher aghnl i,ps, i mg/ml bovine surfactant (alveafact/thomae), i mg/ml artificial snrlhctant (exosurf/wellcotne), it} ug lps + i mghnl bovine snrfactant or ug lps + i mg/ml artificial surfaetant, tlepminised blood withont additions was nsed for controls. platelet aggregation in whole blood was measured by impedance in the aggregometer (g~nstaedt). c) measurement of the dotting activity: citrated bleed of healthy adult w~lunlccrs was mixed with difl'ereul couccalrations of imvine or artificial snrfactant fad then prolhrombiu tiaras and imrlial thrmnlx~plaslia filues were ineasnrcd. for measurement of the prokoagulatioo acfivily the reagent in the qnick test was replaced by surfaclant. results: dependmlt on the dose both surfactants stimulated the release of - but not or tnf-a io wlmle blood. "illere was no suppression of the lps-indaeed eytokine-release. both surfaclants did not directly influence the extrinsic blood coagulation system, while both activated the inniasie activity dependant on the dose. platelat aggregatiun was slightly stimulated by bovine snrfactunt and strongly inhibited by by artificial surthctant. in comhinafion with . ~ both factors showed no difft.'renca to lps ahme.'fhe reltu.tse of eiconasnid~." was stimolated more by artificial surfactant then by bovine surfilctant with regard to the cyehmxygelmse (thromboxsne b ) and the lipooxygenase (lencotrieae b ) pathways. conclusion: we cooclude: ) i:lovine as well as artificial surfaelant stimulate the cellular inmnn]e response. ) bovine as well as artificial surfnctant activate the intrinsic ctmgnlation cascade. ) bovine surlilctant stimulates platelet aggregation, artificial sar-fijctant inhibits platelet aggregation.. introduction: although the use of modem noninvasive methods like measurement of tope , tcpco or san leeds to an carly infonnation about pathologic alterations of the gas exdmage of ventilated patients, these methods cannot replace invasive bloodgas analysis. a new noninvasive method to monitor the capillary gas exchange is the reflection spectrophotometry. to record reflection spectra with a ldgh sensitivity on the surface of tissue we eonstnmted a special mierolightgnide photospectronmter (empito). this spectrometer enables the investigation of local helerogenities of llbo and lb content, capillary flow rate and oxygen uptake rate. aim of the study: ) to compare the sousitivity and specifity ofthe empilo with other non-invasive method~ of monitoring the gas exchange in neonatal intensive care patients. ) to investigate the possibility of obtainiug infonnations about the local nptake and the venous as well as arterial satnration. patients and methods:we investigaled non-selected patients of oar pediatric intensive care unit. for coulinnons monitoring we conslracted a special sappert to fix file end nf the microlightguide+ during the investigation tope , tcpco and san were measured by standard methods. "fo investigate the local tisslm oxygen uptake we recorded spectres within minutes by moving the lightgnide over an described area of the skin of the patient. 'lhe reselting i(gx) l ibo vahms were sorted by a software package. on the assumption that the low values correspond to the tibo value of the veaons ends of the capillaries and the high values to those of the arterial ends we ) it is possible to gel infonnations about the local o -uptake and arterial saturation ia the peripheral tissue by photoslg'ctroscopy. ) in combination with noninvasive pl i-measorement it seems possible to reduce withdrawal of blood for invasivn bhmd gas analysis. objectives:improve ventilation,tissue oxygenation and acid base balance among extremly low birth weightand premature infants. methods: fourteen cases were s~udied,their gestational age ranged from( - )ws.continnous positive air way pressure was applied to six cases at peep level from ( - )cm h o through nasal pronge,(group i),the other cases were managed as routine,(group ii).blood gases, tcpo ,tcco ,resp.rate,depth and pattern were monitored for assessment of tissue oxygenation and ventilation, results: our rasults showed that early application of cpap improve ventilation among ( . %)of cases,while ( . %)of cases need imv.the cases of group ii need imv among ( %)of the studied cases during the second or the third day of life. conclusions:-this preliminary study showed the import-............ ance of early application of cpap before the onset of respiratory distress syndrom to improve spontaneous ve ventilation,tissue oxygenation and to gecrease the risk of intubation. comparative assessment of pediatric intensive care; a national multicenfre siudy. reinoud j.b.j. gemkc, gouke j. bonsel , the dutch picasso (pediatric intensive care assessment of outcome) study group. twilbelmina children's hospital and utrecht university, utrecht department of clinical epidemiology, academic medical center, : amsterdam, the netherlands the performance of all ( ) pediatric intensive care units (icus) in the netherlands ( tertairy and non-tertiary) was analyzed in an open prospective muiticenter study. effectiveness of care was defined as the ratio of observed to prism-score derived expected mortality aenee, standardized mortality rate). efficiency was determined by objective criteria (mortality risk > % or administration of at least icu-dependent therapy)'. consecutive admissions aged < years old were included. overall, observed and expected mortality were in good agreement (p > . ). between hospitals, crude mortality showed wide variations (mean . %, range - %). however, in each center, observed and expected mortality were similar (mean ratio . , range . - . ). in tertiary care centres, severity of illness corrected mortality in high-risk patients was less than in non-tertiary care centres; paradoxically, in low-risk patients the opposite was found. probably the large proportion of low-risk tertiary care patients suffering from severe, incurable chronic disease, explains the higher mortality in this group. this indicates that simultaneous assessment of circumstances of dying and of long term morbidity in similar future studies is imperative. the average proportion of efficient icu days was %, however large variations between units were found (range: - %). in conclusion differences in mortality rates among pediatric icus were explained by differences in severity of illness. high efficiency rates in combination with adequate effectiveness, found in several centres suggest that admission and discharge decisions might be improved by a better selection of high risk patients requiring icu-dependent therapies, especially in less efficient centres. objectives: previously published studies showed that serum lactate levels correlated with outcome of severe ill adult, 'we hypothesized that critically ill newborns are often incurred hypopeffusion manifested by elevated lactate levels. these initial blood lactate levels should be related to nicu outcome. design: prospective study with ethical comfnittee approval. setting: the -bed neonatal intensive care unit of a university hospital material and method: a total of consecutive outbem newborns admitted to nlod from , . to ., . were enrolled to the study. babies who died or were discharged from the unit within hours of treatment were excluded from the study, mean birth weight was g (+/- r), mean gestatational age was weeks (+/- . wks), mean age at the admission was h (+/- hi. multiple (~_ j organ system failure occurred jn . % of babies at the admission./~tertal lactates were measure/at the admission, among - hour and - hour of n[c'lj therapy. outcome was defined as a mortality and length of nicu stay. results" survival rate was . %, mean length of nicu stay for survivors was . days (+/- . day). we found high lactate levels at the admission in . % babies (~ . % with levels above . retool/i). the mean arterial lactate concentrations for nonsurvivors were signiftcahtly higher than for survivors durin~ consecutive da~ as follows: objectives: the purpose of our research was to analyze the frequency of bronchial asthma (b.a.) exacerbations in pregnant women and health status of infants. methods: the research was based on the epidemiological investigation and prolonged observation of pregnant women with b.a. during the gestation period. remission of b.a. before the pregnancy in excess of years was recorded in patients ( . %), patients ( . %) reported a - year remission and patients ( . %) had a remission lasting less than months before they became pregnant. results: seven patients ( . %) developed medium attacks in the second half of pregnancy, four patients ( . %) experienced light attacks of b.a. asthma attacks were most frequently caused by acute respiratory diseases and stress factors. in two cases with grave manifestation of b.a., the pregnancy ended in abortion within the first - weeks due to the frequent and heavy choking attacks. to fight b.a. attacks, five patients used adrenomimetics (salbutamol, becotid) in sprays, six women were administered theophyllinum and salbutamol in the form of tablets during - weeks. a significant portion of pregnant women with b.a. ( %) exhibited frequent complications during pregnancy (toxemia, late gestosis, threat of miscarriage). our findings prove that babies born from women with b.a. of domestic and pollen origin had a low body weight ( - gr), functional immaturity and chronic antenatal and intranatal hypoxia twice as often as the infants born from healthy women without allergic background. conclusions: preventive treatment of women with b.a. prior to pregnancy is required to maintain a stable remission of the disease, which is a key to having healthy children delivered by mothers suffering from b.a. introduction. intracerebral hemorrhage (ich) is a common event in human prematudty, affecting about % of newborns weighing below g who are born before weeks of gestation, however, little is known about the pathogenesis of ich with exception of the prematurity of the brain itself, (birth) trauma, and asphyxia. the postischemic production of oxygen free radicals (ofr) dudng reoxygenation as a cause of brain damage has been demonstrated in animal research. since almost all preventive antioxidant activity of plasma is associated with ceruloplasmin and transferdn we investigated the association of such iron-oxidizing resp. iron-binding proteins and ich. we could demonstrate significantly reduced levels of both, iron-oxidizing and iron-binding proteins, in premature asphyxiated newboms pdor to development of ich. an increase of suparoxide after hypoxia in the presence of iron ions facilitates the formation ofthe highly reactive hydroxyl radicals. our data support the theory that ich may be caused by ofr, which can damage any sensitive tissue including growing endothelial cells. the estimation of transferrin-saturation and measurement of ceruleplesmin levels might help to identify an infant at dsk before the onset of ich. with the new medos | hia-vad | cardiac assist system the missing tool in the armamentarium of cardiac surgeons is available in two pediatric sizes: i -ml and -ml pump volume. the right sided pumps are % smaller for biventricular use. between february and may we implanted this assist system in children. the indications and demographics are indicated in the following table (left ventricular assist device-lvad, right vad-rvad univentricular vad-uvad, post cardiotomy cardiac failure-pcf, dilated cardiomyopathy-cmr bland white garland syndrome-bwg, tetralogy of fallot-tof, hypoplastic left heart syndrome-hlhs). objectives: evaluate tile effeci'of inhaled nitric oxide (no) as puhnona] t vasodilating agent ill tile posloperalivc period after correclion of congenital heart defects in infant. patient n.l: kg, lnonlhs, down syndrome undenvcnl rep~fir of atrioventricular septal defect (avsd). after surgery the puhnonary arlcry pressure (pap) slowly rose to tile syslemic dcspilc tnaximal eonvcnlional fllerapy (fentanyl mcg/kg/h, hypocapnia of mmhg and metabolic alcalinization). no was delivered into tile inspiratory branch of!be breathing circuit at ppm, and the gas aoalyser for no and no (polylron dmger) were situated at the espiratory branch, a rapid dccrcasc of pap io i/ of systemic was obtained with a dramalic improvement. no was continued at ppm for six days and the baby was exlnbated if! days after surgery and discharged from the icu days after. patient n. : . kg, monlhs, onderwen! repair of avsd. the day after surgery the systemic oxygen salnralion was % wilh a pap at % of systemic. two hours of c wenlional therapy failed o improve ihc patient and no administration was slarled at ppm. so dramatically incrcased to %, but the pap dropped only to % of syslemic. nevertheless ihe clinical conditions improved and the no administration could be reduced at ppm in the following days. she was extubaled days after surgery and discharged from the icu days after. patient n. : kg, 'ears. underwen| hearl tral~splantalion for congenital heart disease with moderate hypoplasia of pulmonary arlcrics. at the end of cardiopulmonary bypass the transpnlnlonary al~erio-venoas gradient yeas higher than mnfflg and we speculaled !hat w'ls due to a degree of puhnonary vasocostrictiont. the nsnal dose of no was otilised, however no significant modilicalion of pulmonary pressure or systemic oxygen saluralion was noled, and after h no was discontinned. tile palienl was carried io the icu with maximal inotropic support, extubated after d;b's and disclmrged from the icu after days. in all patient no major adverse effect relaled to no admilfistration ",','as holed. conclusion: in our experience no ms a pulmonary vasodilaling agent is effective and easily adjustable to tile palienls requiemenls, however its use remains limited ill those palienl ill whoin tile alnonll! of fixed inlllllojliify vascular resistance is predominanl. we report the use of ecmo support in two unusual cases of severe tracheal disruption in which it had become impossible to achieve adequate ventilation. case : severe tracheal laceration due to aspiration of a share forelan bodv: a previously healthy month old toddler was referred for ecmo following aspiration of a porcelain foreign body (with razor sharp edges) which had become embedded in the right mainstem bronchus with massive extrusion of air. this was removed on veno-arteda[ ecmo support, as the patient was unventilatable prior to bronchoscopy due to ongoing airieak. ecmg was continued after bronchoscopy to permit airway healing without the presence of an endotracheal tube. unfortunately, an extensive pulmonary haemorrhage on day of ecmo necessited re-exploration of the airway. this revealed a posterior tracheal tear from the cricoid to the middle of the right lower lobe. following repair the patient was left on ecmo support together with high frequency oscillation ventilation (hfov), the latter being used to minimise potential aideak and maximise alveoli recruitment. ecmo was weaned after days ( hours) -the patient was extubated weeks later. case : tracheal wound dehiscence due to seosls -tracheal transelant on ecmo: a month old infant with a c[inically significant congenital long segment tracheal stenosis and left pulmonary artery sling underwent resection of the stenosis, followed by primary reanastomosis. this was complicated, days later, by severe mediastinitis and complete dehiscence of the anastomosis. an autologous pericardial patch was used to repair this, however, the tracheal wound again dehisced days later making mechanical ventilation impossible. in view of ongoing sepsis and a severely disrupted trachea ecmo was the only possible form of support. following resolution of the local sepsis ( days) a definitive procedure in the form of a tracheal homograft (transplant) was undertaken on ecmo. the patient was managed on ecmo and hfov for a further days, the hfov being used to optimize rapid lung inflation. unfortunately this patient died months after weaning from ecmo due to complete disintegration of the homograft, which was not deemed reparable. conclusions: ) ecmo can be used in the acute management of oxygenation when there is major airway disruption making mechanical ventilation impossible. ) hfov was a useful adjunct in aiding recruitment of lung volume on ecmo in these two patients. backoreund: persistent pulmonary hypertension of the newborn (pphn) consists of a heterogenous group of diseases ranging from transient reversibte pulmonary hypertension to fixed primary malformations of the lung (primary pulmonary dyspfasia-ppd). inhaled nitric oxide (ino), a selective pulmonary vasodilator, has been proposed as a treatment for severe pphn. obiective and methods: ino was administered to near term neonates with severe persistent pphn, oxygenation index > and echocardiogrephic evidence of pulmonary hypertension, in order to further determine the clinical role of ino in the treatment of pphn. the response to ino was also analysed retrospectively to examine whether this could be of diagnostic value in differentiating at an early stage patients with reversible from fixed causes of pphn results: twenty one of the patients studied responded to the initial trial of no ( ppm x minutes), as defined by a greater than percent improvement in pad as well as a fall in the el to < . these patients were continued on ino therapy, with patterns of response emerging: pattern babies (n= ) continued to show a sustained response to ino and were successfully weaned from it within days -all survived. pattern babies (n= ) failed to sustain their response to ino over hours, as definded by a rise in the el > . six survived, five with ecmo. pattern babies (n= ) had a sustained dependence on ino for - weeks. all three died and lung histology revealed severe primary pulmonary dysplasia (ppd). patients with ppd (pattern ) not only required ino for longer periods of time than did the sustained responders (pattern ), but also required significantly higher doses of ino we report on the air transport of paediatric intensive care patients. these transports fall into three categories: ) retrieval of critically ill neonates and paediatdc patients referred for either ecmo or inhaled nitric oxide (ino) (n = ). one patient was transferred on ind. mean transfer time . hours (se + . hrs). ) long distance international transport using chartered aircraft (n = ). the indications for these transfers included both urgent retrievals for cardiac surgery and semi-elective transfer of stable patients back to their referring unit following treatment in tertiary centres. mean transfer time . hours (se + . hrs) ) long distance international transport using commercial aircraft (n = ). indications for transfer were either semi-elective retrieval for tertiary treatment or the return of stable chronically ventilated patients to their referring hospitals. mean transfer time hours (se _+ .fhrs, longest hrs). the transport team consisted of a paediatric intensive care doctor of at least registrar grade and a registered sick chidrens nurse with intensive care experience. the administrative components of the transfer (ambulances, airlines, customs) were managed in collaboration with companies specializing in air ambulance transfers. outcome: all the patients were safely transported to their destination without mortality or morbidity. complications durino transfer ir~lv~; ) patient complications -semielective endotracheal tube change and central access needed in the only patient brought to the commercial aircraft by the referring hospital (all others retrieved directly from referral hospital), seizure in patient with known encephalopathy, severe cyanotic spells in patient with fallots tetralogy who was retrieved for urgent surgery for this indication ) mechanical compfications -ventilator failure, incubator battery failure, oxygen regulator failure -all occurred with equipment sent from referral hospital, this was unfamiliar and unchecked by our transport team -it was not the decision of the transfer team to use this equipment on this single occassion. ) administrative complications -confiscation of incubator battery by airport security police, excessive delay by custom officials ( hours) in the airport. the incidence of such problems were felt to be low and unpredictable. in conclusion: mechanically ventilated paediatric patients can be safely transported on both chartered and commercial airlines. these transports are best accomplished by trained intensive care medical and nursing staff with the backing of an air ambulance organization competent in arranging the necessary administrative details. it is essential to use your own equipment and to retrieve the patient _directly from the referrin(] hospital to minimise ootential complications. our experience with anaesthesia for paediatric electromyography _w_._pla_ti_k_a_n_o_v, r.eousseff, k.pavlova, d.marinova dpts. of anaesthesiology and int. care and clinika] neurophysiology, med. university, pleven, bulgaria ~)_b_j#~ti_v~. to t~st a " heavv sedation " regimen of anaest-es~a for the purpose of paediatric electromyography d#s~gil~ non-randomized,non-blinded human trial in the seting of an uriiversity hospetal. _m_a_t_eri_a_is_a_nd_ m_e_th_od_s_. children,asa i-if,median age years,range - who undervent eleetrcmyography required anaesthesia. they recieved low-dose ketamine + i~iazepam or midazolam via musculary route( children,age - yrs,ketamine , mg/kg, diazepam - mg total dose ) or per os ( children,ketamine - mg/kg,diazepam , mg/kg or midazclam , - , mg/kg ) _resu_l_t_s. - minutes after medication a state of heavy sedation with weak spontaneos and stimuli-provoked movements was achieved in all children, that lasted - minutes and allowed adequate needle emg and nerve conduction investigation. children recieved additional , - , vol.% halothane during the placement of the needle. non -invasive blood pressure , breath and heart sounds and hb sad by pulse oxymetry were monitored.none of the older children disclosed memories of pain when asked after they regained adequate verbal contact.no complicationes were observed. antenatal maternal steroids reduce the risk of periventricular-intraventricular hemorrhage in very premature neonates treated with natural surfactants. i.apostolidou, c.papagaroufalis, g.touloumi, m.xanthou, n.kalpoyannis a' and b" neonatal icu "ag. sophia" children" s hosp. athens, greece. dept of hygiene and epidemiology, athens university, greece. obiectives: the aim of the study was to evaluate the association of periventricular-intraventricular hemorrhage (p-ivh) in surfactanl treated premature neonates with pre-and postnatal variables. methods: the population of the study was neonates admitted during the years to , with gestational age _< weeks and severe respiratory distress syndrome (rds) (mechanical ventilation and arterialalveolar oxygen tension ratio (ajapo ) < . ), who received rescue therapy of at least two doses of natural surfactants (alveofact or curosurf) and examined with ultrasound and/or autopsy for the presence of p-ivh (papile's classification). the examined factors in each neonate were the following: gestational age, birth weight, sex, multiple pregnancy, antenatal maternal steroids (complete and incomplete course of betamethasone), a/apo before the administration of the st dose of surfeclant, delivery, apgar score at min, type of surfactant, pneumothorax and patent ductus arteriosus. the statistical methods used were x and one-way analyses of variance followed by logistic regression medels, results: the incidence ot p-ivh was . %. three factors were found to have an independent relation to p-ivh (final logistic regression model): gestalional age, a/apo before surfactant administration, and antenatal administration of maternal steroids (complete and incomplete courses). for every weeks of lower gestational age the neonates had an almost doubled associated risk of p-ivh (or: . , % c : . , . ). for every . on average decrease of a/apo before surfactant administration the risk of p-ivh in the neonates was . times higher ( % ci: . , . ). the neonates whose mothers received antenatally steroids had only one tenth of the risk of p-ivh of the neonates whose mothers had not (or: . , % ci: . , . ). conclusions: our results suggest that the antenatal administration of maternal steroids, even less than hours before delivery, reduce the risk of pqvh in very premature neonates treated with natural surfactants, whereas the small gestational age and the lung immaturity still remain the main risk factors tor the development of p-ivh. we analysed retrospectively the management of ( boys, girls) accidental ingestions of foreign bodies in children (mean age : . years, range : months- years). no child had ingested more than foreign object. the majority of the ingested foreign bodies were : coins (n : ), toy parts (n : ), jewellery (n : ), batteries (n : ), "sharp" materials such as needles and pins (n : ), "large" amounts of food (n : ). impaction of food occurs more frequently in children after oesophageal reconstruction in cases of oesophageal atresia. although according to literature "coca-cola" is reported to be effective, this was not seen in our experience. / patients had minor transient symptoms at the moment of ingestion, such as retrosternal pain. only children experienced severe manifestations (cyanosis, dysphagia). in these children, endoscopy revealed oesophageal and gastric erosions. children were seen at the emergency ward within a few hours after the accident ( mean : hours, range min. - hours). chest and/or abdominal x-ray was performed as first-line investigation ( / objects were radio-opaque), and revealed an (unexpected) oeeophageal impaction in children. in / the foreign body was in the stomach. batteries, sharp objects and objects trapped in the oesophagus were removed, either by endoscopy or by magnet-extraction whenever possible. the outcome of the patients was excellent. no complications were observed. extraction is recommended in symptomatic patients, and whenever the foreign body is trapped in the oesophagus, or if the foreign object is "sharp" or a battery. objectives: two strategies were used for management of malignant diphtheria in children aged from . to years. methods: protocol n consisted of intravenous administration of diphtheria antitoxic serum, prednisolone ( mg/kg bw/day), plasmapheresis and supportive care. protocol n included the use of antitoxic serum against the background of high-dose dexasone ( - mg/kg bw/day), hemocarioperfusion and a preventive use (before the clinical manifestation of myocardial damage) of inotropic medications, inhibitors of angiotensin-converting enzyme and pentoxyphylline. each of protocols included the monitoring of serum toxin (diphtherin) levels. results: the group of patients treated according to the protocol n consisted of children with malignant diphtheria, of them with severe malignant diphtheria (grade and ). all patients exhibited the circulation of toxin during at least three days after the start of treatment. all patients with severe grade of disease demonstrated heavy cardiovascular disturbances associated with malignant diphtheria. of the children in the group died seven. the children of the second group were treated according to the protocol n . out of total of patients of this group. patients had severe malignant diphtheria. in all children a significant reduction in serum toxin level was revealed after hemocarboperfusion. in all but one case the satisfactory control of cardiovascular function on was achieved. of children admitted to the trial survived, one child with malignant diphtheria of grade and congenital filbroelastosys of the left ventriculum died. the severity of neurological complications was similar in each of groups. conclusions: the use of hemocarboperfusion, high-dose dexasone and early prevention of heart failure as a adjunct to the standart treatment has been shown to be of benefit in the management of malignant diphtheria. t. schaible, i. reiss, j. m er, l. gortner med. university of lqbeck, children's hospital, kahlhorststr. - , l~beck, germany surfactant therapy seems a promising approach for the treatment of the biochemical and biophysical abnormalities of the pulmonary surfactant system in severe ards. patients and methods: over a months period non-neonatal pediatric ards patients (age - months) in a "pre-ecmo"-situation (oi over h) were treated with bovine surfactant (alveofact| the underlying conditions-of ards were pneumonia ( ), sepsis ( ), immunosuppression ( ), near drowning ( ), neurogenous ards ( ). a total of - mg/kg b.w. was applied in several fractions. before surfactant therapy, we first tried different ventilation (best peep-finding, inversed i/e-ratio, hfo-ventilation) while monitoring the pulmonary mechanics. for hemodynamic stabilisation both norepinephrine and epoprostenol were used to optimize pulmonary perfusion for max. hrs. if there was no improvement of the oi by at least , further treatment with surfactant was initiated. in addition to surfactant all patients received a treatment with dexamethasone of mg/kg in doses. patients with no benefit (oi remained unchanged or increased within the max. - hrs) were taken on ecmo. results: nine patients improved within hours after surfactant therapy: the oi decreased from a level of (mean, range - ) before our treatment to a level of (mean, range - ) thereafter. in patients we were able to continue the positive effects of our treatment and they could be weaned of the respirator within - days. the other patients got worse despite respiratory improvement, they suffered of multiorgan failure of more than organ systems. the last patient did not benefit from surfactant, he had to be put on ecmo, but died because of a complication (hemopericard)after days. the autopsy of the ecmo-patient showed a pulmonary fibrosis, but the other death were not due to pulmonary failure. conclusion: a different sequential ards treatment integrating surfactant therapy can reduce the number of patients requiring ecmo. but ecmo as a therapeutic tool should be available in centers involved in ards treatment. l.blindl, t.p.le, h.weinzheimer, centre for paediatrics, university of bonn, germany selective reduction of elevated pulmonary vascular resistance by inhaled prostacycliu (pgi) has been reported in adults with acute lung injury, neonates with persistent pulmonary hypertension and in one infant with idiopathic pulmonary hypertension. we report on the effect of aerosolized prostacyclin in two children with secondary pulmonary hypertension. patient : in a boy with down's syndrome an avsd had been surgically corrected at month of age. at , yr of age a catheter examination revealed a pulmonary vascular resistance of % of systemic vascular resistance in room air and at an fin of . . prostacyclin ( . mcg/ml) was administered with a jet nebulizer at an fin of . . pvr declined to . systemic vascular resistance and returned to baseline after stopping pgi-inhalation. subsequent intravenous infusion ( ng/kg rain) had to be stopped after minutes because of systemic arterial hypotension. patient : a month old male infant with bronchopulmonary dysplasia developed suprasystemic right ventricular pressure inspire of therapy with oxygen and nifedipin. while he was spontaneously breathing % oxygen via face mask pao was mmhg, arterial ph was . . systolic arterial pressure was mmhg, a rv-ra gradient of mmhg was measured by cw-doppler. while fio was maintained aerosolized prostacyclin was administered over minutes. rv-ra gradient was mmhg, systemic blood pressure mmhg, pao mmhg. two hours later nitric oxide ( ppm) was inhaled at an fio of ( , . rv-ra gradient declined from to mmhg, systemic systolic blood pressure remained stable at mlnhg. discussion: sporadic experience shows that aerosolized prostacyclin selectively reduces elevated pulmonary vascular resistance in some patients. in patient the poor response to inhaled pgi compared to inhaled nitric oxide may be explained by the fact that the action of pgi is not independent from endothelial function, limiting it's effect in severe vascular disease. during the last two years ( - ), infants weighing less than gr. admitted to our referral unit. thirty four of them ( %) survived, ( % of infants weighing - g and % of infants weighing - gr survived) for the years - - the survival of these infants was % and for the years - - , % (p< . ). we analyzed the perinatal and neonatal factors influencing the outcome of these infants. the comparison among neonatal survivors ( ) to neonatal deaths ( ) shows: gestational age: . w ( ) to . w ( ) (s). birth weight: . g ( ) to . ( ) (s). apgar score: , ( ) to . ( ) (ns). presentation and mode of delivery: breech presentation is associated with higher incidence of neonatal deaths. i.v.h. (at the age of weeks): no one of the survival infants had evidence of i.v.h. respiratory problems: intubation, at the admittance of the infants . ",,( ) to % ( ) (s) use of surfactant: % ( ) to % ( ). bpd observed in % of the babies and only one was dependent on oxygen at home. antenatal betamethasone was given in % of the mothers. in conclusion: ) a great improvement in the survival rate observed in these infants the last years in our unit. ) factors with positive effect are increasing gestational age and birth weight, the absence of i.v.h. and the use of surfactant. the breech presentation and the severe respiratory problems increase the incidence of death. animal experiments demonstrated, that brain temperature determines the amount of neuronal damage caused by hypoxia and that mild hypothermia may have a protective effect. until now there is no method described and evaluated to measure brain temperature in neonatal intensive care units. we non-invasively measured brain temperature analogues, nasopharyngeal (tnasoph) and zero-heat-flux temperature (zht) at the temple whereby under zero heat flux surface temperature represents deep head and thus brain temperature. the aim of our study was to investigate the practicability of the method, the relationship of the two brain temperature analogues to rectal temperature (trect) and their dependence on insulation, thermal environment, body activity and time course. we investigated healthy preterms less then weeks postnatal age (gestational age +_ . wks; x + sd, weight +_ g) in an incubator. tnasoph was measured by a thermistor within a feeding tube, advanced to the nasopharynx, zht temple by a thermistor and a heat flux transducers both covered by an insulating pad, and trect thermal environment was characterised by operant temperature (tair . . + twall . ). body activity was video taped. measurements were performed during the following interventions: i/ insulation increased by turning the temple with sensors onto the mattress ( rain). ii) insulation increased by a cap ( min), iii) min after its removal, iiii) increased operant temperature by . + . ~ ( min). results: seven children with ea had a gasless abdomen, the endoscopic procedure excluded ( ) or diagnosticated an upper pouch fistula ( ). in patients who suspected "h" fistula ( ) broncoscopy has strong advocated method to make diagnosis and established cervical approach. from july newborns with ea and lower pouch tef received a selective transtracheal incannulation. we were not able to proceed just in case with congenital subglottie stenosis. in these patients we provided gastric drainage by radiopaque and flexible - french catheter. the knowledge of the precise anatomic position of tef consent to adjust the tip of the endotracheal tube in order to achieve best ventilation. the presence of the catheter through the fistula helps the surgeon to identify, it quickly. no complications were correlated to the procedure and no babies had early pneumonia. alimentary continuity was achieved in all patients ( primary anastomosis, resections of tef, oesophagocoloplasty and died with gastrooesofagostomy). the late mortality . % ( ) was only directly related to the severity of associated malformations. conclusion: the advantages of this technical approach are unquestionable for the anaesthesiologist and the surgeon. in our experienc e the procedure improves perioperative management of babies and appears to be safe. relation between cytokines, prethrombotic markers and endotelial injury markers in children with septic shock objectives: to establish the relationship between cytokines (tnf, il- , il- ) prethrombotic markers (d.d., pcam) and endothelial injury markers (tm, uwf) in pediatric patients with sepsis and bacteriemia without shock, and patients with septic shock. design and methods: prospective study, children ( months- years) were admitted in our picu in with the following diagnosis: bacteriemia ( ) sepsis ( ) and septic shock ( ) according to jacob's r f criteria. measurements: il- , il- , tnf, tm, vnf, d.d. pcam and routine laboratory data on admision, , , hours and on discharge. the prism (pediatric risk of mortality score) was also recorded. results and conclusions: two patients in the septic shock group died. significant differences were found between non-shock and septic shock patients in relation to tm, dd, pcam, il- , il- and tne high levels of tnf and il- are closely associated with the severity of septic shock with purpura in children. low levels of pcam on admission were associated with severe shock. who underwent open hea~nt surgery, hypervotaemia with or without oliguria was the most frequent reason to start pd ( %). in patients pd lasted less then one week and there were no complications; in patients it lasted - days (one child had a peritonitis). instillation of dialysis fluid into the peritoneal cavity was associated with a significant increase in central venous pressure. there were no significant changes in cardiac output or arterial oxygeu saturation. in all patients pd dhnjnished fluid overload or improved the metabolic status. patients ( %) survived the postoperative course and all had complete reintegration of renal function. conclusion: pd is a useful method to treat the fluid overload and acute renal failure in paediatric patients following open heart surgery with file effects of little importance on the cardiovascular fimction. obieetives: with the marketing of computerised systems for lung function testing in newborns, there has been an increasing interest in clinical approaches. percentile curves of pulmonary parameters permit an appropriate and clinically useful interpretation. however, the manual evaluation of the results using different curves is an impractical technique. therefoi'e a computer programme was developed. methods: the percentiles ( %, %, ~ %, %) of the most important pulmonary parameters were determined non-parametrically in weight-classes. for the calculation we have taken results of our own as well as other laboratories using a meta-analysis of reference studies. in all, individual data of - healthy newborns ageing between - days were collated. using these percentiles, for every parameter in relation to the body-weight the cumulative distribution was calculated approximately using piecewise linear and exponential functions. as shown in the figure the results of computing are represented numerically as well as graphically and can be included in the patient report. conelusions: clinic~d experiences with the programme have shown that representation of all measured parameters on standardised % scales allows an easy interpretation at first sight and improves the detection of pathologic patterns in the parameters. ")supported by bmft, fp "risikoneugeborene" prism (pediatric risk of mortality) score is a well known, already validated scoring system that quantifies severity of illness based on routinely clinical and laboratory variables measuring physiological instability. once computed the score by summing up the weights corresponding to the most abnormal value recorded during the first hours, the overall risk of mortality can be predicted by using the coefficients estimated by a logistic regression where prism score is the main independent variable. (pollack mm et al, -pediatric risk of mortality (prism) score. crit. care med. ; : - . to assess the applicability and validity of prism in the italian setting we launched out a prospective data collection in a sample of pediatric icus. measures of calibration (goodness of fit statistics) and discrimination (receiver operating characteristics and area under the roc curve) are planned to be adopted in the cohort of patients recruited during year period. as the validation study started on july , data collection is still on going and validation analyses will be carried out on july . up to now centers recruited cases. at present, characteristics of the sample recruited are the following: most of the patients were male ( %); the mean age is years with % of patiens having less than days; more than half were medical cases ( %) admitted from emergency room or from hospital floor ( %); % cases were admitted with an organ failure while % to be intensively monitored. icu-mortality was l %. the paper will present final results of calibration and discrimination analyses that will be carried out in the whole sample and across subgroups known to differ in terms of clinical relevance and prognosis. if calibration and discrimination assessment will produce not satisfactoty findings, a customization of the current coefficients will be made allowing a formal comparision of previous and new parameters. jf riera-faneao, m wells, j lipman. baragwanath intensive care unit, university of the witwatarsrand, south africa. [background the prism score is designed to assess the likelihood of death in ipaediatdc icu patients, using only acute physiological disturbances, age and [operative status to predict mortality. there is no evaluation of chronic health status, [including malnutrition. this may significantly affect its ability to accurately predict outcome in a population where malnutdtion is common. aim to determine the influence of nutritional insufficiency, as indicated by a low weight-for-age on outcome prediction by prism. patients & methods we analysed prism, weight and demographic data co ected prospectively from consecutive paediatdc icu admissions over a year pedod. a proportional weight (pwt) was calculated as a percentage from the th centile of the who weight-for-age growth charts. the pwt was compared for survivors and nonsurvivors, and mortality compared for pwt categodes nho wellcome classification). multivariate statistical techniques were used to identity associations with non-survival and to develop a modified logistic regression equation including a measure of i nutdtional status. receiver operating characteristic (roc) analysis was performed including and excluding patients with low pwt for the odginal and modified equations. results non-survivors had a lower weight than survivors ( . kg and . kg medians p = ) a lower pwt ( % and % medians p = . " . the incidence of malnutdtion , in our icu population was %. the mortality of manoudshed patients was' significantly increased (p = . ), with a good correlation with the degree of malnutrition. the accuracy of prism was significantly improved when malnourished patients were excluded from the analysis (roc value increased from . to . ). ! logistic regression and discriminant analysis identified a significant association between prism, pwt and outcome; age and operative status were not significantly related to mortality. the use of a modified equation including the raw prism score, pwt category and age can significantly improve the discriminatory power (az dm/elopmental sample . , az validation sample . ). the modified formula is: legit = - . + . *prism score - . *age + . *weight category, where the probability of mortality is exp(iog/t)/ + exp(iogio. discussion although we can improve the prediction of mortality by a modified or recelibrated formula, this still does not compare with the reference prism population. the need for validation of the score itself, in the association with outcome of the acute physiological variables themselves, is thus apparent. we conclude that while the odginal prism formula can be improved significantly, a modification of the basic variables in this and other third wodd populations may be essential. a high incidence of malnutrition is an independent risk factor of mortality, and an important cause of the poor discriminatory performance of prism. in order to improve the accuracy of prism, nutritional status should be taken into account. objectives: to assess the value of inhaled no to differentiate between pulmonary vascular constriction or fixed anatomical obstruction. methods: we assessed the response to ppm inhaled no in patients( m, f, median age . months, range day to years) with signs of increased pulmonary vascular resistance, there were pre and postoperative patients. patients were divided into responders(+) or non-responders(-). a positive response was defined as a % reduction in pulmonary arterial pressure and pulmonary vascular resistance(pvr) or in the presence of a left to right shunt, a fall in pvr accompanied by increasing pulmonary blood flow. left atrioventricular valve atresia + mustard pat: pulmonary atresia vsd: ventricular septal defect asd: atrial septal defect pda: patent ductus arteriosus tapvc: total anomalous pulmonary venous connection the responders( / ) were characterised by left to right shunts or pulmonary venous hypertension( / ). patient# was weaned from ecmo with inhaled no. patient# , without congenital heart disease, underwent a lung biopsy which confirmed reversible pulmonary vascular changes. patient# had a pulmonary hypertensive crisis which responded to no. all non-responders( / ) had evidence of anatomic obstruction to pulmonary blood flow (# , , )or a low pvr(# ) on subsequent cardiac catheterisation. in patient # , lung biopsy confirmed severe obliterative vascular disease. conclusions: inhaled no appears to be an effective pulmonary vasodilator. a failed response may be evidence of either irreversible pulmonary vascular disease or a residual anatomical obstruction which may be surgically remediable in the postoperative cardiac patient. therefore, inhalation of no may be a useful diagnostic test to differentiate between fixed anatomical obstruction and reversible vasoconstriction. results: during these years, the incidence of sdra was . % of the total of admissions. the most common etiology was meningococcic septic shock. since , there is a decrease of its incidence. (from % to %) and an increase of pneumonia and immtmodeficiencies. mean age of our patients was , years ( % males, % females), total mortality by sdra was % and there is an increase up to % since mean time of stay of the dead was , days and , days those who survived. although during the late years we offer in the picu a better attendance quality to the patients with sdra and the mean stay is longer, both for those who die and for those who survive, mortality of patients with sdra have increased. the incidence of sdra secondary to the septic shock of a meningococcic etiology have decreased. on the contrary, the sdra secondary to infections by opportunistic germs in patients with congenital inmmunodeficiencies or acquired immuodeficiencies have a tendency to increase. in our series, this change of aetiology is the responsible for the increase in mortality. hospital infantil unlversitario "virgen de roclo". sevilla. espalqa aims:to assess the incidence, etiology, clinical course, sequelae and mortality of the patients admitted to a paedfiatic intensive care unit with the diagnosis of severe traumatism. material and method: cases of severe traumatism in children admitted to our icu in the period from january to june were reviewed. age of patient ranged from months to years, % were males. in our series, % of cases suffered traumatism due to a traffic collision and % had a fall from a considerable height. only in one case was traumatism due to violence to the child. we assessed the first assistance received in % of cases: where was it performed, interval of time since the accident, and steps taken. these data were also studied in relation to the latter evolution. results: % of our patients suffered cranioencephalic traumadsm (ct); in % it was an isolated picture and in % of cases was associated to other lesions. there was participation of thoracic and/or abdominal organs in % of cases. % of cases presented important maxillofacial involvement. only one case presented serious cervical medullar lesion. mortality in our series was . %. in . % important sequelae remained. all of these patients presented tepas on admission equal or lower than . % of those with traumatises had slight sequelae. . % of the total evolve towards healing. a polytraumatized child is a patient that benefits considerably of it admission in a paedriatic !cu. the rapidity in receiving first aid and its quality are essential to avoid sequelae and to make mortality decrease. after unilateral lungtransplantation % of the patients develop a lung failure with decrease of perfusion and increase of pulmonary blood pressure in the transplantated lung. the improvement of perfusion is an importent task in the postoperative period. case report: a year old girl with idiopathic pulmonary fibrosis received a left sided single lung transplantation. during the early postoperative period occured a higtter demand of oxygen and an increasment of the pulmonary vascular resistence in the left lung. the pulmonary ventilation and perfusion scintigraphy indicated in comparison with the right lung a reduced perfusion of only % in spite of a ventilation of % of the transplanted lung. to improve the perfusion of the transplant we administrated per inhalation prostacyclin in a maximal dose of ng/kg/min. the arterial blood pressure decreased but the perfusion continued nearly at the same level. during the following administration of ppm no in the respiratory air we achieved a significant reduction of the respiration pressure f~m to nun h and of the pulmonary arterial pressure. the perfusion in the transplanted lung increased to ca/of the total pulmonary perfusion. after days of administration with no we were able to withdraw the axtifical respiration without any following complications. conclusions: the perfusion of transplanted lungs is a major proble_r~ in the postoperative period. this case demonstrated the advantage of no towards the inhalativ application of prostacyclin. no showed a significant improvement of perfusion in the transplanted lung of a year old girl. results: a total of children with ards were treated with bovine surfactant (alveofact| cases were evalable. the median age was . years (range weeks to , years). in six cases ards was associated with pneumonia, in two cases with lung hemorrhage; in one case isolated ards followed hemihepatectomy. the first surfactant application was performed with a median latency of clays (range - days) after first symptoms of ards witha median doseof mg/ kg (range - mg/kg). in patients doses of surfactant were applied. during the hour before therapy, the median pao / fio -ratio was - . within min. after application of exogenous surfactant the pao / fio -ratio increased to with successive decrease over a period of hours to . accordingly, an increase in pao and oxygen saturation and (less significant) a decrease in ventilation parameters could be observed. analysis of broncho-alveolar lavage before surfactant application in children receiving repeated doses revealed in most examined cases either clear surfactant deficiency or pathological function. of treated patients survived ( of the , respectively). of the surfactant doses were applied in the surviving patients.conclusions: the application of exogenous surfactant in children with ards caused a significant increase in oxygenation, which declined over a period of - hours. the effect often could repeatedly reproduced, in one case after applications. the increase in oxygenation often allowed the reduction of fio and/or the inspiratory pressure. no side effects were observed after exogenous surfactant application.in many cases the application of surfactant wag too late after first symptoms of disease (median latency days). ards mostly due to pneumonia seemed to respond to surfactant therapy less well or not at all. permanent junctional reciprocating tachycardia (pjrt) is the most common incesant supraventricular tachycardia (svt) in children. it is usually drug resistant and its onset in early life has been associated with dilated eardiomyopathy. we report our clinical experience with patients detected antenatally and another diagnosed at months of age. method.diagnosis: negative p waves were detected in leads ii,iii and f, p'r > rp" and there was not warm-up at tachycardia onset.clinical records, ekg,x-rays, echo and holter were reviewed. ep studies were undertaken only with therapeutic purposes. results. in a year period patients under y of age fullfilled diagnostic criteria; were detected prenatally ( - weeks) and one was diagnosed at age mo. the fetuses had intermitent svt during gestation. all of them had pjrt in the first month of life at rates between and bpm. they were admitted to the icu but did not develop signs of heart failure. they were controlled with digoxine (d); d and quinidine; d and propafenone in to days. one was in sinus rhytm until age y; he then showed persistent pjrt over % of the day on repeated holters and underwent successful radiofrecuency catheter ablation (rfca).the other two patients showed initially a lowering of tachycardia rate followed by sinus rhytm for over % of the day (follow-up ran and y). the mo. old infant was admitted to the icu in severe cardiac failure. echocardiogram showed marked systolic dysfunction (shortening fraction %) treatment with digoxine, amiodarone and propafenone were unsuccessful despite lowering heart rate to ; rfca was performed at m. of age with restoration of sinus rhytm and rapid recovery of contractility. all patients were given atp at admission with transient ( to see) recovery of sinus rhytm. ff,s clinical course of pjrt is variable. atp is useful only as a diagnostic tool. initial treatment with digoxine + amiodarone or propafenone is adviced. rfca is a very useful therapeutic modality and can also be performed in young infants twelve patients ( %) died. these were meningitis, head injury, sub-arachnoid bleeds, status epileptieus, leukaemie, drowning, and multiple trauma. calculated from the a admission day p edialric risk of mortality score (prism), the probability of death (p) ranged from - %. of the deaths, i were predicted by prism analysis except for the leukaemie patient (p i%) who died from haematological complications following chemotherapy. two children predicted to die (p % & %) survived. the median length of stay was days (range - days). patlents( %) received ventilatn~ support and patienta( %) were transferred to specialist units ( neurosciences, liver, cardiac, bums). this data supports the view that many paediatric patients are being adequately treated in a dgh icu. meningitis and other neurological illness caused the majority of deaths and respiratory problems caused most admissions. most deaths ( of ) occurred within a few hours of admission. ectopic junctional tachycardia (ejt) is one of the most dangerous arrhythmias in the postoperative setting of congenital heart defects since it does not respond to antiarrhythmics or defibrilation. the object of this presentation is to report on two patients who presented f_jt in the early postoperative period and developed intense congestive heart failure which could be controlled after treatment with moderate topical hypothermia. two patients, m and y, diagnosed of atdoventficular septal defect and tetralogy of fallot developed intense heart failure in the early postoperative period. taehyeardia rate was and bpm. medical drug therapy included weaning from vasoactive drugs, iv digitalization and iv amiodarone treatment. there was not response. they were both surfaced cooled by placing plastic bags filled with cold water over the patient's chest and abdomen. temperature was monitored to obtain a central temperature of ~ there was a gradual decrease in heart rate in the following hours ( - bpm) paralel to the degree of surface cooling and clinical course estabilized.both recovered normal sinus rhytm in to hours. there were not significant arrhytmias after the procedure and postop, was uneventful. conclusions. moderate hypothermia is a very useful manuever for the treatment of drug resistant ejt. since it lacks side effects of other antiarrthymics we beleave it should be the treatment of choice for the treatment of ejt in the postoperative patient. present understanding of the pathogenesis of sepsis, based on the theory of systemic inflammatory reaction, has risen new interest in the more invasive methods of treatment, like plasmapheresis, leucapheresis and exchange transfusion (et). obiectives: evaluate the effect of et in the treatment of neonatal sepsis. material and methods: from september to december , a prospective study was carried out, where the severest cases of bacteriologically proven neonatal sepsis (n= ) were treated with et. in total newborns were treated for culture positive sepsis in the intensive care unit during this study period. diagnosis of sepsis was based on the clinical criteria of suspected neonatal sepsis, used by mc harris et al., laboratory data and positive blood culture. newborns with severe congenital malformations were excluded. et was carried out with fresh (less than hours old) adsol-conserved erythrocytes, from which buffy coat had been removed, and same donors plasma, using a slow continuous two-site technique. the mean volume of et was . ml/kg. the effect of et was assessed as a change in the score for acute neonatal physiology (snap), general treatment results were compared with a historical control group of newborns, treated for culture-positive sepsis in the same icu during the first eight months in . students ttest and chi-square test were used in statistical analysis of the data. results: with the use of el a significant decrease in mortality was achieved: death of cases during the study period, compared to deaths among the controls (p< . ). no baby, receiving et, died. the incidence of severe complications did not differ in the two groups. the snap-score showed quick improvement by the first post-transfusion day (p<o. ) and the effect persisted during the five following days. conclusions: we conclude, that the use of et in the treatment of critical cases may help to lower the mortality of neonatal sepsis. it provides a quick improvement in the clinical condition of septic neonates. the granulocyte-colony stimulating factor (g-csf) is largely employed in granulocytopenic patients. experimental studies have' demonstrated the effectiveness and safety of the therapeutic use, nevertheless the human employ is reported almost exclusively in neoplastic patients submitted to chemotherapy and in patients with fungal or pseudomona~ spp infections. the authors report the data concerning three non granulocytopenic children: in the first, o girl years old, affected by pseudomomm aerug/n~a pyeionephritis, the antibiotic therapy was not tolerated in consequence of renal and hepatic failure. the second patient, an infant months old, has been treated with salbactam-ampiciilin, ceftriaxone and chioramphenicol because of haemepldlw iafluem~ meningitis; a late neurological aggravation required the antibiotic therapy recommencement the last, a years old insulin dependent diabetic boy, was affected by cared/do spp systemic infection; the antifungnl therapy w~ not practicable in consequence of renal and hepatic involvement in all the g-csf was administred subcutaneously at the'dose of $ u for days. a significant increase of granulocytes was ever noted already after the second administration until hours after the last dose. clinical signs, fever and biochemical values are promptly influenced positively and all patients are restored to health. no side affects were noted. the granulocyte colony stimulating factor, at indicated doses, can prove of great help in critical patients, in who the antibiotic or antifangal therapies can result toxye or cannot be tolerated. the ~reptococcas p~, among the gram pmltlve~ represents the main causative organism of bacterial meningitis in children, with the majority of deaths occurring within hours of admission, the third generation cepohlosporim were indicated as antibiotic of first choice, and some literature reports have demonstrated no significant dlffereuces in dinical course of patients treated with ce~rlaxoae and of those treated with ampieibin and chlornmphenicol. the authors report the ease of on infant, male, months old, submitted to a neurosurgical interventiol after days the infant became febrile and lethargic and a bacterial meningitis by ~trepmcecctz ~ was diagnosed, in spite of he was given the eoftriaxone therapy.. an amelioration was found only when a systemic treatment with vaucomyein was added. after days an intrathecal administration of vancomyein m~day was started: the norbmlization of the spinal fluid profile was uoted two days later and the infant receve~d progressively. the follow-up after eight months doem't evidentiate motosensorini sequelae-the individuation' of ~cscc~ pmmmsm/ae strains heta-loctam antibiotics resistant requires alternative therapeutic regimens: the k~terity quead vitam and quoad valetudinem of these infections justifies an intrathecal therapy, especially failing o prompt answer to the systemic treatment objectives: to evaluate the incidence of the burnout (bo) of the staff in a picu in a university hospital. the bo is a syndrome charactedzed by many factors like emotional stress, lack of personality and reduced work ability. this syndrome represents a kind of abnormal response in the working habitat, above all, where psychological and personal characters are mostly involved. the symptoms of bo are represented by demoralisation, demotivation, incapability, boredom, isolation up to organic disturbances, like migraine, insomnia, dizziness and gastrointestinal disturbances. the major incidence of this syndrome was found in the hospital staff, especially among the nurses, working in an atmospher of high emotional dsk, just like in an intensive care unit. methods: from january ' till april ' , all the staff of the picu of the a. gemelli hospital of rome, underwent a test to evaluate the bo. the test used was taken from the book "bumout: from tedium to personal growth", by pines and aronson. twenty seven people were studied ( females, males)i out of which doctors, residents and nurses. it was considered sign!ficant as mild bo, a score between - and as severe, the score of bo >. . results: subjects ( %) resulted positive for bo, out of which were females ( %) and were males ( %). the subjects with mild bo were / : was a doctor, residents and nurses. the subjects with severe bo were / , out of which resident and nurses. conclusion: the results obtained show that bo is a condition well represented in the staff of our picu. the category most at dsk seem to be the nurses ( subjects), as well as residents ( subjects), as in literature, which shows a major incidence of the syndrome in younger subjects and having a limited partecipation of functional decision. the results obtained obliged us to start a programme of serial controls so that the subjects most exposed can have a necessary psychological support to react adequately to this condition. the term systemic inflammatory response syndrome (sirs) was adopted by the consensus conference to denote a type of systemic response to severe infection or otherinsults in critically ill patients. when sirs occurs from infection it is called sepsis. sepsis occurs more frequently in persons with perexisting illness or severe trauma. there has been tremendous advances in prophylaxis, diagnosis, and treatment of sepsis. a comprehensive model of the disease progression from sirs to mods should be developed giving priority to severity of illness scoring system and other predictive methods. some recommendations for future clinical trials include: trials should not start with humans. before proceeding to human trials, animal studies should indicate an acceptable risk/benefit ratio. appropriate patient populations must be defined and treatment protocols should be standardized. full and rapid reporting of all results should be mandatory and a central repository of published and unpublished study results could be helpful. accrual at each center should be of sufficient size, and should include the number of patients accrued, mortality rates, and patient characteristics. pivotal trial should be preceded by sufficient pilot or phase ii studies. correct drug dosage and usage should be delineated in pilot studies. large, multicenter, trials should be used to enhance the unversality of trial results. analyses should be planned a priori. definitions for the target population should be explicit, reproducible, and include illness severity scores. outcomes should be relevant reproducible and include both measures of benefit and harm. mods and its reversal should be considered as an endpoint. quality of life should also be considered as an endpoint. the estimators of overall treatment effects should be controlled for base-line prognostic factors and subgroup anaiysis should only be used for hypothesis generation and not to modify the conclusoin of the trial. economic analysis should be included as part of clinical design. evaluatin of source control should be a critical component of any study. standardized clinical mediator assays should be pursued. placebo patients in clinical trials should be studied for a better understanding of the pathogenesis and epidemiology of sirs, evidence based medicine should be used to evaluate the validity of clinical. introduction: use of inhaled nitric oxide (no) as a modulator for optimizing ventilation-perfusion or lowering pulmonary artery pressure is becoming increasingly common. no is a free radical but little toxicological research has been published. clearance of nebulized mtc-dtpa is known to be, a sensitive indicator for early function impaimaent of the alveolocapillary barrier. we investigated whether exposure to no increased clearance of ~tc-dtpa from the lung. methods: three groups of white sealand rabbits (bw . kg) were anesthetized, tracheotomized and paralyzed. groups were ventilated for six hours at pressure regulated volume control, set to deliver ml/kg with a frequency of /rain, i/e ratio = : and peep = cm hzo using a modified servo ventilator (siemens, solna, sweden) with computerized no delivery system. gas mixture per group was either / or / [no (ppm) / fioz]. after six hours of ventilation in these groups and immediately after anesthesia in group (control), ~tc-dtpa was nebulized into the inspiratory line of the breathing circuit and administered as a fine aerosol. gamma counting was measured for minutes, monoexponential curves were fitted to the data and the clearance half-time (t was calculated. the t~/ mean • sd of the different groups were: t~a (mean -sd) h"e,i witl~ arf : di.ff:erent kinds, aged .q-ore mon't.hes to [ gears o : (bodi weight .~rom ., to kg), is presen .... "ed ( i,,~u::trl:e i:ibstraclive d:lse~se... ~ .ards'- ; :~,;,,arf o~ ::entral genes:i s .- , ,~ :inc lud ing men ingeenceph it :is- ~ reye ' s ~yrtdro~e-..#~,bri~:ln pes~.re~nimatior~ disease.." ). int:lrl~]. pa-. "iiulle'i,~s ariel regymes o+ l;mv,l;i"t"v were cle'l'.ermllled by ba- 'i~ier was. about . tuber,, dopamin tiara-:. t.io; was ~.".,,'.r:~r~led. cmv,cppv d~.!"~tion raniled -~rom f to dayns.,~ < .-:in , "t -irl lo;and> davs'-in 'l~atierr~{s i'i"ai s:ltiol~ o ; patterers to imv, simv modee was per.r:)rmed, ~herl pif:' decrease.d to - ml~ar, fi ~ecreased to , . lind less with a = /,,. i:lesq.lts:{ in pat:i.ents e{ group :l, who were tre,~d.ed w&th f'f'v, teoph :i. : . l:i.r~ (is- .mg/kg/day), g lucecdr t icostei~oids ( .... :~;mg/kg/day), when r exceeded in , -.];, times normal va i tea the e aqes/,'!:l"oln ~j,, ite :i.~;::.!;, ~ml"lrj), it was possible 't'(' ce 'e~ e aad]t:..~rom ! . '.' i', to !..'; , - , mml-lg in ~}.. :~.[~ houi,!; ~d'l(:i to ru:}l",g'd!~l:i. e i::h,:~e,'~c['el';i.stil obieetives : this chapter will describe what is knovca of the psychlogical responses of infant and children to hospiuiisation and attendant procedures. the factors which may modify these responses will he discussed and important considemtiorts will be outlined for optimal anaesthetic management and postoperative period of infants and children which will minimised the rise of emotional upset. methods : in this paper the autors will discttssed the probl of: . health children (asa i, ii) facing single uncomplicated surgical elective procedures . various abnormal situations including neurotic children, children facing repeted operations, chronically ill, buaaes and tsaumatically impired ones . unfortunate young patient facing and often expoclting fatal outcome from le "ul'ukaemia, tumors, cystic fibroses or otheq" disease. : management of each child must vary greatly, ifi general the phases of emotional conditioning include home and preadmissiun preparation, admitiun preoperated and operative care and postoperative period. the authors would be happy if the child passes all stages without any trauma which could be prolonged in the future life. introduction ino is used to selectively reduce pulmonary vascular resistan(~e. we applied ino in the postoperative intensive care of patients with pulmonary hypertension and the risk of right ventricular failure after surgical correction of a congenital cardiac defect. methods - ppm no were added to the ventilatory gas mixture using a specially designed equipment (messer-griesheim, germany/austria). indications for application included pulmonary artery pressure > % systemic pressure, critically depressed right, ventricular function or an oxygenation index > . assessment of n oefficiacy consisted of on-off-on measurements according to the clinical stability of the patient including hemodynamic parameters, pulmonary gas exchange, continuous monitoring of ventitatory function and transesophageal echocardiography of the right heart. results in situations ( patients, age days- , years), ino was applied - h postoperatively. oxygenation was improved in situations from _+ to + mmhg pc ; pulmonary pressure was reduced in situations from -* % to _+ % of systemic pressure. in situations, no reduction of pulmonary pressure was present, but measurement of cardiac output or echocardiographic analysis indicated an improvement of right ventricular function (right ventricular stroke volume + -* %, cardiac output + -* %). in situations (immediately postoperativ with suprasystemic pulmonary artery pressures [n= ], multi-organ-failure [n= ]), no response to ino could be determined. conclusions for a special group of patients, the selective reduction of pulmonary vascular resistance by ino has become an important part of postoperative therapy. using this selective afterload reduction, postoperatively depressed right ventricular function can be improved. this effect of ino seems to be the most important one in the postoperative period. thus, ino appears justified to be appfleo when impaired right ventdcular function could be improved even when pulmonary artery pressure is not raised or remains unchanged. obiectives : premature infant are exposed to danger of apaea due to anaesthesia during their tirst months of life. it is yet unknown whether prematurity is corelated to any other kind of reslgratory disorder due to anaesthesia within the tirst year of life. methods : we theretbre researched retrospectively for respiratory disorders in all infants under months of life belonging to asa group . they all had been anaesthetised in . in our clinic for the following surgical reasons: ingvinal haemia, umbilical haemia, hydrocelae testis and phymosis. results : in cases we tbund: lafingospasm during induction in anaesthesia ( , %), bronchospasm during induction in anaesthesia ( , %), impaired intubation ( , ~ postanaesthetic laringospasm ( , %), supposed aspiration ( , %),postanaesthetic inspiratory stridor ( , %), postinductional inngoedema ( , %), death after months in consequative of infection pneumonie ( , %), none of these disorders was correlated the prematurity, infants suffered of post anaesthetic apnea, of them had premature medical history. concludions : prematurity does not enhance the risk of respiratory disorders due to anaesthesia within the first year of life, except the danger of postanaesthetic almea needs spetial cosideration. it could be demonstrated that aepgi lowers pulmonary vascular resistance and indirectly improves cardiac function. this effect seemed to be selective, and was comparable to ino in the doses we have examined. therefore, aepgi could represent a clinically useful alternate to inc. however, further research is necessary to work up the benefits of either therapeutic strategy. objectives: heat and moisture exchange filtem (hme) are used as artificial noses for intubated patients to prevent tracheo-bronchial or pulmonary damage resulting from dry and cold inspired gases. furthermore they are used for the prevention of bacterial contamination of the anesthetic apparatus by the patient's exspired air. so they are considered as a time-and money-saving device in anesthesia. filters are mounted directly on the tracheal tube, where they collect a large fraction of the heat and moisture of the exspired air, adding this to the subsequent inspired breath. the effective performance depends on the water-and bacteria-retention capacity of the filter. this study evaluates the efficiency of four different filters under clinical conditions. methods: four different types of filters ( dar hygrobac, gibeck humidvent, medisize hygrevent and pall bb ) were investigated dudng mechanical ventilation over a pedod of hours. minipigs with hemorrhagic shock were intubated and ventilated for days in an animal intensive care unit (icu). after hours of mechanical ventilation the filter was randomly replaced maintaining the individual ventilatory conditions. the weight of the filter was determined before use and after removal after hours. the airway pressure was monitored online to record changes during use. tracheal secretions and both sides of the filter were microbiolologically tested to see whether bacteria of the animal's respiratory system could be found on the patient's side of the filter or if they even would have penetrated the barrier. results and discussion: over a pedod of hours of types of filters showed an increase in weight of + % and airway pressure. bactedal celonisation ccured in nearly all fillers ( of ) on the patient's side, whereas only three of four types of filters showed identical bacterial colonisation on both sides. the only filter that did not show bacterial penetration, increase in weight or airway pressure was the pall-hme, a condensation humidifier without hygroscopic salts for moisture retention. with respect to our data one should use a condensation humidifier if airway conditions should remain stable dudng mechanical ventilation and desinfection of the anesthetic apparatus should be avoided after each patient. aim: to assess the clinical uses of, and experiences with, the hayek oscillator. this is a non-invasive device capable ef delivering not only continuous negative pressure (cnp) but also external oscillatory ventilation around a negative baseline (eov-nb) using an external cuirass. this type of ventilation avoids the need for intubation and intermittent positive pressure ventilation (ippv) and facilitates weaning in ventilator dependent patients. patients and methods: patients in respiratory failure, age range weeks to years in a total of patient episodes were treated using either cnp or eov-nb mode. duration of treatment varied from hours to days. indications for use ef the device were: ) to facilitate weaning from ippv ) prevent reintubation of patients following unsuccessful extubation, and ) avoid intubation and ippv altogether using the hayek oscillator as the on[y means of respiratory support. results: there was an increase in pao :fio ratio after cnp and eov-nb (p < . , and p= . respectively, wilcoxon signed rank test). patients who were in respiratory failure with hypercapnia showed a statistically significant reduction in paco both with eov-nb and cnp (p= . and p= . respectively) but the magnitude of change was individually greater in the patients who were treated with eov-nb. all patients, however, showed a fall in respiratory rate (p< . ) after the application of the cuirass in cnp mode. there was no physiological deterioration related to the application of external extrathoracic negative pressure in either cnp or eov-nb modes. conclusion: the improvement in pao :fio , the fall in paco and respiratory rate were indicators of an improvement in ventilation. the proposed mechanisms include improvement in frc, recruitment of additional alveolar units, and improvement in secretion clearance resulting in reduction in the work of breathing. meek to ~ month of the lifo,the bemodyuanicfacls were defined uitb the help of tetropolar reography method!. the excretion of !he catbocholauines fcfi] mith the urine gas detertend by taylor ll,laoorsy ~ iacg/dayl. hsaltl in the hypercuagulation stage of bic we deflorteeed the acliuutiun of the tbrubio and plasiin syaet~ mitb the increase of the inhihitnrs, in this case we registered in full uahe dot this process coabined uitb the dayl~ excreliou with lho urine epinopbr ne e], nor~pinopbr no tel and dophanine io], lbat shod the inlensificatiou of the s~nthosis prnoe-s~es and the release of ea in blood fron hissue deport the actffat on of the svnpathadrenui systen ]sfisl assisted to furl the b?perd~nanical rosins of the eircuidion and increase the ,icrocirculatinn, the klinicai sings of the insufissieutly of the circulalion have not defined,that has been associated the conpensatury character uf the ehan~es of ~ and heludy~enic status, t~e uun~u|p-lion ceugulupatby bus been donoustraled in the hypocougulatien stage ~bat man xauifosted b the exhaust of lhe confulalion nod oessel-platel heuostasis, the consuxptton of cnnpononts tbronbln ,plnstin, kallek~eiu-kinln s~slots and the forniration eat in fell canoe clot uas accoqaued bs docrea,e of fl,nfl,o, the products of the xotabolisx of c~ and the activation of xonoaninoxydasu. the decrease of the extoll'on g and the exhaust deport co indicahd about t!e ]ou fund/anal reserve of ~fl~. it was one of the lain reason of ~bo heiod~uanic disbroed iheat insnfissient]~] and the uicrncireulaflion lintestinal codeme with the low effectife periferal flow] and nul[iplay organ failure,the distrued deport of sos mitb throubocytupenin no; be one of the nechanisn the dislrood of uessej-plalol heioshasis, the correlation bolueeo changes of boiostosis c~ and circulation ore reguired aduinistration nedidns, thai reslore the love s of c~ in the blood, prevent uulliplay organ failure and hetorrnge in children with sepsis, ~b~ectives: multi-measured correlative analysis of the most number of non-invasive indices of the cardiorespiratory system function was made to determine the structure of their interrelation and the ways of their adequate and effective correction. hethods: spiremetry, capno~raphy, oxygenography, indirect fick method at recurrent respiration, plethysmography, integral rheography -in all indices were used. the received data were processed on a computer by a standard package of statistical bmdp programs. results: women with ~h-gestosis (i group) and somatically healthy pregnant women (ii group) were studied. cluster analysis has shown that the rate of the mean correlation connection between ventilation indices was % in the ist group and % in the iind group; gaseous metabolism - % and %, respectively; central hemodynamics was ~ in both groups. conclusion: cluster interpretation allowed to suggest that an increase of the rate of the mean correlation connection between the indices was characteristic of effective adaptation as the system was multi-component and well-regulated. on the contrary, the increase of the rate of strong correlation connection between the indices reveals the rigidity of the system and the tensity of adaptation mschaniams, i.e. the proximity to decompensation. it follows from this that in cases of eph-gestgsis, the reliability of regulating ventilation and gaseous metabolism decreases. seve/e hypoxemia in non intubated patients represents a major contraindicafion to fiberoptic bronehoscopy (fob) and bronehoalveolar levage (bal), but these procedures are often required for a correct diagnosis of the causative agent of pneumonia. aim of this investigation was to veaify the safety and efficacy of bronehoseopic procedures during pressure support ventilation administered through facial mask (fm-psv). five intensive care patients, all immunoeompromised, ( males and females; mean age . • were enrolled in the study. all patients presented criteria for pneumonia with pao /fio ratio ~ and were responders to fm-psv. fob and bal were performed afte~ topical anesthesia with fm-psv ( ps = em h ; peep = emh ; trigger = -lemh ) continuously admires" tered ( ' before fob fio = . ; during fob, fio = and for ' alter fob, fio = . ). pao /fio ratio as well as saturation (sat) did not show signifteative changes during the procodure (fig.l) . no complication was observed and hemodynamic conditions were stable for all patients. cmv, pnenmoeystiis ( ), legionella and mycobaetermm tuberculosis were identified from bal allowmg a prompt and targeted therapy. we concluded that mask psv can represent an excellea~ technique to pexform fob and bal in severely hypoxemic patients without deterioration of gas exchanges and avoiding endotraoheal intubation. intensive care unit, hospital general of albacete, albacet~ spain. objective: to analyze the current incidence and epidemiology of total parenteral nutrition (tpn) among critically ill patients placed on mechanical ventilation. design: prospective observational study. setting: medical intensive care unit in a tertiary hospital. patients: a total of consecutive l'ritically ill patients with non-coronary related disease needing mechanical ventilation admitted in our icu during a months period. measurements: data of sex, age, diagnosis, and outcome were recorded. severity of illness and therapeutic effort in the first hours were measured using acute physiology score and chronic health evaluation (apache ii) and therapeutic intervention scoring system (ties). r~ults: mechanically ventilated patients, male and female, were studied. only ten patients needed tpn and their main diagnoses were: five cases of multiple organ failure secondary to pneumonia ( ), ards ( ) and septic shock ( ); two eases of acute panereatitis; and one mesenteric throngmsis, one status epilepticas, and one ,prolonged cholinergic crisis b~ suicidal organophnsphate insecticide subcutaneous injection. no statistically significant differences between both tpn and non-tpn groups were found: objectives: evaluate the efficacy of prone position in ards and determine its importance in the therapeutic algorithm. methods: consecutive patients with severe ards (murray-score > , ; pao / fit < mmhg; male, female, mean age years) were conventionally ventilated (pcv, peep - mbar, i:e=i:i, ppeak < mbar). if after hours pulmonary function did not improve patients were placed in prone position. change from prone to supine position was done every hours. beside ultimate survival, parameters investigated were aado , pao /fio , and venous admixture (qs/qt). results: during the first hours in prone position of patients showed a significant decrease in qs/qt ( . % vs. . %) and aado ( vs. mmhg), and an increase in pao /fio ( vs. mmttg). changes were most pronounced in patients with high qs/qt, and in patients with an onset of ards less than hours before first application of prone position. after an average of position changes ( to ) of patients could be weaned from the ventilator. patient could leave tile hospital. i the later course letality was primarily determined by additional organ failures and by the severity of the underlying disease. negative side effects were minor, including slight cardio-vascular depression and increase in p~co , and never posed a limitation to continuation of prone position. especially in patients with septic shock skin lesions in exposed areas could not always be prevented, prone position could easily be combined with all ventilation modes and with all intensive care interventions. also immediately after major surgery and in patients with open packing prone position was possible. conclusions: in this investigation prone position proved to be an efficient and safe method in the treatment of severe ards. patients with a pronounced ventilation/ perfusion mismatch and patients in the early stages of ards appear to profit most from prone position. though the immediate effect on oxygenation is striking, still more the % of all patients die from multi organ failure and underlying diseases. a proposed therapeutic algorithm for ards is as follows: if under conservative ventilation (pcv, peep < mbar, ppeak < mbar) pulmonary function does not improve within - hours prone position should be applied. when after - position changes no lasting effect can be achieved further ventilation modes (e.g. pc-irv, aprv, no, etc.) should be used in addition to prone position. standard intensive care principles, such as fluid restriction and optimization of circulation, apply also to patients in prone position. objectives: nitric oxide reacts with superoxide to form peroxynitrite, an extremely reactive and toxic species. we quantified the presence nitrotyrosine, the stable product of the interaction ' of peroxynitrite with tyrosine residues in the lungs of pediatric patients that died with respiratory distress syndrome (rds). methods: paraffin embedded lung sections, obtained at autopsy, were incubated with a polyclonal antibody raised against nitretyrosine, followed by a secondary fluorescent antibody. alveolar structure-associated fluorescence was quantified using existing methods. results: tissue sections from patients who died with rds exhibited significant specific immunostaining which was uniformly distributed across the blood-gas barrier. in contrast only background levels of fluorescence were seen in the lungs of patients who died from non-pulmonary causes. intense staining was also seen in the lungs of rats that breathed % for h, a condition known to result in rds-type illness; no immunostaining was observed in air-breathing rats. conclusions: significant levels of peroxynitrite may be formed in the lungs of patients with acute lung injury. peroxynitrite may be contributing to the pathology of rds by damaging key components of the alveolar epithelium including the pulmonary surfactant system. mechanical ventilation time was prolonged ,g • days in patients with ardsvs , _+ l, days in control . mean staylcuwas lg _+ ,g days in the ards group vs , • , days in control group postoperative mortality rate was % in ards patients vs , % in those without respiratory failure. -ards incidence in liver transplantation is low ( , % in our sene) but it causes high mortality ( %) page, gas ventilation of the perfluorocarbon-f'dled lung, supports gas exchange and circulation in small animals (< kg) with lung disease. we hypothesized that large animals could be supported by page without adverse effects on bemodynamics. we first elucidated the determinants of gas exchange in normal sheep, and applied them to a model of adult respkatory distress syndrome (ards). methods: using the ventilator settings determined to be optimal in our pilot study (fio of . , peep of cm h , imv of bpm, it of %, and tv of ml/kg), sheep weighing . ~ . ) kg had lung injury induced by instilling ml/kg of . n hc into the trachea. ten minutes after injury, sheep with pao < ton" were randomized to continue gas ventilation (control, n= ) or to institute page (n= ). page was instituted by instilling . l of unoxygenated pefflubron into the trachea and resuming gas ventilation at the previous settings. abg's were drawn at baseline, minutes after injury, minutes after injury, and then every minutes for hours. objectives: inhaled nitric oxide (no) can improve oxygenation and decrease mean pulmonary artery pressure (papm) in hypoxemic patients with ards. in severe hypoxemic copd patients, it is not known whether inhaled no can exert a similar effect on hemodynamics and gas exchange. therefore, we investigated die response of inhaled no in hypoxemic copd patients and the results compared with those obtained in a group of ards patients. methods: ten copd patients (age _+ y;fev~ . _+ . l) and ards patients (age _+ ; lis . _+ . ) mechanically ventilated were studied. hemodynamic parameters were measured using a swan ganz catheter. arterial and mixed venous blood gas determinations, sao , svo , hb and methb were measured (abl ,osm ). mean intratracheal concentrations of no and no were continuously monitored using a chemiluminescence analyzer (nox ) . during the study the ventilatory pattern and fioz were kept constant. the protocol was for ards group: basalt, no loppm, basal~; copd group: basalz, no lo ppm, no ppm, no ppm and basal . after a steady state of rain hemodynamic and gas exchange measurements were performed. a positive noresponse was defined as a % increment in pao . results: papm was similar in both groups and decreased significantly after no (ards, basal . _+ . mmhg, no . + . mmhg, p < . ) (copd, basal . _+ . mmhg, no- . _+ . nrmhg, p< . ). all other hemodynamic variables remained unchanged after no. basal oxygenation was higher in copd group (paojfio _+ mmhg) vs ards group (paojfio _+ mmhg)(p< . ). after no- , pao increased ( _+ mmhg to _+ mmhg, p< . ) and qs/qt decreased ( + % to _+ %, p< . ) only in ards group. in both groups, significant correlations between basal papm and inhaled no-induced decrease in papm were found. inhaled no-induced increase in pao /fio was not correlated with basal paoflfio . no responders were / ( %) in ards group and / ( %) in copd group (p< . ). conclusions. in hypoxemic ards and copd patients, inhaled no decreased mean pulmonary artery pressure. however, oxygenation only ameliorated in ards group because die number of responders to inhaled no were higher in ards group and this effect seems not to be related to the basal hypoxemia. these results might be explained by the v/q abnormalities present in copd patients. grant fis / . objectives: it has been recently reported that expired con slope as a function of time is modulated by total respiratory system resistance (rrs) in critically ill patients (chest ; : - ) . in this study, we analyze the relative contribution of disease (dis), endotracheal tube resistance (rtube), airway resistance (rmin), additional resistance (~rrs), autopeep (peepi) and dylmmic/static elastance (ed/es) to the co elimination in different clinical conditions. methods: we have studied adult patients ( controls, acute respiratory failure, severe ards and copd) mechalfically ventilated (servo and c, siemens) without peep. we recorded tracheal pressure, airflow and capnograms. signals were analogic to digital converted for posterior data analysis. objectives: alveolar ejection volume (van) can be defined as the fraction of tidal volume (vt) with minimal dead space (vd) contamination. according to the classical paradigm: limvd_~ [vco /vt] =facoz, vco vs vt relationship tends asyntotically to a constant slope when approaches end-tidal volume. we have defined van as the volume that defines this relationship until a limit of % variation. methods: six subjects with normal respiratory mechanics were studied during anesthesia for minor surgery. two subjects, otherwise normals but having high values of total resistance and dynamic compliance, were also studied. capnograms were recorded in steady-state at levels of vt ( . , . and . l) and four levels of peep ( , , and cmh objectives: patients with ards presented lung abnormalities which originate an increase in airway resistance (rmin), in additional resistance (~rrs) and in static elastance (ers). application of peep further increases ~rrs. capnographic indexes reflect lung ventilation]per fusion inhomogeneities. in these conditions, the effects of peep on lung mechanics could be better understood by simultaneous measurement of capnographic indexes. methods: we studied groups of subjects. n: normal subjects scheduled for minor surgery; arf: critically ill patients with mild acute respiratory failure; ards: patients with early ards (< h). we recorded tracheal pressure, airflow and capnograms. signals were analogic to digital converted for posterior data analysis. respiratory system mechanics was assessed by constant end-inspiratory and end-expiratory occlusions technique. at equal tidal volmne ( . l) a peep level of , , and cmh was applied in all patients. we calculated ers (cmh /l), rmin, c~rrs (cmh /l/s) and autopeep. capnographic indexes were alveolar ejection volume (vae)/vt ratio and expired co slope beyond vae (sipco in contrast to synthetic surfactant natural suffactants (alveofact| are able to inhibit pmn-activation. after incubation of activated neutrophils with surfactant, l-selectin expression is decreased. these effects depends on which preparation is used. we conclude, that natural surfactant (aveofact| can perhaps influence early recruitment (,,rolling") of pmn in patients with respiratory failure like ards. with ards hormann cb, baum m, putensen c, knapp r, lingnau w, putz g . clinic for anesthesia and general lntensiv care medicine, university of lnnsbruck, anichstrabe , innsbruck objectives: in thoracic ct scans of patients with severe ards atelectasis and pleural effusion can be found in the dependent lung regions. by rotating these patients from left lateral position to right lateral position a redistribution of the ct densities, a recruitment of atelectasis and therefore an improvement of gasexchange is possible within a few days ( , ). the objective of this study was to find out the mechanism of alveolar recruitment during lateral positioning by ct scanning in left and right lateral position. methodes: after approvel by the local institutional reviewboard we investigated ventilated patients with severe ards (entry criterias: murray score > , ) in the ct scann of the university hospital. after a stabilisation period of minutes in supine position a thoracic ct scan slice cm above diaphragm was taken. then two different positions of the patients were studied in a randomized order: a) degree of left lateral position, b) degree of right lateral position. each lateral position was held for minutes. at the end of each of these periods a thoracic ct scan slice cm above diaphragm was taken. quantitative analysis of ct scan data was based on the frequency distribution of the ct numbers. to quantify the alveolar recruitment during lateral positioning by means of ct scan we defined compartments within the lungs: a) normaly inflated lung, b) poorly inflated lung, c) noninflated lung ( = atelectases) ( ). results: independant of the side of lateral positioning (l) in the non-dependent upper lung a significant increase of the normaly inflated compartment (s: %; l: %) as well as a significant decrease of the noninflated compartment (s: %, l: %) was observed in comparison to supine position (s). in the dependant lower lung the normaly inflated compartment decreased significantly (s: %, l: %) whereas the noninflated compartment increased significantly (s: %, l: %). throughout the whole studyperiode we did not observe any significant change regarding gasexchange and hemodynamic parameters. conclusions: in lateral position the non-dependent upper lung is decompressed. therefore a significant recruitment of atelectases is observed in the upper lung within minutes. on the other hand the dependent lung is compressed by the weight of the upper lung and the mediastinum. a great amount of the alveoli of the dependant lung collapse in this short time intervall. therefore the net effect of recruitment of one positioning maneuver is very small. when positioning patients one should be aware, that the patient is kept in each lateral position long enough to clean up the atelectases in the non-dependant lung and short enough to compress less lung tissue in the dependant lung. objective: to analyze effects of low-dose no inhalation ia patients with severe aeut~ respiratory distress syndrome (ards) over five days. methods: we prospectively studied patients ( men, woman) with severe ards admitted to our icu between may and may who required no inhalation with a dose of ppm for at least days. entry criteria for no injaalafioa were murray score >i . aud pat/fie < nun hg with peep >~ em i~o for at least hours. all patients were sedated, intubated and mechanicauy vantil~ed with volume assist-control ventilation, and had indwelling arterial catheters (pulmonary artery, and radial or femoral artery) to measure cardiac output (by thermodilufion) and relevant intravaseular pressures, and to calculate derived parameters. no was administered between y piece of the ventilator and endotraeheal tube and flow was adjusted to obtain ppm no in the inhaled gas. the no, no and no x concentrations were continuously measured at the distal end of the endouacheal tube by the chemiluminiscence method (nox , see-seres, france). metahemoglobinemia levels were mesured daily. no inhalation was manteined if paojfio ~ improved at least % and was stopped when the change in pao /fio ~ was below % or when the patient presented a paojf > mm hg a~er minutes without no inhalation. every day we made an on-off test to determine if no inhalation improved pao /fio ~. statistics: analysis of vmiance. data: mean + standard deviation. results: the mean age was . +_ . years and mean lung injury score was . • . . mortality was % ( / ), metahemoglobinemia . • . %, and no concentrations zero. paojf~o always improved significantly al~er ppm no inhalation (see :~ conclusions: reintubation in salf-extubated patients strongly depends on the type of meehamcal venfilatory support: the probability of needing a reintabation ff ese occurs during fult vontilatory support is higher than ff ese occurs during weaning. these data suggest that some patients may remain under weaning from mechanical ventilation for unnecessarily prolonged periods of time. objective: the aim of this study was to evaluate the acute effects on gas exehonge and hemodynamics due to positional changes from supine (sp) to prone (pp) in patients with severe acute respiratory distress syndrome (ards). methods: nine intubated, sedated, paralyzed and mechanically ventilated patients with severe ards were prospectively studied. all had a murray score > . , and a pao /f~o < with peep ~ cm h for at least h. all patients had indwelling arterial catheters in the pulmonary artery as well as in the radial or femoral artery in order to measure cardiac output (by thermodilution) mad relevont pressures, and to withdraw blood samples. arterial blood gases and hemodynamie parameters were measured first in sp, and then in pp after minutes of stabilization. vontilatoly parameters remaing unchanged during all the study. statistical analysis was done by the non parametric wdeoxon test. data are expressed as mean ~= sd. results: there were men and women with a mean age of . years ( - ) and mortality was % ( / ). main results are shown below: objective: to describe and compare a new method for obtaining p-v loops (p-vcv) by using a two-way collins valve (twv) with thosu obtained by the supersyringe method (p-vss). methodology: we prospectively studied patients who had an aeute lung injury and were intubated, sedated and paralyzed, and mechanieany ventilated. we performed the p-vev loops and p-vss loops in random order, and the static inflation pressure was limited to emh with both methods. pressure (p) was measured at the airway opening by means of a differential p transducer, and volume was obtained from flow (measured with a pneumotacograph) integration. the p-vse method has already been described (h~trf a,et al.bepr ; : - ) . the p-vev method consists in the following: the inlet of a twv is connected to the ventilator's y-piece, and both outlets are couneeted to the endotraeheal tube by means of an additional y-piece; one of this outlets has a one-way rudolph valve in order to allow inspiration but not expiration during the inflation maneuver. changing the twv tap position allows basal ventilation or progressiveinflation of the respiratory system. this maneuver is as follows: during an end-expiratory occlusion, the ventilatory settings are adjusted to deliver a ml v r with a respiratory rate of /min and i/e ratio : ; at the same time the twv tap is ehonged in order to divert flow through the one-way valve. inflation then begins alter releasing the expiratory oonlusion. pressure and flow signals were digitized and acquired by a computer for subsequent data analysis. we analyzed the following parameters: inflation compllonee ( objective: to analyze the variables which eventually may differentiate ards patients who do and do not respond to low doses of inhaled no. we prospectively studied patients ( men, woman) with severe ards admitted to our icu between may and may who were treated with no ( ppm). the onta'y criteria for no inhalation were murray score >/ . and paojfo z < mm fig and peep >/ cm i~o for at least hours. all patients were sedated, intubated and mechanically ventilated with volume assist-control ventilation. tidal volume was between and ml&g, with constant inspiratory flow, respiratory rate was - /rain, and i/e ratio between : to : . all patients had indwelling arterial catheters (pulmonary artery, and radial or femoral artery) in order to measure cardiac output (by thermodiintion) and relevant intravascular pressures, and to calculate derived parameters. no was administered between y piece of the ventilator and ondotracheal tube, and flow was adjusted to obi~a ppm no in the inhaled gas. the no, no and no x concentrations were continuously measured at the distal end of the endotracheal tube by the chemilumiinscenee method (nox , see-seres, france). metahemogtobinemia levels were measured daily. we considered a response to no inhalation when an improvement in paoz/fo above % was observed after the inhalation of ppm no (group r) . when the cha~age in paojfi z was below % it was considered a lack of response (group non-r small airways functional abnormalities have been recognized as a common feature of lung pathology. however peripheral airways contribute relatively little (~ %) resistance to flow and there disturbances can not be adequately estimated by conventional measurements of respiratory mechanics. the purpose of the study was to evaluate the relationship between raw and small airways conductance following weaning from ventilator methods. patients (age: - years; males) with no serious complications al~er mitral or multiple valves replacements and with more than hrs on mechanical ventilation have been enrolled in this study. the modified flow interrupter technique (ptg "gould" with fleish head # ; differential pressure transducer pm- -tc "statham" w amplifier "kistler ") and flow-volume recording of forced expiration (fleish head # ) have been applied before surgery and following operation on mechanical ventilation (my), after extubation (t:xtijb), on ( nay) and ( day) days. airways specific conductance (sg aw) has been calculated as a mean of - consequent measurements in each patient at each stage. the sac was estimated by max expiratory flow at and % of vc on - f-v curves (mef .~ , mef ) all the data were statistically analyzed with t-test introduction : noninvasive ventilation (niv) reduces the need for endotracheal intubation, the length of stay in icu and the mortality rate in acute exacerbation of copd. however, some patients failed to be ventilated with niv. .objectives...; to further delineate patients who failed to be ventilated with niv and to obtain predicted factors of failure. patients : a cohort of patients ( • years) presenting with acute exacerbation of copd (fevi: • ml, paco : • , ph: . • . ) and nonmvasively ventilated (pressure support through a full-face mask) between april and may twenty-seven ( %) were successfully ventilated with niv (discharged alive without the need for endotracheal intubation) while ( %) failed, requiring endotracheal intubation. .methods : patients successfully ventilated and those who failed were compared according to respiratory and nonrespiratory variables univariate analysis (wilcoxon rank-sum test and fisher-exact test) was performed to select variables included in a multivariate analysis by stepwise logistic regression. results : underlying disease assessed by the simplified acute physiologic score ( • vs • , p = . ), creatinine serum concentration ( • vs • gm/l, p = . ), blood urea nitrogen (bun : • vs mm/l, p = . ), age ( • vs • , p = . ) were higher and encephalopathy ( vs %, p = . ) more frequent in patients who failed. multivariate analysis showed that encephalopathic patients (or (odd ratio) = , p = . ) older than years (or = , p = . ) and presenting with bun >_ mmyl (or = , p = . ) failed to be ventilated with niv. variables related to the respiratory" status (i.e. paco , pao , fev ) were unable to predict tile failure of niv. conclusion : copd patients older than years, presenting with acute exacerbation, encephalopathy and bun > ram/l, should be carefully monitored because of high probability of failure with niv. methods:from february to december we studied pa_ timnts, males and females(mean age +/- ); of the se had emphysema,lo chronic bronchitis, dilatative car diomyopatia,with tracheostomy and emphysema.mean pac at admission in icu was +/- mmhg,while when weaningbegan, +/- .mean autopeep was cmh ( - ).all patients were ventilated in crpv as long as four hours to calculate st tic and dynamic cmpliance and autopeep.then the ventila tion was continued with psv+cpap(peep cmh objectives: analysis of the incidence of neurogenic pulmonary edema (npe) in a population of headtrauma patients with acute respiratory failure (arf). npe can occur after a central nervous system insult. differential diagnosis: cardiogenic pulmonary edema and other forms of non eardiogenic pulmonary edema. true incidence and pathophysiohigy remain poorly defined, however the role of catecholamines seems undeniable. early onset npe (within h after trauma) is characterised by hypoxemia, transient pulmonary hypertension and bilateral central fluffy infiltrates on chestx-ray. characteristics of cardiogenic edema or pneumonia are absent. late onset npe, (beyond hours after trauma), is more insidious. the clinical and radiographic picture has to clear within to hours. ( ) methods: all headtrauma patients admitted from january to december , in a nearotrauma icu setting were retrospectively analyzed for arf with as sole criterinm a pao -fio ratio < . results: neurotrauma patients were admitted during . patients ( %) presented with severe head injury (gcs< ), patients ( . %) with moderate (gcs - ) and patients ( . %) with minor head injury (gcs - ). overall mortulity was . % early (within h. after trauma) and delayed onset respiratory incidents were distinguished, counting for ( . %), respectively patients ( . %), patients ( . %) had early and late respiratory complications. early respiratory insufficiency was caused in patients ( . %) by aspiration, in patients ( . %) by lung contusion, in patient ( . %) by fat embolism and in patients ( %) by npe. in the late onset group patients ( . %) presented with pneumonia, ( . %) with fat embolism and ( . %) with npe. the npe group, patients, presented as follows: patients ( . %) developed early npe, and ( . %) delayed onset npe. patients ( %) died within the first days after admission, showing high mortality. gcs was less than in patients ( . %), indicating severity of head injuries. conclusions: high incidence of arf with various etiology ( , ~ was found in this population. in about % of all admitted hcadtrauma patients ( , % of arf) npe was causing attetial hypoxemia. occurrence of npe seems to be related to the severity of the brain injury and thus to outcome. these data call for extreme vigilance in respect of the insidious occurrence of npe. were included if recovering from respiratory failure and if in the opinion of the primary physician were ready for extubation. patients were excluded if undergoing compassionate withdrawal of support or had tracheostomies. the attending physicians were blinded to the measurements. included patients were placed on pressure support (ps) of em h with demand-flow continuous positive airway pressure (cpap) cm h . after a minimum of minutes on the above sehiogs: gastric intramucosai pc'o , abg, and a p . were measured. the padents were then disconnected from the ventilator for a period of one minute and the patients" respiratory rate and minute ventilation were measured using a wrights respirometer to calculate the frequency to tidal volume ratio (f/vt). patients were then extubated. extubafion failure was defined as the inability to maintain spontaneous ventilation for hours for any reason. results: twenty patients met criteria and were studied over one month period in october . six of the twenty patients ( %) failed weaning. the mean and standard deviation is outlined in failure . +/- . . +/- . . +/- . . +/- . comparison between roc areas shows phi and p . to each show a statistically significant difference from an area of . (p<o. ). the area at which the test has no discriminative value. this is not the case for either the integrative index or the f/vt ratio. the differences between areas for each curve is not statistically significant. the area's for each roc curve is shown in table #' . results. of the newborns referred to us for ecmo-therapy developed barotrauma, of the required ecmo and one of the three other patients who did not recieve ecmo-therapy died. to determine the correlation between the risk factor barotrauma and the severity of the pulmonary situation, we determined the oxygenation index of each patient referred to us for ecmo-therapy . the table demonstrates , d- giessen, frg. inhalation of nitric oxide (no) and aerosulizatiun of prostaglandin (pg) i: have been suggested to achieve selective pulmonary vasodilation and improvement of arterial oxygenation in patients with acute respiratory distress syndrome (ards). we directly compared these two modes of transbronchial vasodilator therapy in ards patients mechanically ventilated for - h (mean murray lung injury score [ ] . + . ). patients were randomized to receive either first no and then pgi (n= ), or vice versa (n= ), with an intermediate baseline period. each drug was titrated individually to find the lowest effective dose for maximum improvement of arterial oxygenation. gas exchange variables, including data from the multiple inert gas elimination technique (miget), and hemodymmaics under application of no/pgi were compared to pro-and past-challenge values. no (mean dose . + . ppm) increased the mean oxygenation index (pao /fio ) from + to + mmi-ig (p < . ) and reduced the shunt-flow from . + . to . : . % (p < . ). aernselized pgi (mean dose . + . " ng/kg rain) augmented pao /fio from + to + mmhg (p < . ), and decreased shunt from . + . to . + . % (p < . ). the miget analysis showed predominant redistribution of blood-flow from shunt areas to regions with normal ventilation-perfusion ratios in response to both agents. in patients, both no and pgi caused an increase in pao /fio by at least rnmhg. two further patients displayed a corresponding improvement of arterial oxygenation in response to either no or pgiz. the mean pulmonary artery pressure decreased from . : . to . : . mmhg in response to no, and from . : . to . : . mmhg (p < . ) in response to pgi . cardiac output, systemic arterial pressure, and right and left heart filling pressures were not affected by either agent. we r that individually titrated doses of inhaled no and aerosolized pgi~ effect selective pulmonary vasodilation and redistribute blood-flow from shunt-areas to weu-ventilated regions with nearly identical efficacy profiles. obieetives: the use of extraeorporeal bypass systems for oxygenation and co -removal is performed in patients with acute respiratory distress syndrome (ards) to reduce mortality and to improve restitution of pulmonary functions. high-dose heparin -commonly used in such patients to prevent thrombotic complications -might cause incurable bleadings as a major risk. this lead to the development of heparinized bypass systems; results of animal and first clinical studies proposed that such systems might run with low-dose heparin or even without any systemic anticoagulation. methods: since , patients with severe ards were treated with extracorporeal lung assist (ela) using heparin-coated systems (type maxima, medtronic, carmeda coating) in our icu. they received a moderate systemic heparinization. standard clotting assays (act, aptt, tt, ptt, at-ill, fbg, fsp) as well as special tests (tat, r~-tg, pf , pal-l, d-dimers, protein c, cl-inhibitor) were performed. results: covalent heparin-eoating of the ela-systems combined with lowdose heparinization could not prevent major changes in coagulation: ) in mean, platelets dropped from /nl to /nl within h after onset of ela. ) tat levels were already elevated before ela start ( ug/]) and demonstrated an additional peak h after onset of ela (up to ug/[). ) in parallel, there was a transient peak of pai-i levels (from to au/ml} h after onset of ela. ) in mean, fibrinogen levels dropped from to mg/ ml within h after onset of ela. ) in mean, cl-inhibitor levels dropped significantly from % to % after onset of ela and reached the initial levels within h. ) after membrane change, there were significant changes for c -inhibitor, fibrin-d-dimers and tt. ) global clotting tests such as aptt, ptt and tt were within normal range. conclusions: patients with severe ards develop a prethrombotic state already before they get connected to the ela bypass system. after onset of ela, they experience additional involvement of procoagulant, anticoagulant, fibrinolytic, and complement systems. in parallel to laboratory findings, clinical data suggest that the use of heparin-coated systems with accompanying systemic low-dose heparinization does not avoid thrombembolic and hemorrhagic complications in tong-term ela patients. thus, at the present, higher dosed individually adjusted heparin treatment has to be recommended. thereby, standard clotting monitoring is not sufficient. objective: poor muscle performance contributes to prolonged dependence on mechanical ventilation. longitudinal data on muscle function in icu patients is scarce. we evaluated changes in inspiratory and peripheral muscle performance during prolonged intensive care in patients with acute respiratory failure. methods: patients requiring intensive care for more than one week were studied. maximum inspiratory pressure (pimax) was measured twice a week for a maximum of three weeks. handgrip power (dynamometer) and subjective fatigue (keldet score) were obtained in survivors only. one measurement was done on the date of extubation. pimax pressure was obtained by occluding the airway for seconds or at least five inspiratory breath attempts. obiectives -measurement of peep-induced changes in lung volume helps to assess respiratory mechanics in acute lung injury (ali). we evaluated the accuracy and stability of a new respiratory inductive plethysmograph (rip), in the measurement of peep induced changes in end-expiratory lung volume (eelv) and tidal volume (vt) against volume reference, pneumotachograph (pnt), methods -two hours periods of basal ventilation and stepwise increases and reductions of peep ( - - - - cm h ) were recorded in patients with all. in addition, the new rip device (respitrace plus tm) was compared to an older rip (respigraph tm, nims, fl, usa) to determine its thermal stability using cold and warm devices and a ventilated lung model. results -the difference between the new rip and pnt in the measurement of vt was - _+ mi (x _+ se) or a - . _+ . % error. increasing peep from to cm h induced a + ml change in eelv. a difference of + ml ( . % of max. eelv change) (ns) was found between rip and pnt eelv readings. during controlled ventilation with constant settings the mean change in eelv was _+ ml/ min (fig.i) . validation of calibration showed a mean error of -+ . % after rain. the new rip had a higher drift when cold (cold + ml/ min vs warm _+ ml/ min), whereas the old rip was thermally stable (cold - + ml/ rain vs warm i + ml/ min). trauma icu, hospital traumatologia y rehabilitacidn. vall d'rebron. barcelona. spain. recent data suggest that the proportion of patients with relevant discrepancies between two jugular bulb (jb) oxygen saturation (sjo ) values is higher than suspected. objectives: determine the incidence, the significance and the pro nosis value of those differences,if they exist,in severe head injured-patients. material and methods: severe head-injured patients, coma glasgow scale (gcs) , with diffuse brain injury according to marshall criteria in the first ct scan, icp recorded, with an interval from accident-double jb monitoring < than hours, were studied. data from bilateral sjo were obtained simultaneously, every hours. discrepancies were considered significant, when differences in sjo were > %. no chan es in treatment protocol (hyperventilation, man• etc) were carried out due to this study. results: men and women were studied, aged • yrs. at arrival at hospital, gcs were < in and ) in to. the incidence of high icp() mmhg) were sz at the entry. the mean therapy index level required to control lop was ~l all patients required vasopressor therapy to maintain upp over ds mmhg. in patients a s.s f swan-ganz fiberoptic catheter was used to obtain a continuous recording of sjo . in the others , sj were intermittently controhed.the mean time of monitoring were d. • days. ten patients died within this period. a total of . blood samples were analized. at arrival, sjo discrepancies were found in patients, b %. at hours, the incidence were lower, / , . %. at th day, were h/ , z and at day , when the catheters were retired, ii[ , z showed discrepancies. the ct showed new injuries in g z of patients with differences > ~ in sd values throughout treatment period. none of those were considered for neurosurgical treatment. no correlation was found between iop and sjo values and sjo differences. conclusions: the incidence of discrepancies between sjo was higher than expected in severe head-injured patients. these situation could reflect disturbances between demands. when differences are known, and those lend to change, the ct scan, nearly always, will show new injuries. platelet-activating factor (paf) is an inflamatory mediator implicated in the pathogenesis of bronchial asthma and acute respiratory distress syndrome (ards). its inhalation in healthy subjects produces transient bronchoconstriction and mild ventilation-perfusion mismatch, together with peripheral leukopenia as a result of intrapulmonary neutrophil (pmn) sequestration. likewise our group has shown in healthy subjects and asthmatic patients that aaibutamol (s) inhibits both pulmonary and systemic effects of paf, suggesting that s may inhibit paf-induced venoconstriction in pulmonary microoirculation. the aim of the present study was to investigate if s inhalation decreases pmn by lung sequestration induced by paf. we studied healthy, non-atop• nonsmoking subjects ( m/ f, + yr), which were pre-treated with s ( ,ug) or placebo, with a randomized, double-blind, crossover, design, before paf ( ,ug) inhalation. we measured the respiratory system resistance (rrs) by forced oscillation, arterial btood gases and both total white cell and pmn count every min over a min. period. simultaneously, we recorded continuously the lung dynamics of inm-neutrophil and tc m-erythrocytes activity, with a gammacamara. after placebo, paf inhalation decreased white cells (from to x /l), and pmn(from to _+ x /l), and increased aapo (from . _+ . to . + . mmhg, p<o. ) and rrs(from . . to . . cmh .s.i q ) (p < . each). the fall in total white cell count correlated with the intrapulmonary pmn retention (r = . , p < . ). by contrast, after s, paf did not induce any change in white ceil count (from to + x /i), pmn count (from to x /i), aapo (from . to . + . mmhg), and rrs (from . . to . . cmh .s.i ). compared with placebo, after s there was a lower ~lln-pmn lung activity ( . . vs . . cts/mci/pixel, p<o. ), lower intrapulmonary pmn retention ( . . vs . . %, p=o, ), and a faster washout ( . . vs . . s ~, p= , ). our results indicate that s inhibits paf-induced intrapulmonary pmn sequestration, being consistent with the hypothesis that s may offset the venoconstriction of pulmonary microcirculadon caused by this mediator. supported inpiratory muscle fatigue with failure of force generation as def'med by a tensiontime index (tti)> . - . has been shown to occur in normal volunteers and in stable copd patients with a specific imposed breathing pattern. its role, however, in hypercapnic respiratory failure is less certain. we studied failed weaning trials in copd patients in which breathing pattern, tension-time index (tti) of inspimtory muscles, dynamic peepi, dynamic lung elastance, lung resistance, and arterial paco and ph were measured at the beginning and end of a t-piece weaning trial. in addition, the change in esophageal pressure during a mueller maneuver (apes max) was measured. a weaning trail has been prospectively defined to have failed if one of the following criteria was met: a rise in pco > mmhg from baseline accompanied by a fall in ph< . ; a respiratory frequency (f) > /min; excessive accessory inspiratory muscle recruitment; and a marked increase in dyspnea. values are expressed as mean • se. weaning failure was characterized by a more rapid, shallow breathing pattern, worsened mechanics, hypercapnia and respiratory acidemia despite an unchanged tri and pes max. we conclude that in this setting hypercapnic respiratory failure is not a consequence of inspiratory muscle fatigue. rather the adopted breathing strategy and resultant hypercapnia may represent an adaptation to forestall the onset of muscle fatigue. concerning the investigated elf-par~eters, no stadstically signhqcant differences were detected between the pgi and the control group. histopathologlcal changes occured in both groups and consisted in rare focal flaaaning f tracheal epithelium with loss of cilia and slight inflammatory cell infiltration, as well as slight swelling of alveolar typo pneumoeytes. sections of generation , and from bronchial tree were free of pathological changes. conclusion: alter h inhalation of p~ji no signs of respiratory-lract tissue damage caused by the aerosol could be detected. the minor pathological findings in the trachea are most likely due to mechanical irritation by bronchoscopy, changes of the alveolar epithelium are known for long-term mechanical ventilation . objectives: the aim of this study was to evaluate of efficiacy of ganglion stetlate blockade in patients with respiratory failure. methods: two groups of patients were investigated: group i (n = ) trauma patients with acute lung injury (ali), group if (n = ) patients with asthmatic status. in all cases continuous mandatory ventilation (cmv) was used with bennett ae. in both groups bilateral ganglion stellate blockade with antero-lateral approach was performed, using . % marcain. the following parameters were analysed: pao , sao , paco~, pip and c~t~t. results: in trauma patients with aij after bilateral ganglion stellate blockade short -lived and slight improvement of pao and sao , decrease of pacoz and pir and increase of static compliance of respiratory system were found. in second group bilateral ganglion stellate blockade interrupted the asthmatic status and significant statistical improvement of parameters of oxygenation, ventilation and respiratory system mechanics were observed. conclusions: we suggest that the bilateral ganglion stellate blockade is a very useful method in treatment of patients with obstructive respiratory insufficiency. the aim of the study was to analyse whether there exists serum and urine electrolyte disorder in patients(pts.) with acute respiratory insufficiency(ari). the study included t pts. with ari (pao : , @ , kpa. paco : , i- , kpa, ph: ~: , , hco : , :~ , mmol/ , sao : , ~- , %) who were hospitally treated due to pneumonia( pts.),emboly of the pulmonary artery( pts.) and severe attack of bronchial asthma ( pts). among tham there were ( , %) males and ( , %) females, average age , ~: , years, otherwise previously healthy. electrolyte concentracions were measured at the onset of the disease in serum and urine collected during hours (sodium-na,potassium-k, chlorine-c , calcium-ca,magnesium-mgand phosphorus-p). the measured serum and urine electrolyte concentrations were compared with respective referent values (rv). by serum electrolyte analysis, the following average velues were obtained: na:l o, the object of our investigation was a group of pts with massive pneumonias, males ( . %), females ( . %),mean age yrs.thirteen ( %) of them were smokers, ( %) nonsmokers. only pt ( . %) had pre-existing chronic respiratory disease, and ( . %) were admitted for the first lime,with no previous respiratory anamnesis. diagnose was based on anamnestic data of productive cough in pts( . %),physicaly ~onchial breathing in i~s ( . %),white cell count onder x /l in pts( . %). radiographicly, bilateral massive homogeneous shadows were found in pts ( . %), onilateral in pts( . %),pleural effusion in pts ( . %). abnormal renal function was found in pts ( . %). sputum culture was positive in pts ( %): slr.pneumoniae, str.pyogenes, pse'udomonas aerug, in , , cases respectively. all patients had remarcable hypoxernia (pao range from , to , kpa) without hypercalmea. all patients needed oxygenotherapy together with antibiotics and other .symptomatic therapy. nineteen pts had anaelioration of general condition and normalization of blood gas analyses, while pts with the lowest hypoxcmia died.in conclusion, massive pneumonias are frequently followed by respiratory insufficiency which is one of the markers of pneumonia severity. as existing hypoxemia complicates the course of the disease,prolonges the recovery, makes therapy more complexe and may be cause of death , frequent blood gas measurement is recomanded. we studied the effects of bosentan (bos), an eta and etb receptor antagonist, to examine if endogenous et mediates pulmonary hypertension in anesthetized and ventilated dogs with acute lung injury due to oleic acid (oa). the gradient between pulmonary artery pressure (ppa) and occluded ppa (ppao), and gas exchange (evaluated by arterial blood gases and sf intrapulmonary shunt) were measured at controlled flow. in dogs (treatment), data were collected at baseline, during long injury (obtained rain after intravenous administration of oa . ml/kg), and again after bos ( mg/kg intravenously). in dogs (pretreatment), data were obtained at baseline, after bos and then after oa. in treated dogs, oa increased (ppa-ppao, mmhg, table, means + sem, * p < . vs base) and deteriorated gas exchange. after oa, bos did not affect pulmonary vascular tone nor gas exchange. in pretreated dogs, bos had no effect on baseline pulmonary vascular tone but prevented the increase in (ppa-ppao) after oa. the deterioration in gas exchange after oa was not influenced by bos pretreatment. objectives: the alveolar tension is measured by the application of the alveolar air equation in which the arterial pco is used or by the simplified form of this equation in which the respiratory exchange ratio is taken at the value of . . the purpose of this study was to estimate the effective alveolar tension (pao eff) during spontaneous breathing with a new bedside technique which is simple non-invasive in normal subjects and patients with chronic bronchitis-emphysema. we also compared these values with the ideal alveolar po (pao (i)), measured from the alveolar air equation in which paco was substituted by the effective alveolar pco (paco eff) and with the alveolar po measured from the simplified alveolar air equation (pa ). this study is complemantary to previous work for the estimation of paco eff. methods: the subjects breathed quietly through the equipment assembly (mouthpiece monitoring ring, fleisch transducer head) connected to a pneumotachograph and a fast response and co analyzer. the method is a computerised calculation of the effective alveolar po quite similar to that of paco eff, obtained from the simultaneously recorded at the mouth expiratory flow, and co concentration versus time curves. results: the results showed a mean difference (pao eff-pa (i)) of - . kpa in normal subjects and - , in patients. the mean of the difference (pao eff-paq ) and (pad (i]-pao z) was much greater than . in all subjects. the limits of agreement for the difference (paozeff-pa (i))were - . to . kpa in normal subjects and - . to . in patients, while those for the differences (pao eff-pad ) and (pao (i)-pad ) were very large ( > - . to > . ) in all subjects. conclusions: the effective alveolar po is very close to the ideal one in normal subjects, tn patients pao eff may excessively deviate from pa (i) due to the observed significant difference between the alveolar/tidal volume ratio for o and that for co . the alveolar po measured from the simplified alveolar air equation (pao ) differed substantially from pao eff and pad (i) in all subjects. the essential role of glucoprotein hormone erythropoietin is to control red cell production. hypoxemia, reduced blood -carrying capacity and increased affinity of hemoglobin for are the primary stimuli for erythropoietin production. both anemia and hypoxemia induce rapidly erythropoietin secretion. kidney erythropoietin rna levels correlate inversely with hematocrit and directly with plasma erythropoietin level. similarly, hypoxemia increases kidney erythropoietin rna and plasma erythropoietin. the effect of hyperoxemia (pa >lo mmhg) on erythropoietin secretion isn't very well understood. the purpose of this study was first to evaluate the erythropoietin secretion in patients with acute respiratory failure and second to determine the effect of hyperoxemia on erythropoietin secretion in patients with and without anemia. sixteen patients with acute or acute on chronic respiratory failure needed mechanical ventilation were included in this study. these patient were divided in two groups. the patient who developed anemia were included in group i and the patients without anemia in group i . erythropoietin was estimated in venous blood in three stages. the first sample was taken during hypoxemia, the second during hyperoxemia and third during normoxemia. all the patients had high erythropoietin level during the hypoxemia period (mean value • mu/ml). during hyperoxemia etythropoietin levels were reduced in both groups ( mean value . + . mu/ml in group i, . • mu/ml in group ii). in normoxemia stage, erythropoietin increased again in anemic patients, and decreased more in the patients of group i . we conclude that hyperroxemia inhibit erythropoietin secretion in spite of anemia and tow arterial oxygen content. hyperoxemia may be a factor of the insisted anemia in with oxygen treated icu patients. the purpose of this study was to determine the relationship between clinical features of acute lung injury (all) and parameters like total proteins, total and individual phospholipids, the presence of paf, and acetylhydrolase activity in bal of mechanically ventillated patients. acetylhydrolase catalyses the cleavage of acetyl-group from the second position of the glycerylether backbone of paf, leading to its inactivation. mechanically ventillated patients were divided to three groups. group i includes patients without all; group ii, comprisespatients with moderate degree all, ( . <g-i < . ); and group iii comprises patients with severe ards (all score > . ). broncoalveolar lavage (bal) was obtained after infusion of normal saline at ~ to intubated patients and cooled immediately. cells were removed after mild centrifugation ( x g, min, oc). aliquots from the supernatant were used for total protein, phospholipid and paf analysis and determination. acetylhydrolase activity was assessed after incubation of bal with h-paf labelled on the acetyl group. released label was measured by liquid scintillation counter in the supernatant after trichloroacetic acid precipitation of the non-reacted substrate. kinetic characteristics of the enzymes were also studied. total phospholipids appear reduced in bal of patients with all, while total proteins increase. these factors appear to correlate with the severity of all. paf was not present in bal samples pretreatad with equal volume of % acetic acid to denaturate acetylhydrolase. detection limit for paf under our experimental conditions: pg paf/ml bal. instead, acetylhydrolase activity was detected in amounts increasing with the total protein content. background: intubated patients without lung injury or impaired breathing control normally display an inspiratory peak flow of below l/s. the aim of our study was to investigate the inspiratory peak flow generated by patients with acute respiratory insufficiency (ari). we had to take into account that both an inspiratory pressure support (ips) and the resistance of the endotracheal tube considerably influence the flow pattern generated by the patient. patients and methods: to investigate the non-influenced flow pattern we developed a new ventilatory mode which automatically compensates for the flow-dependent resistance of the endotracheal tube (automatic tube compensation, atc). furthermore, the mode maintains a constant tracheal pressure in inspiration and expiratio n . consequently, the measured flow pattern exactly corresponds to the flow pattern generated by the patient except that the ventilator modified for this mode (evita, driiger liibeck, germany) was not able to deliver a gas flow of more than l]s. we have investigated patients with ari arising from different reasons. results: the inspiratory peak flow measured in the atc-mode was . l/s _+ . l/s. the maximal deliverable flow of l/s was obtained in of patients. the figure shows the flow pattern under atc and ips in [~s] oi:) one of these patients. conclusions: patients with ari display a highly increased inspiratory peak flow. ventilators used for spontaneous breathing should therefore be able to deliver a gas flow of more than l/s. an overproduction of no and reactive oxygen species (ros) has been demonstratred in septic shock. ros and nitric oxide (.no) are free radicals which are known to react together leading to peroxynitrite anions that can decompose to form nitrogen dioxide (no ) and hydroxyl radical (oh~ thus, no has been reported to have a dual effect on lipid peroxidation (prooxydant via the peroxinitrite or antioxidant via the chelation of ros). in the present study we have investigated in different models the in vitro and in vivo action of no on lipid peroxidation. copper-induced ldl oxidation was used as an in vitro model of lipid peroxidation. ldl ( ~g apob/ml) was incubated with cu + ( , ~tm) in presence or absence of no donor (sodium nitroprussiate or glutathione-no) from to ~m. oxidation of ldl was monitored continuously with conjugated diene formation ( nm) and hydroxy nonenal accumulation (hne). exogenous no prevents in a dose dependent maner the progress of copperinduced oxidation. ischaemia-reperfusion injury (i/r), characterized by an overproduction of ros, is used as an in vivo model. anaesthetized rats were submitted to hour renal isehaemia following by hours of reperfusion. sham operated rats (sop) were used as control. lipid peroxidation was evaluated by measuring the hne accumulated in rat kidneys in presence or absence of l-arginine or d-arginine infusion. l-arginine, but not darginine, enhances hne accumulation in i/r but not in sop (< . nmol/g tissue in sop versus . nmol/g tissue in i/r), showing that in this experimental conditions, no produced from l-arginine, enhances the toxicity of ros. this study shows that the pro-or antioxydant effects of no are different in vivo and in vitro and could be driven by environemental conditions such as ph, relative concentration of no and ros, ferryl species...these conditions are impaired in circulatory shock. methods:" the diagnostic and therapeutic approach was standardized so that data collected over a -year period were comparable. a progressive deterioration of clinical conditions and/or pulmonary gas exchanges was considered as indication for my. variables potentially predicting the need for hv were derived from clinical and arterial gas data, extrapulmonary diseases, use of drugs, chest x-ray and ecg abnormalities. results: rv, performed with external and/or internal ventilators, was necessary in patients ( %). at the hospital admission, pac was higher and ph was lower in patients requiring rv ( pneumomediastinum, pneumothorax, ateleetasis and myocardial infarction are rarely seen in bronchial asthma. these complications occur as a result of the severe asthma.the aim of our retrospective study was to analyse the complications seen in acute asthma attacks. during the years through , patients were admitted to hospital in acute asthma episode. there were ( , %) pts with complications; mean age of yrs; females ( %). clinical history, ecg and chest radiogr~hs were analysed. the mean duration of bronchial asthma was yrs (range from months to yrs), all patients were atopics. there were four ex-smokem and one smoker. the worsening of asthma symptoms begun two days before the admission (range from to days). on ecg all patients had tschycardia. rightward shift of the qrs axis and st-t changes indicative of right ventrieutur strain were found in three pts. these were the transient fmdings that improved after curing the acute asthma attack. non-q myocardial infarction oeeured in one patlent and resulted from the hypoxaemia of asthma. hyperinfl~ion was the usual finding on the chest radiograpk pneumomediastinum and subcutaneous emphysema were apparent in five pts and required no additional treatment unilateral pneumothoraccs were present in two pts and needed eontimous intrapleural drainage; one of these patienst died in eardiorespiratory insufficiency. ateleetasis of right upper lobe was present in one patient. it oceured due to inspissated secretions and needed no additional treatment all these patients, except one who died, improved on lreaanent with oxygcr~ steroids, beta-two agonists, theophylline and antibiotics. in conclusion, complications occur in acute asthma episodes as a result of the severe asthma mediastir,*l emphysema and atelectasis are not serious complications. pneumothorax and myocardial infarction are very serious life-treatening complications and always have to i:m considered in taati~ts with sev~ asthma. acute bronchial asthmatic episodes represent one of the most common respiratory mnergendes, its maximmum expression "status asthmatiens" is one entity of low incidence, still it is a risk to the physical integrity of the patient. during a total of patients with diagnosis of status asthmabcas were hospitalized. out of these palients six had a near-fatsl asthma and they were subjected to a complex examination. near-fatal asthma was defined as either respiratory arrest or acute asttuua with paco greater than , kpa and/or an altered state of consciousness. mean age was , -d: , yrs, four male and two female sex. at presentation two patients suffered from coma, others were confused. they exh'bited severe dystmoes, diffieul~ speaking, used accessory muscles of respiration, increased whee~tg while two cases had silent chest on auscultation. cyanosis indicated a very severe asthma attack in all six patients. mean respiratory rate was ~ /min and puts rate .d: bts/imn. arterial blood gases revealed a pao of , ~ , kpa, paco of , • kpa and ph of , -+- , . area-careful evaluation they received conventional therapy (immediately continuous oxygen, impelled nebulization with high doses of betatwo agonists and ipmtropium bromide, intmvanous st~oids and theophylline). in two eases signs and symptoms of deteriorating airflow and respiratory muscle fatigue determined the need for mechanical ventilation. out of six near-fatal attacks aggressive lrealanent was suscessfull in four patients and fatal in two eases. one patient admittcxl in coma died in severe hypoxae~a upon one hour and one mechanicaly ventilated died from cardiac arrhythmia. life-threatening attacks in asthmatics in our group developed gradual worsening despite neatment which r symptoms in most other patients. one patient had "brittle asthma", other long-standing acute episodes ireated with systemic steroids. conclusions: idantitiechon of fatality prone subjects may lead to fttrther muetion of seveze episodes. respiratory affest and coma upon admission, severe dyspnoca with silent chest on ausouhation, oyanusis and use of accessory muscles of respiration constitute the basic cfinieal picture. hypoxasmia must be immediately eon'ected.the patients and physicians should be able to assess the severity of asthma, a major factor in near-fatal and fatal asthma attacks. objectives :our purpose was to asses if the evolution of patients with a adult respiratory distress syndrome (ards) ,shows any relation to the pulmonary or systemic origin of the disease and whether or not there were differences in the frequency of the syndrome in both groups. methods : randomized prospective study in multidisciplinary icu. one hundred and sixteen patients with a high risk developing ards were distributed into two groups. one was named systemic origin group(so) and the other pulmonary origth group (po).ai patients only showed one cause (pulmonary or systemic) with potential risk of ards.the patient's hemodynamic and respiratory status was evaluated every hours the first day and every hours the second and third day. at the end of hours the patients were diagnosed as ards or non-ards. measurements and main results : of the total patients, were finally included in the so group and in the po group.patients in so group and po group had comparable ages (p<. ).peep in both groups was comparable (=. ) at the mmnent of admission to the study. there were no statistically significant differences for cardiac index and systemic vascular resistances. the pulmonary vascular resistances (pvr) showed significant differences at h.(p<. ) and h. (p<. ).the oxygen comsumption (vo) in patients of the so group showed statistically significant differences at h. (p<. ) with respect to initial values.fifteen cases of ards ( . %) in the so group and twenty five cases ( . %) in the po group were identified. the time of onset of ards was _+ hours in the so group and + b hours in the po group.the final outcome was very similar th both groups : mortality of % in the so group versus % in the pc group. conclusions : the pathogenesis of ards depends on whether the lesion is originated at or outside the lung. the po group showed a sborter thne of onset of ards, a faster and more severe increase of pulmonary shunt and a higher percentage of patients developing ards compared with patients of the so group.the so group showed a higher and faster increase in puhnonary resitances tbat po group and a decrease th oxygen comsumption earlier and more severe than in the po group. these data thus seem to show that there could be two mechanisms involved in the genesis of ards depending on the cause. the fact that the ards genesis is shorter in the cases of pulmonary etiology with faster impairment of pulmonary shunt, and a slower increase in pulmonary resistances in this pulmonary group, would indicate that the underlying mechanisms responsible for the hypoxemia are different to those which thitiate the increase in pulmonary resistances. finally, the exclusive inapairinent of oxygen consumption, which appears earlier than the onset of ards in the systemic origth group, could show the generalized character of the process in this group. perfusion of prostacyclin (pgi ) to treat pulmonary hypertension in adult respiratory distress syndrome (ards) worse pulmonary gas exchange due to a marked impairement of ventilation/perfusion mismatch. recently has been shown that if prostacyclin is given by aerosol instead of intravenous the net effect is an improvement of arterial oxigenation due to a redistribution of blood flow to well ventilated areas. objectives: to asses the effects of inhaled proatacyclin on pulmonary haemodynamics and gas exchange in patients with severe ards. methods : two patients with severe ards (murray score > ) recived inhaled pgi at - ng.kg.min " using an ultrasonic nebulizer. haemodynamic measurements, arterial and mixed venous blood gas analysis were performed before and after rain of pgi inhalation. results: short-terro p~i inhalation improved pulmonary g-~ e-'~hange in both patients. arterial oxygen partial pressure (pao ) increased from to mmhg in patient and from to in patient , the ratio pao to the fraction of inspired oxygen increased from to (patient ) and from to (patient ). venous admixture decreased from % to % and from % to % in patient and respectively. mean pulmonary artery pressure decreased slightly from to mmhg in patient and from to mmhg in patient . no effects on systemic haemodynamics were observed in any patient. conclusions: pgi inhalation improves gas exchange and produces selective pulmonary vaaodilation, thus can be an alternative therapy for the treatment of pulmonary hypertension and hypexemia in patients with severe respiratory falllure. methods: we treated ards-patients (age yr ( - ) mean, range) during - . the lowest pao /fio -ratio was ( - ), the worst murray score . ( . - . ), icu-stay ( - ) days and hospital mortality %. the costs of intensive care were calculated according to intensivity of patient care as assessed by tiss-scoring (therapeutic intervention scoring system). the more intensive the care, the higher are the costs. costs per year of life saved (=life-year" in us $) were compaired by other medical treatments ( - ). it is assumed that the mean expected length of remaining life in ards-survivors after intensive care is years. treatment life-year ($) ' bone marrow transplantation (acute leukemia) lowering cholesterol using iovastatin treating hypertension using nifedipine heart transplantation intensive care of ards-patients conclusions: intensive care of patients with severe ards is highly more cost-effective as compared with many other routinely used medical treatment strategies, the usually good recovery and the reasonable quality of life in survivors justifies investments to care of these patients ( ). there is a close correlation between these two methods of measuring evlw. however there is an underestimation of . % in this kind of pulmonary edema ( oleie acid induced ) with the double dilution method. although the size of the sample is small, in normal lungs there appear not to be this underestimation. the effect of peep on evlw has been studied with contradictory results, probably as a consequence oft differences in methods of measuring evlw, variations in the type and severity of lung injury, and different timings of peep application. objective= ) to analyse the effect of different levels of peep ( , and omh ) on evlw during hpe; ) to establish whether increases in intrathoracic pressure due to high peep levels can obstruct lymphatic drainage. material and methodet hpe was provoked in groups of dogs by inflating a foley catheter in left auricular to a pressure of - r~uhg. peep levels of , i or m~hg were applied. resultst objective: to assess the effect on extravascular lung water (evlw) of the application of peep and the reduction of vt in an oleic acid pulmonary edema model in pigs, using three ventila~ary strategies. material and methods: twelve adolescent pigs (weighing over kg) were randomly divided in three gmups immediately alter infusing via a central vein . ml/kg of oleic acid to produce a permeability pulmonary edema. the ventilatory parameters for each group were as follows: group i (n= ) : vt: - ml/kg; zeep. group :(n= ) : vt: - ml/kg; peep: cm h . group :(n= ) : vt: - ml/kg; peep: emil . (resulting in permissive hypereapnla) after a four-hour period of ventilation the animals were killed and the lungs excised to calculate gravimetrically the extravascular lung water using a standardized procedure ( hemoglobin content method ). ill evlw (ml/kg) group obiective: in the postoperative period, maintenance of adeguate arterial oxygen tension is a major problem in morbidly obese patients probably because of a large reduction in functional residual capacity (frc). the aim of this study was to evaluate the effects of peep on respiratory mechamcs and gas exchange in this kind of patients. methods: in nine postoperative mechanically ventilated morbidly obese patients (bmi> kg/m ) we partitioned the total respiratory system mechanics into its lung ( ) and chest wall (w) components using the airway occlusion technique associated with the esophageal balloon, during constant flow inflation (jap ; : ) . at three different levels of peep ( , , cmh ) we measured: compliance (cst), airway (rim) and "additional" (dr) resistance, frc and gas exchange. obiectives. to describe the use of prone position in our icu we analyzed the clinical records of all patients admitted in - , selecting adult patients with arf defined as: intubation and pao /fio < mmhg plus an fio > . or peep> cm i . results. patients met the arf criteria: of them ( . %) underwent prone positioning (p+). prone position use began in the early phase of arf ( . • days from the beginning, range - , median ). out of p+ pts were treated with controlled ventilation (cppv or pcv), while were on assisted ventilation (simv+ps) and on spontaneous breathing (cpap). only pts were awake when turned prone, while pts required adjuncts of sedation to tolerate the change of position. the duration of prone positioning was variable (average lenght . • h, range . - h). only minor side effects were observed (eyelids and facial edema, chest and facial pressure bruises). we consider responders (r+) those patients presenting at least . mmhg increase in pao /fio : / patients ( . %.) were responders when first pruned. the pao /fio changes induced by prone position are reported in the figure. pao /fio increased when patients were pruned (*p< . ) and remained higher than baseline values when returning supine(*p< . ). paco remained unchanged. prone positioning was used at least twice in / ( conclusions. this retrospective analysis confirms that prone positioning improves oxtgenation in the majorib' of arf patients. altough we have no available criteria to discriminate in advance r+ from r-pts, we now routinely consider the use of prone position in the treatment of severe arf. palo a, otivei m*, galbusera c, veronesi r, sala gallini g, zanierato m, iotti g, braschi a.servizio anest. e rianim. i, *laboratorio biotecnologie e tecnologie biomediche irccs s. matteo, pavia, italy inhaled no can improve arterial oxygenation and reduce pulmonary hypertension in ards patients; little information is, however, available about the dose-response curves. methods seven ards patients (lis . +. ) submitted to mechanical ventilation randomly received inhaled no doses in increasing or decreasing sequence: . , , , , , and ppm. reference measurements were obtained before and after the entire period of no inhalation. hemodynamic parameters and blood gases were measured after min in each condition. cmv was administered under sedation and paralysis, with constant ventilation, peep (lol-_ cmh ) and fit (. +. ). the changes in vt and fit due to the no ( ppm in n ) injection in the ventilator external circuit were compensated for. results . the dose of . ppm, ineffective on papm, significantly improved oxygenation. the increase of pat and the decrease of q'va/q' and papm were nearly maximal at - ppm. no deterioration of arterial oxygenation was observed at no doses as high as ppm. co exchange was not influenced by no inhalation. systemic hemodynamic variables did not change throughout the study. these results suggest that a concentration around ppm is adequate for obtaining maximum effects on hypoxemia and pulmonary hypertension in patients with ards. low-dose inhaled nitric oxide (no) induces redistribution of pulmonary perfusion in patients with severe ards and causes improvement of oxygenation [ ] . however, addition of exogenous lowdose no in the inspiratory gas mixture might be only a replacement of missing atmospheric no ( - ppb) in hospital central-supplied medical air. [ ] we have realised nitric oxide measurements in ten healthy volunteers, ( smokers and non-smokers) breathing with a mouthpiece and occluded nostrils through a ventilator circuit, with separation of inhaled and exhaled gases by a valve. no concentration was measured with a double-chamber chemiluminometer (environnement sa, france) and with charcoal/silicate purified compressed air. there was no nitric oxide detectable in the inspirat ry limb of the ventilator. unfiltered central supply medical air contained : - ppb of no and - ppb of no , whereas central supplied oxygen was no/no free. samples were taken after equilibration periods of minutes, with increasing fit levels of . , . and . for subsequent minutes periods; paired values were recorded every s. the mean no value was . ppb (sd . ) and n o significant differences were found for different fit levels both in smokers and non-smokers. these data suggest that the no concentration of pulmonary origin in the exhaled air of' healthy volunteers is probably lower than that reported by other authors [ ] and that, previously reported, differences between smokers and non-smokers are not always striking [ ] . we suggest the use of activated charcoal/silicate filters for clinical trials in order to achieve standard conditions. [ objective: to compare efficacy and safety of two doses of salbutamol. methods: sixteen adults who had severe acute a~hma were randomly assigned to receive either rag (n= ) or rag (n= ) of nebulized sulbutamol. both groups were similar with respect to age, duration of a~hma, duration of attack before arrival at the hospital and severity of a~hma according to baseline measurements (table) . evaluation was performed , , and rain after the start of nebulization. results: compared with mg regimen, mg regimen resulted in the same improvement in peak-flow and fischl index (figure). the changes in heart rate, respiratory rate and pace did not differ significantly between both groups. the incidence of side effects, which included tremor, palpitations, cardiac arrythmlas and other symptoms, was not sj~ificanfly different in the two populations. conclusion:the results of this study suggest that nebulization of ng of salbutamol is not more effective than rag in the initial treatment of acute severe asthma in adult patients. the prognostic factors of neutropenic patients admitted to the icu remain poorly known. the aim of this study was to determine the respective weight of underlying malignancy and organ system failures on the outcome of these patients. patients and methods: the charts of neutropenic patients (wbc < /mm and/or pmn < /ram ), admitted to the icu between and , were retrospectively reviewed. the characteristics of the neoplastic disease (h~emopathy or solid tumor, tumoral evolution, duration of cancer disease and of neutropenia), the mac cabe's score, the organ system (respiratory, hemodynamic, renal, neurologic, hepatic) failures and the severity scores (saps, saps ii ,osf) were registred within the st day in the icu. when discharged from the icu, the patients were classified as alive or dead. results: fifty-seven patients ( . %) had a h~ematologic malignancy, and ( . %) a solid tumor. fifty-nine of the patients died ( . %); the mortality rate did not differ between both groups ( . and % respectively, p = . ). with univariate analysis, none of the tumoral features is linked to the prognosis; only the respiratory (p < - ) and cardiovascular (p < - ) failures, and the number of organ system failures (p < - ) are associated to the risk of death. the saps (p < - ) and saps ii scores (p < - ) were higher in patients who died. with multivariate analysis (logistic regression), only the respiratory failure is correlated to the risk of death (p = - ); neither the features of the underlying malignancy (p > . ), nor the duration of neutropenia before admission in icu (p = . ), nor the severity scores figs ii: p = . ) are linked to the outcome. conclusions: the tumoral characteristics do not modify the prognosis after admission to the icu. they should not influence the decision to admit or refuse a cancer patient in the icu. respiratory failure at icu admission has the predominent weight on the risk of death in the icu. patients with respiratory acidosis due to asthma occasionally require levels of mechanical ventilation that place them at risk for barotrauma. a few case reports have described the use of an extra-corporeal membrane oxygenator(ecmo) circuit as an alternative means of co removal. generally, this has been used for short periods of time (< h) without serious complications and with low blood flows through the extra-corporeal circuit. we report a case of refractory asthma who could not tolerate even small-volume breaths from a mechanical ventilator due to severe bilateral airleak. ecmo therapy was initiated at the referring hospital prior to helicoptor transport. high blood flows were used ( % of the patient's cardiac output), sufficient to achieve both co removal and oxygenation. satisfactory gas-exchanged was accomplished (pco = - mmhg) with nearly total lung rest for a prolonged period ( h). however, the long ecmo duration was associated with two severe complica-ti ns: ) bilateral hemothoraces due to anticoagu!ation in the extra-corporeal circuit, and ) prolonged weakness as a result of neuromuscular blockade for six days. the patient was discharged from the hospital in good condition. we present the respiratory and hemodynamic features of this case aw well as the potential complications of ecmo therapy in asthma. objectives: parameters derived from tidal expiratory flow ~e) and volume (vt) can be used to detect airflow obstruction in copd patients who might be unable to perform forced spirometry (e.g., icu). however, indices such as ave/v t and at/re are highly variable (thorax, : ; ) . methods: we investigated whether the standardized for v m effective time (teff~) of a tidal breath, which is derived by asimple mathematical procedure (teff,= j'vdt/vt ), is a more reproducible and sensitive detector of airways obstruction, we studied nine normal subjects ( male, -+ yr) and copd patients ( male, -+ yr) in the seated position, with a noseclip on. they breathed quietly, through a pneumotashograph to measure flow (v). volume was obtained by numerical integration of thellow signal. each subject had an initial - min trial run, in order to become accustomed to the apparatus and procedure. when regular breathing had been achieved, all breaths over a min time interval were recorded. the mean value of six consecutive breaths (ers criteria) for each subject was used for analysis under the condition that within session variation of tidal volume (vt) was < %. lung function tests were: in normals (mean-sd), fevl%pred = • fevl/fvc%= -+ % , and in copd patients, fev~%pred= __. and fevi/fvc%= --. %. results: values are shown as mean-..+-sd in the following a su~ve~ os literature sources p~oves that t~aditlona], i.e. medicinal medication and physiothe~apeutic methods os t~eatment often p~ove to be insufficientl~ effective both currently and in the ~emote future. the goal of this study was to investigate the efficacy os t~eatment of b~onchial asti~ma patients by means os speleo-and artificial sp~ay therapy. speleotherapy t~eatment was conducted in the conditions os mic~oclimate os salt mine in solotvino hospital. a~tis sp~ay the-~apy was conducted by means os a self-made device. ou~ method is based on the p~inci-~ le os using the majo~ facto~ of speleo-he~apy -highly dispe~sed sp~ay s sodium chloride. the obtained ~esults ~e~e analyzed in five g~adations. at the end os the speleothe~apy improvement and considerable improvement was observed in , ~ os patients; inconsiderable improvement -in , ~ os patients. having evaluated the e~s os t~eatment using a~tis sp~ay therapy the indices a~e , h and , ~ ~espectively. remote ~esults of t~eatment a~e an important index os t~eatment, the ~esult os ~hich ~e~e studied by means s a ~uestionnaive-method. patients ~ho had been t~eated by speleothe~apy mo~e f~eguently ~e-po~ted a ~elapse in disease ust afte~ the course o~ t~eatment ( , h). ho~eve~, in a ]ate~ phase the ~emission ~ould last ]on-~e~ (s months in , ~ os patients, till one yea~ in ~ ~). in , ~ os patients who passed the co~se os a~tificial sp~ay therapy a ~elapse was ~egiste~ed immediately as the co~se os t~eatment. then thei~ condition stabilized ~hile in , ~ os patients a period os ~emission lasted s ha]s a yea~. , ~ of patients dida't ~epo~t a ~elapse of the disease du~in~ one yea~. evangelismos hospital, critical care department, athens, greece method#: mechanically ventilated patients ( copd, ards, other pulmonary diseases) were studied in two phases: ) during the acute phase of respiratory failure; ) during recovery - days later. we measured mip and monitored the pattern of breathing while the patients were breathing spontaneously through the respirator (pressure support mode with - cmh ) until either the point they were unable to sustain spontaneous breathing (sb) any longer (phase ) or for two hours when they could sustain sb indefinitely (phase ). subsequently the patients were sedated, paralyzed and mechanically ventilated. then we simulated the pattern of sb at the end of the sb trial by manipulating the variables of the ventilator and assessed respiratory mechanics b y the end-inspiratory and end-expiratory occlusion technique. . during recovery, a combination of reduced inspiratory load and increased venfilatory capability makes a patient previously unable to sustain sb to breathe spontaneously. . inspiratory load is reduced during recovery, mainly because both intrinsic peep and breathing frequency are diminished. obiectives: although elevated concentrations of a few cytokines have been shown to be present in the bronchoalveolar lavage (bal) fluid (balf) of patients with the adult (acute) respiratory distress syndrome (ards), the pethogenesis of ards is largely unknown. leukemia inhibitory factor (lif), a growth factor recently recognised as a polyfunctional cytokine integrated in cytokine networks was measured in unconcentrated balf of patients from different patient groups. methods: lif was measured in balf by means of a specific and sensitive elisa (detection limit pg/ml)in balf (lavage of x ml in the right middle lobe). results: lif was not detected in the balf of healthy control patients and in only one ( pg/ml) out of patients at risk for ards (after cadiopulmonary bypass surgery) who underwent bal h after the end of the extracorporeal circulation. high and detectable levels were found in the unconcentrated balf of out of patients with full-blown ards ( + , mean + sem, range - pg/ml). there was a good correlation between the level of lif in the balf and a number of markers of inflammation: neutrophils/ml (r: . , p= . ), albumin ( r: . , p= . ) and protein level (r: . , p= . ). conclusions:the biological role of lif in these balfs is not readily explained by its currently known actions and it is unkwon whether lif contributes to or is a response to local tissue damage. our results indicate that this cytokine with lots of interesting _functions is a pert of the inflammatory cytokine cascade in ards. background and obiective : we recently demonstrated that cisapride -a new prokinetic drug -enhanced enteral feeding in a heter genoas group of ventilated icu patients by significantly accelerating their gastric clearance (crit care meal, ; : - ) . it remains unknown, however, whether certain subgroups of patients might benefit more from adding cisapfide to their enteral nutrition regimen than others. patients with chronic obstructive pulmonary disease (copd) might represent such a subgroup since their illness and its specific treatment put them at risk for gastric emptying disorders. design and setting : prospective, consecutive sample study in an adult medical intensive care unit in a university hospital. patients : mechanically ventilated and hemodynamically stable copd patients. interventions : gastric emptying was evaluated by bedside scintigraphy and expressed as the time at which % of a tcg~-labelled test meal was eliminated from the stomach (t / ). baseline data (do) were recorded after enteral nutrition reached to ml daily. scintigraphic measurements were repeated days after cisapride ( ml orally, q.i.d) had been added to this regimen (d ). patients were considered cisapride responders when gastric clearance improved by more than % from baseline. results : normal values for the test meal and for scintigraphic acquisitions obtained in the supine position were found to be + min. in healthy volunteers (crit care med, ; : - ) . five patients responded to cisapride (t / : + rain vs. + min at do and d , respectively) and five did not (t / : + min vs. _+ rain at do and d , respectively). in contrast with non-responders, all five responders had clinically significant maldigestion at baseline (excessive (> ml) gastric residues, vomiting (> times/day and abdominal distension) which disappeared in of them after the administration of cisapride. conclusion : copd patients who tolerate enteral nutrition well have basal gastric emptying times which are comparable with those of healthy volunteers and are not influenced by cisapride. however, cisapride treatment provides both scintigraphic and clinical improvement in those copd patients who exhibit clinically obvious gastric emptying disorders. cernv v., dostal p., zivny p., zabka l. dept. of anesth. and critical care, charles university, faculty hospital, i-irade~ kralove , czech republic objective: the aim of the study was to evaluate the effect of early entera nutrition started within hours of injury on the incidence of multiple orgar failure (mof) in trauma patients requiring vantilatory support. methods: after institutional approval patients were enrolled in the study enteral feeding was begun within hours of injury in trauma patients (en group) admitted to icu. nasuenteric tube was placed as soon as possible after admission into the distal duodenum under endoscopy. additional parenteral nutrition was used to meet patients energy and protein requirements. the control group (pn) consisted of patients fed during this period paretuerally. severity score apache ii, trauma score, cumulative balance of nitrogen (g), incidence of mof (three and more organs) and length of ventilatury support (days) were calculated. values are expressed as mean + sd. results: tab introduction : parenteral nutrition (pn) is an important aspect in the optimal treatment of patients on gastroenterology or intensive care. the aim of this bi-center study in patients has been to assess tolerence and efficacy of a new protein-lipid mixture for pn from a simple preparation. patients and m~hods : patients were selected in two hospitals (tenon and saint-lazare, paris) and were divided into two groups : group a (gastroenterology~ l short bowel syndrome) and group b (intensive care, surgical patients). all patients likely to require pig for a period of days (group a) or days (group b) were studied. the pn regimens administered were the following : combination with g of mct/lct fat emulsion end , g of nitrogen, in liter end glucose requirements were met by imfizsion of l liter of glucose - % via a "y " connection. lipid thus provided % of the non introgen calories. total daily calorie intake was to ] kced. this study monitored, before and at the end of infusions, the sennn albumin (alb), preaiburtun (prealb), triglycendes (tg), cholesterol (cs), and the serum ammotransferases (sgot and sgpt) end alkaline phosphatase (alp) activities. statistical significances were calculated using the wilcoxon-tost. introduction: many cu patients present a catabolic illness in response to inflammation and infection, characterized by a rapid loss in skeletal-muscle mass despite optimal nutritional support. growth hormone (gh) is responsible for a rise of lipolysis, enhancing the energetic balance, and of protein synthesis. recombinant human gh (rhgh) is nowaday available for clinical use, but its cost is very high. therefore, rhgh should only be prescribed to icu patients when its efficacy can reasonably be anticipated (ie. when the patients are catabolic or stressed, but in order to avoid overprescription for unstressed patients and for those who are overly catabolic). hence, we, as others, recently demonstrated that rhgh had no favorable effect in highly stressed icu patients. objective: to detect on a clinical basis, low (ls), mild (ms) and severe stress (ss) states in icu patients and validate this clinical judgement by objective metabolic mesurements, in order to select early those icu patients potentially able to benefit from rhgh therapy. methods: consecutive icu patients were prospectively stratified as ls, ms and ss by two experienced icu senior consultants (temperature; agitation; heart rate; arterial blood pressure; presence of an infection; respiratory rate; exogenous catecholamines). anabolic (insulin, igf- , gh) and catabolic (cortisol, ghicagon) hormones, and nitrogen balance were determined for each patient within hours after admission in the icu. metabolic and clinical data were then compared. the clinical stress states determined by icu physicians correlate with an objective metabolic assessment. therefore, the patients who will more likely benefit from adjuvant rhgh therapy can be detected simply and early. a prospective study on rhgh therapy in ms icu patients is in progress. berger mm md , chiolero r md , pannatier a phd , berger l , cayeux c , voirol p , hurni m md . surgical icu, pharmacy, and cardiac surgery, chu vaudois, ch-iotl lausanne, switzerland objective. nutrition of the compromised cardiac surgical patient is challenging. numerous factors influence the gastrointestinal (gi) absorption function, among which gut perfusion, which depends largely on the systemic hemodynamic status. patients in hemodynamic failure are prone to organ failure, and may benefit from an early jejunal feeding. the study was designed to assess the absorption function after cardiac surgery in patients with adequate and altered hemodynamic status, using paracetamol as tracer of gi absorption. methods. after cardiac surgery, patients, aged _+ years (mean_+sd) were assigned to groups (anaesthesia: fentanyl gg/kg + midazolam): group (n= ): reference group, with normal hemodynamic status, easy recovery. group ('n= ): patients in low output syndrome, cardiac index < . i/m on day (d ) after surgery, requiring prolonged intensive care, mechanical ventilation + nutritional support. paracetamol g, was given intragastrically on d + d : plasma levels measured (h.p.l.c), at administration (to), t - - - - - and rain. hemodynamic status assessed with pulmonary artery catheter. healthy subjects served as controls. results. compared to healthy controls, absorption was strongly reduced on d in all patients (no difference between groups). on d , peak paracetamol level was significantly lower in group (low cardiac output): in group the area under the curve on d and d were similar. there was a large inter-patient variability, reflecting the hemodynamic status. conclusion. gi absorption was decreased on d in all patients, and reverted to normal between d and d in case of normal cardiac function, but not in case of low output syndrome. the decrease on d can be attributed to fentanyl, known to slow down the gi transit. in patients with cardiac failure, correction of altered absorption was correlated with the hemodynamic status, suggesting that gi absorption is dependent on adequate splanchnic perfusion. the aim of the work was to define specific significance and evaluate efficiency of enteral component of infusion therapy in the intensive care of gastroenterotogic patients of surgical profile with pyo-septic complecations. there were used the methods of radial diagnostics and polyelectrography; the laboratory control on oxygen-transporting function, volumetric and hemodynamic state, changes in metabolic, hormonal and immunologic status was conducted. from january, [ till november, there was carried out the randomized study of patients with general purulent peritonitis; among them persons constituted the control group and -the main one. in the main g~oup the intestinal lavage, enterosorption, enteral introduction of nutrient solutions with gradual turn to enteral nutrition by equalized mixture "ovolaet" were started from the first hours after operation. the data obtained allowed to define the specifity of the program of artificial medical nutrition in the group of examined patients, based on necessity of individual selection of media for enteral introduction depending on the stages of intestinal insufficiency syndrome. it was shown that inclusion of enteral component into the program of infusion therapy during early periods stabilized circulation in the regime of moderate hyperdynamia, considerably decreases the deficiency of circulating blood volume, normalizes the values of oxygen transport, consumption an}d extraction, provides the optimal level of mycardial adaptive possibilities without tension of its compensatory functions and pulmonary circulation overload. due to combined application of parenteral and enteral nutrition the metabolic processes are shifted towards anabolism. this is supported by decrease to normal values in the contents of blood aggresive hormones (acth,hydrocortisone) and increase in somatotrophic hormone. the complete parenteral-andenteral nutrition influences positively on restoration of cellular and tumoral immunity, activates the factors of organism nonspecific protection and recovery from immunodepression, prevents the development of immunodeficiency. impact tm vs control. s atkinson, n maynard, r grover, e sieffert, r mason, m smithies, d bihari departments of surgery and intensive care, guy's hospital, london, u.k objectives: comparison of the effect of an immunonutrient enteral feed versus a control on the outcome of a mixed intensive care unit (icu) population. methods: admissions to this multidisciplinary adu)t icu thought likely to stay more than three days and with tube access to the gi tract ~r randomised to receive either impact tm, a feed with supplemental arginine, dietary nucleotides and omega- fatty acids, or an isocaloric and isonitrogenous control feed. study end points included mortality and icu stay. approval was obtained from the hospital ethics committee. rosults: patients were entered into the trial. the two groups were well matched for age, sex, and admission apache ii with an overall mean admission risk of death of . (std. dev. -+ . ). on an intention to treat basis, there was a no significant difference in icu mortality, icu stay or standardised mortality ratio (s.m.r.) between the two groups (see table) . similarly, there were no differences after stratification for patients receiving or more litres of feed. conclusion: there is no evidence of an effect of impact@, an enteral immunonutrient feed, on pre-determined end-points (icu mortality, icu stay or standardised mortality ratio) in a mixed intensive care unit population over that of an isocaloric, isonitrogenous control feed. objeeflves: evaluate changes of blood laatate levels according to patient medical status after cvvhd initj,~ion using dialysate solution containing lactate. method: review of medioal records of consecutive patients ~eated by cvvhd (dialysate solution hmnosol lg , hospal,uk, lactate concentration retool/l). date obtained hr before and - hrs at~er cvvhd initiation were analysed. results: all data are presented as mean + sem. in one patient, pre end post filter lactate levds were measured during standard cvvhd setting (blood flow ml/mlu, dialysate solution flow i /hr), and approximate daily lactate flux into the patient was calculated to be as high as mmol/d. lactate leveh measured after cvvhd initiation increased significenfly compared to baseline levels ( . + . axtd . + . ,respectively; p< . ,paired t-test). when patiente with increased basal lactete (~- ) were compared to paliente with normal basal values (n= ), no difference in laotete increase was fmmd (p= . , manova). patiente with severe liver dysfunction ( points in mop scomlg, n= ) had higher basal laotate levels than patiente with normal or slightly abnormal liver teste ( or point in mof scoring, n=ll), rite values being . + . and . + . , respectively (p< . , student t-test). increase in blood lactate did not differ between these two groups after cvvhd was stetted (p= . , manova). in pafiente with invasive hemedynamio mo~, no oorrelation batween changes in lactate levels and eitlm" changes in oxygen ddivery (t =o.ol; p--o. ) or oxygen consumption (reversed fie, k) (r -q).o ;p-- . ) were found after cvvhd initiation. conclusion: blood lactate increases on cvvhd with dialysate soh~on rich in lactate. this increase is predominantly caused by influx of lactate into the blood via the filter end does not seem to depend on the liver fimotion and/or oxygen metabolism changes. objectives: the study was designed in order to determine the effect on plasmatic proteins, of two types of aminoacids solutions of parenteral nutrition (pn) adapted to stress, having different concentration of branched chain aminoacids (bcaa), when applying to politraumatized critical patients. methods: a prospective study was performed using a randomized double blind design of polytraumafized patients, split in two groups of ten patients each, with mean ages of _+ an -+ years. due to their condition, all patients required p.n. for at least days. both groups were subjected to isocalorie and isonitrogenous solutions ( ci/kg/ day and . g of nitrogen/ks/day), varying only in the concentration of bcaa; solution a having a % concentration and solution b %. blood samples determinations during days , , , after the beginning of treatment with p.n. were total proteins., albumin, trandferrine, protein binding retinol; prealbumine and fibronectine. the anova test (one and two way) was used to compare the values between the two groups. results: the administration of solution a, showed statistically significant increases in the determinations of the values of protein binding retino] (p < . ) and prealbumin (p < . ). no significant increases were observed in the values of total protein, albumin, transferrine and fibronectin. solution b produced statistically significant increases only in the values of total proteins (p < . ). the remaining proteins did not changed from their control values during the whole period of pn administration. comparing both groups, no statistically significant differences were observed related to the type of diet. nevertheless, differences were found in total proteins, albumin, protein binding retinoi, fibronectin (p< . ) and prealbumin (p < . ) in relation to the time course of pn therapy. only the albumin values showed significant differences (p < . ) when considering the interaction of both the type of diet and the time course of pn. conclusions: . solutions of pn adapted to stress, can maintain the control values of slow turnover proteins and improve the values of rapid turnover proteins. . no significant differences on plasma proteins were found between the two solutions having % or % concentration of branched chain aminoaeids. &determination of rapid turnover proteins does not seems useful for discriminating different solutions of bcaa during pn. obiectives; the hormonal changes in the post-traumatic situation often leads to an elevated blood glucose and a negative nitrogen balance. to reduce the elevated glucose production by aminoacids the apprication of xylitol may be an alternative energy source. in a double-blind randomized study we investigated the effects of a xylitol/glucose solution (group a: aminoacids g/i; glucose/xylito g/ g/l) on metabolism and particularly on pancreatic and liver enzymes compared to a glucose based nutrition solution regimen (group b: aminoacids g/i; glucose g/i). methods: the clinical trial was carried out after the approval by the local ethical committee on patients with severe brain injury. there was no difference in body mass index bmi (group a: . +/- . kg/m and group b: . +/- . kg/m=), age, and sex. daily individual energy expenditure was measured by indirect calorimetry (deltetrac "~). nutrition was started - hours after trauma or surgery with carbohydrates and aminoacids. fat was added h after nutrition had started. to analyze the effects on pancreatic and liver enzymes we investigated the following parameters for days: blood gtucose, serum lipase, serum amylase, asat, alat, ~gt, ap, and serum cholinesterase (che). results: due to the daily indirect calorimetric measurements energy requirements were satisfied. there was no difference in blood glucose concentration and cumulative nitrogen balance between the two groups. neither were there any significant changes in asat, alat, ap, and che for days in both groups. serum tipase steadily rose to lull in group a and . lull in group b, respectively. conclusions: there was no measurable influence of either nutrition solution on liver enzymes. the xylitol/glucose nutrition regimen does not have any advantage over the glucose based nutrition solution concerning blood glucose level or nitrogen balance. the elevation of serum lipase to a -fold level in either group needs further investigation on trauma patients. the effects of fat emulsions in lung function, particularly in lungdamaged patients, have been attributed to alterations in pulmonary vascular tone caused by eicosanoid production modificatione. as the eicosanoid production may depend on the fatty acid profiles of the intravenous fat emulsion, haemodynamic, pulmonary gas exchange and plasma levels of prostanoids were investigated in acute respiratory distress syndrome (ards) patients, during different intravenous lipid emulsions (providing different prostanoid precursors). we studied in a randomized double-blind design groups (n= each) with ards. group i (lct) received a fat emulsion with long chain triglycerids (lct- %), group ii (mct) an emulsion containing a mixture of medium and long chain triglycerids (mct/lct / - %) and group iii placebo (control), during h ( mg/kg/min each). we measured before, at the end of h infusion, and h after the end of the infusion: lipaemia, arterial and venous blood gases, pulmonary and systemic haemodynamics, and plasmatic levels (arterial and in mixed venous sample) of eicosanoids (txb=, -keto pgf~,, and ltb ). at the end of the fat emulsion, groups (i and il) to , • to , • mmol/i), the paoz/fio z remained unchanged in the three groups; no changes in intrapulmonary shunt (qs/qt) were shown; neither in the mean pulmonary artery pressure. in contrast, only in the lct group: cardiac output and oxygen consumption increased significantly ( . % and %) (p< . ). eicosanoids were increased at baseline compared to reference values (p< , ). a decrease (p<o, l in the arterio-venous difference of the vasodilatador prostanoid ( -keto pgf~=) was shown in lct group. our results indicate that fat emulsions in ards patient do not influence pulmonary gas exchange, provided that the perfusion rate were keept at mg/kg/min. the present study was designed to evaluate the metabolic changes of a carbohydrate-based diet versus a fat-based diet on oxidation rate of substrates and energy muscle metabolism in patients with an acute exacerbation of chronic obstructive lung disease. patients were mechanically ventilated with a volume-cycled respirator. after an overnight fast, patients were randomnly treated with a continuous enteral feeding over a nasogastrie tube with a carbohydrate/fat ratio of / in group i (n= ) , and a carbohydrate/fat ratio of / in group i] (n = ) during consecutive days. indirect calorimetry was set at baseline and hours later the enteral feeding was started. muscular quadriceps biopsy was performed on baseline and on day of enteral feeding. urine was collected during hours and was used to measure h urea nitrogen production. the caloric intake was set according to the measured resting energy expenditure. respiratory gas exchange rate were measured using a computerized open-circuit indirect calorimeter. quadficeps femoral muscle samples were obtained by muscular biopsy after local anesthesia. analyses of glycogen, glucose -phosphate, lactate, phosphocreatine and adenosine triphosphate (atp) and enzymes (glycogen synthase and glycogen phosphorylase) were determined. after h of nutrition patients in group i showed an increase in carbohydrate oxidation (from . % to . %, p= . ), and in group ii a decrease in protein oxidation (from % to %, p= . ). after days of enteral feeding a tendency to increase in glycogen concentration (group i, p= . ; and group ii,p= . ) was observed. while patients in group i showed a tendency (p= . ) to decrease glycogen phosphorylase, patients in group ii maintained these enzymatic levels. the increased in glycogen was correlated in group li with degradation enzyme (p = . ). in group i, the pao /fio ratio increased after days of treatment (from . to . ; p= . ), but no changes in days of mechanically ventilation, length of stay in icu, or mortality rate was evidenced between groups. it is concluded that the oxidation rate of substrates used for energy production varies according to the caloric sources administered. with nutritional therapy muscle glycogen concentration increases in both diets, with different enzymatic influence. more studies are warranted to further assess the clinical implications of the different pathophysiologic behavior of the two diets. under certain experimental and human conditions (radiation and/or thermal injury) the gi mucosa is unable to perform this protective function and could play an important role in the pathophysiology of the syndrome of multiple organ failure (smof). the objective of the present multicenter study was to know the gi mucosal permeability in critically ill patients and the relationship with their outcome. the method used to assess the integrity of the gi mucosal barrier measured mucosal permeability to various hydrophilic compounds. specifically, we measured the urinary excretion ratio (uer) of two sugars (lactulose and mannitol) that had been previously administered through a nasogastric tube. urinary excretion rate was measured in healthy humans (control) and in patients admitted to the intensive care unit (icu) at days , and . the apache ii of the patients studied was _+ . there was an increase of uer in the critically ill patients compared with controls (o. _+ . vs . _+ . ) (p< . ). in contrast, no changes in uer between days , and were observed ( . -+ . . significant changes were also established in the different groups: major and minor surgery, general and epidural anaesthesia , transfused and non transfused patients except for iron and ferritin plasma levels which didn't change significantly in patients who had received blood. a positive significant correlation was established between crp and ferritin (r= . ) for patients under general anaesthesia, but not on epidural, regardless of the type of surgery. conclusions: iron and transferrin plasma levels fell acutely in surgical patients while ferritin and crp rose. transfusion implied an acute iron load.the established correlation between cpr and ferritin in patients on general anaesthesia suggests that ferritin behave as an acute phase reactant in that setting, while epidural anaesthesia may ameliorate the inflammatory response. objectives: to analize the effect of gastrointestinal complicacions (gic) related to the enteral nutrition (en) in the real volume of diet administered to icu adult patients. a prospective multicenter study was designed (comgine study) in wich en application, gic definition and his management were defined by collaborative consensus.patients treated with en in one month pedod were included. in each case, daily volume of diet prescribed (pv) and administered (av) was recorded and the volume ratio calculated (vr=pvxl /av). patients were divided for days of en according to the presence (group ) or absence (group ) of gic (abdominal distension, increase of gastdc residuals,vomits or regurgitation, diarrhea,constipation and bronchoaspiration). differences between groups were analized by anova and mann-whitney u test with p< . for statistical significance. (vr%) group (vr%) tolerance to the enteral nutrition (en) has been related to the severity of illness in icu patients. the aim of this study was to evaluate this relationship. methods. a prospective, multicenter, study was performed (comgine study) in wich en application and related gastrointestinal complications (gic) were defined by collaborative consensus. adult icu patients treated with en in one month pedod were included. gic were classified as: ) abdominal distension (abd), ) increase of gastdc residuals (igr), ) vomits (vom), ) diet regurgitation (reg), ) diarrhea (dia) and ) constipation (con). patients were divided in two groups: group a: patients with gic dudng their evolution. group b: patients without gic. differences between groups were analized for apache ii admission score or evolutive variables ( carbon dioxide production is a major determent of work of breathing. increase in co production during nutritional support may precipitate ventilatory failure and difficulty in weaning from mechanical ventilation. in the present study, co output was calculated while passive mechanically ventilated patient were fed with different amount of calories and different proportion of protein, carbohydrate and fat. four clinical stable and mechanically ventilated patients were studied. carbon dioxide was calculated while patients were paralyzed, sedated and mechanically ventilated. six nutritional regimens were used: a) no calories, b) t gr glucose/ h, c) calories equal to rest energy expenditure in special formula with low carbohydrates and high fat (pulmocare) d) calories equal to rest energy expenditure in standard formula (nutdson) e) calories double to rest energy expenditure in standard formula (nutrison) and f) calories equal to rest energy expenditure parenterel (tpn). carbon dioxide output was low while no calories and/or only gr/ h glucose was provided, the mean values of vco output were _+_ and !-_ ml/min respectively. there was no difference in vco output between with low carbohydrates and high fat regimen and standard regimen, mean values were t . -+ and _+ respectively.the high calories regimen and tpn resulted in higher vco output, mean values _+ and • respectively. we conclude that the special with low carbohydrates and high fat regimen did not reduce vco output, in the contrary, high calories intake as well as tpn increased vco output under tested conditions. klouche k., cristol j.p., vela c., canaud b., b raud j.j. m tabolic intensive care unit and nephrology department. lapeyronie hospital. montpeuier france. predictive factors for rhabdomyolysis (rh) -induced acute renal failure (arf) were studied in a retrospective study from january to january . patients (pts) (male: , female:lo; mean age: + y.o.) were admitted with rh defined as cpk> iu/ . etiologies were: traumatic and ischaemic , infectious , toxic , excess activity . factors studied were: simplified acute physiologic score (saps: . + . ), organ systemic failure (osf: . _-!- . ), diagnosis delay (d: +_ h), clinical parameters (sepsis, dehydration), blood chemistry data (cpk, bun, creatinine, potassium, phosphorus, calcium, proteins, hematocrit) and urinary ph. severity of rh was estimated by ward score determined according to phosphorus, albumin, potassium, cpk, dehydration and sepsis. urea appearance rate (uar) and creatinine index (ci*) were determined over a hours period. arf was observed in pts. in non-arf and arf groups respectively, saps ( . _+ . vs . + . ), deshydratation ( vs ), sepsis ( vs ), phosphorus ( . + . vs . -+ . ), calcium ( . + . vs . _+ . ), ward score ( _+ . vs . + . ) were significantly different. however, no significance was observed in uar ( -+ vs -+ ) and ci ( _+ vs _+ ). patients required hemodialysis (hd) ( : sessions) and remained dialysis free. only osf ( . _+ . vs . -+ . ), ward score ( . _-/- . vs . _+ . ) and ci ( +_ vs -+ ) appeared significantly higher in pts requiring hd. pts died from associated disease. all patients suffering from arf recovered a normal renal function. we confwmed that an elevated ward score (over ) is a good predictive index of arf. in addition we found that ci is a severity factor for arf requiring hd. thus, patients suffering for rh with elevated ward score and ci, have a fair chance of dialysis and should be treated more intensively. * ci (expressed in mg/kg) = (car + feces creatinine) / weight. where car: creatinine appearance rate; feces cr~t..= mean plasmatic creatinine x . . tr~er k., cetin t.e., tugtekin i., georgieff m., ensinger h. universit~tsklinik flir an~sthesiologie, uim, germany introduction: endogenous as well as exogenous adrenergic agonists have a profound effect on carbohydrate metabolism in human critical illness. in this study the effects of noradrenaline (nor) and dobutamine (dob) on carbohydrate metabolism during a hr infusion were investigated. methods: after approval by the local ethic committee healthy volunteers were studied. hepatic glucose production (hgp [mg/kg/min]), using , -d glucose as stable isotope tracer, as well as plasma concentrations of glucose (glc [mmol/i]) and lactate (lac [mmol/i]) were measured prior and during infusion of nor ( . pg/kg/min) and dob ( pg/kg/min). blood samples were drawn before and during the agonist infusion. results: no major changes in insulin and gtucagon plasma concentrations could be found during the study period. ::i:::: :iiiii~ ~ i ::i: ~:: : :: i:ii. mean-+sd are shown. # p< . , anova for repeated measurments. conclusions: the effect of nor on hgp and glc were smaller as compared to adrenaline (i) with a similar time course. in contrast to the effects of adrenaline and nor, dob had a different effect on carbohydrate metabolism: a decrease in hcp and glc, which is uncommon for a / -adrenoceptor agonist. since hgp is an energy consuming process that might deteriorate hepatic oxygen balance in critical illness, the differential effects of adrenergic agonists may be of importance and need further clarification. the nutritional insufficiency often accompanies post-operative hypercaloric states, inanition, serious infections and weakening chronic illnesses. that is why the early nutritional support, sufficient and appropriate for each individual base, is a fundamental component of intensive care unit as an indispensable factor for recovery. per this reason, our unit, developed a software for the implementation and nutritional control of t~e assisted patients. this software is incorporated is an expert system called ~i~su, designed and developed by the computational division of our unit. this system arrives to inferred diagnoses such as : respiratory, hepatic, renal(with and without dialysis) dysfunctions, pancreatitis, ards, decrease of consciousness, diabetes. according to these data objectives: to compare the effect of short term enteral feeding versus parenteral nutrition, when a isonitrogenous and isocaloric feeding solution is administered by either mute. methods: in a prospective controlled clinical trial patients were studied; all exhibited moderate degree of malnutrition, normal liver and kidneys, and a functi ning gastrointestinal tract. the patients were randomized to receive a free amino acid and small peptide diet ( patients) or an isonitrogenous isocaloric parenteral support (tpn) ( patients) (total energy: kcal, nitrogen: . g, carbohydrates: g, fat: g, n/non protein calories: / ) at least for days. results: there were no significant changes in anthropometric parameters within either group. nitrogen equilibrium was aqhieved by day in the tpn group and by day in the enteral group ( . % of the enterally fed patients and % of the tpn patients maintained in positive balance the day of the study). there were no significant changes in serum albumin within either group. serum level of transferrin reached a significant increase in both groups (p= . ). thyroxine-binding prealbnmin rose significantly in both groups as well (p= . and . respectively). statistically significant rises in lymphocyte counts (p= . and . respectively), in levels of c (p= . and . ) respectively), iga (p= . ), igg (p= . and . respectively) and igm (p= . ) occurred in either treatment group. there was a high incidence of negative skin tests at the start of the study in the enteral group ( . %) and the tpn group ( %). by the end of the study the incidence of negative responsiveness was . % and . % respectively. despite maintenance of similar glucose levels in both groups, tpn led to significantly higher serum insulin levels. the serum insulin increased almost linearly over the study period and eventually prevented fat mobilization and lipolysis, so that free fatty acid levels had fallen significantly. a significant elevation of the liver enzymes over the study period occurred in . % of the tpn group, but not in the enterany fed patients. conclusions: the present findings provide no evidence that enteral diets containing free amino acids and small peptides, as their nitrogen sources, are in any way inferior to isonitrogenous isoealoric regimes parenterally given. aim: the aim of this study is to describe and explore the expectations of the functions of the critical care nurse to enable the formulation of guidelines for the scope of practice for the critical care nurse with a south african context, methods: phase i was to determine the expectations of the critical care nurse, the nursing service managers and the doctors with regard to the functions of the critical care nurse. a focus group interview was held with a group of experts in the field of critical care. the results were used to compile a questionnaire. this questionnaire was sent to the critical care nurses, the nursing service managers and the doctors in south africa for completion. from these results the functions of the critical care nurse were determined. phase ii was to formulate guidelines for the scope of practice for the critical care nurse within a south african context. through usage of the date (phase i) the scope of practice was formulated. guidelines were formulated for the practise, education and research regarding the limitations of the professional-ethical authoration and the implementation of the scope of practice for the critical care nurse. objectives : high output gastric aspirates arc occasionally observed during fasting in critically ill paticnts, preventing any attempt of feeding via the enteral route. although these patients are often said to suffer from "gastroparesia", the motor correlates of this condition arc lurgcly unknown. in this stud?', wc recorded the gastrointestinal motility of critically ill patients with abundant (> ml/ hours) fasting gastric aspirates. methods : antral ( sites separated each other from . cm), duodenal ( site) and jejunal ( site) contractions were recorded simultaneously by ~eans of a multihimen tube assembly positioned trader fluoroscopic control (perfused catheter technique). tracings from prolonged recordings were obtained on a multichannel recorder ( a recorder, hewlett-packard) then anal) ,ed visually, with a special attention for the following abnormalities which are characteristic of intcstinal pseudoobstmctiou: l) absence or aberrant propagation of the migrating motor complex (mmc), ) presence of bursts (> min) of nonpropagated phasic pressure and ) presence of sustained (> min) uncnardinate pressure activity. patients with a volume of gastric aspirates of • (sd) [median ml/ hrs were investigated for - [median minutes. results : only one patient had no detectable motor abnormality. mmcs were either absent (n= ) or migrated abnormally (retrograde propagation : n= ; retrograde and stationnary : n= ) in pts. bursts of nonpropagated phasic pressure activity were present in the duodenum in pts and sustained uncoordinate pressure activity was found in pts. additional abnormalities included episodes of prominent pyloric activity. (n=l) and sustained antral pressure activity (n= }. conclusion : critically ill patients with large volume of gastric aspirates have manometric evidence of intestinal pseudoobstruction. prokinetic therapy in these patients should thus focus not only on enhancing gastric motility, but also on restoring a normal propagative contractile activity in the intestine. this prospective, open-label, randomized placebo-controlled study included patients with hypokalemia in whom rapid potassium replacement ( meq kci in h) was performed: patients received mg sulfate ( g in hours) and patients received a corresponding saline infusion. measurements were made at time , + , + and + hours results: k levels increased more in mg treated patients than in the patients who received saline infusion at time and h (p < . -students-newman-keuls). (table ). introduction. dual lumen uaso-gastrojcjunal tubes are a major ads'ance in nutritional therapy of mechanically ventilated critically ill patients since the " authorizc jejunal feeding with concurrent gastric decompression, there,, reducing the risk for aspiration. unfortunately, placcmem of these tubes in the jejunum regularly dictates to resort to endoscopy in order to facilitate pyloric intubation. recently, the remarkable gastrokinetic properties of the well known macrolide antibiotic er}lhromycin have been demonstrated in gastroparetic critically ill patients . aim. in the presem stu~,, we evaluated the feasibility of placing dual lumen naso-gastrojcjunal feeding tubes at the bedside without endoscopy, using edthromycin to help iranspy'loric migration of the tube under fluoroscopic control. methnd each patient admitted in our icu during a months period and requiring artificial ventilation and enteral nutrition for a period of at least days was included in the study.. after inserting the tube (stayput| sandoz, usa) in the gastric anmnn, e.rythromycin ( rag) was aduunistored intravenously, to help fluoroscopic positioning of the tube into the jejunum. the total duration of the procedure (from nasal intabatiun to jejunal placement), as well as the duration of ftuoroscopy were recorded in each patient. results. patients (male/female : / : mean age : . + . years; mean apacbell score : .t • . ) wore enrolled into the study.the procedure was performed within the dab,s following institution of mechanical ventilation. jejunal access was obtained in all patients without resort to enduscopy in , • . min.(total duration of the procedure). mean duration of fluoroscopy was . + . rain. conclusion. we conclude that placement of dual lmnen naso-gastrojejunal tubes can be obtained in mechanically ventilated critically ill patients without resort to endoscopy., provided that e rythromycin is used as gastrokinetic agent to help pyloric intubation. the following ad and dis parameters were considered in all patients: -mid arm circumference, triceps skinfold thickness, serum transferrin, albumine and lymphoeites and urinary creatinine/height index. patients whose results were bellow % of normal values in or more of the above criteria were considered undernourished (und).statistical analysis was performed using % analysis.statistical significance was established at p<o.o . results: a total of patients( female, male) -with a mortality rate (~) of , % -were studied, aged -+ years and a median ]enght of stay of days. -nourished (nou) at ad and at dis - ; ~ %; -nou at ad and und at dis - ; ) , % ; -und at ad and und at dis - ; ~ . %; -und at ad and nou at dis - ; ~ , %. we observed a p< . when we compared groups and (p= . ), and groups and (p= . ). variation in nutritional status and longht of stay: -nou at ad and nou at dis = > median lenght of stay days; und at ad and und at dis = > median lengbt of stay days; nutritional status and age at admission: -age > = years : nou ( ) , und ( ) -age < years: nou ( ), und ( ) nutritional status and age at discharge: -age > = years : nou ( ) , und ( ) -age < years: nou ( ), und ( ) we observed a p<o. when we compared groups and (p=o. ) and groups and (p = . ) conclusion: such study permits to conclude that most of our patients ( . %), staying in icu for more than days, were und, namely the elder. we observed that this kind ef patient had a longer median length of stay in icu, associated with higher mortality rate. in conclusion, the nutritional management is an essential element in suportive care of critical)y ill patients. ohiectives: sirs is associated with hypercataholisnl and resistance to nutritional support, despite raised circu&ting levels of growth hormone and insulin. serum igf- levels however are low; thercti~re rhigf-i administration might produce nsefnl anabolic effects. the pharmacokinetics of exogenously administration rhlge-i in such patients are likely to differ from that seen in the less seriously ill due to changes in circulating blood volume, increased capillary permeability, poor nutritional stares, and alterations in binding proteins. the ol jective of this study was to determine the clearance, apparent vohnne (if distribution (vd), time to peak concentration (tmax) and elimination half-like (tia) of a single subctkaneous il~ieetion of rhlgf-i in patients with sirs on the intensive care unit (icu). methods: icu patients with sirs were entered into the study, which had been approved by the ethics comjnittee. in each patient baseline hlood samples for circulating gf-i were obtained over a hour period, prior to il!iection of p.g/kg of rhlgf- subcutaneously. a further l samples were taken fi'om each subject over the next hours. circulating ige-i was measured in serum at each time point by radioimmtme assay, and the area under the curve tbllowing administration of rhlgf-i was derived tbr individual patients fixm~ baseline a~!justed igf-i levels. clearance values were caietdated by dividing the administered dose of rh[ge-[ by the total area under the etnve. vd and tv were calculated by regression analysis of the terminal part nf the log sertnn concentration time profiles. results: results are expressed as median (range). age ( - ) years, apache ii score ( - ), and length of icu stay ( - ) days. baseiine circulating igf- levels were low ( < - ) ng/ml reaching a peak of only ( < - ) ng/ml. of the patients had basal levels predmnhaantly below the inwel-limit of detection of the assay, and showed no appreciable rise in serum igf-[ levels tbllowing rhigf-i injection. parmacokinetic variables could not therefi)re be determined in these two patients. following rhlgf-i injection in the remaining patients tmax was at ( - ) hours, clearance was ( - ) ml/min, vd was . ( . - . ) l/kg, and tia . ( . - . ) honrs. conchlsions: there was marked patient wu-iability in response to rhlgf-i administration. vd was similar to that seen in poshq~erative maior surgery patients ( . vs . l/kg), but clearance was greater ( vs ml/min), tmax earlier ( vs hours) and t~a shorter ( . vs i . homts). if riaigp-i is to be administered to dtically ill patients the dose should he nlodified m the light of these findings. baekgronnd: acute bacterial endoearditis continues to be a condition with high morbidity and mortality. the majority of patients are treated with high dose antibiotics, but a patient group requires surgical treatment. methods and results: from january to march , patients underwent surgery for acute bacterial endocarditis: had native valve endocarditis and had prosthetic valve endocarditis. there were men and women. streptococcus viridans was the predominant infecting agent in native ~alve endocarditis and staphylococcus epidermidis in prosthetic valve endocarditis. progressive congestive failure, uncontrolled sepsis and peripheral emboli were the most common indication for surgery. although the mitral valve is more commonly involved in acute bacterial endocarditis, the aortic valve most often requires surgical inlervetion. the postoperative bleeding in the no-aprotinin group was + cc and in the aprotinin was :t: (p < , ). the mortality in icu was , %, the staphyloccocical endoearditis mortality was , % and the no-staphyloccocical endocarditis mortality was , % (p< , ). conclusions: the early surgery is indicated if endocarditis has no response with medical treatment. the mortality of staphyloceocical endoearditis involving left valves was higher than caused by other infecting agents. aprotinin treatment improved prosta#andin metabolism and preserved pletelet function during open heart surgery and could be useful in this type of interventions. urgent surgery had a high mortality ( %). selective digestive decontamination (sdd) has increasingly become the subject of critical discussion sine~ the development of multiresistant organisms has become an issue. moreover, a selection of gram-positive pathogens must also be taken into account when using the sdd regimen, which is primarily directed at the gramnegative bacterial specumn, with the methicillin-resistant staphylococcus aureus strains (mrsa) being of particular importance. the objective of our study was to determine the extent to which colonization with mrsa strains is promoted by sdd. method: patients (ventilation period > days) were randomized and allocated to the sdd group (n= ) or the control group (n= ). in their general intensive care theraw, there were no differences between the groups. the sdd regimen consisted of the four times daily administration of rag polymi~ mg tobramycin and mg amphotericin b in the nesc, mnoth and stomach. systemic prophylactic ~dmini~/rution of antibiotics was not part of the sdd regimen. smears were taken from the nose and the rectum twice wceldy and from the pharynx and trachea once wceldy, and tested for mrsa. further samples were taken as clinically reqnircr results: smears were examined in the sdd group. mrsa strains were detected in samples ( . %) from patients, and in patients they were detected for a period of up to weeks. the positive smears were districted as follows: tracheal / ( . %), nasal / ( . %), pharyngeal / ( . %) and rectal ( . %). severe mrsa-induced infections were observed in patients (infection rate . % of the colonized sdd patients). smears were examined in the control group. ivlrsa swains were r in samples ( . %) from patients, but only repeatedly over a period of up to days in patients. the po~tive snmars were distributed as follows: traclmal / ( . %), nasal / ( . %), pharyngeal / ( . %) and rectal / ( . %). there were no mrsa infections in the control group. conclusion: the data collected support the view that the use of sdd promotes a selection and persistence of mrsa strains. longer-term colonization with mrsa and sovere systemic inf~ons were only found in the sdd group. although the clinical and epidemiological impact of resistance develol~ng when sdd is applied ~maine unclear, this question should be given close scrutiny. tazobactam/piperacillin (taz/p p) is a new broad spectrum antibiotic, in which the acylaminopenicillin piperaeillin is protected by the betatactamase inhibitor tazobactam from hydrolization by bacterial enzymes. taz/pip has shown to possess a high antibacterial activity against almost all clinically relevant bacteria and is a registered drug in germany. obiectives: purpose of this investigation was to evaluate, whether faz/pip . g is suited for efficient antibacterial monotherapy of severe infections and what influence dosage frequency reveals on clinical efficacy. methods: hospitalized patients have been documented in this multicenter trial during a year period. as this investigation should reflect the usual clinical treatment, the only criteria for enrolment were the typical signs of infection as e.g. temperature > ~ leucocytosis or an isolated pathogen. exclusion criteria did not exist and the patients were treated in accordance to the severeness of infection, underlying diseases, risk factors etc. with taz/pip . g t.i.d, or b.i.d. results: patients suffered in most cases from infections of the lower respiratory tract (n= ), followed by intraabdominal (n= ) and skin and soft tissue infections (n= ). % of the lrtis wvre nosocomial acquired and in % the treatment was conducted as monotherapy. in % the lrti was treated with taz/pip b.i.d, and in % t.i.d. pseudomonas spp. (n= ) and staph..aureus (n= ) were the most isolated pathogens pretrcatment. the clinical response rates (cured/improved) after treatment with taz/pip . g b.i.d, and t.i.d, were % and % respectively. results for intraabdominal-and skin and soft tissue infections will be presented. conclusions: in hospitalized patients with severe infections successful treatment with taz/pip in monotherapy is possible. in this population a reduction of the dosage frequency to . g b.i.d, revealed equivalent clinical response rates. objectives. retrospective evaluation of cases of severe generalized tetanus (sgt), treated in our icu the last years. we review cases of sgt ( m, f), mean age . years. in eases the entry site of c.tetanus was a skin laceration, in case it proved to be the external genitalia, while in the rest no portal of entry could be determined. in the first cases incubation period was short ( - days) and so was the period of onset ( - days). all patients needed mechanical ventilation (range - days), initally through an orotracheal tube,and later through a tracheostomy, performed • days after admission. clinical manifestations of sgt included muscle rigidity and i generalized spasms, persisting for up to weeks in the most severe cases. significant autonomic nervous system dysfunction was present in cases occurring - days after the admission and following the time course of generalized spasm. besides general supportive measures, specific treatment included passive +active immunization, penicillin g, magnesium sulphate and sedation in a variety of regimens. neuromuscular blockade was required in cases. nosocomial infections occurred in eases, with sepsis and mof in one. average stay in the icu was - days. one patient died with severe septic complications and one was discharged with severe disability due to anoxaemie ancephalopathy, after a cardiac arrest on admission. ~ disinfectant in suspension test, without presence of organic load, disinfectants showed efficacy on lm. in the carrier test, in the presence of organic load, out of examined disinfectants did not exposed efficacy on lm. the results of examinations clearly showed that evaluation of disinfectant's efficacy partly depend on the used test method. antun basi , intensive care unit, kb firule split spin~ideva ! jugoslavia bacteremia and sepsis are frequent complications encouuntered in severe icu patients.microorganism identification with hemoculture presents the basis for adequate and successful antibiotic treatment.in many patients damage and vulnerability of the peripheral veins presents an obstacle for obtaining the blood culture from the central venous (cv) catheter sample could be also used. material and methods blood cultures were perfomed in lo patients on blood samples simultaneously obtained from the peripheral vein and cv catheter three times in a -hour period.criteria for the suspected bacteremia were body temperature above c and leucocytosis above ioooo leucocytes/dl. the site for venipuncture and the cv catheter stopcock port were cleansed with povidon iodine.after the initial ml of blood were discarded,lo ml were used for the blood culture.standard laboratory technique for blood cultures was used. results and discussion in ( %) patients hemocultures was negative at both sites,whereas in the remaining ( %) they were positive.for twentyone ( ~ of the positive patients the same results were obtained at both sites (peripheral vein and cv catheter),whereas in ( . %) patients the blood culture were positive only for the cv catheter samples.the cv catheters were in place for less than days in patients and for more than days in patients.from patients with positive blood culture from the cv catheter,one patient had the catheter for three days,whereas the other had the catheter from - o days. we neither found significant differences in hemodynamic dates : objectives: , to count and evaluate bacteria isolated from endotracheal (et) suctiori samples (with and without saline). . to establish the exogenous source(s) of pathogens isolated from carer's hands and the equipment involved in sampling in order to reduce the incidence of contamination and infection. method~: this prospective study included consecutive ventilated patients ( male and female, _ + yr; apache ii score -+ ) over a period of months. et aspirated samples with and without saline were taken daily from day of intubation until pathogen~ were presented in counts of _> per ml. at the same time, samples from both carer's hands were taken before and after et suction and a swab from the ventilator tube. results: the overall length of intubation varied between to days. bacterial transfer between staff and patients was noted in % of patients until day of intubation. there was no significant correlation between severity score and appearance of colonization. the incidence of pneumonia in studied patients was % with an overall mortality rate of %. acinetobacter anitratas (no ), staphylococcus aureus (no. ), klebsiella pna~moniae (no. ) and pscudomonas aeruginosa (no. ) isolates predominated in all our specimens. we noticed increased resistance to most antibiotics with the exception of imipenem for gram (-) bacteria and vancornycin for gram (+) bacteria. conclusions: i. tracheobronchial colonization appears directly in the maiority of intubated patients. . there is a close relationship between the microflora of personnel, patients and equipment. . bacteria transfer was noted both to and from patients. . strict hand disinfection policy remains an important measure for the proper care of mechanically ventilated patients to reduce respiratory infections. nnseeomial pneumonia is the most common nnsocomiai infection in the icu-settiag, reported in up to % of patients admitted to the icu following surgery. it is associated with significant mortality that ranges from ~ to %. enteric gram-negative bacilli have been implicated in % to % of ventilntor-associated pneumonias and pseudomonas aeruginosa accounts for % to % of these pneumonias. importantly, epidemics of/ - actamnse-pruducing enterobacter spp or klebsiella spp that are resistant to extended spectrum cephalosporins or penicillins, pose serious obstacles to effective antibiotic choices. carbapenems provide in ~tro activity against a wide range of enterobacteriaceaeand other gramnegative aerobic bacteria, except steaotrophomonns maltophilia. in vitro meropcnem is more active against pseudomonas spp than imipanem (especially p. aeruginosa and p. cepacia), imipenem and meropenem are effective against more than % of strains responsible for nnsocomial infections. all major pathogens associated with lrti are usually covered by the carbapenems, exceptions are pathogens involved in so-called atypical pneuomouia like mycoplasma, chlamydia and legionella. carbapenems are highly stable in the presence of most chromsomal and plasmid-mediated blactumases and usually offer a postantibiotie effect lasting for three hours against most of the enterubacteriaceae. reeent studies comparing imipenem/cilastatin with other ~-lactams and fluoroquinolones in severe lrti in icu patients resulted in favourable clinical cure rates and good tolerance, but development of resistance in p. aeruginosa and ;. aureus during treatment were of some concern. meropenem offers the advantage of greater stability against enzymatic degradation, so no concomitant administration of an enzyme inhibitor is necessary, and meropenem appears to be associated with a lower risk of seizures, particularly when used at high doses. results from studies with meropenem in lrti, especially in critically ill patients with acute exacerbations of chronic bronchitis, demonstrated excellent cure rates and better gastrointestinal tolerance of this new carbapenem. both earbapenems are effective candidates for use as empiric monotherapy in nosucominl infections of critically ill patients. qbl~ctives a favourable effect of iv immunoglobulins in septic surgical patients has been reported, but not sufficiently validated. we conducted this study on trauma patients to: i) investigate the effect of ivig on septic complications and il) quantify this effect by means of serum bactericidai activity (sba) assessment and iii) to explore the effect of temperature increase (from to ~ c) on the sba methods: twenty trauma patierits matched on admission for age, sex, inju~ severity score and glasgow coma scale, were allocated to receive either wig (ivig group; i patients) or equal volumes of human albumin % (control group; patients). wig (sandoglobulin) was administered in a total dose of g/kg divided in a four time regimen on days , , and post-admission. three blood collections were performe& before the first dose (day ) and hours after the third and the fourth dose (days and respectively). complement, lgg fractions, the sba at ~ and at o c and clinical parameters were recorded. results-similar lgg and igg] serum levels were found in groups ivig and control on day ( +_ vs • ns and + vs + , ns), whereas they were significantly higher (p< ) in the v g group on days ( _+_ vs + , p< ) and ( _+ vs +i , p< . ). the various complement-fractions increased in both groups without inter-group differences the mean (• sbas ( ~ c) at rain in ivig group vs control group were: - _+ vs - • ns for day , _+ vs - _+ p< for day and _+ vs - + p< for day . the mean (+sd) sbas ( ~ c) at rain presented a significant improvement over those of ~ c but for the control group remained negative a~d were respectively as following: -~ • vs - + , ns for day , +_ vs - _+ , p< . for day and _+ vs - _+ , p< . for day . the increase of temperature induced a -fold improvement of sba in iv g group and -fold ofcontrol-~oup positive blood cultures, and the product of the infectious episodes number multiplied by days of occurence, were significantly lower (p< ) in the ivig group than in the control ( vs , and vs , respectively). conclusions: our study shows a significantly favourable effect of ivig administration on septic complications and on sba of trauma patients. the increase of temperature results in a significant improvement of sba of patients that received ivig, which theoretically means a farther prevention of infection in the febrile state. pharmaceutical microbiology, university of bonn, meckanheimer aune , d- bonn, germany infectious diseases in intensive care patients are common in comparison to patients on other wards and out-patients. the main difference is that intensive care patients are much more sensitive even to less virulent bacteria. thus, the spectrum of infecting organisms is different. strains often regarded as pathogens with low virulence cause serious infections in these patients. strains such as serratia, however, have intrinsic resistance to most commonly used agents such as rd generation eephalosporins. furthermore, the common pathogens like staphylococci, psoudomonas aeruginosu, enterocneei and gram-negative bacteria, enterobacteriaeceae as well as the non-fermenters are less sensitive if isolated from intensive care patients. it is difficult to generalize on intensive care units as different patient groups are in different icus aud there are great changes from one hospital to another and from one country to another. if we take s. aurens strains from one study from the'overall resistance in intensive care units towards oftoxacin was %, whereas in other hospital wards the percentage of resistance was . %, in out-patients, however, only .$ %. the same trend was true for entercnecus faecnlis, coagulase-negntive staphylococci, and other bacteria as well as other drugs. one most striking difference was found with klebsialla pneumoniae and gantamycin resistance, which was $ times higher in intensive care units as compared with outpatients, whereas in the same species no difference was to be seen with the resistance towards carbapenems. however, differences between countries seem to be even more striking, as example gantamycin resistance and staph. anrens is given. the extreme difference is more than fold. thus, it is evident that there is a general trend towards higher resistance in intensive care units, but no generalizatiouis possible. therefore, surveillance studies in intensive care units are needed and the antibiotic policy has to be adapted to the specific needs of the unit. in the icu setting the most potent antimicrobial agents are required to address problem organisms including those resistant to penicillins, cephalosporins and aminoglycosides. carbapanems would appear to present a useful option in this setting. objectives of this study was the evaluation of systemic candid• in postoperative cardiac surgery patients (pts) with prolonged icu stay. methods: out of postoperative adults pts of mean age . + . years old, with a mean icu stay of . _+ . days, following an open heart surgery from july to april , pts ( %) remained in icu for more than days because of severe perioperative complications. patients were included in the protocol if they had clinical signs of infection or sepsis, and fungi isolated in blood culture or in culture from at least three different sites. the patients who developed systemic candidiasis received iv fluconazole ( mg/day) ( patients) or amphotericin-b for at least four weeks, and then they were closely monitored. results: out of postoperative pts with prolonged jcu stay, pts ( . %) developed systemic candid• usually after the th postoperative day. they were males and females of mean age +_ . years old. this group of pts had prolonged bypass and aortic cross-clamp time compared to control group ( min vs , and vs min). all these pts received inotropes per• (mean value= . ). during their icu stay, pts developed sepsis of bacterial origin, while the other two severe infection, and received antibiotic regimens for prolonged period. the patients were submitted to mechanical ventilation for a median period of days. the median icu and hospital stay was and days respectively. all pts have been improved and finally negative cultures were obtained. conclusions: . a significant percentage of patients who remained in the postoperative icu for more than days developed systemic candidiasis. . all patients who developed systemic candidiasis had received antibiotics because of sepsis or severe infection, for prolonged period. . fluconazole seems to be a very good alternative to amphotericin-b. . fluconazole is a safe antifungal agent with few side effects. botulism is the most severe and an odd food poisoning. although it is more commonly related to preserved meat derivatives, preserved fish and vegetables are also responsible for a number of cases. obiectives: to evaluate four familiar outbreaks of botulism . methods: we study the patients that were admitted in our hospital because of botulism from may to february . results: the thirteen pacients involved had a previous history of home preserved beans ingestion. after a -hours incubation period, gastrointestinal symptoms (abdominal pain, vomits, constipation) appeared and lead them to hospital consultation in the th to th day after ingestion. two patients died (acute respiratory failure before admission), seven were admitted in icu, two in ward and two of them were discharged from emergency room. clinical symptoms and the previous history of the ingestion established the diagnosis, that was emg confirmed. in all cases, symptoms were consistent with b-toxin botulism. b-toxin was isolated in serum and food proceeding from the third outbreak, and the serum was negative in the other ones. neurological symptoms were predominant: midriasis ( %), dry mouth ( %), dysfagia ( %), asthenia ( %), palpebral ptosis ( %), accomodation paralisis ( %) and urinary retention ( %). muscle weakness lead to acute respiratory failure in three patients (one of them required mechanical ventilation). four patiens developed infections (respiratory, urinary and phlebitis). both died patients and one another presented severe hypertension. all admitted patients were treated with polivalent anti-toxin. the two patients who underwent a more severe muscle weakness received also guanidine hydrochloride, with no answer in one case and provoquing a cholinergic crisis in the other one. icu length of stay was days. at hospital discharge, patients continued symptomatic, mainly with dry mouth, disfagia and impaired vision. conclusions: although botulism is a serious illness, the pronostic seems favorable if treatment and support measures are avaible. usually neurological symptoms we predominant and at discharge some of them could still persist. the arrow "hands-off" (aho) thermodilution catheter (tc) is completely shielded during balloon testing, preparation, and the insertion procedure. in order to assess the value of the aho thermodilution catheter in the prevention of systemic infections associated with pulmonary artery catheterization (siapa), we conducted a randomized prospective study over an -month period. methods : the patients (pts) were randomly assigned to two groups : group i for a standard tc customarily used in the department, versus group for the aho thermodilution catheter. the diagnosis of siapa was determined on the basis of a positive culture of tc and bacteremia with the same organism, with out any other nearby focus, in association with regression or disappearance of the clinical signs of infection after removal of the thermodilution catheter. results ( objectives: the mortality rate (mr) of tb requiring mechanical ventilation (mv) is high ( - %). the aim of the study was to evaluate mr, associated factors, and prognostic significance of mv and hemodynamic disorders from tb in icu in patients with tb. methods: clinical parameters on admission, and complications in icu were related by univariate analysis to icu, hospital, and month outcome. patients required mv; were immunocompromised (ic) including hiv. tb was pleuropulmonary in , disseminated in and meningeal in . results: mr was % in icu, % in hospital and % at month. / ( %) < . mortality was associated with a high saps score, initial shock, mv and nosocomial septicemia. the mr dramatically increased when ards occurred during illness, despite the lack of correlation between mr and initial po /fio ratio or initial murray score. the site of infection did not influence the mr. surprisingly, the mean therapy delay was shorter for non survivors. mr was not related to ic status, nor hivstatus, but was only related to previous steroid therapy. conclusion: mr of tb requiring icu is high ( % at month). need for mv increased mortality ( % vs %). general severity and respiratory dysfunction seem to be major prognostic factors in icu rather than tb per se or than therapy delay. in spite of the improvement in the prognosis of pneumococcal meningitis (pm) with third generation cephalosporins (tgc), this infection still presents a great mortality which could be increased with the appearance of antibiotic resistant streptococcus pneumoniae. objectives: to asses intensive care mortality and morbidity of pm and to define patients (pts) at risk of complicated evolution. patients and methods: a retrospective evaluation of pm cases (all diagnosed by csf culture) admitted in our icu from january tit march . in all pts we analized: demographic data, underlying disease, apache ii score, clinical symtomps, treatment, complications and outcome. statistical analysis was done using bmdp sofware package. results:a total f pts were studied, males; mean age , _+ ( - ); apache ii score , + , ; glasgow coma scale (gcs) at admission , _+ , ; ( %) pts suffer from cronic pathology; ( %) pts diabetes mellitus (dm), ( , %) pts had had a previous cranial traumatism. in cases the source of infection was otic and also in ( %) episodes of pm there were bacteriemia. in out of ( %) pts that ct was performed no radiologic abnormalities were shown, of them presented cerebral oedema and pts a cerebral abscess. twenty-eight percent presented seixures, % hemiparesia, , % respiratory failure, , % shock, i % renal failure, , % multiple organ failure (mof). as for treatment refers , % pts recieved only penicillin, , % pts only tcg, , % pts tcg followed by penicillin and , % pts tcg+vancomycin. seventy-five percelat of pts recieved corticosteroids and , % vasoaetive drugs. the mean icu stay was , : days ( - ). twelve ( , %) pts died, two of them presented pm relapse (resistant streptococcus pneumoniae) and another two pts developed neurological sequelae. factors associated statistically with bad prognosis were dm, the use of vasoactive drugs, shock, mof, the apache ii score at admission, the gcs at the and hours from admission in the icu but not the gcs at admission. didn't resulted statistiealy signifcative age, previous eronie pathology, seizures, baeteriemia, renal failure and coagulation disorders. conclusions: mortality was high and associated to apache ii score at admission, to gcs at and hours after admission, shock, vasoaetive drugs and mof. objectives:the aim of the study was to analyse some of significant immunologycai changes in surgical patients,requiring intensive health care,and to determinate the possibility for evaluation,dynamical examination and importance of immunologycal problems for treatment. methodes:the study concerns a number of patients with expanded surgical intervention or serious postoperative complications.the results has been carried out with fiowcytometryc analyses of lymphocytic suhpopulations and routins methods for investigation of humeral immunity.the"panel" for evaluation of (} immunologycal parameters has been offered:t-calls total/cd +/;t-helper/cd +/;t-supressor/cd +/ th/ts ratio;b-cells/cd +/;naturai kilier/nk/cells;skin test for cellular immune function;phagocytic and oxidative activity;serum levels of immunogiobulins-g ,a,m;protease inhibitors;c-reactive protein.all patients have been studied during suffering and after surgical procedures dynamicaly. results:there have been estimated significant changes in immunologycal parameters especially:decrease of t-cells: cd +mean= . %/ . %- . %/and cd +mean= . %/ % - . %/;inverted th/ts ratio ,mean=o. / . - , /;reduced or negative skin teste;reduced phagocytic and oxidative activity before septic complications. conclusions:dynamical examination of immunologycal parameters shows,that the prolonged t-total,t-helper lymphocytopenia with functional deficience of ceils-mediated immunity correlates with the stage of clinical condition of the patients and has prognostic importance.it's clear,that immunologycal monitoring gives a possibility for immunecorrection. patients (pts) with the human tmunodeficiency virus (hiv) infection have a decreased immune response and are particularly susceptible to infectious endocarditis (ie). the aim of our study was to analyze the prevalence of ie, its clinical and therapeutic implications in a hiv population we prospectively studied pts, . % ( / -group ie+) with ie during the clinical course of this disease. we analyzed the following parameters: age, gender, race, type of hiv, cdc classification, number of t and t type cell population and its ratio, therapeutic with azt, type and number of opportunist infections (inf, mycobacteriosis (mb), neoplasm's (nee) the echocardiographic parameters were lv internal diastolic and systolic diameters, lv percentage of fractional shortening, interventricular and posterior wall thickness, the degree of valvular regurgitations and the presence of pericardial effusion. el was located at the mv in . %, tv in . %, av in % and pv in . ~ and was multiple in . %. hiv el+ pts had larger lv diameters and more frequent significant valvular regurgitations ( % tr, pe %, mortality %). these two groups differed significantly in the following clinical parameters: the typical symptoms were watery diarrhea, high fever, tachycardia,luekocytopenia and oligouria within th postoperative days. the patients with mrsa enterocolitis had positive mrsa culture from the many materials except feces.mesa strains frequently had coagulase type ,enterotoxin a and toxic shock syndrome toxin- .eight of patients had postoperative organ failure.most of the mrsa strains in japan were similar in coagulase type to our hospital and our department.all of mesa strains were susceptible to vancomycin and arbekacin,tbough most of them showed resistant to many other antibiotics.we have employed guidelines for therapies such as oral or enteral administration of vancomycin and correction of the hemodynamics for dehydration and circulatory failure due to diarrhea from .futhermore we have placed colonized or infected patients in private room,worn gown and mask,and carefully washed our hands from . these countermeasures for prevention of nosocomial infections after significantly reduced the incidence of mrsa enterocolitis. conclusions:earlier diagnosis and treatment, and distric prophylactic measureres against mrsa infections are very important. -- cdo ivda leptespiresls affects all the organs with widespread hemorrhage that is more prominent in skin, mucosa, skeletat muscles, liver and kidneys. lung involvement is usually mild and less common. suli, it is very uncommon acute respiratory failure to be the pr sontirlg symptom. a case with leptosplrosl..,s which was presenting with acute respiratory failure is described. a year-old man admitted to icu becauso of fever, myaigla, aevere c~, hemopty~s. his blood gases showed: pao : mmhg with fio : . , pco : mmhg, ph: . , hco : mecl chest x-ray film demonstrated diffuse bilateral alveolar pattern occupying beth lung / ). trarmamlnase, bllllrubln, ~ and esr were elevated, wbc was . mm , platelet: . ram , hematesrlt: %, hemoglobin: .sgrldl=. there was no clinical or ecttlographlc evidence of left heart failure.patient fulfilled the criteria for diagnosis ards he was found to have an ~lutinatlon tlter for leptoq~lral antigens(indirect he~lutlnatlon atomy, ilia} very high ( / , negative<ill ) and iglm antibodies also very high (elisa, a= . , negative< . ) strongly suggesting leptospirosls. treatment with tetracycline and non-tnvaslve mechanical ventilation by nasal mask were started. pre~jre support mode and cpap was usod. the following days the clinical picture,the oxygenation and the chest x-ray of the patients were improved, and patient dl~herged from the icu. the control of leptosplremlc phase as well as his good cooperation during nipsv contributed to rapid recovery and excellent outcome in hiv infections, pneumonias (pnm), mainly due to pne~ mocystis carinii (pc) have an outstanding place in pu ! monary complications. the aim of this work was to compare two group> of patients admitted with pnm in our icu during the same period ( - ): group a, patients hiv+, and group b, patients hiv-. apache ii was identical in the groups (p=ns). group a required more often mechanical ventilation (p= ,o ), had a higher p(a-a)o (p= , ) and metabolic acidosis was more frequent (p= , ). regarding laboratorial parameters group a had a lower no. of linfocytes (p= , ), a higher ldh (p= , ) and a more marked hypoalbuminemia (p=o, ). mortality was higer in group a ( , %) than in group b ( , %), (p= , ). analysing the a group patients, we found no significant differences between alive and deceased patients, with exception for albuminemia, which was lower in the deceased patients (p= , ). in conclusion, the hiv+ patient's pnm have a more agres sive behavior when compared with community acquired hiv-patient's pnm. the prognosis was not influenced by the apache ii. perhaps other parameters such as p(a-a)o , metabolic acidosis, linfocytes, ldh and albumin shoud be more evaluated as possible predictive indices. some prognostic factors, usually accepted as predictive in the analysis of hiv+ patients do not seem to be worth in the late stages of aids, mainly when they reqquire intensive care. intensive care unit, onassis cardiac surgery center, athens, greece. objectives of this study was the comparison of two different antibiotic regimens as prophylaxis in cardiac surgery patients. methods: in a prospective randomised comparative study, two different forms of antibiotic regimens were investigated : a single dose of cefuroxime (zinacef, gr) (group a) given during the induction of anaesthesia, versus a four days combination of amoxiculine (amoxil, gr tid) plus netilmicin (netromycin, mg bid) (group b). a total of patients (pts) ( males and females, of mean age . + . years old) were included in the study over a period of one year; in group a and in the group b. patients were checked for the occurrence of infection during the first postoperative month. results: the total rate of infection in cardiac surgery pts was . %; . % in group a and . % in group b (p=ns). pts ( . %) developed infection following cabg, pts ( . %) following valve replacement and pts ( . %) after other cardiac surgery. they were males ( . %) and females ( . %). endocarditis has occurred . % in group a and . % in group b. severe wound infection was recorded in . % in group a and in . % in group b. one case of sepsis ( . %) in group a and in group b ( . %). respiratory infection occurred in pts of group a ( . %) and in pts of group b ( . %). two cases of urinary tract infection was in group a and one in group b. catheterrelated infection was occurred in ( . %) in group a and ( . %) pts in group b. pts ( . %) had fever of unclear aetiology in group b. conclusions: there was no statistically significant difference regarding the rate of infection in both groups. a single dose administration of cefuroxime is accordingly just as effective as a four days regimen of amoxicilline plus netiimicin. legionella pneumophila is a common bacteria of the environment, and it is an agent responsible for severe community acquired pneumonia (cap). we analyzed the patients with lpp admitted in our icu during the last years ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . they represented . % of cap. seven patients were males and female, with mean age . + . years. tiss was . + . and apache ii . + . . all, but patient, were under mechanical yen tilation (mv) during a mean period of . • (min-l, max- ) days. two pneumonias occurred beyond the season, while patients had an epidemiological history. only patient had no risk factor. in all the others tobacco smoking and alcohol abuse was quite frequent. diagnosis was based on serologic test and culture or direct fluorescent antibody staining of bronchial secretions. seven patients had a multisystemic disease with hepatic dysfunction in , renal failure in (due to rhabdomy~ lysis in ). one patient had a prosthetic valve endocarditis and another developped ards. nosocomial septicaemie occurred in patients. mortality rate was %. deceased patients had initially higher apache ii, (a-a) , and lower natriemia. comparing lpp with the other cap (n= ), both submitted to mv, mortality rate was similar ( , % versus . %). in conclusion lpp can occur all over the year. there was a high incidence of severe complications and outcome was similar to the other cap when requiring mv. prospective specimen brash (psb) with culture > cfu cfu/ml. broncho-alv~lat lavage (bal) ~= c'fu/rnl or positive blood culture. were excluded for rapture of treatment ; were analysed (shift with oral antibiotic : ; prohibited antibiotics associations : ; resistant germ : ). clinical data : age , • , ; saps • , ; mac cabe i : , % -ii : , % -iii : , . , % of the patients were intubated and under mechanical ventilation. the pneumoaiae were : primitive in ( , %), copd ( , %), aspiration pneumonia ( , %). germs were isolated (psb , bal , blood culture ) : s. pneumoniac ( , %), h. influeazae ( , %), sttep~:occns ( , %), saar ns ( , %), enterobaetdrindr ( , %), mosexella catarrhalis ( , %), othem . / ( , %) were sensitive to freatment. the ltentment was mg/kg/d of ampiclllin and mg/kg/d of sulbactam in continuous iv adminisu'ation during at least days. clinical eff~ienev : success ( %), failures ( %) with superinfeetion , worsening or relapse , dead , side effects . there was no difference between etiologies : primiti~;e~ , %, copd , %, aspiration pneamoniae , %. the bacteriological effieieacy was evaluated only for patients with eradication ( , %), eradication but super~ection ( , %) : with pseadomoaas a&ogiuosa , eater~ac~ ; beeteriological failure ( , %). in conclusion, the aasor ampicillin -sulbactam is effective for the i~eatment of severe acquired community pneumonise. objectives : to assess the efficacy of chlorhexidine (cl) gel or suspension applied in the nose and in the op for the prevention of the tmcheobronchial colonization. methods : thirty-seven patients expected to be intubated for > h were randomized to received topical application oga cl suspension ( %) qshrs, a cl gel ( %) q hrs or a placebo. in addition all vpts received a nasal and a op spray ( %) of either cl or placebo administrated according to the same schedule. semi-quantitative cultures of the anterior nares, the oropharynx (op) and the trachea were obtained on admission and once a day until extubation (just before the next application). the results were assessed according to the following criteria: success = no acquisition of gnb in the trachea ; failure = acquisition of gnb in the trachea. acquisition was defined by a follow-up culture positive for a gnb not present in the trachea on admission. results : success failure nosocomialpneumonia overall morality clsusp. placebo clgel placebo n= n= n= n= / / / * / / / / * / / / / / / / / / i *p = , byfisher'sexacttest conclusions : these results suggest that topical cl gel administered q hrs may prevent tracheal colonization by gnb. f. daumal*, m. daumal**, c. plot**, v. vurmmen ~ e.colpurt**, b. manonry** * hygiene hospitali&e, ** service de r enmmtion, * service des admissiens-urgeuces centre hospitalier g- ndral - saint-quentin -france obiectives: evaluate the nosocemial risk due to peripheral venous inserted short catheters, and the quality of care. patients-methods: the intensive tare unit (i.c.u.) is a beds unit. the prospective study includes all the patients comn~ in from / / to / / . the recruitemont uses an evaluation schedule of local clinical signs. the nurses aimed to create this evaluation data which includes the place of entry site, the duration of catheterization and the cause ot withdrawal. only patients staying longer than days in the i.c.u. are accounted for. the diagnosis of uosoenmial infection is assured by the physician taking care of the patient and by the hospital epidemiologist on the next signs: evident pus at the catheter entry site, positive culture of the strain, with or without the same pathogen in the blood sla'uam,the patient having no other distant source of infection. analyses were performed on epi/nfo. results: the occurrence of nosoeomjal inthrtions: i abcess and bacteremia during the first part of the study lent the medical staff to modify the protocol of insertion end survey of the device. so we analysed different periods: period ( / / to / / ) and period ( / / to / / ) for all .e peripheral catheters inserted in the i.c.u. period , % , % en infection due to peripheral venous device is a daily threat. the severity of some clinical situations requiring admission in icu proves it. the motivation of nurses for rigid adherence to established protocol, the daily survey of the entry site, the withdrawal of the peripheral catheter every hours aimed to reduce significantly the local signs of inflammation end infection of peripheral catheters inserted inside the i.c.u. objectives: to investigate the use of a new metabolic monitoring device for different ips levels by comparing oxygen consumption (vo ) to measurements of the mechanical work of breathing (web) and p . . methods: the study was approved by the institutiotml ethics committee. eight patients were investigated during weaning after prolonged mechanical ventilation ( - days) for various diagnoses when the clinical physician judged the patient to be ready fur weainag. ips was setto , , , mbar far rain periods each. all patients had a peep between - mbar.. respiratory frequency (f), tidal volume (tv), minute ventilation (ve) were read from the ventilator display ( ae, puritan bennett, carlsbad, usa). flow and airway pressure were measured at the endotracheal tube site. esophageal pressure was measured using an esophageal balloon catheter (fa. ruesch, frg). web was determined as the area subtended by the pleural-pressure-vohime curve. p . was determined by using standard occlusion technique and graphical analysis of the airway pressure tracing. vo and vco were measured using the pb metabolic monitor (puritan bennett, carlsbad, usa) connected to the pb ae ventilator. all data are given as mean• deviation for each ips level. comparison between the different ips levels was performed using anova for repeated measurements. significance was considered at p< . , compared to ips mbar. results: the values for breathing pattern, web, p . , vo and vco are given in the table for the different ips levels; significance is indicated by ~. objectives: fluidized beds are often used in the management of critically ill mechanically ventilated patients. critically ill patients are increasingly colonized with resistent pathogens [ie: p. aeruginosa, methicillinresistent s. aureus (mrsa), extended spectrum i~-iactamase producing enterobacteriaceae ] that can ultimately cause nosocomial infection. methods: we prospectively monitored bacterial colonization of mechanically ventilated patients and of the fluidized bed (clinitron) inwhich they were treated. multiple samples for quantitative bacterial cultures were taken from oropharynx, trachea, feces and bedsores. samples of ceramic beads from the bed were also taken both during and after patient stay (after bed operation in the absence of patient). re,~ults: episodes in consecutive patients (mean age: . years) were analyzed. all had bedsores and/or urinary catheters and fecal incontinence, patients had nosocomial pneumonia, had urinary tract infection [ with extended spectrum imactamase producing k/ebsie//a pneumoniae (ki~lse)], one had positive blood cultures with mrsa, and one patient had a ki~lse found in high concentrations ( - s cfu/ml) in occasions in feces. patients were heavily colonized: the , samples from ceramic beads showed no growth or became sterile without any sterilisation procedure (even in one case of presence of kf~lse) during the patient stay. conclusions: fluidized beds do not put patients at high risk of acquiring nosocomin pathogens, and cross-contamination between patients seems unlikely, even when multiple resistent organisms were initially present. the recommandation from some manufacturers to undergo extensive sterilization of fluidized beds after use does not seem warranted, at least with the bed used in this study. ant. koutsoukou, a, tahmitzi, p. kithreotis, m. koutonlidou, k. stavrakaki, kainis e, g. vlahogiorgos and e. eliopoulos icu-centre for respiratory failure -chest diseases hospital of athens. the cost-effectiveness issue is becoming vital in modern medicine and may lead to moral dilemmas since sometimes certain groups of patients may not have access to highly specialised modalifies. objective: our study compared the mean daily cost for antimicrobial medication in copd patients treated in icu versus all other patients in the context of relevant epidemiological, prognostic and outcome data. methods: age, sex apache ii score, length of icu stay (los) and in -icu fatality were retrieved from the files of all icu admissions over . mean daily cost for antimicrobial therapy per patient (dcat) was estimated. these variables were statistically compared between copd and non-copd patients. significance was assumed at p< . results: of the total admissions were fully evaluable. of them ( %) were copd patients. data (m---sd) results for statistical test are given in table i . copd patients were significantly older spent more time in the icu and presented with significantly higher apache ii scores. outcome and dcat were comparable in the two groups. objectives: the use of heat and moisture exchangers (hmes) during long term mechanical ventilation (mv) is increasing. in icu patients, they are routinely changed every day, according to the recommendations of the manufacturers, but the clinical basis for such a daily practice is lacking. we therefore prospectively assessed whether changing hmes (dar hygrobac, spa, mirandola, italy) every h only would affect their clinical and bacteriological efficiency. methods: two consecutive groups of patients requiring mv for > h were compared: group = hme replaced every day, n= episodes of mv in patients; group = hme changed every h, n= episodes in patients. tubings were not changed in the same patient during the whole length of ventilatory support. diagnosis of nosocomial pneumonia (np) was based on a positive quantitative culture (~ cfu/ml) of a protected specimen brush in patients with clinical signs of pneumonia. quantitative cultures of pharynx, trachea and y-cannector were performed every h. results: the groups were similar in terms of age, indication for and overall duration of mv ( +_ . vs +_ days, p= . ), and severity of illness (saps: --- . vs . +_ . , p= . ). the maximal values for peak airway pressure were identical in both groups ( . -+ . vs . • cmh , p= . ). obstruction of the tracheal tube was observed in only one instance in a group patient who had tracheal bleeding. circuit colonization was very rare, and of low grade in both groups. the level of patient colonization and the type of organisms were identical in both groups. more importantly, the incidence of np was the same ( / vs / , p= . ), as was duration of mv before the occurence of pneumonia ( • vs . +_ . , p= . ) and overall mortality rate ( vs , p= . ). conclusions: the clinical efficiency of this hme does not seem altered after days of use. indeed, replacing this hme every h only neither affect circuit and patient bacterial colonization nor the incidence of np. therefore, substantial savings could be obtained changing hmes every other day only. obiectives: to evaluate the usefulness of different paraclinical investigations for the diagnosis and prognosis of acute viral encephalitis in icu patients. methods: we reviewed patients (pts) admitted to our icu from july to december with the diagnosis of acute viral encephalitis. all were in coma and were initially treated as presumed herpes simplex virus (hsv) encephalitis. the causative agents were: hsv ( cases), herpes zoster varicellae ( ), measle ( ), rabies ( ), unidentified ( ). eleven pts survived and three presented neurologic sequelae. twelve pts were investigated by mri, and eleven also by spect and multi-modality eps. including brainstem auditory eps (baeps). these investigations were obtained as soon as possible following admission and were repeated during icu stay when possible. the clinical outcome was noted. results: six pts ( / ) had an abnormal mri. among them, pts made a complete recovery, in comparison with / pts with a normal mri. in one hsv infected patient, mri remained normal despite clinical deterioration and bad outcome. when repeated, mri became abnormal in cases (with poor outcome in one) and was improved in one. spect was found abnormal in / pts (among them, pts had thus a normal mr/). the correlation regarding the topography of brain lesions was poor between mri and spect. the findings of spect could not be correlated with a poor outcome. the baeps confmned in % of the pts the clinical diagnosis of brainstem involvement. changes in visual and somatosensory eps were mild in all the pts and were not helpful for the prognosis. eps were otherwise interesting for the follow-up of the coma in these sedated and ventilated pts. conclusions: the value of mri and eps for the diagnosis of acute viral encephalitis is of limited interest. spect seems to show early modifications, even in pts with a normal mri, but this test is poorly specific and does not correlate with mri changes when present. concerning the prognosis, larger studies should probably confmn that a normal mri could usually result in a good outcome. this serie illustrates also that hsv encephalitis could be demonstrated only in a small number of cases and that the prognosis of non hsv encephalitis is not easily assessed. objectives: to study the influence of gram (-) bacterial lung infections on liver function i~ mv icu pts. pts and methods: we studied pts, # ( , %), ( , %). hean age: , • years ( - ). mean stay in icu: , • days ( - ). they were divided in groups: a( pts) who did not suffer from pneumonia and b ( pts) who developed a gram(-) bacterial pneumonia. both groups were consisted of pts with same age, sex and disease distribution and same systemic failures. we measured sgot, sgpt, total bilirubin(tb), direct bilirubin (db), alk.phosphatase (al.ph.), v-gt and albumin (alb.) times: on days o, and of the pneumonia for group b and respectively for g~oup a. conclusions: ) in elderly intubated pts of an icu, kp is isolated more frequently than in icu pts< years (p<o, ). ) the frequency of isolation of kp in icu pts during - was - %, but now ( - ) kp becomes more and more rare ( - %) and is isolated especially in elderly pts. ) its sensibility to antibiotics remains always the same. ) the prognosis of np in our study was independent from age (p<o, ), sex, presence of bacteremia (p< , ) and type of invading microorganism. gram neg bacteria and renal failure (rf) from aminoglycoside toxicity are common and serious complications in critically ill patients. the aim of this prospective, pilot study was to compare the safety and adequancy of the endotrecheal (et) vs the intravenous (iv) administration of aminoglycosides. were measured in the plasma and the bronchial secretions at and hours after the iv (bolus) or the et (nebulized) administration of mg of gm in seven criticcally ill patients ( with established renal failure). safety was defined as peak and trough plasma gm levels _< than and ijg/ml respectively and adequancy as gm levels in bronchial secretions _> , ijg/ml. results: gentamicin was administered by the et and iv routes in and separate sessions respectively. a total of samples were assayed, in bronchial secretions (bs) and in serum. the et route resulted in higher gm levels in the bronchial secretions compared to the iv route ( , + , vs , _+ , pg/ml respectively, p = ns ). adequate bronchial gm levels were achieved in % of patients after et administration, compared to % after iv aaministretion. the blood levels of gm were significahtly lower after the et vs the iv route ( , + , vs , • , pg/ml respectively, p _< . ). the et administration resulted in toxic bronchia~ gm levels in % of the specimens. % of these samples were from patients with renal failure, however toxic blood levels were reached in only % of these. gentamicin seems to be a safe and adequate alternative route of treatment for the lrti. however, in patients with renal failure the et administration of the aminoglycosides should also be modified and continuously monitored. in order to evaluate the pathogenic role of anaerobes in nosocomial pneumonia (np), we investigated the systemic humoral response in patients who developed a np with anaerobic bacteria, especially prevotella species. methods: blood samples from groups of patients were tested. group i: patients with a np in which prevotella spp. was isolated from protected specimen brush (psb), group ih a control group of patients with a np without anaerobic bacteria, group ill: a control group of patients with dental stumps but without pulmonary infection, group iv: a control group of healthy voluntary people with prevotella spp. isolated from the dental plaque. an elisa was used to evaluate the total antibodies level against a mixture of four prevotella strains and a western-blot method was done to identify the antigenic proteins. results: data are expressed as means .+ sd. the antibody levels in patients of group i ( • was statistically higher (p=o.o ) than in the control groups (respectively: + , _+ , _+ ). using western-blot method, the intensity of the response was roughly superposable to levels obtained by elisa and the profiles were different according to the prevotella species. the occurence of a np with anaerobic bacteria (prevotella species) isolated from psb leads to an antibody response which seems specific of the prevotella species isolated. fever is common in the intensive care unit, but is not always related to an infection. we sought to define the epidemiology of febrile patients in a general medical/surgical icu. methods: we prospectively analysed the source of fever (t > . ~ c) in all adult patients admitted for >- hours in the icu during a two month period. these patients were studied for consecutive days. and werc classified in groups according to the evidence of infection (center for disease control criteria) after complete evaluation: documented infection: cdc criteria + isolation of pathogen (d); possible infectron: cdc criteria without isolation of pathogen (p); unlikely infection: patients who did nol meet the cdc criteria (u). results: of a total of patients studied, dec'eloped fever ( %). including (after complete evaluation) d, p and u palients. both the highest temperature in tile first day of fever and the maximal temperature were higher in d than in u ( . • versus . • and . -~ . ~ versus . - . , respectively p= . and p= . ). most common sources of infection in d were the lungs in patients ( %) and urina .ry tract in ( %). of these patients had positive blood cultures ( %). the overall mortality was % ( % in d, % in p and % in u. differences ns). antibiotics were given in % of d, % of p and % of u ( patients). in p there was a non significant lower mortality." in patients who received antibiotics ( / ( %) versus / ( %) patients, respectively). conclusions: in febrile icu patients both the highest first day" temperaturc and maximal temperature are significantly higher in infected than in non infected patients, but the differences are too small to be useful clinicall). mortality rate is not significantly influenced either by the presence of an infection or by the administration of antibiotics, obiective: retrospective study to determine the influence of candida infection on icu outcome. methods: patieet with a stay of more than days in inteaasive care were screened for candida infection. patients were treated with antifungal therapy due to either an increased antigen titre of -> : or clinical evidence of candida colonization. serological candida-antigens (ramco, pastorex) and antibody titres (hemagglutination, lgg-, igm-elisa) were examined routinely. seroconversion was defined as a threefold increase of antibody titre or a titre of : or higher. results: the median length of stay was (ranging from to ) days, the mean apache ii score on admission was (+_ . sd) points. of patients patients died ( . %). in the group treated with antifungnls ( patients) patients died ( . %). although of the patients only ( . %) developed a candida infection as defined above the mortality in the group that showed signs of infection was significantly higher ( . % vs. . %, p < . [chi-square-test]). in patients an antigen concentration-> : was measured. seroconversion was found in patients. the most common fungus was candida albicans ( . %). furtberm re, candida glabrata was found in . %. most of the patients were treated with x mg fluconazole ( patients). in patients therapy was changed to amphotericin b/flucytosine. in patients therapy was started with amphotericine b and flucytosine. in patients a threefold decrease of candida antigen titre was found. patients showed a decrease of candida antibody titre. conclusions: meticulous screening for eandida infection seems to be necessary since the number of patients with fatal outcome is significantly higher in the group with signs of fungal infections and thus requires immediate antifungal treatment. objective: early diagnosis of patients with ventilator-associated pneumonia (vap), and subsequent identification of causative microorganism, and selection of the appropriate therapy are critical important points that affect morbidity and mortality. the results of the quantitative bacterial cultures are not available for at least hours, while a two hours period, since the specimen are obtained is enough to know the gram stain results. the aim of this study is to determine the usefulness of gram stain in specimens obtained by bronchoaiveelar lavage (bal), through the bronchoscope. material and methods: we studied patients ( males and females, age + ) with suspected ventilator-associated pneumonia. the bal gram stain was considered positive when the specimen after a centrifugation at rpm for min revealed: i) more than leukocytes per optic field, ii) squamous epithelial cell less than percent and iii) one or more microorganisms per optic field on magnification. all patients had been receiving antibiotics, with no change during the last days, prior to bronchoscopy. results: patients had vap and patients did not. in cases the bal specimens (quantitative bacterial cultures) established the diagnosis of vap in the remaining three patients the vap diagnosis was established by other procedures (blood or pleural fluid culture, clinical outcome, autopsy). apache fl score in patients with vap was , -+ , , while in patients without vap was , + , . there was a significantly higher incidence of vap in patients who had i) coma (gcs < ) and ii) been receiving neuromuscular blockade (p< . ) . the sensitivity of the gram stain for vap diagnosis was %, the specificity , %, the positive predictive value %, and the negative predictive value , %. conclusion: our data indicate that the gram stain of bal specimens is useful for the early diagnosis of vap and the subsequent administration of the appropriate treatment. the role of anaerobes in mechanically ventilated patients with pneumonia (mvp) have been poorly investigated aim of the study : analyse the prevalence of anaerobic isolation in mvp. methods : between october and february all suspected mvp were investigated using protected specimen brush (psb) technique. brushes were rapidly transported in shaedler broth to laboratory. a special care was tooken for anaerobic isolation. results : among the psb performed for suspected mvp ( nosocomial and community-acquired pneumonia), yielded at least one micro-organism (positive psb : %). of positive psb demonstrated only aerobic bacteria and ( %) yielded with anaerobes. in out patients, anaerobes were associated with aerobic bacteria. anaerobes were mostly isolated in nosocomial pneumonia ( / positive psb). strains of anaerobes were isolated. prevotella species represent out these strains ( %) the most frequent anaerobic species were prevotella oralis ( ) p. intermedia ( ) and p. buccae ( ). comments:using adequate methods, anaerobic bacteria are frequently isolated in mvp. it could be off importance to take in account anaerobes in the choice of empirical antibiotic therapy in mvp. objectives: the majority of patients with multiple trauma are considered immunocompromised. the aim of this study was to identify risk factors of pneumonia in mechanically ventilated patients with multiple trauma or after surgery. methods: in this prospective study we studied multi-trauma patients (mean age + years, apache ii . + ), admitted to a general intensive care unit (icu). all patients were intubated and mechanically ventilated. we were considered that a patient had ventilator associated pneumonia (vap) when the specimens of bronchoalveolar lavage (bal) or protected specimen brush (psi?,), ebb'ned through the bronchoscope, had one or more microorganisms in concentrations greater than and cfu/ml respectively. all patients had been receiving antibiotics, with no change during the last days, prior to bronchoscopy. results: patients had vap, and patients didn't. in the bivariate analysis, the glasgow coma scale (gcs)< (x = . , p< . ), the administration of neuromuscular blockade (x = . , p< . ), the duration of mechanical ventilation to be greater than days (x = . , p< . ), the flail chest (x = . , p< . ), the parenteral nutrition (x = . , p< . ), the ards (x = . , p< . ), the abbreviated injury scale (ais) of more than for thorax (:,: = . , p< . ), the pneumothorax (x = . , p< . ) were statistically significant related to development of vap. in multivariate regression analysis, using the stepwise technique, three of the seventeen studied factors showed to have an indepantent association with the development of vap:the administration of neuromuscular blockade (f: . , p< . ), flail chest (f: . , p= . ), and gcs (< ) (f: . , p= . ). conclusions: in patients admitted to icu for multiple trauma or major surgery, the administration of neuromuscular blockade, the flail chest, and the gcs (< ), in the population under study, were the indepedent risk factors for vap. mof is a sereous complication of differem states: infection, sterile inflamation, extensive fissure injure, intoxication, ets. there is close correlation between extension of mof and death, developement of nasocomial infection. immunologic disfunction. in order to prgnose probability of risk of mof development among the patients with sepsis and septic shock, we achived an eqation, allowing to recive a coeficient, closely connected with this probabiliti. we have used retrospective analisis of cases of sepsis. diagnosis of sepsis was based according to bone's criterions of sepsis. mof was assessed as disfunction of or more systems according to bone's classification of mof. having used correlation analisis we have estimated factors which have had high correlation coeficient with the probability of development of mof. there were: apache-ii score points, evidenceof septic shock, endocrinopathy. with the help of multyple regression analisis we acheved next equation: y= , + , x~ + , x + , x , were x i-apache-ii score points, x -evidence of septic shock, x -endocrinopathy. the explanatory power of this quation was evidenced by roc of . , se (v - . introduction: the presence of liver dysfunction in the process of multiple organ failure is associated with an adverse outcome, particularly when it becomes progressive to liver failure. disturbances of liver function may occur early and their detection may be of significant importance for the further development of organ failure. routinely used liver function tests appear to be inconsistent indicators of hepatic damage. in this study, we used p_lasma disappearance rate (pdr) of indocyanin-green dye (icg) as an early estimate of liver function. methods: we serially evaluated pdr and routine liver function tests (serum bilirubin, sgot, sgpt), as well as acute phase and non-acute phase proteins (crp, transferrin) in patients during the first week after trauma or the onset of sepsis. patients: group : (n = ) multiple trauma iss > , group : (n = ): abdominal sepsis, acute necrotizing pancreatitis (anp) grade iii. patients were selected on the basis of clin cal estimates that these patients would require continued icu observation. pdr was determined by means of a fiberoptic catheter and a computerized system (cold z- , pulsion), which permits repeated bedside measurements. the initial values of pdr, serum bilirubin and transaminases were not significantly different in trauma, sepsis and anp. in trauma patients pdr improved during the first week. in patients with sepsis and anp pdr remained low and worsened with time. the decrease in pdr preceeded an increase in biochemical liver function tests in these patients. + . &-_ ( - ) discussion: routinely available blood tests of liver function are usually altered several days after injury. however, they are generally non-specific indicators and they are influenced by extrahepatic factors. pdr seems to be useful to evaluate impaired liver function early after the onset of sepsis and trauma. objectives: to study frequency of organ system failure (osf) and it's influence on outcome in granulocytopenic patients with hematological malignancies and septic shock(ss). materials and method: retrospective review of medical records of granulocytopenie(wbc< , xl ) patients with hematological malignancies and ss, who were admitted to the intensive care unit (icu). frequency of osf before and after ss was analysed. the patisnts were categorised on survival and non-survival. results: signs of osf were observed in . % of patients before ss and in all patients after ss. only patients presented with hypotension refractory to inotropic therapy. nevertheless there was a significant increase of frequency of acute respiratory failure (arf), acute renal failure (arenf) and liver injury (li) after ss occurred(showed on the figure). only frequency of organ failure before and after objectives: statusmetria allows to define the effective level of oxygen status and accordance to it means of carbon dioxide and elec-trolyte in critical care. the conception of syndrome int~ive care (sic) is exhausted itself and invariable outcomes of sic of multiergan system failure (mosf) confirms that. therefore, an alternative to sic should be advanced. methods: efficlenoy of treatment has been asscsaed in patients with mosf using value of metabolic rate and ability of an organism to cover it by oxygen and substrate supply. oxygen pulse (op) and index of efficacy of oxygen transport (ieto ) was monitored. ~lt~.lntenaive care is considered to be homeostasis-securing therapy (hst) if energostructure deficit is eliminated and necessary for recovery regeneration rate is .restored. op in patients with mosf was . mt-m " , and le,~ and ie'i~ w~ . units in sic. we managed to maintain op of . - . ml.m " and ieto of . - . units in hst. patients from with mosf survived in sic and patients from survived in hst. efficiency of hst appeared to be two times as much as efficiency of sic. cr of homeostasia-se-'uring therapy is advancing. the conception provides restoration of regeneration rate due to effective then in sic elimination of en=gostructure deficit. the conception may be a basis of new technology for treatment of mosf. helen f goode phd, nigel r webster phd. anaesthesia & intensive care, university of aberdeen, ab zd, uk. objectives: xanthine dehydmgenase is converted under conditions of ischemia, reperfusion and endothelial damage to xanthine oxidase, with superoxide anion as a co-product of its catalytic activity. multiorgan dysfunction syndrome is associated with splanchnic vasoconstriction resulting in significant and prolonged gut ischaemia. aggressive volume resuscitation with prompt restoration of blood flow results in reperfusion of the tissue and is likely to cause xanthine oxidase-mediated release of oxygen-derived radicals. this study investigates xanthine oxidase activation and oxygen-derived free radical-mediated damage in such patients. methods: fourteen consecutive patients on itu who met established criteria for septic shock and secondary organ dysfunction were studied. serum xanthine oxidase activity was measured using oxidation of a chromagen in a dual enzyme system and plasma malondialdehyde was measured using a specific spectrephctometdc assay. apache ii scores, blood pressure, svr, cardiac output and day survival were also recorded. biochemical data were compared with results from healthy subjects. results: xanthine oxidase activity was . + . units/i in patients (mean :t: sem) and . + . units/i in controls (p<o. , mann whitney u test), and was highest in the patients who survived (p< . ). malondialdehyde concentrations were elevated ( . • . prnol/i compared with . • . pmol/i in controls, p< . ). xanthine oxidase activity did not relate to apache score or any of the cardiovascular parameters recorded, and was not influenced by the degree of organ dysfunction. conclusions: patients with sepsis and secondary organ dysfunction have xanthine oxidase activation and evidence of free radical damage. the finding that activity was highest in those patients who survived suggests that reperfusion was incomplete in patients who died, with decreased tissue xanthine oxidase ~tash out' into the circulation. influence objective : evaluation of the feasibility of measuring the intragastrie partial pr~sure of carbon dioxide (pco ) using a chemilumin~nt optode and fibre~ptics originally developed for intrav~cular blood gas monitorlng(p ) methods the pco electrode w~ calibrated i~-vitro according to the m~ufaeturers instructions the sensor w~ then stripped of its outer c~ing and threaded down the pile tube of a g~ c enema e (gt) so ha he ens ng portion sat well within the balloon. the modified gt was inserted n~og~trically after induction of anesthesia in ten patients undergoing c~diopuimonary byp~s throughout results: according to the datas of integral rheography % of patients were revealed to have hypodynamic type of blood circulation (cardiac output was decreased on - % and general peripheral resistance increased on - %). it was effective to use complamin (xantinoli nicotinas) in the complex therapy of su~h patients. the dosage was - mg/kg during - days. as a result of such therapy was also the oliguric stage shortening (ac n ).in , % of the cases unsatisfactory datas of central hemodynamic,combined with high (more than cm h ) venous pressure,lung oedema.then nanipruss ( , - , mkg/kg/min) was succesfutly used in complex with routine therapy.in the patients with low cardiac output and low general peripheral resistance mesaton ( , - , mg/kg) and dopamine ( - mkg/kg/min) were effective.change for the worse in the hemodynamics datas, inspire of therapy during - days,was prognostically unfavourable. conclusions:we consider early diagnostic of hemodynamic disorders and adequate correction of them is one of the most important factors, determined the outcome and prognosis in arf patients. obiective: to evaluate the results of renal replacement therapy (rrt) in surgical icu patients with acute renal failure (arf). arf in icu patients is associated with high mortality rates. we investigated the relation between mortality and organ failure in different categories of surgical icu patients receiving renal replacement therapy (rrt) for arf. methods: the records of surgical icu patients with arf requiring rri-(haemodialysis or cavhd) were examined. five different patient categories were defined; .ruptured aneurysm of the abdominal aorta (raaa) n = .elective vascular surgery (evs) n = .abdominal sepsis n - .trauma n = .others ( e.g. malignancy, obstetric emergencies) n- seven organ systems (cns,circulatory,respiratory,hepatic,renal,digestive,haematologic) were scored for possible failure using the mof score. results: mortality was as follows: all patients % , group % , group % , group % , group % , group % . mortality increased with the number of failing organ systems; mortality for all patients with > failing organsysterns was % the only exception being the subgroup of trauma patients where mortality under these circumstances was o% conclusions: mortality in surgical icu patients receiving rrt for arf is high. no significant difference in mortality is found between raaa and evs. mortality increases with the number of failing organ systems. the subgroup trauma patients shows a lower mortality compared to the group as a whole, even with > failing organ systems. to look for the most accurate scoring system to measure the severity of the complications occuring in the early phase ( first day) of kidney transplantation and to asses their prognostic value. methods: in our retrospective study we applied the apache li and the goris scoring system for the kidney recipients who developed multiple organ failure (mof) as a consequence of their pulmonary and. cardiovascular complications following kidney transplantation. we evaluated the recipients the distribution of the women and men ( % ~ % ) was the same as in the kidney recipients. applying the apache ii system most of the patients had their score between and , and the function of , or organs were affected at the time of the onset of mof. the apache ii system gave adequeate information about the disturbance of the function of other organs beside the kidney failure even at the time of the transplantation. the scores and the number of the affected organs correlated with the condition of the patients in the goris scoring system but not as sensitively as in the apache ii scoring system. conclusions: both the goris and the apache ii scoring system can be applied to measure the severity of the multiple organ failure occuring during the early phase of kidney transplantation. however the apache ii system is more suitable to follow not only the stateof the patients at the time of the admission but also the changes occuring in their condition during the complication. v.v.erofeev, v.v.ivleva scientific research institute for general reanimatulogy russian amsci, moscow, russia objectives: the analysis of ssc and results of their treatment in patients following critical states showed the necessity of developing a combined antibacterial therapy. methods: according to the protocol patients ( - years old) with combined trauma and massive hemorrhagy following vast aml traumatic operations were examined. microflora's composition and resistence to up-to-date antibiotics was studied using the anaiyser iems reader by "labsisteme"(finland). general clinical, bacteriological, immunological indices, as weil as the duration of the treatment and recovering rate served as criteria of the combined antibacterial therapy effectiveness. results: it was proved expedient to administer antibiotics in staphylococcus infection in the following combinations: riphampizin with fluoroquinolones; i-ii degeneration, cephalosporins with aminoglycosides; cephalosporins with fluoroquinolones. in case of singling out the exciters of the euterobacteriaceae family, including the pseudomonas aereginosa, -fluoroquinolones combined with modern amynoglycosides; fluuroquinolones with ureidopenicillines; ureidopenicillines with amynoglycosides; amynoglycosides with the ii-iii generation cephalosporins; cephalosporins with fluoroquinolones. in severe ssc caused by combined infection (including anaerobes) clindamicin with modern amynoglycosides was prescribed. conclusion: the combined antibacterial therapy allows: ) to increase the effect on microbic agents and the efficacy of treatment in combined infections; ) to lessen the possibility of the exciters'resistence to antibiotics; ) to prevent the development of superinfection: ) to decrease the doses of medicine and its toxic effect. objectives: two methods of blood volume measurement in a group of critically ill patients were compared to investigate the practical possibilities of a new easy to use method based on carbon monoxide (co) uptake. methods: all patients had multi-organ failure and haemodynamic monitoring with a swan-ganz catheter. mean apache ii score was ( - ). when indicated, patients had blood volume measurements simultaneously based on the techniques of, i) dilution of ~cr labelled red cells, and ii) inhalation of carbon monoxide gas with measurement of the rise of carboxyhaemoglobin produced. the co was administered via a newly designed, ventilator driven, fully closed circle system ensuring co retention and co removal with automatic addition of oxygen to m}ttch patient uptake. a portable computer performed all necessary calculations. results: volumes obtained by co uptake were compared with the "gold standard" radiolabelling method. mean blood volume determined by the co method was ml ( - ml) compared with ml( - ml) with slcr labelled red cells (r= . ). regression analysis produced an intercept at ml. the slope of the regression line was . ( . - . , % confidence limits). discussion: the co method produces volumes in excess of the radiolabelling method. there appears to be a systematic error, and one possible explanation is co binding to substances other than haemoglobin. conclusion: the co method is easier to use than radiolabelling and of the lower cost, since cohb measurement only is required. aceuraey is sufficient for clinical use and our preliminary findings suggest this system will meet the requirements. objectives: this study was conducted to determine the role of nitric oxide (no) in the pathophysiologic alterations and multiple organ damage, and the possible effects of " " " (l-n -monomethyl-l-arglnlne nmma) on hemodynamics and mortality in rats caused by a prolonged hypovolemic insult. methods: a prolonged hemorrhagic shock ( - mmhg for rain) was induced in anesthetized rats followed by adequate resuscitation. l-nmma was administered intravenously at doses of . mg/kg or . mg/kg at the end of resuscitation. results: infusion of . mg/kg l-nmma diminished the fall in mean arterial pressure, significantly increased the cardiac index (ci) and stroke volume (sv), together with remarkable protection from multiple organ damage compared to the controls. the h survival rate was significantly improved from . % in the control group to . % in the treatment group (p< . ). in contrast, the high dose of . mg/kg l-nmma resulted in a strong blood pressure response but a marked reduction in ci and sv concomitant with an increased total peripheral resistance index within the observation period, and caused severe damage to various organs at h after treatment. in addition, marked elevation in both endotoxin and tnf levels were observed in animals subjected to shock insult. conclusions: these results suggest that no induced by hemorrhagic shock in rats is an important mediator for pathophysiologic alterations associating with cardiovascular abnormalities, multiple organ dysfunction, and even lethality. thus, regulation of no generation and use of no inhibitors might provide new aspects in the treatment of hemorrhage related disorders, and the use of l-nmma would be either deleterious or salutary in a dose dependent manner. (hebert, chest- ) . the purpose of this study was to assess the risk factors for hepatic dysfunction in mosf. methods: patients have been hospitalized in our icu from january to may . , ( %) with mosf. among mosf pati~ts, ( %) have had hepatic dysfunction defined according to hebert (bilirubin ~ ttmop , chest ). thirty six of these patients acquired hepatic dysfunction after admission in the icu. these patients were compared with mosf patients without hepatic dysfunction selected blindly. chrorfic diseases, severity scores, eanse of admission, clinico-biologieal and hemodyunrrfic parameters, use of vesopressors, use of hepaiotoxic drugs, use of nutritional support and mortality were compared for hepatic failare and non hepatic failure groups.twenty nine patients had postmortem hepatic histologic examination, results: univaciate analysis: only parameters with p _< . are pre~nted. including these paramet~'rs in a multivariate analysis, anly c~hosis and vascular surgery remain independent risk factors for hepatic dysfunction. in particular, pao /fio , arterial lactate, do were not different between the two groups, some de~'ee of histological abnormalities was found in all liver samples, despite a normal bilirubin level in % of the cases conclusions: in our patients, conu'ary to previous studies, hypoxic and hemody~anfic parameters were not independent risk factors for hepatic dysfantion. this might be due to the inadequacy of the usual biologic definition of hepatic dysfunction as well as to the poor sensitivity of general hamodynamic parameters. critical states of various origin are complicated with the mldtiorgan farm (moi~ oceuzr~ce. due to their and functional features the lungs become the primmy damage target in various critical.states. ard that occurs in such states is associated with pulmonary edema development because of capillary permeability increase mediated by humeral and cenular responses to amag/~ factors exposure. r nmst be emphasized that mediators and effecto~rs of this respo~e affect not only puknonary capillaries, but other organs capiu~es as wellenhancing their permeability. orsans edema is a conmm~ finding at the autopsy of patients died from mof.clinical and radiolosial findings allow to have a diagnosis of pulmonmy edema before ~mi!ar lesions in other organs occm. additionally, there are some techniques that permit quantitative assessment of pulmonary edema flv.id (evlw) volume. in conclusion, we suggest that evlw changes in .dyn~rmcs in patients with mof are considered as a critical state severity measure which reflects indirectly the edema in other organs. objectives: we compared three different dialysis membranes to find out whether or not there were differences between their clearance characteristics on substances such as inuline, creatinine, urea, and phosphate to be eliminated in acute renal failure (arf). moreover, if a loss of clearance did occur we were interested in whether this was due to heparinization and a high production of the thrombine-anti-thrombine-complex (tat). methods: we carried out a randomized controlled study on consecutive critically ill patients presenting with arf, most of them in association with multi-organ failure, to be treated by continuous pump-driven arterio-venous renal replacement therapy on continuous low-dose heparinization. three different types of high-flux filter membranes (f tm [fresenius] , ct tm [baxter] , and filtra tm [hospal]) were assessed. each filter was changed intentionally after a hours" use. together the data of filters were evaluated, each at three different times (immediately after its onset [ hi, after h, and after h). the clearances of creatinine, urea, phosphate, and inuline were measured. results: there were some significant differences in clearance characteristics of inuline, creatinine, urea and phosphate between the filters (p< , ) showing the f tm membrane excelling filtra mand ct tm the more. the loss of inuline clearance ( mi/min/m ) after h, however, was insignificant for all filter types. a continuous low-dose heparinization scheme was applied without any relevant prolongation of the aptt. even lower losses were noted for the clearances of creatinine, urea, and phosphate. we found the tat-producfion increased after h (p< , ), but it did not rise any further. conclusions: as we could demonstrate in our study the clearance data of different types of filter membranes applied during continuous renal replacement therapy do show significant differences. on the other side, no relevant loss of clearance occurs during a hours" period indicating a high efficiency over time. to consider commercial aspects as well it shows that inexpensive conventional filter membranes can successfully be applied even for a longer renal replacement period, if needed. a retrospective study was performed on patients with acute renal failure (arf). we analysed survival in continuous (cd) and intermittent dialysis (hi)). mean age of the patients was years (y), patients ( % ) were < y, patients ( %) were >= y. the incidence of dialysed arf in our mixed intensive care departement is %/admission/y. statistics: fischer's exact test, mann-whitney-u test. efioloev: the contribution sepsis, cardiac failure and aminnglycosidcs was respectively %, % and %. treatment: cavh (cd) or cvvh (cd) was used in patients ( %), hemedialysis (hd) was used in patients ( %). data: mean apache scores were the same for cd and hd ( for both groups), patients treated with continuous dialysis techniques had significantly (p<o, ) more need for ventilation ( % vs %), elevated bilirubin ( % vs %) and a higher vasopresser need ( % vs %@ than patients treated with hemedialysis. there was a trend towards more sepsis ( % vs %; p= . ) mad coaguiation disorders ( % vs %; p= . ) in cd. taere were sign/ficantly more younger patients (< y) treated with cd ( % vs %, p< .os). mean apache score was significantly lower in patiants< y than as patienta>= y ( vs ; p< . ). patients< y had significantly (i}< . ) more coagulation disorders ( % vs %) and elevated bilirabin ( % vs %). there was no significant difference in vasopressur need and ventihatio~ between age groups. outcome:. hi) had a better sr compared to cd ( % vs ~ p< . ). patiants>= y had a comparable sr vs patients< y ( ") */e vs %; p----a.s.). tha global survival rate (sr) was % ( patients). conclusions : diaiysed arf has a well known lowsurvival rate ( %): hc~raedialysed patients had a better survival rate than patients treated with continuous dialysis. this can be explained by the fact that the latter were in a worse condition considering organ failure (more vantilatian, elevated bflirubin and need for vasepressurs), apache score couldn't illustrate that. patient~ y with arf have the same survival rate as patients< y: although patients >=- y have a higher apache score they have less organ faille. the avacbe score is not a good oredictor of survival in p with organ failure. departments of surgery and intensive care, guy's hospital, london, u.g-obiectives: a randomised controlled trial of a management protocol utilising the regular measurement of gastric intramucosal ph (phim) to control the administration of dopexamine. methods: patients admitted to a multidisciplinary teaching hospital intensive care unit (icu) undergoing insertion of a pulmonary artery catheter were managed according to a resuscitation protocol. randomisation was to either the protocol alone or to insertion of a nasogastric tonometer and subsequent management guided by phim. phim < . initiated volume and inotrope resuscitation and, if unsuccessful in elevating phim, dopexamine was commenced. approval was obtained from the hospital ethics committee. results: patients were considered for analysis and the two groups were well matched for age and sex. overall, there was a high hospital mortality of . %. there was no difference in icu or hospital mortality between the two groups (see table) . objectives: to compare cardiac output (co) measurements between continuous termodilution (cco) by thermal wire on pulmonary artery catheter (cco/svo vigilance. baxter critical care), and co measurement using a trans-esophageal doppler (dco) ultrasound system (odm ii, abbott laboratories), in the immediate postoperative period of cardiac surgery. methods: patients undergoing myocardial revascularization were monitored with cco by a swan-ganz catheter and an intra-esophageal dco probe, after induction of anesthesia. exclusion criteria were: aortic valve disfunction, previous valvular surgery esophageal disease, absense of sinus cardiac rhythm, and need of ventricular or intraaortic assistance. hemodynamic parameters, co by both cco and dco, svo . sao , diuresis, pha, and hemoglobin were repeatedly registered during the first hours after surgery, as the patients were kept under sedation and mechanical ventilation. results were compared using the method described by bland and altman. results: measurements of co were obtained, ranging . objectives: a decreased tissue oxygen delivery is responsible for a higher morbi-mortality rate among surgical patients; this diminished oxygen delivery/consumption rate (dojvo ) may origin the lactic acidosis observed in the gastrointestinal tract, reported in patients undergoing hypothermic cardiopulmonary extra corporeal surgery, and can be registered by tonometry as result of the gastric mucose ph. the purpose of this study is to evaluate the reliability of the intramucosal ph (phi) measurement by a nasogastric catheter as indicator of the do /vo > its co> relation to other parameters of do /vo disturbance, and with postoperative complications and clinical course. methods: patients ( male, female) undergoing cardiac surgical procedures were included ( myocardiai revascularizations, valvular substitutions, constrictive pericarditis). mean age was + years, mean weight _+ kg. a nasogastric probe (trie tonometrics) was placed after anesthesia induction; phi values were registered in the postoperative period ( ', ', ", ' and h after surgery end). the corresponding hemodynamic parameters, venous oxygen saturation (svo ), diuresis and arterial ph (pha) were also recorded. results: phi values ranged . to . (mean . ( . ); the mean values of clinical evolution were: extubation time, _+ hr.; discharge from postoperative care unit, - hr.; and hospital total postoperative time, _+ . days. complications registered were: perioperative acute myocardial infarctions, cases of respiratory insufficiency, occlusion of coronary bypass, an ease of hyperamilasemia. all patients with severe complications needing specific treatment showed either a low phi value, or a considerable descent in comparison with the initial register. statistic correlation between low phi and presence of complications was found; the low significance (p > . ) degree may be due to the low population size. conclusions: phi measurement in cardiac surgery patients is a non invasive, uncomplicated method for prediction of doz/vo disturbances, thus reflecting risk of increased major complications, and may precede changes in other usual indicators (svo , pha, cardiac output, ...). work-in-progress with a greater population size may offer more significant results. references: ( ) gutidrrez g: lancet ; : - . ( ) landow i: acta anaesthesiol scand ; : - . the haemoglobin-level (hb) is besides the arterial oxygen saturation and the cardiac index one of the relevant parameters of oxygen supply to the tissue. in contrast to otherwise healthy patients, there is no agreement on tile so-called transfusion-trigger in critically ill patients. in i?ont of this background the question arises, whether and to what extent blood transfusion in critically ill patients improves oxygen supply io tile tissue. this study was performed in critically ill/septic patients in the postoperative period alier an inlcclive/scptie revision operation of the hip or knee joint. on cardiac/seplic reasons monitoring consisted beside other measures of a pulmonary arlery catheter and of an indwelling arterial line li~r measurering/calculating standard haem~dynamic as well as systentic oxygen parameters. the indication for blood transfusion was given by hb together with the cliuical slatus of thc patienl (asa-scorc and multiple organ dysfunction (moi))). statistical analysis w~ks performed by mann-whitney-u-test. by fisher's exact-test and by wii.coxon-test: statistical significance was set with p< . . according tu the pretransfusion value of hb and of lactate (lac) palicnts ;,,'ere divided into groups as follows: a: hb< and b: >sg/dl: i: ac< . and ii: > .smm. in either group blood transfusion results in zt significant increase in hb (a: . _+ . to . + . g/dl; b: .(~ . tt, . + . g/dl; i: . -+ . to . -+ . jdl; i : . -+ . to . + . g/dl). wlailc, however, haemodynamic parameters do not difl)r significantly from each other before and alter blood transfusion, oxygen delivery (do, -ml/min x m-') increases significantly hi either group studied (a: -+ to -+ ; b: + to + ; : -+ to -+ ; i : -+ to -+ ), in contrast oxygen consumption (vo~ -ml/min x m e) does not change significantly in either group (a: i -+ to -+ ; b: -+ to -+ ; i: -+ tu -+ ; : -+ to +_ ); oxygen exlraction ratio decreases. this study in critically ill/septic patients demonstrates, that in this group of patients studied blood transfusion at a base-line-value of > . -+ . g/dl expectedly rises do~, however, it does not improve vo=; even not in septic patients with elevated lac-values. paclitaxel in a new anticancer agent, extract from the bark of the yew tree (taxus brevifolia), employed against breast and ovarian cancers resistant to chemotherapy. it promotes the polymerization of tubuline, and disrupts the normal microtubule dynamics. hematologic toxicity, hypersensitivity reactions (bronchospasm, urticaria and hypotension), and peripheral neuropathy are the main reported toxic effects. cardiac side effects are rare: atrioventricular blocks of higher degree are reported in . % of patients; congestive cardiotoxicity was discussed only in one trial in patients treated with paclitaxel and doxorubicin. we describe the history of a -years-old worn an with a breast cancer, diagnosed in , initial staging t nim , treated with mastectomy, axillary lymphadenectomy, andchemotherapy with a cumulative dose of anthracyclines of mg/m until august . the patient complained of dyspnea and severe hypotension immediately after an intravenous infusion of mg paclitaxel, given over hour for the treatment of bilateral, malignant pleural effusion. at echocardiography die left ventricular ejection fraction was reduced to %. she died days later because of a severe cardiac low output with hepatic and renal failure; an impressive hepatic cytolysis was observed. the post mortem examination confirmed the dilatation of the cardiac cavities, especially of the right ventricle, bilateral pleural fluid, and ascites. the histology was suggestive for a cardiomyopathy secondary to anthracyclines. the electron microscopy revealed a deposition of an unusual pathological pigment in the myocytes; subsarcolemmal deposition or membranous were absent. we hypothesize that paclitaxel was the cause of a major hypersensitivity reaction with shock and severe hepatic cytolysis, worsening the myocardial damage induced by anthracyclines. the possibility that a low doge of paclitaxel could directly increase anthracyclines cardiotoxicity -as decribed in the medical literature -will be discussed. objectives: activated endothelial cells release soluble intercellular adhesion molecule- (sicam- ), vascular cell adhesion molecule- (svcam- ), and e-selectin (selam- ). sicam- , svcam- , selam- , and inflammatory cytokines were determined. methods: sicam- , svcam- , and selam- were determined by elisa. tnf-a, il- , and il- were also measured by elisa. endotoxin was measured by an endotoxin-specific endospecy test after pretreatment of new pea method. results: the sicam- and s vcam-i levels were significantly higher in the septic multiple organ failure (mof) and sepsis groups than in the non-septic mof group. the selam- level was slightly higher in the septic mof group than in the sepsis withut mof group and non-septic mof group. the increases of soluble adhesion molecules were not in agreement with changes of plasma endotoxin level. levels of soluble adhesion molecules were correlated with the levels of plasma tnf-a and il- , but the level of il- . discussion and conclusion: the slcam- and svcam- levels in septic patients closely reflected the severity of the pathophysiological conditon. it was possible that the release of sluble adhesion molecules were not stimulated by plasma endotoxin, but endotoxin in the local infectious region. tnf-c~ and il- also were suggested to be involved in the release of these soluble adhesion molecules. obiectives: cardiopulmonary bypass (cpb) surgery is associated with a systemic inflammatory response attributable to the release of various inflammatory mediators and the activation of complement or coagulofibrinolytic system. in addition, adhesion molecules, such as icam- , elam- , and vcam- , appear to be of central importance in the inflammatory process following cpb surgery. we previously reported the effects of a synthetic protease inhibitor, fut- , reduced release of inflammatory cytokines (tnf, il-lg, il- ), activation of complement (c a, c a) or coagulofibrinolytic system (tat, pic, fpa) and protected platelet function (gpib, gpiib/llla) following cpb surgery. methods: in this study, we analyzed fut- on soluble adhesion molecules following cpb surgery. patients undergoing cpb surgery were divided into two groups, group a consisted of patients who received omg of fut- in priming solution, followed by a continuous infusion at mg/kg/hr during cpb in addition to initial heparin dose of mg/kg. group b, a control group, included patients who were injected with heparin only. the plasma slcam- , selam- , and svcam- concentration was measured by elisa. results: every soluble adhesion molecules decreased during cpb in both groups, and rose after cpb. selam- and slcam- reached their peaks on hours after cpb and on pod respectively in both groups, but they remained lower in group a (selam-i: . + . vs. . • ng/ml, p< . , slcam-i: • vs. • ng/ml, p< . ), svcam- , in both groups, remained lower than preoperative levels, but did much lower in group a. conclusions: fut- reduced adhesion molecules and suggested to be the effect on postoperative organ dysfunction. in the last few :,'ears the conditions of treatment in continuous hemofiltration/hemodiafiltration were discussed controversially. a significant removal of tnf-alpha and il-i could be demonstrated in cvvhd. the aim of our study was to investigate the elimination of tnf-alpha, l- , il- , il- , s-cd- and ifn-gamma in cvvh by measurement in plasma and hemofiltrate of critically ill patients with an acute renal failure. the patients of our study were treated with a continuous veno-venous-hemofiltration (polysulfone-filter, blood flow: - ml/h, filtration rate ml/h). the samples, hemofiltrate and plasma, were taken one hour after the start of treatment. the patients suffered from septic shock ( ), the so called hepatorenal s~aldrome ( ) and a severe pancreatitis ( ). the cytokine concentrations were measured with elisa-method. in contrast to elevated concentrations in plasma for tnf-alpha ( cases), scd ( cases), il- (l case) and il- ( cases), hemofiltrates contained no activities. only il- was removed in significant amounts with even higher levels in hemofiltrate than in plasma. this phenomenon was described so far for tnf-alpha and il- and may be due to the absence of metabolic properties (possibily enz~natic) in hemofiltrate. it can be shown, that tnfalpha, il- , il- could not be eliminated in cvvh with a filtration rate to ml/h. in contrast to findings of other investigators with a higher filtration rate (> ml/h), we found no significant concentrations of tnf-alpha and il in hemofiltrate. we conclude, that for a significant removal of important cytokines higher filtration rates (> ml/h) are necessary. objectives: multiple organ dysfunction syndrome including liver and renal impairment is a fatal complication in patients with the diagnosis of sever sepsis. this study focused to the effects of removing toxic substances from inflamnatory tissue by hemodiafiltration. ~ ethods: eleven patients were admitted to the icu in emergency center and met the criteria of systemic inflammatory response syndrome in association with infection. all patients developed liver and renal dysfunction and were treated by hemodiafiltration with high flux membranes (fb-u:nipro). the hemodiafiltration were performed times using nafamostat mesilate as an anticoagulant in hours with l of substitution fluid (hf-b:fuso). the serdm levels of endotoxin, cytokines, endothelin-i (et-]), human neutrophil elastase ~ -proteinase inhibitor complex (hne-pi), fibronectin (fn), lactate, and amino acids were measured before and after the hemodiafiltration. the hemodiafiltration would be effective to renal dysfunction by reducing endothelin and beneficial to tissue metabolism represented in fisher's ratio, but might be harmful to respiratory function by activating neutropila in patients of severe sepsss. background : intermittent hd may be poorly tolerated in the early phase of arf in hemodynamically unstable patients (pts). this technic may fail to achieve steady state urea low levels in hypercatabolic pts. method : nt = consecutive pts treated with hd; n = consecutive pts treated with cvvhf. hemodynamic unstability is defined by arterial hypotension and requirement of inotropie support despite adequate filling. rate of change in urea (u), ereatinin (cr), k + , ph were computed from a linear regression .analysis of data vs time in each treatment group during the first days of application of the two technics (anova). dally worst values were recorded. results : hd-group : apach% score = _+ ; mean number of organ system failure (osf) = . -+ ; mean blood pressure (mbp) = • mmhg (first day of application of hd). cvvhf-group : apachen score : + ; osf = -+ ; mbp = + mmhg (first day of application of cwhf discussion : during the first days of application of hd/cvvhf, u and cr decreased much more rapidly in the cwhf-group. k* and ph were maintained within normal range in the two groups. initial mbp which was much lower in the cwhf-group significantly improved during the application of cvvhf while mbp remained unchanged in the hd-group. conclusion : despite higher severity of disease in cvvhf group (apachen score, osf, lower initial mbp), we obtained a better performanco with cvvhf regarding the decrease of u and cr and the improvement of mbp. in relation to the different and continuous renal replacement techniques, the continuous venovenous one is the alternative method to continuous arteriovenous for critical patients with acute renal failure (arf). we present you our experience with cvvh in patients with mof. in our intensive care unit (icu) patients with mof were treated with cvvh in the period between january in to march in . the mean (• age of our patient population was , • years, being % male and % female the whole patient population was with mof iust at the moment the technique was accomplished; % was in mechanical ventilation, % needed vasopressor support and % required both of them (mechanical ventilation and vasopressor support) apache ii score mean of the patient population was , ~: , (range - ) and ati of them were with arf oligoanudc. technique: cvvh was accomplished using a single-d~al iumen catheter, ptaced in either a temoral or subclavian vein by the stand ard seld{nger technique. pol{sultone hemofitiers were also used, and the extracerporeal circuit used standard arterial-venous blcod tubing. blood flow and hence oltrafiltration pressure, within the circuit was generated by a roller blood pump. the modulus has a roller pump, a pressure transducer connected in an arterious and venous line, such as an air-transducer which is adapted to a drip-chamber in the return way. the replacement used was a peritoneal dialysis solution. medicine , st. george's hospital medical school, london. england. hepatic sinusoidal endothelium shows a major inflammatory response in porcine sepsis that can be attenuated by the administration of dopexamine hydrochloride. dopexamine is a beta and dopaminergic receptor agonist. the specific beta adrenoceptor antagonist ici has been shown to reduce the protective effects of dopexamine. we investigated the effect of this antagonist on hepatic ultrastructure in porcine sepsis. six pigs ( - kg) divided into groups were anaesthetised and intubated. cardiac output and portal blood flow were measured using standard techniques. the groups were; placebo, (peritonitis induced); blocker, (peritonitis induced and pg/kg ici bolus infused then given hourly). caecal content was aspirated and peritonitis induced. colloid was infused to maintain pawp at - mm hg for eight hours the animals culled, hepatic tissue removed and prepared for electron microscopy. in the placebo group hepatic endothelium was swollen and the sinusoids occluded by wbc. but in the ici blocker group, much of the sinusoidal endothelium was absent and there where large extra sinusoidal spaces among the hepatocytes. an assessment of the two groups showed worse hepatic architecture in the blocker group. the b antagonist blocked any protective effect of endogenous beta adrenoceptor agonist (adrenaline) on hepatic endothelium in porcine sepsis. george's hospital medical school, london. england. dopexamine hydr chloride, a beta and dopaminergic receptor agonist reduces hepatic damage in porcine sepsis. we tested dopexamine's effect on cerebral oedema. the beta adrenoceptor antagonist ici was infused to block any protective effect of dopexamine. nine anaesthetised pigs ( - kg) were randomised into groups; placebo, (peritonitis induced); dopexamine, (peritonitis induced and ~tg/kgdar of dopexamine infused); blocker, (as in dopexamine group but in addition pg/kg ici bolus given then infused at that rate hourly). caecal peritoneum was induced and colloid infused to maintain pawp at - mmhg for eight hours when the animals were culled, cerebral tissue removed, prepared for electron microscopy and digitisation. digitisation of the area of oedema surrounding the blood vessel and expressed as a percentage of the micrograph. . _+ . , dopexamine . + . ", blocker . + . . data expressed as mean + sd. significance p< . . * dopexamine compared to placebo and blocker. in the dopexamine group the area of tissue oedema was significantly lower than either the placebo or blocker groups. there were no significant differences between the placebo or blocker groups. the antagonist completely blocked the protective effect of the drug on cerebral oedema in porcine sepsis. beta adrenoceptor stimulation is protective of cerebral oedema in porcine sepsis. objectives: the hemodynamie~ of hepatic circulation during multiple organ failure (mof) have not been suffleienly studied. we investigated liver hemodynamics in two subgroups of patients with mof, those with either liver or lungs as the main organ of involvement. methods: three groups of patients were created: i) mof-hepatic involvement (mof-hi) ( patients) with bilirubin > . mg/dl and lung injury score < . , it) mof-ards ( patients) with respective values < . and > , iii) patients with head injury with respective values < and < , served as group control. all patients were in haemodynamieally stable state with an oxygen delivery index > ml/min/m prior to measurements. two swan-ganz catheters 'were inserted, one in the hepatic veins and one in pulmonary artery and the following measurements were determined: the hepatic vein free pressure (hvfp), the hepatic vein wedge pressure (hvwp), cvp, paop and co. the gradient of hvwp-hvfp represents liver perfusion pressures. by injecting contrast media at dose of iml/lokg with the balloon inflated to achieve sinusoidai image, the hepatic blood flow (hbf) was concluded by the time in seconds of media removal after balloon deflation. results: the co, cwp and cvp were comparable to all three groups. namely, for mof-hi, mof-ards and control groups the mean (+sd) value of co was . _+ . vs . _+ . (ns) and . _+ . respectively, of the paop was . +_ . vs +: (ns) and . + . respectively and of the cvp was .+. . vs . + . (ns) and . respectively. in contrast the two mof groups were different after the cut-offinclusion criteria ie the mean (+sd) value for bilirubin was . + . vs . + . ( < . ) and . _+ . respectively and lung injury score was . objectives: oxygen delivery (do ) and oxygen consumption (vo ) are increasingly monitored parameters in the icu. there still remain controversies about an oxygen supply dependency in critical illness particularly with respect to vo determination by either indirect calorimetry (vo m) or tick calculation (vo c). the purpose of this study was to investigate the changes in vo m and vo c following do increase. methods: the relatives of critically ill patients (mean age years, mean apache ii , mean mof-score ) gave their written informed consent to participate in this institutionally approved, prospective study. do was increased by fluid loading (hydroxyethylstarch %: mean volmne ml, mean duration of infusion min) and catecholamine support (dobutamine: mean dose , ~g/kg/min). changes in vo m and v c were recorded sinmltaneously before, during and following interventions. calorimetry was obtained with the metabolic monitor integrated in the ventilator (puritan bennett, carlsbad, ca adaptive endocrine response of organism to septic shock consisting in activation of the production of adrenal hormons, renin -angiotensin -aldosterone system (raas) and other hormonal systems has an influence over microvascular changes in these states and for development of multiple organ failure (mof). in patients with peritonitis of different origins ( nonsurvivors and survivors) were followed the changes in cortisol level and raas by radioimmunological methods and many variables for evaluation of respiratory, renal, hepatic function, coagulation etc. as a signs of mof. it was observed significant increase of the level of cortisol ( +_ , nmol/ i), aldosterone ( , • , nmol/i). by factorial statistical analysis we found significantly high correlations between hormonal changes and respiratory function (for example r=- , , p < , between cortisol and pao ; r = , , p < , between cortisol and d (a-v) ; olso renin -cao r=- , , p < , , renin d ~,vl o r = , , p < , ). such significant correlations was found and for raas with respiratory, renal function, byproducts of arachidonic acid thromboxan b and p fla, soluble fibrine degradation products etc. these correlations between the degree of endocrine changes and multiple organ failure in patients with septic shock produced by peritonitis suggest that their effects upon peripheral vascular resistance and constriction of the splanchnic, splenic, renal and other organ vasculatures are not always with physiologic expediency and there are perhaps the possibilities of therapeutic influence. intredu~on : dopexamlne has previously been shown to control hyperkalaemia ia patients with acdto renal failure (arf), however effects on the subsequent course of art are undomunente~ ob_iectlv~ : to evaluate clinical progress in patients with acute renal failure (arf) in an intensive care unit (icu) with regard to biochemical control, need for -and time to -dialysis, and outcome in patients receiving dopexamine. m~ods : consecutive patients meeting standard criteria for diagnosis of arf were included in the study. full cardiovas~dar, biechemical and intervention/outcome details were recorded. dopex.~min~ was infilsed at a dose of pg/kg/min in conjunction with a regimen of inotropir support and blood volume optimization. resn]~ : following the intzoduetion of dopc',~mine ilrinr vohlmes increased slightly over the next hrs fzom + ml/ hrs to + ml/ hrs (ns). data expres,uxl as mean + sem. three patients ( %) became polyuric with urine output > ml/hr within days and did not need dialysis. in the remaining patients the time to dialysis (to correct acid-base deficits or volume overload) was . + . days. serum potassium levels were well controlled. day or immediate pre-dialysis levels were . + . mmol/l compared with pre-lreatment . + . mmol/l overall mortality in this series was / ( %). duration of acute dialysis in survivors with renal recovery was . +_ . days. patients ( %) progressed into chronic renal failure and needed continuing renal replacement therapy. no adverse cardiovascular altects were seen at this low dopoxami~ dose although its competitive inhibition to adrenergic reuptake mechanisms meant that doses of pressor agents could often be reduced. : dopcx:~minr nsed in conjunction with inotropic support and blood volume oplimitntion, can safely postpone, or even avoid, the necessity for acute haemodialysis in icu patients. no evidence of tachyphylaxis to the effect on serum potassium levels was seen over the duration of the study. hen'era m., suarez g., dagn d., varela a., ramos j., garoia jm, aragdm c, jurado l, medina a. icu. hospital regional. malaga. spain. objective: to evaluate the haemodinamic tolerance to the veno-venous continuous hemefiltration (vvchf) system in patients with systemic inflammatory response sindrome (sirs), and the possible beneficial effect of this technique on the haemodinamics in these patients. material: patient admitted to the icu, with diagnosis of sirs and monitored with a pulmonary artery catheter at the beginning of wchf. we performed a complete haemodinamic study to all these patients (cardiac output, vascular resistanoss, ph and co in arterial and mixed venous blood samples, saturation of pulmonary mixed venous blood, do and vo calculations and temperature) and determined the respiratory mechanics (compliance and pao /fie relatinship) before starting the procedure, after minutes operating with the ultraflltrate branch closed (without filtered fluid production), afler and minutes of zero fluid balance bemofiltration and after minutes of filtration with negative balanos adjusted to the patients conditions. for the statistical analisis we have performed the anova test over the mentioned variables. results: we have not detected statisticaly significant differences of the analyzed variables before the beginning after operating the pun'@ for minutes without filtered fluid production and after minutes of zero fluid balance hf. only temperature shows a meaningful decrease in time. objectives: among many organs, playing the important role in pathogenesis of multiple organ failure, the particular place is taken by the intestine. ~ethods: the study was carried out in dogs !~n"~h pi was modelled by severe operative trauma (ot). the dcm was estimated by the indices values of work time (wt), contraction frequency (cf), mean amplitude of contractions (~ac) and motility index (mi) measured by method of tensography. "sl", created on the basis of sorbit and sodium lactate ( mosm/l), was injected in the dose of .o ml/ kg into v. cephalica antebrachii after hrs of ot. the results of the present study are the evidence of "sl" stimulative action on dcm and are experimental ground for "sl" using in complex therapy of pi in clinic. with splanchnic venous blood pc p.f. laterre p. goffette, j.p. fauville, a. poncelet, p. loneux, m.s. reynaert. intensive care unit, st. luc univ. hospital, brussels, belgium. determination of gastric intramucosal ph (phi) by gastric tonometry using the henderson-hasselback equation is expected to allow the detection of splanchnic ischemia in critically ill patients. because of bicarbonate concentration and acidbase balance influences on the calculation of phi, it has been proposed to use arterio-gastric pco,_ gradient [p(gast-a)co,] to assess splanchnic perfusion. htpothesis : pcoz in the gastric mucosa is in equilibrium with intraluminal co z and with co, in the blood leaving the stomach (mesenteric and portal blood). objective: mesure pco; and ph in portal vein blood and compare its value with pco and phi obtained simultaneously by gastric tonometry. material and method : in a patient ( y.), a fiberoptic catheter (baxter r) was positionned in the portal vein after transhepatic stent shunt repermeabilisation. hemodynamic parameters, do, (vigilance n baxter), gastric co and phi (tonometrics baxter) and portal blood gas were determined at regular intervals. results : sets of data were obtained and are expressed in mean + sd. gastric pco z was , + compared to , + . mmhg for portal pco . phi was . +._ , vs . +._o, for portal ph. no correlation was found for these parameters. p (gast-a) c was . + mm hg vs + . mm hg for p (portal-a) coz (no correlation). there was a good correlation between do e and p (portal-a) co z (r = , ) [figure] but no correlation with p (gast-a) c . obiectives: desaturation is a common finding during haemodialysis (hd). pulmonary oedema might be one cause for impaired gas exchange ( ). the aim of this study was to quantitate the amount of extravascular lung water (evlw) and gasexchange in chronic renal failure patients during and after a regular hemodialysis session. methods: chronic renal failure patients without symptoms or diagnosis of cardiac or respiratory disease were studied at the start (i), at the end (ii) and two hours after (iii) a regular bicarbonate hemodialysis session. the double-indicator dilution method, with indocyanine green and the stable isotope h as tracers, was used to measure evlw ( ). arterial bloodgases and endtidal co were registered. evlw data was compared to a group of renal healthy patients ( ). dcp n evlw, ml -pao , mmhg h~o +, nmol/l control group - -- l _+ "* -+ _+ crfgroup ii -+ ~ +- ns -+ "(" iii +- t _+ ns -+ t ** p < . dcp i from dcp , t p < . dcp li or i from dcp i, :~ p < . dcp ii from dcp i the evlw at the start of dialysis was larger in the crf group than in the control group. the evlw decreased significantly to a level not different from the control group in response to the reduction in weight after hd. pao~ was normal at the start of hd and showed a nun-signficant reduction after hd. paco ( . + . kpa) and etco ( . + . kpa) were unchanged while h o+ decreased and bicarbonate increased significantly. conclusions: the elevated level of evlw at the start of hd did not impair gasexchange. the decrease in evlw did not inhibit the decrease in pao . the reduction in h + followed by a fall in alveolar vantilation is the most plausible cause for the decrease in pao in bicarbonate dialysis. . prezant lung ; : - . . wallin j appl physio ; : - . a. dona~ d. battis& l col~ r danieli, d. achill~ l viglienz;~ c. giov-anaini, p. piaropao~ oblectives: to verify if intraoperative modifications of mtramucosal gastric ph (phi) below the normal lowest value . , can be predictive for important complications, as perforation, sepsis, mof or death. methocls: we have considered patients who andenvent major abdominal surgery. all patients received the same drugs in pre-anaesthasia, the same type of anaesthesia (balanced anaesthesia) and the same treatment with h -bloekers. after the induction of anaesthesia a gastric tonometer was positioned and a catheter was positioned in the radial artery. during the operation, every minutes, the following parameters were measured at the same time: phi, arterial ph (pha), blood lactate, mean arterial pressure. in follow up we considered death and complications happened during the hospital stay, in relation to intraoperative phi falls below . . results: among the patients, had a drop of phi below . during surgery. in three of them this fall was a single episode and happened within the first hour after the begiluting of the operation. after that phi rose to nomml values until the end of the operation these patients had a normal post-operative period, without complications, the other patients had a fall of phi during the demolitive manoeuvres. two paticots of them died. the first had a lowest phi= . and the second . . the first one ~zs operated on for hepatic istiecitoma, suffered a complete del'dseenco of the surgical wound on the th day after operation and died on the th day, the second one was operated on for a hepatic carcinoma had an intraoperative haemorrhage and died ~vo hours after the end of the operation. the other patients with a fall of phi had a lowest phi= . . . . . . . respectively.the first patient,operated onfor sigmoid carcinoma, underwent on a second operation for a transmural necrosis of the colic segment on the th day; the second one, operated for carcinoma of the right colon, had a cardiac ischelnia on the th pest-operative day and a dehiscence of the surgical wound on the th day: the third one, operated on for a sigmoid carcinoma, had melena in h post~ operative da b, and finally the fonrth patient, operated on for carcinoma of the tight colon, suffered a fistula of the surgical enteral anastomosis.all these patients were discharged alive from the hospital. the other patients, who had not reductions of phi ditring the operation, had a normal pest-operative period, without complications. conclusion: phi was able to predict the arising of some complications, probably due to intraoperative ischemic events. we can say that gastric tenometry, for its low invasivi.ty, can be included among the intraoperative monitoring in patients that tmdenvent on major abdominal surgery. (ttd),t"ea~rrerj.~ of hours duraticn. all l:atients nm.'-~ms_(~lly va~ ated in eantrol wcde ard_ la':'ad a a,~m--ganz catheter, with optic fibers for contirums mmsuremmt of svo mic studies were performed, c~e before the hegir~ of hd, c~e rain after the ~, ~ne at the middle, ~ne rain before lhe erd ard one rain after the erd of hd. paired t test ~as used far slatistical eval~ti~n. results: daring i~d there was a significant'reductton (p<o.~) of: c~tr~ venc~s eres~.re ( ve)emm to . ~ ~, ) ~arn'~w capil~ ~f~e pressure (i<~p) fr~n to ~mg hg, ) i~ from to . mmg hg. ~here was also a less pmnameed bat also-slatistics/ly significant r~ucticn (p<o. ) of: i) s~o~ from to patients undergoing surgical reconstruction of the aorta due to anenrysms of its abdominal part may develop transient and sometimes sustained episodes of dysoxia despite the conventional appeoreneas of being adequately resuscitated. indirect masurement of gastric mussel ph (phi) is being widely evaluated as a minimally invasive and sensitive means of assessing the adequaey of tissue oxygenation in these circumstances. the duration end degree of gastric intramucosal acidosis are related to the risk developing injured gastrointestinal tract end its putative consequences, i.e. translceation, cytokine release, organ dysfunction end failure, sepsis end death. measurement of phi is obtained indirectly by measuring pc in the lumen of the stomach with a silicone balloon tonometer (tonometrics, inc., worcester, ma, usa) and the bicarbonate concentration in arlz,,rial blood, end substituting these two values in the henderson-hasselbalch equation. objectives: to evaluate whether perioperative phi changes are predictive of complications end outcome end how they compare to standard haemodyuamic and oxygen trensport parameters. methods: patients ( males and female) urtderwent surgical replacement of abdominal aortic anonrysm with the aortic simple or bifurcated grail. patients were operated on eleetively, had an emergency surgery for raptured enentysm. haemodynamic, arterial ph and bicarbonate concentration measurements were taken before and after induction of anaesthesia, after cross-clamping and declamping of the aorta end at admission to itu. phi calculations ware done at the sime time except before induction, as tonometers were inserted after patient had been asleep. we used pulmonary utilizing a computer billing survey as well as hospital service transfer data from a month period ( / - / ), all obstetric patients that were transferred to the med/surg icu were identified, as well as their diagnoses and procedures. twenty-eight obstetric patients were transferred to the med/surg icu, compared to , deliveries occurring during that time period for a . % rate. the following procedural indications for icu transfer occured: insertions of endotracheal tubes, arterial catheterizations, temporary tracheostumy, and venous catheter. the following medical diagnoses were found: hypertensive/eclamptic episodes, hypotensive episodes, pulmonary embolism, mitral stenosis, and coagulation deficiency. there were four episodes of respiratory failure ( %). the historical rates of respiratory failure from the medical literature seen at a university hospital ore higher than those at our community hospital despite comparable icu transfer rates for critically ill ob patients. objectives: to evaluate the usefulness of several isss used in order to predict risk of death (rd). design: prospective data collection for months in a multidisciplinary -bed icu. methods: data from consecutive patients admitted to the icu from / / to / / were studied. all the necessary informations were stored in a computer using special software for every day computation of three isss (saps, saps ii, apache ii) and of the rd predicted by saps ii, mpm , mpm and odin. data from days of hospitalisation were used for comparative evaluation of isss and rd, while sensitivity and specificity in death prediction (cut off point of rd = %) were evaluated from data collected during the day of admission (saps ii, rpm , odin) or after hrs (mpm ). agreement between rd predictions was evaluated by bland and altman analysis. results:our results were the following: objectives: a) to create and validate software specially designed for the collection of demographic data and estimation of illness severity and predicted rd and b) to provide data necessary for the evaluation of the effectiveness and the efficiency of our icu. design: prospective data collection in a multidisciplinary -bed icu. methods: prospective data on specific physiological variables, selected demographic characteristics, comorbidity and the reason for icu admission were recorded every day for consecutive patients admitted to the icu from / / to / / . data were entered into a portable computer using specially designed software allowing the calculation of usual illness severity scoring systems (isss) and the corresponding predicted rd. results: we studied men and women, with a mean age of years. we conclude that, although observed mortality was higher than predicted rd, this difference was not statistically significant. the fact that the sd of predicted rd was too large, limits the usefulness of isss predictions for a comparative evaluation of different icus. objectives :the importance of objective evaluation of patients prognosis at their admission to an emergency department is clear. the aim of this study was to appreciate the prognosis of patients with the simplified acute physiology score ii (saps ii), and correlate this score to the prognosis and orientations of patients. methods : the score which is a reduced form of saps ii was calculated from clinical variables and laboratory items for patients. sensibili}y (se), specificity (sp) and accuracy (ac) were calculated to evaluate the performances of saps i . thresholds were calculated with the youden's test (se+sp- ). results : patients were admitted in the intensive care unit (icu)and patients in medical units; patients died. the saps ii was higher in patients which died than the survivors ( , + , vs. , + , , p< , ; respectively), the best threshold was , se was de %, sp was %, the ac was / . thus for patients admitted in icu than in medical unit ( , : : , vs. , + , , p< , ; respectively); the best threshold was , se was %, the sp was %, the ac was %. conclusions : these preliminary results suggest that saps ii can be used to determine the short term prognosis and the destination of patients seen in an emergency department. design: data was collected on all admissions over a six month period. all patients had a screening hiv elisa test. confirmatory ifa tests, western blot and flow cytometry were performed on hiv positive patients. the institutional ethics committee considered the major clinical impact of the study sufficient cause to waive the patient's right to informed consent, icu staff and patients were blinded to hiv results. following discharge patients were given the option of being advised of their hiv status. setting: the study was conducted in a bedded surgical icu at a tertiary care teaching hospital. patients, participants: all patients admitted during the period in question were included. interventions: "all patients were treated according to standard icu protocols. there were no interventions. results: most patients were admitted following trauma. there were no patients with aids, hiv positive and hiv negative patients. with respect to the latter two groups, the mean age and sex distribution was similar, there was a significant difference in organ failure ( % versus %, p < . ) and septic shock ( % versus %, p , : ) but no difference in icu/hosp[tal mortality or duration of icu/hospital stay. flow cytometry changes in hiv positive patients were consistent with the quiescent phase of hiv infection. conclusion: while morbidity is higher in hiv positive patients, there is no difference in mortality. hiv status should, therefore, not be an exclusion criterion for icu admission in this patient population. , n= ) and january-march (period , n= ) were studied. interventions: a resident micu team led by a trained intensivist took over the medical care from the primary physicians when the patients were admitted to the micu. the intensivist also vetted micu admissions and decided on micu discharge. in addition, there was a resident respiratory therapist to attend to vendlatory care during office hours. after office hours, the care of the micu was delegated to the on-call team on a rotational basis among the medical departments. results: the patients in the two groups were similar with respect to age, sex, race, source of admission and apache scores. the icu and hospital mortalities decreased from . % to . % (p=ns) and . % and . % (p=ns) respectively in period . the mean icu and hospital stay was also decreased from . __+ . to . + . days (p=ns) and . __+ to . • . days (p=ns) respectively. the improved micu length of stay for survivors in period was statistically significant ( . • . days vs . • . days = . ). there was no significant differences in the vse of peritoneal dialysis ( . % vs . %) and mechanical ventilation ( . % vs . %). however, utilisation of intra-arterial lines and pulmonary artery catheters increased from % in both to . % and . % respectively in period . conclusion: the duration of critical illness was reduced in period . hence, we believe that the closed |cu which was staffed by an intensivist and had the services of a respiratory therapist was beneficial for the care of the critically ill. the intensivist, was also more likely to utilise invasive monitoring. in the absence of liver transplantation, intensive care for patients with acute hepatic decompensation arising from alcoholic liver disease (ald) is indicated only for those who are likely to benefit from conventional means of organ support. we have attempted to elucidate potential risk factors and the efficacy of organ support in relation both to hospital outcome and icu costs so as to allow the earlier identification of relatively futile intensive care in this group of patients. methods: over a period of one year, ald patients ( males; females; median age years, median apache ii score ; hospital mortality %)with severe complications ( [ %] with bleeding oesophageal varices, [ %] with hepatorenel failure, [ %] with respiratory failure, [ %] with septic shock, and [ %] others) were studied in our liver icu. organ system failure, daily therapeutic interventions and icu costs were assessed using a patient management system (riyadh intensive care program). results: whilst survivors had a significantly lower admission apache ii score compared with non survivors (medians and , p< . ), or more organ systems in failure in the first hours of icu admission was associated with a % ( ) mortality. mortality was also related to child's grading and the numbers of organs supported. of the patients who received more than one form of organ support only one survived. organs supported mortality a (n= ) % none / ; % b (n= ) . % one / ; % c (n= ) . % two or more / ; % the icu costs for the patients were only s but s ( %, patient days) was utilised by the patients who died, giving an effective cost per survivor (ecps) of s . although the cost of treating the patients with or more organ systems in failure on the day of admission was s ( % of the budget) the ecps was s . conclusion patients with ald who have or more organ systems in failure early in their icu course have a poor prognosis and in the absence of liver transplantation, traditional strategies of organ support are ineffective. this begs the question whether such costly care is appropriate as although the ecps in this sub group is comparable with other patient groups with multiple organ failure, their outcome is considerably worse. objectives: to evaluate the economic impact to the healthcare sector of using dopexamine hydrochloride infusions to deliberately increase perioperative oxygen delivery in high-risk patients. methods: effectiveness data were obtained from a controlled clinical trial in which surgical patients were randomly assigned to either a control group (n = to receive best standard optimal fluid resuscitation perioperatively, or a protocol group (n = ) to receive, in addition, an infusion of dopexamine hydrochloride to increase the perioperative oxygen delivery index to greater than ml/min per square metre. resources consumed by patients during treatment were recorded prospectively and costs of resources at / prices were obtained retrospectively. cost-effectiveness ratios were estimated by dividing the total cost for each treatment group by the total number of patients in each group and by the clinical outcome of mortality days postoperatively. results: in the protocol group, there was a % reduction in mortality days postoperatively (p = . ), a significant reduction in the number of complications (p = . ) and a reduction in length of stay in the icu and surgical ward. the average cost per protocol patient to achieve a . % survival rate days postoperatively was s , , resulting in an average cost of s , per surviving protocol patient. the average cost of a control patient was s , to achieve a . % survival rate days postoperatively, resulting in an average cost of s , per surviving control patient. the use of dopexamine to deliberately increase oxygen delivery perioperatively generated a cost saving to the nhs of s , per patient together with a % reduction in mortality at days postoperatively. hence, the cost per surviving protocol patient was s . less than the cost of a surviving control patient. conclusion: the additional cost of dopexamine in protocol patients was offset by a lower incidence of complications and a shorter stay in the icu and on the surgical ward. hence, increasing oxygen delivery perioperatively in high-risk surgical patients saves both money and lives. objective: although king's college criteria are widely used, indication and timing for liver transplantation in acute liver failure is still far from certain. long-latency sensory evoked potentials -a proven measure of metabolic brain dysfunction (grimm et al. lancet ; : - ; madl et al. lancet ; : - ) -are markedly affected in patients with acute liver failure. serial sensory evoked potential recording should provide very useful information for the management of patients with acute liver failure. methods: recordings of standard bilateral sensory evoked potentials were performed in patients with acute liver failure. findings were focused on cortical n peak -a stable negative deflection occuring • ms after median nerve stimulation in healthy subjects, which can be recorded by skull electrodes over the sensory cortex. results: nine patients recovered spontaneously, patients were referred to emergency liver transplantation, and patients died. in all patients who recovered spontaneously, n peak was detectable between and ms. all patients who were referred to liver transplantation and of patients who died, developed a loss of a prior detectable n peak during the course of acute liver failure. objective: to determine high risk arid low risk patient groups in a medical intensive care unit regarding short term and long term outcome. methods: data on all admissions of the year were collected prospectively. according to their mode of admission patients were classified as admissions by the physician staffed ambulance service (as), admissions through the emergency department (ed)i referrals from non-intensive care wards (ni), and secondary referrals from other hospitals (oth). outcome was assessed in terms of in-unit mortality, in-hospital mortality, and long time mortality. patient groups were compared using the \ -test. life table analysis were per{ormed by kaplan-meier method comparing patient groups by log-rank test. the software spss for windows . . was used for statistical calculations. results: in-unit mortality: / patients ( . %) --oth . % > as . %> ni . % > ed . %; p = . . in-hospital mortality: / patients ( . %) --oth . % > ni . % > as . % > ed . %; p = , . mean survival time in days after discharge: as < ni < oth < ed ; p = . . conclusions: despite an excess in-unit mortality of secondary referrals from other hospitals the iongtime course of this special patient group is not different to others. solsuam, j, marrugat*, g, mirs, j, nolla, a, vazqu~z-sanchez, l alvamz, ~ioio s xndioina i~siw. ir~itate l(~icipal da l~sti~isn l~di~*, ~ospits dal objective: to study the influence of modifiable variables (complications derived from therapeutic activities) on the prognosis of ~atients admitted to the icu indapemently on thn severity of illnsss. patients am methods: between january asd ]lay data from , patients over years of aqe who retained in the icu for mare than hours ~ere pr~pectively regiatered. a cohort st~ly with follo~-~ nf patients durin~ ~eir stey in the hospital was deni~.el in all patients, reasons for a~issien, principal diagnosis sad severity of illn~s moasared by the saps scare vare recorded. fastens affecting patients' outcome that my be proventsd or modified included technical :omplisafioss, heapital-acqnired infections and in~pro~riate therapeutic decisions. a logistic regression model was used to assess the relative risk (l~} for in-heapital mortality adjusted for each variable. results: ic~ mortality ~s . % and in-hospitul mortality . %. patients who died showed a higher spas score then survivors ( , ~ i ,i). after adjusting hy severity of illness, co~;licetices that statistically increased the risk of in-hospital death were septic shock secomery to hoapitul-acqdired infection ( ~ . ; % el, . to . ), pmo~othor~x related to mocasnical ventilation (@ . ; % cl, . to . ) and delay in the insertion of a fln~-quidod catheter (ii~ . ; % ic, i.i to . ). col~lusien: registration of complicaticas derived from therapeutic activities is a valuable tool far quality central in the icu. g, ~i~ , j.l mle~ma, j, ~amqat*, j..~lla, a, vazquez-saltemz, f, alvamz , servioia de nndicina l~siu. i~stitutu ~icipal de ln~sti~acidn ~ i:a*, hospital dsl objective: to dstsr~ine the incidence of self-extebatien and its effect on ~ortality. patients and ]~etheds: betveen january and april , all i~tiente in whom selfextubatien w~s registered were inclnded in a prospective study. patients were divided into @nee who needed r~intabatinn within hoers and those who did not. in all patients, dsmoqraphie and ciinical data were recorded as well as icii mortality, in-hoapital mrtality and severity of illness according to saps score. eta were analyzed usi~ the cbj-square test for cathgorical verinbls, the analysis of varianc~ (anva) for aontinuc~ ~ria~les and a leqi tic regression anal~is to estimate the relative risk (iiii) for mortality as result of celt-nxtt~ation after adjusting for severity of illness. results: a total of intnmtsd patients amre stndied. self-extu~atien occurred in ( . %) patients and . % required reintuhot~pn. when a co,arise was made between patients who did not required reint@atinn and patien~.s who did, statistically significant differences in eqe ( . v_s . years, p = .~ ), ~verity of illness ( . ~ . spas score, p = . ), dia~isstia category ( s. % v_s . % of patients with res~iratury conditiono, p = , } and mean length of stay ( , ~ , days~ p = . ) were fo~m, a~ter ad~sti~ for severity, patients with self-ext@atinn who did not reqnired reintalatien showed a . iir for mortality ( % ci, .i to . ) as co~arod with patients in when self-ext@ation did mot occur. conclnsien: self-~extamtice that does not require reint@ation is associated with a isamr in-hospital natality probably dt~ to a prolonged period of weaming. patients' admissions to ices am often delayed doe to the shortage of beds available. @ile amaltieq icu admission, these patients are treated in observation nits of @e emergency services which bare ,either tile structure nor the trained ~reomenl that are available in leb~. objective: to daterdno the effect on the patient's proqusis of a delay in tile admission to the icu when criteria for icij admission are fulfilled. ~terials and methods: between jme am l?ece~ber all patients who fulfilled criteria to be almittod to the ic who for waste~r reason retained in tile observation unit for more than hours were included in a prospective stedy. in all patients, des~raphic end clinical dabs amre recorded as well as severity of illness aencrdi~j to saps score. a cesucontrol dasi~ was eend with a total ss~ln of , patients who suffered no delay is admission to icii over a period of years. data wen analyzed using the chl.-squ~re test (to aeons the association hetwenn in-patienty mortality end categorical vari~lns) and a maltipln logistic reqression model to sstimta odds ratio for) for in-hospital mortality as result of delay in icy admission as compared with early ad~issi| after adjusting for severity of illness end use of assisted mchenical ventilation. ~ &ults: a total of patients remained in the observation nit for more than hours with a del w in igd admission of . _+ . hoers. assisted mechanical ventilation was requited in % of patients and only monitericatien in %. itsse patients were cspared with ntients from the tet~l sample ratchod by age, sp~ score and rennoss of admission. in-hospital mortality for cases warn % as compared with . % for controls (p = s). after adjamtilg fen spas, age and mobamioal ventihtien, no statistically significant differences between both ~renpa were foam, altho~b there was a tendency towards a higher mortality amen@ patients with delay in icu admission (or = . ; % ci, , to , ). conclnnien: ~se findings suggest that prognosis of critically-ill patients is no worse as a result of admission to the loll being deln~d for borers. all data appropriate for the calculation of the apache ii score (aps) together wi'th other specific cardiac details relevant to these .patients were collected daily, verified and enter~ into a computer database. results: patients were studied. six patients died and five of thee underwent cardiac surgery. the mean aps was for survivors and t for non-survivors (p < . ). the mortality ratio was . and the major markers of mortality were apache ![ score, presence of chronic ill health, mean duration of ventiiation, mean length of icu stay and need for emergen~ surgery. sixteen percent ( ) of icu bed days were occupied by % of patients (non-sarvivors) which resulted in cancellation of cardiac sot#cat sessions in momhs. conclusions: this study concludes that apache t could be used as an audit tool in a cardiac surgical icu and demonstrates the severe compromis~don of cardiac surgical throughput by a few non-survivors, organ to determine the number of organ failure free days (offd) in a cohort of survivors and non-survivors with sepsis syndrome followed over a day period. ) to determine sample size requirements for clinical trials utilizing a increase in the number of organ failure free days as the primary outcome as opposed to mortality. methods: beginning december through to april , patients who met inclusion criteria of the "cardiopulmonary effects of ibuprofen in sepsis syndrome" and who did not have hiv/aids. brain death or moribund state were prospectively identified. presence or absence of failure of organ systems (pulmonary, cvs, renal, hepatic, gi, hematologic, & cns) was recorded daily until death or until days. a score of one was assigned to each organ system free of organ failure in patients still alive, ie, maximum daily off score= , maximum day off scorn= , sample size estimations were performed for variable detectable differences in off scores (delta). alpha was set at . (two-sided), with n/group = [(z a +z b ) o conclusions: a clinically relevant increase in off days may be detected with as small a sample size as to patients per group. this represents a significantly smaller sample size than needed to detect a change in mortality from % to % ( % relative risk reduction) where the n/group= . scoring patients in this manner prevents a lethal inte~entien from providing an improved organ failure score. in addition, an intervention that prolongs survival must also provide greater organ failure free days in order to be counted by this scoring method. survival as an outcome provides no information about the quality of that survival. off days provides a measurement of burden of illness. interventions which lessens this burden may be just as valuable as those that decrease mortality by providing a measure of the quality of survival and by decreasing costs of care. they may also prove to be an accurate surrogate marker of mortality. the advantage of this approach is that the event rote is much higher and sample size requirements are subsequently smaller. this would mean that clinical trials can be completed faster and at lower cost. outcomes such as mortality could then be assessed at a later date utilizing recta-analysis. we suggest that the use of off days is a valid outcome measure that may be utilized in clihieal trials of sepsis syndrome. the icu is perceived by many as being a stressful environment for both patients and staff. stress has been defined in three ways: a stimulus producing a particular response; the physiological and psychological response to a stimulus; an interaction butwom an individual and their environment. stress is currently thought to be a dynamic system of stimulus and. response which takes into account the individual's perception of the stimulus and their ability to respond effectively. stress may, therefore, be positive and allow personal development but an individual unable to respond effectively to a stimulus will experience negative effects or strain. critical illness is an intense stimulus to which the body needs to respond effectively. physiological responses are vital and most of intensive care involves supporting these. alternatively, blocking them, for instance with atom(date, increases mortality. psyehological responses are also vital but often poorly appreciated because of communication problems. many of the problems patients experience in an icu are evidence of psychological strain. this can be exhibited in various ways, for instance, anxiety, depression, passivity and confusion. dealing with critically ill patients is perceived as stressful. we recently studied occupational stress in our icu. most aspects of intensive care were not generally perceived as stressful indicating a self-selectien of icu staff. the most stressful aspects of icu work for nursing staff were the structure of the organization and career opportunities. medical and nursing staff had different stressors and different coping strategies. support for occupational stress, therefore, should focus on the individual and concentrate on information and communication. atmosphere, and especially at intensive care units, we face up to daily decision making. in most cases these are taken on the basis of personal opinion and the processing of a very limited amount of information. rising need to optimize the results of medical attendance becomes necessary to set structured system of d@cision making in which ethical basis have a sp@dial significance in view of next considerations: -we live into a pluralist society in which the importance of values is different. -most persons consider health as the first value only in the event of illness. -medical resources available are limited, whereas medical, attendance demand from population increases in a way many people consider it unlimited. in consequence, it becomes necessary to set up priorities in patients treatment. ehtical basis that rule decision making are essentially these ones: i. beneficence: to provide the patient that is being treated the highest profit. . non maleficence: it is our first duty to avoid hurting or damaging the patient."primum non nocere" . autonomy: in every particular medical attendance, the patient has ability to decide by himself. . justice: as equity: to provide the same treatment for those who have the same pathology, ignoring another factors such as age, sex or race. severe application of these principles can cause difficulty, which resolution requires a systematization of decision making. ( - ) . the lenght of stay between survivors and non survivors didn "t show statistical significance (p = . ). the mean aiii score when considering all admissions was , ( - ) . the initial score between survivors and non survivors showed ststistical difference ( . vs . ) respectively (p < . ). univariate logistic regresion analysis demostrated a % increment in death probability for every points augmentation in the aiii score with a sensitlbity of . % and specificity of . %, the roc curve showed that the best cut off point for death prediction was points with a sensitivity of . % and specificity of . %. if a patient is classified as high risk (> ) the bayesian analysis showed a . probability of death and for one class(fed as low risk (< ) a death probability < %. conclusions: the first day aiii score in this population showed to be a good discriminator between survivors and non survivors, and the risk of death augments as the aiii does. in this population an aiii score > points is asociated with a greater risk of death. using the aiii score in conjuntion with the clinical judgement will help clinicians reducing uncertainty in the every day decision making and better predict outcome, the results from this study should been taken with caution because the data were obtained from a small sample. objective: the quality of life has been considered a "uniquely personal perception" resulting from a mixture of health related factors and social circumstances [t. m. gill, jama , : ] . the aim of this study was to evaluate two measures of pqol in intensive care unit (icu) admitted patients. patients and methods: during icu stay and six-months after hospital discharge, co-operative icu admitted patients were directly interviewed about their pqol. we administered ftrstly the uniscale (pqolu) [sage et al crit. care med. , : - ] and then a step verbal scale (pqolv): best, good, fair, poor, worst. of the studied patients, at the first interview, were able to use both scales, but ( . %) understood only the verbal one. at the second interview, patients were not able to answer, used both scales and only pqolv. statistical analysis was performed using wilcoxon signed ranks, spearman rank correlation, student's t and chi square tests. results: of all cardiac surgery pts, pts ( . %) died in icu. they were males ( . %) and females ( . %). their mean age was (+ ) years and mean ef was . (+ . ). nineteen pts ( %) had low (< . ) preoperative ef. mortality was . % in the coronary artery bypass grafting (cabg) group (n= ) and . % in the valve replacement (vr) group (n= ). in the cabg +vr group, mortality was . % (n= ), and . % in the remaining pts (n= ). cardiogenic shock was the sole cause of death in pts ( %), septic shock in pts, whereas sepsis in combination with ards in pts, sepsis and stroke in two pts. in addition, pts died from cerebrovascular accidents, one from ards and one from pulmonary embolism. the pts who died in the icu had a significantly longer bypass and aortic cross clamp time and received more blood transfusions (p< . ) than a matched control group that survived to icu discharge. the duration of mechanical ventilation and length of icu stay were greater in the pts who died in the icu than in the control group. conclusions: . although cardiogenic shock is the main cause of death ( %)in cardiac surgery pts, sepsis and cerebrovascular accident are relatively frequent causes. . patients who died in the icu had longer bypass and aortic cross clamp time and received more transfusions, compared with the control group. . although renal or hepatic failure contributed to death in some pts, they were not the primary cause of death in any patient. objectives: evaluate the acute and follow-up outcome of patients (pts) treated with primary ptca (without prior thrombolysis) in acute myocardial infarction (ami) after and up to hours after onset of typical thoracic pain ("late" primary-ptca). methods and patients characteristics: from / to / consecutive pts with ami were treated by primary ptca in the wuppertal heart center pts ( , %) were admitted to our hospital > hours and < hours after symptom onset with ongoing chest pain and typical ecg-changes.mean age was years ( - ). pts were male, four female. % had an anterior wall myocardial infarction, % suffered an inferior/postero-lateral wall myocardial infarction.two pts were in cardiogenic shock at admission. singlevessel-disease was documented in . %, multi-vessel-disease in . %. average time of onset of pain to recanalisation was min ( - ). angiography revealed timi-flow in . % of the pts, timi-flow i in . %, timi-flow ii in . %. average follow-up (fu) period was months ( - months). timi iii lv-ef ~ -day major late re-late flow p.i.* aeute/fu mortality bleeds infarction mortality . % %/ % . % . % . % % early mortality occured in the two pts, who were in cardiogenic shock at admission no pt required emergency coronary artery bypass grafting.restenosis > % was seen in % of the pts. conclusions: "late" primary ptca achieves a favourable high recanalisation rate of about % (timi ill-flow) in our study group. additionally, there seems to be a trend for lv-ef improvement in follow-up. early high mortality is influenced by the patients admitted in cardiogenic shock. there might be a trend for increased major bleeding complications. objective: to assess the validity of saps ii (new simplified acute physiology score), comparing it with the previous version, (saps), in a sample of patients recruited by giviti, a network of icu's representative of the italian icu system methods: measures of calibration (goodness-of-fit statistics) and discrimination (receiver operating characteristics curve and area under the curve) were adopted in the whole sample and across subgroups differing in relevant prognostic characteristics. of the patients recruited during one month period, a total of patients were included in this study. for the purpose of the comparison of the two scores, patients with less than years, or having cardiac surgery or staying in the icu less than hours were excluded. vital status at icu discharge in the whole sample and at hospital discharge in half cases wher adopted as outcome measure. re$ ~: saps ii fits the data equally well compared to the older version (goodness-of-fit p= . and in the new and old versions, respectively) but its performance is somewhat better in terms of capability to distinguish patients who live from patients who die (areas under the curve . and . , respectively). furthermore, saps ii is better in terms of uniformity of fit across relevant subgroups, although substantial over prediction of mortality was observed in trauma patients and in patients admitted without organ failure to be intensively monitored. saps ii performed very wet] also in the subsample where hospital mortality was the dependent variable.satisfactory measures of calibration (goodness-of-fit p-- . ) and discrimination (receiver operating characteristics area= . ) were observed. c nr saps ii, a multipurpose scoring system developed in an international study, retains its validity in this independent sample of patients recruited in a large network of italian icus. although it has shown a good performance when adopted to predict icu and hospital mortality in the entire sample, further investigations are warranted. the observed over prediction of mortality in a few subgroups indeed call for a through assessment of the impact of confounders and biases on model performance when saps ii is adopted in samples that do not reflect the "average" icu patient. objectives: ) assess the effectiveness in a group of intensive care units by means of a quality performance index (qpi); ) assess the efficiency by means of a resource use index (rui); ) evaluate the performance of individual icus with respect to both indices (clinical and economical) while controlling for severity of illness. critical from ucis in catalonia patients alearic islands have been included in the study. inhospital mortality and weighted hospital lenght-of-stay (los) have been considered the outcome variables. severity of illness has been measured with the mpm ii at admission. in each icu, expected mortality has been obtained adding the probabilities of dying for its patients. expected los has been estimated adjusting a second order polynomial to the severity of illness. performance indices have been obtained by dividing the observed by the expected outcomes. re~ult~: the overall qpi was . and it ranged from . to . in the icus. the overall rui was and it ranged l~ont . to . . there was not a trade-offpattern between clinical performance and resource use. objectives: teaching hospitals often provide [cu care across a variety of specialized services. overall, this approach appears to result in the best risk adjusted survival rates, but at the highest cost (critical care medicine ; : - ): recently, there has been increasing focus on markers of overall hospital performance. however, in large teaching institutions, such markers may fail to detect intra-institntional variation at a large tertiary care medical center. methods: first intensive care unit (icu) day, acute physiology and chronic health evaluation iii (apache iii) and active therapeutic intervention scoring system (tiss) data were collected on random admissions to specialty icus with beds (range - ) between february i and december l, . post-operative solid organ transplant recipients were excluded. units included general medical, general surgical, and trauma, neurosurgery, cardio-thoracic surgery, and coronary care units. data were analyzed for risk adjusted outcomes: icu and hospital mortality and length ef stay (los); risk of requiring active cu treatment; and icu readmissinn using apache iii risk prediction models. results: the study icus cared for a diverse group of patients. mean apache iii scores ranged from . - . ; predicted risk of hospital death ranged from . - . %. standardized mortality ratios ranged from . to . with icus performing significantly better and performing worse than predicted (p< , ). los ratios and icu readmission rates ranged from . to . (ns) and . to . % respectively. patients predicted at low risk of requiring active icu treatment ranged from , to . % conclusions: there was wide variation in the mean level of patient severity between icus. after controlling for this severity, outcomes also varied widely. no clear pattern of overall institutional performance was evident. these data suggest that efforts to assess performance, improve quality, and maximize efficiency must be focused within individual units. programmatic evaluation of outcome allows for focused review of the processes of care contributing to good outcome (best practices) and where to focus ongoing quality improvement and cost reduction activities. background and method : we compared icu mortality in different age groups presenting with the same severity of disease. we assessed severity of illness by the physiological day -apache~ (physio-aa) score (thus excluding the age related points). for each of the following physio-a n score intervals ( - ; - ; - ; - ; > ) , we compared tcu mortality within age intervals (< ; - ; - ; - ; - ; > years - , - , - ) . in these groups mortality may be twice higher in the > years patients than in the _< years. mortality does not vary with age in low (physio a n = - ) and high (physio a n = > ) risk groups. in the low risk group, mortality is low in all the age intervals because of the begninity of illness. in the high risk group, extreme severity of disease probably blunts the impact of age and leads to high mortality rates in all age intervals. introduction: to access the actual social/clinical outcome of the patients who undenvent intensive care therapy oct) is rather difficult, quality of lilr is not easih.' defined and ohserver subjectivity is a prime factor in the evaluation. mortality ratio after discharge must be established and its causes understood. obieetives: the propose of this stud)-is to look into the mortality ratio that occurred on a series of patients that undorwent ict at our unit from of the ~iew point of severity of the original illness and the diagnostic groups. material and methods: during the period of one )-ear ( ), patients were treated at the unit, of them died, and ~ere not matched in our series because os incumpletc records. thirteen patients died in hospital after their reference to other departments, twelve patients were lost after discharge. thus. at the end. only patients were evaluated on the fu. the, were classified into the follov ng three groups: acute medical, elective surge d and acute and emergency postoperative. the patients were seen at , and months after discharge. the, were evaluated in accordance to their abili~, to being self supported in their daily life and capecity to fully return and hold to their pre~ ous jobs. apache scores were evaluated for each of the three groups and correlated to the icu dead, hospital dead, and mortality after hospital discharge, spss package was used for statistical analysis. remlts/conclasions: data shows that / patients died after discharge from the hospital, of ~itch nine died in the first three months. seventy-eight per cent of the patients were fully self supported in their daily life and % showed some kind of handicap. fosty-nine per cent of the patients wore on retirement either due to age or some form of chronic disease, when admilled to our unit. thirty-two peg cent had not been able to return to work, because the" were incapacitated on discharge. only % had return to their fully jobs but the period of the stu~, is not enough for all of them to be fully physically recovered. preliminmy statistical analysis shows us significant differences among groups. the aim of the present study is to compare the prognostic performance of five general severity indices ou coronary patienta and to find out if a proper ntatistical hundling of these indices could provide better results in these patients. methods: saps ii, mpm ii (mpm ii i mpmp ii ), apach ii end gaprik were evaluated o~ patients with acute myocardial infurction admitted to intensive care units from catulunye. calibration and discrimination were calculated for each index. calibration was calculated by th bosmer-lemeshow test. discrimination was evaluated by the area under the relative operating characteristic (roc)curve. if a model did not show a good performance it was customized using multiple logistic regression. finally, tworeduced models were developed, one fro~ the mpm series (mpm ii cor) and one from the group apache-saps (sapsiicor).their performances were again evaluated. results: discrimination was high enough for all models. neverthelees, oelibration of apache ii, saps ii and mpm was not satisfactory. thus,mpm ii , saps ii and gaprik were customized for coronary patients using the logits of both models, and obtaining good calibrations. mpm ii , and apache-saps were adapted and reduced to (mpm ii cor) end to variables (sapsiicor), respectively . both models showed better oalibrutions end discriminations than the original models. conolusion| models developed for multidisciplinary patients show a good discrimination when applied on aoronar i patients, but some needed customization in order to improve calibration. the number of variables of the principal model can be reduced (even to or variables) without loosing prognostic accuracy. objective: to compare the ability of two methods to predict outcome for intensive care patients. methods: we included consecutive intensive therapy unit (itu) admissions with an itu stay> hrs in a month prospective study (exclusion criteria: burn injury and age < yrs). data were couectsd applying the criteria described by the developers [ , ] . the definition of coma (mpm ii) was modified and the best assessment within in's, rather than the admission score, was used. statistical analysis included classification tables and receiver operaung characteristics (roc) curves to assess discriminative power, and lemeshaw-hosmer statistics and calibration curves to test accuracy of prediction. results~ average abe was yrs (ranse: - ) with a male:female ratio of . : . the actual hospital mortality was . %, mean predicted death rates were . % (mpmz ii) and . % (ap hi). non-survivors had siguitlcanfly higher predicted risks than survivors applying both methods (p< . l, t-test). the total correct classification rates (tccr) for apache iii were bett~r for all decision criteria applied (tccr, decision criterion %: apache ]/i . %, mpm ii . %). the area under the roc curve was . (ap iii) and . (mpm ii) confirming the better discrimination of apache ill. accuracy of risk prediction was similar for both models (ap nl ~ - , mpm b ;( - , lemeslmw-hosmer). showing some fluctuation, calibration curves lay close to the ideal line for predicted risks -< % with increasing deviation for higher risk groups (s. figure) . apache iii underestimated the risks of hospital death for almost all risk groups (curve above diagonal), whereas considerable overestimation for predicted risks > % ceenred with mpm~ii. objective: to assess the goodness-of-fit of the apache iii model for british itu patients. methods: we prospectively studied a cohort of adult patients consecutively admitted to a medical-surgical itu over a period of months. patients with burn injury, age < yrs and itu stay < hrs were excluded. using a eomputerlsed database, we routinely recorded hrs apache ill scores. predicted risks of hospital death were computed by critical audit ltd, london. accuracy of risk prediefion was assessed by hosmer-lemeshaw chi square (;( ) statistics and calibration curves [ ]. discrimination was tested employing classification tables and receiver operating characteristics curves (roc). restths: the mean age of the male and female patients was yrs (range: - yrs). of these patients, % were medical admissions, % were admired after emergency and % after elective surgery. the observed hospital mortality was . %, the overall mean predicted death rate was . %. mean predicted risks were siguifieanfiy greater for nonsurvivors ( . %o) than for survivors ( . %, p< . l, t-test). apache iii showed good calibration (z -~ , lemeshaw-hosmer). however, the calibration curve lay above the diagonal for almost all risk groups reflecting the tendency to underestimate actual mortality (s. figure) . the best total correct classification rate (tccr) was . % (decision criterion: %). the area under the roc curve was . % confirming the good discriminative ability of the model. objectives: the aim of this study is to point out the discrepancies between needs and actual treatment of less severely ili patients admitted in italian intensive cam units (icus) requiring only intensive monitoring, and verify the substantial likelihood of data comparing those collected from a national short term study with a regional long ternl use. ~: less severely ill patients ("observed patients") were only monitored; they did not require intubation, even if for a short period (less than houm) or major cardioeiranlatory supports, and were neurologically normal. epidemiologieal national data were obtained from giviti group (gruppo italiano valutazione interventi in terapia intensiva); this cohort study, collected patients, in two months in summer in all over italy. regional data were echieved in a three years entlection ( -i ) in lombardia' icus from archidia group (arehivio diagnostieo), including patients. mortality, severity score, diagnostic category and some typical intensive procedures were analysed and compared in both studies. patients' disgunstie categories were defined as surgical, medical and trauma, according to the main diagnosis and the presence/absence of surgical procedures. rr observed patients account for . % and % of all icu's patients respectively in national and regional data. very tow mortality rate was found in national data ( . %) and extremely low mortality in regional data ( . %). in both studies mortality, s.a.p.s. and length of stay were much lowor in "observed patients" than in general icu's population (mortality: . % and . %; .a.p.s. score: . and ; iength of stay: % and ). homologous distribution of patients in the two studies was noted for what concern their diagnostic category, aside from a slight prevalence of tranmatised patients in the giviti study. in the two groups the surgical patients were respectively % vs. %, medical patients were % vs. % and traumatised were % vs. %. % of "observed patients" in national study and % in the regional did not received any intensive procedure. only a minority of these patients availed haemodynamie eonu'ol with swan-ganz or renal haemofiltration. conclusions: these results underline that about one fourth patients admitted in italian icus benefit an oversized slructure i, relation to the real needs of their pathology. in hot more than % did non received any advanced treatment and mortality and s.a.p.s. score were substantially lower respect to general population. the results obtained from these two studies are similar, suggesting an uniform distribution of the case mix in italy, even if a different recruitment period and a different gengraphieal distribution were used. some discrepancies in the two studies were found in the diagnostic categories moreover regarding the tranmatised patients ( % vs. %); this can be explained from the seasonal (summer) characteristic of the national study. mutuality, yet very low, is different in the two groups, but these data do not allow any definite explanation. finally these epidemiologieal survey suggest need of further studies settling more strict criteria of admission in icu. this study aims to evaluate patients outcome, quality of care and effectivity of therapy in our intensive care unit. the main goal was to indentify factors that the most influence that outcome. during . the authors collected data of patients outcome and predictor variables. overall mortality rate was , %. the most common causes of death were infection. the diagnosis of sistemic inflammatory response syndrome (sirs) and multiple organ dysfunction syndrome (muds) significantly correlate with death ( %). average length of stay was . days ~. % patients died in the first ten hosiptal days and only % after days. age was directly correlated with death % of dead were older then sixty years. an analysis of physiological variables showed that serum levels of gl~cose ( %) and natrium ( %) were in optimal physiological values. serum proteins ( %) and haemoglobin ( %) levels were inversely related to death. multivariate showed that alveolo-arterio difference in content was the most informative of all mortality predictors (mean value , mmhg in % patients io>mrnhg). factor that most influence the patients outcome was infection (sepsis) and muds. use of predictive indicators of outcome in critically ill patients may help to assess treatment regimens and to compare patient groups. acute physiology and chronic health evaluation (apache if) score (crit. care had. ; : - ) and the sepsis score of elebute and stoner (br. h surg. ; : - ) have been used, objectives: to compare sepsis score and apache ii score in predicting outcome of critically ill patients. methods: overall survival during the past years for patients in our icu was calculated = % (prior probability). the outcome of patients who were admitted to our icu for > hours was observed. apache ii score on admission, patient predicted risk of death (apache ii risk) and the sepsis score on the first day of antibiotic course were prospectively recorded. discriminant function analysis of the scores in relation to outcome was performed. results: apache ii and sepsis scores in the survivors were significantly lower than in those who died ( . i . v~s . • . and . • v's . • . respectively p < . ). correct prediction of outcome by each score is shown in discussion and conclusions: although both scores have been previously evaluated in predicting outcome of icu patients, studies of the sepsis score were conducted in small numbers of patients or involved additional measurements not routinely available. this study demonstrates that the sepsis score alone or in combination with apache ii score is more effective than apache ii score in predicting outcome. objective to test the hypothesis that resuscitation titrated against gastric intramucosal ph (phi) improves survival in critically ill patients as suggested by gutierrez et al~. method emergency admissions to the intensive care unit were randomized into control and intervention groups. in the control group phi was measured at , and h while in the intervention group phi measurements were made hourly for h. both groups were managed according to the same guidelines to achieve the following targets: mean arterial pressure > mmhg, systolic arterial pressure > mmhg, urine output > . /ml/kg, haemoglobin > g/dl, blood glucose < mmol/ , arterial oxygen saturation > % and correction of uncompensated respiratory acidosis. if the phi was < . after achieving these targets, or after maximal therapy to achieve the targets, patients in the intervention group were given fluid to ensure an adequate cardiac preload and then dobutamine at then mcg/kg/h, titrated against phi. this additional therapy was continued until h after entry into the study. in each year patients were subdivided in two series with random selection, so that the st series contained abeat / and the nd / of the patients. the st series of all the years constituted the devdoping data set and the nd series the validation data set. with data of the st series ( patients), we created the predictive model, using stepwise logistic regression (bmdp, usa). each patient has been evaluated in die st, th, th and th day, calculating for each lime the apache ii score (for a total of records), independent variables were, besides time and apache ii of the time ( michaloudia g,, melissaki a., alexias g., gogafi c., kolotoura a., krimpeni g., pamouktaoglou f, filias n. objectives: to determine the medical staff's attitude towards various ethical issues methods : between january and february , anonymous questionnaires were sent to intensive care units, all over greece. results : questionnaires ( , %) were replied and returned back. of them , % were answered by male and , % by female. the doctors replied in the following rate : , % aged up to , % aged between and , % aged over . questions were answered and were divided into main topics, as following: . admission criteria: limited bed availability was the main cause for refusing admission in , % of icu's. , % evaluated each case's viability and only , % used some prognostic score system. , % of icu's accepted all cases and a significant percentage ( %) gave in to pressure coming from their colleagues ( , % female and , % male). . informing the patient/relatives: only , % was willing to tell the whole truth, while , % had given selective information.. in the case of iatrogenic incident, , % withheld it, because either they feared legal implications ( , %), or lost of trust ( , %). doctors are asking consent from the patient and/or his family, in order to include him/her in research protocols, in a rate of , %, while only , % found informed consent necessary for the proposed treatment procedure. . withdrawal of therapy/dnr orders/organ donation: , % were willing to withdraw complex treatment in patients with short life expectancy, except of administi'ating intravenous fluids, feeding and analgesics. in , % such a decis~n was unanimous, while the percentage of those carrying it out was , % ( , % female, , % male). in case of brain stem death , % ( , % female, , % male) withdrew any life support. , % would like therapy withdrawal to be legally established, while only , % would perform euthanasia, if there was substantial legal cover. for these cases, relatives' consent was considered to be necessary from a percentage of only , %. , % considered organ donation to be a necessary proposal, while , % refused to ask the patients' relatives for an organ donation, either because they didn't have the psychological strength for it ( , %), or because they doubted the procedures' objectivity ( , %). note: in greece, icu beds are less than % from the total number of hospital beds available. only a percentage of - % of these admissions comes from the same hospital, with a potentially direct evaluation. usually an icu doctor has to be informed through the telephone. finally, employment conditions in greece are such that any changes of the medical and nursing staffare limited. conclusions: the mathematical model we found has been validated also in the second series and the discrimination capability increases with time. using this model we can evaluate the probability of survive at every, time. its application at different times permits a better evaluation of haemodinamically instable patient trend. introduction: the feasibility to assess pulmonary capillary pressure (pcap) offers the opportunity to determine the longitudinal distribution of pulmonary vascular resistance (pvr). the purpose of this study was to measure pcap and to calculate pvr to determine whether relevant shifts in the distribution of pvr could be expected after routine cardiac surgery. methods: the study population consisted of consecutively admitted patients after cardiac surgery. surgical procedures included coronary artery bypass graft (cabg) (n= ) and mitral valve replacement (mvr) (n=t ). pcap was estimated by analysis of the pressure decay tracing after pulmonary artery occlusion. after estimation of pcap precapillary (ra) and postcapillary resistance (rv) was calculated. a complete set of hemodynamic variables was obtained at hour and at hours after operation. results: there were no significant hemodynamic changes during the first hours after surgery. the mvr group maintained pulmonary hypertension and higher levels of pcap. ra/rv, reflecting the longitudinal distribution of resistances, remained unchanged. however, rv predominated ra during the postoperative period in both groups. objectives: evaluation of the influence of long-term continuous i.v. administration of the ace-inhibitor enalaprilat on regulators of circulatory homeostasis. methods: t trauma and sepsis patients randomly received either . mg/h (group i, n= ) or . mg/h (group , n= ) of enalaprilat i.v. or saline solution (control, n= ) as placebo for days. plasma levels of endothelin- (et), atrial natriuretic peptide (anp), renin, vasopressin, angiotensin-ii, and catecholamines were measured before injection of enalaprilat (='baseline' values) and during the next days. results: except for et, plasma levels of all vasoactive substances exceeded normal range at baseline. angiotensin-ii significantly decreased during enalaprilat infusion ( . mg/h: from . • to . • pg/ml; . mg/h: . • to . • whereas it remained significantly elevated in the untreated control patients. vasopressin increased only in the control group (p< . ) and decreased after . mg/h of enalaprilat. et remained almostunchanged in group , whereas et increased significantly in the control patients (from . • to .t• on the th day). catecholamine plasma levels (epinephrine, norepinephrine) markedly increased in the control group (p< . ), but they did not change significantly throughout the study period in both enalaprilat groups. conclusions: continuous i.v. administration of the angiotensin-converting enzyme inhibitor enalaprilat beneficially influenced systemic and local vasoactive regulators of the circulation, which are normally increased in the critically ill. thus patients at risk of (micro-) circulatory abnormalities may profit from enalaprilat infusion. objectives: to determine the time taken for hemodynamic and gas exchange variables to a reach stady-state after a change from supine to trendelenburg position (trp). methods: we prospectively studied adult patients with severe sepsis or septic shock requiring hemodynamic monitoring. usual cardiorespiratory parameters were measured at baseline, min after the patient was placed in a trp and again min after the return to a supine position. a fiberoptic pulmonary artery catheter (svo~ oximetrix, abbott) allowing continuous svo monitoring wa~used. during the protocol we also continuously measured sao~ by pulse oximetry and vco~ and vo by monitoring partial concentration of o and co ir~ inspiratory and expiratory gases (deltatrac metabolic monitor, datex). therefore, we were able to monitor cardiac output variations by dividing vo~ with arteriovenous difference according to the fick equation (co-fick). results: no significant difference in hemodynamic status was observed min after the patients were placed in trp. despite the fact that no significant change was observed in co and vo~ estimated by thermodilution, co-fick had a tendency to dedrease continuously in trp and then to return to its initial value when patients regained supine position. respiratory gas analysis showed a small but persistent continuous increase in vco without a similar trend in vo values. conclusions: we conclude that no significant hemodynamic effect was detected in our patients after min in trp. evaluation of vo from respiratory gases analysis after a change in body's position should be interpreted with caution, since the patient may not yet have reached a stady-state after rain. since vo did not change, vco~ increase was probably due to position related changes in-pulmonary gas exchange and not to a change in patient's metabolic status. objectives: to determine whether changes in svo and/or other hemodynamic parameters during weaning trials could be used to predict successful weaning. methods: we prospectively studied adult patients with a history or clinical evidence of cardiovascular dysfunction, who were unable to tolerate spontaneous breathing (sb) for hours. for all these patients right heart catheterisation was considered necessary in order to detect hemodynamic alterations during weaning. a fiberoptic pulmonary artery catheter (svo ximetrix, abbott) allowing continuous svo monitoring was sod. hemodynamic status was evaluated ~t baseline and after one hour of spontaneous breathing through a t-piece. patients were assigned to one of two groups depending on whether they tolerated sb for hours. data were analysed by analysis of variance and unpaired student's t-test we also used multiple linear regression analysis to determine which hemodynamic variables were correlated with the magnitude of svo~ change and multiple discriminant analysis to determine if asy of the above variables were associated with toleration of sb for hours and/or successful weaning (s-w). (j physiol ; ." - ) . we tested the hypothesis that the ventilatory stimulation by dead space (vd) loading and % co inhalation is accompanied by a proportionate cardiovascular change. methods: six healthy subjects, mean age, year, performed three incremental exercise tests in a randomized order: ) inspiring air without vd (air control, ac); ) inspiring air with vd of ml (avd); ) inspiring % co ; % oxygen, balance nitrogen. the ventilatory responses were examined at matched heart rate (hr) equivalent to % peak hr. results: ventilation (vi) was significantly greater (p< . ) during the avd and co tests than during the ac test at the same work rates. end-tidal co (petco ) and estimated arterial co (paco ) were significantly greater (p< . ) at w and w. oxygen saturation was significantly lower (p< . ) during the avd test than during the ac and % co exerdse. at matched hrequivalent to % peak hr, vi was significantly greater (p< . ) during the avd and % co tests than during the ac exerdse ( l, l, and /). conclusion: we conclude that the increase in xri and petco due to vd loading and % co inhalation is not associated with an acceleration in hr. sup.ported by mrc (canada). objeetlve: the production of large amounts of oxygen radicals from the onset of ~en may be responsible, st least in part, for peroxidative damage to myocardial tissue. the aim of this study was to evaluate the time dependence of plasma tbars in patients with am] receiving thrombolytie therapy (tt). patients and m~hods: filiy eight patients admitted in icu ( men and women; mean age . - . years) rec~ving systemic tt for possible am] were ~died. all patients received recorabinant haman tissue-type plasminogen activator (r-tpa). the mean time fi'om the onset of symptoms and the be~nning of tt was . - . hours. peripheral veao~s blood samples were obtained fi'om each patient before and serially after tt ( , , and hours). tbars levels woe determined by using a spectrophotometrie technique. rq~r fusion was identified by the timing of ereatine phosphate kkmse (cpk) peak (< hours). table i list the variation of plasma eoneenlrations of tbars (mean -sd) in groups (a,b, and c) as a function of time from the beginning of tr. co,arisen oftbe time cuncentzatiens reveal a difference p<o. between group ami (a and b) versus group c. the between-groups (a-c) comparison showed significant differences (p<~). ) at , and hours fi-om de begin~g of'it. comparison ofthe , and hours eonocnlratiens did not reveafl any difference becween n~ (group b) and angor (group c). condmien: we have observed a maintenance of high level of tbars in reperfused patients enly. these results suggest that the increase of tbars levels may be due to phospholipid derangament of reperfused myocytes. objective: to detemline if tbars levels may be an early index reflecting peroxidative damage in ami patients. patients and methods: by using a spectrophotometric teclmiqtm, based on a modificatien oftbe buege and aust method, tbars levels ware determined in healthy subjects (group i) , patients with several risk factors of ischaemic cardiopathy (group if) and icu patients with possible aim ( were confirmed ami (group ma) and were angor (group iiib)). peripheral blood was obtained at the time of the icu admission in the group i . electrecardiographic data and eehocardiographic wall motion were used to identify ami location (anterior, inferoposterinr and indeterminate). statistical analysis was made with a standard statistical package (rsigma, horus hardware). , h , s, , h statistically significative increase of ' ix~e/ea.ee x~* tbars levels (p< . ) only in pstients with con/tuned ami (group ilia) . no differences were found between the rest of the groups. the figure shows the relationship between the tbars values and the time from the onset of the aim's symptoms. conclusion: we have found that in am/patients the tbars levels can be used as an early index reflecting peroxidative damage occurring to ischemie tissues. perioperative risk in patients with ischemic heart disease. the protective role of diltiazem. lg. hatziantoniou, p. tassiopoulos, c. fakiolas, ! g. foussas~ m. lycourinas perioperatlve morbidity and mortality are mainly of cardiac origin, particularly among elderly patients (pts) ~ith ischemic heart disease. we performed a randomized trial, in order to investigate the possible protective activity of diltiazem (d). methods: pts (aged zo• with a history of coronary insufficiency were subjected to major urological operations. they were randomized to two groups: group i ( pts) -p:ithout d and group ii ( pts) -d ~as administered . mg/kg iv bolus hours prior to anesthesia and . mg/kg/h upon the end of operation and for at least hours post-operatively. iv was substituted by oval administration of x mg starting the next day and for the rest of hospital stay. all pts underwent daily clinical, electrocardiographic and laboratory (ck-mb) control. results: are shown in the following interactions between the heart-lung unit and a cardiac assist device are the crucial issues for successful outcome of patients under mechanical circulatory support. several factors have been indicated and we can diffrentiate between anatomical and hemodynamic interactions. especially right heart failure and pulmonary hypertension have been proven to limit left ventricutar assist device (lvad) performance. in order to study the effects of right heart failure (rhf) and pulmonary hypertension (pht) on mechanical circulatory support, we designed an experimental study in dogs and combined in six groups left heart failure (lhf) and rhf and pht, respectively. in the control group we induced lhf with subsequent occlusions of lad and cx followed by reperfusion: in the next group we supported with an lvad during minutes starting minutes after cx occlusion (group if). in the next group we added right ventricular ischemia by occluding the rca simultaneously to the cx (group iii). these both groups we repeated only with pre-existing acute pht induced by the injection of o fm glass beads (groups vi and v). a last group was similar to group v (lhf and rhf and pht), but instead of a lvad, we used bvad support. in i and v no animal survived the second perfusion period ( hours). in ii and iii (no pht), all dogs survived in stable conditions. in iv (lvf, pht), % survived, the remainder died of incomplete recovery. in vi with bvad, only % survived. in iii and v, during occlusion of the rca, the right ventricle stopped contracting and right atrial pressure and mean pulmonary pressure equalized. this lead to a significant drop in inflow on the left heart side, which still provided sufficient lvad performance in case of absent pht (iii) and lead to death due to "low lvad output" syndrome in v. this "low lvad output" snydrome could be partly overcome by bvad support. we conclude that heart-lung interactions play a major role in lvad performance. by optimizing the perioperative management, they all can be overcome, except the occurrence of alveolar leakage syndrome. obiectives : we propose a new approach of transmural pulmtmary artery occlusion pressure (paoptm), in presence ef peep, from the folluwing hypothesis : if respiratory swings of paop are compared to those of alveolar pressure (apalv = plateau pressure -total peep), an index of transmission of airway pressures to pulmonary vessels is obtained (i t = apaop/apalv). the value of the product of it by peep can be substracted from end-expiratery paop (paopee) to obtain a calculated paoptm (paoptrnc). thus paoftmc = paopee -(apaop/apalv x peep). methods : we tested this hypothesis in patients by comparing paopee, paoptmc, and paopnadir obtained within the first seconds after disconnection from the ventilator, value of reference of paoptm in absence of intrinsic peep (peepi). at zeep, peepi was absent in patients (group a) but present in others (group b). patients were studied under the peep level chosen by the attending physician-(gr a : +_ ; gr b : _+ cmh ). results : l. gr a : paopee ( _+ mmhg) differed (p < - ) from paopnadir ( • mmhg) and paoptmc ( _+ mrahg). gr b : paopee, paopnadir, paoptmc differed between themselves ( " - , + , + mmhg respectively). . good correlatkm (r - (i. ) and agreement between paopnadir and paoptm were found in gr a, while there was no agreement in gr b (bland and altman analysis). . lung compliance (v t/bpah,) correlated well with i t in both groups (r - . ), suggesting that our hypt)thesis was strtmg even in patients with peepi. conclusions : paoptm under peep ventilation can be obtained, even in patients with peepi, from parameters easily measured at the bedside. introduction: cardiopulmonary bypass (cpb) may cause ischemia in several organ systems like the heart, brain and kidneys. reactive oxygen species (ros) are formed by subsequent reperfusion and stimulation of neutrophils by cpb. ros are harmful to biological systems e.g. cellular membranes, enzymes~ dna. many natural antioxidant systems protect against the effect of ros. in patients undergoing cabg we evaluated the production of ros by total plasma antioxidant status (tas) and lipid peroxidation measured by lipofuscin flip). methods: tas (randox, uk) and concentrations ofllp (tsuchida et al.) were measured in consecutive patients undergoing cabg. all the patients had a normal serum creatinine clearance (> ml/min). serum samples were obtained a) before operation, b) after removal of the aortic crossclamp, c) at admission to the icu, d) hours after operation, e) hours after operation. results: tas was significantly decreased after removal of the aortic crosselamp ( b, c and d lower than a), followed by a subsequent significant increase of lip ( c and d higher than b). the levels of tas and lip returned to baseline hours after operation. methods: patients with preoperative lvef< % undergoing coronary artery bypass grafting were studied. after surgery, a f femoral artery catheter was inserted and connoted to a fiberoptic monitoring system (cold z- t; pulsion medizintechnik, germany); this allows, with a double-indicator dilution technique, the calculation of cardiac index (ci,l/min/m ), intrathoracic bood volume (itbv,ml/m ), pulmonary blood volume (pbv,ml/m ) and extravascular lung water (evlw,ml/kg). with a f pulmonary artery catheter, wedge (w,nunhg) and central venous pressure (cvp,mmhg) were measured, while extraction ratio (o exr,%) and oxygen delivery (do ,ml/min/m ) was calculed. peak inspiratory pressure (pawp,cmh ) and mean airway pressure (mawp,cmh ) were measured with a varflex flow transducer (bicore,sensormedics,us). the patients were studied after minutes (to) of volume controlled standard ratio ventilation (vc), and after minutes (ti) of stabilisation period of pcirv ( % inspiratory time, % pause). vt,ve and total peep were held constant in every mode of ventilation. +_ . " *'p < , versus to conclusions: these data show that pcirv : is a safe ventilatory support also in cardiac patients with impaired ventricular function, and monitoring of itbv is more reliable to measure and optimise circulatory volume status, than w and cvp. c.ledeki-,g.rldisis,s.karotzai,c.micheilidis,m.agioutantb, g.beltapaulos. objeolivee:to evaluate the influence of lvswl on the well known correlation of sr and svo . paw eight patients ( melee end females) were included in this study regerdlen of the icu ~h"niseion couse. all paints were ,'~theta~ with e fiboroptir pulmonary artery catheter connected with an oxymetfir (r)~ so /co abbot computer.for any pulmonary artery catheter insertion, two pain= of sr and svo were obtained, one dudng inserlion and one during taking the catheter out. for any pair obtained, we eleo collected the deta concemig with the pedient's hemodynamir and oxygenation end we calculated the lvswi. were significantly (p<o. ) higher in group i. conclusion: breathing room air, the less hypoxemic patients had a rather satidactory do and tissue oxygenation (pro ) because they had properly adapted their ci. the absence of this mechanism (right heart impairement ?) in the hypoxemic patients, in spite of higher blood ne and e, was responsible for the poor do and pro . objectives: acute massive pulmonary embolism (pe) increases pulmonary artery pressure (pap) and dght ventdcular aftedoad, which may lead to dght ventdcular failure. inhaled nitdc oxide (no) selectively dilates pulmonary vessels. thus, inhaled no may be of potential therapeutic value in the management of the acute phase of pe. methods: following institutional approval, ten piglets (body weight + kg) were anaesthetised (midazolam/piritramide) and ventilated using a modified servo ventilator (siemens elema, sweden; fio . ). the following variables were obtained: systolic pap (spap), mean pap (mpap), diastolic pap (dpap), mean artedal pressure (map), central venous pressure (cvp), pulmonary capillary wedge pressure (pcwp), cardiac output (co), and artedal (pao ) and mixed venous (pvo ) oxygen saturation. pulmonary vascular resistance (pvr) was calculated. to induce pe, pm microspheres (sephadex g coarse, pharmacia biotech, freiburg, germany) were injected in an amount sufficient to increase mpap to mmhg initially. rain after embolisation when haemodynamics were in a steady state (control ), inhaled no was administered. further measurements were taken min after ppm no (no ), min after ppm no (no ), and min after discontinuation of no administration (control ). the administration of inhaled no resulted in a significant decrease in spap, mpap, and pvr. the cessation of no inhalation led to a complete return to pretreatment control values (table) . co, map, cvp, pcwp, pao?, and pv~ remained unchan no administration. objectivss:evsluate the yield of recombinant tissue plasminogen activater(rt-pa, actiiyse ~ oehringer ingelheim) as a thrombolytic agent ie pulmonary embolism ie .kr~auma patients. methods: in five patients with diagnosed pulmonary embolism(blood gases, chest x-ray, echocardiography, perlesion lung scans) were given rag of actij.yse as ~ hrs infusion, followed by heparin~single j. ihjaction snd iefusion ie doses - j./kg/day).the effectiveness of rt-pg thrembo].ytic sctier~ was svaluated im . . hrs(blood gases) amd on the third dayafter t~eat-,ment(~chocardiography and lung scan). results: three hrs after actilyse was given we observed significant clinical imprevemeet,confirmed by elevation of pao and sao in dlood.echocardiegr~m on the third day showed regression of pulmonary hypertension and lung scans showed % improvement in total lung perfusien. except slight bleeding from the site of injection nc~ more thromboiytic complicatioos were observed. conclusiens: actilyse used in five hrauma patients with pulmonary embol.ism was a very effsctive and safe thrombolytic agerlt, inducing rapid and evident clinical improvement. intermittent positive pressure ventilation ( ppv) by increasing pleural pressure, decreases the pressure gradients for systemic venous return and left ventricular (lv) ejection. we have previously shown that when inspiration is synchronized with systole using synchfjv in patients with severe cardiomyopathy, that cardiac output (co) was increased relative to both ippv and non-synchronized hfjv ( ). however, it is not known if similar effects could be realized in ventilatordependent patients with lesser degrees of lv dysfunction and fluid overload. we thus compared synci-ifjv to ippv in stable patients following coronary artery bypas grafting. methods: normothermic who were stable (< % variance/h.) were studied following admission to the sicu. heart rate (hr), mean arterial (pa), pulmonary artery occlusion pressure(ppao), co by continuous thermodilutiun (vigilance, baxter, usa), mixed venous saturation (svoz) and arterial blood gases (abg) were measured after rain. of each step. ippv was simv adjusted for a rate, tidal volume and fit to insure both normal abg and a peak airway pressure < cm h,o. syncfifjv was delivered by a hfjv ventilator (acutronic) during systole with ventilator parameters adjusted to optimize abg. protocol: patients received three ippv runs (ippvi. , ) with synchfjv runs interposed (hfjvz ). statistics: anova for repeat measures and paired t-test were used to compareruns and demonstrate variability. results:no significant difference in any of the measured hemodynamic variables were seen among the ippv and synchfjv runs (table) . post hoc separation of patients by preoperative ejection fraction (ef; ef > % ; n= and < %; n= ) did not alter these results. back~ound: in man, vascular endothelium-bound ace is expressed in concentrations greater than x that in serum and is believed to be the site of synthesis of circulating angioteusin il it is unclear whether ace inlubitors interact similarly with ace in different vascular beds. coronary vessels possess all the components of the renin-angiotensin system, including ace which may be involved in normalcardiac homeostasis, as well as in the pathogenesis of various cardiomyopathies. obiecfive: to develop a method for assaying the interaction of ace inkibitors with coronary endothelium-bunnd ace in man, methods: ace a~aty was meas~ed in five patients undergoing cabg surgery, from the transeuronary hydrolysis of the synthetic ace substrate h-bpap. trace mnou~ of ~fi-bpap ( gci) were injec~d as a bolus in the root of the aorta and simultaneously blood was withdrawn from a coronary sinus catheter into a syringe containing protease inhibitors which prevented the convession of umeaet~ ai-i-bpap by blood ace. the sample was later centrifuged to separate cells from plasma and the radioactivities due to formed product (~rl-bphe) and total sh were astimated in a [b-counter. two additional such determinations of ace activity were perform~ the second in the presence of . pg/kg e (coinjected with ~-i-bpap) and the third ten minutes after e. results: all subjects were hemodynamically stable throughout the course of the there were no noticeable hemodynamic effects of e. control transcorunary metabolism of~-bpap averaged g -a: %, in agreement with previously reported data. in the presence of e, % metabolism of ~-bpap was reduced to • reflecting a • inhibition of normal ace activity. ten minutes after e, ~ri-bfap metabolism had partially recovered to :l: %, representing a -a: % inhibition of control ace activity. from this data, the dissociation constant of e for coronary ace in vivo was estimated as . x " sec "l. conclusions: we have demonstrated the feasibility of repeated, reproducible measures of coronary endothelium-bound ace activity and of its inhibition by e. this procedure is safe and can be used to study the role of ace in normal cardiac function and in card pathologies. objectives. primary pulmonary hypertension (pph) is a progressive fatal disease of unlmown origin, with median life expectancy of less than three years after diagnosis. the responsiveness of pulmonary hypertension to a variety of vasodilator agents led to the speculation that, concomitant with vascular renmdelling processes, persistent vasoconstriction is an important feature of the disease. long term use of ca-channel blockers and intravenous pgiz may improve mortality in certain populations of pph patients, but both of these treatments lack selectivity for tire lung vasculature. the aim of this study was to test the efficacy of aerosolised prostacyclin and its stable analogue, [loprost for selective pulmonary vasodilatation in pph. methods: in three patients with pph, we compared aerosolisation of prostaglandin iz (pgi ) and iloprost to a battery of vasodilatory agents (diltiazem, nifedipin, inhaled nitric oxide, intravenous pgiz). results: nebulisation of pgi and iloprost tumed out to be most favourable for achieving effective and selective pulmonary vasodilatation. pulmonary vascular resistance decreased from + to -+ dyn*s*cm (p< . ) and pulmonary artery pressure from . + . to + . mmhg (p < . ), cardiac output increased from . + . to . _+ . i/rain (p < . ), mixed venous oxygen saturation from . _+ . to . + . % (p < . ) and arterial oxygen saturation from . + . to . _+ . % (mean _+ sem of trials in patients). -month iloprost nebulisation in one patient ( gg/day in six aerosol doses) demonstrated sustained efficacy of the vasodilator r~men. conclusion: aerosolation of pgi or its stable analogue may offer as new strategy for selective pulmonary vasodilatation in pph. endothelial adhesion molecules may play an important role in the pathogenesis of myocardial cell damage, and may contribute to the progression of heart failure. we measured the plasma soluble intercellular adhesion molecule- (sicam- ), vascular cell adhesion molecule- (svcam- ), and e-selecfin (selam- ) levels in patients with acute myocardial infarction admitted within hours after onset. peripheral venous plasma-samples were collected at the time of admission, , , , , and hours after onset. plasma soluble adhesion molecule concentrations were determined by elisa. patients were divided into groups as follows: group ; killip's class (k) and without thrombolytie therapy, group ; k and with thrombolytic therapy and group ; k and . both plasma sicam- and svcam- concentrations in group and were elevated rapidly and significantly and maintained at a high level during the first days. plasma selam- level did not change in any of the groups. these results suggest that the adhesion molecules icam- and vcam- may play a role in the pathogenesis of myocardial reperfusion injury and may indicate its severity in myocardial infarction. objectives: nitric oxide (no) is known to exert cytotoxic and negative inotropic effects on cardiomyocytes. no synthase activity has been reported to be increased in infarcted area in animal model of myocardial infarction. these findings suggest that no may be an important regulator for myocardial damage and cardiac function after myocardial infarction. we measured plasma no no -(nox) levels and estimated serial changes in acute phase of myocardial infarction. methods: subjects were patients admitted within hours after onset. venous blood samples were collected at -hour intervals on the first day, -bour intervals on the nd day and -hour intervals on the rd day and th days after onset. plasma nox concentrations were determined by griess method. results: the time course of the plasma nox levels (mea~+sem) displayed a tendency to gradually increase and to make a biphasic pattern with two peaks about hours and - days after onset (basal level; . _+ . , first peak; . !-_ . , second peak; . + . ram/l). plasma nox concentration was not influenced by the thrombolytic therapy, and nox values at the time of hours after onset were significantly correlated with maximal plasma creatine kinase level (r= . , p< . ). the levels of plasma nox in the early stage of myocardial infarction (from admission to the th day after onset) did not correlate significantly with the hemodynamic parameters (left ventricular ejection fraction, pulmonary capillary wedge pressure). conclusion: the early and late increase in no production after myocardial infarction may be implicated in the deterioration of myocardial contractility and induction of myocardial damage in the early phase of myocardial infarction. range - ) fullfilling the high risk criteria of shoemaker (colectomy , gastrectomy , pancreaticoduodenectomy , others ). patients were admitted to the icu preoperatively. arterial and pulmonary artery catheters were inserted and hemodynamics and oxygen transport were measured at admission and after stabilization to predetermined physiological end points. patients were considered stable when ci > . l/min/m , pcwp > mmhg, hb > g/l, sat >. . objectives: evaluate the acute effects of , mg ipratropium bromide and , mg fenoterol (ibf) inhaled dose on pulmonary function in nonsmocers (nb:m) and smocers (s) with sever (new york heart association class ii-iii), stabile congestive heart failure(chf) and healthy subjects. methods: pulmonary function tests were performed < h postprandial. the tests consisted el arterial blood gas aspiration followed by routine spirometry and pletismography, and single-breath gas analysis. after performance of these maneuvers, the patients was administred puffs-ipratropium bromide ( , rag) and fenoterol ( , rag). for , h, spirometry was repeated. results: in resting, pulmonary abnormalities observer in the s group were more severe then abnormalities observere in the nsm group. after treatment with ibf the improvement in pulmonary function was even more marked in patients who had smoked. the mean changes by forced expiratory volume in second(eevt) was , % (p< , t) improvement and , % (p< ,ob), forced expiratory flow betwen % and % of the forced vital capacity (fef . ) was , % (p< , ) and , % (p< , ) and maxamal voluntary ventilation (mw) was , % (p< , ) and , % (p<o, ) improvement. the mean changes in normal subjects were mild (fev increased by , %,fef - by , % and mvv by , %). we observed no adverse heamodinamie conseevence and no arrthytmogenicity. conclusion." in patients with chf the airway response to ibf is highly significant. further study is needed to determine whether therapy with ibf will load to improvement quality of life in patients with chf with dearly documented venti/atory defects. compared with unilateral ima grafts, usage of bilateral ima grafts in cabg patients causes greater thoracic trauma and further reduces blood supply to the sternum and intercostal muscles. these effects may be associated with increased postoperative respiratory complications obiectives: to study the effects of bilateral ima grafts on postoperative respiratory morbidity in cabg patients. methods: two groups of patients undergoing cabg were prospectively studied: group (n= ) received both imas as grafts and group (n= ) received only the left ima. the two groups were matched for age, smoking habits, total number of grafts and preoperative ejection fraction. pao /fio ratio was measured in all patients in the icu, at , , minutes on mechanical ventilation (mv), at , , minutes after extubation (ex) and on postoperative day (pod) . in addition, radiografic scores of atelectasis and pleural effusion were assessed postoperatively. results: group had significantly longer bypass ( _+ vs + . p< , ) and aortic cross clamp time ( +- vs + , p= , ). pao /fi ratio was significantly higher in group only at minutes after extubation (table) . there was no difference in the incidence or severity of atelectasis or pleural effusion between the two groups. the duration of mv was longer in group ( +_ vs _+ , p= , ), but the length of icu stay and hospitalization were similar. there was one case of pneumothorax in group and one case of pulmonary infection in each group. after extubation m[n min min min* rain min pod ' _+ _+ + -+ - -+ _+ _+ _+ _+ -+ _+ _+ -+ mean_+sd, *p=o, o conclusions: compared with unilateral ima grafts, the usage of bilateral ima grafts in cabg patients is not associated with increased postoperative respiratory morbidity. the diagnosis of rv ischaemia is difficult in the critical care setting. the purpose of this study was to determine the ability of rv endomyocardial and interstitial ph electrodes to detect rv ischaemia in an animal model of rv infarction produced by fight coronary artery ligation. we hypothesized that changes in transmural and interstitial ph would accompany the induced tissue hypoperfusion. rv interstitial (phint) and transmural endomyocardial ph (phendo) were measured in adult anaesthetized pigs before and serially after coronary ligation. phendo and phint fell progressively and significantly following coronary occlusion. this was accompanied by ischaemic ekg changes. the absolute and relative rates of change were greater for phendo compared to phint, particularly after minutes of ischaemia, ph was unchanged in control experiments when the electrode was placed within the fight atrial or ventricular chambers, as well as when coronary ligation was not performed. these data suggest that rv myocardial ph measurements reflect coronary ligation induced rv ischaemia, ph recorded from an electrode placed against the rv endomyocardial wall via a central vein was as useful as an interstitial measurement that required a thoracotomy. this newly described technique may be helpful in clinical settings where differentiation between ischaemic and nonisehaemic causes of rv dysfunction is important. centre. depts of cardiac surgery and anesthesiology, university of bari, italy. lung injury secondary to cardiopulmonary bypass (cpb) is well recognized. nevertheless, mechanical respiratory changes after cpb have been poorly investigated. aim of the study was to evaluate the effects of cpb on respiratory mechanics. elastance of the lung (est l), chest wall (est cw), and total respiratory system (est rs) were measured in patients without previous pulmonary disease undergoing elective cardiac surgery. there were males and females; no pleurotomy was done. cpb was carried out with membrane oxygenator. mean cpb and cross clamping times were _. and • min. flow (pneumothacograph), airway opening and esophageal pressures (pressure transducers and esophageal balloon) were measured on patients sedated and paralysed. measurements were obtained before sternotomy, at the end of cpb after chest closure, four and seven hours later. est rs, est l and est cw, were measured by occluding the airways and the end of a tidal breath. before end cpb- h after h after stemotomy closed chest cpb cpb estrs (cmh /l) . + . . - . " . _+ . * . - . * est cw " . _+ . . • . + . . -+ . est l " . -- . . - . " . -_ . " . _+ . " x + sd. * p < . : anova vs "before sternotomy". our data show that cpb induces increase in est l, whereas est cw remains unchanged despite sternotomy. impairment in est l after cpb evolves within the first hours and stabilizes hours later. during the clinical course of human imunodeficiency virus infection (hiv), patients (lots) can develop congestive and dilated cardiomyopathy syndrome (dcm). the aim of our study was to analyze the prevalence of dcm among an hiv population, its clinical and echocardiographic changes under a long term follow-up and therapy with an ace-inhibitor agent (captopril). we prospectively studied pts, % ( / ) developed dcm during the follow-up study. among this group % ( / pts) were in class i and ii and % ( / pts) in class iii and iv of the nyha classification. we divided this population in a acei+ ( pts) and acei-( pts), according to the administration of captopril. we analyzed the following parameters: age, gender, race, ivda, type of hiv, cdc classification, number of t and t type cell population and its t /t ratio, therapeutic with acei, type and number of opportunist infections, mycobacteriosis and neoplasm's. we analyzed several echocardiographic parameters, which included the initial (i), final (f) and variation (a) of the lv internal diastolic (lvdd/mm) and systolic (lvsdimm) diameters, lv % of fractional shortening (lv%fs/%), ivs and posterior wall thickness and lv mass (lvm/g). the two groups differed significantly in the following parameters: left ventricular functional indices of patients (pts) with iscjhemic dilated cardiomyopathy (idcm) have a critical value in terms of clinical prognosis of this disease. three-dimensional echocardiography ( -de) is a recently developed method that gives a better evaluation of lv morphology and function. the purpose of our prospective study was to assess the clinical applicability of this new -de method in a population with ischemic dcm diagnosis and calculate its lv indices of global and regional function. we studied a group of idcm pts, mean age _+ yrs, % male gender, using a combined -de tee approach. all pts were in class ill/iv of the nyha classification. first, ekg gated images were acquired through a mechanical pullback of the tee probe, and each set of data was transferred to a conventional ibm-pc system using a dedicated -de software. computer processing and analysis of the tee images led to a -de reconstruction matrix and off-line calculation of several lv global and regional indices. in all idcm lots the lv cavity was clearly reconstructed and end-systole and diastole in several orthogonat projections, out in multiple planes and its function quantitated using -de derived indices. mean values of -de lvesv= -+ ml, lvedv= _+ ml, lvstv= _+ ml and lvef= -+ % were obtained. for all these -de parameters, good correlations were observed with -de lv measurements obtained through biplane tee analysis of the lv cavity (r>. ; p<. ) as well as regional analysis of sequential -de cut planes. conclusion: in our group of patients with the diagnosis of ischemic dilated cardiomyopathy, this new -de method could be applied. our results show that this method allows a better assessment of the lv morphology and spatial geometry, with the calculation of global and regional indices with critical clinical and prognostic value in this particular cardiovascular pathology. simultaneous left atrial (la) and left ventricle (lv) inflow analysis assessed by pulsed doppler tee illustrate the loading conditions and reflect the hemodynamics of the left heart. we performed a prospective tee pulsed doppler study with recordings of the transmitral lv filling and pulmonary venous (pv) flow drainage in a group of patients with dilated cardiomyopathy (dcm). a group of dcm patients, mean age _+ yrs, % male were studied. this population was divided according to tee severe lv dysfunction (group slvd+ % pts; group slvd- % pts) in each pt we measured the peak velocities (vel/m/sec) and time velocity integrals (vti/m) of the transmitral early (e) and late (a) filing waves, the vel and vti of the pv systolic (s), diastolic (d) and atrial contraction (c) reversal flows. -de tee evaluation of the lved, lves, lvst volumes and lvef were obtained. we calculated other parameters, such as e/a, s/d and a/c ratios and the sum of c+a vel, that refelect la systolic function and lv compliance. + -_ . simultaneous and quantitative analytical approach of the pulmonary venous and transmitral flows and ventricular volumes improve the non invasive assessment and understanding of left ventricular diastolic function and cardiac performance in dilated cardiomyopathy patients. objectives : to assess the hemodynamic effects of fluid loading (fl) in acute circulatory failure (acf) due to acute massive pulmonary embolism. methods : hemodynamic measurements (fast-response thermistor pulmonary artery catheter) were performed at baseline (baseline) and after a rapid fluid loading with (fl ) and (fl ) ml of dextl'an (rhemacrodex| in patients free of previous cardiopulmonary disease ( • yrs) with acf (ci < . l/rain/m ) due to angiographicalty proven mpe (miller score > ) . results : are expressed as mean _+ sem and compared by anova. a significant negative correlation (r = . ) was observed between baseline rvedv[ and the effects of fl on ci. such correlation was not observed between baseline rap and the fl induced increased in ci. conclusion : fusibmificantly increases ci in acf due to mpe. however, the simultaneous decrease of arterial content due to hemodilution, limits the benefits expected from improved ci on peripheral oxygenation. obiective: to examine the hemodynamic effects of external positive endexpiratory pressure (peep) on right ventricular (rv) function in acute respiratory failure (arf) patients. methods: incremental levels of peep ( - - - cmh ) were applied and rv hemodynamics were studied by a swan-ganz catheter with a fast response thermistor for right ventrieular ejection fraction (rvef) measurement in mechanically ventilated arf patients (lis = . ~- . sd). according to the response to peep , two groups of patients were defined: group a ( pts.) with unchanged or increased rv end diastolic volume index (rvedvi) and group b (h pts) with decreased rvedvi. results: in the whole sample cardiac index (ci) and stroke index (sj) decreased at all levels of peep, while rvedvi , rv end systolic volume index (rvesvi) and rvef remained anchange d. at zeep the hemodynamic parameters of the two groups did not differ. in group a, ci decreased at peep , rvef decreased at peep (~ . %)~ rvesvi increased only at peep (+ . %) and rvedv[ reded unchanged. in group b, ci and rvedvi started to decrease at peep , 'rvesvi decreased only at peep (- . %), anf rvef was unchanged. individual behaviors of the hemodynamic parameters at the levels& peep were studied. rvedvi and ci were significantly correlated in out of:l patients in group b, and in no patient of group a. on the contrary, mpap and rvesvi were significantly correlated in out of patients in group a, and in no patient of group b. the slope of the relationship between rvedvi and rv stroke work index (rvswi) expresses rv myocardial performance. this relationship was significant (no change in rv contractitity)in patients of group b and in patients of group a. in some patients of group a, increments of peep shifted the rvswi/rvedvi ratio rightward inthe plot (rv function decrease). conclusions: in arf patients peep causes more often a preload decrease with unclmnged rv conctraetility. on the contrary, the finding of increased rv volumes during the application of peep is related to a decrease in rv myocardial performance. thus, these data suggest that application of peep might be considered as a stress test to assess rv function. right introduction: after heart transplant (ht), the right ventricle can be subject to an acute pressure overload, especially in cases where there is a preexisting severe pulmonary hypertension. this provokes right ventricular failure and, occasionally, circulatory collapse in intensive care unit. desire the advances that have been made in systems for preserving the donor heart and in post-surgical management, we have failed in our attempts to totally avoid this problem. the right ventricular function, although it usually remains within tolerable limits in these patients during the post surgery period, represents a factor which limits the results achievable in clinical transplant programmes. objectives: to determine the maximum tolerance of the right ventricle (mxtrv) when faced with acute pressure overload. to study the function of both ventricles of the healthy heart (donor) when faced with different degrees of pulmonary hypertension. to detect possible interactions between the ventricles in the absence of the pericardium to approximate the experimental model to the clinical model of ht. materials and methods: the pulmonary artery is progressively constrained in an experimental model until biventricniar failure is detected. this experiment is performed in two diffferent situations: with and without pericardial integrity. results: when pericardial integrity is maintained the mxtrv faced with a pressure overload is . + . nun hg. when this pressure is exceeded there is a circulatory collapse with a sharp fall in the cardiac output and in the aortic pressure. however, when pericardectomy is performed (model similar to ht), only • . nun hg is tolerated (p < . ). conclusions: with the pericardium open, as in heart transplant, the maximum pressure that the right ventricle can support is significantly less than with the pericardium closed. the pericardium has a positive effect in protecting the systolic ventricular interaction. it is, therefore, advisable to close the pericardium after heart transplant. jb prrez-bernal, a ordrfiez, a. heroandez, jm borrego, map camacho, c cruz, mac s~nchez, j monterrubio, c garcia, e. gonz~lez. hospital uulversitario " virgen del rocio ". sevilla. espaiqa. introduction: nowadays cardiomyoplasty isused incases of cardiac insufficiency as an alternative to cardiac transplant. after surgery the patients show a noteable improvement with the aid of this "biological circulatory assistance". some researchers suspect that the improvement could also be due to the formation of new blood vessels from the muscle that wraps the heart, nourishing the ischemic myocardium. objectives: our cardiovascular research group has proposed as an objective, the detection of any possible myocardial neovascularization through the muscle used for cardiomyoplasty. in the case that there are new blood vessels to the diseased myocardium through the wide dorsal muscle in which it is wrapped and which aids it mechanically, it would be possible to confirm the worldng hypothesis that cardiomyoplasty not only improves the cardiocirculatory funcfinn mechanically but also by facilitating a better blood flow to the ischemic myocardium. materials and methods: the cardiomyoplasty technique is described using an experimental model of myocardial ischemia. the vascular cast is achieved by injecting methacrylate simulataneously into both the coronary tree and the wide dorsal muscle, in five experiments the connections between the coronary vascular system and the vascular structure of the wide dorsal muscle are demonstrated, conclusions: we have demonstrated that cardiomyoplasty, as well as improving ventricular function, favours the revascularization of the myocardium. cardiomyoplasty could be indicated for cases of ischemic cardiopathy in patients in whom it is not possible to perform direct revacularization using conventional methods. a the therapeutic cardiological manouevres necessary in cases of ischeima reperfusion have increased considerably: fibrinolysis, transluminal angioplasty, coronary revascnlarization surgery and cardiac transplant. the appearance of a specific pathology ht acute reperfusion has been related to free oxygen radicals (for) generated by oxidative damage. objectives: to evaluate the appearance of for during a conti-olled process of ischemia-reperfusion in an experimental biological model and compare it with that in clinical cases. materials and methods: transitory cardiac ischemia was performed in five rabbits by reversible surgical ligation of the descending anterior coronary artery. after minutes coronary reperfusion was performed. blood samples were taken in the basal situation, at the end of ischemia and at , and minutes after the start of reperfusion. malondialdehyde (mda) was measured to evaluate the degree of lipid peroxidation (oxidative damage to the membrane). in ten patients undergoing conventional cardiac surgery the production of for was measured after aortic clamping. results: we observed that after minutes of reperfusion there was a highly significant increase (p < . ) in the mda values (mean = . /zmols/l). these returned to basal levels after and minutes of reperfusion. conclusions: an "explosion" of oxygen free radicals was detected very quicldy, just a few minutes after post-ischemia reperfusion. thus, if antioxidant agents are to be used to reduce the toxic effects of the for, these will ordy have a therapeutic effect if they are administered in the early phases of reperfusion. introduction: aortic connterpulsation is a ventricular assistance widely used in intensive care units in patients with cardiogenic shock as a provisional ventricular assistance. paraaortic or external aortic counterpnlsation is been investigated as a definitive veutricular assistance in those cases of terminal congestive heart failure and when heart transplantation is counterindicated. aims: to assess the haemodynamic effects of an aortomyoplasty in a biological model of congestive heart failure. material and method: as specimens, we used "large white" pigs. mean weight was kg. after the administration of conventional anaesthesia, dissection of the ladssimns dorsi muscle was performed on the samples at the laboratory of experimental surgery of our hospital. then we performed a thoracotomy at the level of the fourth intercostal space to reach the thoracic aorta. the aorta is dissecated centimetres from the exit of the subclavia and it is wrapped by the dissecated muscle. a cardiomyostimulator is provided in order to allow the synchronization between the diastole and the muscle contraction. the model of heart failure was provoked using verapamil plus propanolol i.v.. results: a significant increase of the aortic diastolic pressures and a significant decrease of the left ventricle telediastolic pressures were observed. this improvement in the parameters (dpti/tti) implies an increase of the coronary perfusion in a model of heart failure. conclusions: using the external aortic counterpulsation, the aortomyoplasty improves the coronary perfnsion and the heart efficiency in patients with heart failure in whom no conventional therapeutic action is possible. the permanent character of the paraaortic counterpulsation is it main advantage. the appearance of specific pathologies as a resuk of myocardial reperfasion has been related to the oxidative damage secondary to the release of oxygen derived free radicals (ofr). during the myocardial ischemia induced during heart surgery with extraeorporeal circulation, severalsubproducts of the oxygen are produced that shall cause toxic effects after the reperfusion which could be counteracted by the physiological antioxidant systems and/or provided by the medication. aims: to asses the ofr during heart surgery. to check whether an antioxidant treatment administered in the preoperative period make decrease the levels of ofr before and after the myocardial reperfusion and to verify whether its administration have any beneficial effect on the intra and extraoperative management. material and method: the study comprehends patients studied as two groups of individuals each (a and b). all patients underwent conventional heart surgery of valvniar substitmion or myocardial revaseularization. group a patients were administered rag/ hours of vitamin e (tocopherol acetate) hours prior to the intervention as antioxidant treatment. group b patient were not administered vitamin e. we assessed the quantity of malondialdehido (mda) to assess the degree of lipidic peroxidation or oxidative damage of the membrane during the myocardial ischemia and nm after the reperfusion. conclusion: patients who underwent heart surgery and were treated with tecopherol acetate in the preoperative period presented levels of rlo significantly lower than those who were not administered the drug, both during the intraoperative period and after myocardial reperfusion. we detected in these patients a need for antiarrhythmicals and pharmacoiogical support with catecholaminas, although not significant, both in the introaperative period and the immediate postoperative period. recommendations for the treatment of pulmonary embolism (pe) in the presence of right atrial thrombus (at) are conflicting. because of a significantly higher mortality rate due to fulminam or recurrent pe, there is a necessity to treat patients (pts) with mobile type a thrombi compared to pts with adherent type b thrombi. therapeutic strategies include anticoagulation, thrombolysis (t) or surgical thrombembolectomy. combination thrombolysis (cot), predominantly used for the treatment of acute myocardial infarction proved to prevent reocclusion of the infarct related artery at a comparable rate of hemorrhagia. benefit has been related to the alteration of hemostatic proteins by non-fibrinspecific thrombolytic s. administration of cot in pe has been performed sporadically. in the present case, a -year old male with no history of prior cardiovascular disease developed acute dyspnea which was related to pe in the presence of deep vein thrombosis of the left femoral vein. therapeutic anticoagulation was installed for a couple of days until there were several bouts of deterioration. biplane transesophageal echocardiography (tee) was performed and revealed a large, wormlike, hypermobile thrombus within the right atrium. computer tomography (ct) of the chest detected a saddle embolus in the bifurcation of the pulmonary tmnk almost occluding the entire left pulmonary artery (pa) and parts of the right pat consisted of mg frontloaded rt-pa and the subsequent continuous administration of urokinase in a dosis of . u/hr for hrs followed by therapeutic anticoagulation. symptoms, blood gases and ecg improved steadily during infusion, no adverse effects, i.e. minor or major hemorragia were registered. follow-up ct promptly after termination of t showed almost complete resolution of the saddle embelus, whereas tee showed complete dissolution of the at. ' finally, the patient was switched to oral anticoagulants and had an uneventful clinical course until he was discharged. conclusion: in the present case, cot was effective for the treatment of a complicated pe without any adverse effect. introduction: nowadays we can assist hearts with problems of insufficiency by techniques other than transplant. many researchers believe that the best way of assisting insufficient heart muscle is with another muscle from the patient. this technique of ventficular assistance is known as cardiomyoplasty. we describe the surgical technique of cardiomyoplasty using a biological model. the transformed skeletal muscle is transferred to the thoracic cavity where it wraps the heart and assists it. the choice and preparation of this muscle is currently under investigation. our group has focussed on the development of protocols for electrical stimulation to transform a skeletal muscle into a muscle which resists fatigue and which is functionally similar to the myocardium. we detect the optimum time at which this muscle has been transformed, by studying the transmembrane action potentials using intracellular electrodes. when the action potential of the trained muscle behaves like cardiac muscle we consider it ready for cardiomyoplasty. conclusions: cardiomyoplasty is an alternative surgical technique to cardiac transplant, which has a great future in the treatment of patients with advanced cardiac insufficiency. we describe methodology which, by intracellular techniques, allows selection of the optimum moment of transformation of a skeletal muscle trained to perform,like cardiac muscle, without suffering fatigue. purulent pericarditis is a rare disease. its treatment associate systemic antibiotics and drainage of the pericardium. we report a ease of purulent constrictive pericarditis in which intraperieardial fibrinolysis was use. a years old patient admitted in our icu for a constrictive pericarditis as a complication of a purulent pericarditis diagnosed seventeen days before. he had also an aehalasia and the o'esogastric endoscopy had found an oesophageal neoplasm. a fistula was not seen, indeed pericardial of flora was the same that oropharyngeal. hemodynamie and echographic study had confirmed a constrictive pericarditis. because of the poor state of the patient an intraperieardial fibrinolysis was prescribed ( . ui of streptokinase on days , , , ). fluid drainage was improved and cardiac output was also improved (day : . .min "i, day : . l.min'l). no change ofhemostasis was noted. a pericardeetomy and an oesophagectomy were performed after days of evolution. eighteen months latter the patient was still alive. intraperieardial fibrinolysis seems an interesting therapeutic way if rapidly prescribed in the purulent pericarditis course. the decrease in the systolic pressure following a mechanical breath, termed ddown (delta down), has been shown to be a sensitive indicator of preload ( , ) . however, the clinical use of this method necessitates the introduction of a short apnea. we have therefore developed a respiratory systolic variation test (rsvt) which obviates the need for apnea. the test is based on the delivery of successive breaths of increasing magnitude ( , , , and ml/kg). a line of best fit is drawn between the minimal systolic values (one after each breath) and the downslope calculated as the decrease in blond pressure for each increase in airway pressure ( mmhg / cmh ). in mechanically ventilated patients the rsvt was performed during controlled mechanical ventilation under sedation. the test was repeated after the administration of ml/kg of plasma expander. the initial mean downslope of the rsvt was -. + . mmhg/cmh . following volume loading the downslope decreased to -. + . (ns). at the same time, cardiac output (co) increased by . + . l/min (p<. ), end-diastolic area (determined by tee) increased from . + . to . + . cm (ns), and paop increased from + to + mmhg ( p < . ). the preinfusion downslope value of the rsvt correlated significantly with the increase in the co (r = . ) and the eda (r = . ). methods: an expert system has been constructed running on a multimedia computer with the two objectives in mind, viz training of inexperienced staff, and protocol guidance with treatment regimes for all staff. the system is based on experience gained from two previous systems, the one for dealing with acid-base and electrolyte problems in icu patients; the second for stabilisation of patients with heart rate and blood pressure abnormalities. the training section takes the form of a stage-by-stage account of the insertion of the pac and displays of correct waveforms, coupled with indications of possible incorrect placements, and guidance when failing to achieve the perfect positioning. the treatment protocol section extends an existing protocol for correcting abnormalities in heart-rate and blood-pressure, and now takes account of all the indices as measured by the pac. the system will suggest treatment to correct such things as abnormal wedge pressures concomitant with parameter values throughout the rest of the cardiovascular system. the type of patient eg post-operative cardiothoracic or i. c. u. trauma, will be taken into account when recognising abnormal parameter values and when prescribing treatment. results: a working system which will be improved by the finetuning being carried out. the results and lessons learnt will be presented at the conference. method: septic shock was defined as severe sepsis with either persistent hypotension (mean arterial pressure; map < mmhg) or the requirement for a noradrenaline (na) infusion ~ . g/kg/ rain with a map --< mmhg. cardiovascular support was limited to na + dobutamine (db). c was given for up to h at a fixed dose-rate of either , . , , or mg/kg/h iv. during c infusion, na was to be reduced and if possible withdrawn, whilst maintaining map above mmhg and the cardiac index (ci) as clinically appropriate. assessments were made at baseline (t = ); at i h from the start of treatment (t - ); and at the end of treatment (t - ) with c . conclusions: c does not appear to increase mpap or worsen pulmonary gas exchange in patients with septic shock, when given by infusion for up to h. c is a novel vasoactive agent for the treatment of septic shock which will now he evaluated in a randomised, placebo-controlled safety and efficacy study. objectives : to compare cardiac output (q) data obtained for thermal indicators in pulmonary artery (qtpa) and aorta (qtao) and for the stable isotope hzo in aorta (q v~ o) with indocyanine green (icg) in aorta (qicg) as reference. methods : an indicator solution of ice cold h ( . ml), h ( . ml) and icg ( mg) was injected as bolus via the injection port of a swan-ganz catheter. qlco and qzmo was measured using a dual optical system (penn lab instruments, philadephia, pa, usa). qtpa and qtao was measured using a in contrast to the recoveries of thermal indicator in pa and h in aorta the :~covery of thermal indicator in aorta was significantly increased in group ii (n= boluses) over group i (n= boluses) ( . <- . vs. . +- . , p= . ). conclusions: the "overrecovery" of thermal indicator in aorta is in agreement with " biscks deconvolution study (i) and results in erroneous values for q. the most pausible explanation is the distortion of the thermal curve caused by the slow response time of the thermal detection instrument as shown by ganz ( ) objectives: to compare data obtained with the double indicator dilution method using indocyanine green (icg) and the stable isotope h for the estimation of extravascular lung water (evlw hzo) to gravimetriu lungwater data (evlwg~). methods: an indicator solution oflcg ( rag) and h ( . ml) was injected as bolus via the injection port of a swan-ganz catheter. dilution curves for icg and zh was registered in aorta with a dual optical system (penn lab instruments, philadephia, pa, usa). cardiac output and mean tranist time was measured for both tracers (qico, tlco, q n o, t o) ( ). data analysis: evlwg~av was reference for evlwzhzo calculated as q hzo times the difference in mean transit time between t nzo and rico (atm n). as reference for atzn o evlwg~,v was divided by q~cg to obtain atg~,. a reference distribution volume for h was calculated as the sum of central blood volume and evlwg=v. boluses were administrated in a group (i) of anaesthetized pulmonary healthy sheep while q was altered. another boluses were administrated in a group (ii) of anaesthetized sheep with stable oleic acid induced pulmonary oedema. evlwg~v measurement was performed postmortem. results: for boluses h parameters were not significantly different from their respective reference parameter: at vao . +_ . s vs. atg~, . + . s, evlwzh o -+ ml vs. evlwg~,~ + ml. in group i the ratio between hzo parameters and respective reference parameters (n= ) were independent of qlco from . to . l/min. obiectives: to assess the thermo dye method using indocyanine green (icg) and thermal indicator for the estimation of lung water (evlwt). methods: ice cold indicator solution of icg ( mg) in water ( ml the aim of the study was to assess left and right ventricular function in the early postoperative period after orthotopic heart transplantation to elaborate therapeutic approaches of heart function abnormalities correction. mathefial and methods. haemodynamic monitoring data of twenty one patients ( men, women ) age from to were studied. cardiac output, pulmonary artery, right atrium and pulmonary wedged pressure were measured with swan-gans catheter. central haemodynamic indices were calculated with the help of computer-based monitoring system. relations of ventricular stroke work index to it's end-diastolic pressure were used for ventficular function assessment. results. in most cases right ventricular disfunction was the main problem. isolated fight ventficular failure with high pulmonary vascular resistance (pvr) was observed in % ( pts), without high pvr-in % opts) and with left ventricular failure-in % ( pts). one of the most important reasons for fight ventricular failure was the time of heart ischemia more than min, which is of great importance in the ease of distance harvesting. the most effective treatment for cardiac failure was combination of dobutamine with i oprotherenol, atrial pacing and vasodilatators in case of right ventfieular disfunction. all cases with isolated right ventricular failure were treated sucsessfully. biventricular heart failure was a sighn of bad prognosis and the reason of death in cases. conclusion. right ventfieular disfunetion is the main problem during transplanted heart adaptation in the early postoperative period. optimal therapeutic management of cardiac disfunction includes infusion of dobutamine in combination with isoprotherenol, atrial pacing and vasodilatators. cardiology-department of clinical centre-kragujevac institution for occupational health "zastava"-kragujevac, sr yugoslavia the aim of the investigate is analisis five years survives patients with a.i.m.in dependence of locality and risk-factors. we ana~sed- ~-pat~e~ts ( males and woman), average , years. for statistic evaluation we used life-table slstem in oder to estimate prognostic determinants. patients with respkatory muscle paralysis may benefit from respiratory assistance by abdomino-diaphragmatie pneumatic belt. we used a non invasive technique, m-mode sonography, to assess the effect of this device on diaphragmatic excursion. we measured the amplitude of right diaphragm motion in seven patients with duehenne muscular dysl~ophy in supine position with various thoracic posture ( ~ ~ ~ without and during pneumatic belt respiratory assistance. without respiratory assistance, the thoracic posture had no significant consequence on the amplitude of diapttragm motion, either in quiet or deep breathing. the pneumatic belt increased the diaphragm motion amplitude from . +__ . mm to . +_ . ram (p = . ) at ~ tilt angle, and from . + . mm to . + . mm (p = . ) at " tilt angle. the tidal volume increased from + to + rut a * tilt angle, and from + to + ml at * tilt angle (p = . ). two patients could not bear the horizontal position ( ' tilt). in the five other patients, the pneumatic belt increased but not significantly the amplitude of diaphragm motion ( . + . mm to . + . ram). after an overnight respiratory assistance, pao increased from . +_. . to + . mmhg ( = . ), sao increased from . + . % to . +_. % (p = . ), and paco decreased from + . to . +_. mmhg (p = . ) according to the ventilatory pattern result, m-mode sonography allows to measure non invasively the improvement of diaphragm kinetics obtained by pneumatic belt respiratory assistance, and may be helpful for its adjustment. objective: to study the effect of flow triggering (flow sensitivity and l/min) vs pressure triggering (-lcmh ) on inspiratory effort during pressure support ventilation (psv) and assited/controlled mode (a/c) in stable copd patients non-invasively ventilated with a full face mask. methods: the patients were studied during randomized min. runs using a bird st ventilator at zero peep (zeep). trigger values for pressure (-lcmh ) and flow ( l/rain) were the lowest allowed by this ventilator. the transdiaphragmatic pressure time product per breath (ptpdi), dynamic intrinsic peep (peepi,dyn), maximal airway pressure drop during inspiration (apaw) andl ventilatory variables (ti,te,ttot,rr,vt and minute ventilation) were measured. results: no major problems due to airleaks or to auto-triggeriffg phenomena were observed in the patients, so that all of them were able to perform all the protocol runs. minute ventilation and respiratory pattern were not different using the two triggering systems. the ptpdi was significantly higher during both psv ( . + . cmh: x sec) and a/c ( . + . ) with pressure triggering, as respect to psv ( . + . , p< . ) and a/c ( . + . , p< . ) with flow triggering ( l!m). no differences were observed between and l/min flow triggers. apaw was also significantly larger during pressure triggering; peepi,dyn was reduced during flow triggering being . + . cmh (psv flow trigger) vs . + . (psv pressure trigger) and . +_ . (a/c flow trigger) vs'f~ +l (atc pressure trigger). conclusions: in stable copd patients non-invasively ventilated, flow triggering reduces the respiratory effort during both psv and aic mode as compared to pressure triggering. this may be partly due to a decrease in peepi,dyn using a flow-by system. objective. cardiac output is higher during alternating ventilation (av) (i.e. differential ventilation of the lungs with a phase shift of half a ventilatory cycle) than during synchronous ventilation (sv) of both lungs . we verified the hypothesis that the higher cardiac output depended on a lower central venous pressure and intrathoracic pressure, due to a lower mean lung volume, which we attributed to part of the expansion of the inflated lung at the expense of the expiring, opposite lung . we studied this interaction between the lungs during one-sided inflation, which we called cross-talk. method. in anaesthetized and paralyzed piglets we applied short periods ( s) of one-sided ventilation ( breaths per rain, bpm), while the other lung was open to the ambient air. the air flow into the non-ventilated lung during expiration of the ventilated lung was integrated to volume. we studied -to-r and r-to-i cross-talk at ventilatory rates of , and bpm. the amount of cross-talk was the volume displacement in the non-ventilated lung. results. during bpm the r-to-i crosstalk was _+ . % (mean +__ sd) of the tidal volume to the right lung and the -to-r crosstalk _ . % of the left tidal volume. both values increased at bpm to _ . % (p < . ) and _ . % (p < . ) respectively. the values at bpm were in between., conclusion. we concluded that the lower mean lung volume and lower thoracic expansion during av compared to sv depends on partial expansion of the inflated lung into the non-inflated lung, resulting in a lower mean intrathoracic pressure as the main reason for the higher cardiac output during av. obiective: natural surfactant given for rds in premature infants leads to a rapid improvement in oxygenation, but lung compliance did not improve in most studies. however, acute effects on lung mechanics during and immediately after surfactant administration have not been studied before. methods: a total of administrations of bovine surfactant in recommended doses was given via a small catheter into the distal endotracheal tube either as a bolus (n = ) or as a slow infusion (n = ) in infants with established rds. static compliance (c), resistance (r) and time constant (tc = cxr) of the lung were measured every minutes with a lung function cart (sensormedics ) without interrupting ventilation. infants receiving synthetic surfactant were studied as controls. results: after surfactant as a bolus or during infusion c first decreased but then increased, whereas r increased immediately with great fluctuations but did not return to baseline. this pattern was more pronounced in infusion than in bolus administration. change of c and r varied greatly in the individual case, maximum c was > %, maximum r > % of baseline value. retreatment was followed by an increase in r in all patients, but c increased only in the one who was responder. patients receiving synthetic surfactant had no change of c or r and were non-responders. ob~i ctives= acute lung injury (ali} sometimes induces severe hypoxernla which may be refractory to conventional modes of mechanical ventilation (mv). the elm of this study was to observe some cardio-pulmonary effects of an alternative method of ventilatory management of severe ali. five patients with severe ali (murray scores > ) requiring mv were studied. protocol inclusion was considered when a control-mode of mv (with a pzo~=l. and a peep level < cme=o} was not able to get either a p.ojf=o= ratio > or a s.o= > %. patients were sedated, paralyzed, and a ventilator (serve c) was used for pressuz'e-control ventilation (pcv). fio= was maintained at . and peep removed. continuous gas flow ( • ml/kg] was humidified and jet delivered through a tube ( ram id, ml capacity, . ml/cm h=o compllancel ended in a nozzle ( . mm is) attached to the endotracheal tube connector. a thermodilution flcw-dlrected catheter was inserted in pulmonary artery. following variables were recorded minutes before and after protocol started: tidal volume (vt), minute ventilation (vz), intratracheal pressures (p~w), wedge pulmonary artery pressure (wp), central venous pressure (cvp), mean arterial pressure (map), cardiac index (ci), arterial and mixed venous oxyhemoglobin saturation (sao=, svoa) , oxygen delivery (do~) , oxygen consumption (vo ) , intrapulmonary shunting (q./qt) , and oxygen extraction ratio (ero). this observation suggests that hfpv could allow to ventilate at lower fin and improve blood oxygenation during the acute phase after inhalation injury reducing toxicity risk related to high fin . further studies are necessary to confima these results and evaluate the possible implications on mortality alter smoke inhalation and for other icu pts. objectives: to design a system for volume controlled high frequency ventilation (hfv) and to estimate the dependence of the tidal volume (vt) on frequency (f) in normocapnic ventilation in rats at frequencies - hz. methods: a new system for volume controlled hfv was devised consisting of the generator of the constant flow during inspirium and the constant pressure during expirium. the ventilator allows ventilation at frequencies - hz with the relative inspiratory time (ti) . - . . the airway pressure was measured at the proximal port of tracheostomic cannula , at the same site inspiratory and expiratory flow was measured using modified lilly-type of pressure-differential flow sensor. non-linearity of flow sensor was compensated on line by derived equation based on calibration at static and dynamic conditions. flow and pressure data were evaluated on line using original software. value of the positive end expiratory pressure (peep) was serve-regulated by analogous feed-back. in animal experiments white wistar rats ( - g) narcotized with ketamine/xylazine with cannulated carotid and femoral arteries were kept at the rectal temperature ~ the arterial pressure was monitored. after traeheotomy the metal cannula ( mm [.d.) was inserted, animals were curarized and ventilated at the following condition: peep = . kpa, ti = . . the dead space of ventilator including canula was . ml. the initial frequency was hz and rain after each change of the ventitatory regimen the blood gases analysis was performed. the frequency was changed according to the following schedule : hz--> hz--> hz--> hz--> hz--> hz--~ hz--> hz. vt for each frequency was regulated to maintain normocapnie ventilation with arterial pco = + mm hg. the arterial po was always above mm hg. results: for normocapnie ventilation in rats the following tidal volumes vt [ ml/kg] were found : vt = . --+ . ml/kg for ft = hz, vt = . + . mukg for fz = hz, vt = . +_ . ml/kg forf = hz, vm = . + . ml/kg forf = hz andvmt= . + . mukg for fs = hz (presented as mean values _+ s.d., n = ). the regression analysis using the mean values resulted in the equation for normocapnic vt in rats in our experiments : vtn = . * f-e. . conclusions: the described system allowing ventilation in a wide frequency range - hz with accurate measurements of airway pressures and vt might be useful for optimisation of artificial ventilation in new-barns with different lung pathologies. supported by grants iga mz cr nr - and gacr nr . s intensive care unit. university. hospital of south manchester, uk. methods: measurements were conducted on ventilated patients (puritan bennett ac with metabolic monitor pb set to measure end tidal co ). all measurements were repeated with the patient stabilised at cm. cm and cm peep. inclusion criteria were: ) haemedynamic stab(l( .ty for hr; ) pulmonad" anon" flotation catheter in situ: ) volume control ventilation with plateau of . s: ) fio ~ > . to maintain pao~. > kpa with em peep: ) qs/ot > %; ) pao /fio ratio < . measured variab!es included: r minute volume: plateau ainvay pressure: applied and intrinsic peep: fractional end tidal co ; arterial and mixed venous blood gases and hacmod).ttamic variables. results: statistical analysis was performed using repeated measures anova. significant decreases in cardiac index (ch p< . ), compliance (p<t). ) and o,'gcn deliver, index (do , p< . ) occurred with increasing peep (table ) . no other variable showed any significant change. methods : all consecutive patients orally intubated in the micu between january to april were studied. etts were positioned according to the reference marks mentioned above (measurements from upper incisors). the position of the ett tip in relation to the carina was measured on the chest radiograph done with the patient's head in neutral position. results : a total of men and women were studied (n= ). the mean distance of ett tip to carina was . cm. using the reference markings, cases ( . %) had the ett tip < cm from the carina and cases ( . %) > cm. one case resulted in an endobronchial intubation. the mean height of all patients were cm ( - ) for males and cm ( - ) for females. of the patients with ett tip < cm from carina, the mean height was cm and cm respectively. ~ onclusion : adopting the above quoted reference marks did not result in ideal positioning of the ett in a significant proportion of cases ( . %). we postulate that [s because our asian population is generally shorter than those in previous studies. objectives: to measure the changes of pulmonary mechanics before and after tracheostomy in patients with prolonged mechanical ventilation and to determine factors that predict the outcome of liberation from mechanical ventilation. design: prospective. setting: respiratory intensive care unit (ricu) in a tertiary hospital. patients: twenty patients with chronic lung disease requiring long-term mechanical ventilation. tracheostomy is indicated for further care. intervention: tracheostomy. measurements and results: pulmonary mechanics including respiratory rate (rr), tidal volume (vt), peak inspiratory pressure (pip), intrinsic positive end ex~ piratory pressure (peepi), lung compliance (cld), mean airway resistance (rawm), work of breathing (wob), pressure time product (ptp) by bicore cp- pulmonary monitor were recorded hours before and after tracheotomy. ventilator setting parameters remained the same during surgical intervention and were also recorded for comparison. generally, the mechanics including pir wob, raw~x and ptp showed improvment after tracheostomy. but only pip was significantly reduced (pre . _+ . to post . _+ . , p < . ). changes of wobp showed significant correlation with pre-operation rr, minute volume (mv), wobp, and peep(. changes of raw m were also significantly correlated with pre-operation peep, vt, and raw m. the patients were divided into two groups according to their outcome after two week follow-up. group included eight patients who were completely weaned from ventilator; group included twelve patients who still remained ventilator-dependent or were mortality. there was no difference in age, duration of mechanical ventilation, pro, post or changes of several lung mechanics between the groups of patients. pre-tracheostomy peep i and cld showed significant difference between these two groups ( . _+ . vs . + . in peepi; . _+ . vs . _+ . in cld, p < . ). pre-tracheostomy ventilator setting in mode of assist/control also showed significant higher percentage in group ( % % in group vs . % in group ). conclusion: in prolonged mechanical ventilation patients with chronic lung disease, tracheostomy will significantly improve pip and slightly reduce wobp, raw m and ptr patients who used pressure support mode before tracheostomy had better underlying lung conditions (lower lung compliance and auto-peep) will have better chance to wean from mechanical ventilation. forty-eight infants with congenital diaphragmatic hernia presenting within the first hours of life, who underwent surgical rapair,were analysed prospectively in order to produce a reliable inde x of severity of disease that would reliably predict eventual outcome. there were survivors and deaths in this series (mortality %).using arterialpco values measured hours after surgical repairand correlating them with an index of mechanical ventilation,we have been able to clearly define two groups of diaphragmatic hernia based on their response to hyperventilation. the first group, with co retention and severe preductal shunting,was unresponsive to hyperventilation with high rates and pressures the mortality was %. the second group responded well to hyperventilation and demonstrated reversable ductal shunting only. survival in this group was %. arterial co accurately reflects the degree of lung development in this disease and separates those patients with severe pulmonary hypoplasia where the outcome is invariably fatal, from those with a well developed contralateral lung where there is excellent potential for survival. respiratory failure unit, dpt medicine, univ. thessaloniki, thessaloniki, greece the variability of arterial blood gases (po , pc ) and the ph (abg) was examined in stable icu patients, few hours before a successful weaning from the ventilator. all patients were lightly sedated and the ventgatory conti~ons were pressure support (ps) for and ps plus intermitted mantatory ventilation in ii. [n each patient, speciments of abg were measured at min intervals during a - study period. at the same time with abg the arterial blood pressure (bp), the heart rate (cf), the tidal volume (tv) and the respiratory rate (n r were measured. for all the patients, the mean coefficient of variation (c) was . percent for po , . percent for pco and . percent for hco . the average sd for ph was . , the corresponding c for systolic bp, diastolic bp, cf, tv, rf were . , . , . , . , . percent. we conclude that the spontaneous variability of arterial blood gases in icu patients is not substantial ~hen they have stable the heamodynamic and the ventilatory parameters. deptx?fa'aaesthesioiogy and reanimation, rhe sechenov medical academy, moscow, russia objective: ~he prevention and treatment of hypoxia in the critical patiems. methods: i~fusions of perphtoran -a blood substitute with gas-transporting fimclion based on perphtorhydrocarbon -in patients with acute hypovolemia, microcirculatory distnrbance~ tissue gas exchange and metabolism; pulmonary iavage in ; iongterm extrapulmonary oxigenation with tleoroearboa oxygenator in combination whb ~trafiltra!ion, hemosorption and hemodialysis -in patients. results: pe~htoran increases blood volume, co,sv, decreases svr, improves capillary blood flow, increases the blood oxygen capacity, tissue oxygen tension, del, vo by improving the rheologic properties of blood and plasma, normalizes ext., prevents and eliminates fat embolisation and ards. decreases the need for blood transfusions and infusions of plasma expanders by . - . limes. alveolar venti!ation-perfusion ratio remains unchanged with its increased effective utilization. there was no surfactant destruction during lavage. extrapulmonary oxygenation of small volumes of venous blood eliminates venous destruction and then arterial hypoxia and increases pulmonary oxygenation. the use of lluorocarbon cxygenators during hemosorption and hcmodialysis provides the atraumatic and iongterm oxygenation of arterial blood and increases elimination of co which prevents the development of hypoxic complications. conclusions: perphtoran and fluorocarb~n oxygenators are effective in the correction of hypoxia in the criticat patients. objeqtives: to determine if there are differences in oxygen consumption (vo ) during weaning from mechanical ventilation (during total ventilatory support and spontaneous ventilation with cpap), and to compare different predictive parameters of weaning in predicting success of weaning. methods; prospective study in critically ill patients treated with mechanical ventilation for at least h, who fulfilled at least of standard weaning criteria (vt> ml/kg; respiratory frecuency (f) < ; pimax > cm h ; pao /fio > ). baseline measurements: t, vt, p . , pimax, f/vt, p . *(f/vt), p . /pimax. study protocol: measurement of vo , vco (medgraphics), vt, f, ve, and arterial blood gases during total ventilatory support (cmv), and after and minutes of spontaneous ventilation with cpap cm h . the weaning trial was stopped, failure to wean diagnosed, and mv resumed it a patient presented significant tachypnea, tachycardia, bradycardia, cardiac rythm disturbances, hypertension, hypotension, hypoxemia or hypercapnia. results: four patients did not complete the weaning trial, were extubatad, and of them had to be reintubated before h, being considered also weaning failures. during cmv, vo /kg was . + . ml/kg/min, and . _+ . mlo- /kg/min after ' on cpap cm h (p < , ). of patients ( %) with standard criteria were extubated, while only of ( %) with criteria (p< , ). next objectives: compare the extent and distribution of lung injury in dogs preinjured with oleic acid (oa) and ventilated with high tpp and adequate peep in the prone and supine position. methods: lung injury was induced with oa ( . - . ml/kg) in anesthetized, paralyzed, and intubated dogs (n= ) during volume controlled ventilation: rate= /min, peep= cmh , ti/ttot= . , fio = . , vt= ml/kg. animals were rotated during the oa infusion and the following minute stabilization period to assure uniform injury. in the supine position, peep was set - cmh above the lower inflection point (as determined by the pressure-volume curve), and vt was set to obtain a tpp of cmh : animals were ventilated in either the prone (n= ) or supine (n= ) position for four hours. pulmonary artery occlusion pressure was maintained constant ( - mmhg) with saline infusion. at the end of the protocol the lungs were removed and divided by template into dependent (d) and nondependent (nd) sections for wet weight/dry weight (v~n/dw) and grading of nstologic lung injury (hli; scale - ). oseillatron | is a pneumatic device that generates high frequency, oscillation by means of a reciprocating system in the form of a membrane. it generates sinusoidai wave form at ( to ( cycles/rain. the system does not deliver gas but must be adapted to the proximal respiratory, circuit of a conventional ventilator, resulting in ci-ifo. it was developed to enhance intrapnlmona~ diffusion during mechanical ventilation and to mobilise endebronchial secretions. methods. we measured arterial blood gases and haemedynamics during a first period of conventional ventilation (cppv) followed by. two rain periods of chfo (sequences : ( and ) c/rain : group l, n = l: and c/rain : group , n = ). measurements were made at the end of each period. cardiac output was measured using thermedilution method: flu and peep were kept unchanged throughout the study. intrinsic peep was also evaluated by, means of an occlusive valve. results. pa is not significantly modified during chfo at or c/rain. paco is slightly decreased at c/rain (p = .( ). however, intrinsic peep remains unchanged. there is no sequential effect (gr. l vs gr. ). there is no more effect of chfo for patieets who are at a flu higher than . (n = ). no changes in haemodynurmcs are observed except a slight increase in central venous pressure (cvp) during ci-ifo (p < .ol). obiectives: to examine the effects of inspiratory muscles unloading on neuromuscular output at controlled levels of chemical stimuli. methods: the ventilatory response to co was examined in ten normal subjects using rebreathing method. ventilation ~) and respiratory muscle pressure output (pmus) at the same end-tidal partial pressure of co (petco~) were compared with and without combined flow and volumeproportional pressure assist in two protocols (a and b). protocol a (n = ): two levels of assist were studied; flow assist (fa) of cmh /i/sec and volume assist (va) of cmh /i (assist ), and fa of cmh /i/sec and va of cmh /i (assist ). all conditions were applied randomly. v~, tidal volume (vt) and breathing frequency (f) were measured breath by breath and plotted as a function of petco~. protocol b: in subjects, in addition to above measurements, esophageal (pes) and gastric (pg) pressures were measured and the time courses of transdiaphragmatic pressure (pdi) and pmus were calculated. one level of assist (assist ) was studied in this protocol. results: in both protocols inspiratory muscle unloading did not change the f response to c%. compared to control, with assist v t response was displaced upwards; at petco of mmhg v t was increased significantly by . + . i and . + . i in protocol a with assist end , respectively, and by . _+ . i in protocol b with assist (p< . ). ~/~ responses showed similar changes as vtresponses. in both protocols the slope of v~ response (s did not change significantly with unloading. at low petco~ ( mmhg), pdi and pmus waveforms did not differ with and without assist. with unloading, at high petco ( mmhg), pdi and pmus at the end of neural inspiration decreased by . -+ . % and . + . %, respectively, from control values. neither change was significant (p> . ). by theoretical analysis we estimated the expected changes in vt and ~/~ when the levels of assist used in both protocols were applied in the absence of : any change in neural output response to co z. the predicted response was similar to that observed, indicating that the small difference in pdi and pmus between control and unloading runs was due to intrinsic properties of respiratory muscles end respiratory system. conclusions: these results suggest that when chemical stimulus is controlled, respiratory motor output is not downregulated with unloading. the determinants of the response of the respiratory output to inspiratory flow rates (v~) were examined in awake normal subjects. subjects were connected to a volume-cycle ventilator in the assist/control mode and v~ was increased in steps from to i/min and then back to i/min. v~ pattern was square, and all breaths were subject-triggered. in six subjects the effects of breathing route (nasal or mouth) and temperature and volume of inspired gas (protocol a) and in subjects the effects of airway anesthesia (upper and lower airways, protocol b) on the response of respiratory output to varying v~ were studied. in protocol b, in order to calculate muscle pressure during inspiration (pmus), respiratory system mechanics were measured using the interrupter method at end-inspiration. independent of conditions studied breathing frequency increased . significantly and end-tidal concentration of c% decreased as v~ increased. the response was graded and reversible and not affected by breathing route, temperature and volume of inspired gas and airway anesthesia. with and without airway anesthesia (protocol ) neural inspiratory and expiratory time and neural duty cycle, estimated from pmus waveform, decreased significantly as v~ increased. at all conditions studied the rate of change in airway pressure prior to triggering the ventilator tended to increase as v~ increased. the changes in timing and drive were nearly complete within the first two breaths after transition with no evidence of adaptation during a given ~/~ period. we conclude that v~ exerts an excitatory effect on respiratory output which is independent of breathing route, temperature and volume of inspirate and airway anesthesia. the response most likely is neu~'al in origin, mediated through receptors not accessible to anesthesia such as those located in chest wall or below the airway mucosa. it has been shown, in mechanically ventilated awake normal humans, that increasing inspiratory flow rate (~/~) exerts an excitatory effect on respiratory output. it is not known if this effect persists during sleep. to test this seven normal adults were studied during wakefulness and nrem sleep. subjects were connected through a nose-mask to a volume-cycled ventilator in the assist/control mode and ~/t was increased in steps ( - breaths each) from to i/min and then back to i/min. v~ pattern was square, and all breaths were subject-triggered. forty-one trials during nrem sleep and during wakefulness were analyzed. both during sleep and wakefulness minute ventilation increased and total breath duration (ttot) decreased significantly in a graded and reversible manner as ~' increased. these changes were complete in the first breath after v{ transition. the response was significantly less during sleep than during wakefulness (p< . ); at i/min ttot, expressed as % of that at i/rain, was . +_ . % during sleep and . +_ . % during wakefulness. during wakefulness, at i/min, the rate of change in airway pressure prior to triggering the ventilator, an index of respiratory drive, was % of that at i/min (p< . ). the corresponding value during sleep, was % (p> . ). in four sleeping subjects the increase in v~ was sustained for . - min. there was no evidence for adaptation of the response; tro t, averaged over the last three breaths, did not differ from that obtained when vj was sustained for only - breaths. we conclude that ) vt exerts an excitatory effect on respiratory output, mediated by a reflex neural mechanism and ) the gain of this reflex is attenuated by sleep. chest radiographs is a common complementary technique for patients in critical care units, with a low cost and easily available. however, it has certain well-known limits in diagnosis, the most important derived from the low quality of some pictures. in this paper we make a general review of some new technical approaches developed for improving the quality of the images, and so incrensing the diagnostic value of conventional radiology. we begin deaeng with the correct positioning of the patient, trough the filtering techniques, the synchronization of radiology and ventilation, and we make reference to the new computerized systems for digital image processing. conclusions: the portable radiographic system is a device that probably with maintain for many years in critical care units as a basic non-invasive diagnostic tool. but we need an increase in the efficiency of it, applying means as simple as a correct positioning of the patient, or the use of fitlers or synchronizers. thus we should improve the general standards of portable radiography. "are circular circuits safe? quantifying undelivered tidal volume in pediatrics patients". objectives: to evaluate the overall influence of internal compliance of circular circuits on delivered tidad volume (vt). methods: we studied prospectively asa i pediatrics patients ( to yr. old) scheduled for elective general surgery. mechanical ventilation was supplied by an ohmeda excel (circular circuit). the internal compliance of the circuit (cc)-anesthesia machine plus external circuit-was determined by the supersyringe method: corrugated dar tubes of mm. id and . m. long (children < kg), and a corrugated dar set of mm. id and . m. long (children > kg) were respectively used for ccl an cc values of . and . ml/cm h . a vtof mlg/kg and respiratory frequency was adjusted for an end-tidal co (etpco ) between mmhg. tidal volumes (measured by spirometry) and airway pressure (paw) data were recorded every ten minutes. volumes and thorax-lung compliances were calculated as follows: (vt delivered = vtadjusted-vol compressible, being vol. compressible = co x ppeak (aw). apparent compliance (ca) = vt adjusted/pplateau(aw), and true compliance (ct) = =vt delivered/pplatean(aw)). comparative statistics were separately designed between calculated compliance data and tidal volumes on a paired sample ~test basis. results: calculated values for volumes and thorax-lung compliances were: conclusions: due to the elevated internal compliance of the circular circuit there is a remarkable dilference between adjusted and delivered vt: mean undelivered vt was . % and reached as high as . %. teere is also a significative error in calculating true thorax-lung compliance: its overestimation can be as high as . %. circular circuits are considered safe and cost-saving for anesthetical practice. nevertheless we conclude that anesthetists should bearin mind vt losses when using circular circuits, due to compressible volume. tracheal stenosis is one of the most serious complications of patients submitted to prolonged endotracheal intubation, in which the decrease in inner diameter of upper airway makes it very difficult to achieve a correct ventilation. objectives: compare the results of applying high frequency jet ventilation (hfjv) to some of these patients with conventional controlled ventilation (cmv). methods: we used a prototype of high frequency jet ventilator (santiago- ) developed in our university, and we developed a tracheal tube in wich we modified the distal tip (conic tip). we applied this system to two patients which were initially ventilated in the operating room with usuai controlled mecanical ventilation (cmv) following the standards of our department, and then intubated with the special endotracheal tube and ventilated with hfjv. results: we could verify a proper ventilation of both patients with cmv and hfjv. during hfjv, the airway pressures were lower than those recorded during cmv. a lower airway pressure prevents lesions due to high pressures. conclusions: hfjv is a good method of ventilation for patients with significative stenosis of the trachea, not only during surgical procedures, but also during ventilation for long periods in critically patients. the ventilatory setting is pressure support mode. the pressure level and fit were kept constant during h/d. arterial blood gas, wbc count, and mean bp was checked according to the schedule: '(immediately before h/d), ', ', ', ', ', '. respiratory drive (represented by poa), tidal volume(ti) and minute ventilation(ve) were continuously recorded by pulmonary mechanics monitor (bicore cp- ). the mean value of the breaths minutes before blood sampling were used to represent the ventilatory status of that period. anova test is used for comparison between groups. for poa, hierarchical cluster method is applied to divide the cases into two groups of similar change. conclusions: our data suggest that pl is very useful, non invasive and low-expensive emergenc e support for arf, expecially in the elderly with severe chronic pulmonary disease and relative controindications to eti. pl seems to be an effective alternative when it is not immediatly possible to perform etl. the multiple inert gas elimination technique (miget) can be used to assess the effects of any given mode of mechanical ventilation on the pulmonary and systemic factors determining arterial po and pco> however, a potential problem in mechanically ventilated patients is that the l mixing box (mb- l) placed in series in the expiratory side of the circuit of the ventilator to sample mixed expired gas may provoke substantial discrepancies between the tidal votume set in the ventilator and the effective tidal volume delivered to the patient, due to the increase in the compression volume (vc) of the circuit. the effects of the mb- l on the v c were compared with those produced by a new l mixing box (mb- l) specifically designed to produce adequate gas mixing and to prevent loss of the two most soluble gases (ether and acetone) used in the miget. at any given peak cycling pressure (p~ak, cm h~o), the v c (ml) provoked by the mb- l was substantially higher (vc= . *ppeak) than that provoked by the new mb- l (vc= . *ppeak). at a ppeak = cm h ~ the v c were ml (mb- l) and m{ (mb- l), respectively (p< . ). in a group of subjects ( m/ f, _+ years), for each of six the gases used in the miget, the regression line between the mixed expired partial pressures simultaneously obtained from mb- l and mb- l fell on the identity line. it is concluded that the new mb- l allows adequate assessment of the effect of different modalities of mechanical ventilatory support on pulmonary gas exchange, with less potential for gas compression and thus hypoventilation. objectives evaluate the influence of different pressure support ventilation (psv) levels on cardiovascular and respiratory funcion in icu polytrauma patients. metbed&we studied polytrauma icu patients , who were in weaning process , after long term mechanical ventilation for acute respiratory failure . mean age ( - ) yrs . they all were connected to servo ventilators siemens c , and all were in stable condition , without sedation , inotropes or diuretics. the hemodynamic studies were done with continuous svo , swan ganz catheter (oximetrix, abbott). they all were in spontanuous mode (spent) with cm h cpap for at least one hour. we turned them to psv with inspiratory assistance (psv cm h ) and after rain we applied psv cm h , and after min psv cm h . hemodynamlo and respiratory measurements were done before and after the application of insiratory assistance. the results were statistically analyzed with anova. resets . respiratory variables . no significant changes in minute volume (ve). tidal volume (vt) and mean airway pressure (mpaw) increased statistically significant (p< . ) . respiratory rate (rr) decreased significantly (p< . ) . blood gase showed no difference . cardiovascular variables. cardiac output (co) decreased ns , heart rate (hr) had no change , central venous pressure (cvp) , mean pulmonary artery pressure (mpap) , pulmonary capillary wedge pressure (pcwp) , increased ns , oxygen delivery (do ) decreased ns, oxygen consumption (vo ) decreased ns. conclusions. psv is a very useful respiratory mode helping patients to be weaned from long term mechanical ventilation . it has beneficial effects on respiratory function and oxygen consumption without affecting seriously the hemodynamic parameters, possibly due to a decrease of the work of breathing. a. michalopoulos, a. anthi, k. rellos, j. kriaras, s. geroulanos intensive care unit, onassis cardiac center, athens. objectives of this study was to examine the effect of different levels of peep on postoperative svo and pvo values in a group of patients, following open heart surgery. methods: upon transfer to icu, patients ( males and females) of mean age _-+ years, were randomly assigned to receive (n= ), (n= ), or cm of peep (n= ). there were no statistically significant differences in demographic data or preoperative respiratory status among the three groups. all patients were ventilated on the assist control mode with a tidal volume of ml/kg. the fraction of inspired oxygen (fio ) was adjusted to keep a pao around mmhg. mixed venous po and svo were measured at min, and hours after application of mechanical ventilation in the icu, just before extubation (be), half hour after extubation (ae), and at hours post-extubation. differences at each study time were analysed by anova. results: mean svo and pvo values among the three groups, for all study intervals, are presented in the table. conclusion: we found no differences (p=ns) in tissue oxygenation (expressed by svo and pvo ) among the three groups, at any study interval, in the early postoperative course of patients following open heart surgery. intrinsic peep (peepi), and high elastance and resistance increase inspiratory work load in copd. cpap reduces work of breathing by counterbalancing peepi. pav provides flow (fa) and volume (va) assistance proportionally to patient resistance and elastance and inspiratory effort. we studied the effects of partitioned support (cpap-fa-va) on breathing pattern and inspiratory effort in five copd patients on pav compared to spontaneous ventilation (sv) and full support (fs: cpap+fa+va). flow, volume, minute ventilation (ve) respiratory rate (rr), inspiratory swing in esophageal pressure (apes), and its integral per breath (pti/b) and per minute (pti/m) were measured. objectives: to evaluate airway pressure fluctuation (apf) during spontaneous breathing in a high compliance cpap system. methods: the cpap system consisted of two l weighted balloons in a wedge shaped holder. ventilating gas flowed from one balloon through a low resistance one way valve into a tracheal tube (ett) provided with a pycor co sensor to monitor rebreathing. the ett was connected to a piston drive mechanical lung. expired gas flowed through a low resistance valve into a second weighted balloon, from where it was exhausted through a peep valve connected in parallel with the second weighted balloon. we evaluated system performance at v r from to ml, at rr from to bpm, while closely monitoring cpap airway pressure swings. at v v of and ml the rr was limited to bpm. for comparison we explored aps of a one l balloon cpap system, the cpap mode of the puritan bennett , and siemens ventilators, when connected to a healthy adult volunteer breathing through an ett. results: the compliance (cpl.) of one l balloon system was linear over a range from . to . l, with a cpl. of . l/em h .the cpl. of the l balloon ( . l/em h ) was linear between a volume of and . l. apf of the weighted balloon system was under em h at all v r (except at a v r of ml aps was . em h ), while the apf in the l balloon was up to em h . apf witli human volunteers with the two commercially available ventilators in the cpap mode was about cm h ; while under identical conditions apf in the l balloon system was . emhzo; and in the two l balloon system was below lcm h . conelusions: cpap using the two balloon system exhibits lower airway pressure fluctuations than a single balloon system; and is substantially lower than found in the two commercially available ventilators when used in the cpap mode. objective: to perform independent lung ventilation (ilv) with individual tidal volume (vt) set at a value generating a plateau airway pressure (pplat) < crnh~o and to evaluate the usefulness of the continuous monitoring of endtidal co (etco ) as a guide to titrate individual lung vt during ilv and for the weaning from ilv. methods: in seven patients, ilv was performed with ttvo ventilators set with the same fio: and respiratory rate. each lung was ventilated with a vt that developed a pplat < cmh~o. this setting led to a lower vt on pathological lung (pl). vt was increased in pl following etco~ and paco -etco variations. ilv was discontinuated when etco~., vt and statical compliance (cst) were similar in both lungs. results: one hour after starting ilv (ti), pl mean vt was significantly lower than in normal lungs (nl) ( + ml vs + ml, p< ) two individual behaviours were observed on tl in pl: four patients presented low etco: (range - mmhg)and normal pacoz (range - mmhg), while three patients had normal etco (range - mmhg) with high pac (range - mmhg). one hour before stopping ilv (t ), vt, etc and paco were the same in each lung. the pao /fio: ratio improved in all patients from the beginning ofllv cst of pl was + % of the normal lungs' cst on ti and improved to . + % ofnl's cst on t (p< . vs conclusions: setting vt of pl to a value not overcoming a pplat threshold does not impair oxygenation and is helpful in avoiding barotraumatism. measurements of differential etco and of the differential paco -etco gradient can be used to titrate vt allocation during ilv and as a guide for the weaning from ilv. total respiratory resistance in mechanically ventilated patients exceeds values obtained in normal subjects, due to the added and highly flow dependent resistance of the endotracheal tube (rett). this can adversely effect the efficacy of pressure regulated modes of assisted ventilation, such as pressure support (psv) and proportional assist ventilation (pav). recent work demonstrates that the influence of rett during psv can be overcome by using tracheal (ptr) rather than airway opening (pao) pressure to regulate the pressure applied (intensive care med :$ , ) . the purpose of this study was to see if this approach would also be effective during pav. flow, volume, pao, ptr, and transdiaphragmatic pressure (pdi) were measured in intubated patients in which either pao or ptt were used to regulate the pressure applied during pav where volume assistance was varied from to % of respiratory elastance. representative results (mean + se) are shown below. compared to spontaneous breathing (pav %), pav increased tidal volume (vt) while reducing respiratory rate (rr) so that minute ventilation ('~e) also rose. this was associated with a reduction in inspiratory effort, as reflected by a decrease in the pressure-time integral ( [ p) of pes and pdi both per minute and per liter ~re. the effects on breathing pattern were similar for pao and ptr regulated pav. in contrast, the reduction in inspiratory effort was always greater for ptr regulated pav. in conclusion, the volume assistance provided by pav is more effective when ptr rather than pao is used to regulate the pressure applied. pav methods: retrospective data analysis of adult patients with normal pulmonary function before operation and uneventful course following coronary artery bypass graft surgery over an month period. we compared assist/controlled mandatory ventilation (s-cmv, patients), synchronized intermittent mandatory ventilation with inspiratory pressure support (s-imv/psv, patients) and biphasic positive airway pressure ventilation (bipap, patients). results: patients ventilated with bipap had a significantly shorter mean duration of intubation ( . h, p< . ) than patients treated with s-imv/-psv ( . h) and s-cmv ( . hi. with s-cmv . % of the patients required single or multiple doses of midazolam but only . % in the s-imv-/psv group and . % in the btpap group. the mean total amount of midazolam of these patients was significantly higher in the s-cmv group ( . mg) than in the s-imv/psv group ( . mg, p< . ) and in the bipap group ( . mg, p< . ). the consumption of pethidine and piritramide did not differ between s-cmv and s-imv/psv but was significantly lower during bipap (p< . ). after extubation the paco patients was highest in the s-cmv group. conclusion: ventilatory support with bipap reduces the consumption of analgesics and sedatives and duration of intubation. unrestricted spontaneous breathing as well as fully ventilatory support allow adequate adaptation to the patients requirements. bipap seems to be an alternative to s-cmv and sqmv/psv ventilation not only in patients with severe ards but also in short term ventilated patients. _objectitives: after end-inspiratory airway occlusion we examined the ensuing gradual decrease in tracheal pressure (ptr) with the following equations proposed by bates et al. and hildebrandt: pv = p'v e'~cccl~ +pst, rs (bates) [ ] where p'tr is tracheal pressure immediately after occlusion, to= is occlusion time, "r is viscoelastic time constant of respiratory system, and p t is static elastic recoil pressure of respiratory system. p~(t) = h -h log t (hildebrandt) [ ] where h~ and h are parameters depending on lung volume, and initial time is s for analytical reasons. materials & methods: we studied healthy patients intubated, anestethized with propofol, paralyzed with vecuronium, and mechanically ventilated with constant flow ( . i/s) at zeep for minor surgery. pressure was measured in the trachea. flow was measured with a pneumotachograph and volume was obtained by numerical integration. the rapid occlusions were produced by an external valve. the signals were sampled at a frequency of hz and processed on a pc. the influence of the cardiac artifacts during the occlusion time ( s) was reduced by a software low-pass filter kaiser finite duration impulse response of elevated order. results: the mean (+ sd) coefficient of correlation using eq. was , -+ . , and using eq. was . + . . the values ofz~ (eq. ), however, decreased with increasing the tidal volume (vt) according to the following equation: "~ = . - . v t, similary, the values of h~ and h increased with increasing v t according to the following functions: h~ = . + v i and h = . + . v t. conclusions: the behaviour of "% of eq. suggests that the linear viscoelastic model is not sufficient to further describe the mechanical properties of the respiratory system over the vt range ( - ml/kg) in ventilated patients. infect this model predicts that "c is constant and independent of tidal volume. on the other hand the plastoelastic model is not sufficient to further describe the mechanical properties of the respiratory system. in fact "r obtained by fitting an exponential for data of eq. , is determined by the time of endinspiratory airway occlusion. obiectives: according to the viscoelastic model, the viscoelastic pressure of the respiratory system pv=rs during lung inflation with constant flow e~ is t/ r wh t lsms ira tlmeand r given by:pv~c.~ = d~( -'e-~ )[ ] ere " ' p" tory " and "r are resistance and time constant of viscoelastic unit. in the past, the viscoaletic constants were determinated by performing a series of occlusions at different lung volumes, or a sedes of occlusions at a fixed lung volume achieved with various inflation flows. in the present study we have developed a new method for determining "c and r which requires a single constant flow inflation. our method is based on determination of pv~r, during a single breath constant flow inflation, and of z during the ensuing end-inspiratory airway occiusion. dudng the occlusion the tracheal pressure p~, declines according the following function: ptr = p'lr e " too= " z + e~t.r= [ ] where p'~r is tracheal pressure immediately after occlusion, toc c is occlusion time, p,i.rs is static elastic recoil pressure of respiratory system, and ~ is viscoelastic time constant. we first determinated "~ by analyzing the time-course of ptr according to eq and next determining r according to eq. , using the expedmental values of p,i=~, ~ and ti, as well as "~ obtained with eq. . materials & methods: we studied healthy patients intubated, anestethized with propofol, paralyzed with vecurenium, and mechanically ventilated with constant flow ( . i/s) at zeep for minor surgery. pres-sure was measured in the trachea. flow was measured with a pneumniachograph and volume was obtained by numerical integration. the rapid occlusions were produced by an external valve. the signals were sampled at a fi'equency of hz and processed on a pc. the influence of the cardiac artifacts dudng the occlusion time ( s) was reduced by a software low-pass filter kaiser finite duration impulse response of elevated order. results: the mean coefficient of correlation with eq. was . . with v t of ml/kg, the mean values (+ sd) of ': and r of the subjects amounted to . • . s and . • . cmh i "~ s. with the traditional multi breath method the corresponding values were . + . s and . _+ . cmh i " s, respectively. with the t-test the difference between new and traditional "~ was statistically significant, between new and traditional r was not significant. conclusions: with the single breath method it is possible to compute ': and r . the mean values of r with v t of nd/kg, however, was slighuy different than those obtained with the traditional multi breath method. the application of modem principles of respiratory care and mechanical ventilation in icus has resulted in increased survival of critically ill individuals with neuromuscular, skeletal and irrevers~le pulmonary diseases. in these chronically ill individunts mechanical ventilation, long term therapy (ltot) and continuous home care is considered a chronic life supporltng technique that can not be withdrawn after their discharge from an icu. the aim of this study was to present the results of a rehabilitation programme and home care that runs in our ward. twenw three patients were referred to our clinic f~om icus during - . a specific rehabilitation programme designed according to individual's needs was performed. patients that benefitted from this programme were grouped into the following disorders. ) post tb respiratow failure ( %) ) neuromuscular diseases, ( %) } undiagnosed sas { %) ) cope) ( %) ( patients had a overlap syndrom). the programme consists of : ) assessment and mechanical support ff needed of the respiratonj system with non invasive methods (nasal or via tracheostomy). ) group and individual respiratory therapy ) mobilization ) nutritional support ) educational classes for the members of the family. three from the patients passed away (during the year), are under nippv during night with or without supply, pts recieve ltot. conclusion: the development of a programme for chronically ill individuals in especially designed wards in hospitals and the overall care at home is considered necessary at least in hospitals with icus. a rehabilitation programme and home care permits the fast but safe discharge of these patients from units of acute medicine that the cost of treatment is high and besides permits beds that are invaluable. we considered that the rehabilitation prod'amine and home care in our ward is the first performed in greek chronically ill pts and even though there is no special administxative support we think that the results are quite saltsfactory. objective: we postulated that the product of the respiratory frequency (f) and the ratio of inspiratory pressure (ip) to maximal inspiratory pressure (mip) would predict the weaning outcome in deeompensated copd patients better than either variable alone or other indices previously proposed. methods: in decompensated copd patients with difficult weaning, we measured, daily, respiratory mechanics data both during mechanical ventilation and after ten minutes of spontaneous breathing. then we calculated weaning indices reported in literature and some new integrated indices. according to the results of the discriminant analysis, we considered the integrative index crop (acronym of compliance, rate, oxygenation and pressure), the rapid shallow breathing index f/vt, the load/capacity ratio ip/mip, and the following new index: f x ip/mip. we used receiver-operatingcharacteristic (roc) analysis by calculating the area under the curve considered as the overall probability of correct classification. results: main results are reported in the following objective: to evaluate the reliability of some indices of endurance in predicting the weaning outcome of decompensated copd patients. methods: in decompensated copd patients with difficult weaning from mechanical ventilation (mv) we measured, daily, blood gas analysis, ventilatory and airway pressure pattern during mv, breathing pattern (frequency (f) and tidal, volume (v~)), inspiratory pressure (ip), and maximal ip (mip) during spontaneous breathing (sb). thereafter we calculated the following weaning indices: crop (compliance * mip * (pao /pao ) / f), flvt, ip/mip. data obtained the day at which the patient was considered ready for a trial of sb on clinical grounds but weaning failed (wf) and those obtained the day of the successful weaning (ws) were compared statistically through the wilcoxon rank-sum pair analysis. in order to quantify the predictive accuracy for each index with respect to successful weaning we calculated sensitivity, specificity, and diagnostic accuracy according with the standard formulas. methods : five patients ( + yrs) suffering from ards (lung injury score > . ) for hours or less entered into the study. irv (volume controlled, decelerating flow, % inspiratory pause, lie = / ) was compared to conventional ventilation (cv) (volume controlled, constant flow, no inspiratory pause, iie= / ). these two modes were applied for hours in a randomized order, with the same levels of total peep (peept = peep + peepi), tidal volume ( . • . ml/kg), respiratory rate ( • "bpm) mad fit ( • %). measurements (respiratory mechanics, hemodynamics, arterial and mixed venous blood gases) were performed after , , and hours of application of each mode. rvsuils : are expressed as mean + sem and compared by anova. backeround and methods: periodic breathing (pb) is characterized by repetitive cyclic variation in minute ventilation. pb is considewxl to be provoked by an instability in the respiratory control. inintubated, spontaneously breathing patients conventional modes of pressure support ventilation, i.e., triggered inspiratory pressure support ps), do not allow patients to breathe with theirinherent breathing pattern. therefore, pb, if existing, will appear mainiy after extubation. since our new mode of pressure support ventilation" automatic tube compensation" (atc) continuonsly corrects for the flow-dependent tube resistance during insnmdon and expiration ("electronic" extubatim), it pemaits patients to maintain their own inherent breathing pattern. then, ff necessary, tracheal pressure can be additionally supported by volume-proportioead and/or by flow-proportional pressure support (proportional assist ventilation, pav). (~as~: we report the case of a -year-old male patient who was intubated due to acute respiratory insufficiency after acute myocardial infarction with left ventricular dysfunction. during ips of mbar the patient showed a regular breathing pattem which became periodic during atc. in addition, proportional assist ventilation of mbar/l increased periodic breathing in such a way that the typical cheyne-stokes breathing pattem occurred (see figure) . baqkground: the hering-breuer reflex (hbr) is characterized by an inhibition of inspiration during lung inflation. this response has been recognized as an important vagally mediated mechanism for regulating the rate and depth of respiration in newborn mammals. in adult man the hbr is considered to be active only at lung volumes well above functional residual capacity, i.e., at tidal volumes above ml. assessment of the hbr requires specialized methods such as single breath or multiple occlusion technique. methods; in the presence of desynchronization between ventilator and patient, which frequently occurs during triggered inspiratory pressure support ventilation (ips)(see figure) , prolongation of the interval between inspiratory efforts (indicated by negative deflection of the esophageal pressure) due to lung inflation exposes an active hbr. we examined the occurrence of hbr in intubated critically ill patients. strength of hbr was assessed by the formula: prolongation [%] = ((inspiratory interval of interest -preceding inspiratory interval)/preceding inspiratory interval) * ( . rr of patients examined showed moderate to severe desynchronization. in of these patients a (re)activation of the hbr was found. the strength of hbr amounted to + %. there was a significant correlation between tidal volume and strength of hbr. in contrast to previous reports, an active hbr was shown during lung inflation well below ml. b pck~round: triggered inspiratory pressure support ventilation (ips) is commonly used to support inspiration in intubated spontaneously breathing patients. despite its usefulness ips shows some disadvantages which can be deleterious in crificauy ill patients: -additional work of breathing to be performed by the patient due to the flow-dependent tube resistance -desynchronization between patient and ventilator due to inherent triggering failures of the ips mode suppression of the patient's inherent breathing pattern -inability to predict successful extubation in difficult-to-wean patients methods: based on the known flow-dependent tube resistance our new mode "automatic tube compensation" (atc) compensates for the pressure drop across the endotracheal tube ("electronic" extubation). then, if necessary, tracheal pressure can be supported by volume-proportional pressure support (vpps) and/or by flow-proportional pressure support (fpps). results: hitherto, we have examined patients after open-heart surgery and patients with acute respiratory insufficiency (ari) or ards using atc with/without vpps/fpps. preliminary results suggest that the new mode avoids additional work of breathing due to accurate compensation of the pressure drop across the endotracheal tube during in-/expiration prevents desynchronization between patient and ventilator allows patients to breathe with their inherent breathing pattern accurately predicts the outcome of extubation even in difficult-to-wean patients due to "electronic" extubation conclusions: the new mode atc with/without vpps/fpps allows to support ventilation in a more physiologic manner and overcomes the disadvantages of conventional modes of pressure support in intubated patients. backgound: cheyne-stokes respiration (cs) is characterized by regula]; recurring periods of hyperpnea and apnea. in normal subjects, cs may occur after hyperventilation, after arrival in high altitude, or during sleep. it has also been observed in patients with prolonged circulation time due to congestive heart failure, as well as in some neurological patients. there is no report about the influence of sedative drugs on periodic breathing (pb) and cs. methods: in intubated patients conventional modes of pressure support do not allow patients to breathe with their inherent breathing pattem. therefore, periodic breathing and cs are rarely seen. since our new mode of pressure support ventilation "automatic tube compensation" (atc) continuously corrects for the flow-dependent tube resistance during inspiration and expiration ("electronic" extubation) it permits patients to maintain their own inherent breathing pattem even if pathological, e.g., periodic. results: using this new mode of pressure support ventilation, periodic breathing was unmasked in of intubated patients, of which showed cs. in of these patients the occurrence of cs was linked to impaired left ventricular function with increased circulation time. normal left ventricular and neurologic function was found in the remaining patients. in of these patients cs disappeared after intravenous administration of the benzo-diazepine antagonist flumazenil (figure). consequently, in this patient cs was induced by benzodiazepine sedation. objecti',~s: in contrast to conventional rhodes for pressure supported spontaneous breathing, our newly developed ventilatow mode ,,automatic tube compensation" (atc) completely compensates for the flow-depandant pressure drop tlpm-r across endotracheal ttlbe (ett). in the atc mode, the ventilator supplies a flow v' in order to maintain a constant tracheal pressure p~,,~. to this end, pk,,= has to be oontinuousiy determined. since continued measurement of p,,~ by introducing a catheter via the ett is not reliable, we opted for its continuous calculation socordng to the following equation: p~ = p,,, -aperr, pw being the continuously measured airway pressure. this also requires the continual measurement .of flow v' to calculata apm-r using the non-fineer approximation: aport = kvv' + k .w. the constant tube coefficients k~ and k are mathematically determined by mesns of a least-squares-fit procadum based on laboratory investigations. tracheal secretions, however, reduca the omss-saction of the ett. consequently, ~ values of ki end k are changed rendering the p~,ch calculations inaccurate. therefore, k and ~ have to be pedodcally updated to ensure an a~urete monitoring of pn,~ and a complete tube compensation under atc at any time. background: one of the first steps in weaning patients from controlled mechanical ventilation is to stop muscle relaxation and to reduce sedation. it can take several hours, however, until the patient is able to trigger the ventilator and to breathe spontaneously. during this period, many patients display a sudden increase in peak airway pressure of up to %. patients and methods: to investigate the reason for this potentially dangerous effect, we continuously measured lung and chest wall mechanics in post-operatively ventilated patients. lung mechanics (airway resistance and lung compliance) was measured using the esophageal balloon technique as described in [ ] . chest wall mechanics (tissue resistance and chest wall compliance) was calculated from lung mechanics and total respiratory system mechanics as described in [ ] . results: we found a decrease of chest wall compliance (cw) to be the main reason for episodes of sudden airway pressure increase while lung compliance (cl) remained unchanged. the decrease of c w can be inter- gil cano a, san pedro jm ~, sandar d, herntndez . , carrizosa f, , herrero a. emergency and intensive care department, hospital of jerez, spain objective: ) to determine the incidence of hypoteasion (h) associated with emergency intabatian of mechanical ventilation, and ) to establish its relauonship with respiratory mechanics (rm) and arterial blood gases. mechanical ventilation performed in the emergency room, in a prospective eans~eative manner, were evaluated. data collected included patient demographics, diagnoses, blood pressure and arterial blood gas levels before and at~er intabatian, and p_m, including calculated pulmonary end-inspiratory volume above functional residual capacity (veic) and calculated dynamic hypetinflatien (dhc). all patients received midazolen and awaanrinm to facilitate tracheal intubatien and rm measurement. hypotension was defined as a decrease in systolic pressure higher than mmhg or an absolute decrease in systolic blood pressure below to mhg within hour of intabatian. patients were excluded because met at least one of the following exclusion criteria: preexisting shock or h ( ), cardiac arrest ( ) . there weren't any association between peepi or other airway pressures (paw) and h, but calculated pulmonary volitmes had tendency to be larger in patients with h (p < . ). high paco before lrasheal intubatian ( . - mmhg) with a quickly decrease alter starting mechanical ventilation was a usual finding (p < . ) in patients who developed h. paw. ) thexe was a good relatienship between h and high arterial paco before traqueal intahatian and its fast "washing" with mechanical ventilation. ) because cao patients had the highest incidence of h, controned mechanicel hypoventilatien driven by paco changes and pulmonary volumes monitoring instead paw, should be attempted in these patients to avoid this cemplication after tracheal intubatiert. introduction: the endotracheal tube (ett) and demand valve devices cause an added work of breathing (wobadd), which is the work necessary to overcome the resistive load of the ett and the breathing circuit ( ). application of ips has been shown to partly compensate this added work ( ). since tbe amount of wobadd is flow dependent, a fixed ips is not adequate to completly compensate the wobadd ( ). therefore, atc has been developed as a new form of assisted spontaneous breathing ( ), which provides a flow-dependent pressure support. thereby, it theoretically should compensate all the wobadd due to the tube. the purpose of this study was to evaluate the reduction of wobadd with ips and atc for different ett. methods: a mechanical lung model (ls , dr*alger, liibeck, frg) was used to generate a constant spontaneous breathing pattern. the ls was connected to an artificial trachea (at, cm long, mm id). the at was intubated with three different tubes of . , . , . mm id and connected to an evita ventilator modified to provide atc as an option (dfager, liibeck, frg). flow and airway pressure were measured between the y-piece and the ett for four different modes of ventilation: cpap, ips of and cm i and atc all with a peep of cm h . the tracheal pressure (ptrach) was measured in the at. total wobadd was calculated as the area subtended by the ptrach-volume curve below peep. results: the results for total wobadd in nd/ are shown in the figure for the three different ett: breath/mln, s=success, f=failur% *~p<. , **-p< , ns = non significant, f versus s neveltheless, in / patients, invasive ventilation was necessary in mean . _+ hours after beginning of fmpsv. there was no significant difference between the two groups (success, failure) in following parameters : sex, age, previous histoly, medical treatment, saps & , clinical signs (rr, spo , heart rate, blood pressure, glasgow score...), radiological and echocardiographic findings and standard biological parameters. only two parameters were related with failure : .a low value of pac on admission until the patients were intubated. . an increased level of cpk in relation with an acute myocardial infarction ( / cases in the failure group, vs / cases in the success group, x~(with continuity correction) : p<. ). conclusion : fmpsv is a noninvasive, safe, rapidly effective method of treatment in acpe, which may avoid tracheal intubation. further studies are necessary to precise if association of arf and low paco (< mmhg) and/er acute myocardial infarction represents an indication of immediate invasive ventilation. introduction: since the added work of breathing (wobadd) imposed by the endotracheal tube (ets and the breathing circuit is regarded as an important contribution to the total work of breathing, considerable effort has been tmdettaken to compensate for this added work. ips has been fotmd to decrease the wobadd imposed by different ventilators ( , ). because of the flow dependent pressure drop across the etf the tracheal pressure (ptr) should be measured to estimate the total imposed wobadd (wobtut) ( , ). the aim of this study was to assess the circuit imposed work (wobcirc) and wobtot (including ett) for different demand valve ventilators during cpap and/ps. methods: a mechanical lung model (ls , driiger, lfibeck, frg) generated a constant spontaneuus breathing pattern. the ls was connected to an artificial trachea (at), intubated with an . nun et]', end connected to one of four ventilators (servo c and servo , siemens,-elema, sweden; evita , driiges, liibeck, frg; pb ae, puritan bennett, carlsbad, usa). three different modes of ventilator settings were tested (cpap, ips and mbar; trigger set at maximal sensitivity, peep always mbar). flow and airway pressure (paw) were measured between the y-piece and the etr; tracheal pressure (ptr) was measured in the at. wobtot was calculated as the area under the ptr-volume curve below peep, wobcirc was calculated as the area under the paw-volume curve below peep. results: in the foti g., patroniti n., cereda m., sparacino me., giacemini m., pesenti a. inst.of anesth.and intensive care-univ.of milan -sgh monza i aim of the study was to assess cpl,rs measurement obtained by the airway occlusion method during psv. we therefore studied paralyzed cppv ventilated ali patients (lung injury score = . • that were weaned to psv. we performed end inspiratory and end expiratory airway occlusions using the hold function of the ventilator (siemens serve c), first during cppv and then within the th psv hour. airway pressure and flow signals were recorded (cpi bicore) for subsequent analysis. an airway pressure plateau was defined as a flow tracing in which airway pressure was stable for at least . sec. end inspiratory (pel,rsi) and end expiratory (pel,rse) recoil pressures were then measured as the mean airway pressure during plateaus. cpl,rs was computed as tv/ (pel,rsi-pel,rse i) cpl,rs can be adequately estimated during psv using the airway occlusion method; ) during psv inspiratory plateaus are longer than the expiratory ones; ) the length of plateaus is negatively affected by the respiratory drive. foti g., de marchi l., *tagliabue m., gilardi p., giacomini m., sparacino me., pesenti a. inst.of anesth.and intensive care,-univ.of milan *dept.of radiology-sgh monza i we retrospectively compared ct scan and gas exchange findings between a group of patients successfully weaned from vcv to psv (group s = ii patients) and a group who failed the weaning (group f = patients). we selected ali patients (lis= . • in vcv mode who had available a chest ct scan performed within days from the weaning trial. a psv trial was began as soon as the patient reached hemodynamic stability and a pao > mmhg, irrespective of fie (peep < cmh ). maximum psv level was < (pel,rs-peep) measured during vcv, where pel,rs was the respiratory system elastic recoil pressure at end inspiration. psv ventilation was considered successful if a respiratory rate < bpm, an increase in fie lower than . compared to vcv, a pace increase < % of vcv value and hemodynamic stability were maintained during the next hours of psv. if any of these conditions was not met the trial was declared a failure. interdisciplinary critical care unit, regional hospital lugano-ch *surgical critical care unit, university hospital, geneva-ch objective: to assess the degree of correlation of cardiac output measured by thoracic electrical bioimpedance and thermodilution in mechanically ventilated patients with different levels of positive end-expiratory pressure (peep). methods: prospective study with ventilated patients, after head injury and with postoperative sepsis, with normal cardiac output: simultaneous determination of cardiac output by thermodilution and thoracic electrical bioimpedance performed with different levels of peep ( - - cm h ). results: cardiac output measured by thermodilution during sequential increment of peep did not vary: . + . for peep , . + . for peep and . + . l/rain for peep . simultaneously the bioimpedance device recorded a significant increase in cardiac output from . + . for peep to . + . l/mi for peep . (p < , ). conclusion: cardiac output measured by bioimpedance cannot replace the invasive thermodilution methods of cardiac measurement output during mechanical ventilation with peep. we also isolated a subset (h) of patients who had been hypercapnic (paco > mmhg) for at least days (range to days) before the end of cv. the psv trial was started as soon as pao was > mmhg, irrespective of fie and with peep < cmh and the psv level had to be < (pplateau-peep) as measured during cv. pace , pha, base excess (be) were collected before discontinuation of cv and on the ist day of psv: ) . ) weaning is more difficult in pts with head injury(p<o, ) and iss> (p<o,ol), in elderly(p<o, ) and in pts who need fi > , (p<o, ) and peep>io cm h (p<o, ). ) pts with iss> need longer duration of mv (p<o,ol). ) the mortality rate is higher in pts with iss> (p<o,o ), with head injury (p<o,ol) and in elderly (p<o, ). ) paradoxally, compliance was found to be higher in pts> years than in pts< years (p<o, ). s. crotti, p.pelosi, d.mascheroni, m.cerisara, a.lissoni, l.gattinoni. istituto di anestesia e rianimazione -irccs, milano, italia. obiectives. we investigated by ct scan the effects of extrinsic peep (peepe) on lung inflation, tidal volume distribution and regional compliance in sedated, paralyzed chronic obstructive pulmonary disease (copd) patients with dynamic hyperinflation (peep• methods. two ct section (end expiration, end inspiration) were obtained at lung base level in patients (individual analysis for each of the eight lungs) at peepe levels: peepe = cmh (zeep) and peepe amounting to %, % and % of the peep• at zeep ( . • cmh ). tidal volume was kept constant ( • . ml/kg). each lung section was divided into zones equally spaced along the vertical axis: upper (the most ventral), middle and lower (the most dorsal) zone. for each zone we computed: gas volume at end expiration (gase) and at end inspiration (gas• tidal volume (dgas=gasi-gase) and compliance (cpl=dgas/dp;.dp=plateau pressureactual peep• we also computed the lung inflation as the entire ct section gas volume at end expiration (total gase). results. at each peep level both gase and gas• were higher in the upper than in the lower zone ( we cone!ude that in copd patients with dynamic hyperinflation only the application of peepe higher than peepi produces a further increase of lung inflation, decreasing cpl of the upper zone (the more expanded one) probably by stretching phenomena, and causing dgas redistribution from the non dependent to the dependent lung zones. i. ravagnan, p. vicardi, f. valenza, d. tubiolo. p. pelosi l. gattinoni. st . anestesia e rianimazione, universita' di milano, ospedale maggiore -irccs, italy objectives: to investigate the effects of peep and ps on respiratory. pattern and inspiratory effort during ps ventilation in patients with acute lung injury or acute exacerbation of chronic lung disease. methods: pts with acute (a) (paco = • mmhg, pao /pao = . • and pts with chronic (c)(paco = • mmhg, pao /pao = . : . ) lung disease were studied in ps ventilation during the weaning phase. measuring airway pressure, esophageal pressure and gas flow we computed respiratory rate (ril bpm), tidal volume (tv, ml) and pressure time product (ptp, cmh *s/min), which is an index of oxygen muscle consumption. measurements were collected, after rain of stabilization, at and cmh ps and at two different peep levels ( and cndd conclusions: during psv: ) breathing pattern and ptp are different between a and c; ) in both groups peep does not modify breathing pattern; ) peep reduces ptp in c but not in a; ) ps modifies breathing pattern and reduces ptp in c but not in a. to test the performance of a new heat and moisture exchanger (hme): twistair, baxter. this is a hydrophobic-hydrophilic hme without hygroscopic salts. method: we evaluated the hme performance with a previously described method (i); it consists of a "lung simulator" connected to a mechanical ventilator and a flow divider, with a dry and a wet thermal probe inserted into inspiratory and expiratory limbs. on average ps level changes were associate( with opposed changes in both p . and rr. changes in p . were remarkable, homogeneous and highly significant (p<. ), while changes in rr were less pronounced, inhomogeneous and less significant (p<. ). it seems therefore that p . is a better index than rr for estimating a change in load for the respiratory muscles. recently, the lsf method has been described as an interesitng alternative to conventional tecniques used to measure total respiratory mechanics, providing, over these latter, advantages such as no need for hold maneuvers and no need for particular flow patterns. data on the reliability of the lsf method, however, are still few. methods. sets of measurements were obtained in each of ards patients, paralyzed and ventilated in cmv with constant inspiratory flow and an end-inspiratory pause equal to % of ttot. the lsf method provided data for total compliance (ctotlsf) and total resistance (rtotlsf) by multiple linear regression analysis of airway pressure, flow and volume change, applied over the entire breath. the lsf measurements were automatic and continuous, and each value used for analysis was the average of consecutive cycles. conventional measurements of dynamic.compliance (cdyn), quasistatic compliance (cqs), minimum inspiratory resistance (rmin) and maximum inspiratory resistance (rmax) were obtained by the constant flow, end-inspiratory occlusion method, each value being the average of measuremts. ctotlsf was compared with cdyn and cqs, while rtotlsf was compared with rmin and rmax. results. ctotlsf showed a high correlation both with cdyn (cdyn=. .ctotlsf+l. , r =. ), and with cqs (cqs =. .ctotlsf + . , r =. ). the average difference between ctotlsf and cqs, yet, was much lower (+. + . ml/cmh ) than the one between ctotlsf and cdyn (+ . + . ml/cmh ). rtotlsf correlated much better with rmax (rmax=. *rtotlso+. , r =. ) than with rmin (rmin =. .rtotlsf +. . , r =. ). the average difference between rtotlsf and rmin was + . + . cmh / /s, while the one between rtotlsf and rmax was +. + . , confirming the better agreement between rtotlsf and rrnax. conclusion.the agreement between rtotlsf and rmax suggests that rtotlsf takes into account both the airway and the tissue components of resistance, unlike rmin which only expresses airway resistance. the agreement between ctotlsf and cqs indicates that ctotlsf expresses the pure elastic components of the respiratory system. in the paralyzed patient, the expiratory time constant (rce) of the unit represented by total respiratory system and ventilator can be calculated from the slope of the expiratory flow-volume curve. recently it has been suggested that an estimate of this slope is provided by the ve/v'epeak ratio, ve being the exaled tidal volume and v'epeak the peak expiratory flow.the reliability of this method is still little known. methods. sets of measurements were obtained in mechanically ventilated ards patients during paralysis and cmv. measurements of ventilator expiratory resistance (rext) and of total respiratory mechanics were performed in order to calculate these reference measurements for ve/v'epeak: rcdyn=(rmin+rext)ocdyn, rcstat=(rmax+rext)ocqs, rclsf=(rlsf+rext)~ cdyn (dynamic compliance), cqs (quasistatic compliance), rmin (minimum inspiratory resistance), rmax (maximum inspiratory resistance) were obtained by the constant flow, end-inspiratory occlusion method. clsf and rlsf respectively corresponded to measurements of total respiratory system compliance and resistance by the least squares fitting method. ve/v'epeak showed a high correlation with all reference measurements, rcdyn (ve/v'epeak= . orcdyn-. , r =. ), rcstat (ve/v'epeak = . rcstat -. , r = . ), and especially rclsf (see fig the static pressure volume curve of the respiratory system (p/vst) provides valuable information, but the extensive data analysis prevents its use in clinical routine. dynamic p/vcurves are simpler to record. the objective of this study was to develop an automated method to obtain quasi-static p/v-curves (p/vqs) during low flow inflation as well as to measure resistance. preliminary tests were done in normal subjects and subjects with varying degree of lung disease. methods: a computer/ventilator interface (cvl) was constructed for control of a servo ventilator c during an automatic sequence: a) a normal breath, b) a prolonged expiration at zero peep, c) a low flow inflation of a predetermined volume, d) analysis of ventilator pressure and flow. pressure was corrected for tube resistance. airway resistance was calculated from a) and used to derive p/vqs from c). as reference, p/vst was obtained by the occlusion method. results: in non-obstructive diseases the method performed well at volume and pressure controlled ventilation. static and quasistatic compliance were virtually identical. p/vqs clearly reflected the lower inflection point and, when present, the upper inflection point (uip). in some patients uip was more evident in p/vqs, especially at an increased inflation flow rate. in obstructive diseases, the method for subtraction of resistive pressure was inadequate. conclusions: the system for automated computer controlled studies of lung mechanics based on a standard ventilator provides comprehensive information. differences between p/vst and p/vqs imply that the latter reflects also other factors than p/vst that contribute to impedance at hyperdistension. the clinical significance of the two curves remains to be shown. obiective: to evaluate the effect of combined high frequency jet ventilation (chfjv) in patients with severe respiratory insufficiency (sri). methods: in a retrospective study of the period - we analyzed patients suffering from sri who were refractory to conventional mechanical ventilation and were treated with combined high-frequency jet ventilation (chfjv). refractory to conventional mechanical ventilation was defined as a pao /fio < , despite maximal ventilator settings: peep > cm hz , fit > . . a total of patients matched these criteria, males and females with a median age of ( - ) years. seventeen suffered from severe trauma. chfjv was started following a median period of ( - ) days of conventional mechanical ventilation. prior to chfjv ventilation parameters expressed as median were the following: fit . , pao /fio , peep cm h peak airway pressure (pap) cm h . chfjv consisted of high frequency jet ventilation with a frequency of to breaths/minute, driving pressure of . to . arm, and inspiration time of to percent, superimposed on the whole cycle of conventional mechanical ventilation with a frequency of l to breaths/minute and tidal volumes of to ml. results: following two days of chfjv of patients showed an improvement of ventilatory parameters; peep could be reduced to < cm h in patients, the pap was decreased with > cm h:o in patients, fio could be reduced to < . in patients and finally the median pao /fio ratio changed from to . during chfjv patients died, of respiratory failure and due to multiple organ failure, died within two days of chfjv. the median duration of chfjv in survivors and nonsurvivors was days in both groups. conclusions: our data show that with chfjv in the majority of patients with sri who are refractory to conventional mechanical ventilatior" the ventilatory parameters can be improved. backeround and obiectives: although ventilation with peep above the inflection point (pinf) has been shown to reduce lung injury by recruiting previously closed alveolar regions, it carries the risk of hyperinflating the lungs. in the present study we set out to develop a new strategy to recruit the lung during ventilation with small vt, while maintaining peep levels as low as possible. we hypothesized that if the lung was recruited with a sustained inflation (si) to total lung capacity, recruitment would be maintained as long as the peep level was higher than the critical closing pressure of the lung, as observed on the deflation limb of the pv curve (ajrccm ; ( ) :a ). the purpose of this study was to examine the hypothesis that a strategy using si and a peep<pinf would induce less lung injury during small tidal ventilation than ventilation at the same low peep level without using a recmitment strategy in a model of respiratory distress syndrome. methods: we used a randomized protocol with groups to ventilate nonperfused, lavaged rat lungs with small vt ( to ml/kg) for hours and studied the effect on compliance and lung injury. group : peep>ping group : peep<pin f with an si, inflation to on h over sec, to recruit volume; group : peep<pinf without si; group : control group, lungs were inflated at peep<pin f, but not ventilated. results: in group and group static compliance did not change after ventilation (table) . in group static compliance fell significantly. group showed significant changes in the pv curve, which were less severe than in group . results from morphological examination are pending but preliminary results showed less lung injury in group , compared to group . conclusions: small tidal ventilation following a recruitment manoeuvre in a model of respiratory distress syndrome allows ventilation on the deflation limb of the pv curve at a peep below pinf. this strategy ( ) minimizes lung injury as well as, or better than using peep above pint" and ( ) ensures a lower peep to minimize the detrimental consequences of high lung volume ventilation. i~peep>pin~ _objectives-this report is presenting the results of the clinical study for using eeg examination as a method of the evaluation of patients ability for weaning. methods: the study inclljqles eeg examinations with fourier spectral analysis' of patients ~vith respiratory insufficiency and prolonged control mechanical ventilation (cmv). all patients have had a-rhythm of eeg before weaning. we have followed respiratory rate, tidal volume, respiratory pa{tern, end-tidal co and blood gases during weaning. results: patients had invariable eeg activity or short -waves period (till one hour). the weaning of this patients was fast arid sucsessful. other patients have had a decreasing of a-activity, an appearence of -waves for an hour and more, a short episodes of a-and e-activity. after that this patients had gas exchange and respiratory disorders with regression of the weaning right up to cmv. conclusion: eeg could be used as a method of the evaluation of patients ability for weaning from cmv. some eeg signs shows the overstrain of compensatory systems before the change to the worse of gas exchange and respiratory pattern. s. elatrous, p. aslanian, d. touchard, d. corsi, h. lorino, l. brochard. medical intensive care unit, inserm u , hopital henri mender, cr~teil, france. in vitro comparison of flow triggering (ft) systems demonstrated advantages compared to pressure triggering (pt) systems for some ventilators (puritan bennett ) but not others (siemens serve ). we studied the two types of systems in two groups of patients mechanically assisted with pressure support ventilation ( + cmh ). in the first group (pb ) the effort of breathing, assessed by the esophageal pressure time index, was significantly lower with the ft than with the pt ( + cmh .s/min - vs + , p< . ). by contrast no significant difference appeared in the second group (serve ), as predicted by the bench study despite marked interindividual differences ( + cmh .s/min - vs + , p = . ). we conclude that ) rigorously performed bench studies can predict in vivo effects, ) mild advantages can be found for the new triggering systems on some ventilators. objectives: pressore-volume curves (pv) of the respiratory system is of interest for the determination static compliance (cs , lower (lip) and upper (uip) inflection points which indicate zones of airway recruitment and overdistension. this study aimed to compare an "automated low flow inflation" method (alfi) to the reference occlusion (oc) method. the ability of the former method to identify cst, lip and uip was tested in icu patients. me,otis: ( arf and ards) sedated paralysed patients were studied using a serve c ventilator linked to a computer which automatically forced the ventilator to insufflate at a low constant flow a velum up to - ml or a maximum paw of cm h (alfi). the quasistatic elastic pressure (pel,qs was obtained by subtraction of the resistive pressure of tubing and patient and related to volume for calculation of compliance cqst. for oc tidal volumes (v from up to - ml were followed by a s post-inspiratury pause for determination of static pal (pel,st) in relation to volume. compliance was defined from the linear part of the p/v curves. lip and uip were defined from the consistent deviation of p/v data from extrapolated the linear part. ~,~ i~: in ards, mean cst was . + . and cqst . + . ml/cm h (us), lipst . + . and lipqst . + . cm h (us), uipst . + . and uipqst . + ~ cm h (us). nosocomial pneumonias (np) are frequent and often unsuspected during ards (bell, ! ). in the present study, we evaluated prospectively the onset of np during severe ards (group b of the european study). patients and methods: the charts of patients with severe ards have been prospectively recorded. a plugged telescopic catheter (ptc) specimen has been systematically performed every hours, for quantitative bacteriological analysis. the diagnosis of np was defined by a number > colony forming units / ml. results: for the patients studied, the mean saps score (+ sd) was +_ , the initial pao /fio ratio was -&-_ , the duration of mechanical ventilation (mv) was + days. the mean delay before the onset of the first np was . + . days ( - ), and the mean pao /fio ratio was +- . respiratory symptoms (purulent aspirates, new pulmonary infiltrates, or gazometric changes) were present in % of the patients studied. alteration of gas exchange was present in of the patients ( np) . a new pulmonary infiltrate was present in only np ( %). an increase of fever was noted in patients, an increase of leukocytosis > % in patients, an increase of volume and purulence of sputum in of the patients with np. the degree ofgazometric worsening (pao /fio before np minus pao /fio during np) during the first episode of np was + mmhg. excluding the bacteriological criteria of np, the number of criterias of np present was in / patients, ( / ), ( / ) or ( / ). two patients only had a pulmonary colonization (ptc: < cfu / ml) before the first episode of np. the incidence of np is high ( %) during severe ards. the first episode occurs in average:at the th day, and is the cause of a severe hypoxemia (pao /fio ) . the onset of a np may contribute to the high mortality rate observed in our patients ( %). each worsening of hypoxemia during severe ards should induce to suspect a np. respiratory system during mechanical ventilation. the me~hod quantifies the dissipative energy consumption of the respiratory system in terms of energy loss aek, inefficiency ~k~ and respiratory dissipative resistance rk~ over a given partition of the tidal volume. the method can be applied in intensive care units with no interference to ventilatory support. it allows for monitoring the combined effects of inhomogeneities, non-linearities and visco-elastic effects, that are subject to change in the respiratory system. the method is studied on pigs~ in the presence of a log-dose response curve of methacholine (mch) induced disease. in healthy pigs~ we find a mean value of energy loss, ae, of . • j/l, a mean value of inefflency, ~ of . ~= . and a mean value of resistance, ~, of . • cm h s/ . the respiratory resistance, rk, shows a variation over the partition of tidal volume with armax ---- . • . cm h s/l. during methacholine provocation~ ae rises more than five-fold up to . • j/l~ doubles to . • and t~ increases to a maximum of • cm h s/l, with armax : . • . cm h s/ . the variation in rk becomes more pronounced with higher doses of methacholine. methods: ards patients were prospectively studied. initially they were ventilated in the amv (assist mechanical ventilation) mode with the settings prescribed by their primary physician. after stabilization, ventilatory gas exchange and hemodynamic variables were determined. patients were then ventilated in the mrv (mandatory rate ventilation) mode with breaths as the target rate. in mrv the target rate is set and the ventilator autoregulates the pressure support level delivered ~o achieve this rate. after stabilization, the measurements done on amv were repeated. finally, patients were sedated and paralyzed and ventilated in cmv (control mechanical ventilation) with the ventilatory variables they had during mrv. measurements done in amv and mrv were repeated and respiratory mechanics were assessed with the constant flow end inspiratory occlusion method. results: two groups were recognized based on their response to mrv. tn group patients responded to mrv by decreasing their v and increasing the t/t t ratio. ve, vo , and aado decreased while paco increased and tda vo ume and co remained unchanged. on the contrary, in group v, vr and ve increased; ppeak and trr t remained unchanged, paco~ decreased while vo and aado increased with constant co, the pressure support level needed to achieve the target rate was much lower in group than in group ( , -+ . vs . _+ . ). obiectives : in the newly developed mode of ventilatory support ,,automatic tube compensation" (atc) the ventilator compensates for the flow-dependent pressure drop across the endetracheat tube (ett) thus allowing ,,e]ectronic extubation". the aim of the study is to investigate whether healthy subjects perceive atc in inspiration (atc-in) and in expiration (atc-in-ex) and whether atc provides an increase in subjective comfort compared with the conventional assisted spontaneous breathing mode (asb). methods : healthy volunteers (no preceding lung disease, non-smokers, male, - years)breathed spontaneously through an uncut ett of . mm id via a mouthpiece. the ett was connected with a prototype ventilator evita modified by the manufacturer (drfiger, lebeck) for atc. flow and airway pressure were measured at the outer end of the ett. three ventilatory modes, ( ) asb ( mbarover mbar peep), ( ) atcin, ( ) atc-in-ex were selected in random order. immediately following the transition from one mode to another the volunteers answered by hand sign how they perceived the new mode compared with the preceding mode: ,,better" (+ ), ,,equal" ( ) or ,,worse" (- ). inspiration and expiration were investigated separately by presenting mode transitions (in total; including ,,placebo" transitions). results : the difference between atc and conventional asb is perceived in inspiration and in expiration. atc is positively judged; asb is nega ively judged. the diagrams show mean values _+ sd of five volunteers investigated up to now. the new mode atc is perceived as an increase in subjective comfort. our explanation is that atc preserves the natural breathing pattern better than conventional asb. objectives: to determine the role of cerebral vasoconstriction in the delayed hypoperfusion phase in comatose patients after cardiac arrest. to correlate the results with indices of cerebral oxygenation and the levels of several vasoactive hormones in the jugular bulb. methods: in comatose patients after cardiac arrest we measured the pulsatility index (pi) of the medial cerebral artery by transcranial doppler sonography. the pi is a reliable indicator of cerebral vascular resistance. we also sampled blood from the jugular bulb and measured cerebral oxygen extraction ratio and jugular bulb levels of endothelin, nitrate and cgmp. the first measurement was done within hours after cardiac arrest and repeated , , , , and hours later. results: we studied patients, females, mean age , + , years. the pi decreased s!gnificantly between th~ first and the last measurement from . _+ . to . + . (p = . ). cerebral oxygen extraction ratio decreased also from . + . to . + . (.p = . ). endothelin levels were high, but didn't change during the studied period. nitrate levels varied in a wide range, but didn't change significantly. however, cgmp levels increased significantly from very low levels in the first measurement to very high levels hours later, rasp. . pmol/ml (median; th . - th . ) and . pmol/ml (median; th . - th . ) (p = . ). eighteen and hours after the first measurement we found a strong correlation between pi and cerebral oxygen extraction ratio ( r = . , p = . and r = . , p = . ). we.also found hours after the first measurement a significant correlation between pi and cgmp levels ( r = . , p = . ). we found no correlation between pi and endothelin or nitrate levels. conclusion.~; our results show a high cerebral vascular resistance in the first few hours after cardiac arrest, gradually decreasing during the next hours. this is accompanied by an initially high cerebral oxygen extraction ratio and low cgmp levels, suggesting that the cerebral vascular resistance is induced by active vasoconstriction because of insufficient cgmp levels, leading to a decrease in cerebral blood flow and a compensatory ~ncrease in cerebral oxygen extraction. objectives: sudden cardiac arrest is a major cause of mortality in western countries accounting for over half of all cardiovascular deaths. in most cases the mechanism of death is prolonged cardio-circulatory arrest due to ver:tricular fibrillation (vf) preceding final asystole. recurrent syncopes due to idiopathic vf with good neurological prognosis have been reported in patients with and without cardiac etiology ( , ). in the past measurements of cerebral hemodynamics have been repeatedly done in humans during cpr, but until today no studies of cerebral blood flow velocity (cbfv) have been reported during controlled cardiac arrest in humans not under-going cpr. it was the purpose of our study to evaluate the acute hemodynamic effects of untreated vf on cbfv. methods: after approval by the local university ethics comittee, five male patients aged - years without evidence of cerebral disease were investigated during vf while undergoing implantation of a pacer cardioverter defibrillator system (model d; medtronic| a standard anaesthetic regimen was used (propofol, fentanyl). after implantation of the automated cardiac defibrillator vf was induced by electrical countershock to test effective sensing, pacing, and defibrillation. to measure cerebral blood flow velocities (cbfvmca) the doppler probe was placed above the zygomatic arch between the lateral margin of the orbit and the ear and directed towards the m segment of the middle cerebral artery (mca). results: a total of phases of vf were investigated. duration of vf ranged from to seconds, with cbfvmc a (mean_+sd, cm sec - ) flow pattern changing from pulsatile to laminar flow immediately after onset of vf. conclusions: the underlying mechanism of the laminar cerebral blood flow observed during vf in our patients is uncertain, but it may provide insight into the prognosis of patients with idiopathic vf. theoretically, the laminar cerebral blood flow observed in our pulseless patients may provide a substantial amount of cerebral perfusion even during clinical cardiocirculatory arrest objective: to investigate whether the intensive care nursing staff can inflate more accurately a specific air volume with the laerdal resuscitation bag when they receive feedback after each inflation about the delivered volume compared to no feedback. method: icu nurses were asked to inflate a testlung model times with a specific air volume ( ml, ,ml or ml) under three different conditions (normal, decreased compliance and increased resistance) without and with feedback. we measured the mean absolute difference from the specific airvolume after each ten inflations. results: the largest absolute difference was found when icu nurses inflated ml ( ml). the mean inflated volume for this group was ml. when the icu nurses had to inflate ml the mean absolute volume difference was ml with a mean inflated volume of ml. inflating ml produced an absolute volume difference of ml with an mean inflated volume of ml. the absolute volume difference decreased when the compliance of the testlung was decreased and even more when the resistance of the used endotracheal tube was increased. when the icu nursing staff received volume feedback after each inflation the mean absolute volume difference was reduced between the ml and ml for all specific air volumes. % of the last inflations with feedback were significantly smaller than ml from the specific air volume (p < . ). conclusion: the majority of nurses overinflated the specific air volumes. the largest over inflation occurred when ml and the smallest when inflating ml. when nurses were provided with volume feedback the performed significantly better. we concluded that icu nurses are not able to inflate a specific air volume with the laerdal resuscitation bag without receiving volume feedback. feedback is desirable in order to reduce the volume trauma. objectives: a pro_found impairment in systolic and diastolic myocardial function following successful cardiopulmonary resuscitation (cpr) has been demonstrated by using langerdorff method in rats. in the present study we have investigated post resuscitation myocardial dysfunction in a porcine model of cpr. methods: ventricular fibrillation (vf) was electrically induced by alternating current applied to the ep{cardium of the right ventricle in domestic pigs. following rain of untreated vf, precordial compression and mechanical ventilation was initiated and maintained for min. electrical defibrillation was then attempted and of animals were successfully resuscitated. results: following successful cardiac resuscitation, stroke volume index (svi) decreased from prearrest value of . ml/kg to . ml/kg (p< . ), and left ventricular stroke work index (lvswi) from . to . mmhg,ml/kg (p< . ). both svi and lvswi remained depressed for another hours. these decreases were associated with increases in heart rate from bpm to bpm (p< . ). no significant changes from baseline in mean arterial pressure, mean pulmonary pressure, right atrial pressure and pulmonary artery wedge pressure were observed. prehospital resuscitation efforts c. k ppel. g. fahron, h. lufft, a. kruger, c. th(jrk, f. bertschat, f. martens dept, of nephrology add medical intensive care, virchow-klinikum, humboldt-universit~t, d- bedin, germany obiective: the success rate of prehospital resuscitation in patients with cardiocirculatory arrest in an emergency medical system (ems) may reach - % depending on the time of calling the ems, the distance to cover by the emergency ambulance and the training of the emergency physician and his staff. in the berlin ems, which is associated with the berlin fire brigade, the time between alarm and arrival at the scene ranges from - min, mean min. resuscftation is based on the advanced cardiac life support (acls) according to the guidelines of the american heart association. if resuscitation efforts fail to restore circulation, they are terminated after - min, depending on duration of cardiocirculatory arrest, pre-existing disease, age, absence of an even transient response to cpr. however, there is a lack of practical criteria for termination of cpr in individual decision making. patients: we report cases of prehospital cpr with primary asystolia terminated after - rain of frustraneous cpr efforts including highdose epinephrine and dopamine. results: after termination of cpr, the ecg monitor remained connected and showed permanent asystolia in all patients while the emergency physician completed his records. spontaneous resumption of respiration and circulation was observed in these patients after - min and cpr efforts were immediately resumed, nevertheless, of the patients died at the scene, while could be hospitalized with stable circulation. one of them died hours after admission to the icu, the other survived for weeks in a vegetative state. spontaneous resumption of circulation and respiration is most likely due to the development of extreme hypercapnia and acidosis, which -at least in some patients -seems to be a stronger stimulant of the circulatory and respiratory brainstem centers than cpr with high-dose catecholamines, conclusion: because of the legal and ethical implications of this rare phenomenon, emergency physicians should continue ecg monitoring for at least rain. after termination of cpr efforts. pulmonary artery catheterezation is used for patient's monitoring [ ]. we reported our results on such monitoring in [f.coaobbeb,r.fe enb~-kap~monorm~, ,n ,p. - ] .however not all of the received criteria assessments meet demands that are necessary for early diagnosis of critical states. here we report the data on po ,pco (mm rg),so ,ph levels in femoral [af) and pulmonary (ap) arteries blood, as well as on summary gas pressure (sgp) calculated from pe=(po +pco ) in mm hg in ap blood. these data were derived from:i) subjects free of cardiovascular pathology according to catheterization data during their spontaneous air breathing (n group in ap blood appears to be a measure of adequacy ratio between pc and sgp in ap blood during air breathing; partly its characteristics and variations ranges are presented earlier [ j. in control group it is equal to , • mm hg. tests on sgp neither exclude nor substitute conventional (pc and pco ) tests, but rather include them as a part choosing only additive characteristic -pressure. they appear to be a part of general system of human metabolism regulation by pressure (arterial,venous,intracardiac, tissue,liquor,onco-osmotic,etc ietraabdeminal pressure produces perturbations of cardiac, pulmonary, and renal physiology. this most often occurs fonowing eeliotomy for peritonitis or intestinal obstruction; bowel edema and distention prevent wound closure without unacceptable compromise of blood pressure or pulmonary compliance. a variety of temporizing measures have been reported for managing wounds that cannot be closed: ) using towel clips to reapproximate skin only, )i sewing silastic, marlex or other prosthetic grafts to the fascia to "enlarge" the peritoneal cavity, ) using loosely tied retention sutures for partial closure, ) simply packing the wound without attempts at c~osure. these techniques either traumatize the abdominal wall (complicating definitive closure), expose the bowel to damage, or allow excessive loss of fluid and heat. since we have evolved a suturelees technique which permits the abdomen to be partially closed in a quick, safe, sterile, sealed, atraumatic fashion -while providin! decompression of unphysiologic intraabdominal pressure. methods: whenever possible omentum is interposed between bowel and the open incision. viscera are covered by a layer of sterile, non-reactive plastic, placed deep to the fascia and extending we~t beneath the edges. sump tubes are placed above the plastic and covered in turn by two layers of an adhesive plastic drape which sticks to the skin and seals the wound in all directions, the patients remain intubated and paralyzed. results: we have used this technique in a total of patients, four of whom suffered from compartment syndrome. all of the latter were males and ranged in age from to . all four showed immediate physiologic improvement. all four incisions were eventually closed without complication. one compartment syndrome patient died t days later of multiple organ failure. there were no complications related to the closure technique in any of the patients. conclusions; . selected patients with abdominal compartment syndrome will benefit from decompression using this temporary sutureless technique. the technique a) is quick, safe, sterile, sealed, and atraumatic, b) minimizes loss of fluid and heat, c) facilitates eventual definitive abdomina| closure. although m. brunner m. mitllncr objectives: to determine incidence and predisposing factors for cardiac arrest occurring during the first hours after open heart surgery. methods: the study included patients who, following open heart surgery, had adequate cardiac function and in whom cardiac arrest was not anticipated. all data were prospectively recorded and analyzed. results: from / through / , pts underwent open heart surgery at our hospital. of th~se, pts ( %) (age _+ yrs) had a cardiac arrest during the first hours after transfer to icu. they were operated on for coronary artery bypass grafting (cabg) ( pts), valve replacement (vr) ( pts), cabg and vr ( pts) and aortic aneurysm ( pt). the preoperative ejection fraction was _+ % whereas bypass and aortic cross-clamp time were + and + rain, respectively. prior to arrest, they had a cardiac index of . _+ . l/min/m and were receiving . + inotropes. arrythmias leading to cardiac arrest were ventricular tachycardia/fibrilation ( pts) and bradyarrythmia ( pts). closed-chest cpr was initially performed on all pts and was followed by open-chest cpr in pts. eighteen pts ( %) survived to icu discharge. causes of arrest included perioperative myocardial infarct (t pts, %), tamponade ( pts, %), rupture of the proximal vein gra& anastomosis ( pt, %), graft occlusion ( pts, %); no cause was found in pts ( %). conclusions: postoperative cardiac arrest in stable cardiac surgery pts is relatively infrequent (- % incidence) and is associated with a high survival rate following successful cpr. perioperative myocardial infarct is the most common predisposing factor. group ~deptof anaesthesia and intensive care, semmelweis univ. medical school, buda military hospital intensive care unit, budapest background: when a cardiac arrest occurs in-hospital, the outcome can be improved by a higher quality of basic life support provided by the witnessing health care workers until the code team arrives. this basic life ~pport (bls) should include the best available method for airway management as well. since not all medical staff are ready for carrying out endatracheal intnbation, we investigated the effieacy of the use of different airway management methods during bls. methods: we have investigated the efficacy of airway management of doctors and nurses from different hospital wards: internal medicine, department of surgery, trauma, urology and gynaecolagy. comparing the bag-valve-mask, laryngeal mask and the endotracheal intubafion, we have measured the following parameters: time needs for correct application (sec.), number of incorrect applications (out of ten trial), efficacy of artificial ventilation provided by the device. we used a computerised als trainer manikin for the evaluation of the performance. total performance score was created after the measurement between - . after the first screening we held a x hours training. doctors and nurses were trained for the endotracheal intubation (group it , t ) , doctors and nurses were trained to use the laryngeal mask (group lm , lm ) . all respondent were trained to use the bag-valve-mask device. day, month and month after the training we have carried out retention study using the same method. results: we have found that the efficacy of the artificial ventilation using the above mentioned devices were poor before the training. the average after-training performance scores of the groups are presented in the table below. (bls) should be initiated by the witnessing health care professional. the cpr study introduced a multi level code system, which means bls included sophisticated airway management, early defibrillation and early epinephrine administration provided before the code team arrives. our previous studies confirmed a poor level of cpr performance and a high demand for cpr training among health care professionals. method: we established a cpr training course centre, where doctors and nurses are being trained for in-huspital basic and advanced life support. x hours of training were held. after the theoretical introduction a step-by-step training method ws used for trainees to be familiar with all sequences of basic and advanced life support. then we synthetised all separated sequences. afterwards, a r e play of rescue groups was taken in simulated situations. we also trained the multi level alarm system fur the in-hospital resuscitations. after the training all respondents had to sit for examination. the quality of performance was scored and compared to our previous results. semi-structured interviews were carried out before and aider the training among all respondents to collect information about the course. results: we have found a remarkably high interest among doctors and nurses in our cpr training courses. it was very important to use proper equipment for the training: audio-visual training facilities, computerised als trainer manikin, manual and automatic defibrillator units. the evaluation of the examination held immediately a~er the training course showed a significant higher quality of performance than before the training. the self.-eonfidence of the trainees for initiating and carrying out resuscitation had increased. their overall feeling about the course was positive and % responded the course "very useful". . % of doctors and . % of nurses claimed fur regular training facilities with als trainers, conclusion: the cpr training for health care werkers is mandatory including the training of sophisticated airway management and use of elad~l~ills~tt~r wlaa ~en ~r a~ti~atir ~nel r rm~a'*h*nr m~thnd for training will improve the efficacy, the satisfaction of trainees, therefore their compliance for further co-operation will also increase. s objectives: the effect of reinfusion in emergency surgery and gynecology. methods: we had an experience of autologous blood transfusion in patients whom was produce t an emergency surgical or gynecological interventions in occasion with break tubal pregnancies ( . %), penetrating abdominal wounds with injuries of mesenterial vessels ( . %), injuries of the liver ( . %), blunt abdominal trauma with lien ruption ( . %). in . % patients had the previous somatic pathology. blood loss volume was - ml, & the reihfuside blood volume was - ml, consisting - % of blood loss. it was needn't to fransuse donor blood in . % in further but - ml of contanined erythrocytes were frasfused for supporting of hb concentration on the g/l ( g/dl) rate at the other patients with isovolemie hemodiluttion. results: the arterial blood pressure fast stabilisation on the perfusion level had noted after reinfusion, excluding the case, when the volume of reinfused blood had conisted just % of blood loss at the patient with massive blood loss. complications have noted in two cases. one patient with slash wound, injury of arteria gastrica dextra and total blood loss of ml, has an episode of asystoly, dic (disseminated intravascular coagulation) syndrome, acute renal failure, and acute pancreatitis that we haven't connected to reinfusion. all the complications were successfully corrected and at thirty first day patient with subcapsular wound of the lien that has happened days before complicated with external rupture of the capsull & massive intraabdominal bleeding, has the hemolytical shock, dic syndrome, acute renal failure developed after reinfusion. he was died. all another have no complications. posthemorrhagic anemia had corrected rapidly than in case when hemorrange corrected exclusively by donor blood. conclusions: we consider that simplicity, accessibility, high effectiveness, quite well further results of blood reinfusion, except the case of blood reinfusing that was for time-expired out of blood vessels (more than days in our case) will promote to the wide spreading of this method, especially in emergency surgery, in massive injuries, & in disarters, all the cases of insufficiently of time for selection of lot of donor blood. objectives: study of a reaction of the oardioreepiratory system of pregnant women to i/v microperfusion of clophelinum which is known to eliminate hemodynsmic and endocrine nociceptive reactions and can be used for treating hypertensive syndrome in pregnancy and labor. methods: the following non-invasive methods were used: capnography, spirometry, oxygenography, indirect fick principle based on the circle breathing, plethysmography and integral rheography~ functional indices of cardiorespiratory function were evaluated. results: pregnant women with ~h-gestosis were examined before and after i/v infusion of i ml of . % clophelin solution, . mg/kg/hour. before the treatment intensification of carbohydrate metabolism, hyperventilation with moderate hypooapnia and complete respiratory compensation of metabolic acidosis~ increased alveolar ventilation, decreased alveolar volume, predomination of perfusion over ventilation, hypokinetio type of circulation with dominated load by peripheral vascular resistance to the blood flow was observed in this group of patients. microperfusion of clophelin imp~-oved the ventilation/perfusion ratio, ventilatory and gaseous exchange efficiency, resulted in a decrease of congestion in the pulmonary circulation, possibly owing to a decrease of peripheral vascular resistance by %, of the heart rate by io. %, of the oardial output index by . %. conclusionm: the resulted type of circulation with a decreased load on the heart both by resistance and volume allowed to improve the cardioreepiratory system function in pregnant patients. objectives: the injury severity score is a measure of severity of anatomic injuries. iss is a sum of squares of the highest degrees of the abbreviated injury scale (ais) for each of three most severity injured regions. the purpose of the study is to establish correlation between the iss values and mortality rate in older, polytraumatized patients. methods and results: iss was determined for patients. the mean iss value was . + . while the median value was . minor injuries were present in ( %) patients with iss less than , while ( %) patients with iss more than had severe injuries. increased mortality of the older patients was noted in the range - . all patients older than died while % of patients below yrs of age survived, indicationg correlation between iss and mortality rate in polytraumatized patients above yrs of age. conclusions: this mode of evaluating severity of injuries may help in triage, determining appropriate level of care and as an indicator of future outcome of polytraumatized patients. objectives : tissue hypoxia is a non exclusive cause of hyperlactatemia. other serious medical situations induce hyperlactatemia. therefore, lactatemia could be a non specific indicator of severity in patients admitted in emergency unit. the aims of this study were to examine the correlations between lactatemia with the short term survival course prognosis and the unit of hospitalisation; intensive care unit (icu) or medicine unit, in patients admitted in our emergency department. methods -lactatemia was measured as soon as the admittance, in arterial blood sample of patients which needed arterial blond gas. sixty-one patients were included during months. to assess the statistical performances of lactatemia, sensitivity (se), specificity (sp) and accuracy (ac) were calculated for the threshold determined by the youden's test (se+sp- ). results : fifteen patients were admitted in icu and in a medical unit. fifteen patients died. a group of patients had a lactatemia up to mmol.l" . in this group of patients, had acidocetosis, had asthma, had cerebral vascular ischemia, had neoplasia, had cardiogenic shock, was epileptic, had congestive heart failure, had acute respiratory failure, had septicaemia, had hyperosmolar status finally had medicinal intoxication. lactatemia was significantly higher in non survivor than survivor ( . • vs. . + . , p<o.oool, respectively), the cut point of lactatemia was . mmoll" se was %, sp was % and the accuracy was %. on the other hand lactatemia was higher in patients admitted in icu than in medical unit ( . + . vs. . • p<o. , respectively). conclusions : this preliminary results suggest that lactatemia is a good indicator of the short term survival course in patients admitted in an emergency unit. furthermore, hyperlaotemia is present in several pathology seen in emergency. objective: to determine the pattern of injury, total peripheral white cell, neutrophil, and lymphocyte responses, and the outcome of trauma patients who are leucopaenic on admission to the icu. design: prospective, descriptive study of consecutive admissions over months. setting: a -bed surgical intensive care in a teaching hospital. patients: thirty consecutive adults admitted to the icu following trauma. leucopaenia was defined as a total peripheral white cell count of < x , neulropaenia < x , and lymphopaenia < . x ~ cells per litre. measurement and results: the total peripheral white cell count was documented daily and the neurtophil and lymphocyte counts and differential percentages on days , , and . the incidence of leucopaenia was significanfiy higher in patients with gunshot wounds (p < . ) and hollow visceral intra-abdominal injury (p < . ). eight ( %) patients died. no significant differences were found in the initial mean total white cell, neutrophil, or lymphocyte counts nor in the differential percentages between survivors and non-survivors. the total peripheral white cell count increased significantly in survivors compared to those who died (p < . ) and significant differences were found in absolute neutrophil counts (p < . ) and differential percentages (p < . ) on days and . no significant differences were found in lymphocyte counts or differential percentages. conclusions: there is a signficant association between leucopaenia, neutrepaenia, and intra-abdominal hollow visceral injury and peritoneal contamination. survival is related significantly to resolution of these white cell deficiencies. these findings suggest a possible role of granulocyte colony stimulating factor in the trauma patient with intra-abdominal infection and persistent neutropaenia. amelioration of organization emergency care team in order to improve caring for urgent cases. objectives: emergency care team (ect), as integral part of health, respectively as activity of primary health protection care all acute difficult conditions which vitaly danger patients and distressed. the aim of our investigations was to indicate on the possibilities of amelioration of organization ect in order to improve caring for urgent cases. methods: in our investigations we used epidemiologicai and statistical metods all informations and matherials from terrain ects. results: the number of traumatized in traffic accidents etc. have a epidemic character. it is well known that . % traumatized died in first two hours. ect isn't enough qualified to care a traumatized on the place of accident and during transport. because that medical personnel must have an education with solid qualities. conclusions: . besides a physician specialized (vii --+ vii -~ viii gradus) in urgent medicine, it's necessary to introduce two ( ) medical technicians instead of one as is existing now ( ~ ). .the medical technicians can drive cars and one of them always, drives the ambulance car ("b" category). .the technicians have been specially educated for urgent cases (iv ~ v ~ vi). . such a new team structure should be more capable in professional sense. .we can see an importance of team-work in ects. . such teams should also be more economic in comparison with existing one. . we think, that on the general medical studies need to include a new discipline-urgent medicine! objectives: to detoxicate an organism since we have used biological sorbents: isolated from liver and spleen of human or animal cells or tissue fragments. methods: cellular dialysis ( dialyses) in patients with an acute hepatic insufficiency poisoning by hepatotropic poisons: cc , dichloethane, mushrooms -were conducted using "artificial kidney" apparatus, by means of arteriovenous shunt, formed at forearm with disposable dialyzers. hepatocytes suspension was poured into dializing circuit of dialyzer at - mg of cells per i kg of patients weight. dialysis was performed during - hrs. patients with purulent-septic states were treated as for hemoperfusion through prepared sorptional column: . ml of hemosorbent and . ml of fragmented spleen or hepatocytes suspension with the help of roller pump with the rate of - ml/min, during - min. average volume of hemoperfusion made . . conclusions: in all cases we used both native and cryopreserved biomaterial. analysis of the dynamics of clinical, biochemical, scintigraphic and us-investigastions allows to conclude that application of cellular-sorptional method of detoxication enable to prolong life and reduce lethal outcome in some severe category of patients with endotoxicosis. after infusion of diazepam ( . mg/kg),thiopentone ( mg/ kg) and vecuronium (lmg/kg),patient was intubated and mechanical ventilation was adjusted to mantain normoca= pnia. ct scan showed left parieto-occipital hypodensity with brain swelling. after admission in neurological icu,dexamethasone ( mg/ kg/die),mannitol ( .smg/kg) and diphenylydantoin ( mg/ kg/die) were administred. two hours later neurological status of the patien~ was normal and she was extubated. the risks of stereotactie radiosnkgety are related to: hemorrhgge during the latency interval;transient radia= tion effects;permanent radiatio~einduced complications; radiation induced neoplasia. no epilepsy is reported in pts with avm and no seizure before radiosurgery. in c nclusion, epilepsy can be a posmib~e delayed eompli c~t~n, ~fe~r rgdi surgery for cerebral avm. serum potassium deficiency is a frequently reported finding in the time course of acute myocardial infarction (ami). if this is also correct for patients with ami undergoing primary percutaneous transluminal coronary angioplasty (ptca) is unknown.for that reason we analysed in patients ( m., f., + y.) serum potassium concentrations on ad ,mission and directly after ptca.the reference intervall for potassium in our clinical laboratory is , - , mmol/l. although more than % of the patients with ami undergoing ptca showed normal potassium serum concentrations on admission a measurable decrease of potassium could be found in % of patients ( ) after ptca.therefore for the majority of patients with ami potassium supplementation prior to ptca can be justified to avoid electrolyte disturbances as a possible trigger factor for cardiac arrhythmias in the setting of ami and acute reperfusion due to primary ptca. objectives: diagnostic procedures are very important in the management of abdominal injures in trauma. the aim of this paper is to present our experience with peritoneal lavage as diagnostic procedure in abdominal injury. methods: we analyzed patients to whom peritoneal lavage was applied in the surgical emergency from st of january till st of december . results; in this four years period there were abdominal injures. there were blunt injures. among them in patients peritoneal lavage was applied. results were positive in patients and negative in patients. false positive finding were in patients and false negative in two patients. in patients with positive lavage there were more than , /mm red blood cells, more than , /mm white blood cells and the level of amylase was up to u/i. the gall, urine and stool were positive as well. in patients with negative lavage there were less than , /mm red blood cells, less than /mm white blood ceils and amylase were negative. conclusion: peritoneal lavage is useful and important diagnostic procedure in the management of abdominal injures in trauma. our experience with urgent surgical management of the acute gastric and duodenal bleeding s.se en md, z.milo~evi md, *s.srdi md, k.sar ev md. clinic for abdominal and endocrine surgery, institute for surgery; *clinic for cardiology, institute for cardiovascular diseases; school for medicine novi sad, university of novi sad, yugoslavia objectives: acute gastric and duodenal bleeding are very common complication of gastric and duodenal ulcer. the aim of this paper is to present efficiency of our surgical management of these acute conditions. methods: in this paper results of surgical management of patients with acute gastric and duodenal bleeding, treated in our clinic from the st of january till st of december , are presented. results: among operated patients there were females ( . %) and males ( . %). there were patients ( . %) with gastric bleeding and patients ( . %) with duodenal bleeding. bleeding from gastric ulcer were treated with the following methods: excision of ulcer with suture in patients ( . %), ulcer suture in patients ( . %), billroth i in patients ( . %) and billroth ii in patients ( . %). heinecke-mikulicz-weinberger pyloroplastica was the most frequently used in the treatment of the duodenal ulcer bleeding. bilateral truncal vagotomy was done in patients ( %), duodenotomy with ulcer suture was done in three patients ( . %) and three patients underwent billroth ii operation. we had three complicationsduodenal dehiscence in pyloroplasty. there were no lethal complications. conclusions: based on our own experience we conclude that acute bleeding from gastric and duodenal ulcer can be safely managed with urgent and modern operative techniques. dept. of anaesthesiology. emergency center of serbia, belgrade, srj b ectives and methods: cardiac contusion was evaluated by serial determination of cpk-mb fraction and co using non-invasive doppler technique in patients with blunt trauma of the chest. results: miooardial contusion was diagnosed in ( %) patients, while in ( %) it appeared unaffected. cpk-mb of % and more in comparison to total cpkwas . + , % in patients, and , + , % in pts (p< . ).c of . + . l/min in patients with cardiac contusion, measured hrs after admission at the latest, was significantly lower than in group of patients with co of . + . l/min (p< . ). conclusions: co values were significantly lower in patients with cardiac contusion and correlated with pathological values of cpk-mb fraction. objectives: extracorporal plasmophoresis (pph) was implemented by non-stop method in patients with obstructive jaundice. methods: changes of serotonin (s) and histamine (n) in arterial (ab) and venous (vb) blood were investigated before and after one-time session of pph. s and h in blood serum were determined with fluoremetric method. results: before pph the average s contents in ab and vb did not differ. after one-time pph session s in the blood outflowing lungs was % lower than in the blood inflowing. hours after extracorporal detoxication implemented the indices kept the same level. similar dynamics after pph was observed in h. before the session h contens was equal both in the blood inflowing and in the blood outflowing lunge. after pph h contents in ab was % lower compared to the vb and did not change for hours. conclusions: dynamics of changes of biogene amines shows that under the influence of pph there takes place not only mechanical removal of their surpluses together with plasm, but there sharply grows inactivating role of lungs towards ba substances, which is confirmed by reduction of their concentration in the blood outflowing lungs. this effect is probably connected with the "deplasmation" of the lung cellular elements. simultaneously lungs' cells are freed not only from plasm but from toxic adsorbents on their surface. as a result the lung cells activate absorption of the surplus number of amines from the vessel channel. it is not excluded that s inactivation is due to growing activity of monoaminooxidase resulting in deminishing of intoxication. acute pulmonary embolism: thrombolytic therapy or pulmonary embolectomy? i.lodiena md, phd, s.shevchenko md, pphd., medical university, kharkov, ukraine objectives: pulmonary embolism (pe) remains a challenging problem for diagnosis and management for the emergency physician. the aim of this work is to identify the best treatment for massive pulmonary thromboembolism. methods: during recent years patients with symptomatic acute serious pe were reffered to our observations. selective pulmonary arteriography confirmed this diagnosis in all cases. ( . %) underwent urgent surgery, of them ( . %) with cardiogenic shock and ( . %) with massive pulmonary embolism. patients ( . %) underwent thrombolytic therapy. results: in the patients who received thrombolytic therapy successful results were achieved in cases ( . %), in ( . %) patients subsequent pulmonary embolectomy was performed. mortality rate was ( . %) in the patients who underwent pulmonary embolectomy after unsuccessful thrombolytic therapy and ( %) in the patients with cardiogenic shock and massive pe. lower extremity deep venous thrombosis caused pe in % patients. pe mortality rate is repoted to be %, but all patients with cardiogenic shock and massive pe died. this very high mortality rate related to the clinical status of the patients whose condition became worse despite intensive treatment. conclusions: the results of this study show that in most cases thrombolytic therapy is an effective rapid method of treating pe. however, surgical treatment is preferable when the patients reveal adverse effects to drug therapy, when medical therapy is unsuccessful or when the patients are seriously ill with reccurent cardiac arrest. high-quality pulmonary angiography remains the most accurate and reliable means of diagnosing pe. this prospective study was conducted to investigate the serum thyroid hormone levels in traumatized critical ill patients. serum thyroid stimulating hormene(tsh),total thyroxine(tr ),free thyroxine(ft ),total tri-iodothyronine(tr ),free tri-iodothyronine (ff ) levels were measured within hr.of intensive care unit admission(first day) in multiple tratmmtized male patients(injury severity score higher than ). in fifth day the same hormone levels were repeated. tsh,et ,ft ,tr and ft levels were determined by radioimmueoassay(ria). the levels of 'i~sh,xt ,fr ,et and ft in survivors and nonsurvivors were compared with first and fifth days (table) . in conclusion, we are convinced that there was a high correlation between low ser~n thyroid hormone levels and mortality, serum thyroid hormone levels are prognostic value in traumatized critical ill patients. objectives: glucagon improves myokardium contractility, intensifies kidney blood flow, stops bronchospasm ( ), these were the reasons of investigating its effect on hemodynamics and metabolism in hypovolemic shock expermentally and in clinic. methods : in experiments on white rats with traumatic shock glucagon (novo nordisk) was injected intraperitoneally in dose rocg/kg. patients with hypovolemic shock (trauma, hemorrage) were injected glucagon intravenously in dose mg on the background of infusion therapy. results : glucagon hightened recovery indexes of glucose in rats and patients with shock, whereas in groups without glucagon hyperglycemia developed. rats with glucagon injection had double times urea content than the norm ( , + , mmol& norm - , + , mmol/i ), whereas rats without glucagon had urea content , + , mmol/ ( p < , ). osmolarity of blood plasma in rats having glucagon injections was , + , mosm/kg h , without the drug - , + , mosm/kg h ( p < , ), ldh activity - , + . and , + , ( p < , ) mcmol cec- accordingly. lethality in the group of rats without glucagon was % /n= /, with glucagon - (n = ). in patients with hypovolemic shock in minutes after glucagon administration stroke volume increased to % (sv), miocardium contractility -to % (mc), peripheral resistance of vessels ( vr ) decreased to %. in - , hrs sv increased to %, mc-to %, pvr -decreased to %. conclusion : the study provides the evidence that glucagon has an anti-shock effect, improves hemodynamics and metabolism indexes in cases of hypovolemic shock. reference : picazo j. glucagon in acute medicine : pharmacological, clinical and therapeutic implications (norwell, mass:kluwer publishing, ), p. n, vasina (t) ,n.sebbota hph ( ). dept; of acute endotoxicosis, n.v. s~lifosovslay scientific research institute of ermergency ltealth care, boscow, lk'ussia (i}. institute for problems of cryobiology and cryouledicine of the national academy of sciences of the f/maine, kl'k r-key, [ maine ( ), objectives: the investigation of isolated hepatocytes using's efficacy in patients with acute hepatic fai lln-e. methods: native and crioconsrved allo-and xeno-!mmatocztes fixed on semi;ermeable ~mbr~s were used. results: the artificial supporting system with isolated hepatocttes as metabolic ~its was. ap-plied in patients. during tl~ treatmen~ with this cytotherapz an improvement of clinic state and biochemical rates were observed even inthe first we~s. for instance, the kncreasing of glutamin acid's level in blood up to normal value and decreasing of ammontes -concentration from i ~ mmol/l down to # mol/l were discovered. ~ae diminution of ence,%halo;athy was noted too. general lethality was' equal z, there of i z concerned acute hepatic failure (/k~). conclusions: the using of sum~rting hepatic system is able to cope the ~nenomenon of ~i~. objectives: fat embolism (ee) is an important and insufficiently studied problem of the intensive care medicine. fe is clinically diagnosed in % and morphologically in - % of the victims with severe multiple skeletal injury that is accompanied by the shock. methods: during the last years patients with the cerebropulmonary form of fe were treated in the icu. the prognosis of the probability of fe development was done using the computer system "cite-prognosis" in which the triss-method, dynamic and statistical prognosis of the injury outcome~ and the values of the most severe injury in points were realized. the treatment consisted of the surgical stabilization of the fractures with the authors' design of the rod apparatus in the acute period, long-term mechanical ventilation with peep via tracheostomy, complex fluid therapy using perfluorochemical emulsions (pe), and electrochemically active solution of na hypochlorite (snh) via the central vein. results: the treatment of patients with fe gave a good result that was manifested by the complete regression of psychoneurologic and respiratory disorders. conclusions~taking into account the prognostic data~ it is necessary to provide early complex of intensive care to the polytraumatized patients. it includes the surgical stabilization of fractures, fluid therapy using pe and snh~ early long-term mechanical ventilation. dr. alexandr e. poladko, station of medical aid. kiev ukraine. objectives: the reason of investigation is to prove the necessity of beginning of the intravenous infusion of nitroglycerin before the hospitalisation. methods: from january i to june protocols of treatment myocardial infarction patients in kiev medical aid station. results: the results of treatment are better if infusion began early or prolonged during hospitalisation. conclusions: there were patients with acute myocardial infarction treated before hospital by the cardiological groups. patients were treated with the early infusion of nitroglycerin and without. the results of treatment were: in the group with infusion: mortality in the first hours % the full disappear of pain % in the group without infusions mortality in the first hours % the full disappear of pain % that's why our opinion is that infusion of n. is necessary in the treatment of the patients with myocardial infarction from the first minutes of illness. dr. gennady d. kyrzhner, station of medical aid, kiev, ukraine. object: looking for safe medication which is good for the treatment of arterial hypertension and is simple for use. we inspected the effect of prazosin in the conditions of the cail during the year. method: we used mg prazosin tablets sub lingua and measured blood pressure ones during hours. the parameters were registrated in protocol. result." one hundred patients took part in investigation. the middle age of patients was . the reason of hypertension was not taken into consideration. in two hours after beginning of the treatment we caught the reliable lowering of blood pressure in % of patients. the general condition of patients became better in - min. it was only one accident of complication during the treatment -the orthostatic hypoter~sion, conclusion: prazosin hydrochloride in the dose mg sub lingua is safe and simple for use in the urgent situations. objectives: hypomagnesemia is frequently observed in severely burned patients during the early period after injury. increased urinary excretion is insufficient to explain the magnitude of the magnesium (mg) depletion. the possibility of exudative cutaneous mg losses has been proposed, but not yet demonstrated. the study aimed at measuring the mg content of the cutaneous exudates and urine during the first week after major burns. methods: patients, aged _+ years (mean _+ sd), and burnt _+ % of body surface, were studied from day (d ) to d . serum samples were collected at do, serum and urine from d to d , and on dio, d , d . cutaneous exudates were extracted from the textiles surrounding the patients, collected over h periods from d to d , using bidistilled acidified water. mg supplements ( . to mmol/ h) were prescribed from d to dio according to the severity of hypomg (serum mg < . mmol/i). results: mg serum levels decreased below reference ranges in patients between d and d , and normalised thereafter during supplementation. urinary mg excretion was increased in patients, mean excretion being . _+ . mmol/ h until d . mean daily mg cutaneous losses, were mmol/ h, i.e. mmo; in days. large inter-& intra-patient variability: the daily exudative losses ranged from to mmol/ h. conclusions: the mean daily mg cutaneous losses after burns were larger than the urinary losses, and equivalent to the recommended intakes for mg; the addition of the exudative and urinary losses largely explained the increased mg requirements after burns. complex immunologic alterations occur following thermal injury. the activation and consumption of the complement and dotting systems are suggested to play an important role in the development of the capillary leak syndrome, tn burned patients, a generalized inflammatory reaction as well as the impairment of the host defense are considered to be the major reasons for complications, such as sepsis and multiple organ failure. in a pig model we investigated a possible protective effect of cl-inhibitor (berinert, behring). before conducting the animal experiments the human cl-inhibitor concentrate was analyzed for its inhibitory capacity on purified pig cls and its pharmacoldnetic behaviour in pigs (t / ,id ). pigs received anesthesia and analgesia and arterial, venous and pulmonary (swan ganz) katheters were placed into the carotis and jugular veins. the pigs were scalded for seconds with ~ hot water to achieve a % tbs partial-thickness burn. blood samples were taken prior and after surgery as well as , minutes, , , and every further hours after thermal trauma. two control groups (each n= ) included animals which were either scalded or not scalded and treated only by resuscitation of ringers lactat solution. besides various parameters blood samples were analyzed for complement. the pigs (n= ) received c -inhibitor concentrate at an initial dose of u/kg body weight either immediately or hours after thermal trauma (n- ), followed by three further applications (of reduced amounts) every hours. the clinical outcome as indicated by vital parameters and as well as demonstrated by reduced edema and inflammatory tissue destruction suggested a protective effect of cl-inhibitor. complement analysis revealed a faster recovery of the alternative and classical pathway activities in cl-inhibitor treated pigs as compared to the control group but only if the regulator was given immediately after thermal trauma. from these results a protective function of c -inhibitor on thermal trauma can be assumed. objectives: the aim of study was to characterise the pattern of secretion of interleukin- (il- ) and tumor necrosis factor alpha (tnf alpha) in multiply injured or not injured critically ill patients and to relate these results to their outcome. methods: blood samples of multiply injured ( ( ) ( ) ( ) il- (nis) ( ) ( ) ( ) il- (nin) ( ) ( ) ( ) conclusions: this data suggest tnf alpha is a better prognostic marker in patients with multiple injury, than in critically ill patients without injury. il- is not significantly higher in nonsurvivors of both groups. sepsis is associated with an increased production of nitric oxide (no), as reflected by a rise in plasma levels of nitrites (no ) and nitrates (no ). severe bum injury is associated with similar symptoms of inflammation like hypotension, high cardiac output low vascular resistance and increased vascular permeability so that an increased no production may be involved. the present study included patients admitted to the intensive care unit of the burn center of brussels (age : - years; burned surfaee area - %), and control (non-septic) patients hospitalized in the neurological rehabilitation unit of the erasme hospital (age - years). the patients in both groups were fed enterally with to kcal/kg/day of a standard solution. in the burn group, daring the study period, patients were mechanically ventilated, required vasopressor (dopamine) therapy, and received antibiotics; patients were discharged alive from the intensive care unit, and no patient died during the study period. plasma was sampled for no /no determinations (griess reaction) daily from day to day (n=ll) or to discharge (day , n= ; day , n= ) in the burn group, and once the control group. in the burn group, no /no levels were elevated at day ( _+ #moles/i), reached a maximal value on day ( - p.moles/l) and progressively decreased to day (fig). these values were higher than in the control group ( . :t: . #moles/l, all differences p< . ). however, no correlation was found between the plasma no /no levels and the age of the patient or the total burned surface area; burned patients who became infected tended to have higher plasma no /no levels than those who did not ( + vs - #moles/i, ns). the present study indicates that burn noa/noa (llmol**/l) injury is associated with increasedloo] [__ ] ~ no /no plasma levels, which are ao so consistent with an enhanced no pro- o duction, ao obiectives:urapidil has been recommanded for therapy of hypotension in neurosurgical patients, because it was found not to increase intracranial pressure in patients with compromised intracranial dynamics ( ). in contrast several authors reported an increase of icp after urapidil administration in patients with head injury ( ). our study was designed to determin the influence of urapidil on mean lumbar cerebrospinal fluid pressure (csfp) in awake humans with uncompromised intracranial compliance. methods: after approval by the local university ethics comittee, six volunteers (asa , male, female) were studied in the lateral decubitusposition with the vertebral column positioned horizontally. a gauge needle was inserted into the lumbar subarachnoid space at level l /l and connected to a trancducer (mx | medex inc.) for csfp measurements. the volunteers were advised to keep respiratory rate and etco constant. after a resting period of minutes basline measurements were performed including csfp, cvp, map, hr, etco (cardiocap | datex). then the volunteers were given urapidil . mg/kg over a period of minute. minutes later measurements were repeated. results: statistics: wilcoxon signed rank test, p< . significant; values: mean_+sd, si = mmhg. - _ " _+ * _+ * - _+ " _+ csfp: cerebrospinal fluid pressure, cpp: mean cerebral perfusion pressure. conclusions: during normoventilation urapidil leads to a decrease in map parallel by an increase in csfp and therefore in icp, most likley mediated by an autoregulatory dilatation of cerebral vessels. if this cerebrovascular response is suppressed by hyperventilation, no increase in icp is found despite a uredipil induced drop in map ( ). after longterm hyperventilation cerebralbloodflow is normalized. this might be the reason why the drop in bloodpressure following urapidil administration again led to an increase in icp ( background and objectives: the intestine is one of the most sensitive tissues to ischemia-reperfusion injury. reperfusion of the intestine is often associated with increase in mucosal permeability and ulceration. d(-)-iactate is produced by indigenous bacteria found in the gastrointestinal tract and mammals do not possess the enzyme systems to rapidly metabolize it. the present study was designed to determine the kinetics of plasma d(-)-iactate alteration in rats paused by acute intestinal ischemia-reperfusion injury. methods: following the anesthesia, the superior mesentcric artery (sma) was exposed and it was occluded by a micro-bulldog clamp applied at its origin from the aorta. after min of occlusion, the arterial clamp was removed and the supply area of the sma was allowed to be reperfused ( h). plasma d(-)lactate levels were measured by an enzymatic spectrophotometric assay. the endotoxin content of plasma sample was assayed by the limulus amebocyte lysate test with a kinetic modification of the test kit procedure. results: intestinal ischemia for min resulted in a significant increase in d(-)-lactate levels within the portal vein as compared to sham-operated animals. plasma d(-)-lactate levels had a tendency to further increase after reperfusion up to h. it was showed that significant elevation of endotoxin concentrations in portal vein was alread~r detected at the end of -min ischemia, reaching peak at . h post-reperfusion and decreasing gradually throughout the study period. at the end of ischemia, marked mncosai damaged such as edema, hemorrhage and necrosis was observed. there was evidence of injury to ti, e muscuiaris propria together with diffuse mucosal damage and destruction following reperfusion, particular at h postreperfusion. in addition, penetration of bacteria was commonly found in the intestinal wall at various time points following ischemia/reperfusion injury. conclusions: these data suggest that acute intestinal ischemia is associated with permeability change of mucosal barrier resulting in increased plasma d(-)qactate, which is also remarkably influenced by subsequent reperfusion. plasma d(-)-lactate may be a useful marker of intestinal injury following both ischemia and reperfusion insult. objective: to assess the clinical usefulness of two methods of intracranial pressatre (icp) monitoring: intraparonquimatous recording (icpc) and epidural recording (icpe), versus intraventricular icp (icpv) as a gold standard. we prospectively studied patients with severe head injury (glasgow coma score < ) admitted to our icu between fobmaly and december . icpv was monitored in all pativrats by means of a multipzffolated catheter connected to a water coinnm. six of patients were additionally icpc monitored by a fiber optic transducer (comma r~), and seven of patients were icpe monitored by a couplvd fluid system (plastimedr). icpc was placed homolatetal to the focal, lesion m two cases and contralateral in three; icpe was placed homolateral to the focal lesiou in two cases and contralateral in three. all three systems were calibrated at the ear level. stali~cs: correlation coefficient and lineal regression were done between icpe and icpv, and between icpe and icpv with the hourly p~rs of values obtained dttting assistontial period. results: of the six icpc -icpv studied pa~onts, we observed a correlation coef~cieut r = . (p < . ) with a regres~on line y = . + . x. four of ~hx lcpc -icpv patients had r > . when correlaliou eoet~dent was obtained indixddually. of the seven icpe -]cpv studied patients, we observed a cortelafiau ooeffioiont r = . (p < . ) with a regression line y = . + . x. corralalmu eoetfieiont was inwer than . in all seven patients. corrdation eoelfieients for levals of icpv > man hg, > mm hg and > tuna hg with icpe showed r = . , r = . and r = . respectively; and with icpe r = . , r = . and r = . . the obtained values did not change during the study. conclusdns: in our study icpe was considered a good type of icp monitoring. /cpe signiticantly infravalorates icp values. we observed a good correlatinn between icpc and icpv values in patients with high inttacramal presanre. objective: midazolam is a benzodiazepine agonist widely used for sedation in emergency medicine. few studies in animals and humans point to a direct analgesic effect of midazolam probably mediated by spinal antinociceptive receptors and/or peripheral benzodiazepine receptors ( , ). in our experience in the berlin emergency medical system (unpublished results) with anecdotal cases of extreme chest pain due to binge drinking but no evidence of acute myocardial infarction or extreme abdominal pain due to peritonitis, acute intermittent porphyria, peutz-jeghers syndrome or testicular torsion, we found that small doses of midazolam ( - mg i.v.) were much more effective in relieving pain than repeated administration of high doses of buprenorphine or morphine, which may be associated with a considerable respiratory depressant effect. the dose of midazolam required for pain relief in these patients is non-narcotic and allowed further communication on the character and localization of' the residual pain, which might be very important for the further diagnostic procedure. patients: ten patients with abdominal pain due to acute gastrointestinal bleeding, suspected pancreatitis, suspected acute porphyria, and chest pain with no evidence of acute myocardial infarction received first-line midazolam i.v. at an initial dose of mg and were asked how it affected the intensity and character of pain. results: at the chosen dose of midazolam ( - mg), all patients were responsive to detailed questioning on basic orientation, the character, intensity and localization of the pain, and medical history. none of the patients required an additional opiate. all patients stated that the pain was tolerable after midazolam alone. conclusion: our preliminary clinical observations suggest that low-dose midazolam might be an alternative to opiates in extreme pain of presumably visceral odgin. objectives: it is known that severe head injury in elderly patients is associated with higher mortality than in younger patients. it remains however to be clarified whether the preinjury pathology which is frequent among these patients, affects the outcome. methods: in an attempt to investigate this hypothesis, patients aged over years suffering from head injury, with glasgow coma scale (gcs) of or less, were studied retrospectively. twenty-six patients ( . %) had preinjury pathology i.e. diabetes mellitus, arterial hypertension, heart failure, alcoholism, parkinson's disease etc. (group a) and fifty-three ( . %) did not (group b). the following data were recorded: mortality in the i.c.u., duration of hospitalisation, incidence of infective complications and neurologic status at discharge. results: groups were comparable in terms of mean gcs ( . vs. . ) and median age ( . vs. ). the incidence of brain pathology in the two groups was the following: epidural haematoma . % vs. . %, acute subdural! haematoma . % vs. . %, intracerebral haematoma . % vs. . %, subarachnoid haemorrhage . % vs. . %, diffuse haemorrhage . % vs. . %, contusion . % vs. . % and non-visible pathology (normal ct) . % vs. . %. unilateral pupilary dilatation was found to be . % in group a and , % in group b. the mortality during hospitalisation in the i.c.u. was almost the same: % iu group a and . % in group b patients. however, group a patients had significantly more infective complications, required longer hospitalisation and had lower gcs at discharge. conclusions: the results show that the existence of preinjury pathology does not seem to affect the short-term outcome of elderly patients with severe head injury. it has however an impact on morbidity and perhaps long-term survival of these patients. the assessment of clinical development in intensive care patients with severe head injury still remains a problem. to optimize the monitoring of intracraniel prassure (icp) we rautlr~dly implant an eplduml measuring device in our hospital. the aim of this study was to prove the correlation of the icp-values with ct findings and clinical development. during a month period ( - r the icp was monitored in p~,tients ( male, female) with severe head injury by an eplclural measuring device (epldyn~/$plegelberg| the mean age was . years ( - ). the glasgow coma scale at admission was . ( - ). in all cases the device was placed wfihln the first hours after admission. the tcp was compared with physical examination, radioidglcal or intraoperatlve findings and cunlca! outcome. the average time of measuring was . days ( - ) . the traatment depended on the !cp values recorded. rising icp-valuea ~ed to radlologlcal c ntra!s by ct-scan. in case an intracranlai hemorrhage was detected and drained. the overall survival rate was . %. showed a complete resolutl n, in other . % psychological residuals like decreased mentatlon, in . % sensomotorlc residuals like cerebral nerve dysfunction and aphasia, and . % of the injured remained in a comatous status. in % of our cases the measured values correlated with clinical course and management. in cases ( . %) we observed a displacement of the icp-pevice. there was no icp induced infecllon. istituto di anestesiologia e rianimazione, universit& ,,la sapienza", rome, italy * istituto superiore di sanit& -servizio di epidemiologia e biostatistica, rome, italy objectives: acute renal failure (arf) can be a severe complication of trauma. the current incidence of post-traumatic arf is associated with high mortality . identification of risk factors and prevention of this complication could improve the outcome of trauma patients. methods: one hundred fifty three consecutive trauma patients (age . _+ . , injury severity score . + . ) admitted to icu were studied. incidence of arf was . % ( / ). arf was defined as persisteat plasma creatinine > mg/dl with or without oligoanuria . arf was defined as early when occurring within the first hours (earf) and late when the onset was after the first four days (larf). results: earf occurred in patients while larf developed in patients. age, iss, and incidence of rhabdomyolysis and acute respiratory failure were not different in the two groups. an higher incidence of multiple organ failure (mof) and sepsis ( . % for both) were observed in larf group, when compared to earf ( % and % respectively). abdominal trauma was more frequent in earf group ( % vs %). the gs for earf and larf were respectively _+ . and _+ . while in the group who not developed arf (narf) the gs was . • conclusions: gs score difference seems suggestive and can be that an abnormal cerebral activity (hipofisary hormones?) may play a crucial role on onset of arf in these patients. moreover the frequency of acute respiratory failure in the group of arf was higher ( . versus . ) than narf group. the early ipoxia in the early phase of trauma, then, may be another crucial point for development organ failure. these are preliminary data. a more exact statistical analysis must be perform to have definitive conclusions. to compare the active compression-decompression cardiopulmonary resuscitation (acd-cpr) with the standard cardiopulmonary resuscitation (s-cpr) in out of hospital cardiac arrest patients. is a controlled, randomized study. two groups of patients with cardiac arrest out of the hospitalwere formed. group i, (acd-cpr) and group ii (s-cpr). for the acd-cpr groupweusedthecardiopumpdeviceofambulnternational. asfortherest, the erc ( ) algorithms for acls were followed. the utstein style (for out of hospitat cardiac errest) was used for listing and evaluating all cases of the study. the cpr was contucted by the crew and the doctors of our mobile intensive care units (micu). we studied consequitive patients ( in group i) and ( in .group ii). demographics pre-cpr characteristics (e.g. ecg form of cardiac arrest) and procedures (eg bystanders or second tiers crew cpr, defibrillation, drugs) were quite similar for both groups. the mean arrival time of micu was min. in group i we recorded r.o.s.c. (return of spontaneous circulation) , %, death %, continuation of cpr efforts , %. while in group ii, %, %, and , % respectively (recorded percentage until the admission to the hospital). no significant difference was found in anyofthe short term outcome parameters. no complications related to the acd-cpr technique, were noted. not any significant difference between the two methods was proven (from this small evaluated sample). the results of previous clinical studies are controversial (i) . more sophisticated studies proved the superiority, in a certain number of parameters (e.g pressures, flow, etc) of the new technique although there are many difficulties for establishing clinical results. in the pre-hospital setting that is related to many parameters (speed of the intervention, effectiveness of bystanders cpr, education ofparamedics, etc.)the evaluation is even harder. the superiority ofthe acd-cpr can be proven when it is performed in almost times increased number of studied patients as w~ll as improvement of the technique could lead us to more established results. objectives; infectious morbidity is the major cause of mortality after burn injury, and is due to multiple factors. trace elements (te), which are involved in both humeral and cellular immunity, exhibit severely altered status after burns. te supplementation has been shown to be associated with increased leukocyte counts and shortened hospital stay. the trial aimed at studying the immune responses in severely burnt patients receiving normal te supplies or early large supplements. methods: patients, aged _+ yrs (mean_+sd), with burns covering + % of body surface were studied from day (d ) to d post-injury, were randomised in groups (g): g -control receiving recommended te supplies + placebo; g -receiving in addition large supplements of cu, se and zn from d to d . enteral nutrition was started within hours of injury in all patients. immunological parameters: peripheral leukocyte counts, proliferation of mononuclear cells to mitogens, cell surface molecule expression, and neutrophil chemotaxis at d and d . infectious episodes and micro-organisms were monitored until d . results: the patients' characteristics were similar g & g . the total leukocyte counts were higher in g between d and d , due to increased neutrophils (significant from d to d ). total cd + and cdlg+ cells did not differ, whereas cd + (monocytes) were significantly increased at d . proliferation to mitogens was significantly depressed in all patients. chimiotactism was not altered. the number of infectious episodes was significantly decreased in g with a mean of . _+ . infections during the first days versus . _+ . in the control group (p < . ). conclusions: the large te supplements for days was associated with a significant decrease of the number of infectious episodes. supplementation was associated with increases in total leukocyte, monoeyte and neutrophit numbers. further studies are required to determine the precise mechanism underlying the improved immune defences. objectives: evaluate the efficiency of local adsorption (la) with the use of carbon adsorbents in case of severe burns in expertment and clinic. methods: experimental studies on la were performed on a model of % body surface area iiib-iv burn in rats. a burn eschar was excised on the rd day after burn, the wounds were dressed with the gauze bandages (control) or with adsorptive dressings (la), dressings were regularly changed. clinical investigations were carried out in the course treatment of patients with severe thermal and radiation ilia-iv burn. in the dynamics of bum disease some indices of proteometabolism and intoyacation criteria were evaluated. results: the experiments have demonstrated that the application of la after early excision of a burn eschar exerts a pronounced normalizing effect on a protein electrophoregram and the activity of proteases and their inhibitors in burned tissues preserving vitality. thus, by the th day after burn infliction the activity of cathepsin d in injm'ed muscles is times lower under an adsorptive dressing than under a gauze bandage (control) (p< , ), the activity of trypsin-like proteases is . - . times lower and the antitryptie activity does not differ significantly from the normal level. the cytotoxicity of extracts of burned tissues after the adsorptive dressing application fn vivo and adsorption in vitro is - % and - %, respectively, of the toxicity of control extracts. a similar normalizing effect of la is ok~rved for an intact muscular tissue and blood serum. the dectron-spin-resonance studies have demonstrated that la allows to normalize antitoxic activity of liver and functional activity of kidneys. the application of la in the treatment of patients with severe burns have been shown to localize a region of irreversible tissue changes, accelerate rejection of a burn eschar, attenuate an endogenous intoxication level and, as a result, shorten the time for grafting of a burn wound and accelerate wound heating. conclusions: proceeding from the obtained results, we can consider la as an effective method of localization of a region of irreversible tissue changes as well as of correction of local and general metabolism failures and overcoming burn autointoxication during burn disease. c de deyne, t vandekerckhove*, j. decruyenaere, b. vaganee, v vandewalle*, f colardyn depts of intensive care and neurosurgery*-university hospital gent-belgium. jugular bulb oximetry is the first bedside available cerebral monitoring technique providing an estimation of the adequacy of cerebral perfusion. its routine use in all patients suffering from severe head injury admitted to our ic unit enabled an extensive analysis of all very early cerebral perfusion data in order to evaluate the incidence of abnormal sjo~ data (and their possible causes) in this very eady period after traumatic insult and to search for possible implications as to the emergency management. these very early data were defined as the first hours icu data and icu admission had to occur within h of traumatic insult. over the last years, pts with severe head injury (gcs< ) were monitored by jugular bulb oximetry, starting immediately after their arrival at the icu (mean of . h after trauma, range between - h). in a total of pts (= . %), jugular bulb desaturatiens (< %) were noticed during this early h period. in pts (= %), jugular bulb saturations higher than % were observed, whereas pts (= . %) revealed no abnormal sjo data ( - %) during these first h. concerning the periods with too low jugular bulb saturations (n: ), we found the following correlation ; in pts (= . %) cerebral perfusion pressure (cpp) was below mmng, in pts (= . %) paco~ was below mmhg and finally in pts (= %) we found primary intracranial hypertension. for the high jugular saturations (n: ) we found a primary intracraniaf hypertension in f pts (= %), and a pace level above mmhg in pts (= %). in all patients we could restore jugular bulb saturation within normal range ( - %) with the correct!on of the presumed causative factor. we can conclude that ultra early jugular bulb saturation data revealed a high incidence of abnormal values, with a predominance of jugular bulb desaturations, confirming once again the high incidence of disturbed and too low cerebral perfusion within the first hours after severe head injury. these jugular bulb desaturations were especially correlated to systemic causes, as a too low cpp (caused in the vast majority by primary map insufficiency, and not by intracranial hypertension) and hyperventilation were the major causes of the desaturation periods. as jugular bulb desaturatione are known to be significantly correlated to a worse neurological outcome after severe head injury, one might improve outcome by an emergency management avoiding these possible causes of jugular desaturation. therefore, extreme attention should be paid to the maintenance of an adequate mean arterial blood pressure (above mmhg?) even duhng the few time spent at the emergency department. one should be as attentive to the maintenance of normoventilation during this very early period of admission and hyperventilation without any knowledge of icp or sjo should be abandonned. recently, indomethacine has been proposed for the treatment of therapy refractory intracranial hypertension in pts suffedng from severe head injury ( ). indomethacine, a cyclo-oxygenase inhibitor, gives rise to a significant fall in cerebral blood flow by inducing cerebral vasoconstriction. therefore, its use could result in a drastic lowering of the intraeranial pressure (;cp) in pts suffering from intracranial hypertension secondary to cerebral hyperaemia and in whom the use of other cerebral vasoconstrictive drugs (barbiturates or hyperventilation) appears insufficient to control icp. for the last months, we included the use of indomethacine in our therapeutic flow chart for severe head injury management. pts revealing intracranial hypertension (icp> mmhg) and cerebral hyperaemia (sjo~> %) and in whom icp was not efficiently controlled by the combined use of hyperventilation and barbiturates were given indomethacine in a trial to control icp. a total of head injured pts received treatment for intracranial hypertension over the last months. six of them met the criteria set for the administration of indomethacine. in pts, no decrease in icp or in sjo was observed and both pts died due to therapy refractory intracranial hypertension. in the other pts, a significant fall in icp and in sjo was observed shortly after indomethacine administration. in pts we observed a catastrophic fall of sjo= even below %, indicating an extreme cerebral vasoconstriction with the possible risk of inducing cerebral ischaemia. in one of the pts, icp remained under control without further administration of indomethadne, but he died days later in multiple organ failure. the other pts, needed multiple indomethacine administrations (for pt even during consecutive days) to finally control icp. in all pts, icp was finally controlled, but only pt survived. both other pts died from systemic causes (multiple organ failure in pt, massive gut infarction in the other tat, possibly due to the systemic vasoconsttictive effects of the indomethacine administration). in conclusion, indornethacine might have a role in the treatment of intraoranial hypertension, especially when caused by cerebral hyperaemia. we observed however a poor final outcome and a threatening high incidence of systemic events (multiple organ failure, gut infarction) in those pts receiving indomethacine for icp control. therefore, indomethacine in the treatment of intracranial hypertension should be reevaluated in controlled study settings, before its routine use can be considered. untill recently, intracranial hypertension (ich) in pts suffering from severe head injury was managed in a staircase approach, with csf drainage as first therapeutic step, mannitol as second step, hyperventilation as third step, and finally, barbiturates as the last rescue step for therapy refractory ich. this staircase approach for the treatment of tch was only guided by the intracraniat pressure, and not by other parameters such as e.g. the actual state of cerebral perfusion of the concerned pt. jugular bulb oximetry provides us with the first, bedside and continuous available, estimation of cerebral perfueion. its implementation in a rigourous flow chart, based on as well icp-as jugular bulb oximetry-data might result in an altered strategy for ich management. we adopted a '~ugular bulb saturation (sjo~)-guided approach" for ich management in consecutive pts, suffering from severe head injury (gcs< ). we maintained csf drainage as first therapeutic step, but the decision for the second step was guided by sjo information. pts revealing ich and sjo=values above %, were treated with hyperventilation, and did not receive mannitol. if ich persisted, barbiturates were added as a third step. on the other hand, pts with ich and sjo= vales less than %, received mannitol administration as second step. hyperventilation and/or barbiturates were only added if ich persisted and if no cerebral hypoperfusion was discerned (sjo=> %). our objectives were to prospectively analyze this new therapeuticstrategy, as compared to the formerly used staircase approach of ich. we managed pts with ich, with an overall mortality of . % due to therapy refractory ich. all pts received standard primary care with head elevation, full sedation and normovenfilation. fer pts, csf drainage alone was sufficient to control ice of the remaining pts, pts received mannitol and pts were hyperventilated as second approach. in the third line, pts were managed with barbiturates, with mannitol and pts with hyperventilation. finally, barbiturates were used as the final rescue in pts. these results reveal a less frequent use of mannitol as only pts received mannitol, compared to the pts that would have received mannitol using the former staircase approach. hyperventilalien was used much earlier in the treatment course, as lots were already hyperventilated in the second line approach, were this was formerly exclusively reserved for the third line approach. finally, also barbiturates were used much eadier ( pts received barbiturates as third approach). we may therefore conclude to a important change in the management of ich, induced by a sjo -guided flowchart. however, future studies will have to elucidate if this new strategy for the intensive care management of severe head injury will also result in an improved outcome. obsectives: in a first series of experimental brain injury we investigated the course of brain po , icp and cerebral blood flow after traumatic brain injury (tbi), whilst accordingly there are very few data available and the mechanisms leading to secondary brain damage are poorly understood. methods: in piglets ( days old, , - kg) of either sex we produced a moderate brain injury ( , arm., msec.) using a lateral fluid percussion {fp) device. complete measurements were made before and min. after brain trauma and after , and hours including blood gases, cardiac output (htermodilution), heart rate, eeg, laser doppler flow probe (ldf} and icp values (camino), brain temp., po by a clake type oxygen electrode (licox) and coloured microspheres for regional blood flow. results: immediately after the trauma a typical "cushing"response to the icp peak up to mm hg being highly significant (before mean i mm hg, range - mm hg) could be observed: mean arterial blood pressure rose from appr. mm hg to ii mm hg for - min. in two animals this was followed by an ischemic period lasting min. accordingly icp values gradually returned to starting measures within hours; in the ischemic animals they remained at a level of about mm hg.-no secondary increase of icp could be observed, once icp dropped to starting values within hours. cerebral blood flow (ldf) fell from mean values being i before trauma to appr. zero and recovered to around . brain po started at mean values of mm hg (range - mm hg) and fell to around zero depending upon the severity of the ischemic reaction. on average values of mm hg were reached over the time course. conclusions: with our fp trauma model we can reproduce the well known "cushing"-response after brain injury; secondary icp elevations cannot be achieved, although local edema is observed. direct brain po measurement seems to be a very sensitive variable for detection of cerebral ischemia and anticipates eventually following icp elevations by far. pulmonary aspiration s,traoaras. v. sgountzos, p. agouridakis, m eforakopoulou, e. ioannidou. intensive care unit (tcu) of "kat" hospital, athens, greece ob!e=ives: the reported mortality rate after pulmonary aspiration is variable in several series. the purpose of this study was to find out the influence of preexisting disease or situation on morbidity and mortality of intensive care unit (icu) patients with pulmonary aspiration. methods: patients who were treated in icu and had pulmonary aspiration, were studied, entrance's criteria in the study, all of them obliged, were: ) suction of gastric contents from trachea during intubation, ) presense of a predisposing factor, e.g. coma. ) recent hypoxaemia or new infiltrates in xray. preexisting disease was recorded and correlated with complications and outcome. patients with glasgow coma scale , because of cerebral injury, and patients who died within days from cause other than aspiration, were excluded from the study. method of statistical analysis: chi-square test, results: one hundred forty five patients were studied. the trauma patients were and the non trauma patients . from the trauma patients, had cerebral injury and were polytreumatized without cerebral damage. from the non trauma patients, had malignant neoplasms, neurological diseases in terminal stage, old age, drug overdose, and several diseases. eighty seven from trauma patients ( %) and from non trauma patients ( %) manifested several complications (pneumonia, ards, etc), so there was no statistical difference in complications' frequency between the groups (p> , ). the severity of complications was also proportional in the groups. eighteen deaths were recorded in the trauma patients (mortality %). only deaths correlated directly or indirectly with the aspiration ( %). in non trauma patients, deaths were recorded ( %). twelve deaths were recorded in patients with neoplasms, deaths in patients with neurological diseases, deaths in aged patients, death in drug overdose patients, and death in patients with several diseases, the mortality difference in trauma and non trauma patients was statistically significant (p< , ). in patients with drug overdose the mortality was significantly lower from the other non trauma patients and the difference was statistically significant (p< , ). conclusion: the preexisting disease or situation plays a major role in the outcome of the patients with pulmonary aspiration. the mortality of patients with aspiration seems to be caused by severe preexisting situations rather, that lead to death, than from the pulmonary aspiration per se, which may be a final happening in a predetermined course. obiectives; the purpose of this study was to compare fluconazole and amfotericin-b in the treatment of fungal infections in severe trauma patients. methods: thirty five severe trauma patients who were treated in intensive care unit (icu), were studied prospectively. they all developed fungal infections, prooved with blood positive cultures and at least one of the following: fever, positive urine or bronchial secretions cultures, infiltrates in xrays. the patients were separated randomly in groups. the patients of group a ( patients) received fluconazole rag/day for days. and the patients of group ( patients) amfotericin-b rag/day for also days. compaiison's criteria were the clinical responce to treatment (fever etc), the fungal elimination (blood and other cultures), the relapses of the disease, the side effects of drug, and the outcome of the patients. as method of statistical analysis was used the chi-square test. results: nine patients from of the group a ( %), and from of the group b ( %), presented remission of fever (patients of group b had better clinical responce than patients of group a, and the difference was statistically significant, p< , ). all the patients before treatment had positive for fungi blood cultures. after days of treatment, patients of group a and none of group b had positive cultures. eight patients (from who had positive cultures of bronchial secretions before treatment) of group a. and (from ) of group . had positive cuttures of bronchial secretions after days of treatment, so positive bronchial secretions were fewer in group b than in group a, but this difference wasn't statistically significant, (p< , and p> , ): ten patients (from ) of group a and patients (from ) of group b had positive urine cultures, after days of treatment (positive urine cultures were fewer in group b than in group a and this difference was statistically significant. (p< , ). two patients of group a and none of group b had a relapse of fungal disease. in group a, no side effects were obsepced, while in group b were observed only minor side effects (small increase of serum creatinine in patients, chills and fever during infusion in patients, and hypokalemia in patients). three patients of group a and patient of group b died, because of sepsis. conclusion: amfotericin-b (even i~ short regimen of days), is superior to fluconazole in the clinical and laboratory responce and also in the relapse of fungal disease, fluconazole is superior to amfotericin-b as it has no side effects. ob!ectives: flail chest after thoracic trauma is a serious injury. it is controversial if flail chest by itself orthe concomitant intrathoracic injuries e.g. pulmonary contusion, is the cause of the reported significant morbidity and mortality. in this study we searched the influence of concomitant thoracic injuries in the course and outcome of patients with flail chest. methods: eighty five patients with flail chest after isolated chest injuries were studied, for the purpose of analysis, we separated the patients into groups, patients with isolated flail chest were included in group a, patients with flail chest and hemo-pneumothorax in group b, patients with flail chest and pulmonary contusion in group c, and patients with flail chest and hemo-pneumothorax and pulmonary contusion in group d. complications from the chest, duration of mechanical ventilation and mortality were compared in the groups. statistical comparison of results belween groups was made using chi-square and t-studend tests. results: the patients were . all patients received mechanical ventilation, twenty eight patients were ihcluded in group a, in group b, in group c. and in group d. seventy three patients manifested complications from the chest, especially pulmonary infections. there was no statistical difference among the groups as to number of complications ( twenty four patients had chest complications in group a, in group b, in group c, and in group d. p> , }. the duration of mechanical ventilation was not statistically different among the groups (the mean duration was , days in group a, , in group b, , in group c, and , in group d, p> , ). there was also no statistical difference in mortality among the groups (six patients died in group a. in group b, in group c, and in group d, p> , ). conclusion: flail chest by itself is a serious thoracic damage with many complications, regardless of the presense of other thoracic injuries, which don't contribute to greater morbidity and mortality. the present study investigated the correlation between blood lactate mortality and organ failure in trauma patients admitting between december , and july , in the icu. road traffic accidents were the most common cause of trauma in this studded population. brain damage was the main cause of mortality .nevertheless, of patients died from sepsis and multiple organ failure without significant brain damage and these deaths were potentially preventable. respiratory failure was the most common complication and was developed in ( %) of survivors and in ( %) of non survivors .we noted low fncidence of renal failure may be do to the early and aggressive ittv'asive hemodynamic monitoring and cardiopulmonary support. as part of our routine case protocol serial blood lactate levels were measured in each patient at least times a day until the valses returned within the normal range or until death. we analysed the blood lactate levels on admission, the highest value and the number of days until the first normal value (<l.smeq/i). initial lactate and highest lactate levels were significantly higher in patients with than without organ failure.( . vs . , . vs . meq/l, p< . )the duration of hyperlactemia also was higher in the patients with organ complications. ( . vs . days, p< . ). both initial lactate and highest lactate levels were higher in the non survivors than in the survivors.( . vs . , . vs . meq/l, p< . ) the present study demonstrated that not only the degree but also the duration of hyperlactemia can be related to the development of posttraumatic complications. serial blood lactate measurements are reliable indicators of morbidity and mortality following trauma. s current evidence suggest that peep only affects intracrenisl pressure (zcp)when it interferes with systemic arterial pressure, although the effects of peep over cerebral oxygenation remains unknown. objective: determine the effects of peep over icp and cerebral metabolism measured by sj , kjdo and ceo in severe head injured patients. meterial ~ methgds: patients with glasgow coma scale l at arrival, with difusse brain injury in the first gt, according to marshall criteria,lop and jo monitored, under analgesia and sedation, normoventilated with zeep, without mannitol treatment in the previous hours, normal x ray chest and within the first hours from injury, were considered candidates. peep value where increased fro~ zero to cmh , in three different steps, each one with min of duration. all date were analized on line, pmax p'p ..... p.._, from the ventilator, systemlc haemodynem]c data, cerebra perfuslon pressure (cpp), icp and sjo , in the case of hemodynamic deterioration, during the study, ppc ommhg, extra-volume were administered. if persistence, dopamine were begun or increased dosage. if no good response were obtained, patients were retired from the study. results. patients were candidates, of them were exc;uded due to haemodynamic instability, k total of completed all steps and were e~amined, men and women, age ! . yrs. at hospite; arrival, glasgow were < in patients, and > in the rest . patients mmhg at the beginning. zeep ob/ectives. critically ill patients are transpoded to an intensive care unit(icu), under conditions, which have not been systematically evaluated. therefore, we set suite investigate transportation and admission condition of these patients to our department. methods. we studied patients( females), aged (mean-..+-sd) . _ . yrs, which were consecutively (from august to march ) admitted to the icu, through the greek national emergency transporta~on service. apache ii severity score upon admission was . -+ . (range - ). the following data were evaluated: ) number of medical departments, where health care was provided until final admission to the icu, ) ambulance transportation conditions, ) catheters and tubes inserted before admission, ) vital signs upon admission ) information provided by referring physician (scored on a to scale: history, electrocardiogram, chest x-ray, laboratory data, drug therapy already administered), ) comparison of the state of the patient described by referring physicians, to the actual state u pen admission. resu/ts. one to four medical departments had provided health care before the palient was admitted the icu ( : . %, : . %, : . %, : %). thirty/ ( . %) patients were escorted by a physician. twenty-six/ ( . %) were transported on oxyge n, fio (mean__.sd): -+ %, pao : . -+ . mmhg. five of the remaining , for whom no oxygen was provided, had pao : . -+ mmhg. twelve/ ( . %) were intubated and ventilated during transportation. thirtyfour/ had a peripheral venous line, / had an arterial line, / had a nasogastdc tube, / had a urinary catheter. eleven/ were sedated and / were paralysed. three/ were on inotropes. vital signs upon admission were: arterial blood pressure, systolic . -+ mmhg, diastolic -+ mmhg, heart rate -+ bpm, temperature . -+ cc. patient information score was --. . . the actual state upon admission was found substantially different, as compared to the description of the referring physician, in / ( . %) patients. conclusions. we conclude that several aspects of the greek national emergency transportation service to an icu should be reevaluated and further improved, i. e. ventilatory support, adequacy of information provided and accuracy of prior description of the patient's state. a new perspective must be applied for critically ill patients transportation since . % of the patients were evaluated and treated in more than one, medical departments, mostly primary care, before they were finally admitted to our icu. dclhb is a human derived hemoglobin molecule that has been cross-linked to stabilize and permit heat pasteurization to remove residual proteins and inactivate viruses. dclhb is mixed with a lactated electrolyte solution to yield a total hemoglobin concentration of log/dl objective: to present an overview of four recently completed clinical safety studies of dclhb in the u.s. and europe, and to discuss the properties, actions and potential indications for dclhb. method: patient populations in the four studies included males and females ranging in age from to years. dosing ranged from mglkg to mg/kg. the controlled randomized safety studies were conducted in chronic renal failure patients, surgical patients undergoing total hip replacement or abdominal aorta repair and in hemorrhagic hypovolemic shock patients. these very diverse patient populations allowed safety evaluation of the product in patients who were generally elderly, often hypertensive with some degree of cardiovascular disease, and receiving medications for treatment of other conditions. results: over patients received dclhb in the four:studies. no product related sarious adverse events occurred during the clinical trials. conclusion: results from phase itll safety studies of dclhb in patients undergoing chronic renal dialysis, abdominal aorta repair, or total hip replacement and in patients in hemorrhagic hypovolemic shock, indicate that the product was well tolerated in these distinct populations. although these studies were designed to evaluate safety, the data suggest clinical benefit. follow-up efficacy trials are indicated. prehospital emergency services represent the extension of emergency care into the community and constitutes the manpower, communications, transportations and facilities used to provide care for patients outside hospital. one of the main points of the system is how to decide the hospitalization of patients and what kind of facilities to provide : emergency medical service, fire brigade, locat general praclitionner or ambulance officers. objectives : to realize guidelines for using the prehospital emergency medical service in case of patient'calls outside hospital. methods : from st june to july , all the calls for emergency care were analysed using a questionnaire of items (origin of the call, responses to the questions of an emergency practitionner, kind of emergency service provided and the issue of the patient). after taking account of the appropriatness of the decision, statistical method used was a logistic regression. results : calls were analysed. the criteria, for prehospital emergency medical service using, given by the logistic regression were as following : existence of a call for emergency, thoracic pain, dyspnea, seizures, cyanosis, drug intoxication, fall of the patient, fracture, age, the state of consciousness and the neurologic reactivity. the minimal and maximal predictive values of the model given by the logistic regression are respectively % and %. the performance of the model is %. conclusion : it seems possible to help medical decision of emergency medicine by using only some easy criteria and a predictive model. (italy) objective: to evaluate the incidence of blunt carotideal injury (bci) in patients admitted to our icu after head injury. methods: we reviewed the medical records of all patients diagnosed to have a bci. at admission, the severity of trauma was assessed either with glasgow coma scale (gcs) and with ct scan. bci was demostrated by doppler ultrasography (us) and by angiography (ang). results:since may to april , patients were admitted to our icu with bci ( m, f, age + ). a history of direct trauma was present in patients. admission gcs was in all patients, and was associated with hemiparesis in of them; the last became paretic hours thereafter. two patients had concomitant injuries (a homoiateral clavicular and a controlateral zygomatic fracture, respectively). the initial ct scan was negative in every patient, and showed signs of ischemia after a variable timespan ( - days) after the onset of the symptoms. the bci was diagnosed with us and ang, which demonstrated a thrombosis of the internal carotid artery (ic). in two patients, an intimai dissection was also present. three patients were treated with heparin associated with antiaggregating agents and were discharged alive. the last patient was referred to our icu after the development of a massive hemispheric infarction, and died three days after the admission. at necropsy, the ic thrombosis was associated to an extensive homolateral extra and intracranial venous thrombosis. conclusions:the presence of focal neurological signs despite a negative ct scan should address the diagnosis toward a bci, thus implementing the diagnostic workup with us and/or ang. tab i: distribution of l~tients (%) in the groups the outcome were monitorett results were sabmitted to statistical analysis using a continence table x in z test. res.cl~s: of patients were submitted to thrombolysts and died. the higher incidence of bracb, ar~lhmias (ii degree gg p t e and av block. i degree av block. avsb . <ii. sinus arrest) that requited the insertion of avsc . <cl temporar~ pace-maker was recorded in group a b vs c . ns in % of the cas ~. the rapid recognition of life tab li:;~ test. threatening conditions suggests the monitoring of v r-lead r b' in the course of inferior ami. the authors report their own expirience in application of ringer lact.(rl)and , %nacl/ %dextran . methods:in polytraumatized patients with developed hae morrhagic shock,injures of the chest(qg)and abdomen(q ) prevalid.replacement of the volume loss egan in institutions of general medicine,frequently by rl and dextran or haemaccel.after receiving necessary medical aid,polytraumatized patients wer transported to mma by helicopter,continuing replacing of circulation volume by the same solution. results:average quantities of the solution dministered ~o the injured wer~ - ml.a group of the inoured which,after the admission to mma was resuscitated by adml nistration of the , %nacl/ %dextran @(groupii)( -sml/kg observed to the final surgical management,had statistically higher map(increase of % in relation to admission), cvp(average increase of , cmh~o),diuresis(averagely omi after min.),better gas ~nalyses and acid-base status in relation to the group which was administered only rl(groupi)(increase of the map of q %,average increase c~ of cvp , cmh and average diuresis oml after omin). total quantity of the administered solutions was significantly smaller in the groupii( ml: ml).the only ob served complication was hyperhatr~f~a::and~moderat~hyper osmolerity of plasma which disappeared within hours. the quantity of replaced blodd was considerably smaller in the groupii(qooofnl: ooml).in the group i interstitial pulmonary oedema was observed in two patients(qo%),while: in the group ii no complication was observed.coagulation i disorder and hypotension were not recorded because of the fast infusion of hypertonic/hyperoncotic solution in the groupil as the infusion of , %nacl/ %dextran lasted minutes. w.scherzer(l~,k.lechner( ),r.simon( ). ll)dept.anaesthesiology,trauma hospital,vienna-meidlin !( )neurotraum.rehabilitation center,vienna-meidling both austrian workers'compensation board,vienna,austria what we usually call"unconcious" means only that the patient is not able to interact in any kind of way.experiences in intensive care medicine (robinson, ) ,in general anaesthesia (bennet, ) and with evoked potentials show,that unconcious patients are not automatically unhble to process and recall information.this implicates a challenge to start the efforts to restore the traumatica-!ly desintegrated brain function as early as possible in the acute phase ia (zieger, ) .we present a method to ~repare the patient for the rehabilitation goals of the postacute phase ib,the phase of stabilisation ii and of rehabilitation iii within one concept. to achieve sensory stimulation in phase la we use: attempt at some kind of dialogue by speaking to and tou-ching the patient,to make him experience his body limits, ~acio-oral therapy by ice application,tast and smell pro vocations and trials of feeding,early adaption to circadian rhythm and guiding the patient in every-day-life-ac-tivities e.g.:in the brushing of teeth,washing etc. to achieve motor stimulation and orientation in terms of ~-ace,time and gravity in phase la we use: avoidance of perceptual impairment as produced by air-:sack-beds or habituation to supine position,using method~ according to affolter( ) ,basal stimulation (bienstein, ) , bobath-therapy( ) and facilitation of a physiological moving pattern(pnf)according to knott( ) . conclusions: by integrating all these measures in the ~herapy and nursing even in the acute phase la one prei ares the comatose patient for multisensory stimulation nd motor training and all other rehabilitation activities in the following phases of therapy. s objectives." measurement of cardiac output (co) and stroke volume (sv) requires insertion of a central venous catheter and is associated with a considerable risk for complications. non-invasive methods for determination of hemodynamic parameters have been introduced recently. one of these methods is the aortic modelflow program, which provides co and sv continously using a three-element windkessel model. the aim of the study was to evaluate the accuracy of the aortic modelflow program in critically ill patients. methods: patients (mean age: ) admitted to the emergency department after cardiopuimonary resuscitation (n=ll) and for myocardial infaction (n= ), acute congestive heart failure (n= ) and anaphylactic shock (n=l) were included to the study protocol. after stabilization all patients received a swan-ganz catheter (baxter~; edwards swan-g-anz) via a central vein. co and sv were measured by the use of a cardiac output catheter and injection of rrd ice-cold glucose % non-invasive cardiac output measurement was done by using the continuous cardiac output software package modelflow (tno; portapres| results: overall, paired measurements were used for the evaluation of the accuracy of non-invasive obstained sv and co. mean values, standard deviation and range of co and sv evaluated by invasive and non-invasive methods are summarized in the aortic modelflow provides reliable hemodynamic data in critically ill patients. it may be a useful alternative due to its non-invasive approach and continous measurement. objectives: to determine the feasability and accuracy of a rapid urine screening test (triage tm, merck-diagnostika) in an emergency department. methods: prospective analysis of the triage tm testkit (tt) in patients admitted because of suspected drug abuse during an observational period of months. the tt is a eompetitve immunoassay which gives qualitative results within i minutes for methadone, benzodiazepines, cocaine, amphetamine, opiates, barbiturates and cannabis. urine samples were analysed with the tt and compared to the results of a enzyme-lihked tmmuno-assay (el.a) in our labratory (gold standard). results: during the study patients were enrolled, in of these patients substance abuse was proven by tt and verified by eia. we recorded no false positive or false negative results for benzodiazepines, barbiturates, opiates, cocaine and cannabis. two results were false positive and one false negative for methadone; one result was false negative for amphetamines. the triage-testldt had an overall sensitivity of . and specificity of . . conclusions: the triage tm testkit seems to be a a useful rapid test device in addition to quantitative tests for drugs of abuse in an emergency department. objectives: the purpose of this study was to evaluate the influence of several factors of the renin-angiotensin-aldosterone system on blood pressure response in patients with hypertensive crises. methods: patients with systolic blood pressure > rorohg and diastolic blood pressure > nunllg were included into the study. prior to treatment blood samples for determination of plasma renin activity (pra), angiotensin converting enzyme (ace), angiotensin ii (ang ii) and aldosterone (aldo) were collected. all patients received rog enalaprilat intravenously. success of treatroent was defined as a reduction of systolic blood pressure below mmi-ig and diastolic blood pressure below mmi-ig within minutes after start of treatment. results: patients were included in our study, ( %) patients responded successfully to treatment. mean arterial pressure decreased in responders by . mmhg and in non-respenders by . mmhg (p< . ). responders and non-respenders differed signii'icantly concerning pra (p= . ), ace (p= . ) and ang ii (p= . ). . . the extent of blood pressure reduction correlated positively with the pretreatment pra and ang ii concentrations (correlation coefficient for pra: r= . ; ang ii: r= . ). conclusion: our data confirm that in patients with hypertensive crises blood pressure response to ace inhibition is mainly determined by circulatory pra, ace and ang ii. as the extent of blood pressure reduction correlates with pra, ace-inhibitors in patients with suspected high renin status cannot be recommended, as excessive blood pressure reduction, which carries a considerable risk for further organ damage, may occur. f. staikowsky, n. grillon, f.pevirieri, c.jedrecy, c. zanker, f. michard, a. haft medical emergency department. hospital bichat, paris epidemiology of acute intentional self medications-poisoning (smp) in france is especially known by data of poison control centei,s and intensive care units (icu). the purpose of this study is pro~,ided characteristics of this problem in a med for adults. method: july to june , files of patients consulting to the ed for smp have been retrospectively analyzed. results: patients, women and men, . + years old (range - ) have been admitted for episodes of smp ( % of all consultations) whose relapses during the period of study. psychiatric disorders, drug addiction or hiv patients was found for respectively . %, . % and , % of patients. the interval of time between the ingestion and emergency consultation was noted for % of smp ( + min, ranges - ). the involved products name was known in totality in % of cases with an average number by episode of . + drugs (ranges - ). the most often, ( %) or ( %) different products were interfered. the nonbarbiturate psychotropic drugs accounted for . % of the products (benzodiazepines %, antidepressants . %, neuroleptics %, carbamates . %, imidazopyridines . %, cyclqpyrrol nes . %). analgesics and nonsteroidal antiinflammatories represented . % of all drugs, anticonvulsants . %, cardiovascular drugs %, antiinfective agents . %, drugs against cough . %, muscle relaxants . % and antihistamines h . %. the benzodiaz pines were present in episodes, alone in episodes. in . % of cases, there was a simultaneous intoxication with alcohol. the processing consisted of gastric lavage in . % of cases, activated charcoal in . % of cases, flumazenil in . % of cases, naloxone and acetylcysteine in . % of cases; orotracheal intubation was performed in patients. admission in hospital was effective for patients, in medical ward (n = ), psychiatry (n = ) or icu (n = ); no fatal case was recorded. conelusion: smp to ed are often benign. the benzodiaz pines are the most often incriminated but the new anxiolytics and hypnotics (imidazopyridines and cyclopyrrolones) take a growing place. the latsion burn center of athens. its planning constructive and functional refinements j. ioannovich, a. petalas-vourekus, d~ serbetis, h. carsin a bed burns unit is under construction following a donation to the general hospital of athens. the plan of the unit, covering a surface of approximately . m is based on the principle of three identical bed satelites which may function totally independent from each other. in the center of the unit the common facilities are installed, like operation theatres, storage rooms etc. this new modification in the plan of a burn unit is presented in this paper. the advantages from the fucntional, administrative and medical point of view are discussed. tiffs anisotropic conduodon could favour the ocenrence of a circular movement of the impulse that leads to tachyeardias by reentry. purposes of this work were to study, with the help of epicardial mapping, the influence of a trieyclie antidepressant, clomipramine (c), on the conduction velocity longitudinal (vl) and transverse (vt) to myocardial fiber orientation and on anisotropy (a = ratio vl/vt), and their modificutions by the sodium bicarbonate ( ). method: a plaque of electrodes, positioned on the left anterior ventricular wall of anesthetized dogs, allowed to deliver, thanks to central electrodes, programmed electrical stimulations inducing vcuttienlar complexes, and to collect them. each entailed unipolar dectrogram was processed by a computer system that drew the isochrones and a map of activation allowing the calculation of v. the c was infused ( . mg/kg/min iv) during rain; at t , dogs received the b until the retuni of qrs to its initial value fro). a lengthening of qrs of at least % of its value at to was demanded before the administration of b. results: dog was excluded because of an.~nsufficient prolongation of qrs before the administration of b. all values (map : mean arterial pressure, i-ir : heart rate, qrs andqt intervals, v) differed significatively ( < . ) compared to values control fro)except qrs at t . the b ( + ml/kg; ranges . and . ml/kg) modified no studied dements outside of the ( }rs. to ti t t t t t a , + , , + , , + , , + , , + , , + , , +- ,~ conclusion : the c slowed v l and v t without modify the anisotropy. the b did not modify the v of~conduction while the qrs prolongation was corrected. the c acts as a class i antiarrythmie drug on the inward sodium current during the phase of action potential; the gap junctions have shown to be important in the conduction and an action on the gap junctions such as a modulation of the junctional resistivity, can not be rule out. is the doctor a heroe ? p. t.schies~.he, t. bauer, m. seyr dept. of anaesthesiology and intensive care, aokh krems, austria objectives: helicopter emergency services (hes) are getting popular more and more. the results concerning outcome are encouraging. however, some recent accidents with dead or badly wounded hescrew-members have shown the relatively high risk for the crews. therefore we were interested to eval ate the motivation of physicians to participate in a hes. this survey was designed to investigate current concerns about safety and motivation of doctors on emergency call. methods: a questionnaire was sent to doctors of the austrian emergency system. the survey consisted of multiple choice questions and subjective scoring tables from (--full agreement) to (=disagreement). overall, "/. of the active emergency physicians participated in the survey. results: . % of the doctors assume the system is basically safe, experienced doctors tended to have less trust in safety. only % would not hesitate to go into action by dark. . % stdctly refuse night flights to accidents outdoors. although defibrillations are assumed to be safe dudng flight, only % would do it. . % of the doctors would rather stop flying. the most common reasons for ,uitting were wish of family and fear of an accident. . % conclusioq: short transportation times help to avoid trauma related stress, pain and shock-induced organ complications. therefore the physiologic and economic advantages of hes are undebatable. however, the survey data indicate a considerable concern about safety of the medical personal in a hes. crash landings within less than years with deadcases and badly wounded crew members in a small country like austda make desire for safe flying conditions understandable. obiectives: to evaluate the clinical usefulness of trachlight. methods: trachlight is a new device facilitating endotracheal intubation. a stylet with a lightprobe is inserted into the endotracheal tube. intubation is guided by the light glowing through the neck tissues, thus rendering direct laryngoscopy unnecessary. intubation using trachlight was studied in patients (age - years). the indication for intubation was elective surgery in patients (asa i-ii) and emergency intubation in patients. in the elective patients, anaesthesia was induced with thiopentone supplemented with fentanyl, and intubation was facilitated with vecuronium. the cause for intubation in the emergency patients was dyspnea in , cardiac arrest in , trauma in, and unconsciousness due to drug overdose or seizures in patients. intubation was facilitated with medication in patients. results: of the elective patients, ( %) were successfully intubated. six patients ( %) needed two attempts before successful intubation. the duration of intubation exceeded seconds in patients ( %). of the emergency patients, ( %) were successfully intubated. six patients ( %) needed two attempts, and the duration of intubation was more than seconds in patients ( %). in % of all patients, intubation was assessed as easy. no or insufficient glow, prolonging intubation or necessitating two attempts, was noted in patients ( %). oesophageal intubation occurred in patients. conclusions: trachlight may be a valuable adjunct for intubation in varoius settings provided that adequate training is provided. a learning curve was found to exist. objectives: to compare enoxaparin and standard heparin in cavhd and calculate the value of laboratory controls in the treaanent. patients and methods: twenty patients needing dialysis for acute renal failure participated in the study. the main exclusion criteria were massive bleeding or a thrombocyte level < x e /i. in each treatment the same type (av- , fresenius ag, germany) of a polysulfone capillary haemofilter was used. the study scheme consisted of two consecutive four-day cavhd treatments, one course for each type of heparin. the order of heparin administration was counterbalanced between patients. the standard heparin was given as a continuous infusion aiming at an activated coagulation time between and s. the initial enoxaparin dose was rag every :th hour intravenously, but was modified by any signs of coagulation in the dialysis blood lines or bleeding complications. results: the dialysis treatment was adequate in both treatment modes, with mean blood urea levels . and . mmol/l respectively (ns). the bleeding complications were moderate and similar in both treatment modes. the mean life-span of haemofilter using enoxaparin as an anticoagulant was some longer than using heparin ( . + . h versus . + h, ns). the mean aptt-levcl during heparin treatment was s and during enoxaparin treatment s (ref. - s). the mean daily dose of heparin was nag, that of enoxaparin lg mg. the mean anti-xa activities were . u/mi and . u/mi, respectively, reflecting a better bioavallability of enoxaparin. conclusions: both anticoagniation modes were equally effective and well tolerated. the amount of enoxaparin needed for a proper anticoagulation was, however, less than half of that of standard heparin. the changes in aptt level were too slight to make its use possible in controliing the dose of enoxaparin. the use of enoxaparin seems to be rather safe in cavhd even without laboratory controls. the adv~ucea in the management of computerized data of an intensive care unit have been petalled to the clinical advauces and the increasing sophistication of methods of diagnosis fop the clinical application an therapy. this has led our unit to design and develop a computational system called timbu which is used to help physicians assist patients. among its various uses, this system has a software for the hemodynsmic control of a critic patient. this program was carried out to get as fast as possible the hemodynamic data of the patients in an intensive care unit. as an example, we can mention that when we load data obtained through direct measurement from the monitors and the lab, the program calculates parameters that guide, intelligently, to the diagnosis and therapeutic behaviour of the hemodynamic problem through screen messages. the validation of this program in the unit of intensive care has demonstrated that its use allows a more efficient handling of the patient with serious hemodynamics and respiratory disorders. ohieetlve: traema is a heterogeneotm 'disease' that ecatr~ a~"o~s all age ~oupe with v~ying degrees of severity. this imerogeneity has made the di~e, trmma, diflkaflt to r the ehn of this stady wa~ to assr the fitaen of saps in ibis popeleties. methode: in order to compute the ~ probability, a model derived from logistic regression w~ developed. meam'e of calibration (goodaess-of-fit stetislj.r and di~'riminafion (roc ou~e) were adopted in developmm~ and validetlon set randomly taken from a database of pts eeeseemivety admitted in icu (arohidia). ~ witho= salm, p~ yom~ am is yam, with los ~horter thma hotam wore exr fa'om thi~ mmly~ir thi~ model v~s then evahmed on the ~per ~mbgro~ (i.e., trmma pts). if'it did t~t fit the data well ~, new model wm developed rer the logit only on trm=~apm. reims: data were availabte for pts during aperiod of three .y~m , treama pts were . %), teats of calibration iadioaled probability model did mot provide m adequate refle~on of the mortality ezperieace in pm with ireutae, being the observed mortality lower flma the expected (figm'o). a aew model was then variable. this oastomized model fit~ the de~t of trmara pts very well (g =- a p> . ; roc = , ). the di:lferencea between the two modele were evident. conclusion: this ltudy shows that mortality in iramna pts is over wcfe~d when ~se~ed by menm of saps. however the r mode! meets high standmcd in terms of calibration mid dil~'iminat'~o~ ']"he advaatage of ~imd models meaas the colleotion of the ~ set of variables for all pm admitted in icu e~einat the ase of diasma specific ~oring syatex~. ("sl"): effects on cardiovascular and hemostasis systems (cvs, hss) a.oborin~ph, ~.~yndiuk~ph, b.kondratsky ~pt. of'""su~gery and transfusiology, research institute of hematology, lvov, ukraine objectives: great interest has been shown recently in the use of hoss for the initial resuscitation of hypovolemic shock. methods: the study was carried out in dogs -~h hs was induced by jet momentary hemorrhage (h) from a. femoralls (the bloodloss volume made . + . ml/kg). the treatment was begun after .u+o. hrs of h. "sl", created on the basis of-sorblt and natrium lactate ( mosm/l) was injected into v. femofalls at the dose of io. ml/kg. results: it is established that before treatmen-~rterial blood and central venous pressures (abp, cvp) diminished to . mm hg and - . + . cm h (p .o ), while heart rate (hr)-increased to . + . per min (p<.o ). by this the indices of ~latelet counts (pic) and plasma fibrinogen (pf) lowered by . % (p<.i) and . % (p~. ), while fibrin degradation products (fdp) enlarged by . % (p~ . ). after - min of treatment termination abp and cvp increased to . + . mmhg and . +o. cm h (p<.o ), and ~[r diminished to t . + . per min (p>. ). at the same time the indtces of pic and pf enlarged by . % and . % (p>.i), while fdp diminished by . % (p>.i). one of dogs survived. life duration of the other dogs was . + . hrs. conclusions: the obtained data are ~he evidence of normalizing influence of "sl" on cvs and hss, and allow to recommend it as a mean of initial resuscitation of hs in clinic. oblectives: we prospectively studied icu patients with severe head injury (hi), which cerebral lesions monitorized with sjo through opljcal fiber and the cerebral flux with tcd. methods: since january until june , we collected ht admitted to the icu, and of them monitorized with optical fiber in the right jugular bulb and tcd. all patients needed mechanical ventilation related to gcs <__ , with ct in admission (classifing lesions according to marshall and al.) . we related the final results to the evolution of sjo and tcd, with other monitorizing methods like gcs, ct and icp. ~sults: conclusions: in patients with gcs _< , sjo is useful to evaluate the evolution towards vegetative state, still more in cases with ct type ii in admission and higher apache ill. elevation of icp implies an evolutive nsk to brain death and data of tcd is a good indicator of brain death, the complete monitorization of these patients can improve the therapeutic control of this neurologic problem, , ( m, f) , (m. age: + years), divided in two groups (a and b) under specific criteria(tremor and/or fever during admission in i.c.u., or not). the injury severity score was > in all studied patients. tbe group a ( m, ") had no tremor and/or fever on admisskm, while em group b (tin, the above criteria were ix)sitive. bhx~d samplings were taken - hours after accident and - rain. after admisskm in i.c.u. micro-eli~ method was used for measuring cytokinc-levcls. statistic analysis was performed by studcnt-t test. as control group, healthy people were examined. _resu!_ts-il-lct, il-ii~, il- and tnf-tt levels were similar to control group levels in both groups a and b. i!,- and g-csf levels were found increased in both groups (p< jxjl), while il- levels were statistically significant comparing to group a. in con_tin_skin, during immediate post raumatic period,proinflamatory cylokines il-i~, il-i~ and tnf.-ct, produced in an earlier stage than ,. , cannot be detected,whereas .- was increased significantly, especially in group b. g-csf was fimnd in increawal levels in both gr(mps, without statistically significant difference between gnmps a and i|. objectives-l~valantc proteolitic activity, disorders in" eariy, period after combined trauma and p(~.ssibilit, i' of their correction by injection of proteo[ysis inhibitors contrycal and s-fto~:nracil in combination with driving an isotonic snlu~ion of sodlum chloride and polig[ucine. methods: biochemicai studies of proteolitic activity in dogs with limited deep burn and acute bloodloss, . result:s: in case of deep % burn, cornplicated by bloodshed the of blood grows at - times. it; is the restdt of the pancreas glandischemi demage, caused by the centralised circulation of blood and intensifies the deviations of haemodiaamics and albumin exchange. the degree of endogene intoxication by mean mofecular peptides which are the products of albumin decay reses to %, and % in hours. in hours after the trauma the-process is accompanied b ! , % lower inhibitory activity of blood, where as at the peak of the trauma it was , ~ higher. that proves the nnfavuurahle process of the shock in case a combined trauma. conclusion: the vein injection of 'proteolysis inhihitotz cnntrycal and -fforuraei[ in cumbination with driving an isotonic solution of sodium chloride and p.dligh]cine to refill lhe loss of blood helps to lower at times the profeolitic activity of blood. but it still remains above the initial level. the degree of endogene intoxication lowers at times; [ emodinamics aml albumin exchange stahilised. objectives: nimodipine, a known calcium antagonist, has been shown to dispose a beneficial effect on patients with subarachnoid hemorrhage, but its efficacy on traumatic or spontaneous intracerebral hematoma has not been justified. therefore, we studied the effect of nimodipine on the histopathological changes following an experimental intracerebral haematoma in rabbits. methods: twenty-three new zealand albin rabbits of both sexes, weighing - , kgr and at age of - months were anesthetized and a small burr hold in the left parietal aerea was carried out under aseptic conditions. the dura was opened and . ml (this volume assuring a normal incranial pressure after kaufman ) of autologous blood was injected into a depth of mm via a needle of . mm bore. the wound was closed and the animals were left to recover. nimodipine, of , mg/kgr of by weight per day was given via a nasogastric tube to fifteen animals for a period of time of fifteen days (group b). six rabbits were given water and served as control (group a). both groups of animals weie sacrified on the fifteenth day, their brains were removed and immersed into % formalin solution. tissue sections of ~ were embedded into paraphin and stained with haematoxyline and eosin, mason and gfap stain for gliac cells. results: two animals died after the surgical procedure, because they developed large intracerebral bematoma. no animal developed neurological deficit except one of group a which manifested a right side hemiparesis. the results of the bistopathological changes are the following: i) the mean -+ sd diameter of the lesions in the group a was --. ~t while that of group b was + ~t (p< , ) ii) secondary ischaemic neural tissue changes, characterized by the extravasatlon of red cells, the presence of haemosiderin-containing macrophages and signs of low grade inflammation zpredominated in the specimens of group a and were totaly absent from those of group b. iii) a ring of gliac hyperplasia and a low grade local fibrosis was found, encircling the lesions in the specimens of group a in contrast to those of group b. conclusions: nimodipine when administered in rabbits following the development of a non increasing the icp experimental intracerebral haematoma, prevents the extention and the severity of the lesion. objectives: to study the efficacy and side effects of adding intramuscular clonidine (clophelinum) to analgesic regimen in early management of patients with serious burn injury. methods: pts with - % bsa second to third degree flame burns (respiratory tact injury excluded) to yrs of age were randomised to study (n= ) and control (n= ) groups. burn shock was treated with hypertonic saline -bicarbonate solutions ( mmol/l na +) ml/kg/%bsa for the first hours and ml/kg/%bsa for second day. analgesia in control group for the first hours was provided by regular hourly intramuscular administration of mg of morphine sulphate and mg of analgesic -antipyretic analgin with mg of diphenhydramine (dimedrol). from the rd day regular administration of morphine was finished. in the study group ixg of clonidine was added -hourly for hours and dose of morphine halved. vas, verbal rating scale for sedation (vrs, - ), sleeping time, spo , hr, bp, diuresis, vomiting and other complications were comparatively evaluated during patients' stay in icu. results: addition of ~g of intramuscular clonidine daily allowed to achieve better analgesia and sedation with halved consumption of morphine. mean vrs in study group for the first days was . - . vs . - . in control group with twice longer sleeping time. there was significantly less tachycardia in study group; dynamics of bp for the first hours did not differ considerably; later, there, was tendency for hypotension in study group without adverse effects on diuresis or other indices of tissue perfusion. because of high incidence of chronic ethanol abuse among study population pts of control group suffered from psychomotor agitation or delirium, probably as a sign of alcohol withdrawal syndrome (aws). this made regular evaluation of vas impossible. in the study group only pt showed sign of aws. mean vas score was in . - . range for first postburn days. pts appeared excessively drowsy due to clonidine, but it had no adverse effect on their overall clinical course. mean spo values in study group were in - % range, among controls - %; vomiting was absent in. cionidine group vs cases among controls conclusions: clonidine could be a valuable addition to analgesic -sedative regimen in burns, especially for prevention of aws and deserves further study in this regard. hemodialysis -hemoflltration modifications and/or intratracheal gas insuflation have been recently used for blood gas exchange in several models of respiratory failure. objectives: evaluate the combination of cavh-m and igi for respiratory support in experimental acute lung injury. methods: five mongrel dogs ( -+ kgr) were mechanically ventilated inroom air, paralysed, heparinized, connected with a cavh-m system (diafilter- polysulphone membrane) and remained stable for one hour (pao~= . • peco = -+ mmhg, ph= . -+ . , bp= -+ mmhg and pap= -+ mmhg). all was induced two hours after oleic acid infusion ( . ml/kgr) into the pulmonary artery (poo~= . _+ -p< . , paco~- . _+ -p< . , ph= . -+ . -p< . , bp= -+ -p=ns, and pap= _+ -p< . ). fio % for the next minutes did not significantly altered the b ood gas abnormalities. afterwards, pure oxygen applied simultaneously a) through the inlet of the filtrate's compartment of the hemofilter ( l/min) while filtrate and gas were removed from the outlet port (bypass flow ml/min) b) through a thin intratracheal catheter positioned cm above the carina ( l/min). the fio given through the ventilator readjusted to %. results replacement fluids/filtrate during the next four hours were not exceed . l/hour, whilst the blood gases and pressures were improved as follow: cavh-inlet:pao.= . objective. to compare the changes in humoral immunity in trauma patients following massive transfusion of autologous and homologous blood. methods. we studied randomised clinical groups of patients each containing patients with trauma and operation of large arterial vessels. the amount of autologous or homologous blood transfused to the patients was exceeding ml, while the patients in the control group did not recieve blood or blood products. results. we recorded most pronounced and characteristic changes on the -st and on the -th day in the group of patients recieving homologous blood transfusion, i.e. decreased amount of igg,iga,igm,c and c fractions of the complement system, haptoglobin and significant and sustained rise of circulating immune complexes up to the end of the study period. in the control group of patients the decrease was weaker and lasted only during the -st post-operative day; the dynamics of the circulating immune complexes level were almost the same as in the first group of patients. in the group of patients recieving autologous blood transfusion, the parameter values did not change significantly from preexisting levels after the -st day, while on the -th and on the -th day showed a tendency towards aslight rise. conclusions. autologous blood has a favourable effect upon humoral immunity and should be the transfusion medium of choice in cases where autologous blood reinfusion is technically possible. ivan petkov, m.d., rumen farashev, m.d. and dimitar terziiski, m. d. medicine, military medical academy, g. sofiiski str., sofia, bulgaria objective. the amount of blood lost during trauma and operation could hardly be forseen and donor blood supplies are not always available in sufficient amounts. rare blood group types and/or unexpected haemorrhage pose a great challenge to the transfusion therapy and the methods of intraoperative autologous blood transfusion. methods. we report a case of a -year old male patient with extremely massive intraabdominal haemorrhage ( m( blood loss ) during an abdominal aorta reconstruction following a traumatic injury of the abdominal aorta. we achieved a successful reinfusion of ml of autologous blood using an original autotransfusion system developed by us ( pat. no / . . ) . results and conclusions. the autotogous blood in the case reported here was the only and the most suitable transfusion medium for the rapid intraoperative compensation of the acute haemorrhage and the favourable outcome of the patient. the post-operative period was smooth and no significant disorders in the clinical course as well as in the laboratory tests ( morphological,biochemical,coagulation and immunological) were recorded. there were no complications during the postoperative period despite the fact that the amount of blood reinfused to the patient was slightly exceeding his own volume of circulating blood. objective. the haemoglobin concentration and the perfusion pressure value could not be the only criteria for the early signs of tissue and organ dysfunction. because of this, we employed the extensive monitoring of oxygen transport during severe trauma in order to. achieve dynamic evaluation of physiologic compensatory mechanisms and to assess the efficacy of intensive care management. methods. we conducted a prospective controlled trial on the blood oxygenation, oxygen transport and tissue perfusion during the first days after the trauma in patients with polytrauma. we used a swan -ganz pulmonary artery catheter (beckton -dickinson, u.s.a.), deseret cardiac output computer (medical inc., u.s.a.) and hewlett -packard monitor (hewlett -packard, germany) to measure and calculate all the parameter values. the severity of the injury was assessed using the apache ii score system. all the patients had scores over . results. the results show a significant decrease in the arterial blood oxygen content and in the arterio-venous difference, as well as an increase in alveolo-arterial oxygen difference and in the transpulmonary right-to-left shunt. the tissue oxygen supply and the tissue oxygen consumption reveal a tendency towards a decrease below the physiologic minimum of adeqate values. the erythrocyte current velocity and the ratio between oxygen transport and erythrocyte current velocity also decrease inspite of the optimal blood rheology. conclusions. the dynamics in the parameters values are most pronounced between the -nd and the -th hr after trauma, which predisposes patients to the risk of developing stable hypoxemia and characterizes this period as the most critical for tissue metabolism and organ dysfunction. posttraumatic changes in immune mechanisms in lung compartment in trauma were analyzed in ao and da inbred strains of rats which differ in their immunological reactivity: the former being low responder and lat-~er hiperresponsive. methods: the levels of tnf-alpha activity in the supernatants of cultured lung lobes and dynamics of cells migration from tissue explants in h lung cultures were assessed in ao and da rats subject ted to severe burn trauma. results: increased levels of tnf activity ( + pg/ml compared to + . pg/ml in control) were found od day following trauma in lung sups of ao rats while no changes in the levels of activity of this cytokine were found in lung-sups od da rats more pronounced extent and dynamics of cell emigration were noted in da rats, while almost unchanged in ao rats sharp rise in pmn percentages h following trauma ( - % compared to rare pmns in control), followed by increase in lymphocyte numbers at later time points among lung cell emigrants was detected in ao rats. slower but persistent increase ( %, h following trauma and % and % on days and after trauma infliction, respectively) in pmn numbers among da lung cell emigrants was detected, which appeared to be activated, as judged by their nbt reduction capacity. increased percentages of peripheral blood pmns and increased state of leukocyte aggregation/adhesion were detected in both strains, but different levels of plasma tnf: increased levels in ao rats on days and following trauma, and initially but persistently high levels of plasma tnf alpha in da rats ( - fold higher compared to initial levels in ao rats). conclusions:different patterns of local (lung) and systemic changes in cell numbers and cytokine levels implicate differential posttraumatic migratory capacity of pmns vs. lymphocytes in lungs in ao and da rats. early diagnosis of acute intestinal ischemia by color doppler sonography e. danse, b.van beers, p.goffette, f.hammer,aav.dardenne, f.thys, p-f.laterre, m,s. reynaert, .lpringot dept of radiology (profb.maldague) and dept of intensive care ( prof m,s.reynaert), st.luc univ.hospital, brussels, belgium ob emergeny medical squad service is the most important segment in the process of saving the people, in the cases of mass accidents, like industrial accidents caused by the: explosion, fire, chemical poisoning, traffic accident, elemental catastrophes and the war. because of that, each emergency medical squad service needs to have in its motor-pool vehicle for the mass accidents/ for provoding at least people, wounded as well as the people became ill/. objectives: presentation of such special vehicle, produced by "zastava-kamioni" and it's medical-technical equipment. methods: descriptive and comparative analysis of the medical and technical characteristics, based on the actual norms/din, , iso , yus.../ results: on the base of doctrinaired requirements of the emergency medical squad in the case of mass accidents, our researches resulted in the following medical and technical characteristics -the vehicles for mass accidents are gvw/with a payload off cca - t, with the fixed, closed body, type: universal van, -technical equipment aggregates, stretches, anti-fire device, equipment for pitching the tent and for maintaing technical conditions of the work -medical equipment: linen bags with complete sets of bandage material, means for the reanimation and immobilization, for the infusion, medical instruments and remedies as well as the tent for lodging at least wounded and sik people. in federal republic yugoslavia, it was proposed such vehicles for the emergency medical squad needs. conclusion: we suggest to introduce this vehicle in the production range of the ambulance vehicles for saving, especially in the circles where can occur serious accidents. introduction : carbon monoxide (co) poisoning commonly generates central nervous system abnormalities though an important cardiac morbidity and mortality must be considered. long-term exposure to co with cohb levels < % may be more dangerous than short-term levels of - %. we report a case of an adolescent who after prolonged exposure to co developed a severe reversible cardiac dysfunction with low levels of bloed cohe c a.ase history : a year old boy was found comatose at home. his mother in the neighbouring bathroom died severn hours earlier of what was later proven to be a co intoxication. on arrival the gcs was / and the patient was breathing spontaneously. a postictal status with eventual postanoxic encephalopathy was suspected. a coh'b level of % was objectivated. the cardiorespiratory situation quickly deteriorated requiring mechanical ventilation. chest x-ray showed diffuse bilateral patchy infiltrates. ecg revealed signs of ischemia. severe left ventricular dysfunction was evidenced by pulmonary artery catheterisation and echecardiography and later by isotopic angiography (lvef %). treatment was intensified with inotropic support, intta-aortic balloon counterpulsation and oxygen therapy. the clinical course was further complicated by a crush syndrome and renal failure. the patient's condition gradually improved and he fully recovered without any residual lesions (lwf %) conclusion : even after prolonged exposure cohb levels can be misleadingly low. high tissue levels of accumulated co can be associated with coma and fulminant cardiorespiratory failure requiring advanced life support facilities. introduction : both neuroleptics (nlp) and tricyclic antidepressive agents (tca) can induce arrhythmias, prolongation of the qt segment and the pr interval and hypotension. we report a case illustrating that combined overdose of these agents increases the toxicity of each compound and the risk for adverse cardiac events. .c, gse history : a year old male ingested mg doxepin (sinequanr), a tca and mg prothipendyl (dominalr), a potent nlp in an attempted suicide. upon arrival in the emergency department the patient was unconscious (gcs / ), breathing superficially, and presenting signs of recent vomiting. physical examination revealed a taehycardia of b.p.m., an arterial blood pressure of / mmh g. ecg showed a brood qrs complex tachycardia. a chest x-ray revealed the presence of an aspiration pneumonia. laboratory investigation demonstrated increased levels of crcatine phosphokinase, lactate dehydrogenase and aspartate transaminase ; hyperglycemia and leucocytosis were present. the plasma concentrations of doxepin and prothipendyl were respectively gg/l (toxic level #g/l) and i.tg/l (no reference). treatment consisted of mechanical ventilation, gaslric lavage and administration of activated charcoal and iv fluids and antibiotics. a hemodynamically well tolerated veatricular tachycardia developed / h later. nahco ( meq/ h) was administrated inducing an ectopic atrial tachycardia with a normal qrs complex and prolonged qt. h after admission a normal sinus rhythm was present; the prolongation of the qt segment persisted for days. the patient fully recovered. conclusion : the treatment with nahco~, alkalizing the blood and thus increasing the protein binding of the tricyclic antidepressant molecule, can readily correct the potentially life-threatening cardiac arrhythmias and therefore should be part of the routine treatment of combined tca-nlp overdose. ob/ectives: the development of diabetes insipidus (di) in patients with brain injury is a known negative prognostic sign. the aim of this study was to investigate whether this is also a reliable early prognostic sign of brain death. methods: this is a retrospective study of patients treated" during a two year period ( - - to - - ) in our i.c.u who meeted the following criteria: ( ) coma score _< gcs within the first hours, ( ) positive brain ct scan on admission classified according to marshall's diagnostic classification (classes - ), ( ) normal renal function during the entire icu stay. for the definition of di were used the usual di criteria plus hypematriaemia (serum na" >_ meq/l). survival was defined up to the th postadmission day. conclusions: according to the findings of this study, the development of diabetes insipidus in brain injured patients seems to be a highly specific index for brain death (positive predictive value = . ). however, further prospective studies are needed for the definitive evaluation of these findings in such patients. emergency care in italy, despite all efforts, is still lacking a nationwide organized prehospital care system and, until today, there are only different regional solutions. the majority of these realities imply rather simple ambulance first-aid services without attending emergency physicians and without resuscitation equipment. the emergency medical service (ems) system in falconara m., italy, was implemented in august by a collaboration between the school of anesthesiology and intensive care of the university of ancona and the, already existing, volunteer rescuer organisation "yellow cross". according to the guidelines pubblished in [ ] the pre-existing equipment of the volunteers was completed with type a ambulances and special equiped motorcar (patient monitor, defibrillator) for ambulance indipendent physician transpur[. a special data collecting schedule was created to memorise every emergency intervention in a computerised data-base. the intraining members of the school of anesthesiology and intensive care provide hour ready intervention. in this report the authors describe their experience concerning primary firstaid medical interventions. for a preliminary evaluation we considered, retrospectively, consecutive emergency interventions in the time period from novembre , to april , . the emergency physicians treated male ( %) and female ( %) patients, patients died before hospital admission and patients ( %) were treated at home by the ambulance indipendent physician and did not need any further medical treatment. in the same time period year earlier (november to april ) without attending physician the volunteer rescuers transferred all first-aid interventions to near-by hospitals. we conclude that the presence of an attending, iudipendently motorised physician in emergency interventions is essential for the establishment of precise priorities and may be helpful to reduce hospital admissions by ambulance intervention, though reducing primary" health care costs. we have developed the method of liquor filtration which allows to purify the cerebrospinal liquor from blood and its decay products in the subarachnoid bloodstroke. the hemipermeable dialysis membrane was used as a filter, which lets only in water, electrolytes and substances with small molecular weight. the liquor filtration was used for the treatment of patients with the subarachnoid bloodstrokes of different etiology. the perfusion of liquor was performed at the rate ml/min in the recirculatory mode. its duration was - min depending on the bloodstroke intensity. the filtration makes possible the most completely purifying of the hemorragic liquor, the reducing of the content of blood ceils and its decay products - times as less. the monitoring of the patient's state during the perfusion didn't revealed the departure from the norm of the main vital part. the liquor filtration technique compares favo-~ rsbly with the routine method of cleaning by the absence of toxical effect of heterogenous solutions on the central nervous system. the filtrstion of the cerebrospinal liquor in the subarachnoid bloodstroke sllows to provide the the early cleaning of liqour, the regression of meningeal syndrome and to improve the patient's state of health. e tabli~mczr bd ~ of rei~idnal medical first-aid zhoulittoing, ed., tan zi, m.d. dept. of sargery, the first teaching t[ospitat, yejin-l)a-l)ao, wuhan fltlna objectives: the medical first-aid is the most important task of the public hc atth department. in general, single hospital model couldn't fatty, effective ly rescue mony severe patients who need mergant treatment in the scene. bub establishing the medical first-aid network, the severe patients can be given the most timely und the most scientific emergent treatment. so that, the suc cessfut rate of the saving wilt be greatly increased. methods..; our hospital is a general big hospital. through developing and cons tructlng for more than ten years, the medical first-aid network distributed art over the area under our jurisdiction has been set up. it consists of thr ee units: the medical first-aid unib center comartd and mnagment unit, co m~nlcation and tiaison unit. the principle of the network operation is with oat having to far to mergoncy, specialized emergency and the best merge acy. results: the results of the network operation were notable. cmpari~ the to tat successful rate of the saving ( . ~), the successful rate of saving tra ma ( .~), the suscessfut rate of saving shock ( .~) and the successful rate of cardioputmonary resuscitation ( . ~) daring the three years after t he network operated with these before ( . ~), ( ]. ~), ( . ~) and ( ft. ~), the successful rates after operating were remrk~iy higher ( p<i).o ). conctusions~ the above results showed estabiishmnt and mena emont of region at medical first-aid network had very si~nificont action during mergentty s avin the severe patients. moreover, the regi~at medical first-aid network atso take an important part in prevention and health protection of the mass. objectives: se related mortality is due to the occurrence of both rv and lv dysfunction evoking cardiogenic shock and pulmonary edema (f. abroug, intensive care med ; s. nouira. chest ) . prospective evaluation of scorpion antivenon (sav), the only available specific treatment, is lacking. the aim of this study is to assess the effects of sav on the basis of a case-control study. methods:among consecutive victims of se presenting to the emergency department, were managed using sav (group sav+). these patients were matched to envenomated patients who did not receive sav (group sav- chest injuries are the cause of death in % of trauma fatalities and a major contributing factor in an additional %. pneumothorax is a major complication of chest injuries and can be initially overlooked bringing to additional morbidity and mortality especially in patients who require mechanical ventilation. the real incidence of pneumothorax in severe blunt chest trauma hasn't yet been established, as many pneumothorax can be missed on the initial chest x-ray (cxr) and computed tomography (ct) has not been routinely used. to evaluate the incidence of pneumothorax in patients with severe blunt chest trauma. methods: a prospective study. from january to december , all trauma patients with one of the followings conditions: fractures of four or more ribs, signs of lung contusion on the initial cxr or presenting a severe hypoxemia on admission (pao /fio < ) in the absence of pre-existing pathologies, were evaluated by initial cxr and subsequently submitted routinely to a ct. results: severe trauma patients were considered. of them, presenting a severe hypoxemia on admission, had no evidence of major chest trauma (ais< ). hypoxemia was the consequence of severe trauma in other districts; these patients were therefore excluded. patients with severe thoracic trauma (ais>= ) were admitted into the study. the mean iss was . ( - ). thirty-six patients required artificial ventilation for at least hours during the icu slay. three of them, who had a tension pneumothorax, were submitted to an emergency thoracic decompression on the field by the emergency helicopter team. in cases pneumothorax was diagnosed an the initial cxr more patients had a pnx which was identified only on the ct. in cases a large pnx with lung collapse was missed on the cxr. in our group of severe blunt trauma patients, % ( / ) presented a pnx that required the insertion of a thoracic drainage. only one third ( / ) of the pneumothorax could be recognised on the initial cxr, while other were decompressed before performing the cxr. as many as % of the cases of clinically significant pnx were missed on the cxr, and a ct performed soon after admission allowed an early diagnosis bringing to changes in the treatment. (as the patients were mechanically ventilated a chest tube was inserted in all these cases). in cases, the initial cxr overlooked a huge tended pnx which was the cause of hemodynamie instability. conclusion: in patients with severe blunt chest trauma even large pnx can be missed on the initial cxr. moreover due to the non compliant compressible lung, a % pneumothorax which can be recegnised only on a ct, can bring to high intrapleural pressure altering eardiopulmonary function. n. andoeli , .~osid, m.zesevid, m.risovid, d.stepi , d.djokid b~rga~yc~qterclinicalcaqterafserbia, belgrade cb~ctives:~lis study ~ the use of ~rq]ofol earbired with k~t~ine (aq a~sjgh~ic s@~qt widn inirjrsic armlgesic pro~mities) or with fsqtmtyl,with psrtial azgmsis an hgenxlyn-a~ic ~ durirg ~ ~ re:~ver~ f~m ~ in hxh ~ of ~ti~. ~: yali~mial and ~bod: a~it p~tie~ts a~ i-ii were included in ibis shxly. patients were rsrd]nly dieided in two ~ns. all d~tie~ts ~me given - prcpofol bolus doses (o, ~gkg) for ird~iqn of ~. ~ia ~s m~sjn~ with an infusion ~ ~ropafol. as sdflitianal were given fan-i~l (o, n]g) ~tely before ~ anj trad~e~ irfojoation followad by feasted bolus of o,i mg in ~ro o l.patients in gr~ o received i~ (an initial bolus dose of rg slowly intcavax~ rd mg as infusion over ~ rain) .infusions of pro~fol or imcpofol with kg~mine ~ stopfsj - rain ]:~o~ extuhation.arterial blood ~ (sistolic arterial blood preassu-re~zap,mean ~rterial blood pr~,d~lic arterial preassure-[zp a~ h~art rate-~) ~ m~ before induction of a~ io, snd rain aftem ~ intutation. results: arterial blood preasstre ~s decreases duri~ irn~ction of sn~wd~sia in hy~ ~n~s,tnt mare in th~ ~ who r~eived fsqtanyl.~ere w~s statisticslly sifnific~ntly difemerme dmir~ m~ of an~ia. arterial blood r~easatre and heart rate were stable in the t-..e~min -~a ~. all th~,fl-e keta'nire grcqo hsd e~rly :~e~y time. ctrmlusi~s: ~e ombiretion of protxfol wilh keta/ne for irduorion a~d ~ of sn~sd~esis w~s yell accept~ by p~tierfcs anj coald he ~ as an alterrstive ~o ccnva~icrsl a~es -d~sia. objectives : assess the relation between cytokine or endotoxin release and indices of splanchnic malperfasion after hemorragic shock in multiple trauma patients. ]~r study was approved by the local ethical committee. trauma patients admitted to the emergency room who met the entrance criteria of more than hour map < mmhg or use of vasoactive agents or blood lactates > mmol/ were selected for study. a nasogastric tonometer (tonometrics, inc, plastimed, france) and a swan ganz catheter were placed on admission. phi, lactates, hemodynamics, plasma cytokine and endotoxin concentrations were measured on admission and at . , , , hrs. an immunoradiometric assay was used to determine plasma concentrations of il (n< . ng/ml) and tnfc~ (n< pg/ml). plasma endotoxin concentrations were measured using a chromogenic limulus assay (n< . eu/ml)( endotoxine unit= pg). results : severe multiple trauma patients (age = _+ yrs, iss = -!-_ , saps = +'~, mean-+sd) were studied. they received + packed red cells during the first h. mean duration of collapsus before inclusion was . _+ . hrs. death occm'red in ~tients. ~ pglml, *: ng/ml, etox : endotoxin(eu/ml), lact: lactate (retool/l) a significant correlation between initial il level and saps was observed. in the early post-injury period phi, sao , svo , vo were significantly associated with ;il release (p< . at ho, h , h ). later a significant correlation existed between lactates and ii (h , h ). a peak of tnf was detected at and hrs. it was associated with low phi and low arterial ph of the early post-injury period (p< . iat ho, h , h ,h , h ) and with high lactate levels of later period (_>h ). only the late release of endotoxins (i{ ) was correlated significantly with initial !oxygea-delivered parameters. iconclusion : there was a marked increase in il in the early phase of trauma . i and tnf release after major trauma iwith hemorragic shock is associated with splanchnic malperfusion, as assess by the ivery low values of phi. lactates seem to be a later indice. toxic effects are a well-known complication of an overdosage of prescription theophylline. what is less known is that over-the-counter (otc) asthma medications contain theophylline, and that in some cases this might cause toxic effects. a case seen by us involved toxic effects from theophylline in an otc medication and to date is the only published case in the english literaturet the rationale for this study was to delineate the otc products containing theophylline from whatever data sources available. hyperthermia frequently occurs in intensive care treated patients and intentional application of whole body hyperthermia together with chemotherapy is a therapeutical access to treatment of malignant disorders. anaesthetic support is required in either condition. due to the marked decrease in systemic vascular resistance seen in hyperthermia an additional vasodilatory effect of the anaesthetic is unwanted. the vascular effects of anaesthetics in hypertherm organisms is not known in detail. therefore, we performed an experimental study to detect the effects of inhalational anaesthetics in whole body hyperthermia. in sprague-dawley-rats katheters were inserted into trachea, jugular vein, and carotid artery. for continuous monitoring of cardiac output a flow probe was placed around the aortic arch. the rats were mechanically ventilated with different concentrations of inhalational agents in oxygen. we compared the effects of enflurane, isoflurane, and halothane in stepwise increased body temperature by submerging in a temperature controlled water bath. results: isoflurane lowers arterial pressure more than halothane or enflurane. the inhalational anaesthetics lower the cardiac output similarily and independently of temperature. isoflurane decreases systemic vascular resistance independently of core temperature and the decreasing effect of halothane on the resistance is completely abolished in hyperthermia. conclusions: the influence of hyperthermia on the systemic vascular resistance is dangerous. this allows no additional effect of the anaesthetic management. in spite of the vasodilating effect of inhalational agents in normotherm subjects, this effect is abolished in hypertherms using halothane. the condition of management of analgosedation in hyperthermia is different from normothermia. objectives: to evaluate a bedside computer processed cerebral function monitor for assessment of brain wave activity when clinical/visual clues are not present. methods: ten icu patients undergoing neuromuscular blockade monitored with the aspect brain wave monitor from january to june , . results: time to onset and depth of sedation were readily apparent to icu physicians not specifically trained in eeg reading. objectives: to determine whether non-depolarising neuromuscular blockade reduces oxygen consumption (vo ) in sedated, apnoeic patients. methods: haemedynamic. metabolic and oxygen transport variables were determined in sedated, apnoeic patients with severe acute lung injury. all patients were ventilated using a puritan-bennett ae ventilator with integrated metabolic monitor. inclusion criteria were; ) stable cardiorespirator s" status; ) systemic and pulmonary artery catheters already in situ; ) inspired oxygen < %. patients were sedated with midazolam or propofol to abolish response to verbal stimuli, and sufficient morphine or alfentanil to abolish all spontaneous respiratory efforts. following baseline measurements, neuromuscular blockade was induced with intravenous vecuronium, ug/kg, followed by an infusion of ug/kg/h to maintain the train-of-four ratio at . a further four sets of measured and calculated variables were obtained at min intervals. results: statistical analysis was by repeated measures anova. there were no significant changes in any variable over time. the changes in calculated oxygen consumption (vo fick) , and measured oxygen consumption (vo gas), and in energy expenditure (ee), are shown in the table. objetive: to study the effects on coronary hemodyrtamics and myocardiai metabolism of administering propofol during postoperation sedation of patients with normal coronary circulation and good ventricular function undergoing cardiac surgery. patients and methods: patients ( women and men) undergoing aortic and/or mi~-a/ valvular cardiac surgery were selected, with an ejection fraction greater than . and normal coronary circulation. for postoperation sedation propofol was administered in . mg/kg i.v. bolus, followed by a . mg/kgth perfusion. all data were registered before administering propofol and after minutes, the patients being hemodynamically stable and a rectal temperature of _+ . -~ systemic and pulmonary hemodynamics, and global, as well as regional myocardial blood flow, and metabofic variables were measured. results: the patients studied were about years old, and the average period of aortic cross-clamp was . min. the adminstering of propofol caused a decrease in the coronary blood flow (- %), great curonary vein flow (- %), myocardial oxygen consumption (- %), regional myocardial oxygen constanption (- %), myocardial oxygen extraction (- %), regional myocardial ooxygen extraction (- %), while coronary vascular resistances and global coronary vascular resistances did not change. oxygen saturation increased in the coronary sinus (+ %) as well as in the great cardiac vein (+ %). in no patient were significant changes suggestive of myocardial ischemia objectified. there was also found a decrease in systolic (- %), diastolic (- %) and mean (- %) arterial pressure, systemic vascular resistance (- %), and cardiac output (- %). conclusions: in accordance with the clinical conditions of this study, the administering of propofol is not likely to cause changes in coronary autoregulation, oxygenation and myocardial metabolism. obietive: analyse the effects of . % "end tidal" isoflurane (sedative dosage) on the metabolism and coronary hemodynamics during the postoperation period of patients undergoing cardiac surgery. patients and methods: patients ( women and men) undergoing aortic and/or mitral valvular cardiac surgery, with an ejection fraction greater than . and normal coronary anatomy, were selected. after the surgical operation, . "end tidal" isoflurane was administered for postoperadon sedation. the determination of variables to be studied was carried out before and minutes after administering isoflurane, die patients being hemodynamically stable and a rectal temperature of _+ . -+c. systemic and pulmonary hemodynamics, and global, as well as regional myocardial blood flow, and metabolic variables were measured. results: the average age of the patients studied was -+ . years. during surgical operation the period of aortic cross-clamp was . _+ . rain. the administering of isoflurane was followed by a statistically significant drop in coronary perfusion pressure (- %), coronary vascular resistance (- %), regional coronary vascular resistance (- %), regional myocardial oxygen consumption (- %), regional myocardial oxygen extraction (- %) and accompanied by a significant rise in oxygen saturation in the coronary sinus (+ %) and in the great cardiac vein (+ %). myocardial oxygen consumption, myocardial exu'action of lactate and regional myocardial lactate extraction did not change. in no patient were enzyme or electrocardiograph changes objectified. systolic (- %), diastolic (- %), mean (- % ) arterial pressure, and systemic vascular resistances (- %) decreased, while cardiac output did not. discussion: the administering of . % "end ddal" isoflurane, in the clinical conditions of this study, produced a decrease in systemic arterial pressure due to a reduction of systemic vascular resistance without deteriorate cardiac output. at coronary circulation level, has and effect on coronary autoregulation but had no effect on oxygenation and myocardial metabolism. the idea of tiva implies the realisation of major anesthesia components (los of consciousness, neurovegetative inhibition, analgesia, myorelaxatiou, providing the adequate gas-exchange) through i.v. introduction of drugs exclasively. aim: providing for the main tiva components with minimal side effects of the drugs used, taking into consideration the patients characteristics and the surgery specific character. methods: anaesthesias have been conducted in patients aged years ( females, males), undergoing planned and urgent operations with the pathology of lower, extremities, perinaeum, small pelvis, hypogastrium and with reserved spontaneus respiration against a background of % insnffladon through mask. operations lasted from . - . h. anaesthesia adequacy was assested by constant monitoring: "cardiocap" (nibr hr, rr, sao , t), through glykhaemia level and mimicry reactions. standart premedicatioo of m-cholinolytics ( . mg/kg) and h -blockers ( . mg/kg) on the operational table was sumplemented by administration of . - . mg/kg of lidocaine, . . mkg/kg of clonidine, . - . mg/kg of pentamidine by the tachifilaxia method. the premedication adequacy was assessed through haemodynamics characteristics. sedation: . - . mg/kg of droperidoi, .l- . mglkg of diazepam and analgesia: - mkg/kg of phentanyl, . -- . mg/kg of ketamine were introduced fractionally according to indications. infusion rate of ringer-lactat solution was - ml/kg/h and depended on the intraoperational blood loss volume and on the patients preoperational condition. the duration of postoperative analgesia was registered. results: clinical assessment of analgesia according to this techniques allowed to decrease the anaigetics dosage to the subauaesthetic levels. smooth stabilisation of haemodynamics (bp) at proper age norms in patients with the initial hypertension by the -th min. of anaesthesia as well as the absence of its increase in response to the additional introduction of anaesthetic have been achieved. (hr) had no abrupt changes and remained in the range of - per rain. adequate external breathing: decrease (rr) by - per rain., with sao increase from % to - %. hypoventilation was avoided by respirate ventilator. according to unauthentic data the glykhaemia level had been lowered by -t % to the end of the operation with the initial moderate hyperglykhaemia of up to mmol/l the cutaneous covering grew warm and got pink colouring. no mimicry reactions. in the postoperative period patients were in the superficial sleep state ( - ) and analgesia lasted - b. there were no complications due to anaesthesia. conclusion: combined using of bz, opiates, neuroleptics potentiate the i.v. anaesthetics effects allowing lowering of each tiva component dosage and, as a consequence avoiding their negative influence on respiratory and heart vascular systems. complex application of adrenergetics (therapeutic doses of cionidine and pentamini with using of taehfilaxy effects) permitted to provide for analgetic and neurovegetative components of general anaesthesia under subanacsthetic doses of tiva main components, and manifestation of hyperdynamic reactions of haemodynamics decreased while using of lidocaine -the economicai activity of heart-vascular system. good level of muscle relaxation was achieved allowing for widening of surgical intervention extent without respirator ventilators and inhalation anaesthetics application. anaesthesia is easily controlled due to fractional introduction of drugs with quick recovery of cns functions after anaesthesia. postanaesthetic analgesia is increased while concurrent opiates doses are decreased. absence of marced haemodynamic, endocrine and metabolic reactions during the operation and after it resulted in shortening the period of patients staying in hospital. a yo white man was admitted to hospital for dyspnea and a productive cough. he had cabg in past, but no recent cardiac ischemia. physical exam: decreased breath sounds over right lung. chest xray: consolidation of right lung. admission medications included diltiazem, furosemide (both were continued) and trazodone (which was discontinued). admission ecg: sinus rhythm, qt . /qtc . sec, with st and t wave abnormalities similar to prior tracings. he required intubation and mechanical ventilation for progressive hypoventilation and hypoxemia. between icu days and he received haloperidol, - mg/d (cumulative dose rag) for agitation and delirium. icu day : qt . /qtc . sec. icu day : for better control of delirium, trazodone " mg q hs was added. icu day : he developed frequent nonsustained ventdcular ectopy. icu day : qt . /qtc . sec, pha . , paco mm hg, pao mm hg, k . meq/l, mg . meq/l. later in icu day the patient had brief episodes of torsades de pointes, each responding to precordial thump, and finally rhythm stabilized with i.v. lidocaine and magnesium. haloperidor and trazodone were discontinued. ecg was unchanged and myocardial infarction was ruled out. next day, icu day : qt . /qtc . sec. torsades de pointes, a form of ventricular tachycardia characterized by a twisting qrs axis, is commonly associated with qt prolongation. haloperidol is used frequently in icu for control of agitation and delirium, with reported doses up to mg/day. over past decade, cases of torsades de pointes with prolonged qt related to haloperidol have been reported. trazodone may also prolong qt and cause ventricular arrhythmias, especially in patients with pre-existing cardiac disease. in this patient, trazodone likely exacerbated qt prolongation from halopeddol leading to torsades de pointes. critical care physicians must be aware of this interaction. it is imperative to follow the qt interval for patients receiving halopeddol, especially when another drug also known to prolong qt is added. one must consider discontinuing the drug when qt/qtc becomes prolonged. objectives: analgesics and intravenous anesthetic drugs are routinely used in critically fll patients, who often suffer from a secondary impairment of the immune system. previous in vitro studies have demonstrated inhibitory effects of these drugs on polymorpho nuclear cells (pmn). the potentially important role of endothelial cells (ec), however, was not investigated, since suitable test systems were not available until recently. therefore a physiologically more relevant in vitro migration assay through cultured human endothelial cell monolayers (ecm) we established. using this assay system, the comparative effects of fenlanyl, sufentanil, propofol and the known pmn inhibitor thiopontal were tested. methods: human umbilical vein endothelial cells (huvec) were isolated and cultured on microporous membranes (cyclopererm) until an ecm was grown. pmn from male and female volunteers were separated by standard procedures. ecm and pmn were preincubated with clinically relevant concentratious of thiopental ( m), propofol ( p_g/ml), the solvent of propoful (intralipid), fentanyl ( ng/ml) and sufentanil (sng/ml). after preincubatiun (ecm minutes, pmn minutes) with the reslx~tive drug, leukocyte migration towards the chemoatfractant fmlp ( o - m) was measured in a two chamber well system for hours. the migration rate of untreated (untr.) and treated (treat.) pmn through untreated and treated ecm were determined. as a control untreated pmn and untreated ecm were used. results are given as means from independent duplicate determinations and expressed as a percentage of control (table) . statistical analysis was done with student's t-test. results: clinical concentrations of fentanyl, sufentanil and prupofol showed similar inhibitor~ effects as the known pivin inhibitor thit e ). % conclusions: for the first time we could show that analgesics and anesthetics exert their inhibitory effects not only on pmn, but mainly on the interaction of pmn with endothelial cells. moreover, we could shmv a significant suppressive effect of the opinids fentanyl and sufentanil on both ec and pmn. the known inhibitory effect of thiopental obtained in ec-free test systems were also confirmed in our physiologically more relevant assay system. objectives: to investigate when and how sedation is used in a consecutive cohort of patients admitted in a large sample of italian intensive care units (icus), gathered in a network named giviti, representative of the italian icus system. methods; the study called for a recruitment period of one month, from january to february , , data collection included age and other demographic variables, acute diagnostic broad profiles, severity of illness scores, treatments, lenght of stay and vital status at icu discharge. as concerned sedation, each patient was observed until discharge or for a maximum period of seven days. information on all the drugs used for analgesia/sedation, the route and modalities of administration, the timing, dosages and purpose of the administration have been recorded. results: the study involved the cooperation of icus, of which enrolled at least one case. the total sample included patients. overall, . % of patients analyzed (t / ) received at least one prescription of sedative during their stay. globally, at least one sedative drug was prescribed to these patients in days in icu. although over drugs were reported to be used, pharmacological principles accounted alone for % of all prescriptions. opioids were actually used in % of prescriptions; propofol in % and benzodiazepine in . %. as regards the way of administration, intravenous administration was applied in % of cases and, followed by intramuscular in . %. moreover, non-steroidal anti-inflammatory drugs (nsald) were used in % of patients and neuromuscular blockade agents (nmba) in %. detailed analysis on certain subgroups (surgical, trauma, ventilated patients etc.) have been also carried out in order to describe the practice of sedation in these peculiar subgroups. findings will be widely discussed during the presentation. conclusions: these results should be interpreted keeping in mind how peculiar is the intensive care setting compared to many other less complex settings of hospital care. in conclusion we thought it was important to present the data currently available in the most neutral form, to start moving in a direction which will enable us -by means of more specific and detailed studies, and with the cooperation and involvement of all those participating in the project -to shed light on one of the many aspects of medical practice in the field of intensive care which deserve closer attention. introduction: the aged run perilously high risks in cardiac surgery: among others, of haemodynamic fluctuations, respiratory depresskm and organ failure. response to anaesthetics is a crucial determinant for post<)perative complications, none the less being reintubation due to mechanical ventilation difficulties which increase morbidity, mortality and intensive cdre unit (icu) stay. objective: we wanted to assess our a,aesthesia window (selection, and a view of the induction -extubation period) for predicting safe and swift awaking, thus: icu dismissal for the aged. methods: in , selected patients (pts) (> y, f) followed a regular elective cardiac surgery protocol (propofol given at precisely designated time intervals). upon cu arrival, they were subjected to an admission protocol. our predictive criteria for early extubation at h included: a) alertness and ready response to commands; b) adequate gag reflex and sufficient protection for respirak)ry tract; c) pao > mmhg with flu < . ; d) stable ph> . with spontaneous respiration; d) stable haemodynamics without dysrhythmias; e) adequate perfusion and diuresis (> .(i ml/kg/h); f) mediastinal bfeeding< ml/h for at least h; g) normothermia (core temp> ~ and no shivering). subsequent reintubation was for: ) rr> /min; ) spontancx)us ventilation for rain with paco > mmhg; ) pao < mmhg with fio > . ; ) ph> . ; ) heart rate>] bm; and/or ) non mental alertness; and ) other medical disorders, after which adequate weaning therapy was necessary. then, successful weaning after h was considered: ) spontaneous breathing without any forrn of mechanical assistance; ) stability in haemodynamics; and ) elimination of fever threat. results: pts ( %) were extubated at h without complication; other pts ( %) at h but had to be reintubated because they were hypoxic and began weaning therapy; finally, they were all re-extubated by h. only pts ( %) proved problematic. conclusion: a,aesthesia wimhlw options (selectkm, extubation, reintubation and weaning) predicted quick (times propofol administration) and safe (rigid criteria) extubation ( %= h and %= h), exempting pts with developed post-operative complications ( %=extubation< h) unrelated to al~aesthesia window or icu protocol. dismissal and recovery then became an abbreviated question of time. fifisetll p, domeneg~i ~, sforzini i., veronesi i~, maconi a.g. *, breg~ massone p.p h [] ic+pca request conclusions:using e~aprenorphine, a synthetic,long-acting, ago-antagemist opinid drug as analgesic, in the major surgery we obtained the best clinic results with association of conttheus infusion of haft dose drug with bohts of pca in the first - hours and just pca in the secmad day after surgery when the patient is less sleepy. in this way we dent have a great sav~g of suppled drug but the major well-belng of patient without ~erious side-effects and quick mobilization; the dosage used don't compromise a good awake of patient: all patients are sleepy but ready for answer, no allueinatian, bradipnea but not less than b/m without ipoxia. also the patient proffered this kind of truit meut than the traditional at demand. the ward staff feel it useful] and rehabl~ the negative feed-back technology of the electronic infuser system makes possible to use it safe in the ward with high drug's concentration too. the infusion rate of low dose of drug assure a continuative analgesic covering ~n the first postoperative periad; the pca mode involves the patient him-self in the managemenl of therapy and enables him to choose the best way to confront the dll~icuity of postoperative period without call medical stall using pca-device we have had no probicm~ no accident. analgesia during extracorporeal shook wave lithot ripsy a .levit, b.grinbezg regional hospital, ekaterinbu~g, russia b~ectives: our task was to compare ~he analgetic effect of norphin and tramel. methods: study was made of two groups of uro-li~patients aged - . group a ( patients) received baprenorphine hydrochloride (norphin) at dosages of #. • mg/kg. group b ( patients) received tramadel hydrochloride (t~aasl) st dosages of . z . mg/kg. before the procedure diazepam was administrated i.v. ( . ! . mg/kg). blood saturation (spoz), hemodynamics incides (bp, hr,sv,co,sap,svr) were examined and the patients' subjective assessments of snsesthesis quality were analyzed. the hospital ethics committee approved the investigation. results: when using norphin hr increased by . % on the onset of the procedure while sap and sv decreased by .%% and . %, respectively (p< . ). however, there were no reliable co chsnges. spoz ~educed by @. % (p< . ) and remained lower than the initial one after the procedure was oyez. when administrating tramsl min. after ste~ting the procedure sap and svr increased by ~ . % and . % respectively. sv and co decreased insignificantly. nine patients in group b saffeting some dlscomfo~t needed additional tm~msl in~ection. in the course of the whole p~oced~e spo, was constant and was highez than that in ~he case of nozphin (p<o. ). conclusion: respiratory suppression by no~phin can limit its use in case of lithotzip@y while the advantages of tremsl a~e: lack of dyspnoe and good contact with the patti-b_ the role of uncommon agents of antinociception, placed epidurally, in the control of pain transmission in the spinal cord is well documented. somatostatin as an inhibitory agent is found in the dorsal horn of the gray matter of spinal cord. the effects of somatostatin is similar to the opiates if injected into the epidural space (ref. i, , , ) . the aim of the present study is to present the clinical effect of above mentioned palliative therapy in the case of cancer and non cancer pain. informed consent had been obtained from every patient before treatment was initiated under the legalisation of the local ethics committee. using the permanent epidural catheter and continuous infusion pump, we administer somatostatin in the dose of up to microgram per hour for one up to three days. the patients paln feeling was evaluated using a vas (visual analogue scale). we found that the opiate resistant pain level decreased by %. the rest pain could be controlled by pereral opiate analgetics or by combination of somatostatin and an opiate plus a local anaesthetic agent epidurally. theoretically, it seems that epidural administration of somatostatin and local anaesthetic agent is useful in the control of acute pancreatic pain and systemic effect of somatostatin is beneficial in the treatment of acute pancreatitis. few studies have been performed in the critically ill (ci) and because of the complex pharmacodynamic and pharmacokinetic changes that occur, it is difficult to predict accurately drug responses and interactions in individual patients. midazolam (m) is a watersoluble benzodiazepine with a rapid onset and short duration of action in normal individuals; however its metabolism is decreased in the ci. critical care physicians every day experience suggest that among the ci there is a different pattern of response to m; here it is hypothized that such a response could be due to different metabolic behaviours of ci. m (i.v.infusion rate - rag/h) and antipyrine ( rag p.o.) were infused to ci with ( patients -group ) and without ( patientsgroup ) endotracheal intubation. blood samples were collected at fixed times during and after m infusion. total urine nitrogen and antipyrine elimination half-life demonstrated different metabolic characteristics in group chypermetabolizer") as compared to group chypometabolizer"). results follow. the results of our study are preliminary and more kinetic data in critically ill patients are needed to statistically confirm our approach of "hypometabolizer" and "hypermetabolizer". objectives: some clinieai and experimental studies suggest that propofol decreases myocardial contractility in coronary artery bypass grafting (cabg) patients. the intrinsic negative inotropic action of the drug may be independent from changes of preload and afterload, whereas the myocardial depression induced by propofol may depend on changes in ca ++ ious availability. aim of this study was to verify the hemodynamic effects of propofoi in a group of cabg patients with uneompromised contractile function and to minimize myocardial depression, during induction of anesthesia, choosing to associate calcium chloride (cac ) in an other group and to define its role in producing this effect. methods: fourty patients, randomly divided in two groups ( pts a and pts b), undergone elective cabg, were enrolled in this study. anesthesia was induced by senior anesthetist in both groups by means of fentanyl mg• kg < in ", pancuronium . mg x kg - and propofol mg • kg - in ". a blind investigator administered via another venous way at same speed ( ") saline in patients of group a and mg x kg - cac in patients of group b. hemodynamic data (heart rate hr, mean arterial pressure map, mean pulmonary artery pressure pap, pulmonary capillary wedge pressure pcwp, central venous pressure cvp, cardiac index ci, stroke volume index svi, systemic and pulmonary vascular resistances indexed svri and pvri) were obtained at baseline (to), ' after anesthesia induction (t ) and " after tracheal intubation (t ). results: hr decreased moderately in both groups (p = ns). map decreased as well, more markeatly in group a at ti and t . this trend was statistical significant (p < . ) in both groups. pap, pcwp and cvp unchanged following induction in any of two groups. ci decreased in group a (p < . ) dramatically dropping at t , while in group b it showed a negligible decrease at t (p = ns) and value similar to baseline at t . svri and pvri did not exhibit statistically significant changes. conclusions: the use of propofol as a starter of anesthesia in cabg patients allows to reduce total dose of fentanyi, dramatically reducing post-operative intubation time. propofol-fentanyl association prevented the hyperdynamic response to stress (i. e. laryngoscopy, intubation) but severely depressed ci and svi. cac simoultaneous administration effectively minimized the negative inotropic effect of propofol. moreover no unwanted side-effects due to cac were observed. diseoordinated labor activity (dla) is one of most serious in obstetric pathology.medication sleep effect to a woman in birth is of limitation of pathologic impulsation from the central nervous system, but it does not influence processes resulting in and supporting dla on the organ level. constant discoordinated uterine contractions during medication sleep (ms) imerease disturbances of uterine blood flow, organ hepoxemia connected with hyperergia of vascular wall and myometrium to catecholamines, that reduces efficiency of anesthesiologic protection. we applied hexoprenalin in complex with ms to primaparas. efficiency control was being accomlished through hysterograms, grade scale of analgetic effect where hemodynamics reaction to pain, significance of emotional reactions and their vegetative manifestations before and during ms were registered, and also through hydrocortisone level in plasma before and during ms. the examined women's average duration of ms was hours more than in control and made hours, though their average labor duration and in control was the same and made hours. % of the examined women experienced independant labor, as for the control group -only %. supplementary methods of anesthesia were required in % in control,that increased medicamentous depression of the fetus, but for the examined group -only in %. the examinees's newborns experienced favourable terminations, in control newborns were in state of light rate asphixia. analgetic effect was complete in control just in i %, and of examinees -in %. on the women's hysterogrnms before ms discoordinated contractions were registered on the background of increased tonus. during ms in control similar uterine contractions were constantly registered, but for the examinees they were not marked at all or had the proper character. the examinees' hydrocortisone level was reduced for % and in control only for %. the study has allowed to make a conclusion that hexoprenalin applications in complex with ms in case of dla make anesthesiologic care safer and more effective, promote simultaneous removal of patholgic processes in the central nervous system and uterus, which lead to dla development. objectives: the aim of report is to present a clinical study results for the evaluation of anesthesia for a patients in unconscious states by eeg examination: methods: the study was conducted on patients after a severe abdominal operations on stomach and intestine and on one patient after traumaticat exarticulation of upper extremity. all patients have different unconscious state levels from somnolence to coma ]. also thay hav~ had respiratory insufficiency and control mandatory ventilation have been used. we were used intrave,~ous injections of morphine hydrochloride from initial dose of mg. than we were increased the dose to mg i.v. by drops with an accompanying eeg monitoring and fourier spectral analysis. initially all patients have had -rhythm with slow and a-activity. an c~-activity index have been lower than %. results: after anesthesia the o-and a-activity have disappeared. the or-activity index have increased to %. also we have noted decreasing of the unconscious state levels to a possibility of a verbal contacts ( - points gcs). conclusion: the quality of anesthesia could be evaluated by eeg monitoring. a regaining consciousness afte~ the injections of high doses of morphine, probably, may be a result of an opiate deficiency (full or partial). anesthesia with the following drugs: clonidine, l-arginine, l-n-arginine-methyl-ester (l-name), and their combinations. tail-flick latency (tfl) was determined at time zero and min after each treatment. clonidine (i- ~g/mouse) prolonged tfl in a dose-dependent manner. at a clonidine concentration of gg/mouse, tfl increased . -fold compared to time zero. l-arginine increased tfl at a high concentration (i gg/mouse). l-name suppressed tfl . -fold compared to time zero at a concentration of gg/mouse. conclusion: we have found that no is involved in clonidine spinal analgesia. studies are currently being undertaken to assess the effect of combination treatment of the above drugs on clonidine supraspinal analgesia. objectives: hemodynamic changes ussualy accompany laryngoscopy and tracheal intubation.the aim of this prospective study vas tu present the effectivness sufentanil in preventing reflex circulatory respone of laryngoscopy and tracheal intubation and provides stable hemodynamio condition for induction of balanced anaesthesia. methods: adult asa i-ii patients sheduled for elective surgery.they were allocated randomly and divided into two groups:fifteen patients received single bolus of placebo prior to laryngoscopy.and tracheal intubation. anaesthesia induction was then performed with thiopental (smg/kg) and atracurium ( , mg/kg), followed by neurolept anaesthesia. mean arterial preassure (map) and heart rate (hr) were measured before, during and min after intubation. althought ecg was recorded at the same time intervals. results: the groups were compared with regard to the changes in arterial blood pressure,heart rate and electrocardiogram. mean arterial preassure and heart rate were incresed significantly during and after laryngoscopy and tracheal intubation in control group but remained unohange the baselin values in the group who received sufentanil. control group ecg suggested more changes than sufentanil group. conclusions: the results indicated that , mg/kg sufentanil for anaesthesia induction reducing the pressor response to laryngoscopy and tracheal intubation. obiective: the aim of this experimental study was to evaluate morphologically the influence of anesthesia in liver as well as in isolated hepatocytes (hc). methods: a total of female swine ( - kg) were used as liver donors and were randomly assigned to one of two groups regarding anesthesia protocol: group a (n= ): induction with intravenous sodium thiopental in a dose of mg/kg, group b (n= ): propophol in a dose of mg/kg for induction'and mg/kg/h for maintainance of general anesthesia. both groups were under the same preanesthetic regimen (diazepam, ketalar and atropin) and received standarised doses of fentanyl and pancuronium during anesthesia. in beth groups total hepatectomy was performed and the liver was perfused with - it of cold ( oc) university of wisconsin solution for a period of hours before hepatocyte isolation. liver tissue samples were fixed in formalin for the morphological study and stained with hematoxylin-eosin and pas. for hc isolation collagenase solution (type v, sigma, c- , . mg/ml) was infused via portal vein and the liver was incubated at oc for rain. cells were filtered and then washed in cold hanks' solution. isolated hc were fixed and prepared for staining or simply cryopreserved (- oc). results: histology was completed in / experiments ( in group a and in group b). mononuclear infiltration (halothane type injury) was found in all specimens ( / ). focal zonal necrosis and acidophilic bodies were found in specimens from group a ( / and / respectively) while portal inflammation with piece meal necrosis was found in one specimen from group b ( / ). smears of hepatocytes -beth formalin fixed and cryopreserved at - oc -were stained with hematoxylin-eosin and showed morphologically intact hepatocytes. conclusion: pre[imineq~' study of our material reveals mote frequent livet injury in the thiopental group, but this finding has yet to be established by increasing the number of observations. objectives: in this paper we present our experience and point out the importance of sedation of those patients who suffered severe head injuries/contusic cerebri with signs of decelebration/and who were put on ventilatory machine to obtain better mechanical ventilation in neurosurgical intensive care unit of emergency center in belgrade. methods: patients were treated from jan. till dec. results: in patients we successed to reduce agitation and decelebration. conclusions: the major demand of sedation in neurosurgical patients are that the patient should be calm, comfortable and painless. references we compared three analogous groups of patients in each, with orthopedic operations on lower extremities. in each group we applied different kind of analgesia: first group rece-ned local anesthetic ( ml . ~ bupivacaine) when analgesia was first demanded; second group received ml fentanyl via peridurai catheter when analgesia was first demanded, and third group received m] fentanyi intravenously on demand for analgesia. we used visual analog scale (vas) for estimation of pain intensity and success of applied therapy. statistical data analysis was performed using student's t-test. tha best vas had group in which local anesthetic was applied periduraly. second was the group with periduraly applied fentanyl, and third was the group with intravenously applied fentanyl the longest duration of the effect of analgesia ~/as in the second group. there were no adverse effects and complications, apart from mild sedation in the third group. for orthopedic operations on lower extremities, application of peridural catheter for anesthesia and successful postoperative analgesia with local anesthetic, or opioid analgesics is acceptable. background and obiective : tympanic temperature measurement (ttm) is a relatively new procedure which provides accurate estimates of core temperature in stable postoperative patients and in patients admitted to the emergency ward. however, experience with this technique in hemodynamically unstable adult icu patients is limited. design : prospective study with patients serving as their own control. se:ttijlg : adult medico-surgical icu in a tertiary care hospital. patients : consecutively enrolled patients with thermodilution catheters in place and without contraindieation for rectal temperature measurement and without hypothermia (core temperature < ~ interventions : tympanic temperature, measured by a commercialized tympanic thermometer (genius a first temp) was compared with pulmonary artery (pat) and rectal temperature (rt). within minutes, core temperature was assessed in each patient by the same trained individual using the three techniques in random order. measurements and main results : mean bias (ix~ and its variability (sdr of method comparison pairs were calculated using the methods comparison analysis as described by bland and alunan (lancet, ; i : - objective: to measure the prevalence of pressure sores on the intensive care unit and the effect of risk calculation on pressure score prevalence and pressure score severity. method:in during a period of months a series of prevalence studies was carried out on the sicu to investigate how many patient days with pressure sores were taken care for by the icu nursing staff, what kind of preventive interventions were done and what the patient risk was on developing a pressure score. results: on average there was a prevalence of pressure sores on the buttocks of . % on the short stay unit and . % on the long stay unit; preventive interventions increased when the pressure score was visible for the nurse and the majority of patients had a high risk or extra high risk for developing pressure sores according the pressure score risk calculator. as a result of these findings the nursing management decided in that nurses had to complete daily on every patient the pressure score risk assessment in order to be able to take adequate preventive interventions. when the results of the two studies were compared, the most important results were that: ) there is no indication of a reduction in patient days with pressure sores (short stay unit: %, long stay unit: %); ) there is a reduction in severity of pressure sores (grade iv decreased from . % to . %) because adequate preventive measurements are initiated by icu nurses in an earlier stage. possible explanations for the increase of patient days with pressure sores on the long stay unit are that the average pressure score risk score was increased from . to . and the mean frequency of nursing patients on alternate sides decreased from . to . times each day. conclusion: daily assessment of the individual patient risk on developing pressure sores does not decrease development but reduces the severity of the developed pressure sores. method: the conventional woundcare method of patients with an open abdomen is to change frequently the saline soaked ribbon gauze pads ( - times each day). this method is labour intensive for the itu nursing staff and rather uncomfortable for the patient. problems that often occur are: insufficient hygiene, frequent nursing interventions, a progressive risk for deterioration of the skin and underlying tissues, difficult to measure abdominal output and in case of bowel fistulas enteral feeding is hardly possible. in using the new method, stomahesive is applied on the skin surrounding the wound. a large size of surgical film dressing, opsite | is applied over the abdomen. two or more foley ~ catheters ch are inserted through an opening in the surgical filmdressing. the application of several lateral openings in the catheters is advised. the drains are held firmly in place between two layers of sterile opsite | "flexigrid ~'' x with the so called bookend method and are connected to a low vacuum suction system ( - kph) results: we studied the frequency of dressings changes on patients in the itu. in total they had days with an open abdomen. during this period there were dressing changes. this means one dressing change every days. further advantages of the new method are; more hygiene in patient care, no maceration and irritation of the skin, nursing on alternate sides is possible, output can be measured, in case of bowl fistula, enteral feeding is possible and an abdominal lavage is possible on the sicu by opening the opsite | conclusion: this new method of woundcare management is more patient friendly, prevents several nursing complications and decreases the work load for the nursing staff. objective: to investigate the interaction between the ventilator and the closed suction system related to possible induced negative pressure by this sytem. method: we studied in a testlung model what the effect was of the different ventilators (evita: dr~iger; servo c: siemens), ventilation modes ppv, simv) and ventilator settings (tv, trigger level, frequency, peep level) on the induced negative pressure by the closed suction system during suctioning. results: when using the evita the magnitude of the negative pressure increased when the ventilation frequency and tv decreased.. the largest negative pressure (- cm h ) was produced with a tv of ml and a frequency of /min in the ippv mode with trigger level on - cm h and a peep level of + cm h . the servo c showed a complete different pattern. the largest negative pressures were measured when no trigger level was set ( cm h ), the induced negative pressure was not depended on the tv or ventilation frequency but more depending on the ventilator mode. the simv mode produced the smallest negative pressures ( - cm h ) and the ippv mode the largest ( - cm h ). conclusion: the effectiveness of the closed suction system is very much depending on the kind of ventilator, ventilator mode and ventilator setting that is used. if the interaction with the used ventilator is not known by the icu nurse this piece of equipment can cause damage to the patient by inducing large negative pressure in the comprimised lung and there fore creating the possibility of alveolar collaps and atelectasis or oedema. introduction : ethical problems are daily and disturbing preoccupations for the icu staff. objectives : improving ethical management in icu by creation of an intelprofessional group of ethical reflexion ( iger ). methods : existing was evaluated by a preliminary formulated series of questions sended to the whole staff (q , n = , items) after two training sessions (laws, deontology, professional values, culture, norms of quality) followed by persons ( %) and directed by an external chairman, satisfaction and needs of the staff were evaluated by a second series of questions (q , n = , items). at the issue, iger was created. results : q : responders ( %). law's misinformation : to %, disagreement for limitation of intensive cares : %, hope to improve collective decisions and creation of iger : % q : responders ( %) : satisfied by the training sessions : %, non satisfied : %, want to continue the project : %, refuse : %. iger was constitute by physicians, nurses, secretary, dietetic (n = ). the first working theme was {< therapeutic's withholding and withdrawing decisions in icu ~>. four subgroups of iger's members (having access to an ethical library) worked independautly and submitted their reflexions in a tdmestrial plenary session of iger in the presence of an external chairman, allowing a synthesis. at the issue a report was writted to be used as a reference for bedside and individual decisions. conclusions : constitution of iger seems to improve ethical management in icu. the first result of iger is that it is now possible to began collectively a reflexion concerning therapeutic's withholding and withdrawing in icu. the work is going on and further subjects will be studied. objectives: ) to compare the value of heat-moisture exchangers with bacterial filters (hmef) and without bacterial filters (hme) in the prevention of colonization of ventilator tubing and ventilator-associated respiratory infections. ) to asses the temperature and relative humidity of inspired all using both types of heat-moisture exchangers. methods: mechanically ventilated patients were randomized, to either hmef or hme. endotraeheal aspirates, pharyngeal swabs and samples from tubing were collected for bacterial cultures on the st, nd day mechanically ventilation and weekly thereafter. temperature and relative humidity were measured in patients ( hmef and hme) h and h after placing the hme or the hmef. results: both groups were comparable as regards age, mechanical ventilation period, severity score (saps ii), leukocyte count, and number of patients with prior antibiotic treatment. from the hmef group, ( %) ventilator tubing yielded microorganisms in, at least, one sample as compared to ( %) of the hme group; p=ns. the incidence of respiratory infection was similar in both groups ( % vs %, p:ns, for hmef and hme respectively). among the bacterial species isolated from ventilator tubing in the hmef group, ( %) were not isolated from pharyngeal swabs. a similar ratio was shown in the hme group ( / , %). both heat-moisture exchangers were efficacious in keeping a good relative humidity of inspired air ( % • vs % • .%; p=ns, for hmef and hme respectively). relative humidity was significantly higher after h of mechanical ventilation in the hme group as compared to hme group ( . % • vs . % • %; p= . ). conclusions: both types of heat-moisture exchangers have the same effect on the prevention of colonization of ventilator tubing. similar relative humidities are achieved when using either type of heat-moisture exchanger. results: tumor and nontumer enhrgements of the thyroidea were present in ~ of the operated, surgicel adrenal disease in io!, hyperplssle or persthyroid gland tumor in ~ end endocrine pancreatic tumors in %. in the intensive oere unit, these patients wore screened by noninwsive monitoring in ~ of cases: and invasive monitoring was applied in % of ceses.the basic noninvesive methods included: electrocardiogram with standard end precerdial leeds, percutaneous eutomotlc measurement of systolic, diastolic and mean arterial pressure, measurement of hourly diuresis and body temperature, frequency, hearing capacity and rhythm of one s own breathbng bs well as pulse oxymetry. a special plece in monitoring and control of vital parameters in postoperative period belonged to the nurse, thoroughly trained for enelysis end interpretation of the observed parameters which would be discussed in the paper. it has been believed that the leader sits at the pinnacle of power. over the years, this has proven to produce frustruation and anguish instead of the expected results. leaders have not been able to produce the changes they know are essential to their organization's survival with this command-and-control paradigm. through literature reviews and evaluating leadership styles, one can clearly see the most effective form is that of empowering people to a new level of performance -not ordering it. changing the leadership paradigm to a manner/style that has been shown to be effective and one of people empowerment shifts the focus to personal responsibility for performance. removing obstae}es~ stimulating self-directed actions, and determining focus and direction are just a few elements used to create the successful environment of empowerment. with increasing pressure in the health care arena, it becomes critical that a leader's job is to get the people to be responsible for their own performance. developing ownership, creating an environment where people want to be responsible, being a mentor or coach, and learning faster while encouraging others to do so demonstrates the commitment to effective leadership. this presentation will illustrate the critical components that are achieved when every person in the institution is empowered to perform at a level that is directed toward positive, effective results. herrera m. (md) . icu. hospital regional. malaga. spain. the systems of veno-vanous continuous haemofiltration (wchf) have a high cost and a limited life span. in an attempt of lengthening their mean life it has been proposed to accomplish programmed washes of the ~-stems. this practice supposes an increase in nursing workload. in order to evaluate the real efficiency of this practice we have accomplished this study. material: prospective randomized study of all the filters of vvchf used during the last year in our icu. we have determined two groups of filters, in the first (group a) we accomplished washed in a programmed way, and in the other (group b) only when the alarms of the system suggested a clotting of the filter. for the statistical analysis we used the kaplan-meier test for survival analysis. results: we have studied a total of patient submitted to wchf during the last year. we used a total of filters with this results. objectives. sounding out the nurses about the need to inform patients" relatives and the rigth kind of such information, like a preliminary approach to an information cuality assessment, methods: we inquired all the nurses of the intensive care unit of an regional hospital by an semiestructurated questionary which included personal data: age, sex, contractual relation, professional experience.., and opinion data: do you think to inform relatives is a nurse task?. which of the next informafions do you think is more important?, please, write others topics about information you think are relevant. we process the data on epi-info estatistical program and use x test to compare the results. results" from nurses of staff refused to flu the quetionary, and were not available. of the remaining, %were v~men and % men. the mean age were . % had an svable contract and ( eventual, the mean professional experience were of years and % worked in the unit since more than years. the % answered that offer information to relatives is part of the nurse activities. we did not find differences with nurses who answered negatively comparing by sex, age, contractual relation or proffesional experience. the three information topics found out like more important were: ) to inform about patient mood. ) to inform about happenings from the last visit. ) to inform about dressing instrument required by the patient, nurses who answered negatively think that to inform is a doctors task or that nurses are not competent. conclusion~ intensive care unit teams (nurses, doctors and auxiliar personnel) should get accord on who and how to inform relatives, we consider the nurses' role on information as unquestionable. objective: investigate the respiratory and cardiovascular response after discontinuing oxygen therapy durir~ intr~/]o~pital transport. desiqn: fifty-one patients ( male and female, aged + , and , , years respectively, ~+sym) being on therapy were studied prospectively in two consecutive intrahospital transports. oxygen therapy was continued in the first transport while the second one was performed as usually, i,e, without . during transport each patient was monitored by pulse oxymeter and holter whereas arterlal blood gases were tested just before a~xl aft~-trar~portation. results: compared to daseline, pa and sa were signif~canthy decreased in the case of oxygen discontinuation (p< , i). paco was significantly inur~ds~i only in the subgroup of patients with obstructive lun[ disease (p< , ) . heart rate increased in all phases of the transport when administratlon was discontinued. blood pressure remained stable in either case. the percentage of supraventricu!ar extrasysto!es, ectopic v~r[hicui~r contractions and st-s ~ment depression was progressively increasing and became very high at the end of transport in the case of therapy discontinuation. other arrhythmias did not change significantly. conclusion: discontinuation of oxygen therapy during intrahospital transport causes severe drop of pao and sa , increases the heart rate and contributes to the appearance of arrhythmias which were not present before. methods:for evaluation of the functional state of brain the complex of methods was used,whieh included electro encephalngraphy ( brain mapping ), rheoencephalography, tetrapolar transtorax rheography. for the estimation of humoral status the level of histamine and serotonine, products of free-radical oxidation,enzimatic markers of ishemic damage of brain and of endogenous intoxication was investigated. results: patients with encephalopathies after resuscitation were observed.asystolia was as a result of:shock, trauma, asphyxia,poisonings,appiication of drugs, eclamp sia,injury of the heart,diseases of fhe cardiac vessels. all patients with postasystolic syndrome entranced in comafose condition.in the group (reconvalescents) the depth of coma by glasgo~ pittsburg"s scale was , +- , . the duration of coma was from rain. to hour,average , +- ,sh.ln the group (the deads) the depth of come was , +- , .the artificial lung ventilation was used in all patients:in the group , +- , days,in the ~ , +- , days.apallish syndrome developed in cases,in patients diagnozed <<brain death~. the th degree encephalopathy (coma) was found to be associated with disorganized eeg-pattern with predomi nant alpha-( group) and slow ( group) activity. the relative power of delta-and theta-ranges was about - per cent.the patients with apallich syndrome demonstrated greatly elevated theta-range power, that of beta -range was essentially decreased. the degree of disturbances of circulation in the both groups was different.cardiac index (ci) and stroke index (si) in the group decreased on , % and , z, in the -on , % and (; , %.general peripheral resistance (gpr) increased in the group on , %,in the -on (; , %.in the group brain blood flow was increased, in the -decreased on , n.in the group there was the normotonic type of reg-curve,in the -atonic or hypotonic type (without reaction on pharmacologic influ ence).disturbances of permeability of cellular membranes (enhanced free-radical oxidation with an increase in di enic conjugates on and n) and vascular ones (an increase of serotonin concentration on and %, hi stamine content on and %) resulted in hyperfermentia (an increase of concentration of creaune phosphoki nase in the group on %,in the - %.the level of middle molecules (mm) increased in the group on , %, in the -on , %,of polyamines (p) (spermidin,spermin,putrescin).coefficient of correlation between mm and p was , . immediate correction of neurocyte metabolism is impossible due to marked brain oedemaswelling,severe dis ordes of cerebral circulation, disturbances of membrane permeability.thus,the following treatment algorythm might be advisable: . protective inhibition of brain and reduction of its energy requirements. . recovery of cell and vascular membrane fuoctions. .recovery of blood circulatiom .oxygenation of nervous tissue and drainage of brain disintegration products.in patientshbo carried out. .active methods of detoxication (homo-and enterosorption). .correction of cerebral metabolism. . dehydrative therapy must be very cautious. conclusion: the activation of energetic metabolism in neurocytes must be carred out only under neurophysiolngical control and after definite preparation. ( ). the clinical estimation of acute cerebral failure carried out by olasgo-pittsburg"s classification of coma. we studied such groups of patients: poisoning co ( ), asystolia ( ), eclampsia ( ), acute renal failure ( ), control group ( ). methods: electroeneephalngraphy (brain mapping) was fulfilled by means of encephalograph <,medicor ~ in monopolar channels. the estimation of eeg patterns by zhirmunskaya method ( ) was carried out. there were analyzed and changes of eegb by results of rapid transformation furie after rhythmical photostimulation(phts) , , , hz. we studied also the figures of absolute and relative power in such diapason : delta ( - hz), theta ( - hz), alpha ( - hz), betal( - hz), beta ( hz and more). results: all eeo changes were divided into following types: -organized ( , groups); iii -asynehronic ( group); iv -disorganized with prevalence of alpha-waves ( , , groups); v -disorganized with prevalence of delta-and theta activity ( , , ; , groups) akkording to our model of hormonal-metabolic disbalance in pregnancy , one of the main reason of destosis is hypoergos , reesults in endotoxemia and neuro-endokrine disregulation. so, stady of central nervous system function give us the information about adaptation processes. the aim of our work is to study the degree of neurologikal deficit in destosis when olifen and lipin were used. there were studied pregnants with different severe forms of gestosis. the degree of neurologikal deficit was valued by datas of neurologikal status . eeg with ,~brain mappinng~, , electrikal resistance of the skin. the komplex inteensive therapy with applikation of olifen and lipin allowed to improve the patient,s condition , decrease the degree of neurolodikal deficit and mortality . kostenko v.phd,kabanko t.,phd,galalu s.md,beliavtseva n. ,shramenko k. phd intensive care department,donetsk medical university, donetsk, ukraine plasmapheresis (pph),as other extracorporal methods of detoxicatin,has a great importance in contemporary medicine. the role of pph is special,because of its simplicity, effectiveness, atraumatic.we incalcated pph in obstetrical clinic. there are rough changes in agregate condition of blood in more of pregnants.these changes lead to disturbances of central,organ and peripheral hemodynamic.the therapeutic effect of pph is due to influence on agregate condition of blood. we considered that application of pph is very effective in pregnants with:bronchial asthma, severe forms of diabet, psorias, gestosis, allergic diseases. we used the membrane pph in pregnants: apparatus-,,hemos-pf>,, plasmofllter pmf- ,with effective area- cm,the volume of extracorporal contour- ml.such pph has no the ~ agressive effect,,, as in cases of application another extracorporal methods. this method was incalcated in our practice recently, so results will be reported in further publications. ( ). post-operative cerebral neoplasm ( ), post-operative subdural hematoma ( ). icp was monitored via a catheter inserted in the lateral ventricle and values were continuously digitally recorded by means of a bedside computer data acquisition system (maclab). the fiberoptic tracheobroucosenpe, which guided the procedure, was passed between the nasotracheal tube and the trachea in order to avoid hypoventilalion. the patients had stable baseline hemodynaimcs. propofol infusion and fentanyl boli were administered to mantain stable mean arterial pressure values. peak (mean(sd)) icp duping the minutes pre-ciaglia procedure (baseline values) were compared with values during ciaglia procedure, and the minutes p st-ciaglia procedure. data were compared with repeated measures anova. results: ciaglia procedure duration was (mean(sd)) ( ) objectives: transient global amnesia (tga) is a syndrome caracterized by impairment of short-term memory, inability to form new memories, retrograde amnesia and repetitive queries, without other neurological signs and symptoms. the pathophysiology of tga is unknown; thromboembolic, epileptic, migrainous and metabolic mechanisms have been suggested. to address some of these issues, we undertook a study of cases of tga in whom we examined clinical, laboratory data, electroencephalogram, ct of the head, ultrasonography ecodoppler. methods: patients were included in this study: men and women. the mean age was years. all cases underwent a standard clinical examination, electrocardiogram, routinary humoral tests and x-ray, electroencephalogram (eeg), ct scan of the head, ultrasonography ecodoppler. results': the mean duration of amnesia was h. m. +/- h. m. hypertension was found in patients ( %), ischemic heart disease in patients ( %), hypercholesterolemia in patients ( %), hypertrigliceridemia in patients ( %), smoking in patients ( %), atrial fibrillation in patient ( %), history of epilepsy in patient ( %), migraine history was not recorded. ct scans of the head showed multiple small deep infarcts in patients ( %), a single hypodense lesion in patients ( %). in patients electroencephalogram was normal ( %), in patients there were widespread nonspecific electrical changes ( %), in patients there were focal nonspecific eeg abnormalities ( %). conclusion: in our study tga was more common in women ( %). we showed a prevalence of hypertension, hypercholesterolemia and cerebral infarcts compared to normal controls. we have demonstrated a higher incidence of nonspecific electrical changes in tga of lower length, while ischemic lesions in ct of the head were more frequent in tga of greater length. these data seem to be in agreement with the hypothesis that tga is a heterogeneous clinical syndrome, consisting of pure, epileptic, and ischemic types. however we did not find any correlation useful in discriminating pure from associated tga forms. from our study it is tempting to speculate that pure tga is a rare event, underlying still unknown mechanisms wich differ from ischemic, epileptic, migraineous causes. objectives: aneurysmal subarachnoid haemorrhage (sah) is special condition increasing intracranial pressure (icp) in various ways. at the other hand cerebral vasospasm and related delayed ischaemic deficit (did) could answer for the poor outcome. triple h therapy seems today a basic option to prevent did, but it may increase the icp worsening the altered intracranial pressure condition and thereby the cerebral perfusion pressure (cpp). is there any way to individualise the triple h therapy when it is necessary? methods: between sept. march thirty-seven patients with intracranial aneurysms were operated on within hours following sah. five patients were in hunt-hess iv at admission. all patients received triple h therapy in a preventive fashion following surgery and were monitored by daily transcranial doppler ultrasonography (tcd). icp and cpp was measured in twenty-four cases. twenty-two of them received lumbar liquor drainage (lld) and nineteen were administered induced hypertension. the other group was treated by basic triple h therapy. results: in group with monitored icp the outcome was twenty-one excellent, one poor, two died (one of them died from extracranial decease). in the other group four had excellent, six moderate, two poor outcome, and one died. conclusion: according to our recent observation the patients can be divided into two groups of therapy. in group i, the patients with elevated tcd values and either low or high icp reacted to lld. we are concerned that haemodilution and slight hypervolaemia should dominate in the triple h therapy. in group ii patients having high icp with tcd and/or symptomatic vasospasm should be managed by the induced hypertensionhypervolaemia dominated therapy focusing on cpp (icp) and focal neurological signs. air emboli were detected in lo% (n= ) of natients undergoing coronary srtery bypass craftin~ (cabg). central nervous system ~ysfunction occured in ~$ of the nstients with air embnli and in none of those ~ithhout air embo!i. hvtothermia is the classic form of oro-tect~on used dur~nc ~"~" " ~ ~ ca~.,~modu] :r, on~_,_. bj/oass. the surf~eon sho,;,ed thorough!~: evecnnte air from the heart, but the onesthesio!o[[ist can signifieamt!y influence the outcome by emt!oyin ~ methods to detect and treat air emboli. the changes in head rate are primarily due to alterations of autonomic tone. the heart rate variability (hrv), that express the degree of heart rate fluctuation around the mean heart rate, reflects somehow the condition of central nervous system. hrv may be measured by a number of techniques. short-term time-domain variables of hrv are reflect generally the vegal activity. in this study the changes in hrv variables of patients with brain damage, and in addition the changes in hrv measurements in comparison with the clinical evolution were evaluated. eight patient with brain damage and six normal individuals as control group were studied. a elecrocardiographer with availability of computation the sequence of beat-to-beat intervals for one minute was used. the following variables of hrv were measured: ) standard deviation (sd) of beat to beat r-r interval differences that reflects the respiratory control, )the maximum/minimum (max/rain) interval that reflect variability related to baroreflex and thermoregulation and ) the coel~cient of variation (cv), the results are shown in the in the patients with brain death and in vegetate state there were virtually no hrv. increased hrv pattern was found with clinical improvement, the changes of hrv precede of the changes of gcs, we conclude that time-domain hrv could reflects the degree of brain damage, it is good prognostic index of the brain damage and may change earlier than the gcs. objectives: cerebral co vasoreactivity is an important determinant of cerebral blood flow (cbf) and has been shown to be of prognostic value in head trauma (acta anaesthesiol. scand. ; : - ) . we wondered whether co vasoreactivity could be selectively altered in one hemisphere in comatose patients. methods: patients ( m/ f, age - yrs, glasgow - ) in coma due an acute brain lesion (trauma, hemorrhage, or infection) were studied. cbf was measured bilaterally using jugular thermodilution at paco , , , and mmhg by increasing pico with mechanical ventilation kept constant. normal co vasoreactivity was defined as an increase in cbf of at least i ml/min. g per mmhg paco . results: patients had normal co vasoreactivity bilaterally, patients had altered co vasoreactivity at both sides, and patients had a normal response at one side (left or right) with an altered response on the other side (dght or left). for the patients left cbf was in mean ! ml/min. g lower than right cbf (figure methods: following institutional approval piglets (body weight :tl . ) were anaesthetized by % fluothane. a catheter was placed in the right femoral artery for blood pressure monitoring and a fiberoptic catheter (oxymetncs- abbott) was advanced via the right internal jugular vein to the jugular bulb for sjo determinations. another catheter with a balloon on the tip was advanced in the right atrium via the right femoral vein. a mean arterial pressure (bp) at mmhg was achieved by appropriate balloon inflation for rain and two groups were cleated: i) the hypoxemic group by respirator disconnection (*) and it) the hyperoxemic group by fio =l on respirator (o). samples were obtained at time ( ), ' min at hypoperfusion ( ) arid at reperfijsion at ' ( ), ' ( ) and ' ( ). pao , pjo and oxidative brain stress evaluation was performed from jugular bulb blood. the latter included: i) no synthase (nos) and xanthine oxidase (xo) activities by a method based on the oxidation of scopoletin detected fluorometrically, it) no levels estimated as onoo-by luminol enhanced chemiluminescence in the presence of ~tm hydrogen peroxide (h ). resul'~s: the mean pao was mmt-ig for group i and methods: we retrospectively reviewed all upper gi-endoscopies, performed in the period january -july in patients ( men and women) admitted at the icu's of our hospital. results: it concerned surgical, medical, eardiological and neurological patients with a mean age of . yrs (range: - ). in %, the endoscopy was performed at the icu and in % at the endoscopy department. in % of the cases, the endoscopy was primarily diagnostic, of which % was performed for localization of upper gi blood loss. in % the endoscopy was primarily thempentic, of which % was performed for placement of a duodenal feeding canula. location of the upper gi bleeding was: variees ( %), duodenal ulcer ( %), oesophagitis ( %), gastric ulcer ( %), others ( %) and none ( %). as coincidental findings were noted: cesophagitis ( %), gastritis ( %), gastric deer ( %), duodenal ulcer ( %), duodenitis ( %), oesophageal ulcer ( %) and others ( %). conclusions: there were marked differences in indications and findings of endoscopy at the different icu's. these differences reflect an admission bias and differences in populations and treatment preferences. compared with cardiological and neurological icu's, substantially more endoscopies were performed at surgical and medical icu's. in a considerable number of cases, no source of upper gi blood loss could be found endoscopicaiiy. when upper gi blood loss was the icu admission diagnosis, the main cause was needing varices, which could be controlled endoscopically in the vast majority of cases. when upper gi blood loss was ndt the icu admission diagnosis, peigie ulcer and oesophagifis were the main causes of bleeding. because of the considerable number of coincidental almom~adities found at endoscopy, there is still room for debate whether antacid medication and/or motility stimulating agents should be given prophylactically at icu's. many studies have shown that blood lactate levels in survivors and nonsmvivors of traumatic and septic shock are significantly different. the degree of multiple organ failure is related to the duration of lactic acidosis ( ). the aim of this study was to evaluate blood lactate level as a prognostic marker of high risk postoperative patients who may benefit from invasive hemodynamic monitoring and aggressive fluids administration and early inotropic support based on oxygen transport parameters. methods: patients undergoing elective long term vascular and abdominal surgery (asa i-bi) were studied. blood lactate levels were measured after icu admission. in the case of blood lactate level above mmoltl, measurement was repeated every hours for hours or until normaiisation (blood lactate level less than mmol/ ). type of surgery, length of surgery, amount of fluids delivered intraoperatively and postoperatively, hemoglobin levels, hemodynamic variables, diuresis, postoperative complications, length of icu stay and clinical outcome were recorded. because no attempts were made to randomisr therapy or change our standard therapy protocol institutional approval was not required. rebuts: the frequency of postoperative complications was , % and mortafity was , % in a group of patients with blood lactate level less than , mmol/l (n = ). frequency of complications ( , %) was significantly increased in a group of patients with blood lactate levels , - mmol/l (n = ), mortality was , %. mortality ( %) and frequency of complications ( %) were significantly increased in a group of patients with blood lactate levels above mmol/l (n = ). conclusion: blood lactate levels can serve as early marker of high risk postoperalivr patients and may predict increased risk of postoperative complications mad ~e death. objective.~: investigated practicability and clinical value of the routine measurement of hepatic venous oxygen saturation (shvo ) after major liver surgery, as shvo is considered an indirect parameter for splanchthc and hepatic blood flow. methods: consecutive patients were included in this study after liver resections for primary or secondary liver tumors. patients suffered from liver cirrhosis (childs a). immediately after post-operative admission on the icu a pa-catheter ,was inserted under fluoroscopy via the right jugular internal vein into the hepatic vein contralateral to the resection area. hepatic venous and arterial blood samples were drawn every two hours. shvo was correlated to the clinical course, macro hemedynamics, abgs aug other established lab parameters. results: in out of attempts the catheter could be placed correctly. in four cases after right hemihepatectomy the left hepatic vein could not be intubated due to a dorso-lateral tilting of the left liver. this is also reflected in a significantly longer time of fluoroscopy for catheterization of the left hepatic vein ( . _+ % rain vs. . + . rain; p < . ). the procedure requires a total of between and minutes. relevant clinical complications were not observed except for short term supraventricular arrhythmias during passage of the catheter through the right atrium. hemodynamics and pulmonary function could be considered normal in all individuals at time of measurement. shvo showed a span from . % to . % with a mean of . % -+ . %. the following statistically significant findings could be obtained: (a) patients with liver cirrhosis showed a significantly lower shvq than patients without ( . % • . % vs. . % • . %; p < . ). (b) a negative correlation between shvo immediately after operation and the duration of intraoperative hepatic vascular occlusion could be observed (r = - . ; p < . ). this correlation could also be seen for the first post-operative hours (r = - . ; p < . ). (c) a negative correlation between shvo and the difference between arterial and hepatic venous lactate levels was found (r = - . ; p < . ). conclusions: the routine measurement of shvo appears to be a promising extension of post-operative monitoring after major liver surgery. it is a safe method easily feasible on any major surgical icu though relatively time consuming. a further validation of this method is necessary in larger studies. therapeutic recommendations on the basis of shvo findings cannot be given yet. methods: in cases after major liver resection, in which abnormally low readings of shvo suggested an impaired hepatic blood flow, pgi was applied at a dose rate of ng/kg/min. as shvo can be considered an indirect parameter for hepatic blood flow, the effect of pgi infusion on shvo was measured. moreover, the changes of macro hemodynamics and pulmonary function were monitored. results: before the application of pgi z mean shvo for all patients .was . % ( - - - ). in three cases without major structural alteration of the remaining liver tissue the continuous intravenous administration of pgi lead to a sustained increase of shvo z to an average of . % ( . - , ). the postoperative course in these three cases was uneventful. in two cases with compensated liver cirrhosis after hepatitis c no change in shvoz under pgi infusion could be observed. both patients died and days respectively after operation in protracted liver failure. side effects of pgi included a slight decrease of systemic and pulmonary vascular resistances. consequently map decreased by up to % as did intrapuimonary right-left shunt increase. in none of the observed patients did these side effects posed a limitation of continuous application of pgi z. conclusions: in patients without structural alteration of the liver the systemic application of prostacyclin at a dose rate of ng/kg/min could significantly increase an abnormally low hepatic venous oxygen saturation after major liver resections, tn two cases of severe liver cirrhosis a similar increase could not be observed. after first clinical investigations and with the results of recent studies in animal further controlled clinical studies of prostacyclin in the postoperative management after liver surgery appear justified. any delay in gastric emptying can promote micro-aspiration and give rise to ventilator associated nosoarnnial pneumonia. h -receptor antagonists have been suspected of promoting pneumonia by changing the gastric ph. in a few tri',ds on humans ranitidine was noted to delay gastric emptying. the aim of this prospective, randomised, blinded study was to evaluate in a ventilated icu population if there was a difference between cimetidine (c) and ranitidine (r) on the gastric filling index (gfi conclusion: in this population there was no difference in gfi between c and r; however the age and creatinine were significantly different and could have favoured the c group. also the very long t/ could have hidden smaller differences between c and r as has been described in volunteers. between april , and april , , patients with severe acute pancreatitis were admitted to participating hospitals. patients were entered into the study if severe acute pancreatitis was indicated, on admission, by multiple laboratory criteria (imrie score >_ ) and/or computed tomography criteria (balthazar grade d or e). patients were randomly assigned to receive standard treatment (control group) or standard treatment plus selective decontamination (norfloxacin, colistin, amphotericin; selective decontamination group). all patients received furl supportive treatment, and surveillance cultures were taken in both groups. results: fifty patients were assigned to the selective decontamination group and were assigned to the control group. there were deaths in the control group ( %), compared with deaths ( %) in the selective decontamination group. (adjusted for imrie score and balthazar grade: p = . ). this difference was mainly caused by a reduction of late mortality (> weeks) due to significant reduction of gram-negative panreatic infection (p = . ). the average number of laparotomies per patient was reduced in patients treated with selective decontamination (p < . ). failure of selective decontamination to prevent secondary gram-negative pancreatic infection with subsequent death was seen in only three patients ( %) and transient gramnegative pancreatic infection was seen in one ( %). in both groups of patients, all gram-negative aerobic pancreatic infection was preceded by colonization of the digestive tract by the same bacteria. reduction of gram-negative colonization of the digestive tract, preventing subsequent pancreatic infection by means of selective decontamination, significantly reduces morbidity and mortality in patients with severe acute necrotizing pancreatitis. ieco by sodium hypochlorite (nacio) infusion is considered to be a model of microsomal oxidation in liver on cytochrome p- . active c provides oxidation of toxic metabolic products in the blood and exfused during plasmapheresis plasma, and also hydrophobic to hydrofilic transformation of substanses. sterile nacio in necessery concentrations was obtained by electrolysis of saline ( , - , % naci solution) in electrochemical set e~io- (russin,moscow). methods: . the nacio in concentration ragfl ( - ml/ h ) was administred into central veins in patients with extensive peritonitis and endotoxicosis - /t. erytrocytes resistance to nacio, circulating blood volume glycemia and hemostasis were initially estimated. . after plasmapheresis exfused toxic plasma was mixed with nacio conccantration of i mg/t in : ratio in sterile "hemacons".the effectiveness of plasma detoxication and possibility of its reinfusion were evaluated by determination of albumin effective concentration (eca g/l), the concanlration of medium molecular oligopeptides (mm , ) and other biochemical tests (bilimbin, creatinine, carbomide and so on). results: . the intravenous administration of nac excels detoxicative effect of hemosortion by - % provides effictive presentation of protein components and blood cells and improves the transport function of albumin by %. . the return of exfused plasma after its purification ieco was - %. only the remaning - % of deficient plasma were compensated by fresh cryoplasma and albumin solutions. ischemic hepatitis (ih) is a severe complication in critically ill patients. acute circulatory failure of multiple etiology can lead to splachnic hypoperfusion and cause acute and reversible anoxic damage. over a period of mos pts, m and f, mean age + . yrs developed liver disease compatible with ih. eight pts had a documented hypotensive episode (six pts with septic shock and two hypovolemic shock), while cardiogenic pulmonary edema in the absence of hypotension was responsible for ih in the remaining four pts. all the pts had a rapid striking elevation of ast, &lt and ldh with equally rapid resolution of these parameters to near normal wimin days (mean . ). the mean peak level of ast, alt and ldh was iu/l (range to ), iu/l (range to ) and iu/l (range to ) respectively. serum total bilirubin levels rose transiently with a moan t:eak level of . mg/dl (range . to . ), while altered coagulation paran-,ete's (pt> . times normal) was observed in four pts and clinically significant coagulopathy with fibrin degradation products occurred in one pt ( . %). renal impairment (cr> . mg/dl) was manifest in all pts; six pts developed non-oliguric renal failure ( %) while two pts required hemodialysis. ten lots required vasoconstrictor inotropes [dobutamine (range - pg/kg/min) and dopamine (range - pg/kg/min), while replacement of circulatory blood volume was performed in two pts with hypovolemic shock. eight lots expired ( . %), but none died as a direct result of hepatic damage. the mortality rate was higher among pts with concurrent renal failure ( %). it is concluded that: ) ih is not uncommon complication in the icu with the prognosis depending on the underlying disease. ) clinically significant coagulopathy is uncommon complication of ih. ) titration of inotropes is required to obtain optimal cardiac output support and subsequently liver blood flow. it is difficult to ascertain the perfusion of free flaps such as jejunal loops after surgery. objectives: to assess ischaemia as evidenced by intramural ph of jejunal free flaps used for reconstructive surgery following total pharyngolaryngectomy. methods: the sigmoid ph tonometer ( tonometrics inc.,usa ) was used to monitor intramural ph of the jejunal free microvascular flaps ( phig ) in patients who underwent total pharyngolaryngectomy. a standard general anaesthetic was given and all patients were admitted to the icu for controlled ventilation and monitoring. all had similar postoperative care. phig was measured pre, post-revascularization of the flap and on icu admission, , and hours postrevascularization. objectives: to classificate the wide spectrum of itc of anp into distinct pathophysiological patterns according to presentation and course. patients (pts) and methods: pts, ~( , %), ( , %) were admitted in the icu because of anp and acute respiratory failure(arf), ilean age: , • years. hean stay in icu: , • days. pts were operated, of them twice. hean value of ranson's scale: , • ( - ). we analyzed hemodynamic measurements,arterial blood gases(abg), x-ray findings(xrf), ct-scans and operative records. results: patterns of pleuropulmonary complications were identified: a)early hypoxia without xrf - pts. b)early ards with typical xrf - pts( died), c)early arf with xrf(atelectasis,infiltrates)- pts( died). d)late ards with typical xrf- pts( died), e)pleural effusions in various combinations with the above patterns - pts. overall mortality rate: / = , %. conclusions: l)frequent x-rays and abg are important for the classification of itc of anp. )even though patterns of classification in anp are not clearly distinguishable,they facilitate an anticipatory management. )deterioration of abg and xrf indicates that preventive measures for arf must be intensified and agressive surgical therapy is required. )delay of surgical therapy is related to worse prognosis(p<o, ) and prolonged hospitalisation time(p<o,ol). in the contrary, the early timing of the operation before infection and extrapancreatic necrosis is essential for a better prognosis (p<o, ). objectives: the development of cholestasis during intensive care treatment is allied with an inferior prognosis. this study investigates the sensivity, specification and also the positive and negative forecast of patients survival -exemplary for bilirubine. methods: during a period of months all surgical patients on icu were registrated prospectively (n = ). for documentation of disease development a standard foldcrform based on a computer-data-system was used. the results of this kind of documentation showed aapprax. , m!ll. of single patient informatioas. results: of patients didn't suffer from liver disease or have any operation on liver or bile tract. of them have had a normal scale of bilimbine in the postoperative period, a higher scale of bilirabine was regisu'atcd by patients. at a ,,cut-off" of rag% (total-bilirubine) the sensitivity was , , specivity , , positive predicive level , , negative predictive level , for survival criteria of a patient. the max. reached level of bilirubine, also the daily increase turned out almost the same results as they were found for other parameters nf cholcstasis like ap or gamma-gt. objective: the aim of this experimental protocol was to evaluate the morphological and functional parameters of isolated pig liver grafts, perfused in an extracorporeal liver support system. methods: the system consists of the graft liver, a membrane oxygenator (oxygenation surface . cm z, flow= itlmin), a heater, a centrifuge pump and a fluid reservoir. twenty pig livers, mean weight gr (min , max gr) were obtained and after a mean cold ischemia time of min were perfused fo} a mean of . h (min . , max h). perfusion solution consisted of r/l and hemacell. inflow to the graft liver was performed through the portal vein at a mean pressure of ( - ) mmhg at ~ while outflow was secured through the suprahepatic inferior vena cava. during perfusion the following parameters were evaluated through pre-and posthepatic hourly (to-t ) sampling: po , " + + " pco , ph, hco -, na , k , ca , osmolality, glucose, lactate, ast, alt, alp, u bilirubin and coagulation factors i, v and viii. biopsies were obtained periodicallty. b_p_~: results were as follows: mean ph fell from . at t o to . at t while mean output po fell from at t o to at t . mean output ast values increased from at t o to > at t while mean output alp values increased from . at t o to at t . mean output k + values increased from . at t o to > at t . histology revealed lesions of ischemic necrosis, more prominent after t . conclusion: results show that the isolated liver graft presents satisfactory function and morphology at least for a five hour perfusion period in the described extracorporeal circuit. correction of ph contributed to an increase in bile flow. between and the practice of transplantation has changed drasticaily in switzerland -besides kidneys also hearts, heart and lung, lung, iiver and pancreas transplantation has started in several centers. major information efforts have been made, organ exchange rules were set up and a national coordination center was initiated. the aim of this retrospective single center study was to assess the influence of transplantation on organ donation. in the past eleven years organs were donated from potential donors i single, multi organ donations) analysis of refusal was evaluated categorized into medical and/or familiar reasons. the number of potential donors increased from ( ) ,to ( ) with a concomitant drastic reduction of donations from % in to % in ; amounting to a net unchanged number of donations over the last years ( = ; = ) . the import and export of donor organs was balanced since the introduction of the national coordination center. in contrast multi organ donation increased from % in to % in despite of the more stringeant selection criteria, in conc]usion the introduction of a full range of transplantation procedures at several new university programs and the increase of multi organ donation has not had the forecasted impact on organ donation despite a sustained informative and promotional campaign, objective: monitoring hepatic venous oxygen saturation (svho ) provides online information about hepatic-splanchnic oxygen supply-demand ratio [ ]. previously, x~ reported hepatic venous catheterization in patients undergoing orthotopic liver traru~lantation (olt) [ ] . in the present study, we assessed the effects of nitroglycerin (ng), a vasudilator that affects the venous capacitance vessels more than arterial vessels and prostaeyclin (pgi , flolan r~, wellcome, uk), an arterial and splanchnic vasodilator on hemodynamies and hepatic venous oxygen saturation (svho ) in human liver transplantation. methods: with institutional approval and informed consent, consecutive patients, mean age - -_ years, were studied following olt. postoperatively, fiberoptic pulmonary artery catheter was inserted into the right hepatic vein. timed infusions of ng at a rate of . gg/kg/min and pgi at ng/kg/min were initiated for a rain period. each sequence was followed by baseline therapy for rain. results are expressed as mean=tsd. statistical analysis was performed using friedman's-two-way-anova-test, significance was accepted at p< , . results: ng at . gg/kg/min induced a decrease of mean arterial pressure (map) ( _ [baseline] vs. + mmhg) and pulmonary artery wedge pressure (pcwp) ( j: [baseline] vs. : mmhg). cardiac index (ci) ( - vs. + l/rain/m ), oxygen delivery index (do i) ( -+ vs. + mgnfin) and svho ( _~ vs. -l-_ %) were decreased (p< . ). pgi at ng/kg/min induced a reduction in map ( • nm~. _g) and pcwp ( + mmhg). ci ( _+ l/rain/m ), do i ( : ml/min) and svhoz ( + %) were increased (!o< . ). vasedilatation induced by ng decreased systemic oxygen supply and impaired splanclmie oxygenation. pgi increased systemic oxygen delivery in parallel with svho , suggesting a corresponding improvement of hepatic-splanchnic okygenation. thus, if vasedilator therapy is indicated in th orient receiving liver grafting, pgi appears to be advantageous. however, due to its platelct aggregation inhibiting properties, the usefulness and safety of pgi in olt patients has still to be determined. objectives: to analyze the effect of steroid treatment given to donor on the early function of transplanted kidney. methods: from january, until now donors were involved into this prospective study. every other donor was treated with mg/kg solu-medrol one hour before organ retrieval. according to the steroid treatment of the donor the recipients were divided into two groups: group -steroid pretreatment goup (y~= ), and group -control group (n= ). the donors and the recipients were treated using the same kidney transplantation protocol onl~r the adults, and the first cadaver kidney transplanted patients were involved into the study. the daily routine parameters were analyzed pre-and intraoperafive, and on the - th, th and th postoperative days. results: we could not show any clinically important differences between the two groups in respect of donor parameters. preoperative, the patients in group had slightly lower ereatinin level ( -+ g.,non vs. -+ gmol/ ) which persisted into the early postoperative phase. the values of the other examined pre-and intmoperativc parameters were almost the same. during the first postoperative days the patients in group i needed less diuretics (furosemide and renal dose of dopamine) and their sodium excretion was closer to the physiological range than in group . the other parameters did not differ significantly. the less furosemide need in group ! pe~isted to the end of the first month. conclusions: according to our data the steroid treatment of the donors improves the early function of the transplanted kidney in some respects. to prove the real benefit of the donor steroid treatment needs more data and further analysis. objectives: severe infections may compromize the outcome of liver transplantation..determination of new parameters may increase the knowledge of pathophysiologic mechanisms and may lead to changes in postoperative therapeutic management of patients at risk. methods: between august and september , patients with transplants were monitored for cytokines and extracellular matrix pammeters on a daily basis. serious infections (n= ) included microbiologic evidence and more than secondary organ failures. patients with cholangitis (n=ll) or uneventful postoperative course (n= ) referred as control groups. results: -year patient survival was . % ( / ): patients died due to serious infections, while died for other reasons. mean bilimbin, stnf-rii-, ifn- -, il- -, il- -, il- -, laminin-and neopterin levels were significantly elevated in patients with serious infections compared with patients experiencing mild cholangitis or with an uneventful postoperative course. a further increase of all parameters was observed in patients who subsequently died; tnf-ri/: _+ pg/ml vs • pg/ml; ifn- : _+ pg/ml vs . -+ . pg/ml; il- : -+ pg/ml vs -+ pg/ml; il- : -+ pg/ml vs _+ pg/ml; il- : _+ pg/ml vs • pg/ml; laminin: -+ ng/ml vs -+ ng/ml; neopterin: _+ nmol/ vs _+ nmolb for non surviving vs-surviving patients. a significant decrease of sialic acid yeas observed in patients with serious infections; and a further decrease occurred in patients who subsequently died: -+ mg/l vs • mg/ . conclusions: the increase or decrease of various cytokines and extracellular matrix parameters may be indicative for severity of infectiolx routine monitoring of these parameters may improve current diagnostic tools and poss~ly lead to changes in therapeutic management of patients at ~k. objectives: evaluation of the cytokine network after liver transplantation may give some insight in pathophysiologic mechanisms of rejection and may lead to detection of patients at high risk. methods: patients with transplants were monitored for various cytokines on a daily basis between august and september . rejection was assessed by histology in combination with clinical signs of rejection and laboratory investigations. results: during the first postoperative month, patients ( . %) developed rejection; patients were successfully treated with methylprednisolone (steroid-sensible rejection), while further patients required additional treatment with fk or okt (steroid-resistant rejection). patients subsequently developed chronic rejection. mean levels of various cytokines and extracellular matrix parameters including tnf-rii, ifn- , il-ib, il- r, il- , il- , il- , hyaluronic acid and neopterin were significantly higher in patients with steroid-resistant than in patients with steroid-sensible rejection. a further increase of some parameters was observed in patients who subsequently developed chronic rejection; bilirubin: . -+ . mg/dl vs . -+ . rag/all; tnf-rii: -+ pg/ml vs _+ pg/ml; il- : +- pg/ml vs -+ pg/ml; neopterin _+ nmol/ vs -+ nmol/ ; hyaluronic acid: _+ ~tg/l vs _+ ~tg/l for patients with chronic versus patients with acute steroid-resistant ~ejection. sialic acid levels decreased in patients with acute steroidresistant rejection; and a further decrease was observed in patients who tieveloped chronic rejection: _+ mg/l vs _+ mg/ . ~onclusions: various cytokines and extraeeuular matrix parameters were indicative of severity of rejction. the extensive increase of bilirubin, tnf-ii, il- , hyaluronic acid and neopterin may indicate subsequent chronic ection. monitoring of these parameters may, therefore, lead to changes in immunologic management after liver transplantation. background : combined kidney and pancreatic transplantation is being performed with increasing frequency in patients with diabetes mellitus and renal failure, as it offers more chances of success and better results than kidney transplantation alone. mycotic arterial aneurysm constitutes a devastating complication following pancreatic transplantation. all cases of mycotic arterial aneurysms have been however reported with exocrine pancreatic drainage into the gastrointestinal tract. intervention : we describe a series of consecutive whole kidney-pancreas transplantation performed at the university of geneva hospitals ( beds) between december and may . exocrine pancreatic drainage into the bladder (epdb) was performed to improve early detection of rejection episodes. epdb was hypothesized to reduce the risk of contamination from the gastrointestinal tract and the subsequent possible occurrence of potentially fatal infectious complication. in all patients the dual transplantation was performed through a median incision according to the procedure described by nghiem. results : two out of the patients who received kidney-pancreatic transplant developed arterial mycotic aneurysms and days following surgery. aneurysms developed at the site of the arterial anastomosis used to rearterialize the homograft. both patients had peritonitis caused by candida albicans requiring surgical drainage and intravenous antifungal therapy. rupture with hemorragic shock occured in both patients leading to graft removal in one patient, and three episodes of lffetreateniug hemorragic shock followed by graft failure and removal days after transplantation in the other. conclusion : arterial mycotic aneurysm constitutes an early, lifetreatening complication of kidney-pancreatic transplantation; it mandates graft removal. although exocrine pancreatic drainage into the bladder consitutes a definitive advantage for caller diagnosis of graft rejection, it does not eliminate the risk for retrograde colonization and subsequent severe infection in our experience. s. bocharov, i. teterina, regional clinical hospital, irkutsk, russia acute profound loss of blood can result from the very different injuries and hepato-pancreato-duodenai operations enter such a rank. ill-timed and inadeguate correction of operation hemorrage is one of the reasons for postoperation complications, including polyorganic insufficiency. the pathogenesis seems to be very complex. in early stages of bleeding the liquid enters the vessel bed, followed by hypoproteinosis and hematocrit fall. however, as decompensation develops, the fluid leaves the vessel system in the result of increasing postcapillary resistance and lowering col-ioidnooncotic blood pressure (cop). the resulting hypovolemia causes primarily acute disturbance of central hemodynamics and then of microcirculations and transcapillary exchange. central hemodynamic failure after acute loss of blood manifests itself through cardiac output lowering and capillary blood flow deceleration. taking into consideration, that % is critical value for cpv loss and for cev it is %, we consider arising the level of cop to the immediate task. cop raising allows to normalize transcapillary exchange, which we assess through cop and mcp (mean capilary pressure) gradient. the next task is to make up for globular volume till homeostasis providing level. considerable attention is given to catabolism inhibition and maximum possible enegry provision. control over high proteolitic activity of blood and callicreinkinin system activity implies direct proteases inhibitors. reologic, membrane stabilizing, antihypoxanthine and anticoagulant therapies are obligatory. virehow clinic, dept. of surgery, humboldt university berlin, germany regarding a high mortality up to % of fulminant hepatic failure orthotopic liver transplantation seems to be the only promising therapeutic approach in many cases. this study shows experiences from a transplantation center. between june and april patients suffering fulminant hepatic failure were admitted to our surgical intensive care unit all patients showed severe liver dysfunction with grade ii to iv encephalopathy. after a period of diagnostics and conservative treatment ranging from few hours to days (mean . days) we reported of these patients as possible organ recipients to eurotransplant. all of these patients were transplanted within hours, ( %) of them even within hours. the principal aetiologies were hepatitis b ( ), hepatitis c ( ), nanb hepatitis ( ), mushroom poisoning (amanita phalloides ). after transplantation patients suffered from initial-non-function and underwent re-transplantation. the one-year-survival rate was %, patients died within months after transplantation due to various reasons. patients were not referred for liver transplantation. of them never met transplantation criteria, improved by conventional therapy and could finally be discharged from hospital. the known reasons for liver failure in this group were mushroom poisoning ( ), paracetamol intoxication ( ) and fulminant hepatitis a ( ). patients suffering from fulminant hepatitis ( ) or intoxication ( ) were excluded from emergency liver transplantation for various contraindications. of these patients ( %) died despite conventional intensive care. we don't know if some of the patients in the transplantation group would have survived without transplantation, because whenever we decided on transplantation we could perform the operation within hours. but the good survival rate in the transplantation group ( %) the % recovery rate in the group, where there was no transplant-indication in our opinion and the fatal outcome ( % mortality) in patients with contraindications are an encouraging proof of a successful therapeutic strategy in acute liver failure. these results are based on a close cooperation between experienced transplant surgeons, hepatologists and intensive care doctors, using sophisticated laboratory and imaging techniques in a specialized center. introduction: during brain death patients suffer from multiple endocrinologic disturbances. one of the most important are those related with thyroidal axis. it is well described the euthyroid sick syndrome whose more frequent pattern consist of decreased triiodothyronine (t ), increased reverse t (rt ) with normal levels of tetraiodothyronine ( " ) and tsh, this lacking in " " levels lead to a change from aerobic to anaerobic metabolism which results in tissular damage. objective: .to study thyroidal pattern in brain death patients potential organ donors. .to avoid organ impairment by administration of t . .to study the hemodynamic and hormonal changes after the administration of t in these patients. material and methods:population: brain death patients of any etiology potential organ donors admitted to the intensive care unit. patients were classified in hemodynamically stable (group ) and unstable (group ). group received a bolus of . p.gr/kg. and a perfusion at a dose of - . p.gr]h of t . hormonal assays: total t (tt ), total " (tt ), tsh. fxee t (ft ), free " (ft ) and rt were determine at the moment of clinical brain death ( hrs) and in group two these assays were repeted at hours , and . results: patients ( male) with a mean age of years (range to yrs.) were studied. the clinical brain death was confirm later with other explorations (eeg, doppler). there were patients in group ( , %) and patients in group ( , %). hormonal pattern: at the moment of brain death tt was normal in cases ( , %) and decreased in i ( , %); tt was normal in patients ( , %) and decreased in ( , %); ft was normal in cases (i , %), decreased in ( , %); fl' was normal in patients ( , %) , decreased in ( , %) .rt was normal in cases ( , %) and increased in cases ( , %). there were no statistically significant differences in hormonal pattern between the two groups. only t levels at hours , and were significant in group . in the cases with ft decreased, the tt was normal in ( %) and decreased in ( %), tt was decreased in ( , %) and normal in ( , %), tsh was decreased in i ( , %), normal in ( , %) and increased in i( , %) and ft decreased in ( , %) and normal in ( , %) and rt was normal in ( , %) and increased in ( , %). there were no statistically significant differences in cardiac index, vascular resistances and pulmonary shunt before and after the administration ef t . conclusions: . the hormonal pattern most often find in brain death patients was: normal tt , decreased tt , normal tsh, decreased ft , normal fr and normal rt . . there were discrepancies in the values of ft and tt . there were no statistically significant differences in hemodynamic and pulmonary parameters. objectives: magnetic resonance angiographie (mra), a non-invasive procedure, provides flow-related information additionly to the anatomy of the vascular system. measurement of signal intensity and edge detection of vessel structures permits to calculate blood flow velocity and vascular diameters. we examined whether cerebral hemodynamic changes by altering the arterial pressure of carbon dioxid (pace ) could be detected by mra. methods: following institutional approval and informed consent, mechanically ventilated patients without elevated intracraltial pressure underwent mra with defined periods of hyper-, hypo-and normoventilation (pace : , , mmhg; arterial blood gas probes; avl). mra was performed with a . tesla magnetom (vision, siemens). two different mra techniques were used: a conventional time-of-flight- d-angiography (tr: ms; te: ms; fl: deg; slab: mm) for vessel diameter detection and a flash- d-gradient-echo-sequence (tr: ms; te: ms; fl: dog) for measurements of blood flow velocity. an axial view parallel to the ac-pc-iine (anteriorposterior-commissur-line) was used for repeated imaging of identical regions of interest toi) of the proximal part of the internal carotid (ica) and middle cerebral artery (mca) as well as of peripheral branches of the mca and the posterior cerebral artery (pca). results: changes of pace correlated with changing signal intensities, whereby under hyperventilation a decrease of , % (p . ) and under hypoventilation an increase of . % (p . ) was observed compared with normoventilation. blood pressures were stable throughout the whole study period, pace dependent changes in vessel diameters were more pronounced in peripheral branches of mca and pca. a change from normo-to hyperventilation produced a decrease in proximal vessel diameter of - . % (p _< . ) and in peripheral diameter of - . % (p _< , ). a change from normo-to hypoventilation produced an increase in proximal diameter of + . % (p < . ) and of + . % (p -< . ) in peripheral diameter. conclusions: pace related changes of cerebral vessel diameter can be easily detected by mra without injecting a contrast agent. the results confirm that co -reactivity is more pronounced in peripheral cerebral vessels, which are subjected to greater changes in diameter than major basal arteries. hyperventilation leads to a decrease and hypoventilation to an increase in signal intensity thus reflecting the corresponding changes in blood flow velocity, intensive care unit (icu) of "kat" hospital, athens, greece, ob!ective$; the value of bronchoscopy in pulmonary atelectasis of icu patients is under question the presence of an air bronchogram sign in xrays, which is considered as evidence of central bronchus patency, is referred in several studies as a negative criterion for bronchoscopy, whereas its absence as a positive one. it is also referred that air bronchogram sign correlates with delayed resolution of atelectasis, probably because of obstruction of many periferal airways (not central). the purpose of this prospective study was the evaluation of the air bronchogram sign on frontal chest film as a negative criterion for bronchoscopy and as criterion of delayed resolution of atetectasis, methods: icu patients with atelectasis were studied prospectively. they underwent bronchoscopy, bronchoscopic findings, presense of air bronchogram sign, and outcome of atelectasis were recorded, correlations were made, between: ) bronchoscopic potency of airways and air bronchogram sign } resolution time of atelectasis and broncoscopic potency of airways. ) resolution time'of atelectasis and air bronchogram sign, methods of statistical analysis were the t-student test and the chi square test, results:the patients were , men women , seventeen patients had atelectasis of whole lung, of upper lobe, and of lower lobe. ten patients had atelectasis in right and in left lung. eight from patients had air bronchogram sign in x-ray, there was no statistical correlation between air bronchogram sign and bronchoscopic potency of airways [ from patients with air bronchogram sign ( %) and from without air bronchogram sign ( %), had bronchoscopic potency of airways, p> . ], resolution time of atelectasis didn't correlate statistically with bronchoscopic potency of airways (mean resolution time in patients with bronchoscopic potency , days and in bronchoscopically closed bronchi , days, p> , ). there was also not a statistical correlation between resolution time of atelectasis and air bronchogram sign (mean resolution time in patients with air bronchogram sign , days, and without air bronchogram sign , days. p> ). conclusion~i; the presense of an air bronchogram sign in x-ray of icu patients with atelectasis, does not coexist obligatorily with bronchoscopic patency of airways and cannot be used as a negative criterion for bronchoscopy, neither as a criterion of delayed resolution of atelectasis. th. wertgen chest sonography (cs) is routinely used in our department to examine icu patients with clinical symptoms of pulmonary embolism, pneumonia, pleural effusion or unclear chest pain. we perform cs with a sector transducer ( . mhz) and a linear transducer ( . mhz) using acuson xp/ c. the sonographic signs of pulmonary embolism and infarction are most well demarcated, mainly wedge shaped and triangular pleural based lesions, more roughly structured, observed with a hyperechoic reflex in the center corresponding to the bronchitic (fig. ) . pneumonia is characterized by homogenously hypoechoic, wedge shaped parenchymal lesions, containing air or fluid bronchograms; they move with respiration (fig. ) . pleural effusions are spaces of various echogenicities, from anechoic to homogeneously echogenic, which may contain floating strands or complex septa, located between visceral and parietal pleuras (fig. ) . from march to april we did examinations by cs in icu patients ( male, female; age from - ). patients examinations pulmonary embolism pneumonia pleural effusion us-guided thoracic punctions were performed in patients. in two patients we found pneumonia or pleural effusion caused by a lung carcinoma. another two patients showed a normal cs (diagnosis: inflammation of the gall bladder, inflammation of the myocardium). conclusion: cs is a very useful method for icu patients with chest diseases. it takes less time and is less expensive than ctand sometimes of a higher diagnostic value than x-ray. last but not least cs is invaluable for the icu patient, because the examination is done save and quickly at bed side and the results of cs are very helpful in diagnoses and treatment. results : inter-observer reliability was evaluated as an % concordance. results of the tee classification were : class : n = ( %) ; class : n = ( %) ; class : n = ( %) ; class : n = ( %) class : n = ( %). therapeutic implications of tee in class patients were : cardiac surgery in patients (two cases of acute mitral regurgitation, two valvular abscesses and one hematoma compressing the left atrium), discontinuation of peep in one ventilated patient with an atrial septal defect, weaning of mechanical ventilation in one patient with an atrial septal defect, prescription of antimicrobial therapy in patients with endocarditis and prescription of anticoagulant therapy in patients with left atrial thrombus. the only noteworthy complication was a case of spontaneously resolving supraventrieular tachycardia. conclusion : tee is safe and well tolerated, and is useful in the management of icu patients with shock, unexplained and severe hypoxemia or suspected endecarditis. the aim of this study was to determine whether ultrasound guidance can help interns to improve the results of jugular vein access in icu. methods : in a prospective and randomized study, we compared, in patients admitted to the icu, an ultrasound-guided method (ultrasound group : patients) with an external landmark guided technique (control group : patients). all jugular vein accesses were performed by young interns with an experience of < procedures. results : internal jugular cannulatian vein was aci~ieved in all patients in the ultrasound group and in patients ( p.cent) in the control group (p < . ). average access time was longer in the control group ( • sec. vs • see. ; p = . ) and puncture of the carotid artery occurred in patients in each group (p = . ). patients ( p.cent) in the ultrasound group and patients ( p.cent) ia the control group (p < . ) were cannulated in rain. or less. the cannula was therefore unabie to be inserted within minutes in patients in the control group, with failure of eannulation in of these patients ( p.cent). failure was due to thrombosis (n = ), small calibre of the internal jugular vein (< ram) (n = ), abnormal vascular relations (n = ) or cervical irridation (n = ). among the primary failures of cannulation, an internal jugular vein catheter was able to be inserted in cases by an experienced physician on the side initially selected and with ultrasound guidance in cases. the catheter was inserted into the contralateral internal jugular vein under ultrasound guidance in the remaining cases. jugular cannulation was obtained at the first attempt in p.cent in the control group and p.cent in the ultrasound group. conclusion : ultrasound guidance improved the success rate of jugular vein cannulation by inexperienced operators in icu patients. when the internal jugular vein has not been successfully eannulated within minutes by the external landmark guided technique, the authors recommend the use of the ultrasound guidance. in the majority of cases right atrial or ventricular thrombi represent pulmonary emboli in transit. these may be fatal in patients (pts) treated conservatively with anticoagulation only. in literature the incidence of right heart thrombi in pts with proven pulmonary embolism (pe) is said to be in the range of - %. extremely mobile, long, worm-shaped masses in the right heart cavities carry an especially high early thrombus-related mortality rate which ranges from - %. current therapeutic strategies favour fibrinolytic therapy with consecutive anticoagulation. we report five cases ( male, i female, - years) of right heart and pulmonary thromboembolism. in these pts diagnosis and regression of thromboemboli following systemic intravenous lysis therapy with recombinant tissue-type plasminogen activator (rt-pa) was documented by transesophageal echocardiography (tee). a submassive pe occured in pts, a massive pe in pts. one patient (pt) had a cardiac arrest. in all cases tee clearly identified the extensive thrombns formation in the right-sided cavities of the heart and in the central pulmonary artery in cases. all pts were treated with mg rt-pa, pts in a front-loaded regimen over minutes, pt over minutes, and, due to the life threatening situation, in one case a bolus injection as ultima ratio was performed with no intracerebral bleeding complication. regression of thromboembolic masses after fibrinolytic therapy was demonstrated by transthoracic and transesophageal echocardingraphy after to hours. all pts survived and were put on coumadine, pt developed an intracerebral bleeding with persistent hemiplegia. conclusions: the use of thrombolytic therapy is highly efficacious for the therapy of pts with pe and concomitant right or ventricular thrombus formation. transthoracic and especially transesophageal echocardiography are powerful bed-side diagnostic tools for the immediate diagnosis and follow-up of successful treatment in this life-threatening condition. although widely used, catheterisation of the femoral vein in the groin using "landmark" technique is frequently complicated by accidental arterial puncture. suboptimal hygiene and patient discomfort are also associated with this technique. with regard to these last two factors cannulation of the femoral vein - cm below the inguinal ligament would seem an attractive alternative. as "landmark" technique is not possible for the cannulation of the femoral vein in this part of the thigh, ultrasound was used to locate the vessel and the results of this technique were evaluated. methods: a portable compact ultrasound device (site rite,dymax corp.) featuring a . mhz transducer (ultrasound depth - cm) fitted with a needle guide and a cm screen was used by residents with no previous experience in ultrasound guided cannulation. patients consisted of a surgical icu population. results: in patients catheters were introduced.in cases more than one ( - ) attempt was made and in patients the procedure was unsuccesfull due to the fact that the vessel was situated out of reach of the ultrasound (vessel depth > - cm), during the procedures one accidental arterial punction was registered. the catheters remained in situ for a mean of days (range - ) and were used for volume suppletion, medication, parenteral nutrition and haemodialysis.co-ionisation rates compared to those of subclavian catheters in our icu. in the first patients cases of asymptomatic thrombosis of the femoral vein were seer on ct-scans performed for other indications, in the following patients duplex scanning performed after removal of the catheter yielded another cases of asymptomatic femoral vein thrombosis. conclusions: ultrasound guided femoral vein catheterisation - cm below the inguinal ligament is a safe and simple technique that can easily be performed by residents without prior experience. the incidence and impact of thrombo-embolic complications associated with this technique are still subject to further investigation. objectives: to estimate the cost of antibiotherapy (ab-cost) in a multidisciplinary -bed greek icu and to correlate ab-cost with total cost of drugs and consumables and with patient's outcome, severity of illness and type of admission. methods: prospective data from consecutive patients admitted to the icu from / / to / / were studied. a tick chart was designed to record all drugs, materials and consumables regularly used for icu patients, but did not include low price drugs and consumables, which are provided from hospital's pharmacy as stock and were included in a fixed icu cost calculated for a month period. the chart also contained demographic details and data necessary for the calculation of several illness severity scoring systems. obiectives: over years evaluate the necessary efforts and expenses to implement a cis in the routine of a -bed stcu. methods: in june a commercially available, unix-based cis was installed on a -bed surgical icu. the goal was a paperless documentation at the bedside. after more than years clinical experience two aspects were investigated: what effort is necessary to install and support a cis, and what is the benefit for patients and personnel on the icu? results: the installation and support of a full-fledged cis requires a considerable effort: (a) the conceptual framework for the cis has to be defined. this includes the definition of documentation standards, as well as nursing and therapeutic standards, which is the essential basis for the configuration of any cis. (b) configuring a cis, i.e. "fine-tuning" it to the user's specific needs, is always a laborious task. moreover, constant maintenance is necessary. these tasks require the following personnel: experienced health care professionals for defining the conceptual framework, - trained health care professionals for configuration, system administrator. on a single icu ( - beds) these are not considered full-time jobs. (c) training is best done employing the "train-the-trainers" approach. (d) beside the necessary amount of man power and money to install and purchase a cis, administrative and mis support is needed, especially when interfaces to the hospital and laboratory information systems have to be set up. in general, a cis needs the commitment of all people involved. without a really professional approach with a longterm goal any major cis can turn into an unnecessary but inevitable night mare. after years clinical use and a thorough implementation of a cis on a major sicu it can be said that full-fledged cis offers an opportunity to dramatically improve the working environment on an icu. moreover, it adds to patient safety, quality of care and cost efficiency in one of the most advanced and expensive areas of medicine. conclusion: a major investment in man power and money is necessary to install and maintain a full-fledged cis. a sincere professional commitment to the goals of a cis is necessary. in exchange, a well configured and well maintained cis dramatically improves the quality of therapy and care on the icu. even return of investment and financial profitability of a cis seem feasible todayl from the clinical perspective it appears that the users themselves are the central determinant whether a cis makes a dream come tree or turns into a night mare. objectives: to establish a relationship between the activities of the staff and the occurrence of auditory alarms on the i. c.u. ard to evaluate confusion between auditory alarms. methods: laboratory based studies which investigated aspects of confusion between alarms in current use on the i. c. u. the observational studies were conducted over an month period and examined the frequency and duration of alarms together with the concurrent activites being undertaken by staff on the unit. the laboratory based studies showed that there were enduring confusions between the alarms on various items of medical equipment, for example a ventilator alarm and an e. c. g. monitor alarm. the results of the observation studies demonstrated that alarms are activated when specific activities are being undertaken by staff. sounds could be used in future recommendations for alarms on medical equipment. suggestions are also discussed for improving and rationalising auditory warnings in the i. c. u. obiectives: we investigated inferior petrosal sinus (ips), the lowest affluent to jugular bulb (jb), as a possible source of contamination of samples in jb for monitoring oxyhemogiobin saturation (sjbo ). pulling back the catheter the oxyhemoglobin saturation usually rises indicating extracerebral contamination (jakobs en met al: j cereb blood flow metab ; : ). methods: the study was carried out on patients undergoing ips sampling to differentiate cushing disease from ectopic acth syndrome and to lateralize any resulting pituitary lesion. we studied the value of oxyhemogiobkn saturation high in jb (sjbo ), at ips (sipso ) and at mid jugular vein ( th cervical vertebra) (smj ) bilaterally. results: we found significant differences between right sjbo and both right sipso (p= . ) and right smjo ( p= , ) and between left sjbo and both left sipso (p= . ) and left smjo (p= . ) we did not fred any difference bilaterally. objectives: we studied various methods of receiving and editing of clinical datas in critically ill patients (different ethiology). patients were investigated in regional intensive care center. methods : the following datas were studied : anamnesis, status praesens objectivus ( organs and systems ) ,. clinical and biochemical markers of critical condition , datas of eeg ,rheography . the medical information complex contained : channel electroencephalograph, -channel roencephalograph, ad-converter ( analog inputs, bit resolution, k hz), ibm dx , software includes set of routines for spectral eeg analysis, eeg-mapping, correlative analysis, and brain bloodstream reg-monitoring (written in turbo pascal . ), expert programs for estimation objective and humoral patient status (written in clipper . ) and statistics. there were used following programme-language instruments : borland c++ . , nantucket clipper . , ca-clipper tools ii. as the methods of statistical processing of dates were used: t-students criterion , fisher criterion, methods of correlation analisis, calculation of the regression levels, dispersion analysis, results : there was created the optimal structure of hard and sofware complex of search steady objective regularity in dynamic of critically ill patients condition. conclusion : the created system allowed to value effectiveness of intensive care and give us new opportunities in study pathogenesis of systems disorders in critical condition . over a five year period a patient data management system has been installed which allows individualised patient data to be accurately collected. using this data a costing system has been developed which ascribes costs thus: . direct costs -drugs, fluids, consumables, interventions. these are ascribed to individual patients, according to data collected from the pdms. . indirect costs -energy, depreciation, admm costs, maintenance etc. these are summed for the year and ascribed as an overhead per patient day. n.b staffcusts contain art element of both cost types the aim is to make as many costs as possibie 'direct', hence 'activity costs' have been calculated winch comprise staff time, drugs and consumables -these are direct costs. these costs of patient care are then searnlessly integrated into the financial and budget management of the icu environment. it was found that by calculating costs in this manner % of the total cost of icu are captured within the 'direct' element, and so are able to be ascribed to individual patients. this is much more accurate than simply dividing the total costs of ~cu by the number of patient days. temporal costs (variations during patient stay) and cross sectional costs (cost differences between admitting specialities) were also noted with interest. results of the initial analysis of data captured by the system will be presented. little is known about the resource costs (not simply cash costs) of icu. even less is known about individual patient costs, with previous estimates of these costs varying widely. however, if cost effectiveness studies are to be undertaken accurate calculation of individual, group and total icu cost is an essential, prerequisite, which, via this system of costing, is now achievable. information about intensive care of cancer patients is limited in the literature, despite the increasing use of such facilities in oncology over the two last decades. in order to determine if and how critical care facilities can be used specifically for these patients, we performed a world-wide inquiry in anticancer centers selecting the hospitals by using the international directory of cancer institutes and organizations. we mailed a questionnaire to centers and we received responses ( . %). there was at least one uncological (i.e. with > % of cancer patients) icu in (% % an -year old woman with graves disease presents with sore throat, vomiting, diarrhea, sinus tachycardia at /minute and a temperature of ~ several weeks before, treatment with propylthiouraeil had been stopped (rash and fever) and replaced by methimazole and ledide prior to a minor surgery. however, both drugs were discontinued by the patient two weeks before admission. shortly after arrival in hospital, patient's condition progressed to respiratory failure (upper airway edema), delirium and shock requiring icu admission, intubation and resuscitation with fluids and vasopressors. white blood count was /mm ~ with neutrophils. patient's hemodynamic data showed initial hyperdynamic profile followed by low output state with decreased sv ( %) (n - %) and cardiac index ( , ) (n , - ). echocardiogram confirmed cardiac chambers dilation as previously described in thyroid storm. lithium carbonate, corticosteroids, antibiotics and beta-blocker perfusion were given. plasmapheresis was started. free t& (n= , - pmo/l) went from , to , after the first two pheresis. after a remarkable clinical recovery, sub-total thyroideetomy was done i days after admission. in life-threatening thyroid storm, plasmapheresis is a very effective therapy when anti-thyroid drugs are counterindicated. purpose: to compare the reliability of prognostic indexes in crhically iu patients admitted in an intesive care unit (icu) who had acute renal failure (arfi and were treated with different dialytic techniques. material and methods: patients were included in a prospective study from june to november . patients presented arf defined by creatinin serum leve(s greater than pmol/l and previous normal levels. patients were divided in three groups. group i (control) : patients with arf who did not receive substitutive techniques. group ih patients under intermittent hemodialysis (hd) or peritoneal dialysis (pd). group ii : patients under continuous hemodiafiltrstion (hf). the statistical analysis was chi-square test and analysis of variance. results: the table shows the results we obtained, we did not find any significant difference betwen the two groups of patients undergoing dialysis. d(fferences were observed only between group i and the other groups as shown below. we did not find any significant association between the theoretical mortality predicted and the observed mortality according to saps in the three groups. due to exposure to a wide variety of unpleasant stimuli, for example, tracheal suctioning, venipuneture and physiotherapy, most pataents admitted to the icu will require some form of sedation. this review will describe the suggested properties of an ideal sedative agent for use in the icu and review the current limitations of some of the available agents from this perspactive. methods used to quantify the level of sedation, such as the ramsay score, glasgow coma score, newcastle sedation score and visual analogue scores, and their deficiencies will be examined. consideration will be given to defining the optimal level of sedation and the circumstances under which sedation might be varied over the icu course will be discussed. preliminary results from an ongoing study examining the role of light versus heavy sedation and ischaemia in a cardiac surgical icu population will be presented. the pharmacceconomics of icu sedation will be briefly addressed. finally, the role that sedation may play in increasing morbidity, pastieuiarly nosocomial pneumonia, in the icu will be discussed. objectives : therapy cost(tc) in icu patients is a substantial component of total hospital care cost. estimation of tc during this year, partitioning to various groups of drugs used and attempt to minimise it, were considered practically useful. methods : in collaboration with the hospital pharmacy we were able to have a complete report of au drugs used for icu patients (including enteral and parenteral nutrition). mean apache ii severity score upon admission was . and mean length of tcu stay was . days. price per drug unit and cost per group of drugs were also available drugs were divided into two groups: antibiotics ( ) cardiovascular drugs ( ), gastrointestinal system drugs ( ), enteral and parenteral nutrition ( ), respiratory system drugs ( ), sedative, analgesics and paralysing agents ( ), parenteral solutions with electrolytes, vitamins and trace elements ( ), anti-inflammatory agents ( ), protein substitutes and immunomodulation agents ( ), anticoagulative agents ( ). antibiotics were further subdivided into those "freely" prescribed (a) and those whose prescription and administration requires filling of a relevant form (b). results : !) tc for icu patients/day was . drs ($ ). total tc/patient was . drs ($ . . ). ii) partitioning total tc per group of drugs reveals : ( ) %, ( ) . %, ( ) . %, ( ) . %, ( ) . %, ( ) . %, ( ) . %, ( ) . %, ( ) . %, ( ) . %. t ) concerning antibiotics which consist the major cost component, group a and group b contributed by . % and . % to the total icu tc respectively. group b were administered to . % of all icu patients. conclusions : i) for the above studied patient population antibiotics consist almost half of total tc followed by protein substitutes and immunomodulation agents. ii) if tc control could be attempted in the icu, prescription of beth groups must be reviewed. appropriate treatment should be prescribed and readily provided to any patient. clinical significance of routine protein substitution, currently controversial, should be re-evaluated. new antibiotics (third & fourth generation cephalosporins, quinolones, carbaponems) should be prescribed on the basis of strict diagnostic procedures using modern technology available. rationalisetion of antibiotic therapy will lead to cost control, redistribution of icu expenses and substantial contribution to infection policy in our country. objectives: i -to investigate the clinic efficiency of the monitoring of the rso cerebral, in relationship to the stroke prevention, in patient undergoing carotid surgery. -to determinate the variations of the rso during the different surgical and anesthetic procedures in these patients methods: ten patients undergoing carotid endarterectomy. precise neurological exploration previously to the surgery and in the immediate postoperative period. angiography evaluation to the extend of carotid artery disease. invasive blood pressure, ecg, pulse-oximetry ( pso ) and rso were collected previousty to the induction of anesthesia. the premedication was administered intravenously -midazolam ( mcgr/kg) and fentanyl (i rncgr/kg) -. thiopental ( mg/kg),fentanyl ( mcgr/kg) and atracnrium ( , mg/kg) have been used for induction of anesthesia. co te is monitoring al~er the orotraqueal intubation ! the anesthetic maintenance is accomplished with lsofluorane ( , - , %) and bolus of atracurium and fentanyh the surgical procedure is standard (without arterial shunt during the carotid cross-clamping). we register each minutes: blood pressure, cardiac frequency, pso , co te and rso . the rso cerebral variate in relation with: the anesthetic induction, blood ~ressure, co te, cross-ulampping carotid and with the modifications of the head position. the maximum decrease of rso cerebral was in relation with the :ross-clampping carotid ( minimal value: ). no patient had neurologic complications and postoperative stroke after carotid endarterectomy were not observed. objectives: there are more than anesthesia in chelyabinsk emergency hospital every year. to % patients of it emergency anesthesia is applied. more than patients have ishemie heart disease (ihd), hypertansion (hp) and previos miocardial infarction (pmi). more than % of all patients are old patients (op). the resalts deep noninvasive bioimpedance monitoring (nbm) in surgical patients have been studied by us. methods: our nbm system "kentavr" includes parameters of cardiac and vessels function. it is realised by monitors in operation theatres and computer network. moreover we are able to examine surgery patients before anesthesia and perioperatively by using special computers system for cardiovascular reflex control by fast fourie transform (fft) of parameters simultaneously. results: pathients extremly needed peryoperative monitoring of hemodinamics. from these patients more % had stroke volume (sv) less than ml, n -co less than . /mim/m , % -ejection fraction (ef) less than n and % -puls bioimpedans microvessels (pbm) less than morn. patient had intensive care in special department. out of died. comparing with survived with these patients before operation hr was larger, sv, co,ef, pbm and puls bioimpedance aortha was smaller. much more of these patients were with ihd, pmi, hd, op. even with survived patients these parameters decreased the towards the end of operation. surgery patients had different variability of basic hemodinamical parameters with common tendency to increase power amplitude in low frequency by fft. conclusions: using of bioimpedanee noninvasive parameters allows to have criteria for corrections (infusies, vasodilatators, inotrops and others) and then us the final goal, to have more sucssesful surgery. with survived patients was perioperatively and postoperatively care more intensive. obiectives: the aim of the study was to compare the phi with the hemodynamically derived tissue oxygenation indexes as: oxygen delivery (do ), oxygen consumption (vo ), cardiac index (el), and arteriovenous difference in oxygen [(a-v)do ]. methods: patients ( males and females) with major trauma or major abdominal surgery were studied. on admission, a nasogastric tube allowing phi measurement was introduced and a pulmonary artery catheter was inserted for optimal hemodynamic management. each phi measurement was accompanied with a complete hemodynamic study comprising systemic and pulmonary artery pressures, blood gases, and cardiac output measurements with the thermodilution method. derived parameters vo , do , ci, (a-v)do were measured according to the standard formula. hemodynamic parameters were opt• as soon as possible with fluids, inotrepes, and vasopressors according to repetitive hemodynamic measurements. all patients were under mechanical ventilation. after hemodynamic stabilisation phi and hemodynamic measurements were repeated every eight hours, during a -hour study period. a total number of measurements were obtained and compared. statistics: results are presented as means + sd, correlations were performed between phi and the hemodynamically derived oxygenation parameters. a p< . value was considered as significant. results: mean values were phi= . + . , do = + , vo = + , c. = . + . , (a-v)do = . + . . no correlation was found between phi and do , phi and vo , phi and c.i, phi and (a-v)do . on the contrary in patients phi remained below . for more than hours despite adequate hemodynamically derived tissue oxygenation parameters. mortality in this group of patients was very high ( %). conclusion: no correlation was found between phi and the hemodynamically derived tissue oxygenation parameters our data suggest that phi is a better oxygenation indicator than the hemodynamically derived tissue oxygenation parameters, because it is closely related to the patient's outcome. objectives: the pathogenesis of septic shock and multiorgan failure is believed to be related to tissue hypoxia of the gastrointestinal tract. therefore new monitoring techniques, preferably organ specific, are required to establish the adequacy of tissue oxygenation. peep is used to reduce pulmonary shunt volume and improve blood oxygenation, but is accused to impair splanchnic perfusion. we studied mucosal oxygenation and perfusion on the capillary level in the stomach and the duodenum. methods: we used the erlangen microlightguide spectrophotometer (empho ll) together with a specifically designed fibre probe (bodenseewerk ger~tetechnik, berlingen) in combination with a standard gastroscope. measurements were performed on ventilated, traumatized patients (ages - years), with no evidence of shock or severe infection, after informed consent was obtained from the relatives. all patients were hemodynamically stable without inotropic support. an area of cm was analysed in the gastric corpus, the antrum and in the duodenum. in three patients we simultaneously measured the muc sal blood flow using a laser doppler flowmeter ( objectives: to investigate the influence of hb-o affinity in the monitoring of svo~ during improvement of cardiac index (ci) in cardiogenic shock. design: to state whether changes in svo: were associated in changes in actual pso (p~ ) and standard p~ (ps st) consecutive measurements of artero-venous bga, before an.d after therapy-induced changes in ci, were evaluated in patients (mean age -* y) suffering from cardiogenie shock, all under mechanical ventilation in psv modality. methods: together the hemodynamic measures, m~xed venous samples were analysed at ~ c using the abl radiometer for po , pco: and ph, and the osm radiometer for hbo %, hbco% and methb%. psost (i.e. the p~ at ph= . , pco:= mmhg and temperature at ~ c) was calculated automatically by the instruments on mixed venous blood as was the ps "in vivo" (i.e. the pso at the patient's value of ph, pco and temperature), using siggaard-andersen's computerizated algorithm. mean time between paired measurements was . -* . houm. the data were compared by anova test for linear regression and t-test for paired samples. results: a dose linear relationship was found between svo and oxygen extraction ratio (oer), r= . ,p= . . the improvement of ci ( . -* . to . + . l/min/m , p< . ) induced a significant increase in svo~ ( . -* . to . • . %, p<. ). a significant decrease in p ( . • . to . • . mmhg, p< . ) without any significant change in p~ st ( . • . to . • . mmhg, p=ns) was also found. these data show that either oer or the shift to the left of the oxygen dissociation curve account for increase in svo occurring with restoration of systemic blood flow. the program is intended to help the intensive care unit interne providing him with a practical tool when making decisions concerning patients in a critical condition. in his daily practice in intensive care unit, in this case the interne of the unit, uses this program for each patient as follows: on the first stage of data collection he should complete the following modules: ( )personal data ( )patient's pathology ( ) laboratory and~ monitor lug data ( )drugs prescribed or toxic elements ingested. in this way, the system allows optionally the consult with a computerized data base about the drugs prescribed, standardized parameters and techinques performed by the central laboratory. ( )reference to an antibiotics guide regarding becterian sensitivety in our unit, whitch ee checked every six month ( ) access to de questionnaired apache ii to load up new data. ( ) statistcs about patient's admission and discharge. results: once all data collection is finished the system performs the followin duties: ( )detailed drugs interactions, including toxic elements ( )diagnosis starting from the clinical, laboratory and monitoring data. in some cases, it also establishes therapeutic strategies, e.g. a coagulopathy ( ) give the l~narmacological incompatibilities between the drugs p~escribed and %he diagnosis established, and ( )perform dosage adjustments based upon the personal and pathological data. objeatve: to assess the power of diseri~,~ion ofa multiperpose severity score (sai~) when applied to subgroups ofpatieals (pta) according to their lemg~ of ~ay (los) in icu. design: in order to compute the saps probability, a model derived fi~m legible regression was developed. meaumree of calibration (goodmem..of.fit statistics) end discrimination (roc cm've and relative area under the cm've) were adopted in develotammtul asd validation set. the whole databue was ~ati~ed in five gronps reeked on los as follows: los = days, los = - days, los = - da~, los = - days, los > day~. area under the carve (auc) was ud~ninted for each ro~. s~ing: imlimlcus. patents: of ~ pts comec~ively admired ~ a period of three yeet~ ( ) ( ) ( ) , a total of was i~leded in this study. pts without saps, p~ yolmger them yearn, p~ with los shorter ~ hom'~ were excluded from this maly~is. iaterventinns: nose mema'onm~ end result: the logistic model developed gave good remits in terns of calibration md discrimin~on, both in developmental set (do.s g : . , p > . ; auc = . i- . ) and in validation ~t (g.o.g g : . , p > . ; auc = . ..+ . ). auc of each grottp showed a loss in di~zimination (i.e., prediaton) closely related with los, being . i- . in pts with los = days el . ~. ia tm with los > da~ (figure). following the present guidelines of integral management, in order to achieve optimization of sanitary resources and better use of facilities, we feel that the setting up of objetives is a key factor in the continuous process of improvement of quality care. postsurgical intensive care services maintain an interdepent relationship with other hospital services. within the general plan of the hospital it's of the utmost importance to delegate autonomy to the various depertments and service units in determining and achieving objetives. it's also necessary to establish mechanism for coordination of the activities in order to assure the succes of the program. the objetives cannot be improvised, they must be carried out in a specific manner in the following stages: .-analysis of the present situation (starting point). where are we?. defining objetives and making explicit the activities and methods to achieve them is to anticipate the future; it is of the utmost importance to comunicate said plans to all whom affect by encouraging them to attain the desired results. in the present paper we intend to show the guidelines to follow in carrying out a course of objetives. introduction:we presents results related to the quality of life (qol)of critical patients, from paeec project data. material and methods: the paeec project is a multicentre study define the type of patients cared for in spanish icus, and the therapeutic activity provided. ninety-five icus from spain are taking part. this study analyzes the qol of critical patients prior to their icu admission.for the evaluation of qol a questionnaire designed by our team for critical patients was used, with items grouped in sub-scales: physiological functions ( items); functional capacity ( items) and subjective aspects ( items). qol is classified in levels: normality ( points); slight deterioration ( - points);moderate deterioration ( - points); significant deterioration (>i points). the we present results related to therapeutic activity in critical patients and their age, from the paeec project. material and methods: the paeec project is a multicentre study to define the type of patients in spanish icus, and the therapeutic activity provided. ninetyfive icus from spain are participating. this study analyzes therapeutic activity in the first hours as evaluated by tiss, and related factors. results: the sample was , patients, sge . ~ . years. severity by apache ii system was . • points. the tiss score was . • points, distributed as follows: i (<i points): %; ii (i - points): %; iii ( - points): %; iv (> points): %.there is a positive correlation between the level of therapeutic activity and severity by apache ii (r = . , p < . ), and a very weak but negative correlation between tiss and age (r = - . , p < . ), so that an increase in age corresponds to a lower level of therapeutic activity.patients the multivariate analysis of the relationship between tiss and age took into account: severity, existence of previous history, need for mechanical ventilation, size of hospital, diagnosis and mortality. it indicated that there continued to be a relationship between therapeutic activity and age, so that as age increased, therapeutic activity diminished. conclusions: therapeutic activity performed on critical patients is less in the oldest patients, in whom excessively aggressive procedures are limited. a relational data base management system in the icu. c. kotsavassiloglou*, d.matamis, g. dadoudis, j. kioumis, d. riggos. icu dep., g. papanicolaou gen. hosp., exohl, thessaloniki, and * a' neurological clinic of aristotelian university, thessaloniki, greece. objectives: the introduction of the information technology in the i. c. u seems to be unavoidable because of the large amount of produced data and the need for their systematic analysis. such an information system should be a) easy to use, b) friendly to the user, c) powerful and d) modular. on that basis, we created a patient data management system (pdms) according to the expectations of the medical staff of an eighteen bed multidisciplinary icu. methods: we selected paradox for windows v . for the implementation of a relational data base because this program meets the above mentioned criteria. informations regarding the patients include a) demographic data, b) previous medical history, c)diseases upon admission, d)complications during hospitalization and e) outcome data. the diseases' registration consists of items classified in categories upon the principal system affected. specific informations about the need and duration of mechanical ventilation, nutrition, renal replacement, right heart catheterization and icp monitoring are also available. an extension was added concerning icu infections and related informations about antibiotic-resistant pathogens. all icu pathogens can be matched to their resistance or sensitivity and cost of antibiotics. the program can perform queries and various statistical analyses based on complex criteria. new modules can be added later according to the future needs and remarks of the users. results: the program was well accepted by the medical staff and patients were registered as a test. the first analysis of the data related a) observed mortality versus the apache ii predicted mortality, b) mortality according to the age, gender, pathology aud duration of icu stay and c) pathology upon admission and icu related complications. conclusions: the long term use of this pdms can be an efficacious research tool. it can be used in retrospective or prospective studies by addition of necessary modules. the first data analysis revealed the iack of an international diseases' classification system. the development of a worldwide common classification system is essential for the compatibility of the data analysis among various icus. this will allow the realization of multicenter trials on a large scale. s. nanas= n. sphiris, a. precates, a. lymberis, m. pirounaki, and ch. roussos dept. of critical care, university of athens, athens, greece the complexity of the cases submitted to an icu, the variety of underline disease, tbe severity, as well as the large number of substances administered to each patient constitute obvious the need of support with an easy available dss. this system will assure the safety of the administered treatment will help to adjust the dose according to the situation of each patient and it will screen for possible interaction and incompatibilities between the administered drugs. the goal of the present effort is the design and development of a software system acting as a decision support tool to physicians of icu. the application is organised around a relation database management system (rdbms) that consist of: a) all available substances ( . ), b) all generic names of medications available in our country for each substance, c) incompatibilities ( . cases) and d) interactions with other substances ( . cases). the following figure shows the structure of the rdbms. y ta~ortato~ [ c~rs using the stored parameters for each patient the dose and the rate of administration of selected substances will be possible to calculate. the continuous monitoring of the treatment for each patient supports the medical staff to make the necessary changes of the prescriptions. the application is currently developing in wireless pen based computer systems which place patients at the centre of "islands of information" located throughout icu. in conclusion this dss is a powerful and useful tool for icu staff because it provides without additionai work to the routine of daily practice, the currently available information for each order concerning drug interaction and incompatibilities as well as treatment monitoring is to obsea~ among critically ill pfdieats, stdjdivided following the diagn~s at the adn~ssio~ the diffmeax:es in the ~ and oxyplx~efic l~mmems bawe~ strvwors [s] and non sumvors ins] and to test the pc~'bih'ty to have soar survival criteria, as earliest as tx~able. method~ :we made a ~ study on consexa~e ~ilically ill paliffas, subdivided in series following the diastases at the admission: medical pafiea~ ( s and ns), surgical patients ( s and ns), a~d poliwauntas ( s and ns). follow up was done at d,.ays from the admission in ice. all the patienls were ramitored with a ~ c~eter and laeno:lymmi. "c and o .x.xyphorefic txuamaers va:~e couected at fin~es (t): at fiae ~draission (t ), at x~ars from t (t ), at (f ), (y ), (t ), % (t ) and horus from t cf ). in~,h ~ies, for ~y ~ a all the lin'~ n~an and sandaid d~viation was ~ tx~h for s and for ns. th~ betw~ s and ns tl~ roeaas of ~h porarneter ~e ccmpared tt~ng t-lest and p < . w~ considered ska~ significant in each series in the t wheae the mast significative diffemx:as ~goeamd bet~en s and ns, we made a txedictive criterion, asamting as predictive indices for stnvival the i:r values, higher or lower than flae treans of the ~rar~ers of au flae patients, axx)rdhlg to those ones t~iatistically diff~'e~ betw~m s and ns. fhmlly xse co:weatxt onaong the series the nrametees of the st~rs with the analysis of variance, to daserve the lxjsable differealt irea~ of sty hflices, following the diagn~s of admission: :nedkal, angical patient or poll~tam results: we c~ld not find ~ predictive criterion for politraonaas, perhaps ixx:ause of the few ntanber of l~fients. for high ri~ saw~cal patieras the following criterion at t has a sensitivi .ly of ~ ,and a ~ecificity of . %: sv > . nffmin/n~, map> mmhg, pmap< nmalqg cvp<i nunhg will nmah& lvswi> g m/m , sxo > ~ do > mlhnin/m , o er< %. for lx~dical l~tienls at t the following criteric~a has a ser~tivi.ty of % and a ~zificity of . ~ cvp< . mn~g, sao > %, s,g) > ~ vo i< ml/nfin/m , o er< %, shunt< % survlvops' data of the series ~ signitic~atly differenl~ both for the t~mody~nic a~ for fl~e ox rphomfic lxlmn~s; moreover we ~ that the vatt~ of hemodynamic mad ox.~ho~tic indices were higher in politrautms. conclus'ions: acx~ording to the fftffe~mt patho!o~es, the ~ rnelabo~c needs are diffeten~ so that it is juslified to mash ~ the~alceutic goals, following the type oflmthology. hen~ we foru~d for high ~k mrgical pmka~ and for medical patier~s assme, ff mllslied, a good prognosis while, if n [ ntljsfled~ the plinsliclioil ofdl~tth is no[ g(ioct finally, ab~ high iis~ supgical palieaats, according to what other atmhors say, txatws sh ~'n~ers ' therapeutic goalsvvould seem inadeqt~te, bec~jse they need a gear physiologic and themtx~ic elth~ in rdation to the rretabolic needs. figure ) . thus, the smaller european nations had a greater participation than ~e larger ones, with the exception of norway. a similar result was evidenced for contributions to intensive care medicine (figure ). these findings can be explained by different submission policies and language banners. however, there was no significant correlation with the gross national product of each country. conclusion: we conclude that the smaller european countries generally contribute more to international intensive care journals than the larger ones. objectives: to evaluate the agreement between a new and three old methods measuring ctp and to assess their reproducibility. methods: we studied patients ventilated with a siemens c respirator. we measured ctp by dividing the tidal volume with the increase in airway pressure (paw), either with the respirator setting used (ca) or with a fixed setting (cf). by modifing the inspiratory time (ti) without changing inspiratory flow, we were able to deliver two series of inflations ( , ,... ml) before and after curarisation of the patient. the same volumes were also inflated in paralysed patients with a super syringe. at the end of each inflation a plateau of sec was performed and paw was recorded. the above three sets of pressure-volume (pv) points were used to reconstruct the corresponding pv-curves (( , c , c the new method for ctp measurement without a super-syringe had the best reproducibility in paralysed patients and gave similar results without curarisation in the majority of them. however, agreement between the methods tested was unacceptable for clinical purposes. further investigation is required in order to improve the accuracy of ctp measurement in icu patients. m kunert, r.sorgenicht, l.scheuble, k.emmerich, h.g ker med.clinic b (dept.of cardiology) i heart center of wuppertal/university witten-herdecke,germany objective to determine the accuracy of activated partial thromboplastin time (apl-l) and activated clotting time (act) studies when samples are drawn through heparinized central venous catheters (cvc). methods a total sample of paired act/p't-/" values was analysed in patients ( m., f., + y.) for monitoring heparin therapy.all patients had a cvc (certofix trio,braun,frg) in the internal jugular vein receiving a continous infusion of . u heparin via the central catheter.act (hr-act, hemotec,usa) and ap'i-f (neothromtin, behring,frg) samples were drawn from the cvc using the double syringe technique (removing and discarding ml blood before drawing the sample). these blood samples were compared to act/ap'cf blood samples obtained by venipuncture (v.fem.) at the same time, act values were analysed directly in the intensive care unit (icu),api-i samples were measured in the hospital laboratory within minutes. results ac-i -~ pi-f~ cact/~pi r = , ) cvc samples + + . v.femoralis samples " + + p-value n.s. n.s. conclusion there is no difference in heparin anticoagulation studies drawn from heparinized central venous catheters compared to those obtained by femoral venipuncture,withdrawing ml blood prior to obtaining the blood specimen is a safe way for eliminating heparin contamination.not only the aptt test but also the act test is a useful method for heparin anticoagulation assessment in the icu. objectives: evaluation of the delicate balance between filter-coagulation and patient-hemorrhage using heparin as anticoagulant in continuous renal replacement procedures. methods: from january through august , we studied filter surviva[ and hemorrhagic complications during filter periods in critically d[ patients, treated with continuous arterio-venous hemo(dia)filtration, with special emphasis on the heparin dose, concurrent use of coumarins, systemic activated partial thromboplastin tirne(aptr), platelet count, mean arterial bloodpressure and the type of filter used. results: filters ( %) were disconnected because of coagulation. mean survival of multiflow an filters was twofold shorter compared to survival of fh gambm filters. a total of hemorrhagic complications occurred of which three patients died at aptt values of respectively , and seconds. after adjustment for mean arterial bloodpressure, platelet count and the type of the filter, the risk for filter-coagulation decreased % (relative risk . , %c . - . ) for each ten seconds increase in aptt. the risk for patient-hemorrhage increased % (relative risk . , %ci . - . ) at an aptt-increase of ten seconds. the occurrence of filter-coagulation and patienthemorrhage was not correlated with the administered dose of heparin. concurrent use of cournarines had a positive effect on filter-survival, without increasing the overall incidence rate of patient-hemorrhage. conclusions: the systemic apt]" is a good predictor of the risk for filtercoagulation and patient-hemorrhage. heparine therapy seems optimal at an aptt between and seconds, although one should realize that fatal hemorrhagic complications still can occur. objectives: the alterations in vascular tone which are primarily regulated by adreno-sympathetic tone(ast) are compensatory responses in hemorrhagic patients. this study was designed to evaluate the correlation between vascular tone and ast in patients with hemorrhage, methods: the vascular tone was expressed by volume elastic modulus (ev) that is defined as; ev = ap/(av/v) (ap; the arterial pulse pressure, av/v; the volume change ratio). ev was measured using a non-invasive transmittance infrared photoelectric plethysmography (tipp) and a volume oscillometric sphygmomanometer . we prospectively studied patients with hemorrhage. the initial ev measurement was performed on arrival and repeated for a hours duration. as a parameters of ast, serum concentrations of adrenalin (ad), noradrenalin (nor), plasma renin activity(pra) were measured simultaneously. we analyzed the correlation of ev and conventional parameters to ast by multivariate statistical analysis. results: ev values at transmural pressure mmhg on admission and hours later were respectively . + . mmhg, . +_ . mmhg (mean + sd). systolic pressure(pas) and serum hormones on arrival and hours later were respectively, pas; . _+ . , + . mmhg, ad; . _+ . , . _+ . ng/ml, nor; . _+ . , . + . ng/ml, pra; . _+ . , . _+ . ng/ml/hr. the ev values correlated significantly with ad (r= . , p= . , n= ), nor (r= . , p= . , n= ), pra (r= . , p= . , n= ). by multivariate statistical analysis, ev correlated more significantly with ad and nor and pra (p= . ) than the conventional parameters such as pas, heart rate and pulse pressure. conclusions: the alterations of ev correlates closely with ast. the compensatory mechanism in hemorrhagic patients can be detected noninvasively by ev monitoring. obiectives and method: autologous oxygenator blood was processed at the end of cardiopulmonary bypass (cpb) by either hemofiltration (hf , , m , fresenius) or by cell washing with a onntinous autologous transfusion system (cats, fresenius). prospectively the blood of patients for each group was processed and then retransfused intravenously to the patient. besides, volume and time requirements, standard hematologic chemistry, coagulation and complement activation were measured. results (mean values for oxygenator blood at the end of cpb, and results of concentrate after processing by filtration or washing): both processing techniques show excellent hemoconcentration of the diluted cpb blood with a good transfusion effect for the patient. filtration retains all plasma proteins and large molecular weight plasma bound waste products. in contrast, cell washing with cats significantly depletes plasma proteins and waste products. the newely developped cats machine gives eonsisinnt laboratory result in a fully automatic continuous processing mode. in conclusion, both filtration and washing are effective for processing cpb blood. filtra tion yields a highly concentrated whole blood, whereas cats washing produces a high quality autologous erythrocyte concentrate. soluble fibrin has during the last years gained interest as a marker for the activation of the coagulation in connection with various clinical conditions, e.g. disseminated intravascular coagulation, deep venous thrombosis and myocardial infarction. elevated levels of soluble fibrin in plasma can be detected by the chromogenic assay coaset fibrin monomer, relying on the ability of fibrin to enhance the tpa-catalyzed conversion of plasminogen to ,plasmin. using this test, it has been shown that the level of soluble fibrin can be correlated to severeness of illness in critically ill intensive care unit patients. a revision of the coaset fibrin monomer kit has now been made and the new product, coatest soluble fibrin, is considerably more convenient to handle and gives higher resolution at low fibrin levels. the test is performed by the addition of a buffer dilution of the plasma sample to a microstrip well containing the colyophilized mixture of tpa, plasminogen and the plasmin specific cbromogenic substrate s- . the reaction is allowed to proceed at,. room temperature for minutes before discontinuation. the absorbance at nm, measured in a microplate reader, is proportional to the content of soluble fibrin in the sample. the assay is carefully standardized and calibration curves are provided in the kit. the convenient and rapid assay procedure makes the coatest soluble fibrin test well suited for single test analysis in acute situations. objectives : blood coagulation abnormalities have been reported in the systemic blood of patients with cerebral lesions. the physiopathology of such events is not yet completely understood. we compare the coagulation profile of blood from the right jugular bulb with systemic blood of patients with head injury. methods: we studied patients, who were admitted to our neurosurgical intensive care unit between january and march with head injury and no other associated pathology (age - yrs), a glasgow coma score <= g, no abnormality in baseline coagulation profile and no history of coagulopaties. the patients did not undergo angiography. a one-way gauge certofix catheter was inserted through the right internal jugular vein up to the jugular bulb. an identical catheter was inserted through a subclavian vein. blood was sampled from either catheter (a=atrial; j=jugular) - hours after trauma (t ) and t hours later (t the inddence dpontolx'rative thmmhi~e and haumord~gic complieatiom were assessed in padents treated with indobefen, heparin calcine caeca), low mollecolar weight heparin (lmwh) (f.nosheparin) and undergoing hemodiludun, blood predeposhing, intra mad postoperative blood saving. ]'he indolmfon tempota~.norks platelet aggregation through ,,elective inhibition of the cyclatygenasis and thus atacbldonicadd( ).tbe n'mimum effect occurs after hours from the fast administration and is still present after hours. ~- patients, mean age --- yrs., weight --- kg were studied. ( . %) were male and ( . %) female. onderwent hip prosthesis ( previously plate and screw removal) hip revim'un ( stem, cop and stem + cop), tutal knee prosthesis, in the st anaesthesidogy depl from - to - - . as for antithromboembolic ptephylam, apart from hemodihitiun pts were with treated indobufen ndo), with heparin ealdum caeca) and with low mo!lecular weight hepam (lwr, ). as the slightest clinical and/or imtmmental suspidon of deep vein thrombosis (dv'i') or polmonary umbolism(pe), a phlebogram or sdndgram were respectively carried out. -the inddence of homologom transhisiom was significandy lower (p= . l) in the padeats treated with indobufen ( . ) compared .'ith heca ( . %). the con~gency table shows statistical signifleance for the use of heca in patients with vein deficiency in the lower limbs, past dvr and/or pe, coronary heart disease (cdh'), while there is no correlation for renal, cardiac or liver defidency, obesity, systemic hypertemion, atrhythmy, diabetes, chronic bronchitis and rheumatoid arthritis. by comparing the postoperative cumplications with the risk factors, there ks a highly significant correlation (p= . l) between cdh and thrombotic and humord~agic complieatiom (pe, death, he~atoma, die use of hum_ologous blood). thee data show that hep~in, preferred in patients with c'dh, roost likely for leagal-tuedical reasons, did not have the de~'ed effect. conclusions -the stastisfical aar~ais shows ~nifieanfly different efflea~ (pro . ) between the therapies (see table) : it can be seen that in patients undergoing autotramfusiun and hemedihidon, indobufen produo~ a lower incidence of haemotrhagic complieatiens compared to heca and lmwh and is more effective in the prevention d ~c complications at clinical e~idence. the duration of i~toperadve hospital stay is signi~cantlylonger for patients transfused with homologous red ceils and treated with hec, .a ( . -+ . days) and lmwh ( . +- a days) compared with indo(ll. _+ a days). one of the main causes for postoperative complications in major orthopaedic surgery is postopemtive bleeding with local effects in the operation site (hematomata, pain and delayed mobilization) and/or systemic and subsequent cardiodrculamry repercussions that are sometimes severe. the aim of this study is to assess the possibility to apply a new system of monitoring, control and saving postopemtive blood loss from the drainage. the bt recovery dideco (marandola, modena-italy) ~ used since it is the only apparatus capable of doing this. the apparatus consists of a pressure transducer, adjustable from - a + mmhg, which activates a peristaltic pump connected m drainage robes. the bt recovery display shows hourly bleeding in the first hours, total bleeding, time passed since the start of monito~g and subsequent salvage and the aspimtioo pressure on the drainage robes; the latter is inserted at - mmhg and then modified according to bleeding/minute, g bt recovery also has an alarm that sounds automatically if.' blood loss is more than ml/hour; air is in the circuit; the batteries are running low. materials and methods: pts were studied ( m and ~), aged . -+ .lyears, basal hemoglobin . -+ (range . - . )g/all, treated from st january, to mst december, in the st service of anesthesia and intensive care unit of our hospital. the patients underwent the following surgical treatment: total hip revision ( pts), cup revision (~ipts), stem revision ( pts), total knee revision ( pts). the average dumtion of the operations was -+ min. intranpemtive monitoring and blood salvage was applied to all patients. genera! anesthesia was used on pts. and integrated (epidural analgesia + light general) on the remaining t . anttthromboembolic prophylaxis consisted of external pressure bandage, isovolemic hemodilution with iodobufen in ( . %)pts., calalc heparin in ( . %)pts., low molecular weight heparin in ( . %)pts.; pt did not give a predepoalt of blood, gave unit, pts units, pts units, pts units. the data obtained was statistically analysed using contingency tables and anova. results: average intmop salvage was -+ ml, average postop salvage was -+ mi the average intra+postop +- ml. average postop loss was -+ ml. the global incidence of postop complications was: h~natomata . %, dvt . %, pulmonary thromboembolism , , myocardiac ischemia . %, acute myocardic infarction . %, respiratory deflciecy . %, arrhythmia %, cystitis . % there were nn complications in . % of pts. postop bleeding over ml in under minutes (with bleeding alarm activation) occurred in pts ( . %). this sta~tically correlates only with the type of operation performed (more frequently in total hip revision p= . ) and with a significant decrease (p~ . ) in the pruthrombic activity detected about hours after the operation. this bleeding, also made the alarm sound, calling the attention of staff who could act accordingly, by making the drainage pressure positive and incre~sthg the tension of the external pressure bandage. conclusions postop monitoring, control and blood loss salvage combined with predepoalting and intmop salvage has enabled allogenic transfusions in % of cases to be avoided in operations with high postop blood loss like hip or knee revision. the usefulness of the system can be seen by the fact that in the patients with so much bleeding to set off the alarm, there was no significant difference in the incidence of allotransfusions and complications. references )borghi b., bassi a., de simone n., laguardia am., fonnaro g. an injury of the brain may result in various disorders of hemostasis caused by the release of • into the circulation through a damaged blood-brain bar tier. disseminated intravascular coagulation(dic) is one of these disorders. it is a freguent but relatively rare ly diagnosed complication of subaraohnoidal haemorrhage. the aim of this study was to evaluate some parameters of both blood coagulation and fibrynolisis in patients with sah.in addition one wanted to find out wh~ther potential changes correlated with the pa• condition in the acute phase of sah and whether they influenced the course of this disease. patients with sah were studied. in of them sah was due to closed eraniocerebral injury and in the rema ining resulted from vascular malformation. the following parameters were evaluated:the prothrombine time,the activated partial thromboplastin time, the thrombine time,level of factor v,fibrinogen degrada tion products and fibrin monomers. the results let us show the presence of oic in patients with closed craniocerebral injury and in with vas. cular malformation despite the lack of clinical symptoms the tests in posttraumatic patients and in patients from second group showed incomplete dic.on admission patients with such changes in measured parameters were in poor condition.the course of the disease and the effe cts of treatment were also worse in these patients. the results showed ihal in patients with sah complex disorders of both coagulation and fibrynolisis occur, and they depend on clinical condition of the patient. they also influence the course of the disease. methods : charts of all patients admitted with d.i.c. over a ten year period ( - ) were reviewed. diagnosis of dic was based on the association of fibrinogen < g/ -platelets < / -fpd > ~tg/ml in the hours of the admission. results : patients -mean age + y -saps +_ -gestanional age _+ weeks -the two first conditions associated with d.i.c. were placental abruption ( %) and preeclampsia or eclampsia ( , %). bleeding episode was present in pts ( %) and surgical treatment has always been necessary. pts ( %) were given packed red ceils ( + u) and fresh frozen plasma ( + u). patients were given platelets packs. heparin was never administered. pts required mechanical ventilation and two patients hemodialysis. all the patients survived. correction of prothrombin time (p.t.) and fibrinogen (f) was quick (p.t. at t h ~ % -f at t h , + , g/i). but platelets count remained low (plat. at t h + / ) -no difference was observed in patients who received platelets. conclusion : prognosis of critically ill o.p. is good. blood loss is the main complication. correction of hypovolemia and anemia with concomitant surgical treatment are essential. the administration of coagulation factors or platelets is still under discussion. objectives: to evaluate the effects of antithrombin iii i at-iii) and a protease inhibitor, gabexate mesilate foy), on the coagulation and fibrinolysis in disseminated intravascular coagulation (dic). methods: after the approval of our institution and consent from patient's family, patients with a dic score ( , japan) more than points (dic or having a risk for dic) entered this study. they were randomly divided into two groups, foy (i- mg/kg/h for days or more) treated group and no foy group, each of patients. platelet count (plt), fibrinogen (fen), at-iii fibrin degradation product (fdp), d-dimer (do), fibrin monomer (fm), thrombin-antithrombin complex (tat), plasmin-plasmin inhibitor complex (pic), and prothrombin time ratio (ptr) were measured before the start of treatment (at admission) and i, , and days after the admission. at-iii at units for days was administered if the at-iii at admission was less than %. finally the patients were divided into four groups: group a, foy (+) and the at-iii ~ %; group b, foy (+) and the at-iii < %" group c, foy (-) and the at-iii %; group d, foy (~) anffthe at-iii < %, each of patients, to match the patients for backsrounds. all parameters, dic score and survival rate in a month following treatment were compared among the four groups. results: the at-iii and plt from day to were significantly higher in groups a and c than in groups b and d. the fdp, dd, tat, and pic after treatment decreased significantly from the baselines in groups a and c but not in groups b and d. the fgn and fm were not significantly different among the four groups. the ptr decreased in groups c and d but increased in group b. the dic score decreased significantly in groups a and c than in groups b and d. survival rates were %, %, % and % in groups a, b, c and d, respectively, although not significantly different. conclusions: in patients with dic or a risk for dic, foy had no expected effects but at-iii had suppressive effects on the coagulation and fibrinolysis mechanisms. a prognostic factor ? carbon monoxyde intoxication is a classical complication of inhalation injury. carbon monoxyda is also physiologically produced during the heme metabolism: heme is conversed to bi]irubin by the hemeoxygenase which is an intracellular stress protein. icu patients (pts) were studied prospectively for apache ii score and carboxyhemnglobin (hbco) arterial level to assess if hbco level could be correlated with the severity of the pts. objective: to evaluate a new technique of non-surgical tracheotomy. patients: adults, mean age years and children, mean age months ( me.- yrs). method: through a needle inserted in the trachea, a guide wire is retmgradely pushed out of the mouth and attached to a special device formed by a flexible plastic cone with pointed metal tip joined to an armoured tracheal cannula. this device is then pulled back through the oral cavity, larynx and trachea, and outwards across the neck wall by applying traction on the wire with one hand and counterpressure on the neck wall with the fingers of the operator's other hand. when the cone and / of the eannula have emerged, the cannula is cut off from the cone, straightened perpendicular to the skin, rotated and advanced caudally to its final position. results: endoscopic control facilitates and improves the safety of all manoeuvres. the pointed cone easily pierces the tissues, and the cannula is extracted without difficulty since it has the same outer diameter as the cone. tissue adherence around the cannula is absolute thus preventing local inflammation. the time in apnea required for dilation and cannula placement does not exceed see., and it is well tolerated because within safety limits in patients hyperventilated with oxygen. only one case of bleeding occured in a patient on dialysis with severe coagulopathy. autoptic findings in subjects who died due to progression of primary disease showed a very regular stoma with an almost complete lack of hematic and flogistie infiltration in recent tracheotomies. .conclusions: translaryngeal tracheotomy (tlt), by virtue of its greater inherent safety and lower tissue trauma than percutaneous techniques, can also be carded out in infants and children, a severe test bench for any tracbeotomy technique. further specific indications are recently stemotomized patients, since tlt is associated with a low rate of infection, and short term tracheotomies after laryngeal surgery, to prevent obstructive complications. references: fantoni a., translaryngeal tracheotomy, apice, ed. gullo, trieste, , . background: inhalation of no has been shown to reverse hypoxic pulmonary vasoconstriction , to reduce pulmonary pressure in pulmonary hypertension of different origin and to improve gas exchange. in putmoflary embolism, pulmonary hypertension is caused by mechanical vascutar obstruction and by reactive vasoconstriction. the effects of inhaled no in putmonary embofism has been partiatly studied' the purpose of this study was to investigate and determine the effects of no inhalation on pulmonary hemodinamica and gas exchange in a hypoxic canine model of pulmonary embolism. methods: two groups of adult mongrel dogs were studied: group (control} dogs and group (no inhaled) dogs. both groups were anestesized with tiopental, mechanically normoventilated with an hypoxjc mixture of and n~ (f[q , ) and instrumented (swang-ganz catheter, femoral artery catheter) pulmonary embolism (pe) was induced by fisher's method s. no inhalation ( ppm) in group was started rain. pdor to pe and kept constant throughout the experiment. no inhaled concentration was analyzecf by chemiluminiscence technique. pulmonary artery pressure (pap), central venous pressure and sistemic arterial pressure were continuosly recorded. cardiac output, artedat po~ (pan ) and mixed venous po~ were measured in both groups under hypo)dr conditions, before pe and , , and rain. after pe. pulmonary vascular resistance (pvr) and gas exchange (pao fio:~ ratio), were calculate using standard formulas. data were process and analyzed with non pararnetdc test, and reported as mean -so and statistical significance was considered if p < , . : no produced an increase in arterial oxigenation (pao /fio~ ratio) and reduced pap before pe induction in group . after pe we found no significant difference with .respect to the time eour.se of pap, pvr and gas exchange between beth groups throughout the experiment. probably, the severe mechanical obstruction produced in pulmonary embolism masked the small effects of no inhaled. obiectives: blood volume measurement would be useful in critically ill patient management if it were easy to perform. this is not the ease and current methods are based on radiolabelled red cell dilution. inhalation and uptake of a known mass of carbon monoxide (co) gas and measurement of earboxyhaemoglobin increase can give results accurate enough for clinical use. this requires a rebreathing system providing oxygenation and carbon dioxide removal, yet complete retention of all carbon monoxide administer&l, and so most authors hand ventilate with a bag and waters soda-lime canister, adding oxygen as necessary. we aim to popularise this method by; i)design of an automatic co administration system driven by the itu ventilator and ii)writing of software for a portable computer to perform all necessary calculations method: we show the computer is use estimating the co dose required and later estimating the blood volume. we also show the new gas administration system. this is a fully closed circle attached to a "bag in bottle", driven by the ventilator. the novel feature is the mechanism by winch driving gas (set to % ) spills automatically into the circle, balancing o uptake by the patient, yet allowing no co loss. conclusions: this equipment is easy to use, reduces human error and allows optimum ventilator settings to remain. the operator merely administers the volume of co determined by the computer and takes blood on two occasions. carboxyhaemoglobin measurement is easy to perform, thus there is a cost saving also. with our modifications use of this technique may potentially become more widespread, the video demonstrates the method in use in our itu. - ( %) underwent conventional surgical therapeutics. " ( %) with resection of tracheal stenosis with end-to-end anastomosis(rts). i ( %) with broncoscopic dilatation. one patient died and the others still have stable patency(sp) without continued treatment. - ( , %) have received endoscopic laser ablation with or without calibration tubes. of them ( , %) are receiving continued endotracheal treatment until now. ( , %) have sp wihout continued treatment. -i ( , %) endoscopic laser therapeutic case turned to rts and is having sp. conclusion: conventional surgical aproach has been progressively replaced in our hospital by endoscopic laser ablation and silicone calibration tubes. this study suggests that these technics are effective and could be the elective treatment for iatrogenic stenosis. obiectives: hemorrhagic disorders due to thrombocytopenia and thrombocyiopathia remain one of the most serious complications during long-term extracorporeal membrane oxygenation (ecmo) in patients with severe acute respiratory distress ~drome (ards). in the presented study, nitric oxide (no), kwown as a potent endogenous platelet antiadhesive, disaggregating and antiaggregating compound, was evaluated for its possible antagonistic effect on platelet trapping when added to the gas compartment of membrane oxygenators (mo). meti~ods: two parallel separated extracorporeal circuits, consisting of heparin bonded hollow fiber oxygenators (minimax, medtronic, carmeda eioactive surface), tubing systems, low pressure reservoirs, and roller pumps were prepared. for each measurement, a pair of circuits was simultaneously filled blood from the same volunteer. low-heparinized fresh warm blood was obtained from four healthy volunteers, who had no drugs for at least two weeks. the gas inlets of both oxygenators received dry gas ( % oxxygen, % carbon dioxide, % nitrogen); gaseous no ( ppm) was added to the gas of one of the oxygenators (no-mo), whereas the other one (mo) was used as control. after minutes no gas was switched off, so that the no-mo received no more no, and no was added to the gas inlet of the membrane, which had no no before_ to assure iutracircnit volume stability, drawn blood for measurements was replaced with saline, and platelet counts were corrected for dilution by hemoglobin values. the mean of four platelet counts (coulter counter) of each timepoint (start, , , , , , , , and minutes) was used for statistical analysis (paired sample t-test). results: in the no-mo platelets remained at + , % (percentage of baseline value, mean -+ sd) until min. in contrast, platelets of the mo continuously decreased after start and were significantly lower after minutes ( , + , % vs _+ , %(p< . ); min. , -+ , %vs , _+ , %(p< . ); min. , _+ , % ( p < . ). after switching of no gas to the mo, further decrease of plateleta was stopped and platelets remained at , +_ , % until termination of circulation. platelets of the former no-mo decreased slightly after cessation of no gas to , _+ , %. conclusions: these data indicate that gaseous no significantly attenuates platelet trapping in hollow fiber oxygenators, when added to the gas compartment. this might be a new therapeutical approach for membrane oxygenator induced thrombocytopenia during long-term ecmd. objectives: nitric oxide (no) plays a pivotal role in regulation of vascular hemostasis. several studies elucidated the antiadhesive, antiaggregating, and disaggregating properties of endothelially synthesized no to platelets. additionally, agonist-induced no production in platelets by the l-arginine-no pathway was found as a negative feedback mechanism after platelet activation. although noplatelet interactions were intensively studied by several investigators, no data exist, about changes in platelet surface molecule expression in no-modulated platelets measured by flow cytometry using monoclonal antibodies (moabs). methods: p-selectin (alpha-granule-membrane protein, gmp- , cd p) and glycoproteiu (gp , lysosomal protein, cd ) are expressed only after platelet activation and degranulation. activation was quantified in thrombin ( . u/ml) and adp ( . ram) stimulated platelet rich plasma samples (prp). blood was obtained from healthy volunteers (n= ), who had no drugs for at least days. for evahiation of no-modulated activation, the spontaneously noreleasing compound sin-i ( . mm) ( -morpholino-syndonimin-hydrochlorid) was added in parallel prepared samples prior to the addition of agonist. platelet surface molecule expression was evaluated with moabs directed against cd a (gpilbliia, fibrinogen-receptor, phycoerythrin(pe)-conjugated), cd p (fitcconjugated), and cd (fitc). only cd a-positive signals were gated in sideangled light scatter, and assayed for activation marker expression (defined as percent of gated population). results: basal p-selectin expression was . + . %, and increased to . _+ . % after thrembin-activation, and to . + . % in adp-stimulated samples. addition of sin- attenuated p-selectin expression to . - - % in thrombin (p<. , two-tailed paired t-test), and . + . % (p<. ) in adpactivated platelets. basal gp expression was . _+ . % and increased to . + . % in thrombin, and to . _+ . % in adp-stimulated samples. with sin-l, gp expression decreased to _+ . % (p<. ) in thrombin, and . : . (p . ) in adp-stimulated samples. conclusions: these data implicate, that no leads to a significantly reduced activation of surface molecule expression in thrombin and adp-stimulated platelets. in addition, flow cytometry might be a useful tool for studying modulation of platelet activation by no or no-releasing compounds. introduction: acute cadmium poisoning is very rare. on initial presentation may mimic metal-fume fever, but acute inhalation cadmium toxicity may produce fatal chemical pneumonitis. case report: we present a case of acute fatal respiratory failure secondary to cadmium-fume irthalation. a year old patient was trasferred from another hospital with acute respiratory failure presumably due to pneumonia. the last days before he had had commom cold symptoms. he had been cutting with a welder during one hour without any respiratory protective measure. three hours after exposure he developed progressive dispnea and was admitted to hospital. with presumtive diagnosis of respiratory infection, antibiotics were begun, however be failed to improve. all microbiological studies were negative. chest x-ray showed bilateral diffuse infiltrates. on seventh day he needed intubation and mechanical ventilation and on th he was admitted to our icu. antibiotics were stopped and new microbiological studies were performed including brochoalveolar lavage and virologic studies. all results were negative. he developed progressive hipoxemia and hipercapmia and finally, multiorganic disfunction syndrome. he died days after exposure. the metal he had been working with was a % cadmium alleation. blood cadmilam concentration days after exposure was . mcg cd/g cr, and urine cadmium concentration was . mcg/l. on postmortem examination, tissue cadmium concentrations were: blood ng/ml, liver ng/g, kidney ng/g and lung ng/g. these values confirm that cadmium was the cause of the fatal respiratory illness in this patient. conclusion: this case evidences the considerable hazard of acute poisoning after inhalation of eadmium-fume and stresses the need of appropiated safety measures against metal-fume poisoning. aim : lactic acidosis is considered the hallmark of cyanide poisonirig. however, the relationship between plasma lactate and blood cyanide levels has not been determined. the aim of this study was to determine the significance of plasma lactate concentration (plc) during the course of cyanide poisonings. methods : the patients were included according to the clinical suspicion of pure cyanide poisoning at the time of presentation. fire victims were excluded. serial blood samples were collected before and after intravenous hydroxocobalamin (hoco). blood cyanide concentration (bcc) was measured colorimetrically. plc was measured enzymatically. results : patients were studied. on admission, plc ranged from . to mmol/l, and bcc from . to gmol/l. mean systolic blood pressure was • mm hg, mean arterial ph . • . , mean anion gap was . + . mmol/l and mean pao . • . kpa. three patients died. before antidotal treatment, there was a significant correlation between plc and arterial ph (p = . ), anion gap (p = . ) and bcc (p = . ) but not with heart rate, pao , paco and blood glucose, or blood pressure. during the whole course of the poisoning, a plc _> retool/ was a sensitive and specific indicator of a blood cyanide concentration > ~tmol/ . sustained catecholamine administration reduces the correlation coefficient. conclusion : baseline measurement of plc allows assessment of severity of acute cyanide poisoning. thereafter, plc may be used to assess the adequacy of antidotal treatment, more especially in patients not requiring sustained infusion of catecholamines. aim: the aim of this case report was [o study the correlation between the plasma lactate levels and several clinical, biological, and toxicological parameters serially measured during the course of a cyanide poisoning treated with a high dose of hydroxocobalamin. a -year-old male ingested potassium cyanide leading to cardiac arrest. cpr was performed prior to hospital arrival where the patient received g hydroxocobalamin. sbp rapidly returned to normal allowing withdrawal of epinephrine. the patient remained comatose and died from brain injury days after the ingestion. methods plasma lactate and blood cyanide levels were measured serially. blood cyanide levels were measured using a colorimetric method.~ plasma lactate levels were measured using an enzymatic method. for correlation spearman rank correlation test was used. results. initial plasma lactate and blood cyanide levels were mmol/l and gmol/l, respectively. there was no overall correlation between sbp and either blood cyanide or plasma lactate levels. similarly, there was no overall correlation between arterialvenous oxygen saturation difference with either blood cyanide or plasma lactate levels. in contrast there was a strong correlation between blood cyanide and plasma lactate levels (r= . , p< . ). the time-course of the blood cyanide concentrations was described by a mono-exponentiai decay (r = . ) with a blood half-life of . h. similarly, the time-course of plasma lactate levels was described by a mono-exponential decay (r = . ) with a blood half-life of . h. discussion. in this case of acute human poisoning, sbp was a much poorer indicator of continuing cyanide effect both before and after antidotal treatment, than was lactate production. this suggests a potential clinical role for following serial plasma lactate levels as a marker of the evolution of cyanide toxicity. aim : cyanide (cn) poisoning in fire victims is frequent and rapidly fatal. in a prospective study we tried to assess the clinical tolerance of a high dose of hydroxocobalamin (hoco) administered at the scene of the fire in fire victims suspected of cn poisoning. methods : inclusion criteria : soot in mouth or sputum ~ any degree of neurological impairment. exclusion criteria : children, pregnant women, burns of total surface body area > %, multiple trauma. protocol desigrl following examination and the collection of a blood sample in dry heparin, a g dose of hoco ( g in case of cardiovascular collapse) was administered intravenously over min. the systolic blood pressure was monitored before and after the administration of hoco, and one hour later. results : there were females and males. the mean blood cn concentration was • pmol/ . the mean blood carbon monoxide was . • . mmol/ . nineteen fire victims eventually died. among the non-cn-intoxicated patients (blood cn < ~mol/ ), there was no significant change in arterial blood pressure. in the cn-intoxicated patients (blood cn > gmol/ ) a significant increase in blood pressure was observed both immediately (p < . ) and hour later (p < . ) after the admistration of hoco. no allergic reactions were observed. conclusions : in fire victims with cyanide poisoning, the administration of a high dose of hydroxocobalamin was associated with an improvement in systolic blood pressure. hydroxocobalamin is well tolerated in fire victims without cn poisoning. objectives: tricyclic antidepressant (tca) overdose can lead to serious complications including cardiac arrhythmias [ ] . because of the known risk of early deterioration and the implication for management, emergent evaluation is essential. we determined the diagnostic usefulness of the electrocardiogram (ecg) in tca poisoning. methods: retrospective study of all patients with tca intoxication (pos. ,toxicology screening in urine and/or pos. history) in a -beduniversity hospital from through . the severity was graded with mild= no symptoms or agitation; medium= disorientation, somnolence, tachycardia, or convulsions; and sever~ coma, significant arrhythmias or death. we analysed the first ecg after admission with a special emphasis on qrs-and qtc-intervals and the terminal ms frontal plane qrs-vector (tqrs), which, was reported to lie typically between + and * + + • the best correlation with severity grade was found with qrs-and qtc-duration (p= . ), the tca-dose (p= . ) and hf (p= . ); tqrs did not correlate. patients died ( . %). conclusion: qrs-and qtc-prolongation in the admission ecg, and the reported dose of ingested drugs are useful predictors for severity of poisoning due to tricyclic antidepressants. we did not find additional benefit in determining the terminal ms frontal plane qrs-vector. objectives: since treatment of amphetamine poisoning is usually symptomatic and often associated with a fatal outcome, a search for specific drugs to help the amphetamine-intoxicated victim is sorely needed. methods: we report a case of a suicidal ingestion of large amounts of the amphetamine-derivative , -methylenedioxy-ethamphetamine (mdea) and heroin (diacetylmorphine) and present the hypothesis that the two drugs produce opposing clinical effects. results: a year old caucasian male was admitted to the emergency ward because of acute-onset confusion. at presentation, he was agitated and showed increased muscular rigidity. he had taken tablets of "eve" (mdea, approx. g) and g of "smack" (heroin) by oral route approximately h before admission. because of rapidly progressive tachypnea and exhaustion, the patient was intubated and ventilated. the serum concentration of "eve" on admission was ng/ml (lethal range - ng/ml). trace amounts of cocaine and substantial amounts of heroin ( ngtml; mean value in heroin-related deaths: ng/ml) were also found in the serum. the patient was successfully weaned from the ventilator by day and recovered without persistent neurobehavioral disturbance. despite high serum levels of both drugs, the patient did not present with the classic signs and symptoms normally seen during intoxication with these drugs. amphetamines in general, and mdea in particular, have opposite clinical effects to heroin or diacetylmorphine. none of these were however present in the case presented despite the high ingested doses and the serum levels in the lethal range. conclusions: the fascinating fact that, apart from the respiratory depression, none of the clinical signs reported after massive overdose with these two drugs were present, might be attributed to the opposite pharmacological effects of mdea and heroin. we believe that the patient unwittingly saved his own life by the oral coingestion of both mdea and heroin. our clinical data raise an interesting point about the pharmacological treatment of acute poisoning with amphetaminederivatives. introduction: the acute attack of aip still carries a significant risk of mortality of around %. a succesful outcome depends on early diagnosis, removal of pricipitating factors and provision of intensive supportive therapy. objectives: twenty one patients ( females, male) with documented aip were seen over a -year period in the university hospital. patient was in clinical remission and were with the acute attack of aip, among them with respiratory paralysis were required artificial lung ventilation and -assistant ventilation with peee pathologic treatment during the attack was normosany, adenil, androgenes, glueosa, riboxin parenteral and enteral nutrition via nasogastric tube. symtomatic treatment -pethidine, propranoton, antibiotics, bronchoscopia. methods: intermittent phasmapheresis was performed on patients. the following measurements were peformed: level of porphobilinogen (pbg) in the wire and delta-aminolevulinic acid in the blood. hematological and routine chemical evaluations, hepatic, hemodynamic and respiratory function. results: after plasmapheresis the median pbg excretion (normal range - mkg per/ kgr creatinine) fill from mkg on admission . mkg, then on - day raise to mkg and then during treatment with normosong and prasmapheresis lowest level was . mgk. fatalities occured in two females during attacks with proforma cerebral involvement and patients attained clinical remission. conclusion: after therapy with plasmapheresis normosong we found that there was consistently reduce the urinary excretion of pbg and shortening the duration of the acute attack. objectives: pigs has been reported to present with a higher pulmonary arterial pressure (ppa) and stronger pulmonary vascular reactivity than many other species, including man. aim of the present study was to compare pulmonary vascular impedance (pvz) before and after embolisation in weight-matched adult dogs and minipigs. methods: we investigated pvz spectra in anaesthetized and ventilated (fio . ) minipigs and dogs. after baseline measurements the animals were embolised with autologous blood clots to reach a ppa above mmhg. results: flow ( and ppa matched pvz data (mean-+sem) are shown in the table. [zo = hz impedance (z; {dyn.sec_em- }); zl = first harmonic z; zc = characteristic z; z phase = first harmonic phase a@e {radians}; fmin = frequency of pvz the first m{n~mam; *, f p at least < . between dog and minipig, and before v~. after embolisation respectively]. before case report: a -yr-o]d woman affected by legs recurrent thmmbophlebitis, was admired in medmine department for tach.~pnea, chest pain, tachycardia and cyanosis. before starting two-dimensional transesophageal echocardiography (tee) to confirm the suspicion of pulmonary embolism, she suddenly had ventricular fibrillation. resuscitation and defibrillation were readily performed. when sinus rhythm was reinstituted she was in superficial coma with preserved corneal and light reflexes: right hemiplegia, poor perfusion and h~posphygrma of the left arm. tee showed dilation of rigth ventricle (rv), incomplete occlusion of pulmonary arter~ (pal at it~ hifurcation, severe tigth-to-left shunt through a patent foramen ovate, paradoxical embolism with incomplete occlusion of left subclavian artery mechanically ventilated with vt= ml, rr= /mm, fio =l, the patient had ph= . , pao = mmhg and paco = . systemic bp was / mmhg and hr= b/min with low dose epinephrine ( . g/kg/min) a thrombolytic infusion (rtpa: mg/ h) through a peripheral vein was started tee imaging and clinical status hours later were unmodified. a new rtpa infusion was performed through the pulmonary hole of a swan-ganz catheter with the tip close to the embolus. one hour later pa pressure decreased from / mmhg to / mmhg, etco increased from to mmhg and sao improved from % to % three days later the parietal, spontaneously breathing and with normalized tee scans of rv and pa, was transferred to rehabilitation service to perform physical therapy. conclusions: massive pulmonary embolism in a patient with patent foremen ovale, paradoxical embolism and refractory hypoxaemia was unaffected by systemic rtpa infusion, while intrapulmonary rtpa administration dramatically improved gas-exchange, hemodinamics and the general conditions of the patient. the presence of a large rigth-to-left _atrial shunt and the rapid rtpa metabolism could likely explain the effectiveness of its intrapulmonary administration in front of failure of systemic thrombolysis. introduction. cardiogenic shock during massive pulmonary embolism (blpe) is due to an acute increase of right ventricle (rv) afterload and possibly rv ischemia causing a failure of rv pump function. the rec~;mmended therapeutic strategies are: xoiume augmentation ~n ~rder m }ncrease rv pre-h~ad, adrenergic drugs to increase t'ontractillly and maybe coronary perfusion, fibrinolytic drugs to delermine clot lysis. there have been several reports of noradrenaline (na) as a useful drug in this setting for its sluing ~z, but also ~, properties. case report.an obese },ears old woman was transferred to our icu for tetanus. she was given the usual antibiotic and immunoglobuline therapy. l'wo thoracic epidural catheters were put in place at different levels and replenished with marcaine qid. a continous infusion of sedation (diazepam § was started together with mechanical ventilation. curarization ~,as given occasionally. fraxiparine . /die was used for prophylaxis of thrombotic disease, on day th at . a.m. she started to be hypoxic (sa %), tach ,tardic l l(i b/rain.), her blood pressure(rp) dropped frum norma~ values to r mm/hg, the central venous pressure (cvp) raised [rom lb to mm/hg and the end tidal co was mm/hg lower than one hour before. the physical examination of the chest revealed a clear bilateral ventilation and the chest x-ray was normal apart from an elevation of the :tiaphragm as compared to the previous. an e.c.g. showed sinus tachycardia, right bundle branch block and a possible inferior necrosis (which was already present on admission). a trans-thoracic echozardiography was performed which showed "an acute overload of the right centricle wilh remarkable dilatation. tricuspidal regurgitation ++. paradoxical movement of septum. small left ventricle with normal wall kinetics". the cardiac enzymes were later shown to be normal. an acute massive pulmonary embolization was assumed m be present.. a bolus of streptokinase x i(i u. was given fonowed by a continous infusion . two liters of colloids were also given in a sh~rt time, two hours later the patient was still deeply hypotensive, hypoxemic and anurir(bp / mm/hg, cvs mm/hg, spo %) despite a cominnus infusion of dobutamine fag/kg/min and adrenaline . ~tg/kg/min. at this stage a bolus of aoradrenaline ,g was given followed by a cnntinous infusion of . !*g/kg/min. an immediate improvement of the hemodynamics was noticed and one hour later the bp was / mmhg, the cvp mm/hg, the sao % and a brisk diuresis started. the hemodynamics kept stable and weaning from vasoactive drugs was achieved within two days. one month iater the patient was discharged home in good conditions.. con c i u sio n.ne administration may help to restore rv coronary flow and ;~ump function during mpe. aeute putmonary t~omboembo~sm [ffe) cou be mamfeslated with either respiratory or cardiovascular syndromes or both. the arm of the study was to establish leading respn'atory symptoms, frequency and form of the roendganographic (rig) changes as well as blood gas disturbance degree in acute pte with dommam respiratory disease appearance. the study includes retrospeotive analysis of i pte patients (pts), males (average age , yrs) and .q females (average age , yrs). they were admitted at university, olinie" with suspection ofpleuropnlmonary disease, including pte. final diagnosis of pte was based o~ evident risk factors in , % of the eases (deep venous thrombosis, surgery, trauma, imobilisation, malignancy ere), acceptable clinical, rtg, sdntigraphic and laboratory findings, as well as deep veins examination by dopple~-sonographie and radioisotopic -~enogmphy. respiratory symptoms appeared in all cases: sudden pleural pain ( %), dyspnea ( %), hemoptysis ( %), cough ( %) with association of two or more symptoms in %. chest xrays findings were abnormal in % with diaphragmal elevation ( , ~ lung opaeilies ( , %), atelectasis ( , %), plemal effusion ( , %), main pulmonary brancah asimetry ( , ~ oligemia ( %), heart shadow changes ( , %) and pulmonary arteries "cut off' ( , %). the association of two or more abnormalities was found in , % while normal chest x-rot was found in ~ of the cases. hypoxemia with pao < , kpa was found in , % followed with hypocapnia and respiratory alealosis in , % in , % of the gas exchage analysis were within normal limits. among cardiovascular symptoms short syn~cpa appeared in i , %, ecg changes-st q t type in "~ , %. results show high frequency of positive ~g findings in pte pts that is opposite to oppinion that chest x-ray in acute fie is the most ofran normal. leading symptoms are pleural pain and dyspnea, while hemoptysis were found in a half of the study group. blood gas changes were present in two thirds of the cases. kakkar, in his classic work ,clearly demonstrated the efficiency of low doses of heparin in prevention of deep vein thrombosis (lancet : , ) .after this first study the application of heparin prophylaxis became more and more diffused until to be considered a routine in many surgical departement.actually application of blood saving technique induces postoperative hemodilution effect. in that condition prophylaxis routinely applied seems a nonsense and can be at risk for postoperative hemorrhage. methods: to analize this problem we compared patients arrived in our intensive care unit (i.c.u.) in. : (group a) with arrived in : (group b) .every patient was operated for major abdominal surgery.in each one we considered the hemoglobin (hb) value,hematocrit(hct), and coagulation pattern (c.p.) at the arrive in i.c.u. and hours later. the patients was also divided in those receiving heparin prophylaxis (i) from not treated patients (ii) results:the application of blood saving technique clearly appears from the hb and hct level wich have a mean value of , +/- , (hb) and +/- (hct) in group a while in group b mean value are , -/- , (hb) and +/- (hct).patients of group a (ii) are the only one where a pathologycal c.p. with statistical significance has been demonstrated.in this goup we got four cases of evidence of venous thrombosis and one of pulmonary embolism.in patients of group b(i) we encontered the incidence of two cases of severe hemorrhage despite the absence of statistical significance in c.p.modifications. oxygen desaturation during broncho-alveolar lavage: role of oxygen saturation monitoring in prevention of acute respiratory insufficiency g. galluccio, b. valeri, s.batzella, m. di lazzaro*, servizio di endoscopia toracica, ospedale forlanini, rome, italy * servizio die anestesia a rianimazione, osp. forlanini the broncho-alveolar iavage is a diagnostic procedure employed in interstitial diseases of the lung. it requests the introduction through the working channel of a fiberoptic bronchoscope, after occlusion of a segmentary bronchus, of aliquots of saline solution at c, subsequently gently reaspired, in order to remove cells and proteins from elf (endoalveolar lining fluid), which is related to interstitial medium. bronchoalveolar lavage induces deep effects on pulmonary function: -lowering of the alveolar surface of exchange; -shunt effect, depending on the perfusion of non-ventilated districts; -increased pulmonary arterial pressure, due to hypoxic vasoconstriction; -decrease of lung compliance. in this report the authors present the result of oxygen saturation monitoring in a group of patients with interstitial lung disease, who underwent diagnostic broncho-alveolar lavage. in most patients with severe interstitial involvement, the lavage performed without supplement of oxygen induced a severe fall in the oxygen saturation during the late phase of the procedure. if supplementary oxygen was delivered during bronchoscopy, since its beginning, only slight modifications of the curve were detected. in patients without thickening of interstitium, in whom the lavage was performed in order to obtain material for bacterial or cytologic examination, no modification of oxygen saturation was observed in standard procedure. as conclusion the authors strongly reccomend monitoring oxygen saturation in patients with radiologic evidence of interstitial involvement also in patients with no evidence of dyspnoea. g. galluccio, b.valeri, s.batzella, m. di lazzaro*, servizio di endoscopia toracica, ospedale forlanini, rome, italy * servizio die anestesia a rianimazione, osp. forlanini the treatment of choice in patients with alveolar proteinosis consists of pulmonary lavage. this procedure requests the introduction, through the working channel of a fiberoptic bronchoscope, segment by segment, of aliquots of saline solution at c, subsequently gently reaspired, in order to remove the proteins deposited in the alveolar spaces. the method is very similar to that used in bronchoalveolar iavage, a diagnostic procedure used to obtain cells and substances from elf (endoalveolar lining fluid), which is related to interstitial medium. as known, bronchoalveolar lavage induces oxygen desaturation, because of shunt effect. understandably, one lung lavage has remarkably more deep effects on pulmonary function than bronchoalveolar lavage, for the amount of fluid introduced, the length of the procedure and the conditions of controlaterai lung. in this report the authors present the result of oxygen saturation monitoring in a patient who underwent pulmonary lavage for alveolar proteinosis. in the lavage performed without supplement of oxygen a severe fall in the oxygen saturation was observed during the late phase of the procedure. if supplementary oxygen was delivered during bronchoscopy, since its beginning, only slight modifications of the curve were detected. as conclusion the authors strongly reccomend the subministration of supplementary oxygen in pulmonary lavages, also in patients with excellent respiratory conditions. a. b. dublisky prof., m. r. isaakjan ass., v. a. zasukha, s. m. vinichuk prof., v. p. tserty ass. prof., chair of anaesthesiology, resuccitation and medicine of catastrophes, neurology of ukrainian state medical university, kiev, ukraine. objectives: detection of plasmophoresis's influence of results in treatment of ishemic insult. methods: we ve investigate patients with ishemic insult, treated with reverse plasmopheresis in complex treatment. after primary infusive therapy we took ml of patients' blood and separated it within min with rotation frequensy of /rain. after separation of erythrocytes from plasma, the latter has been returned to patients. we made - procedures during - days. hemoglobin, hematokrit, time of blood coagulation were determinated. the brain blood flow in internal carotid arteries, regional volum brain blood flow and total brain biood flow were evaluated with tetrapotar chest rheography and tetrapolar rheoencephalography. obtained date were comparised with control group after traditional treatment. results: it was found that after reverse plasmopheresis the hemoglobin and hematokrit levels decreased significantly in studied patients' plasma (from + . g/l to _+ . g/ and from + . % to _+ . % respectively). the time of blood coagulation by lee-white has increased by - . times (up to - rain). the level of brain blood flow has been increased significantly after reverse plasmopheresis in comparison with control group. the following tests of brain blood flow have been increased: a) the total volume brain blood flow from . + . ml/min to . _+ . ml/min (p < . ); b) the regional brain blood flow from . _+ . ml/min to . + . ml/min (p < . ); c) the brain blood flow in internal carotid arteries from . _+ . ml/min to . + . ml/min (p < . ). conclusions: the use of reverse plasmopheresis in complex treatment of patients with ishemic insult aiiows to improve rheological blood patterns, helps to increase volume brain blood flow. it results in quicer reparation of neurological functions. objectives: a prospective evaluation of the efficacy of continuous infusion of verapamil in reducing the incidence of postoperative atrial fibrillation after pulmonary surgery. methods: a total of consecutive patients, on verapamil, on placebo was included after lobectomy or pneumouectomy. a loading bolus of verapamil ( mg over minutes) was followed by a rapid loading infusion ( . mg/min) for minutes and finally a maintenance infusion ( . rag/rain) for hours. results: a mean plasma level of verapamil of ng/ml was obtained only after more than hours. atrial fibrillation occurred in five out of patients who tolerated the verapamil infusion, and in out of patients on placebo (p = . ). verapamil infusion was not tolerated in patients because of hypotension or a heart rate of less than /min, within hours of the start of the therapy. when atrial fibrillation occurred, the ventricular response, mean _+ sd, was not significantly slower during verapamil infusion ( + ) compared to placebo ( + ). conclusions: because of its frequent side effects and the only modest efficacy verapamil should not be considered for prophylactic therapy of atrial fibrillation after pulmonary surgery, and is probably not a good first choice for slowing the heart rate in case of rapid ventricular response once atrial fibrillation has occurred in these patients. results: study of haemostasis in these patients has showed deep disturbances of blood coagulation. fibrogen level has reduced to . + . g/l, fibrinogen and/or fibrine degradation products concentration have enhanced to . _+ . g/l, monofibrin soluble complex concentration to . -+ . g/l, blood plasmin level was enhanced to . + . mmol/ , plasminogen proactivator level was also enhanced to . + . ram, plateletes aggregation has decreased to %. after plasmopheresis aggregation was decreased in . times. it has been connected with decrease of fibrin and/or fibrinogen degradation products level and level plasmin in . times, and plasminogtnt activator level in . times. at the same time we have observed increase in total antifibrinalitic activity of blood in . times. activity of activators plasmine and plasminogene proactivators has decreased in . times and in the same time activity of activation inhibitors and antiplasmines has increased in times. conclusions: plasmapheresis leads to considerable improvement of a general condition and reduction of the haemorrhagic syndrom's sings (controlling of gastrointestinal haemorrage, reduction of intensity of subcutaneons haematoma). evaluation of continuous cardiac output (cc ) monitoring based on thermodilution technique in critically ill patients. methods: cardiac output (co) was monitored continuously using a modified pulmonary artery (pa) catheter, on which a heating filament is located and by which energy is transmitted to the circulating blood. a microprocessor calculated co by a new algorithm. standard bolus thermodilution technique ( ml of ice-cold saline solution) was used to compare cc with intermittent bolus cardiac output (ic ) measurements. the following subgroups were prospectively studied: i. heart rate (hr) > beats/min, . cardiac output > i/min . cardiac output < . i/min, . rectal temperature > . ~ and . pa catheter was inserted for more than days. results: a total of pairs of ic and cc measurements were obtained from the patients. bias (ico measurement minus cc measurement) of all measurements were . • i/min and the % confidence limits (mean difference• were - . / . i/min. also in the subgroups, cc measurement agreed closely with ico measurement (c > i/min: bias= . • i/min; co < . i/min: bias=- . • i/mln). elevated temperature and prolonged lay-days of the pa catheter did influence agreement of cc measurement with ic measurement neither (> ~ bias= . • i/min). conclusions: monitoring of cc using a modified pulmonary artery catheter with a heated filament has proven to be accurate and precise also in the critically ill when compared with "standard" intermittent bolus thermodilution technique. this method enhances our armamentarium for more intensive monitoring of these patients under various circumstances. background: the number of patients who need coronary artery surgery was) grows every year. most of these surgical operations are with extrar eircuiation (ecc). since january , this surgery is made without ecc in selected patients in our hospital. this technique is exceptional in spain. this type of surgery has proved useful in patients requiring revascularization of the left anterior descending, eireunflex or right coronary artery (not for grafting the pos~tefio~r descending branch}. blethods and results: since , patients aged to years (mean years) underwent cas without ecc. the mortality in programmed surgery was %. no patient was reexplored for hemorrhage. the mean values of some clinics parameters v~ere: a) blood requeriments: units per patient, b) need of mechanical ~entilation: i , hours, c) postoperative bleeding: cc, d) days at icui , . we used the student % t test or fisber~s exact test to compare these results with the mean values of surgery with ecc: a) blood requeriments per patient (p< , ), b) need of mechanical ventilation: hours (p< , ), c) postoperative bleeding: cc (p< , ), d) days at icu: (p< , ), e) programmed surgery mortality: % (p< , ). conclusion: our limited experience shows that this surgery is an alternative in the treatment of coronary disease, especially for aged patients with associated pathology and in jehova's witness. the need of mechanical ventilation, days at icu, blood requeriments and morbi-mortality were fewer than surgery with ecc. to study the hemodynamic and antiarrhythmic influence of ace-inhibitor enalapril in acute myocardial infarction (mi). methods: holter ecg monitoring, heart rate variability analysis, echocardiography ( and l days after beginning of the treatment), stress-echocardiography and stress ecg ( - -th day after the onset of mi). enalapril was included into the treatment of pts with mi (study group), with normal or increased blood pressure, from the -st day of the disease. the data were compared with pts treated without enalapril (control group). results: silent ischemia during stress-test was registered in pts of the study group and of control group, the arrhythmia episodes during stress test -in and pts and episodes of silent nocturnal isehemia -in and pts correspondingly. enalapril importantly attenuated the hypertensi~re re~aetioh % stress test. in pts of the study group the number of perifocal hypokinesis zones decreased; in the control group it didn't change. the quantity of ventricular extrasystoles in the patients of the study group decreased by %; the heart rate variability indices improved as well; in the control group the character of ventrieulir arrhythmias, heart rate and its va]~i~bili%y didn't change significantly. conclusions: the inclusion of enalapril into the treatment of mi is a useful t ol to improve hemodynamie parameters and decrease the incidence of ventricular arrhythmias. objectives: to study left ventricular (lv) systolic function in the patients with acute myocardial infarction (ami) before and after peroral captopril test. methods: the original echocardiographic parameter of lv contractility, "coefficient of effective systolic function" (cesf), was proposed in the study. cesf is calculated from lv stroke volume (sv), obtained from doppler aortic flow in lv outflow tract and lv end-diastolic diameter (edd): cesf =sv/edd. the study included patients with ami, who had local lv dyskinesia and global lv systolic dysfunction (ef< %). besides cesf, the ejection fraction was calculated before and after administration of mg eaptopril (on the fifth day of ami) by methods of bullet and simpson. results: the dynamics of these parameters, as well as heart rate (hr) and mean blood pressure (bp), is shown in the tabte. before cal~topril ef (bullet) . • . ef (simpson) . introduction: the cold system is a monitoring system for measurement of right (copa) and left (coart) ventricular cardiac output, cardiac function index (cfi), fight ventricular ejection fraction crvef), fight ventricular cnddiastolic volume (rvedv), intrathoracic blood volume (!tbv), global enddiastolic volume (gedv), lung water (etv) and excretory liver function (pdr). patients and methods: pts have been monitored by the cold system. above mentioned parameters are measured by thermal dye dilution and a fiheroptic femoral artery catheter. copa, rvef and rvedv measurements additionally were compared to measurements by the baxter explorer. :::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: ;;;k;;;;i cov (%) explorer ! ! [ gedv, itbv and pdr showed a significant decrease dufing the first - h after the operation, cfi and rvef si~canfly improved after k wheras etv showed a i~ in the early postoperative phase and fell to normal ranges at h. comparison of cold/explorer m~ements sb wed good correlations. discussion: concerning m ~toring of ri,ght ventric~ar function cold and explorer can he seen as equal. rvef gives an ar report about the performance of the right ventricle without use o f echocardiography. measuring itbv and gedv ~ improve ~gement and con~ol of th.e volume status, monitoring etv helps preventing lung edema. pdr shows good corre|ati n to liver blood chemistry and is bedside avai|ab|e. thus the cold system offers additional parameters for comprehensive m~nitofing of pts. ~e~ ~c surgery. obiectives: to evaluate the influence of an a!'~ered cardiac function on the cardiovascular response to the increase in oxygen demand induced by an increase in core temperature. methods: this preliminary study included adult critica!ly ill patients monitored by arterial and pulmonary artery catheters in whom thermodilution cardiac index {ci) and arteria! and mixed-vef)ous blood gases measurements could be obtained before and after an acute change in core temperature of at least . ~ (max rain apartl the patients were separated in two groups according to their cardiac function: patients had an impaired cardiac function as defined by a history of cardiac disease and an ejection fraction below % and patients had normal cardiac function. results: individual data are shown in the figure. in contrast to the control group (continuous line) in which c! increased without changes in oxygen extraction ( er), the q er in patients with impaired cardiac function (dottled line) increased without changes in ci. conclusions: the increase in oxygen demand associated with changes in temperature is met by an increase in c! in patients with unaltered cardiac function and in an increase in o er in patients with altered cardiac function. temperature should be taken into account in the assessment of the adequacy of cardiac output in patients with impaired cardiac function. objectives: to define the hemedynamic and metabolic response to physical therapy(pt) in relation to the type/level of sedation and the cardiac status in icu patients. methods: we studied mechanically ventilated icu patients ( • years) in stable hemodynamic status (no change in vasoactive treatment for at least hours), separated in groups: group = deep sedation, cardiac dysfunction required dobutamine (n= )r group = deep sedation (barbiturates), unaltered cardiac function (h=lo), group = moderate sedation, altered cardiac function (h= ) and group = moderate sedation, unaltered cardiac function (n= ). complete hemodynamic data, arterial and mixed venous blood gases, respiratory gas analysis (metabolic cart ccm, medgraphics) were obtained at baseline ( x) and twice (q. min) during leg mobilization. data were analyzed by anova. calcium channel blockers were used in complex preoperative preparation of hypertensive surgical patients. patients were allotted to groups based on their hemodynamic profile: hypokinetic: ejection fraction (ef)< . , patients; eukinetic (ef> . ),i patients and hyperkinetic (ef> . ),i patients. the most noticable change in hemodynamics was in the hypokinetic group: ef and cardiac output (co) were significantly decreased (p< . ) while systolic arterial pressure (sap) (p< . ) and peripheral resistance (pr) (p< . ) were elevated. the results showed that in hypokinetic patients on nifedipine ef (p< . t) stroke volume (sv) (p< . l) and co (p< . ) were increased while pr(p< . t), sap(p< . ) and diastolic arterial pressure(p< . ) were decreased. eukinetic type patients also showed an increase in ef,albiet to a lesser extent,than in the hypokinetic group. increased sv and co(p< . ) were observed in eukinetic patients though this was to a lesser extent than in the hyperkinetic group. in the hyperkinetic group of patients nifedipine had no effect on the aforementioned parameters except for a decrease in sap(p< . i). nifedipine increased ef in all hypokinetic patients. comparative results show that isoptin was less effective than nifedipine in decreasing peripl~eral vascular resistance and had a depressive effect on the myocardium. it can be concluded that the action of calcium channel blockers normalizing the circulation in the hypertensive surgical patient depends on: the condition of myocardium, the patients hemodynamic profile and their pharmacological properties. they were most effective in the hypokinetic group. zalo/nthinos e., daniil z. zakynthinos s., armaganidis a., kotanidou a., nikolaou ch..,roussos ch. critical care department, university of.athens, evangelismos hospital, athens, greece. introduction : surgical is the optimal treatrnent for ioculated effusions and the preferable procedure when multiple bands are seen in the pericardial sac by echo. patients : palients, post cardiac surgery, uremic ( men, women) with large pericardial effusion and clinical or echocardiographic findings of tamponade or both. these particular patients displayed numerous linear echo-dense bands and s~'ands crossing the pericardial space (in one of them a ioculated effusion compressed the left ventricule). one had aptt increased, four were mechanically ventilated. technklue : a fr polyurethane catheter with end and multiple side holes over ga needle was echo-guided to the ideal site (fluid abundant and closest to the transducer). the catheter was attached to a close system with a heimlich valve for continuous drainage (pneumothorax kit). subcostal entry was selected in one patient and chest wall in five. the patient's position was changed every hour at least. (we believe that the small changes in the position of the catheter and the mechanical breaking of the bands in relation with the movement of the heart assist the pericardial fluid to remove). results : in all cases only a small quantity of fluid was withdrawn in the first minutes( - ml) with some clinical and echo-findings improvement. the fluid was bloody or serosanuginous with high protein content (ht= % ,protein , gr/dl) in all cases. in first hours the mean volume of fluid removed was ml ( to ml). in that period echo showed no residual fluid. the catheter remained within the pericardium to days .. no complications are mentioned. conclusion : cardiac tamponade due to hemorrhagic high protein pericardial effusion in uremic and postcardiac surgery patients,, as it is revealed by echo dense bands, can be faced by -d echo guided perieardiocentesis. a -fr polyurethane catheter with multiple side holes, attached to a heimlich valve was effective to evacuate the pericardial fluid. no catheter was occluded though heparin infusions were not used. multiple changes of the patient's position may be fundamental. this -d echo guided pericardiocentesis performed in in~nsive care unit seems to be useful , safe and quick technique. determining the best inotropic drug represents a very serious problems. the use of more selective and potential inotropic and vasodilatative drugs does not always lead to improvement of hemodynamic parameters in patients with low cardiac output syndrome. this paper presents patients with acbp who need an inotropie support after extracorporeal circulation in first hours. the patients were divided into dobutamin et dopamine groups. the heart rate (hr). mean sistemic arterial pressure [map), central venous pressure (cvp). and termodilution cardiac index (ci) were measured. the measurements were without using inotropic drugs, and then using them after rain, min, and finally with one hour rate, within first hours. the statistical analysis shows that both drugs lead to an increase in hr in the first hour of the application. the final effect of dobutamine is no change in hr, whereas the effect of dopanime is very significant increase in hr. thus. an absence of taehyeardie response selects the dobutamine as a better choice. backeround: pulmonary vascular eadothelium possesses major metabolic functions, which when altered contribute to the development of serious pathologies such as ards. one such function is the conversion of angiotensin i to angiotensin ii, catalyzed by angiotensin converting enzyme (ace), located on the luminal surface of the endothelial cells. ace activity has been extensively studied in animals in vivo, by means of indicator-dilution techniques, providing: i) under toxic conditions, an early index of lung injury, and it) under normal conditions, estimations of dynamically perfused capillary surface area (pcsa). objectives: to validate the use of these techniques in matt: i) for pulmonary endothelial function assessment, and it) for pcsa estimation. methods: ace activity was estimated in ten adult haman volunteers, with no pulmonary medical history and normal pulmonary artery pressures, undergoing cardiac catheterization for coronary artery disease assessment. single-pass traspulmonary hydrolysis of the specific ace substrate hbenzoyl-phe-ala-pro (bpap; p.ci) was measured by means of indicatordilution techniques, and expressed as %metabolism (%m) and v=-hi( -m). bpap was injected as a bolus i) into a main pulmonary artery, and it) inside the right atrium, to assess ace activity in one and both lungs. we also calculated a,~,/i~, an index of pcsa. pulmonary plasma flow (fv) was determined by thermodilution. fp in one lung was estimated as . xf v. results: similar values of %m ( . + . vs . • and v ( . • vs . • were observed in both and one lung respectively. a~k~ decreased from • ml/min (both ltmgs) to :~ (one lung). conclusions: i) pulmonary endothelial ace activity and thus pulmonary endothelial function may be assessed in humans by means of indicator-dilution techniques, it) our data denote homogeneous pulmonary capillary ace coneentratious and capillary transit times in both haman lungs, iii) the % reduction of a=~/k~ in one lung suggests that this procedure can be used to quantify pcsa in man. (supported by the fonds de la recherche en saute du quebec and the national health system of greece). objective: verify whether antioxidant activity is higher in reperfused than in no-reflow myocardium after i.v. thrombolysis for acute myocardial infarction (ami). methods: patients with ami were included. blood for estimation of catalase (cat), glutathione peroxidase (gpx) and mn-superoxide dismutase (sod) was drawn before initiation of i. the mechanism of myocardial cell defence against free radicals is probably identical in both reperfusion and no-reflow phenomena. therefore, antioxidants cannot be used as reperfusion markers. objectives_ to evaluate the precipitating factors of hypothermic phrenic nerve injury following cabg with lima. methods: fifty two consecutive patients ( females), with a mean age of + (mean +sd) years were studied. during the ischemic arrest time topical hypothermia was obtained in al~ patients wffh ice slush and no cardiac insulation pad was used. all patients received a lima graft, with or whithout additional vein grafts. supramaximai, bilateral phrenic nerve stimulation was performed percutaneously preoperatively and whithin hours postoperatively. square wave stimuli of . msec duration were applied at the posterior border of the sternomastoid muscle. the compound muscle action potential of the diaphragm was recorded, using surface electrodes on the anterior chest wall. the time interval from the application of stimulus to the onset of diaphragmatic activity, phrenic nerve conduction time (pnct), was measured. values exceeding . msec were considered as abnormal. besults: preoperatively, all patients had normal (mean+sd) pnct, . • msec for the left nerve and . • mseo for the right nerve. on the first postoperative day, right pnct was normal in atl patients ( . • msec) , whereas left pnct was normal in patients ( . • msec) and abnormal in patients (incidence . %). in patients the left phrenic nerve was inexcitable and in patient left pnct was prolonged ( . msec). comparing patients with normal and abnormal pnct there was no difference in age, gender, number of grafts used, aortic cross-clamp and bypass time. however, patients with abnormal pnct had a lower preoperative ejection fraction ( • vs • p= . ). moreover, in all of them lima was dissected from its origin ligating all upper arterial branches, which provide the blood supply to the left phrenic nerve, whereas in those with normal pnct the small vessels originating from the upper to cm of lima were preserved (p= . ). conclusiojel~ a hypoperfused left phrenic nerve seems to be more susceptible to hypothermic injury during cabg with a lima conduit. objectives: to test if necessary interventions on systemic vascular resistance (svr) along with preset pump flew (q) during cpb could adversely affect autoregulatory response and cause vo shifts. methods: we studied males ( - yrs) who underwent cpb for cardiac surgery. at o oesophageal temperature - c we set pump flow at . i.m~ .min - . when map was higher than mmhg we calculated vo by using fick equation. then we infused sodium nitropruaside (sn) to control map at - mmhg for min and we calculated vq . without changing the sn infusion rate we set q at . i.m' .min " . ten min later we measured vo . we took vo changes into consideration if greater than %. statistical analysis using students-t-test for paired data and analysis of variance was used as appropriate. results: depending on the biphasic vo response to sn infusion during low and high q we classified pts in four groups (table). i. vo increases with sn and increases further during high q unmasking hypoperfusion and supply dependency. ii. vo increases with sn but the addition of high q results in systemic shunt. iii. vo increase during high q proves that vasodilatation can turn flow insufficient. iv. vo does not change with any intervention. the small number of pts and the wide standard deviation did not allow any statistical significance. conclusions: cpb is an interesting model for the behavior of microcirculation. intervention on svr and q can improve or impair effective regional oxygen delivery, resulting in either better perfusion or systemic shunt. vo monitoring seems necessary during cpb. preoperative cardiovascular optimization (opt) to ci > . l/min/m , _< paop < mm hg,and svri __< mmhg/ll/min/m decreases cardiac events (events) and mortality (mort) in peripheral vascular surgery patients (pvs). objectives: to determine if opt to the same endpeints decreases events in patients undergoing abdominal aortic aneurysm repair (aaar) and to study the r predictive value in pvs patients. methods: aaar patients and pvs patients were admitted to the s cu monitored with e pa and arterial catheters and treated to achieve opt. patients underwent surgery independent of success of opt data included demograph cs, incremental risk factors, laboratory and hemodynamic data pre, intra, a~nd postoperatively events, and mort. events included arrhythmias requiring treatment or prolonging the sicu stay > hours, a st depression > !mm or t wave inversion, an acute mr defined by a new q wave > . sec or cpk-mb > %. results are presented as means _ -. sd. opt was achieved in of ( %) and in of ( %) in the pvs and aaar group, respectively. events did nat differ between groups of ( , %) and of ( , %) in the pvs and aaar group, respectively (p>o. ). mort was of ( %) and of ( . %) in the pvs and aaar group, respectively (p > . ), while there was no difference in endpoints of opt between patients with and with.out events in the aaar group, there was a significant difference in ci between patients with and without events in the pvs group. of note, of ( %) patients who developed events in the pvs group had a ci < . in contrast to of ( %)in the aaar group. the positive and negative predictive value were % and % in the pvs and % and % in the aaar group. conciusione: f. the endpoints of opt used for pvs patients cannot be ~sed to reduce events in aaar patients; . pvs patients who have net achieved opt are at extraordinary risk of perioperative events; . preoperative card ovascu ar opt in aaar patients makes no difference in cardiac related events, background : comparison of the right and left filling pressures (cvp/pcwp ratio) is considered as a useful diagnostic clue : the normal ratio is _< . ; ratio >_ . may suggest right ventricul~ infarction while equalization of the cvp and pewp is a classic sign of tamponade ( ). however after cardiac surgery, many conditions (diastolic dysfunction, pulmonary hypertension, positive pressure ventilation) are susceptible to modify the '*normal" cvp/pcwp ratio. material and method : we determined cvp/pewp ratio in consecutive patients (pts) after uncomplicated cardiac surgery ( coronary artery bypass grafts; valvular replacements) measurements were made before and after tracheal axtubation. results :cardiac index : . _+ . /minlm~; laotate: + rag/i; cvp range : - rnmhg; pewp range : - mmhg. mean cvp/pcwp ratio before extubation is . ( % confidence imerval : . - . ) and after extubation, . ( % confidence interval : . -. . ), (ns, paired t-test). in % of the pts, cvp was higher than pewp. there are no correlation between the cvp/pcwp ratio and c! before (r = - . ) and after extubation (r = - . ) nor between the cvp/pcwp ratio and mean pulmonary arterial pressure (mpap), before (r = . ) and after extubation (r = - . ), discussion : cardiac performance is adequate according to ci and lactate. however the cvp/pcwp ratio is markedly higher than the "normal" (_< . ) ratio. this difference is not related to mechanical ventilation because the ratio is similar before and after extubation, nor to pulmonary hypetaension because of absence of any correlation with mpap, post-cpb diastolic dysfunction of the right ventricle could be an alternative explanation. in this group of pts, increased cvp/pewp is not associated with any impairment of cardiac performance (absence of correlation with ci), conclusions : cvp/pcwp ratio as high as within a large range of cvp ( - mmhg) and pcwp ( - mmhg) may still be considered as normal after cardiac surgery. this emphasizes the limitations of the hemodynamic monitoring after cardiac surgery (in comparison with echographic technics). careful analysis of the morphology of the cvp and right ventricular pressure curves (x descent, y descent, dip-plateau) is mandatory rather than relying on the quantitative assessment alone. reference : ( ) ntensive care.-university hospital -m~laga (spaink introduction. fibrinolitic treatment (ft) permits the treatment of acute myocardial infarction (ami) addressing the etiology, thereby eading to mproved ventncular function and a marked reduction m mortality. the main clinical oroblem is the reduced time of application. delay in hospitalization, which can be from to minutes, is potentially the most avoidable delay. method. to reduce delays in hospitalization, the following was carried out in two chases. audit: analysis of the time lapse from onset of symptoms to start of ft. showed that during "(he period june to december , patients with chest paros were treated within a eriod varying from minutes to hours from onset of symtoms. ages ranged from to (average , ), oelng males and females. they were glved initial ecgs to determine st mcreases suggesting ami. median t~me for this orocedure was l m.. potentia ami patients were then admitted to the coronary unit, [)atients, under age with no contraindications received ft the median time apse from admission to corona-y care and administration of ft was minutes ( . ), -he total median delay was minutes ~ -i h. min,~ delays n start of this procedure are grouped as follows: extra-hosdita delays (from onset of symtoms to arrival at hospital) diagnostic delays (from hospital arrival to ecg). treatment delays (from diagnosis to ft). objectives: protocol of procedure to implement a fast-track method. a protoco was drawn up with the object of reducing diagnostic delays to -i minutes and treatment delays to less than i minutes results. following rmplementatlon of this protocol in january , fts were glven, with an over all average delay of minutes. this fast-track method did not reveal any inappropnate ft or any increase m complications, conclusions: detailed study of the various times taken for diagnosis ane treatment of ami patients, showed up weaknesses in the system and improvements througn the protocol based on performence orocedures which led to a % reduction in the start of ft background: the importance of the early use of thrombo!ytic agents in acute myocardial infarction (ami) is based in the better remaining ventrictjlar function and smaller mortality rate because of the greater reperfusion and sma!ler infarction size, therefore, it is very impodant to apply this treatment to the maximum number of patients without thrombolytic contraindicati n, and within the minimun period of time. the "thrombolytic fast track" implementation allows to optimize the time to administrate thrombelytic agents avoiding multiple delays~ methodology: we anal!ze the application of thromboly c agents to patients with suspect of ami from the begin!ng of september until the end of february . in this time there are two different periods, during the first months thrombolytic agent were admin!strated at intensive care unit (icu), and during the second period we carried out a protocol of quick detection and thrombolysis therapy in susceptible patients at the emergency room in order to reduce the time to treatment. ma!n results are shown in the faffewins de ay h=hours m=minutes the implementation of the fast track does not need supplementary personal or equipment but a protocelized approach and training of the personal involved the main problem detected was the usual attendance overload of the emergency department that makes difficult to follow many structurated actions. conclusions: pratocqlized changes in the management of ami can significantly reduce the detay in the administration ef thrombolytic agents. it is not necessary to eomplet the procedure iq the emergency department, as the use of bolus schedules allows to begin the treatment in this area and to transfer the patient to icu afterwards. elective cardiac surgery. b calvet, f ryckwaert, p trinh duc, p colson. anesthesia -reanimation, hopital arnaud de villeneuve, montpellier, france. obhectives: the study was aimed at analysing the incidence of renal dysfunction following cardiac surgery and its prognosis (acute renal failure, post-operative morbidity and mortality). methods: two hundred and thirty seven patients (aged from to ) were consecutively operated on for elective cardiac surgery and retrospectively included in the study. patients with preoperative infections and operated on in emergency were excluded. each patient had preoperative invasive cardiac investigation with angiography and calculated ejection fraction (ef). anaesthesia, cardiopulmonary bypass (cpb) and cardiac arrest management were similar in all patients. general body temperature was reduced to - ~ c. renal dysfunction was defined as a % increase from baseline of serum creatinine. demographic data, asa, treatments, pre-operative creaunine level, cpb and clamping (axc) times, intra and postoperative use of inotrope, serum lactate level before surgery, at the end of cpb, at the time of admission in intensive care unit (icu) and on post operative day one and apache score were compared in patients with or without renal dysfunction using anova test for repeated mesures and x when appropriate. data are expressed as mean +__sd. p value less than . was considered statistically significant. results: thirtytwo patients ( , %) suffered from renal dysfunction. age, serum lactate level at the end of cpb, at admission in icu, at pod and apache level at admission in icu, intra-operative use of inotropes were statistically different in patients with or without renal dysfunction (p< , ). mortality rate was statistically different in patients with or without renal dysfunction(~, , % and %, respectively, p= , ). incidence of acute renal failure following renal dysfunction was , % ( patients required hemodialysis). conclusions: although our cdteria for defining renal dysfunction were very sensitive, the incidence of renal dysfunction following elective cardiac surgery was lower than communly accepted in the litterature ( ). however renal dysfunction appeared significantly associated with a poor prognosis. reference: -settergren g, ohqvist g current opinion in anaesthesiology , : - r ; , tzelepis, g. , , late complications were observed in % of cannulations: local infection in (i, %), catheter displacement by the patient in cases ( , %), catheter displacement during nursing care in ( , %) and malfunction in cases ( , %). conclusions: central venous catheterizations are followed by immediate and late complications in almost the same percentage acute poisoning with amphetamines (mdea) and heroin: antagonistic effects between the two drugs methods: after institutional approval and informed consent, selected patients ( _+ years) undergoing peripheral vascular surgery (n= ) or carotid endarterectomy (n= ) were investigated. patients included had either documented cad (n= ) or two or more (n= ) dsk factors (age > years, smoking, diabetes meltitus, hypertension, hypercholesterolaemia > mg/dl). -lead ecg recordings were carded out preoperatively, on ardval in the postanaesthetic care unit, and h, h, h, and h postoperatively. ecg recordings were analysed by an independent blinded cardiologist for signs of pmi (new st segment depression > . mv and/or new t inversion). in addition results: of the patients investigated developed ecg-documented pmi, % occurdng in the immediate postoperative phase. troponin i levels > . ng/ml were found in of these patients thus, comparing a cardiac troponin i cut-off level of ng/ml with intermittent -lead ecg recordings, we found a sensitivity of % and a specificity of % methods: demographic, clinical and ecg data were analyzed. . % of patients were male; . % female. cad was the most common underlying cardiac disease ( . %) and . % underwent open heart surgery. % received proeainamide for supraventricular and % for ven~cular arrhythmias. % received a loading dose. maintenance was provided by iv route in . % and by po in . % ( . %sr end . % ir). . % of patients were obese right ventricular function following cardiopulmonary bypass: is important the mode of myocardial protection we underwent this study in order to examine its safety and usefulness in pts with trustable coronary conditions (unstable angina ua the mean age for group a was • years, for group b • years, and for group c • years. a history of previous myocardial infarction was present in pts of group a, in of group b and in of group c. three pts in group a, in group b and in group c had previous coronary artery bypass grafting. the median time between the onset of symptoms and a was days ( - ) for group a we used a continuous fixed intravenous a infusion at a dose of the sn was % in groups a and b, % in c, and sp % for group a, (fixed defects included) and % for groups b and c. there was no difference of side effects among groups: chest pain (i pt -group a, pts -group b, and pts -group c), transient hypotension ( pt -group c), headache ( pts, group c), dyspnea ( pt -group a), while st depression was seen in pts of group b and in pts in group c. the rate of a infusion was decreased to /kgr/min in one group b pt due to development of chest pain s five year follow up of humoral immunity in paced patients athens polyclinic hospital, department of cardiology athens, greece author index a abiad ch bertschat, e betbes blanch, l del nogal saez e -meneza nolla, j. nolla-salas pilz~ u puig de la bellacasa e scarpa, n. van de wetering objectives: only % of patients suffering from acute guillain-barr@ syndrome (gbs) respond promptly to established therapies like plasma exchange or intravenous immunoglobulines. in contrast to serum, cerebrospinal fluid (csf) of gbs and ctdp patients contains enriched portions of antiexcitatory factors(i) and cytokines ( ) able to induce pronounced conduction block ( ). to reduce or remove such pathologic factors we introduced a technique with direct access to the subarachnoid space. methods: with informed consent we lumbally inserted g catheters in gbs-and cidp -patients under sterile conditions. some of them had not responded very well to established therapies. - ml of csf were withdrawn and retransfused by a bidirectional pump (flofors) after passing newly developed filters (pall). daily filtrations with several cycles were performed ( - ml) over one week. results: the gbs patients improved after days (median) for one grade (according to the gbs-scale from the gbs study group) . the ventilator dependent patients were weaned after days (median). patients not at all treated before ( / ) responded better than patients that had been pretreated ( / ) with plasmaexchange or intravenous immunoglobulines. / cidp patients drew benefit from treatment, stabilized iongterm. conclusions: csf-filtration is a relatively save and well tolerated additional procedure. the costs are considerably lower ( / ) than those for plasmaexchange or intravenous immunoglobulines. references:( )wsrz aet al: csf and serum from patients with inflammatory polyradiculopathy have opposite effects on sodium channels. muscle nerve ( ) . ( ) clinical observations were made in patients admitted to the clinic. they were in coma associated with acute alcohol intoxication.standard evaluations (ecg-monitoring, electrocardiography, neuromonitoring, studies of acid-alkali condition, biochemical and toxicologic investigation of blood and urine) prior to and following the treatment conducted were undertaken in all the patients.to correct irreversible impairement of functions twofold laser blood irradiation by means of alok- apparatus, the exposure within minutes, was carried out.the data obtained confirm more rapid coma withdrawal of the patients, reconstruction of the heart and central nervous system electrophysiologic indeces, reliable reduction in complications compared with the control group. objective: to know the actual incidence of the critical illness polyneuropathy(cip). setting: fourteen intensive/critical care unit beds, in bed university hospital, covering . inhabitants (majority rural area). the icu patients are medical, surgical and coronary, excluded the neurotrauma and neurosurgical. design: a conseculive and prospective study. all the patients admitted during three months, from january lth to march th , were eligible (patients with admittance diagnosis of polyneuropathy were excluded ). methods: patients with apache ii score > , at the admission and six days after admissions were included into the study protocol. diagnosis of sepsis, mof, and all the drugs administered days before were recorded. a complete neurological exam, by a neurologist, in absence of ssdatives and muscles reliant ( th, ~ and th days after icu admittance) was made. we evaluated the nerve and muscles function with and electromyography study in all patients, at same days. in some paeents with cip we performed a nerve biopsy. results: from patients ( apache ii score: . ) admitted in the icu, ( . %) enter the study protocol. seven ( , %) had an axonal polyneuropathy(cip), three very severe. only four of the patients with cip had pathologic clinical exam. apache ii score: cip vs non-cip was . vs . . the incidence of cip by diagnosis (cip/diagnosis) was: sepsis, / and mof, / . conclusions: . -we think that it is necessary to define the "critically ill" for some score, before designing a study to know the incidence of this syndrome. . -we think that the incidence of the cip is lower that the latest papers say. objectives:acute pancreatitis(ap)is becoming a more important problem among the elderly as the population ages. the increasing presence of gallstone disease,as well as the use of certain drugs,may also contribute to the occurrence of pancreatitis. methods:all patients(> years)admitted to our medical department over an eight year period were included.pancreatitis was confirmed by biochemical tests and imaging techniques.scores were developed using ranson's criteria and a multiple organ system failure(mosf)index . overall, patients were evaluated; ( %)had pancreatitis of unknown etiology . results:( )patients with pancreatitis of ~nlqnown etiology were sicker and had greater morbidity( % vs %),mortality( % vs %),and longer hospital stays than p~tierf~ with pancreatitis of known cause.( )the best predicto~of severity and outcome was the mosf index and not ranson's criteria;the higher the score,the greater the associated disease,the worse the outcome.( )curlously,no difference existed in associated medical conditions between patierts withknown and ur ~own causes of pancreatitis. conclusions:greater organ dysfunction exists in patients with pancreatitis of unknown etiology, even though age and associated medical conditions do not differ . the application of the total enteral nutrition in the burns disease has minimized the complication rate and consequently increased the survival rate of children and adults. time of initiation, composition, duration and way of administration are very important in obtaining the optimum beneficial effect from the treatment and diminishing the complication rate and side effects. the above features will be discussed in view of our experience in cases. ta buckle?,, ra freebalm, c gomersall g joynt, r young. tg short. department of anaesthesia and intensive cm+e, prince of wales hospital. the chinese university of hong kong, shatin, hong kong introduction: gastric mucosal ph (phi) monitoring has been proposed as a relatively noninvasive index of the adequacy of aerobic metabolism in the gut. to examine the accuracy of gastric intramucosal pit measurements as a function of time and as a function of the catheter itself to determine whether the measurement error between catheters is clinically acceptable. patients with a gastric tonometer (trip tm, tonometrics, worcester. ma) insitu for > days were studied. following informed consent two new tonometers were inserted equidistantly & correct position was confirmed radiographically. measurements of intramucosal gastric ph were then performed over a hr period. eight -ten measurements were made in each of ten critically ill patients.percent differences between the two new catheters were . % ie at ph . _+ . ( % limits) and between old & new catheters were . %, ie ph j _+ . ( % limits). conclusions: the results suggest that the function of the tonometer deteriorates over time and that the absolute values of phi m~ not ~ufficiently accurate. however as a trend monitor phi may be useful in the clinical setting. despite a continuous decline both in li'equency and severity of gastro-intestinal stress-lesion/-bleeding (gisb) due to both improvement in preclinical support and in intensive care medicine, patients with cerebral lesion are still considered at high risk for developing gis . therefore the question arises, whether m> specific (}lsb-prophylaxis besides general and neurological intensive care, specific pharlnaeothcrapy or even the combination of two specific drugs reveals any protective efli~ct on frequency and severity of gisb.this pntspcclive randomized study has been perfornted in patients snfrering t'rttna head-injury/cerebral lesion and with a glasgow-coma-scale on admission (gcs:,)of < . according to randomization the patients have been grouped as tbllows: h analgesia/sedation (n= ); ih analgesiajsedation plus pirenzepine mg/day (n= ); .[ih anatgcsia/sedalkm plus sncraltate x [ g/day (n= ); iv: analgesidsedatkm plus pirenzcpine mghlay plus sucralfate x e/day (n= ). slalislical analysis has been performed by chl:*tt~sl. rank correlatinn and unpaired t-test; statistical significance has been set with p < . . / patients ( . %) developed gisb. although the mean gcs~-value (x -+ sd) did not reach significance between patients with and without gisb ( . + . vs . -+ . ). a significant inverse correlation between gcs:, and the incidence of gtsb (rs~ = . ) has been shown. the frequency of gisb among the groups is as follows: h . %; lh . %; llh . %; iv: . % (ch -~ = . ; not signilicant). no gisb-induced blood translusion or mortality, respectively, could be demonstrated. survival rate between the groups did not differ significantly (chi-" = . ; p= . ) and reached an overall-value of . %.drug-specific glsb-prophylaxis -administered either as monotherapy (pirenzepine, sueralfate) or in combination of these two specific-drugs -reveals no additional significant influence on the incidence of gisb in patients with cerebral lesion compared to no specific prophylaxis besides the general trauma-/disease-specific intensive care measures. critical care dpt, evangelismos hospital, athens university scho~" of medicine objectives: the correlation of longterm presence of nasogastric tube (ngt) to gastroesophageal reflux (ger) is still in question. in case of positive correlation, peg should represent an alternative to tube feeding in patients unable to be fed orally. therefore, we investigated: i) the correlation between ng and ger and ii) the effect of peg on ger. methods: a -h esophageal ph-metry was performed in patients in recumbent position at ~ who had a ngt for more than days and were on sucralfate for gastric mucosal protection. the tip of the ph-probe was lied cm over the esophagogasttie junction, confirmed by x-rays. patients who presented a percentage of ger-total (i.e. with a ph less or more than ) (ger-t) more than %, underwent ~t peg. the presence of a creseent-notch on the esophagogastric junction persisting on inspiration and the grade os endoseopic and histologic esophagitis (scale= - ) was noted. two ph-metrles repeated on h and on days post-peg were compared to the pre-peg one, with the followin~ parameters taken in consideration: i) % ger-t, ii) number of ger-total per hour (no/h ger-t) and iii) the duration that ph was less than (tph< ). in case ot ger persistence at the ph-metry on ?th day post-peg (group ii) another endoscopy was performed, while patients with reduced ger (group i) were considered as esophagifis-free.results: out of patients presented a ger-t> %. eleven out of group i group (n= ) i ( objectives: the aim of the present study was to compare the performance of a specially modified version of a photo-and magnetoacoustic (pa/ma) gas analyzer (br~)el & kjaer, denmark) with a conventional quadrupole mass spectrometer (ms) (innovision, denmark) in inert gas rebreathing (rb) tests such as determination of functional residual capacity (frc), pulmonary capillary blood flow (pcbf) and lung tissue volume (vtc). methods : from simultaneous readings of inert gas concentrations with the ms and the pa/ma analyzer during rb experiments a comparison was made of the pcbf, vtc and frc values. the rb tests were performed during rest and exercise ( , and w) in ten healthy subjects. results: the differences (mean +/-sd) between simultaneous estimates of rebreathing parameters were the following (pa/ma -ms) for pooled data, pcbf: . +/- . i/min, vtc: - +/- ml and frc: . +/- . liters. conclusions: smell but significant differences were found between the estimates of pcbf, vtc and frc using the ms and pa/ma, respectively. reference: p. clemensen, p. christensen, p. norsk, and j. gr~nlund. a modified photo-and magnetoacoustic multigas analyzer aplied in gas exchange measurements. j appl physiol ; : - . objectives: because transcranial doppler (tcd) has been proposed to explore cerebral co vasoreactivity in brain injury (stroke ; : - ), we compared this technique with the kety-schmidt reference method to assess cerebral vasoreactivity in comatose patients. methods: mechanically ventilated patients (age - yrs, glasgow - ) in coma due to acute brain injury were investigated during stepwise changes in paco ( , , , and mmhg) by increasing inspired pco . middle cerebral artery velocity (vm) was measured by tcd. after insertion of a catheter in the ipsilateral jugular bulb, cerebral blood flow (cbf) was determined by the kety-schmidt method, using the inhalation of % n through the inspiratory line of the ventilator. for each patient a cerebral co~ vasoreactivity index was calculated as the slope of linear relationship between vm or cbf and paco . objectives: after cardiac surgery the fluid shill, between interstitial and intravasal space may be marked. this is due either to the intraoperative volume loading by the extracorporeal circulation or the increased postoperative diuresis. therefore, infusion of a large amount &fluids is necessary during the first postoperative hours. it still remains unclear which of the substances at disposal is the best for this purpose. aim of the present study was to compare the different fluids with special regard to postoperative bleeding and rheological behaviour. methods: patients undergoing cabg-surgery were investigated and randomizedly distributed to three different groups of postoperative volume replacement to stabilize the mean arterial pressure at mm hg. . ringer's solution, . . % gelatine solution, . % hydroxyaethylstarch (mean m.w. . ). we evaluated the following parameters within intervals of min: arterial and central venous pressure, heart rate, postoperative bleeding, urinary output, volume replacement. results: there was no statistically significant difference between the groups with regard to urinary output and bleeding. in spite of larger amounts of fluids necessary in the ringer treated group patients of this group showed symptoms of hypovolemia. hematocrit was increased in the ringer patients. this was statistically significant. introduction: pulmonary wedge pressure (pcwp) and central venous pressure (cvp) are frequently used as parameters for cardiac preload, although it is known that both are poorly correlated to the cardiac index (ci). it has been claimed that intrathoracic blood volume (itbv) measured with the thermal dye dilution method reflects cardiac preload better than pcwp and cvp. we studied the correlation between itbv and ci in a mixed population of critically ill patients. methods: in consecutive patients ( sepsis/sirs, acute heart failure, ards, transjugular intrahepatic portosystemic shunt) monitored with a pulmonary artery catheter, itbv was measured on regular intervals using the pulsion cold z- system (pulsion, munich, germany). ci, pcwp, and cvp were recorded simultaneously. results: a total of ol measurements was made. pcwp and cvp did not correlate to ci, nor did apcwp or acvp correlate to aci. itbv was correlated to ci in a non-linear fashion (f - , df = , p < . , (figure) ). aitbv was correlated to ac in a linear fashion (r = . , f = , df = , p < .o ). a rapid and efficient circulatory support system may save a patient in cardiogenic shock. left heart bypass with percutaneous and transseptal placement of the aspiration canuia simplifies the circuit and avoids the need for an oxygenator. we assessed this preclinical set-up in anaesthetized pigs using a centrifugal pump with a f arterial catheter and a f left atrial aspiration line. animals were supported for two hours at a mean flow of . liter ( ' rpm), a mean hematocrit of % and low heparinisetion (act double baseline). hemodynamic and laboratory samples were taken at baseline (a), minutes (b), one hour ( pulmonary hypertension (ph) usually involves obliteration and loss of functional pulmonary microvasculature. the microvaseular endothelium normally acts as a major metabolic organ, converting angiotensin i to angiotensin ii via the angiotensin-converting ectoenzyme (ace). it is unknown whether the loss of functional vasculature and altered pulmonary blood flow seen in ph will affect lung ace metabolic activity. we therefore estimated pulmonary vascular ace activity in patients with ph of various causes: primary; post atrial septal defect closure (asd); chronic thromboembolic (te); anorexigen; iv drugs; collagen disease. single-pass transpulmonary hydrolysis of the specific ace substrate h-benzoyl-pbe-ala-pro (bpap) was measured and expressed as % metabolism (%me . we also calculated an index of peffused functional capillary surface area (amax/km). all patients with ph had an abnormality of %met or amax/km, or both. as compared to control humans (mean %met = . % _+ . % s.d.), the mean %met in ph patients was . % _+ %. the %met in ph patients correlated inversely with cardiac output (r= . ), possibly reflecting more complete bpap hydrolysis with longer pulmonary transit times. amax/km was markedly decreased in ph ( + ml/min) as compared to controls ( _+ ml]min), consistent with a significant loss of functional capillary surface area. patients with collagen disease, asd and anorexigen-induced ph had the most marked abnormalities. in conclusion, patients with pulmonary hypertension have decreased pulmonary endothelial angiotensin converting enzyme activity, likely due to a loss of functional or perfused pulmonary microvaseulature. supported by the funds de la recherche en same du quebec and the national health system of greece. objective: to investigate adrenocortical function in patients with ruptured aneurysm of the abdominal aorta (raaa). studies investigating adrenocortical insufficiency in critically ill patients report an incidence ranging from % to less than %. this may in part be explained by difference in methods used (single cortisol measurement vs short acth stimulation test) and populations studied (heterogenous groups of patients with great individual variation in underlying disease as well as duration and severity of illness). methods: we investigated the adrenocortical function in patients with (raaa).a short acth stimulation test (synacthen test; ug - acth iv) was performed at hrs within hrs of admission. plasma cortisol was measured before (cort basal) and after stimulation (cort stim). a plasma cortisol level > . umol\l before or after stimulation was considered normal, severity of illness was assessed using apache ii. results: of the patients investigated died and survived. mean cort basal in nonsurvivors was significantly (p< .o ) higher than in survivors; . (range . - . ) vs . (range . - , ). this difference between nonsurvivors and survivors was also present for cort stim but lacked significance; . (range . - . ) vs . (range . - . ). while patients showed a cort basal < . , no cort stim < . was found. there was no significant difference in mean age or apache ii score between survivors and nonsurvivors; vs and vs . conclusions: single plasma cortisol levels were inadequate to assess the adrenocortical function in the patients studied, judged by a short acth stimulation test, our investigation in patients with raaa showed no adrenocortical insufficiency. mortality in raaa is associated with elevated plasma cortisol levels. obiectives: mortality in acute myocardial infarction (ami) prinicipally depends on hemedynamic impairment. thus, patients (pts) with elevated pulmonary wedge pressure (pwp) present high in-hospital mortality. however, the complete right heart catheterization is laborious, so the central venous pressure (cvp) alone is frequently used to assess the severity of ami. the accuracy of cvp in estimating pts with ami was tested in this retrospective study. methods: pts. aged + years, admitted to our ccu from to with their first ami, were inctuded in this study. all had undergone right heart catheterization because of overt or suspected heart failure. swan-ganz catheters ( f, cm, abbott, il, usa) had been used, every treatment had been temporarily interrupted l h before the calheferization. based on ecg findings the pts were retrospectively divided into groups. in group a we included pts with anterior ami, in group b, pts with inferior ami, and in group c, pts with inferior and right ventricular ami. the initial values of cvp and pwp were considered for the linear regression of the pwp variable on cvp and p< . was accepted as statistically significant.results: in g~oup a, the cvp and pwp vaiues were + mmhg and _+ mmhg respectively. despite the signifanf correlation (p< . ) between the two variables, it was not possible fo predict the exact value of pwp based on cvp value, pts ( %) presented cvp> mrnhg and of these ( %) had pwp_> mmhg. in group , the cvp was _+ mmhg and the pwp, _+ mmhg. significant correlation (p< . ) between the two variables also existed, however it was impossible to predict the pwp value. pts ( %) had cvp> mmhg but only of these ( %) had pwp> mmhg, similar was the relation between cvp and pwp in group c (p< . ). cvp averaged + mmhg, and pwp, _+ mmhg. pts ( %) had cvp> mmhg and from these ( %) presented pwp> mmhg,conclusions: a single measurement of cvp in ami does not ensure an accurate assessment of pwp. because every pt with ami needs optimal values of pwp in order to prevent pulmonary congestion or manifestations of low preload, the significance of complete right heart catheterization becomes apparent. in patients (pts) with advanced hf the need and the prognosis for heart transplantation (ht) can be predicted from vo= max. indirect measure of functional capacity with the six-minute walk test can also predict smvival in moderate hf. to predict vos max from indirect astinmtions of functional capadty such as - ~q~/, pulmonary and heart function tests, and to assess the prediddve value of the above parameters in hf pts survival. we evaluated pts (age + yeats nyha class: ii, hi, iv) with hf for pit. they underwent a pmgmmive exercise test on cycle ergometer for vo max determination, a -mw, a right heart catheterization and a spirometry and dlco estimation. introduction: brain death causes myocardial impairment by mechanisms that are not well understood yet. the aim of this work was to assess the echocardiographic features found in these patients from the clinical onset of brain death to somatic death, methods: seven brain dead patients were studied (patients" relatives refused to allow them to be used as donors). mean age was . ( - ) years old. four of the patients were female, none of the patients had any history of cardiac disease. transthoracic echocardiogram (echo) and electrocardiogram (ecg) were obtained at the onset of clinical brain death and were repeated every hours until somatic death. we we detected severe diffuse hypokinesia (ef< %) in patients and mild hypokinesia in others (ef - %). systolic function was strictly normal in only patients. corrected qt interval (qtc) in ecg was . _+ . msec (normal range - msec) just before somatic death (b). conclusion: in patients with brain death we observed a significant increase of left ventricular mass due mainly to ivs "hypertrophy" without any important change in the dimensions of the left ventricle. to our knowledge, this finding has never been reported before and its importantance in heart transplantations may be of particular interest. predict right ventricular outcome. l. jacquet, r. dion, p. noirhomme. m. van dijck. m. goenen cardiothoracic intensive care unit, st-luc univ. hospital(ucl) we have registred: heart rate (hr), blood pressure (bp), pulmonary artery pressures (pap), central venous pressure (cvp), pulmonary capillary wedge pressure (pcwp), pulmonary and systemic vascular resistances (pvr, svr), right ventricle end-diastolic end end-systolic volume (redv, resv), right ejection fraction (ref), right sistolyc ventricular work (rsvw) and cardiac output (co) using a thermodilution thechnique and a microprocessor (model ref- ; baxter-edwards laboratory); duration of cpb and aortic clamping, and the requirements of haemodynamic support after cpb.results: in the c group an increase post-cpb of the fc ( + . + . , p < . ) was produced without significantly changes in the redv, resv, ref, rsvw neither co. in the w group, hr increased from . + . to . + . (p < . ); redv was reduced from . -+ to . _+ . (p < . ); resv was reduced from • . to + . (p < . ). there were not changes in the other haemodynamyc parameters. there was a trend (no significantly) to an increase of ref in the w group ( . + . |• . ) compared with the c"group ( • . ($ . • . ) post-cpb. the need for haemodynamic support was similar in both groups.conclusions: the warm, continuous, anterograde-retrogade myocardial protection has obtained a decrease of preload, hr, and a trend to an increase in the ref, making an improvement in the right ventricular global performance when is compared with the classic form of cold myocardial protection. objective: to evaluate the effect of dobutamine on gastric mucosal ph (phi) after coronaly artery bypass surgery. design: prospective study in a university hospital intensive care unit (icu). subjects: elective cardiac surgery patients. interventions: dobutamine was infused at ug/kg/min for hours immediately after admission to the icu. hemodynamics were measured every minute periods until hours and again hours after stopping dobutamine. results: there were no significant differences in mean gastric phi between the groups but mean phi decreased in both groups during the study period. oxygen delivery and consumption both increased during dobutamine infusion but decreased to the control group level after stopping the dobutamine infusion. lactate levels did not change. baseline objectives: the aim of the study was to evaluate the usefulness of a low dobutamine dose in conjunction with intraaortic balloon pumping and mechanical ventilation in cardiogenic shock. we studied patients . -+ t . years of age suffered of post infarction cardiogenic shock characterized by a systolic arterial pressure< mmhg, urine output< ml/h and mental confusion or purpueral signs of low output, non responded to dobutamine infusion up to pg/kg/min. all patients underwent mechanical assistance by the intra-aortic balloon pump (iabp). five patients were additionally placed on mechanical ventilation due to blood gases disturbances. the end points in our study were: reversion of cardiogenic shock, improvement of patients survival or both on the th post infarction day and months later. results: three patients refused iabp treatment and / survived on the th day. on the th day / supported by the iabp and / that underwent mechanical ventilation plus iabp were alive (p < . ). on the th month / supported by the iabp and / that underwent mechanical ventilation plus iabp were alive (p< . ). conclusions: in conclusion, the combined use of mechanical ventilation and iabp assistance in severe cardiogenic shock might improve survival. obiectives: the study was aimed at analysing predictive factors of swan ganz pulmonary catheter (pc) requiremen t during elective cardiac surgery according to the need of sustained inotropic support after surgery. methods: three hundred patients (aged from to ; females and males)were consecutively operated on for elective coronary artery bypass surgery (cabg, n= ), valvular replacement (vr, n= ), combination of both (vr-cabg, n= ), or others (n= ) and retrospectively included in the study. each patient had preoperative invasive cardiac investigation with calculated ejection fraction (ee). anaesthesia, cardiopulmonary bypass (cpb) and cardiac arrest managements were similar in all patients. pc requirement was estimated from the need of either dobutamine, adrenaline, dopamine or enoximone use during the first hours after cardiac surgery. demographic data, asa and nyha classifications, preoperative ef and treatments, type of surgery, cpb and aortic cross clamping (axc) times, and postoperative incidence of complications were compared in patients with or without inotropic support using either student's t test or x with continuity correction when appropriate. results: seventy hree patients ( . %) required inotropic support after surgery. axc .and cpb times, mean stay in icu were significantly longer in patients with inotropie support (p< . ). type of surgery, preoperative ef, and nyha classification are the first significant factors related to inotropic support (p< . ). most patients operated on for double-vr or vr=cabg required inotropic support ( and %, respectively). postoperative mortality was higher in patients receiving inotropic support ( , % vs , % 'overall mortality, p= . ). conclusions: since pc insertion is most.often justified because inotropes are required, these results suggest that elective rather than routine systemic pc insertion could be helped by considering several but selected preoperative factors. background: cardiovascular depression due to anaesthesia, old age and major gastrointestinal surgery is becoming an increasingly frequent challenge .to the anaesthesia-surgory team. deliberate preoperative manipulation of haemodynamics and oxygen transport parametres towards prede~t~mined optimal values may prove to be effective "in reducing morbidity ~nd mortality in high risk surgical patients,. a new concept of using conlimaous perioperative measurement of cardiac'output to obtain and maintain supranormal oxygen delivery (do i) is presented. methods: continuous measurement of cardiac output is a relatively new form of on-line monitoring, in which trains of impulses are emitted from a thermal filament mounted on a pulmonary artery catheter. computer software recognizes patterns generated by minute changes in blood temperature and ealoalates cardiac output every - seconds. cardiac output and mixed venous blood oxygen saturation are displayed graphically on line. in tins tm study cardiac output was measured continuously by vigilance cardiac outpu t compl/ter (baxter). preoperative haemodynamic optimization was performed with the goal of increa- sing do i to at least ml/min/m accordfing to shoemaker's algorithm . this was.done by infusing colloids (albumin or hydroxy ethyl starch (haes-steril| until the desired do was reached. infusion was stopped if cardiac output ceased to increase with infusion, if there were signs of pulmonary oedema or if wedge pressure reached mmhg. vasoactive or inotropic drugs were infused if the desired do was not reached by infusion alone. anaesthetic technique included continuous thoracic epidural and isoflourane anaesthesia. expected mol:bidity and mortality rates were calculated by the "possum" score aasing preoperative clinical and paradinical estimates of organ function as well as surgery characteristics . materials: asa group ill-iv patients with a mean age of years (range - ) and a mean weight of kg (range - )) scheduled for major abdominal surgery were included. results: patients were excluded because do i could not be raised at all. mean do i was increased from ml/min/m (range - ) to ml/min/m (range - ). mean volume of preoperativdy infused colloid was ml (range - ). during surgery ml (range ) of colloid was infused. mean length of surgery was minutes (range - ). mean blood loss was ml (range ). expected mortality and morbidity rates ("possum") were % and %, respectively, whereas patient follow up upon discharge or at death revealed mortality and morbidity rates of % and %, respectively. conclusion: based on experience from the present study, continuous measurement of cardiac output has proved to be a valuable tool for perioperative optimization of do in asa group ili and iv patients during major surgery. however further studies including a greater number of patients are necessary to confirm the promising preliminary findings. we studied the hemodyn~c effects of three different combinations of positiv inotropic .agents, vasodilators, diuretics and av-filtration (av) in patients (pts) with severe left heart faille (left veutrieul x filling pressure (lvfp) > mmhg) due to acute myocardial infarction. hemodynamic measurements (intravascular pressures (lvfp), thermodilution (cardiac index (ci)) were made before (control) and after each therapy. in furosemide (f) + d butamin (d) + nitroglycerin (ni) reduced lvfp and a small increase of ci occurred. in of these pts :(group a) nitroprusside (hip) instead of ni increased ci significantly, in the other pts adding of amrinone (a) resulted in a pronounced increase of ci. group c (n= ): the combination of ni and av reduced lvfp but did not increase ci which was achieved by av+d+ni. in order to optimize the treatment of acute heart failure a combination of inotropic agents, vasodilators, diuretics and av-filtration should he used guided by hemodynamic monitoring. arias jr, miragaya d, sandard, san pedro dm ~, herndndez d, valenzuela . objectives: to evaluate the variation in nomdrenaline (na) plasma concentrations in patients with acute myocardial infarction (am ) after thrombolytic therapy with noniltvasive reperfusion criteria (clinical, electrocardiographic and enzymatic), in relation to infarct size and location.methods: consecutive patiens with ami, from october , to february , , admitted within hours alter onset of symptoms, undergone successfull systemic thrombolysis. of them were anterior (group a) and inferior (group b) . noradrenaline plasma levels at (na ), (na ) and (na ) minutes after admission were compared with ck-peak plasma levels by linear regression. differences were tested for significance by student-t-test for paired and unpaired values. na plasma concentration was measured by high-presssure liquid chromatography. p< ns . ns means -sem (normal limit for our laboratory: na < / pg/ml; ck < u/i ) conclusions: . the na plasma levels at admission (nai) are more increased in anterior than inferior amis, probably in relation to infarct size. . the decrease in na is more evidence in amis with anterior location. . this decrease is probably due to the major efficacy of thrombolytic therapy in amis with anterior location. arias jd, miragaya (group b) , probably due to certain degree of t~cg'rfueion. . there is not significant variation in na in conventional treated ami (group c). v.suchanov, a.levit, p.trofimov, icu, regional hospital, ekaterinburg, russiaobjectives: our task was to improve the technique of preservation of platelet rich plasma. methods: patients scheduled for multiple cardiac valve replacement in were divided into two groups: group i ( patients) -without pp; group ii ( patients) -pp was performed preoperatively. the first pp was made ten days and the second - days before the operation. prp was preserved by cryoconservation. our technique of cryoconservation is distinguished by the speed of freezing ( - ~ and absence of dmso. this made it possible to preserve % functionally active platelets during days. the prp was transfused back after heparin neutralization. the hospital ethics committee approved the investigation.results: the blood loss through the st p. o. d. was significantly greatest in the group i ( _+ ml) and all the patients required transfusion of the donor blood ( + ml) whereas the blood loss in group ii was +_ ml and olny patients required the donor blood. the number of platelets on the st p.o.d, was _+ . /l (group i) and + . /l (group ii), p < . .conclusions: our technique of prp cryoconservation makes it possible to avoid the crystallization phase during freezing of prr thus the infusion of prp may improve hemostasis after open heart surgery and limit the use of the donor blood. in-hospital outcome of women suffering an ami is generally considered worse than that of men, but it is still debated whether female sex is per sea negative prognostic factor or is merely associated with other negative determinants of prognosis. the purpose of the present study is to evaluate the independence of the association between female sex and mortality (in the patients of the swiss centers) and in the patients randomized in the isis- trail mortality rate in women was . % ( / ) compared to . % ( / ) in men; in switzerland: in-hospital mortality for women was . % ( / ), for men . % ( / ).the table shows the results of isis- in terms of odds ratios and their % confidence intervals either after unadjusted analysis or after adjustment for age, known to be the major confounding variable when prognosis of women after myocardial infarction is considered, and for all the available clinical and epidemiological characteristics collected at trial entry: these observations suggest that there is a small but independent effect of female sex on short-term mortality after acute myocardial infarction. ( ) and bubble ( ) oxygenators a, ere used. anaesthesia was balanced and pts were extubated to hrs after cpb. pts were monitored with swan-ganz catheters (sgc) for hrs after cpb. at that time qs/qt was calculate( according to )be standard shunt equation. after the sgc had been removed, an estimated shunt was calculated. measurements of qs/qt were performed: before induction of anaesthesia ( ), after induction of anaesthesia (i[), mins after cpb (iii) (iv) and (v) hrs afiter cpb, rains after extubation (vi), hrs after cpb (v[ ) and on the nd, rd, th, th and tb postoperative day (pd) (viii, x, x, xi, xi , respectively). analysis of data was performed by two-way analysis of variance, p < . being regard as significant.results: the figure shows the values for qs/qt expressed as means + sd. there was a significant increase in qs/qt above b~setine throughoul the whole investigated period except on the th pd. qs/qt reached maximum at rains after extubation (vi). objectives: many stndies have shown advantages of membrane oxygenalors over ubbie type oxygenators. the aim of this study was to evaluate the influence of x 'genator type on pulmonary shunt (as/at) after coronary surgery. methods: patients (pts) gave their informed consent to the study which was approved by the university ttuman research committee. pts were divided into two groups: a (n = ) with a membrane o~genator and a (n = ) with a bubble oxygenalor used during cardiopulmonary bypass (cpb). ths were monitored with swan-ganz catheters (sgc) for hrs after cpb. at that tfme os/ot was calculated according to the standard shunt equation. alter the sgc had been removed, an estimated shunt was calculated..measurements of os/qt were performed: betore induction of anaesthesia (i), mins after extubation ( ), hrs alter cpb ( ) and on the nd, rd, th, th and th postoperative day (iv, v, vi, vii> viii, respectively). analysis of data was performed by one-way analysis of variance, p < . being regarded as significant.results: the figure shows the values for qs/qt expressed as means _+ sd. os/qt was significantly greater at rains after extubation (ii) in a group. the difl'ereuce between the two groups was no more significant from hrs after cpb (iii) to the end of the investigated period. ! i * p < a. s betw~n ~o~ conclusions: membrane ox 'genation during cpb is accomplished by reduction in blood cellular destruction and less alteration in blood. the results of our study show the influence of oxygenator type on value of qs/ot only after extubation ( to hrs after cpb). the difference in qs/qt disappeared his after cpb and since that time the oxygenator type had no influence on qs/qt. it may be of particular importance in patients with severe forms of cardiopulmonary disease who are at risk of higher postoperative morbidity and mortality. objectives: hypomagnesemia has been reported with a variable prevalence ( to % ) in icu patients. magnesium deficiency can induce a number of climcal symptoms (primarily cardiovascular and neuropsychiatric) but can also be clinically silent ( - % are asymptomadc), methods: we measured whole blood ionized magnesium (lmg++) in patients on admission to the icu, using a nova electrolyte analyzer (nova biomedical), containing an img++ electrode. blood was collected in syringes with dry heparin (radiometer qs ). normal range of img++ was found between . - . mmot/l (healthy volunteers). results: for the entire population, we found a % prevalence ( / ) of hypomagnesemia (figure ) . among the surgical patients, the prevalence was highest after cardiac surgery ( %) and after thoracic surgery ( %) and was lowest after neurosurgery ( %). hypomagnesemia was also common in patients after liver transplantation (lvtx) or with hepatic failure ( % for both groups). conclusion: our findings confirm that hypomagnesemia is common in acutely ill patients, especially in those after cardiothoracic surgery or those with liver disease. nevertheless. it is difficult to define the associated factors with sufficient specificity, so that measurements of img++ are warranted to diagnose hypomagnesemia. hepariu influences platelet function and may lead to thrombocytopenia called heparin-associated thrombocytopenia (hat) regardless of the dose and route of administration. additinnal venous and/or arterial thrombosis may lead to life-threatening complications. the incidence of so-calied heparin-associated thrombocytopenia and thrombosis (hatt) ranges between i- %. hatt is confirmed by a heparin induced platelet activation assay (hipa). results: from / to / consecutive patients of our icu were reviewed retrospectively. all patients were treated with heparim the incidence of hatt was % ( ). in all cases diagnosis was proven by a positive hipa. / patients died. in / hatt could be confirmed before severe thromboembolic complications occured. / patients developed a deep vein thrombosis (dvt), / dvt and pulmonary embolism (pe), / dvt, pe and arterial thrombosis (at) and / a dvt, pe~ at and a sinus thrombosis. conclusion: the incidence of hatt in a r series of pts. is %. presence of thrombocytopenia and thrombosis of the great 'vessels is associated with a significant mortality ( / ). computed tom graphy (ct) and transthoracic/transesophageal echocardiography (tte/tee) are important tools in diagnosing and monitoring the extent of cenlrai venous and arterial thrombosis. a. cabral md, m. shahla md c. meneses-oliveira md and jl vincenl md.phd. department of intensive care. erasme university hospital, brussels, belgium objective: to determine extreme hemodynanuc patterns in cardiogenic shock. although ~.~xdiogenic shock is characterized by a low cardiac index (ci), high systemic w~,scular resistance index (svri), and high cardiac filling pressures, some patients may develop art atypical pattern. we reviewed the hemodyuamic pattern of patients with cardiogenic shock, as defined by an initial ct below . l/rain/m: in the presence of myocardial dysfimction attributed to ischemic heart disease (n= ), heart failure (n= ), valvulopathy (n= ) or recent cardiac surgery (n= ). after exclusion of patients with concurrently suspected/documented infection, this study included patients, of whom ( . %) survived. treatment of shock included dopamine (n= ), dobutamine (n= ), norepinephrine (n= ) and epinephrine (n= ). patients with arterial hypertension (ah) and initially law plasnla renin activity (pra) had been studied. in all patient changes of arterial pressure (ap) after single administration of enap was studied. nypotensive reaction wiht deereasin e of average ap about - mm hg ayter single drug administration observed only in patients. ezap monotherapy accomplished during one week with mg daily dose. hypotensive effect observed in patients including ones which were susceptible to single enap administration. after that first stage of therapy all patints began to combinate enap with hypothyazid in dose of mg per day~ after week of treatment such drugs combination lead to veritable ap lowering in addition patients. in the remaining resistant to such drug combination patients was add corinfar in daily dose of mg. this new drug combination permits to lower ap in patients. subsequent discontinuation of enap administration to such patients aid not connected with increasing of again.therefore the most of the patients with ah and law pra( , %)did not susceptible to enap therapy and enap and hypothyazid combination. on the contrary-combination of corinfar with hipothyazid was effective in % patients with ah and low pra. methods: in patients with cardiogenic shock due to ischemic heart disease (n= ), heart failure (n= ) and valvulopathy (n= ), hemod aamic data including measures of intravascular pressures, cardiac output and mixed venous gases were collected at regular times intervals, at least times a da?. all measurements were obtamed in a relative steady state and in the absence of severe anemia or hypoxemia. treatment of shock included dobutamine (n= ), dopamine (n= ), norepinephrine (n=i ) and epinephrine (n= objective: based on our previous studies of the function of isolated liver grafts, this experimental protocol aims at developing a novel extracorporeal liver support circuit, with an incorporated pig liver. methods:the graft liver was obtained from pigs weighing - kg. under general anesthesia the aqimals underwent total hepatectomy,following cannulation of the portal vein, the infrarenal aorta and the infrahapatic vena cava and peffusion wit h it of heparinised r/l solution at ~ the circuit consisted of the graft liver connected to a fluid reservoir and a centrifuge pump. ten healthy pigs weighing - kgr were connected to the circuit as follows: the rt carotid artery was connected to the portal vein of the graft and the rt jugular vein was connected to the fluid reservoir, through the centrifuge pump. the fluid reservoir collected the outflow from the graft's suprahepatic inferior vena cava. the cystic duct of the graft was ligated and the bile.duct cannulated for bile collection and measurement. bridges were adapted to the circuit to bypass the graft liver when necessary, in cases of by pass blood perfusing the graft was oxygenated through a bubble oxygenator. mean total priming volume of the circuit was ml. temperature was maintained at ~ and portal vein pressure at ( - ) mmhg. the flow was . - . ml/gr of graft liver mass per minute. observation period was hours (t ). results: results of the hemadynamic and metabolic monitoring of the recipients [map (t = mmhg , t = mmhg), hr (t = , t = ), rap (t = mmhg , t = mmhg), pap (t = mmhg, t = mmhg), pcwp (t = mmhg, t = ~mhg), svr (t = dyn'sec/cm ' , t = dyn'seclcm~ pvr (t = dyn.sec/cm o, t = dyn.sec/cm ,'~), co (t = . t/min, t = . t/min), do (t = ml/min, t = . ml/min), vo (t = ml/min, t = ml/min), o er (t = . %, t = . % ), ph (to= . , t = . ), po (t = mmhg, t = mmhg), pco (t = mmhg, t = mmhg), pvo (t = mmhg, t = mmhg), svo (t = %, t = %), be, na, k, ca ++, lactate, osmolality, ast, alt, pt, aptt, revealed hemodynamic and metabolic stability of the animal. consumption, co production and tissue oxygenation of the graft were also studied. conclusion; the described circuit proved to be safe and well tolerated by healthy animals but its value for temporary liver support is currently being estimated, in a surgically induced experimental fulminant hepatic failure modal. introduction: prosthetic materials like silikone, dacron, teflon e.tc. produce auto immune responses and may even trigger clinical syndromes like scleroderma, sjogren, sle el.c. in our study we followed the evolution of humorial immunity parametrs for up to five years in a cohort of paced pts with implanted metallic and silicone materials. method: paced pts (mean age +- yrs) without clinical or laboratory findings of malignancy or immune disorders were included. we measured the immunoglobulins, the complement, the auto antibodies and the proteins involved in inflammatory reactions every months. the initial and final mean values are shown in the obiectives: hsp, a systemic leucocytoclastic vasculitis and anaphylactoid purpura can be accompanied by abdominal pain and life-threatening intestinal bleeding. recently we could disclose, that these patients develop severe fxiii-deficiency and immense haemorrhagic oedema of the intestinal wall. by the following case report we will demonstrate and discuss the importance of fxiiideficiency for pathogenesis, therapy and outcome in hsp. case report: a year old man developed typical skin manifestations of hsp following an episode of severe (biliary ?) pancreatitis and percutaneous draining of a pancreatic pseudocyst. two days later he had a paralytic "ileus with immense hemorrhagic wall-oedema and massive dilatation of the small bowel. he got fever up to . ~ and developed severe gastrointestinal haemorrhage (blood transfusions necessary). the coagulation data disclosed a severe fxhi-deficiency (activity %), whereas quickvalues, platelet count and atiii-level were found to be within the normal range. elastase was markedly elevated. substitution of fxiii to normal levels leeds to the cessation of bleeding symptoms and abdominal pain, later resulting in a restitutio ad integrum. conclusions: hsp with intestinal involvement is a life-threatening vasculitis, in which careful and frequent examinations of the coagulation system, especially of fxiii are necessary. detailed analysis of the coagulation data suggest, that the severe fxiiideficiency is due to a specific degradation by proteolytic enzymes (like elastase) as well as consumption within the immense haemorrhagic oedema of the intestinal wall. knowing these facts, even most severe cases of hsp with intestinal involvement can be successfully treated by substitution of fxih. a -year-old woman presented a year history of occasional self-limited episodes of weakness, generalized edema and o!!~aria. the immunologic testing showed no~nnai levels of complements, clq inhibitor, and serum chemistry values, between or during a attack, she was not treated. she was a~mitted to the hospital with symptoms including nausea, vomiting, weakness and ol!guria. on examination, the patient presented facial and g~neralized edema. the systolic blood pressure was mm hg, pulse beats/mir~ute, hematocrit . , seln~n protein /i, and se~um albumin q/l. an leg-kappa pa[apfotein was demostrated ( . g/l) and urine was neaative for puotein. c~'stalloid and colloid don't increased the blaod pressure but resulted in anasarca, with a total of ii lit[as of in~ravenous fluids. therapy wink flozen plasma, . units of clq inhibitor, cortlcosteroids, annihistwnines and antifibrinolytic agents was uns~iccessfull. the a~minist~ation of dopamine, norepineph~ne and epinephrine was inefective. the patient died at the bores, only a few cases have been reported, all had igg paraprotein, the pathophysio!o~] is urd~no~n% but is possible that the paraprotein may be zesponsib!e for the increased capillary pe~leabilityo despite efforts to res~scinate the patients during an acute attack, the syndrome is often fatal. the variable course of systemic uapiliary leak syndrome and the unpredictability and self-limited nature of attacks cloud assessment of therapeutic inte~-vention. the purpose of the present work is to provide some information about the nursing care and results from our experience in continous arteriovenus hemofiltration (cavh).cavh is an extracorporeal technique, especially applicable in the critically ill patients, for disturbances, and for the control of azotemia.we used this method in critically ill patients men and women ages from - who had sepsis -arf congestive heart failure postoperative multiple organ failure and polytrauma .this method was applied to these patients from to hours. % of the patients recovered completely their kidney function, % improved their kidney function and % died.we concluded therefore that this method was very effective for the critically ill patients to whom it was applied, but it requires excellent and continuous nursing care; under the above mentioned circumstances the method works effectivelly. an animal model with rats undergoing a dialysis procedure was designed to test the hypothesis that recovery from ischemic acute renal failure (airf) may be affected by the type of membrane used in hemodialysis. male sprague dawley rats were allocated to groups: in group i, (n= ) airf was inducted by bilateral renal artery clamping for rain. group h (n= ) rats underwent a sham procedure. in each group, rats were dialyzed twice ( th and th day) with either a cuprophan (cupro), a hemophan (hemo) or a pan (an ) minidialyscr or stayed nondialyzed (no hi)). renal function was monitored daily by measuring urea and creatinine values and by two single shot inulin clearances on the days following dialysis. additionally hemolytical activity of complement was determined. inulin clearance on day was reduced significantly but there was no difference in the degree of decrement in glomular filtration rate (gfr) between dialyzed and undialyzed rats, nor between the dialyzed animals with different membranes (gfr: no hi): . _+ . ; cupro: . _+ . ; hemo: . _+ . ; an : . _+ . ). the evaluation of renal function by day nine revealed significant recovery for all airf-groups compared to day (p< . ), irrespective of wether they underwent dialysis or not, or the type of dialysis membrane. complement activation could be detected in all dialyzed groups but no statistical differences between the animal groups dialyzed with different membranes were noticed. our findings refute the hypothesis that in airf exposure to complement-activating cellulosic membranes impairs the recovery of renal function in rats. changes patients: patients who underwent first cadaver kidney transplantation in our unit between january and december in were involved. the recipients were divided into groups: group i." non functioning graft (n= ); group ii: delayed graft function (n= ), group ili: good graft function (n= ). the grouping criteria were: a/haemodialysis in the fii~t postoperative days, b/diuresis in the i st postoperative day, c,' scram crcatininc difference between the st postoperative day and the preoperative level. all of the parameters were involved into the exarainatio, which we measllre in our every, day practice. results: the preoperative haematocrit level differed significantly between group i. ( . ) and croup ii. and iii. ( . and . , p< . ). intmo! emtive significant differences were found between the different groups in systolic blood pressure (group i. hgrmn, group ii. hgnnn, group iii. hgmm, p< . ), mean arterial pressure (group i. hgmm, vs. group ii. hgnun p< . , vs. group iii. hgmm p< . ), and pulse-amplitude and rate-pressure product too. the second warm ishaemic time in group iii. was significantly shorter than in the other two groups (group iii. inin. vs. group ii. rain. p< . , vs. group i. rain. p< . !). the rejection rate was higher in the first days in the patients with non-functioning grafts (group i. % and group ii. % vs. group iii. %) . the other examined parameters have not differed significantly. conclusion: according to our results the success of the kidney transplantation is mnitifactorial. the most important factors of this relationship are: the perioperative fluid-balance, the maintenance of adequate perfusion blood pressure during the operation, good surgical technique and immunological problems. key: cord- -oecpqf j authors: nan title: aspho abstracts date: - - journal: pediatr blood cancer doi: . /pbc. sha: doc_id: cord_uid: oecpqf j nan myelodysplastic syndrome (mds) and frequently arise in the context of inherited bone marrow failure (bmf) syndromes, such as shwachman diamond syndrome (sds). monosomy /del( q) is associated with high grade mds and propensity to progress to acute myelogenous leukemia, a major cause of morbidity and mortality for patients with inherited bmf. development of non-transplant strategies to treat bone marrow failure without simultaneously stimulating outgrowth of malignant clones remains a major challenge. objectives: the aim of this study is to investigate the molecular consequences of del( q) in the context of bmf with the goal of developing more effective treatments. design/method: to study the biological and molecular consequences of monosomy/del( q) in bmf, induced pluripotent stem cells were generated from sds patients (sds-ipsc) . a deletion of the mds-associated region of the long arm of chromosome was then introduced using a previously published modified cre-lox approach. results: the sds ipsc phenocopied bone marrow failure with slow proliferation and impaired hematopoietic differentiation. we next explored whether deletion of q conferred a relative fitness advantage within the context of bone marrow failure. proliferation of the sds-del( q) ipscs was reduced below that of both the isogenic sds ipscs and normal controls without an increase in cell death. sds-del( q) demonstrated reduced hematopoietic differentiation compared with isogenic sds cells. these data demonstrate that deletion of q fails to confer a relative growth advantage relative to isogenic sds ipscs and results in further impairment of hematopoiesis. to gain insight into the mechanisms of del q-associated clonal evolution in sds, we performed rna sequencing (rnaseq) of sds+/-del( q) ipsc. expression of tgf pathways and their downstream targets were reduced in sds-del( q) ipscs compared to isogenic sds ipsc. single cell rnaseq analysis of primary sds bone marrow cells confirmed that the tgf pathway is hyperactivated in sds. western blot analysis showed increased phospho-smad levels in sds ipscs compared to sds-del( q) and normal controls, while total levels of smad were unchanged. pharmacological targeting of tfg with small molecule inhibitors resulted in selective improvement of sds hematopoietic colony formation and myeloid differentiation without stimulating outgrowth of the isogenic sds-del( q) cells or normal controls. these results demonstrate that del( q) reverses the tgf pathway hyperactivation of sds. furthermore, inhibition of tgf selectively rescues hematopoiesis in sds but not in isogenic del q cells, suggesting a potential strategy to treat bone marrow failure without stimulating del q clonal outgrowth. background: standard therapy of medulloblastoma consists of treatment with alkylating agents and radiation after surgical resection. although a statistically significant increase in survival is reported with this regimen, / rd recur and become resistant this class of agents ultimately leading to mortality. large numbers of somatic mutations were observed in recurrent medulloblastoma (rm) after alkylating agent and radiation treatment. high mutation rates in tumors can have twofold effect; ) a large number of non-synonymous mutations that have no role as drivers can still cause functional tumor antigens increasing the neoantigen burden and immunogenicity. moreover, ) such tumors can gain mutations in canonical or non-canonical dna repair pathways leading to a gain in the number of mutations as seen in case of glioblastoma, this can lead to even higher accelerated mutational rate. evidences suggest that high mutational load can cause higher neoantigen burden thereby making the tumor more susceptible to immune checkpoint inhibition. we propose that post therapy recurrent medulloblastoma gain mutational signature and immunophenotype of malignancies demonstrating clinical response to immune checkpoint therapy. objectives: ) rm has molecular signatures identical to tumors with high immunogenicity and clinical response to immune check point inhibition. ) rm has the immune inflammatory phenotype; harboring high percentage of tumor infiltrating lymphocytes (tils), macrophages and monocytes. design/method: to test our hypothesis, we downloaded the raw bam files of previously published data from international cancer genome consortium (icgc) . this set of about matched primaries and recurrent medulloblastoma cases forms our discovery cohort. we have called somatic variants using the gatk pipeline by the broad institute. to validate our key findings, we have procured human medulloblastoma specimens and are conducting whole exome sequencing. the primary assays utilized to assess immunogenicity are immunohistochemical (ihc) staining of formalin fixed and embedded recurrent medulloblastoma tissue to identify tils, tumor associated macrophages and other markers. mg/m had dlts of dyspnea (grade )/hypoxia (grade ) but no dlts were observed in any other cohort. adverse events were generally mild to moderate, consistent with the safety profile observed in adults. across the desc cohorts, plasma concentrations were dose-proportional and steady state concentrations were lower on day vs. day . mean systemic exposure in the mg/m cohort was ∼ -fold greater compared with the adult rp d of mg bid. a pk:pd relationship between tazemetostat exposure and h k me levels in peripheral blood monocytes and granulocytes was observed in the desc phase. consistent and significant post-dose reductions in h k me occurred at doses ≥ mg/m . further analysis of twelve patients treated at the rp d confirmed that h k me inhibition was maximally inhibited. doses - mg/m showed confirmed objective responses (cr/pr) per recist/rano in patients with es (n = ), chordoma (n = ), and atrt (n = ). background: previous studies established that the platelet/ fibrin(ogen) axis promotes metastatic potential by impeding the clearance of newly formed micrometastases by natural killer (nk) cells. however, multiple important questions remain, including the potential of fibrin(ogen) to promote metastasis through interactions with cells other than platelets (e.g., inflammatory cells), and the fundamental question of whether fibrin polymerization is required for metastasis. objectives: determine the role of fibrin polymerization and fibrin(ogen) engagement of integrins iib and m in metastasis. design/method: we performed experimental and spontaneous metastasis assays in immunocompetent mice carrying specific fibrinogen structure/function alterations. results: expression of a mutant fibrinogen lacking the binding motif for the leukocyte integrin m (fib - a) significantly decreased metastatic potential relative to wildtype fibrinogen, suggesting a role for fibrin(ogen)inflammatory cell interactions mediated by m in metastasis. to directly determine the importance of thrombinmediated fibrin polymerization in metastasis, we analyzed metastatic potential in fibaek mice, which carry a form of fibrinogen essentially "locked" in the soluble state due to a mutation in the a chain thrombin cleavage site. metastatic potential in fibaek mice was diminished relative to control mice, speaking to the importance of thrombin-mediated fibrin polymerization in the metastatic process. however, the fibaek mice retained significant metastatic potential relative to complete fibrinogen deficiency, indicating that fibrinogen monomer retains significant prometastatic properties. in order to better define the role of fibrin(ogen)-platelet interactions in metastasis, we compared metastatic potential in control and fib Δ mice, carrying a form of fibrinogen lacking the chain binding motif for the platelet integrin iib . surprisingly, this mutation had no impact on metastatic potential. together, these studies suggest fibrinogen plays a multifaceted role in metastasis. fibrin(ogen)-leukocyte interactions mediated by m appear to have a role in metastasis. previous studies showed that macrophages promote the metastatic potential of circulating tumor cells, which may represent at least one important m expressing cell type whose prometastatic behavior is influenced by fibrin(ogen) interactions. these studies show that thrombin-mediated fibrin polymerization promotes metastasis, but soluble fibrinogen retains some significant prometastatic capacity. surprisingly, loss of the fibrinogen chain iib binding motif had no impact on metastasis. given the established importance of platelets in metastasis, these findings suggest that fibrin (ogen) is capable of platelet stabilization through mechanism(s) independent of this iib binding motif. platelets may bind polymerized fibrin at other sites, and/or fibrin interactions with other matrix proteins capable of binding iib are sufficient to support platelet functions required for metastasis. the role of platelets in hemostasis and thrombosis is well defined, but it is becoming increasingly evident that platelets also assist in host defense and inflammation. platelets participate in the innate immune system through direct antimicrobial activity and interactions with effector cells (chapman , garlanda , kapur ). in the adaptive immune system, platelets recruit and costimulate t-cells, and promote b-cell differentiation and antibody class switching (kapur , morrell ). the question remains: which mechanisms influence platelet immune function and are they developmentally regulated? preliminary studies in the palis lab have revealed significant dif-ferences in embryonic versus adult platelet gene expression, including regulators of immune and inflammatory responses such as beta -microglobulin (b m) and major histocompatibility complex class i (mhc ). mhc is expressed on all cell surfaces except red blood cells and its molecular chaperone b m is a marker of inflammation highly expressed in platelet alpha granules (zufferey ). preliminary data from the morrell lab reveals a mass release of b m during platelet activation, which drives monocyte differentiation to an inflammatory phenotype through tgfb receptor signaling. we therefore sought to determine whether developmental changes in platelet b m expression mediate differences in platelet-mediated monocyte activation. with trilineage hematopoiesis with a predominance of early myeloid precursors, with full maturation. microarray, elane and sbds sequencing and deletion/duplication analyses were negative. immunologic evaluation was significant for agammaglobulinemia and an absence of memory (cd +cd +) b cells. a gene primary immunodeficiency panel revealed two variants of unknown significance-c. g>a and c. g>t in dnmt b; one previously reported in association with icf . parental testing demonstrated parental heterozygosity. centromeric instability was confirmed in mitogen stimulated lymphocytes showing characteristic, multibranched chromosomes containing at least arms of chromosome and joined near the centromere. decondensation of the qh and qh regions and triradial configuration of chromosome was noted, and a diagnosis of icf syndrome was made. the patient was started on monthly intravenous immunoglobulin (ivig). prophylaxis for pneumocystis jiroveci pneumonia and respiratory syncytial virus was initiated. a / matched sibling hsct is being planned. demonstrated the diagnosis of high grade osteosarcoma. the patient was started on multi-agent chemotherapy with planned a whole femur prosthesis at time of local control. cases of osteosarcoma have been described in the literature in patients with nf (median age; years, range - years) with slightly male predominance ( cases). the femur was the most common site of involvement ( cases). four patients died of metastatic disease despite surgery and multi-agent chemotherapy. conclusion: nf represents a major risk factor for development of malignancy and uncommonly osteosarcoma in adolescents and adults. we report a rare case of an extensive involvement of osteosarcoma of the left femur in a child with known diagnosis nf . this presentation should alert the pediatric oncologists to monitor for bone tumors in patients with nf by physical exam and detailed medical history. hasbro children's hospital, providence, rhode island, united states background: dysautonomia is a paraneoplastic syndrome most commonly described in adult malignancies. despite current therapies aimed at symptoms management, it is often debilitating. we present a case of a -year-old girl who initially presented with autonomic dysfunction and was subsequently found to have hodgkin lymphoma. objectives: describe hodgkin lymphoma presenting with dysautonomia and discuss symptom management with rituximab design/method: case report a year-old-girl presented with severe symptoms of orthostatic hypotension necessitating prone positioning to prevent syncopal episodes. additionally, she reported anhidrosis, xerostomia, urinary retention, and constipation. she had unmanageable peripheral neuropathic pain despite multiple analgesia medications. initially, it was suspected that her symptoms were caused by an atypical presentation of guillain-barre syndrome. she was treated with intravenous immunoglobulin g, without response. due to a suspicion of a paraneoplastic syndrome a positron emission test/cat scan (pet/ct) was performed and revealed widespread fdg-avid nodal and splenic disease. pathology from a thoracoscopic biopsy of a mediastinal lymph node demonstrated classical hodgkin lymphoma. she was classified as stage ivb. a paraneoplastic panel obtained during the first cycle of chemotherapy revealed elevated anti-amphiphysin antibodies and glutamic acid decarboxylase (gad) antibodies. therapy was initiated with abe-pc (doxorubicin, bleomycin, etoposide, prednisone, cyclophosphamide) ; vincristine was held given her significant neuropathy. due to persistence of autonomic symptoms following her first cycle and presence of antiamphiphysin and gad antibodies, rituximab was incorporated into her treatment. following two cycles abe-pc, she had a rapid early response by fdg-pet/ct. she completed an additional three cycles of abd-pc. end of therapy imaging demonstrated complete response with a single persistent mildly fdg-pet avid lymph node (deauville ) and her antibodies were negative. she continues treatment of maintenance rituximab with significant improvement, but not resolution, of her orthostatic hypotension. at this time, the patient can ambulate with assistance. constipation and urinary retention have fully resolved and, her peripheral neuropathy, xerostomia, anhidrosis have improved. conclusion: this is rare case of a pediatric hodgkin lymphoma patient developing dysautonomia associated with antiamphiphysin and glutamic acid decarboxylase antibodies and subsequently managed with chemotherapy and rituximab. clinicians should be suspicious of a paraneoplastic syndrome when a neurologic disorder fails to improve with standard treatment. results: labs obtained at an outside hospital one month prior to presentation showed absolute neutrophil count (anc) and hemoglobin . g/dl. she presented to our institution with days of fever, hepatomegaly cm below costal margin, a white plaque on her tongue, and circumferential perianal ulceration. labs were significant for anc and hemoglobin . g/dl. anti-granulocyte antibody testing was positive. bone marrow biopsy showed arrest of neutrophil maturation. after initiation of filgrastim ( . mcg/kg/day), her anc increased to > and repeat bone marrow biopsy demonstrated left shifted myelopoiesis. biopsy of her oral lesion demonstrated invasive actinomyces prompting a prolonged course of antibiotics. biopsies of her oral and anal lesions were reported as myeloid sarcoma without mll rearrangement. chemotherapy was not initiated due to complete resolution of both lesions within weeks of initiating filgrastim and appropriate antibiotic coverage. she has not developed any further lesions concerning for malignancy. testing for common genes associated with severe congenital neutropenia and autoimmune lymphoproliferative syndrome was negative. her immunoglobulin levels and the measurement of age-appropriate vaccine responses were normal. after her lymphocyte subpopulation analysis indicated a selective deficiency in cd positive t-lymphocytes (absolute cd cell count ), the severe combined immunodeficiency panel from genedx showed compound heterozygous mutations in results: a male infant was born with a large thigh mass. the child was clinically well aside from restricted movement of affected leg. mri showed mass expanding into pelvis without other lesions. an interventional-radiology guided core biopsy of the mass was reported as high-grade spindle cell sarcoma without etv rearrangement. surgery was deferred because of concern that it would result in excessive morbidity. the mass was treated with vincristine and dactinomycin per infantile fibrosarcoma protocols. after months of therapy, no significant change in size of the mass was noted on physical exam or imaging. repeat biopsy was obtained to confirm diagnosis and allow for expanded tumor testing. this biopsy showed triphasic distribution of adipose, fibrous and mesenchymal tissue consistent with fhi with rare sarcomatous foci. additional chemotherapy was deferred and the child was followed clinically. his tumor has remained approximately the same size and still unresectable. next generation sequencing of tumor utilizing panel based technology revealed braf-erc fusion consistent with braf activating mutation. this mutation was confirmed by fluorescent in situ hybridization (fish) probe for braf. braf and mek inhibitors have been pursued as treatments to decrease size of tumor and allow for resection. conclusion: braf mutations have been characterized in a variety of malignancies. inhibition of braf and downstream signaling components has produced promising results in a variety of patients. this is the first case report of a braf mutation in a fhi. although management of fhi is typically surgical, this does suggest a potential therapeutic target and may allow for improved surgical outcomes especially in cases where up-front surgery would result in unacceptable morbidity. genetic sequencing of fhi and other rare tumors is an important tool and has the potential to identify mutations amenable to targeted therapies. background: icf is a rare autosomal recessive disorder characterized by hypo-or agammaglobulinemia and often opportunistic infections suggesting t-cell dysfunction. it is further categorized into subtypes - based on mutations in dna methylation. mutations in the helicase-lymphoid specific (hells) gene, which is required for t-cell proliferation and participates in de novo dna methylation, are characteristic of icf type (icf ). of approximately reported cases of icf, less than percent are characterized as icf . while malignancy has been reported in icf (angiosarcoma, acute lymphoblastic leukemia), and icf (hodgkin lymphoma), here we describe the diagnosis and management of an icf patient with neuroblastoma and neutropenia, which has not been previously described. objectives: describe a novel phenotype and mutation of icf and its management to further expand our understanding of this disease. results: a month ex- week premature male with bronchopulmonary disease and failure to thrive presented with acute respiratory failure in the setting of recent viral bronchiolitis with associated chronic diarrhea. he was subsequently diagnosed with multiple infections including pjp pneumonia, norovirus, parainfluenza, rhinovirus, and pseudemonal cellulitis. he presented with profound neutropenia and agammaglobulinemia with presence of b and t cells on lymphocyte phenotyping. ct revealed a paraspinal mass that was mibg-avid on further study, strongly suggesting neuroblastoma. bone marrow was normocellular and negative for malignancy, however revealed marked granulocytic hypoplasia and maturation arrest concerning for severe congenital or, less likely, immune-mediated neutropenia. metastatic workup was negative. whole exome sequencing revealed a homozygous variant of unknown significance (c. t>c) in the hells gene, portending a working diagnosis of icf syndrome. immunoglobulin supplementation, pentamidine prophylaxis, and g-csf were initiated. he was able discontinue g-csf after months of treatment. his neuroblastoma, initially categorized as l , met criteria for observation. however, followup mri revealed interval growth nearing the spinal canal. he underwent tumor resection, confirming mycn non-amplified, favorable histology neuroblastoma. after infectious prophylaxis and immunologic support were initiated, he incurred two other hospitalizations, the first for g-tube cellulitis and the second for parainfluenza respiratory illness. he now has stable neutrophil counts off g-csf and remains in remission from neuroblastoma. current plan is to proceed with bone marrow transplantation for immunodeficiency. conclusion: icf has not previously been described with neutropenia or neuroblastoma. this report not only describes a novel mutation and phenotype of icf and the management thereof, but also reveals the potential curative role of bone marrow transplantation in such disease. staten island university hospital -northwell health, staten island, new york, united states background: desmoid tumors are rare tumors that arise from highly differentiated fibroblasts. they occur in isolation or as part of the disease spectrum of familial adenomatous polyposis (fap) . fap mutations between codons - typically correlate with increased extraintestinal disease such as desmoid tumors and upper gastrointestinal polyps. we describe a patient with a large intra-abdominal desmoid tumor who is heterozygous for a c. c>t (p.arg cys) apc gene mutation. we are not aware of any other patients reported with this germline apc mutation presenting with a desmoid tumor. objectives: to discuss a novel apc mutation and the presentation of a rare case. design/method: review of clinical presentation, genetic analysis and management of a rare tumor. a -year-old female with no significant medical history presented with abdominal asymmetry and intermittent pain. she reported urinary urgency, shortness of breath, early satiety, decreased appetite and a -pound weight loss over the course of months. ct scan of the abdomen demonstrated a × cm abdominal tumor abutting the local organs but no presence of bowel obstruction. a biopsy revealed a spindle cell neoplasm favoring fibromatosis. there was no known family history of fap, colon cancer, or desmoid tumors. apc gene mutation analysis demonstrated a c. c>t (p.arg cys) heterozygous gene variant. due to size and location of the tumor, it was initially deemed unresectable. the patient was started on a course of monthly liposomal doxorubicin. she tolerated the initial cycles well and interval ct after cycles of chemotherapy revealed a % decrease in tumor volume. variability exists in phenotypic presentation with regards to the location of the afp mutation locus. while fap mutations associated with desmoid tumors typically have changes in the - codon region, our patient presented with a heterozygous mutation resulting in a missense mutation at codon . due to the change in polarity and size, the mutation is not considered to be of conservative nature. we are only aware of one other report of this mutation, which occurred in an individual with a personal and family history of colon cancer. we are not aware of any patients with desmoid tumors who also have this germline apc gene mutation. our case report highlights an apc gene mutation that is not well-described; we are not aware of any other cases of this mutation reported in patients with desmoid tumors. future evaluation and tracking of this mutation may lead to the determination of further clinical significance. background: over time, advanced care planning for location of death has been associated with increased deaths at home rather than in the hospital. in some cases, however, complex management and symptom control can prevent families from achieving their goal of keeping their child out of the hospital and at home at the end of life. ascites is a sequelae of many conditions including malignancy that might lead to significant morbidity. increasingly, interventional procedures are being utilized. peritoneovenous "denver" shunts are placed internally with one end in the peritoneal space and the other buried within a major vessel such as the svc. a one-way valve and pump buried under the skin allows the patient to pump fluid from the peritoneal to the vascular space. the shunt is used frequently in adults, but has not seen much use in pediatric oncology patients. objectives: to describe a case of a terminally ill patient with refractory wilms tumor with ivc involvement who received symptomatic relief with denver shunt placement. results: an -year-old female was diagnosed with relapsed, refractory, metastatic wilms tumor with pulmonary and hepatic involvement, with tumor extension to the hepatic veins and ivc. multiple chemotherapeutic regimens and palliative radiation to the ivc were administered, but her disease continued to progress, leading to pressure on the portal vein and portal hypertension. the resulting ascites was causing the patient significant pain and was difficult to manage. the patient's code status was changed to dnr/dni after discussion with her mother, who identified a desire to have the child die at home as comfortably as possible. a peritoneovenous shunt was placed in order to control the patient's pain and avoid frequent medical procedures and therapies. despite initial anxiety, the patient was able to utilize the pump and achieve significant improvement in her ascites and pain. she was able to spend the remaining six weeks of her life at home. ascites is a common phenomenon of end stage disease. peritoneovenous shunts are a treatment modality that may be considered to allow for pain control at the end of life for pediatric oncology patients with ascites. the procedure is relatively low risk, allows for self-control of the pump to maintain comfort, and is easy enough to use by the patient or family. background: extraneural metastases (enm) from pediatric glioblastoma multiforme (gbm) are rare, with an estimated frequency of . %. etiologic factors include multiple neurosurgical procedures and sarcomatous dedifferentiation. their occurrence can seriously affect the patient's quality of life and survival. while enms have been well documented in adults, pediatric cases have not been previously summarized. a year old male with a cerebral gbm developed extension of disease outside of the neuraxis approximately months post initial presentation and at the time of disease progression. metastases included exracranial temporal lesions, cervical and mediastinal lymph nodes and s of s bilateral lung nodules. a large pleural-based soft tissue metastatic focus was identified on imaging when the patient presented with respiratory distress secondary to a right tension pneumothorax, which was recognized and managed promptly. we summarize the main reported cases in literature to better define risk factors for and evaluate the proposed mechanisms underlying these systemic metastases. design/method: we performed a literature review on the pubmed database using the terms gbm and enm. patients under years of age who met the weiss criteria for the diagnosis of enm from primary cns tumors were included. results: our patient fulfilled two of the three weiss criteria with confirmed gbm at the primary site with all enm in the temporal soft tissue and cervical lymph nodes displaying histopathologic features similar to the primary cns tumor. the intrathoracic adenopathy and lung nodules detected upon chest imaging during workup for respiratory distress were assumed to represent additional metastatic foci. our literature review identified pediatric patients with enm from gbm with a median age of years (range . - years) and a slight female predominance ( % females vs. % males). the most common sites of metastases reported were pleura/lungs, bones, lymph nodes and liver. in of patients, metastases were associated with csf shunting. conclusion: pediatric oncologists should have an increased index of suspicion when caring for patients with gbm, particularly those who have undergone shunting procedures and present with systemic symptoms including bony pain, respiratory changes, transaminitis or cytopenias which should prompt timely investigation for enm. although enm of cns tumors carry very poor prognosis, their diagnosis has potential therapeutic importance because treatment of metastatic lesions may alleviate symptoms and improve the quality of life. additional studies may be warranted to evaluate the incidence of enm that can provide valuable insight into the pathogenesis and biology of high-grade gliomas. nicklaus children's hospital, miami, florida, united states background: sinusoidal obstruction syndrome (sos) has been reported in patients undergoing intensive chemotherapy and as a complication post-hematopoietic stem cell transplan-tation. sos may be complicated by portal hypertension, hepatorenal disease or multi-organ failure. however, despite treatment, there may be further potential complications that can be anticipated in patients with history sos. we report two patients with history of sos presented with post-procedural bleeding after gastric tube placement. we believe that their presentations may be associated to their previous diagnosis of sos. design/method: pubmed search was done with search for terminology including "sinusoidal obstruction syndrome" "defibrotide", and "bleeding". papers relevant to our cases were selected for literature review. results: case : a year-old female with history of desmosplastic medulloblastoma status-post resection and intensive chemotherapy was diagnosed with sos one month after her second part of planned tandem transplant. she was managed with paracentesis and defibrotide. due to malnourishment, patient had a gastric tube placement months after she completed therapy and had an episode of upper gastrointestinal bleeding postoperatively from the g tube site. case : similarly, a year-old male diagnosed with anaplastic medulloblastoma status post resection and adjuvant multiagent chemotherapy. his treatment course was complicated with sos after the second cycle of induction chemotherapy which responded to -day course of defibrotide. likewise, the patient had a major bleeding event from the g-tube site approximately two months after sos diagnosis. defibrotide was discontinued in both cases before g-tube placement. both patients had no previous history of bleeding disorders or relevant family history. in addition, comprehensive laboratory evaluations were within normal limits before both procedures. in sos, there is blockage of fluid out of the liver that leads to congestion, ascites, ischemia of the liver, and post-sinusoidal portal hypertension. two related causes of sos should be considered as an explanation for g-tube bleeding. similar patients should have close monitoring postoperatively or if possible surgical intervention should be delayed until the sos process has been evolved. nicklaus children's hospital, miami, florida, united states background: the development of treatment related acute myeloid leukemia (t-aml) and myelodysplastic syndromes (t-mds) is a potential complication after cytotoxic chemotherapy or radiation therapy. the incidence of development of t-aml/t-mds varies from - % depending on the treatment regimen used. cutaneous myeloid sarcoma (ms) is a common presentation of extramedullary leukemia and usually occurs in the setting of aml. we report a rare case of cutaneous ms in an adolescent female after successful treatment for ovarian yolk sac tumor (yst) stage i with bep (bleomycin, etoposide and cisplatin) therapy. the ms was managed only with biopsy and close observation. design/method: a pubmed search was conducted for queries including t-aml/t-mds, cytotoxic agents, cutaneous myeloid sarcoma, regression. relevant papers were selected for literature review. a year-old female was diagnosed with a left ovarian yolk sac tumor, for which she underwent left salpingooophorectomy and successfully completed cycles of bep over months. during routine follow-up months after initiation of treatment for ovarian yst, she was noted to have a small, non-tender, indurated nodule on the left side of her upper back approximately cm in diameter. punch biopsy of the skin nodule was performed and pathology was positive for cutaneous myeloid sarcoma. at the time of next follow-up less than one month later, the skin lesion had resolved. two subsequent bone marrow aspirates were performed one month apart and were negative for leukemic involvement or mds. examinations and work-up including whole body pet with ct scan were negative for evidence of disease. although cutaneous ms can be regarded as the herald of systemic myeloid disease rather than a localized process, our patient was monitored periodically with physical exam and laboratory evaluations. she remains free of disease more than four years after the presentation of cutaneous ms without any further treatment. spontaneous regression ms has been previously reported. the authors would like to stress that a conservative approach with close observation could be an option in cutaneous ms even with history of chemotherapy exposure. nesreen ali, iman sidhom, sonia soliman, sherine salem national cancer institute, cairouniversity, egypt children cancer hospital egypt, egypt background: acute leukemia is the commonest malignancy in childhood. the coincidental occurrence of leukemia with hemophilia is extremely rare. hemophilia is a congenital rare x linked bleeding disorder. the main complication of the two diseases is bleeding diathesis which may be lifethreatening due to many factors, deficiency of coagulation factors in hemophilic patients, thrombocytopenia from disease and chemotherapy in leukemic patients, certain cytotoxic drugs such as asparaginase which may result in coagulation disorders and infection which may lead to disseminated intravascular coagulation. objectives: reporting such a case is imperative to set up treatment guidelines for prevention of bleeding and to optimize the therapeutic approach for these patients. design/method: seventeen years old boy, presented to children cancer hospital egypt in june with pallor and multiple ecchymoses.he was diagnosed with precursor b acute lymphoblastic leukemia, cerebrospinal fluid (csf) was free, the chromosomal analysis revealed hypodiploidy , xy. he had moderate type of hemophilia a since birth, factor viii level was . % at time of diagnosis, coagulation profile revealed prolonged partial thromboplastin time (normal - ), factor viii was low %, prothrombin concentration and prothrombin time were normal % and seconds, virology screening for hepatitis b core igg/igm, hbs ag, hiv and hc igg /igm were negative.the patient started induction total xv sjcrh protocol, factor viii unit/kg was given at presentation before doing bone marrow aspiration(bma), csf and as a prophylactic before intramuscular asparaginase injection, intrathecal and bma. it was given immediately within hours before the procedures and platelets transfusion was given regularly to maintain platelets count about , . the minimal residual disease by flow cytometry was . % and . % at d and d induction. results: our patient received his induction and reintensification chemotherapy without any major bleeding event which reveals the success of our guidelines for the prevention of bleeding. he developed very early relapse at w maintenance by the same clone. he received salvage chemotherapy but didn't achieve remission and died out of disease and resistant clone. the development of leukemia on top of hemophilia is a major problem. bleeding complication during chemotherapy can be prevented by regular prophylactic factor viii and platelets concentrate transfusion with good supportive care. life threating bleeding complication may be correlated with the severity of hemophilia. we need to collect data about the biology of leukemic cells, complications, and cause of death to optimize care for these patients. background: mucoepidermoid carcinoma (mec) is a rare malignancy that arises from exocrine glands in the upper aerodigestive tract and tracheobronchial tree. conventionally, mec diagnosis is based on histology, with prognosis based on the extent of resection and detection of metastases. mec is characterized by a translocation of chromosomes q and p resulting in a fusion between the mect and maml genes, that occurs in - % of cases. this fusion transcript has been recognized to have a favorable impact on disease features and prognosis of mec. however, recent studies indicate that high grade mec can have mect -maml fusion positivity and multiple other genomic imbalances that have not been studied in much detail. owing to the rarity of mec tumors, more definitive data related to the clinical and prognostic significance of these molecular markers are limited. objectives: . identify the presence or absence of mect -maml fusion in the tissue of our patient. . analyze the incidence of the fusion in mec cases in children and young adults retrieved from the iowa cancer registry. . determine if fusion status correlates with clinical, pathological and outcome data in our cohort. design/method: we describe the case of a year-old caucasian male who presented with recurrent pneumonia, persistent cough and radiographic evidence of right lobar collapse. bronchoscopy revealed an endobronchial lesion and the patient underwent right upper lobe sleeve resection. pathology report was consistent with low grade muco-epidermoid carcinoma. we retrieved archived formalin-fixed paraffinembedded (ffpe) specimens of pediatric and young adult mec cases (ages - ) reported in iowa from - using the iowa cancer registry. testing for the mect -maml fusion in the index case and ffpe specimens will be done using a custom-designed laboratory validated next generation sequencing (ngs) assay with the ability to detect novel fusion partners. clinical, pathological and outcome data (age, sex, tumor site, tumor size, nodal metastases, clinical stage, histologic grade, treatment and follow up) will be analyzed to correlate with fusion status. the mect -maml fusion tested positive in our index patient. we will obtain irb approval to test for the fusion in the archived ffpe specimens and correlate clinical, pathological and outcome data. conclusion: mect -maml fusion is a frequent event in mec that has prognostic and potential therapeutic applications in adults. the results of this study may enlighten the clinical management of mec in children and young adults. children 's mercy hospital, kansas city, missouri, united states background: mutations in the samd gene are associated with a rare syndrome comprising of myelodysplasia, infection, restriction of growth, adrenal hypoplasia, genital phenotypes and enteropathy (mirage syndrome). diagnosis is made through exome sequencing. in the largest reported case series, of eleven patients diagnosed with mirage syndrome, two developed loss of chromosome . given the potent growth restricting activity of samd mutants, the loss of chromosome is considered the first documentation of adaptation by aneuploidy mechanisms in humans and led to myelodysplastic syndrome (mds), with deaths occurring from related complications at and years of age. objectives: to report a case of mirage syndrome with congenital thrombocytopenia progressing to bone marrow failure, managed uniquely with bone marrow transplantation. results: male born at weeks gestation with prenatal diagnosis of iugr, two vessel cord, oligohydramnios was found to have ambiguous genitalia, adrenal insufficiency, partial panhypopituitarism and congenital thrombocytopenia with bone marrow showing absence of megakaryocytic precursors. severe thrombocytopenia was present from birth. bone marrow evaluation demonstrated a hypocellular marrow with markedly reduced megakaryocytic and myeloid precursors and no evidence of myelodysplasia. he required gastric tube placement for failure to thrive, had a laryngeal cleft repaired and developed focal segmental glomerulosclerosis. mpl gene testing for congenital amegakaryocytic thrombocytopenia was negative. testing for fanconi anemia, shwachman-diamond syndrome and dyskeratosis congenita was also negative. approximately % of cells had loss of heterozygosity on chromosome q. exome sequencing showed that he is heterozygous for a de novo gain of function variant, c. g>a (p.arg gln), identified in the samd gene, confirmed by sanger sequencing and consistent with a diagnosis of mirage syndrome. at years of age, he developed pancytopenia requiring frequent transfusions with platelets and packed red blood cells. he underwent a successful bone marrow transplant at years of age without significant complications, and remains transfusion independent without cytopenias greater than months from bone marrow transplantation. conclusion: it is imperative to pursue work up for persistent congenital thrombocytopenia in a stepwise multidisciplinary manner. to the best of our knowledge, this is the first case of mirage syndrome associated bone marrow failure treated with bone marrow transplant. due to the individual rarity of mirage syndrome and pediatric myelodysplastic syndrome, it is important to maintain an index of suspicion given their association and explore bone marrow transplant as a therapeutic option. results: the patient demonstrated disease regression, initially, and continued without disease progression for months. the regimen has been well tolerated with only minimal side effects of dry skin (ctcae grade ) and a transient episode of brief erythrodysesthesia (ctacae grade ) that resolved spontaneously. the combination of sorafenib and capecitabine was effective and well tolerated in this adolescent patient with fl-hcc. our observations, although in a single patient, lend support for further testing of this novel oral chemotherapy regimen in patients with fl-hcc, a disease for which there is no effective standard chemotherapy approach. background: epstein-barr virus (ebv) is a ubiquitous virus associated with a broad range of malignancies due to its oncogenic potential. history of organ or bone marrow transplantation, immunosuppressive therapy, and primary or acquired immunodeficiency syndromes increases the risk of ebvassociated tumors. epstein-barr virus associated smooth muscle tumors (ebv-smt) are unique and rare neoplasms typically discovered in immunocompromised patients. most information related to pathogenesis and therapeutic options is limited to case reports and case series of adult patients. there are several gene expression pathways that ebv utilizes, the most notable of which is the mammalian target of rapamycin (mtor) pathway. the mtor pathway performs a key role through integrating various cell growth signals and factors to regulate protein synthesis and metabolism related to smooth muscle proliferation. sirolimus is an immune modulating therapy that targets the mtor pathway to block activation of lymphocytes. objectives: several case reports have demonstrated shortterm clinical remission of ebv-smt in adult patients with the use of sirolimus. we report the first case of long-term background: bilateral neuroblastoma is characterized as neuroblastoma arising in both adrenal glands, a rare presentation with little data on its genetic make-up. a two-monthold patient was diagnosed with bilateral neuroblastoma in our clinic. her risk assignment was based on biopsy of the left adrenal lesion, which showed mycn amplification, an unfavorable genetic marker. treatment regimen was intensified accordingly and after courses of chemotherapy tumors were excised. patient went on to receive a stem cell transplant and immunotherapy. with no knowledge of genetic similarity between the two tumors it is unclear whether biopsy of the right lesion would have yielded similar results or whether bilateral biopsies are needed for risk assessment of bilateral neuroblastoma. objectives: utilize whole exome sequencing (wes) to characterize the genomic signature of bilateral adrenal neuroblastomas excised following chemotherapy treatment. design/method: paraffin-embedded samples from left (l) and right (r) tumors underwent wes at the broad institute. we analyzed resulting data including somatic variant calls, indel mutations, and copy number variants (cnvs) using ingenuity software to evaluate and compare differences between the two tumor samples. preliminary analysis of the data shows important descriptive information on the two tumor samples. out of somatic mutations in the r tumor cells and mutations in the l tumor cells, only two common somatic mutations were present. out of cnv calls in the r tumor and in the l tumor, cnvs were common between the two tumors, or % of each tumor's cnv calls. there was a fold higher frequency in gains versus losses. the median size of the common cnvs was , (range to , , bp). cancerrelated genes with increased copy numbers included transcription factors, receptors for signal transduction pathways, and histone methylation proteins. conclusion: preliminary analysis of the wes results of the two adrenal tumors show some genomic divergence. because the tumor tissue was exposed to chemotherapy prior to excision it is difficult to determine whether genomic divergence is a result of independently originated tumors or subsequent adaptation to chemotherapy of a clonal cell population. the high number of common cnvs in the two tumors points to a common cell of origin, however the low number of common somatic mutations does not fit that picture. a future study to help elucidate the question will be wes of the original biopsy tissue to provide information on tumor mutations prior to the effects of chemotherapy. baylor college of medicine, houston, texas, united states background: although there has been significant improvement in the overall survival rates of children with cancer many children will still die from their illness or complications secondary to treatment. research surrounding the deaths of children who succumb to their disease is warranted to ensure we are providing the best care possible for these patients. objectives: this case series aims to explore pediatric cancer deaths by focusing on perhaps the most extreme cases of high intensity end of life care. we explore those patients whom we know are dying or our very likely to die as evidence by their do not resuscitate (dnr) orders. in all of these cases despite the patients very grim prognosis, their great likelihood of death and limitations placed of resuscitation methods all patients continued end of life care in the pediatric intensive care unit (picu). the primary medical records of all children with a cancer diagnosis who died between february , and january , in the picu with a dnr order seven days or earlier prior to death. each medical history included disease-directed treatment history and response with particular attention to the events surrounding the terminal admission. results: eight patients met criteria for this study representing . % of all cancer patients who died during this time period and . % of those who died in the icu. the average time between dnr and death is . days ( days - days). the average length of terminal admission was . days ( day - days). the average time between diagnosis and dnr is . months ( months - months). the average time between diagnosis and death is . months ( months - months). conclusion: these cases highlight the journey that patients, families and providers endure leading up to death. medical care is complex, there are very few absolutes that are encountered when caring for patients and decisions around limiting or withdrawing medical care are made in a context of the prior journey. . these cases help to understand the complexity of death and how two seemingly opposite ideals can be congruent in the event of an anticipated death. most of these cases show the need for improved anticipatory guidance surrounding death and greater consideration for de-escalation of care when death is expected. the hospital for sick children, toronto, ontario, canada background: rhabdomyosarcoma (rms) is the most common soft tissue sarcoma in children, with embryonal (erms) and alveolar (arms) representing the most common subtypes. arms tumors are associated with inferior outcome when compared to erms, and they are characterized in about % of the cases by a t ( ; ) or t( ; ) chromosomal translocation with creation of a pax -foxo or pax -foxo fusion gene, respectively. it is increasingly clear that the pax-foxo fusion status is an important poor prognostic factor, thus the histological classification tends to be replaced by the fusion status, particularly in terms of risk stratifica-tion in contrast to arms, there are no recurrent chromosome alterations in erms; however, there are multiple numerical chromosome changes that are frequent in these tumours: gain of chromosome , , and have been found in to % of emrs karyotypes. moreover, erms tumors show frequently allelic loss, the .p . chromosomal region being the most frequently involved. recently, novel gene fusions have been described also in erms tumours. these fusions involved mainly the ncoa and or the vggl genes. the rearrangement partners are variable, and include, i.e. pax ( q ), srf ( q ) and tead ( p ). objectives: to present a patient who died as a consequence of brain metastases while on therapy in the setting of an foxo negative rms and the identification of a new translocation t( ; )(q ;q ). design/method: case report and retrospective review of the literature. we report a case of pelvic embryonal rhabdomyosarcoma in a -month old boy. he was treated as per cog arst intermediate risk group, but unfortunately was found to have a large cerebellar tumour during the course of his chemotherapy treatment and he subsequently passed away. a novel translocation between chromosomes and was observed in of metaphase cells by g-band analysis in the autopsy sample of the brain lesion. breakpoints of the translocation were estimated to be at q and q . there were no additional clonal chromosome abnormalities in the tumour cells. conclusion: erms tumors with fusion genes involved have been exclusively described in patients less than months of age; they seem to be associated with spindle cell histology and, a favorable outcome. in our patient, a novel ( ; ) translocation was found and clinically, the patient had a dismal outcome. further studies are indicated to inquire whether this finding is of significance in term of prognosis for these patients. children 's national medical center, washington, district of columbia, united states background: iatrogenic immunodeficiency-associated lymphoproliferative disorders (lpds) are a group of lymphoid s of s proliferations or lymphomas that are well known to be associated with an immunosuppressed state. these disorders most commonly occur following hematopoietic or solid organ transplantation (called post-transplant lymphoproliferative disorders or ptld), but cases have also been described during the treatment of autoimmune and rheumatologic disorders by immunosuppressive and immunomodulatory medications. these disorders are strongly associated with infection by the epstein-barr virus (ebv) as a result of impaired immune function in the immunosuppressed state. while this phenomenon has been well documented in autoimmune conditions, cases affecting pediatric patients while on antileukemia chemotherapy are lacking. background: atypical teratoid/rhabdoid tumor (at/rt) of the central nervous system (cns) in children younger than years old has a prevalence of % to % and accounts for . % of all pediatric cns tumors. only - % of patients have leptomeningeal dissemination. rhabdomyosarcoma is the most common soft tissue tumor in childhood, but represent only - % of all pediatric cancers. rarely, it can metastasize or even directly extend into the cns, but typically, cases of cns involvement arise either from parameningeal areas or other primary sites. primary spinal or meningeal rhabdomyosarcoma is extremely rare. objectives: our objective is to describe two unique cns malignancies presenting as rare, primary leptomeningeal disease. design/method: case a -month-old female presented with vomiting, fatigue and listlessness, despite a normal head ct and brain mri. csf showed hypoglycorrhachia and mild pleocytosis. ceftriaxone was started, but she developed nuchal rigidity and cranial nerve vii palsy. repeat brain mri showed evolving leptomeningeal enhancement concerning for meningitis. she gradually developed worsening opisthotonus and ultimately a brain biopsy of the temporal lobe was consistent with at/rt. case a -year-old male presented with new generalized tonic-clonic seizure activity and intermittent headaches with photophobia, phonophobia, and vomiting. brain mri was significant for enhancement of interpenducular and suprasellar cisterns extending to the optic nerves and chiasm most consistent with meningitis. neurosurgery ultimately placed a lumbar drain for hydrocephalus, and a tissue biopsy demonstrated primary meningeal rhabdomyosacroma. results: in case , our patient's temporal lobe biopsy demonstrated grade iv malignant tumor cells consistent with atypical teratoid/rhabdoid tumor. fish demonstrated a homozygous deletion of smarcb ( q . ). she was started on chemotherapy per the dana farber at/rt protocol but ultimately was discharged home on hospice. in case , our patient's lumbar arachnoid biopsy demonstrated cellular tumor consistent with group iiia embryonal rhabdomyosarcoma. immunostaining was positive for cd , desmin, myogenin, and myo-d with neural markers ema and gfap highlighting the meninges but without a neural component to the tumor. he completed craniospinal radiation to gy total with lumbar boost to . gy total. he is currently receiving chemotherapy per arst protocol. conclusion: these two cases are particularly instructive because of their similar initial presentations and neuroimaging, but with very different and unique diagnoses. university of iowa, iowa city, iowa, united states background: ebf -pdgfrb fusion causes ph-like b-cell acute lymphoblastic leukemia (b-all), which has a philadelphia positive phenotype without the bcr-abl translocation. this is one of several mutations associated with ph-like b-all and leads to downstream overexpression of tyrosine kinase. ebf -pdgfrb fusion accounts for about % of children with ph-like b-all. patients with ph-like b-all previously had poorer outcomes with conventional chemotherapy. the addition of tyrosine kinase inhibitors (tki), like imatinib, has improved the outcome for many patients predicted to have tki sensitive mutations. objectives: to review clinical characteristics and outcomes of two cases of ph-like b-all at the university of iowa stead family children's hospital and to compare these outcomes to similar cases reported in the literature. design/method: a retrospective chart review was performed for two cases of ph-like b-all diagnosed and treated at the university of iowa stead family children's hospital. results: both patients were males diagnosed at years of age with high wbc count ( , and , ) and positive for ebf -pdgfrb gene fusion. patient (pt ) was cns b at presentation while patient (pt ) was cns negative; neither had testicular involvement. both started treatment according to cog protocol aall . peripheral blasts cleared by induction day for pt and induction day for pt . at end of induction, pt had m bone marrow and pt had m bone marrow but mrd %. dasatinib was started induction day for pt and induction day for pt . pt was still not in remission at end of consolidation; bone marrow cell culture for tki resistance showed best response to dasatinib. pt proceeded to anti-cd car t-cell therapy followed by tbi-based matched unrelated donor bone marrow transplant. pt had negative mrd at the end of consolidation and continues chemotherapy according to aall , dasatinib arm. both patients are currently clinically well. our patients had the same tyrosine kinase gene fusion and similar initial clinical courses. while both patients had persistent disease at end of induction, pt had almost % blasts while pt had significant reduction of disease burden before starting tki. pt showed good response with the addition of dasatinib while pt did not. these findings suggest that response to conventional chemotherapy may potentiate the effect of tki and may predict overall outcome. there are likely additional factors which must be taken into account when determining response to tki for patients with ph-like b-all which have not yet been identified. background: medulloblastoma is the most common malignant brain tumor of childhood. classically, medulloblastoma presents as a well-defined mass lesion in the cerebellum, with a high rate of metastatic dissemination. primary leptomeningeal medulloblastoma (plmb) is an exceedingly rare type of medulloblastoma presentation with a dismal prognosis in which patients present with isolated leptomeningeal disease without an associated mass. to our knowledge, only three pediatric and three adult cases of plmb (ages - years) have been reported, all of which died within months of diagnosis. this is the first case of plmb to report a molecular classification. objectives: to report the case of a pediatric patient with plmb in which histopathologic and molecular characterization was performed and to describe the patient's treatment and clinical course. design/method: retrospective review of the patient's electronic medical record and review of the literature. a -year-old boy presented with headache, vomiting, diplopia, and fatigue. physical examination revealed upward gaze palsy, left-sided extremity and facial weakness, and ataxia. magnetic resonance imaging (mri) of the brain revealed diffuse cerebellar leptomeningeal enhancement and edema without an identifiable mass and moderate hydrocephalus. mri of the spine and cerebral spinal fluid analysis were normal. a diagnosis of cerebellitis was rendered, and the patient underwent placement of a ventriculoperitoneal shunt. an extensive infectious, neurologic, rheumatologic, and oncologic workup did not identify an etiology. empiric antibiotics, high-dose steroids, and intravenous immunoglobulin therapy yielded minimal improvement. two months later, repeat mri of the brain performed for declining mental status demonstrated progressive thickening of cerebellar leptomeningeal disease. a suboccipital craniectomy with decompression and cerebellar biopsy were performed. pathologic examination revealed a diagnosis of plmb, classic histology, non-wnt/non-shh, without gain/amplification of myc/mycn, and p wild type pattern. craniospinal radiation to cgy with a cgy boost to the posterior fossa was delivered with concurrent carboplatin/vincristine over six weeks. two months following chemoradiation, mri of s of s the brain demonstrates significantly reduced pathological leptomeningeal enhancement of the cerebellum, and the patient is awaiting initiation of systemic chemotherapy while recovering from a surgical wound infection. conclusion: plmb is extremely rare but should be considered in patients with cerebellitis and diffuse leptomeningeal involvement who are refractory to medical management or in whom an etiology has not been identified. cerebellar biopsy is recommended early to enable timely treatment and improved outcomes. molecular classification should be performed in cases of plmb to further characterize this disease, inform treatment decisions, and improve clinical outcomes. background: primary intracerebral osteosarcoma is extremely rare and limited to case reports. ptpn gain of function is associated with noonan syndrome, which has increased risk of multiple cancer types including brain tumors, but osteosarcoma has never been described. ptpn mutations have been reported in many cancers as both oncogenes and tumor suppressors, however no ptpn mutations have been described in osteosarcoma. pdgfr-a is a growth factor receptor whose activation is implicated in several malignancies. pdgfr-a and ptpn concurrent mutations are described in glioblastoma. there is no known link between holoprosencephaly, noonan syndrome, and osteosarcoma. we report a case of multifocal intracerebral osteosarcoma in a child with lobar holoprosencephaly and chronic subdural hemorrhage and discuss the genetic changes found in the tumor. design/method: a seven-year-old caucasian female, with a known diagnosis of lobar holoprosencephaly, chronic subdural hemorrhage and well controlled seizure disorder presented with status epilepticus shortly after completing antibiotic therapy for infection of subdural hematoma. mri showed diffuse dural thickening with mass lesions in the frontal lobe, temporal lobe, and the parasagittal region, the largest of which was contiguous with the subdural space but none of the lesions were associated with bone on mri or by direct neurosurgical visualization. tissue obtained for concern for recurrent infec-tion resulted in a diagnosis of high grade osteosarcoma. dna analysis was performed to help guide treatment choice. results: standard metastatic work-up was negative for skeletal primary tumor or metastatic lesions outside of the brain. she was treated with high dose methotrexate for two cycles per modified aost . despite maximal supportive care, she quickly developed rapid tumor growth as well as intratumoral hemorrhage with resultant herniation and death from respiratory failure just three months after diagnosis. tumor gene sequencing discovered three mutations with described roles in cancer: pdgfra d >vr, kdm a loss of exons - , and ptpn a v. conclusion: to our knowledge, primary multifocal extraosseus intracerebral osteosarcoma has not been previously described. despite known cns penetration of high dose methotrexate, this tumor proved resistant and aggressive. holoprosencephaly is associated with a multitude of known genetic drivers, but none are found in this case. furthermore, the genetic changes in this tumor are not typical for osteosarcoma. pdgfr-a over-expression is described in osteosarcoma, but is not clearly correlated with worse overall survival. further research is required to determine the role of ptpn in osteosarcoma. background: anaplastic lymphoma kinase (alk) encodes a receptor tyrosine kinase whose activation induces pathways associated with cell proliferation, angiogenesis, and cell survival. alk rearrangements are rare in neuroblastoma, while alk mutations and gene amplification occur more frequently. alk mutations have been found to be associated with increased alk protein expression that is associated with a worse prognosis. alk is commonly mutated in neuroblastoma at three hotspots (f , r , and f ). the eml -alk rearrangement has mostly been associated with lung adenocarcinomas, with only a few cases of non-lung cancers found. it has never been reported in neuroblastoma. multimodal therapy and to report the successful management of treatment related iron overload. results: a -year old male presented with abdominal swelling and ct showed a right kidney mass and bilateral lung nodules. he underwent right radical nephrectomy with lymph node sampling. pathology was reviewed centrally and revealed wilms tumor with diffuse anaplasia with rhabdomyosarcoma arising within the stromal component and of nodes positive. he received adjuvant intensive chemotherapy and radiation to the hemiabdomen and whole lungs. the -week chemotherapy regimen was vincristine, doxorubicin, cyclophosphamide (per cog arst ) alternating with carboplatin and etoposide (per cog aren revised uh- ). treatment was complicated by multiple episodes of fever and neutropenia and anorexia requiring g-tube placement. post-therapy, he had persistent neutropenia and thrombocytopenia without related complications. every months for evaluations he underwent a bone marrow which revealed normocellular marrow with maturing trilineage hematopoiesis. evaluation for a bone marrow failure syndrome was unrevealing. starting at months into therapy and all posttherapy imaging showed splenomegaly. he received units of packed red blood cells through the duration of therapy. he was diagnosed with iron overload based on serum ferritin and imaging, including t *mri. he received therapeutic phlebotomy for years with normalization of serum iron studies, t * of the heart, and liver iron concentration. he is more than years from completing therapy with no evidence of recurrent disease. asymptomatic cytopenias persist and he has no evidence of iron overload. conclusion: though a rare development, clonal sarcomatous transformation can occur in wilms tumor. our patient's tumor was successfully treated with intensive multimodal therapy targeting the diffusely anaplastic wilms and the rhabdomyosarcomatous component. treatment-related iron overload in a pediatric patient with a solid tumor was successfully treated with phlebotomy. consideration should be given to screen patients with solid tumors who receive multiple packed red cell transfusions for iron overload at the completion of cancer therapy. primary children's hospital, university of utah, salt lake city, utah, united states background: malignant solid tumors are less frequently encountered in infants. primitive myxoid mesenchymal tumors of infancy (pmmti) are a myofibroblastic malignancy and cases are rarely reported in the literature. cure is achieved in the majority of cases with surgical resection, however treatment for unresectable cases remains an enigma. recently published literature postulates that the newly discovered bcor duplication found in pmmti is tumorigenic via an epigenetic pathway. this molecular signature resembles that of clear cell sarcoma of the kidney (ccsk) and the growing number of bcor mutated sarcomas. a similar chemotherapeutic backbone and local control used for ccsk, has been proposed for the unresectable subset of pmmti. utilizing this approach a month-old with relapsed disease has remained disease free for months. however, given the rarity of this disease and the lack of published literature, there is no known standard of care treatment for unresectable and/or recurrent ppmti. we report a case of unresectable recurrent pmmti, a rare infant tumor, with less than cases reported. design/method: medical record, radiological studies, pathology and literature was reviewed. results: our patient is a now month-old female who presented with constipation and lower extremity weakness in the first weeks of life. an mri demonstrated a large lumbar epidural mass with spinal cord impingement. given prolonged (> days) neurological symptoms and location, emergent chemotherapy was initiated. biopsy showed a bcor positive, primitive myxoid mesenchymal tumor of infancy (pmmti). she was treated with ifosfamide, carboplatin and etoposide, and demonstrated clinical and radiographic response. we gave two additional cycles of cyclophosphamide, carboplatin and etoposide until surgical resection was feasible followed by two post-surgical cycles of chemotherapy. unfortunately, four month post-therapy mri demonstrated two new lesions; an unresectable paraspinal soft tissue mass and a left iliopsoas groove mass. given bcor association and reported successful therapy with vincristine, doxorubicin, cyclophosphamide alternating with ifosfamide and etoposide, we elected to incorporate vinca-alkaloid and anthracycline into her regimen. she is being treated with vdc/ie with plan for radiation consolidation. conclusion: pmmti is a locally aggressive tumor, for which surgical resection is curative. for those not amendable to resection, best care practices are still being determined. we report a case of pmmti initially responsive to chemotherapy, but not curative. this is the second case to conclusively demonstrate chemo-responsiveness. bcor mutation seems to be a common feature of this cancer; its role in the pathogenesis and as a target is an area of investigation. medical college of wisconsin, milwaukee, wisconsin, united states background: atypical teratoid/rhabdoid tumors (atrt) are central nervous system (cns) tumors that most commonly occur in very young children. there is no widely accepted standard of care for atrt patients, and while survival rates are improving they are historically poor. patients with metastatic disease to the spine at diagnosis have a worse prognosis, and for patients > years old, the presence of metastatic disease often results in the use of craniospinal radiation. the importance of correctly identifying metastatic disease at diagnosis aids in decision making and can have both prognostic and therapeutic implications. mr imaging at diagnosis is used to identify metastatic disease; however, here we present a case of diffuse leptomeningeal enhancement that spontaneously resolved after resection of a primary supratentorial atrt. objectives: to describe the resolution of diffuse leptomeningeal enhancement after resection of a primary atrt tumor in a -month-old prior to any adjuvant therapy. results: a -month-old male presented with a month history of vomiting and weight loss, regression of gross motor developmental milestones, and left hemiparesis. a brain mri demonstrated a × . × . cm solid and cystic right atrial mass with diffusion restriction and post-contrast enhancement. smooth diffuse enhancement was noted along the surface of the brainstem and within the interpeduncular fossa. a spine mri demonstrated diffuse circumferential post-contrast enhancement along the surface of the entire spinal cord. the patient underwent a successful near total surgical resection of the primary mass. pathology confirmed the loss of ini- staining in tumor cells, consistent with a diagnosis of atrt. no immediate adjuvant radiation or chemotherapy was given. repeat imaging was completed days after resection. brain mr demonstrated expected post-operative changes within the surgical cavity without definitive residual mass or leptomeningeal enhancement. spine mr demonstrated complete resolution of the previously seen circumferential enhance-ment along the entire spinal cord. csf evaluation at that time was negative for tumor cells. after recovery from surgery, chemotherapy treatment was initiated. conclusion: leptomeningeal enhancement at the time of diagnosis of atrt has historically been considered clear evidence of metastatic disease. this case raises questions about the previously accepted etiology of these imaging changes and suggests that widespread leptomeningeal enhancement should be carefully interpreted in future patients with similar imaging findings. in this setting, clinicians should consider repeat imaging following primary surgical resection in order to provide appropriate prognostic information and inform therapeutic decisions. poster # primary ewings sarcoma of cervical cord mimicking cauda equina syndrome sucharita bhaumik, joshua chan nyu winthrop hospital, mineola, new york, united states background: ewing's sarcoma (es) is a malignant primary bone tumor usually involving long bones. primary es of spine is quite uncommon ( . %) and its location in the cervical spine is even more rare. cauda equina syndrome (ces) is symptoms due to damage to the bundle of nerves below the end of the spinal cord known as the cauda equina (low back pain, radiating shooting pain down the legs, paraplegia, and loss of bowel or bladder control). it often occurs with lesions of lumbosacral spine. treatment with high-dose steroids may provide pain relief and improved neurologic function (by reducing edema) while awaiting diagnostic studies objectives: to demonstrate an unusual clinical presentation and emergent management of cervical es presenting with ces like symptoms. : year old male presented with a left sided posterior neck mass. soon after, he developed weakness of left arm, urinary and stool retention and inability to walk or bear weight in both legs. on physical exam a left tempero-occipital × cm fixed, non-tender, non-fluctuant mass was noted as well as motor and sensory impairment of left upper extremity, bilateral spastic paraplegia and loss of sphincter control. mri cervical spine showed a left cervical tumor with moth eaten appearance involving the vertebral bodies of c -c , adjacent muscles, displacing vital structures of the neck and compressing the cervical spinal cord. the thoracic and lumbosacral spine had no disease involvement. due to rapidly worsening spinal cord compression he was emergently treated with high dose steroids. he gained back all function in his extremities and regained bowel and bladder control. this eliminated need for urgent neurosurgical intervention. results: biopsy of the neck mass showed small blue round cells consistent with es with ewsr gene rearrangement. staging work up revealed no additional metastatic involvement. he then initiated treatment for localized es with systemic chemotherapy and radiotherapy and has had excellent response to treatment so far. conclusion: this is the first known case of non metastatic primary cervical es mimicking ces where an acutely enlarging mass presented with rapidly progressive neurologic deficits due to compression of anterior spinothalamic tract. in these unusual presentations of ces without lumbodorsal involvement it is important to consider cervical lesions. early rapid steroid initiation should be considered while awaiting biopsy results to prevent worsening cord compression followed by es focused treatments. this increases the chance of a successful outcome. the initial improvement with steroids may confuse the tumor with being a lymphoma children 's mercy hospital, kansas city, missouri, united states background: von willebrand disease (vwd) is a relatively common bleeding disorder with a high degree of genotypic and phenotypic variation. bleeding is usually mucocutaneous but can be severe and include muscle and joint bleeds especially in type vwd patients. most common bleeding management consists of desmopressin, anti-fibrinolytics, and/or plasma-derived antihemophilic factor/von willebrand factor (ahf/vwf) complex. a recombinant vwf has become available in the last few years. anaphylaxis and inhibitor development in vwd are rare. objectives: to describe the rare clinical manifestation of anaphylaxis to factor concentrate in a patient with severe type vwd. results: a -year-old female with severe type vwd [baseline vwag %, activity < %, factor viii (fviii) %] originally presented with heavy menstrual bleeding (hmb) leading to anemia requiring blood transfusion. she underwent placement of a levonorgestrel-releasing intrauterine device (lngiud) and began norethindrone. her hmb continued despite the lngiud and an increase in norethindrone dosing. plasma derived ahf/vwf complex was administered, which she had previously received. following the infusion, the patient developed anaphylaxis with hives, wheezing, tachycardia, and itching requiring doses of diphenhydramine and dose of hydrocortisone with resolution of symptoms. subsequently, she received recombinant vwf without incident. however, due to her low fviii level, she also required treatment with a full length recombinant fviii product. she again developed hives and itching after this infusion. she has since received recombinant vwf with recombinant fviii/fc fusion protein without further allergic reaction. there was no evidence of an inhibitor with her most recent post-infusion vwf level was %, factor viii %. conclusion: anaphylaxis to plasma derived factor products has been documented far less frequently within the vwd population compared to those with hemophilia and is typically seen in those with large gene deletions, usually with type disease. therefore, similar type vwd patients with severe disease may benefit from gene sequencing. it is unclear in this patient's case to which aspect of her treatment she is allergic, as she reacted to plasma-derived ahf/vwf and full length recombinant fviii, but not recombinant vwf or recombinant fviii/fc fusion protein. we hypothesize that she may be allergic to an epitope in the fviii b domain, or that the presence of fc fusion may have had a protective effect. further investigation including genetic analysis is planned. nodules. biopsies were consistent with neuroendocrine carcinoma, large cell type (g ). next generation sequencing revealed a khdrbs -braf fusion. he received conventional cytotoxic chemotherapy regimens both with cisplatin/doxorubicin, capecitabine/temozolomide, and doxorubicin/etoposide, but achieved a minimal response followed by rapid disease progression, massive ascites, and renal failure secondary to bilateral ureteral obstruction. results: based on his prior genomic testing, therapy with single agent mek inhibitor (trametinib) was initiated. this produced a rapid, dramatic response with greatly reduced disease burden at all sites, resolution of ascites and return to completely normal activity within months. this response lasted for approximately months before the tumor again progressed. further therapy with an erk inhibitor was ineffective, and the patient expired from progressive disease. located on the chromosome q , the braf oncogene, as part of the ras/mapk pathway, is involved in cellular proliferation, differentiation, migration, and apoptosis. braf mutations are recognized in a wide range of adult malignancies: thyroid cancers, non-small cell lung cancer, cholangiocarcinoma, ovarian cancers, and multiple myeloma. braf mutations have also been described in adult neuroendocrine carcinoma of the colon. trametinib is a highly specific inhibitor of mek /mek , a downstream mediator in the braf pathway. it has demonstrated activity in a number of tumors including advanced melanoma and gliomas. trametinib was chosen for this patient based on his atypical braf fusion. we believe this is the first documented case of its successful use in neuroendocrine carcinoma in the pediatric population. conclusion: this case demonstrates the presence of braf fusion in a case of pediatric neuroendocrine carcinoma and significant response to single agent mek inhibition in this context. this cases raises the question as to whether the combination of a targeted inhibitor, in addition to either conventional chemotherapy or other braf inhibitors, might offer a better approach to therapy than current treatment options. albany medical center, albany, new york, united states background: warm autoimmune hemolytic anemia (waiha) is characterized by autoantibody, and occasional complement binding of protein antigens, on the surface of red blood cells at temperatures ≥ oc resulting in targeted destruction. we describe the case of a year old male with a history of evan's syndrome, poor immune response to vaccines and lymphoid hyperplasia, presenting with altered mental status and severe anemia, found to have a warm igg pan agglutinin with evidence of both intra and extravascular hemolysis. his course was complicated by respiratory failure requiring intubation, pulmonary emboli, enterococcus bacteremia and hypertension. he received multiple transfusions with only transient increases in hemoglobin. the aiha was refractory to multiple rounds of treatment with high dose steroids, ivig, rituximab, cyclophosphamide, bortezomib, plasma exchange and mycophenolate mofetil (mmf). objectives: given the refractory nature of our patient's aiha the decision was made to trial eculizumab, a monoclonal antibody targeting c complement, preventing its cleavage and activation, and shown to be effective in treatment of atypical hemolytic uremic syndrome and hemolysis due to an igm cold agglutinin. prior to eculizumab infusion, ch and sc b- assays were significantly elevated. design/method: the patient was given two doses of eculizimab days apart. results: his hemoglobin steadily rose independent of red cell transfusions with a corresponding decrease in reticulocyte count, ldh and ch levels. the patient has remained stable with a normal hemoglobin ( - g/dl) on maintenance steroids and mmf. although we cannot definitively conclude that eculizumab directly caused his recovery, the clinical course post-eculizumab suggests this may be an efficacious treatment for aiha. genetic testing showed monoallelic frameshift mutation of the nfkb gene and monoallelic missense mutation of the dock gene. given the role of nfkb in both immunodeficiency and autoimmunity, it is thought that the patient's phenotype is due to nfkb haploinsufficiency and he is currently considering hematopoietic stem cell transplant. st. joseph's regional medical center, paterson, new jersey, united states background: heterozygous -thalassemia typically manifests as thalassemia minor, characterized by mild microcytic hypochromic anemia with minimal clinical ramifications. coinheritance of -globin gene triplication has been reported to exacerbate the clinical and hematological phenotype ofthalassemia trait, due to increase in the alpha/non-alpha-chain imbalance. reported phenotypes range from asymptomatic thalassemia minor to moderate thalassemia intermedia, usually diagnosed in adulthood without transfusion dependence. this combination has been described in mediterranean, european and asian populations, but rarely reported in hispanics. objectives: to report two cases of unusually severethalassemia intermedia in hispanic patients with heterozygosity for triplicated -globin gene and a ( )-thalassemia allele. results: case : sixteen-month-old male of mexican descent presented with persistent microcytic anemia and jaundice. peripheral smear showed nucleated rbcs with basophilic stippling and target cells. hemoglobin electrophoresis revealed: hba- %, hbf- %, hba - . %. -globin gene testing revealed heterozygosity for ( ) mutation (ivsi-i, g→a). given the unusually severe anemia, -gene testing was performed which showed -globin gene(anti . ) triplication ( / ). at four years, he had splenomegaly and bilateral maxillary prominence. head ct showed irregular contour of the parieto-occipital region due to medullary expansion. due to significant persistent anemia ( - g/dl) and progressive bony deformities of the skull, patient began chronic transfusions at age eight after family declined splenectomy.case : fifteen-year-old female, of peruvian and honduran descent, presented for evaluation prior to cholecystectomy for gallstones and recurrent ruq pain. father had known thalassemia trait. her hb was . g/dl with hypochromia, microcytosis, and target cells. electrophoresis indicated -thalassemia trait (hba- %, hba - . %, hbf- . %), confirmed by gene testing (heterozygous for a ( ) mutation in codon c>t). given jaundice and gallstones, -globin gene analysis was ordered showing triplication ( / ). ruq pain resolved post-cholecystectomy, but she developed persistent painful splenomegaly. she began hydroxyurea to increase gamma-globin production and decrease excess alpha chains, but it was discontinued due to hematological toxicity. due to recurrent luq pain and progressive splenomegaly, she underwent laparoscopic splenectomy at age with resolution of symptoms and improved hemoglobin. conclusion: -globin gene testing should be considered in -thalassemia carriers with an atypical clinical presentation including hispanic patients. the wide variability in the phenotypic expression of (anti . ) mutation andthalassemia trait suggest interplay of other genetic factors which remain undefined. the clinically significant presentation amongst certain subjects, as in our two cases, makes it imperative to identify these factors to aid in phenotype prediction and genetic counseling. ashley bonheur, shivakumar subramaniyam, jogarao vedula, sucharita bhaumik nyu winthrop hospital, mineola, new york, united states background: wilms tumor (wt) is one of the most common solid malignant neoplasms in children. a diverse range of genes and mechanisms are implicated in wt pathogenesis. predisposing syndromes result from a disruption of wt gene, crucial for renal and gonadal embryogenesis. another gene is wt gene locus at p , an area of imprinting. the p tumor suppressor gene on chromosome p . is seen in patients with anaplastic histology. in addition to these genes, whole and partial chromosome gains of q, , q, , , & and losses of p, p, q, q, as well as loss of heterozygosity (loh) are commonly seen. some genetic markers appear to be predictive of outcome and are now incorporated into the assigning of risk-directed therapy. patients with loh at chromosome p and q are treated with more intensive chemotherapy, as they have been associated with increased risk of relapse and mortality. objectives: to describe a new complex translocation involving chromosome , , and in a case of pediatric wt. design/method: a four-year old female presented with abdominal pain and emesis. on exam, patient had a firm and large abdominal mass. radiologic studies revealed a complex lobulated right renal mass. right radical nephrectomy was performed. histopathologic studies showed wt with triphasic histologic features with blastema predominance, invasion of the lymphovascular and perinephric adipose tissues, perinephric lymph node involvement and no anaplasia. chest ct scan showed bilateral lung metastases. tumor cytogenetics showed an abnormal karyotype, a complex translocation of , , and . the rearrangement occurred due to translocation between chromosomal bands q and q , with an insertion of q - on the q region. pcr based genotyping using microsatellite markers additionally identified loh for chromosome p and q . the patient was treated for high risk stage iv wilms tumor with favorable histology and received intensive chemotherapy and radiation therapy to the flank and the lungs. she is now in remission months after, with no evidence of recurrence on surveillance scans. complex translocations associated with wt have not been rigorously studied. a question for further study is whether there is any relationship between recurrence potential with a complex translocation compared to common chromosomal abnormalities. further knowledge of the molecular pathology and genetic changes in wt will help the development of new targeted therapies, as well as new biomarkers to aid diagnosis, risk stratification, and monitoring of treatment and relapse. results: a week-old girl was referred for evaluation of an abnormal newborn screen. mother was a known carrier of hb khartoum trait while father was a known carrier of thalassemia trait. patient's hemoglobin quantification performed by capillary zone electrophoresis showed hbf %, hb variant %, and no detectable hba. the hb variant ran in the d zone, a pattern consistent with mother's hb. alkaline agarose gel electrophoresis banding pattern showed f/s. acid agarose gel electrophoresis pattern showed v/f. later testing revealed abnormal isopropanol stability with + precipitation at minutes. this electrophoresis pattern is consistent with the pattern previously reported of hb khartoum. clinically, the patient is a healthy, active child whom we have followed for two years. she has not had any significant anemia outside of her physiologic nadir. she has not had any hemolytic episodes, and her bilirubin levels have always been within the normal range conclusion: to the best of our knowledge, this is the only reported case of hb khartoum/ thalassemia. the proline to arginine substitution of hb khartoum introduces a charged group on the chain at the site of contact. the resulting unstable chains can dissociate into monomers and favor the formation of methemoglobin, leading to hemoglobin instability. we had wondered if this unstable hemoglobin might result in clinical hemolysis when challenged with oxidative stress, such as in periods of infection. however, in the two years we have followed this patient, she has never had a hemolytic episode. at two years of age, she has hbf . %, hb khartoum . %, and hba . %. whether hbf elevation is protective from oxidative stress remains to be determined as we continue to follow this child. university of puerto rico -medical science campus, san juan, puerto rico, united states background: gm gangliosidosis is a lysosomal disorder caused by -galactosidase deficiency due to mutations in the glb gene. it is a rare autosomal recessive neurodegenerative disorder with an incidence of about : , - : , live births worldwide. this neurological disorder has three clinical forms. gm type , or infantile form is characterized by psychomotor regression by the age of months, visceromegaly (hepatosplenomegaly), macular cherry red spot, facial and skeletal abnormalities, seizures, and profound intellectual disability. we present a -year-old female with gm type and acute lymphocytic leukemia (all). design/method: she was diagnosed with gm type at the st months of age and family history was remarkable for an older sister with gm type . diagnostic studies reveal homozygous exon of the glb gene for a sequence variant defined as c. c>t, predicted to an amino acid substitution p.aarg cs. results: patient presented to our hospital with petechiae in lower extremities, pallor and intermittent tracheal bleeding. physical examination shows a hemodynamically stable girl that is chronically ill dependent of mechanical ventilation, severe mental retardation and scatter petechiae at upper and lower extremities. laboratory workup revealed severe normocytic anemia (hgb: . g/dl) with immature peripheral cells and thrombocytopenia ( × /l). serum chemistry revealed increase ldh ( u/l), increase hepatic enzymes (ast: u/l), normal uric acid level. there was no evidence coagulopathy. chest x ray was unremarkable except for evidence of chronic pulmonary illness. abdominal sonogram hepatosplenomegaly. during hospitalization, bone marrow aspirate and biopsy was performed which was diagnostic of b cell acute lymphoblastic leukemia (all) with . % lymphoblast and orderly myeloid/erythroid maturation. flow cytometry: % b lymphoblast with aberrant phenotype c/w b-acute lymphoblastic leukemia. karyotype revealed hyperdiploid female of favorable prognosis. cytogenetic by fish: hyperdiploid all with extra copies of runx and igh (no bcr-abl translocation). family was oriented about the new diagnosis and the dismal prognosis in conjunction to her primary condition. parents agree on no chemotherapy treatment for all with only supportive treatment. to this date, there is no evidence in literature that has previously described association of gm and leukemia. life expectancy of patient's primary condition is null therefore, correlation with leukemia might not be a coincidental finding. this patient opens the possibility of malignancy as part of gm type thus, malignancy diagnosis should be considered as part of their medical lifetime course. university of south florida, tampa, florida, united states background: hematological manifestations related to hiv infection are not uncommon, with thrombocytopenia having an estimated prevalence of - %. the pathophysiology is likely multifactorial. studies suggest that the primary mechanism may be immunologic resulting in accelerated platelet destruction. additional theories suggest that infection of megakaryocytes may also play a role causing inadequate platelet production. treatment of hiv-related thrombocytopenia is challenging. first-line treatments include initiation and optimization of antiretroviral therapies, immunoglobulin (ivig), and glucocorticoids. however, this approach is not effective in all patients and second line treatment options are less well studied, particularly in the pediatric population. objectives: we aim to present and discuss the case of a year old patient with perinatally acquired hiv- infection and persistent thrombocytopenia who, after failing first line therapies, showed normalization of platelet count on the novel thrombopoietin receptor agonist, eltrombopag. design/method: a retrospective chart review of the case patient's medical record was conducted. additionally, a thorough literature review was performed on this topic including the pathophysiology of hiv related thrombocytopenia and its treatment modalities. the patient required monthly ivig infusions for about year, but did not show a sustained response, often with platelet count dropping to less than , in between infusions. after initiation of mg eltrombopag daily the patient showed a sustained increase in platelet count (range , - , ). during a brief week lapse in eltrombopag treatment his platelet count dropped to , . upon re-initiation of therapy his count increased to , . the patient has remained asymptomatic, off of ivig for over one year, with undetectable hiv viral load and greater than cd t cell counts. no side effects or grade laboratory abnormalities were reported. conclusion: treatment of hiv-related thrombocytopenia can be challenging. first line therapies, including ivig and glucocorticoids, are not effective in all patients. several other treatment modalities have been utilized, including anti-d immunoglobulin, dapsone, danazol, interferon alfa, vincristine, thrombopoetic growth factors including romiplostim and eltrombopag, or splenectomy, but these are less well studied. this represents the first reported case of a pediatric patient with hiv who showed a positive response to eltrombopag with a sustained improvement in platelet count and no adverse effects from treatment. eltrombopag may be a safe alternative to first line therapies in those patients with hiv and refractory thrombocytopenia, however additional studies are needed. university of illinois college of medicine at peoria, peoria, illinois, united states background: achromobacter xylosoxidans is a gram negative rod with peritrichous flagella which causes rare opportunistic infections most commonly encountered by immunocompromised patients. it is primarily associated with uncomplicated bacteremia, cather-associated infections, and pneumonia. most reports of bacteremia associated with a. xylosoxidans are nosocomial, associated with neoplasm, and occurring mainly in adults. most reported infections with a. xylosoxidans in children are associated with cystic fibrosis. there are very few reported cases of septic shock from a. xylosoxidans bacteremia and pneumonia in the pediatric oncology population. objectives: to describe a rare case of a. xylosoxidans septic shock in a pediatric patient with relapsed neuroblastoma results: a -year old boy with history of stage iv highrisk neuroblastoma underwent standard frontline therapy with chemotherapy, hematopoietic stem cell transplant, radiation therapy, and immunotherapy, followed by a dfmo trial for maintenance. his -month follow-up scans demonstrated relapse and he was subsequently treated with additional chemotherapy, surgical resection, and mibg therapy, crizotinib for an eml -alk fusion and finally ifosfamide, carboplatin and etoposide (ice). he developed neutropenic fevers and was started on cefepime, vancomycin and fluconazole. blood cultures were initially negative. on the th day of fever, his previously scheduled pet scan was performed during hospitalization and showed new pulmonary opacities. he did not have respiratory symptoms, but therapy was escalated to meropenem, vancomycin and amphotericin. emergent bronchoscopy was performed the same day, with all bacterial and fungal cultures remaining negative. overnight, he developed tachypnea and saturations in the upper s, requiring nasal cannula. ir-guided lung biopsy was performed the next day, a flexible bronchoscopy was done to remove blood clots in the airway, the patient was placed on a ventilator, femoral lines were placed, granulocytes ordered and pressors were started for deterioration to presumed septic shock. arterial and femoral lines were placed but patient continued to have hemodynamic instability on multiple pressors. the following day, blood and respiratory cultures returned positive for results: at days after the start of iti, the inhibitor was < . bu and continued undetectable months after initiation of iti therapy. in this patient, iti with high-dose plasma-derived factor viii and von willebrand factor (vwf) complex was well tolerated and effective. genetic analysis confirmed a large factor viii gene duplication of exons to . we believe our patient developed inhibitor so quickly ( exposure days) due to the possibility of this mutation causing a frameshift that introduces a premature termination codon. this might be functionally similar to a deletion in the factor viii gene which poses the highest risk for inhibitor development in patients with severe hemophilia a. this variant has only been identified previously in two unrelated patients diagnosed with severe hemophilia a. this duplication is not listed in dbsnp variant database, nor observed in the general population database. our case proves the effectiveness of this method for patients with severe hemophilia a and an inhibitor. it also shows that more research is needed to identify patients at risk for inhibitor development. background: mercaptopurine ( -mp) is a prodrug that is a core component of maintenance chemotherapy for patients with a diagnosis of acute lymphoblastic leukemia (all). suppression of the neutrophil count is used to demonstrate adequate dosing of -mp during this phase of therapy. bone marrow suppression is mediated by the active metabolite -thioguanine ( -tgn), whereas the metabolite -methylmercaptopurine nucleotides ( -mmpn) has been shown to cause hepatotoxicity. allopurinol has been used infrequently in all maintenance therapy in the setting of skewed metabolism when adequate myelosuppression is difficult to achieve due to excessive hepatic toxicity. when given in combination with allopurinol a reduced dose of -mp may result in both increased -tgn levels and decreased -mmpn levels. objectives: describe the characteristics and clinical course of patients treated with allopurinol and reduced dose -mp during maintenance chemotherapy for all. we performed a retrospective chart review of patients at aflac cancer and blood disorders center of children's healthcare of atlanta with new diagnoses of b or t-cell all who received allopurinol during maintenance chemotherapy. we identified eleven patients with b-cell or tcell all who received allopurinol adjunctive therapy during maintenance chemotherapy at a single institution between - . these patients received adjunctive allopurinol for - weeks (median weeks) with reduced -mp ( - % of full dose). all ten patients with genetic testing for thiopurine s-methyltransferase (tpmt) had wildtype genotype associated with normal enzyme levels. indications for allopurinol use were most commonly unfavorable -mp metabolite levels, transaminitis (n = ), pancreatitis (n = ) and hyperbilirubinemia (n = ). favorable metabolite shift was achieved in all patients. liver enzymes improved in of patients with transaminitis after initiation of allopurinol/reduced -mp. three patients who experienced pancreatitis during maintenance did not have recurrence after initiation of allopurinol ( of these patients previously reported). six patients developed pancytopenia while on allopurinol, and two of those patients developed pancytopenia severe enough to require allopurinol cessation. four patients developed isolated anemia (hgb < . g/dl) without thrombocytopenia or severe neutropenia. no patient has experienced a recurrence of leukemia. overall, treatment with allopurinol and reduced dose -mp was successful in producing a favorable -mp metabolite distribution and reducing toxicity. therapy was generally tolerated; however a major and notable side effect was pancytopenia, in two cases severe enough to stop allopurinol treatment. anemia may be more prominent with allopurinol usage. allopurinol effect is variable among individual patients despite normal tpmt genotypes. baylor college of medicine, houston, texas, united states background: congenital sideroblastic anemia, b-cell immunodeficiency, periodic fevers and developmental delay syndrome (sifd) is a rare inherited sideroblastic anemia syndrome, first described in with clinically similar cases. genetic variations of trnt were identified as causative. objectives: to present an unusual presentation of a patient with sifd complicated by diagnosis of concomitant alpha thalassemia trait. design/method: retrospective chart review. a five month old male infant was referred to our hematology center for evaluation of elevated hemoglobin barts identified on newborn screen. despite numerous attempts, blood work was unable to be collected. at seven months of age he had microcytic anemia (hemoglobin . g/dl, mean corpuscular volume fl) more severe than what would be expected with alpha thalassemia trait. no variant hemoglobin was identified with isoelectric focusing or high performance liquid chromatography. by nine months of age he developed growth failure, intermittent emesis with fevers, developmental delays (predominantly gross motor), hearing loss, a disproportionally large head and coarse, thinning hair. over the next ten months, he was seen by numerous specialists for seemingly unconnected problems including sensorineural hearing loss, elevated liver enzymes and growth hormone deficiency. alpha globin analysis revealed deletion of two alpha globin genes. at months of age, he was admitted with one week of fevers, jaundice, and emesis. peripheral blood smear showed microcytic hypochromic anemia with marked anisopoikilocytosis including target cells, elliptocytes, tear drops, spherocytes, poikilocytes, marked polychromasia, and coarse basophilic stippling. given the inconsistency of his laboratory findings with the diagnosis of alpha thalassemia trait and clinical syndromic findings, bone marrow biopsy was performed which revealed rare ringed sideroblasts. one month later whole exome sequencing revealed trnt splicing variant c. - c>g and novel missense variant c. a>t consistent with sifd. hemoglobin barts on newborn screen with moderate to severe microcytic anemia directed initial diagnostic work-up towards variant alpha thalassemia. as additional medical conditions developed the focus shifted to a unifying syndrome. compared to previously described cases, our patient was diagnosed at an older age, presented with anemia rather than episodes of febrile illnesses, and had rare sideroblasts on bone marrow examination. diagnosis in this case led to identification of the novel c. a>t variant in his sister who had similar, but milder, features. sifd is a rare disease with variable phenotypic severity making diagnosis challenging without high index of suspicion which is crucial for appropriate management. wiseman, blood, . chakraborty, blood, background: cholelithiasis is uncommon in childhood. cholelithiasis is known to occur more frequently in children with predispositions, including female sex, obesity, parenteral nutrition, previous abdominal surgery, use of oral contraceptives, family history of gallstones, chronic hemolytic anemias, hepatobiliary disease, or exposure to specific drugs. although there have been occasional case reports linking cholelithiasis to childhood leukemia or leukemia therapy, the prevalence and risk factors of cholelithiasis in patients with childhood leukemia remain unclear. objectives: to estimate the prevalence of cholelithiasis in patients diagnosed with childhood acute lymphoblastic leukemia (all), and to evaluate possible risk factors for the development of cholelithiasis in patients with childhood all. we performed a computer-assisted review of the electronic medical records of patients diagnosed for b or t-cell all at children's healthcare of atlanta in the period from to . patients with diagnoses of cholelithiasis, cholecystitis or who had a cholecystectomy were identified. possible risk factors of age, sex, bmi, history of abdominal surgery and parenteral nutrition use were abstracted. patients with underlying chronic hemolytic anemia or pre-existing gallbladder disease were excluded. results: seventeen cases of cholelithiasis and cases of cholecystitis without documented cholelithiasis were identified. among patients with cholelithiasis, were female. median age at diagnosis of cholelithiasis was . (range . - . ) years. seven patients had no symptoms referable to cholelithiasis at the time of diagnosis. the median age of leukemia diagnosis among these patients was . (range . - . ) years. the median interval from diagnosis of leukemia to gallbladder disease was . years. four patients had bmi over the th percentile for age. two patients had a prior history of intraabdominal surgery. no patient received oral contraceptive pills. six patients received parenteral nutrition for more than days. there was no documented family history of cholelithiasis. seven patients did not receive any cholelithiasis directed therapy. two patients were managed with medical management only, with endoscopic retrograde cholangiopancreatogram with stone extraction, and with cholecystectomy. our study estimates the prevalence of cholelithiasis in childhood lymphoblastic leukemia to be . %, higher than the reported prevalence in the general pediatric population of . - . %. although our cohort size is small, it appears that all therapy and supportive care modalities associated with all are likely to play a larger role in the development of cholelithiasis than known predisposing factors in the general population. further studies are warranted. background: an uncommon side effect of intravenous immunoglobulin (ivig) administration is clinically apparent, sometimes severe hemolysis. we describe a severe case of coombs-positive hemolytic anemia secondary to ivig administration. ivig is a blood derivative manufactured from pools of , to , individual plasma donations. ivig is not abo-type restricted, so anti-a, anti-b and anti-a,b isoagglutinins are detectable. objectives: to describe a rare but serious type of transfusion reaction leading to gross hemolysis after ivig administration. results: a -year-old male with a past medical history of obstructive sleep apnea and obesity was admitted to the pediatric intensive care unit for adenoviral pneumonia and subsequent respiratory failure requiring mechanical ventilation. he had a complex hospital course with many complications including acute respiratory distress syndrome (ards), septic-shock, and coombs-positive hemolytic anemia. the patient was treated with commercial ivig (baxter/baxalta) -mg/kg daily for five days. he had two isolated episodes of severe hemolysis in relation to ivig administration requiring multiple transfusions of packed red blood cells (prbc). examination of pre-transfusion peripheral blood smear showed spherocytosis with rouleaux formation and large clumped rbc aggregates. the patient's blood type was classified as blood group a, rh-negative and his initial prbc transfusions were of this type. subsequently, the patient's coombs test was found to be positive using polyspecific and anti-igg typing sera. the patient's antibody screen against reagent group o screening cells was negative ruling out autoimmune hemolytic anemia. however, type specific anti-a antibodies were detected in his plasma as well as the acid eludate prepared from the coombs-positive red blood cells. it was concluded that the patient's hemolysis was due to anti-a antibodies presumed to arise from ivig. the patient's rbc transfusions were changed to o-negative blood and the hemolytic process resolved. the patient ultimately died due to complications of ards. although hemolysis is a known side effect of ivig, it is rarely considered when deciding to administer ivig. in addition, it has rarely been described in the pediatric population. ivig is used in the treatment of a growing number of medical conditions. due to the critical nature of many of these patients, hemolysis secondary to ivig may not be considered and continued blood transfusions with the patient's specific blood type may be used. it is crucial to remember that severe hemolysis can occur from ivig, and the importance of transfusing with blood group o, rh-negative blood when applicable. university of maryland medical center, children's hospital, baltimore, maryland, united states background: coagulopathy is a well-described complication of acute promyelocytic leukemia (apml), and remains a leading cause in induction failure. with treatment, coagulopathy associated with apml has been shown to rapidly improve. multiple organ dysfunction syndrome (mods) in apml, including acute respiratory distress syndrome (ards), has been associated with infection, traumatic injury, malignant infiltration, and cytokine release syndrome. when mechanical ventilation is no longer sufficient, extracorporeal membrane oxygenation (ecmo) can be considered; however, coagulopathy, severe end-organ damage, and malignancy are all relative contraindications to initiation of treatment. we report the case of a -year-old female presenting in respiratory failure, disseminated intravascular coagulopathy (dic), with intracranial hemorrhage, and mods, diagnosed with apml, successfully treated with ecmo therapy. design/method: retrospective case analysis and literature review. our patient, a -year-old female was admitted in respiratory failure and altered mental status, following a fall shortly prior to presentation. initial laboratory values were notable for pancytopenia, dic, and acute renal failure. a non-contrast head ct showed left temporal lobe intraparenchymal hemorrhage. she was diagnosed with apml by peripheral smear, later confirmed by fish for t( : ), and was started immediately on high-risk induction chemotherapy as per cog protocol aaml , including all-trans retinoic acid, arsenic trioxide, idarubicin, and dexamethasone. cvvhd was required for acute renal failure. despite maximal respiratory support, she remained hypoxemic, with oxygenation index of , pao /fio ratio of . ecmo was initiated hours after start of induction, hours after admission. coagulopathy resolved on day of induction, ecmo was discontinued after days, mechanical ventilation and cvvhd were stopped after days and she continued to improve, eventually achieving remission with few neurologic side effects. despite relative contraindications to ecmo, this patient was successfully treated with ecmo without significant neurologic side effects. the correction of her coagulopathy was multifactorial: ) restoration of adequate oxygen delivery via ecmo improving endothelial function; ) successful organ support to allow sufficient response to induction chemotherapy with atra leading to the terminal differentiation of leukemic blasts; ) complement and contact system activation through contact with ecmo circuitry. this case illustrates that ecmo can still be considered in patients despite coagulopathy and end organ damage. sinai hospital of baltimore, baltimore, maryland, united states background: primary polycythemia vera is an extremely rare diagnosis in the pediatric patient and is defined by a marked elevation of red blood cells due to erythropoietin-independent mechanisms. presentations of this disorder range from the asymptomatic person to severe thrombotic events, such as budd-chiari syndrome or cerebrovascular stroke. mutations in the jak gene are found in adult and pediatric patients with polycythemia vera; however, the jak v f mutation is less commonly identified in pediatric patients. we describe an otherwise healthy -year-old female who presented with a significantly elevated total erythrocyte count, hemoglobin, and platelets, incidentally discovered upon routine annual blood work obtained by her pediatrician. design/method: this is a report and discussion of a rare case. demonstrated cellular marrow with trilineage hematopoiesis and no dysplasia. cytogenetics were not assessed. his hemoglobin and platelet count recovered but leukopenia and neutropenia persisted. follow-up evaluation at three months revealed fevers, ongoing cytopenias, a one-month of a nodular skin rash on the trunk and extremities resembling erythema nodosum, and hepatitis (peak alt and ast of , and , , respectively). following clinical evaluation, a skin biopsy was performed and was remarkable for atypical lymphocytes within the subcutis with t-cell markers, a high ki- , and positive tia- , perforin, and -f immunoperoxidase stains. negative stains for cd , cd , and ebv were noted. these results are consistent with sptcl. additional evaluation did not support a diagnosis of hlh. a staging evaluation was performed. pet-ct showed widespread hypermetabolic subcutaneous activity in the legs, trunk and skull and diffuse marrow hyperplasia. bone marrow demonstrated involvement with precursor b-cell acute lymphoblastic leukemia, with a mll gene rearranagement. his skin biopsy was retrospectively stained with tdt, cd , pax- , cd a, and cd with negative results, and a blood smear taken at the time of the skin biopsy did not demonstrate leukemic cells. conclusion: this is the first report of a patient with sptcl having a synchronous malignancy. the patient is doing well, currently in the maintenance phase of treatment for his all, and his skin disease has resolved on pet-ct. while it is possible that his presentation was a function of chance, the possibility of an underlying immune dysfunction or cancer predisposition warrants further investigation. cincinnati children's hospital medical center, cincinnati, ohio, united states background: hereditary xerocytosis (hx) is a rare red blood cell (rbc) dehydration disorder, characterized by variable hemolysis and propensity to iron overload. hx is often misdiagnosed as hereditary spherocytosis (hs). while splenectomy is curative for hs, it is relatively contraindicated in hx due to a substantial thromboembolism risk, signifying the importance of delineating these diseases. blood smear abnormalities are variable and often insufficient to make an accurate diagnosis. osmotic-gradient ektacytometry and genetic confirmation are critical in distinguishing these overlapping disorders. objectives: describe a family with hx, initially misdiagnosed as hs. discuss the importance of distinguishing these disorders and the utility of ektacytometry in making this distinction. design/method: a -year-old caucasian male was diagnosed with hs after presenting with prolonged neonatal jaundice starting on the first day of life. he described mild scleral icterus and history of intermittent jaundice and dark urine, without need for transfusions. his father, paternal uncle and paternal grandmother were all diagnosed with hs during childhood and underwent cholecystectomy. additionally, his father underwent splenectomy for abdominal pain. the child's blood counts revealed compensated anemia (hb . gm/dl) and reticulocytosis (arc × /mcl) with increased mcv ( . fl) and mchc ( . gm/dl). blood smear showed increased polychromasia and poikilocytosis with rare spherocytes and few stomatocytes. while the child had normal ferritin, his father had iron overload (ferritin ng/ml) despite no prior transfusions. osmotic-gradient ektacytometry profile of the child and father's rbcs showed a characteristic left-shifted, bell-shaped curve with decreased omin and ohyp, diagnostic of hx. the family is currently undergoing genetic studies. despite clinical similarities between hs and hx, distinguishing these diseases has significant management implications. hx is a disorder of rbc permeability, causing shortened rbc survival. stomatocytes on blood smear can raise suspicion for hx, but are insufficient to make an accurate diagnosis. identifying characteristic biomechanical membrane properties using osmotic-gradient ektacytometry is the gold standard for clinical diagnosis, which can then be confirmed by molecular studies. hs and hx can be easily and reliably distinguished using ektacytometry, as both disorders have very distinctive curves representing different rbc deformability patterns. after hx diagnosis was made, we counseled the family against splenectomy, as the risk of thromboembolism is significantly increased in hx compared to hs, and the father was diagnosed with iron overload. conclusion: hx is commonly misdiagnosed as hs. this case highlights the importance of making this distinction, and the utility of osmotic-gradient ektacytometry in reliably distinguishing these conditions. penn state health children's hospital, hershey, pennsylvania, united states background: relapsed acute myeloid leukemia (aml) presenting as an isolated central nervous system myeloid sarcoma (cns ms) is very rare and its treatment is not well-defined. thiotepa, vinorelbine, topotecan and clofarabine (tvtc) has been successful for re-induction therapy to induce remission prior to hematopoietic stem cell transplant (hsct). objectives: to describe our experience in utilizing tvtc therapy in two children with no extramedullary disease at initial diagnosis who presented with relapsed aml as intracranial myeloid sarcomas. results: case : month-old female was diagnosed with flt negative aml and completed treatment per the children's oncology group (cog) aaml study on the low risk arm without bortezomib. cerebral spinal fluid (csf) negative at diagnosis. fish testing positive for tcf gene deletion of unknown significance. mrd was undetectable after induction i and remained undetectable after each cycle. nine months off therapy, recurrent headaches prompted mri imaging which revealed two posterior fossa masses. csf and bone marrow testing were negative. stereotactic biopsy of the larger mass confirmed recurrence of aml. patient underwent two cycles of tvtc with a total of seven doses of intrathecal cytarabine with almost near resolution of the cns ms. completed cranial radiation and proceeded to allogeneic stem cell transplant with unrelated cord marrow donor and is disease free at approximately day + .case : year-old female diagnosed with flt and mll negative aml and completed treatment per cog aaml study on the low risk arm without bortezomib. csf negative at diagnosis. mrd was undetectable after induction i and completed therapy without complications. two months off therapy, a retrospective analysis of her diagnostic bone marrow by the cytogenetic laboratory to test a new panel identifying novel q partners revealed a cryptic insertional : (mllt /mll(kmt a) translocation. at four months off therapy, acute mental status changes prompted mri imaging which revealed two intracranial ms and lumbar spine involvement. resection of the larger lesion for symptomatic relief confirmed the mllt /mll(kmt a) fusion. csf positive for blasts and marrow negative for relapsed disease. patient completed two cycles of tvtc with a total of seven doses of it cytarabine with near resolution of cns disease (only mm contrast enhancement in the medulla). she received craniospinal radiation and is awaiting improvement in her cardiac function before proceeding to hsct. conclusion: tvtc is a successful reinduction regimen for relapsed aml with cns ms prior to hsct. background: acute severe anemia can be a life-threatening medical condition. the differential is quite broad for possible etiologies of acute severe anemia, including autoimmune hemolytic anemia (aiha) and atypical hemolytic uremic syndrome (ahus). autoimmune hemolytic anemia is an antibody-mediated process that targets the protein antigens located on the surface of red blood cells. treatment options for aiha include corticosteroids, with up to % of patients being responsive, with some requiring splenectomy. atypical hemolytic uremic syndrome is a medical urgency, defined as the triad of microangiopathic hemolytic anemia, thrombocytopenia, and acute kidney injury. the etiology is usually due to genetic causes, or less commonly, due to autoantibodies or idiopathic reasons. prognosis is very poor. objectives: differentiating between autoimmune hemolytic anemia and atypical hemolytic uremic syndrome can be a time-sensitive diagnostic dilemma while the patient is in critical condition, but this important delineation can vastly alter therapeutic options. design/method: here we discuss two cases highlighting the diagnostic workup involved in differentiating between atypical hemolytic uremic syndrome and autoimmune hemolytic anemia. patient a is a -year-old male who presented in extremis with severe anemia, uremic encephalopathy, and severe acute renal injury requiring hemodialysis and multiple blood transfusions. patient b is a -month-old male, who also presented in extremis with respiratory failure secondary to adenovirus/rhinovirus/enterovirus, with acute progressive renal failure and microangiopathic hemolytic anemia, requiring hemodialysis and cardiorespiratory support. : patient a underwent a full hematologic and infectious disease workup. subsequent laboratory studies confirmed enteropathogenic e.coli (epec) in the patient's stool; blood cultures remained negative. renal biopsy results were consistent pigment nephropathy. bloodwork indicated positive direct coombs. patient a was ultimately treated with steroids mg/kg/day, with significant improvement. patient b also included a full hematologic work-up, including adamts activity and ahus genetic panel, as well as full infectious disease work-up. subsequent laboratory test-ing revealed blood cultures growing streptococcus pneumoniae, with adamts activity at % (adult ref range: >/ = %), and normal complement levels. imaging findings also supported diagnosis of ahus. the management of a critically ill patient with acute severe anemia requires a thorough hematologic and infectious disease work-up. while molecular and genetic are helpful in definitive diagnosis of ahus, the utility of such results is limited by time. overlapping clinical presentation of a patient in extremis due to acute severe hemolytic anemia with progressive renal failure presents a rather broad differential, with time-sensitive treatment and prognostic implications. the favorable response to steroids delineates aiha from hus. background: d- -hydroxyglutaric aciduria (d- -hga) is a rare metabolic disorder characterized by developmental delay, hypotonia, and bi-allelic mutations in d- hydroxyglutarate dehydrogenase (d hgdh) or isocitrate dehydrogenase (idh ). metaphyseal chondromatosis with d- -hydroxyglutaric aciduria (mc-hga) is a type of d- -hga that has been previously reported in seven patients (omim ; pmid ), three of whom had somatic mosaicism for r variants in isocitrate dehydrogenase (idh ). we describe a -year-old boy with mc-hga who subsequently developed acute myeloid leukemia (aml) and was found to have a r variant in idh in a leukemic bone marrow sample. we report the first case of aml with this metabolic disorder. design/method: a -year-old hispanic boy presented with short stature, developmental delay, abnormal skin pigmentation, and unilateral congenital cataract. workup revealed multiple skeletal enchondromatosis and elevated urine d- -hydroxyglutaric acid levels. he was diagnosed with mc-hga. no pathogenic variants in d hgdh, idh and idh were identified in peripheral blood. germline testing with biopsies of skin lesions was declined by the family. two years later, he presented with streptococcal sepsis and pancytopenia. blasts were noted on peripheral smear. bone marrow morphology was consistent with acute myelomonocytic leukemia (∼ % blasts). chromosome analysis showed normal xy, and molecular testing by pyrosequencing idh and idh revealed a r c variant in idh ( % mosaicism). the patient is being treated as per the cog study aaml . end of induction i bone marrow aspirate was hemodiluted, but there was no obvious residual disease by flow cytometry ( . - . % sensitivity) or morphology. the previously identified idh variant was no longer detectable (limit of detection < %). although targeted therapy for aml with idh mutation is currently in phase i clinical trials in adults, there is no safety or efficacy data for using idh inhibitors in children. treatment with ivosidenib is therefore not currently an option for our patient. conclusion: this is the first case of aml reported with this rare metabolic disorder. somatic r variants in idh have been identified in three other mc-hga cases. this same mutation leads to the accumulation of d- -hydroxyglutarate in gliomas and aml. without any confirmed germline mutation or somatic mosaicism testing of multiple specimen sources, we can only speculate that the patient has an underlying somatic idh mutation associated with mc-hga which subsequently led to leukemogenesis. we present the first case of this association, to increase index of suspicion for development of aml in children with metabolic disorders associated with variants in idh . background: congenital combined deficiency of the vitamin k-dependent coagulating factors (vkcfd) is a rare heterogeneous autosomal recessive bleeding disorder. vkcfd is caused by mutations in the genes of either gamma-glutamyl carboxylase (ggcx) or vitamin k epoxide reductase complex (vkorc), which are responsible for the gammacarboxylation of vitamin k dependent proteins (vkdps) allowing for their activation. the clinical presentation ranges from no bleeding to intracranial hemorrhage. to date, vkcfd has been reported in few patients worldwide. objectives: we report a case of a girl with novel homozygous mutation of the ggcx gene, highlighting her clinical and biochemical characteristics with a review of the literature. a -month-old girl of consanguineous emirati parents, presented to our hospital with a history of bleeding from puncture site after receiving her second-month vaccine. that was associated with episodes of mild mucosal bleeding. review of systems was negative for jaundice, steatorrhea and failure to thrive and physical exam was unremarkable. investigations revealed markedly prolonged pt and aptt with high inr. fibrinogen, hemoglobin and platelets were always normal. activities of vitamin k-dependent factors including fii, fvii, fix, fx, protein c and s were all low. a measurement of proteins induced by vitamin k absence (pivka-ii) was done and came very high. this was associated with a mild elevation in liver enzymes but normal liver function test. the picture was supporting vitamin k deficiency, and as a result, she was started on oral vitamin k supplements of mg/day. she responded partially to vitamin k and required higher doses to stabilize her inr. after excluding acquired causes and due to her requirement of high doses of vitamin k, a mutation in either ggcx or vkorc genes was suspected. genetic analysis was conducted for her which revealed a novel missense homozygous mutation in the ggcx gene (c. a>t) confirming the diagnosis of combined deficiency of vitamin k-dependent clotting factors type . the asymptomatic parents were both heterozygous for the same mutation. results: she is currently stable on mg/day of vitamin k supplements. conclusion: vkcfd is a rare bleeding disorder with an overall good prognosis due to the availability of several effective therapeutic options. the function of the mutated gene is unknown. our patient demonstrated a partial response to vitamin k supplements suggesting presence of a residual carboxylation capacity and a possible role of this gene in the enzymesubstrate interactions. university of alabama at birmingham, birmingham, alabama, united states s of s background: gata is a zinc finger transcription factor that plays a critical role in the regulation of hematopoiesis and lymphatic angiogenesis. mutations leading to gata deficiency (gd) have been linked to a variety of clinical conditions. patients with gd have a striking predisposition to develop myelodysplastic syndrome (mds), acute myeloid leukemia (aml), or chronic myelomonocytic leukemia (cmml). acute lymphoblastic leukemia (all) has not been associated with gd, although the association of bcell all and gd has been previously reported. objectives: to describe a unique association of gata deficiency and t-cell all in a young child. results: an -year-old female presented with a one-week history of fever and malaise. she had a significant past medical history of verruca plantaris and self-resolving leukopenia associated with febrile illnesses. significant family history included sister with neutropenia and human papilloma virus (hpv) infection, and mother with neutropenia, monocytopenia, atypical mycobacterial infections, and hpv infection. peripheral blood revealed hemoglobin . g/dl, hematocrit . %, platelets , /ul, and white blood cell , /ul (neutrophils /ul, lymphocytes /ul, monocytes /ul). patient underwent a bone marrow biopsy demonstrating lymphoblast infiltration. flow cytometry analysis demonstrated monoclonal lymphoid blast population that co-expressed cd , cd , cd , nuclear tdt, cd , however, lacked expression of cd , cd , cd , cd , hla-dr, or myeloperoxidase. findings were consistent with tcell all with aberrant myeloid markers. cytogenetics analysis revealed ,xx,dic( ; )(p . ;p . ). patient began treatment as per children's oncology group aall and achieved remission at the end of induction. course of therapy was complicated by episodes of fever, reciprocating junctional tachycardia, asparaginase-associated thrombosis, viral meningitis, recurrent episodes of verruca plantaris, and resistant streptococcus pneumoniae or haemophilus parainfluenza infections causing chronic cough. later, she was also found to have low igm levels; after completion of therapy, she developed monocytopenia. lymphocyte subset panel revealed absent b cells, decreased number of natural killer (nk) cells, and cd /cd inversion. further work-up included gata sequence analysis that showed heterozygous nonsense mutation (c. c > t/c; reference nm_ ) likely resulting in gata haploinsufficiency. patient continues to be in remission, is receiving monthly immunoglobulin replacement and is on azithromycin for atypical mycobacterial prophylaxis. surveillance bone marrow biopsies have shown no evidence of mds or leukemia, however, have demonstrated persistent hypocellularity. the possibility of undergoing an allogeneic bone marrow transplant is actively being discussed given its curative potential. clinicians should be aware that t-cell all may be associated with gata deficiency. cincinnati children's hospital medical center, cincinnati, ohio, united states background: treatment for severe hemophilia a is centered on factor viii (fviii) replacement therapy. development of an alloantibody (inhibitor) against fviii is a significant treatment complication occurring in as many as - % of patients. high titer inhibitors render treatment with factor viii ineffective, necessitating the use of bypass agents that may not achieve hemostasis with the same efficacy. considering the substantial ramifications of inhibitor development on treatment, eradication of inhibitors is of great importance to achieve adequate hemostasis in this patient population. desensitization by immune tolerance induction (iti) is the primary method of inhibitor elimination. however, not all patients respond to iti. immunomodulation may be considered as the next line of therapy, although controversy remains in regards to agent selection and use. objectives: there is incomplete data on the use of immunomodulation therapy for inhibitor eradication in severe hemophilia a. we present a case of a pediatric patient with severe hemophilia a and high titer inhibitor who failed initial iti therapy to better illustrate potential treatment options for the future. design/method: a retrospective chart review was performed on a patient with severe hemophilia a at cincinnati children's hospital medical center. results: an -year-old caucasian male with severe hemophilia a secondary to intron inversion, was initially diagnosed following extensive bleeding after circumcision at birth. he was identified as having an inhibitor ( bethesda units (bu)) at months of age after exposure days of treatment. he failed multiple attempts of iti, with recombinant and plasma-derived (pd) fviii. he was advanced to immunomodulation therapy in combination with pdfviii, however demonstrated anaphylaxis to rituximab and ofatumumab. he underwent tolerization to rituximab, and received a six month course with a partial response (nadir of . bu). months following last dose of rituximab, a rising inhibitor titer ( . bu) was found. mycophenolate mofetil (mmf) was initiated with subsequent inhibitor stabilization and a decreasing titer ( . bu) over the course of the following year. mmf has been well tolerated without major side effects or infection throughout therapy. conclusion: development of an inhibitor against fviii is a considerable complication in patients with severe hemophilia a. use of immunomodulatory therapies following iti failure remains controversial. mmf has not been well studied in this patient population. we report a case of a patient who is being successfully treated with mmf with minimal side effects. further prospective studies should be considered to further define the role of mmf immunomodulation therapy. background: down syndrome (ds) children with aml (ds aml) have higher cure rates than their non-ds counterparts. outcomes for refractory/relapsed cases, however, remain dismal. somatic mutations of the gene encoding the transcription factor gata in ds aml patients are responsible for the observed hypersensitivity of ds aml blasts to cytosine arabinoside (ara-c). in view of excellent survival rates (approaching %) of ds aml patients, the ongoing children's oncology group (cog) aaml study seeks to determine the feasibility of treating standard risk (minimal residual disease/mrd negative) ds aml patients using a reduced dose ( -fold decrease) ara-c backbone. although results from japanese trials with this approach are promising, north american and european data are conflicting. although chromosome rearrangements in ds aml do not appear to carry the same adverse prognostic significance as in non-ds aml, monosomy in ds aml patients has been associated with a moderately worse outcome. isochromosome q, however, is rare and has only been reported in previous cases of ds aml. objectives: to report our institutional experience of very early relapse involving cases of ds aml patients treated per the reduced dose ara-c arm ( . g/m ) of the aaml study. design/method: we hereby report the disease course and cytogenetics of the above ds aml patients. : patient is a month old caucasian female who had gata mutation negative aml. patient is a -year old caucasian male whose chromosomal analysis revealed isochromosome q ( copies of the long arm of chromosome ). both patients achieved negative mrd (< . %) after induction i chemotherapy with thioguanine, low-dose ara-c and daunorubicin and proceeded per the reduced dose ara-c arm of aaml . patient relapsed immediately after completion of chemotherapy. salvage chemotherapy with mitoxantrone/high dose ara-c (hidac) failed to induce a second remission and the patient subsequently died of disease. patient relapsed within months from end of therapy. the patient underwent salvage chemotherapy utilizing a hidac backbone and remains in disease remission. the noted very early relapse following a reduced dose ara-c regimen in our above ds aml children suggests that testing for gata mutation and chromosome rearrangements may play a useful role in the development of future risk-stratified treatment strategies for ds aml. university of rochester, rochester, new york, united states background: in developed countries in the st century, severe nutritional deficiency is not an often considered differential diagnosis of unexplained childhood anemia. aside from iron deficiency anemia, vitamin deficiency severe enough to impact hematopoiesis is uncommon in the general pediatric population. here we present the unique case of a -monthold infant who presented with intermittent emesis, failure to thrive (ftt), developmental delay, macrocytic anemia, and neutropenia which was initially concerning for a congenital bone marrow failure syndrome. instead, she was discovered to have an underlying, potentially familial deficiency of b . objectives: . to describe the unique case of an infant with b deficiency. . to outline the importance of including b deficiency in the differential diagnosis of unexplained megaloblastic anemia in children. a -month-old exclusively breastfed infant presented for gastroenterology evaluation due to persistent emesis and poor weight gain over the course of months. her history was notable for delayed developmental s of s milestones and hypoactivity. marked pallor prompted hematologic evaluation, which revealed concern for macrocytic anemia (hemoglobin . g/dl, mcv ), reticulocytopenia ( . × ^ / l), and neutropenia (anc . × ^ /l). an otherwise reassuring physical examination and laboratory evaluation was notable only for the discovery of an undetectable b level and marked hyperhomocysteinemia ( mol/l). her hemoglobin (hgb) continued to decline (to . g/dl) over the first few days after presentation, and she required red blood cell (rbc) transfusion. within only a few days of initiation, daily cyanocobalamin injections resulted in a robust reticulocytosis response, improved hgb, immediate normalization in the neutrophil count, and resolution of hyperhomocysteinemia. additional history and laboratory evaluation from the patient's mother revealed a concurrent, asymptomatic maternal b deficiency as well as a history of a need for b supplementation in the maternal grandfather, raising concern for an inherited etiology. despite the rarity of vitamin-deficient hematologic abnormalities in the general pediatric population, b deficiency should be considered as a potential cause of an otherwise unexplained megaloblastic anemia, especially in the setting of concurrent ftt and neurodevelopmental delay. a detailed family history should be obtained in such cases and may have helped to prevent this patient's clinical sequelae had the deficiency been discovered sooner. our patient has experienced a favorable clinical response to b supplementation, attesting to the importance of vitamin b in early childhood growth and development. background: peg-asparaginase is universally utilized in the treatment of pediatric acute lymphoblastic leukemia (all). despite its high efficacy in this disease, it is associated with hypersensitivity and allergy in - % of patients. protracted anaphylaxis has been described in circumstances such as severe food allergy with ongoing allergen exposure; however, it has not yet been described in relation to peg-asparaginase. we describe the first reported case of protracted anaphylaxis after peg-asparaginase administration, provide guidance as to time course and management of protracted anaphylaxis, as well as evidence that erwinia asparaginase may be safely administered even in this high risk population. objectives: to provide guidance regarding the duration, course and management of protracted, severe anaphylaxis after peg-asparaginase therapy. a year old male with very high risk all presented for consolidation therapy with peg-asparaginase (intramuscular) and vincristine. one hour after administration, he developed generalized hives and angioedema, for which he was given diphenhydramine. he then quickly developed progressive hives, angioedema, subjective throat and chest tightness, and wheezing. he was treated with diphenhydramine, epinephrine, albuterol, and methylprednisolone with resolution of symptoms. one hour later, symptoms recurred and the patient became hypotensive; he was retreated with methylprednisolone and epinephrine, and was transferred to the pediatric intensive care unit (picu). in the picu, he was placed on an epinephrine drip, and continued on methylprednisolone, diphenhydramine, cetirizine, albuterol, and ranitidine. the epinephrine drip was successfully discontinued after hours, and his other medications were gradually weaned over the course of two weeks. of note, the patient did have st segment changes in his electrocardiogram during the first hours of anaphylaxis. these were associated with normal ventricular function as per echocardiogram, and resolved within one week. this patient has subsequently tolerated multiple doses of erwinia asparaginase (intramuscular) without premedication. this patient was acutely managed in the pediatric intensive care unit with steroids, anti-histamines, and continuous infusion epinephrine. symptoms consistent with severe anaphylaxis including hives, angioedema, throat and chest tightness, wheezing, and hypotension persisted for a total of four days before finally resolving. he has thus far tolerated multiple doses of erwinia asparaginase without any symptoms of allergy, hypersensitivity, or anaphylaxis. protracted severe anaphylaxis after peg-asparaginase therapy can be successfully managed with multi-agent therapy, including antihistamines, steroids, and continuous infusion epinephrine. re-challenge with an alternate form of asparaginase may be tolerated, even in a patient with protracted anaphylaxis to peg-asparaginase. ucsf benioff children's hospital oakland, oakland, california, united states background: vincristine (vcr) is widely used in pediatric cancers. unlike most cytotoxic agents, hematopoietic toxicity is uncommon. vcr-induced anemia has been observed but its mechanism has not been well studied. vinca alkaloid-induced membrane changes were seen in early studies of hereditary spherocytosis (hs) and anecdotal cases suggest vcr may increase hemolysis in such patients. here we describe a case involving severe vcr-induced anemia in a patient with hs and an explanation as to the mechanism. objectives: to describe the mechanism of vcr-induced anemia in hs. design/method: case report. a year-old female with hs was diagnosed with t-lymphoblastic lymphoma. she had required packed red blood cell (prbc) transfusions as a neonate and thereafter had done well without episodes of acute hemolysis or aplasia. complete blood counts (cbc's) demonstrated a compensated hemolysis, and she did not require further transfusions until she commenced chemotherapy. by the start of maintenance she had received many more prbc transfusions than the average patient. intermittent drops in hemoglobin (hb) did not correlate with any particular agent, and she had stable, mild splenomegaly. a clear pattern emerged during maintenance. her hb was - g/dl at monthly clinic visits, when she received vcr, intermittent intrathecal methotrexate, and corticosteroids. within - days, her hb dropped to . ± . g/dl, and reticulocyte count decreased from . to . ± . %. transfusion at day corrected hb, and the reticulocytes and hb returned to baseline. white blood cell and platelet counts did not change after vcr. blood samples from pre, immediately post, and days post vcr were analyzed and rbc characteristics and markers of hemolysis were not significantly different. ektacytometry showed identical curves, indicating no change in rbc deformability. in vitro incubation of patient blood samples with vcr also did not affect the osmotic deformability, confirming that a change in rbc rigidity was unlikely the reason for the drop in hb. these data indicate that a dysregulation of erythropoiesis was responsible for the anemia after vcr, rather than damage of peripheral rbc's. in most patients, maintenance therapy for lymphoblastic lymphoma does not cause severe anemia, likely because a temporary reduction in erythropoiesis in patients with a normal rbc survival and low reticulocyte count is not noticed. however, in a patient with decreased rbc survival and a brisk reticulocytosis, a disruption in rbc generation is more apparent. in conclusion, vcr administration to patients with an rbc disorder warrants close observation for potentially severe vcr-induced anemia. background: the addition of tyrosine kinase inhibitors (tki) to conventional chemotherapy has improved outcomes for pediatric patients with philadelphia chromosome-positive (ph+) acute lymphoblastic leukemia (all), however there remains an increased risk of relapse compared to other types of childhood all. typically, in relapsed disease the philadelphia chromosome persists and several mechanisms of resistance involving acquired mutations of the bcr-abl chimeric oncoprotein have been reported. objectives: describe a unique case of a pediatric patient with ph+ b-precursor all relapsing with b-precursor all without the philadelphia chromosome. results: an -year-old boy was diagnosed with ph+ bprecursor all with the presence of the t( ; )/bcr-abl translocation by cytogenetics and fluorescence in situ hybridization (fish), respectively. additional abnormalities included gains of runx and loss of one copy of etv . a remission bone marrow with negative minimal residual disease (mrd) was achieved at the end of induction with dasatinib and the esphall chemotherapy backbone. duration of tki therapy was two years post diagnosis. nearly one year after the completion of therapy, cytopenias prompted a bone marrow investigation. relapsed b-precursor all was established by immunophenotyping, however fish analysis did not identify the bcr-abl rearrangement. moreover, quantitative reverse transcriptase pcr was negative for the bcr-abl fusion transcript. again fish analysis of the bone marrow revealed multiple additional copies of runx and mono-allelic loss of etv , similar to the initial diagnostic sample. the patient was re-induced per aall anticipating a ph+ all relapse. however, with confirmation of the loss of the ph+ clone, tki therapy was not re-initiated. due to positive mrd of . % at the end of re-induction therapy, the patient was salvaged with blinatumomab therapy and subsequently underwent an allogenic stem cell transplant with a sibling donor. conclusion: this is the first known report of a pediatric patient with ph+ b-precursor all who developed recurrent b-precursor all without the philadelphia chromosome. the persistent findings of gain of runx and loss of etv makes it unlikely that a second unrelated b-precursor all developed following successful treatment of the original disease. this case highlights the possibility of a genetically distinct subclone present at the onset of disease that shared abnormalities of runx and etv but did not contain the philadelphia chromosome. nevertheless, the subclone harbored leukemogenic potential in the absence bcr-abl expression. it is plausible that the predominant clone present at diagnosis was effectively treated with dasatinib and extinguished, but the bcr-abl -negative clone persisted in the face of tki therapy. background: ligneous conjunctivitis is a rare form of pseudomembranous conjunctivitis that develops specifically in patients with type plasminogen deficiency. lack of plasmin activity in those patients result in defective fibrinolysis and formation of fibrin-rich membranous material/ masses that develops on the palpebral conjunctiva as well as other sites in the body.current management involve surgical excision of the masses that is usually complicated by multiple recurrences. recently, use of topical plasminogen concentrates helped delaying recurrence, but currently, those concentrates are not commercially available. we report on a -year-old omani girl, with hypoplasminogenemia who required optimization of plasminogen level at the time of surgery to delay/ prevent recurrence. objectives: case report on the peri-operative use of ffp versus cryopricipitate transfusion as an alternative replacement of plasminogen during surgical excision of ligneous conjunctivitis. design/method: pharmacokinetic study was performed to assess plasminogen recovery after ffp ( ml/kg) and precipitate ( bag/ kg) transfusion results: plasminogen levels remained subnormal after either ffp or cryoprecipitate administration. with ffp, the maximum concentration reached was almost % of normal. although half-life of plasminogen is known to be - . days, the patient seemed to have a high catabolic rate after receiv-ing cryoprecipitate, with plasminogen levels reaching basal levels within hours. because of the better recovery profile with ffp, we opted to give ffp before and after surgery. peri-operative management included ffp transfusion at ml/kg/ hours one day before and for days post operatively, followed by ml/kg once daily from day - , then ml/kg on th post-operative day. topical treatment was initiated using antibiotic and steroids ed on the day of surgery, followed by heparin ed on the second day. on follow up, she used topical heparin, cyclosporine, prednisolone, and topical lubricant eye drops for variable duration. clinical picture remained stable for almost year post operatively, when she started to develop recurrence of ligneous lesions again. background: ponatinib (inclusig®, ariad pharmaceutical) is a rd generation multi-targeted tyrosine kinase inhibitor (tki) approved for treatment of adults with chronic myeloid leukemia (cml) and philadelphia chromosomepositive acute lymphoblastic leukemia (ph+ all) resistant to or intolerant of other tkis. ponatinib has numerous drug-drug interactions and a black box warning for associated serious adverse vascular events and hepatotoxicity. for this reason, ponatinib use has been confined to specific high-risk populations. however, in patients who prove refractory to other therapies, the potential benefits of ponatinib may outweigh risks. to date, ponatinib has not been studied in the pediatric/adolescent and young adult (aya) population. furthermore, literature describing the use of ponatinib alone or in combination with other agents in pediatric oncology patients is scarce. objectives: to describe a single institutional experience using ponatinib in the pediatric patients with ph+ all. design/method: two cases of ponatinib use in pediatric ph+ patients resistant to other tkis were identified at our institution and are described. peripheral blood samples obtained from both patients identified bcr-abl p fusion transcripts and sanger sequencing was used to identify resistant mutations. results: our first case is a -year-old female who received upfront multi-agent chemotherapy plus dasatinib for ph+ all. relapse was confirmed on end-of-therapy bone marrow evaluation, thus bcr-abl mutation testing was performed and revealed a t i mutation. ponatinib was initiated then discontinued after one week due to clinically significant fluid retention with peripheral edema and bilateral pleural/pericardial effusions. the second case is a lateadolescent female with ph+ all who relapsed -years after stem cell transplant (sct). following relapse, tki therapy included both imatinib and dasatinib. due to persistence of bcr-abl fusion transcript despite tki therapy she was switched to ponatinib. shortly following initiation of ponatinib she developed a diffuse, maculopapular rash, which persisted despite dose reduction, resulting in ultimate discontinuation of the drug. bcr-abl mutation testing identified f l and f v resistance-conferring mutations. to date, there is scant existing literature detailing the use of ponatinib in pediatric patients. appropriate dosing is undefined and side effect profile not well described, particularly when used concurrently with other chemotherapeutic agents. thus, this case series reporting the response to and toxicity of ponatinib in pediatric ph+ all patients has important clinical implications. additionally, this is the first report of a pediatric ph+ all patient with documented t i mutation underscoring the importance of bcr-abl mutational testing, particularly at the time of relapse. cooper university hospital, camden, new jersey, united states background: myh -related disorder is a rare autosomal dominant disease, encompassing several subtypes: may hegglin anomaly, epstein syndrome, fechtner's syndrome, and sebastian syndrome. heterozygous mutations are seen in the gene encoding non-muscle myosin heavy chain iia (nmmhc-iia) which is involved in cell motility as well as functions to maintain cellular shape and integrity. the presentation of myh -rd is mainly characterized by macrothrombocytopenia, but various related expressions exist: nephritis often leading to renal failure, cataracts and sensorineural deafness ( ). a -year-old girl with history of extensive dental caries, hyperactivity, and speech delay due to suspected hearing loss was incidentally found to have thrombocytopenia at the time of genetic evaluation. she did not have any bruising or excessive bleeding. she did not respond to observation, immunoglobulins, or steroid therapy. her platelet count remained persistently low ( - k/ul). she underwent extensive evaluation to rule out platelet disorder vs. coagulation defect. her peripheral smear showed enlarged platelets by giemsa stain but no inclusion bodies were noted in granulocytes. her platelet aggregation and platelet surface glycoprotein by flow cytometry were negative. her coagulation profile was also normal. objectives: this case report summarizes the complexity in diagnosing myh -rd in a pediatric patient. design/method: since a unifying diagnosis for her clinical presentation was not apparent, whole exome sequencing (wes) was undertaken. results: wes revealed the r c heterozygous pathogenic variant, located in exon in the myh gene. myh gene alteration explained the patient's clinical features of macrothrombocytopenia and hearing loss. this mutation was paternally inherited, and her father demonstrates mosaicism. he was asymptomatic with normal platelet count but his morphology showed enlarged platelets with no inclusion bodies in granulocytes. when dealing with patients who have mild or no symptoms of bleeding diathesis but evidence of persistent macrothrombocytopenia, considering a platelet disorder belonging to myh -rd can help delineate certain predisposing syndromes and guide clinical management. patients are likely to benefit from early genetic testing while receiving supportive therapy. wes can highlight syndromes and provide information on recurrence risk for families. the renal and hearing abnormalities are indistinguishable between epstein and fechtner's syndromes, but the pathogenic variants differ ( ). the genotype-phenotype correlation implies that our patient may have either syndrome, although clinical features compatible with nephritis have yet to manifest. patients should be monitored closely for long-term progression of myh disease, and treatments should be initiated accordingly. we present an -year old female evaluated by genetics at birth due to prenatal microcephaly. chromosomes and microarray were normal. at age she developed standard risk pre-b-cell acute lymphoblastic leukemia (all). she completed treatment in and has been doing well in the interim, remaining in complete clinical remission. during and after treatment she exhibited developmental delay and neurocognitive deficits. at age her height and weight were at or below the th centile and head circumference was below the nd centile (approximately standard deviations below the mean and corresponding to the th centile for a -month-old girl). bone age was appropriate. she had a distinctive triangular face with micrognathia and a pointed nose resembling a seckel-like syndrome. the patient also had clinodactyly of the th toes, zygodactylous triradius involving the nd and rd left toes, tendency to sydney line in the right palm and a radial loop in the left middle finger. the patient's unique clinical presentation prompted a more thorough genetic evaluation, which led to a novel finding we feel is clinically significant with regard to the development of malignancy. design/method: whole exome sequencing (wes) was performed on the patient as well as her biological parents (trio). a de novo heterozygous mutation in the gene pcdh with potential relation to the phenotype was discovered. this c. dupa variant causes a frameshift starting with codon asparagine , changing this amino acid to a lysine residue and creating a premature stop codon at position of the new reading frame denoted p.asn lysfsx . this variant is predicted to cause loss of normal protein function via protein truncation or nonsense-mediated mrna decay. conclusion: pcdh is a member of the protocadherins family which is important in cell-to-cell adhesion and synaptic function in the central nervous system and is highly expressed in areas of the brain involved in higher cortical function and speech. aberrant expression of protocadherins has been associated with the development of malignancies in many organ systems. with regards to leukemia, the methylation status of this gene at diagnosis has been implicated in the prognosis of all and could be used as a biomarker to predict relapse. this patient's de novo mutation and clinical presentation are unique to what has been previously presented in the literature. we feel that this mutation is a clinically significant finding that may shed light on the role of this gene in the development of hematopoeitic malignancies. background: acquired hemophilia a (aha) is an uncommon and potentially life-threatening hemorrhagic disease characterized by sudden onset of bleeding in patients with neither personal nor family history of bleeding dyscrasia. it is usually seen in adults with autoimmune diseases, solid tumors, lymphoproliferative diseases, pregnancy or during the postpartum period; occurrence in the pediatric population has rarely been reported. we report a case of an otherwise healthy teenager who was found to have aha when he presented with acute onset of atraumatic soft tissue hematoma. results: a -year old male of middle eastern descent with history of congenital absence of the right external ear, but otherwise in good general health, presented to our emergency department with a three day history of progressive worsening of right lower leg pain, swelling, and paresthesia, without preceding history of trauma. evaluation by the pediatric orthopedics service documented significantly elevated compartment pressures, necessitating immediate four-compartment fasciotomy. pre-operative labs were significant for prolonged activated partial thromboplastin time (aptt) of . ( . - . ) seconds with normal prothrombin time (pt) and international normalized ratio (inr). ptt did not correct on mixing studies, suggesting the presence of a circulating anticoagulant. factors xii and xi were in the normal range; factor ix was elevated, ( - ). factor viii level was % and fviii inhibitor level was . bethesda units (< . ), confirming the diagnosis of aha. work up for autoimmune disease was negative. his bleeding and surgical hemostasis were managed with recombinant factor vii (novoseven) mcg/kg every hours for hours post operatively, with gradual interval prolongation. factor viii antibody eradication was managed with prednisone mg/kg/day. factor viii and inhibitor levels normalized by day of hospitalization. recombinant factor vii was discontinued; steroids were gradually tapered and discontinued at discharge (hospital day ). conclusion: acquired hemophilia is likely an underdiagnosed condition in pediatrics. while it is typically seen in adults with underlying autoimmune disease, solid tumors, lymphoproliferative disease, or during pregnancy or the postpartum period, pediatric cases may have no identifiable etiology. this case highlights the importance of considering this diagnosis in any patient with unexplained bleeding regardless of their age, so as to intervene early and prevent adverse consequences. university of oklahoma, oklahoma city, oklahoma, united states background: myeloid neoplasms associated with eosinophilia is a rare subtype of chronic leukemia characterized by clonal eosinophilia. the true incidence is unknown due to its rarity and possible classification as idiopathic hypereosinophilia syndrome. the most common chromosomal aberrations involve platelet-derived growth factor receptors (pdgfrs). we report one such rare case in a pediatric patient. most of the pediatric management of this entity is derived from adult case reports and case series. objectives: to describe a case of chronic leukemia presenting as eosinophilia results: a previously healthy year old caucasian male presented with a several week history of migrating joint pain, splenomegaly, and abnormal blood counts with leukocytosis, thrombocytopenia and absolute eosinophilia. white blood cell differential showed myeloid precursors suggestive of chronic myeloid leukemia. bone marrow evaluation showed % blasts and % eosinophils. bcr-abl testing was negative, ruling out cml. fish analysis for eosinophilic clonality revealed deletion of chic gene, resulting in fip l /pdgfra fusion gene, diagnostic for myeloid neoplasm with eosinophilia associated with pdgfr abnormalities. treatment was started with tyrosine kinase inhibitor (tki), imatinib mg daily. within months, fish analysis for fusion gene was negative. after approximately months of daily imatinib, he was switched to maintenance dose of mg weekly. he is approximately months since diagnosis and doing well on maintenance imatinib. in , the who revised its classification of some chronic eosinophilic leukemias to myeloid and lymphoid neoplasms associated with eosinophilia and rearrangement of pdgfra, pdgfrb, fgfr . the most common abnormality is the fip l /pdgfra fusion gene. other less common abnormalities include fusion genes kif b-pdgfra and etv -pdgfrb and point mutations in pdgfra . some features of chronic eosinophilic leukemia include absolute eosinophilia, splenomegaly, elevated vitamin b and tryptase levels, and organ damage from eosinophil infiltrates and cytokine release. patients with rearrangements or mutations involving pdgfra are usually very responsive to imatinib. starting doses have not been well studied or established. experts recommend co-administration of corticosteroids during the first few days of imatinib therapy in patients with a history of cardiac involvement and/or elevated serum troponin levels to prevent myocardial necrosis, a rare complication of imatinib therapy in eosinophilic patients. fortunately our patient did not have cardiac involvement and to date has not exhibited signs of chronic tki toxicity. conclusion: myeloid neoplasms with eosinophilia constitute a rare form of chronic leukemias. they are often associated with pdgfr abnormalities and are usually very responsive to tyrosine kinase inhibitor therapy. walter reed national military medical center, bethesda, maryland, united states background: germline samd l mutation is a rare cause of constitutional bone marrow failure with a unique propensity for clonal evolution to monosomy and mds. objectives: previous case series have demonstrated diverse clinical outcomes in patients with a germline samd l mutation. our case presents a novel samd l mutation (p.val leu). additionally, the case highlights the challenges in clinical decision making for a patient with a gene mutation that is known for clonal evolution towards monosomy with risk of progression to myeloid malignancy, but also known for self-correction through uniparental disomy or inactivating mutations which results in disease remission. design/method: a retrospective chart review and review of the literature was performed. dna was isolated from peripheral blood and used for whole exome sequencing. a peripheral blood sample from the patient's mother and father showed no samd l mutation. skin biopsies of the patient and parents were evaluated for uniparental disomy or new mutations. to determine the pathogenicity of this novel mutation, the specific samd l mutant dna was transfected into the human embryonic kidney cell line to assess its role in inhibiting cell proliferation. our patient presented at months of age with pancytopenia and hypocellular bone marrow in the setting of s of s sepsis. he had evidence of dysfunctional immune activation with hemophagocytosis and elevated soluble il with simultaneous severe hypogammaglobulinemia. analysis of the peripheral blood showed no increase in chromosomal breakage, normal telomere length, and normal flow cytometry. gene testing for primary hemophagocytic lymphohistiocytosis and inherited bone marrow failure were negative. after the patient recovered from his presenting illness, a repeat bone marrow biopsy demonstrated improved cellularity with myelodysplasia and cytogenetics significant for monsomy .whole exome testing demonstrated a novel samd l mutation. the patient continued to require intermittent ivig and failed to demonstrate appropriate leukocytosis with intermittent infections. on repeat bone marrow evaluation over the course of months, the patient demonstrated no evidence of evolution towards self-correction and had a persistent monosomy clone. the patient is scheduled to undergo a matched unrelated donor bone marrow transplant. our case highlights the unique clinical picture associated with constitutional marrow failure and clonal evolution secondary to a novel samd l mutation which is thought to cause pancytopenia by inhibiting cellular proliferation and often results in the development of monosomy which rescues hematopoiesis but with a risk for malignancy. background: notable labs developed a flow cytometricbased assay with a custom robotic platform to test fdaapproved drugs for anti-cancer activity against individual patient's tumor cells. this personalized assay is a potential method for identifying novel agents and drug combinations to treat aml patients who have failed standard therapies. objectives: to present the case of a teen who underwent successful treatment of relapsed aml post-sct with bortezomib, panobinostat, and dexamethasone-a regimen selected based upon results of notable lab testing. results: a -year-old male with m -aml had an isolated bone marrow relapse months after completion of scheduled therapy. at relapse, his aml was flt -itd positive. he achieved a second remission with negative mrd and underwent matched sibling donor bmt after busulfan/cyclophosphamide conditioning. bma performed on day + was mrd positive ( . %). repeat bma done on day + showed . % mrd. he started sorafenib on day + . he received donor lymphocyte infusion (dli) on day + , then received cycles of azacitadine (aza) followed by dli. marrow mrd by flow after sorafenib alone, sorafenib with dli, and sorafenib with aza/dli were %, . %, and . %, respectively. treatment was complicated by varicella meningitis, grade i skin agvhd, febrile neutropenia and c. difficile colitis, and metapneumovirus pneumonia. despite extremely low levels of leukemia (marrow mrd . %), notable lab testing performed on the patient's leukemia cells from marrow collected after aza/dli/sorafenib revealed sensitivity of his leukemic blasts to a combination of bortezomib, panobinostat, and dexamethasone. because of prolonged cytopenias, multiple infectious complications, and persistently positive mrd, he discontinued aza/dli/sorafenib and on day + started bortezomib . mg/m iv on days , , , and ; panobinostat mg po on days , , , , , ; and dexamethasone mg po on days , , , , , , , and . chemotherapy cycle started days later. he tolerated treatment without side effects and with resolution of rash and cytopenias. he achieved full donor chimerism, negative flt -itd, and complete remission by morphology and flow after two cycles. notable lab testing is a powerful tool for evaluating the sensitivity of small populations of leukemic blasts to novel drug therapy. results from notable lab testing may serve as a useful guide for treatment selection after failure of standard aml therapy. this patient achieved morphologic and mrd remission post-sct with bortezomib, panobinostat, and dexamethasone-a regimen predicted to be efficacious based upon notable lab results. maria ahmad-nabi, christine knoll, sanjay shah, esteban gomez, lori wagner phoenix children's hospital, phoenix, arizona, united states background: development of inhibitors in patients with factor ix deficiency (fixd) is a well-recognized complication occurring in - % of patients. within this subset a small percentage can develop anaphylaxis to factor. desensitization with cyclophosphamide, an alkylating agent used in the management of various oncologic malignancies, and reported for use in factor viii desensitization has been previously unreported for use in desensitization in patients with fixd. rituximab, an anti-cd antibody, however has been used. objectives: to induce immune tolerance (it) in patients with inhibitors to factor ix with either novel or under reported methods using cyclophosphamide and/or rituximab. we report a case series of patients at phoenix children's hospital with fixd who achieved it with cyclophosphamide and/or rituximab. results: patient one was a year old male with severe fixd, who at the time of desensitization had inhibitor levels of bu. he was desensitized with cyclophosphamide, then admitted for infusion of recombinant factor ix. he experienced a few minor symptoms of intolerance including an urticarial rash which was self-limited, and hemarthrosis of the right elbow on day which responded to novo . he tolerated the remainder of his infusion without issues. he continued recombinant factor ix daily, and returned to clinic for monthly cyclophosphamide for months. he did develop urticaria with hemarthrosis and spontaneous muscle bleeds which were tempered with zantac, zyrtec, solumedrol, and benadryl. he remained without a recurrence of inhibitors, however did have intermittent hemarthrosis of his ankles thereafter requiring prophylactic twice daily dosing recombinant factor ix. patient two was a year old male with severe fixd and a family history of anaphylaxis to factor causing early death in all male relatives with the disease. he had never received factor ix and did not have a detectable inhibitor prior to desensitization. he successfully underwent desensitization to recombinant factor ix with rituximab in the icu, and returned to clinic for weekly infusions x . he experienced no adverse reactions concerning for anaphylaxis. he continued to tolerate factor ix products without evidence of intolerance, development of inhibitors, and continues on as prophylactic dosing of recombinant factor ix every other day. our experience at a single institution proves cyclophosphamide as a novel agent for inducing it in those with fixd and anaphylaxis. it also provides further evidence that rituximab can desensitize patients with severe fixd. differences include longer duration for cyclophosphamide therapy ( months vs month). background: cartilage-hair hypoplasia (chh) is an autosomal recessive chondrodysplasia associated with defective cell-mediated immunity caused by mutations in the ribonuclease mitochondrial rna processing (rmrp) gene. cancer incidence is -fold higher in patients with chh than in the general population, especially non-hodgkin lymphoma. the use of rituximab, an anti cd antibody, results in decreased host b-cell number and impaired humoral function for - months. the safety of rituximab in pediatric patients with cancer and immunodeficiency is not well documented. a diagnosis of underlying immunodeficiency may discourage physicians from using rituximab due to the risk of severe bacterial infection or viral re-activation. objectives: to report a case of burkitt lymphoma in a young adult female with chh and defective cellular immunity successfully treated with rituximab. results: an -year old amish female with disproportionate short stature presented to our center for management of stage iv biopsy proven burkitt lymphoma with myc rearrangement. she had presented a week earlier with cervical, occipital, and submandibular lymphadenopathy, splenomegaly; fevers, night sweats, and weight loss for - weeks. on exam, her height was three feet associated with brachydactyly, mild bowing of the legs, normal size head without frontal bossing, fine and sparse hair. she had normal intelligence. her pattern of dysmorphisms was suggestive of chh (genetic testing not performed at time of diagnosis). pet-ct scan showed stage iv disease with involvement of cervical lymph nodes, spleen, iliac bone and bone marrow. treatment with standardintensity fab/lmb therapy (group c) with the addition of rituximab was initiated. she had an incomplete response to cop (∼ % reduction of tumoral masses) but achieved complete remission after copadam . her course was complicated with severe varicella zoster but she completed therapy and remains in complete disease remission for months after treatment completion. genetic testing subsequently performed proved homozygosity for chh with a n. a>g variant. she had no other opportunistic infections during or after therapy. conclusion: the use of rituximab was both safe and beneficial in our patient despite defective cell mediated immunity secondary to chh suggesting that rituximab may be safe to use in patients with cellular immune deficiencies. background: hemophilia a and b are bleeding disorders characterized by deficiency in factor viii or ix, respectively. spontaneous or provoked hemarthrosis is a known complication of hemophilia. repetitive episodes of hemarthrosis can lead to debilitating hemophilic arthropathy. lyme disease is a tick-born infection which is endemic to increasing parts of the united states. chronic lyme disease, the phase in which lyme arthritis typically develops, occurs months to years after initial infection and is characterized by swelling of one or more large joints generally in the absence of systemic symptoms. objectives: review cases of hemophilia a and b patients with episodes of provoked hemarthrosis refractory to intensive recombinant factor replacement therapy found to have concurrent lyme arthritis. design/method: we report two clinical cases and review relevant literature. results: first, we report a year-old male with moderate hemophilia a with a provoked knee hemarthrosis which failed to improve despite months of intense factor replacement therapy requiring multiple hospitalizations. factor replacement regimens included twice daily standard half-life recombinant factor viii products or daily to every other day extended half-life recombinant factor viii products with trough levels aimed as high as - %. factor viii pk studies were obtained for dosing, to confirm adherence, and to evaluate for subclinical inhibitors (inhibitor testing was negative). given protracted symptoms additional workup for hemarthrosis was pursed. lyme titers were positive for ( )igg, though negative for igm. he was treated with days of doxycycline during which time hemarthrosis greatly improved on examination and imaging, and he was able to recover function through physical therapy. second, we report a year-old male with moderate hemophilia b who required multiple hospital admissions for a provoked knee hemarthro-sis with no improvement in symptoms despite weeks of daily or twice daily factor replacement with standard halflife recombinant factor ix products aiming for % correction. we performed inhibitor testing (which was negative) and pk studies to assess for non-detectable inhibitors, dosing and adherence. lyme testing was positive for ( )igg, though negative for igm. he was treated with amoxicillin for days during which time hemarthrosis significantly improved on examination and imaging. diagnosis and follow-up imaging studies for both patients included mri and serial bedside ultrasounds performed as per uc san diego school of medicine mskus guidelines. background: relapse/refractory aml following allogeneic hematopoietic stem cell transplant (hsct) holds a high mortality rate. current relapse/refractory therapy modalities for younger patients may include re-induction with a clofarabinebased regimen followed by second allogeneic hsct. even for patients who undergo second hsct, the five-year survival rate is dismal. new therapies, including small molecule inhibitors, are being studied in the post-hsct relapse setting or those unfit for hsct with promising results. venetoclax is a small molecule inhibitor that has received breakthrough designation for aml treatment in elderly patients objectives: to report a young adult aml patient with relapse post hsct who was successfully re-induced with topotecan, vinorelbine, thiotepa, clofarabine (tvtc) and has sustained remission with venetoclax maintenance therapy. this approach appears to be unique in terms of reported literature. results: our patient is now a -year-old female noted to have mll rearranged aml at initial diagnosis when she was years old. she underwent chemotherapy consisting of cytarabine/daunorubicin according to standard + . due to persistent disease, she was re-induced with g-csf, clofarabine, and high-dose cytarabine (gclac) which put her in cr. her course was complicated by sepsis, colitis, gastrointestinal bleed, deep venous thrombosis, and transfusionassociated circulatory overload. given her co-morbidities, she received another cycle of clofarabine/cytarabine, and then proceeded to reduced intensity allogeneic hsct, according to bmt ctn . the patient tolerated hsct well and experienced no transplant-related complications, including no acute or chronic gvhd. unfortunately, she relapsed about month's post-hsct. initial salvage therapy consisted of another course of g-clac, but due to persistent disease the decision was made to re-induce her with topotecan, vinorelbine, thiotepa, and clofarabine (tvtc). during this time however, she was found to have extensive infection with a fusarium species requiring a course of anti-fungal therapy. bone marrow evaluation showed no residual disease with an mrd of < . %. once the absolute neutrophil count recovered, the patient was started on single-agent venetoclax for maintenance therapy, which has been well-tolerated. she remains in morphologic remission for over months. we describe herein a young adult with multiply relapsed aml wherein tvtc re-induction, followed by maintenance with venetoclax were safely used in the post-hsct setting. venetoclax therapy in the relapsed aml setting warrants further study. background: vitamin b deficiency is uncommon in children in developed countries, especially in the absence of risk factors like malabsorption or inadequate dietary intake. it often presents with non-specific symptoms and signs and can elude diagnosis. the recognition and treatment of vitamin b deficiency is critical as it can lead to bone marrow failure as well as severe neurological and developmental problems in children. to increase index of suspicion of vitamin b deficiency anemia in children. we report a rare case of vita-min b deficiency anemia in a child who presented with a severe macrocytic anemia, with signs of hemolysis and concern of malignancy. design/method: an almost three-year-old previously healthy girl presented with a few day history of fever, emesis, fatigue and pallor. she had no dysmorphic features, hepatosplenomegaly or lymphadenopathy on exam, growth and development were normal. laboratory findings showed severe macrocytic anemia (hemoglobin . grams/dl; mcv . fl) with reticulocytopenia. signs of intravascular hemolysis were present with elevated lactate dehydrogenase ( , units/l) and haptoglobin below assay limit. immune-mediated hemolysis was ruled out. initial picture of a hemolytic anemia was compounded by other findings of moderate neutropenia, mild thrombocytopenia and peripheral smear showing occasional blasts. further workup was done with a broad differential diagnosis that included leukemias, hemolytic anemias, bone marrow failure syndromes, and specific deficiencies. results: workup revealed abnormally low vitamin b levels along with significantly elevated homocysteine and methylmalonic acid levels indicating functional vitamin b deficiency. bone marrow evaluation showed megaloblastic anemia and dyserythropoiesis consistent with vitamin b deficiency, and ruled out leukemia. vitamin b deficiency can cause a hemolytic anemia like picture secondary to intramedullary hemolysis due to ineffective erythropoiesis. myeloid precursors are also affected which can lead to neutropenia, thrombocytopenia, and abnormal peripheral blood cells. in our patient, initial symptomatic anemia was treated with blood transfusion, followed by intramuscular vitamin b injections with normalizing lab values. so far, workup for an etiology for vitamin b deficiency is negative except for an equivocal range of anti-parietal cell antibodies raising concerns for pernicious anemia; however it is rare in this age group. another rare condition is an inborn error of the cobalamin transporter. she is currently on oral vitamin b supplementation and further workup will be planned based on response. conclusion: this case highlights the importance of early consideration and thorough evaluation of vitamin b deficiency in children with unclear etiology of anemia, so that prompt treatment can be initiated. memorial hospital/ university of miami, miami, florida, united states background: despite great success in the treatment of acute lymphoblastic leukemia (all), the outcomes for patients with relapsed all remain poor. prognostic indicators include timing and site of relapse. blinatumomab, is the first agent in its class that simultaneously binds cd -positive cytotoxic t cells to cd -positive b cells resulting in lysis of malignant cells. however, mechanisms of leukemia resistance to blinatumomab are unclear. objectives: to describe a case with multiple sites of extramedullary (em) relapse during blinatumomab therapy. results: a -year-old hispanic male with philadelphia positive, cd -positive b-precursor cell all refractory to chemotherapy, had failed a bone marrow (bm) and was placed on blinatumomab and imatinib. he achieved minimal residual disease (mrd)-negative systemic remission, but during his fifth cycle developed bilateral periorbital masses. biopsies confirmed cd -negative isolated em relapsed disease, which was treated with radiation therapy (rt). there was notable resolution of em disease and he continued systemic therapy. subsequently, he presented with a painful left scapular swelling. imaging showed muscle and lung parenchymal em relapse with cd -positivity confirmed on histology. he continued on blinatumomab with localized rt while awaiting car-t cell therapy. his bm mrd remained negative until he developed systemic mrd-positivity with cd -positive blasts following the sixth cycle. primary resistance to blinatumomab is poorly understood. it is proposed that expansion of cd -negative clones or downregulation of cd following blinatumomab may play a role. this was observed in our patient's periorbital relapse; but subsequent em and systemic relapses were cd -positive, consistent with the co-existence of multiple clones in relapsed all. it has also been postulated that em relapse could be linked to the failure of blinatumomab or t cells to migrate to em sites of disease or drug inactivation by the microenvironment. the second em relapse in our patient, with cd -positive disease suggests this as a possible mechanism of relapse. this was reported in patients with cd positive non-hodgkin lymphoma (nhl), and higher doses of blinatumomab however, have shown promising results in this population. despite blinatumomab's effectiveness in inducing remissions in patients with refractory/relapsed all, it appears to have limitations in patients with em disease. these may arise either from the multiclonality associated with relapsed all or due to the emergence of resistance to blinatumomab, including failure to migrate to em sites. background: cyclic neutropenia is a rare hereditary disorder, characterized by recurrent neutropenia, cycling at about week intervals, with variable associated symptoms including oral ulcers and fever. there are reported cases of cyclic neutropenia associated with chronic inflammation leading to development of reactive aa amyloidosis. one patient also presented with amyloid goiter. we report a new case of cyclic neutropenia with associated renal and thyroid amyloid. design/method: a -year-old female presented with a month history of thyromegaly, and recurrent aphthous ulcers associated with fevers. laboratory workup showed severe neutropenia, anemia, azotemia, and abnormal thyroid function, with an absolute neutrophil count - / l, hemoglobin - . g/dl, serum creatinine - . mg/dl, and uric acid - . mg/dl. thyroid stimulating hormone was elevated - . iu/ml, and normal free t . urinalysis showed + protein, + blood, and - urine red blood cells/hpf. chest radiograph showed mild narrowing of the trachea from thyroid compression. bone marrow biopsy showed a hypocellular marrow, with tri-lineage hematopoiesis, left shifted myeloid maturation with very rare mature neutrophils. both renal biopsy and thyroid fine needle aspiration revealed abundant amyloid. of note, her father had aa amyloidosis, resulting in end-stage renal disease (esrd) requiring hemodialysis, and recurrent aphthous ulcers. the family history suggested a familial predisposition. genetic testing revealed a pathogenic elane c. a>t gene mutation with autosomal dominant inheritance confirming the diagnosis of cyclic neutropenia. we treated our patient with daily granulocyte colony stimulating factor to reduce the burden of chronic inflammation induced by cyclic neutropenia, and to preserve renal and other end organ function affected by further amyloid deposition. results: proband with elane gene mutation positive cyclic neutropenia, amyloidosis of thyroid and kidney, with a positive paternal history of aa amyloidosis resulting in esrd. cyclic neutropenia may result in chronic inflammatory states leading to secondary amyloidosis. university of kentucky, lexington, kentucky, united states background: overall survival of burkitt lymphoma (bl), regardless of stage, is greater than % in the pediatric population when treated with multi-agent chemotherapy. adenovirus is a common, usually self-limited infection within the pediatric population; however, findings can vary within an immunocompromised host. hepatitis is a rare complication, with very few reports of radiologic findings in this patient population. we discuss a three year old male with history of bl who presented with clinical and radiographic evidence of relapse but was found to have adenovirus hepatitis. design/method: a case report of a patient with bl in complete remission after completion of standard of care chemotherapy, who presented with return of high fever, elevated ldh, transaminitis and hepatic lesions. we describe the hepatic imaging and pathology consistent with adenovirus hepatitis in this immunocompromised host. our patient presented at three years old with a six week history of worsening abdominal pain and fevers. he was found to have a right sided pleural effusion, multiple lesions of the liver, and diffuse abdominal lymphadenopathy; biopsy of lymph tissue was consistent with bl. he completed therapy per anhl arm b and was in a complete remission at the end of planned therapy. one month after completion of therapy, he returned with high fever, abdominal pain and transaminitis, similar to his initial presentation. ct scan showed multiple hypodense discrete lesions throughout the liver and re-accumulation of right sided pleural effusion. ldh peaked at u/l (uln u/l). uric acid remained within normal limits. bilirubin peaked at . mg/dl, conjugated . mg/dl. liver biopsy was performed, showing smudgy nuclei with immunohistochemical staining positive for adenovirus. there was no evidence of lymphomatous involvement. resolution of hepatic lesions and transaminitis, with normalization of ldh and fever, occurred with symptomatic treatment alone. adenovirus is known to cause systemic disease in immunocompromised patients and rarely hepatitis. no pediatric patients with discrete hepatic lesions secondary to adenovirus have been reported in the literature. three cases of discrete hepatic lesions have been reported in adult immunocompromised patients, two with fatal fulminant liver failure and one who required cidofovir. this case demonstrates that a common pediatric viral infection can present with lesions concerning for metastatic disease in a pediatric lymphoma patient. prompt diagnosis is vital in the management of these patients when recurrent lymphoma is in the differential. background: heparin induced thrombocytopenia (hit) is an immunologic process in which antibodies bind a heparin complex and cause a paradoxical hypercoagulable state. ramifications of this process may include a multitude of thrombotic events and bleeding complications secondary to platelet consumption. in our patient, hit manifested as increased bruising, an acute decrease in platelet count, and continual clotting of her crrt circuit. hit, although rare in pediatrics, should be included in the differential for children with thrombocytopenia who have received heparin products. to present a unique case report of a critically ill pediatric patient who developed hit in the presence of multiorgan system failure and to discuss the challenges encountered with identification of an alternative anti-coagulant. results: a yo obese, caucasian female child presented to our facility with bilateral pulmonary emboli (of unclear etiology). initially, she was started on a continuous heparin infusion, but was transitioned to enoxaparin within days without issue. five days after enoxaparin was initiated, the patient developed acute kidney injury (evidenced by increasing creatinine) attributable to her biventricular heart failure. due to her need for continuous renal replacement therapy (crrt), she was transitioned back to a continuous heparin infusion. whereas her initial platelet count on transition was normal, she developed severe thrombocytopenia ( , ul) within hours. due to intermediate risk but low suspicion for hit, pf antibodies were sent which were positive. after much discussion, she was transitioned to an argatroban infusion which was titrated according to ptt levels. within hours, her platelet count normalized. at discharge, she was prescribed apixaban for anti-coagulant management. conclusion: hit is an uncommon presentation in the pediatric population. given its rarity, there is often a delay in diagnosis which increases risk of complications such as bleeding, stroke, and limb ischemia. even if the diagnosis is suspected or proven, there may be challenges in initiating alternative agents as limited data exists on pediatric options. as argatroban remains the treatment of choice for patients with hit, experience in pediatric patients is limited, and dosing recommendations have been extrapolated from adult studies. anecdotal data exists for use of bivalirudin in children, although studies, primarily, focus on use in specific cardiac cases. in our patient's case, choice was further complicated by renal failure. this case study highlights the need for further research regarding the identification of a secondary anti-coagulant agent for use in pediatric patients with hit. background: subcutaneous panniculitis-like t-cell lymphoma (sptl) is a rare form of non-hodgkin's lymphoma characterized by infiltration of cytotoxic t-cells into subcutaneous tissue. sptl occurs in both adults and children and can present in both patient populations as either alpha/beta or gamma/delta subtypes. patients with the gamma-delta phenotype have an overall poorer survival, although the exact etiology is unclear. interestingly, both subtypes of sptl can present with secondary hemophagocytic lymphohistiocytosis (hlh), and this is associated with a worse prognosis. currently, there are no standardized treatment protocols for sptl, and clinical management includes watchful waiting, corticosteroids/immunosuppression, chemotherapy, and stem cell transplant. the primary objective was to compare how two patients with the same diagnosis responded acutely to therapy. we performed a retrospective chart review of two pediatric patients at our institution who were diagnosed with alpha/beta sptl and secondary hlh. we examined each presentation, treatment course, and outcome. we then completed a brief review of the current literature describing treatment of and outcomes for sptl with secondary hlh. results: these two patients presented in a similar manner with signs and symptoms of hlh. each was then subse-quently diagnosed with alpha/beta sptl after biopsy of cutaneous nodules and each had diffuse disease, as measured by pet. however, they demonstrated vastly different acute responses to therapy. one patient was pre-treated with systemic glucocorticoids before receiving definitive chemotherapy and tolerated therapy well as an outpatient. the other patient started systemic chemotherapy without steroid pretreatment and developed severe cytokine storm characterized by hypotension, cardiac dysfunction, multi-organ failure and cytokine elevation. both patients achieved complete remission (cr) after treatment with chop chemotherapy and remain disease-free - months off therapy. in patients presenting with sptl and secondary hlh, we propose that initial treatment with antiinflammatory or anti-cytokine therapy can decrease, or even prevent, the possibility of life threatening cytokine release as a result of cytotoxic chemotherapy. background: congenital dyserythropoietic anemia type ii (cda ii) is a rare autosomal recessive disorder, rarely presenting in the neonatal period. iron overload often occurs as a late sequela of ineffective erythropoiesis and intramedullary hemolysis. objectives: to report the novel use of iron chelation in an infant with cda ii associated with severe iron overload. the patient is a -month-old, former -week infant with prenatal non-immune hydrops and transfusion-dependent fetal anemia who presented with persistent anemia, reticulocytopenia, hyperbilirubinemia, liver dysfunction, and hyperferritinemia. his initial ferritin was . ng/ml, tibc ug/dl, and transferrin mg/dl. his bone marrow biopsy showed trilineage hematopoiesis and erythroid dyspoiesis characterized by binucleation of late-stage precursors. genetic testing revealed a compound heterozygous missense mutation and splice site mutation in the sec b gene, confirming the diagnosis of cda ii. initial liver biopsy revealed mild portal fibrous expansion, and abundant hepatic iron deposition. his ferritin continued to increase, peaking at , ng/ml, along with liver enzymes peaking at an alanine aminotransferase (alt) of u/l and aspartate aminotransferase (ast) of u/l. ferriscan showed an elevated estimated liver concentration of . mg/g dry tissue. repeat liver biopsy months later showed giant cell hepatitis with worsening mild portal fibrosis and hemosiderosis. additionally, tissue liver iron concentration was mcg/g dry weight. cardiac t * mri revealed mild cardiac iron deposition. given his significant degree of iron overload, deferoxamine was used to reduce hemosiderosis and liver morbidity in preparation for bone marrow transplantation. the patient received deferoxamine mg/kg/day iv x days/week for three months, without any clinically significant adverse events. blood counts and hepatic and renal function were monitored weekly without any abnormalities. growth parameters and liver enzymes significantly improved while receiving chelation therapy. as a noninvasive, cost-effective method, serum ferritin levels were monitored monthly to gauge response to treatment. despite receiving blood transfusions every - weeks, serum ferritin decreased to ng/ml and liver enzymes decreased to alt u/l and ast u/l prior to bone marrow transplantation. we report the use of deferoxamine in a patient with cda ii less than years of age, for treatment of iron overload. our patient tolerated deferoxamine well without significant adverse events or organ toxicity. deferoxamine may be a well-tolerated method of reducing iron burden in young patients with iron-loading pathologies. background: low grade gliomas with kiaa- -braf fusions typically have a favorable prognosis with infrequent rates of high grade transformation, low rates of metastasis and even lower rates of extra cns metastasis. while highgrade transformation has been reported for tumors with braf v e mutations and cdkn a deletions, it has not been pre-viously reported in gliomas with kiaa- -braf fusions. while there are case reports of high-grade cns malignancies metastasizing through a ventriculo-peritoneal (vp) shunt, low-grade gliomas metastasizing in this manner are extremely rare. objectives: to describe a unique case of peritoneal tumor dissemination of a braf fusion positive high grade neuroepithelial tumor in a child with a vp shunt placed for multifocal braf fusion positive low grade astrocytomas results: an eight-year-old male was initially diagnosed with multifocal low-grade astrocytomas of the hypothalamus and c -c spinal cord. initial testing revealed the kiaa- -braf fusion, but no cdkn a or braf v e mutation. initial surgical management included a vp shunt and resection of the cervical spinal lesion. he received vincristine and carboplatin, followed by transition to vinblastine given new thoracic metastatic lesions after months of therapy. at months after diagnosis, scans were concerning for diffuse leptomeningeal progressive disease and new intracranial lesions, necessitating craniospinal radiation. following a near cr, he presented months later with acute onset of abdominal pain. a ct scan revealed peri-renal and perirectal soft tissue masses, confirmed by exploratory laparotomy to be peritoneal tumor dissemination of high grade neuroepithelial tumor. a kiaa -braf fusion was noted and confirmed by rt-pcr, identical to that seen in the original cns tumors. additional findings included deletion of chromosome p (without q loss) and heterozygous and homozygous deletion of cdkn a found by fish. brisk mitotic activity justified a high-grade designation. salvage chemotherapy consisted of cycles of ice with subsequent resolution of pet-avid disease and only minimal peri-nephric tissue remaining. given the favorable response, surgical resection and multiple tissue biopsies were performed which documented no residual active disease. the shunt was revised and he started trametinib for maintenance. we present a unique case of peritoneal dissemination of high grade neuroepitheial tumors with the same kiaa- -braf fusion as multifocal low grade astrocytomas in a child with a vp shunt. this raises suspicion for tumor metastasis and transformation to a higher grade malignancy versus two distinct diseases, which may be indicative of an underlying cancer predisposition. texas children's hospital, houston, texas, united states background: polycythemia is a common referral to hematology. it is important to evaluate for a high oxygen affinity hemoglobinopathy, ensuring appropriate testing is performed for early diagnosis and avoidance of additional tests and procedures. a year old mexican female presented with an elevated hemoglobin and hematocrit, symptoms of plethora of her hands and feet, chest pain, palpitations, and fatigue. further confounding the picture, she also had significant menorrhagia and iron deficiency. she was diagnosed with the rare high oxygen affinity hemoglobin new mexico variant, only previously described once in the literature in a year old black boy. objectives: the patient initially presented at age with a hemoglobin of . g/dl and a hematocrit of . %. initial work up consisted of a hemoglobin electrophoresis which diagnosed sickle cell trait, a co-oximetry panel which was normal, and erythropoietin level of mu/ml, also normal. she was then lost to follow up and re-referred at age . she is a competitive basketball athlete, and at that time, she presented with a hemoglobin of . g/dl, and hematocrit of %. erythropoietin level continued to be normal at mu/ml. design/method: cardiology was consulted regarding chest pain and palpitations with a normal evaluation. chest x-ray was also normal. a bone marrow aspirate and biopsy was performed with results significant for mild erythroid hyperplasia and mild reticulin fibrosis. jak mutation, von hippel lindau, bpgm, and hereditary erythrocytosis mutations including phd , hif a, and epor mutation analysis were sent, all of which were normal. testing to mayo clinic for p rbc oxygen dissociation returned low at mmhg ( - mmhg normal range) and subsequently a hemoglobin electrophoresis identified a hemoglobin variant leading to beta globin gene sequencing. results: patient found to be heterozygous for hemoglobin new mexico, with . % hb new mexico and . % hba, and . % hba . there was no evidence of hbs. when evaluating patients with polycythemia, maintaining a high index of suspicion for high affinity hemoglobinopathies may eliminate further unnecessary and invasive testing for patients. caution should be used when using hemoglobin electrophoresis testing since hb new mexico is known to migrate similarly to hbs on hplc with minimal change that may not be detected in regular laboratories. most high affinity hemoglobinopathies are reported to not have significant symptoms. in this case, our patient complains of fatigue, occasional palpitations and plethora of hands and feet. we will need to further follow this patient for possible attributable symptomatology. divya keerthy, simone chang, warren alperstein, patricia delgado, claudia rojas, ofelia alvarez, matteo trucco university of miami jackson memorial hospital, miami, florida, united states background: improved technology is enabling detection of previously unidentified translocations and mutations in otherwise unclassified sarcomas. one such mutation is the bcl- co-repressor -internal tandem duplication (bcor-itd) allowing for the new classification of bcor positive undifferentiated round cell sarcomas (urcs). this sarcoma has a similar appearance to clear cell sarcoma of the kidney (ccsk), potentially representing an extra-renal manifestation of this tumor, but their clinical pathologic features are not identical. objectives: this case highlights how recombinant polymerase chain reaction (rt-pcr) and bcor immunohistochemical staining can ease the diagnosis of this rare sarcoma. results: a month-old female presented for right sided pre-septal cellulitis and a temporal subcutaneous mass. the detection of multiple other subcutaneous nodules on exam raised the concern for malignancy and she was admitted for evaluation. she had two subcutaneous masses on her abdomen, with more cutaneous masses on her legs, back, shoulder, cheek and submandibular areas. she lacked spontaneous lower limb movement and had bilateral clonus. imaging confirmed multiple masses throughout the body including paravertebral area from t to l , bilateral adrenal glands, left kidney and muscles of upper and lower extremities. initial differential included neuroblastoma, infantile myofibromatosis, rhabdomyosarcoma or atypical presentation of a renal tumor. however, synaptophysin and chromogranin stains were negative. with standard immunohistochemistry, the tumor could be only broadly classified as "undifferentiated sarcoma" maintaining the diagnostic challenge. using rt-pcr in the setting of a morphologically primitive round cell neoplasm with strong bcor expression, two external institutes simultaneously diagnosed the tumor as bcor-urcs. the primary lesion is unknown but potentially may have arose from the kidney. bcor-urcs has a heterogeneous histology with tumor cells appearing monomorphic in nests of - cells separated by septa with uniform nuclei. there is frequently an "orphan annie eye" appearance and sparse cytoplasm to the cells. diagnosis cannot be made solely on evaluation of this nonspecific histology. rt-pcr uses the genetic abnormality in undifferentiated sarcomas to narrow the differential and bcor immunohistochemical staining provides further context. bcor has significant diagnostic value given its sensitivity and specificity in urcs. another potential marker includes ywhae-nutm b fusions, which occur in smaller subset of cases, but requires further study. rt-pcr has helped further classify tumors leading to the diagnosis of a rare undifferentiated sarcoma with bcor overexpression. while this technology is beneficial, its availability is limited. if accessibility improves, earlier identification and treatment may be possible maximizing the chance for a positive outcome. background: hematohidrosis is a rare condition that mimics bleeding disorders. cases present with oozing blood tinged fluid from various sites like eyes, ears, nose, skin, etc. reported causes of this condition were stress or fear, physical activity, psychological disorders. the condition is self-limited and don't affect the general condition of the patients, but it may contributes to psychosocial problems and may increases their stress and anxiety. so this condition needs to be promptly treated. to test the response of this disease and the associated headache to propranolol treatment. design/method: our case female patient years old st offspring of non consanguineous marriage, was admitted with recurrent episodes of oozing blood tinged fluid from eyes, ears and nose months before admission, about . - ml from each orifice, lasted - minutes and subsided spontaneously. it could involve the sites simultaneously or - sites. the number of attacks was - times per day then gradually increased to - times per day. later on the patient developed a bleeding attack from umbilicus. these attacks were aggravated by stress and physical activity and decreased with rest and sleep. the condition was associated with severe headache involving the whole head, throbbing in nature of gradual onset, increased by physical activity and relieved by analgesics. the condition was not associated with vomiting, blurring or diminution of vision, ocular pain, eye discoloration. no earache, tinnitus or diminution of hearing. there was no other form of discharge from eyes, ears or nose. no history of ecchymotic patches, bleeding from other orifices or blood product transfusion. no history of trauma, drug intake, fever or rash. no symptoms of other system affection. past history of recurrent attacks of epistaxis and two operations were done that passed without remarkable bleeding. no similar condition in the family physical examination was free, no evidence of psychological problems. complete blood count, coagulation profile, platelets function, factor and c.t brain were normal. oozing fluid from the patient was analyzed showed the same components as blood. results: our case started oral propranolol . mg/kg/day based on its use in similar cases in literature. the frequency of attacks and headache reduced then stopped after months of treatment and didn't recur after stoppage of propranolol. propranolol can treat this condition successfully. further investigations are needed to determine the link between this condition and severe headache our case was suffering from. background: wilms tumor is the most common renal solid tumors of childhood and is derived from primitive metanephric cells located in the kidney. primary extra-renal wilms tumors (erwt) are extremely rare, estimated to comprise . - % of all wilms tumors. despite similar histologic appearance intrarenal and erwts differ in embryologic tissues of origin. erwts arise from the more primitive mesonephric or pronephric origin and, therefore, can develop anywhere along the craniocaudal migration pathway of these primitive tissues, most often retroperitoneal, inguinal/genital, lumbosacral/pelvic and mediastinal. these tumors are typically staged and treated per national wilms tumor study (nwts) guidelines, and, by definition, are stage ii or greater due to location beyond the kidney borders. based on the cases reported in the literature, outcomes for erwt are comparable to renal wilms tumors with an % local recurrence rate and an % two-year event-free survival. we report the first case of a stage iii testicular extrarenal wilms tumor in an -month-old male with an intrabdominal undescended testis who underwent complete surgical excision followed by chemotherapy and inguinal radiation. results: a full term -month old male underwent orchipexy for an undescended left testicle. the testicle was noted to be grossly abnormal with a pea-sized thickened tissue adherent to the upper pole and a separate mass outside of the scrotum on the superior epididymis. both masses were removed, and s of s pathology demonstrated wilms tumor with favorable histology and negative margins. ct imaging of the chest, abdomen and pelvis were negative for a primary renal tumor, local residual disease, pathologic lymph node enlargement or distant metastases. the tumor was classified per nwts as stage iii due to tumor removal in multiple pieces. the patient completed dd- a treatment with vincristine, doxorubicin and dactinomycin per aren with cgy left inguinal radiation. he is currently months off therapy without clinical or radiographic evidence of recurrent disease. primary erwt is an extremely rare malignant neoplasm associated with challenges in diagnosis, staging and treatment. based on the cases reported in the literature, outcomes are similar to that of intrarenal wilms tumor. there are four pediatric paratesticular wilms tumors reported in the literature and, to the best of our knowledge, this is the first case of stage iii testicular wilms tumor successfully treated with dd- a chemotherapy and radiation. in erwt, nwts guidelines for staging and treatment should be applied with evaluation of both kidneys to exclude an intrarenal primary tumor. background: patient is a yo f, with esrd secondary to atypical hus versus ttp, who presented with thrombotic microangiopathy, aki, thrombocytopenia and anemia after a living unrelated donor kidney transplant. patient initially had downtrending creatinine. on post-op day , hematology was consulted for an increasing ldh and drop in platelets. peripheral smear was notable for an absence of schistocytes. yet, biopsy of the kidney revealed microthrombi. the patient was diagnosed with a thrombotic microangiopathy. plasmapharesis was initiated on day # , at which time ms r was noted to have significantly elevated creatinine. plasmapharesis did not yield any correction in labs and significant bruising developed. patient was started on eculizimab; plasmapharesis was stopped. shortly after, creatinine, anemia and thrombocytopenia corrected to levels at which she was discharged. overall, patient was found to have progressive anemia, thrombocytopenia, an increasing creatinine and ldh ( s) concerning for atypical hus, despite absence of schistocytes on peripheral smear. she responded well to eculizimab, with correction of hematologic changes during induction. she was discharged on eculizimab and continued to respond with normalizing platelet counts and hemoglobin. the differential in light of patient's thrombotic microangiopathy and thrombocytope-nia also included ttp. yet, adamts remained normal. dic was unlikely given normal fibrinogen level and d-dimer. objectives: presentations of atypical hus vs ttp. discuss eculizumab as a treatment of atypical hus. highlight atypical presentations of illness in transplant patients. results: despite absence of schistocytes by smear, pt was diagnosed with atypical hus based on presentation and after failing plasmapharesis, she responded well to eculizumab. though her presentation was abnormal, her response to this antibody that blocks the complement cascade suggests that she was experiencing a complement-mediated process. there are rare documented cases in the literature of atypical hus without schistocytes. hemolytic uremic syndrome (hus) is characterized by hemolytic anemia, thrombocytopenia and acute kidney injury. atypical hus is a diagnosis of exclusion, not due common etiologies such as shiga toxin. among atypical causes are complement-mediated forms, caused by an antibody to complement factor. in addition to plasmapharesis, renal transplant and supportive care, the mainstay of treatment for atypical hus is eculizumab (an antibody that blocks the complement terminal cascade). this case describes a patient unique in that, she was diagnosed with atypical hus without any schistocytes by smear. secondly, she responded to eculizumab, with unremarkable gene studies. finally, this case highlights that transplant patients often have unique presentations. nicklaus children's hospital, miami, florida, united states background: synovial sarcoma is a spindle cell tumor categorized as a soft tissue sarcoma. the chromosomal translocation t(x; ) leading to the ss -ssx fusion protein is unique to this sarcoma. it is a slow growing tumor with common recurrences and often, at presentation, with evidence of metastatic disease. if resection is not feasible, then neoadjuvant with adjuvant chemotherapy is recommended. metastasis carries an unfavorable prognosis given synovial sarcoma historically does not respond well to chemotherapy. trabectedin is a well-tolerated alkylating agent currently indicated for the treatment of liposarcoma and leiomyosarcoma. we present a -year-old male with metastatic synovial sarcoma to the lungs that progressed and was refractory to chemotherapy. he was administered trabectedin as a form of palliative chemotherapy, with significant clinical and radiographic response. design/method: pubmed search was done with search for terminology including "synovial sarcoma" and "trabectedin". papers relevant to our case were selected for literature review. a -year-old male patient presented with a large right axillary mass. initial imaging showed a heterogeneous multiseptated mass invading the subscapularis and teres major muscles along with innumerable lung nodules. biopsy confirmed diagnosis of monophasic synovial sarcoma. the patient was started on protocol arst with ifosfomide, mesna, doxorubicin. he completed cycles followed by radical resection and sessions of radiation. due to progression of disease multiple chemotherapy regimens were tried including topotecan and cyclophosphamide, protocol advl with lorvotuzumab, and pazopanib. imaging of the chest continued to show significant progression of metastasis. the patient's clinical status deteriorated with worsening respiratory status, requiring l of oxygen therapy, and inability to ambulate. he was started on trabectedin . mg/m for palliative care. after cycles of treatment patient was no longer requiring oxygen and was ambulating without assistance. radiological imaging showed significant reduction in number and size of lung nodules. trabectedin is a recently approved alkylating agent for the management of sarcomas resistant to first line treatment. response in synovial sarcoma is scarcely documented in the pediatric population. epidemiology places the most common age group in the young adults and children. our case opens the doors to further consideration of the use of trabectedin in the pediatric patient with metastatic synovial sarcoma. background: gata is an x-linked gene that plays critical role in hematopoiesis. mutations of gata gene can be associated to various blood disorders including diamond blackfan anemia, cytopenia, congenital dyserythropoietc anemia and acute megakaryoblastic leukemia. we report a patient with macrocytic anemia and platelet dysfunction who carries a novel gata mutation that has not been reported. results: a now -month-old male with complex medical history including prematurity at weeks, dysmorphic features, global developmental delay, hyperinsulinism, hypogonadotropic hypogonadism, growth hormone deficiency, micropenis, failure to thrive, patent ductus arteriosus status post ligation, and severe hypotonia, was referred to hematology at months old for resolved, transient thrombocytopenia and macrocytic anemia since month of age. chromosomal microarray showed chromosome deletion of q . , which is the rps gene. he doesn't have a family history of diamond blackfan anemia (dba), despite mom having the same rps mutation. he was then diagnosed with dba. his lab workup showed mild macrocytic anemia (hgb . g/dl, mcv fl), normal to inappropriately low reticulocyte count, normal white blood cell and platelet counts, hgf %, erythroid ada . eu/gm hgb (elevated). he has abnormal pfa- , with prolonged closure time of both adp and epinephrine. he had low von willebrand antigen and ristocetin cofactor activity. he has severe pancreatic insufficiency. bone marrow biopsy showed normocellular marrow with trilineage hematopoietic maturation, without ringed sideroblasts. since mother has the same rps gene mutation, maternal labs were done and showed no evidence of macroytosis or anemia. the diagnosis of dba was questioned. whole exome sequencing did not identify any pathogenic sequence changes in the coding regions of rps gene, but detected a gata mutation r w, which was reported variant of uncertain significance. his mother shares the same mutation and is asymptomatic, but she may not be affected since gata iis xlinked. his father doesn't harbor the gata mutation. conclusion: gata gene encodes zinc finger dna binding hematopoietic transcription factor, which is important during erythroid differentiation. gata mutation r w has not been reported in literature and is a novel variant of gata mutation, which might be contributing to this patient's clinical picture. further studies are warranted to confirm gata mutation r w to be a pathogenic sequence change. alexander boucher, tomoyuki mizuno, alexander vinks, greg tiao, stuart goldstein, james geller cincinnati children's hospital medical center, cincinnati, ohio, united states background: hepatoblastoma (hb), the most common pediatric primary hepatic malignancy, can be associated with specific congenital syndromes. recently, chronic kidney disease and genitourinary anomalies have been linked to hb. cisplatin is a key chemotherapeutic agent in treating hb but its renal clearance and toxicity profile can limit its use for those with end-stage renal disease (esrd). objectives: using an institutional case series, we present data using cisplatin for hb in dialysis-dependent esrd and define recommended dosing for future use. design/method: a chart review of patients with concurrent hb and esrd on dialysis treated with cisplatin at our institution was undertaken. demographic data, diagnostic history, tumor pathology, alpha fetoprotein (afp), hearing assessments, dosing schema, treatment outcomes, and therapyrelated toxicities were reviewed. total cisplatin levels were collected at time points within days after each infusion. free cisplatin levels were also collected for infusions, as were dialysate cisplatin levels. pk parameters were generated using bayesian estimation with a published population pk model as a priori information. results: three patients meeting these criteria were identified. each had "low risk" (non-metastatic resectable) disease at presentation and underwent upfront resections. all had congenital renal anomalies with esrd prior to their hb diagnosis. all cisplatin infusions were given over hours, followed hours later by hemodialysis. patients and received cisplatin at % of children's oncology group's ahep weight-based dosing ( . mg/kg). patient received % of ahep body surface area-based dosing ( mg/m ) during cycle but required a second dose reduction ( mg/m ) for cycle due to prolonged cisplatin exposure (total area under the curve mg⋅h/l; average for all seven evaluable cycles mg⋅h/l) and early sensorineural hearing loss at - hz. no other hearing loss in any patient was identified; mild toxicities also included grade - emesis and grade neutropenia and thrombocytopenia. the median (range) of clearance, volume of distribution at steady-state, and elimination half-life at terminal phase for total platinum were . ( . - . ) l/hour/ kg, . ( . - . ) l/ kg and ( - ) hours, respectively. patients and received cycles with rapid afp normalization. patient required an additional cycles, for a likely second primary hb year after initial therapy. cisplatin can be used successfully in pediatric patients with esrd on hemodialysis to treat hb with minimal morbidity using % standard mg/kg-based dosing ( . mg/kg), achieving pharmacologically appropriate cisplatin exposures. background: treatment for immune thrombocytopenia (itp) has been grouped into rescue and maintenance therapy and often is reserved for patients with bleeding, severe thrombocytopenia, or for improvement in quality of life. splenectomy is considered one of the more invasive but definitive treatments with success rates of - %. treatment of itp can be more difficult in the setting of previous treatment with immune modulation or when the patient is immunocompromised and not a candidate for splenectomy. objectives: present an interesting case of a patient with an autoimmune disease that presented with severe thrombocytopenia, un-responsive to rescue therapy, and requiring emergent splenectomy in the setting of acute intracranial hemorrhage (ich). a year old female with a history of juvenile dermatomyositis presented with a fine purpuric rash on her extremities, wet purpura, and a platelet count of k/ l. bone marrow evaluation at that time was consistent with itp. she was on cyclosporine and plaquenil for dermatomyositis. platelets failed to increase after three doses of intravenous immunoglobulin and high dose steroids. following a two week course of oral prednisone and eltrombopag, she presented with persistent severe thrombocytopenia of k/ l, anemia of . g/dl, and a lower gi bleed. she was started on amicar, novo-seven, rituximab, and given platelet transfusions with no improvement in bleeding. subsequently, she developed a subdural hematoma with midline shift. surgery performed an emergent open splenectomy with concurrent continuous platelet transfusion. results: she was monitored closely post operatively and, due to ich, transfused to maintain platelets greater than k/ l. by week post-op she had normal platelet counts off transfusions. all medications were stopped within three days of discharge. she represented eight days later with abdominal pain and thrombocytosis and was found to have a portal vein, splenic vein and mesenteric vein thrombosis. she was started on lovenox therapy and admitted for monitoring due to her history of ich. it is unknown whether our patient's underlying immune dysregulation and history of treatment with immunosuppressive medications may have contributed to her unresponsiveness to multiple therapeutic agents. in addition, her significant bleeding did not allow us to fully evaluate her response to second tier therapy. this adds to the scarcity of literature of itp response in pediatric patients with autoimmune disease, and may support more aggressive therapy upfront in these patients. background: multivisceral organ transplantation involves concurrent transplantation of the stomach, pancreas, liver, and intestine with splenectomy, and has been classically used in the pediatric population for infants with intestinal failure from disorders affecting foregut integrity. while there is some data demonstrating its efficacy in adults with low-grade abdominal malignancies, it has not been traditionally used for hepatocellular carcinoma treatment. to describe a unique pediatric case of multivisceral organ transplantation as definitive therapy for refractory fibrolamellar hepatocellular carcinoma in an adolescent male. a year old male presents with a history of fibrolamellar hepatocellular carcinoma, tumor invasion of the portal vein, severe portal hypertension complicated by bleeding esophageal varices and hypersplenism. he had two treatments with yttrium- radioembolization, without significant response. he completed six cycles of traditional chemotherapy in combination with sorafenib with resolution of petavidity, but minimal decrease in tumor size and continued portal hypertension. since his disease remained relatively stable for over years, he was evaluated and listed for multivisceral organ transplantation. at approximately years and months after diagnosis, he underwent en bloc liver, pancreas, stomach, small bowel, and colon transplant with splenectomy. a single lymph node was positive for malignancy at the time of resection. in addition to expected post-transplant complications, he also developed skin only acute graft versus host disease at weeks after transplant, treated successfully with a thymoglobulin course. he clinically improved and was back to his baseline activity level, on full oral feedings within months post-transplantation. at three and six month post-transplantation, there is no concern for relapsed hepatocellular carcinoma on comprehensive imaging and evaluation. he is maintained on protocol immunosuppression and posttransplant support. we present the first known case of successful multivisceral organ transplantation in the treatment of refractory pediatric fibrolamellar hepatocellular carcinoma. background: hematohidrosis is a rare disorder that presents with spontaneous excretion of whole blood from intact skin or mucosa. diagnosis is based on clinical observation of the occurrence with the proven presence of erythrocytes and other blood components, without other abnormalities to account for the phenomenon. the existing literature is scarce and consists of primarily case studies. most reports describe bleeding from facial sites around the eyes, ears, and nose. the available literature suggests anxiety and physical or emotional stress reactions as the most common inciting events. little evidence exists regarding the ideal therapeutic approach, however propranolol has been used successfully to reduce bleeding frequency and severity in multiple case reports. a specific genetic etiology has not been elucidated, and no familial cases have previously been reported. we present a pair of half-siblings, both of whom presented with spontaneous cutaneous and mucosal bleeding before two years of age, and report on preliminary results of propranolol therapy. tanzania. at months of age, he became ill and developed spontaneous bleeding from his ears, nose, and scalp. he continued to have frequent bleeding episodes, usually related to illness or physical distress. a bleeding diathesis work-up was unremarkable, however some episodes were severe enough to require transfusions. the patient was subsequently diagnosed with hiv and hepatitis b, presumably acquired via unscreened blood product transfusions. patient b is an infant female born to the same mother as patient a, with a different father. she was healthy until two months of age when she developed spontaneous bleeding from the hairline, eyelids, ears and genital/rectal area. bleeding episodes were nearly always associated with irritability and crying. extensive coagulation workup was unremarkable. results: propranolol therapy was started in both patients, titrated to a goal of mg/kg/day. in both patients, the frequency and duration of bleeding episodes significantly improved. patient b continues to have milder occasional bleeding episodes from her eyes, ears and scalp but has significantly less discomfort and irritability during the episodes. conclusion: to our knowledge, there are no prior reports involving two related patients with hematohidrosis. this case series suggests that there may be a genetic predisposition which has yet to be identified. propranolol has shown effectiveness in reducing symptom frequency and severity. background: gliomas are the most common central nervous system tumors in children. they are classified into different grades based on genotype (idh, braf, tsc, etc.). lowgrade gliomas such as oligodendrogliomas, astrocytomas, and mixed oligoastrocytomas are classified as grades i and ii. of the molecular level alterations this case report focuses on the braf v e mutation. braf is a member of the raf family of serine/threonine protein kinases and it plays an important role in cell survival, proliferation and terminal differentiation. objectives: here we discuss two cases where dabrafenib, a braf kinase inhibitor, was utilized in the management of gliomas. the cases focus on the use of dabrafenib late versus early in disease course. design/method: patient jl is a year old female who was diagnosed with a low-grade glioneuronal tumor (c -t with a metastatic lesion to the brain) in . jl was treated with chemotherapy, radiation, and surgical resection. despite treatment, the patient's disease progressed. she developed lower extremity dysfunction, urinary incontinence, poor truncal control, and hydrocephalus. dabrafenib was started after the braf v e mutation was confirmed. patient lg is a year old female who presented in november with left facial and upper extremity weakness. ct and mri scans demonstrated a mixed solid and cystic lesion extending from the optic chiasm and hypothalamus to the right thalamus and posterior basal ganglia with additional involvement of the right cerebral peduncle. neurosurgical intervention was undertaken and dabrafenib was started after the braf v e mutation was confirmed. results: patient jl's mri scans have demonstrated improvement of the spine with diminished areas of enhancement along thecal margins, decreased volume and enhancement within the trigeminal plate cistern and resolution of ependymal enhancement within the right ventricle. the patient's most recent mri exhibits no disease progression in head or spine. jl has shown improvement clinically since starting dabrafenib. patient lg has shown improvement in strength and recent mri of the brain has shown resolution of enhancement along surgical resection margins, decreased hyperintensity along the inferomedial aspect of the right basal ganglia and no new enhancements. conclusion: low grade gliomas can alter a person's quality of life and even lead to life threatening complications. often the standard chemotherapy, radiation and surgery don't prevent these complications. genetic analysis can help clinicians target therapy towards certain mutations such as braf v e. dabrafenib has shown to decrease tumor burden, early utilization as therapy can help prevent morbidity and mortality. children's hospital of pittsburgh of upmc, pittsburgh, pennsylvania, united states background: copper is an essential cofactor in enzymatic reactions essential to proper hematologic, skeletal, neurologic and vascular function. copper requirements in children over the age of are mg/day, which is readily acquired in a typical diet. copper deficiency is known to occur in patients with the rare x-linked mutation and in older individuals with gastrointestinal bypass surgery; however, it is rarely reported in other conditions. objectives: to highlight individuals with autism spectrum disorders or developmental delay with a limited dietary repertoire are at risk for copper deficiency, thus a high index of suspicion must exist in order to diagnose the disorder. design/method: a y/o boy with a prior diagnosis of global developmental delay and oral aversion presented with slowly progressive fatigue, weakness, gait instability, and weight loss. his longstanding feeding difficulties were refractory to intensive feeding programs. his daily diet consisted of - oz of milk and - individual servings of butterscotch pudding ( - calories/day, . mg iron/day). initial complete blood count demonstrated white blood cell count of . , absolute neutrophil count of , hemoglobin of . , mean corpuscular volume of < , reticulocyte count of . , platelet count of . review of his peripheral blood smear revealed microcytic, hypochromic red cells without marked fragmentation, anisopoikilocytosis and ringed sideroblasts; there were no morphologic abnormalities of his leukocytes or platelets. iron studies demonstrated ferritin of , total iron binding capacity of , and % iron saturation. he had no evidence of b , folate deficiency or blood loss. additional evaluation revealed a serum copper level of (range - ), and cerulosplasmin of . (range - ). results: once a diagnosis of copper deficiency was made, the patient promptly began a course of parenteral copper repletion. he received iv copper mcg/kg/day x days then weekly intravenous infusions. given his malnutrition, a gtube was placed to begin oral copper repletion and enteral nutrition. within weeks his copper level improved as well as his blood counts. unfortunately, although his blood counts and copper levels normalized, his neurologic status remains below his old baseline although, he has made gains in his gross and fine motor abilities. conclusion: acquired copper deficiency in the pediatric population is a rare event but given the hematologic and neurologic consequences, prompt recognition and treatment is important. this patient's clinical course demonstrates the need to have a high index of suspicion of concomitant nutritional deficiencies other than those routinely evaluated such as iron, b and folate. background: lymphoepithelioma-like thymic carcinoma (lelc) is a rare, aggressive neoplasm with a high rate of invasion, metastasis and recurrence. there are no known curative therapies for metastatic lelc. we report the case of a -year-old male who presented with metastatic ebv positive lelc. sites of disease included a large primary anterior mediastinal mass and metastases to hilar lymph nodes, lungs and liver. he was initially treated with cisplatin and fluorouracil followed by mediastinal radiation. he had a partial response to therapy but his end of therapy scans showed disease progression in lungs, liver, and hilar, supraclavicular and axillary lymph nodes. objectives: molecularly targeted therapies tailored to the patient's genetic profile offer a novel approach to obtain improved survival outcomes. design/method: the patient enrolled on a precision medicine trial, nmtrc : molecular-guided therapy for the treatment of patients with relapsed and refractory childhood cancer (nct ). in this study, tumor/normal whole exome sequencing and tumor rna sequencing were performed and a molecular report detailing the results of genomic and gene expression analysis was generated. a treatment plan was designed within a molecular tumor board comprising oncologists, pharmacists, genomicists, and molecular biologists with domain expertise. results: exome sequencing revealed somatic coding point mutations and no structural mutations (focal copy number changes or translocations). candidate somatic driver mutations included tp s x and r w as well as kit n k. both genes have been previously implicated in thymic carcinoma. rna expression analysis demonstrated aberrant activation of biological pathways, including overexpression of kit, hdac , and , tyms, and dhfr. the molecular tumor board selected the combination of pemetrexed ( mg/m ) on day of a day cycle, imatinib ( mg daily), and vorinostat ( mg days - , - , and - ) . on day of cycle , he was admitted with a herpes zoster infection and imatinib was discontinued in order to reduce risk of herpes zoster recurrence. imaging after cycles showed a complete metabolic response on f- fdg pet and a partial response by ct size criteria. as of december , the patient had received cycles of pemetrexed and vorinostat. scans in december showed an increase in the size and metabolic activity of two right lower lobe pulmonary nodules. there were no new sites of disease and imatinib was re-started. background: systemic lupus erythematosus (sle) is a chronic autoimmune disease that affects multiple organ systems and is associated with many different autoantibodies. patients can present with vague constitutional symptoms including fever, rash, fatigue, and weight loss. some of the various hematologic manifestations of sle include anemia of chronic disease, leukopenia, autoimmune hemolytic anemia (aiha), and idiopathic thrombocytopenic purpura (itp). these can be the presenting signs of sle. evans syndrome (es), a disease characterized by itp and aiha, is a rare hematologic manifestation of sle. neurofibromatosis (nf ) is a relatively common neurocutaneous disorder. these patients are at risk of developing benign and malignant tumors. its association with autoimmune disorders, including sle, remains rare. objectives: there are few cases in the literature that have patients with the combination of sle and nf . this is the only case that has a patient with sle, nf , and es. results: a -year-old caucasian female presents with two months of vaginal bleeding, weight loss and petechiae. her exam is remarkable for petechiae and café au lait macules. laboratory findings show severe anemia and thrombocytopenia. she receives blood and platelet transfusions during stabilization, and a bone marrow aspirate is performed to rule out a malignancy which is negative. based on the presence of thrombocytopenia and a positive coombs test, an autoimmune process such as es is considered. screening tests for sle reveal positive antinuclear and anti-double stranded dna antibodies as well as low complement. she receives intravenous immunoglobulin and methylprednisolone and eventually her vaginal bleeding slows and her counts recover. she begins sle therapy with hydroxychloroquine and azathioprine. due to the presence of café au lait macules on her exam, a genetics evaluation is performed and the patient is also diagnosed with nf . to date, there are seven cases of sle with nf reported in the literature, only two of which are pediatric cases. there are no reports of the combination of sle, nf , and es. conclusion: es is a rare hematologic manifestation of sle but can be the initial presentation of this disease. one large study estimates % of childhood-onset sle cases are observed to have es. screening for sle should be considered in all es patients even in the absence of typical clinical findings. association of nf and sle has been rarely described. whether this association reflects a causal relationship or is coincidental needs more investigation. (lube, ped blood & cancer, ) . university of california san diego, la jolla, california, united states background: high grade glioma (hgg) has poor outcomes in adults and children. extraneural metastases are very rare in hgg, and poorly characterized with only a few small case series in adults and only isolated case reports in pediatrics. no genomic data has previously been published for any children with hgg who develop extraneural metastases. objectives: our objective is to describe the natural history of two children with hgg and bony extraneural metastases, comparing their clinical characteristics as well as whole exome sequencing data for both tumors. this information would suggest similar patients should be monitored closely for extraneural metastasis and may benefit from more systemic therapy. design/method: we present a case series of two patients who presented with hgg and had development of bony metastases less than six months after initial diagnosis. both patients had molecular profiling with whole exome sequencing (wes). the first patient was an -year-old male with a tumor found in the left lateral ventricle invading into the fornices, hypothalamus, and left midbrain, who had subtotal resection. bony metastasis were found at . months after diagnosis, and he died months after diagnosis. he initially received radiation, followed by nivolimuab. the second was a -year-old female with a tectal/pineal tumor and multiple spinal cord metastases, who had subtotal resection. she developed bony metastasis at . months after diagnosis and died months after diagnosis. her histologic diagnosis was pineoblastoma, revised to hgg after whole exome sequencing. she received craniospinal radiation followed by chemotherapy per acns (cisplatin, vincristine, and cyclophosphamide) for cycles. when she failed to respond satisfactorily to this therapy, wes of tumor was performed and the findings were consistent with hgg. treatment was transitioned to temodar and lomustine after hgg diagnosis was given. she had ongoing progressive disease despite this therapy as well as trials of nivolumab, everolimus, and vorinostat. neither patient had extraneural metastasis at presentation. in both tumors, whole exome sequencing identified the h f a k m mutation. both tumors also had additional known mutations associated with hgg but no other overlapping mutations. this case series represents the first description of the genetic alterations of pediatric hgg patients who developed extraneural metastases. while h f a k m is a common mutation in pediatric midline hgg, especially dipg, and is associated with more aggressive disease, there has not been an association with extraneural metastasis prior to this series. background: deferiprone-induced agranulocytosis is a well -known albeit rare side effect of the drug. incidence of agranulocytosis varies from . - . %, while milder neutropenia is reported in . % of patients treated with deferiprone. deferasirox is unknown to cause such a complication. clinical trials and post marketing side effect monitoring studied possible correlations between different risk factors and development of agranulocytosis. unfortunately, no studies directly addressed a special risk in a community with background of ethnic neutropenia, like oman. objectives: to report on the incidence of neutropenia among omani children with b thalassemia using different iron chelators design/method: a retrospective study conducted on patients < year-old with b thalassemia treated with different iron chelators. electronic patients records were reviewed to detect episodes of neutropenia either mild (anc . -< . /cmm), moderate (anc . -< ), severe < . , or agranulocytosis anc = ). data were collected including sex, age, personal or family history of ethnic neutropenia, iron chelating agent, infective complications, management and outcome. detailed clinical, laboratory ± radiological information were reported for patients who developed life-threatening agranulocytosis. among young patients with b thalassemia, treated between - in squh, neutropenia, was reported in patients ( . %).severe neutropenia was encountered on occasions in patients ( / : . %) ( on deferiprone including episodes of agranulocytosis, on defersirox, on combined chelation, and off chelation). moderate neutropenia was encountered in patients ( / : . %), on occasions: deferiprone ( ), deferasirox ( ), combined chelation ( ), and episodes off chelation. mild neutropenia was more prevalent, encountered in patients ( . %) on occasions ( on deferiprone, on defersirox, on combined chelation, and off chelation) of patients exposed to deferiprone, patients had neutropenia ( %), higher than previously reported. deferiproneinduced agranulocytosis was encountered in patients ( / = . %). three of them had life threatening complications. one patient developed pneumonia complicated by rupture of pulmonary artery aneurysm-massive hemoptysis, who recovered fully after catheter embolization. the second had facial cellulitis and treatment with gcsf was complicated by frequent ventricular extrasystoles. the third had sepsis, disseminated herpes simplex and required admission to icu for inotropic support. in a community with background ethnic neutropenia, neutropenia is more common to be encountered among thalassemic patients, both on and off chelation therapy. careful monitoring of anc and rational choice/modification of chelating agents is required for optimal management of iron overload and to avoid life threatening complications. objectives: this case control study aimed to evaluate the systolic and diastolic cardiac function in groups of children with ti: non transfused group and a group that received early regular blood transfusion comparing them to healthy controls. design/method: thirteen regularly transfused patients with ti with a mean age of . + . years were compared with eight patients who are non-transfused or minimally transfused (< rbcs transfusion/year); mean age . + . years and healthy controls with a mean age of . ± . years. clinical parameters and standard echocardiographic and tissue doppler imaging (tdi) were compared. results: young non-transfused ti patients had a statistically significant higher peak late diastolic velocity of the left ventricular inflow doppler, a mitral valve a wave duration over the pulmonary vein a wave duration ratio and the pulmonary s of s vein s/d velocities ratio compared to the transfused group with p values of . , . , . respectively. in addition, they have a lower e/a ratio of the mitral valve inflow and a larger left atrial to aortic diameter ratio compared to the control group with p values of . and . respectively. the diameters of the right and left outflow tract were significantly larger in the non transfused group with a trend to have a higher cardiac index compare to the transfused group. systolic function was similar in the studied groups and none of the patients had evidence of pulmonary hypertension. young patients with ti who are receiving early regular blood transfusion have normal systolic function. diastolic function assessment revealed indicators of an abnormal relaxation of the left ventricle in the non transfused group which indicate diastolic dysfunction. the abnormalities affected multiple diastolic function parameters which give an indication that the changes are clinically significant. a statistically significant increase in the diameters of the outflow tracts are likely attributed to high cardiac output status in nontransfused ti patients as they had a trend to have a higher cardiac index. these findings support the early commencing of regular blood transfusion therapy for ti patients to prevent serious cardiac complications in adult life. background: in the -week sustain study, crizanlizumab . mg/kg significantly reduced the frequency of scpcs versus placebo ( . vs . , p = . ) and increased the time to first on-treatment scpc ( . vs . months, p = . ) in patients with sickle cell disease (scd). to evaluate time to first scpc in sustain study subgroups and the likelihood of not experiencing scpc for the duration of the trial using post hoc analyses. design/method: sustain was a randomized, double-blind, placebo-controlled, phase study (nct ). inclusion criteria were: scd patients aged - years; - scpcs in previous months; concomitant hydroxyurea use permitted if ≥ months and stable dose for ≥ months. patients were randomized : : to receive intravenous crizanlizumab . mg/kg, . mg/kg, or placebo. study treatments were administered on days and , then every weeks to week , with the final assessment at week . median time to first scpc after first dose was summarized for crizanlizumab . mg/kg or placebo in these subgroups: - or - scpcs in previous months; scd genotype; and hydroxyurea use at baseline. hazard ratios (hrs) for crizanlizumab . mg/kg versus placebo were calculated based on cox regression analysis, with treatment as a covariate. descriptive statistics were used to summarize the frequency of patients who were scpc event-free for the duration of the study by prior scpc events, scd genotype, and hydroxyurea use at baseline. : patients received crizanlizumab . mg/kg and received placebo. there was a meaningful delay in time to first scpc with crizanlizumab . mg/kg versus placebo observed in the entire study population. the effect was present in both scpc subgroups, and the largest treatment difference was observed in hbss scd versus other genotypes ( . vs . months; hr: . ). in patients taking hydroxyurea who experienced - scpcs in the previous year, time to first onstudy scpc was longer with crizanlizumab . mg/kg versus placebo ( . vs . months; hr: . ). a greater proportion of patients treated with crizanlizumab . mg/kg were scpc event-free versus placebo in each of the analyzed subgroups. one third of patients who were taking hydroxyurea and treated with crizanlizumab . mg/kg were scpc event-free during the study versus . % with placebo, possibly suggesting an additive effect. with crizanlizumab . mg/kg, there was a clinically meaningful delay in time to first scpc and an increased likelihood of being scpc-free versus placebo in all subgroups investigated. cincinnati children's hospital medical center, cincinnati, ohio, united states background: shwachman-diamond syndrome (sds) is an inherited marrow failure syndrome associated with increased risk of myelodysplasia (mds) and acute myeloid leukemia (aml). objectives: this multi-institutional retrospective study investigated clinical features, treatment, and outcomes of sds patients who developed mds or aml by central pathology review. design/method: nine individuals presented with aml ( male, female), mds-eb / ( males, females, with mds ( male and female), and one male with isolated persistent somatic tp mutation. one mds-eb and mds patient progressed to aml. median age (years) at diagnosis of mds was (range . - ), mds-eb / was (range . - ) and aml was . (range . - ). complex cytogenetics were noted in / aml cases, with one having normal cytogenetics. complex clonal cytogenetic abnormalities were noted in of mds-eb /eb patients and clonal abnormalities in of mds patients. follow up was available for aml patients; are deceased. received chemotherapy with intent to proceed to hematopoietic stem cell transplant (hsct). four failed to achieve remission and died with disease without proceeding to transplant. one patient proceeded to hsct without prior chemotherapy. four of six transplanted subjects died with relapsed disease. treatment related mortality was largely infectious or gvhd. the sole surviving aml patient had normal cytogenetics, achieved remission with chemotherapy and underwent hscts with separate stem cell infusions due to two primary graft failures. he remains alive in remission more than years after diagnosis. of the mds-eb / patients, underwent ric hsct, three of whom are alive, one died of infection. the fifth patient has stable disease on continued decitabine monotherapy for . years. of mds patients with treatment data, had upfront hsct therapy, upfront chemotherapy and had no therapy. three patients required ≥ hscts all due to graft failure. follow up is available for , of whom are deceased, with relapsed disease. treatment related mortality was largely infectious or graft failure. one individual died of hepatic failure unrelated to mds. seven mds patients are alive in remission. in summary, prognosis is poor for patients with sds who develop aml due to resistant disease and treatment-related complications. better markers for risk stratification are needed to identify patients who would benefit from early transplant. novel therapeutic strategies are urgently needed to improve outcomes of sds patients with mds or aml. background: unlike primary myelofibrosis (pmf) in adults, which is associated with somatic mutations in jak , mpl, or calr, myelofibrosis in children is rare and the underlying genetic mechanisms remain elusive. here we describe families with autosomal recessive congenital macrothrombocytopenia with focal myelofibrosis (cmtfm) due to germline mutations in the megakaryocyte-specific immune receptor tyrosine-based inhibitory motif (itim) receptor g b-b. objectives: to characterize the clinical phenotype, histological features and identify the causative gene for cmtfm. we performed affymetrix snp . genotyping on the index family to identify shared regions of homozygosity by descent. whole exome sequencing (ws) was performed on all three pedigrees to identify potentially causative mutations. we studied affected children from families, with macrothrombocytopenia, anemia, mild leukocytosis and a distinctive pattern of bone marrow (bm) fibrosis centered around clusters of atypical megakaryocytes. affected children had mild to moderate bleeding symptoms and required platelet and red cell transfusions. none showed evidence of extramedullary hematopoiesis, and all were negative for mutations in jak , mpl, and calr. snp genotyping identified multiple statistically non-significant genomic loci, including the region of the major histocompatibility locus (mhc) on chromosome p (lod = . ). we focused on this region because affected individuals in two families shared a common homozygous human leukocyte antigen (hla) type and had congenital adrenal hyperplasia (cah) due to -hydroxylase (cyp a ) mutation; the cyp a and hla loci are located at p . and p . - p . . wes revealed homozygous frameshift mutations in the megakaryocyte and platelet inhibitory receptor g b-b, encoded within the candidate linkage region. we identified two distinct g b-b frameshift mutations (c. _ + dup; p. fs and c. inst; p. fs) in individuals within these three families. no other mutations that segregated with the phenotype were identified. to validate g b-b as a potential disease-causing gene, we evaluated g b-b expression in bm biopsy specimens from affected patient and control samples by immunohistochemical staining using a monoclonal antibody. g b-b was strongly s of s and selectively expressed in megakaryocytes of control samples, but completely absent in clinically affected individuals. a murine knockout that lacks g b-b has a strikingly similar phenotype with macrothrombocytopenia, myelofibrosis and aberrant platelet production and function, further affirming the causality of g b-b mutations. we showed that autosomal recessive loss-offunction mutations in g b-b cause cmtfm, uncovering the molecular basis of this rare disease. loss of g b-b-dependent inhibition of megakaryocyte activation likely underlies the distinctive focal myelofibrotic phenotype and might be important in other forms of marrow fibrosis. cardinal glennon, saint louis, missouri, united states background: intrauterine transfusion is the method of choice for management of fetal anemia due to red blood cell alloimmunization. despite the decrease in prevalence of anemia due to rhesus d alloimmunization with prophylactic administration of anti-rhd immunoglobulin in rh d negative patients, maternal red red blood cell alloimmunization with other type of red blood cell antigens remains an important cause of fetal anemia. newborn who received intrauterine transfusion for hemolytic disease may have prolonged postnatal transfusion requirement. objectives: -to evaluate clinical outcome of fetuses and newborns who received intrauterine transfusions. -to determine the need of packed red blood cell transfusions until months of age. we conducted a retrospective case series study of all intrauterine transfusions due to anemia secondary to red blood cell alloimmunization performed in our regional center ssm in st louis missouri, between april and january . we evaluated the indications, diagnosis, gestational age, and frequency of intrauterine transfusions, along with the infant's gestational age at birth, duration of admission, timing of blood transfusion and monitoring of hemoglobin. results: intrauterine transfusions were performed in patients. the most common causes of alloimmunization were due to d antibodies (n = , %) and kell antibodies (n = , . %). the median gestational age of the first intrauterine transfusion was . weeks, and the median pre-transfusion hemoglobin was . g/dl. the gestational age at the first intrauterine transfusions was found to be significantly correlated with the number of postnatal transfusions (r = . . p = . ). the median gestational age at birth was found to be weeks ( . - . weeks), with a hemoglobin of . ( . - . ). in our population, patients ( %) received postnatal transfusions, of which were during the first weeks of life, and close monitoring follow up with a hematologist was established in patients at their discharge from the nursery/nicu. one neonatal death occurred and severe morbidity due to severe anemia occurred in one infant. despite the continuing risk factor for persistent anemia, only patients had follow up hemoglobin monitored by their primary care provider. conclusion: infants with anemia due to red blood cell alloimmunization treated with intrauterine transfusion should be monitored closely via regular complete blood count for persistent anemia due to suppression of fetal erythropoiesis. sebastian hesse, piotr grabowski, juri rappsilber, christoph klein dr. von hauner childen's hospital, lmu university hospital, munich, munich, germany background: neutrophil granulocytes are the most abundant leukocytes in the peripheral blood. validated diagnostic options for these cells are limited, leaving many patients with functional neutrophil defects without a defined diagnosis. objectives: here we evaluate proteomics as a new diagnostic tool to investigate defects of neutrophil granulocytes. we analyzed neutrophil granulocytes from children with severe congenital neutropenia (scn) associated with elane mutations, children with chronic granulomatous disease (cgd) with cyba ( ) or cybb ( ) mutations and children with leukocyte adhesion deficiency (lad) due to itgb mutations. in addition we collected samples of children with genetically undetermined neutrophil defects. neutrophils from healthy individuals served as controls. cells were isolated from fresh venous blood using negative selection (purity > %). whole cell proteome analysis was done by data-independent acquisition. showed a correlation coefficient of ∼ . . principal component analysis demonstrated unequivocal separation of the proteome of healthy and diseased cells. differential expression analysis showed minimal proteome aberrations in lad with deficiency in cell surface receptors and upregulation of alpl (total downregulated proteins: / total upregulated proteins: ). analysis of neutrophils from cgd patients also showed limited proteome aberration. cyba and cybb were both diminished independent of genotype, whereas protein clusters around a stat / centered network were increased (total down: / up: ). neutrophils with elane mutations showed the gravest proteome disturbance (total down: / up: ) with an upregulated translational apparatus (srpdependent ribosomes and protein folding complexes) and increased mitochondrial proteins. proteins of each granule subset were dysregulated and metabolic pathways upregulated. a detailed analysis of the proteome from patients with genetically undefined diseases is currently ongoing. one patient with clinical phenotype of cgd was found to have no mutations of nadph oxidase members in whole exome sequencing but critically low levels of ncf on protein level. heterozygosity mapping showed autozytocity in the ncf region warranting current efforts to sequence promoters and intronic regions of the gene. mass spectrometry based proteomics promises exciting new insights into monogenic disease of neutrophil granulocytes and may offer new diagnostic options, in particular in synergy with genome sequencing. by virtue of our international care-for-rare alliance, open to new partners, we hope that our proteome focus may lead to better delineation of as yet unknown disease of neutrophil granulocytes. background: warm autoimmune hemolytic anemia (aiha) is an igg mediated disease. although it can be post-viral, it is often idiopathic and can also be a forme fruste for malignancy or an autoimmune disease. initial management includes steroids. it often relapses on steroid wean and can be refractory to the use of second line treatment such as rituximab. objectives: abatacept (ctla- -ig fusion protein, ctla- mimetic) has been used to ameliorate autoimmune manifestation associated with ctla- haploinsufficiency. we used abatacept as a novel therapeutic agent to manage patients with refractory aiha. design/method: a retrospective case series of two patients at phoenix children's hospital with severe refractory aiha. results: patient , a previously healthy year old female, presented with weeks of icterus, fatigue, and hemoglobinuria. spleen was enlarged cm below the costal margin. laboratory evaluation demonstrated: hemoglobin . g/dl, mild leukopenia /microliter, platelets , /microliter, reticulocytosis . %, positive direct coombs' test, mycoplasma igm and igg positive. bone marrow evaluation showed a hypercellular marrow. she continued to need packed red blood cell (prbc) transfusions despite receiving high dose steroids, ivig and rituximab from may-july . in august, she started sirolimus decreasing her transfusion requirement. after starting abatacept ( mg/kg/dose bi-monthly for three doses and then monthly) in october, she maintained hemoglobin of - g/dl without transfusion. patient , a previously healthy month old male, presented with one week of progressive fatigue, jaundice, and poor feeding. splenomegaly was absent. laboratory evaluation revealed hemoglobin . g/dl, leukocytosis , /microliter, platelets , /microliter, reticulocytosis . %, negative direct coombs' test, and non-specific reactivity on antibody screen. evaluation for inherited hemolytic anemia including a next generation sequencing panel was negative. further evaluation by blood bank showed + positive coombs' for c d due to a warm antibody. cold agglutinin disease was ruled out. bone marrow evaluation was normal. he received high dose ivig as a steroid sparing agent but continued to require prbc transfusions weekly. when prednisone did not seem to slow down hemolysis, treatment with abatacept was initiated and he has not required transfusions for two months. steroids are being weaned. we present successful treatment of two refractory aiha cases with abatacept. patient is steroid and transfusion free and continues on monthly abatacept and sirolimus. patient is also transfusion free and continues on a steroid taper. ctla- is crucial for suppressive function of treg cells. abatacept by binding to cd / seems to enhance treg activity ameliorating autoimmune hemolysis. children's minnesota, minneapolis, minnesota, united states s of s background: transfusional iron overload is common in patients receiving chronic red cell transfusions. as a result, iron chelation is required to minimize toxicity from iron overload. chelation with a single agent can be inadequate at controlling or reducing iron burden. when combination therapy is required deferoxamine may be added to oral chelation. deferoxamine is generally given subcutaneous over - hours for - days a week at - mg/kg/day. many patients struggle to remain compliant with this schedule which has prompted trials of intravenous high-dose (hd) deferoxamine. prior reports of short-term hd deferoxamine have shown minimal side effects however, prolonged use of hd deferoxamine has known toxicity. when compliance is a concern, our center has used hd deferoxamine infusions at mg/kg/hr x hours every to weeks. objectives: evaluate the safety and efficacy of hd deferoxamine at our institution to help guide future therapy. design/method: a retrospective review was completed of patients previously treated with hd deferoxamine between april and september at children's minnesota. final sample included patients ages to years with underlying diagnosis of thalassemia ( ) and diamond-blackfan anemia ( ). deferoxamine infusions were given for hours every - days with a mean length of treatment of days. results: all patients were on combination therapy with deferasirox, however deferasirox was held during deferoxamine infusion. mean pre-deferoxamine liver iron concentration (lic) was . mg/g and mean post lic was . mg/g (p = . ). ferritin mean pre-deferoxamine was ng/ml compared with mean post ng/ml (p = . ). two patients had possible allergy, leading to deferoxamine discontinuation. one patient developed hives, eye swelling and cough while the other had emesis and cough. another patient experienced facial nerve palsy of unclear etiology, which did not recur with resumption of deferoxamine. no respiratory complications were seen. results showed significant decrease in iron burden following combination therapy with high dose deferoxamine and deferasirox. no significant pulmonary, liver, renal, vision, or hearing toxicities were observed. three patients reported reactions to deferoxamine infusions. however, one of these was able to successfully continue deferoxamine without further incident. short-term, hd deferoxamine was effective at reducing lic in combination with oral chelation but requires further evaluation to assess for potential increased risk of toxicity. short-term hd deferoxamine may be considered in the setting of poor compliance of subcutaneous administration or inadequate chelation with single agent therapy. further studies are needed to clarify ideal dosing, timing and risk of toxicity. background: immune thrombocytopenia (itp) is the most common cause of symptomatic thrombocytopenia in childhood but remains a diagnosis of exclusion warranting further evaluation if atypical findings are present. two male children ( months and years old) with newly diagnosed immune thrombocytopenia (itp) were found on initial evaluation to have persistent elevations of lactate dehydrogenase (ldh), alanine aminotransferase (alt), and aspartate aminotransferase (ast). these serum enzyme abnormalities cannot be attributed to itp. in the setting of thrombocytopenia, elevated transaminases and ldh create diagnostic complexity for the hematology/oncology provider as their elevation raises concern for malignancy, hemolytic disease, and other systemic diseases. to raise awareness about an unexpected pattern of duchenne muscular dystrophy in patients undergoing evaluation for itp. to expand the differential of a hematologist/oncologist when abnormal labs support a nonhematologic diagnosis design/method: this case-series of two patients with their clinical and laboratory findings were discovered with retrospective chart review. results: after a thorough evaluation for hemolytic anemias, liver disease and infectious etiologies was negative, bone marrow and liver biopsies were considered. eventually, both children were found to have severely elevated serum creatine kinase (ck). skeletal muscle has the highest concentration of ck of any tissue. thus, significant ck elevation is almost exclusively attributable to muscle injury and is the most sensitive and specific enzyme for diagnosis of muscle disease. referral to a neuromuscular specialist and further genetic testing confirmed the diagnosis of duchenne muscular dystrophy in both children allowing initiation of appropriate interventions. to date, there is no clear genetic predisposition to itp in patients with muscular dystrophy although further investigation may be needed. hematology/oncology providers should consider obtaining a serum ck to rule out muscle disease in any male child with unexplained elevations of serum ldh and/or aminotransferases, as it provides an easy and inexpensive, non-invasive approach to screening. additionally, clinical history and physical examination can aid in the diagnosis of muscular dystrophy, with gross motor delay, abnormal muscle bulk, gower's sign, and proximal muscle weakness all possible findings. objectives: to identify the range of cbcs in patients with ds without infections, hematologic or immune disorders and to create more accurate reference ranges for total white blood count; hemoglobin; hematocrit; mcv; platelet count and absolute neutrophils (anc), lymphocytes, monocytes, eosinophils, and basophils. design/method: a retrospective investigation of healthy pediatric patients with ds who received a cbc between and as part of their medical care at a single, large, pediatric teaching hospital. the study group consisted of children with ds (male = , . %; mean age = . years, sd = . ) at time of blood draw. initially children were reviewed for possible participation in the study; however, patients were excluded due to not meeting the study's inclusion criteria. descriptive statistics were performed on demographic and clinical characteristics. kruskal-wallis h tests, anova, and t-tests were run to determine the significant associations between independent means. results: a significant difference in absolute neutrophils between racial groups, f( , . ) = . , p = . , was observed. there was an increase in anc from . +/- . with african americans to . +/- . in the other racial groups and to . +/- . with caucasians. differences were also found in anc in hispanics/latinos versus non-hispanic/latinos. the results were higher in non-hispanics and latinos, a significant difference of -. ( % ci, -. to -. ), t( ) = . , p = . . preliminary kruskal-wallis h tests run determined that there were significant differences between age groups for total white blood cell, hemoglobin, hematocrit, platelets, lymphocytes and anc. further studies are being run to evaluate in which age groups these differences lie and create reference ranges by age, race and sex. conclusion: among patients with ds, there are differences between racial groups and age groups. this data has been compared to previously established reference ranges for cbcs, but we are currently establishing healthy cbc controls which we will use to validate the reference ranges. these ranges will be published to help guide providers in workup and management of patients with ds. background: transfusion is a critical part of the care provided in the neonatal intensive care unit, but it is not without risks. low birth weight and premature infants can become anaemic from an immature haematopoietic system and frequent phlebotomy. these infants often receive multiple red blood cell transfusions. identifying infants more likely to require such intervention is important in ensuring the appropriate usage of this scarce resource. to determine whether birth weight, gestational age, gender, length of stay and mode of delivery can predict red cell concentrate (rcc) transfusion, units required, donor exposure and time to exposure. design/method: a retrospective chart review of all infants born below weeks gestation and/or birth weight less than , g who received a red blood cell transfusion between july and july in the cork university maternity hospital neonatal unit. results: infants met the inclusion criteria, ( . %) received a rcc transfusion. our study showed lower gestational age (p< . ) and lower birth weight (p< . ) infants are more likely to be transfused. donor exposure increases with a lower birth weight (p = . ). multivariate analysis showed infants with a lower gestational age (or - . per day; p< . ); lower birth weight (or - . per g; p< . ) and a longer length of stay (or . per day; p< . ) are more likely to receive a higher number of rcc transfusions. the time to first rcc transfusion is shorter in those with lower birth weight (or . per g; p< . ) and lower gestational age (or . per day; p< . ). gender and mode of delivery were not found to be predictors of red blood cell transfusion in this study. conclusion: low birth weight and premature infants are more likely to receive a rcc transfusion during admission to the neonatal unit. our study highlights predictors of rcc transfusion, donor exposure and time to transfusion. these can be used in identifying at risk infants, counselling parents and in anticipating transfusion requirements. emily southard, r. grant rowe, david williams, akiko shimamura, taizo nakano children's hospital colorado, aurora, colorado, united states background: the mecom locus encodes transcription factors that regulate hematopoietic stem cell self-renewal and maintenance. overexpression of mecom has been noted in - % of acute myeloid leukemia, several solid tumors, and denotes a poor prognosis. mutations that reduce mecom expression or that disrupt protein function, however, have been implicated in the development of bone marrow failure (bmf) through undefined pathways. an association between mecom mutations and radioulnar synostosis with amegakaryocytic thrombocytopenia (rusat) syndrome has been reported, however further characterization of this phenotype has yet to be explored. to characterize the phenotypic spectrum of a cohort of pediatric patients with novel mecom mutations. we performed a retrospective review of five patients with mecom mutations who were referred to hematology at children's hospital colorado or boston children's hospital. clinical, laboratory, and genetic data was collected on subjects and available family members. results: four of subjects were identified in infancy presenting with congenital cytopenias or physical dysmorphisms that prompted broad genetic screening. platforms for genetic detection included microarray, targeted genetic panels, and whole exome sequencing. three of subjects with cytopenias presented with congenital thrombocytopenia, of whom rapidly progressed to severe aplastic anemia. four of subjects presented with congenital anomalies, of whom demonstrated radioulnar synostosis. additional dysmorphic features identified include craniofacial (low set ears x ), cardiac (pda x , vsd x , aortic root dilation x ), pulmonary (pulmonary hypertension x , arteriovenous malformations x ), and developmental delay. one subject presented at age years with acute pancytopenia, hypocellular marrow, no dysmorphisms, and a mecom variant of unknown signif-icance. the identified mecom mutations include one . mb deletion involving several genes including mecom, one variant affecting a splice acceptor consensus sequence predicted to disrupt splicing, and three novel missense mutations, tyr cys, arg thr, and tyr cys, all of which were absent from public databases and were predicted in silico to be deleterious. we describe the phenotypic spectrum of patients with novel mecom variants. a subset of patients lacked radio-ulnar synostosis and had presence of additional systemic anomalies, demonstrating a varied clinical phenotype that is not isolated to rusat syndrome. a centralized publically accessible database to share clinically annotated mecom variants, together with analysis by experts in mecom function would advance our understanding of the clinical interpretation of mecom variants. mecom should be considered in the differential diagnosis of bone marrow failure and we advocate for the inclusion of mecom in targeted sequencing panels. cairo university, cairo, egypt background: beta thalassemia is regarded as a serious public health problem in the mediterranean region, southeast asia, and the middle east. however, very few studies have been conducted to assess the quality of life (qol) among thalassemia major patients. objectives: to assess the quality of life among b-thalassemia major patients using short form (sf)- questionnaire and to determine the factors associated with their quality of life. design/method: a cross-sectional study was conducted among thalassemia major patients who were attending the hematology outpatient clinic at cairo university hospital, during the study period. data were collected between october and march . the quality of life was assessed for patients aged ≥ years. the mean age of the studied group was . ± . years. the majority ( . %) had one monthly blood transfusion. the mean total score of sf- was . ± . . general health perception domain was the most affected domain with mean score, while vitality was the least affected one. there was no statistically significant difference between males and females regarding different quality domains except for vitality where the mean score was significantly higher in males than females (p = . ). age at onset of disease, and at first blood transfusion were the most documented factors positively correlated with the quality of life among the enrolled thalassemia patients. conclusion: the quality of life in thalassemia major patient was found to be compromised. all thalassemia patients should undergo assessment of the quality of life so that interventions focusing on the affected domains can be implemented. background: international adoption of children with special needs has become more prevalent in recent years leading to tremendous growth in the number of u.s. thalassemia patients adopted from foreign countries. currently % of the , thalassemia patients registered in the cooley's anemia foundation (caf) patient database have been adopted from foreign countries, primarily china. as this population continues to grow, further information is needed in order to provide these families with best supportive care. the primary goal of this study is to characterize the socio-demographics and health statuses of adopted children with thalassemia and their families. a secondary goal is to describe adoptive families' motivations, experiences, challenges, and support resources. design/method: a redcap survey was accessed by families of adopted children with thalassemia through the caf website and caf social media from january to august . following a four-question screen, eligible subjects were directed to complete an adoption questionnaire. families who had at least one adopted child with thalassemia receiving care at a participating thalassemia treatment center or hematology office in the u.s. were considered eligible. descriptive statistics were analyzed using sas . . respondents who were ineligible or who provided incomplete data were removed from the dataset prior to analysis. of survey respondents, qualified and completed the survey. these households had adopted a total of children with thalassemia ( . % male), most from china ( . %), where they had been living in orphanages ( . %). legal guardians identified primarily as christian ( . %). the majority had completed post-secondary education ( . %) with reported household incomes greater than $ , ( . %). most adoptive families were connected to an adoption group or community including online groups, local support groups, and adoption networks ( . %). commonly cited challenges were: ) volume of frequent medical appointments, ) insufficient support from their local care centers, and ) financial burdens. the reality of care for the population of adopted patients with thalassemia in the u.s does not seem to match the expectations set by their providers. we are hopeful this data will be used to assist adoptive families navigating the complexities of thalassemia care. the findings suggest that this population would benefit from additional outreach, education, guidance, and advocacy resources -especially in the early stages of adoption and during initiation of post-adoption medical care. background: in many higher-income countries, thalassemia major has become a chronic disorder; many outcomes are different in emerging countries with more limited resources. most analyzes of health-related quality of life (qofl) in thalassemia have been conducted in high-income settings. objectives: to assess the impact of health status on qofl in thalassemia patients in an emerging country. we assessed qofl in randomly-selected patients ( thalassemia major; with hemoglobin e thalassemia; five thalassemia intermedia) at the national thalassemia center in kurunegala, sri lanka where approximately patients are managed. treatment is free, but compared to north america/europe, access to tertiary staff and other resources are limited. overall, control of body iron as estimated by serum ferritin concentration (mean± sem, ± g/l) was not optimal in many patients. to understand the impact of health status on qofl, we used the sf v health survey, analyzing scores of physical function, pain, general health, social functioning, emotional and mental health, to generate overall physical and mental component scores. results: compared to reports from higher-income countries (american journal of hematology ; : - ), physical function scores (mean±sd, . ± . ) were similar in sri lankan patients; indeed, in three categories (physical role, social function, emotional role), sri lankan scores were slightly higher. by contrast, compared to scores from higherincome settings, those estimating bodily pain, general health, and mental health were significantly lower, resulting overall in a significantly lower physical component score in sri lankan patients. male sri lankan patients reported higher scores than females, and somewhat surprisingly, in four categories (physical function, physical role, social function and emotional role) reported higher scores than those obtained in higher-income settings. lower scores in physical functioning, leading to an overall lower physical component score, were recorded by females. patients with hemoglobin e thalassemia reported generally poorer qofl than those with thalassemia major. the lack of differences in qofl in patients with "high" and "low" hemoglobins was likely related to low pre-transfusion hbs (mean±sem, . ± . g/dl) in nearly all patients. these early data in a small cohort of thalassemia patients in an emerging setting suggest that in many patients bodily pain, reduced mental health, and poorer views of general health affect overall qofl. prospective studies in larger cohorts including evaluation of adequacy of transfusions and chelation therapy, complications, and overall accessibility of care may guide approaches to improve qofl in lower-income settings of thalassemia care. geetanjali bora, anand prakash dubey, tarun sekhri, mammen puliyel, aparna roy maulana azad medical college, new delhi, delhi, india background: in the last two decades, the presence of osteopenia has been described in optimally treated patients with transfusion dependent thalassemia, the pathogenesis of which seems to differ from osteopenia in non-transfused patients. the prevalence rate of low bone mineral density (bmd) in pediatric population is highly variable amongst studies done worldwide. furthermore, the role of metabolic and endocrine factors in determining bone mass in this population is not well understood. objectives: to assess bmd in subjects with transfusion dependent beta thalassemia by dual-energy-x rayabsorptiometry and find its co-relation with clinical, biochemical and hematological parameters. design/method: this is a comparative cross-sectional study and includes patients with transfusion dependent beta thalassemia between ages to years enrolled from a thalassemia day care center in the year - . at the time of enrollment age, sex, bmi z scores, pubertal staging, duration and type of chelation therapy were noted. enrolled subjects were scanned for bmd at lumbar spine l - and left femoral neck using dexa scan. the bmd was expressed in mean values and z scores. age, bmi, ethnicity and gender matched historic controls were used to generate z scores. ml of pre transfusion fasting venous blood samples were obtained to test for serum calcium, phosphate, alkaline phosphatase, pth, thyroid function panel, serum ferritin and serum igf- levels. mean values for pretransfusion hemoglobin and serum ferritin over last months were calculated. results: total no of subjects , median age . years, male ( %), female ( %), ethnicity % asian, bmi < rd centile ( %), pre pubertal %, all receiving transfusion and chelation therapy. prevalence of low (z score < - sd) and very low (< - . sd) bmd was %, % at l -l respectively and %, % at left femoral neck respectively. there was trend of lower bmd z scores with advancing age. statistically significant co-relation (p value < . ) was found between low bmd and low mean pretransfusion hemoglobin, serum phosphate, igf - and vitamin d levels conclusion: a sizable proportion of children and adolescents with transfusion dependent thalassemia have suboptimal bone mineral density and this decline may start as early as - years of age despite being on transfusion regimen highlighting the importance of yearly dexa screening and optimization of pre-transfusion hemoglobin, vitamin d and igf levels. vanderbilt university medical center, nashville, tennessee, united states background: it is well described that iron deficiency anemia (ida) can co-present with thrombocytosis or thrombocytopenia, though cases of thrombocytopenia are less frequent than thrombocytosis. prior reports of thrombocytopenia have included adult and pediatric patients with menorrhagia ( - ), menorrhagia due to uterine fibroids ( ), or other gynecologic abnormalities ( ). our cases highlight the pattern of ida, thrombocytopenia, and menorrhagia in the setting of significant menstrual clotting without observed gynecologic abnormalities in african-american adolescents. objectives: to describe the clinical course of three adolescent females with severe ida, menorrhagia, and thrombocytopenia. results: our cases included three female african-american patients ages - who presented with severe anemia and concurrent thrombocytopenia in the setting of menorrhagia. all three patients reported heavy and prolonged menstrual cycle bleeding with significant clots. two of the three were admitted for transfusions at presentation and noted to have significant menstrual bleeding with continued blood loss requiring additional transfusions until bleeding was controlled with estrogen therapy. these two patients were evaluated with pelvic ultrasounds revealing a prominent endometrium in both patients and hyperechoic material consistent with a clot in one patient. average hemoglobin on presentation was . gm/dl ( . - . ), average platelet count was , /mcl ( , - , ), and average mcv was ( - ). all had severe iron deficiency with an average ferritin of ng/ml ( - ) subsequently treated with oral iron. one patient had a prior history of ida that required transfusion and had subsequent normalization of her complete blood count. two patients had subsequent thrombocytosis before normalization of their platelet counts. two patients received platelet transfusions: one due to recent neurosurgical intervention with a higher goal platelet count and the other to help control menstrual bleeding after a nadir platelet count of , . a review of the clinical history and red cell indices pointed to ida and ongoing blood loss from menorrhagia as the reason for the bicytopenias. the thrombocytopenia in these cases may have been exacerbated by consumption of platelets in the significant clots all three patients reported. it is reasonable to treat with iron supplementation and supportive care which may include transfusions or management of menorrhagia with oral contraceptives or other hormonal methods. background: sickle cell disease is one of the most common inherited red blood cell disorders, yet many are not aware of their carrier status. the american college of obstetricians and gynecologists' guidelines recommend that pregnant women of african, mediterranean and southeast asian descent be screened for hemoglobinopathies with a cbc and hemoglobin electrophoresis . however, adherence to this practice and frequency of improper screening with sickledex is unknown. proper screening and counseling can impact families' knowledge, allowing for establishing relationships with pediatric hematology providers earlier. objectives: we sought to assess prenatal hemoglobinopathy screening practice patterns and methods of obstetrics & gynecology (obgyn) and family medicine providers in the nyc regional area. design/method: a cross-sectional electronic survey was administered to obgyn and family medicine practitioners from four nyc institutions. questions focused on prenatal hemoglobinopathy screening practices using case scenarios with variations on parental trait status and ethnicities. chisquare analyses were used to compare the two provider groups on categorical variables. there were total responses; surveys were complete, of which were obgyn and family medicine providers. respondents were mainly from academic medical centers, with the majority being faculty ( % of the obgyns and % of family medicine). no significant difference was found in frequencies of screening patients with a positive family history of a hemoglobinopathy. when asked about screening practices for patients without a personal/family history of a hemoglobinopathy, % of obgyns versus % of family medicine providers "always" screened for hemoglobinpathies (p = . ). when analyzed by ethnic background, there were significant differences by group in screening patients of white ( % vs %), black ( % vs %), mediterranean ( % vs %), and asian descent ( % vs %) (p≤ . for all). however, in cases where the hemoglobinopathy carrier status of both parents was known, there was no difference in screening with a hemoglobin electrophoresis. furthermore, > % of all respondents use sickledex for screening in the case scenarios. conclusion: this pilot survey highlights a difference in the methods and likelihood of prenatal hemoglobinopathy screening based on the type of prenatal care provider. screening differences can lead to variations in prenatal guidance, diagnostic procedures, informed decision-making and knowledge of families referred to pediatric hematology clinics. this is the first study analyzing prenatal screening for hemoglobinopathies in obgyn and family medicine. improving prenatal screening practices by collaborating with hematologists may decrease health care disparities and allow for earlier relationship building with pediatric hematology. . acog, opinion# , poster # hermansky-pudlak syndrome: spectrum in oman background: hermansky-pudlak syndrome (hps) is a rare autosomal recessive disorder, characterized by the triad of oculocutaneous albinism, a hemorrhagic diathesis resulting from storage pool-deficient platelets, and accumulation of ceroid/lipofuscin-like material in various tissues. before , nine different types of hermansky-pudlak syndrome were identified, which can be distinguished by their signs and symptoms and underlying genetic cause. in , a tenth type was defined based on mutations in the ap d gene. hps type is characterized in addition by severe neutropenia and recurrent sinopulmonary infection. the disease is more common in puerto rico, and this is the first report from oman. to describe the clinical, laboratory and genetic characteristics of hps sub-types in oman, including the first cases of hps type . design/method: this is a retrospective study, including cases with hps that had been suspected clinically and confirmed through genetic mutation analysis. clinical data included sex, age at presentation, initial clinical presentation (skin, eyes, development, neurological involvement, bleeding tendency, recurrent infections) and course of disease. laboratory data (complete blood counts, platelet and absolute neutrophil counts, coagulation screening, platelet function tests by platelet function analyzer, and platelet aggregation studies using different agonist had been recorded. pcr and next generation sequencing for genetic confirmation by testing mutations in hps , ap b , hps , hps , hps , hps , dtnbp ,, bloc s , bloc s genes had been done. results: seven omani cases with hps have been identified ( males and females). their age ranged between (at birth) to years. two patients had hps type , patient had type , while the other cases had hps type . no other sub-types were encountered in oman. all patients were products of consanguineous marriage. one patient had adrenal hge, while the others had mild hemorrhagic phenotype, characterized by recurrent bruising and mild epistaxis. laboratory testing confirmed variable platelet aggregation defects with different platelet agonists. all patients had characteristic hypopigmentation, iris transillumination, nystagmus, and foveal hypoplasia. both patients with hps type had the same homozygous mutation in the ap b gene (c. _ delta), and presented with severe neutropenia. early diagnosis and initiation of gcsf on one of them improved outcome and prevented the development of complications. late diagnosis in the other patient resulted in the development of bronchiectasis as a result of recurrent sinopulmonary infections. background: sickle cell disease (scd), a genetic disorder characterized by defective sickle hemoglobin (hbs), triggers red blood cell sickling, hemolysis, vaso-occlusion, and inflammation. ischemic injury from scd starts in infancy and accumulates over a lifetime, causing pain, fatigue, and progressive end-organ damage that culminates in early mortality. voxelotor (gbt ) is an oral, once-daily therapy that modulates hemoglobin's oxygen affinity, thereby inhibiting hemoglobin polymerization. objectives: to assess the safety, pharmacokinetics, and efficacy of voxelotor in pediatric patients with scd. design/method: this ongoing study is being conducted in parts: part a: a single dose of voxelotor mg in pediatric and adolescent patients; part b: multiple doses of voxelotor mg/d or mg/d for weeks in adolescents. part b's primary objective is to assess the effect of voxelotor on modifying anemia. secondary objectives include measuring other markers of disease modification, such as hemolysis; daily scd symptoms, using a patient-reported outcome (pro) measure; and safety. results: as of november , , patients ( females) had received voxelotor mg and patients ( females) had received voxelotor for ≥ weeks. the median age for the patients was years, % were receiving hydroxyurea (hu), and % had ≥ painful crises in the past year. data for hemolysis measures are available for patients who received voxelotor for weeks. six of the patients achieved a hemoglobin (hb) response of > g/dl increase. laboratory markers of hemolysis improved concordantly; the median reductions in reticulocytes and indirect bilirubin were % and %, respectively. ten of patients showed reduction in total symptom scores (tss) at week , with a % median reduction in tss from baseline. there were no treatmentrelated serious adverse events (aes) or drug discontinuations due to aes. voxelotor mg for weeks in adolescents with scd, the majority receiving hu, demonstrated consistent, sustained efficacy on hb levels and measures of hemolysis; > % of patients showed a > g/dl improvement in hb. improvement in tss in mildly symptomatic patients suggests that the pro is sensitive to treatment effect and supports use in the ongoing hope phase study. voxelotor's reassuring safety profile is consistent with results in adults. these interim results support ongoing clinical evaluation of voxelotor as a potential disease-modifying therapy for adults and children with scd. supported by global blood therapeutics. background: acute kidney injury (aki) is a common complication in sickle cell disease (scd), and a potential risk factor for sickle nephropathy. aki is associated with acute decline in hemoglobin (hb) during vaso-occlusive pain crisis and acute chest syndrome (acs). it is unclear which pathologic factor plays a stronger role in aki development during hb drop: increase in free heme during vaso-occlusive events secondary to hemolysis or hb decline itself. objectives: to investigate if hb decline alone is associated with aki, we tested if the renal function of patients with scd worsened during parvovirus b -induced transient aplastic crisis (tac), in the absence of accentuated hemolysis. design/method: with irb approval, a retrospective study of patients who had laboratory confirmed parvovirus-b was conducted. serum creatinine (scr), both during and within months from the tac event, was collected. comparisons of the clinical and laboratory characteristics were analyzed using the wilcoxon test for continuous variables. aki was defined as an increase in scr by ≥ . mg/dl or a % increase in scr from baseline. to evaluate differences in change in hb on aki risk, changes in scr during tac were compared to those during pain crisis or acs admissions by fitting a generalized linear mixed model for binary outcome. a comparative sample of acs events and vaso-occlusive pain crisis were used to estimate rates of aki according to hb levels. results: three ( %) of the patients with scd developed aki during tac. no association was identified between change in hb from baseline to tac event (p = . ). no cases of aki were identified until hb decreased < . g/dl or the change in hb was ≥ . g/dl from baseline. next, we developed a model to evaluate the impact of change in hb from baseline for patients admitted with tac, pain crisis or acs on aki. with a g/dl decrease in admission hb from baseline, patients with tac had a % probability of developing aki, while acute chest syndrome and pain crisis would have a % and % probability, respectively. our data suggest that aki is still prevalent during parvovirus b -induced tac. however, the risk of aki during a tac event is and times lower than that from severe anemia induced by acute chest syndrome and vasoocclusive pain events, respectively. hemolysis-induced anemia during scd crisis appears to have a more significant role in the development of aki as compared to agenerative anemia. background: the natural history of hemoglobin e beta thalassemia (hbethal), the commonest form of severe beta thalassemia worldwide, has been examined in very few longterm studies. previously, we reported findings in hbethal patients in sri lanka. objectives: to evaluate longterm requirements for transfusion and splenectomy, complications and death in hbethal patients. design/method: all available patients were reviewed - times annually over years. results: patients ( %) died, aged (mean ± sem) . ± . years; the (known) causes commonly included iron overload ( ) and infection ( ); patients surviving patients are aged . ± . years. of patients originally classified by severity (group the mildest, and group the most severe, phenotypes), ( %) were assessed as mild (groups and ), of whom transfusions had been discontinued in . ultimately, / ( %) resumed transfusions, often following shifts to increasingly severe phenotypes including increasing intolerance to anemia. age at resumption of transfusions (following a transfusion-free interval of . ± . years) was . ± . years; in the more severe groups and , regular transfusions were stopped in / patients and resumed in / ( %), at younger ages ( . ± . years) and after shorter transfusion-free periods ( . ± . years) than in "milder" patients. mid-parental height (mph) was ultimately achieved in %. patients ( %) were splenectomized; updated analysis of responses to splenectomy (originally "group " patients), showed that splenectomy (at . ± . years) was followed by an extended, but impermanent, transfusion-free interval ( . ± . years); % patients resumed transfusions, usually related to exercise intolerance or poor growth. in groups and , complications of anemia and ineffective erythropoiesis, including leg ulcers (in % and %) and gallstones ( % and %), were more frequent than in groups and ; fractures were observed ( - %) across all groups, except for regularly-transfused group patients ( %). pulmonary artery pressures > mm were recorded in % patients. evaluation of patients with hbethal requires observations over years, without which definition of patients as "mild" or "severe" may be misleading. while in many patients transfusions may be withheld or reduced in frequency, troublesome complications may surface with advancing age even in "milder" patients. although individual consideration of transfusion requirements is critical, the availability of effective chelation, where this can be provided without prohibitive cost, may alter the balance of risks and benefits of regular transfusions in hbethal. (premawardhena a. lancet ). background: social determinants of health (sdh) are environmental and socioeconomic factors, such as access to food and housing that affect health outcomes. pediatricians are increasingly screening for sdh as part of primary care visits, however less is known about screening for sdh in pediatric hematology. evidence suggests that sdh play a role in disease severity for children with scd, who face significant socio-economic and racial disparities. the goal of our quality improvement (qi) project was to increase the percentage of patients with scd who were connected to community resources for unmet social needs. design/method: we based our intervention on the successful implementation of wecare in our institution's pediatric primary care clinic. eligible patients were identified at the start of each clinic session. on arrival the parent was given a self-reported screening tool for six sdh (childcare, education, employment, food, utilities and housing). results were entered in the electronic health record by the physician or social worker who then printed a pre-existing resource list for patients with a positive screen. we used a series of plan-do-study-act (pdsa) cycles to study tests of change. we tracked process measures (percentage of patients screened, percentage of patients with an unmet social need who received a resource sheet), outcome measures (percentage of patients with an unmet social need who connected with a community resource) and balancing measures (staff, patient and provider satisfaction). run charts were reviewed weekly and then monthly to inform further tests of change. examples of pdsa cycles include who gave the paper survey to patients (social worker or physician versus medical assistant) and length of time between surveys ( to months). results: between august and december screening rates improved from % to %. of the patients screened, % report at least one unmet social need; of those % received a targeted list of community resources in the first month of the project, and % in the fifth month. finally, % of patients reached by phone had connected with a community resource within weeks of the clinic visit. we have successfully implemented universal screening for sdh for patients with scd in our urban pediatric hematology clinic without requiring extra staff. next steps include further pdsa cycles to connect more patients to appropriate resources, and tracking improvement in health care utilization outcomes from addressing sdh in this vulnerable patient population. background: the clinical manifestations of sickle cell disease (scd), chronic hemolytic anemia, and vaso-occlusion occur as a direct result of sickle hemoglobin (hbs) polymerization. voxelotor (gbt ) is a first-in-class, oral, oncedaily investigational agent designed to modulate hemoglobin's oxygen affinity in a targeted approach to inhibit hbs polymerization. objectives: to examine the pharmacokinetics (pk), safety, and dosing of voxelotor in children (aged - years) and adolescents (aged - years) with scd from part a of the gbt - study. design/method: gbt - is an ongoing, open-label, phase a study in patients aged - years with scd (sickle cell anemia or sickle beta zero thalassemia). part a of this study (the focus of this abstract) is examining pk of singledose ( mg) voxelotor. pk samples to measure whole blood and plasma voxelotor concentrations were collected up to days following single-dose administration. separate population pk (ppk) models were developed to describe the concentration versus time profiles of voxelotor in whole blood and plasma using nonlinear mixed effects modeling (non-mem, version . ). ppk modeling and physiologically based pk (pbpk) modeling were used to simulate voxelotor pk parameters and support dose selection for future evaluation in younger children. : part a included adolescents ( females; median age years [range - ]) and children ( females; median age . years [range - ]). mean weight was . kg (range - kg) and . kg (range - kg) in adolescents and children, respectively. voxelotor was well tolerated with no drugrelated grade ≥ adverse events (ae) or serious aes. a compartment model with first-order absorption best described the pk of voxelotor (and was the same model structure used for adults with scd). voxelotor pk exposures in adolescents were comparable to those observed in adults, but higher exposures were observed in children. ppk and pbpk modeling support the use of a weight-based dosing strategy in younger children (aged < years) in future trials. adult voxelotor doses can be used in adolescents. however, based on higher pk exposures, a lower weight-based dosing strategy is recommended in children. ppk and pbpk modeling provides an innovative approach to minimize experimental dosing in children and accelerate dose selection of voxelotor in ongoing and future clinical studies. this abstract is supported by global blood therapeutics. background: hydroxyurea (hu) reduces rates of acute complications, and improves long term outcomes in patients with sickle cell disease (scd) and is now fda approved for children. through previous work we have increased the number of eligible patients on hu in our clinic, however accessing a compounding pharmacy remained a significant barrier to hu adherence for infants and children who cannot swallow capsules. objectives: the objective of our quality improvement project was to improve adherence to hu among pediatric patients with scd at our urban safety net hospital by addressing barriers to obtaining liquid hu. design/method: to begin we met with the leadership of our outpatient pharmacy which offers mail order delivery. however, like most retail pharmacies, they do not have the necessary protective equipment to compound liquid hu. through a series of discussions, we began a unique partnership with our institution's inpatient chemotherapy pharmacy who compounds the liquid hu and delivers it to the outpatient s of s pharmacy, who then dispenses liquid hu to families. using a series of plan-do-study-act (pdsa) cycles we tracked adherence by calculating the medication possession ratio (mpr), defined as the percentage of days in a given period of time that each patient had their medication on hand. the mpr for liquid hu mpr among enrolled patients was tracked by pharmacy staff and reviewed monthly. additional pdsa cycles included adding automatic refills and reminder calls by pharmacy staff and improving communication about delivery. we also tracked patient satisfaction. results: between march and december , a total of thirty pediatric patients were enrolled in our program for on-site compounding and free mail order delivery of liquid hu. mpr for liquid hu is currently . % among enrolled patients, significantly higher than the mpr of % reported in the literature, and has risen steadily since the beginning of the project. families are highly satisfied with the program, specifically appreciating the convenience of mail order delivery, saving on delivery fees, and reminder calls when refills were due. by compounding and dispensing liquid hu directly from our institution's outpatient pharmacy we have significantly improved adherence to this hu therapy in our high-risk population. next steps include analysis of change in clinical outcomes for patients enrolled in this program. as adherence to hydroxyurea is associated with decreased acute care utilization and cost, programs such as ours could play a crucial role in reducing the excessive costs and ed utilization among this patient population. background: experience with the iron-chelator deferasirox is reported widely in higher-income settings. by contrast, real-life experiences in emerging countries are infrequently reported. objectives: to evaluate, in a non-trial setting, the real-life response to deferasirox in an emerging country. design/method: in sri lanka's national thalassemia center which manages patients without tertiary staff, quantitative evaluations of body iron or estimates of extra-hepatic iron, the records of patients who began deferasirox in / were retrospectively reviewed. results: baseline assessments (mean±sem) indicated substantial iron loading [serum ferritin (sf) , ± ug/l; serum alt ± . u/l (normal ≤ u/l)]. deferasirox was introduced at low doses ( . ± . mg/kg/day); many patients started at < mg/kg and, after months, doses remained ≤ mg/kg/day in % patients. after months, sf in % patients remained > , ug/l; only by months had (mean) sf declined to < , ug/l ( ± ; p< . ). similarly, mean alt normalized (to ± u/l) only by months. death and complications were not systematically recorded by staff who had been charged, without provision of additional resources, with the introduction of this new drug in hundreds of patients. these results contrast to those in sri lanka's tertiary thalassemia center where, in patients following the introduction of deferasirox ± . mg/kg/day, sf declined rapidly, even in relatively less ironloaded patients (from , ± to , ± g/l after months; p = . ). these findings underscore the importance, during the implementation of new drug regimens in lowerincome centers with marginal resources, for investments in methods to quantitate body iron burden, hands-on educational initiatives to guide day-to-day management by competent but non-expert staff, and data systems to record efficacy, effectiveness, toxicity and compliance. such investment is critical to optimising therapy and improving complications in thalassemia patients worldwide: even in sri lanka, where resources directed to thalassemia management are greater than in most of asia, results in the oldest living cohort (born - ) indicate under-treatment [elevated iron burdens (sf , ± ug/l) and high prevalences of diabetes ( %) and hypothyroidism ( %)]. even in a younger cohort (born - ) which has benefitted from improved treatments, the prevalence of many complications exceeds those reported from high-income settings. over the next decade, and two decades after the who declaration that the impact of thalassemia on global mortality and morbidity is underrecognized, increased investments by governmental and nongovernmental sources will be necessary to improve outcomes for asian patients with thalassemia. background: a major barrier to success in hydroxyurea (hu) treatment of patients with sickle cell disease (scd) is non-adherence. objectives: to optimize hu adherence in patients with scd. design/method: a care model was designed by the sickle cell (qi) team at children's hospital to improve hu adherence among scd patients. the original model included bimonthly family phone contact, monthly dispensing pharmacy phone contact and lab monitoring. adherence measures included obtaining hu from pharmacy monthly, completion of monthly labs, hb f percentage and mcv, and mtd achievement. from / - / , several pdsa cycles refined our care model. a one-year follow-up survey gathered feedback on the care model. the first-year data involved ∼ patients. the biggest improvements resulted from making pharmacy calls before patient/family calls, shipping liquid hu to outlying patients, and tracking call time/content. the qi goal was % hu adherence by / . the % baseline adherence rate increased to % by / , and has remained in that range. the completion rate of patient/parent phone calls increased from % the first month to % at six months. pharmacy prescription pick-up has increased from % to % per month. lack of liquid hu availability was overcome by shipping the medication to the patient's home. parental hesitance to share information by phone, especially with qi team members with whom they had no established relationship, was overcome by having the longtime sickle cell nurse do many of the early calls. however, survey feedback showed families became comfortable with several clinic personnel calling. the calls gave families the opportunity to ask questions about their child and/or get additional information about scd. the calls also provided an opportunity for seasonal flu shot or tcd testing reminders. the surveys gave information on the optimal time of day to reach each family, providing individualization and further increasing the percentage of completed calls. two families surveyed said they no longer needed two calls a month because they were now able to remember to pick up hu, administer it, and get labs on their own. this qi project has not only improved hu adherence, but also fostered health education/counseling, increased patient/parent satisfaction, and enhanced service utilization. medical team member and patient/family comments demonstrate that it has helped build relationships and trust between families and the medical care system. based on survey feedback, we will further individualize care to increase adherence rate and sustain improvements. cincinnati children's hospital medical center, cincinnati, ohio, united states background: the thalassemias are a heterogeneous group of genetic blood disorders caused by mutations that decrease or eliminate the synthesis of the -and/or -globin subunits of hemoglobin. the phenotype of thalassemia depends on the interaction of the -and -globin gene clusters, because both loci determine the -/ -chain balance. for example, a -thalassemia phenotype can be more severe than expected when coinherited with -globin gene triplication (copy number gain), which exacerbates the -/ -globin imbalance. objectives: describe four individuals with an incorrect diagnosis of -thalassemia trait who were later properly diagnosed by comprehensive genetic testing to have -thalassemia intermedia caused by heterozygous -thalassemia mutations coinherited with triplicated -globin loci. design/method: sequence analysis of the -globin (hba /hba ) and -globin (hbb) genes, and copy number variation analysis of the -and -globin gene clusters by multiplex ligand-dependent probe amplification. results: four unrelated individuals of northern european ancestry were evaluated for signs and symptoms not explained by a diagnosis of -thalassemia trait (previously made by a pediatric hematologist), including growth delay, splenomegaly, moderate anemia, marked elevation of hemoglobin f, thalassemic facies, reticulocytosis, and/or indirect hyperbilirubinemia. genetic testing revealed that all were heterozygous ( / ) for the same, single -globin mutation [hbb.c. c>t (p.q *)] and also heterozygous for an -globin triplication ( / anti- . ). their previous diagnoses of thalassemia trait had been made by complete blood counts, hemoglobin electrophoresis, and/or sequence analysis of the -globin genes only. these individuals' phenotypes ranged from moderate anemia only to multiple stigmata of thalassemia, demonstrating the phenotypic variation of a thalassemia genotype. correct diagnosis was made at an average age of . years. a trial of chronic transfusions was initiated for one patient for growth failure. all were educated about the potential for exacerbations of anemia, gallstones, osteoporosis, and iron overload (even without transfusions). parental genetic testing was recommended to assess reproductive risk, because inheritance of this complex genotype can be apparently autosomal dominant. conclusion: heterozygosity for a -thalassemia mutation does not necessarily indicate -thalassemia minor or "trait". when coinherited with -globin gene triplication, a symptomatic form of -thalassemia can occur. correct and timely diagnosis of thalassemia requires careful consideration of the degree of anemia and examination for organomegaly, bony changes, and jaundice. sequence analysis and copy number variation analysis of both the -and -globin gene clusters is key. hematologists need to be aware of this diagnostic possibility and how to test for it to prevent inaccurate or delayed diagnosis. background: the burden of healthcare costs for sickle cell disease (scd) is nationally estimated at over $ billion. the major components of these costs are inpatient and emergency center (ec) visits, many of which are potentially avoidable. in several chronic conditions, a subset of patients account for most of the avoidable encounters. identifying these patients is the first step in targeted care delivery. objectives: to measure and analyze scd patient utilization patterns in the ec and inpatient at texas children's hospital (tch). we identified all individuals under years old with any encounter at tch associated with an international classification of disease (icd)- or code for scd, including hgb ss, hgb sc, and hgb s/beta thalassemia. for each patient, we identified all inpatient and ec encounters in the days prior to their most recent encounter. finally, each encounter was classified as associated with pain, acute chest syndrome (acs), or "other" using an algorithm of discharge diagnosis codes and pharmaceutical delivery. the total number of scd-associated ec and inpatient encounters over the prior year was calculated for each patient. we stratified each patient according to their utilization patterns: low ( - encounters), intermediate ( - encounters), and high (≥ encounters). we identified unique patients with scd that had at least one encounter from july until june . there were , scd-related encounters in the days prior to their most recent encounter. most ( %, n = ) patients exhibited low-utilization patterns and % (n = ) were intermediate. finally, a small subset ( %, n = ) demonstrated high-utilization patterns and accounted for % of all encounters. high-utilization was associated with older age and public payment mechanisms. pain encounters were predominantly in pre-adolescents and teenagers with high-and intermediate-utilization patterns. acs was most frequent in pre-teens and younger teens in the intermediate-utilization group. finally, the youngest-aged high and intermediate users presented for other reasons such as febrile episodes and splenic sequestration. our findings reflect national trends in that a significant portion of encounters are attributed to a small subset of patients exhibiting a high-or "super-" utilization pattern. at our institution, scd super-utilization is associated with older age and pain. we also identified a group of infants and toddlers with frequent encounters for fever. to comprehensively address this burden, it will be important to design interventions targeted toward age and specific medical needs. background: background: the rarity of diamond blackfan anemia (dba) has hindered describing the spectrum of disease, identifying predictive correlations, and guiding datadriven recommendations. long-term toxicities from steroid or transfusion therapy that start in childhood remain the major clinical problems in patients with dba who do not receive stem cell transplant. objectives: objective: to define the dba patient population at st. jude children's research hospital including treatment responses and toxicities to help inform recommendations on treatment and monitoring. design/method: method: medical records were reviewed for all patients with dba treated at st. jude between and for diagnostic testing, treatment types and regimens, and outcomes. two-sample t-test or wilcoxon rank sum test was used to compare continuous variables in two groups depending on the normality of the data tested by shapiro-wilk test. results: a total of patients with dba were identified with a median age of . years (range months - years) at last follow up. a ribosomal protein gene mutation was identified in / patients ( %) with an rps mutation / ( %). thirteen different congenital malformations were described in / patients ( %). fourteen of twenty ( %) patients treated with corticosteroids had an initial response and of those achieved full remission. three patients became steroid-refractory and were unable to wean to an acceptable dose. five of twenty patients continue on lower-dose steroids. five patients currently require no therapy. univariate analysis revealed no statistically significant genetic predictors of response or remission, however, / rpl patients responded to steroids with / ( %) in long-term remission. ten patients are maintained on chronic transfusions and have undergone successful hematopoietic stem cell transplant. nineteen of treated patients ( %) had a treatment-related toxicity. patients on steroids were more likely to have short stature than patients on transfusions or in remission (p = . ). severe bone mineral density deficit occurred in / ( %) patients, in before age years. eight patients had hepatic iron overload, in one documented by age years. other severe toxicities included restrictive cardiomyopathy from iron overload, pathologic fracture, diabetes mellitus, and premature ovarian failure in one patient each. this genotypically and phenotypically heterogeneous dba cohort had a high rate of treatment-related toxicities, notably growth retardation, bone density loss, and hepatic iron overload even in very young children. these findings underscore the need for early standardized monitoring. background: patients with sickle cell disease (scd) face worsening morbidity and mortality between ages and , when they must transition from pediatric to adult healthcare.( ) an effective curriculum addressing disease knowledge, educational and vocational skills, self-efficacy, and social supports is critical to a successful transition. traditional didactic approaches have not led to durable knowledge retention. ( ) technology-based methods have been attempted, but the best educational approach remains unknown. objectives: . to understand how adolescent and young adult (aya) patients with scd view existing transition education. . to include patient preferences in improving our transition curriculum. we developed a qualitative survey to assess patient views of existing approaches for learning about scd and their opinions about preferred transition topics. thirty patients with scd aged to years old were recruited between january and december . responses were managed using redcap electronic data tools hosted at the university of rochester.( , ) qualitative and quantitative data analyses were performed, including independent t-testing to compare responses between age groups. results: approximately % of subjects were under years of age, while % were or older. seventy-one percent had a computer, and . % had a cell phone, with most reporting daily use. subjects reported greatest satisfaction with learning from their doctor during clinic visits ( . % agree or strongly agree) and websites on a cell phone ( . % agree or strongly agree); the least popular methods were online chat rooms and microsoft® powerpoint presentations. satisfaction was similar across age groups. recommended transition topics were viewed positively, with subjects ranking highest understanding their bloodwork ( . % agree or strongly agree) and understanding laws protecting students with chronic disease ( . % agree or strongly agree). older subjects ( - years old) agreed more strongly with learning about opioid addiction and understanding differences between adult and pediatric doctors than did younger subjects ( - years old) (p < . ). this pilot study was successful in helping us to understand the educational needs of aya patients with scd. preliminary data underscore the importance of education provided by the pediatric hematologist. our results also suggest that the optimal use of technology-based methods requires further investigation and that tailoring transition education by age group may be useful. background: similar to patients with transfusion-dependent beta-thalassemias (tdt-beta), survivors of hemoglobin barts hydrops fetalis (homozygous alpha- -thalassemia, tdtalpha) will require lifelong transfusions of erythrocytes. we have previously shown that a transfusion strategy that is based on the guidelines developed for tdt-beta (conventional transfusion) is suboptimal for these patients owing to the differences in the pathophysiology of anemia in the two conditions: in tdt-alpha, conventional transfusion strategy will lead to a gradual increase in non-functional hbh with subsequent tissue hypoxia and hemolysis. an aggressive transfusion strategy that was based on reduction of hbh and increase in "functional" hemoglobin level resulted in improvement of tissue oxygenation and reduction of hemolysis but was associated with significant increase in transfusional iron burden [amid et al, blood ] . objectives: to define the optimal chronic blood transfusion targets for hbh% and functional hemoglobin in patients with tdt-alpha. design/method: following research ethics board approval, longitudinal data of patients with tdt-alpha ( males, median age . ( . - . ) were retrospectively collected. variables of interest included total pre-transfusion hemoglobin, hbh%, and "functional" hemoglobin [measured as total hemoglobin x ( -hbh/ )]. outcome variables were lactate dehydrogenase (ldh, marker of hemolysis), and soluble transferrin receptor (str, marker of erythropoiesis). hemoglobin analysis was done using high-performance liquid chromatography and capillary zone electrophoresis. we examined the association of "functional" hemoglobin with str, and hbh% with ldh, using repeated-measures anova to adjust for the effect of multiple testing. we constructed receiver operating characteristic curve and calculated the area under the curve to define the best cut-off values for variables of interests. there was a strong association between functional hb and str, as well as hbh and ldh. the optimal cut-off for "functional" hemoglobin that was associated with str < . mg/l was g/l (auc = . , sensitivity and specificity of . % and % respectively). the optimal cut-off for hbh to supress ldh to < u/l was % (auc = . , sensitivity and specificity of . % and % respectively). the optimal pre-transfusion hbh% for reduction of hemolysis was % and the optimal "functional" hemoglobin to adequately supress erythropoiesis was g/l. to meet these hbh% and functional hb targets by simple blood transfusions, patients with tdt-alpha would require a hypertransfusion regimen with a minimum pre-transfusion total hb of g/l and consequently high transfusional iron burden. an alternative approach using exchange transfusion to reduce hbh% and improve functional hemoglobin would be associated with less volume of transfusion and potentially better long-term outcome. hospital sacre coeur, milot, haiti background: initial results of work developing a pediatric sickle cell disease (scd) clinic at the hôpital sacré coeur (hsc) in milot, northern haiti were presented at aspho . the purpose of this clinic is for a pediatrician with a special interest in scd to provide scd care, advising on trait and managing disease with penicillin prophylaxis (pcn) and hydroxyurea therapy (hu) for select patients. this clinic was started in collaboration with a us based hematologist and support from yale-new haven hospital. objectives: to describe the success and challenges of providing pcn and hu in the scd clinic at hsc through a review of patient records. design/method: since this clinic's inception, a database of patients, with basic clinical information has been kept and made accessible, through 'drop-box', to the us hematologist. the records of those that presented to the clinic were reviewed. the hemoglobin diagnosis was made either by clinical history and sickle cell prep or by hemoglobin electrophoresis through alpha laboratory, port-au-prince, haiti. results: ninety-nine individuals were seen in the first years of the program. fifty-six underwent a hemoglobin electrophoresis. of these , are ≤ years old. thirty-two were started on pcn vk, of which / ( %) were ≤ years old. eleven patients were started hu therapy. all patients on hu have shown progressive increases in hemoglobin. there have been no clinical complications of hu therapy. none of the patients taking hu have required hospitalization or transfusion in . three patients (not on hu) were hospitalized in for complications of scd (osteomyelitis, pain). in , with less than half the numbers in the program, there were admissions for severe anemia, pain, stroke and splenic sequestration. with ongoing external support and a local reputation for excellence in sickle cell care, the clinic at hsc has been able to expand services and improve the health of a growing number of patients with scd. early data suggests that pcn and hu therapies are helping to reduce complications and improve quality of life. challenges to date have included lack of funding for transportation to clinics, for hospitalizations and to cover the cost of electrophoreses. at the same time as continuing providing excellent care and gathering data, it is crucial to explore opportunities for collaboration and cooperation in ways that will assure that the clinic can become independently sustainable while continuing to improve the quality of life for the individuals it serves. background: ykl- is an inflammatory glycoprotein expressed by infiltrating macrophages in various inflammatory conditions. it has been found to be elevated in patients with different pathological conditions like acute and chronic inflammations, increased remodeling of the extracellular matrix (ecm), development of fibrosis and cancer. several studies have found elevated ykl- concentrations in sera of patients with liver diseases such as hepatic fibrosis by hepatitis c virus. it has been suggested that ykl- concentrations reflect the degree of liver fibrosis. to evaluate serum ykl- levels in patients with -thalassemia and its relation to viral hepatitis, liver stiffness as assessed by transient elastography (fibroscan, fs) and hepatic iron concentration. design/method: a prospective study included patients with -tm ( males and females) with mean age . ± . years (range: - years). serum ferritin level, liver enzymes (alt and ast), hbs ag, anti hcv ab and serum ykl- using elisa kit were evaluated. all patients were subjected to liver mri t * to detect liver iron content by the sequence and transient elastography (fibroscan, fs) to assess degree of liver stiffness. results: mean fibroscan value was ( . ± . ) kpa with a median . (range . to ) kpa. ( %) patients were categorized as f - and ( %) were stage f - , ( %) patients had severe fibrosis. their median serum ferritin was ng∖ml, with ( %) patients had values exceeding g/l. median cardiac t * was . with patients had values below ms, and the median lic was . mg/g dw with patients showed readings above mg/g dw. nyl- was evaluated as a marker of inflammation and liver fibrosis and showed mean value . (± . ) pg/ml, and range from to pg/ml. mean ykl- was significantly higher among males (p = . ), patients on chelation therapy (p = . ), patients on dfs (p≤ . ), in those with abnormal liver enzymes, splenectomised patients, patients with hbv sero-positivity, those with moderate elevation of t * and patients with high grades of liver fibrosis (p< . ). ykl- showed positive correlation with the rate of transfusion, lic, ferritin, alt and ast but negative correlation with weight, height and t *. roc curve analysis revealed that the cutoff value of ykl- at pg/ml could differentiate -tm patients with and without viral hepatitis with . % sensitivity and specificity of . %, area under the curve (auc) . , positive predictive value . and negative predictive value . (p< . ). roc curve analysis revealed that the cutoff value of ykl- at pg/ml could detect -tm patients with liver cirrhosis with . % sensitivity and specificity of . %, area under the curve (auc) . , positive predictive value . and negative predictive value . (p< . ). conclusion: serum ykl- levels are elevated in patients with -thalassemia and can detect patients with active viral hepatitis and liver stiffness. background: the most common splenic complication in pediatric patients with sickle cell disease (scd) is acute splenic sequestration (ass), which has often been managed with splenectomy. although splenectomy has been a treatment of choice for years, long-term vascular complications have not been thoroughly evaluated. pulmonary hypertension (phtn) is a severe complication of scd. in adults with scd, phtn has been associated with a -month mortality rate of approximately %. it has been reported that splenectomized patients with hemolytic disorders are at even greater risk of phtn. several medications exist to treat phtn, but with few studies of their efficacy or toxicities in patients with scd. additionally, these patients are often treated with either chronic prbc transfusions or hydroxyurea (hu) to raise hemoglobin, reduce hemolysis, and prevent vaso-occlusive events. objectives: to evaluate effect of chronic prbc or hu vs. no intervention, on tricuspid regurgitant jet velocities (trv) in pediatric patients with scd and history of splenectomy. design/method: retrospective chart review of splenectomized patients with hbss followed at marian anderson center at st. christopher's hospital for children, philadelphia, between and . we analyzed trvs ( hu, prbc, and from control group receiving neither treatment) from patients ( hu, prbc, neither). mean age at echo was . +/- . . data was analyzed with linear correlations and analysis of variance (anova), including the post hoc test of least significant difference (lsd) for all pairs of treatment groups. results: trv was not significantly correlated with age at time of assessment or with time between splenectomy and trv. univariate anova among groups yielded trv means of: . +/- . cm/s (hu), . +/- . (prbc), . +/- . (neither). we found a notable difference as the mean of the hu group was almost cm/s lower than the others, but no overall statistically significant association for any of the groups exists. however, when we performed post hoc tests to adjust for multiple comparisons and looked at all pairings within the anova, we found that the lsd between the hu and the prbc groups was statistically significant (p = . ), and that a trend exists between the hu group and the neither treatment group (p = . ). our data suggests that treatment with hu is correlated with a reduction in trv in pediatric patients with scd who underwent splenectomy. given these promising results, we believe our data warrants further study with larger treatment groups. nancy olivieri, gaurav sharma, susmita nath, rajib de, tuphan kanti dolai, prakas kumar mandal, abhijit phukan, amir sabouhanian, robert yamashita, angela allen, david weatherall, prantar chakrabarti background: hemoglobin e thalassemia (hbethal), which accounts for % of all severe beta thalassemia worldwide, has an estimated prevalence of . / , in west bengal, from which little information about clinical findings has been reported. objectives: to document clinical and laboratory findings in patients with hbethal, ultimately to improve resources for clinical management. design/method: we reviewed records from: a database recording patient names; clinic charts; "special" charts containing additional details; and, in transfused patients, transfusion day-care records. additionally, because in india's public hospitals original lab/imaging reports are commonly retained at home, % of families were interviewed to provide additional information. we excluded records of patients aged < years and patients aged < years who had not been reviewed since . results: while at least one visit had been recorded in , hbethal patients at nrs hospital, most patients are not regularly reviewed there. we examined charts [ ( %) aged ≥ years; ( %) aged - years; % male], representing approximately % of regularly-reviewed patients. most families ( . %) reported monthly incomes (< , indian rupees), below the monthly cost of living ( , rupees) in kolkata. mean (±sem) hemoglobin was . ± . g/dl. % patients were receiving eight or more transfusions per year; from , % had been treated with deferasirox, . ± . mg/kg/day. iron control estimated by serum ferritin concentration ( . ± g/l) was highly variable. a total of % patients were splenectomized. a substantial obstacle to documenting complications was the lack of recording, in any of the five sources, of many relevant parameters: for example, the status of sexual maturation (normal, delayed, or absent) was documented in less than %, and measurements of fasting blood glucose in less than %, of records. where recorded, complication rates were high: delayed/abnormal sexual maturation was recorded in % patients aged > years; in the patients aged > years and those aged - years, respectively, hypothyroidism was recorded in % and %, and elevated serum alt in % and %. in most evaluable patients > years, height was measured between the rd- th percentiles. cardiac findings, rarely documented, included pulmonary hypertension and reduced left ventricular ejection fractions in a few patients. despite dedicated attention to many aspects of thalassemia care, insufficient documentation limited a clear understanding of the current morbidity in hbethal patients. investment in personnel and technology will be critical to record relevant information, ultimately to improve clinical management, over the next decade. children's hospital of richmond at vcu health, richmond, virginia, united states background: sepsis is a common cause of death in children with sickle cell disease (scd). recommendations for care of fever in children with scd include immediate medical evaluation including blood culture and initiation of broad-spectrum antibiotic therapy. the increasing availability of pcr-based respiratory pathogen panels (rpp) provide the opportunity to rapidly identify viral causes of fever. the role for rpps in identifying the source of fever in children with scd and how it affects provider practice is not well studied. ( ) to determine the epidemiology of respiratory virus-associated fever in children with scd and ( ) to determine whether a positive rpp is associated with reduced risk of bacteremia in this population. this was a single-center, retrospective cohort study. we identified and reviewed the medical records of all children with scd seen in our emergency department (ed) with temperature ≥ . oc at home or in the ed from january , , through september , , as well as, all febrile children for whom rpps were sent since the introduction of rpps april . we reviewed the results of blood cultures, rpps, chest radiographs, and ed notes and discharge summaries to identify sources of infections. independent t test and chi-square analysis were used as appropriate to compare results using spss©. overall, the rate of bacteremia was %. there were no cases of bacteremia among children with positive rpps. % of children with negative rpps had true bacteremia. a positive rpp did not reduce the likelihood of bacteremia (p . ). patients with bacteremia had higher presenting temperatures than those without bacteremia ( . oc vs . oc, p . ). the most common rpp findings were rhinovirus/enterovirus ( %), human metapneumovirus ( %), and influenza a ( %). sending an rpp did not affect admission rate ( % and % respectively, p . ); however, likelihood of admission was lower in patients with positive rpps ( % vs %, or . [ . - . ], p . ). length of stay (los) was shorter in patients for whom an rpp was not sent ( . vs . days, p . ). as previously reported, bacteremia in febrile children with scd is very low, but remains a serious concern, particularly in the setting of high fever (> oc). a positive rpp did not reduce the odds of bacteremia, but did have a sta-tistically significant impact on both admission rate and los. more work is needed to understand how rpp results impact provider decision-making and care for children with scd. cincinnati children's hospital medical center, cincinnati, ohio, united states background: diffuse myocardial fibrosis is a common, if not defining, feature of the heart in sickle cell anemia (sca) that is strongly associated with diastolic dysfunction. we found diffuse myocardial fibrosis in every patient in a sca cohort (n = ) ranging in age from to years (niss ). the treatment and prevention of this complication of sca has not been studied before. objectives: because diffuse myocardial fibrosis must begin in early childhood, we hypothesized that early initiation and uninterrupted use of disease-modifying therapy for sca can prevent it. design/method: we use cardiac magnetic resonance imaging (cmr) to measure the myocardial extracellular volume fraction (ecv) to quantify diffuse myocardial fibrosis in individuals with sca who have been treated, uninterrupted, with hydroxyurea or chronic transfusion therapy since ≤ years of age. two comparison groups were used: individuals with sca who have not been treated with disease-modifying therapy since ≤ years of age (n = ) and controls without sca (n = ). results: we studied individuals ( m/ f) with a mean age of . years (range - ). mean age at the start of diseasemodifying therapy was . ± . years (range - ). only had evidence of mild diffuse myocardial fibrosis (ecv . ); the other had no detectable diffuse fibrosis (all had ecv < . , the upper limit of normal). mean ecv was . ± . , which was significantly lower than the ecv of individuals with sca who have not received early uninterrupted therapy ( . ± . ; p = . ) and not statistically different from normal controls ( . ± . ; p = . ). none had macroscopic fibrosis by late gadolinium enhancement or evidence of myocardial hemosiderosis by t * imaging. no patient had diastolic dysfunction by echocardiographic classification, right heart catheterization, or both. disease-modifying therapy for sca can prevent diffuse myocardial fibrosis, and possibly diastolic dysfunction, if started in early childhood. prospective trials of disease-modifying and anti-fibrotic therapy are planned to prevent diffuse myocardial fibrosis, which can be monitored noninvasively by cmr, and improve outcomes in sca. (niss, blood, ) . background: a statewide sickle cell surveillance system (sscss) was developed with the goal of determining the prevalence of sickle cell disease (scd) in indiana and the level of care that patients receive throughout the state. persons with scd are at high risk of infection, especially with encapsulated organisms, as well as at increased complications from influenza. utilizing sscss data, the relationship between vaccination status and mortality was explored. to determine if vaccination status is associated with mortality in persons with scd. the project was granted a waiver of consent by the st. vincent irb. death certificates were obtained to identify cause of death. deceased patients (cases) were matched by age, gender, and sickle genotype to living patients (controls). vaccination data were collected from the medical record and the children and hoosier immunization registry program (chirp) through the date of death for each case. cases and controls were assigned a point for completion of the pneumococcus, meningococcus and haemophilus influenza type b (hib) vaccine series and one point if the influenza vaccine was given within a year prior to death of the cases [max vaccine status score (vss): ]. total points were compared between the cases and controls. two tailed t-tests to compare means of continuous data and wilcoxon signed-rank test to compare ordinal data. one thousand forty-eight individuals were included in the sscss. six hundred and seven ( . %) were seen at one institution and included in this analysis (mean age = years). thirty-three of the ( . %) were deceased at the time of analysis. six point one ( . )% of controls and . % of cases received a vss of . the mean vss for cases was . ± . and . ± . for controls. thirty point three ( . ) % of controls had a vss of one or more, compared to % of cases (p = . ). patients who died of infection [streptococ-cus (n = ), pseudomonas (n = ) and unidentified organisms (n = )] were not up to date on vaccination against encapsulated organisms, but two had received the influenza vaccine in the year prior to death. in this sample, mortality occurred exclusively among adult patients, which is consistent with current patterns in developed countries. among these adults, vss and mortality rates were not related. limitations to the study include small sample size and potential incompleteness of vaccine records. vaccination rates and other standard of care indicators should be explored in a larger cohort of patients to determine associations with mortality. background: sickle cell disease (scd) is a genetic disorder resulting in acute and chronic complications, including delayed puberty. delayed puberty can have adverse physical and psychosocial effects on affected children and families. there are no published reports from ghana on pubertal timing in children with scd. the aim of this cross-sectional study was to describe pubertal changes in children with scd at korle bu teaching hospital (kbth), accra, and compare these findings to those in a control group without scd. design/method: children with scd and children with hb aa, ages - years, were consecutively recruited and matched for age, sex and socioeconomic status. investigator-administered questionnaires were used to obtain demographic data for all participants and information on menarche (girls only). pubertal status was assessed by physical examination using tanner staging. testicular volumes were determined in boys using a prader orchidometer. body mass index (bmi) and socioeconomic status (ses) of participants were analyzed to determine if there were any associations with tanner stage. of the with scd, ( . %) were hb ss and ( . %) hb sc. females comprised . % (cases and controls). mean age at onset of breast development was significantly delayed in girls with scd ( . ± . years) compared to controls ( . ± . years) but there was no significant age difference at onset of pubic hair development. mean age at menarche was significantly delayed in girls with hb ss ( . ± . years) and hb sc ( . ± . years), compared to those with hb aa ( . ± . years). in boys, the mean ages at onset of puberty were significantly delayed in those with scd ( . ± . years, for genital development and . ± . years, for pubic hair development), compared to those without scd ( . ± . years and . ± . years, respectively). mean testicular volumes were significantly lower in cases compared to controls, across all age ranges (p< . ). mean bmi in both cases and controls were similar at onset of breast development in girls. however, in boys with and without scd, mean bmi values were significantly different at pubertal onset. in univariate analysis, ses was not associated with tanner stage for both genital and breast development. mean ages at pubertal onset were significantly delayed in children with scd. longitudinal studies are needed to further characterize any associations with bmi and determine potentially modifiable risk factors affecting pubertal onset in scd. background: sickle-cell disease (scd) is a life-threatening genetic disorder associated with multiple chronic and acute complications. specific monitoring and treatment for children is a major part of the medical focus, but there remains a lack of real-world evidence of the disease burden and practice patterns among the pediatric scd population. objectives: to examine the clinical burden and management of scd among pediatric patients. design/method: a retrospective claims study was conducted using the medicaid analytic extracts database from jan - dec . pediatric patients (aged < years) with scd were identified using icd- -cm diagnosis codes ( . - . , . - . ). the first observed scd diagnosis during the identification period was designated as the index date. patients were required to have continuous medical and pharmacy benefits for at least months pre-and months post-index period. patient data were assessed until the earliest occurrence of the following events: disenrollment, death, or the end of the study period. patient demographic and baseline clinical characteristics, clinical outcomes (mortality, incidence of pain crisis, complications), scd management, and healthcare utilization were examined. all variables were analyzed descriptively. results: a total of , patients met the study inclusion criteria, with a mean age of . years. most patients were black ( . %) and had a charlson comorbidity index score of ( . %). mortality during follow-up was . in personyears, and the event rate of pain crisis in the inpatient setting was . in person-years. the three most common complications after pain crisis (highest rates in person-years) were fever ( . ), infectious and parasitic diseases ( . ), and asthma ( . ). rates of life-threatening complications were also examined in person-years, including acute chest syndrome ( . ), stroke ( . ), splenic sequestration ( . ), pulmonary hypertension ( . ), and pulmonary embolism ( . ). . % of patients were prescribed antibiotics during the one-year post-index period. other frequent medications utilized among children were folic acid ( . %), nonsteroidal anti-inflammatory drugs ( . %), opioids ( . %), and hydroxyurea ( . %). . % of patients had a blood transfusion within one year post-index date. patients had frequent health care utilizations in the inpatient ( visit), emergency room ( visits), office ( visits), and pharmacy ( visits) settings during the one-year follow-up period. pediatric scd patients are burdened with a high rate of complications including pain crisis. in addition, patients utilized a substantial amount of health care resources including outpatient office care and acute care visits. background: novel use of hydroxyurea in an african region with malaria (noharm, nct ) is a randomized controlled trial of hydroxyurea for very young children with sickle cell anemia living in uganda. during year , study participants received blinded study treatment of hydroxyurea or placebo; those receiving hydroxyurea had no increased risk of malaria, but had both laboratory and clinical benefits. during year , all study participants received openlabel hydroxyurea treatment. to assess the effects of open-label hydroxyurea treatment in a very young population of children with sickle s of s cell anemia living in uganda. study endpoints included the rates and severity of malaria infections, clinical sickle-related events, and laboratory effects. design/method: all children in the noharm trial were enrolled at mulago hospital sickle cell clinic in kampala uganda. during year , all children received open-label fixeddose hydroxyurea ( mg/kg/day) for months, after previously receiving either hydroxyurea or placebo for months. results: a total of children entered year of the noharm trial and received fixed-dose hydroxyurea, including males and females, at an average age of . ± . years. among children previously on placebo, there were malaria events in children, including with severity grade ≥ , and three deaths (two acute chest syndrome, one sepsis). clinical adverse event rates dropped from . to . per patient year, and hospitalizations were reduced from to . expected hematological benefits of increased hemoglobin, mcv, and fetal hemoglobin, along with decreased neutrophils and reticulocytes, were rapidly achieved. laboratory adverse events were infrequent at . events per patient-year, and only half of those were dose-limiting hematological toxicities. among children previously on hydroxyurea, there were malaria events in children, including with severity grade ≥ , and two deaths (one acute chest syndrome, one sepsis). clinical adverse event rates and hospitalizations were maintained at low rates, the hematological benefits of hydroxyurea continued throughout the extended treatment period, and dose-limiting toxicities remained infrequent. fixed-dose hydroxyurea treatment of young children with sickle cell anemia living in uganda is associated with no increased risk for malaria. clinical and laboratory benefits occur, including children previously on placebo who crossed-over to hydroxyurea treatment. future studies should focus on the optimal dosing and monitoring strategies, in an effort to determine the overall feasibility and safety of introducing hydroxyurea therapy across sub-saharan africa. background: acute chest syndrome (acs) is the second most common cause of hospitalization in patients with sickle cell disease and is a leading cause of morbidity and mortality. in mid- , an algorithm was implemented at cohen children's medical center to initiate transfusions within four hours of diagnosis of acs in order to improve patient outcomes. objectives: the aim of this project was to analyze the effect of early blood transfusion on the outcomes of patients with acs. we focused on the number of total transfusions, need for exchange transfusion, need for intensive care unit (icu) stay, and length of hospitalization. design/method: a retrospective chart review was completed on patients admitted to ccmc with a primary diagnosis of sickle cell disease and a secondary diagnosis of either acs or pneumonia during the years of - . data from the three years directly prior to implementation of the algorithm was compared to data from the three years directly after implementation of the algorithm. a total of patients were analyzed, of which belonged to the pre-algorithm group and to the postalgorithm group. patients from the post-algorithm group had a higher incidence of transfusions ( % with a mean transfusion number of . pre versus % with a mean of . post) as well as exchange transfusion ( % pre versus % post). the post-algorithm group had a shorter overall length of stay (mean of . days pre versus . days post). while the overall percentage of patients requiring an icu admission was similar in each group ( % pre versus % post), the post-protocol group had a lower likelihood of requiring an icu admission for reasons outside of line placement for exchange transfusion, most commonly for icu-level respiratory support ( % pre versus % post). despite a higher total number of transfusions, early recognition and transfusion for acs can lead to decreased lengths of hospitalization as well as decreased need for icu-level respiratory support. further studies comparing different center's clinical practice guidelines are necessary to improve the standard of care. background: novel use of hydroxyurea in an african region with malaria (noharm) was the first placebocontrolled randomized clinical trial of hydroxyurea in sub-saharan africa. in noharm, young children with sca received either hydroxyurea or placebo during year , followed by open-label hydroxyurea for all study participants during year . an ancillary noharm project was designed to determine if hydroxyurea treatment lowers transcranial doppler (tcd) velocities and possibly reduces stroke risk in this very young cohort. objectives: to perform tcd screening on the noharm cohort, measuring the time-averaged mean velocity (tamv) at the end of both year and year . we hypothesized that the maximum tamv would be lower for noharm study participants receiving hydroxyurea compared to those receiving placebo, and that key clinical and laboratory parameters would also influence tcd velocities. design/method: all children enrolled in noharm were eligible to undergo tcd examination at two study time points: month - when they were completing the blinded treatment phase, and again at month - at the end of the open-label treatment phase. tcd measurements included tamv readings from the main intracranial arteries: middle cerebral artery, distal internal carotid artery, and bifurcation on tcd. all tcd examinations were scored and classified as normal (less than cm/sec), conditional ( - cm/sec) or abnormal (greater than or equal to cm/sec), with higher scores correlating to greater risk of stroke. results: at the end of year , tcd exams were conducted of which were suitable for analysis ( hydroxyurea, placebo). based on the maximum tamv, the median velocity was cm/sec (iqr - ) for children on hydroxyurea and cm/sec (iqr - ) on placebo, p = . . maximum tamv values had negative correlations with hemoglobin concentration (- . ), fetal hemoglobin (- . ), and oxygen saturation (- . ); positive correlations were noted with age ( . ) and absolute neutrophil count ( . ). at the end of year , tcd exams were conducted and all were suitable for analysis; the median velocity was cm/sec on open-label hydroxyurea treatment, regardless of previous blinded treatment. all correlations with tamv were maintained except for age. conclusion: compared to placebo, hydroxyurea treatment for young children with sca living in uganda was associated with lower tcd velocities, which have been correlated in other studies with lower risk of primary stroke. tcd velocities were correlated with hematological and clinical parameters that can be improved by hydroxyurea therapy. children's hospital of richmond at virginia commonwealth university, richmond, virginia, united states background: acute chest syndrome (acs), defined by respiratory symptoms and a new pulmonary infiltrate, is a serious complication of sickle cell disease (scd). acs can occur during hospitalization for non-pulmonary conditions, such as a vaso-occlusive crisis or after surgery. nih clinical practice guidelines encourage incentive spirometry (is) which decreases the incidence of acs. it is additionally widely accepted that early, frequent ambulation in post-operative and pneumonia patients decreases the length of stay (los). to decrease acs events in children with scd at our children's hospital, we aimed for is use in % of ageappropriate pediatric sickle cell admissions. design/method: a multidisciplinary team examined inpatient acs prevention practices, including is, at children's hospital of richmond. key drivers were identified, including educational awareness of patients and healthcare staff, order placement, and documentation. we aimed for all scd patients ≥ months of age hospitalized with any admission diagnosis to participate in is with the use of a traditional incentive spirometer or similar age-and ability-appropriate devices (e.g. positive expiratory pressure devices, bubbles, and pinwheels). we secondarily aimed to increase activity events, specifically ambulation and out of bed time. educational and outreach tools included patient informational brochure and incentive program, and staff informational sessions and reference materials at workstations. a disease-specific order set was implemented including desired is and activity orders. data were collected prospectively may through november , during which pdsa cycles were conducted. admissions during the corresponding months of the previous year were reviewed for comparison. independent t-test analysis was performed using graftpad prism statistical analysis software. results: improvements reaching statistical significance included increase in is order placement from % to % of admissions (p < . ), and admissions with documented is use increased from % to % (p < . ). los decreased from a mean of . days to . days (p . ). post-admission development of acs also decreased from % to % of admissions, but did not reach statistical significance (p . ). there was an additional increase in appropriate activity order placement and documentation of activity events. conclusion: improving education and outreach to patients and staff, including implementation of a disease-specific order set, can improve is use and activity events. the decline seen in incidence of acs development during hospitalization, though not statistically significant, and the decreased los are encouraging, and efforts continue to improve on these trends. background: painful vaso-occlusive crises (voc) are a frequent and debilitating complication of sickle cell disease (scd) and are thought to occur due to progressive blockage of the microvasculature with rigid sickle shaped red blood cells. any trigger that decreases the microvascular blood flow (mbf) can promote entrapment of sickled cells in the microvasculature and progression to voc. exposure to cold wind and changes in weather are common triggers of voc and are associated with increased frequency of hospitalizations for pain in patients with scd. there is limited experimental data on the physiologic effects of these factors on peripheral perfusion in scd. to study the effect of graded thermal stimuli on the peripheral mbf in scd. design/method: scd and control (healthy or sickle trait) subjects aging to years were exposed to their individual threshold temperatures for heat and cold detection, heat and cold pain via tsa-ii thermode that was placed on the thenar eminence. mbf was measured on the contralateral thumb using photo-plethysmography (ppg). the vasoconstriction response within the complex ppg signal was detected using cross-correlation technique. mean mbf was derived from the ppg amplitude during each of these stimuli and compared to baseline mbf. cross correlation analysis showed that cold pain caused significant vasoconstriction response in % of the subjects, followed by heat pain ( %), cold detection ( %) and heat detection ( %).there was a significant drop in the mbf during cold pain (p < . ), heat pain (p < . ), heat detection (p = . ) and cold detection (p = . ) when compared to baseline mbf, with cold pain causing the greatest drop in mbf. thermal sensitivity and mbf responses were comparable between scd and controls. conclusion: exposure to graded thermal stimuli causes a progressive drop in mbf with exposure to cold pain eliciting the strongest vasoconstriction response. vasoconstriction occurred in the contralateral hand at an average of seconds after the stimuli, suggesting a neurally mediated mechanism. although there was no significant difference in vasoconstriction responses between scd and controls, the drop in mbf in patients with sickle cell disease can increase the likelihood of entrapment of the sickled red blood cells, leading to vaso-occlusion. these findings are consistent with extensive reports in literature that exposure to cold weather is associated with a higher frequency of voc. this suggests that neurally mediated vasoconstriction is likely an important factor in the pathophysiology behind cold exposure leading to voc in scd. background: vaso-occlusive crisis (voc) is a major cause of hospital admissions in children with sickle cell disease (scd). although the use of clinical biomarkers in voc has been studied, especially with regards to acute chest syndrome (acs), there is less data regarding overall voc severity prediction. in addition new biomarkers such as platelet to lymphocyte ratio (plr), neutrophil to lymphocyte ratio (nlr), and lymphocyte to monocyte ratio (lmr) have been little studied with regards to scd. objectives: to identify whether admission laboratory values, changes from well baseline laboratory values, and new biomarkers such as plr, nlr, and lmr could predict severity of vaso-occlusive crisis in children with sickle cell disease admitted with voc. design/method: this was a retrospective single center observational study of admissions of voc in children aged - years with hbss or hbs-b thal from september to november excluding those on hyper-transfusion protocol or having an admission diagnosis of acs. univariate analysis was done using student's t-test, mann-whitney non parametric test, or fischer's exact test as appropriate depending on the distribution between admission laboratory data of complete blood count (cbc), reticulocyte count, comprehensive metabolic panel, lactate dehydrogenase (ldh), change from well baseline cbc values within months previously, plr, nlr, lmr, and the development of complicated voc. complicated voc was defined as the development of secondary acute chest syndrome, prolonged admission duration > days ( hours), requirement of blood transfusion, and readmission within days. results: a total of admissions were studied. fifty-nine ( . %) were female. of the , ( . %) were complicated with no significant differences in sex (p . ) or age (p . ). univariate analysis revealed significant elevations in total bilirubin (p . ), ldh (p . ), and platelet count (p . ) in those with complicated voc. there is also significant difference in the percentage change of platelet count from baseline with greater decline in uncomplicated voc (p . ). there were no significant differences in plr (p . ), nlr (p . ), or lmr (p . ). conclusion: elevations in total bilirubin, ldh, and platelet count in admission laboratory values are associated with developing complicated voc. in addition, those with complicated voc present with significantly less decline in platelet count from baseline well cbc. plr, nlr, and lmr do not seem to be useful predictive biomarkers for severity of voc. background: sickle cell disease (scd) causes health problems of varying frequency and severity. the only validated biomarker for children with scd is transcranial doppler. if reliable predictors existed for scd severity, children with scd could be treated according to risk category. many patients with scd face psychosocial or economic hardships, but these factors have not been evaluated as risk markers for medical or functional severity of scd. objectives: the goal of this project was to develop and stratify a preliminary list of psychosocial risk factors for health outcomes that could be used as scd severity predictors. st. vincent institutional review board. a list of potential psychosocial risk factors for adverse health outcomes was compiled based on assessment materials utilized by the sickle safe program (indiana's hemoglobinopathy newborn screening follow-up program). this list of items was distributed to child abuse prevention ( ) and scd ( ) experts, who ranked each item on a likert scale of (least important) to (most important). mean scores were calculated using spss version ; assessments were retrospectively analyzed to determine psychosocial risk factor frequency. risk factors occurring in ≥ % of homes were considered high frequency events. overall, there was high agreement among experts on the risk factors that were considered the most important predictors of severe scd outcomes. the risk factor with the highest frequency ( %) was eligibility for public assistance programs. fifteen risk factors were rated ≥ by the experts. four ( . %) were high frequency events occurring in ≥ % of homes: a child with hbss or hbs thalassemia not taking hydroxyurea ( %); parent report that they had treated a fever (> ®f) at home in the past months ( %); tobacco use by someone in the household ( %); and the family reporting significant psychosocial stressors in the past year ( %). tobacco use in the home was significantly correlated with several other risk factors (smoking during pregnancy [r = . ], other health concerns in the child [r = . ], and child having health insurance [r = - . ]), suggesting that it is part of a constellation of health risk. in general, the risk factors that were rated as most important for health outcomes occurred less frequently in the sample. this study represents important progress toward identifying a group of psychosocial risk factors for scd severity, which is a necessary first step for future investigation of empirical relationships between candidate risk factors and scd outcomes. unitversity of cartagena, cartagena, bolivar, colombia s of s background: sickle cell disease is an autosomal recessive disorder characterized by a mutation in the -globin chain, which produces hbs. acute and chronic complications as aplastic crisis, acute chest syndrome, priapism, stroke, leg ulcers and primary/secondary prevention of stroke can be treated with simple transfusion or exchange transfusion. the latter offers advantages as lower iron overload, post-treatment hbs goal control, lower viscosity and improved microvascular circulation. but it is not a widely-used option because is associated with technical difficulties. objectives: standardization of a new partial exchange transfusion protocol in a group of patients with sickle cell disease, within the framework of a chronic transfusion program. design/method: this is a prospective descriptive study, which included patients under years with sickle cell disease ( hbss, hbs-tal), with indication of partial exchange transfusion in a chronic transfusion program, according to the institutional protocol; patients who fulfilled the inclusion criteria were enrolled in the study between february and december . a registry of the medical and technical complications was made in each of the procedures. a database was constructed in excel, and the graph-pad prism® version oc software was used for statistical analysis. the sequence is as follows: isovolemic phlebotomy and transfusion of packed red cells. depending of the recent hemoglobin level ( hrs), we do the phlebotomy there: hb: - . : cc/kg, hb: - . : cc/kg, hb> : cc/kg; isovolemic solution (ns , %) there: hb: - . : cc/kg, hb: - . : cc/kg, hb> : cc/kg and packed red cell transfusion there: hb: - . : cc/kg, hb: - . : cc/kg, hb> : cc/kg. the safety of this exchange transfusion protocol was analyzed in patients with sickle cell disease ( procedures). there were no differences in the sex distribution, and the median age was years. % of the population was homozygous. the indication of transfusion was . %( / ) primary stroke prevention, . %( / ) secondary stroke prevention and . %( / ) was other reason. a low percentage of complications was found ( . %); of which, those of medical origin (hypotension and nausea/vomiting) were only presented in . % of the total procedures. the standardization of this protocol was safe and its use could be extended to other low-income centers that treat patients with sickle cell disease that need chronic transfusion program including patient with hemoglobin level until gr/dl. we suggest do studies for measure the security and efficacy of this protocol in patients with acute complications. background: clinical trials that aim to achieve pain reduction have challenges achieving clinical endpoints as pain has no quantifiable biomarkers and may be unrelated to scd. furthermore, the threshold of seeking medical care differs between patients and vocs that occur at home are missed. we present a non-interventional, longitudinal study to identify vocs in patients with scd. objectives: to examine the longitudinal relationship between pros and biomarkers in subjects with scd before, during, and after a self-reported voc event, in order to build a model of in-home and clinical voc and to collect longitudinal pros and biomarker data from subjects that span voc events in the home, clinic and the hospital. design/method: longitudinal measures of pain, fatigue, function, activity, and biomarkers from scd patients in steady state and voc were studied over a six month period. patients self-reported pain, fatigue, function, and medication use using a novel epro tool. voc was reported in real-time, triggering a mobile phlebotomy team. blood was collected sequentially after self-reported voc (at home or hospital). blood samples were drawn two days after resolution of voc, as reported by the patient. during non-voc periods, blood was drawn every weeks to establish a baseline. biomarkers included leukocyte-platelet aggregates and circulating microparticles, cell and soluble adhesion molecules, cytokines, inflammatory mediators and coagulation factors. patients wore an actigraphy device to track sleep and activity and rest. results: twenty-seven of thirty-five patients experienced a total of days with voc > hr, of which only days resulted in healthcare utilization. voc days had significantly higher pain and fatigue scores. voc days were associated with significantly decreased functional scores, with significantly greater decreases during vocs requiring medical contact compared to at-home vocs. different activity profiles were identified for non-voc, at-home voc and medical contact voc days by actigraphy monitoring. at-home voc days exhibited increased daytime resting compared to non-voc days. medical contact vocs had decreased average and peak activity, and increased daytime resting compared to non-voc days. a sleep fragmentation index trended up for both at-home ( %) and medical contact voc days ( %). significant changes during voc days were observed in: c-reactive protein ( % increase), nucleated rbc ( % increase), monocyte-platelet aggregates ( % increase) and neutrophil-platelet aggregates ( % increase), interleukin- ( % increase), interleukin- ( % increase) and tnfalpha ( % increase). the identification and assessment of at-home vocs through use of epros, actigraphy and biomarkers is feasible as demonstrated by this innovative at-home study design. background: risk-stratifying sickle cell disease (scd) patients and demonstrating response to disease-modifying therapies is challenging due to the phenotypical heterogeneity of scd. a pathogenic role for procoagulant von willebrand factor (vwf) via excess vwf high molecular weight multimers (hmwm) has been proposed, with variable reports of increased vwf and hmwm in crisis vs. steady-state in adults, but less so for vwf in children with scd. moreover, vwf and multimers have not been studied in sickle trait. objectives: our pilot study evaluated the potential for vwf antigen (vwf:ag) and hmwm on densitometric tracings to serve as biomarkers for disease severity or treatment response in children and young adults with scd compared to sickle trait (hbas) siblings. design/method: we evaluated vwf:ag, vwf multimers and retrospective clinical data from hbss, hbsc and hbas subjects at steady state. one hbsc subject also had a crisis sample. median scd age was years ( . - . years). % were female. scd severity was judged by annual vasoocclusive and acute chest events, or stroke/elevated tcd. eight of ( hbss and hbsc) took hydroxyurea. four hbss subjects had severe scd, all of whom were chronically transfused. results: mean vwf:ag (normal - iu/dl) was higher for hbss ( +/- . ) and severe hbss ( +/- . ) compared to hbsc ( +/- . , p = . and . , respectively); however, lacked statistical significance when compared to hbas ( +/- . , p = . and . , respectively). vwf:ag was elevated in / ( %) steady-state, including / ( %) with "severe" disease on chronic transfusion and / ( %) taking hydroxyurea, in hbsc crisis but no hbsc / ( %) at baseline. vwf:ag was high in / ( %) hbas siblings. four ( %) had increased hmwm at baseline: hbss/severe disease/chronic transfusion, hbss/hydroxyurea and hbsc untreated. hmwm were increased only during vaso-occlusive crisis in hydroxyureatreated hbsc subject. no ultra-large hmwm were observed. in this preliminary study, in young scd subjects, vwf:ag trended higher in hbss vs. hbsc and in severe hbss participants at a single time-point, but serial evaluations at baseline, in crisis and with optimized diseasemodifying therapy are needed to determine the potential of vwf:ag and hmwm as biomarkers for severity or treatment response. surprisingly, vwf:ag was high in some sickle trait subjects. since hbas is associated with some health challenges such as increased thrombosis risk, further examination of vwf and endothelial dysfunction in sickle trait may provide novel insights into its role as a biomarker. background: the national heart lung & blood institute(nhlbi) guidelines for acute management of voe recommends rapid evaluation and treatment of pain, including administration of a parenteral opioid within -minutes of triage or -minutes from registration, pain reassessment & repeat opioid delivery within - -minutes. inf use has been increasing in peds due to its rapid onset and ease of administration. objectives: to evaluate ped utilization of inf & its effect on intravenous (iv) opioid administration and pain control for the treatment of voe. design/method: a retrospective review of emr was performed on children with scd± years presenting to a ped with voe (pain scores on a - scale) from jan-june . variables studied were median time (iqr, %ci) from ped arrival to first-parenteral-opioid-administration, time-to-first-iv-opioid, first & final pain score, disposition and readmission rate. time-to-first-iv-opioid was also compared to historical data (jan-dec ,n = ) prior to inf protocol initiation. . additionally, % patients received iv opioids within minutes of ed arrival in the inf+iv opioid vs. % in the iv opioids alone group (p< . ). no differences in -hour-returnrates were found in any of the groups, including inf alone group. conclusion: use of inf in the ped for voe is an excellent strategy to shorten time-to-first-parenteral-opioidadministration, improve pain scores & improve adherence to the nhlbi guidelines. however we had distinct unexpected findings: ( ) delays in iv opioid delivery after inf use & ( ) inf alone appeared to provide sufficient pain control without iv opioids for disposition home in % of voe patients. whether the latter reflects insufficient pain management or that there is a milder subgroup for whom inf alone is sufficient, requires further investigation. this study illustrates our experience with a ped-based inf protocol in terms of unanticipated delays in iv opioids and also discharges after inf alone. efforts are underway to further improve use of inf in voe management. st. christopher's hospital for children, philadelphia, pennsylvania, united states background: folate supplementation is commonly included as standard management in patients with sickle cell disease. however, clear evidence supporting the clinical benefits of this practice is lacking. a single study demonstrated improvement on the occurrence of repeat dactylitis at a higher dose of folic acid. to compare clinical outcomes in pediatric patients with sickle cell disease treated with folate supplementation versus those who were not. design/method: this study was a retrospective chart review that included patients to years old with sickle cell disease type ss and s followed at st. christopher's hospital for children. data collected included information about folate supplementation, red cell indices and the presence or absence of clinical outcomes including vaso-occlusive crisis requiring hospitalization in the last six months, acute chest syndrome, infections, asthma, sleep apnea, nephropathy, cerebral vascular disease, stroke and avascular necrosis. analysis of variance (anova) was used to evaluate mean differences between age, number of infections, number of voc events, hemoglobin, reticulocyte count, and mean corpuscular volumes. additionally, chi square analysis was implemented to evaluate differences in folate and non-folate groups for left ventricular remodeling (lvr), sickle cell nephropathy, asthma, obstructive sleep apnea (osa), nocturnal hypoxia, and avascular necrosis (avn). mean differences between the folate and non-folate groups were compared for patients on and off hydroxyurea therapy. one hundred and seven patients met inclusion criteria following review of clinical data. of the patients included in the study, patients were found to be taking folate ( %), while patients were not ( %). statistical analysis showed that there were no significant differences in the incidence of clinical outcomes between patients on folate versus those who were not on folate. of the patients who were not on hydroxyurea, hemoglobin levels were significantly higher in patients on folate versus those who were not (p = . ), but not significantly different for the patients on hydroxyurea. this study suggests that folate supplementation makes no significant impact on the red blood cell indices of anemia nor on the incidence of adverse clinical outcomes in children with sickle cell disease. however, a larger prospective study is needed to guide future considerations for folate supplementation in sickle cell patients in the clinical setting. background: tanzania ranks rd globally for the number of infants born annually with sickle cell disease (scd) but lacks a national newborn screening program. the prevalence of sickle cell trait (sct) and scd is highest in the northwestern regions around lake victoria served by bugando medical centre (bmc) a teaching and consultancy hospital in mwanza. bmc also houses the hiv early infant diagnosis (eid) laboratory that tests dried blood spots (dbs) from hivexposed infants. dbs can be tested for hiv and then retested for sickle cell trait and disease. to determine the prevalence of sickle trait and disease by region and district in northwestern tanzania using existing public health infrastructure. secondary objectives explored associations between sct, scd, malaria and hiv. design/method: the tanzania sickle surveillance study (ts ) is a prospective year-long cross-sectional study of hivexposed infants born in northwestern tanzania, whose dbs collected by the eid program are tested at bmc and available for further testing of sct and scd. samples from children ≤ months of age were tested by isoelectric focusing (ief) and scored independently by two tanzanian staff as normal, sct, scd, variant, or uninterpretable. dbs samples scored as disease or variant were repeated. over the course of months, ief gels have been run. a total of , dbs samples have been scored, including , from children less than -months old. the overall prevalence of sct is . % and the prevalence of scd is . %, along with . % hemoglobin variants. quality of the laboratory results is extremely high, with only . % dbs samples yielding an uninterpretable result. geospatial mapping of the first , samples revealed a regional scd prevalence ranging from . % up to . % among the regions served by bmc. the prevalence of sct and scd is very high in northwestern tanzania. geospatial mapping will identify high prevalence areas where targeted newborn screening can be started using existing public health infrastructure with minimal start-up cost and training. further data will enhance the accuracy of the map to the district level. background: pediatric patients with sickle cell disease (scd) could develop obstructive, restrictive or mixed abnormalities of pulmonary function (pf). several publications report progressive worsening of pf over time, which could lead to severe morbidity in adult patients with sickle cell disease. in adults with sickle cell anemia up to - % of mortality is related to lung disease. early intervention aimed at improvement of lung function could significantly decrease morbidity and possibly improve life expectancy. among disease modifying approaches commonly used in scd are hydroxyurea (hu) and chronic prbc transfusions. both interventions lead to increase of hemoglobin, decrease of hbs fraction, leading to decreased hemolysis. reports of effect of hu on pulmonary function are conflicting with some suggesting no effect and others proposing a slower decline of pulmonary function. the goal of our study is to evaluate effect of disease modifying therapies, like hu and chronic prbc on change of pulmonary function in pediatric patients with sickle cell disease. design/method: this study utilized a retrospective chart review of children with scd who had multiple pfts. we analyzed pfts from patients done during clinic visits. scd patients were divided into three treatment groups: hydroxyurea, chronic transfusions or neither. data was analyzed with linear correlations and analysis of variance (anova). comparison were made between the three groups specifically observing the changes in absolute numbers on pfts over time using the first and last pft the patient had. results: there were a total of patients with multiple pfts (ranging from - ); control ( ), hydroxyurea ( ) and chronic transfusion ( ). the mean changes of the control, and hydroxyurea for the pft parameters fev (- . the chronic transfusion group demonstrated a small improvement in pfts over time for fev ( . ), fvc ( . ), fef - ( . ), however there was a decline in fev /fvc (- . ). however, there was no statistically significant (p-value < . ) in the difference in any pfts parameters between any of the groups. in children with scd there is a decline of pf parameters over time. although no significant differences were seen between the three groups it appears chronic transfusion may improve or limit the decline in pfts. larger studies need to be done to evaluate difference in pf decline in patients with scd patients. background: the use of mobile technology in health care has been a growing trend. patients with chronic diseases such as sickle cell disease (scd) require close monitoring to provide appropriate treatment recommendations and avoid complications. we conducted a feasibility study for patients with scd hospitalized for pain using our self-developed mobile application (tru-pain: technology resources to better understand pain) and a wearable activity tracker. subjective symptoms such as pain and objective data such as heart rate (hr) were measured. we aimed to ) correlate nursing recordings with mobile technology recordings; ) get feedback from patients about usability. design/method: we enrolled patients with scd > years old and < hours from admission for uncomplicated vasoocclusive crisis, excluding patients admitted to icu. patients were given an ipad and a wearable device. they were instructed to record in the application at least once per day and to keep the wearable on, removing only to charge. prior to discharge, patients completed a feasibility questionnaire. we enrolled patients, % females, median age . (range to ) who were admitted for a median days (range to ) for uncomplicated pain crisis. patients used the application throughout hospitalization and made one entry/day (range to ). pain scores recorded via tru-pain correlated well (r = . , p< . ) with pain scores recorded in emr. there was an average of , data points recorded per day, by the wearable, with a maximum of , data points/day. the median amount of hours of wearable data per day was . (maximum of . ). the hr recorded via the wearable correlated significantly with the hr recorded in emr (r = . , p-value < . ). as for usability, % of patients indicated never having a problem with the technology, % found tru-pain 'very easy' or 'somewhat easy' to use, and % were 'very satisfied' with their participation in the study, indicating that it helped them track their pain. our pilot study during hospitalization shows strong potential for using tru-pain for patients with scd. pain data from application and hr from wearable correlated well to the emr data. according to the feedback received, our application was easy to use and helped patients track their pain. despite limitations of battery life, the use of wearable technology is feasible, providing additional data such as activity. we are optimistic that we can continue to improve our tru-pain system to help improve care in patients with scd. background: hydroxyurea, chronic blood transfusion, and bone marrow transplantation can reduce complications, and improve survival in sickle cell disease (scd), but are associated with a significant decisional dilemma because of the inherent risk-benefit tradeoffs, and the lack of comparative studies. these treatments are underutilized leading to avoidable morbidity and premature mortality. there is a need for tools to provide patients high-quality information about their treatment options, the associated risks, and benefits, help them clarify their values, and allow them to share in the process of informed medical decision making. objectives: to develop a health literacy sensitive, web-based, decision aid (ptda) to help patients with scd make informed choices about treatments, and to estimate in a randomized clinical trial the acceptability and effectiveness of the ptda in improving patient knowledge, involvement in decisionmaking and decision-making quality. design/method: we conducted qualitative interviews of scd patients, caregivers, stakeholders, and healthcare providers for a decisional needs assessment to identify decisional conflict, knowledge, expectations, values, support, resources, decision types, timing, stages, and learning, and personal clinical characteristics, and to guide the development of a ptda. transcripts were coded using qsr nvivo . stakeholders completed alpha and beta testing of ptda. we conducted a randomized clinical trial of adults, and of caregivers of pediatric patients to evaluate the comparative efficacy of the ptda, vs. standard of care. results: ptda (www.sickleoptions.org) was developed per decisional needs described by stakeholders and finalized following alpha testing, and beta testing by and stakeholders respectively. in a randomized trial of subjects considering various treatment options, qualitative interviews revealed a high level of usability, acceptability, and utility in education, values clarification, and preparedness for decision making of the ptda. a median % rated the acceptability of ptda as good or excellent and provided narrative comments endorsing the acceptability, ease of use, and utility in preparation for decision making. the ptda met international standards for content, development process, and efficacy with the exception of having a full range of positive and negative experiences in patient stories. compared to baseline ptda group had statistically significant improvement in preparedness for decision making (p = . ) and informed subscale of decisional conflict (p = . ) but not for decisional self-efficacy, knowledge, choice predisposition, or stages of decision-making. a ptda for patients with scd developed following extensive engagement of key stakeholders was found to be acceptable, useful, easy to use, to improve preparedness for decision making, and decrease decisional conflict. background: painful vaso-occlusive crisis (voc) accounts for the majority of emergency department (ed) visits and hos-pitalizations in sickle cell disease (scd). we are interested in studying mental stress and associated autonomic nervous system (ans) imbalance that cause vaso-constriction as possible triggers of scd pain. to this end, we developed a mobile phone application (app) to record daily pain frequency and intensity as clinical endpoints that might be predicted by ans parameters measured in the laboratory. in particular, we think that the aura may represent ans instability that precedes or even triggers change in blood flow and voc. objectives: to assess the feasibility of using an app to evaluate frequency and severity of voc and its potential association with mental stress and presence of aura. design/method: an app was developed for both ios and android systems to allow patients to track pain, stress, and aura. the idea was to create an app that was easy to use with the intent to only capture pain episodes, rather than detailed description of the pain. all scd patients were eligible and a parent version was available for younger children. de-identified data was automatically transferred to a hipaa compliant database via a cloud-based server interfaced to the main research project database. a feedback questionnaire was implemented after at least a month of utilization to assess usability. of the scd patients enrolled, participants utilized the app and of the participants that provided feedback indicated the app was easy to navigate. the mean pain scale was out of (standard deviation . ) for those that entered they had pain that day. although the mean stress level was out of , there was a statistically significant correlation between increasing stress levels and increasing pain scores (p < . ). aura was reported by patients, with patients reporting more than episodes. moreover, on days aura was present there was greater incidence that pain was present as well (p < . ). however, there was no statistically significant association between pain intensity and presence of an aura (p = . ). conclusion: consistent with prior research, reported pain intensity is significantly associated with reported stress intensity. although there was an association between presence of aura and pain, it did not seem to correlate with pain intensity. this uniquely designed app can monitor scd pain clinically and help understand the role of sickle dysautonomia in the genesis of scd pain. university of florida college of medicine, gainesville, florida, united states background: evidenced-based guidelines recommend the emergent evaluation of fever in children with sickle cell disease (scd). as the prevalence of bacteremia has decreased, outpatient management has become more common. however, fever can sometimes herald other complications of scd, such as acute chest syndrome, vaso-occlusive pain crisis, splenic sequestration, or aplastic crisis. institutional practices regarding fever management in scd remain variable, and little is known about the clinical outcomes of children hospitalized for uncomplicated fever. objectives: the primary objective was to determine the rate of bacteremia or scd-related complications per febrile episode in children with scd admitted to a single institution between january and june for uncomplicated fever. this was a retrospective cohort study of febrile patients up to years of age with scd, any genotype, admitted to the university of florida during the defined study period. eligible patients were identified by a database search using admitting diagnosis codes for scd and fever based on the international classification of diseases th and th revisions. encounters were manually reviewed to confirm eligibility. patients were excluded if they had other indications for hospitalization apparent at the time of admission, such as an acute vaso-occlusive episode requiring parental narcotics, asthma exacerbation, or additional complications of scd. the database search identified encounters, of which were excluded based on confounding indications for hospitalization. sixty-three eligible patients accounted for hospitalizations. the median age was years (range weeks- years); . % were male. mean duration of hospitalization was . days (range - days). eight positive blood cultures were identified; six of these were classified as contaminants. bacteremia or the development of a scd-related complication was identified in ( . %) admissions. these included acute chest syndrome (n = ), bacteremia (n = ), splenic sequestration (n = ), and red cell transfusion (n = ). exploratory analyses of potential predictors of bacteremia or scd-related complications showed no association with the presenting white blood cell count or degree of fever (p = . ). of the patients classified as having a scd-related complication, % had hemoglobin ss disease and % had at least one prior documented complication. % of the patients transfused had at least one prior transfusion. conclusion: while improvements in preventative care have substantially lowered rates of bacteremia in children with scd, fever warrants careful evaluation for other acute scdrelated complications. providers should consider inpatient observation in select cases. additional studies are warranted to define subsets of patients suitable for outpatient fever management. background: children with sickle cell disease (scd) exhibit lower neurocognitive functioning than healthy peers, even in the absence of stroke. among the domains commonly affected, working memory (wm) seems particularly affected by disease processes and wm deficits have significant implications for academic achievement and disease selfmanagement. few interventions to improve working memory in pediatric scd have been evaluated. to determine the effects of cogmed, a homebased computerized wm training intervention, in children with scd using a randomized controlled trial design. design/method: participants (ages - ) with scd completed a baseline neuropsychological assessment and those with wm deficits were randomized to either begin cogmed immediately or enter an -week waitlist. cogmed is a homebased intervention completed on an ipad that consists of increasingly challenging exercises targeting visual-spatial and verbal wm, practiced over sessions. at the end of training, participants completed a post-intervention neuropsychological assessment, including tests of visual-spatial and verbal wm from the wechsler intelligence scale for children-fifth edition (wisc-v). results: ninety-one participants (m age = . , sd = . ; % female; % hbss) enrolled in the study; % (n = ) exhibited wm deficits and were randomized to either begin cogmed immediately or wait - weeks before starting cogmed. among those that have received the intervention and reached the end of their training period (n = ), participants ( %) completed at least cogmed sessions, ( %) finished at least sessions, and finished at least sessions ( %). the mean number of completed cogmed sessions was . (sd = . ). paired samples t-tests revealed significant improvements on the working memory index (t[ ] = - . , p = . ) and on the digit span (t[ ] = - . , p = . ), and spatial span-backward (t[ ] = - . , p = . ) subtests. improvements were especially pronounced for participants completing at least sessions. partial correlations controlling for respective baseline scores indicated that the number of cogmed sessions completed was positively correlated with post-test scores on digit span (r = . , p = . ) and spatial span-backward (r = . , p = . ) subtests. among participants who completed at least cogmed sessions, % scored in the average range or higher on the working memory index at the post-intervention assessment, compared to % at baseline. results support the efficacy of cogmed in producing significant improvements in wm. a dose-effect was observed such that participants who completed more cogmed sessions had greater improvements in wm. home-based cognitive training programs may ameliorate scd-related wm deficits but methods for motivating and supporting patients as they complete home-based interventions are needed to enhance adherence and effectiveness. background: sickle cell disease is associated with myriad complications that lead to significant morbidity and early mortality. hydroxyurea has been used successfully to reduce the incidence of these complications and has led to significant improvements in quality and duration of life. at children's minnesota we recommend hydroxyurea in all patients with hb ss/s thalassemia as early as months of age with a goal of starting all patients before months of age. objectives: the purpose of this study was to evaluate the use of hydroxyurea therapy in young patients with sickle cell disease, with particular attention to those children less than one year of age. design/method: a retrospective chart review was conducted on patients less than years of age with sickle cell disease who began hydroxyurea therapy between january , and december , . the study population was divided into three cohorts based upon age at hydroxyurea initiation: cohort ( - year), cohort ( - years), and cohort ( - years). outcomes included laboratory data, clinical events (hospitalization, dactylitis, pain crisis, transfusion, splenic sequestration, acute chest syndrome), and toxicity occurring in the first years of life. results: a total of patients were included in cohorts (n = , mean age . months), (n = , mean age . months), and (n = , mean age . months). patients in cohort had higher hemoglobin (p = . ) and mcv (p = . ) and lower absolute reticulocyte count (p = . ) when compared to cohort . the wbc (p = . , < . ) and anc (p = . , . ) were significantly lower compared to both older cohorts. however, no patient had therapy held because of neutropenia. the mean baseline hemoglobin f in cohort was . % compared to . % and . % in cohorts and respectively (p = . , p< . ). the mean duration of therapy in cohort was . months, compared to . months in cohort (p = . ) and . months in cohort (p = . ). during this time, hb f levels remained higher in cohort (mean . %) compared to cohorts and (mean . %, p = . and mean . %, p = . ). patients in cohort experienced fewer hospitalizations (p = . ), pain crises (p = . ), and transfusions (p = . ). there was no difference in toxicity between groups. hydroxyurea was used safely in infants to months of age and resulted in more robust hematologic responses and a decrease in sickle-related complications when compared with patients starting hydroxyurea later in life. children's national health system, washington, district of columbia, united states background: children with sickle cell disease (scd) have a significantly greater risk of silent or overt cerebral infarction than the general population. infarcts are associated with declines in cognitive functioning and academic achievement. while infarcts are reliably identified using mri, scans are expensive and occasionally necessitate sedation. moreover, mri's are not recommended for routine monitoring of cerebral infarcts. additional tools are needed for discriminating the presence of a cerebral infarct that are brief, noninvasive, inexpensive, and repeatable. objectives: to evaluate differences in performance on cogstate, a computerized neurocognitive assessment, in patients with scd with and without history of cerebral infarct. design/method: participants included children with scd ages - (m = . , sd = . ; % female; % s of s hbss) enrolled in a cognitive intervention trial. participants completed the cogstate pediatric battery, which measures processing speed, sustained attention, verbal learning, working memory, and executive functioning. history of silent or overt infarct was determined via health record review. participants also completed measures of intelligence (iq) and math fluency. results: participants' standard scores across most neurocognitive measures were lower than expected compared to the standardization sample (mean iq = . , sd = . ). thirty percent of participants (n = ) had a documented history of cerebral infarct. participants with a history of cerebral infarct scored lower on cogstate tasks measuring sustained attention (t[ ] = . , p = . ) and executive functioning (t[ ] = . , p = . ), as well as on a measure of math fluency (t[ ] = . , p = . ). receiver operating characteristic (roc) analyses demonstrated that the cogstate task measuring sustained attention was a fair discriminant of patients with and without a history of infarct (auc = . , ci = . - . , p = . ), whereas iq score was not (auc = . , ci = . - . , p = . ). cogstate processing speed and sustained attention tasks fairly discriminated between patients with at least average or below average intelligence (auc = . , ci = . - . , p = . and auc = . , ci = . - . , p = . , respectively). finally, the cogstate processing speed task was good at discriminating between at least average or below average math fluency (auc = . , ci = . - . , p< . ). multiple tasks in the cogstate pediatric battery appear to adequately identify patients with a history of cerebral infarcts. in addition, cogstate tasks appear to be fair predictors of impairments in iq and academic achievement outcomes. cogstate is inexpensive and can be easily administered in a medical setting with minimal training in approximately minutes. results support the potential for cogstate to be used as a screening tool for medical and neuropsychological abnormalities in children with scd. st. christopher's hospital for children, philadelphia, pennsylvania, united states background: cardiovascular disease contributes to the morbidity and mortality of patients with sickle cell disease (scd). hydroxyurea therapy in scd has known clinical efficacy including improving anemia, decreasing episodes of vasoocclusive crisis and acute chest syndrome, and decreasing mortality. effect of hydroxyurea on cardiac function in children with scd is not well studied. an earlier study suggested the protective effect of hydroxyurea on left ventricular (lv) hypertrophy in scd. we hypothesized that hydroxyurea use would be associated with decreased lv remodeling and improved cardiac function. we aimed to evaluate the association between hydroxyurea use and lv remodeling and cardiac dysfunction in children with scd. design/method: we completed a retrospective study of patients with scd who were to years old, followed at st. christopher's hospital for children and had an echocardiogram completed in the past months. data collected included gender, bmi, scd genotype, hydroxyurea use, chronic transfusion use, and d and doppler echocardiographic parameters. cardiac structure, geometry, systolic function, and diastolic function echocardiogram parameters were included. analysis of variance (anova) tests were performed to assess for statistical significance of differences in cardiac parameters between patients with and without hydroxyurea use. analysis of covariance (ancova) tests were performed to control for age. results: demographic and echocardiogram data was collected on all patients who met inclusion criteria. of the patients included, ( %) were on hydroxyurea therapy. patients on hydroxyurea had significantly lower mean relative wall thickness (p = . ) and significantly higher mean peak early lv filling velocities (p = . ) and peak early lv filling/septal annuli early peak (e/ea) velocities (p = . ); however, only the e/ea velocities remained significant when controlling for age (p = . ). mean peak early lv filling velocities approached significance when controlling for age (p = . ). hydroxyurea therapy resulted in a significantly higher e/ea velocity, suggesting that these patients had worse diastolic function. it is possible that the patients initiated on hydroxyurea already had worse disease manifestations than those not on hydroxyurea, possibly accounting for the decreased diastolic function. when controlling for age, hydroxyurea use did not result in significant differences in cardiac structure parameters, systolic function parameters or cardiac geometry. prospective studies and larger sample size are needed to validate our findings, examine for additional statistically significant differences, and develop preventive strategies for cardiovascular disease in children with scd. background: acute chest syndrome (acs) is now the leading cause of death in children with sickle cell disease; mortality in the u.s. is reported to be - % and is mostly due to respiratory failure. early transfusion improves clinical outcomes. although patients with concurrent asthma are considered at increased risk for poor outcomes, risk factors for respiratory failure in pediatric acs have not been well-defined. to determine whether specific epidemiological and clinical features of children hospitalized with acs are predictive of the need for mechanical ventilation. design/method: data from the kids' inpatient database were reviewed to identify patients age < years with a discharge diagnosis of acs for the years , , , and . outcomes were defined by the international classification of diseases, ninth revision, clinical modification code. data were weighted to estimate total annual hospitalizations according to hospital characteristics in the united states. trends in healthcare costs, length of hospital stay, transfusion, and mechanical ventilation use were analyzed using multivariable linear regression. in addition, multivariable logistic regression was used to ascertain specific clinical or epidemiologic factors associated with mechanical ventilation use after adjusting for patient and hospital characteristics. the total hospitalizations for acs were , in ; , in ; , in ; and , in . reported use of mechanical ventilation ranged from . % to . % and was associated with non-black compared to black children (or, . ; %ci, . to . ) and the fall season (or, . ; %ci, . to . ), but not with age, preexisting asthma or hb-genotype. comorbidities of obesity (or, . ; %ci, . to . ), obstructive sleep apnea (or, . ; %ci, . to . ) and heart disease (or, . ; %ci, . to . ) were associated with mechanical ventilation use. the use of simple and exchange transfusion during all acs admissions ranged from . % to . % and . % to . %, respectively. among pediatric acs patients, those with obesity, obstructive sleep apnea or heart disease were at increased risk for respiratory failure and might benefit from early intervention (e.g., transfusion). surprisingly, asthma in children with acs does not appear to be a distinct risk factor for respiratory failure, and further studies are needed to clarify whether differences in treatment approach (e.g., addition of corticosteroids, bronchodilators) might impact on acs progression and/or severity even in high risk patients without asthma. objectives: to compare pulmonary functions between aa and k children with scd and to assess if a high hb f level contributes to better function. design/method: a cross sectional study was done on children with scd (hb ss disease) followed in comprehensive sickle cell programs. aa patients were followed at brookdale hospital, ny and k patients were followed in mubarak hospital, kuwait. children between the ages of and years who had pulmonary function tests (pft) done as a routine screening were enrolled. pft was done using spirometer and plethysmography. patients with congenital or anatomical lung abnormality, heart disease, pulmonary disease such as acute chest syndrome, acute asthma or pneumonia within weeks were excluded. results: there were children ( in each group) with scd,. restrictive pattern on pft was seen in / ( %) of aa vs. / ( %) of k (p> . ). obstructive pattern was seen in / ( %) of aa vs. / ( %) of the k group (p> . ). in both groups, children ( %) had normal pft. three/ ( %) in the aa group had a hb f> % as compared to / ( %) in the k group (p< . ). abnormal pft was noted in / children ( %) in each group. hbf was > % in / ( %) in the aa group vs. / ( %) in the s of s k group (p< . ). in patients with abnormal pft, mean hbf was . ± . in aa group, compared to . ± in k group (p< . ). conclusion: abnormal pft is highly prevalent among children with scd in both groups. aa children are more likely to have restrictive disease and k to have an obstructive pattern. level of hbf did not seem to protect k patients from abnormalities on pft. this finding should emphasize the importance of performing pft as part of the initial evaluation of all children with scd. background: sickle cell disease (scd) is a life-threatening disease with varied clinical spectrum and severity leading to premature death. there is a lack of validated prognostic marker in scd. recent evidence suggests that inflammation and platelet adhesion plays a critical role in the pathophysiology of vaso-occlusion in scd. elevated mean platelet volume(mpv) values are associated with a higher degree of inflammation in many disease states but it's effect on sickle cell disease or it's severity is unknown. objectives: to analyze the role of mpv in predicting disease severity/mortality in pediatric patients with scd. design/method: this is a single center retrospective study and included patients with sickle cell disease between months and years of age during a -year period ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . demographic information, lab data and clinical information including acute chest syndrome (acs), priapism, transfusions, sepsis, pain crisis, avascular necrosis were collected. all laboratory data were collected in steady state with no crisis in the recent past months. the disease severity score/probability of death was calculated using a validated model to predict risk of death in sickle cell disease (sebastiani et al. blood ) . pearson test was used to analyze correlation between mpv and probability of death. results: total no. of patients = ; male ( . %); female ( . %). median age is . years. all patients were of african-american origin. disease severity, hb ss - ( %); hb sc - ( . %) and sickle-beta thalassemia ( . %). patients on hydroxyurea has significantly lower mpv, p = . and this is independent of hb f levels. mpv has a significant positive correlation with the probability of death, p = . and correlation coefficient, r = . . on subgroup analysis, the correlation is even more significant in the age group between and years, p = . , r = . . using linear regression model, with probability of death as a dependent variable and hydroxyurea, mpv as independent variables, mpv maintains a significant association with probability of death (p = . ). conclusion: mpv is an independent biomarker predicting disease severity and probability of death in pediatric patients with sickle cell disease. hydroxyurea a known disease ameliorating agent is associated with lower mpv values. this effect is independent of the levels of fetal hemoglobin and may be due to anti-inflammatory effect of hydroxyurea or effect on the platelets. background: major success with initial qi projects by the sickle cell care team at children's hospital has precipitated ongoing inclusion of the qi approach to many other aspects of patient care. objectives: to optimize scd patient care utilizing qi processes. design/method: success of the scd qi team's initial project on transcranial doppler studies (tcds) and a second more complex project on hydroxyurea (hu) adherence, led to additional projects on completion of key immunizations, rbc phenotyping, and vitamin d level testing. using similar processes and principles from the hu adherence project, plan-do-study-act (pdsa) cycles were used to conduct smallscale tests of change. patient chart prep sheets, created for bi-monthly pre-appointment chart prep meetings, were significantly modified to include these focused care qi objectives. because of difficulty with emr database capability, data collected from the emr was tracked in excel spreadsheets or other unique tracking vehicles for the various parameters. for example, due to the clinic's diffuse, geographically scattered population, many separate non-shared primary care emrs, and lack of a mandatory state immunization registry; immunization records needed to be retrieved from pcps, outlying hospitals, public health departments, and fqhcs, and added to the emr and excel database. starting in / , all such data was collected and updated monthly. in one year's time ( - ) , the average immunization completion rate for seven key immunizations (pcv , pcv , hepatitis a, hepatitis b, meningococcal a, meningococcal b, and hpv) has increased by %. the biggest improvements were a % and % increase in completion for meningococcal a and meningococcal b, respectively. completion rate for rbc phenotyping rose from . % to . %. patients with at least one vitamin d lab test increased from . % to . %. since starting the tcd project in , the percent of patients who have completed their annual tcd has gone from a baseline of % to a sustained value of > %. conclusion: these qi projects have not only increased adherence to national recommendations for care of scd patients, they have helped establish a scd clinic methodology to create and implement sustainable processes. having the focused care initiatives prominently displayed on the patients' chart prep sheet serve as a reminder to medical team members to check the status of that item. this methodology is currently being used to formulate additional qi projects on annual renal function parameters and specialty visits, such as annual eye and dental exams. background: dominican republic has a high burden of sickle cell disease, and - % of children with homozygous hbss (sickle cell anemia, sca) will develop primary stroke. transcranial doppler (tcd) ultrasonography is an effective screening tool for primary stroke risk, but is not routinely available in dominican republic. hydroxyurea and blood transfusions are available, but no prospective screening and treatment program for stroke prevention has been implemented to date. ( ) to screen a large cohort of children with sca living in dominican republic, using tcd to identify elevated stroke risk; ( ) to determine the effects of treatments for stroke prevention (hydroxyurea for conditional velocities and transfusions for abnormal velocities). we hypothesized that both hydroxyurea and blood transfusions will decrease elevated tcd velocities and help prevent primary stroke. design/method: stroke avoidance for children with república dominicana (sacred, nct ) features a research partnership between cincinnati children's hospital and robert reid cabral children's hospital in dominican republic. the protocol, consent forms, and redcap database were prepared collaboratively and translated into spanish, and then irb approval was obtained at both institutions. in the initial prospective phase, children receive tcd screening over a -month period; those with conditional tcd velocities (maximum time-averaged velocity - cm/sec) receive fixed-dose hydroxyurea at mg/kg/day, followed by dose escalation to maximum tolerated dose, while those with abnormal tcd velocities (≥ cm/sec) receive monthly transfusions for stroke prevention. results: a total of children were enrolled in sacred, with an average age of . ± . years. initial tcd screening revealed ( . %) normal, ( . %) conditional, ( . %) abnormal, and ( . %) inadequate velocities. among children ( males, females, average age . ± . years) who initiated hydroxyurea at mg/kg/day for conditional tcd velocities, completed six months of treatment with expected hematological benefits including significant increases in hemoglobin concentration ( . to . g/dl) and fetal hemoglobin ( . to . %). no clinical strokes have occurred in the treatment group. repeat tcd examination after -months of hydroxyurea treatment revealed % ( / ) with previous conditional velocities had normal tcd velocities. the prevalence of conditional tcd velocities in the dominican republic is high, indicating an elevated stroke risk among children with sca. hydroxyurea treatment is associated with improved hematological parameters, lower tcd velocities, and probable decreased stroke risk. sacred is an important prospective and collaborative research trial providing epidemiological data regarding tcd screening, stroke risk, and hydroxyurea effects among children with sca. background: red blood cell aggregation is a rheologic property that explains the shear-thinning behavior of blood. at lower shear rate blood flow, red cells tend to aggregate, s of s whereas in higher shear rate blood flow, these aggregates are dispersed. this property is especially important in the venous system, where low shear rate blood flow predominates. there is inconsistent data in the literature concerning aggregation and aggregability in sickle cell disease (scd). objectives: because the lorrca and myrenne instruments have been shown to be similarly effective methodologies in red cell aggregation measurements, we aimed to determine whether the measurement of aggregation indices in scd, by myrenne and by lorrca, is consistent in our lab. design/method: we measured aggregation in blood samples corrected to % hematocrit. aggregability was measured using kda dextran in the myrenne but not the lor-rca. aggregation index using lorrca was measured in patients with scd and healthy subjects enrolled in a study of blood flow between and . aggregation and aggregability using the myrenne was measured in patients with scd and healthy subjects enrolled in a separate study of blood flow between and . results: using lorrca, we found that aggregation index in patients with scd was less than that of healthy subjects (p< . ). in the myrenne, aggregation at stasis was slightly higher in patients with scd compared to healthy subjects (p = . ) but aggregation at low shear rotation was not different. aggregability was higher in the patients with scd compared to healthy subjects at both stasis and low shear rotation (p< . ). red cell aggregation is an important determinant of low shear blood flow. deoxygenated venous blood is particularly important to low shear blood flow in patients with sickle cell disease. we found that two different aggregometers predict different aggregation results for scd. it is unclear why there is a systematic difference between the two methods, but there are some possibilities. first, the syllectogram in the lorrca is generated by the backscatter of light from the laser, while the myrenne measures transmitted light. second, the distance between the bob and cup in the lorrca is microns, while the gap between plates in the myrenne is microns, which might affect the disaggregation of red cells. further work is needed to understand the differences in red cell aggregation and aggregability when using these instruments, particularly when using aggregation as a predictor of blood flow and tissue perfusion. background: children with sickle cell disease (scd) are at risk of acute splenic sequestration crisis (assc). assc is a life-threatening complication characterized by splenomegaly, pain and severe anemia. assc most often occurs in young children with the most severe forms of scd and one-third of patients will have more than one episode. treatment is based primarily on expert opinion and includes blood transfusion and surgical splenectomy. objectives: we plan to assess the clinical practice patterns of physicians treating children with assc. design/method: a survey study was performed. the survey included six scenarios of severe scd with variation in age, hydroxyurea-use, and episode number of assc; questions focused on the acute and chronic management of assc. the survey was disseminated on three occasions over a six-month period, using an online survey tool, surveymonkey, to pediatric hematologist-oncologists participating in the american society of pediatric hematology-oncology hemoglobinopathy special interest group. the survey had a response rate of % ( / ). most respondents were recent graduates ( %; / ) practicing in academic urban centers with greater than sickle-cell patients. seventy-nine percent ( / ) recommended hydroxyurea initiation in - m/o with severe scd. prophylactic penicillin after surgical splenectomy was continued by % ( / ) after years. for the acute management of assc results did not vary despite patient age, hydroxyurea use, and the number of previous assc episodes. simple transfusion was preferred by % ( / ), with % ( / ) recommending slow transfusion and % ( / ) recommending routine simple transfusion. for the chronic management of assc, results varied based on patient age and the number of previous assc episodes. for a m/o after the first episode, % ( / ) recommended observation and % ( / ) hydroxyurea initiation. for a m/o with any prior episode of assc, % ( / ) recommended chronic transfusion therapy and % ( / ) surgical referral for splenectomy. for a y/o after the first episode, % ( / ) recommended surgical splenectomy and % ( / ) increasing hydroxyurea dose. for a y/o with any prior assc episode, % ( / ) recommended referral for surgical splenectomy. in this survey, we found most providers continue to recommend simple transfusions for assc and surgical splenectomy after two episodes. the majority of providers continue to delay referral for surgical splenectomy until age two, but earlier referral in children under two and use of chronic transfusion therapy were also reported. variability in chronic management highlights the need for further research of splenic sequestration. background: developing therapies for sickle cell disease (scd) is challenging in part because the accepted endpoint, vaso-occlusive crisis (voc), occurs infrequently, does not measure full disease burden, and is a measure of healthcare utilization. in phase / studies of patients with scd, voxelotor (gbt ) has demonstrated increased hemoglobin (hb) levels and reduced hemolysis and has been safe and welltolerated. voxelotor is being evaluated in the ongoing hope phase trial. objectives: to report the innovative phase / hope trial design with novel primary and secondary outcomes to accelerate drug development. design/method: hope (nct ) is a phase , randomized, placebo-controlled, multicenter study of oral voxelotor in patients with scd (aged - years) with baseline hb . - . g/dl and - episodes of voc in the prior year. to accelerate clinical trials to support drug development, the study combines a phase exploratory, dose-selection phase (group ) with a pivotal phase (groups / ). patients in group will be randomized : : to voxelotor or mg/day or placebo. analysis for dose selection will occur when the final patient has received weeks of treatment. group will continue enrollment with randomization : : until dose selection based on analysis of the group cohort. group will allow for a seamless transition into group , which will randomize patients : to the selected dose or placebo. the final data analysis set will include group patients who received placebo or the selected dose and all group patients. the primary endpoint is an objective laboratory measure and surrogate of clinical benefit, increase in hb > g/dl, from baseline to weeks based on voxelotor mechanism of action (inhibition of hb polymerization). this trial is the first to use a patient-reported outcome (pro), the -item sickle cell disease severity measure, as a secondary endpoint. this novel electronic pro, developed specifically for the hope study following fda guidance, will evaluate changes in scd symptom exacerbation and total symptom score from baseline to weeks. additional secondary endpoints include measures of hemolysis, rates of voc, transfusions, and opioid use. the study was designed to enable selection of pro-defined symptom exacerbations or traditionally defined voc as the key secondary endpoint after the group analysis. results: this study is ongoing. the hope trial, expected to complete enrollment by late , will evaluate the efficacy and safety of voxelotor compared with placebo in patients with scd. supported by global blood therapeutics. background: inflammation, coagulation activation, oxidative stress and blood cell adhesion are elements of sickle cell disease (scd) pathophysiology. patients with scd have low levels of the omega- fatty docosahexaenoic acid (dha) and eicosatetraenoic acid (epa) in plasma and blood cell membranes. dha is a bioactive fatty acid with anti-inflammatory, anti-blood cell adhesion and anti-oxidant properties. altemi-atm is a novel dha ethyl ester formulation with a proprietary delivery platform (advanced lipid technology® (alt®)) that enhances oral dha bioavailability. the scot trial investigated the effects of altemiatm in children with scd. objectives: to demonstrate the effects of altemiatm on blood cell membrane omega- index and selected biomarkers of inflammation, coagulation, adhesion and haemolysis associated with scd. s of s design/method: children with scd, aged - years (n = ), were enrolled. subjects were randomized to receive either placebo or one of three daily oral doses of altemiatm ( - , - or - mg/kg/day dha) for two months. the effects of altemiatm on red blood cell (rbc), white blood cell and platelet membrane omega- fatty acids index (total dha + epa levels) were assessed after four weeks of treatment. the effects of altemiatm on markers of inflammation, adhesion, coagulation, and hemolysis were assessed after eight weeks of treatment. cell membrane dha and epa concentration was determined by using lc-ms/ms method. the percent changes from baseline on blood cell membrane omega- index and select scd biomarkers were compared between the three dose groups and placebo using a mixed-model repeatedmeasures (mmrm) analysis with baseline blood cell membrane omega- index, hydroxyurea use, and treatment as fixed effects and patient as a random effect. after four weeks of treatment, blood cell membrane dha and epa levels were significantly increased in all altemiatm doses (p< . ). after eight weeks of treatment, significant reductions were observed in se-selectin (p = . ), and d-dimer (p = . ) in patients exposed to altemiatm dose level vs. placebo. hemoglobin was significantly increased at altemiatm dose level versus placebo. plasma high-sensitivity c-reactive protein, lactate dehydrogenase, soluble vascular cell adhesion molecule- and white blood cell count showed improvement after weeks of treatment in all three altemiatm doses levels but did not reach significance. conclusion: treatment with altemiatm enriches dha and epa in blood cell membranes of patients with scd and improves select sickle cell disease biomarkers of blood cell adhesion and thrombin generation. these findings provide insight into the mechanisms of action of altemiatm in sickle cell disease. brown university -hasbro children's hospital, providence, rhode island, united states background: despite clinical advances in the treatment of sickle cell disease (scd) in pediatric and young adult patients, pain remains a significant source of disease-related morbidity. physical therapy has been shown to be useful for the treatment of pain in children and young adults with various chronic illnesses of which pain is a significant component, however no data exists regarding potential benefits of physical therapy in pediatric and young adult patients with scd. objectives: to query healthcare providers and others involved in the care of pediatric and young adult scd patients regarding possible benefits of and barriers to physical therapy as a potential treatment modality. design/method: we conducted a web-based survey of healthcare providers within the new england pediatric sickle cell consortium (nepscc) in an attempt to identify potential benefits of and barriers to outpatient physical therapy in this patient population. results: nearly % of survey participants felt that physical therapy had the potential to be "somewhat beneficial" or "very beneficial" in pediatric and young adult patients with scd. a majority of physicians reported having referred patients with scd for physical therapy in the past. the most frequently identified perceived potential benefits included improved functional mobility, improvement of chronic pain symptoms, decreased use of opiates, improved mood symptoms, improved acute pain symptoms, and improved adherence with medications and clinic visits. significant perceived barriers identified included lack of transportation, time constraints, patient lack of understanding, and difficulty with insurance coverage. our study indicates that healthcare providers have an overwhelmingly positive view of the use of physical therapy in the management of pediatric and young adult patients with scd. significant barriers exist which need to be addressed. future research should focus on patient and parent perspectives regarding physical therapy, as well as a randomized controlled trial of a physical therapy intervention in this patient population. background: vitamin-d deficiency is fast becoming increasingly recognized in patients with sickle cell disease (scd). while it is estimated that these patients are five times more likely to develop vitamin-d deficiency, the exact clinical significance of this is largely unknown. given that this deficiency can be inexpensively and easily treated, our study sought to establish the prevalence of vitamin-d deficiency in our patient population and its relationship with disease severity. objectives: to estimate the prevalence of vitamin-d deficiency in patients with scd in our institution and to analyze their disease severity in relation to their vitamin-d level. design/method: through retrospective chart review we analyzed subjects that represent a cohort of patients followed at the adult and pediatric hematology services at university of miami with known diagnosis of scd that had a vitamin-d level drawn between january st, and august st, . we conducted a cross-sectional study and recorded the first vitamin-d level during this period. patient demographics, medical and social history information were collected along with laboratory data. the number of admissions for vaso-occlusive crisis (voc) and acute chest syndrome within one year preceding the collection the vitamin-d level was also recorded. results: a total of charts were reviewed, adult charts and pediatric charts. after exclusion, patients were enrolled. subclinical vitamin-d deficiency is only evident on laboratory blood testing of vitamin-d ( -hydroxy) and according to this laboratory result patients were classified as sufficient (≥ ng/ml), insufficient (< to ng/ml) and deficient (< ng/ml). out of the cases, . % ( / ) were deficient, . % ( / ) were insufficient and . % ( / ) were optimal. after statistical analysis two negative correlations were identified, increasing vitamin-d levels with decreasing white blood cell count (ci %- . (- . , - . )and decreasing incidence voc (ci %- . (- . , - . ). conclusion: this study confirms that there is a significant prevalence of vitamin-d deficiency in patients with scd. furthermore, the results of this investigation proved that vitamin-d deficiency is associated with acute pain and leukocytosis in patients with scd. given the multitude of confounding factors that affect vitamin-d absorption and intake, multivariate analyses are required to truly further investigate this relationship. texas children's hospital, houston, texas, united states background: hemophagocytic lymphohistiocytosis (hlh) is a rare but life-threatening condition of hyper-inflammation that is characterized by splenomegaly, cytopenias, hyperferritinemia, hypertriglyceridemia, hemophagocytosis and coagulopathy. although timely diagnosis is imperative, it is often challenging as these individual signs and symptoms may occur in a variety of clinical conditions. to report a case of undiagnosed sickle cell anemia presenting with severe ebv viremia and associated hemophagocytic lymphohistiocytosis results: a -month-old previously healthy male presented with respiratory distress, increased fatigue, and a focal seizure following a two-week history of cough and lowgrade fevers. physical exam was consistent with hypovolemic shock and revealed significant splenomegaly. laboratory testing revealed severe hypoglycemia, acidosis and electrolyte disturbances including hyperkalemia, hyperphosphatemia, and hyperuricemia. labs showed a leukocytosis (wbc , ), severely low hemoglobin ( . ), and platelets of , . coagulation testing revealed prolonged pt/inr and ptt, hypofibrinogenemia and a highly elevated d-dimer. additional workup was completed to determine etiology of acute presentation, given broad differential diagnosis. infectious studies were consistent with an acute ebv infection (plasma ebv pcr > , ). elevated levels of soluble il- and ferritin completed / criteria for the diagnosis of hlh. bone marrow evaluation showed trilineage hematopoiesis with no abnormal blast population or hemophagocytosis. results from hemoglobin electrophoresis sent from the initial cbc sample were notable for hbs . %, hbf . %, and hba of %, confirming the diagnosis of sickle cell disease. the patient was started on hydroxyurea and penicillin and splenomegaly resolved. with supportive care, he demonstrated gradual improvement in symptoms and laboratory abnormalities, including normalization of soluble il- , ferritin, cd , il- levels, immunoglobulins, and declining ebv titers. nk cell function has remained abnormally low, not eliminating the possibility of acquired hlh despite spontaneous improvement. conclusion: splenic sequestration associated with sickle cell disease in combination with acute infectious mononucleosis could have explained many of the presenting symptoms including anemia, thrombocytopenia, and splenomegaly. however, it does not explain the unusually high ebv titer and degree of inflammation meeting diagnostic criteria for hlh, which raises concern for an underlying immunologic abnormality such as x-linked lymphoproliferative disorder (xlp). although testing for xlp was negative, he will require s of s continued monitoring in the future for signs of relapse. this case illustrates the complexity of diagnosing lymphohistiocytic disorders and the significant overlap in presentation between these disorders and other medical conditions. background: vaso-occlusive crisis (voc) is one of the most distressing occurrences in patients with sickle cell disease (scd). patient controlled analgesia (pca) is recommended by nih and expert opinions favor its early use. we aim to review the use of pca in patients with voc and to evaluate if its early use is associated with faster pain control and reduced length of stay (los). design/method: this retrospective single center study included all pediatric patients admitted and treated with pca for a severe voc from to . "early" use was defined as start of pca within hours of arrival in the emergency department (ed) and "late" use after hours. time to reach adequate analgesia was defined as oucher, verbal scale or faces pain scale < / obtained twice consecutively in a -hours interval. time to reach adequate analgesia and los were compared between early-pca and late-pca groups. results: a total of patients presented episodes of voc treated with pca during the study. sixty-one episodes ( %) were treated with early-pca and ( %) with late-pca. both groups were comparable in terms of age ( . vs . years old), gender ( . % female vs . %), hemoglobin phenotype ( . % hbss vs . %), but median pain score at admission was higher in early-pca than in late-pca ( / vs / , median difference ( % ci , ). early-pca was associated with a median reduction in los of . days ( % ci . , . ) (median early-pca los . vs late-pca . days). time to reach analgesia could be evaluated only in a subset of patients ( in early-pca and in late-pca group). although time to reach adequate analgesia tended to be shorter in the early-pca group, it was not statistically different: median . hours vs . hours, difference of . ( % ci - . , . ). side effects were observed during ( . %) pca treatments ( / ( . %) episodes in early-pca, / ( . %) in late-pca group) among which ( . %) were significant adverse events. these were observed in patients who required interventions: desaturations requiring oxygen without intubation, neurologic abnormalities (hallucinations, visual abnormalities, no stroke), urinary retentions. conclusion: early use of pca for severe voc was associated with a reduced length of hospital stay despite that these patients had higher pain score on admission. prospective studies are needed to support these positive outcomes. background: acute chest syndrome is one of the leading causes of death in children with sickle cell disease - . while the cause of acute chest syndrome most commonly is not identified, fat embolism and infectious causes are believed to be most common. with an extremely high mortality rate, rapid identification and initiation of therapy is essential for survival. case presentation: we describe the case of an -year-old female with sickle cell sc disease who was admitted for vasoocclusive pain crisis and quickly progressed to multi-system organ failure due to fat embolism syndrome and parvovirus b infection objectives: the case highlights the presentation and diagnosis so other providers can optimize outcomes for those with this under-recognized syndrome design/method: her parvovirus studies returned after days which showed: parvovirus b dna pcr detected; parvo igg . (positive > . ); and igm . (positive > . ). the patient experienced an approximately . g/dl drop in hemoglobin( . to . g/dl/ hrs) with progressive thrombocytopenia (from , to , /ul) and a peripheral smear showed microcytic,normochromic red cells with nucleated rbcs and occasional nuclear budding, slight polychromasia, schistocytes, and polymorphic cells with toxic granules that suggested leukoerythroblastosis. she was emergently transferred to the regional quaternary care hospital for ongoing ecmo therapy where she experienced a change in her pupillary exam prompting a stat ct scan that showed severe, diffuse cerebral edema with transtentorial herniation. the decision was made to withdraw life-sustaining therapies and her family refused a post-mortem autopsy examination. fat embolism syndrome is a severe and uncommonly recognized complication of sickle cell disease, seen most commonly in those with a non-ss phenotype and previous mild disease course who present with severe, unrelenting vaso-occlusive pain episode and/or acute chest syndrome that progresses to respiratory distress with altered mental status and cutaneous changes. rapid identification and initiation of exchange transfusion therapy should be initiated with clinical suspicion because of the extremely high mortality rate. although previously considered rare, it needs to be considered in the differential diagnosis of more commonly encountered complications of sickle cell disease. background: patients with sickle cell disease (scd) experience vaso-occlusive crisis (voc), which results in extreme pain, often requiring opioids and admission. genetic and environmental factors affect the frequency and severity of these episodes. previous research has born conflicting evidence on whether environmental temperature is contributory. edmonton, alberta is the northern most city with a population over a million in north america. there is an increasing sickle cell population which is exposed to extreme winter conditions. this provides a suitable population and atmosphere to study the influence on cold external temperatures in scd. this study sought to identify if pediatric patients with scd, experience greater morbidity in cold external temperatures. board approved retrospective case control series. patients were identified through a clinical database, and emergency visit, phone call and admission data was collected over a fiveyear period. the average, minimum and change in temperature on day of presentation, and hours prior, was collected from the government of alberta, and was statistically analyzed using descriptive statistics, to determine the relation to vaso-occlusive events. results: one-hundred and eighteen patients were identified, and voc events reviewed. the mean patient age was . years of age with a range from . - years old. the female to male ratio was equivalent with female ( . %) and male ( . %) voc events. eight records ( %) had docu-mented cold exposures. the analysis between the temperature and the frequency of events did not yield significant correlation. average and minimum temperature on day of admission had the largest percentage of voc events occur at mild temperatures, from - . to • c and - . to respectively. change in temperature on day of admission, and hours had the largest percentage of voc events at a mild to moderate change in temperature of - degrees. data at & hours prior to admission showed similar results. secondary data analysis accounting for the lower proportion of extreme weather days in comparison to moderate temperate days showed no significant impact. there was no correlation of average, minimum or change in temperature on day of admission, or hours prior. multiple cofounding factors likely contribute to these results. as it was a retrospective study many confounding and precipitant factors may not be recorded or identified. a prospective study to better record specific cold exposure is warranted. children's national health system, washington, district of columbia, united states background: achieving optimal anticoagulation with unfractionated heparin (ufh) in pediatric patients receiving extracorporeal membrane oxygenation (ecmo) is often challenging due to antithrombin (at)-mediated heparin resistance (hr). intermittent at dosing during pediatric ecmo support does not maintain adequate at levels. continuous at infusion (cati) presents an alternative strategy to achieving consistent goal at levels and optimizing heparinization. however, cati during pediatric ecmo has not been adequately studied. objectives: to describe our center's experience with an ecmo cati protocol. design/method: in , we modified our ecmo anticoagulation protocols to include ufh titration according to anti-factor xa (anti-fxa) levels and cati in patients with at-mediated hr. the cati rate was calculated using baseline and goal at levels while accounting for the circuit volume. cati was administered with ufh into the circuit via a s of s y-infusion set. at and anti-fxa levels were monitored every hours. recombinant at (r-at) concentrate was used at our center until with subsequent transition to a plasmaderived at (pd-at) concentrate. due to the longer half-life of pd-at concentrate, the protocol was modified so cati is stopped once target at and anti-fxa levels are achieved. we conducted a retrospective study of all patients who received cati during ecmo support at our center. data are reported as median and interquartile range and compared using the mann-whitney u test. two-tailed p-value < . was considered statistically significant. since , patients [ males, age month ( . - )] on ecmo support received catis ( rat, pd-at) per our protocol ( patients received pd-at infusions during one ecmo run). the duration of cati was hours ( - ). cati administration led to significant increases in at and anti-fxa levels from baseline of % ( - ) and . units/ml ( . - . ) to the first level within goal of % ( - ) and . units/ml ( . - . ), respectively (p< . ). the respective times to achieve goal at and anti-fxa levels were hours ( - ) and hours ( - ). the respective peak at and anti-fxa levels were % ( - ) and . units/ml ( . - . ). during cati, no patient required circuit change, patient developed cannula thrombosis and patients experienced non-fatal major bleeding. conclusion: cati in pediatric patients receiving ecmo support with close monitoring of at and anti-fxa levels was associated with significant rapid increase in at, optimization of heparin effect, and reduction in thrombotic complications without increase in major bleeding compared to prior reports. a prospective study of this at dosing strategy is warranted. children's hospital of orange county, orange, california, united states background: inherited factor xiii (f ) deficiency is a rare bleeding disorder with wide heterogeneity in clinical manifestations ranging from mild bruising, and mucosal and umbilical stump bleeding to spontaneous, severe intracranial bleeding. the bleeding phenotype is influenced not just by zygosity of the fxiii mutation alone, but also by co-inheritance of variants in other clotting protein genes that also play a major role in clot formation and stability. we present a series of three siblings found with f a gene variant and platelet dysfunction linked to bleeding phenotype. design/method: retrospective chart review of the index case, coagulation studies and whole gene sequencing. the index patient presented at two years of age with a subdural hematoma after a fall, requiring emergent craniotomy. a week after initial evacuation, she re-bled, prompting an extensive work-up for potential bleeding disorders, including f activity, von willebrand profile, comprehensive fibrinolysis panel, pai- antigen level, platelet mapping thromboelastogram (plt-teg), and f genetic analysis. the patient's identical twin and older sibling, who had symptoms of bruising, underwent a similar evaluation. the index patient demonstrated consistently low f activity ( - %), and platelet function testing revealed decreased response to adp agonists. the twin and older sibling had normal f levels, and only slightly decreased response to adp in platelet studies. whole gene analysis of f and other genes on our next generation panel, revealed several intronic deletions in the index patient that were not shared by her siblings, which likely account for her decrease in circulating f levels. her symptoms have responded well to monthly treatment with factor concentrate. all three children shared the f variant, pro leu, previously described as a risk factor for intracranial hemorrhage. the f mutation, pro leu, has been associated with intracranial hemorrhage in young women, but the presence of the variant alone may not be enough to cause a severe bleeding phenotype. family studies identified novel deletions in the index patient which may account for her decreased f levels, which would have been overlooked with standard sequencing. future studies, including evaluation of 'platelet' f levels, should be performed when platelet dysfunction is detected. further laboratory and clinical evaluation is required to delineate the long term implications of the interaction of even mild f deficiency if present with additional clotting disorders such as the platelet function defect in these siblings. background: acquired hemolytic anemia can occur due to mechanical shearing of red blood cells and is classically seen in patients with prosthetic heart valves. there are reports of this same traumatic effect with other repairs, including annuloplasty. following valvular procedures flow disturbances can exist across the valve that lead to shear stress and hemolysis. although von willebrand disease (vwd) is typically seen due to an inherited disorder in the pediatric population, flow disturbances in the setting of valve abnormalities can lead to acquired von willebrand syndrome (avws). von willebrand factor multimers become unfolded and elongated in the setting of shear stress resulting in increased susceptibility to cleavage by adamsts- . specifically, loss of high molecular weight multimers (hmwms) can lead to a syndrome akin to type a vwd. objectives: to describe a case of mechanical hemolysis with acquired type a vwd design/method: a -month-old girl with history of hypoplastic left heart syndrome and severe tricuspid valve insufficiency underwent norwood procedure, blalok-taussig shunt placement and subsequently a bidirectional glenn and tricuspid valve annuloplasty. during the following month she requires weekly red blood cell (rbc) transfusions due to intermittent anemia. she also experienced bloody stools and dark urine. laboratory evaluation was notable for normocytic anemia, reticulocytosis, elevated lactate dehydrogenase, and low haptoglobin consistent with hemolytic process. immune-mediated hemolysis from transfusion reaction or presence of autoimmune or alloimmune antibodies testing was negative. to investigate gi bleeding, work up for vwd revealed normal vw activity and antigen but with loss of high molecular weight multimers consistent with acquired type a vwd. in consultation with cardiology, it was felt her tricuspid valve insufficiency jet could be leading to mechanical hemolysis and avws. a repeat echo showed persistent moderate tricuspid insufficiency but no other significant changes. due to the patient's continued need for weekly rbc transfusions she was subsequently trialed on pentoxifylline which is used in adult patients to decrease blood viscosity and increase erythrocyte flexibility in patients with mechanical hemolysis. her transfusion needs remained the same and the medication was discontinued after two weeks. she required one transfusion a week later but no transfusions since that time. although not commonly seen in pediatric patients, the diagnosis of mechanical hemolysis accompanied by avws should be pursued in a patient with congenital heart disease with significant anemia and/or bleeding. the work up in these patients is difficult as echocardiograms can be inconclusive thus an extensive hematologic evaluation is usually necessary. objectives: our aim was to assess incidence of and potential risk factors for central line-related dvt at our institution between - . additionally, our goal was to analyze if that incidence differed between the three central line types and identification of line-specific risks. design/method: a retrospective chart review of central line placements in pediatric patients at cleveland clinic between - was conducted. data included demographics, potential risk factors, line characteristics and any related thrombotic events. the study cohort consisted of lines in pediatric patients aged - years of age. there were . thrombi ( % ci . - . ) per , line days. statistically significant risk factors for thrombus include diagnosis group (liquid tumor highest rate of %, solid tumor lowest at %), type of line (picc %, broviac %, and mediport %), location of line, greater number of lines per patient, peg asparaginase ( % vs %), sepsis, and history of procoagulant state. line characteristics such as lumen size and number of lumens were not identified as a significant risk. there was a significantly higher rate of thrombus in than in the previous years when pooled ( % in vs . % from - , p = . ). the incidence of dvt in pediatric patients at our institution was highest with broviac lines, and significant risk factors in our patient population included liquid tumor, femoral vein location, peg asparaginase, sepsis, and history of a procoagulant state. the incidence of thrombi was highest in , and therefore highlights the urgent need for improvement in nationwide hospital practices to minimize risk of thrombi formation and early detection in the higher-risk s of s populations. there is still much to be learned regarding the characteristics specific to different central lines, which would influence thrombi formation. nyu winthrop hospital, mineola, new york, united states background: pediatric immune thrombocytopenic purpura (itp) is an autoimmune disorder with platelet counts < causing increased risk for significant hemorrhage. there is increased immunologic platelet destruction due to production of specific autoantibodies along with inhibition of platelet production. few randomized trials exist to guide management and ultimately each patient requires an individualized treatment plan. itp may be acute (diagnosis to m) or chronic (> months). one of the treatments of chronic itp is laparoscopic splenectomy (ls), which is very well tolerated. a rare complication of ls is splenosis, an autotransplantation or implantation of ectopic splenic tissue within the abdominal cavity or in any other unusual body compartment. splenosis is sometimes associated with relapsed itp due to preserved immune activity. the usual management of symptomatic splenosis is surgical resection. objectives: to describe medical management in a young patient with itp relapsed due to extensive unresectable splenosis following ls design/method: our patient was originally diagnosed at years with itp and was treated with ls at years of age for chronic severe thrombocytopenia and persistent bleeding not responding to first line therapies. she tolerated it well and had a complete response (cr) defined as a platelet count of > measured on occasions > days apart and absence of bleeding. she maintained a normal platelet count for twelve years after which she relapsed (loss of response after cr) with severe thrombocytopenia and hematuria necessitating high dose steroids. ct scans showed multiple wellcircumscribed soft tissue masses in the left lower quadrant adjacent to uterus and left ovary, involving left omentum and the anterior abdominal wall partly. findings were confirmed by damaged rbc nuclear scan to be splenosis. during laparoscopy the splenosis lesions were deemed too extensive and were not resected completely to avoid postoperative morbidity. she was started on sirolimus around the same time for treatment of her relapsed itp and steroids were weaned off. results: eight months since beginning sirolimus with therapeutic levels she remains in cr with no bleeding and has not required any steroids, immunoglobulins or anti d immunoglobulin. conclusion: sirolimus is a safe and effective steroid-sparing agent in treatment of chronic itp. this is the first instance of a patient with poorly resectable splenosis responding well to medications for itp. more data is needed regarding the longterm efficacy of such an intervention and whether it will eliminate the need for a second surgery in relapsed itp patients with extensive splenosis. background: storage pool disorders affecting platelets result in bleeding symptoms related to a deficiency or defect in alpha granules or delta granules. in delta-storage pool disorders (dspd,) there is a deficiency of the delta granules and their constituents, which results in the inability of platelets to properly activate as well as lack of proper constriction of blood vessels during bleeding episodes. amongst patients with dspd, females most commonly present with menorrhagia, while males tend to present with epistaxis and easy bruising. the international society on thrombosis and hemostasis (isth) developed a screening bleeding assessment tool (bat) for mild bleeding disorders, shown to be a validated tool in children. diagnosis of dspd is classically made with a platelet electron microscopy (pem) value < . delta granules per platelet (dg/pl), but recently lower diagnostic thresholds of dg/pl or even . dg/pl have been suggested. objectives: evaluate the correlation between pem and bleeding scores, and also examine various cut-off values used to diagnose and risk stratify patients with dspd. design/method: retrospective chart review of pediatric patients followed by hematology with a diagnosis of dspd was performed. clinicians obtained bleeding scores for each patient as standard of care in the hemostasis clinic. quartile ranges were established to appropriate three stages of severity based upon bleeding scores. statistical analysis was performed using software r and exploratory data analysis to evaluate for a correlation. results: amongst all patients, the average bat score was . and pem was . dg/pl. the average bleeding score for pem between . dg/pl and dg/pl was . , while the average bleeding score for pem below dg/pl was . . the correlation coefficient between pem and bleeding scores is . . using a threshold of dg/pl, % of patients would have met diagnostic criteria. quartile ranges for the bleeding scores are as follows: st quartile was - , nd quartile was - , and rd quartile was > . conclusion: patients with a more marked granule deficiency do not exhibit a more severe bleeding phenotype, suggesting proper platelet function is not solely determined by granule quantity in these patients. bleeding severity may be more appropriately assessed with bleeding scores rather than pem values, and using quartile ranges may aide in risk stratification and therapeutic interventions for dspd patients. further work remains to determine the optimal diagnostic threshold of pem dspd in pediatric populations. texas children's hospital, houston, texas, united states background: warfarin management has many challenging aspects including pharmacogenomics, food and drug interactions, lack of standardized dosing, patient compliance, tracking lab results from multiple lab locations, and the potential for significant bleeding or thrombotic complications. a literature review revealed limited data highlighting anticoagulation monitoring workflow and emr documentation and specifically, no data in the pediatric population. historically, the texas children's hospital cardiology and hematology centers were each documenting anticoagulation data within the epic tm system differently. epic's tm original design for anticoagulation documenting resulted in the necessity to duplicate documentation in order to see at-a-glance critical anticoagulation monitoring information. objectives: the objective of this project was to standardize inr documentation across departments to reduce the risk of patient safety events and improve workflow. design/method: a workgroup assembled consisting of nurses from the cardiology and hematology departments, along with staff members from the epic tm is support group. the workgroup identified current documentation practices, available epic tm tools, and brainstormed ideas to streamline and improve both documentation with the current epic tm tools. physician partners were identified in cardiology, hematology and coagulation laboratory to gain their input. a new anti-coag (ac) encounter was developed and first made available in an epic tm practice environment, then once approved, epic tm written education and training session were completed by both departments' staff. results: surveys were sent to health care providers in the cardiology and hematology centers prior to the new ac encounter, and also to health care providers six months after implementing the ac encounter. six responses were received for each survey. the pre-implementation survey showed the most problematic part of the documentation system for anticoagulation was no single place in the emr to find a complete anticoagulation picture. post ac encounter implementation survey results revealed more health care providers using the epic tm inr reminder pool, less time needed to compile a report of three months of anticoagulation information, less time needed to document individual encounters, less locations needed to document ac information and decreased amount of types of documentation used. standardized ac encounters improves workflow with less time needed to document and compile information, less types of documentation utilized and easier access to patients ac information. next steps include retrospective review of patients' inr time in therapeutic range to determine if there was an impact on patient compliance and continue to evaluate and modify the ac encounter to enhance user friendliness. caitlin tydings, jennifer meldau, christine guelcher, carole hennessey, eena kapoor, michael guerrera, yaser diab s of s children's national health system, washington, district of columbia, united states background: venous anatomic abnormalities (vaas) are considered a risk factor for developing deep vein thromboses (dvts) that occur as a result of significant alterations in venous blood flow. identification of predisposing vaas can be challenging. hence, diagnosis can be delayed or overlooked especially in pediatric patients. dvts in children or adolescents with predisposing vaas have been only described in sporadic case reports and small case series. objectives: to describe characteristics and outcomes of dvts in pediatric patients with underlying vaa treated at our center. design/method: we conducted a retrospective chart review of all pediatric patients with objectively confirmed extremity dvt treated at our institution over a -year period from to and identified all patients with underlying vaas. patients were managed according to standardized institutional protocols based on published guidelines. post-thrombotic syndrome (pts) was assessed at our center using the manco-johnson instrument. relevant data were collected and summarized using descriptive statistics. during the study period, of pediatric patients ( %) [ females, median age years (range - )] diagnosed with extremity dvt at our center were found to have an underlying vaa. vaas included may-thurner anomaly ( patients), venous thoracic outlet obstruction ( patients) and inferior vena cava (ivc) atresia ( patients). additional provoking factors were identified in patients at time of presentation. dvt locations included upper extremity veins ( patients), lower extremity veins ( patients) and lower extremity veins and ivc ( patients). the majority of dvts [ patients, ( %)] were completely occlusive. high risk thrombophilia (defined as inherited deficiency of antithrombin, protein c, or protein s, or antiphospholipid antibody syndrome) was present in patients ( %). all patients were treated with therapeutic anticoagulation with patients continuing indefinite anticoagulation. endovascular interventions were performed in patients and included percutaneous pharmacomechanical thrombectomy and/or catheter-directed thrombolysis ( patients), balloon angioplasty ( patients) and stent angioplasty ( patients). surgical interventions included thoracic decompressive surgery ( patients) and surgical thrombectomy ( patient vvas represent an important risk factor for developing extensive extremity dvt in adolescents. this special population is at risk for short-term and long-term com-plications. early identification and correction of vaas may improve outcomes. however, multicenter, prospective studies are needed for developing optimal evidence-based treatment approaches. alexander glaros, roland chu, sureyya savasan, meera chitlur, madhvi rajpurkar, yaddanapudi ravindranath children's hospital of michigan, detroit, michigan, united states background: acute budd-chiari syndrome (bcs) is a rare thrombotic emergency in children, and etiologies/treatment are less well-defined than in adults. in adults, a systematic approach including anticoagulation, relief of venous obstruction, and treatment of the underlying cause has proven successful. more recently treatment has tilted towards aggressive surgical interventions, which carry significant risk and are often not feasible. objectives: review our experience with three different patients with bcs and suggest a mechanistic based approach to treatment. the records of three patients with bcs were reviewed and their presentations, etiologies, treatment, and outcomes were reported. results: patient a was a -year-old female with paroxysmal nocturnal hemoglobinuria who presented with recurrent worsening abdominal pain over several months. narrowing of inferior vena cava (ivc) and hepatic veins was noted on imaging. liver transplant was not considered surgically feasible. she was treated with eculizumab, steroids, and anticoagulation with restoration of hepatic venous flow in weeks. patient b was a -year-old male with several weeks of right upper quadrant pain, fatigue, and pre-syncopal episodes, with a history of blunt abdominal trauma from football scrimmage weeks earlier. he was found to have near complete occlusion of the ivc and hepatic veins. liver transplant was not considered feasible. he was successfully treated with anticoagulation alone. patient c was a -yearold male with acute myeloid leukemia in induction cycle who developed severe pancytopenia; typhlitis was diagnosed and managed medically. days later he acutely decompensated, arrested, and was placed on extra corporeal membrane oxygenation, and imaging showed complete occlusion of the portal vein, hepatic veins, and ivc to the level of the atrium, with bilateral pulmonary emboli. emergency liver transplant or catheter based interventions was deemed not feasible. treatment with eculizumab was considered for presumed inflammation induced complement activation (c mg/dl [normal - ]; ch was u/ml [normal - ]) as a trigger for thrombosis, but the patient progressed quickly and died before it could be initiated. our experience with bcs shows that invasive interventional options and liver transplant may not be feasible in most patients for multiple reasons. rapid diagnosis and aggressive etiology-based medical management are paramount to successful treatment of this rare complication. eculizumab may be considered in treating bcs with complement activation not only due to innate disorders, but also secondary to acute inflammation when proper laboratory evidence is present. background: platelet aggregation studies are the gold standard for the diagnosis of platelet function defects during the evaluation of a patient with bleeding problems. the platelet aggregation test measures how well platelets clot in response to different concentrations of epinephrine, adenosine diphosphate (adp), collagen, arachidonic acid and ristocetin. because platelet function defects are often under-recognized and under-diagnosed in the pediatric patient, the true incidence is unknown. we report our experience in the diagnosis of platelet defects at our institution over a -year period in order to add some clarity to the limited pediatric data available. objectives: our primary objective is to document correlations/trends between less well-known platelet function abnormalities and clinically significant bleeding at our institution over a -year period. design/method: after appropriate irb approval obtained, we performed a retrospective chart review of all children who had platelet aggregation testing done from to . data collected included demographics (age, sex, race), personal and family history of bleeding, screening for coagulation defects and platelet aggregation test results. symptoms examined in our data were limited to epistaxis and heavy menstrual periods. for each of these symptoms, results were further analyzed to those with abnormal responses to adp and epinephrine. patients with existing bleeding diagnoses and those with incomplete medical records were excluded. we identified patients. of the patients with epistaxis, % had abnormal platelet aggregation testing while only % of those with heavy menstrual periods had abnormal results. within our population, abnormal platelet function assay (pfa- ) results or race did not appear to correlate with abnormal platelet aggregation testing. in the cases of epistaxis, sex was also noncontributory. our preliminary results suggest that platelet aggregation testing was more useful in predicting platelet defects in those with a clinical bleeding history of epistaxis as opposed to heavy menstrual periods. for other presenting symptoms, platelet aggregation testing did not offer diagnostic benefit. abnormal response to adp in the platelet aggregation test was the most common finding in our population; the clinical significance of which is not well understood. going forward, we plan to document whether abnormal results correlated significantly with the subsequent final diagnoses of our patients. background: decision making for severe hemophilia a in previously untreated patients (pups) has recently become a significant ethical debate. recombinant factor viii (rfviii) products previously were recommended to avoid transmission of blood borne pathogens associated with plasma-derived fviii (pdfviii) products. however, the increased incidence of fviii alloantibody inhibitors with rfviii products compared to pdfviii products has challenged this former standard of care. despite the support of the medical and scientific advisory council, recommendations considering pdfviii products for a pup remains controversial. design/method: we used a modified utilitarian approach involving clinical, public health, and research ethics. shared decision making permeates the framework to maximize understanding, minimize bias, respect informed consent or dissent, and provide care that aligns with patient and family values when medically and practically feasible. the framework has three tiers. first, it evaluates whether resources are scarce or abundant for equitable resource allocation. if fviii products are scarce, we s of s recommend developing a central supply for emergency use and then evaluating the needs of the severe hemophilia a patients. prioritization of who receives the factor products would be decided by a designated team based on the availability of the factor products and clinical scenarios, with no preference given to those on research trials. however, if resources are abundant, treatment for acute bleeding and standard of care prophylaxis measures, including primary prophylaxis, could continue. the second tier accounts for whether there is a new infectious epidemic or concern where a pathogen cannot be eliminated. if there is, healthcare and public health workers may limit the use of pdfviii products. if not, pdfviii and rfviii products are to be equally considered. the third tier evaluates whether the clinical scenario is emergent or not. if there is acute, emergent bleeding, the immediately available resource should be used, along with bypassing and/or adjuvant resources as needed until the bleeding has resolved or improved. to align with patient and family preferences, attempts to have both pdfviii and rfviii products available at similar costs in institutions would be ideal. this ethical framework endeavors to balance autonomy, beneficence, nonmaleficence and justice in helping guide discussions among providers, pups with severe hemophilia a, and their families. disclaimer: findings and conclusions are those of the author(s) and do not necessarily represent the official position of the centers for disease control and prevention, emory university, or children's healthcare of atlanta. background: von willebrand disease (vwd) is a common bleeding disorder which affects up to % of the population without gender predilection. bleeding associated with this condition results from a deficiency or abnormality in von willebrand factor interfering with formation of primary hemostasis. ehlers-danlos syndrome (eds) is a group of rare inherited connective tissue disorders which may have an associated bleeding manifestation without abnormalities in coagulation testing. bleeding symptoms reported in eds result from capillary and tissue fragility. joint hypermobility syndrome (jhs) is an inherited condition which is nearly indistinguishable from eds iii. reports of coinheritance of vwd and eds or jhs are infrequent. the objective of this retrospective study was to review patients with coexisting vwd and eds or jhs at the indiana hemophilia and thrombosis center in order to describe the type and severity of bleeding symptoms, physical examination findings, and pertinent laboratory data. design/method: the electronic medical record database of the indiana hemophilia and thrombosis center was queried for patients with a diagnosis of vwd and one of the following descriptors: hypermobility syndrome, hypermobility, hypermobile joints, or ehlers-danlos syndrome. the records of identified patients were reviewed for demographics, type and severity of bleeding symptoms, beighton scores (bs), vwd antigen, ristocetin cofactor, factor viii levels, vwd multimer pattern, vwd subtype, genetic testing for eds, and family history of eds. results: a total of patients with dual diagnoses of vwd and eds and patients with vwd and hypermobility were identified with this query. two patients had completed genetic testing for eds, and one had a col a gene mutation identified. significant bleeding symptoms in the vwd and eds group included hematuria and postoperative hemorrhage. two of these patients had delayed wound healing postoperatively. seven of the patients identified to have type i vwd and jhs had moderately severe and somewhat unusual bleeding episodes reported including hematuria, hematemesis, and hemoptysis; of these patients had significant perioperative bleeding. females composed % of the vwd and eds group and % of the vwd and jhs group. conclusion: coinheritance of vwd and eds is an uncommon phenomenon. patients with vwd and eds or jhs may have atypical and moderately severe bleeding, especially with procedural intervention. incorporation of bs into the assessment of patients with bleeding disorders is useful to identify potential inherited collagen disorders, as diagnosis of these conditions may impact clinical management. in the year-long phase ii study (ro fd ), / khe patients responded. patients were followed for years after study completion, collecting data on growth and development, complications of therapy, unexpected toxicities, and need for continuing sirolimus. objectives: after study therapy treatment of one year, objectives include: . assess long term toxicity over the - year period after study therapy completion . assess unexpected toxicity . assess overall condition of the patient . assess need for restart or continuation of sirolimus therapy design/method: prospective follow-up of patients with a diagnosis of khe from institutions. inclusion criteria: follow-up for - years post-study. results: follow-up included data at year (n = ) and - . year (n = ) time points. average age at the start of treatment was months. of patients were available for follow up. four patients are no longer on sirolimus: one patient completed study therapy and remains off treatment (ot) ( years), required years of treatment and is now . years ot and required an additional treatment course prior to successful discontinuation now and months ot. of the patients still on sirolimus, all restarted medication for symptoms of pain, swelling and/or edema interfering with quality of life and have made an average of . attempts to discontinue sirolimus. no patient had reoccurrence of kmp. all patients had improvement in clinical and radiologic appearance of khe but all have residual lesions noted on imaging and/or clinical exam. no unexpected toxicity, growth delay, developmental issues or other long term toxicity of sirolimus was noted. conclusion: this is the first prospective data on long-term follow up of khe patients treated with sirolimus. although numbers are small, sirolimus is well tolerated; however, over half the patients were still on medication at - year follow up. this stresses the need for continued long term follow up in these young patients and investigation of the mechanism of sirolimus effect. nationwide children's hospital, columbus, ohio, united states background: recent studies have identified that adult persons with hemophilia (pwh) have a higher prevalence of hypertension and renal disease than the general population. while hematuria is a known complication of hemophilia a and b (ha, hb), its long-term impact on pwh is not currently known. by annually screening our patients with urinalysis, our pediatric center identified that just under half of our patients demonstrated hematuria over a four-year period. motivated by a desire to identify early markers of hypertension and renal disease, we sought to determine if this finding is reflected in the pediatric hemophilia population as a whole. objectives: establish the population-wide prevalence of hematuria in pediatric pwh. design/method: we used the pediatric health information system (phis) database, which contains clinical and resource utilization data for inpatients from hospitals nationwide, to analyze the prevalence of hematuria, hypertension, renal disease and related diagnosis codes in pediatric pwh who were admitted from january to september . results: during the five-year period, , unique pediatric pwh accounted for , admissions. while the majority of admissions were for bleeding or infectious concerns, ( . %) patients had an affiliated admission code for hematuria. for admissions as a whole, the median age was years with % of those admitted being infants, % toddlers, % children, % adolescents, % older than . we identified % of admissions were for ha with the remaining % were for hb. there were ( %) admits in which a bypassing agent was administered. the median length of stay for persons with hematuria was days compared to days for nonhematuria/other bleeding. there were ( . %) admissions with hypertension reported; though, only patients received an antihypertensive medication during that admission. additionally, only ( . %) admissions reported a diagnosis code of renal disease. our study demonstrated that pediatric pwh are experiencing hematuria. in general, only patients with persistent hematuria require hospital admission so we suspect this data underrepresents the numbers of pwh experiencing hematuria that is managed in the outpatient setting. we also suspect that hypertension is grossly underreported and undertreated in pediatric pwh. additionally, there are a low number of patients experiencing renal disease requiring hospital admission among this cohort. given that there is little research into the long-term impact of hematuria in hemophilia, we feel these findings support the need for further vigilance of our pediatric pwh. background: gla and gsd can aggressively destroy bone, with significant impact on morbidity and mortality. the mtor inhibitor, sirolimus has been shown to be effective in the treatment of these diseases. based on the addition of mtor inhibition to bisphosphonate therapy in metastatic cancer therapy, regimens have been used for refractory or high risk gla and gsd but there is heterogeneity of diagnosis, and variability of drug regimens and assessment of effectiveness. objectives: . assess the variability of clinical features of gla and gsd . assess the heterogeneity of diagnosis . assess drug regimens and response assessment across multiple institutions design/method: we conducted a retrospective review from institutions of cases of gla and gsd treated with sirolimus and a bisphosphonate for at least months with assessment of clinical features, treatment protocols, response regimens and side effects. results: patients included gla (n = ) and gsd (n = ). the average age at diagnosis was years. clinical features included effusions: gla (n = ), soft tissue lymphatic malformations: gla (n = ), gsd (n = ), multiple splenic lesions: gla (n = ), and soft tissue swelling at the site of bony lesion: gsd (n = ). the presenting symptom in patients was pain with patients (gla) presenting with shortness of breath. fracture was noted in patients: gla ( ), gsd ( ). diagnostic and/or response imaging included mri, ct, bone scan, skeletal survey and dexa scan. treatment consisted of: initial sirolimus use with the addition of bisphosphonate secondary to worsening disease (n = ), initial therapy with other agents (interferon, chemotherapeutic agents, radiation) and change to sirolimus and bisphosphonate secondary to toxicity (n = ), sirolimus and bisphosphonates (n = ) and sirolimus, bisphosphonates and interferon (n = ). seventeen patients had stable disease and patients had improvement of disease. sirolimus protocol was standard; however, bisphosphonate protocol varied in dosing and frequency. side effects were tolerable and expected with no grade iii or iv toxicity. sirolimus and bisphosphonates are a safe and effective therapy for gsd and gla. a consistent medication regimen, redefined response and an improved radiologic classification will be important for the development of a prospective clinical trial. background: hemophilia a is a bleeding disorder from the deficiency of clotting factor viii. the most significant sequelae of hemophilia a is the tendency to develop hemarthrosis that incites joint destruction. the prevalence of overweight and obesity has been increasing in the general and hemophilia population and leads to several morbidities including arthropathy. this is a particular concern for hemophilia a as arthropathy is a consequence of joint bleeding. objectives: the purpose of this study was to detect the relation between body mass index (bmi) and joint health endpoints in a pediatric hemophilia population. design/method: participants in this study included patients from the hemostasis and thrombosis center at children's hospital los angeles. participants were pre-screened and approached for this study during routine follow-up appointments. patients aged - years old who have been diagnosed with hemophilia a, including mild, moderate, and severe, qualified for the study. informed consent was obtained from the patients or parents before enrollment. joint health was objectively measured by physical therapists from children's hospital los angeles using the hemophilia joint health score (hjhs). an hjhs total score is calculated by assessing: swelling, duration of swelling, muscle atrophy, crepitus on motion, flexion loss, extension loss, joint pain, and muscle strength in major joints. subjective data was also obtained by patients recording their annual bleed rate within the past year. of the patients, ( %) were normal weight, ( %) overweight, and ( %) obese. we used chi-square analysis to compare joint scores across bmi classifications (chi square = . , df = , p-value = . ). although, this did not approach statistical significance, the average hjhs score in patients who had a hjhs > shows an increasing trend among bmi classifications: . in normal bmi patients, . in overweight bmi patients, and . in obese bmi patients. the average number of annual bleeds in those with positive values show: in normal bmi patients, in overweight bmi patients, and in obese bmi patients. although a positive effect of adiposity was found in the joints of hemophilia a pediatric patients, the effect shows there was not enough evidence to conclude a difference. future studies are needed to address whether obesity has an effect on hemophilia and to determine whether overweight/obesity can lead to further complications in hemophilic joints. background: stagnant blood flow in slow-flow vascular malformations (vm), particularly in their venous components, can lead to localized intravascular coagulation (lic) that is characterized by elevated d-dimer levels, low fibrinogen and decreased platelet count this coagulation derangement can lead to localized thrombosis or bleeding which can result in pain, functional limitations, and possible progression to disseminated intravascular coagulopathy (dic). the treatment of vm and their associated coagulopathy has proven difficult. patients with complex vm are frequently managed with sirolimus, an mtor inhibitor, and have clinical benefits, including reduction of pain and improvement in functional impairment. it is possible that some of these improvements from sirolimus could be secondary to improvement in the coexisting lic. objectives: this study assessed the use of sirolimus to manage the coagulopathy seen in slow-flow vm. design/method: we reviewed charts of patients with vm who are followed in the vascular anomalies center at arkansas children's hospital and were started on sirolimus. efficacy was objectively assessed through improvement of ddimer, fibrinogen and platelet count. three sets of lab values (pre-sirolimus, - months post-sirolimus, and most recent) were obtained for each patient when available. we identified a total of patients who had been prescribed sirolimus. eighteen were excluded based on underlying condition other than slow-flow vascular malformation and for inadequate medical records. a total of patients ( combined vascular, venous) were included in the study. all had elevated d-dimer levels (mean . mcg/ml feu, median . mcg/ml feu, range ( . - . )) prior to treatment. two patients had an associated low fibrinogen (below mg/dl), indicating severe lic. with treatment, ( . %) patients showed an overall decrease in d-dimer levels with an average decrease of . mcg/ml feu between pre-and post-sirolimus labs, and an average decrease of . mcg/ml feu between pre-sirolimus and most recent values. the two patients with low fibrinogen prior to treatment showed a decrease in d-dimer levels (mean decrease of . mcg/ml feu) and an increase and normalization in fibrinogen (mean increase . mg/dl) after beginning sirolimus. no patient had thrombocytopenia. we report that treatment with sirolimus was effective in improving coagulopathy associated with slowflow vm as evidenced by decreased d-dimer levels and increased fibrinogen and/or platelets. long-term use of this medication in this population may decrease the bleeding and thrombotic complications that these patients experience, especially following invasive vascular procedures. background: safety and efficacy of bay - , a sitespecifically pegylated b-domain-deleted recombinant factor viii, in previously treated adolescents and adults aged - years with severe hemophilia a was demonstrated in the phase / protect viii study and ongoing extension. objectives: this subanalysis examines the efficacy and safety of bay - in adolescents in protect viii and the ongoing extension study (data cutoff, january ). design/method: in protect viii, patients (including adolescents) received bay - on demand or as prophylaxis for weeks. prophylaxis regimens for weeks - were twice-weekly ( - iu/kg), every- -days ( - iu/kg), or once-weekly ( iu/kg) infusions based on bleeding during a -week run-in period of iu/kg twice-weekly prophylaxis. patients continued their prophylaxis regimens in the extension or changed regimens at any time. results: twelve patients aged - years were included in the protect viii intent-to-treat population; s of s additional patient discontinued after dose (included in safety population). for patients receiving prophylaxis before study enrollment, median (range) number of total and joint bleeds in the months before study entry was . ( - ) and . ( - ), respectively. ten patients ( . %) had target joints at baseline (median [range], [ - ] per patient). during weeks - of protect viii for the entire time patients remained on their designated prophylaxis dosing frequency, the median (quartile [q] ; q ) annualized bleeding rate (abr) for patients receiving twice-weekly (n = ), every- -days (n = ), and once-weekly prophylaxis (n = ) was ( ; . ), . ( ; . ), and . ( ; . ), respectively (overall prophylaxis [n = ], . [ . ; . ]). two patients switched from once-weekly to twice-weekly (n = ) or every- -days prophylaxis (n = ), and number of bleeds decreased from to in one patient and to in the other. all patients from the main study continued in the extension; mean abr in the extension was . and varied by dosing regimen (twice weekly [n = ], . ; every days [n = ], . ; once weekly [n = ], . ). two patients changed from every- -days to once-weekly prophylaxis during extension (mean abr, . ). one patient had a nonneutralizing antibody to bay - at baseline; end-of-study titers were negative. no patient developed anti-peg antibodies or factor viii inhibitors or experienced a serious adverse event related to bay - during the main study or extension. in previously treated adolescents with severe hemophilia a, bay - prophylaxis was effective in prevention of bleeds, with less bleeding overall versus prestudy, and was generally well tolerated. funded by bayer. cincinnati children's hospital medical center, cincinnati, ohio, united states background: vascular malformations (vms) consist of a heterogeneous group of congenital disorders characterized by the abnormal development of blood and/or lymphatic vessels, which cause a broad spectrum of clinical manifestations. although considered benign, vms are frequently associated with cutaneous complications that can cause significant morbidity such as nodular overgrowth, skin thickening, pruritus, oozing or bleeding of lymphatic blebs and secondary infection. oral sirolimus has shown to be effective in the treatment of complicated vascular malformations but has known side effects and need for frequent laboratory monitoring. currently, there are limited studies on the use of topical sirolimus for the treatment of cutaneous manifestations of vascular malformations. objectives: to evaluate the efficacy and safety of topical sirolimus in vms with cutaneous complications and propose indications for use. design/method: this is a retrospective review of medical records of patients with vascular malformations treated with topical sirolimus from january to december . response was determined by subjective and objective improvement. results: twenty-four patients, ( %) females and ( %) males, with vascular malformations and cutaneous manifestations were treated with topical sirolimus. age ranged from - years. indications for treatment were: blebs ( %, n = ) causing either leaking, bleeding, pain, pruritus, swelling or recurrent infection; nodular overgrowth % (n = ); pyogenic granuloma % (n = ); bleeding % (n = ) and cosmetic % (n = ). treatment course ranged from - months. no major side effects were reported. one patient reported burning and itching sensation. regarding clinical response: % (n = ) patients had improvement in cutaneous lesions; % (n = ) had a stable lesions; and % (n = ) stopped treatment due to side effects. for prior/concomitant treatment: % (n = ) had prior surgery, laser or sclerotherapy; % (n = ) had concomitant oral sirolimus. of the patients not receiving concomitant systemic sirolimus, only % (n = / ) had been on oral sirolimus. of these patients, % (n = / ) had a very good response to topical treatment. : topical sirolimus appears to be beneficial and well-tolerated with a minimal side effect profile for the treatment of cutaneous manifestations of vascular malformations as a single agent or as adjuvant therapy with systemic sirolimus when symptoms are not adequately controlled. further studies are needed to prospectively analyze efficacy and safety of topical sirolimus in this patient population. objectives: to evaluate the safety and efficacy of long-term romiplostim in children with itp. design/method: all patients received weekly sc romiplostim from - g/kg to target platelet counts of - × ( )/l. median (min-max) treatment for the patients was ( - ) weeks for a total of patient-years, or . years per patient. at baseline, median (min-max) age was ( - ) years; % were female; . % had prior splenectomy. median (min-max) average weekly dose was . ( . - . ) g/kg, including escalation to a stable dose; patients started on g/kg. reasons for discontinuing romiplostim (n = , %) included consent withdrawn (n = ), required other therapy (n = ), and ae (n = ) (asthenia, headache, dehydration, and vomiting in one patient and anxiety in the other; none treatment related). fifty four serious aes occurred in patients but were treatment related in one (concurrent grade thrombocytopenia, grade epistaxis, and grade anemia). anti-romiplostim neutralizing antibodies were detected in one patient who discontinued to receive other therapy; antibodies were absent on retesting. from week on, median platelet counts remained > × ( )/l; median platelet counts were > × ( )/l from weeks - . nearly all ( %, / ) patients had ≥ platelet response (platelet counts ≥ × ( )/l, excluding ≤ weeks after rescue medication). most ( %, / ) patients had a platelet response ≥ % of the time and % ( / ) did ≥ % of the time. sixty ( %) patients (or caregivers) self-administered romiplostim. fifteen ( %) patients had treatment-free periods of platelet counts ≥ × ( )/l for ≥ weeks (ie, remission); these patients ( girls, boys) had had itp for a median (min-max) of . ( . - ) years, none had prior splenectomy, and had received romiplostim for . ( . - ) years. all had platelet counts > × ( )/l for ≥ months and / for ≥ months; the median (min-max) duration of being ≥ × ( )/l was ( - ) weeks. of baseline characteristics such as sex, platelet counts, itp duration, and number of past itp treatments ( , , , > ), only age < years was predictive of developing treatment-free periods ≥ weeks (p = . ). in this seven-year open-label extension, > % of children with itp achieved a platelet response and romiplostim was well tolerated. importantly, % of patients were able to discontinue all itp medications for ≥ months. funded by amgen inc. background: sirolimus is an immunosuppressive drug that is widely used in solid organ and bone marrow transplantation, and more recently for the treatment of vascular and lymphatic anomalies. sirolimus has been associated with decreased immunity in the transplant setting in patients that have received other immunosuppressive drugs or were immunosuppressed from previous chemotherapy. the effects of sirolimus on the immune system in chemotherapy naïve children who have not received other immunosuppressive agents are not well understood, and there is variability in the approach to fever and pcp prophylaxis. to understand the effects of sirolimus on the immune system of patients with non-complicated vascular or lymphatic anomalies by evaluating anc, alc prior to and after sirolimus therapy. design/method: multi-institutional retrospective review was done to include patients with non-complicated vascular or lymphatic anomalies. those with effusions/ascites, multiorgan involvement, or history of vascular-anomaly-related infections prior to treatment were excluded. results: twenty patients with kaposiform hemangioendothelioma (n = ), generalized lymphatic anomaly (n = ), cloves syndrome ( ), and simple vascular malformation (n = ) were included. age at initiation of sirolimus treatment ranged from . - years. male to female ratio was : . sirolimus was initiated due to extensive disease, lack of response to steroids or bisphosphonates, pain, dment, lymphatic drainage, and prevention of ongoing overgrowth. prior to the start of sirolimus (sir- ) the mean anc was and alc was . the target level of sirolimus varied by indication and patient, and ranged from to . after the st steady state level, month after sirolimus (sir- ) the mean anc decreased to and alc was . at months after sirolimus (sir- ) the mean anc was and alc was . the first sirolimus levels (sir- ) mean was . ; and sir- level was . . nine patients were placed on pcp prophylaxis at the start of sirolimus. none of these patients had an infectious complication while on sirolimus at a median f/u of months. one patient had mild neutropenia (anc > ) which normalized after discontinuation of pjp prophylaxis. conclusion: in this small cohort of patients we found that the anc and alc level in patients with non-complicated vascular or lymphatic anomalies at sir- was not different from the sir- or sir- . prospective studies that specifically track anc, alc, igg, and lymphocyte function should be conducted to better understand the effects of sirolimus in the immune system. this data will allow for uniform recommendations regarding prophylaxis and management of febrile episodes. background: acute infections and the associated systemic inflammation can increase the risk of venous thromboembolism (vte) and in certain well-defined clinical scenarios may be the primary trigger of vte in pediatric patients. pediatric data on vte in the setting of acute infection are sparse. objectives: to describe characteristics and outcomes of vte in pediatric patients with acute infections. we conducted a retrospective chart review of all pediatric patients with objectively confirmed vte treated at our institution since and identified all patients in whom an acute infection was identified as a vte trigger. patients were managed according to standardized institutional protocols based on published guidelines. relevant demographic, clinical and laboratory data were collected and summarized using descriptive statistics. since , acute infection was identified as a trigger in of vtes ( %) diagnosed at our center. the median age at time of vte diagnosis in this group was . years (interquartile range . - ). males were more commonly affected than females, representing % of cases. neonatal vte events accounted for % of cases. sepsis was the most common acute infection to be identified as a vte trigger [ / cases ( %)]. most vte events ( %) associated with acute infections were considered hospital-associated vtes. at time of vte diagnosis, % of patients were critically ill. extensive vte (defined as completely occlusive thrombosis involving > venous segment) occurred in % of patients. acute infection was deemed to be the primary trigger for vte in / patients ( %). infection-associated vtes in this cohort included cerebral sinus venous thrombosis due to sinus or cns infection ( patients, %), septic throm-bophlebitis ( patients, %), lemierre's or lemierre's-like syndrome ( patients, %) and osteomyelitis-associated deep vein thrombosis ( patients, %). systemic anticoagulation was prescribed in / patients ( %). anticoagulationrelated major bleeding occurred in / patients ( %). vte complications included vte recurrence ( patients, %), vte progression ( patient), acute pulmonary embolism ( patients) and arterial ischemic stroke ( patients). our study indicates that acute infection is a common risk factor for pediatric vte, especially in critically ill children, and can be the primary trigger in a significant proportion of vte cases associated with acute infections. anticoagulation appeared to be overall safe in this population and was associated with low rates of serious vte-related acute complications. however, our study also suggests that this population may be at increased risk for vte recurrence and anticoagulation-related major bleeding. background: epithelioid hemangiomas (eh) are rare benign vascular tumors that occur in soft tissues and bone and present between the third and sixth decades of life. a subset ( %) of eh harbor fos rearrangement. eh has been described in children, but little is known about the long-term outcomes of pediatric eh. the main objective is to obtain data to be used for improved understanding of this rare disease in order to provide standardization of care and development of future research studies. board-approved retrospective review of clinical, pathologic, and radiographic characteristics, and treatment outcomes in patients diagnosed with eh between and . results: eight patients were male; mean age at diagnosis was . years (range: - ). lesions involved the lower extremities (n = ), cranium (n = ), pelvis (n = ), and spine (n = ). multifocal disease was identified in five patients. the most common presentations involved significant localized pain and neurologic symptoms: headache, cranial nerve injury, loss of consciousness. radiographic studies identified variable features, such as multifocal lytic bony lesions with sclerotic margins, enhancing soft tissue component, and surrounding inflammatory edema. histologically, all specimens were composed of vascular channels lined by epithelioid endothelial cells without significant cytologic atypia; solid cellular areas (n = ). endothelial cells were positive for cd and egr, and negative for camta . fos rearrangement was assessed in only one specimen and detected. mean follow-up time was days (range: - ). patients were treated with surgical resection, intravascular embolization, bisphosphonates, propranolol, interferon, and sirolimus. one patient treated with interferon and one with sirolimus exhibited partial response for mean follow-up of . days. although eh is a benign neoplasm, it is difficult to manage without standard protocols and portends considerable morbidity. our findings suggest medical management, particularly sirolimus, may benefit these patients; however, long-term follow-up is needed in treated children. novel fos inhibitors are in development and may benefit patients with fos rearrangement. penn state health children's hospital, hershey, pennsylvania, united states background: central venous catheters (cvc) are often required in critical care settings in order to provide a secure point of access for life sustaining care. clinical studies identify cvc presence as the single most important risk factor for deep vein thrombosis (dvt) in children. venous thromboembolic event (vte) incidence rates in critically ill children with a cvc range from . - % and . - . per catheter days depending on the population studied. per institutional protocol, the penn state health children's hospital picu (hershey, pa) utilizes a low dose continuous infusion of unfractionated heparin (ldufh) at units/kg/hr as prophylaxis against cvc-related vte and to maintain line patency. the efficacy of this approach has never been evaluated. to determine if ldufh for prophylaxis results in lower incidence of cvc-related vte, catheter dysfunction and central line associated blood stream infection (clabsi) without increasing morbidities. to determine if the incidence of catheter related vte is lower than historical published data, a retrospective chart review was conducted utilizing the institutional electronic medical record for all patients in , aged - . years, who had a cvc during a picu admission. secondary objectives such as the incidence of catheter dysfunction, clabsi, and any associated bleeding complications are also being analyzed. results: interim data analysis revealed cvcs ( nontunneled cvc, totally implantable devices, tunneled lines, peripherally inserted central catheters [picc] ) in total patients with a median age of . years. overall vte incidence was . % ( / ) with vtes associated with non-tunneled cvc and with piccs. sixty one percent of non-tunneled cvcs received ldufh and % ( / ) of the patients with vtes associated with non-tunneled cvcs did receive ldufh prophylaxis. vte incidence rate of nontunneled cvcs with ldufh was . % ( / ) and . per picu catheter days. the only other vte events identified within our study cohort were in the picc group where two patients experienced vte, one of which was receiving ldufh. clabsi incidence was . % ( non-tunneled cvc, tunnel cvc, picc). no major bleeding complications were associated with ldufh. preliminary data demonstrates ldufh is efficacious in preventing cvc-related vte in comparison to published reports. further analysis will compare another similar sized and acuity level picu which does not practice the same method. background: fibroadipose vascular anomaly (fava) is a rare, challenging disorder associated with pik ca mutations. fava often causes painful replacement of muscle and soft tissues with fibrotic and adipose tissue and is associated with ectatic draining veins. treatments for focal lesions are surgical excision, cryoablation or sclerotherapy and the role of medical therapy is unclear. some fava lesions are too extensive or directly involve neurovascular structure, resulting in refractory pain. objectives: to retrospectively evaluate the efficacy of sirolimus in patient with residual symptoms after procedural therapies for fava design/method: retrospective review of individual cases from institutions of fava refractory to other therapies treated with sirolimus for at least months. cases were s of s identified by polling member of the aspho vascular anomalies special interest group. results: all seven patients report improvement on sirolimus therapy. all patients had received prior procedures, including sclerotherapy ( patients), cryoablation ( patients) and/or resection ( patients). mean age at sirolimus initiation was y (range - y). mean length of therapy is . months (range - months). six patients were treated with bid dosing and one adult received daily dosing. goals of sirolimus were improvement in pain or musculoskeletal dysfunction. pain and function improved in all patients, including discontinuation of narcotic use and resumption of participation in sports. time to symptom improvement ranged from - weeks. in four patients for whom dose was lowered, pain recurred in all four and responded to restarting or increasing sirolimus dose. while all patients do not have pre-and postsirolimus imaging, decrease in fava lesion size is seen in cases with available imaging. sirolimus side effects are similar to prior reports, most commonly mouth sores, elevated lipids and acne. we report the first known data supporting a role of sirolimus in refractory fava cases. sirolimus is welltolerated and initial improvement is rapid, within weeks of initiation. whether sirolimus has a role in upfront therapy to reduce lesion size prior to procedures deserves further study. objectives: to assess platelet responses in children with itp receiving romiplostim. design/method: eligible children had itp for ≥ months, ≥ prior therapy, and screening platelet counts ≤ × ( )/l or uncontrolled bleeding. weekly dosing was from - g/kg to target platelet counts of - × ( )/l. bone marrow biopsies were evaluated in europe at baseline and after or years (cohorts and ). as of mar , patients received ≥ dose. at baseline, median (min-max) age was ( - ) years, itp duration was . ( . - . ) years, and platelet count was ( - ) × ( )/l; patients ( %) had had prior splenectomy. the median (q , q ) % time with a platelet response (platelet count ≥ × ( )/l, no rescue medications past weeks) in months - was % ( %, %) (primary endpoint). over the course of the study, % ( / ) of patients had a platelet response. four patients maintained platelet counts ≥ × ( )/l with no itp medications for ≥ weeks. median (min-max) treatment duration was ( - ) weeks for patient-years in total. median (min-max) average weekly romiplostim dose over the course of the study was . ( . - . ) g/kg; the median dose was g/kg at year (n = ) and g/kg at years (n = ). most ( %) patients initiated self-administration. sixty-four patients ( %) discontinued treatment, most frequently for lack of efficacy (n = ), patient request (n = ), and adverse event (ae) (n = ). fortyone ( %) patients had serious aes (saes) including epistaxis ( %) and decreased platelet count ( %). five patients had treatment-related saes: headaches, abdominal pain, and each of presyncope and neutralizing antibodies (ab). there were cases of neutralizing ab to romiplostim (of patients tested), but none to tpo; / had continued elevated platelet counts and in / cases ab were not found on retesting. for cohort , of patients with baseline bone marrow biopsies, had evaluable on-study biopsies scheduled for year; patient had an increase from grade to . there were no findings of collagen or abnormalities. in this interim datacut of a romiplostim openlabel study in children with itp, % of children had a platelet response. overall, the median dose was . g/kg; the median romiplostim dose over time reached g/kg. no new safety signals were observed over patient-years. funded by amgen inc. background: hepatic hemangiomas are benign vascular tumors without a medical home, managed by multiple specialties. the diagnosis has been assigned historically to various vascular lesions affecting the liver with completely different clinical presentations, resulting in difficult standardized management. objectives: the consensus steering committee identified an acute need of clear definitions and evaluation guidelines using the updated international society for the study of vascular anomalies (issva) classification. the goal was to formulate recommendations that will be adopted by all specialties involved in the care of children with hepatic hemangiomas. design/method: we used a rigorous, transparent consensus protocol, with input from multiple pediatric experts in vascular anomalies from hematology-oncology, surgery, pathology, radiology and gastroenterology. in the first section, we precisely define the subtypes of hepatic hemangiomas seen in children (congenital and infantile) using clinical course, histology and radiologic characteristics. inclusion and exclusion limits to the diagnosis are noted. the following two sections describe these subtypes in further detail, including complications to be considered during monitoring and respectively recommended screening evaluations. conclusion: while institutional variations may exist for specific clinical details, a clear understanding of the diagnosis of hepatic hemangiomas affecting the pediatric population and the possible complications that require screening during the monitoring period should be standard. as patients with hepatic hemangiomas are managed by different medical and surgical specialties, a multidisciplinary consensus based on current literature, on the data extracted from the liver hemangioma registry and on expert opinion was required and was accomplished by this manuscript. objectives: to investigate the association between routine prophylaxis with bay - and bleeding outcomes after adjusting for key patient and pharmacokinetic (pk) characteristics. design/method: the leopold kids study evaluated safety and efficacy of bay - prophylaxis in previously treated boys aged ≤ years with severe hemophilia a. patients received bay - - iu/kg x/wk (n = ) or > x/wk (n = ) and were followed up for - months. prophylaxis dose and frequency were assigned by investigators. pk parameters, including area under the curve (auc), half-life, and clearance, were derived from a population pk model and reflect predicted pk values with a -iu/kg dose. patient characteristics were compared between the x/wk and > x/wk groups using wilcoxon rank sum or chi-square tests. negative binomial regression was used to model the association between prophylaxis frequency and annualized bleeding rate (abr) for total bleeds, first without adjustment and then adjusting for age, pk parameters, and bleed history. results: mean ± sd age for patients in this analysis was . ± . years. patients receiving prophylaxis x/wk had more bleeding episodes in the months before study entry (mean ± sd, . ± . [median, . ] for x/wk vs . ± . [ . ] for > x/wk; p = . ) and were more likely to have been treated on demand ( % vs %; p = . ). pk parameters were similar between the x/wk and > x/wk groups. without adjustments, abr during the study was % higher in the x/wk group compared with the > x/wk group (rate ratio [rr], . ; % ci, . - . ; p = . ). abr was % lower in the x/wk group (rr, . ; % ci, . - . ; p = . ) after adjusting for age, auc, and number of bleeds in the prior months. conclusion: abr was numerically lower but not significantly different between the x/wk and > x/wk groups after adjusting for age and pk parameters. these findings suggest that even among patient groups that are homogeneous with respect to age, pk, and bleed history, further individualization of bay - prophylaxis based on other characteristics may help reduce bleeding episodes even at a lower treatment frequency. larger real-world studies are needed to verify these findings. funded by bayer. stanford, palo alto, california, united states s of s background: vascular malformations may be of lymphatic, arterial, venous or capillary endothelial origin. they may be simple or complex, with complex malformations being a combination soft tissue and skeletal overgrowth. although likely present at birth, these malformations often become symptomatic with puberty or infection, and range from little or no clinical impact to life threatening symptoms. in malformations primarily of venous origin, pain may be significant and hypothesized to be caused by phlebolith development (intra-malformation thrombi), inflammation, consumptive coagulopathy, vascular engorgement, and endothelial proliferation. anti-angiogenic and anti-platelet therapies have been reported to relieve pain. however, the use of anticoagulation for pain is not well described. objectives: to report clinical features and outcomes of patients with vascular malformations of venous origin treated with anticoagulation for pain. we performed a retrospective review of patients with vascular malformations followed by the hematology service between january and december who were treated for pain with anticoagulation. pain relief was determined both by wong-baker pain scales and patient report. clinical data were extracted from electronic medical records. we identified five patients with venous malformations (vm) who had received anticoagulation for pain. four patients were female and median age was years old (range to years old) at time of initiation of anticoagulation. all five patients had vm of the extremity, two with vm of the lower extremity, and three patients had vm of the upper extremity. two patients had concomitant coagulopathy and demonstrated decreased d-dimer after initiation of anticoagulation. four patients received enoxaparin, and one adult patient received rivaroxaban. all patients reported improvement in pain after administration of anticoagulation. one patient exhibited mild epistaxis and bruising at the injection site. there was no significant bleeding or other complications. pain is a significant complication in patients with venous malformations. our case series suggests that anticoagulation is a safe and effective therapy for pain relief in this population. further investigation is indicated to compare the effect of anticoagulation to other therapeutic interventions such sclerotherapy, surgery, and sirolimus in the treatment of pain associated with venous malformation. maria ahmad-nabi, christine knoll, sanjay shah, lucia mirea phoenix children's hospital, phoenix, arizona, united states background: estimates of the incidence of dvt in patients with osteomyelitis range widely from %- %, however risk factors and outcomes of dvt in this cohort have not been thoroughly established. objectives: this study aims to estimate the incidence of dvt in patients with osteomyelitis, and to assess risk factors and outcomes of dvt in this cohort. design/method: after irb approval, a retrospective chart review was conducted for patients aged - years seen at phoenix children's hospital between - with icd / codes for osteomyelitis. exclusion criteria included chronic recurrent multifocal osteomyelitis, and chronic dvt. demographics, clinical factors and outcomes were compared between osteomyelitis patients with and without dvt using the fisher-exact and wilcoxon-rank sum tests, as appropriate for the data distribution. results: a total of study subjects with osteomyelitis had a mean (standard deviation) age of . ( . ) years. dvt was present in ( % of ) patients, and ( %), ( %) and ( %) patients received anticoagulation for < , - and ≥ weeks, respectively. patients with vs without dvt were more likely to be male ( % vs %; p-value = . ), and had significantly higher rates of bacteremia ( % vs %; p-value = . ). rates of central lines were comparable between dvt and non-dvt patients ( % vs %; p-value = . ); however patients with dvt vs without dvt had significantly longer mean length of stay ( vs days; p-value < . ) and higher rates of icu admission ( % vs %; p-value < . ). the incidence of dvt among osteomyelitis pediatric patients was estimated at %, with risk increased by male sex and bacteremia. patients with dvt had significantly higher rates of icu admission and longer length of hospital stay. many of these patients had standard practice management of their dvt with - weeks of anticoagulation. our data highlights the need for recognition of high risk patients, and the need for future efforts targeting dvt prophylaxis. baylor college of medicine, houston, texas, united states background: lymphatic malformations (lm) frequently occur in the head and neck and can often be disfiguring and even life-threatening. management options include observation, surgery, sclerotherapy, and sirolimus. the optimal sequence of therapeutic interventions has not been determined due to the lack of comparative clinical trials or established guidelines. thus, prenatal planning with a multidisciplinary team is beneficial. we present a case series of ten children with head and neck lms evaluated in at our multidisciplinary vascular anomalies center. a chart review was performed to assess treatment modalities and recent trends. results: seven of patients ( %) with head and neck lms were diagnosed prenatally. six patients required an ex utero intrapartum treatment procedure. all patients were started on sirolimus at a median age of . months (range days - years). four patients most recently started on sirolimus were less than months of age at the time of initiation. six patients underwent partial excision of lm during the first year of life; none of whom received sirolimus prior to surgery. sirolimus was discontinued in one patient given chronic clostridium difficile infections, and non-compliance in another patient. five patients received sclerotherapy. tracheostomy was necessary in six patients; one patient was de-cannulated after months on sirolimus. all patients have had radiographic and clinical improvement of lm with varying treatment modalities. current clinical observations show improved response with sirolimus and demonstrate tolerability of sirolimus at a young age. conclusion: treatment of pediatric head and neck lms is challenging and a multidisciplinary approach is necessary. as the majority of patients are diagnosed prenatally, prenatal planning and discussion of potential use of sirolimus is beneficial. availability of vascular anomalies experts in the prenatal/neonatal period offers the best management results, and early initiation of sirolimus should be considered for complex lesions. long-term follow up is warranted to investigate the efficacy and timing of treatment options. yale school of medicine, new haven, connecticut, united states background: to mitigate transfusion of pathogencontaminated platelets, amotosalen, a synthetic psoralen compound, is added to sdp components. exposure to uv-a light activates amotosalen and crosslinks dna/rna base pairs, preventing replication of a broad spectrum of viral, bacterial, and other pathogens that may contaminate platelets. pr-sdps were fda approved for clinical use with no age restrictions in . we initiated use of pr-sdps in november of for all patients. we retrospectively analyzed usage of pr-sdp vs conventional (non-pr) platelets (cp) in neonatal and pediatric patients with thrombocytopenia to compare hemostatic efficacy and the incidence of transfusion reactions (tr) for these products, after one year of a dual platelet inventory. design/method: since pr-sdp were fda-licensed, no irb approval was required; pr-sdp and cp were both considered standard of care. we evaluated transfusions for all pediatric patients age - years who received any platelet transfusion between november and november . we determined the volume (mean ml ± sd) of each type of platelet component transfused, the number of platelet transfusion episodes, and reported trs based on cdc hemovigilance guidelines. a subgroup analysis was performed for thrombocytopenic neonates ( - months). results: patients - years who received only cps (n = ) received a total of , ml of platelets ( ± ml/patient) over transfusions ( . ± . episodes/patient). for comparison, in patients who received only pr-sdp, a total of , ml of platelets ( ± ml/patient, p = . ) were infused over transfusions ( . ± . episodes/patient, p = . ). for neonates ( - months, n = ) who received only cps, , ml of cps ( ± ml/ patient) were transfused over episodes ( . ± . episodes/patient). for comparison, those who received only pr-sdp (n = ), received , ml of pr-sdp ( ± ml/patient, p = . ), transfused over episodes ( . ± . episodes/patient, p = . ). for all recipients - years (n = ), including additional patients who received both cp and pr-sdp, there were three reported allergic trs over transfusion episodes, while no allergic reactions were reported with pr-sdp transfusions. one febrile tr was reported to cp transfusion, while three were reported for pr-sdp. in conclusion, pr-sdps, in our pediatric population age - years, were comparable to cp products in regards to volume and episodes of platelet transfusions, and incidence/type of transfusion reactions. pr-sdp were safe and effective for use in this pediatric patient population. background: vascular anomalies are classified as either vascular tumors or vascular malformations. fibro-adipose vascular anomaly (fava) is a newly described entity which presents with distinct clinical, radiographic and histopathologic findings. we present a case in which the diagnosis of fava was complicated by a persistent low platelet count secondary to immune thrombocytopenia (itp). to describe a challenging diagnosis of a novel vascular anomaly (fava) complicated by severe thrombocytopenia. a year old male presented to hospital with bruising and left thigh pain related to a remote sports injury. blood work revealed a platelet count of × /l, but with an otherwise normal complete blood count. the following were also normal: aptt and fibrinogen; d dimer levels were slightly increased. he was treated with one dose of ivig ( . mg/kg) for presumed itp and responded well with his platelet count increasing to × /l. he returned to hospital weeks later with recurrent thrombocytopenia and worsening leg pain. an ultrasound of the left thigh revealed a . cm x . cm x . cm lesion within the vastus medialis. the diagnosis of an intramuscular hematoma secondary to persistent thrombocytopenia was made. the patient presented with multiple episodes of thrombocytopenia over the next several months. his itp did not respond to oral prednisone ( mg/day for days). he continued to have short-lived responses to ivig requiring infusions every other week as his platelet count would fall below × /l. his leg pain progressed, restricting him to a wheelchair. further imaging by mri brought into question the diagnosis of a hematoma and a biopsy of the thigh lesion was performed. the results were consistent with a diagnosis of fava; this was subsequently excised. conclusion: this is a unique case where a vascular anomaly was misdiagnosed as a hematoma due to a patient's persistent thrombocytopenia and history of an injury. fava is a newer entity which, unlike other vascular anomalies, has not been linked to thrombocytopenia or a localized consumptive coagulopathy. after excision of the fava, the patient's chronic pain, and mobility resolved, though his itp persisted. objectives: this preliminary, exploratory analysis of realworld administrative data was conducted to determine units dispensed and factor replacement product-related direct expenditures associated with a currently marketed shl or ehl rfix product. design/method: de-identified claims data from the commercially available truven health marketscan® research u.s. claims database were used to identify direct expenditures and number of international units (ius) dispensed for all patients aged - years with a diagnosis code of icd- . /icd- d who used nonacog alfa or eftrenonacog alfa during the study period (june , to july , ). reference weight measurements from the centers for disease control and prevention national center for health statistics' (cdc nchs) anthropometric data were used to estimate product dispensation on an iu per kg basis. the nonacog alfa and eftrenonacog groups comprised and patients, respectively. the median [iqr] age in the two groups was . [ . ] and . [ . ] years, respectively. while of the patients in the eftrenonacog alfa group had > calendar quarter of available data, only of the patients in the nonacog alfa group had > available quarter. the median rfix product dispensation per quarter was , ius (iqr, , ius) in the nonacog alfa group and , ius (iqr, , ius) in the eftrenonacog alfa group. incorporating attributed weight values, the median rfix product iu dispensation per kg per week was . iu/kg/wk (iqr, . iu/kg/wk- . iu/kg/wk) in the nonacog alfa group, and . iu/kg/wk (iqr, . - . iu/kg/wk) in the eftrenonacog alfa group. applying wac prices (eftrenonacog alfa = $ . /iu; nonacog alfa = $ . /iu), the calculated estimates of $/kg/week were $ and $ in the nonacog alfa and eftranonacog alfa groups, respectively. conclusion: preliminary real-world data derived from a large u.s. claims database revealed differences in product dispensation and factor product-related expenditures among pediatric patients with any severity of hemophilia b to whom an shl or ehl rfix product was prescribed. refinements of these data, potentially to exclude instances of sporadic usage, may shed light on real-world dispensation of rfix products among pediatric hemophilia b patients. background: vascular malformations can be classified as simple (including capillary, venous, lymphatic, arteriovenous), combined, malformations of major named vessels or associated with other anomalies. multiple modalities including laser treatments, sclerotherapy, embolization, surgery and pharmacological intervention (with mtor inhibitors like sirolimus) have been used for treatment of vascular malformations. these interventions have been used alone or in combination with varied outcomes. we present our institution's experience with a multimodal approach to simple and combined vascular malformations. design/method: we performed a retrospective chart review of patients with vascular malformations who were referred to our center for an interventional radiology evaluation from june -july . we included patients (age at presentation: months - years), referred initially for interventional radiology procedures (irp) for vascular malformations. all patients had symptoms of pain and/or swelling/deformity. diagnosis of was based on vascular imaging (doppler ultrasound, mri/a/v). nine patients had venous malformations (vm), five had macrocystic lymphatic malformations (lm), six had lymphatic-venous malformations (lvm), and two arteriovenous malformations (avm). patients initially underwent interventional radiology procedures. all the vm patients responded to sclerotherapy alone. three patients with lm responded to sclerotherapy alone, remainder required surgical intervention. one avm patient responded well to embolization, the other needed surgical resection after embolization. four lvm patients underwent irp with minimal improvement in symptoms ( - procedures attempted), surgical resection was attempted in patients with poor response and patients were started on sirolimus ( . mg/m /dose twice a day). all lvm patients started on sirolimus have responded well (decreased pain and swelling); time to initial symptom response ranged from weeks - month from starting medication. in this case series, patients with simple vm responded well to sclerotherapy alone, avm and lm patients needed irp and/or surgery for complete response. complex lvm did not respond well to surgery or irp; . % had improvement in clinical symptoms with addition of sirolimus to the treatment regimen. response to various modalities of treatment varied based on the type of vascular malformation. a multidisciplinary approach to management of vascular malformations is essential to provide multimodal therapeutic options for rapid symptom relief and improve the quality of life of these fragile patients, especially those with complex malformations. background: von willebrand disease (vwd) is the most common bleeding disorder in humans, affecting ∼ % of the united states' population. desmopressin (ddavp) is a longacting vasopressin analog that induces vasoconstriction and release of vwf. ddavp is used in patients with vwd and as a surgical prophylaxis, but carries anti-diuretic properties. to avoid electrolyte imbalance and hyponatremia, fluid restrictions are recommended in the hours post-ddavp administration. objectives: this study sought to examine perioperative practices and outcomes following ddavp administration and a fluid restriction protocol in a population of pediatric patients with von willebrand disease. design/method: a retrospective chart review was conducted for patients with von willebrand disease who underwent surgical procedures at children's hospital of pittsburgh of upmc between january , and december , . patient age, sex, weight, diagnosis, surgical procedure, total fluids administered, and post-operative sodium level were recorded. the primary outcomes noted were the proportion of patients exceeding % of the recommended fluid consumption for the -and -hour periods post-ddavp s of s administration, as defined by local guidelines. secondary outcomes were the presence of any bleeding requiring an er visit or readmission or hyponatremic seizures within hours of ddavp administration. results: data was compiled for patients ( females, males). the mean age was . years (sd . years), median age was years (range to years). procedures included dental ( ), otolaryngology ( ), orthopedics ( ), gastrointestinal ( ), plastics ( ), neurosurgery ( ), ophthalmology ( ), dermatology ( ), general surgery ( ) and gynecology ( ). % of patients exceeded % of the fluid volume recommended for the first -hour period post-ddavp administration while still in the surgical setting. no patients exceeded % of the fluid volume recommended for the total -hour period post-ddavp administration. post-operative sodium levels were obtained in only of patients. no patients returned to the er or were admitted for bleeding in the hours post-ddavp administration. no patients returned to the er or were admitted for hyponatremia or seizures in the hours post-ddavp administration. maintenance of a fluid restriction protocol effectively deterred negative outcomes in this cohort. however, a significant fluid volume was administered in nearly a third of patients despite the restrictions. given the risk of hyponatremia, and limited compliance with fluid restrictions, postoperative sodium levels should be recorded in following ddavp administration to assess the possibility of a hyponatremia and to reinforce the importance of fluid restrictions and their communication. results: a male fetus required in utero insertion of a pleuroamniotic shunt for bilateral pleural effusions diagnosed antenatally by ultrasound. shortly after delivery at term, he developed respiratory distress and was found to have reaccumulation of the pleural effusions. blood work on day of life showed a platelet count of , / l, which then decreased precipitously. he demonstrated schistocytes on blood-smear, signs of consumptive coagulopathy with hypofibrinogenemia and high d-dimers, and compensatory reticulocytosis. he required multiple transfusions and admissions to the intensive care unit for respiratory support. investigations ruled out congenital ttp, neonatal alloimmune thrombocytopenia, and noonan syndrome. given high clinical suspicion for an underlying vascular lesion causing kmp, a full body mri without contrast was undertaken. this showed a focal area of suspicious signal intensity in the upper paraspinal musculature. an ultrasound and mri with contrast demonstrated an extensive infiltrative vascular lesion involving the paraspinal musculature, prevertebral space, posterior extrapleural space, mediastinum, and neck. the child was commenced on prednisone ( mg/kg/day) and rapamycin ( . mg/m twice/day). there was no clinical or laboratory improvement after one month. a biopsy was performed which confirmed khe. in the second month of rapamycin therapy, the platelet count gradually normalized and the patient was discharged from hospital at . -months of life. prednisone was weaned off at . months of life. a repeat mri at months showed significant reduction in the khe. he is now almost years into therapy and doing well. conclusion: this is a unique case of khe with kmp that initially presented with extensive and recurrent pleural and pericardial effusions. this case demonstrates the importance of suspecting an underlying vascular malformation in the presence of kmp. our patient had a delayed but overall good response to rapamycin. further studies investigating duration of rapamycin therapy is key for the optimal management of these patients. rosa diaz, donald mahoney, lakshmi srivaths, donald yee texas children's hospital, houston, texas, united states background: since von willebrand disease (vwd) is the most common inherited bleeding disorder, it must co-exist with other less common bleeding disorders in some dually affected patients. however, reports of combined deficiencies in factor viii (fviii) and von willebrand factor (vwf) are rare. objectives: to study the prevalence and bleeding phenotype of combined deficiencies of fviii and vwf in males with hemophilia a in a hemophilia treatment center. design/method: we retrospectively reviewed the electronic medical records of males with hemophilia a followed at our institution during the past years. the primary and secondary outcomes for the study were ( ) the prevalence of combined fviii and vwf deficiencies and ( ) the bleeding phenotype of these patients. we identified vwf deficiencies in % (n = ) of the patients with hemophilia a. most (n = , %) patients were tested for vwf deficiency as part of the initial hemostatic evaluation, but one-third were tested due to clinical concern for inadequate response to fviii concentrate. the median duration of follow up was . years (range . to . ). patients were referred to our clinic at a median age of months (range to years) for evaluation of easy bruising (n = , %), mucosal (n = , %) and surgical bleeding (n = , %). primary diagnoses included with severe, moderate and mild discrepant hemophilia a. secondary diagnoses included with low vwf activity, type vwd and with type unclassified. patients experienced episodes of musculoskeletal (n = , %), mucocutaneous (n = , %) and cns bleeding (n = , %). a total of patients received factor prophylaxis. half of the patients were initially treated with fviii concentrates but subsequently changed to combined fviii/vwf products due to the frequency of breakthrough bleeding despite good compliance. all patients are on combined fviii/vwf products at the time of this review. a total of ( %) of this cohort developed chronic joint disease manifest as decreased range of motion and/or abnormal mri findings. combined deficiencies of fviii and vwf were present in % of our center's hemophilia patients. these patients exhibited a severe bleeding phenotype as evidenced by the high frequency of hemarthrosis, need for prophylaxis and high prevalence of chronic joint disease. while the optimal treatment strategy remains to be elucidated, early recognition of a combined deficiency may have important clinical implications, particularly in patients who demonstrate a suboptimal response to fviii concentrate alone. background: childhood neutropenia is heterogeneous and may be congenital or acquired. cerebral cavernous malformation (ccm ) is a neurovascular malformation disorder where lesions consist of low flow, dilated capillary endothelial channels with increased permeability, predisposing to hemorrhage and thrombosis. programmed cell death protein (pdcd ) activity has been implicated in glia and neuron migration, and recently linked to the dysregulation of the actin and microtubule cytoskeleton, thereby affecting cellular morphology and migration. variants of pdcd encoding pdcd have been associated with ccm . ccm causes a greater and earlier disease burden than other ccms, with % presenting younger than years. some patients have associated extra-neuronal manifestations, suggesting that pdcd plays a role in other tissues. we describe a patient with significant blood cytopenias associated with ccm . design/method: retrospective chart review to obtain patient data. results: an -month old female presented with seizure and was found to have multiple intracranial cystic lesions and abscesses due to s. pneumonia serotype f. during her treatment, she developed anemia (hemoglobin . - . g/dl), thrombocytopenia (platelets , - , cells/l), and profound neutropenia (absolute neutrophil counts of zero). initial bone marrow evaluation revealed a normocellular marrow but with marked granulocytic hypoplasia and % hematogones on flow cytometry. florescent in situ hybridization excluded cytogenetic changes characteristic of myelodysplastic syndrome. further evaluation included testing for neutrophil antibodies, chromosome breakage, and telomere length and results were normal. whole exome sequencing excluded mutations affecting congenital neutropenia genes, but detected a de novo pdcd variant (c. + g>a), thereby diagnosing ccm . the neutropenia has responded well to granulocyte colony stimulation factor (gcsf), which is still needed at months of age. moreover, the thrombocytopenia has progressed, requiring periodic platelet transfusions. over time, the bone marrow hematogone population has decreased to % at months of age, though the granulocytic hypoplasia persists. conclusion: our case describes the first patient with neutropenia and thrombocytopenia associated with ccm . we hypothesize the pdcd variant is the etiology of bone marrow dysfunction due to its role in actin and microtubule cytoskeleton formation, akin to the pathophysiology of xlinked neutropenia. supportive features of an underlying genetic cause of marrow dysfunction include the persistence of cytopenias beyond infection resolution as well as presence of hematogones. hematogones were previously reported to occur in patients with other congenital neutropenia disorders, indicating they could be a feature of congenital neutropenia and may be reactive to surrounding cell apoptosis. further testing of pdcd role in hematopoiesis should be explored. background: - % of adult women will suffer from heavy menstrual bleeding (hmb) during their lifetime. % of women with inherited bleeding disorders suffer from hmb. there is a paucity of data about hmb among adolescents and young adults (aya), a population in which hmb may have large social and educational effects. objectives: to study the social and academic implications of hmb in an aya population. design/method: this is a questionnaire based survey conducted in a medium-sized city in california. we recruited females - years of age from one high school and from local university. the questionnaire was set up in research electronic data capture (redcap) at our institute which allowed us to obtain objective data about the respondents' menstrual cycles. a link was sent to the high school students via their online portal schoolloop and to the university students via social media and word of mouth. data was collected over weeks from may to august . we received replies, some were not complete. using regression analysis, data was analyzed from respondents in the age group of - (with a mean age of ) years. we developed a composite score for hmb based on factors including saturation levels, number of pads, duration of bleeding, soaking of a pad within two hours, passage of clots, size and number of clots, and gushing sensation. we conducted statistical analysis of the drivers and implications of hmb based on the composite score. results indicate that having a relative with hmb, having other bleeding problems, and having anemia are drivers of higher hmb score. the results also indicate that hmb adversely affects quality of life as measured by participation in sports, social activities, after-school activities, tiredness, absenteeism, and gpa. hmb is also associated with increased rates of anemia and use of anti-depressants. hmb-driven anemia further adversely affects gpa. under-represented minorities are more likely to have a higher hmb score, as well as an increased adverse effect of hmb on gpa. the results suggest that the social costs of hmb are pervasive in the aya population, and especially pronounced among minorities. a relative with hmb is a significant driver of heavy menstrual bleeding. a hemostatic screen should be included when assessing the aya population with hmb. johns hopkins all children 's hospital, st. petersburg, florida, united states background: propranolol is a non-cardioselective beta blocker medication frequently prescribed for hemangiomas and hyperthyroidism. propranolol inhibits types i and ii iodothyronine deiodinases, enzymes that convert bioinactive thyroxine (t ) into bioactive triiodothyronine (t ). hypothyroidism is a well-recognized complication of diffuse hepatic hemangiomas that produce type iii deiodinase, an enzyme that converts t into bioinactive reverse t and t into diiodothyronine. thyroxine is typically selected for replacement in this population, even though doses up to % above physiologic may be necessary. we hypothesized that low dose, nearly physiologic t would be safer and equally effective because it bypasses propranolol's impact on the pituitarythyroid axis. we report an infant with diffuse hepatic hemangiomatosis and acquired hypothyroidism successfully treated with propranolol, prednisone, and triiodothyronine. design/method: a mo healthy female presented with abdominal distension, poor oral intake, and hepatomegaly. mri confirmed diffuse hepatic hemangiomatosis, the largest lesion measuring . cm by . cm. thyrotropin (tsh) was elevated at . (reference range* . - mcgiu/ml), total t # (rr - ng/dl), and total t ^ . (rr - mcg/dl). treatment was started with prednisone ( mg/kg/day) for three weeks, propranolol ( mg/kg/day) and t ( . mcg/kg/day). the t dose was slowly titrated to a maximum of . mcg/kg/day. thyroid hormone levels rapidly improved on t replacement. after two weeks, the tsh was . , tt , and tt . . after eight months, the tsh was . , tt , and tt . . at twelve months, the tsh dropped to . , tt , and tt . , suggesting decreased tumor production of type iii iodothyronine deiodinase. liver mri confirmed fewer hemangiomas, largest being . cm by . cm. the patient's t dose was reduced. both propranolol and t were discontinued after twenty-four months of treatment. one year off all therapy, this child has normal growth and development, only two < . cm hepatic hemangiomas and no evidence of hypothyroidism (tsh . ; tt ; tt . ). conclusion: t at near physiologic doses corrects the consumptive hypothyroidism associated with diffuse hepatic hemangiomas. t replacement is preferable to thyroxine due to its lower risk of rebound hyperthyroidism as the hemangiomas involute and type iii deiodinase production declines. there are two prior case reports describing t use without t , one employing propranolol and the other utilizing steroids for hemangioma management. this is the first case report with long term follow-up of a child treated with multimodal therapy including propranolol, prednisone, and triiodothyronine. *rr = reference range; #tt = total t ;^tt = total t background: multifocal lymphangioendotheliomatosis with thrombocytopenia (mlt) is a rare congenital disorder first described in that is characterized by multiple vascular abnormalities commonly involving the skin and gastrointestinal tract as well as consumptive coagulopathy often resulting in gi bleeding in infancy( ). to describe an unusual presentation and successful management of mlt in a neonate. design/method: baby h was born at full term after a pregnancy complicated by maternal sinus venous thrombosis requiring anticoagulation beginning at weeks. at birth, she was diagnosed with multiple hemangiomas based on clinical exam. at two weeks of age, she developed melena and hematemesis. cbc revealed platelet count of and she was referred to the ed. abdominal ultrasound was concerning for abnormal hepatic waveform; cxr showed multiple pulmonary nodules. workup revealed no other lesions and no further hematologic abnormalities. biopsy of presumed hemangioma ultimately revealed a smooth muscle-lined vascular proliferation without glut- immunoreactivity, consistent with mlt. her early course was complicated by an acute hemodynamically significant gi bleed; esophagogastroduodenoscopy identified six bleeding vascular malformations within the stomach that were injected with epinephrine and sclerosed with successful hemostasis. she received multiple prbc and platelet transfusions. central access was obtained and she was started on oral sirolimus based on previous reports of successful use in management of vascular malformations given its antiangiogenic and immunosuppressive effects ( ). she has tolerated it well with no evidence of toxicity and has achieved a partial response with stable of hemoglobin > and platelet count > . cutaneous lesions have diminished in intensity and she has had no further signs of gi bleeding. she receives pentamidine for pcp prophylaxis. she continues to have appropriate growth and development. we describe here an unusual presentation of an already rare disease. while cutaneous and gi lesions are typical of mlt, pulmonary involvement is not well-described in the literature. early identification of tissue-based diagnosis enabled timely stabilization and treatment of the patient. five months later, she continues to tolerate sirolimus and has shown significant response with diminished coloration of cutaneous lesions, stable blood counts, and no further bleeding. mlt is a relatively newly-recognized disorder with significant phenotypic variability. given that bleeding secondary to a kasabach-merritt-type consumptive thrombocytopenia is the major cause of morbidity and mortality in the first year of life in children with mlt, it is essential to recognize the diagnosis and initiate appropriate treatment as early as possible. north, arch background: patients with generalized joint hypermobility (jhm) may experience easy bruising or bleeding given the association between these symptoms and abnormalities in collagen, a required component of primary hemostasis. heavy menstrual bleeding (hmb) is a common initial presentation for females with underlying hemostatic defects and may be the sole manifestation of a bleeding disorder. however, limited reports describe jhm as a cause of hmb, leading to under recognition. objectives: to describe the clinical characteristics and management of young women presenting with hmb in the setting of jhm. design/method: this study utilized our hmb research registry. we included subjects - years, seen in the nationwide children's young women's hematology clinic between february and november with both hmb and jhm. medical records were retrospectively reviewed for history of presentation, menorrhagia impact questionnaire (miq): a validated quality-of-life tool for females with hmb, medication profiles and relevant laboratory studies. results: twenty-five patients met inclusion criteria (median age years, range - ) with an average beighton score of . (range to ). participants presented an average of . years (range months to years) after menarche despite % of patients reporting heavy to very heavy menses since menarche. according to the miq responses, most participants expressed hmb-associated limitations in physical activities ( %), social activities ( %), and work or school activities ( %). of the participants, % reported bleeding symptoms in addition to hmb, most commonly easy bruising ( %), epistaxis ( %) and cutaneous bleeding ( %). forty percent of young women presented with anemia due to chronic blood loss. results of hemostatic testing were unremarkable, with the exception of one patient who was also found to have type von willebrand disease. additionally, % of females reported arthralgia, with knees and ankles the most commonly affected joints. at time of presentation, % of participants reported failure of initial therapies and most patients ( %) were managed long-term with oral hormone therapy. in a small population of young women found to have jhm who initially presented with hmb, patients were likely to have prior bleeding symptoms as well as substantial delays from menarche to timing of presentation at our young women's hematology clinic despite limitations in activities of daily life. greater awareness of the associations between bleeding symptoms and jhm, despite typically normal hemostatic laboratory results, is necessary so that patients can more easily be identified and receive appropriate therapy. the objective is to determine the impact of cl care practices involving the home environment on ambulatory clabsi rates. design/method: information for the pi was collected through a comprehensive survey that was completed annually by the ccbdn member hospitals. responses to the questions about cl care practices involving the home environment were selected from the pi for . ambulatory clabsi rates and ambulatory total bloodstream infection (bsi) rates were obtained from another ccbdn database. the proportion of hospitals that did or did not employ a particular cl care practice was tallied. the mean ambulatory clabsi rate and mean ambulatory total bsi rate of the hospitals that did or did not employ a particular cl care practice were compared using generalized linear model techniques assuming an underlying negative binomial distribution. results: twenty-five hospitals submitted responses to the questions about cl care practices involving the home environment. one hospital was excluded for lack of bsi data. sixty-three percent of the hospitals programmatically educated parents about all aspects of the cl care bundle. the mean ambulatory clabsi rate for the hospitals that educated parents was significantly lower than that of the hospitals that did not ( . infections/ cl days vs. . infections/ cl days; p = . ). the mean ambulatory total bsi rate was also significantly lower ( . infections/ cl days vs. . infections/ cl days; p = . ). the mean ambulatory clabsi rates and mean ambulatory total bsi rates were not significantly different for the other cl care practices. conclusion: an analysis of cl care practices involving the home environment reveals that parental education of all aspects of the cl care bundle is associated with a lower ambulatory clabsi rate and lower ambulatory total bsi rate. this finding highlights the importance of systematically teaching family members the proper method of handling cl. background: children undergoing chemotherapy are at a high risk for developing nausea. dr. amy baxter in collaboration with pediatric oncology patients and nurses, developed and validated a pictorial nausea rating scale for children aged - years, called the baxter retching faces (barf) nausea scale. staff nurses at a large, academic, pediatric hospital located within washington, d.c., have identified variability in nursing assessment and documentation of chemotherapy induced nausea and vomiting (cinv) in pediatric oncology patients. the purpose of this quality improvement project was to utilize the barf scale to standardize assessment and documentation of nausea in pediatric oncology patients receiving chemotherapy. the primary aims of this project were to: assess feasibility of the barf scale in clinical practice; increase nursing knowledge about cinv through education sessions; increase documentation of nausea assessments through the use of the scale. the secondary aim of this project was to: increase the recognition of nausea through the use of a standardized assessment tool. design/method: the pdsa model was used to guide the design and implementation plan. in the first phase of the project data was collected to identify the prevalence of nausea in patients admitted for chemotherapy in the prior three months. education sessions discussing cinv and the utilization of the barf scale were conducted. pre and post assessment of nurses' knowledge of cinv and documentation were assessed. in the second phase the barf scale was implemented into practice. nurses were asked to utilize the barf scale to assess and document nausea scores in patients, aged to years, receiving chemotherapy. at the end of the implementation period nurses were surveyed about the feasibility of the scale. post data was collected to identify the prevalence of nausea documented in the electronic health record. this project was undertaken as a quality improvement initiative at children's national and it does not constitute as human subjects research. as such it was not under the oversight of the institutional review board. results: all data has been collected; however complete data analysis will be conducted in the upcoming weeks. background: sickle cell disease (scd) is the most common inherited blood disorder in the united states (us); however, there are few quality measurements to evaluate scd practice. in , the nhlbi published guidelines that include two key interventions for children with sickle cell anemia (sca): the use of transcranial doppler (tcd) screening for stroke prevention and hydroxyurea (hu) to prevent scd pain crisis. we conducted a national survey of scd management sent to providers in over institutions in the us to better assess knowledge of the guidelines and barriers to hu counseling and tcd screening guideline implementation. it was hypothesized that the barriers to tcd screening are different than barriers to hu counseling and prescribing. a -question anonymous survey was sent to providers by mail (follow-up by email). survey themes included nhlbi guidelines knowledge and comfort with understanding and implementing both tcd screening and hu use. the response rate was % ( / ) however one survey was incomplete. thus, were analyzed in the final data set. all of the respondents are in active practice, % s of s in academics and all care for children with scd. the majority of providers ( %) felt "very" or "extremely" confident in their knowledge of tcd screening and interpretation. similarly, % of providers felt "very" or "extremely" familiar with hu dosing and management. for tcd screening, % of providers estimated their screening rates were > % and % providers felt their annual screening rates were - %. the two biggest barriers to tcd screening noted by providers (of moderate to extreme significance) included: lack of support staff ( %) and lack of time during a patient visit ( %). regarding hu prescribing practices, % of providers offered hu to at least % of children with sca over nine months of age. the biggest barrier to hu prescribing noted by % of providers was concerns about patient adherence or access to the medication. only % providers felt that lack of support staff was a moderately significant barrier to hu prescribing. the pediatric scd providers surveyed all have access to the nhlbi guidelines. despite widespread guideline knowledge, there are different barriers for tcd screening versus hu prescribing, which prevent optimal implementation. as a result, although both recommendations are from the same nhlbi guideline, they likely will require different implementation strategies (systems-based interventions for tcd screening; interventions to improve patient adherence for hu counseling) to improve outcomes. background: invasive fungal disease (ifd) is a major cause of mortality and morbidity among pediatric immunocompromised patients such as those who receive chemotherapy or hematopoietic stem cell transplantation. the current diagnostic 'gold standard' of ifd remains culture of infected tissue obtained by biopsy. noninvasive biomarker testing for galactomannan or , -beta-d-glucan (bg) can have low sensitivity and does not provide species-level identification. nextgeneration sequencing (ngs) of cell-free plasma is a promis-ing noninvasive approach to providing species-level identification of ifd via a blood test and can further guide specific treatment. objectives: describe the incidence of positivity for fungal specific pathogens on ngs analysis in a high-risk immunocompromised pediatric population and correlate results with other 'standard' infectious studies if performed. design/method: immunocompromised pediatric patients with suspected ifd were enrolled and plasma was collected at time of enrollment. ngs was performed on extracted dna in cell-free plasma (karius, redwood city, ca). after removing human reads, remaining sequences were aligned to a curated database including pathogens. organisms present at a significance-level above a predefined threshold were reported. results: twenty-seven samples from enrolled patients have been processed thus far. of these subjects, were enrolled for prolonged febrile neutropenia (≥ hours) despite broad-spectrum antibiotics, for recrudescent febrile neutropenia, for abnormal imaging, and with other findings. after evaluation of routine studies performed, patients met criteria for proven ifd, for probable ifd, and for possible ifd using eortc/msg guidelines. the ngs plasma test identified the same pathogen as cultured from infected tissue or blood in % ( / ) of the proven cases. in the probable cases, pneumocystis jirovecii was identified in a patient with a positive bg ( pg/ml) and pneumonia. among the possible cases, toxoplasma gondii was detected in a patient with prolonged febrile neutropenia and lung imaging suggestive of ifd. additionally, candida glabrata was isolated in a patient with prolonged febrile neutropenia but no other criteria for ifd. numerous pathogens were also identified that could explain the above clinical parameters, including hsv , cmv, vzv, hhv , ebv, bk polyoma virus, and ureaplasma parvum. the cell-free plasma ngs test can detect invasive fungal infections from blood. the test identified fungi from proven ifd, detected pathogens in both probable and possible ifd cases, and is a useful diagnostic tool in the evaluation of ifd. supplies and sample shipment and processing supported by karius, inc. baylor college of medicine, texas children's hospital, houston, texas, united states background: practicing medicine is a lifelong learning process. as noted in the institute of medicine's seminal report, 'to err is human,' adverse outcomes do not typically result from individual recklessness; rather, they result from faulty systems, processes, or conditions that provide an environment conducive to making a mistake, or failing to prevent one. learning to systematically review errors and translate lessons learned into quality improvement (qi) initiatives is a critical component of practice-based learning and improvement for practitioners at all career levels. objectives: to develop a methodical, self-reflective and nonthreatening approach to incident analysis and translation of lessons learned into qi initiatives. design/method: we used a validated, structured case audit approach, modified from szostek et al: ) review all documentation relating to the case and identify all health care providers involved; ) interview stakeholders, including those who directly provided and supported care; ) use a qi tool to conduct a root-cause analysis; ) identify a systems issue that contributed to the outcome; and ) propose systems-level interventions and prioritize initiatives based on effort-yield projections. results: pdsa cycle : plan: establish a committee to ) identify potential cases, ) triage cases for conference presentation, ) determine timing and frequency of conferences, ) develop a training manual, ) record identified qi initiatives. do: we established a quarterly section-wide meeting to which all members of the pediatric hematology/oncology service are invited, including administrative and nursing leadership. we developed a training manual and structured presentation template. prioritized cases were discussed in advance during multidisciplinary case review sessions, and presented by senior fellows who were instructed to focus discussion on potential opportunities for qi. study: we identified cases, meeting criteria for mmi presentation. qi initiatives identified from this conference resulted in a number of systemic practice changes; however, we encountered challenges to sustaining these changes over time. act: objectives for the next pdsa cycle are to ) establish a method for tracking the adherence to recommended changes in practice, ) maximize sustainability by integrating qi initiatives into institutional qi leadership and practice standardization committees. we have successfully implemented an mmi conference that meets out of institute of medicine quality domains: safety, effectiveness, patient-centeredness, timeliness, and efficiency. a standardized, consistent approach to mmi presentations that includes identification of contributing factors and specific qi implications has the potential for improving both provider education and patient care/safety. johns hopkins university, baltimore, maryland, united states background: receiving a cancer diagnosis is a life-changing event for patients and caregivers, although little is known about the experience. while some oncologists receive dedicated training in delivering this bad news, the initial conversation is often with a primary pediatrician, and these providers often feel they do not receive adequate training in the communication of a cancer diagnosis. objectives: our objectives were two-fold: first, to better define the experiences of caregivers/patients when told of a cancer diagnosis, and to query how caregivers/patients believe providers can improve the disclosure of this bad news. secondly, to assess what, if any, training primary pediatricians received in this skill, and to assess how comfortable providers in various settings and stages of training are with communicating cancer diagnoses. design/method: from november - , semistructured, in-depth interviews were conducted with pediatric oncology patients and caregivers of patients (n = ) diagnosed in the past year regarding their experiences receiving the diagnosis at our institution. in addition, pediatric residents (n = ), outpatient pediatric primary care physicians and pediatric emergency medicine physicians (n = ) were interviewed regarding their experiences delivering cancer diagnoses. interviews were analyzed following principles of thematic analysis. interviewers with patients and caregivers had two common themes: ) all emphasized their wish for direct and thorough information; ) both patients and caregivers emphasized the gratitude they felt for physicians who gave them hope by emphasizing the good prognosis of their child's cancer. lack of training in this area, as well as lack of comfort delivering this news was common will all providers. additionally, providers report variable approaches to giving bad news, including ) whether to tell caregivers separately or tell the child and parents together, and ) whether to give favorable prognostic information. additionally, attending physicians also differed significantly in their approaches to teaching residents. while some believed residents should give the news to gain experience, others felt that this is not appropriate if residents are inexperienced. only one resident reported ever receiving feedback on his communication skills in this type of discussion. conclusion: we plan to build on these interviews to develop a national survey of patients, caregivers, and providers to better understand the issues surrounding this discussion. we will use the findings to develop a communication curriculum for pediatric residents, focusing on the discussions that occur in the outpatient setting by primary pediatricians. background: human papilloma virus (hpv), common in both females and males, is responsible for pathologies ranging from benign genital warts to cervical and penile cancer. hpv strains and are responsible for , malignancies each year in the united states, and one third of them arise in men. pharmaceutical companies have now developed a vaccine that will help prevent the virus-associated malignancies. the cdc initially recommended that females ages - years receive the vaccine series, then starting in they expanded the eligibility to males ages - years. despite being widely available and highly publicized, only % of eligible females receive the full vaccine series. objectives: this study aims to assess the knowledge of hpv, the attitudes towards the hpv vaccine, and identify barriers preventing its full utilization. once identified, we aim to overcome the barrier(s) in order to improve vaccination rates in eligible adolescents. we distributed a standardized questionnaire to the parents of eligible female and male patients in our pediatric hematology-oncology clinic. it assessed the parents' knowledge of hpv and the vaccine, their views of the vaccine, and reasons why they may oppose it. results: approximately % of parents claim they have been educated about hpv, mostly by their primary care physician. however, % did not know what disorders hpv caused; % felt the vaccine should not be added to the typical vaccine schedule; % of parents do not intend to vaccinate their child. of those that opposed the vaccine, one-third were concerned about potential side effects and nearly % feel they do not have enough information. additionally, % of parents are not aware that the vaccine is available at their child's doctor and only % of parents have discussed the hpv vaccine with their child's doctor. the largest barrier to the utilization of the hpv vaccine that we have identified appears to be lack of educa-tion. as a result, we have begun distributing the cdc's hpv and vaccine patient guide to our patients' families as an intervention. we are currently in the process of re-administering our survey to these families after implementing the intervention to assess its success in increasing both knowledge and utilization of the hpv vaccine. cancer institute, chennai, chennai, tamilnadu, india background: rasburicase is a recombinant urate oxidase enzyme approved for use in tumor lysis syndrome (tls) and it acts by reducing serum uric acid levels. using rasburicase at the recommended dose of . mg/kg/day for days is expensive and it is not known whether this extended schedule is clinically beneficial compared to a single fixed dose of . mg. the aim of the present study was to evaluate the efficacy of single dose rasburicase . mg in prevention and management of tls. design/method: rasburicase is available as single use . mg vial. at our institution a single dose of rasburicase . mg irrespective of bodyweight has been used in adults and in children a dose of . mg/kg (maximum . mg) has been used since for prevention and management of tls and subsequent doses are given based on biochemical response and clinical condition. we retrospectively analysed the case records of patients who had received rasburicase from january to january . the study included patients with hematological malignancies who received rasburicase. children accounted for . % (n = ) patients and males comprised % (n = ). rasburicase was used prophylactically in ( . %) patients, for laboratory tls in patients ( . %) and for clinical tls in ( . %) patients. single fixed dose rasburicase prevented laboratory/clinical tls in % of the prophylactic group and prevented clinical tls in % of the laboratory tls group. none of the patients in prophylactic and laboratory tls group developed clinical tls. however, majority of the patients with clinical tls required more than one dose rasburicase. single dose of . mg ( vial) rasburicase is efficient in preventing and managing laboratory tls and is economically viable in resource constrained settings. nicole wood, lauren amos, nicholas clark, chris klockau, karen lewing, alan gamis children's mercy kansas city, kansas city, missouri, united states background: medication reconciliation for newly diagnosed oncology patients is complicated and cumbersome. these patients are often admitted on no medications, and leave on multiple. chemotherapy and supportive medications are crucial. despite numerous individuals overseeing this process, prescribing errors or omissions still occur. when reviewing the literature, improvement occurs when there is an interprofessional and standardized process to medication reconciliation. objectives: this project's aim was to improve the accuracy of the discharge medication reconciliation process from % to % from february -august . the process measure was the percentage of patients discharged with an accurate checklist. additional time for staff spent in completing the checklist and avoiding an increased error rate by changing the prescribing process were followed as balancing measures. we created a discharge medication checklist which included a list of required home medications prescribed by the resident, ideally hours prior to discharge. it required fellow or attending review and pharmacy to review the list and educate the family. checklists were collected monthly and reviewed against the electronic medical record (emr) for accuracy. results: six pdsa cycles were completed. there were errors during the data collection time frame. in pdsa cycle , a patient received acetaminophen for pain control which is avoided at home. in addition, this patient received diphenhydramine instead of ondansetron, which is preferred as an antiemetic. in pdsa cycle , a patient with a pending diagnosis was sent home with acetaminophen. of note, this patient did not have a checklist completed upon discharge. this project provides a novel and important method to standardize the discharge medication reconciliation process in a complex patient population. it clarifies which types of medications these patients need, provides pharmacy teaching to families which was not done previously, and prescribes discharge medications to families sooner. after the first medication reconciliation error, the checklist was revised. no further errors were made following revision, with the exception of one patient without a completed checklist at dis-charge. our accuracy rate increased from % at baseline to % following implementation. we are in the process of making the checklist electronic and accessible in the emr. in the interim between the end of data collection and implementation into the emr, a leukemia patient was sent home without an epinephrine pen, further demonstrating the importance of this standardized discharge process. for this reason, we have re-instituted the checklist until the electronic version is available. background: survivors of pediatric cancer are at risk of losing pre-existing protective antibodies to vaccine preventable diseases. in a prior study, % of children < years lost humoral immunity to measles as a result of chemotherapy induced alterations in immune system. measles in recipients of immunosuppressive chemotherapy has mortality rates up to %. because of volitional vaccine refusal, there has been a dramatic increase in measles infection from cases in to in , including several statewide outbreaks. small pediatric oncology practices frequently share floor/clinic space with the general pediatric patients putting them at risk for measles since virulence starts hours prior to symptoms. there is no standard protocol for revaccinating post-chemotherapy patients. to assess measles risk based on serial humoral immune status in a cohort of pediatric oncology patients receiving intensive chemotherapy design/method: patients < years age with known vaccination status receiving intensive chemotherapy between july -june at our institution's pediatric oncology practice were included in this prospective study. serial measles igg antibodies were measured at diagnosis, months and months after initiation of chemotherapy using elisa. measles immunity was defined per lab standards. a comparison of pre-chemotherapy and serial post-chemotherapy immunization titers was made for all patients by diagnosis. the study population consisted of children ( male); patients had all, non-hodgkin lymphoma, sarcoma and other solid tumors. two patients ( . %), both unvaccinated had non-protective measles antibody levels at s of s baseline. of the remaining patients, . % patients ( leukemia, lymphoma and sarcoma) lost protective antibody titers at months after initiation of chemotherapy and . % ( leukemia, lymphoma and sarcoma) at months after initiation of therapy. % of the remaining patients who retained measles antibody titers within protective range at months also demonstrated a steady decline in antibody titers at and months from therapy initiation. the loss of protective measles humoral immunity occurred significantly more often in patients with leukemia compared to other malignancies. oncology patients in our practice undergoing intensive chemotherapy demonstrated progressive waning of protective measles igg titers. our data suggests that it should be standard practice to check all patients for measles humoral immunity prior to starting chemotherapy and at completion. larger studies need to be performed to establish guidelines for revaccinating post-chemotherapy pediatric patients, an intervention that is easily applicable and of low cost. background: the accurate determination of glomerular filtration rate (gfr) is important to screen for acute kidney injury, to dose chemo-therapy, and to identify risk for chronic kidney disease.being correlated with inulin clearance, measured gfr by iohexol plasma disappearance (igfr) is a new gold standard for measurement of gfr in pediatric cohort studies. igfr is based on the clearance of an exogenous marker and is unaffected by endogenous compounds or a patient's muscle mass. we compared igfr with -hour urine creatinine clearance ( crcl) and gfr estimating equations using serum creatinine (scr) and serum cystatin c (cystc) in pediatric patients with cancer. we recruited participants who were ages to yrs, continent of urine, and diagnosed with a malignancy in the past years. eligible subjects had stable kidney function for at least two weeks prior to the assessment of igfr. consented subjects had baseline assessments including height, weight and vital signs. blood samples were obtained for serum chemistry, and time zero iohexol. igfr determined by ml iohexol solution infused over - minutes followed by ml of sterile saline. blood was drawn at , , and minutes.at the same time of igfr, the crcl was collected. igfr was calculated using a two-compartment model and area under the curve. we compared igfr to published gfr equations (schwartz et al, kidney int ). results: ten subjects ( female/ male) agreed to participate. the distribution of diagnoses for the subjects: all = , lymphoma = , brain tumors = and hepatocellular carcinoma = . six patients were off therapy. the lower gfrs are noted in patients who had malignancies other than leukemia, likely due to the use of cisplatin based therapy. the average igfr was ml/min/ . m^ whereas crcl was . ml/min/ . m^ ; demonstrating the crcl overestimates gfr compared to igfr. comparing igfr to univariate equations using scr, cystc, and the multivariate equation with both, the univariate cystc equation correlated well with igfr; the others overestimated igfr. we found that crcl overestimated igfr. the univariate cystc equation better correlated to igfr than equations with scr. the poor performance of scr based methods to assess gfr might be due to decreased muscle mass and inadequate nutritional status. creatinine-based determinations of gfr alone, may not be accurate in this population. further study is needed to determine if igfr should be a standard of care to assess gfr in children with cancer particularly who are receiving nephrotoxic medications and incontinent of urine. background: pediatric oncology patients undergoing chemotherapy through indwelling venous catheters are at increased risk for severe sepsis especially when neutropenic due to chemotherapy. rapid triage and early recognition are essential because delayed initiation of antibiotics and fluids in these patients or delayed transfer to higher level of care after initial stabilization is associated with poor clinical outcome. our pediatric oncology out-patient clinic is designated as an article unit whereby the providers can initiate and give treatment such as intravenous fluid, antibiotics, chemotherapy and blood products. objectives: global aim-optimize management of early sepsis and decreased morbidity, mortality and hospital length of stay in the high risk pediatric oncology patients. smart aim-improve timely management with initiation of fluids and antibiotics and transfer of septic patients to higher levels of care by % in months in above patients design/method: multidisciplinary team with physicians and nurses was created. retropective chart review of sepsis patients treated at the clinic from april to october was done using an audit sheet to identify the barriers in the delivery of care. three patients were identified and data analyzed prior to intervention; two were analyzed post interventions. a key driver diagram was created by the group to drive intervention. a process map was designed to identify the different steps in the care of these patients to pinpoint areas needing improvement. different timed data points were used starting from time of arrival to clinic, time to antibiotics and fluids and time to transfer to higher level of care. rapid pdsa cycles were done to improve the processes and delivery of care. run charts were created. there was an improvement close to the goal of % for all data points used. pdsa cycles for improvement included conducting frequent mock codes with appropriate feedback real time coaching and process planning with nursing staff. we partnered with pharmacy for close loop communication with clinic staff and we improved communication between physicans at different levels. conclusion: sepsis in neutropenic pediatric oncology patients is deadly and can be reversed with timely management at different levels. given the promising results of the above project, we want re-inforcement of the processes to be a part of the daily practice of first line clinical staff. eventually we will extend the principles learnt in management and triage of sepsis to other outpatient emergencies chemotherapy related anaphylaxis background: chemotherapy-induced nausea and vomiting (cinv) is a common side effect in children receiving antineoplastic chemotherapy. recommended prophylactic antiemetic medications are based on the classification of chemotherapy emetogenicity. however, despite appropriate use of these antiemetic agents, some patients will still experience nausea and/or vomiting. children's oncology group clinical practice guidelines recommend the addition of olanzapine to prophylactic regimens for management of breakthrough cinv. objectives: our pediatric hematology oncology center implemented a quality improvement (qi) project aimed to increase the use of olanzapine in pediatric cancer patients years of age and older receiving moderately or highly emetogenic chemotherapy and experiencing breakthrough cinv over a month period. design/method: this qi project was conducted utilizing plan-do-study-act (pdsa) cycles. for the first pdsa cycle, baseline data was collected through chart review to determine the rate of olanzapine use for breakthrough cinv over a month period from july to december . breakthrough cinv was defined as use of or more doses of antiemetic agents other than those given for cinv prophylaxis. guidelines for treatment of breakthrough cinv were reviewed with pediatric hematology/oncology attending physicians and fellows. flyers were created that listed chemotherapy regimens considered moderately and highly emetogenic. if a patient experienced breakthrough cinv, a flyer was to be placed in the patient's roadmap binder to signal olanzapine should be added to the next chemotherapy block. data was collected over a month period in september following this first intervention. the second pdsa cycle consisted of didactic education and training of pediatric oncology nurses as well as pediatric residents regarding the addition of olanzapine for breakthrough cinv. rates of olanzapine use were then collected from october through november . results: olanzapine use increased from . % at baseline to . % after the first pdsa cycle ( = . , p = . ). after the second pdsa cycle, olanzapine use increased another . % to . % ( = . , p = . ). the administration of olanzapine was successfully increased by modifying patients' roadmaps after patients experienced breakthrough cinv as well as with education and training of pediatric oncology staff, fellows, residents, and nurses. background: venous thromboembolism (vte) is increasingly affecting children. according to an administrative database study, there was a % increase in the incidence of vte among children admitted to free-standing children's hospitals in the united states from to . risk factors for hospital-acquired vte are well-known and well-studied in adults, with evidence-based preventative measures available. similar guidelines are lacking for children. objectives: there is an ongoing national-initiative to develop and institute methods for screening and preventing hospitalacquired vte in children. in / , nationwide children's hospital instituted an electronic screening form required for all patients admitted ≥ hours. patients were scored and riskstratified based on eight risk-categories. a summated score was used to determine the vte risk level, and used to make prophylaxis recommendations for patients ≥ years; as well as patients ≥ years who were admitted to an intensive care (icu), surgical, or trauma unit. the purpose of this irb exempt, quality improvement initiative was to retrospectively review our experience with this risk-stratification tool. results: hospital-acquired vte events occurred in unique subjects. median age at vte diagnosis was years. only ( %) vte occurred in children ≥ years of age. ( %) vte were deep vein thrombosis (dvt), and ( . %) involved pulmonary embolism. vte was most common in subspecialty units including the pediatric and cardiac icus ( . %); neonatal icu, ( . %); and hematologyoncology, ( . %). ( %) vte were associated with central venous catheters (cvc) and events ( %) were associated with altered mobility. congenital heart disease/heart failure was the most common chronic medical condition associated with vte ( ( . %) events); whereas infection and trauma/surgery were the most common acute medical conditions associated with vte ( ( . %) and ( %) events, respectively). during ( %) events, subjects scored a summated score ≥ . in summary, in this single institution, prospectively maintained database, cvc remains the most common risk factor for vte, followed by cardiac disease, infection and trauma/surgery. most subjects who developed vte scored high (score ≥ ) on our screening tool. only a small proportion of vte occurred in patients older than years and thus eligible for thromboprophylaxis. our results indicate that future vte prevention endeavors should include these age groups in addition to exploring more aggressive prophylactic modalities including pharmacological prophylaxis. background: pediatric fellows are required to have active engagement in quality improvement (qi) activities, and yet a national acgme review found most trainees had "limited knowledge of qi methods" and "limited participation in interprofessional qi teams". the twenty fellows in our pediatric hematology/oncology training program identified blood culture utilization as their qi priority. our institution recently introduced a hospital-wide decision algorithm to guide providers regarding when to obtain blood cultures. there is often a low threshold to obtain blood cultures in immunocompromised pediatric oncology patients, but these are often low-yield or result in falsepositives. our fellows spearheaded a project to implement the algorithm in the inpatient pediatric oncology population and improve the proportion of appropriately drawn blood cultures. we investigated how appropriately the algorithm was being utilized on the inpatient pediatric oncology floor prior to and after several educational steps aimed at disseminating the algorithm to members of the care team. our primary endpoint was to quantify the proportion of culture episodes drawn "inappropriately", with a goal of reducing inappropriate episodes to ≤ %. the algorithm was initially introduced to the nursing staff and residents covering the twenty-bed inpatient unit in september . qi project planning took place with upper level fellows in january . fellows and faculty received intensive training on the algorithm in july-august . we then conducted a retrospective chart review of blood culture episodes drawn between august and november . upper level fellows scored ∼ culture episodes as to whether the decision to culture and number of cultures drawn were "appropriate" or "inappropriate", and catalogued the indications for culture episodes and if applicable, why the episode was found to be inappropriate. additionally, fellows discussed inappropriate culture episodes with the team onservice, to provide direct feedback on where the algorithm failed. results: between august -december on average cultures/ patient-days were drawn. forty-nine percent of culture episodes were inappropriate. from january -october , following targeted education on the algorithm, the rate of blood cultures drawn decreased to cultures/ patient-days. the average proportion of inappropriate culture episodes fell to . %, representing a % decrease in inappropriate culture utilization. correct application of a decision algorithm for blood culture utilization can reduce total cultures drawn on an inpatient pediatric oncology unit. fellow-led education of the multi-disciplinary team decreases the rate of inappropriate culture episodes as well as provides active engagement in qi. background: inadequate understanding of sickle cell disease (scd) is common and can affect patients' compliance and therefore their morbidity and mortality, especially after transition to adult care. optimal clinical care for scd includes disease education, which can be difficult given the breadth of possible topics and limited time in clinic. it is unclear how best to provide personalized, efficient education for adolescents with scd. this quality improvement (qi) study aimed to implement a questionnaire-based system to improve patients' knowledge of their scd and documentation of education by the nurse or physician. the study objective was to improve provider documentation and patient knowledge about their scd by identifying patients' gaps in comprehension. by january , the study aimed to increase education documentation from % to %. by april , the study aimed to increase use of a smart phrase for education documentation from % to %. by june , the study aimed to increase patients' knowledge about their disease by %. design/method: twenty-one scd patients enrolled on an irb approved qi study, with twenty active patients. our comprehensive team generated a questionnaire with knowledgebased questions for two age groups: - and - years old. at each comprehensive visit, a questionnaire was distributed, with at least -month intervals. the provider scored questionnaires and reviewed two educational topics, with wrong answers taking priority. plan-do-study-act (pdsa) cycles included pdsa# : patients completed questionnaire. pdsa# : a smart phrase addressing questionnaire topics was created and shared with providers. pdsa# : patients received education handouts during clinic education. documentation in clinic notes was the process measure and questionnaire scores was the outcome measure. results: pdsa# is complete, pdsa# has four patients remaining, and pdsa# is ongoing. due to variable visit frequency, there are multiple concurrent cycles. after pdsa# , free text documentation was completed an average of % over the course of months. after pdsa # documentation increased to % within months and questionnaire scores increased from an average of % to %. of the questions that patients got wrong on their first visit, they were significantly more likely to improve on retesting if the topic was taught to them than if it was not addressed ( % vs. %, p = . ). we are currently completing pdsa# and collection of post pdsa# data. questionnaire-based scd education coupled with standardized smart phrases improves patients' scd knowledge and documentation by providers. further improvement in knowledge is expected with the addition of handouts. background: exposure to suffering can have a profound impact on the wellness of caregivers, often referred to as the "cost of caring". this cost is especially high in pediatric hematology/oncology. repeated exposure to suffering has the potential to negatively impact resilience and increases the risk of burnout, thus impacting quality of care and patient satisfaction. we have developed a peer support team utilizing the critical incident stress management (cism) model. this model has been successfully used in other professions that frequently face traumatic events such as fire fighters, police and emergency medical technicians. the h.o.p.e.s. team (helping our peers endure stress) consists of volunteer multidisciplinary staff members who have received training to provide both group and peer support following any 'critical incident' that may impact one or more staff members. we hypothesize that implementation of the h.o.p.e.s. team will improve staff resilience, decrease overall rates of burnout and improve compassion satisfaction. s of s design/method: we are using both empiric metrics and anecdotal reports to assess the impact of the h.o.p.e.s. team. prior to the activation of the team, all pediatric hematology/oncology clinical staff members were surveyed using validated tools to assess their levels of resilience, burnout, secondary trauma and compassion satisfaction (proqolv and brief resilience scale). they were also asked to rate the number of times they had experienced critical incidents, as well as their perceived level of distress after dealing with traumatic events. after the h.o.p.e.s. team has been functional for months, we will send the same survey to staff members to measure changes, paying special attention to resilience and rates of burnout and compassion satisfaction. results: enthusiasm for development of the team has been high. of people approached to volunteer their time to participate in the multidisciplinary team agreed, including attending physicians, fellows, nurses, nurse practitioners, child life specialists, social workers, clergy and psychologists. all volunteers participated in a -day training conducted by an instructor from the international critical incident stress foundation. engagement in the first staff survey has been high, with of responding to date. data collection is ongoing. clinical staff in pediatric hematology/oncology may be particularly vulnerable to burnout and decreased resilience by repeatedly witnessing suffering and trauma. peer support interventions following critical incidents may lead to increased resilience and compassion satisfaction while decreasing rates of burnout. enthusiasm for the development of a peer support team has been high. background: monthly blood transfusions are an indicated therapy for pediatric patients with sickle cell disease with certain complications. maximizing transfusion efficiency in a busy infusion clinic requires: ensuring that appropriate blood units are available in the hospital blood bank; laboratory specimens are obtained from patients in advance; and coordination of clinic appointment and nursing availability. we sought to improve clinic efficiency through identifying ways to better communicate with patients/families regarding upcoming laboratory and transfusion appointments, and to assess the efficacy of implementing a web-based personalized text reminder (pinger.com). we measured the baseline frequency with which transfusion appointments were missed by families, moved to later within the week, or delayed due to late labs. a convenience sample of patients receiving monthly transfusions received a questionnaire about patient/parent preferences for appointment reminders and barriers to keeping appointments. those patients/parents who did not opt-out of an additional text reminder received personalized texts from their care team reminding them of lab and transfusion appointments. rates of missed/moved/delayed appointments were compared between the group receiving the additional text messages and the group only receiving standard, hospitalgenerated appointment reminders (telephone call). results: forty-one families ( patients) responded to the survey, capturing information on % of patients receiving chronic transfusion therapy. thirteen families ( %) declined the additional text reminders. families reported a preference for text reminders ( %), more often than email ( %) or telephone ( %), and % of families wanted to receive reminders for both transfusion and laboratory appointments. the majority ( %) of families reported competing work/life priorities as the reason for missed/late appointments. other families noted transportation/travel ( %), fear/illness/pain ( %), and lack of reminders ( %) as the reason for missed appointments. at baseline (twelve weeks), . % of appointments were missed on a weekly basis (range - of available per week), . % were moved, and % of appointments were delayed. during our intervention period (twelve weeks), % were missed, . % were moved, and . % were delayed (combined, both groups). there was no difference in missed ( . % texted vs . % standard), moved ( . % texted vs . % standard) or delayed ( . % text vs . % standard) appointments. though families at our center reported a preference for a text-based reminder, personalized text reminders for appointments did not improve clinic efficiency as measured by missed, moved or delayed transfusion appointments. there was no improvement in appointment adherence in the group receiving personalized texts in addition to standard hospital reminders. university of utah, salt lake city, utah, united states background: childhood cancer outcomes have improved significantly, in large part due to multi-institution collaborative clinical trials run by the children's oncology group (cog). approximately half of eligible children with cancer will enroll on a therapeutic trial, but little is known about the factors affecting caregiver decision-making regarding enrollment or how well the required elements of informed consent are conveyed during the consent process. objectives: . assess coverage of ten of the required elements of informed consent for cog therapeutic trials. . describe factors affecting caregiver decision-making regarding therapeutic trial enrollment. we surveyed families of children who were offered enrollment onto a phase cog therapeutic study for an initial cancer diagnosis in the previous months. fisher's exact or wilcoxon rank-sum tests were utilized to compare demographic and other motivating factors related to enrollment decision-making. results: seventy participants were surveyed. regarding of the basic required elements of informed consent, % knew the trial involved research, % knew consent was required, % knew the enrollment length for the trial, % knew they could continue care independent of enrollment, % knew who to contact with questions, % knew there were options besides enrollment, % knew they could withdraw at any time, % knew the information was confidential, % knew there were risks associated with the trial, and % knew there were benefits. of all participants, % (n = / ) enrolled onto a therapeutic study. among enrollees, % (n = / ) of the primary caregivers had completed college compared to % (n = / ) of those not enrolled (p = . ). when asked about factors impacting their decision, % (n = / ) of those enrolled said they felt there were no risks or did not know if there were risks associated with the study compared to % (n = / ) of those choosing not to enroll (p = . ). of those enrolled, % (n = / ) reported the physician recommendation "somewhat" or "strongly" affected their decision to enroll compared to % (n = / ) of those not enrolling (p = . ). of those who enrolled, % (n = / ) reported feeling pressured to enroll while % (n = / ) of those not enrolled reported pressure (p = . ). of enrollees, % (n = / ) reported they did not have enough time to decide compared to % (n = / ) of those not enrolled (p = . ). failure to convey all required elements of informed consent highlights possible deficiencies in the consent process for cog therapeutic trials. caregivers' perception of being pressured and lack of time to make an informed decision may impact clinical trial enrollment. background: abnormal uterine bleeding (aub) is a frequent adolescent gynecologic complaint. however, limited research exists to guide management, and acute care varies. we sought to improve emergency care for adolescents with aub by developing a clinical effectiveness guideline (ceg) and assessing its impact on quality of care. design/method: a stakeholder engagement group consisting of members from the departments of hematology/oncology, adolescent medicine, general pediatrics, and emergency medicine designed a ceg algorithm for emergency aub management. pediatric residents received ceg training and their knowledge and attitudes were assessed using pre and post intervention surveys. icd- and codes identified electronic health record data for patients presenting to the pediatric emergency department (ed) for aub months before and after ceg implementation. pre-pubertal patients and those with vaginal bleeding from trauma were excluded. a weighted, -point scoring system consisting of prioritized aspects of history, laboratory studies and management was developed to quantify the quality of care provided. t-test, chi square test, wilcoxon rank sum test, and a run chart were used for analysis. of the patients identified, met inclusion criteria. there were % of patients currently using some form of contraception, while . % had bleeding related to a current or recent pregnancy. median aub quality care scores were pre-and post-intervention (p = . ). run chart data showed no shifts or trends (overall median score, -points). both pre and post-implementation, points were deducted most frequently for not assessing personal/family clotting disorder history and inappropriate use/dosing of oral contraceptives. we successfully designed and implemented a ceg and educational intervention for aub management in a pediatric ed. these data suggest our ceg may be an effective tool to improve emergency aub care for adolescents, though additional cycles are needed. background: high-dose methotrexate (hd-mtx) is a common chemotherapy administered inpatient at most centers. its administration is particularly susceptible to error due to the need for frequent drug levels with resulting changes in supportive care. errors can prolong patient stay and cause patient harm. objectives: global aim-to reduce the length of stay (los) of hd-mtx admissions. smart aims-to increase the percentage of patients whose pre-hydration fluids are started by am from % to % by / / , and to increase the percentage of patients who receive hd-mtx by pm from % to % by / / . we used rapid process improvement methods to target earlier methotrexate administration. a key driver of prolonged los was hypothesized to be drug levels returning overnight rather than in the day time due to delayed hd-mtx start. changes implemented have included scheduling hd-mtx patients as the first patients of the day for their exam in clinic and scheduling labs to pass for hd-mtx on the day prior to admission. there are ongoing pdsa cycles to change the location of pre-hydration start from the inpatient room to the clinic exam room in order to meet hd-mtx administration time goals. we are piloting two different education materials to improve patient experience. one explains hd-mtx levels in a red/yellow/green stoplight format and the other reminds patients how to prepare for the admission. other interventions regarding how we test urine ph and safety checks in the ordering process for history of delayed clearance are in the planning stage. the project is ongoing, but as of / / , we start methotrexate by pm % of the time which is improved from a baseline of %. when the project was started, pre-hydration was never started before am. now, fluids are started by am % of the time. pdsa cycles are ongoing and we have yet to sustain reductions in los, but some months have shown decreased los by as much as hours from baseline measurements. rapid cycle improvement can be utilized to decrease los hd-mtx admissions. this has important financial implications as well as the potential to reduce secondary harm from unnecessary time in the hospital. pediatric cancer centers should schedule hd-mtx admissions first thing in the morning so that data regarding kidney injury and drug clearance can be interpreted by the day team and children are not cleared for discharge in the middle of the night. background: education and training for interdisciplinary pediatric oncology providers requires training in principles of palliative and end-of-life (eol) care. the experiences of bereaved parents can inform and enhance palliative care educational curricula in uniquely powerful and valuable ways. the objective of this study is to present an innovative palliative care educational program for oncology providers facilitated by trained bereaved parents who serve as volunteer educators in local and national palliative care educational forums and to describe how incorporation of bereaved parents in these educational forums affects participant comfort with communication and management of children at the eol. design/method: survey tools were adapted to determine how bereaved parent educators affected participant experiences in different educational forums: institutional seminars on pediatric palliative and eol care, role-play based communication training sessions, and an international symposium on pediatric palliative oncology. pre-and post-session surveys with incorporation of retrospective pre-program assessment item to control for response shift were used in the evaluation of institutional seminars and communication training sessions. results from feedback surveys sent to all attendees were used to appraise the participants experience in the international oncology symposium. results: involvement of trained parent educators across diverse, interdisciplinary educational forums improved attendee comfort in communicating with, and caring for, patients and families with serious illness. importantly, parent educators also derive benefit from educational with interdisciplinary clinicians. integration of bereaved parents into palliative and eol care education is an innovative and effective model that benefits both interdisciplinary clinicians and bereaved parents. background: poorly controlled chemotherapy-induced nausea and vomiting (cinv) significantly impairs patients' quality of life and contributes to ongoing medical costs through increased length of stay in the hospital or readmissions and outpatient visits for control of nausea, vomiting or dehydration. lack of adherence to national evidenced-based guidelines that dictate antiemetic prescribing for variably emetogenic chemotherapy leaves patients vulnerable to increased cinv and its ensuing complications. objectives: to review our institution's antiemetic prescribing practices and their consistency with the antiemesis guidelines from the national comprehensive cancer network (nccn) and children's oncology group (cog)-endorsed supportive care guidelines and to further develop tools to increase adherence to these national-based guidelines to improve control of cinv. we performed a retrospective chart review of inpatient chemotherapy encounters. we evaluated emetogenicty of chemotherapy (high, medium, low), initial antiemetic regimen ordered, number of as needed medications required and adherence to national evidenced based guidelines tailored to each level of emetogenicity in the prescription of antiemetics. results: fifty-five total inpatient chemotherapy encounters were reviewed over months. eighteen of these encounters were considered to have been highly emetogenic chemotherapy (hec) with the remaining of these considered to be moderately emetogenic. only out of hec encounters completely included all guideline-recommended agents. there was a demonstrable lack of consistency across providers with dosing of aprepitant and most as needed medications. there was significant variation in order of first, second and third line anti-emetics ordered -with lorazepam and promethazine being used most frequently. with an aim of improving antiemetic prescribing practices for our patients, we are currently rebuilding chemotherapy treatment plans in our electronic medical record to incorporate antiemetic drug order sets that follow evidenced-based guidelines for variably emetogenic chemotherapy. this will be used in conjunction with an education initiative about best practices in supportive care for all prescribers of antiemetics. review of our department's recent inpatient chemotherapy encounters show we are falling short in following nationally recommended standards for appropriate antiemetic coverage during chemotherapy. identification of these deficiencies allows for implementation of quality initiatives to improve prescriber adherence to evidenced-based guidelines for better control of cinv. background: there are currently no consensus guidelines for the management of pediatric oncology patients presenting with fever without neutropenia. historically, these patients had been treated similarly to neutropenic patients with empiric antibiotics. while there has been a shift towards reducing unnecessary empiric treatment, there has been limited research into the outcomes associated with withholding empiric iv antibiotics in this patient population. we assessed the safety and efficacy of our institution's current protocol of observing well-appearing patients who present with fever without neutropenia and compared the outcomes of the patients who did and did not receive empiric iv antibiotics. design/method: this was a prospective, single-institution cohort study. patients were included if they were currently undergoing chemotherapy for an oncologic diagnosis and presented initially as an outpatient with fever and nonneutropenia (defined as anc ≥ cells/mm ). for each episode we recorded lab and blood culture results, signs and symptoms of initial presentation, and clinical outcomes, including antibiotic administration and hospital admission. results: a total of episodes of well-appearing patients with fever without neutropenia were identified. compliance with the institutional protocol was high; . % of patients were observed without receiving empiric iv antibiotics. the majority of patients were discharged home and there were no serious complications or infectious deaths. the incidence of positive blood cultures was low ( . % including several likely contaminants), despite the presence of central venous catheters in the majority ( . %) of patients. there were no significant differences in age, oncologic diagnosis, central s of s line access, anc value, or incidence of bacteremia between patients who did and did not receive empiric iv antibiotics. patients who were admitted to the hospital were significantly more likely to have received iv antibiotics (p < . ) despite documentation of a reassuring exam. however, admitted patients who initially received iv antibiotics were just as likely to discharge within hours compared to patients who were observed. we propose that empiric iv antibiotic administration in febrile, non-neutropenic, otherwise well-appearing patients is unnecessary. our study demonstrated no adverse consequences of observation and no significant differences in clinical outcomes between patients who did and did not receive iv antibiotics aside from rate of hospitalization. this supports the practice of observation without empiric antibiotics for such patients. background: children with hepatoblastoma (hb) undergo repetitive computed tomography (ct) scans to determine response to treatment and assess for relapse. this imaging exposes children to radiation, anesthesia, and imposes financial and emotional burden. objectives: review our institutional experience to determine if afp measurements are sufficient to assess response to treatment and detect relapse. we conducted a retrospective chart review of all patients diagnosed with hb at our institution between - . data collected included serum afp, total number and type of imaging studies during and post treatment, and how relapse or progressive disease was detected. results: thirty-one patients were diagnosed with afp positive hb. during therapy, ct scans were performed: to assess for response to therapy or surgical planning (average scans/patient) and due to concern for progression with rising afp. off therapy, surveillance ct scans were performed (average of . scans/patient) and ( %) included the chest in patients with no lung metastasis at diagnosis. relapsed patients averaged . surveillance scans, . of which were done before relapse was noted on imaging. there were no cases of radiographic evidence of relapse without a prior increase in afp. during treatment, response to therapy based on imaging correlated with a decline in afp in all patients, arguing that repetitive scans are not needed in this setting unless required for surgical planning. only of scans performed during off therapy surveillance displayed evidence of relapse, all of which were preceded by rise in afp. our study represents the largest cohort of hb patients. prior studies suggest similar results, but included fewer patients, lower stage of disease and less than years of surveillance monitoring. at our institution, the cost of a ct c/a/p is $ , with reimbursement varying from - %. in comparison, the cost of an afp measurement is $ . . many scans also require anesthesia and result in emotional toil for families concerned about this procedure as well as the results. thus, afp demonstrates greater sensitivity, with significant cost savings and decreased emotional burden, and should be used for monitoring both during and off therapy, replacing routine serial imaging. background: we observed that our practice of drawing daily blood cultures in hospitalized patients with fever and neutropenia was wasteful; it resulted in excessive negative cultures that did not add to patient care. the smart aim of this quality improvement project was to reduce the number of negative blood cultures drawn on hospitalized patients with fever and neutropenia by % in months. design/method: after reviewing published evidence suggesting drawing daily blood cultures in febrile neutropenic patients was unnecessary, a new blood culture guideline was implemented: cultures were drawn at presentation for fever with neutropenia and, if negative at hours, repeat cultures were not drawn except for clinical change, new fever after being afebrile > hours, or antimicrobials were being changed/broadened. to impact key drivers, we educated staff and changed blood culture order sets to require providers to select a reason for ordering the culture and to eliminate a nursing order to draw daily cultures with fever. we compared the number of blood cultures drawn per central linedays (/ -cld) and the proportion of positive versus negative cultures pre-guideline (july -may ) and postguideline (june -december ). we calculated the cost savings from reducing cultures. to assess patient safety, potential septic events without a corresponding positive blood culture were reviewed. data were analyzed by service (oncology and stem cell transplant). a chi-square test was used to compare rates. in stem cell transplant patients, pre vs. postguideline, there were vs. total cultures drawn/ -cld; vs. positive ( % decrease, p = . ) and vs. negative cultures/ -cld ( % decrease, p< . ). in oncology patients, pre vs. post-guideline, there were vs. total cultures drawn/ -cld; vs. positive ( % decrease, p = . ) and vs. negative cultures/ -cld ( % decrease, p< . ). the decreased positive culture rate among oncology patients may be due to decreased culture contaminants and/or the effect of a concurrent initiative to decrease clabsi in that group. there were safety concerns; however, chart review concluded that the guideline did not lead to missed infections in these patients. for the first months of the guideline, the total cost savings in blood cultures was $ , . . the implementation of our new blood culture guideline successfully led to a substantial reduction in the collection of negative cultures and a cost savings without compromising the detection of bacteremia in hospitalized pediatric patients with fever and neutropenia. background: there are various evidence-based guidelines for treatment of adult cancers, such as the nccn guidelines. previously, care was standardized for most new diagnosis pediatric cancer patients through enrollment on a clinical trial. with decreasing clinical trial availability and enrollment and few, if any, evidence-based guidelines for pediatric cancer, care standardization is challenging for pediatric cancers. objectives: to assess consistency of care, as determined by plan of treatment by diagnosis, for pediatric patients receiving chemotherapy for newly diagnosed cancer at a single center. design/method: patients with a new cancer diagnosis at a large, tertiary care pediatric oncology center in calendar year were identified through reports from the chemotherapy order entry (coe) system. reports included diagnosis (recorded through standardized options) and the plan of treatment. chart review was used to exclude patients who started treatment elsewhere and patients being treated for relapse, to clarify diagnosis if the standardized options in coe were unclear, and to clarify treatment plan if needed. data was entered and analyzed in a redcap database. specific diagnoses were clustered into higher level disease groups and the distribution of treatment plans for patients within each was determined. this project was deemed exempt from irb approval for human subject research as a qualifying quality improvement project. of the patients with a first chemotherapy order in , were excluded due to one or more reasons: stem cell transplant ( ), transfer of care ( ), relapse ( ), and other ( ). an additional patients were excluded because < patients/year/diagnosis. there was no cns tumor disease group with > patients. thus, patients with hematologic malignancies or non-cns solid tumors are the focus of this analysis. for patients with intermediate risk rhabdomyosarcoma, the plan of treatment was the standard arm of a cog protocol, arst for patients and arst for subsequent patient after protocol activation. for all other diseases including lymphoblastic leukemia/lymphoma (excluding infants), classical hodgkin lymphoma, aml (excluding trisomy and apml), stage iii/iv burkitt lymphoma/diffuse large b-cell lymphoma, posttransplant lymphoproliferative disease, wilms tumor, rhabdomyosarcoma, ewings sarcoma, osteosarcoma, neuroblastoma, and retinoblastoma, only one treatment plan per risk category was used. conclusion: this analysis demonstrates highly consistent chemotherapy treatment at a single center for patients with hematologic malignancies and non-cns solid tumors. next steps include exploring strategies to group diagnoses for cns tumors and assessing the quality of evidence supporting the treatments given. background: rapid initiation of empiric antibiotics in patients with fever and neutropenia has been shown to reduce morbidity and mortality. current practice guidelines call for the initiation of antibiotics in these patients within sixty minutes and time-to-antibiotic (tta) has been suggested as a quality-of-care measure. many institutions, including our own, face barriers to meeting this time limit. objectives: utilizing a quality improvement model, determine barriers and implement an intervention to reduce the time-to-antibiotics for pediatric febrile patients with suspected neutropenia who present to the emergency department (ed) at our institution. we have identified and implemented an intervention utilizing the plan-do-study-act model for quality improvement. a twelve-month retrospective review was conducted to evaluate the efficacy of the current practice algorithm at our large, academic tertiary-care hospital. subjects identified were pediatric oncology patients undergoing active chemotherapy who presented to the ed with febrile neutropenia. we identified two specific barriers, triage level assignments and delay in ordering antibiotics. to address these barriers, we have created a wallet sized "fever card" that patients were instructed to show upon arrive to the ed. in collaboration with the ed staff, efforts were also made to educate all pediatric staff on the use of the fever card. post-intervention data collection is currently underway and pre-and post-intervention antibiotic delivery times will be compared. the pre-intervention cohort consisted of thirty-three encounters with a mean time-to-antibiotic delivery of minutes, or seventy-five minutes greater than the accepted standard of care. only one patient received antibiotics within sixty minutes of arrival. post-intervention data collection is currently underway. since identifying two barriers to meeting the standard of care at our institution, we have implemented a quality improvement measure that empowers patient families to direct appropriate triage in the ed as well as simplifying the treatment protocol for ed providers. we expect to identify an improvement in time-to-antibiotics from the pre-intervention to the post-intervention period. background: sickle cell disease (scd) is a genetic disorder in which sickle hemoglobin (hbs) triggers multiple downstream effects, including red cell sickling, hemolysis, vaso-occlusion, and inflammation. scd, a lifelong disease initiated at birth with injury that accumulates over time, causes significant end-organ damage and clinical complications that are undertreated and associated with early death. homozygous mutation (hbss) causes the severe form of scd. individuals with scd are at increased risk of infection, stroke, and retinopathy. clinical guidelines for pediatric patients with scd recommend prophylactic penicillin use (ages - ), annual screening for stroke with transcranial doppler (tcd) imaging (ages - ), and annual ophthalmology exams to assess for retinopathy (ages ≥ ). there are limited real-world data on implementation of these nhlbi-based recommendations. objectives: to describe utilization of penicillin, tcd screening, and ophthalmology care in children with hbss disease. medicaid administrative claims databases were used to identify us patients aged - years at first indication of hbss recorded in each calendar year from to . patients were required to have medical and pharmacy benefits for the calendar year in which they were identified and for months prior to their first recorded hbss indication. prior year utilization of penicillin, tcds, and ophthalmologist visits was measured for each annual cohort. annual cohorts included - commercial (mean age . years, % female) and - medicaid (mean age . years, % female) patients with hbss disease. fewer than half of all patients had received a tcd scan in the previous year, with similar rates seen across all age groups for both payers. ophthalmologist visits increased as patients aged, and while patients aged - years had the highest proportion with an ophthalmologist visit in both payer populations, the overall implementation remained low. in contrast to the low use of tcd and ophthalmology visits, penicillin use was highest in the - year age group: > % use in any given year for both payers. conclusion: although our data demonstrated high penicillin use in the - year age group, consistent with guidelines there is an opportunity to improve implementation of other guidelines-based recommended screening. for example, tcd screening can identify children at risk of scd-related stroke in order to initiate preventive therapies. further research to understand potential barriers to proper screening and to evaluate strategies to improve awareness, adherence, and implementation of recommended screenings in children with scd is warranted. supported by global blood therapeutics. background: childhood cancer therapy has improved where there are many long-term survivors. while psychosocial difficulties in pediatric cancer survivors are recognized, the prevalence of these problems at initial survivorship presentation is unclear. objectives: to examine the prevalence of overall internalizing symptoms (e.g., depression/anxiety) in pediatric cancer survivors presenting to a survivorship clinic and to examine how this is mitigated by receiving psychological services and by evidence of parental depression/anxiety. design/method: pediatric cancer survivors attending their first visit at the reach for survivorship clinic at vanderbilt (ages - ) were included. survivors' parents ( % female) completed the child behavior checklist (cbcl), beck depression inventory-ii, and beck anxiety inventory. survivors > years completed a self-report. the wilcoxon rank-sum and pearson's test were used for univariate analyses. the effect size and % confidence intervals (ci) estimated from the multivariable linear regressions were reported. results: childhood cancer survivors a median of years old and . years off therapy were included. thirty one survivors ( %) showed at least borderline clinical internalizing problems (t score > ) on the cbcl, but only of these patients ( %) reported receiving psychological services. nine other survivors with normal t score ≤ also reported receiving psychological services. parental depressive and anxiety symptoms were correlated to the parental report of survivor overall internalizing symptoms (spearman = . , p = < . and = . , p = < . respectively), however they were not correlated to survivor selfreports. furthermore, parents with mild to severe depressive symptoms or mild to severe anxiety symptoms were more likely to rate their child as having higher overall internalizing symptoms (p = . ; p = . , respectively). multivariable linear regression showed that when adjusted for age, gender, cancer diagnosis and time off treatment, reported utilization of psychological services ( = . , % ci [ . , . ],p = . ), and parent depressive symptoms ( = . , [. , . ],p< . ) were significantly associated with child overall internalizing symptoms. in an otherwise identical alternate model substituting parental anxiety for parental depression, parental anxiety was also a significant risk factor ( = . , [. , . ], p< . ). alternatively, parent anxiety/depressive symptoms were not significantly associated with child self-report of internalizing symptoms. childhood cancer survivors have an elevated prevalence of experiencing internalizing symptoms but seldom report receiving psychological services. childhood cancer survivors' parents with anxious/depressed symptoms are more likely to rate their children as having more internalizing problems, compared to patient self-reports. ongoing longitudinal analyses will help clarify the best timing for potential interventions. background: life expectancy for adults with sickle cell disease (scd) has remained unchanged over the past years despite improvements in pediatric scd survival. at greatest risk are the adolescents and young adults (ayas) transitioning from pediatric to adult care. allen county ranks rd in scd incidence among the counties in indiana, and has board certified pediatric hematologist-oncologists. when children "age out" of the pediatric system, there are few providers knowledgeable about managing adults with scd in the region. a novel partnership between hematologists and the family medicine residency program in allen county was initiated to educate family medicine residents (fps) about scd, hydroxyurea (hu), and management of scd-related complications with the goal to increase the number of knowledgeable providers to care for adults with scd. to determine the effectiveness of online learning modules in educating fps about hu, best practices for aya scd care and transition. three online learning modules about scd (comprehensive care of ayas with scd, hu, best practices in aya transition) were developed and cme-accredited. electronic pre-and post-tests were distributed to fps with five questions for each module covering: contraception; screening tests; hu indications, dosing and monitoring; developmental milestones and scd knowledge assessments. the st vincent irb reviewed the protocol and granted a waiver of consent. results: twenty-six fps ( %) completed the pre-and posttests. over two-thirds correctly identified the clinical benefits of hu on both assessments. knowledge about the rationale for hu therapy increased after the completion of the hu module ( % correct on pre-test vs. % on post-test, p = . ). the proportion of correct responses increased for all comprehensive aya scd care post-test questions, but only the leading cause of death and the priapism-related questions reached statistical significance ( % vs. %, p = . ; % vs. %, p = . , respectively). the proportion of correct responses for of the transition-focused questions was unchanged ( % for both), while the proportion of correct post-test responses on the self-care assessment question significantly increased ( % vs. %, p = . ). after module completion, fps were able to correctly identify common scd complications and why hu is an effective treatment for individuals with scd. the best practices of transition clinic module may need modification to improve physician understanding of the intricacies in establishing and maintaining a scd transition clinic. overall, online training is effective at educating fps and could be used to increase the number of providers knowledgeable about scd care. background: survival rates for pediatric hodgkin lymphoma (hl) exceed % with contemporary therapy. studies of pediatric hl survivors treated in the s- s have shown increased risk for treatment-related chronic health conditions. risk-adapted therapy, including tailored radiotherapy, has been developed to reduce long-term morbidity while maintaining excellent survival. little is known about chronic conditions associated with contemporary therapy presenting during the first years from therapy completion (early outcomes). objectives: to analyze survival and early outcomes of pediatric hl patients treated with contemporary therapy. we conducted a retrospective review of hl patients diagnosed < years of age at our institution from - . three-year overall (os) and event-free (efs) survival were calculated with kaplan meier statistics using sas . . results of standardized screening for targeted toxicities that developed between - years from therapy completion were identified and graded per ctcae criteria. censoring occurred at date of death, years from therapy completion, or december , . data from the last collection point were used for prevalence calculations in cases with multiple evaluations. we identified patients ( % male; % non-hispanic white; mean age at diagnosis . ± . years) with a median time since therapy completion of . years (range . - . ). initial treatment included: ( %) chemotherapy only and ( %) multimodality treatment. all patients received anthracyclines (median dose mg/m ) and % received alkylating agents (median cyclophosphamide equivalent dose [ced] mg/m ). the -year os was % with an efs of % ( % chemotherapy only, % multimodality treatment; p = . ). patients with relapsed/refractory disease received salvage treatment including chemotherapy only (n = ), multimodality therapy (n = ), or multimodality treatment including stem cell transplant (autologous n = ; autologous+allogeneic n = ). no patients developed thyroid dysfunction, cardiac dysfunction, subsequent neoplasm, or male gonadal dysfunction during the study period. pulmonary dysfunction was limited to ctcae grade . anti-mullerian hormone (amh) below the normal range was found in / pubertal females who received ced ≥ mg/m compared to / females who received ced < mg/m . two of the females with low amh also had follicle stimulating hormone > iu/ml. this study is the first to evaluate early outcomes in pediatric hl survivors. the results indicate contemporary chemotherapy and a lower rate of radiotherapy utilization lead to excellent -year survival rates with minimal early toxicities. females exposed to ced ≥ mg/m are at increased risk for gonadal dysfunction and should be prioritized for fertility preservation approaches prior to initiation of cancer therapy. background: cancer is one of the leading disease-related causes of death among individuals aged < years in the united states. recent evaluations of national trends of pediatric cancer used data from before , or covered ≤ % of the us population. objectives: this study describes pediatric cancer incidence rates and trends by using the most recent and comprehensive cancer registry data available in the us. design/method: data from us cancer statistics were used to evaluate cancer incidence rates and trends among individuals aged < years during - . data were from states and covered % of the us population. we assessed trends by calculating average annual percent change (aapc) in rates using joinpoint regression. rates and trends were stratified by sex, age, race/ethnicity, us census region, county-based economic status, and county-based rural/urban classification, and cancer type, as grouped by the international classification of childhood cancer (iccc). we identified , cases of pediatric cancer during - . the overall cancer incidence rate was . per million; incidence rates were highest for leukemia ( . ), brain tumors ( . ), and lymphoma ( . ). rates were highest among males, aged - years, non-hispanic whites, the northeast us census region, the top % of counties by economic status, and metropolitan counties. the overall pediatric cancer incidence rate increased (aapc = . , % ci, . - . ) during - and contained no joinpoints. rates increased in each stratum of sex, age, race/ethnicity (except non-hispanic american indian/alaska native), region, economic status, and rural/urban classification. rates were stable for most individual cancer types, but increased for non-hodgkin lymphomas except burkitt lymphoma (iccc group ii(b), aapc = . , % ci, . - . ), central nervous system neoplasms (group iii, aapc = . , % ci, . - . ), renal tumors (group vi, aapc = . , % ci, . - . ), hepatic tumors (group vii, aapc = . , % ci, . - . ), and thyroid carcinomas (group xi(b), aapc = . , % ci, . - . ). rates of malignant melanoma decreased (group xi(d), aapc = - . , % ci, - . -- . ). this study documents increased rates of pediatric cancer during - , in each of the demographic variables examined. increased overall rates of hepatic cancer and decreased rates of melanoma are novel findings using data since . next steps in addressing changing rates could include investigation of diagnostic and reporting standards, host biologic factors, environmental exposures, or potential interventions for reducing cancer risk. increasing pediatric cancer incidence rates may necessitate changes related to treatment and survivorship care capacity. background: while childhood cancer treatment modalities have improved, the delayed effects of cancer treatment continue to compromise the quality of life in survivors. metabolic syndrome (ms) is diagnosed based on the presence of three of the following findings -obesity, dyslipidemia, hypertension and insulin resistance per the world health organization (who) criteria. the increased risk of ms among childhood cancer survivors was first reported in the 's and is known to increase the incidence of cardiovascular disease in these individuals. objectives: assess the frequency of ms in childhood cancer survivors at our institution. . we conducted a retrospective chart review on pediatric cancer survivors, - years of age, who had been treated at sri ramachandra medical institute and research foundation between august and august . patients who received at least one year of treatment with s of s chemotherapy and/or radiation and surgery were included. medical history, family history of diabetes, cardiovascular diseases, and hypercholesterolemia, tanner staging, weight for height (< y per who criteria), bmi (> y per indian academy of pediatrics iap), blood pressure (nhlbi criteria), fasting blood sugar levels and lipid profile were obtained from the charts. statistical analysis of the data was done using ibm spss statistical software (version ). results: patients were studied, . % were male. . % were under years of age, . % between - years and . % above years. leukemia survivors comprised . % of the sample and non-leukemic's were . %. . % were treated with chemotherapy alone, . % with radiotherapy and chemotherapy, and . % underwent surgery with radiotherapy and chemotherapy. hypertension was found in . % of the study group, dyslipidemia in %, impaired fasting blood glucose in . % and . % were found to be obese. % of the study group was diagnosed with ms based on who criteria. conclusion: % of our study population was found to have ms per who criteria. individual metabolic complications were detected in % of the population. acute lymphoblastic leukemia (all) survivors appeared to be at high risk in our population. ms has been known to increase cardiovascular complications in cancer survivors. a multidisciplinary team approach to management of these patients is important to closely monitor and manage the long-term complications related to ms such as type diabetes and atherosclerosis. such an approach is essential to decrease long term morbidity and mortality from ms in this vulnerable population. background: the -year survival rate for childhood cancer exceeds %. however, up to % of these children require admission to the pediatric intensive care unit (picu) within three years of diagnosis. these children account for approximately % of all picu deaths, with mortality being higher for those post-hematopoietic stem cell transplant (hsct). national guidelines recommend that providers share informa-tion regarding prognosis and treatment options within the first hours of icu admission. these prognostic goals of care conversations (pgocc) are critical to the care of children with malignancies, a subpopulation at risk for increased mortality. to determine the frequency of pgocc as well as describe differences in patient characteristics and critical care therapies by pgocc status. design/method: a retrospective cohort study was conducted using the university of michigan virtual picu system database. picu admissions lasting longer than hours for patients ages to years between july , and june , with an oncologic diagnosis and/or hsct were identified. data on pgocc, patient demographics, diagnoses, picu interventions, and outcomes were recorded and compared between children with pgocc and those without using chi square test for categorical variables and kruskal-wallis test for continuous data. of picu admissions, % were male; the mean age was . years. the leading diagnoses were acute lymphoblastic leukemia ( %), acute myeloid leukemia ( %), lymphoma ( %), neuroblastoma ( %), and brain tumors ( %), and % of patients were post-hsct. pgocc was documented in ( %) patients. in comparison with patients who did not have a pgocc, children with a pgocc were more likely to be readmitted to the picu ( % vs. %, p < . ) and more likely to have had relapse of disease ( % vs. %, p< . ). patients with a pgocc had higher severity of illness scores (p = . ), higher use of non-invasive ( . % vs. . %, p = . ) and invasive conventional ventilation ( . % vs. . %, p< . ), and high frequency ventilation ( . % vs. . %, p < . ). also, patients with pgocc were more likely to receive continuous renal replacement therapy ( . % vs. . %, p< . ), arterial catheterization ( . % vs. . %, p< . ), and cardiopulmonary resuscitation ( . % vs. . %, p< . ). in only in critically ill children with hematologic-oncologic disease is pgocc held. children with pgocc were sicker and received more critical care interventions. future research is needed to evaluate the content of pgocc. background: central nervous system (cns) tumors and autism spectrum disorder (asd) represent significant disease cohorts in the pediatric population. asd diagnoses in children have a prevalence of %, in every children in the united states. additionally, more than , cns tumors are reported in children age to years in the united states with brain tumors being the most common solid tumor and the leading cause of death among all childhood cancers. the genetic etiology of autism and cns tumors is complex. specific gene alterations present in certain cancers have similarly been described and suspected to play a role in asd subtypes. targeted therapy panels, like foundation one (fo), have been beneficial in guiding treatment for some cancers based on distinct gene alterations. given the genetic overlap, the potential for therapeutic benefit and crossover from such actionable gene target panels merit further exploration in asd and cns tumors. we aim to identify and describe genetic alterations with known actionable targets in cancer therapy from fo as potential diagnostic, therapeutic and research targets for neurodevelopmental diseases. we plan to discuss the common genetic alterations between our cancers and neurodevelopmental diseases described in the literature. fo data was extracted and compared to the literature. each reported gene alteration from fo plus the keywords "autism", "psych" were used on pubmed to search for a suspected association if any with a neurodevelopmental disorder. results: twenty-one patients representing a cohort of six unique (astrocytoma-five, ependymoma-six, gbm-four, glioma-three, nerve sheath tumor-one, etmr-two) cns tumors were investigated. fo produced eighty total with sixty unique gene alterations. thirty-one ( %) of these yielded at least one published, suspected association to a neurodevelopmental disorder. the most common gene alterations were tp -four, cdkn a/b-five and braf-four. the main functional categories were cellular: proliferation, structure, differentiation and degradation; chromatin modeling; histone transcriptional modification; dna methylation and repair; strna; and neural signaling. sixty unique gene alterations were found in our cns tumor set using foundation one. thirty-one ( %) of these discrete alterations paired with at least one description in the literature as having been similarly altered in an asd subtype. many of these alterations have actionable targeted therapies presented through foundation one for our cns tumors and may be a relevant guide in the future of targeted therapy and research in asd subtypes. monoclonal antibody therapy usage is associated with significantly improved survival in b-cell nhl aya patients. although the usage has increased in the aya population from to , the magnitude of the increase is low. factors that affect the use of mab include race and insurance s of s type. further research is warranted to identify why privately insured patients are less likely to receive these drugs. background: prevention of chemotherapy-induced nausea and vomiting (cinv) remains a challenge despite advances in pharmacotherapy and the development of cinv clinical practice guidelines by the pediatric oncology group of ontario (pogo) that have been endorsed by the children's oncology group. achieving control of cinv in pediatrics further is complicated by the difficulty young children have vocalizing their symptoms. use of a validated nausea-assessment tool in conjunction with improved adherence to evidence-based guidelines may result in better quantification of symptoms and reduction of both nausea severity and vomiting frequency for pediatric patients undergoing chemotherapy. the pediatric nausea assessment tool (penat) has been validated for children ages - , and its integration into clinical practice may help optimize cinv control. objectives: this single-institution study sought to improve control of cinv in patients admitted for chemotherapy by standardizing the antiemetic regimens prescribed by all providers according to an institutional cinv algorithm developed from the pogo guidelines. we hypothesized that treatment using a standardized guideline would improve cinv control in patients admitted for chemotherapy. a baseline cohort of admissions for chemotherapy completed penat assessments and cinv diaries prior to receiving chemotherapy, four times daily during each admission, and daily for days following completion of chemotherapy from may , to january , . providers then were provided an institutional cinv treatment algorithm based on the pogo guidelines and received education at departmental meetings on appropriate implementation of this algorithm. a second cohort of admissions completed penat assessments and cinv diaries in a similar fashion from july , to december , . results: complete control of vomiting markedly improved following cinv guideline implementation ( % vs %, p <. ) with treatment failure also significantly reduced ( % vs %, p <. ). after controlling for the degree of emetogenicity of chemotherapy received, a patient was . times more likely to vomit prior to guideline implementation (or . , ci . - . ). there was no difference in nausea control, even after adjusting for the emetogenicity of chemotherapy. conclusion: control of chemotherapy-induced vomiting (civ) improved following widespread implementation of an institutional cinv treatment algorithm at a single institution. the severity of nausea reported remained unchanged which may reflect the difficulty of assessing nausea or an inadequate sample size. future research may focus on cinv treatment management through the use of guidelines specifically for breakthrough cinv and delayed cinv. background: aspho's professional development committee (pdc) recognized pediatric hematologists-oncologists (phos) serving in the united states (us) military have unique professional development needs that may not be addressed by aspho or a similar professional society. these individuals may also encounter challenges when transitioning to a civilian career. however, barriers to professional development have not been systematically characterized. the objectives were to characterize the number of phos with current or prior military service (mphos) and to identify any unmet professional development needs. design/method: a working group consisting of pdc members and both senior and early career mphos was formed. initial comments were solicited by email from known mphos regarding potential gaps in professional development and interest in working with aspho to improve support of mphos. a survey was developed and piloted with four members of the advisory group, questions were revised based on their feedback, and a final version was distributed via the aspho website and online community forum. targeted emails were sent to mphos identified through aspho and military databases. eligibility to complete the survey included ) completion of a fellowship in pediatric hematologyoncology, and ) current or prior service as an active duty military provider. quantitative and qualitative information were collected, including demographic data and perceived barriers to professional development. responses were summarized using descriptive statistics. results: sixty-five mphos were identified and surveys were completed for a % response rate. respondents were engaged in a variety of professional activities; % were male, % were serving active duty commitments, and % felt there were professional development gaps. areas of concern were categorized into nine themes with the most concerning being ) limited civilian knowledge of mpho practices ( % of participants), ) inability to attend professional society meetings ( %), and possibility of deployment ( %). participants expressed a desire for educational products to meet their specific needs and for networking opportunities with civilian colleagues. qualitative analyses identified concerns about low patient numbers and practice size. a subset of mphos perceive significant gaps in professional development. additional research is needed to better define areas for intervention, but many of the concerns align with those of similarly sized civilian programs and may be addressed through professional society networking opportunities, such as an aspho special interest group. background: infertility is an established cause of distress and has a negative impact on quality of life among childhood cancer survivors. the american society of clinical oncology has established guidelines on fertility counseling for individuals of reproductive age diagnosed with cancer, with the goal of improving reproductive and psychosocial outcomes. studies have shown that instituting a fertility team that can provide counseling and discuss fertility preservation (fp) options results in improved patient satisfaction in patients with cancer. objectives: the goal of this study was to examine predictors of referrals to the multidisciplinary fertility team, and documented fp interventions among these patients. design/method: an irb-approved retrospective medical record review was performed at a large pediatric academic center. all patients with new cancer diagnoses receiving chemotherapy were included from january (when the fertility team was established) to present. a standardized abstraction form was used to collect information about: age at diagnosis, gender, cancer type, whether a fertility consult was placed, and documented fp interventions. data were summarized descriptively and comparisons were made using nonparametric statistical methods. results: patients met inclusion criteria, of which ( %) were male. cancer types were as follows: leukemia/lymphoma, cns tumors, sarcomas, embryonal tumors, and langerhan's cell histiocytosis (lch). the mean age was . years, (range < - years). overall, % of all patients had a consultation with the fertility team. patients were significantly less likely to have a fertility consult if they were younger (p< . ). further, there were differences in the consultation rate between diagnoses, with % of sarcoma patients completing a consult, compared to % of those with cns tumors, % of those with embryonal tumor, % of those with leukemia/lymphoma and none of the patients with lch. our findings show that many children, adolescents, and young adults newly diagnosed with cancer are still not receiving fertility counseling despite: ) an expanding body of literature supporting the need to provide this counseling, ) guidelines published by several organizations recommending discussions about infertility risk and fp options, and ) presence of a multidisciplinary fertility team. specific strategies need to be developed to improve access for younger children, and for disease groups in whom fertility consults are underutilized, such as youth with cns tumors, embryonal tumors, and leukemia/lymphoma. background: socioeconomic status (ses) has on impact on overall survival in the pediatric oncology population. unfortunately, data are insufficiently detailed to explain the mechanism behind this phenomenon. how parents handle the health management demands placed on them at the time of a child's cancer diagnosis may represent a point of differentiation in health outcomes. objectives: determine the association between socioeconomic factors, cancer literacy, and parents' understanding of home emergency management and their responses to instances of pain, nausea, and fever. in a prospective observational study of parents whose children were newly diagnosed with cancer, we obtained demographic information and, using a validated instrument, (dumenci, ) we evaluated cancer literacy. we tested understanding of the education parents received about home emergency management with a -item multiple-choice vignette-based questionnaire focused on actions needed in home scenarios. we then followed parents' actual behavior through periodic phone calls assessing instances of nausea, pain, and fever and their responses to these episodes. results: preliminary analysis of participants showed an average score of on the -item parental understanding questionnaire (range - ). variables associated with increased score were college-level education by . points ( % ci [. to . ]), private insurance by . points [. to . ] and adequate cancer literacy by . points [. to . ]. actual behavior reported by families indicated that married parents and those with income above $ , were less likely to treat instances of pain by % ( % ci [ to ]) and % [ . to ], respectively. white parents, those with college-level education, and those with adequate cancer literacy were less likely to treat instances of nausea by % [ to ], % [ to ] and % [ to ], respectively. no associations were found between socioeconomic markers and parental responses to instances of fever. our findings suggest an association between demographic and socioeconomic markers and improved parental understanding of home emergency management. paradoxically, the same markers show a decrease in treatment response to pain and nausea. larger prospective studies are needed to link this behavior pattern to health outcomes, and help inform the extent of ses impact on home emergency management. emory university/children's heathcare of atlanta, atlanta, georgia, united states background: cardiovascular disease is a leading cause of morbidity and mortality in childhood cancer survivors (ccs). previous research showed wide practice variation in referral patterns to cardiology from the survivor clinic and in recommendations from cardiologists about the need for further testing or exercise restrictions. to develop a cardio-oncology algorithm in order to standardize referrals to cardiology and provide guidelines for cardiologists evaluating pediatric ccs. design/method: survivorship and cardiology experts developed a weighted scoring system for pediatric ccs who received cardiotoxic therapy based on time since treatment and risk factors identified by the children's oncology group (cog) and american heart association (aha). the cardiooncology algorithm assigned a score of - . the score range was categorized to guide cardiology referral: screening echo only ( - ), consider cardiology referral ( - ), recommend cardiology referral ( - ), and regular cardiology follow-up (≥ ). the algorithm also provides recommendations to cardiologists for screening and exercise modifications based on the score. after establishment of the algorithm, a convenience sample of institutional survivor clinic patient charts were retrospectively reviewed from the first month of each quarter from april -march to validate the algorithm, evaluate referral patterns to cardiology, and assess cardiology recommendations. the retrospective chart review evaluated patients ( % male; % non-hispanic white; % leukemia survivors; median age at diagnosis . years [range - . ]; median time off-therapy . years [range . - . ]). patients ( %) received anthracyclines (median dose mg/m , range - ) and ( %) received cardiac radiation. assigned cardio-oncology scores resulted in: % echo only, % consider cardiology referral, % recommend cardiology referral, and % regular cardiology followup. when evaluating detection rates of late effects by cardiooncology score, survivors ( %) had an abnormal echo: / echo only, / consider referral, / recommend referral, and / regular cardiology follow-up. assessing referral patterns prior to initiation of the algorithm revealed forty-two survivors ( %) referred to cardiology: / echo only, / consider referral, / recommend referral, and / regular cardiology follow-up. of the patients seen by a cardiologist at our institution, had further diagnostic testing ordered (i.e., stress test) and received exercise restrictions. a cardio-oncology algorithm and guidelines will standardize cardiac care for survivors by assigning a score to guide referral and cardiology practice after referral. prospective clinical use has begun and review will occur in one year to determine changes in detection rates of cardiac late effects, referrals, and recommendations from cardiologists. oregon health and science university, portland, oregon, united states background: delirium affects - % of patients (pts) in pediatric intensive care units (picu) and is associated with increased length of stay, decreased attention in school, and post-traumatic stress disorder. the diagnostic and statistical manual of mental disorders (dsm v) defines delirium as a "disturbance of consciousness […] with reduced ability to focus, sustain or shift attention" due to an underlying medical condition. despite the medical complexity of the hospitalized pho population, there are no published prospective studies looking at delirium in these pts. hypothesizing that delirium is under recognized in the pho population, we designed a year-long prospective study using a validated screening tool to determine the frequency of delirium in hospitalized pho pts and to identify associated clinical factors. design/method: baseline frequency of pts with symptoms suggestive of delirium was determined through retrospective chart review using a data mining program of electronic medical records (emr). for the prospective study, pho and picu nurses were trained to use the cornell assessment for pediatric delirium and to record scores within the emr on all pho pts once every -hour shift. predetermined demographic and clinical variables were entered daily into a red-cap database on all hospitalized pho pts. results: baseline frequency of delirium, without active screening, was determined to be . % of hospitalized pho pts. in the first months of the prospective study, consecutive admissions occurred among unique pho pts: oncology, hematology, and stem cell transplant pts. pts had at least positive delirium screen, for a prevalence per admission of . %. statistically significant variables associated with delirium, at p < . by univariate logistical regression, included prolonged length of stay, pt location (picu vs pho unit), and fever. adjusting for length of stay, administration of benzodiazepines and opiates were also significantly associated with delirium, p = . and . , respectively. on average, nurses completed delirium screening in % of each pts' -hour shifts. study accrual ends in jan and final data analyses will be reported in the abstract presentation. conclusion: delirium does occur in the pho hospitalized population and screening by trained nursing staff is feasible. pts at highest risk appear to be pts with prolonged hospital stays, picu admissions, or frequent use of benzodiazepines/opioids. routine screening should improve our recognition of delirium and allow us to promptly intervene, or prevent delirium in an effort to avoid potential acute and long term consequences. background: with high survival rates for children and adolescents with hodgkin lymphoma (hl), treatment regimens are now designed to maximize cure while decreasing risk of long-term health outcomes associated with chemotherapy and radiation therapy. within contemporary treatment regimens, the comparison of toxicities experienced by patients receiving chemotherapy plus radiotherapy (crt) versus only chemotherapy (co) has not been studied extensively. objectives: this study examines select self-reported adverse health outcomes in survivors of contemporarily-treated pediatric hl to better understand the balance between efficacy and toxicity associated with chemotherapy and radiation therapy. (cog) ahod that evaluated a response-based treatment paradigm in pediatric hl. patient who received initial chemotherapy were randomized based on early response to continued chemotherapy, chemotherapy plus radiotherapy or augmented chemotherapy plus radiotherapy. patients completed self-report questionnaires on health problems at , , , and years following therapy. we examined selected patient-reported pulmonary, gastrointestinal (gi), cardiac and endocrine outcomes. kaplan-meier survival curves were used to determine probability of survival without the selected adverse health outcome. log-rank tests were used to compare the co versus the crt group. results: a total of , enrolled patients, patients in the co group and patients in the crt group, completed , questionnaires at a median of . years after s of s completion of therapy (q , q : . , . ) which were analyzed. the cumulative -year incidence of endocrine dysfunction was significantly greater in the crt group versus those in the co group ( % versus %; p< . ), driven by the incidence of hypothyroidism ( % versus %; p< . ). there were no significant differences in cardiac ( % versus %; p = . ), pulmonary ( % versus % p = . ), and gastrointestinal dysfunction ( % versus %; p = . ) between the co and crt patients. conclusion: this study demonstrates low cumulative incidence overall of organ dysfunction early post completion of contemporary therapy for hl. the addition of radiation therapy significantly increased risk for hypothyroidism, but with no higher risk noted for cardiac, pulmonary or gi dysfunction. limitations include self-report status, potential selection bias, and relatively short latency period following end of therapy. longer follow-up is needed to determine more delayed risks for organ dysfunction in order to best define the balance between therapeutic efficacy and long-term adverse health outcomes related to chemotherapy and/or radiation therapy. background: identification of an organism via bronchoalveolar lavage (bal) or respiratory tract biopsy (rtb) has historically been considered the gold standard for diagnosis of invasive fungal infection (ifi); however, data previously published by our group showed that these procedures infrequently lead to a change in management in children with an oncological diagnosis or undergoing hematopoietic stem cell transplant (hsct). there is also a paucity of data on the cost of ifi in this population. to compare the costs of work-up and management of pulmonary ifi diagnosed based on ct scan alone versus ct scan or chest x-ray prompting a bal or rtb. design/method: we collected cost data on patients at ann & robert h. lurie children's hospital of chicago undergoing chemotherapy or within months of hsct who were suspected of having an ifi between and . in order to include sufficient time to account for post-procedure compli-cations but avoid including costs unrelated to ifi, data were included for days from the day of their diagnostic scan or procedure. cost data was available for of the patients previously studied. thirty-six of these patients were diagnosed with suspected ifi based on ct only and patients underwent bal or rtb. when evaluating specific costs, inpatient beds costs were higher in the bal and rtb group (median $ , versus $ , , p = . ), yet there was only a trend towards higher costs for antifungal agents (median $ , versus $ , , p = . ) and respiratory support (median $ versus $ , p = . ). many of the initial ct scans were not captured in the -day evaluation period for the bal or rtb group based on the study design; however, even when accounting for ct scans up to a week prior these procedures, the total cost of ct scans was higher in the ct only group (median $ versus $ , p = . ), as they had more scans. despite this, total costs were significantly higher for patients who underwent bal or rtb versus ct scan only (median $ , versus $ , , p < . ). combined with our previous data that bal and rtb infrequently leads to a change in management in children with an oncological diagnosis or undergoing hsct suspected to have an ifi, the significantly higher costs associated with these procedures makes these invasive diagnostic techniques even less desirable. batra, pediatr blood cancer, . background: while infants > months of age with acute lymphoblastic leukemia (all) have a poor prognosis, infants with acute myeloid leukemia (aml) fare better despite more intensive therapy. there are limited data on this difference, particularly differences in supportive care requirements during induction therapy for infants. objectives: to compare induction mortality and resource utilization in infants relative to non-infants aged < years, separately for all and aml. design/method: we used previously established cohorts of children treated for new onset all or aml at children's hospitals in the us contributing to the pediatric health information system. patients with down syndrome were excluded. follow-up started on the first day of induction chemotherapy and continued until the earliest of: days after commencement of chemotherapy, start of the subsequent course, or death. high acuity of presentation, defined as icu requirements involving or more organ systems within the first hours following initial admission were compared using log binomial regression. -day inpatient mortality was compared using cox regression. resource utilization rates (days of use per inpatient days) were compared using poisson regression. results: a total of all ( infants, non-infants) and aml ( infants, non-infants) were included in the analyses. infants were more likely to present with high acuity compared to non-infants for both all ( % and %, rr = . , % ci: . , . ; p< . ) and aml ( % vs %; rr = . , % ci: . , . ; p = . ). infants with all had higher inpatient mortality compared to non-infants even after accounting for differences in acuity of presentation ( . % vs . %, adjusted hr = . % ci: . , . ; p = . ). in contrast, inpatient mortality was more similar for infants and noninfants with aml ( . % vs . %, adjusted hr = . % ci: . , . ; p = . ) and comparable to rates among infants with all. infants with all and aml had higher rates of utilization of fresh frozen plasma, cryoprecipitate, diuretics, supplemental oxygen, and ventilation relative to non-infants. infants with all also had higher rates of total parenteral nutrition, ecmo, and patient controlled analgesics compared to noninfants. infants with all experienced significantly higher induction mortality compared to noninfants, a difference not entirely explained by acuity at presentation. differences in ru among infants may reflect higher presentation acuity and greater treatment related toxicity. further work is needed to elucidate the contribution of treatment related toxicity to early mortality in infants with all. background: fever in a child with cancer is a medical emergency due to the significant risk of a serious bacterial infection. many attempts have been made to risk stratify these patients. the respiratory pathogen panel (rpp) is a panel of polymerase chain reaction tests that identify seventeen common respiratory viruses and three bacterial infections. samples are taken via nasopharyngeal swab. rpps are frequently sent, but we do not have data to determine whether a positive result can lead to stratification to a lower risk of bacterial infection. ( ) to determine the epidemiology of respiratory virus-associated fever in pediatric oncology patients ( ) to determine whether a positive rpp is associated with reduced risk of bacteremia in this population. this was a single-center, retrospective cohort study. we identified and reviewed the medical records of all pediatric oncology patients seen in our emergency department (ed) with fever from the introduction of the rpp in april to september , . we reviewed the results of blood cultures, rpp, chest radiographs, and discharge summaries to identify sources of infection. we also identified the patients' cancer diagnosis, age, absolute neutrophil count (anc), and absolute lymphocyte count (alc). results: positive rpps were found among pediatric oncology patients who presented to the ed with fever. the most common positive rpp findings were rhinovirus/enterovirus (rev) ( %), parainfluenza ( %), influenza ( %), coronavirus ( %), and polyviral ( %). among patients with a positive rpp, % had bacteremia compared to % bacteremia among all pediatric oncology patients with fever (or . [ . - . ], p . ). all cases of bacteremia were associated with rev. there was no bacteremia identified in patients with rpps positive for other viruses (or . [ . - . ], p . ). rev positivity did not confer a lower risk of bacteremia than rpp negative patients ], p . ). anc (p = . ) and alc (p = . ) less than , and number of patients with severe neutropenia (p = . ) were not statistically different between the rev and non-rev positive rpp groups. rpps positive for viruses other than rev reduced the likelihood of bacteremia in febrile pediatric oncology patients in the ed setting. patients with bacteremia may have concurrent infection with rev. a larger study is warranted to determine if positive rpp results can inform clinical management of a child with febrile neutropenia. emily mueller, anneli cochrane, seethal jacob, aaron carroll s of s background: the usage of mobile health (mhealth), which refers to the application of mobile or wireless communication technologies to health and healthcare, has grown exponentially in recent years. mhealth tools have been used by caregivers of other vulnerable populations, but little has been focused on caregivers of children with cancer. objectives: to conduct a survey to understand the mobile technology usage, barriers, and desired mhealth tools by caregivers of children with cancer. we conducted a mailed cross-sectional paper survey of caregivers of all children who were diagnosed with cancer at riley hospital for children between june, and june, . the survey contained questions, both fixed and open-ended, in both english and spanish. up to three rounds of surveys were sent to those who did not respond. of the respondents, they were primarily parents ( . %), median age was . years (range - ), and most were white ( . %) and non-hispanic/latino ( . %). the top three annual household income brackets included $ , to $ , ( . %), $ , to $ , ( . %) and under $ , ( . %). the majority had an education: . % college graduates, % graduate degree, and . % high school education or ged. nearly all respondents owned a smart phone ( . %) and . % owned a tablet. the majority used an ios operating system ( . %), while . % reported use of a device with an android operating system. all caregivers reported use of at least one mobile website/app regularly for their personal use. while . % of respondents reported no barriers to mobile technology use, the top barrier selected was "data limitations" ( . %). overall, . % wanted at least one medical managementrelated website/app: medical knowledge ( . %), healthcare symptom tracking/management ( . %), and medication reminders ( %). healthcare system-related desires were high, as . % wanted access to their child's medical record and . % wanted a website/app to facilitate better communication with medical providers. there were no significant associations between socioeconomic status (income or education) with barriers or types of websites/apps desired by caregivers. since the vast majority of caregivers use mobile technology with minimal barriers, future research should focus on designing an mhealth tool to address the medical management needs by caregivers of children with cancer. by supporting caregivers through this type of mhealth tool, it could positively impact patient clinical outcomes through greater adherence to medications and treatment protocols. background: in children with fever and neutropenia, early initiation of targeted antibiotic therapy improves outcomes, yet there are no standards for choice of empiric antibiotics. in our institution implemented an early empiric ceftriaxone (eec) protocol to reduce time to antibiotic administration in febrile hematology-oncology patients who are potentially neutropenic when the absolute neutrophil count is not yet know. ceftriaxone is given immediately after obtaining blood for culture and lab studies. in patients found to be neutropenic, ceftriaxone is discontinued and cefepime is initiated. the purpose of this retrospective study was to evaluate our eec protocol in neutropenic patients by assessing ceftriaxone sensitivity of positive blood cultures and comparing rates of adverse outcomes with a cohort of patients treated prior to implementation of the protocol. we are now conducting a prospective study to more thoroughly investigate antibiotic sensitivities of organisms isolated from blood cultures of neutropenic patients. design/method: hematology-oncology patients with at least one positive blood culture between january and december were identified. patient demographics, neutrophil count, antibiotic treatment, isolated organisms and sensitivities, and adverse outcomes (increased respiratory support, hypotension requiring intervention, and icu admission) were obtained by retrospective chart review. fisher exact test was used to compare dichotomous variables between patient groups. we are now prospectively identifying febrile neutropenic patients with positive blood cultures and performing antibiotic sensitivity testing to several antibiotics commonly used as empiric therapy for febrile neutropenia. results: retrospectively, we identified neutropenic patients with a total of bacterial isolates from blood cultures. of organisms isolated, were tested for sensitivity to ceftriaxone and ( %) were not sensitive, / ( %) of gram-positive cultures and / ( %) of gram-negative cultures. ten of ( %) eec patients had an adverse outcome versus / ( %) of non-eec patients (p = . ). notably, % of eec patients required icu admission versus % of non-eec patients (p = . ). thus far our data obtained prospectively is revealing similar rates of ceftriaxone resistance with / cultures not sensitive to ceftriaxone ( %, ci . %- . %). in our retrospective study, no statistically significant difference was seen in overall adverse outcome rate between the two cohorts, though icu admission rates were significantly higher in eec patients. ceftriaxone resistance rates were high in tested isolates, which is further supported by preliminary data from our ongoing prospective study. given these data, eec may not be effective at improving outcomes in febrile neutropenic pediatric hematology-oncology patients. background: approximately in children diagnosed with cancer will die of their disease, despite advances in treatment. results: two focus groups of six parents each met in june . the parents were predominantly female ( female, male) and had lost their children an average of . years prior (range - . years). two parents were in the same family. nearly all patients were offered palliative care ( / ), all were offered hospice and most died at home ( at home, in the icu). parent discussion uncovered six broad themes: beneficial provider qualities, optimal communication, helpful systematic supports, struggles to feel like a good parent, struggles with a loss of control and unmet needs. parents appreciated providers who were consistent, reliable and honest. parents desired communication that was sensitive to the needs of the patient and family with a balance of hope and realism. parents appreciated the tangible supports pro-vided by social work and the emotional support of child life both for the patient and their siblings. some parents struggled to define and advocate for their child's quality of life, especially when it led to disagreeing with the medical team. several parents expressed frustration with unfamiliar caregivers in the hospital, especially trainees. they expressed a strong desire for more anticipatory guidance about the end of life including how to discuss it with their children. they also wished for a cancer-specific support group for bereaved parents. conclusion: bereaved parents of pediatric oncology patients in our focus groups appreciated consistent, reliable providers who communicated with a balance of realism and hope. they appreciated the tangible and emotional support they received and wanted more anticipatory guidance at the end of their child's life. these results can help guide clinical care, especially in communities without strong palliative care support. further research is needed to develop interventions to improve end of life care. background: clinical trials involving human subjects depend on informed consent (ic) to ensure ethical protections for participants. parents of children with cancer often lack full understanding of the basic elements of ic for clinical trials. additionally, the stress of their child's cancer diagnosis may affect their decision-making capabilities. this is especially problematic as these children rely on parents to fully comprehend clinical trials and weigh their benefits and risks. physician communication is critical for effective family-centered care. the acgme mandates that training programs teach and assess trainees' communication skills. however, there are currently no published curricula aimed at training pediatric hematology/oncology fellows to deliver ic effectively for cancer clinical trials. to develop and pilot-test a simulation-based curriculum to enhance communication skills of pediatric s of s hematology/oncology fellows in the delivery of ic for cancer clinical trials. we developed, tested, and implemented the curriculum from to in two phases. in phase- , we reviewed literature on simulation-based curricula and completed a needs assessment to create a clinical scenario and full curriculum using standardized patients. using miller's pyramid model, fellows' assessments included: immediate de-brief, surveys to assess pre/post confidence and knowledge of the basic ic elements ("knows" and "knows how"), and -degree summative assessments compiled from fellow self-assessments, faculty, and standardized patients ("shows how"). after initial testing and refinements done with fellow, in phase- , we implemented the curriculum with our fellows. likert scale ( strongly disagree- strongly agree) and basic p values are reported. results: fellows gave high mean ratings for training relevance ( . ) and standardized patients' preparedness ( ). almost all ( . ) reported they have used the knowledge gained in their clinical practice. increase in self-reported confidence (pre/post) was noted in all domains: general -describing possible benefits of the clinical trial . / vs. . / (p = . ), risks and potential side effects . / vs. . / (p = . ), and explaining alternatives . / vs. . / (p = . ); research -discussing purpose of the clinical trial . / vs. . / (p = . ), and randomization . / vs. . / (p = . ); and family-centered -addressing emotions during ic . / vs. . / (p = . ), and delivering bad news . / vs. . / (p = . ). summative evaluation mean ratings for all fellows were . (range . - . ). our novel simulated-based ic curriculum, significantly increased fellows' self-reported confidence and skills during ic delivery. importantly, our ic curriculum addressed not just research-related content but also management of parental emotional needs during the ic discussion. next phase includes kirkpatrick model program evaluation and dissemination across other training programs in our institution. national kaohsiung normal university, kaohsiung, taiwan, province of china background: taiwan's childhood cancer foundation reported in that the -year survival rate of childhood cancer was %. as a result, many childhood cancer survivors were back in school after treatment. however, childhood cancer survivors' educational outcomes suffered because of their long-term absence from school and late effects of cancer and cancer treatment. a few school reentry protocols have been developed by the nursing professionals in taiwan to facilitate students' return to school but remained experimental in nature and hardly accessible. parents, students, and teachers were left to their own devices to make individual school reentry plans. objectives: this study aimed to examine and uncover the commonalities among three middle school students' successful school reentry experiences from their teachers' perspectives and to analyze the factors contributing to their success. design/method: this is a qualitative interview study. indepth semi-structured interviews were conducted with three middle school teachers in december about their perceptions, observations, and experiences working with adolescent childhood cancer survivors. the students were two boys with leukemia and one girl with bone cancer. they were diagnosed in the first year of middle school when they were - years old and returned to school for the third and the final year. these students met the following criteria for successful school reentry: regular school attendance, average/above average academic performance, friendship maintenance, and high school diploma. the theme -bring the class to the hospital was found to be the key to the adolescents' successful return to school. without a prescribed school reentry protocol and in the face of limited bedside education services, the homeroom teachers, as links between school, home, and hospital, brought the class to their hospitalized students. they doubled as bedside teachers conducting lessons at the hospital or students' homes, became friends with the parents, witnessed firsthand the students' pain and triumph during treatment, brought the students back to school for visits and celebrations, delivered the classmates' wishes and news to the students, encouraged and welcomed classmates' visits to the hospital, and, together with parents and other teachers, developed flexible school reentry schedules for the students. this on-going study demonstrated the critical roles and functions of homeroom teachers in successfully bringing the students back to school during and/or after cancer treatment. further analysis will be focused on how and why these three homeroom teachers were able to carry out this unexpected task on top of their already full workload. jennifer kesselheim, shicheng weng, victoria allen, collaborative group fellowship program directors dana-farber/boston children's cancer and blood disorders center, boston, massachusetts, united states background: a novel, -module, case-based curriculum entitled "humanism and professionalism for pediatric hematology-oncology" (hp-pho) aims to foster pho fellows' reflection on grief and loss, competing demands of fellowship, difficult relationships with patients and families, and physician well-being and burnout. in small group facilitated sessions, fellows work to identify coping strategies and explore how the challenges of fellowship influence both their own doctoring and the patient experience. objectives: to administer the hp-pho curriculum in a prospective, cluster-randomized trial, measuring whether exposure to this educational intervention, compared to standard conditions, fosters humanism and professionalism and improves satisfaction with training. design/method: pho fellowship programs (n = ) were cluster-randomized to deliver usual training in humanism and professionalism (control) or the novel curriculum (intervention) during the - academic year. the primary outcome measure was the pediatric hematology-oncology self-assessment in humanism (phosah). secondary measures included a -point satisfaction scale, the maslach burnout inventory (mbi), the patient-provider orientation scale, and the empowerment at work scale. participating fellows were pre-tested in summer and post-tested in spring . a change score was calculated for each study instrument. we compared each outcome between arms using mixed effect models adjusted for pre-test score as a fixed effect and site as a random effect. results: randomization yielded intervention and control fellows. the two arms did not significantly differ in distribution of fellow age, gender, or post-graduate year. the intervention sites successfully administered of ( %) modules. change scores on the phosah were not significantly different between the control and intervention arms (adjusted mean difference = . ; % confidence interval [ci] - . , . ; p = . ). compared to the control arm, fellows' exposed to the curriculum gave significantly higher ratings on several items within the satisfaction scale including satisfaction with their training on "physician burnout" (adjusted mean difference = . ; % ci . , . ; p< . ), "physician depression" (adjusted mean difference = . ; % ci . , . ; p< . ), "balancing professional duties and personal life" (adjusted mean difference = . ; % ci . , . ; p = . ), and "humanism overall" (adjusted mean difference = . ; % ci . , . ; p = . ). change scores on other secondary measures were not significantly different between study arms. conclusion: exposure to the hp-pho curriculum did not alter fellows' self-assessed humanism and professionalism. however, the curriculum proved feasible to administer and intervention fellows expressed higher levels of satisfaction in their humanism training, indicating the curriculum's positive impact both for fellows and their learning environment. background: recent work has documented significant levels of unmet needs among adolescents and young adults with cancer, particularly psychosocial challenges during the transition to adulthood, (e.g., abrupt disruption to school and social life, and social isolation). given that adolescents and young adults drive mobile app use, a mobile-phone may be an ideal way to deliver a psychosocial intervention to adolescents and young adults with cancer. to use a patient-centered approach to inform a mobile-based mindfulness and social support intervention for adolescent and young adult patients with cancer. design/method: participants were ten aya with sarcoma ( % female; % adolescents); parents of the five adolescents, and six healthcare providers (n = ). formative research involved three steps: ( ) in-depth interviews were conducted with ten aya with sarcoma; parents of the five adolescents, and six healthcare providers (n = ). ( ) adaptations were made to an existing mindfulness app which offers a program for youth. modifications included creating a -week "mindfulness for resilience in illness" program, with relaxation exercises, and the addition of videos featuring two sarcoma survivors as program hosts. content was informed by the mindfulness curriculum for adolescents, learning to breathe. ( ) a private facebook usability group was organized to (i) elicit beliefs about the mindfulness app and potential future enhancements, and (ii) promote social support. results of the in-depth interviews revealed themes around adolescents' functioning and coping, including body image concerns; recurrence-related anxiety; anger over loss; and being overwhelmed by medical information. themes from the interviews were incorporated into a demonstration version of the mobile app. a patient-centered approach is widely recommended in the development of mobile-based health behavior change interventions and may be a useful way to inform development of a mobile-based mindfulness and social support intervention for adolescents and young adults with cancer. background: medical trainees consistently report suboptimal instruction and poor self-confidence in communication skills. despite these deficits, few training programs provide comprehensive pediatric-specific communication education, particularly in the provision of "bad news." an in-depth survey to examine the historical experience and communication needs of pediatric fellows was conducted at a large academic pediatric center as the first step towards the development of a comprehensive communication curriculum. to determine the previous educational and clinical experiences of pediatric subspecialty fellows, assess their levels of comfort in the context of various communication topics, and query potential modalities and topics for future communication training. design/method: the needs assessment survey was developed using previously developed and validated questions and review of the literature. the survey was reviewed by internal and external pediatric oncology and palliative experts and pre-tested with a subset of trainees to enhance content validity. results: thirty-two out of a total of fellows completed the survey ( % completion rate), of which % were pediatric hematology-oncology or subspecialty fellows. most fellows had participated in previous teaching sessions ( %), including those involving role play or simulation ( %). however, few fellows had received feedback from senior clinicians on their communication skills ( % of fellows had received feedback ≤ times). on a scale of -x, with indicating "not well prepared," the mean score for of communication items was < . fellows felt least prepared to lead discussions around informed consent for experimental therapies, end of life care, and autopsy. fellows indicated that didactic educational sessions and additional coursework were less useful strategies for improving their communication skills, whereas small group role play sessions with faculty and/or bereaved parent educators were most useful. fellows' overall communication preparedness score was not correlated with post-graduate year but was positively associated with the number of times they previously had delivered bad news to patients and families. fellows requested additional training on many topics, with greatest interest in learning skills to optimize communication with an angry patient or family. additional topic requests included placing limitations on resuscitation, withdrawing/withholding further therapy, and ageappropriate inclusion of patients in difficult discussions. despite self-report of prior communication skills training, pediatric subspecialty fellows felt underprepared to participate in difficult discussions with patients and families. learners identified role-playing and coaching with real-time feedback from other physicians and bereaved parents as more useful training strategies as compared to didactic sessions. background: when children die of cancer, parents must adjust to their child's absence amidst the lingering turmoil of what preceded their death: witnessing their child undergo painful treatments, making difficult decisions, and anticipating a devastating loss, all the while hoping for a recovery. adjustment to a child's death, as depicted by current bereavement literature, necessitates making meaning of one's loss. professional care staff can help parents make sense of their child's illness, and in turn, of their own parental experience during treatment. however, the extent to which relationships with professional care team members influence parents' ability to make sense of, and successfully cope with, their loss has not been examined. objectives: to examine how bereaved parents' interactions with their deceased child's pediatric oncology professional care team have impacted their grief symptoms design/method: to better understand how interactions with professional care staff relate to parents' grief outcomes, we conducted a mixed-methods study examining staff impact on parental grief. thirty participants whose children died of cancer one to three years ago completed an in-depth interview and psychometrically validated surveys measuring meaningmaking, depression, and grief symptoms. results: correlational analyses of the measures found that an increase in meaning making was associated with lower depressive and grief symptoms. a content analysis of the interviews found that many participants regarded staff "like family," had on-going relationships with staff after their child died, and described various ways staff interactions during treatment and after the child's death helped them make sense of their loss. in particular, participants described how interactions with staff have helped them find benefits in their loss and learn to create a new relationship with their child despite their physical absence. quantifying the interview data and statistically analyzing it along with the measures found that participants' increased frequency of describing staff's positive impact on their grief correlated with higher meaning-making scores and lower grief symptom scores. our study found that bereaved parents who lost their children to cancer were articulate in sharing their experiences of staff engagement and communication during treatment, offering numerous examples of how staff aided them in making meaning of their loss that were reliably associated with their subsequent grief. we hope the results of this mixed methods research encourage further study of the importance of staff interaction with families during the critical period of their children's care, and the lasting impact this can have regardless of the treatment outcome. memorial sloan kettering cancer center, new york, new york, united states background: although resiliency has been recognized as necessary for healthcare professionals, trainees feel unprepared for the emotional challenges inherent in caring for sick and dying patients. compounded by long hours, challenging work environments, and lack of formal training on handling emotionally difficult situations, many institutions are recognizing the need for interventions to reduce trainee distress. the goals of this fellow-led quality improvement initiative were: ) to determine whether there is a need for emotional support amongst pediatric hematology and oncology fellows, ) to provide formal resiliency and debriefing sessions, and ) to measure feasibility, acceptability and effectiveness of implemented curriculum. design/method: an anonymous survey to determine need for resiliency and debriefing sessions following a traumatic event was distributed to active pediatric hematology & oncology fellows at memorial sloan kettering cancer center in january . once need was established, an intervention consisting of a formal curriculum was developed and initiated in june , involving: ) scheduled and ad hoc debriefing sessions in response to traumatic events (including patient death, codes, interpersonal conflicts, end-of-life care); led by a psychiatrist and social worker with fellows and a pediatric oncologist mentor in attendance, and ) a resiliency didactic curriculum, led by a palliative medicine specialist, focused on skills such as contesting cognitive distortions and mindfulness. the effectiveness of these sessions will be measured using follow-up anonymous surveys at months (currently underway) and months post-initiation of intervention. the initial survey demonstrated most trainees ( / ) were present at or more deaths during their training, while less than half of respondents had attended a post-event debriefing session. % of respondents felt there was not sufficient emotional support from the institution for physicians caring for dying patients. a separate pre-intervention survey found all respondents ( / ) expressed a need for regular debriefings, and nearly all anticipated that they would benefit from such debriefings. concerns identified by trainees that would preclude participation in the curriculum included preference to deal with emotional situations privately and time constraints. trainees identified a need for formal debriefings and resiliency skill development. the program was easily implemented, and is both feasible and acceptable with good attendance. feedback received at the -month mark will determine deficits and possible improvements to the curriculum. the -month survey will measure effectiveness of the program and whether it should be continued. background: acute kidney injury (aki) is a common but under-recognized complication among patients with leukemia. it is associated with prolonged hospital stays, increased mortality, progression to chronic kidney disease, and delays or changes in cancer therapy which may affect a patient's prognosis. however, data on aki in pediatric patients with cancer is still lacking overall. we investigated the incidence of aki in patients who were newly diagnosed with all at our center from january to september . we performed a retrospective chart review of all patients who were newly diagnosed with all from neonate to years in our facility. we determined the incidence of aki in our population using the kidney disease: improving global outcomes (kdigo) diagnostic criteria. we also assessed for nephrotoxic exposures, nci all risk stratification and risk of aki, and tumor lysis syndrome (tls). we identified patients diagnosed during the study period who met inclusion criteria. median follow-up time was . months (range . - . ). the cohort was predominantly male ( . %) and hispanic ( . %). our analysis showed . % had aki by kdigo criteria ( % grade , . % grade , and % grade ), . % had aki on presentation, and % had multiple aki episodes during the study period. older age and longer length of hospitalization were associated with aki (p = . and p = . , respectively). there was no association between aki and nci all risk classification, contrast exposure, hyponatremia, elevated white blood cell count, uric acid levels, antimicrobial therapy, or diuretic use in this study. conclusion: aki was a common finding in our study population. the majority had grade aki by kdigo criteria. however, aki was associated with older age and a longer length of stay. further study is needed to determine the short-and long-term impact of aki on pediatric patients with all. st. jude children's research hospital, memphis, tennessee, united states background: in some regions, the availability of trained pediatric oncologists is a limiting barrier for the care of children with cancer. in , the unidad nacional de oncología pediátrica (unop) and the universidad francisco marroquín school of medicine in guatemala established a pediatric hematology/oncology fellowship program sponsored by st jude children's research hospital to provide central america and the caribbean with well-trained specialists. a systematic analysis of the impact of fellowship programs in pediatric oncology has never been done, especially in the context of a regional education program. objectives: this study sought to analyze the impact of the unop fellowship program based on the regional number of providers, pediatric cancer centers and patient volume. in addition, it sought to characterize the jobs and scientific output of the graduates. the impact will be evaluated in the context of a cost analysis. to define the volume of providers, pediatric cancer centers and patients, the directors of pediatric cancer centers in central america were sent an online survey to obtain these data. all the centers contacted maintain an updated hospital-based patient registry. in addition, the graduates of the fellowship program were also sent an online survey, asking about their job at graduation, current role and scientific productivity. the cost analysis will include assessment of direct costs including salaries and stipends for away rotations, as well as the indirect costs of faculty time spent teaching. since the establishment of the unop fellowship program, the region has more providers for pediatric cancer (p< . ) and centers treat a larger volume of patients (p< . ). two new centers have opened with graduates of the program. all but one graduate practice pediatric oncology ( / ) and the majority do it in their country of origin ( / ). no graduate practices outside of this region. almost half of the graduates ( %) hold a leadership role at their institution. the majority of their time is spent in the public sector (> %). the majority of graduates participate in clinical research ( %) and have participated in the creation or implementation of therapeutic protocols ( %). on average, the graduates have published peer-reviewed articles since completion of training. the unop fellowship program has had a favorable impact on pediatric cancer care in the region, contributing to the capacity to treat a larger volume of patients. graduates practice pediatric oncology in the region in the public sector, frequently hold leadership roles and are scientifically productive. background: abandonment of treatment is a major cause of treatment failure and poor survival in children with cancer in low-and middle-income countries. the incidence of abandonment in peru has not been reported. objectives: the aim of this study was to examine the prevalence and associated factors of treatment abandonment in pediatric patients with cancer of peru. we retrospectively reviewed the sociodemographic and clinical data of children referred between january and december to the two main tertiary centers for childhood cancer, located in lima, peru. definition of treatment abandonment was used from the siop (international society of paediatric oncology) podc (paediatric oncology in developing countries) abandonment of treatment working group recommendation. results: data of children diagnosed with malignant solid tumors and lymphomas were analyzed, of which ( . %) abandoned treatment. univariate logistic regression analysis showed significant higher abandonment rates in children living outside the capital city, lima (p< . ); prolonged travel time to a tertiary center (> hours; or . , p = . ); living in a rural setting (or . ; p< . ) and lack of parental formal job (or . ; p = . ). according to cancer diagnosis, children with retinoblastoma were more likely to abandon compared with other solid tumors. in multivariate regression analyses, rural origin and lack of formal parental employment were independently predictive of abandonment. conclusion: treatment abandonment prevalence in our country is high and closely related to socio-demographical factors. treatment outcomes could be substantially improved by strategies that help prevent abandonment of therapy based on these results. st. jude children's research hospital, memphis, tennessee, united states background: to improve the quality of a pediatric hematology/oncology fellowship program, a systematic assessment must be performed that can evaluate its current state and identify areas of opportunity, as well as modifications over time. unfortunately, widely agreed-upon metrics of quality for pediatric hematology/oncology fellowship programs currently do not exist. this is particularly important in this field due to the global shortage of specialists. for this reason, an assessment instrument that is applicable throughout the world must be created. objectives: the st. jude global education program assessment tool (epat) is a novel instrument that seeks to evaluate pediatric hematology/oncology fellowship programs around the world in systematic and objective way. epat will help determine key performance indexes that are relevant for quality education in pediatric hematology/oncology fellowship programs and establish the framework for improvement. design/method: firstly, key domains to be evaluated for program assessment were identified a priori based on the continuum of pediatric hematology/oncology fellowship programs in the context of geography and educational structure. subsequently, questions were formulated to evaluate these key domains, seeking to assess elements involved in ensuring competence in clinical practice, academic productivity and regional impact. due to the novelty of this tool and the lack of defined metrics of quality, epat relies on expert opinion in a two-step process: internally in the department of global pediatric medicine at st. jude children's research hospital and, subsequently, from a panel of experts in global pediatric oncology and medical education from around the world. ten key domains were identified to evaluate all aspects relevant to training programs around the world, regardless of educational and geographic context. questions have been created to assess these domains and, to make epat quantitative, these have assigned weights with a value reflective of their relative importance. this grading system allows for a score in each key domain, permitting monitoring of changes over time. epat is currently at the stage of external expert review, and subsequently will be piloted in five fellowship programs around the world to provide different geographical and patient care contexts for its validation. once epat is finalized, it will be distributed to pediatric hematology/oncology fellowship programs around the world to be applied. epat proposes a novel strategy to assess training programs in a systematic way that includes all aspects relevant for a training program in a global context. this tool will help guide improvements in pediatric hematology/oncology fellowship programs and assure a well-trained workforce. background: with the improvement in pediatric oncology patient survival and outcomes in the past several decades, monitoring for recurrence and long-term effects of therapy has become even more important. the utilization of personalized treatment summaries and survivorship care plans (scps) is one way to communicate this information with patients and families. the american college of surgeons commission on cancer (coc) created a standard regarding provision of scps to % of eligible patients by december , as a metric for accreditation of all cancer centers. the standard applies to all patients with stage i, ii, and iii cancer diagnoses and requires creation of the scp within one year of diagnosis or six months of completing treatment. during implementation at our pediatric cancer center, we identified barriers to use of the guidelines in the childhood cancer setting. objectives: define eligibility for an scp for pediatric oncology patients to include all patients with curative intent and to deliver scps within six months of finishing therapy. design/method: using chart review and a cancer center registry query, we identified childhood cancer patients potentially eligible for an scp by collecting stage, goal of therapy, and dates of treatment. all patients with curative intent were deemed eligible for an scp regardless of stage i-iv. patients being followed in the oncology clinic for posttreatment surveillance and care were included even if they had received an scp in the survivorship program or were greater than six months off therapy at time of implementation. as expected in the pediatric oncology population, acute lymphoblastic leukemia (all) was the most common diagnosis comprising . % of patients. all is stratified into risk groups instead of surgical staging categories, and treatment duration is greater than one year, unlike many adult-onset malignancies. these differences required interpretation of the guidelines to apply to our pediatric population for all and other pediatric diagnoses with non-surgically based staging. our pediatric oncology clinic has to date provided scps to of eligible patients by adapting the guidelines to focus on patients with curative intent to receive an scp by six months off therapy. cancer staging guidelines and goals for curative intent as well as lengths of treatment vary between the pediatric and adult populations. the coc guidelines require adaptation for optimal applicability to the pediatric oncology population. background: education in communication for fellows in fields that require difficult discussions with families are few in nature. adult learning pedagogies such as role play are under-utilized in medical education, and have been shown to be as effective as traditional teaching methods such as lecture. an -module course for fellows in hematology/oncology, hospice and palliative medicine, radiation oncology, and pediatric hematology/oncology was implemented in january/february . fellows participated in the program. topics covered including fundamentals of communication, coping and spirituality, delivery of bad news, communicating with families, sexual dysfunction during treatment, palliative care/death and dying, and burnout. objectives: overall goal of this course is to foster holistic physicians who views their patients as people with cancer, not cancer patients, and physicians that can communicate effectively with their patients throughout the disease continuum. by the end of the course, learners should be able to practice the fundamental principles of good communication. design/method: fellows initially participated in a pre-course osce to establish baseline skills. osce was facilitated by the center for learning and innovation at northwell, and included actors portraying a pediatric patient and family member to whom the fellow had to break bad news. two months later, the course was carried out over the span of eight weeks and included didactic sessions followed by minutes of role play scenarios. five of the eight modules included role play, with faculty members serving as simulated patients. after the course, a second breaking bad news osce was held. both osces were filmed, and feedback was given by the on-site actors. additionally, faculty members were given access to the videos in an on-line format and were given an evaluation tool to assess the fellows' performance pre-and post-intervention. fellows were given subjective surveys pre-and post-course as well. results: subjective data from participants showed a noticeable increase in comfort level in all areas on the pre-and post-course survey. data obtained from osce videos showed improvement in communication skills as assessed by sps and faculty members using a new evaluation tool developed by faculty. initial first-run data shows that this course is successful in improving communication skills as well as increasing fellows' comfort level across several domains of communication. future directions for our course include improving and validating our assessment tool, expanding our topic base to include more aya and pediatric scenarios, faculty development for improved role play, and investigating impact on practice after course completion. background: acute lymphoblastic leukemia (all) is the most common form of childhood cancer with approximately children diagnosed each year. survival rates have improved significantly over the past several years. children with all are at risk for developing musculoskeletal complications during and after completion of treatment, which can contribute to impaired activity, elevated body mass index (bmi), and risk for complications. interventions involving physical activity could improve musculoskeletal strength as well as overall health in these children. the aims of this study are to examine the feasibility of a directed physical activity program for children with newly diagnosed all during the initial intensive phase of therapy and to evaluate the overall health and quality of life of children participating in the directed physical activity program. design/method: all subjects will receive education materials about the importance and safety of physical activity and a nutrition handout. all subjects will also participate in the directed physical activity program under the supervision of a trained physical therapist for at least minutes every week for weeks. the program will entail four stations including a cardiovascular, balance/proprioception, strength and flexibility, and coordination and cardio. feasibility will be assessed by tracking the participation rate throughout the study period. other assessments will be made at study entry, at the end of weeks of physical activity initiative and months after completion of the intervention. assessments include overall strength and flexibility, weight, height, bmi, blood pressure and performance scores. descriptive statistics will be used for this study. results: a total of patients, male and female, enrolled in the study over a . month period. patient ages ranged from - years. half of the patients enrolled have completed the week program and all patients had stability or improvement of their physical functioning scores. further data collection and analysis is ongoing. patients in the early intensive phase of all therapy are at risk for complications that can affect their physical functioning. a directed physical activity protocol may improve their overall physical functioning. patients may not need specific physical therapy; however a directed physical activity program appears to be beneficial for these patients. the main roadblocks to successful completion of the program were difficulty with scheduling, strain on the parents and patient from treatment, unplanned admissions for fever, as well as nausea and fatigue at time of visit. albany medical center, albany, new york, united states background: communication skills are a core competency highlighted by the acgme. increasing resident confidence in delivering difficult news has been shown to lead to more s of s effective communication. currently, the majority of residency programs lack formal training in communication skills. our objective was to demonstrate feasibility and efficacy of integrating a standardized-patient based training program for communication skills into the curriculum of pediatric residents design/method: to date, pediatric and medicine/pediatric residents have participated in the program during the intern year. the program consists of three, two-hour long sessions, in which each resident is given several opportunities to act out case scenarios with a standardized patient. scenarios included informing a parent of their child's new cancer diagnosis and disclosure of a positive hiv test to a teenager. residents received post hoc peer to peer, and preceptor to learner feedback. pre and post-program surveys were completed by residents. results: following course completion residents reported an increase in confidence in multiple areas of communication including giving a difficult diagnosis (p< . ), discussing a poor prognosis (p< . ), responding to different patient/family member emotional responses i.e. crying or anger (p< . ), and organizing vital information to be relayed (p< . ). in conclusion, communication skills training of pediatric residents is feasible and provides a platform for developing valuable skills not taught elsewhere within the curriculum. background: for children with cancer, transitioning back to school during or after treatment can be challenging. literature supports the need for school re-entry programs to ease this transition. however, these programs vary widely among pediatric cancer institutions with little data addressing their program components. data from this study provides information on current school re-entry programs across these institutions. objectives: one objective of this study was to assess for correlation between the presence of a school re-entry program and other factors, such as geographic location and institution size. a second objective was to establish a list of differences between institutions' school re-entry program components. finally, we aimed to describe current school reentry practices, as well as program benefits and perceived areas for improvement. states with membership in the children's oncology group were offered enrollment in this study. a member of each institution was invited to participate in a survey established by the research team. this person was closely associated with the institution's school re-entry practices. each interview queried institution demographics, as well as program components (e.g., participants, target audience, resources). comment was also collected on program benefits and potential for improvements. analysis of transcripts was performed using pearson's correlation to assess for relationships between institution size, geographic location, and program presence. grounded theory was used for analysis of benefits and improvements. results: thirty-nine of forty-one pediatric institutions who were offered enrollment participated in this study. twentynine institutions ( %) indicated the presence of a school reentry program, and ten ( %) stated they had none. no correlation was found between institution size and the presence of a school re-entry program (p = . , ns). there was also no correlation found between institution location and the presence of a school re-entry program (p = . , ns). a major theme surrounding the benefits of having a program included education for the returning student's peers. for those with programs, perceived improvements included increasing staffing and the ability to offer more services. the results do not support the hypothesis that the presence of a school re-entry program is influenced by the size and geographic location of the treating institution. however, data seem to suggest that available staffing may influence the presence of a program. future studies are needed to address other potential influences, as well as to take an evidence-based approach to determine the effectiveness of the interventions present in these programs. cohen children's medical center/ zucker school of medicine at hofstra-northwell, new hyde park, new york, united states background: genetics/genomics is evolving at an extremely rapid pace. current advances lead to individual algorithms toward disease treatment for each disease with multiple branch points. fellows learn only a fraction of the knowledge and there is no formal approach to teaching critical analysis of information and application algorithms toward disease. additionally, as knowledge evolves extremely rapidly, any approach must teach self-acquisition and application of evolving discoveries. objectives: to create, implement and evaluate a novel curriculum for genetics/genomics targeted toward pediatric hematology/oncology fellows design/method: the curriculum includes four components: ) genetic and genomic medical knowledge, with one initial team-based learning session and weekly online multiple choice questions; ) essential pathways, which will teach molecular pathways common in oncogenesis and relevant to targeted therapy in microteaching sessions with using auditory, visual and tactile learning; ) knowledge acquisition and clinical judgment, to allow learners to gain experience into researching data available, then developing and prioritizing potential treatment plans using problem-based learning sessions in which they will stage a patient, research treatment options, prioritize and present findings; and ) synthesis to demonstrate independent ability to research and recommend therapy through an independent project in which the learner, given a case, will present the case and research findings, genetics/genomics, molecular pathways and make recommendations for therapy in molecular tumor board for faculty and fellows. to evaluate, we plan to recruit to institutions, match for size of programs and implement in half and evaluate nd and rd year fellows in both groups by mcq exam and satisfaction surveys. the creation of a multi-module, adult-learning based curriculum for genetics and genomics in pediatric oncology is feasible. implementation and evaluation are necessary to demonstrate efficacy. background: neuroblastoma is the most common extracranial solid tumor in children. chimeric anti-gd antibody ch . (dinutuximab) therapy has improved the survival of children with newly diagnosed high-risk, neuroblastoma patients as well at the time of first relapse/progression. acute neuropathic pain is a well-documented side effect of dinutuximab administration. however, additional adverse effects including sensorimotor neuropathy, ocular symptoms, and behavioral changes have been described. the incidence and severity of these effects are currently not well-documented in pediatric patients. with improved long term survival of patients receiving this modality, it is important to look for the potential late effects of dinutuximab. objectives: to determine the incidence and severity of neurologic, ophthalmologic, or behavioral changes after dinutuximab administration at our institution. we performed a retrospective chart review using our electronic medical record. we included all patients with high-risk neuroblastoma between the ages of and years at our institution diagnosed between and who received dinutuximab. patients with history of opsoclonus-myoclonus syndrome or gross sensorimotor neuropathy prior to receiving dinutuximab were excluded. we examined clinical documentation for subjective reports and objective exam findings of neurologic, ophthalmologic, or behavioral changes. we also looked for referrals made to neurology, ophthalmology, physical medicine & rehabilitation (pm&r), and psychology. : twenty-two patients met inclusion criteria. at the time of chart review, patients were alive and were deceased. eighteen patients received dinutuximab per anbl ; patients received dinutuximab per anbl . of these patients, patients reported symptoms of interest and reported multiple symptoms. six patients reported symptoms that began at least months after completing dinutuximab. nine patients had objective findings on exam, including decreased deep tendon reflexes, abnormal pupils, and nearsightedness. for patients, referrals were made to ophthalmology, pm&r for neuropsychologic testing, or neurology. two patients who reported symptoms of interest were not referred to a specialist. conclusion: neurologic, ophthalmologic, and behavioral symptoms were commonly reported and demonstrated on exam among pediatric patients with high-risk neuroblastoma who received dinutuximab. it is important to identify these effects so that appropriate specialist referrals can be placed for adequate management of these changes. we recognize that these symptoms may not be solely due to dinutuximab as these patients receive other agents including opioids, so a prospective trial is needed to further evaluate the long-term effects of dinutuximab and to determine how best to screen for these effects. akron children's hospital, akron, ohio, united states background: pediatric cancer is the leading cause of diseaserelated death in children in the united states (u.s.). in , over fifteen thousand children were diagnosed with cancer in the u.s. this population is at high risk for malnutrition due to the multimodal therapies they receive: surgery, chemotherapy, radiation therapy, antibody therapy, and/or bone marrow transplant. adverse effects of these therapies include taste changes, loss of appetite, diarrhea, vomiting, and/or mucositis, making it difficult for the children to be able to consume adequate amounts of nutrition during therapy. there is no "gold standard" measurement tool for identifying patients at risk for malnutrition. nutritional status is not frequently evaluated as a component of clinical trials. assessment of anthropometric measurements (weight, height, z-scores) at diagnosis, as well as over the duration of treatment, can assist in the early identification of malnutrition. the incidence and prevalence of malnutrition in this population is unknown at akron children's hospital. the purpose of this study is to describe the nutritional status and provision of nutritional support therapies in pediatric patients during their first year post new oncologic diagnosis. objectives: identify the incidence and prevalence of malnutrition across oncologic diagnostic categories over the first twelve months post diagnosis. we performed a retrospective records review of all patients newly diagnosed with cancer in at akron children's hospital. demographic and anthropometric data was collected at time of diagnosis and nutritional status categorized by z score. anthropometric and nutrition support data was then collected every two months for the first year after diagnosis along with incidence of unplanned inpatient admissions. results: a total of patients were included in the analysis, with . % malnourished at time of diagnosis; . % developed malnutrition the first year. patients with solid tumors represented % of patients with pre-existing or acquired malnutrition. overall, % of patients received at least one nutritional support modality. patients with pre-existing or acquired malnutrition had a non-significant increase in unplanned admissions (p = . ). our study demonstrated that patients with solid tumors were found to be at increased risk of pre-existing and acquired malnutrition, followed by leukemias, and experienced higher incidence of unplanned admissions in the time period observed. prospective, multi-center replication of this study, including detailed collection of nutrition therapies is recommended to guide development of diagnosis specific nutrition support guidelines. background: pediatric and young adult oncology patients treated with intense chemotherapy have a high incidence of transfusional iron overload. iron deposition can lead to heart failure/arrhythmias, liver abnormalities, endocrine dysfunction, ineffective erythropoiesis, and increased cancer and mortality risk. however, there is a paucity of data regarding recommendations for management of transfusional iron overload in these cancer survivors. consequently, long-term complications of transfusional iron overload specific to these patients have not been assessed. objectives: to assess screening and phlebotomy-based treatment algorithms for this population. design/method: a retrospective chart review of pediatric and young adults who completed oncology management, had iron overload, and initiated phlebotomy treatment was conducted. tiered screening occurred in patients that received at least packed red blood cell (prbc) transfusions. patients were recommended for evaluation and possible phlebotomy if: ( ) liver iron concentration (lic) > mg of iron/gram dry weight liver tissue by ferriscan and/or ( ) cardiac mri t * < ms. during phlebotomy, iron status was assessed quarterly and phlebotomy discontinued with lic < or normalization of ferritin/imaging lic verification. descriptive statistics were employed to report the characteristics of the study population. spearman correlations were utilized to describe associations between transfusions, lic, ferritin, iron saturation and number of phlebotomy sessions. results: twenty five survivors underwent phlebotomy. the mean age was . years (sd . ) and ( %) were female. oncologic diagnoses: all ( %), aml ( %), nhl ( %), ewing sarcoma ( %), osteosarcoma ( %), neuroblastoma ( %) and cns ( %). patients received a median of . (iqr - ) transfusions. median number of phlebotomy sessions was (iqr - ) over . years (iqr . - . ). prior to phlebotomy, median lic was . mg/g (iqr . - . ) and ferritin was . ng/ml (iqr - ) . no patients demonstrated abnormal cardiac t * mri (n = ). ( %) patients completed phlebotomy. one discontinued due to poor vascular access. no patients developed iron deficiency. lic was reduced by a median of . mg/g (iqr . - . ) and ferritin by ng/ml . correlation between number of transfusions and phlebotomy sessions was poor (r = . ). conclusion: management guidelines are lacking for transfusional iron overload in pediatric and young adult survivors of cancer. we demonstrate a phlebotomy algorithm that is effective and tolerated. correlation between number of transfusions received and phlebotomy treatments was poor, necessitating serial assessments. using this management algorithm, prospective studies can evaluate the effect of iron removal on iron overload complications in this patient population. penn state children's hospital, hershey, pennsylvania, united states background: cancer therapy leads to an impaired immune system that takes time to recover. it is important to ensure that these survivors have adequate immunity to prevent common yet potentially severe childhood illnesses. no validated guidelines currently exist for surveillance testing or re-immunization in this population. retrospective analysis involving a small cohort of pediatric cancer patients treated at penn state children's hospital showed % of patients screened for varicella immunity after therapy completion did not have adequate disease titers. to determine the proportion of pediatric cancer survivors who have lost humoral immunity to previously received vaccines; to determine the rate of response to single dose boosters or full vaccine series in seronegative subjects after one booster. design/method: pediatric cancer survivors treated at the children's hospital who are at least months from completion of cancer therapy are prospectively tested for antibody levels to hepatitis b, tetanus, varicella, measles, and strains of pneumococcus ( , b, v, c, f, and f). samples are analyzed by the cdc for measles and varicella avidity. seronegative subjects by commercial studies, are eligible to receive booster vaccines. titers are rechecked at least weeks after boosters to re-evaluate immunity; if still seronegative, subjects will receive the entire vaccine series. titers are finally tested at least weeks after the final dose of the vaccine series. immunity analyzed after therapy, after boosters, and after vaccine series. results: of pediatric cancers survivors who completed therapy, % were non-immune to hepatitis b, % nonimmune to > % of pneumococcal strains tested, % nonimmune to measles, % non-immune to varicella, and % non-immune to tetanus. of subjects who received mmr vaccine after therapy and prior to study enrollment did not have protective antibodies to measles. of the subjects who received varicella vaccine after end of therapy and prior to study enrollment, did not maintain protective antibody levels. cdc results for measles and varicella are pending, as well as repeat studies after vaccine boosters and series. conclusion: a significant percentage of pediatric cancer survivors do not retain immunity to hepatitis b, pneumococcus, measles, and varicella. after one booster, a high percentage of subjects did not develop protective immunity to varicella. only subject did not have immunity to tetanus, which is consistent with the high immunogenicity of tetanus toxoid. formal guidelines are needed to protect this population from vaccine-preventable illness post-therapy. children's hospital of richmond at virginia commonwealth university health system, richmond, virginia, united states background: childhood cancer survivors are at risk for being overweight. diet and physical exercise are important in maintaining a healthy lifestyle and weight; however, it has been reported that cancer survivors are less active than their peers. one reason for this may be that there are no clearly established risk-based exercise recommendations for cancer survivors. another reason may be that providers tend to focus s of s recommendations for exercise more towards patients who are overweight. objectives: to describe changes in physical fitness of childhood cancer survivors who exercise. design/method: 'moving forward' is a wellness and physical fitness program that the center for care beyond the cure at chor offers in partnership with the ask childhood cancer foundation and the ymca. the program is available for any childhood cancer survivor between y and y age, being seen at our center. survivors define their fitness or wellness goals and then work with a trainer once a week (at least) for min sessions throughout the year to achieve these goals. baseline and ongoing measurements for core strength, endurance, overall strength and balance were collected. the average of each of the parameters of all participants were compared from the beginning to the end of the program. over the year, there was a % increase in endurance as measured by the average of the miles walked in minutes, % increase in core strength as measured by the average number of sit-ups in secs, an % and % increase in overall strength as measured by the average weight lifted by leg press and the average weight lifted by chest press, and a % increase in balance as measured by the average number of seconds balancing on a single leg. in addition, each child had actually gained weight in the process with an approximately % increase in the average of the weights of all children. there are benefits to regular exercise beyond weight control, and improvements in physical fitness can be seen even without weight loss. regular physical exercise results in improved physical fitness and should be universally advocated to all patients. determining insulin resistance, measuring changes in fatigue and wellness perception following exercise are future directions that we intend to explore. dana-farber cancer institute, boston, massachusetts, united states background: improvements in adolescent and young adult cancer patient (aya) survival rates and quality of life outcomes have lagged behind those of children and older adults, highlighting a need for research targeting this unique population. current literature supports the value of strong ayaclinician communication, notably in facilitating therapeutic alliance, however little is known about aya communication priorities during cancer care and barriers to optimal ayaclinician communication. objectives: to explore aya and oncology clinician communication priorities and to identify barriers and facilitators to aya-oncology clinician communication. design/method: semi-structured interviews were held with aya cancer patients and survivors (ages - years) from a single large academic institution and oncology clinicians (physicians and nurse practitioners) from academic institutions in the northeastern united states. interviews were conducted in english by phone or in person. all interviews were audio-recorded and transcribed verbatim. analyses were aided by nvivo software. ayas identified a wide range of topics as important to discuss with clinicians. the most frequently identified topics were ) side effects of treatment (with an emphasis on physical appearance and function, n = ), ) social issues (including friendship, family, and school, n = ), ) looking ahead to the future (n = ), and ) sexual & reproductive health (including future fertility, contraception, and romantic relationships, n = ). clinicians prioritized ) cancer treatment and side effects (n = ), ) emotional and psychological health (n = ), and ) sexual and reproductive health with a focus on fertility risk and fertility preservation (n = ). aya reported facilitators to good communication including an open and long-established relationship with the clinician (n = ) and clinician engagement in age-appropriate and patient-directed conversations (n = ). barriers included parental presence during visits (n = ). clinicians reported barriers including ) clinician discomfort (not feeling wellequipped to discuss psychosocial topics such as sexual health, spirituality, and relationships with peers, n = ), ) presence of parents/family (n = ), and ) perceived patient discomfort discussing specific topics (such as sexual health, n = ). clinicians acknowledged the need for collaborative efforts with additional team members (i.e. nurses, psychosocial providers) to assist in meeting aya communication needs. conclusion: aya and clinician-reported communication priorities are largely aligned. however, ayas emphasize some topics, such as social function, appearance, and sexual health that are not highly prioritized by clinicians, which may result in gaps in care for ayas in treatment and in survivorship. these data identify opportunities for intervention, including clinician education, patient and family education, clinic-based intervention, and systems-based changes that can be developed and tested. background: primary care physicians (pcps) cite lack of knowledge and inadequate communication with the oncology team as major barriers to providing recommended surveillance for late effects of treatment to childhood cancer survivors. a standardized telephone handoff to pcps posttherapy is a potential strategy to increase survivorship care by pcps through interactive communication. to determine the feasibility of a structured telephone communication using the situation, background, assessment, and recommendation (sbar) communication tool delivered by a trained oncology nurse to increase pcp knowledge and willingness to provide survivorship care. design/method: from / / to / / , a registered nurse expert in childhood cancer survivorship attempted to contact by telephone the pcps of the most recent patients attending yale's childhood cancer survivorship clinic that were < years old, english-speaking, and ≥ years posttreatment. all pcps had been previously sent an individualized survivorship care plan (scp) that listed the patient's previous treatment history and recommended surveillance tests. upon successful contact and after confirming receipt of the scp, the nurse explained the definition of late effects, description of patient's diagnosis and treatment history, and associated potential late complications and schedule of recommended surveillance tests. the pcp was also asked about his/her ability and willingness to provide needed surveillance for late effects in the future. overall, of pcps were successfully contacted with a median of phone call (range: - ) that lasted a median of minutes (range: - ) after a median of business day (range: - ). no pcps ended the call mid-conversation. all pcps were receptive and expressed appreciation for the call. twenty-five of ( %) pcps expressed an understand-ing of the material discussed and endorsed belief in their ability and willingness to provide late effects surveillance for their patients. no pcps questioned discussing their patient's care with a nurse versus a physician. interactive, structured communications between nurses and pcps by telephone are feasible and are associated with high-levels of pcp confidence in providing survivorship care. background: childhood cancer (cc) admissions account for % of non-newborn pediatric hospitalizations. these hospitalizations are longer and more expensive than other hospitalizations. admission payer (medicaid or commercial) reflects both health policy and sociodemographic status. the objective of this study was to determine if length of stay (los) or cost of cc admissions differed by payer. we used the kids inpatient database, a sampling of all pediatric hospital discharges in the united states. analysis for this study was limited to admissions containing a cancer diagnosis in any discharge icd- codes. admissions were further subcategorized by discharge codes according to diagnosis (leukemia, lymphoma, solid tumor and brain tumor) and reason for admission (chemotherapy, procedure, infection, non-infectious toxicity or "other"). charges were converted to costs using cost-to-charge ratios. multivariable linear regression models were performed to control for age, gender, race, reason for admission, and diagnosis. results: there were , weighted admissions for children with a cancer diagnosis in . of these admissions, . % had medicaid, . % had commercial insurance, and less than % had other payers. the mean los for medicaid admissions was . days ( % ci . - . ), compared with . days ( % ci . - . ) for commercial insurance. surgical admissions accounted for the largest difference in length of stay with medicaid admissions being . days longer than those covered by commercial insurance ( . days vs . days), however, the difference was significantly different for all reasons for admission. in multivariable analysis admissions associated with commercial insurance were % shorter s of s (p< . ), accounting for approximately one hospital day, than admissions associated with medicaid after controlling for other variables including race. the mean overall cost for medicaid admissions was $ , ( % ci - ), compared with $ , ( % ci - ) for commercial insurance. in the multivariable model, cost was collinear with race. conclusion: los and cost of admissions associated with medicaid differed from those associate with commercial payers. medicaid admissions were % longer on average than commercial insurance, accounting for a difference in length of stay of approximately one day although the difference varied with the reason for hospitalization (chemotherapy, surgical procedure, infection, other toxicity, other). costs of admissions were not independent of race. further investigation into potential explanations for this difference including differential access to home care needs, outpatient reimbursement differences, social indications for prolonged hospitalization, and provider biases, is warranted. background: pediatric cancer is a major cause of morbidity and mortality among children surpassed only by accidents. despite improved outcomes in high income countries (hic) survival rates remain poor in the developing word. there are various diagnostic and therapeutic limitations contributing significantly for the survival gap. the main objective of the study is to to evaluate the outcomes of pediatric cancer in armenia and identify diagnostic and therapeutic limitations in the country. we conducted a retrospective study among (≤ years old) children with cancer (solid tumors and hematological malignancies), who were diagnosed and treated at the clinic of chemotherapy of muratsan hospital complex of yerevan state medical university between and . those patients, who didn't receive chemotherapy for any reason were not included in the study cohort. epidemiological, social, medical information was collected through the patient charts review. this included patient age at diagnosis, sex, place of residence (city vs village), the educational level and employment status of parents, type of cancer, stage, presentation of symptoms, first medical specialty consulted and the time consulted, initial work-up, the type of treatment received, information on the diagnosis/treatment received abroad. results: at our clinic during the mentioned period of time the majority of patients presented with hematologic malignancies- %. ( . %) patients had information on diagnosis delay. average delay in diagnosis was about days. in % of cases the first contact with "healthcare system" was through pediatrician, and in % with surgeon. out of relapsed patients received salvage treatment in armenia and abroad. from those who stayed for treatment in armenia patients survived. majority of relapsed patients had acute lymphoblastic leukemia. from leukemia patients immunophenotyping and cytogenetics were available for ( . %) patients; the majority of missing cases were between and , when these diagnostic modalities were not available or affordable in the country. ( %) patients received part of diagnosis and/or treatment abroad. the most frequent reason for going abroad was bone marrow transplantation, otherwise none available in armenia. out of patients were lost to follow-up, patients had a fatal outcome. patients were in remission at a median follow up of . years. conclusion: unavailability of cancer registry and several essential diagnostic/treatment modalities, luck of multidisciplinary care and palliative support, high rate of out-of-pocket expenses were among the main challenges of pediatric cancer care in armenia. background: adverse drug reactions (adrs) are increasingly recognized as important and sometimes irreversible complications of cancer treatment. anthracyclines and cisplatin are effective chemotherapeutic agents, but their use can be limited by cardiotoxicity (anthracyclines) and ototoxicity (cisplatin) in up to % of patients. genetic variants that can be used to predict who is most at risk of developing these adrs have been discovered and replicated. objectives: to create pharmacogenetic risk prediction models for anthracycline and cisplatin toxicities and discuss results with oncologists to facilitate incorporation into treatment decision-making when appropriate. design/method: risk prediction models were developed from the linear regression of strongly-predictive genomic variants (odds ratios ≥ ) discovered and replicated in at least three patient populations. these models were used to assess an individual patient's genomic risk of developing cardiotoxicity from anthracyclines or hearing loss from cisplatin. risk results were returned to oncologists showing where the specific patient's genetic risk of toxicity lies on a continuum between the lowest and highest risk groups across all studied patients using a multi-gene model. interviews were conducted with patients, families, and oncologists to determine how results were valued and utilized. results: patients have been genotyped and had their genetic risk results returned to their oncologists. the first patients have been characterized to determine the impact these test results have had on their clinical care. results were described as being useful in decision-making by patients and/or oncologists in % of cases. additionally, for patients in the most extreme risk groups (highest and lowest risk), a change in treatment plan was ordered % of the time for cisplatin patients and % of the time for anthracycline patients. this included increased cardiac and audiological monitoring, the addition of a protective agent, or choosing an alternative treatment protocol if the risk outweighed the benefits of remaining on the current treatment plan. in interviews, patients indicated that they felt more involved in decision making, and felt reassured by understanding their genetic risk of toxicities. genetic risk prediction models for anthracycline cardiotoxicity and cisplatin ototoxicity were highly utilized by patients and oncologists in decision-making. results were found to be an important tool for informing patients of the risk of adrs during cancer treatment, and resulted in patients and their families feeling more involved in decision-making. background: childhood cancer survivors are at increased risk of developing executive dysfunction, and low socioe-conomic status (ses) has been identified as one of the mediators of executive functioning. previous studies have used traditional measures of ses, such as parents' education level, family annual income and occupation. but more recently, area based socioeconomic measures like block group poverty status are deemed to be more useful in monitoring of social inequalities in health in the united states. block groups are statistical divisions of census tracts and generally contain between and , people. the current study aims to understand the association of block group poverty status (percentage of households in family's block group of residence living below the federal poverty level) with executive functioning among cancer survivor children. design/method: we used a retrospective cohort of childhood cancer survivors. relevant information was collected from the medical record, administrative data sets and parent-filled surveys. address information was geocoded using arcgis . to obtain data on the block group poverty status. a priori cut-points were set to represent block groups with families living below poverty level at %, . % to . %, and ≥ . %. executive functioning were assessed through a parent-rated instrument, the behavior rating inventory of executive functions (brief). multiple linear regressions were used to determine the relationship between block group poverty status and the brief scores. results: data was examined from families of childhood cancer survivors, ranging in age from to years. in this sample, . % families reported an annual income <$ , , . % reported income between $ , and $ , while . % reported annual income ≥$ , . primary care giver of . % of cancer survivors had more than more high school education, and . %, . % and . %, of families were living in a block groups with %, . - . % and ≥ % poor households respectively. block group poverty level was not significantly associated with annual income levels (spearman's rho = . , p = . ), or parental education level (spearman's rho = - . , p = . ). in a step-wise multiple linear regression, there was no statistically significant association seen between block group poverty status and executive functioning after adjusting for co-variables in the final model. future prospective study with a bigger sample size, longer follow up period and more robust measures of the executive functioning like a clinician administered test are needed to understand the effect of block group poverty status on executive functioning. to d completion was . days (range - ). all parents strongly agreed/agreed that d was helpful and would recommend d participation to another family. ten parents ( %) reported time spent on d was "just right." no parent felt more worried due to the intervention, though parent found d participation stressful. this interim analysis suggests that parents have a favorable d experience and recommend the intervention. to date, < % of enrolled parents fail to participate. d shows promise as an acceptable interdisciplinary communication intervention targeted to the early treatment period for childhood cancer. children 's hospital and research center oakland, oakland, california, united states background: screening echocardiograms are recommended by children's oncology group (cog) guidelines to assess for anthracycline-induced left ventricular (lv) systolic dysfunction. the yield of screening echocardiograms during chemotherapy and in the immediate post-therapy period is uncertain. objectives: to assess the incidence of lv dysfunction detected by screening echocardiograms during chemotherapy and in the immediate post-therapy period, defined as - months off-therapy. design/method: children diagnosed with cancer between january -march who received anthracycline chemotherapy were identified. echocardiograms were performed as per protocol, institutional and cog guidelines, and were reviewed retrospectively. lv dysfunction was defined as fractional shortening (fs) < % or ejection fraction (ef) < % ( ) results: in this cohort (n = , median age years), the most common diagnosis was all ( . %), followed by aml ( . %). of echocardiograms, ( . %) were performed during treatment and in the immediate posttreatment period. thirty-eight ( . %) patients had a > % decrease in fs compared to their pre-treatment echocardiograms. none of these patients required any treatment modification or cardiac medications. only patient ( . %) had echocardiogram-proven lv dysfunction discovered on a screening echocardiogram during her treatment course. she eventually died due to multi-organ failure following septic shock. this patient was receiving treatment for aml and had received mg/m of doxorubicin-equivalent anthracyclines at the time of the abnormal echocardiogram. one patient with metastatic ewing sarcoma had borderline lv dysfunction with a fs of % detected a month before completion of therapy. she had received mg/m of doxorubicin equivalent anthracyclines at the time of the abnormal echocardiogram. she did not require any therapy modification or additional cardiac medications. serial echocardiograms done on this patient have shown stable ventricular function. no off-therapy screening echocardiograms identified lv dysfunction. in our experience, the yield of echocardiograms to detect anthracycline-related cardiac dysfunction during treatment and in the immediate post-therapy period is very low. one patient developed lv dysfunction during treatment and one had borderline fs, while no lv dysfunction was identified within months of completing chemotherapy. though fs decreased in % of patients, none required intervention. further study is needed to optimize the use of echocardiography screening in children treated with anthracyclines. references: . landier w et al. jco . background: platinum-based chemotherapy increases the risk of sensorineural hearing loss in children with cancer. little is known about the impact of hearing loss on cognitive and emotional functioning in survivors. to determine the association of severe/profound hearing loss after platinum-based chemotherapy with ) cognitive impairment and ) emotional distress (i.e. anxiety and/or depression). cross-sectional study of all patients attending yale's childhood cancer survivorship clinic ≥ years off therapy for cancer diagnosed at < years and treated with cisplatin and/or carboplatin, but with no history of cns tumor, cranial radiation, congenital hearing loss, or developmental delay. hearing loss severity and hearing aid data were abstracted from audiograms and detailed clinical history. cognitive impairment was defined as behavior rating inventory of executive function t score ≥ , assessment by neuropsychologist, and/or history of special education. emotional distress was determined by brief symptom inventory t score ≥ (global or two subscales) or behavioral and emotional screening system t score ≥ , psychologist interview, and/or history of psychotropic medication/psychotherapy. the most recent available patient data were used. logistic regression with sas software, version . was performed. results: overall, patients ( % female, % white) met eligibility criteria with a median age of . years (iqr = . ) at diagnosis and . years at evaluation (iqr = . ) after a diagnosis of sarcoma ( %), neuroblastoma ( %), or other ( %) for which % received cisplatin and % received carboplatin. fifteen patients ( %) had severe/profound hearing loss in at least one ear. patients with severe/profound hearing loss had a significantly increased risk of cognitive impairment (or = . ; % ci = . - . ), but not emotional distress, compared to patients without severe/profound hearing loss. there was no significant association between age at diagnosis, current age, time since diagnosis, sex, race, ethnicity, or diagnosis with either cognitive impairment or emotional distress. similarly, there was no significant interaction between ) age at diagnosis and hearing loss or ) sex and hearing loss with either cognitive impairment or emotional distress. ten of the ( %) patients with severe/profound hearing loss in at least one ear were recommended hearing aids, of which ( %) reported compliance most of the time. we conclude that severe/profound hearing loss is significantly associated with cognitive impairment, but not emotional distress, in childhood cancer survivors. our data supports the need for interventions to improve hearing in these patients, including compliance with hearing aids. background: who grade anaplastic astrocytoma is a high grade glioma dependent on vascular endothelial s of s growth factor (vegf) mediated angiogenesis for its growth and infiltration. bevacizumab is a recombinant humanized monoclonal antibody which binds vegf-a and inhibits angiogenesis. common adverse effects of bevacizumab are hypertension, proteinuria, thrombosis and bleeding. while animal model based studies have shown that bevacizumab may impair ovarian function the effects of bevacizumab therapy on human fertility are not clear. since the physiology of pregnancy involves neovascularization/angiogenesis it is recommended that conception be avoided for at least months following exposure to bevacizumab. to describe the course of a young adult who became pregnant after receiving bevacizumab and radiation therapy for treatment of an anaplastic astrocytoma. a year old woman diagnosed with a localized hemispheric who anaplastic astrocytoma was treated with chemotherapy and radiation (temozolomide/ . gy) followed by cycles of bi-weekly bevacizumab/temozolomide. patient opted not to pursue fertility preservation prior to initiation treatment. she experienced bevacizumab-associated proteinuria and hypertension during treatment but received all protocol mandated doses (cumulative doses: bevacizumab = mg/kg; temozolomide = . gm/m ). she had a spontaneous unassisted pregnancy months after completing treatment. her pregnancy was uneventful and she was normotensive throughout. fetal ultrasonography at , , , weeks revealed no abnormality of the brain, heart, great vessels, kidney, extremities, placenta and umbilical cord. at weeks she delivered a female infant via cesarean section (birth weight: grams, apgars: and ) excessive post-partum hemorrhage was not reported. placenta was bi-lobed and weighed g. histological analysis revealed normal placental villous development and maturation and two small infarcts. conclusion: exposure to bevacizumab in our patient had no detrimental effect on fertility and on placental/fetal vascular development. we hope this report will add to the existing data on the effects of bevacizumab therapy on fertility. children's healthcare of atlanta, emory university school of medicine, atlanta, georgia, united states background: reports of malnutrition incidence and prevalence in young cancer patients are variable and not well established. previous research suggests children, especially less than years old, treated with intensive cancer-directed therapy are at higher risk for malnutrition. however, no standardized assessment has been used to evaluate risk in this population. objectives: we aim to assess the trends of weight-for-age for patients following cancer diagnosis. this study will be the first to use a standardized measure of treatment intensity (intensity treatment rating scale, itr- ) and will assist in targeting interventions for identification and treatment of malnutrition. design/method: this observational, retrospective study obtained data through the center's pediatric cancer registry and electronic medical record. patients were classified by tumor type (brain or non-brain tumor) and treatment intensity (itr- ). itr- incorporates diagnosis, chemotherapy, radiation, and surgery, beginning with lowest intensity ( ) to highest intensity ( ). inclusion criteria included new cancer diagnosis - at less than years old, with weight obtained and available within days of therapy start date. incomplete data, alternate growth charts, or treatment intensity of , were excluded. weight was obtained at start of therapy and through years after treatment initiation (approximately days) and converted to z-scores adjusted for age and sex. weight trajectories were modeled using generalized linear mixed models with subject-specific random intercepts and spline functions. separate functions were constructed for subgroups of interest (tumor type and itr). results: there were patients included: patients with brain tumors ( . %) and with non-brain tumors ( . %). of included patients, had treatment intensity of ( . %), of ( . %) and of ( . %). over the observation period, , valid weights were recorded. at initiation of treatment, no difference existed between z-score by tumor type (p = . ) or by intensity ( vs. , p = . ; vs. , p = . ; vs. , p = . ). tumor type did not affect z-score through the follow up period. z-scores were higher for intensity rating vs. and vs. (p = < . and p = . respectively) at days after the start of treatment and persisted through days (p = . and p< . respectively). higher treatment intensity is associated with decline in z-score and failure to return to baseline. future directions include further analysis on specific risk factors and timing of weight loss, longer-term follow-up of weight trends, and targeted interventions for identification, prevention, and treatment of malnutrition. objectives: asses the pt requirements for bleeding episodes in a prospective cohort of pcp using a < × e threshold compared to a < × e /l threshold in a historical cohort. we collected pt data in all pcps treated at our center between january/ through december/ . diagnosis, prescription for pt (prophylaxis vs bleeding disorder), plt count and transfused units were assessed for each pt. pcps treated from january/ through june received prophylactic pt with a < × e threshold (cohort a), and pts treated from july/ through december/ received prophylactic pt with a < × e threshold. pts done for procedures and pts with concomitant hemorrhagic pathology were excluded. we compared the number of pts prescribed as prophylaxis vs bleeding episode between cohorts. data analyzed: graphpad prims . ®. statistical analysis: percentages with confidence interval (ci); t-student test (parametric variables) and mann-whitney test (nonparametric variables). statistical significance: p< . . we reviewed pts ( in cohort a, cohort b) in patients. % had acute leukemia, % received and auto or allo hsct. diagnoses and the proportion of patients undergoing hsct was comparable in both cohorts. the average number of pts per patient was , in cohort a and , in cohort b (p = ns), but a significant difference was found when hsct patients were excluded from this comparison ( , pt per patient in cohort a vs , in cohort b, p = , ), which resulted in an estimated , % reduction in pts prescription. furthermore ( , %) pts were prescribed for bleeding episodes in cohort a versus ( , %) in cohort b (p = ns). patients receiving hsct in the entire group ver-sus those not receiving hsct had similar pt requirements for bleeding episodes ( % vs , % p = ns) conclusion: a < × e plt count threshold for prophylactic pts is safe in pcp in chemotherapy and hsct. it can result in a significant reduction in pt usage. key words: platelets, transfusions, prophylaxis, cancer, childhood. ucsf benioff children's hospital oakland, oakland, california, united states background: transition of care for adolescent and young adult (aya) survivors of childhood cancer from pediatric to adult-oriented long-term follow-up (ltfu) is complex. loss to follow-up is common, and little is known about the success rates among different models. the survivors of childhood cancer program (sccp) at ucsf benioff children's hospital oakland employs a community-based model for transitional care. our multidisciplinary team provides aya survivors a comprehensive treatment summary and recommendations, then facilitates transition to primary care or adult oncology ltfu programs. evaluate the success rate for transition of care among aya survivors of childhood cancer in our ltfu program, and identify barriers to successful transition. design/method: aya patients seen from november to august in the sccp with intent to transition were asked by email or telephone if they had followed up with their designated provider. the primary outcome was successful transition, defined as establishing care within months of their visit. patients were also asked about barriers to transition and to rate the new provider's familiarity with their cancer history and ltfu needs. results: transition was intended for patients. eightyseven were contacted and responded. of these, ( %) successfully transitioned, while ( %) were lost to followup. ages ranged from to years, at to years since completion of therapy. ten ( %) transitioned to a primary care provider, ( %) to an adult oncology ltfu program, and ( %) to a pediatrician. patients rated their new provider's knowledge above average ( . ) on a -point scale from poor ( ) to excellent ( ). survivors lost to follow up indicated the following barriers to transition: loss/change of insurance ( ), inability to find a provider ( ), too busy/forgot ( ), problems with transportation ( ), concerns about cost/copay ( ), and s of s other ( ). twelve patients requested further assistance with transition. conclusion: two-thirds of responding patients successfully transitioned. more work is needed to overcome various barriers to transition for one third of aya survivors. albany medical center, albany, new york, united states background: the transition from active treatment, to offtherapy follow-up, is a stressful event for parents of children with cancer. the psychosocial needs of parents after therapy have received limited attention in the united states with only published quantitative studies, the largest with parents. we have secured funding for and recruited a transition care coordinator (tcc) to investigate this further. objectives: our objective is to assess and screen parents at the end of their child's treatment, and to develop interventions to support parents during this time and thereafter. design/method: after informed consent, a standardized questionnaire, the psychosocial assessment tool (pat . ), was administered to parents at end of therapy (t ), months later (t ) and year later (t ). the tcc provided "universal" intervention to all families with an end of therapy binder containing a treatment summary, follow-up roadmaps, information on late effects, and survivor scholarships. based on their pat . scores, some parents were provided intervention specific to symptoms (targeted intervention for scores - . ) or referred to a behavioral health specialist through the clinic social worker for counseling (for scores > ). results: analysis of pat data showed that % of parents (n = ) scored in the targeted or clinical ranges; % of parents scored in those ranges at pat . significant gender differences were revealed with the mean score for men of . and for women of . . this was confirmed by showing statistical significance (p = . ) when analysis was conducted for only a subgroup of data composed of couples (n = ). analysis of pat data by couples (n = ) showed the mean score for men was . and for women was . (p = . ). gender differences were most apparent in caregiver stress reaction questions that focused on ptsd symptoms. when the subgroup of couples' scores (n = ) for caregiver stress reaction at pat was analyzed, there was a significant difference (p = . ) in caregiver stress reaction with a mean of . for men versus . for women. [note: subcategory scores range from to ]. this study was initiated in october using a tcc and the pat . screening tool. the results suggest greater stress on mothers after therapy, with a substantial proportion of parents having symptoms of ptsd after therapy. background: hodgkin lymphoma (hl) is a common childhood cancer characterized by an inflammatory microenvironment. chemotherapy and radiation may exacerbate this inflammation and contribute to the development of late effects (pneumonitis or pulmonary fibrosis). in a heterogeneous cohort of childhood cancer survivors exposed to pulmonarytoxic therapy, no association between pro-inflammatory cytokines and late pulmonary dysfunction was observed. our objective was to test this association in a relatively uniform cohort of survivors of hl, given the well-recognized proinflammatory background of this disease. objectives: to characterize off-therapy pulmonary function in survivors of hl treated with contemporary therapy, and to investigate its association with persistent systemic inflammation. design/method: blood samples, clinical data, and pulmonary function tests were obtained from survivors of hl ≥ months off therapy. lung function score (lfs), a validated method for assessing degree of pulmonary dysfunction on a scale of i to iv, was determined from diffusion capacity and forced expiratory volume in one second (fev ). for a control group, blood samples from patients with benign, noninflammatory hematologic conditions were used. plasma concentrations of inflammatory cytokines were measured on a luminex platform (emd millipore). associations between clinical features or cytokine levels and lfs i (normal) vs. ii-iv were evaluated using logistic regression or wilcoxon rank sum tests, respectively. results: of survivors (mean age at diagnosis: years, range: - ; mean time off therapy: . years, range: . - ), % were categorized as lfs ii (mild dysfunction), % as lfs iii (moderate dysfunction), and no survivors as lfs iv (severe dysfunction). higher lfs was associated with female sex (p = . ) but not other demographic, disease, or treatment factors. forty-eight survivors had blood samples collected at a mean age of . years (range: - ) with a mean time since treatment completion of . years (range: . - . ). of controls, the mean age at time of blood collection was years (range: - ). survivors did not have significantly elevated cytokine levels compared to controls. female survivors of hl ≥ months off therapy are at increased risk of pulmonary dysfunction. neither evidence for pulmonary dysfunction, as measured by lfs, nor duration of time off therapy were related to systemic inflammation in this study. pulmonary function deterioration and clinical pulmonary symptoms are rarely observed immediately following therapy but increase over time. future studies may consider exploring the contribution of systemic inflammation to pulmonary late effects in survivors farther off therapy, when risk for this late effect is greater. background: thyroid carcinoma is a very rare tumor in pediatrics, accounting for . - % of childhood carcinomas in the united states and europe. we aim to detect the risk of second malignancies among pediatric thyroid cancer survivors. the cohort analysis consisted of pediatric cancer patients aged less than years diagnosed with a primary thyroid cancer and identified by site code icd- - : c , reported to a seer database between and . they were followed up by death or the end of the study period (december , ) . out of patients diagnosed primarily with thyroid carcinoma, there were patients who had incidences of subsequent malignancies. the mean age of patients at initial diagnosis of thyroid cancer was years. females ( . %) had significantly higher incidence of second malignancies (sm) than males ( . %). the overall standardized incidence ratio (sir) of sm in thyroid pediatric patients was higher than expected (sir = . ). some specific sites showed significantly higher incidences: salivary gland (sir = . ), gum and other mouth (sir = . ) and kidney (sir = . ). the overall risk of sm in patients received radioactive iodine was higher than expected (sir = . ). the cumulative inci-dence of sms from the initial diagnosis of thyroid cancer was calculated with the survival methodology of competing risk, death treated as a competing event. cumulative incidence of sm was . % [ % ci ( . , . %)] at years and substantially expanded after years, reaching . % [ % ci ( . , . %)] at years. the cumulative incidence of each tumor type at years was . % [ % ci ( . , . %)] for breast cancer, . % [ % ci ( . , . %)] for salivary gland, . % [ % ci ( . , . %)] for each one of kidney and cervix uteri and . % [ % ci ( , . %)] for each one of ovary and melanoma of the skin. cumulative incidence of sm was stratified based on race, gender and radiotherapy exposure, but there was no statistical difference in each of them. conclusion: race, gender, histological subtypes, and radioactive iodine may play an important role as prognostic factors for developing sm among pediatric thyroid cancer survivors. identification of underlying mechanisms that raise the risk of sm is important for both treatment and follow-up strategy. background: the ethical practice of informed consent requires it be both voluntary and understood by the research participant. in pediatric oncology, parents must undergo informed consent to enroll their child with cancer into clinical trials, but often it can be difficult to understand especially for parents with low english proficiency. previous research has shown that parents of children with cancer have difficulty understanding voluntariness, and that parental satisfaction with informed consent does not always correlate with adequate comprehension. objectives: to examine socio-demographic and contextual correlates of comprehension of informed consent, voluntariness, and satisfaction in parents who consented to participation of their child in a cancer clinical trial. we focused on characterizing differences between non-hispanics and hispanics, the fastest growing ethnic group in the u.s. design/method: parents/guardians (n = ) of children aged - years with newly diagnosed cancer, who had consented to participation of their child in a clinical trial for cancer treatment at rady children's hospital-san diego were s of s prospectively recruited. parents completed questionnaires assessing comprehension, voluntariness, satisfaction, health literacy, socio-demographics, and acculturation level, if hispanic. comprehension was surveyed at baseline and longitudinally at months. comprehension, voluntariness and satisfaction outcomes were analyzed by socio-demographics, health literacy, and acculturation level using logistic regression. results: of the participants surveyed, ( . %) were hispanic and ( . %) were non-hispanic. we found that higher health literacy was associated with greater objective comprehension (p< . ), voluntariness (p< . ), socioeconomic status (p< . ), and acculturation (p< . ). hispanics reported lower objective comprehension (p = . ), voluntariness (p = . ), health literacy (p< . ) and ses (p = . ) compared to non-hispanics. spanish-speakers reported lower voluntariness (p = . ), health literacy (p< . ), and acculturation (p< . ) compared to englishspeakers. at the -month follow-up, comprehension in hispanics significantly improved (p = . ) compared to their baseline comprehension. satisfaction was moderately high across all subgroups and was not significantly impacted by socio-demographics, health literacy, or acculturation. in this study, with equivalent numbers of hispanic and non-hispanic participants, we found that hispanic and spanish-speaking parents of children with newly diagnosed cancer had inadequate informed consent comprehension, voluntariness and health literacy despite high satisfaction. our study suggests that hispanics and individuals with limited english proficiency are not making truly informed decisions for their child with cancer. to ensure the ethical practice of research in pediatric oncology, the informed consent and decision-making process must be improved with culturally and linguistically interventions for these underserved populations. memorial sloan kettering cancer center, new york, new york, united states background: pediatric oncology patients undergo repeated bone marrow aspirations and biopsies (bma/bx). these potentially painful procedures can exacerbate anxiety and distress. standard practice at memorial sloan kettering (msk) department of pediatrics is to use propofol, which has amnestic but no analgesic properties. we sought to evaluate whether the addition of local anesthetic would improve patient experience with bma/bx. the purpose of reppair: reducing procedural pain and improving recovery of quality of life (qol) (nct ) is to evaluate the efficacy of local anesthesia with ropivacaine in reducing procedural pain and improving post-procedure qol in pediatric neuroblastoma patients undergoing bma/bx with general anesthesia. reppair is a prospective, randomized, crossover clinical trial that opened for enrollment october . eligible patients were - years old with neuroblastoma. participants were observed on trial for two sequential bm procedures; one procedure with intervention a: propofol alone (pa), and the other with intervention b: propofol plus ropivacaine (p+r). participants were randomized to intervention sequence ab or ba and were blinded to the order of interventions. participants and recovery room (rr) nurses, who were also blinded, followed a standardized postprocedure pain management algorithm. the primary endpoint was percentage of participants requiring opioid analgesia in the hours post-procedure. secondary endpoints included total opioid in hours, non-opioid analgesia use, pain scores, time to first opioid, and short-term qol. qol was assessed by a parent-proxy metric that evaluated pain interference with sleep, physical, emotional, and social recovery. as of january , patients were assessed for eligibility and patients were randomized ( have completed both procedures). for the primary endpoint, a slightly higher proportion of participants required opioid for pa than p+r ( % versus %, p = . ). pain scores in the rr were significantly higher for pa than p+r (median [ th, th percentile]: [ , ] versus [ , ], p = . ). there were no statistically significant differences in total opioid or non-opioid analgesia, -and -hour pain scores, median time to first opioid, or pain interference scores. there were no adverse events. conclusion: preliminary findings of the reppair trial suggest that local anesthesia does not reduce the need for opioid analgesia or improve short-term qol in pediatric patients undergoing bma/bx with general anesthesia. local anesthesia did improve pain scores in the immediate recovery period. final results of this study will help establish evidence-based guidelines and optimize the experience of pediatric patients with bone marrow procedures at our center. background: children with advanced cancer experience a range of symptoms throughout treatment or at end of life, some of which are poorly controlled. minimizing suffering, including effective symptom management, in children with advanced cancer is a central value for pediatric oncology clinicians. patient-reported outcomes have been used in symptomrelated research in pediatric oncology patients; however the majority of literature specific to symptoms during palliative care and end of life for children and adolescents with advanced cancer is based primarily upon medical record reviews and to a lesser extent, patient self-report. the purpose of this study was to prospectively describe symptom frequency, severity, and level of distress in children/adolescents with advanced cancer using patient selfreport and parent proxy. design/method: a prospective cohort design was used for this study. five pediatric oncology institutions from across the united states participated. children and adolescents were eligible to participate if they were - years of age, englishspeaking, and had a diagnosis of advanced cancer, defined as a -week history of progressive, recurrent, or non-responsive disease or a decision not to pursue curative-focused therapy. a modified version of the memorial symptom assessment scale (msas) was used to measure symptom frequency, severity, and level of distress and was administered to child/parent dyads electronically via smartphones every two weeks. information regarding disease status and cancer treatment was collected concurrently. data was analyzed using descriptive statistics and univariate logistic regression analysis. results: a total of children and adolescents and parents participated in the study. the median age of child participants was years, with half being male. the median age of parents was years. the child participants had a variety of primary diagnosis, including: leukemia/lymphoma (n = , %), solid tumor (n = , %), and brain tumor (n = , %). the most frequently reported symptoms by children with advanced cancer and parents were pain (n = / , . %), lack of energy (n = / , . %), and nausea (n = / , . %). presence of disease (p = < . ), recent disease progression (p = . ), and receiving cancer therapy (p = . ) were significant factors on the presence of pain. high intensity cancer therapy was a significant factor on pain frequency (p = . ) and level of distress (p = . ). it is feasible to collect data prospectively in children with advanced cancer regarding symptom frequency, severity, and level distress. clinicians' increased understanding of the symptom experience may promote communication with children and adolescents and timely intervention. more research is needed to understand symptom clusters in children with advanced cancer. vanderbilt children's hospital, nashville, tennessee, united states background: febrile neutropenia (fn) is a frequent occurrence in children undergoing chemotherapy. though guidelines recommend adding a second antibiotic to broad-spectrum antipseudomonal coverage in specific scenarios, augmenting empiric therapy with a second antibiotic is common practice. additional empiric antibiotic (aea) use increases the risk of antibiotic toxicity and future antimicrobial resistance. data clarifying the indications for aea are limited in pediatric patients. objectives: to identify risk factors for gram-positive (gp) and gram-negative (gn) bacteremia in patients presenting with fn to determine situations in which aea use is warranted. design/method: a retrospective chart review was conducted of pediatric severe fn with absolute neutrophil count < / l occurring at a single institution between and . potential a priori risk factors based on clinical reasons for antibiotic expansion were chills, hypotension, mucositis, skin or soft tissue infections (sstis), recent administration of highdose cytarabine (hdac), and a diagnosis of acute myeloid leukemia (aml). potential factors for gn bacteremia were chills, hypotension, mucositis, and abdominal pain. the association between each potential risk factor and gp or gn s of s bacteremia was identified. logistic regression was used for multi-variable analysis. the review yielded episodes. gp bacteremia was isolated in cases ( . %) and gn bacteremia in episodes ( . %). in multivariable analysis, hypotension (or . ( % ci . , . ), p = . ) and sstis (or . ( . , . ) , p = . ) were independently associated with increased risk of gp bacteremia, while mucositis (p = . ), recent administration of hdac (p = . ) and chills (p = . ) were not. ten patients with aml didn't receive hdac, thus the association between aml and gp bacteremia could not be reliably estimated. hypotension (or . ( . , . ), p< . ) and chills (or . ( . , . ), p< . ) were independently associated with a higher risk of gn bacteremia, while mucositis (p = . ) and abdominal pain (p = . ) were not. of the gn infections, ( %) were resistant to cefepime, the empiric agent of choice at our institution. patients with fn with sstis, hypotension, or recent hdac had increased risk of gp bacteremia indicating potential benefit of empiric vancomycin in these settings, while mucositis and chills were not associated with gp bacteremia. hypotension and chills were associated with gn bacteremia, potentially warranting empiric antibiotic expansion, while mucositis and abdominal pain were not. identifying specific indications for aea use in pediatric severe fn use may improve antimicrobial utilization, decrease unnecessary antibiotic use, and improve patient outcomes. background: for children/young adults with incurable high grade gliomas (hggs), like diffuse intrinsic pontine glioma (dipg) or glioblastoma multiforme (gbm), oncologists endeavor to align therapy with patient/family goals of care, but may be influenced by providers' preferences or limited resources. ethical challenges can arise around the perceived purpose, risks and benefits of therapy options, provider conflicts of interest, access to care, deciding decisional priority between patients and families, and conflicts around end-oflife care. objectives: evaluate factors that play into longitudinal decision making for children and young adults with hggs, their families and oncologists using a qualitative approach with ethnographic elements. design/method: eligible patients were aged - with dipg, gbm, or secondary hgg. patient exclusions included: non-english speaking, in state custody, death prior to diagnosis, seen by oncology once, or an oncologist declined participation. key decision making visits (e.g. mri reviews) were serially audio-recorded, along with subsequent : semistructured interviews with patients and/or parents about the decision making process. field notes from clinician meetings, chart notes, and oncologist questionnaires were obtained. discussions and interviews were transcribed and independently coded by three investigators. inter-rater reliability was assessed during code book development. discrepancies were discussed until consensus met. constant comparison analysis with maxqda software continued until thematic saturation. results: twenty-two of eligible patients were approached; agreed to participate. one withdrew upon transferring care. mean age was . years (sd . ); % male, % caucasian, % african american, % hispanic, and % asian. four encounters, ( . hours), were recorded on average per patient. parent/patient interview themes included: ) hope (for a cure, prolonged life, and quality of life), ) importance of physician recommendations, ) importance of support systems (family, community, social media), ) food (as cancer etiology, intervention) ) finances (personal, research funding), ) communication (with medical providers, family, community), ) death, and ) god (beliefs, prayer, existential questions). oncologists desired prolonged quality of life, while patients/families transitioned to that hope from hope for a cure. decisions made in the setting of hggs are multi-factorial, ultimately reflecting the competing values of decision makers. optimism about treatment efficacy is held in tension with poor prognosis, allowing for functional hope. acknowledging patients' and families' shifting hopes allows for changes in goals of care and shared decision making. future work is needed to ) develop preference tools for pediatric patients and families to inform medical providers and ) provide training in communication and shared decision making with oncologists. emory university, atlanta, georgia, united states background: bone marrow transplantation (bmt) is a potentially curative but underutilized treatment for scd. our previous work has shown that there is variation in physician philosophy and practice in considering bmt as a treatment option for patients with scd, and physicians may not discuss this with patients and families as a potential treatment option. in a randomized clinical trial to test the effectiveness of a decision aid for disease modifying therapies for sickle cell disease, adult patients with scd as well as caregivers of adult/pediatric patients were interviewed about how they seek or have sought information related to scd, made decisions about treatments for scd, and identified a treatment option they were interested in learning more about using the decision aid tool. we performed a secondary analysis of these baseline data to understand patient information needs and attitudes regarding bmt as a treatment option for scd. the goals of this analyses was to understand patient and caregivers' attitudes and perceived information needs regarding bmt as a treatment option for scd. we performed an analysis of baseline interviews from caregivers of patients with scd or adult patients from a randomized control trial for a decision aid tool for scd. of the interviews belonged to caregivers of patients with scd. in addition to reviewing interviews for discussion of bmt, we interrogated for mention of terms such as 'bone marrow transplant' or 'cure' or 'stem cell transplant'. interviews were coded using nvivo and analyzed for emerging themes. results: of the baseline interviews, interviews met selection criteria. thirteen of the interviews were with caregivers of pediatric patients, and the remainder were with adult patients, including young adult patients with scd. the majority of participants want to learn about bmt or curative options. in many participants, this was expressed despite knowledge that they were not a likely candidate for transplant. desired information about bmt included eligibility, benefits, risks, long-term effects, quality of life and financial aspects related to bmt. of the patients who discussed how they learnt about bmt, approximately half mentioned that their healthcare provider had not previously mentioned this to them. we then examined knowledge of bmt and attitudes with demographic and clinical variables. patients and caregivers of pediatric patients with scd want to learn about bmt as a treatment option. healthcare providers should consider discussing bmt with their patients with scd. natasha frederick, anna revette, alexis michaud, jennifer mack, sharon bober dana-farber cancer institute, boston, massachusetts, united states background: adolescents and young adults (ayas) consistently identify the need for improved patient-clinician communication on sexual and reproductive health (srh) issues. however, oncology clinicians do not routinely integrate srh conversations with ayas through disease treatment and survivorship. little is known about why these conversations do not take place. objectives: explore aya perceptions of and receptiveness to srh communication with oncology clinicians and to identify barriers and facilitators to these conversations. design/method: semi-structured interviews were held with aya cancer patients and survivors (ages - years, men, women). twelve participants were on active treatment and were within years of treatment completion. interviews were conducted in english by phone or in person. the interview transcript underwent pre-testing with ayas. all interviews were audio-recorded and transcribed verbatim. transcripts were analyzed and summarized by two trained qualitative researchers according to standard comprehensive thematic qualitative analysis methods. analyses were aided by nvivo software. results: ayas perceived existing srh communication between ayas and oncology providers as inadequate. all ayas reported a need for improved srh communication with oncology providers, and three key areas of need emerged: ) general education; ) addressing specific srh issues experienced during treatment and survivorship; and ) understanding the long-term impact of cancer and treatment on srh. ayas felt that current srh discussions are limited and too narrow in scope and scale. ayas reported that most srh conversations focus exclusively on fertility (n = ), usually taking place at the start of treatment. other additional yet limited communication reported was about sexual activity (n = ), contraception (n = ), sexual function (n = ). no ayas reported conversations about potential treatment complications related to sexuality other than infertility. key barriers to srh conversations include patient discomfort initiating conversation (n = ) and presence of family members (n = ), with additional reported barriers including perceived provider discomfort (n = ), lack of rapport with provider (n = ), and age/gender differences (n = ). ayas felt that s of s communication tools such as handouts, brochures, and websites would be helpful facilitators to direct communication from the oncology clinician, and wanted conversations to start before treatment initiation and to continue through treatment and survivorship conclusion: ayas identify a key role for pediatric oncology providers in srh care from diagnosis through survivorship, however multiple barriers interfere with discussions about srh on a regular basis. identified barriers suggest that future efforts should focus on provider education and training in srh and srh-related communication in order to optimize care provided to this unique patient population. background: peripherally inserted central venous catheters (picc) provide secure vascular access in pediatric patients for the delivery of necessary therapies. the ease of placement in the inpatient and outpatient settings has expanded their utilization. however, recent data analyses show a significant increase in venous thromboembolism (vte) risk with the use of picc lines. with its rising use, modifiable risk factors need to be understood for preventative measures. objectives: in this study we aim to understand patient and catheter specific characteristics in relation to the development of vte. design/method: with irb approval, a retrospective interrogation of the electronic medical record and a picc database, at rainbow babies and children's hospital, was completed. the study cohort contained patients < years of age who had a picc line placed between january of and december of . data collected included indication for line placement, line dwell time, location of insertion including blood vessel and extremity, number of attempts at line placement, lumen size and indwelling line length. in addition, we collected number of days to vte formation, associated symptoms and location of vte. chi-squared analyses and fischer's exact test were used where appropriate for statistical analysis. we analyzed ( neonatal) newly placed picc lines. fifty line-associated vte events were found, for an incidence of . %. all vte occurred with the placement of the first picc line. intravenous therapies were the most common reason for line placement. no statistical significance was found between various indications for placement. the most common symptom of vte manifestation was extremity swelling, follow by extremity pain. right extremity picc was found to have a higher incidence of vte. larger catheter lumen sizes (> french) had a higher incidence of vte. we found a mean time of . days to vte detection. we were unable to find any clinical, patient or line specific factors leading to increased vte formation after statistical analysis. special consideration should be given to the duration of picc line use as this may reduce the incidence and comorbities associated with vte. there is still much to be understood about catheter associated vte formation as our analyses indicates the need for prospective data collection on a larger scale in hopes to create guidelines related to catheter use in pediatrics. background: the decision to transfuse a patient is a complex one and is never based solely on a number; however, certain hemoglobin or platelet count thresholds have been proposed in aiding physicians make transfusion decisions. in our hospital, the thresholds for packed red blood cell (prbc) and platelet transfusion in pediatric oncology patients are hemoglobin levels below . g/dl and platelet counts below , /mm (< , for brain tumors), respectively. recently, these thresholds have been questioned and we were asked whether we could safely lower the thresholds to < . g/dl of hemoglobin and < , /mm platelet count objectives: to investigate platelet and hemoglobin transfusion thresholds for oncology patients at children hospital of michigan design/method: retrospective chart review over a -month period, examining platelet and hemoglobin pretransfusion levels for each prbc and platelet transfusion given to oncology patients results: over the course of months, eligible oncology patients (median age years) received transfusions ( prbc transfusions and platelet transfusions). the mean pretransfusion hemoglobin level was . ± . g/dl (range . - . ) (n = ) for total prbc transfusions and this was not different among disease categories (p = . ). patients who had anemia symptoms and signs (n = ) had a slightly lower hemoglobin level compared to those who did not (n = ): . ± . vs . ± . g/dl (p = . ). the mean pretransfusion platelet count was , ± , /mm (range , - , ) for total platelet transfusions (n = ); , ± , /mm in patients with brain tumors (n = ); , ± , in patients with leukemia (n = ); and , ± , in patients with solid tumors (n = ). the mean pretransfusion platelet count was significantly higher in transfusions for brain tumors compared to that in the other disease groups (p< . for both). the mean pretransfusion platelet count was not different among those patients who had bleeding/bruising symptoms ( , ± , , n = ) versus those who did not ( , ± , , n = ) (p = . ). the bleeding/bruising rate was slightly but insignificantly higher in those who had platelet counts < , vs those who had ≥ , ( . % vs . %, p = . ). since most patients develop symptoms of anemia at hemoglobin above g/dl and about / of patients develop bleeding/bruising symptoms at platelet counts above , /mm , our current policy so far reflects a safe threshold for transfusion, and further lowering of the thresholds should be investigated in prospective studies. background: renal impairment is an important complication of childhood cancer and its treatment. serum creatinine level is frequently used as a screening test to monitor renal function; however, patients can have significantly decreased glomerular filtration rate (gfr) with normal serum creatinine. to determine the prevalence of chronic kidney disease (ckd) among children with cancer diagnosis, based on calculated gfr. to compare the difference between using serum creatinine value alone versus gfr in detecting ckd. design/method: retrospective review of medical records of patients, age - years, diagnosed between / - / with solid tumors were analyzed. serum creatinine and calculated gfr using schwartz formula were recorded. ckd as classified by the foundation of kidney disease and outcome quality initiative was used: ckd stage : gfr ( to ml/min per . m ) ckd stage : gfr ( to ml/min per . m ) statistical analysis using spss software v. . chi-squared test for proportions within group, and pearson chi-squared and fisher exact tests for statistical differences between groups. p-value < . was considered to indicate significance results: out of the records reviewed, ( %) were males and ( %) females, with mean age of . ± . years. ( . %) patients received one or more of nephrotoxic chemotherapy drugs; cisplatinum, carboplatinum, or ifosphamide mainly in the non-wilms solid tumors group ( . %) compared to ( . %) in the wilms tumor (wt) group. based on calculated gfr (by schwartz formula) ckd stage /or was diagnosed in ( %) patients with overwhelming majority ( %) were in the mild stage ckd, only ( . %) of those patients had abnormally high serum creatinine levels (p = . ). . % of patients who received nephrotoxic chemotherapy developed ckd, compared to . % in those who did not receive it, (p = . ). despite that only / ( %) of wt group patients received nephrotoxic chemotherapy, yet this group had higher percentage of ckd ( . %) compared to non-wt group ( . %) p = . . significantly lower mean gfr . ± was noticed in the wt group compared to . ± in non-wt group (p = . ) conclusion: high prevalence of mild ckd was found among solid tumor patients. using serum creatinine alone as measure of renal function significantly under estimates renal impairment in those patients. early identification of ckd is easily achieved by using calculated gfr, which can helps providers and care givers to avoid potential nephrotoxic antibiotics, contrast media, nsaids and dehydration that may further deteriorate renal function the university of texas southwestern medical center, dallas, texas, united states background: children with down syndrome (ds) have increased risk of developing leukemia. pediatric patients with ds-associated acute lymphoblastic leukemia (ds-all) are known to have significant toxicities with reinduction chemotherapy and historically poor outcomes with stem cell transplant (sct). anti-cd chimeric antigen receptor (car) t-cell therapy, tisagenlecleucel, demonstrated high rates of durable complete remission (cr) and a manageable safety profile in children with r/r b-cell acute lymphoblastic leukemia (b-all). objectives: characterize the efficacy and safety of tisagenlecleucel in pediatric/young adults with ds-all. design/method: pooled data from single-arm, multicenter, phase trials of tisagenlecleucel in pediatric/young-adult patients with r/r b-all (eliana, nct ; ensign, nct ) were analyzed. eight patients with ds-all were enrolled (data cutoff: eliana, november ; ensign, february ). seven were infused with tisagenlecleucel; patient died from all progression and intracranial hemorrhage before infusion. no manufacturing issues occurred during production. / infused patients were male, / had prior sct (age range, - years). / patients achieved cr or cr with incomplete blood count recovery (cri) by day (d) (cr+cri, %); died before d and was not evaluable. analysis of minimal residual disease was negative in bone marrow in responding patients. two patients had cd negative relapses at and months. ongoing remissions in patients without relapse ranged from to months. the safety profile (n = ) appears similar to that in patients without ds in the same trials (n = ). grade (g) / cytokine release syndrome occurred in % ( / ) of patients with ds and in % without ds. rates of other g / adverse events of special interest did not appear to favor a consistent trend between patients with/without ds (febrile neutropenia: % vs %; neurological events: % vs %; tumor lysis syndrome: % vs %). g / infections were not observed in patients with ds ( % vs %). one patient died after infusion due to intracranial parenchymal hemorrhage on d associated with ongoing coagulopathy. time and extent of tisagenlecleucel expansion and long-term persistence were similar between groups. conclusion: this is the first analysis of car t-cell therapy in pediatric patients with r/r b-all and ds. these data suggest that toxicities appear similar to those in patients with b-all without ds, remission rates in ds-all are high, and longterm outcomes with sustained persistence appear promising. further exploration of tisagenlecleucel as an alternative to sct in children with r/r ds-all is warranted. sponsored by novartis. background: hispanic adolescence and young adults are twice as likely to develop acute lymphoblastic leukemia (all) with high risk features as non-hispanic whites. they also have poor prognosis and % higher death rate. b-all with crlf overexpression caused by genetic alteration of the cytokine receptor, crlf is five times more common in this subgroup. approximately % of crlf b-all cases also have ikzf genetic alterations. ikaros is involved in transcriptional regulation of several important genes involved in leukemogenesis. overexpressed casein kinase ii (ck ) impairs functions of ikaros. objectives: understand the molecular mechanisms that regulate crlf expression in crlf b-all. here we present evidence that ikaros-mediated repression of crlf transcription in b-all in hispanic children is regulated by ck . design/method: primary b-all patient samples from hispanic children were used. ikaros retroviral transduction, ikaros shrna transfection, real time-pcr, luciferace assay, quantitative chromatin immunoprecipitation (qchip) coupled with the next-generation sequencing (chip-seq), cytotoxicity assay and western blot. results: ikaros binding to promoter of crlf was confirmed using quantitative chip. functional experiments such as overexpression of ikaros in b-all primary cells results in transcriptional repression of crlf whereas ikaros silencing using shrna resulted in increased transcription. these results suggest that ikaros negatively regulates crlf expression. molecular inhibition of ck with shrna targeting the ck catalytic subunit, as well as pharmacological targeting of ck with cx resulted in transcriptional repression of crlf . ck inhibition was associated with increased ikaros dnabinding to the promoter of crlf . however, the ability of cx to repress crlf is lost or severely reduced, in cells with shrna silencing of ikaros, as compared to cells with intact ikaros. moreover, similar results were noted following treatment with cx in leukemia cells obtained from high risk b-all patients with deletion of one ikzf allele. ikaros binds poorly to promoters of crlf gene in these cells. treatment with cx restores ikaros dnabinding to the promoters of crlf , which is associated with its strong repression. serial qchip analysis of the epigenetic signature at the crlf promoter showed that increased ikaros binding to the crlf promoter, following ck inhibition, is associated with enrichment for the h k me histone modification, which is a marker of repressive chromatin. results demonstrate that crlf expression is epigenetically regulated by the ck -ikaros axis .cx show antileukemic effect via restoration of ikaros tumor suppressor function, resulting in crlf repression suggesting advantage of using ck inhibitors as potential therapeutic approach in crlf altered b-all. results: hypodiploid all (modal chromosome number < and/or di < . ) was identified in patients ( . % of all patients; . % of nci standard risk (sr) and . % of nci high risk (hr)), who were removed from frontline protocol therapy post-induction. overall -year efs and os were . %± . % and . %± . %. transplant status was retrospectively available for / ( %), of whom underwent hsct in cr . five-year efs with hsct was . %± . % vs. . %± . % without (p = . ). -year os with and without hsct was . %± . % vs. . %± . % (p = . ). when corrected for the median time to hsct ( days), there were no significant differences in -year efs or os rates with and without hsct: . %± . % and . %± . % vs. . %± . % and . %± . %. no nci risk group or mrd subset benefitted significantly from cr hsct. sr patients (n = ) had -year efs and os of . ± . % and . %± . % with hsct (n = ) vs. . %± . % and . %± . % without. hr patients (n = ) had -year efs and os of . %± . % and . %± . % with hsct (n = ) vs. . %± . % and . %± . % without. for those with end-induction mrd < . % (n = ), -year efs and os were . %± . % and . %± . % with hsct (n = ) vs. . %± . % and . %± . % without. end-induction mrd-positive patients (n = ) fared poorly with both year efs and os of . %± . % with hsct (n = ) vs. . %± . % and . %± . % without. multivariate regression analysis including nci risk group, mrd, and cr hsct, showed only mrd negativity was significantly associated with efs (hr . , p< . ) and os (hr . , p< . ). patients with hypodiploid all fare poorly, particularly those with end-induction mrd ≥ . %. while cr hsct is a standard treatment approach, it does not confer significant benefit. we were unable to assess bridging therapy prior to hsct, and comparator groups are small. taken together, however, new strategies are urgently needed for these patients. background: ras-pathway mutations are known to play a pivotal role in a significant proportion of myeloid malignancies, including upwards of % of pediatric aml cases. ras-pathway mutations in myeloid malignancy commonly co-occur with mutations of epigenetic regulators, suggesting cooperative leukemogenesis. among the epigenetic modifiers most frequently mutated in myeloid malignancy are regulators of dna methylation. this indicates that the alteration of dna methylation contributes to leukemogenesis. the ten-eleven translocation (tet ) is an epigenetic regulator that plays an important role in regulation of dna methylation through its action of hydroxylation of -methylcytosine, which ultimately leads to passive de-methylation of dna cytosines. in myeloid malignancy, loss of function tet mutation is one of the most frequently co-occurring lesions in ras mutated malignancy. how specifically the altered methylation patterns in ras-pathway driven diseases promotes leukemogenesis is unclear. objectives: we hypothesize in mice with a ras-pathway mutation, that when an epigenetic modifier co-occurs, such as loss of function of tet , this primes stem cells and/or early differentiating progenitors for transformation by preventing the repression of stem cell self-renewal genes, inhibiting differentiation, enhancing ras signaling and leading to leukemogenesis. we have generated a novel murine model with constitutive deletion of tet (tet -/-) combined with an inducible activating krasg d mutation (krasg d/wt). mice have been tracked for evidence of hematologic malignancies and compared to mice with corresponding single genetic lesions. cooperative leukemogenesis will be demonstrated by decreased latency to disease onset, impact on malignancy lineage, in addition to investigating mechanistically through which pathways leukemogenesis may be promoted. results: krasg d/wt/ tet -/-mice demonstrate statistically significant differences in peripheral white blood cell count, hemoglobin, and platelet levels as early as -weeks post ras-pathway activation. peripheral cell lineage analysis demonstrates early skewing toward myeloid differentiation and marked splenomegaly in mice harboring both genetic lesions compared to wild type or mice with single genetic lesions. phospho-flow cytometric analysis reveals increased perk and ps activation in krasg d/wt/ tet -/-sca- enriched bone marrow cells compared to either genetic lesion alone. our study utilizing a murine model to examine how in ras-pathway mutations the addition of a co-occurring epigenetic lesion demonstrates that these lesions appear to cooperate to promote early myeloid differentiation with attendant changes in signaling pathways. this exploration to elucidate the mechanics of ras-pathway mediated disease lay the foundation for identification of patients who may benefit from existing therapies, such as dmtis, or identify new signaling targets for therapeutic exploration. background: the humoral immunogenicity of car , a chimeric antigen receptor (car) with a murine scfv domain developed for treatment with tisagenlecleucel in relapsed/refractory (r/r) pediatric/young-adult acute lymphoblastic leukemia (all), was evaluated in studies. little is known about the presence/impact of preexisting/treatmentinduced anti-murine car (mcar ) antibodies in patients treated with car therapy. objectives: patients from eliana (nct ; n = ) and ensign (nct ; n = ) were evaluated before and after tisagenlecleucel infusion to determine the impact of anti-mcar antibodies on cellular kinetics, efficacy, and safety. design/method: anti-mcar antibodies were determined by flow cytometry and reported as median fluorescence intensity. assay validation included evaluation of the interferences of intravenous immunoglobulin (ivig) treatment with the anti-mcar antibody assay. impact of preexisting and treatment-induced immunogenicity on cellular kinetics, efficacy, and safety was determined. treatment-induced immunogenicity was defined by a positive increase in anti-mcar antibody levels over baseline and was assessed by calculating the fold-change between preexisting (ie, baseline) and postinfusion levels. results: % of patients displayed preexisting anti-mcar antibodies; a similar incidence was detected in healthy volunteer samples during method validation. % of patients developed treatment-induced anti-mcar antibodies. no relationship was identified between tisagenlecleucel expansion (auc - d) and preexisting/treatment-induced anti-mcar antibodies (r < . and r = . , respectively); similar results were seen for cmax. presence of treatment-induced anti-mcar antibodies did not appear to impact transgene persistence or response. kaplan-meier estimates showed that preexisting/treatment-induced anti-mcar antibodies did not appear to impact duration of response or event-free survival. strip plots showed consistent levels of preexisting/treatment-induced anti-mcar antibodies across patients with safety events, including cytokine release syndrome, neutropenia, thrombocytopenia, and neurological events. there was no apparent relationship between treatment-induced anti-mcar antibodies and b-cell recovery categories (≤ months, > and ≤ months, > months, and ongoing sustained aplasia). no association existed between time of b-cell recovery and presence of treatment-induced anti-mcar antibodies. b-cell aplasia requiring ivig occurred following tisagenlecleucel in the majority of patients. the tisagenlecleucel concentration-time profiles in patients with treatment-induced anti-mcar antibodies were categorized by time following ivig administration. time of ivig administration had no impact on in vivo transgene expansion and persistence. we report the first comprehensive assessment of the impact of anti-mcar antibodies on clinical endpoints with car therapy. pediatric/young-adult patients with r/r all had a high frequency of baseline anti-mcar antibodies, and preexisting/treatment-induced anti-mcar antibodies did not impact the cellular kinetics, safety, and efficacy of tisagenlecleucel. cell-mediated immunity studies are ongoing. sponsored by novartis. background: adoptive immunotherapy, using cd engager (cd -eng) t-cells, has shown success in preclinical studies, recognizing and killing acute myeloid leukemia (aml) blasts in vitro and in vivo. cd -eng t-cells secrete bispecific molecules that recognize cd (t-cells) and cd (aml blasts), and are able to direct transduced t-cells and recruit bystander t-cells to kill cd -positive blasts. however, cd -engs do not provide costimulation and have not shown the capability for sequential killing of targets in vitro. we are seeking to improve the expansion, persistence and sequential killing capabilities of cd -engs by genetically modifying these cells with an inducible costimulatory molecule, which can be activated by a chemical inducer of dimerization (cid). we generated a retroviral vector encoding cd -eng and the inducible costimulatory molecule myd .cd linked by a a sequence (cd -eng. a.imc). cd -eng and cd -eng.imc t-cells were generated by retroviral transduction, and their effector function was compared with and without cid. we used flow cytometric analysis to assess transduction efficiency, chromium release assays to evaluate cytolytic activity, and elisa to determine cytokine production. we successfully generated cd -eng.imc tcells and achieved a mean initial transduction efficiency of % that was maintained above % throughout our study period. cd -eng.imc t-cells +/-cid and cd -eng t-cells readily killed cd -positive aml blasts (molm and kg a) in cytotoxicity assays when compared to the cd -negative control (k ). in co-culture assays, cd -eng.imc t-cells secreted increased il- and ifn-gamma in the presence of cid and cd -positive targets (kg a and molm ) when compared to co-culture with cd -positive targets in the absence of cid. in addition, cd -eng.imc t-cells displayed enhanced sequential killing capabilities and ifn-gamma secretion when stimulated weekly with cid and tumor cells at a : ratio when compared to cd -eng t-cells. conclusion: cd -eng.imc t-cells are able to recognize and kill cd -positive aml blasts in an antigen dependent manner. cd -eng.imc t-cells have improved effector function in the presence of cid as judged by cytokine production and their ability to sequentially kill cd -positive target cells. thus, inducible myd and cd costimulation is a promising strategy to improve the effector function of cd -eng t-cells, and warrants further active exploration in preclinical studies. background: eliana (nct ; n = ) is a pivotal multicenter study testing the efficacy of tisagenlecleucel, anti-cd car-t, in children/young adults with r/r b-all. tocilizumab (toci) has been used for management of moderate/severe (grade / ) crs in ≈ % of patients treated with tisagenlecleucel at equivalent doses used in approved nononcological pediatric indications (< kg received mg/kg; ≥ kg received mg/kg [ mg max dose]).( ) crs onset, as graded by the penn grading scale, generally occurred at a median of days (range, - ) after infusion, requiring administration of - toci doses in some patients via a protocol-specific treatment algorithm. toci is a humanized monoclonal antibody that inhibits il- receptor (il- r) signaling. the pharmacokinetics (pk) and pharmacodynamics (pd) of toci in pediatric patients with b-all with carassociated crs have not previously been described. objectives: characterize toci pk/pd for crs management following tisagenlecleucel infusion and describe its impact on cellular kinetics. design/method: toci pk and levels of soluble il- r (sil- r) were determined from serum and quantified using validated assays. maximum toci concentration (cmax) was derived using noncompartmental methods. sil- r, proinflammatory cytokines, and crs resolution time were characterized to describe toci pd. summary statistics and graphical analyses of tisagenlecleucel exposure by number of doses were performed to describe the impact of toci on tisagenlecleucel kinetics in patients responding to tisagenlecleucel infusion. : / patients with crs received the first toci dose at a median of days (range, - ) after crs onset. seventeen patients received dose (range, . - mg/kg); received doses ( - mg/kg); received doses ( - mg/kg), per the crs treatment algorithm. first-dose mean cmax (sd) was ≈ ( . ) g/ml; second dose, ≈ ( ) g/ml. individual patient pd concentration-time profiles showed increased sil- r levels after the first toci dose which remained elevated following the second dose. following toci administration, median time to crs resolution (including fever resolution) was days (range, - ). crs onset coincided with tisagenlecleucel expansion, followed by a peak in serum cytokines, including il- . the geometric mean auc - day and cmax of tisagenlecleucel transgene (by pcr) were % and % higher in tisagenlecleucel-responding toci-treated patients. conclusion: crs symptoms resolved within a median of days after toci administration. toci levels achieved in patients with b-all were similar to reported pediatric nononcological indications (tocilizumab label) and resulted in concentration/time-dependent sil- r increases. transgene continued to expand and persist following toci administration. these data support treatment with toci for crs management. ( ) buechner, eha, . sponsored by novartis. background: in acute myeloid leukemia (aml), mesenchymal stem and stromal cells (mscs) in the bone marrow microenvironment contribute to extrinsically mediated chemo-resistance and are therefore important potential therapeutic targets. the study of patient-derived mscs is at a competitive disadvantage, however, because traditional means of isolating mscs from a bone marrow aspirate interferes with isolating the more highly prioritized leukemic cells. many opportunities to study mscs are therefore missed. objectives: to develop a novel method of isolating mscs using the otherwise discarded portion of a bone marrow aspirate, thereby de-coupling the isolation of primary mscs from the isolation of leukemia cells. design/method: aml patient bone marrow aspirates were obtained prospectively from the children's oncology group. healthy patient marrow was purchased. experimental mscs were isolated from the bottom-most layer (rbc-layer) produced by density-gradient separation of a bone marrow aspirate, which is typically discarded. control mscs were isolated from the buffy coat (mnc layer). non-adherent cells were removed after hours, and adherent cells were cultured at % co with mem-alpha containing % fbs. growth curves were obtained by seeding -well plates with , cells per well. cells were stained using oil red o to observe adipocyte differentiation. results: rbc-layer mscs grow successfully following overnight shipment of the aspirate. identical to mnc-layer mscs, rbc-layer mscs exhibit a fibroblastic morphology and are adherent to plastic. rbc-layer mscs persist in culture up to passages before senescence. they exhibit a slower growth curve relative to mnc-layer mscs, but their overall doubling time is similar at approximately hours. surprisingly, mscs from the rbc-layer exhibit adipocyte differentiation on stimulation, revealing their stem-cell like qualities. we present a method of isolating mscs from the discarded portion of a bone marrow aspirate that does not interfere with the isolation of leukemia cells from the same patient. this portion of the aspirate can be shipped, or can sit for at least hours, without sacrificing its mscs. rbclayer mscs are nearly identical to mscs obtained conventionally. perhaps most importantly, rbc-layer mscs retain a stem-cell like capacity, showing them to be a highly valuable cell population in aml research. future plans include investigating potential selective enrichment of stem-cell mscs in the rbc-layer, which could explain the unexpected difference in growth kinetics. aml researchers now have the opportunity to study this exciting component of the bone marrow microenvironment without sacrificing valuable leukemic cells in the process. background: neutropenia is one of the most frequent side effect of chemotherapy associated with an increase in the risk of infection, especially in the cases when the depth and duration of neutropenia are extended. some genes, as variations of darc, gsdma and cxcl are known to influence white blood cell and neutrophil counts. our previous study conducted in children with acute lymphoblastic leukemia (all), showed that polymorphisms in these genes might play a role in the onset of chemotherapy complications during consolidation and maintenance treatment. objectives: in order to support our previous finding, we have expanded the study to the induction period in a cohort of all children treated at the sainte-justine university health center between july and july . design/method: previous associated single nucleotide polymorphisms (snps) in darc, gsdma and cxcl genes were analyzed for an association with the complications occurring during induction including the duration of low neutrophil count (pnn) and low absolute phagocyte count (apc), proven infections and delay between induction and consolidation phases. results: significant effect was found for all studied polymorphims. minor alleles of darc rs , cxcl rs and gsdma rs were all associated with higher risk of complications during induction treatment, whereas that of darc rs (particularly gg genotype) had a protective effect. the gg genotype of rs was associated with a lower risk of post-induction delay (p = . or = . , %ci . - . ), less frequent febrile episodes (p = . ) and lower number of days with apc/pnn count reduction (p = . for apc< . and p = . for pnn< . ). in contrast, the minor t allele of another darc polymorphism (rs ), was associated with longer apc/pnn count reduction (p = . for apc< . and p = . for pnn < . ), as it was the tt genotype of gsdma rs (p = . for apc< . and p = . for pnn< . ). the patients with the gsdma rs had also a higher risk of documented febrile episodes (p = . or = . %ci - . ). the aa genotype of rs cxcl was associated with a higher risk of post-induction delay due to infection (p = . , or = . , % ci . - . ). conclusion: this complementary study confirmed our previous results, showing overall that variations in darc, gsdma and cxcl genes influence the onset of chemotherapy complications in pediatric all, regardless of treatment phases. these polymorphisms might be useful pharmacogenetics markers possibly guiding an adjustment of chemotherapy intensity. background: pediatric acute myeloid leukemia (aml) has a poor survival rate of about % and there is an urgent need for newer targeted therapies. car t-cell based therapies are effective against all but similar therapies against aml are still under development. recent clinical trials have highlighted the concerns about toxicity and therapy related deaths from car t-cells. antigen selection is the key factor determining the specificity, efficacy and toxicity of car t-cells. while contemporary adoptive t-cell therapies use monoclonal antibodies against tumor associated antigens we employed the naturally occurring flt ligand (fl) to target aml cells expressing flt receptors. flt receptor is expressed on multipotent and myelomonocytic progenitors as well as myeloid leukemia cells. to generate fl containing chimeric tlymphocytes designated flcar t-cells and to evaluate their efficacy against aml cells. design/method: flcar was constructed by fusing the coding sequences of the human fl, cd costimulatory domain, and cd -zeta chain (intracellular region) in series. it was then cloned into the phiv-egfp lentiviral vector for expression in cell lines and primary t cells obtained from healthy donors. the empty phiv-egfp vector was used as a negative control. flcar was expressed on both cd + and cd + t-lymphocytes, confirmed by western blot. cell cytoxicity was evaluated by co-culturing flcar t-cells and aml cells followed by flow cytometric analyses. cytokine production was assessed by analyzing expression of interleukin- using quantitative rt-pcr. results: flcar t-cells were generated from cd + jurkat and cd + tk- cell lines with up to % lentiviral transduction efficiency. the efficiency for primary t cells was lower ( - %). flcar was expressed as a ∼ kda protein in cells and was partially phosphorylated on tyrosine. the expression of flcar on lymphocytes lead to increased basal il- expression in the cells. this was further augmented (by > folds) upon co-incubating flcar t-cells with flt expressing target cells. jurkat cells, tk- cells and primary human t cells expressing flcar suppressed the growth of flt -expressing aml cell lines and primary aml cells in vitro. notably, flcar t-cells generated from healthy donors caused strong inhibition of aml cells even at a lower transduction efficiency. in vivo experiments using nsg-sgm mice xenografted with human aml cells are underway. our data demonstrate that flcar can be effectively expressed on t-lymphocytes and mediate potent cytotoxicity against flt -expressing aml cells in vitro. being a completely human derived chimeric protein, it represents a promising candidate for further therapeutic development. holly pacenta, kelly sullivan, ahwan pandey, kelly maloney, joaquin espinosa children's hospital colorado, denver, colorado, united states background: individuals with down syndrome (ds) have a -fold higher risk of developing acute lymphoblastic leukemia (all) than the typical population. there are several important differences between all in individuals with ds (ds-all) and all in individuals without ds (nds-all): first, patients with ds-all have a lower percentage of favorable cytogenetic features compared to nds-all. second, patients with ds-all are more likely to have activating mutations in jak , crlf overexpression, and ikzf deletions. despite these clear genotypic differences, this knowledge has not yet been exploited for therapeutic purposes in ds-all. when outcomes for ds-all are compared to nds-all with similar cytogenetic features, the survival rates are similar. however, individuals with ds-all have an increased risk of treatment-related mortality (trm). current therapy for ds-all is similar to that for nds-all, with the exception of small changes to decrease toxicities that are more prevalent in ds-all. it was recently identified that interferon signaling is constitutively activated in healthy individuals with t . we hypothesize that aberrant interferon signaling could play a role in the unique leukemias observed in ds patients. objectives: to identify differences in gene expression and intracellular signaling cascades that are unique to individuals with ds-all, relative to both nds-all and healthy individuals with ds that can be exploited for therapeutic use. design/method: bone marrow samples were obtained from ds-all patients and matched nds-all patients based on clinical characteristics and genetic features. rna sequencing of these samples was performed and a total of samples were used for the transcriptome analysis ( ds-all vs. nds-all). the differential expression data was generated by deseq and analyzed using ingenuity pathway analysis. the analysis revealed that the chromosome genes that have been implicated in leukemogenesis are not differentially expressed in the ds-all samples, relative to nds-all. an inflammatory signature was identified, which included interferon gamma as an upstream regulator with predicted activation in ds-all. this finding is consistent with prior observations from healthy individuals with ds. other examples of results with potentially actionable targets include the upregulation of several genes in the ras pathway and genes involved in histone methylation. the increased interferon signaling seen in healthy individuals with ds was also identified in ds-all. this may contribute to the development of mutations in inflammatory pathways such as jak and crlf in ds-all. targeting these common pathways with small molecule inhibitors may have a therapeutic benefit in ds-all. cincinnati children's hospital medical center, cincinnati, ohio, united states background: next-generation sequencing (ngs) guides precision medicine approaches in oncology using therapies targeting molecular alterations found within an individual cancer. increased availability of ngs coupled with a proliferation of targeted drugs in development heightens the need for reliable pre-clinical animal models. here we report a patientderived xenograft (pdx) system with integrated molecular profiling for pre-clinical testing of conventional cytotoxic and novel targeted agents. objectives: to utilize ngs from patients with pediatric leukemia to guide rational pre-clinical trials in pdx leukemia avatars, and to determine pdx mice tolerance of and response to cytotoxic and targeted therapies. pediatric acute lymphoblastic leukemia (all) samples were obtained in adherence to an irb-approved protocol and xenografted into nod/rag/interleukin- (il- )rg (nrg) mice. ngs was performed clinically using the foundationone® heme panel. a de novo all sample bearing mutations involving jak , crlf , ntrk , cdkn a/b, ptpn and wt was used for pre-clinical testing. thirty-seven nrg mice were transplanted with million patient cells/mouse via iv injection. standard -drug induction chemotherapy was administered consisting of vincristine, dexamethasone, pegaspargase, and daunorubicin [vxpd, n = mice], in comparison to vehicle control [n = ]. parallel pdx cohorts were treated with single agent targeted therapies based on ngs findings, including ruxolitinib [n = ], crizotinib [n = ] and loxo- [n = ]. the four-week treatment period began on day + from transplant after confirmation of engraftment. following completion of therapy, residual disease burden was analyzed by flow cytometry (hcd +, mcd -cells) in the bone marrow [bm] . to date, pdx models have been established using over thirty ngs-profiled pediatric all samples, including six samples bearing philadelphia (ph) chromosome or phlike mutations. pre-clinical testing was performed in a repre- conclusion: ngs reveals concomitant mutations in ph-like all that may represent additional targets for therapy, or predict tyrosine kinase inhibitor (tki) resistance. we show that all xenograft nrg mice can tolerate a -week multi-agent cytotoxic chemotherapy induction regimen, as well as rational targeted agents, and serve as a robust pre-clinical model for precision medicine trials. background: osteonecrosis is a well-characterized all therapeutic toxicity attributed to glucocorticoids, asparaginase, and methotrexate that disproportionately affects adolescents. in ccg- , alternate-week dexamethasone during double delayed intensification (di) reduced osteonecrosis vs continuous dexamethasone with single di in rapid early responders (rer) ≥ y. to compare efs and os between hr-all patients with vs without osteonecrosis. design/method: hr-all patients - y on aall ( - ) received cog augmented therapy with a × randomization to: ( ) induction dexamethasone ( mg/m d - ) vs prednisone ( mg/m d - ), and ( ) interim maintenance (im) high-dose methotrexate (hdm) vs escalating-dose methotrexate/pegaspargase (ema). rer received single, and slow early responders (ser) double, im/di. initially, all received monthly dexamethasone maintenance pulses, patients ≥ y received di alternate-week dexamethasone, and patients ≤ y received di continuous s of s dexamethasone. there were osteonecrosis-related amendments: after / all patients ≥ y received di alternateweek dexamethasone; after / all patients ≥ y were assigned to induction prednisone, and all patients received di alternate-week dexamethasone and maintenance prednisone pulses. results: osteonecrosis was confirmed in / patients. the y cumulative incidence (ci) was . % overall and increased with age: - y . %, - y . % (alternateweek dexamethasone . % vs continuous dexamethasone . %; p< . ), ≥ y . % (p< . ). among randomized rer patients ≥ y, ci differed by glucocorticoid (dexamethasone . % vs prednisone . %; p = . ) but not methotrexate assignment (hdm . % vs ema . %; p = . ). among randomized ser patients ≥ y, ci was . % with no difference by regimen. results were similar for patients ≥ y. in the entire study population, patients with osteonecrosis had superior y efs ( . % vs . %; p< . ) and os ( . % vs . %; p< . ) than those without osteonecrosis. y efs was significantly higher among randomized patients ≥ y with vs without osteonecrosis ( . % vs . %; p< . ); this finding was present in different age ranges (≥ y, ≥ y, ≥ y) and rer/ser subsets within each, especially in the ≥ y rer ( . % vs . %; p = . ) and ser ( . % vs . %; p< . ) cohorts. across groups, asparaginase allergy was significantly associated with reduced osteonecrosis risk (≥ y: hr . ; p = . ). patients who develop osteonecrosis have significantly increased efs and os, suggesting host differences that increase sensitivity to develop osteonecrosis and render all cells more chemo-responsive. pennsylvania state university, hershey, pennsylvania, united states background: cdc (cell division cycle protein ) belongs to rho family of small gtpases in ras-oncogene superfamily. pro-oncogenic role of overexpressed cdc in ras driven solid tumors are well known. however, role of cdc in leukemia is yet to be established. ikzf encodes ikaros protein which has important role in regulation of lymphoid development and tumor suppression in leukemia. casein kinase ii (ck ) oncogene is overexpressed in leukemia. ck impairs ikaros function which can be restored by using ck inhibitors. objectives: to investigate role of cdc in leukemia and regulation of cdc by ikaros and ck in b-cell acute lymphoblastic leukemia (b-all). shrna transfection, real time-pcr, luciferace assay, quantitative chromatin immunoprecipitation (qchip) coupled with the next-generation sequencing (chip-seq), cytotoxicity assay and western blot. results: cdc is identified as one of the ikaros target genes by analysis of genome-wide dna binding of ikaros using chip-seq and qchip in b-all primary cells. expression of cdc was also noted to be higher in all patient samples compared to normal bone marrow. functional experiments showed that ikaros overexpression via retroviral transduction results in transcriptional repression of cdc . ikaros silencing using shrna resulted in increased expression of cdc . these data suggest that ikaros negatively regulates transcription and expression of cdc . ck directly phosphorylates ikaros and impairs its function as transcription factor. we noted that molecular inhibition of ck via sirna as well as treatment with specific ck inhibitor, cx also decreases expression of cdc . treatment with cx of primary b-all with ikaros haploinsufficiency restores ikaros binding to cdc promoter and represses cdc expression. however, this effect is evident only in presence of ikaros. treatment with cx in ikaros silenced (ikaros shrna) cells showed no change in expression of cdc . these results emphasizes the importance of ikaros in regulating cdc expression. furthermore, we analyzed the changes in epigenetic signature at the cdc promoter following treatment with cx . results show that loss of histone marker of open chromatin (h k ac) and increased histone marker for repressive chromatin (h k me ), at the cdc promoter. these data suggest that ikaros transcriptionally represses cdc via chromatin remodeling. a specific cdc inhibitor, ml showed cytotoxic effects on primary b-all cells. conclusion: cdc may have important role in hematologic malignancies. expression of cdc in b cell all is regulated by ikaros and ck . these results suggest that targeting cdc could be a potential therapeutic strategy in leukemia. caitlyn duffy, laura hall, justin godown, koyama tatsuki, scott borinstein monroe carell jr. children's hospital at vanderbilt, nashville, tennessee, united states background: systemic corticosteroids are widely used as treatment of acute lymphoblastic leukemia (all) and lymphoblastic lymphoma. there are anecdotal reports of bradycardia in pediatric patients receiving corticosteroids, but a more extensive analysis of this effect is needed. objectives: the aim of this study was to describe the incidence, severity, and timing of steroid-induced bradycardia and document any adverse events associated with bradycardia. design/method: we performed a retrospective review of all newly diagnosed patients at our center ( - ) with all/lymphoblastic lymphoma who received corticosteroids (dexamethasone - mg/m /dose or prednisone mg/m /dose) during induction chemotherapy. patients were excluded if they had a pre-existing cardiac abnormality or if they received prior corticosteroids. the average hour heart rate (hr) was assessed for the period prior to initiating steroid therapy and for the hour period surrounding the nadir following steroid administration. the degree and time of steroid induced bradycardia was assessed. adverse patient events and concomitant medication use was documented to identify other contributing factors to bradycardia. a total of children ( females, males, months- years) were included in the analysis with demonstrating a decrease in mean hr following steroid administration. median hr decrease was . beats per minute (quartiles . - ) from prior to initiating steroids to surrounding nadir. sixty one percent developed bradycardia less than or equal to the st percentile for their age range. nadir occurred doses (range - ) into treatment, which corresponded to hours ( - ) after initiation of therapy. of patients who experienced bradycardia, % were associated with dexamethasone rather than prednisone. hr nadir was not associated with other vital sign abnormalities. after completion of induction chemotherapy, % of patients had documented resolution of bradycardia with hr greater than the th percentile for age. it was observed that the children who continued to have relatively low hr were often younger ( months- years old). examination of nadir hr during subsequent hospitalizations in which steroids were not being administered (excluding hr during procedural sedation) did not demonstrate a significant incidence of bradycardia. concomitant opioid, beta-blocker, or other medication exposure did not contribute to the incidence of bradycardia. corticosteroid-induced bradycardia is extremely common in children, teenagers, and young adults with all receiving induction chemotherapy. bradycardia was not associated with clinical adverse events and resolved after completion of corticosteroid treatment. therefore, further cardiac assessment may not be warranted in the presence of bradycardia suspected to be secondary to steroid administration. baylor college of medicine, houston, texas, united states background: survival in newly diagnosed pediatric acute myeloid leukemia (aml) is approximately %; however survival falls dramatically if a patient relapses. currently, approximately one-third of patients with pediatric aml relapse on standard chemotherapy regimens. aml cells are exposed to proteotoxic stress at baseline due to their rapid and inefficient metabolism; proteotoxic stress increases after chemotherapy due to accumulation of reactive oxygen species resulting in misfolded proteins. this leads to activation of cell stress pathways, such as the unfolded protein response (upr) in the endoplasmic reticulum. because an activated upr can make cells more sensitive to proteotoxic stress, we hypothesize that upr activation correlates with response to chemotherapy. objectives: determine the status of upr in pediatric aml and its correlation with chemosensitivity; design/method: peripheral blood samples from pediatric patients with aml were collected at the start of induction chemotherapy, - hours (h) and h post initiation of systemic chemotherapy. tumor cells were sorted from peripheral blood mononuclear cells. expression of upr proteins was determined by chemiluminescence using an automated capillary electrophoresis system. clinical correlations were performed using an annotated database. we measured five upr proteins: grp (glucose regulated protein kda), phospho-eif , inositol-requiring enzyme (ire ) and activating transcription factor (atf ). patients with aml had - times higher expression of upr proteins (except atf ) at baseline than normal controls. grp -the key upr driver-had the highest level of protein expression in myeloid blasts. there was a wide variability in the level of baseline upr expression. eight out of samples expressed > fold increase in grp above those with the lowest grp levels. similarly, and patients respectively, had a > fold increase in peif and ire , compared to patients with low basal expression of these upr proteins. in our limited sample set, there was a trend towards lower overall survival (os) and event-free survival in patients with low baseline grp and ire . conclusion: upr has a variable expression at baseline in pediatric aml, with a trend towards lower os in patients with a low basal grp and low ire expression, suggesting less chemosensitivity in this subgroup. conversely, it is possible that blasts with an upregulated upr prior to chemotherapy manage proteotoxic stress less effectively, having faster apoptosis and hence a better response to chemotherapy in patients with a high basal upr. we are currently expanding our findings in a larger cohort of patients enrolled in the children's oncology group aaml protocol. background: children with newly diagnosed acute lymphoblastic leukemia (all) undergo chest x-ray (cxr) evaluation during initial diagnostic workup to ensure safe airway management. however, to our knowledge, no systematic assessment of cxr findings has been reported. objectives: to evaluate cxr findings at diagnosis of all and their associations with clinical characteristics. we reviewed the cxr findings at diagnosis of all in patients treated on the total xv and xvi protocols at st. jude children's research hospital. findings were evaluated for associations with clinical characteristics at presentation, and the clinical management of mediastinal masses was reviewed. mediastinal masses were seen in ( . %) of patients evaluated and were more common in older patients (mean age, . years) than in younger patients (mean age, . years) (p = . ), in males than in females (p = . ), and in patients with t-all than in those with b-all (p< . ). also associated with mediastinal masses were a higher white blood cell count (wbc) at diagnosis (mean, . × /l) (vs. a lower wbc; mean, . × /l) (p< . ), cns involvement (vs. no involvement) (p = . ), and standard/high-risk disease (vs. low-risk disease) (p< . ). other cxr findings included pulmonary opacity ( patients [ . %]), bronchial/perihilar thickening ( patients [ . %]), cardiomegaly ( patients [ . %]), and osteopenia/fracture/periosteal lesions ( patients [ . %]). pulmonary opacity was more common in younger patients (mean age, . years) than in older patients (mean age, . years) (p = . ) and in those with t-all (vs. b-all) (p = . ). bronchial/perihilar thickening, cardiomegaly, and osteopenia/fracture/periosteal lesions were also more common in younger patients than in older ones (p< . , p = . , and p< . , respectively) and in those with low-risk disease (versus standard/high-risk disease) (p< . , p = . , and p = . , respectively). of the patients with a mediastinal mass on cxr, underwent a confirmatory chest ct scan, and ( . %) were confirmed to have a mediastinal mass. notably, patients ( . %) had airway compression, and compression of venous structures was identified in of patients ( . %) who received iv contrast. the clinical course was evaluated for patients with mediastinal masses detected by cxr. fifty patients ( . %) required icu admission (mean stay, . days). general anesthesia was used for only patients ( . %), and patients ( . %) had a less invasive peripherally inserted central catheter. no deaths occurred in the acute phase. conclusion: cxr at the time of all diagnosis can detect various intrathoracic lesions and is helpful in planning initial diagnostic workup and management. background: mertk is a receptor tyrosine kinase that is aberrantly expressed in % of pediatric primary aml samples. mertk inhibition with the small molecule tyrosine kinase inhibitor (tki) mrx- decreases tumor burden and prolongs survival in aml xenografts. while treatment with mrx- reduces leukemia in the peripheral blood, it is less effective in the bone marrow, suggesting a role for the marrow microenvironment in therapeutic resistance. the jak/stat pathway has been implicated as a mediator of bone marrow derived resistance to tkis and inhibitors of this pathway are in clinical development for the treatment of aml. to determine the role of the bone marrow stromal niche in mediating resistance to mertk inhibition and to evaluate the efficacy of combined mertk and jak/stat inhibition. design/method: aml cell lines were cultured with or without the hs stromal cell line or hs conditioned medium, then treated with mrx- +/-the jak/stat inhibitor ruxolitinib, or control. induction of apoptosis and cell cycle arrest in aml cells was measured by flow cytometry. expression of h ax and total and phosphorylated stat were determined by immunoblot. results: co-culture with stromal cells significantly reduced aml cell death and g /m phase arrest in response to treatment with nm mrx- compared to no co-culture (cell death: . % versus . %, p< . ; g /m arrest: . % versus . %, p< . ). g /m arrest was accompanied by an increase in h ax expression which was similarly abrogated in co-culture. conditioned medium did not provide protection from mrx- induced apoptosis, g /m arrest, or h ax induction. mrx- inhibited stat phosphorylation but direct co-culture and conditioned medium potently increased basal stat phosphorylation which was not inhibited by mrx- . to determine whether the observed induction of stat phosphorylation was functionally relevant, cocultures were treated with both mrx- and ruxolitinib. while ruxolitinib potently inhibited the phosphorylation of stat in the presence of co-culture, combination treatment did not overcome stromal mediated protection from mrx- induced apoptosis. similarly, the addition of exogenous gm-csf induced stat phosphorylation but did not yield protection from mrx- functional effects in the absence of co-culture. together these data support a model whereby direct cell-cell contact with stromal cells in the bone marrow niche protects leukemia cells from mrx- induced apoptosis, cell cycle alterations, and dna damage. while co-culture potently induces phosphorylation of stat in leukemia cells, this is neither necessary nor sufficient for stromal-cell mediated protection from mertk inhibition and combined treatment with jak/stat inhibitors is unlikely to be therapeutically efficacious. background: mercaptopurine ( -mp) is an immunosuppressive thiopurine drug that is a key component of acute lymphoblastic leukemia (all) treatment. -mp is metabolized into -thioguanine ( -tgn), which is responsible for anti-leukemic effects, as well as -methylmercaptopurine nucleotides ( -mmpn/ -mmp), which are associated with hepatotoxicity. some patients preferentially metabolize -mp to -mmpn/ -mmp, increasing their risk for hepatotoxicity and potentially reducing anti-leukemic effects. hepatotoxicity can cause interruptions or delays in therapy that may jeopardize cure rates. allopurinol has been increasingly used in patients with inflammatory bowel disease (ibd) to shunt -mp metabolism toward -tgn and away from -mmpn to minimize hepatotoxicity and preserve therapeutic effects. objectives: this retrospective chart review expands upon our previously published case series of three patients with all in whom allopurinol was successfully used to redirect -mp metabolism. twelve additional patients have subsequently received allopurinol and -mp combination therapy at texas children's hospital. data from this larger patient sample, with longer follow up, is being analyzed to increase knowledge of the effectiveness and longitudinal effects of adding allopurinol to -mp to reduce risk of hepatotoxicity. design/method: data were abstracted from the electronic medical records of patients with all treated at texas children's hospital from to present, who had been found to have evidence of altered -mp metabolism and in whom allopurinol was added to -mp therapy due to concern for risk or recurrence of hepatotoxicity. metabolite levels, -mp dose, and alanine transaminase (alt) prior to initiation of allopurinol and approximately weeks later were compared. wilcoxon signed-rank test was applied for statistical analysis. : after the addition of allopurinol, patients experienced a significant decrease in mean levels of -mmpn (p = . ), correlating with a significant decrease in mean alt (p = . ). with the initiation of allopurinol, the mean -mp dose was decreased from to mg/m /day over an -week period. mean -tgn levels increased (p = . ). in follow up beyond weeks, no patients had further holds in -mp due to hepatotoxicity. addition of allopurinol appears to shift metabolism from -mmpn toward -tgn, with increases in mean -tgn levels despite a decrease in mean -mp dose. this may limit negative side effects, thus resulting in fewer gaps in therapy and possible improved outcomes. further analysis of -mp dose titration and effects on anc over time as well as effects on overall survival is ongoing. prospective background: alterations in epigenetic patterning are a fundamental feature in acute myeloid leukemia (aml). treatment with dna methyltransferase inhibitors (dnmti) yields responses in aml, but the molecular mechanisms underlying this effect are poorly understood. in prior work, we demonstrated induction of genes involved in the pirna rna (piwi) silencing pathway as a common gene feature of aml cell lines treated with decitabine. the piwi pathway is an rna silencing system, distinct from classical small rna transcriptional silencing, responsible for transposon-silencing in gametogenesis; emerging data suggest a role for this system in somatic cells. based on these data, we postulate that piwi induction plays a crucial role in aml recovery following demethylation and that disruption of this pathway would modulate response and/or recovery from decitabine treatment. to assess the effect contribution of the pirna pathway response following dnmti treatment in aml. design/method: to choose target genes in the pirna pathway for disruption, molm cells were first treated with escalating doses of decitabine. using quantitative rt-pcr, the dose-dependent expression of several pirna-associated genes were analyzed. two genes, mael and piwil , were selected for disruption experiments based on preliminary data suggesting decitabine dose-dependent responses. molm cells were transduced with shrna targeting these genes using a lentivirus delivery system with selection in puromycin. knockdown efficiency was assessed by rt-qpcr. to determine how gene disruption affected cell growth, knockdown cells were treated with decitabine nm. proliferation was assessed by celltiter glo assay following decitabine treatment. clonogenic potential was assessed by colony forming assays of transduced cells after treatment with decitabine at nm and nm. results: following decitabine exposure in molm , there was a markedly increased expression of mael and piwil compared to untreated cells ( : and : , respectively) . thus, these were the candidate genes chosen for disruption. of mael shrna constructs, two resulted in a % relative expression of mael compared to controls. of the piwil shrna constructs, the best knockdown showed % relative expression. there were no significant differences in proliferation or clonogenicity of stably selected mael or piwil knock-down molm cells following decitabine treatment. using gene knockdown procedures, mael and piwl do not appear to have a marked effect on growth and response to decitabine treatment in molm . however, these results may be limited by inefficient knockdown using shrna targeting methods. further work using a cas /crispr based inactivation of these genes is ongoing. children cancer hospital cairo, egypt background: hypodiploidy < chromosomes is very uncommon and have particularly poor outcomes in childhood acute lymphoblastic leukemia (all). it is subdivided into: near-haploid ( - chromosomes), lowhypodiploid ( - chromosomes) and high-hypodiploid ( - chromosomes). to determine if minimal residual disease (mrd) can identify a group of patients with better prognosis in the hypodploid population who can be treated with intensive chemotherapy alone. design/method: a retrospective study that included all patients under age of diagnosed as hypodiploid b-precursor all during the period between january -december and treated at children's cancer hospital egypt on sjcrh total study-xv for ir/hr all. sixteen patients had < chromosomes ( nearhaploid and low-hypodiploid), constituting % of all pediatric patients with b-precursor all during the study period. patients with near-haploid all had a median age of years (range - ), initial leukocyte count (wbc) median of . × /l (range . - . ), ( . %) were males and / ( . %) had hr-nci criteria. four patients ( . %) are alive in complete remission(cr) (range - months, median ), one died in induction and ( . %) had hematological relapse (range . - months, median ). patients with low-hypodiploid all had significantly older age (median years, range - ), median wbc . × /l (range . - . ), / ( . %) were males. one patient ( . %) is alive in cr, one died in induction, one failed to achieve cr post-induction and patients( %) had hematological relapse (range . - . months, median . ). mrd< . % by flow-cytometry on day- and end of induction was achieved in / ( . %) and / patients( %) with near-haploid, compared with / ( . %) and / patients( %) with low-hypodiploid; respectively (p = . , p = . ;respectively). allogeneic transplantation was performed during initial remission only in mrd negative patients (one relapsed and one is in cr) and in the patient with induction failure (relapsed post-transplant). five of the total six patients who had negative mrd on day- and end of induction are alive in cr ( / with chemotherapy alone). all patients with negative mrd at end of induction but with mrd levels≥ . % on day- (range . - . %) relapsed as well as all patients with detectable mrd at the end of induction. the difference in relapse was statistically significant in relation to negative-mrd on day- (p = . ), but not at end of induction(p = . ). conclusion: children with hypodiploid all and negative mrd on day- of induction are highly curable with intensive chemotherapy alone, while patients with negative mrd at the end of induction and detectable mrd on day- had dismal outcome. background: overall survival in pediatric acute myeloid leukemia (aml) has plateaued between - %, with death during induction chemotherapy seen in - % of patients. respiratory complications contribute to morbidity and mortality in pediatric aml induction, however the incidence, patterns, and predictors of respiratory adverse events (aes) during this period are unknown. to estimate the incidence of respiratory aes during induction therapy for de novo pediatric aml, to characterize and grade these respiratory aes, and to identify predictors of respiratory ae development. we conducted a retrospective longitudinal study from presentation to day in institutional de novo pediatric aml patients (≤ years) between march and december . outcomes included any nci ctcae grade - respiratory ae or death from another cause. demographic, disease, and treatment-related data were abstracted. the most specific, best-fitting ctcae category and grade for each ae was determined. descriptive statistics, survival analysis, multivariable logistic regression analysis, and time-toevent distributions were performed (sas v . , cary, nc) . among eligible patients, . % (n = ) experienced discrete respiratory aes. incidence of grade - aes was . % (n = ). a bimodal time-to-event distribution demonstrated peaks at treatment days and . induction death occurred in . % (n = ) including deaths from respiratory failure associated with disseminated fungal disease. in univariate analysis, those experiencing aes differed significantly in regards to older age at diagnosis (p< . ), higher initial wbc (p = . ), higher initial peripheral blast percentage (p = . ), coagulopathy at diagnosis (pt (p = . ), d-dimer (p = . )), fluid overload status (p< . ), occurrence of infection (p = . ), and occurrence of tumor lysis syndrome (tls) (p = . ). patients with hyperleukocytosis (p = . ), fluid overload (p< . ), and fab m morphology (p = . ) each had a significantly decreased probability of completing the follow up period without experiencing a respiratory ae. on multivariable analysis, fluid overload (aor . [ % ci: . - . ) and older age (aor . [ % ci: . - . ) were significantly associated with ae occurrence when gender, hyperleukocytosis, tls, and infection status were held constant. we describe a high incidence of respiratory aes during pediatric aml induction. fluid overload and older age at diagnosis are independently associated with ae development when controlling for other proposed risk factors. interventions focused on conservative fluid management and offset of fluid overload should be explored in newly diagnosed pediatric aml in an effort to reduce respiratory complications during induction. overall, all survival rates are outstanding and have continued to improve with risk-adapted therapy. the most striking improvement occurred in t-all where -year os rates now exceed % and parallel b-all. survival improvements, however, have not been observed uniformly across all subgroups. while the gap in outcome differences narrowed among blacks, outcomes for hispanics have remained static. further, no improvements in survival were observed in infants or ayas and new treatment approaches have been implemented for these populations. background: acute myeloid leukemia (aml) accounts for approximately % of new childhood leukemia cases. chest x-ray (cxr) is performed in all newly diagnosed aml cases to evaluate the safety of airway management for anesthesia during diagnostic procedures; however, cxr results in pediatric patients with aml have not been described. objectives: the primary objective was to evaluate cxr findings at diagnosis in patients with aml. the secondary objectives included assessing associations between cxr findings and clinical characteristics, with the overall goal of aiding in the evaluation of the use of cxrs as an initial diagnostic study in pediatric patients with aml. design/method: cxr findings and clinical characteristics were evaluated in patients with newly diagnosed aml who were enrolled in one of three protocols at st. jude children's research hospital (aml , aml , and aml ). the findings were categorized based on radiologic reports. further, the associations of these findings and clinical characteristics were evaluated. we evaluated cxr findings in a total of patients: from aml ; from aml ; and from aml . common cxr findings were pulmonary opacity (n = , . %), bronchial/perihilar thickening (n = , . %), splenomegaly (n = , . %), mediastinal mass and lymph nodes (n = , . %), pleural effusion/thickening (n = , . %), demineralization/fracture/periosteal lesions (n = , . %), scoliosis (n = , . %), and granulomatous disease (n = , . %). three cxr findings were associated with younger age at diagnosis: pulmonary opacity (median age, . years in patients with positive findings vs. . years in those with negative findings, p< . ), bronchial/perihilar thickening (median age, . years vs. . years, p< . ), and demineralization/fracture/periosteal lesions (median age; . years vs. . years, p = . ). two cxr findings were associated with older age at diagnosis: scoliosis (median age, . years vs. . years, p< . ) and granulomatous disease (median age, . years vs. . years, p = . ). higher white blood cell counts (wbcs) at diagnosis were associated with cxrs showing pulmonary opacity (median wbc; . × ^ /l vs. . × ^ /l, p = . ) or splenomegaly (median wbc; . × ^ /l vs. . × ^ /l, p = . ). french-american-british (fab) m /m subtypes were more frequently associated with pulmonary opacity compared with others (p< . ). we did not find significant differences between female and male patients. conclusion: cxr in patients with newly diagnosed aml showed a variety of thoracic, abdominal, and bony lesions that are important for the initial evaluation and management. pulmonary opacity was the most common finding and was frequently seen in patients who were younger or had higher wbcs at diagnosis or fab m /m . background: children diagnosed with acute lymphoblastic leukemia (all) require a central venous catheter (cvc) to administer chemotherapy safely. both external and internal cvcs carry risks of complications including thrombosis, infection, and possible replacement. internal catheters, such as a port, are generally used for the majority of patients for the duration of treatment since therapy lasts for several years. many institutions place a port at the time of diagnosis. other institutions prefer to start induction therapy via placement of a peripherally inserted central catheter (picc) and defer port placement until the completion of induction therapy due to concerns of increased risk of infectious complications with port placement. objectives: to compare rates of common cvc associated complications by type of cvc placed at start of induction therapy in children treated for newly diagnosed all at the jimmy everest center (jec) at the university of oklahoma health sciences center. design/method: a retrospective chart review analyzed data from newly diagnosed all patients treated at the jec between - . data was collected on complications including thrombosis, bacteremia, insertion site infection, cvc malfunction and need for removal. data collection began at the start of induction and was completed at the end of induction therapy. statistical analysis used a univariate and multivariate logistic regression model to compare complication rates between those who had a port versus those who had a picc placed at start of induction. results: data was collected on patients. fifty-six patients had a port placed at start of therapy while had a picc placed. fourteen percent of patients had a cvc associated complication. univariate analysis showed no statistically significant difference in rates of cvc associated complications between the groups (port %, picc . % p = . ). the rates of hospitalization for cvc associated complications were similar between both groups (port %, picc % p = . ). rates of cvc removal were also similar between both groups (port %, picc % p = . ). multivariate model that included baseline patient characteristics including type of all, patient body surface area, gender, ethnicity and age continued to demonstrate no significant difference in cvc associated complications between both groups. conclusion: this single institution study showed that there was no significant difference in cvc associated complications between port and picc line placement at the start of childhood all induction therapy. port placement can be considered as a safe option at the start of induction therapy. complete remission [cr] or cr with incomplete blood count recovery [cri]) within treatment cycles - . interim data are reported (nct ). results: seventeen patients were enrolled and received ≥ dose of lenalidomide; median age was years (range - ); patients were female. patients received median prior regimens (range - ). nine patients had previously undergone bone marrow transplantation (bmt). four patients had relapsed aml and were refractory to immediate prior treatment. median duration of study treatment was weeks (range - ); patients completed a median of treatment cycle (range - ). all patients were evaluable for primary outcome; achieved morphologic cri after cycles (no patients achieved cr). the responder was a -year-old male with history of r/r aml after first-and second-line treatment, bmt, and salvage chemotherapy. at baseline, he had a complex cytogenetic karyotype (monoallelic − q . , − q, − q . , − p ) with no identifiable molecular mutation; he was also positive for del( q) (− q , − q ). his post-treatment karyotype showed no abnormalities. sixteen patients experienced treatment failure; due to resistant disease, of indeterminate cause, and had treatment failure before a post-baseline assessment was performed. all patients experienced ≥ grade - treatment-emergent adverse event (teae). the most commonly reported were thrombocytopenia (n = ), anemia (n = ), febrile neutropenia (n = ), and hypokalemia (n = ). fifteen patients experienced ≥ teae related to lenalidomide. all patients discontinued treatment; remain in follow-up. the study is now closed to enrollment. ten patients died on study: during treatment, during follow-up. all deaths were attributed to aml or complications due to aml. conclusion: third-line lenalidomide monotherapy was associated with clinical response in of pediatric patients with r/r aml; however, treatment exposure was limited. safety data are consistent with the known profile of lenalidomide. lenalidomide was not an efficacious treatment for r/r pediatric aml. funding: celgene corporation, summit, nj, usa. cook children's medical center, fort worth, texas, united states background: it is well documented that pediatric patients with acute lymphoblastic leukemia (all) often experience significant weight gain during induction therapy and later struggle with obesity. however, some patients experience unintended weight loss during induction therapy; since this issue is not well reported, it often goes undertreated. although malnutrition is reported to be associated with decreased survival, increased risk of infection, and loss of lean body mass, there remains a scarcity of in-depth analysis of prevalence and risk factors that contribute to this problem. our study attempts to address this critical yet unmet need. objectives: our aim was to identify the clinical risk factors and outcomes associated with weight loss during induction therapy for pediatric all. design/method: this was a retrospective chart review of patients between and years of age diagnosed with all at cook children's medical center from / / to / / . for each patient, we collected height, weight, age, body mass index (bmi) z-scores at diagnosis and end of induction therapy, risk stratification, and whether consolidation was delayed. patients with a bmi > th percentile at diagnosis were categorized as being overweight or obese. using logistic regression analyses, we examined which variables predicted whether the patient had an increase or decrease in bmi z-score throughout induction. a critical alpha level of . indicated statistical significance. results: ninety-six patients met our inclusion criteria. of these, % experienced a decrease in bmi during induction therapy. compared to patients whose bmi increased during induction, patients with a decrease in bmi were more likely to be overweight or obese at diagnosis ( % vs. %; p< . ), to be ≥ years of age ( % vs. %; p< . ), to have a high-or very-high-risk stratification ( % vs. %; p< . ), and to experience a delay in the start of consolidation therapy ( % vs. %; p< . ). conclusion: this research highlights a risk not previously identified in the literature that may impact outcomes. patients treated on high-or very-high-risk protocols, who are overweight or obese at diagnosis, and who are ≥ years of age at diagnosis should be monitored closely for weight loss during induction therapy. patients who experience weight loss should receive prompt intervention. it is our hope that this information can be used for future prospective studies and to help develop evidence-based guidelines. background: p abnormalities have been observed in some patients with hematologic malignancies. loss of p function as a tumor suppressor gene in the chromosome plays an important role for development of leukemia. these patients usually have poor outcome due to the chemotherapy and are associated with poor prognosis. objectives: this study aimed to identify frequency of p abnormalities between iranian children and adult patients with aml (acute myeloid leukemia) malignancy. design/method: the p abnormalities were analyzed via bone marrow karyotyping and fish method in acute myeloid leukemia patients. in this study, p abnormalities were observed in ( %) patients out of diagnosed cases. a significant strong correlation between p abnormalities and other high risk factors (poor risk cytogenetic) were observed. from patients with aml malignancy ( p abnormalities), ( %) patients have complex karyotype, ( %) patients monosomal karyotype and ( %) patients have monosomal karyotype accompanied with a complex karyotype. overall, p abnormalities are independent risk factor in acute myeloid leukemia and evaluation of these abnormalities by fish or other complementary techniques prior to treatment, might help for better risk stratification of high risk aml patients. background: hepatotoxicity in treatment of acute lymphoblastic leukemia (all) is well studied and transiently affects most patients receiving antimetabolite therapy. rarely, patients develop liver injury severe or prolonged enough to undergo a liver biopsy. little is known about how these patients differ from patients that develop transient hepatotoxicity. we sought to describe disease and treatment characteristics for all patients that developed hepatotoxicity severe enough to undergo liver biopsy. we also looked for pre-dictive factors for liver biopsy, including signs of early hepatic injury from the initial treatment protocol. design/method: pathology reports of all patients from the liver biopsy database at children's healthcare of atlanta were collected. controls were matched : for age, all subtype, and treatment protocol. demographics, treatment protocols, and overall outcomes were collected through the electronic health record. hepatic lab results for transaminases, coagulation, and albumin were collected for induction, consolidation, interim maintenance, delayed intensification, and maintenance. results: sixteen patients diagnosed between - (median age at diagnosis years, range - ; % male; % pre-b all) were included in the case series. the median time from diagnosis to liver biopsy was . years (range - ). eight patients ( %) were in maintenance at the time of biopsy; none had active disease. eight ( %) were postbone marrow transplant. biopsy results included: steatosis ( ), acute inflammatory/infectious ( ), liver infiltration ( ), fibrosis ( ) and graft-vs-host disease (gvhd) ( ). six patients were deceased; -year all-cause mortality from diagnosis was %. thiopurine methyltransferase (tpmt) status was known in % cases and % controls. all cases had intermediate or wildtype status, which did not differ from controls (p > . ). patients requiring liver biopsy did not have evidence of acute hepatotoxicity (ast/alt > × normal values) during their initial treatment protocol. hepatotoxicity requiring liver biopsy is a rare outcome of all treatment. these patients had elevated rates of relapse, bmt, and -year all-cause mortality, suggestive of a more severe disease process. however, it is difficult to sort out the temporality of relapse, bmt, and hepatoxicity requiring biopsy in this limited sample. additionally, patients with bmt preceding liver biopsy have other confounding factors that makes them difficult to include in the analysis. finally, our limited descriptive data show no notable correlation between early hepatotoxicity and later indication for liver biopsy. future cohort or case-control studies with larger sample sizes are required to further explore early predictive factors for severe hepatotoxicity requiring liver biopsy. nathan gossai, joanna perkins, michael richards, yoav messinger, bruce bostrom background: the majority of chemotherapeutic agents used to treat hodgkin lymphoma are teratogenic. pregnancy screening prior to the start of chemotherapy is supported by clinical guidelines and baseline testing is a standard component in therapeutic trials. there is limited data available on the incidence of pregnancy screening prior to the start of hodgkin therapy but previous studies suggest that pregnancy screening, especially at pediatric institutions, is not consistently completed. objectives: the objective of this study is to evaluate the incidence of pregnancy screening and contraceptive counseling prior to the start of therapy in females diagnosed with hodgkin lymphoma. design/method: a retrospective chart review was performed for all female patients newly diagnosed with hodgkin lymphoma from to at the hospital for sick children in toronto, ontario. all patients who were intended to receive multi-agent chemotherapy were included, regardless of age. data collected included demographic and disease information, chemotherapy regimen and enrollment on clinical trial. all pregnancy testing within two weeks prior to the start of therapy was captured, as well as type of pregnancy test performed, documentation of menstrual status, contraceptive counseling and contraceptive provision. univariate and multivariate analyses were used to describe factors influencing the incidence of pregnancy testing. results: a total of female patients with newly diagnosed hodgkin lymphoma between the ages of and years were identified. sixty patients ( %) had pregnancy testing done prior to the start of therapy. testing modalities included serum and urine screens as well as quantitative beta-hcg measures. older age (p = . ), documentation of menstrual status at diagnosis (p = . ) and diagnosis between and (p = . ) were associated with higher incidence of screening. enrollment on a therapeutic trial was not associated with a higher incidence of screening (p = . ). contraceptive counseling was documented for patients ( %) and patients ( %) were prescribed contraceptive medications during therapy. pre-chemotherapy pregnancy testing was completed on % of females with newly diagnosed hodgkin lymphoma. improvement is required and interventions, including clarification of institutional standards, modification of chemotherapy order sets and staff education, are planned. (rao et al., cancer, ) . university of louisville, louisville, kentucky, united states background: granulocytic sarcomas (also known as chloromas or leukemia cutis) were first described by a. burns in . they are solid tumors comprised of immature granulocytic cells and represent extramedullary manifestations of underlying leukemia. chloromas are most commonly associated with acute myeloid leukemia. they may arise in other myeloproliferative disorders but are rarely seen in b or t cell acute lymphoblastic leukemia (all). objectives: although patients with all rarely have chloromas, it should remain on the differential for patients with unusual swelling or masses. design/method: we present a case series of two patients from our institution diagnosed with b cell all who had a chloroma as the presenting symptom. the first patient is a yo who presented to his primary provider with nasal congestion and a one-week history of bilateral eye swelling and was referred to an allergist when the symptoms did not resolve with anti-histamines. his review of systems was otherwise negative. he was referred urgently to ent two months later for a × cm mass palpated along the medial border of the left eye. an mri showed a left facial mass surrounding the zygoma and extending into the anterior inferior left orbit. biopsy revealed b cell acute lymphoblastic lymphoma, and bone marrow aspirate and biopsy confirmed the diagnosis as b cell all. the second patient is a yo who presented to his primary doctor for rapid growth of a scalp nodule that had been present for about months. he was referred to dermatology and treated for a supposed kerion from tinea capitis. the lesion continued to grow and became more irritated with this treatment. punch biopsy revealed a complicated phenotype of lymphoblastic lymphoma. however, after a lymph node biopsy and bone marrow aspirate and biopsy, the diagnosis was confirmed as b all. his only other positive point on review of systems was a questionably pathologic -pound weight loss and an area of matted cervical lymph nodes. for both of our patients, the chloromas completely disappeared during induction therapy. it is worth noting that both of these patients presented with the chloroma as the only symptom of the underlying leukemia. this led to initial misdiagnosis and delay in identifying their leukemia. therefore, while it is very rare for a patient with b all to present with a chloroma, our experience shows that all should be on the differential for patients presenting with unusual swelling or masses. background: hodgkin lymphoma (hl) is a lymphoproliferative neoplasm that commonly presents with history of adenopathy and a predictable pattern of disease involvement with or without systemic symptoms of fever and/or weight loss. in the hands of an experienced oncologist the diagnosis of hl is usually not a challenge. occasionally a diagnostic challenge is presented by a patient who has an atypical presentation which is suggestive of an alternative diagnosis. we describe a case series of patients diagnosed with hl whose initial clinical presentations lead to a diagnosis different form hl. honduras, nicaragua and the united states. results: six pediatric oncology centers from the american continent conducted a retrospective review of patients diagnosed with hl since . patients that had an initial presentation not suggestive of hl or who were initially diagnosed with a disease other that hl were included for a total of patients. argentina n = , guatemala n = , honduras n = , nicaragua n = , united states n = . five patients were female and male. patient's ages ranged from to years. most patients (n = ) were older than years. three patients ( %) presented with non-immune cytopenias without overt lymphadenopathy, of those one had active hemophagocytic syndrome. five patients ( %) were suspected to have localized solid tumors: ewing sarcoma n = , rhabdomyosarcoma n = , hepatocellular carcinoma n = , and soft tissue tumor of the cheek n = . two ( %) metastatic solid malignancy as they presented with disseminated pulmonary nodules. five ( %) with autoimmune disorders: hashimoto thyroiditis n = , autoimmune hemolytic anemia n = , nephrotic syndrome n = . ten ( %) with chronic infectious processes: brucella n = , tonsillar abscess n = , splenic abscess n = , and tuberculosis (tb) n = . patients with suspected tuberculosis were diagnosed outside of the united states. six of patients were ultimately diagnosed as having both tb and hl. seventeen patients had ann-arbor stage iii or iv, seven patient had stage ii with either b symptoms or bulky disease. patients were treated with various chemotherapy regimens according to the treating center: abvd, abve-pc oepa-copdac, avpc, beacopp. two patients had recurrent disease, one died of disease progression and one died from causes not related to hl conclusion: a small proportion of hl patients have atypical or unusual presentations. hl should be included in the differential diagnosis of solid tumors, autoimmune disorders, infections or cytopenias. the most common atypical presentation is an infectious process. background: acute lymphoblastic leukemia (all) represents the largest group of pediatric malignancies. the high cure rate of childhood all represents one of the most remarkable success stories in the war on cancer. in a lower middle income country (lmic) like the philippines, we reviewed the five year survival in a tertiary referral center. objectives: this retrospective cohort study aims to determine the survival of children - years old with all treated at a tertiary referral center for childhood cancer in the philippines from january to december . design/method: this is a retrospective cohort study that reviewed medical charts of newly diagnosed all ages to years old from january to december . a total of subjects were included in the study. the year overall survival (os) and event free survival (efs) were . % and . %, respectively. the year os for standard risk all was . % and for high risk patients was %. the year os for the patients on remission was . % and for those who relapsed was . %. univariate and multivariate by cox proportional hazards regression revealed wbc count at diagnosis, risk classification, immunophenotyping, and development of relapse showed significant prognostic impact for mortality. age and gender were reported with no prognostic significance. the -year os and efs were lower compared to developed countries but are comparable with other lmics. the prognostic factors for relapse and mortality were compatible with the literature. overall, the adopted treatment protocols for childhood all in this institution showed acceptable results. relapse has a significant prognostic impact for mortality. development of accessibility to care, increase awareness, early detection and resources at hand should be achieved. improvement in the follow up protocol to prevent delays in the treatment, patient education to prevent non-compliance and psychosocial support, to developed better supportive care, and expand facilities should be given emphasis to further improve survival and prevent relapse. objectives: here, we seek to further characterize this entity by describing the pathologic and clinical features of pediatric cases of burkitt-like lymphoma with q aberration. we collected pathologic and clinical data from the medical record on all pediatric high grade b-cell lymphoma (hgbcl) cases diagnosed at our institution over a -year period ( - ) . for those cases classified as neither burkitt lymphoma nor diffuse large b-cell lymphoma (dlbcl), fish for myc, bcl- and bcl- , as well as array comparative genomic hybridization (acgh), were performed. we identified cases of hgbcl, including cases of burkitt lymphoma presenting as purely leukemic phase. of the hgbcl cases, had burkitt lymphoma as defined by myc rearrangements, and had dlbcl. collectively, the majority of these patients had primary disease outside of the head/neck, and most patients presented with advanced stage (iii-iv) disease. of the remaining cases, q aberration was identified in cases using acgh. all cases histologically and immunophenotypically resembled burkitt lymphoma but lacked myc rearrangement, instead showing proximal gains in q -q and telomeric losses in q . qter. all cases involved primary disease in the cervical lymph node and/or tonsil. three of these cases were localized (stage ii), and the fourth case involved a few metabolically active but non-enlarged lymph nodes in the chest and abdomen (stage iii). all patients achieved complete remission with standard therapy for mature b-cell lymphoma, and were alive with no clinical evidence of disease at a median follow-up of months. although the number is small, our results suggest that the majority of non-burkitt, non-dlbcl cases of pediatric hgbcl carry q aberrations. in addition, patients with q aberrations appear to be more likely to present with lower stage disease, thus requiring less intensive therapy, and also tend to have primary disease in the head/neck. these findings further support the classification of burkitt-like lymphoma with q aberration as a distinct pathologic and clinical entity, and we propose that all pediatric non-burkitt, non-dlbcl cases of hgbcl regularly undergo further workup for possible q aberrations. marie claire milady auguste, joseph bernard st damien hospital, port-au-prince, port-au-prince, haiti background: hodgkin lymphoma (hl) and non-hodgkin lymphoma (nhl) account for % of cancers in the united states pediatric population ( , ). in central america and the caribbean, they are in second position among all types of pediatric cancers ( ). a previous study on pediatric cancers in haiti showed that the lymphomas were in fifth place after the leukemias, wilms tumor, retinoblastoma and the sarcomas ( ). the main objective of this study is to present the epidemiological profile of lymphomas managed at a haitian pediatric hospital. design/method: this is a retrospective study conducted on the cases of lymphoma diagnosed and managed at st damien hospital from january to december . key variables such as age, gender, stage at diagnosis, histopathological types and outcome were collected to present the characteristics of this retrospective cohort. of the cases of cancer diagnosed during the study period, ( . %) had the diagnosis of lymphoma. the sex ratio was . ( males for females) and the average age was . years [ - years]. there were cases of hl ( . %) and cases of nhl ( . %). . % of the patients were diagnosed at stages iii and iv. among the hl cases, ( . %) were nodular sclerosis lymphoma, ( . %) with mixed cellularity and ( . %) with lymphocytic predominance. for the nhl cases, ( . %) were burkitt's lymphoma and ( . %) lymphoblastic t-cell lymphoma. among the patients for who immunohistochemistry was found, the cases of hl were cd -positive and out of cases of nhl were cd -negative. only patient was hiv-positive, and patients had a confirmed exposure to epstein-barr virus. patients ( . %) were lost to follow-up, ( . %) were in remission, ( %) relapsed, ( . %) were still in treatment and ( %) were deceased. university of chicago, chicago, illinois, united states background: due to the adoption of risk-adapted therapy, pediatric and adolescent acute lymphoblastic leukemia (all) is associated with high cure rates. despite excellent outcomes in most children, patients with certain blast cytogenetic features do not fare as well. furthermore, african american, native american, and hispanic patients have worse outcomes than caucasian patients. while the outcome discrepancies are certainly multifactorial, and blast cytogenetics are related to age, it remains unclear whether ethnicity and blast cytogenetics correlate. the diverse patient population at the university of chicago provides an opportunity to evaluate for such a correlation. objectives: to describe cytogenetic findings in a racially and ethnically diverse population of patients of all age groups diagnosed with all at university of chicago from to and determine if there is a correlation between race/ethnicity and blast cytogenetics. results: a total of newly diagnosed patients with all between the ages of - from - were included in this study. of those, patients ( . %) had b-all, had t-all ( . %), one had early t-cell precursor all and one had mixed phenotype all (b/t). caucasians accounted for % of patients, african americans (aa) %, hispanics . %, asians . %, and % were of other races. age distribution had a bimodal pattern, with a peak in incidence at and another at years of age, consistent with published data. cytogenetic categories included: t( ; )(p ;q ), q rearrangements (kmt a), iamp , t( ; )(q ;p . ), t( ; ) (q ;q ), hypodiploidy, hyperdiploidy and double trisomy of chromosomes and . aa and hispanic patients with b-all presented more frequently between the ages of - years compared to caucasians (p = . and . , respectively). in aa patients, t( ; ) (q ;p . ) was overrepresented (p = . when compared to caucasians), and was mainly observed in patients between - years. caucasian patients were more likely than non-caucasians to have hyperdiploidy (p = . ), especially in patients aged - years. the rate of t( ; )(q ;p . ) was significantly higher in aa patients in our cohort, in particular in patients between the ages of - years. hyperdiploidy was more likely in caucasians aged - years. these findings may suggest that varying blast cytogenetics could contribute to outcome differences between races. ahmed elgammal, yasser elborai, mohamed fawzy, asmaa salama, eman d el-desouky, lobna shalaby national cancer institute, cairo, cairo, egypt background: hodgkin lymphoma (hl) in children is one of the malignancies that have a high chance of cure. stage iv hl remains a challenge for getting good clinical outcome as in other stages. many treatment protocols used to give combination chemotherapy while combined modality treatment is the mainstay in other treatment protocols. objectives: we aimed in to assess the outcome using consolidation radiotherapy to chemotherapy (combined modality treatment) versus combination chemotherapy alone in treatment of stage iv hl. design/method: we included patients with stage iv hl and whose data were retrieved from the medical records of the pediatric oncology department, national cancer institute, cairo university, egypt from till june and were followed till august . treatment was either to give cycles of abvd (adriamycin, bleomycin, vinblastine, dacarbazine) only or to give cycles of abvd followed by consolidation radiotherapy. the study included cases; were males and were females. mean age was . years ranging from to years. the histopathology subtype was nodular sclerosis in the majority of cases ( cases) followed by mixed cellularity ( cases) then only one case of lymphocyte rich. nine cases were initially bulky while cases were not. constitutional manifestations were present in cases while it was absent in cases. bone marrow was involved in only cases. radiotherapy was given after completion of chemotherapy to cases while cases received chemotherapy only. the -year overall survival for patients who received radiotherapy was superior to those who received chemotherapy alone; % versus . % respectively with statistical significance (p = . ). the -year progression free survival was also higher with radiotherapy than others; % versus . % (p = . ). patients with stage iv hl who received consolidation radiotherapy apparently had a better outcome than those who received chemotherapy only. this suggests that radiotherapy contributes significantly with chemotherapy to the cure rate for those patients. the feinstein institute for medical research, manhasset, new york, united states background: microrna (mirnas) are short non-coding rnas that play a decisive role in cancer biology, including leukemia. exosomes are microvesicles ( - nm) produced by most cells in biological fluids. exosomes represent the fingerprint of the parental tumor and are loaded with bioactive markers such as mirnas, which may regulate tumor growth. exosomal cargo can be transferred into target cells changing their biological properties. our study investigates a functional role for exosomal mir- a in pediatric acute lymphoid leukemia (p-all). objectives: / to demonstrate that p-all exosomes induce cell proliferation / to confirm that exosome-induced cell proliferation is disease-stage specific / to analyze exosomal mir- a expression profiles in p-all / to authenticate that inhibition of exosomal mir- a reduces leukemia proliferation design/method: exosomes were isolated by ultracentrifugation from healthy donors (hd) & p-all serum and conditioned medium (cm) of sup-b , jm , and cl- (control) human cell lines. cell lines were exposed to different sources of leukemia-derived exosomes in a paracrine or autocrine fashion for hrs in triplicates. proliferation was assessed by microscopic cell counting and confirmed by gene expression for proliferation, pro-survival and pro-apoptotic genes. mirna profiling was performed with the human cancer pathway finder microarray (qiagen). silencing of exosomal mir a was carried out by a mir- a inhibitor (qiagen), utilizing exo-fecttm exosome transfection reagent (sbi, system biosciences). further, exosomal mir- a silencing was confirmed by q-pcr. cellular uptake of texred-sirna (sbi, system biosciences) was confirmed by flow cytometry. transfer of exosomal mir a to the target cells was evaluated by q-pcr. we elucidated that cm-derived exosomes from sup-b and jm cell lines induce cell proliferation in sup-b , jm (autocrine and paracrine) and cl- cells (paracrine) (p< . ). serum p-all exosomes promote paracrine cell proliferation in all cell lines compared to hdderived exosomes (p< . ). heatmap analysis of mirna profiles of leukemia exosomes (all cell lines and p-all) identified mir- a significantly upregulated in leukemia exosomes compared to controls. mir- a was also upregulated in all cell lines after exposure to leukemia exosomes that induced proliferation. moreover, exosomal mir- a inhibition reduces leukemic proliferation in pediatric all. our data suggest that all exosomes induce cell proliferation of leukemic cell lines in both paracrine and autocrine fashion. exosomes regulate these phenomena in a highly orchestrated way, by transfer of functional exosomal mirnas such as mir- a. the results of this study suggest s of s that exosomal mir- a inhibition can act as a novel way for growth-suppression of pediatric leukemia. results: a total of disease sites were detected at pet/ct, while sites were detected at contrast-enhanced ct and bone marrow biopsy (bmb). pet/ct showed improved detection of nodal lesions (p < . ) (kappa value = . ), extranodal lesions (p < . ) (kappa value = . ) and bone marrow (p < . ) (kappa value = . ) compared to contrast enhanced ct and bmb. pet/ct had upstaged cases ( %) and down-staged cases ( . %) (p < . ) (kappa value = . ). among the upstaged cases, patients ( . %) were upstaged from stage ii to iii, based on residual in pet/ct not seen in contrast enhanced ct after abdominal mass excision. four patients ( . %) were upstaged from stage iii to iv based on bone marrow uptake in fdg-pet without positivity in bma or bmb.regarding response assessment, sensitivity was % for pet and % for contrastenhanced ct (p = . ). specificity was % for pet and % for ct (p< . ). positive predictive value for pet was %, while was % for ct scan (p< . ). negative predictive value for both pet and ct was % (p = . ). five patients had nd biopsy to confirm viability of the residual lesions, lesions were negative in pathological examination (all of them were metabolic negative in pet/ct; deauville score below ). one lesion was positive in pathological examination (was positive in pet/ct; deauville score of ). conclusion: pet/ct detected additional sites compared with contrast-enhanced ct and resulted in changing stage of disease. pet scan is significantly more specific than ct in the management of children with burkitt lymphoma. background: deep sequencing of the immunoglobulin heavy chain (igh) locus indicates that each b all is composed of innumerable subclones. in many cases, subclones exhibit differing phenotypic qualities. however, it remains unclear whether subclones demonstrate distinct tissue distribution within a patient. objectives: . to quantify the extent of clonal heterogeneity in diagnostic b all specimens; . to identify variability in clonal composition between bone marrow (bm) and peripheral blood (pb) disease sites. design/method: igh sequencing was performed on purified dna from pairs of matched bm and pb patient specimens. multiplex pcr was used to globally amplify the igh locus; next generation sequencing (ngs) was performed using illu-mina® miseq. index clones (defined as ≥ % of all sequence reads in a specimen) and their subclone progeny (defined by shared nucleotide bases immediately upstream of a common jh, or n_jx) were identified using igblast-determined vh and jh alignments (http://www.ncbi.nlm.nih.gov/igblast/) and an established in-house computational pipeline. results: up to index clones per specimen were discovered in of the samples. in the remaining ( bm/pb pairs), pair did not reveal a clonal igh and was eliminated from analysis; in the other, clone frequency did not reach the % index threshold, but predominant clonal precursors were inferred by the prevalence of their subclone progeny. subclone counts ranged from to , per index clone. a combined , subclones derived from pb index clones were observed; in contrast, bm index clones gave rise to only subclones. subclone heterogeneity was observed between all paired specimens. in bm/pb pairs, index clones existed in equivalent proportions between disease sites. in contrast, bm/pb pair demonstrated high-frequency index clones in the bm ( . % & . %) with limited representation of these clones in the pb ( . % & . %, respectively); in this case, the most prevalent clone in the pb ( . %) matched the least frequent index clone in the bm ( . %). similarly, another pair showed a predominant index clone in the pb ( . %) which was below index threshold ( . %) in the bm. in paired patient specimens, index clone predominance was discovered to be overtly distinct between bm and pb. among all pairs, the extent of subclone progeny derived from each index clone showed marked variability, with far higher subclone frequency in the pb than in the bm. our data indicate that b all clonal composition differs between disease sites. valley children's healthcare, madera, california, united states background: tuberculosis (tb) presenting with hodgkin lymphoma (hl) is rare. their coexistence could lead to delay in diagnosis of both tb and hodgkin lymphoma due to the similarities in signs and symptoms of presentation. most cases have been reported in the adult literature. we describe a case series of children that were suspected to have tb and were found to have coexisting tb and hl. results: a retrospective review of hl patients in guatemala and argentina over six years, uncovered patients with simultaneous diagnosis of tb and hl. eight patients were from guatemala (incidence of . %) and from argentina (incidence of . %). there were females and males. age ranged from - years (mean . years, media years). nine patients were suspected to have tb at presentation by the referring physician. two patients were found to have tb at the time of relapse through routine tissue culture. initial systemic symptoms included fever (n = ), weight loss (n = ), and night sweats (n = ). six patients had a second systemic symptom in addition to fever. time for referral to oncology center ranged from weeks to months. nine patients were diagnosed with tb and hl through a tissue cultures and with serum quantiferon. one patient was found to have hl without tb. two patients had no systemic symptoms and the diagnosis of tb came to light through routine tissue culture. five patients had stage iiib and ivb, two stage iia and one iib at diagnosis. hl treatment was given according to the insti-tutional standards depending on stage and risk with abvd, oepa/copdac +/-radiation therapy, and ice for relapse. five patients started anti tb treatment (isoniazid, rifampin, pyrazinamide +/-ethambutol for months followed by isoniazid and rifampin for - weeks) simultaneously with chemotherapy, and three others after completing cycles. the two relapsed patients started tb treatment after cycles of chemotherapy. seven patients are alive and have been followed for months - years. one patient died during therapy, another died for causes not related to tb or hl and one is currently receiving treatment. conclusion: tuberculosis can coexist with hl. in areas were the prevalence of tb is high, microbiology investigations of biopsy specimen should be strongly considered. therapy for tb can be given simultaneously with chemotherapy. coexistence of tb and hl does not appear to affect outcomes. the children's hospital affiliated to the capital institute of pediatrics, united states background: the pi k/akt signaling pathway plays a central role in cell growth, proliferation and survival in physiological conditions. this signal pathway is considered to be an innovative targeted therapy of cancer, and its abnormal activation has been proved to be related to t-cell acute lymphoblastic leukemia (t-all). despite improved treatment strategies, such as multi-drug combination, high-dose chemotherapy and all kinds of application and popularization of hematopoietic stem cell transplantation, children with drug resistance or relapse t-all are still rather worse and its overall outcome and prognosis are much poorer than the more common b-lineage all. objectives: to explore the relationship between the pi k/akt pathway and the pediatric t-all, so as to probe the exact molecular mechanisms of t-all and provide more directions for its treatment. design/method: cases of new or recurrent acute t lymphocyte leukemia children with clinical information were collected in the children's hospital affiliated to the capital institute of pediatrics from dec. to oct. , with age and gender matched healty children as control (all was informed consent). the expressions of key genes in pi k pathway were s of s analyzed by western blot rt-pcr analysis, the pi k enzyme activities were detected by elisa,and the ccrf -cem's proliferation and its apoptosis were tested by mtt and flow cytometry technology on t-all cell lines ccrf-cem in different treatment group. the results of t-all children in clinical showed that pi k protein and gene expression level were higher apparent than the control group (p< . ), and pi k enzyme activity increased as well (p< . ); pi k inhibitor ly made a significant inhibition of cell proliferation and promoted cell apoptosis. ly also enhanced the effectiveness of clinical commonly used chemotherapeutic drug dnr. in combination ly and dnr treatment group cell viability dramatically declined, apoptosis and the apoptosis relation protein casepase expression in t-all patients was obviously higher than the control and the single drug group; pi k/akt signaling pathway related proteins and gene expression level, pi k, akt, gsk transcription in ccrf-cem were significantly higher than the control (p< . ), while pten transcription was significantly lower than the control (p< . ). the abnormal activation of pi k/akt signaling pathway might play an important role in pediatric t-all patients, especially in the cell proliferation or apoptosis. the results might provide new train of thought and direction in targeted suppress this signal pathway or in combination with other chemotherapy drugs therapy in looking for the more effective and less cytotoxic treatment of pediatric t-all. cleveland clinic children's hospital, cleveland, ohio, united states background: non-hodgkin lymphomas (nhls) are a heterogeneous group of lymphoproliferative diseases which comprise % of all childhood malignancies. nhls can be divided in to b cell lymphomas and t cell/natural killer (nk) cell lymphomas depending on immunophenotype, molecular biology, and clinical response to treatment. although nk/t cell lymphomas occurring in childhood and adolescence comprise a small portion of all lymphomas, they present many diagnostic and therapeutic challenges. the role of angiogenesis in lymphoma pathogenesis is becoming more evident. high molecular weight kininogen (hk) is a central compo-nent of the kallikrein-kinin system. it has been previously reported that cleaved hk (hka) induces apoptosis of proliferating endothelial cells and inhibits angiogenesis in matrigel plug and corneal angiogenesis models. however, the role of endogenous kininogen in regulation of angiogenesis is in tumor microenvironment is unknown. objectives: to elaborate the role of hk in lymphoma angiogenesis, we used a murine t-cell lymphoma model and compared angiogenesis and tumor growth between wild-type and kininogen deficient (mkng -/-) mice. we also evaluated the effect of hka on lymphoma cell proliferation. design/method: el- murine t-cell lymphoma cells ( × ^ ) were implanted into wild-type and mkng -/-mice. tumor size was measured using calipers and tumor volume was calculated using the formula volume = length × width^ × . . seventeen days after cell implantation, tumors were harvested and processed by immunoblotting and immunofluorescent staining. cell proliferation assays (mts) were performed to investigate any possible inhibitory effect of hka on el- cell growth, with human umbilical vein endothelial cells (huvec) were used as a positive control. results: el- lymphomas grew more rapidly and to larger sizes in mkng -/-mice compared to wild-type mice, with significant differences apparent by day after tumor implantation (p< . ). by day , the volume of tumors in mkng -/-mice was approximately . -fold larger than in wild-type mice (mean volume ± standard deviation; ± vs. ± mm , respectively, p< . ). mts assays showed that hka does not directly inhibit the proliferation of el- cells in vitro, though it does significantly impair the viability of ecs studied simultaneously. conclusion: these findings suggest that hk is an important endogenous regulator of angiogenesis and tumor growth in this t-cell lymphoma model, and suggests that hka specifically modulates endothelial proliferation in tumor microenvironment. further work is needed to understand the mechanisms underlying these findings and provide future anti-angiogenic approaches to increase the therapeutic options for patients with nhl. bruce bostrom, jack knudson, nathan gossai, joanna perkins, michael richards, jawhar rawwas, susan sencer, julie chu, nancy mcallister, yoav messinger children's minnesota, minneapolis, minnesota, united states background: osteonecrosis causes significant pain and morbidity in older patients treated for acute lymphoblastic leukemia. besides altering the schedule of dexamethasone in delayed intensification there is no other intervention known to reduce the incidence of symptomatic osteonecrosis. pamidronate has been shown to reduce bone pain from osteonecrosis but not to prevent joint collapse when advanced. objectives: to compare the incidence of symptomatic osteonecrosis in patients who received prophylactic pamidronate compared with concurrent controls. to describe any increase in side effects from the use of pamidronate. design/method: patients age to years at time of all diagnosis were given intravenous pamidronate monthly for one year at the discretion of the primary oncologist starting in the first year of therapy. concurrent controls were patients age to who did not receive pamidronate. all patients were treated according to the concurrent cog protocols and received intermittent dexamethasone during delayed intensification. patients with bcr-abl all were excluded as the use of imatinib may increase the risk of osteonecrosis. imaging was only done if osteonecrosis was suspect based on clinical symptoms. patients were censored at the time of relapse. data were analyzed as of / / . this retrospective study was approved by the children's minnesota irb. of the patients evaluated % were male and % female, % had b-cell and % t-cell. the median followup is . years with a range of . to years. pamidronate was given to patients with developing symptomatic osteonecrosis. there were concurrent controls with developing osteonecrosis. there was no significant difference in the leukemia lineage, gender distribution or body mass index (bmi) at diagnosis between groups. for all patients the median bmi was with a range of to . the age at diagnosis was significantly higher in the pamidronate group with a median of . years vs. . in the controls (p = . ). by kaplan-meier analyses the incidence of symptomatic osteonecrosis was significantly lower in the pamidronate group at % vs. % in controls. the log-rank p-value was . and the breslow p-value, which is more sensitive to early events, was . . there were no untoward side-effects from pamidronate. pamidronate infusions significantly reduced the incidence of symptomatic osteonecrosis in patients over the age of compared to concurrent controls who did not receive pamidronate. arahana awasthi, dina edani, janet ayello, christian klein, mitchell cairo new york medical college, valhalla, new york, united states background: mature b-nhl, including bl and pmbl express cd +/cd b+ and have an excellent prognosis, however, subset of patients relapse secondary to chemoimmunotherapy resistant disease and have a dismal prognosis (≤ % yr. efs, cairo et al. blood. ; gerrard/cairo et al., blood, , goldman/cairo et al. leukemia, . pv has been demonstrated to possess significant preclinical activity against indolent cd b+nhl (polson et al. can. res. ). we previously observed that obinutuzumab (anti-cd mab) significantly enhanced cell death and increased overall survival against bl (awasthi/cairo et al., bjh ) in xenografted nsg mice. however, additive/synergistic effects of pv with obinutuzumab against mature pmbl/bl are unknown. to determine the efficacy of the pv or obinutuzumab/rtx alone or in combination against pmbl and rituximab (rtx) sensitive/resistant bl cell lines. design/method: raji rh (provided by m. barth, md, roswell park cancer institute) and raji/ karpas p (atcc, usa) were cultured in rpmi. tumor cells were incubated with pv, and/or anti-cd b, mmae (generously supplied by genentech inc.) with obinutuzumab /rituximab ( ug/ml) for hr with nk cells at : e: t ratio and cytotoxicity was determined by delfia cytotoxicity assay. six to week old female nsg (nod.cg-prkdcscid il rgtm wjl/szj), were divided into groups: pbs, isotype control, pv, anticd b mab and mmae ( mg/kg). mice were xenografted with intravenous injections of luc+ bl and pmbl cells and tumor burden was monitored by ivis spectrum system. results: os of mice receiving pv alone was significantly increased compared to anticd b ab or isotype control in raji ( . vs. vs. . our preliminary data indicates that pv significantly increased survival in bl and pmbl nsg xenografts compared to anti-cd b ab alone. furthermore, pv in combination with obinutuzumab significantly enhances in-vitro cytotoxicity in bl and pmbl compared to obinutuzumab or pv alone. results: maximal grades (g) / , , and crs occurred in , , and patients, respectively. median lowest fibrinogen levels were . , . , and . g/l in patients with maximal g - , , and crs, respectively. %, %, and % of patients with maximal g - , , and crs had lowest reported fibrinogen levels of ≥ to < . g/l. eight patients (all with g crs) had very low fibrinogen levels (< g/l), which occurred before (n = ) or during (n = ) maximal crs grade or at time of improvement (n = ). no patients with maximal g - crs had < g/l fibrinogen levels. at the onset of < g/l fibrinogen levels, patient had concurrent g , and had g - increased international normalized ratio and activated partial thromboplastin. cryoprecipitate was the primary treatment in the us, and fibrinogen concentrate (fc) guidelines for tisagenlecleucel-associated coagulopathy were developed for other countries because administration of fresh frozen plasma can be problematic. fc was available at / sites for infused patients: / (g crs) and / (g - crs). cryoprecipitate was available at / sites for infused patients: / (g crs), / (g crs), and / (g - crs). risk of bleeding increases in pediatric patients with comorbid thrombocytopenia and anticoagulant treatments. / patients had g / decreased platelets within day of < g/l fibrinogen levels. fatal case of intraparenchymal cranial hemorrhage occurred during resolving crs with g hypofibrinogenemia, ongoing thrombocytopenia, and continuous veno-venous hemofiltration with citrate. hypofibrinogenemia was observed more frequently in patients with higher crs grades during/when crs was improving or resolving. fc and cryoprecipitate treatment guidelines were developed. frequent monitoring and fibrinogen replacement are needed in patients with g / crs. sponsored by novartis. its prolonged cns half-life, may allow a reduction in the number of intrathecal injections. objectives: to safely reduce the burden of therapy by reducing the number of it injections and reducing the total dose of doxorubicin with the addition of liposomal cytarabine and rituximab. design/method: patients ( - years) with cd + b-nhl with fab group b good risk (=stage i/ii and stage iii with ldh < xuln), fab group b intermediate risk (=stage iii ldh ≥ xuln and stage iv {bm blasts < %}) and fab group c high risk were eligible. patients received fab backbone therapy with the addition of six rituximab ( mg/m ) doses; two doses prior to each of two induction courses and one dose prior to each of two consolidation courses. cumulative doxorubicin was reduced from to mg/m in gr patients. after systemic methotrexate clearance, patients received age based dosing of it liposomal cytarabine. it injections were reduced from nine to five. the primary outcome is safety and toxic deaths among evaluable patients with an estimated -year survival above %, monitored by an independent dsmb. results: to date, evaluable patients, fab group b and group c ( cns positive), median age years (range - ), males, burkitt/ dlbcl with gr, ir and hr have enrolled. there has been one grade anaphylactic reaction to rituximab and one grade facial nerve palsy. no other serious adverse events were attributable to protocol therapy. there has been death from progressive disease and relapse at a median follow up of months. efs and os are % and %, respectively. our initial results show excellent efs and os, consistent with published standard of care outcomes, with the addition of rituximab and intrathecal liposomal cytarabine despite the reductions in therapy. further enrollment is ongoing and continued long term outcomes are needed to confirm early results. future randomized studies are needed to examine both short term (mucositis, infections, hospitalization days) and long term (late cardiac toxicity) endpoints. . goldman etal, leukemia, . cairo etal, jco st. jude children's research hospital, memphis, tennessee, united states background: bereaved parents identify significant spiritual needs around time of death and throughout their bereavement journeys. spirituality has been identified as a primary means by which bereaved parents can find meaning in their losses, and this ability to find meaning is associated with lower maladaptive grief symptoms. the use of spiritual coping strategies has been associated with improved coping and mental health outcomes among bereaved parents. objectives: to better understand how bereaved parents' experiences with spirituality throughout bereavement effects objective measures of grief, depression, and meaning-making. design/method: thirty participants whose children died of progressive cancer or related complications one to three years prior to participation completed an in-depth semi-structured telephone interview about their experiences with grief. participants were prompted to describe the impact of their spirituality on their bereavement processes. additionally, participants completed surveys related to grief (prolonged grief disorder questionnaire, pg- ), depression (beck depression inventory, bdi), and meaning-making (integration of stressful life experiences scale, isles). results were analyzed using a mixed methods approach including semantic content analysis of qualitative content and kruskal-wallis h test and post-hoc analyses of quantitative data. results: correlation analyses demonstrated significant differences between participants with positive and negative spiritual experiences of bereavement. participants with negative experiences of bereavement had a statistically significant increase in scores on the pg- compared to those with positive spiritual experiences signifying greater symptoms of prolonged grief. participants with negative spiritual experiences with grief had significantly lower scores on the isles, suggesting a lesser degree of adaptive integration of their losses. there were no significant differences in depression scores between groups. conclusion: bereaved parents that have a negative spiritual experience of bereavement are at increased risk for prolonged grief symptoms and are less likely to find meaning in their children's deaths than bereaved parents that describe a positive spiritual experience of bereavement. providers should consider exploration of spiritual beliefs and provision of spiritual care for parents of children facing life-limiting illnesses during treatment and bereavement. background: langerhans cell histiocytosis (lch) is an inflammatory myeloid neoplasia characterized by frequent relapse, with treatment failure associated with higher risk of death and neurodegenerative disease (lch-nd). activating somatic mutations in mapk pathway genes have been identified in almost all cases, with braf-v e in approximately % of lesions. targeted therapies have been successful in treating other refractory cancers with braf v e mutations (such as melanoma). given the central role of mapk pathway activation in lch, mapk pathway inhibition may be an effective therapeutic strategy for children with lch. objectives: the purpose of this study was to report the efficacy and toxicity profile of a retrospective cohort of patients with lch treated with mapk pathway inhibitors. design/method: medical records from pediatric patients with lch (systemic and/or lch-associated neurodegeneration) who were treated with a mapk pathway inhibitor were retrospectively reviewed from five institutions. all patients had failed at least one prior systemic therapy and had a proven mapk pathway mutation. results: all patients in this series were less than years old (median = . years; range: - years) with a median of three prior treatments (range: - ). at the time of initial mapk inhibitor use, nine of the patients had lch-nd diagnosed clinically and/or by radiographic imaging; the remaining three patients had systemic disease. patients were treated for a median of months (range: - months) with various reasons for discontinuation. three patients received combination mapk inhibitor therapies and three patients received other concurrent lch-directed therapies. four of the twelve patients had a grade or toxicity reported and three of these patients required dose reduction in order to be able to successfully resume therapy. overall survival was % with median month follow-up (range: - months) with only one patient achieving transient complete response. the remaining ten patients had partial response or stable disease and four of these patients developed progressive disease while on therapy. conclusion: mapk pathway inhibitors may be a relatively safe salvage therapy for refractory systemic lch and lch-nd but the efficacy and durability of this strategy remains to be defined. combination with cytotoxic chemotherapies may be required in order to eradicate the disease-causing cell. future prospective trials of mapk pathway inhibitors for patients with refractory lch are needed in order to directly compare their efficacy and toxicity relative to other current salvage strategies. cincinnati children's hospital medical center, cincinnati, ohio, united states background: medication adherence during maintenance therapy has been shown to have a direct relationship with disease relapse in pediatric leukemia. previous research determined that patients who are ≤ % adherent to mercaptopurine ( mp) have a greater risk for relapse. the primary aim of the present study is to examine the relationship between metabolite profiles of mp with behavioral adherence rates obtained via electronic monitoring at , , and days. it is hypothesized that patients demonstrating low levels of thioguanine (tgn) and methylated mercaptopurine (mmp) will have lower behavioral adherence rates prior to the blood draw. design/method: in a multisite, prospective study of patients ages - years diagnosed with acute lymphoblastic leukemia (all) or lymphoblastic lymphoma (lbl), mp adherence was measured across months of maintenance therapy using behavioral adherence (electronic monitoring) and pharmacological (metabolites) measures of mp. mp is metabolized into mmp and tgn. cluster analysis was used to generate three mutually-exclusive profiles of mp adherence. behavioral adherence rates were calculated for , , and days prior to the blood draw. results: this study identified three metabolite profiles of mp across months. previous research indicated that low levels of both metabolites suggest nonadherence to medication. low levels of one metabolite with high levels of another metabolite indicate adherence to mp. in this study, . % of the low tgn-low mmp group had -day behavioral adherence rates ≥ % (mean = %); . % had adherence rates < % (mean = . %). in the high tgn-low mmp group, . % had a mean -day adherence of %; . % had adherence rates < % (mean = . %). the low tgn-high mmp group had % of patients with a mean -day adherence level of %; % had adherence rates < % (m = . %). at and -days, to % of patients in the low tgn-low mmp group had adherence rates < %. conclusion: these findings suggest that electronic monitoring and metabolite concentrations can be used to monitor mp medication adherence during maintenance therapy. it is notable that there is a sub-sample of pediatric patients who are identified as being nonadherent to mp based on electronic monitoring, however, metabolite levels indicate adherence to mp. similarly, a sub-sample of patients were identified as being adherent based on electronic monitoring, but metabolite profiles indicated sub-therapeutic levels of mp. our findings underscore the clinical significance of using both objective measures of medication adherence to inform clinical decision making. cincinnati children's hospital medical center, cincinnati, ohio, united states background: hemophagocytic lymphohistiocytosis (hlh) is a life-threatening hyperinflammatory syndrome characterized by non-remitting fevers, rash, hepatosplenomegaly, cytopenias, liver dysfunction and coagulopathy, and can include central nervous system involvement. several genetic diseases cause hlh by impairing normal lymphocyte or macrophage function. the hlh panel at the cincinnati children's genetics laboratories includes genes associated with hlh and other lymphoproliferative diseases, including the genes that cause primary hlh (prf , unc d, stxbp , stx , rab a), x-linked lymphoproliferative diseases (sh d a, xiap), itk deficiency (itk), hermansky-pudlak syndrome types and (ap b and bloc s ), chediak-higashi syndrome (lyst), cd deficiency (cd ), xmen syndrome (magt ) and lysinuric protein intolerance (slc a ). deletion/duplication analysis is available as a reflex test for all genes, as copy number variations (cnvs) are not directly assessed by sequencing. objectives: the prevalence of cnvs among large groups of patients with hlh in north america is unknown. we assessed the frequency of cnvs in the genes on the hlh panel through a retrospective review of orders for deletion/duplication analysis performed after next-generation or sanger sequencing: orders for all genes on the panel, and orders of - genes from the panel. deletion/duplication analysis was performed on a custom × k microarray annotated against ncbi build (ucsc hg , march ). deletion/duplication analysis resulted in a confirmatory diagnosis in of cases ( . %). pathogenic or likely pathogenic cnvs were most common in the three x-linked genes: sh d a ( deletions), xiap ( deletions, duplication), and magt ( deletions). hemizygous deletions in xlinked genes in male patients were typically suspected after amplification failure during previous sequencing. of the autosomal recessive genes, pathogenic cnvs were observed once in each of three genes: rab a (heterozygous), lyst (heterozygous), and stxbp (homozygous). in the two heterozygous cases, a second change was not identified by sequencing, so deletion/duplication analysis did not offer a confirmatory diagnosis. in patients, deletion/duplication analysis was performed after a pathogenic or likely pathogenic variant was identified in an autosomal recessive gene during sequencing; however, in no case was a second mutation uncovered by cnv analysis. we recommend that deletion/duplication analysis be routinely performed in all male patients with hlh who lack a genetic diagnosis after sequencing of hlh-associated genes, especially if any regions failed to amplify. deletion/duplication analysis may be performed in female patients after sequencing if a genetic form of hlh is highly suspected, but the yield is expected to be low. cleveland clinic children's hospital, cleveland, ohio, united states background: the development of post-transplant neoplasia, typically from lymphoproliferative disease (ptld), is a severe complication in transplant recipients and affects approximately % of pediatric solid organ recipients. rates of lymphoma in adult heart transplantation patients are comparatively low, at less two percent at ten years. there are few published reports of the long-term outcomes of neoplasia after pediatric heart transplantation. we aimed to identify the subsequent malignancies that occurred in pediatric heart transplantation patients in a large single institution, and describe their treatment and subsequent clinical course. we performed a retrospective chart review of all pediatric heart transplant recipients followed at the cleveland clinic children's hospital from january to october . we excluded patients who died within days of heart transplantation. we reviewed in depth the history and clinical course of subjects who developed neoplasms. results: between and , patients underwent heart transplantation and survived at least days post transplantation. nine patients ( . %) developed a subsequent malignancy. in this case series, the median age at heart transplant was years old and the median time to develop neoplasia was . months. primary neoplasia included monomorphic ptld ( ), polymorphic ptld ( ), burkitt lymphoma ( ), hodgkin's lymphoma ( ), plasmacytoma-like lymphoma ( ) and epstein-barr virus-associated smooth muscle tumor (ebv-smt) ( ). one patient with hodgkin lymphoma subsequently developed monomorphic ptld, one patient with polymorphic ptld subsequently developed ebv-smt and later, an undifferentiated gastric cancer. one patient with monomorphic ptld developed an ebv-smt. evidence of epstein-barr virus was present in six of nine patients at diagnosis of first malignancy. four of nine patients received reduction in immunosuppression as a primary intervention for the initial malignancy, with two complete responses (cr), one partial response, and one with progressive disease. five patients were treated with chemotherapy, with four cr and one with progressive disease. three patients died of malignancy (recurrent ebv-smt, undifferentiated gastric cancer, and monomorphic ptld post-hodgkin disease) and two patients died of other transplant related complications. conclusion: secondary malignancies represent a significant disease burden to survivors of cardiac transplantation. as expected, much of the malignancy burden is driven by ebv. despite aggressive histology, many malignancies can be successfully cured in this setting with a multidisciplinary approach. stanford university school of medicine, palo alto, california, united states background: current treatment of langerhans cell histiocytosis (lch) is based on extent of organ system involvement and if high risk systems are affected. gastrointestinal (gi) involvement is diagnosed in about % of lch patients, and classically presents in children under years of age with malabsorption, failure to thrive, bloody diarrhea and anemia. although the gi system is considered standard risk, a mortality rate over % occurring within years of diagnosis has been reported. this study was performed due to this discrepancy and the limited number of published cases. objectives: to review the clinical course and outcomes of patients diagnosed with gi lch. design/method: a retrospective chart review of patients with histologically confirmed gi lch diagnosed in the last years identified from the bass center histiocytosis clinical database was performed. two other pediatric hematology/oncology centers (ucsf benioff children's hospital oakland and san francisco) were queried for additional cases. results: four patients with biopsy proven gi lch [ subjects ( . %) from database records and l from center queries] were identified. failure to thrive, hypoalbuminemia, bloody diarrhea and rash were the most common presenting symptoms. lch of the skin was found in all patients. risk organ systems were involved in patients. of note, subjects were of african racial background. the median age at diagnosis was . months ( . months to years), mean albumin . g/dl ( . - . g/dl), mean esr of mm/hr ( - mm/hr). all patients initially received combination therapy per lchiii protocol (vinblastine, prednisone, and mercaptopurine). two patients had recurrent disease and received second line therapy (cytarabine, cda, and local radiation therapy). all patients are alive without active disease at last follow-up ( to months after completion of therapy). a systematic approach to evaluate gi involvement should be performed in children diagnosed with lch. from our experience, combination chemotherapy for patients with lch involving the gi tract is an effective intervention for active disease. cincinnati children's hospital medical center, cincinnati, ohio, united states background: bhatia indicated that rates of mp adherence ≥ % have better clinical outcomes. those with adherence rates ≤ % have an increased risk for disease relapse. the present study investigated patterns of mp medication adherence using group-based trajectory modeling in a large sample of pediatric patients. to describe patterns of behavioral adherence during the maintenance phase of therapy for a cohort of pediatric patients ages - years who were diagnosed with acute lymphoblastic leukemia or lymphoblastic lymphoma (n = ). previous research has documented the relationship between optimal levels of medication adherence with positive health outcomes. it was hypothesized that three groups would be identified: optimal adherence, deteriorating adherence, and chronic nonadherence. it was hypothesized that patients in the optimal adherence group would have adherence rates ≥ %. those with poor adherence would have adherence rates ≤ %. design/method: the present study was a longitudinal, multisite study investigating adherence to -mercaptopurine in a pediatric cohort of patients using electronic monitoring devices. daily adherence rates (electronic monitoring of mp) were examined across -months. health outcomes were measured at quarterly intervals through medical chart reviews. results: unconditional growth curve modeling indicated that the mean percentage of behavioral adherence was . % at baseline and declined to . % at -months. three trajectories of mp behavioral adherence were identified: ) optimal adherence ( % of patients): averaging % behavioral adherence across months; ) moderate adherence ( %): relatively stable nonadherence with rates of % across months; and, ) chronically nonadherent ( %): adherence decreased from % to %. with respect to patterns of medication adherence and relationship to clinically-relevant health outcomes, there were no significant differences in health outcomes between patients in the adherent versus nonadherent trajectories, including mean absolute neutrophil counts (anc), risk for infection as measured by anc, healthcare utilization, or risk for disease relapse. although longitudinal patterns of mp behavioral adherence were not related to health outcomes, it is notable that only % of the current sample had adherence rates ≥ %. in fact, % of the current sample demonstrated adherence rates ≤ %. our findings are important for development of future adherence promotion studies in pediatric cancer. our findings underscore the relative significance of tailoring adherence promotion interventions to subgroups of patients, including those with problematic patterns of adherence. patients who demonstrate adequate levels of adherence could still benefit from less intensive, preventative interventions to sustain and improve adherence. sophie gatineau-sailliant, pascale grimard, marie-claude miron, guy grimard, anne-sophie carret, jean-marie leclerc chu sainte-justine, montreal, quebec, canada background: vertebral involvement in langerhans cell histiocytosis (lch) is still a subject of interest, due to its low frequency and the absence of management's guidelines. objectives: to provide additional information on presentation, treatment and morbidity of pediatric lch vertebral lesions, we report cases of children with vertebral lesion of biopsy-proven lch, between january st and december st , at sainte-justine university health center (montreal, quebec, canada). we conducted a retrospective study by reviewing charts and imaging of vertebral lch in a population of children (median age of . years at lch diagnosis), followed for a median duration of months. symptoms at presentation, treatment modalities and morbidities were collected. results: vertebral lesions were present at lch diagnosis in of cases. they were usually diagnosed secondary to back pain in of cases and were asymptomatic in only one case. despite an epidural extension in of cases, no child developed neurological symptoms. lesions frequently involved vertebral body ( of cases) and were rarely unstable ( of cases). out of vertebral lesions, most of them had a dorsal localization ( of lesions) and of patients had lch in multiple vertebrae. at diagnosis, median vertebral height loss was . % compared to % at last imaging control. most used imaging modalities were pet-scan and plain x-rays. treatments were diverse and consisted in chemotherapy in all children but three and bisphosphonates in only cases. radiation therapy was not used in any patient. six out patients did benefit of an orthosis. a lch recurrence was observed in patients and involved vertebrae in cases. one patient with treatment-resistant lch disease had relapses, and required multiple lines of treatment. all children were alive and disease-free at their last follow-up, patients having radiological vertebral sequelae and only had clinical sequelae. our study is consistent with the epidemiological data described in larger cohorts of children with vertebral lesions of lch and the favorable prognosis associated with such lesions. nevertheless, aggressive treatment and long term follow-up seemed to be essential as recurrences are s of s not rare and spontaneous bone regeneration often incomplete. plain x-rays appears to be a good follow-up tool for vertebral lesions as it allows reliable measures, less exposure to radiation at lower cost. national cancer institue, giza, giza, egypt background: acute lymphoblastic leukemia (all) is the most common type of childhood cancer and also the most complicated in the treatment, so it requires many interventions for both treatment and to alleviate suffer form side effects. pancreatitis is one of the toxicities, which is more common in all as it appears in about % of the patients. it occurs in many drug combinations which induce pre-pancreatitis and even direct destruction of pancreatic tissues. pancreatitis can be induced by many drugs used in the treatment such as chemotherapeutic agents or supportive treatment. lasparaginase is the backbone drug of the treatment of all in which to doses are required to achieve complete remission status in the induction phase of treatment and to doses in the maintenance phase.it is an enzyme that destructs the l-asparagine amino acid into aspartic acid and ammonia thus deplete the asparagine from the extracellular matrix . many drugs are investigated for their effect on treatment of induced pancreatitis such as interleukin- , nsaid as antiinflammatory, glycerin tri nitrates as improvement of microcirculation, tnf-alpha antibody, paf inhibitor as specific anti-inflammatory and low molecular weight heparin .none of the drugs was investigated for their ability to prevent the occurrence of pancreatitis. objectives: this study was designed to evaluate the protective effect of enoxaparin and diclofenac against l-asparaginase induced pancreatitis design/method: acute pancreatitis was induced in rats by intra-muscular injection of l-asparaginase ( i.u/kg) given daily for five days. enoxaparin was given subcutaneous ( i.u/kg) and diclofenac was given intra-peritoneal ( mg/kg) daily for five days. then, markers of pancreatic injury, lipids, immune cell infiltration and oxidative stress were analyzed with histo-pathological examination of the pancreatic tissue results: during acute pancreatitis, oxidative stress markers were significantly changed as indicated by reduced tis-sue glutathione and increased malondialdehyde levels. this was accompanied with significant increase in immune cells infiltration as indicated by high levels of myeloperoxidase and pro-inflammatory cytokine tnf-alpha. triglyceride only showed increase level. treatment with enoxaparin and/or diclofenac restored levels of biochemical markers including serum alpha-amylase, reduced glutathione, malondialdehyde, pro-inflammatory cytokine tnf-alpha, myeloperoxidase and triglyceride. histological injuries of pancreatic tissues as vacuolation and necrosis of epithelial lining pancreatic acini, inflammatory cells infiltration and focal pancreatic hemorrhage were also reduced by treatment with enoxaparin and/or diclofenac. the present study emphasizes the potential protective effect of enoxaparin and diclofenac against l-asparaginase induced pancreatitis background: rosai dorfman disease (rdd), or sinus histiocytosis with massive lymphadenopathy (shml), is a rare condition of immune dysregulation of unknown etiology arising from the massive accumulation of non-langerhans type histiocytic cells inside lymph nodes. the disease classically presents as bulky, painless lymphadenopathy often associated with infection showing distension of lymph node sinuses by abundant histiocytic cells (cd a(-), s- (+)/cd (+)). in some cases, the disease can be self-limiting, but in cases with a prolonged chronic course of exacerbations and remissions, those with extranodal involvement, or disease that threatens vitals structures, treatment may be necessary. there is no treatment consensus. to describe a case of life-threatening, unresectable, recurrent rdd successfully treated with langerhans cell histiocytosis (lch) -inspired therapy. design/method: we compared this case to the current literature on chemotherapeutic treatments for rdd. we searched pubmed, ovid, and google scholar for similar cases. we believe this to be the first reported case of using lch therapy to successfully treat rdd. an -year-old male presented to an outside hospital with two years of massive neck swelling causing torticollis. biopsy confirmed rdd. he was intermittently treated with courses of antibiotics with partial response. surgical removal of the affected lymph nodes was unsuccessful due to proximity to the spinal cord. two years later, the patient presented to our institution. he was initially treated with prednisone with a fast tapering dose, but after a second relapse the decision was made to try chemotherapy following the lch- protocol of weekly vinblastine ( mg/m ), -mp ( mg/m ), and high dose steroid bursts. he experienced two additional relapses off therapy at ages and years old, including cmv(+) associated septic shock and cytokine storm requiring rapid response, picu admission, and ionotropic support. this last episode was treated with a more prolonged induction and maintenance therapy. an extended and slowly tapered maintenance therapy regimen of . years of daily -mp, monthly vinblastine and steroids with a slowly tapered dose during his fourth remission has resulted in -months of continuous complete remission-the longest stretch of his life. no similar cases were found. literature search demonstrated no consensus regarding the most effective treatment of rdd, with no previous cases being successfully treated following lch chemotherapy protocols. we hypothesize that the multi-agent relatively mild lch- therapy mitigates the immune dysregulation of rdd. this case suggests that lch- therapy can be used to treat cases of rdd that is not amendable to surgery or observation. nicklaus children's hospital, miami, florida, united states background: central venous catheters (cvc) are necessary in the management of patients with malignancies, especially children. patients with acute leukemia (al) have higher rates of central line associated complications such as bloodstream infections compared with other malignancies. objectives: to examine the choice of placement of cvc and the differences in outcome between peripherally inserted central catheters (picc) and ports in patients with leukemia during induction. design/method: retrospective chart review of patients with newly diagnosed leukemia at nicklaus children's hospital between and . results: ninety four patients with a new diagnosis of leukemia undergoing induction chemotherapy were identified. the average age was . years. overall, ( . %) patients had a port placed and ( . %) had a picc placed. the decision for picc or port was subjective and physician based. the main outcome measures were local inflammation/infection, bacteremia, thrombophlebitis, blocked catheter and premature removal. the most common complication was bacteremia ( . %). in a multiple logistic regression analysis for predicting whether patients had at least one complication, results showed that having at least one complication is . times the odds in patients with aml compared to patients with all (p = . ). when comparing picc vs. ports, patients with picc had more frequent episodes of blocked catheters ( . %) and premature removal ( . %) compared to the patients with ports ( . % and . %) (p = . and p = . respectively) during induction. local inflammation, bacteremia and thrombophlebitis were not statistically different (p = . , p = . and p = . respectively). the most common place for port placement was the right subclavian vein ( %). there was no significant association between port location and having at least one complication (p = . ). acute lymphocytic leukemia subgroup analysis: fourteen patients ( %) in the picc group had at least one complication and ( %) in the port group but that was not statistically significant (p = . ). our series showed a higher incidence of blocked catheters and premature removals with picc compared to ports in patients with leukemia during induction. the choice of placement of picc vs port was subjective and physician based. patients with all, despite receiving steroids and asparaginase during induction, did not show a statistically significant increase risk in thrombosis or infection but larger numbers may be needed in future studies. university of california, san francisco, san francisco, california, united states background: hemophagocytic lymphohistiocytosis (hlh) is classically a disorder of young children meeting systemic hyperinflammation criteria. presentation in late adolescence is uncommon. furthermore, though cns signs occur in - % of cases, initial isolated neurologic presentation is rare, frequently resembling encephalitis or demyelinating disorders. these cns signs can be isolated or precede systemic disease, delaying hlh diagnosis. hlh declaring in adolescence with predominant psychiatric features has not been well documented. objectives: to describe a case of cns hlh presenting with neuropsychiatric features in absence of classic hlh criteria. design/method: retrospective review of clinical, radiologic, histologic, immunophenotypic, and molecular features of a patient with cns hlh. a -year-old female presented with acute-onset headaches following nine months of progressive anxiety, short-term memory loss, emotional lability, perceptual disturbances, and hypomania. brain mri demonstrated numerous enhancing t hyperintense supratentorial and infratentorial white matter lesions in the left thalamus and caudate head. brain biopsy showed histiocyte-rich inflammation and associated demyelination. extensive evaluation including universal microbial pcr failed to reveal underlying infection or malignancy. past medical history was notable for presumptive pulmonary sarcoidosis diagnosed months prior with progressive respiratory failure with associated granulomatous pulmonary nodules which responded to systemic immunosuppression. at presentation of her neuropsychiatric symptoms, she had normal sil- r, ferritin, fibrinogen, and triglycerides. there was no pancytopenia, coagulopathy, bone marrow hemophagocytosis, fevers, or splenomegaly. given the possibility of partial immune suppression of systemic symptoms and the prominent neurologic symptoms, hlh screening labs were sent and notable for decreased natural killer and cytotoxic t lymphocyte function, normal granzyme expression and cd a mobilization, and absent perforin expression. genetic testing confirmed compound heterozygous mutations in prf (c. g>a, c. a>c) and familial hlh type . she was treated with low-dose dexamethasone and intrathecal chemotherapy per hlh- . due to lack of evidence of systemic inflammation, vp- and high-dose steroids were held. within one week of initiating therapy, she had decreased anxiety and improved cognition, with sustained, incremental neuropsychiatric improvement with additional intrathecal treatments. she tolerated dexamethasone tapering without symptom flare. mri also demonstrated parenchymal lesion improvement. for definitive treatment, she underwent unrelated allogeneic hematopoietic cell transplantation and remains at neurologic baseline as of eight months post-transplant with ongoing imaging improvement. conclusion: this case of familial hlh with compound heterozygous perforin mutations in an adolescent with isolated neuropsychiatric symptoms illustrates that cns hlh may be an underrecognized phenomenon in absence of systemic signs. standard hlh therapy may effectively reverse these symptoms with associated radiologic responses. rush university children's hospital, chicago, illinois, united states background: posterior reversible encephalopathy syndrome (pres), a recognized complication of pediatric leukemia treatment has been reported in up to % patients in various series. hypertension, chemotherapy and cortical spreading depression have been implicated in the pathophysiology. due to the combinations used, it is difficult to identify the offending drug, several have been implicated. since delay of chemotherapeutic treatment in children with high risk leukemia is unfavorable, it is important to recognize the characteristic radiologic findings, manage appropriately and reintroduce the treatment as soon as possible. pharmacoethnicity is now recognized as an important factor for variation in neurotoxicity in children with all. ethnic differences in reported pres events in pediatric patients with all has not been well described in literature. to describe the factors associated with pres in a cohort of high risk pediatric all patients at a single institution. design/method: a total of children with an average age of years ( - years) diagnosed with all between - were retrospectively reviewed for the occurrence of pres. various demographic factors, therapy received, clinical features, radiology related findings and management were reviewed. a search for all published articles on pres in leukemia was conducted using pubmed databases. results: five ( %) children (average age . years) developed pres during days - of induction. % of the patients that developed and % of those that did not develop pres were hispanic. all the patients that developed pres and % of those that did not were diagnosed with high risk all. all patients received vincristine, % received daunomycin and intrathecal methotrexate and % received asparaginase in the week prior to the event. mri findings confirmed pres in all patients with no evidence of methotrexate related leukoencephalopathy or leukemia. at the time of pres all patients were in remission based on mrd and spinal fluid cytology. two-thirds of the patients had seizures and hypertension at the time of the event with no prior history of either. all patients had complete recovery of normal mental status after resolution of pres. a higher incidence of pres than previously reported was noted in our series. hispanic ethnicity, high-risk all and exposure to vincristine, daunomycin and intrathecal methotrexate in induction were associated with pres in our cohort. a new association that emerged was that of hispanic ethnicity with pres .larger studies to understand the importance of pharmacoethnicity in pres may help in individualization of chemotherapy based on ethnic differences. children's hospital of illinois, peoria, illinois, united states background: hyper ige syndrome is a primary immunodeficiency characterized by susceptibility to skin and lung infections as well as increased propensity for malignancy. hemophagocytic lymphohistiocytosis (hlh) is a syndrome characterized by overwhelming activation of t lymphocytes and macrophages occurring as either primary hlh caused by genetic abnormalities or secondary hlh associated with infectious, malignant, metabolic, or immunodeficiency causes. we describe the first case to our knowledge of hlh in a patient with hyper ige syndrome. to describe a case of hlh in a pediatric patient with hyper ige syndrome. results: a -year old caucasian male with known autosomal dominant hyper ige syndrome (stat mutation) was transferred to the pediatric intensive care unit secondary to concern for septic shock. the patient had persistent slow bleeding from oral lesions and central catheter sites despite the addition of aminocaproic acid and recombinant factor viia. he also required numerous blood product transfusions sec-ondary to anemia and thrombocytopenia. clinical suspicion was high for hlh and the patient met criteria for diagnosis of hlh with the following: ferritin > , ng/ml, triglycerides mg/dl, decreased nk cell function with the sample only containing % nk cells, elevated soluble il- receptor at u/ml, splenomegaly, and fever. infectious workup was remarkable for a positive ebv qpcr with , copies/ml suggestive of ebv driven secondary hlh. familial hlh testing was unable to be completed. therapy was initiated based upon the hlh- study. the addition of ruxolitinib and anakinra were considered but the patient declined rapidly prior to treatment. ct of the head was concerning for a stroke with signs of edema and increased intracranial pressure likely leading to the development of symptoms consistent with brain stem herniation. the decision was then made to withdraw care. conclusion: to our knowledge, this is the first report of hlh in a patient with hyper ige syndrome. diagnosing hlh requires a high index of suspicion in critically ill patients, and prompt initiation of therapy is essential. this challenging case of hlh in a patient with hyper ige syndrome highlights the diagnostic challenge, variable presentation, and need for effective therapy in this vulnerable patient population. background: adolescents and young adults (ayas) with cancer are at risk for psycho-social as well as physical symptom burden during cancer therapy. the purpose of this study is to explore psychological and physical symptoms endorsed by aya while receiving therapy for cancer design/method: surveys were given in both inpatient and outpatient settings during cancer therapy. symptom screening in pediatrics tool (sspedi) and memorial symptom assessment scale (msas). symptoms severity was rated by teens on a point likert scale. spss , used for statistical analysis. results: : a total of aya on cancer therapy (age range - . years) % female, % male, . % acute leukemia, . % solid tumors, and . % diagnosis was not reported. % of aya on cancer therapy reported at least or more symptoms, % reported > symptoms cluster. of the physical symptoms that were reported as most distressing to the teens, mouth sores and headaches were the top causes. of the physical symptoms that were most frequently endorsed; fatigue was on the top ( %), followed by change in appetite %, vomiting %, and pain %., the least was bowel habit changes. aya rated sadness as the most frequent psychological symptom %, followed by feeling angry %, and scared %. statistically significant difference was noticed based on gender difference with more females reported symptoms (p = . ), while type of cancer (acute leukemia versus solid tumors) was not statistically different. conclusion: aya with cancer reported multiple physical and psychological symptoms with significant distress. females seem to report more symptoms compared to males. screening aya for cancer therapy related symptoms is feasible during routine visits and adds important information about the aya well-being. background: sinus histiocytosis with massive lymphadenopathy (shml), also known as rosai-dorfman disease, is a rare histiocytic proliferative disorder of unknown etiology. many treatment modalities have been employed; however, no uniform guidelines exist. objectives: literature review of treatment options for shml. design/method: chart review was performed on pediatric patients diagnosed with shml at the children's hospital at montefiore between and after irb approval. inclusion criteria included children between the ages of and years with shml. exclusion criteria included children with cutaneous shml. four cases of shml seen at montefiore are described. a comprehensive review of the literature identified additional cases published between and . manuscripts that did not include the treatment modality or outcome were excluded. results: many of the patients with shml responded to observation alone. of patients, patients were observed, with ( %) having resolution of disease, five having stable disease, and five being lost to follow-up. one patient received subsequent systemic therapy. surgical management was con-ducted upfront in patients. of those, ( %) had resolution of disease, one had stable disease, and one had recurrence with no further therapy noted. of the remaining nine patients, % were successfully treated with systemic therapy, consisting of either steroids ( ) or steroids and chemotherapy ( ). systemic therapy was used as first-line therapy in patients. steroids alone or in conjunction with chemotherapy resulted in resolution of disease in / and / patients ( / , %), respectively, with four patients having stable and three with progressive disease. chemotherapy without steroids resulted in resolution of or stable disease in / patients. radiation was ineffective. conclusion: shml is a rare disease with no published guidelines for treatment. from the results of the cases and a detailed review of the literature, it can be suggested that observation may be considered as first line management in patients providing there are no significant symptoms. for patients who are symptomatic or have significant progression, surgery may be considered. in patients with recurrence or refractory disease, steroids and/or chemotherapy may be used. the presence of nodal or extra-nodal disease did not seem to have a significant impact on the course of treatment. given the rarity of the disease, it is difficult to conduct a randomized control trial. further work, involving collaboration between centers and cooperation with the international rare histiocytic disorders registry would be helpful. boston children's hospital, boston, massechusettes, united states background: increasing census and intensified work compression on the inpatient oncology service at our institution was identified as leading to resident dissatisfaction, impaired resident learning and decreased perceived quality of patient care. objectives: to evaluate the impact of a redesign of a pediatric inpatient hematologic malignancy (ihm) service on resident perceptions of the educational value of the rotation and safety of patient care. design/method: during the - academic year, we initiated a bundled intervention on the ihm service. modifications included ) decreased patient volume: the ihm service was divided into two teams, utilizing an extra attending -a teaching service consisting of residents and fellows and a team comprised of nurse practitioners. ) intentional patient team assignment: patients were deliberately assigned to a care team based on educational opportunities and provider skill sets. ) intentional attending faculty selection: attending faculty with deeper clinical and teaching experience were selected to supervise on the teaching team. ) increased weekend staffing. after completing the service, junior residents completed an electronic survey to evaluate their perceptions of the educational value of the rotation, as well as their ability to deliver safe care while on the rotation. fisher's exact tests were used to compare responses from residents in who experienced the redesign to residents in , whose experience results: survey completion rates were % ( / ) in and % ( / ) in . intervention residents were significantly more likely than comparison group residents to choose the answers "very good" or "excellent" to describe both the overall quality of the rotation ( % intervention vs. % comparison, p< . ) and the educational experience on rounds ( % intervention vs. % comparison, p< . ). intervention residents also reported caring for fewer average primary patients daily on weekdays as compared to comparison residents ( . vs . patients, p< . , % ci - . to - . ). furthermore, intervention residents were more likely than comparison residents to "agree" or "strongly agree" that they could provide safe patient care on weekend days ( % intervention vs. % comparison, p< . ) and on nights ( % intervention vs. % comparison, p< . ) while on the oncology service. a redesign initiative of an oncology service with the development of a new teaching service led to improved resident perceptions of the educational value of the rotation and ability to provide safe care to patients. this approach could be useful to other services and institutions to promote similar outcomes in resident education and patient care. background: alk-positive histiocytosis is a rare histiocytic proliferative disorder that has been reported in three infants presenting primarily with hepatosplenomegaly, anemia, and thrombocytopenia. given the rarity of this disease, there are no standard treatment algorithms for this diagnosis and the disease course and outcomes remain largely unknown. the published series describes treatment ranging from monitoring alone to multi-drug chemotherapy regimens. there was ulti-mately resolution of presenting symptoms in all three cases despite varying treatment strategies. objectives: to report a newly diagnosed case of alkpositive histiocytosis that was treated with a novel approach using cytarabine monotherapy. results: a full term male infant presented at birth with difficulty feeding and hyperbilirubinemia. over the first few weeks of his life, he subsequently developed thrombocytopenia, transaminitis, and profound hypoalbuminemia. by six weeks of life, he was experiencing significant abdominal ascites requiring repeat paracenteses, massive hepatosplenomegaly, respiratory distress secondary to abdominal distension, anemia, and coagulopathy. he underwent numerous diagnostic tests, including a liver biopsy followed by a bone marrow biopsy that showed alk-positive histiocytic infiltrates in both sites. treatment was initiated with cytarabine mg/kg/day x days, repeating every weeks. throughout his course of five cycles of treatment, he experienced intermittent fevers and mild nausea with no other adverse events. by the end of five cycles, his hepatosplenomegaly resolved, his blood counts normalized, he demonstrated weight gain on oral feeds, and his liver enzymes normalized. he is currently months post completion of therapy and remains well with a normal physical exam and laboratory values. conclusion: treatment of alk-positive histiocytosis with lose dose cytarabine resulted in complete resolution of our patient's symptoms with minimal treatment related adverse effects, and few long-term treatment related risks. given the rarity of the diagnosis, the reporting of effective novel treatment options is important for future patient care. background: adult patients with melanoma or lung cancer harboring braf v e have benefitted from the development and subsequent approval of specific braf inhibitors. as such, delineating the subset of similarly targetable pediatric oncology patients may spur development and rational use of these inhibitors in children. importantly, other point mutations and fusions of braf may also be targetable in s of s children analogous to recent emerging data in adult cancer patients. objectives: to define the genomic landscape of known and novel braf alterations and raf fusions in pediatric malignancies and report index cases with clinical response to braf or mek inhibitors. design/method: dna was extracted from microns of ffpe sections of , tumors from pediatric (< years of age) oncology patients, and cgp was performed on hybridization-captured, adaptor ligation based libraries to a mean coverage depth of x for up to cancer-related genes plus introns from genes frequently rearranged in cancer. genomic alterations (ga) included base substitutions, indels, copy number alterations and fusions/rearrangements. a total of ( . %) braf-altered pediatric malignancies were identified. ( . %) harbored a single kinaseactivating braf short variant, indel, or fusion. an alteration resulting in reduced braf kinase activity was identified in ( . %) tumors while ( . %) tumors harbored multiple braf alterations, of which contained at least a single activating short variant. the remaining tumors ( . %) contained functionally uncharacterized variants. kinaseactivating braf alterations were identified in diverse tumor spectra comprised of brain tumors ( . %; subtypes), carcinomas ( . %; subtypes, with melanoma constituting % of cases), hematological malignancies ( . %; subtypes), sarcomas ( . %; subtypes), and extracranial embryonal tumors ( . %; subtypes). seventy-two ( . % of braf-altered cases) braf fusions were identified, ( . %) of which were kiaa -braf; involved the novel fusion partners: stard nl and khdrbs . seven ( . %) raf fusionpositive cases, predominantly brain tumors ( ), were identified; involved the novel fusion partners: tmf and sox . index cases of response to therapy of intracranial tumors will be presented. we describe a population of pediatric patients with targetable braf alterations predominantly enriched in primary intracranial tumors, but spanning diverse solid tumor types and hematologic malignancies. we additionally report a cohort of raf fusion-positive patients. an index case and multiple previous reports suggest raf or mek inhibitors may benefit pediatric patients with either intracranial or extracranial disease, and development of such drugs in pediatric indications is strongly warranted. background: diffuse midline gliomas (dmg) with h k m mutation, including diffuse intrinsic pontine glioma (dipg), are the leading cause of brain tumor-related deaths in children. there are no effective therapeutic strategies and the median survival remains dismal. genomic studies have identified a recurrent mutation in the majority of dmgs involving a lysine to methionine substitution (k m) in histones . and . , resulting in changes in the epigenetic landscape that dysregulate gene expression and promote gliomagenesis. panobinostat, a multiple histone deacetylase (hdac) inhibitor, was found to be one of the most effective agents against dipg patient-derived cell cultures and xenograft models in previous studies and is presently in clinical trial for dipg. hdac inhibition with panobinostat may also exhibit activity against h k m+ diffuse midline gliomas of the thalamus and spinal cord. to evaluate the effect of panobinostat as a single agent against patient-derived thalamic and spinal cord h k m+ diffuse midline glioma cell cultures and in an orthotopic xenograft murine model of h k m+ spinal cord glioma. design/method: patient-derived thalamic and spinal cord h k m+ diffuse midline glioma cell cultures were treated with single agent panobinostat at a range of concentrations. cell viability was evaluated using the celltiter-glo assay. panobinostat was systemically administered to orthotopic xenograft murine models of luciferase-expressing spinal cord h k m+ diffuse midline glioma. response to panobinostat was evaluated with ivis in vivo imaging. results: hdac inhibition with panobinostat significantly decreases cell proliferation with an ic of nm and nm in the spinal cord and thalamic glioma patient-derived cell cultures respectively. panobinostat slowed tumor growth in murine models of spinal cord glioma by . -fold in the brain (p = . , n = ) and -fold in the spinal cord (p = . , n = ) when compared to vehicle controls after week of administration. panobinostat is in clinical trials for dipg. this study suggests that hdac inhibition with panobinostat may also be beneficial for patients with thalamic and spinal cord diffuse midline glioma h k m mutants. background: brain tumors are the most common solid tumor of childhood and the leading cause of childhood cancer deaths. while medulloblastoma is the most common malignant brain tumor of childhood with a -year survival - %, children with high-grade gliomas (hggs) such as glioblastoma multiforme (gbm) fare much worse with a -year survival of - %. implicated in this poor outcome is the presence of treatment resistant brain tumor stem-like cells. gbm stem-like cells (gscs) have been implicated in tumor growth, treatment resistance and patient relapse, making them a key therapeutic priority. antipsychotic drugs (apds) have been used for decades in various psychiatric clinical settings and are associated with a lower incidence of cancer, including malignant brain tumors. currently, atypical apds are being evaluated for their potential to alleviate cancer and treatment induced side effects. furthermore these drugs may have direct anti-tumor effects, potentially via inhibition of dopamine d receptors (drd ). objectives: determine the anti-cancer effects of atypical apds on gbm stem-like cells design/method: the anti-cancer effects of apds (quetiapine and risperidone) were evaluated on gbm stem-like cell lines developed in our laboratory (glio and ) and the group medulloblastoma cell line hdmbo . cell proliferation/viability was determined using trypan blue exclusion and mts assays. the effect of apds on cancer stem cell self-renewal was determined by neurosphere assay. receptor expression and apds effect on cell cycle proteins were examined by western blot analysis. results: western blot analysis of gscs and hdmbo demonstrated robust drd expression indicating a viable therapeutic target. both apds induced dose dependent cell death of all cell lines tested. treatment with only um of either apd for days significantly reduced cell proliferation by % (hdmbo ) and - % (gscs). consistent with these findings, we observed an increase in cell cycle inhibitors p and p . furthermore at day both apds induced a robust increase in gsc death, approximately % compared to only % in non-treated controls. lastly, um apds significantly reduced gsc neurosphere formation compared to untreated controls by up to % suggesting inhibition of gbm stem cell self-renewal. our data indicates that clinically relevant concentrations (low micromolar) of these apds induce anticancer effects in both gscs, which are enriched with tumor initiation/propagation properties, and in the group (myc amplified) medulloblastoma cell line. these apds represent strong candidates as potential adjuvant therapies for the treatment of these brain tumors. background: while the poor prognosis for high risk neuroblastoma (hrnb) underscores the need for new treatment strategies, the elucidation of specific biologic subsets of neuroblastoma suggests a way to improve disease management. the identification of agents that target specific molecular pathways associated with the development or progression of diseases holds promise. dfmo, an inhibitor of odc, has been shown to decrease lin and mycn and target cancer stem cells in preclinical studies. currently % of patients undergoing immunotherapy relapse. dfmo is in studies to prevent relapse after immunotherapy and may be helpful during immunotherapy as well. the hypotheses for this study were that: ) the incorporation of a targeted therapy, selected based upon upfront tumor genomic interrogation, into standard induction chemotherapy for hrnb is safe, feasible and may increase the pr/cr/vgpr response rate at the end of induction therapy; and ) the addition of dfmo as maintenance during immunotherapy is safe and feasible and may decrease the relapse rate for hrnb. a multicenter feasibility pilot trial in subjects with newly diagnosed hrnb within the beat childhood cancer consortium. at diagnosis, patients' tumors underwent dna exome and rna sequencing which were analyzed within a molecular tumor board to identify the single best drug of targeted agents to be added to cycles - of induction chemotherapy. after consolidation with asct and radiation, the patients received dfmo along with standard dinutuximab and retinoic acid and dfmo for years after immunotherapy. patients were evaluated for additional toxicities with the addition of targeted agents and dfmo in addition to induction response. results: the pilot study of eligible patients has shown this process to be feasible. all patients have completed induction portions of the study. the combination of targeted agent with chemotherapy was shown to be safe without any unexpected toxicities. delays between induction cycles were < weeks and related to surgery, infection, or thrombocytopenia. the induction response demonstrated % cr/vgpr/pr rate, which suggests improvement over historical %. in addition, patients were eligible for the combination of dfmo with dinutuximab and retinoic acid was well tolerated and safe without additional toxicities due to dfmo. the pilot study of patients has shown the process of genomic sequencing and addition of a targeted agent to upfront chemotherapy and addition of dfmo to dinutuximab and retinoic acid maintenance therapy in newly diagnosed hrnb patients and is feasible and safe without any unexpected toxicities. background: identifying sub-populations of medulloblastoma tumors with stem cell-like properties holds promise for reducing disease recurrence, but there is no known unifying marker of medulloblastoma cancer stem cells. the granulocyte stimulating factor receptor (gcsf-r or cd ) is well understood in the context of hematopoiesis, but its role in solid tumor pathogenesis is less clear. neuroblastoma and melanoma subpopulations expressing gcsf-r have cancer stem cell properties of chemoresistance and increased tumorigenicity, and are enriched in tumors after chemotherapy. gcsf-r activation leads to signaling through the jak-stat pathway, suggesting a potential therapeutic target. we hypothesized that a subpopulation of medulloblastoma cells would express the gcsf-r and that this subpopulation would demonstrate chemoresistance and response to inhibitors of the jak/stat pathway. objectives: our objective was to identify a subpopulation of medulloblastoma cells expressing the gcsf-r and determine their relative growth rates, tumorigenicity, and responses to chemotherapy and jak/stat inhibition. design/method: medulloblastoma cell lines were sorted via flow cytometry for gcsf-r surface expression. subpopulations of gcsf-r-positive and -negative medulloblastoma cells were then monitored for growth by continuous live cell imaging. responses to chemotherapy were measured in subpopulations of gcsf-r-positive and -negative medulloblastoma cells using continuous live cell imaging to measure percent cell confluence and cell viability assays. ic values were calculated for each cell line and each agent. parental medulloblastoma cell lines and isolated gcsf-r-positive and -negative subpopulations were also treated with the jak / inhibitor ruxolitinib and growth rates, viability, and ic values were calculated. results: gcsf-r surface expression was identified on . - . % of medulloblastoma cell lines. isolated gcsf-r positive cells demonstrate a slower growth rate compared to gcsf-rnegative or parental unsorted medulloblastoma cells. gcsf-r positive cells are more resistant in vitro to vincristine, etoposide, and carboplatin, when compared to the gcsf-r negative population and an unsorted population of the same cell line. ruxolitinib is cytotoxic to medulloblastoma cells in vitro, with higher ic values noted in gcsf-r positive cells compared to unsorted and gcsf-r negative cells. we show that a subpopulation of gcsf-r positive cells are present in multiple medulloblastoma cell lines via flow cytometry, and that isolated gcsf-r-positive cells have a slower growth rate than gcsf-r-negative or unsorted populations. we also show that ruxolitinib has in vitro activity against medulloblastoma cell lines. we propose that jak inhibition may represent an adjunct therapy targeting overall tumor burden and specifically targeting the gcsf-r-positive subpopulation of medulloblastoma cells that may drive tumor recurrence. we investigated the efficacy of intensified adjuvant chemotherapy in osteosarcoma patients. design/method: we retrospectively analyzed the medical records of children with osteosarcoma treated at asan medical center between and . all patients received a -drug induction consisting of cycles of cisplatin and doxorubicin along with cycles of methotrexate (map), and proceeded to surgical resection. adjuvant ct was map or map with the additional ifosfamide and etoposide (mapie), and mapie was mainly considered for poor responders (tumor necrosis below %) or patients with metastases. results: among patients, patients had metastases at diagnosis. surgery was conducted in patients who responded to induction ct, and showed over % tumor necrosis. among patients who proceeded to adjuvant ct, and patients received to map and mapie protocols. with a median follow-up of months, the -year overall survival (os) and event-free survival (efs) rates of all patients were % and . %. of those patients, patients recurred, and of them died of disease progression. relapsed patients received salvage ct and/or surgery, and were rescued after autologous stem cell transplantation (sct). three patients developed treatment-related acute myeloid leukemia, and they are alive after allogeneic sct. according to the response to neoadjuvant ct, the os rates of good responders (n = ) and poor responders (n = ) were % and . % (p = . ), and efs rates were . % and . % (p = . ). of the poor responders, patients received map as adjuvant ct, and the other received mapie. the os rates of map and mapie group were . % and . % (p = . ), and efs rates were . % and . % (p = . ), respectively. when patients were classified into three groups: . localized disease & necrosis ≥ % (n = ), . localized disease & necrosis < % (n = ), . metastatic disease (n = ), survival rates were in the order of group > > (os = %: . %: . %, efs = . %: . %: %). in each group, intensified adjuvant ct by mapie did not improve survival outcomes. conclusion: initial metastatic disease and poor histological response to neoadjuvant ct were major risk factors for poor survival in osteosarcoma patients. we found that adding ifosfamide and etoposide to map did not improve survival outcomes of patients with adverse risk factors. more effective adjuvant therapy for these patients is needed. background: circulating cell-free dna (cfdna) that shed from tumors into circulation have been used for noninvasive molecular profiling in adult cancers but little is known about its utility in pediatric cancers. pediatric patients with metastatic and refractory solid tumors are known to have poor survival rates, and a key challenge in their management is obtaining biopsy samples especially at times when disease is widely spread or the patient is physically unfit for sampling. the development of a noninvasive profiling strategy is critical for optimizing molecularly guided therapy and assessing response to treatment. in this study, we want to determine the utility of cfdna to noninvasively analyze the molecular profiles of pediatric solid tumors such as neuroblastoma (nb), osteosarcoma (os), and wilms tumor (wt). design/method: tumor, plasma, and matched controls were collected from patients with nb, wt, and os, at diagnosis or time of disease progression. cfdna was extracted from the plasma and analyzed through multiple methodologies including a targeted next generation sequencing panels and shallow whole genome sequencing (swgs). results: fifteen nb patients, os patients, and wt patients had tumor molecular profiles known from different targeted next-generation sequencing platforms. in the cfdna of / nb patients, somatic mutations and copy number alterations previously reported in the tumors were detected, including recurrent nb drivers such as mycn amplification, alk, and atrx mutations. mutations not detected in the original tumor were also found in / nb patients including nras, mll , arid b, some of which are potentially actionable. in os, mutations known from the tumor were found in the cfdna of of patients, including atrx and notch mutations, as well as copy number alterations such as cdk amplification, which has targetable therapeutics available. of the two wt patients analyzed, cfdna revealed the same mutations as tumor in one patient, however in a cohort of patients where tumor was not available, cfdna revealed recurrent driver mutations such as amer , dicer . it is feasible to noninvasively identify somatic mutations and copy number alterations in cfdna of patients with pediatric solid tumors. establishing a platform using cfdna to identify molecular profiles of these tumors can serve as a powerful tool for guiding treatment and monitoring response to treatment. background: despite multi-modality therapy, the prognosis for patients with metastatic osteosarcoma remains poor necessitating development of novel targeted therapies. immunotherapy can be exploited to target osteosarcoma with exquisite specificity but remains limited by insufficient tumor specific targets. objectives: to overcome the dearth in tumor specific antigens, we have explored the use of tumor derived mrna (representing a tumor specific transcriptome) for development of personalized nanoparticle vaccines. design/method: rna-nanoparticles (rna-nps) can be amplified from limited amounts of biopsied tissue for induction of tumor specific t cells against osteosarcoma. since local vaccination strategies are mired by poor overall immunogenicity, we assessed the feasibility, immunogenicity and antitumor activity of intravenously administered rna-nps (tumor mrna complexed to dotap nanoliposomes) in pre-clinical murine and canine tumor models. we identified a clinically translatable np formulation for the delivery of rna to antigen presenting cells (apcs) that induces in vivo gene expression and preserves rna stability over time. tumor derived rna-nps induced antigen specific t cell immunity and mediated anti-tumor efficacy in several pre-clinical solid tumor models (i.e. b f , kr b). when administered intravenously, rna-nps increased expression of co-stimulatory molecules (i.e. cd , cd , cd , ccr ) and pd-l on cd c+ cells throughout reticuloendothelial organs (i.e. spleen, liver, bone marrow) and within the tumor microenvironment; this phenotype was strictly dependent on type i interferon. targeted inhibition of type i interferon signaling (via infar mabs) abrogated anti-tumor efficacy mediated by rna-nps. we enhanced the immunogenicity of this platform by simply combining mrnas encoding for immunomodulatory molecules (i.e. hcv-pamps, gm-csf) or by combining rna-nps with immune checkpoint inhibitors. addition of checkpoint inhibitors (pd-l mabs) to rna-nps increased tumor infiltrating lymphocytes, and intratumoral mhc class i/ii expression, and mediated synergistic anti-tumor activity in settings where pd- or pd-l inhibition alone did not confer therapeutic benefit. we then explored the feasibility of rna-nps in a large animal osteosarcoma model. in ongoing studies for canines with osteosarcomas, we have shown that sufficient amounts of rna can be extracted, amplified, and manufactured into personalized rna-np vaccines. conclusion: rna-nps reprogram systemic immunity and mediate anti-tumor activity providing near immediate immune induction without the complexity of cellular immunotherapy. the immune correlate of preclinical response to rna-nps is hallmarked by interferon dependent pd-l expression on activated apcs (cd c+ mhcii+ cd + cells). based on these findings, we are exploring the preclinical safety, efficacy and immunologic effects of rna-nps targeting canine osteosarcoma before first in-human evaluation. background: ewing sarcoma is an aggressive bone tumor affecting mainly adolescent and young adults. treatments are based on compressed schedule chemotherapy combined with local control (surgery and/or radiation). prognosis is poorer for patients with metastatic disease, older age and central primaries. survival when disease recurs within two years of diagnosis is < %. the ews-fli fusion gene t( ; ) (q ; q ) has been well characterized as a dominant ews driver-gene. the most common variation is ews exon with fli exon ( % of fusion positive patients). we designed a novel pbi-shrna tm ews/fli type lpx which has demonstrated, safety and efficacy in animal model (rao et all). the pbi-shrna strategy silences target gene expression by concurrently inducing translational repression and p-body sequestration as well as post-transcriptional mrna cleavage. to determine the safety and maximum tolerated dose of intravenous administration of pbi-shrna tm ews/fli type lipoplex in patients advanced ews. design/method: phase i study × escalation cohort. testing pbi-shrna tm ews/fli type lpx (starting iv dose of . mg/kg) on patients (≥ age ) with advanced ewing's sarcoma, all with a type translocation. intravenous infusion was given twice a week for weeks with the following escalation schema: % → % → % → % → %. required kps > % and adequate organ function. cytokines induction pre and post-infusion was analyzed (il- , il- , tnf-alpha, il ra). first cohort of patients has been enrolled (ages between - years). three relapsed patients had > lines of therapy and patient had refractory disease, patients received a complete cycle of pbi-shrna tm ews/fli type lpx with twice a week infusions. a total of doses were given. the most prominent related toxicity has been hematological, patient developed transient g neutropenia, another patient developed g anemia that required prbc transfusion, and of note this patient had significant bone and bone marrow involvement. one patient only received two lpx infusions; she developed a fatal rsv pneumonia. other reported grade toxicity includes fatigue and headache. evaluable patients (n ) had stable disease between and months before progression. one patient had sustained response for month before progression, two patients are still alive. our preliminary experience supports the safety and potential efficacy of pbi-shrna tm ews/fli type lpx as novel treatment for advanced ews with limited toxicity. il- increase correlates with higher bi-shrnai ews/fli lpx infusion rate and clinical symptoms. further clinical testing is indicated. background: as more children with cns malignancies (bt) are surviving, the late effects of the therapies they receive are better described. studies show that radiation therapy is particularly harmful to neurocognitive functioning, specifically processing speed, working memory, and attention span. these deficits have negative effects on quality of life, especially in academic and professional settings. a large proportion of s of s adult survivors of bt are unable to reach adult milestones such as living on their own, holding a steady job, and getting married. proton beam radiation therapy (pbrt), is touted for the potential to have fewer and less severe side effects than traditional photon radiation therapy (xrt). because of the properties of protons, the amount of damaging energy released in non-target healthy tissue is reduced when compared to xrt. although a study comparing iq testing between pbrt and xrt found no difference between the two therapies, no studies have compared the specific neurocognitive domains. it would be valuable to evaluate full neurocognitive testing scores (nct) since the specific domains, particularly processing speed (psi), appear to be most vulnerable to radiation therapy. objectives: our primary aim was to assess differences in psi for patients with bt who underwent pbrt versus xrt. a secondary aim was to assess differences in iq (fsiq) and working memory (wmi). we retrospectively evaluated all patients treated for bt at the jimmy everest cancer center within the past years who received rt and had nct post radiation. we examined the full nct results for both subsets of participants to evaluate differences in the specific domains of processing speed, working memory, and iq by measuring percentiles scored in these domains. objectives: we report our experience on imaging children with mm treated uniformly on an institutional melanoma trial. we retrospectively reviewed the clinical and imaging findings of patients with ajcc stage iic-iv cutaneous mm treated on our institutional mel protocol. brain mri/ct, pet/ct, ct chest, abdomen, and pelvis (ctcap) were performed at diagnosis in all patients. on treatment, stratum a patients (peg-interferon; ajcc iic, iiia, iiib) (n = ) had the same imaging repeated every months; stratum b (peg-interferon and temozolomide; unresectable measurable disease metastatic, or recurrent) (n = ) had pet scans every months and brain imaging every months; those in stratum b (peg-interferon and temozolomide; unresectable non-measurable, metastatic, or recurrent) (n = ) had the same imaging performed every months. off therapy all patients continued same imaging every months for years. results: there were patients ( female; median age years). eleven had spitzoid and conventional melanoma. primary sites included head/neck (n = ), trunk (n = ), and extremities (n = ). patients with spitzoid melanoma had imaging studies ( pet, ctcap, ct chest, ct brain, and mri brain) with a median of , , , and studies/patient respectively. median cost per patient was $ , . thirteen studies ( . %) showed suspicious lesions with additional scans and diagnostic biopsies of which one only was positive stratum a with tert promoter mutation and died from disease). for conventional mm, studies ( pet, ctcap, ct chest, ct brain, and mri brain) were performed with a median of , . , , , studies/patient respectively. median cost per patient was $ , . twenty ( %) showed suspicious lesions with additional scans and diagnostic biopsies; four were positive (two at diagnosis); both died of disease; the other two recurred locoregionally and were detected clinically; both are alive and disease free; one patient had diffuse metastases and died shortly after enrollment. after a median follow up of . years (range . - . ) patients are alive and disease free. children with spitzoid melanoma should have minimal imaging at diagnosis and follow-up given the low risk of recurrence and low yield and high cost of aggressive imaging protocols. patients with conventional mm should be imaged according to the adult guidelines. nationwide children's hospital, columbus, ohio, united states background: the role of infections in the long term outcome of patients with bone tumors is controversial. two retrospective studies have shown increased survival in osteosarcoma patients who had a post-operative wound infection, while another showed no changes in overall survival. to determine the relationship between wound infections and/or bloodstream infection (bsi) on survival in pediatric and young adult patients with osteosarcoma and ewing sarcoma treated at a tertiary children's hospital. design/method: a retrospective chart review was performed for patients with diagnosis of osteosarcoma or ewing sarcoma from - . patients received standard chemotherapy regimens for their disease type and stage. local control included surgical resection and/or radiation therapy. presence of infection was determined by bsi or wound cultures while receiving treatment for primary tumor. the median age of patients was (range - years) at diagnosis. % had a diagnosis of osteosarcoma and % had ewing sarcoma. of these, % of patients developed an infection during treatment; % had bsi, % had wound infections, and % had both. patients with bsi had a year os of . %, compared to % in those without bsi (p = . ). those with both bsi and wound infections had the poorest overall survival of %, compared to . % for patients without any infection. patients with wound infections alone had a year os of . %, compared to % of patients without a wound infection. our analysis revealed decreased os in patients with bsi; however, this could be due to other confounding factors in the presence of bsi. those with bsi or bsi and wound infections had the poorest survival. wound infections without bsi were associated with a slight increase in survival; however, this study was limited by the number of patients that had local wound infections. with the use of newer surgical techniques, availability of antimicrobials and routine use of prophylactic antibiotics, the incidence of infections while undergoing treatment is low. however, the importance of this clinical observation indicates a likely enhanced immune system associated with infection, supporting the role of immunotherapy for treatment of these aggressive tumors. background: hypoalbuminemia is a well-recognized effect of cancer and other chronic illnesses and is often regarded as a marker of malnutrition. in adults, hypoalbuminemia has been associated with adverse outcomes in patients with cancers of the lung, pelvis, head and neck, gastrointestinal tract, and bone marrow, as well as in some pediatric patients with ewing sarcoma and hodgkin lymphoma. hypoalbuminemia has not been well studied in children with cancer. to determine the incidence of hypoalbuminemia (using age-specific references) in children with cancer receiving chemotherapy at baseline (prior to starting chemotherapy) and to determine whether hypoalbuminemia is associated with inferior -year overall survival. design/method: we performed a single institution, irbapproved, retrospective review of pediatric oncology patients diagnosed between and . five-year survival was estimated using the kaplan-meier method; groups were compared using cox regression. we identified pediatric patients with a first diagnosis of cancer, brain tumor, or other condition possibly requiring chemotherapy. of these patients, were excluded for reasons including not receiving chemotherapy and missing data, leaving patients who had a serum albumin level within days prior to starting chemotherapy. the mean age was . years (sd . years); % were male; % were non-hispanic. the most common diagnosis was acute lymphoblastic leukemia ( of ; %). one hundred thirty nine of ( %) had hypoalbuminemia prior to starting chemotherapy. there was no statistically significant difference in -year overall survival between those with and without hypoalbuminemia ( % vs. %, respectively; hazard ratio . , % c.i. . - . ). conclusion: hypoalbuminemia at baseline in pediatric oncology patients requiring chemotherapy is common (one in five), and was not associated with inferior -year overall survival in this cohort. leptomeningeal metastases at diagnosis. standard treatment for completely resected, non-anaplastic supratentorial ependymomas is close observation. treatment for anaplastic or incompletely resected non-anaplastic ependymomas is maximal safe surgical resection followed by focal radiation. however, up to % of localized ependymomas recur. the role of chemotherapy in treating ependymomas is under investigation. extraneural metastases of anaplastic ependymomas have rarely been reported and the outcome is dismal. objectives: to report extraneural cervical node metastases of a non-anaplastic ependymoma and successful treatment with surgical resection, radiation, and systemic chemotherapy. design/method: retrospective review of patient medical records, including radiographic imaging and tumor tissue pathology, and comprehensive literature review. results: a previously healthy -year-old girl underwent gross total resection (gtr) of an isolated right parietal lobe ependymoma (who grade ii). at age years, magnetic resonance imaging (mri) revealed an isolated localized recurrence. she underwent gtr followed by observation. at age years, she again experienced isolated localized recurrence and underwent gtr followed by . gy focal conformal photon radiation. at each recurrence, pathology revealed a non-anaplastic ependymoma, and cerebral spinal fluid (csf) cytopathology and spine mri were negative. at age years, she developed an enlarged right posterior cervical chain lymph node. subsequent mri revealed a large rim-enhancing, t hyperintense lymph node and multiple abnormally enhancing regional nodes consistent with metastases. biopsy revealed a non-anaplastic ependymoma. mri of the brain and spine, computed tomography of the chest, abdomen, and pelvis, and csf and marrow evaluations were unremarkable. chemotherapy according to acns was initiated. mri after course demonstrated significant node size reduction. she underwent right neck node dissection. only one right level ii lymph node showed metastases. she was treated with . gy irradiation to the neck and additional courses of chemotherapy. she remains in remission months and months after diagnosis of metastatic disease and end of therapy, respectively. literature review reveals rare reports of extraneural metastatic disease of anaplastic ependymomas to bone, lung, or liver, and only involving lymph nodes, all associated with a poor outcome despite multimodal therapy. to our knowledge, this is the first report of extraneural metastases of a non-anaplastic ependymoma. extraneural metastases should be considered in children previously treated for non-anaplastic ependymomas who experience systemic symptoms, even in absence of cns relapse. multimodal treatment offers potential long-term disease control with acceptable toxicity. arun gurunathan, joel sorger, andrew trout, joseph pressey, rajaram nagarajan, brian turpin cincinnati children's hospital medical center, cincinnati, ohio, united states background: pigmented villonodular synovitis (pvns) is a benign neoplasm of the synovium. standard treatment is surgery, but post-operative recurrence rate is as high as %. radiation therapy can be used for local control, but is associated with late effects. while pvns is rarely fatal, aggressive disease and/or extensive surgery can result in substantial functional impairment. colony stimulating factor- (csf ) overexpression, often due to chromosomal translocation involving csf , drives pvns through recruitment of synovial-like mononuclear cells expressing the csf -receptor. tyrosine kinase inhibitors such as imatinib are active against the csf -receptor, and have shown benefit in the post-surgical relapse setting. however, questions remain regarding the broader application of imatinib and regarding optimal response assessment. to present three patients with pvns, each with different clinical scenarios, who demonstrate clinical response to imatinib monitored by changes in metabolic activity (maximum suv) on pet/ct. results: three patients with pvns demonstrate pet/ct response to imatinib, guiding management of their challenging clinical scenarios. patient is a year-old female with left hip pvns and high grade articular cartilage loss, with decrease in metabolic activity (suvmax . to . in months) on neoadjuvant imatinib, enabling total hip replacement surgery planning. patient is a year-old female with left knee pvns with recurrences after synovectomies, spared subsequent surgical control attempts after clinical improvement correlating with pet/ct response to imatinib (suvmax . to . in months). patient is a year-old male with right knee pvns that recurred after total knee replacement, now with clinical improvement correlating with pet/ct response to imatinib (suvmax . to . in months). all patients would have been characterized as stable disease by response evaluation criteria in solid tumors (recist). in each of these patients, imatinib has been tolerated well, with no therapy interruptions and absent or easily managed side effects (one patient takes dronabinol for decreased appetite, one patient takes prn immodium for diarrhea). all patients are currently still taking imatinib, with therapy length ranging from five to eleven months. in our series of three patients with pvns, imatinib shows promise for disease management in neoadjuvant and adjuvant settings with a tolerable side effect profile. imatinib should be considered in the treatment of pvns to spare surgical and radiotherapy related morbidity, and treatment effect can be monitored by pet/ct. background: metastatic rhabdomyosarcoma (rms) carries a poor prognosis with three-year event free survival rates ranging between %- % (depending on oberlin risk factors) due to the lack of significantly effective breakthroughs in the recent past. there is an urgent and unmet need for new treatment strategies against this disease. metastatic rms cell lines exhibit increased expression of the erm family membrane-cytoskeleton linker protein ezrin. knockdown of ezrin expression using sirnas decreases the metastatic potential of these cells, whereas forced expression of ezrin results in increased degree of metastasis. the activity of ezrin is controlled by its phosphorylation at the threonine (thr ) residue at the c-terminus of the protein, suggesting that alteration of ezrin phosphorylation may control rms growth and metastasis. our goal was to determine if pharmacological inhibition of thr phosphorylation in ezrin affects the growth, survival and metastasis in rms in vitro as well as in vivo. design/method: rms cell lines representative of the alveolar and embryonal histological subtypes were used. rms cells were treated with a small molecule inhibitor of ezrin, nsc , which specifically dephosphorylates ezrin at the thr residue. baseline expression of ezrin and perm levels as well as the effect of nsc on perm levels in the rms cell lines was determined by western blotting of cell lysates. viability of cells was assessed by trypan blue exclusion, and morphology visualized by bright field microscopy. the extent of apoptosis was detected by imaging caspase / activation using fluorescent microscopy. motility of rms cells was examined by performing a wound-healing assay. subcutaneous and orthotopic xenografts were established in nsg mice using rd cells (embryonal rms). mice harbor-ing xenografts were treated with intraperitoneal injections of nsc or dmso. results: ezrin is constitutively phosphorylated at the thr residue in a majority of the rms cell lines examined. nsc dephosphorylates ezrin at the thr residue in these cell lines. treatment with nsc inhibits growth, induces apoptosis and inhibits the migration of rms cell lines in vitro. further, treatment of nsg mice bearing subcutaneous or orthotopic embryonal rhabdomyosarcoma xenografts with nsc significantly impedes tumor progression without any obvious adverse effects. our findings suggest that dephosphorylation of ezrin at the threonine residue may have the potential to be a novel therapeutic strategy for rms patients. all india institute of medical sciences, new delhi, new delhi, delhi, india background: the role of laparoscopy in the management of pediatric intra-abdominal solid tumors is yet to be established. the safety of laparoscopic management of pediatric intra-abdominal tumors is still questionable. we study the results of the initial case series of pediatric intraabdominal tumors managed laparoscopically at our institute from july onwards. design/method: total children ( -males, females) who presented to us with pediatric intra-abdominal tumors were included. the tumors included wilms tumor (n = ), neuroblastoma(n = ), adrenal cortical tumor(n = ), ovarian teratoma(n = ).children were between months - years and received neo-adjuvant chemotherapy. a -port laparoscopic nephrectomy and lymph node sampling for wilms tumor and adrenalectomy for adrenal tumors was performed. the tumors were removed in-toto with no rupture (except in one). specimens were retrieved through a lumbar incision (n = ) or an inguinal incision(n = ). all the children are under regular follow up. two children with wilms tumor had recurrence. the neuroblastoma child underwent open surgery for recurrence later. conclusion: laparoscopy/laparoscopic assisted removal of pediatric intra abdominal tumor is a feasible and safe option. it has the advantage of less postoperative pain, shorter hospital stay and a better cosmetic result. proper patient selection, port placement and laparoscopic experience are contributory. background: targeting of proteins and cell surface antigens specific to cancer cells with monoclonal antibodies has proven to be an effective form of treatment in many forms of cancer. gd is a cell surface disialoganglioside that is expressed on the cell surface of some normal tissues including nerve cells, melanocytes, and mesenchymal stromal cells and is overexpressed in some pediatric cancers like neuroblastoma and osteosarcoma. dinutuiximab is a chimeric monoclonal antibody that is fda approved for the treatment of patients with high risk neuroblastoma and under investigation for the treatment of relapsed osteosarcoma. little is known about the patterns of gd expression in other pediatric malignancies. objectives: we sought to describe the patterns of gd expression in the following pediatric sarcomas: synovial sarcoma, rhabdomyosarcoma and ewing sarcoma. design/method: synovial sarcoma (n = ), rhabdomyosarcoma (n = ) and ewing's sarcomas (n = ) formalin fixed, paraffin embedded cores were obtained from the seattle children's research institute tissue microarray (tma) biorepository. tma blocks consisting of melanoma cores stained with and without gd antibody were used as positive and negative controls, respectively. slides were incubated with anti-ganglioside gd antibody clone q (ab from abcam) diluted : in % normal goat serum and % bsa in tbs overnight at ˚c. the negative control of human melanoma section was incubated in % normal goat serum and % bsa in tbs without primary antibody. the expression of gd was indicated by characteristic brown diaminobenzidine staining. the intensity and location of tissue staining were assessed and compared to positive and negative controls. staining was considered positive (+++) if the intensity of the staining was consistent with that of the positive control with - % of cells staining positive. classification of intermediate gd expression (++) was assigned to slides in which - % of cells stained positive. slides were classified as sporadic staining (+) if - % of cells stained positive. tissue was considered (-) if there was complete absence of staining, similar to the negative control. objectives: to evaluate the clinical presentation, management and treatment outcomes of children with malignant germ cell tumor at our institute design/method: a prospective study was conducted from june to dec in the department of pediatric surgery in a tertiary care institute in a developing country. all patients were evaluated for local disease and metastatic disease by imaging and tumor markers. risk stratified chemotherapy was used with low risk tumor receiving no chemotherapy, intermediate risk: courses of peb chemotherapy and high risk: courses of peb + courses of pe. upfront resection of the primary or the residual disease after neoadjuvant chemotherapy if feasible was performed. follow up was done with monthly tumor markers for months and imaging studies every - months for initial years. five year overall survival and disease free survival was calculated. results: during the study we treated children who formed the study group. of these ( %) were gonadal ( ; % testicular and ; % ovarian) and the remaining ( %) were extragonadal with sacrococcygeal (sct) being the most common site ( %). one hundred and thirteen children ( %) presented to us primarily while the remaining had received treatment elsewhere. stage or stage disease at presentation was present in ( %) children. recurrence was noted in ( %) patients. respectively. patients with testicular mgct and children with age - years and males had significantly poor rfs rates. conclusion: patients with mgct should be staged correctly and adjuvant chemotherapy is advisable to all patients except stage i endermal sinus tumor of testis. awareness regarding the same is still lacking in our country. meticulous follow up is needed as more than % of will recur. cure rates are dismal in children with recurrent mgct especially those who are not chemotherapy naïve. nemours children's specialty care, jacksonville, florida, united states background: radiotherapy for pediatric head and neck tumors often results in mucositis, limiting oral intake and compromising patients' nutritional status. this may be reduced through the improved conformality offered by proton therapy. despite widespread use of enteral tube feeding through a percutaneous gastrostomy (peg) or nasogastric tube (ngt), there is little data available regarding overall incidence of ngt/peg placement and perspectives of pediatric patients and caregivers. objectives: to (a) estimate the need for ngt/peg support and (b) characterize patient and caregiver perceptions surrounding enteral feeding in children with head and neck tumors undergoing proton therapy. design/method: dependent on development stage, patient (n = ) or parents (n = ) filled out a series of customized surveys according to a prospective irb approved study. seventythree percent of patients also received concurrent chemotherapy. questions addressed their current feeding route and perception, for example, "what aspect(s) of tube feedings are beneficial to you?" and "what aspect(s) of tube feeding worry or scare you?" fifty-five surveys were distributed before and after radiation, and with any change in feeding route. results: at the start of proton therapy, patient had a ngt and patients had peg. of these, patients ( %) had a ngt/peg in place exclusively for the administration of medication; only patient ( %) needed a ngt/peg for nutrition. in those patients without ngt/peg, % would "consider" enteral feeds. in patients without ngt/peg, the most commonly cited benefit was "maximizing my nutrition" ( %) and the most common negative aspect was "fear" of tube placement ( % of patients). all sub-populations ( % of patients) cited change in appearance as a negative aspect. in patients without ngt/peg at the start of proton therapy, % of patients/caregivers felt enteral feeding to be "unnecessary," and % of these patients would not "consider" ngt/peg even if their "physician advised it." over the course of proton therapy, the patients/caregivers who deemed enteral feeding "unnecessary" decreased from % to %. at completion of treatment, patients ( %) were using a ngt/peg tube for nutritional support but only one ( %) patient relied exclusively on their enteral feeds. two patients (without ngt/peg) ( %) required parenteral support. our data does not support prophylactic placement of ngt/peg in of children with head and neck tumors undergoing proton therapy. ongoing research is needed to identify which patients will need ngt or peg to supplement their diet. in this cohort, anticipatory counseling should focus on pain, cosmesis, and utility. children's national medical center, washington, district of columbia, united states background: ovarian sex cord-stromal tumors (osct) are rare neoplasms that typically present with signs/symptoms of an adnexal mass and signs of hormonal production approximately % of ovarian sex cord-stromal tumors in children are sertoli-leydig cell tumors (slct) with median age of presentation years overall. to our knowledge the youngest reported case in the literature describes a -month old female in china with a slct that was treated with oophorectomy alone. some studies have found an association in families between pleuopulmonary blastoma and osct with a germline mutation leading to dicer syndrome, which has been associated with a younger age at diagnosis. , objectives: to describe an unusual case presentation of slct in an infant results: -month old, twin female, ex- week premature infant presented to the emergency department on multiple occasions for abdominal distention and feeding intolerance initially thought to be related to previous omphalocele repair and umbilical hernia. an ultrasound demonstrated an × cm mass arising from the right ovary with large volume ascites. she required admission to the intensive care unit due to s of s respiratory distress from her significant ascites. serum tumor marker including hcg, afp and ldh were negative. patient underwent right oophorectomy with tumor capsule noted to be open at time of surgery. further imaging post operatively demonstrated no other sites of disease. the patient was classified as figo stage ic due to the presence of her significant abdominal ascites that was presumed to be malignant pre-operative tumor rupture. the pathological diagnosis was challenging and eventually resulted as a mixed germ cell sex cord stromal tumor with pattern of sertoli cell tumor with neuroendocrine differentiation. based on the staging of figo ic with pre-operative rupture, the decision was made to treat with a standard platinum based regimen as there is a higher incidence of relapse in stage ic patients when compared to ia treated with observation alone. our patient tolerated four cycles of chemotherapy well and end of therapy scans showed no evidence of disease. interestingly, her dicer mutation genetics performed by ion torrent tm next generation sequencing was negative in germline and tumor studies. to our knowledge, our patient is the youngest described with slct. she will continue to be followed with serial imaging alone as she had no evidence of elevated tumor markers at diagnosis. , due to young age and unusual diagnosis, she was referred to cancer genetics team. background: approximately % of patients with wilms tumor (wt) have metastatic disease at diagnosis and often have a grave prognosis. limited cell lines are available for the study of metastatic wt and long-term passaged cell lines do not always recapitulate the human condition. focal adhesion kinase (fak) is a non-receptor tyrosine kinase that controls cellular pathways involved in the tumorigenesis of pediatric renal tumors. using a novel patient-derived xenograft (pdx) model from a patient's primary wt (coa ) and matched isogenic metastatic wt (coa ), we previously demonstrated that fak is expressed and its inhibition led to decreased tumorigenicity of both the primary and metastatic pdxs. kinomic profiling is an innovative, high-throughput method used to investigate kinase signaling to identify potential therapeutic targets. to date, the kinomic profile of primary and metastatic wt has not been examined. objectives: investigate baseline kinomic differences between primary and metastatic wt and evaluate kinases upstream and downstream of fak as potential targetable therapies. design/method: cells from coa and coa were treated with pf- , (pf), a small molecule fak inhibitor. protein from cell lysates of treated and untreated coa and coa were combined with kinase buffer, atp, and fluorescently labeled antibodies and loaded into a phosphotyrosine kinase or serine-threonine kinase pam-chip® per the uab kinome core protocol. phosphopeptide substrate analysis with the pamstation® kinomics workstation (pamgene® international), pamchip® protocol using evolve software, and bionavigator v. . were used to analyze kinases upstream and downstream of fak. the primary wt had increased epha , ror sgk and decreased pdgfrb relative to the paired metastatic wt at baseline. treatment with pf increased ron, pdgfrb, p s kb, mak, camk g, vacamkl, camk d, ck a and pskh in the primary wt. treatment with pf decreased tnk , lmr , cck , epha , pdk , sgk , lkb and increased pskh in the paired metastatic wt. primary wt displayed a different kinomic profile compared to metastatic wt in a matched isogenic pdx model. these data reveal that alternative therapies to specifically target metastases are needed. furthermore, fak inhibition resulted in diverse kinomic alterations between primary and metastatic wt. inhibitors targeting many of these pathways, such as pdgfrb inhibitors, are currently available and potentially could be combined with fak inhibitors in the treatment of wt. the results of the current study indicate that kinases upstream and downstream of fak in primary and metastatic wt warrant further investigation. background: use of high-dose methotrexate (hd-mtx, g/m^ ) is a mainstay of standard therapy for pediatric osteosarcoma (os) in north america. in pediatric os, there is a narrow therapeutic window for hd-mtx, with decreased tumor response rate with mtx concentrations < m and decreased survival due to severe toxicity with concentrations > m. risk factors for hd-mtx toxicity have been defined in adults, including body mass index (bmi) and male gender, but such studies have not been conducted in children. we sought to examine the relationship between mtx levels and toxicities during hd-mtx infusion for pedi-atric os, thereby identifying risk factors for increased toxicity and providing a framework for therapeutic drug monitoring. design/method: this retrospective chart review included patients treated at texas children's hospital with hd-mtx as first-line therapy for os from - . data abstracted from electronic records included patient characteristics, bmi and body surface area (bsa), baseline and post-treatment laboratory values, mtx levels and hours after dose given ( h, h), hour mtx cleared (mtx < . um), grade / mucositis, myleosuppression, persistent lft elevation (ctace v . ), and % tumor necrosis. correlation between h mtx level and other covariates was summarized using descriptive statistics. we reviewed hd-mtx infusions corresponding to patients. bmi was found to significantly impact h mtx level (p< . ). female gender was also significantly associated with higher h mtx level (p< . ). percent necrosis (available in patients) was associated with h mtx levels at near-statistical significance (p = . ). h mtx level was not found to contribute to toxicities or associate significantly with mtx clearance. analysis in a larger cohort is ongoing. we have identified at least one patient factor (bmi) that significantly impacts h mtx levels and is of potential use for future modeling, as current models incorporate bsa only. our findings concord with studies in adult os in that bmi significantly impacts h mtx level but diverge in that female gender is associated with higher h levels. importantly, these data support targeting h mtx levels to ensure that minimum concentration for adequate tumor necrosis is reached. these results do not suggest that monitoring h levels would prevent toxicities, thus necessitating further characterization of any intrinsic patient factors that associate with toxicity. overall, our definition of the clinical factors that associate with h mtx levels contributes to a framework for therapeutic drug monitoring in pediatric os. children 's mercy hospital kansas city, kansas city, missouri, united states background: post consolidation immunotherapy with dinutuximab, aldesleukin (il- ), granulocyte macrophage colony stimulating factor (gmcsf) and isotretinoin is standard of care for children with high risk neuroblastoma. dinutuximab is combined in alternating cycles with s of s gmcsf or il , followed by a th cycle with isotretinoin alone. il- is administered as a hour continuous infusion on days - at miu/m /day followed by a higher infusion dose, . miu/m /day, in combination with dinutuximab on days - of cycles and . the miu/m /day dose may be administered inpatient or in the ambulatory setting. objectives: to retrospectively compare the incidence of inpatient and outpatient side effects and complications associated with low dose ( miu) il to provide the tolerability data necessary to evaluate these venues for future administration options. design/method: this study was a descriptive, singlecentered definitive study utilizing a retrospective convenience sample population of children with high risk neuroblastoma who received low dose il either as an inpatient or an outpatient without exclusion from may to june . subjects were identified by a tumor registry query post irb approval. electronic and paper medical records were reviewed for the dates and location of the infusions, the home health company used if applicable and all documentation regarding clinical status, side effects and toxicity. demographics was limited to age and gender. results: infusion venue was chosen by provider preference. twenty-six infusions, inpatient and outpatient via separate home health companies were all administered in entirety and without interruption. there were males and females ranging from - years of age. two children received a single outpatient infusion due to intolerance of il when combined with dinutuximab and received therapy in both settings. fever, inpatient and outpatient was the only common side effect. no source of infection was ever identified. there was one incidence of diarrhea and one patient with pruritus in both the outpatient and inpatient settings respectively. no planned outpatient infusions required subsequent admission however the outpatient fever did necessitate an er evaluation. conclusion: low dose il can successfully be administered outpatient. the medication has minimal side effects with fever occurring in %, none of which were associated with infection. no outpatient infusion required a subsequent admission. no patients who received cycle infusions outpatient opted to receive the next cycle inpatient. baylor college of medicine, houston, texas, united states background: metastatic ewing sarcoma (es) has an extremely poor overall survival, necessitating investigations into molecular mechanisms to identify novel targets and develop new therapies. we previously performed an in vivo study, using our mouse model, designed to provide insights into transcriptomic and proteomic signatures for metastatic es to identify potential therapeutic targets. comparing profiles of primary tumors to corresponding metastatic lesions, we identified aberrant expression of integrin ß (itgb ) and downstream activation of integrin-linked kinase (ilk) in metastatic lesions compared to primary tumors, implicating this pathway as a key regulator in the ability of es to establish and enhance metastasis. our hypothesis is that upregulation of itgb and its downstream signaling events play a key role in es metastasis and are viable therapeutic targets. objectives: to investigate the role of itgb and its downstream signaling pathways in driving the establishment and enhancement of metastasis in es and to investigate this pathway as a potential therapeutic target. to investigate the role of itgb and ilk in es metastasis, we used sirna to knock down itgb and ilk expression in established es cell lines and then performed functional assays in vitro, including cell proliferation and invasion/migration assays. we also tested inhibition of this itgb signaling pathway using available small molecule inhibitors targeting itgb , ilk and the downstream target ap- , using cilengitide, compound and sr , respectively. we are currently using these small molecule inhibitors as treatment in vivo and assessing rates of metastatic tumor formation. we generated stable itgb and ilk overexpression and knockdown cell lines, which we are using for similar in vitro and in vivo investigations. knockdown of itgb and ilk in our sirna cell lines resulted in decreased cell proliferation and decreased invasion and migration compared to controls. we also found significantly decreased cell proliferation using each of the small molecule inhibitors in vitro. our preliminary studies using compound in vivo established a safety profile and dose escalation is underway to assess the effectiveness of inhibiting es metastasis. these results support our hypothesis that itgb and its downstream signaling events play a key role in the ability of es to establish metastatic foci and may serve as a potential therapeutic target. we continue to investigate this pathway in vitro. we are also using our small molecule inhibitors and itgb and ilk overexpression and knockdown approaches to study these effects on metastatic tumor development in vivo using our mouse model. background: neuroblastoma (nbl) is characterized by phenotypic heterogeneity. outcome is excellent for patients with low-(lr) and intermediate-risk (ir) disease, whereas only % of high-risk (hr) patients will survive. -hydroxymethylcytosine ( hmc) is an epigenetic marker of active gene transcription, and hmc profiles are prognostic in many types of adult cancers. we hypothesized that hmc profiles will serve as robust biomarkers in children with nbl tumors, refining current risk stratification. objectives: analyze genome-wide hmc in nbl tumors and correlate hmc deposition with chromosomal copy number and gene expression. design/method: hmc was quantified by nano-hmc-seal-seq from the dna extracted from hr, ir and lr nbl tumors. read counts and clinical data were analyzed with deseq to identify genes with differential hmc patterns between risk groups. chromosomal copy number was assessed by chromosomal microarray analysis (cma) in a subset of samples ( lr and hr). expression of genes located on chromosome p was evaluated using publically available microarrays (e-mtab- ) of hr nbl tumors with known p loh status. results: globally, lr tumors had more hmc peaks ( , ) than ir ( , , p = . ) tumors, or hr tumors ( , , p = . ). , genes had different patterns of hmc deposition in hr versus lr tumors. ( %) of these genes mapped to chromosome p and had decreased hmc in hr versus lr tumors (padj < . ). in the cma analysis p deletion was detected in of the tumors tested. in the tumors with p loss, genes that map to p showed decreased hmc deposition compared to the hr tumors without p loss (p< . ). further, compared to the tumors without p loss, the expression of of the p genes was decreased (p< × - ), including chd , camta , and arid a, known and proposed tumor suppressor genes in nbl. conclusion: different patterns of hmc accumulation are associated with neuroblastoma risk classification. nano-hmc-seal-seq is sensitive to copy number variations and has the potential to identify these changes in patient tumors. our results suggest that hmc deposition contributes to the silencing of tumor suppressor genes in p and may also regulate the transcription of other genes that drive tumor phenotype. background: metastatic osteosarcoma has a -year survival rate of - %. pulmonary metastases remain a major treatment challenge in osteosarcoma. current treatment with conventional chemotherapy shows inadequate activity towards metastases and has toxic systemic side effects. chloroquine is a widely used anti-malarial drug and has been shown to have promising anti-cancer and anti-metastatic activity. polymeric drugs have been shown to have multiple advantages over their small molecular parent drugs, including enhancing the therapeutic efficacy, an improved pharmacokinetics profile and decreased systemic toxicity. we hypothesized that by developing chloroquine into a polymeric drug and combining it with conventional chemotherapy it will improve the treatment of metastatic osteosarcoma. objectives: to identify the optimal combination of polymeric chloroquine (pcq) with conventional chemotherapy active in osteosarcoma as a new means of treating metastatic disease in a murine osteosarcoma model. we synthesized and developed pcq and evaluated its anti-invasive activity using an osteosarcoma cell migration and invasion assay. we evaluated the efficacy of cell killing using combination drug therapies with pcq and a panel of conventional chemotherapy agents (doxorubicin, docetaxel, cisplatin and paclitaxel) using celltiter blue cell viability assay. to develop the murine osteosarcoma model, we intravenously injected luciferase-expressing human osteosarcoma cells b into nsg mice. we administered the drug combination that showed the strongest in vitro synergy to the mice and evaluated their anti-cancer and anti-metastatic effects in vivo. tumor growth and suppression were evaluated using whole body bioluminescence imaging. results: we successfully synthesized pcq that contains . % chloroquine with a molecular weight of . kd. pcq was also found to decrease the toxicity of the parent chloroquine. pcq showed strong inhibition of osteosarcoma cell migration with % inhibition compared to % by chloroquine. we screened the combination drug therapies and found the combination of pcq and doxorubicin to show the strongest synergism. the pcq/doxorubicin combination is currently being evaluated in the murine model. combination drug therapy using pcq and doxorubicin showed synergistic cell killing and inhibition of cell migration in vitro. the combination represents a promising treatment strategy for pulmonary metastatic osteosarcoma. emory university/children's healthcare of atlanta, atlanta, georgia, united states background: survival for relapsed high-risk neuroblastoma (rnb) is < %, underscoring the critical need for novel therapies. rnbs have increased ras/raf/mapk mutations and increased yes-associated protein (yap) transcriptional activity. yap is a transcriptional co-activator that binds with tea-domain (tead) transcription factors to regulate cellular proliferation, self-renewal, and survival. we found that shrna inhibition of yap decreases nb cell proliferation and sensitizes ras-mutated nbs to mek inhibitors, supporting yap as a tractable therapeutic target. verteporfin (vp), a photodynamic drug used for macular degeneration, is the only drug found to inhibit yap expression or yap:tead binding to kill tumor-derived cells. peptide is a mer yap peptidomimetic that also disrupts yap:tead interactions. we sought to determine whether these compounds are potent in nb via yap direct effects. design/method: yap expressing (nlf, sk-n-as) or yap null (ngp, lan , sk-n-as-shyap) human-derived nbs were incubated with vp, with and without direct light exposure, or with peptide . celltiter-glo and immunoblots were used to assess for cell death and yap-downstream protein expression, respectively. results: without direct light exposure, vp inhibits yap expression at nm dosing, yet no nb cell death was observed at equal or higher concentrations. egfr and erk / were inhibited along with yap, confirming yap/ras pathway coregulation. when vp was exposed to direct incandescent light for minutes, > % nb cell death occurred in all nbs tested, even those lacking yap. peptide caused no cell death or yap inhibition up to um. neuroblastomas are resistant to vp at doses sufficient to inhibit yap expression. in macular degeneration, light-activated vp produces reactive oxygen species, which we hypothesize is the off target mechanism killing nbs independent of yap. given the off target effects and the need for light activation, vp is not an ideal preclinical or clinical yap inhibitor. accordingly, peptide has poor cell permeability and low tead affinity, leading to its lack of efficacy. given the relevance of yap in rnb and other cancers, we are chemically optimizing a yap peptidomimetic with enhanced permeability, nuclear localization, and tead affinity to create a bonafide yap inhibitor for preclinical and clinical application. kayeleigh higgerson, aaron sugalski, rajiv rajani, josefine heim-hall, jaclyn hung, anne-marie langevin ut health san antonio, san antonio, texas, united states background: osteosarcoma is the most common bone malignancy in children, adolescents, and young adults. most study cohorts have to % hispanic patients that encompass many different hispanic backgrounds. the university of texas health science center at san antonio (uthscsa) sarcoma team serves a latino population that is predominantly mexican american, thus providing a unique opportunity for evaluation this population. this study expands on previous data collected from january to december from the same institution, providing increased insight into outcomes of mexican american children, adolescents, and young adults with osteosarcoma. objectives: to further understanding of osteosarcoma in latino children, adolescents and young adults. design/method: a retrospective analysis of demographics, tumor characteristics, response to treatment, and survival outcome of all localized osteosarcoma of the extremity patients below years of age diagnosed and treated by the uthscsa sarcoma team between january and june was performed. results: in our original cohort from january to december , we observed a significantly decreased -year eventfree survival (efs) in patients diagnosed before age (preadolescent) relative to patients diagnosed between ages and ( % vs. %, p< . ). patients had a -year overall survival (os) and event-free survival of % and % respectively. in our expanded cohort from january to june we evaluated sixty-six patients with a median age of (range, to y) with localized high-grade osteosarcoma of the extremity. the expanded cohort was % mexican american, with a median follow-up of months (range, to ). the analysis of our expanded cohort is ongoing and we postulate that the findings will hold true, as we increase the cohort size and length of follow-up. conclusion: analysis of our previous cohort, predominantly of mexican american ethnicity, showed that preadolescent patients had an increased rate of relapse when compared with previous large studies. we also showed a trend towards decreased efs for the entire cohort. we hypothesize that we will further validate these findings with this expanded cohort and this will support further investigation into potential causes of poor outcome in this vulnerable latino population. background: neuroblastoma in infants has the potential to regress or mature spontaneously. growing literature showed that some cases subjected to initial observation didn't show inferior outcome compared to actively treated similar categories. objectives: we investigated whether early active treatment can be safely avoided/deferred in selected favorable cases at the children's cancer hospital-egypt (cche). design/method: patients enrolled on the watch and see strategy (w&s) at cche had small primary tumor; inss stage - , uncomplicated stage s or stage infants (< days). tissue biopsy was not mandatory for infants below months of age with localized adrenal mass (stage - ). on progression, immediate intervention took place according to stage and risk of disease after biological characterization. results: thirty four nbl patients were enrolled on w&s strategy; m/f: . / . eighteen patients had stage s disease, patients had stage - and were stage . primary adrenal site was reported in patients ( . %), patients ( . %) had small mass measuring ≤ cm in its largest diameter. the -year os & efs were . ± . % and . ± %, respectively, with months median follow-up (range: - months). spontaneous total/near total resolution of mass occurred in / patients ( %). median time to eliciting regression was . months (range: . - . months), and . months (range: - months) till complete resolution. only / patients ( . %) witnessed progression ( local, distant and combined local and distant progression); median time to progression was months (range: - months) with / deaths after starting chemotherapy. watch and see strategy is a safe approach in localized and uncomplicated stage s neuroblastoma. progressive cases could be rescued. baylor college of medicine, houston, texas, united states background: ga- dotatate binds to somatostatin receptor expressed in neuroendocrine tumors (nets). it was approved by fda in for use with pet/ct scan for localization of somatostatin receptor positive nets in adult and pediatric patients. pediatric approval was based mainly on extrapolation of data from adults. objectives: to describe the use of ga- dotatate pet/ct scan in children with neuroendocrine tumors and compare with other imaging modalities. design/method: patients with nets enrolled in texas children's rare tumor registry between february and october were reviewed and those patients who underwent ga- scan were included. results: four patients with nets underwent ga- scans without any adverse reactions. first patient was a -yearold female with small bowel net with multiple liver metastases. mri abdomen and fdg pet at diagnosis showed s of s multiple liver metastases but could not identify the primary lesion. ga- scan was able to accurately identify the enlarged lymph nodes in the small bowel and was better than fdg pet in delineating the liver metastases. second patient was a -year-old female with recurrent small bowel net with liver, lung and paraspinal metastases. the lesions were initially detected by ct scan. octreotide scan failed to show any uptake in the identified lesions while ga- was taken up by the liver lesions, lung lesions > cm in size and the paraspinal lesion. third patient is an year-old male with pancreatic net with peripancreatic lymphadenopathy, multiple liver metastases and cardiophrenic lymph node involvement. the primary lesion in the pancreas could not be identified by ct scan, ct angiogram, mibg scan, or octreotide scan. in addition, there was uncertainty about involvement of the enlarged cardiophrenic lymph node. in addition to clearly identifying the primary lesion, ga- scan was able to detect multiple peripancreatic lymph nodes not detected by other scans and revealed uptake in the cardiophrenic lymph node confirming its involvement by the tumor. fourth patient is a -year-old female with malignant abdominal paraganglioma with solitary lung metastasis. both mibg scan and ga- scan were able to identify the primary lesion. ga- scan was performed after the lung metastasis was removed and thus its ability to detect it could not be confirmed. background: neuroblastoma is the most common extracranial solid tumor of childhood, with overall survival for high-risk patients (hrnbl) near %. the outcomes of hrnbl have improved with high dose chemotherapy followed by autologous stem cell rescue (abmt). data about factors influencing the rate of hematopoietic recovery following abmt in hrnbl is lacking in the literature. our objective was to identify factors influencing the rate of hematopoietic recovery following abmt in hrnbl. design/method: this was a retrospective chart review of patients with hrnbl treated at texas children's hospital from to . neutrophil engraftment was considered the first of three consecutive days with post-transplant neutrophil count greater than cells/ul. red blood cell and platelet engraftment were considered at a hemoglobin greater than g/dl and platelets greater than , /ul three days after the last transfusion. race and conditioning regimen were analyzed using one-way anova; amount of infused cells was analyzed using pearson correlation coefficients; chemotherapy delay and bone marrow (bm) involvement after cycle of induction chemotherapy were analyzed using independent sample t-tests. the study included males and females with a median age at diagnosis of . years. thirtyeight patients were caucasian, african-american, hispanic, asian, and did not have race documented. the mean dose of infused cd + cells was . × ^ cells/kg. forty-five patients received conditioning therapy with carboplatin/etoposide/melphalan (cem), received busulfan/melphalan (bu/mel), and received thiotepa/cyclophosphamide (thiotepa/cpm). the conditioning regimen administered was significant (p = . ) for time to engraftment of neutrophils, with bu/mel at . days, cem at . days, and thiotepa/cpm at days. a delay of chemotherapy during induction (n = ) was significant (p = . ) for time to platelet engraftment of greater than , /ul and trended towards significance (p = . ) for time to neutrophil engraftment. bm involvement at diagnosis and after cycle of induction was not significant for time to engraftment. dose of stem cells infused was the only variable significant for hemoglobin engraftment. background: osteosarcoma (os) is the most prevalent aggressive primary malignancy of the bone affecting children and young adults. approximately % to % of patients have metastatic disease at initial presentation, and % of those patients have isolated pulmonary metastases. although overall survival in patients with os has improved with advances in therapy, there have been no significant improvements in survival outcome in patients with metastatic disease. recent studies suggest that tumor-associated vascular cell adhesion molecule (tvcam- or cd ) plays a critical role in the metastatic progression of various tumors. indirect evidence from these studies suggest that vcam- / integrin signaling promotes tumor survival and metastatic progression by changing the tumor niche and associated immune response. to determine if interfering vcam- / signaling between pulmonary metastatic osteosarcoma (pos) and macrophages (macs) by down-regulating vcam- , depleting macs or blocking vcam- / signaling will reduce pos and improve overall disease-free survival. design/method: we used a pair of spontaneous, high-grade murine os cell lines from balb/c mouse (h- d), k and k m (derived from in vivo k metastasis). we used lentiviral shrnas to knockdown vcam- mrna and protein expression in k m (vcam- kd). we introduced luciferase into k , k m and various k m shrna cell lines to follow lung metastasis by bioluminescence (bli). we depleted macs by intranasal administration of liposomal clodronate formulation. we tested the ability of k and k m supernatants to polarize m macs into m or m phenotype in vitro. we also administered anti- monoclonal antibody (anti- mab) intranasally to assess the outcome of functional blockade of vcam- / signaling. results: k m over-expressed vcam- compared to k . mac depletion in k m -bearing animals exhibited reduced pos. weekly administration of anti- mab resulted in % tumor-free rescue among mice with established k m pos. interestingly, supernatant from k m but not k preferentially induced m -like macs, suggesting a novel integrin-mediated mechanism of m differentiation. validation data with additional os cell lines will be presented. despite aggressive multimodal therapy, overall outcome for patients with pos remains dismal at - %. for this reason, novel and directed therapy approaches are desperately needed. molecular targeted approaches for therapy are challenging, due to the complex genetic heterogeneity of os. immune-modifying therapy is a promising new alternative approach for pos. university of chicago, chicago, illinois, united states background: only half of all patients diagnosed with high-risk neuroblastoma achieve long-term survival. imetaiodobenzylguanidine (mibg) scans are routinely used to evaluate disease at diagnosis and following treatment, and the extent of disease is quantified using the curie scoring system. a previous study by yanik et al., has shown that for high-risk patients with mycn non-ampliified tumors, scores less than versus greater than following cycles chemotherapy are associated of superior survival, whereas scores less than versus greater than were prognostic in patients with mycn-amplified tumors. however, the prognostic significance of specific sites of metastatic disease at diagnosis is not known. to determine if site of metastatic disease determined by i-metaiodobenzylguanidine (mibg) imaging in high-risk patients at the time of diagnosis was associated with outcome design/method: we performed a retrospective chart review of high-risk neuroblastoma patients treated at comer children's hospital and lurie children's hospital in chicago between and with positive mibg scans at the time of diagnosis. we collected imaging data as well as other clinical data including bone marrow status. sites of disease were defined as curie regions with any positive value. kaplan-meier analysis was performed to evaluate the association with disease sites and survival. pearson correlation coefficients were calculated to compare bone marrow disease to sites of positivity on mibg scan. the cohort consisted of high-risk patients. had skull disease, and had pelvic disease. the presence of mibg positive disease in the skull and in the pelvis trended toward worse efs. efs at years for patients with disease in the skull at diagnosis was ± % and for patients without skull disease was ± % (p = . ). efs at years for patients with and without pelvic disease was ± % and ± % (p = . ). consistent with prior data, we found that the presence of bone marrow disease was associated with worse survival with year efs of ± % and ± % with and without marrow disease at diagnosis (p = . ). there is the highest correlation between pelvic disease on mibg scan and bone marrow disease with pearson coefficient . . pelvic disease noted on mibg scan likely reflects underlying bone marrow disease. in patients with high-risk neuroblastoma, skull disease and pelvic disease on mibg scan at diagnosis may predict worse event free survival. background: osteosarcoma is one of the deadliest cancers in the pediatric population with little progress in morbidity and recurrence rates since the 's. oncolytic herpes simplex- virus (ohsv) is an attenuated virus that has shown encouraging results against certain solid tumors. programmed cell death protein (pd)- -mediated t cell suppression via engagement of its ligand, pd-l , is also of particular interest due to recent successes in selected cancers, especially those with high genetic mutational loads. most pediatric cancers do not have a wide variety of mutations; however, osteosarcoma has a chaotic genome, prone to genetic mutations. it has been shown through numerous other studies that pd- inhibition alone is not sufficient to result in statistically significant tumor growth delays in osteosarcoma models and patients. we hypothesize the addition of ohsv therapy as an immunologic stimulus to pd- inhibition is efficacious for osteosarcoma. ( ) to determine whether ohsv therapy enhances response to pd- inhibition in immunocompetent murine models of osteosarcoma and ( ) to quantify and characterize the anti-tumor t-cells infiltration after treatment with ohsv and pd- inhibition individually and in combination. we utilized an immunocompetent transplantable murine model using a cell line derived from a spontaneous metastatic osteosarcoma (k m , balb/c background). we transplanted established tumor wedges subcutaneously and monitored tumor volume by caliper measurement. once tumors reached - mm , we administered intratumoral injections of hsv ( × plaque-forming units) every other day for a total of injections. we then gave intraperitoneal injections of ug anti-pd- or control antibody twice weekly, up to weeks, starting from the last dose of virus treatment. we monitored tumor growth via calipers twice weekly until tumors reached mm or cm diameter. we quantified and characterized innate and adaptive immune cell infiltrates in tumors using flow analysis. we found significantly prolonged survival with our combination therapy group compared to all other groups. we found that anti-pd- by itself had little impact on t cell recruitment while the combination group had higher influx of cd + cells with a reduced amount of t-regulatory cells (cd +foxp +cd +). we also found an increase in cd + effector memory cells. osteosarcoma is a deadly cancer with therapeutics remaining unchanged for the last years. here, we describe prolonged murine survival after treatment with combination of pd- inhibition and ohsv injection. the combination treatment changed the microenvironment to be more inflammatory. our data support further preclinical and clinical studies. background: neuroblastoma is the second most common cause of cancer related death in children. treatment for high-risk neuroblastoma has improved significantly over the past twenty years, however cure rates remain below %. immunotherapy has emerged as an effective therapy for neuroblastoma, however new modalities and targets are needed to improve outcomes. objectives: our lab has developed a chimeric antigen receptor (car) that targets b -h (cd ), an immune checkpoint molecule overexpressed on many cancers, including neuroblastoma. we hypothesized that b -h would be a good target for car based immunotherapy for neuroblastoma. design/method: neuroblastoma tissue microarrays of primary patient samples were screened for b -h expression by immunohistochemistry and cell lines were screened using flow cytometry. b -h car t cells were tested in vitro by measuring tumor cell killing and cytokine production after coculture with tumor cell lines and in vivo in an orthotopic model of neuroblastoma. results: b -h expression was detected by ihc on % of the screened neuroblastoma patient samples. b -h was expressed at high levels ( + or +) in more than half of these samples ( %). almost all cell lines screened were homogeneously positive for b -h by flow cytometry. retrovirally transduced b -h . - bb. car t cells were cocultured with three b -h positive neuroblastoma cell lines (sk-n-be , kcnr, and chla ) and robust tumor cell killing was demonstrated using an incucyte assay. supernatant from the co-cultures was harvested after hours and both interferon gamma and il- production were detected by elisa.in an orthotopic subrenal capsule xenograft model of neuroblastoma, mice treated with b -h car t cells show significant reductions in tumor growth and prolonged survival compared to those treated with untransduced control t cells. however, the treatment is not always curative.b -h car t cells express high levels of exhaustion markers (pd , tim , and lag ) when compared to cd car controls. in order to overcome inhibition from exhaustion, b -h car t cells were co-cultured with neuroblastoma cell lines and pd- blocking antibody. nivolumab significantly increased the production of il- and interferon-gamma by b -h car t cells. further studies are underway to determine if b -h car t cell activity is enhanced in vivo by treating animals with pd- blockade along with car t cells. conclusion: b -h is expressed on a majority of neuroblastoma samples and appears to be a promising candidate for car t cell therapy. b -h car t cells demonstrate activity against neuroblastoma xenografts that may be enhanced by the addition of pd inhibitors. helen devos children's hospital, michigan state university, grand rapids, michigan, united states background: osteosarcoma is the most common bone tumor in children. it is often metastatic at diagnosis and in this scenario less than % of children survive. polyamines, small molecules found in all cells, are involved in many cell processes including cell cycle regulation, immune modulation, cell signaling and apoptosis. they are also involved in tumor development, invasion and metastasis. in neuroblastoma, inhibition of the polyamine biosynthesis pathway with odc inhibitor alpha-difluoromethylornithine (dfmo) results in decreased cell proliferation and differentiation. these finding have led to multiple phase i and phase ii multicenter clinical trials in pediatric neuroblastoma patients. dfmo is an attractive drug as it is oral, well-tolerated, can be given for prolonged periods and is already used in pediatric patients. the polyamine pathway has not been evaluated in osteosarcoma. objectives: evaluate effect of inhibition of polyamine biosynthesis with dfmo on osteosarcoma proliferation and cell differentiation. design/method: up to three osteosarcoma cell lines were used: mg- , u- os and saos- . cells were exposed to mm dfmo for days with replacement of media and dfmo on day . intracellular polyamine levels were measured by high performance liquid chromatography (hplc). cell numbers were obtained with a hemocytometer using trypan blue. flow cytometry cell cycle distribution (facs) and propidium iodide were used to evaluate for cell cycle arrest. the protein expression of several osteosarcoma differentiation markers was measured by sds-page and western blot using differentiation specific antibodies. a bioluminescent cell viability assay was used to measure cell recovery over several days after dfmo was removed and replaced with standard media. results: dfmo exposure resulted in significantly decreased cell proliferation in all cell lines. after treatment, intracellular spermidine levels were nearly eliminated in all cells. cell cycle arrest at g was observed in u- os. cell differentiation was most pronounced in mg- and u- os cells as determined by increased osteopontin levels. remarkably, cell proliferation continued to be suppressed for several days after removal of dfmo. conclusion: based on our findings dfmo is a promising new adjunct to the current osteosarcoma therapy for high risk patients. it is a well-tolerated oral drug that is currently in phase ii clinical trials in pediatric neuroblastoma patients as a maintenance therapy. the same type of regimen may also improve outcomes in metastatic or recurrent osteosarcoma patients for whom there have been essentially no medical advances in the last years. background: recent studies demonstrate that lower levels of the ews-fli fusion oncoprotein are associated with enhanced metastatic capability in ewing sarcoma. the nf-kb transcription factor is a critical mediator of cxcr and cxcr -driven metastasis in multiple cancers, and increased cxcr and cxcr expression have each been associated with increased metastasis and poor prognosis in ewing sarcoma. we thus sought to investigate the impact of ews-fli on cxcr /cxcr -dependent nf-kb signaling in ewing sarcoma. objectives: the goals of this study are ) to determine the impact of cxcr /cxcr signaling on metastasis-associated nf-kb target gene expression in ewing sarcoma and then ) to investigate how the ews-fli fusion oncoprotein modulates this response . design/method: we utilized multiple ewing sarcoma cells lines including a , chla , chla , tc and tc . cxcr /cxcr cell surface expression was determined by flow cytometry. ews-fli level was modulated using sirna and expression levels were confirmed by western blot and rt-pcr. p dna binding was measured via elisa. nf-kb target gene expression was assessed via rt-pcr. results: consistent with ihc analysis of primary and metastatic patient tumor samples, the paired primary and metastatic ewing sarcoma cell lines chla and chla showed dramatic differences in cxcr and cxcr expression, with the metastatic chla line demonstrating much higher expression of both receptors. other cell lines (nonpaired) showed variable cxcr /cxcr expression. genetic knock-out of cxcr lead to significant decrease in expression of both cxcl /sdf- and il- , two nf-kb transcriptional targets known to play a key role in tumor metastasis. knock-out of cxcr did not alter endogenous ews-fli mrna levels. conversely, lowering the level of ews-fli using sirna lead to enhanced nf-kb signaling, indicated by an increase in p dna binding. consistent with this observation, treating ewing cell lines with ews-fli sirna also resulted in significantly increased nf-kb target gene expression compared to control cells and target gene expression was then further enhanced upon cxcr /cxcr receptor stimulation with the receptor ligand cxcl /sdf- . our findings indicate that the ews-fli oncoprotein negatively modulates cxcr /cxcr -dependent nf-kb signaling. this suggests that ews-fli low, cxcr /cxcr high cells, which are associated with enhanced metastasis and poor prognosis, would be anticipated to exhibit enhanced expression of key nf-kb target genes. importantly, the nf-kb pathway is a druggable target that could potentially serve as an "achilles heel" in this subset of high risk tumors. current work is evaluating nf-kb inhibition as an approach to treating metastatic and refractory ewing sarcoma. background: acute graft versus host disease (agvhd) is a major cause of morbidity and mortality following allogeneic bone marrow transplant (bmt) in pediatric patients. gastrointestinal (gi) agvhd is the most serious manifestation. recently, decreased paneth cell (pc) in a predominantly adult cohort was shown to correlate with agvhd clinical grading and response to treatment. we aim to demonstrate the relationship between pc counts and gi agvhd stage and response to therapy. design/method: charts of patients who underwent endoscopy following bmt between - were reviewed. for repeated biopsies during the course of agvhd, only the first was included for analysis. one pathologist retrospectively reviewed the biopsies and counted pcs in high powered fields; the average pc count was analyzed. twenty-six percent of biopsies were reviewed by a second blinded pathologist. statistical associations between pc counts and day (d ) response, agvhd stage, and other study covariates of interest were gauged using general linear regression. agreement in pathologist pc counts was quantified by intraclass correlation (icc). the research was approved by the children's healthcare of atlanta irb. results: seventy-eight biopsies were included in the analysis. mean age at transplant was . years ± . (range: months - years). most patients underwent transplant for hematologic malignancies ( , %). the majority of transplants used a matched unrelated donor graft -including cords ( , %) and myeloablative conditioning regimens ( , %) - % received total body irradiation. of these, % were diagnosed clinically with gi agvhd (stage , %; stage , %; stage , %; stage , %). icc showed good agreement ( . ) between the pathologists. mean pc was . for patients with no gut agvhd, . for stage , . for stage , . for stage and . for stage (p = . ). on multivariate analysis pc was strongly associated with gi agvhd stage (p< . ) after controlling for age, preparative regimen intensity, and diagnosis (malignant vs. non-malignant). mean pc counts were significantly lower in patients with no response to steroid therapy at d (complete response (mean . ) vs. persistent disease ( . ) vs. partial response ( . ) (p = . )). patients diagnosed with gi agvhd with pc counts less than had a higher risk of mortality (hr . , % ci: . , . ; p = . ). lower pc count correlated with stage gi agvhd, refractory disease at d , and mortality. incorporating pc count in pathology review during gi agvhd work-up may help in agvhd risk stratification. background: there have been increasing discussions pressuring health care teams and institutions for potentially bearing the cost of clostridium difficile infections (cdi) as a health care-associated infection in the recent years. the pediatric oncology patient population, though small, accounts for significant portion of all cdi with - -fold increased risk. hematopoietic stem cell transplant (hsct) recipients constitute a unique subset with distinct risk factors, such as severe immune deficiency state and graft versus host disease (gvhd). although there is ample data on cdi in adult hsct recipients, reports on pediatric experience are limited. objectives: to evaluate the incidence and patterns of cdi among pediatric hematology, oncology and hsct inpatients at our institution. a retrospective review of all clostridium difficile (cd) stool tests performed using toxin enzyme immunoassay and later, polymerase chain reaction targeting toxin genes between and in a large, urban academic children's hospital was performed. the data were analyzed for hematology, oncology, hsct inpatient population and all the other cases separately and statistical comparisons were performed. results: a total of samples were submitted to the microbiology laboratory for cd testing during the study period. while hematology patients constituted . %, oncology . %, hsct . % and others . % of the cases on whom cd testing was done; per patient average test number was . , . , . , and . , respectively. of all the cd tests per-formed, . % were positive. test positivity was higher in hsct ( . %) and oncology ( . %) cases tested compared with hematology ( . %) and other cases ( . %) with statistical significance (p< . ). overall recurrence rate was . %; hsct patients had the highest recurrence with a rate of % followed by oncology ( . %), hematology ( . %) and other ( . %) cases, again reaching statistical significance (p< . ). again, hsct patients had the highest average number of recurrences at . ( - ) followed by oncology . ( - ), general . ( - ) and hematology . ( - ) groups. there was no seasonal variability in the incidence of cdi among populations analyzed. prolonged hospital stay/antibiotic use and persistent diarrhea due to gvhd are the likely reasons for higher rate of cd testing in hsct as a result of increased monitoring and thus might have even caused underrepresentation of positive cd test frequency. higher incidence and frequencies of recurrence underscores the inevitable nature of cdi in hsct population as a consequence of the current therapies and may lead to future radical treatment approaches like fecal implantation. background: viral infections remain a challenge to treat post hct in children, and significantly contribute to morbidity and mortality. virus specific t cells (vsts) have shown tremendous clinical efficacy in treating viral infections post-hct, with minimal toxicity and long term efficacy. we have used donor-derived vsts in individual patients, however not all donors are agreeable to the process, and numerous patients may benefit from vsts who do not have an identified donor/have other disease indications objectives: we sought to actively build a third-party vst bank, for "off the shelf" use in eligible patients. design/method: vsts targeting cmv, adenovirus and ebv were manufactured using one of techniques. initially ebv transformed b cells were genetically modified with an ad f pp vector and used as antigen presenting cells (apc) to stimulate and expand ebv, ad and cmvpp specific t cells. more recently, vsts were expanded using s of s apc pulsed with commercially available peptide pools (pep-mixes) to expand ebv/cmv/ad specific t cells. products were entered into the "bank" via two mechanisms: a) left over products from our "donor-derived" protocol when patients no longer required vsts or were not at risk of developing viral infections, or b) by targeting regular blood donors based on their hla typing to ensure an appropriate mix of high frequency hla types for optimal patient matching and antigen presentation based on current knowledge of antigen presentation. results: a total of products are currently in the thirdparty vst bank ready for use. twenty seven of these are from our donor derived protocol, and three from targeted donors. all vst products met safety and in vitro efficacy testing. thirteen vst infusions have been given to patients. eleven infusions have been given for cmv and two for adenovirus. five out of seven patients responded to thirdparty vst infusions, with a median of vst infusions per patient (range - ). the median hla matching was out of per patient (range to ) no patients experienced adverse reactions, gvhd or other toxicity related to the vst infusion. a third-party vst bank is feasible and produces clinically appropriate vsts for use in patients with viral infections. hla typing and matching of vst products is essential to reduce toxicity and promote appropriate antigen presentation and expansion of vsts in vivo. further work is underway to further characterize the vsts using epitope mapping to better define the hla restriction and immunogenicity of each vst product. akron children's hospital, akron, ohio, united states background: acute graft-versus-host disease (agvhd) is a well-known complication of hematopoietic stem cell transplant (hsct) and a major cause of post-transplant related morbidity and mortality. first line therapy of agvhd involves corticosteroids and calcineurin inhibition. in patients with severe refractory gvhd, mortality can reach up to %. currently, there is no standard of care for the treatment of steroid refractory agvhd. many centers have looked at the use of antibody mediated control of agvhd to competitively inhibit the inflammatory cascade. basiliximab, a chimeric monoclonal antibody against the t-cell il- receptor, has been used in adults with steroid refractory agvhd. patients receiving this medication have demonstrated complete and partial responses to therapy with minimal toxicities. objectives: report the successful use of basiliximab in the treatment of agvhd in a -year-old following matched unrelated (mud) hsct. design/method: a -year-old male underwent mud transplant for high risk aml with monosomy . conditioning regimen included busulfan, fludarabine and equine atg. his clinical course was complicated by fever, mucositis and agvhd (stage skin; stage gi-biopsy proven). gvhd prophylaxis included tacrolimus and methotrexate, however with progressive skin rash, diarrhea, and early satiety, gvhd treatment with corticosteroids was initiated. as the patient continued to have worsening symptoms, basiliximab therapy was started. the patient received doses ( mg) iv basiliximab on two consecutive days and then received weekly therapy for a total of doses leading to initial improvement. the patient further developed acute on chronic gvhd on day + , and subsequently received a second course of basiliximab. after initial administration of basiliximab, the patient had near complete resolution of symptoms. however, with a small wean in his tacrolimus dose, the patient experienced another skin gvhd flare prompting the second basiliximab course. the patient was subsequently weaned off all immunosuppression by day + . the only acute complication the patient experienced while receiving basiliximab was right toe paronychia and asymptomatic low ebv titer. the patient is currently off all immunosuppression at the time of report without evidence of cgvhd. conclusion: this single case report, in a young pediatric patient, demonstrates the use of basiliximab may be a safe and efficacious treatment for pediatric patients with agvhd. university of california, san diego, la jolla, california, united states background: clinical outcomes after allogeneic hematopoietic stem cell transplantation (hsct) depend on restoration of t lymphocyte populations. association between recovery of cd +foxp + regulatory t cells (tregs) and protection from chronic graft versus host disease (cgvhd) has been described in adult hsct. in adults, t cell recovery is driven by expansion of donor t cells and treg reconstitution is hypothesized to result from peripheral conversion. restoration of t cells in pediatric patients has a larger contribution from thymopoiesis, however, the relationship between thymopoiesis and treg recovery is undefined. objectives: we hypothesized that effective thymopoiesis is important for restoration of treg populations and protection from cgvhd in pediatric hsct patients. design/method: we performed longitudinal flow cytometry of peripheral blood t cells from pediatric hsct patients and age-matched healthy donors. laboratory data were correlated with clinical outcomes to evaluate impact. recovery of tregs occurred in / ( . %) patients by post-transplant day . day treg frequency in patients that developed cgvhd ( . ± . % of cd + t cells) was reduced compared to cgvhd-free patients ( . ± . %). failure to restore tregs to > . % of cd + cells by day was associated with increased risk of cgvhd in the first year post-hsct (rr = . , p = . ). a majority ( . ± . %) of tregs from patients recovering the peripheral treg compartment expressed helios, a marker of thymic-derived tregs; only . ± . % of tregs expressed helios in patients failing to restore adequate tregs. this prompted examining the relationship between defects in thymopoiesis and inability to restore tregs. we evaluated thymic function by flow cytometry quantification of cd ra+cd +ptk + recent thymic emigrant (rte) cd + cells (confirmed by qpcr for trec content). most ( / , . %) hsct patients had detectable rtes by day post-hsct. thymic production of rtes was persistently absent in patients that developed cgvhd (< / ^ cd + cells in / patients), compared to cgvhd-free patients ( / patients > rte/ ^ cd + cells by day , average . ± . / ^ cd + cells). post-hsct thymic activity as measured by rte enumeration correlated with treg restoration; / ( %) rte+ patients restored tregs, compared to / ( %) of rte-patients. conclusion: failure to restore tregs after allogeneic hsct results in increased risk for cgvhd. in pediatric patients thymic generation of new t cells is an important contributor to restoration of the treg compartment. this data supports further investigation into mechanisms impairing post-hsct thymopoiesis and suggests peripheral blood tregs may be a prognostic biomarker for cgvhd. background: haploidentical stem cell transplantation (haplo sct) is riddled with unique challenges. objectives: we present our experience in the use of haplo sct with post-transplant cyclophosphamide (ptcy) and the adaptations required for each disorder for optimal outcome. design/method: we performed a retrospective study at the pediatric blood and marrow transplant unit, apollo cancer institutes, chennai, india. children up to years of age, diagnosed to have benign disorders and underwent haplo sct with ptcy from to july were included. results: ptcy was used in i.e. % haplo transplants for children with benign disorders. the underlying conditions included fanconi anemia , severe aplastic anemia , mds , jmml , hemoglobinopathy , prca , xld and primary immunedeficiency disorders (pid) . source of stem cells was peripheral blood in %, bone marrow in %. conditioning included fludarabine with treosulphan or cyclophosphamide for pids and aplastic anemia respectively. neutrophil engraftment by day+ - with a durable graft was noted in % transplants with graft versus host disease in %, cmv reactivation in %. mortality rate was % with infants less than months of age developing severe fatal cytokine release syndrome. the median follow up is year with years being the longest. no significant late effects have been noted with chronic skin gvhd in children. survival rate was superior among children with pids with survival of % in this group. haplo sct with ptcy is a feasible and costeffective option for cure in children with life-threatening benign disorders with no compatible family or matched unrelated donor. careful patient selection, reducing cyclophosphamide related free radical toxicity with the use of n acetylcysteine, limiting t cell numbers by capping cd at × /kg, post-transplant viral monitoring protocols are required to reduce morbidity and mortality. we have been working on universal access to care for children from s of s all socioeconomic background and incorporating innovations to reduce the cost of hsct without compromising outcomes. haploidentical hsct using tcr / depletion costs usd as compared to ptcy priced at usd. children with severe aplastic anemia and pids can be transplanted using reduced intensity conditioning and ptcy. in hemoglobinopathies, pretransplant immunosuppression is required to prevent graft rejection. graft versus host disease remains the main cause of mortality in children with fanconi anemia. mortality in infants less than months after ptcy has been high, tcr / depletion would be superior in this cohort. cincinnati children's hospital medical center, cincinnati, ohio, united states background: fanconi anemia (fa) is a congenital bone marrow failure syndrome with hsct the only curative option for associated bone marrow failure. patients with fa undergoing hsct may experience increased toxicity related to either their underlying disease, or the effects of medications, resulting in the inability to tolerate prophylactic medications or sideeffects from anti-microbial therapy. objectives: we postulated that increased cd cell dose would be associated with a rapid immune reconstitution and therefore early withdrawal of anti-infective prophylactic medications. design/method: patients with fa transplanted at cchmc from an unrelated donor had peripheral blood stem cell grafts collected and cd selection performed. where possible, patients had serial measurements of their immune system performed at varying intervals post hsct. we defined immune reconstitution as normalization of lymphocyte subsets-cd , cd , cd and cd cells, as well as a normal response to mitogen stimulation including phytohemagglutinin, concanavalin a and pokeweed. the first measurement of either normal cell number or mitogen response was recorded for each patient. results: a total of patients underwent hsct for fa at cchmc between and . patient demographics included a median age of years at hsct, the vast majority of patients having a fully matched or one anti-gen mismatched donor, and the majority of patients transplanted for bone marrow failure. there was a statistically significantly decreased time post-transplant to immune cell recovery in patients receiving > × /kg cd cells (median . ) compared to those receiving < × /kg cd cells (median . ). the median time to normalization of cd count was days (cd count > /kg) versus days (cd count < /kg), cd count days (cd count > /kg) versus days (cd count < /kg), cd count days (cd count > /kg) versus days (cd count < /kg) and cd count days (cd count > /kg) versus days (cd count < /kg). time to normalization of mitogen response was decreased posttransplant in those patients receiving increased cd cell dose at time of transplant, though this was not significant, reflecting low number of patients with evaluable responses. no patients in either group experienced gvhd or graft failure. patients with fa who are transplanted with higher cd cell doses have quicker immune reconstitution than those who receive lower cell doses. along with benefit to patients including less risk of infection and early termination of immune-prophylaxis medications, this supports the use of high dose cd selected grafts in this vulnerable population. background: parvovirus b (pvb ) infection after transplantation was first reported in . since then, numerous cases of pvb infections after hematopoietic stem cell transplantation (hsct) and solid organ transplantation (sot) have been reported. most report anemia as the predominant clinical manifestation. however, pvb has been associated with pancytopenia, hepatitis, myocarditis, and allograft rejection. we present a patient with acute lymphoblastic leukemia who developed bone pain and pancytopenia following hsct in the setting of pvb infection. to describe an unusual presentation of pvb in a patient with acute lymphoblastic leukemia following hsct. design/method: a search of the english-language medical literature was performed using pubmed and medline databases. a review of the patient's medical history was performed. a year old male with relapsed b-cell all and history of "fifth disease" in infancy presented four months after hsct with focal left arm pain and difficulties fully extending the arm. bone mri showed enhancement of the medullary space centered within incomplete transverse cortical fracture interpreted as pathologic fracture due to neoplastic involvement of the ulna with no history of inciting injury. subsequently, peripheral blood counts decreased from low normal values to wbc . k/microl, anc /microl, plt k/microl, and hemoglobin . g/dl. the patient's chimerism remained % donor. a bone marrow biopsy and aspirate were performed to assess for recurrent leukemia given persistence of bone pain and developing pancytopenia. marrow findings included morphologic cytopathic effects with erythroid precursors and strong parvovirus staining with no signs of red cell aplasia or recurrent b-cell disease by morphology or flow cytometry. pvb was detected in blood by pcr and immunoglobulins with resolution of cytopenia and bone pain. this case highlights an unusual constellation of symptoms following hsct in a child with all. unexplained bone pain and medullary infiltrates with pancytopenia suggestive of recurrent leukemia were likely triggered by pvb infection. the question remains if he had reactivation of pvb , a primary infection by a new strain, or the virus was aquired through stem cells. bone biopsy could not be justified in light of clinical improvement. so far, bone lesions have only been described with congenital pvb infection. pvb appears to be uncommon after hsct, with a review of literature yielding pediatric cases. however, it may be underestimated due to lack of routine screening. our patient's presentation supports that evaluating for pvb may be warranted in hsct patients presenting with symptoms suggestive of relapsed leukemia. background: cardiac injury may occur during hematopoietic stem cell transplant (hsct) in pediatric patients and can be asymptomatic for many years. recommendations for screening are available for patients who received anthracyclines or chest irradiation, but no guidelines exist for unexposed longterm survivors. we sought to define the prevalence of echocardiographic abnormalities in long-term survivors of pediatric hsct and determine the need for screening in asymptomatic patients. design/method: we analyzed echocardiograms performed on long-term survivors (≥ five years) who underwent hsct at cincinnati children's hospital between and . we analyzed echocardiograms for left ventricular ejection fraction (ef), end-diastolic dimension (lvedd), septal thickness, posterior wall thickness, and global longitudinal strain (gls). we normalized linear measurements for age and patient body surface area. we included for further analysis patients who had echocardiogram obtained for routine surveillance. results: a total of patients underwent hsct and were alive more than years after transplant in , with having an echocardiogram obtained ≥ five years postinfusion. those with an echocardiogram were transplanted more recently (median vs. ). however, no difference between screened and unscreened individuals was noted for age at transplant, sex, transplant indication, anthracycline exposure, chest irradiation, or cyclophosphamide based preparative regimen. indications for echocardiograms included: cardiac symptoms ( . %), congenital cardiac anomalies ( . %), hypertension ( . %), known cardiac or pulmonary disease ( . %), routine post-hsct surveillance ( . %), and unknown ( . %). the mean time post-hsct was . years. among routine surveillance echocardiograms, the mean ef z-score was - . . mean lvedd zscore was - . , mean septal thickness z-score - . , mean posterior wall thickness z-score - . , and mean gls - . %. for patients that had echocardiogram performed for routine surveillance, / patients ( . %) had ef measured, and / ( . %) had ef z-scores ≤ - . (abnormally low). patients exposed to anthracyclines had a mean z-score ef of - . vs. unexposed patients - . (p = . ). among individuals who received neither anthracyclines nor tbi only / ( . %) was found to have an abnormal ef, . % (z-score - . ) or gls (- . %). only one patient who had a normal ejection fraction (z-score - . , ef . %) had an abnormal gls, - . % (normal ≤ - . ). long-term survivors of pediatric hsct who are asymptomatic and did not receive radiation or anthracyclines likely do not require surveillance echocardiograms, unless indicated by clinical symptoms. patients exposed to anthracyclines or tbi require close echocardiographic s of s screening and clinical monitoring for the development of cardiac complications. duke children's hospital, durham, north carolina, united states background: children undergoing pediatric blood and marrow transplants (pbmt) experience significant symptom distress. mobile health (mhealth) technologies can be leveraged to collect and monitor patient generated health data, and subsequently enhance our understanding of pbmt symptom clusters, patterns, and trajectories. better understanding of symptom complexity can foster development of precision health strategies to improve patient outcomes. however, limited research exists in integrating mhealth technology into pbmt management. we aimed to explore the feasibility, acceptability, and usability of using a pbmt specific mobile application to collect and monitor symptoms and wearable technology (apple watch) to measure objective data such as heart rate (hr) and activity. design/method: an exploratory mixed method design began in october to monitor pbmt symptoms for patients using real-time data from: ) a self-developed mhealth application (app) to collect subjective symptom data; and ) apple watch to collect physiologic measures such as heart rate and number of daily steps. data is collected pre-transplant through days. acceptability will be assessed through satisfaction surveys at study completion. we have enrolled patients to date who are all currently using the app and watch. patients' average frequency of daily charting in the app %. the wearable average daily recorded measurements are for hr and for step count. most common symptoms recorded within the app include fatigue and pain. we have noted trends in data including a decrease in activity following transplant and gvhd and an increase following engraftment. patients have stated "the app is helpful to keep track of how my pain is doing day to day" and "i try to take more steps each day than the day before". patients often remove the watch for charging, then forget to put it back on, but consistently put it on upon reminder. finally, parents often were required to make app entries with patients too sick to record. we continue to enroll patients with enthusiasm from both patients and parents to use mhealth during pbmt. preliminary findings suggest feasibility of using the mhealth devices is strongly correlated to the patient's post-transplant stage and is facilitated by caregiver participation with device management (charging devices, reminders to wear watch and record in app). patients reported satisfaction and ease of use with devices, but found it difficult to keep up with charging and charting. these findings indicate using mobile devices may be useful methods to collect patient generated health data. cincinnati children's hospital medical center, cincinnati, ohio, united states background: bacterial bloodstream infections (bsi) are a common complication following hematopoietic stem cell transplantation (hsct) in both pediatric and adult populations, and are associated with poor outcomes. there is limited data describing the outcomes and characteristics of patients who develop three or more bsi after hsct. objectives: to describe the characteristics and outcomes of pediatric patients who develop three or more blood stream infections in the first-year post hsct. design/method: we performed a retrospective chart review of consecutive patients who underwent hsct at our institution from through to compile this case series. data were collected through the first year post-hsct including: patient demographics, underlying disease and therapy characteristics; and transplant complications such as thrombotic microangiopathy (tma), graft versus host disease (gvhd) and overall survival. bsis were classified according to current center of disease control guidelines. results: of patients, ( %) developed or more bsi in the first-year post transplant (total bsi cases = including all patients). of the cases, the majority underwent allogeneic hsct (n = / ; %). most cases were from unrelated donor (n = / , %). more than half of patients had grade - gvhd (n = / , %). sixteen ( %) had tma. of these cases, tma preceded the first bsi in n = / ( %). the majority of bsis were classified as central line-associated bloodstream infections (clabsis, n = / , %), followed by mucosal barrier injury laboratory-confirmed bloodstream infections (n = / , %) and secondary bsi (n = / , %). the majority of isolated organisms ( %) were associated with mucosal barrier injury pathogens. one-year overall survival in the cohort was % (n = / ). pediatric patients undergoing hsct who develop or more bsis in the first-year post transplant demonstrated an increased rate of tma compared to the overall institutional incidence of roughly %. tma diagnosis preceded the first bsi in over half of patients, suggesting that tma may predispose to recurrent bsi. improved strategies for early detection and treatment of tma as well as prevention of clabsis may help reduce the number of bsis ultimately leading to decreased morbidity and mortality in this patient population. background: in neutropenic pediatric patients, infection remains a significant cause of morbidity and mortality. while granulocyte transfusions have been utilized for decades to treat infections, including in the pediatric population, the efficacy of this intervention remains poorly described. previous guidelines have primarily utilized information from adult populations. furthermore, recruitment of donors typically involves friends or relatives of the patient with periodic involvement of community donors. the use of a readily available local donor population to improve availability has yet to be well described. as the immunocompromised population is particularly susceptible to worsening infection and clinical deterioration, the ability to rapidly harvest and deliver granulocytes warrants further investigation. to investigate the efficacy, safety, and outcomes of severely immunocompromised patients receiving granulocyte transfusions from a local altruistic granulocyte program in a pediatric tertiary care center. design/method: a retrospective review was performed to evaluate the context for receiving a transfusion as well as primary outcomes including infection clearance, survival to discharge, and overall mortality. the indiana blood bank assisted with timing the interval from initial order placement to onset of first granulocyte infusion. results: among the patient population reviewed, patients received separate granulocyte regimens. ages ranged from - years with a mean neutrophil count of at time of first transfusion. indications for transfusions included bacteremia (n = ), fungal pneumonia (n = ), and fungemia (n = ). primary outcomes included clearing infection ( %) and surviving to discharge ( %). the median time from initial order placement to infusion was hours, although there was no significant difference between responders who cleared the infection and non-responders who did not. however, additional investigation found that ward patients had a % chance of surviving to discharge while patients in the icu at time of initial transfusion had a % chance of survival to discharge. the readily available granulocyte transfusion program allows patients to quickly receive therapy in neutropenic settings. this is beneficial for patients as transfusion prior to clinical decompensation correlates with increased likelihood of infection clearance, and subsequently improved mortality. further investigation is needed, likely as a prospective study, to better explore circumstances that are beneficial for granulocyte transfusions. background: donor lymphocyte infusions (dli) are composed of immune cells to treat relapse after hematopoietic cell transplantation (hct). to date, data regarding its efficacy is limited in pediatric populations. furthermore, while outcomes related to cd content have been characterized, to our knowledge, the relationship between outcomes and other cellular content in dli has never been reported. objectives: determine whether the primary hematological malignancy, presence/absence of graft-versus-host disease s of s (gvhd), and unique phenotypic content of each dli impact overall survival (os) in pediatric patients with hematological malignancies. design/method: irb-approved, retrospective study investigating all consecutive dlis given to patients at the children's hospital of wisconsin. analyses were conducted using mann-whitney, fisher's exact, and chi-square. from from - patients ≤ years old with hematologic malignancies [myeloid (aml/ mds/cml/jmml),n = ; lymphoid (all),n = ] underwent dlis ( %% ≥ dlis). the median time between hct and dli was . (range, . - . ) years. there were significant differences between the lymphoid and myeloid groups, respectively, in regard to median age at hct ( . vs . yrs, p = . ) and at first dli ( vs years, p = . ). ultimately, there were no statistically significant differences in gvhd or os in products with either higher or lower cd , cd , cd , cd , or cd cellular content. however, the median cd /kg content was more than double in the patients who developed gvhd as compared to patients who exhibited no gvhd after dli ( . × vs . × , p = . ). patients receiving one dli had a -year os of ± % vs those receiving + dli of ± % (p = . ). with a median follow-up of . (range, . - . ) years, the year estimated os of patients in the lymphoid group was higher at ± % vs ± % in the myeloid group, although not significant (p = . ). our results indicate a survival benefit when using dli in a subset of patients who relapse after hct. unlike adult studies demonstrating little effect of dli in lymphoid diseases, many children with all achieved durable remission. while our analysis did not demonstrate that dli cellular content had a statistically significant effect on gvhd or os, it is possible that differences could be found if a larger population and more targeted cell doses were studied. more data will be needed to further define these relationships and identify patients who stand to benefit most. cincinnati children's hospital medical center, cincinnati, ohio, united states background: many arabic speaking muslim parents of children requiring bone marrow transplantation (bmt) receive medical care in the united states. providers may not understand the impact of islamic parents' religious beliefs and practices on their health care experience. objectives: to explore how islamic parents used religion in decision making and to understand the impact of their religious beliefs and practices on their overall health care experience. design/method: we used grounded theory, an inductive method gathering data from interviews and analyzing text, to identify core themes. ten caregivers of bmt children from middle eastern countries were interviewed by an arabicspeaking provider; interviews were coded by an interdisciplinary team. we identified key themes: . patience is a core belief in islam. patience results from the acceptance of allah's will. behaviors showing patience include praying rather than questioning and crying. . al qur'an provides comfort, healing, and protection. families listen to recitations of al qur'an in the patient's room because they feel that this practice not only comforts them but promotes healing as well. for some, certain portions of the qur'an were especially meaningful such as surat al-baqara, which explains that while we may think something is bad for us, allah will know it is good for us. . religious care in the medical center helped families feel respected. religious care in the medical center included interactions with chaplains, who were understood to be "religion experts," and provision of space for prayer and religious resources. . seeking religious consultation. religious consultation from imams or religious scholars (muftis or sheikhs) provides interpretations of the qur'an applied to the family's specific situation helps families make difficult decisions and follow allah's plan. . muslim beliefs guided decision making; muslim practices brought comfort, strength, and peace. drawn from the parents' understanding of islam. parents who addressed this topic said they would only do what islam allowed. they did indicate that most aspects of healthcare were understood to be allowed within islam. additionally, muslim practices of prayer, reading/listening to qur'an, and giving alms all provided comfort, strength and peace. we identified several recurring themes through our interviews that allowed us to understand how families use their muslim faith to deal with their children's illnesses and how it influences their decision making. we believe this better understanding will allow for more informed conversations about patients' health care and decision making, and shows respect for religious beliefs and practices. nemours/dupont hospital for children, wilmington, delaware, united states background: virtually all children will be infected with human herpesvirus (hhv- ) by the age of two. hhv- reactivation after stem cell transplantation causes multiorgan toxicities, including encephalitis, with inflammation and destruction of the temporal lobes and hippocampi, memory loss, and seizures. catatonia is characterized by posturing, immobility, mutism, and autonomic instability, and it's associated with various psychiatric and medical conditions. we describe a patient with hhv- encephalitis and unusual neurologic sequelae, including cognitive and neurobehavioral dysfunction and catatonia, which may impact our understanding of the pathophysiology of hhv- reactivation encephalitis. objectives: describe a case of hhv encephalitis with practice implications for stem cell transplantation. results: our patient was diagnosed with acute myeloid leukemia at age . within years, he relapsed and received two stem cell transplants. on the th day after his second transplant, he developed hyponatremia and refractory seizures. brain mri showed edema in the medial right temporal lobe with linear ischemic change. eeg showed diffuse encephalopathy. cerebrospinal fluid (csf) demonstrated white blood cells, red blood cells, and hhv- by pcr. his prophylactic antiviral was switched to foscarnet and ganciclovir. repeat mri showed abnormal signals in bilateral medial temporal lobes and the right insula. three months later he developed episodes of diaphoresis, hypothermia, agitation, mutism, and unusual posturing, recurring almost daily, recognized as catatonia. mri showed improvement of the abnormalities in the bilateral medial temporal lobes and hippocampi. eegs showed diffuse slowing. after months of antiviral therapy, csf was negative for hhv- . over the ensuing years, he had numerous episodes of diaphoresis, hypertension, hypothermia, pruritis, confusion, agitation, cogwheel rigidity, and bizarre posturing. dopamine blocking agents did not help. clonazepam helped reduce their frequency, and hot showers helped break acute episodes. further mris showed generalized cortical volume loss. he suffered from depression and severely impaired sleep and cognitive function. we describe a novel, debilitating outcome of hhv encephalitis which may provide diagnostic considerations as we continue to improve our understanding of the breadth of possible neurologic sequelae in transplant patients. hhv- is understood to infect and destroy the temporal lobes and hippocampi, but our patient's autonomic dysfunction indicate involvement of the hypothalamus and basal ganglia. antidopaminergic agents may worsen catatonia, and they were not effective for our patient. treatment of catatonia includes benzodiazepines; electroconvulsive therapy was not attempted in this case but may also be useful. background: epstein-barr virus (ebv)-related posttransplant lymphoproliferative disorder (ptld) is a lifethreatening complication in patients following hematopoietic stem cell transplantation, with a frequency estimated at . % and a cumulative incidence of mortality estimated as high as %. studies of ebv have hypothesized that the tonsils are critical for propagating this infection, as tonsillar epithelial cells have been shown to be the site of primary viral infection and continued viral shedding; however, to date no studies have been performed assessing the role of tonsillectomy in patients with ebv ptld. objectives: identify patients with localized ebv ptld treated with tonsillectomy to identify prognostic factors that may be able to help guide future treatment decisions. design/method: patients treated at memorial sloan kettering cancer center who had received hematopoietic stem cell transplantation and had billing codes for both ebv and tonsillectomy were eligible for inclusion in this study. a retrospective chart review was performed, assessing patient demographics, transplant characteristics, laboratory values, tonsillar pathology, and clinical course. any patient who did not have unilateral or bilateral tonsillectomy performed or who had non-localized disease (defined as disease involvement outside of the oropharynx and neck) was subsequently immunodeficiency; % (n = / ) fanconi anemia (fa); % (n = / ) hemoglobinopathy; % (n = / ) non-fa marrow failure and % (n = / ) a metabolic disorder. seventy one percent (n = / ) had normal amh for age pre-transplant, % (n = / ) had low amh for age pre-transplant; of these, % (n = / ) had an oncologic diagnosis; % (n = / ) had fa; % (n = / ) had previously treated hlh; % (n = / ) had non-fa marrow failure; one had a metabolic disorder and one a hemoglobinopathy. of the patients with post-transplant amh measurement % (n = / ) had low levels. of the patients with previously normal pre-transplant amh % (n = / ) underwent myeloablative conditioning (mac) regimen with a % (n = / ) having low amh levels post-transplant compared to %(n = / ) who underwent reduced intensity conditioning (ric) regimen with % (n = / ) having low amh levels post-transplant (p . ). fifteen percent (n = / ) had low levels pre-transplant and underwent mac regimen with % (n = / ) remaining low; % of these patients (n = / ) had fa. nine percent (n = / ) had low levels and underwent a ric regimen with % (n = / ) of amh levels remaining low; % (n = / ) of these patients had hlh treated prior to transplant. conclusion: amh levels can be used for detection of premature ovarian failure and fertility counseling. there is a higher risk of premature ovarian failure with mac regimens and prior chemotherapy vs ric regimens. follow up of this cohort will provide more information to understand the effects of hsct in ovarian function and the usefulness of amh as a predictor of fertility potential. background: there are no proven strategies to prevent blood stream infections (bsi) secondary to oral mucosal barrier injury after hematopoietic stem cell transplant (hsct). additionally, we recently reported progressive gingivitis and dental plaque accumulation in hsct recipients despite our current oral standard of care (three times daily oral rinse). xylitol is a non-fermentable sugar alcohol that reduces dental caries, plaque accumulation, and oral disease progression by inhibiting bacterial growth. we hypothesized that the addition of xylitol to standard oral care will decrease dental plaque accumulation, gingivitis and bacteremia from oral flora. objectives: identify a clinically effective strategy to improve oral health and prevent bsi secondary to bacterial translocation through the oral mucosa in patients undergoing hsct. we are conducting a prospective randomized control study to test our hypothesis. those in the intervention arm receive our current standard of care (three times daily oral rinse) in addition to daily xylitol wipes; controls receive oral standard of care alone. oral exams are performed at baseline and weekly for the first days post hsct. metagenomic shotgun sequencing (mss) of gingival samples is performed at all time points to evaluate microbiome diversity and pathogenic bacterial load. finally, we performed whole genome sequencing of pathogenic bacterial isolates causing bacteremia to assess for genetic relatedness to corresponding strains present within the patient's oral microbiome preceding the infection. : preliminary interim analysis of patients demonstrates improved oral health in patients receiving xylitol (n = ) over those receiving standard of care (n = ), measured by the oral hygiene index (p = . ) and gingivitis index (p = . ). in the nine patients having complete oral mss analysis, xylitol appeared to be associated with decreased streptococcus mitis/oralis domination in the oral microbiome. finally, patients receiving xylitol had no incidence of streptococcus mitis/oralis bacteremia through the first days compared to three patients ( %) in standard of care arm. interestingly, streptococcus mitis/oralis comprised % of the oral microbiome in one child who subsequently developed a streptococcus mitis/oralis bsi. we expect to complete this study in the next months (n = ). the addition of xylitol to oral standard care appears to decrease dental plaque and gingivitis in patients undergoing hsct. xylitol may also impede streptococcus mitis/oralis dominance in the oral microbiome with potential reduction in blood stream infections. (range: - days). twenty-one mdli ( %) were administered because of lymphopenia, fourteen of them ( %) in patients with concomitant viral/opportunistic infections. mixed chimerism/graft failure was the motive of % of the mdli (n = ) and six ( %) were administered to accelerate immune reconstitution. all infusions were well tolerated without appearance or worsening of gvhd. an increase in t-cell counts was observed following six mdli ( . %), although it was a transitory response ( - weeks) in five cases. viral/opportunistic infections were controlled in five cases ( . %), requiring a median of mdli to achieve this response. none of the mdli administered in cases of mixed chimerism/graft failure were effective in reverting this situation. our preliminary data suggests that mdli, is a safe adoptive immunotherapy strategy even with high dose of t-cells without infusion side effects or gvhd complications. some efficacy has been observed in patients with lymphopenia and opportunistic infections, with no positive results in patients with mixed chimerism/graft failure, up to date. however, to determine the real efficacy of this strategy, prospective studies are required. jun zhao, kristen beebe, lucia mirea, alexandra walsh, shane lipskind, alexander, ngwube phoenix children's hospital, phoenix, arizona, united states background: male adolescents undergoing myeloablative hematopoietic stem cell transplantation (hsct) develop infertility with impaired spermatogenesis with reported rates ranging from % to %. in nonmalignant diseases, myeloablative regimens have been replaced with reduced intensity conditioning (ric) with the hopes of better survival rate, less organ toxicity and improved quality of life. despite the increased use of ric regimens for hsct, the effects of ric on fertility remain unknown. objectives: to assess fertility following ric hsct in young adult males. we assessed gonadal function and semen characteristics in adolescent males (> years) who received a single ric hsct at phoenix children's hospital for nonmalignant diseases during - . male patients who were a minimum of year from ric hsct and had postpubertal development at tanner stage iii or above were eligible for this study. gonadal status was assessed by measuring fsh, lh, testosterone, and inhibin b levels, and semen anal-yses assessed fertility indicators (semen volume, sperm concentration, motility, viability, forward progression, morphology, and total count). results: hormone levels and semen analysis have been obtained for patients thus far. the median time between transplant and semen analysis was years. post hsct, ( %) patients showed abnormally elevated lh levels, but fsh, testosterone (total and free), and inhibin b levels were within normal range for all patients. sperm morphology and viability testing were not able to be performed due to low concentrations and volumes. as a result, the total motile sperm count, the most useful estimate for fertile potential, is essentially for all patients. conclusion: recruitment is ongoing, but so far our limited results suggest that ric hsct may have detrimental longterm effects on male fertility. a multi-institutional trial may be appropriate due to small patient numbers at each institution. we are currently exploring options to expand to other centers. further consideration is warranted regarding decisions made by providers, ways to improve anticipatory counseling provided to patients and their families prior to transplant, and how to augment the preventive care of these patients in longterm follow-up. currently all male patients being considered for ric transplant should be counseled to sperm bank prior to transplant. background: a previous systematic literature review identified all published studies of defibrotide treatment for patients of all ages with vod/sos. to assess day+ survival for defibrotidetreated pediatric patients (≤ or ≤ years, per study) all patients exhibited infectious complications with at least viral infection. four patients also had bacterial infections. of note, no patient developed evidence of fungal infections. conclusion: early institution of ecp in patients with high risk acute gvhd (grade - ) was very effective at treating agvhd, allowed for an aggressive steroid taper and contributed to excellent overall survival rates ( %). infectious complications were primarily viral and bacterial, with no fungal infections in this very high risk population. background: vod/sos is a life-threatening complication of hsct conditioning. vod/sos with multi-organ dysfunction (mod) may be associated with > % mortality. defibrotide is approved to treat hepatic vod/sos with renal/pulmonary dysfunction post-hsct in the us and severe hepatic vod/sos post-hsct patients aged > month in the eu. there are few published data on survival of neuroblastoma patients with vod/sos post-hsct. objectives: to report day+ survival and safety post hoc for patients with neuroblastoma and vod/sos post-hsct in the defibrotide t-ind trial. design/method: vod/sos was diagnosed by baltimore or modified seattle criteria or biopsy, with/without mod, after hsct or chemotherapy. defibrotide treatment ( mg/kg/day) was recommended for ≥ days. this post hoc analysis is based on adult and pediatric patients receiving ≥ dose of defibrotide, including with mod. results: among patients with neuroblastoma, developed vod/sos after hsct. for these post-hsct patients, . % were male and . % were female, median age was years (range - years): . % aged - months, . % - years, . % - years, and patient > years. day+ survival data were available for / of these neuroblastoma patients ( with mod and without mod); had autologous and had allogeneic transplants. kaplan-meier estimated day+ survival for the neuroblastoma group was . % ( % confidence interval [ci] , . %- . %). for the mod and no mod subgroups, kaplan-meier estimated day+ survival was . % ( % ci, . %- . %) and . % ( % ci, . %- . %), respectively. in the overall t-ind hsct population aged ≤ years (n = ) and pediatric autologous hsct subgroup (n = ), kaplan-meier estimated day+ survival was . % and . %, respectively. treatment emergent adverse events (teaes) occurred in . % (n = / ), with serious teaes in . % ( / ; most common: multi-organ failure, . % [ / ]). teaes lead to treatment discontinuation in . % (n = ; most common: pulmonary hemorrhage, n = ); death occurred in . % (n = ; > %: multi-organ failure, . %; vod/sos, . %). treatment-related adverse events, as assessed by investigators, occurred in . % (n = ; most common: pulmonary hemorrhage, . %). this post hoc analysis found kaplan-meier estimated day+ survival of . % in patients with neuroblastoma and vod/sos post-hsct, which was consistent with outcomes in pediatric patients after autologous hsct. the safety profile of defibrotide in neuroblastoma patients was consistent with the overall hsct population in this study and other defibrotide studies in pediatric patients. cincinnati children's hospital medical center, cincinnati, ohio, united states background: blood stream infections occur in nearly % of patients undergoing hematopoietic stem cell transplant (hsct) and fever is often the first symptom. timely administration of antibiotics is associated with improved outcomes, thus, early recognition of fever is paramount. current standard of care (soc) includes episodic monitoring of temperature in hospitalized patients, which may delay fever detection. therefore, continuous real-time body temperature measurement may detect fever prior to the current soc. temptraq is a food and drug administration cleared class ii medical device and consists of a soft, comfortable, disposable patch that results: of patients, were started on a pca in the days post hct. % were male with median age of y. % had all, and % aml. matched related donors were used in % and % received tbi. pca was initiated median d+ . oral mucositis alone was the most common indication ( %). a majority of patients were started on hydromorphone ( %); % started on morphine and % started on fentanyl. % started on continuous infusion. pca was used for a median of days (range - days). median pain score was highest d+ of pca use, however, there was inconsistency in charting of numerical pain scores. on d+ , patients had insufficient data to determine efficacy of pain control; of the remaining patients, % had good pain control while % had moderate and % had poor pain control using our devised scale. the most common toxicity observed was respiratory depression (∼ %), however, etiology was often multifactorial and not due to opiates alone. analysis is ongoing to assess variables predicting pca use as well as efficacy of pain control and correlation between current reporting scales and patient perception. conclusion: pca use is common in pediatric hct yet pain control remains inadequate. there's a need for better evaluation of pca management, especially uniform assessment of pain, thereby improving quality of life post hct. children's national health system, washington, district of columbia, united states background: actinomycosis is a rare invasive anaerobic gram-positive bacterial disease caused by actinomyces spp. that may colonize the oropathynx, gastrointestinal tract and urogenitial tract and can lead to abscesses. respiratory tract actinomycosis is characterized by pulmonary cavities, nodules, consolidations and pleural effusions. although actinomyces are nearly always sensitive to penicillin they are frequently resistant to cephalosporins and variable sensitives to fluoroquinolones. although rare in children, immunosuppressed patients are at increased risk for actinomycosis. to describe a case of next-generation sequencing identification of actinomycosis. a -year-old male with a history of very high risk b-cell acute lymphoblastic leukemia who was months status post a / matched unrelated donor bone marrow transplant complicated by prolonged fevers, persistent weight loss, and splenic lesions, treated with posaconazole and levofloxacin developed fever and cough in the setting of neutropenia. blood cultures demonstrated staphylococcus epidermidis. ct showed micronodules and effusion not consistent with s. epi, prompting bronchoscopy. all bacterial cultures were negative. patient was prescribed a three-week course of vancomycin with rapid improvement. design/method: s next generation sequencing (ngs) from bronchoalveolar levage sample was performed at the university of washington laboratory results: ngs assay from bronchoalveolar lavage showed major abundance of actinomyces most closely related to meyeri or oodontolyticus. demonstrated actinomyces. the patient was started on a six month course of amoxicillin with continued clinical improvement. in retrospect, the splenic nodules that were presumed fungal disease were likely actinomycosis, partially treated with levofloxacin. this case highlights the potential utility of ngs in the diagnosis of rare diseases in immunocompromised patients. actinomycosis was only demonstrated through ngs and led to a change in treatment regimen and durable clinical improvement. because actinomyces often mimics malignancy, tuberculosis or nocardiosis, the use of this novel test both targeted appropriate therapy and reduced the exposure to unnecessary medications to treat the differential diagnosis. finally, we highlight that actinomyces should be considered in patients who present with unexplained fevers, weight loss, and night sweats. haneen shalabi, cynthia delbrook, maryalice stetler-stevenson, constance yuan, bonnie yates, terry j. fry, nirali n. shah center for cancer research, national cancer institute, national institute of health, bethesda, maryland, united states background: car-t therapy, while effective, may not be durable for all, and antigen negative escape is a growing problem. hct, in relapsed/refractory all, can be curative, particularly for those in an mrd negative remission. we demonstrated that cd directed car-t therapy effectively rendered patients into mrd negative remissions (by flow cytometry) and the leukemia free survival post-hct was high . in pastorek, jesssica bruce, michael a. pulsipher, chloe anthias, peter bader, andre willasch, jennifer sees, jennifer hoag, wendy pelletier, brent logan, pintip chitphakdithai, lori wiener university of pittsburgh, pittsburgh, pennsylvania, united states background: more than , pediatric hscts are performed in north american and europe each year. the ethics of exposing a healthy child to donation procedures which have some risks and no direct medical benefits continue to be a topic of debate. pediatric donors may experience psychological distress and poorer quality-of-life during and after donation compared to healthy controls. although there are fact/jacie requirements related to the management of pediatric donors, it is unclear what standardized practices exist for psychosocial assessment/management of this group. objectives: to describe transplant center practices for psychosocial evaluation/ management of pediatric donors (< years) and to examine differences in practices by location (cibmtr/ebmt) and number of harvests (volume). design/method: data were collected via a single crosssectional survey distributed electronically to cibmtr and ebmt centers between / / and / / . : / ( %) of cibmtr and / ( %) of ebmt centers completed the survey. most centers had written eligibility guidelines for pediatric donors ( %). most also had a process for ensuring that donors were freely assenting to donate ( %), managed by a transplant physician ( %). a single physician often jointly managed donor/recipient care ( %). half of centers had a pediatric donor advocate ( %), who was most often a physician ( %) or social worker ( %). cost was the largest barrier to having a donor advocate ( %). most centers performed psychosocial screening of donors ( %) but rarely declined donors based on psychosocial concerns ( %). less than half of centers provided post-donation psychosocial follow-up ( %). comparisons by center location indicated that ebmt centers were more likely to have a physician doing joint donor/recipient care ( % vs. %; p = . ), less likely to have a psychosocial assessment policy ( % vs. %; p = . ), less likely to have a donor advocate ( % vs. %; p = . ), but marginally more likely to do post-donation psychosocial follow-up ( % vs. %; p = . ). large volume centers were more likely to have a psychosocial assessment policy than their medium/smaller counterparts ( % vs. %, %; p = . ) â€"there were no other differences on key psychosocial management variables by volume. although most centers have written guidelines for pediatric donor eligibility and mechanisms for ensuring assent, substantial numbers of donors do not undergo psychosocial assessment, are jointly managed with the recipient by a single physician without an assigned donor advocate, and do not receive psychosocial follow-up. the field would benefit from guideline development for the psychosocial management of pediatric donors. background: germline mutations in samd and samd l genes cause mirage (myelodysplasia, infection, restriction of growth, adrenal hypoplasia, genital phenotypes and enteropathy) and ataxia-pancytopenia syndromes, respectively, and are associated with chromosome deletions, mds and bone marrow failure (bmf). there are limited data on outcomes of hct in these patients. to describe outcomes of allogeneic hct in patients with hematologic disorders associated with samd /samd l mutations. results: seven patients underwent allogeneic hct for primary mds (n = ), congenital amegakaryocytic thrombocytopenia (camt)(n = ), and dyskeratosis congenita (n = ). retrospective exome sequencing revealed gain-of-function mutations in samd (n = ) or samd l (n = ) genes. constitutional mosaic monosomy was present in cases. two samd patients had features of mirage syndrome. unusual findings of panhypopituitarism, laryngeal cleft, and glomerulosclerosis were noted in one case. in another case with a samd mutation hypospadias & bifid scrotum were the only findings. the remaining patients had no phenotypic abnormalities. median age at hct was y (range: . - . ). patients received transplants from bone marrow (matched unrelated (n = ) & hla identical sibling (n = )), or unrelated cord blood (ucb) (n = ). five mds patients received myeloablative s of s conditioning (busulfan-based (n = ) or tbi-based (n = )); patients (mds (n = ); camt (n = )) received reducedintensity conditioning (ric) (fludarabine, cyclophosphamide, with ratg or alemtuzumab). syndrome-related comorbidities (diarrhea, infections, malnutrition, electrolyte imbalance, lung disease and hypoxia) were present in both patients with mirage syndrome. one patient with a familial samd l mutation, mds and morbid obesity failed to engraft following ric double ucbt. she died one year later from refractory aml. all other patients achieved neutrophil and platelet engraftment, at a median (range) of ( - ) and ( - ) days, respectively. posttransplant complications included severe hypertension (n = ), pericardial effusions (n = ), veno-occlusive disease of liver (n = ), and recurrent aspiration pneumonias (n = ). one patient developed grade iii agvhd which resolved with treatment. one patient developed mild skin cgvhd and suffers from chronic lung disease. all surviving patients had resolution of hematological disorder and sustained peripheral blood donor chimerism ( - %). overall survival was % with a median follow-up of years (range: . - . y). patients with hematological disorders associated with germline samd /samd l mutations tolerated transplant conditioning without unusual, or unexpectedly severe toxicities. allogeneic hct led to successful resolution of mds or bmf, with excellent overall survival. more data is needed to refine transplant approaches in samd /samd l patients with significant comorbidities, and develop guidelines for their long-term follow-up. shyamli singla, tiffany simms-waldrip, andrew y. koh, victor m. aquino background: steroid-refractory acute graft versus host disease (agvhd) is a potentially fatal complication of allogeneic hematopoietic stem cell transplantation (hsct). basiliximab (anti-il -r monoclonal antibody) as a single agent or in combination infliximab (anti-tnf-monoclonal antibody) has demonstrated efficacy in adult cohorts with steroid-refractory agvhd, but has not been well studied in the pediatric population. we adopted the use of basiliximab and infliximab as our institutional standard of care for steroid-refractory agvhd in pediatric hsct patients. to determine the response and survival of hsct children who received basiliximab and infliximab for the treatment of steroid-refractory agvhd. design/method: we retrospectively reviewed children who received basiliximab and infliximab for steroid-refractory agvhd refractory between september and december . complete response (cr) was defined as resolution of all clinical signs of agvhd. partial response (pr) was defined as at least one grade reduction in one target organ (e.g. skin, gut or liver) without increased grade in another target organ. no response was defined as either no improvement or progressive worsening of agvhd in at least one organ. baseline demographics, transplant details, laboratory findings, and treatment outcomes were also evaluated. results: of the evaluable hsct patients, children (median age yrs, range mo- yrs) with steroid-refractory agvhd received combination monoclonal antibody (mab) therapy. the median time from the start of steroid therapy to initiation of mab was days. the overall glucksberg grade of agvhd at the time of initiating mab therapy was grade i (n = , . %) ii (n = ; %), iii (n = ; %) or iv (n = ; %). the overall response rate was %, with ( %) patients achieving cr, ( . %) patients achieving pr, and ( . %) patients with no response at days following the start of mab therapy. the median overall survival was , , and days for patients who exhibited cr, pr, and no response, respectively. the overall survival at year following start of mab therapy was %. background: the role of high dose chemotherapy (hdc) and autologous stem cell rescue (ascr) in patients with high risk (advanced metastatic or relapsed) soft tissue sarcomas is controversial. despite multimodal chemotherapy, radiotherapy, and local control measure advancements, prognosis of patients with advanced metastatic or unresectable and relapsed sarcomas remains poor, with less than % years disease free survival. objectives: to determine if consolidation with myeloablative hdc and ascr improves relapse free (rfs) and overall survival (os) outcomes in a high risk patient subgroup. we performed retrospective review of all high risk soft tissue sarcoma patients who underwent hdc and ascr at the children's hospital at montefiore, bronx, ny between october and january . the protocol was approved by albert einstein college of medicine institutional review board. results: patients ( primary metastatic high risk disease, relapsed or recurrent disease) received hdc with ascr. primary diagnoses were rhabdomyosarcoma (rms) (n = , alveolar histology), primary site nasopharynx (n = ) and lower extremity (n = ). ewing's sarcoma (ews) (n = ), axial site (pelvic) in patients ( %). median age years (range - years), ( %) were male. all patients were in complete metabolic remission before transplant. median pre transplant comorbidity index was (range - ). patients ( rms and ews) received conditioning with carboplatin, etoposide and melphalan. remaining patients with ews received conditioning with busulfan, melphalan and topotecan. all patients received peripheral blood mobilized hematopoietic stem cell transplantation. stem cell mobilization achieved with high dose filgrastim in all patients except one who required addition of plerixafor. median cd +/kg s of s recipient body weight cell dose infused was . × ^ (range . - . × ^ ). median times to neutrophil and platelet (> , / l) engraftment were (range - ) and ( - ) days respectively. patients ( %) developed bk viuria (one with grade iii hemorrhagic cystitis); ( %) developed cmv viremia; and one patient ( %) had asymptomatic ebv viremia. there was no graft failure, sinusoidal obstruction syndrome or transplant related mortality. median follow up post-transplant was days (range - days). year probability of os and rfs were % and % respectively. hdc with ascr is a promising therapeutic strategy to consolidate remission and improve survival in select high risk soft tissue sarcoma patient subgroups. prospective clinical trials will inform the impact of disease status prior to hdc and ascr on outcome, optimal conditioning and long term relapse free and overall survival. background: absence of minimal residual disease is paramount for cure of pediatric acute lymphoblastic leukemia (all). the testis may harbor occult leukemia and this disease may result in treatment failure. objectives: the purpose of this study was to assess the longterm outcomes of boys with or without testicular leukemia pre-hematopoietic stem cell transplantation (hsct). design/method: retrospective analysis of boys with high-risk de novo ( with hypodiploidy all) or recurrent/refractory all was conducted. flow cytometry of bone marrow mononuclear cells was used to determine remission status. testicular evaluations were performed by physical examination and wedge biopsy pre-hsct. the median age at time of transplant was . years. all patients were in remission by flow cytometry of bone marrow mononuclear cells at the time of transplant and none had evidence of clinically apparent testicular disease. testicular leukemia was detected in patient and he underwent bilateral orchiectomy. he developed acute graft versus host disease (gvhd) of the duodenum and sigmoid colon which resolved, and the leukemia remains in second complete remission and he is free of hsct-related morbidity . months post-hsct. of the patients without testicular leukemia died a median of . months (range, . to . ) post-hsct ( with adenovirus infection and each with thrombotic microangiopathy and aspergillus pneumonia); experienced infection (staphylococcus species, corynebacterium, enterococcus, klebsiella, citrobacter, e. coli, epstein barr virus, adenovirus, bk virus, human herpesvirus- , candida albicans, fusarium, aspergillus, yeast, and other fungus); experienced gvhd ( of the gi tract, of the skin, of the liver, of the eyes, of the mouth, and of the lungs); and developed a second neoplasia (right lower leg leiomyosarcoma). one patient developed bone marrow minimal residual disease ( . % phenotypically abnormal cells detected months after / matched sibling hsct). reinduction therapy comprised weekly doses of rituxan, courses of blinatumomab and donor lymphocyte infusions with il- . two subsequent bone marrow evaluations were minimal residual disease negative. thirteen months post-hsct residual disease recurred ( . %) and he will receive inotumumab. overall median survival post-transplant of the boys is . months (range, . to . ) and of the surviving boys is . months (range, to . ). conclusion: testicular biopsy can detect occult leukemia pre-hsct. testicular leukemia pre-hsct does not appear to increase the risk of subsequent relapse or other hsct-related adverse events compared to those without it. yaya chu, nang kham su, sarah alter, emily k. jeng, peter r. rhode, mathew barth, dean a. lee, hing c. wong, mitchell s. cairo new york medical college, valhalla, new york, united states background: rituximab has been widely used in frontline treatment of b-nhl including burkitt lymphoma (bl), however, some patients retreated with rituximab relapse, which limit patient treatment options. novel therapies are desperately needed for relapsed/refractory b-nhl patients. several strategies for overcoming rituximab-resistance are currently being evaluated, including engineering immune cells with chimeric antigen receptors (car), as well as second-generation anti-cd antibodies. nature killer (nk) cells play important roles in the rejection of tumors. however, nk therapy is limited by small numbers of active nk cells in unmodified peripheral blood, lack of tumor targeting specificity, and multiple mechanisms of tumor escape of nk cell immunosurveillance. our group has successfully expanded functional and active peripheral blood nk cells (expbnk). b t m was generated by fusing alt- , an il- superagonist, to four single-chains of rituximab. b t m displayed tri-specific binding activity through its recognition of the cd molecule on tumor cells, activated nk cells to enhance adcc, and induced apoptosis of b-lymphoma cells. objectives: to examine if b t m significantly enhances the cytotoxicity of expbnk against rituximab-sensitive and -resistant bl cells. design/method: expbnks were expanded with lethally irradiated k -mbil - bbl and isolated using miltenyi nk cell isolation kit. alt- and b t m were generously provided by altor bioscience. nk receptors expression and cytotoxicity were examined as we previous described. ifng and granzyme b levels were examined by elisa assays. equal doses of rituximab, alt- , rituximab+alt- , obinutuzumab (obinu) were used for comparison. igg was used as controls. anti-cd car expbnk cells were generated as we previously described by mrna electroporation. rituximab-sensitive raji andresistant bl cells raji- r and raji- rh, were used as target cells. results: b t m significantly enhanced expbnk cytotoxicity against rituximab-sensitive raji cells, rituximab-resistant raji- r cells and resistant raji- rh cells compared to the controls igg, rituximab, alt- , rituximab+alt- , obinu (p< . , e:t = : ). furthermore, we confirmed the enhanced cytotoxicity by measuring ifn-g and granzyme b production. b t m significantly enhanced ifn-g and granzyme b production from expbnk against raji, raji- r and raji- rh compared to igg (p< . ), rituximab (p< . ), alt- (p< . ), rituximab+alt- (p< . ), and obinutuzumab (p< . ). when compared to anti-cd car expbnk cells, b t m + expbnk had the similar cytotoxicity against raji, raji- r and raji- rh as anti-cd car expbnk cells did (p> . ). conclusion: b t m significantly enhanced expbnk activating receptor expression and in vitro cytotoxicity against rituximab-sensitive and -resistant bl cells. the in vivo functions of b t m with expbnk against rituximab-sensitive and -resistant bl cells using humanized nsg models are under investigation. background: cardiac dysfunction, including left ventricular systolic dysfunction (lvsd), is a known complication in stem cell transplant (sct) survivors. while detection of lvsd by echocardiography is important in this population, there has been minimal research to determine if subclinical cardiac dysfunction exists in sct patients. cardiopulmonary exercise testing (cpet) is a valuable tool to assess cardiac function, and to determine how the heart responds to the stress of exercise. no studies have been performed to determine if sct patients with normal lvsd on standard echocardiography may have abnormal cpet. to determine the feasibility of cpet, as well as additional echocardiographic parameters, to detect dysfunction in sct patients with a normal ejection fraction on echocardiogram. design/method: we performed a cross-sectional analysis of sct survivors who were at least years post sct, years of age or older and with an ejection fraction > % (low end of normal range) on echocardiogram. we assessed the exercise capacity of all patients with cpet, and sub-clinical cardiac dysfunction through tissue doppler and strain analysis from the echocardiogram. results: seven patients ( male) have qualified and completed this study so far with an average age of . ± . years. the median time from transplant is . ± . years. all seven patients had a normal ejection fraction, however four patients had abnormalities on their cpet. these abnormalities included abnormal predicted peak oxygen consumption (vo ) ( %± . , normal > %) (the best predictor of functional capacity), predicted oxygen pulse ( %± . , normal > %) (measure of cardiac stroke volume) and ventilatory efficiency (ve/vco slope) ( ± . , normal < ). submaximal exercise data, used when patients are unable to complete a maximal effort test, demonstrated low-normal predicted vo at anaerobic threshold ( . %± . %, normal > % of was . days while patients who received autologous infusions had a mean number of days to engraftment of . . engraftment after hsct needs to be prompt to minimize duration of neutropenia and maximize survival rates . our data demonstrates that the infusion of hematopoietic stem cell products with a syringe or iv pump is an effective method of delivery for stem cell products and does not delay the time to engraftment. the median days to neutrophil engraftment was . days. this is comparable to data from the nmdp, which reports engraftment occurs within - days. the main limitation to this study was its small sample size due to the number of transplants done at our center. however, it does provide evidence to support that infusion of stem cell products via pump mechanism is a safe alternative to the infusion by gravity method in the process of the hematopoietic stem cell administration. johns hopkins all children 's hospital, st. petersburg, florida, united states background: leukemic relapse remains the most common cause of treatment failure after allogeneic hematopoietic cell transplant (allohct) for myeloid malignancies. most children who relapse post-allohct will die of their disease, making interventions to minimize this risk a high priority. objectives: to evaluate the safety and efficacy of posttransplant azacitidine for relapse prevention in children undergoing allohct for myeloid malignancy. design/method: we retrospectively reviewed the charts of children undergoing allohct for myeloid malignancies between february and november at johns hopkins all children's hospital. results: during the study period, children (ages to years, median ) underwent allohct for myeloid malignancies: de novo acute myeloid leukemia (aml), ; mixed phenotype acute leukemia, ; treatment-related aml, ; juvenile myelomonocytic leukemia with aml transformation, ; and myelodysplasia/aml, . thirteen were in first complete remission, were in cr or greater. most patients ( / ) received fludarabine/melphalan/thiotepa conditioning; received hla-identical related or unrelated donors, and received haploidentical bone marrow grafts with post-transplant cyclophosphamide. three patients never received planned azacitidine ( early relapse; early trm), leaving evaluable patients. azacitidine ( mg/m /dose for days, in -day cycles for up to cycles) was started at a median of days post-transplant (range - ). two-thirds ( / ) of patients received eight or more cycles. of five patients who stopped therapy early, only one was due to toxicity; other reasons included severe gvhd ( ), parental preference ( ), and relapse ( ). cycle delays occurred in patients, with a median cycles delayed per patient, mostly for mild myelosuppression with early cycles. no patient required blood product transfusion during therapy, but g-csf was used in three patients to maintain anc> / l. dose-modifications were made in patients (renal tubular acidosis, acute kidney injury, and myelosuppression). there were relapses ( %), two of which occurred in patients in cr , for a relapse incidence of % in patients in cr , with a median follow-up of months (range . to ). no patients who received azacitidine died of transplant-related mortality. conclusion: administration of azacitidine in children undergoing allohct for myeloid malignancies is safe and feasible, with most patients successfully receiving all planned cycles. toxicity was acceptable and there was no trm or secondary graft failure. despite the limitations of a small cohort, relapse incidence-particularly in patients transplanted in cr suggests a potential benefit in disease control that warrants investigation in follow-up studies. background: despite significant improvements in the success rate of hematopoietic cell transplantation (hct), graft failure remains an important complication in patients transplanted for severe aplastic anemia (saa). second allogeneic hct can salvage patients, but -year overall survival (os) rates have been reported as low as % . objectives: identify patients who developed dropping donor chimerism, graft rejection, and/or graft failure after first hct for saa, necessitating additional hcts or cellular boosts (defined as stem cell products infused without preceding chemotherapy), and evaluate treatment-related complications and os. with vod/sos with and without multi-organ dysfunction (mod) pubmed and embase databases were searched for "defibrotide and retrospective chart reviews; excluded publication types were: case reports (< cases); meta-analyses; reviews; animal, modeling, pharmacokinetic, chromatography, and adult-only studies; guidelines; articles; and letters. resulting reports were screened for exclusion criteria. full-text articles were then reviewed for eligibility. study characteristics of selected publications were summarized, and publications were categorized by patients' mod status. when necessary, additional data tables were requested. a random effects model was used for pooling data for efficacy. interstudy heterogeneity was assessed with cochran's q-test. percentage of total variation across studies due to heterogeneity (i ) was evaluated we quantified ∼ proteins in each sample. reproducibility for one donor at different time points children 's minnesota, minneapolis, minnesota, united states background: pediatric and young adult hodgkin lymphoma (hl) has five-year survival rates > %. chemotherapy required to achieve this rate is associated with a lifetime risk of cardiac deaths, second malignancies, pulmonary disease and infertility. as effective salvage therapy exists, outcomes may be improved by de-intensifying initial therapy to lessen toxicity.objectives: we piloted a regimen in low and intermediate risk hl patients using agents without known association to significant late effects. this retrospective chart review was approved by children's minnesota irb.design/method: the bvg(p) regimen incorporated bortezomib ( . mg/m day , , , ); vinorelbine ( mg/m day , ); gemcitabine ( mg/m day , ) every days and prednisone ( mg/m /dose bid x days). we treated newly diagnosed patients, ages - years, with non-bulk stage iia (n = ) or iib (n = ) hl. two patients received bvg and received bvgp with the addition of prednisone.results: newly diagnosed patients were all pet negative after the first or second cycle and remained pet negative at end of therapy, cycles. nausea was well controlled with -ht antagonists and scopolamine. pegfilgrastim was not necessary due to the high absolute neutrophil count nadir [median . and minimum . × /l]. there were no episodes of febrile neutropenia, infection or transfusion need. no patients experienced alopecia. one patient developed sensory neuropathy after the eighth dose of bortezomib that was controlled with gabapentin and a switch to subcutaneous bortezomib administration. of the five newly diagnosed patients, four remain in remission at , , , days; relapsed at previous disease sites at days and subsequently achieved remission with bvgp with the addition of brentuximab. this series provides early evidence to stimulate expansion of this pilot experience and subsequent multiinstitutional study leading to a randomized trial of bvgp and current chemotherapy for low and intermediate hl. st jude affiliate clinic at st francis hospital, tulsa, oklahoma, united states background: symptoms suggestive of morning hypoglycemia has been noticed in children receiving all chemotherapy. only few small studies looked at this therapy related complication. factors increase risk of hypoglycemia in all patients include accelerated starvation, steroid induced adrenal suppression, mercaptopurine therapy and prolonged fasting for procedures.objectives: to study the prevalence and risk factors for hypoglycemia during all therapy design/method: medical records of of children (up to years old) treated for all between - ( patients) were studied for evidence of morning hypoglycemia defined as blood sugar (bs) < mg/dl. statistical mean differences between the subgroups were analyzed with spss using a nonparametric mann-whitney u test.results: fifty two percent ( %) of patients developed hypoglycemia during all treatment, with an average of . episodes/patient. % were males and % females. almost / ( %) of patients with hypoglycemia were in maintenance phase of therapy. % of hypoglycemic episodes occurred in % of patients. majority of hypoglycemic episodes ( . %) occurred on the day of procedure when patients were fasting overnight. . % of hypoglycemic episodes occurred in children ≤ years, with . % in ≤ years. patients who developed hypoglycemia were significantly younger (mean age at time of diagnosis of all was . ± . at the hypoglycemia group versus the non-hypoglycemia ( . ± . ) p< . . no statistically significant difference was found regarding sex, or tpmt genotype. % of hypoglycemic children-all < years of age-presented with life threatening hypoglycemia symptoms including seizure and loss of consciousness. this study showed high prevalence of hypoglycemia during childhood all therapy. younger age, especially ≤ years, is associated with higher risk of hypoglycemia as well as life-threatening episodes. to decrease fasting hypoglycemia during therapy for childhood all, we recommend that children under the age of years receive bed time snack high in proteins and complex carbohydrates, and to get them up early the day of procedure to take clear sugary drink. hospital for sick children, toronto, ontario, canada ann & robert h. lurie children's hospital of chicago, chicago, illinois, united states background: childhood brain tumors are the most common solid malignancy and the leading cause of cancer-related mortality in children. the most aggressive type of pediatric central nervous system (cns) tumors is diffuse intrinsic pontine glioma (dipg). despite decades of clinical trials, there has been no substantial improvement with respect to therapeutic outcomes with most children eventually succumbing to the disease. research on adult high-grade gliomas has shown a targetable pathway through the inflammationinduced expression of indoleamine , dioxygenase (ido ) and its recognized ability to suppress the anti-tumor immune response. a limited understanding into the role of ido in pediatric central nervous system tumors serves as the foundation of this research project. furthermore, the integration of nanotechnology is a fundamental step for the investigation and targeting of ido . spherical nucleic acids (snas) composed of nanoparticles have been shown to transverse cellular membranes, exhibit stability in physiological environments, escape from degradation, and create precise targeting in brain tumors.objectives: the purpose of our project is to delineate the role of ido in pediatric dipg, and develop small inhibitory (si)rna oligonucleotides and snas aimed at therapeutically inhibiting the gene expression of immunosuppressive ido . our specific aims are to: ( ) confirm the gene expression ido in different human dipg cell lines; ( ) generate and characterize sirna oligonucleotides targeting human ido in vitro; and ( ) generate and characterize gold nanoparticles for targeted inhibition of ido .design/method: unique patient-derived dipg cell lines were grown in culture, stimulated with increasing concentrations of the proinflammatory cytokine, ifn , and analyzed for mrna levels. sirna specific to ido was transfected into cells. sna generation is in progress.results: ido is expressed in multiple human pediatric dipg cell lines. sirna targeting ido among exons and results in a significant decrease in overall ido expression by dipg cells. sna generation for targeting ido with improved penetration & stability is ongoing, with preliminary results demonstrating a robust ability to inhibit ido expression. the grim prognosis of children with dipg, the lack of effective therapies, and the expression of ido by human dipg cells emphasize the importance of developing the treatment capability to inhibit ido gene expression, as a excluded from this study. the remaining patients were analyzed using descriptive statistics.results: a total of patients meeting inclusion criteria were identified. of these, patients ( . %) received tonsillectomy alone, ( . %) underwent tonsillectomy and decreased immunosuppression, ( . %) received tonsillectomy and rituximab, and another ( . %) received tonsillectomy with additional therapy (including ebv-specific cytotoxic tlymphocytes, donor leukocyte infusion, and chemotherapy). of the patients who received tonsillectomy with or without a decrease in immunosuppression, all were diagnosed with high-grade lymphoma and achieved clinical remission following tonsillectomy with no evidence of relapse to date. on further analysis looking at ptld risk factors, all patients were under years of age, all received t-cell depleted grafts, and none had significant graft-versus-host disease (gvhd) at the time of ptld diagnosis. we have identified a population of patients with localized ebv ptld that achieved clinical remission with no evidence of recurrence following tonsillectomy, suggesting that tonsillectomy alone may be an adequate treatment for localized ebv ptld in a specific subgroup of patients. further analysis is needed to identify characteristics of this subgroup to determine which patients would be most likely to respond to this treatment. university of rochester, rochester, new york, united states background: malignant central nervous system (cns) tumors in young children have a poor prognosis and pose a significant therapeutic challenge. consolidation therapy with carboplatin and thiotepa was piloted in ccg- , cog acns , and cog acns with the goals of intensifying therapy and omitting or delaying radiation.objectives: to document outcomes for patients undergoing carboplatin/thiotepa consolidation with autologous stem cell rescue (ascr) and to demonstrate the feasibility and toxicity of this regimen.design/method: patients up to years old (median age: months) with malignant cns tumors treated at the university of rochester from - with at least one cycle of carboplatin ( mg/kg/day x days) and thiotepa ( mg/kg x days) followed by peripheral blood ascr were included in retrospective analysis. data were recorded on time to engraftment (defined by absolute neutrophil count (anc) recovery to > . × ^ /l), length of hospitalization, toxicity with each consolidation cycle, progression free survival (pfs) and overall survival (os). stem cell harvest data were also collected.results: eleven patients with malignant cns tumors ( atypical teratoid/rhabdoid tumor, primitive neuroectodermal tumor, glioblastoma multiforme, and pineoblastoma) received a total of cycles of carboplatin/thiotepa. of these, underwent stem cell harvest at our institution, with complications limited to procedure-related hypotension for patient with known autonomic instability, and catheter-associated deep vein thrombosis (dvt) for patient. four patients were in complete remission (cr) /status-post gross total resection, was in cr , and had residual tumor at the time of consolidation. nine patients received planned consolidation cycles, patient (of ) planned cycles, and patient of an anticipated cycles thus far. average time to engraftment for these cycles was . (+/- . ) days, with a mean hospital length of stay of (+/- . ) days. fever occurred in of cycles ( %); infectious toxicity included documented bacterial infection in cases (enterococcus faecalis bacteremia in , klebsiella pneumoniae in ). there were no regimenrelated deaths. with a mean follow-up of months, survivors have not yet completed all therapies, and patients have relapsed ( have died of disease). of the survivors, have been disease-free for > months. background: autologous hematopoietic stem cell transplantation (auto-hsct) has resulted in improved survival for patients with high-risk neuroblastoma. treatment intensification is however associated with greater complications. data on early infectious complications in low-and-middle income countries are limited.objectives: to review the early infectious complications following auto-hsct in patients with high-risk neuroblastoma.design/method: a retrospective chart review of pediatric patients with high-risk neuroblastoma who underwent auto-hsct at the american university of beirut medical center between and was conducted. infectious complications during the first days post-transplant were reviewed.results: forty-three patients ( males and females) with a median age at diagnosis of . years [range: . - . ] years underwent auto-hsct during the above-mentioned period. conditioning regimen consisted of melphalan, etoposide and carboplatin. all patients received antiviral and antifungal prophylaxis. median time for neutrophil engraftment was days [range: - ]. bacteremia and clostridium difficile infections occurred in ( %) and ( %) patients respectively. seven ( %) patients developed enterocolitis diagnosed by imaging, were adenovirus induced. cmv viremia was diagnosed in ( %) patients, of whom required treatment. varicella zoster reactivation, parvovirus viremia, toxoplasmosis encephalitis, bk virus cystitis ( patients) and central nervous system ebv related post-transplant lymphoproliferative disorder were diagnosed in different patients. there was no invasive fungal infection. sixteen ( %) patients have died, of whom died in the early post-transplant period, due to disease progression and ( . %) due to infectious complications. among the patients who died due to infection, developed toxoplasmosis encephalitis, developed severe enterocolitis, of which were adenovirus related. the mean igg level within one week post-transplant was lower in patients with clinically significant viral infection compared to others ( vs . mg/dl, p: . ). the mean igg level at the time of clinically significant bacterial infection was lower in infected patients compared to others ( . vs . mg/dl, p: . ). neither absolute lymphocyte count nor absolute neutrophil count at day post-transplant affected the incidence of clinically significant infections. our results show that the rate of infections during the early post auto-hsct period is higher than what has been described in developed countries and has a significant impact on mortality. prevention, early detection and improvement in the treatment is required to improve outcome. university of miami, miami, florida, united states background: allogeneic hematopoietic stem cell transplantation (allo-hsct) is a curative treatment for many malignant and non-malignant (bone marrow failure, immunodeficiency, or metabolic diseases) in pediatrics. despite advances in medicine, graft-versus-host-disease (gvhd) remains a significant cause of non-relapsed morbidity and mortality, specifically in those with malignant diseases.objectives: to highlight the complexity to acute gvhd management and seldom-described treatment approach. a year male with a history of high risk acute myeloid leukemia (aml) due to failed induction therapy. he received a matched ( / ) unrelated donor hsctmarrow product-conditioned with busulfan, fludarabine, and anti-thymoglobulin (atg). his post-transplant course was complicated by hhv- viremia, pres (prompting a change from prograf to cyclosporine), mucositis, and grade iii acute gvhd (skin s , gut s , liver s ) around post transplant day , which later morphed to ocular involvement by d+ . he was started on mg/kg steroids with good response but flared up with each attempt to taper steroid dose. a course of rituximab and later atg were tried without success in weaning off steroids. switching cyclosporine to sirolimus did not provide any additional benefit either. extracorporeal photopheresis (ecp) was started times a week. he initially responded well, yet was not able to wean off steroids. in addition, he developed a flare when ecp session was reduced to days per week. ecp was therefore increased to days per week, which appeared to stabilize skin lesions. a trial of weekly methotrexate was attempted to wean off steroids and photopheresis, which provided no response. finally, a trial of bortezomib on days , , , and of a day cycle as published in a case series of multiple myeloma patients who developed post hsct gvhd. skin lesions improved remarkably however dose had to be reduced due to related pancytopenia. given the response to therapy, he was continued on a weekly dose of bortezomib, receiving a total doses, which has permitted the slow taper of prednisone that has since been discontinued without a major flare. he however is currently maintained on ecp times per week, which is now been slowly withdrawn.conclusion: management of acute gvhd in pediatric patients after hsct can be challenging with no definite options for those who fail steroids or become steroid dependent after initial response. in these situations, bortezomib could be a valid therapeutic option. background: neuroblastoma (nbl) is the second most common solid tumor in children and despite recent treatment advances, overall survival for high risk nbl remains < %. the addition of immunotherapy has improved survival and includes anti-gd antibody therapy. the success of antibody therapy in neuroblastoma is primarily due to natural killer (nk) cell mediated antibody dependent cellular cytotoxicity. we previously demonstrated that nk cells from patients with high risk nbl can be successfully isolated and expanded to large numbers and exhibit potent anti-tumor effects against nbl ( ). thus, infusions of autologous expanded nk cells in high risk nbl in combination with anti-gd antibody are being studied in clinical trials. toll-like receptors (tlr) present on the surface of leukocytes are responsible for pathogen recognition, and activation of these receptors stimulate the production of cytokines that critically link innate and adaptive immune responses. the tlr agonist, poly(ic) is a synthetic analog of dsrna that has previously been shown to directly stimulate cytokine production and improve cytotoxicity in primary nk cells through activation of genes regulated by interferon-response elements (ire) ( ). we hypothesized that ex vivo activation of tlr pathways in nk cells during our normal -day expansion using k feeder cells expressing membrane bound il- would enhance their function.design/method: nk cells were isolated from peripheral blood mononuclear cells and expanded with our previously described expansion protocol in media containing il- and ug/ml poly(ic) ( ). at the end of the -day expansion, nk cells expanded with poly(ic) were compared to controls using a calcein cytotoxicity assay to measure cytotoxicity against high risk neuroblastoma and cytometric bead array to measure cytokine production. : surprisingly, the addition of poly(ic) during nk cell expansion did not improve proliferation, cytokine production or cytotoxicity compared to our standard expansion method. rnaseq demonstrated that our standard expansion method results in a modest decrease in tlr expression at the transcriptional level, but significant upregulation of several ireregulated genes. we conclude that either our standard approach interferes with tlr signaling or saturates the innate immune response pathway such that co-stimulation with poly ic does not produce an additive effect. we are performing expression analysis on nk cells receiving poly(ic) during expansion to further explore this hypothesis. background: gonadal dysfunction leading to infertility is a complication after hematopoietic stem cell transplant (hsct). anti-müllerian hormone (amh) is a marker of ovarian reserve; it is not controlled by gonadotropins and has minimal inter-cycle variations, therefore, it can be used as a marker of ovarian reserve and aid in fertility counseling.objectives: assess ovarian reserve in hsct patients utilizing amh levels. background: tgf beta is an immune suppressive cytokine frequently elevated in the tumor microenvironment causing tumor immune evasion. acute tgf beta treatment potently inhibits nk cell cytotoxicity, cytokine secretion, and proliferation. however, tumor infiltrating nk cells receive chronic inhibitory tgf beta signals in conjunction with activating signals from tumor cells. objectives: to this end, we hypothesized that long-term tgf beta-cultured nk cells would induce functional and phenotypical changes on nk cells that differ from short-term tgf beta treatment.design/method: to explore this, primary human nk cells were cultured with the leukemia cell line, k , alone or with exogenous tgf beta for weeks. : surprisingly, nk cells cultured in tgf beta proliferated faster, and upon challenge with a variety of cell line targets they secreted much greater quantities of ifnÎ ( -to -fold increase against / cell lines) and tnf ( -to -fold increase against / cell lines). further, the high cytokine secretion induced in these nk cells was no longer inhibited by adding additional tgf beta. degranulation was also increased ( / cell lines), however cytotoxicity was not enhanced in a -hour cytotoxicity assay. after resting in il- , the cytokine hypersecretion of tgf betacultured nk cells was maintained for several weeks suggesting this functional change might involve cellular reprogramming. we investigated the mechanism behind these functional changes and profiled genes involved in tgf beta signaling. we found significant reduction of smad transcription which corresponded to a striking decrease in smad chromatin accessibility. we also found significantly increased smad and decreased tgfbr expression. phenotypic analysis revealed that tgf beta also induced remodeling of the nk receptor repertoire with decreased nkp , cd , and klrg and upregulation of trail. the functional consequences of these tgf beta-induced changes on in vitro and in vivo nk cell function are currently under investigation. background: the use of t-cell depleted grafts in haploidentical stem cell transplantation (hsct) has been associated with a delay in early t-cell recovery which increases the risk of viral infections, relapse or graft rejection. conventional donor lymphocyte infusion (dli) after hsct transplantation is effective but conditioned because of a high prevalence of gvhd. the infusion of selected lymphocyte subpopulations with low aloreactivity is emerging as an effective strategy to rectify this issue. the depletion of cd ra+ naive lymphocytes, preserving cd ro+ memory t-cells, could provide a safe source of functional lymphocytes with anti-infection, antileukemic and anti-rejection properties, and lower rates of adverse effects. our objective is to present data of patients that have received cd ro+ memory t-cells dli (mdli) and assess its safety and outcome. we present data of mdli performed after hsct in cases of mixed chimerism, persistent lymphopenia, viral/opportunistic infections or as a strategy to accelerate immune reconstitution.results: fifteen patients with diagnosis of all (n = ), aml (n = ), mds (n = ), saa (n = ), sideroblastic anemia (n = ) and cgd (n = ), received mdli after hsct. a total of forty-three mdli were infused. the median dose of cd ro+ memory t-cells infused was . × /kg (range: . × - . × /kg), with a median dose of cd ra+ naive t-cells of . × /kg (range: - . × /kg). the mdli were infused at a median of seventy-seven days after hsct (range: - days), with a median interval between mdli of thirty-four days results: eight published studies reported survival outcomes for pediatric vod/sos patients (n = ), across all defibrotide doses. estimated day+ survival ( % confidence interval) was % ( %- %). for vod/sos with mod, studies were identified (n = ) with pooled estimated day+ survival of % ( %- %). only one openlabel expanded-access study, the treatment-ind, reported outcomes separately for pediatric vod/sos patients without mod (n = patients aged ≤ years). the day+ kaplan-meier estimated survival for those patients was % ( %- %). safety results were not pooled due to differences in reporting methodology; however, study results were consistent with the safety profile of the phase historicallycontrolled trial in vod/sos patients with mod ( % pediatric), in which / defibrotide-treated patients and all controls experienced ≥ ae. hypotension was the most frequent ae ( %, defibrotide; %, controls); common hemorrhagic aes (ie, pulmonary alveolar and gastrointestinal hemorrhage) occurred in % of defibrotide-treated patients and % of controls. in this pooled analysis of studies with defibrotide-treated pediatric patients with vod/sos, estimated day + survival was % (without mod, %; with mod, %). safety results in individual studies were generally consistent with the known safety profile of defibrotide. taken together, these results show a largely consistent defibrotide treatment effect in pediatric patients treated with defibrotide for vod/sos, with or without mod. results: six patients met inclusion/exclusion criteria. all patients were started on ecp while concurrently receiving . to mg/kg steroid therapy for agvhd plus a calcineurin inhibitor. patients had initiation of ecp within a maximum of weeks from initial diagnosis of agvhd (range - days). patients had grade - agvhd ( / patients with grade ) with skin, liver, and gi gvhd represented. patients received ei-ecp - times per week for the first weeks and then had ei-ecp frequency tapered based on initial response.after weeks of therapy patient had a decrease in overall gvhd grade by grade. all patients were able to have steroids tapered, with doses decreased by an average of % ( % - % decrease).at weeks of therapy, one patient with grade agvhd died of mof associated with infections. three patients had complete resolution of agvhd and patients decreased by grade. steroid doses were decreased by an average of % ( % - % decrease). continuously measures axillary temperature and wirelessly transmits real time-time data. the primary aim of the study was to evaluate the feasibility, safety and tolerability of continuous temperature monitoring in hsct patients using temptraq. we are performing a prospective observational study of pediatric patients ( - years of age) undergoing hsct at cincinnati children's hospital in cincinnati, ohio. enrolled patients wore a temptraq patch for days. a - rating scale survey was completed by the parent/guardian at the end of the study to determine tolerability, ease of use, satisfaction and desire for future use in the inpatient and outpatient setting. temperature data from the temptraq patch was compared to the standard episodic temperature monitoring to determine detection of febrile episodes. seven of ten patients have completed screening. we anticipate completion of the study in early february. the temptraq patch was well tolerated by study subjects (mean tolerability rating of . / ). one patient developed skin breakdown at the site of the temptraq patch attributed to recent thiotepa. the patch was easy to apply with an easy of application rating of . / . parents were overall satisfied (rating . / ) and would like to use the temptraq patches in future hospitalizations (rating . / ) and at home (rating . / ). temptraq patch identified fever (≥ . • f) in patients. the fever was never detected by episodic monitoring (soc) in patients and significantly delayed in the other patients (> hours). temptraq was well tolerated in pediatric hsct patients. timely fever detection was improved in temptraq over the current soc. background: serotherapy is commonly used in patients undergoing hematopoietic stem cell transplant (hsct) to reduce the incidences of engraftment failure and graft versus host disease. however, one well-known side effect is fever. as children undergoing hsct have compromised immune defenses, fever may also be an early indicator of bloodstream infection, which would warrant prompt use of broad-spectrum antibiotics. in a subset of patients with serotherapy-associated fever, antibiotics, which may induce antibiotic resistance and increase costs, may be unnecessary. we aimed to determine the incidence and characteristics of serotherapy-related fever, as well as the likelihood of concomitant bacteremia, in our institutional experience. a -year retrospective chart review was conducted of pediatric patients who received serotherapy as part of hsct conditioning at the university of minnesota. one-hundred sixty eight consecutive hsct patients who received serotherapy -either atg (n = ) or alentuzumab (n = ) -were identified. the median age at hsct was -years (range, . - years). a total of patients ( %) developed fever while on serotherapy (atg = , alentuzumab = ). one-hundred sixteen patients presented fever following the first infusion, and the median onset of fever was hours after commencing infusion (range, . - hours). fever resolved at a median hours (range, - hours). one hundred and fourteen patients ( %) underwent blood cultures. only seven patient were not started on ( %) empiric antibiotics, while % (n = ) were on antibiotic treatment prior to serotherapy for previously known or suspected infections. nine patients ( % of febrile patients, % of all patients) had positive blood cultures (atg = ; alentuzumab = ). no infection-associated deaths were observed.conclusion: while fever is common during serotherapy conditioning in children undergoing sct, episodes of concomitant bloodstream infection are rare. ongoing analysis identified potential risk factors for bacteremia as recent history of infection, first episode of fever following second or subsequent infusions, and previous central line placement. further analysis is being conducted to identify subgroups of patients for whom close monitoring alone may be safe. background: hsct is potentially curative for caya with high-risk leukemias; however, most lack an hla-matched aspho abstracts related donor. the risk of gvhd is increased with unrelated (urd) or partially matched related (pmrd) donors. selective t-cell depletion based on the elimination of t cells carrying and chains of the t-cell receptor may greatly reduce the gvhd risks, while allowing the maintenance of mature donor-derived alloreactive nk cells and / (+) t cells, which may augment the anti-leukemia effect.objectives: this is a prospective study of caya with acute leukemia who underwent hsct with mmrd or urds and tcr / /cd depletion. outcomes included engraftment, toxicities, viral reactivation, and relapse.design/method: this study included caya with acute leukemia transplanted between october and may . all received a myeloablative preparative regimen with targeted busulfan (n = ) or tbi ( cgy/ fractions) (n = ), with thiotepa ( mg/kg) and cyclophosphamide ( mg/kg). atg ( mg/kg x ) was given to those receiving haploidentical grafts and to the first who received urd grafts. immune suppression was not given post-hsct. the stem cell source was mobilized peripheral blood stem cells (pscs), which then underwent tcr / /cd depletion utilizing the clinimacs device under gmp conditions in the chop cellular immunotherapy lab.results: median age was (range . - . ). diagnoses included all ( -b-cell, -t-cell) and aml ( ; -secondary aml). urd were used for ; were / allele matched and were / matched. haploidentical donors were used for . median cd (+) dose - . × , / (+) cd (+) cells - . × , and b cells - . × . all patients achieved an anc at a median of d+ ( - ), and % had platelet engraftment at median d+ ( - ). nine patients ( %) developed acute gvhd (all skin, grades i-iv). five developed chronic gvhd (skin, gut, lung): limited in , extensive in . viral reactivations included: adenovirus ( , %), bk virus ( , %), cmv ( , %), and hhv ( , %). nine ( %) patients relapsed at a median of days (range - ) post-hsct, including aml patients ( . %) and all patients ( . %). transplant-related mortality was %; causes included sepsis ( ) and ards ( ). os was %; efs was % (gvhd-free efs %, lfs %). hsct with tcr / /cd depletion demonstrates excellent engraftment kinetics with limited gvhd without immune suppression. elimination of post-hsct immunosuppression may offer an excellent platform to augment anti-leukemic immune therapy or to enhance immune reconstitution. background: hematopoietic cell transplantation (hct) is the only curative treatment available for patients with sickle cell disease (scd). low bone mineral density (bmd) has been described in scd, but little is known about the impact of curative hct on this outcome. to determine the prevalence of low bmd and variables associated with low bmd in scd patients after hct. we conducted a retrospective chart review of scd patients who underwent hct at children's healthcare of atlanta (choa) between / and / and survived ≥ year post-hct. transplant characteristics, post-hct dual-energy x-ray absorptiometry (dexa) scan results, vitamin d levels, graft-versus-host-disease (gvhd) status, and fsh levels were reviewed. for patients - years of age, height corrected z-scores were calculated using a nihvalidated calculator, with t-scores used for older patients. bmd was categorized as low if between - and - sd below the mean and clinically significantly low if >- sd, in accordance with the children's oncology group long-term follow-up guidelines. vitamin d levels < ng/mol were considered deficient, and fsh levels > miu/ml suggestive of premature ovarian failure. fisher's exact test was used to compare variables in those with normal versus abnormal dexa scan results, with p< . considered significant.results: hct was performed on patients with scd, with surviving ≥ year post-hct. dexa scans were obtained in patients ( % female), with mean time from hct to dexa scan being years ( . - . years) and mean age at time of dexa . years ( . - . years). patients with and without dexa scans did not differ by sex, donor source, age at transplant, or vitamin d status. low bmd was noted in patients ( . %), with these patients more likely to be > years (pubertal; . versus . %, p = . ). acute gvhd was more common in patients with low bmd ( . versus . %), but not statistically significant (p = . ). clinically significant low bmd was noted in patients ( . % of those with dexa scans). these patients were older ( . years at testing), were more likely to be male ( . %), and all had acute and chronic gvhd, while none had evidence of gonadal failure.conclusion: clinically significant low bmd is uncommon after hsct for scd. patients at risk for low bmd include older patients and likely those with gvhd. this preliminary data suggests routine dexas may not be indicated for all patients who undergo hct for scd, but further data is needed. background: causes of renal dysfunction after hematopoietic cell transplantation (hct) include damage from radiation, nephrotoxic medications, graft vs. host disease (gvhd), hepatorenal syndrome, viral infections, or transplant associated microangiopathy. we sought to investigate the incidence of, and risk factors for, acute kidney injury in pediatric hct patients and associated risk with mortality.design/method: data from patients who underwent hct between and at a single institution were sequentially retrospectively captured on irb approved protocol. acute kidney injury (aki) was defined at multiple time points post-hct using the standardized criteria: kidney disease: improving global outcomes (kdigo). interval differences between values were analyzed using wilcoxon rank sum testing and categorical variables were analyzed using chi-square analysis.results: ninety-eight patients were included in the study: allogeneic (n = ) and autologous (n = ), mean age . years, of whom % were african american, % asian, % caucasian, % latino, and % mixed race. forty-seven percent of patients developed aki within the first years of hct. increased risk for aki was associated with a lower pre-transplant creatinine level (p = . ), abnormal pretransplant bun (p = . ) and an unrelated donor (p = . ) while preparative regimen intensity, race, or primary disease were not. twenty-six percent of patients developed aki within days of hct. of those with aki, % were exposed to either cidofovir, aminoglycosides, and/or ambisome for at least days versus % without aki and % were exposed to vancomycin compared to % without aki. evaluating outcomes at year after hct, of those with stage aki: % had reduced gfr and % died, while % had reduced gfr and % had died for patients with aki stage or . the absence of aki by day was associated with % reduced gfr and % death at -year after hct. overall, those with aki at any time in the first year post-hct had a . fold increased risk of death compared to those without. for patients who required renal replacement therapy (rrt, n = ), the risk of death was . fold greater compared to those who did not. in the % of patients who survived rrt, both recovered renal function within years.conclusion: acute kidney injury is common after pediatric hct, and may be associated with low creatinine, abnormal bun, unrelated donor pre-hct, and renal toxic medications. early-onset aki post hct is associated with an increased risk of mortality. these data should be validated in a larger prospective study but may offer opportunities to intervene and enhance outcomes. background: myeloablative hematopoietic stem cell transplant (hct) for pediatric malignant disease is associated with significant morbidity with % patients experiencing mucositis. patient controlled analgesia (pca) utilizing opioids is an effective strategy for pain management. we sought to describe and analyze pca use in d+ days post myeloablative hct for malignancies at lurie children's hospital of chicago from - .design/method: utilizing retrospective chart review, pca details were collected: indication, initiation day, pca duration, team managing pca (anesthesia or palliative), medication and dose in morphine equivalents, and pca toxicities. efficacy of pca was evaluated on pca day + , + , + , + using demands %, maximum pain score (rflacc, faces, vas) and subjective patient, parent and/or pain team perception of pain control. we devised a scale based on the above to designate pain control as good, moderate or poor. variables being analyzed include recipient age, sex, donor type, source, diagnosis, tbi use, gvhd/trm. this analysis, we analyze the depth of remission, car-t persistence, and post-transplant gvhd on our phase i anti-cd car-t protocol (nct ) to better understand the role of car-t in the peri-hct setting.design/method: children and young adults with relapsed/refractory cd + all treated on our phase i anti-cd car-t protocol were analyzed. mrd was assessed by flow cytometry (fc) in all, with pcr-based mrd analysis using igh or tcr testing assessed in select patients. hcts were performed at each patient's local institution based on standard of care and included varying conditioning regimens, donor types, stem cell source, and gvhd prophylaxis.results: on our cd car trial, patients were treated, the majority of patients (n = ) having relapsed following a prior hct. / patients ( %) attained a cr, of whom were mrd negative by fc. concurrent pcr based mrd analysis available in patients demonstrated that all patients achieved pcr based negativity. in , this was simultaneous with the month mrd negative fc, and in , pcr negativity was achieved over time (fc remained negative). patients proceeded to hct at a median time of days (range: - days) post-car-t, which was a first hct in . these two patients remain in an mrd negative cr, year post-car-t. no patients developed acute or chronic gvhd. car persistence was seen in patients who had detectable car-t cells on the pre-hct marrow suggesting the possibility of ongoing anti-leukemia surveillance prior to initiation of the conditioning regimen.conclusion: by inducing pcr negativity, car-t therapy may have a synergistic role with hct to improve leukemia free survival, prior to emergence of antigen negative leukemia, without an increased risk of gvhd. while the sample size is small, car-t therapy may offer an effective bridge to hct, particularly for those who are pcr negative, and those who have not had a previous transplant. given the underlying risk of hct related trm, pre-hct car may potentially allow for hct conditioning de-intensification as it may not be needed to eradicate residual disease. lee dw, ash abstract , background: post-transplant lymphoproliferative disease (ptld) is a complication after solid organ transplantation (sot) that is frequently due to epstein -barr virus (ebv) as a decrease in ebv-specific t cell immunity due to immune suppression allows for uncontrolled proliferation of ebv-infected b cells. outcomes for ptld are suboptimal with relapse rates approaching %. however, ebv-infected b cells in ptld express the ebv antigens lmp and lmp that can be targeted with immune therapy.objectives: we hypothesize that third party "off the shelf" lmp-specific t cell products may improve outcomes and decrease associated co-morbidities for patients with ptld by not only target the lymphoproliferating ebv-infected b cells but also restoring ebv-specific immunity.design/method: lmp-specific t cells (lmp-tcs) are manufactured from eligible donors with a broad range of hla types in our gmp facility to be used in a children's oncology group (cog) trial (anhl ) for patients with ptld after sot. lmp-tc products are manufactured from healthy donors using autologous monocytes and lymphoblastoid cell lines (lcl) transduced with an adenoviral vector expressing Δlmp and lmp as antigen presenting cells. lmp-tc products undergo comprehensive characterization by ifn-elispot assay to determine lmpspecific epitopes, class i and/or ii response, and hla restriction to guide selection of lmp-tc product for each patient.results: thus far, lmp-tc products have been manufactured. lmp-tcs were active against lmp (mean: sfu/ × ^ cells; range: - ), lmp ( ; - ), and lcl ( ; - ) as determined by ifn-elispot assay. at the time of cryopreservation, the lmp-tc products comprised a mean of % cd + t-cells, % cd + t-cells, and % nk cells. no b cells or monocytes were detected in the final products. thus far, we have identified novel lmp epitopes (lmp specific: n = ; lmp specific: n = ). approximately % of the lmp-tc products have lmp-specific activity through multiple hla alleles, and % have a mixed class i and class ii response. conclusion: thus, lmp-specific t cell products can be expanded from healthy donors to creat a third party bank, and identifying epitopes and hla alleles with lmp activity will facilitate selecting the most appropriate product for patients. while lmp-specific t cells have previously demonstrated safety and efficacy in phase i studies, anhl is the first trial using cellular therapy within a cooperative group setting. children's cancer hospital at the university of texas md anderson cancer center, houston, texas, united states background: in , the united states food and drug administration (fda) approved the first chimeric antigen receptor t cell (car-t) therapy; tisagenlecleucel. this cd -directed genetically modified autologous t cell immunotherapy has shown response rates of almost % among children and young adults with b-cell precursor acute lymphoblastic leukemia (all) that are refractory or in second or later relapse. cytokine release syndrome (crs) and car-t cell related encephalopathy syndrome (cres) are well described toxicities associated with car-t therapy. crs is a systemic inflammatory response and is typically characterized by fever, hypoxia, tachycardia, hypotension and multi-organ toxicity. cres may occur concurrently or following crs, or without any associated crs symptoms and is characterized by encephalopathy, delirium, seizures and rarely cerebral edema. almost half of patients who receive tisagenlecleucel may require pediatric intensive care unit (picu) support. crs and cres are generally reversible but may be associated with fatal outcomes. pediatric specific management guidelines, comprehensive training of multidisciplinary staff, effective communication and phased infrastructure ensure that adequate resources are available to facilitate early diagnosis and appropriate management of pediatric patients with crs and cres and allow for optimal patient outcomes and accreditation by the foundation for accreditation of cellular therapy (fact).objectives: develop a comprehensive program to ensure safe administration of immune effector cell (iec) therapy to pediatric patients.design/method: an inter-disciplinary pediatric cartox (car t cell therapy associated toxicity) committee consisting of cell therapy and picu physicians, neurologists, fellows, nursing leadership, advanced practice practitioners, pharmacists, registered nurses and social workers was created to monitor patient toxicity and establish specific clinical guidelines and diagnostic and treatments algorithms for pediatric patients receiving iec therapy. educational modules were developed as (i) live in-services and (ii) an online module with a competency based assessment. electronic medical record (emr) order sets and documentation and warning systems were also developed by the committee. the pediatric cartox committee developed a diagnostic and treatment algorithm for patients receiving iec therapy. emr orders and flowsheets were developed to support adherence to the algorithm. inter-disciplinary staff training and competency assessments were closely tracked. almost % of identified staff have completed training and achieved competency including, pediatric cell therapy staff, emergency center, picu, outpatient clinic/triage, neurology and sub-specialty staff and nocturnalists.conclusion: an inter-disciplinary approach can assist in institutional readiness for an iec program, promote quality assurance and perhaps fact iec accreditation. future directions include a program for ongoing staff competency assessments. predicted peak vo ) and abnormal oxygen uptake efficiency slope at the anaerobic threshold ( . ± . . , normal ± ). additionally, on echocardiogram three patients had evidence of diastolic dysfunction as evidenced by an elevated e/a ratio ( . ± . ) on tissue doppler. three patients demonstrated depressed longitudinal peak systolic strain (- . ± . ), indicating dysfunction not captured by ejection fraction. in this feasibility study, sct patients without evidence of lvsd on standard measures by resting echocardiogram can demonstrate abnormal exercise capacity. additionally, they can demonstrate systolic and diastolic dysfunction by measures not always included in standard echocardiography. these data suggest the need for a more thorough screening of survivors, and will be further validated as additional patients are recruited for this study. background: in hematopoietic transplantation, the t lymphocytes of the inoculum play a determining role in promoting hematopoiesis, transferring immunity to pathogens and acting as mediators of the graft-versus-leukemia effect (gvl). however, they are also responsible for graft-versus-host disease (gvhd), the main cause of post-transplant morbidity and mortality. the depletion of cd ra lymphocytes, by eliminating naive t lymphocytes from the inoculum, aims to conserve the gvl without producing gvhd.design/method: since april , patients ( boys and girls), with a median age of years, have undergone an allogeneic hematopoietic transplant from an hla donor identical with cd ra/cd depletion. the indication for transplant was: acute lymphoblastic leukemia ( ), acute myeloblastic leukemia ( ), myelodysplasia ( ) and medullary aplasia ( ). the donor was familiar in cases and unrelated in . the conditioning regimen was with fludarabine, busulfan and thiotepa. the median of cd + cells infused was . × / kg. on the day , + and + a programmed infusion of × / kg lymphocytes cd ra-was performed.results: all the patients grafted with a median leukocyte (> . × / l) and platelet (> × / l) engraftment time of and days, respectively. only one patient has developed acute gvhd grade i and no patient has developed chronic gvhd. immune reconstitution was early and rapid in all t cell subsets no patient has relapsed so far and only patient with myelodysplasia has developed an aml. she has received a nd transplant and has died of relapse. there was no case of toxic mortality. the event-free survival (sle) was ± % with a median follow-up of months. at present, patients are alive, out of immunosuppressive treatment and doing well. allogeneic transplantation with cd lymphocytes ra depletion resulted on very encouraging results, with a very low incidence of acute and chronic gvhd, but preserving the gvl effect by infusing cd ra-donor lymphocytes. miami children's health system, miami, florida, united states background: hematopoietic stem cell transplantation (hsct) using autologous or allogeneic progenitor cells is a potentially curative treatment for patients with high-risk malignancies and nonmalignant conditions. the american society for blood and marrow transplantation developed a task force to establish consensus guidelines for defining patient care in hsct and advocated for further studies to delineate safe procedural steps as an increasing amount of hsct are being offered to patients. there is limited evidence to support engraftment in recipients who receive their infusions via iv or syringe pump. we present novel data from patients who achieved neutrophil engraftment following hsct by a pump mechanism.objectives: to provide evidence supporting the use of pump (intravenous or syringe) infusion method in hematopoietic stem cell transplantations.design/method: a retrospective review was completed for patients who underwent hsct between and . inclusion criteria included patients who had received hematopoietic stem cell transplants between and and who were ages months to years old. the main outcome measure was days to neutrophil engraftment (defined as the first of three consecutive days with an anc > × /l).results: among patients who received infusion of hematopoietic stem cell products via pump mechanism, patients ( . %) received autologous products and ( . %) received stem cells from allogeneic donors. neutrophil engraftment (anc > × /l) occurred in a median of . days after stem cell infusion. the mean number of days to engraftment for patients who received allogeneic infusions s of s design/method: a retrospective chart review was performed at the children's hospital of wisconsin. statistical analyses included kaplan-meier estimate for os, mann-whitney test for comparing outcomes between subjects, and descriptive analyses.results: from - , patients with a median age of . ( . - . ) years at st hct were identified. patients were conditioned with cy/atg (n = ), cy/flu/atg (n = ), or cy/flu/atg/tbi (n = ) and received marrow (n = ) or cord blood (n = ) with median cd /kg dose of . ( . - . ) × . two patients developed grade i acute graftversus-host disease (gvhd); none developed chronic gvhd. due to dropping chimerism, graft rejection, or graft failure, nd hct (n = ) or boost (n = ) was offered. the median cd chimerism prior to hct/boost was ( - )%. median time between st hct and nd hct or boost was days ( days- . years). in patients receiving nd hct, used the same donor, of which used the same stem cell source (marrow) and switched to peripheral blood stem cells (pbsc). in patients who switched donors, used pbsc and used cord blood. most patients receiving nd hct underwent a uniform conditioning regimen of cy /flu /equine atg/ gy tli (n = ) or cy /flu /rabbit atg/ gy tbi (n = ); one received cy/atg. acute and chronic gvhd (limited seen in %) developed in % and % of patients, respectively. four patients required additional boosts and additional hct. after final intervention, cd and whole-blood chimerism at last follow-up was between - % (n = ) and - % (n = ), respectively. with a median follow-up of . ( . - . ) years, of patients are alive with an estimated -year os of . ± . %, having performance status ≥ % (n = ) or % (n = ). one patient developed chronic extensive gvhd and died of fungal infection . years after nd hct. our single-center experience demonstrates excellent ability to salvage patients who develop graft failure after initial hct. transplant-related complications such as gvhd and infections remain significant concerns. key: cord- -atbjwpo authors: nan title: poster sessions date: - - journal: febs j doi: . /febs. sha: doc_id: cord_uid: atbjwpo nan ** each poster has been given a unique number beginning with the letter p; the next part relates to the session in which the poster will be presented. moreover, klf is also acting on cellular processes such as cell migration, apoptosis, inflammation, angiogenesis and differentiation. previous studies showed a novel role for klf as a regulator of proliferation and differentiation in skeletal muscle stem cells. detecting klf at the protein level harbored technical obstacles. commercially available antibodies exhibited low affinity, low specificity and failed to recognize post-translationally modified forms that are directly relevant to the function. thus, these obstacles prevent further functional protein studies such as western blots, protein co-immunoprecipitation and chromatin immunoprecipitation (chip) assays. therefore, we used crispr/cas system to establish a stable cell line which carry v epitope tag into the n-terminal of klf gene. insertion into the target side of klf gene via crispr-cas system provided an opportunity to overwhelm the above mentioned obstacles. v epitope tag would not interfere with the function of the klf and also enable us to recognize endogenous klf via anti-v antibody in the mouse myoblast cell lines (c c ). we confirmed the targeted insertion into the exon of the klf gene both at the dna and protein levels. the conformational dynamics of structural domains plays an important role in functioning of many proteins. the reca proteins from e. coli are known to be the central catalyst of homologous recombination and repair in bacteria. it forms a helical filament on ssdna capable to bind homologous dsdna and catalysis of the exchange of the complementary strand. significant mobility if its c-terminal domain has been observed experimentally by cryo-electron microscopy. however its potential significance for reca protein activities still remains unclear. in this work we investigated this question by construction of a mutant reca protein with artificial disulfide bridge between central and c-terminal domains. the wild type protein has no disulfide bonds, and therefore its native mobility can be restored in vitro, by addition of b-mercaptoethanol. our data suggest that the s-s bridge decreases both the rate of atp hydrolysis in vitro and the e. coli resistance to uv in vivo. thus, our experimental results indicate that the flexibility of the c-terminal domain significantly affects recombination activity of reca protein in vivo and in vitro. hydroxiurea (hu) is an inhibitor of ribonucleotide reductasethe enzyme that catalyzes the process of free dntps synthesis in living cells. treating cells with hu causes diminishment of the nucleotide pool. as a result, single-stranded dna regions are generated, which leads to s-phase checkpoint activation. the progression of replication forks is blocked and the completion of dna replication is prevented. this results in s-phase cell arrest. nevertheless, our results demonstrate that after prolonged hu treatment, the saccharomyces cerevisiae cells seam to escape the arrest and continue the progression of their cell cycle. we show that when cells re-enter the cell cycle, mrc , but not ctf is detached from chromatin. our data also shows that meanwhile, rad checkpoint activity is diminished in order to allow s-phase checkpoint escape and completion of the cell cycle. moreover, cells not only continue the cell cycle, but steadily surmount in the presence of hu. all this data indicates that cells have made the decision to compromise s-phase checkpoint and to adapt to the novel environmental conditions in order to survive. as both mrc and ctf are known to be responsible for polymerase and helicase harmonization during replicative arrest, our data indicates that mrc has a more specific role in the process of adaptation. our data demonstrates that mrc is a leading protein to regulate the stability of s-phase checkpoint arrested replication forks. zinc finger domain is the most common dna binding domain in metazoa. almost drosophila proteins with c h zinc fingers also have zinc finger associated domain (zad). several proteins with zad (zw , pita and zipic) were found to interact with cp and act as insulator proteins. for some of the zad-containing proteins (for example, weekle and grauzone) it was shown that their zad domains can form dimers with each other. the ability of these proteins to dimerize appears to be especially important in the light of the model suggesting that dna-binding insulator proteins can support genome looping and organization of chromatin structure via interaction with each other. in this work we aimed to understand the role that zadmediated protein-protein interactions play in maintenance of dna loops, focusing on proteins: zw , pita, zipic and cg . first, we performed co-precipitation and yeast two hybrid assays to confirm dimerization of isolated zads in vitro. we observed that only zads from the same protein can specifically interact with each other (homodimerization) and they are unable to interact with zads from different proteins (heterodimerization). we confirmed homo-but not heterodimerization of zads in vivo with coimmunoprecipitation experiments in s cells. furthermore, we found that zad proteins can support longdistance interactions in transgenic constructs in flies. using model system with cg protein, we demonstrated that zad is essential for these interactions. proteins without zad cannot maintain loop formation. finally, analysis of chip-seq experiments for zw , pita, zipic and cg revealed that binding sites of zad proteins often overlap with regions of inter-chromosomal contacts known from hi-c experiments. we conclude that zad-containing proteins can support longdistance genomic interactions and dimerization of zads is necessary for these interactions. this study was supported by the russian science foundation (project № - - ). over the years a large body of clinical knowledge has accumulated on pharmacological effects of drugs on thyroid function. antipsychotics are administered over long periods in humans; therefore their possible adverse side effects should be taken into consideration. the aim of this study is to evaluate the effects of haloperidol and clozapine on plasma t and t concentrations in adult male wistar rats. fifty rats aged between and weeks ( ae g) were divided into five groups (n = in each group), and drugs were administered each day intraperitoneally (ip) for days. the first group was a sham group. the other four groups were considered as low and high treatment doses of the drugs. after a one-week habituation period, animals was administered haloperidol ( . mg/kg, n = and mg/kg, n = ) and clozapine ( . mg/kg, n = and mg/kg, n = ). the rats were anesthetized with ether, and bloods were collected by direct cardiac puncture hours after the last injection. the t and t plasma concentration levels were analyzed with chemiluminescent immunoassay. statistical analysis was performed with ibm spss v . . kruskal-wallis and bonferroni tests were used. t plasma concentration levels significantly differ between sham (median= . mg/kg) and haloperidol ( mg/kg) (median= . mg/kg), haloperidol ( . mg/kg) (me-dian= . mg/kg) and clozapine ( mg/kg) (median= . mg/ kg), haloperidol ( mg/kg) (median= . mg/kg) and clozapine ( mg/kg) (median= . mg/kg) groups (p < . ). however, no significant differences between the groups regarding to t plasma levels were observed. in conclusion, haloperidol and clozapine increased the t plasma concentrations, but didn't have any significant effect on t plasma concentrations. p- . . - isolation of lipase producing strains of bacillus obtained from olive wastewater and screening for substrate specificity in this work, wastewater samples of an olive factory from yusufeli (artvin, turkey) were collected carefully. after a centrifugation period of samples, supernatants were applied to a . lm filter and incubated on lb agar medium for hours. based on differencies of colony morphologies, isolates were selected and purified for identification. s lipase activity assay was carried out by rhodamine b. all of the strains exhibited lipase activity. for determining the substrat specificity of isolates, different substrates were used; nitrophenyl-butyrate, -nitrophenyl-caprylate, -nitrophenyl-laurate, -nitrophenyl-myristate, -nitrophenyl-palmitate. results were measured spectrophotometrically at nm. all of the strains hydrolyzed -nitrophenyl-butirat, while there was no activity with -nitrophenyl-palmitate. bacillus sp. l was the most efficient strain that hydrolyzed all of the substrates. the gene encoding for lipase of bacillus sp. l will be cloned and expressed for more analyses and industrial applications. p- . . - some quantitative aspects of hair follicle layers differentiation e. vsevolodov , , v. golichenkov , a. mussayeva , , i. latypov llc "kazcytogen", almaty, kazakhstan, "institute of general genetics and cytology" sc mes, almaty, kazakhstan, lomonosov's moscow state university, moscow, russia in the course of stable hair growth the differentiation of hair bulb cambium cells to several layers with dissimilar cytochemistry and morphology takes place. this means the activation of different genes in the cells of different layers. depending upon the hair diameter some layers may be absent (medulla in the thin hairs). the hair diameters of the carpet sheep breeds vary widely even within the same square mm of the skin. we compared the different layers thicknesses proportions for the follicles with varying hair diameters. the follicle layers were measured on microphotos of transverse histological sections of the follicles made under the standard magnification. all follicles belonged to the same skin biopsy. the measurements were made at the levels just below the fissure separating the hair and inner root sheath appeared. the empirical regressions of the layers thicknesses and of ratios of different layers against hair diameters were counted. the computer model was made on the basis of these regressions which allowed to obtain the absolute parameters of the layers as well as ratios of these parameters for every chosen hair diameter. using this model we found an essential trend in changing the proportions in relative layers dimensions as we choose the follicles with more and more thick hair. when we change the follicles with mcm hair diameter for those with the hair diameter mcm the ratio of hair medulla diameter to hair diameter increases from . to . . the ratio of hair diameter to the diameter of inner root sheath increased from . to . . it means that the thicker is the hair the higher proportion of cells produced by cambium are spent to build innermost layers (medulla layer within the hair or hair within the complexinner root sheath + hair). these data may throw some light on positional information mechanism of layers differentiation. lignin is a heterogeneous polymer that constitutes % of woody plant cell walls. microorganisms that degrade lignin are fungi, actinomycetes and to a lesser extent, bacteria. in case of industrial applications, the use of fungi is not feasible due to the structural hindrance caused by fungal filaments, requirement of particular culture conditions such as humidity, aeration which are not compatible with industrial processing environments. bacteria are worthy of being studied for their ligninolytic potential due to their immense environmental adaptability. environmental concerns and increasingly stringent emissions standards have led the pulp and paper industry to devise ways to decrease the level of chlorinated lignin residues in its effluents through both production process changes and improved treatment technologies. bleaching with the enzymes is the most promising because the enzymes may be very efficient, and can be used under industrial conditions. the main objective of this study was to investigate the adequency of klebsiella pnuemonia gst (glutathione-s-transferase) pretreatment for bleaching of calabrian pine kraft pulp. for this purpose the following conditions were investigated: enzyme loadings from to u/g pulp basis and the consistecy of the pulp was between and %. enzyme at the desired concentration was added to the pulp and the mixture was incubated at °c for hours. after the enzymatic pretreatment to determine the optimum conditions the kappa number of all reactions were analyzed according to tappi standarts. as a result of this study we determine the optimum conditons as % pulp consistecy, u/g enzyme for pulp treatment. after the enzymatic treatment carried out under optimum conditions we are planning to submit a short bleaching sequence and analyze for physical properties such as viscosity and brightness. owing to this bleacing sequence we are going to able to compare the enzymatic and chemical treatments of pulp in bleaching prosess. p- . . - biochemical characterization of lipase from bacillus subtilis strain a from olive waste water f. ay sal, m. kac ßagan, s. c ß anakc ßi, a. o. beld€ uz karadeniz technical university, trabzon, turkey lipases (triacylglycerol acyl hydrolases, ec . . . ) are regarded as mild and environment-friendly biocatalysts for triacylglycerols hydrolysis. in addition to this hydrolytic reaction, they also catalyze reverse reactions of esterification, transesterification, and interesterification in non-aqueous environments. substrate, stereo-, regio-and enantio-specificities, and chiral selectivity are certain unique attributes of lipases that make them industrially attractive. these properties are often exploited in the manufacturing of detergent formulations, synthesis of fine chemicals, useful esters and peptides, food processing, paper manufacturing, degreasing of leather as well as in bioremediation. in this study, lipase from bacillus subtilis strain a is partially purified and characterized. bacillus subtilis strain a is isolated from olive factory from soke (aydin, turkey) and identified with s rrna analysis. lipase activity is screened on petri supplemented with rhodamine b. bacteria was grown in lb medium supplemented with % olive oil (vol/vol) for hour at °c. after incubation, cells were harvested by centrifugation at , rpm for minutes, resuspended in mm tris-hcl (ph . ) buffer, followed by sonication with sartorius labsonic m to release intracellular proteins. q-sepharose is used as ionexchange column chromatography for lipase purification. effects of temperature on activity and stability were determined spectrophotometrically using p-nitrophenyl laurate as the substrate. effects of ph on activity and stability were also determined. the effects of various metal ions and other reagents on the hydrolytic activity were assayed at °c. the enzyme was active and stable in the broad ph range of . - . and temperature range of - °c. bacillus subtilis strain a have high lipolytic activity. after cloning this enzyme to an expression vector and detailed characterization, this may suggests its usefulness in industrial applications. p- . . - investigation of pin as a nuclear factor one binding partner s. saritas, a. e. yilmaz, a. kumbasar department of molecular biology and genetics, istanbul technical university, istanbul, turkey the nuclear factor one (nfi) proteins are important regulators of gene expression in the developing embryo and in adult stem cell niches. this transcription factor family has four members: nfia, nfib, nfic, and nfix. nfi proteins bind a consensus sequence on gene regulatory regions as homo or heterodimers. each member of nfi family has a highly conserved n-terminal dna binding and dimerization domain and a diverse proline rich c-terminal transcriptional activation/repression domain. as knockouts of nfi genes display distinct developmental phenotypes, we hypothesized that specificity of nfi protein function may arise from their interactions with binding partners. a yeast-two hybrid screen identified protein interacting with never in mitosis a (pin ) as a potential nfib interactor. pin is a ubiquitously expressed protein that specifically recognizes and binds to a phospho-serine or a phospho-threonine followed by a proline (ps/pt-p motif), and catalyzes isomerization of peptidyl-prolyl bonds. interestingly, both n-terminal and c-terminal domains of four nfi isoforms contain several conserved putative ps/pt-p motifs and some of these are reportedly phosphorylated. we looked for nfi pin interactions in vitro by gst-pulldown and co-immunoprecipitation assays. while gst-pin fusion protein interacts with all of four nfi isoforms, it binds nfib most strongly, nfia and nfic moderately, nfix most weakly. moreover, deletion of the cterminal domain leads to loss of nfi affinity for pin implicating this domain in nfi-pin interactions. co-immunoprecipitation assays where we co-expressed various epitope tagged nfi and pin proteins in hek t cells showed that pin precipitates nfib, as well as other nfi isoforms and nfib can, in turn, precipitate pin . we are currently carrying out site-directed mutagenesis on nfib to identify the specific residues that pin recognizes. we will further explore if this interaction regulates nfi function during embryonic development. that pre-adapt migrating fish to the life in seawater. among others, smoltification induces intense growth of fish that enter the ocean at a size where risk of predation is significantly reduced. skeletal muscle growth depends on a tightly controlled balance between protein synthesis and degradation. protein synthesis driven by hormone regulation is well studied in smoltified atlantic salmon; while less is known on protein degradation occurring via a number of pathways including cytosolic ubiquitin-proteasome system and calcium dependent calpains. the aim of this study was to compare calpain and proteasome enzymatic activities in the skeletal muscles of s. salar parr, pre-smolts and smolts. calpain and proteasome activities were determined by casein or suc-llvy-amc hydrolysis in the skeletal muscles of s. salar from indera river (kola peninsula, russia). our results demonstrated the significant differences in studied protease activity levels between parr and smolts. calpain and proteasome activities in s. salar smolt muscles showed a significant drop compared with that of parr. the negative correlation between proteases activity levels in the muscle tissue and overall fish growth rate was shown. so, our data indicated life stage specificity in skeletal muscle protein degradation capacity in migrating fish. we suppose that intense muscle growth in s. salar pre-smolts is supported by various mechanisms including accelerated muscle protein accretion through the reduction of protease activities. obtained results enhance our knowledge in the mechanisms of atlantic salmon smoltification. the work was supported by the russian scientific foundation, project no. - - . p- . . [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] the sociodemographic characteristics of the pregnant women who double and triple prenatal screening test h. d€ ulger, s. yabanci€ un meram medical faculty, n.e.university, konya, turkey double and triple prenatal screening tests which are applicable during first and second trimesters of pregnancy predict existent abnormalities at early stage. the aim of this study is to investigate the relationship between positive results of double and triple tests, further confirmatory tests during prenatal phase, postnatal status of babies and maternal age. in this study, double and triple test results of pregnant women who were admitted to meram faculty of medicine during - period were scanned from archive and test results indicating risk were detected. from these results, those which were above cut-off values for down syndrome, trisomy , open spina bifida were determined. a questionnaire was carried out with voluntary participants by reaching to these individuals. positive-negative result ratio of all double and triple test results and sociodemographic features such as age, occupation, presence of consanguineous marriage were investigated. all data from archive and answers from survey questions were assessed statistically. participants of the study were to years old and their average age was . ae . . ofthem ( . %) were under years of age whereas of them ( . %) were above years of age. number of pregnancies were scaling between to with an average of . ae . . of mothers ( . %) were not undergone amniocentesis, whereas babies with chromosomal abnormalities were detected among mothers who were undergone amniocentesis. in conclusion, there may be regional, sociological and such that reasons for those who were not undergone amniocentesis despite positive double and triple test results. ( . %) chromosomal abnormalities were detected among pregnancies with increased risk assessment with positive double and triple results. p- . . [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] the effects of oil on the growth and development of amphibians l. sutuyeva, t. shalakhmetova, a. ondassynova al-farabi kazakh national university, almaty, kazakhstan currently, the pollution of ecosystems by oil and oil products is increasing everywhere. the oil gets into water and ground during oil production, transportation and accidents. as a result, terrestrial animals and hydrobionts are exposed to oil contamination. thus, populations of animals decline. it can be assumed that the most sensitive to the effects of pollutants are animals in early stages of development. amphibians have established themselves as the most convenient bioindicator species. since lake frog (rana ridibunda) and green toad (bufo viridis) are the bioindicator species in kazakhstan, the study of the effects of oil on their larvae was carried out. we used water-soluble fraction of the oil from zhanazhol field (aktobe region) in our test. the larvae of control group were kept in pure water, and larvae of test groupsin aquariums with . , . and % concentrations of the oil fractions. the concentrations were chosen in accordance with the level of pollution of kazakhstan's water bodies with oil. mortality of larvae, morphometric parameters and morphogenesis were studied. it was found that high mortality of larvae is the most visible reaction when exposed to oil. this indicator rose noticeably depending on the doses ( . , . % and %) in both species with percentages %, % and % in r. ridibunda and %, % and % in b. viridis, respectively, while in the control group it was about %. furthermore, delayed larval development was detected. thus, the larvae from the control and . % oil group reached gosner stage (gs) , tadpoles from . % and % groups were at gs- and gs- , respectively, by the th day of life. moreover, behavioral abnormalities (sluggish movements) and decreased sensitivity to mechanical stress (touch) were observed under the influence of high concentrations of oil fractions. thus, oil in low concentrations alters the growth and development of tadpoles of anurans, and causes their increased mortality in high concentrations. p- . . - effect of catechin loaded plga nanoparticles on glioma cell line histone h t is a linker histone which binds to dna and contribute in chromatin condensation as well as regulation of specific genes through spermatogenesis. replacement of this histone h subtype and hyperacetylation of histone h tail, facilitate the replacement of histones with sperm chromatin condensing proteins of tnps and prms. ethical approval and informed patient consent was gained from infertile men referred to royan institute. testicular biopsies were collected from patients through assisted reproductive techniques (art) procedure. based on pathological results samples were classified into the following three subgroups: obstructive azoospermia (as positive control), complete maturation arrest and sertoli cell only syndrome (negative control). chromatin of tissues evaluated for presence/absence of histone h t protein in regulatory regions of tnps and prms genes using chip-real time pcr. results showed lower incorporation of h t protein on regulatory regions of tnps and prms genes in two spermatogenic failure group versus positive control. in this study, it can be concluded that the decreased levels of h t histone variant in testis tissues and failure in chromatin condensation have significant association with male infertility. p- . . - serum dickkopf- levels in obese children and adolescents that obesity is detrimental to bone health despite potential positive effects of mechanical loading conferred by increased body mass on bones. the wnt/b-catenin pathway is essential for normal osteogenesis. serum dickkopf- (dkk- ) is one of the most important inhibitors of the wnt//b-catenin pathway. the aim of this study was to investigate the serum dkk- levels in obese and non-obese children and adolescents. materials and methods: the study included obese children and adolescents ( males and females) aged from to years and healthy normal-weight controls ( males and females) aged from to years. serum dkk- levels were measured by elisa method using commercially available kit. results: body mass index of the obese children was significantly higher than that of non-obese children (p = . ). however, there was no significant difference between dkk- levels of the groups. (these results are preliminary and the study is continuing). discussion and conclusion: our result showed that serum dkk- levels were not changed in obese children and adolescents. p- . . - transcriptional regulation of cdo by nuclear factor one proteins b. kutay, c. lektemur, v. g€ uler, a. kumbasar department of molecular biology and genetics, istanbul technical university, istanbul, turkey nuclear factor one (nfi) transcription factors play important roles in regulation of central nervous system development. three of the four members of nfi family, nfia, nfib, and nfix are expressed in neural progenitors, as well as neurons and glia in the embryo. inactivation of these genes in mice show that they function in development of neocortex and hippocampus in the forebrain, cerebellum, spinal cord and precerebellar nuclei of the hindbrain, regulating neurogenesis, gliogenesis, as well as neuronal migration, axonal outgrowth and guidance. all three neural specific nfis are expressed in precerebellar neuroprogenitors, however, only deletion of nfib leads to a delay in development of precerebellar neurons. investigation of misregulated genes in nfib À/À precerebellar neuroprogenitors identified cell adhesion associated, oncogene regulated (cdo) as a potential downstream target of nfib. interestingly, this gene has been reported to be upregulated in nfia À/À hippocampus as well. cdo, a cell surface glycoprotein of the ig superfamily, has been found to regulate neurogenesis in vivo, is highly expressed in the developing brain and can induce neural differentiation by promoting heterodimerization of basic helix loop helix transcription factors with e proteins. bioinformatic analysis of the kb human cdo promoter region identified five nfi binding sites: one cluster in the first kb region, another in the . kb upstream region. electrophoretic mobility shift and supershift assays showed that nfib binds to all five sites. furthermore, nfib, along with the other neural nfis, inhibits the proximal cdo promoter driven luciferase activity by up to % in hek t cells. preliminary data indicate that nfis bind to sites in both clusters in human neural stem cells (hnscs) suggesting that these sites are functional in vivo. we are currently investigating this possibility through nfi overexpression and silencing experiments that will examine regulation of cdo in hnscs. differentiation. the aim of this study is to investigate bdnf and drd /ankk gene variants in eos development. in this study, eos patients and healthy controls were used. genomic dna extraction was performed from peripheral blood leukocytes. drd /ankk taq a (rs ) and bdnf val met (rs ) polymorphisms were determined by real-time polymerase chain reaction (rt-pcr). positive and negative syndrome scale (panss) was used to determine eos severity. for drd /ankk rs polymorphism, there was a significant difference in the genotype frequencies between patients and controls for the co-dominant model (p = . , or = . ; % ci: . - . ). however, no significant relationship was observed in the genotype frequencies of bdnf val met polymorphism between eos patients and controls (p = . ). these results indicate that, drd /ankk rs genotypes may affect eos development. however, bdnf val met polymorphism may not be associated with eos. lack of association of bdnf val met polymorphism may be due to limited number of patients. our findings need to be confirmed by further studies. various dyes used in the textile industry are discharged in large quantities to the receiving environment in the manufacturing process. this is the beginning of a process that is difficult to compensate for environmental and human health. therefore, contaminated areas should be cleaned. in addition, technologies with high polluting potential should be integrated with biological approach and thereby the impurities consisting of dyes should be reduced. in this experiment; burdirect black meta konz (c.i. direct black ) was intended to decolorization using laccase. firstly, enzymatic decolorization of the dye was determined using spectrophotometry. the wavelengths of maximum absorption of burdirect black meta konz (c.i. direct black ) was determined between and nm. then, optimization studies have been done. for optimization studies; dye concentration, laccase activity, ph, buffer concentration, temperature, mediator effect, mediator concentration and time parameters were determined. lastly, in optimal conditions, atr-ftir and gc-ms analyzes of ensuring decolorization of dye were analyzed. decolorization of burdirect black meta konz (c.i. direct black ) was performed successfully and the absence of any metobolite in the decolorization medium has been provided by atr-ftir and gc-ms analyzes. assessing in terms of application, it can be easily applied by provided the reaction conditions in textile factories. laccase is a tool of decolorization of dyes in environmental friendly process. thus for the development of spermatids into mature sperm able to fertilize the oocyte.one of the causes of male infertility is in fact impaired sperm fertilization capacity due to sperm chromatin abnormalities and aberrant protamine replacement.recent research has focused on protamine biology,including protamine gene and protein structure,mechanisms of protamine expression regulation and involvement of the protamines in male fertility.various studies reported abnormal expressions of protamine (prm) genes in sperm of infertile men.the aim of the study is to investigate the gene expression of prm , prm and their relationship with defective spermatogenesis. materials and methods: this study has been performed on infertile and fertile turkish men.total rna was extracted from the sperm pellet using trizol reagent.after rna extraction and cdna synthesis,real-time quantitative polymerase chain reaction (rt-qpcr) was used to determine the expression of prm and prm . results: distinct levels of spermatozoal prm and prm mrna were found in infertile patients compared to fertile control groups.we found that the mrna levels of prm was reduced in (% ), and the mrna levels of prm was reduced in (% ) out of infertile patients.in the current study,we found statistical significant association between the prm expression and infertility (p < . ).although prm gene expression was decreased in most of infertile patients compared to fertile control groups,the differences between the groups were statistically insignificant (p > . ). discussion: the results of the study suggested that, the protamine expressions which were associated with spermatogenesis may be important in infertility treatment. further studies are required in a large series of different populations to clarify the role both prm and prm themselves and their mrna expression on male fertility. the study was conducted to characterize the processes of muscle growth in atlantic salmon (salmo salar l.) of different ages inhabited rivers indera and varzuga (kola peninsula, russia) in summer and autumn. the expression levels of genes myosin heavy chain myhc, myostatin (mstn), and myogenic regulatory factors myf , myogenin) in white muscle were studied in salmon parr of age groups +, +, + in june and october. the changes in expression levels of mrfs, myhc and mstn indicating the extent of hyperplasia, hypertrophy, and restriction of muscle growth at different ages of parr were revealed. the pattern of age-related changes differed between seasons. especially, the expression of genes myod, myogenin and myhc peaked in yearling parr ( +) in summer, that indicated the high rate of hyperplastic and hypertrophic muscle growth in yearlings ( +). at the same time, the mstn expression level, the negative regulator of muscle growth, was highest in parr at age +. possibly, it is the necessary regulation mechanism to attenuate hyperplasia and hypertrophy and control muscle growth. in autumn, the expression level of myhc and myogenin were higher in salmon of age + and + then in +, indicating the higher intensity of hypertrophy in parr at both first ages in comparison to +. there was no differences in expression level of myod, myf and mstn between age groups in autumn. moreover, the expression levels of genes studied were lower in autumn than in summer. thus, it indicated the decrease of muscle protein synthesis and muscle growth rate in autumn. these findings expand knowledge on age-and season-related features of muscle development in young atlantic salmon in their natural habitat. the study was supported by the grant of the russian science foundation no. - - . p- . . - lmp and lmp gene polymorphisms in the southeastern anatolia population of turkey d. mihc ßioglu , f. ozbas gerceker sanko university, gaziantep, turkey, gaziantep € universitesi, gaziantep, turkey introduction: the low molecular weight polypeptide (lmp ) and low molecular weight polypeptide (lmp ) genes are located in the class ii region of the major histocompatability complex (mhc) locus on chromosome . these genes encode peptides forming the large components of the proteosome complex which degrades short-lived cytoplasmic proteins. due to the significant role of lmp products antigen presentation, these genes can be accepted as strong candidates of susceptibility factors for different diseases. population genetic studies can also contribute to understanding of the possible role of lmp gene polymorphisms. the aim of this study was to determine the allele and genotype frequencies of the lmp and lmp gene polymorphisms in southeastern anatolia population and to compare these with the frequencies in other populations previously reported. material and methods: a total of healthy and unrelated individuals participated in this study. polymorphism analyses were done by polymerase chain reaction (pcr)-restriction fragment length polymorphism (rflp) method and allele/ genotype frequencies of lmp and lmp genes were determined. results: a deviation from the hardy-weinberg equilibrium (v = . ,p < . ) was found for the genotype distribution of lmp gene polymorphism, while the lmp genotypes found to be distributed (v = . ,p > . ). discussion: available allele frequency data for different populations were used to calculate genetic distances and to construct a neighbor-joining tree. among the included populations, nahuas (mexico) population was found to have the lowest genetic distance from the southeastern anatolia-turkey population. conclusion: it can be concluded that, more studies using different types of genetic markers are needed to clarify the filogenetic relationships of southeastern anatolia population with other populations and also the number of population studies on lmp and lmp genes should be increased to understand their effects as a genetic marker. p- . . - investigation of in vitro antioxidant activity of quercetin loaded plga nanoparticles pharmacological effects. but its usage is restricted because of low aqueous solubility, poor bioavailability, poor permeability and instability in physiological medium. these problems can be overcome with encapsulation of quercetin into nanocarriers such as biodegradable plga based nanoparticles. polymeric nanoparticles which have - nm particle size and providing controlled released of biological active agent are prepared by using biodegradable and biocompatible polymers. in this study, encapsulation of quercetin molecules into plga nanoparticles was carried with using the single emulsion (w/o) solvent evaporation method. size measurements of the obtained nanoparticles were performed by zetasizer and their size were found . ; . ; . nm respectively. the morphological features were examined by sem images. antioxidant activities of q , q ve q nanoformulations have been investigated by dpph and no (nitric oxide) methods. it is thought that the nanoparticular formulations that is developed in this study can be useful model for the other antioxidant molecules and will provide a significant contribution to the food and pharmaceutical industry. "this research has been supported by yıldız technical university scientific research projects coordination department. project number: - - -gep ". p- . . the effect of environmental enrichment on spatial memory and certain nmdars, and ht a expressions in rat pups introduction: the aim of the study was to investigate the effect of environmental enrichment exposed during whole childhood on spatial learning and memory and certain nmdars, and ht a in the hippocampi of pups. materials and methods: four-weeks old, male, weaning rats were randomised into groups as enviromental enrichment (ee, n = ) and standard cage control (scc,n = ) groups. eeg housed in an enriched environment and sccg were kept in standard cages for weeks. following the experiment the rats were trained and tested in the morris water maze (mwm) , open field test (oft) and forced swim test (fst) in order to assess the neurobehavioural effects of ee. nr a, nr b, ht a protein levels were analyzed by western blotting from hippocampi of rats. results: the positive effect of ee was seen at the learning phase in the mwm as 'latency to locate the hidden platform' between groups thoughout the training days showed that eeg located the hidden platform significantly earlier than sccg on days , (p = . , p < . ). also eeg significantly spent lower time in the outer zone of the maze on days , which was the sign of low anxiety level (p = . , p = . ). the parameters of oft which indicated increased locomotion, exploration and low anxiety were significantly higher in eeg (p < . ), in fst comparison of groups showed no difference (p > . ). the levels of nr b and ht a were significantly increased as compared to sccg as well (p < . , p = . ). discussion & conclusion: these findings showed that exposure to ee throughout the whole childhood causes several neurobehavioural effects like increased exploration and low anxiety. these effects may lead to improvement in speed of learning. increase in the nr b and ht a concentrations which are the receptors that are related to learning and memory in the hippocampi accompanied these changes which may be basis of the neurobehavioural improvements or may provide contribution to positive neurobehavioural effects. p- . . - effects of monosodium glutamate exposure during prepubertal term on several biochemical parameters in rats h. i. b€ uy€ ukbayram, d. kumbul doguc ß, i. ilhan, a. y. ismail s€ uleyman demirel university, isparta, turkey monosodium glutamate, which is commonly used in processed foods as flavor enhancer, is considered 'generally recognised as safe' by fda; however many studies have revealed the negative effects of msg.we aimed to evaluate the effects of msg in childhood on several serum parameters. sixty-six rats, ( weeks old) were divided into groups as control (cg, n = ; + , male+female) , experiment (msg-low dose, e g, n = ; + , male+female) and experiment (msg-high dose, e g, n = ; + ) groups. msg was administered at mg/kg/d to e g, . g/kg/d to e g for weeks by oral gavage. the rats were sacrified and blood samples were collected from aorta. the blood samples were centrifuged, the serum samples were separated and glucose, alt, total protein, albumin, creatinine, cholesterole and triglyceride levels were analysed by beckmann au autoanalyser. level of total protein was significantly increased in e g and e g groups when compared to cg (p < . ). level of alb€ umine was also increased in both egs but significant difference was seen in e g as compared to cg. creatinine levels were significantly increased in egs when compared to cg (p < . ). although the glucose levels in both egs were increased, the increase in e g was statistically significant (p < . ). the alt levels of in egs were also increased but the significant increase was seen in e g (p < . ). the effect of msg seem to be dose dependent and especially effect on carbonhydrate metabolism. increasing doses caused increase in glucose level, and tendency to glucose intolerance. increasing doses of msg also caused increase in creatinine and urea. another apparent effect of msg was detected on alt activity. in conclusion the negative effect of msg on glucose level, liver and kidney functions depends on daily dose intake. consumption of msg seem to be inevitable it has to be restrained in children otherwise early metabolic problems may be future problems for these children. ( mg/kg) + tartrazine ( mg/kg) + brilliant blue fcf ( mg/kg) + ponceau r ( mg/kg) + azorubine ( mg/kg) + indigotine ( mg/kg) + erythrosine ( mg/kg). artificial food color mixture were administered to g and g and drinking water was applied simultaneously to g by oral gavage per day for weeks. after application all rats were sacrificed, the total oxidant (tos)/antioxidant (tas) capacity were analyzed in rats' brain, liver, kidney homogenate and serum with rel tos-tas diagnostics assay kit.the statistical analysis was carried out by using kruskal wallis test. tas and tos levels in liver homogenate were not found significantly different between all groups (p > . ). in serum and kidney and brain homogenate, tas levels were not significantly different between all groups. tos levels in g were higher than g and g in serum and kidney and brain homogenate (p < . ). exposure to synthetic food colors may increase oxidative stres in vitale organs such as brain, kidney in female rats. these alterations differ according to organ and dose. parallel with increasing trends on healthy eating habits, consumption of prebiotics and probiotic microorganisms have been popular due to their benefits on human health. functional dairy foods such as probiotic yoghurt and cheese are the most common foods including probiotic microorganisms. due to some considerations such as standardization and quality in bulk production, starter cultures are used in industrialised fermentative food production to start fermentation. starter culture basically refers the microorganisms which induce and maintain fermentation of the fermentative foods and starter cultures including probiotic microorganisms are called as probiotic starter cultures. in this study, probiotic cheese starter cultures as a microbial community were investigated using computational systems biology tools. a metabolic network model of probiotic cheese starter culture was reconstructed using microbial community network modeling approach. literature-based genome-scale metabolic models of commonly used lactic acid bacteria were used for the microbial community metabolic model. the microbial community metabolic model simulated metabolic interactions of the microorganisms in the probiotic starter culture. metabolic flux values computed by the metabolic network model also predicted the metabolic pattern of the glycolysis (conversion of lactose), lipolysis (conversion of fat) and especially amino acid catabolism which are associated cheese flavor metabolism. simulations obtained by metabolic network-based analysis of cheese starter cultures can also be used for other fields like genetic engineering, upstream processing of the functional cheese production. p- . . - er quality control protein network in cf to modulate f del-cftr rescued phase ii xenobiotic metabolizing enzymes convert parent compounds into more hydrophilic metabolite by catalyzing conjugation reactions including glutathione and amino acid conjugation, glucuronidation, sulfation and acetylation. this study was aimed to describe the best cell line model for studying phase ii xenobiotic metabolizing nqo and gst-pi enzymes. for this purpose, mrna and protein expression of nqo and gst-pi enzymes were analyzed in ht and sw (colon); hepg and huh (liver); pnt a and pc (prostate) cell lines by qrt-pcr and western blotting techniques, respectively. protein expression analysis revealed that nqo protein was expressed in all cell lines and relative protein expression is highest in the hepg ( %) and pnt a ( %) while huh ( . %) showed relatively low expression of nqo . in addition, nqo mrna expression was relatively high in ht ( . fold) and pnt a ( . fold) when compared with liver cell line hepg ( . fold). gst-pi protein expression was found very high in huh ( %) while there was no expression in hepg . gst-pi mrna expression was relatively higher in pnt a ( . fold) and ht ( . fold) when compared with huh ( . fold). according to these results, choosing the best cell line as model depends on the purpose of the research. for studying metabolism of a chemical by nqo and gst-pi or effect of a chemical on translational regulation of these enzymes, it is better to consider protein expression of the cell lines for choosing best model. however, if the aim is to study effect of a chemical on transcriptional regulation of these enzymes, it is better to choose a cell line that expressing highest mrna of gene of interest. in conclusion, considering both mrna and protein expression levels together, the best model cell lines for studying phase ii xenobiotic metabolizing nqo and gst-pi are ht and huh , respectively. p- . . [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] the studies on the pancreatic cells' surface glycoconjugates profiles in rats fed with high fat with lectin labelling methods by flouresans microscopy y. mater, s. beyhan ozdas gebze technical university, kocaeli, turkey in this study, the backbone of the cellular adhesion-recognition mechanism, located in the cell membrane. the study material selected pancreas tissue, has a privileged structures. the pancreas is one of the main organs to aid in digestion. the pancreas functions as an exocrine gland and role in digestion. in addition, the pancreas also functions as an endocrine gland, secreting several hormones into the blood that control the blood levels of glucose and other nutrients. due to the pancreas have been selected for this unique feature. thus, different types of cells in the same sample will be able to study the structure of the surface glycoconjugates. generally researches about determination of carbohydrates in the cell, glycoproteins or/and glycolipids are cut with enzymes. next step, the oligosaccharide mixture obtained, than establishing the complete structure of oligosaccharides and polysaccharides requires determination of branching positions, the sequence in each branch, the configuration of each monosaccharide unit, and the positions of the glycosidic links. this is a more complex problem than protein and nucleic acid analysis. these processes are indispensable for the understanding of the chemical structure of the sugar. whereas in cells using labeled lectins specific sugars, it is possible to accurately determine. in this study, was used triticum vulgaris (wga) labeled with fluorescein (fitc). thus, the cells located on the cell surface and neu ac (sialic acid) for wga sugar residues were investigated. according to preliminary results of this study, wga labeled with fitc is specifically binding of these sugars. when this study is completed, the differences of sugar on the surface of different type of cells in the pancreas can be distinguished in micrographs. thus, in the cells of the pancreas, the sugar units involved in adhesion-recognition can be possible to determine specifically. large scale gene networks could be topologically analyzed in order to obtain possible global system-level structure cancer gene co-expression networks can have lower connectivity as compared to normal samples. using colorectal tissue gene expression datasets, we observed that tumor specific networks are less connected than normal networks. functional enrichment analysis suggested that cell cycle genes and methylation-associated cell adhesion genes can specifically play a role in the connectivity loss of carcinoma samples. literature confirmation provided a gene network including significant genes playing roles in the intersections between cell cycle, cell adhesion, and cell skeleton dynamics. this network can provide novel insight to our understanding of the molecular mechanisms of colorectal cancer. p- . . - tf-mirna circuits specific to epithelial cancers y. oztemur, a. aydos, b. gur dedeoglu ankara university biotechnology institute, ankara, turkey cancer is the most common cause of death in the world but there are still a lot of uncertainties about the exact mechanism taking roles in regulation of it. cancers can be classified according to cell type; in which they start. carcinomas are the most prevalent types of cancer and start in epithelial tissues. they are also named as epithelial cancers (ecs) and make up about out of every cancers. over the past few years, many studies are concentrated on mirnas, which have emerged as important regulators of gene expression like transcription factors (tfs). tfs are regulators at transcriptional level while mirnas are post-transcriptional regulatory key-elements. otherwise the transcription of mrnas and mirnas are known to be regulated by tfs and tfs are the targets of mirnas. therefore, it is crucial to characterize the relation of tfs, mirnas and their targets by building circuits in diseases such as in ecs. for this study, mirna and mrna expression studies including epithelial tumors and normal samples searched in geo and array express microarray databases. mrna studies and mirna study, which were designed for different ecs (breast, lung, ovary and colorectal) were selected to be analyzed. differentially expressed (de) mrnas and mirnas between epithelial tumors and normal samples were extracted (p ≤ . , fold change). among de genes, transcription factors and mirnas were identified and listed for epithelial tumor vs. normal comparison. circuit analysis resulted with remarkable circuit, which was common for all the types of ecs that includes klf transcription factor and hsa-mir- . in the literature hsa-mir- and klf are known as important regulators in different types of cancer, which indicated that the motifs involving tfs and mirnas might be useful for understanding the regulation of ecs. as a conclusion finding out new and common circuits may aid us in predicting new or alternative diagnostic and/or prognostic biomarkers for ecs. mesenchymal stem cells (mscs) are multipotent stromal cells that can differentiate into a variety of cell types which are used in cell therapy. although they are the most attractive cell type for cell therapy studies, primary mscs lose their differentiation potential with increasing time in culture and passage so they are of limited use. due to this disadvantage, msc lines are more suitable for in vitro researches owing to their immortality. in this study we compared primary bone marrow-derived msc (bm-msc) with bone marrow derived msc line (rcb ) in terms of cell characteristics and gene expression profiles to determine the functional differences among mscs types. firstly, mscs were identified by using cd , cd , cd and cd as positive markers and cd as a negative marker. gene expression profilling was investigated using affymetrix hg-u -plus arrays. the significant go biological process terms and kegg pathway enrichment analyses of the identified degs were performed using david (p < . , fold change≥ ). the analysis showed similar pathway clustering in both cell types. the resulting quantitave transcriptome of genes were identified that differentially expressed in msc line versus primer mscs ( upregulated and down-regulated). functional classification of changed genes was mainly clustered in cell cycle, cell death and mismatch repair. kegg pathway analysis revealed that the genes were significantly enriched in pathways including "cell cycle, dna replication and focal adhesion" pathways. in conclusion, our results indicate that msc lines can be used instead of primary mscs. these quatitative results provide an important basis to adapt cell lines to more closely resemble physiological conditions as oppossed to animal experimentation. this could help to minimize the use of animals in research. p- . . [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] association between loss of q , gain of q . and progression in sporadic colorectal cancer n. belder , b. savas , m. a. kuzu , i. pak , h. s€ umer c ß elebi , a. ensari , h. € ozdag biotechnology institute, ankara university, ankara, turkey, school of medicine, ankara university, ankara, turkey, ankara oncology training and research hospital, ankara, turkey colorectal cancer (crc) is one of the most diagnosed cancer and the third leading cause of cancer deaths throughout the world. identifying of copy number variation (cnv) profiles between early and late stage cancers can be useful to understand the progression and aggressiveness of cancer. the main goal of this study was to construct a comprehensive insight of association between cnv and sporadic crc stages in order to identify novel candidate targets which may contribute to tumor progression. affymetrix . genechip snp arrays were used for characterization of cnvs in tumor and matched normal formalin-fixed, paraffin-embedded (ffpe) tissues from stage i, stage ii and stage iii samples. paired cnv analyses were performed using partek genomic suite . and genomic segmentation algorithm was performed using a minimum of markers per segment, a signal-to-noise ratio of . and the cut-off value for the gain and loss was set of ae . . the adjusted p-value ≤ . were considered to be significant. whole genome cnv analysis revealed that amplification of q . with genes was found the most frequent ( . %) in stage ii tumors. the most frequent ( %) amplifications were q . and p . in stage iii tumors. while deletion of chromosome q . in stage iii with a frequency of % was found the most frequent loss, deletion of q . was seen the most frequent ( . %) in stage ii tumors. two tumor suppressor genes smad and smad which are found in these deletion regions were common genes between stage ii and stage iii. our results showed that gain of q . might have a significant role in the progression of cancer. loss of q comprising two tumor suppressor genes is also another important finding. q loss can be a significant prognostic value in colorectal cancer even though validation of target genes requires additional study and larger sample size. this work was supported by tubi-tak project no: s . p- . . - meta-analysis based mirna signature discriminates cervical cancer from normal samples a. yucel polat, y. oztemur, a. aydos, b . gur dedeoglu biotechnology institute, ankara university, ankara, turkey gynaecological cancers are common problems in female health. squamous cell carcinoma (scc) is a type of these malignancies. this tumor type is derived from pre-cancerous lesions, which is called cervical intraepithelial neoplasia (cin). cin is classified as cin , cin and cin according to their dysplasia grade in the cervical tissues. mirnas are small non-coding rnas that were shown to have important roles in the development and progression of various cancers. the aim of this study is identifying mir-nas, which are playing a part in progression of cervical lesions by a ranking based meta-analysis approach. two mrna and three mirna expression studies, which include normal, cin , cin and scc samples were selected from arrayexpress and gene expression omnibus (geo) databases. three mirna studies were combined with anova dependent ranking based meta-analysis program which was developed in our laboratory to find out a mirna signature that can discriminate cin , cin and scc samples from normal samples. the top five mirnas with the highest ranks in meta-list were selected for further analysis. predicted targets of these mirnas were identified by mirdb target prediction tool. additionally two mrna datasets were selected for mirna-target validation studies. common genes, which were obtained from meta-mirna targets and differentially expressed genes between normal and cin , cin and scc groups from two independent studies, were identified and they were subjected to pathway enrichment analysis. pathway enrichment analysis that was performed with common genes showed that these targets were significantly enriched (p < . ) in especially cell proliferation, cell survival and cell cycle pathways, which are the key players of cancer development and progression. the meta-analysis results together with validation analysis of their targets may point out the potential roles of mirnas as biomarkers for the diagnosis and the treatment of cervical cancer. p- . . [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] the hypoglycaemic and regenerative activity of thymbra spicata in alloxanized-diabetic rats thymbra spicata (labiatae), a carvacrol and thymol containing plant, is one of the medicinal herbs used by diabetic individuals to reduce blood glucose in turkey. we investigated the hypoglycaemic and anti-lipemic effects of the aqueous extract prepared from dried leaves and flowers of this plant in alloxanized-diabetic rat model. rats were divided as: diabetic control (group ), dia-betic+glibenclamide (group ), diabetic+plant extract (group ), untreated control (group ) and control+plant extract (group ) groups (n = for each group). serum glucose, lipid levels and body weight changes were mesasured and pancreas and liver histology of the rats were examined. each rat in all groups were administered the plant extract ( mg), and the reference drug glibenclamide ( mg/kg) by gastric gavage every day for weeks. in group , blood glucose, serum alt, ast, triglyceride, cholesterol and ldl cholesterol levels increased while body weights decreased. in group , serum glucose, alt, ast, triglyseride and hba c levels decreased compared to group while cholesterol and ldl levels were high. in group , serum alt, ast, trigliserit, cholesterol, ldl levels decreased significantly but serum glucose and hba c were higher compared to group . body weights increased except group and hdl levels were not altered. histologically degenerative changes observed on pancreas of group were decreased in groups and . there was no difference on liver histology of the groups. in conclusion, thymbra spicata showed a protective and regenerative effect on diabetic pancreas. the hypo-lipidemic effect of the plant extract was also more effective than glibenclamide possibly due to the flavonoids, saponins and triterpenoids contents in the extract. its hypoglycaemic and protective activity should be tested for different doses and extract preparations and for longer periods. our study suggests that thymbra spicata is an excellent candidate for future studies on diabetes mellitus. with three different transcriptome data sets from the public gene expression omnibus database: time dependent data of dphop mutant, dargr mutant and wild type strain. the dynamic data spanned both primary and secondary phases of the metabolism. statistical results of transcriptome data were used for reporter metabolite analysis and reporter pathway analysis, which identify the metabolites (or pathways) with a significant coordinated transcriptional change in response to gene deletion perturbation in phosphate and nitrogen metabolisms. further, the production of actinorhodin, a pharmaceutically important compound, was modeled in the two deletion strains by calculating the metabolic fluxes subject to transcriptional level constraints on enzyme-coding genes. the metabolic switch from primary to secondary metabolism was highlighted in terms of the activity of pathways and fluxes as a result of the computational analyses in this work, leading to a better understanding of the role of phosphate and nitrogen metabolisms in increasing production levels. introduction: as a member of legume family licorice (glycyrrhiza glabra l.) has been widely used by human kind for many years as food constituent. especially by folks in rural sites licorice consumed widely. beside food constituent licorice has been used for medical purposes as well. licorice found effective with scientific datas on peptic skin infections, ulcers, inflammation, eczema, alzheimer disease, liver disease, and cancers. it also has been used as natural sweetener and food additive for preparing candies, chewing gum and beverage since ancient times. like all other medicine it has not been free of adverse event or toxicological effects. material and methods: alcoholic extracts of plant obtained by maceration process. for in vitro examination of anti-oxidant profile of licorice dpph free radical scavenging, abts cation radical scavenging and cupric ion reducing antioxidant capacity assay applied. application of extract made by oral route to rats for a week. anti-oxidant profile has been evaluated by myeloperoxidase (mpo), arylesterase (ares), total oxidative stress (tos) and total antioxidant status (tas) of serum levels. determination of toxicological effects alt, ast, ldh and alp values studied. histological investigation applied on liver and kidney tissues. results and discussion: results compared with control and standarts. antioxidant potential of licorice has been observed by in-vitro assays. serum mpo and ares values also compared with in-vitro results and correlation between them has evaluated. toxicological investigations made after evaluation of ast, alt, ldh and alp values. conclusion: in vitro assays has showed that licorice has potential anti-oxidant effect. investigation revealed that a mild toxic effect of licorice by biochemical tests. toxicological profile compared with control group and alt, ast values found slightly decreased and a mild elevation has been seen in ldh and alp values. for further and detailed investigation is needed. p- . . - on the applications of a metabolic network model of mesenchymal stem cells h. fouladiha, s. a. marashi, m. a. shokrgozar, m. farokhi mesenchymal stem cells (mscs) have several applications in tissue engineering and regenerative medicine. mscs can be very useful in stem cell therapy, because they can be isolated bone marrow or adipose of an adult. these cells have also been used as gene or protein carriers. therefore, maintaining them in a desire metabolic state has been the subject of several studies. here, we have used a genome scale metabolic network model of bone marrow derived mscs for exploring the metabolism of these cells. then, we try to validate the computational results by experimenal tests. we analyzed metabolic fluxes in order to increase stem cell proliferation using the metabolic model. consequently, the experimental results were in consistency with computational results. in the present work, the applicability of the metabolic model was successfully approved. therefore, this metabolic model can be useful in biomedical researches of stem cells. p- . . - qtl analysis for body weight and fatness in bxd recombinant inbred mouse strains a. dogan , c. neuschl , r. alberts , g. a. brockmann school of medicine, istanbul kemerburgaz university, istanbul, turkey, department for crop and animal sciences, humboldt-universit€ at zu berlin, berlin, germany, helmholtz-zentrum f€ ur infektionsforschung, braunschweig, germany genetic variation in body weight and composition is under the influence of many genes and have different genetic architectures. in the present study, the genetic factors contributing to body weight and fatness were examined under energy rich feeding conditions. growth traits, lean and fat weight, fat mass gain were analyzed to map qtls in a set of bxd ri strains. genome-wide analyses were revealed several genomic loci that control body weight and associated bodily changes in a sex and age-specific manner. the genetic data provided evidence for significant qtls on chromosome (chr) , , , and . most likely candidate genes within or near the regions with the highest significance levels were identified. the genes f rik, gbe , a n , and four genes cenpc , stap , uba , gnrhr for example, are suggested as most likely positional candidates accounting for the qtl effects on chr for fat mass, on chr for fat mass gain and on chr for lean weight, and chr for body weight, respectively. our results showed that body composition and fatness are highly complex that many genetic factors regulating and suggested candidate genes, which may help for studies of human fatness. related to serotonergic and gaba systems in response to hormonal changes. the nutrients involved in neurotransmitter synthesis may be the cause of relationship between diet and premenstrual syndrome. therefore, the aim of this study was to investigate the effect of various nutrients and premenstrual syndrome. this study was conducted to healthy women aged - years. participants were asked to fill in premenstrual assessment form. dietary intakes (three days in each phases) were recorded during premenstrual, menstrual and postmenstrual phases. energy, protein, amino acids, iron, calcium, and magnesium intakes were estimated. statistical analyses were performed using the spss software. friedman tests were conducted and differences were considered to be statistically significant for p-values lower than . . . % of the participants reported premenstrual symptoms and premenstrual symptoms related nutrient intake were increased in these women. it was determined that energy (p = . ) and protein (p = . ) intakes were higher in the premenstrual phase. during premenstrual phase; tyrosine (p = . ), isoleucine (p = . ), leucine (p = . ), lysine (p = . ), methionine (p = . ), cysteine (p = . ), tryptophan (p = . ), and glutamic acid (p = . ) intakes were higher than other phases. likewise, iron intake was higher on premenstrual phase (p = . ). on the other hand, intake of other potential premenstrual syndrome related nutrients like fat, cholesterol, calcium, magnesium, and vitamin b were not significantly different within the menstrual phases. amino acids including tyrosine, tryptophan, glutamine, and vitamin b are involved in neurotransmitter synthesis and might be related to premenstrual symptoms. consequently, elevated intakes of dietary protein and some amino acids during premenstrual phase may be related to premenstrual syndrome symptoms. until now far uv cd spectra of only two potexviruses were published. the papaya mosaic virus (papmv) spectrum, measured by leclerc and co-authors contained no obvious anomalies and was similar to the spectrum of isolated papmv coat protein (cp). but measured years earlier by homer and goodmanfar uv cd spectrum of potato virus x (pvx) itself had anomalous character and differed strongly from the spectrum of isolated pvx cp. in the present work we measured far uv cd spectra for two more members of potexvirusgenus: alternanthera mosaic virus (altmv) and potato aucuba mosaic virus (pamv) and their free cps. the altmv virion and altmv cp spectra were similar to each other and to the spectra of papmv and its cp. the pamv spectrum resembled the pvx spectrum in anomalously low ellipticity of the negative band at nm, but in contrast to pvx, did not have additional peak at nm. homologous modeling showed that cp of the three viruses is very similar in the core structure, and the observed difference may be explained by differences in disordered parts of proteins. possible reasons of potexvirus structural variability are discussed and it is suggested that the intravirus potexvirus cps may assume different conformations in different virions of the same preparation or even along the length of one virus particle. this work was supported by the russian science foundation (grant - - ). the antimicrobial potential of different phenolics was tested on pectobacterium in search of possible mode of action. in this respect, biofilm formation, exoenzyme activity, gene expression and virulence on its natural host (potato, cabbage, calla lily) were performed. also computational approach to show interaction between phenolic compounds and target protein was carried out using docking tools. the virulence determinants of pectobacterium were significantly impaired, at compound concentrations that did not affect bacterial cell growth. these observations suggested a mechanism which specifically interferes with bacterial virulence. since, these virulence determinants in pectobacterium are controlled by quorum sensing (qs), we focused on the effect of phenolics on the qs system in pectobacteria. the study revealed an inhibiting effect of the tested compounds on the expression level of central qs system and controlled genes, using qrt-pcr. also, there was a prominent reduction in the level of qs signal molecules n-acyl-homoserine lactone (ahl) accumulation. in addition infection capability was also practically blocked, which was completely recovered by application of exogenous-ahl. these results were supported by a potential interaction of plant phenolics with qs targets, as shown by molecular docking tool. collectively, results suggest the potential interference of phenolic compounds with qs central components (expi/expr proteins). moreover, it holds potential for future development of control measures against pectobacterium, and possibly other pathogens with similar mode of virulence. saccharomyces cerevisiae has been a key experimental organism for the study of infectious diseases, including double-stranded rna (dsrna) viruses. the l-a dsrna virus family of s. cerevisiae is widely distributed in nature. several versions of l-a virus are described and new ones continue to be discovered. some s. cerevisiae strains along with l-a dsrna possess smaller dsrnas, called m satellites. these dsrnas encode a sole secretable protein, known as k , k , k and k-lus toxin. l-a genome encodes the gag major structural protein and gag-pol fusion protein, formed by ribosomal frameshifting. gag-pol has transcriptase and replicase activities are necessary for maintenance of both l-a and m satellite dsrnas. so far, it's not known whether certain l-a virus has evolved to maintain a distinct type of satellite dsrna or this phenomenon lacks inherent specificity. we developed universal strategy to obtain full length l-a and m dsrna genomes from s. cerevisiae. complete viral dsrna genomes can now be cloned, as evidenced by l-a- dsrna, analyzed and sequenced directly from any yeast strain by means of enzymatic manipulations on total or fractioned rna content. we have identified previously undescribed l-a variant from different yeast strains specifically associated with certain type of m satellites. moreover, we identified for the first time full -utr and -utr sequences of m satellite. highly conserved sequence regions along with variable fragments were discovered at protein level, revealing clear trend to form clusters among different l-a gag-pol proteins. the obtained data suggest that each l-a virus variant can specifically maintain a distinct type of satellite dsrna. p- . . - physic-chemical characterization of plga adjuvants for immunization per os t. chudina, d. kolybo palladin institute of biochemisry of the national academy of sciences of ukraine (nasu), kyiv, ukraine antibodies against diphtheria toxin play the most important role in the immunity against corynebacterium diphtheriae. all current diphtheria vaccines have parenteral route of administration. undoubtedly, oral administration of antigens would be the most patient-friendly way of immunization. however, the efficacy of free antigens oral administration is limited by their degradation in the gastrointestinal tract and poor absorption by m-cells. biodegradable and biocompatible polymers, like poly (d,l lactide-co-glycolide) (plga), are widely used for the design of mucosal immunizing agents. importantly, that the way of particle preparation plays an important role in plga biodegradation and antigen release. the aim of this work was to characterize the main physic-chemical properties of two types of plga particles: with immobilized antigen (plga ) and with encapsulated antigen (plga ) . we have prepared two types of plga particles containing egfp-sbb proteins (non-toxic recombinant fragment b of dt fused with egfp). the antigen loading efficiency of particles was determined based on the ratio of protein concentration in solution before and after loading and shown better results for plga particles (plga - . %, plga - . %). the flow cytometry results demonstrated that % of plga particles conjugated with egfp-sbb, and only . % of plga particles conjugated with protein.the particle sizes had the slight difference by the results of two different techniques (ntanumber based, the software tracks individual particles; dls -scattering intensity weighted), however demonstrate similar patterns. dls data showed that the mean plga particles size was . nm and plga - . nm. nta data also showed that mean plga particles size a little smaller than plga ( . nm and . nm respectively) . demonstrated differences in the properties of synthesized particles may have an influence on the immunogenicity of the used for oral immunization antigen. p- . . - a suitable system for studying the functionality of a plasmodial protein in mammalian cell lines cho-mt , a mutant cell line was proved to be an appropriate tool for investigating intracellular function of cct. in this cell line, the endogenous cct activity decreases dramatically at °c, blocking membrane synthesis and ultimately leading to apoptosis. we have studied the rescuing potential of pfcct in cho-mt cells with the isogenic cho-k cells as a control. cells after transient transfection were incubated at °c and then analysed by facs using the fluorescence of egfp fused to pfcct. the proportion of cells undergoing apoptosis was determined by propidium-iodide staining. we have demonstrated for the first time that heterologously expressed pfcct is able to complement endogenous cct activity in mammalian cells. thus, a suitable system has been established for functional investigation of structural elements of pfcct. in order to reveal the role of different protein sequences in enzymatic function, we redesigned the structural gene of pfcct obtaining a modular system where different domains are easy to be removed or exchanged. here we designed a series of different truncation and deletion constructs to reveal the role of plasmodium specific sequences. in parallel, heterologous expression experiments of different constructs in the mutant cho-mt and the wild type control cell lines are performed to validate the reported model system. p- . . - host-pathogen interactions: is there a relationship between tlr polymorphisms and tuberculosis in a group of turkish patients? introduction: tuberculosis (tb) is a global health problem and according to world health organization (who) each year more than million individuals die from tb and each year , cases of tb are notified in turkey. malatya is the third largest city in east anatolian region of turkey and tb incidence rate is higher ( . / , ) comparing to the general population of the country. for this reason it is important to determine the factors that lead to tb in this population. disease agent can stay in the latent phase for long periods of time after infecting the individuals. while some infected individuals show the symptoms some others never do and even % of these never develop clinical disease. various mechanisms take place during the host response to infectious agents. toll-like receptor (tlr) genes are shown to be candidate genes in these responses. materials and methods: in this study tb patients and healthy controls were included. tlr genotyping for rs , rs was performed by using a commercial taqman snp genotyping assay kit. data were summarized by count and percent. hardy-weinberg equilibrium was tested by chi-square distribution with df. differences between groups due to allelic and genotypic distributions were analyzed by pearson's exact or fisher's exact tests. in all comparisons significance level was considered to be . . results: the single nucleotide polymorphisms (snps) which were subject of this study haven't been screened in turkish population earlier. no significant association was found between tb and the snps we screened in our group of patients. discussion and conclusion: unlike other populations results we couldn't find a significant association between the disease and the genotypes of our patients. the study should be performed in bigger populations in order to confirm the results. p- . . - lytic action of bacteriophages as a tool for the obtaining of images p. boltovets , r. radutny , t. shevchenko institute of semiconductor physics nas of ukraine, kyiv, ukraine, scientific and technical center of advanced technologies nas of ukraine, kyiv, ukraine, taras shevchenko national univercity of kyiv, kyiv, ukraine obtaining of images by different types of bacteria now became a very special branch of skill at the interface between science and art. however the authors did not found any scientific article, where bacterial lawn was used as the background and the image was formed by the lytic action of the virus (bacteriophage). whereas the mentioned approach could be used not only with artistic aims but for the practical use. the aim of this work was to demonstrate a possibility to obtain the image on the bacterial lawn by the lytic action of the bacteriophage. the bacterial lawn was obtained by the standard metod using the . % agar with the nutrient medium and the . % agar containing escherichia coli culture. stencils with the preparation of the bacteriophage t were applied. samples were incubated during the twenty-four hours at + °c. after that stencils were removed and the samples were stained by coomassie blue r- or fuchsine (with further fixation by the % acetic acid). several approaches to obtain the image by the lytic action of the virus were applied. first of all stencils made from printing paper and filter paper were compared. it was demonstrated, that the use of filter paper stensil allows to obtain more accurate and controllable images, than the use of the printing paper stensil. in the next series of the experiment the possibility of the reversed stencil use (where the image is formed not by the lytic zone but by the zone of bacterial growth) was demonstrated. also the possibility of the partial staining of the obtained image was explored. it gives an opportunity to obtain polychrome images using available colorants. summarizing the above it should be noted, that it was the first time when the graphical image was obtained by the lytic action of the virus on bacteria. this approach could be used not only for the artistic aims but as well for the practical use, for example, for the restriction of the action of microorganisms in out-of-theway places. burgdorferi the identification and characterization of possible antigens is essential for the improvement of current laboratory diagnostics for lyme disease and vaccine development. in this study, several recombinant b. burgdorferi outer surface proteins have been obtained and their antigenic properties have been evaluated in an effort to characterize novel immunodominant antigens. because b. afzelii and b. garinii are the most prevalent species in latvian ticks, proteins with conserved domains were included in this study. a panel of serum samples of lyme disease patients with early and disseminate disease stage was used. the controls were matched by age and sex to the patients and represented the same geographic area. the results show that proteins of several b. burgdorferi gene families have properties with respect to their candidacy as a subunit assay for a novel lyme disease immunodiagnostic. especially, the difference in their size in a range on the western blot assay may provide good discrimination between protein bands. however, they have potential for diagnosis if used in combination with other antigens but not as a "stand alone" test. in conclusions, this study showed the existing challenges in serological testing of early lyme disease. the conservation of the sequence of antigen between species of b. burgdorferi complex is essential for the most successful serodiagnostic marker candidate. the presence of homologous proteins in treponema species could lead to the cross reactivity in syphilis patients, and should be carefully evaluated. antimicrobial resistance is one of the greatest challenges in modern medicine. there is a pressing need for better understanding of the specific mechanisms that contribute to resistance to optimize existing therapies. in in georgia extended-spectrum beta-lactamase (esbl)-producing e. coli strain was isolated from the post-surgical sample obtained from gallbladder of the patients with chronic calculous cholecystitis which belongs to the sequence type (st ) complexes with ctx-m gene. is this strain characterized by other differences on a proteome level? are antibiotics against which the strain is resistant inducing the changes in bacterial proteome? the present work was aimed (i) to study the differences on a proteome level (i) between e. coli - / -g and attc e. coli-reference strain and (ii) to compare the proteomes of strain at two conditions: with and without antibiotics. strain was grown in the presence of three antibiotics: rocephin (ceftriaxone), fortum (ceftazydym) and claforan (cefotaxime sodium) together. proteomic expression was analyzed using two-dimensional gel electrophoresis and mass spectrometry. significant differences were found for several proteins, including putative abc trnsporter arginine protein , cystine-binding periplasmic protein, fkbp-type peptidyl-prolyl cis-trans isomerase, outer membrane protein a, d-galactose binding periplasmic protein and some others. the importance of these differences for anti-microbial resistance will be discussed. p- . . - molecular characterization of resistance and virulence features in staphylococcus aureus clinical strains isolated from cutanaeus lesions in patients with drug adverse reactions i. lupu , i. gheorghe , , m. popa , , a. ion , m. mihai , v. lazar , , m. c. chifiriuc , carol davila" university of medicine and pharmacy, bucharest, romania, research institute of the university of bucharest-icub, bucharest, romania, faculty of biology, university of bucharest, bucharest, romania patients treated with epidermal growth factor inhibitors often experience cutaneous adverse reactions. however, the infectious complications of these toxic effects and the contribution of specific pathogens, such as the community emergent methicillin resistant staphylococcus aureus strains. the present study was aimed to identify the types of sccmec and virulence genes profile in clinical s. aureus isolated from cutaneous lesions of different severity degrees in patients with dermatologic toxic effects. this study was conducted on a total of s. aureus clinical strains isolated in from acneiform reactions pustulae and periungual lesions in patients with drug cutaneous adverse reactions. multiplex pcr was performed on genomic dna from isolates in order to identify the sccmeccentral elements and the virulence genes: bbp (bone bound sialoprotein), ebps (elastinbinding protein), fnbb, fnba (fibronectin-binding proteins), fib, clfa, clfb (clumping factors a and b), cna (collagen-binding protein), luk-pv (panton-valentine leucocidin), hlg (haemolysin), tst (toxic shock toxin). the mrsa phenotype was genetically confirmed by the presence of meci gene in case of . %, meca in . %, sscmec type ivd element in . %, ccrb in . % and sccmec types i, iii, iv in . % of the studied s. aureus strains. regarding the virulence genes encountered in s. aureus strains, the most frequent was clfa ( . % of the isolates), followed by clfb ( . %), fib ( . %), hlg ( . %) and bbp ( . %). these results confirm the high prevalence of mec i and sscmec type iv elements, usually encountered in communityacquired mrsa strains, in cutaneous isolates from patients with dermatologic toxic effects. more data on the virulence and genetic background of these local strains are needed to appropriately assess the risk of such infections and avoid the inappropriate administration of beta-lactams. p- . . - analysis of toxicogenic properties of staphylococcus aureus strains isolated from cows with subclinical form of mastitis in the central area of russian federation. pore-forming toxins and enterotoxins), which are present in s. aureus strains isolated from clinically healthy cows. staphylococcus strains were isolated from cow's milk. disk diffusion method was used to determine the sensitivity to antibiotics. pcr analysis was used for detection of meca, mecc genes and genes of toxins. investigated strains were resistant to oxacillin ( %), vancomycin ( %) . it was found that all strains, which contain meca and mecc genes, showed resistant to more than antibiotics. it was determined that among the investigated strains % contained meca, % -mecc, % contained both meca and mecc. some strains contained genes of panton-valentine leukocidin (pvl) or alpha-hemolysin and several strains contained both types of genes. enterotoxin a (sea) gene was detected in . % of cases, sed - %, seg - %, sei - %. genes of staphylococcal toxins b, c, e, h were not found. the presence of phenol soluble modulin biosynthesis genes was determined: genes of alpha peptide synthesis were found in % of strains, beta peptide toxin genes in %, delta toxin gene in %. it was determined, that clinically healthy animals are carriers of s. aureus strains that cause mastitis. high level of antibiotic resistance was found in strains containing meca and mecc genes. the major part of the strains carried genes of phenol soluble modulin biosynthesis. the role of phenol soluble modulins as well as of pvl and alpha-hemolyzin in the development of mastitis is not completely clear. we conclude that pore-forming toxins have dominant role in the latent form of mastitis. p- . . - impact of lactoferrin on the hydrophobicity and adherence to the inert substratum of staphylococcus aureus strains isolated from patients with cutaneous drug reaction skin healing is a complex biological process that requires the involvement of different cell types and humoral effectors. one of the main factors are aggravating and delaying the healing process is represented by the supra-infection with pathogenic or opportunistic microorganisms that grow in specialized consortia embedded in a self-produced extracellular polymeric matrix, called biofilms, which are extremely resistant to any antimicrobials and host immune response. lactoferrin (lf) is an ironbinding glycoprotein which promotes skin healing by enhancing the initial inflammatory phase, but also by inducing an overabundant immune response. the aim of this study was to investigate the influence of lf, one of the main components of innate, humoral anti-infectious immunity on some microbial features, involved in the first steps of the infectious process, such as hydrophobicity and adherence of staphylococcus aureus strains isolated from maculo-pustular lesions in patients with adverse reactions to epidermal growth factor inhibitors. for hydrophobicity measurement the bacterial suspensions were grown in the presence or absence of lf, and then, the "microbial adherence to hydrocarbons test" (math) was performed. the capacity to develop biofilms on inert substrata and the influence of lf on this feature was spectrophotometrically quantified using an adapted microtiter method, after crystal violet staining. our results showed that lf decreased the hydrophobicity and limited the biofilm development of all s. aureus tested strains, in a dose and time dependent manner. the decreasing effect on the microbial hydrophobicity was accompanied by a lowering effect on the adhesion of microbial strains to the inert substratum. in conclusion these observations indicate that lf exhibits a wound pro-healing effect, by limiting the microbial colonization and biofilm formation and thus, the occurrence of infectious complications of skin lesion. p- . . [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] host-specificity determinants of bacteriophage vb_ecom_fv considered vehicles of s.aureus intoxication in humans throughout the world. the objective of the present study was to assess the presence of enterotoxigenic and methicillin-resistant s. aureus in water buffalo milk and dairy products. a total of water buffalo milk and dairy products ( water buffalo cream and water buffalo cheese) were collected from different dairy farms, smallholders and local bazaars in samsun, turkey. all samples were analyzed using the standard procedure en iso - and isolates were confirmed for the presence of the s rrna and nuc gene by polymerase chain reaction. s. aureus was identified in of water buffalo milk ( %), of water buffalo cream ( %), and of water buffalo cheese ( %). a total of isolates were confirmed as s. aureus by pcr. genotypic methicillin resistance was evaluated using pcr for the meca gene. out of isolates, ( %) were found to be methicillin resistant (meca gene positive) by pcr. the enterotoxigenic s. aureus was identified in out of ( %) isolates by the mpcr technique. five isolates produced staphylococcal enterotoxins sea ( / ; . %), two isolates produced sec ( / ; . %), one isolate produced ( / ; . %) sed, one isolate produced ( / ; . %) see and three isolates produced sec+sed ( / ; %) . none of samples were positive for seb. in conclusion, the presence of enterotoxigenic and methicillin-resistant s. aureus in milk and dairy products is of significant for public health concern and also these enterotoxin genes sea and sed are predominant toxins that can cause staphylococcus intoxication in humans. this study was funded by ondokuz mayıs university, samsun, turkey, scientific research project programs (project no: pyo. vet - . . ) and this article was part of a phd thesis. p- . . - identification and biochemical characterization of an immune modulating protein from helicobacter pylori b. kaplan t€ urk€ oz faculty of engineering, department of food engineering, ege university, izmir, turkey helicobacter pylori is able to achieve persistent infection with minimal immune response. the first line of defence during h.pylori infection is through gastric epithelial cells which present toll like receptors (tlr). a family of bacterial proteins which share homology with the toll/il- receptor (tir) domain were identified. the structure of btpa from brucella showed that bacterial tir proteins (btp) mimick human tir domain proteins and act on myd signaling pathways to suppress tlr signaling. h.pylori might also produce a similar protein. a putative h. pylori tir protein was found based on sequence homology and the corresponding gene; hp ; was cloned in fusion with an n terminal cleavable his-tag. the recombinant protein, his- was purified using nickel affinity chromatography. was subjected to limited proteolysis and the bands were analyzed by peptide mass fingerprinting (pmf). oligomerization of was investigated by in vitro pull-down and size-exclusion chromatography. , a amino acid protein, has a predicted c terminal tir domain similar to other btps and sequence alignments verified the presence of tir domain signature regions. recombinant his- was produced with a yield of mg/l culture. a structurally stable kda fragment was obtained from limited proteolysis which contained the tir domain as verified by pmf. in vitro pull down assays showed interacts with itself forming dimers as shown by size-exclusion chromatography. tir domain proteins function by interacting with themselves and other tir domains. our results showed that also form dimers, supporting that it is a btp. current research is focused on solving the structure of and investigating its interaction with myd . might play a direct role in reduced immune response against h.pylori by binding to myd analogous to other btps. further characterization of will provide the first solid evidence of presence of a tir domain protein in h.pylori. p- . . [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] lipopolysaccharides with different lipid a acylation status from vibrio cholerae and campylobacter jejuni contribute differently to il production by bone marrow-derived macrophages k. korneev , , e. sviriaeva , lipid a is a biologically active part of lipopolysaccharide (lps) from gram-negative bacteria that is responsible for the activation of the innate immunity through interaction with toll-like receptor (tlr ) and subsequent production of proinflammatory cytokines. bacteria frequently transform their lipid a so that its recognition by tlr is not sufficient for induction of effective antibacterial immune response. we compared biological activity of various lps from pathogenic bacteria vibrio cholerae and campylobacter jejuni. we purified r-form lps for each strain by hydrophobic chromatography. the biological activity of lps preparations was evaluated by their ability to activate production of proinflammatory cytokine il by bone marrow-derived macrophages from c bl/ mice, using tlr -deficient macrophages to control for specificity of tlr signaling. lps from e. coli and inactive lps from f. tularensis were used as positive and negative controls. lps from v. cholerae demonstrated biological activity similar to that of lps from e. coli, consistent with the presence of highly acylated lipid a in both strains. however, the former was a slightly weaker activator than the latter, because lipid a from v. cholerae had on average shorter acyl chains. lipid a from c. jejuni had on average longer acyl groups than in e. coli, while degree of acylation was lower, and as a result its lipid a displayed significantly lower biological activity. our study demonstrates importance of functional groups of lipid a in the ability of lps to activate production of il by macrophages. in line with our previous reports, we confirmed a direct correlation between biological activity of various lps species with their lipid a acylation status: the biological activity increases with increase in the length and in the number of the acyl chains. excess proinflammatory cytokine production through tlr activation can cause sepsis, while inefficient activation may result in the failure to clear bacteria. clostridium perfringens phospholipase c (cpplc) is the most toxic extracellular enzyme produced by this bacterium and it is an essential virulence factor in the pathogenesis of gas gangrene. cpplc may lead to cell lysis at concentrations that causes extensive degradation of plasma membrane phospholipids. however, at sublytic concentrations it induces cytotoxicity without causing evident membrane damage. the results of this work demonstrated that the cytotoxic effect of cpplc requires its internalization and the activation of the mek-erk pathway. cpplc internalizartion occurs through a dynamin-dependent mechanism and in a time progressive process: first, cpplc colocalizes with caveolin both at the plasma membrane and in vesicles, and later it colocalizes with early and late endosomes and lysosomes. the results also showed that cpplc requires endocytosis in order to activate mek-erk, because treatment with the dynamin inhibitor, dynasore, prevents cpplc endocytosis, erk / activation and cytotoxcity. cholesterol sequestration as well as inhibition of actin polymerization also prevents cpplc internalization and cytotoxocity, involving endocytosis in the signaling events required for cpplc cytotoxic effect. once internalized, cpplc induces reactive oxygen species production through the activation of pkc, mek/erk and nfjb dependent pathways. inhibition of either of these signaling pathways prevents cpplc's cytotoxic effect. in addition, it was demonstrated that nfjb inhibition leads to a significant reduction in the myotoxicity induced by intramuscular injection of cpplc in mice. these data provide new insights about the mode of action of this bacterial phospholipase c, previously considered to act only locally on cell membrane. understanding the role of these signaling pathways could lead towards developing rational therapeutic strategies aimed to reduce cell death during a clostridial myonecrosis. p- . . - apoptosis induced by clostridium perfringens phospholipase c is mediated by reactive oxygen species m. flores-d ıaz , l. monturiol-gross , m. j. pineda padilla , c. araya-castillo , a. alape-gir on bacterial phospholipases are lipolytic esterases surface associated or secreted by a wide variety of bacterial pathogens. clostridium perfringens, the most broadly distributed pathogen in nature, secretes a prototype phospholipase c (plc), also called a-toxin, which plays a key role in the pathogenesis of gas gangrene. this toxin causes death to cultured cells and extensive myonecrosis when injected intramuscularly in experimental animals. the results of the present study showed that c. perfringens plc ( - ng/ml) induces morphological and biochemical changes characteristic of apoptosis in cultured cells, as determined by scanning electron microscopy. nuclei condensation and fragmentation were observed by fluorescence microscopy and a typical ladder fragmentation pattern of genomic dna was detected by dna in agarose gels. cell death was prevented by the caspases inhibitors z-devd-fmk and z-vad-fmk. c. perfringens plc induces oxidative stress in cultured cells as determined by fluorescence microscopy and flow cytometry using the membrane permeable probe dcfda. different antioxidants including the gluthation precursor nac, several iron chelators and the free radical scavengers tiron and edaravone prevent cell death induced by c. perfringens plc in cultured cells or in mice challenged intramuscularly with . lg of that toxin. thus, this work provides compelling evidence that superoxide, hydrogen peroxide, and the hydroxyl radical are involved in the cytotoxic and myotoxic effects of c. perfringens plc. furthermore, the data demonstrated that edaravone, a clinically used hydroxyl radical trap, reduced the myonecrosis and the mortality caused by c. perfringens in a murine model of gas gangrene, induced by intramuscular bacterial injection of bacteria. this knowledge provides new insights for the development of novel therapies to reduce tissue damage during clostridial myonecrosis. lectins are ubiquitous proteins able to recognize mono-and oligosaccharides with high specificity and low affinity. lectins do not have any catalytic activity, unlike enzymes, and they are not products of the immune system in contrast to antibodies. lectins play a crucial role in cell interactions on molecular level showing their importance in various physiological and pathophysiological processes as well as both mutualistic and parasitic interactions between microorganism and hosts. photorhabdus luminescens is a gram-negative bacterium from the family enterobacteriaceae. the bacteria have a complex life cycle that involves mutualistic and pathogenic interaction with two different invertebrate hosts. it is highly pathogenic towards insect larvae. in addition, p. luminescens lives in the intestine of infective juveniles of nematode heterorhabditis bacteriophora, together forming an effective entomopathogenic complex. we have identified several soluble lectins produced by p.luminescens. in this study, we focus on proteins from p. luminescens, which show a high sequence homology with each other. a wide range of methods was used for structural and functional studies of photorhabdus lectins, e.g. surface plasmon resonance, isothermal titration calorimetry, analytical ultracentrifugation and x-ray crystallography. all lectins from p.luminescens recognize l-fucose and d-mannose. despite being closely related, they differ in fine binding specificities. to determine their biological function, knock-out mutants of p. luminescens are being prepared to study its interaction with axenic nematodes and insect larvae. breast cancer is the major disease of women in developed countries occuring predominantly after the age of . triple negative breast cancer (tnbc) is a typical subtype of epithelial breast cancer which lacks estrogen receptor (er), progesterone receptor (pr) and human epidermal growth factor receptor (her ) all together. although various researches have been focused on characterizing tnbc and enlightening different molecular markers with the aim of improving the overall outcome, currently the sole affective therapy action for tnbc is chemotherapy. thus chemoresistance is the main clinical challange and accounts for % of failures in terms of treating the disease. multidrug resistance (mdr) is defined as simultaneous resistance towards the drugs which do or do not demonstrate structural resemblance and have different effects on their molecular targets. p-glycoprotein (p-gp) is a membrane protein coded by abcb (mdr- ) gene. p-gp is an atp-dependent pump which pumps a wide range of drugs out of the cells including chemotherapeutic agents such as doxorubicin (dox) and pactilaxel. in the present study, tnbc cell line mda-mb- was treated with increasing doses of dox, cell viability was examined with srb assay and development of mdr was investigated through mdr assay and rt-pcr. results demonstrated that cell viabiliy decreased significantly with the treatment of higher doses. mdr was shown to be increased when cells were treated with , and nm of the drug respectively along with lm of p-gp inhibitor verapamil. rt-pcr results were obtained to be consistent with mdr assay results and indicated increased mdr- gene expression with the treatment of dox. especially after nm of dox treatment, mdr- was overexpressed to be fold when compared to control. in conclusion, it was demonstrated that mda-mb- cells have shown to display elevated resistance to higher doses of dox. p- . . - targeting dna damage response pathway in cancer cells under heat stress and the mechanical effect of ultrasound y. furusawa , t. kondo toyama prefectural university, imizu-shi, japan, university of toyama, toyama, japan ultrasound (us) has been widely utilized for diagnosis and therapy in many medical fields. the biophysical modes of us are divided into three classes, thermal, cavitation and non-thermal non-cavitation effects. in clinical use for cancer therapy, the thermal effect was utilized for hyperthermia therapy with focusing us on cancer to rise the temperature from °c to °c, or further which could induce thermal ablation of cancers. cavitation leads to a variety of mechanical stress such as shear stress, shock wave, high pressure, and chemical stress such as free radical formation, both of which have been inferred to act simultaneously on all biological materials. it has been indicated that us induces cell killing, cell lysis, loss of viability, and loss of clonogenicity. recently, we found that heat stress as well as us without thermal effect induce not only dna single-strand breaks but also dna double-strand breaks, a most cytotoxic region of dna, in chromatin dna detected by both gammah ax staining and neutral comet assay. in response to the stresses which induce dna damage, the dna damage sensor protein kinase, ataxia telangiectasia mutated (atm), atm and rad related (atr), and dna-dependent protein kinase (dna-pk) become activated form to initiate signal transduction pathways activating cell-cycle checkpoints, dna repair, and apoptosis. the molecules consisting of dna damage response pathway were expected as therapeutic targets because defects in the response to dna damage agents can be lethal. this work was designed to explore the possible therapeutic targets of the molecules in dna damage response pathways for future us-aided therapy. finally, several kinases (e.g., checkpoint kinase) on dna damage response pathway seems to be the targets for hyperthermia and us therapy. (ural branch) , ekaterinburg, russia, shemyakin and ovchinnikov institute of bioorganic chemistry, russian academy of sciences, moscow, russia based on the recently synthesized (s)-( -aminopurin- -yl) amino acids (gly, ala, val, phe, pro), we obtained a series of novel modified nucleosides using the transglycosylation reaction. for the first time, it has been demonstrated that the corresponding nucleobases are good substrates for the genetically engineered recombinant e. coli purine nucleoside phosphorylase (conversion to nucleosides reached - %). nucleosides, such as ribosides, -deoxyribosides, and arabinosides were obtained in high yields ( - %). it has been found that yield in the transglycosylation reaction does not depend on the structure of the amino acid fragment. the nucleosides synthesized are considered as potential inhibitors of intracellular adenosine deaminase (ad), the increasing activity of which is observed in hepatitis, cirrhosis, hemochromatosis, obstructive jaundice, prostate and bladder cancer, hemolytic anemia, rheumatic and typhoid fever, gout, and cooley's anemia. cytotoxicity of the synthesized nucleosides was tested in the jurkat (model of human t-lymphoblastic leukemia) and el- (model of mice t-lymphoblastic leukemia) cell lines. the compounds studied did not exhibit cytotoxic activity compared to the activity of the known antitumor agent nelarabin. the work was financially supported by the russian science foundation (grant - - ). p- . . - dna binding, dna cleavage, antimicrobial activities, antimutagenic and anticancer studies of a schiff base and its complexes n. yildirim , n. demir , m. yildiz health services vocational school, c ß anakkale onsekiz mart university, c ß anakkale, turkey, department of biology, faculty of arts and sciences, c ß anakkale onsekiz mart university, c ß anakkale, turkey, department of chemistry, faculty of arts and sciences, c ß anakkale onsekiz mart university, c ß anakkale, turkey schiff bases are considered as favored and the most widely used ligands, due to their metal complexes having variety of applications as antibacterial and anticancer agents. the rational design and synthesis of new schiff bases and their metal complexes have been drawing great interest because of their diverse biological and pharmaceutical activities. so, exploring and designing novel molecules that have biological activities and capable of interacting with nucleic acids has a great significance for disease defence and to discover new dna-targeted anticancer drugs for chemotherapy. in this study, we report the synthesis and characterization of a novel schiff base and its ni(ii) and cu(ii) complexes. the minimal inhibitory concentration (mic) of the compounds was screened in vitro against bacteria and yeast cultures using broth micro dilution test. dna binding and dna cleavage activity of the compounds were investigated by uv-vis spectroscopy and agarose gel electrophoresis. antimutagenic activity of compounds were tested in the absence of microsomal enzymes (s -). also, cytotoxicity of the compounds against hepg cell lines was assayed by the mtt ( -( , -dimethylthyazolyl- )- , -diphenyltetrazolium bromide) method. consequently, uv-vis spectroscopy studies indicated that the compounds interact with calf thymus dna (ct-dna) via intercalative binding mode. dna cleavage activity studies showed that the cu(ii) complex can effectively cleave pbr plasmid dna. compounds inhibited the base pair mutation with high inhibition rate in the absence of s . also, schiff base complex had cytotoxic activity towards hepg cell line, that it was found to be more potent than the control cisplatin. p- . . - single particle electron tomography of rnap elongation complex, stalled at position + genome in vivo is constantly exposed to the damaging effects of the environment. single-strand breaks (ssbs) are the most frequently occurring dna lesions. accumulation of unrepaired ssbs can interfere with the cells metabolism and increase genomic instability. in vivo, ssbs are repaired in specific pathway, but, in eukaryotic nuclei, dna is organized in chromatin that could affect the accessibility of lesions to sensor proteins. breaks in a template strand induce arrest of rna polymerase ii (polii) in vitro and in vivo and can be revealed in a transcription-dependent manner. our recent biochemical studies identified two key intermediates formed during transcription through a nucleosome by rnap that are nearly homogeneous, active and stable by biochemical criteria (complexes stalled after entering or bp into the nucleosome; ec+ or ec+ , respectively). hear we produced two complexes, both stalled in the + position, one without break in the dna, and the other with introduced ssb at position + of a non-template dna strand. complexes were purified using affinity chromatography and applied to a carbon-coated, glow-discharged em grid. tomographic studies were performed at ae °in a jeol microscope at kv accelerated voltage. images were recorded using a gatan ccd camera. image analysis was performed using the imod software. the resulting structure of the ec+ complex with no break in dna consist of two domains, connected by a single dna string. the complex with a break introduced into the dna has a more compact appearance and its two domains were connected by two dna strings, thus forming an intranucleosomal dna loop. our data suggest that ssbs in a non-template strand can induce the formation of stable non-productive transcription intermediate. the inhibitory effect of ssbs onto transcription may suggest a possible mechanism for their recognition in vivo with a transcription-dependent pathway. this work has been supported by the rsf grant # - - . colorectal cancer (crc) is one of the leading causes of cancerrelated deaths in the developed countries. according to who report new incidence rate of crc in turkey is . % among other cancer types. owing to difficulty of the low allele frequency variations detection, genetic association profiles of crc have not been entirely identified. low allele frequency variations mlh À g>a (rs ) promotor substitution, mlh g>c (rs ) exonic substitution, mthfr c t (rs ) and apc t>a (rs ) were investigated in this study. these snps "rs , rs , rs , rs " are located on p . , q , p respectively. colonoscopic investigations were performed on both cancer and control group. the snps were genotyped using kompetitive allele specific pcr technology in cases and healthy controls. statistical analysis was carried out with cochran-armitage chi-square test. in this study these of the snps in mlh , mthfr genes were examined for the first time in turkish sporadic crc cases. statistical analysis showed no significant association within our turkish sporadic crc population. percentage of mlh À aa genotype in group aged ≥ was found to be . % in cancer versus % in control group. moreover apc a, mlh c alleles were detected only and allele respectively. previously, apc a allele was determined in . % of a turkish cohort. however in the present study apc a allele was detected on allele only. studies showed mlh À promoter variation as a risk factor for microsatellite instabile crc but for the current study this data is not available. in spite of literature mthfr c t and mlh g>c snps were not found to be associated with sporadic crc in turkish population. this research demonstrates that importance of population based studies in multifactorial disease. p- . . - excision of damaged bases from transcription intermediates by fpg/nei superfamily dna glycosylases k. makasheva, d. zharkov sb ras institute of chemical biology and fundamental medicine, novosibirsk, russia oxidative lesions are abundant due to constant presence of reactive oxygen species in living cells. repair of oxidative base lesions is initiated by dna glycosylases. for example, bacterial fpg and nei dna glycosylases excise oxidized purines and pyrimidines, respectively, from dna. their human homologs, neil and neil , have been reported to show preference towards oxidized lesions in dna bubbles. from these observations, it had been hypothesized that neil proteins may be involved in the repair of lesions in dna bubbles generated during transcription. however, it is not presently clear how neils would behave on bubbles more closely resembling transcription intermediates (e. g., containing the rna strand), and bacterial homologs fpg and nei had never been investigated with bubble substrates. we have studied excision of either -oxoguanine ( -oxog) or , -dihydrouracil (dhu) by e. coli fpg and nei and human neil and neil from single-strand oligonucleotides, perfect duplexes, bubbles with different number of unpaired bases ( to ), d-loops with dna or rna and from complexes with rna polymerase. fpg, neil and neil efficiently excised dhu located inside a bubble. fpg and neil was generally more active than neil in excision of -oxog from ssdna and bubbles. nei, on the other hand, was active only on dhu located in dsdna (either perfect duplex or dna/dna d-loop). fpg and neil also have shown activity in d-loops with rna. the presence of an additional unpaired -tail of the third strand of d-loops didn't affect the glycosylases activity. the activity of fpg was observed in pre-assembled transcriptional complexes with e. coli rna polymerase and depended on the position of the lesion in the transcription bubble, possibly reflecting local accessibility of the lesion within the elongation complex. this work was supported by rsf ( - - ). nucleotide excision repair (ner) is a multistep process that eliminates a wide range of lesions in dna, including uv photoproducts and base modifications by many carcinogenic and chemotherapeutic agents. one of the advanced approaches to ner process investigation is based on reproducing the repair reaction by mixing protein extracts from mammalian cells with model linear dnas, bearing lesions. long linear dnas ( bp) containing efficiently recognized and processed by ner system lesions (fluoro-azidobenzoyl photoactive lesion fab-dc, nonnucleoside lesions nflu and nant) in both strands have been synthesized. we have demonstrated that dnas containing closely positioned lesions in the both strands represent difficult-to-repair (fab-dc/nflu(+ ), fab-dc/nflu(À )) or unrepairable (nflu/nflu (+ ), nflu/nflu(À ), nant/nflu(+ ), nant/nflu(À )) structures. besides, it has been shown that model dnas bearing bulky lesions in opposite positions (fab-dc/nflu( ), nflu/nflu( )) represent unrepairable structure as well. the model substrates with increasing distance between lesions in the duplex demonstrated the full recovery of substrate properties in ner process (fab-dc/nflu(+ ), fab-dc/nflu(À ), fab-dc/nflu(À ), nflu/nflu (+ ), and nant/nflu(+ )), whereas the level of specific excision from nflu/nflu(À ), nflu/nflu(À ) and nant/nflu(À ), nant/nflu(À ) was approximately % of the nflu/dg or nant/dg dna respectively. it has been shown that modified dna-duplex ( bp) with fab-dc has decreased structurally dependent affinity for xpc-hr b compared to duplexes containing lesions in both strands being analyzed (fab-dc/dg, fab-dc/nflu(+ ), fab-dc/nflu (À ), fab-dc/nflu(+ ), fab-dc/nflu(À ), fab-dc/nflu(- )) and increased compared to umdna. the data provide an argument that the ner system of higher eukaryotes recognizes and eliminates injured dna fragments on a multi-criteria basis. it is well known that dna plays crucial role in the biological system because of including all the genetic information for cellular function. therefore, the interaction of molecules with dna has gained interest in the medicinal chemistry to explore new anticancer agent. photodynamic therapy which is alternative cancer treatment method depends on free radicals and singlet oxygen to destroy tumor tissue via necrosis and apoptosis. phthalocyanines (pcs) are used for photodynamic therapy because of their absorption of high wavelength light ability and they have high triplet quantum state yields and long lifetimes in triplet states. also they do not have any toxic effect without light. in this study the novel synthesized - [ -( morpholin- -ylethoxy) ethoxy]phthalonitrile substitued zinc(ii), manganese(ii) and copper(ii) phthalocyanines were used. the potential properties of phthalocyanine compounds for photodynamic therapy were purposed to reveal by the preliminary work. for this aim, the mode of dna binding, photocleavage and topoisomerase i inhibition of these compounds were investigated. - [ -( -morpholin- -ylethoxy) ethoxy]phthalonitrile substitued zinc(ii), manganese(ii) and copper(ii) phthalocyanine compounds have been synthesized. the interaction of novel pcs compounds with calf thymus (ct) dna was investigated by using uv-vis spectroscopy, thermal denaturation studies and viscosity measurements. additionally, dna photocleavage and topoisomerase i inhibition studies were performed to pbr dna by using agarose gel electrophoresis. the interaction studies indicated that pcs compounds powerfully bound via an intercalation mechanism with ct-dna. these compounds showed efficiently dna photocleavage under irradiation at nm. the all of pcs inhibited topoisomerase i in a dose-dependent manner. all the experimental studies showed that pc compounds might be used agents for photodynamic therapy. p- . . - target search by base excision repair dna glycosylases e. dyatlova, g. mechetin, d. zharkov institute of chemical biology and fundamental medicine, novosibirsk, russia the problem of rapid target search in dna is faced by transcription factors, restriction endonucleases, dna repair enzymes and other sequence-or structure-specific dna-binding proteins. theoretically, the fastest target search in dna can be achieved by combining one-dimensional diffusion along the dna contour (processive search) and three-dimensional diffusion (distributive search). the balance between these search modes depends on many factors affecting dna-protein interactions, such as the presence of mono-and divalent cations, competing proteins, crowding effect, etc. presently, the mechanisms of target search are understood only for a handful of enzymes. we have recently developed an assay to study target search by dna repair enzymes, based on cleavage of oligonucleotide substrate containing two targets. thus, the distance between the targets can be precisely controlled, and any modification can be introduced into dna. subsequently, the probability of correlated cleavage (p cc ) is estimated, reflecting the efficiency of enzyme transfer between the specific sites. in this work, we have investigated five repair enzymes: e. coli endonuclease viii (nei), its human homologs neil and neil , and uracil-dna-glycosylases (ung) from e. coli and vaccinia virus. as expected, p cc of all enzymes depended on the ionic strength of the solution and the presence of mg + . ung from vaccinia virus was the most sensitive to these factors, raising questions about its proficiency as a suggested processivity factor of viral dna polymerase. nei, neil and neil showed a peak of p cc at low but non-zero ionic strength indicating that nonpolar interactions contribute to binding of these proteins to nonspecific dna. this conclusion was also supported by analyzing amino acid conservation in the catalytic core of nei. introduction of bulky fluorescent group between two specific sites greatly reduced the ability of glycosylases to slide along dna. this work was supported by rsf ( - - ). p- . . - does causes mhz magnetic field application kras and p mutations in colon?: occurences histopatologically and microbiologically changes in colon determination of kirsten rat sarcoma (kras) and p gene mutations in colon. materials and methods: in this study, three groups were prepared as control,sham and electromagnetic field (emf) group. mhz radiofrequency (rf) radiation was produced by using an electromagnetic energy generator.the emf group rats were exposed to electromagnetic field for weeks as minutes per day.at the end of experiments, rats were sacrificed under ethyl ether anesthesia and the rat colons were dissected.fecal speciments were collected.fecal dna (for detection of fusobacterium and bacteroides) and colonic dna (for detection of kras and p mutations) were isolated.rt-pcr tchnique was used for detection of bacterias and mutations. results: no any differences was observed histopathologically between control and sham groups.erosions and partial losses were observed at mucosal epitelium in the emf group.the corrupted gland structure, the mucosal edema and the inflammatory cell infiltration were observed.the amout of collagen was increased and fibrosis was detected in emf group.goblet cell number decreased statistically significant when compared to control and sham groups (p < . ).the amount of fusobacterium increased significantly in emf group compared to controls.the difference was not detected between groups in the amount of bacteroides.all the samples analysed for kras and tp mutations in the colon tissue were found to be wild type.no significant difference was observed between the control group and the emf applied group. discussion and conclusion: in conclusions,for weeks minute/day exposure to mhz emf caused histopatological damage in rat colon.the amount of fusobacterium is increased.emf exposure did not caused to kras and p mutations in colon tissue. p- . . - synthesis, antimicrobial activity, genotoxicity, dna binding and dna cleavage studies of new glycine methyl ester derivative schiff base there has been an increasing focus on the binding study of small molecules to dna during the last decades, since dna is an important genetic substance in organisms. therefore, the current growing interest in small molecules that are capable of binding and cleaving dna is related to their utility in the design and development of synthetic restriction enzymes, new drugs, dna agents, and also to their ability to probe the structure of dna itself. in recent years, schiff bases have found increased application in pharmaceutical research, organic synthesis, and bio-processes. schiff bases are considered as favored and the most widely used ligands, due to their metal complexes having variety of applications as antibacterial and anticancer agents. in this study, we report the synthesis and characterization of a novel glycine methyl ester derivative schiff base. the minimal inhibitory concentration (mic) of the compound was screened in vitro against bacteria and yeast cultures using broth micro dilution tests. antimutagenic activity of compound was tested in the absence of metabolic activation. also, dna binding and dna cleavage were investigated of compound by uv-vis spectroscopy and agarose gel electrophoresis respectively. consequently, this compound differs significantly in its activity against tested microorganisms. this difference may be attributed to the fact that the cell wall in gram-positive bacteria is a single layer, whereas the gram-negative bacteria cell wall is a multilayered structure, and the yeast cell wall is quite complex. the compound inhibited the base pair mutation in the absence of s with high inhibition rate. uv-vis spectroscopy studies of the interactions between the compound and calf thymus dna (ct-dna) showed that the compound interacts with dna via intercalative binding. to date a large number of the sequences in the human genome (g motifs) with the potential to form a spatial structure, gquadruplexes is known. g motifs were found in the promoter regions of most of the known oncogenes. recent experimental studies have shown that genome instability directly related to the non-canonical dna structures, including g-quadruplexes. in this work we study the distribution of somatic snvs within the g motifs in tumor samples with the aim to identify involvement of the motifs in the process of mutagenesis in pancreatic cancer. using the access kindly provided by the international icgc consortium to the database, we analyzed samples of pancreatic ductal adenocarcinoma and samples of pancreatic endocrine neoplasms. we considered only the promoter regions as the richest with g-quadruplex motifs. we found that quadruplex sequences have the ability to focus somatic snvs. this could be explained by the errors of polymerase during replication through secondary dna structures. furthermore, the snvs occur much more often in loops of g motifs than in g blocks, without changing the motive. in addition, t>g(a>c) and t>c(a>g) substitutions occur significantly more likely in loops which in turn stabilize the g-quadruplex structure. the cancer-related mutations tend to increasing the length of g blocks. the conservation of g motifs may indicate an important functional significance of g-quadruplex structures in human genome. supported by project no. - - of the russian science foundation. background: multiple myeloma (mm) is a rare, leading to bone destruction and marrow failure, largely incurable malignant disease of plasma cells. anemia (mostly normocytic normochromic) is seen in most patients. mean platelet volume (mpv) is a laboratory marker of platelet function and activity, the most accurate measure of platelet size. the aim of this study was to investigate the mean platelet volume (mpv) values in this disease. materials and methods: whole blood samples were collected from healthy controls and patients with mm. the mean age for controls and patients were . ae . and . ae . years, respectively. mpv levels were calculated with cancer is a chronic disease in the world which is the second leading cause of death, after cardiovascular diseases. benzimidazoles have been known to act as antiproliferative or anticancer agents in chemotherapeutic drug research area. in this regard we aimed to investigate the cytotoxic and apoptotic properties of novel benzimidazole derivatives bearing pyridyl/pyrimidinyl piperazine moiety against a lung adenocarcinoma cells. a lung adenocarcinoma cell lines were used in the studies. the cytotoxic activities of the tested compounds were determined by mtt assay. detection of apoptosis was performed using annexin v-fitc apoptosis detection kit bd, pharmingen according to the manufacturer's instruction. all measurements were performed on a facs-calibur cytometer. the ic values of the compounds were determined for a cell line. compounds , and which were including -chlorophenyl, -nitrophenyl on pyridine ring; -fluorophenyl on pyrimidine moiety, had significant cytotoxic activity with ic values lower than . ae . lg/ml. compound showed the highest cytotoxic activity with a ic value of . ae . lg/ml, whereas cisplatin ic values were . ae . lg/ml lg/ml against a cells. cytotoxic activity of compound and with a ic value were . ae . and . ae . lg/ml, respectively. also, compound showed the highest population of early apoptotic cells ( . %) of the tested compounds which was . -fold higher than for cisplatin. compound produced a comparable population of apoptotic cells with a percentage of . %, respectively according to cisplatin's percentage of . %. it was determined that synthesized compounds , and had considerable anticancer activity against a cell lines compared to cisplatin. compound including -florophenyl on pyrimidine ring was the most cytotoxic compound against the a cell line. our study results demonstrated that compound , also induced apopototic pathway on a cells. p- . . in vitro/in vivo antimitotic activity and structure-activity relationships of new glaziovianin a isoflavone series glaziovianin a (gva), isolated from the leaves of the astelia glazioviana, demonstrated cytotoxicity, disrupting microtubule structure and dynamics of hl- cells. the aim of the present work was to devise a concise synthetic route toward gva and its derivatives in order to expand structure-activity relationship studies and to investigate their anti-mitotic effect. a concise six-step protocol for the synthesis of gva and its alkoxyphenyl derivatives starting with readily available plant metabolites from dill and parsley seeds was developed. the sea urchin embryo tests confirmed that gva directly affects tubulin/ microtubule dynamics and structure. the b-ring substitution pattern of gva derivatives exhibited strong effects on activity. according to the assay results, the anti-mitotic activity decreased in the following order: gva > myristicin ≥ , , -trimethoxyphenyl = -methoxyphenyl > dillapiol > -methoxyphenyl> , dimethoxyphenyl > , , , -tetramethoxyphenyl derivatives. a methylenedioxy moiety was essential for the activity of compounds substituted with four b-ring alkoxy groups. the mts assay of the limited panel of cancer cell lines shows that gva displayed the highest inhibitory activity, with ic values ranging from . (a cells) to . lm (mda-mb- cells). compounds, containing , , -trimethoxy and apiol-derived b-rings, respectively, were less active. other isoflavones did not affect cancer cell growth up to lm. anti-proliferative effects of isoflavones observed in both the sea urchin embryo model and human cancer cell lines correlated well. importantly, none of the synthesized isoflavones demonstrated cytotoxicity in human pbmcs, up to lm. in summary, gva and its analogues were synthesized via a scalable six-step reaction sequence. the gva and its analogues containing , , -trimethoxy and apiol-derived b-rings were found to be promising anti-mitotic microtubule destabilizing agents with low toxicity against human pbmcs. bag- is a multifunctional protein which has interactions with a number of cellular proteins; nuclear hormone receptors, bcl- , hsp /hsc family, growth hormone receptors, raf- , ubiquitin machinery and dna to regulate cell survival. for this reason, bag- is a critical molecular player in the regulation of cell survival signaling and apoptosis mechanism. elevated expression levels of bag- are associated with progression of cancer. in the treatment of breast cancer, silencing tools as a promising combined therapy strategies in the presence of classical chemotherapeutics gain importance to investigate interaction networks of cell death and survival signaling pathways. therefore, we aim to understand potential role of bag- silencing in the treatment of breast cancer cells with apoptotic agents; cisplatin or paclitaxel. our results showed that, silencing of bag- enhanced cisplatin or paclitaxel-induced apoptosis in mcf- cells by down-regulating antiapoptotic and upregulating proapoptotic bcl- family proteins, changes on cell cycle, upregulation on subg phase, activating caspases and cleavage of parp. in addition, knockdown of antiapoptotic bag- has a suppressive role in pi k and akt signaling pathway in mcf- breast cancer cells through inhibition of akt phosphorylation and downregulation on pi k. investigation targets of akt pathway showed that mtor cell survival pathway also affected through bag- silencing. bag- silencing inhibited mtor signaling via downregulating both rictor and raptor proteins which are the members of rapamycininsensitive mtorc and rapamycin-sensitive mtorc complexes, respectively. knockdown strategies of bag- is important to enlighten the network interactions of bag- and clarify its interaction partners in the cells. therefore utilization of bag- targeted strategies might further increase therapeutic efficiency of drugs through inhibiting cell survival machinery in the treatment of metastatic breast cancer. p- . . - biological activity evaluation of new , , trisubstituted triazine derivatives bearing different heterocyclic rings against lung cancer cell lines l. yurttas, g. akalin c ß iftc ßi, h. e. temel, b. demir anadolu university, eskisehir, turkey cancer is one of the major death causing disease worldwide. among the various cell types occurs on different organs, lung cancer is one leading cause of cancer death accounting for approximately % of all female and % of all male cancer deaths in . the resistance development, cytotoxicity and inadequacy are the main encountered problems by the treatment with existing chemotherapeutic agents. therefore, there is continuous need to discover new active and non-toxic molecules. -[ -( , -bis( -substituted phenyl)- , , -triazin- -yl)piperazin- -yl]- -[benzimidazole/benzoxazole/benzothiazole- -yl)thio]ethanone ( - ) derivatives were synthesized with a four-step synthetic procedure using toluil, anisil and -chlorobenzil as starting materials. the anticancer activity of the compounds was evaluated using the methods mtt ( -( , -dimethylthiazol- -yl )- , -diphenyltetrazolium bromide), brdu (bromodeoxyuridine) assays and flow cytometric analysis against lung cancer cell lines. the lipoxygenase enzyme inhibition activity of the compounds were also investigated using the method described by baylac and racine. compounds was found to have (inhibition concentration) ic values between - lg/ml. the early and late apoptotic cell percentage was determined as . for compound by flow cytometric analysis. the lox inhibition activity was found . ae . for compound . compound bearing -chlorobenzil and benzoxazole moieties was found as the most active compound when we evaluate anticancer potential of all compounds. the lox enzyme inhibition was indicated for the compound including methyl substituent on phenyl rings. the dna synthesis inhibition of the compounds has been still studied at the concentrations ic / , ic and ic x . p- . . - single amino acid substitutions and deletions modulate the drp-lyase activity of human dna polymerase iota n. miropolskaya, i. petushkov, a. kulbachinskiy, a. makarova institute of molecular genetics, moscow, russia dna polymerase iota (pol ι) is a y-family dna polymerase that possesses an unusual combination of properties. due to the special organization of the active site pol ι has a very low accuracy of dna synthesis but possesses an ability to bypass a variety of dna lesions. in addition to the dna polymerization activity, human pol ι also possesses an intrinsic -deoxyribose phosphate (drp)-lyase activity. removal of the drp group is a pivotal step in base excision repair (ber) in vivo. although pol b plays a key role in the drp group cleavage and dna synthesis during ber, pol ι was shown to complement the in vitro single-nucleotide ber deficiency of pol b null cell extracts and was suggested to be involved in ber under oxidative stress. the drp-lyase active site in pol ι is still not known. to address the mechanism of the drp-lyase activity of pol ι we obtained a series of pol ι mutant variants including point mutations of conserved lysine residues and deletions in different locations. we purified human pol ι variants from yeast saccharomyces cerevisiae and tested the effect of mutations on the cleavage of an internal -drp group in oligonucleotide dna substrates in the presence or absence for me + ions. the experiments revealed several point amino acids substitutions that significantly affected the drp-lyase activity of pol ι, thus suggesting a possible location of the drp-lyase active site. furthermore, we showed that deletions in the n-terminus of pol ι and metal ions modulate its drp-lyase activity, which may play an important role in the regulation of pol ι activities in vivo. this work was supported by russian foundation for basic research grants - - -a and - - -mol-a-mos and by the russian academy of sciences presidium program in molecular and cellular biology. rosmarinus officinalis, commonly known as rosemary, is an aromatic plant belongs to lamiaceae family. from past to now, rosemary have been used as a traditional medicine to cure for various illnesses such as diabetes, rheumatism and cancer. recent studies have shown that rosemary is effective for various cancer types. in this study we aimed to investigate the effect of rosemary in glioblastoma cells (gbm) by comparison with etoposide and the effect of rosemary by concurrent application with the etoposide. gbm cells (u mg) were seeded into the well plates and cultured with dmem supplemented with % fetal bovine serum. rosmarinus officinalis tea was prepared just as traditional usage and filter sterilized. at the second day of the culture rosemary in / (v/v) dilution ratio was given to first group, lm etoposide was given to second group, / (v/v) diluted rosemary and lm etoposide together were given to third group. after one day incubation cell viability was measured by neutral red assay. it was observed that rosemary reduced the viability of gbm cells by nearly % , etoposide reduced the viability by nearly % and rosemary with the etoposide reduced the viability by nearly % . the results showed that rosemary was able to reduce the viability of gbm cells but hadn't got an increasing or inhibiting potential over the etoposide's cytotoxic effect. from our previous studies we know that rosemary increases the proliferation of mouse embryonic fibroblasts. it is considered that rosemary might have a protection potential from dna damages and when rosemary is used with etoposide during the cancer treatment, it might reduce the side effects on healthy cells. in conclusion rosemary promises hope for developing new cancer treatment strategies and reducing the side effects of chemotherapeutics. for further studies it is aimed to examine the effects of rosemary with other chemotherapeutics and if rosemary has got a protection potential from the genotoxic stress. morpholine moiety has been found to be an excellent pharmacophore in medicinal chemistry and a number of molecules possessing morpholine skeleton are the clinically approved drugs. in this present study, we aimed to investigate the possible underlying apoptotic mechanism for the cytotoxicity of new morpholine dithiocarbamate derivatives bearing -( -aryl- -oxoethyl)- -substituted benzimidazole moiety on c glioma. c glioma cell lines were used in the studies. the cytotoxic activities of the tested compounds were determined by cell proliferation analysis using standard ( -( , -dimethylthiazol- -yl)- , diphenyltetrazolium bromide (mtt) assay. detection of apoptosis was performed using annexin v-fitc apoptosis detection kit bd, pharmingen according to the manufacturer's instruction. all measurements were performed on a facs-calibur cytometer. the ic values of the compounds were determined for c cell line. compounds , , , , and , which were including hydrogen, -methyl, -methoxy, -chloro and -floro substituents on phenyl acetyl moiety, had significant cytotoxic activity with ic values lower than lg/ml. compound showed the highest cytotoxic activity with a ic value of lg/ml, whereas cisplatin ic values were lg/ml against c cells. cytotoxic activity of compound , , , and with a ic value were , , and lg/ml, respectively. compound , and showed the highest population of early apoptotic cells as . , . , and . % respectively compared to cisplatin ( . %). also, compounds caused dna synthesis inhibition depend on their ic values by brdu assay. conclusions: it was concluded that synthesized compounds had considerable anticancer activity against c cell lines. however, compound , and including -methyl, -chloro and -floro substituents were the most active compounds against the c cell line. also our study results showed that compound , , induced apoptosis in c glioma cells. rutin is a glycosided flavonoid and known to have antioxidant and anti-inflammatory properties.trail induces the apoptosis of tumor cells and has no significant toxic effect on normal cells. although trail is a promising anticancer agent, trail resistance is a major barrier to effective cancer therapy. this study was conducted to examine the utility of the combined use of rutin and trail in prostate cancer cells. pc- and du prostate cancer cells were treated with rutin ( - um) and/or trail ( ng/ml), cell viability and migration were examined. cell viability was determined by trypan blue exclusion and mtt assay. cell migration was determined by wound healing assay. furthermore, lactate dehydrogenases (ldh) levels of medium were determined as biochemical markers of cell viability. pc- and du- prostate cancer cells were treated with rutin for and hours incubation and ic doses for hours incubation were determined um and um respectively. treatment with rutin, pc- cells is more sensitive than du cells. rutin and rutin plus trail inhibit prostate cancer cell growth in a dose-dependent manner. treatment with trail has no effect at inhibiting growth of pc- and du prostate cancer cells. the combination of rutin and trail elicit a synergistic antitumor effect on pc- and du prostate cancer cells. there is a significant increased in rutin and rutin+trail treatments group of ldh activities with respect to control and trail group. conclusion: present data show that rutin efficiently enhanced trail effects in prostate cancer cells. combined treatment with rutin and trail is more effective than the individual treatments of trail at inhibiting growth of prostate cancer cells. p- . . - determination of antigenotoxic, proliferative and cytotoxic properties of ellagic acid since ancient time, people use plant for traditional treatment. plants or fruits are produced different type of secondary metabolites. particularly phenolic phytochemicals from plants play an important role in the prevention and treatment of radical damage by inactivating the reactive oxygen compounds due to their antioxidant properties. however, the structure and the activities of many herbal products are not fully elucidated yet and there are several studies about the toxicity of herbal antioxidants and their possible risks to human health. ellagic acid, phenolic compounds, is an important substance. ellagic acid is a naturally occurring plant phenol found in numerous fruits, including blackberries, raspberries, strawberries, cranberries, walnuts, pecans, pomegranates and wolfberries. different researchers give some information about the biological activities of ellagic acid. in this study, we aimed to determine the cytotoxic, proliferative and antigenotoxic effects of ellagic acid, which is phenolic compounds found in natural products. cytotoxic effects of ellagic acid on huvec is investigated by lactate dehydrogenase (ldh) and cell proliferation (wst- ) methods; and antigenotoxic effects against ccl on human lymphocytes is investigated by single cell gel electrophoresis (comet) methods. the rusults showed that high concentration ( and lm) of ellagic acid has cytotoxic and mutagenic effects, but showed antiproliferative effects. on the contrary, low concentrations ( , , . lm) of ellagic acid has anticytotoxic and antimutagenic effects. as a conclusion, low concentrations of ellagic acid might be use treatment of some disease. but high concentrations of ellagic acid constitute a risk factors for people. keywords: cytotoxicity, antiproliferation, wst- , ldh, rtca-sp the constitutive nuclear factor kappa b (nf-kb) activation is widely found in diverse types of hematologic malignancies such as acute myeloid leukemia (aml) and chronic myeloid leukemia (cml) as well as solid tumors. inhibition of nf-kb signaling via proteasome inhibitors such as bortezomib can induce apoptosis in myeloid leukemia cell lines. however it is not clear whether the cytotoxic effects of bortezomib on myeloid leukemia cell lines is due to direct inhibition of nf-kb or another pathway, such as dna damage. in this study, cml cell line k and aml cell line hl- were treated with bortezomib (bor) , etoposide (eto) and camptothecin (cpt) alone or in dual combination with these drugs, following by measuring the effects on cell viability, apoptosis and signal pathways. the effect on cell viability was determined using the mtt assay. the data were used in combination index and isobologram analysis. the expression levels of apoptototic genes (bcl , bax and caspase ), the related dna damage genes (atm and atr) and the involved genes in nf-kb signaling (rela and p ) were determined by real time rt-pcr. we showed that combinations of bor with topoisomerase inhibitors (cpt and eto) exhibited synergistic cytotoxic effect in k cell line but not in hl- cell line. the combination treatment increased apoptosis and dna damage response. dnadamage-sensing kinases were detected in k and hl- cells following treatment with bor as similar as topoisomerase inhibitors. bor increased the mrna levels of atm and atr dramatically, which indicated active dna damage in the myeloid cell lines. furthermore, bor induced apoptotic cell death by decreasing bcl and increasing bax and caspase levels. these effects of bor were observed to correlated with increasing the p expression levels. this study on the mechanism of action of bor indicates that this compound affects several pathways involved in the control of cell cycle progression, apoptosis and dna damage. p- . . - analysis of molecular cytogenetic alterations in gastric and colon carcinoma by array-based comparative genomic hybridization (array cgh) introduction: genomic dna regions are frequently lost or gained during tumor progression. we aimed to evaluate tumor samples of patients with gastric cancer and colorectal carcinoma to show these genetic alterations by array-based comparative genomic hybridization (array cgh) method. materials and methods: dna isolation was performed from the tumor samples obtained from sixteen patients with primary gastric adenocarcinoma and twelve patients with colon adenocarcinoma. then, agarose gel electrophoresis was performed in those dna samples. following electrophoresis of dna, array cgh procedure was performed to four patients with gastric adenocarcinoma and three patients with colon adenocarcinoma who had dna breaks with - kb. results: after array-cgh study, many common genetic changes in gastric and colon cancer genome were determined. in gastric cancer dna samples, common losses were detected in chromosome p . , p . , q , q , p . , q . , q . , q . , q . , p , q . , q . , q . , q . , q . , q . , and q . , and also common gains were detected in chromosome p . , q , q . , q . and xq . in colon cancer dna samples, common losses were detected in chromosome p . , q , p . , p . , q . , q . , q . , q . , p . , p . , q . , and q . , and also common gains were detected.in chromosome q . , xp . , xp . , xp . , xp . and xq . both in gastric and colon cancer dna samples, common losses were detected in chromosome q . , q . , and p . , and common gains were detected in xq . discussion and conclusion: we think that these common changes, generally in dna loss areas harboring tumor suppressor genes and dna gain areas harboring oncogenes, may important in gastrointestinal tumorigenesis. the dna of every cell is under a constant attack by various mutagenic factors which damage the dna and can cause cell cycle arrest and even cell death. accumulation of dna damage is the basis for cancer development and one of the reasons for aging of the organisms. in order to preserve the integrity of its dna cells have evolved an impressive array of dna repair pathways, which are precisely coordinated with the progression of the cell cycle. one of the first events at the site of dna damage is poly(adp-ribose) polymerase (parp ) recruitment which is a sensor for single strand breaks in dna. parp catalyzes the synthesis of poly(adp-ribose) or par which is needed for the recruitment of many other dna repair proteins by means of par-binding domains. we used high speed confocal spinning-disk microscopy of living cells to obtain precise kinetics of recruitment of par-dependent proteins to the sites of laser induced dna damage. our results show that the investigated par-dependent proteins are recruited to dna damage sites in the matter of seconds, they reach peak intensities for to seconds after damage infliction and start dissociating. the recruitment of the proteins is entirely dependent on par because addition of parp inhibitor abbrogated their recruitment. the use of spinning-disk microscopy of living cells allowed us to obtain the kinetics of recruitment of the studied proteins to the sites of dna damage. the results are consistent with the fact that parp and par-dependent proteins are quickly recruited to damage sites and generation of par is essential for other dna repair protein recruitment. the precise kinetic curves may serve as a basis for investigating how they will change or if they will change at all when cells are put in different conditions or treated with various chemical substances affecting dna metabolism and repair. introduction: chronic myeloid leukemia (cml) is a myeloproliferative disease associated with reciprocal translocation between chromosomes and . bcr-abl fusion gene which exhibits constitutively active tyrosine kinase activity has a main role in cml. the tyrosine kinase inhibitor imatinib is used as a first line treatment in cml patients, but imatinib resistance leads to failure in therapy. the application of imatinib in combination with other anticancer agents may be a strategy to increase the antileukemic effect of imatinib. in this study, we have investigated the antiproliferative effect two novel agents: a benzamide derivative xt and a benzoxazole derivative xt b in combination with imatinib. these molecules were investigated in imatinib-sensitive (k s) and imatinib-resistant (k r) cml cell lines. materials and methods: antiproliferative and apoptotic effects were assessed by mtt assays and flow-cytometry, respectively. we also evaluated the effects of these compounds on the expression of apoptosis-related genes bax, bcl- , bad, bim, bcl-xl and mcl by real-time quantitative pcr. results: treatment of k cells with xt increased the expression levels of the pro-apoptotic genes bax, bad and bim in both sensitive and resistant cells. however, xt b was not found to have similar effects on k r and k s cells. combined application of xt increased cell death in the mtt assay. mtt assay demonstrated that ic for xt treated cells in k r with imatinib (ic = . ) is lower than k r without imatinib (ic = . ). discussion and conclusion: our results showed that combining xt with imatinib has more antiproliferative and apoptotic effect on a cml cell line. as a result combination of xt with imatinib can be an alternative approach to overcome imatinib resistance. introduction: the mmr(mismatche repair) system recognizes base-base mismatches and insertion or deletion loops in doublestranded dna, and it degrades the error-containing region of the newly synthesized strand, allowing the polymerase to correctly resynthesize the second strand according to the template sequence. the human mmr system includes the mlh and msh . alteration in expression or a defect in mlh or msh can cause resistance to anti-cancer drugs used in chemotherapy. the attempt of the mmr system to detect drug induced dna damage, triggers the activation of apoptosis, a mechanism which may enhance the cytotoxicity of chemotherapy. loss of the mmr system would make the neoplastic cell less able to initiate apoptosis. inability to initiate apoptosis could be a mechanism of resistance to drugs. chronic myeloid leukemia (cml) is a clonal disease originating from aberrations in hematopoietic stem cell. imatinib, a tyrosine kinase inhibitor has significantly improved clinical outcome for cml patients. however, patients develop resistance when the disease progresses to the blast phase (bp) and there are several mechanisms involved in imatinib resistance. in this study we investigated the role of mmr system in imatinib resistance. materials and methods: k s (sensitive) and k r (resistance) were grown in rpmi- . k r cells were maintained in rpmi- medium supplemented with lm imatinib rna isolation, cdna synthesis, rt-pcr was performed respectively. results: the results demonstrated that expression of mlh in k r cells is dramatically lower than equal amount of imatinib treated k s cells, whereas msh expression level did not change in both cell lines. conclusion: it can be suggested that alteration and down-regulation of mlh genes leads to imatinib resistance. p- . . - characterization of interaction between rad inhibitor dids and human serum albumin d. velic, s. henry, c. charlier, m. popova, p. weigel, j. masson, i. nabiev, f. fleury cnrs/university of nantes, nantes, france -diisothiocyanostilbene- , -disulfonic acid (dids) has been largely used during the last years for its inhibitory effect on anion transporters and channels. more recently, ishida and colleagues have described a possible mechanism by which dids inhibits rad -mediated homologous pairing and strand exchange, key processes in dna repair by homologous recombination. thus, dids could act as a potential revertant of radioand chemo-resistance in cancer cells, which is the major cause of failure during therapeutic protocols. new drugs targeting rad protein have since been developed with potential use for medical applications. in this context, we attempted to determine the behaviour of dids towards blood and plasma proteins such as serum albumins. firstly, we analysed the effects of several environmental factors such as solvent polarity, which may affect the stability of the molecule. secondly, we analysed the spectroscopic properties of dids in the presence of human or bovine serum albumin proteins. uv-visible absorption, circular dichroism, fluorescence spectroscopy and isothermal calorimetry were used. here we show for the first time that dids can interact with both serum albumins. we have also determined the characteristics of these interactions. the comparison of several dids derivatives led us to identify the essential chemical moiety of this compound involved in the interaction. moreover, by using site competition approaches we show that the main binding site for this molecule is in subdomain ib of the protein. these findings show that the binding of dids to serum albumin proteins may change the equilibrium between the free and bound dids forms, thereby affecting its bioavailability and efficiency against the rad recombinase protein. p- . . - mechanism of tap beta-mdm autoregulation p is a transcription factor which is the member of a p family. it regulates many cellular processes, such as apoptosis, cell cycle, and senescence. in contrast to p , p is rarely mutated in tumors and elevated p expression is observed in many types of cancers including hepatocellular carcinoma, neuroblastoma, and lung. defining regulatory mechanisms which control p protein abundance and activity will be crucial for the development of new therapeutic strategies for cancers. mdm is known as the key player in regulation stability and activity of p . in addition, p induces mdm transcriptional activity, and caspase- , activations which cleave mdm n-terminal at asp . cleaved form of mdm binds p and promotes its stabilization. mdm suggested as a candidate to modulate p activity and stability too. however, an interaction between p and mdm has not defined well. in this study, we aimed to analyze the role of mdm in p stability. to define this relationship, firstly, we overexpressed the tap beta isoform using trex system in hep b. tap beta and mdm protein levels were determined by western blot. to examine whether mdm mediate tap beta protein degradation by the proteasomes, cells were treated with proteasome inhibitor, mg for hours prior to analysis. previous studies showed that p -induced caspase- and caspase- activation cleaves mdm . considering this, we firstly examined caspase- activation by western blot in hep b tap beta cells. then we analyzed expression of cleaved mdm and tap beta levels following caspase inhibitor, z-vad-fmk treatment. as a conclusion, tap beta-induced full-length mdm- expression. furthermore, tap beta enhanced cleavage of mdm via increased caspase- activation. in addition, inhibition of caspase- activation caused a decrease in cleaved-mdm levels in parallel with tap beta expression repression. our results suggested positive regulation between mdm -tap beta. hepatocellular carcinoma (hcc) is one of the most common type of liver cancer and third leading cause of cancer related deaths in worldwide. discovery of new targets is important in survival of hcc patients. p is a transcription factor which is the member of p family. it has two promoters; while p promoter expresses apoptotic ta isoforms, p promoter expresses anti-apoptotic dn isoforms. in addition, alternative splicing in c terminal creates many isoforms of ta and dn p . it has been shown that both tap and dnp isoforms are expressed in hcc patient tissue and cell lines. the ratio between tap and dnp affects the apoptotic response, drug response and prognosis. accordingly, identification of the role of p and its targets are important in discovery of new treatment strategies in hcc. to understand the role of p isoforms in hcc, firstly we performed mtt assays following dna-damaging drugs and multikinase inhibitor, sorafenib treatment to categorize hcc cell lines as resistant or sensitive. after that, we analyzed the expression levels of tap isoforms via western blot in all hcc cell lines. then we overexpressed the tap beta isoform using trex system in hep b and snu cells. these two clones were analyzed for dna damaging drug response by mtt, cell cycle and apoptosis by flow cytometry, and tumor formation by in vitro and in vivo experiments. in scope of our study; . only tap alpha isoform is expressed in a few hcc cell lines. . there is no correlation between basal expression of p isoforms and drug responses in hcc cell lines. . there is no change in expression of p isoforms after treatment of drugs. . we showed that the ectopic expression of tap beta in hep b arrested the cell cycle in g / s and decreased the colony formation. therefore, the capacity of tumor formation of the cells dramatically decreased in scid mice. as a result, we revealed that tap beta play role in tumor formation, cell cycle arrest, dna damage responses in hcc. p- . . - biochemical characterization of exonuclease iii-family ap endonuclease point mutants reveals role of conserved amino acid residues in the nir-specific enzymes a. mursalimov, z. koshenov, t. yeleussizov, m. redrejo-rodriguez, a. ishchenko, b. t. matkarimov, m. saparbaev national laboratory astana, astana, kazakhstan oxidative dna damage caused by reactive oxygen species is believed to be a major type of endogenous cellular damage. oxidatively damaged dna bases are substrates for two overlapping repair pathways: dna glycosylase-initiated base excision (ber) and apurinic/apyrimidinic (ap) endonuclease-initiated nucleotide incision repair (nir). in the ber pathway, an ap endonuclease cleaves dna at ap sites and -blocking moieties generated by dna glycosylases, whereas in the nir pathway, the same ap endonuclease incises dna to a number of oxidized bases. majority of characterized ap endonucleases possess classic ber activities and about half of them are able to catalyze nir activity. at present, the molecular basis of dna substrate specificities of various ap endonucleases remains unclear. here, we examined amino-acid sequence requirement of the nir activity of human major ap endonuclease (ape ). amino acid sequence alignment of various ap endonucleases including e coli exonuclease iii (xth), human ape and archaeal mth revealed conserved amino acid residues in the nir-specific ap endonucleases ape , mth and exoa that are absent in xth. based on these data, we constructed four ape point mutants y h, n q, g s and t d and examined their dna substrate specificities. results obtained from biochemical characterization of ape mutants are discussed in the light of the evolutionary conserved dna repair functions of ap endonucleases and whether these functions can be mutationally separated from. since its discovery some years ago, cisplatin has evolved for its efficacy in one of the most used drugs in treatment of various cancer types. huge effort was invested in understanding the action of cisplatin and development of more potent drugs. they target mainly neighboring purine bases of nuclear dna forming covalent intra-or inter-strand cross-links that affect inhibition of replication and transcription, cell cycle arrest, and attempted repair of the damaged nucleotides. if such damage cannot be removed the cell dies. we have studied the details of the binding site of the short oligonucleotide modified by a platinum compound using complementary solution techniques used in modern structural biology, including raman spectroscopy with dft calculations aided interpretation of the obtained vibrational spectra. moreover, the calculated structure of the dna duplex was verified using saxs (small angle x-ray scattering) curve. in our contribution, we will present an nmr structure of a dna cross-linked with a cisplatin derivative containing a cyclohexane ring. at this atomic level resolution, structural features probably influencing cytostatic effects are described and compared with previously published structures. common structural features of previously determined structures are: a significant roll ( - °) of the guanine bases involved in the cross-link, bending and unwinding of the double helix at the site of cross-link and orientation towards the major groove. also, the platinum-guanine plane angle varies between and °. although the experimental structures were often used as the starting models for molecular dynamics (md) simulations, results of these md still leave many questions unresolved. the results of this research have been acquired within ceitec (lq ) project with financial contribution made by the ministry of education, youths and sports of the czech republic within special support paid from the national programme for sustainability ii funds. p- . . - ercc /xpd polymorphisms and colorectal cancer risk: a case control study in a north eastern iranian population j. mehrzad islamic azad university, neyshabur, iran excision repair cross-complimentary group (ercc ) is one of the important dna repair genes.ercc codon and polymorphisms has been shown to modulate cancer risk. we therefore assessed the relationship between the ercc polymorphisms and the susceptibility to colorectal cancer in a case-control study. there were lung cancer cases and matched healthy controls in this study. information concerning demographic and risk factors was obtained, each person donated ml blood for biomarker testing. ercc genotypes were determined by t-arms-pcr method. all of the statistical analyses were performed with spss (v . ). there was significant difference between the frequencies of ercc polymorphism in cancer cases and controls (p < . ). the frequencies of ercc gln allele were . % in controls and . % in cancer cases. the individuals with lys/gln+gln/gln combined genotype were at an increased risk for lung cancer as compared with those carrying the lys/lys genotype (adjusted or= . , %=ci . À . ). the above findings indicate that the genetic polymorphism in the ercc codon is associated with the risk of colorectal cancer in an iranian population (neyshabur citizenship). peptide pore blockers are potent tools to study structure and function of potassium voltage-gated channels (kv). kcsa-kv .x chimeras, in which a ligand-binding site of eukaryotic kv-channel is inserted into bacterial kcsa channel, mimic properly the pore domain of kv-channels. a fluorescence-based approach to study the binding of peptide blockers with kcsa-kv . -kcsa-kv . chimeras was developed by us. this approach rested on high-level expression of kcsa-kv .x chimeras in e.coli inner membrane, binding of fluorescently-labeled toxin at the surface of the spheroplast and analysis of competitive binding of studied ligands by laser scanning confocal microscopy (lscm). here we report on a new analytical system for search and study of kv . -channel blockers that combines bl (de ) cells expressing kcsa-kv . and rhodamine-labelled agitoxin (rh-agtx ) as a fluorescent probe. by tuning cultivation conditions, the high-level of membrane expression of kcsa-kv . was achieved. it was found that lowering both the growth temperature and the concentration of inducer resulted in significant increase in membrane-embedded kcsa-kv . . for system validation, wellknown kv channel blockers were studied by the method of competitive binding, and equilibrium dissociation constants were estimated for agtx , osk , and kaliotoxin. a new system was applied to study molecular determinants of peptide-kv . channel binding using a number of agtx mutants constructed by us, whose affinities to kcsakv . were measured. a new bioengineering fluorescent system is a robust and sensitive assay for assessing the binding activity of kv . channel blockers. it can be used to study interaction interfaces of toxinchannel complexes, to search for novel peptide blockers and to develop new potent and selective kv . -blockers for scientific and medical purposes. the work was supported by the grant - - from russian science foundation. asparagus racemosus root extracts (ar) have been exhibited to show a wide range of pharmacological benefits. in this study, liposomes of ar were developed and assessed their physicochemical properties and anti-inflammatory activity in monocytic leukemia cell line (thp- ). liposomes containing ratios of ar to lipid and phosphatidylcholine to cholesterol ratio were synthesized by thin-film hydration (tf), reverse-phase evaporation (rev), and polyol dilution (pd). the in vitro anti-inflammatory activity was assessed in terms of inhibition of tumor necrosis factor alpha (tnf-a) in lipopolysaccharide activated thp- by elisa. the size of ar liposomes prepared by tf were larger, whereas those prepared by rev and pd were smaller. ar to lipid ratio was shown to have no influence on particle size, whereas zeta potential enhanced with increasing ar to lipid ratio. ar liposomes with lipid ratio of : achieved the highest value of entrapment efficiency and were at the highest with polyol dilution method. ar was found to have no toxic effects on thp- cells. the anti-inflammatory activities of ar and ar liposomes in terms of tnf-a in thp- cells were was exhibited to possess the highest values of around % at ar concentration of lg/ml and % tnf-a inhibition tended to decline with the increasing amount of ar. this result may be attributed to the increased amount of liposomal particles being uptaken into the cells as a result of the increasing ar concentrations. it can be suggested that ar liposomes could be an alternative choice of topical/transdermal drug delivery for anti-inflammatory activity. p-mis- inhibition of ire signaling enzyme increases the expression of tumor suppressor genes and modifies their hypoxic regulation in u glioma cells d. tsymbal, o. minchenko palladin institute of biochemistry of the national academy of sciences of ukraine (nasu), kyiv, ukraine gliomas constitute one of the most aggressive groups of malignant neoplasms with poor survival prognosis and scarce therapeutic options. plentiful studies have proven the connection between endoplasmic reticulum stress and malignant growth. we have studied the effect of inhibition of ire (inositol requiring enzyme ), which is a central mediator of endoplasmic reticulum stress and controls cell proliferation and tumor growth, on hypoxic regulation of the expression of different proliferation related genes in u glioma cells. it was shown that inhibition of ire leads to up-regulation of the expression of krt , cd , mest, cenpu, myl , ing , ing , mybl , and mybl genes at the mrna level in u glioma cells, with more profound changes for mest, mybl , and cd genes. hypoxia leads to up-regulation of the expression of cd , ing , and ing genes and to down-regulationof krt gene in glioma cells. at the same time, inhibition of ire modifies the effect of hypoxia on the expression of all studied genes: suppresses effect of hypoxia on ing gene, eliminates hypoxic regulation of krt , cd , and ing genes in glioma cells. the present study demonstrates that inhibition of ire enhances the expression of all studied genes and modifies the hypoxic regulation of these gene expressions in gene specific manner and thus possibly contributes to slower glioma cell proliferation, but several aspects of this regulation remain to be further clarified. amplification and clonig of dna polymerase (pol ) of thermus scotoductus k isolated from an armenian goethermal spring a. saghatelyan, h. panosyan, a. trchounian, n. birkeland yerevan state university, yerevan, armenia the most important enzyme ''mined'' from thermophilic microorganisms is dna polymerase, which widely used in molecular biological studies. although dna polymerase produced by thermus aquaticus (taq polymerase) was launched into the market long back, isolation of more processive, reliable and stable dna polymerases from other species is a demand. the purpose of this work was to amplify and clone the pol gene of t. scotoductus strain k recently isolated from an armenian geothermal spring. the draft genome sequence of strain k was deposited under accession number ljjr . . genomic dna was isolated using genelute bacterial genomic dna kit. primers for the pol gene were designed manually. the gene was amplified using pfu polymerase, and amplicons (~ . kb) were ligated into the pet- b(+) vector (novagen) and transformed into chemically competent top escherichia coli. inserts were sequenced with t prom and t term primers, which showed that the gene sequence was correct and in the right reading frame and could be expressed in mesophilic e.coli. dna polymerases patented form different species of thermus are mostly comparable, suggesting that only limited natural variations in taq-like dna polymerase may be discovered. the pol gene from k shares % and % similarity with pol of t. scotoductus sa- ( . kb) and t. aquaticus, respectively. although the difference is not huge at sequence level, possible functional differences (e.g. stability, proofreading activity, resistance to different pcr inhibitors etc.) may occur. therefore, it is important to express and purify dna polymerase from strain k for further investigations. peptide ligands of the immunoglobulin g fc region identified by screening phage libraries and site-directed mutagenesis n. kruljec, p. molek, t. bratkovic young researcher, ljubljana, slovenia affinity chromatography based on immunoglobulin (ig)-binding proteins, such as staphylococcal protein a and streptococcal protein g, typically represents the initial step in therapeutic antibody purification process. however, this approach suffers from high cost, poor ligand stability and the requirement for relatively harsh elution conditions that can negatively impact activity and immunogenicity of antibodies. compared to protein ligands, peptides represent an interesting alternative due to higher stability and less expensive production. furthermore, the expected lower affinity for immunoglobulins should allow for elution under milder conditions. the aim of our research was to identify short peptide ligands for the fc region of human iggs. we have screened three commercially available phage display libraries of random cyclic and linear peptides for binding to human fc region in solution using an optimized biopanning approach. five non-homologous linear peptides were shown to specifically interact with the fc portion of immunoglobulins as verified by a set of phage elisa assays. individual phage-displayed peptides were able to recognize specific subclasses of igg. the highest-affinity peptide ( l- fc), which competed for fc binding with protein a, was subjected to mutagenesis studies. we displayed on phage several variants of l- fc with individual amino acid residues exchanged for alanine as well fragments of the parent peptide of different lengths and evaluated binding to fc with phage elisa to identify the minimal binding motif. binding characteristics of the minimized peptide were further analyzed using spr biosensor. the details will be disclosed at the meeting. diverse effects of ganoderma lucidum in combination with tamoxifen citrate and doxorubicin in mcf- breast cancer cells ganoderma lucidum, an edible medicinal fungus, has been known with its anti-metastatic, anti-carcinogenic bioactivities and widely used in asian countries in complementary and alternative medicine. however, there is no information regarding its combined usage with tamoxifen and doxorubicin in breast cancer treatment. we investigated the interactions between ganoderma lucidum and tamoxifen or doxorubicin in mcf- human estrogen receptor positive breast cancer cell line. anti-proliferative properties of six extracts were assessed by wst- method. the most effective extract in inhibition of mcf- cell viability was then evaluated in terms of its anti-metastatic activity by boyden chamber assay. apoptosis and cell cycle assays were performed by flow cytometry. ganoderma lucidum ether extract (g.ether) was the most effective extract on inhibition of cell viability among others with ic ( ) values of lg/ml and . lg/ml at h. and h. respectively. we found that g.ether is capable of inducing apoptosis and changing cell cycle dynamics. however, incubation with g.ether did not affect mcf- cell motility significantly. we then assessed the interactions between g.ether and tamoxifen or doxorubicin in mcf- cells. the interactions between g.ether and cancer therapeutics were examined by combination index analysis and macsynergy ii software. interestingly, g.ether increased the anti-proliferative effect of tamoxifen although exhibited strong antagonism with doxorubicin in mcf- cell line. testing the best matrix/analyte combination for maldi tof mass spectrometric detection of steroid hormones, amino acids, vitamins and carbohydrates in spite of numerous advantages, there are serious drawbacks of the application of matrix assisted laser desorption/ionization time-of-flight mass spectrometry (maldi tof ms) for smallmolecule analyses (below da) and quantification. the main problem is the background interference from commonly used maldi matrix materials. the aim of this work is to evaluate maldi tof mass spectra of physiologically relevant small molecules: steroid hormones, vitamins, amino acids and carbohydrates, acquired with several organic, traditional matrices. small volume, . ll, of each sample solution (testosterone, progesterone, estradiol, l-cysteine, l-alanine, dl-methionine, glutathione, d-(+)-glucose, d-(+)-maltose, vitamin a, vitamin e) was mixed on the sample plate with the same volume of organic matrix solutions (dhb, thap, chca, -aa). for each molecule/matrix pair, we determined quantitative and qualitative parameters of ms analysis. to calculate within day and day-today variation we used excel tools (anova tests). in addition, homogeneity of the sample/matrix distribution on the target was also calculated and expressed as the coefficient of variation of a series of measurements. our results show selectivity of the detection of individual molecules related with the matrix applied. the statistical analysis of certain molecule/matrix pairs gave within and day-to-day variations less than %. additionally, homogeneity of the sample/ matrix mixture distribution on the target plate was with some matrices, also less than %. some of the used matrices have a great potential for the analysis of small molecules with good analytical parameters, with low variations and high homogeneity of samples on the maldi target plate. these results hold potential for quantification of metabolically-significant small molecules and are very promising for future applications of maldi tof ms analyses. stress causes different expression of mitochondrial biogenesis markers in rat steroid-producing cells of adrenal gland and testes i. starovlah, s. radovic, t. kostic, s. andric faculty of science univeristy of novi sad, novi sad, serbia functional mitochondria of steroid producing cells of adrenal cortex and leydig cells of testes are essential for steroid hormones biosynthesis and regulation. the aim of this study was to determine transcriptional profile of mitochondrial biogenesis markers in adrenal cortex and leydig cells by applying in vivo and in vitro studies. immobilization stress (imo), was performed for hours daily for one ( ximo), two ( ximo) or ten ( ximo) consecutive days. in in vitro studies, primary cultures of purified leydig cells from undisturbed rats were stimulated with stress hormone adrenaline, propranolol (nonselective b-adrs-blocker) and prazosin (the selective a -adrs antagonist). rq-pcr results showed that the transcription of the main regulator of mitochondrial biogenesis, ppargc a and ppargc b, significantly decreased in adrenal cortex of ximo rats. oppositely, the significant increase of the same transcript was registered in leydig cells from the same rats. in parallel, transcription of ucp , the mediator of regulated proton leak, decreased in adrenal cortex, but increased in leydig cells of the same group of rats. incubation of leydig cells with adrenaline, increased transcription of the main markers of mitochondrial biogenesis (ppargc a, ppargc b, nrf and nrf a). nonselective b-adrsblocker attenuated this effect. the selective a -adrs antagonist did not change adrenaline-induced stimulation of ppargc a, ppargc b, nrf and nrf a transcription in leydig cells, indicating that the most of the effects are probably mediated by b-adrenergic receptors, not by a -adrs of leydig cells. in summary, the results suggest that reduction of transcription of mitochondrial biogenesis markers could be a possible mechanism that protects body from excessive glucocorticoid production from adrenal glands in stress conditions, while at the same time stimulation of mitochondrial biogenesis markers transcription in leydig cells could serve as mechanism to preserve testosterone production. p-mis- generation of new mitochondria is possible protection mechanism of basal steroidogenesis in leydig cells s. radovic, i. gak, t. kostic, s. andric faculty of science, university of novi sad, novi sad, serbia mitochondria are the most important component of stress response in all cells and for steroid-hormones-producing cells they are the starting point for steroid biosynthesis. here we investigated the parameters of mitochondrial biogenesis in these cells from rats exposed to the psychophysical stress by immobilization (imo). imo stress was applied for hours daily for one ( ximo), two ( ximo) or ten ( ximo) days.hormone levels were measured employing eia, elisa kit or ria. mitochondrial membrane potential (Δwm) was measured by tmre fluorescence, mitochondrial mass was detected by quantitative analysis of mitotracker-green fluorescence as well as relative intensity of fluorescence, since number of mitochondria and mitochondrial architecture were defined using transmission electron microscopy. relative gene expression and proteins analyses were performed by rq-pcr and western blot. there was positive correlation between Δw m of leydig cells and androgens production of leydig cells. both of them were reduced in all stressed rats but partially recovered in ximo group. the mitochondrial mass in leydig cells from ximo group was increased. transmission electron microscopy analyses showed that acute and two times repeated stress altered architecture of mitochondrial cristae, while ximo increased number of mitochondria and recovered mitochondrial architecture. there was significant increase in the expression of the all markers of mitochondrial biogenesis in leydig cells from ximo rats compared with other groups. accordingly, stress-triggered mitochondrial biogenesis represents an adaptive mechanism and does not only correlate with but also is an essential for testosterone production, being both events depend on the same regulators. supporting the evidence that stress, a constant factor in life of humans, induces mitochondrial biogenesis in leydig cells, our results indicate this mechanism probably protects the basal steroid production in stress conditions. targeting survival pathways in leukemic cells through synergism of metformin and thymoquinone u. glamoclija, m. suljagic international university of sarajevo, sarajevo, bosnia and herzegovina generation of resistance to current treatment options is common problem in the therapy of many hematological malignancies. combined therapies utilizing compounds with low toxicity that act synergistically, are proposed to overcome this problem. metformin and thymoquinone (tq) are two molecules which have proven safety profile and represent potential candidates for treatment of hematological malignancies. there are more than clinical trials, at different stages, exploring metformin anticancer activity. metformin activates amp activated protein kinase (ampk) leading to inhibition of the mammalian target of rapamycin (mtor) and induction of apoptosis in different cancers. however, human leukemic cells with increased basal protein kinase b (akt) phosphorylation were shown to be resistant to metformin-induced apoptosis. it was found that activity of metformin can be enhanced by combination with akt and/or nuclear factor 'kappa-lightchain-enhancer' of activated b-cells (nf-jb) inhibitors. tq is phytochemical compound that has shown inhibitory capacity on both of these targets. wst- assay was used to evaluate the effects of metformin and tq in dhl (b cell lymphoma) and k (chronic myelogenous leukemia) cell lines. compusyn software was used in order to calculate the combination index (ci). the ci value indicates whether two drugs have synergistic (ci< ), additive (ci= ) or antagonistic effects (ci> ). we have shown that separately, metformin and tq, exhibit dose dependent inhibition of dhl and k cells. in combinatorial study with fixed constant ratio and simultaneous drug exposure, in dhl and k cell lines, ci values were . and . , respectively. to our knowledge, this is the first report showing synergistic effects of metformin and tq in lymphoma and chronic myelogenous leukemia derived cell lines. these promising data are currently being investigated in order to obtain the insight into their molecular mechanisms. for the last decade many methods of calculating and analysing the physical characteristics of dna has been developed. these methods allow to estimate distributions of free energy, propensity to bend, stress-induced duplex destabilization (sidd), electrostatic potential (ep) etc. and most of them have been used for prediction of genomic regulatory site positions. the main idea of such approach is that proteins recognize genome regulatory sites by these physical and chemical properties, so the physical characteristics are used to predict the location of regulatory sites. most of the characteristics mentioned above describe properties of dna at equilibrium or steady state, but we propose to use characteristics of internal dna dynamics. in this work we used the coarse-grained model of dna, developed recently, to simulate dynamics of the dna open states. with this model we were able to calculate trajectories of the open states moving along the molecule and their dynamical characteristics, such as: open state activation energy, size, half decay time and sound velocity in dna. we use distribution of four dynamical characteristics around transcription start site of experimentally found e.coli promoters taken from regulon db to organise them in stable clusters. clusterization was made with ward method and consensus clustering technique was applied to clusterization results for analysis of its consistency. the same procedure was applied to equilibrium dna characteristics for comparison. distribution of go functions among clusters was also analysed. stable promoter clusters obtained with different physical properties share some similarity. it was not surprise that clusters obtained with dynamical characteristics of dna more similar to sidd clusters then to ep clusters. the data highlights the possible role of dna dynamical properties in transcription initiation and its applicability to promoter identification together with other physical and textual properties of dna. chromium complex with -hydroxyflavone acts on metabolic pathways the development of novel therapeutic strategies for obesity treatment are urgently required as obesity is currently the main leading cause in type ii diabetes and insulin resistance. among natural compounds, flavonoids have recently gained interest due to their positive role in maintaining blood glucose levels and insulin secretion. their association with trace elements, wellknown for their capacity in increasing the efficiency of insulin, might potentiate flavonoids biological effects. in this context, the aim of our study was to investigate the in vitro changes in energetic metabolism related genes expression profile in the presence of a chromium complex with -hydroxyflavone. dna microarray technology was used for a large scale screening of differentially expressed genes in human adipose stem cells (hascs) after weeks of adipogenic induction in the presence of the chromium complex with -hydroxyflavone. moreover, perilipin expression was assessed by flowcytometry. the chromium complex with primuletin negatively regulates the expression of key genes involved in adipogenesis and also modulates the expression of the genes associated with triglyceride synthesis and subsequent fat storage in mature adipocytes. consequently, the chromium complex with -hydroxyflavone can be further employed in studies on animal models to investigate the possible improvement of metabolic disorders. deinococcus radiodurans is a highly radioresistant and stress-resistant bacterium. despite extensive studies, the mechanisms of transcription regulation that contribute to the stress-resistance are still poorly understood. d. radiodurans encodes multipe stress-related proteins including three members of the gre-family of transcription factors: grea, gfh and gfh . while grea is a universal bacterial factor that stimulates rna cleavage by rna polymerase (rnap), the functions of lineage-specific gfh proteins remain unknown. we cloned, expressed and purified d. radiodurans rnap and gfh factors and their mutant variants and analyzed their properties using various in vitro transcription approaches. we tested gfh effects on rnap activity in promoter, elongation and termination complexes assembled on natural and synthetic dna templates under different conditions. we found that the gfh factors strongly enhance site-specific pausing and intrinsic transcription termination by d. radiodurans rnap but do not act on active transcription complexes and do not compete with the grea factor. uniquely, the pause-stimulatory activity of gfh is greatly enhanced by manganese ions, which are accumulated in d. radiodurans cells under stress conditions, and is modulated by the secondary rna structure. we revealed functionally important regions in the gfh factors and the rnap active site involved in transcriptional pausing. we propose that gfh factors inhibit rna extension in paused complexes through binding within the secondary rnap channel, coordinating metal ions in the rnap active site and stabilizing an inactive enzyme conformation. this may serve as a sensitive mechanism to regulate transcription under stress conditions and coordinate it with dna repair and replication. our data suggest that gre and gfh proteins target different structural states of the transcription elongation complex and reveal functional diversity of the factors that bind within the secondary channel of rnap. from planktonic to biofilm state of growth, flagella formation is turned off, and the production of fimbriae and extracellular polysaccharides is activated. bola protein is widespread in nature and has been associated with several cellular processes. using high-troughput techniques we showed that bola protein is a new bacterial transcription factor, which regulates the switch between motile and sessile lifestyle. it negatively modulates flagellar biosynthesis and swimming capacity in escherichia coli. moreover, bola overexpression favors biofilm development, involving fimbriae-like adhesins and curli production. our recent results show that bola action in these pathways is related with cdi-gmp a relevant intracellular signaling molecule involved in biofilm formation. we demonstrate that bola contributes to a fine-tuned expression of different diguanylate cyclases and phosphodiesterases and c-di-gmp has a negative influence in the bola mrna transcription. herein we propose that bola is a key player in motile/adhesive transcriptional switch, contributing to a fine-tuned regulation of these important pathways. background: deep venous thrombosis (dvt) is an important health problem worldwide. its pathophysiology is multicausal and involves environmental, genetic and acquired factors. factor v leiden (fvl), prothrombin g a (pt g a), and methylenetetrahydrofolate reductase (mthfr) gene mutations are to predispose to venous thrombosis. the aim of this study was to compare the frequency of fvl, pt g a and mthfr polymorphisms between patients with dvt and healthy controls. methods: this study was conducted at the bozok university hospital. total participants were included in this study, patients with dvt and healthy blood donors. in order to identify fvl, pt g a, mthfr c t and mthfr a c, the polymerase chain reaction (pcr) method was utilized combined with the amplification refractory mutation system. results: in patients fvl was present in ( . %) patients while in controls fvl was present in only ( . %). frequency of fvl was significantly higher in cases as compared to controls (p < . ). pt g a mutation was present in patients ( . %) and in healthy participants ( . %). mthfr c t and mthfr a c polymorphisms were almost equally distributed among patients and healthy participants. however, the concomitant presence of fvl and double heterozygous polymorphisms of mthfr c t/a c was found in patients ( . %) and in healthy controls ( . %), showing significant association with deep venous thrombosis. conclusion: in this study, the frequencies of fvl and pt g a polymorphisms were found significantly higher in patients with dvt than those in healthy participants. thus, fvl and pt g a polymorphisms have a contributory role on the development of dvt in contrast, mthfr c t and mthfr a c genotypes were not associated with a predisposition to development of dvt. but, a combination of double heterozygous polymorphisms of mthfr c t/a c with fvl may be associated with increased risk of dvt. p-mis- self-assembling micellar clusters comprising drugs, nanoparticles and fluorescent compounds for bilogical applications when designing drug carriers, the drug-carrier ratio is an important consideration, because the use of wrong drug-carriers relation can result in toxicity as a consequence of poor metabolism and elimination of the carriers. solubility problem of various substances also plays an important role in many aspects of fundamental science and practical field. specifically, it is an important parameter as well as bioavailability, which determines the required concentration of drug in the body needed to achieve a pharmacological response. among the variety of solubilization methods micellar solubilization is widely used as an alternative to the dissolution of poorly soluble drugs. here, we show a specific approach based on sequential selfassembly of nonionoc detergent micelles (t , tx ) followed by enacpsulation of various nanoparticles (noble metals, magnet etc.), drugs, fluorescent compounds leads to the formation of stable micellar nano-amd microcomplexes. we propose ways of micellar clusterisation. in the first one micelles are modified by semi-hydrophobic chelator followed by addition of metal ion to make cross-linking. the second way is similar to the first one and suggests application of the metal complex with incresed denticity instead of naked metal ion, and the third one involves micelles clusterisation by semi-hydrophobyc metal complex directly. therefore, one can stabilize micellar network by means of 'interactions on interface': semi-hydrophobyc metal complexes are embedded inside micelle due to hydrophobyc interactions. hydrophobic fluorescent compounds-loaded micellar complexes demonstrates better optical response in aqueous media without crystallization. such obtaining clusters are also very flexible and can be modified by nanoparticles to obtain various nanocomposites, such as fluoromagnetic clusters. this work was supported by russian foundation of basic research grants no. - - r_center_a ( no. - - r_center_a ( - no. - - r_center_a ( ) and - - mol_a_ved ( no. - - r_center_a ( - . lamellipodia and membrane blebs utilize different signalling pathways to induce directional movement of walker carcinosarcoma wc cells in a physiological electric field clear if those reactions are mediated by similar mechanisms. to establish that, we performed proteomic analysis and subsequent investigation of the role of differential signalling pathways in electrotaxis of cells representing various strategies of movement. cells were exposed to ef in galvanotaxis apparatus and their reaction was recorded. in some experiments cells were pre-incubated with erk / or btk- inhibitors. the phosphorylation of erk / and btk- was determined by western blot analysis. proteomic analysis was performed by ultimate rs lc nanosystem coupled with a q-exactive mass spectrometer. both blebbing (bc) and lamellipodial (lc) cells show cathodal migration in a physiological ef ( v/cm). comparative analysis of bc and lc cells proteomes revealed about differential proteins. functional analysis in ingenuity analysis pathway allowed to determine the statistically significant signalling pathways in which these proteins are engaged. among the most distinctively regulated pathways are tec kinase and erk/ mapk signalling activated in lc but not bc. it was found that btk- is required for directional movement of lc but not for bc cells. moreover, ef induced stronger and faster btk- phosphorylation in lc than bc cells. in contrast erk / activity was not necessary for electrotaxis of lc cells and ef did not induce erk / phosphorylation. our results reveal that both lamellipodia and membrane blebs can efficiently drive electrotactic migration of wc cells but it is mediated by different signalling pathways. this work was supported by a grant from the national science centre / /b/nz / , poland. newborn screening for congenital hypothyroidism in turkey: a regional evaluation € o. demirelce , n. y. saral , f. b. aksungar , , a. coskun , , m. serteser , , i. unsal , acibadem labmed, istanbul, turkey, acibadem university, istanbul, turkey congenital hypothroidism (ch) is the most common congenital endocrine disorder and the most important cause of preventable mental retardation. it is important to begin the treatment within weeks before the development of brain damage. tsh based newborn screening programs are shown to be useful for implementing early treatment of ch. in this study, regional results of ch screening program in turkey between and were assessed retrospectively. we have evaluated the results of marmara, central anatolia, aegean and mediterranean regions in which our laboratories are located. screening was based on tsh determination in dried blood spot specimens. tsh limits determined to be lu/ml for cut off point and lu/ml for clinical decision point. tsh was measured using enzyme immune assay (eia). blood spot tsh data for newborns during this time period were evaluated. permanent or transient ch was determined according to the results of thyroid function tests. confirmed ch cases were based on local endocrinologists' report and initiation of thyroxine treatment. the frequency of neonatal tsh levels were found to be under the cut off level of lu/ml in ( . %), between and lu/ml in ( . %) and above the level of lu/ml in ( . %) babies, respectively. recall rate was . %. ch cases of neonatal tsh levels greater than lu/ml were . the incidence of ch of this group was : . there were no significant differences in the number of congenital hypothyroidism between males and females (p > . ). the preliminary results of our study indicate that the incidence of ch in our region is higher than the worldwide reports as has been proved by preceding studies. iodine deficiency, dyshormonogenesis, highly consanguineous population, may contribute to the high incidence of ch in turkey. newborn screening of ch must be developed for detecting true cases and tsh cut off point must be reviewed for decreasing redundant recall rate. in silico analysis of the first complete genome sequence of lactobacillus acidipiscis species k. papadimitriou , m. kazou , v. alexandraki , b. pot , e. tsakalidou agricultural university of athens, athens, greece, institut pasteur de lille, lille, france introduction: lactic acid bacteria (lab) constitute a significant group of microorganisms for the food industry, as they play a key role in food fermentation and consequently in human health. lactobacillus acidipiscis aca-dc is a gram-positive, motile, rod-shaped lab isolated from traditional greek kopanisti cheese. here we present the in silico analysis of the first complete genome sequence of l. acidipiscis in order to explore the biology of the species. materials and methods: sequencing of l. acidipiscis genome was performed using the hiseq and pacbio rsii sequencing platform technologies and the genome assembly was validated against an nhei optical map of the l. acidipiscis genome. protein-coding sequences were predicted by glimmer, rrna genes by rnammer and trna genes by the trnascan-se server. potential genomic islands were detected using the island-viewer software tool, prophage regions by phast and the subsystem-based annotation by rast server. finally, the circular representation of l. acidipiscis genome keyed to the cog groups was constructed by cgview server. results: the sequencing analysis resulted in one continuous genomic scaffold of , , bp with a g+c content of . %. the genome contains , protein-coding genes on the chromosome covering up to . % of the genome sequence, trna and rrna. according to the subsystem-based annotation, , protein-coding genes were assigned to metabolic subsystems. the most abundant of the subsystems are related to carbohydrates (n = , . % of total protein-coding genes) and protein metabolism (n = , . % of total protein-coding genes). furthermore, three prophage regions were detected; one intact ( . kb), one incomplete ( . kb) and one questionable ( . kb). discussion and conclusion: the whole genome analysis of l. acidipiscis aca-dc provided interesting information about a not well-studied species. investigation of serum irisin levels of patients with metformin taking new onset type diabetes mellitus increases glucose tolerance and energy expenditure and improves carbohydrate homeostasis. metformin is a biguanidine class antidiabetic drug which inhibits liver gluconeogenesis and decreases insulin resistance and is frequently recommended in treatment of new onset type diabetes mellitus (t dm). irisin has a role in the regulation of energy metabolism pathways and its level in blood of persons with t dm has been reported to decrease. regarding this relationship, it was aimed to reveal the effect of metformin on serum irisin levels. patients with impaired oral glucose tolerance test were included to this investigation. they were recommended to take metformin and to change their life style, such as exercise and diet. their blood were taken at the beginning and after month. also, a healthy control group (n = ) was formed from persons with similar age and sexual distribution as the patient group. irisin levels of their sera were measured by enzyme-linked immunosorbent assay (elisa) method. statistical evaluation of the measurements showed no significant difference (p = . ) between the irisin levels of the patients at the beginning and after month treatment. a similar result was found between the control and the treated groups (p = . ), while a significant difference (p = . ) was observed between the control and untreated patients groups. the results obtained from this study do not show a clear and significant change in the blood irisin levels of the patients with new onset t dm taking metformin together with life style change. a longer period of treatment and a higher number of patients may be needed for more reliable results. thermodynamics of dna ligands binding at specific sites of telomeric g-quadruplex dna g-quadruplexes are a perspective target for anticancer therapy. for example stabilization of the telomeric g-quadruplex dna formed by single-stranded ends of the chromosomes leads to inhibition of telomerase, which is active in % of cancer cells. similarly, small molecules targeted to a specific g-quadruplex would inhibit various cellular processes. stoichiometry and affinity of interaction of these compounds to dna is determined by specific structural motifs within a g-quadruplex. rational design of novel chemical compounds requires an in depth knowledge of interactions between known ligands and g-quadruplex structures. experimental methods that are used for determination of thermodynamic binding parameters, such as isothermal titration calorimetry, differential scanning calorimetry, ultraviolet absorption and circular dichroism spectroscopy provide a collective characteristic for all of the ligand molecules bound to dna, while the information on ligand affinity to individual dna binding sites is lost. we propose a complimentary method for detailed analysis of thermodynamic parameters of ligand binding based on the introduction of fluorescent probes in the structure of g-quadruplex. monitoring fluorescence quenching of the fluorescent labels allows to derive binding constants of the dna-ligand interaction at a specific binding site. temperature dependence of the fluorescence quenching determines the thermodynamics of the dnaligand complex formation. since only a proximal ligand is able to quench the fluorescence, this method allows characterization of the ligand binding to a particular site the g-quadruplex structure. the study was supported by project no. - - of the russian science foundation. the correlation between biochemical and dynamic surface tension parameters of calves blood serum during the animal ontogenesis, as well as by various pathologies or poor diet, the imbalance of protein, mineral, lipid components is observed (the changes in all parameters of biological liquids are accompanied of these metabolism peculiarities). the dynamic surface tension (dst) of serum essentially depends on these factors and (in combination with the biochemical parameters) can provide the valuable information for evaluation of the physiological and biochemical status of the organism (can be used as an express test for animal diagnostics in future). the aim of the work was to study dst and biochemical parameters of calve serum, as well as their correlations, as the main indicators of the animals. ) of calve serum were in the range of the normal values for healthy animals and can be considered as reference data for animal science and practice. the obtained results enable us to establish correlations between the dst and biochemical parameters of calves serum. this work was supported by the russian scientific foundation (grant - - ). the middle strong correlations of dst values of calves serum with the level of total protein, albumin, billirubin, some enzymes and cholesterol, whereas only weak correlations with the other biochemical parameters (urea, calcium, magnesium, phosphorus, etc.) were found. in the veterinary science and practice such correlations are important for the estimation of the organism physiologicaland biochemical status, for general inspections of cattle before vaccination (immunization) or slaughter, for "quick separation" of healthy and ill animals in the case of infection, etc. role of protein kinase c in the regulation of astrocytic glutamine transporter sn in ammonia-exposed mouse cortical astrocytes (bisi; lm). total pkc activity was analyzed by a direct pkc assay and phosphoserine detection by western blot (wb) analysis. protein level of sn and sn , second astrocytic gln transporter belonging to system n, in a membrane fraction was also analyzed. the total uptake and system n-mediated (l-ala and l-leu-inhibitable) gln uptake was tested. treatment of astrocytes with ammonia resulted in a decrease of pkc activity, whereas pma treatment increased pkc activity in ammonia-independent way. bisi treatment reversed fully, and ammonia partially, the pma-induced pkc activity. pma treatment resulted in only a slight decrease in sn protein level in both control and ammonia-treated astrocytes, while a decrease of total and system n-mediated gln uptake were noted in control astrocytes, an effect not exacerbated by ammonia. in turn, cotreatment with pma and bisi reversed the decrease of total gln uptake and showed tendency towards increase in system nmediated gln transport. the results suggest that: a) ammonia changes the dominating direction of system n transport from release to uptake, which may be related to decreased phosphorylation or to alterations in relative phosphorylation by different pkc isoforms. this inference remains to be verified in further studies; b) changes in system n transporter function induced by ammonia appear to involve mechanisms other than changes in transporter expression. evidence for human ghrelin ghs-r a and orexin ox heteroreceptor complex formation in a heterologous system ghrelin and orexin are two peptides implicated in the regulation of energy balance and modulation of food-related motivation at the level of the midbrain dopamine reward system. their function in the hypothalamic arcuate nucleus and the ventral tegmental area (vta) has already been described, but the modulation at the level of receptors remains unclear. the action of these peptides is mediated by g-protein-coupled receptors (gpcrs): ghrelin a and b (ghs-r a , ghs-r b ) for ghrelin, and orexin and (ox , ox ) for orexin. traditional approaches to know the mechanism of neurotransmission of dopaminergic neurons in the mesolimbic system have focused on targeting neuronal receptors as single entities. from the discovery that gpcrs for neuromodulators may form heteroreceptor complexes, our hypothesis is that ghrelin and orexin receptors may interact and form novel functional units that may specifically participate in the central regulation of food intake and energy balance. as a proof of concept we have investigated the potential of human ghs-r a and ox receptors to form heterocomplexes. formation of ghs-r a -ox receptor heteromers in transfected hek t cells was detected by bioluminescence resonance energy transfer (bret) and proximity ligation (pla) assays. furthermore, a negative crosstalk was identified in cells co-expressing both receptors by assessing mitogen-activated protein kinase (mapk) and adenylyl cyclase (camp) pathways, and by a label-free dynamic mass redistribution assay. experiments in sources endogenously expressing ghs-r a and ox receptors are needed to know the functional relevance of the heteromer. from the negative crosstalk here identified, it is tempting to speculate that ghs-r a -ox receptor heteromers are important players in mediating the response to the combination of different orexigenic signals. lysosomal storage diseases which are related to deficiency of specific lysosomal hydrolases resulted to clinical aspects due to accumulation of substrates in different tissues. since dried blood spot (dbs) is non-invasive, low-cost, easy transportable, acceptable enzyme stability compared to leucocyte and/or fibroblast culture, it's recommended as a first screening test. however the false positive rate with dbs sample is higher compared to other samples. we aimed to investigate any possible effect of leucocyte number on enzyme activity in dried blood samples in a retrospective study. we re-evaluated the lysosomal enzyme activity results in regard to leucocyte number among data within last year. enzyme activities had measured by using fluorometric and lc msms method. we determined the correlations between the lysosomal enzyme activities of alpha glycosidase, glycocerebrosidase, alpha galactosidase, sphingomyelinase, galactocerebrosidase and alpha-l-iduronidase in healthy population (n = ). while glycocerebrosidase and galactocerebrosidase positively correlated with the number of neutrophils, alpha galactosidase, sphingomyelinase and alpha-l-iduronidase positively correlated with the number of lymphocytes. alpha glycosidase activity showed a correlation both lymphocytes and neutrophils. the patients having the glycocerebrosidase enzyme activity which was lower than . nmol/ml/hour (which is accepted as the cut off value to recall the patients) existed significantly lower number of leukocyte, lymphocyte and neutrophil compared to those of patients having higher enzyme activity than . . our data indicated that the enzyme activity in dried blood samples including low leucocyte number might be found lower than reference intervals resulting in false positive diagnosis. therefore we suggest that the laboratory scientists should evaluate the number of leucocyte levels while they were interpreting data. using dna-markers for estimation of genetical variability of two kazakh sheep breeds a. mussayeva , , b. bekmanov , , a. amirgalieva , k. dosybaev , , z. orazymbetova , , r. zhapbasov , a. zhomartov , n. zumadillaev , n. zumadillaev llp "kazcytogen", almaty, kazakhstan, "institute of general genetics and cytology" sc mes, almaty, kazakhstan, branch "scientific research institute of sheep" llp "kazakh research institute of animal husbandry and feed", almaty, kazakhstan to compare the frequencies of different microsatellite loci in sheep breeds subpopulations genomic structure of edilbay and kazakh archaromerinos was investigated. different methods for homogeneity testing of two breeds were elaborated. inter simple sequence repeats (issr) pcr analysis of the breeds studied displayed species and breed specific fragments with different frequencies (population frequency more than . ) there were found rarely met fragments (frequency lower than . ). the combinations of these fragments present the specific issr-spectra which arrange genofond profiles of breeds. using panels of microsatellits (recommended by isag) breeds ( populations) were characterized. informative value and resolving capacity of the sum of str-loci were estimated. wide polymorphism of alleles length was demonstrated both when the breeds were compared and within the breeds. informative markers were chosen for both two breeds, markers being used for both breeds, while other markers were informative for one of the breed only. when the animals of one breed were compared unique alleles which were met only within one of populations were of much interest. for example the allele of bm was met in birlik population of edilbay breed as often as in % of animals while in two other populations there were no this allele. in kumtekey population one can meet % animals having particular locus (dyms ), while in the other population (cf ablay) this locus was not met at all. basing on genetical distances obtained using fragment analysis phylogenetic relationships between populations were estimated. so for example edilbay population of cf ajar has the larger distance from two other populations (birlik and bayserke-agro) than each of them from one another. two subpopulations of kazakh arkharomerinos breed (cf kumtekei and cf ablay) also have the genetical difference. how preeclampsia affects oxidant status and antiinflammatory potential of breast milk? preeclampsia is a pregnancy syndrome associated with hypertension, proteinuria and edema, leading to maternal morbidity/mortality and preterm delivery. in this study we aimed to investigate if the breast milk of preeclamptic mothers is effected in oxidative status and anti-inflammatory activity in comparison to the breast milk of mothers with healthy pregnancies. for the aim of the study, hyaluronidase and myeloperoxidase activities (mpo), total oxidant status (tos), total antioxidant status (tas), oxidative stress index (osi) and tbars levels were measured in breast milks of preeclamptic mothers and mothers with healthy pregnancies as control group. when the control group and preeclamptic group were compared, hyaluronidase activity, tas, tos and osi levels showed statistically significant differences in the preeclamptic group. hyaluronidase activity was significantly higher in the preeclamptic mothers' breast milk ( vs u/ml, p = . ). while tos levels were significantly higher in the preeclampsia group ( . vs . lmol/l, p = . ), the tas levels were significantly higher in the control breast milks ( . vs . mmol/l, p = . ). as expected osi levels (tos/tas ratio) were significantly higher in the preeclampsia group. even though the mean levels were higher in preeclamptic group, the difference in mpo activities and tbars levels did not show statistic significance. oxidant status parameters also suggest that preeclampsia effects in both ways by increasing oxidant status and also decreasing antioxidant capacity shifting the balance to the increased oxidant stress side. as the results showed that the preeclampsia group had higher hyaluronidase activity, this can be interpreted as preeclamptic mothers' milk have higher inflammatory potential as this enzyme enhances inflammation by catalyzing the depolymerization of certain acidic glycosaminoglcans. p-mis- investigation of relationship between postprandial lipemia and erythrocyte membrane cholesterol level postprandial lipemia is a metabolic condition related to an increase in plasma triglycerides. remnant-like lipoprotein particles are predominant in postprandial phase and they play an important role in development of atherosclerosis. cholesterol is a prominent component of erythrocyte membranes and regulates the membrane functions such as viscosity and permeability. free cholesterol derived from erythrocytes is thought to participate in the atherosclerotic plaque formation. in the current study, it was aimed to investigate the relationship between postprandial lipemia and erythrocyte membrane cholesterol level in healthy subjects. study group included subjects ( female and male with age range of - years). then these individuals were divided into three groups according to the values of area under curve (auc) calculated by using triglyceride levels at the fasting state and at nd, th and th hours after the high fat diet (ottt). lipid and erythrocyte membrane cholesterol (emc) values were compared between groups with low and high ottt response. while tc, tg, ldl-c and emc were significantly higher, hdl-c was significantly lower in high ottt response group than low ottt response group. it was not observed any statistically significant difference when compared emc values between women and men study groups. on the other part, it was seen positive correlation between emc and auc (r = . , p = . ), tg (r = . , p = . ), tc (r = . , p = . ), ldl-c (r = . , p = . ) in the total study group. it was concluded that, postprandial lipemia may show atherosclerotic tendency not only with atherogenic lipid profile but also with increasing emc. p-mis- eu-openscreen: the european infrastructure for chemical biology b. stechmann, p. gribbon eu-openscreen, fmp leibniz institute for molecular pharmacology, berlin, germany small molecules that can be applied as chemical 'tool' compounds (or 'probes') have become indispensable in basic research for the elucidation of fundamental biological mechanisms. they act directly with the protein-of-interest and often allow for the interrogation of biological processes that cannot be properly studied with traditional genetic or rna interference approaches. eu-openscreen (www.eu-openscreen.eu) is the largest emerging academic chemical biology research infrastructure initiative in europe and will provide access for molecular and cell biologists to screening infrastructure, well-characterized highquality chemical libraries, and facilities for medicinal chemistry services for compound optimization. molecular biologists who have a robust and suitable biological assay and are interested in collaboratively developing chemical tool compounds to validate their targets-of-interest are welcome to work with eu-openscreen. selected assays are screened against a collection of more than , compounds, incl. confirmatory and counter screening, ic/ec determination, sar (structure-activity relationships) and qc of confirmed hit compounds. eu-openscreen will start operations in , but it can already look back on a growing number of transnational activities: joint screening projects, exchange of local compound libraries, development of new design principles for its compound collection; exchange of experimental data through its pilot database etc. steps towards an arthrobacter nicotinovorans based biotechnology for production of hidroxy-nicotine as the archetypal agonist of nachr, nicotine stands up as a powerful scaffold for developing new alzheimer disease therapeutic agents in form of nicotine derivatives. in this context, arthrobacter nicotinovorans pao and its wide range of nicotinederivatives produced when grown on nicotine have a huge biotechnological potential. indeed, the metabolic intermediate -hydroxy-nicotine ( hnic) produced by a. nicotinovorans pao was shown to bind to the nachrs, and by modulating their function, to sustain spatial memory formation in a rat model of ad. the current work presents the first attempts to produce and isolate hnic by using a genetically engineered a. nicotinovorans strain. the growth and the hnic accumulation were compared for two strains: . a. nicotinovorans pao wild type strain and . a genetically engineered a. nicotinovorans pao strain (part ndh) containing the nicotine-dehydrogenase (ndh) genes cloned in the nicotine inducible part vector. the growth curves were followed spectrophotometrically. the consumption of nicotine and accumulation of hnic were monitored by hplc using a mn nucleodur - c ec column and . m sulfuric acid at a flow rate of ml/minute. the growth curve of the part ndh strain shows that the bacteria grow slower when compared with the wt. as a result, in the wt strain, the nicotine is quickly depleted from the medium and only low amounts of hnic are observed. although the sds-page analysis of the total protein extracts from the part ndh strain did not show clear signs of ndh overexpression, the enzyme is produced and is active, allowing a fold accumulation of hnic in the growth medium. the first attempts to purify ndh from the part ndh strain using imac were nevertheless unsuccessful. in conclusion, using the part ndh strain for hnic production is feasible. further improvements of the growth condition and strain are envisioned (i.e. knocking the ndh downstream genes; adding inhibitors for the downstream enzymes). studies on the impact of butyrylcholinesterase (bche) on the symptoms and progression of cognitive impairments like alzheimer's disease (ad) or other neurodegenerative disruptions speak in favour of selective bche inhibitors as a new approach in future ad pharmacotherapy. some derivatives of quinine and quinidine, present in the cinchona species bark, have already been identified as selective bche inhibitors with respect to acetylcholinesterase (ache); therefore, further investigation of these compounds might result in promising leads for enhanced anti-ad drugs. we synthesised ten quaternary derivatives of cinchonines and their corresponding pseudo-enantiomeric cinchonidines. quaternization of quinuclidine moiety was carried out with groups diverse in size: methyl and differently meta and para substituted benzyl groups. all of the compounds were prepared in good yields, characterized by standard analytical spectroscopy methods, and were tested for their bche and ache inhibition potency. the inhibition potency of the compounds was defined by the dissociation constants of the enzymeÀinhibitor complex (ki). all of the tested compounds reversibly inhibited both human bche and ache. the compounds inhibited bche with ki constants in the range of . - lm, and ache in the range . - lm. five cinchonidines displayed a - times higher inhibition selectivity to bche over ache, and four of them were potent bche inhibitors with ki constants up to nm. bche affinity toward the studied compounds depended on the size of the substituent on the nitrogen of the quinuclidinium part of the molecule and on the resonance stabilization of the substituent at the quaternized nitrogen. based on the presented results, cinchonidine cd-(pbr) can be pointed out as a potent and selective bche inhibitor that could be considered for further research in alzheimer disease pharmacotherapy. exposure to nmda ( lm) for h increased the expression of kir . mrna and decreased that aqp -and gs mrna. the expression of kir . was decreased by h exposure to glu ( mm) and tnfa ( ng/ml). at h incubation, nmda induced a decrease of kir . expression in the presence but not in the absence of calcium in the medium. nmda did not alter the expression of nmda receptor subunits. tnfa increased the expression of the nr subunit, and decreased that of nr b mrna. glu decreased the expression of out of subunits. the study demonstrates, to our knowledge for the first time, that prolonged exposure of astrocytes to nmda alters the expression of mrna coding for critical astrocytic proteins. the dependence of the decrease of kir . mrna expression on extracellular calcium suggests the ionotropic nature of nmda receptor stimulation. the effects of nmda receptor stimulation occurred by a mechanism bypassing changes in subunit composition of the nmda receptor. experiments are under way to establish whether the tnfa-induced changes in the expression of nmda receptor subunits contribute to modulation of nmda receptor stimulation by inflammation. the importance of education in reducing preanalytical errors the preanalytical phase includes the request of test, the preparation of patient, the obtaining of sample from the patient, the transport of the sample to the laboratory, and the pretreatment of sample. the preparation of patient and the obtaining of sample are considered as the most common error sources. in order to reduce preanalytical errors, we aimed to provide training for phlebotomists and to also determine their knowledge level about the preanalytical phase before and after these training. it was given the training related with preanalytic phases to pediatric nurses and adult nurses, other phlebotomists in march. the surveys which are made before and after the training were consisted of questions that are related with demographyic features and preanalytic phases. in order to determine the effects of training to the preanalytic phase, the preanalytic error rates before (in february) and after (in april) traning was calculated with the formula of: (the number of rejected samples/the number of total samples)x . the average age of participants was ae years. it was not found significant difference between their correct answers rate before the training and the education degree of the participants. the correct answer rate before the training was % and after the training it was %, which showed an increase of %. the preanalytic error rates which were . % in february were decreased to . % in april. in our study, the positive results were obtained through the training aimed to reduce the preanalytical errors. by providing regular training to the phlebotomists and also providing pretraining to the beginners, the updating of their information about preanalytic phase can be achieved. in this way, the loss of labor and economic related to preanalytical errors can be avoided and the accurate results can be obtained in short time. curcumin, the active compound of turmeric (curcuma longa) has antiinflammatory, antioxidative and antitumour effects. unfortunately, curcumin has a poor absorption and low stability. both can be solved by encapsulation of curcumin using a proper technique like electrospray. it was reported that piperin, the active compound of black pepper, enhances the intestinal absorption of curcumin and thus its bioavailability. due to these facts it was aimed in this study to nanoencapsulate turmeric extract in order to enhance its absorption and stability. for that purpose, it was encapsulated with the maize protein zein, chitosane and black pepper extract by varying the voltage and flow rate of electrospray and the concentration of the compounds. the nanocapsules were characterised by measuring their particle size and with help of sem photographs. the particle size of the final nanocapsule formulation was nm and had a sufficient stability over a period of months, visually determined. by encapsulating turmeric extract into double layer nanocapsules with help of black pepper extract, zein and chitosane, the turmeric extract could be protected from degradation, which was observed for the pure turmeric extract in form of clearing its yellow colour. analysis of the human genome reveals that potential g-quadruplex sequences are enriched in promoters of the oncogenes. growing body of evidence suggests that g-quadruplexes (g ) may play putative roles in various biological processes, such as the regulation of gene expression. consequently, targeting the oncogenic g-quadruplexes using small molecules is an alternative strategy for the potential treatment of cancers. porphyrin derivatives are promising class of drug in this respect, being nucleic acids binders and generators of reactive oxygen species under visual light irradiation. interaction between porphyrin derivatives and g dna from oncogene promoter region has been studied in vitro. we applied chemical probing, circular dichroism spectroscopy and uv melting techniques in order to map the oxidized bases, monitor structural rearrangements and evaluate stability of the resulting dna structures. specifically, we observed that g dna is considerably more susceptible to lightinduced modification than duplex dna; -terminal tetrads of the g dna are preferably oxidized; structural changes induced by oxidation result in decrease of the thermodynamic stability of the g dna. irreversibility of these effects on dna make porphyrin derivatives perspective lead compounds for rational design of ligands targeting human oncogenes. the study was financially supported by project no. - - from the russian science foundation. resistin levels in denervated obese rats n. saglam , t. ahmedi rendi , c. kahraman , a. alver department of medical biochemistry, faculty of medicine, karadeniz technical university, trabzon, turkey, school of health, d€ uzce university, d€ uzce, turkey the sympathetic nervous system is an important factor affecting the metabolic and secretory function of the white adipose tissue. resistin is mainly expressed by mononuclear cells, also it is expressed by adipocytes, pancreatic cells, and muscle. resistin induces insulin resistance and glucose intolerance in mice. resistin plasma levels depend on fat depots size and sex. resistin levels decrease in short-term fasting in mice, then it increase refeeding. also, it increase as a response to fed with the high fat diet. in our study we aimed to determination of the effect of high-fat diet and denervation on serum resistin levels in rats. in this study experimental groups were formed each consisted of rats. during weeks, first two groups are fed with high-fat diet and other two groups are fed with standart diet which they purchased from research diets company. at the beginning of the feeding periods, retroperitoneal fat tissiues of animals assigned to the first and the third groups were denervated. second and fourth groups were not denervated. at the end of the week feeding periods, blood collected from rats and blood resistin concentration was determinated by elisa. in denervated and fed with high fat diet groups serum resistin levels higher than control groups (p < . ). according to our literature research, there are no studies demonstrating the relationship between resistin and the sympathetic nervous system. also, denervation may lead to increase in serum resistin levels. the amount of resistin is possibly reduced by b -adrenergic activation. in conclusion, it was concluded that there is differences on serum resistin levels depending on diet in bilateral denervation of retroperitoneal fat tissues of rats. stress activated protein kinases regulates the ribosomal frameshift rate in est gene, encoding subunit of telomerase s. t€ urkel, s. sarica uludag university, bursa, turkey est gene (ever shorter telomere) of s. cerevisiae encodes one of the essential subunits of telomerase enzyme. expression of est gene is regulated at the translation level by + programmed ribosomal frameshift (prf). it is known that the physiological stresses affect telomere length. in this study, we have investigated the effects of stress activated protein kinases snf p (ampk) and gcn p (eif kinase) on the prf rate in est gene. prf rate of est gene was quantified in plasmid based expression system. expression vectors were transformed in to the wild type and mutant yeast strains that deleted for snf , or gcn genes. yeast cells were grown in normal conditions or subjected to acid stress, osmotic stress, or glucose limitations to activate protein kinases gcn p, and snf p, respectively. prf rate of est gene was measured as % in the normal growth conditions in the wild type cells. but, the prf rate of the wild type strain grown in glucose limited conditions decreased more than -fold, giving less than % prf rate. contrary to glucose limitation, osmotic or acid stress activated frameshift rate by -fold in the wild type cells and prf rate increased to %. when the prf rate was analyzed in gcn and snf mutants, frame shift rate of est was - % in normal growth conditions. when these mutants were subjected to acidic or osmotic stress, prf rate activated slightly. we have also shown that gcn p and gcn p, positive regulator of gcn p, is also essential for the regulation of prf in est in response to stress conditions. it is clear that the basal level expression of est is highly dependent on the gcn p kinase complex. gcn p is also associates with ribosomes, indicating that gcn p might have a significant function in connecting the stress signals to biosynthesis of the full length est peptide. this regulation might also link the biosynthesis of functional telomerase and telomere replications to cell physiology through protein kinases such as snf p and gcn p. inflammation might have a role in erosive esophagitis but not in non-erosive reflux disease the relationship between inflammatory activation mechanisms and acid-peptic injured esophageal tissue is not clear. we evaluated whether there are differences between inflammation and tight junctional proteins such as e-cadherine among subtypes of gastroesophageal reflux disease. the aim of this study was to investigate any possible role of inflammation in pathologic mechanism of reflux disease by determining the inflammatory markers in injured esophageal tissue as well as serum of patients. three groups (erosive-ee, n = ; nonerosive-nerd, n = ; healthy controls-hc, n = ) were evaluated with upper gastrointestinal endoscopy. the esophageal biopsies and blood samples were collected. serum e-cadherine levels, nfkb, chitotirosidase (chit), myeloperoxidase (mpo) activities in serum and homogenized tissues were determined. nkfb levels in tissue was significantly higher in subjects with ee ( . ae . ng/mg.prt) versus hc ( . ae . ng/mg.prt, p = . ). mpo tissue activities in ee group were significantly lower ( . ae . u/mg.prt) than hc ( . ae . u/mg.prt, p = . ) while mpo serum levels were higher in ee ( . ae . ul) versus hc ( . ae . ul, p = . ). tissue chit levels were three fold increased in ee versus hc (p = . ). none of these measurements showed any differences in nerd group. nfkb and mpo levels had a negative correlation (r=À . , p = . ) in tissue. nfkb and ecad levels had a positive correlation in serum (r = . , p < . ). inflammatory process might play a pivotal role in injured mechanism only in erosive esophagitis but not in nerd. noninflammatory mechanisms might be responsible such as hypersensitivity in patients with non-erosive reflux disease. d-dimer (a fibrin degradation product) test is used to aid in the diagnosis of intravascular coagulation. the aim of this study is to investigate the correlation between d-dimer levels and other inflammatory markers including procalcitonin. anonymized data on d-dimer, fibrinogen, hscrp, wbc, neutrophil% (neut%) and procalcitonin levels from , patients (mean age ae sd, . ae . ) were used for the correlation (excel analyze-it v . . ) and linear regression (pasw statistics v . ) analysis between the measured parameters. there was a significant (p < . ) age-dependent increase in d-dimer levels between different age groups. patients with the highest d-dimer levels were also found to have an increased frequency of hscrp levels. d-dimer levels showed a significant correlation with hscrp, wbc and neut%. a model describing the positive association between these parameters were built. the resulting equation is as follows: d-dimer = (hscrp* . ) + ( . *age) + ( . *wbc) + ( . *neut%)À . . correlation analysis between procalcitonin and d-dimer levels gave pearson's correlation coefficient of . . our results suggest that the age-dependent variations should be taken into account while interpreting d-dimer test results. in addition, neut% ratio was found to be the most important parameter for estimating d-dimer levels. our equation can be used when the d-dimer test is not available or for control purposes only. in the field of cancer research great hope lies in finding more powerful and selective way for the direct elimination of cancer cells. this task can be solved by means of nanobiotechnology. recent progress in this field has arisen interest in a carbon nanostructurefullerene c . fullerene exhibits not only unique physico-chemical properties and biological activity but also a significant potential to serve as a nanocarrier for selective drug delivery into cancer cells. the aim of this study is to analyze a unique tool for cancer therapy. the main idea is realized by the non-covalent conjugation of c with the well-known anticancer drug -doxorubicin (dox). two types of conjugate with different c -dox ratio ( : and : ) were studied. conjugates absorbance and fluorescence, size distribution as well as a mass data were recorded utilizing optical and analytical equipment (microplate reader, zetasizer, lc-ms/ms and maldi-tof). in vitro studies were performed including evaluation of c -dox conjugate effects on human leukemic cells (jurkat, ccrf-cem, thp ad molt- ) viability. conjugates accumulation and distribution within cancer cells was monitored using fluorescent microscopy accompanied with fluorescence-activated cell sorting. it was evidently proven that both c -dox conjugates were stable and could be used as reliable candidates for biological application. cellular accumulation and distribution studies showed that conjugation of dox with fullerene promoted its entry into leukemic cells. accumulation of dox in the form of conjugates within cancer cells was intensified compared to the free drug. the results show that conjugated dox is more cytotoxic and the value of its ic are lower compared with the free dox. obtained results confirm nanocarrier function of fullerene c and the perspective of its application for optimization of doxorubicin efficiency against leukemic cells. comperative investigation of protective effects of tea and tea-related wastes on reducing potaential of h o -induced erythrocytes tea processing waste (tpw) formed during the tea production process in tea factories is up to , tones/year in turkey. tpw is one of the abundant available phenolic biomass among plantal wastes. in this study, black and green teas and their wastes were used. the aim of the study is to determinate the phenolic content and the radical scavenging activities of the samples, and to measure their effects on hydrogen peroxide-induced erythrocyte damage due to analyzing the reducing potential of erythrocyte involving glutathione reductase (gr), glutathione peroxidase (gpx) activities and reduced glutathione (gsh) content. total polyphenol content of samples was determined as mg catechine per dry mass by using folin-ciocalteau reactive and dpph radical scavenging activity was estimated by cuendet method as equivalent catechine standard. in erythrocyte, gsh level was measured by method of sedlak and lindsay while gr and gpx activities were assayed by the methods of bergmeyer and beutler, respectively. the highest phenolic content was observed in green tea and its wastes (p < . ) whereas black fiber waste had the lowest phenolic content. therefore, the highest radical scavenging activity and gsh level were detected in green tea and its wastes (p < . ). erythrocyte with the extracts of the teas and their wastes had the similar enzyme activities for both gpx and gr. in sum, the teas and wastes have antioxidant activity but, green tea and its leaf waste hade higher antioxidant activity than other samples. the tea wastes might be evaluated as many of protective health products, particularly in cosmetic fields thus, these by-products no application for any area is expected to become an economical value. fluorouracil ( -fu) is a chemotherapeutic drug classified as an "antimetabolite". it works through irreversible inhibition of thymidylate synthase. chemical derivatization of -fu with carbohydrtates is being investigated widely in order to enhance its bioavailability, therapeutic efficiency and to reduce its toxicity. however, water solubility of the newly derived compounds is usually very low. so, in order to obtain a pharmaceutically relevant formulation they need to be formulated appropriately. in this study, we prepared micellar delivery system for the new tetra-o-acetylglycose derivative of -fu synthesized via "click reaction", namely f -[{ -( ″, ″, ″, ″-tetra-o-acetyl-b-dglycopyronosyl)- h- , , -triazole- -yl}methyl] -fluorouracil. since the water solubility of this compound is very limited, we tested its solubility in several pharmaceutically relevant solvents by visual estimation after stiring increasing amount of the compound in ml of solvent for h. to estimate the carcinogenic potential of this compound, salmonella/microsome mutagenicity assay (ames test) was performed in four histidine-requiring strains of s. typhimurium, tester strains ta , ta (for the detection of frameshift mutations) ta and ta (for detection of base pair substitutions) according to the oecd guideline . the drug was solubilized ( lg/ml) with no precipitation in lutrol Ò -f /ethanol/water ( . : . : . , wt/wt) micelles ( . ae . nm). the results of ames test were negative so the compound neither produced frame shift mutations nor base pair mutations in s. typhimurium strains. the results imply that the new compound can be dissolved in aqueous micellar delivery system in order to be used for further studies, and that it was not mutagenic in the tested s. typhimurium strains. in conclusion, the formulation of the newly synthesized compound is not carcinogenic, and can be evaluated for anticancer activity in vitro and in vivo. integral metabolism parameters of dairy goats during reproductive cycle periods d. solovyeva, e. zarudnaya, s. zaitsev moscow savmb, moscow, russia study of the goat metabolism at different periods of the reproductive cycle allows to correct feeding ration, to increase the age of the productive use of animals and to receive high-quality products. the aim of the work was to determine the metabolic parameters of blood serum of goats, expressed in terms of biochemical parameters and interfacial tensiometry and study their relationship to metabolic processes in the body goats depending on the age and the period of the reproductive cycle. the healthy goats were divided into groups. the dynamic surface tension (dst) parameters were obtained from dependences of a surface tension (r) vs. time (t): at t? (r ), at t = . s (r ), t = s (r ) and t?∞ (r ). this work was supported by the russian scientific foundation ( - - ). all animals had - % fat content. the contents of total protein ( . %), albumin ( . %) and urea ( . %) are higher for the lactating animals as compared to the normal goat values. the levels of total cholesterol ( . %) and creatinine ( . %) are higher for the lactating animals. in lactating animals have the highest level of, which along with high phosphorus level talks about the intensification of energy processes during lactation. the correlations were found between the biochemical and dst parameters of the goat blood: lipids or cholesterol levels with r (r = À . ), r (r = À . ), r (r = À . ); total protein or albumin levels with r (r = À . ), r (r = À . ), r (r = À . ); aminotransferase activity with r (r = À . ), r (r = À . ). the correlations were found between the total protein and albumin levels with k (r = . ), k (r = . ); glucose levels and r (r = . ), r (r = . ). thus, the dst and biochemical parameters of goats have strong correlation relationships that are important for biomedical and veterinary applications. the relation of the severity of atherosclerotic disease with oxidative stress in patients with stable coronary artery disease h. sezen harran university, sanliurfa, turkey introduction: because, to the best of our knowledge, the relationship of total oxidant status (tos) and total antioxidant status (tas) with the severity of stable coronary artery disease (cad) has not been investigated in the literature so far, the present study was conducted to address this issue. materials and methods: this study consisted of consecutive patients and controls who underwent coronary angiography. for each patient, the total gensiniscore (gs) was calculated andthose with a gs of > were classified as the high gs group (hgg), and those with a gs less than were defined as the low gs group (lgg). the total oxidant status (tos) and total antioxidant status (tas) levels were measured using the erelmethod. the osi, which is an indicator of the oxidative balance, was calculated as the percentage ratio of tos to tas. results: the tas was lower in the hgg than lgg. the tos and osi were higher in the hgg than lgg. the correlation analysis showed that gs was negatively associated with the tas and positively with the tos and the osi. the multivariate analysis showed that age, tos, and hdl-c were independent variables for a high gs. the cut-off level of . lmol h o equiv./ l for serum tos levels predicted high gs with a sensitivity of % and a specificity of %. discussion: information on the severity of atherosclerosis is requiredtopredicttheprognosis of an individualpatientandtodetermine the proper treatment modality. the gs system has beenproventodemonstratethe severity of atherosclerotic disease. inthepresentstudy, thepatientswith a high gs had increasedlevels of oxidants. inaddition, tos was an independentindicator of theseverity of atherosclerosis. the optimal cut-offvaluefor tos topredict high-gens score was . (sensitivity % and specificity %). conclusions: the results suggest that the severity of atherosclerosis in stable cad is associated with increased oxidative status. evaluation of roemerine as a multidrug resistance pump inhibitor f. g. avci , c. velioglu , e. recber , c. unsal , g. gulsoy , b. sariyar akbulut marmara university, istanbul, turkey, istanbul university, istanbul, turkey efflux by multidrug resistance (mdr) pumps is a common defense mechanism used against antimicrobials. by pumping the drugs out, these pumps significantly reduce the efficacy of drugs. one approach to overcome this limitation is offered by the combinatorial therapies where drugs are co-administered with together with pump inhibitors. by simply preventing the efflux of the drug, the presence of inhibitors enhance drug efficacy. (-)-roemerine is an aporphine type alkaloid with significant antibacterial (against bacillus cereus, escherichia coli) and antifungal (against candida strains) activities. interestingly, (-)-roemerine was also found to enhance the cytotoxic response mediated by vinblastine in multidrug-resistant kb-v cells. in the same study, this finding was linked to its possible interaction with p-glycoprotein, a eukaryotic mdr pump. taking this finding as the starting point, the current study investigates the potential of roemerine as an inhibitor of the p-glycoprotein homologue pump, bmra, in bacillus subtilis . the antimicrobial agent berberine was used as the model agent since its efficacy is reduced by efflux through mdr pumps. to this end, bacillus subtilis cells were subjected to lg/ml berberine, a value well below the mic. this concentration only slightly retarded growth for hours but then cells resumed their regular growth. upon addition of lg/ml (-)-roemerine to the bacillus subtilis cells treated with berberine, growth pattern changed, indicating possible interaction with bmra. further investigation for the change in the expression of bmra was achieved with real time pcr analysis. glucose oxidase is an enzyme that catalyzes the oxidation of glucose to d-glucono- , -lactone and hydrogen peroxide. we hypothesized that enzyme would cause a double negative effect on cancer cells, by reducing the presence of glucose in cancer microenvironment and producing reactive oxygen species. to increase enzyme stability and enhance cellular uptake we encapsulated the enzyme with a thin acrylamide layer. the purpose of this work was to optimize the synthesis of these glucose oxidase nanoparticles and investigate their effect on cancer cells. nanoparticles containing single glucose oxidase were synthesized in two steps; first by introducing the vinyl groups onto the surface of enzyme by acyloylation followed by polymerization step with acrylamide monomers. encapsulated enzymes are approximately nm in size and retain most of their activity. after the optimization of nanoparticles, the anticancer potency of these nanoparticles was in vitro tested in mcf- breast cancer cell line. according to results, both nanoparticles and free enzyme are capable of inhibiting viability of cancer cells in a similar manner at very low concentrations. currently we are investigating mechanisms involved in this viability inhibition. initial results demonstrated that glucose supplement does not rescue cells from death induced by the activity of glucose oxidase, suggesting an oxidative stress related cause of inhibition. further studies are required to elucidate the exact mechanism. until now there is no determined advantage of glucose oxidase encapsulation against proteolysis. however, encapsulation may induce the accumulation of enzyme in cancer microenvironment. furthermore results suggest that glucose oxidase has a high effect on the viability of mcf- breast cancer cells indicating that this enzyme may have a potential use in cancer treatment. studies on the interaction of human phospholipid scramblase with c-terminal domain of topoisomerase iia u. sivagnanam, s. n. gummadi applied and industrial microbiology lab, bhupat and jyoti mehta school of biosciences, indian institute of technology madras, chennai, india human phospholipid scramblase (hplscr ) is a multifunctional protein that plays key roles in several cellular processes including apoptosis, tumorigenesis, anti-viral defense, cell signalling and several protein-protein interactions. it has been shown that hplscr interacts with the c-terminal domain of topoisomerase iia (topo iia) and enhances its decatenation activity in vitro. the interacting region in topo iia was identified but till date, no reports exist on the binding region in hplscr . this study aims to identify the region of hplscr that interacts with topo iia. to identify the topo iia interacting sites in hplscr , nterminal deletion constructs of hplscr viz Δ -hplscr , Δ -hplscr , Δ -hplscr , Δ -hplscr and Δ -hplscr were generated by pcr, cloned, overexpressed and purified to homogeneity using ni + -nta purification. the cterminal domain (ctd) of topo iia was cloned in pgex p- and was expressed as a gst fusion protein. gst pull down assays will be performed with the deletion constructs of hplscr and the gst-ctd-topo iia. the binding region in hplscr will be confirmed by peptide competition assays. our initial results show that the decatenation activity of topo iia was enhanced when the topo ii was pretreated with hplscr . Δ -hplscr did not show any enhancement of the decatenation activity compared to full length hplscr . hence, the binding region could be in the - region of hplscr . further deletions were done in the - region of hplscr as described earlier. gst-pull down assays and decatenation assays will be performed for the deletion constructs to narrow down the region of hplscr that binds to topo iia. we conclude that hplscr interacts with and enhances the activity of topo iia and the - region of hplscr is critical for enhancement of decatenation activity. further work is under progress to identify the exact topo iia binding region of hplscr and the physiological relevance of this interaction in the cell. a. ugur kurtoglu , v. aslan , e. kurtoglu department of biochemistry, antalya education and research hospital, antalya, turkey, department of hematology, antalya education and research hospital, antalya, turkey beta-thalassemia is a common autosomal recessive disorder resulting from over different mutations of the beta-globin genes. our aim was to creat a mutation map of beta thalassemia in province of antalya, turkey. in this study, mutation analysis of a total of beta-thalassemia patients followed up at the thalassemia center of the antalya education and research hospital, antalya, turkey, were included. according to our results, the ivs . is the most frequent mutation type in our province same as other geographical regions of turkey. the most frequent mutations in heterozygous or homozygous patients are ivs . , ivs . , ivs . and ivs . . our results indicate the importance of micromaping and epidemiology studies of thalassemia, which will assist in establishing the national prevention and control program in turkey. keywords: beta-thalassemia, beta-globin gene, mutation p-mis- investigation of the in vitro effects of some antibiotics on the purified beta-glucosidases from the rat liver n. t€ urkmen , h. kara karadeniz technical university medical biochemistry department, trabzon, turkey, balikesir university veterinary faculty biochemistry department, balikesir, turkey beta-glucosidases catalyzes the hydrolysis of the glycosidic bonds to terminal non-reducing residues in b-d-glucosides and oligosaccharides.b-glucosidases are widely distributed in the living world.b-glucosidases which in mammals, primarily found in the liver and kidneys;lysosomal b-glucosidase (gba ),non-lysosomal b-glucosidase (gba ), cytosolic b-glucosidase (gba ),intestinal lactase-phloriz the hydrolase (lph). liver tissues of wistar-albino rats were homogenized with homogenizer in the extraction buffer and crude extract was obtained after centrifugation.ammoniumsulfate precipitation range designated crude extract was purified by sepharose b-ltyrosine- -naphthylamine hydrophobic gel.commercially availabled antibiotics were prepared with substrate buffer.it was investigated inhbition effects of cefuroximesodium, ampicillin-sulbactam, amoxicillin trihydrate/potassium clavulanate, cefazolin sodium, gentamicin sulfate and ceftriaxone disodium antibiotics onto gba .inhibition types and k i values of related antibiotics were determined with p-npg substrate.lineweaver-burk plot was used for that purpose. rat liver gba was purified at . -fold with . % yield.gba was illustrated and kda at sds-page.ic value of ampicillin/sulbactam antibiotic for gba was found . mg/ml with competitive type inhibition and other antibiotics didn't inhibit. purfication methods are being used in the literature for the purified b-glucosidase from different sources.purified gba was illustrated and kda at sds-page.about molecular weight of bglucosidases is presented different information in the literat€ ure. this has been reported because of acid beta glucosidases are abnormal migration at the acrylamide or agarose gels.it was investigated inhbition effects of various antibiotics onto purified gba .ampicillin/sulbactam antibiotic inhibited to purfied gba at the competitive type.similiar antibiotics studies have been made in the literature for different enzymes. effect of glutamine on insulin resistance and endoplasmic reticulum stress g. aydogdu , p. b. sermikli , a. abbasi taghidizaj , e. yilmaz ankara university, institute of science, ankara, turkey, ankara university, biotechnology institute, ankara, turkey obesity and diseases are one of the most important public health problems of the world.excess fat storage in adipocytes leads to the release of increased amounts of non-esterified fatty acids, glycerol, hormones, cytokines, which are factors involved in the development of insulin resistance that cause type diabetes. one of the major differences between obese and lean individuals is the amino acid concentration in the circulation. although there are many studies about the amino acid metabolism associated with insulin resistance in obese individuals, the effect of glutamine metabolism in insulin resistance mechanisms are not well understood yet. glutamine can be used as fuel and its levels in tissues and circulation can regulate cell responsiveness to insulin and cellular metabolism. therefore, glutamine is a potentially important factor that might help us better understand insulin resistance and type diabetes. to determine whether glutamine effect on insulin resistance and endoplasmic reticulum stress, t -l cell is treated with different concentration of glutamine and analyzed by western blot for er stress markers. our results indicated that glutamine reduced endoplasmic reticulum stress and related with that attenuated insulin resistance. in case of transport of amino acids, insulin resistance, how it is affected when we have the information about the important tips on energy requirements and metabolism reach insulin resistance and type- diabetes treatment is likely to reveal a possible new targets. how does different lead levels affect tsh, ft , ft , vitamin b and folate? e. ozkan ankara occupational disease hospital, ankara, turkey exposure to heavy metals is increasing with the industrialization of society. one of the most intense exposure to heavy metals is pb on this issue. this study was aimed to determine the relationship between different blood pb levels and serum thyroid hormones (th), vit b , folate. the cases were - years old, male individuals who admitted to our hospital between april -march for periodic inspections because of occupational exposure to pb. the parameters of the cases were retrospectively retrieved. according to their pb levels, exposed workers (n: ) were divided into four subgroups; group (g) : - . lg/dl, g : - . , g : - . , g : ≥ . from these, the number of cases whose th levels were measured (n: ) given respectively; g : , g : , g : , g : cases. also the number of cases whose vit b and folate levels were measured (n: ) given respectively; g : , g : , g : ,g : cases. levels of pb were determined by icp-ms. th, vit b , folate were determined by cmia. between the groups formed according to pb levels, there was no significant difference in terms of average t , tsh and vitamin b (p > . ). on the other hand there was statistically significant difference between t and group , , (p < . ) but there was no difference between group (p > . ). the average folate belongs to the first group was about % higher than the other groups, and found that the difference was statistically significant (p < . ). there are many publications which have various results between pb levels and t ,t , tsh. but this study is important to compare the effect of different levels of pb. up to day there was no publication about the relation between different pb levels and vit b , folate. it was seen that there was no significant clinical relation between different pb levels and thyroid parameters, vit b . but the low levels of folate in the high pb levels groups shows us that we need further studies about this relationship. fluorescent study of in meso crystallization of membrane proteins with the introduction of membrane protein in meso crystallization years ago by landau and rosenbusch, a new era of membrane protein structural research has emerged ( ). since that time this method became associated with a number of major breakthroughs in the field ( ) including exceptional successes in structural studies of microbial rhodopsins and g-protein coupled receptors ( ) . here we used fluorescence microscopy to study in meso crystallization process of bacteriorhodopsin. several observations provide new insights into the in meso crystallization process. the crystallization starts with formation of microcrystals, followed by growth of a dominating crystal at the expense of smaller ones and formation of a depletion zone around it. these observations demonstrate an ostwald ripening mechanism of the in meso crystal growth. the depletion zone formed around the growing crystal is consistent with the previously proposed analogy relating in meso crystallization with the crystallization in a microgravity convection-free environment. this work is supported by rsf - - . ( ) landau, e. m.; rosenbusch, j. p. proc. natl. acad. sci. u. s. a. , , À . ( ) caffrey, m. acta crystallogr., sect. f: struct. biol. commun. , , - . ( ) katritch v., cherezov v., stevens r.c. ( ) . annu rev pharmacol toxicol , - . p-mis- stamp is critical for both ar and mtor signaling in prostate cancer cells x. sheng, y. jin, f. saatcioglu university of oslo, oslo, norway androgen receptor (ar) signaling plays a central role in the initiation and progression of prostate cancer (pca), including when the disease progresses to castration-resistant pca (crpc). the second central signaling pathway in pca, similar to various other cancers, is the pi k-akt-mtor signaling. importantly, these two oncogenic pathways cross-regulate each other in pca cells by reciprocal feedback, thereby maintaining tumor cell survival even when one is suppressed. we have previously identified that the six transmembrane protein of prostate (stamp ) promotes pca cell proliferation as well as inhibits apoptosis through, at least in part, regulating the erk mapk signaling. human pca cell lines lncap and vcap were used in the study. colony formation, soft-agar growth, prostatosphere formation assays were performed. for in vivo xenograft experiment, the cells were implanted subcutaneously into the flanks of nude mice. here, we show that stamp knockdown caused defects in colony formation, anchorage-independent growth and prostatosphere formation in lncap and vcap cells both in vitro, as well as tumor formation and growth in vivo. this may be due to the impaired ar and mtor signaling in these cells upon stamp knockdown. interestingly, in the crpc cell line rv , where-stamp knockdown did not affect mtor signaling, there was a remarkable repression of tumor take rate and growth. these results clearly indicate that stamp is essential for both ar and mtor signaling, and is crucial for pca growth in vitro and in vivo. however, the detailed molecular mechanism requires further investigation. taken together, these data unveil a critical role for stamp in coordinating the ar and mtor signaling pathways in pca cells, solidifying the basis for its pro-survival effects in pca, including in advanced disease. quantification of d thin layer chromatograms using d gel analysis software and gel documentation system o. kaynar, m. ileriturk, d. kaynar, s. kurt ataturk university, erzurum, turkey introduction: thin layer chromatography (tlc) is an important chromatographic technique that is widely used as a cost-effective method for rapid-sensitive analysis of compounds in plants, animals, and humans. however, one dimentional ( d) tlc is not sufficient for the separation of complex compounds. therefore, two-dimentional ( d) tlc was developed. the quantitative evaluation of plates are performed with tlc scanners or documentation systems. however, these systems specific for d plates, and cannot be adapted to quantitative evaluations of d plates. in this study, the applicability of the gel documentation systems and d analysis software for the analysis of d tlc plates were examined. material and method: d tlc of lipids: st dimension: methyl acetate/n-propanol/chloroform/methanol/ . % kcl ( / / / / v/v); nd dimension: chloroform/methanol/acetic acid/ water ( / / / v/v); detection: charring. d tlc of aminoacids: st dimension: . % (v/v) formic acid; nd dimension: toluene/glacial acetic acid ( : v/v); detection: uv. phospholipid and aminoacid standards, each include different classes were developed by d tlc. plates visualized with biorad geldoc xr, and band volumes on plates were calculated with biorad pdquest d gel analysis software. for the method validationa) plates containing same lipid classes were developed in the same day, and results were used for the calculation of intra-assay cv;cv% = average of each sample standard deviation/mean of sample b) plates containing same lipid classes were developed in different days, and results were used for the calculation of interassay cv; cv% = standard deviation of each sample average/mean of the plates results: volume of each phospholipid and aminoacid had less than % intra and inter-assay cv. conclusion: gel documentation system with d gel analysis software can be used for the quantitative analysis of the d tl plates both at uv and visible light. the role of na + k + atpase activity in the vasodilatory effect of n-acetylcysteine introduction: spasm occurred at the stage of and after the preparation of arterial grafts used in coronary artery bypass surgery (cabg) is effective on morbidity and mortality in the first hours of postoperative patients. n-acetyl cysteine (nac) that vasodilatory effect is known,may be considered as a suppressor agent for vasospasm developing during cabg. however, for the prevention of complications that may arise during or after cabg mechanism of these vasodilatory effects should be described. this study was aimed to investigate the role of atpase enzyme on the vasodilatory effect of nac. materials and methods: in this study, adult male wistar albino rats were used. rats were separated into four groups as control rats (g ), mm nac (g ), mm nac (g ) and mm nac (g ). a portion of the thoracic aorta isolated from rats was used for the relaxation response recording, and the other portion was used for measurement of nakatpase activity. isolated smooth muscle rings are suspended in the ml organ bath containing krebs solution for relaxation responses. in all groups, level of smooth muscle contraction were allowed to reach a plateau by adding mm kcl to the organ bath. then, in the first minutes of application relaxation responses which created by adding nac to the medium were recorded and the maximum relaxation responses were measured. nak atpase activity was determined using the mazzanti method. groups means were compared by one-way analysis of variance (anova). the threshold for statistical significance was set at . . results: the contraction force decreased in all nac dose groups compared to control group and this reduction was statistically significant (p < . ). similarly, nak atpase activity is also decreased in a dose dependent manner (p < . ). the findings obtained in this study suggest that vasodilator effect of nac formed in thoracic aortic smooth muscle was associated with the activity of the enzyme na k atpase. in the presented study, we isolated and characterized a novel feather-degrading bacterium that shows keratinolytic activity. a bacillus uk , which was isolated from the soil samples taken from farmland on kahramanmaras sutcu imam university campus, showed high keratinolytic activity when cultured on feather meal medium. the enzyme activity was studied in the ph range of . - . . the optimum temperature for keratinase activity was investigated by varying the incubation temperature between °c and °c. optimum keratinolytic activity was observed at °c and ph . . the enzyme was stable at °c. the activity was investigated in the presence of some chemicals, including sds, tween , dmso, triton x- , edta, nacl, zncl , cacl , glucose. the keratinolytic activity was inhibited by all chemicals tested to some degree. the molecular weight of keratinase was determined by polyacrylamide gel ( %) using standard molecular weight marker and estimated about kda by sds-page. the keratinase isolated from bacillus uk could be used in biotechnological processes i.e. feather degradation, wastewater treatment and in industrial processes, such as detergent, food and leather industries. introduction: hemoglobinopathies, including thalassemia, abnormal hemoglobins, constitutes a major group of inherited disorders of hemoglobin synthesis. the reduced or absent of the beta (b) or alpha (a) globin chains of the adult human hemoglobin molecule results beta or alpha thalassemias, leading to imbalanced a-globin/non a-globin chains. the aim of this study was to give a quik desicion with a/b-globin mrna ratio for sequencing of a or b gene, when the anemia is not detectable. materials and methods: mrna and cdna extraction of bthalassemia and a-(including two of . kb del./hbs) thalassemia subjects and normal controls were accomplished using the high pure rna isolation kit and transcriptor first strand cdna synthesis kit, respectively, following the manufacturer's instructions. we used cdna as a template in the real-time pcr amplification using primers specific for a, b globin genes. amplification was performed in a lightcycler Ò instrument. the a/b-globin mrna ratio of each sample was calculated based on the Àddct method. results: a/b-globin mrna ratios calculated in a-thalassemia subjects relative to normal control as a result of numbers of defective a-globin genes. the a/b-globin mrna ratio was found higher in b-thalassemia subjects. coinheritance of a-thalassemia in hb s subjects concluded a stabile a/b-globin mrna ratio as per a-thalassemia or b-thalassemia subjects. discussion and conclusion: instability in a/b-globin chains is a significant factor of thalassemia disease severity and can be used before deciding type of gene sequencing when the anemia is not detectable. this study indicates that imbalance in globin gene expression could be demonstrated by measuring a/b-globin mrna ratio, which was conveniently and accurately determined by qrt-pcr and give an information about globin gene function which gene should be correct to investigate an individual for globin gene mutation. p-mis- self-assembling peptides mimic supramolecular biochirality r. garifullin , , m. o. guler bilkent university unam, institute of materials science and nanotechnology, ankara, turkey, kazan federal university, institute of fundamental medicine and biology, kazan, russia supramolecular chirality is rooted in asymmetric spatial arrangement of structural elements (e.g. molecules or units with higher hierarchy). self-assembled systems giving rise to this kind of chirality are of great importance because they closely resemble natural biological systems and potentially can lead to new advanced functional materials. in the process of self-assembly, both molecularly chiral and achiral structural units can organize into chiral nanostructures. chiral arrangement of chromophore molecules in space is known to result in emergence of chiroptical properties of a chromophore. organization of pigment-protein complexes into macrodomains in green plants gives rise to biochirality emanating from long-range chiral order of complexes. owing to this order, macrodomains start to absorb circularly polarized light intensively and thus exhibit huge circular dichroism (cd) signal. in our study, a simple approach which was aimed at mimicking the biochirality phenomenon makes use of self-assembling peptide amphiphiles and their interactions with pyrene chromophore. designed peptide amphiphiles are capable of self-assembly into nanofibers with chiral interior, which in principle gives an opportunity to achieve long-range chiral order. two modes of interactioncovalent and noncovalentwere utilized in order to induce supramolecular chirality. covalent interaction mode included direct covalent attachment of pyrene to peptide sequence. upon self-assembly of peptide amphiphile into nanofibers intense circular dichroism phenomenon was observed. noncovalent interaction mode envisioned encapsulation of pyrene molecules in the hydrophobic core of nanofibers of another peptide amphiphile. co-assembly of peptide amphiphile and pyrene molecules led to chiral order and intense cd signal. in addition, it was possible to control the sign of cd signals by using either of peptide isomers, l or d. p-mis- pon activity in hdl subgroups of obese, overweight and normal weight subjects objective: the aims of this study were isolation of hdl-c subgroups by using precipitation method, determination of pon- activity in both total and hdl subgroups, and evaluation of performance characteristics of pon- activity measurement method in newly diagnosed obese, overweight and normal subjects. material and methods: the study population consists of newly diagnosed obese, overweight and normal subjects. fasting morning blood samples were taken from all study groups. hdl subgroup was obtained by heparin-mn-dextran sulphate precipitation method and cholesterol was measured with direct (homegenous) hdl-c method. hdl -c concentrations were calculated with the subtraction of hdl -c from total hdl-c. hdl -c and total pon- activity were determined by using eckerson method. non-hdl pon- activitiy was calculated with subtraction of hdl pon- activity from total pon- activity. results: total hdl-c, hdl -c and hdl -c concentrations and the activity of total pon- and hdl pon- were found lower in obesity according to overweight and normal subjects (p < . ). negative correlations were found between body mass index and hdl -c, total pon- and hdl pon- (r = À . , p < . ; r = À . , p < . ; r = À . , p < . , respectively). conclusion: our findings indicated that hdl-c metabolism and lipoprotein associated antioxidant defense mechanisms were adversely affected with obesity. in conclusion we think that precipitation method using for separating hdl subgroup, is simple and cost effective for routine applications in clinical laboratories. besides hdl -c measurements, pon activity, measurement of total and hdl -c subgroup might be helpful to evaluate the atherosclerotic process in obese subjects. keywords: obesity, body mass index, paraoxonase, hdl subgroup, cholesterol p-mis- hepatitis e virus antibody prevelance among persons who work with animals in north cyprus introductions: hepatitis e infection is a major cause of viral hepatitis in many developing countries. the objectives of the present study was to determine the seroprevelance of hev infection in peoples who work with animals in northern cyprus. materials and methods: prevelance of hev infection were determined in study group population: persons without occupational exposure to animals; persons who work with animals; veterinarian and butcher. a total of blood samples were collected. all serum samples were tested elisa using a commercially available kit according to the manufacturer's instructions. ti-test were used for istatistical analyses. p > . was accepted as significant value. results: in a study of blood donors ( male, female), the overall prevelance of anti-hev igg antibodies were . %. the blood samples were collected different areas. the prevelance of anti-hev igm antibodies was . % and he was years and acting a butcher during years. the prevelance of anti-hev igg of women were approximately two fold higher than men. no significant difference in anti-hev prevelance was observed between the age of the blood donors. according to the anti-hev igg prevelance, the without occupation expose to animal animal were %, the animal husbandry were % and the veterians and the butcher were % were found. discussion: the prevelance of anti-hev in the north cyprus ( %) was found low such as the prevelance of the turkey ( %). the prevelance of anti-hev igg in animal husbandry were higher that the other groups because of they may be more spend of time and contact with animals. the prevelance of igm results suggested that the possibility of outbreaks may be low in north cyprus. conclusion: this study was the first seroprevelance analysis of north cyprus according to the population number.the further studies could be included the seroprevelance of anti-hev from the animals. most errors in the clinical laboratory occur in the preanalytical phase the aim of this study was to investigate the causes and rates of rejected samples, regarding to certain test groups in our laboratory. this study was designed on the rejected samples between january and january . clinical chemistry, coagulation, hormone, cardiac markers, total urine evaluation and other (ethanol level, hba c, hb electrophoresis, neonatal bilirubin, drug level, blood gas, fecal occult blood) test groups were included. the total number of specimen and rejected samples was obtained from the hospital information system retrospectively. types of inappropriateness were evaluated as follows: erroneous coding, clotted specimen, hemolysis, insufficient volume, incorrect patient, incorrect tube and inappropriate specimen. it was determined that blood samples were sent to our laboratory in one-year period. . % of them were rejected because of preanalytical errors. erroneous coding was found as the most common rejection cause ( %). rejection rates of clotted specimen, hemolysis, insufficient volume, incorrect patient, incorrect tube and inappropriate specimen were found to be %, %, %, %, % and % respectively. in our study, erroneous coding was the most common cause of preanalytical errors. education of medical secretaries is relevant and important as can be seen in the decrease of sample errors and the resulting quality improvement. glycosylated hemoglobin test (hba c) is important for screening, diagnosing, and monitoring diabetes and prediabetes. however, hba c levels may dependent on patient ethnicity suggesting that the diagnostic cut-offs should be evaluated for specific populations. therefore, our aim in this study was to evaluate the efficiency of hba c for predicting diabetes in comparison to oral glucose tolerance test (ogtt) results for turkish population. the study included anonymous lab results (acibadem labmed laboratories in turkey) of patients ( female, male) aging . ae . years ( - ) who had an initial diagnosis of diabetes. glucose and insulin levels during ogtt were measured after the initial administration of g sugar ( hour), -hour and -hour. these parameters were statistically analyzed in comparison to simultaneous hba c results. glucose measurements at hour had better distinction power (p < . ) between these individual groups than initial and -hour glucose measurements. the average hba c (%) levels for healthy, pre-diabetic and diabetic individuals were . ae . , . ae . and . ae . , respectively. roc curve analysis showed . % sensitivity and . % specificity for the clinically accepted hba c cut-off value of . %. hba c cut-off value of . % had a higher sensitivity of . % and comparable specificity of . %. the highest discrimination power between healthy, pre-diabetic and diabetic individuals was observed at glucose concentration at -hour after sugar administration in ogtt test as opposed -hours generally used for diagnosis. low sensitivity was observed for the clinically adapted . % cut-off value of hba c. the cut-off value of . % for hba c was found to be more sensitive with comparable specificity than the . % cut-off values for diabetes screening in our population. our results suggest that . % for hba c should be considered for diabetes cutoff value for turkish population. induction of the glutathione-dependent detoxification capacity is involved in the hepatoprotective effect of silymarin against acetaminophen-induced hepatotoxicity y. kim, d. kwon, c. ahn seoul national university, seoul, south korea recent findings in this laboratory showed that silymarin was capable of promoting hepatic glutathione (gsh) synthesis via a modification of the transsulfuration reactions in the liver. to investigate its pharmacological significance, we examined the hepatoprotective effect of silymarin against liver injury induced by acetaminophen (apap). adult male mice were treated with silymarin ( mg/kg, po) every hours for a total of doses prior to an apap challenge ( mg/kg, ip). the apap-induced liver injury was assessed by histopathological examination and measurement of changes in plasma enzyme activities, lipid peroxidation and formation of nitrotyrosine protein adducts in the liver. plasma levels of apap and its major metabolites were monitored for hours to estimate the metabolic transformation of apap. also protein and activity of the major cyp subtypes involved in the metabolic activation of apap into a toxic metabolite were determined in liver of the mice treated with silymarin only. silymarin pretreatment attenuated the apap-induced liver injury significantly when determined hours later. plasma concentrations of apap, apap-glucuronide or apap-sulfate in plasma were not changed, but thiol conjugates of apap, such as apap-glutathione, apap-cysteine and apap-n-acetylcysteine, were elevated significantly in the mice pretreated with silymarin. however, silymarin treatment did not affect protein expression of cyp e , cyp a , or cyp a in the liver. also hepatic microsomal enzyme activities measured using p-nitrophenol, ethoxyresorufin and erythromycin as substrates, were not increased by silymarin, indicating that the elevation of apap-thiol conjugates should be attributed to an augmentation of the gsh conjugation capacity. it is suggested that silymarin may protect the liver against an electrophilic substance-induced toxicity by increasing gsh availability which would enhance the detoxifying capacity of liver cells. prostate cancer (pca) is the second leading cause of death among men in western countries. we have previously found that the six transmembrane protein of prostate (stamp ) promotes pca cell proliferation as well as inhibits apoptosis through, at least in part, regulating the erk/mapk signaling. we also found that stamp is highly mobile in pca cells and shuttles between the plasma membrane and the golgi, often found in vesiculotubular structures in the cytosol. using advanced imaging techniques, we have now characterized the trafficking of stamp from the plasma membrane to early endosomes in lncap cells, by analysing its dynamic targeting to the three main endocytosis pathways: clathrin-mediated endocytosis, caveolae/lipid rafts, and the arf -dependent pathway. we found that stamp fused to cyan fluorescent protein (cfp-stamp ) is present at the plasma membrane where it accumulates in punctate structures. live cell confocal imaging showed that these puncta were dynamic over time indicating that stamp may be constitutively delivered to the plasma membrane and removed from it by endocytosis. co-expression of cfp-stamp with various fluorescent protein markers revealed that cfp-stamp puncta corresponded to lipid rafts that were labelled with caveolin- -rfp or antibodies against flotillin. live cell imaging showed that cfp-stamp and caveolin- -rfp disappeared at the same time from the same region of the plasma membrane suggesting that lipid rafts are likely to be responsible for stamp internalization. notably, stamp was absent from other endocytosis structures such as clathrin-coated pits/vesicles. further work is needed to determine whether stamp internalization is required for its function, such as its link to erk signaling, and whether interference with lipid rafts influences stamp effects on pca cell proliferation and survival. antithrombin-iii, mpv and plasma total homocysteine levels in behcet's disease introduction: behcet's disease is a multi-systemic and chronic inflammatory vasculitis of unknown etiology characterized by recurrent oral and genital ulcers, uveitis, arthritis, arterial aneurysms, venous thrombosis and skin lesions. platelet indices such as mean platelet volume (mpv) is a standart indicator of platelet function in disease pathophysiology. antithrombin, a glycoprotein synthesized in the liver, is the major plasma inhibitor of thrombin thus modulating blood coagulation. antithrombi-iii (at-iii) is a enzyme even moderate deficiency significantly increases the risk of thrombosis. homocysteine (hcy), that is formed during the metabolism of methionine. several clinical studies have clarified that elevated blood hcy levels are related to atherosclerotic disease. in our study, we investigated ovocystatin is one of the best characterized members of cystatin superfamily of protease inhibitors, and it has been frequently used for pathophysiological studies as the model protein, representative for this superfamily. its application has been supported by high structural similarity to human cystatin c as well as several common biological activities. as regard to biological activity, cystatins, including ovocystatin, are best characterized as inhibitors of cysteine proteases of papain family (c ), such as cathepsins b, h, l and s. these inhibitors participate in intra-and extracellular control of proteolytic events, both in physiological and pathological states. in the recent decade also new activities of cystatins, not assigned to inhibition of papain-like cysteine cathepsins, were found. these activities are associated with an alternative active center for legumain-type proteases in the molecule. here we report a chemical modification of ovocystatin that disables the anti-papain activity of the inhibitor but does not affect its anti-legumain activity. the chemical knockout has been obtained by reaction with -hydroxy- -nitrobenzyl bromide (hnbb) that covalently modifies the trp residue in the molecule. the reaction has been monitored by uv-vis and fluorescence spectroscopy. the anti-papain activity of the inhibitor has been measured colorimetrically against bana as a substrate. the anti-legumain activity was assessed fluorometrically using z-ala-ala-asn-amc. the reacted inhibitor exhibited an additional, characteristic for hnbb, band at nm in uv-vis scan. accordingly, an ablation of trp fluorescence was also observed. the molecule fully retained the anti-legumain activity, while only residual antipapain activity ( %) was observed. the modified ovocystatin can be a useful molecular tool for studying the physiological and pathological processes specifically associated with legumain activity. departments of medicine (hematology/oncology) and biochemistry and molecular biology, university of louisville, james graham brown cancer center, louisville, ky, united states -phosphofructo- -kinase/fructose- , -bisphospatase (pfkfb) family of enzymes are responsible for the conversion of fructose- -phosphate (f p) to fructose- , -bisphosphate (f , bp) and vice versa, and f , bp is an allosteric activator of phosphofructokinase- (pfk ), a rate-limiting enzyme of glycolysis. among the four identified pfkfb isozymes (pfkfb - ), pfkfb is the least studied isozyme in human cancers. there exists two different splice variants of pfkfb , variant- and variant- , coding two different isoforms, isoform a and b, respectively. in this study, we first analyzed the effect of k-ras(g d)induced oncogenic transformation on pfkfb expression in pancreatic duct cells. we found that oncogenic k-ras induction in immortalized pancreatic duct cells (ipde) was associated with decreases in total pfkfb mrna and protein expressions (mrna; ipde: ae . ; ipde+kras: . ae . and protein; ipde: ipde+kras: . ). we then, checked individual expressions of splice variants and observed that while pfkfb splice variant- (p -v ) expression was reduced by k-ras induction (ipde: ; ipde+kras: . ), pfkfb splice variant- (p -v ) expression was increased (ipde: ; ipde+kras: . ). then, we checked effects of p -v and p -v on glycolytic phenotype of ipde and ipde+kras cells. over-expression of pfkfb variants increased f , bp concentration (p -v : . ; p -v : . fold; compared to empty vec), glucose uptake (p -v : %; p -v : %) and glycolysis (p -v : %; p -v : %) in ipde+k-ras cells. we next analyzed the subcellular localizations of pfkfb isoforms and observed that both pfkfb isozymes localize to the nucleus, with more prominent nuclear localization of p -v compared to p -v . also, nuclear localization ratio of p -v increases after oncogenic transformation with mutant k-ras. taken together, these results suggest that pfkfb may have a role in the glycolytic phenotype of pancreatic cancers characterized with hyperactive k-ras signaling. effects of p map kinase inhibitors on mda-mb- cell line introduction: p mapk phosphorylates serine and/or threonine residues of the target proteins. the activation of p mapk leads to cell growth, differentiation, survival or apoptosis. in this study, we tested the effect p mapk sb and sb on mda-mb- cells to further elucidate the controversial role of p mapk on cell proliferation or cell migration. materials and methods: mda-mb- cancer line was cultured in rpmi- supplemented with % fbs. the cytotoxic and cell migration effects of sb and sb inhibitors were tested by mtt assay and wound assay, respectively. the effects of both inhibitors on proliferation and adhesion of md-mb- cells were determined by icelligence system. results: it was found that sb p map kinase inhibitor was more effective than sb . however, no significant effects of low doses of lm and lm of both inhibitors were seen on cell proliferation as compared to the dmso-treated control cells for up to hours as determined by icelligence system. on the other hand, both sb and sb significantly prevented cell proliferation at a concentration of lm. both sb and sb significantly reduced cell migration in a time-dependent manner at a concentration of lm. then, we tested whether each p mapk inhibitors have any effect on cell adhesion during a treatment period of hours using icelligence system. only lm concentration of sb reduced cell adhesion for about . hour (p < . ). conclusion: p mapk inhibitors sb and sb differentially affect cell proliferation, survival and migration. acknowledgements: this study is financially supported by dumlupınar university, scientific research project no - . mutagenicity of a series efficacious benzoxazine derivativesa new approach to evaluate ames test data e. foto , f. zilifdar , s. yilmaz , t. sarac ßbasi , i. yalc ßin , n. diril hacettepe university, ankara, turkey, ankara university, ankara, turkey testing safety of drug candidates is as crucial as evaluating their efficacy in early drug development. we previously synthesized a series of , -benzoxazine- -one derivatives showing significant antimicrobial, in vitro anticancer, topoisomerase i inhibitory activities and studied their several mechanisms of action. in this present study, we have evaluated mutagenic activities of these compounds and their potential metabolites. moreover, we aimed to develop a new statistical algorithm available for structureactivity relationship analysis to identify the regions responsible for the activity. to evaluate mutagenicity of the compounds, ames salmonella/microsome test was used. salmonella typhimurium ta and ta strains were used to detect for frameshift and basepair substitution mutagens, respectively. additionally, mutagenicity of potential metabolites of them were evaluated by adding metabolic activation system (s ) which was prepared from a pool of male sprague dawley rats. results were evaluated with student's-t test. following regression model estimation analysis, we detected minimum mutagenic doses of all tested compounds for generating a d-common features pharmacophore model with hiphop method. according to the results, only bs , bs , bs and bs exhibited strong mutagenic effects on both strains in the presence and absence of s . additionally bs , bs , bs and bs (in the absence of the s ), bs , bs and bs (in the presence of the s ) showed weak mutagenic effects on ta . hiphop analysis results revealed that mutagenicity was increased in the presence of aromatic desactivating groups which might form hydrogen bonds at the position of r and hydrophobic groups at the position of r of the benzene ring in the structure of benzoxazine. the new statistical approach developed in this study can be useful for assessing the ames test data available for structure activity relationship analyses. background: recently more than thirty different diseases can screen simultaneously with expanded newborn screening (nbs) programs by tandem ms.expanded nbs with tandem ms is performed routinely at akdeniz university hospital central laboratory since .the aim of this study was to evaluate our nbs results with some second-tier and confirmatory tests. materials and methods: nbs results (n = ) were evaluated in dried blood samples which sent to our laboratory for the study between august and august . electrospray ionisation (esi)triple quadrupole mass spectrometer (shimadzu lc-ms/ms ,japan) was used for nbs analysis,acylcarnitine and amino acid profile were screened with mrm (multiple reaction monitoring) spectrum within minutes.second-tier tests were performed as urine organic acid analysis by gas chromatography-mass spectrometry (gc-ms),plasma and urine quantitative amino acid analysis by high pressure liquid chromatography (hplc).pathological nbs results were assessed in three separate groups as amino acid metabolism disorders, fatty acid oxidation defects and organic acidemias. results: metabolic diseases were found in ( . %) patients by the second-tier tests performed.there were detected amino acid metabolism disorders in ,organic acidemia in ,fatty acid oxidation defects in patients. conclusions: the reason of high positive results in our laboratory could explain that our study includes both screening and monitoring of previously diagnosed metabolic patients.nbs is performed in only a few centers in turkey although there were the national screening programs included nbs in many foreign countries.more expanded nbs programmes in our country is required to start treatment of patients before irreversible damage is not occured. although many reports indicate the involvement of calpain in several human pathologies, it is not yet clarified how the protease can recognize the substrates to digest and how can escape to its natural inhibitor calpastatin. answers to these questions have been obtained by identifying specific intracellular localizations of calpain and its substrates and analyzing the interactions of the protease with calpastatin. these studies were carried out using human sknbe neuroblastoma cells. protein-protein interactions and intracellular localization of calpain and the related proteins were determined by immunoprecipitation and isolation of membrane microdomains. we have observed that small amounts of calpain- are localized in lipid rafts microdomains together with n-methyl-d-aspartate receptor (nmdar) containing nr /nr b subunits. immunoprecipitation experiments have demonstrated that nmdar containing nr /nr b subunits, calpain- , hsp and neuronal nitric oxide synthase (nnos) but not calpastatin and calpain- are present in specific protein complexes. thus, in this localization calpain activity is regulated by hsp that reduces the affinity for ca + of the protease. cell stimulation with nmdar agonists induces calpain activation that specifically cleaves the subunits nr b of the receptor promoting changes in lipid rafts organization and internalization of nmdar without affecting cell viability. moreover, in these conditions, also nnos is digested and converted in the active form by calpain- . our data suggest a physiological role of calpain- at specific cell sites. the protease inserted in lipid rafts microdomains is in strict contact with its targets and escapes to calpastatin which is not inserted in these structures. following an increase in ca + influx, the activated protease regulated by hsp , promotes the removal of nmdar from the plasma membranes, decreasing ca + entrance through this receptor-channel and protecting cells from ca + overloading. tissue transglutaminase (tg ) is a multifunctional protein complex that can act as a crosslinking enzyme, gtpase/atpase, protein kinase and protein disulfide isomerase. at the cell surface, tg was shown to be involved in adhesion, migration, invasion, growth, epithelial mesenchymal transition and hence implied in the metastatic development of many different tumor types. renal cell cancer (rcc) is one of the most common type of cancer in adult males that generally grows as a single tumor within a kidney. our previous findings indicate that the increased expression of tg in rcc results in tumor metastasis with a significant decrease in disease-and cancer-specific survival outcome. herewith, the role of tg in cell migration of rcc was investigated in this study by transducing the model rcc mouse cell line renca with a series of tg mutant constructs. renca cells were transduced by lentiviral particles encoding wttg , transaminase-defective tg -c s form with low gtpbinding affinity, gtp-binding deficient form tg -r a, and transaminase-inactive tg -w a. in order to investigate the role of tg transamidating and gtpase activity in cell migration, scattering assay was used where colonies for each mutant clone was followed for a time interval of hours. our results showed that non-transduced control and tg -c s mutant renca cells demonstrated a similar migration pattern with a % of scatter activity. on the other hand, % colonies formed by renca cells overexpressing wttg and tg -w a mutant scattered away from each other. a small insignificant increase in scattering was seen in % of the total number of colonies for renca cells overexpressing tg-r a construct. data from this study supports that gtp-binding activity of tg is the drive force in migration driven scattering of renca cells, suggesting that inhibitors targeting the gtp-binding activity of tg may serve as a new therapeutic approach in the treatment of rcc. background: in this study, we aimed to investigate the relationship between level of vitamin d with subclinical hypothyroidism and subclinical hyperthyroidism. material and metod: study groups planned as three groups such as euthyroid (n = ), subclinical hypothyroid (n = ), subclinical hyperthyroid (n = ). serum tsh, free t (ft ) and free t (ft ) levels were determined by chemiluminescence immunoassay and serum -hydroxy (oh) vitamin d (oh) d level were determined by liquid chromatography-tandem mass spectrometry. euthyroidism was defined as a normal level of tsh (range, . to . miu/l), ft (range, . to . ng/dl) and ft (range, . to . ng/dl). subclinical hypothyroidism is defined as an elevated serum tsh level associated with normal total or free t and t levels. subclinical hyperthyroidism is defined as low serum tsh levels associated with normal free t and free t levels. results: subclinical hyperthyroid group had significantly higher (oh) vitamin d levels compared to the euthyroid and subclinical hypothyroid groups (p < . ). (oh) vitamin d levels in subclinical hypothyroid group was not statistically significant when compared with the euthyroid group. food processing wastes provide carbon sources in high amounts for fermentative microorganisms to produce energy. converting carbon-rich biomass into bioethanol through fermentation by microorganisms both provides energy requirement for humankind and also decrease pollutant gases like co , no x and so x (ghorbani et al., ) . fermentation processes for bio-ethanol production could be achieved by saccharomyces cerevisiae, zymomonas mobilis, and escherichia coli. bacterial hemoglobin (vitreoscilla hemoglobin, vhb) is the first and best characterized prokaryotic hemoglobin molecule. the function of vhb is supporting the cellular respiration through binding to oxygen at microaerobic environment, transferring it to the terminal respiration oxidases (geckil et al., ) and thus improving growth and productivity of the microorganisms. in this study, e.coli strains fbr , ts and ts were used as ethanologenic microorganisms. expression of vhb in ts is lower than in ts strain. for the efficient ethanol production effect of different inoculum sizes, sugar species and sugar concentrations in the growth medium were investigated. vhb expression increased effectively the viability of ts strain by up to . x cfu per ml of fructose ( %, w/v) supplemented lb medium starting with small inoculum for fermentation. this indicates that vgb expression should be at the certain level to maintain sufficient the cell growth for ethanol production. geckil h, gencer s ( ) . production of l-asparaginase in enterobacter aerogenes expressing vitreoscilla hemoglobin for efficient oxygen uptake. applied microbiology and biotechnology : - . ghorbani, f., younesi, h., sari, a. e., najafpour, g. ( ) . cane molasses fermentation for continuous ethanol production in an immobilized cells reactor by saccharomyces cerevisiae. ethanol production from dairy industry by product using bacterial hemoglobin t. sar, g. seker, a. g. erman, m. yesilcimen akbas gebze technical university, depertment of molecular biology and genetics, kocaeli, turkey bioethanol production from biomass has a great potential to reduce greenhouse gases emissions. ethanol has several applications in industries (chemical, medical, pharmaceutical, food etc.) in the form of raw material, solvent and fuel. one of the most abundant liquid wastes is cheese whey generated from dairy industries. whey powder is concentrated form of whey and contains lactose and also protein, lipid, minerals and vitamins. vitreoscilla hemoglobin (vhb) is the first bacterial hemoglobin. the main function of this molecule is to improve oxygen transfer to cellular oxidases and thus supporting cellular growth and productivity at low oxygen levels (kallio et al. ) . in this work, e. coli strains fbr , ts (low level vhb expressing) and ts (high level vhb expressing) were used as ethanol producing microorganisms. fermentation medium containing whey powder supplemented with lb material was inoculated with these strains and incubated for hours at °c and rpm in a ml erlenmayer flask. the ethanol production was improved over % by using lower vhb expressing strain. the ethanol levels (v/v, %) were determined as . , . and . for fbr , ts and ts strains respectively. it is shown that the certain levels of vhb could be useful tool to increase the growth and productivity of ethanol from dairy industry wastes. kallio p.t., kim d.j., tsai p.s. and bailey j.e. ( ) . bioethanol is usually produced from cellulose, hemicellulose and lignin. the lignocellulosic wastes should be hydrolysed into fermentable sugars by using enzymes or dilute acids before microbial fermentation. acidic hydrolysis methodology is cheaper than enzymatic hydrolysis but it can cause production of some inhibitors like aliphatic acids, which affect the growth of microorganisms. vitreoscilla hemoglobin (vhb) is the first described prokaryotic hemoglobin. the recombinant strains carrying vgb gene (e. coli, p. aureginosa) which encodes vhb showed increased bacterial growth, productivity of metabolites compared to untransformant counterparts under low oxygen concentrations [nasr et al., ; geckil et al., ] . in this study, ethanologic e. coli strains fbr , its derivative strains ts (vgb+) and ts (vgb+) were used. ts was constructed in such that it could express more vhb than ts . bioethanol production by these strains in presence of lignocellulosic hydrolysates derived inhibitors was investigated. different acetic acid concentrations ( . - mm) were used as inhibitors from lignocellulose hydrolysate. . mm acetic acid was used as an inhibitor. the growth of vhb expressing ts and ts strains was inhibited about % after hours fermentation time. strain fbr was inhibited as high as % by using the same inhibitor including growth medium. it was shown that the expression of vhb could improve growth and productivity in presence of lignocellulosic inhibitors. differentiation of preadipocyte, also called adipogenesis, leads to the phenotype of mature adipocyte. however, excessive adipogenesis is closely linked to the development of obesity. thus, any drug or chemical that can inhibit adipogenesis may have preventive and/or therapeutic potential against obesity and related diseases. azd , an inhibitor of the family of pim kinases, is known for anti-cancer activity. here we investigated the effect of azd on adipogenesis in t -l preadipocytes. notably, azd treatment led to a concentration-dependent inhibition of both lipid accumulation and triglyceride (tg) synthesis during the differentiation of t -l preadipocytes into adipocytes with no cytotoxicity. on mechanistic levels, azd strongly reduced not only the expression levels of ccaat/enhancer-binding protein-a (c/ebp-a), peroxisome proliferator-activated receptor-c (ppar-c), fatty acid synthase (fas), and perilipin a but also the phosphorylation levels of signal transducer and activator of transcription- (stat- ) during adipocyte differentiation. furthermore, azd largely decreased leptin, but not adiponectin, mrna expressions during adipocyte differentiation. collectively, these results demonstrate that azd inhibits adipogenesis in t -l preadipocytes and the inhibition is largely attributable to the reduced expression and/or phosphorylation levels of c/ebp-a, ppar-c, fas, perilipin a, and stat- . effect of intrauterin exposure to artificial food colourings on dna damage in rats in many research genotoxic potential of food additives has been investigated. however there are few findings about the effect of artificial food colourings (afc) on dna. in this experimental study, we aimed to analyze whether in utero exposed artificial food colourings would have effect on dna and cause damage.thirteen female rats were included to the study which were equally divided into two groups as control (cg, n = ) and food colouring (fcg, n = ) groups. a mixture of nine food colours were given daily to fcg by oral gavage from preconception to birth. no adverse effect level (noael) of artificial food colourings for each colouring was administered to fcg. three months after the birth, offspring from each group were selected randomly as control (cg) and experiment (eg) groups. then they were sacrified under anesthesia. for performing the alkaline comet comet assay leukocytes were seperated from whole blood samples. the alkaline comet assay was performed. the extent of dna damage was assessed from the length of dna migration derived by subtracting the diameter of the nucleus from the total length of the image and graded into categories and these grades were converted into arbitrary unit (au). differences between the means of data were compared by independent samples t test. the results were given as the meanaesd, p values of less than . were considered as statistically significant. although the extent of dna damage was higher in eg, the comparison of experiment ( . ae . ) and control ( . ae . ) groups showed no statistical difference (p = . ). relationship between glucocorticoid receptor gene polymorphisms and recurrent depression l. aydogan, i. benli, z. c. ozmen, i. butun gaziosmanpasa university medical faculty, department of biochemistry, tokat, turkey objective: sensitivity to glucocorticoids varies between individuals and these differences have been implicated in the etiology of psychiatric diseases such as depression. recent studies have found relationship between common glucocorticoid receptor (gr) gene (nr c ) polymorphisms and unipolar or bipolar depression. the nr c gene is a candidate gene affecting depressive disorder risk and management. the aim of the present study was to evaluate the relative distribution of specific polymorphisms of nr c (bcl and rs ) in recurrent depressive disorder (rdd) patients. methods: our study included volunteers with recurrent depressive disorder and healthy individuals without any mental illness. depression was assessed by hamilton and madrs depression scale. nr c gene polymorphisms were detected by real-time pcr, with hybridization probe method. allele and genotype frequencies at two loci (bcli and rs ) were investigated in rdd patients and controls. results: genotype distribution among rdd patients and the control group for bcl- (g/c) were as follows: cc % and %, gc % and %, gg % and %, respectively. there was not a significant difference when the frequency of the allele (p = . ) and genotype frequency (p = . ) were compared between the patients and the control. genotype distribution in the rs region (a/t) of the patients and controls were tt % and %, ta % and %, aa % and %, respectively. allele frequency (p = . ) and the genotype frequencies (p = . ) were not significantly different among the groups. conclusion: numerous nr c gene polymorphisms were previously reported in association with modification of depressive disorders. the results of our study showed no association between gr genotype and recurrent depressive disorder. nr c polymorphism does not play a role in the development of recurrent depressive disorder. thymoquinone (tq) has been shown to supress the proliferation of various tumor cells, while it is minimally toxic to normal cells. the aim of this study is to investigate the potential therapeutic effects of tq on cell proliferation, apoptosis, invasion, migration, colony formation and wound-healing in sh-sy y human neuroblastoma cell line. sh-sy y cell line treated with - lm tq by solving medium for , and h considering a time-and dose-dependent manner. the cytotoxic effect of tq was determined by mtt method. total rna was isolated by trizol reagent. cdna synthesis was performed by using commercial kit. mdm , p , p , akt, pten, cdk , cyclin d , caspase- , - , - , - , bcl- , bax, parp, bcl-xl, bid, dr , dr , puma, noxa, mmp- , - , timp- , - and gapdh gene expression profiles were analysed by real-time pcr method. effects of tq in sh-sy y cells on invasion, colony formation and cell migration were detected by matrigel-chamber, colony formation assay and woundhealing assay, respectively. statistical analysis were performed with rt profiles array data analysis by using student's t test. ic value of tq in sh-sy y cells was detected as lm at th hours. by rt-pcr results, it was determined that tq caused a decrease in the expression of mdm , akt, cdk , cyclin d , bcl- and mmp- . it is also observed that tq caused a significant increase in the expression of p , pten, caspase- , - , bid, dr , puma, noxa and timp- . it was also found that tq in sh-sy y cells suppressed invasion, migration and colony formation by using matrigel invasion chamber, wound healing and colony formation assay, respectively. in conclusion, we demonstrate that tq significantly effect cell cycle, apoptosis, invasion, migration and colony formation of sh-sy y cells. tq may be a potential candidate as chemotherapeutic agent for the treatment of neuroblastoma. more studies have to be performed to profile the mechanisms and genome wide effects of tq to prove its therapeutic potential. dna aptamers can achieve a very high affinity to the target due to the potential of developing broad target-binding interface. however, classic strategy selection of aptamer binders is a challenging task requiring multiple rounds of panning and post-selection optimization. we have developed fast and convenient technique for the selection of dna aptamers based on the offrate selection and tandem affinity purification (tap). we constructed and produced in e.coli recombinant chimeric protein, comprising two affinity tags (his and gst) separated from each other and from the target protein (anthrax protective antigen domain iv, padiv) by sumo protease recognition polypeptide and synthetic cleavage site for the anthrax lethal factor (lf). the protein bound to aptamer library is first captured by imac resin, cleaved by sumo protease, captured by gst resin and eluted by lf following the lines of the tap method. the gst-captured aptamer-target complexes were subjected to the off-rate selection using soluble padiv as the competitor. multiple selection rounds are cumbersome and can result in carryover. high abundance of moderate affinity aptamers in the resulting pools obtained by classic selection approaches suggests that the procedure to counter-select them at the beginning of panning is needed. reduction of the contact duration between the aptamer library and the target was crucial for efficient selection of high-affinity binders. on the other hand, tap prevents contamination, and bundled with the off-rate selection, allows for clean isolation of high-affinity binders with affinity in the low nanomolar range. the developed technique is applicable for efficient selection of high affinity dna binders to soluble recombinant proteins and their fragments. dna aptamers obtained will be further used for the development of diagnostic and therapeutic tools for the detection and treatment of anthrax. the work was supported by russian science foundation research grant no. - - . the role of macab efflux pump in protection of serratia marcescens against antibiotics and oxidative stress the emergence of bacterial multi-drug resistance is a growing problem of public health worldwide. bacterial drug efflux pumps are membrane protein complexes that function to expulse drugs from the cell. they play a crucial role in the rising rates of antibiotic therapy failures. the homolog of macrolide-specific pump macab was identified in opportunistic pathogen serratia marcescens and was used in this study to characterize its role in protection against antimicrobials and other processes beyond the active efflux of antibiotics. here we used method of serial dilutions to determine minimum inhibitory concentration (mic) for s. marcescens sm wild type (wt) and its isogenic Δmacab mutant strains. we also used h o survival assay to evaluate the ability of wt and the mutant strain to withstand an oxidative stress. finally, we used b-galactosidase assay to evaluate macab promotor activation in the reporter strain and followed macab expression by western blotting analysis using macab- xhis strain. we show that in contrary to its e. coli homolog, macab pump in s. marcescens is not involved in the protection against macrolides but instead it is required for protection against aminoglycosides. we further show that similar to its salmonella typhimurium homolog, s. marcescens macab is essential for protection of bacteria against h o . transcriptional analyses demonstrate that while low level of macab promotor activity can be detected after hours of growth in lb-broth there is at least -fold increase in expression in response to the presence of h o . on the protein level macab can be detected starting from hours of growth in lb-broth and it reaches maximum expression on hour of growth. our data suggest that macab pump in s. marcescens is involved in protection of bacteria against aminoglycoside antibiotics and is crucial for protection against reactive oxygen species. we are currently working on identification of macab substrate with anti-h o properties. antiproliferative and apoptotic effects of noscapine on mcf- and mda-mb- human breast cancer cell lines approximately - % of breast cancers are negative for estrogen receptor, progesterone receptor, and human epidermal growth factor receptor . these are most aggressive tumor and a clinical problem because of lack of targeted therapies. noscapine is an alkaloid from opium. noscapine is a microtubule-interfering agent. it causes mitotic arrest, induces apoptosis. in this study, we aimed to investigate the effects of noscapine in mcf- and mda-mb- human breast cancer cell lines. the cytotoxic effects of docetaxel, tamoxifen, and noscapine on the mcf- and mda-mb- cell lines were analyzed by roche xcelligence system. the cells were cultured in % fetal bovine serum containing dulbecco's modified eagle medium at °c in a humidified atmosphere containing % co . h after seeding, the cells were treated with different doses of docetaxel ( . to nm), tamoxifen ( . to lm), and noscapine ( . to lm). cultured cells were harvested, fixed with % formalin, and centrifuged. pellet was blocked, fixed, and embedded in paraffin. paraffin-embedded cells blocks were sectioned at lm thickness and stained with h&e, ki- , bcl- , cyclin-d , and bax. sides were assessed under a light microscope. quantification of the analyzed proteins were evaluated by the percentage of positive cells. all drugs showed cytotoxic effects on both cell lines. all drugs inhibited the proliferation of breast cancer cells, but effects were dependent on time and dose. all drugs were especially more effective on mcf- cells. immunohistochemical examinations revealed that tamoxifen was more effective on mcf- cells, hovewer docetaxel and noscapine were more effective on mda-mb- cells. tamoxifen has more apoptotic and antiproliferative effects on mcf- cells. docetaxel and noscapine showed more apoptotic and antiproliferative effects on mda-mb- cells. noscapine may be an effective anticancer agent due to antiproliferative and apoptotic effects on breast cancer cells. negative selection of dna aptamers to reduce non-specific binding in solid-phase-based selection procedures carryover by binders specific to the components of the selection system can be a serious issue in hampering the aptamer selection campaign. solution-or "mass"-based techniques still cannot substitute classic phase-separation strategies. one approach to prevent selection of "passenger" phase-specific (plastic, beads) or blocking agent specific aptamer species is their depletion from the initial library pool. our aim was to develop the universal technique for removal of such aptamers exemplified by bsa-and casein-specific binders, while preserving the initial library complexity. the dna aptamer library was subjected to three rounds of depletion using magnetic beads with covalently attached casein and bsa. to ensure high depletion efficiency, beads were pelleted in a -ml centrifuge tube by a neodymium magnet through a -cm cushion of % sucrose, thus preventing weakly bound aptamers from re-populating the library. high complexity of the input library helped to avoid pcr amplification after depletion rounds preventing the library bias introduced by dna amplification. the depletion effciency was confirmed by real-time pcr. resulting oligonucleotide sub-library was analyzed for binding to the targets using solid-phase real-time pcr assay. we have shown that three rounds of panning under the conditions employed provided full depletion of the initial dna pool from nucleic acid structures capable of binding to protein competitors and hampering the process of aptamer selection. we compared selection efficiency of aptamers specific to type a botulinum neurotoxin light chain in depleted vs undepleted library. the yield of the target-specific aptamers was -fold higher in the library subjected to the depletion procedure. removal of undesired binders from aptamer libraries appears an important step of solid-phase selex procedure. it can become a useful approach in optimizing solid-phase selex. the work was supported by russian science foundation research grant no. - - . epithelial mesenchymal transition (emt) is a critical trans-differentiation program driving cancer metastasis. patients showing signs of emt or presence of distant metastasis have poor prognosis. another well-known feature of decreased cancer-associated survival is the lack of anti-cancer immune responses. thus we hypothesized that the emt and anti-tumor response should be linked via altered secretion of soluble factors by metastatic cells. all cell lines were grown in dmem. emt status of crc cell lines were assessed by investigating canonical markers of emt. cytokine/chemokine expression of crc cells was performed using r&d systems antibody arrays and validated using ccl sandwich elisa and rt-pcr. the mechanism of action of zeb / on ccl promoter has been studied by luciferace assay and chip. ccl coding region was cloned into pcdna . and stably transfected into dld- cells. ccl deficient ct cells were generated using lentivirual shrna transduction. cells overexpressing or knock/down ccl were injected orthotopically into mice. t lymphocyte (til) infiltration in respect to ccl and sip expression was studied using ihc or flow cytometry. emt status catagorised crc cell lines into epithelial, intermediate epithelial, intermediate mesechymal and mesenchymal. cytokine/chemokine antibody arrays showed a significant increase in ccl in induced dld-sip cells. elisa, multiplex assays and rt-pcr confirmed a significant increase of secreted ccl in the induced dld-sip cells as well as mesenchymal crc cells as compared to epithelial ones (p = . ). promoter studies showed that zeb / bind to ccl promoter and and activate ccl gene expression. no metastasis was observed for dld- cells overexpressing ccl but significant alterations of tumour associated lymphocytes were identified in syngeneic orthotopic crc models. our data shows that ccl is up-regulated by emt inducing transcription factor sip , and mesenchymal (metastatic) crc cells secrete significantly more ccl compared to epithelial (non-metastatic) ones. ccl did not induce emt per se but abundant secretion of ccl by metastatic crc cells was a crucial regulator of immune infiltrate in crc. inhibiting ccl in metastatic crc may have a therapeutic potential. barley (hordeum vulgare l.) belongs to the grass family, poaceae (gramineae). it is the fourth most important cereal crop after wheat, maize and rice and is among the top ten crop plants in the world. talbina was used to be recommended for the sick and for one who is grieving over a dead person. talbina is made by adding one or two tablespoon of barley flour (must be percent wholegrain barley flour) to one-and-a-half cups of water and placed on low heat for - minutes (optional: add milk or yoghurt and sweeten with honey). the main objectives of this investigation were determine the a-tocopherol contents and antimutagenicity activity of talbina (hordeum vulgare l.). our results showed that the total tocopherol content was in the range of . to . lmol/g fw. talbina extract was shown to have greater antimutagenic activity observed in the lg/plate concentration s. typhimurium ta . at all the doses antimutagenic response was significant at (p < . ) against both the strains with a percent mutagenicity decrease from to for ta followed by ta with percent antimutagenicity from to . the results of the study concluded that talbina is a better antimutagenic agent than vitamin e and combination of vitamins did not produce any synergistic activity. the compounds containing thiadiazoles have diverse applications as antifungals, anticancer agents, antibacterial, antiinflammatory drugs, antidepressants and carbonic anhydrase inhibitors according to literature. in this study some novel thiadiazole compounds [( , , , )-tetrathia[ . ] ( , )- , , -thiadiazolophane; ( , )dioxo- , , , )-tetrathia[ . ]( , )- , , -thiadiazolophane; ( , , , )-tetraoxo- ( , , , )-tetrathia[ . ]( , )- , , -thiadiazolophane and ( , , , , , )-hexaoxo- ( , , , )-tetrathia [ . ] ( , )- , , -thiadiazolophane] were used to evaluate the cytotoxicity on healthy human lymphocytes and the antibacterial activities. cytotoxicity tests were perfomed using mts assay and the trypan blue test. cells were incubated with the compounds for hours. at the end of the each hour, cell vitality was assessed by measuring the absorbance ( nm) of each well using a microplate reader for mts assay. in addition, viability percents of the cells were determined after trypan blue test. as a result, the compounds showed cytotoxicity in a dose dependent manner. for the concentrations of : of . mg/ml, the cytotoxic effect was eliminated. also, antioxidant capacity was determined using , -diphenyl- -picrylhydrazyl (dpph) reagent. moreover, the antibacterial activities of the compounds were analyzed using a microdilution test against e. coli and s.aureus. compounds having various concentrations showed different antibacterial effects against these two bacteria. arabidopsis thaliana ecotypes vary in their ability to utilize organic p substrates insufficient quantity of inorganic phosphorus in soil is an evergrowing problem that affects many fields of agriculture. unlike inorganic phosphates, organic phosphorus compounds are very common in many soil types, but plants are often unable to efficiently utilize them. to better characterize the extent of natural variation in the ability of the model plant arabidopsis thaliana to grow on organic phosphorus compounds, we grew arabidopsis ecotypes on several organic and inorganic sources of phosphorus. plants were grown in liquid or solid media containing naphosphate, phytate and atp as the sole supply of phosphorus or in absence of any phosphorus source. after several weeks of growth, plants were assayed for changes in their morphological and physiological characteristics. phytate was shown to be the least preferred source of phosphorus compared to inorganic phosphate and atp. the rate of biomass accumulation in all ecotypes decreased in the following order from inorganic phosphate to atp to phytate. lateral root formation was markedly reduced in the absence of any phosphorus source or in the presence of phytate. we also showed that phosphomonoesterase activity in intact roots increased when plants were grown on atp and phytate. overall phosphorus content in leaves and roots was similar when plants were grown on atp or inorganic phosphate, but it was markedly reduced on phytate. substantial differences between ecotypes were also observed in root length, p content in ash and phosphomonoesterase activity in intact roots. our analysis of the ability of arabidopsis ecotypes to grow on several different phosphorus sources provides a unique opportunity to investigate the degree of natural variation in this plant's ability to adapt to different nutritional environments. analysis of many important morphological and physiological changes observed in these plants can further extend our understanding of the full range of plant responses to phosphorus availability. laboratory tests are important in terms of confirmation of diagnosis given by clinics and implementation of appropriate treatment protocols for patients. laboratory tests used by the clinics have been increased in parallel with time.there are many reasons for increased use of the test such as increase of elderly population, increase in standard of care, lack of information and shortening of turn around time. unnecessary laboratory testing also constitute one of the reasons for increased use of laboratory tests. in our study we aimed to investigate the unnecessary laboratory testing for fpsa test. fpsa tests which are ordered with total psa tests that values of less than ng/ml or greater than ng/ml were accepted as inappropriate initial testing. fpsa tests were evaluated as unnecessary laboratory testing. the clinic which ordered the maximum unnecessary laboratory testing with was urology within all the clinics. although to the restrictions about the ordering of total psa and fpsa tests there were no decrease in the number of unnecessary laboratory testing. unnecessary usage of laboratory testing may cause increase of false positive results, increase in the use of invasive testing, unnecessary drug consumption and increase of healtcare costs. some precautions may be effective in reducing unnecessary tests such as to inform clinicians about the cost of laboratory tests, to increase the clinician education programs and to develop usage of disease specific diagnostic algorithms about test ordering. local clinical validation of blood collection tubes although the tubes with gel and clot activator are widely used due to the advantages, there are ongoing discussions about the effects of the blood collection tube on clinical outcomes in the analysis of biochemical parameters. therefore, we aimed to prove the local clinical validation of the new produced blood collection tubes with low-volume. the blood samples of patients who referred to the hospital phlebotomy unit were collected using holder into the different tubes. first tube was ml glass tube and with no additive, second was ml tube with gel separator, third was ml tube with gel separator. serum was separated and immediadiately analysed for biochemical parameters. the difference between the analyte amounts in the different tubes was evaluated using paired t-test. the clinical significance was evaluated using significant change limit. bias (%) between the other tubes with the reference tube was also evaluated according to the ''allowable total error". when we compared the other test tubes to a glass tube which was assumed reference tube, total protein, albumin, amylase, calcium, triglyceride, cholesterol, hdl-cholesterol, total and direct bilirubin, iron, gamma glutamyl transferase, magnesium, phosphorus results were statistically significant. but the results of all the analytes were within the significant changes limit and the allowable total error was not significant. while a biochemical parameters have analysed, it may be absorbed into the gel and this may caused from factors such as the chemical structure of the gel, analyte itself, the residence time in the gel, storage temperature and volume of the sample e.g. as well as the leaking of gel material to the sample was reported to be another factor for affecting the analysis. despite these factors, we observed that neither gel-clot activator tube with low nor high volume affect the clinical results. the research of the frequency of interference in thyroid function tests interference is defined as the effect of substance in the sample which changes the correct value of laboratory results. the frequency of interference in immune techniques is varied. the frequency of interference depends on population of the study, technique for detecting the reaction and researcher's method. unexpected or inconsistent results with clinical findings should suggest the possibility of interference. in this study it is aimed to investigate the frequency of interference in thyroid function tests (tsh, ft , ft ) which are the most common requested laboratory tests. thyroid function tests of patients are analyzed in ankara numune education and research hospital in october -may . five samples which had the incompatible results with clinical findings are re-evaluated just because of the suspicion of interference. the detection of interference included; repetition of test via different immune techniques, serial dilution, polyethylene glycol (peg) precipitation and incubation with heterophilic blocking tubes (hbt). the results of two different immune techniques and before/ after incubation with hbt showed no significant difference. linear curves had observed in serial dilution. after peg precipitation; below % of recovery had obtained in one sample, therefore it is interpreted as macro-tsh. the frequency of interference in thyroid function tests for -month study period was . %. no information is found about the best test for defining the cross reaction. it is also aforethought that interference should not be excluded by using any single procedure. p-mis- development of polyclonal and monoclonal antibodies against fatty acid binding protein (fabp /ap ) a. abbasi taghidizaj, g. aydogdu, b. p. sermikli, e. yilmaz ankara university, ankara, turkey recombinant proteins and antibodies can be use for therapeutic or diagnostic purposes which produced in many different host organisms. the technique for the production of immortal cell making single antibody, fusing target antibody-forming b lymphocyte precursor with a suitable myeloma cells. the fused hybrid cells (called hybridomas), as a cancer cell will reproduce rapidly and will produce large amounts of the desired antibodies. fatty acid binding protein (fabp ) is a well characterized intracellular lipid transport protein and plays a key role in the intracellular fatty acid transport and adipose tissue metabolism. fabp as a adipokine that regulates glucose homeostasis and has various features for metabolic syndrome associated with obesity. in this study, production of monoclonal antibodies against immunogenic fabp protein made by recombinant dna technology. recombinant his-fabp was expressed in e.coli and purified. balb/c mice used for immunization and serum anti-fabp antibodies determined by enzyme-linked immunosorbent assay (elisa). hybridoma cells created by fusion of splenocytes and myeloma partner cells. after selection of antibody producing cell clones, injecting hybridomas into the peritoneal cavity in balb/c mice ascites fluids was obtained. we have selected fifteen hybridoma clones that produced antibodies specific for fabp , as shown by western blotting and immunocytochemistry. as a result we produced mabs that will be useful for the scientific community working on fatty acid binding proteins and lipid metabolism. in near future, therapeutic approach for this antibody maybe a possibility in metabolic syndrome. thioridazine, an anti-psychotic drug, inhibits migration, invasion and epithelial mesenchymal transition in breast cancer cell lines thioridazine (thz), an antipsychotic drug, exhibits anti-angiogenic effects on breast cancer cell lines. however the mechanistic insight in exerting antiangiogenic effect is not clearly understood. the objective was to investigate the role of thz in epithelialmesenchymal transition (emt) by using cell migration assay, scratch assay, western blot (wb) and immunocytochemistry. thz treatment reduced cell viability on mda-mb- , mcf- and cd + /cd -cells and ic values of thz were found to be lm, . lm and lm respectively, at hours. invasion potency of mcf- , cd + /cd -and mda-mb- cells were determined as %, %, . % when compared to relevant treatment controls. migration potency of mcf- , cd + /cd -and mda-mb- cells was determined as . %, . %, % respectively. among the three cell lines mda-mb- cells display enhanced invasive and migration ability when compared to other cell lines. western blotting results demonstrate that thz significantly increases e-cadherin, cytokeratin- , b-catenin, while inhibiting n-cadherin, vimentin, fibronectin. immunocytochemistry studies revealed decrease in e cadherin and a concomitant increase in vimentin level for all three cell lines upon treatment with thz. moreover thz significantly inhibited the cell migration, invasion and emt in mda-mb- , mcf- and cd + /cd cell lines by suppressing mesenchymal markers. in conclusion, these data suggest that thz might be a novel anti-proliferative and anti-metastatic agent for treatment of breast cancer. effect of seasonal temperature and humidity on urine density in children environmental heat and humidity are important factors affecting hydration status in childhood. hereby, we aimed to investigate the effects of seasonal climate changes on urine density of children living in mediterranean climate, cyprus. healthy - year children's ( girls, boys) age, sex and urine density results were collected retrospectively for three consecutive years. the correlation of urine density with each seasonal and months' average temperature and humidity has been analysed. the urine density results had a positive correlation with temperature (r = . , p = . ) and a negative correlation with humidity (r= À . , p = . ). mean urine density in spring was higher than that of autumn (p = . ) and winter (p = . ). mean value of summer was higher than autumn (p = . ) and winter (p = . ). - months age group had lower urine density. evaluation of urine density based on gender and puberty revealed no statistically significant difference. seasonal mediterranean climate changes have an impact on urine density in children which may affect hydration status especially in infants < yrs of age. during high temperature seasons ensuring adequate water intake is essential in this age group in mediterranean climate. p-mis- implementation related to the use of antibiotics and data sources by community pharmacists in north cyprus as the resistance to antibiotics is gaining importance in today's world;the solution to this problem is possible through a common consciousness of the doctor who prescribes antibiotics,the pharmacist who sells and the patient who consumes antibiotics. irrational use of drugs is an economic and medical problem in many developed and developing countries around the world.the aim of this study is to determine the sales ratio of non-prescription antibiotics in pharmacies which is the biggest category of the antibiotic group sold as well as the indications that lead to its' prescription. eighty-four pharmacies out of pharmacies located in north cyprus were involved in the study with %stratified systematic sampling, questionnaires were filled and a consent form was signed by the participating pharmacists. the pharmacists involved in the study stated that non-prescribed antibiotics were demanded from the pharmacists and all except two ( . %),responded positively to this demand. it has also been identified in the study that . % of the daily sale of antibiotics in the first half of the year was non-prescribed. the most purchased antibiotics either with or without prescription was found to be the penicillin and its derivatives with . % and upper respiratory tract with . %. when the level of selfawareness of the pharmacists was examined, the rate is found in north cyprus to be ( . %),compared with the studies conducted in greece,italy,malta and spain % and egypt . %that designated the non prescribed antibiotics purchased from the public pharmacies. the rate of sale of non-prescribed antibiotics in north cyprus has been found to be at a higher level compared to the rates in many developed and developing countries. furthermore, the upper respiratory tract infections are amongst the most common viral causes which lead to a high consumption of both prescribed and non-prescribed antibiotics. this study was supported by turkish viral hepatitis prevention society. acrylamide has cytotoxic, antiproliferative and apoptotic effects on human lung adeno carcinoma cell line a acrylamide (aa), a widespread substance in many fields, forms in foods during high temperature processing such as baking, roasting, frying. aa is a potent neurotoxic, genotoxic and clastogenic agent being a strong electrophile and forming adduct with biological molecules or potent nucleophiles. up to now, several studies confirmed the toxicity of acrylamide to several organs. on the other hand, aa is reported to have inhibition effects both on proliferation and differentiation of different cancer cells in a time and dose-dependent manner. in addition, natural and synthetic acrylamide derivatives are also used as potent anti-cancer agents. moreover, inhibition concentration (ic ) values of aa against these cancer cells have not been investigated in detail yet. thus, the goal of this study is to investigate the cytotoxicity of aa on a cells including with ultrastructural and morphological effects. ic value of aa on a cells for h was detected with mtt ( -( , -dimethyl- -thiazolyl)- , -diphenyl- h-tetrazolium bromide) colorimetric assay. we evaluated morphological changes under confocal microscopy and ultrastructural changes under transmission electron microscopy (tem). our results demonstrate that aa inhibits the proliferation of a cells in dose-dependent manner and ic on a cells was found to be . mm for hours. confocal microscopy evaluations showed that aa caused nuclear condensations, fragmentations, cytoskeleton lacerations and membrane blebbing. tem results revealed membrane blebbing, chromatin condensations and cell shrinkage. although aa is a probable carcinogen substance, it drastically inhibited cell viability in dose-dependent manner. from microscopic assessments, aa is suggested to induce apoptosis in a cells. in conclusion, the present study confirms the high potential of aa for cytotoxic, antiproliferative and apoptotic activity on a cells. however, appropriate aa dose is critical to prevent its possible adverse effects. effect of hemolysis and lipemia on some immunochemical tests in beckman coulter unicell dxi immunoassay analyzer c. yilmaz, s. yildiz, m. senes, v. fidanci, d. y€ ucel ankara training and research hospital, ankara, turkey the aim of the study was to investigate the effects of in vitro hemolysis and lipemia on immunoassays studied by the beckman coulter unicell dxi immunoassay analyzer. we prepared a serum pool without hemolysis, lipemia and icterus. baseline serum pool concentrations of tests were measured by the beckman coulter unicell dxi . d _ ifferent serum pools, six for hemolysis and five for lipemia, were spiked with increasing concentrations of hemoglobin ( . , . , . , . , . and . g/l hemoglobin) and intralipid ( . , . , . , and g/l intralipid). the hemolysate was prepared by osmotic shock method. intralipid ( %, baxter, deerfield, il) was used to mimic the effect of lipemia. the hemolysis (h), lipemia (l) and icterus (i) indices were measured on beckman coulter au . after spiking the pools, the tests were measured again in duplicate on beckman-coulter dxi analyzer. a change of % from baseline results was taken as evidence of interference and the interfered tests were also evaluated according to total analytical error based on analytical imprecision and intraindividual biological variation. we observed a positive interference due to hemolysis for folat, vitamin b , testosterone and by lipemia for cortisol. there was a negative interference of hemolysis for ca . , ca , ca . , insulin, pth and e , and of lipemia for progesterone, ca . , vitamin b and pth. we found clinically significant effect (>total analytical error) of hemolysis on folate and insulin, and lipemia on cortisol. investigation of the effect of two different p mapk inhibitors in rats subjected to isoproterenol-induced acute myocardial injury: an experimental study objective: acute myocardial infarction is a serious acute condition. in the current study, we aimed to investigate the possible effect of two different mitogen-activated protein kinase (p mapk) inhibitors in rats subjected to isoproterenol (iso)induced myocardial injury. materials and methods: a total of male wistar-albino rats were equally and randomly seperated into four groups as follows: control, iso, iso plus sb andiso plus tak- . treatment agents were orally administered and myocardial injury was induced by subcutaneous injection of iso. serum cardiac troponin-i (ctni), ischemia modified albumin (ima), heart fatty acid binding protein (hfabp) levels and paraoxonase- (pon- ) activity, tissue tos (total oxidant status), tas (total antioxidant status), tt (total thiol), tumor necrosis factor-a (tnf-a) levels, superoxide dismutase (sod) and glutathione peroxidase (gsh-px) activity levels were measured. tissue mrna levels of nf-jb, p mapk and nuclear factor erythroid -related factor (nrf ) were analyzed. heart tissues were also immunohistochemically and histopathologically evaluated. results: both compounds have led to a decrement in myocardial damage, apoptosis, ctni, ima, hfabp, tos, and tnf-a levels, nf-jb, p mapk, phosphorylated c-jun n-terminal protein kinase (pjnk / ) expressions. on the other hand, the applied treatment increased sod, gsh-px, tas and tt levels, as well as phosphorylated extracellular signal-regulated kinase (perk / ) and nrf expressions. conclusion: data established from the current study suggest that administered agents have protective effect against cardiac injury induced by iso, which was more prominent in rats received sb treatment. p mapk inhibitors may constitute a useful choice as cardioprotective agents due to their antiinflammatory, antioxidant and anti-apoptotic effects. keywords: _ isoproterenol, myocardial infarction, myocardial ischemia, p mitogen-activated protein kinases, sb , tak- . silicosis composes the vast majority of occupational lung diseases. silicosis, caused by inhalation of crystalline silica, is a chronic lung disease characterized by parenchymal nodules and pulmonary fibrosis. the susceptibility of patients with silicosis to infection is thought to be due to toxic effects of silica on pulmonary macrophages. ada activity is considered as a nonspecific marker of t cell activation and cellular immunity. this study aimed to compare the serum ada activity in silicosis patients with spirometric values. in this study there were males in each groups which contained patients with silicosis (group ), individuals having similar symptoms with silicosis from same occupational area (group ) and healthy subjects (group ). routine hematological and biochemical parameters were also measured. the serum ada activity and spirometric values (fev , fev %, fev /fvc, fev / fvc%, fef - and fef - %) were compared. the average age of group , and are . ae . , . ae and ae . years, respectively. there was a significant difference between group and in terms of the ada level (p < . ). there was a negative correlation between ada activity and fev , fev %, fev /fvc, fev /fvc%, fef - values. elevated serum ada activity has been shown in many diseases with induced cellular immunity. despite initially toxic effects were lead to a little immunological reaction in patients with silicosis, continuation of this immunological response is important in some chronic manifestations of silicosis. the release of chemotactic factors and inflammatory mediators cause the migration of polymorphonuclear leukocytes, t lymphocytes and macrophages. in this study, the ada activity was significantly higher in patients with silicosis than others. increased immunity in patients with silicosis is being considered, increasing ada activity might be help of earlier recognition of these patients and to take better quality of life. atlantic salmon (salmo salar l.) is an important model system in evolutionary and conservation biology that provides fundamental knowledge into population persistence, adaptive response and the effects of anthropogenic change. the role of behavioral and body size variation in environmental adaptation of atlantic salmon is well known, by contrast, the underlying biochemical mechanisms are largely unknown. intracellular proteases, such as cathepsins b and d in lysosomes and calpains and proteasome in cytosol, due to their metabolic and regulatory role may contribute to phenotyping speciation of salmon young. we examined the activity of intracellular proteolytic enzymes in skeletal muscles of atlantic salmon parr from two local habitats of the varzuga river (the main channel and small tributaries) differing in hydrological and feeding parameters. calpain and proteasome activities were determined by casein or suc-llvy-amc hydrolysis in the skeletal muscles of s. salar from varzuga river (kola peninsula, russia). it is known that salmon parr originated from a common hatch became phenotypically divergent during the settle in the biotopes. reliable difference in studied enzyme activities in the salmon parr from two local habitats was found; furthermore, calpain and cathepsin b proteolytic activities were found to negatively correlate with parr body size. muscle proteolytic activity data support an idea on protease contribution to environmentally-driven adaptation and speciation process in fish. the work was supported by the russian scientific foundation, project no. - - . the phylogenetic analyses of anthriscus (apiacea) species from turkey based on non-coding "trn" regions of chloroplast genome p. yilmaz sancar , m. tekin , s. civelek firat university, elazig, turkey, cumhuriyet university, sivas, turkey anthriscus pers. (apiaceae) species belongs to apiaceae family and is represented by genus on the world and by genus in turkey. anhriscus species are used extensively for treatment various disease such as asthma, alzheimer and show anti-tumoral, anti-microbial, antioxidant features. for determining exact species which treat disease it is necessary sorting species correctly with molecular markers to support morphological features. anthriscus species were defined by examining insufficient quantity of samples in turkey flora. besides, no detailed study was found in our country after flora study. for this reason a revision study was made with the aim of solving some systematical problems in by tekin. the result of the study provided important contribution to the systematic of the species in turkey. however a molecular study was also required for building the obtained results on a more solid ground. in this study, the aim to reveal systematic and phylogenetic relationship among species of anthriscus in turkey, by using trnl-f region in chloroplast genome. dna was isolated by ctab method and amplified in pcr by using e-f primaries. the obtained data was evaluated by mega . program and phylogenetic tree was prepared by using maximum likelihood method. according to the phylogenetic tree that we prepared by using the sequence line up of trnl-f section, it was observed that a. cerefolium, a. caucalis and a. tenerrima species completed their speciation and an isolation with other species in terms of speciation was provided. it was also observed that a. kotchi, a. sylvestris subs. sylvestris, a. sylvestris subs. nemarosa and a. lamprocarpa'nın provided hybridization among themselves but they did not complete their speciation. it was determined that a.lamprocarpa var. chelikhii which is one of the two different varieties of a. lamprocarpa is actually a new sub-species. this fact was supported by molecular data obtained from the study we made after morphologic data. introduction: excessive production of androstenedione can becaused by defects of adrenal steroid biosynthesis, tumors of ovarian and adrenal origin, polycystic ovarian syndrome, increased peripheral sensitivity to androgens, and increased peripheral production of androgens. most epidemiologic studies use enzyme-linked immunosorbentassay (elisa) to measure sex steroid hormones because they have acceptable turnaround times and arerelatively inexpensive. mass spectrometry-based methods are currently the most specific quantitative analytical methods for steroid determination. mass spectrometry methods are independent of matrix effects or cross-reactivity. in this study, a new liquid chromatography-tandem mass spectrometry (lc-ms/ms) method was developed. materials and methods: for serum androstenedione measurement, ll of internal standard (d - deoxycortizol) in methanol was added to ll standart or serum and centrifuged at . rpm for minutes to remove the precipitated proteins. supernatant was transferred to clean tubes and this procedure was performed twice. the supernatant was collected and dried under a nitrogen gas flow at • c and dissolved in mobile phase. ll was injected in to the ultra performance liquid chromatography analytical column for chromatography. elisa study was conducted with drg (lot. no. k ) brand kit. results: method comporison between lc-ms/ms and elisa was found slope value , , intercept value À . and r² value . . the regressione quation was elisa= À . + . lc-ms/ms. discussion and conclusion: method comparison study presented higher results in elisa compared to lc-ms/ms. in our opinion, this might due to the interference in elisa systems. our lc-ms/ms method allows rapid, sensitive and specific determination of androgens in plasma and serum.the specificity of liquid chromatography-tandem mass spectrometry (lc-ms/ ms) offers advantages over immunoassays. heparins play an important role in cell growth, differentiation, migration and invasion. however, the molecular mechanisms of heparin mediated cellular behaviors are not well defined. to determine the effect of heparin on gene expression, we performed a cdna microarray in a hepatocellular carcinoma cell line and found that heparin regulates transcription of genes involved in glucose metabolism. in this study, we showed a new role of heparin in the regulation of thioredoxin interacting protein, which is a major regulator of glucose metabolism, in hepatocellular carcinoma cell lines. we determined the importance of a unique carbohydrate response element located on its promoter for the heparin-induced activation of thioredoxin-interacting protein and the modulatory role of heparin on nuclear accumulation of carbohydrate response element associated proteins. we showed the importance of heparin mediated histone modifications and downregulation of enhancer of zeste polycomb repressive complex expression for heparin mediated overexpression of thioredoxininteracting protein. when we tested biological significance of these data; we observed that cells overexpressing thioredoxininteracting protein are less adhesive and proliferative, however they have a higher migration and invasion ability. interestingly, heparin treatment increased thioredoxin-interacting protein expression in liver of diabetic rats. in conclusion, our results show that heparin activates thioredoxin-interacting protein expression in liver and hepatocellular carcinoma cells and provide the first evidences of regulatory roles of heparin on carbohydrate response element associated factors. this study will contribute future understanding of the effect of heparin on glucose metabolism and glucose independent overexpression of thioredoxin-interacting protein during hepatocarcinogenesis. prolidase activity in chronic obstructive pulmonary disease and asthma t. g€ uc ßl€ u , h. s€ urer , g. bilgin , d. y€ ucel ankara training and research hospital, medical biochemistry department, ankara, turkey, ankara training and research hospital, chest diseases department, ankara, turkey chronic obstructive pulmonary disease (copd) is a consequence of an underlying chronic inflammatory disorder of the airways that is usually progressive and causes dysregulation in the metabolism of collagen. and asthma is a disease where there is an accumulation of collagen in the reticular basal membrane of the airway leading to chronic inflammation. prolidase has an important role in the recycling of proline for collagen synthesis and cell growth. we measured and compared prolidase activity in healthy individuals with copd and asthma patients to find out that whether its activity might reflect disturbances of collagen metabolism in the patients. patients with copd, patients with asthma and healthy control subjects with similar age range and sex were included in our study. the patient and control groups do not have any other chronic disease. serum prolidase activity was measured in the patient and control groups. ferritin and alpha- antitrypsin concentrations were also compared. there was no significant difference between serum prolidaz activities of asthma and copd patients. serum prolidase activities of both copd and asthma patients were significantly lower than those of the control subjects (p < . ). there was no significant difference for ferritine and alpha- antityripsin levels between the groups. the prolidase activity is significantly lower in asthma and copd patients comparing with control subjects. the collagen metabolism may be undergone to a change in these patients. hence, there may be an effect on the accumulation of collagen in the reticular basal membrane. the results suggest that collagen turnover are altered by the development of copd and asthma in human lungs, and prolidase activity may reflect disturbances of collagen metabolism in these pulmonary diseases. monitoring serum prolidase activity may be useful in evaluating fibrotic processes and in the chronic inflammatory lung diseases in human. acyclovir molecule in the active site of e. coli purine nucleoside phosphorylase (on the basis of x-ray study) i. kuranova , , v. timofeev , , n. zhukhlistova , y. abramchik , t. muravieva , r. esipov shubnikov institute of crystallography of fsrc "crystallography and photonics" ras, moscow, russia, national research centre "kurchatov institute", moscow, russia, shemyakin-ovchinnikov institute of bioorganic chemistry, russian academy of sciences, moscow, russia e. coli purine nucleoside phosphorylase (pnp), which catalyzes the reversible phosphorolysis of purine ribonucleosides, belongs to the family i of hexameric pnps. due to key role in the purine sulvage pathway pnps are attractive targets for drug design against some pathogens. they also used widely in biotechnology for the synthesis of nucleoside analogues as well as for the activation of the prodrugs in anti-cancer gene therapies. the acyclovir (acv), acyclic derivative of guanosine, is antiviral drug for the treatment of some human viral infections. the crystalline complex of e. coli pnp with acyclovir was prepared by co-crystallization using counter diffusion in capillary through the gel layer. the set of x-ray data at k from single crystal grown in space (sp. group p ) was collected on the spring- synchrotron-radiation facility (japan) and the structure was solved at . a resolution, using the molecular replacement method (pdb id i c). acv molecule was located in the nucleoside binding pocket of the enzyme in two conformations. the phosphate binding site was occupied by so ion. the hydrogen bonds network and hydrophobic interactions stabilising acv molecule in the active site as well as the conformational changes upon ligand binding were described. the comparison of e. coli pnp/acyclovir complex and the similar complexes of bacillus subtilis pnp (pdb id da ) and human pnp (pdb id pwy) allowed to establish the peculiarities of acv binding of in the e. coli enzyme. gonadotropins are glycoprotein hormones that regulate normal growth, sexual development, and reproductive function. these are large, up to kda proteins, which are synthesized and secreted by the gonadotropic cells of the anterior pituitary gland. these hormones may vary in the level of glycosylation depending on the tissue and the metabolism cycles. follicle-stimulating hormone (fsh) and upon binding to fsh receptor, a g-protein coupled receptor (gpcr), regulates the development, growth, pubertal maturation, and reproductive processes of the body. human chorionic gonadotropin (hcg) and luteinizing hormone (lh) act via a shared gpcr (lh receptor) and regulate mechanisms essential for ovulation, early pregnancy and placental function in females as well as spermatogenesis and testosterone production in males. activation of gpcrs by these hormones can be measured by monitoring formation of cellular cyclic adenosine monophosphate (camp). the level on camp was measured using a f€ orster resonance energy transfer (fret)-based biosensor tepacvv (h ) kindly provided by dr, kees jalink. the biosensor was expressed using the developed bacmam gene delivery system (recombinant baculoviruses carrying the transgene under a strong mammalian promoter). kgn cells expressing the fsh receptor and cos cells expressing the lh receptor served as study objects. monitoring of specific gpcr activation in living cells, allows detection of only the biologically active agonists, which has real impact in quantification of large hormones. differences in levels of hormone glycosylation may affect their biological function. investigation of this phenomena is planned for near future. detection of biological activity of gonadotropins is of importance for pharmaceutical industry, where today the concentration of recombinant proteins is mostly estimated using immunological assays only. development of a colorimetric aptasensor for the detection of peanut allergen protein ara h in food samples b. bora ege university, izmir, turkey food allergy, especially peanut allergy is a life-threatening problem, and severe reactions against these foods can be observed. since unintnded consumption of non-labeled foods is the most dangerous risk, any residual allergen protein should be tested and labeled by the manufacturers. an aptamer based colorimetric test is a powerful alternative to commercially available rt-pcr and elisa test kits. the main objective of this study is to develop an aptamer based colorimetric test fort he detection of major peanut allergen protein ara h . ara h aptamer was used to recognize any residual peanut major allergen protein ara h in food samples. recombinant ara h protein was produced and puirifed to be used as a target. ara h aptamer was used in combination with a blocking sequence, to prevent non-specific binding event, a biotinylated complementary strand to the blocking sequence, and finally strp-hrp interaction in order to facilitate colorimetric reaction. optimal blocking sequence length was optimized and introduced to the site of aptamer sequence to construct an aptamer-hairpin structure. liberation of the blocking sequence allows biotinylated complementary strand to bind to the blocking sequence and consequently str-hrp conjugate to achieve color development that is proportional to the target concentration. since, the aptasensor will be used for the detection of ara h in food samples, total protein extraction from chocolate samples was also optimized. in order to lower the detection limit of aptasensor, aptamer coupled magnetic bead based pre-enrichment assay was aslo optimized for the total protein extraction. as a result, a sensitive, fast and reliable aptamer based colorimetric assay was developed for the detection of peanut allergen protein from food samples. moreover, the assay has the advantages like ease of application and low cost which makes the assay a promising and a powerful alternative to commercially available rt-pcr and elisa tests. the association between lipid parameters and waist circumference in female university students in turkey s. ozen, a. cort sanko university, department of nutrition and dietetics, gaziantep, turkey a high waist circumference is associated with an increased risk for type diabetes, dyslipidemia, hypertension, and cvd in patients with a bmi in a range between and . kg/m . monitoring changes in waist circumference may be helpful, in addition to measuring bmi, since it can provide an estimate of increased abdominal fat even in the absence of a change in bmi. objective of the study was to find an association between plasma lipid profile and anthropometric parameters (waist circumference percentage of body fat and body mass index (bmi)) in abdominal obesity in turkish university students. lipid profile and anthropometric parameters of obesity were studied in a sample of women. students with high bmi (> ) had higher values of low-density lipoprotein (ldl), triglycerides (tg) and cholesterol (c) than students with low bmi (< ) but these differences were not significant. high-density lipoprotein (hdl) levels were non-significantly higher in low bmi (< ) student group. waist circumference, percentage of body fat was higher in high bmi (> ) group than low bmi (< ) group. waist circumference, percentage of body fat was positively correlated with bmi in both samples (bmi (> ) and bmi (< )). students were grouped depend on their waist circumference. healty individuals who had lower than cm waist circumference had decreased tg levels compared to cardiovascular risk group who had higher waist circumference than cm. this study shows an association between waist circumference, percentage of body fat, body mass index and lipid parameters in young female university students. with regard to the relationship, the screening females for central obesity to prevention of cardiovascular disease are recommended. a new biotechnological product from propolis with low allergen: anti-inflammatory effect propolis is extensively used in food industry due to its special medical properies (antioxidant, antimicrobial, antiseptic, antibacterial, anti-inflammatory and antimutagenic effects). even these positive properties it may cause some allergic reactions in consumers with allergic predispositons. previously, we demonstrated that biotransformation of propolis by some special strains of lactobacillus plantarum ( , , aatc strains) might decrease the allergenic molecules in propolis. in this study, we aimed to investigate the effect of biotransformation of popolis on it's antiinflammatory activities. before biotransformation, propolis samples were treated with different solutions ( % ethanol and polyethylene glycol -peg %) and different method (ultrasonic treatment w/ o c/ minutes) in order to facilitate solvation of solid samples which are very dense and not suitable for fermentation. fermantations were performed at o c/ hours under constant agitation conditions. the anti-inflammatory activity was determined in-vitro conditions using hyaluronidase's analysis and the xanthine oxidase activity. the highest inhibition (%) of radicals produced by xanthine oxidase was determined in solid samples treated by peg prior to biotransformation and using of l.plantarum strain during fermentation ( . %), followed by liquid samples treated by ultrasonic method prior to transformation ( . %). concernig the results of hyaluronidase activity (%) inhibitions, the best value were determined in the solid sample treated by peg prior to biotransformation and using of l.plantarum strain during fermentation ( . %). results indicated that the anti-inflammatory activities of analysed samples are quite high and depending of used extraction methods prior the biotransformation and used specific strain of l.plantarum could be optimized in terms of other required parameters. faceanti-mullerian hormone is not predictive for poor neonatal outcome aim: anti-mullerian hormone (amh) is a growth factor specific to ovaries. it is commonly used to predict ovarian reserve and outcomes of fertility treatments. recently, low levels of amh have been shown to be related to hypertensive diseases of the pregnancy and the risk of preterm labor. the aim of this study was to investigate the diagnostic performance of amh levels of mothers to predict poor neonatal outcome in term pregnancies and the relationship between amh and birthweights of the newborns. materials and methods: patients, having delivery beyond weeks, and who did not have any other medical problems were included in the study. the patients had normal g. oral glucose tolerance test results. they were divided as groups, based on their newborns' birthweight as " g. and g.". level of amh was determined by elisa method. results: there was not any relation with the amh of the mothers and the poor neonatal outcome of the newborns, in all groups. also no siginificant difference was observed in amh levels of the patients having delivery in early term and late term periods. when the patients of the same group were evaluated; amh levels were irrelevant to age, gravidy, delivery week, body mass index, the weight gain during pregnancy, and poor neonatal outcome. conclusion: amh is not a predictive factor for poor neonatal outcome and it is not a determinant of the weight of the newborn. objectives: the aim of the study was to investigate the effects of differing amounts of hemolysis on serum high sensitvity troponin i (hs-tni), ck-mb mass and myoglobin measurements. materials and methods: we prepared serum pools having troponin i, ck-mb and myoglobulin concentrations at low ( . ng/l, . ng/ml and . ng/ml respectively), normal ( . ng/l, ng/ml, . ng/l respectively) and high ( ng/l, ng/ml, g/ml respectively) values. the osmotic shock method was utilized to prepare a hemolysate. hemolysate was added into serum pools increasing concentrations of hemoglobin ( . , . , . , , . and . g/l hemoglobin). troponin i, ck-mb (mass) and myoglobin concentrations were measured in duplicate by beckman coulter access analyzer. the hemolysis indices were measured on beckman coulter au . a change of % from baseline results was taken as evidence of interference and the interfered tests were also evaluated according to total analytical error based on analytical imprecision and intraindividual biological variation. results: we found a positive interference due to hemolysis for ck-mb (mass) at low concentrations ( . ng/ml), and a negative interference for myoglobin at low concentrations ( . ng/ml) and high concentrations ( ng/ml). conclusions: ck-mb increase and myoglobin decrease in hemolyzed samples with hemoglobin ≥ . g/l, but the bias might not be clinically significant (< total analytical error) in samples. a retrospective study to determine a reliable marker for selective screening of pompe disease lysosomal storage diseases (lsd) are rare inherited metabolic disorders caused as consequence of a deficiency in a specific enzyme required for lysosomal function. pompe disease is one of these disorders with deficiency of a- , glycosidase enzyme with an incidence of : , - : , . as enzyme replacement therapies are available nowadays, early diagnosis is crucial and selective screening is a rational method to reach pompe patients among people who administer to healthcare with lsd suspected symptoms. this study aims to examine the relationship between basic biochemistry parameters and a- , -glycosidase activities retrospectively, in order to find a key parameter for selective screening of pompe disease. for this reason a- , glycosidase, creatine kinase (ck), creatine kinase-mb (ck-mb) activities calcium, phosphate levels of those who had been suspected to be lsd patients and administered to our laboratory for analysis are examined retrospectively. out of patients's examined, of them were diagnosed with pompe disease depending on clinical findings & low a- , glycosidase activity. enzyme activities of pompe patients were . nmol/ml/hour as lsd suspected patients'activities had a mean of . nmol/ml/hour (p = . ).comparison of ck activity was compared results showed significant difference between pompe patients and lsd suspected patients. even though ck activity levels of the lsd suspected patients were much higher ( vs - u/l) than reference interval, the levels of the pompe disease patients' were still more than twice of the lsd suspected group ( vs u/l, p = . ). ck-mb, ca, p levels didn't show a significant difference. a strong (-) correlation (p = . r=À . ) was observed between a- , -glycosidase and ck activities (n: ). selective screening is a rational way to diagnose rare diseases. this study's results show that ck activity can be used as a key parameter to determine patients for selective screening of pompe disease within lsd suspected population. the functional effect of stem cells on the reproductive organs infertitility is considered as a major health problem of recent century. importance of stem cell is increasing so it is searched new features and supposed to be involved in the infertitility treatment where oxidative stress and apoptosis play importany role. we aimed to investigate the beneficial effect of the stem cells related to free radicals and cell death on testis and ovary. biopcy model of wound healing was created in the rat testis and ovary with ppd syringe where stem cells were delivered by injection. rats were divided into four groups including controls, sham, wound healing and wound healing with stem cell. after the creation of the wound, bone marrow-derived mesenchymal stem cells from the tibia of the mature rats and medium were administered to ovaries and testes. following the applications, ovary and testis samples were investigated for oxidative stress and apoptosis by immunohistochemistry. in comparison with the medium and stem cell applications without a medium support, it was meaningfully determined that healing effect in testicles and ovaries were spotted specifically on the seven day. tissues were analysed for these staining by h-score and h-score results were determined using one-way anova test statistically. our results show the positive effects which clinic applications can bring by displaying the great contribution of the stem cell application in the treatment of testicle and ovary damage. these findings suggest that transplantation of the mesenchymal stem cells may help to promote better enviroment for the reproductive organs by the effect on oxidative stress and apoptosis. the further studies of these results in the molecular level can lead the way to solve the problem of infertility, to increase the percentage of success in the ivf and icsi techniques and more importantly to perform a differentiation from a somatic cell to a germ cell. the antimicrobial activity of ( h)-furanone derivative on staphylococcus aureus nosocomial infections caused by methicillin-resistant staphylococcus aureus strains are known to be a reason of many infectious diseases like osteomyelitis, endocarditis, sepsis etc. being organized in biofilms these bacteria become extremely resistant to antimicrobials and host immune system leading to difficulties in treatments. here we report the effect of ( h)-furanone derivative possessing sulfonyl group and l-menthol moiety (f ) on biofilms formed by s. aureus atcc and mrsa cells. while exhibiting relatively high minimal inhibiting concentration -mic ( mg/l), clear synergy with a number of antibiotics was found in the checkerboard assay. thus, in the presence of mg/l of f the mic of kanamycin was decreased -fold, and the mics of both erythromycin and ampicillin were lowered -fold. at the concentration of mg/l f also completely inhibited the biofilm formation by s. aureus; the cell growth was suppressed by two orders of magnitude as judged by differential fluorescent staining with syto and propidium iodide. the addition of f to preformed h-old biofilms increased the fraction of red-stained (dead) cells of both s. aureus atcc and mrsa strains uniformly throughout the whole profile of the biofilm. the quantitative analysis of clsm microphotographs revealed that f at concentration of mg/l led to death of up to % of biofilm-embedded cells. this fact suggests that f efficiently penetrates into the biofilm matrix and kills the cells without visible damage of biofilm structure. in summary, furanone f seems to be a promising compound for drugs design to treat biofilm-embedded s. aureus. this work is supported by the russian science foundation, project № - - and the german academic exchange service (№ ). pneumonia is an inflammatory lung disease which can be associated with inadequacy of host defense system and the proliferation of various pathogenic microorganisms into the lower respiratory tract. community acquired pneumonia (cap) is one of the leading causes of death in elderly. the incidence of pneumonia in people aged and over is - times more than young adults. creactive protein (crp) is an acute-phase protein of hepatic origin that increases following interleukin- secretion by t cells and macrophages. procalcitonin (pct) is a peptide precursor of the hormone calcitonin, the latter being involved with calcium homeostasis. it is composed of amino acids and is produced by parafollicular cells (c cells) of the thyroid and by the neuroendocrine cells of the lung and the intestine. the level of pct rises in a response to a proinflammatory stimulus, especially of bacterial origin. the aim of this study was to compare crp and pct levels in young and elderly patients with pneumonia. recently diagnosed young and elderly patients with pneumonia and their respective aged matched controls (n = , n = ) were enrolled this study. crp and pct levels were by immunoturbidometric and by elisa methods respectively. crp and pct levels for young control and patients and elderly control and patients respectively are . ae . mg/l, . ae . ng/ml, . ae . mg/l, . ae . ng/ml, . ae . mg/l, . ae . ng/ml and . ae . mg/l, . ae . ng/ml. young patients with pneumonia have significantly higher crp and pct levels than their controls (p < . and p < . ). elderly patients with pneumonia have significantly higher crp levels than their controls (p < . ). crp and pct are important markers in the diagnosis of pneumonia. effect of serum albumin concentration on total and ionized calcium z. adiyaman, c. yilmaz, s. a. peker, d. y€ ucel ankara training and research hospital, ankara, turkey objective: the aim of the study is to investigate in vitro effect of albumin concentration on total and ionized calcium concentrations. materials and methods: a serum pool with low albumin ( . g/dl) and normal calcium ( . mg/dl) concentrations was prepared from leftover sera. from this serum pool, two parts, each of ml were aliquoted. purified albumin, . g, was added to one of these pools and albumin concentration was determined as . g/dl. the low and high albumin pools were mixed at different ratios and pools with . , . , and . g/dl albumin concentrations. total calcium and albumin concentrations of these pools were measured at a beckman-coulter au analyzer and ionized calcium was measured at a radiometer abl blood gas analyzer in triplicate. total and ionized calcium concentrations were evaluated as compared to those of the original pool with an albumin concentration of . g/dl. results: total calcium concentrations are increased with the increasing albumin concentrations: . %, . %, . %, and . %, respectively. whereas, ionized calcium concentrations were decreased with increasing albumin: . %, . %, . %, and . %, respectively. conclusions: when total allowable error limits based on biological variation were considered, total calcium concentrations are significantly increased at > g/dl albumin concentrations. ionized calcium is significantly affected by . g/dl and over albumin concentrations. a regression equation based on albumin concentration may be useful for corrected ionized calcium concentrations. relationship between lipoprotein (a) and hba c in patients with type ii diabetes , is a complex lipoprotein consisting of ldl and apolipoprotein(a). lp(a) is a risk factor for coronary artery disease and stroke. the relationship between lp(a) and diabetes mellitus is not clear. in this study, the relationship between lp(a) and glycemic parameters such as hba c and fasting glucose concentration was investigated. lp(a), hba c, fasting glucose, triglyceride, total cholesterol, ldl-and hdl-cholesterol concentrations were screened retrospectively from july to july . there were patients with these test results at the same time. the patients were grouped according to hba c values: group i < . % (n = ), group ii . - . % (n = ), and group iii > . % (n = ). the relationship between these parameters were statistically within each group and all groups. there was not a statistically significant difference between the lp(a) concentrations of group i and group ii. lp(a) concentrations of group i and ii were significantly higher than those of group iii.. _ in total, lp (a) was negatively correlated with hba c (r = . ; p < . ), but there was not a significant correlation with fasting blood glucose. _ in groups, there was a significant and negative correlation between lp(a) and fasting glucose in only group i. the negative correlation between lp(a) and glycemic parameters is interesting in patients with diabetes. despite lp(a) is an independent risk factor for cardiovascular diseases, on the contrary to expectations, lp(a) concentrations are decreased in diabetes. effect of blood collection through intravenous lines on hemolysis erroneous results are one of the most important causes of medical errors and may lead to unnecessary investigations or inappropriate interventions. total testing process consists of preanalytical, analytical and postanalytical phases. hemolyzed specimens that one of the most common source of preanalytical errors are frequently observed in laboratory practice and associated with incorrect laboratory results. blood collection through intravenous lines frequently results in hemolysis especially at eds and icus. in this study, we aimed to compare the effect of blood drawing by using bd luer-lock adapters and injector on the hemolysis rates at the ed. patients who has been admitted to the ed were included in this study. all samples were drawn from newly inserted iv lines. the first blood sample was drawn with injector and the second one was drawn with luer-lock adapters to vacuum tubes. after the centrifugation routine chemistry tests and hemolysis indices were analysed on a beckman coulter au analyzer for each serum tube. the statistical significance of differences between two tubes was calculated with paired samples t test and statistical significance was accepted as p < . . there were statistically significant differences between the two groups of tubes for the following parameters: ldh, ck, ast, k + , total bilirubin, protein, albumin, alp, calcium and hemolysis index (p < . ). the use of luer-lock adapters instead of injector could reduce the hemolysis rate. because of it reduces false results and unnecessary investigations, this approach will be more appropriate and cost-effective in ed. hemolysis and test rejection: are we following a reliable process? introduction: in laboratories, some blood samples are rejected due to hemolysis. we usually cancel only some of the tests that are affected by hemolysis. however, the frequency of the test cancellation may be relative. each test is affected in different degrees of hemolysis; some of them are not even affected at all. in this study, we aim to investigate unnecessary cancellations and explain the relationship between hemolysis and test results according to their kit inserts. materials and methods: we measured hemoglobin levels of hemolyzed serum using drabkin method (abbott). interference studies are conducted using clsi protocol nccls ep -p is written in kit inserts. target values ( %) and their change due to different degree of hemolysis have been defined. results: hb concentration ranges of hemolyzed sera were found from to mg/dl. according to kit inserts, aspartate aminotransferase (ast) test results deviate . % from the target when the degrees of hb are mg/dl. when the degree of hemoglobin is mg/dl, the test strays about . %. potassium levels increase ( %) at mg/dl hb while this increase reaches to . % at mg/dl hb. sodium, calcium, ck, crea, total bil, lipase are not significantly affected even at mg/dl. in lactate dehydrogenase (ldh) tests, test reporting is not allowed at any hemolysis level. alt increases %, at the mg/dl hb. ast and potassium results were excluded from patients' reports even though those samples had low hb. some of them were reported despite of excess hemolysis. some tests are even blocked without ever being studied. discussion: prior to the approval of the lab specialist, technicians decide whether to cancel the tests affected by the hemolysis according to the visible hemolysis based on their personal knowledge. conclusion: we should use the hemolysis index, in which standards would be defined via guidelines. this way, all technicians and specialists could know which results are false. the dna-binding hu-proteins are present in all bacteria and belong to the family of nucleoid-associated proteins. these proteins can be considered precursors to eukaryotic histones. gene knockout of hu-proteins partially inhibits the growth of bacteria, their ability to resist various stressing factors and in some cases leads to their death. since the spatial structure of hu-proteins is highly conserved it is possible to create inhibitors that will affect them in a broad spectrum of pathogenic bacteria. in the present work the preparation of the recombinant hu protein from mycoplasma gallisepticum, crystallization of this protein, and x-ray diffraction study of this protein has been reported. the crystallization conditions for studying protein were found by the hanging-drop vapor-diffusion method. found conditions have been adapted to the counther-diffusion method in the capillary. the x-ray diffaction dataset from grown crystals have been collected using synchrotron radiation. d-structure of the hu protein from mycoplasma gallisepticum have been determined with a resolution. structural features of the investigated protein are described. this work is supported by russian scientific fund ( - - ). a novel sensitive disposable indium tin oxide (ito)-based electrochemical immunosensor was developed for simple, rapid and sensitive biomonitoring of sox . sox is a cancer biomarker and used for detecting of small cell lung cancer, lung adenocarcinoma, squamous cell carcinoma, skin cancer, prostate cancer, and breast cancer. in this study, indium thin oxide (ito) thin film was used as working electrode. carboxyethylsilanetriol was also used for electrode modifying so as to obtain self-assembled monolayers. the formed self-assembled monolayers were activated with -ethyl- -( -dimethylaminopropyl) carbodiimide (edc)/n-hydroxysuccinimide (nhs) chemistry. edc was used as a heterobifunctional crosslinker. nhs was used in conjunction with the crosslinker edc. anti-sox antibody was used as a biorecognition element and it was covalently immobilized onto the ito electrode modified with carboxyethylsilanetriol. immobiliztion steps were characterized by cyclic voltammetry (cv), electrochemical impedance spectroscopy (eis), and scanning electron microscopy (sem). the optimal immobilization conditions for the best sensitivity of the new immunosensor were investigated. under optimal conditions, this immunosensor demonstrated a wide linear range ( . - pg/ml) with a detection limit as low as . ng/ml sox . furthermore, the developed sox immunosensor had good storage stability, repeatability and reproducibility. in this work, we successfully fabricated disposable ito thin film based electrodes for sensing the interaction between sox antigen and anti-sox antibody by electrochemical impedance spectroscopy and cyclic voltammetry. and our developed immunosensor has an acceptable performances for the detection of sox antigen, exhibits low detection limit, has selective and reproducible results in immunoreaction analysis. we are thankful for the support from t € ub _ itak (the scientific and technological research council of turkey, project number: z ). applying multiple linear regression model to determine the relationship between anti mullerian hormone with age, luteinizing hormone, follicle stimulating hormone and estradiol: a data mining study introduction: anti mullerian hormone (amh) has a widely used in our life because it is a good indicator of reproductive age to estimate the time of menopause. the purpose of this retrospective data mining study is the estimate of ovarian reserve by using amh and determines relationship between other indicators which are luteinizing hormone (lh), follicle stimulating hormone (fsh), estradiol and age. materials and methods: . women members were included this retrospective data mining study who were applying to acıbadem labmed laboratory. multiple regression analysis of age related changes of amh ( - ) and lh, fsh and estradiol were investigated. beckman gen ii elisa kit was used for amh and the technique of electrochemiluminescence and roche elecsys cobas analyzer were used for the measure of other hormones. results: amh shows meaningful correlation between lh, fsh, estradiol and age but also seen there is no correlation between progesterone. after the multiple linear regression analysiz amh= . -( . age)À( . fsh) + ( . lh)À( . estradiol) is detected and the model's r = . is also detected. conclusion: nowadays there are lots of methodology were developed the estimate the function of ovary and biological age of ovarian. age, fsh, lh and estradiol show ovarian reserve by indirectly. this study shows the mathematical relationship between amh and the other indicators and results are thought to lead to future developments. antioxidant and anticancer effect of artemisia absinthium extract on colon and endometrium adenocarcinoma cells plants have always been among the common sources of medicines that have many phytochemicals with various bioactivities, including antioxidant and anticancer activities artemisia absinthium (ar) has been used as an antipyretic, antiseptic, anthelmintic, tonic, diuretic, and for the treatment of stomachaches in turkish folk medicine. this study aimed to investigate antioxidant, cytotoxic, genotoxic and apoptotic effect of methanol extracts of ar activities on the human colon (dld- ) and endometrium (ecc- ) adenocarcinoma cell line. total phenolic, flavonoid content, and antioxidant activities were determined using suitable methods (abts, cuprac i.e). cytotoxic effects of ar on cells were determined by mtt and neutral red uptake assays. genotoxicity was evaluated by comet assay and, apoptosis induction were detected by apoptosis elisa and acridine orange staining methods at the half maximal inhibitory concentrations (ic ) levels. it was determined that extract have shown antioxidant activity in all tests and that they could be considered as a source of natural antioxidants. cytotoxic effects were concentration-time dependent. specifically, apoptotic and genotoxic effect increased at and lg/ml concentrations by hours. we found that ar extract had antiproliferative, genotoxic and apoptotic effects on the human cancer cell lines dld- and ecc- . however, further studies at molecular level are required to support our findings and to elucidate chemopreventive and chemotherapeutic effects of ar on colon and endometrium cancers. keywords: artemisia absinthium, antioxidant, anticancer, apoptosis, genotoxicity introduction: colorectal cancer is considered as a major gastrointestinal. this cancer is the second cancer related cause of death after lung cancer in worldwide. we designed a vaccine chimeric including cea and ca - against colorectal cancer (ce-ca). materials and methods: the construct were analyzed by bioinformatics softwares. in this study, the ce-ca gene was optimized using the codon bias of e.coli and synthesized by biomatik company. then construct (ce-ca) was cloned into an expression vector and recombinant constructs transferred to e.coli bl de bacterium and desired recombinant protein was expressed. recombinant protein was purified using ni-nta affinity chromatography. the content of secondary structures was obtained by circular dichroism (cd) spectrum. then recombinant protein was confirmed using western blot analysis and indirect elisa method. results: sds-page analysis showed that the recombinant protein was highly expressed and purified. western blot analysis confirmed recombinant protein. also cd spectrum confirmed predicted structures by bioinformatics tools. the elisa results showed significantly high affinity toward recombinant ce-ca protein. discussion: based on many studies, cea as potential immunogenic candidate could be considered in vaccine studies. also ca - is a cell-surface antigen that has significant increase of expression in colorectal cancer, thus as marker of colorectal cancer. based in available data, these two antigens, in combination can provide specificity for production of colorectal cancer vaccine. conclusion: these findings suggest that ce-ca as potential immunogenic candidate which could be considered in future vaccine studies and detection of colorectal cancer. flow cytometric cell cycle and apoptosis analyses of some wild animal species a. tas, e. koban bostanlar tubitak, marmara research center (mrc), genetic engineering and biotechnology institute (gebi), animal genetic and reproductive biology laboratory, kocaeli, turkey cell biobanking; more specifically cryopreservation of biological diversity, is promising as a tool to preserve wild animals as well as domestic ones via nuclear transfer. in this study, we investigated the viability and cell cycle characteristics of wild animal species (fallow deer, red deer, wild sheep, wolf, wild goat). auricular tissue samples were maintained in pbs+ %psa. tissues were seeded on mm petri dishes containing dmem/high glucose supplemented with % (v/v) fcs and incubated %co in air at % relative humidity and at °c. after seeding, the medium was unchanged for days and then it was changed in every days for days at maximum. once the cells were obtained; flow cytometric cell cycle and apoptosis analyses were done. in terms of apoptosis, all the groups showed high viability rates (over %) in culture when compared with the negative control ( %). the cell cycle comparisons were made between serum-starved cells and roscovitine treated cells, both for which untreated cells were used as control, which revealed different results for different species. there was no difference found between serum-starved cells and roscovitine treated cells for red deer and wolf. the serum-starved cells resulted in higher g /g phase for fallow deer and wild goat. on the contrary, roscovitine treated cells resulted in higher g /g phase for wild sheep. as a result; the cells obtained from wild animals had high viability and g /g phase rates. therefore, they may serve as a donor cell source for nuclear transfer studies.(grant: tubitak kamag, turkey, g ). the interaction of different types of antibiotics with endothelial cells in the presence of nanoparticles the interaction of nanomaterials with cells and lipid bilayers is critical in many applications such as phototherapy, imaging, and drug/gene delivery. the aim of this study was to investigate the interaction of nanoparticles (fe o ) or nanoparticles fused with different antibiotics with cell membranes in order to reveal changes in the membrane organization. endothelial cells were used to determine the effect of different antibiotics (gentamicin, kanamycin, amikacin, penicillin, polymyxin, neomycin, cefotaxime, bacitracin, moxicillin, erythromycin, streptomycin and vancomycin) on the membrane organization. for recording the anisotropy of cell suspensions treated with antibiotics or nanoparticles fused with antibiotics we used - -trimethyl- -phenyl , , hexatrien p-toluenesulfonate (tma-dph). we decided to use nanoparticles fused with antibiotics because they contain small amounts of antibiotics which makes them less toxic than simple antibiotics,which is very important in patients with genetic diseases such as cystic fibrosis, that should be treated with antibiotics for a long time. our results showed that at temperatures between and °c simple nanoparticles decreased the membrane fluidity. at physiological temperatures ( - °c) nanoparticles fused with antibiotics (gentamicin, vancomicin, cefotaxim, bacitracin, amoxicillin) increase more the membrane rigidity compare with simple antibiotics or nanoparticles.erythromycin, polymyxin and penicillin increase the membrane rigidity at °c, and at °c the same effect was obtained in the presence of nanoparticles fused with these antibiotics,suggesting that the nanoparticles are dependent to temperature for penetrating the membrane. in conclusion the membrane fluidity does not depend on antibiotics types, the modification are present in many antibiotics irrespective of class type.the presence of nanoparticles fused with antibiotics is very important for long term treatment. objectives: hypertension is an important cardiovascular risk factor for the development of atrial fibrillation (af). increased atrial electromechanical coupling time interval measured by tissue doppler is accepted as an important factor for prediction of af development in hypertensive patients. monoamine oxidases (maos), are enzymes which catalyze the oxidation of monoamines. -isoprostane is considered as an indicator of oxidative stress. mao activity and -isoprostane levels were measured in some diseases. however, there are no information on -isoprostane levels and mao activity in newly diagnosed patients with stage hypertension has not been observed in a study of literature. aim: this is the first study, we aimed to evaluate the levels of mao and -isoprostane in newly diagnosed patients with stage hypertension. the study included newly diagnosed stage hypertensive patients with no other systemic disease. patients were selected as randomized ( women, men; range of age - years) and healthy individuals as control ( women, men; range of age - years). all the underwent tissue doppler echocardiographic examination. blood samples were taken from patients and controls and, the levels of mao and -isoprostane in serum samples were measured by elisa. results: baseline blood pressures, electrocardiographic and echocardiographic findings, and atrial electromechanical coupling were similar in both groups (p > . ). compared to the control group, the activity of mao and -isoprostane levels were found significantly higher in patients (p < . ). conclusion: increased -isoprostane level indicate that there is oxidative stress in newly diagnosed patients with stage hypertension. also, increased mao activity may be biochemical biomarkers for the diagnosis of hypertension. keywords: hypertension, monoamine oxidase, -isoprostane p-mis- determining the indirect reference intervals for complete blood count parameters in bursa, turkey reference intervals (ris) for laboratory test results are defined as the most commonly used diagnostic tool in medicine. therefore, careful determination of ris by the laboratory for use is a very important task. although c -a guideline recommends the direct ris (dris) calculated from healthy subjects, ris can be calculated from laboratory data which are called as indirect ris (iris). the study was carried out at the central laboratory for clinical chemistry, teaching and research (uludag university, bursa, turkey) . the results of the laboratory analyses from , males, , females, stored for approximately one year, were used for statistical analysis. data for hospitalized patients and for ambulatory patients from the intensive care unit were eliminated. furthermore, we used evidence based criteria to enrich the health-related values. a modified bhattacharya procedure was used to estimate the iris from hospital patient data. the nested anova was used to evaluate variations among genders and ages. cell dyn analyzer (abbott diagnostics, il, us) was used for the measurements of complete blood count. the obtained iris were also compared the dris determined in our previous ri study and the ris suggested by the manufacturer. we found that the ris of rbc, hb and hct required strong gender partition and calculated the ris of rbc, hb and hct separately. the observed iris for wbc, sub-fractions of wbc and plt in both genders are in good accordance with the dris reported in previous study. age-related changes were noted for rbc, hb, and hct. the calculated iris for rbc, mcv and rdw are different from the ris suggested by the manufacturer. we believe that, using this relatively easy technique, every laboratory can produce its own iris, divided, where possible, according to sex and age and according to local conditions. these ranges can be complementary to dris obtained for reference individuals according to the ifcc recommendations. the principal sigma subunit, involved in transcription of most house-keeping genes in escherichia coli, was also shown to induce rnap pausing during transcription elongation, by interacting with promoter-like motifs in the transcribed dna. such pauses were proposed to play important roles in the regulation of phage and cellular genes. e. coli contains six alternative s subunits but little is known about their ability to induce transcriptional pausing. we expressed and purified alternative s subunits of the sigma family and tested their effects on transcription elongation in vitro on natural and synthetic dna templates containing consensus promoter motifs. the structure of the paused complexes was analyzed by dna footprinting methods. in vivo analysis of transcription was performed using reporter genes placed under the control of corresponding promoters. we demonstrated that the stationary phase sigma subunit induced efficient rnap pausing on both synthetic and natural dna templates containing promoter-like motifs in initially transcribed regions. in contrast, the sigma and sigma subunits did not affect rna elongation. we showed that the sigma -induced pausing depends on sigma contacts with both nontemplate dna strand and rnap core. the pausing results in formation of backtracked transcription elongation complexes which can be reactivated by gre factors that stimulate rna cleavage by rnap. our results for the first time reveal transcriptional pausing induced by an alternative s subunit. analysis of sigma -dependent promoters shows that a substantial fraction of them contains potential pause-inducing motifs suggesting that such pausing may be a widespread phenomenon. we propose that sigma -dependent pauses may play important roles in genetic regulation and modulate the binding of transcription repressors or activators to promoter regions. the crosstalk between streptococcus pneumoniae rnase r, ribosomes and translation c. b arria, s. domingues, c. arraiano instituto de tecnologia qu ımica e biol ogica, lisbon, portugal ribonucleases (rnases) are enzymes that ensure maturation, degradation and quality control of rna thus, contributing to the maintenance of the optimal amount of each transcript in the cells. escherichia coli rnb family of enzymes is present in all domains of life and includes rnase r, rnase ii and the eukaryotic rrp /dis , dis l and dis l proteins. in streptococcus pneumoniae only rnase r was identified. rnase r, encoded by the rnr gene, hydrolyzes rnas starting from the end. rnase r level is increased in several stress conditions such as heat shock, stationary phase or cold shock, conditions in which most of the proteins translation is blocked. moreover, rnase r is the only exoribonuclease able to degrade highly structured rnas without the help of a helicase which is critical at low temperatures. here, we investigated the role of this enzyme by comparing the wild type strain with an rnr mutant strain. for that purpose we performed northern blots analysis of transcripts involved in translation. also, we investigated rnase r connection to the ribosome and polysome fractions using sucrose gradient polysome separation and western blots. in this study, we highlight the importance of s. pneumoniae rnase r in translation. we show that this enzyme interacts with ribosomes mostly with the s subunit at °c. moreover, in the absence of this enzyme we have observed a decrease in the amount of the s ribosomal subunit, concomitantly with the increase of s and s subunits. rnase r seems also to modulate the amount of the elongation factors ef-tu and ef-g transcripts. nevertheless, preliminary results further suggest other roles of rnase r in translation. modified nucleotides are present in many rna species in all domains of life. the biosynthetic pathways of such nucleotides are well studied. however, much less is known about the degradation of rnas and the salvage of modified nucleotides, their respective nucleosides or heterocyclic bases. using an e. coli uracil auxotrophic strain, we screened the metagenomic libraries for genes, which would allow the conversion of -thiouracil to uracil and thereby lead to the growth on a defined synthetic medium. we show that a novel gene encoding previously uncharacterized domain of unknown function (duf) is responsible for such phenotype. we have purified this recombinant protein and demonstrated that it contains a fe-s cluster. the substitution of cysteines, which have been predicted to bind such clusters, with alanines abolished the growth phenotype. we conclude that this domain is required for conversion of -thiouracil into uracil in vivo. this work is supported by the research council of lithuania (lmt, mip- / modified nucleotides are present in almost all classes of rna. they have great chemical diversity and are critical for rna folding, stability, interaction with cellular proteins and thereby for various cellular processes such as translation, stress response, and signaling pathways. biosynthesis of pyrimidine nucleotides and their modified derivatives in rna is well studied. nonetheless, not much is known about the cellular degradation of these compounds and the enzymes catalyzing such processes. using an e. coli uracil auxotrophic strain, we screened metagenomic libraries for genes encoding isocytosine deaminases. three novel genes were obtained, one of which encodes a protein similar to oxoguanine deaminases. the other two encode proteins resembling hydroxydechloroatrazine ethylaminohydrolases. we confirmed that these proteins are functional in vivo, allowing growth of e.coli on minimal medium with isocytosine. we also demonstrated that such purified recombinant enzymes catalyze the conversion of isocytosine, but not cytosine, into uracil in vitro. natural products display special attributes in the treatment and prevention of various human diseases, including cancer. a significant number of organic compounds from plants exhibit anticancer properties as attested by in vitro and in vivo studies. emerging evidence supporting the antineoplastic activity of natural compounds has rendered them promising agents in the fight against cancer. in this study, skin from limnio grape, a red greek grape variety that is indigenous to the greek island of lemnos, was extracted using mixtures of methanol, water and acetone; the apoptosis-inducing properties of these extracts were studied in the human ovarian malignant adenocarcinoma cell lines tov- g and tov- d. for this purpose, tov- g and tov- d cells were treated with limnio grape skin extracts at a range of concentrations, at °c, for , and hours. untreated cells incubated for the same time intervals served as controls. cell viability was determined by measuring metabolic activity (colorimetric mtt assay) and observing cell membrane integrity (cell staining with trypan blue). after the determination of the optimal concentration of the extract, total rna was extracted from treated and untreated (control) tov- g and tov- d cells. after determination of rna concentration and subsequent first-strand cdna synthesis, mrna expression analysis of apoptosis-related genes was performed with rt-pcr using gene-specific primers. an increasing percentage of non-viable cells was observed by increasing cell exposure time and extract concentration. distinct modulations of the expression of apoptosis-related genes at the mrna level were also observed, mainly concerning bcl , bclx, bax, bak and bcl l , along apoptosis induction. in conclusion, the cytotoxic properties of limnio grape skin extracts against ovarian malignant adenocarcinoma cells merit further investigation. the intrinsic apoptotic pathway seems to be the major mechanism of action induced by these plant extracts. almost all eukaryotic mrnas are polyadenylated by a complex machinery that recognizes the poly (a) signal, cleaves the mrna and adds the poly (a) tail. % of human genes harbor multiple poly (a) signals. alternative polyadenylation (apa) generates transcript isoforms with different utr (untranslated region) lengths due to the use of proximal or distal poly (a) signals. hence, tightly regulated apa has been observed in normal physiological settings as well as in diseases. considering that utr shortening cases have been linked to increased protein levels, we hypothesized deregulated apa to be one of the potential cancer related mechanisms. we investigated the utr alterations in er(+) breast cancer patients and cell models compared to normal breast tissue, using gene expression data and a probe-based quantification tool, apadetect. based on means of proximal to distal probe sets, slr (short-long ratio) were calculated as an indication apa. significance analysis of microarrays (sam) determined significant genes. the gse numbers of the datasets are gse , gse and gse . we analyzed two datasets of er(+) breast cancer patient samples (n = , n = ) compared to normal breast tissue (n = ) using apadetect and sam. a total of utr shortening and utr lengthening events were detected in breast cancer samples compared to normal breast tissue. ontology analysis suggested almost all the utr shortening genes were proliferation related and were indeed reported to be upregulated in breast cancer. to further investigate the connection between apa and era status, we used data from a cell line model; wild type or era transfected mda-mb- cells that are otherwise of triple negative nature. our results suggested that most of the genes are utr shortened or lengthened via direct binding of era to dna. our results suggest involvement of apa mechanisms in era action mechanisms. possible link between era regulated transcription and apa remains to be elucidated. contamination of nucleic acids (na) as a result of na extraction protocols may result an inaccurate measurement of dna copy number. agarose gel electrophoresis and spectrophotometric methods are commonly used to check dna purity. however, the resolution of these methods may not be good enough for special applications such as determination of dna copy number and separation of base pairs (bp) that are close in their bp number. in this study, we have developed a new method for separating na's ranging between - bp also detecting the impurities in dna solution in %, % and % ratios to the dna of interest. the developed method was validated using the in-house dna fragments of , and bp. the dna mixture analyzed using analytical hitachi elite lachrom hplc using the guard and analytical columns tskgel dna-npr, . lm, . mm id . cm and tskgel dna-npr, . lm, . mm id . cm, respectively. the validation of the analysis was performed by running each sample five times on three different days. the linearity of the detector response was established by plotting a graph to quantity versus area of bp dna. the lod and loq were then measured by calculating the minimum level at which analyte can be readily detected and quantified. the ratios calculated with hplc were compared to the ratios calculated by quant-it kit. recovery values were calculated for each measurement and the uncertainty were calculated for each ratio. the method was found linear for bp in the range of . ng to ng dna with the regression coefficient of r = . . lod and loq for the bp dna was found to be . ng and . ng, respectively. the recovery values for the %, % and % impurity ratios were found . . . and . , respectively. the purity of the synthetic dna was determined by hplc and related uncertainty was calculated. the developed method is a simple alternative to electrophoresis and spectrophotometric methods with higher resolution and separation range. physical and chemical factors can disturb the conformation of proteins maturing within the cellular secretory pathway. in response to unfolded proteins the cell activates several stress signaling and adaptive response mechanisms. the aim of our study was to investigate small non-coding rnas as the potential regulators of cellular response to unfolded proteins (upr). for this, we conduct the next generation sequencing of small rna and transcriptome analysis of mrna from jurkat cells exposed to dithiothreitol (dtt), which reduces protein disulfide bounds. analysis of mirnas reveals the differential expression of mirnas. we observe a decrease in the normalized amount of reads aligned to mirna loci in stressed cells. affymetrix analysis with subsequent gsea reveals downregulation of reactome mirna biogenesis pathway (fdr = . ). the length distribution of small rnas revealed nt-peak corresponding to trna-derived fragments, amount of which was increased by . -fold under dtt treatment. the trna isotypes that gave rise to almost % and % of all nt rna fragments in stressed and control cells, respectively, include glycine, glutamic acid, aspartic acid and valine. the vast majority of nt fragments produced from these trnas are precisely phased halves with the characteristic cleavage patterns generated by rnase a angiogenin (ang). observed upregulation of tirna in stressed cells is accompanied with upregulation of ang mrna and down-regulation of angiogenin inhibitor (rnh ). we speculate that translational repression, associated with observed tirna, is an additional mechanism of reducing global protein synthesis in response to dtt-induced stress. collectively, our findings reveal the increase in tirna, the differential regulation of mirna expression together with the global mirna downregulation as the most prominent small rnome reprogramming events and possible fine-tuned levels of post-transcriptional regulation upon dtt-induced cellular stress response. global gene expression changes after spinal cord injury j. k. hyun , , , j. kim , , j. y. hong dankook university, cheonan, south korea, institute of tissue regeneration engineering (itren), cheonan, south korea, the neuronal regeneration is hardly achieved spontaneously after spinal cord injury (sci), and the restoration of somatic and autonomic functions after sci is also challenging in the clinical field. the pathophysiology of sci is extremely complex and many in vitro and in vivo studies continued to report opposite results each other in spite of the same treatments, therefore a fundamental analysis such as an extensive assay of global gene expression is required to find a way for spinal cord regeneration. in this study, we aimed to detect the changes of global gene expression after spinal cord contusion in rats according to the time sequence. the spinal cord tissues at contusion site were sequenced after spinal cord contusion in rats using rna-sequencing technology. for time sequence analysis, five time points was determined; hour, day, week, month and months after spinal cord contusion, and sham operated rats at each time point were used as controls. quantitative rt-pcr analysis was also performed to validate expression changes of candidate genes in each category. we found that the pattern of changes in gene expression at acute and subacute stages was quite different from that at chronic stage, especially genes associated with with neurotrophin signaling and apoptosis pathways. most of gene expression levels of inflammatory cell markers were increased and peak during acute stage ( hour to week) and maintained until chronic stage. some of regeneration-associated genes (rags) including brain derived neurotrophic factor, glial cell derived neurotrophic factor and ciliary neurotrophic factor were increased at hour or day after sci. we concluded that the information of gene expression level according to the time sequence after sci might be useful to determine treatment strategies for spinal cord regeneration especially in chronic stage. p- . . - utr length isoform generation profile in a differentiation model alternative polyadenylation (apa) is the regulated selection of a specific poly(a) signal among other proximal and/or distal signals on the utrs (untranslated region) for the endolytic cleavage and addition of a poly(a) tail to form the mature mrna. consequently, position of the poly(a) site determines the length of the utr which is known to harbor microrna and rna binding protein sites. such apa isoforms have already been linked to altered protein levels and even functions. therefore we hypothesized apa to be one of the mechanisms to generate isoform diversity in proliferating and differentiated cells to better understand the molecular basis of cancer. we used a combinatorial in silico and in vitro approach to analyze a well known enterocyte differentiation model; caco- cells. initially we analyzed gene expression datasets for the proliferative and differentiated caco- cells using a probe based apa detection tool. to better understand the significance and to validate these results, we used proliferating and differentiated (day ) caco- cells and tested sample apa events by rt-qpcr. utr isoforms were identified by using race pcr. we identified genes ( % of all apa events) to undergo utr shortening in differentiated cells compared to proliferating cells. on the contrary genes ( % of all apa events) went through utr lengthening events. several genes have been validated to follow the pattern that was seen in apa detection tool so far. to begin understanding the mechanism behind these observations, we are investigating potential inducers of apa during the complex events of differentiation. our next aim will be to further validate and investigate the consequence of such isoform generation events both in the context of differentiation in colon cancer cells. recognition of phosphorylated threonine- of rna polymerase ii c-terminal domain by end processing apparatus o. jasnovidova, m. krejcikova, k. kubicek, r. stefl central european institute of technology, masaryk university, brno, czech republic rna polymerase ii has evolved an array of heptad repeats with the consensus sequence y -s -p -t -s -p -s at the c-terminal domain (ctd) of its largest subunit, rpb . phosphorylation of serines (s , s , and s ) and tyrosine- orchestrate the binding of rna processing and transcription factors in the site of transcription. several recent studies showed that also threonine- site can be phosphorylated which has a number of functional consequences. to reveal the structural basis for the recognition of threonine- phosphorylated ctd, we set out to investigate several proteins factors that were implicated with a high levels of threonine- ctd phosphomarks using integrative structural biology. one of them, a factor involved in the -end processing and transcription termination, showed a high affinity to the phosphothreonine ctd. using nuclear magnetic resonance spectroscopy (nmr), we determined its structure bound to the ctd phosphorylated at threonine- that reveals a direct read-out of the phosphothreonine. altogether, our data provides the first insights into the recognition of this poorly understood ctd mark that plays important role in the ctd code of rna polymerase ii. the results of this research have been acquired within ceitec (lq ) project with financial contribution made by the ministry of education, youths and sports of the czech republic within special support paid from the national programme for sustainability ii funds. introduction: the treatment of brain tumor glioblastoma (gbm) is still one of the greatest challenge. anti-inflammatory drug indomethacin (ind) mainly acting through the inhibition of cyclooxygenase (cox) has also anti-cancer activity including brain tumors. the aim was to investigate how ind effects an immortality enzyme telomerases' activity. materials and methods: monolayer and spheroid cultures of t g human gbm cell line were used to evaluate the effects of ind ( lm) on cell proliferation, viability, apoptosis, cell cycle, camp levels, the levels of apoptotic and anti-apoptotic proteins, morphology (sem) and ultrastructure (tem) for hours. results were analyzed using the student's t-test. results: ind decreased cell proliferation (p < . ), cell viability (p < . ), cell rate at s phase (p < . ) and g + m phase (p < . ), camp levels (p < . ), the levels of pdgfr-a (p < . ), mrp- (p < . ), nf-jb (p < . ) and cox- (p < . ) in comparison to control group. ind mildly increased apoptosis (p < . ) and caspase- levels (p < . ). interestingly, ind increased htert levels ( %, p < . ; %, p < . ). sem evaluation showed that ind led to decreased and shortened microvilli, the lost of cell interactions and the conversion of many cell shapes from spindle to oval. many cell remnants in the intercellular area, intact cell membranes, many dense lipid droplets and few autophagic vacuols in the cytoplasm were observed under tem. discussion and conclusions: the effect of ind on telomerase activity can only be found in publications at pubmed research that they only showed its' inhibitory effect in colon, gastric, head and neck cancers. in contrast to previous studies, it was shown for the first time that ind increased telomerase activity in gbm cells and this increase was independent from cox- and other tested factors. p- . . - interaction between fibrinogen and insulin-like growth factor binding protein- under physiologic conditions and influence of diabetes mellitus type on this interaction n. gligorijevic, o. nedic institute for the application of nuclear energy, university of belgrade, belgrade, serbia fibrinogen is plasma glycoprotein and principle participant in blood coagulation. it interacts with many proteins, including insulin-like growth factor binding proteins (igfbps). one of them, igfbp- , is controlled by insulin. metabolic changes due to diabetes mellitus (dm) affect igfbp- . besides glucose regulation, igfbp- stimulates wound healing. we have investigated complexes formed between fibrinogen and igfbp- , their change in dm type (dm ) patients and involvement in fibrin clot. samples from adult healthy persons and dm patients were studied: plasma, isolated fibrinogen and fibrin. the amount of igfbp- /fibrinogen complexes was determined using immunoblotting. immunoprecipitation and lectin affinity chromatography were used to confirm interaction between fibrinogen and igfbp- . in vitro incubation of fibrinogen with excess glucose or methylgyoxal (mgo) was employed to demonstrate influence of glyco-oxidation on complexes. results have shown that igfbp- /fibrinogen complexes can be differentiated from igfbp- oligomers and igfbp- /alpha- macroglobulin complexes. the amount of igfbp- /fibrinogen complexes was lower in patients with dm . complexes participated in fibrin clot formation, the amount being significantly lower in patients' samples. the quantity of igfbp- monomer in fibrin clot was greater in patients' samples. in vitro experiments revealed that complexes undergo glyco-oxidative modifications leading to their reduced formation, cross-linking and increased acidity (faster electrophoretic movement). isolated fibrinogen from patients with dm was additionally able to bind exogenous igfbp- . since igfbp- stimulates wound healing, directly and by delivering igfs, igfbp- /fibrinogen complexes may be seen as igfbp- storage instrument, ready to participate in fibrin formation and to assist in damage repair. reduction of complexes due to glyco-oxidative stress in patients with dm may be part of the mechanism responsible for impaired coagulation process. human interferon gamma (hifnc) is a proinflammatory cytokine involved in the regulation of nearly all phases of immune and inflammatory responses. its abnormal expression is associated with the aetiology of many inflammatory and autoimmune diseases. recently we have been exploring the idea to counteract the over-expression of the endogenous hifnc by competitive inhibition with inactive hifnc mutants. they are designed to have preserved affinity to the hifnc receptor, but to be deprived in their capability to trigger the intracellular signal transduction. to this end a library of mutants was created and two potential hifnc antagonists were selected for further investigations: a single point mutant k q (q substitution for k in position ) and a double mutant with additional substitution in the n-terminus. both mutants and the wild type hifnc were expressed in e. coli employing the established by us methodology for large scale production of aggregation-prone proteins in soluble native form. the purified mutants were screened for interferon activity (antiproliferative assay), binding affinity (isothermal titration calorimetry) and ability to compete with the wild type for the hifnc receptor (competition assay on wish cells). the selected mutants demonstrated (single mutant) and (double mutant) times lower antiproliferative activity than the wild type. measuring the binding thermodynamic parameters, we proved that the receptor binding affinity of both mutants was preserved, which is an indication for their potential to compete with the wild type hifnc for its receptor. finally, the biological assay performed on wish cells showed a distinct dose-dependent competition between the wild type hifnc and the mutants. based on the results presented in this study we conclude that the two hifnc mutants are potential candidates for autoimmune therapy based on selective suppression of the endogenous hifnc activity. mesencephalic astrocyte-derived neurotrophic factor (manf) is an er (endoplasmic reticulum) stress-inducible protein and widely expressed in mammalian tissues. it has been identified as a secretory protein that protects cells against er stress-induced damage. er-stress is one of the main mechanisms that play a role in ischemia/reperfusion (i/r)-induced renal injury. recent studies demonstrated that manf can protect cardiac myocytes and cortical neurons against i/r-induced injury. moreover, it has been suggested that it has a restorative effect in ischemic injury. nevertheless, the function of manf in i/r-induced renal injury is still not known. in the present study, we investigated the function of manf by manipulation its expression level in ischemic acute renal failure model established in proximal tubular kidney cells (hk- cells). for this purpose, the cells were transfected with either manf sirna or manf encoding plasmids for silencing or over-expression of manf, respectively. then, the cells were exposed to hypoxia-reperfusion (h/r) induction for indicated times. evaluations of cell viability were determined with wst- reagent. the changes in protein levels of h/r-induced stress markers were analyzed byimmunoblotting. the results showed that the overexpression of manf has provided a significant resistance to h/r-induced cell death, whereas silencing of manf has rendered the cells more susceptible to death. it was also determined that the pretreatment of cells with manf conditioned medium caused a decrease in cell death. additionally, oxidative/nitrosative stress (os/ns) and er stress levels were decreased with over-expression of manf and increased by silencing of manf in hk- cells. taken together, our study suggests that manf may have a protective role against h/r-induced renal cell injury, possibly through the reducing effects on os/ns and er stress. p- . . - his-flag tag as a fusion partner in insect expression systemgain or loss? e. krachmarova , m. tileva , k. maskos , i. ivanov , g. nacheva institute of molecular biology "roumen tsanev", sofia, bulgaria, proteros biostructures, martinsried, germany human interferon gamma (hifnc) is a glycoprotein playing major role in the regulation of innate and adaptive immunity. glycosylation is not essential for hifnc activity but is important for its stability, half-life and protease resistance in blood. the commonly used hifnc in therapy and research is produced in e. coli and therefore is not glycosylated. bearing in mind the above mentioned shortcomings of the non-glycosylated hifnc we expressed it in mammalian cells and transgenic mice, however very low yields were achieved. to obtain glycosylated hifnc, here we employed a secretory expression of n-terminal his-flag fusion protein in baculovirus-infected insect high five Ò cells. this small hydrophilic tag is designed to not affect the proper folding of the target protein and to facilitate the detection and purification procedures. in parallel the same fusion was expressed in e. coli cells. the fusion proteins were purified to high degree of purity by affinity and size-exclusion chromatography. bioassay carried out on wish cells showed that the antiproliferative activity of both fusion proteins was times lower than that of the native hifnc. this result shows that, in contrast to the generally hold view, the n-terminal his-flag tag interferes with the biological activity of hifnc despite of the protein glycosylation. in order to restore the biological activity we attempted to remove the his-flag tag enzymatically. surprisingly, we found that the fusion protein obtained from insect cells was resistant to enterokinase, independently of the enzyme source and experimental conditions, whereas the protein isolated from e. coli was susceptible and the tag-free protein showed fully restored biological activity. we are prone to explain the enterokinase resistance of the fusion protein from insect cells with either the specific conformation of the glycosylated protein or with the interaction of the carbohydrate residues with the enzymatic activity of the enterokinase. p- . . - development of fluorescence assay for highthroughput screening system based on flow cytometry for directed evolution of cellobiose dehydrogenase cellobiose dehydrogenase (cdh) is an enzyme produced by phanerochaete chrysosporium and it has been already successfully cloned in other organisms. one of the most important roles of cdh is removing products of cellulose degradation. cdh is very important for biofuel and biosensor industry. for improvements of enzyme properties we have used directed evolution. the most important step is to develop screening system that reflects properties of interest. screening in microtiter plates (mtp) is expensive, time-consuming and has low throughput with a small number of variants detected ( - in months). the aim of this work was the development of screening system for mutant libraries of cdh expressed on surface of yeast cells based on fluorescent enzymatic assay and flow cytometry. the screening method should be capable of screening cellobiose dehydrogenase variants mutated for higher activity and higher thermostability by error prone pcr. the fluorescent assay was beta-galactosidase (ec . . . ) also known as lactase is the enzyme that typically catalyzes hydrolysis of beta- , -d-galactosidic linkages in beta-d-galactosides, including disaccharide lactose, with glucose and galactose as end reaction products. this enzyme is able to catalyze synthesis of oligosaccharides, in particular galactooligosaccharides via galactosyl transfer reaction. arthrobacter sulfonivorans beta-galactosidase of unique for prokaryotes extracellular localization may find application in food industry for manufacturing lactose-free dairy products and in pharmacology as bioactive principle of medicines prescribed for patients suffering from lactase deficiency. the study was aimed at cloning of the gene encoding a. sulfonivorans beta-galactosidase, purification and characterization of the enzyme. a novel extracellular beta-galactosidase from a. sulfonivorans was recovered with an overall -fold purification, a . % yield and specific activity uÁmg À protein. the subunit molecular mass of the enzyme determined by sds-page analysis equalled kda. it was found that the enzyme displays pi . , prefers ortho-nitrophenyl-beta-galactoside as substrate (km mm) and shows maximum activity at °c and at ph . - . . the beta-galactosidase gene was isolated from the genomic dna library of a. sulfonivorans, sequenced, cloned and deposited in the genbank database under accession number km . . it was established that the gene carries an open reading frame consisting of bp ( amino acids) and encodes beta-galactosidase referred to glycosyl hydrolase family (cazy database). p- . . - different splice-forms of tdrd protein mutated in cataract's and glaucoma's interacts with s k / o. skorokhod, v. filonenko department of cellular signalling, institute of molecular biology and genetics nas of ukraine, kyiv, ukraine ribosomal s kinases (s k) are important players in cellular pi k/mtor signalling network, deregulation of which has been associated with methabolic disorders, inflammation and cancer. previously we had identified a novel binding partner of s k -tdrd (trap). tdrd is a scaffold protein detected in complexes involved in the regulation of cytoskeleton dynamics, mrna transport, protein translation, non-coding pirnas processing, transposons silensing. it was reported recently that mutations in human tdrd result in cataract and glaucoma formation, defined by elevated intraocular pressure (iop) and optic nerve damage. the aim of our study was to confirm s k-tdrd interaplay and study its role in cells. bioinformatical analysis of tdrd sequence revealed the presence of potential phosphorylation sites of s k . using in vitro kinase assay, we have demonstrated that recombinant s k phosphorylate from fragments of tdrd . formation of s k -tdrd complexes in vivo was further confirmed by coimmunoprecipitation using anti-s k and anti-tdrd antibodies generated previously in rat brain lysates. this interaction was further confirmed by confocal microscopy, oleksandr had shown that tdrd co-localize with s k in hepg cells, predominantly in perinuclear region, enreached for one of the tdrd isoforms identified previously. moreover, we have detected that c-terminal synthetic peptides of s k with methylated arg interfere with tdrd from hepg lysates. the physiological characteristics of s k -tdrd interaction and the role of this complex formation in neuropathology's development need further investigation. many biological function of placenta are performed not just a set of individual proteins, but also different oligomeric structures and complexes. herewith, activities of complexes may considerably differ from activities of individual proteins. therefore, identification and characterization of placental multi-protein complexes is an important step to understanding the placenta function. the aim of the present work was to investigate a composition and biological functions of the very stable high molecular mass multi-protein complexes (spc) from placenta of healthy mother. we isolated spcs (~ kda) from the soluble fraction of three human placentas. light scattering measurements and gel filtration showed that the spc is stable in presence salts, acetonitrile and triton x- in high concentrations, but efficiently dissociates in the presence of m urea and mm edta. such a stable complex is unlikely to be a random associate of different proteins. it was shown the spc includes a number of proteins with molecular weights of to kda. several protein components of the spc were identified, including serum albumin, transferrin, iggs, annexin a and other proteins. serum albumin, transferrin and protein with molecular weight , kda are the main proteins of the complex. it was shown high the spcs from three placentas possesses dnsase and catalase activities. an addition, investigation of cytotoxic effect on human cancerous cell lines has shown that the spcs reveal high cytotoxicity. antibody-cytochrome b fusion protein, characterization and applications for antibody development process antibodies have recently become an essential tool being a part of immunodiagnostics, therapeutics and as a valuable instrument in life science research. an enormous number of options utilizing a various tags were used to create a universal antigen-binding domain, which can be easily detectable, highly soluble and might be produced in high yields with low costs, but no multipurpose solution exists yet. we addressed the question whether a single tag could be found for enhancing solubility of recombinant fab antibody fragment and providing its detection and accurate quantification by rather simple method. a new application for hemeproteincytochrome b as the antibodies fusion partner were proposed. we have constructed of recombinant fab antibody fragment cytochrome b fusion protein. we have shown that cytochrome b enhance expression of fab antibodies fragments in bacterial system, and could be a versatile tool for recombinant proteins folding, redox (oxidation) state studies and for their precise concentration determination in the turbid solutions. fusion fab-b protein has a stable red color and characteristic absorbance spectrum with the maximum absorbance at nm in oxidized environment. cytochrome b change its spectrum maximum depending on environmental redox potential and its folded state, so one can track these events in real time spectrophotometrically. binding activities of fab-b fusion protein and hybridoma secreted immunoglobulin were measured by biolayer interferometry and elisa. no significant difference between them was revealed. due to this feature we can distinguish the chimeric protein of interest in complex mixtures and control the process of recombinant proteins expression and purification in real-time. besides, cytochrome b fusion tags multiples recombinant antibody yield (from to times) and doesn't affect antigen-binding properties. the bb - site of fibrin molecule is the site of fibrin protofibrils lateral association l. urvant palladin institute of biochemistry nas of ukraine, kyiv, ukraine previously we showed that fibrin-specific monoclonal antibody i- c (monab i- c) inhibited the fibrin protofibrils lateral association. we suggested that the epitope of monab i- c in bb - of coiled-coil region of fibrin molecule coincides with the site involved in fibrin protofibrils lateral association. the aim of this study was to localize the site of protofibrils lateral association in fibrin molecule using the synthetic peptides bb - , bb - and both their scrambled version, and bb - peptide. monab i- c was isolated from hybridoma culture medium by affinity chromatography on fibrin-sepharose. turbidity analysis was used to study the effect of synthetic peptides on fibrin polymerization. the interaction between peptides and monab i- c was investigated by spr method using plasmon- device. we investigated the effect of synthetic peptides which corresponded to amino acide sequences of fibrin molecule bb - , bb - , bb - , and the scrambled versions of bb - and bb - peptides on a binding to monab i- c and on the fibrin polymerization process. in spr analysis was showed that bb - and bb - peptides, but not their scrambled version, binds to monab i- c, immobilized to a chip. turbidity data showed that only bb - and bb - peptides caused the -fold decrease of the rate of the lateral association of protofibryls at the concentration . À m and . À m, respectively. both of them decreased the final clot turbidity. our data let us to suggest that the bb - site is the site that involved in protofibryls lateral association. it has been recently shown that irisin immunoreactivity was altered in gastrointestinal cancers. as known hematological malignancies was one of the most common malignancies through world, but no study was present how irisin was changed in this type of cancers. therefore, purpose of this was to investigate how immunoreactivity to irisin was altered in hematological malignancies (blood cancers). we used an antibody from phoenix to demonstrate how a kda band after deglycosylation of irisin altered in hematological malignancies. here we first time showed that irisin tissue immunoreactivity from acute lymphoblastic leukemia (all) and acute myelogenous leukemia (aml) patients was increased when compared with unaffected biological tissue parts. from the immune-histochemical (ihc) investigations it is concluded that hematological tissue and blood cells may be another source of irisin and increased with cancer, thus this finding might help to enlighten pathophysiology of hematological malignancies. the value of urine neutrophil gelatinaseassociated lipocalin (ngal) in acute heart failure n. serdarevic clinical centre, sarajevo, bosnia and herzegovina introduction: renal dysfunction is very common in heart failure (hf) and neutrophil gelatinase-associated lipocalin (ngal) is used as an early marker of acute renal tubular injury. recent studies have been reporting that ngal is inhibitor of inactivation of matrix metalloproteinases (mmp- ) which results in enhanced proteolytic activity with prolonged effects on collagen degradation. due to its relation to extracellular matrix degradation in myocardium and infammation, we hypothesized possible increased ngal expression in hf besides it renal dysfunction etiology. patients and methods: in study were included patients hospitalised with signs and symtoms of ahf. urine samples for ngal analysis were collected at admission and analysed by the chemiluminescent microparticle immunoassay (cmia) for the quantitative determination of neutrophil gelatinase-associated lipocalin in human urine (abbott, architect analyzer). refferent range for urine ngal is - ng/ml. on admission blood samples for bnp (brain natriuretic peptide) analysis were drawn and tested by architect bnp chemiluminescent microparticle immunoassay (cmia), abbott laboratory. results: the mean age of the patients (male= , female= ) was . years (sd . years). among them ( %) patients was diagnosed as a hf-pef (hf with preserved ejection fraction) while ( %) as a hf-ref (hf with reduced ejection fraction). mean bnp values was . pg/ml (sd . pg/ml) and mean lvef was . % (sd . %). mean urine ngal was . ng/ml (sd . ng/ml). we found significantly positive, but weak correlation among ngal and bnp only by pearson correlation test (r = . , p = . , wilcoxon signed rank test z = À . p < . ). conclusion: bnp levels are elevated in hf with reduced and preserved ejection fraction. urine ngal is not elevated in acute heart failure, but it is slightly positively correlated with serum bnp values. converging evidence implicates the intermediate and medial mesopallium (imm) of the domestic chick forebrain in memory for a visual imprinting stimulus. a number of learning-related changes have been found in plasma membrane and mitochondrial proteins of imm. for broader analysis of these changes we employed two-dimensional gel electrophoresis/mass spectrometry approach and identified differentially expressed proteins in membrane-mitochondrial fraction of the imm across chicks with different estimated levels of imprinting h after training. we further inquired whether the amounts of those proteins in the imm and a control region (posterior pole of the nidopallium, ppn) are correlated with memory for the imprinting stimulus. learning-related increase in the amounts of the following proteins was demonstrated in the left imm, but not in the right imm or left and right ppn: (i) membrane cognin;(ii) a protein resembling the p subunit of splicing factor sf ;(iii) voltage dependent anionic channel- ;(iv) dynamin- ; (v) heterogeneous nuclear ribonucleoprotein a /b . obtained results indicate that the molecular processes involved in learning and memory of imprinting cover a wide range of cellular activities, including stabilization of protein structures, increased mrna trafficking, synaptic vesicle recycling and specific changes in the mitochondrial proteome. the aim of this work is to study the substrate and inhibitory properties of uridine derivatives in the reactions catalyzed by e.coli up in order to shed some light on the substrate's conformation in the productive complex with the enzyme. we studied the e.coli up-catalyzed phosphorolysis of uridine and its derivatives modified in the heterocyclic base and the sugar moiety. the kinetic constants (km, ki, kcat ) of the phosphorolysis reaction of near uridine derivatives were determined. the combined kinetic (nnna, , ) and structural data (acta crystallogr., d , , ) provide clear evidence that up binds uridine in the most energetically unfavorable conformation, which, to the best of our knowledge, has no precedents in the enzymes of nucleic acid metabolism. this is possible due to multiple interactions between the substrate and the protein environment (active site residues) mainly through hydrogen bonds. these results are important for understanding the mechanism of action of this class of enzymes. an analysis of the conformations of nucleosides in solution and rotational barriers suggests that the energy difference between the ground state of uridine and uridine complexed with up may be high as - kj/mol. the binding in a high-energy conformation results in the weakening of the glycosidic bond. the observed conformation of uridine complexed with sulfate (mimetic of phosphate) may be very similar to its conformation in the transient state. until now, foxp (forkhead box p ) has been identified as a tumor suppressor in several correlation studies in breast cancer. although, foxp is defined as a transcriptional repressor that interacts with other transcription factors in various mechanistic studies, there is no study that explains its repressor functions in breast cancer biology. here we demonstrate the repressor function of foxp on nfat (nuclear factor of activated t cells) and the migratory effect of this repression in mda mb breast cancer cells. we performed co-immunoprecipitation experiments for the investigation of protein-protein interaction between two transcription factors. protein-protein interaction on dna was investigated with emsa and transcriptional effects of foxp on nfat, lusiferase reporter assay was performed. wound healing assay was used to analyse the effects of overexpression of foxp on tumor cell migration. our results showed that foxp has protein-protein interaction with nfat on dna and enhances breast cancer cell migration by repressing nfat transcriptional activity and foxp shows oncogenic function by regulating breast cancer cell motility. introduction: phosphodiesterase (pde ) is one of phosphodiesterase lead to hydrolyzing cgmp.the cgmp signaling pathway has an important role in proliferation of cells. previous studies showed pde was increased in cell lines cancers thus pde inhibitors can used as efficacious therapeutic option for treatment of cancers. the current study was to investigation the effect of hydroalcoholic achillea.wilhelmsii extract (hawe) on the pde gene expression and cgmp signaling in the mcf- er + and mda-mb- er À . methods and materials: the ed of the hawe on both cell lines were examined by using mtt viability test then the expression of pde and cgmp concentration were measured in timedependent manner (in the ed ) by real-time rt-pcr and colorimetric assay respectively. results: treatment with the hawe showed, lg/ml is ed for both cell lines and the hawe lead to reduction in pde mrna expression and evaluation of intracellular cgmp showed an increase pattern in the time-dependent manner. conclusion: our results showed that the hawe has anti-proliferative property in the mcf- and mda-mb- , cell lines of breast cancer through the cgmp pathway, these data suggested that the hawe can be potential source for the isolation of effective anti-proliferative molecules. keywords: achillea.wilhelmsii, breast cancer, anti-proliferative, phosphodiesterase, cgmp signaling pathway. outer membrane protein g (ompg) is a stable monomeric porin having -stranded beta barrel form from e.coli. its exact function is not fully understood; however, it allows the passage of molecules up to da in neutral ph but the pore is closed by going through a conformational change under ph . . as being monomeric and having ph-dependent gating characters, it is suitable for biosensor and targeted drug delivery applications. an attempt on ompg is to create a larger pore while its stability is undisturbed. ompg- s is obtained by adding amino acids to the primary chain in order to have a -stranded beta barrel porin. ompg- sl is formed by further adding amino acids to loop l and by replacing lysines with arginines. ompg- s and ompg- sl mutants are investigated by fourier transform infrared spectroscopy (ftir) and compared with ompg-wild type (wt) in terms of ph-dependent conformational changes and thermal stability. each mutant is prepared in na-phosphate buffer pd . / . and infrared spectra are recorded. further, temperature profiling are recorded for the range between to °c. results show that both mutants are responsive to ph changes. while turning the ph from acidic to neutral, beta sheet signals shift to lower wavenumbers showing difference in secondary structure, implying the existence of closed and open states. on the other hand, mutant proteins show structural differences compared with the wt protein. porins are known for their remarkable thermal stability. the mutans retain this character by having transition temperature of $ °c, although this is less than the wt transition at $ °c. in conclusion, two mutants show signs of open and closed states as ompg-wt and even if the mutants are less stable than ompg-wt. this study shows that the attempted alterations in ompg structure are successful in terms of ph-response but it needs improvement in terms of stability when necessary. nad is a key factor in the regulation of mitochondrial metabolism. besides its vital role as redox carrier, nad serves as substrate for protein adp-ribosylation and deacetylation, modifications which modulate enzyme activities in mitochondria. these functions depend on how nad levels are maintained in this organelle. in human cells, mitochondrial nad is segregated from the cytosolic pool and can be synthesized from nmn, which is probably imported into the matrix. here, we tested whether the nudix pyrophosphatase nudt participates in the regulation of the mitochondrial nad pool. this enzyme has a predicted nadh pyrophosphatase zinc ribbon domain and a mitochondrial targeting sequence at its n-terminus. however, it has not yet been functionally characterized. we overexpressed nudt endowed with a c-terminal flag-epitope in human cells. to evaluate changes in the mitochondrial nad concentration, we used a reporter system which includes the overexpression of the catalytic domain of poly(adpribose) polymerase (parp ) within the organelles (mitoparp). thereby mitochondrial nad is converted into protein-bound poly(adp-ribose) (par). the extent of par formation correlates with the mitochondrial nad availability and is detected by western blotting. our results established that nudt is indeed a mitochondrial protein, as it was localized exclusively to these organelles. moreover, when nudt was overexpressed along with the mitoparp detector system, a dramatic decrease of par was observed. the obtained results indicate that nudt is enzymatically active upon overexpression in the mitochondrial matrix and that it might cleave nad, thereby modulating its organellar level. however, at this point we cannot exclude the possibility of direct par cleavage by nudt . further characterization of nudt will define its substrate specificity and clarify its role in mitochondrial metabolism. the incidence of increase in colorectal cancer (crc) worldwide has become a major health problem. early diagnosis and treatment of crcs are of importance for improving survival. in the present study, it was aimed to investigate chemopreventive effect of rosmarinic acid and evaluate the angiogenesis process in azoxymethane (aom)-induced crc model. male sprague-dawley rats were randomly divided into a control group, aom-induced rat colorectal cancer group ( mg/kg body weight aom; ip, weekly for four weeks), and rosmarinic acid ( mg/kg body weight; oral, daily for four weeks)-treated group. in addition to the standart diet of the all groups . % peanut oil was added throughout the experiment. the all rats were sacrificed at the end of weeks. biochemical examinations were performed in rat plasma. histopathological adenocarcinoma rates were observed in . % of aom group. the incidence of adenocarcinoma was showed a reduction in the treatment group. significant increases in plasma tos and mcp- levels were found in the aom group compared to controls. these increases were reduced in the treatment groups but no significant. a significant increase was detected in tas levels in the treatment group when compared to the aom group. significant decreases in plasma adiponectin levels were found in the aom and the treatment groups compared to controls. in conclusion, treatment with rosmarinic acid reduced the occurrence of inflammation and was helped to maintain the oxidant-antioxidant balance in the model of aom-induced rat colon cancer. mitochondrial genome, while being strongly reduced in course of evolution, still codes for several proteins. the vast majority of them are components of the respiratory chain complexes. to produce these proteins, the system of mitochondrial translation is presented in the organelles, which is in common close to that in bacteria. translation initiation in bacterial cells is orchestrated by three protein factors called if , if and if . the orthologs of the two latter proteins are commonly found in mitochondria. however, mitochondrial if could not been identified in several groups of organisms, including s.cerevisiae, for a long time. recently we have shown that baker's yeast protein aim p possesses a function of mtif . however, the mitochondrial translation has not been stopped in the yeast strain without aim p which is surprising taking into account the fact that if is obligatory for the translation in bacterial systems. instead of blocking of mitochondrial protein synthesis in absence of aim p, we observed the translational imbalance: the synthesis rate of the complex v subunits was increased while the synthesis rate of the complex iv subunits was repressed. thus, in addition to its general role in translation initiation, aim p might specifically affect the biosynthesis of individual mitochondrial-encoded protein species. our genetic experiments have revealed that, indeed, aim p is almost indispensable for cox p synthesis, and that it affects the translation of cox mrna through its -utr, like classical mitochondrial translational activators. this is in accordance with our measurements of complex iv activity which is several times less in yeast lacking aim gene than in the wild-type. taken together, our results point on the multiple role of aim p in mitochondrial translation: in addition to its function as mitochondrial if , it specifically regulates the amount of complex iv subunits and its activity. p- . . - the circulating betatrophin and irisin levels in polycystic ovary syndrome patients with and without insulin resistance introduction: polycystic ovary syndrome (pcos) is the most common endocrine/metabolic disease in women around the world, characterized by oligo-or anovulation, polycystic ovary, and/or hyper-androgenism. insulin resistance (ir) and obesity are common findings in patients with pcos. irisin is a recently identified myokine secreted from skeletal muscle in response to physical activity. irisin has been postulated to induce the differentiation of white fat tissue into brown fat tissue. betatrophin is a currently discovered new hormone proposed to stimulate b-cell proliferation. in this study we investigated the levels of irisin and betatrophin in pcos patients. materials and methods: our study group was consisted of patients with pcos and healthy volunteers. patients group was divided into two subgroups according to presence of ir. (pcos+ir and pcos-ir). the oral glucose tolerance test (ogtt) and the homeostatic model assessment (homa-ir) were performed to assess glucose tolerance and insulin sensitivity. irisin and betatrophin levels were measured by elisa method. results: circulating irisin was significantly higher in the pco-s+ir subgroup than the control group (p < . ). circulating betatrophin was significantly lower in both patients subgroups than the control group (p < . ). there was no negative or positive correlation between irisin and betatrophin levels. discussion: these data suggest that irisin and betatrophin may act a role together in the ir mechanism in pcos patients. butyrylcholinesterase (bche) synthesized in liver has long been associated with hyperlipidemia, type diabetes and obesity. there are also reports on bche knockout mice becoming obese. the exact involvement of how bche interacts with lipids is still not clear. previously we displayed a correlation between leptin, waist circumference, fat mass and bche levels. recently, we have also shown that bche overexpression in hepg cells is regulated by alpha linoleic acid. as the next approach on the analysis of lipid metabolism and bche interaction, we considered the capability of bche to hydrolyze lipids. human serum bche was purified by subsequent deae-tris-acryl m and procainamide chromatography. the purified bche was utilized in a modified acid lipase assay with the acid lipase substrate -methylumbelliferyl palmitate ( -mu-palmitate). as the second alternative substrate trioleic acid was utilized. the triolein hydrolysis was measured by the nefa kit. verification that bche hydrolysis of these lipid substrates was not due to another esterase was done by iso-ompa inhibition studies. also, lectin binding studies with bche and rca were carried out to rule out non-specific esterase activity. using purified human serum bche and hepatic lipase as control enzyme we found that bche is able to hydrolyze the acid lipase substrate -methylumbelliferyl palmitate ( -mu-palmitate). we found that bche hydrolyses this molecule at ph rather better than at ph . . at ph values, purified human bche has a km value that was times bigger than that of human pancreatic lipase. with the bigger molecule the triolein, the difference between the km values of bche and pancreatic lipase was smaller. bche seems to hydrolyze triolein with an efficacy comparable to approximately % that of human pancreatic lipase. our results display that another function of bche may be its lipid hydrolyzing activity. p- . . - determination of regional reference ranges for erythropoietin with laboratory data mining serum erythropoietin (epo) levels are the main regulator factor of erythrocyte production and increase in response to hypoxia. our region is a location dominated by hypoxic conditions due to the high attitude. in this study we aimed to investigate the mean serum epo levels in the living conditions of our region. two hundred and eighty epo results from our laboratory data whose hemoglobin levels were normal were evaluated in the study. mean serum epo levels were analyzed via chemiluminescence method in beckman coulter dxi auto analyzer. the epo levels of samples was . ae . mul/ml (ranged between . and . ) mul/ml. when we performed ae sd for the studies population we determined normal serum epo levels were as . - . mul/ml. the upper limit determined by our results was % higher than that of determined by the manufacturer as . mul/ml and the lower limit determined by our results was % higher than that of determined by the manufacturer as . mul/ml. normal serum epo levels were considerable for our region and the upper and lower limits were higher than those of determined by the manufacturer. more detailed studies considering the physical properties of participants including a higher number participants are necessary. subclinical hypothyroidism is the precursor to hypothyroidism because it has a tendency to transform into hypothyroidism. subclinical hypothyroidism is considered one of the risk factors causing metabolic syndrome. metabolic syndrome can be characterized by plasma level of apelin released from adipocytes. in the present study, we aimed to measure serum apelin level of patients with subclinical hypothyroidism and compare them with serum apelin level from healthy individuals. our study group included patients diagnosed with subclinical hypothyroidism and healthy volunteers. serum samples were obtained from each participant for the measurement of apelin. these were then stored at À •c until the time of analysis. serum apelin concentrations were determined using an enzymelinked immunosorbent assay. the mean serum apelin levels of subclinical hypothyroidism and control groups were ng/l, control group ng/l respectively. there was no statistically significant difference in terms of the mean apelin levels between the groups (p > . ). apelin levels didn't show significant correlation with bmi (p > . ). in the present study, no significant difference of serum apelin level was observed between patients with subclinical hypothyroidism and healthy control subjects. however, the apelin levels were higher in the patients with subclinical hypothyroidism than in the control group. the possible relationship between thyroid hormones and apelins is critical to understanding the etiopathogenesis of metabolic disorders. the mitochondrial erv /mia import system does not impact cytosolic fe-s cluster protein maturation and iron regulation erv is a sulfhydryl oxidase that partners with the import receptor mia to import small cysteine-rich proteins into the mitochondrial intermembrane space. it has also been suggested that erv has an additional role in maturation of cytosolic fe-s cluster proteins and regulation of iron homeostasis in s. cerevisiae. however, these studies were performed on one particular erv mutant strain (erv - ) that we discovered has additional defects in glutathione (gsh) metabolism. since gsh is required for iron regulation and cytosolic fe-s cluster assembly, this complicates our understanding of erv s role in these processes. we discovered that the erv - strain originally tested for fe-s cluster defects was the only strain to exhibit defects in the cytosolic fe-s enzymes. mitochondrial and cytosolic fe-s protein activities in the other erv and mia mutants tested were similar to the wt control. in addition, while all the erv and mia mutants tested exhibit temperature-dependent defects in mia oxidation, only the erv - strain has significantly reduced gsh levels and more oxidized gsh: gssg redox state. we determined that the cause of gsh depletion in the erv - strain is an additional mutation in the gene encoding the glutathione biosynthesis enzyme (gsh ) that compromises gsh protein folding and/or stability. to address whether gsh deficiency in the erv - mutant is the underlying cause for the cytosolic fe-s cluster defects and iron misregulation for this strain, we measured fe-s protein activity, iron-regulated gene expression, and iron accumulation in erv and mia mutant strains. only the erv - strain exhibited iron misregulation and accumulation of mitochondrial iron, while exogenous gsh rescued these defects. these results demonstrate that the defects in cytosolic fe-s enzymes and iron homeostasis in erv - are due to gsh depletion and neither erv nor mia play significant roles in cytosolic fe-s cluster assembly and iron homeostasis. human c-peptide is a amino acid polypeptide, which is secreted into blood from b-cells in the pancreas where pro-insulin undergoes a post translational modification and cleaved into insulin and c-peptide. human c-peptide concentrations in blood plasma and urine reflect the level of insulin resistance associated b-cell function and can point out insulin secretory failure. the reference intervals in blood plasma and urine are . - . ng/ml and - ng/ml respectively. c-peptide measurement in urine and plasma provides a guide for therapy in diabetes. this study describes a method for the development and validation of picaa (peptide impurity corrected amino acid analysis) method for the determination of the purity of the human c-peptide which could be used as a reference material to measure cpeptide concentrations in plasma. two different methods were performed for the picaa; aaa-id-ms/ms for quantification of constituent amino acids following hydrolysis of the material and rp-hplc-esi-tof ms for determination of the peptide related impurities. the result of the aaa id ms/ms method was corrected for the amino acids originating from the impurities. id ms/ms-aaa was performed with zivak Ò hplc and zivak Ò tandem gold triple quadrupole ms equipped with a phenomenex ez:faast l aaa column ( mm i.d). the mobile phase was composed of, a: mm ammonium formate (af) in water, b: mm af in acetonitrile (acn). the intact peptide analysis was performed by a hitachi lachrome elite hplc and bruker microtof-q mass spectrometer equipped with a capcell pak mg-ii c column ( mm i.d., mm particle size). the purity of the synthetic c-peptide was determined by picaa analysis and related uncertainty was calculated. traceability to si was established using the amino acid standards of which the purity was determined by tub _ itak ume using qnmr analysis. picaa is a simpler alternative to the full mass balance approach which requires large quantities of the peptide material. p- . . - heat shock proteins: complementary therapies in brain tumors with viscum album e. onay-ucar, s. n. biltekin istanbul university, faculty of science, department of molecular biology and genetics, vezneciler, istanbul, turkey cancer is one of the lethal diseases in the world. different cancer types possess overexpressed hsps levels. viscum album extracts with their anticancer and antioxidant properties are being used in cancer therapies. biochemical composition of this plant is known to vary its features depending on the host trees and time of harvest. in our previous study, it has been found that v.album inhibited hsp expression and induced caspase-dependent apoptosis in c rat gliomas. the aim of the current study is to find out whether different v.album extracts have different effects on hsps expression level and apoptosis in c glioma cell line or not. in this study, three different extracts of v.album were compared for their potential inhibition effects on hsps. the cytotoxic effects of extracts have been determined via mtt test. different experiment groups were set up subjected to heat shock and/or incubated without any heat shock application. overexpression of hsps was induced by heat shock at °c for h in c cells. expression levels of hsps were determined by western blot analysis. the apoptosis inducing effect was also evaluated via caspase- activation in c glioma cells. pretreatment of the cells with non-toxic dose ( lg/ml) of v.album extracts prior to heat shock, reduced significantly the expression levels of hsps. similarly, pretreatment with the extracts prior to heat shock increased apoptosis via caspase- activation in c glioma cells. these results will be utilized in the determination of the relation between extract composition and stress protein expressions. these results suggest that different extracts of v.album are able to down regulate expression of hsps, and induce apoptosis. this warrants further exploration as a potential resource of bioactive compounds that can be used in cancer therapy. future studies targeting hsps for the development of chemosensitizers may help improve the treatment of cancer in combinational therapy. biological drugs (biologics) are the fastest-growing category of therapeutics among those approved by the agencies for drugs regulation. most biologics are proteins designed for parenteral use. however, proteins are characterized by poor pharmacokinetic and safety profiles. peg-coating (poly-ethylene glycol coating) of biologics provides several benefits, including an increased half-life related to reduced renal clearance, an increased stability to degradation, and a reduced immunogenic/antigenic response. preservation of the three-dimensional structure and activity of the pegylated form is a strict requirement for human use. the recombinant proteins used for this studies (as-sod, superoxide dismutase; mmp , matrix metalloproteases ; ansii, l-asparaginase ii) were cloned and then over-expressed in escherichia coli. pegylation reactions were performed using commercial reagents. all the protein samples were purified and analyzed by solution and solid-state nmr (fields from mhz to mhz). we developed new protocols to prepare samples of pegylated proteins, demonstrating that solid-state nmr spectra of exceptionally good quality can be obtained for pegylated proteins in the sedimented state (obtained by either ultracentrifugation or rehydration of freeze-dried samples); surprisingly, sedimentation of pegylated proteins to this end has never been attempted. the spectral quality is comparable toor better thanthat of the corresponding crystalline samples. the excellent quality of the solid-state nmr spectra would make it possible to perform extensive resonance assignment and even a conventional full structure determination of biologics. the proposed method is based on the comparison of a standard twodimensional solid-state nmr spectrum of the sedimented pegylated protein with that of the crystalline state of the native proteinfor which the x-ray structure is available. all eukaryotic creatures hereditarily have natural defense mechanisms and are protected from the infections with this defense mechanism. antimicrobial peptides (amp) contain - amino acid content, are positively charged with amphipathic feature. the antimicrobial activities of amps are thought to be depended on the microbiocidal effects by binding to the surface of microorganisms and creating pores in their membranes. defensins are both effector and mediator small antimicrobial peptides of the immune system. these peptides in cationic and amphipathic structure have broad spectrum antibacterial, antifungal and antiviral features. defensins regulate the innate and acquired immune systems by suppressing proinflammatory responses during infection. mammals have three structural subfamilies of defensins. these show differences according to the trisulfide arrays in their structure and are classified as a,b, h defensins. human beings have tissue-specific six functional a defensins. human hnp- and hnp- encoded by defa , defa and defa genes are firstly expressed in neutrophils. human hdp and hdp encoded by defa and defa are firstly expressed in paneth cells in the intestines and play important role in the defense and homeostasis. human beings have many pseudogenes such as defap and deftp in addition to these functional genes. according to literature data, defensins play an important role in defense against microbial placements on mucosal surfaces. in addition, the antimicrobial spectra of defensins include gram negative and gram positive bacteria, fungi and viruses. in addition to their antimicrobial efficiency, they can accelerate the wound healing due to their mitogenic effects on epithelium cells and fibroblasts. bile salt hydrolase (bsh) enzyme catalyzes the hydrolysis of glycine and/or taurine-conjugated bile salts into amino acid residues and the free bile acids that reduce cholesterol. however, some intestinal bacteria have an excessive deconjugation of tauro-conjugated bile salts and production of secondary bile acid having potential harmful side effects to the host. the catalytic mechanism and substrate preference of such bsh enzyme is not clear. in this study, bsh gene from lactobacillus plantarum gd strain was cloned, expressed, characterized in escherichia coli blr(de ) strain, and then val- and phe- amino acids, supposed to be responsible for substrate preference, were substituted for met- and ile- amino acids respectively by site directed mutagenesis. the hydrolysis activities and stability of the mutant recombinant bsh (mrbsh) enzymes were examined along with six different bile acids by ninhydrin assay and sds-page respectively. ninhydrin test results indicated that wild-type recombinant bsh (wrbsh) hydrolyzed six major human bile salts with an apparent preference towards glycine-conjugated to tauro-conjugated bile salts. however, the activities of mrbsh/phe ile enzyme are %, %, %, %, % and % of the activity of wrbsh against to glycocholic acid (gca), glycodeoxycholic acid (gdca), glycochenodeoxycholic acid (gcdca), taurocholic acid (tca), taurodeoxycholic acid (tdca) and taurochenodexycholic acid (tcdca) respectively. the activities of val met mrbsh enzyme are %, %, %, %, % and % of wrbsh against to gca, gdca, gcdca, tca, tdca and tcdca respectively. our findings support the suggestion that bsh enzymes recognize their substrates predominantly at the amino acid moieties and not at the cholate moieties. however, further pcr-based site-directed mutagenesis and structure-driven computational and theoretical approaches are required for the precise determination of their substrate specificities and the selection of probiotic bacteria. we deposited bacteriorhodopsin in purple membranes under applied electrical field onto ito (indium tin oxide) support. purple membranes film, highly oriented in one direction, was placed between two ito electrodes. we studied dependence of electrical properties of these films on light illumination. we argue that this setup can be used for functional studies of microbial rhodopsins. in opposite to already published results where this system was used as a photocondensor for studying functional properties of bacteriorhodopsin, we studied electric properties of such systems and we found strong light dependence of resistivity of bacteriorhodopsin in purple membranes films. optogenetics is already used in study of neuronal cells cooperation in vitro and in vivo by means of microbial rhodopsinsion pumps and channels incorporated in membranes of neurons changing their electrical potential while receiving a light quantum by laser or led source. best perspectives optogenetics will give after successful transfer to medical applications, such as the treatment of blindness, treatment of disorders like parkinson's disease etc. but to achieve these we need a broad set of tools, optogenetics tools, highly specialized to solve specific problems of neurophysiology. to the creation of such tools our work is dedicated. new optogenetic tools can be made by mutations in existing ones altering their properties (mainly spectral characteristics, selectivity and conductivity) or some promising mutations in conserved residues can be found in existing organisms. a halophilic archaeon halosimplex carlsbadens is a host of protein of our interest. according to the theoretical data based on the alignment with br and the d structure model of this novel protein, we suppose this protein functions like the light-driven h+ pump: all the key residues are the same or at worst have the similar properties, except one in the position leucine instead of the aspartic acid. a gram-positive bacteria deinococcus-thermus phylum syntheses rhodopsin with substitution of this aspartic acid to alanine. sphingomonas paucimobilis has rhodopsin where aspardic acid in position is changed to serine residue. and one yet uncharacterised guillardia theta rhodopsin even has the same as br motif (d , t , and d ) but according to alignment is closer to chr even the last one motif is e , t , n . it is expected that all of them will show us new properties. though the further experimental data are essential. the work is supported by rsf - - . evaluation of some thymus proteins in patients with crimean congo hemorrhagic fever i. b€ ut€ un , s. sahin , f. duygu university of gaziosmanpasa, department of biochemistry, tokat, turkey, oncology education and reasearch center, ankara, turkey crimean congo hemorrhagic fever (cchf) is a tick-borne viral zoonotic disease. it has a high fatal rate (% - ). tokat is one of the cities having the most reported cchf cases, in turkey. clinical presentation of the disease varies widely among patients. thymic peptides are small molecules synthesized by thymic epithelial cells. they play role in the immune response, as well as anti-inflammatory process. fourty patients referring to the hospital with tick-contact history and/or presenting clinical manifestations consistent withcchf and with positive pcr results for cchf virus in blood samples were included to the study. the wbc and platelet values at application and before the patients were discharged were recorded. the healthy control group consisted of age and gender matched healthy volunteer adults free of any chronic disease. thymosin alpha (ta ), thymuline and thymosin beta (tb ) were studied by the elisa method in this study. biochemical parameters were also analysed. ast and alt values were significantly higher (p < . ) and plt and wbc levels were significantly lower in the cchf group (p < . ). levels of tf, ta and tb were found to be significantly higher in cchf (p < . ). there was no mortality during the study period. duration of hospitalization was . ae . days. levels of tb were significantly correlated with duration of hospitalization (r= À . , p = . ). alt levels were significantly correlated with tf levels (r = . , p = . ). patients received ffp and apheresis for the supportive treatment, while patients received only ffp and patients got only apheresis. patients did not get any of these blood products. there was not a statistically significant differences in thymus peptides among these treatment groups (p > . ). we report survived cchf patients with elevated thymic peptides. pathogenesis of cchf has many points to be highlighted. thymic peptides may play role in the clinical situation of the patients with the disease. the effect of methocarbamol on the peroxiadse activity of human erythrocyte hemoglobin hemoglobin is released to blood circulation, after red blood cells lysis. it is carried in circulation by binding to haptoglobin. in normal persons, no free hemoglobin is observed in the blood, because most of hemoglobin is in the form of haptoglobin complex. in some diseases that are accompanied by hemolysis, the amount of released hemoglobin is higher than its complementary haptoglobin. as a result, free hemoglobin appears in the blood, which is a toxic compound for these patients. free hemoglobin has been showed to have peroxidase activity and considered a pseudoenzyme. in this research, the effect of methocarbamol on the peroxidase activity of human hemoglobin was studied. our results showed that the drug inhibited the pseudoenzyme by un-competitive inhibition. both k m and v max decreased by increasing the drug concentration. k i and ic values were determined as and mm, respectively. molecular docking results showed that methocarbamol did not attach to heme group directly. a hydrogen bond connected nh of carbamate group of methocarbamol to the carboxyl group of asp side chain. two other hydrogen bonds could be also observed between hydroxyl group of the drug and ser and ser residues of the pseudoenzyme. p- . . - dca reduces viability and down regulates mapk protein activations in human malignant mesothelioma cells and pericardium. microarray analyze results performed in mm patients revealed that one of the most prominent changes is upregulation of many genes involved in glycolysis and the krebs cycle. dichloroacetate (dca) is an inhibitor of pyruvate dehydrogenase kinase (pdk) that enhances the oxidative activity of cells by activating pyruvate dehydrogenase (pdh) in mitochondria. dca has shown as a promising anti-neoplastic agent that re-sensitizes cancer cells to apoptosis. the aim of this study is to elucidate the coupling between pdk inhibition and mm cell proliferation and cell cycle. human malignant mesothelioma (spc ) cell line was used as a model for dca treatments. cell viability was measured by mts assay; mapk protein activations and expressions were assessed by western blotting; cell cycle profile was analyzed by flow cytometry. statistical analysis was performed by utilizing one-way anova test. results showed that dca reduced viability of spc cells in a concentration and time dependent manner. protein analysis indicated that mapk pathway was down regulated at concentrations greater than mm. moreover, primary cell cycle analysis has indicated arrestment at g /m phase in hours. our findings corroborate with recent reports where dca treatments resulted in reduction of viability and g /g and g / m arrest in other cell lines. abnormalities in mapk signalling play a critical role in the progression of cancer. here, we showed for the first time that dca decreased mapk activation in h. our results suggest that dca is an anti-prolifertive agents for mm cells in vitro. however, it requres extra analysis with other mesothelial cells. future study will focus on investigating relation between mapk and mitochondrial apoptosis. adrenomedullin (adm) is a vasodilator peptide consisting of amino acids. adm is synthesized in many tissues. and is a biologically active peptide that has various effects including vasodilatation, the regulation of vascular endothelial function and adjusting adipogenesis. hypoxia inducible factor alpha (hif a) is a subunit of a heterodimeric transcription factor hypoxia inducible factor . it is the master transcriptional regulator of cellular and developmental response to hypoxia. the dysregulation and overexpression of hif a by either hypoxia or genetic alternations have been heavily implicated in cancer biology as well as a number of other pathophysiologies. in our research, the adm and hif -a levels in heart, kidney and lung tissues of rats were investigated in control, hypoxia, control+adm and hypoxia+adm groups. rats in hypoxia groups were provided hypoxic environment containing of - % oxygen and - % nitrogen for week. rats in adm groups were injected intraperitoneally in a dose of . nmol/kg for four days before the collection of the tissues. the control group was oxygenated with normal air. the control and treatment groups were formed from - animals and adm, hif -a levels were measured in taken tissues with immunoassay method. the aim of this study was to investigate the reaction of the organism when exposed to hypoxic conditions and the effect of adm over hif -a level. adm levels and hif -a in heart tissue were found decreased in hypoxia group, and adm levels increased in hipoxia+adm group. hif -a levels decreased in hypoxi+adm group. adm levels in liver tissue were found decreased in hipoxia and control+adm groups than control group. hif -a levels were higher in control+adm group. adm has a role in angiogenic process, and our experiment showed that adm reacts earlier than hif -a, and affects its synthesis. organism increases its vascularization as a reaction to hypoxic condition, and adm treatment may provide a rapid adjustment. p- . . - covalent conjugation and characterization of immunogenic protein of toxoplasma gondii and polyacryclic acid as vaccine candidate r. c ß akir koc ß yildiz technical university, department of bioengineering, istanbul, turkey toxoplasmosis is a major medical and veterinary disease caused by toxoplasma gondii which infect approximately half of the world's population. this infectious disease especially gains importance in pregnant women and immunodeficient individuals. also t. gondii infection has economic importance. however, there are only one attenuated-live t. gondii vaccine for veterinary uses and no vaccine against t. gondii is available for humans. therefore development of an effective vaccine would be extremely valuable for preventing disease in human and veterinary medicine. subunit vaccines are very attractive vaccine candidates but there is low antigenicity problem when they are used alone. polymers themselves don't stimulate immune response while they used with antigenic structure of various infective agents enhance immune response because when proteins are covalently conjugated with hydrophilic polymers, ( ) their circulatory-lives and stability (in different ph and temperature values) enhance ( ) binding to proteases and clearance by the reticuloendothelial-system decreases. in this study, immunogenic protein of t.gondii and polyacrylic acid with immune stimulant properties was covalently conjugated and conjugation was demonstrated by size-exclusion chromatography (sec) and fluorescence spectroscopy. it is significant to detect time of death in case of a sudden death for medical and legal concerns. there is no known method that can be used for post mortem time detection. based on this deficiency pmi detection in narrow time frame is a big problem. in this study, we aimed to investigate and determine timedependent expressional changes of apoptotic markers by western blot technique. postmortem skeletal muscle were analyzed hour periods in first -hour after death. nd and rd -hour periods were statistically significant (p < . ). keywords: post mortem interval, time of death, apoptosis. hyaluronidases are excessively found in nature and involved in numerous biological functions. hyaluronidases primarily degrade hyaluronic acid (ha) and have significant role in fertilization during acrosomal reactions. therefore, the measurement of hyaluronidase enzyme activity may provide valuable information about acrosomal function and the fertilizing ability of the sperm. the aim of this study was to investigate the semen hyaluronidase enzyme activity changes among four different sheep breeds (akkaraman, suffolk, merino, and kıvırcık). in this research, ten ram testis tissues from each sheep breed, a total of , were cut and collected on ice. ovine testicular hyaluronidase of four different sheep breeds was purified from a crude ammonium sulfate-precipitated fraction of an extract of ram testis. the semen hyaluronidase enzyme activity differences between the sheep breeds were examined by spectrophotometrically monitoring the appearance of ha at nm. analysis of variance test was used to examine the possible mean differences among the four different sheep breeds. the observed mean differences in enzyme units for kıvırcık, suffolk, akkaraman, and merino were as follows . , . , . , and . , respectively. the observed mean differences in absorbance values for kıvırcık, suffolk, akkaraman, and merino were as follows . , . , . , and . , respectively. the results showed that the observed mean differences in enzyme units and absorbance values among the four different sheep breeds were not statistically significant. despite that, in average kıvırcık had higher values for the activity of each sample and yet it had the smallest values for standard deviation. therefore, in order to achieve higher enzyme activity and more homogenous samples kıvırcık breed should be preferred. what is extra to learn from protein drying measurements? hydrations of soluble proteins are crucial for their functionality. therefore elucidating the details of protein hydration is still of interest in the proteins' action mechanisms. this is the motivation of the present study. in order to study protein hydration, changing concentrations of the well-studied serum albumin protein was measured with the spectroscopic techniques like uv-vis and ft-ir spectroscopy. spectral data is analysed and calculations were performed on the data to extract the relevant changes in the protein. experimental parameters' variation in association with the spectral changes implies the involvement of protein structure and hydrogen bonding in the drying process. the protein's reactions may not be merely a feature of the protein structure in the common sense but it could be related directly to the protein hydration states as well. this is understandable since it is already known that enzymatic proteins lose their functionality when they are dried while this drying may or may not involve dramatic structural changes. on the other hand, here it is claimed that the role of water in gaining the functionality that was lost in the dried state is not just about enhanced diffusion processes and the dynamicity but could be related to the functionality of water in the energy transfer processes as well. investigating the cellular effects of the aldoketo reductases akr b and akr b in hct- colon cancer cells b. taskoparan, e. g. seza, m. s. ceyhan, s. banerjee middle east technical university, ankara, turkey aldo-keto reductases (akr) are nad(p)h dependent oxidoreductases are best characterized as glucose reducing agents, and have been implicated in diabetic pathophysiology. increased expression of akr has been associated with tumors of lung, breast, prostate, cervix, ovarian and colon. two members of the akr superfamily that have been associated with different cancer types are akr b ; aldo-keto reductase family , member b , and akr b ; aldo-keto reductase family , member b . both are -kda cytosolic reductases that are similar in both amino acid sequence identity ( %) and tertiary structure with the (a/b) barrel topology. while hct- , a colorectal cancer cell line, cells expresses akr b robustly, there is no expression of akr b . in this study, we have stably knocked down akr b through shrna technology and overexpressed akr b in hct- cells. comparisons were made with a known akr inhibitor sorbinil. with the knock down of akr b , we have observed reduced cellular proliferation, enhanced apoptosis, delay in cell cycle progression, reduced expression of mitogenic proteins and a decrease in activation of the inflammatory transcription factor nuclear factor kappa b (nf-kappab). interestingly, although akr b overexpression did not affect cell proliferation, apoptosis or cell cycle, some effect was observed with nf-kb signaling. our data indicate that, although closely related, akr b and akr b have very different contributions towards signaling pathways in colorectal cancer. comparison of different nisin quantification methods and optimization of nisin production by lactococcus lactis z. girgin ersoy, g. demir, m. f. cesur, s. tunca gedik gebze technical university, kocaeli, turkey nisin, which is produced by certain strains of lactococcus lactis, is the only bacteriocin approved by world health organization (who) as a food additive. it prevents the growth of foodborne bacteria which cause food spoilage. nisin research and applications necessitates developing an accurate and reproducible method for its quantification. the agar diffusion bioassay is the most widely used method for quantifying nisin, although it has limitations especially diffusion-related difficulties of the active substance. in the present study, "agar diffusion bioassay", "enumeration of colony forming units", "colorimetric assay" and "flow cytometry" methods were compared with each other to determine antibacterial activity of nisin on micrococcus luteus. moreover, this study also covers the results about the effect of different cultural conditions to optimize nisin production by l. lactis. galactose, lactose and their combination in m medium (ph ) boosted nisin production at °c, as the addition of . lg/ml hemin into the fermentation broth. to our knowledge, this is the first study showing the usage of "flow cytometry" method to determine nisin activity of fermentation broth filtrates. p- . . - coronaviral nucleocapsid protein is an antiviral target for drug development institute of genomics and bioinformatics, national chung hsing university, taichung, taiwan between and , the severe acute respiratory syndrome (sars)-cov caused a worldwide epidemic and had a significant economic impact in the countries affected by the outbreak. recently, the middle east respiratory syndrome human coronavirus (mers-cov) was found in patients with severe acute respiratory tract infections in the middle east and south korea. as is true for all coronavirus infections, there are no efficacious therapies currently available against coronaviral diseases, making the development of anti-coronavirus compounds a priority. the cov genome consists of positive-sense, single-stranded rna approximately kb, and it contains several genes encoding several structural and non-structural proteins that are required for progeny virion production with a conserved order. the n proteins exist in the center of the viral particle and represent a helical structure complex. nucleocapsid protein is most abundant structural protein of covs, binds the viral rna genome to form the virion core, leading to the formation of a ribonucleoprotein (rnp) complex or to a long helical nucleocapsid structure, that is important for maintaining the rna in an ordered conformation for replication and transcription. the cov n protein is also involved in the regulation of cellular processes, such as gene transcription, interferon inhibition, actin reorganization, host cell cycle progression, and apoptosis. two strategies to inhibit oligomeric n protein function have been reported. the first strategy is to discover antiviral agents that target the rna-binding site. the second one is to impair normal n protein function by interfering with monomer-oligomer equilibrium. our recent studies suggest that n proteins in infections caused by coronaviruses will be useful antiviral drug targets because they serve many critical functions during the viral life cycle. post-translational modification of vascular endothelial growth factor (vegf) in colon cancer cells s. tunc ßer, e. solel, s. banerjee middle east technical university, ankara, turkey vascular endothelial growth factor a (vegf-a), commonly referred as vegf, is a potent secreted mitogen crucial for tumor initiation and progression. the gene for vegf is translated into a number of splice isoforms that lead to , , and amino acid proteins, with different receptor-binding and matrixbinding properties. in the present study, we discuss the functional significance of post-translational modification/processing of vegf isoform in hct- colon cancer cells. we also focus on the role of calcium in the post-translational modification of vegf . we show that vegf undergoes n-linked glycosylation in hct- cells. perturbation of cellular calcium may affect vegf driven malignant phenotypes. p- . . - novel methods for modulating the activity of bcl family proteins in apoptosis p. rowell, j. miles, a. wilson, t. edwards apoptosis, also known as programmed cell death, is an essential cellular process, but is implicated in several human diseases, including diabetes and cancer, when it is up-or down-regulated respectively. bcl- family proteins are major players in the control of intrinsic, or mitochondrial apoptosis; they respond to intracellular stress signals, function through protein-protein interactions and converge on the mitochondrial outer membrane to cause membrane permeabilisation, release of cytotoxic molecules, and initiation of an apoptotic cascade that leads to cellular demise. our work aims to identify molecules able to bind and modulate the activity of several key players in the bcl- family, including the pro-survival members bcl- , bcl xl and mcl , and the death promoting family member bax. adhirons, novel non-antibody peptide display scaffolds developed at the university of leeds, have been used to construct a phage display library containing over clones, and form a key part of the strategy to identify such molecular modulators. adhirons able to selectively bind individual bcl- family members have been identified, in vitro assays carried out to test for modulatory activity, and xray crystallography used to elucidate details of how they interact with their target proteins. more recently, studies have been carried out to identify adhirons able to target multiple bcl- family members, with the aim of selectively inhibiting defined groups of proteins in cells. this work provides opportunities to differentiate the activities carried out by different bcl- family proteins in apoptosis, enabling us to better understand how their dysregulation contributes to human disease. biophysical and evolutionary study of the structural flexibility of adp-dependent sugar kinases from mesophilic and psychrophilic archaea r. zamora , v. castro-fern andez , c. a. ramirez-sarmiento , e. a. komives , v. guixe facultad de ciencias, universidad de chile, santiago, chile, department of chemistry and biochemistry, university of california, san diego, united states of america the capability of extremophiles microorganisms to live at low temperatures is mainly attributed to the high structural flexibility of its enzymes. several sequence and structure features have been associated to a high structural flexibility that enables metabolic processes to occur at low temperatures. during evolution, the general mechanism adopted by these enzymes has been to reduce the free energy of the transition state rather than the michaelis constant, k m . increased structural flexibility and decreased affinity for its substrates in psychrophilic enzymes is compensated by an increase in the catalytic rate, k cat . few psychrophilic enzymes have been reported to performance the optimization of their catalytic efficiency (k cat /k m ) by decreasing k m values. we use the adp-dependent kinase sugar family of archaea as a model, to identify particular structure and sequence features of a psychrophilic enzyme that would make this enzyme more flexible than their thermostable homologues. we characterize the bifunctional psychrophilic enzyme phosphofructokinase/glucokinase from methanococcoides burtonii (mbpfk-gk) and the bifunctional mesophilic enzyme phosphofructokinase/glucokinase from methanococcus maripaludis (mmpfk-gk) by spectroscopic, biophysical and computational techniques. the comparison showed that the absence of two ion pairs is primarily responsible for the increased structural flexibility accounted in the psychrophilic model. this increase in structural flexibility is reflected in the exponential increase in the k m values with temperature. additionally, we reconstruct the sequences of all ancestral enzymes between the current enzymes and their last common ancestor, which was used to trace the occurrence of these electrostatic interactions during evolution in the adp-dependent sugar kinase family. our results suggest that electrostatic interactions are a dominant feature in the transition from psychrophilic to thermophilic environments. fondecyt . elucidating the domain swapping mechanism of the forkhead domain of human foxp fox transcription factors control gene transcription during key processes, such as embryogenesis and immunity, and feature a conserved dna-binding domain known as forkhead. while most forkhead domains are monomeric, solved structures of members from the p subfamily (foxp) show that they can oligomerize by domain swapping (ds), a mechanism where protein segments are exchanged between subunits leading to an intertwined dimer. the biological relevance of ds in foxp has been stressed by disease-causing mutations that impair this process. however, for many proteins ds takes days to occur and requires global protein unfolding. thus, the current mechanism impedes a conciliation of the occurrence of ds of foxp in a biological context. here, we elucidate the biological feasibility of this process by biophysically characterizing the ds mechanism of the forkhead domain of foxp using size exclusion chromatography (sec), circular dichroism, and hydrogen-deuterium exchange mass spectrometry (hdxms). our results show that ds of foxp occurs at micromolar protein concentrations, within hours and is energetically favored. remarkably, dimeric foxp follows a threestate n « i « u folding mechanism, where dimer dissociation into a monomeric intermediate (i) precedes protein unfolding, in contrast to other ds proteins. using sec and hdxms, we show that the i state of foxp largely resembles the native state, but has a larger hydrodynamic radius and a higher deuterium uptake in regions that maintain the compact monomer, suggesting that the i state is an 'open' conformation en route of ds. finally, we compared the local flexibility of the dimer and monomer of foxp , showing that only the hinge region connecting ds segments exhibits different deuteration rates. our results show that ds in foxp follows an unusual threestate folding mechanism that proceeds through transient structural changes rather than needing protein unfolding as in most ds proteins. (fondecyt , ). p- . . - the sustained release of growth factor proteins following their implantation in tissue engineering j. jang bone tissue engineering has become a promising approach for bone regeneration. however, insufficient vascularization during bone regeneration, particularly with large bone defects, results in poor and unsustainable bone formation due to central necrosis. therefore, vascularization following implantation in vivo is essential to the successful formation of new bone tissue. we evaluated the release profile of vegf from bgs using a novel fluorescence-based retention assay, which revealed that vegf loaded on bgs can be released in a sustained manner without an initial burst (near zero-order cumulative release) with a controlled release rate of . % per week for up to weeks. in contrast, an elisa-based release assay showed vegf to have an early burst-release profile for the first week. however, the biological activity of vegf released from the bgs was preserved over the -week release period, which is consistent with the sustainedrelease profile observed in the fluorescence-based retention assay. we developed a novel fluorescence-based retention assay to evaluate the release of vegf from bgs. this fluorescence-based retention assay, which detects the vegf that remains on bgs, reveals that vegf loaded on bgs can be released in a sustained manner, with a minimal initial burst, for up to weeks. these results indicate that the sustained biological activity of the vegf released from bgs over the full -week period promotes bone regeneration, and suggest its potential use for bone tissue engineering. irisin is a recently discovered myokine which regulates energy metabolism and is associated overweight. we aimed to evaluate serum irisin levels in the patients with morbid obesity. a total of sixty patients with morbidly obese and thirty healthy control subjects were included in this study. all participants were measured body weight and height, the lipid profile, and plasma glucose, hba c, insulin and irisin levels. irisin levels were measured by elisa method. serum irisin levels were significantly lower in morbidly obese patients than healthy controls (p < . ). there was no statistically significant difference in terms of age or gender. serum irisin was negatively correlated with bmi, insulin levels, and homa-ir (p = . , p = . , p = . , respectively). our study revealed lower irisin levels in morbidly obese patients with respect to control subjects. the lower irisin levels observed in morbidly obese patients might suggest a loss of browning of subcutaneous adipose tissues. p- . . - pka inhibition restores adenosine uptake in renal tubular epithelial cells under high d-glucose conditions w. garrido, j. catal an, s. alarc on, r. san mart ın universidad austral de chile, valdivia, chile introduction: diabetic nephropathy (dn) is the leading a cause of end-stage renal failure whose pathogenesis must to be elucidated. the progression of dn has been associated with elevated levels of adenosine. extracellular adenosine availability is regulated by the activity of the equilibrative nucleoside transporters (ents). due to the ents have putative sites of phosphorylation our objective was to evaluate the role of pka and ck kinases on ents activity. methods: adenosine uptake ( lm adenosine, s, °c) was assayed in hk cells preincubated with mm or mm d-glucose for h and exposed to lm -br camp, lmh or lm tbb for h. plasma membrane and intracellular proteins were fractionated by the biotinylation method and ent and ent contents were quantified by western blot. results: high d-glucose in hk cells inhibited the uptake of adenosine. this effect was reversed using a pka inhibitor (h ) through an increased ent uptake activity. we noticed this pka inhibitor did not regulate the plasma membrane localization of ent or ent under normal d-glucose ( mm) or high d-glucose conditions ( mm). also, we saw that tbb (ck inhibitor) decreased the activity of ent and ent under normal glucose conditions, decreasing the localization of ent at cell surface, while the membrane localization of ent decreases under the effect of tbb and high d-glucose conditions. conclusions: pka inhibition reversed the effect of high d-glucose, increasing the uptake of adenosine mediated by ent . this could be a new target for the restoration of adenosine levels in dn. relation between serum lipo (a), plasma fibrinogen, red cell distribution width and mean platelet volume in healthy adult men the aim of this study was to investigate the relationship between the serum lipo (a) and plasma fibrinogen, red cell distribution width (rdw) and mean platelet volume (mpv) in healthy adult men. for this purpose, healthy adult men have normal physical examination and laboratory findings and not use any drug were included to the study. serum lipo (a) levels and hematologic parameters (fibrinogen, rdw-sd and mpv) were measured by autoanalyzer and commercial kits. the mean of the age of the persons was . ; body mass index was . ; serum lipo (a) level was . and plasma fibrinogen level was . . there was significant positive correlation between the serum lipo (a) and plasma fibrinogen levels (r = . ; p = . ), significant positive correlation between the serum lipo (a) and rdw-sd (r = . ; p = . ) and significant negative correlation between lipo (a) and mpv (r= À . ; p = . ). the plasma fibrinogen and the serum lipo (a) levels have been known as the risk factors for cad (coronary artery disease) increase together in healthy adult men. similar findings have been reported in cad patients. it has reported that elevated rdw is associated with intracoronary thrombotic burden and may be associated with the severity and instability of acute myocardial infarction. in addition, mpv is predictor of severe atherosclerosis and may be used for the prediction and identification of cardiac risks in cad patients. our findings show that elevated rdw and decreased mpv may predict to increased risk of cad in the future, in healthy adult men. follicular fluid is rich in peptides, which significantly influence the growing oocyte. due to existence of a link between kisspeptin (metastin) cells and gonadal steroids kisspeptin might manipulate the gonadotropin axis and folliculogenesis. in this context, the study was planned to investigate for the first time that the follicular fluid (ff) and serum concentration of kisspeptin in high and poor responders undergoing in vitro fertilization (ivf)/intracytoplasmic sperm injection (icsi). biological samples were collected from twenty infertile women with polycystic ovary syndrome (pcos) and poor responder participants undergoing controlled ovarian stimulation (cos) with gonadotropin-releasing hormone (gnrh) antagonist protocol for ivf/icsi treatment. kisspeptin concentrations were measured in serum and follicular fluid by using elisa, whereas fsh and lh levels were detected by routine laboratory methods. it was found that kisspeptin levels were significantly lower in serum and follicular fluid of infertile women with pcos. kisspeptin levels were correlated with fsh and lh level in infertile women with pcos. it can be concluded that low level of kisspeptin might inhibit gnrh release that might cause to the inhibition of fsh and lh release and might disrupt folliculogenesis. decline in serum and ff levels of kisspeptin might be possible cause of anovulation and subfertility in pcos subjects. cryptococcus albidus d is a newly identified yeast isolates from petroleum area in _ izmir as a lipase producer. the molecular weight of the enzyme is . kda as found. optimum temperature was °c and half-life times were , , and . min at , , and °c, respectively. optimum ph value was . . however, it shows significant ph stability at ph values . and lower. the existence of acetone in the solution as a solvent enhanced lipase activity. cryptococcus albidus d lipase was able to catalyze the esterification reaction between fructose and palmitic acid to produce fructose palmitate using acetone as the solvent. due to its stability in organic solvents, we propose that in order to increase the yield of fructose palmitate, we could immobilize d lipase. therefore, the effect of immobilization on kinetic parameters of d lipase was investigated. different immobilization materials and methods were used to find efficient support materials for d lipase immobilization. additionally, fructose palmitate production processes will be optimized with immobilized lipase. introduction: the diagnosis of osteoarthritis (oa) is based on clinical symptoms and radiographic findings. it is known that the pathologic changes at the molecular level in the joint cartilage tissue start before symptoms appear in oa. c q tumor necrosis factor-related protein (ctrp- ), c q tumor necrosis factor-related protein (ctrp- ) and kallistatin are related to many different cellular processes including bone and cartilage tissue metabolism. the aim of this study was to investigate any probable association between the serum ctrp- , ctrp- and kallistatin levels and diagnosis and radiologic staging of knee oa patients. materials and methods: this study included patients with knee oa and healthy individuals for control purposes. the patient group was divided into four stages radiologically. ctrp- , ctrp- and kallistatin levels were measured in serum samples of patient and control groups with elisa method, and the differences between the groups were analyzed with statistical methods. results: the levels of serum ctrp- in the patient group were significantly higher than in the control group (p = . ), serum ctrp- and kallistatin levels were not statistically different (in order of p = . , p = . ). in the patient group, there was not a significant difference between serum ctrp- , ctrp- and kallistatin levels and radiologic stages (respectively p = . , p = . , p = . ). there was a significant positive correlation between the radiologic stage and patient's age, body mass index, western ontario and mcmaster universities arthritis index and visual analogue scale values (respectively p = . , r = . ; p = . , r = . ; p = . , r = . ; p = . , r = ). discussion and conclusion: serum ctrp- levels were detected significantly increased in patients with knee oa, but there was no significant difference in ctrp- and kallistatin levels. there was not a significant association between the radiologic stage and levels of ctrp- , ctrp- and kallistatin. enzymes in microorganisms, especially termophilic bacteria are more attractive in biotechnology and molecular biology due to the higher catalytic activity. turkey is rich in geothermal resources and it is important to determine unknown microbial content of geothermal sources. in this study, water and sludge samples were taken from ayder, kizilcahamam and gonen hotsprings. firstly, ph, temperature, salt concentration, gram reaction, mobility, endospore formation, oxidase and catalase tests were carried out as conventional characterization. molecular characterizations of isolates were achieved by fames, rep-pcr and s rrna sequencing. finally, test isolates were evaluated according to enzyme production capability by petri dish. as result of conventional tests, isolates were determined as gram positive, mobile-rod shaped, aerobic, oxidase, catalase and endospore positive. the growth range for ph and temperature of the isolates were determined as - and - °c. in consequence of the salt test, the test isolates were grown at - % nacl. of thermophilic isolates were selected by rep-pcr and according to s rrna sequencing analysis test isolates were belonging to bacillus, geobacillus, anoxybacillus and brevibacillus genus at a range of - %. enzyme tests showed that, some of the isolates were able to produce protease (f , f , f , f , f and f ), amylase (f , f , f , f and f ), cellulase (f , f , f , f , f and f ), xylanase (f , f , f , f and f ) and lipase (f , f , f , f and f ). it can be concluded that, geothermal regions are rich in bacillus and related genera. fame analysis was particularly insufficient for diagnosis of thermophilic microorganisms, but rep-pcr was successful in separation of organisms at species and even subspecies levels. most of our bacterial isolates have industrially important enzyme production capacities. it is a pioneer result to use bacteria for industrial applications which need higher temperatures. p- . . - warburg effect was investigated by studying various metabolic molecules and assays in mammalian cell lines z. i. kanbagli, b. kiratli, h. cimen yeditepe university, istanbul, turkey majority of the different cancer cells switch their metabolism from oxidative phosphorylation pathway to glycolytic pathway; in order to meet excessive energy requirement, which is also called warburg effect. acetylation is one of the most crucial post-translational modifications playing key roles in metabolic reprograming. in this study, the relationship between acetylation dependent changes in energy metabolism and apoptotic pathways were investigated in pnt a, du , hela, hep b, hek t, shsy y. immunoblotting experiments were applied by using antibodies against acetylated-lysine to examine the changes in overall acetylome. candidate proteins displaying elevated acetylation was identified with mass spectrometry based-proteomic analysis. glucose transporter (glut ) was used to detect insulin-stimulated glucose transport, total oxphos rodent antibody cocktail to identify variations in complexes which are responsible for most of the atp production. caspases (casp- , - ) to unreveal different activation levels of apoptotic pathway among the cell lines. mitochondrial membrane potential was measured by using rho-damine by employing confocal microscopy. the expression level of respiratory chain complex iv subunit mtco and casp- was higher in hek t compared to other cell lines. casp- was upregulated in cancer cell lines, mostly in hep b. glut- levels were downregulated in cancer cell lines in contrast to healthy cell lines. findings imply that these proteins might have significant roles leading to variable metabolic and apoptotic activity of each cell line during energy production. due to the results, mtco might be important in adaptation of different cell lines to regulate the overall respiratory chain complex activity. reduction in glut level demonstrates insulin desensitization in cancer cell lines, which might lead to metabolic defects in these cells. besides, since p has a repressive effect on glut , it also can lead us to study about p levels. the effect of inhibition of pi k/akt/mtor signaling pathway on receptor tyrosine kinase expression in breast cancer cells g. tunali, a. l. dogan department of basic oncology, hacettepe university cancer institute, ankara, turkey the increased expression and activation of receptor tyrosine kinases (rtk) (egfr, her , her ) play important roles in breast cancer pathogenesis. her /her interaction is the most potent heterodimer and it causes oncogenic pi k/akt activation. inhibitors of pi k/akt pathway (akt inhibitor and pi k/mtor dual inhibitors) lead to increase in rtk levels and activities while blocking signaling pathway. in this study, the time dependent effect of dual pi k/akt inhibitor pi- on receptor tyrosine kinase expressions' in breast cancer cells was investigated. two breast cancer cell lines, mda-mb- cells (which has egfr overexpression and pten deficiency) and skbr- cells (which has her overexpression) were evaluated for the effect of dual inhibitor. these cells were treated with dual pi k/akt inhibitor pi- for different time periods ( - h) . egfr, her her total rtks expression and pi k/akt pathway inhibition (p-akt and p-p s k expression) were evaluated by western blot. in mda-mb- cells, there were significant decrease in p-akt and p-p s k proteins' expression during the first h. this inhibition was followed by reactivation of the signaling pathway after h. in skbr- cells, p-akt and p-p s k proteins' expression were significantly decreased during the first h. the pi k/ akt signaling pathway in these cells were reactivated after h. basal expression of egfr and her in mda-mb- cells and basal expression of her and her in skbr- cells were found to be very high. transient inhibition of akt and mtor protein kinase activation in tumor cells followed by reactivation of signaling pathway did not result in a time-dependent difference on egfr, her and her expression levels. these results suggest that dual pi k/mtor inhibiton by pi- may trigger receptor tyrosine kinase reactivation due to the signal distruption without affecting total protein expression level. site-specific bioorthogonal reactions are one of the significant tools for discovering different aspects of biological systems in live cells. the reactions should be highly stable and rapid in physiological conditions. various chemical tools can be used in bioorthogonal reactions to monitor biological systems, therapeutics, microscopy and diagnostic applications in live cells. synthetic covalent chemistry in the study of biological systems has been used to label biomolecules selectively in their native environment. for example, small synthetic fluorophores can be added to biomolecules without disturbing other molecular biological pathways. aldehydes or ketone-based functional handles can be attached onto protein at specific sites via chemoenzymatic reactions. labeling of carboxy terminus of a-tubulin has been successfully studied in our previous studies by replacement of wild type tyrosine with unnatural amino acid -formyltyrosine in the presence of tubulin tyrosine ligase enzyme (ttl)-as its role can suggest whether certain cancer cells might grow more aggressively than others. in this work, we highlight the synthesis and spectroscopic properties of azacoumarin chemical probes to study tubulin-tubulin tyrosine ligase (ttl) system in live cells. significant increase in fluorescence quantum yield or a red shift on absorption and emission maxima is observed when the conjugated product is formed. bioorthogonal fluorescent labeling is such a favorable reaction to perform rapid kinetics, localization and high site-specificity in cell environment. newly synthesized azacoumarin fluorophores should therefore not only be useful for studying ttlbased biological systems, but also would enable broad range of high-yielding and fast diagnostics for future biolabeling applications in biochemistry, cell biology and beyond. binase is an extracellular ribonuclease from bacillus pumilus which shows antiviral and antitumor activities in cell cultures. however, the action of binase on intracellular functions and processes has not yet been identified. here, for the first time we report the whole transcriptome analysis of binase-treated human lung adenocarcinoma epithelial a cells. a plasmid-based reverse genetics system and colorimetric cell viability assay were used to identify the binase internalization and binase cytotoxicity towards a cell line, respectively. for the whole cell transcriptome analysis a cells were treated with lg/ml of binase for h followed by mrna extraction and library preparation. sequencing was performed on solid xl wildfire next-generation sequencer. we found that binase internalized into a cells after h of incubation. the binase at lg/ml was absolutely non-cytotoxic towards a cell line and was active in the cell culture medium during h incubation. the analysis of rna-seq data showed that among thousands of protein coding transcripts transcripts were up and down regulated by binase, among them transcripts were induced and repressed. binase repressed the production of s a and tnxb which act cancer biomarkers, scn a and drd which play a crucial role in cancer metastasis and responsible for pediatric tumors, respectively. the induction of transmembrane protein transcript abcb by binase can help binase to internalize into the cell as abc transporters are often account for transporting drugs across the cellular membrane. binase induced the production of nlrp , rasgrp and alpk transcripts which can activate apoptosis, cytokine or t cell activation in cancer cells. thus, binase exerts different effects in cancer cells. the rnaseq data obtained will help to understand the mechanism of binase anticancer action. . ) is a specific group of phosphatases capable of hydrolyzing myo-inositol , , , , , -hexakisphosphate (phytate) with the formation of less phosphorylated inositol derivatives (from mono-to pentaphosphate). three major types of phytases are recognized on the basis of the first phosphate group hydrolyzed by the enzymes: -phytase, / -phytase, and -phytase. due to the stereospecific way of phosphate release from the phytate molecule by the action of phytases, these enzymes by themselves and their composition may serve as a potential alternative for production of myo-inositol phosphate isomers with therapeutic properties. chemical synthesis of these compounds is inefficient and costly. pantoea sp. strain . . showing high phytase activity was isolated from the forest soil sample of the republic of tatarstan, russia. in this study the main objective was the cloning and expression of pantoea sp. . . phytase gene in e. coli. first, we amplified the phytase gene (agpp) from the genomic dna of the bacteria using specific primers phmh_dir and phmh_rev. size of phytase gene corresponded to base pairs. during the optimization of amplification conditions it was found that the optimum temperature for primer annealing was °c. this temperature increases the specificity and efficiency of annealing. then the pcr-product of agpp gene was cloned into the pbad myc/ his vector first. on the next step we carried out subcloning of the agpp into a pet a expression vector. multicopy plasmid pet a/agpp contained the sequence of the phytase gene of pantoea sp. . . under t promoter. the corresponding recombinant protein was expressed in e. coli as a fusion with a his-tag and was detected by western blotting. recombinant phytase was purified via affine chromotography on the ni-nta column and displayed high phosphomonoesterase and phytase activities. bag- (bcl- associated athanogene) is a multifunctional protein that interacts with diverse array of cellular targets and modulates a wide range of cellular processes, including proliferation, cell survival, transcription, apoptosis, metastasis and motility. in human cells bag- exists as three major isoforms (bag- s, bag- m and bag- l) derived by alternative translation initiation from a single mrna, which allows interactions with various molecular targets such as hsp /hsc molecular chaperones, components of the ubiquitylation/proteasome machinery, bcl- , raf- kinase, nuclear hormone receptors and dna. our work aims to investigate how altered bag- expression levels affect cell survival in mda-mb- (er, pr and her /neu negative) breast cancer cell lines. we first cloned bag- l gene to a cloning vector, later we transfected mda-mb- cells for overexpression of bag- . we also used bag- sirna to silence bag- gene. western blot analysis was applied to demonstrate relative expression levels of bag- , its interacting partners and certain proteins which are important for apoptosis pathway. we performed xtt cell viability assay for bag- overexpressed cells to checkbag- 's impact on cell survival, and observed enhanced survival rates on cells compared to that of the untreated cells with bag- overexpression. in addition, our study revealed that once bag- forms a complex with c-raf/b-raf/hsp /akt/bcl- , modulation of cell survival was observed. we believe that once the exact localization and involved molecular mechanisms of bag- and its isoforms are found, the role of each bag- isoform in cell survival can be understood better. this can further provide routes to study tumor development. the aim of this study is testing the recombinant glp encapsulation into a biocompatible material. we also tested if it can be a therapeutic candidate drug for type diabetes. the incretin hormones, which are also named as endogenic peptide hormones have become a more attractive therapy for type diabetes because of different physiological effects. in circulation, glp is cleaved by ddp in a very short time. if glp can be protected from cleaving, the effective time of glp would be increased and by this way it can replace the therapy of insulin. chemical synthesis methods of peptides are limited because of low efficiency and high cost. the production of peptides by recombinant e. coli is an alternative way because of effective production, simplicity and low cost. however, the major disadvantage derived from the recombinant e. coli is the frequent formation of inclusion body. for that reason, extra methods are needed for obtaining soluble recombinant peptides. glutathione s-transferase (gst) tag is commonly used as affinity and solubility tag to improve the solubility of recombinant peptides. in this study, we cloned and heterologously produced glp using the gst fusion system in e. coli. affinity purification of recombinant protein was achieved by using glutathione immobilized columns. characterization of the gst-tagged glp was performed by sds-page. the purity of fusion protein was found to be %, as confirmed by glp elisa kit. then, the fusion protein was encapsulated in a chitosan coated polygalacturonic acid. the different ph stability and in vitro release tests also in different phs was studied. morganella morganii is an opportunistic pathogen capable of causing a wide range of clinical infections. it is known that microbial metalloproteases play an important role in the development of bacterial infections. thus, investigation of m. morganii metalloproteases has a particular interest. bacteria were grown in lb medium at °c. as a bioinformatics tool blast was used. for molecular biological experiments, thermo scientific kits and sibenzyme enzymes were used. pbad/myc-his plasmid was used as an expression vector. bacterial transformation was carried out by heat shock method. bacterial cells were disrupted by sonication. gene expression products were analyzed by western blotting. to analyze the actinolytic activity of bacterial extracts sds-page electrophoresis was used. the putative metalloprotease gene (an cp . ) has been found in the genome of annotated strain of m. morganii kt. its amino acid sequence has partial homology ( %) with actin specific metalloproteases grimelysin from s. grimesii and protealysin from s. proteamaculans. using specific primers the gene with % homology was identified in the genome of clinical isolate of m. morganii . rt-pcr analysis showed that this gene had the maximum expression at h of growth. in addition, the cellular extract of m. morganii had small actinolytic activity. cloning of the gene into e. coli dh a cells led to the synthesis of the kda protein. it is known that the highest expression of serratia proteases is observed at h of growth, and the molecular weight of the mature proteins is kda. it was shown that metalloprotease gene of m. morganii expressed at the same time of growth. moreover, the recombinant e. coli cells synthesized protein with the similar weight ( kda) which perhaps is a mature form of the metalloprotease from m. morganii. as a result, in the genome of m. morganii the metalloprotease with similar properties to grimelysin and protealysin proteases was identified. the preliminary characterization of p-ii like protein glnk from lactobacillus brevis z. iskhakova , d. zhuravleva , a. laykov , k. forchhammer , a. kayumov kazan federal university, kazan, russia, eberhard-karls university tuebingen, tuebingen, germany the p-ii proteins in bacteria, archaea and plants regulate the activity of a variety of proteins in response to specific metabolic signals which affect their structural state and interaction ability. among various bacteria belonging to lactobacillus only some species have genes encoding pii protein in the genome. here we report the preliminary characterization of pii-like protein lbrglnk from lactobacillus brevis. while the amino acid sequence alignment revealed only - % homology of lbrglnk with other well studied pii proteins, lbrglnk also has the atp binding motive gdgk. trimeric structure of lbrglnk was confirmed in vitro by size exclusion chromatography, suggesting possible similarities of lbrglnk properties with pii proteins. the isothermal titration calorimetry revealed a preferential binding of adp (kd = lm) over atp (kd = lm) suggesting that they compete for binding to lbrglnk. neither -oxoglutaric acid nor other nucleotides were interacting with lbrglnk in itc measurements. the mutation gly ala in the atp binding motive completely abolished the interaction with both adp and atp. the pull down of lbrglnk with l. brevis cell extract allowed identification of chaperonin grol, transketolase and glnr-like transcriptional regulator from merr family as most probable partner proteins for interactions with lbrglnk. this work was supported by the russian foundation for basic research (project no. - - a background: hemophilia is a bleeding disorder due to the deficiency in coagulation factors viii (hemophilia a) or ix (hemophilia b). hemophilia patients are essentially treated with intravenous replacement of the missing or dysfunctional factors fviii or fix by recombinant proteins. these therapies often induce the generation of acquired antibodies, and thus, novel approaches are needed. most recent hemophilia strategies target the tissue factor pathway inhibitor (tfpi), which is the major inhibitor of the coagulation cascade, particularly of the extrinsic tenase complex. anti-tfpi agents have been empirically developed such as aptamers, peptides, monoclonal antibodies. we have followed a structure-based strategy, to design a mutated fxa that would show more affinity for tfpi, and thus trap this inhibitor. tfpi exists as two isoforms are folded as multi-kunitz domains related by linkers. the second kunitz type domain of tfpi (tfpi-k ) is known to bind the catalytic site of fxa. methods: the molecular complex of tfpi-k -fxa was modeled and submitted to molecular dynamics (md), allowing the identification of low-spots interaction. modified fxa with theoretically stronger interaction with tfpi-k were predicted using md. the mutants and wild type proteins were expressed in hek cells, and their processing status was checked. they were tested by western blotting, by chromogenic activity using a specific substrate of fxa, by thrombin generation assay in fviii depleted plasma. finally, their binding to a tfpi-k peptide array was compared. results: the mutants showed better efficiency to restore thrombin generation in plasmas from hemophiliacs and displayed stronger binding to tfpi-k than the wild type fxa. conclusions: the proof of concept of the synergistic approaches of md and mutagenesis was obtained and an efficient tfpi trap was designed. the mutated fxa is a candidate for a new hemophilia therapy. organophosphorus acid anhydride (op) nerve agents are potent inhibitors which disrupt the mechanisms of neural transmission. organophosphorus acid anhydrolase (opaa; e.c. . . . ) is a class of enzyme that potentially acts on phosphorus anhydride bonds, reported intracellularly in diverse organisms, albeit notably the enzyme belongs to alteromonas species are more extensively studied. whereas mass-transfer problem is a major issue in native whole cell biocatalysis, new anchor system derived from the n-terminal domain of ice-nucleation protein from pseudomonas syringe inav (inav-n) was used for the first time to display opaa onto the cell surface. tracing of the recombinant protein and its activity assay showed a successful presentation of opaa and its significant ability for biodegradation of organophosphorus compounds. further studies on bacterial fractions confirmed that opaa is remarkably located on the outer membrane. the specific activity of recombinant bacteria to degrade diisopropylfluorophosphate (dfp) was measured at u/mg of cell wet weight, which almost all was observed in the outer membrane fraction. recombinant cells could also degrade chlorpyrifos (cp) compound in . u/mg activity. it can be concluded that inav-n anchor is efficient for targeting opaa on the cell surface and can effectively eliminate the masstransfer problem in native whole cell bioconversion system. proper spatial and temporal organization of proteins involved in cell signal transduction is crucial for the specific and efficient information transfer. scaffold proteins coordinate the action of signaling molecules by their physical binding and organization in multiprotein complex assemblies. multiple protein binding is often mediated through intrinsically disordered regions of the scaffold, where the interaction epitopes are defined by linear peptide motifs. using a hub scaffolding protein axin as a paradigm, we have employed peptide microarray technique to identify the binding epitopes for axin interaction partners at high resolution. this enabled us to design axin-derived peptides corresponding to the respective binding epitopes that compete for the interaction in vitro. by transfection of chemically stabilized competitive peptides directly into the cells, we have shown the effect of specific interaction blocking on axin-mediated signaling in vivo. our data demonstrate a proof of concept for a rational design of inhibitors of protein-protein interactions that allow specific intervention with single function of the targeted protein (i.e. recruitment to the axin complex). contrary to the inhibitors that completely disrupt the protein function (e.g. inhibition of a kinase catalytic site), this approach provides a tool for investigating specific action within the axin complex, while the other cellular functions of the targeted protein remain preserved. the results of this research have been acquired within cei-tec (lq ) project with financial contribution made by the ministry of education, youths and sports of the czech republic within special support paid from the national programme for sustainability ii funds. de novo design of an artificial biocatalyst using immunoglobulin template became rather routine procedure due to the achievements of molecular biology and crystallography. recently the 'reactibody' approach was developed based on the chemical selection of catalytic repertoires from immunoglobulin library followed by expression of these biocatalysts in eukaryotic system. in this study we structurally characterize the a antibody, its kappa and lambda variants, in order to understand the difference on the active site between a and a which although there are two antibodies sharing very high homology and sequence identity their active residues are located in a different region of the antibody. the structures of the a antibody kappa and lambda variants have been already determined, there was no structural information though about the a antibody. the structural analysis revealed dramatically different angle in position of nucleophilic residue tyr and area of solvent accessible surface. the structural difference of active center reflects on kinetics of the a organophosphate modification. both variants of antibody bind with organophosphate throw induce-fit mechanism, but rate of the step of induce fitting is different (k obs are s À and s À for a kappa and a lambda respectively). this observation may hint at novel means of regulation of velocity and specificity of artificial biocatalysts. this study was supported by grant #rfmefi x . translation elongation factor ba (eef ba) is a component of a heavy form of translation elongation factor (eef h). it functions as a catalyst of gdp/gtp exchange in translation elongation factor a (eef a) restoring its active conformation appropriate for aminoacylated trna binding. eef ba forms a tight complex with translation elongation factor bc (eef bc) via the n-terminal domain, while its c-terminal domain executes the catalytic activity. eef bc has been shown to enhance the attributed to the c-terminal domain catalytic activity of eef ba. this suggests that the eef ba n-terminal domain may influence the guanine nucleotide exchange process. to test this hypothesis we prepared a set of n-terminal truncated forms of human eef ba and checked their activity in the guanine nucleotide exchange assay on both isoforms of eef a, eef a and eef a . we showed that recombinant eef ba is a non-globular monomeric protein in solution with an elongated shape by analytical ultracentrifugation approach. the truncation of the dispensable for the catalytic activity n-terminal domain of eef ba resulted in significant acceleration of the rate of guanine nucleotide exchange in eef a comparing to full-length eef ba. similar effect on the catalytic activity of eef ba was observed after its interaction with eef bc. in contrast, the effect of full-length eef ba and its truncated forms on the rate of guanine nucleotide exchange in eef a was similar but relatively modest compared to eef a . this can be explained by higher rate of spontaneous gdp dissociation from eef a comparing to eef a and lower affinity of eef a to eef ba. thus, we propose that the n-terminal domain of eef ba via flexible linker region may interfere with eef a binding to the cterminal catalytic domain that results in a decrease of the overall rate of guanine nucleotide exchange reaction. the formation of a tight complex between eef bc and eef ba n-terminal domains abolishes this inhibitory effect. p- . . - assessment of quantitative proteomics results in large-scale data-independent with fragmentation spectra reproducibility measure reduces variation and allows to use lowintensity signals organisms with reduced genomes that lack the vast majority of transcriptional or translational regulation systems tend to adapt to changing environment with a variety of subtle changes in protein abundances. as soon as relative changes for most proteins fall below %, the power of traditional label-free proteomic analysis rapidly becomes insufficient for robust profiling of hundreds of samples. intoduction of frament-by-fragment and sample-by-sample signal quality assesment in mrm and dia experiments helps to increase accuracy of methods and at the same time reintroduce cases which could have been excluded during bulk quality assessment due to lower signal-to-noise ratio for several fragments. samples of mycoplasma gallisepticum were acquired in data-independent manner on sciex tripletof + mass-spectrometer (swath acquisition) during the year. the samples were produced from mycoplasma gallisepticum culture cultivated at different temperatures. the signals for each fragment were extracted with vendor-supplied software with the theoretical fragment ions for each peptides instead of spectral library. the results were used for relative protein quantitation in two manners the first conventional method included direct use of peptides with top most intense signals. the second included selection of peptides and ions for quantification for each pair of samples based on the reproducibility of fragmentation patterns after computing the areas of chromatographic peaks for each ion. spectral angle was used as a distance measure for fragmentation patterns for clustering. further, a base set of detected ions was selected for each peptide and a subset for comparison of each pair of runs. the first method resulted in quantitation of proteins across all samples with variation across lc-ms replicates was % on average, and the second approach led to quantitation of proteins in total, of them across % of samples, all with the variation about % on average. p- . . - interaction of plasminogen fragments k - and k with fibrin fragment dd t. yatsenko, v. rybachuk, l. kapustianenko, s. kharchenko, o. yusova, t. grinenko palladin institute of biochemistry of nas of ukraine, kyiv, ukraine introduction: plasminogen interaction with specific binding sites in c-terminal d-domains of fibrin molecule initiates the activation process of proenzyme and subsequent fibrin clot lysis. the sites are exposed under fibrin polymerization. plasminogen kringle domains ensure the proenzyme interactions with fibrin clot. in this study, we investigated the binding of human plasminogen kringle fragments k - and k with human fibrin fragment dd and their effect on glu-plasminogen interaction with dd. results: kringle-containing fragments k - and k reduce plasminogen activation by tissue-type activator on fibrin fragment dd. the level of glu-plasminogen binding to dd is decreased by - % in the presence of k - and k . fragments k - and k have high affinity to fibrin fragment dd (dissociation constant is . lm for k - and . lm for k ). analysis of k - and k binding to fibrin fragment dd with reduced disulfide bonds showed the interaction of both plasminogen fragments with c-c-chains of fragment dd. k - interacts with complex of fragment dd-immobilized k as well as k with complex of fragment dd-immobilized k - . the plasminogen fragments do not displace each other from binding sites located in fibrin fragment dd, but can compete for the interaction. analysis of k - and k binding to fibrin fragment dd with reduced disulfide bonds showed the interaction of both plasminogen fragments with aand c-chains of fragment dd. conclusions: widely known specific plasminogen-binding site located in aa - region of fibrin molecule is not a single binding sequence of fibrin peripheral domains or plasminogenbinding site is not linear and contains amino acid residues from other polypeptide chains of fibrin d-domains. fibrin fragment dd contains different binding sites for plasminogen kringle fragments k - and k , which can be located close to each other. possible plasminogen kringle-binding sites are located in aand c-chains. p- . . - implementation of budded baculovirus particles for characterization of ligand binding to g protein-coupled receptors a. allikalt, a. rinken university of tartu, tartu, estonia g protein-coupled receptors (gpcrs) constitute the largest class of membrane receptors involved in regulation of signal transduction into the cell in response to various extracellular stimuli. for that reason, gpcrs have become important targets for variety of drugs. as these receptors are present in native tissues at very low concentrations, efficient recombinant expression systems are needed to produce sufficient amounts of protein. we have shown that budded baculovirus particles, which display gpcrs on their surfaces can be used as a source of receptors for the investigation of ligand-receptor interactions. this expression system can be used for radioligand binding assay as well as for fluorescence anisotropy-based assay (fa). we have validated the system with budded baculovirus particles produced in spodoptera frugiperda (sf ) cells expressing human dopamine d receptors using [ h]sch- and bodipy-fl-skf- as reporter ligands for corresponding assays. this system has many advantages, for example good signal to noise ratio, homogeneity of the receptor, high expression levels and long-term stability of the receptor preparation. fa method allowed real-time monitoring of reporter ligand binding in the absence and presence of different dopaminergic ligands, giving information about their kinetic properties. association, as well as dissociation of the bodipy-fl-skf- itself were rapid with an apparent half-life of t / = . ae . s for association ( nm) and t / = . ae . s for dissociation. we determined the pharmacological profiles of different dopaminergic ligands in displacement binding assays with membranes of sf cells or budded baculovirus particles. the data were in good agreement for both membrane preparations tested in radioligand binding as well as in fa assay. obtained results indicate that budded baculovirus particles can be proposed as a source of gpcrs for performing fluorescence anisotropy as well as radioligand binding assays. gastrointestinal (gi) cancer includes a variety of cancer types affecting the structures and functions of the gi system, encompassing the gi tract and the accessory organs of digestion, from the esophagus, stomach, biliary system and pancreas to the intestine, rectum and anus. despite the significant advances however, much remains to be learned in the spectrum of gi cancer. several investigators have shown that both gas and its receptors, axl, sky, and mer are expressed in various types of cancers. however, the expression level of gas in gi cancer remains unclear. the aim of the study was to determine and compare plasma gas levels in gi cancer patients. female and male patients were included in the study (n = ): colorectal, gastric, pancreatic, liver, ampullary, gall bladder and esophageal. from all gi cancer patients, ml venous blood was collected in citrate tubes before surgery. blood samples were centrifuged at g for min, and plasma samples were carefully removed and stored in À °c prior to use. the level of plasma gas was measured using a commercial developmental elisa kit (r&d systems, minneapolis, mn) which is validated by our laboratory. plasma gas levels in cancer patients were determined as follows: . ae . ng/ml in colorectal; . ae . ng/ml in gastric; . ae . ng/ml in pancreatic; . ae . ng/ml in liver; . ae . ng/ml in ampullary; . ae . ng/ml in gall bladder and . ae . ng/ml in esophageal cancer. preliminary findings indicate that there is a relation between gi cancers and plasma gas levels. taken together, these results suggest that gas may be a candidate biomarker for diagnostic use in gi cancer. inhibition of gas would be an attractive therapeutic target for slow down the progression of gi cancer. monday september : - : computational biology p- . . - computational approaches as an assay for blactam hydrolysis in class a b-lactamases c. tooke university of bristol, bristol, united kingdom b-lactam hydrolysing enzymes, in particular carbapenem-hydrolysing enzymes, are an increasing clinical threat. herein we show that molecular dynamics (md) and combined quantum mechanics/molecular mechanics (qm/mm) approaches are a predictive tool of carbepenemase activity in class a b-lactamases. b-lactam drugs are the most prescribed class of antibiotics worldwide, especially in the treatment of gram-negative pathogens such as klebsiella pneumoniae and escherichia coli. these organisms produce b-lactamases, enzymes which hydrolyse the b-lactam ring, a key resistance mechanism. class a b-lactamases have the ability to hydrolyse carbapenems, termed 'last resort' antibiotics. in particular, the kpc (klebsiella pneumoniae carbapenemase) family are the most clinically important, and recently identified natural kpc variants show increased hydrolytic activity against ceftazidime, a third generation cephalosporin. here we use computational simulations of b-lactam hydrolysis by b-lactamases. in particular, molecular dynamics (md) combined with qm/mm approaches have been used to model the deacylation of the carbapenem meropenem across class a b-lactamases. this method has been extended to model cephalosporin hydrolysis across class a b-lactamases, including kpc variants. these approaches calculated the free energy barriers and correctly distinguished carbapenemases from carbapenem-inhibited enzymes. preliminary results suggest this protocol is also a predictive tool for ceftazidime hydrolysis. further, md simulations of kpc variants (single and double amino acid changes) were analysed to identify structural changes in the active site, highlighting that variants differ in the size of the active site opening, corresponding with experimentally derived kcat values. these computational assays provide a predictive tool of b-lactam hydrolysis and has potential to provide insights into important mechanistic differences both across class a b-lactamases and within the same families. p- . . - computational design of a novel polyglutamic dendrimer-based platform as an anticancer therapeutic approach poly (glutamic acid) (pg)-dendrimer as potential nanocarriers for cancer therapies, to specifically deliver tumor associated antigens (taa)mannosamine and melanato target cells and to modulate cancer antigen intracellular trafficking within the cytoplasm to promote an efficient and selective antitumor immunotherapeutic effect. the theoretical structures were obtained using x-plor software. the molecular dynamics simulation of pg-g -dendrimer and taas was performed using desmond. the electronic properties of the structures were determined by semi-empirical methods using mopac. docking studies of taa to pg-g -dendrimer to mannose receptor (mr ) were performed using hex . . software. taa lumo atoms were conjugated to homo atoms of pg-g dendrimer using maestro software. results showed that pg-g -dendrimer displays carboxylic end groups available for covalent interaction with taas. the homo molecular orbitals of the dendrimer was located on the a-carbon of the carboxylic acid groups from backbone chain and it preferentially interacts with lumo molecular orbitals of amine group from taas. no differences in the gap energy of homo/lumo of all pg-g -conjugates. taas bind preferentially to a-carbon of cooh of backbone chain instead of cooh from side chain. docking results showed that majority of taa conjugated pg-g -dendrimer binds to the core of the mr receptor. increasing of the number of mannosamine conjugated to pg-g -dendrimer more close and stable is the conjugated to the receptor. this system shows promising results as a novel functionalized pg-dendrimers for cancer therapy. theileria parva is one of the the economically important protozoan of the theileria genus belong to apicomplexa phylum which include plasmodium spp. and toxoplasma gondii, causative agents of malaria and toxoplasmosis respectively. this parasite is the disease agent of tick-borne east coast fever (ecf) ranks first among the tick-borne diseases of cattle in sub-saharan africa. the disease caused by the parasite affects a large proportion of domestic and wild animals and leads serious economic losses in the world. major problems in dealing with this illness are the high cost of drugs, development of resistance, and absence of effective vaccines. thus, it is important to develop an efficient and affordable antitheilerial agent. for this aim, -deoxy-d-xylulose- phosphate reductoisomerase (dxr) which subjected to identify novel drug aganist malaria and toxoplasmosis, of theileria parva was selected as potential target for improving novel inhibitors aganist ecf. a computational molecular modeling approach was conducted to determine the d structure of tpdxr by phyre . energy minimisation and root mean square deviation (rmsd) was performed by drefine and superpose servers. to ensure the quality of modelling, stereochemistry, energy profile and residue environment of modelled structure were checked by different servers and possible ligand binding pockets were identified by metapocket . server a reliable d model for dxr from t. parva was modeled by using au as a template. the ca rmsd and the backbone rmsd deviations for the model and the template crystal structure were found to be . and . a, respectively. the ramachandran plot for the predicted model by rampage reveals that model shows an acceptable stereochemistry. top three considered possible binding pockets have been identified. these results have important implications for future screens aimed at finding new and safe molecular entities active against tpdxr through docking studies. p- . . - molecular binding profile of protoberberine alkoloids on amyloid precursor proteincleaving enzyme (bace ) as a drug candidate for alzheimer's diseases g. yalcin , i. yildiz biotechnology institute, ankara university, ankara, turkey, department of pharmaceutical chemistry, faculty of pharmacy, ankara university, ankara, turkey alzheimer's disease (ad) is the most prevalent neurodegenerative disorder that leads to dementia and nowadays over million people live with dementia worldwide. because of the prevalence and economic burden of the disease, drug development studies have picked up speed and scientists especially focused on natural products. ad is basically characterized with tau hyperphosphorylation and accumulation of amyloid b (ab) proteins. ab proteins are generated from sequential cleavages of amyloid precursor protein (app) by b and c secretases, and b-site app cleaving enzyme (bace ) is a b secretase essential for ab production. the alkaloids represent a very extensive group of secondary metabolites, with diverse structures, distribution in nature and important pharmacological activities. protoberberine alkaloids, which belongs to isoquinoline alkaloid class, are widely arranged in many species of the berberidaceae, annonaceae, fumariaceae, papaveraceae, and other plant families. recent searches showed that some of the protoberberine alkaloids such as berberine, palmatine, jatrorrhizine, columbamine, magnoflorine prevents the progress of neurodegenerative disorder. however, the mechanisms of them are not absolutely clear. therefore, we have aimed to elucidate the binding and affect mechanism of these alkaloids on the bace open and closed forms in here. for this purpose, molecular docking studies were applied for these natural products to the both forms of bace by using autodock vina and it was subjected to explicit solvent simulations by amber molecular dynamic package. our preliminary studies indicate that gly , thr , gln , phe , tyr , lys , thr , arg , thr residues of binding pocket have affiliations with all of the mentioned alkaloids and the binding of them generates alterations on closed form of bace . the complexity of animal milk needs to apply numerous approaches and methods for its investigations. an understanding of the processes occurring in the milk can be used, for example, for quality control of the products. fat and protein are main components of milk which have a significant influence at its colloid properties, such as dynamic surface tension (dst). the application of regression-correlation analysis to milk data enables to develop a reliable quantitative model. the aim of our investigation was to perform the regression analysis to establish the relationship between above-mentioned parameters. for this purpose, we used a statistical software packages r version . . . dst was determined by bpa - p tensiometer. milk fat (f) and protein (p) contents were measured by analyzer bentley . this work was supported by the russian scientific foundation (grant - - ). obtained formulas characterized the degree of influence of fat and protein contents of a milk sample for each of the dst parameters (r , r , r , r , k , k ): r = . + . * p À . * f r = . + . * p À . * f r = . + . * p À . * f r = . + . * p + . * f k = . + . * p + . * f k = . À . * p À . * f these formulas show that the maximum total effect of fat and protein contents influences at r and r . a significant coefficient (> ) before the fat is observed in the formula, which describes the value of the tilt of final part of the tensiogram (k ). the resulting regression equations have fundamental importance. with their help it is possible to calculate the dst parameters without their experimental determination, positioning fat and protein contents data. obtained dst parameters promote more complete characterization of the properties of the milk that may be used for dairy products. p- . . - molecular studies of scorpion toxin and its mutants interactions with voltage-gated potassium channels the voltage-gated potassium kv . channel is mostly expressed in neurons and immune cells. its blockage has a high therapeutic potential, for example, specific inhibitor shk toxin is undergoing clinical trials on psoriasis. goal of the current study was an interface analysis in complexes of hybrid channel kcsa-kv . with peptide blockers agitoxin and its mutant forms. d structure was generated by homology modeling method using complex of mutated kcsa channel with charybdotoxin (pdb-code a h) as a template and equilibrated by molecular dynamic simulation in gromacs software. analysis of hydrophobic and stacking interactions, hydrogen and ionic bonds of the toxin and potassium channels was performed for representative frames with optimal toxin orientations using program platinum and apbs software package. we performed contacts energy characteristics estimation to predict key toxin residues for binding process and possible mutation sites for changing selectivity against kv .x channels. the results of investigation are in good agreement with the experimental values of binding constants, obtained by competitive binding assays. results of the conducted investigation may find an application in fundamental science and drug design. the research was supported by the russian science foundation grant no. - - . simulations were performed using the supercomputing center of lomonosov moscow state university. p- . . - homology modeling and molecular docking study of the paraoxonase- and its polymorphic variants q/r and m/l for non-statin lipid lowering drugs paraxonase- (pon ) enzyme is an hdl associated ester hydrolase exhibiting paraoxonase, arylesterase and lactonase activity, and reduces the formation of atherosclerosis blocking the ldl oxidation and reducing levels of oxidized lipids. in this study, molecular docking approach and molecular dynamics simulation were applied for finding the affinity of non-statin lipid-lowering drugs to pon and its polymorphic structures pon q/r and m/l . fibrates (bezafibrate, ciprofibrate, clofibrate, fenofibrate, gemfibrozil), phytosterols (beta-sitosterol, brassicasterol, campesterol, stigmasterol) and other lipid lowering drugs (ezetimibe, niacin, orlistat, probucol, and sibutramine) was obtained from pubchem database. x-ray crystallographic structure of human pon and its polymorphic variants pon q/r and m/l was generated via 'modeller', homology modelling software, from human-rabbit hybrid x-ray crystal structure of pon (pdb code: sre). ns molecular dynamic simulation analysis was performed using gromacs . . . affinity of lipid lowering drugs to pon and its polymorphic variants was predicted by molecular docking approach using autodock . suite. unlike other lipid lowering drugs that they have negative Δg values for affinity, probucol, orlistat and betasterol was calculated by positive Δg values ( . , . and . kcal/mol). these values suggest that they may have no affinity to pon q/r polymorphic structure. in all drug groups, brassicasterol and stigmasterol to pon -m/l and sibutramine to pon q/r were calculated as the highest affinity. in generally, phytosterols predicted by high affinity to pon and m/l polymorphic structures in comparison to other lipid lowering drugs. our study demonstrated that phytosterols predicted as high affinity compounds on pon structures may reduce the activity of antioxidant pon enzyme. this study need to be supported by in vitro and in vivo detailed studies. prolactin and its cognate receptor, prolactin receptor (prlr), are involved in over distinct functions in mammalians. the mammalian prlr gene consists of - exons and several and regulatory sequences. in this study, gaps and annotation errors in the rat prlr gene were corrected by comparing the genomes of mammals and rodents and new putative exons were identified. the rat prlr gene sequences from two different sources (rnor_ . , nc_ . and rn_celera, ac_ . ) were used and primary analysis showed that both sequences contain several gaps (varying from . to kbp), corresponding to about . % ( - kbp) of the gene. using the rat known prlr mrna exon sequences, it was found that the rnor_ . prlr gene has two exon- (one is about kbp long and the other immediately after this). comparisons of mammalian and rodent prlr gene structures showed that the kbp stretch is an assembly artifact. by comparing both gene sequences (and also other available rodent prlr genes), the gaps in the rat prlr gene were reduced from . % to . % (from kbp to kbp). functional annotation of the gene revealed that r. norvegicus prlr gene could have two more additional exons, exon- and - , similar to mus musculus prlr gene. in mammals, prlr mrnas contain non-protein coding exons in the utr (exon- and - ). in rats, there are exon- variants, resulting from alternative promotor usages. studies on the rat and mouse prlr genes revealed that both rodents share common non-protein coding exon- variants. in conclusion, it is found that the rnor_ . version of the prlr gene has the highest number of unidentified base pairs (corresponding to . % of the gene) and the second exon- is the assembly artifact. the rat prlr genes in both databases have several gaps and our corrected version is the best available and characterized form of the rat prlr gene. in silico affinities of some statins to paraoxonase- enzyme the structure of the statins (atorvastatin, fluvastatin, lovastatin, mevastatin, pitavastatin, pravastatin, rosuvastatin and simvastatin) was obtained from pub chem database, and x-ray crystal structure of pon (pdb id: sre) from protein data bank. modeller software was used for homology modeling of pon and its polymorphic variants that's called as pon q/ r and m/l . amino acid sequence of human serum pon (uniprot: p ) was used as the modeller template. all molecular dynamics simulations were carried out with gro-macs . . software. molecular docking calculations on each of the polymorphic structure of the pon was performed with auto dock . . suite. for each substrate, y residue showed open conformation in pon and m/l polymorphic structures while q/r polymorphic structure showed closed conformation. in comparison between structures of pon variants, in most cases statins had lower affinity to q/r polymorphic structure than to the other variant. in this study, among statins, atorvastatin showed lowest but simvastatin highest affinities to pon . by considering that the high affinity drugs can have reducing effect of pon activities, it may be more appropriate to use the low affinity statins in hyperlipidemia treatment. however, these findings need to be supported with in vivo and in vitro studies. p- . . - self-assembly of lipidoids for sirna uptake and release mechanisms studied by molecular dynamics simulations o. acar , d. alpay , a. r. atilgan , c. atilgan sabanci university, istanbul, turkey, northwestern university, evanston, united states small interference rna (sirna) has the ability to bind a specific mrna which provides silencing of selected genes. nanocarriers made out of self-assembled lipidoids encapsulate sirna and deliver them into target cells effectively. in this study, a library of lipidoid structures is constructed and studied by molecular dynamics (md) simulations in different solvents, including sodium acetate, to ferret out their self-assembling mechanisms. the effect of the protonation state of the head group of lipidoids on the final shape of the self-assembled carrier is also studied. we further examine the role of the size of hydrocarbon tails in the packing. we study the final topology and the geometry of the self-assembled lipidoids both in the presence and in the absence of sirna. we find that stable clusters form with as few as chains. for lipidoids having neutral head groups, clusters are in the form of dense bundles, while those with charged head groups form spherical capsids which are depleted of the salt on the inside and having a salt rich phase on the outside. in the self-assembled structure, lipidoids are arranged so as to expose the nitrogen and oxygen atoms to the solvent. while partial capsids with these properties also form at lower lipidoid numbers, chains are necessary to form a fully closed capsid. in the presence of the sirna, the capsid assembles around the nucleotide. the free energy to remove the sirna from the assembly is calculated via repeated steered md calculations utilizing jarzynski's equality relating it to the irreversible work along and ensemble of trajectories. we therefore determine an optimal tail length for the most stable nanostructure, paving the way for designing nanocarriers with high efficacy. milk is one of the most valuable products for humans and attracts a lot of interest of researchers in various fields such as biochemistry, biology, food science and technology. the methods of milk study are quite varied. we chose the combination of the ultrasonic and dynamic surface tension (dst) measurements with the possible correlations among the obtained parameters. the aim of this work is to study the correlation between the parameters of milk, such as a content of fat, protein, lactose, minerals, dry milk solids and dst parameters. for this purpose we used milk analyzer 'klever- m' and tensiometer 'bpa- p'. three groups of animals were formed from clinically healthy holstein cows at the age of - years according to the fat content in the milk sample. group i - cows (milk fat content . ae . %), group ii - cows (milk fat content . ae . %), group iii - cows (milk fat content . ae . %). this work was supported by the russian scientific foundation (grant - - ). the biochemical parameters of the milk samples of all three groups are in the range of the 'normal' values for healthy holstein cows: protein content varies from . % to . %, lactose and mineral content varies from . % to . %, respectively. the dst parameters (r , r and k ) for the group i have strong positive correlations with the fat content in the studied milk samples. at the same time for the groups ii and iii the fat content in the milk indicates only medium positive and weak positive correlations with the r , r and k . obtained absolute values of the dst parameters of the milk samples showed some differences between all three groups. thus, the dst parameters are changing in direct proportion to fat content in the milk sample that can be explain by the primarily role of the milk lipids in the formation of the water/fat surfaces (such as fat globules, lipid-protein particles, etc.). p- . . - exploration of allosteric paths in caspase molecules using energy dissipation e. n. bingol, o. sercinoglu, p. ozbek sarica marmara university, istanbul, turkey caspases are highly regulated aspartate-specific cysteine proteases that have major roles in programmed cell death; apoptosis. effector caspases are at the terminal step of the pathway, hence they are considered as death switches. with the discovery of the presence of allosteric sites, these molecules attracted the attention of the pharmaceutical studies and became drug targets. as a result of the binding of small molecules to the dimeric interface, active site loops are shifted to an unfavorable position. this is associated with a network between distal allosteric sites and the active site loop. an energy dissipation model was applied in order to analyze this matter in further detail. perturbation of specific residues enable us to determine a possible signaling network in proteins using external energy as an input, while focusing on the dispersion of this energy between residues throughout the structure. molecular dynamics simulations were performed with and without energy perturbation using namd software with charmm force field. energy perturbation was applied by increasing the velocity of a chosen residue at the desired time step of the initial md simulation. energy change of each residue was calculated upon the application of perturbation. as a result, residue response times, corresponding to the time of the response of a residue after the perturbation of another chosen residue, are obtained. combining reponse time data with a residue interaction network, it is possible to construct a final network that shows the communication started by perturbation within the molecule. it is shown that perturbation of allosteric sites result in the disruption of the catalytic sites given in literature. our findings support this and also gives a little detail of the possible communication between distal allosteric site and the active site loops. this finding enables the usage of this methodology for similar structures where the exact allosteric mechanism is yet not known. p- . . - effect of complex mammalian membrane models with multiple membrane components on ras protein nanoclustering a. farcas , , l. buimaga-iarinca , c. floare , l. janosi faculty of physics, babes-bolyai university, cluj-napoca, romania, national institute for research and development of isotopic and molecular technologies, cluj-napoca, romania ras proteins are essential for the cellular signal transduction that regulates cell proliferation and differentiation and act as binary switches between gdp and gtp forms. a wide range of human tumors are associated with defective ras protein signaling. the production of permanently activated ras proteins is correlated with mutations in ras genes. experiments and computer simulations have shown that membrane-bound ras proteins form nonoverlapping dynamic nanosized subdomains (nanoclusters) in activation state-/isoform-dependent manner. we performed coarse-grained molecular dynamics simulations to investigate the effect of complex mammalian membrane models on formation and evolution of ras nanoclusters. a fundamental part of the plasma membrane is the phospholipids bilayer, which contains phosphatidyl-choline (pc), phosphatidylethanolamine (pe), phosphatidyl-serine (ps), sphingomyelin (sm) and cholesterol (chol). the nature of lipid-lipid and protein-lipid interactions was studied in binary (pc:chol) and quinary mixtures (pc:pe:ps:sm:chol). because the polar lipids are not uniformly distributed between the two leaflets of the membrane, the construction of the plasma membrane with five-component lipid mixtures took into account the asymmetry between the outer and inner mono-layers. the phospholipids chain saturation (combined with the presence of cholesterol) constitute the dominant factor in phase separation and was, therefore, modeled in different lipid tail combinations for various headgroups. using microsecond timescale simulations of membraneembedded ras proteins, we have shown that the nanoclusters are spontaneously forming dynamic structures whose behavioral characteristics is modulated not only by the ras isoform, but also by the complexity of the membrane model. furthermore, we showed that variations in the plasma membrane lipid composition have important implications in the localization of ras protein nanoclusters. optogenetics comprises biological methods to achieve gain or loss of function of well-defined events in specific cells of living tissue by means of targetable control tools that respond to light and deliver the effector function. microbial rhodopsins (mrs) have been established as powerful light-sensitive tools for optogenetics. acting as ion pumps or channels, mrs are used to induce cell (de)polarization to control neuronal activity in a wide range of living organisms. mrs are membrane proteins found in a large clade of organisms, including eukaryotes, bacteria, and archaea. they share a common architecture of transmembrane a-helices and a covalently linked retinal, which is employed to absorb photons for energy conversion or the initiation of cellular signaling. major efforts are put into screening of natural and generating of synthetic mrs with desirable properties for optogenetics, e.g. ion selectivity. however, experimental study of mrs is difficult and resource consuming owing to, among other factors, low expression levels and protein stability. thus, there is a need in developing of computational tools for identification of mrs with desirable properties. we used non-redundant atomic structures of mrs taken from protein data bank to develop a set of numerical descriptors that reflects functional properties of mrs. then, we calculated the descriptors for non-redundant sequences of mrs with known function taken from the uniprot database, resulting in the feature matrix. we applied the support vector machine and the fold cross-validation procedure, using the feature matrix as the training set. as a result, we obtained the classifier that discriminates mrs in terms of the ion selectivity, e.g. na + , h + , or cl À pumps, with high precision. finally, we used the derived classifier on a test set of proteins and identified mrs for the further experiment in vivo. rational design of peptides with required stability and functional activity properties becomes a real instrument for the new generation drug development. the reca bacterial protein (and human rad homolog) is considered to be the central catalyst of homologous recombination, a mechanism essential for the accurate repair of double-strand dna breaks. dna repair via homologous recombination requires reca nucleoprotein filaments assembly. using seqopt (http://mml.spbstu.ru/seqopt/), a novel method for a-helix sequence optimization we present the successful design of peptide sequences capable to maintain a very stable a-helix structure and to inhibit reca activity. novel a-helical amino acids peptide is constructed based on reca-dna complex structure. we observed in vitro inhibition of reca atp hydrolysis, dna strand exchange reaction and reca filament formation. also, we observed lower e. coli resistance to uv and sos-response suppression in vivo. computational identification of promiscous enzyme activity for the morita-baylis-hillman reaction k. ozturk, s. sayin, n. celebi olcum yeditepe university, istanbul, turkey enzyme promiscuity attracts considerable attention in terms of enzyme evolution, protein engineering and biocatalysis. especially, development of highly efficient novel biocatalysts starting from promiscuous enzymes that have the catalytic machinery to perform desired chemistry is an intense area of research in recent years. in this work, we computationally explored the catalytic promiscuity of natural enzymes for the synthesis of morita-baylis-hillman (mbh) adducts, which display antitumoral activity against human cervical cancer cells, by mining structural protein databases using quantum mechanically optimized theoretical active site models (theozymes). catalytic interactions in the active sites of selected hit proteins with potential mbh activity were evaluated in solvated dynamic environment using molecular dynamics simulations. computational screening of the protein data bank for the quantum mechanically determined optimal arrangement of catalytic functional groups for the target mbh reaction successfully identified an enzyme with experimentally determined promiscuous mbh activity. ras proteins mediate a wide variety of signal transduction pathways that regulate cell growth, proliferation and differentiation. these proteins are small gtpases that act as binary switches between gdp-bound 'off' and gtp-bound 'on' states. oncogenic point mutations of ras are associated with~ % of all cancers and up to % in specific tumors and many developmental disorders. both experimental and in silico results showed that the membrane-bound ras proteins form non-overlapping dynamic nanosized subdomains called nanoclusters in an activation state-/ isoform-dependent manner. we performed coarse-grained molecular dynamics simulations in order to investigate the formation and evolution of ras nanoclusters in mammalian model membranes. ras proteins were inserted into the cytoplasmic side of the plasma membrane model (di-c : -phosphatidyl-choline: di- : -phosphatidyl-choline: cholesterol : : ) where they formed highly dynamic nanoclusters, both in size and in composition. furhermore, we found that the presence of ras protein nanoclusters has a significant impact on the model membrane behavior. properties such as phase behavior, diffusion coefficient, surface tension and lipid tails order parameter are also influenced by the temperature variation of the model membrane. we have investigated dynamics in three different crystal forms of ubiquitin, as well as ubiquitin in solution, with particular emphasis on (i) conformational exchange between b turn type i and ii in the region - and (ii) rocking dynamics where protein molecules as a whole undergo subtle reorientational motion within the confines of the crystal lattice. experimentally, both motional processes have been probed using relaxation dispersion techniques, including recently developed near-rotary-resonance dipolar relaxation dispersion experiments. thereby it has been determined that rocking motion in one of the crystal forms (pdb id n ) occurs on the time scale of tens of microseconds, whereas the conformational exchange has characteristic time constant of ca. ls. using molecular dynamics simulations, we have shown that the similarity of motional time scales is not accidental: bi↔bii exchange and rocking motion appear to be coupled. we have investigated the mechanisms of this coupling and predicted a number of point mutations that are expected to abrogate (or enhance) rocking. the crystals of ubiquitin containing these mutations have been modeled in silico. we have also investigated the interactions (in particular, crystal contacts) that control the balance between bi and bii conformations in different crystal forms. finally, we have used md simulations as a basis for chemical shift calculations and illustrated how relaxation dispersion effects can emerge as a function of bi↔bii exchange in conjunction with the rocking motion. the md simulation study was supported by rsf grant - - . serine/threonine kinases are attractive targets in targeted cancer therapy due to their overexpression in several forms of cancer. flavonoids are highly bioactive plant secondary metabolites that are important in human health due to their antioxidant property. quercetin, a natural flavonoid derivative, has been shown to regulate several signal transduction pathways and is in phase i clinical trial as an anticancer drug. this study explored the inhibitory potential of quercetin and its derivatives using in silico methods like molecular docking and molecular dynamics simulations. quercetin and its derivatives were observed to bind to several serine/threonine kinase family proteins with binding energy significantly better than other known inhibitors and commercially available drugs. this study thus sheds light on the atomic level interactions that define the polypharmacological nature of quercetin and its ability to interfere with a number of cancer pathways. introduction: noninvasive prenatal diagnosis (nipd) of the fetal rhd status by rhd genotyping of the maternal plasma was initially applied in alloimmunized pregnant women. fetal rhesus d status detection for management of rhd incompatibility using circulating cell-free fetal dna from maternal plasma or serum is now accepted by many obstetricians in europe as reliable and useful. the aim of the study was to detect fetal rhd specific antibodies in maternal plasma using a nanopolimer based electrochemical biosensor. materials and methods: a three-electrode system, consisting of a gold electrode, an ag/agcl reference electrode and a pt counter electrode, was accommodated in a -ml electrochemical cell. anilin and jelatin were used for immobilization of rhd antibody. the polimerization was occured at nm uv light. antibodies of rhd antigen were detected using differential pulse method at between . and . v potentials by observing the differentiations in the current values. results: the rhd status of the fetus was predicted in rhdnegative pregnant women ( - th week of pregnancy). rhd antibody were detected in maternal bood using biosensor in of the fetuses. the results were confirmed with real-time pcr. the fetuses found rhd (+) for exon and of rhd gene by multiplex real-time pcr. discussion and conclusion: biosensors based studies might be useful, because they allow to monitor the molecular interactions in real-time providing qualitative and quantitative information, through kinetics, affinity and concentration analyses. we found that more advantages in comparison to other methods reported in the literature so far; it was determined that the method is sensitive, specific, economic, practical and less time-consuming. fetal rhd detection at low concentrations and in the early week of pregnancy is possible with this method. p- . . - investigation of phylogeography of cricotopus sylvestris (diptera: chironomidae) using mitochondrial and nuclear molecular markers the family chironomidae is one of the most widely distributed insect families of diptera, and this family is distributed in all continents and all habitats from the tropics to the arctic in lakes, streams and puddles. in this study, we aimed to determine the dispersal of c. sylvestris using molecular phylogenetic markers not only in turkey but in the world and to reveal from where this species may have entered to turkey in the past. c. sylvestris larvae were collected from lakes across turkey. after total genomic dna extraction from body of larvae, fragments of two mitochondrial genes, cytochrome c oxidase subunit i (coi) and cytochrome b (cytb), and one nuclear gene, carbomyl phosphate synthase domain (cps) of cad, were amplified and sequenced. in addition, several sequences of these three genes of c. sylvestris from different countries of different continents such as south corea, japan, canada, denmark, and sweden were obtained from genbank. all sequences were aligned using mega and bioedit version . . . and were used for phylogenetic analyses. neighbour-joining (nj) tree was created in mega and paup . b with bootstrap replicates. maximum likelihood (ml) analysis was performed in raxmlgui . using gtrgamma model with bootstrap replicates. beast v . . was used for bayesian analysis. our phylogenetic analyses indicated that the japanese, south corean and american c. sylvestris were different from european and turkish members. turkish members of c. sylvestris were closely related to european ones according to our bayesian, nj and ml analyses. in turkish members, c. sylvestris collected from hazar and c ß ıldır lake was more ancient than those from marmara, sapanca, c ß ıldır, aygır, beys ßehir, e girdir and sıhke lakes. in conclusion, our results clearly suggest that several transoceanic dispersal events among the continents may have occurred and that the entrance of turkish c. sylvestris to turkey may have been from southeast and northeast of the country. metagenomics is providing great help to explore world of unculturable microorganisms in the natural samples to enhance our knowledge about microbial diversity. here, we have performed metagenomic analysis of fresh water lake bacterial community using pyrosequencing techniques. we have observed a wide array of bacteria from phylum proteobacteria and family enterobacteriaceae as well as very few viruses from podoviridae, siphoviridae and unclassified phages. we have conducted a metagenomics analysis with the primary focus on the examination of the community of bacteria in a fresh water lake ecosystem. roche gs flx software gave us total reads (with an average read length of . bp). there were contigs having > bp sequence length whereas contigs with > bp sequence length. for further analysis we have taken contigs with > bp only. further, we have analyzed the microbial community composition using blastn/blastx against nt/nr databases with e-value cutoff of À . ≥ % of total contigs were mapped to the reference with ≥ % contig match coverage. the community analysis revealed that domain bacteria is predominantly present ( . %) in the water sample, followed by eukaryota ( . %), viruses ( . %) and other sequences ( . %). most abundant phyla was proteobacteria ( . %) and the most dominant family was enterobacteriaceae ( %) followed by xanthomonadaceae ( %), vibrionaceae ( . %), pasteurellaceae ( . %), shewanellaceae ( . %). we performed functional analysis of all contigs using rapid annotation using subsystems technology (rast) which detected coding sequences and rnas in subsystems. among the classified cds from rast showed major cds hits for enzymes involved in the subsystems amino acids and derivatives and the carbohydrate metabolism. the great diversity of microorganisms present in the lake may reflect the human activity in the area. maldi-tof mass spectrometry is a ubiquitous and widespread tool for protein identification. once the protein sequence is unavailable, unambiguous identification cannot be performed, and predictability is limited by the presence of sequenced homologous proteins. we present a statistical approach to predict a number of structural, localization and functional properties of unknown proteins by direct analysis of mass distribution shapes of their post-cleavage fragments obtained from maldi-tof mass spectrometry data. secondary structure of proteins is best predicted by their specific cleavage at the inertial hydropathy group amino acid residues (filmv), with thermolysin (afilmv) being the closest commercially available reagent, leading to distinguishing between proteins with presumably ahelixes or b-sheets with % accuracy. cellular localization of proteins is best predicted by their specific cleavage at the external hydropathy group amino acid residues (dehknqr), exemplified by gluc(phosphate)+lysc(dek) cleavage. protein location in the cell membrane and its localization character (monotopic/ transmembrane, single-pass/multi-pass transmembrane) are predictable with~ % accuracy by this single cleavage, with optimal combination of - cleavages improving the accuracy tõ %. functional prediction of proteins is the best among membrane-associated proteins with characteristic structural conformations. we attribute the differences in the mass distribution shapes to the characteristic clustering of amino acids residues with respective hydropathy properties that are involved in the formation of d structural conformations of proteins. the suggested approach allows for a non-parametric statistical prediction of uncharacterized proteins from their maldi-tof mass spectrometry data without knowledge or reconstruction of their primary sequence. potential applications include proteomic studies of organisms with unavailable genomic sequences and highly variable proteins analysis. the cancer genome atlas (tcga) represents a comprehensive database of genomic, transcriptomic and epigenetic alterations across more than tumor types. earlier we developed cross-hub tool aimed at multi-way analysis of tcga data in the context of gene expression regulation. in the present work, the software was updated with new features that are described below. crosshub is a python-based application. one of the features of crosshub is the combining tcga rna-seq co-expression analysis to encode chip-seq data in order to reveal most possible transcription factor (tf) targets and coupling mirna-mrna co-expression to several algorithms of mirna target prediction in order to enhance its efficacy. the key feature of the updated crosshub version is the analysis of the associations between expression ratio of tf to its targets and tf mutation status. this allows identification of tfs that are functionally (in)activated with driver mutations in a particular cancer type. the second novel feature of crosshub is the analysis of associations between 'tf-to-targets' expression ratio and tumor characteristics (tnm classification, pathological stage), patient follow-up, etc. in turn, this analysis may result in the identification of 'tf-targets' functional relations that are important for disease progression, tumor invasion, response to chemotherapy. thus, crosshub was supplemented with new features that can be useful for comprehensive tcga data analysis. the updated version of crosshub is freely available at http://sourceforge.net/ projects/crosshub/. this work was financially supported by the russian foundation for basic research (grants - - , - - and - - ) and ras presidium program 'molecular and cellular biology'. p- . . - mutations leading to increased rnase production and streptomycin resistance in bacillus pumilus bacillus pumilus strain - which was derived from soil-isolated b. pumilus p using chemical mutagenesis is characterized by resistance to streptomycin (str, up to lg/ml) and ability to produce extracellular enzymes in quantities almost -fold higher than the parent strain. these features make the - strain suitable for industrial production of rnase (binase) which is known for its antitumour and antiviral properties and can be used as an rna-degrading tool in molecular biology. the whole genomes of both mutant and wild-type b. pumilus strains were sequenced recently. to reveal the exact genetic features responsible for rnase overproduction and str resistance we have fulfilled comparative genome analysis of b. pumilus p and - strains. facilities of rast server, edgar platform and additional bioinformatics tools (plasmid finder, prophinder, bl seq) were used. it is found that both b. pumilus genomes under study contain an intact prophage, while only wild-type strain bears a kb cryptic plasmid. none of the systems is inactivated in mutant strain according to the results of metabolic reconstruction. . % of total cdss differ in - strain in comparison to p one, % of them are hypothetical. the altered genes are involved in membrane transport, cell wall composition, chemotaxis, spore formation, carbohydrate metabolism, dna metabolism, translation and transcription regulation. mutation (k n) leading to str resistance is identified in s ribosomal protein s p. regulatory and coding regions of binase gene have no modifications. candidate genes which can account for binase overproduction are selected. mutation k n is classical in str resistance and leads to enhancement of decoding accuracy while decreasing elongation speed. rnase overproduction is brought about by non-specialized mechanism since other hydrolases are also overproduced in mutant strain. genes encoding extracellular serine protease, sporulation initiation phosphotransferase f, gnat-family acetyltransferase and cell wall modifying enzymes are reported previously to increase production of degradative enzymes. the action of encoded by them proteins lead to increase of stability and release of secreted proteins to environment and to derepression of their transcription from negative regulators bacillus pumilus strain p has been identified on its ability to produce ribonuclease and different extracellular proteases. in order to increase inherent biosynthesis of proteases the p strain was screened on culture medium supplemented by streptomycin. derivative b. pumilus strain - gains the resistance to streptomycin and also shows the increased ribonuclease activity. we used genomes of both these strains to explore streptomycin susceptibility and increased activity of hydrolytic enzymes. whole-genome shotgun sequencing was performed using a combination of pyrosequencing and ion semiconductor sequencing, which provided x ( p) and x ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) overall genome coverage. assembled genome sequences of p and - strains included and scaffolds > bp with a calculated genome size of bp and bp, respectively. the gc content was %. both draft genomes have been deposited at genbank (jojx . for p and jhud . for [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] . detailed comparative genomic analyses of strains have been performed. we calculated average nucleotide identity (ani) values between the genomes of our strains and completed b. pumilus genomes deposited in ncbi database. two b. pumilus strains (sh-b and safr- ) revealed the max. ani value ( . % and . %, respectively). b. pumilus sh-b strain has been used as a reference for snp calling in strains p and - . snps for the p strain and for the - strain were classified as nonsynonymous variants. radical nucleotide substitutions from the - genome were not found in p genome. among them, the mutation in the codon of rpsl gene (coding s ribosomal protein s ) is probably associated with resistance to streptomycin. also, two mutations in rpob and nusa genes (coding rna polymerase and transcription termination factor rho, respectively) may be related to increased enzymes activity. both our strains contain protease-coding genes. twelve of them are encoding extracellular proteases. here we propose an algorithm that can predict an antibodies mutant forms with desired specificity. this algorithm allows to determine the position and type of amino acid residue for mutagenesis. approach is based on a hybrid method of quantum and molecular mechanics (qm/mm) that allows to understand the reaction mechanism and the role of active center amino acids. catalytic antibody a , that is able to hydrolyze pesticide paraoxon, was selected as a model. however, the hydrolysis efficiency of paraoxon by a antibody is only m À min À , that is insufficient for using this antibody as antidote. the main fundamental goal of our study is to determine the necessary conditions for improving the binding reaction of paraoxon by catalytic antibody a . the hybrid qm/mm method allows to study the reaction mechanism of interaction of a with paraoxon. it was shown that the reaction proceeds via the classical s n mechanism. the key step of the reaction is the proton transfer from the catalytic residue tyr- to paraoxon. qm/mm approach determines position for mutagenesis -leu- in light chain. for one of the mutant in this position -leu argwere predicted (i) increased probability of formation of a hydrogen bond between the catalytic moiety and paraoxon compared to the wild type antibody and (ii) smaller value of the diffusion coefficient, which reflects the best positioning of paraoxon in the active center. steady-state kinetic analysis shows that leu arg exhibits a -fold increase in k /k d compared to a ( m À min À vs. . m À min À ). double mutant leu arg/ser ala also has improved constants of interaction with paraoxon in comparison with the wild type antibody, however, a single mutant leu arg still binds paraoxon three times better, that may be due to the fact that the serine in position increase the nucleophilicity of tyr . thus, our results are in line with our computed predictions. this work was supported by rfmefi x . due to high prices of meat and meat products, low quality raw materials like offal tissues are commonly used in turkey. in the retrospect of the studies for evaluating and detection of unwanted tissues in the sample is basic histological examination. the light microscopy techniques are very strong method if a researcher qualification is enough. a new researcher-independent method must be developed. therefore, different tissues and organs constitute of unique mrna and protein. our method is based on this event, so the antigenic sites of the tissues can be detected by selected antibodies. the first set of the antibodies are for detecting muscle and adipose, consist on muscle actin and adipose triglyceride lipase. this set is used for calibration on standard meat sample. the second set of the antibodies are detecting of offal tissues, consist on trrap and casein. anti-casein antibody is selected because the mammary gland usage in grinded-meat is very common. immuno-staining started with hier (heat mediated epitope retrieval), then classical ihc method applied to slides with dab-chromogen. after all process completed the slides were photographed by las (leica application suite) on microscope. the capture settings were remained same on both sets. image capture size is x pixels and field of view (fov) is lm. all the image files were converted to binary for threshold operation. the threshold values of first set and second set were calculated and their ratios were compared. the formula is based on the distribution (dst) of pixel intensity (int) over threshold (thrs) values on all fov (axis: the results are good enough to detect the unwanted micro-structures on % raw meat and % offal tissue. calculations proofed with imagejÒ. future application of this method and opencv-based software algorithm is to port the source code to a single board computer (sbc) with a digital microscope connected. monday september : - : mechanisms of pro-inflammatory diseases p- . . - the effects of raas inhibition in rate limiting step by aliskiren on testicular torsion injury in rats testis torsion is a urological emergency condition that results in necrosis of the testis if the condition is not treated. unfortunately treatment of testis torsion is not fully understood, therefore clinical and experimental studies are performed continuously. reninangiotensin-aldosterone system (raas) contributed to pathophysiology of several diseases. aliskiren (als) inhibits the renin on the first step of this system. our aim is to investigate the protective effect of aliskiren on unilateral testis damage caused by experimental testis torsion and detorsion. the forty-eight rats were separated into eight groups of six animals: sham, sham+als mg/kg (oral) group, torsion group (tor), torsion/detorsion group (tor/det), tor+als mg/kg (oral) group, tor+als mg/kg (oral) group, tor/det+als mg/kg (oral) group, tor/det+als mg/kg (oral) group. in the tor and tor/det groups, the left testes were rotated °clockwise together with the spermatic cord and tunica vaginalis in the scrotal space. the left testes of the rats were subjected to torsion and detorsion during h. after experimental procedures, testicular tissues were examined by histopathologic and molecular analyses. the il- b and inos mrna expressions were increased in tor and tor/det groups when compared with sham group. both doses of aliskiren administration decreased these expressions in tor/det groups. the stereological results revealed that aliskiren administration promote the numerical density of mature spermatids in tor and tor/det groups. the numerical densities of tor/det+als and tor/det+als groups were similar and these two groups have significant difference when compared to the tor and tor/det groups. the administration of als may be useful for preventing ischemic damage on unilateral testes injury in rats. this study supported by a tubitak project, coded s . ) has recently been recognized as a potent immunomodulator which acts through regulation of gene expression involved in immunity response thus affecting various inflammatory and autoimmune diseases. the study was aimed at investigating hepatoprotective role of d in vdr-mediated regulation of pro-inflammatory factors in diabetic liver. materials and methods: type diabetes was induced in male c bl/j mice by i.p. injection of high-dose stz ( mg/kg b.w.). after weeks of stz-induced diabetes animals were treated with/without d ( iu/mouse per os) for weeks. blood serum ohd was assessed by elisa. rel-a, vpf, inos and vdr expression was measured by qrt-pcr and/or western-blot. results and discussion: diabetes caused two-fold reduction of serum ohd level, indicative of d deficiency. significant alterations in d -endocrine system were found as is evident from reduced expression of cyp a , cyp r , vdbp and vdr at transcriptional and translational levels. these changes were accompanied by a marked increase in mrna and protein levels of inflammation markers rel-a, vpf and inos in hepatic tissue of diabetic mice. diabetes also led to structural lesions in liver tissue. complete restoration of ohd content and partial normalization of liver tissue structure were achieved after d treatment. d administration partially normalized expression of cytochromes involved in d metabolism and hepatic pro-inflammatory factors. d treatment prevented overexpression of rel-a and phosphorylated p /rel-a translocation to hepatocellular nuclei that is most likely mediated through , (oh) d and vdr. conclusion: study confirmed that diabetes-induced liver abnormalities are associated with chronic inflammation that can be linked to impaired d metabolism and deficiency. our findings demonstrate protective vdr-mediated effect of vitamin d against diabetes-induced liver injury. p- . . - lavandula stoechas extract increased glucose uptake and protein levels of key signaling molecules in insulin resistant c c muscle cells s. savranoglu , h. ipek , s. arslan , h. delig€ oz , a. r. t€ ufekc ßi , i. demirtas , t. boyunegmez t€ umer graduate program of biology, institute of natural and applied sciences, c ß anakkale onsekiz mart university, c ß anakkale, turkey, graduate program of bioengineering, institute of natural and applied sciences, c ß anakkale onsekiz mart university, c ß anakkale, turkey, deparment of biology, faculty of arts and sciences, pamukkale university, denizli, turkey, department of chemical engineering, faculty of engineering, pamukkale university, denizli, turkey, department of chemistry, faculty of sciences, c ß ankiri karatekin university, c ß ankiri, turkey, department of molecular biology and genetics, faculty of arts and sciences, c ß anakkale onsekiz mart university, c ß anakkale, turkey introduction: the aim of this is to identify remedial effects of lavandula stoechas, anatolian traditional medicine, against metabolic disorders developed on the ground of insulin resistance. ethyl acetate extract (eae) of l. stoechas was investigated in c c myotubes which were made insulin resistant by free fatty acid (ffa) treatment, for its effects on glucose uptake and as well as on the activation of akt- (by pakt/ akt ratio) molecule which plays a central role in insulin signaling through serine ( ) phosphorylation. in addition, the protein level of lipoprotein lipase (lpl) enzyme was also evaluated. material and methods: c c cells were made insulin resistant by palmitic acid (ffa) and effects of eae on p-akt (ser )/akt ratio and lpl level were determined by sds-page/western blot. the effect of eae on glucose uptake in insulin resistant cells were determined by the -deoxyglucose uptake assay. results: eae at and lg/ml significantly increased the glucose uptake and % compared to insulin resistant control cells. metformin at mm increased this parameter up to %. eae increased pakt ser /akt level - % and lpl expression - % for and lg/ml, in insulin resistant myotubes, respectively (p < . ). discussion: eae of l. stoechas improved impaired insulin sensitivity through both enhancing glucose uptake and activation of akt molecule through ser phosphorylation. in addition, it also considerably increased lpl level which has very important function in lipid metabolism. conclusion: overall, results demonstrated that l. stoechas contain phytochemicals which can be effective for the prevention and also treatment of insulin resistance and associated conditions. our research group is on the way for the identification of these 'bioactive' molecules with bioassay guided fractionation studies. tubitak (projectid: t ) supports this study. achievement of complete pain control is very difficult task, which requires a search for new molecular targets during the analgesic substances development. considering the importance of glial cells and their signaling molecules, development of new gliotropic therapeutic methods is a promising direction in pain treatment. polyunsaturated fatty acids, including docosahexaenoic acid demonstrating anti-inflammatory and antioxidant activity are of considerable interest. docosahexaenoic acid (dha, : n À ) analgesic activity was studied using a chronic constriction injury (cci) rat model. animals were subcutaneously injected with dha emulsion at a dose of . mg/kg ( mm/kg) daily during weeks after surgery. collection of material for subsequent immunohistochemistry investigation was performed on day . we clearly demonstrated that the activation of neurokinin neurotransmission and nnos synthesis are coincided with the astroglial activation in the spinal cord dorsal horn (scdh) superficial lamina during neuropathic pain development. however, the detailed mechanisms of interaction between substance p (sp)-, no-ergic systems and astrocytes in the spinal cord remain to be elucidated. systemic administration of dha to cci animals reduced neurogenic pain intensity and duration, leading to an earlier stabilization of paw weight distribution and preventing the development of degenerative changes in denervated limb. this drug treatment reduced the level of the sp-and no-ergic neurotransmission and decreased astrocytosis in the scdh superficial lamina. thus, the ability of dha to affect nociception is a promising and safe alternative to current pharmaceutical therapeutics. immunohistochemistry studies carried out with the russian science foundation financial support (agreement no. - - ), obtaining dha and all manipulations with animals of the material was funded by rfbr according to the research project no. - - mol_a. p- . . - circulating endothelial-derived apoptotic microparticles and aopps are related to highsensitive troponin t in patients with chronic hepatitis c infection the aim of this study was to evaluate non-standard risk factors for cardiovascular events, such as endothelial dysfunction assessed by endothelial-derived microparticles (emps) (cd +/ cd + ), advanced oxidation protein products (aopps), and low-grade inflammation, that are potentially associated with elevated levels of high-sensitivity troponin t (hs-tnt) and n-terminal pro-brain natriuretic peptide (nt-probnp) in patients with chronic hepatitis c (chc). methods and results: eighty-six chc patients and healthy control subjects were enrolled in the study. circulating levels of hs-tnt, nt-probnp, aopps-albumin (the ratio of aopps to albumin content), emps (cd +/ cd + ), hs-crp, and tnf-a were assessed. compared with chc patients, the chc patients with diabetes mellitus (dm) had higher levels of emps (cd +/ cd + ) and aopps-alb, which were associated with elevated hs-tnt levels (≥ . pg/ml). nt-probnp positively correlated with tnf-a level in all chc patients and this correlation was stronger in diabetic patients. in multivariate logistic regression analysis, the independent factors associated with the presence of elevated hs-tnt levels were the presence of dm (p < . ) as well as high levels of aopps-alb, apoptotic emps (cd + /cd + /an-v + ), and nt-probnp (p = . , p = . , p = . respectively). conclusion: the prevalence of elevated hs-tnt were increased significantly in the diabetic patients with chronic hepatitis c. hs-tnt was related to non-standard risk factors for cardiovascular events, and circulating endothelial-derived apoptotic microparticles (cd + /cd + /an-v + ) level was an independent predictor for elevated hs-tnt levels, potentially indicating some abnormalities in the myocardium. apnea; and healthy individuals; and assessing the connection between the pain and the dimension of the sleep disorder. material and methods: patients who were diagnosed with obstructive sleep apnea and healthy individuals who were similar in terms of age and gender were included in this study. the patients, who were diagnosed with obstructive sleep apnea with the examination and sleep tests, were assessed according to the american college of rheumatology (acr) criteria in terms of fms. serum d vitamin level was measured by using the ultra performance liquid chromatography method. findings: when the fibromyalgia syndrome and obstructive sleep apnea and pure obstructive sleep apnea patient groups are compared with the control group, the vitamin d level was found to be low at a significant level (p = . , p = . , respectively). no significant difference was found between the vitamin d levels in fibromyalgia syndrome, obstructive sleep apnea and pure obstructive sleep apnea patient groups. a negative correlation was found between the number of the sensitive points and vitamin d levels in fibromyalgia syndrome patients (p = . ). results: it has been concluded that the obstructive sleep apnea and fibromyalgia syndrome patients have low vitamin d levels, and this situation must be considered in treatment modalities. on the other hand, the results obtained in the study make us consider that vitamin d metabolism is not influential in the pathogenesis of the fibromyalgia syndrome and obstructive sleep apnea togetherness. p- . . - decreased chitotriosidase activity and levels in familial mediterranean fever discussion: familial mediterranean fever is an inflammatory disease. several cytokines and inflammatory mediators are playing role on pathogenesis of the disease. although ıt has been demonstrated that the increased concentrations of cht in patients with fmf. we found lower cht activity and concentrations in patients with fmf. conclusion: serum cht enzyme activity and concentrations may not be considered as a biomarker in fmf patients taking colchicine. new studies are needed to evaluate the changes of the enzyme activity, concentration and the role of cht in patients with colchicines negative patients. chronic hyperglycemic state leads to an increase in subclinical systemic inflammatory response in diabetes mellitus type (dmt ) patients. inflammation-based scores, neutrophil to lymphocyte ratio (nlr), platelet to lymphocyte ratio (plr) and red blood cell distribution width to platelet ratio (rpr) are biomarkers able to quantify systemic inflammation. the aim of the study was to investigate association of the inflammation-based scores with short-and long-term glycemic control markers, and whether they could be used as indicators of glucoregulation in dmt patients. the cross-sectional study included dmt patients, treated at the primary health care centre zenica from december to april , distributed into groups according to glycated hemoglobin (hba c) values: a (n = , hba c ≤ . %) and b (n = , hba c > . %). complete blood cell count, fasting blood glucose (fbg) and hba c measurements were determined at the primary health care centre zenica and at the department of laboratory diagnostics, cantonal hospital zenica by standard laboratory methods. all statistical tests were performed using spss . . p values fasting blood glucose and hba c were significantly higher in the group b compared to the group a (p < . ). there was no significant difference of nlr, plr and rpr between the groups (p = . ; p = . ; p = . , respectively). significant correlation of inflammation-based scores with fbg and hba c was found only between plr and hba c in the group a of dmt patients (r = . , p = . ). inflammation-based scores could gather meaningful clinical information, either diagnostic or prognostic, on a variety of hyperglycemic, inflammatory, cardiovascular and thrombotic disorders. since there was no statistically significant difference of nlr, plr and rpr between dmt patients with good and poor glycemic control, we conclude that these scores could not be used as indicators of glucoregulation in dmt patients. chronic inflamation plays a central role in the development and progression of diabetes and in the pathogenesis of its comlications. the neutrophil-lymphocyte ratio (nlr) and platelet-lymphocyte ratio (plr) are indicators of subclinical inflamation. mean platelet volume (mpv) is one of the platelet function indices that reflects the platelet production rate and stimulation. we investigated the association of nlr, plr and mpv with prediabetes and type diabetes mellitus (t dm) and determine whether or not these are reliable markers for diagnosis. we evalueted people's results who were carried out oral glucose tolerance test (ogtt). acording to -h values of plasma glucose in the ogtt; . group (normal glucose tolerance: ngt): under mg/dl (n = ), . group (prediabetic: impared glucose tolerance (igt)): ranging from mg/dl to mg/dl (n = ), . group (firstly diagnosed diabetic by ogtt): above mg/dl (n = ). . group is clear diabetic without complication (taking treatment) group (n = ). we compered nlr, plr, mpv and some biochemical markers between four groups. there are significantly differences between all groups in nlr (p = . ) and plr (p = . ) values. nlr values are significantly higher in prediabetic ( . it is recognized that a chronic low-grade inflammation and an activation of the immune system are involved in the pathogenesis of insulin resistance and type diabetes mellitus (t d). this study aimed to analyze the long-term impact of altered metabolism in female t d patients at the level of mediators of inflammatory response. this study included femalet d patients and control subjects, which were recruited at the clinical center university of sarajevo and the general hospital tesanj. in this study the effects of glycemic control on markers of the inflammatory response crp, fibrinogen, leukocytes, sedimentation, and cytokine il- , were analyzed. all subjects included in this study were free of evidence infections, surgery, thyroid disease, polycystic ovarian syndrome, active liver and kidney damage. all biochemical analyses were performed by employing standard ifcc protocols. results from this study demonstrated significant increase of fibrinogen (p = . ), crp (p = . ), il- (p = . ), leukocytes (p = . ) and sedimentation rate (p = . ) in female t d population compared to control subjects. interestingly, a significant correlation was shown between crp and hba c (p = . ), il- and glucose ( . ), il- and bmi ( . ). in our study, female t d compared to the healthy population had significantly higher levels of fibrinogen, leukocytes, il , crp and sedimentation. other studies conducted in female population associated elevated levels of il- and crp with t d independent of other risk factors for diabetes. crp being most robust predictor of diabetes. studies have shown that crp is an important predictor of t d for the female but not the male population. thus, our data suggest that inflammation play an important role in the pathogenesis in female diabetic population. a more detailed study on a far larger number of subjects should point out fact if they can effectively be used as biomarkers in the primary prevention of t d in this population. objectives: bone and mineral metabolism disorders hold an important place among the complications after renal transplantation. the purpose of this study was to demonstrate the relationship between vitamin d, calcium, phosphorus metabolism with graft function and to measure , (oh) d levels with lc-ms/ ms in renal transplant recipients. design and methods: this study included renal transplant recipients ( female, male; mean age: . ae . ) from living related donors were transplanted. blood samples were collected immediately before and after transplantation at month . serum creatinine, bun, calcium, phosphorus, alkaline phosphatase, glucose, albumin, pth, (oh)d and , (oh) d levels were measured. gfr values were estimated by ckd-epi. plasma , (oh) d levels were determined in a lcms- triple quadrupole tandem mass spectrometer (shimadzu corporation, japan) by mrm. spss . software was used for statistical analysis. results: although plasma , (oh) d levels significantly increased (p = . ), we did not find any significant differences for serum (oh)d levels after transplantation. when posttransplant levels of serum phosphorus, pth, creatinin, bun and alp levels were found to be significantly decreased (p = . , p = . for alp), we observed significantly higher calcium and gfr values (p = . ). vitamin d insufficiency was present . %, deficiency . %, severe deficiency % before transplantation, insufficiency was also seen . %, deficiency %, severe deficiency . % after transplantation at month . conclusions: in our study, all patients were found to vitamin d deficiency and insufficiency. determination of vitamin d deficiency and consequently treatment with vitamin d supplements could lead to better graft surveys. free fatty acids (ffa) represent important link between obesity, insulin resistance, type diabetes (t d), and dyslipidemia. increased adiposity, as approximated by body mass index (bmi), correlates well with increased serum levels of leptin-adipocyte derived hormone implicated in the regulation of adipose mass and alterations in insulin action and secretion. the main objective of the present study was to investigate the potential association of serum ffas with leptin levels in healthy and newly diagnosed type diabetic subjects. this study involved newly diagnosed type diabetics and healthy subjects. all participants in the study were free of evidence of hepatitis, viral infection or active liver and kidney injury. for biochemical analyses of glucose, glycosylated hemoglobin (hba c), and lipid profile, standard ifcc protocols were used. analysis of free fatty acids (ffas) was done by gas chromatography, while serum leptin levels were determined by the elisa kit. in addition to the expected differences in glucose, hba c, and bmi, our results also showed significant differences in leptin, myristoleic, palmitic, linolenic, arachidic, and arachidonic acids between t d and control subjects. in healthy subjects, a significant correlation was demonstrated between glucose and lauric, arachidic, arachidonic acid levels, body weight, and bmi. newly diagnosed diabetics showed significant association between glucose and lauric, myristoleic and linolenic acid levels; with leptin being associated with myristic and palmitoleic acid levels. interestingly, in all participants, significant association was found between glucose and hba c, glucose and leptin, myristoleic, arachidic, and bmi as well as between leptin, arachidic acid, and bmi. thus, our data point out association of different types of ffas with leptin levels in newly diagnosed type diabetics. however, further studies should be done in larger number of patients to confirm our results. rheumatoid arthritis (ra) and ankylosing spondylitis (as) are chronic inflammatory diseases with distinct clinical manifestations in many ways. the aim of this study is to evaluate the serum levels of molecules which may be used as markers for angiogenesis and vascular leakage in the processes of two clinically different pictures, ra and as. ra patients, as patients and healthy volunteers with mean age of - were included in the study. serum levels of vegf, angiopoetin- and tie- were measured by enzymelinked immuno-sorbentassay (elisa) using a commercially available kit. serum nitricoxide levels were evaluated by the griessreaction. serum vegf, ang- and no levels were significantly higher in the as group ml, p < . ; p < . ; p < . ). no differences were found between as and ra for tie- (p > . ). vegf, ang- , tie- and no levels were positively correlated in both as and ra patients (p < . ), but no correlation was detected between clinically activation index das- , basda _ i scores and laboratory measurements such as sedimentation, crp and anti-ccp (p > . ). when the diagnostic performance of the parameters were evaluated with the roc analysisonly the performance of the ang- in as patients was sufficient (auc ( % cl): . , p < . ). elevation of angiogenic factors in the serums of as and ra patients supports the role of angiogenesis in the etiopathogenesis of these diseases. however, lack of relationship between disease activity leads to not to use these factors as a marker for clinical follow-up. only ang- measurements may be useful for the differantial diagnosis. the evaluation of ischemia modified albumin as an early biomarker of acute myocardial infarction introduction: acute myocardial infarction (ami), remains a leading cause of morbidity and mortality worldwide. early diagnosis of ami is very important because early treatment may reduce the extent of injury to the myocardium. currently, biomarkers of myocardial necrosis such as myoglobin, ck-mb and troponins are highly sensitive and exhibit good specificity. however, these biomarkers increase after tissue injury, approximately - h after the cardiac event and detect only the consequences of prolonged ischemia. recently, ischemia modified albumin (ima) has been assessed and found to be very useful for the diagnosis of myocardial ischemia and it is considered as a serum biomarker. the aim of the present study was to evaluate the serum level of ima and determine the relation between patients with ami and control group, in order to verify its potential as a novel marker for early detection of mi. materials and methods: the study was performed with patients and healthy controls. blood samples from all subjects were collected by venipuncture in plain tubes, and immediately centrifuged at g for min at °c. the serum samples were stored at À °c until analysis. the serum levels of ima were determined using the cusabio biotech human ischemia modified albumin, elisa kit according to manufacturer's instructions. the results are given as international units/milliliter (iu/ml). results: our findings revealed that ima showed no significant difference between the groups. conclusion: our results suggest that ima assay is not a sensitive marker for early detection of ischemic hearth disease and cannot be used alone for the diagnosis of ami. prospective studies are needed to identify ima's potential as a biomarker for ami. p- . . - neutrophil-to-lymphocyte ratio and platelet-tolymphocyte ratio in polycystic ovary syndrome polycystic ovary syndrome is a complex and multifactorial disease with metabolic dysfunction and the etiopathogenesis is not well established. emerging data suggest that adiposity and chronic low-grade inflammation are involved in the development of the metabolic dysfunction. neutrophil-to-lymphocyte ratio (nlr) and platelet-to-lymphocyte ratio (plr) have recently been investigated as two new inflammatory markers used in the assessment of systemic inflammation in many diseases. the purpose of the study was to investigate their relation with pcos patients. the study population consisted of patients with polycystic ovary syndrome and healthy women controls. nlr and plr obtained by dividing absolute neutrophil to absolute lymphocyte count and absolute platelet count to absolute lymphocyte count, respectively. the neutrophil count ( . ae . vs. . ae . , p < . ) and platelet count ( . ae . vs. . ae . , p < . ) were higher in patients with pcos compared to the control group. lymphocyte count was . ae . in pcos patient and . ae . in control group. the nlr and plr of pcos patients were significantly higher compared to those of the controls ( . ae . , . ae . p < . , . ae . , . ae . p < . , respectively). in this study we found nlr and plr were significantly increased in patients with pcos compared to healty control. nlr and plr were two useful inflammatory markers for assessment of patients with pcos. imbalance in neurotransmission in conjunction with neuroinflammation contribute to neurological dysfunction observed during acute liver failure (alf). own observations indicate that alf in a mouse model is associated with altered expression and/or intracellular distribution of synaptic proteins. since neutralization of tgf-b appears to improve the neurological score in alf mice, we examined the possibility that increased levels of tgf-b , caused by liver damage, may affect the expression of selected synaptic proteins. expression and/or cytoplasmic vs. membrane distribution of a number of functionally critical synaptic proteins in cerebral cortex and blood tgf-b were measured in c bl mice with alf induced by single i.p. injection of aom ( mg/kg of b.w.) and after neutralization of tgf-b induced by single i.p. injection of ab-tgf-b ( mg/kg) h before aom injection. in alf mice, blood tgf-b was increased, and the expression of presynaptic proteins: synaptophysin and synaptotagmin was increased in the cytosolic (s ) fraction by~ % and %, respectively, but was slightly depressed in the membrane (p ) fraction by~ % and~ %. aom induced an increase of postsynaptic proteins: psd- and nnos by~ % in p fraction. tgf-b neutralization resulted in a reduction in the expression of presynaptic proteins by~ % in s fraction and~ % in p fraction, in control animals and normalized their amount in the cytosolic fraction after aom injection, but was ineffective with regard to psd- and nnos. the results indicate that in alf mouse, neutralization of cytokine tgf-b normalizes synaptophysin and synaptotagmin expression in the synaptoplasm, without affecting their synaptic membrane content. effect of tgf-b neutralization appear to be confined to the presynapse. % of acute pancreatitis (ap) patients develop severe acute pancreatitis (sap), which is is resulted in multiple organ dysfunction syndrome. an extensive inflammatory response occurs due to inflammatory mediators synthesized and secreted during sap. since preventing the inflammation in sap is important in the prognosis of the disease, new drug candidates having strong antiinflammatory effects will provide a new concept for therapeutic strategies against acute pancreatitis. non-steroidal anti-inflammatory drugs (nsaids) show their effects by inhibiting cyclooxygenases (cox- and cox- ) and they play an important role in the pathogenesis of acute pancreatitis. since conventional nsaids inhibit both cox- and cox- , they have serious side effects on gastrointestinal system. therefore, new highly selective cox- inhibitors having fewer side effects are needed. in the present study, selective cox- inhibitory activities and cytotoxic effects of new series of -benzoxazolinone and thiazolo [ , -b ]- , , -triazole derivatives previously synthesized as specific cox- inhibitors with no side effects on gastrointestinal system were investigated. permeability of the compounds was tested by pampa using caco- cells. compounds were found highly selective, non-toxic and permeable. ap was induced in rats via retrograde injection of stc into the pancreatic duct system. rats were pre-treated with saline or celecoxib or the new compounds before stc injection and sacrificed h later. the severity of ap was evaluated using biochemical and histopathological analyses. edema, inflammation, hemorrhage and acinar cell necrosis were detected in the pancreatic tissue of sap group. sap was remarkably increased serum lactate dehydrogenase, ast, alt, lipase and amylase activities and serum tnf-a, il- b, il- , il- and il- levels. tissue myeloperoxidse activity was also increased. pretreatment with the novel compounds reserved all these biochemical and histopathological parameters. alopecia areata (aa) is an inflammatory disease which is affects hair follicles, and sometimes nails. it is suggested that cytokinemediated immunity plays an important role in etiopathogenesis of aa. this study was planned to evaluate the serum ykl- and tgf-b levels of patients with aa. patients with aa and healthy volunteers were recruited into the study. fasting venous blood samples were collected from the participants and serum was obtained by centrifugation. serum ykl- and tgf-b levels were measured by enzyme linked immunosorbent assay (elisa). serum tgf-b levels in the patient group were significantly lower compared to the control group whereas serum ykl- levels were significantly higher in patient group. tgf-b levels of men and women with aa were found to be significantly lower than that of controls. while serum ykl- level of male control group is higher than the male patients, there were no significant differences between women groups. the increased serum ykl- levels in aa patients suggests that ykl- plays a crucial role in the pathogenesis of aa. arterial immune mediated inflammation participates centrally in all stages of the development of atherosclerosis, from the initial lesion to the end-stage thrombotic complications. although emerging evidence supports augmented cardiovascular morbidity and mortality in cutaneous psoriasis (psc) and psoriatic arthritis (psa) as compared to the general population its underlying mechanism is poorly understood. here we analyzed the inflammatory burden in recent onset of psa patients without traditional cardiovascular risk factors (cvrf) in a transversal study measuring carotid intima media thickness (cimt) (measured with ecodoppler), and proatherogenic inflammatory molecular markers like c-reactive protein (crp), interleukin (il- ), and soluble intercellular adhesion molecule- (sicam- ) in comparison with control patients. cimt values are similar in psa ( , ae . *) and psc ( , ae . ) patients. however, both of them were significant increase compared with control ( . ae , ). regarding inflammatory markers il- serum levels in patients with aps was higher than pcs ( ae . ) and healthy controls ( , ae . ) but the difference did not achieve statistical significance (*p > . ). on other hand mean of sicam- , value from patients with recent onset of psa is significant higher than controls. psc remain without significant changes compared to control (*p > . ). in addition mean value from patients with recent onset of psa is significantly higher than in controls (*p < . ) and psc group. overall, preliminary findings suggest for the first time that patients with early psa, without evident traditional cvrf have significant increased values of cimt, sicam- crp against the general population control group. this data strongly supports that early cv molecular markers are increased after the first symptoms and signs of this disease even in the absence of traditional cardiovascular risk factors. furthermore, this give new windows for a proper treatment. p- . . - protective effect of trail against proinflammatory cytokines on pancreatic beta cells correlated with decrease in dr and increase in dcr expressions universitesi, antalya, turkey introduction: proinflammatory cytokines are known to have destructive effects on beta cells, which contribute to type diabetes (t d) development. the combinatory effects of three of these cytokines in particular, namely tnf-alpha (tnf-a), ifngamma (ifn-c), and il- beta (il- b), are claimed to render beta cells prone to t cell-mediated destruction. the recently identified anti-inflammatory feature of tnf-related apoptosis-inducing ligand (trail), its possible protective role in this process. in this study, the effects of applications of trail with tnf-a, ifn-ᵞ, and il- b on beta cell viability and correlation of these effects with trail receptor expression patterns were investigated. methods: glucose-responsive insulin-secreting nit- mouse beta cell lines were treated with tnf-a, ifn-ᵞ, il- b, and soluble trail (strail) individually and in various combinations. cell viabilities were determined at and h by mtt assay. trail ligand and receptor expression profiles on nit- cells, and alterations in receptor expression levels following cytokine applications were determined by western blotting analysis. results: trail treatment did not have any cytotoxic effects on nit- beta cells at h, while increasing cell viability following il- /ifn/trail and il- /tnf/trail combined applications. substantial levels of death receptor (dr ) expression were detected on nit- cells before applications, yet it displayed decreased levels at h of trail treatment. lower levels of decoy receptor (dcr ) expression detected prior to treatments increased significantly in contrast. discussion: the fact that trail co-treatment with tnf-a, ifn-ᵞ and il- b increased cell viability in nit- beta cell lines along with reduction in dr death receptor expression and an increase in the decoy receptor dcr expression, points out to a possible protective effect of trail in insulitis, and strengthens its potential as a putative therapeutic molecule in prevention of beta cell loss. behc ßet's syndrome (bs) is a multisystemic inflammatory disorder with a strong and complex genetic background. being a prevalent disorder both in turkey and also in the ancient trade road 'silk road' countries, bs is an important cause of impairment and disability owing to its chronic and relapsing nature. besides, bs is reported to be an important cause of mortality among the young male patients. while the epidemiology of bs is substantially well documented, currently, the etiology, the molecular mechanisms underlying its pathogenesis, and the classification of the disorder remain to be elucidated. our aim was to disclose the disease mechanisms at molecular level in turkish bs patients by obtaining, comparing, and analysing the transcriptome data of bs patients with age and gender matched healthy controls. for this purpose, by using the affymetrix hg u plus . microarrays, peripheral blood cell mrna profiles of bs patients (b) and matched healthy controls (c) were obtained. following bioinformatics, gene ontology, and pathway analysis, validation experiments of the identified prominent mrnas were performed by qrt-pcr methodology. the comparison of b vs. c yielded differentially expressed gene numbers of and for the chosen fold changes of . and . respectively (p ≤ . for both). during gene ontology and pathway analysis, immune system process, immune system diseases, systemic lupus erythematosus, arthritis, and intestinal immune network for iga production categories/pathways were significantly enriched. clustering analysis revealed a molecular signature which accurately distinguished b and c samples, while the qrt-pcr analysis successfully validated the chosen mrna transcripts. this study documented differential expression of a large number of immune system and immune disease related genes in bs patients. the uncovering of the molecular disease mechanisms of bs will point to novel candidate molecules to be targeted for the treatment of the disorder. obesity is a public health problem in developed countries and worldwide with increasing prevalence through a relationship primarily with atherosclerotic cardiovascular diseases as well as several metabolic disturbances such as increased insulin resistance and diabetes. although several studies identified obesity as an independent risk factor for atherosclerotic cardiovascular diseases, the mechanism underlying the increased cardiovascular risk in obese patients has not been clearly delineated. adma, no, endothelin- and homocysteine are an indicator of endothel disfunction that plays an important role in the pathophysiology of atherosclerosis. in our study, obese children and the control group were compared in terms of adma, no, endothelin- and homocysteine, we also investigated whether there is a correlation between these parameters. obese and healthy children, participated in the study. when the obese group was compared to the healthy controls, the adma level of the obese group were significantly higher than those of the control group but there was no statistically significant difference in no, endothelin- and homocysteine. increased adma level might trigger the pathogenesis of atherosclerosis starting from the childhood years onward. that is why controlling obesity in this age group with diet and other treatment modalities will prevent the mortality and morbidities that will be seen in adult years. inh deficiency leads to the formation of bradykinin causing to dilation of blood vessels. furthermore, the study conducted by shagdarsuren, on the damage done by c -esterase, demonsrates that the complement system and triglyceride levels are affected. we investigated lipid oxidation and fetuin a levels in patients with c _ inh deficiency. materials and methods: people with c _ inh and people without any illnesses were taken into the study. fetuin a was studied using an el _ isa kit from raybio (usa). ferrous ion oxidation-xylenol orange test was used to find looh serum levels. sh (free thiol groups) test was studied with regards to ellmans method modified by hu. _ ibm spss . was used for statistical results. results: in assessments made between the healthy and the illness groups, there was significant differences in the levels of fetuin (p = . ), looh (p = . ) and sh (p = . ). when pearson correlation analysis was performed, we detected a significant positive correlation between fetuin a and looh levels (r: + . ) discussion and conclusion: in these patients, lipids is secreted from the adipose tissue. in response, anti-atherosclerotic fetuin a levels were risen. patients also possessed increased lipid peroxidation, this increase shows positive correlation with fetuin a levels. in conclusion, we identified that sh with antioxidant properties have increased levels. aim: high fructose corn syrups are found in soft drinks, juice beverages, breakfast cereals, most of the processed foods. it has been shown that high dose of fructose intake may lead to a reduction in the number of hepatocytes, deterioration of liver function, increasing reactive oxygen species and liver steatosis. the aim of this study was to explore whether caffeic acid phenethyl ester (cape) has any potential protective effect on high fructose diet-induced fatty liver model. materials and method: totally fifty rats were divided into five groups. control group, % fructose administered group, cape group, % fructose + cape administered group and ethanol group. after weeks, liver oxidant and antioxidant status, and blood tnf alpha, il- , and il- , tissue nfkb levels were quantified. protein levels were investigated against, nfkb and p-nfkb antibodies and normalized and analyzed against b-actin antibody by western blotting. results: serum tnf-alpha, il- , il- levels were found to be increased in fructose group compared with the control group (p < . ). in liver tissue of % fructose administered group, mda, protein carbonyls and no levels were higher than control group. however sod activity did not show any difference among the groups. in the fructose administered group, caspase showed liver apoptosis and was considered as positive. acquired data revealed that nfkb protein level was decreased in the presence of cape while increment in nfkb protein level was observed in the fructose administered group compared with control group. in case of pnfkb antibody, increment observed in fructose only and both cape and fructose administered groups, respectively. in cape only administered group, there was a decrement in the level of pnfkb protein. conclusion: depending on further analysis, experimental findings are expected to implicate the role of cape as a protective agent on high fructose diet-induced fatty liver model in relation of inos, nfkb and p-nfkb pathways. the investigating association of hepcidin levels with iron homeostasis and inflammation variables in pregnant women with intrauterine growth restriction a. g. agg€ ul , n. uzun , e. c ß inar tanriverdi , h. € un agri ibrahim cecen university, agri, turkey, nenehatun maternity hospital, erzurum, turkey this study was designed to investigate hepcidin levels and their associations with iron homeostasis and inflammation variables in pregnant women with intrauterine growth restriction (iugr). a total of pregnant women were included in this study. pregnant volunteers were divided into two groups ( healthy pregnant women and pregnant women with iugr). serum hepcidin, total free iron, ferritin, transferrin, transferrin receptor and interleukin- (il- ) levels were measured by elisa. also, hemoglobin (hb) and c-reactive protein (crp) levels were determined in serum samples from the healthy pregnant women and the pregnant women with iugr. there were significant differences in hepcidin, ferritin, transferrin receptor, crp and il- levels between healthy pregnant women and pregnant women with iugr. hepcidin, ferritin, crp and il- levels in pregnant women with iugr were significantly higher than healthy pregnant women (p). the mediators of systemic inflammation in lipopolysaccharide-induced neonatal sepsis rat model sepsis is an excessive inflammatory response that causes shock, multi-organ failure and high mortality. foreign bacterias and lipopolysaccharides lead to stimulation of endothelial cells to produce biologically active mediators such as proinflammatory cytokines and chemokines, cell adhesion molecules, and growth factors. then these mediators could be act on targets, which were involved in the initiation of systemic inflammation in neonatal sepsis. our aim was to indicate a protective role of thalidomide and etanercept, which have anti-tnf-a activity on systemic inflammatory response in lipopolysaccharide (lps)-induced neonatal sepsis rat samples. thirty -day-old wistar rats were randomly divided into five groups: a control group that received normal saline, a sepsis group that received lps, thalidomide, etanercept and both thalidomide and etanercept treatment group that were administered with therapeutic agents hrs after lps injection. the rats were sacrificed at hrs after lps or normal saline injection (n = ). hepatic tissue tnf-a, il- , icam- and pdgf levels were determined by enzyme-linked immuno sorbent assay (elisa) method in all groups. in sepsis group, tissue tnf-a, il- , icam- and pdgf levels were statistically significantly higher than in controls (p < . ). at same time, pretreatment with both thalidomide and etanercept were found statistically dramatically decreases the levels of tnf-a, il- , and pdgf when compared to sepsis group (p < . ). there were no significant differences in the icam- levels between the all treatment groups and the sepsis group. higher liver tissue tnf-a, il- , icam- and pdgf levels are associated with severe bacterial infection. these proinflammatory cytokines and angiogenic factors may be important in the endothelial dysregulation seen in sepsis. therapeutic agents used in the present study can be help to avoid devastating effects of neonatal sepsis. n-stearoylethanolamine (nse)is saturated minor compound of natural origin that represents the large family of signaling lipids n-acylethanolamines, which belong to endocannabinoid system. considering the crosstalk between obesity-induced inflammatory response and its key role in synaptic dysfunction and neurodegeneration, our current study aimed to investigate the biological effect of nse on brain tissue under high fat diet-induced insulin resistance. previously we found that nse administration to insulin resistant rats caused normalization of liver and pancreas lipid composition followed by the improvement of glucose tolerance and insulin sensitivity (decline in serum insulin level and homa-ir value). moreover, this effect of nse correlated with inhibition of nf-kb translocation into the nucleus of peritoneal macrophages and decreased pool of serum tnfa level in obesity-induced insulin resistant rats. further experiments showed that fat overload triggered significant reduction in the level of main phospholipids (phosphatidylethanolamine, phosphatidylcholine and sphingomyelin), while there were no changes in cholesterol content. nse at a dose of mg/kg during weeks of administration to insulin resistant rats showed a tendency to restore the phospholipid level that was accompanied by increased neural cell survival ( %) compared to rats without treatment ( %). neuroinflammation accompanied by intensive reactive oxygen species (ros) production impairs neurotransmission in a wide range of neurodegenerative pathologies. flow cytometry is used for quantitative analysis of global dna methylation, but fluorescence microscopy is mostly preferred to qualitatively reveal intranuclear localisation of dna methylation and its copattern with other markers. both methods use a similar immunostaining protocol. in this study, we aimed to compare these methods concerning the detection of the global amount of dna methylation. for this, mouse embryonic fibroblasts were cultured either with or without phenol red and then stained for dna methylation or positive controls (histone, betaactin, phosphoakt) by specific antibodies, or nonspecific control antibodies. some cells were incubated with trypan blue before or after the addition of antibodies. fluorescence intensities were measured by the green fluorescence channel ( / nm). autofluorescence spectrum of cells was analysed, and fluorescence channel used for dna methylation detection was changed to red ( nm lp). a poor discrimination between signal and noise was detected due to cellular autofluorescence interfering with specific detection of dna methylation by flow cytometry but not by microscopy. it was also the case for the other markers examined. conventional advances to reduce autofluorescence such using phenol red free culture media or trypan blue quenching were not effective, but using the red channel regarding autofluorescence spectra allows detecting specific staining of dna methylation by flow cytometry. but, green channel did work well for microscopy analysis. findings show that flow cytometry detection of dna methylation requires much attention to quench cellular autofluorescence compared to detection by fluorescence microscopy. one reason could be that flow cytometry detects all cellular content, but manual image-based analysis can exclude cytosolic components. these results suggest the usability of flow cytometry and microscopy as complimentary methods for dna methylation detection, but optimisation to reduce autofluorescence is crucial for flow cytometry. objectives: lung cancers are divided in two main groups as small cell lung cancer (sclc) and non-small cell lung cancer (nsclc) . docetaxel (dtx) and cisplatine are chemotherapeutic that has an anti-tumor activity against various solid tumors. the growing resistance against dtx and cisplatine (cis) still continues to be the biggest obstacle for the treatment success of nsclc patients. deguelin (deg.) is a natural plant derivative and has an encouraging activity against a lot of human cancers. the comparison of the treatment activity of the separate and combined usage of deg., which is a potential chemotherapeutic agent, and dtx, cis which are used in standard treatment, is aimed in this study. material-method: the ic doses of dtx, cis and deg. on the a and h nsclccell lines were determined via the cell vitality tests in our study. the active concentrations determined were applied to nsclc cell lines as deg., dtx, cis and their combinations. the impacts of the medicine are studied by applying flow cytometric analyzes (apoptosis, cell cycle), glutathione and reducted glutathione, colony formation, migration and angiogenesis analyzes on the treated cells and measuring the oxidative stress index (osi). statistical analyse program, rstudio (v. . . ) and the r-script language were used to examine the differences between the agents. the states in which the pvalue was lower than . were accepted as statistically meaningful. results: we found that deg. has pro-apoptotic, anti-migratory and cytotoxic potential on lung cancer cells. deg. amplified cis and dtx-related anti-cancer efficacy (increased apoptotic cell content and cytotoxicity, reduced migration). also, deguelin pretreatment sensitized the cells dtx-treatment (reduced ic values). these effects were remarkable in p -mutant cells. conclusion: deguelin, solely, has anti-cancer potential on nsclccells. both deguelin pre-treatment and combinantion with standart chemotherapeutics result in enhanced anticancer efficacy. the % of the lung cancers are non-small cell lung cancers (nsclc). despite docetaxel (dtx) and cisplatine (cddp) are agents used in the standard treatments of these patients and the recent improvements in the treatments, the response and remission rates observed on the patients are relatively nominal. selenium (se) is an essential diet component and is introduced to have a preventive impact on different levels of cancer. the aim of our study is to investigate the impacts of selenium addition on anticancer feature and tumor prevention before or/and during nsclc standard treatment. the ic doses of dtx, cddp and selenium on the a and h (p mutant) nsclc cell lines were determined via the cell vitality tests in our study. the active concentrations determined and the stipulated available concentrations were applied to cell lines as dtx, cddp, se combinations. the impacts were compared by applying flow cytometric analyzes (apoptosis, cell cycle), glutathione and reducted glutathione, western blot analyzes on the treated cells and measuring the oxidative stress index (osi) and thioredoksin reductase activity. selenium pre-treatments reduced dtx-related ic concentrations at lower doses in both nsclc cells. however, cddprelated ic concentrations reduced dose-dependent manner. selenium supplementation also altered cell-cycle charactheristics at several concentrations and combination regimens. the remarkably higher osi values were observed after dtx treatment and osi levels were found to be lower in selenium pre-treated nsclc cells. selenium sensitizes nsclc cells to dtx treatment at lower concentrations. however, this effect is obtained dose-dependent fashion for cddp regimen. breast cancer is the most common female malignancy worldwide. human epidermal growth factor receptor (her ) is overexpressed in % of breast cancers in association with aggressive phenotypes. the prognosis of metastatic breast cancer remains poor in spite of advances in therapy. as such, her has long been studied as a potential target for anticancer drugs. the modulation of intracellular signaling pathways leads to altered cell metabolism that triggers tumorigenesis and adapts cells to cancer cell metabolism. this characteristic hallmark of cancer metabolism is known as warburg effect meaning energy production via enhanced glycolysis. despite of several studies in breast cancer metabolism, little detail exists on the link between her overexpression and warburg effect. we have committed examining the nature of aerobic glycolysis in her overexpression. in breast cancer cell line mcf , her overexpression (mcf-her ) results in mitochondrial dysfunction with low mitochondrial membrane potential (Δᴪm) and ros accumulation. intracellular iron levels are also higher in mcf -her cells than vector control (mcf -vec). additionally, mcf -her cells show enhanced levels of atp and lactate in association with increase in glucose levels. we have found that complex i activity increases in mcf -her and decreases in knockdown of her in hcc cells that is her positive breast tumor cell line. based on these results, we conclude that there is a link between her overexpression and metabolic indicators of warburg effect. expression and methylation analysis revealed microrna genes deregulated by methylation and new potential target genes of mir- and mir- - p in breast cancer micrornas (mirnas) and methylation of mirna genes play a great role in epigenetic deregulation in malignant tumors. the aim of our study was to assess the contribution of methylation to expression level alterations of mirna genes and to search for novel potential targets of these mirnas. to analyze alterations in expression we used qpcr technique with references (rnu , rnu ) and paired (tumor/normal) breast cancer (bc) samples. for methylation analysis a methylation specific pcr and the same set of bc samples were used. significant downregulation was shown for mir- b- p, - - p, - - p, - a- p, - b- p, - - p, - - p, and - - p (p ≤ . , fisher's exact test) in bc. we observed mirna genes to be hypermethylated and mir- hypomethylated. hypermethylation for of these mirna genes was shown for the first time: mir- , - , and - ( - % of bc cases). a significant correlation between methylation and expression alterations was revealed for mirnas with downregulation: mir- b- p, - - p, - - p, - a- p, and - b- p (spearman's correlation coefficient (rs) was in the range À . to À . , p ≤ . ), and for mirnas with both scene (down-and upregulation) as well: mir- a- p, - a, and - (rs = À . to À . , p ≤ . ). comparative analysis of the data on expression alterations of mirna genes and protein-coding genes, which were predicted as targets by mirwalk . , revealed the negative correlation between expression levels for some potential mirna-mrna interaction pairs. for example, for pairs mir- /rhoa, mir- /rassf (a), mir- - p/dapk (rs = À to À . , p ≤ . ). thus, both mirnas and methylation affect regulatory networks in bc. novel potential mirna-mrna interaction pairs could be useful in the development of bc therapy approach. this work was financially supported by grant - - from the russian science foundation. the authors thank the n.n. blokhin cancer research center for tissue samples. clear cell renal cell cancer (ccrcc) with metastases has pour prognosis: -year survival is about %. micrornas (mirnas) and methylation of mirna genes play a great role in epigenetic deregulation in malignant tumors. the aim of our study was to find out mirnas which methylation contributed to ccrcc progression, including metastasis, and to reveal potential target genes of these mirnas. to analyze methylation status, we used a methylation specific pcr as a method and a representative set of paired (tumor/ normal) ccrcc samples. we also used post-mortal renal tissues from individuals without cancer history as additional control. for expression analysis we used qpcr method and paired ccrcc samples. we observed mirna genes (mir- a- /- /- , - - , - - , - b/c, - - , - a, - ) to be hypermethylated, (p ≤ . , fisher's exact test), mirna genes to be hypomethylated and mir- a with both scene (hyper-and hypomethylation was detected). methylation of mirna genes (mir- a- /- , - b/c, - - , - , - a, - a) correlated with advanced stage and/or tumor size and/or dedifferentiation. hypermethylation of mir- - , mir- a, and mir- significantly correlated with metastasis presence (p < . , fisher's exact test). besides, preliminary data revealed the positive correlation between hypermethylation of mir- - and up-regulation of p protein-coding genes: rarb( ), rhoa, nkiras , and chl , which were predicted as targets by mirwalk . (spearman's correlation coefficients (r s ) was in the range . - . , p ≤ . ). in conclusion, novel supposed interactions of mir- - with target genes could be useful as missing chains in signaling pathways. tests for hypermethylation of mir- - , mir- a, and mir- could be suggested as markers of metastasis and pour prognosis of ccrcc. because of difficulty in diagnosis and treatment hc is a clinical problem: early symptoms of hc are often non-specific and surgical resection is the only curative treatment for hc. it is well known that epigenetic alterations are linked to cancer development. the purpose of this study was to determine potential mechanisms of epigenetic regulation of genes related to energy metabolism in hc. we have performed bioinformatics analysis of the cancer genome atlas (tcga) project rna-seq data with crosshub software and found a number of genes involved in glycolysis and differentially expressed in cholangiocarcinoma. qpcr analysis revealed significantly decreased expression of pgm and eno genes in a majority of hc samples which were known as up-regulated in other human cancers according to the literature date. on the basis of tcga methylation dataset ( k illumina microarrays) we supposed that cpg methylation of pgm and eno promoters may play a role in their inactivation. using bisulfite sequencing study we identified several regions within the gene promoters (pgm :~ bp and bp upstream tss; eno :~ bp downstream tss) that are frequently methylated in hc samples (up to %, / ) with down-regulated pgm and eno expression. thus, we demonstrated frequent and significant pgm and eno down-regulation associated with hypermethylation of the specific regions within the gene promoters in hc. the pattern of pgm and eno gene promoter methylation suggests a possibility of ones to be used for the hc diagnosis and development new strategies for therapy. this work was financially supported by grant mК- . . from the president of the russian federation. the work was performed using the equipment of eimb ras 'genome' center. introduction: the development of stomach cancer is a multifactorial and complex process and includes multiple epigenetic, genetic alterations and dietary/non-dietary factors. iodine as an antioxidant may play a protective role against gastric cancer. the aim of this study was to investigate the changes in iodine level in rat with stomach cancer induced by n-methyl-n -nitro-n-nitrosoguanidine (mnng). materials and methods: a total of sprague dawley rats were randomly divided into six groups. rats were administered with mnng ( lg/ml) by oral gavage on days , and to initiate stomach cancer. during the experiment, rats died and those surviving were sacrificed in the rd, th, th, th and th months of the experimental period (group i, ii, iii, iv, v, respectively). the control group (group vi) contains rat which are given only food and water for months. the stomach tissue was examined histopathologically. and also, iodine levels in stomach tissue was determined using the foss method. results: a decrease in iodine level was determined in stomach cancer tissue of rats in group i-v compared with normal healthy stomach tissue in group vi. when the control (group vi) iodine level was taken as % baseline, the % iodine levels of all groups were determined as follows . , . , . , . and . for groups i-v, respectively. the pathological diagnosis of gastric cancer was adenocarcinoma. discussion and conclusion: the iodine levels of group i were higher than those of group ii (p < . ) and of groups iii, iv and v (p < . ) and also were lower than in the control group (p < . ). iodine deficiency as one of the risk factors of stomach cancer strongly supports the necessity for the application of effective iodine prophylaxis in the areas with iodine deficiency. iodine supplementation might be useful in stomach cancer therapy and therefore, further research is warranted. this study was supported by ataturk university (project number: / ). effect of water extract of turkish propolis on mitochondrial membrane potential in human laryngeal epidermoid carcinoma cell lines propolis is the generic name for the resinous substance collected by honeybees from the buds of various plant sources and it is used by bees to seal holes in their honeycombs, smooth out the internal walls, and protect the entrance of bee hive against intruders. the aim of this study is to investigate what kind of changes the turkish propolis cause on mitochondrial membrane potential (mmp) of human laryngeal epidermoid cell lines (hep- ), by considering its anticancer features. water extract of turkish propolis (wep, - mg/ml) and ethanolic extract of turkish propolis (eep, . - mg/ml) were prepared and incubated with hep- cell lines ( , , and h). mmp was investigated with a flourometric method by using dioc ( , -dihexyloxacarbocyanine iodide). the most significant mmp decrease was seen on rd hour. both wep and eep extracts at all concentrations decrease mmp according to that of control. the recent studies have shown that propolis extracts have induced apoptotic cell death by decreasing mitochondrial membrane potential in various cancer cells. it was concluded that both wep and eep decreased mitochondrial membrane potentials on hep- cell series according to control ( concentration) depending concentration and time. there are numerous transcription factors involved in the regulation of the inducible gene expression. thus, transcription of proinflammatory genes, steroid hormone receptors, etc. is controlled by the group of factors triggering gene expression which includes nf-kb. another group of factors is involved in the formation of the structure of the chromatin of the inducible genes regulatory regions, providing competence for gene expression. it is expected that this group of factors includes the proteins of nf (nuclear factor ) family. there are few data suggesting that the nf factors maintain potentially active state of the chromatin of the hormone-dependent gene promoter regions. these findings initiated studies of the correlation between presence of the nf transcription factors on the chromatin of a gene regulatory region and the functional state of the gene in vivo. as a model we chose the rat tryptophan dioxygenase (tdo) gene which is expressed tissue-specifically in the liver under control of glucocorticoid hormones. three constitutive dnase i-hypersensitive regions are identified in the regulatory region of this gene. to conduct the study we used rat liver and kidney. the basic methods were electrophoretic mobility shift assay (emsa), immunoblotting assay and chromatin immunoprecipitation combined with real-time pcr (chip-qpcr). using emsa we found that the proteins of nf family interact with the constitutive dnase i-hypersensitive regions in vitro. immunoblotting assay of the protein fraction from rat liver used in emsa experiments showed the presence of the nf -b isoform. chip-qpcr revealed statistically significant differences in the level of the factor nf enrichment of the tdo gene regulatory region between the rat liver and kidneys at p < . . these data suggest the involvement of the nf proteins in the formation of the chromatin structure of the rat tdo gene promoter region. reciprocal ( ; ) translocation and bcr-abl fusion protein that is responsible for developing leukemia are observed in more than % of chronic myeloid leukemia (cml) cases. epigallocathecin- -gallate (egcg) is a green-tea flavonoid and egcg is proposed as a natural anti-cancer agent. histone modifications which contain histone deacetylases (hdac) and histone acetyltransferases (hat) are parts of epigenetic regulations. hdacs play important roles in different human malignancies including leukemia via activation of abnormal signaling pathways. hdac inhibitors have become remarkable therapeutic molecules for malignancies. the aim of this study is to determine the expression changes of leukemia-related hdacs with the treatment of egcg in k- cells. the cytotoxic effect of egcg on k- cells was determined in time and dose dependent manner by wst- analysis. total rna was isolated from k- cells. reverse transcription procedure was performed for cdna synthesis and gene expressions were detected by rt-qpcr. the expression level of hdac , hdac , hdac gene that supports cell proliferation was down-regulated . , . , . folds in k- cells treated with ic dose of egcg, according to control, respectively. our current findings suggest that is a polyphenol egcg may be a hopeful agent in treatment of cml by hdac inhibitory effect. chronic lymphocytic leukemia (cll) is a disorder of morphologically mature but immunologically less mature lymphocytes and is manifested by progressive accumulation of these cells in the blood, bone marrow, and lymphatic tissues. carbonic anhydrase (ca) is a metalloenzyme which is widely distributed in the living world, and it is essential for the regulation of acid-base balance. anti-ca antibodies have been reported in many disorders, such as systemic lupus erythematosus, sj€ ogren's syndrome, rheumatoid arthritis, endometriosis, idiopathic chronic pancreatitis, type diabetes and graves' disease. the goal of this study was to investigate carbonic anhydrase i and ii (ca i and ii) autoantibodies in cll. patients with cll and healthy controls were included in the study and ca i and ii autoantibody levels were investigated by elisa. the ca i autoantibody levels of cll group were significantly higher than the healthy group (p = . ) while there was no statistical difference between serum ca ii autoantibody levels of the groups (p = . ). we found a significant positive correlation between hemoglobin and hemotocrit levels in patients with cll (r = . , p = . ). cut-off value of . absu for anti-ca i was associated with % sensitivity and % specificity and a cut-off value of . absu for anti-ca ii was associated with % sensitivity and % specificity for predicting cll. the ca i autoantibody levels in patients with cll were found higher compared to control group and the results suggest that ca i autoantibody may be involved in the pathogenesis of cll. genetic and epigenetic aberrations can lead to the activation of oncogenes and inactivation of tumor-suppressor genes (tsgs) followed by the development of malignant tumors. in the present work we evaluated the frequency of alterations of cpg island methylation and dna copy number in paired (tumor/normal) breast cancer (bc) samples using comparative dna hybridization on noti-microarrays and original niman software. the microarrays contained noti-clones associated with chromosome genes. expression alterations were assessed with the use of qpcr technique, ddct method and original atg software. in total, noti-sites with high ( - % of cases) hypermethylation/deletion (hm/d) frequency were revealed in bc. among genes associated with these sites, there are both known tsgs and tsg-candidates (aldh l , vhl, ctdspl, etc.) as well as genes, which involvement in breast oncogenesis was shown for the first time (lrrn , foxp , prickle , etc.). noti-microarray data were verified selectively using bisulfite sequencing for vhl, nkiras , itga , lrrc b, and ctdspl genes. several genes with high hm/d frequency (aldh l , ephb , itga , and ropn ) were tested for expression alterations using qpcr. frequent ( - % of cases) and significant (> -fold) down-regulation was shown for all of them in bc. the most significant expression loss was observed for aldh l geneon the average -fold mrna level decrease in % of samples. the involvement of the majority of genes with high hm/d frequency in breast oncogenesis was shown for the first time. these genes are novel tsg-candidates in bc. functional hypermethylation associated with expression loss was shown for aldh l , ephb , itga , and ropn genes thereby strengthening the speculation on tumor suppressor abilities of these genes. methylation and expression analyses of genes, that were revealed by noti-microarrays, were financially supported by grant - - from the russian science foundation. functional hypermethylation of a number of chromosome genes was revealed in colon cancer using noti-microarrays cancer is a disease of genome caused by genetic and epigenetic aberrations. noti-microarrays, that were developed by prof. e.r. zabarovsky, is a unique tool that allows us to simultaneously detect hypermethylation of cpg islands and dna deletionstwo major reasons of inactivation of tumor suppressor genes (tsgs). in the present work, the frequency of chromosome genetic and epigenetic alterations in colon cancer (cc) was evaluated. noti-microarrays, that contained noti-clones associated with chromosome genes, were used for comparative (tumor/normal) hybridization of dna from paired cc samples. data analysis was performed using original niman software. expression alterations were evaluated using qpcr technique and original atg software. in total, noti-sites with % and above hypermethylation/ deletion (hm/d) frequency were revealed in cc. among genes associated with these sites, there are several known tsgs and tsg-candidates (for example, vhl, ctdspl, and itga ), but for the majority of genes, involvement in colon oncogenesis was shown for the first time (for example, lrrn , nbeal , and ube e ). the highest hm/d frequency was observed for ankrd , nkiras /rpl , itga , cmtm , and gor-asp /ttc a genes - - %. expression alterations were evaluated for genes with high hm/d frequency (plcl , prickle , and ppp r a) and significant mrna level decrease (> -fold) associated with hypermethylation was shown for all of them in the majority of samples. a number of novel potential tsg-candidates was revealed in cc. functional hypermethylation associated with expression decrease was shown for plcl , prickle , and ppp r a genes thereby enhancing the suggestion on tumor suppressor function of these genes. this work was financially supported by in many countries, radon is the second leading cause of lung cancer, which accounts from % to % of cases. it is obvious that the population of all the developed and industrial countries in the world spend most f their time, almost %. therefore it is necessary to explore the obtained radiation dose, because of the presence of radon in a room due to the radon emanation from the soil and exhalation from a variety of building materials. the developed countries solve this problem of radon pollution as well as create a special monitoring services. the paper presents some data of genes molecular-genetic analysis from patients with lung cancer who live in almaty located in a foothill area of tectonic faults. the object of research were blood samples obtained from patients diagnosed with lung cancer who are receiving a treatment at the almaty oncology center and living in the city of almaty, where the level of radon activity exceeds the norm approved by the international commission on radiation safety. as a control group relatively people living in the plains, characterized by a lower radon emanation have been considered. to determine mutations in the genes polymerase chain reaction with a subsequent analysis of restriction fragment length polymorphism has been conducted. the pcr products were subjected to hydrolysis by bstni restriction endonucleases haeiii, ras i. disturbances in the genes under consideration to variour types of cancer development. the analysis showed that examinees do not have mutations in the kras gene codons - , which corresponds to a control group consisting of people living in the city of balkhash. on the whole, molecular genetic studies have shown that examined patients do not have mutations in the kras gene. one mutation was been found in the egfr gene. aim: polyps are abnormal growths of tissue that can be found in gastro intestinal system. they are most often found in the colon and rectum. most polyps are noncancerous (benign) however, because of abnormal cell growth, they can eventually become cancerous. the aim of this study is to determine the concentrations of trace element contents in colon and rectum polyp tissues and whether there is any relationship between polyp tissue element levels and the disease. material and method: the present study was conducted on total of individuals including patients and healthy subjects. while receiving normal intestinal tissue from healthy control group; from the patient group both normal tissue and polyp samples were taken during colonoscopy procedure. the concentrations of the elements (al, cr, mn, fe, co, ni, cu, zn, as, se, ag, cd, hg and pb) were determined with induced coupled plasma-mass spectrometer. results: the mean concentrations of cr, mn, ni, se and ag in colorectal polyp tissues of patients were significantly higher than in colorectal tissues of control subjects (p is less than . ). on the other hand the mean concentration of cd and pb in colorectal polyp tissues of patients were significantly lower than in control colorectal tissues of control subjects (p is less than . ). there was no any significant difference between the groups in terms of concentrations of al, fe, co, zn, as and hg (p is more than . ). conclusion: the differences found in some elements between polyps and a control tissues may provide an indication about the role of trace elements in the early stage (polyps) in the colon carcinogenic process and encourages further studies to confirm the involvement of such elements in neoplastic processes. the use of herbal medicines is steadily growing, with approximately % of the population use herbs to treat various illnesses in the western world. vitex agnus-castus has been used since ancient times as a remedy. the aim of this study was to investigate the in vitro anticancer activities of vitexagnus-castus oil. for this purpose, the cytotoxicity of vitexagnus-castus oil in sh-sy y cells was investigated by crystal violet staining. ec was found to be . %(w/w) vitexagnus-castus oil for this cell line. this dose was applied to the cell for h, and the cells were harvested for further studies. vitex agnus-castus oil treatment increased bax and p mrna levels. on the other hand, bcl- , bcl l , erk- , jnk, caspase and mrna expression levels were reduced significantly withvitexagnus-castus oil treatment while p and pten remained unchanged. these results indicate that another effector caspase such as caspase or may be involved apoptosis process which remains to be elucidated. moreover, mapk pathways, p and erk, may be involved in vitexagnus-castus oil induced apoptosis in sh-sy y cells. these initial observations suggest that this agent might not be useful in treating cancers. further detailed studies should be carried out to elucidate the exact mechanism of vitexagnus-castus oil in neuroblastoma cell lines. melanoma is a skin cancer with a melanocyte origin that can occur in any part of the body that contain melanocytes. while melanoma is less common than other skin cancers, it causes the majority of deaths related to skin cancer. several gene expression databases have shown that interferon regulatory factor (irf ) is upregulated in melanomas, and genome wide association studies linked variation at irf locus with skin cancers. irf was first identified to have roles in lymphocyte development and function. studies have identified a 'non-oncogene addiction' of malignant cells to irf in various hematopoietic cancer types. the aim of this study is to investigate the role of irf in melanoma cell lines. lentiviral vectors were used to reduce irf levels in melanoma cell lines. a gfp competition assay was performed to study the competitive fitness of melanoma cells with irf knockdown (gfp positive cells) over melanoma cells with normal irf levels (gfp negative cells). cell cycle profiles were investigated in melanoma cells with irf knockdown by propidium iodide staining. migration potential was assessed as well by wound healing assay. our preliminary data showed a decreased competitive fitness for cells with decreased irf levels. cell cycle profiling showed increased g /g and decreased g /m levels in irf knockdown cells compared to controls. wound healing assay results showed no difference between controls for cells with reduced irf levels. taken together, these results indicate that irf knockdown affects the melanoma cell lines' survival and cell cycle profile, suggesting a non-oncogene addiction of melanomas to irf . these observations are largely similar to previous observations in hematopoietic cancers. unravelling the role of irf in melanoma will increase our knowledge about melanoma development and progression and thereby may lead to targeted therapy in melanoma treatment. humans are exposed to various chemicals having beneficial or toxic effects at a time in their daily lives. , -dimethylbenz[a] anthracene (dmba) is a carcinogenic compound produced during the incomplete combustion of carbon-containing compounds. endosulfan is an organochlorine pesticide used against insects on food. morin is an antioxidant, antiinflammatory and chemoprotective flavonoid. this study is aimed to determine the effect of morin in the presence of dmba and endosulfan. for this purpose, adult wistar male rats weighing - g were randomly selected and divided into eight groups. mg/kg body weight (b.wt.) morin and . mg/kg b.wt. endosulfan were given to morin and endosulfan treated groups three times in a week. the rats in dmba treated groups were gavaged with . mg/kg b.wt. dmba three times during the administration period ( days). cytochrome p a (cyp a) associated -ethoxyresorufin o-deethylase (erod) and glutathione s-transferase (gst) activities were measured in rat liver cytosols and microsomes. in addition, liver tissues were evaluated by histopathological analysis. erod activities of control, morin, endosulfan, dmba, morin+endosulfan, morin+dmba, dmba+endosulfan and morin+dmba+endosulfan groups were ae , ae , ae , ae , ae , ae , ae and ae pmol/min/mg protein, respectively. all treatments increased erod activities. gst activities of these groups were ae , ae , ae , ae , ae , ae , ae and ae nmol/min/mg protein, respectively. histopathological studies showed that endosulfan and dmba induced inflammation in the liver tissues and morin reduced their effects. in conclusion, morin treatment increased the metabolism of dmba and endosulfan by inducing cyp a activity. gst activities of morin+dmba+endosulfan group were not significantly different from those of dmba group. histopathological studies indicated that morin administration reduced the toxic effect of endosulfan and dmba in the liver cells. hepatocellular carcinoma (hcc) is the sixth most common cancer and third most frequent cause of cancer-related death worldwide. molecular mechanisms of hepatocarcinogenesis is still unclear. the impairment of epigenetic mechanisms is implicated in the development of multiple cancers, including hcc. transforming growth factor-beta has been shown to play both tumorsuppressive and tumor promoting roles. transforming growth factor-beta signaling pathway involves activation of smad and smad by the type i receptor and formation of smad / / heteromeric complexes that enter the nucleus to regulate transcription. -deazaneplanocin a is an inhibitor of the histone methyltransferase ezh . we aimed to reveal the effect of -deazaneplanocin a on transforming growth factor-beta /smad pathway in hepg cell line. hepg , a human liver cancer cell line cultured in dulbecco's minimal essential medium supplemented with % fbs. the cells were seeded the day before -deazaneplanocin a administration and then the cells were treated with lm -deazaneplanocin a for days. expression levels of genes were analyzed by roche lightcyclerÒ . gapdh was used as housekeeping gene. apoptosis assay was performed by the muse annexin v and dead cell assay kit. the unpaired t-test was used to compare variables and p < . was accepted as statistically significant. -deazaneplanocin treatment was significantly reduced transforming growth factor-beta, smads - in hepg cells (p < . ). we also found that -deazaneplanocin induces apoptosis in treated cell line (p < . ). as a result, -deazaneplanocin a may take place in treatment of hepatocellular cancer by its inhibitory effect on transforming growth factor-beta /smad pathway and inducing apoptosis in liver cancer cells. brefeldin a (bfa) is a lactone antibiotic first isolated from the fungus eupenicillium brefeldianium. bfa inhibits the transport of secreted proteins from endoplasmic reticulum (er) to golgi apparatus, leading to disruption of golgi function, accumulation of unfolded and not fully incompletely processed proteins in er. bfa also inhibits cell proliferation, phosphorylation and migration of cancer cells. therefore in this study, we investigated the effects of bfa on breast cancer cell proliferation of various phenotypes. in we observed that bfa inhibited the proliferation of all three phenotypes of breast cancer cells, but the effects of bfa were seen at different times and doses. according to time and dose, bfa was observed more effective to mcf- compared to other cell lines. physiological, pathological and physical factors. moreover, nlr may represent the two opposing inflammatory and immune pathways that exist together in cancer patients. we aimed to investigate nlr in breast cancer in our population. methods: using data retrieved from the medical records, women diagnosed primary breast cancer met our study inclusion criteria as they had a complete blood count with leukocyte differential performed before any anti-cancer therapy. and women with benign mammary neoplasm/disease, followed up in the outpatient clinics of mammary disease and confirmed with sonographical/histopathological examination, made up our controls. exclusion criteria included laboratory evidence of white blood cells count (wbc) > . /l. differential leukocyte counts were obtained by bc (mindray medical international ltd., china), we examined wbc, neutrophil, lymphocyte, platelet counts, and hematocrite, nlr, mean platelet volume values. results: although there is lack of evaluation of tumor-associated neutrophils and lymphocytes, higher nlr median values and lower lymphocyte mean counts (lymphopenia) were shown in women with breast cancer (p < . ). there was a weak negative correlation in breast cancer between nlr values and platelet counts (r s = À . ; p = . ). holmboe] is distributed throughout southern mediterranean europe from spain to the eastern mediterranean on anatolian peninsula of turkey. present study was designed to investigate the in vitro anti-cancer activities of turkish black pine essential oil. the essential oil was extracted by steam-hydrodistillation and its chemical composition analyzed by gc-ms. the major components of the essential oil were a-pinene, b-pinene and trans-b-caryophyllene, respectively. the crystal violet staining method was used to investigate the cytotoxicity of essential oil in sh-sy y cells. ec was found to be . % (w/w) essential oil for sh-sy y cells. neuroblastoma cells were incubated at °c for h. after h, cells were harvested for further studies. bax and p mrna levels were significantly elevated in essential oiltreated cells. on the other hand, bcl- , bcl l , casp- , casp- , erk- and jnk expression were significantly downregulated. unlike these proteins, p and pten mrnas were not changed. in this study, apoptosis was enhanced by turkish black pine essential oil treatment which was activated by the involvement of another effector caspase subfamily, like casp- and casp- . additionally, erk and p mapks may be associated with upregulation of the level of bax. based on these results, we suggest that p. nigra subsp. pallasiana essential oil might not be well-suited in cancer treatment. however, further detailed research is necessary to establish the exact role of p. nigra subsp. pallasiana essential oil in sh-sy y cells. p- . . - the protective effect of newly derivatized compound naringenin-oxime and relative to naringenin against cisplatin-induced nephrotoxicity and genotoxicity in rat background: the aim of this study was to evaluate the possible protective effect potentials of newly derivatized compound naringenin-oxime (ng-ox) relative to efficacy of free naringenin (ng) on cisplatin (cis) induced nephrotoxicity and genotoxiticity in rat. methods: totally, fifty six male wistar albino rats were equally divided into eight groups as follows: control; cis treatment ( mg/kg b.w., i.p.), ng and ng-ox ( mg/kg b.w., i.p daily for days) alone treatment; cis + ng ( or mg/kg b.w., i.p daily for days) and cis+ng-ox ( or mg/kg b.w., i.p daily for days) combination treatment. at the end of the study total antioxidant capacity (tac) levels, total oxidant status (tos), lipid peroxidation (lpo), total thiol, catalase (cat) were studied in homogenate kidney. peripheral lymphocyte cell dna damage was investigated with comet assay results: the results suggest that cis induces oxidative stress resulting in increased tos and lpo reduction thiol, tac and cat in kidney and increased peripheral lymphocyte cell dna damage. the treatment with naringenin and naringenin oxime alone or with cis treatment showed a protective effect against the toxic influence of cp on peroxidation of the membrane lipids and an altering of the total thiol status in the kidney of rats. from our results we conclude that naringenin and naringenin oxime functions as a potent antioxidant and suggest that it can control cp-induced nephrotoxicity and genototoxicity and ng-ox was found more protective than that of ng on cisplatin induced toxicity in rats. keywords: naringenin, naringenin-oxime, antinephrotoxic, antigenotoxic, comet assay. introduction: oxidative damage is considered to play a pivotal role in ageing, several degenerative diseases, and carcinogenesis. lung cancer is the most common type of cancer, resulting in over . million deaths each year worldwide. accurate and reliable determination of superoxide radicals has been widely investigated using spectrophotometric, electrochemical, amperometric, polarimetric, piezoelectric technologies. among these methods, electrochemical detection is a most promising approach to achieve accurate, separate and rapid superoxide radicals monitoring with using biosensor system. materials and methods: we used a new technic for detecting superoxide radicals in samples. superoxide dismutase (sod) enzyme immobilized on the surface of gold electrode with the help of gelatin, bovin serum albumin (bsa) and glutaraldehyde (ga) crosslinker. for the biosensor preparing benzoquinone selected as a mediator in working buffer and measurements were carried out at À . v. result: for the optimization studies, effect of the bsa, gelatin, glutaraldehyde, ph, buffer concentration on biosensor response. characterization of the biosensor commitment to the work process and answer reproducibility were evaluated. the analytical characteristic of the biosensor were evaluated by measuring the steady state current response to superoxide radical concentrations. the electrochemical response of the enzyme electrode was linearity gradually leveled of at higher concentration. we found that crosslinking of the sod (e.c. . . . ) with glutaraldehyde could be achieved over a wide range of relative mole ratios in mm phosphate buffer at ph . , glutaraldehyde concentration of % . . discuss and conclusion: in this study, a new technique for developed sod biosensors has been developed, which features effective combination of sod/gelatin/bsa/ga modified electrode, trapping of sod and glutaraldehyde cross-linking. this technique is reliable and cost effective. the effect of astaxanthin on apoptosis and cell arrest in u brain cancer cell line f. s€ og€ utl€ u, b. € ozmen yelken, c ß . kayabasi, a. asik, s. gonca, r. gasimli, s. yilmaz s€ usl€ uer, c ß . biray avci, c. g€ und€ uz department of medical biology, izmir, turkey a brain tumor is a collection, or mass, of abnormal cells in your brain. brain tumors can be cancerous (malignant) or non-cancerous (benign). the brain is one of the least accessible organ that active pharmacological compounds cannot be delivered. the two physiological barriers control and block the entry and exit of endogenous, exogenous compounds. one of these is the bloodbrain barrier and the other is the blood-cerebrospinal fluid barrier. this structures maintain protection of the brain. when there is a cancer case, it can lead to problem. astaxanthin with potent antioxidant properties can cross blood-brain barrier. in our study, we aimed to evaluate the effects of astaxanthin on apoptosis, cell cycle and also migration in brain cancer cell line. in present study, xcelligence real-time cell analyzer was used so as to determine cytotoxic effect of astaxanthin in u cell line. changes of apoptosis and cell cycle in u cell line exposured to ic dose of astaxanthin ( . nm- lm) are detected with annexin v-egfp apoptosis detection kit and cycle test plus dna reagent kit with facs, respectively. the result of apoptosis and cell cycle test was analysed in flow cytometry. the group to which active substance was not treated was used as controlled. the wound healing assay performed in order to measure migration ability of u cell line to which astaxanthin was treated or not. ic dose of astaxanthin was calculated as . lm at h by xcelligence rtca sp based on time and dose. astaxanthin decreased the migration ability at rate of % in u cells treated by ic dose of astaxanthin. astaxanthin had no apoptotic effect on viability in u cell line and astaxanthin caused an increase of g /m phase arrest ( . fold) and s phase arrest ( . fold). astaxanthin has cytotoxic effects in brain cancer. it determined that astaxantin decreases cell cycle potential at g /m even a little. the effect of anticancer of astaxanthin should be researched further. interferon regulatory factor (irf ) is a critical transcription factor in development and survival of different cell types including immune cells and melanocytes. furthermore, it has been demonstrated that irf expression levels are elevated in several lymphoid cancers, and irf is one of the key transcription factors for the survival of these cancers. several genome-wide association studies identified irf -linked genetic variants to increased melanoma incidence. in addition results from our lab and elsewhere have shown high levels of irf expression in melanoma cell lines. furthermore our preliminary results suggest melanoma cells are sensitive to irf expression levels. however, there are no published studies about irf target genes in melanoma cells. in this study, we are investigating the genome-wide target genes of irf in melanoma cell lines via high-throughput sequencing of immunoprecipitated chromatin (chip-seq). we have identified possible irf binding regions in loci with known key roles in development of melanocytes from neural-crest cells. one such key factor is mitf, which is the master regulator in melanocyte development and also plays critical roles in melanoma. integrating chip-seq and rna-seq data suggests irf as a transcriptional regulator of genes related to progression of melanoma. objectives: aim of this study was to evaluate prognostic importance of selected laboratory parameters (c-reactive protein (crp), gama glutamiltransferaz, ferritin (fer), potassium, chloride, calcium, phosphorus, magnesium, total protein, aspartat aminotransferaz, alanin aminotransferaz (alt), ifn-c, il- , tnf-a) in non-small cell lung cancer (nsclc). material and methods: patients with nsclc who were treated with chemoradiotherapy (crt) prospectively evaluated. all patients were newly diagnosed tumour. heparinized blood samples were taken from the patients before and after the completion of crt. fer analyzed by chemiluminescence method on beckman coulter dxi ; ifn-c, il- , tnf-a were analyzed with elisa kits (boster biological technology) and other biochemical parameters analyzed on abbott architect c . post-crt and pre-crt levels compared with survival. results: the lr cox regression analysis revealed that pre-crt ferritin was significantly associated with survival of patients with nsclc (hazard ratio (hr) = . , p = . , %ci; . - . ). it was also demonstrated by lr cox regression analysis, high levels of pre-crt crp was associated with worse outcome of patients (hr = . , %ci; . - . , p = . ). after crt, mean alt level was determined as . . there was survival difference in nsclc patients with high post-crt alt (hr = . , %ci; . - . , p = . ). conclusions: there exists a clinically relevant relationship between pre-crt fer concentration and the prognosis of survival in patients with nsclc. elevated fer is the result of inflammation rather than body iron overload. ferritin showed negative correlation with survival so it could be a useful biomarker to indicate bad prognosis of the patients with nsclc. additionally, crp which is easy to detect and feasible for the use in the routine clinical practice should be considered in the prognosis of nsclc patients. keywords: ferritin, nonsmall cell lung cancer, survival, c-reactive protein. epigenetic therapy tries to reverse the aberrations followed to the disruption of the balance of the epigenetic signaling ways through the use of natural and synthetic compounds, active on specific targets, such as dna methyltransferases (dnmts). we previously synthesized some benzoxazole and benzamide derivatives which might have anticancer activities on account of their heterocyclic structure. our studies showed that not only these compounds caused selective cytotoxicity towards cancer cells (hela) with little or no toxicity on normal cells (l ) but also were not genotoxic. in this study, we aimed to test whether these compounds changed global demethylation profile of normal and cancer cells. we used methylation specific comet assay (msc assay) to determine global methylation levels of cells. cells were treated with the tested compounds at ic concentrations for h. slides were prepared as did in alkaline comet assay, then they were incubated with methylation specific restriction enzymes (mspi, hpaii) before electrophoresis. differences in global methylation levels between nontreated control cells and cells treated with compounds were compared by using tail moment data. -aza-c, a demethylating agent, was used as reference drug. msc assay results revealed that none of the tested compounds caused hypermethylation on both cell lines. however, global methylation levels decreased statistically (p < . ) through both cells treated with c- and c- . only c- decreased methylation level on l but not on hela. consequently, c- and c- caused demethylation on hela cells similarly with -aza-c at low concentrations. for the reason that dna methylation is regulated mainly dnmt enzymes in the cell, c- and c- might cause global demethylation in the cell by inhibiting dnmt activity. further studies will be done to support this prediction. overall, macrophages and some subtypes of lymphoid cells are found in tumour stroma. these cells secrete a variety of growth factors, proinflammatory cytokines and chemokines, esp. tnf-a, il- b and il- , causing the formation of inflammatory microenvironment around tumour cells. tnf-a and il- b signaling increases activity of nf-kb pathway. at the same time, il- , triggers jak-stat signaling pathway, which effector is stat . nf-kb and stat activity facilitates hyperexpression of mir-nas mir- , mir- and mir- as well as down-regulates expression of mirnas mir- / , mir- and let- . this investigation aims to identify in what way these shifts in mirnaome can lead to epigenome reorganization supporting the cell transformation. mirna targets within gene transcripts were predicted in silico using targetscan software. transcripts of hdac / / / and sirt / genes encoding histone deacetylases carry targets for at least one of up-regulated mirnas mir- , mir- or mir- . also, these mirnas can silence ezh , mll, mll , nsd , setd / / , smyd , suv h genes encoding histone methyltransferases. mirna mir- suppresses gene encoding de novo dna methyltransferase dnmt b. at the same time, down-regulation of mirna mir- / can allow hyperexpression of gene encoding acetyltransferase elp . these shifts impair dna and histone methylation, cause the increase of overall level of chromatin acetylation and expression and, therefore, create epigenetic background for reactivation of silent transposons, oncogenes as well as other genes important for cell transformation. immune system can paradoxically facilitate the tumour growth instead of healing. cancer-related inflammation leads to the mir-naome and epigenome shifts contributing to the tumour promotion and progression. lysine acetylation is one of the key mechanisms to regulate chromatin structure and transcriptional activation. acetyl-lysine modifications are recognized by bromodomains, which are small interaction modules found on diverse proteins including histones. among these acetyl-lysine reader proteins is the family of the bet (bromodomain and extra-terminal) proteins which contain tandem bromodomains (bd and bd ). the recent discovery of potent and specific inhibitors for the bet family proteins has stimulated intensive research activity in diverse therapeutic areas, especially in oncology, where bet proteins regulate the expression of key oncogenes and anti-apoptootic proteins. several bet inhibitors are currently in clinical trials and reported to exhibit promising clinical activities. however, pleiotropic nature of bet proteins regulating tissue-specific transcription has raised safety concerns and suggested that attempts should be made for domain-specific targeting. here, we report the recent progress in the development of bet inhibitors in korea research institute of chemical technology (krict). we have identified the bet inhibitors with a novel scaffold different from the previously reported diazepine and azepine scaffolds and specific for first bromodomains (bd s). a medicinal chemistry effort is currently made to optimize the pharmacokinetic properties of these lead compounds for further drug development. the experimental data from the biochemical and cell-based assays for these bd -selective bet inhibitors will be presented. family of small c-terminal domain serine phosphatases (scp), which includes ctdspl, ctdsp , and ctdsp , plays a regulatory role in a number of vital processes. in particular, it is shown that ctdspl is capable to activate the retinoblastoma protein (rb) which is well-known tumor suppressor and one of the key cell cycle regulators. although the question on whether ctdsp and ctdsp dephosphorylate rb is open, high similarity of sequences and three-dimensional structures of phosphatases may indicate the similar function of these enzymes. in the current study expression of scp genes was evaluated by quantitative pcr in non-small cell lung cancer (nsclc) samples. using original crosshub software, that combines an analysis of high-throughput sequencing data of the cancer genome atlas project (tcga) and databases of mrna-mirna interactions (targetscan, mirtarbase, etc), the involvement of mir- - - microrna cluster in co-regulation of ctdspl/ / genes in nsclc was predicted. the significant ( -fold on the average) and simultaneous decrease of mrna levels of ctdspl/ / genes was revealed in the majority of nsclc samples ( %, / ). such unidirectional expression change and strong positive correlation between phosphatase expression levels (r s = . - . , p ≤ . ) allowed us to suggest a common mechanism of their inactivation. we evaluated the expression of predicted co-regulators of scp gene expression, mir- - - family, in examined nsclc samples. as a result, the simultaneously increased levels of all three mir-nas in most nsclc samples ( %, / ) and negative correlation with phosphatase gene expression was shown. the results suggest the ability of investigated phosphatases to exhibit tumor-suppressive activity and the involvement of mir- - - micrornas in the regulation of rb protein activity via inactivation of ctdspl/ / in nsclc. cancer is one of the leading causes of death in all around the world. cancer is defined as a disease involving abnormal cell growth with the potential to invade or spread to other parts of the body. tumor markers are substances that are produced either directly by the tumor or as an effect of the tumor on healthy tissue. tumor markers can be used for screening, determining prognosis and monitoring effectiveness of therapy and disease recurrence. the aim of this study is to investigate the frequency of tumor markers orders and the appropriateness of these requests. laboratory information systems data for were reviewed. for , a total of patients and tumor marker requests were included. carbohydrate antigen - , cancer antigen , cancer antigen - , prostate specific antigen, alphafetoprotein and carcinoembryonic antigen were measured by chemiluminescence method. according to the data from the year of , both positive tumor markertest resultsratio and the positive patient ratio were %. in the patients group with increased marker levels, % of the patients had no history of cancer. in the patients group with tumor marker levels in referenceranges, % patients with diagnosed cancer history in remission. the ratios of positive tumor markers were % forca - , % for ca , . % for psa, %for ca - , . %for afp, and . % for cea. in conclusion; unnecessary test requests increase laboratory work load and health expenses. laboratory and clinical staff collaboration is crucial to increase the appropriate use of tumor markers. dna methylation is an epigenetic modification that is involved in both normal biological and disease states. hypermethylation of promoter regions of tumor suppressor genes have a role in tumor development. therefore, the measurement of promoter methylation of genes can be used for diagnosis and prognosis purposes of cancer. to detect dna methylation alterations in a sample (biopsy, blood, saliva, etc.), sensitive detection systems and optimization of the methods are needed. as a part of a collaboration project between national metrology institute of korea (kriss) and national metrology institute of turkiye (tubitak ume). dna methylation status of apc and gstp genes were studied. dna methylation measurements were performed using stepone real-time pcr system and results were analyzed using hrm (high resolution melting) software. the parameters effecting the quantification of dna methylation were found as primers, annealing temperature, pcr cycle number, fluorescence dye and the commercial dna methylation standards used for quantification of dna methylation. since, the accurate measurement of dna methylation is very critical in early diagnosis of cancer and choosing the right therapy, optimization of the method is required. cancer is a disease that includes heterogenic and complex molecular changes. anti-carcinogenic effects of resveratrol, a natural polyphenol, have been proved in a variety of cancer cells. considering the effects of resveratrol, the influence of the signal transduction pathways in the presence or absence of p of colon cancer cells is gaining importance. our aim was to investigate the effects of resveratrol in the presence or absence of p on cell viability, apoptotic cell death ratio and fold changes of proliferative or anti-proliferative gene expressions, which may have important effects on colon cancer, in hct colon carcinoma cells. ic doses of resveratrol were determined by wst- assay. the apoptotic cell death ratios in treatments of resveratrol were determined by annexin-v-fitc/pi assay for flow cytomety . the changes of ccnd , fra , ppard, egfr, birc , pcna, mcl , stat , fos, jun, p , atf , trail, puma, gadd a, rb , faslg, tnf, socs , stat gene expressions were evaluated by real time pcr. all data were statistically analyzed by student's t test. our research has revealed that resveratrol ( lm) causes decrease in cell viability and increase in apoptotic cell death in hct p (+/+) and hct p (À/À) cells significantly (p < . ). the fold changes of the gene expressions have shown that resveratrol has significant (p < . ) and different effects on the expressions of the genes related with the existence of p in hct cell lines. therefore we proposed that resveratrol might show proliferative or apoptotic effects related with p mutation of colon cancer cells and we predicted that unconscious consumption of resveratrol in colon cancer patient might cause adverse effects. introduction: colorectal cancer (crc) is the third most common cancer worldwide. alterations in methylation profiles of tumor suppressor genes (tsgs) have been recognized as a key mechanism in colorectal cancers. in the current study, we investigated the hypermethylation status of tsgs in colorectal cancer tissues. materials and methods: formalin-fixed paraffin-embedded (ffpe) tissue samples obtained from patients with crc. methylation specific-multiplex ligation dependent probe amplification (ms-mlpa) technique was used to assess the methylation status of tsgs. the findings were evaluated in terms of age, mortality, survival, positive lymph node status, lymphovascular invasion, and perineural invasion. results: hypermethylation-detected patients and hypermethylation-undetected patients were called as group and group , respectively. hypermethylation was detected in atm, cdkn a, and gata genes. mortality rate was ( . %) in group and group (p > . ). mean -years survival rate in group was ae months and mean -years survival in group was ae months (p > . ). positive median lymph node count was ae for group and ae for group and the difference was statistically significant (p < . ). frequencies of perineural invasion and lymphovascular invasion rate in two groups were % (p > . ). discussion and conclusion: our findings suggest that tsg hypermethylation found in crc patients may increase the lymph node metastasis. further investigations with larger sample size are required to support our results. boron (b) is known to be important for cell replication and development, but the underlying mechanism remains obscure. recently b has also become important in some specific anticancer processes. some recent reports advise using of some boron compounds for the treatment of specific forms of cancer. for instance, boron-based drugs (bortezomib) are now being developed for use as therapeutic agents with anticancer activities and several other boron-based compounds are in various phases of clinical trials. it has been shown that bortezomib disrupts the regulation of cell cycle and induces apoptosis in both hematologic and solid tumor malignancies except for colon carcinoma. colorectal cancer (crc) is the third most common cancer in men and the second in women, accounting for % of all tumour types worldwide. cytotoxic effects of boron compounds on crc cells and changing of its effects related with p mutation, which is mutated % of cancer cases, have not take part in literature yet. for this purpose; the aim of the study was designed to investigate the effects of borax pentahydrate and disodium pentaborate decahydrate compounds on cell viability, apoptotic cell death ratio and parp protein expressions in p (+/+) and p (À/À) hct colon carcinoma cells lines. the effects of the boron compounds on cell viability were assessed by xtt assay and apoptotic effects and parp protein expression of the compounds were evaluated by flow cytometry and western blot analysis respectively. our results showed that borax pentahydrate ( mm) and disodium pentaborate decahydrate ( mm) significantly causes nearly % reduction of cell viability at h (p < . ). apoptotic cell death ratios and parp expressions revealed that both of the compounds might have a potential for a candidate of anticancer agent. epithelial-mesenchymal transition (emt) is a significant event for metastasis, and could be mediated by several pathways such as pi k/akt, map kinases and many epigenetic regulators. satb is an epigenetic regulator involved in emt and osteoblastic differentiation. since preliminary results indicate that there is a crosstalk between p and akt pathways in nsclc cells, we aimed to determine whether this crosstalk has a regulatory effects on emt and satb expression in nsclc cells. we used a and h cells as a model to evaluate the effects of the crosstalk between p and akt on emt of nsclc cells. therefore, cell culture, inhibition of p activation via sb , transient expression assay for (ca-akt), western blot analysis, sirna transfection for satb , wound healing and invasion assay were performed in this study. firstly, the expression statues of e-cadherin, satb , p-p , p , p-akt and akt was examined in a and h cells by western blot analysis. we observed that e-cadherin and satb are downregulated in a cells (highly active p , lowly active akt) compared to h cells (lowly active p , highly active akt), suggesting that e-cadherin and satb are associated with the crosstalk between p and akt pathways. our results demonstrated that p inhibition in a cells leads to decreased pten expression and subsequently increased akt activation. then, we found that p inhibition upregulated satb expression, and reversed emt in a cells. furthermore, alone satb knockdown is sufficient to induce emt, and prevented the effects of p inhibition on emt. all these results strongly indicate that the crosstalk between p and akt pathways might determine satb expression and epithelial characters of nsclc cells, and satb is a critical epigenetic regulator for emt in nsclc cells. therefore, it is also need to explore how p and akt signalling pathways could regulate satb expression. this work was supported by tubitak ( s , z ). introduction: lung cancer is a disease characterized by uncontrolled cell growth in the lung tissues. the most common causes of lung cancer are tobacco smoke, radon gas, asbestos, air pollution, and genetic factors. nitric oxide (no) has potential mutagenic and carcinogenic activity and may play important roles in lung cancer. endothelial no, synthesized from l-arginine by endothelial no synthase (enos), inhibits apoptosis and promotes angiogenesis and tumor cell proliferation. the aim of the present study was to examine the possible relationship between enos gene intron vntr and exon -g t (glu asp) the stressful ecosystems exert strong adaptive pressure and proteins that facilitate these adaptation processes are candidate drug targets. nucleotides are the core of biochemical pathway required for cancer cell growth and replication and genetic changes will lead in oscillation in their pools. although it is questionable whether the warburg effect actually causes cancer, impairing dglucose uptake and metabolism induces oxidative metabolism. lproline (lproline) homeostasis is critical in a constellation of human diseases, in parametabolic linkage between cancer, epigenetics (phang et al. ) and bioenergetics (pallotta ) where degradation and biosynthesis are robustly affected by oncogenes or suppressor genes that can modulate intermediates involved in epigenetic regulation. lproline-fueled mitochondrial metabolism involves the oxidative conversion to l-glutamate by a flavin dependent lproline dehydrogenase/oxidase and a nad +dependent l-d -pyrroline- -carboxylate dehydrogenase. in saccharomyces cerevisiae an important test tube, put p and put p respectively help cells to respond to changes in the nutritional microenvironment by initiating lproline breakdown after mitochondrial uptake (pallotta ) . in this preclinical study, low molecular weight compounds were tested for inhibiting lproline mitochondrial transport and put p/put p catalytic activities. thus, in seeking for natural bioactive compounds targeting lproline pathway and its substrate channeling (becker's group ), we report data using in silico screening and in vitro researches in saccharomyces cerevisiae with genetic background atcc but different phenotypic landscape induced by nutritional stress/ ph changes. cells vitality, dΨ measurements, nad(p) + /nad(p) h pool and flavine turnover were determined in spectrofluorimeter microplater reader and via hplc (pallotta et al. (pallotta et al. , (pallotta et al. , pallotta ; di martino pallotta ) thus in supporting of future cancer therapies with decreasing side effects. evaluation of lymphocyte to monocyte ratio (lmr) in patients with colorectal cancer introduction: inflammation may play an important role in cancer progression and a high neutrophil to lymphocyte ratio (nlr) has been reported to be a poor prognostic indicator in several malignancies. the aim of this retrospective study was to evaluate the prognostic value of nlr, lymphocyte to monocyte ratio (lmr) and platelet to lymphocyte ratio (plr) in patients with colorectal cancer (crc). : patients who were diagnosed with colorectal cancer between january and january ; were evaluated retrospectively. the cutoff value was determined using receiver operating characteristics curve analysis. survival analysis was performed using the kaplan-meier method and log-rank test. the cox proportional hazard model was used to identify the influence of factors related to survival. (tnm stage, tumor differentiation, age, tumour size and lmr) results: receiver operating characteristic curves showed that lmr was superior to plr and nlr as a predictive factor in patients with colorectal cancer. the cutoff value for lmr was . . cancer-specific survival was not significantly different between the high-and low-lmr groups (p = . ). age was identified as independent prognostic factor in colorectal cancer (hazard ratio: . ; % confidence interval: . - . ; p = . ). discussion and conclusion: our preliminary study showed that the lmr was not an independent prognostic factor in crc patients, but additional large sample sized prospective studies will be needed to confirm these findings. the aim of this study is to investigate the effects of luteolin treatment on enzymatic activity of arginase, and ornithine and polyamine levels (putrescine, spermidine spermine) in serum and cancer tissues of ehrlich ascites breast cancer model. balb/c female mice were divided randomly into following groups: healthy control, healthy treatment, cancer control, treatment and treatment . . ml ehrlich ascites tumor cells was inoculated subcutaneously to medial part of left hind leg. healthy treatment and treatment groups, and the treatment group were given mg/kg and mg/kg dose of luteolin, intraperitoneally, for a days period, respectively. luteolin has a hydroxylated flavonoid structure and shows potent antioxidant, anti-inflammatory, and anticarcinogenic properties. luteolin not only leads to cell death in various tumors by suppressing cell survival pathways and stimulating apoptotic pathways, but also sensitize them to cytotoxic therapy. supporting various previous studies, tumor implantation to healthy mice resulted in statistically significant elevation of serum arginase and polyamine levels (p < . ) indicating the tumor cells as the main source of this production. furthermore, luteolin treatment abolished this increase in serum arginase and polyamine levels (p < . ). tissue measurements of arginase and polyamine levels indicated that luteolin treatment resulted with an increase in these parameters of tumor tissue while the serum levels of them showed a significant decrease. our results revealed that increased tissue arginase and polyamine levels might be related with estrogenic agonistic effect of luteolin on utilized tumor model in this experiment; and decreased serum levels of these parameters while there is a significant increase of them in tissue levels might be a result of a suppression of polyamine efflux from the tumor tissue by inhibitory effect of luteolin on plasma membrane polyamine transporters. hepatocellular carcinoma (hcc) is the third most common cause of cancer-related deaths. around - % of hcc patients are diagnosed at an early stage of the disease. hepatic resection, liver transplantation are common strategies in hcc treatment. even if, most of the patients present advanced-stage tumors and have a restricted survival rate. for the reason, resistance against existing tumor stress conditions have been demonstrated in hcc. hypoxia, hyperglycemia are general stress sources in hcc and result in aggressive cell phenotype, resistance to apoptosis and therapeutic drugs. thioredoxin interacting protein (txnip) regulates cellular responses under stress conditions. over-expression of txnip results activation of oxidative stress and apoptosis. in cancer models txnip is considered as a tumor suppressor gene. however, its role in the development, progression of hcc and mechanisms behind it warrant further investigation. in this study expression levels of txnip were examined in hcc cell lines by rt-pcr and western blotting. txnip expression was significantly high in poorly-differentiated snu- , snu- and snu- than the well-differentiated hcc cell lines such as huh- , hepg and plc/prf/ . besides, expression of txnip was examined in non-hcc and hcc tissue samples by immunohistochemical staining. txnip positivity was observed in % of well and % of poor differantiated hcc tissues. however, no txnip positivity was observed in non-hcc tissues. to investigate whether txnip might be involved in biological responses such as cell proliferation, motility and invasion, we used overexpression and silencing strategies. overexpression of txnip minimally inhibited adhesion and proliferation, whereas boyden-chamber motility and invasion assay showed that invasiveness of cells were increased. our findings suggest that txnip expression is increased in hcc and txnip over-expression is important for invasive phenotype during hepatocarcinogenesis. cardiovascular diseases are the leading cause of morbidity and mortality in the western world. it was shown that ischemic tolerance of the heart can be enhanced not only by ischemic or pharmacological conditioning (pre-and postconditioning), but also by adaptation to chronic hypoxia. different studies have indicated that these cardioprotective phenomena may at least partly share the same signaling pathways. the jak/stat signaling pathway has been demonstrated to participate in the development of cardioprotection by conditiong apparently through the inhibition of gsk- b. the aim of our present study was to determine whether this pathway also takes part in cardioprotection induced by adaptation to chronic hypoxia. we investigated the effect of inhibitor of jak kinase (ag- ) on myocardial infarct size and the jak /stat signalling pathway and other effector molecules that may participate in cardioprotection conferred by adaptation to hypoxia. adult male rats were adapted to intermittent normobaric hypoxia ( % o , weeks, h/day) and part of them recieved ag- ( mg/kg) min before ischemia. control rats were kept under normoxia. infarct size was assessed in isolated perfused hearts. relative expression of the key components of the jak /stat signalling system and other proteins was detected using western blotting. preliminary data indicate that administration of the jak inhibitor ag- caused a significant increase in infarct size in hypoxic rats. western blot analysis revealed changes in phosphorylation of jak , stat and some other proteins involved in cardioprotection (akt, erk / , gsk b). these results suggest that the jak/stat signaling pathway could participate in the development of a cardioprotective phenotype in rats exposed to chronic hypoxia. however, further research will be needed to clarify in more detail the role of this signalling pathway in the cardioprotective mechanism. p- . . - detrimental effect of hypertension on myocardium was reversed by liver x receptor agonist gw hypertension is a cardiovascular disease that causes functional and structural changes in the heart. nuclear liver x receptors (lxrs) are involved in the control of cholesterol and lipid metabolism. however, effect of lxr activation on the hypertensive heart is not well characterized. in this study, the effects of lxr agonist gw on hypertension-induced damage of myocardium were investigated. hypertension was induced by deoxycorticosterone acetate (doca) injection ( mg/kg, twice a week) following the unilateral nephrectomy in male -week-old wistar albino rats for weeks. blood pressure was measured by using tail-cuff method. gw ( mg/kg/day, i.p.) was administered last week. expression of various markers (grp , perk, p-perk, ikb-a, nf-kb p , tnf-a, bax, bcl- , mmp- ) in the ventricular tissue were examined by western blotting. inflammation and fibrosis were evaluated in histopathological examination. gw treatment reduced systolic blood pressure of hypertensive animals. expressions of endoplasmic reticulum stress markers grp and p-perk were increased by hypertension and gw treatment reversed them. hypertension-induced increase in nuclear nf-kb p expression and decrease in ikb-a expression were reversed by gw treatment. while bcl- expression was lower, bax level was higher than control in the hypertensive animals. in hypertensive group, fibrosis marker mmp- expression was augmented and gw treatment reversed this elevation. hypertension-induced increase in interstitial and perivascular collagen deposition and inflammatory cell infiltration in left ventricle were prevented by gw treatment. these results suggest that lxr activation by gw restored the hypertension-induced structural changes of heart in the doca-salt hypertension. methylphenidate (mph) is a psychostimulant prescribed for the treatment of attention deficit hyperactivity disorder (adhd), one of the most common neurobehavioral disorders of childhood and adolescence. in fact, despite the widespread use of mph the full comprehension of its cellular/molecular mechanisms is still elusive, including its effect on blood-brain barrier (bbb). this barrier is a key structure in the central nervous system since it protects the brain and its dysfunction has been described as a critical event in several brain diseases. thus, the aim of the present study was to clarify the effects of mph on the bbb function in both physiological and adhd conditions. for that, we used a rat model of adhd, the spontaneously hypertensive (shr) rats, and wistar kyoto (wky) animals as inbred comparator strain. also, to mimic a clinical dosing schedule for adhd treatment, rats were administered for monday-friday with vehicle or mph ( . mg/kg/day or mg/ kg/day, per os) from p -p . chronic mph treatment ( mg/kg/day) promoted cortical bbb permeability in both wky and shr animals; however, more prominent in wky rats. this effect can be explained by the downregulation of claudin- and collagen-iv, tight junction and basal lamina protein, respectively. noteworthy, wky animals also showed an increase in the expression of caveolin- and in both vascular cell and intercelular adhesion molecules. these bbb alterations led to subsequent infiltration of peripheral immune cells, including cd + macrophages. furthermore, hippocampal bbb disruption was only observed in wky rats with mg/kg of mph. here, mph decreased collagen iv expression and upregulated caveolin- , with no alterations in claudin- . overall, our results show that chronic exposure to mph can led to brain vascular alterations particularly under physiological conditions. this highlights the importance of an appropriate mph dose regimen for adhd, and also that mph misuse can have a negative effect. regulators of g proteins signaling (rgs) serve several cellular functions varying from tolerance, dependence, neuroprotection, transcription and tumorgenesis. despite their initial role as gtpase activating proteins, evidence suggests that rgs proteins are localized in the nucleus, interact with transcription factors thus regulating transcriptional responses. it was shown that rgs directly interacts with and interferes in opioid receptor (or) signaling. rgs is mostly expressed in brain and is implicated with brain structural alterations; however, the molecular mechanisms of how rgs could be involved in cellular differential functions remains unclear. based on these observations we examined whether rgs can regulate transcriptional responses mediated by the stat b transcription factor. isolated neural stem cells from rgs À/À mice were immunostained for the mitosis marker ph and the mrna levels of antiapoptotic genes were determined. proliferation assays were performed with brdu staining in neuro a cells stably expressing rgs . the functional assays of stat b transcriptional activation were performed in hek expressing either the erythropoietin receptor (epo-r) or the delta opioid receptor (d-or). the present data demonstrate that rgs blocks stat b phosphorylation and transcriptional activation by interfering in stat b heterodimerization upon epo-r or d-or activation triggered by cytokines or opioids administration. lack of functional rgs results in increased mrna levels of stat b target genes such as the members of the bcl anti-apoptotic family bcl- , bcl- and bcl-xl. this upregulation of stat b inducible gene transcription results in an increased proliferation rate of neural stem cells. this study demonstrates for the first time a non-canonical function of rgs in stat b mediated transcriptional responses and a novel selective role of rgs in transcription. role of the pre-molten globule structure in amyloid fibril formation a. eshaghi department of biology, faculty of science, islamic azad university, mashhad branch, mashhad, iran the major factor that caused extensive research on the protein fibrillation is their crucial roles in important diseases known as the amyloidosis diseases. neurodegenerative diseases, including alzheimer's, parkinson's, diabetes and huntington are the most important types of this disease. understanding the mechanisms of fibril formation and ways of treatment can be useful in reducing this type of disorder. in this project, the fibrillation of carbonic anhydrase protein was investigated as a model. carbonic anhydrase creates two stable intermediated known as pre-molten and molten globule, in different ph solution. this protein at ph between ph - molten globule structures was formed while the pre-molten form took place under ph . in our tests at ph . when the protein in molten globule structures only the amorphous aggregates were formed. instead, at ph . in pre-molten globule structure amyloid fibrils formed in the protein. there some reports, indicated the protein from pre-molten globule structure go toward amyloid assembly. even intrinsically unstructured proteins such as alpha-synuclein first took a structure similar to pre-molten globule and then made amyloid fibrils. it seems pre-molten globule structure have the major role in promoting to amyloid fibrils. perhaps drugs that prevent the formation of premolten globule structure have an important role in inhibiting amyloid fibrils. identification of compounds preventing the biochemical changes that underlie the epileptogenesis process and understanding the mechanism of their action is of great importance. we have previously shown that myo-inositol (mi) daily treatment for days prevents certain biochemical changes that are triggered by kainic acid (ka)-induced status epilepticus (se), [ , ] . however in these studies we have not detected any effects of mi on the first day after se. in the presented study we broadened our research and focused on ka induced other early molecular and morphological changes and influence of mi treatment on these changes. the increase in the amount of voltage-dependent anionic channel- (vdac- ), mitochondrial-plasma membrane cofilin and caspase- activity was observed in the hippocampus of ka treated rats. administration of mi h later after ka treatment abolishes these changes, whereas under the same time schedule diazepam treatment has no significant influence. the number of neuronal cells in ca and ca subfields of hippocampus is decreased after ka induced se and mi post-treatment significantly lessens this reduction. no significant changes are observed in the neocortex. obtained results indicate that mi post-treatment after ka induced se could successfully target the biochemical processes involved in apoptosis, reduces cell loss and can be successfully used in the future for translational research. references . r. . neuroscience letters, vol. , no. , pp. - . . r. solomonia, et al; . cell. mol. neurobiol. vol. , no extracellular deposits of amyloid-b peptide (ab) in brain parenchyma via proteolytic processing of amyloid precursor protein (app) are one of the typical characteristics of alzheimer's disease (ad). these aggregates mainly occur as a result of an increase in ab production or a decrease in its degradation. it was found that the neurotoxicity of ab aggregates is accelerated by acetylcholinesterase (ache). besides, ab-ache complex has a prominent neurodegenerative effect in brain. thus, cholinesterase inhibition and preventing ab production are current treatment strategies for ad. recent studies have shown that methylene blue (metb), a cholinesterase inhibitor with phenothiazine structure, inhibits the formation of amyloid plaques and neurofibrillary tangles. azure b, the major metabolite of metb, has been shown to inhibit ache and bche with ic values of . lm and . lm, respectively. in the present study, we tested whether azure b, may effectively lower the levels of ab / . we treated chinese hamster ovary cells, which stably express human wild type app and presenilin- (ps ) with - mm azure b or vehicle for h. to determine the effect of azure b treatment on ab / levels, we used separate sandwich-based elisas and normalized to total protein levels, determined by bca protein assay. azure b treated ps cells were also assessed by propidium iodide in flow cytometry for cellular toxicity. we observed a significant decrease in both extracellular ab and ab levels with a dose range treatment of azure b in ps cells. ab levels were reduced by . % in lm and . % in lm azure b-treated cells when compared to control. additionally, ab levels were decreased by % in lm and . % in lm azure b-treated cells when compared to control. overall, these preliminary results suggest that azure b may have beneficial effects for the treatment of ad. the effect of green silver nanoparticles (agnps) on the amyloid formation in alphalactalbumin and chaperone action of alphacasein a. ghahghaei, m. dehvari, j. valizadeh formation and deposition of protein fibrillar aggregates in the tissues is associated with several neurodegenerative diseases such as alzheimer's and parkinson's disorders. molecular chaperones are a family of proteins that are believed to have ability for inhibiting protein aggregation. in the present study the effect of different concentrations of green synthesis silver nanoparticles (agnps) from pulicaria undulate l. on the amyloid formation of a-lactalbumin (a-la) and chaperone action of a-casein have been investigated. the effects of the agnps were determined using light scattering absorption, tht binding assay, intrinsic fluorescence assay, ans binding assay, cd spectroscopy and sds-page. light scattering and tht assay results showed that agnps have the ability in preventing aggregation of a-la in a concentration-dependent manner. consistent with these results, sds-page results represented that by increasing the concentration of agnps the adsorption and interaction between agnps and protein have increased. light scattering and tht assay results, also, revealed that the amyloid fibrilation decreased in the presence of both agnps and a s -casein compared to presence of a s -casein alone. fluorescence results, however, show that agnps have no effect on the chaperone ability of a-casein and in fact they perform their protection of protein aggregation action independently. consistent with the above experiments, cd spectroscopy also revealed that agnps have decreased structural changes in reduced a-la in absence and presence of a-casein, both the tertiary and the secondary structure of the proteins. our finding represented that agnps have preventing effects on protein aggregation and have no effect on the chaperone ability of a s -casein. in the main, results of this study show that biosynthesized agnps mediated by >pulicaria undulate l. maybe could be affective as a therapeutic agent for inhibiting aggregation in treatment of amyloidosis disorders. pink is a mitochondrial kinase with multiple cellular functions. while loss-of-function mutations of pink gene lead to early onset parkinson's disease, its over-expresion is associated with cancer development. parkinson is a multifactorial neurogenerative disease, with a complex aethiology including various cellular stressors. it is now known that genotoxic stress also triggers the release of soluble factors able to induce changes in neighboring cells enhancing the initial lesions, process known as bystander phenomena. althrough the mechanisms are still unclear, recent studies point towards a role for mitochondria in this process. our work investigates pink role in intracellular and intercellular stress response, comparatively in various models: fibroblasts (mefs) and neuroblastoma (sh-sy y) used as a tumoral model or differentiated to a neuronal phenotype. pink role in this process was analyzed using genetically engineered pink deficient cells exposed to a genotoxic agent, bleomycin. the modified cell lines showed a reduced level of basal atp production. pink proved to be involved in cellular vulnerability to stress. despite differences in cellular sensibility between our models, genotoxic treatment of pink deficient cells induced consistently higher lesions compared to corresponding wild type variant. pink deficient cells showed altered intercellular signaling of stress, impairing bystander phenomena induction, by suppression of signal formation in treated cells, but also by altering the capacity to respond to the signals in neighboring cells. our hypothesis is that pink contributes to the management of cellular stress being involved in bystander transmission of detrimental effects through intercellular communication. this is determined mainly by its role in maintaining mitochondrial homeostasy and atp levels, pink deficient cells lacking the amount of energy required for rapid dna repair and stress signaling transmission. p- . . - intranasal administration of synthetic fragments from receptor for advanced glycation end products prevents memory loss in olfactory bulbectomized mice the receptor for advanced glycation end products (rage) is a member of the immunoglobulin protein superfamily. activation of rage causes brain inflammation, oxidative stress and secretion of beta-amyloid that has been recognized as an essential phase in the development of alzheimer's disease. it is known that the receptor soluble isoform (srage) which lacks the transmembrane and cytosolic domains binds to ligands and prevents negative effects of the receptor activation in in vivo and in vitro experiments. we proposed that potential ligand-binding peptide fragments from srage would demonstrate the same biological activity. we have selected and synthesized peptide fragments from unstructured surface-exposed regions of rage. synthetic peptides were intranasally administrated into olfactory bulbectomized (obe) mice with neurodegeneration of alzheimer's type. we have found that only administration of rage fragment ( - ) effectively prevents the obe murine memory from impairment, leads to decrease of beta-amyloid level and blocks the development of neuronal pathology in the brain of experimental mice. six overlapping fragments of rage ( - ) peptide were synthesized in order to find a site, responding for the therapeutic effect. tests in obe mice carried out with these fragments showed that only the n-terminal part of the molecule is responsible for preventing obe mice memory from impairment. all fragments which do not include n-terminal - dipeptide have been fully inactive in these experiments. we have proposed that active peptides can interact with beta-amyloid or s b protein preventing these ligands from binding with rage. this interaction can inhibit the development of neurodegeneration. the aim of this study was to examine effects of social isolation, enriched environment and exercise on learning in rats. the study included female day old wistar rats. the rats were randomly divided into four different groups; control, exercise, social isolation and the enriched environment groups. the social isolation group and the enriched environment group were housed under their specific conditions and the exercise group and the control group were housed in standard conditions during weeks. the rats in the exercise group swam for weeks. after weeks, the rats were evaluated in the morris water maze. brain and blood samples were taken and the hippocampus tissue was dissected. bdnf and ngf levels were measured in these samples. in conlusion, while enriched environment was a positive effect on spatial learning, social isolation was a negative effect on spatial learning and increase thigmotactic behaviors. according to the analysis results ngf and bdnf levels in the hippocampus and plasma did not change with environmental conditions and exercise. time of exposure to social isolation, procedures of the enriched environment, time of exposure to the environment, type and duration of exercise and gender may affect the results. alzheimer's disease (ad) was characterized by dementia that typically begins with subtle recognition failure and poor memory. it slowly becomes more severe and, eventually, incapacitating. the cholinergic system seemed particularly susceptible to synapse loss, especially in cortical regions associated with memory and executive function ( ) . recent studies showed that the main cause of the loss of cognitive functions in ad patients was a continuous decline of the cholinergic neurotransmission in cortical and other regions of the human brain ( ) . acetylcholinesterase (ache) and butyrylcholinesterase (bche) are hydrolytic enzymes that act on acetylcholine (ach) to terminate its actions in the synaptic cleft by cleaving the neurotransmitter to choline and acetate. both enzymes are present in the brain and detected in neurofibrillary tangles and neuritic plaques. it was suggested that ache predominates in the healthy brain, with bche considered to play aminor role in regulating brain ach levels. however, bche activity progressively increases in patients with ad, while ache activity remains unchanged or declines. both enzymes therefore represent legitimate therapeutic targets for ameliorating the cholinergic deficit considered to be responsible for the declines in cognitive, behavioral, and global functioning characteristics of ad ( ). we initiated a study to screen their acetylcholinesterase (ache, ec . . . ) inhibitory activities, which are the key enzymes taking place in pathogenesis of ad. newly synthesized chiral benzimidazole derivatives with thioure structure showed ic values in the range of . - . nm for ache. this study was financed by turkish research council-tubi-tak (kbag z ). p- . . - f -a h, novel fingolimod derivative, activates camp-dependent signalling pathway in sk-n-sh cell line g. celik turgut , a. sen , d. doyduk , y. yildirir department of biology, faculty of arts and sciences, pamukkale university, denizli, turkey, department of chemistry, faculty of sciences, gazi university, ankara, turkey fty , a sphingosine -phosphate (s p) receptor modulator, is the first oral disease-modifying therapy to be approved for the treatment of relapsing-remitting multiple sclerosis. in this study, we have synthesized and characterized novel derivative of fty , namely f -a h, and have determined its underlying camp regulation in sk-n-sh cell lines. for this purpose, we first determined the regulation of the camp response element (cre) activity and camp concentration by f -a h along with fty using pgl . luciferase reporter assay and camp immunoassay, respectively. then, we have determined their effect on camp/pka-related gene expression profiles using custom arrays along with fty treatment at non-toxic doses. it was found that f -a h significantly activate cre and increase camp concentration in the sk-n-sh cell line, indicating that it activates camp pathway through cell surface receptors as fty does. furthermore, f -a h modulates the expression of the pathway related genes that are important in camp signaling pathway. in summary, our data demonstrate that the novel fty derivative act as a modulator of camp ultimately by influencing the gene expression via the camp and downstream transcription factor cre pathway. in conclusion, f -a h might contribute future therapies for multiple sclerosis. alzheimer disease (ad) results in memory impairment and accompanied by neuroinflammation, cholinergic deficit and amyloid-beta (ab - ) accumulation in brain. we found that bacterial lipopolysaccharide (lps) injections or mice immunizations with extracellular a nicotinic acetylcholine receptor (a - nachr) domain resulted in astrogliosis, decrease of a nachr density, accumulation of ab - in brain and episodic memory impairment. the aim was to reveal main event triggering ad-like symptoms development. c bl/ mice were injected with lps, immunized with recombinant a - or a - endoglycosidase treated to remove carbohydrates. two immunizations with week interval were performed. control mice obtained complete freund's adjuvant injections. mice were tested for memory performance, blood sera were examined for presence and fine specificity of a - -specific antibodies and brain preparations were studied for a nachr, ab - and il- levels. the original a - ('glyc') was more immunogenic than 'deglyc', and their epitopes were recognized with different efficiency. in contrast to lps and 'glyc' a - immunization with 'deglyc' a - did not stimulate il- elevation in brain and had no proinflammatory effect. immunizations with 'glyc' or 'deglyc' a resulted in similar a nachrs decrease and ab - accumulation in brain and significant episodic memory decline comparable to those after lps injections. a nachr interacts directly with amyloid-beta precursor protein and facilitates its proper processing and metabolism. our data indicate that decrease of a nachr density caused by a - -specific antibody is critical for ab - accumulation and episodic memory impairment while pro-inflammatory capacity of a - -specific antibody plays secondary role in ad-like symptoms development. in vitro antioxidant and antiacetylcholinesterase activity of achillea millefolium alzheimer diseases (ad) is a neurodegenerative condition without a current effective treatment. increase in reactive oxygen species and lipid peroxidation or decrease in total antioxidant capacity causes oxidative stress-induced tissue damage. it has been suggested that decrease in oxidative stress and inhibition of acetylcholinesterase (ache) activity play a major role in the prevention and slowing of cognitive symptoms of ad. recently, studies have been directed for the discovery of medicinal plants and natural substances that are known to have natural antioxidants. achillea millefolium (a. millefolium) is a traditional herbal medicine that contains natural compounds with antioxidant activity and has been used as a carminative, diuretic, menstrual regulator and wound healer, however the mechanism of its actions are unclear. the aim of our study was to investigate the effects of a. millefolium extracts on free radical production, acetylcholinesterase (ache) activity and lipid peroxidation in vitro. methanol (me) and ethanol (ee) extracts of a. millefolium were prepared to determine (a) in vitro antioxidant capacity (by using , -diphenyl- -picrylhydrazyl assay, radical scavenging activity, phosphomolibdenum-reducing antioxidant power, ferricreducing antioxidant power, and total phenolic-total flavonoid contents), (b) effects on ache kinetics (by using a colorimetric assay) and (c) effects on sodium nitroprusside-induced lipid peroxidation in mice brain homogenates. me showed a higher antioxidant activity compared with ee in the biochemical assays tested. similarly, me demonstrated significant inhibition of ache activity that was potent than ee. both extracts dose-dependently decreased malondialdehyde content in mice brain homogenates suggesting a strong inhibition of lipid peroxidation. these results showed that a. millefolium has a high antioxidant capacity and antiache activity, indicating a potential use as an adjuvant therapy in ad. b-cells are known to play a key role in multiple sclerosis (ms) progression and autoimmune response. cxcr is the main b-cell chemokine receptor that under normal conditions directs their migration to specific areas of secondary lymphoid organs. in ms, areas of demyelinating lesions have been reported to attract bcells due to overexpression of cxcl , the cxcr ligand. we aimed to determine whether snp rs located in the promoter of cxcr gene and associated with high risk of multiple sclerosis could have a direct effect on of cxcr promoter activity. mef c binding to dna was assessed using pull-down assay. b-cell stimulation was performed using lps, pma and ionomycin. activities of variants of cxcr promoters containing different rs alleles were estimated using luciferase reporter assay. we determined that minor rs allele creates functional mef c-binding site within one of the regions required for the basal activity of the cxcr promoter. cxcr promoter containing minor rs variant that is statistically associated with low risk of ms showed significantly decreased activity in stimulated human b-lymphoblastoid cell lines. mef c has been reported to play an essential role in b-cell survival and b-cell responses. we determined mef c as the main regulator of rs -dependent modulation of cxcr promoter activity in b-lymphoblastoid cell lines. this link may be directly related to pathogenic b-cell activities in multiple sclerosis. introduction: parkinson's disease (pd) is the second most common neurodegenerative progressive brain disease with increasing prevalence in aging population. the etiopathogenesis involves many cellular procesess, but is not fully elucidated yet. treatment of pd is based on levodopa and dopamine agonists, but mao-b inhibitors, comt inhibitors, amantadine or anticholinergics may be used as initial monotherapy or as adjuvant therapy. treatment related adverse drug reactions (adrs) are frequent, but cannot be predicted and/or prevented. non-motor adrs, such as nausea, somnolence, hallucinations and hypotension are frequent in dopamine agonist therapy, while dyskinesias along with motor fluctuations are the most common late adrs with levodopa. the aim of our study is to combine clinical data with genetic and epigenetic biomarkers in the algorithm for personalized approach to pd management. materials and methods: we are planning a clinical study to assess the combined impact of selected clinical, genetic and epigenetic factors on the progression of pd, adrs and treatment response. our study will have a retrospective and prospective arm. we will collect peripheral blood samples of pd patients and clinical data. single nucleotide polymorphisms (snps) in the genes involved in dopamine, neurotransmitter and drug metabolism and transport, receptors and signalling pathways will be genotyped. snps within inflammatory, neurodevelopmental, antioxidative defense, synaptic transmission and immune response pathways will also be analysed. in the prospective arm we will isolate the exosomes and check their mirna content at the time of diagnosis and after the treatment initiation. the combined effects of clinical, genetic and epigenetic factors will be analyzed using lasso penalized regression analysis. conclusions: we hope to identify genetic and/or epigenetic biomarkers that may predict progression of pd, adrs and treatment response and may support personalized tratment of pd. most evidence indicates that g protein-coupled receptors form heteromers between them and with other receptors. by allosteric mechanisms, them acquire a multiplicity of unique pharmacological and functional properties. recently, we discovered that dopamine d receptors (d r) and histamine h receptors (h r) form heteromers through which h r ligands can inhibit d r function. d rs also physically interact and modulate ionotropic glutamate nmda receptors (nmdar). in the present work, we investigated if nmdar, d r and h r form a heterotrimeric complex in brain. the heteromer expression was studied in slices from both rat and mouse brain cortex by co-immunoprecipitation (co-ip) and proximity ligation assays (pla). the ability of d r and h r to interact with nmdar in transfected hek cells was analyzed by bioluminescence resonance energy transfer (bret) with bimolecular fluorescence complementation (bifc) experiments. heteromer properties were studied by analyzing erk / phosphorylation and cell death in cortical slices. endogenous d r-h r heteromers were detected in rat and mouse cortical slices, where h r ligands decreased d r signaling (erk / pathway) and were also able to block the cell death induced by overstimulation of either d r or nmdar. by bret experiments in transfected hek cells, we demonstrated that both d r and h r form heteromers with nmdar subunit a in the presence of subunit b. d r-h r-nmdar heteromers were detected by bret with bifc. endogenous d r-h r-nmdar heteromers were observed in rat and mouse cortex by pla. many systems, including the glutamatergic and dopaminergic, are involved in neurodegeneration. our innovative finding is that d r, h r and nmdar form heteromers that may be a point of intervention for cognitive disorders in neurodegeneration. d r-h r-nmdar heteromers are expressed in brain cortex and a complex interaction exists between protomers in the heteromer, where h r ligands act as a 'molecular brake' for d r and nmdar signaling. studies conducted on obesity and hfd (high fat diet) revealed hypothalamus have crucial roles on development of metabolic diseases. after chronic over nutrition or high fat diet, as a neurodegenerative condition, premise inflammation, neural stress and development of functional impairments are observed. these studies generally focused on changes in neurons, but it's effects on brain vessels are still unknown. in this study, as a neuronal damage infrastructure, changes in hypothalamic vascularity investigated. experiment initiated with weeks old total male wistar rats. in order to acquire obese phenotype, the rats were fed either cafeteria diet as hfd, or normal/chow (standard diet, sd) for months. intravenous glucose tolerance tests performed before sacrification. animals were exposed for s to co and then decapitation was performed with guillotine. isolated brains were directly immersed into liquid nitrogen and stored at À °c. the hypothalamic sections were acquired with the cryostat instrument at different. immunofluorescence was performed on serial sections through the hypothalamus using the antibody smi- and cd . changes in tight junction (tj) proteins (occluding and zone occludin- ) are evaluated via western blot (wb) analysis. the hfd-treated consumed significantly more food than did control animals, when examining average food consumption per day and rats that received the hfd diet weighted significantly more at the end of month diet treatment. there were no differences acquired for glucose tolerance tests. however, after hfd treatment, wb analysis have shown that tj proteins decreased even if hypothalamic micro vessel number increased and smi- staining have shown that increased. our primary results have shown that hfd diet can affect hypothalamic vascularity and such changes might initiate neurodegenerations and functional impairments as observed in neuroretinal degeneration in relation to vasculopathy in diabetic patients. defects of mitochondrial trafficking are common problem in many neurodegenerative diseases. its dysregulation can contribute to changes in bioenergetics profile of the cell and can lead to cell death. in our study we investigate distribution of mitochondria and their transport in primary fibroblasts derived from patients with sporadic form of alzheimer's (ad) and parkinson's (pd) diseases. our data revealed that in the most cases the velocity of mitochondrial movement is lower in ad and pd cells in comparison to the control. the most intense differences between ad, pd patients and control group are observed in the case of movement of large mitochondria. owing to the fact that mitochondrial trafficking depends on mitochondrial state, we investigated the 'age' of mitochondria. we observed a diminished mitochondrial turnover in ad and pd fibroblast. evaluation of the mitochondrial distribution within the cell in all groups (ad, pd and control) showed that in the perinuclear area are accumulated 'old' and 'worn out' mitochondria, probably dedicated to remove from the cell. because mitochondrial biogenesis, shape and size depends on fusion/fission proteins we assessed their level within the cell. to summarise, our results revealed alterations in mitochondrial trafficking in fibroblasts derived from patients with alzheimer's and parkinson's diseases in comparison to the healthy control cells. carbonic anhydrases (cas, ec . . . ) is a zinc metalloenzyme that catalyzes the reversible reactions of co and water. carbonic anhydrases (cas, ec . . . ) form a family of metalloenzymes that play an important function in various physiological and pathological processes. therefore, many researchers work in this field in order to design and synthesize new drugs. carbonic anhydrase activators are important as much as inhibitors. caas have polar groups to make hydrogen bond in the main body and the activation property of enzyme increaase in this way. caas are have polar groups to make hydrogen bond in the main body and the activation property increaase in this way. furthermore, recent studies suggest that ca activation may provide a novel therapy for alzheimer's disease. in this study ca activators are determined. human carbonic anhydrase isozymes ca i and ca ii are isolated from human blood erythrocyte. hca-i and hca-ii isoenzymes were purified using sepharose- b-l tyrosine-sulfanilamide affinity colum. finally, hca-i and hca-ii isoenzymes were eluted with appropriate elution buffers. enzyme purity was checked by sds-page. the enzyme activity system contained . m tris-so ph . , r-nitro phenol in ml total volume. effects of some macrocyclic thiacrown ethers derivates were investigated. enzyme activities were measured at constant substrate and different activator concentrations to find ac value. these compounds are thought to be useful for treating alzheimer's disease. introduction: gender differences in stress models are not studied in detail. we compared different stress conditions on brain bdnf levels, in social isolation (sit) and predator scent tests (pst) in rats. bdnf levels in cortex, hippocampus and amygdala were compared, effects of chronic fluoxetine (flu) treatment were evaluated. methods: rats were used. for sit, animals were kept individually for month and for pst, rats were exposed to dirty cat litter for min at the first day of month stress. flu was given ( mg/kg, ip) through stress. controls, stress and treated groups were evaluated in elevated plus maze (epm), anxiety scores were calculated. brain bdnf levels were determined in cortex, hippocampus and amygdala by western blot. p < . were considered significant. results: sit and pst induced anxiety in both male and female rats, females having greater anxiety scores than males (p < . ). flu restored anxiety scores in both sexes (p < . ) in two settings. male and female rats exhibited reduced cortical bdnf levels in sit (p < . ). pst reduced cortical bdnf in females, but increased in males. hippocampal bdnf expression was lowered in sit (p < . ) and pst (p < . ) in both sexes. female rats had % lower bdnf expression than males in amygdala in sit. flu did not restore cortical bdnf in females in both tests, but reduced incresed bdnf levels in males (p < . ). flu did not restore reduced brain bdnf in males in hippocampus and amygdala, but restored in hippocampus, in females. discussion: our findings indicate that sex differences must be considered in studies related to mood disorders of animal models, and suggest that bdnf expression in different brain regions are altered differentially in a gender-dependent manner in rats. antianxiety effect of flu is not mediated through increasing bdnf activity in cortex in both genders. increased bdnf in hippocampus and amygdala may reflect its antidepressant effect in female rats, but not in males. perineuronal nets (pnns) are special forms of neural extracellular matrix found around neuron bodies and neurites. hyaluronan and proteoglycan link protein (hapln ) is one of the major elements of pnns. hapln interacts with tenascins and aggrecan which are other essential pnns components. in most of neurodegenerative disorders caused by neuritogenesis defects, disrupted pnns structure and decreased expression of hapln were observed. however, the role of hapln in neural differentiation is unknown. the aim of this study is to determine mrna and protein levels of hapln during differentiation using pc cell line as a neural differentation model, derived from rat pheochromocytoma. after pc cells were stimulated to differentiate into neurons by nerve growth factor on days , and ; cells were collected, qrt-pcr and western blot were performed. also, in order to find out whether there is a physical interaction between hapln and proteins related to neuritogenesis defects, spinal muscular atrophy (sma) was used as a neurodegenerative disease model. therefore, a detailed hapln and survival motor protein (smn ) network analysis were performed in-silico. as a result, we analyzed fold increase in hapln mrna level compared to undifferentiated state. on the other hand, a decrease in protein level was detected. this decrease in cellular hapln level suggests that, hapln is required for formation of pnns structure, thus secreted to extracellular environment at early stage of differentiation. in addition, according to in-silico analysis, an indirect path between hapln and smn through fibulin (fbln ) was detected. fbln was also found to be an interaction partner between different matrix molecules such as aggrecan and hapln which form a macromolecular meshwork. the results of this study will pave the way for investigating the role of hapln and fbln in neurodegenerative disease models. also it will help us to understand the mechanism of neuritogenesis defects. determination of properties of bone marrow and tissue-derived mesenchymal stromal/stem cell population in neurofibromatosis type patients neurofibromas, complex tumors deriving from schwann cells and containing fibroblasts, vascular structures and mast cells, are part of the clinical picture in nf . the risk of malignancy is increased in nf , wound healing is delayed and keloid formation is frequent. because multiple tissues are involved in malignant and non-malignant manifestations of nf , we considered the mesenchymal stem/stromal cells (msc) carrying the nf mutation might play a role in the microenvironment. mscs affect the biological behaviour of other cells: they alter their proliferation, apoptosis and migration through various secreted growth factors, cytokines, chemokines, or by direct contact. we examined the msc of nf patients. methods: the adipogenic and osteogenic differentiation potential of mscs from nf and healthy subjects was examined in vitro and by rt-pcr. msc's migration potential was measured in the scracth assay. mscs' interaction with schwann cells and their effect on tumorigenesis was examined in co-culture by apoptosis markers on flow cytometry. results: nf -mscs' adipogenic and osteogenic differentiation potential was lower than healthy controls as assessed by staining aizerin red s and oil red o and rt-pcr for osteopontin and collagen . mscs cultured from dermal neurofibroma showed faster closing of the scratch compared to the same patient's normal and caf e au lait skin. on the other hand, mscs obtained from plexiform neurofibroma healed late, while mscs derived from the same patient's caf e au lait skin showed the fastest healing. hepatic encephalopathy with ammonium ions accumulation is accompanied by some disorder in the brain due to toxic material concentration being usually detoxified in the liver. one of the reasons for hyperammoniemia could be some imbalance in brain glutamine metabolisation induced by the key enzymes glutamine transferases (gts), which catalyze the reaction of glutamine transamination resulting in neurotoxic product of a-ketoglutaramate (akgm). akgm is hydrolyzed to a-ketoglutarate and ammonia by x-amidases. in the study, the dynamics of the enzymes activity in the tissues and biological liquids of experimental animals with hepatic dysfunction induced by thioacetamide (taa) was under investigation. white laboratory rats of wistar line (female, weight of g) chronically intoxicated with hepatotrophic toxine of taa. every weeks, some biological samples were collected to assess gt-k and x-amidase activities. x-amidase activity was the highest in the kidney tissue in the control and decreased by % in the experimental group. in the experimental hepatic x-amidase activity decreased by % compared to those in the control. the average x-amidase activity in the blood serum ( . nmols/ mg/min) and in the brain ( . nmols/mg/min) differed faintly. maximal gt-k activities were revealed in the kidneys; in the controls, it was about % higher than those in the experimental animals. the difference between average enzyme activities in the liver of the control and experimental animals reached %. the average gt-k activities in the blood serum and brain of the control and experimental animals were rather similar. the decrease in x-amidase and gt-k activities obtained in the study during hepatic pathology development could testify to imbalance of glutamine metabolism, possibly aimed at declining the level of akgm neurotoxicant under the hepatic dysfunction. acknowledgments: supported by the russian federation ministry of science and education (grant no rfme-fi x ). wilson disease is an autosomal recessive disorder of copper metabolism characterized as neurodegeneration and liver abnormalities. it is caused by defects in the atp b gene. atp b is responsible for the sequestration of cu into secretory vesicles, and this function is exhibited by the orthologous ccc p in the yeast. we aimed to characterize clinically-relevant novel mutations of p.t i, p.v i and p.r g-fsx in yeast lacking the ccc gene. the patients with these mutations have copper storage abnormalities in different parts of their bodies; p.t i mutation mainly affects the liver and the nervous system, p.v i mutation affects the nervous system, and p.r g-fsx mutation causes damages to the liver. to better understand the effects of these mutations on normal functions of atp b, we cloned human atp b gene onto a yeast expression vector and created the same mutations by site directed mutagenesis. then, wild type and mutated forms of atp b genes were transformed into yeast cells lacking the homologous ccc gene for functional comparison. first, we analyzed the expression of atp b and its variants in yeast cells by a real time pcr approach and western blot to make sure that transformed cells express the plasmids. expression of human wild type atp b gene in ccc d mutant yeast restored the growth deficiency and copper transport activity, however, expression of the mutant forms did not restore the copper transport functions and only partially supported the cell growth. our data support that p.t i, p.v i and p.r g-fsx mutations cause functional deficiency in atp b functions and suggest that these residues are important for normal atp b function. in recent years, attempts were made to develop miniaturized potentiometric biosensors which is particularly important to reduce the amount of enzyme and reagents needed. the miniaturization of a biosensor is possible by using an all solid-state polymer membrane ion selective electrode which is cheap, easy to prepare and allow micro-sized construction. the use of all solidstate polymer membrane ion selective electrode as the basic sensing element also has the advantage of providing biosensors that are easy to fabricate, exhibit rapid response and have long life-times. they are also mechanically stable and allow flow-through configuration. genetical and chemical modifications for the alteration of enzyme molecule characteristics are gained considerable importance. enzymes can be modified chemically by using water-soluble polymers or some chemicals. conjugates of natural and synthetic macromolecules with enzymes provides wide usage in medicine and in many fields of biotechnology. in this study, enzyme-polymer conjugates with different molar ratios were synthesized using urease enzyme. in this study micro sized potentiometric urea sensitive biosensor has been developed in which urease-polymer conjugates were immobilized on polymeric membrane ammonium ion selective electrodes whether pvc or derivatized-pvc via glutaraldehyde cross linking reaction. biosensor is not include inner reference electrode and inner reference solution. potentiometric performance of biosensor will be examined with a computer-controlled measurement system designated. the most important features of the obtained micro sized urea biosensor by using enzyme-polymer conjugations were being highly sensitive, having long life-time, easily built at a low cost, and having short response time when compared with conventional potentiometric urea biosensor. also, these biosensors were easily built at micro-construction. this study was supported by grant from the tub _ itak research fund (project number: z ). creative drama technique as a new tool to increase enthusiasm and to achieve learning objective for medical students e. y. sozmen , , e. erem faculty of medicine, ege university, izmir, turkey, center for continuing education, ege university, izmir, turkey, recently drama in education techniques have been implemented successfully in education program of primary and secondary high school and positive effects of these techniques on learning ability and attitude of students have been shown. the aim of this study was to organize an education program based on drama in education techniques in a special module of ege university medical faculty and to test any effect of this technique on achievement of learning objectives and student's perspectives on drama. the special module program was on the oxidative stress and antioxidants. the program covered the drama in education sessions (improvisation, role play, game) linked with learning objectives (understanding of free radical generation and free radical reactions in body, evaluation of the effect of free radical reactions in diseases as well as increase the ability usage of scientific information), laboratory work (antioxidant activity determination) and searching a special scientific topic on literature. students (in rd year of faculty) who had taken theoretical lecture on this subject a year ago, participated in this special module. the opinions of the students on the program were obtained through a questionnaire form and the increase in knowledge was evaluated via pre/posttest. the mean of pretest point was . / , that increased to . / in the posttest evaluation. % of students pointed that they enjoyed participating in drama activities in the pre-questionnaire, this rate was % in the final questionnaire. they all remarked that implementation of drama in education was beneficial for their communication skill, helping them to learn more about science and increased their enthusiasm to learn and discuss the scientific information. although the preparation process might take more time and need to hard work for teachers, we concluded that the drama methods as a new tool to increase of participant's interest might be proposed for students in higher education. laboratory-based performance assessment in medical education: an opportunity for connection between scientists and medical students h. tuncel cerrahpasa medical faculty, istanbul university, istanbul, turkey number of medical students who interested in basic medical sciences is declining and medical sciences literacy is falling, it is crucial to develop ways for students and scientists to connect. students need to know that science is an intensely human endeavor, and scientists need mechanisms to bring that truth to the community at large. based on continued interest and experience on the part of faculty, and on student feedback, the development of a more effective and stimulating interactive learning tool was undertaken. an in-depth knowledge of laboratory medicine principles is vital to all practicing physicians. great variation exists in the ways that medical students learn the principles of laboratory medicine. there are a number of programs for electronic media that emphasize laboratory-related skills. some of these are appropriate for medical students in the clinical years. programs that teach skills in common laboratory procedures, such as interpretation of peripheral blood smears and microscopic examination of urine sediment, have been shown to improve student performance. to ensure that important principles are addressed, medical schools should establish goals and objectives specifically related to laboratory medicine and experiment with optimal teaching and assessment methods. we also hope that this study will inspire dialogue among primary care and specialist physicians as to the proper degree of education in this area. ideally, it will encourage scientific studies that address evidence-based possibilities for improving critical laboratory medicine educational outcomes, that is, the training of physicians who optimally use laboratory diagnostics and therapeutics. engaging medical students in scholarly scientific activities and producing clinically competent and research-oriented medical workforces are essential demands, particularly in developing countries. an experimental special study module for medical undergraduate students: learning western blot analysis and detection of b-actin protein expression in tissue and cell culture samples learning, introduce basic principles of laboratory research and to present the results.b-actin is one of six actin isoforms which is mainly expressed in all eukaryotic cells. western blotting is a widely used laboratory technique to determine specific proteins and to evaluate protein expression in tissues and cells. in our study, different concentrations of rat spleen homogenates ( , , lg/well) and lg protein/well of human lung and ovary cancer cell lysates were used. the proteins were seperated by % sds-page, transferred to pvdf membrane, incubated with specific b-actin antibody and then with hrp-conjugated antibody. protein bands were detected with ecl and densitometric analysis of proteins was quantified by imagej software. differences in protein band intensities were compared using one way anova.a value of p < . was considered statistically significant. we detected b-actin expression in rat spleen homogenates, human lung and ovary cancer cell lysates, as a kd protein. the protein band intensities were in correlation with protein concentrations. the highest concentration resulted in the highest signal intensity in rat spleen homogenates.b-actin level was higher in ovary cancer cells than in lung cancer cells, although both proteins were loaded equally. the feedback showed that students were very satisfied with this laboratory ssm. they developed their independent study skills, planned a research, worked in a laboratory, learned and performed a technique, western blotting. the hands-on experience is very important for medical undergraduate students for their future scientific career. three-dimensional structure of truncated human kv . voltage-gated potassium channel kv . belongs to the ether-ago-go family. it has been proved that its mutants are involved in development of neurological diseases and some types of tumor. directed drug design needs knowledge of details of the threedimensional channel structure. the members of the kv - subfamilies are characterized by extremely long n-and c-terminal intracellular tails, which possess a number of structural domains. the n-terminal pas domain in kv plays an important role in activation, and is thought to alter the rate of deactivation, possibly by binding at or near the s -s linker at the inner mouth of the pore. here we present an improved d structure of the truncated human kv . channel, obtained by single particle em. this channel lacks its cytoplasmic pas domain but it still forms tetrameric particles. earlier we showed that the full length kv . channel is build according to the 'hanging gondola' type, and its cytoplasmic and transmembrane parts are connected by linkers. the cytoplasmic part includes the interconnecting pas and cnbd domains. deletion of the pas domain leads to the conformational change in the cytoplasmic part of the channel. for interpretation of the d structures we used homology modeling and molecular dynamics simulation. there are several templates available to the moment including eag domain-cnbhd complex of the mouse eag channel, full-length shaker potassium channel kv . , c-linker/cnbhd of zelk channels and others. but there are still no templates for many fragments that led to necessity of partial de novo modeling. analysis of molecular trajectory allowed estimating dynamical characteristics of channel, supposing interdomain interactions. results of the conducted investigation have a great interest at both the academic and the industrial levels. the objective of this task program is to enable students to gain scientific attitude and skills for them to be able to deal with the problems they'll confront in future research careers. it's been emphasized in various studies that medical students are keen on conducting scientific research, and it's been stated that they need to be supported in this respect, as they lack the adequate fund of knowledge. this study aims to share information throughout a -year performance of the research training program (rtp) conducted at ege university, faculty of medicine. rtp is an educational program applied in addition/parallel to the bachelor's degrees for establishing scientific thought, attitude, proceeding and knowledge of the willing medical students, and enabling them to adopt study skills. the dynamic program produced by the rtp committee in has been developing each and every year via feedback received from the students. an operating principles, a manual for advisor and an introductory booklet have been laid out. applications are being accepted at the end of first academic year, making announcement to the freshmen in advance. students are being admitted to the program, taking the assessment criterias into consideration. second and third year medical students attend the didactic part of the program during the terms devoted to special study modules. thereafter, they go through the project management phase, and accomplish their projects under supervision of a faculty member until their graduation. first graduates of the program, accomplishing their projects, received their certificates at the graduation ceremony of graduation. currently, there are students in total from all classes who perpetuate their studies within the program. an inventive training pattern of ege university faculty of medicine, rtp experience is being maintained as a dynamic process and successfully keeps the students advised of conducting scientific researches, cultivating scientific awareness. objectives: objectives selection and verification of blood collection tubes is an important preanalytical issue in clinical laboratories. in this study comparison with the reference glass tube of ayset plastic tubes containing separator gel and assessment for routine clinical chemistry laboratory testing in samples were aimed. materials and methods: thirty-four volunteers were included in the study. samples were taken into two different tubes by two experienced technologists according to the clsi protocol [tube : z (becton dickinson and company, franklin lakes, nj, usa); tube : ayset (lot , turkey)]. glucose, urea, creatinine, ast, alt, total-cholesterol, triglycerides and high density lipoprotein-cholesterol were analyzed subsequently (olympus au ) and randomised samples stored at - °c for and h. th hour sample was analyzed immediately after collection and accepted as the reference for the comparison of the other samples. a paired t-test and wilcoxon signed rank sum test were used to test the significance of differences between the reference tube and test tubes. results: the difference between the results of reference tube and test tubes for glukose, urea, creatinine, ast, alt, total cholesterol, tg and hdl-cholesterol at , and h were statistically no significant (p = . , p = . , p = . , p = . , p = . , p = . , p = . , p = . , p = . , p = . , p = . , p = . , p = . , p = . , p = . , p = . , p = . , p = . , p = . , p = . , p = . , p = . , p = . , p = . , respectively). conclusions: no significant difference was observed between ayset tubes' results and the reference tube's results. e. akin c ß akir d€ uzen laboratuvarlar grubu, istanbul, turkey insulin resistance underlies the development of obesity which is a global health problem. obesity is a main concern of scientists because it's associated with type diabetes, hypertension and some cancers. recently, inflammation centered mechanisms are deeply investigated as well as the effects of anti-inflammatory diets which are highly rich in vitamins, minerals, fibers and healthy oils. these diets are proposed to inhibit or supress the secretion of the inflammatory mediators and also improve the intestinal microflora. the aim in this study is to highlight the increasing trend of publications in regard to insulin resistance and inflammation based obesity along with the effects of antiinflammatory diets used for its treatment in the last decade. we performed a pubmed search with key words of 'obesity and insulin resistance and inflammation' ( / / - / / ) (search # ). besides, we performed another search with key words of '(anti-inflammatory diet or dietary supplement) and (obesity or insulin resistance)' (search # ) to highlight the value of anti-inflammatory diets and dietary supplements in combating inflammation based obesity and insulin resistance. search # revealed articles; of these were clinical trials, were observational studies. human studies were while animal studies were . overall, there were review articles and meta-analysis in the field. search # revealed articles of which were clinical trials, were review articles, were meta-analysis. human studies were and other animal studies were . the relationship of metabolic diseases with a low grade inflammatory state has opened a new area of research to understand the consequent causes of inflammation in the human body. the increasing scientific data in the field indicates that antiinflammatory diets may serve as powerful tools to solve the inflammation and the consequent insulin resistance and obesity. medical and biological illustrations for life sciences education: is 'a picture worth a thousand words' in visualizing medicine and science? medical and biological illustrations (mbi) convey complex ideas with just an image and they are powerful intersections of science and art. the clarification of complex pathways via illustrations can be effective means in education as they help the student to visualize the biomolecular world and understand the mechanisms. our aim is to illustrate how a mbi is developed over the example of mechanism of insulin action, via the phosphoinositide (pi) kinase-protein kinase b (akt) pathway. organising one's thoughts and clarifying relationships and then using the optimal complexity level to illustrate the pathway most clearly are the basics of mbi. thus, we made a thorough investigation of insulin mechanism on glucose uptake in skeletal muscle and adipose tissue; a biochemical process that includes insulin receptor (ir), ir substrate, pi kinase, pi-dependent kinase and akt. then, we found the d structures of molecules via protein databanks and accordingly created drawings and diagrams of each component in both molecular and macrolevels by adobe photoshopÒ software. graphics tablets and a compatible pc were also used in the production phase. the use of computer hardware/software enables unlimited detail in images and provides the flexibility that classical drawing techniques can not. thus, the final diagram clarifies the underlying molecular mechanisms of a biochemical pathway along with the physiologic actions. recent improvements of computer technology have resulted in the creation, and reproduction of high-quality lower cost medical art. mbi's can be used in education to explain concepts/pathways to students to enhance learning. similarly, mbi's are great tools to show mechanism/procedures to enhance patients' understanding of their medical condition. considering their unquestionable contribution to education, research and patient care, the creation of mbi's should be promoted as a graduate level course and the discipline should be represented at academic level. biochemistry is a compelling field with broad applications in many disciplines like medicine, dentistry, pharmacy and bioengineering. biochemical research increasingly combines ideas from genetics, molecular biology, etc. and collaborates with many disciplines. our objective is to conduct a scientometric analysis of the last decade's postgraduate theses in the field of biochemistry (ptb) in regard to number, collaborations, subject area distribution, etc. to discover the characteristics and trends in turkey. we searched the turkish higher education council's theses database ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) which includes master of science (msc.), doctorate (ph.d.) and specialization (s) theses in all disciplines. an electronic search with the keyword of 'biochemistry' (in the thesis subject area) was conducted, thus it brought all theses either in the biochemistry discipline or theses in other disciplines but have a biochemistry component. we performed data cleaning and further quantitative analyses in excel. we also executed word count analysis on the titles of theses to derive the main subject areas in ptb. of the total of ptb ( s, msc, phd theses) . % was in natural sciences while . % was in health sciences. the theses output-growth measured by the compund annual growth rate was % over the -years. the top clinical disciplines in collaboration with biochemistry were pediatrics, surgery and cardiology, and the top science disciplines were biotechnology, bioengineering and biology. oxidants-stress and antioxidants ( ), endocrine-metabolism ( ) and enzymology ( ) were the top research areas in ptb, followed by genetics ( ) and cancer ( ). scientometrics is a powerful tool to understand the direction of science and research. our ptb analysis indicated that prominent areas like stem cell, biosensors, geriatrics are somewhat lagging in turkish biochemistry research while postgraduate education and research in total is growing fast with sound collaborations. the st turkish in vitro diagnostic symposium evaluation objective: in vitro diagnostic (ivd) medical laboratory tests and the equipment are closely related the public health, patient safety and the safety of all who utilize these tests. it depends on auditing of the process from the production to the consumption of these materials, that they do not pose a risk to individuals and society. upon these basic requirements; 'turkish in vitro diagnostic symposium: medical laboratory tests' was held in february , organized by the cooperation of turkish biochemical society branch of izmir, and dokuz eylul university health sciences institute. it was intended to shed light on some questions such as, what is the place and importance of ivd in turkey? what are the responsibilities of educational institutions?, what is the role of ministry of health? to put across the conditions of preparing a substructure that may provide achieving success in producing ivd medical devices and in this sector, in our country. material-method: invited speakers attended the symposium, along with the participation of both as lecturers and attendees; ministry of health, turkish standards institution; representatives of manufacturer enterprises; representatives of enterprises manufacturing in turkey; scientists conducting considerable researches on health technology; students and representatives from some of the non-governmental organizations. in addition to the presentations, gathering up the written opinions of the participants, a report was prepared. results: the symposium that lasted for days was realized with participants in total, of which from universities; representatives of their companies; from chamber-institute-public establishments and of which from public hospitals. of the participants were from izmir, of them were coming from out of izmir. conclusion: at the end of the symposium, % of the participants gave feedback. among the feedback selected; . % of the participants evaluated the symposium overall, as successful. . % of them found the symposium successful with regard to its scientific content. their feedback were . % positive in terms of the symposium's contribution to the situation assessment on ivd in turkey, and . % of them stated they would consider participating in the second of the ivd symposium if it is to be organized. perceptions of molecular life science master's students on their scientific and academic competencies and prospective plans for professional development the master's education (me) in molecular life sciences (mls) is aimed at strengthening the knowledge and skills base of the young scientist, preparing him for the competitive academia/industry positions. the rapidly developing pace of science and research forces the master's student (ms) to play a central role in monitoring and guiding his scientific education and professional development (pd). thus, the aim of our study was to examine the perceptions of ms of mls, regarding their scientific and academic competencies. with this data, we planned to analyse if this awareness channels ms to take action and/or matches with their prospective plans. we developed a item online survey with sections (demographic data, current data-contributions of me, competencies and prospective data-action for pd, future plans) and distributed it via e-mail to various postgraduate institutes. at the end of the -day period, ms students (in the thesis phase) answered the questionnaire (female: . %, male: . %). the most highly rated activities that contributed to their scientific knowledge and skills gained in the me were laboratory work ( %), visits with their mentors ( %) and theoretical lessons ( %). ms expressed low levels of sufficiency both in theoretical scientific knowledge and laboratory skills (only % and % sufficiency, respectively). communication skills ( %) and team work ( %) were rated as the highest professional competencies followed by literature search and research planning (both %). it was striking that ms perceived themselves as quite insufficient in scientific writing ( %), data analysis ( %) and project writing ( %) while proficiency in english ( %) was the first area they wanted to take action. despite their perceptions of insufficiencies in many areas, a majority ( %) wanted to continue to phd education. these and similar surveys may lead to an increase in selfawareness in ms and the data may contribute to the revision of me. the report of the st turkey in vitro diagnostic symposium results the following aspects and suggestions took place in the results report prepared after the symposium: about the national ivd-tc r&d, production, forming quality assurance and innovation strategy and policy the cooperation of the university and the industry is not sufficient most of the industrialists cannot take enough advantage of the support provided by the institutions like tubitak, the ministry of science, technology and industry and the ministry of development the statistics on the ivd-tc in turkey should be carried out as soon as possible national standards should be determined in parallel with the international standards the vat rate of the exported raw materials that would be used in ivd production should be decreased. about the education and training, the job titles and positions the related graduate programs, which would focus on all steps of the whole life cycle related to the ivd-tcs one by one, are not widespread there is no 'postdoc' application in turkey. 'postdoc' staff is needed for insufficient component human resources the lecturers should not be restricted to one discipline only graduate programs on laboratory medicine are needed to be established and spread, in order to train component labor specified on the ivd-tc about research and development there are almost no researches related to product development. this should be associated with the education and training institutions about the research centers currently, there is a real infrastructure on health technology in turkey, but there are difficulties in its instituonalism the insufficient cooperation of the university and the industry does not allow the inventions to turn into products the cooperation supports of r&d, being restricted to tech-nopark and r&d centers, are open fields for improvement p-edu- phd training in medical education: career profiles and satisfaction levels of graduates from dokuz eylul university graduate school of health sciences this survey was carried out within the scope of special study modules that is entitled 'phd training in medical sciences' by a group of medical students in deu. the purpose of the survey to investigate the members of health sciences that have successfully completed their phd training in terms of the levels of satisfaction and the status of their career. from this scope we generated two hypothesis: we expected that graduate phd graduates are mostly involved in academy and find their satisfaction levels at moderate level as to phd education. the study was designed as cross-sectional. we reached phd graduates who had graduated from deu graduate school of health sciences between and from different departments via e-mail. the survey was included questions, which were prepared in the light of the existing literature. among the phd graduates, ( %) participated in the study. through this survey, perception of phd students on supervisors' scientific and educational abilities, opinions on phd training, productivity of phd training, number of articles published, their position and related satisfaction levels after graduation were investigated. according to the results, more than half of the graduates (% . ) are well satisficed from the education they had taken. beside this, interestingly we found that % . of graduates prefers staying in the academic positions and % . of them sustains their communication with their supervisors. in conclusion, most of phd graduates were contented with phd training and their career profiles. as a result of this survey, we produced a novel and precise contribution to the literature. in a further study, this survey may extend to other parts of turkey and compile the results in order to get more accurate and inclusive data. phd is an international degree that is reached by conducting an original research after finishing bachelor or master's degree. doctoral degree (phd) can open the door of academic career; on the other hand, a person with a doctoral degree is equipped to carry out important work in research, industry, or public sector. today, gradually increasing number of phd students have brought some problems in phd training. the purpose of this study is to investigate and review activities that have been done by the following international organizations: orpheus: (organization for phd education in biomedicine and health sciences) eua-cde: european university association-council on doctoral education. febs education committee: federation of european biochemical societies these three organizations have done workshops on phd training to pay attention to the following points: *a phd student must take some courses and trainings outside her/his institute, should not be limited to the institute. *the phd training programme should include transferable skills courses. *clinicians, if involved in phd training, should be given free time from their clinic duties. *with regards to potential problems with the supervisor, the institute should provide the student an advisory system. *students should be encouraged to participate in the management of doctoral programmes in the institute. *the students should be given be opportunity to select their own supervisor (thus their thesis area). the phd training has gained quality thanks to these organizations. it is advised that graduate school of health sciences should follow the recommendations and report from these organizations. itsn and itsn are genes encoded adaptor proteins with multiple isoforms participating in clathrin-mediated endocytosis (cme), mapk signaling and reorganization of actin cytoskeleton. changes in itsns expression can lead to different neurodegenerative disorders and cancers. to date little is known about regulation of itsn genes on posttranscriptional level. the aim of our work was to predict and experimentally confirm target sites for micrornas that could potentially regulate itsns expression. using web servers we analyzed utrs of short and long isoforms of human itsn mrnas and found conservative target sites for mir- , mir- , mir- , mir- / , mir- , mir- and mir- in utr of itsn -s, predicted by servers, mir- predicted by servers for itsn -l, and mir- , mir- / , mir- , mir- and mir- predicted by - servers for itsn -l. to elucidate potential impact on cme, mapk signaling and actin cytoskeleton regulation by these mirnas we performed enrichment analysis by diana-mirpath server and found that mir- , mir- , mir- / , mir- , mir- and mir- were highly enriched for all analyzed pathways. using regrna . and scan for motifs services we predicted types of different regulatory elements in utr of itsn and itsn : k-box and brd-box, musashi binding element for rbps musashi and musashi , gu-rich element (gre) and au-rich elements (are) that regulate mrna decay. to confirm itsn -s regulation by micrornas we cloned utr of itsn -s into luciferase reporter vector and transfect hek cells by this construction and mir- a, mir- a and mir- a. for mir- transfected cells, we found - % decrease of expression of itsn -s utr-bearing construction. for other mirs we did not obtain strong reproducible effect in luciferase assay. these data may confirm mir- target site in utr of itsn -s mrna but needed additional research. objective: stroke is an acute neurological disorder that is mostly caused by ischemia in central neural system. % of stroked patients lose their life in year, and remaining / of the living patients continue to their lives as dependent to others. nihss and mrs are two scales which are used in prognosis studies because they can show stroke intensity and after stroke functional recovery. microrna's which have effects on transcription and posttranscription gene regulations are small rna molecules. their roles have been investigated on pathophysiology and treatment of diseases. in this study, it was aimed to detect changes in blood serum levels of mir- a, - , - , b, - , , - a and let- f of ischemic stroke patients and to investigate role in predicting prognosis methods: patients diagnosed by acute ischemic stroke admitted to neurology service of g€ oztepe hospital and healthy individual were included in the study. after stroke patients' blood samples were taken periodically in st day, st week, and rd month, and at the same time nihss and mrs scores were determined. set mirna blood serum levels were measured by rt pcr results: when compared to the control group, we found that after stroke st day peripheric blood levels of mir- a,- ,- a and let- f were significantly low; when st week and st day serum records were compared there was a significant increase in mir- level; and when st week and rd month records were compared we noted that there was a significant increase in mir- a,- and let- f levels. from prognosis point of view; after ischemic stroke measurements showed that mir- b in the st day, mir- a and mir- in the st week showed positive significant correlation with rd month mrs scores (p = . , p = . , p = . , respectively) conclusion: according to the outcomes of this study, after stroke st day mir- b, st week mir- a and st week mir- levels can be stipulated to use in predicting patients' rd month prognosis p- . . - inhibitory rna aptamer against lambda ci repressor showed the transcriptional activator activity s. ohuchi, b. suess tu darmstadt, darmstadt, germany because of the variety of functionalities on gene regulation and the easiness of molecular engineering, functional rnas are promising parts for the construction of genetic circuits. artificial affinity rna, or rna aptamer, is one of such genetic parts. in the previous study, an inhibitory rna aptamer against a repressor protein, tetr, was developed as a transcriptional activator [ ] . the expression of this aptamer abolishes the repressor activity of tetr, resulting in the elevated gene expression under the control of tetr. because of simplicity of the mechanism, similar transcriptional activators can be generated by using rna aptamers against other repressor proteins. here, we examined the generation of an activator based on an rna aptamer against one of the most frequently applied repressor proteins, lambda phage ci. in vitro selection (selex) was performed targeting a recombinant ci protein employing an rna pool containing -nucleotides of a random region. after rounds of selex, the pool rna showed the affinity, as well as the inhibitory activity, against ci in vitro. then, rna aptamers with the transcriptional activator activity were screened from the enriched pool in vivo employing a reporter plasmid on which the expression of a reporter gene, lacz, is repressed by ci. when the variants of the rna pool were transformed to e. coli cells harboring the reporter plasmid, about half of the transformants showed the elevated reporter expression. interestingly, all of these desired rna clones shared the same sequence. quantitative analysis indicated that -fold induction of the reporter expression was achieved upon the aptamer expression. our results suggested that diversity of artificial transcriptional activators can be extended by employing rna aptamers against repressor proteins to broaden parts for the construction of genetic circuits. [ ] hunsicker, et al. ( ) an rna aptamer that induces transcription. chem. biol., : - . p- . . - microrna expression signatures between non-atherosclerotic plaque and atherosclerotic plaque in cad with humans, and parallels whole blood rnas and represent a new important class of gene regulators. the present study was designed (i) to investigate the mirna expression profile in human atherosclerotic plaques from peripheral arteries aorta as compared to non-atherosclerotic left internal mamary artery (lima); (ii) to examine the expression levels of mirna in whole with correlation mirnas of aorta tissue. material and methods: thirty-one patients with cad were enrolled in study. lima and aorta tissue samples were obtained during coronary artery bypass surgery. whole blood samples were collected before cabg surgery. each patient with cad was obtained from whole blood, aorta and limas tissues. these tissue samples were immediately soaked in rnalater solution and homogenized using a magnalyser. the rna was extracted using the trizol reagent and the mirneasyÒ mini-kit. the expression profiles of mirnas were evaluated using highthroughput qrt-pcr. results: we found that mir- - p was expressed only in aorta. mir- - p and were expressed both aorta and whole blood. mirnas were significantly up-regulated in aorta when compared to lima tissue (fc > ). mirnas were significantly down-regulated in aorta compared to lima. conclusion: in conclusion, our study suggests that mir- - p, mir- - p and might be a potential for cardiovascular disease development. also mir- - p and might serve as novel non-invasive biomarkers for cad p- . . - mir b regulates cell proliferation and colony formation in pancreatic ductal adenocarcinoma n. gurbuz, e. isildar due to the strong metastatic potential, pancreatic cancer has the highest mortality rate of all major cancers. therefore, the investigators are in urgent need of developing the new alternative therapeutic approaches for the prevention of pancreatic cancer. mirnas, small noncoding rnas, regulates as an inducer or inhibitor in expression of key mediators related molecular mechanisms in cancer promotion. to investigate the effect of mir b on pancreatic ductal adenocarcinoma cells, we performed the cell viability and clonogenic assays by mts and crystal violet dye, respectively, in panc- and miapaca- cells transfected with mir b mimic. our data revealed that mir b led to decrease the cell viability depending on enhanced mir b doses, which are , , and nm, as the ratio of % , , and , respectively, in miapaca- cells and as the ratio of % , , and , respectively, in panc- cells compared with control condition of each cell. this inhibition mediated by mir b was also obtained in colony formation both of pancreatic cancer cells. when the induced effect of mir b on the death of pancreatic cancer cells was compared with gemcitabine, which is currently used as a clinical drug for pancreatic cancer patients, we determined that mir b was more effective than gemcitabine. based on our findings, it is clearly shown that mir b serves as a tumor suppressor in pancreatic ductal adenocarcinoma cells. we strongly believed that mir b gene therapy might be more effective and targeted approach than classical gemcitabine therapy for pancreatic cancer patients. *this work was supported by tubitak (the scientific and technological research council of turkey) grant s . breast cancer is the most common cause of cancer death in women. trastuzumab is a therapeutic agent frequently used against her + breast cancers, which has role in approximately % of invasive breast cancers. with the discovery of their activity in cancerogenesis, micrornas (mirnas) have become potential candidates to mediate therapeutic actions by targeting genes that are effective in drug response. recent studies have showed that mirnas are induced by targeted therapies. in this study, we aim to find out mirna-mediated mechanism, which is driven by common trastuzumab responsive micro-rnas in her + breast cancer. for this purpose, the common trastuzumab responsive mirnas were determined in treated bt and skbr cells by microarray profiling. two datasets were intersected to find out common mirnas for both cell lines. the overlapping predicted targets of common mirnas were provided by two different mirna-target prediction databases and then a mirna-gene network was built in cytoscape by using networkanalyzer plugin. the most shared target genes were chosen to be analyzed in the ebi-embl gene expression atlas for their expression patterns in breast cancer. common mirnas were found to have overlapped targets in two target prediction algorithms that were used to build the mirna-gene regulatory network. overlapped targets were determined as the most shared genes in the mirna-gene network. expression pattern of each shared gene in the gene expression atlas showed that out of the most shared target genes were strongly dysregulated in several breast cancer types. our results suggest that mirnas might show a common response to the targeted therapies and network analysis can be profitable to have a better explanation of the regulatory mechanisms between drug responsive mirnas and their target genes. revealing the mirna-potential target interactions might provide novel key players that mediate the mechanisms of action in drug treatment. chronic myeloid leukemia (cml) is a clonal disease of primitive pluripotent stem cells that identified with a specific t( ; ) reciprocal translocation that encoding bcr-abl oncoprotein. resveratrol (res) is a natural phytoalexin found in grapes and induces apoptosis, erythroid differentiation and autophagy in leukemic cells. micrornas are small, single strand, non-coding rna molecules that regulate post-transcriptional gene expression via disrupting the stabilization of target transcripts or inhibiting protein translation. in our study we aimed to determine cytotoxic effect of res in k human cml cell line and to evaluate the expressions of mirnas that are associated with genetics of leukemia after treatment with res; to investigate target genes of mirnas which show significant expression alterations and molecular mechanisms of res treatment. k cells were treated with lm (ic dose) res during h and cytotoxicity was evaluated by using wst- assay. the rt-qpcr is used for mirna and gene expression analysis. results showed that; res up-regulated tumor suppressor mir- - p level . fold and significantly downregulated hdac gene expression (p = . ) and upregulated p / sqsmt gene expression (p = . ), according to the control cells.p /sqstm interacts with lc and plays role as a critical player in the autophagic degradation of the bcr-abl fusion protein. our findings showed that resveratrol acts as a hdac inhibitor targeting hdac and p /sqsmt gene expression level. treatment with hdac inhibitors results apoptosis, cellcycle arrest, cell differentiation, anti-angiogenesis and autophagy. downregulation of hdac provides post-translational modification for expression of tumor supressor genes and leads to cell cycle arrest and increases apoptosis. these results could be linked to hdac dependent induction of gene associated with autophagy like p /sqsmt and resveratrol could be a therapeutic candidate as a hdac inhibitor for cml treatment. the mirna used in this study are hsa-mir- , hsa-let- a, hsa-mir- b and hsa-mir- . thereafter, we bought pre-mirnas and their mirnas commercially. we apply them to the a cell line in different combination and different concentrations. these mirnas applied solely onto cells or in combination as; four of them, let + , let + b, let + , + b, + , + let + b, + let + b. the cell viability was detected by wst- kit in a well plate elisa reader. cells were seeded as per well, mirnas incubated with cells for h in an appropriate atmosphere. according to our results some combinations and mirnas didn't alter viability, however + b and + combination increased the cell viability dramatically. on the other hand let + b and only applications decreased the cell viability. the other applications' viability results are not different from the control cells significantly. in this study, we used a cell line also called non-small lung cancer (nsclc) cell line and possibly effective mirnas on lung cancer. it is important to exhibit the mirna combinations should be effective on cancer cells' viability. the prospect combinations were determined which is crucial to develop new strategies for cancer treatment. competing endogenous rnas (cernas) act as molecular sponges for the same pool of micrornas through their mirna response elements (mre), titrate mirna levels and thereby regulate gene expression post-transcriptionally. smad interacting protein (sip ), a member of the zeb family is a regulator of epithelial-to-mesenchymal transition (emt) program, which is active during embryogenesis and tumor invasion and metastasis. hence, we investigated the regulation of sip by cernas in hepatocellular carcinoma (hcc) cells. among hundreds of sip cernas listed at competive endogenous mrna database (cerdb), transcripts (pten, zeb , ptch , creb , acvr b, enah, robo , erbb , e f , foxo , rictor, klf , ets , cdk ) sharing at least common mre sites with sip were selected and their expression in hcc cell lines were determined by qrt-pcr. ets was found to be highly correlated with sip in hcc. furthermore, repressing sip expression by shrna in hcc cells resulted in decreased expression of ets , pten and zeb . our results suggest a possible bidirectional and post-transcriptional regulation of sip and its cer-nas in hcc. a meta-analysis for the identification of common microrna signatures in colorectal cancer n. sahar , , n. belder, h. ozdag biotechnology institute, ankara university, ankara, turkey, comsats institute of information technology, islamabad, pakistan colorectal carcinogenesis (crc) has quite frequent incidence and mortality rates worldwide, despite being studied for decades now. new biomarkers are needed to be identified in addition to the existing ones, due to heterogeneous nature of this disease. the regulatory molecular machinery of a cell, including micrornas (mirnas), contributes to this heterogeneity upon aberrant expression. herein, for a mechanistic understanding of differential gene expression in crc tissue we analyzed mirna expression profiles of crc tumors against normal colorectal mucosa samples, using raw data from e-mtab- and e-geod- (affymetrix microarrays), and gse and e-mtab- (agilent microarrays) datasets obtained from gene expression omnibus and arrayexpress. raw samples were normalized (different platforms separately) using quartile normalization in brb-array-tools. differential expression of mirnas was identified using cut-off values of p ≤ . , fold change ≥ . and stringent false discovery rates. mirtarbase and mirwalk . databases were explored to identify validated targets. we found thirty (including mir- and mir- ) and thirteen (mir- , mir- , mir- , etc.) mirnas commonly upregulated and downregulated respectively, in both affymetrix and agilent microarray results. predicted targets of these mirnas frequently belong to pathways related to cancer like b-catenin, phosphoinositol- kinase, and transforming growth factor-b, to name few. moreover, the target genes were significantly enriched in clusters related to cell cycle, cell differentiation and regulation of apoptosis. these promising results will further be compared with differentially expressed gene profiles from a cohort of turkish crc patients. hence the integrated study will refine the panel of diagnostic and prognostic crc markers. hsa-mir-x modulates motility and invasion in triple breast cancer cell line s. noyan , h. g€ urdal , b. g€ ur dedeoglu biotechnology institute, ankara university, ankara, turkey, department of pharmacology, ankara university, ankara, turkey breast cancer is a heterogeneous disease and expression levels of certain receptors have demonstrated subtypes which characterize clinically distinct breast tumors. a triple-negative phenotype lacks expression of er, her and pr and is known as basallike carcinoma. micrornas are a class of small non-coding rnas that participate in the gene expression in many biological processes. e-cadherin is an important mediator of adhesion in epithelial tissues, and loss of e-cadherin can play a critical role in tumor invasive behavior. another key player of cell integrity pip ( , , ) triphosphate is generated at the leading edge of the cell and leads to cell polarization. pip is generated by hydrolysis of pip ( , ) bisphosphate, which is synthesized by pip k . any dysregulation in these molecules may support the invasive behavior of the cells. the aim of this study is to find out the role of mirna precursor (hsa-mir-x) in invasion and motility in triple negative breast cancer cells. in this study a triple-negative breast cancer cell line bt- was transfected with hsa-mir-x or scrambled control sirna. to check its role in motility and invasion, wound healing and invasion assays were performed respectively. cell invasion was monitored over a period of h by xcelligence real-time cell analyzer using a double-plate and measuring impedance-based signals. additionally emt markers were analyzed by qrt-pcr to explain the molecular mechanisms beneath motility and invasion. we observed that cell motility and cell invasion diminished after transfection of bt- cells with mimic for hsa-mir-x. furthermore, qrt-pcr experiments indicated that transfection of hsa-mir-x decreased the expression level of pip k c while increasing the e-cadherin expression level. wound healing and invasion assays together with qrt-pcr results support the role of hsa-mir-x in cell motility and invasion. this process might be explained via e-cadherin mediated met or gsk- -beta related inhibition of invasion. expression level of five micrornas as diagnostic markers in glioblastoma situated in the main brain lobes, but can also be found in other brain regions. while microrna (mirna) as non-coding rnas, play a crucial function in the post-transcriptional regulation of gene expression by mrna degradation or translational repression. in the present study, we aimed to investigate the contribution of gene expression of the five mirnas and to unravel their role in brain tumor cell lines, the mirnas to the risk of gbm tumor. the five gbm cell lines (crl- , crl- , crl- , crl- and htb- ) were evaluated with non-malignant (normal) brain cell line (hcn- ) . determinations of expression level of five mirnas (mir- , mir- , mir- , mir- , and mir- ) were evaluated by monitoring quantitative rt-pcr (qrt-pcr) technique. the expression levels of four mirnas (mir- , mir- , mir- , and mir- ) were significantly decreased while the expression level of mir- was increased in gbm cell lines according to hcn- cell line. consequently, these five mirnas can potentially be used as biomarkers for gbm tumor; further studies are mandatory to a better understand and confirm our preliminary findings. background: noncoding rna are known to be crucial molecules with diverse regulatory roles in neural oncology and neurodegenerative disease. the recent study suggested that lncrna anril play role in the development of neuroblastoma and alzheimer disease via binding disease-specific micrornas. material and methods: we used lncrnadisease, hmdd v . , mir disease to predict lncrna-and mir-associated disease in our study. in addition, we utilize tardetscan to search lncrna-mirna interaction. results: disruptions of lncrna anril expression (also named as cdkn b-as, locus cdkn a/b (ink /arf), chromosome p ) have been associated with the development of neuroblastoma and alzheimer disease. here, we predicted interactions between noncoding transcripts encoded by locus cdkn a/b and their molecular partners -microrna. anril can act as decoy while containing sequences that mimic mirna target sites to titer these mirs away from their primary targets thereby act as molecular sponge. using targetscan . , we predicted target sites for hsa-mir- -p/ -p/ -p/ -p/ -p/ -p and hsa-mir- - p/ in anril utr. then, we used hmdd v . and mir disease databases to define if any of these mirs participate in alzheimer disease and neuroblastoma. according to both databases, mir- is implicated to alzheimer disease and mir- to neuroblastoma. as soon as anril participate in the development of both abovementioned disorders and can have microrna sponge activity, it could potentially positively regulate mir- and mir- targets by competing with them for micro-rna binding sites thus restoring the expression of target genes. in our further research we plan to experimentally validate predicted microrna sites in anril utr. conclusions: we predicted sites for mir- and mir- in utr of anril lncrna that could uncover its possible sponge activity in the development of neuroblastoma and alzheimer disease. aim: matrine excracted from saphora flavescens root and demonsrated that indicates pro-apoptotic and anti-proliferative effect in many types of cancer. acute lymphoblastic leukemia (all) is an acute form of leukemia, or cancer of the white blood cells which characterized by the overproduction and accumulation of lymphoblasts. mirnas play important roles in deregulated cell death mechanisms. we aimed to investigate the effects of critical mirnas during the development of matrine resistance on all cell line ccrf-cem. material-method: ccrf-cem cells were treated with different ( . - mg/ml) concentrations for h and cell viability measurements were carried out with xcelligence device to determine the cytotoxic effects of matrine. mirnas were extracted from treated and untreated ccrf-cem cells using the mirna isolation kit. cdna was synthesised using allin-one first strand cdna synthesis kit. expressions of selected mirnas were analysed with miprofiletm custom mirna qpcr array using the applied biosystem fast real-time pcr system. results: according to the cytotoxicity assay, it was determined that 'treatment with increasing concentrations of matrine, decreased the viability of the ccrf-cem cell line. expression levels of different mirnas were studied for indicated passages in two replicates. our results showed that hsa-mir- b- p (- , fold, p = . ), hsamir- - p (- , fold, p = . ), hsa-mir- a- p (- , fold p = . ), hsa-mir- a- p (- , fold, p = . ), hsa-mir- - p (- , fold, p = . ), hsamir- b- p (- , fold, p = . ), hsa-mir- b- p (- , fold, p = . ), hsamir- b- p (- , fold, p = . ), hsa-mir- - p (- , fold, p = . ), hsamir- a- p (- , fold, p = . ) expression were decreased during the development of matrine resistance. conclusion: these data suggested that especially hsa-mir- b- p plays a critical role in the matrine response. ericd (e f -regulated inhibitor of cell death) is a newly found lncrna. it is located at q . . it has two exons and its transcript size is bp. ericd is regulated by e f (transcription factor ) and modulates the cellular response to dna damage. arid a is a family member of the at rich interaction domain (arid) dna-binding proteins that participate in diverse biological processes like development, cell cycle control, chromatin remodeling and epigenetic regulation. both, ericd and arid a have just opposite roles in apoptosis in case of dna damage indicating a probability of reciprocal interaction between each other. till now, there is no work related to the interaction between lncrna and arid a in cancers. herein we try to find a probable interactive role between these in cancers. in this study, different cancer cell lines, osteoblast cell line and different types of normal human tissues rnas were selected for expression analysis of ericd and arid a. after rna isolation, cdna was converted from their rnas. expression profile analysis of ericd and arid a in different cancer cell lines and normal tissues was done using imagej program for semiquantitative and (-ddct) method for quantitative rt-pcr. among used cancer cell lines, ericd was highly expressed and arid a had lower expression in u- os (osteosarcoma), a- (glioblastoma) and a (lung cancer). at the same time, ericd expression was lower and arid a had high expression in hfob . (osteoblast cell line) and normal tissues like brain and lung . both ericd and arid a are cell cycle regulated and are commonly regulated by e f. they have just opposite roles in apoptosis during dna damage. these two genes have a probability of reciprocal interaction between each other in cancer. our results indicate that both ericd and arid a might have opposite roles in lung cancer, glioblastoma and osteosarcoma. ericd and arid a might act as cancer promoting and tumor suppressor genes respectively in these cancers. the importance of mirna expressions in infertilty implantation process is controlled with endometrium, factors secreted by the embryos and in accordance with these factors embryo and/or endometrium via receptors on. more than human microrna (mirnas) that are small noncoding rnas were shown to play an important role in intracelluler cycle regulation in both normal and pathological conditions. in this study we aim to identify mirnas and controlling molecules expressions in different time period of endometrium in fertile and infertile cases. the endometrial samples were taken from fertile and infertile patients in proliferation and early secretion periods. the samples are fixed and stained either with hematoxylen-eosin for morphological analysis or with immunohistochemistry for distributions of anti-dicer, anti-drosha, anti-eif a and anti-eif c. mir- - p, mir- a, mir- b, mir- - p, mir- , mir- a*, mir- , mir- a, mir- a, mir- b, mir- a/b/c were analyzed with qrt-pcr. while dicer immunoreactivity was detected weakly only proliferation phase of fertile group, this immunoreactivity were detected strongly in both proliferation and early secretory phases of infertile group. drosha immunoreactivitiy was also weakly detected in the proliferation phase of fertile group, it was moderately detected in both proliferation and early secretory phases of infertile group. eif a immunoreactivitiy was similar in each groups but there were a few differences between fertile and infertile group. eif c immunoreactivitiy was negative in all groups. mir- , mir- a* and mir- a were highly expressed in proliferation phase of fertile group, mir- a and mir- b were highly expressed in early secretion phase of infertile group. in conclusion, dicer and drosha immunoreactivities and different expression of mirna's were detected in all groups. implantation problems may be reason for different mirna expression which controlling with dicer and drosha in the infertile endometrium in both proliferation and early secretory phases. wheat is an important agricultural crop with an over . million metric tons harvesting capacity annually. drought and salinity are environmental stress factors that affect yield and quality of wheat, dramatically. there are different defense mechanisms against these stress conditions in plants. altering gene expression profiles by micrornas at post-transcriptional level is one of the most conserved mechanisms among plants. micrornas are an extensive class of noncoding rnas, approximately nucleotide length which regulates the expression of genes by binding to the -untranslated regions of specific mrnas. micrornas implicated under salt and drought stress have widely been reported in numerous plant species and wheat genomes in the last years; however, studies on einkorn wheat (triticum monococcum spp. monococcum) are not yet available. the goal of this study is identification of conserved micrornas from einkorn wheat using next generation sequencing technology and bioinformatic analysis. in this study, small rna molecules were extracted from pooled plant samples grown under normal, drought and salinity conditions. sequencing analysis revealed unique small rna sequences obtained from raw reads. after bioinformatic analysis based on comparative genomics approaches, we identified putative mature microrna sequences belonging to distinct microrna families. since chromosomal sequence data is not available for triticum monococcum spp. monococcum, we used available sequences from triticum urartu, a close relative, as template to extract precursor microrna sequences. of precursor sequences showing % homology to triticum urartu genome were analyzed for secondary structure prediction using mfold software. data provided in this study is critical to investigate transcriptional regulation of genes involved in stress metabolism in einkorn wheat. the role of vim-as , a natural antisense transcript, in cancer coding or non-coding transcript. in this regard, vim-as is nats located antisense to vimentin gene. in the present study, we aimed to determine tissue and cell line distribution of vim-as . materials and method: for the tissue expressions analysis, human total rna master panel ii (containing different human tissue samples) was used. total number cancer cell lines and normal cell lines included in the study. for the expression analysis rt-pcr and qpcr methods were used. results: as a result, expression levels of vim-as were found to be tissue specific. particularly, while vim-as was highly expressed in lung and thyroid gland tissues, its expression was not observed brain, stomach and adrenal gland tissues. also, vim-as was also found to be differentially expressed in cancer cell lines. vim-as expression was found to be lost in cal , pc , and hct and highly diminished a cancer cells. also, it is found to be highly expressed in bcpap, panc and beas b cells. discussion: results of the current study suggest that vim-as may have significant role in the regulation of vim gene in thyroid gland tissues, as it is highly expressed in both thyroid gland tissues and bcpap thyroid cancer cells. moreover, vim-as and vim axis can be involved in the formation of lung tumors because vim-as was highly expressed in normal lung tissues and beas b cells and expressed very low levels in a lung cancer cells. lung cancer is the leading cause of cancer related deaths in the world and approximately % patients with lung cancer ultimately die from metastatic disease. metastasis is the most dangerous step of cancer. in our recently published work showed that akt/nf-kb pathway is continuously active and induces cellular invasion and pten suppresses cellular invasion via inhibition of akt/nf-kb pathway. in this study we aimed to show nf-kb mediated induction of mirna expression can responsible for inducing nsclc invasion. we used chromatin immunoprecipitation (chip) assay kit for detection of tnf-a induced nf-kb mediated mirnas. therefore, h and pc cells treated by tnf-a ( ng/ml) for chip assay. chromatin regions, reading with chip-seq, were analyzed using bioinformatics tools. we also performed additional bioinformatics search to find nf-kb related mirnas which potentially take a role in nsclc invasion. we investigated the effects of mirna which determined at the bioinformatics analysis results on invasion using invasion chamber method. we found mirnas which potentially induced by nf-kb and related with nsclc invasion. our invasion results indicate that mir- a- p, mir- as- p, mir- , mir- , mir- - p, mir- q mimics can induce cellular invasion on h , mir- v, mir- h- p, mir- - p, mir- a- p, mir- as- p, mir- mimics can induce cellular invasion on pc . we also verified our results by qrt-pcr, because we want to sure that mirnas which can induce invasion, can also transcriptionally regulated by nf-kb or not. we found that mir- q, mir- a- p, mir- as- p, mir- , mir- in h , mir- - p, mir- a- p, mir- as- p, mir- in pc can induce cellular invasion by nf-kb. as a conclusion, our investigation indicate that nf-kb can induce nsclc invasion via mir- a- p, mir- as- p and mir- . (this study is supported by tub _ itak grand number s ). to understand of the molecular mechanisms of cellular invasion is very important for fight against cancer mechanisms and first step of invasion is emt. cells change phenotypical and genotypical in emt progress. in this study, we focussed on the explore molecular mechanism of tnf-alpha induced cellular invasion of nsclc. we use western blot, qrt pcr and mirna transfect methods for this purpose. we find that tnf-alfa treatment reduce the expression of pten and induce e cadherin expression in a cells. when we inhibit nf-kb activity by p targeted sirna tnf-alpha can not reduce pten expression means that tnf-alpha inhibits pten expression through on nf-kb. because tnf/nf-kb pathway change the transcriptional level of mir- as and pten untranslated region has recognition site for mir- as. therefore; we transfected a cells by mir- as. mir- as transfection leads to inhibition of pten expression. our results indicate that tnf-alpha mediated activation of nf-kb can inhibit pten expression on induction of emt through on mir- as. (this study is supported by tubitak grand nummber s ). introduction: the corpus luteum (cl) is an ephemeral tissue whose regulated secretion of progesterone is essential for maintenance and/or timely termination of pregnancy in rodents. our previous finding that cl of pregnant rats does not possess fas/ fasl system suggests that this tissue may undergo autophagic, but not apoptotic, cell death during regression. we here investigated the presence of autophagic system in cl and its any implications in rodent pregnancy and parturition. materials and methods: lc (-i and -ii) expression in cl was estimated by western blot analysis in comparison with progesterone secretion and luteal mass throughout pregnancy. lc was also tested by immunocytochemistry. functional implication of autophagy in this tissue was examined by local treatment with bafilomycin a (autophagy and v-atpase inhibitor, . pg/ . ml/ovary) on day of pregnancy. reproductive, biochemical, and morphological outcomes were evaluated. results: while the expression of cytosol-associated lc -i was not significantly altered throughout pregnancy, that of autophagosome-associated lc -ii increased significantly from day , showed a peak on day , and decreased on day (day of normal parturition). lc -ii / i ratio had positive correlations with steroidogenic activity and cell size. immunoreactive lc was found to be present in the cytosol of steroidogenic cells and showed marked aggregation in cells on day . in vivo treatment with bafilomycin a resulted in unaltered delivery, but in significant reductions in steroidogenic cell size and neutrophil infiltration compared to vehicle-treated control groups. discussion and conclusion: the ratio of lc -ii / i in cl was markedly up-regulated in the late phase of pregnancy. manifestation of this autophagy parameter was temporally matched with further structural and functional activation of cl. autophagy may contribute to activation, but not regression, of rodent cl and thus their female reproduction. apoptotic and necrotic effects of low dose bisphenol a in shsy y neuroblastoma cells b. ayazg€ ok, t. t€ uyl€ u k€ uc ߀ ukkilinc ß faculty of pharmacy, hacettepe university, ankara, turkey bisphenol a (bpa) is a commonly used chemical in industry to make plastics. 'low-dose' term has been expressed for the first time in studies with bpa in . the value of low dose bpa was received as < lm. in this study, matrix metalloproteinases (mmps) together with their tissue inhibitors (timps), involved in tissue remodeling after i- therapy, have been examined in patients ( m/ f) with ptc and ( m/ f) with ptc+ht. peripheral blood samples were collected just before and, subsequently, at days after i- administration ( . gbq). ptc+ht patients had positive titers of anti-thyroglobulin autoantibodies (tgab). the serum levels of tgab, mmp- , mmp- , timp- and timp- were measured by elisa. there were no significant changes in serum concentrations of mmp- , timp- and mmp- /timp- ratio after i- in the two groups. in ptc patients, i- administration resulted in an increase with % in timp- level (p = . ) and a reduction with % in mmp- /timp- ratio (p = . ). in ptc+ht patients it has been observed an increase with % in tgab level (p = . ), % in mmp- /timp- ratio (p = . ) and unchanged timp- serum concentration. tgab titers were positively correlated with mmp- /timp- ratio (r = . , p < . ). our data suggest that radioiodine therapy for ptc patients, but not for ptc+ht, modulates the balance of mmp- /timp- for anti-invasion and anti-migration by augmenting timp- . in criminal cases, the determination of the time of death of the bodies step in the analysis of events is making a big contribution. today, forensic and molecular methods utilized time of death rather than provide clear information offers potential death time interval. principally, 'time of death' is a term that should be avoided. in forensic science, the postmortem 'interval' is the term to be considered. nowadays, there is no precise molecular method that can be used alone in the determination of pmi. aim of this study is to analyze the usability of ecm components, adamts , and and mmp , and to determine pmi. for this purpose, with iliopsoas muscle tissues provided by ethical board of the ankara institute of forensic medicine, cases have been included in this study, divided into groups according to their pmis: ' - h', ' - h' and ' - h'. from these tissues, western blotting technique is used to analyse the expression of adamts , and and mmp , and . it is determined that when pmi increases; adamts- and amounts decrease. on the other hand adamts- amounts are examined to increased related to the interval., especially on the ' - h' dataset. additionally, considering metalloprotease levels, mmp- and amounts decrease as pmi increases. unlike mmp- and ; mmp- levels increase proportional to the interval, especially on the ' - h' dataset. these results are the first data on pmi determination from iliopsoas muscle tissue. in this study, it is suggested that adamts- and mmp- , proteases responsible for ecm degradation, can be used to determine pmi as markers. here we present the first observations of postmortem variation of mmp and adamts activities in skeletal muscle. in recently, popular mmps and adamts s pathways of the relationship between time-dependent changes to investigate the post mortem time interval determination to shed light on the future. the role of functional polymorphisms of matrix metalloproteinases and in spontaneous abortion samples capillaries, which are responsible for maintenance of implantation and placental nutrition, have major effects on mechanisms underlying abortion. matrix metalloproteinases (mmps) function in various cellular pathways. they play a role in patholohical conditions, metastasis; as well as normal physiological functions like tissue and bone regeneration, physiologic function of uterus, ovulation, embryogenesis and embryo implantation. mmp and mmp (gelatinases) have key roles at organisation of extracellular matrix and affect endometrial implantation. previous studies have shown that mmp - c>t and - c>t polymorphisms cause loss of gene function, and mmp - c>t polymorphism causes a decrease in gene expression, and also gene expression levels are lower in abortion specimens, compared to control specimens. the goal of this study was to investigate the potential effects of functional mmp - c>t and - c>t polymorphisms, and mmp - c>t polymorphism on etiology of abortion. restriction fragment length polymorphism (rflp) method was used to analyze the polymorphisms those evaluated in the study. study group consisted of samples collected from spontaneous abortion specimens, and control group consisted of peripheral blood blood samples collected from healthy subjects. the risk of abortion was . -fold higher in patients with heterozygous - c>t polymorphism (p = . ). combined genotype analysis showed that the risk of abortion was . -fold higher for patients with normal - c>t polymorphism, and heterozygous - c>t polymorphism (p = . ). functional polymorphisms of mmp and mmp may have a role in etiology of abortion. p- . . - changes in the specific extracellular matrix proteins and expression of adamts proteinases and effects of hypoxia in the adriamycin-induced renal fibrosis model renal fibrosis is a common cause of renal dysfunction with chronic kidney diseases. this process is characterized by excessive production of extracellular matrix (ecm) or inhibition of ecm degradation. adamts proteinases, which are widely presented in mammals, have very critical roles in ecm remodeling. we aimed to study the role of adamts proteinases in the pathogenesis of renal fibrosis and the effets of hypoxia by studying adamts expressions in rat kidney after adriamycin (adr) administration. adr was administered intravenously in consequtive two doses ( . and mg/kg) to the rats. in addition to control and adr groups, another rats were assigned into three groups as sham, min and min ischemia-reperfusion. after months following the first dose, the expression of adamtss were determined in the renal tissues using western blot analysis. additionally, renal nephropathy and fibrosis were assessed pathological and immuno-histochemical staining methods. in the adr group rats developed renal dysfuntion and tissue damage in favor of renal fibrosis pathologically. it is observed that occurred remarkable changes in the expression of adamtss. it is showed that hypoxia and hypoxia time enhanced tubulointerstitial fibrosis in the rat kidney tissues. expression differences were absorved also in the hypoxia groups, and especially the expression of adamts- and - genes were showed an increase in various rates. the restricted and different expression pattern of adamts protein profiles in the adr-induced renal fibrosis suggest that adamts family members are related with development and progression of fibrosis. moreover, our findings raise the possibility that the hypoxia promotes renal fibrogenesis. the monitoring of adamts proteinases might contribute to the early diagnosis of renal fibrosis and chronic kidney disease. adams (a disintegrin and metalloproteas) are transmembrane proteins that contain a pro-domain, a metalloprotease, a disintegrin, a cysteine-rich, an epidermal-growth factor like and a transmembrane domain, as well as a c-terminal cytoplasmic tail. they are involved in cell adhesion and they have protease activities. previous studies showed that some adam proteins act in a highly diverse set of biological processes, including fertilization, neurogenesis, myogenesis, embryonic tgf-a release and the inflammatory response. although there are more researches about adam proteins, still the function of all adam proteins remain unclear. we aimed to investigate the potential link of infertilty with adam , - , and - . in this study twenty four patients were included. the patients were classified as normozoospermia (ns; n = ), oligozoospermia (os; n = ), azoospermia (as; n = ) groups. adam , - and - protein levels in infertility indviduals were analysed by western blot. adam protein level was . fold lower in the os and as groups than in the ns group. adam protein level was . fold higher in the as group than in the ns group. adam protein level was fold lower in the as group accourding to ns group. we observed no change between protein level of adam and adam of os and ns groups . in conclusion, adam proteins may have a potential role in male infertility. our study is a preliminary and first study on this issue. keywords: adam, infertility. the role of tissue metalloproteinase inhibitors thymus chemokine and thrombospondin- on prognosis of crimean-congo hemorrhagic fever s. bakir, m. bakir, s. ersan, a. engin cumhuriyet university, sivas, turkey crimean-congo hemorrhagic fever (cchf) is a disease which is caused by an arbovirus carried by ticks and characterized by the sudden onset of high fever, severe headache, dizziness, back and abdominal pain. cchf pathogenesis is still not resolved today to fully open. therefore, in this study, to determine the level of tck- , timp- and tsp serum samples obtained from cchf patients and the control group is intended to be examined for the pathogenesis and prognosis of the disease. the study sample was created patients with diagnosis of cchf. healthy volunteers were chosen control group matched for gender and similar to in terms of age. tsp, tpc- and timp- levels of patients and a control group were analyzed using the human elisa kits. serum timp- tck- and tsp levels in cchf patients were measured significantly higher than the in the control group. cchf pathogenesis of today still have not provided fully open. therefore, it reveals the importance of this work. in our study, presence of high timp- , tck- and tsp levels indicate important direction for pathogenesis and prognosis of cchf disease. p- . . - activation of calpain and protein kinase ca promotes a constitutive expression and release of matrix metalloproteinase in peripheral blood mononuclear cells from cystic fibrosis patients matrix metalloproteinase (mmp ) is physiologically involved in remodeling the extracellular matrix components but its abnormal release has been observed in several human pathologies, including cystic fibrosis. we have studied if the alteration in intracellular ca + homeostasis, observed in peripheral blood mononuclear cells (pbmcs), isolated from cystic fibrosis (cf) patients homozygous for deletion of phenylalanine in gene of cystic fibrosis transmembrane conductance regulator (f del-cftr), could be involved in the abnormal presence of mmp in the extracellular fluids of cf patients. pbmcs were isolated from healthy donors and cf patients homozygous for f del-cftr. mmp levels were evaluated following h of cell incubation. our investigations show that all cf pbmcs analyzed constitutively express and release high levels of mmp ; conversely, in pbmcs from healthy donors, expression and secretion of mmp are undetectable but both events can be evoked, after h of cell culture, by a possible paracrine stimulation. we have demonstrated that in cf and h-cultured control pbmcs mmp secretion is prevented by chelation of intracellular ca + and mediated by the concomitant activation of calpain and protein kinase ca (pkca) and also that mmp expression is mediated by the sequential activation of pkc and extracellular signal-regulated protein kinases and (erk / ). moreover, the rescue of active f del-cftr reduces the extent of mmp secretion, correlating the channel defect to the [ca + ] i dysregulation of cf pbmcs. our results indicate that the high level of intracellular ca + concentration in cf pbmcs, promoting the aberrant activation of both calpain and pkca, induces a constitutive release of mmp . these data characterize new alterations in mononuclear leukocytes of cf patients that may be of primary importance in the progression of the disease and indicate that pbmcs may contribute to the accumulation of mmp in fluids of cf patients. p- . . - aebp /aclp is upregulated in differentiation, injury repair and fibrotic degeneration of skeletal muscle c. € ozdemir , , u. akpulat , i. onbasilar , c ß . kocaefe department of medical biology, faculty of medicine, hacettepe university, ankara, turkey, department of stem cell, institute of health, hacettepe university, ankara, turkey, laboratory animal breeding and research unit, faculty of medicine, hacettepe university, ankara, turkey aebp /aclp is an ambiguous gene with several attributed functions and cellular events, adipogenic differentiation, cell adhesion, pattern development and fibrosis are the well-understood. aebp is the short isoform that acts as a transcriptional repressor by targeting the ap promoter and aclp, which is the long isoform that harbors a leader sequence that directs the peptide to the extracellular compartment. the latter is known to be associated with development of the connective tissue, injury repair and fibrosis in certain pathological conditions. aebp /aclp displays a moderate expression in skeletal muscle where the role is not known. we have investigated the spatial and temporal expression of aebp /aclp in defined models of skeletal muscle differentiation, injury repair and fibrosis. aebp /aclp expression is present in steady state dividing myoblasts. this basal expression is upregulated folds upon the induction of differentiation in c c cells. considering that differentiation and post-natal injury repair share several common aspects, we also investigated the expression of aebp /aclp in acute injury-repair model. in the course of cardiotoxin induced injury, aebp /aclp expression peaks up to folds in the th day of regeneration. this time point concomitantly corresponds to tissue remodelling. since aebp /aclp is also known to be associated with fibrotic events in chronic pathological conditions, we also have investigated its expression in tenotomy induced skeletal muscle degeneration which mimics endomysial and perimysial fibrosis. aebp /aclp expression is upregulated up to folds in early time-point samples. these results depict a novel role for aebp /aclp in extracellular remodeling of the skeletal muscle during injury repair as well as fibrotic degeneration. the source of this expression might come from fibroadipogenic precursers which reside in endomisial area of muscle. our current efforts are focused on presenting of this endomysial expression. the mprbp gene from b. pumilus - encoding a novel secreted metalloproteinase was identified. based on the primary structure the enzyme has been classified as metzincin metalloproteinase that combines the features of two families: astacin and adamalysin. representatives of the adamalysin family previously have not been described for bacilli. the aim of the work was to elucidate the mechanisms of the gene expression regulation of a new bacillus pumilus - extracellular metalloendopeptidase. promoter region analysis revealed the presence of potential binding sites for transcription factors spo a (sporulation) and degu (biodegradation). study of mprbp expression in strain defective in regulatory proteins degs and degu shows that the productivity of metalloproteinase biosynthesis decline in average % compared with the strain with a complete degs-degu system. we also studied mprbp expression in strains with a mutation in the gene degu, leading to stabilization of degu~p protein. it is known, that this mutation leads to a multiple increase in the gene expression level, positively regulated by degs-degu system. our data shows a -fold increase in metalloproteinase productivity in the recombinant strain. thus, deg-system participates in control of the proteinase synthesis but not only in the regulation of mprbp gene expression. the mprbp expression in the strain deficient in regulatory protein spo a remained at the level with expression in the strain with the complete spo a. a similar pattern we observed in the study of mprbp gene expression in strains defective in other spore-specific regulatory proteins (spo b, spo f, spo k, spo j, sigf, sigh, sigk). these data indicate that mprbp gene expression is free of spo-regulatory proteins. on this basis, we concluded that the expression of metalloproteinase gene is not correlated with the sporulation. p- . . - paricalcitol attenuate activity and expression of matrix metalloproteinases in a rat model of renal ischemia-reperfusion injury matrix metalloproteinases (mmps) are endopeptidases involved in the degradation of extracellular matrix. they have been postulated to have a role in the pathogenesis of ischemia-reperfusion injury (iri). in the present study, we investigated the effect of paricalcitol, a synthetic vitamin d analog, on mmps in renal iri. wistar albino rats were divided into three groups: sham operated, ischemia-reperfusion, and paricalcitol-pretreated. iri model was induced by bilateral clamping of renal arteries for min followed by h of reperfusion. the analysis of serum creatinine levels and activities/expressions of mmp- and - were performed after h of iri. the effects of paricalcitol on activities and expressions of mmp- and mmp- levels were investigated by gelatin zymography and immunohistochemistry, respectively. the pathological examinations were performed to score tubular damage by light microscopy. creatinine levels increased significantly in the iri group. rats in the paricalcitolpretreated group showed significant decrease in expressions and activities of mmp- and mmp- during iri. moreover, pathological examinations displayed significantly lower score of tubular damage in paricalcitol-pretreated group. in conclusion, paricalcitol attenuated iri by downregulating the expressions and activities of mmp- and - . p- . . - the changes of matrix metalloproteinase , activity and hyaluronic acid level in rat's heart and serum under cadmium influence o. fomenko , o. shaulska , y. kot , g. ushakova , a. shevtsova dnipropetrovsk medical academy, dnipropetrovsk, ukraine, kharkiv national university, kharkiv, ukraine, dnipropetrovsk national university, dnipropetrovsk, ukraine the changes in the molecular mechanisms of the extracellular matrix degradation under toxic factors are not well known. the main goal of work was the investigation of the mmp and mmp activity and hyaluronic acid level in the heart and blood serum under cadmium influence at different doses. the wister rats divided to groups were used for the experiment. cdcl x . h o in doses . lg/kg and lg/kg was given to rats intragastrically in drinking water during days. the rats were decapitated under isoflurane anesthesia according to ethical rules; the heart was quickly removed. the relative activity [in arbitrary units (au)] of pro-and active forms of mmp and mmp , total protein (tp) and hyaluronic acid levels were calculated. it was shown that low doses of exogenous cadmium ( . lg/ kg) lead to reduced activity of pro-and active forms of mmp in myocardium ( . ae . au/mgtp and . ae . au/mgtp compare to the . ae . au/mgtp and . ae . au/mgtp in the control rats accordingly) and in serum ( . ae . au/mgtp and . ae . au/mgtp compare to the . ae . au/mgtp and . ae . au/mgtp in the control rats accordingly), but pro-mmp activity in heart was increased ( . ae . au/mgtp compare to the . ae . au/mgtp in the control rats); level of ha was decreased in both tissues ( . ae . lg/ml and . ae . lg/ml compare to the . ae . lg/ml and . ae . lg/ml in the control rats accordingly). high doses of cadmium ( lg/kg) caused a reliable increase of both gelatinase activity in the myocardium: mmp increased from . ae . au/mgtp to . ae . au/mgtp, prommp to . ae . au/mgtp, mmp to . ae . au/mgtp. ha level was increased in serum ( . ae . lg/ml) and decreased in heart ( . ae . lg/ml). the results indicate the dose-dependent and tissue-specific effect of cadmium on mmp-depended protein degradation and level of hyaluronic acid. a disintegrin-like and metalloproteinase domain with thrompospondin- repeats (adamts) are a large family of proteoglycanase that show proteolytic activity towards proteoglycans like aggrecan, brevican, neurocan, and versican. interleukin- (il- ) is an il- cytokine family member that uniquely plays a role as a cytokine and nuclear factor. it is released by necrotic epithelial cells and activated innate immune cells as an alarming danger signal. adamts and il- implicated in brain cancer pathogenesis. we aimed to seek the amount of adamts in u proteolytic enzymes are able to speed up wound healing by removal of the necrotic tissues and fibrin. several investigations have reported that proteases damage also the microbial biofilms formed by opportunistic bacteria including staphylococci on surfaces of chronic and acute dermal wounds. therefore, proteases are seemingly perspective enzymes for biofilm eradication by hydrolysis of both matrix proteins and adhesins, proteins providing cells attachment onto solid surface and other bacteria, as well as by the cleavage of signalling peptides of intercellular communication of gram-positive bacteria. here we report that ficin, a plant protease, efficiently degrades the structural components of biofilm matrix formed by s. aureus and s. epidermidis at concentrations of lg/ml while trypsin and chimotrypsin are used as - mg/ml solution. the spatial structure of the biofilm was analyzed by atomic force microscopy. after ficin treatment, the biofilm structure became porous, with reduced viscosity. the congo red staining of the treated biofilms confirmed the hydrolysis of the protein component of the matrix. moreover, the biofilm treatment with ficin increased the antimicrobial efficiency of ciprofloxacin against biofilm-embedded cells of s. aureus and s. epidermidis. while h antibiotic treatment did not lead to the increase of dead cells of neither s. aureus nor s. epidermidis embedded into the biofilm matrix, in the presence of ficin the fraction of viable cells decreased significantly. accordingly, soluble ficin appears beneficial for outer wound treatment biofilm eradication and reduces the reinfection risk. the wound-healing activity of ficin requires further investigations. this work was supported by the russian science foundation (project no - - ). resveratrol (resv) is an antioxidant that belongs to the group of plant compounds, called polyphenols. resv is defined as an antimicrobial substance that is produced by several plants (red grape skin, peanuts and berries) to protect them from rough environments like excessive ultraviolet light, infections and climate changes. as an antioxidant, this polyphenol protects the body against cardio-vascular and cancer diseases. besides, resv has anti-inflammatory, neuro-protective, anti-diabetic and other pharmacological effects. although the positive pleiotropic effects of this polyphenol are well documented, there is a huge need to understand its influence on the biophysical properties of lipid bilayer. in the present work, the interaction of resv with membranes composed of palmitoyl-docosahexaenoyl phosphatidylcholine (pdpc) or palmitoyl-oleoyl phosphatidylcholine (popc), sphingomyelin (sm) and cholesterol (ch) was investigated by means of fluorescence spectroscopy. generalized polarization of the fluorescent probe laurdan (gp) as a function of temperature was used to probe the changes in the fluidity of lipid bilayer induced by different resv concentration. the obtained results showed decreased lipid ordering from to lmol resv and opposite effect from to lmol in pdpc/sm/ch mixtures as compared to the control without resv. the interaction of resv with popc/sm/ch mixtures caused only an increase in the lipid ordering as a function of resv amount. popc and pdpc have the same head group but different fatty acid chains at sn- . since resv changes the physicochemical properties of lipid bilayer by different ways one might suggest that the interaction of polyphenol with the membrane depends on the level of fatty acid unsaturation. this specific effect of resv on lipid organization could be related to its unique properties to prevent the cell from oxidative stress. neurodegeneration is the umbrella term for the deseases including progressive loss of structure or function up to death of neurons. beta-amyliod peptide is proteolytic fragment of the amyloid protein. the spontaneously formation of selective, voltage-dependent, ion-permeable channels in the lipid bilayers was reported as one of amyliod peptide toxicity mechanisms. the aim of our study was the investigation of the influence of the flavonoids (phloretin, phlorizin, quercetin and genistein) on the membrane activity of amyliod peptides. virtually solvent-free bilayer lipid membranes were prepared from mixtures of phospholipids in . m kcl (ph . ) using monolayer-opposition technique. using spectrofluorimetry we estimated prepared from phospholipids by extrusion the liposomal membrane permeability for calcein. we found that the addition of phloretin into membrane bathing solution led to an signicant increase in the channel forming activity of fragments - of amyloid peptide, fragment - of [gly ]-amyloid peptide and - of human prion protein. addition of other flavonoids did not cause any changes in the steady-state amyloid-induced current. it was found that the effect was caused by electrostatic interaction with the peptide. we found that time course of amyloid induced leakage calcein from liposome's is characterized by two components: the fast one is related to sorption of b-amyloid peptide on the membrane and the slow one is related to the oligomerization of the peptides on the surface of the lipid bilayer. addition of the phloretin simultaneously with b-amyloid peptide to the suspension of liposomes caused significant reduction in time parameters characterizing fast and slow components. from this results we can proposed that phloretin compensates the positive charge of the b-amyloid peptides and leads to the changes in their oligomerization status. the study was supported in part by rfs ( - - ) and sp- . . . ferritin nanocarriers: a focus on a metal-based drug encapsulated inside the protein cavity s. ciambellotti , c. bernacchioni , f. scaletti , p. turano cerm (magnetic resonance centre), florence, italy, department of biochemical sciences, university of florence, florence, italy, chemistry department 'ugo schiff', florence, italy ferritin is one of the main player involved in the iron metabolism. the biological role of ferritin is the storage of iron atoms inside the cavity preventing the uncontrolled accumulation of toxic species inside cells. ferritins are polymers constituted by subunits that self-assemble giving rise to an almost spherical nanocage. in vertebrates, ferritins are formed by two distinct subunits, the heavy chain (h), with oxidoreductase activity, and the light chain (l) without catalytic activity. ferritins are promising nanocarriers for the delivery of contrast agents for diagnosis and of drugs for therapeutic purpose. their endogenous origin and the possibility to stabilize and protect the enclosed cargo inside the cavity, make ferritin a biocompatible vehicle. moreover, there are specific receptors on cells that recognize and incorporate ferritin by endocytosis, prospecting a kind of targeted-delivery. following the increasing interest in nanotechnology, we studied the interaction between different isoforms of ferritin with an antimetastatic drug, called nami-a, which is the first ruthenium derived anti-cancer drug to have entered clinical evaluation. this molecule is a metal-based prodrug that can release the metal ion ligands. here, we describe nami-a hydrolysis in the presence of recombinant homopolymers of ferritin followed spectrophotometrically. thanks to characteristic time dependent changes of spectral profile in the uv-visible region, we could detect differences in the hydrolysis process. the formation of a ru-adduct with hferritin was established by uv-visible and circular dichroism spectroscopies, as well as by kinetics measurements that showed inhibition of the ferroxidase activity of h-ferritin. crystallization trials are in progress to identify the binding site of ru by solving the x-ray structure of the complex. finally, we planned to test the cytotoxicity of ferritins pre-incubated with nami-a, using different cancer cell lines. a. cort , t. ozben , a. sansone , s. barata-vallejo , c. chatgilialoglu , c. ferreri sanko university, gaziantep, turkey, akdeniz university, antalya, turkey, cnr, bologna, italy, universidad de buenos aires, buenos aires, argentina, national center for scientific research 'demokritos', athens, greece liposomes as biomimetic models of cell membranes were used for examining some novel aspects of drug-metal induced reactivity with unsaturated lipids under oxidative conditions. the chemical basis of cis to trans transformation was ascertained by liposome experiments, using bleomycin-iron complexes in the presence of thiol as a reducing agent that by incubation at °c gave rise to the thiyl radical-catalysed double bond isomerisation of membrane phospholipids. the effect of oxygen and reagent concentrations on the reaction outcome was studied. as a chemical biology model for antitumoral strategies, liposomes highlight the role of cell membranes, which are not spectators but important targets of the drug effect, with synergic roles for chemotherapeutic effects. indeed, fatty acid recruitment and membrane formation are attracting a lot of interest in cancer, and in this context the loss of the natural cis geometry and the oxidationinduced lipid remodelling are worthy of deeper studies in antitumoral strategies. furthermore, the interaction between drugs and lipids can be suggestive of novel aspects of chemical reactivity for liposome carriers when circulating in vivo. gpr is a g-protein coupled receptor (gpcr), expressed in cells of brain, heart and kidney. it is related to the leukotriene and purinergic subfamilies of the rhodopsin-like class a gpcrs. gpr plays controversial role in the brain and spinal cord cells recovery after injuries. it is assumed that gpr is one of the cell death regulators immediately following an injury but at later stages it also takes part in tissue regeneration. there are also data implying some role of gpr in glucose homeostasis. drugs targeting gpr may help with treatments of multiple sclerosis and ischemia. the damage of rat's brain in artificially induced ischemia disease decreased after gpr inhibition. in addition, gpr takes part in myelin sheath formation, the lack of which is known to be the reason of multiple sclerosis. to better understand functional role of gpr and enable design of more efficient ligands we initiated structural studies of this receptor. to improve receptor stability and facilitate crystallization we created a series of chimeric constructs using different fusion partnerssmall soluble proteins inserted into the native amino acid sequence. preliminary experiments were carried out to evaluate the influence of different ligands on the receptor stability and cell surface expression in insect sf cells. this work was supported by russian federal target sterols are significant for the structural and dynamical features of cell membranes. among them, cholesterol is the major sterol in mammalian cell membranes whereas stigmasterol is the predominant sterol in plant membranes. stigmasterol varies structurally from cholesterol in having both an ethyl group at carbon and an additional trans double bond between carbons and . dimyristoylphosphatidylcholine (dmpc) is a widely studied synthetic lipid, which has a neutral (zwitterionic) pc headgroup and two symmetrical -carbon fatty acyl chains. the studies on the interactions of cholesterol and stigmasterol with dmpc membranes at molecular level are very limited. in the present study, a calorimetric comparison of the effects of the animal sterol cholesterol and the plant sterol stigmasterol on zwitterionic dimyristoylphosphatidylcholine (dmpc) multilamellar vesicles (mlvs) was investigated for the first time by using differential scanning calorimetry (dsc). our dsc studies indicate that with the inclusion of increasing cholesterol and stigmasterol concentrations from to mol% into pure dmpc mlvs, the pretransition disappears, the main phase transition shifts to lower temperatures and then disappears at cholesterol and stigmasterol concentration above mol%. the main phase transition enthalpy (dh) is progressively reduced whereas full width at half maximum (dt ½ ) gradually increases with increasing cholesterol and stigmasterol concentrations. moreover, the main phase transition peak consists of overlapping sharp and broad components, indicating the hydrocarbon chain melting of sterol-poor and sterol-rich dmpc domains, respectively. in conclusion, this study shows clearly that both cholesterol and stigmasterol interact effectively with dmpc membranes and cause changes in their structural and functional properties. p- . . - trh receptor mobility in the plasma membrane is affected by its interaction with its cognate signaling molecules and by cholesterol depletion r. moravcova, b. melkes, j. novotny department of physiology, faculty of science, charles university in prague, prague, czech republic g protein-coupled receptors (gpcrs) play a fundamental role in transferring information from extracellular environment to the cell interior. some gpcrs are supposed to form signaling complexes with their cognate g proteins and possibly other accessory proteins, which may facilitate the activation of g proteins and thus accelerate signal transmission. here we investigated the role of some components of thyrotropin-releasing hormone (trh) receptor signaling in hek cells stably expressing yfp-tagged trh receptor using fluorescence recovery after photobleaching (frap). we observed significant changes in values of the diffusion coefficients if expression of b -arrestin or gb subunit were suppressed by sirna. results of our frap experiments indicated significant difference between control and trh-treated cells as the diffusion coefficient markedly decreased after agonist stimulation. on the other hand, the same decline of the diffusion coefficient value was found after silencing with sirna and subsequent treatment with trh for most of the screened proteins. treatment of cells with À m trh led to fast internalization of trh receptor, which was revealed by real-time confocal microscopy. it is known that cholesterol is an essential component of the cell membranes and it exerts modulatory effects on the functioning of various membrane proteins. disruption of plasma membrane integrity by cholesterol depletion using b-cyclodextrin significantly reduced the apparent diffusion coefficient values. interestingly, addition of trh to cells treated with b-cyclodextrin did not further reduced trh receptor mobility. it can be concluded that stimulation with agonist and/or sirna silencing of some components of the trh receptor signaling cascade significantly affects the mobility of trh receptor in the plasma membrane. p- . . - l-opioid receptor mobility in the plasma membrane is diversely affected by biased ligands b. melkes, l. hejnova, j. novotny opioid receptors belong to the large family of g protein-coupled receptors (gpcrs), which are currently considered among the most important targets for pharmacological manipulations. during the past few years, a great deal of attention has been devoted to biased agonism. this phenomenon reflects the ability of different ligands to selectively affect the functioning of some gpcrs so they can display marked differences in their efficacies for g protein-or b-arrestin-mediated signaling. here we decided to investigate the effect of different agonists of the l-opioid receptor (l-or) on the lateral mobility of this receptor in the plasma membrane of hek cells which were stably transfected with l-or tagged with yellow fluorescent protein (l-or-yfp). it has been found previously that damgo stimulates g-protein-dependent signaling, endomorphine stimulates arrestin-dependent signaling and morphine does not show any significant bias towards these two signaling pathways. in our experiments, we used the fluorescence recovery after photobleaching (frap) method to estimate the diffusion coefficients of l-or-yfp in the resting state and after addition of the above mentioned specific agonists. we observed that addition of damgo increased the value of the diffusion coefficient and addition of endomorphin decreased the value of diffusion coefficient of l-or-yfp. addition of morphine or the l-or antagonist naloxone did not change the value of the diffusion coefficient compared to the resting state. these results indicate that different biased agonists of l-or may differently affect the mobility of this receptor in the plasma membrane. these findings provide new insights into the dynamics of l-or in the plasma membrane and contribute to better understanding of the mechanism of biased agonism at gpcrs, which is of central importance for receptor homeostasis and fine regulation of receptor activity. color tuning and adding potassium selectivity to a light-driven sodium pump k. kovalev , , v. polovinkin , , , v. shevchenko , , v. gordeliy , , moscow institute of physics and technology, dolgoprudniy, russia, research centre j€ ulich, j€ ulich, germany, institut de biologie structurale, universit e grenoble alpes, cnrs, and cea, grenoble, france recently a light-driven sodium pump has been discovered, characterized and tested as an inhibitory optogenetic tool. sodium pumping rhodopsin from dokdonia eikasta kr has an absorption maximum at nm at ph . and to create more redshifted variants we analyzed available structures of the kr (pdb codes: xtl, xtn) and did the rational mutagenesis of residues in the retinal proximity region (i.e. m , g and s ). the mutants of kr under investigation were: m a, g v, m a/g v, s a, s f, s g, s l, s m, s n, s t, s v, s y. the protein mutants were expressed in escherichia coli c strain, expression was induced by the addition of mm isopropyl b-d- -thiogalactopyranoside. the cells were then washed trice with unbuffered mm nacl or kcl solution. finally, the ph changes in cell suspensions (od = . ) were monitored. ph changes upon the addition of lm of protonophore carbonylcyanide m-chlorophenylhydrazone were also measured. the following mutants completely abolished the protein function and were not used for further characterization: s f, s l, s m, s n, s v. the remaining mutants have shown sodium pumping activity and s a mutant has gained an additional potassium pumping activity. all functionally active mutants were purified using ni-affinity chromatography and the absorption spectra were collected for them at ph . ( mm na/na-pi, mm nacl). m a mutant absorption maximum is blue-shifted to nm. g v and m a/g vblue-shift to nm. s a, a potassium pumping variant,red-shift to nm. s g, s yred-shift to nm. s tno change in absorption maximum position. based on structural analysis of kr we discovered another potassium pumping variant and provided the variants with absorption maximum blue-shift up to nm and red-shift up to nm. human endothelin receptors belong to the g-protein coupled receptors (gpcrs) superfamily. this class is pharmacologically important, with more than % drugs targeting it. the human endothelin system, which includes endothelin receptors types a and b (etb and eta), plays a highly important role in the blood pressure regulation. endothelium cells produce peptides, known as endothelins - , which activate endothelin receptors and launch cascades of reactions that lead to vasoconstriction or vasodilatation depending on the receptor subtype and the tissue. additionally, endothelin receptors take part in such processes as transmission of nerve impulses, development of neural crest, and regulation of acid-base-salt balance in kidneys. in order to stabilize etb receptor for crystallization trials we introduced a compact soluble protein, apocytochrome b ril (bril), is the third extracellular loop of the receptor. bril is known to be an effective crystallization driver for gpcrs. the engineered protein was expressed using baculovirus system in sf insect cells, purified and subject to variety of pre-crystallization assays. localization of the overexpressed protein in insect cells was visualized via the confocal microscopy. thermal stability of the protein in the presence and absence of ligands was measured by the thermal shift assay. finally, the mobility of the receptor in lipidic cubic phase (lcp) at many different conditions was probed by the lcp-frap (fluorescence recovery after photobleaching) assay. these tests showed that the obtained protein is thermally stable, functionally active and diffuses well in lcp at certain conditions, making it a suitable candidate for proceeding to in meso crystallization trials. this work was supported by the russian science foundation (project no. - - ). mitochondrial oxidative phosphorylation is the key metabolic pathway for the production of atp. mitochondrial respiratory chain (rc) defects are some of the most commonly diagnosed inborn errors of metabolism with a diverse spectrum of clinical phenotypes. the aim of the study is to evaluate the rc enzyme activities and histopathological findings in muscle biopsies of patients with suspected mitochondrial disease. muscle biopsy samples were collected from pediatric patients. the samples were homogenized in seth buffer using a glass/glass homogenizer. the activities of citrate synthase (cs) and rc enzymes (complex i, ii-iii, and iv) were measured in tissue homogenates by kinetic spectrophotometric assays by schimadzu uv spectrophotometer (uv- ). non-collagen protein was determined by the modified lowry assay. activities of complex (c) i, ii-iii and iv (cox) were normalized by cs. histopathological investigations included h&e, modified gomori trichrome, periodic acid schiff, oil-red-o, nadh, sdh, cox and atpase stains. deficiency of rc complexes was detected in biopsies ( %). c iv deficiency was most common ( %), followed by c i ( %) and c ii-iii ( %). multiple complex deficiency was present in % and isolated deficiency was present in % of the biopsies ( % c i, % c ii-iii, % c iv). cs activity was elevated in % of the biopsies. decreased c i/cs, c ii-iii/cs and c iv/cs ratio was observed in %, % and %, respectively. comparing with histological data, biochemical analysis revealed additional findings in % of biopsies. complex iv deficiency, either isolated or accompanied by other complex deficiencies, is most common in our cohort. rc analysis may reveal additional findings to histopathological results and careful clinical investigation with correlation of clinical, biochemical and histopathological data is mandatory for the challenging diagnosis of mitochondrial disorders in childhood. investigation of adipocytokines, activity of glut and na + /k + -atpase in rats fed glucose, fructose, starch-based sugars objective: all over the world, shows a significant increase in obesity and diabetes. intake of foods that contain fructose, glucose and starch-based sugar is a potential risk for metabolic syndrome. obesity and diabetes are important effects of high fructose corn syrup (hfcs). we aimed to research, activity of na + /k + -atpase in addition to glucose transporter (glut) , resistin, adiponectin and other biochemical markers in rats fed glucose, fructose and starch-based sugars. materials and methods: study was performed on rats and groups were included in the study. rats were fed with chows that were given either normal diet for control group ( % carbohydrate, % protein and % fat), high fructose ( % carbohydrate ( % fructose and % starch), % protein and % fat), or high sucrose ( % carbohydrate ( % sucrose and % starch), % protein and % fat). rats were fed with chows for weeks. in this process, the weight of the rats were followed. at the end of the experiment, blood is taken in all groups. level of hba c, glucose, resistin and adiponectin were studied. glut and na + /k + -atpase activity were studied in the liver tissue. results: a significant increase in adiponectin levels were determined in rats fed both hfcs and sucrose (p < . ). a significant decrease in level of na + /k + -atpase activity were determined in rats fed both hfcs and sucrose (p < . ). there was no significant differance level of hba c, glucose, resistin and glut in rats fed sucrose or hfcs (p > . ). conclusions: fructose-rich diet has an effect on changes in the atpase activity and is a major risk factor for obesity. keywords: adiponectin, fructose, glucose, high-fructose corn syrup, na + /k + -atpase, resistin. p- . . - nucleic acid-biomembrane lipid selfassemblies: from primordial soup to novel genome organization model and cellular nonviral nanotherapies f. k. demirsoy , n. eruygur , e. s€ uleymanoglu biotechnology central laboratory, biotechnology institute, ankara university, ankara, turkey, department of pharmacognosy, faculty of pharmacy, cumhuriyet university, sivas, turkey, department of pharmaceutical chemistry, faculty of pharmacy, gazi university, ankara, turkey turkey nucleic acid-cell membrane complexes has attracted research interest as models in gene regulation, cell cycle and division, as biosensors designs, as well as in molecular evolution. zwitterionic phospholipids, complexed with polyribonucleotides by divalent metal cations (mg +) are considered as genosome vehicles. their formations are studied by spectroscopic, thermodynamic, interfacial and microscopic approaches to build thermodynamic and kinetic models of their structural transitions. dna forms a mg +-driven ternary complexes with neutral liposomes both at the airwater interfaces and at vesicle surfaces. the described self-assemblies form relevant models for nuclear pore complexes and their further implications in gene expression and functions. such membrane contacts could be considered also in prokaryotic nucleoids important in bacterial segregation, whereas in eukaryotes these complexes can be regarded as focal points for transcription-translationtranslocation processes. the effects of ozone/oxygen mixture on citrate synthase and mitochondrial complex activities of striated muscle tissue of healthy mice we investigated the effects of ozone/oxygen mixture and oxygen on citrate synthase (cs) and succinate dehydrogenase (sdh) activities of striated muscle tissue of healthy mice. thirty-six mice were included the study. firstly muscle samples were taken from all mice's left thigh muscle in under anesthesia (group ). secondly mice were randomly divided in four groups as: group : oxygen was given once at days for days, group : ozone/oxygen was given once at days for days, group : oxygen was given once at days for days, group : ozone/oxygen was given once at days for days. ozone/oxygen mixture and oxygen were given at a dose of mg/ kg groups ( ) ( ) ( ) ( ) . after treatment animals were sacrificed, and muscle samples were taken and stored in À °c for until the analyses. muscle tissues were homogenized in . m tris-hci and . m kci. cs and sdh activities were measured with spectrophotometer. cs and sdh activities were expressed as lmol/min/g tissue. cs and sdh activity results were given as mean ae sd. cs activity has been found in group ( . ae . ), group ( . ae . ), group ( . ae . ), group ( . ae . ) and group ( . ae . ). sdh activity has been found in group ( . ae . ), group ( . ae . ), group ( . ae . ), group ( . ae . ) and group ( . ae . ). there was no statistically significant difference among all groups in terms of cs (p > . ) and sdh activities (p > . ). there was no difference between all groups in terms of inflammation, muscle fiber size, regeneration or necrosis. vascular structures, connective tissues, lipid and glycogen content of fibers were normal. cytochrome oxidase activity was also normal. ratio of ragged blue fibers of all groups were less than . %, so they were scored as . there was no difference among groups for ragged red fiber content. we have not found a significant effect of ozone/oxygen mixture and oxygen on cs and sdh activities of striated muscle tissue of healthy mice. lipidic cubic phases (lcps) consist of bicontinuous lipid bilayers and water channels. lpcs are widely used for membrane proteins crystallization and further determination of their spatial structures by means of x-ray crystallography. this approach was successfully used for studying g-protein coupled receptors structures. usually crystallization initiates by adding the precipitants (buffers with high salt concentrations). here we propose to use photo-switchable analogs of -monoolein to change lattice parameter of lpc. we synthetized a number of novel diazo-analogs of -monoolein. their structures were confirmed by nmr-spectroscopy and mass-spectrometry. being incorporated in phospholipid vesicles or detergent micelles they subjected to trans-to cis-isomerization under the light exposure at nm. also we characterized the lcp's structures and properties by small-angle x-ray scattering on the rigaku instrument. one of the synthetized compounds, -( -{-[ -(octyloxy) phenyl] diazenyl} phenoxy) propane- , -diol ( % mol), was incorporated into the -monoolein cubic phase. according to small-angle x-ray scattering data the structure of the monoolein cubic-pn m phase with lattice parameter . angstrem was not affected by insertion of this photo-switchable monoolein's analog. after the light exposure at nm we observed trans-cis-isomerization. in the same time the cubic-pn m phase was not changed but the lattice parameter reduced to . angstrem. this effect on monoolein lpc is similar to the addition of a precipitant to initiate protein crystallization process. the spontaneous return to the initial lattice parameter was completed after days in dark. thus, we demonstrated the possible controlling of the monoolein cubic phase lattice parameters by adding the photo-switchable diazo-derivatives of monoglyceride analogs, which can be used for crystallization of membrane proteins. evaluation of certain protein and phosphoprotein expression levels by using western blot technique in head and neck squamous cell carcinoma a. kalayci yigin , t. cora cerrahpasa faculty of medicine, istanbul university, istanbul, turkey, faculty of medicine, selcuk university, konya, turkey introduction: head and neck squamous cell carcinoma (hnscc) is a primer tumor type in head and neck cancers, characterized by aggressiveness, early recurrence and metastasis. while alcohol and smoking play an important role at pathogenesis of disease, deregulation of some signaling pathways, genes and protein levels related to these pathways are considered as important at contribution of development of hnscc. materials and methods: in this study, protein and phosphoprotein expression levels of the frequently phosphorylated sites (egfr, pegfr, igf-ir, pigf-ir, pdgfrb, ppgdfrb, pten, ppten, akt and pakt) were investigated by using a western blot to confirm the expression of mrna in the context of protein levels at normal-tumor tissues of hnscc and sccl-mt that is a hnscc tumor cell line and hek- that is a normal cell line. results: as a result of western blot analysis egfr, pdgfrb and igf- r were detected as highly overexpressed cell surface receptors in tumor tissues of hnscc. discussion and conclusion: the findings of this study revealed the overexpression of other cell surface receptors as well as egfr in hnscc. in conclution, potential pathways were identified by determining the cell surface receptors overexpressed in hnscc, these data support each other and may be important in pathogenesis of hnscc. introduction: the investigation of final products of lipid peroxidation is considered as the main mechanism involved in development of pathogenesis, diagnostics and prognosis of various parasitic illnesses. materials and methods: the concentration of lp-ap in the blood was determined in the study group considered of women ( %), and men ( %). results: before antiparasitic treatment, women infected with g. intestinalis showed a statistically significant . times increase of gpx activity levels; and . times ada level increase compared to the control group. after the treatment, the cat activity showed a sharp increase, whereas the ada activity decreased by . times, compared to the average level before the treatment. the results of the blood samples of the infected men with giardiasis, show the statistically significant increase in the level of all the studied parameters of lipid peroxidation, except the total primary production (tpp). the exception was the mda level, remaining significantly increased, in contrast to the control group and to the condition after antiparasitic treatment. in infected men, the level of cat activity was more than . times higher than that noted in control group. after treatment the levels of ada activity and gpx returned to the values of the control group, while the level of cat activity remained elevated. conclusion: an accumulation of primary and secondary metabolites in the course of giardiasis seems to confirm its involvement in the induction of oxidative-antioxidative homeostasis. antiparasitic treatment in giardiasis leads to normalization of the ap parameters studied in women and men, except the mda content in the blood of men. therefore, additional antioxidant treatment is advised for the antiparasitic therapy of men. in vitro effects of ethanol on rat brain synaptosome and dose-dependent antioxidative role of boric acid ethanol is a psychoactive drug that is very large and used frequently today. it has suppressive effects brain's comminication pathway. depending on its acute or chronic use and the dose, ethanol increase membrane fluidity and it causes oxidative stress. this study deals with the in vitro effects of ethanol toxicity ( mm) and potential protective effect of different doses of boric acid (ba) ( , and mm) on rat brain synaptosomes. with this aim, five male spraque dawley rats are killed by decapitation under anesthesia. after the frontal cortexes of the rats are taken out, each of them is divided into four pieces. these pieces were used as a sample in five groups (control, ethanol, ethanol+ mm ba, ethanol+ mm ba, ethanol+ mm ba) which include six samples. the synaptosomal fractions are prepared by the homogenization of the frontal cortex pieces and centrifugation for each samples. as markers of ethanol-induced oxidative stress in the synaptosome of the rats, malondialdehyde (mda), nitric oxide (no) and catalase (cat) levels were measured. mda levels in the ethahol group were a quantity increased compared with those in the control group but it unchanged significantly as statistically (p < . ). however the mda level in the ethanol+ boric acid ( mm) group was shown to be significantly decreased compared with that in the ethanol group (p < . ). the cat activity of the ethanol group was significantly higher than that in the control group and cat activity of the ba ( mm, mm) groups were close compared with control groups (p < . ). no levels in ethanol groups were decreased but unchanged compared with control groups as statistically. neverthless, no levels in ethanol+ boric acid ( mm) groups were increased (p < . ). these results demonstrate that ethanol ( mm) is capable of triggering damage to rat brain synaptosome and ba could be influential in antioxidant mechanisms against oxidative stress resulting from ethanol exposure. acute myeloid leukemia (aml) is the most common form of acute leukemia in adults and its incidence increases with age. carbonic anhydrases (cas) are zinc-containing enzymes. these enzymes catalyze a very simple physiological reaction, the inter conversion between carbon dioxide and the bicarbonate ion, and are thus involved in crucial physiological processes connected with respiration and transport of co /bicarbonate between metabolizing tissues and lungs, ph and co homeostasis, electrolyte secretion in a variety of tissues/organs, and biosynthetic reactions and many other physiologic or pathologic processes including reproductive tract. investigation of autoantibodies in aml patients have been popular research area in recent years. the aim of the current study was to investigate carbonic anhydrase i and ii (ca i and ii) autoantibodies in the serum of subjects with aml based on the information and considerations of autoimmune relation of acute myeloid leukemia. anti-ca i and ii antibody levels were investigated by enzyme-linked immunosorbent assay method (elisa) in serum samples of thirty patients with aml and thirty healthy peers. anti-ca i and ii antibody titers of aml group were significantly higher compared with the control group (p = . ), (p = . ), respectively. we found significant positive correlation between anti-ca i antibody and anti-ca ii antibody titers in patients with aml (r = . , p = . ). we found significant positive correlation between anti-ca i antibody and anti-ca ii antibody titers in women and the men (r = . , p = . ), (r = . , p = . ), respectively. at an anti-ca i cut-off point of . absu, sensitivity was % and specificity %. at an anti-ca ii cut-off point of . absu, sensitivity was % and specificity %. the ca i and ca ii autoantibody levels in patients with aml were found higher compared to control group and the results suggest that ca i and ca ii autoantibodies may be involved in the pathogenesis of aml. aim: behc ßet's disease (bd) is a systemic autoimmune disease. recurrent oral and genital mucosal ulcers, uveitis, and skin lesions are characteristic findings for bd. platelet-lymphocyte ratio reflects a novel marker for romatological diseases. the aim of this study was to investigate the platelet/lymphocyte ratio in behc ßet's disease. methods: whole blood samples were collected from healthy control and patients with behc ßet's disease. the mean age for controls and patients were ae . and ae , respectively (p = . ). patients with chronic disease and inflammatory disorders were excluded. thrombocyte and lymphocyte counts were analyzed with abbott cell dyne heamotolgy analyzer. statistical analysis was performed with ibm spss v . results: platelet counts were higher but not statistically significant in patients with behc ßet's disease compared to control group ( ae vs. ae ) (p = . ). lymphocyte counts were lower in patients with behc ßet's disease compared to control group ( . ae . vs. . ae . ) (p = . ). platelet/lymphocyte ratio was higher but not statistically elevated in patients with behc ßet's disease compared to control group ( ae vs. ae ) (p = . ) conclusions: platelet/lymphocyte ratio (nlr) and mean platelet volume (mpv) as inflammatory markers recently became popular because of their simplicity, cost effectivity and their advantages to predict clinical prognosis of specific diseases. according to this study's results, platelet/lymphocyte ratio must be analyzed in vast scale patient populations to identify the disease. objectives: systemic lupus erythematosus (sle) is a chronic relapsing autoimmune disease characterized by production of autoantibodies against a series of nuclear antigens and by chronic inflammation. in recent years, neutrophil-lymphocyte ratio (nlr) was determined to be a good indicator of inflammatory status. nlr can be easily calculated from a whole blood count. introduction: neuroblastoma, an embryonal malignancy, is the most common extracranial solid tumor of childhood. untreated neuroblastoma tumors and cell lines are reported to have reduced hla class i expression, rendering them potentially susceptible to natural killer cell killing due to lack of engagement of hla class i-specific inhibitory killer cell immunoglobulin-like receptors (kirs). the aim of this study was to investigate whether kir genes could influence the risk of neuroblastoma and prognosis of the patients. materials and methods: study group consisted of neuroblastoma patients ( male, female, median age: months) followed at the pediatric oncology clinic of c ß ukurova university medical faculty. control group consisted of healthy children. patients had stage , , or s disease, patients had stage disease. different kir genes were analysed by sequence specific oligonucleotide probe (ssop) analyses. statistical analysis were done using fisher's exact test. results: compared to the control group, neuroblastoma patients had lower expression of activating kir gene, kir ds (p = . ), and higher expression of inhibitory kir gene dl (p = . ). additionally kir ds genes were more common in patients with early stages (stage , , or s) (p = . ) and kir dl genes were more common in patients with stage (p = . ). furthermore, there were no statistically significant differences between the rate of aa and bx genotypes and their centromeric/ telomeric regions of patients and controls. discussion: kir dl gene can have a triggering effect in neuroblastoma pathogenesis; whereas kir ds can have a protective role. investigating nk cell infiltration and kir receptors in neuroblastoma tissue samples will give more insight to the pathogenesis p- . . - neuroprotective and immunomodulatory effects of urtica urens s. arslan , g. terzioglu , b. kabalay , a. r. tufekci , a. sen , i. demirtas department of biology, faculty of arts and sciences, pamukkale university, denizli, turkey, deparment of chemistry, faculty of arts and sciences, c ß ankiri karatekin university, c ß ankiri, turkey urtica urens (small stinging nettle) has been used for medical purposes in turkey as an alternative therapy. it has been used in the treatment of inflammation that is early, non-specific immune reaction to tissue damage or pathogen invasion, plays an important role in the initiation of neurodegenerative disorders such as multiple sclerosis. however, there are limited studies that investigate anti-inflammatory activity of urtica. therefore, aim of this study is to find out theanti-inflammatory effect of chloroform extract in caco- cell line. for this purpose, firstly, chloroform extract of urtica leaves was prepared. chemical composition of extract was determined by lc-ms. the effect of chloroform extract on selected pro-inflammatory and inflammatory proteins such as tumor necrosis factor-a (tnfa), nuclear factor kappa b (nf-jb), c-x-c motif chemokine (cxcl ), and (cxcl ) were determined. whole genome transcriptome analysis was performed by using human ht- v beadchip. extract treatment caused % and % increases in protein and mrna levels of nf-jb, respectively. on the other hand, tnf-a protein and mrna levels decreased significantly ( % and %, respectively). similarly, cxcl and cxcl mrna levels decreased % and %. transcriptome analysis showed that probes were significantly changed (p < . ). pathway analysis revealed that the extract altered a group of genes involved in immune response, calcium ion homeostasis and transport, potassium channel complex, g-protein coupled receptor protein signalling pathway, etc. it is well established that calcium is very critical for brain cell death and formation of many brain disease including multiple sclerosis. these observations suggests that urtica maybe used in neurodegenerative diseases. in order to further test this hypothesis experimental autoimmune encephalomyelitis experimentsand activity guided fractionations have been still continuing. this work is supported by tubitak t . p- . . - linear low molecular weight a- , -glucan from bifidobacterium bifidum bim b- d is implicated in pathogenesis of celiac disease the bifidobacteria are recognized as human commensals and widely used as probiotics. earlier, we have found (kiseleva et al., benef. microbes, , ( ) : - ) that bifidobacterium bifidum bim b- d contains low molecular mass ( - kda) a- , glucans (g anti-tpo and g anti-tg ) that interact selectively with human autoantibodies to thyroid peroxidase (anti-tpo) and thyroglobulin (anti-tg), recognized markers of autoimmune thyroid disease (atd). the aim of the study was isolation and identification of b. bifidum bim b- d biopolymers (bps) interacting selectively with autoantibodies to tissue transglutaminase (anti-ttg) and antibodies to gliadins (anti-gl), recognized markers of celiac disease (cd). we used affinity chromatography with anti-gl, size exclusion chromatography, h and c nmr spectroscopy, elisa with immobilized bps, tissue transglutaminase (ttg) and gliadins (gl) as positive controls. the bp isolated by affinity chromatography with anti-gl (as more available marker of cd) and size exclusion chromatography was identified by two-dimensional nmr spectroscopy as - kda linear a- , -glucan identical to g anti-tpo and g anti-tg . the functional activity of the bp named g anti-gl , viz., ability to interact selectively with anti-ttg and/or anti-gl was proven by elisa with (i) serum samples of cd patients containing either both anti-ttg and anti-gl without anti-tpo and anti-tg or anti-gl without anti-ttg, anti-tpo and anti-tg vs. serum samples of healthy donors without four types of antibodies and (ii) pure anti-gl vs. pure total igg (without anti-ttg, anti-gl, anti-tpo, anti-tg). since (i) serum samples of cd patients do not contain anti-ttg without anti-gl and (ii) pure anti-gl isolated by affinity chromatography with gliadins (gl) cross reacts with tissue transglutaminase (ttg), additional studies with pure anti-ttg are necessary to find out which of the two antibodies, anti-ttg and anti-gl, bind g anti-gl . in conclusion, we proved that b. bifidum bim b- d cells contain linear low molecular mass a- , -glucan, g anti-gl , that interacts selectively with anti-ttg and/or anti-gl. since g anti-gl is identical to earlier found g anti-tpo and g anti-tg , we hypothesize that the a- , -glucan is implicated in pathogenesis of both autoimmune diseases, cd and atd. influences of elevated serum ferritin levels on insulin resistance and non-insulin-dependent diabetes mellitus (niddm) have predicted either because of increased body iron stores or influenced by several inflammatory diseases. low serum hydroxyvitamin d is known to perturb cellular function in many tissues, including the endocrine pancreas, which are involved in obesity and niddm. we planned to investigate the association between hydroxyvitamin d with hematologic parameteres and iron status in obesity vs. diabetic patients. study groups consist of control, non-diabetic obese, obese-diabetic and lean-diabetic groups. serum triglycerides, total cholesterol, ldl-c, hdl-c, fasting glucose, hba c, uric acid, creatinine, ggt, -hydroxyvitamin d, insulin, crp, esr, total blood count and iron status. apart from the three parameters, there were no significant difference (p > . ) between groups. serum ferritin and mchc levels were significantly higher in lean-diabetic patients (p < . ). on the other hand, rdw are determined to be significantly lower (p < . ) in the non-diabetic obese group. no difference was detected in -hydroxyvitamin d levels between the control and the study groups (p > . ). non-diabetic obese patients had significantly (p < . ) higher levels of tg and lower levels of hdl compared to obese-diabetics. insulin levels were higher in nondiabetic obese and obese-diabetics than lean-diabetics (p < . ). this study provides evidence that lean diabetic patients show higher ferritin and mchc levels than obese patients. the increase in serum ferritin and mchc levels is related with altered iron metabolism at cellular level. at late mitosis, the mother cell divides, leaving two daughter cells connected by a thin intercellular bridge (icb). during abscission of the icb, the ingression of the cleavage furrow is formed, and the central spindle microtubules are compacted into the structure known as midbody (mb). the mb is situated within the icb, with the abscission usually occurring at one side of the mb. as a result, only one daughter cell inherits the post-mitotic mb. these mbs can then either accumulate in the cytoplasm or be degraded. recent studies have identified mbs as novel signaling platforms regulating stem cell fate and proliferation. indeed, stem cells as well as cancer cells were shown to accumulate post-mitotic mbs, resulting in reprogramming of the cell fate and conversion to highly-proliferative, stem cell-like phenotypes. it has been proposed that regulated macroautophagy may be playing a key role in mediating pots-mitotic mb degradation. therefore, the experimental approach involved studying the dynamics and function of a protein known as fyco , which associates with postmitotic mbs and may regulate their degradation. in this study we identified fyco as a protein, which associates with post-mitotic mbs and may regulate their degradation. interestingly, fyco is also known to be present on autophagosomes, and overexpression of fyco can induce the formation of enlarged lc -containing autophagocytic structures. here we demonstrate that fyco knock-down leads to defects in autophagic mb degradation, and that fyco functions by targeting endocytic membranes to the autophagic phagophore during early stages of mb degradation. additionally, we showed that fyco depletion leads to increased proliferation and cell growth in soft agar. based on all these data, we hypothesize that fyco mediates selective mbs degradation via endosome-dependent extension of the phagophore around the post-mitotic mbs, and that mbs may be the regulators of cancer proliferation and progression. p- . . - proliferative effect of hypericine on human skin fibroblast cells and identification of the mechanism of action in molecular level to drawbacks associated with efficiency and viral genome integration. in order to improve reprogramming efficiency and compensate for viral transduction, new chemicals have been explored through ipsc research. the aim of this study was to investigate the proliferative effect of hypericine on human skin fibroblast cells (sf) in-vitro, and to identify the mechanism of action in molecular level. the proliferation was measured using the clonogenic and dimethylthiazol diphenyltetrazolium bromide (mtt) assays. real-time quantitative polymerase chain reaction (qrt-pcr) was performed to detect the mrna levels of cyclins (d and b ) and cell cycle controller genes (p and p ). sf cells were treated with different doses ( nm- lm) of hypericine for h and h. a significant cell proliferation was observed in moderate concentrations ( . - lm; % -% ), but at high concentrations ( - lm) cytotoxic effects emerged in sf cells (ic = . m, r = . ). qrt-pcr results revealed that the most proliferative dose of hypericine ( lm) stimulates cyclin d . the anti-proliferative activity of hypericine was accompanied by inhibition of cyclin b mrna, whereas it induced expression of p and p genes, and thus apoptosis was observed by dna laddering at the same dose ( lm). overall results suggested that hypericine can compensate for viral transduction and improve reprogramming efficiency of ipscs by enforcing them in g phase. hence we report that hypericine can be a good candidate component for cocktails produced to trigger ipsc proliferation. glioblastoma (gbm) is the deadliest brain tumor. the mean survival time of gbm patients is approximately months, increasing to months after treatment with temozolomide, which is the gold standard chemotherapy. the resistance of gbm to chemotherapy seems to be associated with the blood-brain barrier (bbb) that limits the delivery of chemotherapeutics, and the presence of a population of cells that expresses stem cell-like properties, which are known to be chemo-and radioresistant, the glioblastoma stem cells (gscs). the difficulties imposed by these two factors could be reduced by the use of a targeted drugdelivery liposome-based strategy that allows bbb passage and reduces the side effects of chemotherapeutics. the present study evaluated the ability of the f peptide-targeted ph-sensitive lipid-based nanoparticle containing doxorubicin (dxr) to target gscs and non-gscs. we evaluated the expression of cell-surface nucleolin by flow cytometry, as well as of stem cell-like markers, in two gbm cell lines. we also determined the ability of gbm cell lines to specifically uptake the f peptide-targeted ph-sensitive lipid-based nanoparticles, by flow cytometry, and correlated it with the expression of stem cell-like markers. moreover, to ascertain the impact of intracellular delivery of chemotherapeutic drugs into gbm cell lines, cytotoxicity was further assessed by the mtt assay. our results showed that the f peptide-targeted ph-sensitive lipid-based nanoparticles successfully targeted glioblastoma cells and particularly gscs. in addition, the results also provided evidence of the nucleolin overexpression-dependency of this strategy, emphasizing the need to adapt the therapeutic strategy to the individual patient. this study showed that f -targeted ph-sensitive liposomes may constitute an appropriate strategy to overcome the chemoresistance associated with glioblastoma cells. p- . . - leukemic cell plasticiy as a resistance mechanism towards tyrosine kinase inhibitors chronic myelogenous leukemia (cml) is a hematopoietic stem cell disease characterized by the t( ; )(q ;q ) translocation, which encodes the chimeric tyrosine kinase onco-protein, bcr-abl. the tyrosine kinase inhibitor (tki) imatinib is the first-line treatment for patients with cml. unfortunately drug resistance is one of the main problems observed. while secondary resistance is associated with bcr-abl kinase domain mutations, oncogene amplification and mechanisms interfering with intra-cellular drug concentrations; primary resistance mechanisms haven't been elucidated. we generated high dose imatinib-resistant k subclones (k -ir) by clonal selection to study primary resistance mechanisms in vitro. drug resistance was shown by caspase and annexin v/pi assays. we also showed cellular uptake and function of imatinib with western blot technics. k -ir cells are not only resistant to imatinib but also to nd, rd generation tyrosine kinase inhibitors. we demonstrated that k -ir cells have a highly adherent character, proliferate slowly and are resistant to drug-induced senescence. microarray analysis revealed that k -ir cells differentially express tissue/organ developement and differentiation genes at high levels. we showed that k -ir cells forms intact tumor spheroids in d cell culture conditions which is a marker of tumor initiating potential. cell surface maker analyses and protein analyses of k -ir cell population, points towards an epithelial-mesenchymal plastic cell capable of adopting different morphologies. we hypotizied that imatinib and other tyrosine kinase inhibitors may cause the gain of phenotypic plasticity potential in leukemic cells, by interfering with signalling pathways; which in itself may lead to therapy resistance. hypoxia has multiple effects on cancer cells, which are critically involved in tumor progression. hypoxia leads to changes in tumor cell metabolism and can promote cancer cell survival, invasion and metastasis by its critically important role on maintenance of cancer stem cell (csc) phenotype. in this research, human cd + cscs isolated from human osteosarcoma cell line saos- using macs magnetic separation technique were characterized, and their stemness properties under hypoxic ( % o ) and normoxic ( % o ) conditions were compared in two and three dimensional culture conditions. two different d culture techniques (nanofibrous bacterial cellulose scaffolds and scaffold free microtissues) were used to evaluate effects of hypoxia on csc behavior, and the results were compared with the cell behavior in classical d culture systems. the morphologies of cells were examined by scanning electron microscopy (sem); rt-pcr and immunocytochemistry staining were used to examine the cancer stem cell phenotype maintenance under hypoxic and normoxic conditions. it is shown that hypoxia supports the expression of stemness markers such as oct / , nanog and sox compared to normoxic conditions in d cultures. although similar effects of hypoxia were observed in d cultured cscs, the expression levels of stem cell phenotypeindicative markers were significantly lower on d compared to d culture systems. this study is seen as an introduction to develop a more relevant d hypoxic cancer stem cell based tumor model to study csc behavior and tumor genesis in vitro for testing of novel cancer stem cell therapeutics and to understand signal transduction in cancer stem cells. prostate cancer (pca) is the second most frequent cause of cancer-specific mortality in the world. cancer stem cells (cscs) are a subpopulation of cells that involved in drug resistance, metastasis and recurrence of cancers. the efficacy of natural flavanone apigenin on cell survival, apoptosis and migration of cscs were evaluated. cd + cscs were isolated from human pca pc cells using a magnetic-activated cell sorting system. pc and cscs were treated with different concentrations of apigenin, docetaxel and combinations of the two agents for h. apigenin dose dependently inhibited cscs and pc cell viability, and this was accompanied with a significant increase of the cell cycle inhibitors p and p (kip ). the flavonoid significantly induced apoptosis via an extrinsic caspase-dependent pathway by upregulating the mrna expressions of caspases- , - and tnfa, but failed to regulate the intrinsic pathway as determined by the bax, cytochrome c and apaf- in cscs. in contrast to cscs, apigenin induced intrinsic apoptosis pathway as evidenced by the induction of bax, cytochrome c and caspase- while caspase- , tnf-a and bcl- levels remained unchanged in pc cells. the ability of apigenin to inhibit the proliferation of cscs through apoptosis was confirmed by tali image-based cytometer. the flavanone strongly suppressed the migration rate of cscs compared to untreated cells. significant downregulation of mmp- and - exhibits the ability of apigenin treatment to suppress invasion. the expressions of pi k/akt and nf-kb p / p were significantly decreased after h apigenin treatment. taken together, these data demonstrated that flavonoid apigenin is an invaluable chemopreventive compound that inhibits proliferation, invasion and the stemness properties of cscs. this study was funded by the scientific and technological research council of turkey (tubitak, grant no. s ). (pi k), are frequently found in patients with severe early-onset segmental overgrowth. whilst differences in timing and location of the founder mutation are likely to explain part of the observed disease heterogeneity, it is less clear whether and how quantitative differences in the strength and timing of pi k activity contribute to phenotypic variability. our aim is to characterise pik ca mutant-specific signalling as well as to explore the effects of varying the strength and/or temporal pattern of pi k activation on downstream output specificity in the cell. we are currently employing crispr/cas mediated gene editing in human induced pluripotent stem cells to generate isogenic disease models of three such activating pik ca mutations. these cells will be used for signalome profiling by reverse-phase protein arrays (rppa) to compare and contrast mutant-dependent alterations to candidate signalling networks. in parallel, ongoing efforts focus on developing an endogenously expressed optogenetic p a, allowing precise spatiotemporal control over pi k signaling to unravel the extent to which pi kdependent phenotypes are determined by strength of activation and/or dynamic encoding. ultimately, the outcome of this research will yield novel insight into fundamental aspects of pi k signalling and potentially aid the development of targeted therapies for human diseases of pi k hyperactivation. e. gov, n. kaya, k. y. arga cancer stem cells (csc) have been proposed to be the cancer initiating cells. because of their highly tumorigenic and drug resistant properties, cscs offer significant potential for developing novel anticancer drugs and therapeutic strategies. in the present study we analysed eight gene expression datasets for breast, ovarian, lung cancer and glioblastoma by comparing gene expression levels between stem cells and tumor cells and integrating them with genome scale biological networks. consequently, mutual molecular signatures (i.e: differential expressed genes, transcription factor, mirna) and biological characteristics were determined via integrative analyses, which might be feasible to uncover the mutual biological mechanism insights behind the cscs. it was identified twenty mutual differential expressed genes in four cancer types; jun and klf as transcription factors, egfr and cdk as receptors come into prominence as mutual signatures. molecules and pathways that were related to mapk, wnt, p signaling and pathways in cancer were the common indicators in csc types. our results provided similarities in gene expression profiles of various cscs and gave clues about the seed of tumorigenesis. this study proposed signatures and pathways that could be considered as effective therapeutic approaches in further experimental and clinical applications to eliminate subpopulation of csc. colorectal cancer (crc) is one of the leading causes of mortality worldwide. metastasis is associated with the presence of circulating tumor cells (ctcs) in the peripheral blood of cancer patients. ctc cut-off values have been shown to predict for poorer overall survival in metastatic breast (≥ ), prostate (≥ ), and colorectal (≥ ) cancer based on assessment of . ml of blood. in our study, ctcs were detected in blood samples of colorectal cancer patients, using with our modified convenient method for the strategies of ctc enrichment and detection. . ml peripheral blood samples were firstly collected and peripheral blood mononuclear cells (pbmcs) were isolated from the fresh blood samples by ficoll gradient separation. next, the leukocytes in pbmcs were removed by magnetic microbeads conjugated with cd for a negative selection. finally, the retained cells were labeled with anti-epithelial cell adhesion molecule (anti-epcam), cytokeratins (ck , ck ) and the leukocyte-specific marker as anti-cd . all samples were analyzed by bd facs aria iii flow cytometry. in total, patients and healthy people were included in this study. the results showed that ctcs were not detected in the blood samples of healhty volunteers, but - ctcs were detected with ck , , , -based gating strategy in the blood samples of colorectal cancer patients. it is accepted that the cut off value is ctcs for colorectal cancer and ctc is negative if it is below this value or ctc is considered as a positive, if it is equal to or above this value, which might be an indication for poor prognosis. thus ctc's detection may serve a representative surrogate tumor biomarker for real-time monitoring of disease status and tailoring personalized therapy. cells were grown in culture flasks in a humidified incubator at °c with % co and were used at the proliferation and confluent stages. cultured cells were exposed to the pemf and prfe. the proliferations of the cells are measured by mtt assay for the effect of emf on the cancer cells. on the other hand the wound healing was investigated by closure of the wound by the cell proliferation with cell morphology using inverted microscope images. the proliferation decreased significantly by the effect of pemf on the semi confluent mcf- and mda-mb- cells. this effect was observed more prominent on mcf- . considering prfe therapy this effect is much more pronounced especially for mda-mb- comparing with pemf. the phase contrast observations of these results were consistent with mtt analyses. similarly, this effect was seen less for pemf but the proliferation was more suppressed with prfe on the wound models. it was considered that the emf applications could be effective in cancer cells, but this effect has not been studied how it occurs in invasive cancers. in our cell culture study, the appropriate emf applications were found to be effective though the inhibition of proliferation of cancer cells even in invasive cancer but with lower effect. this means that emf applications may support the existing treatment methods of cancer patients and even people who suffer from invasive cancer. metastasis is the one of the most known causes of death in patients diagnosed with cancer. circulating tumor cells (ctcs) are shed from primary tumors and circulating in the bloodstream, and thought to play a key role in metastasis. a hypothesis that ctcs may contribute to metastasis was first introduced in the mid th century by thomas ashworth, an austrilian pathologist. in today's research, identification and molecular characterization of ctcs are thought to be a novel target for treatment of cancer and a key factor to understand the metastatic process. existing methods of ctc capture based on the cell search system, flow cytometers, laser scanning cytometers instruments, fiber-optic array scanning technology (fast), isolation by size of epithelial tumor cells (iset), and definition fluorescence scanning microscopy. ctcs are increasingly considered as a 'liquid biopsy' and when liquid biopsy is compared to tumor tissue biopsy, liquid biopsy for ctcs detection can be carried out routinely in patients due to accessibility and ease of blood collection. also, primary tumor sampling may not reflect the actual metastatic conditions, ctcs are thought to be a novel tumor biomarker for real-time monitoring of disease status and tailoring personalized therapy. with futher works, ctcs may be used as liquid biopsies and it might provide better understanding metastatic process, new approaches in cancer diagnostics and treatment. mesenchymal stem cells (mscs) are distributed all over the organism as a source of tissue formation and regeneration. glucose is vital for the proliferation and differentiation of mscs. glucose uptake is mediated by specific glucose transporters of two families, the na-coupled glucose transporters (sglt) and glucose transporter facilitators (glut). the presence and function of glut proteins in human placental amnion derived mscs (hamscs) is unknown. we aimed to investigate the presence of glut , glut , glut proteins and genes in hamscs isolated from term placentas. mscs were isolated from human term placenta amniotic membrane, the characterization of cells were provided by flow cytometry. mscs were used to assess their chondrogenic, osteogenic and adipogenic differentiation potential. the expression of glut , glut and glut proteins was detected in hamscs by immunofluorescence. glut , glut , glut protein and gene expression in these cells were investigated by western blot and real-time pcr, respectively. flow cytometry analysis results of isolated cells showed that they were positive for cd , cd , cd , cd (mesenchymal stem cell markers) and hematopoietic markers cd , cd b, cd , cd and hla-dr were negative. the presence of glut , glut , glut proteins and genes were identified in hamscs. in this study, for the first time in literature, glut , glut and glut gene and protein presence was determined in hamscs. therefore, gluts could mediate glucose transport in human amniotic membrane mscs. proliferation and differentiation of mscs in vitro are still not optimized. further studies are required to clarify the complex mechanisms regulating the relationship between glucose and mesenchymal stem cells. disclosure of this relationship may provide a better understanding of glucose-related pathologies such as diabetes. tumors have hierarchically organized heterogeneous cell populations and a small subpopulation of cells, termed cancer stem cells (cscs), is responsible for tumor initiation, maintenance as well as drug resistance. therefore, killing the cscs along with the other cancer cells is gaining an importance. in the present study, it was aimed to evaluate the cytotoxic and apoptotic activity of a novel platin (pt) (ii) complex [pt(hepy) cl ] on mammospheres obtained from mcf- human breast cancer line. elevated expression of stemness markers were determined by western blotting. cytotoxicity was assessed using the atp viability assay. effect of the pt (ii) complex on the formation and development of mammospheres was analyzed with sphere formation (sfa) assay. apoptosis was determined via cytofluorimetric analysis (caspase / activity, annexin-v-fitc and bcl- activity) as well as gene expression analysis. cytotoxicity was confirmed with the atp viability assay after the treatment with zvad-fmk (an apoptosis inhibitor) and necrostatin (a necroptosis inhibitor). in addition, alterations in mitochondrial membrane potential were evaluated by jc- staining. mammospheres exhibited increased oct- and sox (stemness markers) expressions compared to parental mcf- cells. cytotoxicity by pt (ii) complex was evident in a dose-dependent fashion ( . - lm) . pt (ii) complex significantly prevented mammosphere formation and disrupted mammosphere structure in a dose-dependent manner. pt (ii)-induced apoptosis was determined based on the presence of caspase / activity, annexin-v-fitc positivity and bcl- inactivation. apoptosis was also confirmed with increased tnfrsf a and hrk gene expressions. in addition to apoptosis, necroptosis was also present as evidenced with increased mlkl expression. mitochondrial membrane was depolarized. in conclusion, the pt (ii) complex seems to be a powerful apoptosis-inducing compound on cancer stem cells, thereby warrants further in vivo experiments. cancer is a disease which arises from destruction of growth and proliferation mechanisms in cells and is the second leading cause of death worldwide [ ] . in the development of primary cancers, the head and neck cancer is accounting for approximately . new cases annually around the world [ ] . laryngeal cancer is a type of head and neck cancer in which malignant cells arise from the mucosal tissues of the larynx [ ] . cancer might spread from primary tumor by getting into the lymph and blood vessel system and forms secondary tumor. greater than % of deaths in cancer patients are attributed to metastasis [ ] . circulating tumor cells (ctc's) provide an opportunity to understand the metastatic process of cancer patients. identification and molecular characterization of ctc's in the peripheral blood of cancer patients is a promising research area in the field of biomarker development and novel treatment targeting in today's cancer research [ ] . the detection of ctc methods include cell search system, flow cytometry, high-definition fluorescence scanning microscopy, fiber-optic array scanning technology, isolation by size of epithelial tumor cells, and laser scanning cytometers [ ] . in our study, . ml of peripheral blood samples were collected from larynx cancer patients and healthy volunteers and the samples were analyzed by bd facs aria iii flow cytometry via biomarkers epcam, ck , ck for positive selection and cd for negative selection [ ] . according to the results of our study; ctcs were detected in larynx cancer patients by our newly modified method whereas there was no ctc's detection in the samples of controls. thus, this study may provide us monitoring of the treatment process of larynx cancer and this method might be used as diagnostic, prognostic, and predictive biomarkers in cancer therapy as a liquid biopsy. prostate cancer is the second most common cancer and the fifth leading cause of death from cancer in men . circulating tumor cells (ctcs) present in the peripheral circulation of cancer patients with different solid malignancies including prostate cancer and have a potential as a liquid biopsy to monitor disease progression and response to therapies at cell and molecular level . one of the general methods in ctc detection is flow cytometry . radical prostatectomy is the most frequently applied procedure in the surgical management of localized prostate cancer. in this surgical operation, the surgeon removes the entire prostate gland with the seminal vesicles. a radical prostatectomy procedure can be done using the da vinci robotic system (intuitive surgical, sunnyvale, ca, usa) . robotic surgery has been suggested to have fewer complications, lower risk of infections and shorter recovery period following robotic radical prostatectomy , . in this study, our aim was to detect ctcs before and after robotic radical prostatectomy in clinical localized prostate cancer patients. the ctc detection study was performed with our modified method in which . ml of peripheral blood samples were collected from each prostate cancer patient and healthy individual; the samples, using with biomarkers epcam, ck , ck for positive selection and cd for negative selection, were analyzed by bd facs aria iii flow cytometry . according to our results, we detected ctcs in the peripheral blood samples of prostate cancer patients before robotic radical prostatectomy. however, following this surgical procedure no ctc or decreased number of ctss was detected. our study might contribute to understand disease progression after robotic radical prostatectomy in clinically localized prostate cancer patients that warrants further research. keywords: circulating tumor cells, prostate cancer, flow cytometry, robotic radical prostatectomy. p- . . - determination of effect cytotoxic, apoptotic, caspace- activity and mrna expression levels of apoptototic related genes of vulpinic acid on breast cancer cell lines n. kilic ß, s. aras, d. cansaran-duman ankara university, ankara, turkey breast cancer is the most common cancer types in women. several drugs used to treat breast cancer patients are developing resistance to the treatment for this reason success rate falls. therefore the discovery of alternative therapeutic agent and molecular detection of anticarcinogen effect because of treatment for cancer patients may be a source of hope for the contributions. in this study, different concentrations ( . , . , . , . , , , lm) vulpinic acid (va) lichen seconder metabolite was determined to cytotoxic, apoptotic effect and caspase- activity in breast cancer cells (mda-mb- , mcf , bt- , sk-br ) and normal cell (mcf a). in addition to the quantitative real-time pcr (qrt-pcr) using apoptose specific primers (tp- , bcl- , bax, birc- , gapdh, caspase- , caspase- , caspase- , caspase- ) and sybr green dye were performed to determine expression patterns of transcript level in cancer cell lines, using gapdh as a reference gene. the antiproliferative characterization of va effects identification of the gene set at molecular level and we determination role of va on apoptotic pathway. according to our study, va is demonstrated significantly (p < . ) effect cytotoxic, apoptotic, caspase- activity. beside this, dose dependent expression patterns decreased apoptose spesific genes (except of bcl- ) mrna levels from six to eleven fold change more than untreated va cell lines. va will be used as candidate molecule for effective treatment on breast cancer in the future. glycosylation largely determines the variety and functions of proteins. paucimannose, a mannosidic n-glycoepitope has long been thought to be specific for plants and invertebrates. recently, it has also been detected in mammalsin physiological conditions (stem cells) and in pathophysiological conditions (inflammation and cancer). in glioblastoma cells, paucimannose also seems to play a role in cell proliferation. glioblastoma is the most frequent brain tumor in adults with poor prognosis due to a lack of suitable treatments. we hypothesize that paucimannose could be a promising new biomarker as it is otherwise rarely found in mammals. therefore, paucimannose levels were investigated in different glioblastoma cell lines differing in their proliferation rate and tumorigenicity. the highest paucimannose levels were detected in low proliferating, nontumorigenic cells. furthermore, we found that modulation of paucimannose function by application of a specific antibody regulated cell proliferation and the capability of cells to form colonies in soft agar. these data support a functional role of paucimannosidic epitopes in tumorigenic processes. glioblastoma multiforme (gbm) is the most lethal type of malignant brain tumors. recently, gbm stem cells (gscs) have been studied in great deal and accepted that they have a legitimate role in tumor formation, development, chemo-resistance and recurrence. in this study, it is aimed to investigate new therapeutic targets within apoptosis related molecules to select and eliminate cd + gscs effectively. ten primary gbm cells were isolated from gbm tissue samples and they were cultured among with the gbm cell lines (u , u , u and t ). cd + and cd À cells were seperated by macs method via anti-cd (ac ) antibody from cultured cells and cell lines. rna isolation from cd + and (À) cells, cdna synthesis was performed. finally, by performing pcr array, mrna expression levels of genes were detected. proper results were collected and analysed statistically. according to the results of pcr array; it has been found that cd + cells express approximately fold tnfrsf and fold tnfsf when they are compared with control cells. tnfsf binds to cd that is expressed on the surface of tcells. cd does not have a death domain, instead it has a cytoplasmic tail which binds to trafs. trafs act as adaptor molecules that are related with jnk and nf-jb signalling pathways. tnfrsf (dr ) is a death receptor which are known for transmitting the pro-apoptotic signals from outside to the inside of the cell. it negatively regulates t-cell activation and the release of few cytokines. as a conclusion, tnfsf and tnfrsf both are found on immune system cells, mostly on t-cells, which may mean that gbm stem cells act as a immune system cells to avoid the elimination by the immune system. to conclude, acting as an immune system cell and promoting survival via tnfsf and tnfrsf , these molecules may be essential markers to target cd + gbm stem cells. the effect of docetaxel on p , sin a and mdm gene expression in mcf- breast cell line docetaxel is a cytotoxin effective in treating breast cancer. it stabilizes microtubules and causes catastrophic cell cycle arrest in g /m. it also initiate signaling through cell death pathways that result in programmed cell death. in this study, it was aimed to investigate apoptotic and cytotoxic effects of docetaxel has on the mcf- breast cancer cells line. in this study, mcf- breast cell line was applied different doses docetaxel ( nm, nm, lm, lm, lm) as h and h. mtt analysis was performed to the mcf- breast cancer line in control group and groups of docetaxel. afterwards, evaluation of apoptosis by tunel and levels of p , sin a and mdm gene expression by real-time pcr were determined in an order. it was observed cell variable was significant lower in docetaxel groups compared to control group (p < . ) in h as mtt analysis. the lowest cell viabilty was determinated in group applied lm docetaxel. while the lowest positive cell density was determinated in control group, it was observed apoptotic cell density gradually increased with increasing docetaxel concentration in groups treated docetaxel (p < . ). the highest p , si a and mdm expressions were apperared in nm docetaxel group compared to control group. human alpha-fetoprotein (afp) and afp receptor binding domain (afprbd) are able to bind and internalize effectively by wide range of human tumor cells and tissues. as other vector molecules afprbd has insufficient quantity of chemical groups which can be conjugated with drugs or diagnostic agents. conjugation of vector molecules with macromolecular polymer carriers like dendrimers aims to solve this problem. our study describes influence of afprbd-dendrimer-doxorubicin conjugate surface charge on intracellular trafficking routes and toxicity. the amineterminated (g ) and acetyl-terminated (g ) nd generation pamam dendrimers carrying doxorubicin (dox) were used to synthesize conjugates with afprbd. unmodified by afprbd g and g dendrimer derivates labeled with dox were absorbed by the cells at °c with different efficiency. g -dox derivate characterized much slower internalization rate than nonacetylated g -dox. only g -dox shown partial colocalization with lysosomal marker lamp after h of incubation. internalization of afprbd-g -dox and afprbd-g -dox did not show significant difference. at the same time, both conjugates contained afprbd wyкy almost fully associated with lamp already after min of incubation. cytotoxicity results revealed that ic levels of g -dox and afprbd-g -dox coincided and demonstrated a bit higher activity against sensitive to dox skov and resistant skvlb cells than afprbd-g -dox conjugate after h of incubation. at the same time, after h of incubation afprbd-g -dox and afprbd-g -dox were much more than g -dox and g -dox. we may conclude that there is significant difference in ways of dendrimers internalization by tumor cells depending on nature of surface chemical groups. on the other hand, chemical modification of dendrimer conjugated with does not afprbd influence dramatically on the protein trafficking and resulting cytotoxic effect. russian scientific foundation supported this study (no. - - . ) , a key enzyme in glycolysis, catalyzes conversion of phosphoenolpyruvate (pep) into pyruvate with regeneration of adenosine triphosphate (atp). the key regulator of the metabolic alterations found in tumor cells is the glycolytic isoenzyme pyruvate kinase type m that is generally expressed in all proliferating cells and overexpressed in all tumor cells investigated to date. during carcinogenesis a shift in the pyruvate kinase isoenzyme equipment always takes place, such that the tissue-specific isoenzymes disappear, and m -pk is expressed. breast carcinoma, the third most common cancer worldwide, accounts for the highest morbidity and mortality. breast cancer tissue analysis confirmed the upregulation of m -pk in breast cancer, and high m -pk levels were associated with poor prognosis of breast cancer patients. materials and methods: poly hema (mac) nanoploymers were immobilized by binding covalently with sulphur atoms on the gold electrod's surface. pyruvate immobilization was actualysed with cross linking reagent glutaraldehyde. biosensor was developed by preparing pottasiumferrociyanide, selected as a mediator. results: cyclic voltammograms have been carried out at between~ . and . v potentials vs. ag/agci. m -pk activty was detected by using differential pulse method at between . and À . v potentials by observing the differentiations in the current values. in the optimization studies, some parameters such as optimum ph, temperature, concentration of glutaraldehyde and p-hema-mac, were investigated. discussion and conclusion: the method developed for the measurement of the tumor m -pk activity by using biosensor. we found that more advantageous in comparison to other methods reported in the literature so far; it was determined that the method is sensitive, economic, practical and less time-consuming. piruvat kinase tumor m -pk activity determination at low concentrations is possible with this method. p- . . - tie /tek: a potential biomarker for targeting glioblastoma stem cells role in angiogenesis, endothelial cell survival, proliferation, migration and adhesion. therefore, tie /tek could be a potential target for therapeutic strategies directed against glioblastoma stem cells and their microenvironment. in this study, we investigated the gene expression levels of tie /tek in both cd + gscs and cd À gbm cells. gbm primary cells were freshly isolated from glioblastoma tissue samples and cultured in dmem supplemented with % fetal calf serum and % penicillin-streptomycin at °c in % co -humidified incubator. we isolated cd + and cd À cells from gbm primary cells using macs system. following rna isolation from healthy brain tissues, cd À and cd + cells, cdna synthesis was performed. finally, according to microarray protocol, cell surface marker panel array was applied. expression levels were analyzed using the delta delta ct method. statistical analysis was performed using spss software for windows version . . tie /tek gene expression was determined as . fold higher in cd + gscs than normal brain tissue (p < . ). morever it was determined . fold higher compared to normal brain tissue in cd À (p < . ). according to our results tie /tek expression was higher in gscs, indicating that tie / tek may be a potential marker for targeting cancer stem cells in gbm. this research has been supported by the scientific and technological research council of turkey (no: s ). adenosine inhibited the breast cancer stemlike cell population through erk / pathway s. m. jafari, m. aghaie cancer stem cells (cscs) are immortal tumor-initiating cells that can self-renew and drive tumorigenesis in various cancers, including breast cancer and others solid cancers. in a study indicated that extracellular atp reduces tumor sphere growth and cancer stem cell population. but at present, there are no reports available in literature on the effect of adenosine on breast cancer stem cells. in this study we evaluated the effect of adenosine inhibition and its mechanism of action in breast cancer stem cells isolated from breast cancer cell lines. our result showed that adenosine significant reduces breast cancer stem cell population. reduction of erk / protein levels was also observed after treatment cancer cells with adenosine. in conclusion, our results indicate that adenosine decreases the breast cancer stem-like cell population through erk / pathway. taxanes are commonly used for the treatment of many cancers as chemotherapeutic drugs that resistance to these agents has become a major clinical obstacle. taxane based chemotherapy drugs such as paclitaxel, docetaxel and cabazitaxel bind microtubules and inhibit to microtubule polymerization appear to stimulate programmed cell death. taxane-resistance to cancer has not been clearly in progression and development of drug resistance. multiple mechanisms are involved in the drug efflux proteins as multidrug resistance protein, differences in amino acid sequences among the b-tubulin isotypes. we investigated taxane resistance with different doses of paclitaxel, docetaxel and cabazitaxel in prostate cancer stem cells. we compared the expression level of apoptotic proteins, and its functional role in resistance mechanisms in cd + /cd + prostate cancer cell lines. taxane drugs were categorized as concentration-dependent or time-dependent. cabazitaxel caused a time-dependent and dose-dependent reduction in cell viability in all tested cell lines. resistance activity was consistently higher in docetaxel in prostate cancer cells compared with the other drugs. there are many different response of clonogenic formation cd + /cd + cells with resistance to docetaxel, paclitaxel and cabazitaxel in prostate cancer stem cells. the innate of prostate cancer resistances are important characterization steps and critically limits treatment outcomes therefore novel drugs must be focus on antiresistance and molecular based combinations. mesenchymal stem cells (mscs) are self-renewing cells with ability to differentiate into organized, functional network of cells. mscs isolated from various tissues including adipose tissues, bone marrow, umbilical cord, placenta and pancreas have different differentiation and proliferation potential. good knowledge of the metabolism and proliferation mechanisms of stem cells is required for stem cell therapies. glucose is an important molecule in the culture of stem cells. glucose concentration affects the differentiation and proliferation potential of stem cells. the aim of the study was to investigate the proliferation status by identifying the proliferating cell nuclear antigen (pcna) expression under normoglycemic and hyperglycemic conditions in mscs. mscs were isolated from human term placenta amniotic membrane. characterization of the isolated cells was performed using flow cytometry. chondrogenic, osteogenic and adipogenic differentiation potential of these cells were investigated. characterized cells were cultured in normoglycemic and hyperglycemic conditions for and h and the expression of pcna protein expression in these cells were investigated by western blot. flow cytometry analysis showed that isolated cells were positive with mesenchymal stem cell markers cd , cd , cd , cd and negative with hematopoietic markers cd , cd b, cd , cd and hla-dr. western blot result of pcna protein expression statistically significantly increased in human amniotic membrane mscs under hyperglycemic conditions for and h culture. the glucose content of stem cell medium is important because glucose is an effective molecule of the proliferation of stem cells. proliferation of mscs in vitro are still not optimized. when the relationship between glucose and stem cells be understood, it will provide a better understanding for the glucose-related pathologies such as diabetes during pregnancy. prostate cancer (pca) is the second most common type of cancer among men in the world. it is revealed that some gene, protein and metabolite sets control the pca, however the whole metabolomics changes are not completely understood yet. pca is common among older men, and this is an important health problem in developed countries. sarcosine is the n-methyl derivative of the glycine amino acid. glycine n-methyl transferase produces sarcosine from glycine. besides, it is metabolized to glycine by sarcosine dehydrogenase. in , high level of sarcosine in urine was associated with pca by sreekumar et al. they identified sarcosine as a pca biomarker that was significantly increased in urine during prostate cancer progression to metastasis. following this study, several studies have been published indicating sarcosine as a pca biomarker. in our study, a preliminary biosensor system was fabricated for determination of sarcosine in urine by using sarcosine oxidase. sarcosine oxidase was immobilized on au electrode surface using gelatin as an immobilization matrix. glutaraldehyde was used as a cross-linking agent to avoid the loss of the enzymegelatin mixture. optimization and characterization studies were carried out. sarcosine concentrations were detected carefully with the developed biosensor system. the fabricated preliminary biosensor is a promising system that can allow lower detection limits after surface modifications. activation of the epithelial-mesenchymal transition (emt) program in tumor cells is associated with invasiveness and stemness. recent studies implicate emt-inducing molecules in reprogramming energy metabolism. the -phosphofructo- -kinase/fructose- , -bisphosphatase- (pfkfb ) regulates glycolysis by producing fructose , -bisphosphate (f , bp). given that pfkfb is induced by several established emt-inducers in tumor cells, e.g. hif- a and ras, we hypothesized that pfkfb may be involved in regulation of the emt in tumor cells. silencing of pfkfb in pancreatic adenocarcinoma cell lines panc and s vp was achieved using specific sirna molecules. mrna and protein expressions of the cdh gene (encoding e-cadherin, an established epithelial marker), as well as zeb and snai genes, by real-time quantitative (q)-pcr and western blot, respectively. immunfluorescence analysis was performed to visualize e-cadherin protein expression on plasma membrane. in order to test the effect of pfkfb on the invasive ability of the cells, a matrigel invasion assay was performed. ectopic expression of zeb was achived by transfecting cells with a plasmid carrying zeb cdna. cells that were depleted of pfkfb exhibited markedly increased cdh mrna and e-cadherin protein expressions and reduced snai and zeb mrna expressions. immunfluorescence analysis confirmed the upregulation of the e-cadherin protein on plasma membrane. silencing of pfkfb caused approximately % reduction in matrigel invasion, compared to non-targeting sirna. inhibition of the matrigel invasion caused by pfkfb depletion does not appear to be associated with reduced zeb expression, as ectopic expression of zeb did not reverse the effect of pfkfb silencing on invasion. taken together, these data suggest that pfkfb may be required for the maintenance of the mesenchymal phenotype and associated traits in pancreatic adenocarcinoma cell lines. introduction: leukemias are neoplasms that arise from hematopoietic cells initially proliferate in the bone marrow, and then disseminated in the peripheral blood, spleen, lymph nodes and eventually to other tissues. lymphomas occur primarily in the lymph nodes, but can be extended in peripheral blood and bone marrow infiltrate. aim: to determine the values of haematological parameters the control and test groups. to determine the prevalence of types of chronic leukemia in relation to the experimental group. compare haematological parameters in relation to the type of chronic leukemia. materials and methods: a prospective-retrospective study included subjects who were made laboratory hematology in oj clinical chemistry and biochemistry ukcs. blood tests conducted on the hematology analyzer siemens advia hematology system and abbott cell dyn and microscopic analysis of the peripheral blood smear. results and discussion: according to the age of respondents test group was established mild form of anemia, a red blood cell count is totaled . ae . x , which is signifycantly lower compared to the control group. the average number of leukocytes was significantly higher in subjects studied groups and amounted to . x , with a maximum value of x . in the peripheral blood of patients with chronic leucosis has established a significantly higher number of cells compared to the control group (p = . ), while the number of monocytes was a significantly smaller. in the group of patients with chronic leukosis largest number had chronic lymphocytic leukemia ( %), and chronic myeloid leukemia had % of respondents. conclusion: subjects with cll were statistically older than patients with cml, and as regards the gender structure, men have dominated in cll and cml in women. white bloodline was found that the number of leukocytes in both forms of chronic leukemia high above the reference value. p- . . - effect of enzymatic and non-enzymatic isolation methods of endometrial stem cells on their cell proliferative potential and mesenchymal stem cell characteristics human endometrial stem cells (hescs) are responsible for the monthly renewal of the basal layer of the human endometrium by facilitating stromal and vascular regeneration. in this study, hescs were isolated with three different isolation methods including non-enzymatic and enzymatic digestion using trypsin and collagenase type . the effect of these three isolation methods on the acquisition of mesenchymal stem cells (msc) and on hesc proliferative potential was evaluated through flow cytometric analysis of cd surface markers and wst- tetrazolium salt assay. our findings indicate that hescs isolated with these three methods have statistically similar cell proliferation rate at h time point. however, at h time point, hescs isolated with the non-enzymatic and collagenase type method displayed a higher expansion in cell number when compared to the hescs isolated with trypsin. the late passage of hescs isolated with non-enzymatic and trypsin methods showed the highest proliferation rate in comparison to the hescs obtained via collagenase type isolation method at h, h and h. the three isolation methods for the early passages of hescs had a resemblance in their msc profile with no significant difference. on the other hand, late passage hescs isolated using trypsin non-enzymatic method showed a higher cd and lower cd profile. moreover, late passage of hescs isolated with non-enzymatic method displayed a significant reduction in their cell surface cd , cd , and cd surface expression levels. only hescs isolated with collagenase type did not present a significant shift in their mesenchymal cd marker profile from early to late passages, taken together results from this study suggest that the longterm maintenance of mesenchymal markers can only be achieved in cell isolation with collagenase type , while non-enzymatic method is more suitable to obtain higher msc cell yield for immediate use. hepatocellular carcinoma (hcc) abundantly arises on the viral and/or chemical-induced cirrhosis in liver. cirrhosis is defined as one of the premalignant stage hcc in which microenvironmental changes occurred such as uncontrolled production of collagen type i and activation of hepatocyte growth factor (hgf)/c-met signaling. it has been shown that epcam+/cd + subpopulation of cells isolated from hcc tissue can initiate tumor at very low concentration in xenograft model and behaves as hepatic cancer stem cells. however, the molecular mechanisms supporting hepatic stem cell activation are not well understood and knowledge about the role of hgf/c-met pathway in this process is not clear. in this study, we aimed to define effect of collagen type i and hgf induction on the cell behaviours of epcam+/ cd . epcam+/cd + cells were sorted by magnetic separation from huh- cells. then proliferation and invasion of cells were analyzed under the hgf induction as well as branching morphogenesis in vitro. after hgf stimulation, phosphorylation level of c-met increased in epcam+/cd + subpopulation. moreover, presence of collagen type i enhanced significantly effect of hgf stimulation in the invasion of epcam+/cd + cells. we also have showed that hgf stimulation increased branching tubulogenesis capacity of epcam+/cd + subpopulation while it did not effect proliferation of cells. these effects of hgf reverted by c-met inhibitor, su , in vitro. all these findings showed that hgf and collagen type i regulates aggressive phenotype as microenvironmental changes via induction of invasiveness of epcam+/cd + subpopulation of huh- . in conclusion, we showed that hgf/c-met signaling causes to get more metastatic phenotype based on invasion and tubulogenesis in epcam+/cd + hepatic cancer stem cells in hcc and it might be possible to use c-met inhibitors to target hepatic cancer stem cells during hepatocarcinogenesis. endometriosis is defined by the migration of endometrial mesenchymal stem cells (emscs) into the peritoneal cavity or other site of body rather than uterus in a retrograde fashion. its previously known intracellular crosslinking enzyme called tissue transglutaminase (tg ) was shown to play important roles in the extracellular matrix (ecm) modelling, fibrosis, cell adhesion and migration. we have hypothesized that tg might be expressed in emscs and take part in the formation of endometriosis. the difference in the proliferation capacity of emsc isolated from endometrial tissue with/without endometriosis was determined using wst- assay and tg activity and expression levels were analysed by btc assay and rt-pcr. the biosynthesis and activity for mmp- and - were investigated with zymography and rt-pcr, respectively. although tg activity was found to be % less in emscs isolated from endometriotic tissue, these cells showed times higher tg protein expression than those isolated from the control tissue without endometriosis. emscs from endometriotic tissue have . times higher tg and . fold higher itgb mrna levels when compared to the cells of healthy group. similar results were observed in sdc- gene expression with a . fold increase. endometriotic emscs demonstrated an average of . -fold increase in the mmp- activity while a onefold increase was evident in mmp- activity when compared to the healthy emscs. emscs from patient group possessed a higher proliferative ability in comparison to that of healthy subjects within h. the fact that emscs from the control tissue showed lower tg protein levels with a high enzyme activity suggested that tg might be important in the development of endometriosis not only by destabilizing ecm but also enhancing the cell migration. in this context, the upregulation of tg along with itgb and sdc was evident in emscs of endometriosis which was possibly associated with the increase in the activity of mmp- and - . recent studies have indicated that pluripotent stem cells and some stromal stem cells such as mesenchymal stem cells (msc) are metabolically different from their differentiated counterparts. in this study, the cellular mechanisms controlling metabolic changes in stem cells was investigated using wharton jelly mesenchymal/stromal stem cells (wj-mssc). wj-msscs were isolated by the explant method and cultured in dmem-f with % fbs. endothelial differentiation was induced by the addition of vegf, egf, insulin and hydrocortisone for days. neuronal differentiation was achieved by using commercial neuronal differentiation medium (millipore) for days. in parallel experiments, cellular metabolic activity such as lactate production was measured. the msc characterization was performed by flow cytometry using antibodies against cd , cd , cd and cd (bd human msc analysis kit). the differentiation process was followed by measuring the expression of cd , cd for endothelial and gfap, neu and tyrozine hydroxylase proteins for neuronal cells by immunofluorescence. for gene expression, nanog, cd and gapdh genes were analyzed by rt-pcr. differentiation stimuli to endothelial or neuronal cells resulted in a significant decrease in msc marker proteins. expression of stem cell markers other than cd were decreased to - %. differentiation induced the expression of cd , cd for endothelial and gfap and neu proteins for neuronal cells. in vitro lactate production was decreased following differentiation in both lineages. neuronal differentiation increased glucose consumption by~ % and the extracellular calcium concentration of these cells was significantly lower than synchronous undifferentiated cells. glycolytic activity is decreased during in vitro differentiation of wj-msscs. metabolic reprogramming and glucose uptake of cells may be an early indicator of the differentiation process in wj-msscs, supporting the view on their metabolic plasticity. store-operated ca + entry (soce) activated by depletion of intracellular ca + stores has been shown to control intracellular ca + homeostasis in many physiological and pathological events. stromal interactive protein, stim , as endoplasmic reticulum (er) ca + sensor and orai protein as pore-forming subunit of soc channels play crucial roles in the activation of soce channels. stim and orai were reported to have pathophysiological roles especially in hepatocellular carcinoma (hcc). anticancer chemotherapy frequently falls back because of these tumor-initiating subpopulations, tentatively called 'cancer stem cells'. the purpose of this study was to investigate the roles of stim and orai on soce in differentiation of huh- hccs expressing epcam and cd surface adhesion molecules (epcam + cd + ). epcam + cd + subpopulations in huh- cells were separated via flow cytometry and transfected with stim and orai- over-expressing (oe) plasmids. expression levels were confirmed by rt-pcr. changes in intracellular ca + concentration were monitored via dual wavelength spectrofluorimeter in fura -loaded cells. in epcam + cd + cells, er ca + release increased without any change in soce compared to that of epcam À cd À cells. similar results were observed in stim -oe epcam + cd + cells. on the other hand, increase in orai has no effect on either parameter. cancer is globally one of the most death causes. recently, huge improvements occurred in the cancer diagnosis and treatment due to advanced technology, however recurrence occurs almost - % of patients and their survival times decreases. in this study, we aimed to investigate of relationship between the cancer stem cells which are strongly associated with chemotherapy and radiotherapy resistance and recurrence with the non-classical mhc i antigens which have immunosuppressive properties. for this purpose, we immunohistochemically evaluated the expression patterns of cd , cd , nanog, oct / , hla-g and hla-e in the advanced stage colorectal, gastric and breast cancer and also non malign biopsy samples. we detected that the cancer stem cell markers cd , cd , nanog and oct / significantly increased in the advanced stage cancer tissues. however, the immunosuppressive hla-g and hla-e expressions increased only in the colorectal and gastric tumor tissue. in addition to the presence of cancer stem cell like cells in the tumor tissues, increased expressions of hla-g and hla-e may indicate an immune evasive adaptation of tumor cells. according to our findings, the hla-g and hla-e may be potential therapy targets to elimination of cancer stem cells of colorectal and gastric cancers. however, more detailed studies are needed to support our findings and also to determinate of clinical values of these markers. endocannabinoids increase sdf- release from human mesenchymal stem cells s. k€ ose , f. aerts kaya , d. uc ßkan c ß etinkaya , p. korkusuz stem cell research and application center, hacettepe university, ankara, turkey, department of histology and embryology, hacettepe university, ankara, turkey lipid-structured endocannabinoids are endogenous morphine ligands and present widespread receptor-mediated effects at physiological and pathological levels on the nervous system as well as many other systems. these effects are partially realized through mechanisms affecting cell growth, differentiation, apoptosis and migration at the molecular level. the hematopoietic progenitor cells (hpcs) and mesenchymal stem cells (mscs) form a distinct niche in bone marrow where they interact with each other in harmony. the stromal cell-derived factor (sdf- /cxcl ) is a chemotactic factor in bone marrow and is released from mscs and their receptor cxcr is found in hpcs. with these rationale in mind, we asked if hpcs and msc interaction mediates sdf- release via endocannabinoidal system. bone marrow mscs obtained from healthy donors and passage mscs were induced with ng/ml lipopolysaccaride (lps) for h. antagonists for cb (am ) and cb (am ) receptors were added to cultures for days. after incubation with antagonists msc culture supernatants collected and processed with human sdf- beta in elisa medium. analyses demonstrated direct decreasing effect of endocannabinoid receptor antagonists on sdf- beta release from bone marrow mscs. in conclusion, endocannabinoidal system regulates sdf- release on mscs and directly act on hpcs mobilization in bone marrow microenvironment (niche). this may have a clinical implication on therapeutic mobilization strategies for hscs in hematology clinical applications. implantation is invasion of the embryo into the endometrium and occurs in three stages apposition, adhesion and invasion, via the complex cellular and molecular mechanisms. during these stages, both of maternal endometrium and embryo should be appropriate for the implantation which is the beginning of pregnancy. receptivity of uterine consists in the existence of growth factors such as tgfbeta- , igfr , vegf. it is indicated that damages of factors relesead from endometrium and blastocyst prevent implantation. recently, stem cells can be obtained from many sources to use for therapeutic purposes and mesenchymal stem cells derived from bone marrow are the most studied. in our study, it was aimed to investigate molecules play a role in blastocyst implantation after bone marrow derived mesenchymal stem cell application into the rat endometriyum. female rats were divided into three groups which were saline (sf, n: ), media (m, n: ), stem cell in media (m+bmsc, n: ). after vaginal smear technique, female rats in estrous cylcle were injected into the uterine and periton ll saline, ll culture media and cell/ ll culture media. the pregnant female rats on the day were sacrified and uterine samples removed and were stained with heamatoxylin-eosin histochemically and anti-tgfbeta- , anti-igfr , anti-vegf and anti-pcna immunohistochemically and obseved under light microscope. h-score results were determined using one-way anova test statistically. it was found that intraperitoneal administration of stem cells with media, was increased tgfbeta- , igfr , vegf and pcna parameters when compared with the intrauterine administration of stem cells. in this study, it was revealed that distribution of molecules play role in implantation were changed due to stem cell application. it is supposed that stem cell treatments can be cured the molecules caused infertility. many unconventional biochemical factors remain to be investigated for their potential effects on stem cells. among others, endogenous gasotransmitter h s, generated from l-cysteine and organosulfur-compounds (oscs) metabolisms, plays very important roles in the central nervous, respiratory and cardiovascular system. slow-releasing h s donors are viewed as powerful tools for basic studies and innovative pharmaco-therapeutic agents for cardiovascular and neurodegenerative diseases. exogenous h s administration is able to promptly scavenge ros, activate myocardial k atp channels and increase pro-cell survival signaling, very likely activating erk and phosphatidylinositol -kinase (pi k)/akt pathways. the effects of h s-releasing agents on the growth of stem cells are not yet widely investigated. therefore, stem cell therapy combined with h s may have great clinical relevance in cell-based therapy for regenerative medicine. the effects of slow-releasing h s agents on the in vitro cell growth and differentiation of human lin À sca + cardiac progenitor cells (hcpc) were here studied. in particular, the effects of h s-releasing agents, such as na s, gyy and water-soluble gsh-garlic conjugates (gsgaws), on the cell viability and differentiation of hcpc were here investigated by colorimetric assay, immune-fluorescence microscopy and western-blotting analysis. the treatment with slow-releasing h s donors increased the cell proliferation in a concentration dependent manner respect to the control. moreover, the treatment with gsgaws led to an up-regulation of the expression of proteins involved in the cell adhesion and differentiation processes. these preliminary results highlight on the effects of this gasotransmitter on the stem/progenitor cells and on the possibility to develop functional d-systems for cardiac tissue repair, that take into account the relevant biological role of h s in the cardiovascular system. p- . . - investigation of the protective effect of boric acid and omega- fatty acid in model of acute myocardial infarction changes in myocardial rats ischemic heart disease being the most common cause of the mortality and morbidity in worldwide commonly results from the occlusion or narrowing of the coronary arteries by atheromatous plaque and thus is named as coronary artery disease. male sprague dawley rats were used in the present study. rats were divided into groups with rats in each: control, mi, mi+boric acid, mi+omega- and mi+boric acid+omega- groups. control rats were treated with ml/day saline, boric acid-treated rats received mg/kg/day boric acid and omega- -treated rats received mg/kg/day for days by oral gavage. for the experimental mi model, mg/kg izoproterenol-hcl (iso) was administered subcutaneously two times with a -h interval in the last days of the boric acid and/or omega- treatments. twelve hours after the second dose of iso, general anesthesia was induced. under general anesthesia and spontaneous respiration, ecg recordings were obtained by using a computerized data recording and analysis system (mp , biopar) and d-ii recordings were used in the analysis. compared to the control group, serum ck-mb, bnp and tnf-a levels were higher in mi group (p < . , p < . and p < . respectively). in the heart tissue homogenate, biochemically measured calpain activation and mda were increased (p < . and p < . , respectively) and pon levels were decreased (p < . ). according to the ecg recordings, st wave and heart rate were found to be decreased (p < . and p < . , respectively). on the other hand, all above mentioned parameters were found to be improved in rats treated with boric acid and/or omega- after induction of mi. moreover, histological analysis including light microscopy and tem revealed a significant histological improvement in rats treated with boric acid and/or omega- after induction of mi. results of the present study suggest that omega- and/or boric acid treatment significantly decreases the cellular damage in mi. this is study is aimed at measuring the level of serum heart-type fatty acid binding protein (h-fabp) in patients presenting with diabetic ketoacidosis (dka) and diabetic ketosis (dk) and to determine its role in identifying early period cardiac ischemia by comparing this level with the level of a control group at a comparable age this study was planned to be a prospective study and it included patients diagnosed with dka, patients diagnosed with dk and voluntary pediatric and adolescent healthy control subjects. the h-fabp, creatine kinase-mb (ck-mb) and troponin-i levels were studied in patients with dka and dk as well as in the control group at the time of presentation. for dka patients, their h-fabp values were measured once again after acidosis correction and compared with the values they had at the time of presentation there were no differences among groups in terms of sex, age, height and weight. no statistically significant differences were found among groups with respect to troponin-i values ( . ae . , . ae . . ae . ; p = . ). no statistically significant differences were found among groups with respect to ck-mb values ( . ae . , . ae . , . ae . ; p = . ). the h-fabp values of dka patients at the time of presentation were found to be statistically significantly higher than those of dk patients and control group ( . ae . ; . ae . . ae . ; p = . ). the h-fabp value of the dka group at the time of presentation was found to be statistically significantly higher than the value at hour after acidosis correction ( . ae . ; . ae . ; p = . ) the fact that h-fabp levels were found to be high in pediatric patients diagnosed with dka at the time of presentation suggested that myocardial ischemia had been triggered. in diabetic patients, every ketoacidosis attack may lead to cardiac ischemia, thereby accelerating progress to necrosis. in conclusion, we would like to propose h-fabp as a potential marker for indicating myocardial ischemia. p- . . - genome-wide analysis of hypoxic stress response in human cardiomyocytes stress in human cardiomyocytes on a genome-wide scale remains poorly understood. this study aimed to identify the gene expression patterns of adaptive response of the human cardiomyocytes (hcm) to hypoxic stress. in vitro experimental models of hypoxia mimicking in-vivo coronary ischemia, are useful tools to identify molecular pathways involved in myocardial ischemia. in the current study, we cultured ac -hcms in dmem/f with %fbs. to simulate hypoxia model, cardiomyocytes were plated in hypoxia chamber ( %o , %co , %n ) for , , , h and the control group was incubated in normal conditions ( %co , %o ). cell viability was determined using mttassay. annexin-v assay was used to monitor apoptosis. gene expression profiling was analysed with affymetrix-hg-u -plus- arrays. following bioinformatic and statistical analyses differentially expressed genes (deg) were classified according to gene ontology using david and kegg pathway analysis tools. according to mtt, annexin-v and hif gene expression results, hypoxia time was determined as h. we identified genes ( down-regulated and up-regulated) (p < . , fold change ≥ . ) were differentially expressed in hypoxic-ac vs. ac . degs were mainly clustered in cell proliferation, regulation of cell death, cell adhesion and response to stress. furthermore, transcriptome analyses revealed that 'metabolic, cytokinecytokine receptor interaction, hif- signaling, tgf-beta, cell cycle and apoptosis' pathways were involved in the hypoxic stress response of human cardiomyocytes. this study provides molecular information regarding gene expression reprogramming of human myocardial hypoxia. the pathways identified in this study may pave the road for translational medicine. this study was supported by tub _ itak project number s . autologous ips cells after reprogrammed into endothelial progenitor cells (epcs) may offer several advantages in the treatment of cardiovascular disorders because of their cardiogenic and vasculogenic differentiation potential. to reach that purpose, we differentiated and characterized mouse ips cells into flk + , a well-recognized epc marker. further maturation of epc was characterized by the expression of cd and cd markers. purified ips cells were differentiated into flk + cells with the use of differentiation medium on type iv collagen-coated dishes in the absence of lif. we then analyzed flk gene expression and protein levels with qrt-pcr, western blot and immunocytochemical methods on days . to . . flk + cells isolated with macs system and then recultured these cells in differentiation medium with vegf to induce epc cells. following induction, cd and cd gene expression and protein levels were analyzed with genomic and proteomic methods. after isolating these cells and aggregate overnight, we cultured cells in three-dimensional condition in collagen type i and used differentiated medium including vegf and egf. we found that flk expressing cell number reached to a peak level ( %) on day . followed by a progressive decline subsequently. in the second step, cd and cd positive cells were generated and enriched during day of induction. we showed optimal time for harvesting flk + cells is day . of initial differentiation. following isolation of flk + progenitor cells they were further matured into functional epcs by vegf within days of induction. additionally for evaluation of angiogenic potantial differentiated cells, we monitored epcs behavior along vascular formation in d culture. our work demonstrates that epcs could be successfully derived from ips cells and these cells have vascular formation and angiogenic potential in d culture. epc drived ips cells play important role in the treatment of cardiovascular disease. p- . . - electrophysiological, biochemical and genotoxic effects of luna experience on heart tissue in rat model pesticides are widely used for the control of agricultural, industrial and domestic pests. however, the uncontrolled use of pesticides has diverse effects on ecological system and public health. fungicides are one of the pesticide type used to kill fungi or fungal spores. in this study, the effect of different doses of luna experience, a fungicide, on the cardiac electrophysiology and genotoxicity in rats were investigated. among five groups ( mg, mg, mg, control and positive control for comet assay) treatment groups received by gavage doses of luna experience for days. electrical activity of heart were recorded using electrophysiological recording techniques. tissue activities of paraoxanase (pon) and arylesterase (are) and level of malondialdehyde (mda) were measured using biochemical methods. comet assay was performed on heart tissue. we calculated genetic damage index (gdi) and damaged cell percent (dcp) from comet assay. it was observed that there is a significant decrease in heart rate in all treated groups as compared with control group (p < . ). amplitude of p wave and qrs complex did not change (p > . ). in all treated groups, statistically significant differences were found for values of pon, are, mda, gdi and dcp when compared to control group (p < . ). according to our results, exposure to different doses luna experience have a probable hazard potential for the cardiac system. the macrocyclic cage complexes iron (ii) clathrochelates are of the interest due to their bioactivity; they are able to inhibit t- rna polymerase, possess toxicity to leukemia cells hl- and suppress amyloid fibril formation. their binding to serum albumins was reported; the extreme binding affinity to albumins is observed for the compounds bearing carboxy groups. upon this interaction, clathrochelates quench protein intrinsic fluorescence and gain optical activity inducing circular dichroism (cd) signal in - nm region. here we examine the effect of spatial arrangement (isomery of substituents) of clathrochelates on their binding to globular proteins. we study bis-substituted clathrochelates bearing two same or different isomers (ortho-/meta-/para-) of carboxyphenylsulfid groups. their interaction with bovine (bsa) and human serum albumins, b-lactoglobulin and lysozyme are explored by cd and protein fluorescence quenching method. the binding of compounds to albumins evoked the cd bands of the same shape, but their intensities vary up to times depending on substituents isomery. in the presence of b-lactoglobulin, the intensities, shape, and positions of the induced cdbands differ for the compounds with different isomer groups. the cd bands induced by the lysozyme in the case of di-para substituted clathrochelate are shifted relatively to the bands of other isomeric compounds. the pronounced quenching of protein fluorescence by clathrochelates was observed only in the case of bsa, its intensity depends on the geometry of substituents ( - times). the different spatial arrangement (isomery) of carboxyphenylsulfid substituents in clathrochelates causes the distinctions in both their cd-signal induced by interaction with proteins and their effect on the protein fluorescence. the geometry of ribbed substituents is important for their binding to biomolecules (particularly proteins) and is suggested to determine the structure of the formed guest-host complex. d bioprinting is a new technology that revolutionized the field of tissue engineering and regenerative medicine, allowing reconstruction of living tissue and organs preferably using the patient's own cells. using a d printer we can design biological structures by controlling exact deposition of cells, growth factors and extracellular molecules in a spatially-controlled manner. the aim of this study was to evaluate the differentiation of human amniotic fluid stem cells (afsc) into endothelial progenitor cells using a bioinkÒ hydrogel photopolymerized in a d network resembling vascular tissue. characterization of afsc was performed by flow cytometry, followed by sorting of the cd + stem cell subpopulation. cd + stem cells were stained with cell tracker red cmtpx and then mixed with bioinkÒ hydrogel. printing was done using a lm diameter needle, under bar pressure, and mm/min speed. the network models with define distance apart were printed and analyzed by fluorescent microscopy. mtt test was used to evaluate the viability of the cd + stem cells. our results showed that afsc remained viable as shown by mtt assay. the fluorescent microscopy images confirm the viability biochemical test showing that the cd + cells viability is maintained after days of cultured in bioinkÒ hydrogel. furthermore, histological section of hydrogel showed that cells have a relatively uniform distribution forming network interactions between cells. flow cytometry assay showed that cd + cells expressed endothelial markers such as cd , cd , cd , cd and vegfr . in conclusion d printers are useful tools for creating three-dimensional scaffolds that mimics the cell microenvironment where different types of cells could proliferate, differentiate and crosslink with each other forming tissue-like structures. this study aims to reveal the biocompatibility, biodistribution and immunomodulatory impact on the production of inflammatory citokines of magnetite (fe o ) nanoparticles functionalized with natural compounds with proved antimicrobial and immunomodulatory effects. co-precipitation synthesized fe o were functionalized with plant-derived compounds: eucalyptol, carvone, limonene and b-pinene. characterization was done by ir, sem and hr tem, while in vitro biocompatibility was tested using endothelial human cells (fluorescence microscopy and proliferation assay). in vivo biodistribution was tested in a balbc mouse model at and days post-intraperitoneal injection, followed by experimental organ removal. tissue sections obtained from vital organs were stained with hematoxylin-eosin. production of inflammatory cytokines was assessed by elisa. results demonstrated that, at concentrations of lg/ml, all prepared nanosystems have a good biocompatibility in vitro and in vivo, allowing the development of cultured cells and also not affecting any visible behavior and organ morphology of the mice. microscopy evaluation of the organs sections revealed that nanoparticles are not present in vital organs such as brain, heart, kidney and liver, but aggregates were visible in the lungs and spleen. at days post-injection no visible aggregated were found in the lungs, few dark-brown nanoparticles clusters being visible in the red pulp of spleen. elisa results revealed that fe o functionalized with carvone and limonene significantly stimulated the production of il- , il- and il- , while reducing the production of tnfa. other nanosystems din not impact significantly on the cytokine production. functional fe o nanoparticles are efficient drug delivery shuttles, able to stabilize pharmacological compounds, such as plant-derived bioactives, and their biocompatibility, specific biodistribution and limited immunomodulatory effects recommend their use in pharmacological formulations. p- . . - new approach for cell imaging with fluorescent carbon nanoparticles m. dekaliuk, k. pyrshev, o. demchenko palladin institute of biochemistry, kiev, ukraine in the nanotechnology field, much interest was focused on the new carbon nanomaterials for cell imaging. recently discovered inorganic carbon nanoparticles ('c-dots') due to their excellent fluorescence characteristics and biocompatibility have ample opportunities for their use in imaging and functional transformations in living cells. their distinctive features, such as high brightness, small sizes, high biocompatibility, small negative charge on the surface and very easy methods of their preparation present a good alternative to other nanoscale materials. the focus of our research was to determine the possibility of using c-dots as the easily available probes for apoptotic cells detection. the carbon nanoparticles were prepared from alanine, citric acid, urea, etc by hydrothermal treatment at c. the studies were performed with adherent epithelial vero and hela cell lines (atcc). with these tools we demonstrate that both native and apoptotic cells can be easily visualized. the cdots uptake occurs probably by endocytosis, which allows for much larger their number to accumulate in apoptotic cells. using the different methods of sample preparation, they show the ability for labeling various structural compartments of the cell. for living cells there are the intracellular vesicles and lysosomes. in contrast, in fixed cells the nucleus is labeled preferentially. the fact that apoptotic cells accumulate strongly increased amount of cdots can be efficiently used in flow cytometry for characterizing the cell populations regarding the relative amount of apoptotic cells in different experimental conditions. the application of such cheap and easily accessible nanoparticles provides more opportunities to simplify the popular methods of cell labeling and detection. previously, our studies showed the possibility of using these nanoscale fluorophores for super resolution method sofi. a new electrochemical microbial biosensor for the fast detecting of dopamine and epinephrine based on candida tropicalis immobilized in a carbon paste electrode (cpe) modified with single wall carbon nanotube (swcnt) was described in this paper. the immobilized cells were used as a source of polyphenol oxidase (ppo) to develop voltammetric epinephrine and dopamine biosensor. voltammetric determination of phenolic compounds like epinephrine and dopamine is a simple technique available. direct oxidation of phenols can be used, but the oxidation potentials of this compounds are similar and they can not be detected distinctively. another possibility is the use of biosensors based on the polyphenol oxidase (tyrosinase) enzyme that oxidises the phenolic compounds into their corresponding quinones. by this way phenolic compounds that epinephrine and dopamine that used in this study were detected at the different potential. the effect of varying the amounts of swcnt and microorganism on the response to epinephrine was investigated to find the optimum composition of the sensor. the effects of ph and temperature were also examined. increases in biosensor responses were linearly related to dopamine concentrations between . and . mm and epinephrine concentrations between . and . mm. limits of detection of the biosensor for dopamine and epinephrine were calculated to be . and . mm, respectively. finally, proposed systems were applied to epinephrine and dopamine analysis in pharmaceutical drugs. objective: it has started a long time ago to search for a material that can replace blood. this material does not require special storage conditions, independently of the recipient's blood group and can be applied to all individual. milk, casein derivatives, starch, saline and ringer were used for this aim in the past. the determination of toxic effect of natural hemoglobin (hb) on human, researchers have focused on development modified blood. in this work, the development of an artificial biomaterial alternative of blood for using as preoperative and operative aims was aimed. material and methods: in our study, ultrapure hb molecules are immobilized on triethanolamine coated magnetic nanoparticles using various techniques. prepared nanoparticles were characterized by ft-ir, ctem, xrd and cyclic voltammetry (cv). the cytotoxic effects of artificial blood were tried on mtt cell proliferation. results: the characteristic peaks of hemoglobin were obtained from ft-ir spectra differently from support. particles size is concluded by using debye-scherrer equation as > nm from xrd spectra. sem and ctem images supported xrd result. cv results showed that hb molecule has À . v cathodic potential against ag / agcl standard electrode. significant differences were not observed in the mtt results (p < . ). conclusion: the nanoparticles were obtained in accordance with the intended desired method. it is determined that the hemoglobin molecules give the same potential with natural blood even after weeks of immobilization and carrying oxygen as natural blood. there are statistical differences between results of mtt tests due to used concentration. but, it is considered that decantation advantage of the artificial blood minimized cytotoxic effects. proteoglycans are among the most abundant molecules of the inter-cellular structure and they are present in extracellular matrices of connective tissues. these glycosylated proteins contain one or more (gag) chains that are covalently attached to the core protein and their hydrodynamic function is mainly due to the physicochemical characteristics of this gag component which provides hydration and swelling pressure to the tissue. gag levels excreted via urine are used as a marker to monitor different diseases (chronic renal disease, renal fibrosis, glomerular filtration abnormalities, bladder stones, breast and lung cancers, hypertension and diabetes, etc.) besides the well known mucopolysaccharidoses. however, their detection by using chromatographic methods is hard, because of the high polarity of negative charges and different functional groups such as acetyl sulfates that generate microheterogenity. in this study, we developed molecularly imprinted chromatographic hplc columns for specific heparan sulfate (hsa), chondroitin sulfate (cs) and dermatan sulfate (ds) detection in urine. positively charged acrylamide monomers were first polymerized by precipitation polymerization, to produce polymers which will show specific recognition for gag's via electrostatic interactions and hydrogen bond formation. these gag selective polymers were then filled in the steel hplc columns and columns eluents were chemically degraded. degradation products of gag's were examined offline column coupled with tandem mass spectrometry. the results showed that our imprinted columns separated gag's specifically and sensitively. thus, urine gag's can be specifically determined by using a gag specific molecularly imprinted column. in this study internal standart weren't used because the matrix effect was lower than % for each urine samples. %cv of ds, cs and hsa was calculated as; supported lipid bilayers (slb) were started to be used for cell culture studies to focus on cell adhesion, cell signaling etc. testing the stability of slbs is essential to utilize them as cell culture platforms. in this study, the stability of phosphatidylcholine (pc) lipid bilayers on glass was investigated under milli-q water, phosphate buffer saline (pbs) and dulbecco's modified eagle medium culture (dme) medium supplemented with/without serum. the stability was also checked by enriching slb with different lipids. pc-liposomes were prepared by hydrating the dried thin lipid film with pbs and then by extruding the suspension through a polycarbonate membrane. a negatively charged phospholipid, phosphatidylserine (ps, %); a positively charged phospholipid, dotap ( %) and cholesterol ( %) were also used for liposome preparation. liposomes were fluorescently labelled and series of slb imaging were taken for a week. in all experiments in milli-q water and pbs, the stability was conserved for days. pc bilayers in medium supplemented with serum showed hole formations on the second day and their number and size increased rapidly in time. when the bilayers were prepared in medium without serum, disruption was lowered but not completely removed as a result of other factors in medium. cholesterol providing an increased rigidity to the membrane caused higher stability. positively charged bilayer structures also showed increased stability. this can be explained by decreased mobility of bilayer as a result of electrostatic interaction between positively charged molecules and negatively charged glass surfaces. decreased mobility decreases the interactions within the medium. lastly, negatively charged bilayers did not show high stability. strong repulsive forces between the negatively charged surface and bilayer probably prevented the integrity of the bilayer and increased the deformation. in recent years the use of biopolymers has gained priority in tissue engineering and biotechnology, both as dressing material and for enhancing treatment efficiency. there is a demand for new biopolymers designed with protease inhibitors and antimicrobials. ll- is an important antimicrobial peptide in human skin and exhibits a broad spectrum of antimicrobial activity against bacteria, fungi, and viral pathogens. using lignin which is an abundant carbohydrate polymer in nature and a polyacrylic acid, we prepared a polymer film by plastifying caprolactone and polyacyrlic acid. films were actified to immobilize ll- . the structure was elucidated in terms of its functional groups by fourier transform infrared spectroscopy (ftir), and the morphology of the film was characterized by scanning electron microscopy (sem) before and after the immobilization process. the amount of ll- immobilized was determined by elisa method. . % of ll- peptide was successfully immobilized onto the films. antimicrobial activity was determined in the film samples by quantitative antimicrobial activity method. according to the results, ll- immobilized film samples were effective on test organisms; gram-positive staphylococcus aureus and gram-negative escherichia coli. in bio-compatibility assays, the ability to support tissue cell integration was detected by using t mouse fibroblasts. samples were examined under transverse microscope, non-immobilized sample showed a huge cellular death, whereas ll- immobilized film had identical cellular growth with the control group. this dual functional film with enhanced antibacterial properties and increased tissue cell compatibility may be used to design new materials for various types of biological applications. p- . . [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] in vitro modulation of the cross-talk between macrophages and osteoblasts by titania nanotube-modified ti surfaces p. neacsu, a. mazare, p. schmuki, a. cimpean bone remodeling is a dynamic process that maintains a fine balance between bone formation and resorption, and is highly influenced by the inflammatory state of the local microenvironment. therefore, a proper modulation in the cellular interactions and cytokine expression is a promising approach to achieve enhanced bone healing. as the biomaterials surface has a major impact on cellular behavior, the goal of the current study was to investigate the influence of tio nanotube-modified ti surfaces (ti/tio ) on the cross-talk between raw . macrophages (mf) and mc t -e preosteoblasts (ob) in mono-and co-culture systems in comparison with flat ti (cpti). raw . and mc t -e cells were seeded on the test surfaces and grown in standard culture conditions for various periods of time. for co-culture studies, the cells were cultivated using a transwell system. inflammatory mediators released by raw . cells were measured using elisa technique, while the ob capacity to produce calcified bone matrix was evaluated by alizarin red staining. in co-cultures, lps-stimulated tnf-a, il- and mcp- release was significantly increased at h, while after days only il- exhibited higher amounts when compared with mf cultures alone. moreover, the secretion of these mediators by cells exposed to ti/tio was diminished, especially in lps evoked conditions. also, alizarin red staining demonstrated the presence of calcium deposits when ob were co-cultured with mf for h and days, whereas the presence of the mf for weeks significantly inhibited mineralization. on ti/tio surface elevated calcified matrix was observed, as compared with cpti. this study reveals that the overall effect of inflammation suppression induced by ti/tio may contribute to the enhanced mineralization. also, chronic inflammation may inhibit or delay the regeneration process. therefore, an adequate modulation of mf and ob interactions is vital for the biomaterials success in stimulating bone regeneration. p- . . - synthesis and characterization of the branched magnetic polymer for drug delivery systems t. tarhan , , b. tural , s. tural mardin artuklu university, mardin, turkey, dicle university, diyarbakir, turkey magnetic nanoparticles (mnp) have gained a lot of attention in biomedical and industrial applications due to their biocompatibility, easy of surface modification and magnetic properties. magnetic nanoparticles can be utilized in versatile ways, very similar to those of nanoparticles in general. however, the magnetic properties of these particles add a new dimension where they can be manipulated upon application of an external magnetic field. this property opens up new applications where drugs that are attached to a magnetic particle to be targeted in the body using a magnetic field. often, targeting is achieved by attaching a molecule that recognizes another molecule that is specific to the desired target area. in recent years, the development of the systems in which drug is delivered magnetically to the target is drawing considerable attention since it is a current issue. it is possible to eliminate the most of the problems caused by high doses of chemotherapy by using the magnetic drug delivery systems. therefore, it is important to design delivery systems with high drug loading capacity. it is necessary to increase the number of reactive groups on the surface of nanoparticles in order to increase drug loading capacity. in this study, we synthesized a novel magnetic surface for drug delivery systems. magnetic dextran-nta (md-nta) was synthesized by using magnetic o-carboxymethyl dextran (ocmd) and nana-bis (carboxymethyl) -l-lysine hydrate (nta) in order to increase the number of reactive carboxyl groups on the surface of biocompatible and biodegradable magnetic dextran. magnetic material (md-nta) which was prepared and characterized by the analysis of transmission electron microscopy (tem), scanning electron microscope (sem), vibrating sample magnetometer (vsm), fourier transform infrared spectroscopy (ftir) and x-ray photoelectron spectroscopy (xps). there are three subtypes of the tgf-b protein that has been reported to be involved in tissue repair process; scar tissue formation has been reported on tissues that has been affected by tgf-b and due to high collagen synthesis. on the other hand the other isoform tgf-b , suppresses the dense collagen production caused by tgf-b and prevents the scar formation. to be able to use these growth factors local or iv route, new drug transport systems are needed to protect the bioactivity during the treatment and controlled release. for this purpose poly(lactic-co-glycolic) acid polymer which is widely used in controlled release systems was chosen as the matrix material. aim of the project was to design, formulate, prepare and optimize tgf-b loaded plga nanoparticular and/or plga polymeric film drug delivery systems and to test their effect on cell proliferation. tgf-b loaded nanoparticles was prepared with emulsion-solvent evaporation method; whereas polymeric film systems was prepared with film castingsolvent evaporation method. following the preparation tgf-b loaded drug delivery systems was characterized. quantification and in vitro release of the growth factor tgf-b was studied with elisa. hepg cell line was used on mtt cell proliferation assay for both tgf-b loaded nanoparticles and films on a time course study. nanoparticles and films were prepared and loading efficiency of the nanoparticles were found to be . %. particle size, zeta index and polydispersity index for this formulation were determined as . ae . nm, . mw and . , respectively. thickness of the prepared films were ae . nm. additionaly prepared nanoparticles and films were found non-toxic. tgf-b nanoparticles and films which were prepared in this study are planned to be used as an effective treatment strategy for wound healing after injury. this project was supported by grand s from the scientific and technological research council of turkey (tubitak). polyvinylpyrrolidone (pvp) is a biodegradable material and natural polymeric biomaterial in such studies. ganoderma lucidum is a natural material containing triterpenes, polysaccharides, adenosine, polypeptides, and amino acids. these constituents have been shown to exhibit anti-cancer properties, enhance and regulate immunity, resist oxidation and ageing, and promote metabolism and cell proliferation. composites of polyvinylpyrrolidone (pvp) have been prepared by solution intercalation method using ganoderma lucidum at different loading amounts. the characterization of pvp/ ganoderma lucidum composites was made by x-ray diffraction (xrd) and scanning electron microscopy (sem); the interactions between ganoderma lucidum and pvp was determined by ftir-atr; the thermal stability was determined by simultaneous tg/dta. hemocompatibility of the prepared composite samples were investigated by a -well plate spectrophotometer. in addition, contact angles and antimicrobial activity of biomaterials were also determined. ftir-atr confirms interactions formed between ganoderma lucidum and pvp. xrd and sem results give evidence that ganoderma lucidum was well dispersed and homogenously in the pvp matrix. thermogravimetric analysis indicated that introduction of clay to the polymer network resulted in an increase in thermal stability. the results of in vitro hemocompatibility test were showed that pvp/ ganoderma lucidum composites are used as biomaterial. the development of synthetic materials, textured polymers and metals and their increasing use in medicine make research of biomaterials' hemocompatibility very relevant. composite material is a multi-phase system consisted of matrix material and reinforcing material. matrix material is a continuous phase and reinforcing material is a dispersed phase. the main two bioactive components of ganoderma lucidum can be broadly grouped into triterpenes and polysaccharides. despite triterpenes and polysaccharides being widely known as the major active ingredients at anti-cancer effect. this study describes the synthesis and characterisation of biocomposites of different molecular weight of peg (polyethylene glycol) as matrix with ganoderma lucidum as a filling material at different loading (% , % . , % wt). the composites have been prepared by solution intercalation method using ground and sieved ganoderma lucidum at micron scale. the characterization of composites was made by x-ray diffraction (xrd), scanning electron microscopy (sem) and fourier transform infrared attenuated total reflectance (ftir-atr) also in this study the hemocompatibility and antibactarial properties of composite investigated. when xrd and ftir-atr results discussed, all of the composites using the different loading amunt of ganoderma lucidum (% , % . and % wt) were shown a homogen distribution in the matrix (peg). and an interaction have occured between matrix and filling material. the sem photos have confirmed these results. peg and composites have been detected as hemocompatible. these results showed that they can be used as biomaterials. p- . . - evaluation of the genotoxic potential of some nanocomposites by comet assay b. yilmaz , s. dogan , s. celikler kasimogullari department of molecular biology and genetics, balikesir university, balikesir, turkey, department of biology, uludag university, bursa, turkey due to its similar nature to the bone, nanohydroxyapatite is a biocompatible particle and poly(methyl methacrylate) (pmma) is a polymer that has been used in dentistry and orthopedic applications for years. in this study, genotoxic potential of pmma/nanohydroxyapatite nanocomposite films composed of polymers having different molecular weights and nanohydroxyapatite fillers in different concentrations ( , . and %) were investigated by comet assay which is a kind of gel electrophoresis that can be used to measure dna damage in individual cells. if the dna is damaged we expect broken ends to migrate apart from the head. at the end of the assay performed after incubation with lymphocytes of healthy humans, we measured the dna damage index (ddi) and percentage of damaged cells (pdc). in addition, to prove the morphological properties of the nanocomposites scanning electron microscope was used and an interaction between the matrix and nanoparticles with a homogeneous dispersion was observed. protein adsorption on stimuli-responsive mixed pdmaema/peo polymer brushes a. bratek-skicki , , c. dupont-gillain universit e catholique de louvain, louvain-la-neuve, belgium, j. haber institute of catalysis and surface chemistry, polish academy of sciences, krakow, poland smart polymer brushes are made of macromolecules that are sensitive to stimuli from the external environment, including ph, ionic strength, temperature, etc. when stimuli-responsive polymer brushes are introduced onto material surfaces, their properties can be adjusted by tuning the environmental stimuli. these brushes can find promising applications across many areas of research, including surface science, nanotechnology, and biotechnology. in our work, the adsorption of human serum albumin (hsa, molecular weight of . kda, isoelectric point ip at ph . ) and lysozyme (lys, molecular weight of . kda, ip~ ) was studied on polymer brushes composed of poly(ethylene oxide) (peo) and poly ( -(dimethylamine) ethyl methacrylate) (pdmaema). peo is a protein-repellent polymer and pdmaema is a polyelectrolyte bearing a variable density of positive charges depending on ph. a gold substrate was modified by these thiolated polymers according to the 'grafting to' method. the obtained polymer brushes were characterized by xray photoelectron spectroscopy, static contact angle measurements and atomic force microscopy. polymer brush formation and protein adsorption were monitored by quartz crystal microbalance. surface characterization of the mixed brushes revealed the presence of both polymers at the surface. conformational changes of pdmaema/peo brushes were experimentally evidenced, and the results indicated that the brushes collapse at ph . (pdmaema is neutral in such conditions) and were swollen at ph . (pdmaema is positively charged). protein adsorption was performed at different ph values ( . - . ) and salt concentrations ( . - . m). it was shown that pdmaema has a high affinity to hsa at ph above its isoelectric point. however, the adsorption of positively charged lysozyme in a wide range of ph was not observed. these results indicate that pdmaema/peo brushes are promising candidates for selective adsorption from a mixture of proteins. clay-polymer nanocomposites (cpn) developed in recent years as a new type of inorganic-organic hybrid materials that were conceived for medical uses such as tissue engineering or drug delivery [ ] , [ ] . the understanding of the structure and physico-chemical properties of cpn is a first step in the investigation of biomaterials, but their potential in this respect is determined by their interaction with living tissue components. in this study, pure kaolinite was intercalated with dimethyl sulfoxide (dmso) and then intercalated kaolinite was modified pyridine, -amino pyridine and , -diamino pyridine to expand the interlayer basal spacing. modified kaolinite samples as filler and poly(vinyl chloride) (pvc) polymer as matrix were used in the nanocomposite synthesis. nanocomposites of pvc have been prepared by solvent blending method using thf as a solvent. the material characterizations were carried out by xrd, afm, ftir-atr, dta/tg and dsc. the xrd results reveal the formation of intercalation/exfoliation of modified kaolinite in the pvc matrix. ftir and afm results confirm the presence of nanomaterial in kaolinite/pvc nanocomposites. tga data show that the modified kaolinit/pvc nanocomposites have significant enhanced thermal stability. the glass transition temperature (tg) of pvc nanocomposites is higher than that of pure pvc. in addition, the antimicrobial activity of clay-polymer composites were also determined. introduction: polyhydroxyalkanoates (phas) are biocompatible and biodegradable materials obtained from microorganisms. they are produced in the cytoplasm of several bacteria as energy reserve. the physical properties of poly( -hydroxybutyrate) (phb), which is from the group of phas, make it a competitive source to petrochemical plastics. phb has potential in order to be used in a variety of application fields such as packaging industry, printing materials, agriculture and food industry. furthermore, phb meets expectations for tissue engineering applications, since it is biocompatible, biodegradable, non-toxic and has good mechanical properties. although its many advantages, blending approach could be needed in order to fulfill all expectations of a material. due to its flexibility, polycaprolactone (pcl) is a promising candidate to be blended with phb. the aim of this study is to construct a scaffold by using phb produced by extreme alkaliphilic b. marmarensis gmbe t (dsm ) and commercial pcl as components and investigate its properties. materials and methods: electrospinning method was used in order to construct scaffolds from blend polymer solution containing phb from b. marmarensis and commercial pcl. results: nanofiber structures were observed on scanning electron microscope (sem) images and fourier transform infrared resonance (ftir) analyses have shown characteristic peaks for both phb and pcl. discussion and conclusion: phb could be blended with other polymers in order to enrich its properties. in addition, nanofiber structure of electrospun phb-pcl blend makes it a rewarding material as scaffold for several tissue engineering applications. q fever is a zoonotic disease that is encountered widely around the world, the most common acute form of q fever shows the following symptoms; a sudden fever, shivering, lassitude, headache, anorexia. because this disease does not show specific symptoms its diagnosis is possible with laboratory tests. current diagnostic kits lack effectiveness; this is why the main goal of our studies is to come up with a new diagnostic kit that does not have disadvantages that current diagnostic kits show. with this goal, nine mile i strain (rsa ), s serologic virulent phase i, were obtained from slovak science academy, virology institute for rickettsia reference and research from who co-operation centre. these cells were purified and lipopolysaccharide (lps) isolation from coxiella burnetii was performed. the polymeric carrier, poly (n-vinyl- -pyrrolidone-co-acrylic acid) [p(vp-co-aa)] was synthesized and characterized. physical complexes of obtained lps and p(vp-co-aa) with varying ratios. ternary complexes of lps-cu + -p(vp-co-aa) were also synthesized with copper metal mediation. structure and interaction of lipopolysaccharide-p(vp-co-aa) complexes were investigated with zeta-sizer device using zeta potential analysis and ftir spectrophotometry according to the ratios of components, reaction environment conditions and chemical structure of the polymer. the best complex ratio according to analysis results will be used in the future studies for obtaining monoclonal antibodies which will be an important step for obtaining more effective and stable diagnostic kits that can be used for q fever. this in this study; new types of water soluble polymer-biomolecule conjugates were synthesized using covalent bonding techniques between polymers and co-polymers (varying monomers of polyacrylic acid and acrylic acid) with peptides. different compositions of polymers, varying ratios of biomolecule/polymer and different molecular weight of polymer has yielded new types of bioconjugates. conjugation mechanism, composition and structure were investigated with various physicochemical methods (uv, ftir, hplc, gpc, etc.). the peptide used in this study was the antigenic peptide epitope of sheep-goat pox disease (eakssiakhfslwksyadadiknsenk). whether this peptide series was bound to polymers or whether it was bound to polymer-protein carrier; peptide-specific immunogens that were capable of producing antibodies were synthesised. it is thought that using polymer-peptide bioconjugates that contain just peptide will yield a higher peptide-specific immunogenicity compared to traditional adjuvants. in vitro and in vivo investigations of bioconjugates effectivity is planned to be done in the future studies. p- . . - bioinert fluorinated ethylene-propylene copolymer modified for keratinocyte adhesion surface properties are crucial when adhesion of a cell to a polymeric material is required for a biomedical application. one of the methods for polymer surface tailoring is argon plasma treatment. this simple and reproducible method alters the surface properties such as roughness and wettability without affecting the bulk properties of the material. for the modification of the bioinert fluorinated ethylene-propylene (fep), related to teflonÒ, we employed argon plasma treatment with the powers of and w for - s. the human keratinocytes of the hacat cell line served as a model cell line for biocompatibility testing. we studied adhesion, proliferation and morphology of the cells on modified fep matrices as well as controls (pristine fep and standard polystyrene tissue culture dish) by means of fluorescence microscopy. further morphological details were acquired by scanning electron microscopy. furthermore, fluorescence microscopy with immunochemical labelling was used to determine the size and distribution of focal adhesions in cells grown on the modified matrices. the overall effect of the matrices on metabolic activity of cultured hacat cells was also evaluated using the wst- reagent. the ar plasma treatment of fep matrices improved significantly cell adhesion and proliferation and promoted spreading of the hacat cells compared to the pristine fep, on which cells were not able to spread properly. also, increased metabolic activity rates for cells cultured on modified matrices were found in comparison to the pristine fep. altogether, we found that ar plasma treatment improved the surface properties of fep to such extent, that it allows cultivation of adherent cells on its surface. we therefore propose that ar plasma treatment is a useful method for fep surface modification. p- . . - graphene oxide enriched biomaterials display potential for tissue engineering applications tissue engineering (te) requires more efficient systems that favor local tissue regeneration with minimum cytotoxicity. materials based on natural compounds ensure biocompatibility and have better effects for regeneration. graphene oxide (go) has been shown to enhance cell adhesion and to improve the rate of cell differentiation. in this context, the aim of this study was to evaluate if the addition of different concentrations ( . - wt.%) of graphene oxide (go) improves the properties of cellulose acetate (ca) materials for biocompatibility and cell differentiation, in the prospective of using these films for te applications. go-containing ca films were tested for cytocompatibility by quantitative and fluorescence microscopy assays, and compared to the ca control. cell cytoskeleton architecture in contact with biomaterials was revealed by confocal microscopy. furthermore, bioconstructs were exposed to in vitro osteogenic and adipogenic induction and monitored for days. histological stainings were performed to validate differentiation. osteogenic and adipogenic markers gene expressions were assessed via qpcr. ca/go wt.% revealed best biocompatibility among all tested scaffolds. adhesion proved to be dependent on the percentage of go in material's composition. cells cultivated on ca/ go wt.% expressed adipogenic and osteogenic markers earlier than cells cultivated on materials with lower go content. differentiation markers displayed an increasing profile of gene expression from to days post induction, with higher levels registered for materials with high go content as compared to films with low go content and to the control. go added to ca materials positively influenced cell survival, proliferation and cell differentiation. ca/go films represent potential candidates for te applications. the design of appropriate scaffolds remains one of the most important challenges for te. current idea is that the cell-scaffold interaction could drive cell differentiation and be linked to gene expression and protein organization. therefore, their quality is essential and should favour cell attachment, growth, migration, in situ vascularization and release of biochemical and physical factors able to address the cell fate. moreover, for an ideal scaffolding material an adequate and interconnected porosity is relevant for facilitating cell spreading and colonization of the inner layers. a combination of optimal mechanical and biochemical properties were here utilized to design a d composite hydrogel scaffold ( d-chs) in order to favour cell-scaffold interactions and promote a functional differentiation of human lin À sca + cardiac progenitor cells (hcpc). the biocompatible peg-diacrylate (pegda) was used to prepare hybrid protein-pegda hydrogels with embedded albumin-microspheres (ms) as protein component. ms were able to modulate the mechanical and biological behavior of the scaffold acting as air-reservoir, porogen agents and potential carriers of biomolecules. an increase of the hcpc viability in the ms-concentration dependent manner was observed. moreover, the microarchitecture of the d scaffold also plays a key role in the stability and functionality of cellularcomposite systems. therefore, pegda-honeycomb structures were fabricated using microstereolithography process and the hcpc viability and adhesion to the microstructures were assessed. d-chss were synthesized embedding honeycombstructures into ms-pegda hydrogel and the effects on cell proliferation, cell-cell interactions and cellular alignment were investigated. these results could be of relevant interest for expanding the knowledge on cell-scaffold interaction processes and to promote the development and the application of d-chs for tissue regeneration using the emerging bioprinting technologies p- . . - gene expressions of mesenchymal stem cells after osteogenic induction on ceraform bone substitute a. kilic s€ uloglu, e. karacaoglu, h. akel, c ß . karaaslan hacettepe university, ankara, turkey ceraformÒ, is a synthetic calcium phosphate ceramic with the chemical composition of hydroxyapatite % and tricalcium phosphate %, with - % pore volume and - lm pore diameter. in this study adipose tissue derived mesenchymal stem cells were differentiated into osteoblast cells and loaded on cer-aformÒ. in order to improve cell adherence, ceraformÒ was covered with fibronectin. the cells were cultivated for -day period by osteogenic induction medium. days , , , and were selected as specific intervals for incubations. total rna was isolated and cdna was synthesized. differences in the expression of runt-related transcription factor (runx ), bone morphogenetic protein- (bmp- ), and osteocalcin (ocn) were determined by qpcr. the peptidylprolyl isomerase a (ppia) gene was used as an internal control. according to the qpcr results, ocn gene expression was observed on the day th, continued to increase in day . bmp- gene expression was increased in , , day compared to day. on the other hand, runx gene expression was increased only on days and . these findings pointed out that the osteogenic induction was successfully activated on fn coated bone material. therefore, these results can be used in bone injury treatment and related disorders. p- . . - on the in vitro cytotoxicity of graphene oxide nanomaterials v. grumezescu , i. negut , f. sima , e. axente , l. e. sima national institute for lasers, plasma and radiation physics, magurele, romania, institute of biochemistry, romanian academy, bucharest, romania during the last decade, graphene and its derivates have proven unique physicochemical properties, several applications being continuously developed. among them, electronic, catalytic, mechanical, optical, and magnetic properties have attracted huge interests. however, the merging of graphene and graphene oxide (go) with biotechnology is still in its infancy, many challenges remaining unexplored. potential applications are related to biosensors, drug delivery or gene therapy and cells imaging. in order to use gos as drug release matrices for cancer cells targeting, it is necessary to ensure that these molecules do not affect normal cells within tissues. it was shown that the cytotoxicity of graphene nanomaterials is highly dependent on surface functionalization. studies suggest that pristine and reduced go with fewer surface functional groups tend to be more toxic than go. in striking contrast, it has been reported that functionalized graphenes, can significantly reduce the cytotoxicity even at relatively high concentrations. in this study, we report on the comparison between go and protein functionalized go when submitted to in vitro cytotoxicity tests. bovine serum albumin (bsa) was used for the noncovalent go surface conjugation. three case-studies were investigated: aqueous nano-colloids consisting of serial dilutions of both go and go-bsa conjugates, dropcasted thin films and laser-assembled thin films on glass substrates. safe concentration windows were identified by live/dead staining and mts assays for different human melanoma cell lines, while melanocytes and human dermal fibroblasts were used as normality controls. the predominant melanoma subtype is represented by cells bearing braf (v e) activating mutation. with a view to target this specific melanoma subpopulation, we embedded braf inhibitors into go laser-deposited scaffolds and tested their anti-tumoral effect. our results evidence the high potential of these nanomaterials for biomedical applications. osteoporosis is a skeletal disorder associated with low bone mass and increase in bone fragility due to increased osteoclastic activity. binding of rank ligand to its receptor on osteoclast precursor cells results in the osteoclast differentiation. sirna is a dsrna, used to inhibit the translation of the target gene. the aim of the study is to develop an injectable sirna-delivery system targeted to the bone for osteoporosis treatment. pei (polyethyleneimine) and rank complex was loaded into poly(lactic acid-co-glycolic acid) (plga) nanocapsules which are bound to hydroxyapatite (hap)-specific elastin-like protein (elp) for targeting to bone tissue. plga nanocapsules were prepared by w/o/w double emulsion technique. affinity of elp to hap was determined by ftir. elp was coated on the nanocapsules by using the transition temperature of elp. elp on plga nanocapsules were crosslinked by genipin and binding of elp on plga nanocapsules were studied by xps and tem. the optimum ratio of n (pei) to p (sirna) in the complexes to be loaded into plga nanocapsules were studied by etbr staining and zeta potential measurements with varying n/p ratios and finally pei-dnaoligo encapsulation efficiency of the capsules was determined by picogreen reagent. xps results of elp treated plga (elp-plga) nanoparticles indicated the presence of nitrogen atom ( . %) in the sample which appeared as a fuzzy halo in tem micrographs. n/p ratios up to show negatively charged particles. when n/p was , the zeta potential of complex was neutralized which also resulted in larger particles compared to the others. zeta potential moved to positive values when n/p was higher than . the migration of polyplexes with different n/p ratios ( - ) was analyzed by gel electrophoresis. dnaoligo complexes show the same patterns of complexation wih that of sirna and thus were used in the encapsulation efficiency studies instead of sirna. the encapsulation efficiency of pei-dnaoligo in plga nanocapsules was %. tuesday september : - : aging p- . . - novel benzenesulfonamides exhibit low toxicity on zebrafish embryonic development and selectively inhibit carbonic anhydrase ix with nanomolar affinity in xenopus oocytes introduction: the toxic effects of two recently discovered inhibitors (vd - and vd - - ) that selectively and with extraordinary strong, picomolar affinity bind to human carbonic anhydrase (ca) ix, an anticancer target, were investigated on zebrafish embryonic development and in xenopus laevis oocytes. zebrafish has emerged as a promising animal model to evaluate the toxicity of the drug candidates. xenopus oocytes do not natively possess any ca activity and thus became a convenient in vivo model system to study the ph effects and the selectivity of synthetic ca inhibitors. materials and methods: morphological changes in zebrafish treated with the compounds were studied by light-field microscopy and histological analysis. ca activity in xenopus oocytes was monitored by measuring ph in the cytosol and at the outer membrane surface and confirmed by mass spectrometry of lysed oocytes. the toxicity studies showed lc values to be lm for vd - , lm for vd - - and lm for ethoxzolamide (eza), a non-selective ca inhibitor commonly used in clinic. the zebrafish exposed to lc doses of vd - and vd - - showed fewer phenotypic abnormalities and less morphological changes compared to the zebrafish treated with the corresponding dose of eza. vd - - exhibited - nm ic for both intracellularly and extracellularly expressed ca ix in xenopus oocytes while exhibiting strong selectivity over ca ii, ca iv and ca xii. discussion: interestingly, the compounds exhibited -fold lower toxicity, induced fewer side effects in zebrafish than eza and the amount of vd - - needed to cause complete inhibition of ca ix enzymatic activity in xenopus oocytes was -fold lower than eza. conclusions: vd compounds did not lead to deleterious effects on the zebrafish embryonic development and reached the ic of nm for ca ix in xenopus oocytes. the compounds could be further developed as anticancer drugs. cacybp/sip is present in various cells and tissues, both normal and pathological. in normal tissues, e.g. stomach or colon, cacybp/sip is weakly or barely detected whereas in gastric or colon cancer this protein is expressed at a high level. there are also data indicating that the level of cacybp/sip expression correlates with tumor metastatic potency and multidrug resistance. taking into consideration data that suggest association of cacybp/sip with many vital cellular processes, in this work we decided to investigate the possible mechanism involved in regulation of cacybp/sip gene expression, mainly by transcription factors and, on the other hand, the influence of cacybp/sip on the expression of other genes. we have shown that nfat (nuclear factor of activated t cells) influences the cacybp/sip gene expression and that overexpression of cacybp/sip has an effect on the level of ap- and on the activity of nfat and ap- transcription factors. by analyzing the cacybp/sip gene promoter sequence we also found potential binding sites for transcription factors from the stat family, which are involved in interferon signaling. microarray data indicate that indeed overexpression of cacybp/sip affects levels of the stat proteins as well as of some interferons and interleukins. based on functional analysis we have found many genes the products of which are involved in immune response. to analyze in more detail the influence of an altered level of cacybp/sip on interferon signaling pathways as well as on factors involved in expression of interleukins, including nfkappab, we plan to apply methods such as luciferase assay, real-time pcr or immunocytochemistry. one of the pathological hallmarks of alzheimer's disease (ad) is the neuritic plaques occurred as a result of the extracellular accumulation of aß peptides formed from amyloid precursor protein (app) via the ß-amyloidogenic pathway. aß is more prone to aggregation to form plaques and more toxic to neurons than aß . in addition to change in app metabolism, the decline in levels of neurotransmitter acetylcholine and cholinergic dysfunction are also observed in ad. thus, current strategies for ad treatment focus on compounds with inhibitory effect on cholinesterases as well as preventive effect on aß aggregation. in our earlier studies, toluidine blue o (tbo), a phenothiazine dye, was shown to be a highly effective inhibitor of cholinesterases with k i values in nm range. we also found that intracellular app and aß levels are reduced in human neuroblastoma cells after treatment with tbo. additionally, an earlier study revealed that tbo has a selective inhibitory effect on tau aggregation, the other pathological characteristic of ad. the aim of this study was to investigate whether tbo may effectively lower the level of extracellular aß / in an ad-like cellular model. chinese hamster ovary cells that express human wild type app and presenilin , namely ps , were treated with a dose range of tbo ( - lm) or vehicle control for h. after treatment, aß / levels in cell culture media were assayed by separate sandwich-based elisas and normalized to total protein levels, determined by bca protein assay. besides, biocompatibility of tbo was evaluated in the ps cells using cell viability assay for flow cytometry. strikingly, all dose ranges of tbo inhibited both aß and aß secreted into the cell culture media. significant reduction for both aß species was evident at lm (p < . ), lm (p < . ), and lm (p < . ) of tbo vs. vehicle control. in conclusion, these results support the idea that tbo may be used as a therapeutic in ad. monitoring the changes of key molecules participating in the osmo-regulatory response of nucleus pulposus intervertebral disc cells during stress-induced senescence e. mavrogonatou, d. kletsas ncsr 'demokritos', athens, greece introduction: intervertebral disc cells are faced with a harsh extracellular milieu characterized by hyperosmotic conditions, nutrient and oxygen deficiency because of the absence of vascularization and oxidative stress due to the accumulation of their metabolism's by-products. we have previously shown that high osmolality is anti-proliferative for disc cells through the activation of the g and g cell cycle checkpoints by p and p mapk, respectively. in addition, we have shown the participation of nine solute transporters, with the a subunit of na + /k + -atpase being central in this response. here we assessed the changes in the expression of these key osmo-regulatory molecules during in vitro stress-induced senescence. materials and methods: changes in cell cycle progression were assessed using flow cytometry; overall transcriptional alterations were assessed by whole-genome arrays; differences in expression at the mrna and protein level were revealed by quantitative rt-pcr and western blotting, respectively; knocking-down of selected proteins was performed by sirna. results: high osmolality led to the differential expression of > genes, including nine genes encoding transporters. p mapk and p were demonstrated to differently participate in the regulation of the aforementioned transporters, while knocking-down of three selected transporters had a distinct outcome on the overall cellular response towards hyperosmotic stress. these molecules were found to show differences in their expression in senescent cells. discussion: given that the presence of senescent cells has been demonstrated in the intervertebral disc in vivo and could most probably attributed to the prevailing stressful conditions, here we showed differences in the expression profile of known key molecules for osmo-adaptation during senescence. conclusion: understanding disc cells' physiology is of outmost importance when designing cell-based therapies for disc degenerative disorders. p- . . - smad specific e ubiquitin protein ligase (smurf ) and its potential effects on inhibitory transmission in aging adams , , , interdisciplinary program in neuroscience, bilkent university, ankara, turkey, national nanotechnology research center (unam), bilkent university, ankara, turkey, department of molecular biology and genetics, bilkent university, ankara, turkey, molecular biology and genetics zebrafish facility, bilkent university, ankara, turkey, department of psychology, bilkent university, ankara, turkey smad specific e ubiquitin protein ligase (smurf ) is part of the tgf-b signaling pathway associated with cellular proliferation, differentiation, genomic stability and senescence. moreover, smurf , via its downstream partners, may regulate inhibitory synaptic transmission. our research group previously found that the smurf transcript is significantly higher in old zebrafish brains. thus, smurf may alter inhibitory synaptic transmission in aged animals. the focus of this study was to examine age-related changes in smurf protein levels and related key inhibitory synaptic proteins; gephyrin (gep), a scaffolding protein for gaba receptors, and gaba a , an ionotropic gaba receptor subtype. additionally, the levels of those proteins were studied in a mutant zebrafish line, which lacks acetylcholinesterase (ache) and is suggested to be a delayed aging model. whole brain tissues were isolated from young, middle-aged and old male and female zebrafish brains (ab/wildtype strain), as well as from old male and female ache mutant zebrafish (ache sb /+ ). animals were maintained and raised in standard conditions. the extracted brain tissue was homogenized in ripa buffer and subjected to western blot analysis to determine differences in the relative protein expression levels. our preliminary data indicated that smurf and gep levels remain stable in the aging brain (p = . , p = . ), and in the ache mutants gep levels are increased compared to the wildtype controls (p = . ). further analysis of the relationships between smurf and gaba a levels and brain aging is ongoing. we predicted that alterations in smurf levels would parallel changes in key synaptic inhibitory proteins during the aging process, which was the case for the gep levels. while smurf may regulate inhibitory synaptic transmission, the exact roles of those synaptic proteins in the context of normal and delayed brain aging are not known well-understood and the subject of continuing study. in recent years, express the hypothesis that aged individuals are vulnerable to infectious and other inflammatory agents and they become more prone to develop majority of severe age pathologies, including cardiovascular and oncology diseases, neurodegenerative diseases, type diabetes mellitus and inflammatory diseases, etc. one of the central components of immune response is the family of toll like receptors (tlr). there are several opinions that single nucleotide polymorphisms (snp) leading to a loss of function of the respective tlrs can be associated with age and increase the risk of age related diseases, especially cardiovascular diseases (cvd). however, many available studies focusing on tlr snps and cvd are with conflicting results. the aim of this study was to assess the potential interaction between genetic variants of tlr and tlr and ischemic heart disease (ihd) in kazakhstan population over years old. we evaluated patients with ihd and healthy subjects aged years and over (ethnical kazakhs and russians living in republic of kazakhstan). polymorphic loci of the genes tlr rs and tlr rs were genotyped by pcr with subsequent restriction analysis. our results indicated that the genotype and allele frequencies of tlr (arg gln) and tlr (asp gly) were not significantly different between the groups (p ≥ . ). statistical analysis didn't elicit any association between studied gene polymorphisms and predisposition to ihd in individuals over years old (p ≥ . ). for these polymorphisms, age, fasting blood sugar and serum lipid levels were not also significantly different among different genotypes in the ihd and control groups. in conclusion, the data shows that there is no interaction between tlr and tlr and ischemic heart disease (ihd) in kazakhstan population over years old. we plan to include other types of polymorphisms in tlr and tlr genes and increase the volume of patient cohort in our future studies. p- . . - evaluation of prognosis with total oxidant/ antioxidant status and some oxidative stress parameters in patients with acute ischemic stroke stroke is the third most common cause of death after coronary heart disease and cancer. strokes are classified into two groups according to their pathology: ischemic stroke and hemorrhagic stroke. ischemic strokes make up % and hemorrhagic strokes % of all strokes. during ischemic stroke, oxidative stress has been shown to play a major role in the occurrence and progression, formed oxidants also affect cell membranes and genetic material such asdna, rna, and various enzymatic events, and they lead to cell damage. some studies have shown oxidant-antioxidant status but have not shown the relationship with prognosis. this study has investigated the relationship between prognosis and total oxidant/antioxidant status and biochemical parameters in patients with acute ischemic stroke patients, with acute ischemic stroke and healthy controls we reenrolled in the study. blood samples were taken within st and th days, and after rd months in the patient group for analysing serum total oxidant status (tos), antioxidant status (tas), catalase, arylesterase, and thiol. prognosis was evaluated with national institutes of health stroke scale (nihss) and-modifiedrankinscale (mrs) scores. there was no significantly difference between groups by means of serum tas, tos and catalase levels. but arylesterase (p: . ) and thiol (p: . ) levels were significantly higher in first h blood samplingthancontrolgroup. statistically significant negative correlation was observed between the rd month values of tos and nihss score (r = . , p = . ). but there was no correlation between mrs scores and serum tas, tos, catalase, thiol and arylesterase. similarly, our findings suggested some serum oxidant levels were increased in acute ischemic stroke patients and total oxidant status might be used in evaluation of prognosis but larger studies are needed. p- . . - amylin and preptin regulate glucose homeostasis in infertile women with polycystic ovary syndrome and poor responders undergoing ivf/icsi disrupted glucose homeostasis leads not only metabolic disturbance such as polycystic ovary syndrome (pcos), but also influences oocyte growing. this study was designed to evaluate follicular fluid (ff) and serum levels of glucoregulatory hormones, amylin and preptin, in infertile women with pcos and poor responders undergoing ivf/icsi. human follicular and serum were obtained from infertile women with pcos and poor responder participants undergoing controlled ovarian stimulation (cos) with gonadotropin-releasing hormone antagonist protocol for ivf/icsi treatment. ff and serum amylin and preptin levels were measured by elisa. it was found that ff and serum amylin and preptin were lower in infertile women with pcos when compared with poor responder participants. ff amylin and preptin concentrations were lower than that of the serum amylin and preptin concentrations. decreased follicular fluid amylin and preptin levels suggest that amylin and preptin may have a physiological role in follicular maturation via controlling local glucose homeostasis. despite high serum levels of amylin and preptin in pcos their low concentration within the follicle may be main culprit of defective folliculogenesis seen in pcos subjects. similar to insulin resistance in pcos subjects existence of amylin and preptin resistance support the critical role of both peptides in follicular maturation in pcos. keywords: follicular fluid; amylin; preptin; polycystic ovary syndrome; infertility. the transcription initiation on p promoter of xp bacteriophage in presence of p protein, a modulator of rna-polymerase activity a. shadrin g.k. skryabin institute of biochemistry and physiology of microorganisms, ras pushchino, russia many bacteriophages are able to manage the transcription system of their bacterial host for their own needs. for example, bacteriophage xp , in the early stages of infection of xanthomonas oryzae inhibits transcriptional activity of bacterial rna-polymerase on majority of promoters via p protein, except of bacteriophage p promoter responsible for expression of the bacteriophage 'middle' class genes. the focus of this work is to study the mechanism of action of p protein in the transcription initiation and identification of the role of the individual elements of p promoter of xp bacteriophage, enabling x. oryzae rna-polymerase escapes inhibition by p protein. we have designed a set of promoter probes representing the combination of sequences of p -resistant p promoter and p sensitive t n promoter. using fret-based assay it was shown that the truncated probes corresponding to promoter dna downstream À position, relative to the transcription initiation start site, did not lead to dissociation of the sigma-factor. longer probes, containing À promoter element, induce dissociation sigma-factor. the in vitro transcription experiments show that the deletion of region , a sigma-factor domain responsible for interaction with À promoter element during the transcription initiation, is not critical for inhibition of rna-polymerase by p protein. promoter probe with up-element of p promoter had affinity to x. oryzae rna-polymerase a several times higher than a probe containing the consensus up-element for e. coli rna-polymerase . summing up the results, it seems like the transcription initiation on p promoter of bacteriophage xp can escape inhibition by p protein through a high affinity interaction between the up-element and c-terminal domains of the alpha subunit of rna-polymerase x. oryzae. p- . . - distribution of soluble form of glial fibrillar acidic protein in the different areas of gerbils brain during development and aging y. kovalchuk, g. ushakova oles honchar dniepropetrovsk national university, dniepropetrovsk, ukraine astrocytes are the most abundant cell type within the cns and play an important role in cns homeostasis and function. glial fibrillary acidic protein (gfap) forms the main astrocytic intermediate filament (if). the overall level gfap in different parts of the brain uneven and depends on the number of astrocyte cells. gfap is very sensitive to any kind of neurodegenerative diseases and aging. during aging, a glial reaction is observed in the human brain, as well as in rat and mouse brains. the aim of our study was to investigate the quantitative astrocytes-specific protein gfap in different areas of the gerbils brain at the first stages of postnatal development and aging. for the study gerbils brains were used and divided into groups (n = ): : newborn animals ( day), - : , and days respectively, : animals aged years. the animals were decapitated under mild anesthesia (thiopental), with isolated brain three divisions: the cerebellum, thalamus and hippocampus, which are then used to produce cytosolic protein fractions. the level of gfap in the obtained fractions were determined according to the method of competitive elisa. newborn gerbils found no significant content of soluble form of glial fibrillar acidic protein in all investigated parts of the brain, and a sharp increase of amount within days (in cerebellumamounted to . ae . lg/ mg tissue; to - days increased to . ae . lg/ mg tissue, and began to grow again in older individuals aged years). unlike the cerebellum, the level of sgfap in hippocampus and thalamus reached the maximum at days p.d. ( . - . lg/ mg tissue), and unchanged for days. these results revealed that the most intensive development of astrocytes in the cerebellum to p.d. of gerbils, and in the thalamus and hippocampus are formed within the first month of life. the plastid-nucleus located protein whiry acts as an upstream regulator of leaf senescence binding to the promoter of senescence associated genes (sags) like senescence marker gene hvs . in order to investigate the impact of whirly on drought stress-induced senescence, transgenic barley plants with a knockdown of whirly (hvwhy kd) were grown under untreated and drought stress conditions. the leaf senescence evolution was monitored by physiological parameters and gene expression studies of senescence and drought stress related genes. to reveal the epigenetic indexing at hvs at onset of drought-induced senescence in wild type (wt) and hvwhy kd lines, stress-responsive loading with histone modifications at gene regions of hvs ( regions in the promoter, one region around translation start site and regions located in the gene body) was analysed by chip and quantified by rtq-pcr. in barley, drought treatment caused acceleration of leaf senescence in wildtype (wt) plants, whereas why kd lines showed a staygreen phenotype. expression of senescence-associated and drought stress responsive genes expression was delayed in hvwhy kd indicating that whirly protein acts as an upstream regulator of drought stress-induced senescence. the chip results showed that drought treatment is causing in wt a significant increase in the levels of h k ac all over the analyzed gene regions, correlating with a massive induction of hvs expression, while drought stress caused no substantial increase of h k ac in why kd plants. the results suggest that drought induced expression of hvs is under epigenetic control, and furthermore that why is involved in this epigenetic control level. oncolytic viral therapy is based on the capabilities of selective lysis of tumor cells and is a prospective trend in cancer disease treatment. in vitro experiments showed that plant rhabdoviruses does not have any direct cytotoxic effect upon sarcoma cells, causes induction of apoptosis in these cells and does not pose any threat to somatic cells of warm-blooded animals, which makes it possible to use this virus for therapy of malignant neoplasms. buckwheat burn virus (bbv), the prototypic member of the family rhabdoviridae, contains surface glycoprotein and which is lectin-active. its carbohydrate branch can aid adhesion of lymphocytes to tumor cells. the present study has addressed the effect of bbv on cancer cell viability. all studies were carried out after week of inoculated with erlich cancernome ( cells/animal, i. p.) in months male balb/c mice treated at once with or without plant extract with bbv ( mg/kg, i. p.). by fluorescent microscopy and using two due staining by acredine orange and propidium iodide it was found that in the rd day of administration of bbv lead to increasing of necrotic and apoptotic cells on % and % respectively versus to untreated group. at the same time the viability of investigated cells was impaired too and according to flow cytometry analysis using propidium iodide the amount of dead cells was elevated by fivefold ( . % versus . % in untreated group). also as was shown in previously reports bbv decreased activity of macrophages in the early stages after injection and it may have a positive effect when using this drug in tumor therapy. when using this drug appears to slow down the possibility of a sharp activation of macrophages, and as a consequence of the development of cytotoxic effect will be prolonged. key words: rhabdoviruses, buckwheat burn virus, cancer, cell viability. plants are considered as one of most promising sources for new antimicrobials, based on the evidence of their use in folk medicine to treat various infectious diseases since ancient times. despite relatively small area size, armenia has large diversity of flora with many endemic species. the main goal of this study was the screening of various parts of herbs (widely being used in armenian folk medicine) for their antimicrobial activities in order to select most prospective plants for further comprehensive studies. plant crude extracts were obtained with maceration technique using five solvents: water, methanol, chloroform, acetone and hexane. agar well diffusion assay was used to evaluate antimicrobial properties of plant crude extracts at lg/ml concentration against escherichia coli vkpm-m , pseudomonas aeruginosa grp , bacillus subtilis wt-a , salmonella typhimurium mdc and staphylococcus aureus mdc , candida albicans wt- and candida guilliermondii hp- . statistical analysis was done using graphpad prism . . crude extracts of all tested plant materials expressed antimicrobial activity against at least one test strain. most of the tested extracts inhibited growth of both gram-negative and gram-positive bacteria. in contrast, only some plant materials exhibited inhibitory activity against yeast strains. according to obtained data sanguisorba officinalis, rumex confertus, hypericum alpestre, lilium armenum and agrimonia eupatoria possessed the highest and broadest antimicrobial activity. moreover, the results showed that acetone was the most effective solvent for solubilizing antimicrobial compounds from plant materials followed by methanol, chloroform, hexane and water. the results demonstrated high antimicrobial activity of medicinal plants used in armenian traditional medicine. five plant species were selected for further comprehensive studies. besides, acetone was proposed as efficient solvent in antimicrobial screening protocols. p- . . - effects of aluminum stress on photosystem-i apoprotein a gene (psab) transcription level in lichen xanthoria parietina (l.) th. fr. unal € ozakc ßa ege university, izmir, turkey in this study the effects of shortrerm aluminium (al) toxicity on the lichen xanthoria parietina (l.) th.fr. were investigated at physiological and transcriptional level. lichen thalli were treated with alcl in different doses ( . , . , and mm). lipid peroxidation and chlorophyll integrity were determined by spectrophotometer. expression level of psab gene was also investigated. chlorophyll a content was significantly (p ˂ . ) decreased after hours treatment with mm and mm of al, while chlorophyll b content was increased significantly due to treatment with increased concentration of aluminum. also treatment with . and . mm al for hours increased the gene expression level of psab by . % and . % respectively. our results indicated that aluminum treatment has decreased the chlorophyll biosynthesis and increased the lipid peroxidation depending on time and concentration. this study also demonstrates that the psi can be readily photo-inhibited by aluminum stress. in conclusion, mm al exposure for hours could damage the electron transport in photosystem i. p- . . - nigella sativa reduces paracetamol-induced nephrotoxicity and oxidative stress in rats: biochemical evaluation background: nigella sativa l. (ranunculaceae) (ns) is traditionally used to treat many conditions such as inflammation. this study evaluates the effects of ns seeds ethanol extract in paracetamol-induced acute nephrotoxicity in rats. material method: forty-eight female wistar albino rats were divided into eight groups: i = sham; ii = sham + mg/kg ns; iii = sham + mg/kg (n-acetyl cysteine) nac; iv = g/ kg paracetamol; v = g/kg paracetamol + mg/kg nac; vi, vii and viii = g/kg paracetamol + , and mg/kg ns, respectively. paracetamol administration (oral) was carried out h after ns and nac administrations (oral), and all animals were sacrificed h later. result: urea and creatinine levels were determined in serum, while glutathione, malondialdehyde levels and superoxide dismutase activity were determined in the kidney tissues. there were significant increases in the serum levels of urea and creatinine in the paracetamol-administered group. serum levels of urea and creatinine were decreased in all groups administered ns with paracetamol. ns administration dramatically restored sod, gsh, and mda levels in the kidneys. conclusion: the results suggest ns has a significant nephroprotective activity on paracetamol-induced nephrotoxicity. it may be suggested that the antiinflammatory and antioxidant effects of ns ethanolic extract originated from different compounds of its black seeds. p- . . - the study of problems of preservation of the birches e. shadenova , , e. zhumabekov , m. sembekov , m. burchaeva institute of general genetic and cytology, almaty, laboratory of genetics and reproduction of forest culture, institute of general genetics and cytology, almaty, kazakhstan nature of deciduous trees have a whole range of various medicinal properties. instead of synthetic hormone substitutes, you can use medicinal infusions and decoctions of natural phytohormones are widely used in both folk and professional medicine. one of these plants is birch, its young leaves and buds. however, they also must be used with caution because overdose of these compounds is very dangerous, not only can you not get the desired effect, but also face the opposite of his action. in our research to mass replication of plants (different types of birches (betula ajanensis, yarmolenko, jacguemontii, maximowiczii, ulmifolia, middendorffii, kelleriana, tianschanica)) we use nutritional medium excluding the application of phyto promoters in order to prevent mutation. the object of research serve as the old, the sick, being on the verge of extinction, mature trees as explant meristema. since from the moment of calling experience and most cultivation occurs at nutritional medium without hormones. as a result of molecular analysis we get without virus, genetically identical plants. molecular certification of different types of birches of interest, both in terms of organizing, and in terms of selection and genetic improvement of valuable forms, identification of lines selected from natural populations and clones obtained in vitro. relationship between clones and installed parent form by comparing profiles amplific pcr products using issr-marking. according to the results of carried out works really recovered clones obtained from one source tree, indicating the potential for certification of clones studied forms of birches pcr. a study performed in the framework of the state grant project "conservation of breeding valuable species of birches". p- . . - fractionated triterpenoid glycosides from sea cucumber inhibit invasion and metastasis in human cancer cells sea cucumbers are slow-motioned invertebrates. holothuria polii delle chiaje, is widely distributed sea cucumber in _ izmir coastline (turkey). it secretes saponins i.e. triterpenoid glycosides (ttg) as secondary metabolites. the aim of this study is to evaluate anti-invasive and anti-migrative effects of fractionated ttgs obtained from h. polii on ht- , t and upci-scc- cancer cell lines. the semi-purified ttgs was extracted from h. polii collected from coast of _ izmir-dikili. the four different fractions (fraction a-d) were collected by using hplc (high-performance liquid chromatography) and characterizated with maldi-ms/ ms. the fractions obtained from h. polii extract include holothurin a ( . m/z) and -dehydroechinoside a, scabraside a or fuscocinerosides b/c isomer ( . m/z). anti-invasive and anti-migrative effects of the fractions on the cancer cell lines were detected with xcelligence rtca dp system. the results showed that fraction a-d inhibited migration and invasion of human cancer cell lines at th and th hours compared to control group. this study shows that holothurin a, dehydroechinoside a, scabraside a or fuscocinerosides b/c isomer could be evaluated as promising anti-cancer agents for human cancers. acknowledgement: the authors acknowledged the scientific and technological research council of turkey (t € ub _ itak) for financial support ( z ). p- . . - alternative splicing regulation of sr proteins in response to environmental stress in chinese cabbage serine/arginine-rich protein (sr protein) family, which acts as rna-binding protein, plays a major role in post-transcriptional regulation of pre-mrna, such as alternative splicing (as). these proteins cause pleiotropic effect by regulating as of pre-mrna in a tissue and developmental stage-specific and stress-responsive manner in arabidopsis. here, we identified genes encoding sr proteins in chinese cabbage (brassica rapa chiifu- ) from brassica database and analyzed their phylogenetic relationship. b. rapa has types of sr protein that are classified into common (sr, rsz and sc) and plant specific (scl, rs z, rs and sr-like) subfamily similar with arabidopsis. interestingly, the as pattern of most sr genes changed at the late stage ( and days after germination). to verify the correlation between sr genes and environmental stress, we screened the as pattern of sr genes to various abiotic stress using rt-pcr and a microarray analysis. in particular, the expression level and the as pattern of bra and bra were affected significantly by heat stress. these results suggest that the as regulation by sr protein correlates with adaptation mechanism to the environmental stress in chinese cabbage. p- . . - characterization of recombinant prolyl oligopeptidase from myxococcus xanthus and potential use in gluten hydrolysis e. k. kocaazorbaz, f. zihnioglu faculty of science, biochemistry department, ege university, izmir, turkey a recombinant prolyl oligopeptidase from myxococcus xanthus was purified with a specific activity of u mg(- ) by using nickel-metal-chelate affinity chromatography and gel permeation chromatography. the recombinant enzyme had a monomeric molecular weight of kda. its isoelectric point, determined by two dimension polyacryl-amide gel electrophoresis, was close to . . the optimum ph and temperature was estimated as . and °c, respectively. the purified enzyme was stable from ph . - . and able to thermal stability up to °c. the k(m) and v(max) values were . mm and . micromol/ min per mg. the enzyme exhibited hydrolytic activity for suc-gly-ala-pna, suc-gly-pro-pna, z-gly-pro-pna, igf- , substance p, whereas no activity for h-gly-pro-pna, h-val-ala-pna, h-arg-pro-pna, h-ala-pro-pna, glu-ala-pna, pro-pna, leu-pna. its proteolytic activity was inhibited by activesite inhibitors of serine protease, z-pro-prolinal pmsf, and metal ions, cd + and hg +. the potential use of the enzyme was tested by the hydrolysis of the wheat gluten. the resulting gluten hydrolysate were characterized by means of their antioxidant, antibacterial, trypsin inhibition and prolyl oligopeptidase inhibition activities. keywords: serine protease, prolyl oligopeptidase, bioactive peptides, , , -trinitrobenzene sulfonic acid. proteomic analysis is probably the best approach to analyze seed germination. however, it is difficult to analyze complex samples and there are many obstacles that must be faced in order to achieve a reasonable proteome coverage. for example, the barley (hordeum vulgare) genome was fully sequenced in , but the uniprot database contains less than reviewed sequences, which is approximately -fold less than for arabidopsis thaliana. here, to improve the barley proteome coverage, we employed several fractionation methods including polyethylene glycol precipitation, strong cation exchange chromatography, off-gel separation, sds-page and acetonitrile elution gradient. proteomic analyses were performed using an lc-ms-based analyses and an uhr q-tof mass spectrometer. the candidate peptides were targeted via selected reaction monitoring (srm) and triplestage quadrupole (tsq) mass spectrometer. in total, proteins were identified, which represents a three-to four-fold increase compared with the standard shotgun analysis of the same sample. out of these, were only accessible by one of the techniques and, besides, the detection limits were not similar. we hypothesized that an srm-based targeted analysis will allow detection and quantitation of most of these proteins, even without the application of proteome fractionation. we can conclude that all peptides from the library with ms/ms spectra of the total intensity above , are easily detectable in the total protein extracts. p- . . - transcriptome sequencing based identification of alternative oxidase genes in white waterlily, nymphaea alba alternative oxidases (aoxs) are the terminal oxidases in the respiratory electron transport chain of plants. they reduce molecular oxygen to water with low proton translocation across the inner mitochondrial membrane. in plants, aoxs increase local tissue temperature to release volatile compounds thereby attracting pollinator insects and regulation of mitochondrial retrograde signaling pathway. regulation of retrograde signaling pathway is currently under investigation to improve cultivation studies in many plants. water lilies are aquatic ornamental and economically valuable plants classified under nymphaea family. nymphaea alba, white water-lily, has a special focus since its applications in landscaping of parks and gardens, farming as vegetable and medical applications. however, cultivation of n. alba is a challenging process. we hypothesized that by controlling alternative oxidases, success rate can be increased for n. alba cultivation. to identify alternative oxidase encoding genes in n. alba, we performed transcriptome analysis. by using transcriptome analysis data, aox gene sequences, subcellular localization of aox proteins and structural modelling of aox proteins were predicted. in transcripts, database search with trinotate tool revealed transcripts with aox domains characterized in known alternative oxidases. blast analysis of these sequences with known aox proteins revealed three distinct aox genes (nalba-aox , nalba-aox and nalba-aox ). after subcellular localization analysis of three identified aox proteins by using targetp server tool, nalba-aox , nalba-aox are predicted as mitochondrial while nalba-aox is localized in chloroplasts. template based structural modelling results showed that all identifed proteins are statistically similar to known structure models of corresponding aoxs. most environmental contaminants have toxic and mutagenic effects on living organisms as a result of the activation of free radical formation and inhibition of reparation activity. it is becoming relevant to search for protectors of natural origin from the effects of xenobiotics. many biologically active substances (bas) of inartificial origin are found to be antioxidants and can increase the body's resistance to the toxic and mutagenic effects of a wide range of pollutants. the aim of the study was to investigate the antioxidant and antimutagenic properties of bas from medicinal plants limonium gmelinii (plumbaginaceae) and inula britannica (compositae). the antioxidant potential of plant extracts was determined by the activity of superoxide dismutase (sod), catalase, and the content of malonic dialdehyde. mutagenic and anti-mutagenic properties of the extracts were determined in the test by counting chromosomal aberrations in root meristem of barley seeds. barley seeds were treated with an aqueous solution of unsymmetrical dimethyl hydrazine (udmh), which is highly toxic i class hazardous material, well known pro-oxidant. the results showed that udmh enhanced the process of lipid peroxidation and decreased the mitotic activity. treatment of barley seeds with extracts from i. britannica and l. gmelinii and their germination in the presence of stress factors stimulated antioxidant defenses in the primary roots of barley seeds. increase of the activity of sod and catalase, and reduction of peroxidation level of lipids were observed. cytogenetic study showed no mutagenic activity in plant extracts. when effects of plant extracts and udmh were combined there was a significant reduction in the frequency of structural mutations, induced by the toxicant. conclusion about the presence of the antioxidant and antimutagenic activity in the studied plant extracts is made. the work done within the framework of the mes project (no. gr rk ). p- . . - comparative analysis of cytokinin dehydrogenase inhibition and trans-zeatin treatment in arabidopsis seedlings j. nov ak , v. koukalov a , z. medvedov a , c. martin , j. hradilov a , l. sp ıchal , b. brzobohat y mendel university in brno, brno, palack y university in olomouc and centre of the region han a, olomouc, czech republic cytokinins are plant hormones regulating many processes during plant life ranging from germination to senescence. manipulation of cytokinin levels and their impact on plant vitality, production and ability to defend against stresses is in great interest of agriculture. in this work we focused on comparison of inhibitor of the cytokinin degradation incyde ( -chloro- -( -methoxyphenyl)aminopurine) and exogenous application of trans-zeatin on arabidopsis thaliana seedlings. transcripts of genes regulating cytokinin metabolism were analysed by rt-qpcr analysis. classical cytokinin root essay revealed that incyde effect is comparable to that of trans-zeatin in a similar concentration-dependent manner. besides a negative effect on the primary root length, both substances induce flavonoid accumulation and an increase in the root hairs formation. histochemical staining of transgenic plants expressing glucuronidase (gus) under cytokinin-responsive promoter of arr gene revealed increased gus activity in cotyledons following incyde treatment suggesting diverse localization of cytokinin modulation upon trans-zeatin and incyde treatment, respectively. possible molecular differences originating in different cytokinin population and distribution following trans-zeatin or incyde treatments were monitored on the level of gene expression and via an lc-ms proteome analysis in roots and shoots of -day-old plantlets. rt-qpcr analysis revealed an alteration in cytokinin metabolism that could explain observed differences on the proteome level between incyde and trans-zeatin treated seedlings. pharmacologically inhibited cytokinin degradation could be very efficient tool for modulation of cytokinin levels. interestingly, the application of incyde and trans-zeatin shows a contrasting spatial and temporal pattern on molecular levels. incyde represents potent growth regulator with interesting properties useful for agriculture. p- . . - the expression yield of prokaryotic alphaamylase is significantly magnified by molecular cloning techniques randomly hydrolyzing glycosidic bond alpha-amylase has been traditionally employed in bread and similar industries. in that regard, increasing the overall expression level of the enzyme is a crucial concern in biotechnology. to reach the goal, appropriate alpha-amylase producing species and expression vector were carefully selected. therefore, genome of bacillus subtilis was extracted and amplified by polymerase chain reaction (pcr) using specifically designed primers. subsequently, the extracted gene was inserted in expression vector pht and transferred to e. coli as intermediate host followed by bacillus subtilis host replacement. the recombinant vector was expressed in bacillus subtilis and the expression was evaluated by agarose gel electrophoresis. relative purification of the recombinant enzyme was performed by kda filtration to remove impurities. to identify the biochemical characteristics, starch was used as specific substrate to measure enzyme activity and the enzyme was exposed to various ph and temperatures. the extra-cellular expression of alpha-amylase enzyme was successfully elevated by folds in comparison to the native enzyme. the optimum temperature and ph for the enzyme was carefully determined as °c and , respectively. the enzyme was stable at °c, but thermal stability was dramatically decreased at higher temperatures up to °c. kinetic parameters were also measured; vmax was . u/ml min and km was . mg/ml. it is concluded that the elevated expression extent of recombinant alpha-amylase together with appropriate qualifications could make the clone a good choice for various industrial applications. flax seedlings of cultivars tmp , lira and lines g- / _o, g- / _k were treated for and hours with lm alcl solution or distilled water (control). twelve small rna libraries were constructed and sequenced using illumina gaiix. to identify known mirnas, obtained sequences were aligned with mirnas from mirbase (http://www.mirbase.org/). fold change value was calculated to identify up-and down-regulated mirnas under al stress. in total, about million raw reads were obtained and conserved mirnas from families were identified. significant expression alterations in flax plants under al treatment were shown for mir and mir . expression level of mir was varied in similar way in resistant and susceptible to al genotypes: mir was up-regulated after hours of alcl exposure and down-regulated after hours. mir expression was increased after hours of alcl exposure and decreased after hours in susceptible to al flax genotypes (lira, g- / _o), while in resistant genotypes (tmp , g- / _k) mir level was decreased after both and hours of al treatment. in other plant species, mir and mir were identified as al-responsive. mir targets mrna of tcp (teosinte branched/cycloidea/pcf) transcription factors, which control plant growth. mir targets mrna of tas protein, which regulates lateral root growth via degradation of arfs (auxin response factors). in flax, the involvement of mir and mir in response to al stress was shown for the first time. moreover, we revealed diverse expression alterations of mir in susceptible and resistant to al genotypes. this work was financially supported by grant - - from the russian science foundation. p- . . - association genetics of phenylalanine ammonia lyase (pal) and cinnamyl alcohol dehydrogenase (cad) enzymes involved in lignin biosynthesis of european black poplar (populus nigra) b. taskiran, z. kaya middle east technical university, ankara, turkey populus nigra l. are considered as one of the most economically significant forest trees with respect to production of wood, biomass, and other wood-based products. while wood quality and biomass are directly associated with high cellulose content, lignin emerges as an undesirable polymer for both pulp and biofuel manufacturing industries. the aim of the study is by choosing the superior and eliminating the inferior clones to make a contribution to woody feedstock development and to improve wood quality of populus nigra. to estimate association genetics of pal and cad enzymes which have important functions in lignin biosynthesis, the important germplasms of populus nigra has been sampled from year old poplar trees ( clones x replicates x ramets) which were grown in behic ßbey plantation clone bank in ankara. additionally, five commercially registered clones and six foreign clones were included to the study to make comparison. the average mean values of cellulose, lignin and glucose content were calculated as . ae . lg/ml, ae . lg/ml, and ae . lg/ml, respectively. even though for pal and cad enzymes, data gathering process have been still resuming, particular clones have been separated from all in terms of pal and cad activities as expected. key words: populus, poplar, lignin, pal, cad, genetic variation, feedstock p- . . - proteomic analysis of the molecular mechanisms of the response of plant seeds to pre-sowing treatment by stressors seed treatment with non-ionizing low-level radiation (nr), such as cold plasma (cp) or electromagnetic field (ef), is a modern eco-agricultural technology for stimulation of plant germination and performance. the molecular determinants of seed response to these treatments are not established and no genomic studies of plant seed response to nr have been reported. we studied the effects of pre-sowing seed treatment, using vacuum ( min), radio-frequency ef ( - min) and cp ( - min), on germination and growth of non-oilseed helianthus annuus. to gain an insight into the molecular mechanisms underlying effect of nr on sunflower seed germination and dormancy, we estimated changes induced in the balance of plant hormones and differential protein expression. the results of the germination tests and estimation of seedling morphology showed that response develops in time and is stronger when sowing is performed in days in comparison to days after seed treatment. the d dige analysis revealed differentially expressed proteoforms in kernels of seeds treated with cp or ef. proteins involved in biological processes of seed maturation, response to stress, response to abscisic acid stimulus, processes of organonitrogen compound metabolism and glucose catabolism were identified. while expression patterns for majority of the proteins were highly specific to cp and ef treated seed kernels, accumulation of several proteoforms of seed storage proteins (ssp), including vincilin-like, miraculin-like protein and albumin- were common for both experimental groups. this suggested that response to nr treatment could be at least partially associated to function of ssps in response to oxidative stress that protects proteins required for seed germination and seedling formation. variation of abundance of distinct proteoforms of helianthinin, vicilin-like and s globulin-like ssps suggested that post-translational modifications are involved in regulation of the function of ssps. p- . . - suppression of lipopolysaccharide-induced inflammatory responses in raw . macrophages by tuber extract of cyclamen l. turkey is a prominent centre of plant diversity, being the meeting point of three main floristic zones. geophytes which have underground storage organs such as, tubers, bulbs and rhizomes. cyclamen l. is a tuberous geophyte traditionally used by some people for treating whooping cough, headaches or sinusitis, and confirmed to have antioxidant, analgesic and anti-inflammatory properties by several reports. a prolonged inflammatory response is often associated with chronic diseases such as cancer, arthritis and autoimmune disorders. recently, plant based products are used as an alternative and complementary treatment of these diseases. in this respect, the present study was aimed to determine the effects of three cyclamen tuber extracts on lps-induced inflammatory responses of murine raw . macrophages. firstly, c. cilicium (endemic), c. pseudibericum (endemic) and c. graecum subsp. anatolicum were collected from different localities of turkey. the tubers of plants were air-dried and grounded to fine powder and then extracted with ethanol. cell viability assay was performed to evaluate the nontoxic concentration in cell line by mtt assay. several measurements were performed including tnf-a, no and il- concentration assay by elisa after treatment compared to non treated cells to determine the anti-inflammatory activity. also, tnf-a and inos mrna levels were evaluated by quantitative rt-pcr. the cytotoxic activity which is considered safe on raw. . cell were found as . - lg/ml. studied cyclamen taxa inhibited tnf-a and il- release on lps stimulated-raw. . in a concentration-dependent manner. among the three cyclamen tuber extracts evaluated, the highest nitrite-associated no inhibitory activity was obtained from c. pseudibericum compared to other two cyclamen l. taxa. collectively, these results suggest that cyclamen tuber extracts possess anti-inflammatory properties. p- . . - in vitro hypoglycemic activity of ziziphus jujuba recent reports have indicated that continuous treatment with nutritional jujuba (ziziphus jujuba miller) fruit extracts in diabetic rats improved glucose utilization and produced a significant decrease in the blood glucose. in the present study, hypoglycemic activity of z. jujuba was investigated using various in vitro techniques. the hypoglycemic effect of z. jujuba in phosphate buffered saline which grown in balıkesir was studied by measuring glucose adsorption, glucose diffusion and glucose uptake by yeast cells. the glucose content in the solution measured by spectrophotometrically with commercially kits. the adsorption capacity of the z. jujuba was found to be directly proportional to the molar concentration of glucose. the glucose binding capacity of extract increased in higher glucose concentratrations. there was significant differences were observed between the adsorption capacities of z. jujuba and control samples (p < . ). the rate of glucose diffusion was directly proportional to the time. diffusion rate was significantly lower in the solution containing z. jujuba compared to control (p < . ). the extract demonstrated significant inhibitory effects on movement of glucose into external solution across dialysis membrane compared to control. the rate of glucose transport across cell membrane in yeast cells was observed to be inversely proportional to the molar glucose concentration. z. jujuba inhibited glucose transport across the yeast cells. the results showed that z. jujuba reduced glucose levels at least by three mechanisms. first by increasing glucose adsorption capacity during postprandial hyperglycemia; second by retarding glucose diffusion rate and third, at the cellular level by inhibiting glucose transport across the cell membrane. all of these decreased the absorption of glucose in the intestinal cells and the concentration of postprandial serum glucose. p- . . - cucurbitacin b increased the anticancer effect of imatinib mesylate through inhibiton of matrix metalloproteinase- expression in colorectal cancer cells f. bakar ankara university, ankara, turkey several natural products have been investigated for their anticancer effects. among these, cucurbitacin b (cub) has been reported as its inhibitory effects on cancer cell proliferation. matrix metalloproteinases (mmps) belong to endopeptidase family and they are received as potential biomarkers for several types of cancer. the aim of this study is to investigate the effect of cub in combination with imatinib mesylate (im) on mmp- mrna expression of human sw colorectal carcinoma cells. the cytotoxicity analysis was performed via mtt assay. muse cytofluorimetric analysis system was performed to evaluate apoptotic cell population. the mmp- mrna expression was determined by quantitative real-time pcr. this study was supported by scientific and technological research council of turkey grant, sbag- s . data obtained from the cell culture experiments were expressed as mean ae sd and one-way anova test was applied for multiple comparisons. cub alone significantly inhibited cell growth at lm and higher concentrations. the most potent effect was observed in cub-im combination treatment with . lm ic value. in cub-im treated group, the apoptotic effect was higher than cub and im treated groups. cub-im induced apoptosis significantly at lm concentration when compared to control and lm (p < . ). cub alone showed inhibitory effects on mmp- mrna expression at lm and higher doses significantly (p < . ). the results showed that the combination treatment of cub with imatinib synergistically inhibited human sw cell growth and induced apoptosis by increasing the anti-histone antibodybound nucleosom levels and annexin v binding. although cub could inhibit mmp- expression alone at higher treatment doses, it enhanced the inhibitory effect of im on mmp- synergistically in a dose dependent manner. in conclusion, this study suggests that cub combined with imatinib mesylate may enhance the effects of chemotherapy in patients with colorectal cancer. plants are most important parts of natural resources that alternatively referred to synthetic drugs for reasons such as being less side effects and lower costs. ziziphus jujuba miller (z. jujuba), a plant used in traditional medicine, is one of the most important ziziphus species belonging to rhamnacea family. the fruit and seeds of this plant are used different purposes such as antiinflammatory, antioxidant, immune-stimulant and wound healer. in this study, we investigated the antibacterial effects of z. jujuba. the aims of this study were to screen the antibacterial activity of z. jujuba. the extract was obtained from z. jujuba fruits pulverized with the aid of ball mill using % aqueous-ethanol solution. extracts were screened for antimicrobial activity against six different standard strains of bacteria by determining minimum inhibitory concentration (mic) according to clsi criteria. serial dilutions are made between mg/ml and . mg/ml concentration range. the lowest concentration of wells that no visible growth has been accepted as mic value. materials in the mic and lower concentrated wells were transferred to % sheep blood agar petri dishes for calculation of minimal bactericidal concentration (mbc). the lowest concentration that no colony formation has been accepted as mbc value. jujuba showed the most potent effect on strain of s. aureus atcc is gram-positive cocci (mic: mg/ml). the mic values of other gram-positive bacteria s. aureus atcc , e. faecalis atcc , l. monocytogenes f and m. smegmatis cmm were detected as , , and mg/ml respectively. mic values of gram-negative bacilli were detected as > mg/ml. consequently, z. jujuba was found to be effective on grampositive cocci bacteria (s. aureus atcc , s. aureus atcc and e. faecalis atcc ). the strongest effect was observed on s. aureus atcc strain. in contrast, extract showed less effect on gram-negative bacilli. p- . . - selective cytotoxic effect of morus rubra extract in human lung cancer cells through enhancing apoptosis and cell cycle arrest cancer is a disease that develops as a result of unlimited proliferation of abnormal cells that occurs due to loss of control over the mechanisms of normal growth and differentiation of cells. morus rubra, known as "red mulberry" belongs to family of moraceae. for many years, the fruits of morus species have been used to treat many diseases in traditional medicine. biological effects of morus species is predominantly attributed to its content of polyphenolic compounds. many studies have evaluated the cytotoxic effects of different morus species, but there is no study about cytotoxic effect of m. rubra. in this study, we aimed to evaluate the cytotoxic effect of m. rubra extract in human lung cancer cells (a ) with regard to apoptosis, cell cycle and mitochondrial membrane potential. cytotoxic effect of m. rubra extract on human lung cancer cells was determined using mtt assay. then, mechanisms of cytotoxic activity of m. rubra extract on a cells were examined in terms of cell cycle, apoptosis and mitochondrial membrane potential using flow cytometric methods. m. rubra extract exhibited selective toxicity against a cells compared to normal foreskin fibroblast cells. we determined that m. rubra extract increased cell cycle arrest at g phase, the level of apoptotic cells and decreased mitochondrial membrane potential in a cells. our results showed that m. rubra extract has pro-apoptotic and antiproliferative effect in a cells. further studies are also needed to fully mechanisms underlying this effect of m. rubra extract. p- . . - dipeptidyl peptidase iv inhibitory activity of arctium tomentosum l. a. zeytunluoglu , f. zihnioglu denizli vocational school of technical sciences, pamukkale university, denizli, department of biochemistry, faculty of science, aegean university, izmir, turkey type diabetes mellitus (t dm) is rapidly growing metabolic syndrome of multiple aetiologies causing hyperglycaemia with insulin resistance at cellular level. a novel approach in the treatment of t dm is based on preventing of rapid inactivation of the incretin hormone glucagon-like peptide- (glp- ) and glucose-dependent insulinotropic polypeptide (gip) by dipeptidyl peptidase-iv enzyme. in this study; dipeptidyl peptidase iv (dpp-iv; ec . . . ) inhibitory activity of the aqueous and methanolic extracts of arctium tomentosum leaves were successfully tested in vitro conditions. our study revealed that both aqueous and methanolic extracts obtained from test material had a significant dppiv enzyme inhibitory activity in changing ratio. the ic values were also determined by nonlinear regression curve fit using graph pad prism . with appropriately diluted of lyophilized arctium tomentosum. diprotein-a (ile-pro-ile) was used as reference inhibitor. a. tomentosum aqueous extracts showed ic . lg/ml while the standard (positive control) diprotin a displayed the ic value of . lg/ml. this study demonstrates that a. tomentosum aqueous extracts could be a good lead for further development as a new antidiabetic agent. p- . . - dna recognition determinants of arabidopsis thaliana b transcription factors g. sasnauskas, k. kauneckaite, k. lapenas, v. siksnys institute of biotechnology, vilnius university, vilnius, lithuania transcription, one of the most important cellular processes, is regulated by transcription factors (tf), proteins that often directly interact with gene promoter sequences. tf binding to dna is mediated by various dna binding domains. the b tfs constitute a large, plant-specific protein family (approx. % of all tf proteins in the flowering plants), which is characterized by the presence of one or several small (approx. amino acids) b dna binding domains. currently the b tfs are divided into four groups (lec -abi /val, arf, rav and rem). the preferred recognition sites were identified for representatives of all groups except the rem family. currently, only a single structure of a dna-bound b domain (arf , arf family) is available, thus the mechanism of site-specific dna recognition by the lec -abi /val and rav b domains remains poorly understood. based on the arf -dna structure (pdb ldx) we have built homology models of dna-bound b domains from a. thaliana abi (lec -abi /val family) and nga (rav family) transcription factors, mutated putative dna-interacting amino acid residues and characterized the dna binding ability of the purified mutants using electrophoretic mobility shift assay and a set of radiolabelled dna substrates carrying various variants of the optimal recognition site. we confirm the importance of several positively charged amino acid residues, which are conserved between the abi / nga b domains and structurally related dna-binding domains of bacterial restriction endonucleases ecorii, bfii and ngoavii; furthermore, we identify residues in the 'n-arm' and 'c-arm' loops that may be involved in specific interactions with the dna bases. our results therefore help us refine the homology models of the dna-bound b domains and in the future may help us predict the dna binding properties of currently uncharacterized b domains. p- . . - immunohistochemical analysis of inhibitory effects of origanum hypericifolium oil on dipeptidyl peptidase iv in streptozotocininduced diabetic rats p. ili , a. zeytunluoglu denizli health services vocational high school, pamukkale university, denizli, denizli vocational school of technical sciences, pamukkale university, denizli, turkey diabetes mellitus (dm) is a serious metabolic disorder with micro-and macro-vascular complications that result in a significant morbidity and mortality. glp- and gip have significant role in pancreatic beta cells and prevention of inactivation of them by dipeptidyl peptidase iv (dpp iv) inhibition is a novel approach to treatment of dm. origanum hypericifolium (lamiaceae) is an endemic turkish plant and its essential oil is mainly composed of monoterpenes including carvacrol and thymol. streptozotocin (stz) is used to induce diabetes in rats. the aim of this study is to investigate the inhibitory effects of o. hypericifolium essential oil on the dpp iv in stz-induced diabetic rats. the animals (female spraque-dawley rats) were assigned to four groups (group : control, group : stzinduced diabetic, group : o. hypericifolium injected, group : stz-induced diabetic and o. hypericifolium injected). dm was experimentally induced in groups and by a single intraperitoneal injection of stz at a dose of mg/kg body weight. in groups and , rats were intraperitoneally injected with o. hypericifolium oil at a daily dose of ml/kg body weight for consecutive days. at the end of the experimental period, all animals were sacrificed by cervical dislocation under ether anesthesia and liver and kidney tissues of each animal were rapidly excised. tissues were fixed in sainte-marie fixative. after routine histological processes, samples were embedded in paraffin, immunohistochemical staining for dpp iv was performed on sections and then they were photographed. the immunohistochemical reaction intensity differences were observed between the groups. in conclusion, the immunohistochemical distribution of dpp iv in the tissues that the test oil was applied in the diabetic rats may be important for the investigation of the inhibitory effects of oil on the enzyme. moreover, our findings suggest that o. hypericifolium oil may be used for prevention of diabetic diseases. introduction: all eukaryotic cells need microtubules for purposes of nuclear and cell division, organization of intracellular structure, and intracellular transportation, as well as ciliary and flagellar motility. microtubules are made of polymerized a/btubulin subunits. mec is important for microtubules, because it encodes the enzyme that adds acetyl groups to lysine (k ) of tubulin. k is largely conserved in a-tubulins of many eukaryotes, and acetylation is thought to stabilize microtubule structure. in algae, the effect of acetylation by mec on flagellar motility and phototaxis has not been tested previously. materials and methods: in this study, mec mutant chlamydomonas reinhardtii cells were compared to wild-type cells to see the effect on flagellar motility and phototaxis. we tested phototaxis, eyespot size and quantity under the microscopy. in addition to this, we fixed cells and examined them by immunofluorescence microscopy using antibodies to tubulin, acetylated tubulin, and photoreceptor. results: we observed that some mec mutant cells contain more than one eyespot. we detected no acetylated-tubulin (ac-tub) by immunofluorescence. the cells still phototax and have normal motility discussion and conclusion: interestingly, mec cells still have the ability to phototax and they have normal flagellar motility, even though they contain occasional additional eyespots and no ac-tub. chlorella vulgaris as a model system for screening of plant growth modulators p. volynchuk , e. marusich , r. chuprov-netochin , j. neskorodov , y. mishutkina , s. leonov life sciences center, moscow institute of physics and technology, dolgoprudny, center "bioengineering", russian academy of sciences, moscow, russia the discovery of new plant growth modulators became extremely important task as an alternative approach to overcome plants resistance to herbicides and pesticides, which leads to harmful action on plants and land rising, environmental and ecological problems. small molecules provide agricultural biotechnology with valuable tools, which help to circumvent the need for genetic engineering and offer unique benefits to modulate plant growth and development. we developed a system to explore molecular modes of action of plant growth modulators using chlorella vulgaris model. our model allows applying high content screening approach in well plate format for fast and robust effect assessment of large number of tested modulators. chlorella v. was grown in climate chamber under optimized constant temperature ( °c) and light conditions ( : hours/light:dark). modulating effect of tested compounds was estimated by spectrophotometric measurement of microalgae density at the beginning of the experiment (start point- . od) and hours later. to validate our system we used known cytokinins and auxins ( mm) as positive controls of growth stimulation. we showed that in presence of each compound the density of chlorella v. was increased in - times range, compared with only times increase in control group. eight new chemicals ( lm), which demonstrated modulation effect on nicotianatabacum l. pollen and arabidopsis thaliana models, were tested on developed chlorella v. model. positive controls showed no stimulating effect at this concentration, while tested compounds were confirmed as hits and increased the density up to %. we demonstrated that developed model system, based on chlorella v., is an effective system for primary screening of plant growth modulators. the main advantages of this system are short time of assay, simplicity of performance, possibility of automation and low cost. selected hits can be recommended as perspective candidates for future test on crop field. sunflower is under a big threat of downy mildew which is a fungal disease caused by plasmopara halstedii. the disease can cause up to an % yield loss in sunflower production. downy mildew resistance genes (r) denoted as pl has been discovered to date in sunflower. in recent years, single nucleotide polymorphism (snp) markers have become widely used in plant breeding programs. in this study snp markers have been currently developing for pl , pl , pl , pl arg genes by competitive allele specific pcr (kasp) assay which enables bi-allelic scoring of snps and insertions/deletions (indels) at specific loci. in total sequence tagged site (sts) sequences from ncbi were aligned for pl , pl , pl , pl arg genes to identify conserved regions for each gene. based on the conserved regions, specific pcr primers were designed in order to make sequencing of these genes in five crosses and their f progenies. sequence data will be used to design an allele specific primer maches the target snp and amplifies the target region with the common reverse primer provided by kasp genotyping assay. snp markers linked to pl genes which are being developed in this study, have the potential to be used in marker assisted selection (mas) for sunflower breeding programs. p- . . - investigation of the antidiabetic effects of hibiscus sabdariffa, teucrium polium and myrtus communis in hepg cells line s. altundag , pamukkale university, denizli, istanbul medeniyet university, istanbul, turkey some antidiabetic plants currently are used in alternative treatment of type ii diabetes. hibiscus sabdariffa, myrtus communis and teucirum polium plants are also known for their antidiabetic properties. hibiscus sabdariffa, myrtus communis and teucrium polium; depending on the impact on hepg - cells to investigate the possible mechanisms of type ii diabetes with researches on glucolysis and glucogenesis pathways gene expressions (pk m , glut- ,pepck). plants were obtained in dried state from reliable herbalists in denizli and mersin. plants treated with the extractor device. plants obtained aqueous extract was subjected to lyophilization process. human cancer cells have been used throughout the study. the cytotoxicity of the cells was measured by elisa plate reader . total rna was isolated using trızol Ò solution was carried out according to the instructions of the manufacturer's (thermo scientific) recommended procedures were performed, but we have to optimize our own laboratory conditions. pk m , glut- ,pepck genes were synthesized by b _ ioneer. during our study the activation of certain genes (pk m , glut- ,pepck) were examined by real time pcr. in our study hibiscus sabdariffa, mrytus communis and teucrium polium plant to extract applied hepg - cell line in the gluconeogenesis and glycolysis pathways in involved in some important genes (pepck, pk m , glut- ) analyzed the expression levels . teucrum polium plant extract is applied in hepg - cells the glycolysis pathway genes (pk m glut- ) an increased expression also genes of gluconeogenesis pathway (pepck) were not decreased. however hibiscus sabdariffa and the expression of genes involved in glycolysis and gluconeogenesis pathway mrytus communis plants were observed to have a full effect as diabetic or hypoglycemic . in this context, it is considered that the plant teucrum polium on the line hepg - cells showed antidiabetic effect. p- . . - purification of b-glucosidase from malatya apricot (prunus armeniaca l.) seeds and some of its biochemical properties h. kara , s. sinan , z. ekmekci , y. turan university of balikesir faculty of veterinary, balikesir, university of balikesir faculty of arts and sciences, balikesir, turkey introduction: b-glucosidases are one of the key enzymes in carbohydrate metabolism and located in glycosyl hydrolases (ec . . ) family. plant b-glucosidases have biotechnological significance as they are effective on glycosidic bonds of flavor and aroma precursors in plants. b-glucosidases that located in fruit seeds are important because they affect the amygdalin. aim of this study is purification and partially characterization of b-glucosidase from malatya apricot seeds. materials and methods: apricot seeds were homogenized with extraction buffer to prepare of crude extract. the enzyme protein was precipitated with % ammonium sulfate then purified by hydrophobic interaction chromatography using sepharose b-ltyrosine- -naptylamine gel. para-nitrophenyl b-d-glucopyranoside (p-npglc) was used as substrate to determine biochemical properties of the enzyme. the optimum ph was determined using buffers between ph - and thermal optima was determined using - °c temperature range. inhibitory effects was determined with mm substances. results: the enzyme was . -fold purified with yield of %. purified b-glucosidase from apricot seed was visualized about kda molecular weight on sds-page. the kinetic parameters were determined against p-npglc substrate as km and vmax values of . mm and . eu, respectively. the optimum ph and temperature were determined . and °c respectively. effects of cacl , kcl, nacl, mgcl , k so , na so , cuso , fecl , pb(ii) acetate, agno , zncl and glucose on purified enzyme activity were investigated. kcl, na so , pb(ii) acetat and cuso reduced the enzyme activity. discussion and conclusion: in this study, b-glucosidase was purified from malatya apricot seed and some of its biochemical properties were determined. because this enzyme has pharmaceutical importance hydrolyzing amygdalin. the results showed that immobilized almond b-glucosidase was used to break amygdalin and release -cn compound that effective to shrink cancer mass. p- . . - a new affinity gel for purifing polyphenol oxidase enzyme a. erg€ un , , o. arslan balikesir university, science and technology application and research center, balikesir, department of medical chemistry, faculty of science, balikesir university, balikesir, turkey polyphenol oxidase (ppo) enzyme, sometimes called as phenol oxidase, catecholase, phenolase, catechol oxidase or tyrosinase, is considered to be an o-dipenol. ppo (ec . . . ), a multifunctional copper containing metalloenzyme, is widely distributed in nature. ppo exists in many kinds of plants and fungi, such as banana, mushroom, butter lettuce, napoleon grape, potato, coffee, marula fruit, artichoke heads, longan fruit, tobacco, wheat flour. in this study, a novel affinity chromatography gel was synthesized for purifing ppo enzyme. the affinity chromatography gel was synthesized by coupling aniline as a specer arm to cnbr activeted sepharose- b. then, p-amino benzoic acid was coupled to aniline as a ligand. ppo was purified from musa sapientum var. cavendishii (banana) by using sepharose- b-aniline p-amino benzoic acid affinity chromatography gel. % . yield and . fold purification were achieved. sds-polyacrylamide gel electrophoresis of the enzyme indicates a single band with an apparent mw of kda. the v max and k m of the purified enzyme were determined , u/ml min and . mm, respectively. p- . . - phenolic content and antioxidant capacity of gamma irradiated olive leaves m. e. diken , b. kocat€ urk , s. dogan , h. tuner balikesir university, balikesir, kavram vocational school, istanbul, turkey in this study, dried in diffirent ways (such as microwave, infrared, convection heaters and under normal atmospheric conditions) olive leaves has been used as experimental material. radiation has been applied to dried olive leaves in three diffirent dosages in room temparature. the amount of radiation to be implemented to the samples have , , kgy/min. in this study, how gamma rays (radiation) effects phenolic components, total phenolic content and antioxidant capacity of dried olive leaves has been determined. the phenolic components, total phenolic content and antioxidant capacity were analysed with hplc, folin ciocalteu and dpph radical scavenging method, respectivelty. gamma rays is well known as a decontamination method for many foodstuffs and plant materials, being an environment friendly and effective technology to resolve technical problems in trade and commercialization. for this reason, nowadays it is utilized as an alternative method of sterilization. gamma rays are of ionizing radiation. when ionizing radiation interacts with matter, generally it causes a break in the molecular bonds and/or breaks the bonds between the molecules. these intermediates have unpaired electron and called free radical. gamma radiation or the radiation-induced free radicals would break or cause damage to the dna molecules of living organisms. gamma irradiation is predict to change phenolic content and antioxidant capacity in living tissues. phenolic compounds are secondary plant metabolites naturally present in fruits and vegetables. in recent years there has been a growing interest in food phenolics because of their potential health benefits mainly due to their antioxidant and free radical scavenging activity. despite the controversy about potential risks posed by genetically modified plants on human health, environment and microorganisms, cultivation area of these crops increases day by day. this increment has revealed concerns especially related to hgt. hgt studies indicated that antibiotic resistance genes in gm plants have a potential to transfer to soil microorganisms. in this study, hgt of widely used genetic elements such as regulatory sequences, from transgenic plants to bacteria was investigated. three soybean feed and four seed examples from turkish feed manufacturers' association were used for genetic analysis based on foreign gene determination. gmo analysis were conducted by camv s promoter-specific pcr in genomic dnas. in gm positive samples, genomic dnas sheared into appropriate fragment size by ultrasonication for the purpose of bacterial transformation. presence of s promotor region in fragmented dnas was proved by pcr. escherichia coli dh a strain was transformed by fragmented dna samples according to cacl method. s promotor sequence screened by using pcr in bacterial genomic dnas. as a result of gm screening, all feed and three of the seed samples were found to be transgenic. ultrasonication conditions were optimized for shearing dna's to - bp for bacterial transformation. fragmented dnas confirmed for carrying intact s promotor sequence. none of bacterial genomic dnas were found to be s-positive. according to the transformation results, absence of s promotor sequence in all tested bacterial genomic dnas, proved the dna samples belonging to gm plants can not transfer into compotent e. coli dh under laboratory conditions. for verification of this finding, transformation studies will continue with acinetobacter baylyi bd strain which is naturally competent soil bacterium for natural transformation. we believe that all of our findings will contribute to constitute transformation system which can be used as model in hgt studies. p- . . - preliminary studies on differential methylation in a and d sub-genomes of upland cotton (gossypium hirsutum l.) four species of cotton (gossypium l.) provide raw materials for the textile industry. among the four species, two have diploid genome and another two have tetraploid genome. tetraploid genome consists of a and d sub-genomes. a sub-genome belongs to asian cotton while d-sub genome belongs to american cotton. previous studies revealed that d sub-genome of gossypium species contributes to the superior yield and quality of tetraploid gossypium l. species (atdt). dna cytosine methylation of four regions of dna sequences located on a and d sub-genomes of gossypium hirsutum l. texas marker (tm- ) was investigated using bisulfite sequencing technique. among the regions studied two could not be located on subgenomes due to sequence identity match between a and d subgenomes. on the other hand two dna regions could be located on a and d sub-genomes using the blast searches. some of the dna sequences located on different sub-genomes showed polymorphic nucleotides including c/t and g/a polymorphisms. in silico analysis indicated that some alleles located on different sub-genomes of cotton have c/t and g/a polymorphisms. c/t polymorphisms between the sub-genomes could be thought as unmethylated cytosine using the bisulfite sequencing technique. this indicated that an extra attention needs to be paid in dna total cytosine methylation studies in polyploid species such as cotton using bisulfite sequencing, methylation sensitive amplification polymorphism (msap), whole-genome bisulfite sequencing (wgbs). otherwise, t in c/t polymorphism between the subgenomes could be thought as unmethylated cytosine. based on the two genomic regions we could conclude that a sub-genome may be more methylated than d sub-genome. differential methylation of genes located on different sub-genomes may provide another mechanism responsible for differential gene expression of genes located on different sub-genomes. p- . . - cleaved minisatellite locus (cml) markers for fingerprinting of cotton cultivars grown in turkey e. u. gocer, m. karaca akdeniz university, antalya, turkey after their discovery by alec jeffreys in , minisatellites have been used in genetic studies of many organisms. minisatellites, also called variable number tandem repeats (vntrs), are composed of arrays of longer repeats mostly dispersed throughout heterochromatin (centromeres and telomeres). direct amplification of minisatellite regions of dna using a single core primer is a powerful method to amplify minisatellites (damd-pcr). although the damd-pcr technique has been applied to many plant species, the level of polymorphisms in cotton (gossypium l.) is very low due to very narrow turkish cotton genetic base. the objective of this study was to improve the level of polymorphisms by cleaving minisatellite loci by restriction enzyme digestion. genomic dna samples of twenty-one turkish cultivars, pima - , tm- and ps- were extracted. twenty-one minisatellite primers were screened using the damd-pcr technique. monomorphic amplicons were digested using several restriction enzymes. three to five micro liters of amplified products were digested with various restriction enzymes. digested products of minisatellite loci were separated in % high resolution agarose gels. comparison studies of digested and undigested markers revealed that cleaved minisatellite markers showed polymorphisms in those cotton lines that could not be differentiated by microsatellite and minisatellite markers. this approach was called cleaved minisatellite locus markers (cml). the amplification reactions of minisatellites used touch-down (td) cycling conditions. the use of td offered a simple and rapid means of optimizing polymerase chain reaction (pcr), increased specificity, sensitivity, and efficiency without the need for lengthy optimizations of minisatellite primers. the cml markers were obtained at a °c annealing temperature, which is a temperature higher than those used in random amplified polymorphic dna (rapd) inter-simple sequence repeat (issr) markers. p- . . - association between cytosine methylation and tissue specific expression of microsatellites a. g. ince, m. karaca akdeniz university, antalya, turkey heritable covalent modification of dna, rna or protein without altering their primary sequences is defined epigenetics. because all biological events are influenced by epigenetics, it is one of the most important fields in science. dna methylation is one of the most important epigenetic mechanisms. dna cytosine methylation is a process by which methyl groups are added to cytosine bases of dna. microsatellites, also knows simple sequence repeats are dna sequences consisting of - nucleotide repeats. there is a large body of information regarding the relationship between microsatellite instability and abnormal gene expression, and between dna methylation and altered gene expression. however, there is limited information on cytosine methylation of microsatellites. in the present study, we investigated whether there is any association between cytosine methylation and tissue specific expression of microsatellites. genomic dna samples of various tissues and developmental stages of pepper line demre sivrisi (capsicum annuum l.) and cotton line tm- (gossypium hirsutum l.) were extracted. cdna samples were synthesized using mrna expressed in pepper tissues. cytosine methylation levels were investigated using bisulfite sequencing methods. screening studies of microsatellites revealed that some genes containing microsatellites were differentially expressed in tissues and developmental stages of pepper. microsatellite containing genes that expressed differently among tissues had also showed different methylation levels in cg, chg and chh (where h refers to a, c or t) contexts. methylation level differences between microsatellites were also observed. as far as our knowledge, it is the first report on differential expression of genes containing methylated microsatellites. p- . . - pcr-lg: an alternative way to assign the chromosome location of genes/markers in cotton a. aydin, m. karaca akdeniz university, antalya, turkey assignment of genes and dna markers on chromosomes is very important in life sciences, especially for plant breeding and medicine. there are several methods for the assignment of a gene or dna sequence to a specific location on a chromosome. for example, the most widely used technique is the assignment of fluorescently-labeled gene or dna sequences (markers) on chromosomes using the fluorescently-labeled gene (for instance, fish technique). another example is the construction of a genetic map (linkage map) which orders the targeted genes along the dna strand based on recombination frequency. sequencing is the most precise technique in which coding (gene-containing) and noncoding dna region of genes could be located on a chromosome molecule. aneuploid lines could also be used to locate genes in a specific chromosome, but maintenance of these lines is difficult. here we report the use of chromosome substitution lines to indirectly locate genes/markers on chromosomes. we used chromosome substitution lines (csls) that carry a chromosome pair or chromosome arms from gossypium barbadense l. while the rest of chromosomes belong to g. hirsutum l. a total of chls, a homozygous cotton line tm- and a double haploid line pima - were used as plant materials. twenty microsatellite primer pairs were utilized in touch-down polymerase chain reactions. we developed a method, called polymerase chain reaction to locate gene (pcr-lg), to assign genes/markers on chromosome or chromosome arm. with the use of pcr-lg approach any polymorphic genes/markers between tm- and pima - (g. hirsutum and g. barbadense) could be assigned to a chromosome or chromosome arm. results indicated that if csls were used any polymorphic markers (genes) with known primer pairs could be assigned to cotton chromosomes. although we used cotton chromosome substitution lines to validate the proposed technique, it could be applicable all the species that have chromosome substitution lines. p- . . - pecularities of genome variability of antarctic hairgrass deschampsia antarctica desv. from the maritime antarctic deschampsia antarctica desv. (poaceae) is the only grass species native to the antarctic region, adapted to harsh environmental conditions. however, reasons for its unique success remain unexplored. stressful environmental factors can influence a plant genome and cause changes in the chromosome number and morphology and increase genetic variation. therefore, the purpose of our research was to explore alterations in the d. antarctica genome both at the chromosomal and molecular levels and to investigate species genome stability using in vitro tissue cultures. plants used for the study were grown in vitro from seeds collected in the argentine islands region during - . chromosome number was determined in plant root apical meristems and specimens prepared from tissue cultures. rrna genes localization were determined using the fish technique. moleculargenetic analysis was performed using pcr with polymorphic issr-primers. new forms of chromosome polymorphism, associated with aneuploidy ( n = - ), polyploidy ( n = - ) and the occurrence of additional b-chromosomes ( n = + - b), were observed. fish analysis also confirmed that genotypes with a different chromosome numbers varied in the number of s rdna and s rdna sites. assessment of genetic variation demonstrated a low level of diversity: differences between the plants with different chromosome numbers do not exceed the level of within-population variation. cytology analysis of d. antarctica cultured tissues revealed aneuploidy (up to . %) with predominance cells with diploid and near-diploid chromosome number irrespective of plant's initial karyotype (diploid, mixoploid or polyploid). we assume that discovered intraspecies chromosomal polymorphism is a manifestation of quick genome reaction to harsh antarctic conditions. whereas the results of molecular-genetic analysis and study of cell cultures of this species suggests on the relative stability of d. antarctica genome. p- . . - angiotensin converting enzyme inhibitory activity of morchella esculenta (l.) pers a. zeytunluoglu , i. arslan biomedical equipment technology, pamukkale university, denizli, turkey, denizli, biomedical engineering, pamukkale university, denizli, denizli, turkey hypertension is a multi-aetiological, chronic pathophysiology that leads to multi-organ dysfunctions like cardiovascular diseases, strokes, and renal complications. natural extracts play an important role in traditional medicines for the treatment of hypertension and are also an essential resource for new drug discovery. mushrooms are use as therapeutics in alternative and complementary medicine as functional food because of contain a large number of biologically active components that offer health benefits and protection against many degenerative diseases. morchella esculenta is one of the most highly priced edible mushrooms worldwide. it contains a wide range of active constituents which include tocopherols, carotenoids, organic acids, polysaccarides and phenolic compounds which exhibit a wide range of medicinal and pharmacological properties including anti-microbial, anti-inflammatory, immunustimulatory, antitumor and antioxidant. in this study; the in vitro angiotensin converting enzyme-i (ace-i) inhibitory activity of m. esculenta peptides were generated by alcalase hydrolysis were studied. the kda < peptides < kda in the ultrafiltration fractions displayed highest ace inhibition ( . ae . % at lg/ml). the results indicate that m. esculenta derived peptides may have potential as functional food ingredients in the prevention and management of hypertension. p- . . - modulations of antioxidant enzymes, gsts and catalase, by salvia absconditiflora in hepg cell line d. irtem kartal , a. altay yuzuncuyil university, van, erzincan € university, erzincan, turkey oxidative stress is considered to play a important role in the pathogenesis of aging and several degenerative diseases, such as cancer. in order to cope with an excess of free radicals produced upon oxidative stress, humans have developed several mechanisms for maintain redox homeostasis. these protective mechanisms either scavenge or detoxify ros, block their production, and include enzymatic and nonenzymatic antioxidant defenses. in enzymatic defenses include glutathione s-transferases and catalase enzymes. many epidemiological studies have revealed that there is a strong correlation between consumption of polyphenol-rich foods and the prevention of certain diseases like cancer, cardiovascular diseases and aging. phenolic compounds are abundant in all plants. so, they form an integral part of the human diet. salvia species, commonly known as sage, have been used since ancient times for more than different ailments ranging from aches to epilepsy. there are around species of salvia, of which are represented in turkey including salvia absconditiflora. in this study, s. absconditiflora collected from metu campus (ankara, turkey) is extracted with methanol and water. effects of the water and methanol extracts on the mrna expressions of antioxidant enzymes gstm and catalase in hepg cells were investigated by q-rt-pcr technique. it was also monitored the effects of the extracts on the enzyme activities of gsts and catalase by spectrophotometrically. water and methanol extracts decreased gsts mrna expression in hepg cells for hours and hours incubation and methanol extract decrease catalase mrna expression for only hours incubation. on the other hand, extracts highly increased the gsts and catalase activities in both hour incubation. overall, these results indicate that s. absconditiflora and/or its components have regulatory activities on antioxidant enzymes and they may have a potential as a therapeutic agent in the treatment of cancer. p- . . - transcriptomics and proteomics approach to drought stress mechanism in wheat b. cevher keskin tubitak marmara research center genetic engineering & biotech. institute, kocaeli, turkey birsen cevher keskin, yasemin yıldızhan, oktay kulen, bayram y€ uksel, selma onarıcı, _ ismail t€ urkan, as ßkım hediye sekmen, u gur sezerman, bu gra € ozer identification of novel stress-responsive genes and their role in drought response is an important area for the improvement of the crops. drought-related genes were investigated in leaves and roots of three wheat genotypes after different drought stress treatments by rna sequencing (rna seq) technology and de novo assembly was performed before comparative transcriptome analysis. analyzing gigabases of bp paired end illumina reads from a hexaploid wheat poly(a) rna library, we identified common and new differentially expressed transcripts. selected differentially expressed genes were confirmed by qrt-pcr. we also performed root proteome analysis with nano electrospray ionization source coupled to a high-performance liquid chromatography system (nanouplcÀesiÀqtofÀms) to identify drought-related proteins. totally proteins were differentially expressed in root tissues of tolerant and non-tolerant wheat genotypes. responses of antioxidative defense system to drought stress were comparatively studied in the same wheat cultivars. similarities between protein and rna levels help increase our confidence in novel biomarkers, differences may also reveal other post-transcriptional regulatory junctures. all these analyses will allow us to get a better idea about the possible role of these genes in the drought-response mechanism. the drought-related genes that are functionally characterized could be introduced into agronomically important wheat cultivars. this work offers a resource for accelerating drought-related gene discovery and improving this important crop. p- . . - isolation and characterization of a hexose converter from olive s. altunok , e. d€ undar department of biology, university of balikesir, balikesir, department of molecular biology and genetics, college of arts and sciences, balikesir university, balikesir, turkey introduction: hexose sugars are key components of glycolysis and photosynthesis. the genes regulating their conversion into one another, is therefore, of great importance for the control of carbon metabolism. in this study, we report isolation and characterization of a cdna associated with conversion of hexoses in olive. the cdna putatively named aldolase based on bioinformatic and experimental analyses. material-methods: characterization based on nucleotide and amino acids were conducted using bioinformatic tools such as nucleotide and protein blast, bioedit, primer , finchtv, clc genomic workbench, expasy, targetp, sosui and web promoter scan. comparison of the genomic and cdna sequence of the gene and detailed bioinformatic analyses including cellular location, hydropathy analysis, amino acid-nucleotide composition and predicted d structure were also conducted using the bioinformatics tools mentioned above. temporal expression pattern of the putative aldolase were conducted using real-time pcr experiments. sds and western blot analyses were completed while biochemical analyses are ongoing. oleocanthal is an important secondary metabolite that has been reported to be useful against important human diseases including cancer. the aim of this study was to identify and characterize the key biochemical and genetic components of oleocanthal biosynthesis. to determine the biochemical components of the pathway, multiple olive cultivars along with their spatial and temporal points were determined. the expression levels of multiple candidate genes were also aimed via real-time pcr. nucleotide blast and protein blast (for comparison of the similarity of the candidate genes with that of other organisms) were conducted on ncbi web page. phylogenetic tree construction, amino acid composition analysis, nucleotide composition analysis, hydropathy analysis and translations through expasy were conducted. primer was used to design forward and reverse primers to amplify the target genes from different olive tissues at different times. analysis of the first candiate gene with bioedit program revealed that a+t ratio was more than g+c according to the nucleotide composition analysis. according to amino acid composition analysis isoleucine, lysine and leucine were more than other amino acids while kyte&doolittle hyddropathy analysis revealed that the protein was hydrophilic. abundance of hydrophobic amino acids (leucine and isolecine) along with an abundant hydrophilic amino acid (lysine) suggest the existance of hydrophobic pockets in the protein which may mean a membrane bound protein or a sitoplasmic protein with a strong hydrophobic core. the molecular weight of the protein was kda with a pi of . . the protein was found to have a signal peptide. according to the sosui gramn , intracellular localization was found to be in the inner membrane. analysis of other candidate genes contiunes. acknowledgements: this study was supported by tubitak with grant number o . key words: olive, olea europaea l., secologanin, polymorphism, allele diversity p- . . - antioxidant potentials of propolis and its bioactive components, and their effects on cyp e gene expression in ht- adenocarcinoma cell line a. altay , d. irtem kartal erzincan € university, erzincan, y€ uz€ unc€ u yil university, van, turkey propolis is a resinous mixture that is collected by honeybees from plants, and is combined with beeswax and secretions from the bee's salivary glands plus some pollen. it is a rich mixture of polyphenols, flavonoid aglycones, phenolic acids and their esters. it has been used in traditional medicine for thousands of years because of these ingredients. propolis, just like honey, has been the subject of many studies due to its antimicrobial, antifungal, antiviral and hepatoprotective activities. the cytochrome p enzymes are involved in phase i xenobiotic and drug metabolism. cyp e is present in high levels in human tumors demonstrated by qrt-pcr and immunohistochemical studies. in this study, propolis collected from datc ßa (mugla, turkey) is extracted with % ethanol. phenolic contents of the propolis were measured by lc-ms/ms. cytotoxic effects of the propolis on ht- human colon adenocarcinoma cell lines were examined via xtt colorimetric cell proliferation assay. effects of propolis extract and its main bioactive component caffeic acid on the expression of phase i detoxification enzyme cyp e in ht- cells were investigated bu using q-rt-pcr technique. ic values for dpph radicals scavenging activities of the extract was calculated as . mg/ml. tpc and tfc were determined as . mg gae/g extract and . mg qe/g extract, respectively. caffeic acid content of the extract was measured as . lg/g extract. ic values for xtt assay in hours incubation with the extract and caffeic acid were evaluated as . mg/ ml and . mg/ml, respectively. propolis extract and its main phenolic content caffeic acid significantly dicreased cyp e mrna expression with . and . fold, respectively in ht- human colorectal adenocarcinoma cells for hours incubation. overall, these results indicate that propolis and/or its components have regulatory activities on cyp e expression and they may have a potential as a therapeutic agent in the treatment of cancer. p- . . - effects of histone h lysine inhibition on gene expression profile in tobacco (nicotiana tabacum l.) differentiation is the characteristic of multicellular organism. cellular dedifferentiation underlies topical issues in biology such as reprogramming in stem cell research, regeneration and nuclear cloning, and has common features in plants and animals. the state of dedifferentiation is evidenced by changes in cell morphology, genome organization and the pattern of gene expression as well as by the capability of plant tissues to differentiate into multiple types of cells depending on the type of stimulus applied. chromatin reorganization appears to be a fundamental theme in cellular dedifferentiation and reentry into the cell cycle both in plants and animals. the chemical modifications of histone proteins which are structural units of the nucleosome, generate 'codes' for the recruitment of proteins or protein complexes that affect chromatin structure and gene expression according to 'histone code' hypothesis. methylation of histone h at lysine residue by specific methyltransferases suv h in humans and kyp/suvh in arabidopsis generates a'code' for the recruitment of hp proteins. in this study, to enhance the dedifferentiation efficiency, chaetocin which inhibits suv h has been used at the germination stage of tobacco seeds in in vitro conditions. our results showed that chaetocin induced callus formation from leaf discs of tobacco in the early stage of the inhibitor application. chaetocin can enhance reprogramming of plant cells in seed development treatment as callus induction. it is known that the formation of callus which is the non-differentiated cell community in plants, is a consequence of the changes in the gene expression profile. it has been found that epigenetic modifications play a crucial role in some of these changes. the definition of the genes related to callus formation by the inhibitation of an epigenetic modification -h k methylation-in tobacco might be used to bear on various dedifferentiation-driven cellular processes. induction of tumor cell death by the use of some phytochemicals that consumed through diet, and derived from medicinal plants opens up new horizons for cancer treatment researches. rheum ribes species, which is studied in this research, is one of the commonly used herbs in pharmacological researches. the high content of phenolic compounds in r. ribes extracts were known to be responsible for the high antioxidant and antibacterial activities. our aim in this study is to assess cytotoxic and apoptotic changes by way of implementing methanol extract of the rheum ribes (root) to the mcf- breast cancer cell line. cytotoxic effect of rheum ribes extract was evaluated by using the xtt ( , -bis( -metoksi- -nitro- -sulfofenil)- h-tetrazolyum) test. in order to determine the dose of ic , plant extracts were applied as time and dose dependent in the range of - ug. in nd hour, the ic value is determined as ug. to examine the apoptotic effects of the extract, total rnas were isolated from dose group and the control cells firstly, then cdnas were synthesized. expression profile of the target genes(caspase- , caspase- , caspase- , caspase- , bax, bcl- , fas) are determined by qpcr. according to the results, when the control group compared with the cells, it was determined that, while . and . -fold respectively increase in the gene expressions of caspase- and caspase- of dose group cells, . -fold decrease in the gene expressions of bcl- . no significant difference was observed in the other genes examined. based on the obtained data, we believe that methanol extract of the rheum ribes induces apoptosis by activating intrinsic pathway. as a result, this plant species can be a new and effective therapeutic candidate for the medical world in search of alternative anti-cancer approaches, and could shed light on the work to be done in this area. p- . . - the effect of ferulic acid and -fluorouracil combination on apoptosis in pc- human prostate cancer cells prostate cancer is quite often seen in industrialized countries and has the second most common death rate due to cancer after lung cancer in men. -fluorouracil ( -fu) is a pyrimidine analog and cell cycle-targeting drug by inhibiting dna synthesis. it has been widely used for treatment of several cancers such as gastric, colorectal, and breast cancers. phenolic compounds found in foods are potential antioxidants of harmful oxidative processes related to cancer and also important due to induction of different mechanism such as apoptosis. ferulic acid (fa; -hydroxy- -methoxycinnamic acid), a phenolic compound, is abundant in fruits and vegetables. the purpose of this study was to investigate combination effect of fa and -fu on apoptosis in pc- human prostate cancer cell line. the effects of -fu, fa, and combination of both of them on cell viability were determined by xtt method. total rna isolation was conducted using trizol reagent. expressions of important genes in apoptosis including casp , casp , casp , casp , bcl , bax, fas and cycs were investigated in four groups by qpcr. the ic doses of fa and -fu were found to be lm and lm for hours in pc- cells, respectively. in order to determine combination effect, pc- cells were treated with <ic doses ( lm fa and lm -fu). according to qpcr results, a significant increase in the expressions of bax and cycs genes and a decrease in the expression of bcl were observed in the fa group, compared with the control group cells. after the treatment with -fu, the expression of casp was significantly increased compared with the control group. furthermore, combination of fa and -fu significantly increased expression of casp , casp , fas and cycs genes. in conclusion, comparing with the single treatments, it was observed that combination of fa and -fu affected expression of different genes in apoptosis in pc- cell line. p- . . - combination of ferulic acid and gemcitabine affects expression of some apoptotic genes in pc- human prostate cancer cells prostate cancer, the second causing of cancer-related death in men, is an important cancer type due to the late age of onset, slow the progression, high incidence. gemcitabine is an effective agent in several cancer types including non-small cell lung cancer, pancreatic, bladder and breast cancer. it is known that gemcitabine is used single agent or as a part of combination treatment in prostate cancer therapy. nowadays, new treatment methods have been tested for cancer therapy including natural compounds with low toxicity. ferulic acid (fa) one of these agents, an abundant phenolic compound found in various fruit and vegetables. in this study, objective was to investigate combination effect of ferulic acid and gemcitabine on apoptosis in pc- human prostate cancer cell line. cell viability was determined by using xtt method after the treatment with gemcitabine, fa and combination of both of them. total rna was isolated with trizol reagent. expressions of casp , casp , casp , casp , bcl , bax, fas and cycs genes are important in apoptosis, were evaluated in four groups by qpcr. the ic doses of fa and gemcitabine were found to be lm and lm for hours in pc- cells, respectively. for determination of combination effect, pc- cells were treated with <ic doses ( lm fa and lm gemcitabine). when compared with the control group, qpcr results illustrated, a significant increase in the expressions of bax and cycs genes whereas a decrease in the expression of bcl gene in the fa treatment group. after the treatment with gemcitabine, the expression of casp and fas genes were significantly increased compared with the control group. furthermore, combination of fa and gemcitabine significantly increased expression of casp , casp , casp , fas and cycs genes. in conclusion, it was observed that combination of fa and gemcitabine affected different genes in apoptosis compared with the single treatments in pc- human prostate cancer cell line. pistacia lentiscus linn. is widely distributed in mediterranean europe, morocco and turkey. the resin part of its known as mastic gum and plant called as mastic tree. it has been referred to over centuries as having medicinal properties to treat a variety of diseases. the aim of the present study are to evaluate antioxidant, cytotoxic and antimicrobial activities of heptane, chloroform and methanol extracts from p. lentiscus leaves and mastic gum. the antioxidant activities of chloroform and methanol extracts were assayed with various methods, including tpc, dpph free radical and abts radical cation scavenging activity. also, cytotoxicity of extracts was evaluated and screened against human mcf- , hela, a , and ht- cancer cell lines and nih- t cells. the viability of cells in lg/ml concentration of extracts was evaluated using mtt assay. antimicrobial activity of extracts were investigated against s aureus, s epidermidis, e coli, p aeruginosa, p vulgaris, k pneumoniae, c albicans, c glabrata, c guilliermondii, c tropicalis, c parapsilosis test organims by the agar well diffusion and broth microdilution methods . according to our results, the methanol extract of p. lentiscus leaves showed the highest dpph free radical scavenging activity (ic = . ae . mg/ml) and abts radical cation scavenging activity ( . ae . mg/ml). this study also exhibited that methanol extract of p. lentiscus leaves had the highest tpc ( . ae . mg gallic acid equivalents/g extract). the hexane extract of mastic gum showed antifungal activity against all of the tested candida species ( - mm / < . - mg/ml). the methanol extracts of p. lentiscus leaves showed the highest antimicrobial activity against all of the tested bacteria except k pneumoniae strain ( - mm/> mg/ml). on the other hand, p. lentiscus showed no cytotoxicity against cancer and normal cells. the results suggested that p. lentiscus may be natural source of antioxidant and antimicrobial activities. p- . . - antibacterial activity of and chemical composition of alcoholic extract of marjoram against some human pathogens m. ahanjan, m. rahbar mazandaran university of medical sciences, sari, iran herbs enjoy a unique value and importance in sustaining healthy communities in terms of disease prevention ( ) . in this regard, marjoram is a plant of the mint family which has antibacterial properties on microorganisms ( ) . the current study aims to investigate the anti-microbial activity of the alcohol extracts (i.e., methanol or ethanol) of marjoram plants on the bacteria of staphylococcus (atcc: ), aureus e. coli (atcc: ), and salmonella enterica (atcc: ) and p. aeroginosa through utilizing disk diffusion method. also, the minimum inhibitory concentration and the minimum bactericidal concentrationwere measured through tube. the measurement of minimum inhibitory concentration and minimum bactericidal concentration of ethanol and methanol extracts on e.coli were equal with and milligrams per milliliter, subsequently. moreover, the measurement of the minimum inhibitory concentration and of the minimum inhibitory concentration of marjoram ethanol extraction on staphylococcus aurous was reported to be milligrams and milligrams per milliliter, subsequently. in addition, the amount of ethanol and methanol extracts on salmonella enteric and p. aeroginosa was equal with and milligrams per milliliter, subsequently. the results showed that marjoram alcoholic extract enjoy antibacterial properties. also, among the alcoholic extracts, the ethanol extract has demonstrated to be the most effective extract on salmonella enterica and e. coli and p. aeroginosa. p- . . - molecular analysis of serine/arginine rich sc splicing factor from olive b. bas , e. d€ undar depertmant of biology, university of balikesir, balikesir, department of molecular biology and genetics, college of arts and sciences, balikesir university, balikesir, turkey olive (olea europaea l.) is an evergreen fruit tree adapted to mediterranean climate and rich in tannins, essential oils and organic acids. serine/arginine rich splicing factors are essential in seqeunce specific splicing of pre-mrnas. in this study we report molecular characterization of an serine/arginine rich sc splicing factor (oesarsc sf) that was isolated from a cdna library constructed from olive pedicels. nucleotide blast and protein blast (for comparison of the similarity of the candidate genes from other organisms) were conducted on ncbi web page. amino acid composition analysis, nucleotide composition analysis, hydropathy analysis, open reading frame determiantion, through, molecular weight and the isoelectric points calculations were conducted using online expasy software. primer was used to design forward and reverse primers to amplify the target gene from different olive tissues at different times. analysis with bioedit program revealed that a+t ratio was more than that of g+c. oesarsc sf was a protein consisting of amino acids. as expected, amino acid composition analysis revealed that serines and arginines were more than other amino acids. kyte&doolittle hyddropathy analysis revealed that the protein was hydrophilic. the molecular weight of the protein was kda with an isoelectric point (pi) of . . the protein was found to have a signal peptide. according to the predotar analysis results, intracellular localization was found to be in the mitochondrial. the combined results suggest oesarsc sf might function as splicing factor as its homologs from the other plants. confirming this hypothesis with futher experimental characterization including biochemical function analysis continues. acknowledgements: this study was supported by tub _ itak with grant number o . keywords: olea europaea l., oesarsc sf, alternative splcing, pre-mrna splicing, bioedit, pedicel specific cdnas. p- . . - application of three-phase partitioning for the purification of peroxidase from kiwano (cucumis metuliferus) z. denli , g. arabaci kto karatay university faculty of medicine, konya, faculty of arts and sciences, sakarya university, sakarya, turkey peroxidases are enzymes able to catalyze reduction of h o and oxidize various substrates. the kiwano is an oval shaped fruit which has an orange skin with lots of tiny horns. in this study, peroxidase isolated from kiwano is purified with three-phase partitioning (tpp). kiwano fruit was homogenized and obtained crude enzyme extract. the extract was saturated with % (w/v) ammonium sulfate ((nh ) so ) and added t-butanol with the ratio of : . (v/v). the lower and interfacial layer was collected. the influence of percent saturations of (nh ) so ( , , , , %) and tbutanol ratios ( : . , : , : . , : ) to the partitioning behaviour of peroxidase were analyzed. after dialyzed, the interfacial and lower phases were measured for peroxidase activity and protein content. the protein pattern of the peroxidases was evaluated by using gel electrophoresis. peroxidase activity recovery and the purification fold of interfacial and lower phases were . , . % and . , . . therefore, other experiments were continued with interfacial phase. at constant t-butanol with the ratio of : . , the enzyme activity recovery and purification fold of interfacial phase for saturations of (nh ) so ( , , , %) were . , . , . , % and . , . , . , . . the interfacial phase was not dissolved in % (nh ) so . at constant % (nh ) so , the enzyme activity recovery and purification fold of interfacial phase for t-butanol ratio ( : . , : , : . , : ) were . , . , . , . % and . , . , . , . . finally, at optimum conditions (% (nh ) so , t-butanol : . ) after dialyzed interfacial phase, the enzyme activity recovery and the purification fold were . % and . . the results of gel electrophoresis showed that the molecular weight of enzyme was between - kda. the applications of tpp gave the maximum recovery of . % and . -fold purification. as a result, for purfication of peroxidases, tpp is a rapid, simple and economical technique. accumulating the most robust genes and proteins in elite genotypes without any harmful effect on the potential plant yield is an urgent need to enhance productivity under various stressors. among the stressors, drought is a major challenge for agricultural productivity. brachypodium distachyon, with its close relationship to agriculturally and economically important crops, is an important model plant species. although ongoing transcriptomic analyses in brachypodium distachyon available, proteomic analyses are required to obtain an integrated picture of drought response. in the current study, a comprehensive proteome analysis was conducted on brachypodium leaves under increasing levels of drought stress. to screen gradual changes upon drought stress, brachypodium leaves subjected to drought treatment for , and days were collected for each treatment day. the cellular responses were investigated through a proteomic approach involving two dimensional difference gel electrophoresis and subsequent combined tandem mass spectrometry. for the validation of transcriptional expression, the genes encoding selected proteins were examined through quantitative real-time pcr. spot detection on cye-dyed gels revealed a total of distinct spots in brachypodium protein repertoire. a total of differentially expressed proteins (deps), with at least -fold changes in abundance, were identified by mass spectrometry and classified according to their functions. the biological functions of deps included roles in photosynthesis, protein folding, antioxidant mechanism and metabolic processes, highlighting the significant degree of overlapping between metabolic alterations induced by drought stress. identified proteins in this study and understanding the molecular mechanisms of drought response and defense mechanisms in plants will contribute to the researches on development of drought tolerant crop species. p- . . - immunohistochemical and electron microscopy investigation of tmv-based chimeric virus particles carrying conserved influenza antigen in nicotiana benthamiana recently we obtained and partially characterized set of viral vectors based on tobacco mosaic virus (tmv) genome displaying conserved influenza a m e epitope from matrix m protein. purified chimeric virus particles (cvp) conferred protection of mice against lethal homologous and heterologous influenza virus challenge. we revealed significant difference in symptoms of infections caused by tmv-m e recombinant viruses containing cysteine (cys) to serine (ser) or alanine (ala) substitutions in the human consensus m e sequence. accumulation level of m e-ala recombinant coat protein was significantly higher than m e-cys/ ser (ratio : ). tmv-m e-ser infection, in contrast to ala mutant, suspended growth and development of nicotiana benthamiana. non-inoculated leaves ( d.p.i.) were fixed with ethanol and histological sections were incubated with mouse serum to m e and secondary antibodies conjugated with either hrpo or fitc. cvps of all three mutants were detected in epidermal and stomata cells as well as in sieve elements and minor veins. electron microscopy analysis of mesophyll cells revealed typical rigid helical particles. cys/ser mutants mostly accumulated within ground cytoplasm as aggregates of discrete tubules in parallel arrangement, which were not delimited by lipid membranes. we discovered huge amount of cvps in the cytoplasm and lesser amount diffused in the central vacuole. essential part of ala particles was located in the cytoplasm, but mentioned aggregates were not found and only insignificant number of virions was revealed in vacuole. unlike wild-type tmv, none of the mutants was revealed in chloroplasts. diameters of cvps were as follows: sersingle particles in cytoplasm ae . cyanidin is a natural anthocyanidin found in a variety of fruits (grapes, blackberry, blueberry, cherry and cranberry etc.) and vegetables (red cabbage, red onion). this polyphenolic compound is a flavonoid with significant antioxidant activity. cyanidin and its glycosides have vasoprotective effects and can interfere with inflammation, carcinogenesis, obesity, and diabetes. one important role of the macrophages is the release of pro-inflammatory mediators, such as nitric oxide, various cytokines, in response to activation signals, including chemical mediators, cytokines, and bacterial lipopolysaccharide (lps). in this study, we investigated the role of cyanidin chloride in inflammation. anti-inflammatory effects of cyanidin chloride were examined in lps-stimulated murine raw . macrophages. we observed the level of various inflammation markers such as nitric oxide (no), inducible no synthase (inos), cyclooxygenase- (cox- ), tumor necrosis factor-a (tnf-a) and interleukin- (il- ) under lps treatment with or without cyanidin chloride. cyanidin chloride inhibited not only no production but also the expression of cox- and inos, without any cytotoxicity. cyanidin chloride also attenuated pro-inflammatory cytokines and other inflammation-related markers such as il- in a dosedependent manner. in conclusion, cyanidin chloride may be beneficial for the prevention and treatment of anti-inflammatory diseases. p- . . - the investigation of centranthus longiflorus plant extacts effects on cell proliferation and apoptosis activity in the cell lines of mcf- breast cancer h. askin ataturk university, erzurum, turkey introduction: in the u.s., breast cancer is the second most common cancer in women after skin cancer. current treatment of cancer can be done by surgery, chemotherapy, and radiation therapy. in addition, there is widespread use of complementary and alternative medicine in developed countries. plants and plant extracts play a critical role in the research into new anticancerogenic agents. centranthus longiflorus (cl) is used in alternative medicine for sedative and antispasmodic purposes. a plant of turkish origin, centranthus longiflorus used as traditional turkish medicine have remained uninvestigated for familial hypercholesterolemia, diabetes, coronary artery disease and cancer for their in vitro biological activity despite their use for sleep disorders. in this study, growth-inhibiting and pro-apoptotic effects of hexane, ethyl acetate and ethanol extracts of cl in mcf- breast cancer cell line were investigated. material and method: aerial parts of cl were collected in erzurum province. hexane, ethyl acetate and ethanol extraction were done by soxhlet extractor. the plant extracts obtained from cl was analyzed using a gc-ms system. dose-and time-dependent cytotoxic and apoptotic effects of cl were evaluated by mtt cell proliferation kit and cell death detection elisa kit, respectively. manufecturer's protocol was followed for analyses. then, apoptotic genes; caspase , bax and p and antiapoptotic genes; bcl- and pi expression levels were determined by rt pcr. results: according to our results, cytotoxic effect on mcf- cell was only observed in and lg/ml doses of cl. however, any of the application doses showed an apoptotic effect on mcf- cells. they exhibited a necrotic effect rather than the apoptotic effect. although alterations in expression levels of these genes were determined, this alterations was statistically insignificant. discussion and conclusion: consequently, we can say that cl have a cytotoxic effect on mcf- breast cancer cell lines. p- . . - reduction of the chloroplast genome and the loss of photosynthetic pathways in the mycoheterotrophic plant monotropa hypopitys, as revealed by genome and transcriptome sequencing e. gruzdev, a. mardanov, a. beletsky, v. kadnikov, e. kochieva, n. ravin, k. skryabin institute of bioengineering, research center of biotechnology of the russian academy of sciences, moscow, russia genomes of parasitic plants represent interesting model systems to study effects of relaxed selective pressure on photosynthetic function. previous genomic studies of nonphotosynthetic plants revealed reduction of their chloroplast genomes, but the corresponding changes in their nuclear genomes are less known. here we present the data on the transcriptome and the chloroplast genome of the non-photosynthetic mycoheterotrophic plant monotropa hypopitys. the chloroplast genomes were sequenced for two specimens of m. hypopitys, collected in different regions of russia. the cpdnas are , bp (mon- kalr) and , bp (mon- volr) long and rearranged with respect to each other. both genomes contains genes encoding ribosomal proteins, infa, matk, and ribosomal rna genes. and trna genes were predicted in two cpdna. genes encoding nadh dehydrogenase, plastid rna polymerase, all genes related to photosynthetic apparatus, clpp, ycf , ycf , accd, and some genes for ribosomal proteins are missing or became pseudogenes. the reduction of gene content is associated with extensive gene order rearrangement and the lack of inverted repeats. overall, the size and gene content of m. hypopitys cpdna indicates that it is close to the end of plastid genome degradation process. in order to get insights into the changes in the nuclear genome associated with the transition to nonphotosynthetic lifestyle, we sequenced and assembled the transcriptome of m. hypopitys. as expected for holoparasites, we did not found transcripts for the nuclear genes encoding the components of photosynthetic machinery, including photosystem i and ii, cytochrome b f complex, and ribulose bisphosphate carboxylase. contrary to the holoparasitic plant phelipanche aegyptiaca, almost all genes of chlorophyll biosynthesis pathway from protoporphyrin ix were not found in the m. hypopitys transcriptome. this work was supported by the rsf grant - - and rfbr grant - - (mon- volr cpdna sequencing). introduction: beta-sitosterol is a substance found in plants. chemists call it a plant sterol ester. it is found in fruits, vegetables, nuts, and seeds. it is used to make medicine. beta-sitosterol is used for heart disease and high cholesterol. the federal food and drug administration (fda) allows manufacturers to claim that foods containing plant sterol esters such as beta-sitosterol are for reducing the risk of coronary heart disease (chd). centranthus longiflorus (cl) is used in alternative medicine for sleep disorders. a plant of turkish origin, cl used as folk medicine have remained uninvestigated for familial hypercholesterolemia, coronary artery disease and preventing colon cancer for their in vitro biological activity despite their use for sleep disorders. we investigated of the chemical constituents from dried aerial parts of centranthus longiflorus. material and method: aerial parts of cl were collected in erzurum province. hexane, ethyl acetate and ethanol extraction were done by soxhlet extractor. the plant extracts obtained from the aerial parts of cl was analyzed using a perkin-elmer gc-ms system. results: ten compounds were obtained and identified as butanoic acid, hexadecanoic acid (palmitic acid), -methyl-z-tetradecen- -ol acetate, octadecanoic acid (stearic acid), diisobutyl phthalate, -octadecenamide, octacosane, nonacosane, alfa amyrin and beta sitosterol. the latter two were obtained in all extraction (hexane, ethyl acetate and ethanol). discussion and conclusion: all of these compounds are isolated from centranthus longiflorus for the first time. these findings may shed light on the design of new drugs, the cholesterollowering effect. p- . . - role of lutein for the high light-induced inhibition of photosystem ii related reactions in thylakoid membranes of arabidopsis thaliana, wt and lut k. dobrev, d. stanoeva, m. velichkova, a. v. popova institute of biophysics and biomedical engineering, bulgarian academy of sciences, sofia, bulgaria photosynthetic reactions taking place in thylakoid membranes of higher plants are extremely sensitive towards different environmental stress conditions such as high and low temperature, high light intensity, uv radiation etc. carotenoids are intrinsic component of photosynthetic pigment-protein complexes and are involved in performing multiple important functions. their role of accessory pigments in absorbing sun light, participation in photoprotection via dissipation of excess absorbed light, deactivating of stress-induced reactive oxygen species and structural role are well documented and recognized. the role of lack of lutein in high light-induced alterations in structural organization and functional activity of the main pigment-protein complexes was evaluated using isolated thylakoid membranes of arabidopsis thaliana, wt and mutant lut , deficient in lutein, subjected to photoinhibitory treatment for different periods of time. alterations in photochemical activity of photosystem i and photosystem ii were determined by a clark-type electrode in the presence of exogenous electron donors and acceptors. activity of oxygenevolving complex and of the grana and stroma situated photosystem ii reaction centers was evaluated by determination of flash oxygen yields and initial oxygen burst under constant light without donors and acceptors. low-temperature ( k) fluorescence was applied for unraveling of light-induced alterations in energy transfer and interaction between the main pigment-protein complexes. maximal quantum efficiency of psii was registered by pulse amplitude modulated fluorescence method. results obtained are discussed in respect to the importance of lutein for the organization and sensitivity of photosynthetic apparatus towards high light intensity treatment. modern agriculture relies heavily on phosphate rock fertilizer to improve phosphorus availability in many soils, but this approach is not sustainable long-term. phytate (myo-inositol hexakisphosphate) is an organic phosphorus compound often present in many soils. however, phytate can not be utilized by most plants, and its accumulation in soil leads to substantial ecological problems. phytases are enzymes that hydrolyze phytate and release inorganic phosphate. many microorganisms such as bacteria and fungi synthesize highly diverse phytases which are suitable for plant biotechnology. generation of transgenic plants expressing phytases of bacterial origin has been proposed as one option to improve plant phosphorus nutrition. in this study, we generated and characterized transgenic arabidopsis thaliana plants expressing a modified phytase gene paphyc from pantoea sp. under strong camv s promoter. three individual transgenic a. thaliana lines expressing the bacterial phytase gene, as well as negative control plants harboring the camv s promoter alone were identified. expression of phytase in plants was verified at both transcription and translation levels. phytase-expressing plants grown on media with phytate as the sole source of phosphorus demonstrated better than wild-type growth rates, shoot dry mass, shoot phosphorus content, as well as higher phytase activity in cell-wall extracts. overall, we show that plants expressing bacterial phytase are capable of better growth on phytate as the only source of phosphorus in laboratory conditions. further research investigating the applicability of using bacterial phytase expression to improve plant growth in soil is necessary to evaluate the different routes of solving the phosphorus deficiency problem in agriculture. p- . . - the role of elevated temperature in photoinhibition and recovery of photosystem ii in thylakoid membranes from arabidopsis thaliana a. faik, m. gerganova, m. velitchkova institute of biophysics and biomedical engineering, bulgarian academy of sciences, sofia, bulgaria photosynthesis of higher plants is the principle process to transform light energy into biochemical usable energy. in nature, plants are exposed to the environment where light, temperature, uv-b radiation varied and very often their extreme values that are unfavorable for effective performance of photosynthetic reactions. plant are developed various strategies to cope with stress including radical scavenging enzyme system, accumulation of protective compounds, etc. pigment-protein complexes of photosystem i and photosystem ii and their light harvesting antenna, situated within thylakoid membranes, are involved in the primary reactions of photosynthesis -absorption of light, charge separation and electron transport. photosynthetic process is sensitive towards higher than optimal temperatures, the photosystem ii and oxygen evolving complexes being extremely sensitive to elevation of temperature. in present work pam fluorescence was applied to evaluate the effect of long term action of elevated temperature ( / °c) on the quantum yield of photosystem ii, non-photochemical quenching and rdf, the latter quantifying the photosynthetic process. in addition, the activity of oxygen evolving complex was determined polarographically in the presence of exogenous electron acceptor , -benzoquinone. sds-page electrophoresis and western blot were applied to determine the damage of d -reaction center protein of photosystem ii. alterations of mutual organization within photosystem ii complex and its antenna and of energy interaction between them were followed by analysis of k steady state chlorophyll fluorescence spectra. the simultaneous application of high temperature and high light intensity resulted in a well pronounced reduction of non-photochemical quenching that restore to the initial values after recovery for days at optimal conditions. d was also restored while quantum efficiency of photosystem ii did not recuperate to initial values. p- . . - reorganization of the main pigment-protein complexes in thylakoid membranes from tomato (solanum lycopersicum) during long term exposure to elevated temperature the changes of earth climate resulted in unfavorable environment for plants. depending on the duration of influence of stress factors, the response of plants includes short and long term acclimation. the population, structure and organization of pigmentprotein complexes within thylakoid membranes are dynamic and flexible, thus providing for the acclimation of the photosynthetic apparatus to the changed environment. the main pigment-protein complexes, involved in energy transduction, are photosystem i, photosystem ii and light harvesting complexes. they are separated in grana and stroma regions of thylakoid membranes but it is well established that they can rearrange as a result of alterations of light intensity, temperature increase and decrease in order to balance the perception and utilization of excitation energy. in present work the effect of long term action of elevated temperature on organization and stoichiometry of main pigmentprotein complexes in the thylakoid membranes from tomato plants (solanum lycopersicum cv. m ) was investigated. three weeks old tomato grown at optimal conditions ( / °c day/ night temperature and light intensity lmol/m /s) plants were exposed for and days to elevated temperature at / °c. by means of blue-native electrophoresis the effect elevated temperature on the populations of psii (dimmer and monomers) and lhcii (monomers and trimers) was estimated and compared with the same parameters for control plants. the ability of plants to recover from this treatment was checked after days under optimal conditions. the changes of content of chlorophylls and carotenoids were determined at every stage of treatment. based on the results obtained it can be concluded that one of the mechanisms for regulating the energy balance and maintenance of efficient photosynthetic process involves a change in the organization and stoichiometry of the photosystem ii and oligomer state of light harvesting complex ii. aim of the study, was to evaluate the anti-tumor effects of silymarin, curcumin and propolis on leptin-induced mcf- cells. mcf- cells were incubated various concentrations leptin (physiological, obesity and pharmacologically doses; respectively , and ng/ml) . then different doses of silymarin ( , , , lm), curcumin ( , , , lm) and propolis ( . , . , . , . mg/ml) were added. after , , and hours incubation periods different area images were taken digital camera. then using dye release reagent we determined the intensity of apoptosis via colorimetric determination by elisa reader. absorbance was directly proportional the number of apoptotic cells (biocolor cell-apo percentageapoptosisassay). also, we examined the effect of these natural products on proliferation rate of leptin-induced mcf- cells for , , and hours (biovision cell proliferation kit) all experiments were carried out different days, at least times. all of three compounds were stimulate the apoptosis at all time points and all different doses of leptin. the differences was statistically significant at the level of p < . between and hours. it was found that there were not seen much cells at and hours time points. we thought that most of the cells were gone necrosis instead of apoptosis. the best effective doses on apoptosis of propolis was . mg/ml, silymarin and curcumin were lm. also, we evaluated the effects of on proliferation rate the mcf- cells, we found that only propolis was effective of inhibiting proliferation at all doses of leptin induced mcf- cells in hour. we hope this study will be a guide for the further studies in anti-cancer agent development field and show that the natural origin substances cause cancer cells apoptosis and provide targeted treatment for cancer therapy. p- . . - investigation of some lichen-derived substances' cosmetic potential for skin protection against ultraviolet b due to the depletion of the stratospheric ozone layer and chronic exposure, the occurrence of various skin diseases have been increased in recent decades. thence, people and cosmetic companies have progressively given more importance natural sunscreen products for the protection from harmful sun rays, especially ultraviolet b rays. we, therefore, isolated some lichen-derived substances; -hydroxyphysodic acid and protolichesterinic acid from hypogymnia tubulosa and cetraria aculeate, respectively. chemical characterization and identification of the isolated lichen substances were accomplished by using ftir, h-nmr and melting point analyses. the theoretical uv-vis spectra and d conformations of the isolated compounds were determined by using the gaussian software with hf theory at the b lyp/ - g level. the dark toxicities and ultraviolet b protection capacities of the substances were lighted up as previously described [ , ] on hacat human keratinocyte cell line by using mtt cell viability and ldh cellular membrane degradation assays. the obtained results from the assays showed that protolichesterinic acid has a more dark toxic activity on keratinocyte cells than hydroxyphysodic acid, and the toxic activities were found sufficient as much as % at the highest doses of the substances; lm. however, it was observed that the cytotoxicity of the substances were reduced at the rate of approximately % by the irradiation. consequently, we think that the substances block the ultraviolet b rays but their cytotoxic feature is an important limitation to their usage in cosmetic industry. references [ ] varol, m., t€ urk, a., candan, m., tay, t., koparal, a. t. ( ) photoprotective activity of vulpinic and gyrophoric acids towards ultraviolet b-induced damage in human keratinocytes, phytotheraphy research : - . [ ] varol, m., tay, t., candan, m., t€ urk, a., koparal, a. t. ( ) a great effort and financial supports have been consumed to explore and design novel sun protection factors due to the unhindered increase of malignant and non-malignant skin diseases caused by the chronic exposure and depletion of the stratospheric ozone layer. the testing of naturally produced compounds seems to be the best and inexpensive way to search for potentially photoprotective substances. on the other hand, as photo-resistant species, lichens are still poorly exploited. norstictic acid was, therefore, isolated from the acetone extract of pleurosticta acetabulum. ftir, h-nmr and melting point analyses were performed to identify the chemical features of norstictic acid. gaussian software with hf theory at the b lyp/ - g level was also performed to determine the theoretical uv-vis spectrum and d conformation of the isolated compound. the dark cytotoxicity and ultraviolet b-protection capacity of norstictic acid were comparatively tested as previously described [ , ] by using mtt cell viability and ldh cellular membrane degradation assays. as a result of the experiments, it is observed that norstictic acid has a dark-cytotoxicity as less as % at the highest dose of the substance; lm. however, ultraviolet b-induced damage on human keratinocytes was blocked by the lower concentrations of norstictic acid as , and -lm, and % of cells were protected according to the control experiments of irradiated cells. consequently, we think that norstictic acid might be employed as a sun protection factor at the low concentrations, and further studies should be performed. years, researchers have focused on the lichen acids because of their biological activities. it is also suggested that lichens can be used as anticancer agents. vulpinic acid, an important lichen seconder metabolite, has antimicrobial activity and strong antimutagenic, anticancer and antioxidant capacity. nanotechnology has the potential to offer solutions to current obstacles in cancer therapies, because of its unique size ( - nm) and large surfaceto-volume ratios. so, in this study we aimed to determine the cytotoxic and proliferative effects of vulpinic acid and magnetic nanoparticles loaded with vulpinic acid (fe there are four species of wild rice known around the world. zizania aquatica l., zizania palustris l. and zizania texana hitche are found in north america, whereas zizania latifolia (griseb) turcz) is native to east asia. cwr mainly grows in the areas along the yangzi river and the huai river in china without any cultivation and domestication. cwr was an ancient grain that has been used in chinese herbal medicine to treat a variety of ailments associated with nutrition, including gastrointestinal disorders and diabetes. our previous studies have demonstrated that consuming chinese wild rice can significantly improve blood lipid profiles and ameliorate high-fat/cholesterol diet-induced insulin resistance. however, compared to the well studied common dietary white rice, active composition and the associated proteomic information of chinese wild rice have yet to be investigated. in this study, we compared and analysed the different proteins between chinese wild rice and white rice by proteomics method. our study provides insights and experimental evidence for further exploration of this ancient medical food in disease prevention and therapy. the homology between cwr and n is %, but significant differences also exist between the two. we gained new insight by analyzing the biological function of the high reliability (credibility score or higher, p < . ) peptide mass fingerprint of cwr -de electrophoresis revealed differences in protein composition between cwr and n . information obtained from the pmf indicates that glutelin precursor, caffeoyl coenzyme a (coa) omethyltransferase and putative bithoraxoid-like protein can provide gene evidences for its biological function. p- . . - mir and growth-regulating factors interaction during maize leaf growth under low-temperature stress g. aktug, f. aydinoglu gebze technical university, kocaeli, turkey microrna (mirna) genes are a class of non-coding small rnas about nucleotide-long which are revealed as regulators of plant growth and stress responses. the mirna mir targets and regulates growth-regulating factors (grfs) which are plant specific transcription factors family and this regulation machinery is conserved among plant species. plant growth is a result of cell division and expansion which took place as spatial gradient zones throughout maize leaf which are meristem, elongation and mature zones. cells proliferate in meristem, migrate to elongation zone and finally reach to mature zone to get its final size. it has been shown that mir affects cell division by regulating grfs and changes leaf size which are determined by cell number and cell size of leaf. this study aims to investigate the role of mir and grfs interaction during maize leaf growth under low-temperature stress. maize seedlings were grown under low-night temperature for stress treatment to generate growth retardation and control conditions as well to make comparative analysis. length of the third and fourth leaves of seedlings was measured every day and leaf elongation rate was calculated to observe stress effects on the leaves. growth zones of fourth leaves were harvested during steady-state growth phase for determining expression level of mir s and their target by q-rt-pcr. we mined mir genes sharing sequence similarity and grf targets. the expression analyses of mir s and grf are proceeding for different growth zones. in conclusion, this is the first study investigating the regulation network between mir s and grf in different developmental stages of maize leaf under low-temperature stress. oeigpd cdna was isolated from a cdna library we constructed from olive pedicels. homology searches for nucleotide, amino acids and alternative open reading frames were conducted utilizing blastn, blastp, and blastx, respectively. nucleotide sequences of homologous genes from other plants were aligned using bioedit and the number of snps were detected. the alignment was then used to generate a phylogenetic tree using mega program. another alignment with amino acid sequences of the homologues proteins was also generated to construct a phylogenetic tree displaying oeigpd's position among other plants. various aspects of oeigpd including amino acid composition, hydropathy analysis, isoelectric point (pi) and three dimentional structure of the protein were determined using online software at expasy. multiple primer pairs to amplify the full length open reading frame of the gene, to clone the gene into the expressing vector plate , and to detect expression through real-time pcr were designed using primer . amino acid composition analysis revealed that oeigpd contained serine, arginine and isoleucine predominantly while hydropathy analysis suggested it was an hydrophilic protein. isoelectric point (pi) of the protein was calculated as . . the molecular weight of the protein was calculated as kda. analyses continue to determine the polymorphism of oeigpd among olive cultivars, and biochemical function of the gene in olive. p- . . - cytotoxic effect of fractionated triterpenoid glycosides from holothuria polii in human cancer cells sea cucumbers are the members of class holothuroidea and they have more than described living species all around the world. sea cucumbers secrete special secondary metabolites from their body walls and they are called triterpene glycosides (tggs). in this study, cytotoxic activity of fractionated ttgs from h. polii on different cancer cell lines were carried out. h. polii delle chiaje, samples were collected from dikili-_ izmir. the semipurified extracts were fractioned by using hplc. four different fractions (fraction a-d) were obtained. in order to characterize the fractions, maldi-tof/ms was used. the cytotoxic activity of the fraction a-d were tested on ht- , t and upci-scc- cell lines by using xcelligence rtca sp system. the cells were treated with three different concentrations of the fractions for hours. the cell index data were compared with the control group. ic values of the fractions for three cell lines were calculated. according to the results, the fractions have holothurin a ( . m/z), -dehydroechinoside a, scabraside a or fuscocinerosides b/c isomer ( . m/z). the fraction d was the most effective on all cell lines with ic value of . ae . mg/l, . ae . mg/l and . ae . mg/l for ht- , upci-scc- and t , respectively. in conclusion, sea cucumber ttgs are promising agents for colon adenocarcinoma, oral squamous cell carcinoma and colorectal carcinoma (metastatic) treatment. p- . . - effect of horse-chestnut (aesculus hippocastanum) seed extract on matrix metalloproteinases during diabetic wound healing impaired wound-healing in diabetics is a major public health problem. the expression and activation of matrix metalloproteinases (mmps) are also impaired in diabetic wounds according to previous studies. their main function is to degrade the various components of the extracellular matrix. also, they participate physiological processes such as inflammation, angiogenesis, tissue remodeling. horse-chestnut seeds (hc) are rich in saponins and flavonoids. it has been shown that hc has antiinflammatory, antioedema, vessel protective, and free radical scavenging properties. the aim of this study is to determine with molecular signs on cutaneous wound healing effects of the ethanol ( %) extract of hc (hce) seed in rats by excision wound model. this study was conducted on diabetic wistar albino rats, which were injected by a single dose ( mg/kg i.p.) streptozotocin. diabetic treatment rats were applied topically % (w/w) ointment with hce and control rats were applied topically simple ointment, once a day during the experimental period. the gene expression levels of mmp- , mmp- by qpcr and levels of nitric oxide (no), hydroxyproline and malondialdehyde in wound tissue investigated at the end of rd, th, and th days. wound closure was also measured. the hydroxyproline and no levels were significantly increased in the hce treated group versus control after the rd and th days. the malondialdehyde levels were significantly lower in the treatment group. mmp gene (associated with collagen processing and reepithelialization) expression levels in hce treated rats were increased in the th day while it was reduced in th day. mmp gene (associated with inflammation and gelatinase) expression levels in hce treated rats were decreased in th, and th days compared to the control. these findings indicate that hce accelerated the cutaneous wound healing process in diabetic rats via mmp and mmp regulation. p- . . - isolation and molecular molecular characterization of vps /vam from olive b. celikkaya, e. dundar molecular biology and genetic at balikesir university, balikesir, turkey vps /vam promotes aggregating and fusing of endosomes and lysosomes. it is a component of a protein complex that is found in vacuole membranes. this gene has been studied from various organisms including humans, drosophila, arabidopsis and rice. no studies on olive vps /vam , however, have been reported. the aim of this study is to report information of olive vps /vam including expression pattern and biochemical characterization. vps /vam was isolated from a cdna library we constructed from fruited olive leaves in july. to determine the putative name of the cdna, blast analyses were conducted for nucleotide, open reading frame and amino acid sequence comparisons. bioedit program was used to determine the nucleotide and amino acid composition along with its molecular weight and isoelectric point (pi). hydropathy analysis was conducted using kyte and doolittle program. phylogenetic analysis was done using mega . cellular localization of the product was predicted using sosui gramn. the three dimentional structure of the protein was calculated using i-tasser and compared to previously known structures using cn d. the blast and bioedit analyses revealed vps /vam had base pairs coding amino acids with a molecular weight of . kda, and pi of . . the at/gc ratio was very high ( . ) comparing to its homologs from other plants suggesting to expect significant differences of this gene's function from the others. amino acid composition analysis revealed high rates of serine, leusine and isoleucine indicating a hydrophobic property of the protein. the hydrophobic feature was confirmed by kyte and doolittle analysis while the cellular location was revealed to be extracellular. the hydrophobic nature despite extracellular location suggests it is a membrane associated protein which was confirmed by transmembrane domain analysis. as expected no signal peptide was detected. the d structure of the protein was similar to its previously reported homologs. p- . . - isolation and characterization of the ribosomal l protein from olive s. cinarli, e. dundar department of molecular biology and genetics, balikesir university, balikesir, turkey despite as a ribosomal protein, l is known as the inhibitor of the cellular aging gene and it has been reported to have roles in apoptosis. the ribosomal l protein is larger than the lsu of ribosome and contains domains as -layered alpha/beta domain and -layered alpha/beta domain. in ribosomes, it functions in translocation and orientation of trnas. although the ribosomal l (rl ) gene has been studied in many plants, reports on olive rl (oerl ) are very rare. this study presents molecular characterization of rl gene from olive. oerl was isolated from a cdna library we constructed from unfruited olive leaves in july. homology analyses were conducted using blast programs. nucleotide and amino acid compositions, molecular weight, isoelectric point (pi) and at/gc ratio were determined using bioedit and expasy programs. cellular location of the l protein was determined using sosui-gramn program. signal peptide detection, transmembrane domain detection, three dimensional ( d) structure analysis, and phylogenetic analysis were conducted using signalp . , thhmm, i-tasser/cn d and mega , respectively. oel was found to have an open reading frame of base pairs coding amino acids that constitutes a molecular weight of . kda and a high pi of . . lysine, leucine and valine had higher rates. the hydrophilic nature suggested by kyte and doolittle analysis despite high rates of leucine and valine suggests an amphipathic nature of the protein that can bind to both hydrophilic and hydrophobic proteins and / or function in both media. a . at/gc rate is significant comparing to that of its homologs from other plants. sitoplasmic location predicted by sosui-grann is in agreement with the hypothesis suggesting an amphyphatic nature for oerl . likewise, no signal peptide was detected and it was predicted to have at least one transmembrane domain. further characterization of oerl with respect to expression pattern and biochemical function continues. p- . . - isolation and characterization of an olive splicing factor b subunit m. nurcin, e. dundar department of molecular biology and genetics, balikesir university, balikesir, turkey splicing factor b subunit (sf b ) functions in the regulation of translation and gene expression. sf b forms u small nuclear ribonucleoprotein complex (u snrnp). splicing factors a and b binds pre-mrna at the site of the intron branching point. this binding joins u snrnp to pre-mrna. although sf b from various plants have been widely studied, no studies on olive sf b (oesf b ) have been reported. this study reports information on various aspects of oesf b . oesf b was obtained from a cdna library we constructed from fruited olive leaves in december. it was putatively identified as a splicing factor using blastn, blastp and blastx. to determine wheter oesfb was a sitoplasmic protein, sosui gramn was used. tmhmm was used to detect any transmembrane domains while signal peptide analysis was conducted by signalp. i-tasser and cn d were used to generate the calculated d structure and to compare it with experimentally generated models, respectively. nucleotide and amino acid compositions along with the calculated molecular weight and isoelectric point (pi) were analyzed using bioedit and online expasy software. the phylogenetic trees revealed genetic relationship of olive among other plants based on oesfb . the orf contained nucleotides coding amino acids that produce a . kda peptide with a pi of . . alanine, valine and leucine were found at high ratios suggesting a hydrophobicity which was also predicted by kyte and doolittle analysis. the at rich property of oesf b is not unusual comparing to most plant genes. cellular localization of the gene was suggested to be in mitochondria with no signal peptide indicating oesf b could be synthesizing in mitochondria. the predicted d structure of oesf b was similar to experimentally produced structures while some hydrophobic pockets were predicted. further characterization of the gene with respect to temporal and spatial expression pattern and biochemical function continues. p- . . - kafirin profile of turkish originated sorghum populations r. temizg€ ul, s. yilmaz, m. kaplan, t. akar department of biology, faculty of science, erciyes university, kayseri, turkey sorghum bicolor l. is the fifth important crop in the world with its high photosynthetic activity and resistance to unfavourable conditions as high temperature, drought, salt, and ph changes. sorghum has attracted great interest due to its intensive usage both as human and animal nutrition, and contribution to resistance against many diseases. some proteins of sorghum exerts reducing effect on nutrient digestion through making connetions with other proteins and/or carbohydrates. kafirin proteins have the highest proportion in grain with a range of - %. they are grouped into a ( - kda), b ( kda), c ( kda) and d ( kda) subunits depending on molecular weight, solubility and structure. in the current study, kafirin proteins from turkey originated sorghum populations were acquired through sequential extraction; first, non-prolamines were removed through application of % naci concentration, and second, kafirins were obtained using tertiary butanol ( %) and reducing agents. sds-page was conducted for seperating and visualising the subunits of kafirins. the a, b, c, and d subunits of populations were respectively estimated as , , , and %. of the total proteins, % was identified as a, % b, % c, % d, and % non-prolamines. non-prolamin group of proteins were visualised as different bands ranging from . to kda. c and b group of proteins were only viewed when treated with reducing agents as -me and dtt suggesting that they are connected with complex cross-links. however, a group of proteins visualized without using these agents due to not having intra molecular disulphide bridges and inter molecular cross-links. non prolamins, except for . , . , . , . and . kda, were able visualised in the presence of reducing agents. transcriptomic analysis of the genes encoding analysed proteins needs to be elucidated for better understanding of the genetic diversity and biochemical characteristics of sorghum. p- . . - untargeted metabolomic profiling of romanian and uk tomatoes varieties by high performance liquid chromatography coupled with mass spectrometry c. socaciu , university of agricultural sciences and veterinary medicine, cluj-napoca, center for applied biotechnology ccd-biodiatech at proplanta ltd, cluj-napoca, romania tomato flesh is a rich source of many phytochemicals of high nutritional value, including a large variety of carotenoid derivatives with health promoting properties. metabolomics became the most adequate technology for an accurate chemotaxonomic classification and discriminations between different varieties, based on untargeted profiling or targeted, quantitative analysis. different varieties of tomatoes (b-carotene-rich, lycopene-rich, ketocarotenoid-rich) cultivated in romania and uk were comparatively studied using enriched fractions obtained by a preliminary fractionation of the whole pulp homogenate. two methods were applied for carotenoid extraction: a mixture of hexane/ethanol ( ) and chloroform/methanol ( ) . the dried extracts were dissolved in ethyl acetate and analyzed by uv-vis spectrometry and hplc-esi(+)qtof-ms (bruker gmbh). the base-peak chromatograms were processed by specific biostatistics software (data analysis and profile analysis) and the molecular identification were determined by comparison with the data base lipidomics gateway (www.lipidmaps.org). the content of carotenoids were significantly higher using extraction ( ) , ranging from . to . mg/ g. the major carotenoid derivatives, were represented by lycopene, hidroxy-lycopene, all-trans or cis-beta-carotene, echinenone, all-trans retinyl palmitate, but also sterols, phospholipids, di/tri glycerides and ceramides. the romanian varieties were more rich in polar carotenoids and lipids, in general, while the uk tomatoes proved to be enriched in non-polar derivatives, especially esterified carotenoids, keto-carotenoids and glycerides. new molecules were identified, as good discriminatory markers of each tomato variety. acknowledgements. this work was supported by a grant of the romanian national authority for scientific research and innovation, cccdi -uefiscdi, project nr. / , pncdi . glycogen is a multi-branched polysaccharide that serves as the main form of glucose storage in the body, where the main reserves are in the liver and muscle. it has been observed that glycogen metabolism is altered in many tumor types, and that glycogen content is inversely correlated with proliferation rate. in addition, it has recently been described that when glycogen accumulation is forced in glioblastoma u cells in hypoxia, senescence is induced and tumor growth is inhibited in vivo. our laboratory has various animal models with different parts of the glycogen metabolism pathway affected. most notably, we have two animal models lacking glycogen: muscle glycogen synthase (gys ko) and liver glycogen synthase (gys ko) knockout animals. we isolated mouse embryonic fibroblasts (mefs) from gys ko to perform replicative senescence assays. in addition, we induced hepatocellular carcinomas in gys ko animals via n-nitrosodiethylamine (den) injections in order to track tumorigenesis in animals lacking hepatic glycogen. lastly, we performed partial hepatectomies (phx), which involves the resection of two thirds of the liver, on gys kos to evaluate the effect of the lack of glycogen on hepatocyte proliferation. interestingly, we have observed that glycogen levels are increased in human and mouse fibroblasts under replicative senescence, and that mefs depleted of glycogen bypass senescence and immortalize faster than wts. we have also demonstrated that senescence pathways are down regulated in mefs lacking glycogen. furthermore, gys kos treated with den show higher tumor burden and mortality than controls. we also evaluated the effect of glycogen on hepatocyte proliferation after phx. gys ko mice present faster proliferation and liver regeneration rates, when compared to wt counterparts. collectively, our preliminary data suggest that glycogen metabolism plays a crucial role in the regulation of cell cycle in both physiological and pathological states. it is established that pineal is involved in circadian regulation of testosterone secretion from leydig cells. however, the precise routes of this regulatory involvement are still unknown. as cgmp has been also regarded as modulator of steroidogenesis we sought to study the effects of pineal removal on the circadian pattern of cgmp variations and expression of the genes that encode elements of no-cgmp signaling pathway in adult rat leydig cells. the analysis was performed on testicular leydig cells obtained from pinealectomised and shame pinealectomized rats, in six time point during hours. the pinealectomy was confirmed by serum melatonin eia measurement. the androgen levels were measured by ria; cgmp by eia and gene expression was quantified by rq-pcr. all results were analyzed by cosinor method. data revealed circadian transcriptional pattern of nos , nos (genes encoded no producers) and pde a (gene for cgmp remover) in leydig cells from adult rats. pinealectomy significantly increased expression of nos which lost rhythm and increased and delayed amplitude of nos expression. further, pinealectomy initiated cyclic transcription of gucy b and noncyclic transcription of gucy a (genes encoded cgmp producers) and increased mesor and amplitude of pde transcription. the transcription of prkg , the main effector in this signaling pathway was not affected with pineal abolition. additionally, pinealectomy did not influence the circadian transcription profile of coxi or other investigated genes (coxi , nrf , nrf a, pgc a) related to mitochondrial function and biogenesis. finally pinealectomy reversed phase of circadian cgmp oscillation in leydig cells, increased amplitude and slightly advanced peak of serum testosterone oscillation. results suggested pineal influence on circadian rhythm of no-cgmp signaling in leydig cells. further studies based on these data are needed to better understand the relationship between pineal and circadian rhythm of testosterone production. influenza is a contagious respiratory infection caused by a variety of influenza viruses. neuraminidase inhibitors is a new class of antiviral drugs that inhibit influenza viruses. the most popular antiviral agents is oseltamivir, having a commercial name of tamiflu, within anti-influenza antivirals. as well as tamiflu is a member of neuraminidase inhibitor group drug. therefore, this study was performed to determine the effect of tamiflu on cultured human peripheral blood lymphocytes. material and methods: for examining the presence of the indirect mutagenic effect of oseltamivir in iver s fraction mix was used. cells were treated with . , and lg/ml oseltamivir, the tamiflu capsule ingradient, for or hours in the absence or presence of an exogenous metabolic activation system. the test chemical did not demonstrate any genotoxic effect dose-dependently but it showed a weak cytotoxicity on cells in this study. on the other hand, some concentrations of tamiflu induced sce and also decreased significantly the proliferation index (p ˂ . ) in the absence of s mix. result: tamiflu did not induce significant increases of ca or micronucleated cells in vitro in cultured peripheral blood lymphocytes under the treatment conditions used but week sce induction was observed. on the other hand, the weak cytotoxic effects observed disappeared in the cultures treated in presence of the s mix. discuss and conclusion: tamiflu weakly induced sce at the highest concentration with/without added s mix in cultured human peripheral lympocytes. it could be assumed to be a sce inducer. sces can be increased by several agents that attack dna. tamiflu decreased the proliferation index and nuclear division index at some concentrations thus interferring it as being weakly cytotoxic, though this effect disappeared in the presence of s mix applications. this finding is important for showing the inefficiency of tamiflu metabolites on the cell cycle. introduction: chronic renal failure as a result of the progression of diabetic nephropathy is the main cause of mortality in patients with type diabetes. chronic hemodialysis is a life-saving therapy for patients with strong renal disorders. the main goal of hemodialysis is toxins removal from the patient. the monitoring of hemodialysis is the best way for biomedical evaluation of correctness and efficiency of this clinical treatment. according to the published data, the markers of development of diabetes complicated with renal failure are increased levels of glucose, urea and creatinine in the patient blood. today colorimetric and spectrometric methods are most commonly used for determination of the above metabolites in biological samples. however, these methods are complex in application, have low selectivity, and require pretreatment of samples. materials and methods: we propose for levels of glucose, urea and creatinine detection the potentiometric multibiosensor based on ph-sensitive field-effect transistors and immobilized enzymes developed in our laboratory. results: we developed a potentiometric multibiosensor and studied its main analytical characteristics. linear dynamic ranges of determination of substrates were following: . - mm of glucose, . - mm of urea, and . - mm of creatinine. it was shown that the potentiometric multibiosensor had good reproducibility, and its bioselective elements were working independently from each other, because test of substrates cross-selectivity was negative. discussion and conclusion: very sensitive, fast and selective multibiosensor for simultaneous measurement of three metabolites in a single cycle based on ph-sensitive field-effect transistors and immobilized enzymes is developed. the developed potentiometric multibiosensor was verified by quantitative analysis of glucose, urea and creatinine in blood serum of patients with diabetic nephropathy. p- . . - ph-dependent interaction of asymmetrically charged peptides with a protein nanopore over the past two decades, the ability to use natural or artificial nanopores to probe at uni-molecular level the structural and kinetic features of various bio-molecules (peptides, dna, rna) was successfully achieved. the operating principles of the nanopore-based single-molecule technique are simple: the single macromolecule capture, entry and subsequent translocations through a free-standing, voltage-biased nanopore, depend upon the physico-chemical and topological features of the analyte. the concentration, identity volume and charge of the analyte are then deduced from the analysis of the stochastic current blockade events caused by the trafficked analyte across the nanopore. herein, we used the a-hemolysin (a-hl) nanopore and set up an experimental model providing efficient control of a-hl-peptide interactions, in the presence of a ph gradient across the nanopore. for this, we engineered a amino acids long peptide containing a neutral asparagines-containing sequence, flanked by oppositely charged aminoacid patches at the n-(glutamic acids) and c-termini (arginines), whose length was set as to span a single a-hl protein. when the ph of the solution in contact to the a-hl's b-barrel opening is changed from neutral to acidic values, the electrostatic interactions between the protein's mouth and either the n-or c-terminus end of the peptide occurs, and this influences strongly the dynamics of a peptide translocating the nanopore. we further proved that during the same experiment, peptide entry into the nanopore can be set to occur with either n-or c-terminus end head on, by simply changing the sign of the transmembrane potential across the nanopore. nanopores are emerging as a powerful and broadly applicable tool in biophysics, which allows one to study the features of charged macromolecules under confinement. a few noteworthy examples are: determining the electrophoretic mobility, effective charge and diffusion coefficients of charged molecules; exploring the folding and unfolding of peptides and proteins; analyzing biopolymers trafficking, protein transport, dna translocation, rna and dna sensing and sequencing. herein, we employ single molecule analysis techniques using a wild-type ahemolysin (a-hl) protein nanopore to study the capture and translocation behavior of a short cationic peptide ( amino acids in length) at an extremely low ph value. our experiments revealed that an effective absorbing field is created by the electroosmotic flow, against the electrophoretic force, which enables the peptide capture inside the nanopore. furthermore, our findings show that the trajectory of a single peptide can be experimentally visualized and the main steps determined: the peptide capture, reversible translocation across the pore's vestibule and lumen regions, and the peptide release from the nanopore. also, the kinetic analysis of the main steps observed allowed us to describe the free energy profile of the peptide interactions with the protein nanopore. the presented work provides evidence for the ability of controlling the dynamics of a single-peptide, its capture and passage inside a a-hl nanopore, that underlie the processes naturally occurring in cells, thus proving a powerful approach for probing single molecule biophysics phenomena, in general. changes in the physical conditions of the cancer microenvironment driven by elevated tissue growth and angiogenesis, may introduce exposure of laminar fluid flow, which effect the key factors of cancer, such as progression, immune-escaping and metastasis. conventional experimental models fail to mimic the physical cues on tumor microenvironment. microfluidic culture techniques allow precise control of fluids, simultaneous manipulation and analysis of cultured cancer cells. here, we present a platform that can be used for the investigation of the role of flow mediated mechanical stimuli on cancer cells. microfluidic cell culture platform was fabricated using polymethyl methacrylate and double-sided adhesive films with mm dimensions. ovary adenocarcinoma cells (efo- and onco-dg- ) were used for the optimization of the platform. to understand the fluid and gas distribution patterns, specific modeling was performed. dynamic microfluidic cell culture and static conventional cell culture conditions were compared for the differences of cancer cell phenotype, such as proliferation, viability, epithelial-mesenchymal transition. we confirmed that, the proliferation and viability of cancer cells are increasing under dynamic fluid flow. the proliferation rate of ovary adenocarcinoma cells was correlated with the increase of fluid flow rate. immunocytochemical analysis showed that fluid flow causes decrease in e-cadherin expression, and increase in n-cadherin and vimentin expressions, which indicate mesenchymal phenotype of cancer cells. our results showed that, cancer cells present different characteristics due to fluid flow of tumor microenvironment. to understand the role of physical dynamics by using microfluidic culture techniques, is a key to elucidate the mechanisms underlying disease progression, and may lead to new diagnostics and therapeutic approaches. (this study was funded by turkish scientific and technical research council (tubitak- s ). high-sensitive detection of low-affinity antibodies by immuno-pcr with supramolecular olygonucleotide-streptavidin complex detection of low affinity antibodies in blood sera and cell surface outwashes is important both in the study of molecules that bind to cellular receptors (circulating tumor cell masking antibody, for example) and medicine (diagnosis of allergy). low affinity igm and ige antibodies can not sometimes be determined by conventional methods. we using supramolecular oligonucleotide-streptavidin complex formed from single-stranded synthetic oligonucleotide ( n) contains biotin on '-and '-ends, and sterptavidin in molar ratio : . this complex represents a structure with equivalent electrophoretic mobility of bp dna and preferred "valency" of streptavidin is . this universal immuno-pcr approach make it possible to increase a signal by using several oligonucleotides per one antibody. after the method optimization we achieved - times highter sensitivity than elisa. to reduce the matrix effect we used - fold dilutions of sera samples. this approach achieved a significant advantage, because it allows working with small-volume samples (need only mkl of serum sample). antibodies to the disaccharide galb - glcnac (le c ) are typical of the natural antibodies. the igm anti-le c antibodies are found in almost healthy people without the epitope specificity variation. we have shown that the concentration of igm anti-le c antibodies was higher (p ≤ . ) for health donor sera (n = ; . ae . pg/ml) compared with sera from patients with breast cancer (n = ; . ae . pg/ml). sensitivity of igm anti-le c antibodies detection was pg/sample ( mkl) ie . molecules. thus for the immuno-pcr detection of antibodies the - tumor cells are sufficient. such amount of cells seems to be a realistic one for detection of antibodies masking circulating tumor cells. this study was supported by a grant from russian science foundation (# - - ) and by russian federation president scholarships donated to d. yu. riazantsev (# sp . . bacterial pathogen detection and identification is of crucial importance for disease diagnosis, bacterial contamination surveys and water quality assessment. we propose herein a novel method for bacterial detection based on the interaction of single gram-negative bacterial cells (i.e.: escherichia coli and pseudomonas aeruginosa) with an ahemolysin (a-hl) protein nanopore embedded in a reconstituted lipid bilayer, at neutral ph. as a consequence of an applied voltage, the negatively charged bacteria suspended in saline buffer solution are electrophoretically driven towards the pore opening, inducing reversible blockages in the ionic current through a-hl. experiments were also performed in the presence of an antimicrobial peptide, cma , as well as in acidic environment. statistical analysis of the frequency and duration of blockage events allowed us to discriminate between the two types of bacteria. the frequency of interactions was higher for escherichia coli with respect to pseudomonas aeruginosa. adsorption of cma peptides on the membrane of bacteria increased the frequency of interactions with the pore, contrary to the expected effect induced by lowering the net surface charge of the cells. in experiments performed at ph = , the frequency of blockage events was found to be two orders of magnitude higher, with longer interaction life-times. the net negative charge ( uncompensated aspartate residues) localized at the entrance of the pore contributes an additional electrostatic repulsion interaction between negatively charged bacterial cells and a-hl. thus, adsorption of cationic peptides at the interface will reduce this repulsive interaction. the same effect was recorded at ph = , when the aspartate residues are partially protonated, confirming our understanding of the previously observed results. this method could be further developed and integrated with other techniques, making nanopore-based systems a fast and reliable bacterial detection and identification tool. this study was performed to analyze the effects of tunicamycin (tm) and taurohyodeoxycholic acid (tudca) on thle- cells. cells were treated with tm to induce endoplasmic reticulum (er) stress and tudca was administered as an er stress inhibitor. cytotoxicity was evaluated at different times of exposure by incubating cells with increasing concentrations of either tudca, tm or both. thle cells were cultured in fibronectin, bovine collagen i and bovine serum albumin coated plates. cell lines were grown in begm media supplemented with epidermal growth factor, phosphoethanolamine, fetal bovine serum, u of penicillinstreptomycin and maintained in a humidified incubator at °c and a % co atmosphere. cell viability was measured using the colorimetric -( , -dimethylthiazol- -yl)- , -diphenyltetrazolium bromide (mtt) assay kit. cells were grown to confluence in well plates and incubated with ll/ml dmso, - lg/ml tm, . - mm tudca, or lg/ml tm + . - mm tudca for - hours. control cells were prepared in plates containing only medium. at the end of the incubation period, mtt was added to each well and incubation was carried out for hours at °c. formazan production was expressed as a percentage of the values obtained from control cells. at all hours of incubation neither dmso or mm tudca was cytotoxic. at and hours incubations mm tudca and lg/ml tm + mm tudca were significantly cytotoxic compared to control, dmso and mm tudca groups. treatment of cells with . mm tudca hours before administrating ug/ml tm significantly decreased the cytotoxic effect of tm. we conclude that tudca may show cytotoxic effects at mm concentration when treated with tm. therefore . mm of tudca, administered hours before tm treatment should be applied to protect against er stress. acknowledgement: this study was supported by a grant from the scientific and technological research council of turkey (tubitak; s ). recent studies reveals that history of preeclampsia is an independent risk factor for cardiac events and stroke. lipoprotein-associated phospholipase a (lp-pla ) is a vascular inflammatory marker associated with cardiovascular diseases (cvd). we hypothesize that vascular inflammation (lp-pla mass, activity, index) related genetic variations (pla g ) increase the risk for developing future cardiovascular disease in women with pe. a group of preeclamptic patients and normal pregnant women were recruited from university of istanbul, cerrahpasa medical school, department of gynecology and obstetrics included into the study. the control group was matched for maternal and gestational age at time point of sampling. preeclamptic patients were starified into two groups; early-onset and late-onset according to the gestational weeks. enzyme-linked immunosorbent assay procedure was used to determine the serum lp-pla mass level. lp-pla activity were determined by kinetic method. plag snp genotyping performed by using the sequenom massarray iplex. the rs tt genotype had a higher lp-pla index (p = . ) for early onset preeclampsia, cc genotype had a higher lp-pla mass and lp-pla index for late onset preeclampsia. no difference were found for control. the rs gg genotype had higher lp-pla mass and index for late onset preeclampsia (p = . , p = . respectively). stepwise logistic regression analysis performed to identify cardiovascular disease related variables that independently and significantly contributed to the presence of alleles of rs and rs snps in early, late onset preeclampsia and control group. only lp-pla mass was independently and significantly associated with both snps in early onset preeclampsia. the association between lp-pla mass, index and rs , rs snps might be useful genetic markers to adress future cvd risk in patients with preeclampsia. introduction: b-thalassemia is one of the most monogenic autosomal recessive disorder characterized by defective production of the b-chain of hemoglobin. definition of the b-globin genotype is necessary for genetic counselling in the carriers, and for predicting prognosis and management options in the patients with thalassemia. dna-based diagnosis of b-thalassemias routinely relies on polymerase chain reaction (pcr) and gel electrophoresis. the aim of this study is to develop a new procedure, a dna-based piezoelectric biosensor, for the detection of b-thalassemia ivsi- mutation, the most common b-thalassemia mutation in turkey. materials and methods: b-globin gene of genomic dna isolated from whole blood, was amplified by pcr. bioactive layer was constituted by binding -hidroxymetacrilate metacriloamidoscystein (hema-mac) nanoploymers on the gold electrode's surface. single oligonucleotide probes specific for ivsi- mutation of b-thalassemia were attached to the nanopolymer via reactive cross-linker glutaraldehyde. the measurements were executed by piezoelectric resonance frequency which is caused by binding of pcr products in media with single oligonucleotide probe on the electrode surface. the results were confirmed by the conventional molecular method as arms. results: the piezoelectric resonance frequencies obtained by hybridization of the pcr products on bioactive layer were found ae , ae , and ae hz for the samples of normal b-globin, heterozygote, and homozygote of ivsi- mutation, respectively. discuss and conclusion: the developed biosensor serves as a specific result to ivsi- mutation. it could accurately discriminate between normal and ivsi- mutation samples. because of low costs, fast results, specificity and high detection/information effectiveness as compared with conventional methods, we can be offered this techique as an alternative to conventional molecular methods. the increasing use of nano-sized materials in the last several years has compelled the scientific community to investigate the potential hazards of these unique and useful materials. one of the most widely used nanoparticles is titanium dioxide. the objective of the research is to investigate the alterations in molecular and cellular responses in culture of primary lymphocytes to tio nps. human lymphocytes isolated from heparinized blood of healthy individuals were exposed to tio nanoparticles. viability, ros generation, the changes in the expression of genes encoding proinflammatory mediators tnf-a, il- b and il- and dna damage were assessed. human lymphocytes were incubated with nanoparticles of different concentrations and viability was determined in and hours after treatment, respectively. cell viability was decreased by a treatment with nanoparticles in both a time-and concentration-dependent manners. the ability of tio to induce ros formation in lymphocytes was evaluated using dcf fluorescence as a reporter of oxidant production. the fluorescence intensity of oxidized dcf was increased in cells treated with nps. this means that ros generation occurred in response to the treatment with tio . to investigate the expression level of mrna related to the inflammation responses in human lymphocytes real-time pcr was performed. the expression of il- b, il- and tnf-a genes were increased by the exposure to nanoparticles of , and lg/ml for - hours. tio nanoparticles were shown to induce the dose-dependent fragmentation of dna strands. much evidence of hazardous health effects of nps has been reported. in this study, viability was reduced under the exposure to tio . oxidative stress was elevated by the treatment with tio nps. oxidative stress can also trigger inflammation signals. induced by exposure to nanoparticles they may cause the translocation to the nucleus of transcription factors, which regulate proinflammatory genes, such as tnf-a, il- b, il- . background: endothelial cells (ec) represent one of the primary targets of the major pro-inflammatory cytokinetumor necrosis factor (tnf). development of the new approaches for the treatment of acute and chronic inflammatory conditions, including the strategies aimed to tnf neutralization, requires the usage of the adequate cellular models closely resembling the properties of the endothelium. the endothelium-derived ea.hy cell line expresses several inflammation and neoangiogenesis markers in response to activation factors however their expression can differ from the patterns demonstrated by primary ec. the aim of the current study was to compare the expression of the known endothelial cellular markers including receptor of vascular endothelial growth factor- (vegfr ) and a v b -integrin on d and d cultures (spheroids) of ea.hy . methods: the ea.hy cell line was used with permission from dr. edgell. the cells were cultivated in the presence of tnf ( ng/ml) or vegf a ( ng/ml) for hours. mrna was isolated using rneasy kit from qiagen and reverse-transcribed with revertaid kit (fermentas). rt-pcr was performed with specific primers. expression of vegfr and a v b -integrin was visualized by confocal microscopy using specific monoclonal antibodies and previously developed fluorescent hybrid proteins. results: the expression of a v b -integrin and vegfr- increased on the d culture compared to d according to confocal microscopy and rt-pcr. the aforecited methods revealed elevated expression of a v b -integrin in the d culture of the ea.hy cell line activated with tnf. also increased expression of vegfr in the d culture activated with vegf a. then by confocal microscopy, we analyzed our fluorescent hybrid proteins that bind a v b -integrin and vegfr on the surface of d and d cultures as well as antibodies with fluorescent label. conclusions: d cultures of the ea.hy cell line represent a promising model for the inflammation studies. tumor necrosis factor (tnf) is a trimeric cytokine associated with the inflammatory response to tissue injury and found to possess a key role in rheumatoid arthritis pathogenesis. spd is a highly toxic recently discovered tnf inhibitor that promotes trimer dissociation and lead to the inactivation of the protein. according to the traditional anti-tnf treatment of ra, we aim at extracellular inhibition of this pro inflammatory cytokine as an effective therapy. the project plan comprises design, synthesis and validation of candidate inhibitors (measurement of dissociation constant and aqueous solubility). because of the elevated percentage of insoluble compounds a solubility enhancement protocol has been developed. the experimental procedure was the following:: a. drug design. identification of novel drug compounds are based on two approaches: i) structure based drug design using the d structure of tnf and ii) design of more potent and less toxic spd analogues. b. drug synthesis. a series of spd analogues were in house synthesized while novel candidates discovered by in silico approaches were commercially available. the purity of the majority of the compounds exceeded %. c. solubility measurement and enhancement. samples were incubated under specific conditions that can enhance aqueous solubility and solubility measurement with a direct uv method pursued. d. measurement of the dissociation constant. a fluorescence binding assay was used in order to evaluate the inhibitory activity of the compounds. from our results it can be concluded that dmso, peg and b-cyclodextrin can be used for solubility enhancement without interfering with fluorescence assay. however peg -in contrast to dmso-is not suitable for isothermic titration calorimetry measurements. dissolution procedure also plays a crucial role in the levels of solubility reached. finally, it has been shown that some of the studied spd derivatives have better dissociation constants than spd . the effect of exercises on serum bmp- levels of knee osteoarthritis cytokines. more complicated approaches are expected to focus on molecular proteins as bone morphogenetic proteins (bmps) of the transforming growth factor (tgf)-beta superfamily. bmps associated with many cellular functions, such as proliferation, differentiation, and apoptosis. bmp- is significantly important for the endochondral bone formation. inflamation can induced serum bmp levels in oa patients. the aim of this study is to evaluate the clinical findings of oa patients after the isokinetic exercise together with the serum levels of bmp- to sustain the molecular approaches for treatments. a total of patients were included in this study. the groups are formed as follows: group , oa patients before the exercise; group , oa patients after the exercise; group , oa patients before the isokinetic exercise; group , oa patients after the isokinetic exercise clinical and biochemical findings were evaluated before and after weeks of the exercise programme. self reported severity of pain was measured using the mm visual analog scale (vas), womac scores were calculated and isokinetic knee muscle strength testing was measured using cybex dynamometer that a standardized protocol previously described was applied in a subject-specific range of motion. serum bmp- levels of all patients were studied by elisa method. results represented a better vas and womac scores for all exercise groups after treatment. the serum bmp- levels were significantly decreased in group compared to group ( . ae . ; . ae . respectively, p < . ) and in group compared to group ( . ae . ; . ae . respectively, p < . ). there is not any statistically differences between group and group (p > . ). as a conclusion, the decreased serum levels of bmp- may be suggested as a biochemical marker for oa patients during exercise programmes. p- . . - tnf-a blokade efficiently reduced severe intestinal damage in necrotizing enterocolitis c. tayman, s. aydemir, i. yakut, u. serkant, a. c ß iftc ßi g€ olbasi devlet hospital, ankara, turkey objectives: to ascertain the beneficial effects of infliximab an inhibitor of tumor necrosis factor alpha (tnf-a) on the development of nec in an experimental nec rat model. material and methods: thirty newborn sprague-dawley rats were randomly divided into three groups as nec, nec+ infliximab, and control. nec was induced by enteral formula feeding, exposure to hypoxia-hyperoxia and cold stress. pups in the nec+ infliximab group were administered infliximab at a dose of mg/kg daily by intraperitoneal route from the first day until the end of the study. all pups were sacrificed on the th day. proximal colon and ileum were excised for histopathologic, immunohistochemical (tunel and caspase- ), and biochemical evaluation, including, total antioxidant status (tas), total oxidant status (tos), malonaldehyde (mda), and myeloperoxdase (mpo) and tnf-a activities. results: we observed better clinical sickness scores, weight gain, and survival rate in the nec+ infliximab group compared to the nec group (p < . ). histopathological and apoptosis examination (tunel and immunohistochemical evaluation for caspase- ) revealed lower damage in the nec+ infliximab group compared to the damage in the nec group (p < . ). tissue mda, mpo, tnf-a levels, and tos were significantly decreased in the nec+infliximab group, whereas tas was significantly increased in the nec + infliximab group (p < . ). conclusion: tnf-a blockade with infliximab efficiently reduced the intestinal injury and preserve the intestinal tissues from severe intestinal damage by its complex mechanisms on nec. therefore, it may be an alternative option for the treatment of nec.keywords: tnf-a; infliximab; necrotizing enterocolitis; newborn; protection; rat; treatment p- . . - short-term diabetes causes cardiovascular inflammation: anti-inflammatory effect of resveratrol introduction: diabetes is a metabolic dysfunction and has been associated with various disorders including inflammation, cardiomyopathy and coronary artery disease. inflammation is a protective mechanism elicited by the host in response to infection, injury, and tissue damage. the aim of this study was to investigate the effect of intraperitoneally resveratrol administration on cardiac and vascular function in diabetic rats. materials and methods: diabetes was induced in sprague-dawley rats by using injection of streptozotocin ( mg/kg, i.p.). rats were divided into group i: control, ii: control/ mg/kg resveratrol; iii: diabetic/vehicle; and iv: diabetic/ mg/kg resveratrol. histopathological examinations with masson's trichrome and verhoeff-van gieson staining were carried out to reveal cardiac and vascular tissue damage and inflammation. in addition to plasma glucose and cardiac & vascular mda levels were measured by standard enzymatic kits while tnf-a, il- b, il- (mbl) were analyzed by elisa kit. results: final body weight decreased in all groups compared to control. in the diabetic rats, plasma glucose and vascular mda levels were enhanced while cardiac mda was unchanged compared to control. vascular tnf-a, il- b and mbl and cardiac mbl were increased in the diabetic groups compared to control. discussion and conclusion: it has been found that resveratrol has greatly normalized altered parameters. taken together, resveratrol partly improved cardiac and vascular inflammation induced by diabetes. this may be due to the healing activity of resveratrol on pro-inflammatory markers. p- . . - cytokine network is critical in growth hormone-induced resistance mechanism against curcumin which modulates jak/stat/ socs pathway in mda-mb- and mcf- breast cancer cells m. c ß elik, a. c ß oker g€ urkan, e. damla arisan, p. obakan yerlikaya, n. palavan unsal t.c. istanbul k€ ult€ ur university, istanbul, turkey curcumin (diferuloylmethane), a polyphenolic compound that triggers apoptotic cell death in various cancer cells such as prostate, colon, melanoma and breast cancer. a pituitary-derived hormone, growth hormone (gh) play role in elongation and differentiation of ductal epithelia into the breast terminal and buds. in this study, our aim is to determine the role of inflammation in curcumin induced apoptotic cell death via acting on jak/stat/socs pathway in wt and gh+ mda-mb- and mcf- breast cancer cell lines. according to mtt cell viability assay curcumin triggers cell viability loss in time and dose dependent manner in mda-mb- wt and mda-mb- gh+ breast cancer cell lines, respectively. selected concentrations of curcumin as lm (for mcf- ) and lm (for mda-mb- ) decreased cell proliferation and induced apoptosis through causing jak dephoshorylation, stat , , dimerization and acting on socs proteins expression in each cell lines. in addition, activated jak/stat/socs pathway, via forced gh expression has been suppressed following curcumin treatment for hours. lm curcumin-induced apoptotic cell death via dephosphorylating jak at tyr / residues and decreased phospho-stat , level in both breast cancer cell lines. although curcumin dephosphorylated stat in both mda-mb- and mcf- wt cells, no significant effect has been observed in mda-mb- gh+ and mcf- gh+ cell lines. in consequence, although forced gh expression induced cell proliferation in mcf- and mda-mb- breast cancer cells, curcumin overcame gh-mediated resistance mechanism via acting on jak/ stat/socs signaling, which is related to pparg-induced inflammation. acknowledgment breast cancer is one of the highest cancer type among women worldwide. various enviromental and genetic factors such as age, gender, family history, metabolic diseases and gene mutations are involved in the breast cancer pathogenesis. growth hormone (gh), a pituitary derived hormone, has essential role on postnatal growth and development. it is also established that signalling route of gh and its receptor (ghr) activity is increased in different cancer types. curcumin, a nutraceutical deriatives from rhizomes of turmeric (curcuma longa), has potential therapeutic activity against cancer cells, including breast cancer. curcumin inhibits proliferation of cancer cells such as prostate, colon, melanoma, cervical and breast cancer via induction of apoptosis and inflammation. stat , a major downstream target of gh/ghr signalling, is related to survival, proliferation and differentiation. in this study, our aim was to investigate curcumin-induced apoptotic cell death in gh overexpressed mda-mb- breast cancer cells via jak-stat/socs signalling and inflammatory response profile. according to mtt cell viability assay, curcumin decreased cell viability in time and dose dependent manner in wt and gh+ mda-mb- breast cancer cell lines. we found that lm curcumin-decreased in apoptotic cell death through inactivity at jak which led to dimerization of stat , stat , stat . concomitantly, curcumin affected stat regulating socs proteins in mda-mb- breast cancer cell line. in addition, we demonstrated that lm curcumin induced pparg expression and altered inflammatory cytokine signalling cascade. consequently, although gh overexpression led to agressive profile in mda-mb- breast cancer cells, curcumin overcame this resistance. inflammation is involved in many systemic disturbances, including osteoarthicular or skin diseases, coordinating the signaling network that contributes to tissue injuries. the aim of our study is to reveal pro-inflammatory messengers at the cutaneous barrier (keratinocytes, fibroblasts, endothelial cells), simulating the dermal impact of active principles, especially polyphenols and flavones from vegetal sources: salvia officinalis, asculum hippocastanum and calendula officinalis. we focused on il and il cytokines as main mediators of inflammation progression, correlated in keratinocytes with il a as skin irritation indicator and vegf as pro-angiogenic factor, as well as in endothelial cells with icam- and vcam- adhesion molecules expression. in order to in vitro mimic the inflammatory conditions, we used targeted stimuli for each type of cells: for fibroblasts and endothelial cells -tnfa, a systemic stimulus, single or combined with pma that activates protein kinase c and up regulates nadph oxidase, which lead to superoxide anion production; for keratinocytescontrolled uv-a and uv-b radiation, simulating the solar damages or potential uv interactions with active principles in light exposed skin. the main analysis technique was flow cytometry: beads bases assay for soluble factors and fluorescent antibodies staining. our results prove the different involvement of polyphenols and flavones in the anti-inflammatory mechanisms, depending of the vegetal source: active principles from salvia officinalis induce a strong inhibition of il and il in tnfa stimulated keratinocytes, fibroblasts and endothelial cells, reduce the icam- over-expression but have no effects on irradiated keratinocytes; biocomplexes from asculum hippocastanum inhibit only il release in stimulated fibroblasts, but protect keratinocytes from uv-a and uv-b radiation; compounds from calendula officinalis are active on il signaling in fibroblasts and counteracts only uv-b inflammation. ischemia and/or reperfusion injury is one of the most common causes of acute renal failure. ischemia-reperfusion associated with thrombolytic therapy, organ transplantation, coronary angioplasty, aortic cross-clamping, or cardiopulmonary bypass results in local and systemic inflammation. within the endothelium, ischemia produces expression of proinflammatory gene products (e.g. cytokines) and bioactive agents (e.g., endothelin), while preventing other "protective" gene products (e.g., thrombomodulin) and bioactive agents (e.g. nitric oxide). therefore, ischemia induces a proinflammatory state that increases tissue vulnerability to further injury on reperfusion. this experimental study was designed to investigate the protective effect of salvia l. extracts on kidneys from i/r injury. salvia lamiaceae have been used for treatment of some illnesses in turkish folk medicine. forty spraque dawley rats were divided into groups (n = ). right nephrectomy was performed to all groups. group i: control group; group ii: i/r group; group iii: i/r + mg/kg salvia l.group; group iv: i/r + mg/kg salvia l. group; group v: i/r + mg/kg rosmarinic acid. group. salvia l. and rosmarinic acid for days was given single dose as a gavage. minutes ischemia, minutes reperfusion were applied to groups except control. intracardiac blood samples were taken, high sensitive crp (hscrp), tumor necrosis factor-a (tnf-a), interleukin (il)- and interleukin ib (il- b) levels were detected. serum hscrp levels were also determined in our clinical laboratory using routine standard methods. serum tnf-a, il- and il-ib levels were evaluated using an enzyme-linked immunosorbent assay technique. mean values were evaluated by statistical analysis. serum hscrp, tnf-a, il- , and il- b concentrations were significantly increased after renal i/r as compared to the control group. our treatment group mg/kg salvia l. and mg/kg rosmarinic acid especially mg/kg of salvia l. were found to show a protective effect against renal structure and function. we concluded that salvia l. extracts could be beneficial in the treatment of renal ischemic injury. but mg/kg salvia l. extract were more effective than mg/kg salvia l. extract and used as synthetic mg/kg rosmarinic acid. acne vulgaris is a common chronic inflammatory skin disease of unknown etiology. excess levels of secretory phospholipase a (spla ) contributes to inflammatory diseases and studies indicate that lipoprotein lipase (lpl) has differential effects on several inflammatory pathways. the aim of the present study was to assess serum activity of spla , lpl and evaluate changes in circulating protein levels of angiopoietin-like protein (angptl ), angptl , cyclooxygenase (cox) and prostaglandin e (pge ). serum from control subjects and acne vulgaris patients with moderate and severe disease was evaluated for levels of spla , cox, pge , lpl, angptl and angptl . disease activity was determined according to the national health service (nhs) lambeth and southwark clinical commissioning group guidelines for the management of acne. lipid profile, routine biochemical and hormone parameters were assayed by standard kit methods using autoanalyzers (beckman coulter au clinical chemistry and unicel dxi immunoassay systems). serum levels of spla and lpl were significantly increased in acne vulgaris patients compared to age and gender matched controls. no significant differences were found for cox, pge , angptl and angptl levels between acne vulgaris patients and controls. the results of this study reveal the presence of a proinflammatory state in acne vulgaris as shown by significantly increased serum spla activity. increased lpl activity in serum of acne vulgaris can be protective in patients through its anti-dyslipidemic actions. to our best knowledge, this is the first study investigating spla , lpl, angptl and angptl levels in acne vulgaris. future studies are aimed to understand the regulation of spla and lpl expression in acne vulgaris patients. acknowledgement: this study was supported by a grant from the scientific and technological research council of turkey (tubitak; # s ). p- . . - -ohdg and hogg levels are as an oxidative dna damage markers in acne vulgaris treated with isotretinoin h. ecevit, m. izmirli, b. gogebakan, e. rifaioglu, d. sonmez, b. bulbul sen, t. sen, h. m. okuyan mustafa kemal university, hatay, turkey acne vulgaris is a skin disease that characterized by comedones, papules, pustules, nodules and cysts at face, back and body skin. isotretinoin is one of the treatment agents in acne vulgaris. about weeks after drug treatment, the amount of sebum which is produced by sebaceous gland reduces keratinization disorder and the number of propionibacterium acnes normalizes. however, isotretinoin is known that has a wide range of side effects. in recent studies, isotretinoin treatment has been shown to increase the oxidative stress. -hydroxy- -deoxyguanosine ( -ohdg), an important indicator of oxidative dna damage, hydroxyl ion is bound at the th carbon of guanine. this structure is repaired through a base excision repair mechanism and the human -oxoguanine dna glycosylase (hogg ) plays a key role in this processes. in this study we aimed to evaluate the dna damage and it's repair in acne vulgaris before and after months of isotretinoin treatment by measuring -ohdg and hogg levels. the current study includes acne vulgaris patients who are diagnosed in mustafa kemal university, department of dermatology. -ohdg and hogg levels were measured by enzymelinked immunosorbent assay (elisa) method for before and after months of isotretinoin treatment. the commercial elisa kits (cloud-clone corp; usa and cell biolabs; usa) were used for the assessment of hogg and -ohdg, respectively.both -ohdg (p as a conclusion, isotretinoin increases dna damage and high serum -ohdg and hogg levels as a result of isotretinoin treatment may effect on the amount of reactive oxygen species. the pineal gland is a circumventricular organ which serves as a major neuroendocrine gland in the brain. its primary function is the production of melatonin which is controlled by signals from the suprachiasmatic nucleus. melatonin codes the length of the night and it is well recognized for its anti-inflammatory effects. lipopolysaccharide (lps) is the essential component in the outer surface membrane of gram-negative bacteria and act as a strong stimulator of natural and innate immunity in all eukaryotic species. furthermore, lps reduces melatonin synthesis and induces the expression of the serine protease inhibitor (spi- ) in the stat -mediated manner in pinealocytes. however, the precise function of stat in the cell signaling in the pineal gland is not yet known. here we investigated the effect of inhibition of stat on lps-induced changes in melatonin levels, expression of arylalkylamine n-acetyltransferase (aa-nat) and spi- in the pineal gland. experiments were performed in vitro using organotypic and primary cultures prepared from the rat pineal glands. levels of melatonin and spi- were determined from tissue homogenate by enzyme-linked immunosorbent assay (elisa). the pinealocytes were used to carry out sirna stat transfection. the successful transfection and subsequent decline in stat expression levels were proved by sodium dodecyl sulphate-polyacrylamide gel electrophoresis (sds-page). the changes in synthesis of aa-nat and spi- were studied by rt-pcr. in conclusion, lipopolysaccharide can affect the immunomodulators secreted by the pineal gland. the clarification of the effect of inhibition of stat on those immunomodulators is important from the clinical point of view because inhibitors of stat are nowadays used as tumour suppressors. silica nanoparticles have a great potential for a variety of industrial, diagnostic and therapeutic applications. in this study, we have evaluated the in vitro effects of amorphous silica nanoparticles ( nm) using human lung mrc- fibroblast as model. cells were exposed to . lg/ml silica nanoparticles for , and hours. the cytotoxic and inflammatory response, and matrix metalloproteinase expression were examined. the pro-inflammatory cytokine il- b, il- , il- , tumor necrosis factor (tnf-a), matrix metalloproteinases (mmp- , mmp- , mmp- ) and tissue inhibitor of metalloproteinase- (timp- ) were analyzed by western blot method. cytotoxicity was evaluated by lactate dehydrogenase (ldh) released into the culture medium by damaged cells. the level of ldh activity was increased after exposure to silica nanoparticles, in a time-dependent manner compared to control. the protein expression of il- , il- , il- and tnf-a as well as of mmp- and timp- , was up-regulated whereas those of mmp- , mmp- was down-regulated after and hours respectively. in conclusion, our data indicate that amorphous silica nanoparticles generate a cytotoxic and inflammatory response, as well as an imbalance in extracellular matrix due to the differential regulation of mmps and tissue inhibitor of metalloproteinase- in mrc-cells after and hours. p- . . - association of fto gene variant (rs ) with markers of t dm and obesity in population from bosnia and herzegovina and kosovo fto (fat mass and obesity-associated gene), recently discovered in a genome-wide association study for type diabetes (t d) encodes a -oxoglutarate-dependent nucleic acid demethylase and is mainly expressed in the hypothalamus. this gene may play important role in the management of energy homeostasis, nucleic acid demethylation, and regulation of body fat masse by lipolysis. the aim of this study was to analyze the association of this single nucleotide polymorphisms (snps) with clinical and biochemical parameters of obesity, t d, prediabetes and at the level of healthy population from bosnia and herzegovina (bh). the study included patients with t d and prediabetes and healthy controls both sexes, aged from up to years. patients were recruited at the clinical centre university of sarajevo, university hospital of clinical centre in banja luka, general hospital in te sanj and health centre in prizren. genotyping of analyzed polymorphism was performed by rt-pcr method in cooperation with the department of clinical chemistry, faculty of pharmacy, university of ljubljana (ljubljana, slovenia) and university hospital of charles university (hradec kralove, czech republic). our results did not show significant differences in genotype frequencies of the analyzed polymorphisms between patients with t d, pre-diabetes and healthy population also, results of logistic regression analyses did not show significant association of risk a allele of fto gene polymorphism -rs with increased risk of t d (or = . , % ci . - . , p = . ). a allele was significantly associated with higher values of hba c, insulin, homa ir index, diastolic blood pressure and higher levels of inflammatory markers (fibrinogen and leukocytes). interestingly, a tendency of association of a allele with higher values of obesity markers (bmi, waist and hip circumference) was noted. further studies are needed on a larger population in order to confirm these results. the water extract of capparis ovata (cowe) has been shown to be used as an alternative medicine for the treatment of multiple sclerosis (ms). cowe was further fractionated and studied for additional anti-neuroinflammatory effects in sh-sy y cells. for this purpose, the dichloromethane sub-fraction of the cowe extract was tested for its anti-inflammatory effects on selected anti-inflammatory genes believed to be important in ms pathophysiology using sh-sy y cells. cell viability was assessed using lactate dehydrogenase (ldh) activity in the media conditioned by the crystal violet cell staining. in these cells, levels of the tumor necrosis factor-a (tnfa), nuclear factor kappa-lightchain-enhancer of activated b cells (nf-jb ), glial fibrillary acidic protein (gfap), c-x-c motif chemokine and (cxcl , cxcl ), matrix metalloproteinase (mmp ), chemokine (c-c) motif (ccl ) and tyrosine-protein phosphatase non-receptor type (ptpn ) were determined by quantitative reverse transcriptase-pcr assay (qrt-pcr). we have found out that the dichloromethane sub-fraction of cowe effectively inhibited the expression of all of the genes given above in sh-sy y cells. thus, phytochemicals present in the dichloromethane sub-fraction of the cowe extract could be beneficial in preventing/treating neurodegenerative diseases in which neuroinflammation is part of the pathophysiology. studies are underway to identify the individual compound(s) in this subextract of the cowe extract contributing to these effects. this work is supported by tubitak s and pamukkale university paubap fbe . p- . . - apigenin and luteoline were identified as active anti-inflammatory constitutents of lavandula stoeachas by bioassay guided fractionation h. ipek , s. savranoglu , a. r. t€ ufekc ßi , f. g€ ul , i. demirtas , t. boyunegmez t€ umer graduate program of bioengineering, institute of natural and applied sciences, c ß anakkale onsekiz mart university, c ß anakkale, graduate program of biology, institute of natural and applied sciences, c ß anakkale onsekiz mart university, c ß anakkale, department of chemistry, faculty of sciences, c ß ankiri karatekin university, c ß ankiri, department of molecular biology and genetics, faculty of arts and sciences, c ß anakkale onsekiz mart university, c ß anakkale, turkey introduction: lavandula stoechas, in the genus of lavender, has distinct therapeutic uses among anatolian people. rather than worldwide use of its essential oil in aromatherapy, specifically the aqeous portion as decoction has been traditionally used in anatolia against the components of metabolic syndrome, all of which share a state of chronic inflammation as an underlying cause. the anti-inflammatory constiutents of l. stoechas were isolated using a bioassay guided fractionation in lipopolysaccharide (lps) inflammed raw . macrophages. materials and methods: an aqeous extract was partitioned into ethyl acetate (eae) and n-butanol fractions. the eae, determined as bioactive extract was seperated into subfractions by column chromatography. e was identified as active subfraction subjected to sephadex column to get pure compounds which were then applied to nmr, ir, and uv analyses for structure determination. in raw . cells, the effects of extracts/fractions/subfractions/compounds on lps induced no production was determined by using griess method. the potential inhibitory effects of each compound on lps induced inos expression were determined by qpcr and western blot. results: p-coumaric acid, apigenin and luteoline were found in the e , and the first two compounds appeared to be primarily responsible for the anti-inflammatory activity. apigenin and luteoline at lm decreased no production and %-ic : and lm-by inhibiting inos gene expression and % as well as protein expression and %, respectively (p < . ). conclusion: this is the first time that luteoline and apigenin have been found in eae of l. stoechas, and the anti-inflammatory properties of the eae can be attributed, at least in part, to the presence of these two compounds. we are on the way to gain further insight for the action mechanism of these two active principles as anti-inflammatory agent. tubitak (project id: t ) support this work. the role of tip in the inflammation process immun response generates the first line of host defense during inflammation and plays an important role inducing pro-inflammatory response by generating early response against pathogens. il- (interleukin ) is one of the pro-inflamatory cytokines and its expression increases during the infection to activate the jak/ stat pathway. jak/stat pathway is regulated by hamp (hepcidin antimicrobial peptide). our previous study, we reported that hamp gene expression was decreased in liver-specific tip conditional knockout mice, so we thought that tip may have a direct or indirect role on inflammation mechanism. tip (tat interacting protein, kda) is a member of the myst enzyme family of histone acetyltransferases (hats) and plays an important role in multiple function including cellular signaling, dna repair, cell cycle and apoptosis. in this study, the quantitative gene and protein expression of il- were investigated by using taqman real time pcr, western blot and immunohistochemistry analysis in control group, lpsinduced inflammation group and liver-specific tip conditional knockout group mouse liver. according to our preliminary results, the gene and protein expression of il- was increased in lps-induced inflammation group (p < . , p < . ) and liver-specific tip conditional knockout group mouse liver (p < . , p < . ). our initial data suggest that tip may be essential for the inflammation process. this work was funded by grants from the scientific and technological research council of turkey (tubi-tak) (grant number: z ). although intracellular reactive oxygen species (ros) level is necessary to maintain cellular homeostasis, elevated intracellular ros level with the impact of unfavorable environmental conditions leads to oxidative stress that may cause damage to dna, proteins and lipids. in case of inflammation, organism seeks to provide cellular homeostatis by increasing ros levels via antioxidant molecules and enzymes. therefore, it was thought that there can be a direct or indirect relation between inflammation and oxidative stress. in this study, inflammation was performed by intraperitoneal injection of lipopolysaccharide (lps). the gene expression and activity of antioxidant enzyme including superoxide dismutase (sod), catalase (cat), glutathione peroxidase (gpx), glutathione s-transferase (gst), glutathione reductase (gr) and glucose -phosphate dehydrogenase (g pd). additionally, any change of reduced glutathione (gsh), oxidized glutathione (gssg), malondialdehid (mda), and hydrogen peroxide (h o ) level are accepted as an indication for the accumulation of ros, the relative levels of them were also studied. to show our inflammation model was performed in mouse kidney with lps treatment or not, the expression of interleukin (il ), which is accepted as a inflammation marker, was investigated by real time pcr. the expression of il was significantly increased in lps treated group. while the level of mda and h o was elevated in lps treated group, gssg was decreased. no changes was seen for gsh level. the correlation was observed between enzymatic and molecular levels. while the gen expression and the enzyme activity of sod, cat, gst, gr, and g pd were decreased, gpx was increased with inflammation. in conclusion, increasing ros level was observed in the inflammation process and, the antioxidant system was affected at the molecular and protein level. this work was funded by grants from the scientific and technological research council of turkey (tubitak) (grant number: z ). the aim of our study is to evaluate effect of vitamin d levels on hemogram parameters including neutrophil %, lymphocyte %, neutrophil % / lymphocyte % ratio (nlr) and mean platelet volume (mpv) in behcet's patients. fifty eight patients with diagnosis of behcet that applied to selcuk university faculty of medicine department of dermatology are recruited to the study. clinical and laboratory characteristics of the patients were obtained from hospital automation. t test was used to examine the differences between the parameters. p < . was taken to be statistically significant. there was a statistically significant difference between vitamin d values and age (p = . ) whereas difference was not significant between vitamin d and neutrophil %, lymphocyte %, nlr, mpv values. according to the literature, there are a lot of studies that show the relationship between vitamin d and hemogram parameters. however, contrary to the previous studies, we were unable to find any significant relationship between vitamin d and these hemogram parameters. these results serve the idea that the effects of vitamin d on the hematopoietic system should be further investigated experimentally and clinically. crimean-congo hemorrhagic fever is a tick-borne disease caused by the arbovirus and characterized by a sudden onset of high fever, severe headache, dizziness, back and abdominal pains. the exact pathogenesis of cchf has not been clarified yet. the aim of this study, clinical cases of cchf in cu, se and zn is to examine the relationship between the concentration of trace elements. the study sample consisted of patients which have been diagnosed with cchf. matched for gender, healthy volunteers were similar to the control group according to age. the patients and control groups, serum cu, zn and se levels were analyzed using atomic absorption spectrophotometer. cchf patients in the group, cu zn and se serum levels were significantly lower compared with the control group. in our study, the cofactor of the antioxidant enzyme cu, zn and se elements were lower. this shows us in cchf disease, a decrease in antioxidant enzyme activity, and suggest that they contribute to the immune system's degradation. p- . . - inhibitors of mdm ubiquitin ligase as prospective modulators of autoimmunity e. bulatov, a. valiullina, r. sayarova, a. rizvanov kazan federal university, kazan, russia ubiquitin-proteasome system is seen as a pool of promising protein targets for therapeutic impact in many human diseases. mdm is an e ubiquitin ligase widely studied due to its wellknown role in cancerit negatively regulates p oncosuppressor that mediates apoptosis in tumour cells. inhibitors of p / mdm interaction have long been known as potential anticancer therapeutics. however, recent advances in the field suggest that both mdm and p might be playing a substantial role in autoimmune processes. we used a small molecule p /mdm inhibitor nutlin- a to test the effect of p activation on peripheral blood mononuclear cells (pbmcs) from both healthy volunteers and patients diagnosed with multiple sclerosis. in our study we employed a variety of molecular biology methods, such as immunoblotting, real-time pcr, mts cell proliferation assay, fluorescence flow cytometry and confocal microscopy. we demonstrated that disruption of p /mdm interaction by nutlin- a alters the p levels and also affects the lymphocyte subpopulations within pbmcs. our findings suggest that p /mdm interaction inhibitors can potentially be used as prospective modulators of immune response in autoimmune diseases such as multiple sclerosis, systemic lupus erythematosus and other. the study was funded by rfbr research grant - - mol_a_dk. can ykl- be an inflammatory biomarker in vitamin d deficiency? object: the tumor necrosis factor (tnf) was found to be cytotoxic to tumor cells and to induce tumor regression in mice. except for one member, all receptors to the tnf superfamily bind tnf-related ligands and act mostly on inflammatory system. there are currently tnf superfamily ligands. tnf superfamily ligands share several common features. tnf ligands are generally type ii transmembrane proteins whose extracellular domains are be divided by enzyme to create cytokines. the tnf superfamily currently consists of receptors. tnf family receptors are type i or type iii transmembrane proteins that contain multiple extracellular domains. in this study, we investigated to presence, differences and effects of tnf superfamily and receptors genes in human and mice by using bioinformatics techniques. methods: the nucleotide and amino acid sequence of each protein in human and mice was determined using t-blast-n for homologous sequences. homologous sequences of human tnf family genes found an automated procedure by using psi-blast. the secondary structure of and three-dimensional of the protein were analyzed by psipred and ffas server. netcglyc . and netphos . program were used for post-translocation modifications. the web apoptosis database was also used for the lists of domains, proteins containing these domains and their associated homologs. results and conclusion: humans tnf ligands have genes encoding proteins that contain a conserved carboxy-terminal domain. this family of proteins is highly conserved between humans and mice. humans contain genes encoding tnffamily receptors. sequence data from the ncbi databases demonstrated the presence of mouse tnf-family receptors with orthologs in humans and one additional receptor found only in mice. the differences and similarities in the tnfs genes in humans and mice will provide information for understanding the utility and limitations of the mouse models of disease and comparing of immunology outcomes. the development of left ventricular remodeling after acute myocardial infarction is a predictor of shock. the genetic influence on cardiac remodeling, and shock in the early period after acute myocardial infarction are unclear. the aim of the present study was to investigate the relationship between angiotensin converting enzyme (ace) gene polymorphism and modified shock index (msi) in the early period in patients with acute anterior myocardial infarction. overall patients with a first acute ami were included in this study. dna was isolated from peripheral leukocytes. the id status was determined by pcr. based on the polymorphisms of the ace gene, they were classified into groups: deletion/deletion (dd) genotype (group , n = ), insertion/deletion (id), insertion/insertion (ii) genotypes (group , n = ). blood pressure and pulse measurements were performed in all patients within minutes admitted to coronary care unit. msi was defined as heart rate (hr) divided by mean arterial pressure (map). echocardiographic examinations were performed in accordance with the recommendations of the american echocardiography committee. one-way analysis of variance (anova) and chi-square analyses were used to compare differences among subjects with different genotypes. the study was approved by the local ethics committee, and each patient gave a written consent. there were no significant differences among clinical parameters of patients. msi was significantly higher in patients who have ace dd genotype than in patients who have ace id / ii genotypes ( . ae . and, . ae . , p < . ). presentation time hypotension or developing hypotension during admission was reported to be an important predictor of intensive care unit admission besides other vital sign measurements. our results suggested that, ace gene i/d polymorphisms d allele may affect modified shock index in patients with a first acute anterior mi. glucocorticoids (gcs) are widely used in medicine, despite their side effects, e.g. osteoporosis. however, precise molecular mechanisms of gc action, especially on bone marrow (bm) cells, remain controversial. given the osteoprotective role of vitamin d , the aim of our study was to examine prednisolone-induced changes in the rank (receptor activator of nuclear factor kappa-b)/rankl (rank ligand)/opg (osteoprotegerin) pathway of rat bm depending on the state of vitamin d endocrine system. female wistar rats received prednisolone ( mg/kg b.w.) with and without iu of d (for days). the levels of rank, rankl, opg, a-hydroxylase (cyp b ) in bm were determined by western blotting. vitamin d receptor (vdr) and rankl mrnas were measured by quantitative rt-pcr. ohd content in the serum was assayed by elisa. rankand vdr-positive bm cells were quantified using flow cytometry and visualized by confocal microscopy. prednisolone induced a marked increase in rankl and rank levels, while opg level was shown to decrease. this reflects disturbances in cytokine-mediated regulation of bm progenitor cell function. data from flow cytometry indicated a significant growth in the number of rank-positive cells (hematopoietic osteoclast precursors) compared to control. these changes were accompanied by a decrease in the levels of vdr and cyp b , which is responsible for , (oh) d synthesis, in bm and ohd content in serum. co-localization of vdr and rank in mono-and multinuclear bm cells was observed, indicating a close relation between vitamin d and rank/ rankl/opg pathway. vitamin d co-administration prevented prednisolone-induced changes in bm cells through restoration of vitamin d bioavailability and vdr signaling that resulted in a reduction of the osteoclast progenitor pool in bm. thus, prednisolone-induced imbalance in rank/rankl/ opg system components is associated with impairments of vitamin d endocrine system in bm and can be ameliorated by vitamin d treatment. p- . . - heat shock pathway in response to different stress factors the heat shock response is an emergency pathway of the cell, which mediates repair and protection from cellular stress and therefore guarantees the survival of the cell. this stress can range from heat or hypoxia to chemicals and heavy metals. it is highly conserved in all eukaryotic cells and plays an important role during atypical conditions. due to its high complexity, the pathway is not yet completely understood. most important, after activation of the pathway, is the refolding of proteins or, in case of severe misfolding, the depletion of proteins to maintain proteostasis. heat shock factor encoded by the hsf gene is known as the main switch point in heat shock regulation. after activation it trimerizes and binds to heat shock elements in target gene promoters. one of these promoters is the hspa a promoter (hsp promoter). the promoter was analyzed by dismantling it to its functional parts. especially three elements, the heat shock elements, were in the focus of this work. in first place parts of the promoter were multimerized and combined with different reporters, like luciferase, by cloning. also mutations in the natural promoter were designed by cloning. the focus now is on the heat shock elements, where hsf can bind as a trimer. the idea is that these different elements have various effects on different stressors like heat, chemicals (geldanamycine as hsp inhibitor, mg as proteasome inhibitor) or heavy metals (cadmium, arsenic, zinc) . this was tested on cells transiently transfected with those promoter variants. for promising variants stable cell lines were created. in these stable cell lines further experiments on mrna level can be conducted. in the last months experiments with the crispr/cas system were started. furthermore, experiments on transcriptional (qpcr) and translational (dual-luciferase assay) levels were done as well. in the end we hope to get a clear picture on the regulation of the hspa a promoter by different stress factors. invasive cancer cells form membrane protrusions, invadopodia, that facilitate cell invasion and metastasis. key players invadopodia include the adaptor proteins tks and tks , the actin regulators cortactin, wip and n-wasp, the kinase src and others. in spite that in the last two decades significant advances in our knowledge of the structure and development of invadopodia have been made, detailed mechanisms they are functioning is not yet available. we have identified a series of new tks binding partners including adaptor proteins itsn , itsn , crk and grb , kinase src, amph , bin , plcg and also another member of the tks family -tks . it may indicate the possible role of tks in transport and sorting of cell vesicles. current data are supported by interaction with the proteins of amph and bin , as their main functions are membrane trafficking and remodeling. adaptor proteins crk, grb and itsns are important for the actin cytoskeleton rearrangements, endocytosis and signal transduction. moreover, we have identified and characterized new tks isoform -tks -beta. we suggested that an active state of tks is regulated via intramolecular interactions between its proline-rich motifs and own sh -domains. we have shown the interaction between itsns and other prominent component of invadopodia wip. data from immunofluorescent analysis revealed co-localization of itsn and wip at the sites of invadopodia formation and in clathrin-coated pits. we have also demonstrated that the key protein itsn and wip and n-wasp can form a complex in cells. together, these findings provide insights into the molecular mechanisms of invadopodia formation and identify itsns as scaffold proteins involved in this process. we have shown the interaction between itsns and other verprolin family members cr and wire which play an important role in the reorganization of the actin cytoskeleton. we have demonstrated that cr and wire interact with sh domains of itsns in complex with actin. p- . . - correlation between proteomic and phenazine profile of pseudomonas sp. phenazines are widely known compounds with huge variativity of biological activities which are produced by pseudomonas sp. and some other bacteria species. the results of our work shows the correlation between the changes of proteomic profile of pseudomonas aeruginosa caused by a mutagenesis and the secondary metabolism of antibiotics (phenazine) profile. different strains of pseudomonas aeruginosa were obtained using mutagenesis, after that bacterial cells were destroyed by ultrasound. protein-containing fractions were isolated using methanol-chloroform method as well as phenazines compounds were extracted from culture media using liquid phase extraction. obtained proteome was analysed by shotgun-proteomics technique. as the result of the liquid phase extraction phenazine compounds were mainly extracted to the organic phase. this phase was evaporated and re-dissolved in % methanol. after sample preparation obtained solutions were analyzed by hplc-agilent with quadrupole tof mass-detector. results of the analysis were compared with the library of known phenazine compounds mass-spectras generated by cfm-id online resource. obtained phenazine profiles were compared with each other and correlation with the changes in proteome was analyzed. received results promote better understanding of mechanisms of phenazine production. this data opens possibilities for targeted changes in the methabolic pathway in order to obtain phenazine compound with required biological activity. insulators are genomic elements which block enhancer-promoter interaction and prevent spreading of heterochromatin. cp protein is an integral component of most known drosophila insulators, it interacts directly with ctcf and pita dna-binding insulator proteins using dimeric btb-domain, but function of cp within insulators still remains to be elucidated. recently we described an interaction between cp btb-domain and cterminal domain of ctcf insulator dna-binding protein, subsequent deletion analysis allowed us to isolate aa fragment within ctcf c-terminal domain sufficient for interaction with cp btb, but deletions of flanking regions also lead to the loss of interaction with cp in vivo. at the same time crosslinking experiments suggest that a dimer of btb interacts with one molecule of ctcf, presuming that it could recognize two peptide fragments within ctcf c-terminal domain. we solved crystal structure of btb-domain from cp insulator protein at . a resolution. overall structure is similar to other btb-domains. cp btb-domain has peptide-binding groove similar to that previously found in bcl btb domain. inspection of btb-domain surface revealed several possible binding sites for polypeptide fragments from ctcf protein. based on these observations a set of point mutations within peptide-binding groove of btb-domain has been designed and we tested ctcf-interaction abilities of these mutants using gst pull-down assay and yeast two-hybrid assay. the most significant impact was found with alanine-substitutions of hydrophobic residues whereas substitutions of hydrophilic amino acids were less effective. therefore our results support that cp btb-domain recognizes ctcf protein using peptide-binding groove. this study was supported by the russian science foundation (project № - - ). p- . . - comparative study of the fatty acid composition of lipids in the raw meat samples obtained from hybrid sheep one of the most important tasks in the animal biology and husbandry is to clarify the role of animal genetic diversity in providing nutrients to the diversity of animal products. the objective of our work was to study the chemical compositions of raw meat samples obtained from domestic (group i -purebred romanov sheep) and hybrid sheep (group ii -f hybrids of romanov sheep with . % of argali blood). the significant changes in fatty acid composition of the lipid fraction from the fat and muscle tissue of the hybrid sheep as compared to the control were found. the content of saturated fatty acids (sfas) in the fat samples of the hybrid animals was by . % lower ( . ae . %, p < . ), but polyunsaturated (pufas) or monounsaturated fatty acids (mufas) contents were by . % and . % higher ( . ae . and . ae . (p < . ), respectively) as compared to purebred romanov sheep. the most pronounced changes were found for palmitic acid (decreased from . % to . %) and for oleic, linoleic, arachidonic acids (increased from . %, . %, . % to . %, . %, . %, respectively). the last two acids together with the linolenic acids belong to the so-called essential acids and very important for the animal metabolism. a similar trend was observed on the composition of the lipid fraction of muscle tissue. sfas, pufas and mufas content in muscle tissue of hybrid sheep was . ae . , . ae . and . ae . %, that was . % lower (p < . ), and . % and . % higher (p < . ) compared to purebred romanov sheep. these results emphasized the difference of the pufas/sfas ratios in fat and muscle tissues, respectively) and characterized the biological value of the lipid fraction of fat and muscle tissue. the obtained data gave evidence of the positive changes in the fatty acid compositions of the lipid fractions for the hybrid animals as compared to the purebred sheep. supported by the russian scientific foundation, no. - - . foodborne illnesses resulting from the consumption of agricultural commodities contaminated with enteric pathogens are an increasing problem around the world. while various possibilities of produce contamination with pathogens exist, the global warming combined with a widespread use of animal manure in agriculture will likely contribute to an increased number of such outbreaks. thus, phages isolated from different agroecosystems may prove to be useful in detection/biocontrol of enterobacteria in produce. during the investigation of the impact of global warming on the diversity and co-evolutionary dynamics between microorganisms and viruses in lithuanian agroecosystems, a novel enterobacteria phage vb_ecos_nbd (nbd ) was isolated from agricultural soil using e. coli novablue for phage propagation. nbd genomic dna was isolated from cscl-purified phage particles, and was subjected to illumina dna sequencing. nbd is a virulent siphovirus that has a low-temperature plating profile (fails to form plaques at a temperature > °c). the genome of nbd is $ kb long, and has a total of probable protein-encoding genes as well as gene for trna ser . the genome analysis revealed that nbd orfs encode unique proteins that have no reliable identity to database entries. among the orfs that encode proteins with matches to those in other sequenced genomes, are similar to proteins from phages that infect different members of enterobacteriaceae, while nbd orfs are most similar to those from bacteria. based on the similarity to biologically defined proteins, nbd orfs were given a putative functional annotation, including genes coding for morphogenesis-related proteins, as well as associated with dna replication, recombination, and repair. phylogenetic analysis revealed that enterobacteria phage nbd is distantly related to phages belonging to the subfamily tunavirinae. this research was funded by a grant (no. sit- / ) from the research council of lithuania. p- . . - the antibiotic novobiocin affects the composition of the escherichia coli proteome n. e. arenas , j. williamson , v. schw€ ammle , s. douthwaite universidad de cundinamarca, cundinamarca, colombia, university of southern denmark, odense, denmark novobiocin (nov) is an aminocoumarin which competitively inhibits the atp binding site in the gyrase-b subunit of prokaryotic topoisomerase ii. nov remains a therapeutic choice for treating infections with bacterial pathogens that are resistant to more commonly used drugs. the aim of this study is assess the proteomic response of e. coli strain upon nov treatment. minimum inhibitory concentrations of nov were measured by standard assays. three different e. coli strains (as , as -rlma::aph and b) were grown aerobically in nutrient rich lb media at °c during one hour. the whole cell proteome (five biological replicates in each sample,) was assessed by lc-ms by using tmt labelling protocol. raw files were imported to proteome discoverer (thermo fisher scientific) and searched together with mascot against the uniprot e. coli reference proteome. mics for nov were determined to be > -fold higher the wild-type b-strain of e. coli than for the hypersusceptible as strains ( lg/ml). whole genome comparison of the b and as strains were characterized by an increase in proteasome components ( proteins), chaperones ( ), error-prone dna polymerase components ( ), ribosomal hibernation factors ( ), heat shock response ( ), electron transport coupled proton transport ( ), pentose phosphate pathway ( ), flagellar assembly ( ), oxidative phosphorylation ( ) and tca cycle ( ). whereas ribosomal proteins ( ), aminoacyl-trna synthetases ( ), rnases ( ), abc transporters ( ), mismatch repair ( ) and sec secretion pathway ( ) were significantly down-regulated upon nov treatment. the three e. coli strains respond similarly upon nov treatment and their proteomes showed upregulation of heat shock response with changes in the components of translation and transcription, the proteasome and atp biosynthesis. the changes observed can be used to define the processes that are required for antibiotic tolerance and survival of e. coli against aminocoumarin antibiotics. postnatal growth is under control of pituitary derived hormone, growth hormone (gh) that triggers bone, fat tissue growth and development via acting on protein, carbohydrate and fat metabolism. gh functions on postnatal development by jak /stat signaling following gh:gh receptor (ghr) dimerization. isolated growth hormone deficiency (ighd) is a medical condition of insufficient production of growth hormone (gh) that is caused by mutations on gh-n gene in different ethnic origin children. various mutations within gh has been determined in different populations so far, and glutamic acid to glycine (e g), asparagine to aspartic acid (n d), threonine to alanin (t- a) missense mutations, alanine to serine (a s) substitution, tryptophan to stop codon (w- x), gaaa insertion in intron of gh-n gene and both intron (+ c) and deletion of . amino acid of gh protein phenylalanine (f del) mutations were detected in turkish ighd children. the potential role of these mutations on cell growth, proliferation, emt via acting on gh signaling pathway has not been observed yet. all these mutations were performed on wild type gh-n gene inserted pc . vector by site-direct mutagenesis and stable cell line of each gh gene mutations were generated by neomycin selection. although w- x, e g, f del, a s and n d mutations suppresses gh signaling via acting on either jak dephosphorylation or stat downregulation, t- a, gaaa insertion and deletion of + c mutations have no significant effect on gh signaling. in addition, each mutation lead different growth suppression effect and colony formation potential and intracellular polyamine levels and odc expression profiles were essential role in emt potential of hek cell lines. as a result, w- x, e g, f del, a s and n d mutations prevented gh signaling and cell growth and differentiation via polyamine metabolism. pulmonary embolism (pe) is a common cardiovascular emergency and affects a large number of patients. acute pe-induced oxidative stress can lead to the accumulation of specific nitroproteins that may play a role in disease progression. the impact of nitration of a single tyrosine residue often has broad implications on the activity of biologically critical proteins, which has become increasingly related to pathological conditions. in this study, we used a proteomic approach to analyze nitrated serum proteins in patients diagnosed with acute pe and healthy controls. nitrotyrosine (no tyr)-containing proteins were immunoprecipitated from serum with a no tyr affinity sorbent. precipitated proteins were separated by sds-page and visualized by coomassie blue staining and western blotting with mouse monoclonal anti-no tyr antibody. among the numerous immunoreactive bands observed in disease patients, the kda protein band was in-gel digested and analyzed by maldi-tof mass spectrometry (ms). mass fingerprint data sets obtained from the peptide fragment ions matched human collagen alpha- (iii) chain (co a _hu-man) with mascot algorithm analysis giving a score of (p < . ). collagen alpha- (iii) chain is a fibrillar collagen that is found in extensible connective tissues such as skin, lung, and the vascular system. altered metabolism of collagen and its excessive deposition in the matrix of the connective tissue is a hallmark of chronic interstitial lung diseases. collagen can be measured in serum and bronchoalveolar lavage fluid from patients with numerous chronic interstitial lung diseases. given these considerations, future studies are aimed understand the relevance of no tyr modifications in co a relating to changes in protein structure and function. recent studies have shown that the genes involved in dislipidemia represent potential loci to be associated with diabetes as a disease. recent genome wide association (gwa) studies have associated rs in gckr gene and rs in galnt gene with parameters of t d and diabetic dyslipidemia. in this study, the association of these single nucleotide polymorphisms (snps) with t d and dyslipidemia was tested in the population from bosnia and herzegovina (bh). our study involved patients with t d and healthy subjects. biochemical and anthropometric parameters were measured in all participants. after dna extraction, sequenom iplex platform was used for the analysis of galnt polymorphism (rs ), while polymorphism in gckr (rs ) gene was analyzed by using real time pcr. our results demonstrated significant association of gckr rs variant with waist circumference (p = . ) and fasting glucose levels (p = . ) in the control group. no such association was demonstrated for rs galnt gene. in the group of diabetic patients, significant association of gckr rs variant with levels of bilirubin (p = . ) and rs galnt variant with hba c (p = . ) and triglyceride levels (p = . ) was also demonstrated. our results suggest an association of variations of gckr and galnt genes with specific markers of t d and dyslipidemia. further studies would be needed in order to confirm these genetic effects in other ethnic groups as well. osteoporosis is the most common metabolic bone disorder affecting the normal bone turnover with low bone mineral density (bmd) and risk of fragility fractures. polymorphisms at the sp binding site of the collagen type a (col a ) gene is associated with low bmd. we examined the distribution of col a gene polymorphism in young osteoporotic women and in control group in turkish population. patients had low bmd with t score ≤ . sd and controls was healthy women ( - years). mean age ( . ae . ) and ( . ae . ) respectively. the bmd, as g/cm , was measured in the hip and the lumbar spine (l -l ) with (dexa). dna was isolated from blood. col a gene was analysed with genomica clinical array system. the x test was used to compare allele and genotype frequences between patients and controls. mean of t score in patients was À . ae . . mean bmd (as g/cm ) was . ae . , and ( . ae . ) genotype distribution were ( %) ss, (% )ss, (% )ss for patients, and ( )ss, ( )ss, ( )ss for control . patients had (% )s allele, ( %) s allele, controls had ( %)s allele, ( %)s allele. when genotypes and bmd were compared in patients, there was no significant correlation between osteoporosis and genotypes. the allelic distribution was not significant between patients and controls p > . . genotypic distribution in patients were significantly different. patients had a higher frequency of the ss(% ) than controls (ss % ) p < . . this study shows that high prevalences of the ss genotype at the col a locus, in osteoporosis . _ it is possible that the presence of the s allele causes variation col a and col a mrna's producing abnormal collagene protein. since collagen protein is major protein of bone, it is to be expected that a defect in this protein will produce bone fragility. col a gene should be detected early to initiate preventative therapy for bone health. the biological activity of nigella sativa seeds is mainly attributed to its essential oil component which is pre-dominantly ( - %) thymoquinone (tq). therapeutic effect of tq was exhibited in many diseases including inflammation, cancer, sepsis, atherosclerosis and diabetes. tq has been reported to exhibit antiproliferative effects on cell lines derived from breast, colon, ovary, larynx, lung, myeloblastic leukemia, and osteosarcoma and inhibited hormone refractory prostate cancer. tq induces apoptosis in tumor cells by suppressing nf-jb, akt activation, and extracellular signal-regulated kinase signaling pathways and also inhibits tumor angiogenesis. the aim of this study was to evaluate the anti tumor effects of tq on hepatoma cells. these antitumor assays include cell viability assay, clonogenic assay, scratch assay and molecular expression studies of death related genes. cells were treated with different concentration of tq in hep b for cell proliferation by mtt and clonogenic assay. in addition, the metastatic character of tq was investigated by scratch assay in hep b at - and hours. the effect of tq was also evaluated at mrna level by real-time-pcr. tq was treated on the hep b cells in three different concentration, namely - and . lm. tq showed the cell cytotoxicity in concentration and time dependent manner. the scratch assay revealed no healing in the scratched area due to the decreased cell viability. maximum permissible dose was lm. proapoptotic genes, bax and bad, and autophagy genes, beclin- and lc , were upregulated in hep b cells after hours treatment in contrast, antiapoptotic gene, bcl- , expression level was decreased for hep b cells after hours. p- . . - association of irs genetic variation with type diabetes and insulin resistance in patients from bosnia and herzegovina insulin receptor substrate- (irs ) encodes the irs protein, a substrate for the insulin receptor tyrosine kinase and has a critical role in insulin-stimulated signaling pathways. previous studies showed that irs single nucleotide polymorphisms (snps) were associated with type diabetes mellitus (t d). this is the first study performed in a population from bosnia and herzegovina (bh) in which we examined the association of rs (g>a), rs (t>c) and rs (a>t) with t d risk and related traits. our study involved t d patients and healthy subjects. biochemical parameters, including but not limited to insulin, homa-ir, hba c, glucose, and lipoprotein levels, were measured in all participants. genotyping analysis was performed by mass array sequenom iplex platform in cooperation with lund university diabetes centre, malmo, sweden. statistical analysis was done by spss . our results demonstrated a significant difference in frequency of rs (p < . ) and rs (p = . ) snps between t d patients and control subjects. interestingly, here we showed a significant association of irs rs risk t allele with increased insulin levels (p < . ) and homa-ir (p < . ) in t d patients. similarly, rs variant was also associated with the same markers of insulin resistance in diabetic patients, i.e. insulin levels (p = . ) and homa-ir (p = . ). no such association was demonstrated for rs . however, this irs variant was associated with changes in lipoprotein levels, where risk c allele increased vldl (p = . ) and decreased hdl levels. our results suggest that irs variants are associated with t d susceptibility in bh population, thus confirming similar findings in other population cohorts. furthermore, the associations of these variants with markers of insulin resistance and dyslipidemic metabolic changes point to their role as potential t d biomarkers. the adra a gene encodes alpha- a adrenergic receptor which mediates adrenergic suppression of insulin. a genetic variant in adra a was recently associated with defective b-cell function. the objective of this study was to analyze association of two adra a polymorphisms (rs a>g and rs g>t) with type diabetes (t d) and its related traits. in this study we have included t d patients and healthy subjects from bosnia and herzegovina (bh). biochemical parameters, including but not limited to insulin, homa-ir, hba c, glucose, and lipoprotein levels, were measured in all participants. genotyping analysis was performed by mass array sequenom iplex platform in cooperation with lund university diabetes centre, malmo, sweden. statistical analysis was performed by ibm spss statistics software. our data showed that frequencies of both, rs and rs , variants were not significantly different between t d and control subjects. however, rs risk a allele appear to increase insulin levels (p = . ) and homa-ir index (p = . ). furthermore, this variant also seems to affect vldl levels (p = . ) and waist circumference (p = . ) in diabetic patients. the genotype analysis of rs variant demonstrated that risk g allele decreased hdl (p = . ) and increased ldl levels (p = . ), as well as affected the waist circumference (p = . ) in diabetic patients. interestingly, haplotype analysis demonstrated the association of rs a / rs g with higher homa-ir index. here we demonstrated that although both, rs and rs , adra a polymorphisms were not associated with t d risk in our cohort, they were associated with markers of dyslipidemic perturbations and insulin resistance in diabetic patients. further studies in larger cohorts are needed in order to explore these possible interactions and confirm our findings. smad-interacting protein (sip ), also known as zeb is a member of zeb family transcription factors and was shown to regulate epithelial-to-mesenchymal transition, cell cycle, cellular senescence and cancer stemness. bipartite zing finger motifs at amino and carboxyl termini of the sip mediate its binding to ebox sequences in the genome. however, there are only limited data about sip target genes. by using a home-made anti-sip monoclonal antibody, clone e , we conducted chip-seq in three hepatocellular carcinoma cell lines, namely snu , plc/prf/ and sk-hep- and found receptor tyrosine kinase-like orphan receptor (ror ) as one of the targets. sip dnabinding consensus motif cacctg was found at + kb, + kb and + kb from ror transcription start site. chip experiments validated sip binding to all consensus motifs in the ror gene region. interestingly, the strongest enrichment was at + kb suggesting that long-range interactions play an important role in the regulation of ror by sip . sip knockdown by shrna in high-sip expressing snu cells resulted in the repression of ror expression. ror is expressed in embryogenesis and fetal life, and is absent within most of adult normal tissues. however, overexpression of ror was observed in many human cancers, from hematological malignancies to solid epithelial tumors. ror -positive cancer cells have enhanced proliferation, invasion and metastasis capacities, show resistance to apoptotic stimuli and display cancer stem cell characteristics. therefore, sip and ror act in similar pathophysiological processes. our finding that ror is regulated by sip at least in hepatocellular carcinoma cells adds another level of complexity to the molecular mechanisms of proliferation, invasion and stemness of cancer cells. hepatocellular carcinoma (hcc) is the most prevalent primary liver cancer and is one of the leading causes of cancer related deaths. smad interacting protein (sip ), a member of the zeb family of emt inducers, is involved in cellular proliferation, senescence, invasion and metastasis in human tumors. however, genes regulated by sip in hcc are yet to be identified. we conducted a chip-seq study in high-sip expressing hcc cell line snu by using a home-made anti-sip antibody, clone e . among annotated genes, we selected six for further studies because of its increased expression in multiple cancers and its association with poor prognosis. sip dna-binding motif cacctg was found at - kb from transcription start site of six gene. chip qpcr experiment validated sip binding to this region with , fold enrichment. compared to healthy liver, six transcripts were upregulated in of hcc cell lines included in this study. knockdown of sip by shrna in snu cells caused upregulation of six . immunohistochemistry studies in hcc tissue arrays showed increased expression of six in tumors and inverse association with sip expression in a tumor grade dependent manner. therefore, our results strongly suggest an inverse correlation of sip and six in hcc bone mineral density (bmd) and bone turnover are under genetic control and variations in the vitamin d receptor (vdr) are related to bmd. bmd is known to be affected by -hydroxy vitamin d ( (oh)d) and intact parathyroid hormon (ipth) levels. we aimed to determine correlation blood levels of vitamin d (vitd), ipth, and vdr gene effect in healthy turkish women. the subjects were healthy women in age - years. the bmd was measured as a t score in the lumbar spine (l -l ) with dexa. all subjects had normal t score between (- . to . ) sd. vitd was measured by lc- -at shimadzu. ipth was measured by chemiluminescence method, dna was isolated from blood. the fok i (vdrf-foki) and bsmi (vdrb-bsmi) polymorphisms of vdr gene was analysed with genomica clinical array system. the mean vitd level was ( . ae . ) lg/l, mean plasma ipth level was ( . ae . ) pg/ml. pearson correlation test showed no relation of vit d with bmd. there was moderately negative correlation between ipth and bmd (r = À . ). genotype distribution and allele frequency of subjects were as follows: ( %) ff), ( %) ff, ( %) ff genotype in vdrf -fok gene, ( %) bb, ( %) bb, ( %) bb in vdrb-bsmi gene. allele frequencies were f: %, f: %; b: %, b: %. when fok and bsmi were combined, %(ff-bb) and % (ff-bb) were found as the most frequent genotypes. bsmi frequency was in hardy weinberg equilibrium (p > . ). but foki was not (p = ). it was found that vit d, ipth levels and bmd were in normal levels in all carriers of ff genotype and in combined (ff-bb) type carrying healthy women ( %). the association vdr genotype and bmd may be different in various ethnic and geographical groups. therefore it is worthwhile to assess vdr polymorphism among turkish population. these type of distribution studies of vdr in healthy and in osteoporotic women may enlighten to earlier diagnosis and treatment planning. p- . . - determination of hb a c values in beta thalassemia f. g€ uzelg€ ul , g. s. seydel , a. e. yalin , e. s€ onmez , k. aksoy c ß ukurova university, adana, nigde university, nigde, mersin university, mersin, turkey introduction: hemoglobinopathies are most commonly seen hereditary blood diseases worldwide. our aim was to compare the hba c values measured on cation-exchange high performance liquid chromatography (hplc) in beta thalassemia cases. materials and methods: we collected ml of whole blood k edta containing tubes from forty-nine cases. arms, rflp and dna sequence analysis methodologies were carried out for determination of beta thalassemia mutations. hb a c values were measured using the agilent hplc system. results: forty-nine diabetic and non-diabetic patients were diagnosed with beta thalassemias: twenty-one ivs - /ivs - , one ivs - /ivs - , one ivs - /ivs - , two ivs - /ivs - , two ivs - /ivs - , one fsc /fsc , one fsc /fsc , two - /- , two cd /cd , one cd - /cd - , one cd - /cd - , two cd /cd -g/ cd /cd -g, two ivs - / ivs - , one ivs - / ivs - , one ivs - /fsc , one ivs - /cd , one ivs - /cd , one ivs - /cd - , one ivs - /ivs - , one ivs - / ivs - , one ivs - / ivs - , one ivs - /cd and one fsc /cd . cases were classified as diabetic ( ), prediabetic ( ) and non-diabetic ( ) introduction: members of aurora kinase family aurora a, b and c are conservative kinases of cell cycle which are encoded by genes aura, aurb and aurc respectively. overexpression of aura and aurb was found in human cancers, especially in prostate cancer. moreover, there is the evidence that aurb interacts with one of the major oncogenic kinases -braf. little is known about implication of aurc in cancer, but it was demonstrated, that it can overlap aurb function and shares its location. we studied expression of genes of these kinases in urine of prostate cancer patients aiming to evaluate their involvement in this disease and their potential as tumor markers. materials and methods: urine samples from patients with prostate cancer were gathered after prostate massage before surgical invasion. we used urine samples from healthy men as control. we obtained cells from each urine sample by centrifugation and isolated rna using standard approach with phenol and guanidine thiocyanate. cdna was synthesized and taken to qpcr reactions. data was statistically analysed. results: expression of all studied genes was detected in urine of patients with prostate cancer and of healthy men. expression of aurb and aurc in cancer samples each was higher than expression of aura. the cumulative expression aurb and aurc was higher than expression of aura in samples from . we observed positive correlation between expression of aurc and braf (rs = . , p = . ). discussion and conclusion: previous investigation showed, that for normal prostate tissue % of aurora family expression was presented by aura. we suppose that presence of aurb and aurc cumulative overexpression means presence of cell cycle deviations in prostate tissue of these patients and might be further studied as prognostic marker. in this study we first showed the correlation between aurc and other carcinogenic kinase braf expression, which opens the perspective for investigation of role of aurc in carcinogenesis. bacillus marmarensis sp. nov. is an extreme obligate alkaliphile isolated from mushroom compost near marmara region of turkey. it can survive at extreme ph values up to . . based on its genome sequence, metabolic pathways for proteases, amylases, cellulases, lipase, n-butanol and a biodegradable plastic poly-b-hydroxybutyrate were annotated. in addition to being a potential extracellular hydrolase producer, its ability to survive in the high ph range of . to . makes it an attractive microorganism for different industrial applications. in the current study, the adaptation strategy of b. marmarensis sp. nov. to alkaline conditions was investigated using proteomic tools. the organism was grown at two different ph values, . and ph . . for extraction of whole cell proteins, cells were disrupted with mp bio fast prep device. protein extracts were treated with protease inhibitors and a nuclease mix. salts were removed using a cleanup kit. obtained proteins were separated based of their isoelectric points in the first dimension and then based on their molecular weights in the second dimension. proteins maps of cells grown at these two extreme ph values showed significant differences in protein expression for alkaline adaptation. p- . . - biochemical and proteomic analyses of normal human astrocytes and glioblastoma exposed to dichloroacetate treatment f. c. atilgan, h. cimen yeditepe university, istanbul, turkey glioblastoma (gbm) is an aggressive malignant tumor composed of astrocytes in brain tissue. gbm cells utilize glycolysis rather than oxidative phosphorylation to support rapid growth rate which is called warburg effect. dichloroacetate (dca) is an antiglycolytic agent that inhibits pyruvate dehydrogenase kinase (pdk) activity and induces apoptosis via normalizing the mitochondrial activity. this study aimed to demonstrate the metabolic alterations between the normal human astrocytes (nha) and gbm cell lines which are exposed to dca, and to identify the differentially expressed proteins by ms-based proteomic analyses. nha cell line, u mg and u as gbm human cell lines were examined through analyzing the alterations in the glycolysis metabolism upon dca treatment by measuring the variations in the pyruvate levels, lactate dehydrogenase a, pdk . mts was performed to investigate the effect of dca treatment on cell viability. immunoblotting of pgc -a, oxphos complexes, and mitotracker green staining was employed to reveal the mitochondrial differences between normal and the cancer cells, and upon dca treatment of these cells. proteomic analyses were utilized for the identification of candidate proteins depending on the acetylation status. in this study, compared to nha, the pyruvate and ldha levels were elevated and pdk levels in u mg were reduced by %. due to mts results, ≤ mm dca treatment showed significant decrease in gbm cells compared to nha cells. immunoblotting and mitotracker green staining results showed increase in mitochondrial mass. elevation in the pyruvate and ldha levels and reduction in pdk level in u mg and u cells indicates glycolysis dependent metabolic switch in energy metabolism. proteomic analyses demonstrate that most of the differentially expressed proteins comprised of metabolic enzymes. this study provides novel information about metabolic alterations existing between nha and gbm, which can inspire further studies for therapeutic applications. kidney stone is a complex disease resulting from environmental as well as hereditary factors and principally composes of approximately % calcium oxalate (caox) crystals, which are formed through a multi-step process. vitamin d receptor (vdr) gene encodes the nuclear hormone receptor for vitamin d ; downstream targets of this gene are chiefly contributed in mineral metabolism though the receptor regulates a variety of other metabolic pathways. calcium sensing receptor casr plays an important role in sustaining mineral ion homeostasis. the aim of this study is to profile the expression level of vdr and calcium sensing receptor (casr) genes and to unravel their role in rat kidney stone induced by ethylene glycol, in order to explain the underlying molecular mechanisms. total rna were extracted from paired sample before and after ethylene glycol treated of rats. the mrna expression level of vdr and casr gene were measured employing quantitative rt-pcr (qrt-pcr). the mrna expression levels of both genes were significantly down-regulated according to before treated. in conclusion, our data suggest reduced mrna expression in vdr and casr genes might be a risk factor for kidney stone formation. further studies are necessary to verify these findings in different ethnic groups. p- . . - apj receptor a c gene polymorphism in turkish patients with coronary artery disease against different models of expected frequencies/counts to understand the evolutionary dynamics of saars in proteins. we obtained from ensembl the assemblies of genomes/proteomes of human and nonhuman primates (chimpanzee, gorilla, and rhesus monkey), rodents (mouse and rat), and birds (chicken and zebrafinch). the expected probabilities for the occurrence of saars based on their nucleotide frequencies in coding regions and amino acid frequencies in individual protein sequences or across the whole proteome were compared with the observed repeat occurrences. we found that with all three methods and in all eight species the correlation between observed and expected repeat counts decreased above a saar length threshold. the percentage of saar proteins for each amino acid also exhibited variability among species when both the repeat length and counts were taken into account. however, clustering based on saar characteristics generally reflected the known phylogenetic relationships between species. our comprehensive bioinformatics analyses reveal that saars show amino acid-specific occurrence patterns with respect to species as well as saar length. tissue proteins play important roles in biological metabolic processes. the qualitative and quantitative analysis of tissue proteins facilitates the understanding of molecular mechanisms that differentiate between physiologic and pathologic states. health and research institutions routinely prepare formalin-fixed paraffinembedded (ffpe) tissue blocks for histopathology. proteomics on ffpe tissue still requires standardization of tissue solubilization processes to overcome variability in protein extraction results. our aim is to compare the proteomic studies of fresh frozen and ffpe rat renal tissues. fresh frozen and ffpe preparations from renal tissues were included in this study. an adult rat was sacrificed and the dissected kidneys were divided two equal section. one immediately frozen in phosphate buffer, and the other tissue specimen not thicker than mm to allow rapid penetration of the fixative put in % buffered formalin for hours. the fresh frozen tissue was dissolved and homogenised in the cold phosphate buffer solution containing protease inhibitors. paraffin blocks were performed from formalin fixed tissue specimens. we have extracted the protein from the ffpe tissues using our previously verified method. we have utilized electrophoresis three times to compare protein yield, number, intracellular and intercellular of homogenised samples obtained from ffpe and fresh frozen kidney samples. the number of proteins identified from fresh frozen kidney tissue has generally been shown to be increased compared with ffpe tissue. decrease of the qualitative results in electrophoretic bands was found similar in all replicative studies. ffpe tissues undergo extensive cross linking between protein/ dna/rna molecules during formalin fixation, which creates inter-molecular crosslinks. on the other hand, ffpe tissues represent a valuable resource to carry out retrospective studies aimed to biomarker discovery in kidney cancer as well as other kidney diseases. background: development of atrial fibrillation (af) during the course of chronic primary mitral regurgitation (mr) is common and represents complex molecular mechanisms. however, the gene expression profile of human atrial fibrillation (af) in the setting of chronic primary mr remains uncharacterized. in the current study, we aimed to compare the gene expression profiles of patients with severe degenerative mr in sinus rhythm (sr) and af. methods: left and right atrial tissue samples were obtained from patients with chronic primary severe mr in permanent af (n = ) and sinus rhythm (n = ). we performed a novel micro-dissection technique for thin sections of atrial tissue samples and immediately fresh froze intra-operatively. transcriptomes of left and right atrial appendages of degenerative mitral regurgitation patients with sr versus af were compared by microarray analysis on affymetrix hgu- plus platform. bioinformatics, data mining and pathway analyses were conducted on partek gs and webgestalt. genome-wide gene expression profiles were compared between af and sr groups among . transcripts representing . well-characterized human genes. differentially regulated genes were evaluated according to fold change (fc ≥ . ) with a p-value ≤ . . results: most remarkable pathways altered in af atrial tissues compared to sr group, were extracellular matrix-receptor interaction; mapk, adipocytokine, and calcium signaling; apoptosis and cardiac muscle contraction pathways. conclusions: this is the first human study of comparative transcriptomics in left and right atrial tissues of patients with af versus sr associated with severe degenerative mr. the main findings of this multidisciplinary translational research provide novel candidate targets for the treatment and prevention of af. in order to acquire iron under iron-limiting growth conditions, bacteria employ specific mechanisms such as production and secretion of siderophores. siderophores are low molecular metalchelating compounds that contribute not only to iron scavenging, but also participate in other important processes including oxidative stress response and cell signaling. serratia marcescens, gramnegative bacterium, could be found in various environments, including wastewater, plant rhizosphere and hospital setting where s. marcescens can cause serious life-threatening infections. in this study, we performed a detailed characterization of the siderophores of the clinically important pigment-free s. marcescens strain sr - and environmental pigment-producing s. marcescens strain sm . bioinformatic analysis of these genomes by antismash software revealed the presence of several clusters involved in non-ribosomal peptides synthesis (nrps). we found four nrps clusters in genome of s. marcescens sm . cluster has a low level of identity to enterobactin gene cluster typical for bacteria producing catechol-like siderophores. second cluster has only % of identity to xantholipin biosynthetic gene cluster. clusters and of nrps genes of s. marcescens sm did not show any homology to known nrps clusters. in contrast, the genome of s. marcescens sr - contains only one genetic cluster of nrps genes. this cluster does not have similarity to any of the known bacterial nrps genes. thus, genetic analysis of two isolates of s. marcescens allowed us to identify nrps genetic clusters and showed that the repertoire of these genes is different between strains. we hypothesized that the strain isolated from environment has competitive advantage over clinical isolate due to genetic diversity of siderophores. on the other side, clinical isolate has specific genetic cluster of siderophores which may promote s. marcescens growth and adaptation to the extreme niches present in medical facilities. p- . . - the first glance on the genome's structure and activity in hibernator edible dormouse hibernation is a unique adaptive way of survival in extreme environmental conditions where mammals decrease their metabolic rate and demonstrate physical inactivity for prolonged periods of time (up to - months). remarkably, some hibernating animals have a long average lifespan and the ability to avoid muscle atrophy caused by disuse or immobilization. to identify main molecular pathways behind the protective musculoskeletal adaptation and genome structure in hibernator edible dormouse (glis glis), whole-genome analysis of mrna expression in muscles (m. soleus and m. edl) and lumbar spinal cord samples was conducted. three groups of the dormice: ) active animals ) hibernated animals and ) animals immobilized for weeks in laboratory, were examined. rna libraries have been sequenced using hiseq illumina platform. coupled with genome dna sequencing provided x coverage of the estimated genome, we have assembled de novo transcriptome of the dormice. differentially expressed genes in response to immobilization and hibernation were determined. transcriptional program of these phenotypes was similar. pathways enriched by differentially expressed genes were identified. gene expression of the key muscle proteins and muscle atrophy markers was analyzed. muscle-specific e -ubiquitin ligases murf and mafbx revealed no changes in mrna expression. our study represents the first attempt to elucidate changes in transcription profiles of skeletal muscles and spinal cord during hibernation and hypokinesia in edible dormice. in corroboration to the gene expression data, they demonstrated minimal morphological evidence for muscle disuse atrophy during physical inactivity. edible dormice, thus, can be considered as a novel model organisms in investigation of the genetic mechanisms of hibernation and prevention of muscle atrophy. the work is performed according to the russian government program of competitive growth of kfu and supported by rfbr jsps_a no. - - . in response to diverse environmental cues bacteria form complex structured communities called biofilms. the metabolic pathways activated by these cues are remarkably different depending on the species studied. however, they all lead to the formation of an extracellular matrix that holds the cells together. non-pathogenic gram-positive spore-forming soil b. subtilis strain is recognized as a model system for the study of biofilms. to discover the pathways regulating biofilm formation in b. subtilis, we studied the natural isolate of b. subtilis strain , and constructed the recombinant strains with knocked out genes of following regulatory proteins: abrb (global transcriptional regulator), degu (two-component response regulator of signal transduction system degs-degu), ccpa (regulator of carbon catabolism) and spooa (regulator of sporulation). in the minimal medium broth b. subtilis wild-type strain forms biofilm with its maximum on th hour of culture growth. ph-optimum for biofilms formation by the wild-type strain is in the range of . - . . the temperature optimum is in the range from °c to °c. this corresponds to the natural conditions of the b. subtilis habitat in rhizosphere. the level of biofilm formation by regulatory mutant strains with deleted abrb, degu, ccpa, spooa genes is on average % lower than by the wild-type strain. this indicates that global regulatory system controlls biofilm formation process. statistically significant differences in the levels of biofilm formation between regulatory mutants haven't been identified. ph and temperature optima of mutant strains are the same as for the wildtype strain - , - and °c - °c respectively. the crataegus genus which is a member of rosaceae family, has approximately species worldwide and species in turkey. all plant species in this genus have the common name "hawthorn". crataegus microphylla (c. microphylla) c. koch which is characterised by having erect sepals in fruit and smaller leaves in comparison with the other species, is one of the wild edible fruits in turkey. crataegus species have been used as food and also in folk medicine for the treatment of various diseases. for this purpose, the potential biological properties of crataegus microphylla were aimed to reveal by the preliminary work. in this study, prevention of oxidative dna damage using supercoiled pbr plasmid dna, acetylcholinesterase, tyrosinase, a-glucosidase inhibition and antioxidant effects: , diphenyl- -picrylhydrazyl radical scavenging effect, phosphomolibdenum-reducing antioxidant power, ferric-reducing antioxidant power with total phenolic and total flavonoid contents of the c. microphylla leaves, stem barks and fruits that extracted with ethanol, methanol and water were investigated. the experiments of oxidative dna damage studies and antioxidant activities of c. microphylla extracts showed that methanol and ethanol extracts possessed a strong ability to prevent dna damage and significantly antioxidant activities. methanol extracts of stem barks from c. microphylla exhibited the highest acetylcholinesterase and tyrosinase activities ( . ae . % and . ae . %, respectively), at lg/ml. in addition, ethanol extract of leaves from c. microphylla inhibited the a-glucosidase activity significantly when compared to acarbose. this study explained significant antioxidant, enzyme inhibitory, hypoglycemic, and neuroprotective activities of methanolic or ethanolic extracts prepared with stem bark and leaf from c. microphylla and also strong ability to prevent dna damage that corresponded to antioxidant potential of methanol extracts of leaf and stem bark. the yarrowia lipolytica species (yl) is nonconventional yeast widely used for recombinant protein expression due to its system of post-translation protein modification, which is the most similar to that of higher eukaryotes. yl appears the promising producer of recombinant proteins with much more complicated molecules compared to those of prokaryotic producers. however, an important feature for a producer strain of recombinant proteins is the genes, the expression of which undertakes under controlled conditions, and consequently, search of new effective inducible promoters in the yl genome is of great interest. proteome analysis of the yl cells grown at different ph values ( . , . , . ) showed that under alkaline conditions the amount of mitochondrial porine vdac (voltage dependent anion channel), one of the most abundant protein of the mitochondrial outer membrane, increased significantly. vdac is supposed to let reactive oxygen species out of mitochondria protecting the cell against oxidative stress. therefore, the por gene expression, encoding vdac should increase in the stress conditions. the promoter of the por gene was used to construct some new expression systems based on yl w . a new genetic construct bearing a reporter bgalactosidase gene under control of the por promoter. b-galactosidase activity was assayed in the cells grown in various ph conditions and exposed to exogenous oxidants such as hydrogen peroxide, menadione, and methyl viologen. it was shown, that in h o and methyl viologen treated cells b-galactosidase activity increased . - . -fold reaching its maximum in the cells, grown at ph of . . thus, we demonstrated high inducibility of the por promoter, which is essential for effective action of the expression system based on it and potency of application for transformed lines of producers. acknowledgments: supported by the russian foundation for basic research (grant no - - mol_a). aspergillus nidulans is able to detoxify and catabolize the toxic proline analogue, lazetidine- -carboxylic acid in nature, azc serves as a plant protectant against infections and consumption. we have obtained evidence that azc is not only non-toxic for the model ascomycete aspergillus nidulans, but it can be utilized as a poor nitrogen source. in order to elucidate the molecular mechanism underlying azc detoxification, we have constructed and studied a. nidulans strains deleted in the cognate genes involved in azc detoxification in pseudomonas and saccharomyces cerevisiae. these genes, found by in silico analysis, encode a putative hydrolase, acha, and an azc acetyltransferase, ngn , respectively. gene deletion was accomplished through double crossover. a cassette containing the~ bp ' and ' flanking sequences of each gene, with the afpyrg gene as a selection marker, was contructed. crossing the achad and the ngn d strains isolated the achad ngn d double mutant strain. rt-pcr was used for gene expression analysis in the wild type strain, area-loss of function and crea-derepressed mutant strains. our results clearly show that azc can be used as a poor nitrogen source by a. nidulans. this utilization requires a) acha, a putative azc hydrolase, and b) a fully active gaba catabolic pathway, as lack of either amdr or gata abolishes azc utilization. most importantly, the double mutant, achad ngn d, shows azc toxicity, suggesting that ngn is a true orthologue of mpr , able to detoxify azc, a phenotype that can be observed only in the absence of acha. as a final point, ngn was shown to be induced by the presence of azc and and to be under nitro the spatial genome organization plays a great role in the maintenance of the nuclear architecture and regulation of all processes occurring in the nucleus. this system is controlled by a set of special proteins having an architectural function. however, the mechanisms of their action remain unknown. among these proteins are, in particular, zad-domain-containing proteins. zinc finger-associated domain (zad) is a ubiquitous motif of c h zinc finger proteins of drosophila. genes that encode zad proteins are specific for and expanded in the genomes of insects. only a few zad-encoding genes have known functions, and the role of zad is being discussed. up to date there was only one known crystal structure of zad-domain from drosophila transcription factor grauzone (grauzad). here, we present for the first time the crystal structure of the zad-domain of serendipity-d transcriptional activator of the egg-polarity gene bicoid. zad-domain was cloned, overexpressed in e. coli, purified and the structure was solved at . a by mad technique. detailed analysis of the structure proved that the protein exists in dimeric form and revealed unique spatial organization of the protein, different from those for grauzad. this work is supported in part by russian ministry of education and science grant ( . . . ). mycoplasma gallisepticum is a convenient model object for studying the regulation of transcription because it has a reduced genome, lack of cell wall and many metabolic pathways and also easy to culture and non-pathogenic to humans. due to the nature of the genomic organization and the loss of many of the known regulators, the effect of disrupting the function of some proteins may be a useful tool for studying the regulation of transcription. the gene expression study was performed on agilent onecolor microarray with custom design and random-t polymerase primer for cdna synthesis. microarray represents probes for orf including genes and ncrna. in this work, we have investigated the effect of changes in the level of gene expression of m. gallisepticum for two different types of conditions: a genetic knock-out mutants and the cell response to treatment with sub-lethal concentrations of antibiotics. we characterized transcription of m. gallisepticum when the cell responses to dysfunction of proteins with metabolic potential, possible regulators of expression, in violation of permeability of membrane by cccp, inhibition of ribosomal synthesis by tetracycline, dna gyrase by novobiocin and atp synthase by oligomycin. the data obtained allow to characterize the transcriptional response under different conditions and to identify groups of genes that change expression together. major transcriptional changes were observed in the response of cells under cccp treatment due to uncoupling of the proton gradient and further reducing the membrane potential, as well as under novobiocin treatment due to changing the topology of dna. global problem of oil pollution forces scientists to search for a new safe remediation technologies constantly. careful attention is paid to bacteria, some of which possess additional biotechnologically valuable properties, such as utilization of hydrocarbons and production of biofurfactants. in this regard, we carried out proteogenomic characterization of tsukamurella tyrosinosolvens strain ps , which was isolated from chemical sludge and capable for alkane degradation and biosurfactant production. whole genome of the strain was sequenced on the miseq (illumina) platform, assembled and annotated. proteome on mineral medium with glucose, sucrose and hexadecane as a sole carbon and energy source was studied. shotgun proteomics approach was performed on hybrid chromatography-mass spectrometry machine (maxis impact). alkane oxidation genes (alkane- -monooxygenase, rubredoxin and rubredoxin-reductase) under genome sequence, as well as two pathways of trehalose synthesis and genes for mycolic acids production were found. emulsification activity of cell-free culture liquid was about four times higher on hexadecane in comparison with sugars. proteomic profile was different at various culture conditions. all glycolysis genes, beginning with glucose- -phosphate isomerase to pyruvate kinase, were found on the media with sugar. the medium with hexadecane helped to reveal enzymes involved in the beta-oxidation of fatty acids, for example , -dienoyl-coa reductase, -ketoacyl-coa thiolase and enzymes of the initial mycolic acid synthesis pathways. thus we have established that the strain t. tyrosinosolvens ps utilizes sugar by glycolysis. also, the bacterium is capable for alkane oxidation followed by beta-oxidation of fatty acids. based on the proteogenomic data, we assume that the bacterium is able to synthesize trehalose lipids, namely, trehalose mycolates. obtained results could be useful to create conditions for increased biosurfactants production. gestational diabetes mellitus (gdm) is a glucose intolerance firstly diagnosed during pregnancy. in this study, we aimed to investigate the association between serum adiponectin, resistin levels and insulin resistance in gestational diabetic patients. a total of patients; healthy pregnant women (control group) and pregnant women diagnosed with gdm (gdm group) were included in this study. serum adiponectin, resistin, glucose, insulin, hba c levels and lipid parameters were measured. insulin resistance index homa-ir values were calculated. in this study, serum glucose, insulin, hba c levels and homa-ir were significantly higher in gdm group compared to the control group (p = . , p = . , p = . , p = . , respectively). serum adiponectin levels were significantly lower (p < . ); whereas serum resistin levels were significantly higher (p = . ) in gdm group than in the control group. it can be concluded that resistin contributes to the formation of insulin resistance, adiponectin plays an important role in the regulation of this resistance and they also have effects on gdm pathophysiology. hematological cancers including acute myeloblastic leukemia (aml) and acute lymphoblastic leukemia (all) in terms of incidence and mortality, are the second most important cancer type in turkey. numerous studies show that cancer patients respond differently to treatment thus supporting the idea of personalized therapy need for individuals. renin angiotensin system (ras) have key roles in aml and all progression and it has been shown by many studies suggests that these system's genes might be good biomarkers for aml and all personalized therapy. we aimed to identify ras gene based homogeneous subgroups of acute leukemia and determine the most effective chemotherapoetic agent for each subgroup. after validation and verification of the results, more effective drugs can be recommended for the use in clinics for chemotherapy of aml and all. results of our preliminary studies showed that we are able to identify subgroups of aml and all as well as correlating each existing subgroup with fda approved drugs. considering the long and highly cost process of developing new drugs for cancer treatment makes the present study all the more valuable. in addition, there is a serious need for change in aml and all therapy since there is no highly effective chemotherapy protocol available for their treatment. welcome trust sanger (wts) and cancer cell line encyclopedia (ccle) databases will be used to determine subgroups of aml and all based on ras genes or whole genome expression using standard deviation and hierarchical clustering analysis. the most effective drugs for each subgroup will be identified using pearson's r correlation analysis with drug sensitivity data (ic , ic , amax, aare, etc.) available in same databases. further validation tests will be performed by in vitro validation using aml and all cell lines: drug sensitivity profiles will be determined and gene expression will be shown by q-rt-pcr. p- . . - functional polymorphisms of ephx in a turkish population h. pinarbasi, i. sari cumhuriyet university, sivas, turkey soluble epoxide hydrolase (seh; ec . . . ) is encoded by ephx and catalyses the degradation of endogenous fatty acid epoxides generated by cyp epoxygenases. these fatty acid epoxides such as epoxyeicosatrienoic acids (eets) have been shown to posses vasodilator, anti-inflammatory, anti-platelet, anti-hypertensive, anti-apoptotic, anti-thrombotic and natriuretic effects. it has been reported that eet levels are associated with hypertension, stroke and cardiovascular diseases. individual differences in the ephx gene that affect the seh activity may alter the circulating levels of eets. k r and r q polymorphisms have been known to cause increased and decreased seh activity, respectively. therefore we aimed to determine the genotype frequencies of these two polymorphisms in a turkish population. k r and r q polymorphisms were determined by the real time pcr using double-dye hydrolysis probes or pcr-rflp method. the observed genotype frequencies for k r polymorphism were . % wild type (aa) and . % polymorphic genotype (ag+gg) and for r q polymorphism . % wild type and . % polymorphic genotype (ga+aa). the genotype distributions for both polymorphisms were in hardy-weinberg equilibrium. pregnancy is one of manifestations for thrombophilia factors, which in its turn leads to various complications of its course. one of the markers of hereditary thrombophilia is mutations in the folate cycle mtr, mtrr and mthfr genes. insufficient intake of folate during pregnancy disrupts the functioning of the genome, leading to miscarriage, violation of embryogenesis and various fetal malformations. however, results of studies on the role of hereditary thrombophilia in the occurrence of complications during pregnancy are rather contradictory. aim of this study was to determine the frequency of alleles and polymorphic variants of folate cycle genes mtr a g, mtrr a g and mthfr c t in women of kazakh ethnic group with pregnancy complications. we used real-time pcr. blood samples for dna isolation were obtained from pregnant women. the main group consisted of women (n = ) which had a history of two or more pregnancy complications in the form of pre-eclampsia, eclampsia, missed abortion, miscarriage, and etc. control group consisted of women (n = ) with two or more normal pregnancy outcomes, and had no complications during pregnancy in history. average age of women in experimental group was . ae . years compared with control of the age . ae . . the analysis of the frequency distribution of alleles of genes in experimental group of women with complications of pregnancy revealed no significant differences relative to the control group. analysis of the distribution of polymorphic variants of folate cycle genes showed significant difference between the study and control groups in the occurrence frequency of heterozygotes for the mutant allele g in the gene mtrr a g (or = . , ci % = . - . ; v = . , p < , ). no significant differences in alleles between homozygous wild-type and homozygous mutant alleles were observed. this work was funded by the mes kazakhstan (gr rk project number). p- . . - a study on the association between rs polymorphism in connective tissue growth factor gene and pseudoexfoliation syndrome pseudoexfoliation syndrome (pes) is a disorder of the extracellular matrix characterized by the production and progressive accumulation of an abnormal fibrillary material in many ocular tissues. pes prevalence is . % above the age in turkey. since pes is characterized by excessive synthesis of elastic microfibrillar components throughout the body, growth factors can have important roles in the pathophysiology of pes. human connective tissue growth factor (ctgf) is a protein expressed in a variety of tissues, including the anterior chamber of the eye. ctgf coding gene has several genetic polymorphisms. rs g/c single nucleotide polymorphism (snp) is found at position À , in promoter region. the presence of a c allele for rs is critical for transcriptional suppression of the ctgf gene which would reduce ctgf production. aim of this study was to investigate if there is any association between pes and rs polymorphism of the ctgf gene. study population consisted of patients with pes and controls. blood samples were collected by g€ ulhane military medical academy, department of ophthalmology, ankara, turkey. genotypes were assigned by pcr followed by restriction fragment length polymorphism analysis. genomic dnas were isolated from whole blood samples using manual dna isolation. the frequency of ctgf rs polymorphic allele g was . in patients, and . in controls ( . , p = . ). distribution of genotypes was gg: . %, gc: . % and cc: . % among patients, while gg: %, gc: . % and cc: . % (or = . , p = . ) in controls. statistical analysis showed that there is no significant relationship between ctgf rs snp and pes. these are the preliminary findings of a research project which is the first study analyzing the relationship between ctgf rs snp and pes. this work did not point out a role for ctgf rs in the risk for pes. a significant relationship might be found when the study population is enlarged. p- . . - evaluation of rs single nucleotide polymorphism of clusterin gene in pseuodoexfoliation syndrome risk pseuodoexfoliation syndrome (pes), an age-related systemic disorder, is characterized by production and accumulation of abnormal fibrillar extracellular material in anterior structures of the eye. clusterin (clu) is a multifunctional glycoprotein produced and secreted by almost all cell types and is found in all body fluids and in accumulated pes material. under cellular stress conditions, clu provides inhibition of stress-induced precipitation and aggregation of misfolded proteins. clu expression level in pes patients is unexpectedly low and this could be due to single nucleotide polymorphisms (snp) on the gene coding for clu. rs c/t polymorphism has been found to be associated with alzheimer's disease and pathophysiology of alzheimer and pes are similar. this study aimed to determine whether rs snp of clu gene have a role in the development of pes. study population consisted of patients with pes and controls. blood samples were obtained from g€ ulhane military medical academy, department of ophthalmology, ankara, turkey. genomic dnas were isolated from whole blood of subjects using manual dna isolation. genotypes were assigned by pcr followed by restriction fragment length polymorphism analysis. t allele frequency of pes patients was . and that of controls was . ( . , p = . ). the distribution of genotypes was cc: . %, tc: . % and tt: . % among patients while cc: . %, tc: . % and tt: . % ( . , p = . ) in controls. there was no statistically significant difference between pes patients and controls in terms of tt genotype and t allele frequency. these are the preliminary findings of a research project which is the first study analyzing the relationship between clu rs snp and pes in turkish population. this work did not point out a relation for polymorphic genotype in the risk for pes. however, a relationship between clu rs polymorphism and pes can be found when we enlarge the study population. the tumor suppressor tp is the most frequently mutated gene in head neck squamous cell carcinoma cancer and represents a known transcription factor and tumor suppressor gene that regulates different microrna and target genes. the aim of our work is to construct the transcriptional and post-transcriptional network regulated by tp and to evaluate the difference at mrna and protein expression levels of the tp target genes in hpv negative head and neck squamous cell carcinoma (hnscc) patients with distinct tp mutation states and to elucidate the molecular mechanism that underlie the poor prognosis of tp mutation. to show the tp mutation landscape and its prognostic relevance for survival, we used cbioportal for cancer genomic analysis. we downloaded mutational profiles of hpv negative hnscc patients. employing different databases we constructed the tp regulatory network. and then, to evaluate the effect on mrna, protein and microrna regulated by tp we used the mrna and protein expression profiles of patients from tcga. our results show that hotspot, truncating and missense mutations have statistical significance in the univariate analysis. the tp regulatory network show the involvement of important target involved in the progression of hnscc and the deregulation of protein expression of an important key epigenetic modifier ezh was significantly associated with tp mutational state. ezh is a member of the polycomb group protein enhancer zeste homolog which is known to be directly repressed by tp and indirectly by the activation of mir- a and mir- b. we found a significant up-regulation of ezh that depend from tp mutation. it is important to understand the difference in mrna and protein expression of tp regulatory network that could depend from its mutational state. this finding suggest that ezh might be a potential therapeutic target for hnscc. p- . . - next generation sequencing based approach for monitoring of minimal residual disease in acute lymphoblastic leukemia minimal residual disease (mrd) monitoring is widely used to evaluate efficiency of chemotherapy and to choose a strategy for further treatment in acute lymphoblastic leukemia (all). the most commonly used approaches for mrd detection are based on flow cytometry and qpcr. these methods have several important limitations including insufficient sensitivity, complicated experimental setup and false positivity. the newly developed next generation sequencing (ngs) approaches could overcome the existing limitations in mrd monitoring. here we describe a new mrd monitoring approach based on targeted deep sequencing of malignant rearrangements. first, we identified bcr/tcr rearrangements specific for the leukemic clones in initial bone marrow samples of all patients. for this, we used sanger sequencing of the products of multiplex pcr, performed with bcr/tcr specific primers combined according to the optimal frequency distribution of v/j-genes in healthy donors. second, we analyzed concentration of malignant clone rearrangements, identified at the first step, in dna samples obtained from bone marrow after days of treatment. for this purpose, we performed ngs of libraries for each identified leukemic rearrangement. four libraries were amplicons of bcr or tcr gene rearrangements generated using characteristic v and j segment specific primer combination. six additional libraries were amplicons of the same primer combination from the same dna sample which contained initial leukemic dna spike-in (in concentrations corresponding to per , and , cells) for a calibration curve generation. using this approach, we analyzed all clone specific rearrangements for three patients and calculated concentration of the leukemic clones by using the calibration curve. for one patient we didn't find any leukemic cells and for two patients we found leukemic cell per , analyzed cells. znf is considered as a transcriptional target for p and plays an important role in the homologous recombination, mitosis, centrosome dynamics. as was shown by gwas some snps in znf have strong association with the risk of breast cancer (bc). however, it was unclear whether the same snps are associated with risk of bc in kazakhstan. therefore two polymorphisms (rs , rs ) of znf were investigated in kazakh population in this study. the present case-control study was carried out with participation of kazakh females with bc and cancer-free donors. additionally, subtypes of bc, stratified by estrogen receptor (er+/À), progesterone receptor (pr+/À) and human epidermal growth factor receptor (her +/À) status were estimated. pearson p-value, odds ratio, % confidence interval tests were applied to data analysis. significant differences were found in allele frequency and genotype distribution at rs locus in znf between the patients and control groups (p = . for allele; p = . for genotype). moreover, significant association with bc was revealed for rs after dividing patients according to er+/ À, pr+/À and her +/À status of the tumor. the g allele was associated with er+ (p = . , or = . , %ci: . - . ), pr+ (p = . , or = . , %ci: . - . ) and gg genotype with her -bc carriers (p = . , or = . , %ci: . - . ). also, g allele can be considered as a risk factors in er+/ pr+/her -luminal type of tumor (p = . , or = . , % ci: . - . ). our findings correlate with the data of several gwas where the association of the rs polymorphism with higher mammographic density and the risk of breast cancer have been shown. the obtained results allow us to consider g allele and gg genotype of rs as a marker of bc risk with predictive value, restricted to er, pr and her status of the tumor in the kazakh population. breast cancer (bc) is the most common cancer among women in most of countries. alternative variants of low-penetrance genes such as fgfr (rs ), tox (rs ), map k (rs ), lsp (rs ) are shown to have high frequency in north america, south-east asia, australia, europe populations and a multiplicative effect on the development of bc. in this study was investigated assosiasion between alleles/genotypes combinations of these genes with increase/decrease of bc risk. the case-control study included bc patients and healthy women from kazakh and russian populations. genotyping was performed by pcr-rflp methods. combined effect of allele and genotype variations in four different genes on bc risk was assessed by apsampler algorithm. the fisher exact test, odds ratio (or) with % confidence intervals ( % ci) were applied to data analysis. according to obtained results combinations of allele c of tox rs and a of map k rs (p = . , or = . ), also allele c of tox rs and c of lsp rs (p = . , or = . ) associated with increased bc risk in the russian population. consequently, combinations with c allele of tox rs contribute significantly to bc risk with p-value = . , or = . . on the contrary, tt genotype of tox rs with p = . , or = . and its combination with allele t of lsp rs with p = . , or = . determine a bc risk reduction in russian population. in addition, a risk combination of allele c of lsp rs and a of map k rs was found in kazakh population (p = . , or = . ). studies have shown that a genetic predisposition to bc can be determined by the cumulative effect of individual alleles and genotypes and possible epistatic interactions of studied genes. obtained combinations of alleles and genotypes can be considered as complex genetic markers of bc and may be used as predictive. cancer that is caused by excessive proliferation of cells and reduced apoptosis is a pathological condition. currently, studies that are comitted with breast cancer are great important early detection and diagnosis of breast cancer. after the discovery of cisplatin as chemoterapy drug, new transition metal based complexes have been developed for treatment of cancer. in this study, anti-cancer activity of azo-azomethide ligand and its mononuclear metal complexes is studied on human cancer cell lines (mcf- ) and mouse fibroblast (l ) cell lines. cells were studied four different concentrations ( , ; ; ; lm). xtt ( , -bis-( -methoxy- -nitro- -sulfophenyl)- h-tetrazolium- -carboxanilide) protocol was applied after and hours. in our study % fetal bovine serum (fbs), % l-glutamine, iu/ml penicillin and mg/ml streptomycin in dmem (low glucose) were used. cancer cell lines in dmem medium is produced in % humidity and % co incubator at °c. anti-cancer activity of synthesized complexes were determined on mcf- and l . in the biological activity studies, synthesized compounds showed higher anticancer activity than positive control ( -fu). finally, our new synthesized complexes can be suggested that potent ajan for anti-tumuour for breast cancer drugs. large interindividual differences in response to chemotherapy present an important issue in cancer treatment. malignant mesothelioma (mm) is an aggressive tumor with poor prognosis, treated mostly with gemcitabine/cisplatin (gem/cis) or pemetrexed/cisplatin (pmx/cis) chemotherapy. as both clinical characteristics and genetic variability may affect treatment outcome, our aim was to construct and validate clinical-pharmacogenetic prediction models of treatment outcome in mm for both chemotherapy regimens and to develop an algorithm for genotype-based treatment recommendations. clinical-pharmacogenetic models were built on gem/cistreated and pmx/cis-treated mm patients. pharmacogenetic scores were assigned by rounding the regression coefficients. gem/cis model was validated on independent mm patients. model predicting outcome of gem/cis chemotherapy included crp level, histological type, performance status, rrm rs , ercc rs , ercc rs , and xrcc rs . values ranged between and . ; cutoff value of . had sensitivity of . and specificity of . . patients with higher score had shorter progression-free and overall survival (p < . ). in the validation group, positive predictive value was . and negative predictive value was . . model predicting outcome of pmx/cis chemotherapy included crp level, mthfd rs , and abcc rs with scores ranging between and . . cutoff value of . had sensitivity of . and specificity of . . patients with higher score had lower probability of good response and shorter progression-free survival (p < . ). clinical-pharmacogenetic models could enable stratification of mm patients based on their probability of response to gem/cis or pmx/cis and improve treatment outcome. this approach could be used for translation of pharmacogenetic testing to clinical practice as it would facilitate the selection of the best treatment option for each patient. p- . . - evaluation of anti-diabetic potential of circiliol and circilineol using caco cell line diabetes mellitus is a metabolic disorder, and many people are suffering from this disease in the worldwide. oral hypoglycemic agents such as sulfonylureas and biguanides are currently used for the treatment. however, studies searching for a more effective anti-diabetic agents are being carried out continıously. based on that we aim to investigate the potential anti-diabetic effects of circilineol and circiliol isolated from teucrium alyssifolium extract, using in vitro cell culture models. for this purpose, the anti-diabetic actions were investigated by applying model caco (colorectal adenocarcinoma) cell line. we determined the level of ag (alpha-glucosidase), sglt (sodium-glucose transporter- ) and glut - and glucose transport. neither ag activity nor sglt activity was increased with either circiliol or circilineol treatment in caco cells compared to positive control. similarly, neither the activity nor the expression level of glut *- was increased in caco cell line with either circiliol or circilineol treatment relative to control. in conclusion, these results strongly suggest that circiliol and circilineol do not possess any anti-diabetic potentials.supported by tubitak z and paubap fbe the purpose of this study was to characterize and assess the impact of a novel magnetite (fe o ) nanosystem functionalized with the natural origin compound eugenol (e) on the pseudomonas aeruginosa virulence, biofilm formation and qs signaling in order to advance research aimed to find alternative and personalized therapeutic approaches for severe infections produced by this opportunistic pathogen. fe o nanoparticles were obtained by a co-precipitation method and functionalized with analytical purity e. functionalized nanoparticles (fe o @e) were characterized by ir, sem, tga and hr tem. one laboratory and p. aeruginosa clinical isolates were utilized in the study. growth and biofilm formation were assessed by an adapted microdilution method followed by absorbance reads and viable count analysis in dynamics ( , , and hours of treatment). soluble virulence factors production was assessed by enzyme activity evaluation of bacteria grown on specific media. the expression of qs core genes was analyzed by qrt-pcr and a luminescence assay. results demonstrated that the average size of the obtained nanosystem ranges - nm, particles are relatively homogenous and have a low tendency to form aggregates. subinhibitory concentrations of fe o @e limited biofilms formation in a time and strain dependent manner, and significantly inhibited the production of toxin pore forming enzymes (haemolysins and lipases) in most strains. the expression of lasi and lasr genes was three fold downregulated, while the expression of pqsr was upregulated in planktonic cultures suggesting that pqs signaling may be involved in virulence modulation after nanoparticle stimulation. the modulation of bacterial virulence and molecular signaling by functional nanoparticles utilized in subinhibitory amounts offer valuable perspectives to develop personalized antimicrobial approaches based on molecular communication control that clearly modulate pathogenicity and progression of the infectious process. p- . . - specimen processing and handling for plasma ammonia measurement b. sarac ßligil , , s. abus ßo glu , f. aky€ urek , b. € ozt€ urk selc ßuk medical school, konya, biochemistry department, selcuk university faculty of medicine, konya, turkey objectives: ammonia requires special processing and handling conditions due to its' unstability. in this study, our aim to investigate a preanalytical factor (delayed analyze) affecting plasma ammonia measurement. design and methods: blood samples were obtained from healthy volunteers. for determining different handling and storage conditions, the following protocols were applied: first protocol (a) transportation on ice and separation (centrifugation at °c) within minutes of collection and analyze immediately. second protocol (b) transportation on ice and separation (centrifugation at °c) within minutes and analyse refrigerated - °c hours (a , b ) and hours (a , b ). all plasma ammonia levels was analyzed enzimatic glutamate dehiydrogenase methods by abbott architect c clinical chemistry analyzer. results: there were statistically alterations in all protocols compared to first protocol. prolonged centrifugation time for plasma ammonia lead to have higher results ( . versus . lg/dl, p < . ). in all protocols including a , a , b , b also cause an elevation in plasma ammonia results ( . , . , . and . ; p = . , p < . , p < . , p < . , respectively). conclusions: ammonia concentration in the blood sample increases over time due to high concentrations in cells as erythrocyte or platelets (three fold). blood samples collected for ammonia determination should be stored on ice, and measured immediately. the wnt/b-catenin signaling pathway has been considered to be a factor in the development and progression of colorectal cancer. many studies have demonstrated that the presence of mutations or polymorphisms in ctnnb (gene encoding b-catenin; mostly mutations in exon ) can lead to aberrant activation of wnt/bcatenin signaling at the onset of various types of malignancies, including colorectal cancer. the aim of our study was to assess ctnnb alteration in the patients with colorectal cancer and compared their tumor and normal tissues. a total of paraffin-embedded colorectal tumor specimens were obtained from department of pathology in cerrahpasa medical faculty. also a total paraffin-embedded normal tissue was used from same cases as a control group. ten-micrometer-thick tissue sections were placed on a glass slide and stained with he. then the tissue sections were dehydrated in graded ethanol solutions and dried without a cover glass. dna was extracted from the tissues with ll of extraction buffer at °c over night. the tubes were boiled for min to inactivate the proteinase k. ctnnb exon was amplified by pcr. sscp is used to observe any difference between the groups. genomic dna was isolated as described above. ll of each pcr products mixed with ll denaturating buffer and were denatured by heating at °c for minutes in, and then were rapidly cooled on ice. the denatured pcr samples are run on % acrylamide/ bis gel in . tbe buffer for . hours at v at room temperature with water cooling system. the gel was stained with silver staining method. migration and adhesion involve continuous modulation of cell motility, beta-catenin play major roles. beta-catenin gene alterations frequency range between and % in colorectal cancer according to the different published studies. in our study no significant differences were found in the ctnnb exon between the tumor group and normal groups. p- . . - theranostic approach in agressive recurrent meningiomafirst experience in turkey m. o. demirkol , b. uc ßar koc ß university, istanbul, american hospital, istanbul, turkey meningiomas arise from the meningothelial cells of the arachnoid membranes of the leptomeninx, which are attached to the inner layer of the dura mater. meningiomas can be classified into three grades (i-iii): grade i meningiomas which are benign, exhibit slow growth; grade ii (atypical) and grade iii (anaplastic) meningiomas, which have a much more aggressive clinical behaviour. meningiomas express non-steroid hormones, including somatostatin. in the brain, somatostatin-a cyclic tetradecapeptide neuropeptide-is believed to act as a neurotransmitter and neuromodulator. somatostatin performs its physiological functions by binding to specific receptors (sstri-sstrv). sstr exhibit high affinity for octreotate (tate). tate is a polar, watersoluble peptide that does not penetrate the intact bbb (brain-blood barrier). pet and scintigraphic imagings can only demonstrate somatostatin receptor positive intracranial lesions if the bbb is disrupted. in this aim, dotatate (dota-dphe , tyr -octreotate, tate) has been labelled with the positron emitter ga and the beta and gama emitter lu. in this case, we conducted a study to evaluate peptide receptor radionuclide therapy (prrt) planning based on pet/ct imaging of meningioma in the department of nuclear medicine and molecular imaging at the amerikan hospital. [ ga] dota -tyr -oc-pet/ct has been established as the imaging modality of choice for the diagnosis and management of patient with skull-base malign meningioma (rapid progress -to mm. from mm. in d.-after fifth operation). due to its high sstr selectivity, [ lu]-tate showed significantly lower uptake/dose delivered to normal tissues, gatate-pet represents the imaging strategy of choice for an accurate assessment of sstr expression levels. although some studies have not shown a clear advantage over pet/ct, there is some evidence that it will have an advantage in selected body sites such as the head and neck, liver, and the pelvis. p- . . - cardiovascular diseases can be treated by using 'tetr-odd-vp ' and 'hre' hypoxia inducible systems a. celik , t. kaya , s. cigdem , m. g€ und€ uz department of medical genetic, turgut ozal university, ankara, faculty of medicine, turgut ozal university, ankara, turkey ischemia is an insufficient supply of blood to a tissue or organ, usually due to a blocked artery by a blood clot. up to now, the number one cause of death worldwide is caused by ischemia and related conditions such as heart attack or stroke. hif- a is a transcription activator that functions as a master regulator of oxygen homeostasis. hif- a protein levels increase under hypoxic conditions as a result of decreased o -dependent prolyl-hydroxylation, ubiqutination and degradation. we aimed to break up clots in blood vessels and to prevent damage caused by ischemia by using hypoxia inducible systems. we added oxygen dependent degredation domain (odd) of hif a between and in front of tetr dna binding domain and vp transactivation domain, so that tetr-odd-vp or odd-tetr-vp could activate transcription of tissue plasminogen activator (tpa) controlled by tetracycline response element (tre), in a hif a independent manner. in addition, we also designed tissue plasminogen activator (tpa) under control of hypoxia response element (hre) of hif a target genes. western blotting and immunofluorescence assay results showed the expression and nuclear localization of tetr-odd-vp and odd-tetr-vp constructs under hypoxic conditions, but not normoxic. in addition, using fluorometric reporter systems and tpa enzymatic assay we proved functionality of these constructs under hypoxic conditions. final apporoach to our project is predicting kinetic enzymatic activity of tpa during break up blood clots by using matlab. the results of the present investigation showed, the developed hypoxia responsible systems that can be engineered into endothelial cells to prevent ischemia related cardiovascular diseases. p- . . - osteogenic potential assessment of some original scaffolds with magnetic properties new advances in bone tissue engineering demand the development of materials that can not only replace bone, but also regenerate the damaged tissue based on external or even internal stimulus. magnetic materials inside bone scaffolds are known to be a promoting factor for bone healing especially when the therapy is accompanied by application of external magnetic stimulation. based on a recent report, the presence of iron oxide in hydroxyapatite can improve the radio opacity and osteoblast proliferation. in this view, this study focuses on the development of silk fibroin-magnetite biocomposites for potential uses in bone tissue bioenegineering. such novel composites possess good mechanical properties, biocompatibility and biomineralization potential by in vitro tests and could become smart arhiectures, able to stimulate bone regeneration. a new culture model was developed by exposing a d cell/ scaffold bioconstruct to a continuous magnetic field during weeks of osteogenic induction. in this view, mc t -e murine osteoblastes progenitor cells were seeded inside the novel silk fibroin-magnetite biocomposites and subjected to osteogenesys in a magnetic field during days. osteogenic specific markers were evaluated every week in the presence and absence of the field. our results showed that the osteogenic marker's expression started earlier when mc t -e cells were exposed to the magnetic field. consequently, in our experimental model, the magnetic field had a benefic effect on the osteogenic differentiation process as mc t -e cells differentiated more efficiently in its presence. these results suggest that the bone healing process could be improved in the presence of a magnetic field. nevertheless, further in vivo studies on animal model should be employed for validation. p- . . - impact of physical activity performed on different times of day on cardiac and skeletal muscle damage in trained and untrained male subjects s. algul, m. kara, o. ozcelik y€ uz€ unc€ u yil university, van, turkey introduction: physical activity elevates creatine kinase (ck) and creatine kinase myocardial band (ck-mb) levels which have been considered to be an indirect marker of skeletal and cardiac muscles damage. purpose: impact of physical activity performed on different times of day on serum levels of ck and ck-mb were investigated in trained and untrained male subjects. materials and methods: trained (n = , . ae . yr, . ae . kg) and untrained (n = , . ae . yr, . ae . kg) subjects performed three soccer matches ( min) in field ( m versus m) in morning (m), afternoon (a) and at night (n) on separate days. the study protocol was approved by the local ethics committee. venous blood samples were taken at onset and at end of match. serum ck and ck-mb levels are measured using autoanalyser. data are expressed as mean ae s.e., compared by wilcoxon-signed rank and mann-whitney u-tests. p < . was accepted as statistically significant. results: ck and ck-mb levels increased in three matches in both groups (p < . ). importantly, there were significant increases in ck-mb levels in a and n exercises compared to m exercise (p < . ) in trained ( . ae . u/l versus . ae . u/l, % (m) . ae . u/l versus ae . u/l, % (a) . ae . u/l versus . ae . u/l, % (n) and also untrained groups ( . ae . u/l versus . ae . u/l, % (m), . ae . u/l versus . ae . u/l, % (a) . ae . u/l versus . ae . u/l, % (n). discussion: increased metabolic stress or muscle damage during physical exercise elevate serum ck and ck-mb levels. however, higher percentage of increase in ck-mb levels in a and n exercise may reflects additional increases in cardiac muscle stress despite the similar skeletal muscle stress as indicated by ck levels. conclusion: considering the observation of higher percentage increase in ck-mb levels in untrained and also trained subjects, the caution should be taken while performing an exercise in a and n time especially in subjects who has cardiac weakness. p- . . - regional assessment of hematological and discrimination indices of complete blood count for beta-thalassemia screening beta-thalassemia is one of the most common genetic abnormality causing health problems worldwide. blood count and film of beta thalassemia trait and iron deficiency anemia have similar features. therefore, several simple screening indices have been developed for differentiating between these diseases. it was to asaimed to assess the hematological parameters and discrimination indices in patients with betathalassemia trait who admitted to our hospital. the parameters of complete blood count (cbc) in subjects ( males and females) diagnosed by mutational analysis (pcr, gene amplification, dna sequencing) between and , were retrospectively screened and the thalassemia status of patients was assessed in terms of discrimination indices (eng-land&fraser (ef), green&king (gk), mentzer (m), ricerca (r), shine&lal (s-l), srivastava (s), ehsani and sirdah). the percentages of being above the cut off value were detected by ef . %, gk . %, m . %, r . %, s-l . %, s . %, ehsani . % and sirdah . %. the percentages of falsely negatives for the indices of ricerca and shine&lal were lower than others. morever, when the first three common mutations of our study were considered, out of , out of and out of patients were up to the cut off values in terms of e&f, g&k, m, s, ehsani and sirdah indices for ivs-i- (g>a), ivsii- (g>a) and heterozygous codon deletion (-aa), respectively. the molecular diagnosis and prenatal detection for families at risk is important because of the difficulties of treatment in this disease. however, the use of discrimination indices may be valuable for distinguishing of thalassemia trait from iron defiency anemia when the equipment of molecular diagnosis are limited. in our study, ricerca and shine&lal had lower falsely negative results than others. nevertheless, further studies to detect diagnostic perfomance of discriminant indices should be conducted. p- . . - novel therapeutic agents in the development of effective drug combinations to treat glioma s. avdieiev , l. gera , r. hodges institute of molecular biology and genetics, kyiv, ukraine, university of colorado, aurora, co, united states glial tumors are driven by multiple molecular aberrations that cannot be controlled by a single targeted agent. so, it is possible to expect that the combined multitarget anti-cancer therapy aimed simultaneously at different elements of tumor formation mechanisms will be more effective and will promote the extension of patients' life. to find out which drug combinations will enable the development of therapeutic regimens with improved effectiveness and decreased toxicity, the cytotoxic effects of several bradykinin antagonists (ba) were analyzed for different glioblastoma (gb) cell lines. among all the ba under investigation, bkm- appeared to be the most effective, with ic values of lm and . lm in rat glioma c and human glioblastoma u cell lines, respectively. bkm- suppressed erk / and akt phosphorylation in u cells. temozolomide (tmz), the firstline anti-gliomic drug used in clinics, has only a temporary positive effect and severe side effects in gb patients. we showed that the combination of bkm- and tmz led to significant potentiation of tmz cytotoxicity at sub-therapeutic concentrations. recombinant proteins with cytotoxic properties are promising agents for complex therapeutic applications. we revealed that the glioma-associated protein chi l inhibited the viability of u cells more effectively than tmz. furthermore, the combination of chi l and bkm- resulted in an additive cytotoxic effect. chi l -mediated decrease of cell viability was associated with a g /s transition arrest. chi l provoked the dramatic reduction of prb phosphorylation and a significant decrease of cyclin d expression, as well as a substantial increase in p level. in addition to the accumulation of p , we observed the upregulation of cdk inhibitor p . therefore, g /s arrest in chi l -treated cells could be realized via activation of prb, downregulation of cyclin d, and activation of p . harmful hereditary mutations in brca and brca are one of the most important risk factors of breast cancer. the aim of this study is to determine the mutations which are associated with breast cancer in people which is diagnosed breast cancer and/or have breast cancer-diagnosed family members by sanger sequencing and thus provide predictive and prognostic utility. our ongoing study is present the genetic variations in brca and brca genes in breast cancer-diagnosed patients, that one of them is male, and person yet healthy whose brca was sequenced by sanger sequencing. the data were analyzed by using seqscape software . and detected variations were compared with literature. in brca , we determined different benign genetic variations and variation with unknown significance and variation which has not in literature. in brca gene of patient and healthy person, benign variations, variations with unknown significance, variations which has not in literature and mutation were determined. this mutation is c. - delgtca and is located in occr. c. - a>c variation in brca gene, was determined in only male patient.c. t>a variation in exon of brca , was observed in only the youngest patient who has no family member with breast cancer and healthy person. while this variation takes place in literature as variation with 'uncertain clinical significance', an in silico program mutation taster speculated as 'disease causing' for this variation. also, almost all of variations with 'unknown significance' literature knowledge were determined in only one and different cases. this situation increases the possibility of being pathogenic of this variations. the our findings until now can contribute to variations with uncertain clinical significance in the literature. also the variations that have not in the literature but we suggest the possible relation with breast cancer as an estimate may be added to literature by expanding the study. p- . . - inhibition of the recombinant human butyrylcholinesterase with paraoxon and coumarin analog of soman organophosphorus compounds (op) represent a class of extremely toxic chemicals that are used as warfare agents. uncontrolled utilization of op is highly dangerous due to their high potential to be efficient poisons in terrorist attacks. current therapy of op poisoning include intravenous administration of atropine and acetylcholine reactivators however, it does not completely eliminate brain damage effects. alternative experimental therapy against op poisoning is utilization of bioscavengers that irreversibly react with op and rapidly inactivate them. recombinant human butyrylcholinesterase (rhbche) is one of the most promising candidates as bioscavenger due to its pharmacokinetic characteristics and broad spectrum of op neutralizing activity. here we investigated in vitro inhibition of rhbche with two model oppesticide paraoxon (pox) and coumarin analog of soman (gd c ). both op lead to rapid and irreversible inactivation of rhbche that was monitored using ellman assay and fluorescence measurements. bimolecular inhibition rate constants dramatically differ between pox and gd c that could be explained by steric hindrance in soman analog. the next steps forward creation of catalytic bioscavengers based on rhbche should be done based on mechanisms of op-rhbche interactions. this work was performed in frame of grant rfme-fi x . non-hodgkin lymphomas (nhls) represent a heterogeneous group of malignancies that arise from the lymphoid system. at the present time exist a lot of drugs for the nhls therapy, but mostly all of them are unsafe and there is no consensus regarding the best treatment protocol. to increase the efficacy and safety of therapeutic b-lymphocyte depletion in lymphomas and leukemia's it would be preferable to induce the death of pathological b cells without affecting normal b cells to prevent side effects. similar to other types of cancer, nhls arise by a multistep accumulation of genetic aberrations that induce a selective growth advantage of the malignant clone. all b-cells of organism have a unique cell surface markerantigen b-cell receptor (bcr). we generate novel approach for personalized non-hodgkin lymphomas therapy based on peptide specific to malignant cells surface receptor. for this purpose we designed new lentiviral peptide library screening technique based on fluorescent reporter cells system. herein aa peptide library was used for screening of nhl's malignant receptor agonist. patients' lymph nodes biopsy samples mrna was used as a source of malignant bcr nucleotide sequence. variable domain of the lymphoma bcr was used for chimeric receptor generation, where bcr vh/vl part responsible for agonist recognition and bottom part of receptor was retranslate signal to the reporter gene. in this embodiment of the method, very large numbers of candidate aa peptides expressing lentivirus and eukaryotic reporter cells are packaged together in a format where each is capable of replication, thereby forging a direct link between genotype and phenotype. after four rounds of screening we discover peptides specifically interacted with malignant bcr's. selected peptide ligands were fused with chimeric antigen receptor for expression on t-cells. modified tcells selectively eliminate nhl's malignant cells ex vivo. this work was supported by grant rfmefi x . introduction: pesticides are used to prevent damage of unwanted insects, rodents, plant, moss and other pests. excessive use of pesticides may cause adverse effects in animals and humans. chlorpyrifosethylene (cpe) is an organophosphate pesticide, used in many agricultural products such as figs, cherries, olives worldwide; caused acute poisoning and chronically oxidative stress. rosadamascena mill (rosaceae) is a rose, used for production of rosewater (rw) and rose oil worldwide. rosaceae products are consumed in food and cosmetic industries. materials and methods: in this study, we investigated that cpe and rw effects on kidney tissues of rats. this study was included adult male rats, divided into groups. each group included rats. i.group: control (regular feed), ii.group: cpe ( . mg/kg/day), iii.group: rw ( mg/kg/day) and iv.group: cpe ( . mg/kg/day) + rw ( mg/kg/day). following days, kidneys were taken after sacrificed. analyzes were performed that malondialdehyde (mda), nitric oxide (no) as oxidant; superoxide dismutase (sod), glutathione reductase (gr) as antioxidant parameters. results: as compared with control, mda and no levels in cpe were a significant increase was determined (p conclusion: cpe is shown that significant increase on oxidant parameters, but significant decrease on antioxidant parameters. rw occurs opposite situation. similarly results of cpe, rw + cpe increased oxidant parameters, but decreased antioxidant parameters. these changes are lower than only cpe. these results showed that positive effects both rw and rw + cpe increasing on antioxidant parameters, also decreasing on oxidant parameters. we provide the comparative analysis of the reduced glutathione (gsh), reactive oxygen species (ros), a-tocopherol levels, an intracellular labile zn + pool and esterase activity of red blood cells of patients with diagnosed components of the metabolic syndrome (ms)arterial hypertension and diabetes mellitus type ii (ah + dm + ). as the comparison groups were selected patients with one diagnosed component of msarterial hypertension (ah + dm À ) or without any diagnosed component of ms (ah -dm -). patients of all investigated groups were at the hospital treatment with a diagnosis coronary heart disease (chd) ii degree. human blood was obtained from normal donors and patients with chd ii stage. cytosolic esterase activity was assessed using calcein-am test. ros level was evaluated using cm-h dcf-da. gsh level was estimated using lowry method. an intracellular labile zn + pool was assessed using fluozin- -am. investigations were performed on the specord m , hplc system lc- prominence (shimadzu) and facscantoii (bd). a significant decrease of the intracellular level of labile zn + in erythrocytes of patients with ah + dm + compare with ah + dm À and ah À dm À was shown. this fact confirms our assumption concerning the important role of zinc homeostasis in the etiopathogenesis of diabetes mellitus type ii. a direct relationship between the intracellular zn + level modification and erythrocytes esterase activity of patients with chd ii degree was observed. moreover, in ah + dm + group of patients this relation was more marked. the unidirectional alteration in the erythrocytes redox state (gsh and a-tocopherol levels reduction, ros formation activation) was revealed at the whole of investigated chd patients groups (ah + dm + , ah + dm À , ah À dm À ). however, the pathological erythrocytes response on in vitro action of the different antioxidants (n-acetylcysteine, ascorbic acid, a-tocopherol, quercetin) had a diverse character that can be a significant test under antioxidant therapy prescription. it is known that long-term social isolation and the disorder of natural circadian rhythm is considered an important stress factors, which cause a variety of metabolic and mental disorders. it should be noted that the impact of the stresses takes up a larger area, according to, review of the action of their mechanism is one of the topical issues of modern science. it is estimated that as a result of stress the metabolic processes change in the organizm. because of this, we've studied the functionality of the antioxidant system in laboratory rat heart muscle cells and blood under psycho-emotional stress. it was found that quantitative changes of nitric oxide (no) was initiated the process of lpo, which caused oxidative stress in the cells and decreased antioxidant enzymes activity, such as catalase,sod, gpx and gr. the results suggested that psycho-emotional stress was accompanied by oxidative stress, causing a reduction in the intensity of energy metabolism in cardiac muscle cells, which was further strengthened by the fact that the activity of the enzymes involved in atp synthesis in mitochondria was reduced. also, we've studied exogenous creatine positive and negative affects on energy metabolism and blood lipid spectrum. based on this, we proposed that psychological stress is one of the factors contributing to the development of various cardiac diseases. the importance of free radical lipid transformations, which differ from the peroxidation processes, was pointed out for the first time in our laboratory studies. we have found that ros can induce free radical destruction processes of sphingolipids with c-c-bond cleavage [lipids, , : - ; lipid insights, , - ] . in case of acylated sphingolipids, they can undergo decomposition with c-c-bond cleavage upon direct uv irradiation [photochem. photobiol., , : - ] . it was of interest to establish the possibility of photosensitized decomposition reactions of not acylated sphingolipids, which do not absorb an ultraviolet. in this work we studied photosensitized reactions of sphingosines containing a free amino group, and low molecular compounds, which simulate their structure, such as aminoalcohols (serinol). as photosensitizers, the salts of transition metals, hydrogen peroxide, and acetone were used. oxygen was removed by bubbling with argon to reduce the probability of side reactions during photolysis of sphingolipids, such as oxidation processes (including oxygen reactions with alkyl radicals). we have shown that the action of uv-radiation on aminoalcohols and sphingosines in aqueous solutions in the presence of photosensitizers induces their destruction with c-c bond rupture. the main carbonyl product of sphingosines free radical destruction was an unsaturated aldehyde - -hexadecanal. it was found, that -hexadecenal possesses a wide spectrum of biological activity: it promotes reorganization of the cell cytoskeleton and modifies the redox state of the cells [febs journal (suppl. ), abstracts: mem. biol. s , lipid signaling & dynamics, p. .] . the results of this study can expand the frontier of research regarding free radical lipid damage, which could contribute to a better understanding of the origins of diseases associated with the activation of free radical processes in living organisms. structural basis for the - - proteindependent inhibition of apoptosis signalregulating kinase protein kinase ask (apoptosis signal-regulating kinase ) is a member of the mitogen-activated protein kinase kinase kinase (map k) family that plays a crucial role in immune and stress responses. the activity of ask is regulated through homo-oligomerization and interaction with other proteins including the - - protein which binds to the phosphorylated motif located at the c-terminus of the kinase domain of ask and suppresses its catalytic activity through unknown mechanism. under stress conditions, ask is dephosphorylated at ser and the - - protein dissociates. this dissociation is then one of the factors that lead to the activation of ask . we performed low-resolution structural analysis of the kinase domain of ask (ask -cd) bound to - - using chemical cross-linking, analytical ultracentrifugation and small angle x-ray scattering. the low-resolution structural analysis shows that ask -cd binds to the - - protein in two to two stoichiometry through a small binding interface involving surface of - - outside its central channel and several regions from the c-lobe of ask -cd. the complex is dynamic and conformationally heterogeneous. phosphorus nmr and time-resolved fluorescence measurements, together with low-resolution structural analysis, indicate that binding of ask -cd to - - modulates conformation of ask 's activation segment. these results suggest that the - - binding suppresses the catalytic activity of ask through direct structural modulation of its activation segment. our study provides new insight into the interaction between the kinase domain of ask and - - and offers a plausible structural explanation for the - - protein-dependent inhibition of ask kinase activity. introduction: thymoquinone ( -methyl- -isopropyl- , -benzoquinone, tq) exerts a great antitumor activity against different types of cancer cells. a growing body of evidence indicates that reactive oxygen species (ros) generation followed by modulation of the akt and mapk pathways is a general mechanisms underlying the tq antitumor action. however, the data of tq effects on the mapk pathway are conflicting. to date, the activation or inhibition of the mapk protein family seems to depend on the cell type and on the tq concentration used. in order to elucidate the antitumor potential of tq against gliomas and the underlying molecular mechanism, tq influence on c rat glioma cells functioning was studied. results: it has been shown that the cultivation of c cells with tq in concentrations of - lm during hours strongly inhibits cell proliferation and induces cell death with id of lm. at the same time, tq induces ros generation and intracellular gsh depletion in a dose-dependent manner, that is followed by the mitochondrial potential decrease. interestingly, ros production has only cytoplasmic, but not mitochondrial origin in cells challenged with tq at the concentrations up to lm. two-electron reduction of tq by dt-diaphorase attenuates tq anticancer efficiency whereby inhibition of dt-diaphorase by dicumarol increases tq-induced c cell death by %. we analyzed mapk pathways involvement in c cells growth inhibition at tq treatment. it has been shown that inhibition of the erk pathway by pd and jnk pathway by sp does not influence on tq-induced effects. on the contrary, the specific phosphoinositide- -kinase (pi k) inhibitor (ly ) abrogates tq-induced growth arrest. conclusion: antitumor effects of thymoquinone on c glioma cells is a result of ros generation and intracellular gsh depletion, that is followed by mitochondria disfunction, and growth arrest via pi k pathway. assessment of oxidative stress and antioxidant defense activity parameters in patients with hiv-infection is of great importance, especially for hiv-positive women of reproductive age planning to have children. data of women of reproductive age with hiv-infection analyzed: patients with hiv-monoinfection (n = ) and patients with co-infection (hiv and hepatitis b and / or c) (n = ). as a control we used the data of healthy women (n = ). serum and hemolysate used as material for the study. lpo-aod products were determined by spectrophotometric and fluorometric methods. average value of initial lpo products -diene conjugates was significantly increased in the group with hiv-co-infected compared to control ( . times; p = . ) and group with hivmonoinfection ( . -fold; p = . ). the level of secondary products -ketodienes and conjugated trienes increased in patients of both groups compared to control ( . times (p = . ) and . -fold (p < . ), respectively). at the same time isolated double bonds and tba-active products content showed no significant changes (p > , ). total antioxidant activity parameter decreased . fold (p = . ) in the group with hiv-monoinfection compared to control. decrease in activity of the primary antioxidant enzyme -superoxide dismutase (p = . , compared to the control and p = . , compared with the group with hiv-monoinfection) and the level of a-tocopherol ( . -fold to control and . fold to hiv-monoinfection) was detected in the group with hiv-coinfection. . -fold higher content of retinol in hiv-coinfection group (compared to the control) revealed. in women with hiv-coinfection the oxidative stress was significantly higher than in women with hiv-monoinfection. suggested to include antioxidant supplements in the complex pathogenetic therapy in women with hiv-coinfection (hiv and hepatitis b and / or c), which will contribute to women's ability to bear children. p- . . - acute different doses of malathion induce cholinesterase inhibition, glucogenic enzymes and histopathological change in rat liver malathion, which is an organophosphorus compound, is a widely used pesticide all over the world. despite its benefits, malathion has many toxic effects on many tissues including liver. we designed to evaluate the acute different doses of malathion on cholinesterase (che) inhibition, gluconeogenic enzymes and histopathological change of rat liver. for this purpose groups were formed. rats in group served as control group animals which were only given corn oil. group , group and group were administered , , mg/kg of malathion, respectively, dissolved in corn oil by oral gavage. the rats were sacrificed after hours following administration and the livers of rats were removed. the liver che, alanine aminotransferase (alt), aspartate aminotransferase (ast) and lactate dehydrogenase (ldh) were studied using autoanalyzer. histopathological investigation was performed using microscope. the liver che activities of group , group and group were inhibition percentage of %, %, and % respectively, comparison of group 's che activity. the liver alt, ast and ldh increased in group and group compare to group and group (p < . ). we also observed that there was vacuolar and hydropic degeneration in liver of group . according to our result, acute administrations of malathion result in hepatotoxic effects with increasing doses. background and aims: an imbalance between free radicals and antioxidants is closely linked to the onset of an acute myocardial infarction (ami). the aim of this study was to investigate the antioxidant status and the lipid peroxidation in patients admitted to hospital immediately after ami. methods: the study population comprised patients with ami and healthy subjects. patients that had an acute myocardial infarction (ami) less than hours since onset were selected for this study. antioxidant status was assessed by lactonase activity of paraoxonase (pon dhc), trolox equivalent antioxidant capacity (teac) and plasma uric acid level. malondialdehyde was used as marker of lipid peroxidation. results: compare with the control group, the levels of mda and pon dhc were significantly higher in group with ami (p < . , respectively p < . ). elevated levels of mda (p < . ) were found in patients with ami compare with the control subjects. ami patients had also statistically significant reduced levels of teac (p < . ) comparative with healthy subjects. no statistically significance was found for plasma uric acid level in subjects from our study. conclusion: a high lipid peroxidation correlated with a decreased teac activity suggest an exacerbated oxidative stress in subjects admitted to hospital immediately after an ami. p- . . - dealing with copper toxicity: new insights into copper detoxification in yeast copper (cu), an essential metal, is a double-edged sword, as its essential nature is counterbalanced by the toxic effect that it can exert on cells when not properly controlled. as such, organisms have evolved defence mechanisms against cu toxicity, and in the yeast saccharomyces cerevisiae, the transcription factor ace orchestrates several of those mechanisms, by activating cu-detoxification genes. in s. cerevisiae iron (fe) uptake is partially dependent on cu, as the membrane multicopper-oxidase fet , which is part of the high-affinity iron uptake system, requires cu as a cofactor. aft , the low iron-sensing transcription factor in yeast, is known to regulate the expression of fet gene. however, we found that a strain lacking fet is more sensitive to cu surplus conditions than a strain carrying the aft gene disrupted. this finding suggests that under such conditions another regulator came into play and controls fet gene expression. we next evaluated whether ace could be the alternative regulator of fet under cu excess. to test this hypothesis we first constructed the double mutant aft ace and assayed its fitness under cu surplus. as expected, the double mutant is much more sensitive to cu than the single aft or ace mutants. we next monitored the expression of fet gene in cells lacking ace , using yeast-one hybrid and qrt-pcr approaches. our data clearly indicates that fet expression is dependent on ace when cu is overly abundant. altogether our data unveil a novel mechanism of cu detoxification relying on the activation of fet by ace in an aft independent way. experiments to understand the consequences of this regulation in terms of cu detoxification are currently being undertaken. in joint degeneracy, reactive oxygen species manifest their toxicity both through intrinsic reactivity and the inflammatory process activation, leading to cartilage dysfunctions, injuries of matrix proteins and cytokines stimulation. the study is focused on the identification of oxidative balance modulation (enzymes and oxygen free radicals) by a bioactive extract obtained from small sea fish. the cellular support was represented by the chondrocyte line chon- derived from human long bones (atcc Ò crl- tm ), that assure the reproducibility of a standardised biological system. the oxidative stress was induced through stimulation with il b, a cytokine-factor that promotes the protein catabolism and also with tnfa, the initiator of pro-inflammatory activation, combined with pma, the activator of protein-kinase c, triggering of oxygen reactive species generating cascades. the antioxidant effect was compared with known antioxidants: vitamin c, x fatty acid, n-acetyl -cysteine. the acellular antioxidant/antiradical screening was done using two complementary techniques for total antioxidant status evaluation and completed by measuring cellular catalase (cat) and superoxidedismutase (sod) activity, correlated with intracellular hydrogen-peroxide and superoxide anion monitoring through flow cytometry. the antioxidant properties of the bioactive extract proved in acellular systems are confirmed at cellular level by the involvement of the product in the enzymatic cascade cat -sod, potentiating the catalytic action of the enzymes, and by the decline of both intracellular reactive oxygen species (the hydrogen peroxide decrease with %, the superoxide anion is reduced with % compared with the stimulated control). the demonstrated antioxidant synergy assures a complete cellular protection induced by the small sea fish extract in human condrocytes. introduction: alzheimer's disease (ad) is a progressive neurodegenerative disorder characterized by memory loss, cognitive impairment. oxidative stress is a contributory factor in ad pathogenesis. glutathione (gsh) is the main antioxidant cellular defence. the ratio of gsh/gssg shows the redox status of gsh, and plays important role in maintaining intracellular redox homeostasis. the current study was carried out to determine oxidative dna damage and ratio of gsh/gssg which plays an important role in protection of target molecules from oxidation in the patients with ad. methods: the study subjects were consisted of patients with ad (n = ) and age matched control group (n = ) who were treated and followed in the cerrahpasa medical faculty hospital, department of neurology and department of internal medicine/ geriatrics. dna strand breaks and h o -induced dna damage were determined in lymphocyte dna with comet assay. the gsh and gssg levels in the erythrocyte lysates were measured by using a commercial spectrophotometric kit. the ratio of gsh/gssg were calculated. statistical analysis was performed with spss software package. results: dna strand breaks and h o -induced dna damage were found to be higher (p = . for all), the ratio of gsh/gssg was found to be lower (p = . ) in the ad group than control group. there was no significant difference between male and female for dna strand breaks and h o -induced dna damage in the ad group, but ratio of gsh/gssg were higher in male when compared with female (p = . ). no significant difference was found between the men of ad group and men of the control group for gsh/gssg ratio whereas women of the ad have a lower gsh/gssg ration than those in the women of the control group (p = . ). conclusion: increased systemic oxidative dna damage and dna susceptibility to oxidation may be resulted from diminished gsh/gssg ratio in ad patients. this finding shows the importance of antioxidant support in ad management. p- . . - validation of a liquid chromatography-tandem mass spectrometry method for the measurement of lipid peroxidation product iso-prostaglandin f a in urine m. kant , m. akıs ß , h. _ is ßlekel , department of medical biochemistry, school of medicine, dokuz eylul university, izmir, department of molecular medicine, school of medicine, dokuz eylul university, izmir turkey -iso-prostaglandin f a ( -iso-pgf a ) is a reliable indicator of lipid peroxidation resulting from oxidative lipid damage and is postulated as a gold standard biomarker for the evaluation of oxidative stress. the aim of this study was to validate non-invasive and highly accurate stable isotope dilution-multiple reaction monitoring liquid chromatography-tandem mass spectrometry (sid-mrm lc-ms/ms) method for identification and quantification of -iso-pgf a . twenty four hour urine samples were collected from healthy volunteers at medical school of dokuz eylul university for analytical performance studies. lc-ms/ms analyses were performed on conventional hplc coupled to a triple quadrupole ion trap mass spectrometer equipped with a turboionspray tm source. analyst software version . were used for data analyses. mrm transitions used were m/z? / for -iso-pgf a and m/z? / for -iso-pgf a-d . analytical performance of the method was evaluated by linearity, selectivity, sensitivity, precision and accuracy studies using pure standards and samples extracted from urine of healthy volunteers. the linear calibration range for -iso-pgf a was determined as ng/ml by using standards ranging from . - ng/ml. analytical sensitivity of the method was determined by lod with s/n of and loq with s/n of . lod and loq for iso-pgf a were . À and À ng/ml, respectively. the assay stability and reproducibility were assessed by the precision and accuracy of intra-and interday measurements (n = ). the intra-and interday cvs for -iso-pgf a were . % and . %, respectively. sid-mrm lc-ms/ms method for absolute quantification of -iso-pgf a was optimized and validated in our laboratory and therefore this highly accurate method can successfully be applied to clinical patient samples. p- . . - synergistic anticancer effects of sulforaphane and cisplatin through the induction of apoptosis and autophagy following oxidative stress in malignant mesothelioma cells malignant mesothelioma is characterized by poor responsiveness to current chemotherapeutic drugs, usually owing to high resistance to apoptosis. here, we investigated chemosensitizing effects of phytochemical resveratrol, in combination with cisplatin, on malignant meothelioma cells. cell viability was evaluated using mtt assay. cell apoptosis was detected with dapi staining, caspase / activity assay and flow cytometry. cell cycle distributions, ros levels and mitochondrial membrane potential were determined using flow cytometry. the expression of cell cycle-, apoptosis-, and autophage-related proteins was measured with western blotting. the combination treatment of cisplatin and resveratrol (cis/res) synergistically induced apoptosis, as evidenced by typical cell morphological changes, the appearance of a sub-g /g peak, an increase in the annexin v(+) cells and the cleavage of caspase- and parp. cis/res increased ros production and depolarization of mitochondrial membrane potential with an increase in the bax/bcl- ratio. these changes were attenuated by pre-treatment with n-acetylcysteine, suggesting that cis/res induced apoptosis through oxidative mitochondrial damage. compared with msto- h cells, cis/res was less efficient in killing h- cells. h- cells exhibited an enhanced autophagy to cis/res, as observed by an increase in viable cells exhibiting intense lysotracker red staining and up-regulation of beclin- and lc a. inhibition of autophagy by bafilomycin a rendered cells more sensitive to cis/res-induced cytotoxicity and this was associated with induction of apoptosis. these data indicate that the increased resistance of h- cells to cis/res is closely related to the activation of self-defensive autophagy, and provide the rationale for targeting the autophagy regulation in the treatment of malignant meothelioma. stress oxidative induced by chemotherapy with cyclophosphamide (cp) causes vulnerability in sperm and decline of fertility. this study was aimed to evaluate the role of ethyl pyruvate (ep) in the amelioration of fertility and growth of primitive embryo in animals that received cp. adult male mice ( - weeks) were randomly divided into groups: control group received normal saline ( . ml/day, ip), cp group received cp ( mg/kg/week,¬ ip), the cp+ep group received ep ( mg/kg/day, ip) along with cp, were treated for days. mice from each group were arranged for evaluation of sperm quality and in vitro fertilization (ivf) too. afterward, the separated oocytes from ovulation stimulated mice were conducted to evaluation of ivf and embryo development. the results revealed that cp caused notable decrease in percentage of fertilization in cp group, but administration of ep along with cp caused an increase in the percentage of fertilization in comparison to cp group. the percentage of the two cell zygotes in cp+ep group, and the percentage of blastocysts in control and cp+ep groups were higher than that in cp group (p < . ). results showed that the total number of arrested embryos in control and cp+ep groups was decreased in comparison to cp group (p < . ). the percentage of arrested embryos type i, ii, and iii in cp+ep group was decreased in comparison to cp group, but that decrease was significant only in types i and ii (p < . ). the average motility, viability, nucleus maturity and sperm morphology were decreased significantly in cp group in comparison with control and ep groups, whereas ep caused significant increase of these parameters (p < . ). also, the percentage of dna damage was increased significantly in cp group in comparison with control and ep groups (p < . ). the results of this study indicated that the ethyl pyruvate was able to suppress free radicals and enhance the ivf and quality of sperm in cp treated animals. malathion, which is a member of organophosphate chemical family, is used to control pests and is a widely used pesticide all over the world. however it is also known to be highly toxic on many tissues including pancreas. to test this we set groups to administer a single dose of malathion dissolved in corn oil via oral gavage at the doses of mg/kg (group ), mg/kg (group ) and mg/kg (group ). only plain corn oil was given to control group (group ). the rats were sacrificed hours after administration of the chemical and the pancreases of rats were removed. in an attempt to evaluate the dose dependent response, we measured amylase and lipase activities, insulin, malondialdehyde (mda), total oxidant status (tos) levels in rat pancreases. all of the parameters were measured spectrophotometrically. we found that pancreas insulin levels significantly increased in group compare to group , besides the insulin levels of group and group were significantly higher than group (p < . ). pancreas amylase and lipase activities significantly decreased in group and group compare to group and group (p < . ). however, there was no significant change in pancreas mda and tos levels (p > . ). according to correlation analysis, when pancreas amylase levels declined, lipase levels were decreased simultaneously and there was a strong positive correlation between them (p < . ). in addition, when the comparison was evaluated as a binary, while pancreas amylase and lipase levels diminished, pancreas insulin levels increased and a strong negative correlation between them was found (p < . ). according to our result, acute administrations of malathion leads to alterations of insulin, amylase, and lipase levels with a dose dependent manner, while it does not to change oxidant status. the aim of this study is to evaluate the potential toxic effects of mancozeb on the stress biomarkers such as catalase (cat) activity, malondialdehyde (mda) level and protein levels in the brain tissue of zebrafish (danio rerio). mancozeb, is a synthetic fungicide contaminating aquatic environments as a potential toxic pollutants, was investigated in the present study for acute toxicity. zebrafish groups (m-low and m-high) were exposed to different doses of mancozeb ( mg l- and . mg l- ) for hours except the control group. catalase (cat) activity, malondialdehyde (mda) level and total protein levels were determined by spectrophotometer. the results showed that cat activity and mda levels were decreased in all experiment groups. protein levels were increased in experiment groups when compared to the control group. in conclusion, the changes in the cat activity and mda levels were time and as well as mancozeb dose-dependent. furthermore, the biochemical parameters of mancozeb exposure on zebrafish, showed that mancozeb has significant effect on the zebrafish and/or aquatic organisims. paracetamol (para), which is antipyretic and analgesic, is widely used around the world. paracetamol can be recommended for moderate or mild pains especially in pregnancy as an analgesic. it is known that, paracetamol can cause hepatotoxicity or nephrotoxicity. we were aimed that in this study to show potential hepatoprotective and nephroprotective effect of betaine against long term paracetamol using at therapeutic doses. it has been prepared groups, control, para and para+-betain groups. paracetamol and betaine were administered by gavage to pregnant rats, from first day to the last day of pregnancy (aprox. day). ml physiological saline (% . nacl solutions), mg/kg/day paracetamol, mg/kg/day paracetamol and mg/kg/day betain was given by orally to control, para and para+betain groups respectively. the day of the birth, newborn rats anesthetized by ether and after decapitated. newborn rat's liver and kidney tissues used for biochemical analysis [malondialdehyde (mda), reduced glutathione (gsh), nitric oxide (no) and paraoxonase-arylesterase (pon-are)] and rat's liver and kidney tissues used for histological studies. we showed that, mda and no levels was significantly increased, while pon activities decreased. on the other hand gsh levels and are activities was decreased but these decline wasn't significant in the liver and kidney para group. these biochemical results showed hepatotoxicity and nephrotoxicity in neonates which can be formed in long term maternal paracetamol using at therapeutic doses. also our histological findings was support these biochemical results. we used betaine against potential hepatotoxic and nephrotoxic effect of long term maternal paracetamol using at therapeutic doses for neonates. betaine has antioxidant properties and also used as a methyl donor for transsulfuration reactions in the cell. biochemical and histological examinations showed that betaine protected the tissue injury relatively. p- . . - lipid rafts are involved in modulation of ca + responses induced by glutoxim and molixan in macrophages pharmacological analogues of oxidized glutathione (gssg) disulfide-containing drugs glutoxim Ò (gssg disodium salt with dmetal nanoaddition, «pharma-vam», st. petersburg) and molixan Ò (complex of glutoxim with inosine nucleoside) have found clinical application as a wide range immunomodulators and hemostimulators. however, the cellular and molecular mechanisms of these drugs action are still unclear. previously we showed for the first time that glutoxim and molixan cause biphasic intracellular ca + concentration ([ca + ] i ) increase due to ca + mobilization from thapsigargin-sensitive ca + stores and subsequent store-dependent ca + entry in rat peritoneal macrophages. it is known that key proteins involved in ca + signaling are localized in discrete plasma membrane lipid rafts domains. lipid rafts are cholesterol and sphingolipids enriched microdomains that function as unique signal transduction platforms. thus, the aim of the present work was to elucidate the possible involvement of lipid rafts in glutoxim and molixan effects on [ca + ] i in macrophages. [ca + ] i measurements were performed with fura- am microfluorimetry. to examine the involvement of lipid rafts in the effect of gssg-based drugs on [ca + ] i we used methyl-bcyclodextrin (mbcd), widely used to remove cholesterol from membranes, thus disrupting the lipid raft domains. we have shown for the first time that macrophage preincubation with mm mbcd for hours before molixan addition causes significant inhibition of both ca + mobilization (on average, by . ae . %) and subsequent ca + entry (on average, by . ae . %), induced by molixan. similar results were obtained in experiments with glutoxim. thus, we have demonstrated for the first time that mbcd significantly decreases both phases of glutoxim-or molixan-induced ca + responses in macrophages. the results suggest that intact rafts are required to initiate complex signaling cascade activated by glutoxim or molixan and leading to [ca + ] i increase in macrophages. plant-derived natural substances (phytochemicals) with potent pro-apoptotic activity towards cancer cells in vitro are considered as promising nutraceuticals in anticancer therapy. nevertheless, due to their relatively low bioavailability, administration of high doses of nutraceuticals that are not achievable in vivo seems to exert potentially negligible physiological effects in clinical trials. thus, there is a need for revealing novel cytophysiological effects of low doses of phytochemicals towards cancer cells. in the present study, we have considered thirty one nutraceuticals and selected four phytochemicals acting at low micromolar range ( to lm) against phenotypically different mcf- , mda-mb- and sk-br- breast cancer cells, namely diosmin, sulforaphane, ursolic acid and betulinic acid. nutraceuticals inhibited cell proliferation and caused changes in the cell cycle that was accompanied by elevated levels of p , p , p and/or p . apoptosis (annexin v staining, multicaspase and mitopotential assays) was observed exclusively when nutraceuticals were used at the concentration of lm, whereas at the concentration of lm, stress-induced premature senescence was noticed (sa-b-gal activity). nutraceuticals diminished the levels of glut- and selected glycolytic enzymes. nutraceuticals promoted oxidative and nitrosative stress as judged by increased production of total reactive oxygen species, total and mitochondrial superoxide, nitric oxide and protein carbonylation. nutraceuticals also stimulated dna single and double strand breaks that was accompanied by atm phosphorylation and to a lesser extent by histone h ax phosphorylation and bp foci formation. taken together, several responses to nutraceutical treatment were observed in breast cancer cells that may reflect the heterogeneous nature of cancer cell populations. this study was supported by grant from the national science center, / /d/nz / . nucleolus is thought to be a stress sensor and oxidative and ribotoxic stimuli may cause the inhibition of rrna synthesis by the inactivation of transcription factor tif-ia/rrn that is accompanied by the relocation of nucleolar proteins and p -based cell cycle arrest and/or apoptosis. as nutraceutical-mediated modulation of nucleolar activity may be considered an attractive anticancer strategy, in the present study, we have investigated the effects of three selected nutraceuticals, namely sulforaphane, ursolic acid and betulinic acid on nucleolus state in three breast cancer cell lines (mcf- , mda-mb- and sk-br- ). we found that low dose nutraceutical treatment resulted in p -mediated inhibition of cell proliferation, a decrease in rrna synthesis, shifts in lamin a/c and b pools, changes in the nucleolar protein levels and their carbonylation, and changes in nucleolus size and number. breast cancer cells differed in erk activity that resulted in different patterns of erk activation/inhibition, phosphorylation status of s and autophagy induction upon nutraceutical stimulation. nutraceuticals also affected dna methylation parameters, namely the levels of dnmt , dnmt a and dnmt b that resulted in both global dna hypo-and hypermethylation. taken together, after nutraceutical treatment, nucleolus-centered cellular response was revealed in breast cancer cells of different phenotypic characteristic that may be considered a potential target of anticancer therapy. this study was supported by grant from the national science center, / /d/nz / . p- . . - rate of apoptosis in human macrophages infected with leishmania tropica promastigotes infection of the cells with parasites or exposing cells to heat stress induces a cellular stress. in the present study human macrophages are infected with leishmania tropica promastigotes and exposed to heat stress. the measurement of cytoplasmic histone-associated dna-fragments was carried out using elisa technique. visualization of apoptotic cells was performed by the terminal deoxynucleotidyl transferase dutp nick end labeling staining method (tunel). degree of oxidative stress on cell is evaluated by measuring nitric oxide (no), malondialdehyde (mda), reducte glutathion (gsh) levels and superoxide dismutase (sod) activities. results of the elisa technique showed that infection of macrophages with promastigotes induced apoptosis rate significantly (p < . ), heat stress however decreased the rate of apoptosis in infected macrophages remarkably (p < . ). high levels of apoptosis rate in infected macrophages and drastic decdrease in apoptosis in heat subjected macrophages infected with promastigotes are confirmed by visualisation of apoptotic cells using tunel method. levels of glutathion (gsh) in infected macrophages decreased significantly (p < . ), while malondialdehyde (mda) levels increased notably (p < . ). however, no statistical significant alterations were detected in the nitric oxide (no) values and superoxide dismutase (sod) activities. results of the present study indicates that infection of human macrophages with leishmania tropica induces a cellular stress response, characterized by decreased values of gsh and increased levels of mda. increased rate of apoptosis in infected macrophages may be due to the increased cellular stress caused by leishmania tropica amastigotes. decreased rate of apoptosis measured in heat exposed macrophages infected with promastigotes indicates an extention in life span of macrophages. measurements of the parameters characterizing the redox and inflammatory processes in blood are essential for diagnosis and prognosis of type diabetes mellitus (t dm), but also for monitoring the effectiveness of medical treatments. along with other biochemical effects, hormonal imbalance leads to modified transport function of erythrocytes due to changes in enzyme systems involved in upholding of cellular homeostasis through a rapid degradation of altered proteins, being the second line of defense against the free radicals, which degrade and eliminate the damaged molecules. some of these enzymes are hemoglobin peroxidase (pa) and esterase (ea). the aim of this research study was to identify new parameters with a potential role of biochemical markers in t dm like hemoglobin peroxidase and esterase activity from erythrocyte. our data showed that pathological processes involved in t dm imply an increased enzymatic activity of pa ( . %), which correlates with increased levels of ea ( . %) and glycated hemoglobin (hba c) ( . %), compared with control group. the variables hba c, pa and ea are correlated: the identified pearson correlation coefficients r = . and r = . respectively, have an associated probability of p < . and p < . a value that indicates a strong positive correlation between the dependent variables pa and ea and independent variable hba c. based on these results we concluded that together with glycosylated hemoglobin assay, all the studied parameters can be successfully used as extra test for diabetes associated with oxidative stress and disorders in erythrocyte functions or blood rheology. the radioprotective effects of propolis and caffeic acid phenethyl ester on radiationinduced oxidative/nitrosative stress in brain tissue s. taysi , e. demir , k. cinar gaziantep university, school of medicine, gaziantep, haran university, sanliurfa, department of neurosurgery, medical school, gaziantep, turkey head and neck cancer patients treated with radiotherapy suffer severe side effects during and following their treatment. efforts to decrease toxicity of irradiation to normal tissue, organs and cells have led to searching for cytoprotective agent. investigations for effective and non-toxic compounds with radioprotective capability led to increasing interest in antioxidant such as propolis and caffeic acid phenethyl ester (cape). the aim of this study was to evaluate the antioxidant and radioprotective effects of propolis and cape on radiation-induced oxidative/nitrosative stress in the brain tissue. fourty sprague-dawley rats were randomly divided into five groups. group (irradiation (ir) + propolis) received total cranium irradiation and propolis was given orally through an orogastric tube daily. group (ir+cape) received total cranium irradiation plus cape, was dissolved in dimethyl sulfoxide (dmso) just before giving to the rats, intraperitoneally (ip) every day. group (ir) received gy of gamma irradiation as a single dose to total cranium plus ml saline daily. group received daily plain dmso. group received daily plain saline. at the end of the day time period, xanthine oxidase (xo), nitric oxide synthase (nos) activities, nitric oxide (no•) and peroxynitrite (onoo -) levels were significantly higher in ir group compared to all other groups. in conclusion, the results suggest the radioprotective ability of propolis and cape involving prevention of radiation-induced oxidative/ nitrosative damage. p- . . - role of leptin and adiponectin in obesityassociated oxidative stress e. becer , a. c ß irakoglu near east university, nicosia, cyprus, istanbul university, istanbul, turkey objective: increased oxidative stress is one of the major characteristics of obesity and obesity-related complications. adipokines also induce the production of reactive oxygen species and generating oxidative stress in physiological and pathological conditions of obesity. the aim of this study was to determine the association of leptin and adiponectin levels with body mass index, lipid parameters and oxidative stress biomarkers in obesity. methods: the study included obese and non-obese subjects. plasma leptin and adiponectin levels (ng/ml) were measured using commercially available enzyme-linked immunosorbent assay kits. serum lipid, superoxide dismutase, malondialdehyde and antropometric parameters were measured. results: obese and non-obese subjects did not differ in age, while plasma glucose, total cholesterol, triglycerides, ldl cholesterol and leptin levels were significantly higher and mean hdl cholesterol and adiponectin levels were significantly lower in obese than non-obese subjects. the plasma leptin (p < . ) and adiponectin (p = . ) levels were significantly correlated with bmi in both obese and non-obese subjects. in obese subjects, leptin levels were significantly correlated with superoxide dismutase (p < . ) and malondialdehyde (p < . ). strikingly, adiponectin was significantly correlated with superoxide dismutase (p = . ) and malondialdehyde (p = . ) levels in obese group. conclusion: our results suggest that leptin and adiponectin levels are associated with defective antioxidant status and increased lipid peroxidation which may have implications in the development of obesity related health problems. clinical trials of biologically active plant substances show a significant preventive effect in cancer, cardiovascular diseases and peptic ulcer disease in the form of both nutritional supplements and therapeutic intervention. anthocyanins contained in dark berries show great antioxidant potential, with the most important including a reduction in oxidative degradation of lipids or tyrosine oxidation by peroxynitrite. our previous studies of the antioxidant properties of extracts from vaccinium corymbosum, aronia melanocarpa and sambucus nigra, however, indicated that their activities largely depend on the method of extraction. while quantitative determination of anthocyanins pointed to a disproportionately larger content of anthocyanins in isolates from lyophylized berries, their scavenging activities against hydroxyl radicals was surprisingly the lowest. inflammatory processes, vascular damage, atherosclerosis and others are caused by oxidativenitrosative stress, so we tested their efficiency to scavenge no degradation products. we found that only purified extracts of lyophilized berries showed the most significant effects against no degradation products, with efficacy of around %. an extract from aronia showed greater than % efficiency, and a net ethanol extract from all the berries showed a % effect. cleaned ethanol extracts showed the lowest effects, while aronia initiated production at a concentration of mg/l. conversely, all acetone extracts consistently initiated no degradation products. these findings are in complete contrast to their determined action against reactive oxygen species. in summary, it follows that a particularly adjusted lyophilized extract of the berries could be responsible for the increased biological activity of no and the observed biological and pharmacological activities of anthocyanins in circulatory disorders. the study was supported by grant vega / / and / / . p- . . - attenuation of dysfunction, oxidative stress and apoptosis by resveratrol in benzo(a)pyrene exposed ins -e / pancreatic beta cell line s. c ß elik, b. baysal faculty of medicine, afyon kocatepe university, afyonkarahisar, turkey diabetes is one of the most important problems in the world. this disease is a very important health problem due to affects many different organs and systems. it has been well established that, environmental pollutants had deleterious effects on glucose metabolism, and caused insulin resistance and type diabetes. with this investigation, it was aimed to investigate the effects of benzo(a)pyrene on pancreatic beta cells and treatment affects of resveratrol. in this study, rat ins- e beta cell line was used. after reaching the appropriate number of cells culture operations by cell culture, benzo(a)pyrene ( lm, hours) application have been made after resveratrol ( lm, hours) application. after incubations oxidative stress, insulin secretion (in cell and in medium), cell proliferation and apoptosis were analysed in cells by biochemical and molecular techniques. b(a)p application resulted in no increase and resveratrol also increased this level of no. resveratrol increased the tas levels decrased by b(a)p, and tos levels were also increased by resveratrol interestingly. osi levels determined with tas and tos levels, has no significant change between groups. gsh levels were decreased by b(a)p while resveratrol increased its' level to control level. mrna expression levels of beta cell functions related genes ins- , ins- and sirt- were increased by resveratrol treatment. insulin levels in cell and in medium were increased after resveratrol treatment. mrna expression level of foxo- gene was increased while pdx- was decreased by resveratrol treatmeant. b(a)p suppressed the mrna expression of p gene, but resveratrol increased. the effects of b(a)p on pancreatic beta cells and the protective effects of resveratrol on this cells were investigated in vitro with this research firstly. the results obtained from this research showed that oxidative changes, functional impairment and carcinogenetic effects of b(a) p in pancreatic beta cells could be blocked by resveratrol. the protective effect of vitamin e (alphatocopherol) on ischemia-reperfusion injury in rat liver ischemia-reperfusion (i/r) process is usually used during transplantation and resection of the liver but liver dysfunction and cellular death due to lack of oxygen in tissues, changes in the balance of oxidant/antioxidant in favor of oxidants, and inflammatory response are inevitable during this process. in the present study, it was aimed to investigate whether vitamin e(alpha-tocopherol), an antioxidant agent, has a protective effect against liver ischemia reperfusion injury in rats by using morphometric methods. for this purpose, adult sprague-dawley male rats were divided into groups as; control, ischemia / reperfusion (i/r), and vitamin e+ischemia/reperfusion (evit +i/r). in experimental groups, the total hepatic ischemia was applied for minutes followed by a hour of reperfusion. in the treatment group, days before ischemia mg / kg dose of vitamin e was administered intraperitoneally once a day. after the termination of the reperfusion, the rats were perfused by cardiac way and liver tissues were dissected. following volume and weight calculations, the livers were subjected to the standard histological preparation methods and embedded in paraffin. serial sections at lm thickness were obtained from these blocks, stained with hematoxylineosin, and analyzed with morphometric methods. in light microscopic examinations of the i/r group, irregularity in lobules, dilatation in central veins and sinusoids, extensive areas of necrosis and pycnotic nuclei were seen in hepatocytes. the volume density of sinusoids to liver parenchyma was estimated as % in the control group, whereas it was % in the i/r group. this value was decreased to % in the evit + i/ r group. however, no significant difference was found among the groups in the lobule area calculated by the point counting method. these results show that intraperitoneal vitamin e administration for days prior to ischemia partially inhibits damage caused by ischemia-reperfusion injury in the liver. the leaves, fruit and bark of annona muricata, a member of the annonaceae family, are commonly used in the traditional medicine of tropical and subtropical regions. in recent years, many studies have shown their anti-cancer, anti-convulsant, antiarthritic, anti-parasitic, anti-malarial, and anti-diabetic activities. it should be noted that these characteristics have been described using different types of extracts from different parts of the plant. our studies have focused on the systematic characterization of activities most easily accessible from an aqueous extract of leaves, with hitherto documented antihypertensive and hepatoprotective effects. we found that the extract shows almost % efficiency against hydroxyl radicals. with increasing concentrations, the effectiveness weakened, reaching a second peak ( %) at a concentration of mg/l. the scavenging activity against no degradation products maintained a continuously increasing trend with a maximum at a concentration of mg/l. surprisingly, the extract initiated peroxynitrite production in a similar trend, except at mg/l, where it scavenged peroxynitrites with relatively high efficiency, up to %. these findings are consistent with the elevated levels of reduced glutathione detected after incubation of liver mitochondria with extract to a maximum concentration of mg/l, with subsequent sharp decline. the activity of glutathione s-transferase was decreased, although not significantly. this indicates a reduction of metabolic processes of compounds, allowing their action over a longer period of time. in a live system, even antihypertensive effects can be observed. however, a significant outflow of gsh to create the gsh adducts of active substances, and particularly s-nitrosoglutathione from increased production of peroxynitrites, can cause liver toxicity. the study was supported by grant vega / / and / / . the role of polyamine metabolism in curcumin induced apoptosis via reactive oxygene species (ros) generation in growth hormone (gh) overexpressed t d breast cancer cells r. genc ß, a. coker gurkan, e. d. arisan, p. obakan yerlikaya, n. palavan unsal, n. palavan unsal t.c istanbul k€ ult€ ur € universitesi, istanbul, turkey autocrine growth hormone (gh) signaling triggers cell proliferation, growth, metastasis and drug resistance in cancer cells. polyamines (pas) play an essential role in cell cycle, proliferation, growth and carcinogenesis of various cancer types such as prostate, colon and breast cancer. odc (ornithine decarboxylase) is the key enzyme in the pa biosynthetic pathway that is under control of antizyme (az) and antizyme inhibitor (azi) activity. pa catabolic enzymes polyamine oxidase (pao) and spermine/spermidine acetyle transferase (ssat) by-products triggers reactive oxygene species (ros) generation and apoptotic cell death. curcumin decreased cell viability in dose and time dependent manner in t d wt and gh+ cells. although forced gh expression induced cell proliferation, lm curcumin inhibited cell invasion. curcumin ( lm) induced apoptosis by acting on intrinsic and extrinsic pathway in both cell lines. moreover, curcumin supressed odc, azi expression in wt and gh+ t d cancer cells. although curcumin decreased az expression in t d wt cancer cell, increased az expression was determined in t d gh cancer cell. pao and ssat expressions were upregulated in t d gh+ cells. concomitantly, putrescine levels were increased in t d gh+ cancer cell compared to wt cells and curcumin depleted spermidine and spermine levels in wt and gh + t d cells. curcumin induced-apoptotic cell death via ros generation and co-treatment of n-acetyl cysteine (nac) overcame curcumin effect. conclusion, forced gh expression triggers cell proliferation and growth via acting on polyamine metabolism and curcumin-triggered ros generation was prevented by nac treatment in t d wt and gh+ breast cancer cells. acknowledgment: this study was supported by tubitak research project (project no: z ). the radio-protective effects of propolis and nigella sativa oil on oxidative/nitrosative stress in liver tissue of rats exposed to total head irradiation s. taysi our purpose is to investigate propolis and nigella sativa oil (nso) for their antioxidant effects on the liver tissue of rats exposed to ionizing radiation. a total of sprague-dawley rats were divided into five groups to test the radioprotective effectiveness of of propolis and nso administered by orogastric tube. appropriate control group was also studied. biochemical parameters in liver tissue of rats were determined by spectrophotometer. xanthine oxidase (xo), nitric oxide synthase (nos), superoxide dismutase (sod) activities, nitric oxide (no•) and malondialdehyde (mda) levels were higher in ir group while glutathione-s-transferase (gst), glutathione peroxidase (gsh-px) level in the ir group were lower in this group when compared to the other groups. gst activity in ir plus propolis group was statistically higher than in all other groups. propolis and nso clearly protect liver tissue from radiationinduced oxidative stress. the effects of royal jelly on the antioxidant parameters in the breast tissues of the rats with breast carcinoma treated with paclitaxel or not effects of royal jelly on the breast tissue antioxidant parameters in rats with breast carcinoma treated with paclitaxel or not. - weeks old female sprague-dawley rats (n = ) included in current study were divided into groups: control group (n = ) with healthy rats; breast cancer group (n = ); breast cancer group (n = ) treated with mg/kg paclitaxel injection (once a week for weeks); breast cancer group (n = ) treated with mg/kg royal jelly (by oral gavage for days); and finally breast cancer group (n = ) treated mg/kg royal jelly in addition to mg/kg paclitaxel injection. rats with breast carcinoma was obtained at th days after a single dose injection of mg/kg n-methyl-n-nitrosourea (mnu). all cancer groups were followed by days with treatment of paclitaxel and/or royal jelly. the antioxidant parameters in rat breast tissues, superoxide dismutase (sod) and catalase (cat) activities were determined by spectrophotometric colorimetric methods and glutathione (gsh) by high performance liquid chromatography (hplc). all the antioxidant parameters decreased in breast cancer group without any treatment (p < . ). but, statistically non significant increases were observed by paclitaxel and royal jelly treatment (p > . ). this study indicated that royal jelly supplementation can not be sufficient to increase the antioxidant parameters in breast cancer. we are going to continue to identify the effects of royal jelly on breast cancer detail. the effects of n-acetylcysteine on microsomal and serum paraoxonase activities at high fat diet induced obese rats obesity is a chronic disease that develops from the interaction between genotype and environmental factors and increase in the accumulation of body fat. it is related with glucose and lipid metabolism disorders, cardiovascular diseases and increased oxidative stress. paraoxanase (pon ) is an enzyme which plays a protective role in oxidative stress, inflammation and liver diseases. it has been suggested that pon has protective effects against high fat diet induced obesity and obesity related disorders. n-asetylcysteine (nac) is a potent antioxidant due to its ability to stimulate glutathione synthesis. the aim of this study was to evaluate the microsomal and serum pon enzyme activities (paraoxonase, arylesterase and lactonase) at high fat diet induced obese rats in the presence of nac. this study consisted of control, obese and nac-supplemented obese ( g/l nac) groups. eighteen sprague-dawley rats were randomized into three groups (n = ). control rats were fed by standart food and obese and nac groups were fed by high fat diet. the microsomal and serum paraoxonase, arylesterase and lactonase activities were determined by colorimetric methods. serum paraoxonase, arylesterase and lactonase activities decreased in obese and nac groups when compared to control groups. on the other hand microsomal paraoxonase, arylesterase and lactonase activities increased in nac group when compared to control and obese groups. however there was no statistically significant difference between the groups. it has been concluded that the microsomal and serum paraoxonase enzyme activities did not change at high fat diet induced obese rats in the presence of n-asetylcysteine. reactive oxygen species, playing an active role in the early and late course of acute pancreatitis, lead to dysfunction of cell membrane and releasing of lysosomal enzymes, and thereby to the injury in pancreatic cells. gallic acid, found in vegetables such as green tea, is an active component which has antioxidant, antiinflammatory, antiviral, anticancer activities. the aim of this study was to investigate the effects of gallic acid in experimental acute necrotizing pancreatitis (anp) model in rats. eighteen male sprague-dawley rats were divided into three groups ( rats in each group). group : sham + saline; group : anp induced by intraductal glycodeoxycholic acid and intravenous cerulein; and group : anp + gallic acid ( mg/kg/day, intraperitoneal). at the end of th hours, pancreas histopathology was examined. the levels of serum amylase as a diagnostic marker of pancreatitis, interleukin- (il- ), total antioxidant status (tas), nitrite + nitrate, total thiols as antioxidant marker and thiobarbituric acid reactive substances (tbars) to measure malondialdehyde (lipid peroxidation product) were determined by spectrophotometric methods. serum amylase, il- , plasma tbars levels were significantly higher but total thiols levels were lower than sham group in anp group without treatment (p < . ). however; tas and nitrite + nitrate levels did not show any significant difference (p > . ). on the other hand, while serum amylase, il- and tbars levels were lower, total thiols levels higher in gallic acid treatment group than in the untreated anp group, but statistically insignificant (p > . ). in conclusion, gallic acid treatment is beneficial but not sufficient to treat the acute necrotizing pancreatitis in rats. p- . . - evaluation of oxidant/antioxidant system parameters, il- and il- levels in amniotic fluid of pregnancies with down sydrome b. _ imge erg€ uder , s. bahsi , t. bahsi , v. topc ßu , a. bakir ankara universty faculty of medicinel, ankara, zekai tahir burak research and training, hospital genetic center, ankara, turkey introduction and aim: down sydrome (ds) can be diagnosed at high-risk of down syndrome pregnancies by invasive prenatal testing. in this study we aimed to demonstrate antioxidant/oxidant system markers, il and il levels in amniotic fluid samples of pregnancies affected by ds. materials and methods: for this purpose we collected amniotic fluid samples from pregnancies affected by down sydrome and normal healthy pregnancies who applied to zekai tahir burak research and training hospital genetic center and were proceeded with amniocenthesis. in the amniotic fluid samples; malondialdehyde (mda), superoxide dismutase (sod), glutathion peroksidase (gsh-px) xhantine oksidase (xo), catalase (cat), adenozine deaminase (ada), nitric oxide (no), nitric oxide senthase (nos) enzymatic activities were evaluated by spectrophotometric methods, il and il levels are evaluated by elisa. for statistical analysis student's t-test and spearman corralation analusis are used. results: it was found that sod levels are significantly elevated in study group compared to control group (p < . ). besides this, in study group, cat and il- levels are found singnificantly lower than control group (p < . ). we couldn't find any significant difference between two groups in terms of mda, gsh-px, xo, no, nos, ada ve il- levels (p > . ). discussion and conclusion: there is an important decrease in inflammation compared to normal pregnancie in the amniotic fluid of pregnancies having ds. based on these results, sod enzyme may be used as a marker for prenatal diagnosis of ds. for this purpose these experiments should be tried on larger sample groups. the aim of our work was to compare prooxidant and antioxidant properties of linalool, which is the oxygenated monoterpene compound reported to be a major volatile component of the essential oil of several aromatic species, in hep g cells. cytotoxicity of linalool was assayed by celltiter-blue Ò cell viability assay. malondialdehyde levels result in membrane damage in hep g cells were assayed by using fluorometric method. hep g cells were incubated with linalool at , and hours. the viability of hep g cells decreased in a manner dependent upon concentration and incubation time. the ic values were calculated . lg/ml ( hours), . lg/ml ( hours) and . lg/ml ( hours). but, cell viability of hep g cells increased when the cells preincubated with linalool at lower concentrations (˂ic ) against h o cytotoxicity. membrane-damaging effects of linalool were increased with accelerating concentrations. on the other hand, membrane damaging effect of h o was decreased when the cells preincubated with linalool before h o incubation. oxygenated monoterpene linalool had both prooxidant and antioxidant properties showing membrane damaging and protective effects on hep g cells depend on concentration. postprandial lipemia is primarily characterized by increasing triglyceride levels after the lipid rich meal. postprandial lipemia may cause oxidative stress by increasing free radical production and increasing oxidative stress could be responsible for the development of many diseases. plasma oxidant-antioxidant status was evaluated in healthy individuals with postprandial hypertriglyceridemia generated by performing oral triglyceride tolerence test (ottt). the study group included subjects ( female and male). ferric reducing ability of plasma (frap), total thiol and thiobarbituric acid reactive substances (tbars) levels were determined by colorimetric methods at fasting and nd, th and th hours following ottt. the levels of frap and thiol were significantly higher in males than females (p = . and . , respectively). thiol levels decreased significantly in both gender at postprandial nd, th and th hours as compared with fasting condition (p = . ). while tbars levels increased at postprandial nd hour, that was only significant for male individuals (p = . ). it has been concluded that postprandial lipemia may change oxidant-antioxidant balance in favor of oxidants and gender is an important criteria while assessing the oxidant-antioxidant status in postprandial lipemia p- . . - ischemia modified albumin and c-reactive protein levels in prediabetes prediabetes is a state of abnormal glucose homeostasis characterized by the presence of impaired fasting glucose, impaired glucose tolerance, or both. the aim of this study was assess serum ischemia modified albumin (ima) in prediabetes and determine its correlation with other risk factors for chronic complications such as inflammation and hyperglycemia. glucose, insulin, total cholesterol, hdl cholesterol, triglycerides, albumin, c-reactive protein (crp) and ima were measured in patients with prediabetes and controls. prediabetes patients had higher levels of ima and crp in comparison with control subjects but there was no significant difference between groups for ima. significant positive correlation was observed between crp and fasting glucose, insulin. there was no significant correlation between ima levels and the parameters tested. we have shown higher level of crp in prediabetes. these results support the hypothesis that chronic inflammation may be involved in development of hyperglycaemia. p- . . - the effects of s _ io nanoparticles of rat uterine smooth muscle specially used in textile field sio nanoparticles on uterus smooth muscle was aimed to be researched. in this study wistar albino female rats were used. rats were separated in groups as control, dose ( lg/ml), dose ( lg/ml) and dose ( lg/ml). nanoparticle's size was chosen as nm. preparations of four groups were evaluated for biochemical and histological examinations. all isolated uterine smooth muscle stripts except the controls were treated with sio for two hours. in biochemical examinations in order to evaluate oxidative stress level of malondialdehit (mda), activity of superoxide dysmutase (sod) and glutathione peroxidase (gsh-px) were measured. in histological examinations via electron microscope ultrastructure of uterus was examined as well as apoptotic cells detected with immunofluorescent labeling method. intergroups differences were defined by statistical analysis. while mda level increased depending on the dosage, sod level was decreased depending on the dosage. gsh-px rate was decreased for each dosage with respect to control. however, no significant difference is detected between groups. in electron microscopic examination no changes were observed in uterus ultrastructure with compare to control. however, in immunofluorescent labeling it was detected that apoptosis increased in dosage groups with compare to control group. as a result, it was thought that application of sio nanoparticles, in nm size and in , and lg/ml dosages caused of oxidative stress and apoptosis. this results suggested that sio has toxic effects on uterine smooth muscle. uterine myomas are the most common benign pelvic tumors arising from myometrium. they are rarely associated with mortality but responsible for significant morbidity and have adverse effects on quality of life especially in reproductive age women. reactive oxygen species and superoxide dismutases, as well as sex steroids play important roles in the reproductive physiology processes. in addition, oxidative stress and impaired antioxidant defense system have been linked to pathophysiology of various diseases including malignant gynecological disorders. clinical investigations indicate that women with myoma may have increased risk of developing malignant tumors particularly sarcomas. the present study aimed to investigate the possible role of oxidant and antioxidant status in myomas. blood and urine samples of myoma patients were collected. activities of erythrocyte antioxidant enzymes [copper-zinc superoxide dismutase (cuzn-sod), catalase (cat), glutathione peroxidase (gpx )] and levels of lipid peroxidation biomarkers [plasma malondialdehyde (mda) and urine -epi-prostaglandin f a ( -epi-pgf a)] were determined. the results were compared with those of controls. the groups were matched in terms of age, body mass index, smoking habit, coexisting chronic diseases, menopausal status and sex steroid hormone levels. all antioxidant enzyme activities were higher ( % for cuzn-sod, p = . ; % for cat, p . ) and the levels of lipid peroxidation biomarkers were lower (% for mda, p = . and % for -epi-pgf a, p > . ) in myoma patients compared to controls. correlation analyses showed a significant negative correlation between erythrocyte cuznsod activity and plasma mda levels (r = - . , p = . ). the decreased lipid peroxidation may be the consequence of elevated antioxidant enzyme activities and the data suggests a protective role of activated antioxidants especially cuznsod and cat in patients with myoma. p- . . - investigation of ischemia-modified albumin levels in patient with acute limb ischemia introduction: acute limb ischemia commonly occurs as a result of embolus caused by cardiac origin and which may end up with limb loss or even death if left untreated. thrombosis are usually seen where the arteries give branches and tendency to atherosclerosis is more serious at these sites. involvement of several arteries in either embolus or in situ thrombosis limits the adequacy of collateral circulation. restriction of blood flow due to arterial stenosis or occlusion often leads patients to complain of muscle pain on walking. any further reduction in blood flow causes ischemic pain at rest, which affects the foot. early recognition may prevent limb loss or death. ischemia can alter the capacity of the amino terminus of the albumin to bind free metal atoms such as cobalt, copper and nickel. this new, chemically changed albumin is called ischemia modified albumin (ima). ima is a sensitive marker of myocardial ischemia, skeletal muscle ischemia, pulmonary embolism, mesenteric ischemia and stroke. therefore, in this study it was aimed to investigate the ima level in acute limb ischemia. materials and methods: in this study, patients with acute limb ischemia (li group; mean age years) and healthy individuals (control group; mean age years) were included. ima levels were detected in control and li group by elisa (organo teknika, avusturya) using ima el _ isa kit. results: ima values were compared with nonparametric methods mann whitney u test, and significantly decreased ima level was statistically significantly different between li group and control group (p < . ). conclusion: there is a significant increase in serum ima in limb ischemia, so that alterations also might be clinically useful in the diagnosis of limb ischemia, but should be supported with further studies. object: polycystic ovary syndrome (pcos) is a multifaceted disorder with a pathogenetic pathway that is not fully understood yet. apart from hormonal derangements, insulin signaling defects and adipose tissue dysfunction, oxidative stress, defined as an imbalance derived from excessive formation of oxidants in the presence of limited antioxidants defenses, has been actively implicated in the etiology of the syndrome. the aim of this study was to determine of serum myeloperoxidase activity (mpo), paraoxonase activity (pon ) and arylesterase activity (are) in patients with pcos. material and methods: the study was carried out on women consisted of patients with pcos and healthy ones as control. serum pon activities were measured spectrophotometrically using diethyl-p-nitrophenylphosphate as substrate. phenylacetate was used as substrate for are measurement, and are activity was determined by measuring absorbance of the resulting phenol at nm. molar absorptivity coefficients were used in the calculation of pon and are activities as nmol phenol/ml serum/min. result: the mpo and are activities were significantly lower in the patient groups when compared with the control group ( . ae . - . ae . u/ml p < . , . ae . - . ae . u/ml p < . , recpectively). the pon activities are higher in the patient group ( . ae . u/ml) compared to the control group ( . ae . u/ml) are found, but are not statistically significant. conclusion: lower serum mpo and are activities might contribute to the increased susceptibility for the development of diseases risk in women with pcos. because free oxygen radicals are thought to contribute to the complication of many chronic diseases, the pcos may be related to oxidative stress. subclinical hypothyroidism, defined as an elevated serum thyroid stimulating hormone level associated with serum thyroid hormone concentrations within the reference range. free radicalmediated oxidative stress has been implicated in the pathogenesis of thyroid disorders. the ischemia-modified albumin (ima) has been proposed as a marker of protein oxidative damage, which has been found to reflect hypoxic stress. this study aimed to investigate the influence of subclinical hypothyroidism on serum ima levels. thirty-one subclinical hypothyroidism patients and control subjects were enrolled in the study. albumin, ima were measured and ima/albumin ratio was calculated. to determine the ima levels the measurement method based on albumin cobalt binding assay was used. serum ima levels of patients with subclinical hypothyroidism were . ae . absu, ima levels of control subjects were . ae . absu. ima levels were significantly higher in patients with subclinical hypothyroidism patients than in control subjects (p < . ). when ima values were normalized for albumin concentrations, the ima/albumin ratio was also significantly elevated in patient group compared to control group (p < . ). ima levels are increased in patients with thyroid dysfunction. elevated levels of ima can be a clinically useful marker of protein oxidative damage in subclinical hypothyroidism. p- . . - the effects on endothelial dysfunction of quercetin in streptozocin-induced diabetic rats excessively produced in pathologic conditions. ultimately, imbalance between oxidants and antioxidants results with oxidative stress (os). in this study, we investigated some os parameters in standard ( % protein, % ( % sucrose) carbohydrate, % lipid) and sucrose ( % protein, % ( % sucrose) carbohydrate, % lipid) diet fed bdnf heterozygous mice liver tissues. the male c bl strain wild type (+/+) and bdnf heterozygous (+/À) mice ( weeks) were obtained. the animals were fed ad libitum by special standard and sucrose diets. twenty four mice were divided into four groups and each group consist six mice. all mice were fed for weeks. first group involved in c bl wild type mice and fed by standard diet. second group contained c bl bdnf heterozygous mice and fed by standard diet. third group consisted c bl wild type mice and fed by sucrose diet. fourth group involved in c bl heterozygous mice and fed by sucrose diet. in first group, mda levels, sod and cat activities were higher than other groups. in second group, cat activities were lower than other groups. but, we could not find any statistically significant differences between all groups about mda, sod, cat levels in bdnf heterozygous mice liver tissues. in conclusion, standard and sucrose diet feeding may not affect mda, sod and cat levels in bdnf heterozygous mice liver tissues. brain-derived neurotrophic factor (bdnf) is member of neurotrophin family which plays critical roles in the development, differention, survival, maintenance of the central and peripheral nervous systems. bdnf also contributes to food intake and body weight control. bdnf heterozygous mice display increased body weight and mild hyperphagia. expression of bdnf is not limited to the brain, it also express some peripheral tissues like adipose tissue, liver, kidney, skeletal muscle, heart. even though roles of bdnf are well known relatively in central nervous systems, effects of this protein is not clear in peripheral tissues. as mentioned before, it is expressed in organs involved in energy, lipid and glucose homeostasis, including the liver, adipose and muscle tissues, but its role there remains unclear. in this study, we aimed to investigate role of bdnf on liver oxidative stress parameters in heterozygous mice model fed fat diet induced obese mice. in this study, we used c bl/ mice inbred strain wild type and bdnf heterozygous (+/À) mice. animals were divided to two groups: wild type (n = ) and bdnf heterozygote mice (n = ). the animals were fed ad libitum by high-fat diet during month. weight gain was recorded every th days. in liver tissues were measured malondialdehyde (mda), superoxide dismutase (sod) and catalase (cat) by spectrophotometric methods. liver mda levels decreased in obese bdnf heterozygous mice compared to obese wild type group and statistically significant difference between groups. bdnf heterozygous mice cat activities were higher than the other group and this difference was statistically significant. there was no statistically significant difference between the groups in terms of sod activities. it has been concluded that the mda levels and sod enzymes activities changed at high-fat diet induced obese bdnf heterozygous mice compared to wild type mice liver tissues. p- . . - disturbances of microelements profile in serum of overweight/obese adult females with acute and persistent pro-inflammatory chlamydia pneumoniae infection p- . . - determination of reactive oxygen species induced dna damage using modified cupric reducing antioxidant capacity (cuprac) colorimetric method s. uzunboy, s. demirci c ß ekic ß, r. apak department of chemistry, istanbul university, faculty of engineering, istanbul, turkey reactive oxygen species (ros) term is a common name of a group of species. hydroxyl radical and singlet oxygen can be taken into account as ros samples. ros may be formed as a result of endogenous or exogenous reasons. although ros have some beneficial functions, they should be balanced by antioxidants (aox). excessive amounts of ros can attack biological macromolecules including dna. dna damage is usually related with mutagenic and carcinogenic changes. that's why determination of dna damage is so important and there are a great many studies in literature comprising different techniques. one of the most common of them is the 'comet assay'. but application of the method and interpretation of the results is not easy. investigation of certain dna damage products is also very common. these methods usually need expensive instrumentation such as using tandem mass spectrometry. on the other hand, depicting total dna damage on a certain product may cause misinterpretations. in the presented study, dna was decomposed by hydroxyl radicals produced by fenton method. in the study while dna is not cuprac reactive the oxidation products can react with the cuprac reagent. the effect of aox was also investigated. for this purpose, selected aox compounds were added to the reaction medium. because of their radical scavenging effect, the cuprac absorbance decreased in the presence of aox. in the presence and absence of aox, absorbance differences were calculated. the calibration graphs between final concentration and absorbance differences were drawn for each aox. gallic acid was determined as the most effective one among the tested aox samples. for statistical comparison with the presented study, tbars was used as reference method. direct use of dna as a probe material to determine oxidative damage may be an advantage to understand dna hazard in biological systems. the proposed method can be applied in all laboratories having a spectrometer as a cost-effective and simple procedure. p- . . - effects of alpha- antagonists on oxidative system of rat heart tissue benign prostate hyperplasia is a progressive process occurring in the stromal and epithelial components of the prostate. alpha- receptor blocking agents are used for relaxation of the smooth muscles in the prostatic stroma. our aim was to investigate the effects of alpha- antagonists on oxidative system of rat heart tissue. male wistar albino rats were divided into groups randomly. ) tamsulosin ( mg/kd/day), ) terazosin ( mg/kg/day), ) doksazosin ( mg/kg/day), ) alfuzosin ( mg/kg/day), ) control. all drugs were administered every other day single doze via oral. rats were sacrificed after days. heart tissue was taken for biochemical analysis. malondialdehyde (mda), nitric oxide (no), protein carbonyl (pc) levels and superoxide dismutase (sod), glutathione peroxidase (gsh-px) enzyme activities were determined in supernatant samples. there was not an significant difference between terazosin, doxazosin, alfuzosin, tamsulosin groups in means of sod, mda and gsh-px levels. no levels were significantly different between tamsulosin group and the control group (p = . ). in addition, tamsulosin group and terazosin group were also significantly different (p = . ). according to these results we can say that tamsulosin group had higher no levels than control and terazosin group. tamsulosin's enhancer effect on no levels leads to relaxation of the heart muscle and vascular relaxation, and so fewer side effects than other alpha antagonists. the effect of rat liver tissue radical metabolism and the protective role of hippophae rhamnoides l. on cold and immobilization stress model cold and immobilization stress is a widely used model for study the changes that occur on oxidant-antioxidant balance. hippophae rhamnoides l. (seabuckthorn; sbt) a unique and valuable plant has recently gained worldwide attention, mainly for its medicinal and nutritional potential. this study was aimed to investigate the protective role of sbt which is a natural herbal product with high antioxidant content on oxidative and nitrosative stress induced by cold and immobilization stress in rats. wistar albino rats were divided into groups randomly. control (i.p. physiological saline), sbt (i.p. mg/kg/ hours sbt), stress (i.p. physiological saline; hours cold + immobilization stress) and sbt + stress (i.p. mg/kg/ hours sbt; hours cold + immobilization stress) groups were formed. nitrotyrosine levels were determined by elisa whereas total antioxidant capacity, total thiol, total glutathione, nitrite-nitrate levels and superoxide dismutase and glutathione peroxidase activities were measured by colorimetric methods. sbt + stress group nitrite-nitrat (p = . ), total glutathione (p = . ) levels and glutathione peroxidase activities (p = . ) were found to be significantly higher whereas superoxide dismutase activity was found to be lower (p = . ) when compared to stress group. there was no significant differences between stress group total thiol and total antioxidant capacity levels compared with stress + sbt group. stress + sbt group oxidative and nitrosative stress marker -nitrotyrosine level was found to be significantly higher when compared with control group (p = . ) whereas there was no significant differences between stress and stress + sbt groups. all this data show that sbt has antioxidant properties on cold and immobilization induced oxidative and nitrosative stress in rat liver tissue. obesity is a major health problem with growing incidence and accompanying complications. its relation with diminished cognitive functions was reported. this study aims to evaluate the effects of obesity induced oxidative stress and metabolic alterations on the cognitive functions of children and adults. children and adolescents with obesity (age: - ); and age and gender matched healthy subjects were enrolled. all subjects completed the battery tests of cnsvs via computer. the scores were compared by using commercial software (ibm spss statistics ). biochemical parameters, malondialdehyde (mda) and protein carbonyl (pc) levels were estimated. mda and pc levels were significantly higher in subjects with obesity ( . ae . lmol/l; . ae . nmol/ml) than the controls ( . ae . lmol/l; . ae . nmol/ml) (< . ). there was statistically significant difference between study and control groups on all cognitive performance domains. significant correlation was detected between mda, pc levels and the cognition indexes. children with obesity should be evaluated for the cognitive functions, together with the metabolic follow-up. obesity induced oxidative stress may be the reason of the diminished cognition in children as well as the changes in the lipid profile and inflammation, but we need larger study groups to lighten these complex process. p- . . - relative contribution of nitric oxide synthase (nos) isoforms to oxidative/nitrosative stress in the cerebral cortex of rat with acute liver failure (alf) acute liver failure (alf) is associated with deregulation of nmda/cgmp/no signaling and oxidative/nitrosative stress in the brain. however, the relative roles of the different nos isoforms and the mechanisms underlying alterations in their activities during alf are not fully clear. here we investigated gene and protein expression of nos isoforms, nos activity, enos uncoupling and total no production in cerebral cortex of rats with thioacetamide (taa)-induced alf. sprague dawley rats ( - g) received three i.p. injections of taa ( mg/kg) at hours intervals. the brain cortex expression nos isoforms (enos/inos/nnos) was measured by real-time pcr and western blot, nos activity was tested by monitoring the conversion of radiolabeled arginine to citrulline. reactive oxygen species (ros) were quantified in the presence of nos substrate l-arginine, using the carboxy-h dcfda probe. no was measured with the griess procedure. the enos expression was decreased, whereas the enos dimmer/monomer ratio and nnos/inos expression were elevated in taa treated rats. while the total nos activity was decreased, the inos activity was elevated and no concentration tended to increase. ros production was elevated by taa. unspecific nos inhibitors l-name and l-nna attenuated ros production in both control and taa rats, but with higher efficiency in the latter case. ca + chelation had almost the same effect as pharmacological nos inhibition suggesting that ca + -independent inos activity is not the main source of ros. incubation with high dose of tetrahydrobiopterin (bh ) with which is critical for enos dimerization and subsequent no production also reduced ros production indicating the enos uncoupling phenomenon in taa cortex. the study points to enos downregulation due to lowered protein expression and uncoupling as a novel mechanism contributing to enhanced superoxide o anion formation, and confirms the role of inos/nnos in enhancing no synthesis in alf-affected brain. introduction: diabetes mellitus (dm) is an endocrine disorder of world which is characterized by altered blood glucose levels and related complications including hepatic injury. myrtus communis l. (mc) is widely used by diabetic patients in the folk medicine of turkey as well as they are used worlwide. it is known that of leaves, oil and fruit of myrtus communis l. (mc) have therapeutic effects on diabetes mellitus (dm). this study was aimed to analyze the possible antidiabetic and hepatoprotective effects of mc berries in streptozotocin (stz) induced diabetic rats. materials and methods: a total of thirty rats composed of six groups as each included five rats were used. mg/kg stz was injected once to animals to induce dm. after stz injection, rats were exposed to three different ethanol extracts of mc berries ( , and mg/kg) by oral gavage during days. alanine aminotransferase (alt) and aspartate aminotransferase (ast) levels were determined in serum and glutathione (gsh), malondialdehyde (mda) levels and superoxide dismutase (sod) activity were determined in liver tissue. results: mc administration provided significant reducement in the altered serum glucose, ast and alt levels in all diabetic groups. mc extract showed significant antioxidant activity by altering sod activity and gsh level and reducing mda levels in diabetic rats compared to controls (p < . ). serum ast and alt levels were reduced by mc administration in all diabetic groups. mc administration provided significance increment in sod activity and gsh level, and significant reduction in mda levels compared to controls (p < . ). the maximum hypoglycemic and antioxidant effects were observed at mg/kg dose of mc. background: human serum paraoxonase (pon ) is a calcium dependent esterase that hydrolyzes organophosphates and also arylesters such as phenyl acetate. pon prevents ldl oxidation by hydrolyzing lipid peroxides. pon is inhibited by various chelating agents, heavy metal ions, and sulfhydryl reagents. in our study we investigated the effect of calcium on ldl oxidation of purified pon q r isoenzymes. methods: pon q r isoenzymes were partially purified from human serum. both allozymic forms were treated by preincubation with mm edta for minutes. ldl oxidation was induced by copper ions. formation of thiobarbituric acid-reacting substances (tbars) was used as a measure of lipid peroxidation. homocysteine thiolactonase (htlase activity) and arylesterase activities were measured spectrophotometrically by using homocysteine thiolactone and phenylacetate as the substrates. results: addition of mm edta to partially purified hdl-pon q r isoenzymes inhibited % of htlase and arylesterase activities. inactivation of pon for arylesterase/htlase activity by the addition of edta did not reduce the abilities of both allozymic forms in protecting ldl from oxidation. conclusion: ca + -dependent inhibition of pon q r arylesterase/htlase by using the metal chelator edta, did not alter pon 's ability to inhibit ldl oxidation. pon 's ability to protect ldl from oxidation may not require calcium. p- . . - evaluation of cholinesterase inhibitory effect, anti-radical and anti-lipid peroxidation activities of mentha pulegium i. hamad , college of applied medical sciences, aljouf university, aljouf, saudi arabia, faculty of medicine, bahri university, khartoum, sudan introduction: many studies indicated that intake of dietary and medicinal plants is effective in preventing or suppressing many diseases, therefore, there is a growing interest in plant'sbioactive compounds. mentha pulegium, is widely used in gulf countries in herbal teas or as additives in commercial spice mixtures for many foods to offer aroma and flavor. the aim of this study is to investigate the in vitro radical activity, the total phenol and flavonoid content, anti-lipid peroxidation and the cholinesterase inhibitory effects of mentha pulegium methanol extract. methods: the acetylcholinesterase and butyrylcholinesterase inhibitory potentials of extracts, were evaluated by colorimetric assay. the in vitro antioxidant activity was measured by dpph assay, the total phenols content was measured by folin-ciocalteau assay, the flavonoids content by the alcl colorimetric method, and the protective effect of menthe mentha pulegium extracts against lipid peroxidation was evaluated using a liposome oxidation system. results: the methanol extract showed a scavenging activity nearly equivalent to vitamin c which is attributed to its high phenolic and flavonoid contents. the extract possessed protective effect against lipid peroxidation in a dose dependent manner. the methanol extract shows very little anticholinesterase activity as compared to the standard compound, physostigmine. conclusion: results presented here indicate that mentha pulegiumpossess strong antioxidant activity and protective effects and they can therefore be used as a natural additive in food, cosmetic and pharmaceutical industries. type diabetes mellitus is a long term metabolic disorder that is characterized by hyperglycemia and insulin resistance. because of the hyperglycemia and free radicals, diabetes can cause cellular instability. micronuclei is a sensitive indicator of genetic damage and a marker of dna damage. micronuclei is also a morphological marker of chromosomal instability. in this study, we aimed to evaluate the frequencies of micronuclei in papanicolaou stained buccal cells of type diabetic patients. a total of type diabetic patients and healthy individuals were involved into our study. buccal smear samples that belong to these individuals were stained by using papanicolaou method for cytologic examination and the stained slides were evaluated by light microscopy (olympus bx- ). cells with micronuclei in each papanicolaou stained buccal smear sample were counted under light microscopy. the frequency of micronucleated epithelial cells were seen as significantly higher in type diabetic patients than the control group (p < . ). one of the boron compounds is sodium perborate tetrahydrate (nabo . h o), which the most widely used solid peroxygen compounds. it is used in safety bleach formulations, detergents and tooth powders. as known these products are commonly used in daily life. however, the actions on blood antioxidant defenses of sodium tetraborate against reactive oxygen species are not identified yet. it is reported that oxidative stress caused by ros damages. in this study, we searched enzyme activities of superoxide dismutase (sod), catalase (cat), glutathione-s-transferase (gst), glutathione reductase (gr), glutathione peroxidase (gsh-px) and glucose- -phosphate dehydrogenase (g pd) also the effect sodium perborate tetra hydrate on activities of these enzymes from human erythrocyte under in vitro conditions. according to our findings sodium perborate tetrahydrate caused significant (p < . ) increasing in the cat activity from red blood cell. the other antioxidant enzyme activities (sod, gst, gr, gsh-px and g pd) did not show any changing by influence of sodium perborate tetrahydrate. metabolism of obese individuals could be exposed to risk of chronic low-grade pro-inflammatory effect and oxidative stress. some inflammatory and oxidative markers have been studied recently. plasma total antioxidant status (tas) and total oxidant status (tos) parameters can be non-invasive markers of diseases such as fatty liver disease, laparoscopic procedures (pneumoperitoneum), accompanying inflammatory condition like urinary tract infection, diabetic neuropathy, chronic hepatitis. the study groups have been comprised of two groups with normal to over-weight children. tas and tos levels were detected and the oxidative stress index (osi) was computed as a marker of the grade of oxidative stress. the over-weight group displayed higher levels of fasting glucose, insulin resistance, the body mass index. also, we know that insulin resistance leads to increased lipolysis and free fatty acid output. higher tos as well as crp is related to the group, also lower tas than other group is shown. crp levels in plasma were positively correlated with insulin and glucose levels. in addition, there was a significant relationship between osi and insulin resistance in the over-weight group. tas and tos are together more accurate sings of oxidative and antioxidative status of people. as well as a raise over weight-related subclinical inflammation and a fall antioxidant capacity is significant even in children. this condition may eventually develop the risk of long-term vascular damage. the effects of hydrogen peroxide pretreatment on antioxidant enzyme activities in calli tissues of two eggplant genotypes under salinity o. yasarkan , e. aky€ uz , g. baysal furtana , s. s. ellialtioglu , r. tipirdamaz nezahat g€ okyigit botanic garden, istanbul, department of biology, faculty of sciences, gazi university, ankara, department of horticulture, faculty of agriculture, ankara university, ankara, department of biology, faculty of sciences, hacettepe university, ankara, turkey the effects of hydrogen peroxide (h o ) pre-treatment on catalase (cat) and superoxide dismutase (sod) were investigated and lipid peroxidation measured as malondialdehyde (mda) content of the calli from salt-sensitive (artvin) and salt-tolerant (mardin) eggplant genotypes under salinity stress. the seeds from each genotypes were germinated on ms medium for weeks and hypocotyl tissues from these plantlets were used as explants for calli induction on ms medium including mg/l , -d and . mg/l kinetin. as for the pre-treatment, the subcultured calli tissues were transplanted on the mediums containing and lm h o for hours and then transplanted on the mediums including mm nacl for hours. antioxidant enzyme analysis and mda measurement was carried out for the control, nacl-only, h o -only and h o pre-treated tissues. pre-treatment with h o decreased the deleterious effects of salt stress on mda contents. in comparison with salt stressed groups, h o pre-treatment with or without nacl reduced mda content especially in artvin. comparing two genotypes, a decrease was observed on sod activity in artvin genotype and an increase in mardin genotype by comparison of salt stressed groups. higher increase on sod activity was observed in lm h o + nacl groups on each genotypes. comparing two genotypes, a decrease was observed on sod activity in artvin genotype and an increase in mardin genotype by comparison of salt stressed groups. higher increase on sod activity was observed in lm h o + nacl groups on each genotypes. the result showed pre-treatment of lm h o induced acclimation of the plants to salinity. in addition, lm h o pre-treatment, as a stress signal, could trigger the activation of antioxidant enzymes in calli and in this way alleviated the oxidative damage in calli growth under salinity. the investigation of effects of ghrelin and cannabinoid cb receptor agonist and antagonist on oxidant and antioxidant mechanisms on brain tissues of penicillininduced epileptic rats the aim of this study is to investigate the individual effects of ghrelin and cannabinoid type (cb ) receptor agonist acea, the antagonist am- and the interaction of these two different systems on oxidant and antioxidant systems in the brain, cerebellum and brain stem tissues of penicillin-induced epileptic rats. in this study male wistar albino rats were used weighing - g. each group was consisted of rats. study groups: : control, :penicilin( iu), :penicillin( iu) + ghrelin( lg), :penicillin( iu) + am- ( . lg), :penicilin ( iu) + acea( . lg), :penicillin( iu) + am- ( . lg) + ghrelin ( lg), :penicillin( iu) + acea( . lg) + ghrelin( lg). than the levels of mda, gpx and sod are measured in plasma and tissue samples of these rats. penicillin was found to be induced lipid peroxidation in the brain, cerebellum and brain stem tissues in our study. ghrelin and acea, which both have anticonvulsant effects, were shown to be effective in reversing the oxidative damage caused by penicillin and proconvulsant am was found to further increase the oxidative stress caused by penicillin in these tissues. ghrelin also was found to suppress the oxidative stress caused by am in the cerebellum tissue but it did not contribute to antioxidant effects produced by acea. since the role of oxidative stress in epilepsy has been established, it may be suggested that ghrelin and acea may have anticonvulsant effects via their antioxidant features. the discovery of inhibitors for enzymes that metabolize endogenous ghrelin and cannabinoids through new studies may contribute to the improvement of seizure resistance in epilepsy. accelerated atherosclerosis in patients with ankylosing spondylitis (as) give rise to increased cardiovascular morbidity and mortality. endothelial dysfunction could be the initial process in the development of atherosclerosis. human endothelial cell-specific molecule- (endocan) is a novel human endothelial cell-specific molecule. therefore, we assessed serum endocan levels and carotid intimamedia thickness (cimt) as a surrogate marker of atherosclerosis in patients with as. a total of patients with a diagnosis of as according to newyork ctriteria and control subjects were included in our study. serum endocan, interleukin- (il- ), tumor necrozis factor-a (tnf-a), c reactive protein (crp) and cimt were measured in all participants. serum endocan, il- , tnf-a levels were measured with elisa. the other parameters were done by routine biochemical methods. as patients exhibited increased serum endocan levels and cimt compared to matched controls (p < . ). whereas, serum il- , tnf-a were similar between grous. in patient with as, there were no significant differences between active and inactive patients by means of il- , tnf-a, endocan and cimt. in as group, cimt correlated with disease duration and age (r = . , p = . ; r = . , p = . ). we could not find any significant correlation between serum endocan levels and parameters studied. our study shows increased cimt in as patients without traditional risk factors such as increased bmi, lipid profile compared to controls. although we found increased circulating endocan levels in patients with as, the other factors could affect increased atherosclerosis in this population because of lack of correlation between endocan and cimt. probable biomarkers could be related to increased cimt in patients with as should be investigated in larger study groups. keywords: ankylosing spondylitis, atherosclerosis, carotid intima media thickness, endocan p- . . - investigation of pentose phosphate pathway and oxidative stress in erthrocyte infected babesia ovis a. bildik, t. karagenc ß, p. a. ulutas, n. aysul, h. aksit adnan menderes university, aydin, turkey introduction: babesia infections occur in cattle, sheep, goat, horse, dog, cat pig and rodents. in this study, the effects of babesia ovis living and present in the erythrocytes to glucose metabolism was researched. at the same time, biochemical parameters were also associated with parasitemia. materials and methods: babesia ovis (israel) cell culture was provided from dr. abel martin gonz alez oliva (portugal). culture passaged or hours according to parasitemia state ( - %). biochemical analyses were performed in erythrocyte culture in which parasitemia between % and %. cell counts and hemoglobin concentration of erythrocytes culture suspension were measured at cell counter instrument and than it was washed times with physiological saline, erythrocyte suspensions were stored at- oc analysis. gssg (oxidize glutathione), gsh (reducte glutathione), nadph, glukoz p dehydrogenaz, gshpx (glutathione peroxidase), gshrx (glutathione reductase) were determined by commercial kits. all experiments were done in duplicate, the results were calculated by the number of erythrocytes. results: parasitemia was positively correlated with gsh, nadph and gshrx (p < . ). a correlation between other biochemical parameters was not observed. discussion: the pentose phosphate pathway in erythrocytes has an important role such as to provide pentose sugar required for the synthesis of nucleic acid, to reduce glutathione, to produce nadph and to protect from methemoglobin accumulation. in studie sthat naturally infected erythrocytes with babesia parasites, it was seen to be caused to oxidative stress, however gsh results in these investigation were obtained differently . conclusion: according to the results of this study that performed in vitro, it can be suggest that their glutathione metabolism and pentose phosphate pathway of parasites may active.key words: babesiosis, gsh, gssg, nadph, g pdh, gshpx, gshrx p- . . - in vitro protective effect of betaine on peroxidative injury caused by ethanol and aspirin exposure on rat brain synaptosomes i. sogut , g. kanbak istanbul bilim university vocational school of health services, istanbul, eskisehir osmangazi university medical school department of biochemistry, eskisehir, turkey aspirin intake of specific daily doses are advised by doctors to postmenapausal women and men above years of age to prevent heart attack and even cancer in recent times. in this study, the aim is to investigate the in vitro cytototoxic effects of different doses of ethanol ( mm, mm ve mm) alone and together with lg/ml aspirin, and possible protective role of mm betaine on rat brain synaptosomes. male sprague dawley rat forebrains were divided into equal pieces and pooled to form study groups. synaptosomal fractions extracted from pooled rat brains were incubated with different doses of ethanol, aspirin and betaine, and malondialdehyde (mda) levels, an important indicator of cellular damage, were measured. a significant increase (p < . ) was observed in mda level of mm ethanol group compared to control group. different doses of ethanol ( mm, mm ve mm) + aspirin exposure significantly increased (p < . ) mda levels compared to controls, whereas betaine administration significantly decreased (p < . ) lipid peroxidation caused by ethanol + aspirin treatment. we conclude that ethanol and ethanol + aspirin administration increases lipid peroxidation in rat brain synaptosomes while betaine helps prevent this peroxidative membrane injury.keywords: aspirin, betaine, ethanol, malondialdehyde (mda) p- . . - analyses of mitochondrial biogenesis in hepatocellular carcinoma treated with berberine f. aygenli, h. c ß imen yeditepe proteomics and mass spectrometry group (yediprot), genetics and bioengineering, yeditepe university, istanbul, turkey objective: berberine (bbr) has been demonstrated to have anticancer activities against various cancer types, particularly hepatoma. in this project, we aimed to reveal the effect of bbr treatment on mitochondrial biogenesis through sirtuins and hif- a in hepatocellular carcinoma cell line, hep b under hypoxia. method: hep b cells were subjected to normoxia ( % o ) and hypoxia ( % o ) in the presence or absence of bbr treatment. the amount of bbr was optimized via cell viability (mts) assay under normoxia. then, immunoblotting experiments were performed to identify the effect of bbr on hif- a, pgc- a, and sirtuins involved in mitochondrial stress. the variation in the oxphos complexes and the level of reactive oxygen species (ros) were also measured to investigate the effect of bbr on mitochondrial energy stress state. results: here, we present that cell viability was significantly decreased at lm. bbr treatment has shown significant reduction in hif- a and sirt which responsible for up-regulation of glycolysis. also, succinate dehydrogenase (cii) and cytochrome c oxidoreductase (ciii) of the oxphos complexes were downregulated without any change in nadh dehydrogenase (ci) or atp synthase (cv). bbr significantly abolished to oxidative stress under hypoxia, which was demonstrated as a reduction in the level of reactive oxygen species by decreasing on sirt expression. bbr induces the overexpression of sirt and its deacetylated-pgc- a, which might be an indicator of being a potent protective agent against hypoxia by normalizing mitochondrial function and inducing mitophagy in impaired mitochondria caused by deficiency of glycolysis and oxphos. conclusion: detailed information about the communication between hif- a and sirtuins and their relation to mitochondrial energy production was provided with the alteration of their activity by bbr treatment. it is highly expected that bbr and its derivatives might become important during the development of supplemental therapies. introduction: reactive oxygen species are involved in a variety of biological phenomena, such as carcinogenesis, inflammation and aging. among the targets of ros, dna appears most important in tumor biology since it is firmly established that cancer is a genetic disease. ros induce several kinds of dna damage, including strand breakage and dna-protein cross-linkage. fruit of zizyphus jujuba, a traditional chinese herb widely consumed in asian countries, has been reported to possess several vital biological activities. this study intends to evaluate their antioxidant activity on glioblastoma cells. materials methods: cell survival was quantified by colorimetric mtt assay. human gliblastoma cells were pretreated with lm h o after minutes lm ziziphus jujuba essential oil was added to the cells for three hours. then, the cell homogenates were taken and glutathione, total oxidant and total antioxidant capacity and nitric oxide levels were estimated using spectrophotometric methods. results: ziziphus jujuba treated cells could prevent intracellular glutathione from being depleted following an exposure of h o . also our data suggest that ziziphus jujuba is effective in preventing h o induced oxidative stress and nitric oxide levels. discussion: some research showed that h o was over produced in the pathological process of acute and chronic neuronal toxicity, the toxicity effect of b-amyloid on the cultured neuron and neuronal cell line was mediated by h o . the traditional medicine recommend several medicinal plants for providing relief from various inflammatory diseases. many research has been reported that the essential oil from seeds of helping to prevent the oxidative stress and neuronal diseases in brain. introduction: toxicity by oxygen radicals has been recommended as a major cause of cancer, heart disease, and aging. oxygen radicals and other oxidants appear to be toxic in large part because they start the chain reaction of lipid peroxidation. most of the analytical techniques for peroxide determination are generally time consuming and not very suitable for routine or on line analysis. we aimed to design a new biosensor for rapid determining of oxidant agent hydrogen peroxide. materials and methods: all reagents were of analytical grade unless stated otherwise, and were purchased from sigma aldrich. firstly, the -hidroxymetacrilate metacriloamidoscystein nanoploymers were immobilized by binding covalently with sulphur atoms on the gold electrod's surface. free nh groups of catalase enzyme make schiff bases between nanopolymer's carbonyl groups, then immobilization was actualysed with cross linking reagent glutaraldehyde. we developed a biosensor system preparing ferrociyanide, selected as a mediator, in the buffer solution. results: polyhemamac nanopolymer and catalase complex were immobilized by glutaraldehite to construct a hydrogen peroxide biosensor. the responses of the biosensor are therefore proportional to the oxidation peaks of the complex at + . v potential. the cyclic voltammograms obtained from the experiments showed that, pottasiumferrociyanide mediator complex positively affected the biosensor responses for hydrogen peroxide determination. discussion and conclusion: as a result of this study, the method developed by the catalase enzyme electrode was found to be more advantageous in comparison to other methods reported in the literature so far; it was determined that the method is sensitive, economic, practical and less time-consuming. since biosensor technology provides economical, practical, specific and sensitive results for the determination of hydrogen peroxide, it was improved very efficiently. p- . . - impact of amoxicillin, gentamicin and cefazolin sodium antibiotics on antioxidant gene expression and enzymatic activities in mouse liver p. g€ uller , h. budak , m. sisecioglu , m. c ß iftci department of chemistry, faculty of science, atat€ urk university, erzurum, department of molecular biology and genetics, faculty of science, atat€ urk university, erzurum, department of chemistry, faculty of arts and sciences, bing€ ol university, bing€ ol, turkey reactive oxygen species (ros) are highly reactive molecules, which are produced by living organisms as a natural byproduct of the normal metabolism and environmental factors. living organisms have the antioxidant defence systems to block harmful effects of ros. the imbalance between oxidants and antioxidants is termed oxidative stress. the antioxidant defence mechanisms are divided into two groups as enzymatic and nonenzymatic defences. enzymatic defence mechanisms consist of enzymes like superoxide dismutase (sod), catalase (cat), glutathione peroxidase (gpx), glucose- -phosphate dehydrogenase (g pd) and glutathione s-transferase (gst). the present study was designed to determine the effects of gentamicin, amoxicillin and cefazolin sodium antibiotics on the hepatic antioxidant system and to determine any possible correlation between enzymatic and molecular levels. for this reason, effects of these antibiotics on the transcription of the antioxidant system has been investigated by real time pcr, and then the enzyme activity of these enzymes have been measured in whole liver homogenate obtained from control group and the drug administered groups mice. our results demonstrate that administering antibiotics led to crucial inhibition of all antioxidant enzyme activity. while significant transcriptional activation for sod and cat was seen in the gentamicin treated group, the transcription of gst and g pd was decreased. however transcriptional activation was seen for sod and cat in amoxicillin administered group, the transcription of gst was decreased as compared with the control group. in the cefazolin sodium treated group, while cat and gst transcription were elevated significantly, the expression of sod and g pd were decreased. in conclusion, gentamicin, amoxicillin and cefazolin sodium affect the hepatic antioxidant system at the molecular and protein level. this work was supported by scientific research project of ataturk university of turkey (grant no: / ). p- . . - protective effects of curcumin supplementation on oxidant/antioxidant system changes created by organic phosphorus pesticide poisoning organic phosphorus pesticides (opp), widely used in agriculture or as insecticides in home, cause adverse health effects. chlorpyrifos is one of the most commonly used opp. we aimed to investigate the possible protective effects of curcumin (cur) supplementation, the principal curcuminoid of turmeric, on poisoning symptoms and oxidant/antioxidant system changes caused by chlorpyrifos. adult sprague-dawley rats were used. cur ( , and mg/kg) were administered orally for days. on the sixth day, chlorpyrifos ( mg/kg, s.c.) was administered. twenty four hours after chlorpyrifos administration, body weights, locomotor activities and body temperatures of rats were measured. following the measurements, rats were decapitated and the blood, brain and liver tissue samples were taken and prepared for the biochemical and histopathological measurements. chlorpyrifos administration increased the malondialdehyde (mda) levels but decreased catalase (cat), superoxide dismutase (sod), glutathione reductase (grx) concentrations and reduced/oxidized glutathione (gsh/gssg) ratio in the blood samples, brain and liver tissues compared with the control group (p < . - . ). the concentration of advanced oxidation protein products (aopp) were increased only in the brain tissue after chlorpyrifos administration (p < . ). cur administration reduced all of these changes (p < . - . ). similarly, cur at the doses of mg/kg reduced the decreases in body weight, body temperature and locomotor activity with chlorpyrifos (p < . ). additionally, the histopathological damage scores induced by chlorpyrifos (p < . - . ) were decreased by the administration of cur (p < . - . ). our findings suggest that cur supplementation can ameliorate the poisoning effects of chlorpyrifos via supporting the antioxidant mechanisms and cur could be used for protective purposes against oxidative stress and tissue damage caused by chlorpyrifos. the effect of ogtt applied for screening in pregnancy on adenosine deaminase and xanthine oxidase activity in normal and prediabetic pregnant women z. c. ozmen, k. deveci, i. benli department of biochemistry, gaziosmanpasa university medical faculty, tokat, turkey objective: it was reported that the activities of adenosine deaminase (ada) were different in normal pregnant women and pregnant women with gestational diabetes mellitus (gdm). it was also stated that the activity of xanthine oxidase (xo) was increased in pregnant women with gdm. the objective of this study was to evaluate if glucose have effects on oxidative stress in prediabetic women by affecting ada and ox after g ogtt which was applied in pregnant women for screening. methods: the serum specimens of pregnant women who applied to the outpatient clinic of the obstetrics and gynecology department and had g ogtt, were used in this study. ada and xo activities were analyzed in the serum specimens taken from the normal (n = ) and prediabetic pregnant women (n = ) in the th and th minutes of ogtt. ada and xo activities were measured with the spectrophotometric method and the u/l enzyme activity was calculated. findings: there was no significant difference between the th and th minutes regarding the ada activities in the normal and prediabetic pregnant woman groups. however, we observed a significant difference between th and th minutes regarding the xo enzyme activity in normal pregnant women (p = . ). in normal pregnant women, the median xo enzyme activity in the th minute was . ( . - . ) u/l and it was . ( . - . ) u/l in the th minute. nevertheless, there was no correlation between the xo activity and glucose level. as to the prediabetic pregnant women, there was no significant difference between the xo enzyme activities in th and th minutes. the results of our study showed that the xo activity increased as a response to ogtt in the normal pregnant women compared with the prediabetic pregnant women. this finding made us think that the oxidative stress caused by ogtt did not affect the xo response in prediabetic pregnant women and that there would be some adaptive mechanisms against the chronic exposure to high level glucose. rainbow trout (oncorhynchus mykiss) aquaculture continuously increases in turkey. the objective of the present study is to increase the productivity in fish farming of rainbow trout just via intervention in physical cases without the effects of any chemicals and investigate whether this conditions cause oxidative stress. in this experiment eight tanks were used and rainbow trout larvae were placed in each tank and these tanks were illuminated with light in different wavelengths; natural sunlight, and incandescent long-wave (red light), medium-wave (green light) and shortwave (blue light) led lights. the experiment took days. biochemical changes in rainbow trout exposed to light in different wavelengths (red, green, blue) were analysed via the variations in gr, gst, g pd, gpx, sod and cat enzyme activities, which are significant for enzymatic antioxidant defence system and in ache activity, which plays an important role on central nervous system. maximum activity change in liver tissue was observed for gst and g pd enzymes in fish grown under green light and for sod enzyme in fish grown under blue light. in gill tissue, sod and g pd activities were affected the most, and in brain tissue, these were gst and sod activities. it was observed that the average weight of the fish increased . times under red and blue lights and . times under green light. the highest weight increase was observed under green light, however, antioxidant enzyme activities increased in the liver and gills and decreased in the brain tissue under this light condition. in conclusion, it was observed that productivity was . times under red light when compared with control group and it was determined that the fish grown under red light can tolerate oxidative stress more than other wavelength. p- . . - effect of nigella sativa on biliary obstructioninduced oxidative stress and apoptosis in rats human safety concerns, since that these agents may not only cause acute toxicity via inhibition of acetylcholinesterase but they can also induce delayed toxicity in the nervous system. a key interest to the current work is the potential correlation between gene expression and cytoskeletal protein changes in differentiating neural cells exposed to sub-lethal neurite outgrowth inhibitory concentrations of specific ops, which was addressed by analysing the underlying changes in the levels of cytoskeletal gene expression and protein levels. to assess the molecular effects of op exposure, phenyl saligenin phosphate (psp), chlorpyrifos (cpf) and its metabolite chlorpyrifos oxon (cpfo) were applied at the point of induction of differentiation of rat c glioma and mouse n a neuroblastoma cells and incubated for hours. at sub-lethal concentrations ( , , lm) all three ops used in this study were able to inhibit the development of neurites with no significant effect on cell viability, as determined by neurite outgrowth and mtt reduction assays. to understand the possible effects of ops on cytoskeletal gene expression, primers for genes encoding glial fibrillary acidic protein (gfap), biii tubulin, growth associated protein (gap ) and neurofilament heavy chain (nefh) were optimized for qpcr analysis and the levels of the corresponding proteins were detected by western blot analysis. exposure to ops caused in most cases a reduction in the levels of cytoskeletal proteins, and the results from qrt-pcr analysis also indicated reductions in the gene expression of gfap in c cells, and of nefh and biii tubulin in n a cells, in a dose dependent manner. thus, the observed changes in protein levels are at least partly due to altered gene expression. curcumin is extracted from a perennial herbaceous plant known as curcuma longa. in recent years, considerable interest has been focused on curcumin due to its use to treat a wide variety of disorders without any side effects. earlier studies have shown that curcumin has anti-apoptotic, anti-inflammatory, antiproliferative, antiangiogenic, anticancer and antiplatelet activities. the goal of the present study was to investigate the effects of curcumin on peroxy radical-induced oxidative changes in human platelets. healthy volunteers were enrolled in the study. none of the study participants were on anticoagulation therapy. citrated venous blood samples were centrifuged at g for minute to obtain platelet-rich plasma (prp). the platelet pellet was washed and suspended with tris-nacl buffer. then, platelets were incubated with h o absence and presence of curcumin ( - lg/ ml) for hours at °c. to determine the preventive effects of curcumin on the oxidative stress and apoptosis induced by peroxy radicals in human platelets were determined by measuring levels of of lipid peroxidation, total antioxidant capacity, caspase , and activities, and mitochondrial membrane potential. additionally, we also studied the effects curcumin on platelet aggregation induced by adp. pre-treatment of platelets with curcumin caused a marked reduction in oxidative stress, activation and apoptotic markers in a dose-dependent manner. on the other hand, pre-treatment of platelets with increasing doses of curcumin resulted in inhibition of platelet aggregation induced by adp. in the light of our findings, we suggest that curcumin may have a therapeutic potential to prevent platelet activation related disorders. people have been using mushrooms in the treatment of diseases as well as food, for centuries. most of the edible and inedible mushroom species were used in important medical studies and their effects were begun to be used in the treatment of diseases. this study focuses on the hepatoprotective effects of tricholoma anatolicum, which is endemic specie in turkey, against oxidative stress based on hydrogen peroxide (h o ) on hepg liver cancer cell line. t. anatolicum used in this study was extracted with the help of ultrasonication and fraction methods. then the cytostatic effects of extracts on hepg cells were explored and their hepatoprotective effects were determined. moreover, various concentrations of aqueous extract (ehta) of t. anatolicum were determined by hepg cells's - - hours effect analysis on their cellular morphology, xtt and real-time cell analysis in of xcelligence device. ehta extract's cell pathway (apoptosis and necrosis) effects on hepg cells were determined with flow cytometry method with the help of annexin v-apc and aad fluorescent dye. finally, the phenolic compounds found in ehta extracts were determined with the help of hplc methods. according to xtt cytotoxicity analysis, the ehta extract values were determined as follows: hours ic > lg/ml, hours ic . furthermore, according to the real-time cell analysis made with xcelligence, ehta extracts were found to be; hours ic = . lg/ml, hours ic = . lg/ml, hours ic = . lg/ml. increasing concentrations of ehta extracts were determined to direct hepg cells to apoptosis. moreover, considering the hplc analysis -according to the reference point of mg in g sample-within ehta extracts, catechins and vanillic acid peaked. the final results revealed that t. anatolicum's effect on hepg was cytostatic at low doses, and cytotoxic at high doses. p- . . - relationship between serum ceruloplasmin levels and coronary blood flow background: there is growing evidence that oxidative stres plays an important role in the development of the slow coronary flow (scf) phenomenon. ceruloplasmin (cp) is a copper containing metalloenyzme which has antioxidant functionthrough its ferroxidese activity and is associated with cardiovascular diseases. we aimed to investigate the relationship between scf and serum cp level. methods: patients who underwent elective coronary angiography and had no significant epicardial coronary disease were included in the study. patients who had thrombolysis in myocardial infarction frame counts (tfcs) above the normal cutoffs were considered to have scf and those within normal limits were considered to have normal coronary flow (ncf). a total of patients ( subject as scf and subjects as ncf) were analyzed. ml blood samples were taken from the groups to study ceruloplasmin activity. serum ceruloplasmin levels were determined spectrophotometrically. results: the serum cp levels were statistically lower in scf group than in the ncf group ( ae versus ae ng/ml, p = . ). also there was a significant correlation between serum cp levels and tfcs (r = À . , p = . ). conclusion: the findings of this study suggests that patients with scf had lower serum cp levels correlated with tfcs. we concluded that reduced serum cp levels might represent a biochemical marker of scf. introduction: sleeve gastrectomy (sg) has been used for the surgical treatment of morbid obesity, as a first step or definitive treatment. alterations of thyroid hormones in gastrointestinal surgery were previously studied. the aim of the present study was to determine the effects of triiodothyronine (t ) supplementation on oxidative stress parameters in anastomotic tissue level. materials and methods: twenty-four male wistar albino rats were divided into control (n ), and experimental (n ) groups. rats were underwent a sg, with a hand-sewn suture. experimental group rats received a single dose of t ( mg/ g) in postoperative day. rats were sacrificed on postoperative day . serum thyroid stimulating hormone (tsh), free t (ft ), and free thyroxine (ft ) were analysed using elisa. each tissue was homogenized in ice-cold pbs (ph: . ) and centrifuged at rpm for minutes ( °c) to avoid contamination with cellular debris. the supernatants were used to measure total oxidant status (tos), total antioxidant status (tas), nitric oxide (no) and malondialdehyde (mda) levels. all tissue parameters were analysed by spectrophotometric methods. oxidative stress index (osi) values were calculated. results: rats given t hormone had not decline in ft levels compared with the control groups. a significant decrease in ft levels was found in t given rats on postoperative day . whereas tissue tos levels did not alter by thyroid hormone treatment, tas levels significantly decreased. osi values were not statistically different in tissues. tissue no levels were also similar in both groups. mda levels increased in t given rats compared with the control group. discussion and conclusion: this study showed that anastomosis after sleeve gastrectomy is associated with decreased ft level. although tos levels and osi values were similar in both groups, t supplementation induced lipid peroxidation by increasing tissue mda levels that might deplete tissue antioxidant level. reactive oxygen species (ros) are reactive chemical molecules, which are produced by living organisms as a natural byproduct of the normal metabolism and environmental factors. although intracellular ros level is essential molecules for the signal transduction pathways, elevated intracellular level of ros leads to oxidative stress that causes damage to dna, proteins and lipids. therefore, excessive ros levels have to be eliminated by antioxidant defence systems. tip (tat interacting protein, kda) is a histone acetyltransferases (hats) that catalyses multiple functions in metabolism such as dna repair, apoptosis, etc. we thought that if tip has a role in signal transduction and apoptosis, it might have direct or indirect relationship with the antioxidant system. the present study was designed to determine the impact of tip gene on the hepatic antioxidant enzymes including superoxide dismutase (sod), catalase (cat), glutathione peroxidase (gpx), and glutathione reductase (gr) both gene and protein level. for this reason, quantitative gene expression analysis on the antioxidant system has been investigated by real time pcr, quantitative protein expression has been investigated by western blot analysis, and then the activity of these enzymes have been measured in whole liver homogenate collected from control and liver-specific tip conditional knockout mice. additionally, since any change of reduced glutathione (gsh), oxidized glutathione (gssg), malondialdehid (mda), and hydrogen peroxide (h o ) level in the cell might be an indication for the accumulation of ros, the relative levels of them were also studied. our data showed that the absence of tip affects the antioxidan system both gene and protein level. in conclusion, our initial data suggest that tip may be essential for the (ros) homeostasis and redox regulation. curcumin is a major chemical component produced from the rhizome of the plant curcuma longa. lt has been demonstrated that curcumin has an antioxidant, anti-inflammatory, and antiproliferative effects and, protects tissues against ischemia/reperfusion (i/ r) injury. i/r has detrimental effects on transplanted organs including uteri. the major consequence of l/r injury is oxidative stress leading to the generation of ros. uterine transplantation (ut) has been gaining popularity around the worid in the past few years. the aim of our study was to examine the antiapoptotic effects of curcumin on uterine l/r injury. the rats were randomized into three groups of seven rats each, group i consisted of rats that did not receive any treatment, group ll exposed to . hour of lschemia and hour of reperfusion, group iii of rats that received intraperitonealy curcumin ( mg/kg) . hour before the induction of i/r. then, the rat uterine tissue levels of mda, tac, and activities of caspase , and were measured. furthermore, the apoptotic index was determined immunohistochemically by the tunel method using light microscopy. biochemical analysis results showed that curcumin decreased the mda and caspase- and ieveis, and increased the uterine tissue levels of tac but, caspase activity did not changed by curcumin suggesting that curcumin induces apoptosis via intrinsic apoptotic pathway. on the other hand, an high apoptotic index was observed in i/r group ( . ae . %) and decreased after treatment with curcumin ( . ae . %). in conclusion, we demonstrated the protective effect of curcumin on apoptosis immediately after reperfusion induction in uteri and we can say that curcumin could improve ir injury and decrease apoptotic index. we propose that curcumin may be a novel approach for improvement of uteri i/r injury. glutathione and the related enzymes belong to the defence system of the tissues against chemical and oxidative stress. these enzymes especially glutathione s-transferase are often overexpressed in tumor cells and are regarded as a contributor to their drug resistance and are thought to play an important role in cancer progression. the purpose of this study is to evaluate the protective effects of chlorophylline as an antioxidant molecule which has inhibitory effects on gst p - on chemically-induced breast cancer model. in our previous work, we had observed that this molecule led to proliferation in breast cancer cells. in this study, n-methyl-n-nitrosourea (mnu) used for inducing carcinogenesis in eighteen, -day-old female sprague-dawley rats. chlorophylline and mnu solutions were injected intraperitoneally when the rats were , , and days old. their weight and tumor diameters were measured throughout the months study period. at the end of the study, all animals were sacrificed and determined both glutathione levels and related enzymes activities (gluathione s transferase, glutathione reductase and glutathione peroxidase) in tumor and tissues such as liver, kidney, heart and spleen were studied and analyzed. as a result, in breast cancer model, glutathione and related enzyme activities were protected by chlorophylline treatment whereas mnu made them decreased compared to the control group. in conclusion, chlorophylline with antioxidant features decreased the toxic effect of mnu by regeneration of glutathione and enhancement of its related enzyme activities. the use of antioxidant molecules, because of proliferative effects and defence-oriented behaviours, should be discussed in cancer therapy. p- . . - effect of overexpression of bacillus catalase on lactococcus lactis nisin production z. girgin ersoy, s. tunca gedik gebze technical university, kocaeli, turkey nisin, has been used commercially (e ) in food preservation for approximately years. it's the only bacteriocin which is approved by world health organization as a food additive. the fundamental problem that limits nisin usage in food preservation is low product yield by producer strains. because of high commercial potential of nisin, studies about increasing the production efficiency of nisin is kept in the forefront in recent years. since nisin biosynthesis and bacterial growth are occuring in parallel to each other, conditions that promote growth are also expected to encourage nisin production. it is known that, when supplied with exogenous heme, lactococcus lactis cells can respire under aerobic conditions and produce higher energy which in turn cause higher biomass. however, aerobic conditions also cause oxidative stress since catalase enzyme, which detoxify hydrogen peroxide, is absent in l. lactis. in this study, to complete the missing component of the defence mechanism of l. lactis, catalase (kate) gene of aerobic bacterium bacillus subtilis was overexpressed in facultative anaerobe l. lactis cells. for this, kate gene of b. subtilis was amplified by polymerase chain reaction (pcr). plasmid constructions were established in e. coli by using an e. coli-l. lactis shuttle vector and then the recombinant plasmid was transferred to l. lactis cells by electroporation. the presence of catalase activity in the recombinant strain grown on the solid medium was first detected by dropping hydrogen peroxide directly on the cells, then with enzyme assays. fermentation studies are going on to determine nisin production of the recombinant strain. to the best of our knowledge, this study presents the first preliminary results that shows the effect of overexpression of catalase gene on nisin production. cancer is among the leading causes of morbidity and mortality worldwide. chemotherapy is one of the major cancer treatment strategies. remarkably, natural products have garnered increased attention in the chemotherapy drug discovery field because they are biologically friendly and have high therapeutic effects. humic acid (ha) is a natural product which is forming during decomposition of organic matter in humus. in recent years, there are some resarches on the medical use of humic acid. the present study investigated anticancer effects of ha in several human cancer cell lines. ha was purchased from sigma-aldrich. in this study, we used several human cancer cell lines: the human breast cancer cell line, mcf- , colon cancer cell line, ht- , lung adenocarcinoma cell line, a , and servical cancer cell line, hela. the cells were maintained in dmem medium supplemented with % heatinactivated fbs and % penicillin/streptomycin. cells were grown in petri dishes in a humidified atmosphere containing at •c. five different concentrations ( ug/ml, ug/ml, ug/ ml, ug/ml, ug/ml) were prepared using a stock solution of ha. the cell proliferation and migration was measured. on the other hand, the apoptotic mechanisms induced by ha in cancer cells were investigated using "apoptosis antibody array kit". the effects of ha on cancer cell lines were evaluated over hours. according to our results, ha induced a decrease in ht- , a and hela cell numbers in a dose-dependent and time-dependent manner. contrary to this, ha induced proliferation of mcf- cells in dose dependent manner. ha inhibited cell migration in a dose dependent manner except mcf- cell line. it was also determined apoptotic pathways in cancer cells induced by ha. it was concluded that ha has an inhibitory effect on certain some cancers. since the effect of ha on tumor progression is unknown, further studies are needed to clarify the rol of ha on cancer activity. p- . . - chronic immobilization stress in rats: fluoxetine and amisulpride protects against chronic immobilization stress-induced biochemical alterations in the present study, the effects of amisulpride and fluoxetine on serum total sialic acid (tsa) and lipid bound sialic acid (lsa) levels was investigated in the rats exposed to chronic immobilization stress. the study was administered using male wistar albino rats weighing - g. rats were divided into five groups (n = / group). group i comprised the control group, group ii was exposed with saline + immobilization stress ( minutes daily immobilization stress for days and . ml saline was administered perorally minutes before immobilization), group iii was exposed amisulpride ( mg/kg/day) + immobilization stress, group iv was exposed fluoxetine ( mg/kg/day) + immobilization stress and v. group was exposed amisulpride ( mg/kg/ day) + fluoxetine ( mg/kg/day) + immobilization stress. statistical analysis showed that the saline + stress, amisulpride + stress and amisulpride + fluoxetine + stress groups was significantly higher than the control group with regards to tsa levels (p < . ). whereas, the fluoxetine group was significantly lower than the group regarding tsa levels (p < . ). on the other hand, saline group was significantly higher than the control group with regards to lsa level (p < . ). whereas, no significant differences in lsa levels were observed in the amisulpride, fluoxetine and amisulpride + fluoxetine groups, as compared to the control group (p > . ). the present study demonstrated beneficial effect of fluoxetine and amisulpride on the concentration levels of lsa and tsa in stress. p- . . - protective effect of borax and boric acid on total sialic acid and lipid-bound sialic acid levels against -methylcholanthrene and benzo(a)pyrene induced oxidative stress in rats s. ekin , g. oto, f. g€ ok, y. karakus, d. yildiz y€ uz€ unc€ u yil university, van, turkey the present study was performed to investigate total sialic acid (tsa) and lipid bound sialic acid (lsa) levels as possible in vivo chemoprotective effect of borax (bx) and boric acid (ba) again-st -methylcholanthrene ( -mc) and benzo(a)pyrene (b(a)p) induced oxidative stress in rats. the rats were divided into nine groups of six rats each. group i: control, untreated animals were given % . nacl, group ii: the b(a)p were administered mg/kg via ip. four times. group iii: the -mc-treated animals were administered mg/kg via ip. four times, group iv: ba was given mg/l/day with water. group v: bx was given mg/l/day with water. group vi: b(a)p mg/kg via ip four times + ba mg/l/day dosage with water. group vii: -mc mg/kg via ip four times + ba mg/l/day with water. group viii: b(a)p mg/kg via ip four times + bx mg/l/ day dosage with water. group ix: -mc mg/kg via ip four times + bx mg/l/day with water. the experimental period was continued for days. statistical analysis showed that the -mc + ba group was significantly higher than the control group with regards to tsa and lsa levels p < . , p < . ,p p- . . - effects of aluminum exposure on trace elements in rat tissues b. ozturk kurt, s. ozdemir department of biophysics, cerrahpasa medical faculty, istanbul university, istanbul, turkey aluminum (al) is the most abundant metal and the third most abundant element in the earth's crust. people are constantly exposed to al which is found in most rocks, soils, waters, air and foods, due to a result of an increase in industrialization and improving technology practices. the study was designed to examine the possible effects of aluminum exposure in different durations on trace elements in rat tissues. twenty-four healthy male wistar rats weighed - g were randomly divided into three groups: control group (gc) received only drinking water, short-term group (gs) and long-term group (gl). the study groups were orally exposed to mg/kg body weight alcl in drinking water for and weeks, respectively. at the end of the treatment period, rats were sacrificed and the kidney, liver, brain and cerebellum tissues were removed to analyse the levels of al, ar, b, ni, si, cr, cu, fe, mg, mn, se, cu and zn by icp-oes. the statistically significant increase were determined in cerebellum al, cu, as, b and cr levels in gl according to the gc. while as levels were statistically increased, ni levels were decreased in gl in the kidney and liver. while cu, mg and cr levels were higher, se and b levels were lower in the gs than gc in the brain. there were no significant difference in si and mn levels. as a result of our study, it may be concluded that al accumulation may lead to changes in tissue trace element levels. tacal, o., tacal, Ö., take, g., takic, m.m., taldykbayev, z., talim, b., tamashevski, a., tamer, f., tamer, l., , , taneva, s., taniyan, g., , tanrisev, m., tanriverdi, e.c., tanriverdi, k., tarhan, m., tarhan, t., tartar, s., tas, a., , taskin, a., taskin, t., taskiran, e., taskiran, b., taskoparan, b., taspinar, r., , tastan, Ö., tatli, Ö., tauraite, d., tay, t., tayman, c., taysi, s., , teker, h.t., tekes, s., tekin neijman, s., tekin, m.h., , tekin, g., , tekin, m., tekin, n., tekin, g., telci, d., , telefoncu, a., temel, h.e., , , temelie, m., temizgül, r., temlyakova, e., teplova, v., terashima, r., tercan avci, s., terekhov, s., tereshenko, o., terzi gulel, g., terzi, e., , terzi, e., terzioglu, g., terzioglu, o., testoni, g., tetik vardarli, a., tevdoradze, t., tevzadze, l., tezcan, Ö., tezcanli kaymaz, b., thielens, n., thomaidou, d., thomas, a., thornton, j.d., ticea, a.c., tikhonova, a., tileva, m., , timofeev, v., , timofeev, v., timofeeva, e., tipirdamaz, r., tiryaki, m., , tok, m., tokay, e., toker, a., , tokgun, o., toksoy Öner, e., tokyol, Ç., toman, r., tomasi, a., tombul, n., , tooke, c., topaloglu, h., topbas, m., topcu, b., topcu, c., topcu, g., , , topçu, v., topcu, c., topçuoglu, c., , topel, h., , toprak, b., toprak, m.s., torac, e., tosner, z., tosun, m., , toy, h., toymentseva, a., tozkoparan, b., trabulus, d.c., trantirek, l., trantirkova, s., trchounian, a., , trizna, e., , troshagina, d., tro t, m., truncaite, l., , tsakalidou, e., tsarkov, d., tsarkova, m., , tsigara, e.g., tsigara, m.g., tsverava, l., tsvetkova, e., tsyba, l., tsyganov, d., tsymbal, d., tüfekçi, a.r., , tufekci, a.r., tufenkci, h., tuglu, m.i., , tuglu, i., tuli, a., , , , tuli, a., tulubas, f., tunali, g., tunca gedik, s., , tunca gedik, s., tunçdemir, m., tuncel, h., tuncel, h., tunçer, s., tuncer, e., , tuncer, z.s., tuncer, b., tuncer, e., tuncez akyurek, f., tunçez akyürek, f., tuner, h., tüney kizilkaya, i., tural, b., tural, s., turan, i., turan, m., , turan, v., turan, y., turan, c., turano, p., , türel, s., , turhan, t., , turhan, y., , turk, s., turkan, a., türkcan kayhan, c., turkekul, k., türkel, s., turkeri, o.n., turkeri, n., turkkan, b., turkmen, s., türkmen, n., turkon, h., tutar, y., tüten, a., tutkun, e., , tüylü küçükkilinç, t., tuz, m.u., twardovska, m., tyapkina, o., tzartos, s., photoprotective activity of vulpinic and gyrophoric acids towards ultraviolet b-induced damage in human keratinocytes evaluation of the sunscreen lichen substances usnic acid and atranorin pleiotropic anticancer activity of selected nutraceuticals against mcf- bucharest, national institute for marine research and development "grigore-antipa uk in some adult and elderly populations the acute and/or persistent infection with the common intracellular respiratory pathogen chlamydia pneumoniae (chl) may be associated with increased risk of developing obesity or cardiovascular disorders. thus, microelements modifying oxidative stress status were determined by icp-ms/ms in the hno diluted serum samples collected from chl-positive adult females (n = ) living in urbanized area in poland. chl infection was confirmed by igg+ antibody elisa and real-time pcr assay. all females were classified under their body-mass index values to the normal-weight (nw), over-weight (ow) and obese group (ob) although there are many drugs currently used in the treatment of peptic ulcer, such a drug providing radical treatment without side effects is not available. since oxidative stress is involved in peptic ulceration, this study was designed to investigate antiulcerogenic and antioxidant effects of hippophae rhamnoides l. ether extract on indomethacine-induced stomach ulcer in rats. materials and methods: thirty-five sprague dawley male rats (weights ranging - g) were randomly divided into groups, as each composed of rats. after hippophae rhamnoides l. leaf ether extracts of mg/kg, mg/kg and mg/kg doses and mg/kg doses of famotidin orally administered, mg/kg doses of indomethacine were orally applied to rats in order to make ulcer. on the sixth hour of indomethacin administration all rats were sacrificed using thiopental ( mg/kg). the stomachs were removed, and ulcer areas were evaluated macroscopically. superoxide dismutase activity (sod), glutathione (gsh) and malondialdehyde (mda) levels in stomach tissues of rats were determined by elisa method with respective kits conclusions: we can conclude that the ether extract of hippophae rhamnoides l. leaves reduces free radical formation and has antiulcerogenic effects on stomach tissue control group; hours torsion/ hours detorsion group (t/d); all other groups were saturated for four days egcg, cape and egcg+cape ( lml/kg). sections were taken from bouine's-fixed and paraffin-embedded testicular tissue blocks and stained with h&e. immunohistochemistry was applied for the detection of pi k, akt and mtorc. intensities were evaluated as mild ( ), moderate ( ) or strong ( ). serum ohdg, plasma mda levels were analyzed using elisa method. results were analyzed by anova statistical test. testis samples in control group exhibited normal histological morphology. disorganization and separation of seminiferous tubule cells and accompanying interstitial edema and vessel dilation were while mda level decreased significantly in cape+egcg group, ohdg level showed significant increase in cape group. in conclusion, cape and egcg exerted protective effects on tt. effects may be achieved through pi k/ akt/mtorc pathway involved in cell proliferation, angiogenesis, apoptosis. prophylactic use of egcg prior to tt surgery improved testicular morphology, therefore could prevent destructive effects of tt lmol/l), c ( . ae . lmol/l)), respectively. conclusions: this study is important for konya region, mitochondrial fatty acid b-oxidation disorders studies subject areas. this study is the first study to assess acylcarnitine levels of patients living in our region. we believe that our results will be useful for future studies. key words: acylcarnitine, mass spectrometry, dried blood spot p- . . - binding of fas and cu(ii) ions to hsa changes its cys thiol group antioxidant capacity and carbonylation pattern with methylglyoxal binding of cu(ii) ion ( . mol/mol hsa) led to increase of k' value if fish oil extract was present, but for other fas k' value decreased. the content of free hsacys -sh decreased for % after cu(ii) ion binding, and during hours incubation at °c, it was further decreased for % (stearic acid, mixfas) and % (myristic, fish oil extract, oleic acid). carbonylation of fa-hsa-cu(ii) complexes with mg ( mol/ mol hsa), lead to decrease in cys -sh content depending on fa present: %- % for myristic and stearic acid, % for oleic acid and mixfas and % for fish oil extract. carbonylation of fa-hsa-cu complexes could contribute to further enhancement of oxidative and carbonyl stress in diabetes as well as other diseases pirto ek p- . . - anti-proliferative and inducing apoptosis of the hydro alcholic achelia. wilhelmsii extract on human breast adenocarcinoma cell lines mcf- and mda-mb- background: vitamin d deficiency is associated with several conditions and/or diseases like inflammation, atherosclerosis, cardiovascular disease and mortality. several studies showed that lower vitamin d levels were associated with high serum levels of inflammatory biomarkers. ykl- is a glycoprotein, secreted by macrophages, neutrophils and different cell types. it is also associated with inflammation and pathological tissue remodeling. in this study, we aimed to evaluate relationship between the vitamin d deficiency and ykl- levels. methods: our study group includes subjects with vitamin d deficiency (group ) and age and sex-matched healthy subjects with normal serum levels of vitamin d (group ). plasma (oh) vitamin d levels were measured with liquid chromatography-tandem mass spectrometry (lc-ms/ms) method. plasma ykl- analysis was performed by elisa. serum hs-crp levels were measured with nephelometric method. results: plasma vitamin d levels below ng/ml were accepted as vitamin d deficiency. although we could not find any significant differences by means of serum hs-crp levels between groups (p > . ), plasma ykl- levels were significantly higher in group than group (p < . ). conclusions: in literature, vitamin d deficiency is associated with inflammation. in our study, we found similar hs-crp levels between groups and higher ykl- levels in group . vitamin d deficiency may be related to increased ykl- levels in terms of causing chronic inflammation.keywords: vitamin d deficiency, ykl- , inflammation. evaluation and comparison of tnf-family ligands and receptors genes in mice and humans by bioinformatics techniques stance called plaque builds up inside the coronary arteries. apelin is a novel endogenous peptide with inotropic and vasodilatory properties and is the ligand for the angiotensin receptor-like (apj) receptor. we aimed to determine genotype and allele frequencies of apj receptor a c gene polymorphism in turkish patients with cad and healthy controls by rflp-pcr. this study was performed on unrelated cad patients and healthy controls. we obtained aa, ac and cc genotype frequencies in cad patients as . %, . % and . %, respectively. in the control group, frequencies of genotypes were found as . % for aa, . % for ac and . % for cc. we did not observe difference in apj receptor a c polymorphism between cad patients and healthy controls (v = . ; df = ; p = . ). the a allele was encountered in % ( ) of the cad and . % ( ) of the controls. the c allele was seen in % ( ) of the cad and . % ( ) of the controls. allele frequencies were not significantly different between groups (v = . ; df = ; p = . ). the frequencies of apj receptor a c genotype were not significantly different between control and patients. individuals with cc genotypes had significantly higher weight, systolic and diastolic blood pressure levels and systolic blood pressure than other genotypes, p ≤ . . in addition, hdl-c level was found decreased, but this reduction was not statistically significant. contrarily, the low levels of weight, sbp, dbp and tc were statistically significant in the subjects with aa genotype in cad. in conclusion, cc genotype carriers may have more risk than other genotypes in the development of hypertension in cad. we suggest that this polymorphism may not be a marker of cad, but it may cause useful in function of the apelin/apj system and may be a genetic predisposing factor for diagnostic processes and can be helpfull in finding new treatment strategies. p- . . - comparative genomics/proteomics analyses of single amino acid repeat containing proteins across different vertebrate taxa a. g. keskus, o. konu department of molecular biology and genetics, bilkent university, ankara, turkeyconsecutive runs of single amino acids lead to overrepresentation of certain physicochemical properties in protein sequences. researchers also demonstrated a link between single amino acid repeat (saar) containing proteins and neurodegenerative diseases as well as biological functions. moreover, saar frequencies were shown to vary across species based on selected orthologous proteomes and/or proteins. hence, analysis of whole proteomes across multiple vertebrate taxa may provide additional species-and sequence-specific trends for saars. in addition, there is a need for testing the observed saar occurrencesthe aim of this study is to evaluate the effect of quercetin (q) on liver injury secondary to cerulein induced-acute pancreatitis (ap). for this reason, rats were randomly divided into four groups ( rats for each group) control group received physiological saline, four time and dimethyl sulfoxide, two time, at hours intervals, intraperitoneally (i.p.). cerulein group received cerulein ( lg/ kg-rat weight, in physiological saline), four times, and dimethyl sulfoxide ( %), two times, at hour intervals, i.p. quercetin pretreatment (q+cer) group received quercetin ( mg/kg-rat weight, in dimethyl sulfoxide) one time, one hour before cerulein treatment and physiological saline, one time, six hour after cerulein treatment. quercetin post-treatment (cer+q) group received dimethyl sulfoxide, one time, one hour before cerulein treatment and quercetin, one time, six hour after cerulein treatment. cerulein treatment increased significantly vascular congestion in hepatic cells. quercetin treatment also decreased significantly vascular congestion. the liver mda and carbonyl levels in cerulein group were significantly higher than the control group (p < . , p < . , respectively). the mda and carbonyl levels in q+cer group decreased significantly compared to the cer group (p < . ). the mda, carbonyl, mpo levels in cer+q group were significantly lower than the cer group (p < . ). the gssg/gsh ratio of q+cer and cer+q groups were significantly lower than the cer group (p < . , p < . , respectively). the sod activity in cer group was significantly lower than the control group, but the sod activity in q+cer and cer+q groups was significantly higher than the cer group (p < . ).this study shows that quercetin treatment was reduced the severity of liver injury secondary to cerulein induced-ap as reflected by changes in the parameters of hepatic oxidant and antioxidant. p- . . - identification of water extract of propolis components by using different columns in gas chromatography-mass spectrometry propolis is a natural material obtained by honey bees from various plants. protective effect of propolis against damages of free radicals is due to different compounds within propolis. the aim of this study is to identify qualitatively and quantitatively the chemical composition of water extract of propolis (wep) provided by erzurum region using rtx- and rtx- ms column of gas chromatography-mass spectrometry (gc-ms) and to compare with two columns.in this study, wep of mg/ml was prepared, cleared by membrane filter of . lm and freezed at À °c. then, it was lyophilized up to dry form and derivatized to apply for gaseous form. mg of dry extract was reacted with ll pyridin + ll bis-trimethylsilyl trifluoroacetamide (bstfa) mixture including % trimethylchlorosilane (tmcs) and incubated for minutes at °c. all analyses were performed with shimadzu gcms-qp ultra by using a flame ionisation detector (fid). rtx- and rtx- ms capillary columns and helium for carrier gas at a flow time of ml/minute were used. injection was applied on split mode at °c. derivatized propolis sample was injected as ll, initial column temperature was adjusted as °c, then increased to °c with increments of °c. total analysis time was determined as minutes. relative percent amount of separated compounds was calculated from total ion chromatogram with computerised integrator. all components were defined by using nist and wiley libraries.peaks obtained from rtx- column were much more than those of rtx- ms. on the other hand, analyses performing with both two columns have similar carbohydrate, aromatic acid and other acid contents.consequently chemical constituents of wep were determined qualitatively and quantitatively with gc-ms. it was concluded that rtx- column among both columns differentiating for polarities may produce more compounds in the propolis analysis. introduction: aquatic environment can be mostly contaminated by mixtures of metals. biochemical parameters have gain importance to characterize the effects of metals on aquatic organisms. glutathione s-transferase (gst) and its substrate glutathione (gsh) are important parameters of antioxidant defense system of fish metabolism due to their vital role in xenobiotic conjugation. objective: the goal of the current study to evaluate the changes in gst and gsh levels in response to cd, zn and cd+zn effects after and exposure days. materials and methods: fish were obtained from cukurova university fish culturing pools (turkey). fish were exposed to . lg/ml of cd (cdcl .h o) and zn (zncl ), and their mixture, for , and days. at the end of the exposure period, liver tissues were dissected and homogenized in a phosphate buffer (ph . ). homogenates were centrifuged at , g ( min, + °c). supernatants were stored at À °c until the analysis. one-way anova was used to compare data (mean ae se) followed by duncan's test (p < . ). results: gst and gsh changes were recorded as decreases after all metal exposures at day . although day exposure was found as less effective, combined effects caused significant decreases in gst and gsh levels. also longer exposure durations were appeared to be more effective in that situation. conclusions: significant decreases in gst and gsh levels could be occurred due to increased reactive oxygen species caused by metals particularly their combined effects. metal type, their single and combined effects and also exposure duration should be also taken into account when considering the antioxidant system response. gst and gsh might be considered as sensitive biomarker in toxicity assessment of metal mixtures.financial support: this study was supported by a grant from c ß ukurova university (turkey).background/aims: the activation of lectin-like oxidized low density lipoprotein receptor- (lox- ) on endothelial cells leads to intracellular oxidative stress and inflammation and a feed-forward cycle of injury in diabetes, since both oxidized low density lipoprotein (oxldls) and glucose increase lox- expression. quercetin (qr) is part of a subclass of flavonoids called flavonols. polyphenolic compounds affect the development of atherosclerosis not only through antioxidant properties but also by modulation of serum lipids, thereby influencing the immune and inflammatory processes associated with the development of atherogenic diseases. we investigated the effects of dietary qr on endothelial dysfunction mediated by oxidized low density lipoprotein (oxldl)/lectin-like oxidized low density lipoprotein receptor- (lox- ) in animal model of type diabetes mellitus. methods: we compared groups of male adult wistar albino rats: a control group, an untreated diabetic group, diabetic groups treated with qr, and qr group. diabetes was induced by a single injection of stz ( mg/kg). animals were kept in standard condition. in day after inducing diabetic, serum was collected for biochemical parameters. glucose, lipid profiles, microalbuminuria, oxldl and lox- levels were determined. results: serum triglyceride, ldl, vldl levels in diabetic control group (without treatment) was significantly higher than control group (normoglycemic untreated group). supplementation with quercetin decreased serum total cholesterol and increased hdl-cholesterol compared with the control group. serum oxldl and lox- levels in diabetic control group (without treatment) were significantly higher than control group (normoglycemic untreated group). conclusions: consumption of quercetin reduced oxldl and lox- levels. thus, quercetin could be effective in improving hyperglycemia, dyslipidemia, and endothelial damage in type diabetes. p- . . - investigation of some oxidative stress parameters in bdnf heterozygous mice liver tissue a. bodur , i. ince , i. abidin , a. alver objectives: the aim of this study was to evaluate the possible protective effects of nigella sativa (ns) against cholestatic oxidative stress and liver damage in the common bile duct ligated rats. methods: a total of male wistar albino rats were divided into three groups:sham control, bile duct ligation (bdl) and bdl+received ns; each group contain animals. the rats in ns treated groups were given ns ( . ml/kg) once a day orally for weeks starting days prior to bdl operation. results: the changes demonstrating the bile duct proliferation and fibrosis in expanded portal tracts include the extension of proliferated bile ducts into lobules, mononuclear cells, and neutrophil infiltration into the widened portal areas were observed in bdl group. treatment of bdl with ns attenuated alterations in liver histology. the alpha smooth muscle actin (a-sma), transforming growth factor beta (tgf-b ) and the activity of tunel in the bdl were observed to be reduced with the ns treatment. bdl significantly increased the tissue hydroxyproline (hp) content, malondialdehyde (mda) levels, and decreased the antioxidant enzyme (superoxide dismutase (sod) and glutathione peroxidase (gpx)) activities. ns treatment significantly decreased the elevated tissue hp content and mda levels and prevented the inhibition of sod and gpx enzymes in the tissues. conclusion: the data indicate that ns attenuates bdl-induced cholestatic liver injury, bile duct proliferation, fibrosis, apoptosis and oxidative stress. the hepatoprotective effect of ns is associated with antioxidative potential. organophosphorous compounds (ops) are used widely as pesticides for agricultural purposes, as oil additives or as flame retardants. however, due to their widespread use, there are major introduction: in this study, the antiulcerogenic effect of a water extract (cawe) obtained from a spices sample, cinnamomum aromaticum, was investigated using indomethacin-induced ulcer models in rats. materials and methods: experimental groups consisted of six rats. antiulcerogenic activities of , , and mg/kg body wt. doses of the cawe were determined by comparing the negative (treated only with indomethacin) and positive (famotidine) control groups. results and discussion: although all doses of the cawe showed significant antiulcerogenic activity as compared to negative control groups, the highest activity was observed with mg/kg body wt. doses ( %). the cawe showed similarly antioxidant activity when compared with trolox and ascorbic acids used as positive antioxidants. in addition, the activities of catalase (cat) and myeloperoxidase (mpo) enzymes were determined in the stomach tissues of rats and compared with those of the negative and positive control groups to expose the effects of these enzymes on antiulcerogenic activity. the enzymatic activities of cat and mpo and lipid peroxidation (lpo) level in indomethacin-administrated tissues were increased significantly by indomethacin in comparison to control groups. these enzymes and lpo level were decreased, however, by the cawe. in contrast to lpo level, cat and mpo activities, glutathione (gsh) level was decreased by indomethacin and increased by all doses of cawe and famotidine. the present results indicate that the cawe has a protective effect in indomethacin-induced ulcers, which can be attributed to its antioxidant potential. introduction: thiol groups (-sh) are important anti-oxidants and essential molecules protecting organism against the harmful effects of oxidative stress. the aim of our study is to evalute thiol-disulphide homeostasis with a novel and automated method in patients with prostate cancer (pc) before and after radical prostatectomy (rp). material and methods: patients with prostate cancer and healty control subjects were enrolled into the study. plasma samples were collected from patients before rp and months after the rp operation. thiol-disulphide homeostasis was determined with a recently developed novel method. prostate specific antigen, albumin, total thiol, native thiol, disulphide and total antioxidant status (tas) were evaulated and compared between the groups. results: native thiol levels were . ae . lmol/l in the control group, . ae . lmol/l in the patients before rp, and . ae . lmol/l in patients after rp. native thiol, total thiol and tas levels were significantly higher in the control group than the patients before rp (p values < . ). native thiol, total thiol and tas levels were higher months after rp compared to before rp in patients, but these changes were not significant statictically (p values . , . and . respectively). discussion and conclusion: our study demonstrated that antioxidant defense mechanism was weakened as indicated by the decreased thiol levels in the patients with pc. increased oxidative stress in prostate cancer patients may cause metabolic disturbance and have a role in the pathogenesis of prostate cancer. p- . . - is there any relation between g oral glucose challenge test and serum total oxidant-antioxidant status in pregnant woman? the purpose of this study was to test the hypothesis that any degree of antepartum screening for gestational diabetes mellitus with oral g glucose challenge test (gct) should be associated with oxidant-antioxidant status.in this prospectif study, oral glucose challenge test was applied to pregnant women aged - years and at - weeks of gestation. plasma glucose concentrations were measured initial, hour and in addition to test hours after ingestion of g glucose. at the same time serum insulin, cortisol, total antioxidant status (tas), total oxidant status (tos) levels were measured and the oxidative stress index (osi) was calculated.ten pregnant women (forty percent) had a positive glucose challenge test (gct). a positive moderate relation with initial and hour serum total antioxidant status (tas) levels (r = . ) and the oxidative stress index (osi) (r = . ) was found. there was a positive weak correlation with initial and hours total oxidant status (tos) levels (r = . ) but statistically significance difference was not found (p > . ).in this study after ingestion of g glucose serum total antioxidant status (tas), serum oxidant status levels (tos) and serum oxidative stress index (osi) levels were higher than the initial levels.the results of this study suggest that antepartum screening for gestational diabetes mellitus with g oral glucose challenge test (gct) weakly associated with oxidant-antioxidant status and to confirm this results the longer follow-up studies with more participants are necessary.wheat (triticum ssp.), cultivated for centuries in the middle-east, central asia, europe, and north-africa, is one leading staple crops around the world, and its marginally grown ancestor einkorn (triticum monococcum ssp. monococcum), possesses rich gene resources for wheat improvement and have bioactive compounds reducing and preventing chronic diseases such as diabetes, cancer, alzheimer, and cardio vascular diseases, beside their nutritional properties. however, as more attention has been given to wheat cultivars with strong gluten, protein content, starch composition, and resistance to biotic and abiotic stresses in bread wheat and yellow-colored pasta product in durum wheat health compounds such as fibers, phytochemicals, and bioactives have been underestimated so far. the aim of this study was, then, to examine the total phenolics and flavonoids, quantify their phenolic acids, a-tocopherol by high performance liquid chromatography (hplc), and their , -diphenyl- -picrylhydrazyl (dpph) scavenging activity of bread (triticum aestivum l.), durum (triticum turgidum ssp. durum desf.) wheat cultivars and einkorn (triticum monococcum ssp. monococcum) wheat populations collected from different provinces (bolu and kastamonu) of turkey. ferulic acid ( . - . -lg/g), p-coumaric ( . - . -lg/g), and total phenolic content (ranged . - . -lmol gae/g) of einkorn populations were significantly higher than bread and durum wheat cultivars. results suggested the possibility of production of einkorn wheat populations, and hopefully cultivars rich in particular health beneficial component(s) may provide benefit to the consumers. in addition, higher phenolic content of einkorn may offer novel wheat genetic resources for the improvement of new wheat cultivars and the development of wheat-based functional foods. oxidative damage due to ischemia and acute kidney injury (aki) after coronary artery bypass graft (cabg) surgery are the leading complication during this process. in the kidney, ischemia/ reperfusion injury contributes to aki that is a clinical syndrome with rapid kidney dysfunction and high mortality rates. some animal and clinical studies have demonstrated an increase in serum and urinary neutrophil gelatinase-associated lipocalin (ngal) expression after renal ischemic injury.in this study, our aim was to investigate the relationship betwwen ngal and oxidative stress parameters due to ischemia caused by total perfusion time (tpt) in patients who have undergone on-pump cabg. materials and methods: the study was conducted in patients who received on-pump cabg at university of istanbul, cerrahpasa medical faculty, department of cardiovascular surgery. blood samples were collected prior to surgery and after hours following the termination of cardiac pulmonary bypass (cpb) . following centrifugation, serum samples were separeted and stored at - c until analysis. serum ngal, ima (ischemia modified alb€ umin), pco (protein carbonyl), nt (nitrotyrosine), lpd (lipid peroxide) levels were determined by elisa procedure. results and discussion: serum ngal, pco, nt levels in after hours following cpb were significantly higher than the before surgery (p < . , p < . , p serum ngal levels in after hours following cpb was found to have positive correlation with ima, pco, nt, and lpo levels (r = . , p < . ; r = . , p < . ; r = . , p < . ; r = . , p < . respectively). ngal levels were positively correlated with total perfusion time after cbp (r = . , p < . ).the results of our study show that, increased ngal levels hours after cpb were positively correlated with oxidative stress parameters and total perfusion time. investigation of the effects of thymoquinone against indomethacine induced gastric damage in rats introduction: incidence and high cost of acute stomach mucosa damages make this issue a very interesting issue for study. for this reason, it is aimed to investigate the effects of different dosage of thymoquinone (tq) against indomethacine induced gastric damage in rats. material and method: in our study, six groups of wistrar male rats were used. groups are named as healthy, ind control, famotidine ( mg/kg) and three different doses of tq ( . , and mg/kg). while any treatment or drug administration will done on healthy group, model was generated to other groups by giving fam or tq with tap water via oral gavage. min later, mg/kg ind administrated to each rat. animals were sacrified about hour later and stomach samples of each groups were collected for macroscopic study and gsh levels measurements. results: lower doses of tq is more effective and all tq groups exhibit reduced ulcer region with respect to the ind control group. gsh level of ind control group is lower than healthy group. the gsh level of tq, especially in lower doses, and fam groups statistically exhibit an increase in gsh level. conclusion: it is observed that ind induced gastric damage cause ulcer and increase in free radical. it is determined that lower doses of tq ( . , and mg/kg) is also exhibit a protective effect on ind induced model. it is tought that quinone in tq structure have a strong redox feature and this feature clean up the free radicals caused by ind, it reduces the oxidative stress and protect the stomach from ulcer. anzer honey is the most famous honey in turkey with many endemic species flowers. the anzer plateau is located rize province of eastern black sea region. in this study, antioxidant and anti-hyaluronidase and anti-urease activities were investigated of the plateau bee pollen. the antioxidant capacity was determined by total phenolic content (tpc), total flavonoids contents (tfc), ferric reducing antioxidant power (frap) and , diphenyl- -picrylhydrazyl (dpph) radical scavenging activity. atherosclerosis is the leading cause of mortality worldwide, and as a chronic inflammatory disease, caused by a complex interplay between inflammatory and oxidative events.quercetin, a plant derived flavonoid and a well-known antioxidant, has shown great promises with regards to its protective effects against oxidative stress.however due to its physicochemical properties, the optimum pharmacokinetic behavior is a challenging issue.herein, we aimed to fabricate quercetin loaded solid lipid nanoparticle (quer-sln) to improve the bioavailability and therapeutics efficiency. furthermore the in-vitro capacity of quer-sln for ameliorating tnf-a induced oxidative stress in human endothelial vein cell (huvec) was evaluated. quer-slns were prepared by simple hot homogenizing method and characterized by means of drug loading (dl), encapsulation efficiency (ee), cytotoxicity, size, zeta potential and morphology. antioxidant activity of plain quercetin and quer-slns were then investigated using intracellular reactive oxygen species (ros) detection method (dcfh-da assay) by facs flowcytometryin conclusion, the results here showed superior control of oxidative stress by quercetin nanosystem as compared to plain quercetin. precirol based slns as a biocompatible/biodegradable lipid, may provide a novel drug delivery system for quercetin with improved beneficiary impact in atherosclerosis. objective: zinc is known as an antioxidant essential trace element. we aimed to evaluate the dose-dependent effects of zinc on the oxidant-antioxidant system in liver, kidney and brain tissues of rats and the histological alterations in the absence of oxidative stress (os). material and methods: thirty-nine female weighing about gr wistar albino rats were divided into four experimental groups as ad libitum (al) diet (control), al diet + mg/kg zn sulfate (low dose; group ), al diet + mg/kg zn sulfate (middle dose; group ) and al diet + mg/kg zn sulfate (high dose; group ). zn sulfate solutions were administered . ml/day orally for days and in day rats were sacrificed and tissues were excised for detecting malondialdehyde (mda), advanced oxidation protein products (aopp), superoxide dismutase (sod), glutathione peroxidase (gsh-px), glutathione reductase (gr), and glutathione-s-transferase (gst) activities. histological evaluation was also performed to confirm the effects of zinc. results: in liver tissues aopp levels decreased in all groups receiving zinc as compared to the control group. liver mda levels were increased in group and ; sod and gsh-px levels were both increased while gst levels were decreased in all groups compared to control. gr levels were increased only in group . in kidney; aopp level was decreased only in group and sod level was only decreased in group as compared to control while gr levels were increased in all doses of zinc. in brain; aopp, gsh-px and gr levels were decreased in all groups receiving zinc as compared to control group. sod activity in brain tissues was increased by the administration of middle dose of zinc (group ). gst level was decreased in only group conclusions: the biochemical and histological findings of this study suggest that zinc has various effects on liver, kidney and brain tissues in the absence of os.key words: zinc, liver, kidney, brain introduction: this study aimed to investigate the effect of diabetes mellitus (dm) on oxidative stress and antioxidant capacity in humour aqueous (ha) and venous serum using total antioxidant capacity (tac) and total oxidative stress (tos) levels in serum and ha in cataract patients. materials and methods: in this study patients were divided into two groups. group was composed of patients with type dm and cataract and group was composed of patients with cataracts who are not accompanied by dm and cataract patients who are not accompanied by systemic diseases. each group consisted of patients, totally patients were included in the study. the ha which was collected from the eyes at the beginning of the cataract surgery and venous blood serum collected from the same patients were analyzed. in both groups, ha and serum tac and tos levels were measured with elisa. results: : serum tac levels in the dm group were significantly lower than in the control group (p < . ). tos serum levels in dm group was statistically higher than the control group (p < . ). differences between tac and tos levels were not statistically significant when compared the two groups' ha results (p > . ). group , divided into two subgroups according to their hba c levels, there was no statistically significant difference between the subgroups when hba c levels were compared with the relationship between serum and ha's tac and tos levels (p > . ). there was not an association between the gender, age and the levels of tac-tos in both groups (p > . ). discussion and conclusion: presences of dm is the only risk factor for increase of oxidative stress and decrease of anti-oxidant capacity in patients without a systemic complication of dm and diabetic retinopathy. in our study, diabetic patients without retinopathy showed similar ha tos and tac levels to healthy individuals, this finding indicates that blood-aqueous barrier is protected in these patients. the effect of ferulic acid against testicular ischemia/reperfusion injury in rats u. sac ßik , g. erbil , z. c ß avdar , c. ural department of histology and embriyology, school of medicine, dokuz eyl€ ul university, izmir, department of molecular medicine, health science of institute, dokuz eyl€ ul university, izmir, turkeytestis torsion is one of the urologic emergencies occurring frequently in neonatal and adolescent period. testis is sensitive to ischemia/reperfusion (i/r) injury and, therefore, ischemia and consecutive reperfusion cause an enhanced formation of reactive oxygen species (ros) that result in testicular cell damage and apoptosis. ferulic acid, known as an antioxsidant, is a phenolic acid found in seeds and leaves of the plants. we aimed to investigate potential protective effect of ferulic acid against testis i/r injury.thirty five wistar rats were randomly divided into groups; control, ethyl alcohol, ischemia, i/r, i/r-ferulic acid groups. animals were exposed to hours of ischemia followed by hours of reperfusion. ferulic acid was administered ( mg/ kg) before reperfusion intravenously. testicular cell damage was examined by h-e staining and pas. tunnel, active caspase- , inos and mpo were evaluated by immunostaining. malondialdehyde (mda), glutathione (gsh) levels, glutathione peroxidase (gpx) and superoxide dismutase (sod) activities were assessed by biochemical methods.histological evaluation showed that ferulic acid pretreatment reduced significantly testicular cell damage and decreased tun-nel, caspase positive cells; inos and also mpo expression. in addition, ferulic acid administration decreased significantly the mda levels increased by i/r. morever, ferulic acid increased significantly the sod activity levels, which was decreased by i/r. there were no statistically significant differences in the levels of gsh and gpx activity in all groups.the present results suggest that ferulic acid is a potentially beneficial agent in protecting testicular i/r. background: in heart failure (hf), angiotensin antagonists (aa), beta-blockers (bb), spironolactone, diuretics and acetylsalicylic acid are often used. top pharmaceutical groups reduce mortality. on the increased oxidative stress (os) in patients with hf, it is known to have beneficial effects of certain groups of drugs. however, the net effect of these drugs in os is unknown. the aim of this study was to investigate the effects of drugs used in hf on os. materials and methods: patients were included in the study. all of the patients had systolic heart failure and all of them were under treatment. drugs used by the patients were recorded. the levels of total antioxidant status (tos), total oxidant status (tas), the enzymatic activity of ceruloplasmin, paraoxonase- and arylestherase were measured according to erel's method. serum total thiol levels were measured with sh modified hu method and the lipid hydroperoxide levels were measured with the ferrous ion oxidation xylenol orange assay. the percentage tos / tas was determined as osi. results: in patients treated with acetylsalicylic acid (asa), spironolactone, beta blocker and furosemide, there were increased tos, decreased tas and osi (p < . ). in patients treated with angiotensin blockers, increased tas and looh, and decreased sh were found (p < . ). in patients treated with nitrates and ccb, tos and osi were found decreased. correlation analysis showed that increased tas correlated with the use of angiotensin blockers, asa, furosemide and beta blocker positively; and with the tos and osi level correlated with the use of spironolactone, asa spironolactone and furosemide (p < . ). conclusion: current medical agents that are being used in hf are effective in reducing os in hf patients. one of the effective mechanisms to reduce the mortality of some of these drugs may decrease os.key words: heart failure, drug use, oxidative stress p- . . - across adjacent ring formed titanium phthalocyanine-mediated photodynamic therapy alters and degrades filamentous actin cytoskeleton and internal membranes photodynamic therapy (pdt) is widely accepted as a promising and minimally invasive treatment strategy due to its applicability on a wide range of cancer diseases. this clinically approved treatment method relies on the dramatic production of singlet oxygen and reactive oxygen species (ros) in target tissue to evoke apoptotic cell death [ ] . we, therefore, focused on the intracellular ros accumulation, internal membrane degradation, filamentous actin cytoskeleton alteration and nucleus morphology changes induced by pdt-mediated across adjacent ring formed titanium phthalocyanine which was previously synthesized bis(ethane- , p-phenol- , -p-phenoxy) phthalocyaninatotitanium (iv).characterization of the synthesized metallophthalocyanine was accomplished by using uv-vis, ir, h-nmr and maldi-tofmass spectroscopies. the dark and pdt-mediated activities of bare and phosphonolipids (max. %) charged titanium phthalocyanine ( . , . , . , and lm) were determined on a human lung carcinoma and hacat human keratinocyte cell lines by using intracellular ros assay, dioc( ), tritc-phalloidin and dapi staining protocols. waltmann pdt l was used as the non-toxic light source at j/cm fluence and mw/ cm fluence rate. the experiments showed that pdt-mediated titanium phthalocyanine leads to significant and concentration dependent reactive oxygen species accumulation. moreover, internal membrane degradation, apoptotic bodies on nucleus and filamentous actin cytoskeleton alteration were observed. consequently, the activity mechanism of pdt-mediated titanium phthalocyanine seems to be in a tight relationship with ros accumulation-mediated internal membrane degradation, filamentous actin cytoskeleton alteration and apoptotic pathways activation. introduction: retinal vein occlusion (rvo) is a common retinal vascular disorder that can affect visual acuity and cause blindness in elder population. sulphur containing aminoacids such as cysteine (cys), cysteinylglycine, glutathione, homocysteine and c-glutamylcysteine are reported to be associated with the pathogenesis of rvo. thiols are organosulfur compounds that are formed of a carbon-bonded sulfhydryl group. sulphur containing aminoacids slightly contribute the composition of plasma thiol pool. thiols can undergo oxidation reaction via oxidants and form disulphide bonds our purpose is to research the relationship between a novel oxidative stress marker serum dynamic thioldisulphide homeostasis and retinal vein occlusion. materials and methods: rvo patients and controls were included in the study. native thiol, total thiol, disulphide levels are measured in the serum samples of rvo and control group by using an automated method described by erel et al. also disulphide/native thiol and disulphide/total thiol ratios were calculated. results: there were no significant difference between the rvo and control group in native thiol, total thiol, disulphide disulphide/native thiol and disulphide/total thiol ratios.(p > . for all) conclusion: our study is the first report evaluating the dynamic thiol-disulphide homeostasis in rvo patients by a newly developed method by erel et al. further large sample sized studies investigating the levels of sulphur containing aminoacids may additionally be planned to verify this study. purpose: the purpose of this study was to evaluate markers of systemic oxidative stress and antioxidant capacity in subjects with severity of osas. methods: a total of osa patients were included in the study ( controls, with mild, with moderate, and with severe osa). patients were grouped according to apnea-hypopnea index (ahi) as mild, moderate and severe osa. patients with ahi< served as control group. known risk factors for oxidative stress, such as age, sex, obesity, smoking, hypelipidemia, and hypertension, were investigated as possible confounding factors. plasma arylesterase, total oxidative stress (tos), total antioxidant capacity (tac), total thiol, catalase (cat) levels were measured for all patients. results: the mean age was . ae . years and . % ( / ) of the study population was female. plasma arylesterase, tos, tac, total thiol, and cat plasma values were not different between mild, moderate, severe osa groups and controls (p > . ). catalase levels were significantly lower in women patients with severe osa compared to healthy women controls (p < . ). there was a negative correlation between ahi and serum total thiol levels (r = À . , p < . ) in severe osa groups. conclusionthe present prospective study provides evidence that osa might be associated with decreased antioxidant burden possibly via catalase way. results: the sera -ohdg, mda and il- were significantly higher in diabetic group than control group (p < . ). although there was a notable positive correlation between mda and -ohdg, there was no a relationship between -ohdg or mda with il- . discussion: in agreement with previous studies our data illustrated that high levels of oxidative stress is associated with increased production of oxidized lipids and nucleobases in diabetic patients compared to control group. also enhanced proinflammatory cytokine, il- , induced inflammmation in these patients.conclusion: oxidative stress and inflammation play pivotal roles in the development of diabetes and can cause major complications in dm. so we suggest that early detection of these measurable indicatores can help to diagnosis the severity or presence of some complication in diabet. the effect of quercetin on erythrocyte glucose- -phosphate dehydrogenase enzyme activity in ethanol treated rats in this study, we aimed to evaluate the effects of ethanol on erythrocyte (g- -p-d) enzyme activity and the effects of quercetin on erythrocyte g- -p-d activity in the recovery of the effects of ethanol.rats were randomly divided into four groups. the control group (n = ) received physiological saline. the quercetin group (n = ) received quercetin ( mg/kg/ day) via i.g. route the alcohol group (n = ) received ethanol ( % v/v, ml/day) via i.g. route. the alcohol + quercetin group (n = ) received ml of ethanol ( % v/v) hours after quercetin treatment ( mg/ kg/day). experimental procedures were peformed for days. erythrocyte g- -p-d activity was found to be higher in the quercetin group than those in the alcohol group (p < . ). in the alcohol group, the erythrocyte g- -p-d activity was found to be significantly decreased than those in the control group (p < . ). statistically significant differences were observed in erythrocyte g- -p-d activity between the alcohol group and the alcohol + quercetin group (p < . ).as a conclusion, our results demonstrate that ethanol decreased erythrocyte g pd activity and quercetin was found to be beneficial in the prevention of toxic effect raised by ethanol.key words: erythrocyte, ethanol, g pd, oxidative stress, quercetin p- . . - effects of the sulphasalazine to the cerebral hypoxia reperfusion injury in rat background: cerebral ischemia/ reperfusion (i/r) injury is still a difficult process to treat and rehabilitate today. this study was designed to investigate beneficial effects of sulfasalazine in cerebral i/r injury in rat. methods: except control group (n = ), wistar albino rats were divided into four groups for acute and chronic stage investigation of i/r injury, and temporary aneurysm clips were attempted to both internal carotid arteries for duration of minutes. four hours later, except control, sham-a, sham-c groups, mg/kg once a day sulfasalazine was administered to animals, orally. animals were sacrified and then necrotic neuronal cells of hippocampal ca , ca , and ca region, and cortical necrotic neurons, perivascular edema, pyknotic neuronal cells, irregularities of intercellular organization (iio) were counted and scaled histopathologically. tissue il- b, il- , malonyldialdehyde (mda), myeloperoxidation (mpo), no, and tnf-a levels were measured by using elisa, too. results: sulfasalazine could reduce perivascular edema, iio, cortical and hippocampal neuronal cell death in both stages. it could decreased mda in acute stage, but not reduce il- b, il- , mpo, no, and tnfa levels. it could increased il- b levels in chronic stage but not affect to il- , mpo, mda, no, tnf-a levels.conclusion: sulfasalazine could improve histopathological architecture of hypoxic tissue in both stages of i/r injury. it could inhibit lipid peroxidation cascades in acute stage but not affect to tissue mpo, no, il- , and tnf-a levels in any stage in rat. these results suggested that therapeutic mechanisms of sulfasalazine should be investigated by using more specific laboratory methods in future studies.key words: antiinflamatory, cerebral hypoxia reperfusion injury, sulfasalazine, stroke. camel and horse milk xanthine oxidase (xo) was found to catalyze the reduction of nitrate and nitrite to nitric oxide (no) under aerobic condition. to date, mammalian nitrate reductase (nar) and nitrite reductase (nir) have not been identified. no, a gas, is found to control a seemingly, limitless range of functions in animals.one assay was used to determine nar and nir activities of milk xo: ( ) nitrite formation from nitrate by nar, and ( ) nitrite utilization by nir. nitrite concentrations were determined by using sulfanylamide and n-( -naphtyl)-ethylenediamine, which form red color measured at nm.these activities of the milk xo require nadh as a physiological electron donor. high xo, nar and nir activities are detected only after heat treatment ( °c, min) of the fresh milk in the presence of molybdate. in both camel and horse milk nar activity of xo was almost two times higher than its nir activity. it is well known that xo can be reversibly converted from the dehydrogenase form to the oxidase through the oxidation of sulfhydryl groups. cysteine and, to a lesser extent, glutathione increased nir activity of milk xo but not its nar activity. the mechanism of this increase of nir activity remains unclear and is currently under study. substitution of tungsten for molybdenum under above conditions gave no detectable nar and nir activity of milk xo. the molybdenum site-directed inhibitor, tungsten inhibited in a dose-dependent manner. therefore, nitrate and nitrite are clear to interact with mo center of xo.camel and horse milk are traditional drinks in central asia and kazakhstan. therefore, it is very important that xo provide a mechanism for generation of no in camel and horse milk where nitric oxide synthase, no producing enzyme, does not exist. p- . . - the influence of phytomedicine on metabolic processes of white rats undergone to ionized radiation the study of peroxide lipids oxidation (plo) process is used as one of stability parameters of organism's changes and as a key mechanism for understanding of adaptation reactions and of pathogenesis of different diseases. it's determined by high biological activity of products which are formed in the plo reactions, in this relation lipids with high contents of fat acids play important role. to investigate the influence of phytomedicine eminium regelii on the metabolic processes (peroxide lipids oxidation) of white rats' organism in conditions of ionized radiation.the animals were exposed to ionizing radiation (gamma-radiation co) on the radiotherapeutic equipment teragam in a dose of gy and received phytomedicine eminium regelii in a dose of . mg/kg orally within days following the ionizing radiation exposure. gamma-rays caused the increase of lipid peroxidation (lpo) primary (dc) and secondary products' (mda) concentrations in spleen, liver, thymus and adrenal glands.treatment by phytomedicine resulted in contents of dc decreased in times in spleen, in times in thymus, in times in adrenal glands, in liver in times, in lymph nodes of small intestine it in times. mda decreased in liver up to and times, in spleen in . times, in thymus in times, in liver in times, in adrenal glands in time, no changes in lymph nodes of small intestine.the effect of phytomedicine treatment of organisms exposed to sublethal dozes of gamma-radiation results in the lpo primary and secondary products concentrations decrease in spleen, liver, thymus and adrenal glands. p- . . - evaluation of serum levels of ischemia modified albumin (ima) in bipolar disorder patients k. € unal , c. topc ßuoglu , m. cingi clinic of biochemistry, ankara polatli duatepe public hospital, ankara, clinic of biochemistry, ankara numune training and research hospital, ankara, clinic of psychiatry, ankara numune training and research hospital, ankara, turkey introduction: bipolar disorder is one of the most debilitating psychiatric disorders characterized by disruptive episodes of mania/hypomania and depression. considering the complex role of biological and environmental factors in the etiology of affective disorders; recent studies have focused on oxidative stress, which may damage nerve cell components and take part in pathophysiology. aim of our study is to contribute these data about oxidative stress in bipolar disorder, by detecting ischemia modified albumin (ima) levels of bipolar disorder patients in remission and also by comparing these results with healthy controls. methods: study population consisted of patients meeting the diagnostic and statistical manual of mental disorders, fifth edition (dsm- ) criteria for bipolar disorder i. healthy subjects were included as control group (hc). serum ischemia modified albumin (ima) levels of all participants were determined. results: statistical analysis on serum ischemia modified albumin (ima) levels did not show any significant difference between bipolar disorder patients in remission and healthy controls.conclusion: studies on oxidative stress in bipolar disorder have reached controversial results up till now. in this study, no statistically significant difference was detected between oxidative parameters of bipolar disorder patients in remission and healthy controls. in order to evaluate oxidative stress in bipolar disorder comprehensively, further studies are needed. keywords: bipolar disorder, ischemia modified albumin (ima), oxidative stress p- . . - xanthine oxidase and adenosine deaminase activity in patients with familial mediterranean fever (fmf) objective: fmf is an autosomal recessive dissease which is characterized by recurrent fever and inflammation of serous membranes. in this study we measured serum adenosine deaminase (ada) and xanthine oxidase (xo) levels in fmf cases. method: serum ada levels were measured with a sensitive colorimetric method described by giusti and xo levels were analysed by the method of worthington in fmf patients and healthy controls. results: there was a significant difference in xo and ada levels between controls and cases. ada and xo levels were higher in patents with fmf. humic acid (ha) is a natural product which is forming during decomposition of organic matter in humus. in recent years, there are some resarches on the medical use of ha. the present study was undertaken in order to evaluate the anticancer properties of the ha using a prostate cancer and osteosarcome cell lines pc- , sjsa as an in vitro model system.ha was purchased from sigma-aldrich. the cells were maintained in dmem medium supplemented with % heat-inactivated fbs and % penicillin/streptomycin. cells were grown in petri dishes in a humidified atmosphere containing at •c. five different concentrations ( ug/ml, ug/ml, ug/ml, ug/ ml, ug/ml) were prepared using a stock solution of ha. we measured cell proliferation and migration to understand of progression effects of ha in pc- and sjsa cell lines in vitro.according to our results, ha treatment caused cytotoxicity and induced cell death in vitro in pc- cells with an ic value of . lg/ml. contrary to this, ha induced proliferation of sjsa cells in dose dependent manner. ha demonstrated the highest proliferatif activity against sjsa cells with an ic value of > lg/ml. on the other hand, cell migration was reduced in pc- cell line and interestingly, migration was accelerated in sjsa cell line.our study may provide new insights into the regulatory effect of ha in cancer, but further studies are needed to clarify the role of ha in cancer pathogenesis. the febs journal (suppl. ) ( )